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IPAP JUNIOR SEM. > PHARM LAST JUNIOR TEST > Flashcards

PHARM LAST JUNIOR TEST Flashcards

1
Q

When does LH and FSH spike?

A

On day 14 of a woman’s cycle

This is peak ovulation

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2
Q

When does progesterone spike

A

During the luteal phase

From the corpus luteum

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3
Q

What are the lengths of the various phases of Menstration

A

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

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4
Q

What are the three phases of the ovarian cycle

A

Follicular, ovulatory, and luteal

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5
Q

What are the three phases of the uterine cycle

A

Mensuration, proliferation, secretory

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6
Q

How long must sex be avoided when using the Temp, Mucus, colander methods

A

Most effective to combine all 3 methods
Standard Days Method
Track cycle for several months

Avoid unprotected sex on days 8-19!

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7
Q

How long can a diaphram BC stay in place

A

6-8 hours remove after 24

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8
Q

How long can a cervical cap remain in place

A

6-8 hours remove within 48

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9
Q

How long can a BC sponge stay in place

A

Remain in place for 6 hours after intercourse

Remove within 30 hours

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10
Q

How long can spermicides stay in place

A

Insert close to uterus, < 30 mins prior to intercourse

Remain in place for 6 hours

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11
Q

How do tubal implants work

A

Scar tissue forms and blocks sperm

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12
Q

Where is the cut in a vasectomy

A

Vas deferens

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13
Q

What is the difference between a copper and a hormonal IUD

A

Copper IUD
Remain in place for 12 years

Hormonal IUD
Releases progestin in uterus
Remain in place for 3-5 years

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14
Q

How does a vaginal ring work for BC

A

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

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15
Q

How does the BC implant work

A

Releases a low dose of progestin

Protects for up to 3 years

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16
Q

How do you instruct a pt to use a BC patch

A

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

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17
Q

What should you tell a pt who is getting injectable BC

A

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

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18
Q

What is the drug in injectable BC

A

Injection of a medroxyprogesterone

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19
Q

When is Estriol made

A

In the placenta during pregnancy

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20
Q

What are the 4 different types of phases for BC

A

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

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21
Q

What is the difference of extended vs continuous BC admin

A

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

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22
Q

What is the difference between V. Low dose, low dose and high dose EE

A

V low dose is less than 30
Low dose is 20-30
High dose is any thing above 50
(Assoc with increase ADE/VTE)

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23
Q

What are the three different approaches to EE starts

A

Quick and Sunday appracohes
(Both require 7 day condoms)

1st day dosing, may not require condoms

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24
Q

What is the approach to missed EE

A

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

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25
Q

What is the Best BC method for a pt that is breastfeeding

A

Progestin only

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26
Q

What pts is progestin only BC best in

A 
Migraines
Breastfeeding 
Smokers
CV risk 
HTN 
Post Birth
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27
Q

If a pt in taking progestin only BC and then miss a dose, what is the window and time to use back up

A

Miss dose window of 3 hours

And 48 hours of back up contra

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28
Q

What is the advantage of using progestin only BC

A

No risk of VTE or ADE in CV pts

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29
Q

What are the approaches to starting progestin only BC

A

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

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30
Q

What are the ADE of progestin only BC

A

Increased bleeding/ spotting and wt gain

But there is no associated VTE, or HA

May have more androgen effects

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31
Q

What are the 4 generations of Progestin only BC and the specifics of each

A 
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)
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32
Q

How long after the stop of COC is a woman fertile

A

1-3 months

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33
Q

how long after injection BC is a woman fertile again

A

10 months

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34
Q

How long after an implant in removed is a woman fertile again

A

1 month

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35
Q

When should a woman use the Patch for BC

A

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)

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36
Q

How should a woman use the nuvaring

A

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

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37
Q

How can a woman use the depo shot BC

A

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

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38
Q

What pts can not get a copper IUD

A

Known or suspected cancer, STD within 3 months, currrently pregnant, allergy to copper, small uterus lesss than 6 or greater than 9 cm

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39
Q

What pts can not get an hormone IUD

A

Pts with a history of PID, multiple partners , post partum in the last 3 months to include abortions, or actively preg.

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40
Q

What are the ADE of hormone BC

A 
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)

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41
Q

What are the high risk pts for starting BC

A

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

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42
Q

What are the drug classes that decrease BC

A 
Anticonvulsant 
Anti infectious (rifampin) 
ABX (broad spec) 
St Johns wart 
Garlic
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43
Q

What are the two kinds of emergency BC

A 
Plan b ( used asap up to 72 hours) 
And Ulipristol (Rx)
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44
Q

What is Yaz and what is its major ADE

A

Drospiridone and it causes PE

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45
Q

What is the onset of menopause

A

At the end of a woman’s menses

Usually 51 y/o

LF and FSH run high with an unresponsive uterus

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46
Q

How do we decide to start a pt on Menopause Horm. Tx

A

Look at HPI

Look for Cancer RSK, Cv RSK , HTN, VTE risk

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47
Q

How long should hormones therapy be used in menopausal women

A

No more than 5 years

Optimal 2-3 years

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48
Q

What is MHT

A

Menopausal hormone therapy

Can decrease pain during sex
Decrease hot flashes
Decrease Bone loss

ADE: increased CV risk, VTE, and CA

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49
Q

What is the MHT approach to a woman with an intact uterus

A

EE only

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50
Q

What is the MHT approach to a woman with out a uterus

A

EE plus progestin

Example medrosyprogestrone, that can lower RSK of CA, increased the efficacy of Estrogen, but also increase wt gain

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51
Q

What is the F/u criteria for MHT

A

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

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52
Q

What is the role of progesterone in the body

A

Conception and maintain pregnancy

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53
Q

What is the diff of Cyclic vs Continous MHT

A

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

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54
Q

How do you recognize a progestin product

A

End in -drones, or have -gest- in them

Also remember megestrol

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55
Q

What is the major benefit of using Micronized progesterone

A

Can prevent endometrial hyperplasia in women that are post menopausal

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56
Q

What is bazedoxifene

A

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

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57
Q

What are some non hormonal options for post menopausal women

A

Lube for sex
SERMS
SSRI- paroxetine to Tx hot flashes

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58
Q

What are some herbal tx for menopause

A

Red clover
SOY (no data)
Black cohosh (limit use)

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59
Q

What are ospenifine, tamoxifen, and raloxifine

A

SERMS

ADE: CV risk, Hot flashes, DVTs

Non hormonal txs for menopausal women

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60
Q

What can ospemifine treat

A

Is a SERM used to tx painful intercourse when added with progetrin

Do not use in CA pts

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61
Q

What is Tamoxifen used to treat

A

Used to treat Cervical Cancer!

Can have increased Hot flashes!

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62
Q

Can you used SERMS is pregnant pts, or premenopausal women

A

NO!

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63
Q

Rolaxafine has what positve effect on menopausal pts

A

Increased bone health

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64
Q

What is the role of clomiphene

A

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

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65
Q

What is the role of letrozole, anastrazole, and exemestone

A

Aromatase inhibitors

Indicated for the advanced tx of estrogen dependent breast cancer

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66
Q

What are the DOC for advanced stage breast cancer that is estrogen dependent

A

Letrozole (Femara)
Anastrozole (Arimidex)
Exemestane

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67
Q

What are the approved Tx that testosterone can be used for

A 
Osteoporosis(senile) 
And Anemia 
RHT 
Hypopituitary 
And Breast Cancer
 Endometriosis
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68
Q

What is the role of mifepristone

A

Can TERMINATE a pregnancy or endure ABORTION at 70 days gestation

Also can treat hyperGL in a DM pt with cushings

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69
Q

What are the ADE of Test

A 
Raises LDL 
Lowers HDL 
Priapism 
Acne 
Gyno 
Stunted growth 
Masculinization

Do not apply any test treatment to the scrotum

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70
Q

What are two drugs that can be used both as replacement test and to treat carcinoma of the breast

A

Fluoxymesterone and methylestosterone

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71
Q

What is the androgen than can promote wt gain in pts with underlying protein def. / breakdown D/o

A

Oxandrolone

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72
Q

What is the androgen than can tx anemias with underlying RBC def production

A

Oxymethalone

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73
Q

What is the MOA and C/U on Danazol

A

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

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74
Q

What is the role of antiandrogens and Androgen antagonists

A 
Clinical Use:
Prostate Cancer
Endometriosis
Advanced Breast Cancer
Female hirsutism
Alopecia
Acne
Precocious puberty in males (covered in previous lectures)
Benign Prostatic Hypertrophy
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75
Q

What is the Tx approach to BPH

A

Using either Alpha blockers
(-zosin, sulosin)

Or 5a reductase Inh ( Finasteide)

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76
Q

How does finasteride work

A

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

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77
Q

What is the Tx approach to male ED

A

Can use PDE5 drugs like viagra, (verdenafil/ sildanafil/ avanafil/ tadalifil)

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78
Q

What are the ADE of PDE5 drugs

A 
Vasodilation effects 
Congestion 
Flushing 
HA 
Vision Ect

Do not combine with nitrates

Caution use if A-blockers
(Use tamsulosin)

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79
Q

What is aprostadil

A

Ed injection or urethral pellet

Can not have a Hx of priapism

Injection or pellet directly into the penis

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80
Q

What is the approach to Female sexual dysfunction

A

Lubricants for sex
Body image
Testosterone creams

Rx: Flibanserin

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81
Q

What is flibanserin

A

Female sex drug

Causes increased libido through and unknown mechanism

Tx for hypoactive sex d/o

ADE: HOTN, Syncope,
Do not combine with alcohol

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82
Q

What is the building block for all hormones

A

Cholesterol, made in your sleep

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83
Q

What specific steroids are made in the adrenal glands

A

G: Mineralcorticoids (aldosterone

F: Corticol

R: Androgens

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84
Q

When shoud glucocorticoids be taken

A

In the morning to mimic natural steroid release

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85
Q

What is CBG in relation to glucocorticoids

A

Corticosteroid binding globulin

Binds about 90% of glucocorticoids

Can be increased by pregnancy and decreased by hypothyroid or protein def,

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86
Q

What are the major effects of glucocorticoids in the body

A

Hyperglycemia can occur

Hematopoietic effect on white blood cells, and can increase HbG, platelets, and leukocytes

And Antiimflammatory by blocking arachadonic acid

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87
Q

What is the perferred steroid in Adrenal Insf.

A

Hydrocortisone

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88
Q

What is the Steroid OC for asthma

A

Prednisone/ Predisolone

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89
Q

What is the steroid to use for the acceleration of lung maturation

A

Dexamaethsone or betamethasone

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90
Q

What is the steroid OC for COPD

A

Methylprednisone and Prednisone

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91
Q

What is the Steroid OC for Connective tissue/ Rhematic disorders

A

Prednisone

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92
Q

What is the Steroid OC for N/V for rads and chemo Tx

A

Dexamethasone IV

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93
Q

What is the steroid OC for IVY/OAK/ sumac

A

Prednisone

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94
Q

What is the role of systemic steroids in asthma

A

Rapid response during an exacerbation ( IV)

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95
Q

Are glucocorticoids potassium reducing drugs?>

A

Yes

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96
Q

What are the common ADE of glucocorticoids

A

Acute: face flushing, GI irritation, HA, mood swings, Hyoperglycemia

Long term:
Osteoporosis, glaucoma, central obesity, growth suppression, HTN, edema, Hypokalemia , Immunsuppresion

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97
Q

How do you do a steroid taper

A

5-20% reduction every week over 1-2 weeks

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4
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98
Q

What level of steroids is likely to cause HPA suppression

A

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

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99
Q

When do you not use Topical steroids

A

Warts, fungal infections, ulcers, Rosacea, or Acne Vulgaris

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100
Q

What potency is Augmented Betamethasone Diproprionate 0.05 %

A

Very High Potency

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101
Q

What are the Three very high potency steroids

A

Clobetasol proprionate

Augmented Bethamethasone disproporionate OINTMENT AND GEL

Fluconinide

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102
Q

Which is more potent

Lotion/ Cream

Or Oint/Gel

A

Oint Gel is more

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103
Q

What are the 4 high potency steroids

A

Augmented Betamethasone LOTION and CREAM

betamethasone (not augmented) 0.05% OINTMENT

Triamcinolone

Flucinonide 0.05%
(Note that 0.1% is very high potency)

104
Q

What potency is hydrocortisone

A

LOW LOW LOW

105
Q

What potency is Desonide steroid?

A

LOW potency

106
Q

Where should ointments not be used

A

DO not use on Hairy areas

107
Q

When are creams best to use

A

Not as potent and dry clear after application

108
Q

What type of steroid is good on hairy areas

A

Lotions, Gels, and Foams

109
Q

What is the scale that determines steroid strength

A

Grade 1 (high) to 7 (low)

110
Q

When should a very high potency steroid be used

A

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)

111
Q

When should we use low potency steroids

A

On high sensitive areas like the face , armpits, folds of skin ect

112
Q

When can we use Flucocinonide

A

It’s high potency, do not use longer than 3 months

113
Q

Rank the following oral steroid strengths

Prednisone 
Methylprednisolone 
Prednisolone 
Hydrocortisone 
Triamcinolone 
Dexamethasone
A 
Hydro (weakest) 
Pred
Predisolone 
Methyl 
Tri 
DEXA (strongest)
114
Q

What level of action is prednisone steroids

A

Intermediate acting

Stronger than hydro but weaker than DEXA

115
Q

What is the DOC for adrnocortical insufficiency

A

Hydro/ Cortisone

116
Q

What is Ketoconazole

A

Corticoide anatagoinst

Used to treat fungal
And also cortisone excess ( cushings)

Can cause gyno

117
Q

What pts for we use aldosterone in

A

Addisons pts

118
Q

What stops drugs from making it to the blood stream through the skin

A

Stratum Corneum

rate limiting step for skin absorption

119
Q

What are things that impact topical efficacy of drugs

A 
Skin permeability 
Dosage 
Thickness/ presence of stratum corneum (burns) 
Hydration status
Age ( more in kids) 
Frequency of application 
Occluding ( increase absorption)
120
Q

Using Ointments on hairy areas can cause..

A

Foliculitis and acne

121
Q

Aerosols are best to use on what body part

A

Good for application to the scalp or hairy areas

122
Q

Where should pastes not be used

A

Weeping lesions or hairy areas

123
Q

What are the stages of dermatitis

A

Acute: wet lesions, blisters, oozing

Subacute: crusts/ scabs over the wet lesions

Chronic: dry and thickened, lichenified

124
Q

What is the tx approach to contact dermatitis

A

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)

125
Q

What is seborreic dermatitis and tx>?

A

Eczema

Anti fungals (fluconazole) and low dose steroids

126
Q

What is the tx approach to atopic dermatitis

A

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)

127
Q

How do Topical immuno modulators work ?

A

Inhibit T cell activation in inflamed skin by blocking cytokines (interlukings, Interferons)

—pimecrolimus
—tacrolimus

128
Q

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

A

TIMS : pimecrolimus or tacrolimus

Look out for skin burning/ warmth or flu like s.s

129
Q

What is the Black box warning of TIMS

A

Rare skin cancer or lymphoma

Limit to short term use only (6 weeks)

130
Q

What is the Tx approach to impetigo

A

ABX : Mupirocin or systemic ABX like Dicloxacillin

131
Q

What is the tx approach to acne vulgaris

A
  1. Normalize the follicular keratinization (open the pore)
    - benzoyl peroxide
    - Retnoids
    - Azelaic acid
  2. Decrease sebum production
    - retnoids
    - hormone manipulation
  3. Suppress bacteria
    - ABX
    - benzoyl peroxide
    - retnoids
    - azelaic acid
  4. Prevent inflammation
    - ABX
    - retnoids
132
Q

What is the bacteria that cause acne

A

Proprionibacterium acnes

133
Q

How long should we treat acne before seeing improvement

A

1-2 months

134
Q

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 >?

A

Acne rosacea

Avoid: skin care products with drying agents

ABX of choice is metronidazole

If persistent use brimonidine gel

135
Q

How does Benzoyl peroxide work

A

two mechanisms (makes it the best acne drug option )

  1. Antibiotic
  2. Irritant to inhance skin turnover

Reduced 75% of acne in 8 weeks

136
Q

What can you add to Benzoyl peroxide to enhance it for acne

A

Topical erythromycin

137
Q

What are the topical ABX that can be used in Acne Treatment

A

Clindamycin
Erthyromycin
+/- benzoyl

Limit use to less than 8 weeks to avoid psuendomonas colitis

138
Q

What are the systemic ABX that can be used for Acne

A

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

139
Q

What is the MOA and C/u of retnoids

A

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)

140
Q

What kind of drug is tretinoin, adapalene and Tazarotene

A

Topical retinoids

141
Q

What is the oral retinoid for acne vulgaris ( very severe)

A

Isotretinoin (High ADE and PregX

142
Q

What must be told to the pt taking Isotretinoin

A

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

143
Q

What is azelaic acid used for

A

To treat rosacea With minimal toxicity

Can cause pruritus, stinging, and tingling , with darkening complexion!!!
WARN PTs

144
Q

When would you use brimonidine in the treatment of rosacea

A

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)

145
Q

A pt presents with silver, scaling skin lesions

What is the Dz and Tx/>

A

Psoriasis
(Inflammatory mediators cause inflammation in the skin)

Tx:
Target those mediators
Topical agents, UVB, and oral agents

146
Q

What are the degrees of severity of psoriasis

A

Mild: less than 5%
TX w topical Tx
And UV tx

Mod-severe: 5-10%
Tx with topical, UV and systemic Tx

147
Q

What is the 1st line treatment to mild to mod psoriasis

A

Topical steroids

(Add with vit D anaolgs to decease ADE)

Limit use for 2-4 weeks with high potency agents

148
Q

How do we use coal tar in psoriasis tx

A

Use in mild to mod

Warn pt about the weird smell

Consider in pts that can afford Rx options

MAJOR ADE: cancer in rabbits!!

149
Q

What is the common words in Vit D3 agonist and what are they used for

A

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!

150
Q

What is the MOA and C/U for Tazarotene

A

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

151
Q

What oral retinoid is used to treat psoriasis

A

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!!!

152
Q

What is the role of cyclosporine in psoriasis tx

A

Can be used in combo with Vit D3 analog

Can caused nephrotoxic, skin cancer

153
Q

What is the PDE4 inhibitor that can be used for psoriasis

A

Apremilast

Can be used in pts with photo Tx

Has a Low ADE profile

154
Q

What is the folic acid antagonist that can be used in psoriasis

A

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)

155
Q

What is the reversal agent for methotrexate

A

Folic acid (luecovorin)

156
Q

How do biological agents (Humira) work against psoriasis

A

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

157
Q

What are the two vaccines to prevent HPV

A

Cervarix and Gardasil

158
Q

What are the options to TREAT HPV

A 
Salicylic Acid 
Podofilox 
Podophylium 
Imiquimod
 (externally only for genital warts) 
DUCT TAPE

Or Cryotherapy

159
Q

What is the MOA and Clin use of Imiquinod Cream

A

Immuno modulator that can externally treat warts (HPV)

160
Q

What can happen if you incorrectly apply Podofilox or Pdophyllum to a Wart (HPV)

A

Tissue necrosis

161
Q

What are the two types of allergic rhinitis (chronic)

A

Intermittent or persistent

162
Q

Define allergic rhinitis

A

IgE mediated inflamation in the nares

163
Q

What are the 5 main triggers of allergic rhinitis

A 
Molds
Pollens 
Dust mites 
Animal Dander 
Insect allergens
164
Q

When is the late phase response of allergic rhinitis

A

2-12 hours after exposure

165
Q

What is the difference between intermittent vs persistent allergic rhinitis

A

Intermittent: less than 4 days a week or less than 4 weeks total

Persistent: more than 4 days or more than 4 weeks

166
Q

What is the classification of mild vs mod-severe allergic rhinitis

A

Mild: normal sleep, no limitations

Moderate: sleep d/o, disturbing daily life, s/s at workplace or school

167
Q

What is the Tx approach to allergic rhinitis

A

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)
168
Q

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?

A
  1. In steroid (Flonase)
  2. Oral antihistamines or LTRA

Add on Ipatropium for rhinorrhea
And add on Oral decongestant or steroid burst for blockage

169
Q

What is the difference between 1st and 2nd gen antihistamines

A

1st are sedative

2nd non sedative

170
Q

What are the Major ADE of 1st vs 2nd gen antihistamines

A

1st: drowsiness
2nd: HA

171
Q

1st gen antihistamines can cause what effect in children

A

Paradoxical hyperactivity

172
Q

What are the high sedation 1st gen antihistamines

A

Diphenhydramine and Promethazine

173
Q

What is the preferred antihistamine in pregnancy

A

Chlopheniramine

174
Q

List the 1st gen Anithistamines

A 
Bromphenirarime 
Chlopheniramine 
Diphenhydramine 
Promethazine 
Hydroxyzine 
Meclizine 
Cyproheptadine
175
Q

List the 2nd gen Antihistamines

A 
Fexofenadine 
Loratadine 
Desloratadine 
Cetirizine 
Levocertirizine

Intranasal:
Azelastine (crosses the BBB more)
Olopatadine

176
Q

How long should decongestants be used

A

Limit use to less than 10 days to prevent round congestion

3-5 days is ideal

177
Q

Can you take decongestant with MAOI

A

Must take 2 weeks apart

178
Q

How do decongestants work

A

vasodilation through A1 agonist

179
Q

What are the ADE of decongestant

A

Increased BP that can increased stroke, CNS stimulation, Urinary retention, increased gl, rhinitis medicamentosa (rebound)
Increased ocular pressure
Nasal irrational

180
Q

What are the C/u of phenylephrine

A

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

181
Q

What is the generic name for Afrin/ visine and what do we use it for

A

Oxymetazoline
Can be used in the eyes or nose to vasocon and decrease congestion

(Limit use to avoid rebound)

182
Q

What receptors does Pseudoephedrine act on

A

Direct acting A and B agonist, while also displacing NE from storage sites

183
Q

What pts should not receive decongestants (psuedofed)

A 
Heart Dz 
HTN 
Thyroid Dz 
DM 
Glaucoma 
BPH
184
Q

What are the option for pts who need decongestant but cant take psuedofed

A

Coricidin !
Nasal strips
Or Intranasal saline

185
Q

What are the two oral and two intranasal decongestants

A

Oral: phenylnephrine and Psuedoephedrine

Intranasal: Oxymetazoline(Afrin) and Phenylephrine (Neo)

186
Q

How do Leukotriene antagonist work

A

AKa montelukast

Inhibit inflammatory mediators (cysteinyl)

IS comparteble to antihistamines

Safe in pregnant pts

187
Q

How long should Intranasal steroids be used

A

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

188
Q

How do we use oral burst therapy in Allergic rhinitis

A

Short course prednisone can be used for severe/ debilitating rhinitis

189
Q

What is the perferred INS in pregnancy

A

Budesonide

190
Q

What are the two INS that are most likely to cause growth suppression

A

Beclamethasone

Flunisolide

191
Q

What is the role of Ipatropium?

A

Muscarinic blocker to dry up secretions

192
Q

What is the DOC for pregnancy rhinorreha and sneezing

A

Cromolyn

193
Q

What is the MOA of Cromolyn

A

Inhibits mast cell degranulation

194
Q

Can you use cold compresses for conjunctivitis

A

Yes, they effectively reduce itching

195
Q

What is the step wise managment for conjunctivitis

A

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

196
Q

What are the two non selective ocular antihistamines for conjuctivitis

A

Azelastine or levocabastine
(H1 receptor)

May cause stinging, dry eye, HA, bitter taste

Do not use in glaucoma pts

197
Q

What are the two selective ocualr antihistmines

A

Ketotifen and Olopatadine (Rx)

2nd gen H1 blocker

198
Q

What are the three ocular decongestants for conjunctivitis

A

naphazoline
Oxymetazoline
Tetrahydrozoline

All end in -zoline

199
Q

What is the only ocular NSAID

A

Ketorolac

Has a 5 day limit for use!
May cause an asthma attach in pts with ASA

200
Q

What is the ocualr steroid

A

Loteprednol

Can cause increased infections

201
Q

Define chronic bronchitis

A

Excessive mucus production x 3months over 2 years

202
Q

Classify GOLD 1-4 for COPD

A

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

203
Q

What are the non pharm tx for COPD

A

Excercise, supplemental O2 (88)

Reduce exposure to irritants

204
Q

What is the MGMT approach to stable COPD

A

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

205
Q

What are the 4 principle bronchodilators

A

B2 agonists
Anticholinergics
Theophylline
Combo Tx

206
Q

What is the role of Ipatropium bromide

A

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

207
Q

What is the role of Tiotropium Bromide

A

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)

208
Q

What are the SAMAs and LAMAs

A

SAMA: Ipatropium

LAMA: Tiotropium
Glycopyrronium
Aclidinium
Umeclidinium

209
Q

Do steroids modify the progressive decline of FEV1 or decrease mortality in COPD

A

NO!

They do increases the risk of pneumonia tho!

210
Q

What is the role of theophylline

A

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

211
Q

What is Roflumilast

A

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

212
Q

When should pts with impaired lung function get the pneumococcal vaccine

A

At diagnosis and if older than 65 if they have had the IM in the last 5 years

213
Q

What empiric ABX can be used in COPD pts

A

Azithromycin and Erthryomycin

Increased risk of resistance

214
Q

What is the tx approach to acute COPD exacerbation

A

O2 (sat greater than 90)
NIPPV

Plus Bronchodilator (SABA) 
Burst Steroid Tx

Antibiotics x 7-10 days

215
Q

What is the pathology of Asthma

A

Allergen activated T cells which reales cytokines with then lead to B cells and eosinophils increasing inflammation and bronchconstriction

Aka mucus and bronchcon

216
Q

In pts older than 12 years of age, what medication can be used at a pre treatment to excercise or allergen exposure in asthma

A

Inhaled BA, montelukast, or nedocromil

217
Q

Define intermittent asthma

A 
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

218
Q

Define Mild asthma

A

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

219
Q

Define Moderate persistent asthma

A

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

220
Q

Define Persistent Severe Asthma

A

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%

221
Q

What is STEP one NON Gina asthma Tx

A

used for pts with intermittent asthma

No long term controller needed
SABA PRN

222
Q

What is Step 2 non Gina Tx for asthma

A

Used for mild Asthma

Low dose ICS
With Saba PRN

223
Q

What is step 3 Non Gina Asthma Tx

A

Low dose ICS plus LABA
Or (medium ICS alone)
With PRN SABA

For persistent mod asthma pts

224
Q

What is step 4 non GINA asthma Tx

A

For Persistent Mod Asthma
Medium Dose ICS plus LABA
Can Add LAMA if uncontrolled

225
Q

Step 5 Non Gina Asthma Tx

A

For persistent Severe asthma
High Dose ICS plus LABA
Consider omalizumab
Add on LAMA if still uncontrolled

226
Q

Step 6 Non Gina Asthma Tx

A

For persistent severe asthma

High Dose ICS plus LABA
Plus steroid burst
And consider omalizumab for allergic asthma
LAMA if still uncontrolled

227
Q

Pts with persistent mod and beyond asthma should receive what inhaler

A

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
228
Q

Define well controlled asthma

A

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

229
Q

Define Not well controlled asthma

A 
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

230
Q

Define VERY POORLY controlled asthma

A

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

231
Q

What is the approach to asthma tx

A

First determine severity, then determine control and need for what step vs step up step down

232
Q

What is the major GINA Asthma change

A

Rescue inhalers are ICS and formoterol instead of SABA

233
Q

What is the approach to tx EIB

A

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

234
Q

What is the DOC for acute bronchospasm

A

SABA

Albuterol and Leavlbulteroll

235
Q

What is the black box warning for LABAs

A

Increased risk of death in Asthma, take to long to onset

236
Q

What are the 1st line anti- imflammatory drugs in asthma

A

Steroids (inhaled)

237
Q

What is the role of Cromolyn in asthma tx ?m

A

mast cell stabilizer
Anti Inflamation

Alternative medication for MIld persistent asthma instead of increasing steroids

238
Q

What is the role of omalizumab in asthma

A

Anti IgE monoclonal antibody

Add on tx for mod- severe asthma that is not already controlled with an ICS

239
Q

What is the role of Montelukast/ zafirlukast in asthma

A

Inhibit cyteninyl leukotriene

In mild persist at or combo in moderate asthma ass on tx

240
Q

What is the major ADE of montelukast

A

Liver problems, so D/c med if jaundice

241
Q

What is the role of zileuton PO in asthma

A

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

242
Q

When would you use Anitcholinergics in asthma

A

in pts that cant use beta agonist in asthma

Never as monotherapy

(Ipa/ Tiotropium)

243
Q

How do you treat a mild asthma exacerbation

A

SABA at home, not an emergency

244
Q

How do you treat a moderate exacerbation of asthma

A

If FEV1 50-69% then start O2
And use a SABA

Start short course OCS

245
Q

What is the tx for a severe asthma exacerbation

A

FEV1 less than 50 then
ADMIT!
Start a Saba
And failure to respond to tx within 2 hrs start steroids

246
Q

IN a pts with an FEV1 less than 25 percent what do we do

A

ADMIT immediately

Give IV steroids!

247
Q

If a pt is on an ICS and has an exacerbation what should we add on to their tx

A

Short course pred. (Burst steroid)

248
Q

What is the major ADE of bupropion

A

Homicidal ideation

249
Q

How does varencline work

A

Partial agonist at the nicotinic receptor

250
Q

What is the tx approach to osteoporosis

A

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

251
Q

What is the MOA of -dronate drugs

A

Block Osteoclasts

252
Q

What is the osteoporosis drug specific to women

A

Ibandronate

253
Q

What is the use of Denosumab

A

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

254
Q

What is the role of calcitonin in Osteoporosis

A

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

255
Q

What is the role of teriparatide in osteoporosis

A

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

256
Q

If a pt has osteoporosis and cant take bisphenophosphate rx

What is the alternative

A

Raloxifene

For post menopausal women aged 50-60

257
Q

What is the cycle of osteoclasts to osteoblasts

A

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.

IPAP JUNIOR SEM. (43 decks)

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