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NAPLEX BABY > Module 3: Chapters 18-26 > Flashcards

Module 3: Chapters 18-26 Flashcards

1
Q

What select drugs cause kidney disease?

A

-Aminoglycosides
-Amphotericin B
-Cisplatin
-Cyclosporine
-Loop diuretics
-NSAIDs
-Polymixins
-Radioactive contrast dye
-Tacrolimus
-Vancomycin

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2
Q

What are the criteria for confirming CKD? (3)

A

1- eGFR < 60 ml/min/1.73
2- albuminuria equivalent to urine albumin excretion rate > 30mg/24 hr or urine albumin to creatinine ratio > 30
3- decreased eGFR or albuminuria has occurred for greater than 3 months (to distinguish from AKI)

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3
Q

Delaying progression of CKD: ACEi & ARBs for albuminuria

A

-who: rec in pts with HTN and albuminuria
-why: to prevent kidney disease progression
-how: inhibit renin-angiotensin-aldosterone system, causing efferent arteriolar dilation
-what: reduce pressure in the glomerulus, decrease albuminuria and provide cardiovascular protection

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4
Q

DM management in CKD

A

-SGLT2i (canagliflozin, dapaliflozin, and empagliflozin) have demonstrated a reduction in cardiovascualr events and CKD progression (if they cannot take- GLP1 can be used)
–> Finerenone: a nonsteroidal mineralocorticoid receptor antagonist, is indicated to reduce CKD progression and cardiovascular risks; it can be added to an SGLT2 inhibitor and maximally-tolerated dose of an ACE or ARB in pts with eGFR > 25

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5
Q

Drugs that require adjustment in CKD: anti-infectives

A

**increase dosing interval
-aminoglycosides
-beta-lactams (except antistaphyloccal oenicillins and ceftriaxone)
-fluconazole
-quinolones (except moxifloxacin)
-vancomycin

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6
Q

Drugs that require adjustment in CKD: Cardiovascular drugs

A

-LMWH (enoxaparin)
-Rivaroxaban
-Apixaban
-Dabigatran

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7
Q

Drugs that require adjustment in CKD: Gastrointestinal Drugs

A

-H2RAs (famotidine, ranitidine)
-Metoclopramide

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8
Q

Select drugs that are CI on CKD: CrCl < 60 ml/min

A

nitrofurantoin

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9
Q

Select drugs that are CI on CKD: CrCl < 50 ml/min

A

-tenofovir disoproxil fumarate containing products ( complera, delstrigo, stribild, symfi)
-voriconazole IV

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10
Q

Select drugs that are CI on CKD: CrCl < 30 ml/min

A

-tenofovir alafenamide containing products (Biktarvy, Descovy, Genvoya, Odefsey, Symtuza)
-NSAIDs
-Dabigatran
-Rivaroxaban
-avanafil
-bisphosphonates
-duloxetine
-fondaparinux
-potassium-sparing diuretics
-tadalafil
-tramadol ER

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11
Q

Select drugs that are CI on CKD: CrCl GFRv < 30

A

metformin (do no initiate if GFR < 45)

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12
Q

Select drugs that are CI on CKD: others

A

-meperidine
-SGLT2i
-dofelitide
-edoxaban
-glyburide
-sotalol

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13
Q

Phosphate binders: Aluminum hydroxide suspension

A

-300-600 mg PO TID w/ meals
-SEs: aluminum intoxication, “dialysis dementia”, osteomalacia, constipation, nausea
-monitor: Ca, PO4, PTH, s/sx of aluminum toxicity

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14
Q

Phosphate binders: calcium acetate (phoslyra)

A

*1st line
-1334 mg PO TID w/ meals, titrate based on PO4 levels
-SEs: hypercalcemia, constipation, nausea
-monitor Ca, PO4, PTH
-binds more dietary phosphorus than calcium carbonate

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15
Q

Phosphate binders: calcium carbonate (tums)

A

*1st line
-500 mg po TId w/meals, titrate based on PO4 levels
-SEs: hypercalcemia, constipation, nausea
-monitor: Ca, PO4, PTH

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16
Q

Phosphate Binder: Sucroferric oxyhydroxide (velphoro)

A

-500 mg PO TID w/ meals
-SE: diarrhea, constipation, discolored poop
-monitor: PO4, PTH
*absorption is minimal

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17
Q

Phosphate Binders: Ferric citrate (Auryxia)

A

-2 tabs (420 mg) PO TID w/ meals
*iron absorption occurs, dosage reduction of IV iron may be necessary
-SE: diarrhea, constipation
-monitor: PO4, PTH, iron, ferritin, TSAT

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18
Q

Phosphate Binders: Lanthanum carbonate (Fosrenol)

A

-500 mg PO TID with meals *must chew tablet throughly to reduce risk of severe GI AEs
CI: GI obstruction, fecal impaction, ileus
-warnings: GI perforation
-SEs: N/V, diarrhea, constipation, abdominal pain
-monitor: Ca, PO4, PTH

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19
Q

Phosphate Binders: Sevelamer Carbonate (Renvela) and Sevelamer hydrochloride (Renagel)

A

-800-1600 mg PO TID w/ meals
-CI: bowel onstruction
-Warnings: can reduce dietary absorption of vitamins D, E, K and folic acid
-SEs: N/V, diarrhea, dyspepsia, constipation, abdominal pain, flatulence
-monitor: Ca, PO4, HCO3, PTH
*can lower cholesterol and LDL by 15-30%

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20
Q

Phosphate binder interactions

A

**important to separate the administration of phosphate binders from levothyroxine, quinolones and tetracyclines

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21
Q

Cholecalciferol

A

-vitamin D3
-synthesized in the skin after exposure to sunlight

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22
Q

Ergocalciferol

A

-vitamin D2
-produced from plant sterols and is the primary dietary sourced of vitamin D

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23
Q

Vitamin D analog: Calcitriol (Rocaltrol)

A

–> active form of vitamin D : take with food or shortly after a meal to dec GI upset
-CKD: 0.25-0.5 mcg PO daily
-Dialysis: 0.25-1 mcg PO daily ot 0.5-4 mcg IV 3x weekly
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D

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24
Q

Vitamin D analog: Calcifediol (Rayaldee)

A

–> prodrug of calcitriol
-CKD stage 3 or 4: 30 mcg PO QHS
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D

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25
Q

Vitamin D analog: Doxercalciferol

A

CKD: 1-3.5 mcg PO daily
Dialysis: 10-20 mcg PO 3x weekly or 4-14 mcg IV 3x weekly
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D

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26
Q

Vitamin D analog: Paricalcitol (Zemplar)

A

CKD: 1-2 mcg PO daily or 2-4 mcg PO 3x weekly
Dialysis: 2.8-7 mcg IV 3x weekly
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D

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27
Q

Calcimimetic drugs

A

-increases sensiticity of the calcium-sensing receptor in the parathyroid glad, which causes dec PTH, Ca, and PO4

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28
Q

Calcimimetic drugs: Cinacalcet (Sensipar)

A

-mimics the actions of calcium on the parathyroid gland and causes a further reduction in PTH
-Dialysis: 30-180 mg PO daily w/ food, take tablet whole- do not crush or chew
CI: hypocalcemia
Warnings: caution in pts w/ hx of seizures
SEs: hypocalcemia
Monitoring: Ca, PO4, PTH

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29
Q

Calcimimetic drugs: Etelcalcetide (Parsabiv)

A

-Dialysis: 2.5-15 mg IV 3x weekly
Warnings: hypocalcemia
SEs: muscle spasms, paresthesia
Monitoring: Ca, PO4, PTH

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30
Q

Anemia of CKD * as kidney function declines, EPO production decreases*

A

-ESAs work like EPO to produce more RBCs and can prevent the need for blood transfusions
ex: epoetin alfa (Procrit, Epogen, Retacrit) and darbepoetin alfa (Aranesp)
–> ESAs have risk of inc BP, thrombosis
**only be used with hemoglobin is < 10 and d/c or held if hemoglobin exceeds 11 g/dL
-only affective if iron is available, IV iron is used
(daprodustat (Jesduvroq) option for CKD pts that have been recieving dialysis for 4 months, used to increased erythropoietin levels)

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31
Q

Select drugs that raise potassium levels

A

-ACE/ARBs
-aldosterone receptor antagonists
-aliskiren
-canagliflozin
-drospirenone-containing COCs
-potassium-containing IV fluids
-potassium supps
-bactrim
-cyclosporine, everolimus, tacrolimus
-chronic heparin use
-glycopyrrolate
-NSAIDs
-Pentamidine

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32
Q

Treating Severe Hyperkalemia: 1- stabilize the heart

A

-calcium gluconate: IV, 1-2 min onset
-does not. decrease potassium but stabilizes myocardial cells to prevent arrthythimas

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33
Q

Treating Severe Hyperkalemia: 2- shift K intracellularly (4 options)

A

1: regular insulin: IV, 30 min onset –> co-adminstered with glucose ot dextrose to prevent hypoglycemia
2: dextrose: IV, 30 min onset –> stimulates insulin secretion, but does not shift K intracellularly on it own
3: Sodium bicarbonate: IV, 30 min onset –> used when metabolic acidosis is present
4: albuterol, nebulized, 30 min onset –> monitor for tachycardia and chest pain

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34
Q

Treating Severe Hyperkalemia: 3- elimiate K from the body (5 options)

A

1: furosemide, IV, 5 min onset –> eliminates K in the urine, monitor volume status
2: sodium polystyrene sulfonate (SPS): oral or rectal, 2-24 hr onset –> binds K. in the GI tract, due to GI necrosis, used for emergency situations only
3: Patiromer: oral, ~7 hrs onset –> binds K in the GI tract, delayed onset limits use in emergencies
4: Sodium zirconium cyclosillicate: oral, 1 hr onset –> binds K in GI tract, potassium binder with fastest onset of action = preferred for emergency situations.
5: hemodialysis: meh

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35
Q

Treating Severe Hyperkalemia: Sodium polyrtyrene sulfonate/ SPS (kayexalate)

A

-15 g 1-4 qd po
Warnings: electrolyte disturbances, fecal impaction, GI necrosis, can bind other oral medications
SEs: N/V, constipation or diarrhea
Monitoring: K. Mg, Na, Ca
*do not mix oral products with fruit juices containing K
–> due to risk of GI necrosis, limit use to specific situations (life-threatening hyperkalemia etc)

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36
Q

Treating Severe Hyperkalemia: Patiromer (Veltassa)

A

-8.4 gm PO once daily, MDD 25.2 mg
Warnings: can worsen GI motility, hypomagnesemia, binds to many oral drugs, separate by at least 3 hours before or 3 hours after
SEs: constipation, N/D
Monitoring: K, Mg
–> delayed onset of action, limits the use in life threatening hyperkalemia
-store powder in fridge, must be used within 3 months if stored at room temp

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37
Q

Treating Severe Hyperkalemia: Sodium zirconium cyclosilicate (lokelma)

A

-10 g PO TID for up to 48 hrs
Warnings: can worsen GI motility, edema, contains sodium, can bind to other drugs; separate by at least 2 hours before and 2 hours after
SEs: peripheral edema
-generally the preferred potassium binder due to fastest onset of action
-store at room temp

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38
Q

Metabolic acidosis and drugs to treat it (2)

A

-when bicarbonate is < 22 mEq/L
1- sodium bicarbonate: sodium load can cause fluid retention, monitor sodium level and use caution in patients with hypertension or cardiovascular disease
2- sodium citrate/citric acid (Cytra-2): monitor sodium levels, metabolized to bicarbonate by the liver; may not be affective in pts with liver failure

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39
Q

Factors affecting drug removal during dialysis:
1) molecular weight/size
2) Volume of distribution
3) Protein-binging

A

1) MW: smaller molecules are more readily removed by dialysis
2) Vd: drugs with a large Vd are less likely to be removed by dialysis
3) Pb: highly protein-bound drugs are less likely to be removed by dialysis

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40
Q

Factors affecting drug removal during dialysis:
1) membrane
2) blood flow rate

A

1) M: high-flux (large pore size) and high-efficiency (large surface area) HD filters remove more substances than conventional/low-flux filters
2) BFR: higher dialysis blood flow rates increase drug removal over a given time interval

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41
Q

Hepatitis A facts

A

-acute
-fecal-oral transmission
-has a vaccine
-1st line tx: supportive

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42
Q

Hepatitis B facts

A

-can be acute or chronic
-blood, body fluids transmission
-has a vaccine
-1st line tx: PEG-INF or NRTI (tenofovir or entecavir)

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43
Q

Hepatitis C facts

A

-can be acute or chronic
-blood, body fluids transmission
-does NOT have a vaccine
-1st line tx:
–> tx niave: DAA combination
–> others: Diret acting antivirals + robavirin

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44
Q

what are the 2 medication regimens that are recommended for treatment naive Hep C pts without cirrhosis:

A

-Glecaprevir/pibrentasvir (Mavyret)
-Sofobuvir/velpatasvir (Epclusa)

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45
Q

Drug tx for Hep C: NS3/4A protease Inhibitors

A

Name clues: -previr (P for Pl)
- Glecaprevir
-Grazoprevir
-Voxilaprevir
**Protease Inhibitors & Grub (PIG): take with food!!

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46
Q

Drugs tx for Hep C: NS5A Replication Complex Inhibitors

A

Name clues: -asvir (A for NS5A)
- Elbasvir
-Lediopasvir
-Pibrentasvir
-Velpatasvir

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47
Q

Drug tx for Hep C: NS5B Polymerase Inhibitors

A

Name clues: -buvir (B is for NS5B)
-Sofosbuvir

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48
Q

Safety profile for all Direct acting antivirals (DAAs)

A

-BBW: risk of reactivating HBV; test all patient. for HBV before starting a DDA
-warnings: for sofosbuvir-containing regimens, to NOT use amiodarone - as serious symtomatic bradycardia has been reported
-SEs: well tolerated, HA, fatigue, D/N
-monitoring: LFTs (including bilirubin), HCV-RNA

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49
Q

DAA: Glecaprevir/pibrentasvir (Mavyret)

A

-3 tabs once daily WITH food
-CI: moderate to severe hepatic impairments (childs pugh B or C) or hx of hepatic decompensation, use with strong CYP3A4, use with ethinyl products
-approved for all 6 genotypes for treatment naive patients and for 8 week course of therapy in select pts

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50
Q

DAA: Sofosbuvir/velpatasvir (Epclusa)

A
  • 1 tablet daily w/ or w/o food
    -approved for all 6 genotypes for treatment naive patients
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51
Q

All DAA drug interactions

A

-CI with strong inducers of CYP3A4
-most DAAs inc statin concetration and myopathy risks
-dec BG can occur with insulin and other diabetic medications

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52
Q

DAA Drug interactions: Mavyret

A

-do not use with strong CYP3A4 inducers, ethinyl estradiol-containing products, lovastatin, simvastatin or cyclosporine

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53
Q

DAA Drug interactions: Epclusa, Harvoni and Vosevl

A

-contains sofosbuvir; do not use with amiodarone due to the risk of bradycardia
-antiacids, H2RAs and PPIs can dec concentrations of ledipasvir and velpatasivir
–> seperate from antiacids by 4 hours
–> take H2Ras at the same time or seperated (~12 hours) and use famotidine < 40 mg BID
–> PPIs are not recommended with Epclusa

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54
Q

DAA Drug Interactions: Zepatier

A

-do not use with efavirenz, HIV protease inhibitors or cyclosporine
-not rec with nafcillin, ketoconazole, bosentan, tacrolimus, etravirine, Stribild, Genvoya and modafinil

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55
Q

Ribavirin (used with DAAs for HCV tx)

A

-400-600 mg BID
BBW: significant teratogenic, not effective as monotherapy, hemolytic anemia
CI: pregnancy
SEs: hemolytic anemia
* need 2 relaible forms of BC during tx and 6 months after tx

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56
Q

Nucleoside/tide reverse transcriptase inhibitors (NRTIs) used for monotherapy in HBV

A

-inhibit HBV replication
-decrease dosing for CrCl < 50
BBW: lactic acidosis and severe hepatomegaly with steroids, exacerbation of HBV can occur upon d/c

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57
Q

NRTIs: Tenofavir disoproxil fumarate, TDF (Viread)

A

*preferred therapy
-300 mg daily
Warnings: renal toxicity, fanconi syndrome, osteomalacia and dec bone mineral density
SEs: renal impairment, dec bone mineral density
–> dispense in original contianer

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58
Q

NRTIs: Tenofivir alafenamide, TAF (Vemlidy)

A

*preferred therapy
-25 mg daily with food (crcl < 15 = not rec)
Warnings: renal toxicity, fanconi syndrome, osteomalacia and dec bone mineral density
SEs: nausea
–> TAF is associated with dec renal and bone toxicity
–> only approved for treating HBV (not HIV)

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59
Q

NRTIs: Entecavir (Baracclude)

A

*preferred therapy **take on empty stomach
-tx niave: 0.5 mg daily
-lamivudine-resistant: 1 mg daily
SEs: peripheral edema, ascites, inc LFTs
-food recuded AUC by 18-20%; take on an empty stomach (2 hours before or after a meal)

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60
Q

NRTIs: Lamivudine (Epivir HBV)

A

-100 mg daily (150 mg BID or 300 mg daily if co-infected with HIV)
BBW: do not use Epivir HBV for tx of HIV - can result in HIV resistance
SEs: headache, N/V/D, fatigue, insomnia, myalgias

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61
Q

NRTIs: Adefovir (Hepsera)

A

-10 mg daily
BBW: caution in pts with renal impairment or those at risk of renal toxicity
SEs: headache, weakness, abdominal pain, hematuria, rash

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62
Q

Interferon Alfa for the tx of chronis HBV: Pegylated interferon-alfa-2a (Pegasys)

A

SC dose weekly
BBW: can cause or exacerbate neuropsychiatric, autoimmune, ischemic or infectious disorders, if use with ribavirin, teratogenic/anemia risk
CI: autoimmune hepatitis, decompensated liver disease in cirrhotic pts, infants/neonates
SEs: CNS effects, GI upset, inc LFTs, myelosuppresion, flu-like symptoms; pre-treat with APAP and an antihistamine

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63
Q

Lab tests for liver disease

A

-acute liver toxicity: inc AST/ALT
-chronic liver disease: inc AST/ALT, alk phos, Bili, LDH, PT/INR, dec albumin
-alcoholic liver disease: inc AST > inc ALT, inc gamma-glutamyl transpeptidase (GGT)
-Hepatic encephalopathy: inc ammonia
-Jaundice: inc Tbili

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64
Q

Childs-Turcotte-Pugh classification of liver disease

A

Class A (mild disease): < 7
Class B (moderate disease): 7-9
Class C (severe disease): 10-15

–> the model for end stage liver disease (MELD) ranges from 6-40

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65
Q

What is a natural product used in tx of liver disease?

A

-Milk thistle

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66
Q

Select drugs with a Boxed warning for liver damage

A

-Acetaminophen (high doses, acute or chronic)
-amiodaraone
-isoniazid
-ketoconazole (oral)
-methotrexate
-nefazodone
-nevirapine
-NRTIs
-Propylthiouracil
-valporic acid

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67
Q

Alcohol associated liver disease tx

A

-can include fatty liver, alcoholic hepatitis and chronic hepatitis
–> chronic consumption of alcohol results in the secretion of TNF-alpha, IL-6, and IL-8 = inflammation, apoptosis and eventually fibrosis of liver cells
TX: naltrexone, acamprostate, thiamine, folate

68
Q

Vasoconstricting medications for bleeding varices: Octreotide (Sandostatin)

A

-bolus: 25-100 mcg IV can repeat in 1 hour if hemorrhage not controlled
-continuous infusion: 25-50 mcg/hr x 2-5 days
SEs: bradycardia, cholelithiasis, biliary sludge
Monitoring: blood glucose, HR, ECG

69
Q

Vasoconstricting medications for bleeding varices: Vasopressin (Vasostrict)

A

-infusion: 0.2-0.4 units/min IV, max duration 24 hrs
SEs: arrthythmias, chest pain, MI, dec cardiac output, inc BP, N/V
Monitor: BP, HR, ECG, fluid balance

70
Q

Non-selective beta blockers for portal hypertension

A

nadolol (40 mg) and propranolol (20 mg BID) are used for primary and secondary prevention of variceal bleeding –> help to reduce portal pressure

71
Q

Hepatic Encephalopathy

A

Symptoms: musty odor of breath or urine, changes in thinking, confusion, forgetfullness
–> a result of accumulation of gut-derived nitrogenous substances in the blood (ammonia, glutamate)
-tx includes reducing blood ammonia levels through diet and drug therapy
-first line: lactulose
-second line: rifaximin

72
Q

Hepatic Encephalopathy tx: Lactulose

A

*1st line tx
-tx: 30-45 ml/hour until stool evacuation. PO 3/4 times a day, titrate to produce 2-3 soft BMs daily
-prevention: 30-45ml PO 3-4 times a day, titrate until 2-3 soft BMS a day
CI: low galactose diet
SEs: flatulance, diarrhea, dyspesia, abdominla pain
Monitor: BMs, ammonia

73
Q

Hepatic Enephalopahty tx: Rifaximin

A

*2nd line tx
-TX: 400 mg PO Q8h x5-20 days
-Prevention: 550 mg PO BID
SEs: peripheral edema, dizziness, fatigue, nausea, ascites
monitor: mental status, ammonia

74
Q

Ascites

A

-fluid accumulation within the peritoneal space that can lead to the development of bacterial peritonitis (SBS) and hepatorenal syndromw (HS)
-pts with ascites due to portal HTN should limit dietary sodium intake to <2 grams/day

75
Q

Ascites treatment

A

-diuretic therapy: spironolactone monotherapy or w/ combination of furosemide
-in severe cases- abdominal paracentesis is needed to directly remove ascitic fluid

76
Q

Spontaneous Bacterial Peritonitis (SPS)

A

-an acute infection of the ascitic fluid
-target streptococci and enteric gram - pathogens with ceftriaxone for 5-7 days
-pts who have survived an episode of SBP should receive secondary prophylaxis with oral cipro or bactrim

77
Q

What are the common live vaccines? (MICRO-VY)

A

MMR
Intranasal influenza
Cholera
Rotavirus
Oral Typhoid
Varicella
Yellow fever
(TB, dengue, smallpox, ebola)

78
Q

General rules for all vaccines

A

-vaccines can usually be given on the same day or spaced 4 weeks apart
-multiple vaccine series requires > 1 dose, the intervals between doses can be extended without restarting the series, but they should not be shortened in most cases

79
Q

Live vaccines and antibody general rules

A

-MMR and varicella-containing vaccines require separation from antibody containing products (blood transfusion, IVIG)
–> vaccine - 2 weeks - antibody containing product
–> antibody containing product - 3 months or longer - vaccine
-simultaneous administration of vaccine and antibody is recommended for post-exposure prophylaxis of certain diseases

80
Q

vaccinations can be given, if indicated, in the following situations:

A

-mild acute illness (slight fever, mild diarrhea)
-current antimicrobial treatment
-previous local skin reaction from a vaccine
-allergies: bird feathers, penicillin, allergies to products not in the vaccine
-pregnancy (except live vaccines), breastfeeding, preterm birth
-recent tuberculin skin test
-immunosuppressed person in the household, recent exposure to the disease or convalescence
-family hx of AEs to the vaccine

81
Q

Vaccines for infants and children

A
  • 3 dose hep B vaccine started at birth
    -other vaccines started at 2 months: PCV13 or PCV 15, DTaP, Hib, polio, rotavirus
    -live vaccines started at > 12 months: MMR, varicella
    -no polysaccharide vaccines before age 2
82
Q

Vaccines for healthcare professionals

A

-annual influenza
-hep B
-Tdap: 1 dose, if not up to date, then Td or Tdap every 10 years
-Varicella
-MMR

83
Q

Vaccines for adolescents and young adults

A

-MCV4 (Menactra, Menveo, or MenQuadfi)
–> 2 doses, 1 dose at age 11-12 and 1 dose at age 16
–> first year college students
-HPV
–> rec at age 11-12, 2 or 3 doses depending on age started
-Tdap: first dose at age 11-12

84
Q

Vaccines for those with sickle cell disease and other causes of asplenia

A

-H. influenzae type b (Hib) vaccine
-pneumococcal vaccine (19-64 y/o) with either
–> PCV20 x1
–> PCV15 x1 then PPSV23 x1 > 8 weeks later
-Meningococcal vaccines
–> menactra, menveo or menQuadfi
–> Bexsero or Trumenba

85
Q

Vaccines for pregnancy

A

-live vaccines are contraindicated
-Influenza vaccine, inactivated can be given in any trimester
-Tdap x1 with each pregnancy (weeks 27-36)

86
Q

Vaccines for immunodeficiency

A

-live vaccines are contraindicated
-pneumococcal vaccine (19-64 y/o) with either
–> PCV20 x1
–> PCV15 x1 then PPSV23 x1 > 8 weeks later
-herpes zoster vaccine (shingrix): > 19 y/o, 2 doses, 2-6 months apart
-vaccines with pts with HIV:
–> menactra, menveo or menquadfi
–> Hep A and Hep B

87
Q

Vaccines for older adults

A

-shingrix, age > 50: 2 doses, 2-6 months apart
-Pneumococcal vaccine ( > 65 y/o), give:
–> PCV20 x1
–> PCV15 x1, then PPSV23 x1 > 12 months later (or > 8 weeks if immunocompromised)

88
Q

Vaccines for people with diabetes

A

-Pneumococcal vaccine ( > 65 y/o), give:
–> PCV20 x1
–> PCV15 x1, then PPSV23 x1 > 12 months later (or > 8 weeks if immunocompromised)
-Hep B (age > 60)

89
Q

Vaccinations for adults

A

-influenza
-Tdap,Td: Tdap x1 if not gotten previously then TD or Tdap q 10 years
-Shingles: all adults > 50 or > 19 yrs if immunocompromised
-HPV: < 26 y/o
-Hep A. Hep B
-meningococcal
-pneumococcal

90
Q

Influenza vaccine tips

A
  • can be given annually to all pts > 6 months
    -6 months - 8 yrs (not previously vaccinated) : give 2 doses ( 4 weeks apart)
    -egg allergy?
    –> can receive age appropriate inactivated
    –> egg free = Flublok (> 18 y/o), and Flucelax (> 6 months)
    –> do not give the live vaccine (FluMist)
    -Pregos: can recieve age appropriate inactivated
91
Q

SC vaccine administration

A

-yellow fever
-Dengue
-Smallpox
-Monkeypox

92
Q

IM or SC vaccine administration

A

-MMR
-MMRV
-Varicella
-PPSV23
-Polio

93
Q

Intranasal vaccine administration

A

-FluMist (live vaccine)

94
Q

PO vaccine administration

A

-Typhoid
-cholera
-rotavirus

95
Q

What drugs are used for prophylaxis for travelers diarrhea?

A

-Bismuth subsalicylate 524-1050 mg PO 4 times a day (with meals and at bedtime)
-antibiotics (rifaximin preferred) –> only if there is a high risk of complication from TD

96
Q

what drugs are used for tx of travelers diarrhea?

A

Mild TD: loperamide or bismuth subsalicylates
Moderate TD: loperamide +/- antibiotic
–> azithromycin or a quinolone
–> Rifaximin is an alternative
Severe TD: antibiotics +/- loperamide
–> azithromycin preferred
–> quinolones or rifazimin as alt

97
Q

what are the inactivated travel vaccines?

A

-Hep A (Havrix, VAQTA)
-Hep B (Engerix-B, Heplisav-B)
-Hep A/B (Twinrix)
-Menigoccous (Menactra, Menveo, MenQuadfi)
-Polio (POL)
-Typhoid-IM (Typhim Vi)

98
Q

What are the activated/live travel vaccines?

A

-Cholera-PO (Vaxchora)
-Typhoid-PO (Vivotif)
-Yellow Fever-SC (YF-VAX)

99
Q

What medications should be started 1-2 days prior to travel?

A

-Doxycycline: take daily, stop 4 weeks after travel (prevents rickettsial infections and leptospirosis; preferred in hiking/camping) - causes photosensitivity
–> do not use in pregos and kids under 8 (tooth development/discoloration)

100
Q

What medications should be started 1-2 weeks prior to travel?

A

-Chloroquine: stop 4 weeks after travel, take weekly,
–> SEs: retinol toxicity and vision changes, do no use in areas wehre chloroquine or mefloquine resistance

101
Q

What medication is used for altitude sickness and motion sickness?

A

-Acetazolamine: take as prophylactic day prior to travel (125 mg BID) or on the day of the ascent.
–> SEs: polyuria, photosensitivity, taste alteration
CI: with sulfa allergy

102
Q

What does a gram + organism show on stain?

A

thick cell walls and stain purple/blue

103
Q

What does gram - organisms show on stain?

A

think cell wall and stain pink/reddish color

104
Q

what are examples of gram + Cocci in clusters?

A

-staphyloccus spp. including MSSA or MRSA

105
Q

What are examples of gram + cocci in pairs and chains?

A

-streptococcus pneumoniae (diplococci)
-streptococcus spp. (inclusing S. pyogenes)
-enterococcus spp (VRE)

106
Q

What are examples of gram + rods?

A

-Listeria
-monocytogenes
-corynebacterium spp.

107
Q

What are examples of gram + anaerobes?

A

-peptostreptoccus
-propionibacterium acnes
-clostridioides difficile
-clostridium spp.

108
Q

What are examples of atypical bacteria?

A

-do not stain!
-Chlamydia spp.
-Legionella spp.
-Mycoplasma pneumoniae
-Mycobacterium tuberculosis

109
Q

What are examples of gram - cocci?

A

Neisseria spp.

110
Q

What are examples of gram - Anaerobes?

A

-Bacteroides fragilis
-prevotella spp.

111
Q

What are examples of gram - coccobacilli?

A

-acinetobacter baumannil
-bordetella pertussis
-Moraxella catarrhalis

112
Q

what are examples of gram - rods that colonize the gut (enteric)?

A

-proteus mirabilis
-escherichia coli
-klebsiella spp.
-serratia spp.
-enterobacter cloacae
-citrobacter spp.

113
Q

What are examples of gram - rods that do NOT colonize the gut?

A

-Pseudomonas aeruginosa
-Haemophilus influenzae
-Providencia spp.

114
Q

What are examples of gram - bacteria that are curved or spiral shaped rods?

A

-H. pylori
-Campylobacter spp
-Treponema spp
-borrelia spp
-leptospira spp

115
Q

What is MIC?

A

Minimum inhibitory concentration: the minimum concentration of each antibiotic that inhibits bacterial growth

116
Q

what are the common resistant pathogens? (Kill Each And Every Strong Pathogen)

A

K: klebsiella pneumoniae (extended spectrum beta lactamase (ESBL) & carbapenem resistant enterobacterales (CRE)
E: e. coli (ESBL, CRE)
A: acinetobacter baumannii
E: enterococcus faecalis, enterocooccus faecium (vancomycin resistant enteroccus (VRE)
S: staph aures (MRSA)
P: pseudomonas aeruginosa

117
Q

What antibiotics come with a warning of C.diff?

A

-all do but highest risk with:
-broad spectrum penicillins and cephalosporins
-quinolones
-carbapenems
-clindamycin (BBW)

118
Q

What are the hydrophilic abx and their properties?

A

-Beta-lactams, aminoglycosides, vancomycin, daptomycin, polymyxins
1- small volume of distribution = less tissue penetration
2- mostly renally eliminated = drug accumulation and SEs can occur if not dose adjusted
3- low intracellular concentrations = not active against atypical pathogens
4- poor-moderate bioavailability = IV:PO ratio is NOT 1:1

119
Q

what are lipophilic agents and their properties?

A

-quinolones, macrolides, rifampin, linezolid, tetracyclines
1- large volume of distribution = better tissue penetration
2-mostly hepatically metabolized = potential for hepatotoxicity and DDIs
3- achieve intracellular concentrations = active against atypical pathogens
4- excellent bioavailability = IV;PO

120
Q

Cmax:MIC (concentration dependent) dosing of abx

A

-aminoglycosides, quinolones, daptomycin
Goal: high peak (inc killing), low trough (dec toxicity)
Dosing strategies: large dose, long interval

121
Q

AUC:MIC (exposure-dependent) dosing of abx

A

-vancomycin, macrolides, tetracyclines, polymixins
Goal: exposure over time
Dosing strategy: variable

122
Q

Time > MIC (time-dependent) dosing of abx

A

-Beta-lactams (penicillins, cephalosporins, carbapenems)
Goal: maintain drug level > MIC for most of the dosing interval
Dosing strategy: shorter dosing interval, extended or continuous infusion

123
Q

how do beta-lactam abx work?

A

ex: penicillins, cephalosporins and carbapenems)
-have a chemical structure that is characterized by a beta lactam ring
-they inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins = prevents the final step of peptidoglycan synthesis in bacterial cell walls

124
Q

Safety/SE/Monitoring of penicillin class abx

A

-BBW: pen G benzathine (IM ONLY) - not for IV use, can cause cardiorespiratory arrest and death
-CI: CrCl < 30- do not use ER oral formulations of amoxicillin and augmentin XR or the 875 mg of augmentin
-SEs: seizures (w/ accumulation), GI upset, diarrhea, hemolytic anemia
-Monitor: renal function

125
Q

Natural Penicillins

A
  • Pen V potassium: PO
    -Pen G aqueous (Pfizerpen): IV
    -Pen G benzathine: IM (1.2-2.4 million units x 1)
126
Q

Anti-staphylococcal Penicillins

A

-Dicloxacillin PO
-Nafcillin IV/IM
-Oxacillin IV
–> preferred for MSSA soft tissue, bone and joint, endocarditis and bloodstream infections
–> no renal dosing adjustments
–> Nafcillin is a vesicant: admin through a central line is preferred; if extravasation occurs, use cold packs and hyaluronidase injections

127
Q

Aminopenicillins

A

-Amoxicillin PO
-Amoxicillin/Clavulanate: PO
-Ampicillin: PO/IV/IM
-Ampicillin/Sulbactam (Unasyn): IV
–> ampicillin PO is rarely used due to poor PO biavailability: amoxicillin PO is preferred if switching from IV ampicillin
–> amox/clauv: use a 14:1 ratio to dec diarrhea cause by the clauv part
–> IV ampicillin and ampicillin/sulbactam must be diluted in NS only

128
Q

Extended - Spectrum Penicillins

A

-Piperacillin/Tazobactam (Zosyn) IV
–> contains 65 mg Na per 1 gram of piperacillin

129
Q

Penicillin Drug Interactions

A

-Probenecid can inc the level of beta lactams by interfering with renal excretion, this combination is sometimes used in severe infections to inc antibiotic levels
-Penicillin can inc the serum concentrations of methotrexate
-Beta-lactams (except nafcillin and dicloxacillin) can enhance the anticoagulant effect of warfarin be inhibiting the production of vit K
-nafcillin and dicloxacillin can inhibit the anticoagulant effect of warfarin

130
Q

Class features of penicillins

A

-all penicillins should be avoided in pts with a beta-lactam allergy
–> exception: tx of syphilis during pregnancy (all pts) or in pts with poor compliance/follow-up = desensitize and treat with pen G benzathine
-all penicillins increase the risk of seizure if accumulation occurs

131
Q

Key features of Penicillins: outpt (oral therapy)

A

-Pen VK: 1st line tx for pharyngitis (strep throat) and mild non-purulent skin infections (no abscess)
-Amoxicillin: 1st line tx for acute otitis media (ped dose = 80-90 mg/kg/day)
–> drug of choice for infective endocarditis prophylaxis before dental procedure ( 2 g PO x 1, 30-60 mins before)
–> used in H. pylori tx
-Amox/Clauv: 1st line tx for acute otitis media (ped dose = 90 mg/kg/day) and bacterial sinusitis –> use the lowest dose of clauv to decrease diarrhea
-Dicloxacillin: covers MSSA only (no MRSA) and no renal dose adjustment needed

132
Q

Key features of penicillins (Parenteral therapy)

A

-Pen G Benzathine: drug of choice for syphilis (2.4 million units IM x1), not for IV use = can cause death
-Nafcillin/Oxacillin:covers MSSA only (no MRSA) and no renal dose adjustment needed
-Pip/tazo (Zosyn): only penicillin active against Pseudomonas, extended infusions (4 hrs) can be used to maximize T > MIC

133
Q

1st generation cephalosporins

A

-excellent activity against gram + cocci and preferred for MSSA
-Cefazolin IV/IM
-Cephalexin (Keflex): used for skin infections (MSSA) or strep throat: PO 250-500 mg q6-12 hrs
(cefadroxil)

134
Q

2nd generation cephalosporins

A

-Cefuroxime: cover staphlocci, S. pneumonae, haemophilus, neidderia, proteus, E. coli and klebsiella (PO/IV/IM) –> PO use for acute otitis media, CAP
-Cefotetan & Cefoxitin: (IV/IM) added activity against gram - anaerobes (B. fagilis)

135
Q

3rd generation cephalosporins (group 1)

A

-cover resistant streptococci (s. pneumoniae and viridans), MSSA, gram + anaerobes and resistant strains of HNPEK
-cefdinir (PO)- used for acute otitis media
-ceftriaxone (IV/IM)
-cefotaxime (IV/IM)
-cefixime (PO)
-cefpodoxime (PO)

136
Q

3rd generation cephalosporins (group 2)

A

-lacks gram + activity but covers pseudomonas
-Ceftazidime (IV/IM)

137
Q

4th generation cephalosporins

A

-cefepime: has broad gram - activity (HNPEK, CAPES, and pseudomonas) and gram + activity similar to ceftriaxone

138
Q

5th generation cephalosporins

A

-ceftaroline: has gram - activity similiar to ceftriaxone, but broad gram + activity
-only beta-lactam that covers MRSA
–> common uses: CAP, skin and soft tissue infections

139
Q

Cephalosporin drug interactions

A

-insoluble precipitates may form when ceftriaxone is administered in the same line as calcium-containing IV fluids
-drugs that decrease stomach acid can decrease the bioavailability of some oral cephalosporins
–> cefuroxime, cefpodoxime and cefdinir should be seperated by 2 hours from short acting antiacids –> avoid H2RAs and PPIs

140
Q

1st gen cephalosporin inpatient use

A

-cefazolin: surgical prophylaxis

141
Q

2nd gen cephalosporin inpatient use

A

-cefotetan and cefoxitin:
-anaerobic coverage (B. fragilis)
-common uses: surgical prophylaxis (GI procedures)
–> cefoteran can cause a disulfiram-like reaction with alcohol ingestion

142
Q

3rd gen cephalosporin inpatient use

A

-ceftriaxone and cefotaxime
-common uses: CAP, meningitis, spontaneous bacterial peritonitis, pyelonephritis
–> ceftriaxone: no renal dosing needed, do not use ceftriaxone in neonates (age 0-28 days)

143
Q

Carbapenems do NOT cover

A

atypicals, VRE, MRSA, C. diff, stenotrophomonas
–> ErtAPenem does not cover PEA: pseusomonas, enterococcus, acinetrobacter

144
Q

Cabapenem drugs: Meropenem and Ertapenem

A

M: IV
E: IV/IM: stable in NS only
CI: anaphylaxtic reactions to beta-lactams
-Warning: do no use with PCN allergy, CNS effects like seizures
-SEs: diarrhea, rash/DRESS, bone marrow suppression with prolonged use
-Monitor: renal function
–> Imipenem is combined with cilastatin to prevent drug degradation by renal tubular dehydropeptidase
(E:commonly used for diabetic foot infections)

145
Q

Carbapenem class effects

A

-all active against ESBL-producing organisms and (except E) pseudomonas
-do not use with penicillin allergy
-seizure risk (with higher doses & failure to renally dose)

146
Q

Carbapenems common uses

A

-polymicrobial infections (diabetic foot infections)
-empiric therapy when resistant organisms are suspected
-ESBL-positive infections
-resistant pseudomonas or acinetrobacter infections
–> all are IV only, ertapenem must be diluted in normal saline

147
Q

Monobactam: Aztreonam

A

-inhibits bacterial cell synthesis by binding to penicillin binding proteins –> which prevent the final step of peptidoglycan synthesis in bacterial cell walls
-covers many gram - organisms: pseudomonas and CAPES
**used when there is an penicillin allergy

148
Q

Key features of aminoglycosides

A

-kill gram - pathogens, are synergistic with beta-lactams from some gram + organisms and have low resistance and drug cost
-gentomycin and streptomycin are used for synergy, in combo with a beta-lactam or vancomycin, when treating gram + infections
-have notable toxicity that require monitoring nephrotoxicity and ototoxicity, which may be irreversible

149
Q

Aminoglycosides dosing

A

-traditional dosing = uses lower doses more frequently
-extended interval dosing = higher doses less frequently –> less accumulation of drug, loer risk of nephrotoxicity and decreased cost (also gives time for the kidney to recover between doses

150
Q

Amino glycoside: Gentamicin

A

-IV, IM, opthalmic, topical: 1-2.5 mg/kg/dose
-crcl > 60: q 8hr
-extended iv dosing: 4-7 mg/kg/dose

151
Q

Aminoglycosides: SEs,/Safety/Monitoring

A

BBW: nephrotoxicity, ototoxicity, neuromuscular blockade
SEs: use caution in pts with renal disease or elderly and those taking other nephrotoxic drugs (amphotericin B, cisplatin, polymixins, cyclosporine, loop diuretics, NSAIDs, radiocontrast dye, tacrolimus and vanco)
-Monitor: drug levels, renal function,
–> draw a trough level immediately before (30 min) the 4th dose; draw a peak level 30 min after the 30 min infusion for the 4th dose

152
Q

Aminoglycosides: Tobramycin

A

-IV, IM, opthalmic, inhaled (for CF)
-T IV dosing: 1-2.5mg/kg/dose
-E IV dosing: 4-7 mg/kg/dose
-crcl > 60 = q 8 hrs

153
Q

Aminoglycosides: Amikacin

A

-IV, IM
5-7.5 mg/kg/dose q 8 hr

154
Q

Quinolones: Safety, SEs, Monitoring

A

BBW: tendon inflammation and/or rupture, peripheral neuropathy, seizures (has CNS effect)
CI: cipro and tizanidine
Warnings: QT prolongation (highest with moxi), hypo/hyperglycemia, psychiatric disturbances, avoid systemic quinolones in children and prego/breastfeeding, photosensitivity
SEs: N/V/D, headahce, dizziness, SJS/TEN

155
Q

Quinolones: Ciprofloxacin

A

*anti-pseudomonal (including pneumonias)
-PO: 250-750 mg q 12
-IV: 200-400mg q8-12
(crcl 30-50 = q 12, crcl < 30 = q 18-24)
CI: cipro & concurrent admin of tizanidine
–> Cipro oral suspension: shake well, do not administer thru NG or feeding tube
–> can cruch immediate release tabs, mix with water and give via a feeding tube, hold tube feedings at least 1 hr before and 2 hrs after the dose

156
Q

Quinolones: Levofloxacin

A

*anti-pseudomonal (including pneumonias)
*respiratory quinolones (s. pneumoniae activity)
*IV:PO = 1:1
PO/IV: 250-750 mg qd
-CrCl: < 50 = Q 48hrs or dec dose

157
Q

Quinolones: Moxifloxican

A

*only drug in class that is not renally adjusted (do not use for UTIs)
*IV:PO = 1:1
-IV/PO: 400 mg q 24 h

158
Q

Quinolones: drug drug interactions

A

-antacids and other polyvalent cations can chelate and inhibit quinolone absorption & should not be taken at the same time
-lanthanum and sevelamer can dec the serum concentration or oral quinolones ; separate admin by at least 2 hrs before & after
-can inc affects of warfarin
-inc effects of sulfonylureas, insulin & other hypoglycemic drugs
-qt-prolonging
-Probenecid and NSAIDs can inc quinolone levels
-cipro is a strong CYP1A2 inhibitor = inc levels of caffine, theophylline and tizanodine by redusing metabolism

159
Q

Macrolides: random facts

A

-bind to the 50s ribosomal subunit
-excellent coverage of atypical (legionella, chlamydia) but utility against S. pneumoniae, haemophilus, chlamydia and morexella

160
Q

Macrolides: Azithromycin

A

-zpack: 500 mg day 1, 250 mg days 2-5
-IV: 250-500mg daily
-no renal dose adjustments needed
*Used for: COPD exacerbations, pertussis, chlamydia (in pregos), prophylaxis for mycobacterium avium complex, severe traverlers diarrhea

161
Q

Macrolides: Safety/Side effects/ Monitoring

A

CI: hx of cholestatic juandice/hepatic dysfunction w/ prior use
*do not use clarithromycin and erythromycin with lovsatatin or simvastatin
Warnings: QTc prolongation (E > A> C), hepatotoxicity,
SEs: GI upset

162
Q

Macrolides: Clarithromycin

A

PO: 250-500 mg q 12 or 1 g (ER) qd
-used in H. pylori tx regimens
-caution in pts with CAD

163
Q

Macrolides: Erythromycin

A

-dosing depends on product
-increases gastric motility and is used for gastroparesis
*highest risk of qtc prolongation

164
Q

Macrolides: drug drug interactions

A

-E and C are major substrates of CYP3A4 and are inhibitors –> CI with lova and simva
-caution with CVD, dec potassium and magnesium & other QTc prolonging drugs

165
Q

Tetracyclines:

A

NAPLEX BABY (23 decks)

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