Exam 4 Flashcards
(156 cards)
1
Q
oral contraceptives decrease risk of…
A
ovarian cancer
colon cancer
endometrial cancer
benign breast disease
ovarian cysts
endometriosis
fibroids
ovulation pain
PMS, PMDD
2
Q
oral contraceptives may improves
A
Acne
Hirsutism
3
Q
What day should po contraceptives be started
A
First day of menses or sunday after first day
4
Q
Education for starting pt on po contraceptive
A
use backup birth control method for first 7 days
5
Q
Reasons to choose progestin only contraceptives, depo-provera, IUD or nexplanon
A
Hx smoking
Over age 35
Abnormal vaginal bleeding
DM with vascular complications
DVT
PE
Ischemic heart disease
Breast cancer
Headache with focal neuro symptoms
6
Q
Who cannot use nexplanon
A
History of hepatic disease or thrombosis
7
Q
OBC choice for endometriosis
A
monophasic continuous therapy
8
Q
OBC choice for post-partum/lactating
A
progesterone only (mini pill)
9
Q
OBC choice for noncompliant patient
A
Depo shot, subdermal implant
10
Q
OBC choice for breakthrough bleeding in first half of cycle
A
High estrogen content in first half of cycle
11
Q
OBC choice for breakthrough bleeding in second half of cycle
A
High progestin content in first half of cycle
12
Q
OBC choice for adolescent, peri-menopausal, post-partum nonlactating, and no medical risks
A
Any OCP <50mcg EE
13
Q
Serious side effects of oral contraceptives
A
Increased risk of:
VTE
MI/Stroke (esp over 35 y/o)
Liver disorders
14
Q
Frequency of depo-provera
A
every 13 weeks. If presenting after 13 week mark, must take pregnancy test first
15
Q
Hormones in depo-provera
A
Progestin only
16
Q
When to start depo-provera
A
Within 5 days after menses
17
Q
Side effects of depo-provera
A
Weight gain, HA, dizziness, nervousness, amenorrhea, irregular bleeding
18
Q
Effect of depo-provera on fertility
A
Slower reversal: 70% of women can conceive within the first year and 90% within the first 2 years. Not best choice if wanting to get pregnant right away after stopping. Discuss family planning before starting.
19
Q
Depo-provera is safer choice for women with….
A
CV disease, stroke, VTE, PVD, and sickle cell disease
20
Q
Efficacy rate of IUD
A
<1% risk of failure
21
Q
Education for IUD
A
Easily reversible
Hormonal (progestin) and non-hormonal options
Maintenance is checking strings after period
Good choice for dysmenorrhea, menorrhagia, and anemia
22
Q
SE of IUD
A
PID
Ectopic pregnany
Uterine perforation
Expulsion
Ovarian cysts
Irregular bleeding
Amenorrhea
Pelvic pain
23
Q
Contraindication of IUD
A
Suspected pregnancy
Uterine abnormalities
PID
Unexplained vaginal bleeding
24
Q
Contraception that has decreased efficacy in pts with high BMI
A
Xulane transdermal patch
-Increased failure rate and risk of VTE in patients with BMI >30 or over 198lbs
25
Best practices for using emergency contraception
1) Use within 5 days of unprotected sex but 3 days in best
2) Perform pregnancy test if no period within 21 days
3) Works by preventing ovulation
26
Drug options for emergency contraception
1) Copper IUD - most effective and offers long term protection up to 10 years
2) Levonorgestral (LNg, Plan B, Julie) -94% or less effective, best within 3 days, less effective for women over 165lbs
3) Ulipristal Acetate (UPA or Ella) - 98% effective, best within 3 days, less effective if over 195 lbs
4) Yuzpe (combo) - less effective, causes N/V
27
First Line Treatment for VVC (yeast infection)
OTC monistat (tioconazole, miconazole, clotrimazole) X 1-7 days
OR
Diflucan (fluconazole) PO 1 time dose
28
Second Line Treatment for VVC
Cultures for recurrent VVC
7-14 days topical
PO Fluconazole q72h x3 doses
29
Third Line Treatment for VVC
Referral
10-14 days topical OR
PO fluconazole maintence therapy 1x a week for 6 months
30
First Line Treatment Trichomonas
Metronidazole or Tinidazole 2g single dose
OR
Metronidazole 500mg BID x 7 days
Must also treat sex partners.
Avoid sex until treatment complete and symptom-free
31
Second Line Treatment Trichomonas
Try alternative 1st line option and refer to a specialist after recurrent failure
32
First Line Treatment Bacterial Vaginosis
PO metronidazole, topical clindamycin cream, metronidazole gel intravaginally
33
Education for treatment of BV
Metronidazole and Tinidazole - can cause n/v if alcohol ingested during treatment or w/in 72 hours after stopping
Avoid tight fitting clothes, allow ventilation, avoid douching or other hygiene products, avoid scented products that may alter pH
Instill vaginal creams and suppositories at bedtime and wear pad or pantyliner
34
Menopause hormone therapy for patient WITH uterus
Systemic estrogen (po or transdermal) PLUS progestin.
Estrogen alone can cause endometrial hyperplasia/cancer
35
Menopause hormone therapy for patient WITHOUT uterus
Estrogen alone
36
Hormone therapy contraindications
Estrogen-dependent neoplasia, thrombophlebitis/thromboembolic disorder, pregnancy, vaginal bleeding, uncontrolled HTN, acute liver disease
37
Monitoring for patients taking hormone therapy
1) Follow up 4-8 weeks after initiation and then every 3-6 months
2) Reevaluate yearly
3) Continue mammograms, Paps, and DEXA scans
4) Height/weight, lipids, BP, breast exam, full pelvic exam
5) stop 1-3 years after menopause
6) stop gradually to reduce rebound symptoms
7) risk of breast cancer if used over 3-5 years
38
Best treatment for vasomotor symptoms of menopause when hormone therapy contraindicated
SSRI
SNRI
Gabapentin
Clonidine
39
SSRIs for VMS
Paxil, Zoloft, Celexa, Lexapro
40
SNRIs for VMS
Effexor, Pristiq
41
Best route of treatment for Genitourinary syndrome of menopause (GSM)
Hormonal: Low dose vaginal estrogen OR transdermal estrogen OR ospemifene
Transdermal and vaginal have lower risk of VTE compared to oral.
Non-hormonal: Vaginal lubricant and moisturizers, continued sexual intercourse
42
Medications used to treat Pelvic Inflammatory Disease
Cephalosporins (ceftriaxone)
Doxycycline
Clindamycin
Gentamycin
Probenecid
Metronidazole
Empiric, broad spectrum coverage of ALL likely pathogens
43
Treatment of mild to moderate Pelvic Inflammatory Disease
Parenteral or PO/IM treatment with cephalosporins, doxycycline, clindamycin, gentamycin, probenecid, or metronidazole
44
Treatment of Severe Pelvic Inflammatory disease
Parenteral therapy with transitioin to PO within 24-48 hours after symptom improvement
45
Treatment of Gonorrhea in patients allergic to Cephalosporins
Gentamycin IM PLUS azithromycin PO
46
Suppressive therapy for Genital Herpes
Acyclovir, Valacyclovir, Famciclovir
Acyclovir has more frequent dosing due to low bioavailability so compliance may be harder
47
Genital herpes treatment for pregnant women
Acyclovir or valacyclovir
48
Treatment of Chlamydia for pregnant patient
Azithromycin 1g PO x 1 dose
Amoxicillin is alternative
Doxycycline is contraindicated in 2nd and 3rd trimester
Retest 3-4 weeks after treatment and again after 3 months to make sure it doesn't pass to child
49
Patient Applied treatment for Genital Warts
Imiquimod (aldara): apply with finger at bedtime for up to 16 weeks. Wash off after 6-10 hours.
Podofilox (Condylox): Apply with cotton swab or gel with finger BIDx3 days, then no therapy for 4 days. Repeat 4 cycles.
Sinecatechins (green tea extract): Apply up to 3x/day for up to 16 weeks. DO NOT wash off.
50
Treatment for Syphilis in pregnant patient with allergy to Penicillin
PCN G is only effective treatment during pregnancy. Must desensitize mom to PCN and treat with PCN G. Allows temporary tolerance.
51
Contraindications of Phosphodiasterase-5 inhibitors
Do not use with Nitrates - causes extreme hypotension
Alpha blockers, angina, hypotension, uncontrolled HTN, recent stroke, arrhythmias, MI w/in 6 months, severe HF, renal failure, liver failure, potent CYP450 inhibitors
52
First Line treatment of erectile dysfunction
Phosphodiasterase-5 Inhibitors:
Cialis
Vardenafil
Sildenafil
Avanafil
53
Considerations for Cialis
Long MOA, avoids need to plan for sex, 30 min onset
54
Consideratons for Vardenafil
60 min onset, decreased absorption with fatty foods
55
Considerations for Sildenafil
Take 30-60 minutes before sex, 3-5hr half life, decreased absorption with fatty foods
56
Considerations for Avanafil
Take 15 min before sex, half life 5-10 hrs
57
Second line treatment for ED
Refer to urologist
58
Complimentary treatment for ED
yohimbine, gingko biloba, ginseng, HCG, l-argine
59
MOA of antimuscarinics
Inhibit binding of acetylcholine at muscarinic receptors M3 on detrusor smooth muscle cells, causing relaxation and increasing bladder filling capacity
60
SE of antimuscarinics
Anticholinergic side effects: Constipation, dry mouth (xerostomia), urinary retention
61
Contraindication of antimuscarinics
Narrow angle glaucoma, urinary retention, other CYP450 drugs
62
Names of Antimuscarinics for overactive bladder
Oxybutynin/Ditropan
Tolterodine/Detrol
Solifenancin/Vesiare
63
First line treatment of uncomplicated UTI
Bactrim x3 days
Nitrofurantoin (Macrobid)
Fosfomycin (Monurol)
Macrobid best choice per text.
NO Bactrim if allergy to Sulfa drugs.
64
Second Line treatment of uncomplicated UTI
Increase Bactrim to 7 days if no allergy.
If Sulfa allergy, use Cipro or Levaquin (fluoroquinolones)
65
Black box warning for fluoroquinolones
Achilles tendon rupture
66
Macrobid considerations
Caution in renal dysfunction. Do not use if creat clearance is less than 30.
Do not use during 1st trimester or last 30 days of pregnancy.
67
Bactrim considerations
Not to be used in sulfa allergy.
Caution with renal dysfunction.
Not used in pregnancy or breastfeeding.
Concerns for resistance and sulfa skin reaction.
68
Third line treatment of uncomplicated UTI
Treat based on culture results.
Keflex, Amox, Augmentin only if susceptible on report
69
Treatmeant of complicated UTI in males, post-menopausal women, patients with catheters
Ciprofloxacin or levafloxacin for at least 10 days
70
Treatment of complicated UTI in pregnant women
NOT fluoroquinolone.
Start with amoxicillin
Keflex
Macrobid and Bactrim but not in the first trimester or last 30 days of pregnancy
71
Treatment of UTI in geriatrics
Often asymptomatic. First s/s altered mental status.
Nitrofurantoin (macrobid) not recommended.
72
Special considerations for treating UTI in pregnancy
Take ALL UTIs seriously, treat even asymptomatic.
30% of UTIs in pregnancy develop pyelonephritis.
Urine culture 1 week after treatment and then every 4-6 weeks.
73
Special considerations for treating UTI in children
UTI can indicate genitourinary abnormality.
Treat quickly to reduce renal scarring in <5 years old.
Kids <3 should have renal US
74
First Line treatment of UTI in children
First Line: Augmentin, cephalexin, cefpodoxime, Bactrim (abcc)
75
Why is treatment required for prostatitis
Because inflammation (presence of pro-inflammatory cytokines) of the prostate can restrict the urinary outflow via the urethra.
S/S lower abdominal pain, difficulty emptying, weak stream, nocturia, fever, malaise, pain on ejaculation, rectal pain if very large
76
First Line therapy for prostatitis
Fluoroquinolones: Cipro or levaquin are best choice
Sulfa (Bactrim) may not be as effective
4-6 weeks up to 12 weeks
77
Second Line therapy for prostatitis
Doxycycline or Azithromycin or Calrithromycin
78
Classes of meds prescribed for BPH
Alpha-Adrenergic Blockers
5-Alpha-Reductase Inhibitor
Combo
PDE-5 Inhibitors
79
Alpha-Adrenergic Blockers MOA
Relax smooth muscle of the prostate and bladder neck to decrease bladder resistance to urinary flow
80
Names of Alpha-Adrenergic Blockers
For BPH
Terazosin
Doxazosin
Tamsulosin
Silodosin
81
Side effects of Alpha-Adrenergic Blockers
Hypotension
Orthostatic hypotension
Fluid retention
HA
Dizziness
Weakness
Drowsiness
82
CI of tamsulosin
contra in prostate CA
83
CI of doxazosin
Avoid in CHF and renal failure
84
CI of silodosin
Contraindicated in hepatic/renal impairment
85
5-Alpha-Reductase Inhibitor MOA
weakens prostate growth by inhibiting the conversion of testosterone to DHT.
pregnant women should NOT handle drug (affects fetus genitals)
86
Names and side effects of 5-Alpha-Reductase inhibitors
Finasteride: Impotence, decreased libido
Dutasteride: Orthostatic hypotension, priapism, risk of prostate ca
87
Combo tamsulosin/dutasteride MOA
complementary mechanisms affect hormonal and smooth muscle pathways, inhibiting enlargement of the prostate and producing muscular relaxation, resulting in a decrease of symptoms
88
PDE-5 Inhibitors Side effects and contraindications
Cialis: Headache, flushing, GI upset. CI with nitrates and alpha blockers. Good for patients who also have erectile dysfunction.
89
Monitoring during BPH treatment
BP during first 2 weeks. Open discussion about sexual health.
AUA symptom score: Over 7 = pharm treatment
<7 lifestyle modification
Monitor for decrease in score after starting treatment. 3-4 point improvement is significant.
Try different agent if side effects occur.
90
First Line Treatment for BPH
AUA 7 or less: watchful waiting
91
Second Line treatment for BPH
AUA >7: Alpha adrenergic blocker OR 5-alpha-reductase inhibitor OR PDE5 inhibitor
92
Third Line treatment BPH
Combo therapy of 5 alpha reductase inhibitor AND alpha blocker
93
Fourth Line treatment BPH
Refer to urology for possible surgical intervention
94
Consideration for Terazosin (BPH)
Somnolence, take at bedtime
95
Risk factors with longer term use of H2RAs (histamine type 2 receptor antagonists) Famotadine and other "dines"
May lead to reduced efficacy or tachyphylaxis and tolerance to the medication. Intermittent use preferred.
96
Risk factors with longer term use of PPI (prazole)
Can cause hypergastrinemia, fractures with osteoporosis, GI infections (cdiff and bacterial gastroenteritis) vitamin B12 deficiency, hypomagnesemia. High dose >1 year= osteoporosis/fracture
97
Treatment regimen for NSAID induced PUD
1) Test for H pylori and treat if present
2) D/C NSAID and give alternative pain med
3) Use enteric coated NSAIDs, take with meals, add misoprostol
4) Switch to selective COX-2 inhibitor
98
First Line treatment for NSAID induced PUD
PPI, Histamine 2 Receptor Antagonists (H2RA), sucralfate (if NSAID can be dc'd)
99
Treatment for PUD if NSAID cannot be dc'd
Treat with PPI x8 weeks with NSAID (or misoprostol)
100
Treatment for PUD if NSAID can be dc'd
Treat with PPI for 4 weeks
101
Misoprostol contraindication
Pregnancy
102
Side effects of Tums, Mag salts, and aluminum salts
Rebound hyperacidity
Diarrhea (with mag containing)
Constipation (aluminum containing)
Nausea
Stomach pain
Chalky taste
Hypercalcemia
103
Considerations for antacids
No contraindications
Take 1-4 hours after taking iron, sulfonylureas, tetracyclines, and quinolones
Do not heal ulcers, only provide symptom relief
104
First Line treatment for nausea/vomiting
Phenothiazine (promethazine, prochlorperazine) for mild/mod
105
Second Line treatment for nausea/vomiting
Antihistamine/anticholinergic (hydroxyzine/atarax, meclizine/bonin) useful for mild n/v
106
Third line treatment for nausea/vomiting
re-evaluate cause, eliminate insulting agent
107
How to manage motion sickness
Hydroxyzine (vistaril, atarax)
Meclizine (bonine, antivert)
Dramamine
Scopolamine
108
Antimotility agents for diarrhea
Lomotil
Loperamide
109
Lomotil MOA
Decrease GI motility
110
Loperamide MOA
Opioid receptor agonist, acts on myenteric plexus of the large intenstine
111
Contraindications of antimotility agents
Infectious diarrhea.
Don't use with fevers, bloody diarrhea, fecal leukocytes.
Caution in hepatic dysfunction.
112
Side effects of Antimotility agents
Constipation, drowsiness, blurry vision, lomotil can increase risk of HTN if used with MAOIs
113
MOA Adsorbents
Kaopectate
Binds to diarrhea and toxins to solidify stool. Add a dose after each BM
114
MOA Absorbents
Fibercon
Absorbs H2O in the GI tract to make stool less watery
115
Best treatment for travelers diarrhea
Rifaximin
116
Use of antidiarrheals in pediatrics
Oral rehydration in priority. Agents are not recommended in children 1 months to 5 years.
Lomotil not for children under 4
117
Atypical antidiarrheal antisecretory agent
subsalicylate (pepto bismol, kaopectate)
118
SUbsalicylate MOA
not well understood, Anti-inflammatory, antacid, antibacterial properties
119
Subsalicylate contraindications
Hypersensitivity to ASA (breaks down into salicylate)
Not used in kids with flu or chicken pox - ASA induced Reye Syndrome
120
Subsalicylate side effects
Black stool, dark tongue, tinnitus.
May interact with warfarin
121
Indications for laxative use
Attempt lifestyle modifications first (diet, exercise, bowel training).
Eliminate secondary cause if possible.
Then add pharmacologic therapy.
122
Goal of laxative therapy
Increase water content of the feces and increase motility of the intestines using the lowest dose of a laxative for the least amount of time.
123
Types of drugs that increase gastric motility
Stimulant laxatives (bisacodyl, sennakot)
Saline laxatives (mag citrate, mag hydroxide, mag sulfate, sodium phosphate, sodium biphosphate)
Bulk forming laxatives (metamucil, citrucel)
Hyperosmolar laxatives (lactulose, sorbitol, miralax)
124
Antimotility agent
Imodium - decreases GI motility
125
MOA stimulant laxatives
Bisacodyl, sennakot
increase peristalsis, effects smooth muscle of intenstines
126
MOA saline laxatives
Mag citrate, mag hydroxide, mag sulfate, sodium phosphate, sodium biphosphate
Draw water into the intestines through osmosis - increase intraluminal pressure - increase intestinal motility
127
MOA Bulk forming laxatives
Metamucil, citrucel
Bind to the fecal contents and pull water into the stool - stimulates movement of the intestines
128
MOA hyperosmolar laxatives
Lactulose, sorbitol, miralax
Osmotic pressure by drawing fluid from less concentrated gradient to a more concentrated gradient - increased osmotic pressure - stimulates intestinal motility
129
First line constipation treatment
Bulk-forming laxative: Metamucil, citrucel
130
Second line constipation treatment
Mag hydroxide, saline laxative
131
Third line constipation treatment
Stimulant laxative: bisacodyl, sennakot
132
Length of use for OTC laxatives
OTC not to be used for more than 7 days in a row
133
Enema contraindication
CI in children under 2 years old
134
Gastric motility management in pregnancy
Docusate is safe. Avoid castor oil.
135
Geriatric considerations with gastric motility management
Bowel obsessed
Risk of electrolyte imbalances with laxative use
Eliminate causative agents (antipsychotics, TCAs, Ca)
136
Effect of IBD on pregnancy
increased rates of abortions, stillbirths, and developmental defects with active disease.
Treat aggressively to prevent dehydration, anemia, nutritional deficiency
137
Azathioprine during pregnancy
Controversial, if absolutely necessary to limit pancytopenia in the fetus, dose of 2mg/kg/d or less
138
IBD meds contraindicated during pregnancy and lactation
Methotrexate - may cause spontaneous abortion and teratogenicity
Caution with all TNF-alpha inhibitors, inadequate human data
139
IBD meds contraindicated during nursing
Azathioprine and mecaptopurine: potential of fetal immunosuppression
140
IBD med used for severe refractory cases
Cyclosporine - can cause growth retardation
141
Considerations for sulfasalazine
Women taking it should be given higher doses of folate (2mg/d) because sulfasalazine interferes with folate absorption
142
Counseling for IBD in pregnancy
Give attention to maintaining body weight before conception and preventing exacerbations during pregnancy. Preconception counseling should discuss the condition, lifestyle changes, nutritional issues, and treatment options
143
Aminosalicylates MOA
Azulfidine/sulfasalazine, mesalamine/asacol
Decrease inflammation in the GI tract by inhibiting PG synthesis.
Quick onset, 1 week
144
Corticosteroids MOA
Prednisone, methylpred, hydrocortisone, dexamethasone, budesonide.
Immunosuppression and PG inhibition if aminosalicylates fail
145
Immunosuppressive agent MOA
Imuran/azathioprine, puriethnol/6-mercaptopurine, rheumatrex/methotrexate.
Decrease production of various inflammatory mediators
146
Antibiotics forUC and CD MOA
Flagyl, Cipro.
Link between IBD and infectious cause. Abx that act against gram neg and mycobacterial organisms with low SE profile
147
Biologics: TNF Inhibitors MOA
Remicade/infliximab, humira/adalimumab, cimzia.
Overexpression of immunologic cytokines including TNF seen in CD - TNF inhibitors neutralize soluble forms of TNF and inhibit its binding to TNF
148
Biologics: Selective Adhesion Molecule Inhibitors MOA
Tysabri/natalizumab, entyvio/vedolizumab.
Prevent migration of inflammatory lymphocytes into the gut mucosa
149
Ulcerative colitis mild disease treatment
PO and Rectal aminosalicylates (combo therapy)
150
Ulcerative colitis moderate disease treatment
add corticosteroid to PO and Rectal aminosalicylates
151
Ulcerative colitis severe disease treatment
Hospitalization, d/c oral and topical agents, add corticosteroids.
If no improvement in 7-10 days:
IV cyclosporin
IV iremicade
Humira
IV entyvio
152
Crohn's Disease Mild treatment
Oral/rectal aminosalycylates OR rectal corticosteroid
153
Crohn's Disease Moderate treatment
PO AND Rectal aminosalycylate AND short-term steroids
154
Crohn's Disease Severe treatment
IV corticosteroid and/or IV cyclosporine, IV remicade, SQ humira, and supportive care (ivf, bowel rest, tpn)
155
Agent to treat hepatic encephalopathy
1) Lactulose oral and rectal
2) Add rifaximin
3) Add Miralax
156
ROME III criteria for IBS
Criteria met for 3 months with onset 6 months prior.
Recurrent abdominal pain at least 3 days/month associated with 2 of following:
Improvement with defecation
Onset associated with change in frequency of stool
Onset associated with change in form of stool
