Unit 4 Exam Flashcards
Non-contraceptive benefits of combination oral contraceptives
Decreased risk of ovarian, endometrial and colon cancer.
Decrease benign breast disease and ovarian cysts.
Decrease risk of endometriosis, fibroids, ovulation pain, PMS, PMDD, cramps, migraines and anemia.
Improves acne and hirsutism.
When to start oral contraceptives?
Day 1 start: first day of menses.
Sunday start: Sunday after menses (no weekend menstruation).
How long to use back up birth control after starting oral contraceptives?
7 days
Serious Side Effects of Oral Contraceptives
VTE
MI/Stroke (especially if over 35 and smoking)
Liver disorders
Minor Side Effects of Oral Contraceptives
Breast tenderness
N/V
HA
Bloating
Acne
Mood changes
Spotting
Side Effects of Progestin-Only Contraceptives
Irregular bleeding
Acne
Breast tenderness
Mood changes
HA/Migraines
N/V
Ovarian cysts
Weight gain
Fluid retention
Acne
ACHES Acronym
severe Abdominal pain (gallbladder).
Chest pain (PE or MI)
Headache (stroke, HTN, migraine)
Eye problems (stroke or HTN)
Severe leg pain (DVT)
Depo-Provera Dosing Schedule
Initiated within the first 5 days after menses.
Given every 13 weeks (if missed, perform pregnancy test).
Depo-Provera Side Effects (6)
Weight gain
HA
Dizziness
Nervousness
Amenorrhea
Irregular bleeding
Depo-Provera Long Term Effects
Can cause significant loss of bone mineral density (reversible after stopping).
Increase calcium and vitamin D intake and increase exercise.
Depo-Provera Population
Issue with daily compliance.
Safe in hx of CV disease, stroke, thromboembolism, PVD and hemoglobinopathies (sickle cell).
Slow reversal: 70% conceive within first year, 90% within first two years. Not a good option if someone wants to conceive after stopping birth control.
IUD Education
Highly effective (<1%) and easily reversible.
Hormonal (progestin-only) and non-hormonal options.
Only maintenance is checking strings after each period to ensure placement.
No associated decline in fertility.
Placed in office.
IUD Population
Dysmenorrhea
Menorrhagia
Anemia
Side Effects of IUDs
PID
Ectopic pregnancy
Uterine perforation
Expulsion
Ovarian cysts
Irregular bleeding
Amenorrhea
Pelvic pain
Contraindications for IUDs
Suspected pregnancy
Uterine abnormalities
PID
Unexplained vaginal bleeding
What contraceptive method has decreased efficacy in patients with high BMI?
Xulane Transdermal Patch (Noregestromin and ethyl estradiol)
Increased failure rates and increase VTE risk if over 198lbs or BMI >30.
Best Practices for Emergency Contraception
Stops ovulation from occurring.
Should be utilized within 120 hours (5 days) of unprotected sex.
After use of any regimen, pregnancy test should be performed if no menstruation occurs within 21 days.
Types of Emergency Contraceptives
Copper IUD
Levonorgestrel (LNg or Plan B or Julie)
Ulipreistal Acetate (UPA) “Ella”
Combinded estrogen progestin (Yuzpe regimen)
Copper IUD
Most effective (>99%) and can remain in place for continued contraception.
Up to 10 years.
Levonorgestrel (LNg) “Plan B or Julie”
94% effective
Given as single dose (1.5mg) or split dose (0.75 mg) 12 hours apart.
Most effective within first 3 days and less effective in those more than 165 lbs.
Ulipristal Acetate (UPA) “Ella”
98% effective.
Progesterone receptor antagonist - inhibits follicle rupture even near ovulation.
Single dose (30mg)
Most effective within first 3 days and less effective in those more than 195lbs.
Combined Estrogen Progestin (Yuzpe regimen)
Less effective than LNg and UPA
Given in two doses (100 mcg ethinyl estradiol plus 0.5 mg LNg followed by repeat dose 12 hours later)
Side effects: N/V
Treatment Order for Vulvovaginal Candidiasis (VVC)
1st line - OTC antifungals 1-7 days; or single dose oral fluconazole (150mg)
2nd line - Assess w/ cultures; treat with 7-14 days of topical antifungal; OR oral fluconazole 150 mg every 72 hours x 3 doses.
3rd line - Treat with 10-14 days topical azole; OR oral fluconazole with maintenance therapy for 6 months (150 mg PO weekly); monitor liver function.
Treatment Order for Trichomoniasis
1st line - Metronidazole or Tinidazole (2g single dose); OR metronidazole 500 mg BID x 7 days; treat sex partners and avoid sex until therapy complete AND symptoms free.
2nd line - Try alternative first line treatment; if recurrent failure, consult specialist.
Treatment Order for Bacterial Vaginosis
1st line - PO metronidazole (500 mg BID x 7 days); OR topical clindamycin cream (2% intravaginally x 7 days); OR metronidazole gel (0.75% intravaginally x 7 days).
2nd line - Treat recurrence with same or difference first line regimen; metronidazole gel (0.75% twice per week x 6 months).
Education Regarding Treatment of Bacterial Vaginosis
Metronidazole/Tinidazole - AVOID ALCOHOL: N/V if ingested during treatment or within 72 hours.
Clindamycin - May weaken latex condoms and diaphragms.
Avoid tight fitting clothes, allow vaginal ventilation, avoid douching or other hygiene products (esp. scented) that may alter pH.
Proper instillation of vaginal creams and suppositories - best to perform at bedtime, wear a pad or panty liner on underwear.
Hormone Therapy for Patient WITH Uterus
Progestin + synthetic estrogen (oral or transdermal)
*Estrogen alone can lead to endometrial hyperplasia and risk of endometrial cancer.
Hormone Therapy for Patient WITHOUT Uterus
Estrogen alone
Contraindications for Hormone Therapy in Menopause (6)
Estrogen-dependent neoplasia
Thrombophlebitis/thromboembolic disorder
Pregnancy
Undiagnosed vaginal bleeding
Uncontrolled HTN
Acute liver disease
Monitoring Considerations for Patients Taking Hormone Therapy (7)
Follow up 4-8 weeks after initiation and then 3-6 months.
Decision to continue HT reviewed yearly.
Note any vaginal bleeding, ensure mammograms/PAPs/DEXA UTD
Height/weight, lipids, BP, breast exam, full pelvic exam.
Should be dc’d 1-3 years after menopause.
Discontinue gradually (4-6 week intervals) to reduce rebound symptoms.
Use beyond 3-5 years no recommended d/t increased risk of breast cancer.
Best Treatment of Vasomotor Symptoms in Menopause when HT is Contraindicated
SSRI (Zoloft, Lexapro)
SNRI (Effexor, Pristiq)
Gabapentin
Clonidine
Progestin only
Paroxetine (Paxil) FDA approved for moderate to severe VMS.
Best Route/Treatment for GU Syndromes of Menopause (GSM)
HT - Low dose vaginal estrogen OR transdermal estrogen or ospemifene (nonestrogen): lower risk of VTE compared to PO.
Non-HT - Vaginal lubricant and moisturizers and continued sexual intercourse.
Routes: Vaginal tablets, rings or cream.
Medications Used to Treat Pelvic Inflammatory Disease (6)
Cephalosporins (“Cef-“)
Doxycycline
Clindamycin
Gentamycin
Probenecid
Metronidazole
IV Treatment Used to Treat Pelvic Inflammatory Disease (PID)
Ceftriaxone + doxycycline + metronidazole
Cefotetan + doxycycline
Cefoxitin + doxycycline
Ampicillin-sulbactam + doxycycline
Clindamycin + gentamincin
IM or PO Treatment Used to Treat Pelvic Inflammatory Disease (PID)
Ceftriaxone + doxycycline + metronidazole
Cefoxitin + probenecid + doxycycline + metronidazole
3rd gen cephalosporin + doxycycline + metronidazole
Treatment of Gonorrhea for Patients with Cephalosporin Allergy
Gentamycin IM + Azithromycin PO
Suppressive Therapy for Genital Herpes
Acyclovir (more frequent dosing d/t decrease bioavailability; pregnancy).
Valacyclovir (Used in pregnancy)
Famciclovir
Treatment of Pregnant Patients with Chlamydia
Azithromycin 1g PO x 1 dose (Amox is alternative)
Considerations of treatment of chlamydia in pregnant patients
Doxy is contraindicated in 2nd-3rd trimester
Retest 3-4 weeks after treatment and again after 3 months to make sure it is not going to be passed to child during birth
Patient-Applied treatments for genital warts
Imiquimod (Aldara)
Podofilox (Condylox)
Sinecatechins (Green tea extract product)
Treatment of pregnant patients with syphilis and allergy to penicillin
PCN G = only effective treatment
Desensitize mom to PCN and then treat with PCN G.
Allows temporary tolerance.
Treatment of erectile dysfunction
1st line - Phosphodiesterase-5 inhibitors (PDE-5)
2nd - line refer to urologist.
Complementary - Yohimbine, ginkgo bilboa, ginseng, HCG, L-arginine
Examples of PDE-5 Inhibitors
Tadalafil (Cialis)
Vardenafil (Levitra)
Sildenafil (Viagra)
Avanafil (Stendra)
Contraindications of PDE-5 Inhibitors (12)
Concurrent use of NITRATES
Alpha-blockers
Unstable angina
Hypotension
Uncontrolled HTN
Recent stroke
Arrhythmia
MI within 6 months
Severe HF
Renal failure
Liver failure
Potent CYP450 inhibitor
Antimuscarinics MOA
Inhibit binding of Ach at muscarininc receptors M3 on detrusor smooth muscle cells, causing relaxation and increase bladder filling capacity.
Antimuscarinics Adverse Effects
Anticholinergic side effects (xerostomia, constipation, urinary retention).
*Can’t see, can’t spit, can’t pee, can’t shit.
Antimuscarinics Contraindications
Narrow angle glaucoma
Urinary retention
Use of other drugs metabolized by CYP-450
Antimuscarinics Examples
Oxybutynin (Ditropan)
Tolterodine (Detrol)
Solifenacin (Vesicare)
1st Line Treatment of Uncomplicated UTI
Nitrofurantoin (Macrobid) - Avoid in 1st trimester and last 30 days in pregnancy.
TMP-SMZ (Bactrim) - Avoid in sulfa allergy.
Fosfomycin (Monurol) - x1 dose, dissolved in water.
2nd Line Treatment of Uncomplicated UTI
Increase Bactrim dose to x7 days
Ciprofloxacin (Cipro) - Achilles tendon rupture
Levofloxacin (Levaquin) - Achilles tendon rupture.
3rd Line Treatment of Uncomplicated UTI
Treat based on urine culture results.
Cefalexin (Keflex), Amoxicillin, Augmentin.
Treatment of Complicated UTI for Males/post-menopausal women/catheters
Ciprofloxacin (Cipro)
Levofloxacin (Levaquin)
Treatment of Complicated UTI for Pregnant Women
Amoxicillin
Cephalexin (Keflex)
Nitrofurantoin/Bactrim (Not is 1st trimester or last 30 days).
Geriatric Considerations for UTI Treatment
Commonly asymptomatic - 1st sign is AMS
Increased UTIs in postmenopausal d/t loss of estrogen and increased pH
Fecal incontinence, incomplete bladder emptying, malnutrition and increased urine pH
***Nitrofurantoin not recommended (CrCl 40 ml/min)
Pregnancy Considerations for UTI Treatment
Take all UTIs SERIOUSLY
Treat asymptomatic UTIs
30% untreated develop pyelonephritis
Changes during pregnancy increase risk
NO bactrim or nitrofurantoin during 1st trimester and last 30 days.
Urine cx 1 week after treatment and every 4-6 weeks
Children Considerations for UTI Treatment
UTI can indicate GU anomaly
Treat quickly to reduce risk of renal scarring in kids <5
Kids <3 with 1st UTI should have renal US
1st line - Augmentin, cephalexin, cefpodoxime and bactrim.
Reason for treatment of prostatitis
Required d/t inflammation of the prostate can restrict the urinary outflow via the urethra.
1st line treatment of prostatitis
***Fluroquinolones (Ciprofloxacin; Levofloxacin)
Sulfas (Bactrim)
2nd line treatment of prostatitis
Doxycycline (Vibramycin) or Azithromycin or Clarithromycin
Adjunctive treatment of prostatitis
Sitz baths
Analgesic stool softeners
Antipyretics
Rest
Prostatic massage
Voiding in warm bath
Limit caffeine/alcohol
Alpha-Adrenergic Blocker MOA
Relax smooth muscle of prostate and bladder neck, decreasing bladder resistance to urinary flow.
Alpha-Adrenergic Blocker Side Effects
Orthostatic hypotension
Somnolence/drowsiness (take at night)
Fluid retention
HA
Dizziness
Weakness
Alpha-Adrenergic Blockers Examples + Side Effects (“-osin”) (4)
Terazosin (Hytrin) - Causes somnolence, take at bedtime.
Doxazosin (Cardura) - Avoid in CHF/renal failure.
Tamsulosin (Flomax) - Contraindicated in prostate CA.
Silodosin (Rapaflo) - Contraindicated in hepatic/renal failure.
5-Alpha Reductase Inhibitor MOA
Blocks 5-alpha reductase, weakening prostate growth by inhibiting conversion of testosterone to DHT which lessens LUTS.
5-Alpha Reductase Inhibitor Examples + Side Effects (“-eride”)
Finasteride (Proscar) - Impotence and decrease libido
Dutasteride (Avodart) - Orthostatic hypotension, priapism, increase risk of prostate CA.
5-Alpha Reductase Inhibitor Considerations
***Not to be handled by pregnant women
Can affect genitalia of the fetus
Other BPH Medical Treatments
5-Alpha Reductase Inhibitor + Alpha-Adrenergic Blockers (Combo)
PDE-5 Inhibitors (contraindicated w/ nitrates and alpha-blockers)
Supps/Herbals - Saw palmetto, pygeum, zinc
Monitoring of Medical Treatment of BPH
Decrease in AUA score by 3-4 is significant
BP should be monitoring during first 2 weeks
Keep open communication regarding sexual health
If side effects occur, try a different agent.
Treatment Order of BPH
1st line - AUA <7 = watchful
2nd line - AUA >7 = AAB or 5ARI or PDE5
3rd line - 5ARI + AAB
4th line - Refer to urology for surgical intervention
Risk factors with long-term use of H2RAs
Reduced efficacy
Tachyphylaxis
Tolerance
*Intermittent use preferred
Risk factors with long-term use of PPIs
Hypergastrinemia
Fractures with osteoporosis
GI infections (C. Diff + bacterial gastroenteritis)
Vitamin B12 deficiency
Hypomagnesemia
Treatment regimen for NSAID-induced PUD
1st line - PPI, H2RA, Sucralfate (if NSAID can dc’d)
If NSAID cannot be dc’d - treat with PPI x8 weeks with NSAID (or misoprostol)
If NSAID can be dc’d - treat with PPI for 4 weeks
Misoprostol contraindicated in pregnancy.
Considerations for NSAID-induced PUD
Test for H. pylori and if present, treat accordingly
Find another pain management modality (dc NSAID)
Use enteric-coated NSAIDs, take with meals, add misiprostol (cytotec), switch to a selective COX-2 inhibitor
Antacid Examples
Calcium-carbonate (Tums)
Mag Salts
Aluminum salts
Antacid Adverse Events
Rebound hyperacidity (w/ mag)
Constipation (w/ aluminum)
*No contraindications
Antacid education
Take 1-4 hours after administration of: iron, sulfonylureas, tetracyclines and quinolones.
Alters rate and absorption.
Do not heal ulcers. Only symptom relief.
Treatment N/V due to drugs, ketoacidosis or uremia
Phenothiazines (Compazine; phenergan)
Metoclopramide (Reglan)
Treatment N/V due to GI Disorders (Obstruction/Gastroparesis)
Metoclopramide (Reglan)
Treatment N/V due to Visceral Pain
Analgesics
Treatment N/V due to Motion Sickness or Vestibular Inflammation
Antihistamines/Anticholinergics (Hydroxizine, meclizine, dramamine).
Treatment N/V due to Higher Brain Stem Function (Emotions, Sights, Smells, and Tastes).
Benzodiazepines
Dronabinol
Corticosteroids?
Treatment Order for N/V
1st line - Phenthiazine (mild/mod)
2nd line - Antihistamine/anticholinergics (mild)
3rd - re-evaluate physiological cause
Anti-motility Agents MOA
Lomotil - Decrease GI motility
Loperamide - Opioid receptor agonist, acts on myenteric plexus of the large intestines
Contraindication to Anti-motility Agents
Infectious diarrhea (fevers, bloody diarrhea, fecal leukocytes)
Caution in hepatic dysfunction
Lomotil - Risk of HTN crisis if used with MAOIs.
ADsorbents Ex + MOA
Kaopectate
Binds to diarrhea and toxins to solidify stool (add a dose after each BM).
ABsorbents Ex + MOA
Fibercon
Absorbs H2O in the GI tract to make stool less watery.
Semisynthetic Antibiotics Use + Ex
Rifaximin (Xifaxin)
For noninvasive strains of E. coli
Best for travelers diarrhea
Semisynthetic Antibiotics Side Effects
Peripheral edema
Nausea
Fatigue
Dizziness
HA
Muscle spasm
Treatment of Diarrhea in Pediatrics
***Oral rehydration is PRIORITY
Antidiarrheal agents are not recommended in children 1 month to 5 years.
Lomotil - not for children under 4
Atypical Antidiarrheal-Antisecretory Agents Example
Subsalicylate (Pepto-Bismol + Kaopectate)
Subsalicylate (Pepto-Bismol + Kaopectate) MOA
Not well understood.
Anti-inflammatory action, antacid and antibiotic properties.
Subsalicylate (Pepto-Bismol + Kaopectate) Contraindications
Caution in hypersensitivity to ASA
Not used in kids with flu or chicken pox = ASA-induced Reye-Syndrome
Subsalicylate (Pepto-Bismol + Kaopectate) Adverse Events
Black stools
Dark tongue
Tinnitus
Subsalicylate (Pepto-Bismol + Kaopectate) Interactions
May interact with other medications that interact with ASA (e.g. warfarin).
Steps/Goal of Laxative Use
First - attempt lifestyle modifications = diet, exercise, bowel training habits (same time every day). Eliminate secondary cause.
Second - Add pharmacological agent.
Goal = increase water content of fees and increase motility using the lowest dose of laxative for least amount of time.
Agents that increase GI motility
Stimulant laxatives
Saline laxatives
Bulk forming laxatives
Hyperosmolar laxatives
Agents that decrease GI motility
Anti-motility agents (Imodium and Lomotil)
Stimulant Laxatives MOA
Increase peristalsis, effects smooth muscle of intestines.
Ex. Bisacodyl, Sennakot
Saline Laxatives MOA
Draw water into the intestines through osmosis = increases intraluminal pressure = increase motility
Ex. Mag citrate, milk of mag, fleet enema.
Bulk Forming Laxatives MOA
Binding to the fecal contents + pull water into the stool = stimulates movement of the intestines.
Ex. Metamucil, Citrucel
Hyperosmolar Laxatives MOA
Osmotic pressure by drawing fluid from less conectrated graident to a more concentrated gradient = increased osmotic pressure = stimulates intestinal motility
Ex. Lactulose, Sorbitol, Miralax
Treatment Order for Gastric Motility Managment
1st line - Bulk-forming laxatives (all constipation)
2nd line - Mag Hydroxide (saline laxative)
3rd line - Stimulant laxative
Gastric Motility OTC Management
Do not use more than 7 days in a row
Increase oral fluid intake
Gastric Motility Management Pediatrics
Pharm tx is controversial
PEG preperation or mineral oil
NO ENEMAS <2 y/o
Gastric Motility Management Women/Pregnancy
Docusate for Pregnancy
Castor oil can stimulate contractions
Gastric Motility Management Elderly
Bowel obsessed
Eliminate causative agent (antipsychotics, TCAs, calcium).
High risk of electrolyte imbalances with laxatives
Treatment Order of IBS-C
1st line - Linaclotide or lubiprostone + osmotic laxative to avoid diarrhea.
2nd line - Osmotic laxative
3rd line - Stimulant laxative short term for resistant cases
Treatment Order for IBS-D
1st line - Loperamide
2nd line - Diphenoxylate HCL (short term); rifaximin (long term)
Management of IBD (7)
Resume normal ADLs
Restore general physical/mental well-being
Maintain appropriate nutritional status
Maintain remission
Decrease frequency and severity of exacerbations
Decrease medication side effects
Increase life expectancy
Crohn’s Disease Management
Mild - Aminosalicylate OR rectal corticosteroid.
Moderate - PO + rectal aminosalicylate AND short term steriod.
Severe - IV corticosteroid AND Cyclosporine
Fulminant - IV corticosteroid AND/OR cyclosporine, infliximab or adalimumab
Patho: Chronic inflammatory disease characterized by transmural lesion located at ANY point in the GI tract.
Ulcerative Colitis Management
Mild - Combo PO + rectal aminosalicylates
Moderate - ADD corticosteroid
Severe - Req hospitalization, DC oral/topical agents, add corticosteroids
If no resolution in 7-10 days = IV cyclosporine, infliximab, adalimumab, vendolizumab
Patho: Chronic disease of mucosal inflammation LIMITED to the colon and rectum.
Aminosalicylates MOA
Decrease inflammation in the GI tract by inhibiting prostaglandin synthesis (quick onset - 1 week).
Ex. Azulfidine (Sulfasalazine); Mesalamine (Asacol)
Corticosteroid MOA
Immunosuppression and prostaglandin inhibition when disease fails to respond to aminosalicylates.
Ex. Prednisone; methylprednisolone
Immunosuppressive Agents MOA
Decrease production of various inflammatory mediators.
Ex. Cyclosporine, Methotrexate
Antibiotics MOA
Link between IBD and infectious cause.
Abx that act against gram (-) and mycobacterium organisms with low side effect profile.
Ex. Metronidazole (Flagyl); Ciprofloxacin (Cipro)
Biologics: Tumor Necrosis Factor (TNFa) Inhibitors MOA
Over-expression of immunologic cytokines including TNF seen in CD.
TNF inhibitors neutralize soluble forms of TNF and inhibit its binding to TNF receptors.
Ex. Infliximab (Remicade); Adalilimumab (Humira); Certolizumab (Cimzia)
Biologics: Selective Adhesion Molecules Inhibitors MOA
Prevent migration of inflammatory lymphocytes into gut mucosa
Ex. Naralizumab (Tysabri); Vedolizumab (Entyvio)
Treatment of Hepatic Encephalopathy
1st line - Lactulose
2nd line - Rifaximin
3rd line - Polyethylene glycol (Miralax)
Rome III Criteria for IBS
Diagnostic criteria must be fulfilled for last 4 months with symptom onset at least 6 months prior to diagnosis.
Recurrent abd pain or discomfort at least 3 days/month in the last 3 months associated with two of the following:
- Improvement with defection
- Onset associated with change in frequency of stool
- Onset associated with a change in form (appearance of stool)
