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Week 5 Flashcards

1
Q

Normal Bladder function physiology

A

Normal micturition occurs when bladder contraction is coordinated with urethral sphincter relaxation.

storage phase:
micturition phase:

SYMPATHETIC NERVOUS SYSTEM:
beta activity relaxes the detrusor muscle
alpha activity contracts smooth muscle sphincter

PARASYMPATHETIC NERVOUS SYSTEM:
contracts the bladder detrusor muscle through cholinergic fibers from the pelvic nerve. (muscarinic receptors)

SOMATIC NERVOUS SYSTEM:
contracts the striated muscle sphincter thorugh cholinergic fibers from the pudendal nerve

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2
Q

Common causes if incotinence

A

urethral obstrucction (BPH)

impair bladder contraction

incompetent sphincter

bladder inflammation

bladder stones

malignancy

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3
Q

common meds affecting incontinence

A

alpha agonists/antagoinsts

alcohol

anticholinergics

CCB

diuretics

narcotics

antidepressants

antiphysicotics

sedative/hypnotics

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4
Q

urinerary incotinance examination

A

physical exams
*digital rectal or pelvic exam
*neurologici exam
*PVR
cystoscopy/cystometroghram?

labs
*U/A w. micro
serum bun/Cr
*PSA

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5
Q

Drug: DESMOPRESSIN nasal spray (Noctiva) aka ADH

Indication
warnings:
monitoring:
CI:
Dosing:
How supplied

A

Drug

Indication: nocturnal polyrucia (awaken >/2x/night to void
warnings: fluid retention, hyponatremia, nasal conditions
monitoring: Na+ levels

CI: hyponatremia, polydypsia, primary nocturnal enuresis, concamminant use of loop diuretics or systemic or inhaled glucocorticouids, egfr<50, SIADH, during illness that can cause fluid retention or rlectrolyte imbalance, NYHA CLASS ii-iV CHF, uncontrolled HTN

Dosing: age 50-65>1 spray (1.66 mcg) either nostril~30 min before bed
age >65-: 1 spray (0.83 mcg) either nostril~30 min before bed

How supplied

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6
Q

Types of incontinance

Urge incontinance (Overactive bladder)

A

what is it: involentary leakage of urine and involentary contraction of bladder

causes: detrusor hypperreflexia
*neurologic
stones
tumor
cystitis

mechanism to treat: anti-muscarinic with atropine like effects
*antispasmodics

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7
Q

TREATMENT OF OAB

list of drugs that work on PSNS (micturition phase) ( antimuscarinics/ antispasmodics)

A

oxybutinin

tolteridine

trospium (sanctura)

Darifenacin (Enablex)

Solifenacin (Vesicare)

Fesoterodine (Toviaz)

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8
Q

oxybutinin

moa:
dose:
notes:

A

moa: anti-musc, anti spasmodic
dose: 5mg big-tid
notes: oxytrol patch

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9
Q

Tolderidine

moa: anti-muscarinic
dose: 1-2 bid ER
notes: decrease bbb crossing, decreased lipo and salivery

A

moa:
dose:
notes:

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10
Q

Trospium

moa:
dose:
notes:

A

moa: antimuscarinic
dose: 20 mg bid
notes: decreased bb crossing

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11
Q

Darifenacin(Enablex) AND Solifenacin(Vesicare)
moa:
dose:
notes:

A

moa: both M3 specific
dose: 7.5 mg, 5 mg
notes: decreased side effects due to m3 specificity

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12
Q

Fesoteridine
moa:
dose:
notes:

A

moa:
dose:
notes:

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13
Q

Adverse effects of SM- relaxants

A

dry mouth

dry eyes/blurred vision

urinary retention

palpitations

constipation

dizziness/ drowsiness

confusion/delerium/dementia

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14
Q

which anticholinergic drug for OAB in adults

A

ER tolteridine solifenacin, and derafenicin have increased efficacy and decreased risk for adverse effects
dry mouth

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15
Q

other agents for OAB

A

imipramine or other TCA
*CONTRAINDICATED IN ELDERLY. risk for orthostasis, cardiac arrythmia, and other anticholinergic effects

Botox: detrusor overasctivity associated w. neurologic condition in adults with an inadequate response or intolerance to an anticholinergic medication

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16
Q

Drugs that treat SNS (storage phase) for OAB

A

B3 adrenergic receptor agonists

Mirabegron

Vibegron

Solabegron

Ritobegron

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17
Q

Drug: Mirabegron ER

Indication
warnings:
monitoring:
CI:
Dosing:
How supplied

A

Drug:

Indication: OAB
moa: detrusor muscle relaxation through agonism of b3 adrenergic receptor

pk: ~50 hrs half life

AE: nausea, headache, HTN, diarrhea, constipation, dizziness, and sinus tachycardia

warnings: uncontrolled HTN (sbp?180 mmhg or DBP?110
monitoring:
CI:
Dosing:
How supplied

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18
Q

Drug:Vibegron

Indication
warnings:
monitoring:
CI:
Dosing:
How supplied

A

Indication: OAB
moa: detrusor muscle relaxation through agonism of b3 adrenergic receptor

half life:

AE: nausea, headache, HTN, diarrhea, constipation, dizziness, and sinus tachycardia

warnings:

monitoring:

CI:

Dosing:
*no

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19
Q

AUA guidelines on OAB

A

1st line: behavioral therapies (bladder training, bladder control strategies, pelvic floor muscle training, fluid managemnt)

2nd line
oral antimuscarinics or oral b3 agonists
ER>IR
transdermal oxybutinin may be offered
combo anti-muscarinic and b3 agonist refractory to monotherapy
manage constipatio and dry mouth before abandoing effective antimuscariinic therapy
caution anti-m w. ther

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20
Q

Stress incontinance

A

involentary leakage with stress
*increased intra-abdominal pressure

decrease pelvic wall musculature

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21
Q

treatment of stress incontinance

A

alpha receptor agonists

  1. increase intra-urethral pressure
    *pseudoephedrine
    *midodrine

2.Estrogen replacement
*causes proliferation of urethral mucosa
*improves mucosal “outflow resistance”
AE: pap/mammogram, bleeding, DVT

Duloxetine
supresses bladder activity thorugh 5ht receptors and enhances external urethral sphincter activity

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22
Q

Overflow incontinence

A

Leak urine thoughout the day

due to “weight of urine”
r/t
BPH
neuropathies
anticholinergics

treatment: Bethanechol (urecholine)
stimulates muscarinic receptors to increase bladder tone

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23
Q

BPH (benign prostatic hyperplasia

A

proliferation of smooth muscle cells in prostate which increases size

proliferation of stromal and epithelial cells (static)

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24
Q

BPH patho

A

increase in smooth muscle tone (dynamic phase)

DYNAMICA bladder obstructiondue to alpha adrenergic receptors
*a1A, 70% of a receptors in prostate
*a1b
*a1d

sttaic bladder obstruction
*5a-reductase enzymes

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25
symptoms of bph
incomplete emptying frequency intermittency urgency weak stream straining nocturia boyardsky index AUA symptom index international prostate index score
26
nonpharm bph mangement
incontinance pads TURP(transurethral resection of th eprostate) urethral dilation foley catheters other (TUIP, TUDP, VLAP, microwave hyperthermia, enzyme injection
27
general meds used for bph
black a-1 in prostae to reduce muscle tone terazosin>doxazosin>prazosin howveer, ALLHAT trial: these meds were orginally used for htn. trial showed these meds did not reduce risk of heart events when used. should not be ysed for bp reduction, only bph. however need to monitor for bp lowering
28
alpha blockers AE for bph
POStural htn dizziness/vertigo blurred vision drowsiness asthenia first doe effect , added effect with other htn meds)
29
a1-A specific blockers
selective for a-1a Silodosin (38x)>>lfuzosin~tamsulosin Tamsulosin(flomax): 0.4-0.8 mg daily alfusozin 10 mg daily w. food sildosin (8mg daily)
30
adverse effects of a-1a specific blockers
rarely htn, vertigo, drowsiness floppy iris synrome ejaculatory dysfunction (sildosin>tamsulosin>
31
treatment of cellularity portion of bph
5-a-reductase inhibitor finasteride inhibits types II 5-a1 reductase decrease dht 3-6 MONHS OF THERAPY, TAKES TIME 5 MG PO QD DUTASTERIDE *Selective inhibitor of type I and II 5-a-reductase dose: 0.5 mg po qd Jalyn (0.5 mg dutasterise/0.4 mg tamsulosin)
32
drugs o avoid in bph
TCA diphenhydramine disopyrimaide psuedoehedrine ephedrine ACH drugs (including otc)
33
other bph treatments
tadalafil *moa not established *pde5 inhibitor * this in combo w. alpha blocker can causesymptomtic hypotension entadafi (finasteride 5 mg and tadalfil 5 mg
34
otc treatment of bph
SAW PALMETTO been found it did not improve sympoms or objective measures of bph
35
guidelines for treatment of bph
initial: alpha blockers *if t has bph and ed, pde5 can be started lock or incomplete response.... consider pde5 if size is >30cc, 5 alpha reductase inhibiot can be added
36
erectil dysfunction patho
normal "penal flaccidity *penile erction
37
risk factors for ED
MEABOLIC SYNDROME LOWER UTI OF BPH tobacco smoking neurologic ocnditions spina cord injury depression endocrine conditions dm
38
drugs that can cause erectile dysfunction
diuretics htn meds (only betablockers except nebivolol) cardiac and cholesteral antidepressants tranquilizes h2 antagonists cytotoxic agents opioids nsaids
39
drug therapy for ED
androgens pde5 adrenergic receptor antagonists apomorphine trazodone transurethral therapy intracavernous
40
pde5 in ed
inhibits pde5 results in SM relaxation and inflroof blood into corpus cavinosum pk: cyp3a4 CI: dont use inpts using nitrate therapy additive effects c/ a-blockers
41
pde5 moa
pde5 prevent break down of cGMP(produces erection) and prevents conversion to gmp which is inactive
42
cardiac risks of pde5
low risk:Risk Category Description of Patient’s Condition Management ApproachLow risk Has asymptomatic cardiovascular disease with <3 risk factors for cardiovascular disease Has well-controlled hypertension Has mild congestive HF (NYHA class I or II) Has mild valvular heart disease Had a MI >8 weeks ago Patient can be started on phosphodiesterase inhibitor Intermediate risk Has ≥3 risk factors for cardiovascular disease Has mild or moderate, stable angina Had a recent MI or stroke within the past 2-8 weeks Has moderate congestive HF (NYHA class III) History of stroke, transient ischemic attack, or peripheral artery disease Patient should undergo complete cardiovascular workup and treadmill stress test to determine tolerance to increased myocardial energy consumption associated with increased sexual activity. Reclassify in low or high risk category High risk Has unstable or refractory angina, despite treatment Has uncontrolled hypertension Has severe congestive heart failure (NYHA class IV) Had a recent MI or stroke within past 2 weeks Has moderate or severe valvular heart disease Has high-risk cardiac arrhythmias Has obstructive hypertrophic cardiomyopathy Phosphodiesterase inhibitor is contraindicated; sexual intercourse should be deferred
43
Sildenafil (Viagra®) Vardenafil (Levitra®, Staxyn) Tadalafil (Cialis®) Avanafil (Stendra) Dose(Range) 50mg/day (25-100mg) 10mg (5-20mg) (Staxyn ODT) 10mg (5-20mg) 2.5mg daily 100 mg (50-200mg)50mg if stable -blockerOnset 30 - 60 min 60 min 30-45 min 15 minDuration 2-4 hours 4-6hrs 24-36 hrs 4-6 hoursfat meal  Tmax & Cmax Cmax No effect c/ or s/ foodVision changes Blurred/blue (3-11%) <2% <0.1% <2%Wait time Nitrates 24h 24h 48h 12h? (24h)Nickname “little blue pill”, “Vitamin V” “the weekender” “the quickie”
44
algorithm for selecting treatment for ED
pt w. ed 1. treat underlying cause 2. d/c meds that could contribute 3. remove risk factors 4. if pt has hypogonadism, give testosterone supplements once all of those done.. can ocnsider pde5 a)if effective, continue. if not, pt should have 7-8 doses before deemed non effective, dosage is titrated up b)if CI or pt prefers use vaccume erecction device
45
pde5 therapy counseling points
taking med will not result in an erection in the absence of sexual stimulation 7-8 doses needed to analyse efficacy need sufficient time to take before engaging in intercoursw
46
asessment of neuropsychiatric symptoms(NPS) in dementia
mild depression anxiety, irritability, apathy severe (agitation, aggregasion, vocalizations, hallucinations, delusions, disinhibition differential dx (acute vs gradual, pain, environment, drugs) medical causes of agitation in dementia (medication, infection, cva, trauma, pain assessments and diagnostic tests (PE (w/ cognitive testing), labs, drug levels
47
general approack to behavior mgt
define target symptoms establish or revisit medical dx establish or revist established neuropsychiatric dx assess and reverse ggravating factors adapt to specific cognitive defecits identify relevant psychosocial educate care givers employ behavior mgt principles use psychotropics for specific psychiatric syndrome
48
consider symptomatic pharmacotherapy
use "psychobehaviorial metaphor" (eg. features of psychosis or depression) startlow, go slow avoid toxicity use lowest effective dose withdraw after appropriate period, observe for relapse serial trials someitmes needed
49
evaluating the pt w. hallucinations or dellusions
1. peprform cognitive exam a: abnormal: and no multiple cognitive effects: evaluate for focal brian syndrome b: if normal... eva;uate for neurologic disorder/opthamologic disorder present: assess and treat absent... evaluate for mood disorder a: if absent: dx delusional disorder if prresent: dx schizophrenia
50
BBW for APS used in elderly
increased risk of death in elderly patients being treated with APS for use in dementia related psychosis risky agents: Jaloperidol>olanzapine>quetiapine quetiapine is the saferrrrr agent to use, not just safe
51
d/c of aps in elderly
52
Neuropsychiatric symptoms of dementia
psychotic symptoms (delusions, hallucinations) depressive symptoms apathy manic like behavioral symptoms agitation or aggregasion (differential anxiety) "sundowning" insomnia
53
environmental interventions
general: family and caregivers structureing hte physical and psychosocial environment behavioral interventions milg: environment and interventions severe: constant supervision
54
non pharm trt ofNPS
care givers *scheduled toileting and promted toileting *offer graded assitance (little as possible to performing adls *avoid adversiarial debates *maintain calm demeaner *use services of caregiver support groups problem behaviors *music during meals *walking or light exercise *simulate family presence w. video or audio tapes *pet therapy *speak at pts comprehensive levels *bright light, "white"noise
55
abpout schizophrenia and schizophrenia like syndromes
positive SS (hallucinations, delusions, and htought disorders) negative SS 85% of oldr adults w. schizophrenia experiences onset of illness in adult early in life late onset schizo "40-60 y.o very late onset >60
56
psychotic symptoms of AD
seen in about 20% alzheimers disease patients delusions halucinations d2/d3 receptor
57
psychotic disorder caused by general medical conditions
parkinsons *secondary dopiminergic agent, visual hallucinations before any medications are started *educateion and support *significant emotional distress or gangerous or upsetting behavior *QUETIAPINE or OLANZAPINE may be beneficial Lewy body dementia *cognitive decline accompanied by motor features of parkinsonism. prominant visual hallucinations *avoid conventional APS
58
depressive symptoms: okay meds to use
SSRI's, SNRI's mirtazipine trazadone
59
depressive symptoms, meds not to use to treat
paroxetine, despiramine, nortriptyline (ach effects)
60
apathy
high overlap w. depressive symptoms but lacks depressive mood, guilt, and hopelessness treatment: a) DIVALPROEX SODIM (better tolerated and can be sprinkled on to food)methylphenidate, dextroamphetamine, modafinil
61
Agitstion and regression
determine whether delusions or hallucinations are interfering w. function selct med agent on the basis of symptoms
62
non pharm trt for agitation and aggresion
exclude underlying physical discomfort positive reinforcement try not to physically restraint
63
meds for agitation and aggresion
agitation in context of psychosis: 2nd gen aps agitation in depression: SSRI's ANCIETY: buspirone sexual aggression: seocnd gen APS
64
sundowning
forgetfullness, confused, delerius, agitated that occurs late afternoon-early evening non pharm: nightlights, check ins acute meds: trazadones, first gen and second gen APS long term: trazadone, melatonin
65
insomnia
principles of sleep hygeine caffeine, fluid intale, light activity, time inbed acute: trazadone, melatonin, bzds long term, trazadone, melatonin
66
Patho of pain
nociceptive pain: atimulation, transmission, perception, modulation (pain caused by injury to bosy tissues) Neuropathic pain *spontaneous transmission hyperalgesia allodynia (pain initiated or caused by a primary lesion or dysfunction in nervous system)
67
acute vs chornic pain
acute: trauma surgery chronic pain: muskuloskelatal (arthritis, RA, OA, low back disorders *neuropathy *vascular *cancer
68
consequences of lack of knowledge of pain mgt
overuse of inappropriate meds failure to use multimodal approach failiure to target mechanism of pain failure to treat neuropahthic pain w. adjunctive meds heavy us ofe SA-opioids instead of long acting
69
assessment of pain
patient interview: PQRST *palliative quality radiation severity Painscales (UNIVERSAL PAIN ASSESSMENT TOOLS) Flacc Scale pain diaries
70
non pharm pain mgt in older pts
physical activity pt education CBT adjuncts like heat, colf, massage, ligaments, spirituality
71
approach to the mgt of pain
mild pain: non opioid + adjuvent (adjuvent used for neurologic pain) mild opioid for mild-mod pain _/= nonopioid +/- adjuvent mod-severe *opioid +/- nonopioid +/- adjuvent
72
pros and conc of non opioid APAP
pros *selder safe *adjunctive *useful to mild-mod pain *starting point) concs *very few *watch total apap 4g MDD *need to counsle pt if started on opioid/apap combo before
73
pros an d cons of nsaids
pros *useful in mild-mod pain *may be ocnsidered rarely and should be used w. extreme caution after other safer meds have failes Cons *ceiling effect CI: peptic ulcer disease, ckd, HF *cardiac risk (CHF, MI risk) note: topical diclofenac safer than other nsaids, esp oral evalute risk vs. beengit use lowest effective dos epossible analgesic vs anti inflammatory (cox2 may be safer)
74
adjunctive pain agents
all pts w. neuropathic pain are candidates for adjunctive analgesics ( it could even be first line) first line: a2 ligands (pregablin, gabapentin), SNRI's second line: (topical agents) ex: duloxetine lidocaine avoid tertiary TCAs
75
pros and cons of opioids for pain
pros *no celing dose mod-severe pain *many diff routes of admin
76
side effects of opioids
AE: respiratory depression (esp. w. concaminnat disease(asthma, copd, sleep apnea) lethargy/sedation miosis constapation fears of addiction or dependence
77
signs of opioid toxicity
severe resp, depression, apnea decreased LOC, unarousable ocular: "pinpoint pupils
78
preferred opioids in elderly
morphine hydrocodone oxycodone hydromorphone fentanyl less preffered: codeine methadone?
79
equianalgesic intial doses of opioids
PO: morphine, hydrocodone, oxycodone~30 mg hydromorphone: 7.5 mg fentanyl: 100mcg/hr IV: morphine: 10 mg hydromorphone: 1.3-1.5 hydrocodone, oxycodone not available IV
80
routes of admin for opioids
PO/SL/ transbuccal inhaled intranasal rectal topicals (fentanyl, bupenorphine)
81
considerations for opioid transdermal formulations
active ingredient may still be present after tpx obsolecense improper disposal could lead to accidental/unintended exposure extrnal heat, fever, and exertion could impact rate of absoprion products w. meta lfoil backing preclude use if an MRI isn ecessar
82
mgt of gi effects (n/v) in opioid use
butyrophines phenothiazines antihistamines anticholinergic seretonin antagonsits
83
mgt of constipation in opioid use
softening agents (docusate) stimulants (bisacodyl, senna) osmotics saline opioid antagonists lubricant
84
prescribing opioids in pts w. chornic pain
selective and careful prescribing does not apply to pain caused by sickle cell disease, mgt of cancer related pain, or palliative care or end of life care.
85
concept of palliative care and hospice
palliative care: the active total care of pts whose disease is not responsive to curative trtment focus: control of pain, other symptoms, and psychologica, social, and spiritial problems. should be given in conjunction w.curative care hospice:philosphy and program that delivers palliative care. centers around an interdisciplinRY TEAM medicare deifnition: qualify for hospice if dx w. terminal illness w. a prognosis of 5 months or less as certified by the physician and the hospice medical director
86
palliative care vs hospice
poallitive: improving quality of life for those w. serious illness. can be adminis hospice: subset of palliative care for end of life care, requires a prognosis of 6 months or less. can occur in home, nursing home, hospice general unit, hospital. occurs when curative care has ceased
87
the dying experience (1-3 mo)
withdrawal from the world an dppl decreased food intake increase in sleep going inside seld less ocmmunication
88
changes during the dying process
fatigue and wekness (decreasing function, hygeine, inability to move aroundi nbed, inability to lift head from pillow cutaneous ishamia (erythema over bony promminences, skin breakdown/wounds) decreasing appetite food, intake cardiac dysfunction: tachycardia, HTN followed by hypotension, peripheral cooling, peripheral and central cyanosis, mottling of slin, venous pooling neurologic: decrease level of consiousness, decreased ability to communicate, terminal delerium respiratory dysfunction loss of abiolity to swallow loss of sphincter control pain loff of ability to close eyes
89
palliative care toolkit
intensol (concentrated liquid) morphine liquid lorazepam liquid haloperidol liquid atropine 1% examethazone liquid ondansetron odt
90
symptoms in hospice and palliative care N/V causes: treatments:
symptoms in hospice and palliative care causes: *gutwall: gastirc irratants, abdominal radiotherapy,intestinal distention,cytotoxic chemo treatments: step1 h2 antagonst PPI step2: metoclopramide step3: ondansetron
91
n/v due to area postrema
causes: morphine, digoxin, hypercalcemia/uremia, clonidine, cytotoxic chemo treatments: haloperidol, metoclopramide step1+metoclompramide step 3: ondansetron+dexamethasone
92
dyspnea
step 1: step2: ipratropium/albuterol step3: morphine step4:
93
dyspnea and opioids
help releieve sensations of sob
94
treatment of cough
treat underlying cause 2. supress cough (morphine, hydrocodone dextromethorphan step: dexamethasone or glycopyrolate
95
anxiety vs delerium
anxiety: *treatments 1. non pharm 2. short term benzos step2 long term: buspirone deleriium (hallucinations, aggressive) *step1: haloperidol (its okay to use veen the there is a BBW) step2: haloperidol+lorazepam combo
96
constipation prevention
opioid: senna or bisacodyl+/- docusate_/= metaclopramide step2: sorbitol, lactulose
97
bowel obstruction
metaclopramide
98
depression
>4 weeks survivial: SSRI >4 weeks w. other SS

Peds and Geriatrics (5 decks)

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