Pharmacology

Question 1

What are the possible adverse effects of ketamine?

Answer 1

• Emesis (8.4)
• Hypersalivation
• Agitation (7.6%)
• Apnea (0.8%)
• Laryngospasm (0.3%)
• Other airway events (e.g. stridor, hypoventilation, desat) (2.8%)

Question 2

What are the clinical symptoms and timing of onset after drug exposure for SJS/TEN?

Answer 2

• Clinical symptoms - prodromal flu like illness, mucocutaneous involvement, bullae, desquamation
• Onset is 1-3 weeks after initial drug taking but up to 8 weeks

Question 3

What are the contraindications for the live attenuated influenza vaccine (LAIV)?

Answer 3

• Severe asthma
  
  • Current active wheezing
  • Currently on PO steroids or high-dose ICS
  • Medically attended wheezing within the previous 7 days
• Pregnancy
• 2-17 yoa on ASA
• Less than 2 yoa

Question 4

Compare serotonin syndrome vs. NMS vs. anticholinergic toxicity

Answer 4

Serotonin vs. NMS vs. anticholinergic

Serotonin syndromeNMSAnticholinergy toxicity Time course< 12 hours3-4 days< 12 hours VS↑ BP, RR, HR, T↑ BP, RR, HR, T↑ BP, RR, HR, TPupilsEnlarged Normal EnlargedMucousSialorrheaSialorrhea DrySkinDiaphoresisDiaphoresisRed, hot, dry Neurologic↑ reflexes (LE) toneRigidNormalMental statusAgitationStuporAgitation

Question 5

What are the side effects of cephalosporins?

Answer 5

• GI: diarrhea (most common 1-19%), N/V, transient transaminitis, biliary sludge
• Hypersensitivity: rash (1-3%), urticaria (<1%), serum sickness (<1%), anaphylaxis (0.01%)
• Heme: eosinophilia (1-10%), neutropenia, thrombocytopenia, etc.

Question 6

What are the common treatment regimens for H pylori eradication?

Answer 6

Amoxicillin + Clarithromycin + PPI.

OR Amoxicillin + Metronidazole + PPI

OR Clarithromycin + Metronidazole + PPI.

Question 7

What are side effects of NSAIDs?

Answer 7

• 1. PDA closure
• 2. GI ulceration, bleeding, perforation
• 3. Cardiovascular thromboembolism (MI or stroke)
• 4. Impaired renal function
• 5. Hyperkalemia
• 6. Prolonged bleeding time
• 7. May increase risk of aseptic meningitis in patients with SLE/CTD

Question 8

What are side effects of risperidone?

Answer 8

1. Weight gain
2. Metabolic dysfunction - increased fasting glucose, hyperlipidemia
3. Prolactinemia
4. Extrapyramidal symptoms (dyskinesia, tremor, rigidity, difficulty swallowing, akathisia)
5. Hematologic abnormalities: Leukopenia, neutropenia, agranulocytosis
6. Neuroleptic malignant syndrome

Question 9

What are long term side effects of cyclophosphamides?

Answer 9

1. Infertility, gonadal dysfunction
2. pulmonary fibrosis
3. cardiomyopathy
4. secondary malignancy (leukemia, bladder CA, lymphoma) AML
5. myelosuppression
6. hemorrhagic cystitis - more short term
7. SIADH

Question 10

What are reasons to consult anesthesia for more complex procedural sedations?

Answer 10

• Acute illness (e.g. URTI)
• Active chronic conditions (e.g. asthma)
• Less than 6mo
• Obesity
• Features of difficult airways (e.g. hx of difficult intubation)
• Preterm infants until cGA 60wk
• Hx of OSA

Question 11

What are the recommendations made in a letter in April 2021 by CPS?

Answer 11

1. Implement immediate regulatory change that mandates the submission of pediatric data in all drug submissions when pediatric use of a medication can be expected or anticipated
2. Accelerate and expand the use of Trusted Foreign Decision Pathways
3. Develop a dedicated pediatric “Off-Label Drug Use” strategy, focused on high-cost drugs
4. Address our continued reliance on compounding medications
5. Invest in pediatric-focused post-market surveillance activities, including the establishment and expansion of stable, permanent pediatric postmarket safety and efficacy surveillance infrastructure
6. Establish an Expert Pediatric Advisory Board (EPAB)

Question 12

What percentage of medications prescribed in pediatrics are believed to be “off-label”?

Answer 12

80%

Question 13

What are the main 4 recommendations to policymakers regarding establishing Pharmacare in Canada, from the pediatrics perspective?

Answer 13

1. Federal, provincial and territorial governments should develop and implement pharmacare plans that mandate universal, comprehensive, portable prescription drug coverage for children and youth. Specifically:

• Coverage should be consistent across Canada, eliminating the “postal code lottery” and ensuring that children and youth maintain comparable coverage when they move between jurisdictions. Child refugee claimants covered under the Interim Federal Health Program should be fully included.
• Engagement with First Nations, Inuit, and Métis partners is necessary to ensure that the knowledge and perspectives of Indigenous peoples is integrated in planning and implementation.
• Coverage should include medications for children with rare diseases.

2. The federal government should develop a comprehensive, evidence-informed, national list of paediatric drugs for inclusion in a national pharmacare program. All children and youth should have access to drugs on this list.

• Decisions to include drugs must be guided by paediatric experts, as informed by the best available paediatric evidence, and not solely defined by Health Canada’s approved indications.
• A permanent, dedicated, appropriately-funded Expert Paediatric Advisory Board at the Health portfolio level should be established and charged to lead this expert panel.
• The added value of commercial paediatric formulations over compounded preparations should be recognized by prioritizing them on the national list of paediatric drugs.
• The federal government should also support the development of detailed dosing information and compounding instructions for drugs that are not commercially available as child-friendly formulations. This policy would enhance uniformity of practice and reduce the need for hospitals and pharmacies to individually develop dosing or compounding instructions.

3. Health Canada must modernize processes for drug approvals and oversight to expand access to paediatric medications and ensure appropriate paediatric labelling for all medications marketed in Canada.

• Health Canada should proactively request manufacturers include paediatric-specific data when paediatric use can be expected or anticipated (as is currently done by regulators in the United States and Europe), and provide manufacturers incentives to do so.
• Health Canada should create an expedited process to support the review of paediatric products that have been labeled, marketed and widely used in trusted foreign jurisdictions.

4. The federal government should support paediatric drug trials, cost-effectiveness research in children and youth, and the development of commercial paediatric drug formulations.

• Paediatric outcomes data (e.g., medication safety, comorbidities, duration of use) should be gathered and studied to better inform drug development and reimbursement decisions.
• Research budgets should include dedicated funding for paediatric drug studies proportionate to population size and reflecting the economic and social returns on investment from paediatric focused research.