What are the three predictors of lung volume?
Gender
Height (taller = larger vol)
Age
What is the pattern of asthma and what drug class does it best respond to?
eosinophilic - allergic, inflammatory pattern
STEROIDS
do daily symptoms of asthma or QOL correlate with lung volume findings?
No
Asthma SX and QOL do not correlate with lung volume
COPD depicts which pattern and responds well to what drug class?
neutrophilic (chronic mucus production allows bacterial growth)
ANTIBIOTICS
What is the greatest risk factor for COPD?
Smoking
What is Asthma COPD Overlap Syndrome (ASCOS)
involves inflammation and bronchoconstriction
Do Asthma or COPD have alveolar destruction?
COPD
Which drugs are generally classified as relievers? What does it mean to be a reliever?
Albuterol
Salmeterol
Tiotropium (anti-cholinergic)
Theophylline (rarely used)
- relievers bronchodilate to RELIEVE symptoms
Which drugs are administered PO for Asthma TX?
Montelukast (controller)
Theophylline (rarely used)
- because PO, systemic side effects common
How are Spacers Helpful?
- more drug into the lungs (from 1/3 to 1/2)
- less drug into the gut
(fewer systemic side effects)
What is the MOA for montelukast?
leukotriene receptor antagonist (LTRA); block LTD4, LTE4, stop binding
(oral admin)
- CYP3A4 metab
otherwise, minimal adv. effects
What is the MOA for theophylline?
similar to caffeine; CNS stimulant
- bronchodilates
- not an alternative to ICS; more like LABA
Which controller medication is primarily used in asthma tx?
Montelukast (Singulair)
lipoxygenase pathway (block pathway: prevent leukotriene production)
which drug blocks IgE production and plays a HUGE role in asthma treatment?
Corticosteroid - Beclomethasone (ICS)
- broad anti-inflammatory drug of choice
Which Short Acting Beta Agonist (SABA) is used as a short acting rescue inhaler for asthma?
Albuterol (Salbutamol)
- onset in 90s, increases lung volume 20%
Is Albuterol meant for daily use?
No
Daily use = poorly controlled
Which drug is albuterol related to and what S/E are expected with this drug?
Like Epinephrine
- Tachycardia
- Hypertension
- Jitteriness/Mild Anxiety
Should you recommend an OTC inhaled epinephrine such as asthmanefrin for asthma?
NO! Works like an inhaled Epi-Pen; 15s-5 min duration, NO BENEFIT
which Long Acting Beta Agonist (LABA) is used, often in combination with steroids for Asthma TX? How long does it work?
Salmeterol - increases lung volume
> 10% in 10 min,
> 30% in 1 hour.
Declines to 15% in 12 hours
Does salmeterol control disease progression?
No; rarely used in practice, more risk of adverse effects (over-stimulation)
Which anti-cholinergic has a persistent effect and does not easily achieve tolerance?
Tiotropium
How does Tiotropium compare to Salmeterol?
Salmeterol (LABA) loses persistence long term, less tolerance;
equal clinical effects
How do inhaled corticosteroids (ICS) target inflammation, are they relievers or controllers? what should patients be reminded of? why?
block IgE, controllers
- remind patient to rinse mouth after use; local thrush infxn; effect on LONG BONEs
Are steroids used to control of Asthma or COPD?
steroids are recommended for
BOTH ASTHMA and COPD
CONTROLLER DRUGS
What are the first steps in treating asthma?
start with albuterol
then low-dose ICS (or theophylline)
then move to salmeterol (or tiotropium)
omalizumab should be considered for allergic patients
then oral corticosteroid if still not controlled
are anti-cholinergic indicated for patients with asthma?
Yes - when tiotropium was added to ICS, improved sx and lung function
Do current medications slow or stop functional decline in COPD?
no
What are the first steps in treating COPD?
start w/ removing risk factors (smoking) then albuterol (prn) then long acting broncho-dilator such as: tiotropium or theophylline then ICS (beclomethasone)
For COPD if pulse ox drops <88% what do you do?
administer oxygen
what does an anti-histamine MOA look like?
blocks H1 receptor sites
what is the main difference between bacterial and viral conjunctivitis?
bacterial - purulent d/c
viral - little to no d/c
which drugs is reserved for prophylaxis of neonatal gonococcal and chlamydial infections?
erythromycin ointment
what is the MOA for macrolides? which drugs are in this group?
inhibit bacterial protein biosynthesis by binding 50s subunit
- bacterioSTATIC
- azithromycin (Gonorrhea, Chlamydia)
- erythromycin (prenatal gonorrhea)
what s/e should be considered with erythromycin administration?
GI sx (N/V/D) prolonged QT hepatotoxicity
Does erythromycin have multiple drug interactions?
Yes, CYP450-3A4 inhibitor
which aminoglycoside is a commonly used topical for bacterial conjunctivitis? what spectrum is this drug?
Tobramycin
BROAD spectrum antibiotic
- staphylococcus is the common bacteria responsible
when treating primary open-angle glaucoma, which drug class is recommended due to fewer side effects?
prostaglandin analogs over beta blockers
both work to decrease aqueous production.
what is the number one treatment for glaucoma?
Lantanoprost
prostaglandin analog
decreases aqueous production, increased outflow
which treatment topical or transdermal is most easily absorbed? how else can you compare and contrast topical vs transdermal?
- creams are most easily absorbed (topical)
- transdermal has systemic effects
which topical antimicrobial is indicated for MRSA, a drug of choice for limited number of lesions in Impetigo?
Mupirocin
S/E increase with larger area to treat
What is the MOA of Mupirocin (Bactroban)? used for which kinds of bacteria?
inhibits bacterial protein synthesis
- effective against gram +
- bacterioSTATIC
How are topical corticosteroids categorized in regard to potency? which category is used in children?
Class I - most potent
Class II-III - high potency
Class IV-V - medium potency
Class V-VII - low-potency (USED IN CHILDREN)
what is the MC used topical steroid class due to lower risk of systemic effects, but high enough potency for effect
class IV-V*
What caution should be taken with the use of isoretinoin (accutane)?
TERATOGENIC*
- do not take while pregnant!
what are the bactericidal antibiotics? which ones are concentration dependent or time dependent?
aminoglycosides (concentration dependent)
fluoroquinones (concentration dependent)
beta-lactams (time dependent)
vancomycin (time dependent)
how is sensitivity, the degree to which organisms are killed by an antimicrobial, determined?
- must reach microorganism
- bind to it
- interfere with vital function
- remain intact chemically while acting upon organism
what is the MOA of the sulfonamide: Sulfamethoxazole w Trimethoprim (Bactrim)?
inhibits FOLIC ACID synthesis, resistance is increasing
which anti-microbial is indicated for community acquired MRSA?
Sulfonamide:
Sulfamethoxazole w Trimethoprim (bactrim)
- if suspicion of MRSA, tx empirically with this
What adverse or drug interactions should be considered with sulfonamides?
allergic conditions
Drug interactions:
Para-aminobenzoic acid (PABA)
WARFARIN* (increases effects)
what is the MOA for penicillins such as amoxicillin? what is the characteristic structure responsible for this?
Inhibit cell wall synthesis by binding Penicillin Binding Proteins (PBPs)
- beta lactam ring
- bacteriCIDAL
Which penicillin is used to treat otitis media and sinusitis?
Amoxicillin
- binds PBPs, stops cell wall synth
- narrow spectrum
which antibiotic is avoided in cystitis due to high resistance? Unless?
Amoxicillin
- ONLY USE if enterococcus is suspected*
which antibiotic is the treatment of choice for enterococci?
amoxicillin
- also great for OM (first line tx)
Amoxicillin/clavulanic acid (Augmentin) is effective against?
MSSA sp, but EXCELLENT against ALL anaerobes
what should be considered when administering Amoxicillin/clavulanic acid (Augmentin)
clavulanic acid is a beta lactamase inhibitor; increases effect of penicillins against resistance
- increases GI S/E; Diarrhea is common
Major interactions with acacia
should amoxicillin/clavulanic acid be considered for MRSA?
no, non-MRSA
What is the most severe cause of antibiotic induced diarrhea? which antibiotic may be to blame?
pseudomembranous colitis
- amoxicillin/clavulanic acid (Augmentin)
what adverse effects should be considered with penicillins?
allergies (with 1 hr admin)
seizures
may interact with Ginkgo or seizure drugs
which anti-microbial class should NEVER be used to treat enterococcus?
Cephalosporins - RESISTANT*
what is the MOA of cephalosporins?
bind PBP on cell wall, disrupt synthesis (similar to penicillins); beta lactam
- time dependent, repeat dosing
-cephalexin
what class is cephalexin in and what is it’s MOA?
first gen. cephalosporins
- bind PBP on cell wall to disrupt synth
what is cephalexin indicated for?
- MSSA*
- UTI
- respiratory infections
- surgical prophylaxis
- skin infections
What can be considered second options (2) if allergic to penicillin and infected with GABHS?
cephalexin (cephalosporin)
azithromycin (macrolide)
A Z-pack is which anti-microbial? What do you need to advise your patients of?
Azithromycin
- Food decreases absorption
- take 1 hr before, or 2 hours after meals
What is the adverse reaction of concern with macrolides? Of the two macrolides, which has the least adverse rxns?
DIARRHEA - stimulates enteric plexus, increases peristaltic movement
Azithromycin: (compared to erythromycin)
fewer GI symptoms
fewer drug interactions (consider CYP450-3A4)
less effect on QT interval
(compared to erythromycin)
Which concentration-dependent macrolide is key to treating both gonorrhea AND chlamydia? What gets added if suspect Gonorrhea?
Azithromycin (1g PO)
IF GONORRHEA
add: ceftriaxone
IF unsure?
Treat like it’s Gonorrhea.
What is the MOA of tetracyclines?
inhibits protein synthesis by binding 30s ribosomal subunit
bacteriostatic
What should be remembered about tetracyclines?
bind to calcium ions, should not be taken with dairy or calcium supplements
Which tetracycline is used to treat community acquired MRSA - and is also an alternative to penicillin allergy?
Doxycycline
binds to 30s ribosomal subunit, bacteriostatic
What adverse reaction should be known about tetracyclines?
TOOTH DISCOLORATION in children
C/I in pregnancy and kiddos
Photosensitivity
- can be used in renal failure
when empirically treating pneumonia, which antibiotic should be considered if patient is at risk for QT prolongation?
Doxycycline
Which drug treats chlamydia?
Doxycycline
OR Azithromycin
what is the MOA for quinolones? which antibiotics are they?
inhibit bacterial DNA gyrate, inhibiting replication and transcription
bactericidal
- ciprofloxacin
- moxifloxacin
which antibiotic drug class is effective against b. fragilis?
quinolone (moxifloxacin)
- grapefruit drug interactions
- orally binds to cations
what is the MOA of metronidazole?
inhibits nucleic acid synthesis
RESISTANCE RARE
- anti-biotic/protozoa
Which antibiotic is indicated for clostridium difficile associated diarrhea OR abdominal abscess? and specific for which bug?
METRONIDAZOLE*
anaerobic specific* b.fragilis
What is the most common s/e with metronidazole?
disulfiram interaction - creates nausea with any alcohol consumption*
Which antibiotic is indicated for lower UTI but NOT pyelonephritis?
Nitrofurantoin
What is the MOA of Nitrofurantoin?
disrupts both DNA and RNA of bacteria sensitive to the drug.
SAFE in PREG until 38 weeks gestation
What are the S/E of Nitrofurantoin?
N/V/D
less common
fever, chills, pulmonary fibrosis
which antibiotic class has the side effect of nephrotoxicity and ototoxicity? Which one is it and what is it used for?
Aminoglycosides (bactericidal); use primarily for gm -, aerobic infxn (pseudomonas)
-tobramycin (bacterial conjunctivitis)
Differentiate CA-MRSA to MRSA
CA-MRSA - pustular abscess, drainable lesions
MRSA - more of a superficial cellulitis
Which antibiotic is used to treat MRSA? How is it administered?
Vancomycin; IV
When is vancomycin PO used?
ONLY for C. DIFF*
Which PO drugs (3) treat pseudomonas colitis?
Metronidazole (mild cases)
Vancomycin (moderate to severe)
Ciprofloxacin
What drug class is ciprofloxacin in? What is it used to treat?
Fluoroquinolone’s (BROAD spectrum)
- ind. bacterial conjunctivitis after tobramycin
Fluoroquinolone antibiotics should not be used due to ?
increased risk of bacterial resistance
- not indicated for cystitis
which condition is, 90% of the time, caused by viral infection?
pharyngitis
60% are treated with antibiotics
What are the centor criterion?
Point for Each
- no cough
- fever
- tonsillar exudate
- 3-14 years of age
- anterior lymphadenopathy
> 2 = culture and treat.
when should you begin an antibiotic with a child experiencing otitis media?
if child worsens in 48-72 hours
All children < 6mo, tx
6-24 mo, tx if BL AOM or if otorrhea
If > 2 yr, and otorrhea, tx
What is “treatment failure”
no improvement after 48-72 hours of initial treatment
Does purulent D/C predict bacterial infection?
no, palpate for facial pressure and pain
for sinusitis, when do symptoms peak an which is the most common of the bugs?
sx peak 7-10 days
bugs: s. pneumonia, h. flu (also both MC for pneumonia)
75% bacterial infxn
are antihistamines recommended for sinusitis?
no.
what are the common bugs for cystitis? how do you treat?
e coli
klebsiella
- tx empirically with nitrofurantoin
IF resistance - TMP/SMX
when is the only time to think amoxicillin with cystitis?
if enterococcus is suspected
which anti-fungal for superficial mycoses is PO administration?
Terbinafine/Lamisil
- topical admin, not successful for hair and nails; when ingested, accumulates in hair and nails - WHO lists as ESSENTIAL med for dermatophyte infxn
What is the MOA for Terbinafine?
interferes with ERGOSTEROL biosynthesis
- primary use: dermatophyte infxns (skin/nail)
What are the S/E of Terbinafine?
abdominal discomfort, diarrhea, N / HA
Which systemic anti fungal is reserves as GOLD STANDARD IV for life threatening infxn?
Amphotericin B
- extremely broad spectrum, inexpensive
What is the famous side effect of amphotericin B?
“Shake and Bake”
Toxicity related to infusion: Fever, NVD chills, renal toxicity
What class of anti-fungals is amphotericin B?
polyenes
what is the MOA of amphotericin B?
binds to ergosterols in membrane, forming pores (kills cell)
What is the MOA of azoles?
block formation of ergosterol - fungal static
What is the most used systemic anti-fungal? S/E?
Fluconazole (PO triazole)
- narrow spectrum
- low toxicity; some GI upset
What drug do you need to take caution with when using fluconazole?
Warfarin
CYP450 - increases levels
which organism lacks both a cell wall and membrane; consists of nucleic acids surrounded by protein capsule
viruses
which virus is the MC cause of regular seasonal outbreaks for influenza in all age groups?
orthomyxoviridae
determined by surface antigen subtypes : Hemagglutinin and Neuraminidase
which topical ointment is reserved for HSV and VZV?
Acyclovir
What is the MOA of Acyclovir?
guanosine analog; stops further DNA synthesis
Which anti-viral can cross BBB and be used to tx Herpes Meningitis and Encephalitis? What caution MUST be taken?
Acyclovir IV
- RENAL TOXICITY; MANDATES PROPER HYDRATION
increasing resistance
What biomarkers indicate acute hepatitis?
ALT/AST > 500-1000 U/L
What is the only effective TX for HDV Co-Infection?
Peg-Interferon Alpha (pegasys)
first line tx; cytokine inducing causing specific and non-specific immune responses
monitor CBC and TSH x 3mo
What is the preferred first line therapy for Hepatitis B? Also effective against?
Tenofovir
- also effective against HIV/AIDS
- adjust dose if CrCl is < 50 ml/min
What is the class/MOA for tenofovir?
nucleoside reverse transcriptase inhibitor (NRTI)
HIV nucleoside analog reverse transcriptase inhibitor Anti-HBV reverse transcriptase inhibitor (NRTI)
What is guaranteed after 2-4 years with tenofovir?
resistance
What S/E should be considered with Tenofovir?
Lactic Acidosis
Acute Renal Failure (Nephrotoxicity)
decreased bone mineral density
- Preferred in PREG,
- active against HEP B
What class of anti-virals is Darunavir? And what is the MOA?
HIV Protease Inhibitor (NRTI)
MOA: inhibit protease cleaving of GAG and GAG-POL viral proteins
what are the S/E of darunavir?
hyperlipidemia
hypertriglyceridemia
insulin resistance
- inhibition of CYP450 3A4
generally administered with low-dose ritonavir (prevents breakdown) keeps concentrations higher
what vaccines are recommended for HIV? Live?
Pneumococcal
Flu
HPV
- Never live, esp if CD4 < 200 cells/mm3
Is the live attenuate flu shot recommended in pregnancy?
no
What immunosuppressing biologic is administered subdermally with a MOA of human monoclonal antibody against TNF-alpha?
Adalimumab (Humira)
Which medication class for influenza is no longer recommended due to high rate of resistance?
Adamatanes
- active only against A; but best used for Parkinson’s treatment
what anti-metabolite, purine analog inhibits purine synthesis and DNA replication resulting in apoptosis? What is it used for?
Azathioprine
Use: IBS, Organ Transplant
Azathioprine is a pro-drug, meaning once it’s metabolized it turns into what?
6-mercaptopurine
What is the time of onset for Azathioprine and what adverse effect should be noted?
1-3 month onset
- major interaction: ethanol
what stimulant laxative stimulates peristalsis by direct irritation to the smooth muscle of the intestine?
Bisacodyl (dulcolax)
- stimulates enteric plexus
This drug interacts with oleander increasing the the risk of cardiac glycoside toxicity by depleting K+
Bisacodyl (Dulcolax)
- stimulates enteric plexus
When do you avoid use of Bisacodyl (Dulcolax)?
if there is actual / possible BOWEL OBSTRUCTION
which glucocorticoid is used almost as a topical to the ileum and ascending colon with minimal absorbance and therefore S/E? MOA?
Budesonide
works when pH is > 5.5 by inhibiting leukocytes and fibroblasts and inhibiting capillary permeability to the immune system
DO NOT consume W/GRAPEFRUIT
What is the difference between budesonide and prednisone?
Budesonide has fewer steroid side effects b/c only 9-21% absorbed (significant first pass metabolism)
Common steroid S/E:
- acne
- weight gain
- insomnia
- easy bruising
what is the MOA of Docusate?
reduces surface tension of the oil-water interface in stool acting as a SOFTENER
- sometimes used as cerumolytic
What is the drug of choice for tinea?
Ketoconazole
What is the MOA of keotconazole?
inhibits sterol synthesis
S/E - skin irritation
Which antacid may cause diarrhea and is 20% absorbed systemically?
Magnesium Hydroxide
20% magnesium absorbed
Metoclopramide, commonly used to treat nausea and vomiting, has effects on which receptors?
Dopamine (D2)
Serotonin (5HT4)
Metoclopramide has which adverse event that should be considered at high doses?
dopamine-suppression
extra-pyramidal effects
- used to tx N/V
Which pharmacologic agent is used to control gas?
simethicone
what is the MOA of simethicone and which drug does it interact with?
MOA: silicon polymer acts as a de-foaming agent; reduces surface tension of gas bubbles
levothyroxine - decreases serum concentration of this drug
What is the MOA of tetracycline? Is it bacteriostatic or bactericidal?
inhibits protein synthesis, binds 30s ribosomal subunit
-bacteriostatic
Common Adverse Reaction in Tetracyclines?
Tooth discoloration in children - C/I pregnancy and children
- can be used in renal failure
Overall use has decreased due to resistance
This prostaglandin analog decreases aqueous production and increases aqueous outflow for use in glaucoma, it also has a lower risk of S/E compared to another common glaucoma drug?
Bimatoprost
less S/E than BB; may have local irritation, iris pigmentation
Which drug is MC used to treat Hepatitis C, the MC blood borne dz in the US?
Sofosbuvir-Velpatasvir (Epclusa)
When should you avoid using Sofosbuvir-Velpatasvir (Epclusa)
significant renal dysfunction
This salicylate (class 5-ASA) is used in treatment and prevention of UC/RA flares and it works by decreasing inflammation?
sulfasalazine
What S/E should be known about Sulfasalazine?
Increases effects of Warfarin
decreases effects of BB
This anti-retroviral medication is preferred in pregnancy to inhibit the spread of HIV to the fetus during birth
zidovudine
This anti-retroviral nucleoside analog is used in combination with peg interferon drugs to treat HepC, but comes with severe S/E and interactions
ribavirin
- severe birth defects
- hemolytic anemia*
What does DMARD stand for and which drugs reside in this class? What are they used for?
Disease Modifying Anti-Rheumatic Drug
- Adalimumab (TNF-alpha)
- Azathioprine (inhibit purine synth)
- Sulfasalazine (MOA unclear, decreases inflammation)
IBS, Crohn’s, RA
what are the steps in Viral Replication?
- attachment
- penetration
- un-coating (disassembly)
- transcription and translation
- assembly and release
Which drugs are our anti-viral drugs (6)?
- Acyclovir (HSV, VZV, Herpes Meningitis, Encephalitis)
- Adamatane (was flu, more anti-Parkinsons)
- Darunavir (HIV)
- Sofasbuvir/Velpatasvir (Hep C)
- Tenofovir (Hep B, HIV/AIDS)
- Zidovudine (prevents prenatal HIV transmission)
What is an odd, but maybe, nice adverse reaction to Bimatoprost?
eyelash elongation
the prostaglandin brimatoprost does what for its MOA?
increases outflow of aqueous fluid and decreases production lowering IOP
smooth muscle stimulant
Which two drugs have an interaction with Warfarin, possible increasing it’s effects?
Fluconazole (systemic anti-fungal)
Sulfasalazine (UC/RA)
Which two drugs have an adverse reaction associated with alcohol/ethanol consumption?
metronidazole
azathioprine
Which two antibiotics are effective against MSSA?
Cephalexin (cephalosporin)
Amoxicillin/clavulanic acid
what should be considered for asthma patients with allergy?
omalizumab should be considered for allergic patients
