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Ultimate Sadness > Study Gal Tips and Key Drugs > Flashcards

Study Gal Tips and Key Drugs Flashcards

1
Q

Capecitabine active metabolite

A

fluorouraciil

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2
Q

clopidogrel active metaolite

A

just know that it is metabolized into an active metabolite by CYP2C19 enzymes

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3
Q

codeine active metabolite

A

metabolized into morphine by CYP2D6

CYP2D6 ultra-rapid metabolizers change it into morphine too fast, tox risk

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4
Q

Colistimethate active metabolite

A

colistin

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5
Q

Cortisone active metabolite

A

cortisol

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6
Q

famciclovir active metabolite

A

penciclovir

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7
Q

fosphenytoin active metabolite

A

phenytoin

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8
Q

Isavuconazonium sulfate active metabolite

A

isavuconazole

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9
Q

levodopa active metabolite

A

dopamine

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10
Q

lisdexamfetamine active metabolite

A

dextroamphetamine

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11
Q

prednisone active metabolite

A

prednisolone

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12
Q

primidone active metabolite

A

phenobarbital

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13
Q

tramadol active metabolite

A

just know it has one

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14
Q

valacyclovir active metabolite

A

acyclovir

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15
Q

valganciclovir active metabolite

A

ganciclovir

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16
Q

Common CYP inducers involved in drug interactions

A

PS PORCS

  • phenytoin
  • smoking
  • phenobarbital
  • oxcarbazepine
  • rifampin (rifabutin, rifapentine)
  • carbazepime
  • st. john’s wort
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17
Q

Patches that can be applied twice a day

A

diclofenac

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18
Q

Patches that can be applied daily

A
  • Methylphenidate (Daytrana) - apply 2hr before school
  • Nicotine (NicoDerm CQ)
  • Rivastigmine (Exelon)
  • Rotigotine (Neupro)
  • Selegiline (Emsam)
  • Testosterone (Androderm) - apply HS, NOT to scrotum
  • Lidocaine - on for 12hr, off for 12hr PRN
  • Nitroglycerin - on for 12-14hr, off fr 10-12hr
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19
Q

Patches that can be applied Q72H

every 3 days

A
  • fentanyl (but if it wears off after 48hrrs can change to q48h)
  • scopolamine (Transderm Scop) - PRN
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20
Q

Patches that can be applied twice a week

A
  • Estradiol (Alora, Vivelle-Dot) - can applied twice a week continously or in cycles of 3 weeks on, 1 week off
  • Oxybutynin (Oxytrol)
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21
Q

Patches that can be applied weekly

A
  • Donepezil (Adlarity)
  • Buprenorphine (Butrans)
  • Clonidine (Catapress-TTS)
  • Estradiol (Climara) - can be applied continously or in cycles of 3 weeks on, 1 week off
  • Estradiol/Levonorgestrel
  • Ethinyl etradiol/norelgestromin (Xulane, Zafemy) - in cycles of 3 weeks on, 1 week off
  • Ethinyl estradiol/levonorgestrel (Twirla) - in cycles of 3 weeks on, 1 week off
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22
Q

Drugs that require non-PVC containers

A

LATTIN (Leach Asorbs To Take In Nutrients)

  • lorazpam
  • Amiodarone
  • Tacrolimus
  • Taxanes (exception: paclitaxel-albumin bound can do PVC)
  • Insulin
  • Nitroglycerin
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23
Q

Drugs to mix in saline only

A

ADIACEP (A DIAbetic Can’t Eat Pie)

  • ampicillin (much shorter stability in dextrose)
  • daptomycin
  • infliximab
  • amp/sul
  • caspofungin (Cancidas)
  • ertapenem (Invanz)
  • phenytoin (Dilantin)
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24
Q

Drugs to mix in dextrose only

A

OSA (Only Sugar Always)

  • oxalipltin
  • smx/tmp
  • amphotericin B (all)
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25
what injectables should NOT be mixed with Ca
- ceftriaxone - phosphate - if making TPN phosphate first, Ca last | remember that LR contains Ca, don't do LR with CTX
26
Drugs that require filters
my **GAL Is PAT** who has a **MaP** - **G**olimumab - **A**mphotericin B (lipid formulations) - needs a 5 micron filter - **Is**avuconazoium - **P**henytoin - filter only required for continuous infusion, NOT IV push - **A**miodarone - **T**axanes - **M**annitol >20% - **P**arenteral nutrition - 1.2 micron filter ## Footnote also - abatacept - select albumin products - antithymocyte globulin - infliximab
27
Injectable drugs that should NOT be refrigerated
**D**ear **S**weet **P**harmacist, **F**reezing **M**akes **M**e **E**dgy - **D**exmetodomidine - **S**mx/tmp - **P**henytoin - crystallzies - **F**urosemide - crystallizes - **M**etronidazole - **M**oxifloxacin - **E**noxaparin ## Footnote also - APAP - acyclovir - crystallizes - deferoxamine - precipitates - levetiraceta - pentaidine - crystallizes - valproate
28
Injectable drugs that need to be protected from light
**P**rotect **E**very **N**ecessary **M**ed from **D**aylight - **P**hytonadine (VitK) - **E**poprosteol - **N**itroprusside - **M**icafungin - **D**oxycycline ## Footnote also - amohtericine B deoxycholate - anthracyclines - dacarbazine - if it extravasates, protect exposed tissues from light - pentamidine
29
How to look for med problems in a pt case
- untreated condition - meds without an indication - improper drug selecgion - improper dose - therapeutic duplication - lack of pt understanding - drug allergy - drug interaction - improper use of med - failure to receive med - adverse drug reaction - nonadherence
30
Aminophylline - theophylline dose conversion
aminophylline x 0.8 = theophylline ## Footnote ATM (aminophylline to theophylline, multiply)
31
Calcium salts dose conversion
- calcium carb = 40% elemental Ca - calcium citrate = 21% elemental Ca
32
iron salts dose conversion
- Fe gluconate - 12% elemental Fe - Fe sulfate - 20% - Ferrous sulfate, dried (ER) - 30% - Ferrous fumarate - 33% - Carbonyl iron - 100% - Polysaccharide iron complex - 100% - Ferric maltol - 100%
33
loop diuretic dose converson
the following are PO equivalent doses | bumetaanide and ethacrynic acid have IV:PO 1:1, furosemide IV:PO = 1:2 ## Footnote - furosemide 40mg - torsemide 20mg - bumetanide 1mg - ethacrynica acid 50mg
34
opioid dose conversioin
the following are equivalent: - **morphine**: 10mg IV = 30mg PO - **hydromorhine**: 1.5mg IV = 7.5mg PO - **oxycodone**: NA IV = 20mg PO - **hydrocodone**: NA IV = 30mg PO - **codeine**: 130mg IV = 200mg PO - **fentanyl**: 0.1mg IV = NA PO - **meperidine**: 75mg IV = 300mg PO - **oxymorphone**: 1mg IV = 10mg PO ## Footnote to convert, calculate the 24 hr dosse and reduce dose by 25% for cross tolerance (if the exam does NOT specify to reduce, do NOT)
35
statin equivalent doses
- pitavastatin 2mg - rosuvastatin 5mg - atorvastatin 10mg - simvastatin 20mg - lovastatin 40mg - pravstatin 40mg - fluvastatin 80mg
36
metoprolol IV:PO dose conversion
IV:PO 1:2.5
37
levothyroxine IV:PO dose conversion
IV:PO 0.75:1
38
ratio strength to percent strength
% strength = 100 / ratio strength
39
dissociation particles vs. valence
- valence: outer electrons/bonds that can be made - dissociation particles: number of particles made by breaking something apart ## Footnote - NaCl: 1 bond therefore 1 valence; Na and Cl therefore 2 particles - CaCl2: 2 bonds therefore 2 valence; Ca and 2 Cl therefore 3 particles
40
carbs kcal/gram
4 kcal/gram
41
fat kcal/gram
9 kcal/gram
42
protein kcal/gram
4 kcal/gram
43
dextrose monohydrate kcal/gram
3.4 kcal/gram
44
glycerol/glycerin kcal/gram
4.3 kcal/gram
45
injectable lipid emulsion (ILE) 10% kcal/mL
1.1 kcal/mL
46
injectable lipid emulsion (ILE) 20% kcal/mL
2 kcal/mL
47
injectable lipid emulsion (30%) kcal/mL
3 kcal/mL
48
amino acid solutions kcal/gram | `
4 kcal/gram
49
how to interpret ABG (acidosis vs alkalosis)
1. low pH is acidosis, high pH is alkalosis 2. if there is a change in CO2 it has a respiratory origin; if there is a change in HCO3 it has a etabolic origin 3. if both CO2 and HCO3 are abnormal, see which abnormality matches the pH, the other value is compensatory (CO2 is acidic, HCO3is basic)
50
rounding when calculating NNT and NNH
- always round up for NNT: 1.2 -> 2 - always round down for NNH: 1.2 -> 1
51
what is covered in USP 795
nonsterile (hazardous and non hazardous)
52
what is covered in USP 800
hazardous (sterile and nonsterile)
53
what is covered in USP 797
sterile (hazardous and nonhazardous)
54
torsion balances
Class III (Class A) torsion balances require outside wts to determine a wt >1 gram and has interal weights for < 1gram ## Footnote has a sensitivity requirement that is typically 6mg -> based on a standard acceptable error of 5%, the minimal weighable quanitity is 120mg
55
Ora-Plus vs. Ora-Sweet
Ora-Plus - keeps drug particles susended, prevents them from settling - bland taste, must be combined with Ora-Sweet ## Footnote Ora-Sweet - simple to simple syrup - provides flavor - available in sugar-free formulations
56
HLB number
- HLB scale ranges from 0 to 20 - Surfactants with an HLB number **< 10** are ore **lipid soluble** and used for **water in oil** emulsions - If > 10, more water solule and used for oil in water emulsions
57
When compounding, what patient population should alcohol be avoided in?
children ## Footnote alcohol is used as a solvent
58
When compounding, what patient population should aspartame be avoided in?
aspartame containes phenylalanine, avoid in patients with **phenylketonuria (PKU)**, they are uunable to metabolize the phenylalanine ## Footnote aspartame is used as a sweetner
59
When compounding, what patient population should gelatin be avoided in?
anyone who wishes to avoid animal products ## Footnote can use hypromellose capsule shells which are made from cellulose and are therefore vegan
60
When compounding, what patient population should gluten be avoided in?
patients with celiacs and those who wish to avoid gluten ## Footnote gluten is used as a starch (filler) and is in wheat, barley and rye - may use corn or potato starch or tapioca
61
When compounding, what patient population should lactose be avoided in?
lactose intolerance or allergy ## Footnote lactose is used as a sweetner, to compress tablets, and as a filler/diluent
62
When compounding, what patient population should preservatives be avoided in?
neonates
63
When compounding, what patient population should sorbitol be avoided in?
IBS (sorbitol can cause GI stress) ## Footnote sorbitol is used as a sweetner
64
When compounding, what patient population should sucrose be avoided in?
diabetics (depending on the amount) ## Footnote sucrose (table sugar) is used as a sweetner and in coatings
65
66
When compounding, what patient population should xylitol be avoided in?
- dogs (it can cause xylitol toxicosis - hypoglycemia and hepatotox) - humans with hx of GI upset with xylitol use ## Footnote xylitol is used as a sweetner
67
how to prepare a solution
1. gather ingredients 2. reduce particle size o fine powder 3. dissolve solute in solvent 4. Add any required excipients: buffer, preservative, flavors, sweetners, coloring 5. package and apply BUD with apropriate auxiliary labets ## Footnote dissolution rate can be increased if the particles are smaller, if the preparation is stirred or if heat is applied
68
how to prepare a suspension
1. gather ingredients 2. reduce particle size to fine powder 3. wet powder ad levigate to form paste 4. continue to add in liquid in portions 5. add in surfactant to keep suspension dispersed 6. transfer to dispensing container and QS the volume 7. add any required excipients: preservatives, flavor, sweetneres 8. package and apply BUD - make sure to include a shake sticker
69
how to prepare emulsions | dry gum method (continental method)
1. levigate gum with oil 2. add water all at once 3. triturate by shaking in a bottle or ixing in a mortar until a cracking sound is heard and mixture is creamy white 4. add other ingredients by dissolving them first in solution and QS with water up to final volume 5. homogenize with a homogenizer machine
70
how to prepare an emulsion | wet gum method (english method)
1. triturate the gum with water to form a mucilage (thick and sticky like mucus) 2. add oil in slowly while shaking or mixing 3. add other ingredients by dissolving them first in solution and QS with water up to final volume 5. homogenize with a homogenizer machine
71
how to prepare a molded tablet
1. triturate the dry ingredients and mix by geometric dilution 2. add alcohol and/or water to moisten the powder (should be a pasty consistency) 3. mold the paste into a tablet using tablet mold and allow to dry
72
how to prepare ointments
1. triturate powders well using a levigation agent which is miscible with base 2. powder then mixed into ointmet base using geometric dilution ## Footnote certain ointments need heat (called fusion)
73
methods to prepare suppositories
- hand molding - fusion molding - compression method
74
non sterile BUD dates - aqueous nonpreserved - aqueous preserved - nonaqueous oral liquid - nonaqueous other forms
- aqueous nonpreserved: 14 days in fridge - aqueous preserved: 35 days - nonaqueous oral liquid: 90 days - nonaqueous other forms: 180 days ## Footnote aqueus: Aw > 0.6 nonaqueous: Aw < 0.6
75
master formulation record vs. compounding record
- master formulation record: wht you should do - compounding record: what yu did
76
CSP
compounded sterile product
77
SVP
small volume pareteral (IV bag 100mL or less)
78
LVP
large volume parenteral (>100mL)
79
PPE
personal protective equipent
80
PEC
primary engineering control - sterile hood that provides ISO 5 air
81
LAFW
laminar airflow workbench
82
SEC
ssecodary engineering control - room ontaining ISO 7 air where PEC is located (buffer room)
83
SCA
segrated compounding area - contains a PEC but is not an SEC
84
CAI
compounding aseptic isolator - a closed front PEC used for nonhazardous drugs
85
RABS
restrited access barrier system - any closed front PEC, used for either hazardous or nonhazardous (CAI) | "glovebox"
86
ISO air requirements
- PEC: ISO 5 - SEC: ISO 7 - anteroom: ISO 7 or 8 - dt positive pressure, can have ISO 8 because the air is blowing out of the SEC into the anteroom (therefore anteroom can have dirtier air) | if being used to compound hazadous materials, the anteroom must be ISO 7
87
Sterile product BUDs - immediate use - made outside of PEC but with aseptic technique - category 1 - made in a PEC located in an SCA - category 2 - made in a PEC located in an SEC - category 3 - made in a PEC located in an SEC with additional requirements
- **immediate use**: 4 hours no matter how it is sstored - **category 1**: 12 hrs at room temp **/ ** 24 in fridge - **category 2**: up to 45 days at room temp **/** 60 in fridge **/** 90 if frozen - **category 3**: up to 90 days at room temp **/** 120 in fridge **/** 180 in freezer
88
important 5 alpha-reductase inhibitors on the NIOSH list
- dutasteride - finasteride
89
important abortifacients on the NIOSH list
- mifepristone - misoprostol
90
important anticoag on the NIOSH list
warfarin
91
important antivirals on the NIOSH list
- cidofovir - ganiciclvor - valganciclovir
92
important antiseizure meds on the NIOSH list
- CBZ - oxCBZ - foshenytoin - phenytoin - topiramate - valproate
93
important benzos on the NIOSH list
- clonazeam - temazepam
94
important dyslipidemia meds on the NIOSH list
lomitapide
95
important heart failure meds on the NIOSH list
spironolactone
96
important hepatitis meds on the NIOSH list
ribavirin
97
important pulmonary arterial HTN meds on the NIOSH list
- ambrisentan - bosentan - macitentan - riociguat
98
important retinoic acid deritvatives on the NIOSH list
tretinoin
99
important SSRIs on the NIOSH list
paroxetine
100
important thionamides on the NIOSH list
- methimazole - propylthiouracil
101
important transplant meds on the NIOSH list
- cyclosporine - mycophenolate - tacrolimus - sirolimus
102
important meds to treat autoimmune conditions on the NIOSH list
- acitretin - azathioprine - fingolimod - leflunomide - teriflunomide
103
important hormonal agents on the NIOSH list
- androgens - estrogens - oxytocin - progestins - SERD/SERMS - ulipristal
104
important nephrotoxic drugs
- aminoglycosides - amphotericin B - cisplatin - loops (associated with AKI dt excessive volume loss) - cyclosporine - NSAIDs - polymyxin B - radiographic contrast dye - tacrolimus - vanc
105
CrCl vs. GFR
CrCl - medication contraindications and dosing adjustments are typically based on CrCl using the Cockcroft Gault equation ## Footnote GFR - not commonly calculated by pharmacists but may be reported with the BMP - CKD-EPI and MDRD equations are used - used for staging kidney disease and for dosing select drugs (metformin adn SGLT2i) - if GFR is not provided, CrCl provides an estimate to determine drug contraindications adn dosing adjustments
106
ACEi and ARBs for albuminuria ## Footnote - who: what pts should get an ACE/ARB - why - how: MOA of the ACE/ARB - what: what is the benefit
- who: ACE or ARB recommended in pts with HTN and albuminuria - why: to prevent kidney disease progression - how: inhibit RAAS -> efferent arteriolar dilation - what: reduce pressure in the glomerulus, decrease albuminuria and delay progression to ESRD
107
Key drugs that require change in dosing interval in CKD
- aminoglycosides (usually increase interval) - beta lactams (except nafcillin, oxacillin, and CTX) - fluconazole - quinolones (except moxifloxacin) - vancomycin - enoxaparin - xarelto (for afib) - eliquis (for afib) - pradaxa (for afib) - H2RAs - metoclopramide - bisphosphonates - Li
108
Key drugs that are contraindicated in CrCl < 60
nitrofurantoin
109
Key drugs that are contraindicated in CrCl < 50
- tenofovir **disoproxil fumarate** containing products* - voriconazole IV dt vehicle ## Footnote *Complera, Delstrigo, Stribild (for treated pts do not start if CrCl < 70), Symfi
110
Key drugs that are contraindicated in CrCl < 30
- tenofovir **alafenamide** containing products* - NSAIDs - dabigatran (for VTE) - rivaroxaban (for most indications, CI CrCl 15 in PAD and CAD) | *Biktarvy, Descovy, Genvoya, Odefsey, Symtuza
111
Key drugs that are contraindicated in eGFR < 30
metformin | for treated pts, do not start treatment if eGFR < 45
112
Key drugs that are contraindicated in eGFR < 60
meperidine
113
Key drugs that raise potassium level
- ACE/ARB - aliskirin - canagliflozin - drospirenone-containing COC - K containing IV fluids - K sparing diuretics (triamterene, spironolactone) - K supplements - Bactrim - Transplant drugs (cyclosporie, tacrolimus)
114
Hyperkalemia treatment
1. stabilize heart (if applicable) - IV calcium 2. shift K into the cell - insulin +/- dextrose; sodium bicarb (if acidosis); albuterol neb 3. eliminate K from body (see below) ## Footnote - Loops: onset of 5 min - SPS: onset 2-24 hrs (up to days for PO) - binds K in GI tract (ADR GI necrosis) - paitromer: onset 7 hrs - binds K in GI tract - sodium zirconium cyclosilicate: onset 1 hr - binds K in GI tract - HD
115
HepA, HepB, HepC comparison: acute or chronic
- HepA: acute only - HepB: acute or chronic - HepC: acute or chronic
116
HepA, HepB, HepC comparison: transmission
- HepA: fecal-oral - HepC: blood, body fluid - HepC: blood
117
HepA, HepB, HepC comparison: are vaccines available
- HepA: yes - HepB: yes - HepC: no
118
HepA, HepB, HepC comparison: first line treatments
- HepA: N/A - HepB: Peg-IFN or NRTI (tenofovir or entecavir) - HepC: treatment naive - direct acting antiviral (DAA) combination | select HepC patients can do DAA + RBV
119
direct acting antiviral mechanisms and agents
- S3/4A protease inhibitors (-previr) - glecaprevir - grazoprevir - voxilaprevir - NS5A replication complex inhibitors (-asvir) - elbasvir - ledipasvir - pibrentasvir - velpatasvir - N25B polyermase inhibitors (-buvir) - sofosbuvir | take with food (except for elbasvir/grazoprevir)
120
lab tests for liver disease
- **acute liver tox **(including from drugs): increased AST, ALT - **chronic liver disease**: *increased* AST, ALT, alk phos, Tili, LDH, PT/INR; *decreased* albumin - **alcoholic liver disease**: increased AST, ALT (but AST almost double ALT), GGT - **hepatic encephalopathy**: increased ammonia - **jaundice**: increased bili
121
key drugs that have a black boxed warning for liver damage
- APAP (high doses) - amiodarone - isoniazid - ketoconazole - MTX - nefazodone - nevirapine - propylthiouracil - VPA - zidovudine
122
Key common live vaccines
- MMR - Intranasal flu - Cholera - Rotavirus - Oral typhoid - Varicella - Yellow fever | MICRO-VY
123
Vaccine timing and spacing
- vaccines can usually be given at same time - multiple live vaccies can be given on same day (or if not on same day, spaced 4 weeks apart) - if vaccine series requires more than 1 dose, the intervals between doses can be extended without restarting the series, but they shouldn't be shortened ## Footnote - MMR and varicella containg vaccines should be separated from antibody containing products (blood, IVIG) - vaccine -> 2 weeks -> Ab containing product - Ab containing product -> 3+ months -> vaccine - Simultaneous admin of vaccine and Ab (in the form of Ig) is recommended for PEP of Hep A, B, rabies, and tetanus
124
**invalid** contraindications to vaccines
- mild acute illness (slight fever, mild diarrhea) - current ABX treatment (CI if it is a live vaccine) - hx of mild-mod skin rxn to vaccine - allergy to penicillin or products not in vaccine - pregnancy (CI if it is a live vaccine) breastfeeding, premature birth - recent Tb skin test - immunosuppresed person in household - Recent exposure to the disease or convalescence - family hx of ADR to vaccine
125
Preferred flu vaccine for patients > 65
- Fluzone High-Dose - Fluad - Flubok
126
What population should receive 2 flu vaccines spaced 4 weeks apart
pts age 6 months to 8 years if not previously vaccinated
127
Drugs for travelers' diarrhea **ppx**
- bismuth subsalicylate 524-1050mg PO with meals and HS - ABX (rifaximin preferred) - only use if high risk of complications from TD
128
Drugs for travelers' diarrhea **treatment**
- mild diarrhea: loperamide or bismuth subssalicylate - moderate diarrhea: loperamide +/- ABX (zithro or quinolone if low resistance, rifaximin as alt) - severe diarrhea (including dysentery): abx +/- loperamide (zithro preferred, quinolones or rifaximin as alt)
129
travel vaccines
- HepA: Havrix, VAQTA - HepB: Engerix-B, Helisav-B, Recombivax HB - HepA/B: Twinrix - Japanese encephalitis: Ixiaro - Meningocus: Menveo, MenQuadfi - Polio: IPOL - Typhoid-IM: Typhim Vi ## Footnote - Cholera-PO: Vaxchora (live) - Typhoid-PO: Vivotif (live) - Yellow fever-SC: YF-VAX (live)
130
Class effect of penicillins
- all penicillins should be avoided in pts with a beta-lactam allergy (EXCEPT: for treatment of syphilis in preggers or in pts with poor compliance - densitize and treat with pen G) - all penicillins increase the risk of seizure if accumulation occurs
131
Oral penicillins and key uses
- penicillin VK: first line for strep throat (pharyngitis) - amoxicillin: first line for AOM, drug of choice for endocarditis ppx before a dental procedure - augmentin: first line for AOM and bacterial sinusitis (use lowest dose of clavulanate to reduce diarrhea) - dicloxacillin: covers MSSA, no renal dose adjustment
132
Parenteral penicillins and key uses
- Penicillin G IM: drug of choice for syphilis (do NOT use IV, can cause death) - nafcillin and oxacillin: covers MSSA, no renal dose adjustment - zosyn: only penicillin active against pseud
133
class effect of cephalosporins
- cross reactivity is low, do not choose a cephalosporin if pt has a true penicillin allergy - risk of seizure if accumulation
134
PO cephalosporins and key uses
- 1st gen cephalexin: MSSA, strep - 2nd gen cefuroxime: AOM, CAP - 3rd cefidinr: AOM
135
parenteral cephalosporins and key uses
- 1st gen cefazolin: surg ppx - 2nd gen cefotetan (can cause disulfiram-like reaction with alcohol ingestion), cefoxitin: anaerobic coverage, GI surg ppx - 3rd gen CTX (no renal adjustment, do NOT use in neonates): CAP, mengitis, SBP, pyelo ## Footnote - ceftaz (3rd gen) cefepime (4th gen): pseud activity - ceftolozane/tazobactam and ceftazidime/avibactam: for MDR gram neg (including pseud) - ceftaroline (MRSA activity): CAP, SSTI
136
class effect of carbapenems
- active against ESBL producing organisms (except erta) and pseud - do NOT use with penicillin allergy - seizure risk ## Footnote - do NOT cover: atypicals, VRE, MRSA, c. diff, steno - erta does NOT cover (APE): acinetobacter, pseud, erterococcus
137
class effects of aminoglycosides
- kill gram neg (including pseud) - synergisitc for gram positive organisms when combined with beta-lactams or vanc - [ ] dependent activity - do an extended interval dose (takes advantage of [ ] dependent activity and gives kidneys recovery time) - post-ABX killing effect ## Footnote - nephrotox - ototox (potentially irreversible)
138
Resipriatory quinolones
- levofloxacin - moxiflxoacin ## Footnote reliable s. pneumo coverage
139
anti-pseud quinolones
- ciproflox - levoflox
140
which quinolone is not renally dose adjusted
moxifloxacin
141
which quinolone should NOT be used for UTIs
moxiflox
142
which quinolones have a 1:1 PO IV ratio
- levoflox - moxiflox
143
class effects of quinolones
- caution with CV disease pts: quinolone decrease K and Mg - caution with other QTc prolonging agetns - Avoid in pts with hx of seizure - Avoid in children ## Footnote - avoid sun exposure - separate from polyvalent cations - monitor BG in diabetics - ADR: tendon rupture, neuropathy, CNS and psych ADR
144
Doxycycline uses
- SSTI (covers MRSA) - acne - tick borne illness (Lyme, Rocky Mountain Spotted Fever) - chlamydia - CAP - bacteria sinusitis - VRE UTI
145
What population should tetracyclines be avoided in
preggers, breast feeding, children < 8 yrs
146
In what patient population should nitrofurantoin be avoided
- CrCl < 60 - G6PD deficiency
147
Commonly used drugs for MSSA infections
- dicloxacillin, nafcillin, oxacillin - cefazolin, cephalexin and other 1st and 2nd gen cephalosporins - augmentin, unasyn
148
Commonly used drugs for MRSA infections
- vanco (consider using an alt if MIC > 2) - lineolid - dapto (NOT for PNA dt inactivation in lung) - ceftaroline ## Footnote MRSA SSTI: bactrim, doxy, clinda
149
Commonly used drugs for VRE infections
- linezolid - dapto ## Footnote - e. faecalis: PenG or ampicillin - cystitis: nitrofurantoin, fosfomycin, doxy
150
Commonly used drugs for atypical infection
- zithro, clarithromycin - doxy, minocycline - quinolones
150
Commonly used drugs for HNPEK infection
- beta-lactam with a beta-lactamase inhibitor - 1st gen cephalosporins - carbapenems - aminoglycosides - quinolones - bactrim | Haemophilus, Neisseria, Proteus, E. coli, Klebsiella
151
Commonly used drugs for pseud infection
- zosyn - cefepime - ceftazidime +/- avibactam - ceftolozane/tazobactam - carbapenems (minus ert) - ciproflox, levoflox - aztreonam - tobramycin
152
Commonly used drugs for CAPES infection
- zosyn - cefepime - carbapenems - aminoglycosides | Citrobacter, Acintobacter, Providencia, Enterobacter, Serratia
153
Commonly used drugs for ESBL producing gram-neg rods
- carbapenems - ceftaz/avibactam - ceftolozane/tazobactam | E. coli, K. pneumo, P. mirabilis
154
Commonly used drugs for CRE infection
- ceftaz/avibactam - cilistimethate, polymixin B - meropenem/vaborbactam - imipenem/cilastatin/releactam
155
Commonly used drugs for gram-neg anaerobes
- flagyl - beta-lactam with a beta-lactamase inhibitor - cefotetan, cefoxitin - carbapenems - moxifloxacin (but reduced activity) | bacteroides fragilis
156
Commonly used drugs for c. diff infection
- PO vanc - fidoxomicin - flagyl
157
key ABX that do NOT require renal dose adjustment
- antistaph penicillins (dicloxacillin, naficillin) - zithro and erythromycin - CTX - clinda - doxy - flagyl - moxiflox - linezolid
158
timing of perioperative ABX
- **pre-op**: infuse 60 min prior to first incision (unless using quinolone or vanc, then use 120min prior) - **intra-op**: additional doses may be adminsitered if surgery longer than 4 hrs or if there is major blood loss - **post-op**: ABX typically not needed
159
empiric meningitis treatment in pts < 1 month old
ampicillin + (cefotaxime, ceftazidime, cefepime) +/- gentamicin ## Footnote - ampicillin is used for listeria coverage - no CTX because of biliary sludging and kernicterus
160
empiric meningitis treatment in pts 1 month old to 50 years old
CTX + vanc ## Footnote vanc is added for double coverage of s. pneumo
161
empiric meningitis treatment in pts > 50 years old **or** immunocompromised
ampicillin + CTX + vanc ## Footnote - amp added back on for listeria coverage - vanc for double s. pneumo coverage
162
when to treat observe (vs treat) kids with AOM
if symptoms not severe (ear pain < 48 hrs, no atorrhea, temp < 39C) and - age 6-23 months: symptoms in 1 ear only - 2 years+: symptoms in 1 or both ears | observe for 2-3 days and if no improvement, then treat
163
Recommended empiric CAP treatment for patients with no comorbidites
- amoxicillin 1g TID - doxycycline - zithro or clarithromycin if local pneumococcal resistance < 25% | one of the above
164
Recommended empiric CAP treatment for pts with comorbidities ## Footnote chronic heart, liver, or lung disease, DM, EtOH use disorder, CA, asplenia
- beta-lactam + (macrolide or doxy) - respiratory quinolone (moxiflox, levoflox) | one of the above
165
Empiric regimen for HAP or VAP
- all pts need antipseud and MSSA coverage - MRSA coverage if: IV ABX use in past 90 days, prior MRSA infection, + MRSA swab - double pseud coverage if at risk for MDR gram-neg (IV ABX use in past 90 days, hospitalized > 5 days prior to onset of VAP) | double pseud coverage should not be 2 beta lactams
166
tuberculosis treatment | and important notes on each drug
RIPE: rifampin, isoniazid, pyrazinamide, ethambutol ## Footnote - Rifampin: orange secretions, flu-like symptoms, strong CYP450 inducer (can use rifabutin instead if needed), monitor for hemolytic anemia (Coombs test) - Isoniazid: neuropathy -> give with B6 (pyridoxine) 25-50mg QD, monitor for DILE, monitor for hemolytic anemia (Coombs test) - Pyrazinamide: increases uric acid -> avoid in acute gout - Ethambutol: can cause visual damage (baseline and monthly eye exam), monitor for confusion/hallucinations
167
Treatment of **first** c. diff episode
- fidaxomicin 200mg BID 10D - vanc 1.25mg PO QID 10D - flagyl 500mg PO TID 10D (only if nonsevere and above unavailable) | one of the above
168
Treatment of **second** c. diff episode | first recurrence
- fidaxomicin 200mg PO BID 10D - vanc 1.25mg PO QID 10D followed by prolonged pulse/taper course | one of the above ## Footnote don't have to do the taper course for vanc if first episode treated w flagyl
169
Treatment of **third+** c. diff episode | 2nd + recurrence
- fidaxomicin 200mg PO BID 10D - vanc 1.25mg PO QID 10D followed by a prolonged pulse/taper course (only an option if wbC <15 and SCr < 1.5) - vanc 1.25mg PO QID 10D followed by rifaximin 400mg PO TID 20D - fecal transplant | one of the above
170
Treatment of fulminant or complicated c. diff
dx when systemic toxic effects present: shock, ileus, or toxic megacolon ## Footnote vanc 500mg PO /NG tube/PR QID + flagyl 500mg IV Q8H
171
key issues with all -azole antifungals
- increased LFTs - QT prolongation (except for isavuconazoium) - many DDI
172
key issues with fluconazole
the only azole that requires renal dose adjustment ## Footnote - increased LFTs - QT prolongation - many DDI
173
key issues with ketoconazole
heptatotx has led to liver transplantation ## Footnote - increased LFTs - QT prolongation - many DDI
174
key issues with itraconazole
can cause heart failure ## Footnote - increased LFTs - QT prolongation - many DDI
175
key issues with voriconazole
can cause visual changes and phototox ## Footnote - increased LFTs - QT prolongation - many DDI
176
key issues with posaconazole
- tablet dose does NOT equal suspension dose (different bioavailbilty) - take with food ## Footnote - increased LFTs - QT prolongation - many DDI
177
IV:PO ratio for azole antifungals
1:1 for all
178
which IV azole antifungals have sulfobutyl ether beta-cyclodextrin (SBECD) vehicle
- vorconazole - posaconazole
179
ADR and side effects for all NRTIs
warnings - lactic acidosis - hepatomegaly with steatosis (fatty liver) - is a boxed warning for zidovudine ## Footnote common side effects - diarrhea, nausea
180
HBV/HIV coinfection boxed warnings
- severe acute HBV exaceration can occur if emtricitabbine, lamivudine, or tenofovir containing products are stopped - do NOT use *Epivir-HBV* for the treatment of HIV - its dose of lamivudine is not high enough to treat HIV
181
abacavir key features and safety issues
boxed warning for risk of hypersensitivity reaction (HSR) - screen for HLA-B*5701 allele - pts with this allele have a higher risk for HSR and use is contraindicated - pts must carry a med card indicating that HSR (fever, rash, N/V/D, fatigue, dyspea, cough) is an emergency - never rechallenge pts with a hx of HSR ## Footnote - lactic acidosis and heaptomegaly with steatosis - nausea, diarrhea
182
emtricitabine key features and safety issues
hyperpigmentaiton of palm of hands or soles of feet ## Footnote - lactic acidosis and hepatomegaly with steatosis - nausea and diarrhea
183
tenfovovir key features and safety issues
Higher risk of the following with TDF vs TAF - renal impairment including AKI and Faconi sundrome (renal tubular injury and electrolyte abnormality) - decreased bone mineral density - consider Ca or VitD supplement and DEXA scan | TAF is higher risk of lipid abnormalities ## Footnote - lactic acidosis and hepatomegaly with steatosis - nausea, diarrhea
184
zidovudine key features and safety issues
hematologic tox: neutropenia and anemia | macrocytosis (high MCV) is a sign of adherence ## Footnote - BBW for lactic acidosis and hepatomegaly with steatosis - nausea and diarrhea
185
Side effects and warnings for all INSTIs
- weight gain - insomnia - risk of depression and suicidal ideation in pts with pre-existing psych condition ## Footnote polyvalent cations can decrease INSTI absorption dt chelation - take INSTI 2 hours before or 4 hours after
186
Which INSTIs increase SCr (by inhibiting tubular secretion) and has no effect on eGFR
- bictegravir - dolutegravir
187
INSTIs with the following safety issues: - increased CPK, myopathy and rhabdo - hypersensitivity reaction
- raltegravir - dolutegravir
188
which INSTI can cause heptatox (esp if pt is co-infected iwth HBV or HCV)
dolutegravir
189
INSTI with injection site reaction ADR
cabotegravir | and Cabenuva (cabotegravir/rilpivirine)
190
key features and safety alert with all NNRTIs
- hepatotox; rash/severe rash (including SJS/TEN) - highest risk with nevirapine - all NRTIs are major CYP3A4 substrates - used in alternative HIV ART regimens (not first line in most pts) - 1 NNRTI vs. 2 NRTIs
191
efavirenz key features and safety issues
- psych symptoms - depression and suicidal thoughts - CNS effects - impaired concentration, abnormal dreams, confusion - generally resolve in 2-4 weeks in most pts - increased total cholesterol and TG - moderate CYP3A4 inducer in addition to being a major substrate ## Footnote - heptatotox - rash, SJS/TEN
192
rilpivirine key features and safety issues
- depression - increased SCr with no effect on eGFR - do NOT use if initial viral load is > 100,000 and/or CD4 count < 200 - high failure risk - do NOT use with strong CYP3A4 inducers - needs acidic environment to be absorbed - avoid with PPis, separate from H2RAs and antacids ## Footnote - hepatotox - rash, SJS/TEN
193
doravirine key features and safety issues
do NOT use wiith strong CYP3A4 inducers dt it being a major sustrate
194
etravirine key features and safety issues
is a moderate CYP3A4 inducer in addition to being a major substrate
195
key features and safety issues in all protease inhibitors
- **metabolic abnormalities** - hyperglycemia/insulin resistance, dyslipidemia (increased LDL, TG), increased body fat and lipodystrophy -> increased CVD risk - **hepatic dysfunction**: increased LFTs, hepatitis, and/or exacerbation of preexisting hepatic disease - **hypersensitivity reactions** - rash (SJS/TEN), angioedema, bronchospasm, anaphylaxis - diarrhea, nausea - **All are major CYP3A4 substrates** and most are strong CYp inhibitors - used in alt HIV ART regimens (not first line in most pts) - 1 protease inhibitor (boosted iwth ritonavir or cobicistat) + 2 NRTIs
196
which protease inhibitors' use should be cautioned in pts with a sulfa allergy
- darunavir - fosamprenavir - tipranavir
197
which protease inhibitors can cause a disulfuram reaction if taken with flagyl
Kaletra (lopinavir/ritonavir) oral soln contains 42% alcohol
198
which protease inhibitor can cause hyperbilirubinemia
atazanavir ## Footnote - hyperbilirubinemia (jaundice, or scleral icterus) - reversible, does NOT require discontinuation - atazanavir also requires an acidic environment for absorption - separate from antacids and H2RAs - avoid PPIs unless boosed, then can take 12 hrs after a PPI dose equivalent to omeprazole 20mg
199
protease inhibitor and pharmacokietic booster (enhacer) key drug-drug interactions
- alpha-1a blockers - tamsulosin, sildosin, alfuzosin - amiodarone, dronaderone - apixaban, rivaroxaban, ticagrelor - azole antifungals - hepC protease inhibitors - grazoprevir, glecaprevir - lovastatin, simvastatin - PDE-5 inhibitors used for pulmonary hypertension (sildenafil, tadalafil) - strong CYP3A4 inducers (CBZ, phenytoin, rifampin) - systemic, inhaled and intranasla steroids (except betamethasone)
200
HIV PrEP
- PO truvada daily - PO descovy daily (not approved for AFAB) - IM cabotegravir (Apretude) monthly for 2 doses then Q2mo. | one of the above ## Footnote - take **before** high risk activity
201
HIV PEP
- truvada (if CrCl > 60) with dolutegravir (*Tivicay*) - raltegravir (*Isentress*) | one of the above ## Footnote - take **after** HIV exposure, start within 72 hrs and take for 28 days
202
key drugs that increase LDL AND TG | separate from drugs that only increase one or the other
- diuretics - efavirenz - immunosuppresants (cyclosporine, tacro) - atypical antipsychotics - protease inhibitors
203
key drugs that ONLY increase LDL
- fibrates - fish oils (except Vascepa)
204
key drugs that ONLY increase TG
- IV lipid emulsions - propfol - clevidipine - bile acid sequestrants
205
conditions taht can raise LDL and/or TG
- obeisty - poor diet - EtOH use disorder - hypothyroidism - smoking - DM - renal/liver disease - nephrotic syndrome
206
patient groups that qualify for primary prevention with a statin and what intensity should they get
- **LDL >190**: high intensity - **DM and age 40-75**: moderate intensity (if **multiple ASCVD risk factors**, do high intensity instead) - **age 40-75 with an LDL >70 with a 10 year ASCVD risk of >7.5% with risk enhancing factors**: moderate intensity (**if risk >20%**, high intensity regardless of risk enhancing factors)
207
high intensity statins
- lipitor 40-80 - rosuvastatin 20-40
208
moderate intensity statin
- lipitor 10-20 - crestor 5-10 - simvastatin 20-40 - pravastatin 40-80 - lovastatin 40 - flovastatin TDD of 80 - any dose of pitavastatin
209
low intensity statin
- simvastatin 10 - pravastatin 10-20 - lovastatin 20 - fluvastatin 20-40
210
statin equivalent doses
- pitavastatin 2 - rosuvastatin 5 - lipitor 10 - simvastatin 20 - lovastatin 40 - pravastatin 40 - fluvastatin 80
211
how to reduce risk of myalgia
- avoid drug interactions, including OTC - do NOT use simvastatin dose of 80/day - do NOT use gemfibrozil alongside a statin
212
what to do if myalgia occurs
1. hold statin, investigate other causes 2. after 2-4 weeks: re-challenge with same statin at a lower dose 3. if myalgia occurs, stop statin. once symptoms stop, challenge a low dose of a different statin and slowly increase dose ## Footnote if a pt is unable to tolerate a statin after 2 attempts, non-statin treatment may be considered
213
significant drug interactions for simvastatin or lovastatin
G-PACMAN - **g**rapefruit - **p**rotease inhibitors - **a**zole antifungals - **c**yclosporine, cobicistat - **m**acrolides (except zithro) - **a**miodarone - simvastatin MDD of 20, lovastatin MDD of 40 - **n**on-dhb CCBs: simvastatin MDD of 10, lovastatin of 20 ## Footnote - crestor should have a MDD of 5 ig alongside cyclosporine - lipitor should have a MDD of 20 if alongside cobicistat
214
drugs that can increase blood pressure via increased sympathomimetic activity
- ADHD drugs - decongestants (pseudophed, phenylephrine) - recreational substances (cocaine, caffeine) - antidepressants (TCAs, SNRIs, MAOi)
215
drugs that can increase blood pressure via increased Na and water retention
- NSAIDs - immunosuppresants (cyclosporine) - systemic steroids
216
drugs that can increase blood pressure via increased blood viscosity
erythropoeisis stimulating agents (epo alpha)
217
what to do when using a blood pressure monitoring device
- go to the restroo and empty the bladder - sit in a chair and relax (both feet on floor with back supported) for at least 5 min - use of correct cuff size - arm at heart level - wait 1-2 min in between measurements
218
what NOT to do when using a blood pressure monitoring device
- talk - lie down or sit without back supported - drink caffeine, exercise or smoke 30 min prior - use a finger or wrist monitor
219
types of self-monitoring BP devices
- ambulatory BP monitor: typically worn continously for 24 hrs during daily activities and during sleep - reads bp every 15-60 min - home bp monitoring device: pt measures and records the average of at least 2 readings in the morning and evening before eating or taking any meds
220
when to start HTN treatment
- stage 1 HTN (SBP 130-139) and one of the following - clinival CVD - 10 year ASCVD risk > 10% - does NOT meet bp goal after 6 months of lifestyle mods - stage 2 HTN (SBP >140 or DBP >90)
221
initial drug selection in treatment of HTN
- one of the following: TZD, DHP CCB, ACE or ARB - if CKD: ACE or ARB ## Footnote start with 2 meds of different classes if BP is >20/10 mmHg above goal
222
key IV medications for HTN emergencies
- clevidipine - enalaprilat - esmolol - hydralazine - laetalol - nicardipine - nitroglycerin - nitroprusside
223
treatment approach for stable angina
ABCDE - **A**ntiplatelet and antianginal drugs - **B**lood pressure - **C**holesterol, cigarettes (cessation) - **D**iet and diabetes - **E**xercise and education
224
UA vs. STEMI vs. NSTEMI: symptoms
chest pain
225
UA vs. STEMI vs. NSTEMI: cardiac enzyme presence
- cardiac enzymes: negative - STEMI and NSTEMI: positive
226
UA vs. STEMI vs. NSTEMI: ECG changes
- UA and NSTEMI: none or transient - STEMI: ST segment elevation
227
UA vs. STEMI vs. NSTEMI: blockage
- UA and NSTEMI: partial blockage - STEMI: complete blockage
228
drug treatment options for ACS
MONA-GAP-BA - **M**orphine - **O**xygen - **N**itrates - **A**spirin - **G**PIIb/IIIa antagonsits - **A**nticoagulatns - **P**2Y12 inhibitors - **B**eta blockers - **A**CE inhibitors ## Footnote UA and NSTEMI: MONA-GAP-BA +/- PCI STEMI: MONA-GAP-BA + PCI or fibrinoytic
229
Drugs for secondary prevention after ACS
- Aspirin 81 indefinitely - P2Y12 inhibitor - done alongside asa 81 for at least 12 months (select pts with a coronary stent and are low bleeding risk may consider indefinite DAPT) - Nitroglycerin - indefinte PRN - Beta-blocker: for at least 3 years (continue indefintely if pt has other indication for beta-blocker) - ACE inhibitor: indefintely in pts with EF < 40%, HTN, CKD, or DM - consider for all other pts - Aldeosterone antag: indefintely in pts with an EF < 40% and symptomatic HF or DM pts receiving target doses of beta-blocker and ACE - Statin: indefinite high intensity for most pts (if 75+ may consider mod) | prasugrel only for PCI treated pts, NOT for medical management pts
230
labs and biomarkers consistent with HF
- increased BNP: normal is <100 - increased NT-proBNP: normal is < 300 ## Footnote BNP and NT-proBNP are used to distinguih between cardiac and non-cardiac causes of dyspnea
231
General signs and symptoms of HF
- dyspnea at rest or on exertion - cough - fatigue, weakness - reduced exercise capactiy
232
s/s of left sided HF
- orthopnea: SOB when lying flat - paroxymal nocturnal dyspnea (PND): nocturnal cough and SOB - bibasilar rales: crackling lung sounds heard on lab exa - S3 gallop: abnormal heart sound - hypoperfusion - renal impairment, cool extremities
233
s/s of right sided HF
- peripheral edema - ascites - jugular venous distension - neck vein distension - hepatojugular reflux 0 neck vein distention from pressure placed on the abdomen - hepatomegaly - dt fluid congestion
234
key drugs that can worsen HF
DI NATION - **D**PP4 i - alogliptin, saxagliptin - **I**mmunosuppresants: TNF inhibitors (adalimumab, etanercept) and interferons - **N**on-DHP CCBs: dilt and verapmil if HF is < 50% - **A**ntiarrhythmics: class 1 agents (quinidine, flecainide) and dronedarone - amiodarone and dofetilide are preferred in pts with HF - **T**ZDs - **I**traconazole - **O**nc drugs: anthracyclines (doxorubicin, daunorubicin) - **N**SAIDs
235
GDMT for HFrEF
for everyone without contraindications - **RASS inhibitors**: reduce morbidity and mortality (ARNI moreso than ACE and ARBs) - **BB**: select agets reduce mortality and hospitalizations - **Aldosterone receptor antag**: reduce morbidity and mortality in NYHA class II and IV HF - **SGLT2i**: reduce hospitalzations and mortality ## Footnote additional meds for select pts - **loop diuretics**: reduce edema and congestion, provide symptom relief - **hydralazine/nitrate**: reduce morbidity and mortality in Black pts NYHA class III-IV; can also be considered in pts who can't do a RASS inhibitor - **digoxin**: small improvement in cardiac output, improves symptoms, reduces hospitalziations - secondn line - **vericiguat**: reduce risk of hospitalizations adn CV death after recent HF hospitalzation or need for IV diuretics - second line
236

Ultimate Sadness (9 decks)

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