Week 11 Reproductive & Joint systems Flashcards
Which is an effect of estrogen for bone density?
Maintenance of bone density by decreasing the rate of bone resorption is an effect of estrogen. This is through the antagonizing effects of the parathyroid hormone.
Which adverse reaction is common with menopausal estrogens?
Elevation of systemic blood pressure
Patients treated with androgen therapy should be instructed to seek emergent evaluation if which adverse reaction occurs?
Priapism is an emergent condition in which a male can experience a sustained erection. It is important that a patient treated with androgen therapy is educated to seek emergent evaluation if this occurs.
Which contraceptive methods contains only progesterone?
Nexplanon (implant)
Which progesterone offers a decrease in androgenicity when compared with the other progesterones?
desogestrel and norgestimate
The decrease in androgenicity is thought to reduce adverse effects on carbohydrate and lipid metabolism, along with improving acne and hirsutism.
The recommended maximum daily dose of acetaminophen for a person who is suffering from moderate osteoarthritis (OA) pain, and has a history of alcohol and drug use with hepatic issues, is a maximum of how many grams per day?
3 grams/day
is the current recommended maximum dose, especially when scheduled, rather than intermittent, dosing is utilized.
Tumor necrosis factor (TNF) inhibitors used for the treatment of rheumatoid arthritis (RA) are associated with serious side effects, such as increased risk of which condition(s)?
Heart failure, vasculitis, and vision issues
TNF inhibitors do slow RA progression, but there are rising concerns about extra-articular risks (heart failure, vasculitis, and vision issues).
Which drug is most appropriate for a patient with high uric acid levels who undersecretes uric acid and has adequate renal function?
Probenecid
What drug is best for patients who overproduce uric acid.
Allopurinol or febuxostat
Which warning would the APN provide to an older patient taking calcium supplements and anticoagulants (such as warfarin)?
Calcium supplements contain high vitamin K levels, and warfarin doses may need increasing.
Which statement is most accurate regarding biosimilar drugs used to treat rheumatoid arthritis (RA)?
All biosimilar drugs must demonstrate patient outcomes similar to the parent drug, and clinicians must monitor for the same side effects.
Usually less expensive
Probenecid, taken to control uric acid levels, should not be prescribed for persons allergic to which of the following?
Sulfa-containing drugs
Which statements are most accurate regarding bone mineral density (BMD) in African American women when compared with white women?
- African American women have higher BMD than white women,
- more likely to die from hip fracture.
- lactose intolerant, which leads to poor calcium intake.
Indomethacin (COX-1 inhibitor) is no longer the first choice for pain and inflammation relief in gout due to which factor?
- gastric bleeding
- gastric peptic ulcers and
- renal dysfunction
- the Beers list.
To minimize gastrointestinal side effects, it is recommended that bisphosphonates should be taken in which manner?
- First thing in the morning on an empty stomach with a full 8 oz glass of water
- decreases the risk of esophagitis and gastric irritation and maximizes absorption in the gut.
Research from a Women’s Health Initiative (WHI) study resulted in which evidence-based recommendation regarding the use of estrogen and selective estrogen receptor modulators (SERMs) for the sole purpose of treatment for osteoporosis?
The WHI findings recommend BISPHOSPHONATES as the first-line treatment of osteoporosis because of potential risks associated with estrogen and SERMs, such as cardiovascular (CV) events and cancer.
Which method of action do injectable parathyroid hormone (PTH) analogues (such as Forteo) have on bone remodeling?
Stimulating osteoblastic activity
PTH analogues differ from other drugs to treat osteoporosis in that instead of preventing bone breakdown, they stimulate new bone formation and osteoblastic activity.
Colchicine, a medication used in treatment of gout, has a primary method of action that includes which of these?
Decreasing inflammation by uric acid crystals
PROPHYLACTIC, reduces inflammation, incidence of acute attack, and relieves residual pain postacute attack.
The rate of decline of bone loss is greatest for women during which period of their lives?
Within 2 years of menopause
When gout occurs in postmenopausal women, it is almost exclusively associated with which factors?
Hypertension, renal insufficiency, and diuretic use
To relieve the acute pain of a flare of gout, which drug is the currently recommended first-line treatment?
(NSAIDS)
Which recommendation should be made to a patient with a creatinine clearance (CCr) less than 30 to 35 mL/min and a serum creatinine of 5.1 regarding consideration of drug therapy with a bisphosphonate for osteoporosis treatment?
Bisphosphonates are not recommended for patients with moderate to severe renal impairment (CCr less than 30 to 35 and serum creatinine greater than 4.9) because the drug is mainly excreted in the urine.
Current (USPSTF) guidelines make which recommendation for the use of raloxifene (a selective estrogen receptor modulator [SERM]) for primary prevention of osteoporotic fragility fracture in postmenopausal women?
Raloxifene is a second-line therapy for those unable to tolerate other osteoporotic prevention therapies.
Raloxifene may be used for those unable to tolerate other therapies for osteoporosis; however, the same precautions are in place, including avoidance of use in those with history of deep vein thrombosis (DVT) or embolism because of increased risk of thromboembolic events.
Tumor necrosis factor (TNF) inhibitors used for the treatment of rheumatoid arthritis (RA) are associated with serious side effects, such as increased risk of which condition(s)?
Heart failure, vasculitis, and vision issues
Gout is caused by an alteration in purine metabolism, resulting in high levels of which of these?
Uric acid
hyperuricemia and deposition of urate crystals in various body tissues.
How do rates of hip fracture and vertebral fracture among Asian American women compare with those among white women?
Asian American women have lower hip fracture rates and higher vertebral fracture rates.
Asian women consume less calcium, because 90% of Asians are lactose-intolerant.
Colchicine, a medication used in treatment of gout, has a primary method of action that includes which of these?
Decreasing inflammation by uric acid crystals
Colchicine is prophylactic, reduces inflammation, incidence of acute attack, and relieves residual pain postacute attack.
Testosterone
MOA Indication ADR #4 Contraindication #6 Drug Interactions #3 Monitoring Parameters #4
MOA:
-highly protein bound
Indication: **only for testosterone deficiency, not spermatogenesis
- male primary hypogonadism (Kleinfelter’s)
- male hypogonadotropic hypogonadism (Pituitary condition, DM, cirrhosis, steroids)
- Delayed male puberty
- Transgender males
- Endometriosis & postmenopausal (Not FDA approved)
ADR:
- Acne
- Prostate disorder
- Sleep apnea
- Erythrocytosis
Contraindication:
- “Trial basis” on healthy, middle aged men
- Prostate/male breast cancer
- lower urinary tract symptoms (because prostate responsive to testosterone = BPH symptoms)
- erythrocytosis (HCT >50)
- severe untreated sleep apnea (CPAP its ok)
- CHF (increased Na+ retention)
Drug Interactions:
- Anticoagulants (Warfarin effects will be increased)
- Diabetic Agents (profound hypoglycemia)
- Corticosteroids (enhanced fluid retention r/t Na+ effects)
Education:
Minimize exposure to children (gel)
Monitoring Parameters:
- Reevaluate for prostate cancer @3 months & year
- HCT 3-6 months, then annually
- Lipids
- LFTs
When can the effects of testosterone be seen?
3-6 months, bone density in 2 years
Finasteride (Proscar, Propecia)
Drug Class
Indication
MOA
Monitoring Parameters
5-Alpha Reductase Inhibitors
Indication:
- BPH
- Male pattern baldness
MOA:
- Inhibits enzymes that coverts testosterone to DHT
- Anti Androgen Effects
Monitoring Parameters:
Prostate evaluation for increase in PSA
**Risk of high-grade prostate cancer
Leuprolide (Lupron)
Drug Class
MOA #2
Indication #4
GnRH Analogues
MOA:
- LH antagonist
- Anti Androgen Effects
Indication:
- Advanced prostate/breast cancer
- Endometriosis & fibroids
- Precocious Puberty
- Suppress puberty in transgender
Spironolactone
Drug Class MOA #3 Indication #3 ADR #2 Pregnancy
Aldosterone Antagonist
MOA:
- Aldosterone antagonist
- 5-alpha reductase inhibitor
- potassium sparing diuretic
Indication:
- PCOS
- Acne
- Hirsutism
ADR:
GI
Gynecomastia
PREGNANCY: NO
Ethinyl estradiol
Drug Class
MOA
Contraindication #7
Drug Interactions #2
Estrogen in Oral Contraception
MOA:
-Metabolized in Liver
Contraindicaton:
- > 35years & smoke
- Uncontrolled HTN
- Embolism/stroke
- Current breast cancer
- Cirrhosis
- Migraine w/aura
- Ischemic heart disease or risk factors
Drug Interactions:
- Any drugs that increase liver enzyme activity
- Anticonvulsants/Rifampin, Griseofulvan
Estrogen in Menopause
Indication #3
Oral vs. Transdermal ADR #3
Indication:
- Vasomotor S/S (vaginal dryness)
- GU S/S
- Benefit > risk for healthy women w/in 10 years of menopause or younger than 60
Oral Systemic treatment ADR:
- Oral has greater effect on liver = increased clotting factors, proteins, lipids
- Oral = Estrogen increases blood clot risk (negative effect on lipids)
- reduces thyroid function
Transdermal Estrogen
-Lower risk thrombosis/stroke
Vaginal Estrogen in Menopause
Indication #2
ADR #7
Vaginal Estrogen in Menopause
Indication:
- low dose for vaginal atrophy
- high dose = Vasomotor symptoms
ADR:
- Breast soreness
- Headache
- hypertension
- DM exacerbation
- cholestasis
- Thrombosis
- Endometrial hyperplasia
Contraindications to Menopausal Hormone Therapy (MHT) #6
- Breast cancer
- CAD
- Thrombosis/stroke
- Acute liver disease
- unexplained vaginal bleeding
- high risk for endometrial cancer
Raloxifene (Evista)
Indication
MOA #3
ADR #2
Teaching point
Estrogen and Bone Health
MOA:
- Selective estrogen receptor modulator (SERM)
- Estrogen agonist in bone
- Estrogen antagonist in breast (reduces breast cancer risk)
ADR:
Hot Flashes
Thrombosis
Teaching point:
*no effect on endometrium
Ospemifene (Osphena)
MOA
What does it do?
Indication #2
Caution #2
MOA:
Selective estrogen receptor modulator (SERM)
-Estrogen agonist in endometrium
What does it do?
Increases thickness & moisture of vaginal mucosa
Indication:
- Dyspareunia in postmenopausal females
- Vaginal dryness in postmenopausal females
Caution:
- increased risk of endometrial cancer
- Stroke/DVT
Bazedoxifene (Duavee)
MOA
pt population
MOA:
Combo estrogen derivative w/SERM
Patient population w/ intact uterus
Role of Progesterone #4
Thickens & stabilizes endometrium
Thickens cervical mucus
Relaxes smooth muscle of uterus
Thins vaginal mucosa
Etonogestrel implant (Nexplanon) Levonorgestrel-releasing intrauterine devices (Mirena, Skyla) Depot medroxyprogesterone injection (Depo-Provera)
MOA #5
ADR #5
Contraindication #3
Drug Interactions #2
MOA:
- Thickens cervical mucus to inhibit sperm migration
- Suppresses ovulation
- Lowers mid cycle peak FSH & LH
- Slow egg movement
- Thin Endomedrium
- less complications than estrogen
ADR:
- Irregular breakthrough bleeding
- Breast tender
- Galactorrhea
- nausea
- Acne
Contraindication:
- Breast Cancer
- Undiagnosed uterine bleeding
- Live disease (extensively metabolized by liver)
Drug Interactions
- Drugs the increase liver enzyme activity EX: Anticonvulsants
- Rifampin reduces efficacy
Norethindrone (Camila)
Progesterone only pills
**Half of women ovulate, just makes environment unsuitable
EDUCATION:
needs to be taken at same time everyday
Drospirenone (Slynd):
Progesterone only pills
Suppresses ovulation
antimineralcorticoid activity
Medroxyprogesterone Acetate (MPA)
Indication
Increased risk for ? #3
Which patients?
Contraindicated #2
1st or 2nd line?
Progesterone in Menopause
Indication:
-To prevent Endometrial Hyperplasia
Increased risks:
- Breast cancer
- CAD
- negative effect on lipids
Patient type:
-For women with uterus
Contraindicated:
- Women with hysterectomy
- Low risk women on low dose estrogen
**Not preferred
Micronized Progesterone
Indication
1st or 2nd line?
Patient education
-To prevent Endometrial Hyperplasia
PREFERRED
Bioidentical
Minimal effect on lipids, no increased risk cancer, CAD
Patient Education:
Monthly withdrawal bleeding
Mifepristone (Mifeprex, Korlym)
Drug Class
Indication #2
ADR #2
Progesterone Antagonist
Indication:
- Terminate Pregnancy
- Cushings
ADR:
- Bleeding
- Bacterial Infection
Biphosphonates
Indication #5 MOA ADR #5 Patient Education Contraindication #6
Indication:
- Osteoporosis
- High fracture risk (long term steroids, bone mineral density FRAX score)
- Hypercalcemia
- Bone cancer
- Paget’s
MOA:
-Inhibit bone resorption by reducing osteoclast # & fx
ADR:
- Esophagitis/gastric Irritation
- Atypical femur fractures (long term)
- Bone/joint/muscle pain
- Hypocalcemia
- Jaw osteonecrosis (IV) discontinues between oral surgery
Patient Education:
Empty stomach w/ 8oz water & stay upright for 30 mins
Contraindication:
- Renal disease
- Uncorrected hypocalcemia
- Delayed esophageal emptying (stricture/achalasia)
- Can’t sit up right
- aspiration
- UGI Pathology (esophagitis, ulcers, dysphagia)
Risedronate (Actontel)
MOA
Indication
Drug Class:
Biphosphonate
MOA:
Inhibits bone resorption w/o inhibiting bone formation
Indication:
Prevent hip or non-vertebral fractures
Alendronate (Fosamax)
Drug Class
MOA
Indication
Biphosphonate
MOA:
Highly selective inhibitor of bone resorption
Indication:
Prevent hip or non-vertebral fractures
What do you do if someone’s fracture risk remains high while on bisphosphonates
More than 5 years take a drug holiday
Which bisphosphonates prevent hip and non-vertebral fractures?
Alendronate (Fosamax)
Risedronate (Actontel)
Zoledronic Acid (Reclast)
ADR #2
Creatine
Education
**IV
ADR:
Risk renal toxicity
Flu-like ache symptoms (give Tylenol)
Monitor:
Creatinine
Education:
Calcium & Vitamin D supplement
Allopurinol & Febuxostat
Drug Class Indication MOA ADR #5 Contraindication Drug interaction #3 Peds Pregnancy Lactation Patient Education #2 Special Patient Consideration
Xanthine Oxidase Inhibitors
Indication:
Chronic gout
MOA:
Inhibits xanthine oxidase to prevent conversion into uric acid
ADR:
- Maculopapular skin rash
- Arthralgia
- GI
- Hepatoxicity (RARE)
- Hypersensitivity (RARE)
Contraindication:
-Hepatic dysfunction
Drug Interaction:
Azathioprine
Mercaptopurine
Theophylline
Peds: >6 years old
Pregnancy: NO:
Lactation: allopurinol only
Patient Education:
- Takes 1 week to see effects
- Administer with NSAID or Colchicine for 6 months to prevent flare up
Special Patient considerations:
Asians receive testing for allele, if positive prescribe alternative agent
*High risk for ADR steven-Johnson syndrome
Which Xanthine Oxidase Inhibitor is the first line?
Allopurinol
Black Box warning for Febuxostat?
Increased risk of cardiac related deaths
Probenecid
Indication ADR #5 Contraindication #3 Drug interaction Pregnancy/lactation
Indication:
-Chronic gout
MOA:
-Increases excretion of uric acid by inhibiting reabsorption in kidney
ADR:
- GI
- urinary frequency
- flushing fever
- gout exacerbation (in beginning)
- Blood dyscrasias (RARE)
Contraindication:
- Blood dyscrasias
- Renal failure
- G6PD deficiency/sulfa allergy
Drug interaction:
-Aspirin
Pregnancy/lactation: NO
Colchicine
Indication MOA #2 ADR #3 Interaction Peds Patient education #2
Indication:
-Acute Gout Flare up
MOA:
- Inhibits neutrophil migration, degranulation & activation
- CYP450
ADR:
- GI
- Blood dyscrasia
- Alopecia
Interaction:
-Grapefruit Juice
Peds: >16 years
Patient Education:
- Report abdominal pain r/t hepatoxicity
- 18-24 to work
What do you give for a gout flare-up that started more than 36 hours ago?
NSAIDs or Corticosteroids
Prednisone
Indication #2 MOA ADR #3 Contraindication Caution #3 Peds Patient Consideration
Corticosteroids
Indication:
- Acute Gout
- Rheumatoid Arthritis
MOA:
-suppress leukocytes & reverse capillary permeability
ADR:
- Hypertension
- Insomnia
- Cushings syndrome
Contraindication:
-Uncontrolled infection
Caution:
- Prolonged use = adrenal suppression/immunosuppression
- Diabetics
- Active GI disease
Peds: OK
Patient consideration:
-Calcium & Vitamin D supplement
Acetaminophen
Indication MOA Contraindication ADR Preg/lact/peds Patient Education
Indication:
-Mild to Mod OA
MOA:
- CNS & COX = decreased prostaglandin synthesis
- not anti-inflammatory
Contraindication:
-Liver disease
ADR:
- Skin rash
- Dizzy
Preg/lact/Peds: OK
Patient Education:
-Takes one week to work so should be taken on schedule
What is the first line treatment for OA?
Acetaminophen
NSAIDs
Indication #2 MOA ADR #4 Caution Contraindication Black box warning #3 Pregnancy Lactation Peds
Indication:
- Mild-mod OA
- RA
MOA:
-prevents conversion of arachidonic acid
ADR:
- Edema
- GI
- Elevated LFTs
- Bleeding
Caution:
-Cardiovascular disease
Contraindication:
-Renal failure
BLACK BOX WARNING:
risk thrombotic evens; GI bleeding, ulcer, perforations
Pregnancy: NO
Lactation: ok
Peds: >6 months
Tramadol
Indication MOA #2 ADR #3 Caution #2 Contraindication Interactions #2
Indication:
-OA pain not responding to APAP & NSAIDs
MOA:
- Mu opioid receptor agonist inhibits pain pathways
- Inhibits serotonin & norepinephrine
ADR:
- Dizzy/Drowsy
- Dependency
- Respiratory depression
Caution:
- substance abuse history
- other CNS depressants
Contraindication: Seizure history (lowers seizure threshold)
Interactions:
- Do not mix with serotonergic agents r/t serotonin syndrome
- CNS depressants
Methotrexate
Drug Class MOA ADR #4 Contraindication Black Box Warning #6 Patient Education #2
Disease Modifying Antirheumatic Drugs
MOA:
-Folic acid antagonist = leukocyte depression
ADR:
- GI
- Photosensitivity*
- Elevated LFTs
- Alopecia
Contraindication:
-Blood dyscrasias
BLACK BOX WARNING:
- Hepatotoxicity
- Renal impairment
- Pneumonitis
- Bone marrow suppression/Opportunistic infection
- GI Toxicity/stomatitis
- Derm reaction
Pregnancy/Lactation: NO
Patient Education:
-Folic Acid supplementation
-Takes 3-8 weeks to work so need NSAID or prednisone
Contraception??
Rituximab (Rituxan); Abatacept (Orencia)
Drug Class MOA ADR #4 Caution Patient consideration Peds
Biologic DMARDS (TNF inhibitors)
MOA:
Binds & inactivates TNF-alpha = recuded infiltration of inflammatory cells
ADR:
- Injection site reaction
- infection
- headache
- nausea
Caution:
-new/recurrent infection
Patient Consideration:
Update immunizations
Peds: >2yrs
What special consideration should you take when starting a patient on Rituximab & Abatacept?
Immunizations; live 3 months before or 3 months after medication
When and why would you prescribe a DMARD?
The severity and impact of RA has led experts to endorse the early use of DMARDs to slow disease progression and minimize disability.
Which recommendation is most appropriate for a person who requires chronic lowering of uric acid levels before initiation of therapy with febuxostat (Uloric)?
Prophylactic administration of an NSAID or colchicine
Lowering uric acid levels for up to 6 months before initiation of febuxostat (Uloric) can decrease the risk of acute gout flares.
What should you screen for before initiating Rasburicase (Elitek)
G6PD deficiency
Prescription of a disease-modifying antirheumatic drug (DMARD) of any sort would be contraindicated in a patient with which condition?
Hepatitis B
Any DMARD suppresses the immune system and may encourage risk of significant exacerbation of latent infection, such as hepatitis B.
Persons with gout who are taking uric acid–lowering drugs should have their serum uric acid levels assessed at which interval(s)?
At baseline and after 1 to 3 weeks of drug therapy
Selective estrogen receptor modulators (SERMs) such as raloxifene should not be prescribed for pre- or perimenopausal women because of which possibility?
Triggering intolerable hot flashes
SERMs do not reduce natural estrogen production, but block estrogen binding, resulting in higher levels of freely circulating estrogen in pre- and perimenopausal women, triggering intense hot flashes.
When adding a new drug, such as another disease-modifying antirheumatic drug (DMARD) or biologic, to the treatment regimen of a patient with rheumatoid arthritis (RA) who is taking methotrexate, consideration of which characteristics is most important?
Protein-binding characteristics of the new drug
Methotrexate is heavily protein bound and adding a new protein-binding drug will result in competition for binding and disruption of the anti-inflammatory effect
What would someone on methotrexate need to supplement with?
Folic Acid
Can methotrexate be used with other DMARDS & biologics?
Yes, can increase the therapeutic effect
To reduce the risk of toxicity and rise in serum urate levels, which class of antihypertensives should be avoided in persons with hypertension taking allopurinol?
Thiazide diuretics have the potential to raise uric acid levels and greatly increase the risk of toxicity.
To minimize the risk of osteonecrosis of the jaw, persons with cancer who have been taking IV doses of bisphosphonates or oral doses of bisphosphonates for more than 3 years, and who are planning elective invasive dental procedures, should take which action?
Stop bisphosphonate therapy 3 months before the dental procedure.
Evaluation of which indicator is used to diagnose and signal need for treatment in Paget’s disease?
Alkaline phosphatase
Alkaline phosphatase is a bone marker that is elevated during periods of high bone turnover, and it serves as a marker for bisphosphonate treatment when it is twice the normal level.
According to American Association of Clinical Endocrinologists (AACE) guidelines, dual energy x-ray absorptiometry (DEXA) scans are appropriate for which patients?
women over 65 years old, those over 40 years old with fractures, and those with primary hyperthyroidism to aid treatment decisions and monitoring for effect,
Patients taking allopurinol or colchicine should have liver function tests (LFTs) evaluated if they develop which cardinal symptoms?
The cardinal symptoms of potentially severe hepatic dysfunction in those taking allopurinol and colchicine are anorexia, weight loss, or pruritus, and LFTs should be evaluated.
Which intervention is recommended by most experts to relieve moderate pain in osteoarthritis (OA)?
Acetaminophen is considered the most benign way to treat the pain of OA, either alone or in combination with a topical agent.
