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Pharmacology II > Pharmacology Test 3 > Flashcards

Pharmacology Test 3 Flashcards

1
Q

Monoamine-deficiency theory

A

underlying pathophysiological basis of depression is a depletion of the neurotransmitters serotonin, norepinephrine, or dopamine in the CNS

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2
Q

Major mediators of the symptoms of anxiety disorders

A

Norepinephrine, serotonin, dopamine, and gamma-aminobutyric acid (GABA)

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3
Q

First generation antidepressants

A

Tricyclic antidepressants (TCA)
Monoamine oxidase inhibitors (MAOIs)

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4
Q

Second generation antidepressants

A

Selective serotonin reuptake inhibitor (SSRI)
Serotonin/norepinephrine reuptake inhibitor (SNRI)
Atypical antidepressants
Serotonin modulators

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5
Q

Suicidality and Antidepressant black box warning

A

effective 2005 and extended to young adults aged up to 25 years old

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6
Q

5HT2A distribution and effects

A

Distribution- platelets and cerebral cortex
Effects- cellular excitation, muscle contraction

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7
Q

5HT2B Distribution and effects

A

Distribution- stomach
Effects- Appetite

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8
Q

5HT2C Distribution and effects

A

Distribution- hippocampus, substantia nigra
Effects- anxiety, mood

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9
Q

SSRIs

A

first line antidepressant
effective, tolerated well, general safety in overdose
Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine, Sertraline
-pram -ine

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10
Q

SSRIs MOA

A

decrease the action of the presynaptic serotonin reuptake pump by 60-80%
used for anxiety disorders, premenstrual dysphoric disorder, bulimia

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11
Q

SSRIs length of time for benefit

A

takes at least 2 weeks to produce significant benefit and up to 12 weeks
slow titration needed to discontinue due to possibility to precipitate a discontinuation syndrome

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12
Q

Withdrawal syndrome with SSRI

A

With abrupt discontinuation usually
usually within 24-48 hours after discontinuation
somatic symptoms- dizziness, chills, light-headedness, vertigo, fatigue, headache, nausea
Psychological symptoms- anxiety, agitation, confusion, insomnia, irritability, mania

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13
Q

SSRI side effects

A

QT prolongation, GI effects, weakness and fatigue, sexual dysfunction, serotonin syndrome, bleeding risk if used with antiplatelets or anticoagulants
BLACK BOX: increased suicidal thinking and behavior

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14
Q

Serotonin syndrome with SSRIs

A

precipitated by the overactivation of both the peripheral and central postsynaptic 5HT-1A and most notably, 5HT-2A receptor
mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity
usually begins within 24 hours of an increased dose of a serotonergic agent

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15
Q

Serotonin-norepinephrine reuptake inhibitor (SNRI) MOA

A

act primarily upon presynaptic serotonergic and norepinephrine neurons, but have little or no effect upon cholinergic or histaminergic receptors
used for depression, anxiety disorders, chronic pain syndromes

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16
Q

Examples of SNRIs

A

more inhibition on serotonin reuptake
Duloxetine
Venlafaxine
Desvenlafaxine
more inhibition of norepinephrine reuptake
levomilnacipran
milnacipran

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17
Q

Side effects of SNRIs

A

fewer receptor-mediated adverse effects than the TCAs
may increase HR and BP due to increase in noradrenergic activity
relative decreased parasympathetic tone leading to constipation, dry mouth, urinary retention
nausea, dizziness, diaphoresis, sexual dysfunction, serotonin syndrome
give with food
taper off over 2-4 weeks

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18
Q

Drug to drug interactions with duloxetine

A

CYP2D6 inhibitor
substrates are tramadol, metoprolol, codeine, celecoxib

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19
Q

interaction between MAOIs and SNRIs

A

2 weeks between administration due to possible serotonin syndrome or hypertensive crisis

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20
Q

Atypical Antidepressants

A

mixed group of agents that have actions at several different sites
used with major depression who have inadequate responses or intolerable side effects with first line SSRIs or SNRIs
used as mono therapy, initial treatment
Bupropion
Mirtazapine

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21
Q

Bupropion

A

a weak dopamine and norepinephrine reuptake inhibitor (no serotonergic effect)
used for major depression, seasonal affective disorder, tobacco dependence
also for ADHD and hyposexual disorder

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22
Q

Bupropion for tobacco dependence

A

used for decreasing cravings and attenuating withdrawal symptoms of nicotine

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23
Q

Side effects of bupropion

A

dry mouth, sweating, nervousness, tremor, and a dose-dependent increased risk for seizures

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24
Q

Avoid bupropion in patients at risk for….

A

seizures or bulimia
taper off slowly

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25
Q

Bupropion dosing for depression

A

do not exceed 150mg in a single dose
up to 100mg 3x/day

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26
Q

Bupropion dosing for smoking cessation

A

150mg once daily for 3 days; increase to 150mg twice daily
treatment should start while patient is still smoking
patients should stop smoking during second week of treatment
maximum daily dose: 300mg/day
If quit in 2 week, continue meds for at least 12 weeks
If he haven’t quit in 7 weeks, consider discontinuing

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27
Q

Mirtazapine (Remeron)

A

major depression
antagonist at central presynaptic a2 receptors
serotonin antagonist
sedating because of potent antihistaminic activity (Histamine 1 receptors)- take at bedtime
does not cause antimuscarinic side effects or interfere with sexual function like SSRIs

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28
Q

AEs of atypical antidepressants

A

sedation, increased appetite, dry mouth, weight gain, withdrawal symptoms

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29
Q

Serotonin Modulators

A

effects upon norepinephrine reuptake are minimal
for depression
nefazodone
trazodone
vilazodone
vortioxetine

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30
Q

Nefazodone and trazodone

A

both are sedating- due to potent histamine H1 blocking activity
Trazodone- off-label use for insomnia

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31
Q

AEs of Nefazodone and Trazodone

A

priapism and orthostatic hypotension (trazodone), hepatotoxicity (nefazodone), orthostasis and dizziness, nausea, somnolence, dry mouth, constipation

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32
Q

Trazodone dosing for insomnia

A

25-50mg at bedtime, 200mg/day

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33
Q

Withdrawal syndrome with serotonin modulators

A

usually appear within a period of 24 to 48 hours after discontinuation
Somatic symptoms
Psychological symptoms
Primarily happen following abrupt discontinuation

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34
Q

Tricyclic Antidepressants MOA

A

inhibits reuptake of serotonin and/or norepinephrine which increases the amount of neurotransmitters in the synaptic cleft

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35
Q

Therapeutic index of tricyclic antidepressants

A

narrow- 5-6x the max daily dose can be lethal

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36
Q

Absorption of tricyclic antidepressants

A

absorbed in the small intestine rapidly and nearly completely

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37
Q

Dosing of tricyclic antidepressants

A

not first line therapy (severe side effects)
usually QD dosing at bedtime due to sedation
ok to give BID to TID with smaller dose
should taper TCA off

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38
Q

AEs of tricyclic antidepressants

A

from interaction with many neurotransmitter systems
muscarinic or histamine receptors, noradrenergic activity
cardotoxic: HR variability, prolonged QT interval, due to noradrenergic activity
Orthostatic hypotension- from blockade of A1 receptors on the blood vessels
decreased seizure threshold
can be fatal in higher doses

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39
Q

Monoamine Oxidase enzyme

A

found in nerve, GI tract, and liver
In the neuron- functions as a “safety valve” to oxidatively dominate and inactive any excess neurotransmitters

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40
Q

Monoamine Oxidase Inhibitors

A

a minimum of 2 weeks of delay must be allowed before starting a different category of antidepressant
Not a first or second-line antidepressant (extensive side effect profile and drug-to-drug interactions)
used for resistant depression

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41
Q

AEs of MAOI

A

potent hypotension effects, dizziness, dry mouth, GI upset, urinary hesitancy, headache, myoclonic jerks, afternoon fatigue, serotonin syndrome, hypertensive crisis

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42
Q

Hypertensive crisis with MAOIs (cheese reaction)

A

increased tyramine (substrate of MAO) causes release of large amounts of stored catecholamines from nerve terminals
increased catecholamines = increased HTN
AVOID tyramine-containing foods (aged cheeses and meats, liver, pickled or smoked fish, red wines)

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43
Q

Selegiline

A

MAO B inhibitor at low doses
no benefit for depression
used for Parkinson’s disease
Non-selective MAO inhibitor at high doses
used for depression

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44
Q

Dietary restrictions for MAOIs

A

required if dose is 9mg/24hrs or 12mg/24 hours patch is used

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45
Q

MDD DSM V Criteria

A

Five or more symptoms during the same 2 week period and one of the symptoms is either depressed mood or loss of interest or pleasure

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46
Q

Major Depressive Disorder in primary care

A

collaborative care
primary care clinician- prescriber
case manager
mental health specialist- psychiatrist

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47
Q

Severe MDD

A

should be referred to a psychiatrist for management and generally require hospitalization

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48
Q

MDD general approach

A

aim to induce remission of the major depressive episode
aim to achieve a full return to patient’s baseline
choice of medication should be guided by anticipated safety and tolerability, physician familiarity, and history of previous treatments
address possibility of treatment failure

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49
Q

Mild to moderate MDD pharmacological treatment

A

SSRI, SNRI, atypical and serotonin modulator are all ok for initial treatment
improvement may be observed as early as the first 1-2 weeks
Dose: start low to reduce SE and improve adherence

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50
Q

Timing of treatment of Mild to moderate MDD

A

treat for 6-12 weeks before deciding whether antidepressants have sufficiently relieved symptoms
duration of treatment should be 4-9 months once satisfactory response is achieved
longer duration with a history of 2 or more episodes of depression

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51
Q

Cross-tapering

A

gradual reduction of the current antidepressant with the new antidepressant being increased to therapeutic range over the same time period
best technique to minimize the risk of drug-drug interactions while preventing depressive symptoms from abrupt withdrawal

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52
Q

Switching antidepressants- SSRI to venlafaxine or duloxetine

A

SSRI to venlafaxine or duloxetine
switching immediately from most SSRIs to the equivalent does is typically well-tolerated
caution is needed in switching from fluoxetine or paroxetine

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53
Q

Switching antidepressants- bupropion to or from antidepressants other than MAOIs

A

no mitigation needed for possible discontinuation symptoms
when switching from an SSRI, a TCA, venlafaxine, duloxetine, or mirtazapine to bupropion

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54
Q

Discontinuation of Antidepressants

A

typical taper length is 2-4 weeks to minimize symptoms associated with abrupt discontinuation

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55
Q

General Anxiety Disorder

A

excessive worry and anxiety that causes significant distress and impairment and occur on more days than not for at least six months
effectively treated with serotonergic antidepressants, psychotherapy, or a combination of the two

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56
Q

Co-occuring depression & other anxiety disorders

A

effectively treated with SSRIs or CPT
benzodiazepines are not effective

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57
Q

Which SSRI or SSNI has superior efficacy in GAD

A

NONE… selection based on AEs drug-drug interactions and treatment history/preference

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58
Q

Timing for GAD medication (SSRI/SSNI) to take effect

A

4 weeks

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59
Q

Second-line anxiety disorder medication

A

Buspirone 10mg/day and increased weekly or biweekly in increments of 10mg to a max dose of 60mg

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60
Q

Buspirone

A

reduce symptoms of anxiety without risk of dependence
thought to affect the serotonergic system via blockade of 5HT1A autoreceptors
time to onset: 4 weeks
weaker anxiolytic affect than benzos
may be used as mono therapy 10-60mg/day

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61
Q

Pregabalin (Lyrica)

A

second-line anxiety medication
therapeutic range of 50-300mg/day
SE: sedation and dizziness

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62
Q

Benzodiazepines

A

acute management of anxiety during the period before SSRI or SNRI takes effect
used for short term crisis
slow tapering off of medication- 10% dose reduction per 1-2 weeks

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63
Q

S/S of withdrawal from benzodiazepines

A

early signs: anxiety, dysphoria, and tremor
advanced manifestations: perceptual disturbances, psychosis, and seizures

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64
Q

Pharmacotherapy for anxiety disorders

A

should be continued for at least 12 months
after 2 relapses when tapering off medication, ongoing maintenance treatment should be considered

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65
Q

Tier 1 contraceptives

A

intrauterine devices
implants
irreversible methods- vasectomy, tubal ligation

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66
Q

Tier 2 contraceptives

A

pills, patches, vaginal ring, injections

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67
Q

Tier 3 contraceptives

A

condoms, diaphragms, spermicides, sponges, periodic abstinence

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68
Q

Only contraceptive to protect against STI

A

Condoms

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69
Q

Three types of estrogen

A

Estradiol, estrone, estriol

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70
Q

Estradiol

A

most potent estrogen produced and secreted by the ovary
principle estrogen in premenopausal women

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71
Q

Estrone

A

metabolite of estradiol
1/3 the potency of estradiol
primary circulating estrogen after menopause
generated mainly from the conversion of DHEA in adipose

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72
Q

Estriol

A

metabolite of estradiol
significantly less potent than estradiol
present in significant amounts during pregnancy
synthesized by the placenta

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73
Q

Ethinyl estradiol

A

synthetic estrogen
only estrogen used in contraceptives
(ee)
blunts release of FSH and LSH by the pituitary gland = preventing ovulation

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74
Q

Progesterone

A

endogenous steroid and progestogen sex hormone

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75
Q

Progestins

A

synthetic form of progesterone
suppression of LH surge = suppression of ovulation
development of viscous and scant cervical mucus to deter sperm penetration
prevention of proper endometrial growth and development

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76
Q

Most common estrogen used in contraceptives

A

ethinyl estradiol (synthetic estrogen)

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77
Q

Most common progestin used in contraceptives

A

norethindrone, norethindrone acetate, levonorgestrel, desogestrel, norgestimate, and drospirenone
etonogestrel (synthetic long acting)

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78
Q

Contraceptive Implant

A

single rod of ethylene vinyl acetate
progestin contraceptive
contains 68mg of etonestrel
Nexplanon
SubQ in upper arm over area of triceps
visible under skin & palpable

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79
Q

How long does the nexplanon last?

A

3-5 years

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80
Q

How long does it take for nexplanon to become effective?

A

within 24 hours of insertion
if inserted during the first week of menstrual cycle

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81
Q

Rate of release of contraceptive implants

A

begins at 70mcg/24 hours
decreases to an average of 30mcg/24 hours in the latter years of use

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82
Q

Contraindications of contraceptive implants

A

known or suspected pregnancy
active liver disease
current or past breast cancer

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83
Q

Do you have to use back up contraception after contraceptive implant insertion?

A

If inserted day 1-5 of cycle: immediate contraceptive effect
after day 5: back up contraception for 7 days

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84
Q

Side effects of contraceptive implant

A

unpredictable menstrual bleeding pattern
headaches
bloating
weight gain
acne
breast tenderness

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85
Q

Copper IUD

A

no impact on ovulation
works by foreign body effect induced by ICU frame (spermacidal effect)
works for 10 years

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86
Q

MOA of Copper IUD

A

enhances the cytotoxic inflammatory response within the endometrium which impairs sperm migration, viability & impairs implantation of a fertilized egg

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87
Q

Menses changes with copper IUD

A

may be heavier, longer, or more painful for first several cycles after insertion
improves rapidly within six months

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88
Q

Levonorgestrel IUD (LNG IUD) MOA

A

effect of progestin is at the level of endometrium
direct ovicidal effects
changes in cervical mucus
thinning and glandular atrophy of endometrium inhibits implantation

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89
Q

Side effects of LNG IUD

A

bleeding, uterine cramping, or pain
infection or PID
malposition
expulsion
pregnancy
hormone side effects

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90
Q

contraindications for LNG IUD

A

pregnancy
active uterine infection
malignancy in the uterus or cervix
inability to place or retain the device
unexplained abnormal bleeding
adverse reaction to product ingredients

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91
Q

First generation combined oral contraceptive pills

A

norethindrone acetate
not very potent
negligible androgenic side effects

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92
Q

Second generation combined oral contraceptive pills

A

Levonorgestrel
more potent than 1st gen
longer half life
used in mirena
associated with more androgenic effects such as increased LDL, acne, oily skin, facial hair, increased libido

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93
Q

Third generation combined oral contraceptives

A

desogestrel
norgestimate
potent but not designed to reduced androgenic side effects
fuller expression of pill’s estrogen effects
treats cystic acne, prevents hirsutism

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94
Q

Unclassified combined oral contraception

A

drospirenone

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95
Q

Monophasic COCs

A

same dose of estrogen and progestin during active pill phase

96
Q

Multiphasic COCs

A

biphasic or triphasic
different doses or either or both hormones
introduced as a strategy to reduce AEs and unscheduled bleeding
efficacy is similar across all COC types
biphasic formulations may be associated with more unscheduled bleeding

97
Q

cyclic use of COCs- 21/7 regimen

A

hormones for 21 days followed by 7 day placebo pill
follicles may develop and secrete enough estradiol to “repair” or stimulate proliferation of thin endometrium
will have regular withdrawal bleeding with less breakthrough bleeding

98
Q

cyclic use of COCs- 21/4 regimen

A

shorter time off hormones with low-dose COCs.
four days of placebo pills
reduced symptoms associated with hormone withdrawal
less folliculogenesis
may have more unscheduled bleeding in early cycles

99
Q

Missed pills in continuous use with COCs

A

single pill: take as soon as noticed then take as prescribed
no additional pills needed
two or more pills: take remaining at usual time
use backup contraception

100
Q

missed pills in 28 day pill cycle with COCs

A

If 2 or more pills missed in first week of cycle: use EC
If pills were missed in last week of hormone pills: finish last week, skip week 4 then start a new pack
if not possible then back up contraception should be used until hormone pills have been taken for 7 days

101
Q

Transdermal patches for contraceptoin

A

xulane
twirla

102
Q

Xulane

A

transdermal contraceptive patch
norelgestromin (0.15mg/day)
Ethinyl estradiol (releases 35mcg/day)
may have diminished effect in women over 90kg
new patch applied every 7 days for 3 weeks followed by patch-free week

103
Q

Twirla

A

transdermal contraceptive patch
levonorgestrel (releases 0.12mg/day)
ethinyl estradiol (30mcg/day)
contraindicated in women with BMI greater than 30 for decreased efficacy and increased risk of VTE
new patch applied every 7 days for 3 weeks followed by a patch free week

104
Q

Vaginal rings for contraception

A

NuvaRing
EluRyng
Annovera

105
Q

NuvaRing and EluRyng

A

etonogestrel (0.12mg/day) ethinyl estradiol (15mcg/day)
ring inserted for 3 weeks followed by 1 week without ring in place
new ring at beginning of each cycle

106
Q

Annovera

A

segesterone (0.15mg/day) and ethinyl estradiol (13mcg/day)
ring inserted for 3 weeks followed by 1 week without ring
ring then reinserted for first 21 days of next cycle
one ring is used for one year

107
Q

Progestin only injectable

A

depot medroxyprogesterone acetate (DMPA)
progestin-only
highly effective, three month long reversible contraception
a micro-crystalline suspension
eliminates the need for daily user action
can be IM or SubQ
low solubility of microcrystals allows drug level to persist for several months

108
Q

When to initiate DMPA

A

within 7 days of onset of menses or before discontinuing another method of contraception
can be started almost anytime if not pregnant
repeat every 3 months with up to 2 week grace period

109
Q

Emergency contraception

A

works by delaying ovulation
Plan B (LNG)
Ulipristal (Ella)
Copper IUD

110
Q

Plan B (LNG: levonorgestrel)

A

OTC
prevent ovulation
2 high-dose tablets of LNG 0.75mg
1 tablet within 72 hours and another 12 hours later

111
Q

Ulipristal (Ella)

A

Rx required
prevents ovulation
progesterone receptor modulator
postpone follicular rupture and alter endometrium
greater efficacy than LNG
take within 5 days, 30mg tablet
repeat dose if vomiting within 3 hours

112
Q

Potential side effects of hormonal contraceptives

A

nausea
breast tenderness
headaches
breakthrough bleeding
amenorrhea
HTN
VTE
MI and stroke
lipid change
some possibility of increased STI
bone loss with progestin only injectables

113
Q

Most common early side effect of hormonal contraceptives

A

unscheduled bleeding
affect 1/2 of women during first cycle of use
higher with formulations with 20mcg ethinyl estradiol or 24/4 day dosing

114
Q

Amenorrhea with hormonal contraceptives

A

intended outcome when using continuous methods
happens with lowest dose combined oral formulations
low ethinyl estradiol level (relative to much larger progestin dose) is inadequate to stimulate endometrial growth
can occur even after discontinuation
does not indicate that patient is not ovulatory or patient cannot get pregnant
evaluate if no menstruation after 90 days of d/c

115
Q

Hypertension with hormonal contraceptives

A

may cause mild elevation
a newer progestin, drospirenone has antimineralocorticoid effects
appears to blunt the BP incresing effect of estrogen

116
Q

VTE with hormonal contraceptives

A

low risk in young women
greatest risk in first few months of use
risk factors: smoking, obesity, PCOS, older age, and immobilization

117
Q

MI and stroke with hormonal contraceptives

A

reduced risk with lower estrogen content
rare: absolute risk of stroke in young women is low
increases with higher estrogen doses
does not vary by progestin type
compounds containing levonogestrel and 30mcg of estrogen appear to be safest

118
Q

STI acquisition as a side effect of hormonal contraceptives

A

increased rates of bacterial vaginosis, trichomoniasis, and candida vaginitis
no data that support any influence of COC use on acquisition of HIV
no restrictions on COC use among women with STI, PID, or HIV

119
Q

Black box warning for Depo-Provera

A

bone loss that may not be completely reversible even after stopping the drug
studies have contraindicated the warning

120
Q

ACHES acronym

A

potential side effects of hormonal contraceptives
A: abdominal pain
C: chest pain
H: headaches
E: eye problems
S: severe calf or thigh pain

121
Q

Contraindications to use of hormonal contraceptives

A

pregnancy
older than 35 and smoker
past or current history of thrombosis
hepatic tumor or liver disease
undiagnosed abnormal genital bleeding
known or suspected breast cancer
allergy to method
hypertension
ischemic heart disease
history of stroke
migraine with aura
complicated valvular heart disease

122
Q

Drugs and herbs that reduce the effects of OCs

A

rifampin
ritonavir
troglitazone
antiepileptic drugs
St. Johns wort

123
Q

Drugs whose effects are reduced by OCs

A

warfarin
insulin
oral hypoglycemics

124
Q

drugs whose effects are increased by OCs

A

theophylline
imipramine

125
Q

Vasomotor menopause symptoms

A

hot flashes
sweating
palpitations
the main indication to treat menopause with MHT

126
Q

Genitourinary syndrome of menopause

A

vaginal dryness, superficial dyspareunia, urinary frequency and urgency
use of vaginal estrogen preferred

127
Q

Types of estrogen therapy

A

micronized 17-beta estradiol
conjugated equine estrogens
esterified estrogens
estropipate
ethinyl estradiol

128
Q

Micronized 17-beta estradiol

A

structurally identical to the endogenous estrogen
all commercially available oral 17-beta estradiol products are micronized for better absorption

129
Q

Conjugated equine estrogens

A

derived from pregnant mares’ urine
synthetic derived from plant source is also available

130
Q

Ethinyl estradiol

A

used in almost all oral contraceptives
more potent than other estrogens used for MHT
used in very low doses (5mcg)

131
Q

Oral estrogen effects on lipid profiles

A

increased HDL and TG and decreased LDL

132
Q

Potential AEs of oral estrogen

A

prothrombin effects including reduction in serum fibrinogen, factor VII, and antithrombin III
an increase in hepatic synthesis of vascular inflammatory markers (CRP)

133
Q

Standard-dose estrogen

A

conjugated estrogen 0.625mg

134
Q

Dosing equivalents of estrogen

A

0.625mg conjugated estrogen
1mg micronized 17-beta estradiol
0.05mg/24hr transdermal patch

135
Q

Progestin Types

A

Medroxyprogesterone acetate (MPA)
micronized progesterone

136
Q

Risk of medroxyprogesterone acetate

A

excess risk of cardiovascular events and breast cancer

137
Q

What is preferred over MPA

A

micronized progesterone- less risk!

138
Q

Contraindications to menopausal hormone therapy

A

hx of breast cancer or endometrial cancer
porphyria
severe active liver disease
thromboembolic disorders
unexplained vaginal bleeding
endometriosis
uterine fibroids

139
Q

Avoid oral estrogen with…

A

hypertriglyceridemia
active gallbladder disease
thrombophilias
migraine with aura

140
Q

Dosing of estrogen for VMS

A

lower doses
less vaginal bleeding, breast tenderness, fewer effects on coagulation and inflammatory markers and possible lower risk of stroke and VTE
lowest transdermal dose approved for prevention of bone loss (0.014mg)

141
Q

Side effects of estrogen only products for VMS

A

endometrial CA
endometrial hyperplasia
thromboembolism
retinal thrombosis
MI
stroke
HTN
breast cancer
ovarian cancer
uterine fibroids
vaginal bleeding
abdominal distention/cramping
N/V
breast pain
cervical secretion changes
HA
migraine
fluid retention, weight changes

142
Q

Contraindications to estrogen-only products for VMS

A

do not use estrogen alone for post-menopausal women with intact uterus
due to endometrial hyperplasia and cancer from unopposed estrogen
use with progestin

143
Q

Vaginal estrogen for genitourinary syndrome of menopause

A

most commonly used in very low doses for the management of vaginal atrophy
not associated with cardiovascular or oncologic complications
results in less estrogen absorption than oral or transdermal estrogen therapy
use with caution in patients with or at risk for estrogen-dependent tumors
addition of progestin not necessary

144
Q

Examples of vaginal estrogen products for GSM

A

tablet or capsule
Estring vaginal ring
vaginal cream

145
Q

Dosing of vaginal estrogen tablet

A

vagifem, yuvafem, imvexxy
estradiol estrogen
10 or 4 mcg
one daily for 1st two weeks then twice weekly

146
Q

Estring vaginal ring

A

estradiol estrogen
7.5mcg per day over 3 months
insert Q3 months

147
Q

Vaginal cream- Premarin

A

conjugated estrogen
QD for two weeks and then twice weekly
21 days on, 7 days off

148
Q

Vaginal cream- Estrace

A

Estradiol estrogen
QD for 1-2 weeks followed by maintenance dose of 1g 1-3 times per week

149
Q

AEs of vaginal estrogen for GSM

A

breast pain
enlarged breasts
itching of vagina or genitals
headache
nausea
stinging or redness of genital area
thick, white vaginal discharge
feeling of vaginal pressure
uterine bleeding or spotting
vaginal burning or pain

150
Q

Other treatments for genitourinary syndrome of menopause

A

first line: vaginal moisturizers and lubricants
moisturizer: use routinely, typically two or three days per week
lubricants: only at time of sexual activity: water, silicone, or oil based
oil-based cause breakdown of latex condoms

151
Q

Dose of medroxyprogesterone

A

2.5mg PO QD

152
Q

Dose of progesterone micronized

A

200mg/day for 12 days (cyclic)
add progestin in half each month

153
Q

AEs of progestin only products for VMS

A

headaches
painful or tender breasts
vaginal spotting
stomach cramping or bloating
N/V
hair loss
fluid retention
yeast infection

154
Q

No hyperkalemia in combination estrogen-progestin products with…

A

drospirenone

155
Q

Duration of MHT

A

the standard recommendation is 5 years or less and not beyond age 60
less recurrent sx with tapering method
decrease estrogen by one pill per week every few weeks over 3-6 months
if unsuccessful, repeat tapering over one year
progestin is tapered on same schedule

156
Q

Transition from OC to MHT

A

age 40-50 still candidates for OCS (low-estrogen)
Age 50- discuss stopping OC or changing to MHT if necessary

157
Q

Antiresorptive agents for osteoporosis

A

decrease osteoclasts activity
biphosphonates
alendronate
risedronate
ibandronate
zoledronic acid
denosumab
selective estrogen receptor modulators
estradiol

158
Q

Anabolic agents for osteoprosis

A

directly stimulate bone formation
parathyroid hormone/parathyroid hormone-related protein analog
Teriparatide
Abaloparatide
Romosuzamab

159
Q

Biphosphonates

A

first-line drugs
suppress respiration by preventing osteoclast attachment to bone matrix
reduction of fracture risk by approx 50%

160
Q

AEs of biphosphonates

A

esophagitis
osteonecrosis of the jaw

161
Q

Osteonecrosis of the jaw

A

exposed, nonmetal bone involving the maxillofacial structures

162
Q

Antiresportive agents

A

recommended to be off meds for 2 months before having a dental procedure

163
Q

Drug holiday for biphosphonates

A

no supportive clinical data
may be considered after 5 years of treatment

164
Q

Denosumab (Prolix) MOA and dosing

A

binds to RANKL and blocks the interaction between RANKL and RANK preventing osteoclast formation leading to decreased bone resorption and increased bone mass
approved for women receiving aromatase inhibitors and men receiving gonadotrophin reducing treatment
60mg SubQ q6 months

165
Q

Denosumab AEs and contraindications

A

AEs: peripheral edema, eczema, hypocalcemia, headache, arthralgia
Contraindications: hypocalcemia, pregnancy, hypersensitivity

166
Q

Selective Estrogen receptor modulators

A

Tamoxifen: hormone receptor-positive breast cancer
Raloxifene
MOA: act as an estrogen agonist in the bone to prevent bone loss and increase bone mineral density
Antiresorptive effects are less than those of biphosphonates
no effect on non-vertebral fractures
decreases risk for BRCA

167
Q

AEs for SERMs

A

increased risk of VTE
hot flashes
leg cramps

168
Q

Parathyroid Hormone analog

A

Teriperatide
MOA: stimulates bone remodeling by increasing bone formation
20mcg SC QD
moderate to severe osteoporosis
should not be given for more than 2 years over life-time

169
Q

AEs and contraindications of Parathyroid Hormone analog

A

mild, transient hypercalcemia, orthostatic hypotension, dizziness, HA, nausea, arthralgia, rhinitis, increased uric acid, hypercalciuria, osteosarcoma (animal studies)
Contraindications: hypercalcemia, hyperparathyroidism, multiple myeloma, bone mets, skeletal tumor, do not use in children with growing bones

170
Q

Monoclonal antibodies for osteoporosis

A

Romososumab
inhibits sclerostin, a regulatory factor in bone metabolism
210mcg SC Qmonth x 1 year

171
Q

Contraindications and side effects of monoclonal antibodies for osteoprosis

A

contraindications: hypocalcemia
side effects: hypocalcemia, MI, stroke, ONJ, arthralgia, headache, insertion site erythema

172
Q

Calcium and vitamin D for osteoporosis

A

Post-menopause: 1200mg of calcium QD and 800 units of Vitamin D
Pre-menopause: 1000mg calcium and 600 units of Vitamin D daily
Calcium carbonate taken with meals
calcium citrate is recommended for those taking PPIs or H2 blockers

173
Q

Neurotransmission in CNS

A

an impulse in the presynaptic terminal cause the release of the neurotransmitter
molecules bind to transmitter-gated ion channels in the postsynaptic membrane
Na enters postsynaptic cell and depolarizes the membrane
results in changing the membrane potential

174
Q

Alzheimer’s disease

A

progressive loss of cholinergic in discrete brain areas
impaired cognition, movement, or both and behavior problems

175
Q

Current therapies for Alzheimer’s Disease

A

Acetylcholinesterase Inhibitors
NMDA receptor antagonists
Monoclonal antibody

176
Q

Acetylcholinesterase Inhibitors

A

aim to improve cholinergic transmission within the CNS
inhibits acetylcholinesterase within the CNS
improves cholinergic transmission at functioning neurons
Galatamine, Donepezil, Rivastigmine

177
Q

NMDA receptor agtagonists

A

prevent cytotoxic actions resulting from overstimulation of NMDA receptors in selected areas of the brain
Memantine, Dextromethorphan/quinidine, Eketamine

178
Q

Goals of pharmacological treatment for Alzheimers

A

modest short-term benefit
none of the available therapeutic agents alter the underlying neurodegenerative process

179
Q

Monoclonal antibodies for Alzheimers

A

Aducanumab
Laboratory-made proteins that mimic the immune system’s ability to target specific antigen on cell surface

180
Q

Acetylcholinesterase

A

a cholinergic enzyme primarily found at postsynaptic neuromuscular junctions (muscles and nerves)
breaks down or hydrolyzes acetylcholine into acetic acid and choline

181
Q

Donepezil (Aricept)

A

acetylcholinesterase
starts at 5mg in Qhs
Adjust the dose in 4-6 weeks
max dose 23mg

182
Q

Max dose of donepezil

A

23mg (may not give additional benefit) but does increase side effects

183
Q

AEs of Donepezil

A

possible irregular or slow heart rate or fainting
ok to give in am if it causes nightmares
GI symptoms
symptomatic bradycardia, QT prolongation
rhabdomyolysis (rare)
neuroleptic malignant syndrome (rare)

184
Q

Galantamine (Razadyne)

A

acetylcholinesterase inhibitors
start at 8mg QDay
adjust dose in 4-6 weeks
give with meals due to GI AEs
should not be used in patients with end-stage kidney disease or severe hepatic impairment

185
Q

Who should galantamine not be used for?

A

ESRD or hepatic impairment

186
Q

AEs of galantamine

A

gastrointestinal symptoms
symptomatic bradycardia
CNS depression
skin reactions

187
Q

Rivastigmine (Exelon)

A

transdermal patch is preferred (tolerated better with similar effect)
adjust the dose Q4 weeks
Oral meds with meals (start at 1.5mg BID)

188
Q

Who requires dose adjustments for Rivastigmine

A

hepatic impairment and low body weight

189
Q

AEs of Rivastigmine

A

N/V
anorexia
headaches
dizziness

190
Q

Contraindications of Acetylcholinesterase inhibitors

A

bradycardia or known cardiac conduction system disease, increased risk of syncope, falls, and fractures

191
Q

Use acetylcholinesterase inhibitors in caution with…

A

combination therapy with other drugs that cause bradycardia or alter AV conduction (beta blockers, calcium channel blockers, lacosamide)

192
Q

NMDA

A

an amino acid derivative that acts as a specific agonists at NMDA receptor site mimicking the action of glutamate

193
Q

NMDA receptor

A

a glutamate receptors
mostly exist in the CNS

194
Q

NMDA receptor antagonist MOA

A

blocks overstimulation of glutamate receptors in extra-synaptic area that causes excitotoxic effects on neurons that is caused by neurodegenerative or apoptotic processes
blocks activities in extra synaptic NMDA receptors

195
Q

AEs of NMDA receptor antagonists

A

hallucinations, lightheadedness, dizziness, fatigue, headache, out of body sensation, nightmares, sensory changes

196
Q

Memantine

A

indicated for moderate to severe Alzheimers disease
Dose adjustment Q weekly or longer
often given in combination with an AChE inhibitor

197
Q

AEs of memantine

A

well tolerated with few dose-dependent AEs
confusion, agitation, and restlessness

198
Q

Aducanumab

A

clinical trails saw no benefit
AEs included headache, diarrhea, change in mental status
severe: cerebral edema, micro brain bleeding
majority went to normal after stopping meds

199
Q

Parkinson’s Dease

A

progressive neurological disorder of muscle movement
tremors, muscular rigidity, bradykinesia, postural and gait abnormalities
dementia is a late symptom
correlated with destruction of dopaminergic neurons in the substantial nigra
consequent reduction of dopamine actions in the corpus striatum (motor control)

200
Q

Drugs Used in Parkinson’s disease

A

MAO-B inhibitors
Antiviral (Amantadine): NMDA receptor antagonist
Anticholinergics (Trihexyphenidyl)
Levodopa
Dopaminergic agonist
aim to maintain constant CNS dopamine levels
temporary symptom relief
do not arrest or reverse neuronal degeneration

201
Q

MAO-B inhibitors

A

for patients with mild symptoms/minimal impact on daily life
selegiline
rasagiline
safinamide

202
Q

Selegiline

A

MAOB inhibitors
5mg QD: irreversibly binds to MAO B and a single dose is sufficient to achieve enzymatic inhibition for longer than 24 hours
morning and mid-day dosing
may be able to reduce dose of levodopa/carbidopa by 10-30%
do not use higher than 10mg daily

203
Q

AEs of Selegiline

A

headache dizziness, nausea, suicidal ideation (transdermal)
insomnia
exacerbation of hypertension
orthostatic hypotension

204
Q

Use selegiline with caution in patients with…

A

cerebrovascular disease, hypovolemia, or concurrent medication which may predispose to hypotension/bradycardia

205
Q

Rasagiline (Azilect)

A

adjective therapy with levodopa
0.5mg daily and may increase to 1mg/day (max dose)
when adding to levodopa therapy, a dose reduction of levodopa may be required to avoid exacerbation of dyskinesias, typical dose reduction of 9-13%

206
Q

Do not use Rasagiline with

A

Meperidine, methadone, propoxyphene, tramadol
cyclobenzaprine, dextromethorphan, St. Johns wort

207
Q

AEs of Rasagliline

A

headache, ecchymosis, GI symptoms, melanoma, aggressive behaviors or agitation

208
Q

Safinamide (Xadago)

A

mono therapy possible
usually given as adjective therapy with levodopa to help with motor fluctuations

209
Q

Safinamide (Xadago)

A

mono therapy is possible
usually given as adjunctive therapy with levodopa to help with motor fluctuations

210
Q

AEs of safinamide

A

dyskinesia, HTN, orthostatic hypotension, insomnia

211
Q

Amantadine

A

antiviral NMDA receptor antagonists
for patients with mild symptoms/minimal impact on daily life
weak, uncompetitive NMDA receptor antagonists
may increase dopamine release and inhibit dopamine reuptake
Monotherapy is alternative (for tremor and dyskinesia)
very well tolerated
transient benefits in some patients and often limited to a year or two

212
Q

AEs of amamtadine

A

orthostatic hypotension, pre-syncope, peripheral edema, dry mouth, constipation, hallucinations, delusions

213
Q

Amantadine ER (Gocovri) dosing

A

QHS
concentration rises slowly overnight and achieves their peak in the morning
use with or without dopaminergic medications
can be added in addition to levodopa/carbidopa when experiencing “off” episodes

214
Q

Amantadine ER (Osmolex) dosing

A

combination of extended-release and immediate-release amantadine for treatment of Parkinson’s and drug-induced extrapyramidal reactions in adults
immediate-release outer layer and an extended-release inner core
makes concentration higher in the day and lower during the night

215
Q

Anticholinergics for patients with Parkinsons

A

patients with mild symptoms/ minimal impact on daily life
monothearpy for patients <65 years with increased tremor but no bradykinesia or gait disturbance
avoid this in older patients due to significant cognitive impairment due to the increased risk of adverse effects

216
Q

What is the most widely prescribed anticholinergic agent?

A

Trihexyphenidyl

217
Q

AEs of anticholinergics

A

dry mouth, blurred vision, constipation, nausea, urinary retention, impaired sweating, tachycardia
caution is advised in patients with known prostatic hypertrophy or closed-angle glaucoma
cognitively impaired may be more susceptible to memory impairment, confusion, hallucinations

218
Q

Levodopa

A

the preferred therapy for patient with moderate to severe symptoms
penetrates the blood brain barrier and converts to dopamine by amino acid decarboxylase enzyme
rapid conversion of levodopa to dopamine in GI and peripheral tissues by decarboxylase enzyme

219
Q

What is levodopa administered with?

A

Carbidopa to inhibit rapid conversion to dopamine in peripheral tissues- reduces needed dose of levodopa by 75%
at the beginning take with meal or snack to avoid nausea
with more advanced disease it is more effective if taken on an empty stomach 30 minutes before or one hour after meals

220
Q

Carbidopa

A

dopamine decarboxylase inhibitor
does not pass BBB
diminishes the metabolism of levodopa in the periphery
increase the availability of levodopa to the CNS
given with levodopa
decreases severity of AEs from peripherally formed dopamine

221
Q

Reasons to use levodopa

A

for mild symptoms in older adults and younger adults
initial therapy
intolerant of other drugs

222
Q

AEs of levodopa

A

nausea, somnolence, dizziness, and headache
older patients: confusion, hallucinations, delusions, agitation, psychosis, and from overactivity of dopamine in the basal ganglia, orthostatic hypotension

223
Q

Drug interactions of levodopa

A

vitamin pyridoxine (B6)
nonselective monoamine oxidase inhibitors (MAOIs)
caution in psychotic patients
low doses of atypical antipsychotics (quetiapine or clonazapine) can be used to treat levodopa-induced psychotic sympotms
use with caution in cardiac patients- monitor for the possible development of arrhythmias

224
Q

Dosing for carbidopa/levodopa

A

careful upward titration over several weeks to a full tablet three times daily (taken every 4-6 hours during waking hours)
2x daily, at intervals not less than 6 hours
may adjust no faster than 3 days to max dose of levodopa 2.4g/day
not recommended as initial therapy

225
Q

Max daily dose of carbidopa/levodopa

A

200/2000mg dosing > 4x daily may be required
if not responsive to levodopa at 1000-1500mg think other diagnoses
carbidopa needs to be 70-100mg/day to reduce n/v

226
Q

Should carbidopa/levodopa be discontinued abruptly

A

no! risk of neuroleptic malignant syndrome

227
Q

Dopaminergic agonist

A

Ropinirole, Rotigotine, Pramipexole
adjective therapy for wearing off effect
dose of levodopa should be lowered or adjusted accordingly

228
Q

Pramipexole

A

dopaminergic agonist
switch from IR to ER overnight at same daily dose: >80% successful rate

229
Q

New generation anti seizure medications

A

Gabapentin, lamotrigine, pregabalin, topiramate, levetiracetam, oxcarbazepine
simple pharmacokinetics
more limited effects on liver metabolism
reduced need for serum monitoring
once or twice daily dosing for some
few drug-drug interactions

230
Q

Benzodiazepines

A

Clobazam, clonazepam, clorazepate, diazepam, lorazepam
bind to the GABA (A) receptor and facilitate the attachment of GABA to its binding site on the receptor

231
Q

What is most often used for myoclonic and atonic seizures?

A

clonazepam

232
Q

Low voltage-gated calcium channel blockers

A

Ethosuximide
Pregabalin
Gabapentin
Levetiracetam

233
Q

Ethosuximide

A

blood level should be checked initially after 1-3 weeks
time to steady state 12 days in adults, 6 days in children
check right before the scheduled dose

234
Q

Pregabalin dosing

A

150mg with or without food in BID or TID up to 600mg
Dose adjustment Q weekly is ok

235
Q

Gabapentin

A

300mg three times daily or 300mg first day, 300mg twice daily second day, 300mg three times daily on the third day
up to 1800-2400mg/day

236
Q

Antiseizure medication interactions with other medications

A

phenytoin, carbamazepine, phenobarbital, primidone, and oxycarbazepine and topiramate are the most problematic for drug interactions with warfare, oral contraceptives, and anticancer and anti-infective drugs

Pharmacology II (3 decks)

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