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Pharm 2 > GU > Flashcards

GU Flashcards

1
Q

Overall medications

A

BPH
1.Alpha 1 antagonists
2. 5-Alpha-Reductase inhibitors (5-ARIs)
3.Phosphodiesterase type - 5 (PDE-5)
4. Antimuscarinic agent
Urinary incontinence
1. Anticholinergics/antimuscarinics
2. Beta-3-agonists
3. Duloxetine
Interstitial cystitis/bladder pain syndrome
1.pentosan polysulfate
2. Amitriptyline
Erectile dysfunction
1. Phosphodiesterase-5 (PDE-5)
2. Alprostadil
Priapism
1. Phenylephrine
Testosterone replacement therapy

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2
Q

Benign Prostatic Hyperplasia

A

Clinical p:
-lower urinary tract symptoms= obstructive/voiding symptoms and irritative/storage symptoms
-enlarged prostate-> DRE OR ULTRASOUND TO RULE OUT PROSTATE CANCER-> large is >40 mL
-elevated PSA level

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3
Q

BPH drugs: Culprits for drug-induced LUTS (lower urinary tract symptoms)

A
  1. Testosterone replacement therapy
  2. alpha-adrenergic agents-> pseudoephedrine
  3. Anticholinergic drugs
  4. Antihistamines
  5. Tricyclic antidepressants (TCAs)
  6. Inhaled anticholinergic agents
  7. Diuretics
  8. Caffeine
  9. Alcohol
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4
Q

Initial tx of BPH

A

bph- >
-Mild LUTS
1. Watchful waiting
-Moderate/severe LUTS
1.Prostate <40 g or PSA< 1.4 = Alpha 1 adrenergic antagonist
2. Prostate > 40 g or PSA > 1.4= 5 alpha-adrenergic antagonist OR 5 alpha-reductase inhibitor + alpha 1 adrenergic antagonist
3. Erectile dysfxn= Phosphodiesterase inhibitor OR 5 alpha-reductase inhibitor to alpha 1 adrenergic antagonist
4. Predominant irritative voiding symptoms= Add anticholinergic agent or beta 3 agonist to alpha 1 adrenergic antagonist OR 5 alpha reductase inhibitor

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5
Q

BPH: Alpha1 Antagonist

A

-osin
1ST LINE FOR MODERATE AND SEVERE BUT W/OUT COMPLICATIONS
improve urinary flow and symptoms
Interactions: CYP3A4, PDE-5 inhibitors

  1. Uroselective- days onset, less SE
    -Tamsulosin (Flomax)
  2. Nonselective- weeks onset, more SE
    -Terazosin
    -Doxazosin

MOA: Block alpha 1 and Beta1 receptors-> sm relaxation in bladder neck, prostate capsule, and prostatic urethra-> improve urinary flow
-A&B blockers-> decrease PVR in arterial and venous= lower BP
-Alpha1-> uroselective and decreased effect on bp

pharmacokinetics: well absorbed for oral, better with food
Silodosin requires dose adjustment in renal impairment/dysfxn –stopsign

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6
Q

BPH: alpha 1 antagonist Patient ed, AE, special notes, other features

A

Pt E: “first dose effect”- exaggerated orthostatic Hypotn= SYNCOPE
-minimize by adjust first dose to 1/3-1/4of normal dose
-admin at bedtime
AE:
dizziness- least tamsulosin and most terazosin
Hypotn- best tamsulosin, worst terazosin
Syncope- none w/ tamsulosin and silodosin
intraoperative floppy iris syndrome- every med
ejaculatory dysfunction-> silodosin and tamsulosin
Notes:
terazosin and doxazosin NOT TAKEN W/ ERECTILE DYSFXN MEDS-> dilodosin minimal SE for ejac
other:
Benefit: improve lipid profiles adn glucose metab
HT: decreases BP but not used as monotherapy for HTN

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7
Q

BPH: alpha 1 antagonists drug interactions

A
  1. drugs that inhibit cytochrome p450- increase plasma conc of doxazosin, alfuzosin, tamsulosin, silodosin
  2. drugs that induce CYP450-> decrease plasma conc bc body metabolizes it faster
  3. alfuzosin may prolong QT interval-> cautious w/ other drugs that prolong
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8
Q

BPH: 5-alpha- reductase inhibitors (5-ARIs)

A

1st LINE FOR MODERATE TO SEVERE SYMPTOMS-> PROSTATE MUST B ENLARGED (>40 ML)
Ex: Dutasteride (Avodart) and Finasteride (Propecia) + for male pattern baldness
Benefits: reduce prostate size, reduce BPH progression, prevent complications, improve urinary symptoms
Onset of actions: 3-6 months SLOWEST
combining w. alpha1 antagonist= IMPROVES RESULTS
MOA: Inhibit 5-alpha reductase enzyme which is the enzyme that converts testosterone into DIHYDROTESTOSTERONE (DHT) -> more active form
-DHT= stim prostate growth-> inhibit then shrinks prostate and urine flow improves
Dutasteride= more potent than finasteride= greater decrease in DHT

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9
Q

BPH: 5-alpha-reductase inhibitors: pharmkinet, AE, contraind, warning, notes

A

Pharmacokinetic= food-> no effect on absorp
AE: Sexual SE - decreased ejaculate, libido, ED, oligospermia (low), gynecomastia
Contrain: FINASTERIDE & DUTASTERIDE TERATOGENIC
-no prego, or childbearing age= serious birth defects on male fetus genitalia
-avoid semen of men on meds, men can’t donate blood until 6 mo after last dose
Warnings: Not idea w/ Testosterone therapy bc drug decreases testost effectiveness-> increased risk of male breast cancer
Special notes:
-Monotherapy= months for full effect
-GREAT FIRST LINE CHOICE IN PT W/ ENLARGED PROSTATE and psa >1.4-> usually in combo therapy
-More sexual dysfxn than alpha1 adrenergic

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10
Q

BPH: contrasting Alpha 1 antag and 5-alpha-reductase inhib

A
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11
Q

BPH tx- combo options

A

Dutasteride 05 mg + Tamsulosin 0.4 mg= Jalyn
-taken 30 min after same meal every day
-significant drug interactions

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12
Q

Other BPH tx options

A
  1. Phosphodiesterase 5 (PDE-5) inhibitor
    -Tadalafil (cialis) -> mono for BPH or BPH+ED
    moa: PDE-5 is w/in Prostate and Bladder-> inhibit causes vd and relaxation of sm of prostate and bladder= improves bph symp
  2. Antimuscarinic agent
    -Off label (tolterodine-Detrol)
    -anticholinergic- increased risk of SE espec in elderly
    May b useful AFTER CONVENTIONAL THERAPY in those w/ urge incontinence symp-> w/out elevated postvoid residuals
  3. Herbal therapies- only in europe
    -Saw palmetto- no studies
    -Beta-sitosterol- som improvement
    -Cernilton- rye grass pollen no improvement
    -PYGEUM AFRICANUM- extract of bark from an african plum tree-> some efficacy 23% increase in peak urinary flow
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13
Q

BPH summary of recommendations

A

1st line: Alpha blocker-> if inadequate response/cant tolerate
2. if urgerncy predom- OAB tx
2. trial of PDE5
2.Adding 5ARIs if large prostate

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14
Q

Urinary incontinence types

A
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15
Q

Incontinence tx

A

drug tx should be combined w. behavioral/nonpharm
-pelvic floor exercises (kegels), biofeedback, weight loss, bladder retraining, avoidance of caffeine, carbonated beverages, alcohol, drink water in small amounts
Look for reversible causes
Remove meds causes if possible:
-functional: diuretics, opioids, benzo, alcohol, antipsyhc, anticholin
-stress: diuretics, alpha 1 antag, ACE inhib
-Overflow- diuretics, anticholin, TCAs, CCBs
-OAB:diuretics, anticholinergics, cholinesterase inhibitors

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16
Q

reversible causes

A
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17
Q

Common types of UI and drug induced causes

A
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18
Q

Meds that can contribute to Urinary incontinence

A
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19
Q

Initial management of UI

A
  1. Stress, urgency, mixed, or overactive bladder OAB
    -lifestyle mods: weight loss, dietary changes, constipation, smoking cessation
    -pelvic floor musc: kegels
    BLADDER TRAINING= MOST EFFECTIVE FOR URGENCY INCONTINENCE
    tx for 6 weeks to 6 months prior to new therapies
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20
Q

UI: tx of OAB

A
  1. Antimuscarinic/Anticholinergic agents
    -Oxybutinin (Oxytrol) high SE of elderly)
  2. Beta 3 agonists
    -Mirabegron (Myrbetriq)
    -Vibegron (Gemtesa)
  3. Onabotulinumtoxin A (Botox)
  4. Duloxetine (Cymbalta)- SNRI may be effective= off label use
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21
Q

UI tx: Anticholinergics/Antimuscarinics- moa, pharmaco

A

MOA: Competitively block muscarinic receptors in the bladder= decrease intravesical pressure, higher bladder capacity, adn frequency of bladder contractions reduced
pharmac: all in oral, Oxybutynin= patch and gel, all but trospium metab by CYP450

FIRST LINE FOR TX OF URGE INCONTINENCE IN WOMEN
AE: blurred vision, dry mouth, heart palpitations, drowsiness, anxiety, ams, Dry mouth, eyes, constipation
Contrain: pts with UNCONTROLLED NARROW ANGLE GLAUCOMA- wide angle isnt, Dementia, urinary retention, bowel obstruction
Renal: reduce dose
Hepatic : reduce dose
USE CAUTION IN COGNITIVE IMPAIRMENT AND W/ ELDERLY

22
Q

UI tx: Anticholinergic/antimuscarinic AE on cognition

A

Factors in AE profile:
receptor specificity in CNS, lipophilicity, P-glycoprotein active efflux transport, charge/polarity, molecular weight

Oxybutynin: MOst= IR, MOd= ER, Least= Patch and gel
-Tolterodine= more SE w/ IR than ER
-Trospium=crosses BBB to a lesser extent
-M3 uroselective agents: solifenacin, darifenacin

23
Q

UI OAB: Beta3 agonists

A

MOA: Activates beta3 adrenergic receptors in the bladder resulting in relaxation of the detrusor sm during the urine storage phase= increasing bladder capacity
1. Mirabegron (Myrbetriq)- AE: HTN
2. Vibegron (Gemtesa)
preferred over antimusc in elderly
Indications: overactive bladder and urgency urinary incontinence
AE: htn, nasopharyngitis, UTI, headache, angioedema
NOT FOR PT W/ UNCONTROLLED HTN

24
Q

UI: tx of stress and overflow incontinence

A
25
Q

UI: Bladder botox

A

indications: Refractory overactive bladder (OAB)- 3rd line
MOA: blocks actions of acetylcholine adn paralyzes bladder musc
No effect right after injection-> muscle paralysis slowly over next few days (7-10 best) and lasts 6-12 mo
AE: dysuria, hematuria, procedure related uti, increase in post void residual volume leading to urinary retention

Procedure: bladder filled w/ sterile water- small injections in bladder wall away from trigone area

26
Q

UI: management in geriatrics

A
  1. Hx
  2. Reversible
  3. Care giver involvement/non pharm
  4. Drugs
    -Men= alpha blocker or 5 alpha reductase inhibitor
27
Q

Dysuria

A

Phenazopyridine (Azo)
Indications: symptomatic relief of dysuria (pain, burning, urgency, frequency)
MOA: urinary anesthetic -> azo die is local anesthetic by unknown mech
Special notes: only used for 2 days and urine= ORANGE

28
Q

Interstitial cystitis/Bladder pain syndrome

A

-unpleasant sensation w/out infection or identifiable causes-
Symp: intermittent, severe suprapubic pain, urinary freq, urgency, hematuria, dysuria
Labs: Cystoscopy= mucosal fissues and punctate hemorrhages, Biopsy= rule out carcinoma
TX:
Pentosan polysulfate (Elmiron)
Amitriptyline

29
Q

IC: Pentosan polysulfate (Elmiron)

A

indication: relief of bladder pain secondary to IC
MOA: low molec weight Heparinoid-> acts as a buffer of bladder wall to protect tissues from irritating substances
expensive
SE: bleeding comp
Cautions: increased bleeding risk, Ocular effects= Pigmentary changes in retina
Contraind: hypersens to pentosan polysulfate and heparin

30
Q

IC: Amitriptyline

A

Indications: off label indications for IC
MOA: increase synaptic conc of serotonin and norepi in CNS by inhibiting reuptake by presynaptic neuronal mem pump
Class: tricyclic antidepressant
SE/contrain: Sedation, overdose, orthostatic hypotn, suicidal ideation, many interactions
START LOW AND GO SLOW, 10 mg hs, increase weekly

31
Q

Erectile dysfxn

A

1 of mc male sexual dysfxn= 1/3 of adult men, coexist with other sexual dysfxn, often w/ htn, hypercholesterolemia, dm or bph
TX:
penile implants, intrapenile injections of alprostadil, intraurethral suppositories of alprostadil, PDE-5 inhibitors, vacuum devices

32
Q

ED tx

A

1st line: PDE-5 or testosterone replacement for hypogonadism
2nd line: vacuum constriction device
-contra for sickle cell, warfarin, DOAC
3rd: injected vd
4th: unapproved agents= supplements

33
Q

ED tx: PDE inhibitor

A
  1. Sildenafil (viagra)
  2. Vardenafil (levitra)
  3. Tadalafil (cialis)
  4. Avanafil (stendra)
    all effective w/ similar AE
    Sildenafil adn tadalafil= tx pulmonary HTN but different dosing
    MOA: allows prolonged cGMP activity on vd
    65% effective
34
Q

ED tx: PDE Inhibitor chart

A
35
Q

ED tx: PDE AE, contraindications, precautions, notes

A

AE: HA, hyptn, PRIAPISM (medical emergency), CP
INHERENT CV risk W/ SEXUAL ACTIVITY even w/out PDE-5 tx

Contraindications: NO NITRATE BC OF HYPOTN RISK
NO VARDENAFIL AND DRONEDARONE TOGETHER= PROLONGS QT INTERVAL

Precautions: Concomitant alpha1 antagonist therapy-> use uroselective alpha1 antag to avoid hypotn
avoid high fat foods w/ sildenafil and vardenafil

PRIAPISM IS RARE AND DOES NOT IMPROVE LIBIDO

36
Q

ED tx: Alprostadil

A

Structure: synthetic prostaglandin E1 (PGE1)
MOA: relaxes SM in corpus cavernosum by unknown mech-> increased blood flow-> compresses venous flow-> blood entrapment-> erection
Local effect: less AE
urethral suppository and injectable
Pharmacokinetics: little systemic absorption
AE: rare due to systemic-> Hypotn, HA, PRIAPISM-> local penile pain, urethral pain

37
Q

Meds that can contribute to or cause ED

A

Antihypertensives
antidepressants
antipsychotics
antiandrogens
alcohol

overview

38
Q

Priapism

A

AN EMERGENCY-> may result in low blood flow leading to penile ischemia and potential necrosis
Management depends on cause
med induced= inj of a weak alpha agonist into corpus cavernosum is often effective= PHENYLEPHRINE

39
Q

Low T manifestations

A

Specific:
delayed sexual development, decreased libido, gynecomastia, decreased spontaneous erection, loss of body hair, low sperm counth

Nonspecific:
decreased energy, depression, anemia, sleep disturbances

40
Q

Testosterone

A

Schedule 3 Rx- acts thru psychogenic channels to enhane libido
To confirm hypogonadism= 2 serum total testosterone conc on diff days
PREGNANCY CATEGORY X= TERATROGENIC
*Contraindication:
*severe renal/cardiac/hepatic disease
*male breast cancer
*prostate cancer
*sleep apnea
*peripheral edema
Replacement therapy:
levels should be <300 ng/dl on 2 separate morning measurements-> follow levels thru tx-> caution w/ topical bc of transfer-> CAUTION W/ EXISTING PROSTATE CANCER AND BPH

SE: MAY INCREASE RISK OF HEART ATTACKS and STROKES-> hA, changes in libido, acne, priapism

transdermal preparations- gel, patch, spray, solution, IM, implantable pellets
*pregnant and lactating women

41
Q

Testosterone replacement therapy Patient Ed

A

Patch- 4 different areas= front of thighs, back of thighs, stomach, arms, back-> NON HAIRY area changed q 24 hrs and allow 7 days btwn app to same site-> COVER AND TRASH AWAY FROM CHILDREN, PETS, WOMEN
Gel- upper arms and shoulders-> never on stomach, penis, scrotum, armpits, or knees->avoid exposure

42
Q

Urinary tract infections

A

Cystitis, pyelonephritis, urethritis, epididymitis, orchitis, prostatitis
Main study sheet
Women: acute simple cystitis= macrobid or bactrim

43
Q

Complicated UTIs including pyelonephritis

A

Men w/ simple cyst= tx like complicated
Uptodate: Nirtofurantion, bactrim for empiric tx in a healthy male without neurogenic bladder

44
Q

outpatient uti

A

Ciprolevofloxacillin

45
Q

inpatient uti tx

A

Ceftriaxone, piperacillin, cipro/levo

46
Q

Urethritis- STDs

A
  1. Gonococcal-> Neisseria gonorrhea= high dose IM Ceftriaxone
  2. Non-gonococcal -> Chlamydia, mycoplasma genitalium, ureaplasma urealyticum, trichomonas-> Empiric= Doxycycline
    tx the cause
    -Chlamydia and mycoplasma= doxy
    -trichomonas- metronidazole
47
Q

Epididymitis and Orchitis

A

< 35 yoa= likely STI= Chlamydia trachomatis or N. gonorrhea
> 35 yoa= gram neg rods= E. coli
acute < 6 wks
chronic > 6 wks
dont have cremasteric reflex
Amiodarone-> self limiting epididiymitis
Tx: Rest, ice, elevation -> AB for underlying cause
Not an STI= use fluoro= levofloxacin

48
Q

Prostatitis

A

Acute: Ampicillin and gentamicin
Chronic: Ciprofloxacin or levofloxacin

49
Q

Seen more frequently

A

BPH
-Tamsulosin
-Tadalafil
Urinary incontinence
-elderly= Mirabegron
-not elderly= Oxybutynin
ED
-PDE-5 inhibitors

50
Q

Pt taking a PDE-5 inhibitor for ED is diagnosed w/ angina. Which antianginal med would be concerning?

A

Nitroglycerin

51
Q

Which is CORRECT regarding the local administration of alprostadil?
A. local administration of alprostadil allows for low systemic absorption
B. increases chance of drug interactions
c. accomplished by application of a cream
D. Causes changes in color vision

A

A. low systemic absorption

52
Q

Which is correct regarding finasteride?
A. assoc w. significant hypotension
B. assoc w/ birth defects
C. effective within 2 weeks of initiation
D. renally eliminated

A

B. birth defects= prego cat x

Pharm 2 (15 decks)

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