Pharm Reproduction Exam 2 Flashcards
Menopause and non hormonal therapy
The best studied agents with positive results include
SSRI SNRI Anti epileptics Clonidine Oxybutynin Centrally acting drugs
MHT
Menopausal hormone therapy (MHT)
Broad term that describes unopposed estrogen use for women who have undergone hysterectomy,
and
combined estrogen-progestintherapy (EPT) for women with an intact uterus who need a progestin to prevent estrogen-associated endometrial hyperplasia.
The primary goal of MHT is to?
Relieve vasomotor symptoms (hot flashes).
Other symptoms associated with perimenopause and menopause that respond to estrogen include
sleep disturbances, depression/anxiety, and, in some cases, joint aches and pains.
Standard recommendations of use of MHT
3 to 5 years
Extended use can be done in severe or persistent cases
Which types of estrogen are good for hot flashes
All types of estrogen are equal for hot flashes
17 beta estradiol is preferred
structurally identical to estrogon secreted by ovary
Estradiol indications
Estrace (estrogen)
Moderate-to-severe vasomotor symptoms of menopause. Atrophic vaginitis. Hypoestrogenism. Osteoporosis prevention.
Estradiol
Contraindications
warnings
Contra Breast or estrogen dependent cancer Thromboembolic disorders Undiagnosed abnormal genital bleeding Preg CAT X
Warnings
Increased risk of endometrial carcinoma or hyperplasia in women with intact uterus (adding progestin is essential).
Increased risk of cardiovascular events (eg, MI, stroke, VTE); discontinue if occurs. Manage risk factors for cardiovascular disease and venous thromboembolism appropriately.
Breast cancer, endo cancer, thrombo, preg, CV, bleed
Estradiol
Box warnings
Box Warnings
Endometrial cancer
Breast cancer
Cardiovascular disorders
Probable dementia
Estradiol Pregnancy category
CAT X
Amenorrhea (primary)
Absence of menses at age 15
in the presence of normal growth and secondary sex characteristics
Secondary amenorrhea
Absence of menstruation for 6 months or more
or a period of time of 3 consecutive cycles
in a woman who was previously menstruating
Secondary amenorrhea Causes
Pregnancy is most common cause
Drug use stress Significant weight changes Excessive exercise Asherman syndrome PCOS
2 types of dysmenorrhea
Primary and secondary
Primary dysmenorrhea
Natural uterine contractions due to high prostaglandin concentration, aimed at shedding its lining
Begins 1st day of period
lasts 8-72 hours
Lower abdomen (radiate to legs and back)
Improves with age
Common and normal
Secondary Dysmenorrhea
Endometriosis
Uterine fibroids
PID
Begins 1-2 days before period
Lasts for over 3 days
Lower abdomen (radiate to legs and back)
Gets worse with age
Indicates reproductive tract disease
Which type of dysmenorrhea gets better with age
Primary dysmenorrhea
Dysmenorrhea treatment goal
Relief of pain
Should allow women to perform usual activities
Primary dysmenorrhea can be treated empirically
Dysmenorrhea resistant to treatment
NSAIDS
Hormonal contraceptives’
are mainstay of treatment
Dysmenorrhea resistant to treatment
NSAIDS
Ibuprofen 400-600 Q6 or
Ibuprofen 800 Q8
If no relief
mefenamic acid (Fenamate) 500mg loading dose 250mg Q6 x 3 days
Mefenamic acid
Ponstel (NSAID)
Dysmenorrhea
Contra
Aspirin allergy, CABG
Risk of serious cardiovascular and GI events
PMS First line and don’t want contraception
SSRI is first line
for moderate to severe
who do not contraception
PMS Treatment who don’t respond to SSRI
COC Combination oral contraceptives
If cannot tolerate COC or SSRI
GNRH trial
(Leuprolide)
COC, Leuprolide
Leuprolide
Lupron Depot (GNRH analogue)
Endometriosis (pain/lesions)
Contra
Vaginal bleeding, Pregnancy, Nursning
Adverse
Hot flashes, HA, Decreased libido, Depression, Dizziness, NV, Pain, weight change, Vaginitis, Amenorrhea, Acne, Bone density loss
therapies for PMS
SSRI
Ovulation suppression agents
COC (20/90), (20/3)
GNRH (Leuprolide)
Alprazolam (not recommended)
PID treatment
Inpatient
Cefoxitin/Cefotetan and Doxy
or
Clinda plus Genta
Outpatient
IM ceftriaxone plus
Doxy 14d
Flagyl 14d
Cervical cancer Types
Squamous cell carcinoma
Adenocarcinoma
Endometrial cancer
Affects postmenopausal women almost exclusively
Endometrial hyperplasia drug causes
Tamoxifen
Prevention for ovarian cancer
OCP (oral contraceptive pills)
Decreases risk of developing ovarian cancer
especially in young women who have used it for several years
If used for over 5 years, 50% less chance of ovarian cancer
First trimester abortion medication
Mifepristone (progesterone antagonist)
in combination with
Misoprostol (Synthetic Prostaglandin e1)
Can be used up to 70 days gestation
Routinely used up to 77 days (11weeks)
M&M
Mifepristone MOA
Blocks progesterone receptors on the uterus
Misoprostol MOA
Stimulates Uterine contractions
Mifepristone
Mifeprex (abortifacient)
Contraindications
Ectopic, Adnexal mass, IUD, Adrenal failure, Prostaglandin allergy, Bleeding disorder, Porphyria’s, long term steroid or anticoagulants
Box warning
Serious/fatal infection or bleeding
Misoprostol
Cytotec (prostaglandin analogue)
Contra
Pregnancy
Warning Abortifacient properties (don't give to others)
Adverse
Diarrhea, abdominal pain, HA, Gyn Effects, Abortion, Birth defects, uterine rupture, premature birth
Abruptio Placentae
If less than 34 weeks with no evidence of major blood loss or coagulopathy
Conservative management until 37-38 weeks
Use antenatal corticosteroids
Oxytocin
Pitocin
Improve uterine contractions, abortion adjunct, control postpartum bleeding
Contra
In antepartum
Cephalopelvic disproportion
Unfavorable fetal position
Box warning
Not for induction of labor
Oxytocin MOA
Activates G protein coupled receptor IP3
Increases intracellular calcium
Increases local prostaglandin production
Ectopic pregnancy
Extrauterine pregnancy
96% in fallopian tubes
Can be treated with
Methotrexate
Surgery
or expectant management
Methotrexate MOA
Interferes with DNA synthesis by inhibiting synthesis of pyrimidines leading to trophoblastic cell death
Auto enzymes and maternal tissues then absorb the trophoblasts
Gestational diabetes Treatment
Insulin is first line
If cannot take insulin
Glyburide or metformin
Placental passage effects are unknown
Gestational diabetes test
Fasting = 95
1 hour after glucose = 180
2 hours after = 155
3 hours after = 140
100mg glucose load (drink)
Gestational trophoblastic disease
Low risk GTN = single agent chemo
Methotrexate over dactinomycin
Anti HTN Pregnancy meds
Labetalol - BB (combined Alpha/beta blocker)
Hydralazine - Peripheral vasodilator
Nifedipine - CCB
Nicardipine - CCB
Methyldopa - Centrally acting alpha agonist
Incompetent cervix
If prior spontaneous preterm birth
Progesterone at 16-20 weeks through 36 weeks
can be before/during/after cerclage
Corticosteroid MOA
Induces fetal lung antioxidant system
Regulates gene function in maturing lung
Induces pulmonary beta receptor
Increases surfactant production
Improves lung mechanics and gas exchange
Upregulates gene expression of Na channel
Accelerates development of type 1/2 pneumocytes
Induces production of surfactant protein
Induces production of phospholipid synthetase
Primary Post partum Hemorrhage
Primary PPH Occurs 24 hours after delivery
Causes
Atony, Trauma, acquired/congenital coagulation defects
Secondary Post partum hemorrhage
Secondary PPH occurs after 24 hours to 12 weeks after delivery
Causes
Atony, Trauma, acquired/congenital coagulation defects
4 T’s of post partum hemorrhage
Tone (atony)
Tissue (retained placenta)
Trauma,
Thrombin (coag)
Post partum hemorrhage
First line Treatment
Uterotonic Agents
Oxytocin
Ergot alkaloids (Ergometrine, Methyl ergonovine)
Prostaglandins (misoprostol, Dinoprostol)
Tranexamic acid
TXA (Lysteda) (antifibrinolytic)
Cyclic or heavy menstrual bleeding
Not recommended for children (Pre menarche)
Contra
Active/ history of thromboembolic events
Combination oral contraceptives
TXA MOA
Antifibrinolytic
Inhibit the activation/action of plasmin
Stops conversion of plasminogen to plasmin
Premature rupture of membranes vs PPROM
PROM >37 weeks
PPROM <37 weeks
Premature rupture of membranes
managment
for stable patients <34 weeks
Expectant management
Antenatal steroids to reduce morbidity and mortality if preterm labor occurs
Prophylactic ABX
IV Ampicillin 2g q6 for 48 hours then,
Amoxicillin 875mg PO BID x 5 d
Also give 1g azithromycin PO on admission
Steroids & AAA
Rh Incompatibility
Signs and symptoms
Hemolysis Jaundice Anasarca Resp Distress Circulatory collapse Kernicterus
occurs several days after delivery
Has poor feeding
Decreased activity
Rhogam
Contra
RH positive patients
Preventing Rho(D) sensitization in nonsensitized Rho(D) negative or Du negative patients to the Rho(D) factor, following pregnancy or accidental transfusion. - - - - - RH neg mom, RH pos baby, mom builds AB, If 2nd bay is RH pos, moms AB will attack babies blood cells
Estrogen and progesterone are two types of?
Female sex hormones
Estrogen and progesterone are both?
Steroid hormones
part of Contraceptive mix of birth control pills
Estrogen and progesterone are secreted?
During menstrual cycle
and play a role in pregnancy
Difference between Estrogen and progesterone
Secretion
Estrogen is secreted by ovaries prior to ovulation
Also produced by placenta
Progesterone Secreted by ovaries after ovulation Also produced by placenta - - - - Estrogen before, Progesterone after ovulation
Difference between Estrogen and progesterone
Regulation
Estrogen is regulated by FSH
Progesterone is regulated by LH
Difference between Estrogen and progesterone
During pregnancy
Estrogen is involved in the enlargement of uterus and breasts
Progesterone is involved in the reduction of contractility of the uterus and the growth of the mammary glands
Example of endogenous Estrogen
Estradiol
Example of Exogenous estrogen
Ethinyl estradiol
Progestins used in contraceptive pills
First gen
Norethindrone acetate
Ethynodiol diacetate
Lynestrenol
Norethynodrel
Progestins used in contraceptive pills
second gen
Di-norgestrel
Levonorgesterel
Progestins used in contraceptive pills
Third gen
Desogestrel
Gestodene
Etonogestrel
Norgestimate
Progestins used in contraceptive pills
Unclassified
Drospirenone
Cyproterone acetate
Etonogestrel
3rd gen Progestin
Found in Implant and Nuva Ring
POPs
Progestin only contraceptive pills
Good for High risk patients with
CAD, CVD, PE, HTN (also migraines)
When estrogen is contraindicated
Have little effect on Coags, BP, inflammatory markers or lipids
Vaginal contraceptives
etonogestrel / ethinyl estradiol vaginal
Nuva Ring, EluRyng
etonogestrel / ethinyl estradiol vaginal
120mcg/15/mcg per day
Nuva Ring Hormonal contraceptive (Progestin + estrogen)
Insert 1 ring, leave in for 3 weeks, remove for 1 week
Box warning
Smoking increases risk of serious cardiovascular events
Warnings
Smokers, especially over 35
Discontinue if thrombo event
Smoking, thrombo
etonogestrel / ethinyl estradiol vaginal
120mcg/15/mcg per day
Nuva Ring
Contraindications
High risk of arterial or venous thrombotic disease
(eg, smokers or migraineurs over age 35, history of DVT or thromboembolism, cerebrovascular or coronary artery disease, thrombogenic valvular disease, atrial fibrillation, subacute bacterial endocarditis, hypercoagulopathies, uncontrolled hypertension, diabetes with vascular disease, headaches with focal neurologic symptoms).
Breast or other estrogen or progestin-sensitive neoplasms.
Hepatic disease or tumors.
Undiagnosed abnormal uterine bleeding.
Pregnancy. - - - Smoking, thrombo, liver, cancer, preg, bleed
COC
Monophasic
Same amount of hormone in pill every day
Except in placebo pills
Most common type of BC pill
Usually start on low dose to reduce risk of stroke
Switch to higher dose if bleeding or spotting
COC
Biphasic
Amount of hormone may change halfway through cycle
two sets of different strength pills
Progestin changes, estrogen stays same
then have placebo pills
COC
Triphasic
Amount of hormone changes every week
Traditional:
Progestin usually changes and estrogen stays same
3 strengths of progestin (gradually increases)
Similar to bodies natural function
Most common, 7d, 7d, 7d, then 7d of placebo
Estrophasic
Estrogen changes
COC
Quadriphasic
Estrogen and progestin changes
Four varying amounts throughout monthly pack
Levonorgestrel/ethinnyl estradiol
(fayoism, Quarette, Rivelsa)
Estradiol valerate/dienogest (Natazia)
Drospirenone 3mg
Ethinyl estradiol 20mcg
YAZ (progestin + Estrogen)
Pill
Warning
Smoking increases risk of serious CV Events
Contra
Renal, adrenal, Hepatic, High risk VTE/CVD/CAD/Etc, Breast/uterine neoplasm, uterine bleeding, pregnancy
Progestin only oral contraceptives
Norethindrone Drospirenone (Slynd)
Injectable Contraceptive
Medroxyprogesterone acetate
Depo-Provera
Intrauterine Contraceptive Device
Mirena
Mirena (progestin IUD)
Good for up to 6 years
Contra
Uterine anomaly, PID, Postpartum endometritis or septic abortion in last 3 months
Interactions
Antagonized by CYP3A4 inducers
Potentiated by CYP3A4 inhibitors
Caution with anti coags
Adverse
Bleeding pattern changes, Abdominal/pelvic pain, amenorrhea
Medroxyprogesterone acetate
Depo-Provera
Depo-Provera (Progestin)
Injectable contraceptive
Contra
Thrombophlebitis, Stroke, Breast cancer, Liver, Vaginal bleeding, Pregnancy, VTE
Warning
Loss of bone mineral density
Norelgestromin 150mcg/day
ethinyl estradiol 35mcg/day
Patch
Xulane (progestin + estrogen)
Transdermal contraceptive
Apply 1 patch per week for 3 weeks, 1 week off
Box warning
CVD risk with smoking, VTE
Infertility medications
Clomiphene (clomid)
Letrozole (Femara)
Metformin (Glucophage)
Chorionic gonadotropin (Novarel)
Aromatase inhibitors
In patients with PCOS
a double blind trial showed Letrozole was better than Clomiphene
for inducing ovulation and live birth
Labor inducing drugs
Synthetic oxytocin (Pitocin) - Activates oxytocin receptors
Misoprostol - PGE1 analogue
Dinoprostone - PGE2 analogue
Tocolytic Drugs
Nifedipine - CCB
Terbutaline - Beta 2 agonist
Mag sulfate - Unknown (might compete with calcium)
Indomethacin - COX inhibitor
Atosiban - Oxytocin/vasopressin competitive antagonist
Tocolytics
inhibit labor
24-32 weeks gestation
indomethacin is first line for labor inhibition
If cant use indomethacin
Nifedipine
Herbs used in reproduction
Black cohash Fenugreek Maca Red clover Vitex
Herbs
Black cohash
Supports female reproductive system
used for menopause, PMS, painful menstruation, Osteoporosis (weak/brittle bones)
others
Herbs
Fenugreek
Supports the optimal production of breast milk
Herbs
Maca
Supports healthy libido and normal fertility
Herbs
Red clover
A rich source of naturally occurring phytoestrogens
Herbs
Vitex
Supports female hormone production and balance
Especially during transitions of life
Labor induction goals
To delay labor as long as possible
Give steroids for 48 hours <34 weeks
If first drug does not produce contractions,
stop and start next drug
Which of the following classes of medications do not cause galactorrhea secondary to hyperprolactinemia?
1st generation antipsychotic meds
Tricyclic antidepressants
Salicylates
Antihypertensives
Salicylates
Which of the following contraindications is a contraindication for the drug, tamoxifen (Soltamox)?
History of DVT
Pregnancy Category C
Renal impairment
Prolongation of QT interval
History of DVT
Which of the below medications for breast cancer is an aromatase inhibitor?
Tamoxifen (Nolvadex)
Letrozole (Femara)
Raloxifene (Evista)
Estradiol (Estrace)
Letrozole (Femara)
Which of the following medications has a MOA of blocking progesterone receptors on uterus?
Misoprostol (Cytotec)
Oxytocin (Pitocin)
Mifepristone (Mifeprex)
Tinidazole (Tindamax)
Mifepristone (Mifeprex)
Which of the following medications is not used for patients with hypertension in pregnancy?
Labetalol (Trandate)
Lisinopril (Zestril)
Hydralazine (Apresoline)
Methyldopa (Aldomet)
Lisinopril (Zestril)
Which of the following is an example of endo-estrogens?
Estradiol valerate
Estradiol
Ethinyl estradiol
mestranol
Estradiol
Which of the following medications is considered a middle level of androgenic activity of progestins in contraceptive pills?
Norgestrel
Drospirenone
Norethindrone
Desogestrel
Norethindrone
Which of the following terms best illustrates amount of weekly hormone changes every week within OCCs?
Monophasic
Biphasic
Triphasic
None of the above
Triphasic
What are common dosages of oral estradiol (Estrace)?
- 1mg, 0.2mg, 0.5mg
- 2mg, 0.4mg, 0.6mg
- 5mg, 1mg, 1.5mg
- 5mg, 1mg, 2mg
0.5mg, 1mg, 2mg
Which of the following is a contraindication for the drug, mefenamic acid (Ponstel)?
CABG
Acetaminophen allergy
GI tumor
Renal impairment
CABG
Polypharmacy types
Same class (2 or more meds from same class)
Multi class (2 or more drugs from different classes for same symptoms) (i.e. ACE, CCB)
Adjunct (use of one med to treat side effects of another med)
Augmentation (use of one drug at a low dose from one class and another drug from a different class to get full therapeutic dose for same symptoms
How many elderly patients find it difficult to afford meds
24%
What is Area Agency on Agingfacilities
The Federal Government has mandatedArea Agency on Agingfacilities in every county/city.
These agencies have professionals who hold vast knowledge on all things ‘social services for the elderly’ related.
Pharmacokinetics in aging
distribution
Albumin, the primary plasma protein to which drugs bind, is usually lower in older adults.
Because of that, there is a higher proportion of unbound (free) and pharmacologically-active drug.
With aging, there is a decrease in elimination resulting in the accumulation of the unbound drug in the body.
Examples are
ceftriaxone, phenytoin, valproate, warfarin, diazepam, and lorazepam.
Drugs that build up in body due to aging
ceftriaxone, phenytoin, valproate, warfarin, diazepam, lorazepam.
Pharmacokinetics in aging
Elimination
Renal size and bloodflow is decreased
Glomerular filtration declines
Over dose in elederly
An excessive dose of an appropriate drug may be prescribed for older adults if the prescriber does not consider age-related changes that affectpharmacokineticsandpharmacodynamics.
Poor communication in elderly
Poor communication of medical information at transition points
(from one health care setting to another)
causes up to 50% of all drug errors and up to 20% of adverse drug effects in the hospital.
Under prescribing in elderly
Drugs that are often underprescribed in older adults include those used to treat
depression, Alzheimer disease, pain (eg, opioids), heart failure, post-MI (beta-blockers), atrial fibrillation (warfarin), hypertension, glaucoma, incontinence.
BEERS criteria
the American Geriatric Society (AGS)
Beers Criteria®
for Potentially Inappropriate Medication Use in Older Adults
have been a leading source of information about safely prescribing medications for older people.
The AGS Beers Criteria®identify medications with risks that may be greater than their benefits for people age 65 and older.
Drug categories that pose high risk in elderly
analgesics, anticoagulants, antihypertensive, antiparkinsonian drugs, diuretics, hypoglycemic drugs, psychoactive drugs
Elderly prescribing tips
Treat the disease process rather than symptoms
Be cautious about adding new medication
‘Start low, go slow’
Monitor closely for adverse effects
Manage the whole of the patients treatment
regimen
Drug disease interactions
Cardiovascular
Heart Failure
May promote fluid retention and exacerbate heart failure
Cilostazol,
COX-2 inhibitors,
dronedarone
nondihydropyridine CCB’s (diltiazem,verapamil),
NSAIDs,
thiazolidinediones (pioglitazone,rosiglitazone)
Drug disease interactions
CNS
Falls/Fractures
Can cause ataxia, impaired psychomotor function, syncope, and additional falls
Anticonvulsants,
antipsychotics,
benzodiazepines,
nonbenzodiazepine hypnotics
(eszopiclone,zaleplon,zolpidem),
opioids,
TCAs,
SSRIs
Drug disease interactions
CNS
Delirium
Can worsen delirium,
antipsychs can increase stroke risk
Anticholinergics, antipsychotics, benzodiazepines, chlorpromazine, corticosteroids, H2 blockers (cimetidine,famotidine,ranitidine), meperidine, sedative hypnotics
Drug disease interactions
CNS
Insomnia
Can cause CNS stimulant effect
Oral decongestants (pseudoephedrine,phenylephrine),
stimulants (amphetamine,armodafinil,methylphenidate,modafinil),
theobromines (theophylline, caffeine)
Drug disease interactions
CNS
Parkinson’s
Dopaminereceptor antagonists with potential to worsen parkinsonian symptoms
Antiemetics (metoclopramide,prochlorperazine,promethazine),
antipsychotics (except foraripiprazole,quetiapine, andclozapine)
Drug disease interactions
GI
Gastric/duodenal ulcers
Exacerbate existing ulcers or cause new ulcers
Can take PPI
Aspirin(> 325 mg/day),
non–COX-2 selective NSAIDs
Drug disease interactions
Renal
CKD (stage 4) (CrCl <30)
Increased risk of acute kidney injury and further decline of renal function
NSAIDs (non-COX and COX-selective, oral and parenteral)
Drug disease interactions
Renal
Lower UTI/BPH
May decrease urinary flow and cause urinary retention in men
Drugs that have strong anticholinergic effects (except antimuscarinics for urinary incontinence)
