Study Guide Exam III Flashcards
what are the first line drugs for PD treatment?
dopaminergics & dopamine agonists
what are the dopaminergics & dopamine agonists used to tx PD?
Bromocriptine (Parlodel) Pergolide (Permax) Pramipexole (Mirapex) Ropinirole (Requip) *as symptoms worsen, introduce levodopa* cholinergic blockers control tremor (relax smooth muscle)
how do anticonvulsants work?
stimulate influx of chloride ions (usually associated with GABA)
delay influx of sodium
delay influx of calcium
what are the most common ADRs of hydantoins?
nystagmus dizziness pruritis paresthesia HA somnolence ataxia confusion
what are the ADRs of iminostilbenes?
bone marrow depression liver damage impairs thyroid function drowsiness dizziness blurred vision N/V dry mouth diplopia HA
what are the ADRs of succinimides?
GI most common somnolence fatigue ataxia agranulocytosis aplastic anemia granuloytopenia
what are the ADRs of GABA?
somnolence
CNS effects
what are the ADRs of lamotrigine?
GI: mostly N/V constipation chest pain peripheral edema somnolence fatigue dizziness anxiety insomnia HA amblyopia nystagmus
what are the goals of migraine therapy?
minimize impact on quality of life
avoid medication overuse
which medications are used in prophylactic treatment of migraines?
beta blockers
tricyclic antidepressants
antieleptic drugs
when is preventative migraine therapy initiated?
consider for pts with more than 2 migraines per months
goal: 50% reduction
Use HA diary
takes time to work (4 wks)
which beta blockers are FDA approved in preventative migraine therapy?
propranolol
timolol
which beta blockers should be used in pts who have asthma or respiratory concerns?
metoprolol
atenolol
what are the ADRs of beta blockers?
fatigue
lethargy
depression
which TCAs are used for migraine prevention?
Elavil
nortriptyline can be used
what are the ADRs of TCAs?
drowsiness
weight gain
constipation
which antieliptics are used for migraine prophylaxis?
depakote
neuronton
topamax
what are the miscellaneous drugs used for migraine prophylaxis?
NSAIDs (Naproxen for menstrual migraines)
CCBs (verapamil for pts with HTN who cannot tolerate beta blockers)
what are the medications used to treat Alzheimer’s disease?
Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne)
Memantine (Namenda)- *not a cholinesterase inhibitor
what are the ADRs of drugs used to tx Alzheimer’s disease?
Constrict pupils Increased saliva Bronchoconstriction Increased GI mucous Bladder fundus contraction
what is used to tx tension HAs?
beta blockers TCAs *non-pharma therapy -stress management -biofeedback -exercise -acupuncture -heat/cold -massage therapy -relaxation therapy
when is treatment for tension HAs considered?
if more than 1 or 2 per week
what do tension HAs NOT respond to?
triptans
ergots
what are the combination drugs used to tx tension HAs?
Fiorinal/Fioricet
Midrin
what are the SSRI medications?
Fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) fluvoxamine (Luvox) citalopram (Celexa) escitralopram (Lexapro)
what is the MOA of SSRIs?
have selective inhibitory effects on presynaptic serotonin reuptake and wqak effects on norepinephrine and dopamine neuronal uptake; more serotonin is available to bind with the postsynaptic receptors
explain the pharmacokinetics of SSRIs
slow absorption
half-life 21-26 hours
extensive first pass metabolism
*fluoxetine half-life of 1-3 days & first metabolite 4-16 days (why it can be given weekly)
what is the indication for prescribing SSRIs?
depressive d/o
anxiety
panic d/o
*fluvoxamine (Luvox) is approved for OCD
what are the ADRs of SSRIs?
CNS
GI
sexual dysfunction (up to 35%)
caution: pts with severe hepatic or renal impairment
what should you educate patients who are taking SSRIs on?
adherence (can take 3-4 wks)
suicide risk
avoid alcohol, OTC meds that stimulate, insomnia or dizziness, suicide ideology
SSRIs are pregnancy category what?
B/C
avoid in 1st and last trimester
*Sertraline been used w/o adverse consequences
what are the initial SE of SSRIs?
nausea light-headedness sedation muscle restlessness sleep disturbances
what should you monitor in elderly patients taking SSRIs?
electrolytes
*half dose recommended
higher doses of Celexa put the patient at risk for what?
QTc prolongation
Lexapro is the active metabolite of what?
citalopram (Celexa)
what are the indications for Prozac?
depression
OCD
bulimia
panic d/o
what are the indications for Luvox?
OCD
social anxiety d/o
depression (off-label)
what are the indications for Paxil?
Depression OCD panic disorder social phobia PTSD anxiety PMDD (CR)
what are the indications for Zoloft?
Depression OCD GAD PMDD PTSD Social Anxiety disorder
when does serotonin syndrome happen?
in the presence of serotogenic activity
serotonin syndrome can be fatal. what are the symptoms?
nausea diarrhea chills sweating hyperthermia HTN myoclonic jerking tremor agitation ataxia disorientation confusion delirium
what can be done to prevent serotonin syndrome?
Adhere to maximum recommended doses
Avoid adjunctive combinations of serotonergic agents
Adequate time for titration when changing agents (5 half lives per dose decrease)
what is withdrawal syndrome?
when shorter half life drugs can show withdrawal symptoms with just one missed dose
which medications have the potential for withdrawal syndrome?
paroxetine
sertraline
citalopram
escitalopram
what are the symptoms of withdrawal syndrome?
nausea
dizziness
paresthesias (electric shock sensations, visual tracers w/eye movements)
SSRIs require gradual slow tapering except…
fluoxetine (long half-life, active metabolites)
the black box warning on all antidepressants for increased risk of suicidal though and behavior affects which population?
children
adolescents
young adults to age 24
- during first two months of tx
what is the MOA of benzos?
all benzos work on chloride ion channels of GABA-A receptors; enhance GABA neurotransmission which lengthens hyperpolarization and slow down responses
benzos are:
anxiolytic
anticonvulsion
muscle relaxants
sedating
what is the non-benzo GABA agonist?
Buspar
what are the short-acting benzos?
Clorazepate (Tranxene)
Halazepam (Paxipam)
Prazepam (Centrex)
what are the intermediate-acting benzos?
Alprazolan (Xanax)
Lorazepam (Ativan)
Oxazepam (Serax)
Chlordiazepoxide (Librium)
what are the long-acting benzos?
Diazepam (Valium)
Clonazepam (Klonopin)
when are benzos used as anxiolytics?
muscle relaxant pre-anesthesia sedation prevention and tx of panic attacks acute agitation and dystonia emergency tx of uncontrollable seizures restless leg syndrome
which benzos are thought to be higher risk for dependence?
alprazolam
lorazepam
d/t high potency, and rapid, short-term action
when are benzos contraindicated?
pregnancy lactation children < 6 hepatic & renal disease *caution in elderly
when do the symptoms of benzo withdrawal usually occur?
1-2 days after last dose of short-acting
5-10 days after long-acting
what are the main ADRs of benzos?
excessive sedation
potential for cardiac & respiratory depression in combo with other CNS depressants
paradoxial anxiety, agitation & acute rage may occur
why should Buspar be taken with food?
reduces first pass affect, allowing for more active drug going directly into circulation
why is Buspar contraindicated with panic attacks?
one metabolite has noradrenergic effects
how long does it take for Buspar to take effect?
up to two weeks for onset
and up to six weeks for max effect
what is the half life of Buspar and why is that important?
1-10 hours
requires multiple dosing during the day
what are the positive symptoms in psych disorders?
agitation/aggression disorganized speech hallucinations delusions paranoia
what are the negative symptoms in psych disorders?
anhedonia (no pleasure) flattening of affect poverty of speech content poor self care social withdrawal decreased motivation
what are the phenothiazines used to tx + symptoms in psych d/o?
Chlorpromazine (Thorazine) fluphenazine (Prolixin) Perphenazine (Trilafon) Thioridazine (Mellaril) Trifluoperazine (Stelazine)
what are the non-phenothiazines used to tx + symptoms in psych d/o?
Haloperidol (Haldol)
molindone (Moban) Thiothixene (Navane)
Loxapine (Loxitane)
what are the ADRs of the typical antipsychotics?
*too much dopamine stimulation* Shuffling pill-rolling cog-wheeling tremors drooling akathisia (restlessness) dystonia (involuntary movements) tardive dyskinesia (involuntary buccolongual movements) -------------------------------------- sedation weight gain photosensitivity reduction of seizure threshold sexual dysfunction
what is given to counteract EPS?
antiparkinson
antihistamines
anticholinergics
what is neuroleptic malignant syndrome (NMS)?
life threatening fever up to 107 elevated pulse diaphoresis rigidity stupor/coma acute renal failure
what are the high-potency typical antipsychotics?
haloperidol
fluphenazine
what are the low-potency typical antipsychotics?
chlorpromazine
thioridazine
what are the contraindications for typical antipsychotics?
narrow-angle glaucoma
bone marrow depression
severe liver or cardiovascular disease
what are the atypical antipsychotics?
Aripiprazole (Abilify) Asenapine (Saphris) Clozapine (Clozaril) -Risk of fatal agranulocytosis – monitor CBCs Iloperidone (Fanapt) Olanzapine (Zyprexa, Zyprexa Zydis, IM, Relprevv) Olanzapine-fluoxetine: Symbyax Paliperidone (Invega, Invega Sustenna) Quetiapine (Seroquel, Seroquel XR) Risperidone (Risperdal, Risperdal Consta) Ziprasidone (Geodon) -Mild to moderate QTc prolongation
what kind of symptoms do atypical antipsychotics tx?
+ and -
what are the ADRs of atypical antipsychotics?
weight gain- can lead to metabolic syndrome seizures hyperprolactinemia dizziness orthostatic hypotension tachycardia sleep disturbance constipation *caution: hepatic or renal dz
what makes clozapine unique?
risk of fatal agranulocytosis
reserved for tx of severe schizo refractory to complete trials of at least two different types of antipsychotics
available only through patient management system in which clinician and patient are both registered
clozapine should be monitored for how long after tx is discontinued?
4 wks
what are the indications for using atypical antipsychotics?
schizophrenia schizoaffective d/o depression or mania with psychotic features severe agitation delusions with dementia
when changing from one atypical antipsychotic to another what should be done?
slowly titrating off the first and on to the second
washout period if possible
what are the pseudoparkinsonism extrapyramidal symptoms?
Tremor
muscle rigidity
stooped posture
what are the acute dystonia EPS?
Muscle spasms of face, tongue, neck or back
what are the akathisia EPS?
Inability to rest and relax; pacing
what are the tardive dyskinesia EPS?
Lip smacking
wormlike movements of the tongue
uncontrolled chewing and grimacing
schizophrenia & atypical APs increase the risk of what?
diabetes
what should be assessed before starting any atypical AP?
waist circumference BMI blood pressure fasting plasma glucose lipid profile
what is lithium used to treat?
considered tx of choice for classic bipolar mood d/o
adjunct for tx of unipolar depression
what is the half-life of lithium?
15-36 hours
steady state: 5-7 days
what is the therapeutic index for lithium?
0.6-1.5 mEz/L
what are the signs of lithium toxicity?
hand tremors N/V diarrhea confusion stupor polydipsia/polyuria muscle weakness ataxia
lithium takes how long to reach max efficacy?
10-14 days (not for acute mania)
lithium is indicated for what?
maintenance of mood stability
prevention of mania or hypomania
pts should be educated on what in regards to intake of lithium?
maintain adequate salt intake
take with food to minimize GI distress
lithium is contraindicated in which pt population?
children < 12
what are the ADRs of lithium?
Fine tremors
nausea
dry mouth
headache
drowsiness
Hypothyroidism and kidney failure may occur with long term administration
Sustained released – can minimize adverse effects associated with dosage peaks
lithium interacts with which medications?
Diuretics – increase sodium excretion and increase lithium levels
NSAIDs – reduce renal elimination and increase lithium levels
what are the most common pathogens that require anti-infectives?
staph aureus
strep pyogenes
what are the basic principles of topical anti-infectives?
culture if unsure treat empirically follow progress & culture watch for resistance change med if appropriate
what are some of the common antibacterials used to treat skin d/o?
bacitracin
mupirocin
retapamulin
neomycin
polymyxin B
double antibiotic (polymyxin B, bacitracin)
triple antibiotic (polymyxin B, neomycin, bacitracin)
what are the indications for using bacitracin?
minor cuts
wound
impetigo (1-2 lesions only)
what are the indications for using mupirocin?
impetigo
nasal colonization with MRSA
what are the indications for using retapamulin?
impetigo
what are the indications for using neomycin?
minor cuts
wounds
impetigo (1-2 lesions only)
what are the indications for using polymyxin B?
minor cuts
wounds
impetigo (1-2 lesions only)
what are the indications for using double antibiotic?
minor cuts
wounds
impetigo
what are the indications for using triple antibiotic?
minor cuts
wounds
impetigo (1-2 lesions only)
what are some of the common antifungals used to treat skin d/o?
butenafine ciclopirox olaminr clotrimazole econazole gentian violet ketoconazole miconazole naftifine nystatin oral suspension nystatin cream or ointment oxiconazole sertaconazole terbinafine tolnaftate
what are the indications for using butenafine?
tinea corporis (ringworm) tinea cruris (jock itch)
what are the indications for using ciclopirox olamine?
tinea corporis (ringworm) tinea cruris (jock itch)
what are the indications for using clotrimazole?
oral candidiasis
fungal skin infections, including candidiasis
tinea pedis (athlete’s foot)
what are the indications for using econazole?
tinea corporis (ringworm) tinea cruris (jock itch) tinea pedis (athlete's foot)
what are the indications for using gentian violet?
oral candidiasis
what are the indications for using ketoconazole?
tinea corporis (ringworm) tinea cruris (jock itch) tinea pedis (athlete's foot)
what are the indications for using miconazole?
fungal skin infections, including candidiasis tinea pedis (athlete's foot)
what are the indications for using naftifine?
tinea corporis (ringworm) tinea cruris (jock itch) tinea pedis (athlete's foot)
what are the indications for using nystatin oral suspension?
oral candidiasis
what are the indications for using nystatin cream or ointment?
cutaneous candida infections
what are the indications for using oxiconazole?
tinea corporis (ringworm) tinea capitis (ringworm of the scalp) tinea pedis (athlete's foot)
what are the indications for using sertaconazole?
interdigital tinea pedis in immunocompetent patients
what are the indications for using sulconazole?
tinea corporis (ringworm) tinea cruris (jock itch) tinea pedis (athlete's foot)
what are the indications for using terbinafine?
tinea corporis (ringworm) tinea cruris (jock itch) tinea pedis (athlete's foot)
what are the indications for using tolnaftate?
tinea pedis (athlete’s foot)
what are some of the common antivirals used to treat skin d/o?
acyclovir
docosanol
penciclovir
what are the indications for using acyclovir?
initial herpes genitalis
mucocutaneous HSV infections in immunocompromised patients
what are the indications for using docosanol?
recurrent oral-facial herpes simplex episodes
what are the indications for using penciclovir?
recurrent herpes labialis (cold sores) on lips and face
what are the low potency topical corticosteroids?
hydrocortisone 1% or 2.5%
triamcinolone acetonide 0.025%
what are the intermediate potency topical corticosteroids?
hydrocortisone valerate 0.2% triamcinolone acetonide 0.1% betamethasone valerate 0.12% desoximetasone 0.05% mometaxone furoate 0.1%
what are the high potency topical corticosteroids?
betamethasone dipropionate augmented 0.05% (cream or lotion)
triamcinolone acetonide 0.5%
halcinonide 0.1%
what are the super-high potency topical corticosteroids?
bethamethasone dipropionate augmented 0.05% (ointment or gel)
clobetasol propionate 0.05%
flurandrenolide 4-mcg/cm2 tape
topical corticosteroids are pregnancy category what?
C
avoid use and/or limit amounts and duration
who should not use high and super high potency topical corticosteroids?
children
what is used to treat contact dermatitis?
topical corticosteroids
oral corticosteroids ( up to 2-3 wks of therapy)
wet dressings or baths: Al acetate solution (Burow’s, Domeboro) applied 30 mins 4x/day; colloidal oatmeal solids (Aveeno) or oils (Alpha Keri Bath Oil, Lubriderm Bath Oil)
what is used to treat seborrheic dermatitis?
topical anti-seborrheic shampoo (selenium sulfide, ketoconazole, pyrithione zinc) topical corticosteroids (low potency, only if no response from shampoo)
which medications are used to tx psoriasis?
topical intermediate to high potency corticosteroids
coal tar- creams, shampoos, ointments, lotions, gels, and oils 1-2x/daily (can cause photosensitivity)
what should be used in the tx of scabies?
permethrin
lindane
topical corticosteroids for itching & inflammation (prolong healing phase)
what are the topical retinoids used to tx acne?
tretinoin (Retin-A)
adapalene (Differin)
adapalene & benzoyl peroxide (Epiduo)
what kind of acne do retinoids tx?
inflammatory & noninflammatory
- can cause redness and peeling
- can cause acne to initially worsen
what are the topical antibiotics used to tx acne?
benzoyl peroxide benzoyl peroxide/clindamycin erythromycin benzoyl peroxide/erythromycin clindamycin tetracycline metronidazole
what are the oral antibiotics used to tx acne?
tetracycline
erythromycin- *take with food
minocyclin
what is the only oral retinoid?
isotretinoin
what does a pt need to be educated on when taking an oral retinoid?
pregnancy category X
reseved for severe recalcitrant cystic acne
requires iPledge
liver enzyme and lipid levels need to be monitored
what is acne rosacea?
chronic inflammatory d/o of the blood vessels and pilosebaceous glands of the face
what is used to tx acne rosacea?
topical metronidazole (Metro-gel, Noritate) tx for life
how long does it take to determine of tx of acne rosacea is effective?
6-8 weeks
what are the most common bacterial skin infection pathogens?
s. aureus
strep pyogenes
what is used to tx worsening impetigo or > 5 lesions?
oral medications: cephalexin amoxicillin/clavulanate dicloxavillin clindamycin
if MRSA is suspected with an impetigo infection, which medication should be used?
clindamycin
TMP/SMZ
doxycycline
which pathogen causes a furuncle?
s. aureus
which medications are used to tx furuncles?
cephalexin
amoxicillin/clavulanate
dicloxacillin
which medications are used to tx perianal strep infections?
penicillin
erythromycin
which pathogen causes cellulitis?
strep pneumoniae
s. aureus
haemophilus influenzae (children only)
which medications are used to tx oral candidiasis?
topical nystatin
oral fluconazole
which pathogen causes tinea capitis?
microsporum (present with broken hairs and fine gray scale) trichophyton tonsurans (black dot tinea; presents with tiny black dots- remains of broken hair shafts)
which medications are used to treat tinea capitis?
oral griseofulvin
biweekly shampoo with selenium sulfide or ketoconazole
which pathogens cause tinea corporis & tinea cruris?
microsporum canis
t. tonsurans
epidermophyton floccosum
which pathogen causes tinea pedis?
dermatophytes
e. floccosum
t. rubrum
t. mentagrophytes
c. albicans
which pathogens cause tinea vesicolor?
pityrosporum orbiculare
which medications are used to tx tinea vesicolor?
selenium sulfide shampoo topical antifungal (miconazole, clotrimazole, econazole)
which medications are used to treat onychomycosis?
griseofulvin ketoconazole itraconazole terbinafine ciclopirox nail lacquer efinaconazole (Jublia)- for up to 48 wks
which medications are used to treat superficial fungal infections?
azoles allylamines: naftifine (Naftin) benzylamine: butenafine (Lotrimin Ultra) ciclopirox olamine tolnaftate (Tinactin) nystatin
what are the systemic antifungals used to tx fungal infections of the skin?
griseofulvin ketoconazole itraconazole fluconazole terbinafine (Lamisil)
what precautions are there with systemic antifungals?
used cautiously in pts with liver disease
griseofulvin has possible cross-sensitivity with penicillin
what are the ADRs of topical antifungals?
skin irritation itching burning rash gentian violet can cause staining of skin/clothing
what are the drug interactions associated with topical antifungals?
theoretical interaction with azoles and amphotericin B
clotrimazole intravaginal should not be administered concurrently with nonoxynol-9 and octoxynol
which medications are used to tx candidiasis infections?
Cutaneous Candida: OTC azoles, nystatin, prescription azoles
Gentian violet can be used for thrush refractory to azoles
Fluconazole may be used systemically for thrush or vaginal candidiasis
which medications are used to tx tinea capitis infections?
Griseofulvin Terbinafine Use sporicidal shampoo -Selenium sulfide -Ketoconazole
which medications are used to tx tinea corporis infections?
topical azoles
naftifine
ciclopirox olamine
which medications are used to tx tinea cruris infections?
topical azoles
which medications are used to tx tinea pedis infections?
topical azoles
which medications are used to tx tinea vesicolor infections?
selenium sulfide shampoo
topical antifungal
what should be monitored when taking griseofulvin?
renal
liver
CBC
what should be monitored when taking ketoconazole?
liver function
what should be monitored when taking itraconazole?
liver function
electrolytes
what should be monitored when taking terbinafine?
liver enzymes
CBC
which medications should be used to tx head lice?
pyrethrins
permethrin
benzoyl alcohol (Ulesfia)
2nd line- lindane & Ovide
which medications should be used to tx body lice?
topical lindane & permethrin
which medications should be used to tx pubic lice?
topical lindane, pyrethrin, & permethrin
lindane should not be used in which population?
pregnancy
children
which medication is safer to use in pregnancy for lice?
permetherin
what are the anticholinergics?
Darifenacin (Enablex) Fesoterodine (Toviaz) Oxybutynin (Ditropan, Ditropan XL) Solifenacin (VESIcare) Tolterodine (Detrol, Detrol LA) Trospium (Sanctura)
what are the anticholinergic ADRs?
Dry mouth Dilate pupils Increased contractility Increased HR Bronchodilation Blurred vision Constipation Drowsiness/sedation Hallucinations/delirium Confusion Decreased sweating Decreased saliva Bladder fundus relaxes, sphincter contracts (urinary incontinence)
what are the alpha1 antagonists?
Tamsulosin (Flomax) -Use caution in hepatic impairment Alfuzosin (Uroxatral) -Dose not use with mild to moderate hepatic impairment -Use caution with CrCl < 30 do not use
what are the alpha1 antagonist ADRs?
Orthostatic Hypotension – may result in syncope – tends to occur within 30-90 minutes of drug administration (decreased w/evening administration) fluid retention nasal congestion blurred vision dry mouth constipation impotence urinary frequency
what is testosterone replacement therapy used for?
muscle mass/strength
sexual desire, function, & performance
TRT is contraindicated in which patients?
male breast or prostate cx
pregnancy & lactation
transdermal NOT used in women
what are the ADRs of TRT?
hepatitis
hepatic neoplasm
cholestatic hepatitis
jaundice
hepatocellular carcinoma
Men: gynecomastia, reduced sperm levels, decreased libido, depression
Women: menstrual irregularities, virilization
what are the PDE5 inhibitors?
Sildenafil citrate (Viagra) Tadalafil (Cialis) Can be given 2.5-5mg once daily instead of prn Vardenafil (Levitra) Avanafil (Stendra)
what are the PDE5 inhibitor contraindications?
food decreases absorption
cannot use concurrently with nitrates
alpha blockers have additive hypotension
what are the ADRs of PDE5 inhibitors?
HA flushing dyspepsia blue hue vision change tadalafil- low back pain & < visual disturbances
what is priapism?
erection > 4 hours
diflucan doesn’t reach steady state for how many days?
5-10
what is diflucan used for?
vaginal candidiasis
oropharyngeal candidiasis
UTIs can be treated empirically with which medication?
bactrim 1st line when no complicating factors
UTIs should be treated with what kind of medications?
gram -
which pathogen is the primary culprit for UTIs?
E. coli
what is the alternative first-line treatment for UTIs?
ciprofloxacin
can also use levofloxacin
which medication should not be used to treat UTIs?
moxifloxacin (poor concentration in urine)
which medication should be used in children when treating a UTI?
ciprofloxacin
what is second line therapy in treatment of UTIs?
amoxicillin
or cephalosporins
which medications should be used to treat UTI in pregnancy?
2nd line drugs
nitrofurantion
when is nitrofurnation contraindicated?
Contraindicated in CrCl<60- no harm to the patient but not effective; UTI won’t go away
what are the antibiotics used to tx UTIs?
Trimethoprim/sulfamethoxazole (TMP/SMX, Bactrim) Nitrofurantoin (Furadantin, Macrodantin) Fluoroquinolones -Ciprofloxacin (Cipro) -Levofloxacin (Levaquin) Cephalosporins -Cephalexin (Keflex) -Cefpodoxime (Vantin) -Cefixime (Suprax) Penicillins -Amoxicillin (Amoxil) -Amoxicillin/clavulante
when is estrogen only contraindicated?
women with an intact uterus Pregnancy (category X) Breast cancer Estrogen-dependent cancers Active DVT or PE Hx in past year of stroke or MI Liver dysfunction Smokers
what are the ADRs of estrogen?
can interfere w/lab tests (endocrine, LFTs, thyroid, & PT)
impaired glucose tolerance
increased triglycerides
thromboembolic phenomena (leg pain, visual disturbances, severe HA- smoker s& diabetics are at increased risk)
what are the common drug interactions with estrogen?
anticoagulants
anti-TB drugs
corticosteroids
anti-seizure
what are the delivery methods of contraception?
oral topical vaginal ring subdermal implants IM IUDs
when choosing a contraceptive, what should be done first?
start with absolute contraindications- estrogen contraindications
what are the common oral contraception formulations?
progestin only ultra low dose (20m mcg EE) monophasic COC multiphasic COC non-daily administration
what are the two formulations of estrogen that are available in contraceptive preparations?
ethinyl estradiol (EE) mestranol (rarely seen)
when there is an increased dose of estrogen, what kind of symptoms does the patient have?
more pregnancy symptoms
when there is a low dose of estrogen, what kind of symptoms does the patient have?
less cycle control
what are the first generation progesterones?
Norethindrone norethindrone acetate ethynodiol diacetate
what are the SE of first generation progesterones?
highest chance of spotting & breakthrough bleeding
least risk of androgen SE
what are the second generation progesterones?
norgestrl
levonorgestrel
what are the SE of second generation progesterones?
lowest risk of breakthrough bleeding
increased risk of androgen SE (acne, hirsutism, dyslipidemia)
what are the third generation progesterones?
desogestrel
norgestimate
what are the SE of third generation progesterones?
balance between 1st & 2nd gen
reduce SE on carbohydrate and lipid metabolism; acne; hirsutism
which generation of progesterones are first line for contraception?
third
what are the goals of OC treatment?
tolerance
-current OCs has less estrogen (less pregnancy like symptoms)
-newer gen progestins have fewer weight changes, reduced mood swings
effectiveness
-N/V decrease effectiveness (decreased absorption), backup method x7 days
what are the dosing regimens for OCs?
traditional- 21 days active drug, 7 inactive
extended cycle: 84 days of active, 7 days off
monophasic: same dose of estrogen & progestin for full cycle
biphasic: vary dose of progestin (rare)
triphasic: vary estrogen, progestin or both (more popular)
what are the extended cycle dosing medications?
seasonique
loSeasonique
lybrel
what is the difference of new monophasics?
24 active and 4 non-active pills per cycle
-goal lighter & shorter withdrawal bleeds & to decrease breakthrough spotting
when are progestin-only pills used?
when estrogen is contraindicated
what are the common ADRs of progestin-only pills?
changing bleeding patterns
breast tenderness
what should pts taking progestin-only be educated on?
dose MUST be taken at the same time daily
if a pill is taken even a few hours late, backup method is recommended for 48 hours
how do progestin-only pills work?
thickening of cervical mucus and prevention of sperm penetration
what are the injectable progestins?
depo-provera
what are the advantages of the injectable progestin?
once every 12 week dosing
effective
what are the disadvantages of the injectable progestin?
spotting and then amenorrhea
weight gain
depression
decreased bone-density with long-term use
how do intrauterine progestins work?
releases 20 mcg of levonorgestrel daily
how long can IUDs be left in place?
5 yrs
what is an advantage of IUDs?
only small levels of systemic circulating hormone
minimal SE
can cause changes in menstrual bleeding, amenorrhea
what are the progestin implants?
implanon/nexplanon; contains 68 mg of etonogestrel
how long do progestin implants provide contraception?
up to 3 yrs
when is hormone replacement therapy used?
any time there is a loss of the body’s ability to produce estrogen and progestin (removal of ovaries, menopause)
what are the goals of HRT treatment?
provide relief from symptoms associated with menopause
used to tx moderate to severe menopausal symptoms
used to tx/prevent other chronic illness not encouraged
lowest dose & shortest duration recommended
what are the symptoms of decreased hormones?
vasomotor symptoms
vaginal atrophy
osteoporosis
what are the “rules” for rational HRT drug selection?
use lowest dose that relieves symptoms for shortest time (up to 5 yrs)
individualize the drug choice and dose on woman’s risk profile
monitor women annually for changes in risk profile, development of AE, & cont. need for therapy
when is HRT not recommended?
to prevent CHD
women with h/o breast cx or 1st degree family memeber
when is HRT indicated?
can decrease r/o colon cancer
reduces r/o osteoporosis
will improve symptoms of vasomotor symptoms & vaginal atrophy
what is estrogen therapy used for?
relief of perimenopausal/postmenopausal symptoms
vulvovaginal atrophy/dryness
reduction in colon and rectal cancers
when treating vulvovaginal atrophy & dryness what is the preferred route?
topical d/t lower overall estrogen dose
oral estrogen improves symptoms
what are some of the alternative “medications” used to treat perimenopausal/postmenopausal symptoms?
phytoestrogens -red clover -soy -black cohosh botanicals/herbals -black cohos -chaste tree fruit
there is an increased risk of what type of cancer with estrogen therapy?
endometrial with unopposed estrogen
the risk of what increases with estrogen therapy?
CHD
stroke
thromboembolic events
estrogen therapy is correlated with reduction of what?
colon and rectal cancers
what is progestin alone used for?
contraception
menorrhagia
progestin is combined with estrogen to treat peri & postmenopausal women for what reason?
prevent endometrial hyperplasia (increases risk for endometrial cx)
combo of estrogen & progestin are used when what is intact?
uterus
what are the combo medications available?
prempro
premphase
what is the outcome of continuous regimens?
eliminate monthly withdrawal bleeding
have higher rate of breakthrough bleeding esp. first 6 mths
what is the outcome of cyclical/sequential therapy?
given when problem with breakthrough bleeding
estrogen taken daily
medroxyprogesterone taken part of the cycle
when is testosterone therapy used?
when hot flashes don’t improve with HRT/ERT
testosterone is combined with what?
estrogen
testosterone alone an lead to what?
masculinization
