Physical Effects of Meds Flashcards
mechanism of drug-induced urticaria, rash, or allergy
- IgE-mediated, Type I reaction
- Hypersensitivity
Which medications can cause drug-induced urticaria, rash, or allergy?
- Penicillin, ampicillin, amoxicillin, and related antibiotics
- Sulfonamides
- Carbamazepine and several antiepilelptic drugs (AEDs)
- Allopurinol
- Monoclonal antibodies
characteristics of drug-induced rash / allergy
Morbilliform (AKA exanthematous; appears maculopapular)
Warning signs (red flags) for a more severe reaction of a drug-induced urticaria, rash, or allergy
- Pain
- Facial edema
- Blisters or epidermal detachment
- Fever
- Involvement of the mucous membranes
- Painful erythema
- Shortness of breath or wheezing
What does DRESS stand for?
Drug Rash with Eosinophilia and Systemic Symptoms
DRESS characteristics
- Morbilliform rash with red flag symptoms
- need immediate evaluation -> ER
common medications that cause DRESS
- AEDs – carbamazepine, lamotrigine, phenytoin
- Sulfonamides – sulfamethoxazole, sulfasalazine
- Other antibiotics – vancomycin, minocycline, dapsone
- Allopurinol
timing of DRESS to occur
2-6 weeks of drug initiation
mortality rate of DRESS
5-10%
management of DRESS
- Stop medication and avoid it in the future (further administration can cause a more severe reaction)
- Antihistamines +/- corticosteroids often used to help symptoms resolve
What are conditions that consists of a series of mucocutaneous reactions with extensive necrosis and epidermal attachment?
- Erythema multiforme (EM)
- Stevens-Johnson Syndrome (SJS)
- Toxic Epidermal Necrolysis Syndrome (TENS)
- TENS/EM/SJS
What is the mechanism of TENS/EM/SJS?
- T-lymphocyte-mediated immune reaction
- Leads to widespread apoptosis of keratinocytes
- Considered a type IV extreme cutaneous reaction
- Primarily caused by medications
EM
- Maculopapular rash +/- vesicles occurring on the trunk
- Accompanied by target lesions on hands or forearms; presence of the target lesions puts pt at higher risk for SJS and TENS
- Typically has an infectious cause but can be medication-related
SJS
- Also known as EM major
- Vesicular and bullous lesions of mucous membranes (e.g. mouth, eyes, GI tract)
TENS
- Widespread epidermal necrosis
- Resembles 3rd degree burns
- 20-30% mortality rate
common medications that cause EM
- NSAIDs
- AEDs
- Antibiotics Sulfonamides
common medications that cause SJS
- Allopurinol
- AEDs
- Antibiotics Sulfonamides
- Oxicam NSADs (meloxicam, piroxicam)
common medications that cause TENS
- Allopurinol
- AEDs
- Antibiotics Sulfonamides
- Oxicam NSADs (meloxicam, piroxicam)
triage considerations of TENS/EM/SJS
- Immediate evaluation – ED
- Early diagnosis, withdrawal of offending agent, supportive care offer best chance at recovery
- Any of the three manifestations indicates the medication should never be used again
What does skin color blue-gray indicate?
possible cause of amiodarone or tricyclic antidepressants
What does hyperpigmentation indication?
- melanin sensitivity
- possible cause of chemotherapeutic agents, hormones, prostaglandin agonists (bimatoprost, latanaprost)
What does jaundice indicate/
- Hyperbilirubinemia
- possible cause of Atazanavir
Triage considerations of skin pigmentation changes
- Refer to prescribing provider
- Not life-threatening, more of a cosmetic issue
- Adherence can be affected
- Reversal of pigment changes can take months
characteristics of tardive dyskinesia
- Intermittent hyperkinetic involuntary movements
- Typically involve face, tongue, eyelids, or limbs
- Difficult to define temporal relationship as timing often delayed
mechanism of tardive dyskinesia
Acetylcholine deficiency combined with dopamine receptor sensitivity
common medications that cause tardive dyskinesia
- Antipsychotics: Typical (e.g. haloperidol) > atypicals (e.g. risperidone)
- Metoclopramide
triage considerations for tardive dyskinesia
- Occurs at a rate of about 20-40%
- Difficult for patients to have to live with
- Direct patient to prescribing provider; can provide recommendations
recommendations for drug-induced tardive dyskinesia
- Dose reduction
- Addition of a benzodiazepine
- Switch to an agent with less risk (e.g. atypical antipsychotic)
characteristics of pulmonary symptoms
most common are
- SOB
- cough
mechanism of pulmonary symptoms
- Oxidant injury
- Immune-mediated
- Drug mechanism-mediated
common medications that cause pulmonary symptoms
- Beta blockers – drug induced bronchiole constriction
- ACEI or ARB – cough only
- Cytotoxic agents typically cause the most severe effects
triage considerations for pulmonary symptoms
- Refer to PCP if non-severe symptoms; ED if severe (assess the patient)
- Often a diagnosis of exclusion – everything else is ruled out before meds are suspected
- Assess via dose reduction or drug discontinuation
characteristics of angioedema
- Swelling of dermis and subcutaneous tissue, development of wheals; typically non-pruritic
- Wheals forming in mouth and pharynx can cause airway obstruction
mechanism and common causes of angioedema
- Most commonly IgE-mediated mast cell activation – opioids, NSAIDs, aspirin
- ACEI – inhibition of kinin metabolism
- CCBs – histamine-release
triage considerations of angioedema
immediate attention -> ER
characteristics of peripheral edema
swelling of lower extremities
mechanism of peripheral edema
- Increased hydrostatic pressure from pre-capillary dilation (CCBs cause arterial vasodilation) and post capillary constriction
- Thiazolidinediones and NSAIDs – increased sodium reabsorption in kidneys; more commonly an issue in those with pre-existing heart disease
common medications that cause peripheral edema
- DHP CCBs
- Vasodilators – hydralazine, minoxidil
- Thiazolidinediones – pioglitazone, rosiglitazone
- NSAIDs
triage considerations of peripheral edema
- A benign effect; cosmetically an issue but not an indicator of a systemic danger
- Diuretics not needed
- Be sure to assess the whole patient
• Other symptoms of fluid retention (e.g. weight gain, SOB, orthopnea) indicates another process is going on
• Often drug-induced edema is a diagnosis of exclusion
Gynecomastia characteristics
breast enlargement in males
mechanism of Gynecomastia
- Enhanced estrogen activity
- Inhibition of testosterone action or production
common medications of Gynecomastia
- Most have either an effect on sex hormones or a steroid-like structure
- Enhanced estrogen activity – estrogens, anabolic steroids
- Inhibition of testosterone – spironolactone, megestrol, efavirenz, ketoconazole, phenytoin
triage considerations for Gynecomastia
- Refer to prescribing provider
- Not systemically harmful
- Patient can report chest pain; use patient assessment skills to discern
- Typically resolves a few days after treatment discontinuation
alopecia characteristics
hair loss
common medications that cause alopecia
- variable mechanisms handout. - Chemotherapeutic agents - AEDs - Hormones - Statins
triage considerations for alopecia
Can be reversible with treatment discontinuation
hair growth mechanism
- Hirsutism – often related to androgenic stimulation of hormone sensitive hair follicles
- Hypertrichosis – a specific pattern of hair growth along the temporal regions and forehead
common medications that cause hair growth
- Hirsutism: anabolic steroids, contraceptives, testosterone
- Hypertrichosis: Minoxidil (aka Rogaine®), Phenytoin, Cyclosporine
common medications (and mechanisms) that cause musculoskeletal effects
- Diuretics – cramping can result from electrolyte imbalances
- Statins – typically affects larger muscles (e.g. back, leg muscles)
- Fluoroquinolones – can lead to tendon rupture; typically Achilles tendon
triage considerations for musculoskeletal effects
- Diuretics – check BMP, treat as needed
- Statins – assess whether myalgia, myositis, or rhabdomyolysis; will need prescribing provider intervention
- Fluoroquinolones – discontinue
characteristics of Gingival hyperplasia
overgrowth of gum tissue
common medications that cause Gingival hyperplasia
- CCBs
- Phenytoin
- Cyclosporine
triage considerations for Gingival hyperplasia
- Prevention and reduction can be accomplished with good oral hygiene
- Cosmetic issue but can also lead to increased risk of infection
- Not reflective of systemic disease
mechanism of Gingival hyperplasia
proliferation of epithelial keratinocytes, fibroblasts, and collagen
characteristics of skin necrosis
Cutaneous infarction
mechanism of skin necrosis
- Precipitous fall in protein C (anticoagulant)
- Promotion of hypercoagulable state
- Thrombosis occurs in the cutaneous microvasculature
common medications that cause skin necrosis
- Warfarin
- Injection site reactions: Heparin, Interferon
triage considerations of skin necrosis
immediate treatment -> ER
skin necrosis: warfarin
- Usually starts between 3 and 5 days after initiation
- Tends to occur in higher-fat areas (breasts, buttocks, abdomen)
characteristics of Petechiae
Small red/purple spots caused by bleeding under the skin; typically do not blanche
mechanism of Petechiae
- Usually indicates a hemotologic abnormality (often thrombycytopenia)
- Caused by a medication or underlying disease process
- Must evaluate both possibilities
common medications that cause Petechiae
- Heparin
- Antiplatelet medications
- NSAIDs
- Chemotherapeutic agents
- Beta lactam antibiotics, linezolid
- AEDs
triage considerations for Petechiae
Not immediately life-threatening but warrants quick workup – immediate PCP or urgent care/ED if unavailable
