Unit 2 Exam Flashcards
Side Effects of Macrolides
QTC prolongation
LFT abnormalities
GI upset
Examples of Macrolides
Azithromycin
Clarithromycin
Caution with Macrolides
Arrhythmias or heart disease.
Hx of cholestatic jaundice or hepatic dysfunction w/ prior use.
Interactions CYP3A4 - statins use same pathway, hold statins during treatment.
Sinusitis Treatment
-Intranasal corticosteroids
-Augmentin
-Clindamycin
-Cephalosporins
-Doxycycline
-Fluoroquinolones
Sinusitis Treatment with ABX
ABX after “watchful waiting” 7 days unless severe.
First Line Treatment of Sinusitis
Amoxicillin with/without clavulanate 5-10 days
With clavulanate for high risk of infection from amox resistant organism
Sinusitis Treatment w/ Allergy to PCN
Use doxycycline or respiratory fluoroquinolone
Considerations with Augmentin Use
Do not use in pts with cephalosporin (cefazolin, ceftriaxone) allergy because of cross-sensitivity reaction with PCN and cephalosporins
Antihistamine MOA
Blocks the release of histamine from mast cells and basophils in the nasal passageways and competitively antagonize histamine at the H1 receptor.
1st Gen. Antihistamines Ex.
Benadryl
Chlorpheniramine
2nd Gen. Antihistamine Ex.
Fexofenadine (Allegra)
Loratadine (Claritin)
Cetirizine (Zyrtec)
Intranasal Antihistamines
Azelastine (Astelin)
Olopatadine (Pantanase)
Considerations of 1st Gen. Antihistamine Use
Causes drowsiness/sedation - ON BEERS LIST
Contraindicated in breastfeeding
AVOID IN NEWBORNS - SIDS
Benadryl Caution
Caution in asthma, CV disease, increased IOP, BPH, and thyroid dysfunction.
Chlorpheriniamine Caution
Caution in narrow-angle glaucoma, bladder neck obstruction, BPH.
Considerations of 2nd Gen. Antihistamine Use
Less sedating, but caution in renal and hepatic impairment.
Allegra + Claritin Adverse Effects
Somnolence
Dry mouth
Pharyngitis
Dizziness
Zyrtec Adverse Effects
GI upset
Drowsiness
Headache
Nausea
Viral infection
Astelin Adverse Effects
Bitter taste
HA
Nasal burning
Pharyngitis
Dry mouth
Fatigue
Dizziness
Patanase Adverse Effects
HA
Cough
Epistaxis
Bitter taste
Dry mouth
Overall Antihistamine Considerations
Caution in elderly - d/t confusion, constipation, dizziness, dry mouth, urinary retention, sedation (1st gen).
ON BEERS LIST
2nd gen ineffective for cough d/t colds as they may induce dryness causing worsening congestion d/t impairment of mucous flow.
Decongestants MOA
Sympathomimetic agent that stimulate alpha + beta receptors causing vasoconstriction
Decongestant Examples
Topical - Afrin and phenylephrine
Oral - Pseudoephedrine
Topical Decongestant Considerations
Don’t use more than 2-3 days due to side effect of rhinitis medicamentosa (rebound congestion).
Oral Decongestant Considerations
Given at least 2 hours before bed.
ER form should not be crushed, broken, or chewed.
Decongestant Overall Contraindications
Narrow angle glaucoma
Severe uncontrolled HTN
CAD
Recent use of MAOI
Decongestant Adverse Effects
HTN
Increase HR
Palpitations
Insomnia
Tremors
Urinary retention (caution w/ BPH)
GI upset
Dizziness
Acute Bronchitis Treatment
Antitussives
Expectorants
Antibiotics
Antivirals
Acute Bronchitis Patho
Infection of the bronchial tree.
90% caused by viruses
Hallmark sign - dry, non-productive cough, followed by a moist productive cough.
Antitussive Ex.
Benzonatate - mild cough
Dextromethorphan - mild cough
w/ codeine or hydrocodone - severe cough
Expectorants Ex.
Guaifenesin - decreases thick secretions
Antibiotic Indication for Bronchitis
Hx of COPD
High fever/ cough over 4-6 days
>65 years w/ comorbid conditions (CAD, DM)
Antiviral Indications for Bronchitis
If caused by flu A or B
Treatment of CAP in pts w/ comorbidities
Amoxicillin-clav + macrolide
Cephalosporin + Macrolide OR doxycycline
Fluoroquinolone monotherapy
Treatment of CAP in pts w/o comorbidities
Amoxicillin 1g TID
Doxycycline 100mg BID
Azithromycin (Zpack)
Clarithromycin 500mg BID
Oseltamivir (Tamiflu) Considerations
Rec within 48 hrs of symptoms onset
Can be used as prophylaxis for up to 6 weeks during a community outbreak
Tamiflu Considerations
Dosage adjustment with reduced kidney function.
Not recommended in ERSD.
Tamiflu Adverse Effects
N/V/D
Can feel worse taking tamiflu
Only really used for people at risk of hospitalization.
Theophylline Adverse Events
Tachycardia
Restlessness
Insomnia
N/V
GERD
Seizures
***Potential for life-threatening cardiac arrhythmias
Theophylline Med Class
Methylxanthines
Leukotriene Modifiers Indications
Asthma
Allergies
Leukotriene Receptor Agonists Ex.
Montelukast (Singulair)
Zafirlukast
“-lukast”
5-Lipoxygenase Inhibitors Ex. (Leukotriene modifier)
Zileuton
Montelukast (Singulair) Considerations
Black box warning - Serious behavior and mood related changes.
Zafirlukast Considerations
7 years and up
Metabolized by CYP450 enzyme
Adverse events - pharyngitis, HA, rhinitis, gastritis.
Rare liver failure resulting in death or liver transplant - monitor LFTs q 2-3 months***
Zileuton Considerations
12 years and up
Metabolized by CYP450 isoenzyme
Adverse events - Dyspepsia, abd pain, and nausea.
Monitor LFTs before treatment, once a month for 3 months, and once q 2-3 months***
Increases theophylline levels and PT/INR
Quick Relief Treatment Recommendations for Asthma
Short-acting beta agonists (SABA)
SABA Ex + Onset
Albuterol
Levalbuterol
Onset 10 mins, last 3-4 hours
May be repeated q 20 mins for 1 hr, then q 3-4 hours for 24-48 hrs.
Short-Acting Muscarinic (anticholinergic) Antagonist Mechanism of Action
Blocks acetylcholine muscarinic receptors, decreasing cGMP which relaxes airway smooth muscle and increases bronchial ciliary activity, therefore decreasing mucous secretions.
SAMA Ex + Onset
Ipratropium Bromide (Atrovent)
Onset - 15 mins, duration 2-5 hrs.
Gold Group D Option 1
Daily LABA/LAMA
Ellipta, Genuair, Respimat
“REG”
Gold Group D Option 2
Daily ICS/LABA
Advair, Airduo, Breo, Dulera and Symbicort
Gold Group D Option 3
Daily ICS/LABA/LAMA
Can add theophylline, phosphodiesterase-4 inhibitor, macrolide abx or quad therapy (ICS + LAMA + LABA + roflumilast = Trelegy)
LABA Ex.
Salmeterol
LABA Black Box Warning
Black box warning - increased asthmas related death.
MUST be used with ICS
LABA Adverse Events
Tachycardia
Tremors
Nervousness
Dizziness
Hyperglycemia
LABA Contraindications
Hypersensitivity
LABA Cautions
Known cardiac disease
DM
Glaucoma
Seizure dx
Combo ICS/LABA Ex
Advair Diskus (fluticasone/salmererol)
Breo (Fluticasone/vilanterol)
Dulera (Mometasone/formoterol)
Symbicort (Budesonide/Formoterol)
Namenda (NMDA) MOA
Blocks activation and overstimulation of NMDA receptor during glutamate abundance inhibiting neuronal degeneration.
Goals of Drug Therapy for AD
To maintain and maximize the pt’s functional ability, quality of life, and independence for as long as possible while minimizing adverse events and cost.
Meds to Control Non-cognitive Symptoms
Antipsychotics Agents
Benzodiazepines
Antidepressants
Antipsychotic Agents Ex.
Haloperidol (Haldol) - Typical antipsychotic
Risperidone (Risperdal) + Olazapine (Zyprexa) - Atypical antipsychotic
Haloperidol (Haldol) Considerations
High side effect profile, including risk for extrapyramidal symptoms (Parkinsonian symptoms)
Last resort!
Antipsychotic Black Box Warning
Increased risk of death in dementia related psychosis associated with increased risk of stroke
Benzodiazepine Use in AD
PRN for anxiety and episodic agitation
Start at lowest dose, use sparingly
Short Acting preferred - Ativan/Xanax
Adverse effects = falls, sedation, delirium
Antidepressant Use in AD
High incidence of depression associated with AD
Can improve QOL
SSRIs preferred - Lexapro/Zoloft
1st Line Treatment of Mild to Moderate AD
Cholinesterase Inhibitors
1st Line Treatment of Moderate to Severe AD
NMDA receptor agonist (may be used WITH cholinesterase inhibitor)
2nd Line Treatment of Moderate to Severe AD
Trial of second cholinesterase inhibitor.
Cogentin Contraindications
Narrow-angle glaucoma
Cogentin Adverse Events
N/V
Constipation
Dizziness
HA
Peripheral edema
Insomnia
Orthostatic hypotension
Dyskinesias
Cogentin Special Considerations
Avoid with KCl - can increase risk of ulcers
Concomitant use of glucagon can increase GI adverse effects
Avoid use with other anticholinergics - can cause additive side effects
Treatment of Motor Symptoms in PD
Anticholinergics
Amantadine
Monoamine Oxidase-B (MAO-B) Inhibitors
Dopamine Agonists
Levodopa
Carbidopa/Levadopa
Catechol-O Methyltransferase Inhibitors (COMTIs)
AACC-MDL
Anticholinergic Ex.
Trihexyphenidyl (Artane)
Benztropine (Cogentin)
Amantadine Ex.
IR (Symmetrel)
ER cap (Gocvri)
ER Tab (Osmolex)
MAO-B Ex.
Slegiline (Eldepryl)
Basagiline (Azilect)
Safinamide (Xadago)
Dopamine Agonists Ex.
Pramipexole (Mirapex)
Ropinirole (Requip)
Rotigotine (Neupro)
Apomorphine (Apokyn)
Carbidopa/Levadopa Ex.
IR (Sinemet CR)
CR (Sinemet CR)
ER (Rytary)
COMTIs Ex.
Entacapone (Comtan)
Tolcapone (Tasmar)
“-capone”
Non-motor Symptoms in PD
Depression
Psychosis
Dementia
Insomnia
Autonomic/other issues (Hypotension, drooling, constipation).
Treatment of Depression in PD
Pramipexole (Mirapex)
Venlafaxine (Effexor)
TCAs (Elavil)
Dopaminergic drugs (Wellbutrin)
Treatment of Psychosis in PD
Clozapine (Clozaril) - preferred
Quetiapine (Seroquel) - most effective
Donepezil (Aricept)
Rivastigmine (Exelon)
Ziprasidone (Geodon)
Treatment of Insomnia in PD
Rotigotine (Neupro)
Treatment of Hypotension in PD
Fludrocortisone (Florinef)
Indomethacin
Droxidopa
Treatment of Drooling in PD
Sublingual atropine drops
Glycopyrrolate
Botulinum toxin injections
Treatment of Constipation in PD
Stimulant laxatives
Stool softener
Amantadine MOA
Binds to and blocks N-methyl-D-aspartate (NMDA) glutamate receptors and increases the release of dopamine.
Used for dyskinesia.
Levadopa MOA
Dopamine precursor, cross the BBB, converts via dexarboxylation (L-DOPA decarboxylase) to dopamine and stored in the presynaptic neurons until stimulated for release.
Carbamazepine (Tegretol) Serious Side Effects
Hypersensitivity to medication/TCAs, bone marrow suppression, recent use of MOAIs
Inducer of several CYP pathways, pregnancy category D, can lead to hyponatremia in older adults.
Blood dycrasias, SIADH, cardiac conduction issues, SJS, and DRESS.
Carbamazepine (Tegretol) Black Box Warning
Risk of toxic epidermal necrosis/SJS, aplastic anemia, and agranulocytosis.
Screen for human leukocyte antigen (HLA)-B*1502 allele - seen in Asian decent
Hydantoins (Phenytoin, Fosphenytoin) Adverse Effects
Lateral nystagmus, ataxia, lethargy, acne, increased body hair, arrhythmia, gingival hyperplasia.
Check levels with concern for these SEs
Contraindicated in HB and SB
Acute Treatment of Status Epilepticus
Benzodiazepines
Benzodiazepines MOA
Depresses all levels of the CNS including the limbic system and reticular formation, probably through the increase action of GABA
Benzos Used in Status Epilepticus
Lorazepam
Diazepam (can also be rectal gel)
MUST BE IV
Preventative/Prophylactic Treatment for Cluster Headaches
Verapamil IR
Lithium
Melatonin
Warfarin
Galcanezumab
GLMVW
Prophylactic Treatment for Cluster Headaches
1st line - TCAs
2nd line - SNRI (Venlafaxine) or atypical antidepressants (Mirtazapine)
Amitriptyline (Elavil) for TTH
1st line, GOLD standard for TTH
Given at bedtime
Amitriptyline (Elavil) Adverse Events
Weight gain
Anticholinergic effects
Drowsiness
Amitriptyline (Elavil) Cautions
Use in caution in patients with Hx of CVD, BPH, glaucoma, urinary retention, DM, CNS drugs/alcohol, elderly.
Amitriptyline (Elavil) Black Box Warning
Risk of suicidal ideation in pts <24 years old with major depressive disorder or other psychiatric disorders.
Venlafaxine (Effexor) Adverse Effects
Nausea
Somnolence
Sexual dysfunction
Sweating
Nervousness
Venlafaxine (Effexor) Special Considerations
Multiple drug interactions
Use in caution in older adults
Mirtaxapine (Remeron) Adverse Events
Somnolence
Increased cholesterol
Dry mouth
Weight gain
Constipation
Mirtaxapine (Remeron) Special Considerations
Use caution in seizure disorder, hepatic/renal dysfunction, older adults
1st Line Prophylaxis for Migraines
Anticonvulsants (Valporic acid, topiramate)
Beta blockers (propranolol, metoprolol, timolol)
TCAs (Amitriptyline)
SNRI (Venlafaxine)
ABTS
2nd Line Prophylaxis for Migraines
CCBs (Verapamil)
Injectable CGRP Inhibitors (Amovig, Ajovy, Emgality, Vyepti)
3rd Line/Alternative Prophylaxis for Migraines
Botox
Second Line Treatment Options for Migraine
Triptans
Ditans
CGRP receptor antagonists
Ergot Derivatives
Barbiturates
Opioids
Steroids
Antiemetic Agents
Triptans Examples
Sumatriptan
Zolmitriptan
Rizatriptan
Eletriptan
Fovatriptan
“-triptan”
Ditans Examples
Lasmiditan (Reyvoew)
“-ditan”
CGRP Receptor Antagonist Examples
Ubrogepant (Ubrelvy)
Rimegepant (Nutec)
“-gepant”
Ergot Derivatives Examples
Ergotamine Tartrate (Ergomar)
Dihydroergotamine/DHE (Migranal)
Ergotamine-caffeine (Cafergot)
“Ergot”
Barbiturates Examples
Fioricet (butalbital/caffeine/acetaminophen)
Forinal (butalbital/caffeine/aspirin)
“Bit”
Opioids Examples
Butorphanol Tartrate
Tramadol
Acetaminophen + codeine
Steroid Examples
Dexamethasone
Antiemetic Agent Examples
Proclorperazine
Metoclopramide
Droperidol - QT prolonging
Contraindications/Considerations to Triptan Therapy
Should not be used more than 9 days per month
Should not be used within 24 hours of other vasoconstricting drugs (ex. ergotamine).
Avoid in patients with basilar, hemiplegic, reigonal migraines.
Avoid in patients with CAD, CV disease, severe PVD.
STRONGLY contraindicated in pregnancy .
Not indicated for children HOWEVER safety and efficacy for age 12-17 have been demonstrated for nasal and oral dosages.
Contraindication for Zolmitriptan
Patients with Wolf-Parkinson-White (WPW) sydrome
Medication Overuse Headache (MOH)
Headache recurs as each dose of med wears off causing the patient to take another analgesic and thus continuing the cycle of pain.
MOH Diagnosis
Treating more than 2 headaches with OTC analgesics or other abortive medications per week for migraine or TTH can lead to the development of chronic daily headaches.
Treatment of MOH
With holding all OTC analgesics for 1-2 weeks.
Identify triggers and encourage healthy lifestyle.
Bisphosphonate Therapy Education
AM dosing on an empty stomach - absorption decreases with food.
Must be taken whole w/ 8oz of water and remain upright for 30-60 mins.
Daily, weekly, and monthly formulations.
Omit in patients with GERD d/t risk of esophagitis.
Monitor via DEXA scans, if scan is good, pt can take holiday from medication.
1st Line Acute Gout Treatment
NSAIDs - Naproxen, indomethacin, sulindac
Systemic corticosteroids
Colchicine - must be given within 24-48 hrs.
2nd Line Acute Gout Treatment
Switch to an alternative 1st line
Do not mix NSAIDs with steroids
1st Line RA Bridging Treatment
NSAIDs or corticosteroids in ACUTE episode until DMARDs are therapeutic (most common is methotrexate).
Other RA Bridging Treatments
Glucocorticoids are used to rapidly suppress inflammation and relieve symptoms.
Treatment of Fibromyalgia
SNRIs - start low
SSRIs
TCAs
Cognitive Behavioral Therapy
Exercise
Examples of SNRIs for Fibromyalgia
Duloxetine (Cymbalta)
Milnacipran (Savella)
Venlafaxine (Effexor)
Examples of SSRIs for Fibromyalgia
Fluoxetine (Prozac)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Considerations for TCAs in Fibromyalgia
Sedation, TD, orthostatic hypotension, weight gain, anticholinergic symptoms, QT interval prolongations, and arrhythmias.
Use caution in elderly.
Psoriasis Treatment Considerations with Coal Tar (Cutar)
Odor, staining, photosensitivity, and folliculitis.
Use sunscreen.
Side effects = poor compliance
Herpes Zoster Treatment Options
Acyclovir - 800 mg x5 per day for 7-10 days
Famciclovir - 500 mg x3 per day for 7 days
Valacyclovir - 1 g x3 per day
Systemic Antivirals Considerations
Very effective against herpes virus
Recommended for adolescents, adults, and high-risk patients.
Not indicated for “healthy children” (<12)
Oral Terbinafine (Lamisil) Contraindications for Tinea Pedis (Toenail fungus)
Acute or chronic hepatic disease - check LFTs before start and 6-8 weeks after.
Interactions with Tagamet and antagonized by Rifampin
Terbinafine (Lamisil) Adverse Effects
Elevation in AST/ALTs
Diarrhea
Dyspepsia
Rash
HA
1st Line Impetigo Treatment
Topical mupirocin TID x7-10 days
Oral antibiotics
Oral ATB for Impetigo
Broad PNC - Amox-Clav or Dicloxacillin
1st Gen Ceph - Cephalexin
PNC allergy - Clindamycin***
Clotrimazole (Lotrimin) Topical Antifungal Considerations
Continue 1 week after infection clears.
NOT recommended during pregnancy or lactation
Avoid Ketoconazole in patients with sulfa-sensitivity
Clotrimazole (Lotrimin) Adverse Events
Pruritis
Irritation
Stinging
Considerations for Rx Systemic Corticosteroids for Contact Dermatitis
Initiate when dermatitis is widespread or resistance to topical preparations.
Rx as tapering dose
Take in morning to minimize insomnia
<2 week can lead to rebound dermatitis
Contraindications and Caution with Systemic Corticosteroids
Contraindicated - pts with systemic fungal infections and receiving vaccination.
Caution - TB, hypothyroidism, cirrhosis, renal insufficiency, HTN, osteoporosis, diabetes.
Systemic Corticosteroid Adverse Effects
GI upset
Mood swings
Sleep disturbances
Decreased efficacy if administered with barbiturates or rifampin
Treatment of Dermatitis on the Face and Intertriginous Regions
Use low potency steroids - think skin, so steroids will be absorbed faster and have a stronger effect.
Isotretinoin (Accutane) Rx Considerations
Only 30 days can be prescribed at a time.
Use 2 forms of contraception.
Before start - CBC, chem, fasting lipids and 1 month after.
Pregnancy should be avoided for 1 month after therapy is dc’d.
Should not be used in adolescents who have not finished growing, drug may cause premature close of the epiphyses.
Accutane Black Box
May cause increase in aggressive or violent behaviors or suicidal ideation.
Accutane Contraindications
Teratogen - serious birth defects
Prescribers must be registered in SMART program.
Accutane Adverse Effects
Teratogenicity
Elevated trigs
Dry skin and mucous membranes
MS aches
Corneal opacitities
1st Line Treatment for Acne
Topical Thearpy
Topical Medications for Acne
Retonoic Acid (Tretinoin)
Adapalene Gel (Differin)
Taxarotene Gel (Tazorac) - Retinoid prodrug
Skin care is most important
Role of Oral Contraceptives in Acne Treatment
Contraceptives that contain ethinyl estradiol, levonorgestrel, and norgestimate or drospirenone.
Effective due to decrease of testosterone production.
MRSA and Superficial Bacterial Infection Treatment
Vancomycin
Daptomycin
Linezolid (Zyvox)
Mupriocin (nostrils)
Treatment of CA-MRSA
Trimethoprim/Sulfamethoxazole (Bactrim)
Topical Preparation Absorption Rate Factors
Amount of agent applied
Surface area of the application
Length of application time
Frequency of the applicaiton
Application to broken skin/erosions
Choice of vehicle used
Thickness of the stratum corneum
1st Line Treatment of Rosacea - Topical
Metronidazole (MetroGel, Noritate)
Azelaic Acid (Finacea)
Sodium Sulfacetamide w/ Sulfur
Sulfacetamide, Sulfur, and Urea
2nd Line Treatment of Rosacea - Oral ATB
No improvement in 6 weeks
After 2 weeks of therapy, dose is reduced by 50% and then after 6 weeks, oral ATB is dc’d.
Topical treatment is continued indefinitely.
Oral ATB for Rosacea
Tetracycline
Doxycycline (Vibramycin, Monodox, Doryx)
Erythromycin
Trimethoprim/Sulfamethoxazole (Bactrim)
TDTE
3rd Line Treatment of Rosacea
If no improvement after 6 weeks
Start Isotretinoin (Accutane) or refer to dermatology.
