Pulmonology Pharm Flashcards
1
Q
Community-acquired pneumonia-previously healthy Pt
A
Macrolide(Azithromycin, Clarithromycin or erythromycin)
Or Doxycycline
2
Q
Community-acquired pneumonia with presence of co-morbidities
A
Respiratory fluoroquinolone(moxifloxacin, levofloxacin) Or a beta-lactam(high dose amoxicillin, amoxicillin/clavulanate) And a macrolide(Azithromycin, Clarithromycin or erythromycin)
3
Q
Hospital Acquired Pneumonia Treatment-nonMRSA decreased risk for gram neg
A
One of the following:
Piperacillin-tazobactam 4.5g IV q 6hrs
Cefepime 2g IV q 8hrs
Levofloxacin 750 mg IV q 24 hrs
4
Q
Hospital Acquired Pneumonia Treatment= MRSA risk and decreased risk for gram neg
A
One of the following: Piperacillin-tazobactam 4.5g IV q 6hrs Cefepime 2g IV q 8hrs Levofloxacin 750 mg IV q 24 hrs Ceftazidime 2 g IV q 8hrs Ciprofloxacin 400 mg IV q 8hrs Aztreonam 2 g IV q 8hrs
Plus one of the following:
Vancomycin 15 mg/kg (max 2 g initial dose) q 8-12 hrs target of 15-20 mcg/ml
Linezolid 600 mg IV q 12 hrs
5
Q
Most common pathogen for Community acquired Pneumonia
A
S Pneumoniae (MC), Haemophilus influenzas, Legionella
6
Q
Common pathogen for Hospital acquired pneumonia
A
E. coli, klebsiella, Enterobacter, Pseudomonas, MRSA
7
Q
Common pathogens for aspiration pneumonia
A
Pseudomonas, Bacteroides, peptostreptococcus, fusobacterium nucleatum, prevotella
8
Q
Common pathogens for Bronchitis
A
Influenza A and B, parainfluenza, Coronavirus 1-3, rhinoviruses
9
Q
Amoxicillin-class
A
Beta lactate antibiotic
10
Q
Amoxicillin MOA
A
Inhibits bacterial cell wall synthesis
11
Q
Amoxicillin Adverse effects
A
Headache
N/V/D
C diff
12
Q
Amoxicillin Contra indications
A
Serious hypersensitivity
Super infections
13
Q
Amoxicillin Indications
A
Community acquired pneumonia outpatient/inpatient along with macrolide
Treats Strep, staph and H. Influenza
14
Q
Amoxicillin monitoring and special considerations
A
Pregnancy cat B
Excreted in breast milk
Prolonged therapy monitor renal, hepatic and hematologists function
15
Q
Amoxicillin dosing
A
1g TID x min of 5 days should be afebrile>48hrs
16
Q
Amoxicillin/Clavulanate (augmentin) Class
A
Beta lactam w/beta lactamase inhibitors
17
Q
Amoxicillin clavulanate MOA
A
Beta lactam inhibits bacterial cell wall synthesis while the inhibitor stops betalactamase from breaking down beta lactam
18
Q
Amoxicillin clavulanate indications
A
Community acquired Pneumonia caused by confirmed or suspected beta lactamase producing pathogens(H influenza, Moraxella catarrhalis, Klebsiella pneumoniae, MSSA, Strep Pneumoniae
19
Q
Amoxicillin clavulanate dosing
A
ER-2g q12 hrs as dual therapy
20
Q
Amoxicillin clavulanate adverse effects
A
Diarrhea, abdominal distress, nausea and vomiting
21
Q
Amoxicillin clavulanate contraindications
A
Hypersensitivity, severe renal impairment
22
Q
Amoxicillin clavulanate special consideration, monitoring and Pt education
A
Monitor liver functions
Take until 48 hrs without fever
23
Q
Doxycycline class
A
Tetracycline derivative
24
Q
Doxycycline MOA
A
Inhibits protein synthesis by binding with the 30s ribosomal subunit
25
Doxycycline Indications
Alternative agent for inpatient and outpatient treatment of CAP empiric treatment
26
Doxycycline adverse effects
HTN, anxiety, hyperglycemia, Diarrhea, and pain, nasopharyngitis
27
Doxycycline contraindications
Hypersensitivity, use in children <8, pregnant and breastfeeding
28
Doxycycline special considerations, monitoring and education
CBC, renal and liver functions periodically for prolonged therapy,
29
Azithromycin class
Macrolide
30
Azithromycin MOA
Inhibits RNA dependent protein synthesis at the chain elongation step
31
Azithromycin Indications
Empiric Treatment of CAP or due to Chlamydia pneumonia, H flu, Legionella, Morexella, Mycoplasma and Strep Pneumoniae
32
Azithromycin dosing for CAP
Outpatient 500mg x1 day, 250mg qday x 4 days
33
Azithromycin Adverse effects
Loose stools, nausea, vomiting, diarrhea, Abd pain, rash,
34
Azithromycin contraindications
Hypersensitivity
35
Azithromycin special considerations, monitoring and Pt education
CYP3A4
| Liver functions, CBC with dif
36
Levofloxacin class
Respiratory Fluoroquinolone
37
Levofloxacin MOA
Inhibits bacterial DNA uncoiling and promotes breaking of DNA
38
Levofloxacin Indications
Treatment of CAP as monotherapy in hospital an outpatient
39
Levofloxacin dosing
750 mg PO/IV qday for 5 -7 days or until afebrile >48hrs
40
Levofloxacin Adverse effects
Tendonitis, Headache, dizziness, N/V/D
41
Levofloxacin contraindications
Hypersensitivity
| Tendinitis Hx
42
Levofloxacin monitoring, special considerations and education
May prolong QT
Hypoglycemia
Hepatoxicity
Pregnancy class c
Monitor renal, hepatic and hematopoietic syste ms periodically
Crystalluria, AMS and tendonitis(especially elderly)
43
Cefdinir class
3rd gen cephalosporin
44
Cefdinir MOA
Inhibits bacterial cell wall synthesis
45
Cefdinir Indications
CAP-alternative for immunocompromised and co morbidity Pts
| COPD exacerbation caused by H influenza, strep pneumonia and Moraxella
46
Cefdinir Adverse effects
Diarrhea
| Nausea and rash
47
Cefdinir contraindications
Hypersensitivity
48
Cefdinir monitoring special considerations and education
```
Monitor renal function
Pregnancy class B
```
49
Ceftriaxone class(Rocephin)
3rd gen cephalosporin
50
Ceftriaxone MOA
Inhibits bacterial celll wall synthesis
51
Ceftriaxone Indications
CAP alternative for immunocompromised and commorbidities Pts
52
Ceftriaxone Adverse effects
Skin tightness, rash
| Nausea, diarrhea
53
Ceftriaxone contraindications
Hypersensitivity
54
Ceftriaxone special considerations, monitoring and education
May elevate INR, Hemolytic anemia, pancreatitis
Monitor INR
Pregnancy class B
55
Oseltamivir Class
Antiviral-Neuraminidase inhibitor
56
Oseltamivir MOA
Binds to Neuraminidase and does not allow virons to be released from infected cells
57
Oseltamivir Indications
Influenza A and B post exposure prophylaxis and treatment
58
Oseltamivir Adverse effects
Headaches, nausea and vomiting
59
Oseltamivir contraindications
Hypersensitivity
60
Oseltamivir special considerations, monitoring and education
Prophylaxis for high risk population(lung and cardiac disease, Immunocompromised, pregnant)
Treatment- start in first 48hrs, willl only shorten symptoms by couple of days, may lessen severity
Monitor for unusual behavior
61
Exacerbation of chronic bronchitis(COPD)
Maintenance therapy-Long acting bronchodilator
**systemic corticosteroids(5-7days)
**Antibiotics 5-7 days-Based on severity-SimpleAmoxicillin, doxycycline, Azithromycin or SMXTMT
Complicated-Amoxicillin clavulanate or Ceftriaxone or doxycycline
Severe complicated-Levofloxacin
62
5 A’s of smoking cessation
```
Ask
Advise
Assess
Assist
Arrange
```
63
Symptoms of Nicotine withdrawal
Cravings, nervousness, restlessness, irritability, mood lability,anxiety, sleep disturbances and weight gain
64
Follow up after prescribing smoking cessation
Follow up within one week of quit date
65
Smoking cessation treatment algorithm
Smoke in preparation/action phase—>Set quit date and begin behavioral therapy—>Start first line therapy(Bupropion SR, Varenicline and nicotine replacement—>Follow up with in 1 week of quit date—>Successfull—>follow up in 1 month—>still successful—>Provide follow up as needed
If not successful—>try combination therapy, switch to different monotherapy, intensify behavioral therapy
66
Smoking cessation behavioral therapy
Important aspect for every Pt
Support groups
Behavior modification program
67
Nicotine replacement therapy
Considered first line therapy
68
Nicotine gum dosing
If first cigarette within 30 min of waking start at 4mg otherwise 2 mg
Week 1-6===1 piece every 1-2 hrs
Week7-9===1 piece every 2-4 hrs
Week 10-12==1 piece every 4-8 hrs
69
Nicotine patch class and MOA
Long acting Nicotine replacement therapy
| Replaces nicotine in blood stream from nicotine received from tobacco
70
Nicotine Patch Indication
For Pt’s wanting smoking cessation
71
Nicotine patch dosing Greater than 10 cigarettes/day
21mg/day x 6 weeks
14mg/day x 2 weeks
7mg/day x 2 weeks
72
Nicotine patch dosing less than 10 cigarettes/day
14mg/day x6 weeks
| 7mg/day x 2 weeks
73
Nicotine patch adverse reactions and contraindications
Erythema, burning or priorities at application site
Nightmares
Headache
Caution-recent MI(2 weeks)
Serious arrhythmia
Worsening angina
Active peptic ulcer disease
74
Nicotine patch special considerations, monitoring and education
Apply to non hairy, clean dry skin upper body or outer arm-rotate site each day
Nicotine will continue to be delivered after patch is removed
Do not cut
Need to abstain from smoking
75
Bupropion class/MOA
Non-nicotine aid to smoking cessation/antidepressant
Blocks neuronal resp take of dopamine and norepinephrine-metabolite is a nicotine antagonist
76
Bupropion contraindications/precautions/adverse effects
CI:HIstory of seizure disorder
Coadministration with MAOI
Current or prior diagnosis of bulimia or anorexia nervosa
Precaution: Do not use with Wellbutrin/WellbutrinSR(antidepressant version)
Carbamazepine interactions-decreases serum concentrations of bupropion
AE: Seizures with high dose, insomnia, irritability, dry mouth, headache, weight gain/loss
77
Bupropion dosing
150 mg SR PO qday for 3 days, then increase to 150 mg SR BID for 7-12 weeks
Initiate therapy while still smoking and have target quite date 7 days after starting
Decrease dose by 50% in Pts with renal and hepatic insufficiency
Can be combined with NRT
78
Varenicline class and MOA
Alpha 4beta2 nicotine acetylcholine receptor agonist
Selectively blocks nicotine binding to A4B2 nicotine acetylcholine receptors
Reduces severity of cravings and withdrawals
79
Varenicline adverse reactions
Nausea, sleep disturbances, head aches, abnormal dreams, suicidal ideation,
Possibly linked to MI, seizure, DM, dizziness and confusion
80
Intermittent Asthma
```
Symptoms-2 or fewer days a week
Night time awakenings-2 or fewer a month
Use of SABA-2or less days /week
Interference with normal activity-none
Exacerbation requiring systemic steroids-0-1
Normal FEV1 between exacerbation
```
81
Mild persistent asthma
Symptoms-more than 2 days /week but not daily
Nighttime awakenings-3-4 nights per month
SABA use-More than 2 days per week but not more than 1 time per day
Interference with normal activity-Minor limitations
Exacerbation requiring systemic steroids-2 or more per year
FEV1>80%
82
Moderate persistent asthma
Symptoms-daily
Nighttime awakenings-more than 1 time per week-not daily
SABA use-Daily
Interference with normal activity-Some limitiation
Exacerbation requiring systemic steroids-2 or more per year
8060
83
Severe persistent asthma
Symptoms-throughout the day
Nighttime awakenings-often 7 times per week
SABA use-several times per day
Interference with normal activity-extremely limited
Exacerbation requiring systemic steroids-2 or more/year
FEV1<60
84
Well controlled asthma
```
Symptoms-2 or fewer days/week
Nighttime awakenings-2 or fewer nights/month
Interference with normal activities-none
SABA use-2 or fewer days per week
FEV1 or PEF->80%
Exacerbation-0-1/year
```
Treatment-Maintain current step
Regular follow up every 1-6 mo
Consider stepping down if well controlled for at least 3 mo
85
Not well controlled Asthma
```
Symptoms-More than 2 days per week
Nighttime awakenings-1-3 nights per week
Interference with normal activities-some limitations
SABA use-more than 2 days per week
FEV1-60-80%
Exacerbation>2/year
```
Treatment
Step up one step
Reevaluate in2-6 weeks
86
Very poorly controlled Asthma
Symptoms-through out the day
Nighttime awakenings-4 or more nights per week
Interference with normal activity-Extremely limited
SABA use-several times per day
FEV1<60%
Treatment
Consider short course oral CS
Step up 1-2 steps
Reevaluate in 2 weeks
87
Asthma STep wise
| Step 1
SABA PRN
88
Asthma STep WIse
| Step Two
Low Dose ICS
89
Asthma STep Wise
| Step 3
Low dose ICS + LABA
| Or Medium DOse ICS
90
Asthma STep Wise
| Step 4
Medium DOse ICS+LABA
91
Asthma STep WIse
| STep 5
High Dose ICS+LABA and consider Omalizumab for Pt w/allergies
92
Asthma STep Wise
| Step 6
HIgh dose ICS +LABA +Oral CS and consider Omalizumab for Pt with allergies
93
Goals of Asthma Therapy
Reduce impairment and reduce risk
94
Proper MDI use technique
Exhale, puff MDI, inhale, hold for 10 seconds
95
Proper use of DPI technique
Click DPI, hold level, exhale away from DPI, form seal around dpi, inhale
Always swish and spit after use
96
Treatment for acute exacerbation of Asthma
```
2-6 puffs on own SABA-repeat in 20 minutes and then in 3-4 hrs
Can Add short course of Oral CS
If not relieved by the personal SABA
Repetitive or continues SABA new/MDI
O2 if SPO2<90
SYstemic CS
Can add a SAMA for severe Pt
```
97
Fluticasone propionate class
Inhaled Corticosteroid
98
Fluticasone proprionate MOA
ASthma controller medication
Improves control more effectively than other long term control meds
Reduces impairment and risk of exacerbation
Reduces airway inflammation, decreases airway hyper-responsiveness
Not for Rescue purposes
99
Fluticasone proprionate Indications and dosing
Pt on Step 2 or higher comes in 3 MDI 44, 110, 220mcg/puff
Low dose88-264mcg BID
Medium dose 264-440mcg BID
High Dose >440 mcg BID
100
Fluticasone proprionate Adverse Effects and contraindications
Oral Candidiasis
Hoarseness
CI:Hypersensitivity t CS or lactose/dairy proteins
101
Fluticasone proprionate Special considerations/monitoring/Pt ed
```
Dose depends on severity
BID
Titrations to lowest effective dose once control has been achieved
Not for acute relief
Rinse/gargle and spit after use
```
102
Albuterol class and MOA
SHort acting broncho dilator-beta 2 agonist
| Short term stimulation of beta 2 adenergic receptors
103
Albuterol indication and dosing
Most effective medication for relief of acute bronchospasm
PRN
Usually 2 puffs PRN
Acute exacerbation 4-8 puffs every 20 min for 3 doses
104
Albuterol Side effects and contraindications
SE:
| Tremor, increased HR, palpitations, Hyperglycemia, hypo Kalem is, hypomagnesemia
105
Albuterol special considerations, monitoring and Pt ed
Use caution with cardiac Pts, Hx of dm, hyperthyroid seizures,and glaucoma
Beta blockers dismiss the effects
Concurrent sympathomemetics can enhance risk of adverse effects
106
Prednisone class and MOA
Oral corticosteroids works on establishing control-anti inflammatory
Burst therapy
107
Prednisone indication
SABA unresponsiveness
Gradual deterioration
Establish control in existing or newly diagnosed Pt
108
Prednisone Side effects and contraindications
Sodium and water retention
Increased appetite, weight gain, CNS stimulation/nightmares, peptic ulcers and leukocytosis
CI: Hypersensitivity
109
Salmeterol/fluticasone Class and MOA
Duo therapy LABA and ICS
| Work on beta 2 receptors as an agonist and work to decrease the inflammation
110
Salmeterol/ fluticasone Indication
And above, limiting amount of meds a Pt needs to purchase and increasing compliance
111
Salmeterol fluticasone SE/CI
SE:Oral candidiasis, hoarseness, Tachycardia, palpitations, tremors
CI: Hypersensitivity
112
Montelukast class and MOA
Leukotriene modifying
| Blocks the conversion of arachiodonic acid into a broncho constrictor and a proinflammatory
113
Montelukast indication
Long term controller to be added to ICS
114
Montelukast ADverse effects/Contraindications
Headache, fatigue, dyspepsia, sleep disturbances, agitation
CI:
Hypersensitivity
Chewable-Pt with phenylketonuria
115
Montelukast special considerations/Pt ed/ monitoring
Not for acute relief
| Once daily in evening
116
Ipatropium class and MOA
SAMA
Competitively blocks muscarinic receptors in lungs causing bronchodilator
Slower onset and longer duration than Beta 2 agonists
117
Ipatroprium Inidications
Symptomatic relief from COPD
118
Ipatropium adverse reactions and contraindications
Cough dry mouth, dry throat, throat irritation, blurred vision, mydriasis, dyspepsia
Metal taste
Use with caution with Pts with narrow angle glaucoma, myasthenia Gravis, prostatic hyperplasia,
119
Tiotropium Class and MOA
LAMA, Competitively binds to muscarinic receptors causing broncho dilation
SLower action longer duration
120
Tiotropium indication and dosing
18mcg qday spiriva handihaler
121
Roflumilast CLass, MOA, Indications, Adverse reaction, contraindications and special considerations
C;Phosphodiasterase 4 inhibitor
M;Selectively inhibits PDE4, a major cAMP metabolizing enzyme, increasing intracellular cAMP in the lung cells
I:Decreases risk of exacerbations in Pt with severe COPD an h/o exacerbations
AE:SVT, weight loss, diarrhea, anxiety, depression and suicidal ideation
CI:Hypersensitivity, moderate-severe hepatic impairment
Special:Adjunct therapy with broncho dilators
122
Oseltamivir treatment dosing
75mg BID x 5 days
123
Oseltamivir Prophylaxis treatment
75 mg q day x 7-14 days
124
4 drugs used as initial TB treatment
```
RIPE
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
```
Until susceptibilities come back
125
Latent TB treatment
Isoniazid 9 months
Isoniazide with RFP 6 months
Rifampin 4 months
126
Active T infection treatment
Isoniazid, pyrazinamide and rifampin- 6 months
INH/RIF-9 months
RIF/EMB/PZA 6 months
RIF/EMB 12 months
127
TB treatment will be extended for
those with extrapulmonary TB, HIV and immunocompromised Pt
128
Hospital-acquired pneumonia treatment
Piperacillin-tazobactam 4.5 g IV q 6hrs(alone if no MRSA and No Gram neg)
Plus Levofloxacin IV 750 mg q day ( if Gram neg and /or MRSA)
Plus Vancomycin 15mg/kg IV q 8-12 hrs (If MRSA risk)
129
Salmeterol Class
LABA
130
Salmeterol Contraindications
Monotherapy in Asthma
