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1

What are the indications for use of a loop diuretics?

Edema, hypercalcemia, hyperkalemia, anion overdose (fluoride, bromide, iodide).

2

MOA of loop diuretics

Inhibits sodium/potassium/chloride transporter at the thick ascending limb of the loop of henle.

3

Which loop diuretic should be used when concerned about sulfonamide allergy (even though there is no cross reactivity between loops and sulfa abx)?

Ethacrynic Acid (Edecrin)

4

Indications for the use of Spironolactone

Primarily hypokalemia (px and tx); hyperaldosteronism, PCOS

5

What are Eplerenone, Triamterene, and Amiloride indicated for? (All potassium sparing diuretics)

Hypokalemia px and tx

6

What is Conivaptan indicated for?

CHF, SIADH

7

Drugs that induce ED

Beta blockers,Clonidine, methyldopa, haloperidol, chlorpromazine, thioridazine, Fluphenazine, SSRIs, SNRIs, Finasteride, Dutasteride, Silodosin, Opioids (esp Methadone), nicotine, excess alcohol

8

Onset and Duration of Sildenafil (Viagra)

onset in 30 m - 1 hour; duration 4 hours

9

MOA of PDE Inhibitors

inhibits phosphodiesterase enzymes, slowing the breakdown of cGMP and allowing for the depression of calcium, leading to smooth muscle relaxation, allowing erection (arteriodilation + venoconstiction)

10

MOA of Alprostadil (injectable PGE-1)

increases cAMP leading to a drop in calcium

11

meds that induce BPH

testosterone, alpha agonists (pseudoephedrine, ephedrine, phenylephrine), anticholinergics (antihistamines, phenothiazine, TCAs), large doses of diuretics

12

ADE of Tamsulosin (and other alpha 1 adrenergic antagonists)

dizziness, hypotension, syncope with first dose, muscle weakness, H/A, floppy iris syndrome

13

indication for Finasteride (5-alpha reductase inhibitor)

BPH

14

MOA of 5-alpha reductase inhibitors

relax smooth muscle, decrease prostate size, halt disease process, and decrease PSA

15

What is the most commonly used herbal supplement in the tx of BPH?

Saw Palmetto

16

Drugs that cause/worsen Urinary Incontinence

diuretics, alpha receptor antagonists, sedation hypnotics, antidepressants, TCAs, alcohol, angiotensin converting enzyme inhibitors

17

first-line agent in the tx of stress induced urinary incontinence

Duloxetine (Cymbalta)

18

first-line tx for overactive bladder

Oxybutynin (Ditropan)

19

agents that cause vasodilation of the efferent arteriole

ACE-Is, ARBs, Diltiazem, Verapamil

20

drug class that affects blood/urine pH through the movement of H+ ions with K+ at the collecting duct

Potassium Sparing Diuretics

21

drug class that acts on the distal convoluted tubule and enhances calcium reabsorption into the blood stream

thiazide diuretics

22

Cholinesterase Inhibitor that is reversible and has specificity for only acetylcholine

Donepezil Hydrochloride (Aricept)

23

Cholinesterase Inhibitor that comes in capsule, solution, and patch forms

Rivastigmine

24

Rivastigmine Tartrate (Exelon) ADE

N/V/D, dizziness, H/A, insomnia, depression, somnolence

25

What drug is FDA approved for the tx of moderate to severe AD?

Memantine (Namenda)

26

What should all Alzheimer's patients receive?

ASA therapy to improve vascular function

27

Which drug used to tx Alzheimer's Disease is considered medical food?

Caprylidene (Axona)

28

Caprylidene (Axona) ADE

risk of DKA in diabetics, may increase TGs

29

drugs that cause visual abnormalities

Carbamazepine, Eslicarbazepine, Locasamide, Lamotrigine, Oxcarbazepine, Phenytoin, Pregabalin, Tiagabine, Vigabatrin

30

Anticonvulsants that cause weight loss

Ethosuximide, Felbamate*, Topiramate, Zonisamide

31

Anticonvulsants that cause weight gain

Gabapentin, Pregabalin, Valproic Acid, Vigabatrin

32

Why does Cimetidine cause significant DI's?

it is a CYP inhibitor

33

tx algorithm for early-established seizures

0-10 minutes: IV lorazepam (or diazepam)
10-30 minutes: IV phenytoin or fosphenytoin
30-60 minutes: additional dose of hydantoin 5 mg/kg, IV phenobarbital 20 mg/kg at a rate of 100 mg/min

34

treatment algorithm for refractory seizures > 60 minutes wit 10-15% GCSE

additional dose of phenobarbital 10 mg/kg every hour until sz stop
or
IV valproate 15-25 mg/kg followed by 1-4 mg/kg/hr
or
medically induced coma

35

only class that should be used in the elderly to tx sx of anxiety, restlessness, and insomnia in AD

Benzodiazepines (Lorazepam, Diazepam, Temazepam)

36

use of anticonvulsants (Carbamazepine, VA) in non-elderly AD pts

agitation or aggression

37

use of anitpsychotics (Aripiprazole, Olanzapine, Quetiapine, Risperidone) in non-elderly pts with AD

disruptive behavior, agitation, aggression

38

medications associated with memory loss

anticholinergics, benzos, other sedative hypnotics, opioid analgesics, antipsychotics, anticonvulsants, NSAIDs, H2 receptor antagonists, digoxin, amiodarone, corticosteroids, antihypertensives (dizziness)

39

Indications for Rasgiline (Azilect - MAOB Inhibitor)

mono tx in early PD or adjunct to LD in advanced PD (typically first-line in early disease)

40

medication used for Parkinson's that is an antiviral

Amantidine (Symmetrel)

41

drug used to tx PD for which tachyphylaxis may be expected in 4-8 weeks

Amantidine (Symmetrel)

42

drug of choice in PD if resting tremor is the initial presenting sx

Benztropine Mesylate (Cobentin) or Trihexylphenidyl* (Artane)

43

Pt population in which Benztropine and Trihexyphenidyl (Anticholinergics) should be avoided.

pts with cognitive deficits

44

MOA of Ergot Derivative Dopamine Agonists (Bromocriptine, Pergolide)

Moderate affinity for D2 and D3 receptors.

45

What needs to be done for patients who have renal issues and are taking Pramipexole (Mirapex)?

dose adjust

46

Drug class of Ropinerol (Requip)

Non-Ergot Derivative Dopamine Agonists

47

Indication for Rotigotine (Neupro - Non-Ergot Derivative Dopamine Agonist)

early stage idiopathic PD and advanced stages

48

Which Non-Ergot Derivative Dopamine Agonist comes in patch form?

Rotigotine (Neupro)

49

indication for Apomorphine (Apokyn)

rescue med for "delayed on"/"no on" or "freezing episodes" (PRN)

50

What prophylaxis is required when using Apomorphine (Apokyn)?

Trimethobenzamide 3 days prior

51

Indication for CD/LD

cornerstone of tx of PD, required by nearly all PD pts at some point in dz but use as first-line is controvertial d/t ADE

52

MOA of CD/LD

CD inhibits decarboxylase, delaying the conversion of LD to dopamine prior to crossing the BBB, increasing its bioavailability once on the other side of the BBB

53

ADE of CD/LD

N/V, orthostasis, confusion, postural hypotension, vivid dreams, wearing-off fluctuations, dyskinesias (5-10%), random motor oscillations possible with chronic use; issues with dose gap (add DA's)

54

Special Recommendations for pts taking CD/LD

avoid high protein meals, take 30 m before or 60 m after meals d/t competition with other aa's for GI absorption

55

major ADE of COMT Inhibitors (Entacapone, Tolcapone)

brownish-orange urinary discoloration, potential for serious liver dysfunction (monitor LFTs!)

56

Stalevo

CD/LD + Entacapone

57

What is the purpose of COMT Inhibitors in PD therapy?

increases the "time on" by 1-3 hours when used as an adjunct to CD/LD (Entacapone*)

58

drugs that extend the effects of CD/LD

DA's and COMT-I's

59

appropriate tx in a Parkinson's pt experiencing freezing or start hesitation who is on CD/LD

increase CD/LD dose, add DAs or MAO-B-Is, PT, sensory cues, walking devices

60

For a pt presenting with tremor who is already being tx'd for PD, how does age change the tx's available?

If under 65 consider an anticholinergic or Amantadine, if over 65 anticholinergics should not be used

61

monitoring for Phenytoin (Dilantin)

CBC, LFTs, albumin, and serum concentration

62

What disturbing oral ADE is Phenytoin (Dilantin) associated with?

Gingival Hyperplasia

63

What would be seen if Carbamazepine were to be given concomitantly with CYP inhibitors (ex: Cimetidine)?

increase in serum concentration

64

Pan-Inducers used to tx seizure disorders

Carbamazepine and Phenobarbital

65

Topiramate (Topimax) ADE

weight loss, cognitive functioning impairment, kidney stones, ataxia, somnolence

66

Lamotrigine (Lamictal) ADE

rash (SJS, TENS), coordination abnormalities, anxiety, mania, diplopia, insomnia, drowsiness, fatigue

67

Indication for Valproic Acid/Divalproex Sodium/Valproate Sodium in sz disorders

primary generalized sz (myoclonic, atonic, absence); partial sz, mixed disorders

68

What is unique about the metabolism of Valproic Acid/Divalproex Sodium/Valproate Sodium?

undergoes gluconuridation and inhibits glucuronidation in other agents

69

Valproic Acid/Divalproex Sodium/Valproate Sodium ADE

dose related: N/V, abdominal pain, heartburn, sedation, fine hand tremor, weight gain and increased appetite, hair loss, hepatotoxicity, thrombocytopenia

70

Gabapentin ADE

somnolence, ataxia, tremor, dizziness, H/A

71

Pregabalin ADE

dizziness, ataxia, somnolence, peripheral edema, weight gain, H/A (NO DIPLOPIA!!)

72

Zonisamide ADE

fatigue, dizziness, ataxia, somnolence, anorexia, weight loss, psychomotor slowing

73

Indication for Ethosuximide (Zarontin)

absence sz

74

Risk Factors for Iron Deficiency Anemia

premature infants, children in rapid growth periods, pregnant and lactating women, pts undergoing chronic hemodialysis, pts after gastrectomy, pts with small bowel disease, menstruation, occult GI bleeding

75

Which form of parenteral iron requires a 25 mg test dose for anaphylaxis?

Iron Dextran

76

How long is the tx of B12 Deficiency Anemia with cyanocobalamin?

typically for life

77

Indications of Nasocobal (nasal spray) Use

maintenance therapy in Vit B12 Deficiency Anemia tx

78

What is the difference in half life of ESAs (Darbepoetin and Epoetin Alfa)?

Darbe has a much longer half life allowing for less frequent dosing

79

What are the supportive tx's used in Sickle Cell Anemia?

NS for hydration
Acetaminophen and NSAIDs for mild-moderate pain
Opioids for moderate to severe pain

80

What causes reduced efficacy of cancer drugs on cancer cells?

cancer cells can alter their characteristics to reduce their susceptibility

81

Where in the cell cycle do Alkylating Agents (Carmustine, Lomustine, Mechlorethiamine, Melphan, Thiotepa, Procarbizine, Chlorambucil, *Cyclophosphamide*, Bendamustine, Temozolamide, Dacarbazine) act?

cell cycle non-specific

82

Ankylating Agent (Cyclophosphamide) ADE

bone marrow toxicity, mucositis, sterility, N/V, *tissue damage following extravasation*, risk of secondary malignancies

83

Where in the cell cycle do Platinum Analogs (Carboplatinum) act?

cell cycle non-specific

84

ADE of Carboplatinum

myelosuppression

85

Where in the cell cycle do Antimetabolites (Methotrexate, 5-FU, Cytarabine) act?

S phase (DNA synthesis)

86

Cytarabine (Ara-C) ADE

cerebellar toxicity

87

Indication of Leocorvin (Special Antimetabolite)

reduction of MTX toxicity and increased colon cancer tx

88

Cell cycle phase where Leocorvin is active

S phase/DNA phase

89

Leucorvin MOA

no anticancer action! rescues normal cells by bypassing the inhibition of DHFR by MTX. increases 5-FU activity against colon cancer by enhancing binding.

90

Vincristine (Vinca Alkaloid) MOA

inhibit tubulin polymerization required for microtubule assembly; prevents microtubule formation, blocking cell division during metaphase, resulting in cell death

91

Cell cycle where Vinca Alkaloids are active

M phase

92

Vincristine ADE

potent vesicant action upon extravasation

93

Cell cycle where Taxanes (Pacitaxel) act

M phase

94

cell cycle where Antitumor Abx/Anthracyclines act

cell cycle non specific

95

Doxorubicin (Anthracycline) ADE

vesicant if extravasated

96

What is an important aspect of tx with Doxorubicin?

limit lifetime dose of anthracyclines in general and use in combo with dextrazoxane

97

cell cycle where Bleomycin (antitumor antibiotics) is active

cell cycle-non specific

98

What are the toxicity risks of Bleomycin?

persons > 70, *cumulative dose > 400 units*, underlying pulmonary disease, prior mediastinal radiation, supplemental disease

99

Indication for use of Imatinib (TKI)

Ph+ CML and ALL

100

MOA of TKIs

(Imatinib) binds to and blocks specific sites on various TKI's that are needed to activate them, promotes cancer cell death via apoptosis (phosphorylate mostly cell surface receptors)

101

Tx for multiple myeloma

Thalidomide (Immunomodulators)

102

Tx for Breast Cancer that is HER-2/neu overexpressing

Monoclonal Antibodies

103

MOA of Monoclonal Antibodies

targets specific proteins in CA cells and blocks their standard function

104

Monoclonal Antibody ADE

Trastuzumab: infusion related rx (px with acetaminophen, diphenhydramine +/- dexamethasone), *HF*

105

Major warning associated with ESA use

increased mortality, increased CV and TEEs, increased tumor growth or loss of remission

106

translocation that occurs in CML

t9:22 = Philadelphia Chromosome

107

What is breast cancer tx based on?

pre or post menopausal status

108

What are the hormonal therapies for Breast Cancer?

Tamoxifen, Raloxifene, Anastrozole, Letrozole, Leuprolide

109

What is the goal of chemo tx in malignant melanoma?

prolong survival

110

How do secondary malignancies and de novo cancer differ?

secondary malignancies are more difficult to tx than de novo cancer

111

What kind of tx is chemo considered?

systemic

112

What is the principle of cancer cell growth that describes how the growth fraction of a tumor changes over time?

growth fraction decreases as tumor size increases, therefore fewer cells are susceptible to chemo (Gompertzian Model of tumor cell growth)

113

Define adjuvant therapy

used after local therapy to improve long term effect by eliminating any remaining undetected CA cells

114

define remission

complete response (CR), when the presence of cancer is undetectable

115

define palliation

used to reduce sx of disease, improve QOL, and prolong survival; cure unlikely

116

Cyclophosphamide (Ankylating Agent) MOA

targets DNA/RNA to transfer ankylating groups to other molecules in the strands, preventing their use in replication and cell division; = apoptosis

117

Methotrexate (Antimetabolite) MOA

inhibits dihydrofolate reductase which converts one form of folic acid to another (blocks purine synthesis), also inhibits thymidine synthase

118

Vincristine (Vinca Alkaloids) MOA

inhibits tubulin polymerization requried for M.T. formation, blocking cell division during metaphase

119

What is the mechanism by which resistance to TKIs may occur?

mutations in the AA sequence of TK may cause the site bound to be inadequate

120

What are two mechanisms of drug interactions with TKIs?

changes in metabolism secondary to other drugs affecting CYP450 3A4 and reduced absorption secondary to acid reducing drugs (ex: PPIs)

121

families of drugs with vesicant activity if extravasated

antitumor antibiotics, vinca alkaloids, alkylating agents

122

Carboplatin ADE

myelosuppression

123

Doxorubicin ADE

cardiotoxicity

124

Cytarabine ADE

cerebellar toxicity

125

What are two methods to reduce the risk of cardiotoxicity associated with Doxorubicin?

limit lifetime dose, use in combo with dextrazone

126

What occurs in phase III of drug trials?

assess efficacy of compound compound compared to standard tx

127

hormone sensitive cancers

breast and prostate

128

MOA of Carbonic Acid Anhydrase Inhibitors

Inhibits enzyme responsible for dehydration of H2CO3 (H2CO3 ->HCO3)