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PHRM864 > Exam 4 > Flashcards

Exam 4 Flashcards

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1
Q

What parts of the GI tract are affected by ulcerative colitis?

A

rectum and colon

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2
Q

Does smoking have a protective effect in ulcerative colitis or Crohn’s disease?

A

ulcerative colitis

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3
Q

What drug classes may trigger disease flares in IBD?

A

NSAIDs and antibiotics

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4
Q

What drug class should generally be avoided in patients with IBD?

A

NSAIDs

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5
Q

Is enteral or parenteral nutrition used as nonpharmacologic therapy for IBD?

A

enteral nutrition

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6
Q

What are ADRs of sulfasalazine?

A

-N/V
-HA
-anorexia
-rash
-anemia
-hepatotoxicity
-thrombocytopenia
-hypersensitivity reactions (sulfonamide allergy)

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7
Q

What are monitoring parameters for sulfasalazine?

A

-CBC and LFTs at baseline, QOW for 3 months, QM for 3 months, then periodically
-BUN/SCr periodically

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8
Q

What are drug interactions with sulfasalazine?

A

-antiplatelets
-anticoagulants
-NSAIDs

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9
Q

Do sulfasalazines or mesalamines have more ADRs?

A

sulfasalazines

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10
Q

What are the formulations of mesalamine?

A

-topical (enema)
-suppository
-oral

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11
Q

For what type of ulcerative colitis are topical formulations of mesalamine used for?

A

left-sided disease

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12
Q

For what type of ulcerative colitis are suppository formulations of mesalamine used for?

A

proctitis

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13
Q

What is the specific dosage form of oral formulations of mesalamine?

A

delayed/controlled release

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14
Q

What are ADRs of mesalamine?

A

-N/V
-HA

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15
Q

What are drug interactions with mesalamine?

A

-antiplatelets
-anticoagulants
-NSAIDs
-agents affecting gastric pH

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16
Q

What is the indication of corticosteroids for use in IBD?

A

induction of remission

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17
Q

What are ADRs of systemic corticosteroids?

A

-hypocalcemia
-hypovitaminosis D

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18
Q

What are monitoring parameters for systemic corticosteroids?

A

occasional bone mineral density scans

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19
Q

What patients taking corticosteroids for IBD should be receiving occasional bone mineral density scans?

A

->60 y/o
-risk of osteoporosis
-using steroids for >3 months
-recurrent steroid user

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20
Q

What is a benefit of budesonide based on its mechanism of action?

A

minimal systemic exposure due to extensive first pass metabolism

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21
Q

Is azathioprine or mercaptopurine a prodrug?

A

azathioprine

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22
Q

What are the indications of azathioprine and mercaptopurine for use in IBD?

A

-fail ASA and/or refractory to/dependent on steroids
-maintenance of remission

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23
Q

What are ADRs of azathioprine and mercaptopurine?

A

-N/V
-diarrhea
-anorexia
-stomatitis
-bone marrow suppression
-hepatotoxicity
-fever
-rash
-arthralgia
-pancreatitis

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24
Q

What are the monitoring parameters for azathioprine and mercaptopurine?

A

-TPMT at baseline
-CBC and LFTs at baseline, QW for 1 month, Q1-2W after dose change, Q1-3M

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25
What are the indications of cyclosporine for use in IBD?
-induction of remission for refractory UC -refractory to/dependent on steroids
26
What are ADRs of cyclosporine?
-nephrotoxicity -neurotoxicity -HTN -HLD -hyperglycemia -GI upset -gingival hyperplasia -hirutism
27
What are the monitoring parameters for cyclosporine?
-BP at baseline, every visit -BUN/SCr at baseline, Q2W until stable, periodically -LFTs at baseline, Q2W until stable, periodically -cyanuric acid trough concentration baseline
28
What type of substrate is cyclosporine?
CYP3A and P-glycoprotein substrate
29
What is the indication of methotrexate for use in IBD?
induction of remission for CD
30
What are ADRs of methotrexate?
-bone marrow suppression -N/V -diarrhea -stomatitis -mucositis -cirrhosis -hepatitis -fibrosis -hypersensitivity pneumonitis -rash -urticaria -alopecia
31
What are monitoring parameters for methotrexate?
-chest X-ray at baseline -CBC, SCr, LFTs at baseline, Q4-8W
32
What are contraindications for methotrexate?
-pregnancy -pleural effusions -chronic liver disease/alcohol abuse -immunodeficiency -preexisting blood dyscrasias -leukopenia/thrombocytopenia -CrCl < 40 mL/min
33
What are the TNF-α inhibitor ADRs?
-increased risk of serious infections -injection site reactions (SQ) and infusion related reactions (IV) -risk of malignancy -hepatosplenic T-cell lymphoma (HSTCL) risk -risk of demyelinating disease -may exacerbate CHF -development of anti-drug antibodies
34
When should TNF-α inhibitors be avoided?
active infection
35
What monitoring parameters in regards to infections should be measured before treatment initiation?
-PPD skin test for TB -chest X-ray -hepatitis B and C
36
What is a good recommendation for TNF-α inhibitors?
ensure vaccinations are up to date
37
What is contraindicated during TNF-α inhibitor therapy?
live vaccines during treatment and for three months after
38
What patients are contraindicated for TNF-α inhibitor therapy?
-cancer -demyelinating CNS disease -optic neuritis -NYHA Class III/IV HF
39
What are baseline monitoring parameters for TNF-α inhibitors?
-chest X-ray -PPD skin test for TB -s/s of infection -urinalysis -CBC -SCr -electrolytes -LFTs -hepatitis B and C
40
What baseline monitoring parameters are different from the maintenance for TNF-α inhibitors?
-chest X-ray -PPD skin test for TB -hepatitis B and C
41
What maintenance monitoring parameter is different from the baseline for TNF-α inhibitors?
inflammatory markers
42
How often should monitoring occur for TNF-α inhibitors?
Q8-12W
43
What are the indications for infliximab?
-moderate to severe active CD and UC -induction and maintenance therapy
44
What is the route of administration for infliximab?
IV
45
What drugs can be used concomitantly with infliximab for increased efficacy?
immunosuppressives
46
When is there an increased HSTCL risk for infliximab?
co-administeration with azathioprine
47
What are monitoring parameters specific to infliximab?
-vitals -infusion reactions
48
What are the indications for adalimumab?
-moderate to severe active CD and UC -induction and maintenance therapy
49
What is the route of administration for adalimumab?
SQ
50
What are the indications for golimumab?
-moderate to severe active UC -induction and maintenance therapy
51
What is the route of administration for golimumab?
SQ
52
What are the indications for certolizumab pegol?
-moderate to severe active CD -induction and maintenance therapy
53
What is the route of administration for golimumab?
SQ
54
What TNF-α inhibitor has the highest risk of developing ADAs?
infliximab
55
What are the TNF-α inhibitor drugs?
-infliximab -adalimumab -certolizumab pegol -golimumab
56
What is the mechanism of action of natalizumab?
anti-α subunit of integrins
57
What are the indications for natalizumab?
-CD -induction and maintenance of therapy
58
What drugs can natalizumab not be used with?
-immunosuppressants -TNF-α inhibitors
59
What is the route of administration for natalizumab?
IV
60
When should natalizumab be discontinued in patients?
-no benefit by 12 weeks (3 cycles) and/or -steroid-dependent within 6 months
61
What is an ADR associated with natalizumab?
PML
62
What causes an increased risk of PML with natalizumab use?
-longer duration of therapy (> 2 years) -prior immunosuppressant use -JC antibody positive
63
What is the mechanism of action of vedolizumab?
anti-α4β77 integrin antibody
64
What are the indications for vedolizumab?
-CD and UC -induction and maintenance therapy
65
What is the route of administration for vedolizumab?
IV
66
What is the mechanism of action of ustekinumab?
IL-12 and IL-23 antagonist
67
What are the indications for ustekinumab?
-CD and UC -induction and maintenance therapy
68
What is the route of administration for ustekinumab?
SQ
69
What is the mechanism of action of risankizumab-rzaa?
selective IL-23 antagonist
70
What are the indications for risankizumab-rzaa?
-moderate to severe active CD and UC -induction and maintenance therapy
71
What are the routes of administration for risankizumab-rzaa?
IV and SQ
72
What are common ADRs of risankizumab-rzaa?
-headache -nasopharyngitis -arthralgia -abdominal pain -anemia -nausea
73
What are ADRs associated with risankizumab-rzaa?
-potential hepatotoxicity -increase in lipids
74
What are baseline monitoring parameters for risankizumab-rzaa and mirikizumab-mrkz?
-chest X-ray -PPD skin test for TB -hepatitis B and C -lipids -LFTs -renal function -s/s of infection
75
What is the mechanism of action of mirikizumab-mrkz?
IL-23p19 antagonist
76
What are the indications for mirikizumab-mrkz?
-moderate to severe active UC -induction and maintenance therapy
77
What are the routes of administration for mirikizumab-mrkz?
IV and SQ
78
What are common ADRs of mirikizumab-mrkz?
-headache -arthralgia -rash -injection site reaction
79
What is an ADR associated with mirikizumab-mrkz?
potential hepatotoxicity
80
What criteria need to be confirmed to determine that an IBD patient is at treatment failure?
-inflammation -exclude infection and noncompliance to treatment -serum drug therapeutic and ADA levels
81
What type of treatment failure is a combination of subtherapeutic drug levels and detectable ADAs?
immune mediated pharmacokinetic failure
82
What is the next step of therapy for immune mediated pharmacokinetic failure?
change to alternate drug within the same class +/- immunomodulator
83
What type of treatment failure is a combination of subtherapeutic drug levels and undetectable ADAs?
non-immune mediated pharmacokinetic failure
84
What is the next step of therapy for non-immune mediated pharmacokinetic failure?
increase dose
85
What type of treatment failure is a combination of therapeutic drug levels and detectable ADAs?
false positive or mechanistic failure
86
What is the next step of therapy for a false positive?
repeat TDM levels
87
What type of treatment failure is a combination of therapeutic drug levels and undetectable ADAs?
mechanistic failure
88
What is the next step of therapy for mechanistic failure?
switch to different biologic class agent
89
What are the other biologic drugs?
-natalizumab -vedolizumab -ustekinumab -risankizumab-rzaa -mirikizumab-mrkz
90
What is the mechanism of action of tofacitinib?
JAK inhibitor
91
What is the route of administration for tofacitinib?
oral
92
What is the indication for tofacitinib?
UC
93
What are the clinical pearls for tofacitinib and upadacitinib?
-rapid onset -should NOT be used with immunosuppressants or biologics -short half-life -eliminated via hepatic metabolism and renal excretion
94
How much should the dose of tofacitinib be decreased by for moderate/severe renal impairment or moderate hepatic impairment?
50%
95
When should tofacitinib be avoided?
-severe hepatic impairment -strong CYP3A inducer
96
What are the drug interactions for tofacitinib?
-moderate or strong CYP3A inhibitor with strong CYP2C19 inhibitor -strong CYP3A inducer
97
How much should the dose of tofacitinib be decreased by for use of moderate or strong CYP3A inhibitors with a strong CYP2C19 inhibitor?
50%
98
What are common ADRs of tofacitinib?
-diarrhea -elevated cholesterol -headache -shingles -increased creatine phosphokinase -nasopharyngitis -rash -URI
99
What are rare ADRs of tofacitinib?
-malignancy -serious infection -neutropenia -hypersensitivity
100
What is the black box warning for tofacitinib and upadacitinib?
-increased mortality in RA pts ≥ 50 y/o with at least one CV risk factor -thrombosis
101
What are baseline monitoring parameters for tofacitinib?
-chest X-ray -PPD skin test for TB -hepatitis B and C -ANC -CBC -lipids -LFTs -infection -skin exam
102
What is the mechanism of action of upadacitinib?
selective JAK1 inhibitor
103
What is the route of administration for upadacitinib?
oral
104
What are the indications for upadacitinib?
CD and UC
105
When are dose adjustments for upadacitinib required?
-renal impairment -mild to moderate hepatic impairment
106
When is upadacitinib not recommended?
-ESRD -severe hepatic impairment -strong CYP3A inducer
107
What are the drug interactions for upadacitinib?
-strong CYP3A inhibitor -strong CYP3A inducer
108
What are common ADRs of upadacitinib?
-URI -acne -increased creatine phosphokinase -elevated cholesterol -headache -shingles
109
What are rare ADRs of upadacitinib?
-malignancy -serious infection -increase in LFTs -anemia -neutropenia -lymphopenia -hypersensitivity -tetratogenicity
110
What is another baseline monitoring parameter for upadacitinib in addition to tofacitinib?
ALC
111
What is the mechanism of action of ozanimod?
selective sphingosine-1-phosphate (S1P) receptor modulator
112
What is the route of administration for ozanimod?
oral
113
What is the indication for ozanimod?
moderate to severe active UC
114
What are the contraindications for ozanimod?
-patients experiencing the following in the last six months: MI, unstable angina, stroke, TIA, decompensated HF requiring hospitalization, class III/IV HF -Mobitz type II 2nd or 3rd degree AV block, sick sinus syndrome, or SA block unless patient has functioning pacemaker -severe untreated sleep apnea -MAO inhibitor
115
What is ozanimod metabolized by?
-ALDH/ADH -CYP3A4
116
What are the ADRs of ozanimod and estrasimod?
-increased risk of infection -bradycardia/AV conduction delays -liver injury/elevated transaminases -moderate increase in SBP -respiratory effects -macular edema -reversible posterior leukoencephalopathy syndrome (RPLS)/posterior reversible encephalopathy syndrome (PRES)
117
What are the drug interactions with ozanimod?
-adrenergic and serotonergic drugs -combination BB and CCB -foods high in tyramine -MAO inhibitors -strong CYP2C8 inhibitors -strong CYP2C8 inducers
118
What are the baseline monitoring parameters for ozanimod and estrasimod?
-chest X-ray -PPD skin test for TB -hepatitis B and C -CBC -LFTs -infection -BP -spirometry -ECG -eye exam
119
What monitoring parameters for ozanimod and estrasimod are only measured at baseline?
-chest X-ray -PPD skin test for TB -hepatitis B and C -ECG
120
What is the mechanism of action of estrasimod?
selective sphingosine-1-phosphate (S1P) receptor modulator
121
What is the route of administration for estrasimod?
oral
122
What is the indication for estrasimod?
moderate to severe active UC
123
What are the contraindications for estrasimod?
-patients experiencing the following in the last six months: MI, unstable angina, stroke, TIA, decompensated HF requiring hospitalization, class III/IV HF -various cardiac conduction abnormalities
124
What is estrasimod metabolized by?
-CYP2C8 -CYP2C9 -CYP3A4
125
What are the new small molecule drugs?
-tofacitinib -upadacitinib -ozanimod -estrasimod
126
What are the antimicrobial drugs?
-ciprofloxacin -metronidazole -rifamycin antibiotics
127
What is the indication of antimicrobials for use in IBD?
adjunctive therapy for treatment of complications
128
What are the ADRs of antimicrobials?
-agent-specific ADRs -resistance -C. diff
129
What objective markers are only affected by acute liver injury?
-AST -ALT -alkaline phosphatase
130
How is AST affected by acute liver injury?
increased
131
How is ALT affected by acute liver injury?
increased
132
How is alkaline phosphatase affected by acute liver injury?
increased
133
How is bilirubin affected by acute liver injury and chronic liver disease?
increased
134
How is albumin affected by chronic liver disease?
decreased
135
How is INR affected by chronic liver disease?
increased
136
How is thrombocytopenia affected by chronic liver disease?
decreased
137
What are the classifications of drug-induced liver injury?
-direct hepatotoxicity -idiosyncratic hepatotoxicity -indirect hepatotoxicity
138
What are high-risk medications for drug-induced liver injury?
-acetaminophen -anti-infectives
139
What dose of acetaminophen is considered a high dose?
≥ 8 g
140
What are the signs and symptoms of acetaminophen overdose?
-abdominal pain -jaundice -N/V -diarrhea
141
When should activated charcoal be administered for acetaminophen overdose?
within 1-2 hours of ingestion
142
When should NAC be administered for acetaminophen overdose?
≥ 4 hours after ingestion
143
For the Rumack-Matthew Nomogram, which side of the line indicates treatment with NAC?
right
144
What formulation of NAC is preferred for acetaminophen overdose?
oral
145
What are the monitoring parameters for NAC?
-liver enzymes Q12-24H -s/s of acute liver injury
146
What class of drugs should be avoided with cirrhosis?
NSAIDs
147
What are causative factors of cirrhosis?
-chronic alcohol use -viral hepatitis -metabolic liver disease -cholestatic liver disease -drugs
148
What are the signs and symptoms of cirrhosis?
-pruritus -fatigue -weight loss -ascites -jaundice -hepatomegaly or splenomegaly -encephalopathy
149
What are the assessment tools for severity of cirrhosis?
-Child-Pugh -Model for End Stage Liver Disease (MELD)
150
What are the signs and symptoms of ascites?
-abdominal distention -abdominal pain -SOB -nausea
151
What are nonpharmacological treatments for management of ascites?
-sodium restriction (< 2 g/day) -assessment for liver transplant
152
What is the first-line treatment for ascites?
spironolactone and furosemide
153
What is the second-line treatment for ascites?
-paracentesis -TIPS
154
What is the initial dose of spironolactone/furosemide?
100 mg/40 mg
155
How often should spironolactone/furosemide be titrated?
every 3-5 days
156
What is the maximum dose of spironolactone/furosmide?
400 mg/160 mg
157
Is spironolactone or furosemide preferred if choosing monotherapy?
spironolactone
158
What are side effects of spironolactone?
-AKI -hyperkalemia -gynecomastia
159
What are side effects of furosemide?
-AKI -hypokalemia
160
What are the monitoring parameters of diuretics for the treatment of ascites?
-s/s of ascites -SCr -potassium
161
When should albumin be administered in the case of paracentesis?
> 5 L removed
162
What is the dose of albumin for ascites?
25% albumin IV
163
What is the dosing of albumin for ascites?
6-8 g of albumin/liter removed
164
What are the risk factors for esophageal varices?
-varices size -cirrhosis severity -red color markings on endoscopy -active alcohol use
165
What are the treatment options for variceal bleeding prophylaxis?
-NSBB -EVL
166
Which NSBBs are used for esophageal varices?
-nadolol -propranolol -carvedilol
167
How often should NSBBs be titrated for esophageal varices?
every 3 days until goal achieved
168
What are the side effects of NSBBs?
-drowsiness or insomnia -bradycardia -hypotension
169
What is the target HR when taking NSBBs?
55 to 60 bpm
170
What is the target SBP when taking NSBBs?
> 90 mm Hg
171
What drugs should not be used to treat esophageal varices?
-PPIs -vitamin K
172
What is the initial treatment for variceal bleeding acute management?
-blood transfusion -octreotide -antibiotic prophylaxis
173
What type of drug is octreotide?
vasoconstrictor
174
How long should octreotide be used for?
2 to 5 days
175
What are the side effects of octreotide?
-N/V -HTN -bradycardia -hyperglycemia
176
What are the monitoring parameters of octreotide?
-s/s of N/V -BP -HR -BG
177
What antibiotics should be used in liver disease?
third generation cephalosporins
178
What is a side effect of third generation cephalosporins?
diarrhea
179
What is a monitoring parameter of third generation cephalosporins?
s/s of infection
180
What is the maximum duration of use for antibiotic prophylaxis?
7 days
181
When should an EVL be performed?
within 12 hours of presentation
182
What are the treatments for secondary prophylaxis of variceal bleeding?
-EVL every 1 to 4 weeks -NSBBs indefinitely until decompensation
183
What are the signs and symptoms of hepatic encephalopathy?
-jaundice -delirium -convulsions -coma
184
What are the objective markers of hepatic encephalopathy?
-EEG -evoked potentials
185
What is the first-line treatment for hepatic encephalopathy?
lactulose 25 mL BID
186
What is the diagnostic level of polymorphonuclear (PMN) leukocytes for spontaneous bacterial peritonitis?
≥ 250 cells/mm^3
187
What is the duration of use of third generation cephalosporins for treatment of spontaneous bacterial peritonitis?
5 to 7 days
188
What is the dosing of albumin for day 1 of spontaneous bacterial peritonitis?
1.5 g/kg for one dose
189
What is the dosing of albumin for day 3 of spontaneous bacterial peritonitis?
1 g/kg for one dose
190
How soon should albumin be administered after diagnosis of spontaneous bacterial peritonitis?
within 6 hours
191
What drugs are used for secondary prophylaxis of spontaneous bacterial peritonitis?
-sulfamethoxazole/trimethoprim -ciprofloxacin
192
What are the monitoring parameters for sulfamethoxazole/trimethoprim?
-SCr -electrolytes -CBC
193
What are the monitoring parameters for ciprofloxacin?
-mental status -CBC -renal function
194
How long should secondary prophylaxis be used for spontaneous bacterial peritonitis?
indefinitely
195
What is the dosing frequency of secondary prophylaxis for spontaneous bacterial peritonitis?
QD
196
What are the two types of stroke?
-ischemic -hemorrhagic
197
What are the two types of ischemic stroke?
-atherosclerotic -cardioembolic
198
What are the modifiable risk factors for stroke?
-CVD -diabetes -HLD -HTN -illicit drug/alcohol abuse -obesity/physical inactivity -cigarette smoking
199
What is the clinical presentation of stroke?
-dysphagia -facial droop -unilateral or bilateral weakness -ataxia -vision changes -headache
200
What are the imaging diagnostic criteria for stroke?
-head CT -MRI
201
What are the vital signs diagnostic criteria for stroke?
-BP -oxygen saturation
202
What are the labs diagnostic criteria for stroke?
-BG -BMP -CBC -INR -aPTT
203
What is the test diagnostic criteria for stroke?
-ECG
204
When should hyperglycemia in a patient experiencing stroke be treated with an insulin drip?
acidosis
205
How often should BP be checked in patients experiencing stroke?
-Q15 minutes for 2 hours -Q30 minutes for 6 hours -Q1H for 16 hours
206
What is the BP goal for the first 48 hours for a patient experiencing ischemic stroke with no tPA administration?
< 220/110 mm Hg
207
What is the BP goal for the first 48 hours for a patient experiencing ischemic stroke with tPA administration?
< 180/105 mm Hg
208
When should the BP goal be lowered to the outpatient goal in a patient experiencing stroke?
after 48 hours
209
What type of agents should treat hypertension in a patient experiencing stroke for the first 48 hours of admission?
parenteral
210
What is the maximum dose of alteplase in stroke patients?
90 mg
211
What is the maximum dose of tenecteplase in stroke patients?
25 mg
212
Is alteplase or tenecteplase administered as an infusion?
alteplase
213
When should antiplatelets and anticoagulants be avoided?
24 hours after administration of thrombolytics
214
What type of stroke should thrombolytics be used for?
ischemic
215
What are the inclusion criteria for use of thrombolytics in ischemic stroke patients?
-ischemic stroke -symptom onset ≤ 4.5 hours -age ≥ 18 y/o
216
What is the first-line treatment for acute management of ischemic stroke?
aspirin
217
How long should high-dose aspirin be administered for ischemic stroke patients?
2 to 4 weeks
218
What are the monitoring parameters for antiplatelets?
-s/s of bleeding -stroke
219
When should aspirin and clopidogrel be used for ischemic stroke?
minor strokes (NIHSS ≤ 4)
220
When should ticagrelor and aspirin be used for ischemic stroke?
minor strokes (NIHSS ≤ 5)
221
What antiplatelets require loading doses?
-aspirin -ticagrelor
222
What is the protocol for an admitted stroke patient on an anticoagulant?
D/C and start aspirin
223
When should an anticoagulant be initiated for stroke patients?
≥ 2 to 14 days after stroke
224
What is the antidote for warfarin?
IV vitamin K
225
What is the antidote for heparin products?
protamine
226
What is the antidote for dabigatran?
idarucizumab
227
What is the antidote for other DOACs?
recombinant coagulation factor Xa
228
What is the BP goal for the first 24 hours for a patient experiencing hemorrhagic stroke?
< 180/110 mm Hg
229
What is the BP goal after 24 hours for a patient experiencing hemorrhagic stroke?
< 160/90 mm Hg
230
What is the BP goal after 48 hours for a patient experiencing hemorrhagic stroke?
< 140/90 mm Hg or < 130/80 mm Hg
231
What type of stroke is prevention of vasospasm indicated for?
subarachnoid hemorrhagic stroke
232
What is the treatment for prevention of vasospasm?
nimodipine 60 mg PO Q4H for 21 days after stroke
233
Are anticonvulsants indicated for stroke patients?
no
234
What are the first-line treatments for secondary stroke prevention antiplatelet therapy?
-aspirin -dipyridamole/aspirin
235
What is the second-line treatment for secondary stroke prevention antiplatelet therapy?
clopidogrel
236
What is a first-line treatment for secondary stroke prevention antiplatelet therapy of minor stroke?
clopidogrel
237
What is a second-line treatment for secondary stroke prevention antiplatelet therapy of moderate to severe stroke?
clopidogrel

PHRM864 (6 decks)

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