rxfiles notes Flashcards
2 antibiotics used in acne products; when should they be stopped
clinda and eryth; mostly for inflammatory lesions, always use with BP to prevent resistance, d/c when no further inflammation
how long to see noticeable improvement in acne, and how long long to max effect
2-4 weeks see worsening, 8-12w to improve, /max response
which acne product must be refrigerated? which doesn’t but has an expiry anyway
benzaclin (3 month expiry), clindoxyl can be at room temp but 2 month expiry
oral acne ABX
tetracycline, doxycycline, monocycline, erythromycin (2n line- increased GI and resistance), trimethoprim (3rd line)
which tetracycline is the most photosensitizing? hardest on stomach? what must you take on empty stomach? which do youseparatefrom cations?
doxy, tetra, tetra (abs decreased by dairy and food), all separate
what is pulse therapy with acne abx
use for 2-4 months, then follow with topical ABX and BP
which tetracyclines have cross resistance
doxy and tet
before starting acutane
need 2 negative pregnancy tests, and 2 reliable forms of contraception for one month before and one after using
SE of acutane
dryness (worst in first 8 weeks), sun sensitivity, minor aches
dose of accutane
0.5mg/kg/day divided BID CC for 4 weeks, then 1mg/kg/day for 3-7months (max 2mg/kg/day)
what to avoid with accutane
other acne topicals (increased dry), and vitamin a supplements (increased tox)
order of potency (high to low) of topical steroids
clobestasol (1-2), betamethasone diproprionate (2-4), beta valerate (5), HC (6-7)
how long to see the optimal effects of nasal steroids
3-14 days. best if given regularly and about 1 week before onset of allergen exposure
when should oral testosterone be taken
after meals- sig increase in absorption
where should transdermal gel (does not apply to patch, which is treated like any other patch) testosterone gel be applied, precautions
shoulder, abdomen or upper arms and wash hands. wait at least 6 hours before showering, can transfer to partners and kids so change t shirt
normal testosterone injection dose IM
100-150mg q2-3 weeks
disadvantages of testosterone injection
yoyo effect, more prone to AE. oral and transdermal def provide more stable levels
benefits and risks of testosterone therapy
B; decrease body fat, increase lean body mass and bone density and grip strength, improvement in mood and possibly libido (DOES NOT treat erectile dysfx). R; CV increased risk, fluid retention and HF exacerbation (made even worse with steroids), gynecomastia, testicular atrophy/infertility, increased prostate size and difficult urinating, acne, exacerbation of aggression,
how long should you wait after a dose change or new med before taking a TSH level
6-8 weeks
should we treat subclinical hypothyroid
research shows doesnt improve survival or CV mort. but monitor q6-12 months. If tSH >10 recheck in 6-8 weeks, and if still high treat on trial basis. If >4.5-10, consider tx expecially if sx or DM or lipids/HTN/pregnancy/planning, depression, etc
which drugs cause increased/decreased TSH
Inc; amiodarone (usually this), interferon, lithium, opiates, metoclopramide. Decr; amiodarone, dopamine, glucocorticoids, metformin, somatostatin, endogenous hormones too
when do patients see clinical improvement with thyroid tx
hypo- 2 weeks, hyper 3-4 weeks
how to space levothyroxine
1/2 hour before meals or 4 hours after, 1 hour after coffee/tea, 2-4 from al, ca, fe, mg, supplements, cholestyramine, cipro, colesevelam, orlistat, sevelamer, simethicone, etc, 8-12 from raloxifene
which drugs can decrease levothyrox levels
SSRI
what might levothyrox increase the effect of (drug)
TCAs- increase arrythmogenic effect/stimulatory effect - monitor for cardiac arrhythmia and CNS stimulation
average levothyroxine dose to start
1.6ug/kg/day (IBW) *entire dose may be given once weekly if non compliant
drugs that can cause constipation
NSAIDs, opioids, antipsych, benztropine, oxybutinin, antiparkinsons (amantadine, bromocriptine, pramipexole), anticonvulsants (gaba, pheny, pregabalin), TCA, antidiarrheals, antiemetics, 1st gena antihist, alpha agonists (clonidine), BB, CCB (esp verap), diuretics, dicyclomine (antispasmodic), Ca/Fe/bismuth/Al, chemo (vincristine/cyclophosphamide), resins
alarm sx of constipation
50 or over with new onset, rectal bleed, nocturnal sx, significant weight loss, fever, anemia
how to increase fibre, and what goals for adults should be for constipation
by 5g/week. 20-35g/day
treating constipation in infant (<1)
glycerin supp, lactulose or PEG okay. If over 6 months, may try apple/pear or prune juice (has sorbitol)
children >/= 1 yr for constipation
peg (0.4-1g/kg/day-max 17g.day), then MOM or lactulose.
constipation in pregnancy
increase fibre/fluid/activity, then bulk forming (psyllium etc), then osmotic lax (peg/lact), then short term stimulant
constipation in opioid use
tolerance doesn’t devlop, not thought to be dose dependent either;start a stimulant laxative with or wihtout stoool softener when opioid is started (1-2 tabs senokot HS)
bulk forming agents for constipation counselling
improve stool weight and consistency by increasing stool fluid content, onset 12-72 hours, psyllium has most efficacy data, take with full glass of water to prevent esophageal irritation and fecal impact. AE- flatuance, bloating; titrate slowly to minimize. Space by 2 hours from all others meds.
osmotics counselling constipation
poorly absorbed sugars to draw water into lumen and stimulate peristalsis. PEG: 48-96hrs, dissolve in water/juice/soda/coffee/tea (tasteless and odorless), less bloating vs lactulose. 17g=1sachet=1capfull per day. Not approved for 18 and under. Lactulose= 24-48hrs, sweet, safe in DM bc not absorbed, 15-30ml up to TID max 90mL/day. Glycerin supp: 15-60min, local irritation, moisten in lukewarm water before insert and hold in 15-30min. MOM; 0.5-6hours, CI renal or cardiac impairment.
stimulants counselling constipation
alter electrolyte transport in colon, increase intralumin fluids, stimulate peristalsis. Bisacodyl: 6-12 hrs (rectal 15-60 min), stronger vs senna, space milk, antacids (decrease acidity causes early disintegration), PPIs by 1 hr. Senna: 6-12hrs, mildest stimulant, may discolor urine/feces, SE dose dependent, no known clinical DI, DOSE: 2 tabs HS max 2 BID for preg and kids 6-12, and 2-4tabs HS or 4 tabs BID is max except in palliative- 4 tabs TID
5asa vs asa
5asa does not actually contain asa- no antplatelet effects
probiotics in IBD
more promise in UC vs CD
name some live vaccines. Who are they CI in? Preg?
MMR, varicella, zoster, yellow fever, oral typhoid/polio, rotavirus, flumist, BCG; do not give if planning immunosuppressives in 2-12 weeks. avoid in immunodef patients. avoid live in preg too but assess benef/risk (absolute CI MMR, varicella, zoster)
therapy used for UC
acute; 5asa (oral and PR), steroids, might use sulfasalazine, inflix if mod-sev and inadequate response or refractory to steroids. Maint; 5asa po or pr (pr is 2x/wk), mesalamine enema, sulfasalazine, infliximab if used to induce maintenance in mod to sev
therapy used for CD
acute; prednisone (may add AZA or 6-MP due to slow onset), sulfasalazine, if ineffective consider MTX, inflix or adalimumab. main; tx not always required if mild, can use 5ASA, MTX, AZA or 6MP, if mod to sev and induction successful with it continue inflix or other anti tnf.
what is the only 5asa form that covers all parts of GI system? Which are only good for colitis and not crohns? What covers least?
all- pentasa. Only colitis- topicals and enemas. Least- suppository (rectum only)
what is cleaved into 5asa and sulfapuridine- who is this CI in? what should you consider with it? What are the main SE? what if you don’t tolerate one?
sulfasalazine- CI in hypersensitivity to sulfonamides or salicylates. Caution in G6PD. Consider folic acid supplement as it decreases its absorption. SE; dose related=GI and HA and arthralgia. Non dose related- rash (SJS), hepatotox, bone marrow supp, pancreatitis, nephrotoxic, photosens, can discolor skin/tears/urine, oligospermia (reversible when stop)- start low dose and increase q2-3days to decrease SE. If don’t tolerate SSZ 80% tolerate 5ASA
time to effect of IBD agents
sulfasal, 5 asa; 2-4 weeks, CS; 7-10 days, purine antimetabolites (ASA and 6MP); 3-6 months, biologics; 2 weeks
what’s up with the enteric coated tabs of 5asa
for IBD- pH dependent release in terminal illeum for the rectum
which purine antimetabolite has to be adjusted for kidney and liver?
azathioprine- mercapto you don’t have to
how do ppis help with gastric ulcer
decrease re bleed risk and need for surg, but NOT mortality
acid suppression in preg
tums/alginates preferred, ranitidine and omeprazole safe, lansoprazole and pantoprazole and cimetidine/famotidine likely safe
when should DAPT be using gastric protection (PPI)
hx of GI bleed or ulceration, multiple concurrent risk factors (65 or older, concurrant anticoagulant, h pylori infection, NSAIDs, steroids); ie these are high and med risk. If lw risk (no GI risk factors), w/o ppi is okay
ppis most and least likely to have DI
most- omeprazole and esomep. least- pantoprazole and rabeprazole
only ppi available IV
pantoprazole
what adjustments need to be made to ppis and H2blockers for organ fx
ppis- adjust for liver, H2 adjust kidney
how to get most accurate readings for urea breath test and h pylori
prevent false neg by stopping ABX x4weeks, bismuth xat least 2w, ppis at least 3d, and H2blockers at least 1 day before testing. Can use antacids prn
what is triple h pylori therapy, and what is used if it fails
triple= amox, clarith, ppi x7-14 days (10-14 usually recommended). Fail? repeat with alternate regimen (metro, clarith, ppi) OR treat for 2 weeks or use quad therapy (metro, tetra, bismuth-use suspension or caplets to prevent DI with tetra, ppi). Another quad option= ppi, amox, metro, clarith
non pharm N/V
avoid unpleasant odors, get fresh air, smaller meals, loose clothing, distraction, avoid rapid head movements if motion induced
when to repeat a dose of meds it vomit up
within 30 minutes orally
what to use for post op or for chemo induced NV
post op; dexameth, granisetron, dolasetron, droperidol, metoclop, ondansetron, diminhydr, haloperidol. Chemo- use seratonin antagonists (ondans, graniset, dolasetron)
all therapies used for NV are _____ of different receptors. Name classes and where they work
antagonists. DA; haloperiodol, metoclopramide, domperidone (act at CRTZ- good for opioid induced esp halop bc most potent). Weak DA phenothiazines (prochlorperazine) (sig AE), sertatonin antagonists (5HT3)=ondans, granis, dolasetron (act centrally and peripherally- CTZ and gut- but no action on DA therefore not for opioid induced, well tolerated). Antihist (histamine and muscarinic ie cholinergic), esp for motion. Antichol (M1)- scopalamine (sedation, blurry vision, dry mouth, limit)- mostly for motion tx and prevention. Benzos (no direct effect, can be for post chemo, usually to reduce anx and psych factor of NV). CS (dexa)-preferred for severe or refractory. Somatostatin analogues (octreotide) and neurokinin 1 ie substance p antag (aprepitant and fosaprepitant)- used with CS for highly emetogenic regimens
increased risk of post op NV if
female, hx of it or motion sick, non smoke, taking opioids post op
what is betahistine used for
BID prn for motion related NV- meniere’s, vestibular disorders (vertigo) etc
comment on PDE5 inh onset and duration
onset about 30-60 minutes, SV last 4-12h, T lasts 36 or less.
how far should alpha blockers be spaced from pde5 inh
4-6 hours or avoid
which pde5inh can increase QT
vardenafil
name 3a4 inhibitors- what is the significance with pde5inh?
azole anttifungals, cimetidine, cipro, erythro, clarithro, tac, doxy, grapefruit, isoiazid, PI, quinidine, verapamil -USE lowest dose of PDE5 inh as it can increase the levels
high fat meals may delay abs and decrease efficacy of these pde5inh
silden, varden
which pde5inh doesn’t have to be adjusted for renal fx
vardenafil; ALL must be adjusted for liver
intercavernosal injections dosing
no more than 3 per week and must have 24 hours between doses
how to apply antifungal topical
1-2inches beyond rash, continue one week after sx gone and skin looks healed, keep area clean and dry
tx of choice for syphillis
benzathig pen G (1 IM dose). Doxy 100mg BID x14days alternative if allergy
tx of choice gonnorhea
cetriaxone 250mg IM OR cefixime 800mg PO stat + azithro 1g po stat (for chlamydia coverage). If severe ceph allergy, do azith 2g po x1 stat
tx of choice chlamydia
azith 1g x1 dose or doxy 100mg BID x7days
when treating STIs do you treat partners? How long abstain sex?
all partners test and treat 60days or less. abstain f7d after tx
amox vs ampicillin
recommend amox- both PO, but amox has better absorption, is given q8h vs 6, decreased rash and diarrhea- unless shigella/citrobacter/enterobacter/listeria
amox clav must be givin with food- TF?
T- increased absorption. also may decrease stomach upset. higher ratio formulations give less diarrhea as given q12h
only penicillin that needs to be adjusted for renal fx
ampicillin
antibiotics adjusted for renal dysfx
ampicillin, cefuroxime, cephalexin, FQ, clarith, septra, tetracycline, nitro (avoid under 60), probenacid
what is the estolate form of eryth more useful for
kids as it is most acid stable. Not recommended in adults or pregnancy!
how long to separate tetracyclines from ca and fe
take tetra 1 hour before or 2 hours after them
which tetracycline must be on an empty stomach with water
tetracycline
nitrofurantoin is used for ___ only and should be avoided in this part of pregnancy
UTI (also proph)- avoid at term ie 3rd tri/36 weeks
what is the most potent antacid
calcium carbonate
