Exam 5 last one ever Flashcards
(107 cards)
1
Q
NIHSS
Score?
A
High score worst
5 or greater you start looking to use a fibrolytic agent.
2
Q
What are some indications that a pt would need higher immunosuppression?
What are some other things you want to take into account when looking at a donor recipient?
A
- Younger in age
- Black
- HLA matching gives you a indication of how its going to go after transplant
- If there PRA is high
- cross matching
3
Q
Infectious Dx prophylaxis
Typicall a ___ drug regimen
What are the drugs and the length of time needed to be on it?
A
- CMV: Valgan in high/mod risk, acyclovir in low risk for 3-6 mos
- PCP: Bactrim or (dapsone/pentamidine for sulfa allergic pts) for 3 mos- 1 year
- Oral candidiasis: Nystatin swish and swallow or clotrimazole for 1-3 mos or until prednisone dose if low <20 mg daily
- Lung transplant patients usually get addition fungal prophylaxis
4
Q
A pts only exclusion criteria is there BP so that means its? What are the first options you should try to use?
A
- >185/110
- Labetalol
- Enalaprit
- Hydrazaline
- IV fast acting options
5
Q
IVIG
Uses in SOT 4
A
- Antibody Bcell mediated rejection
- Desensitization
- Viral infections
- Hypogammaglobulinemia
6
Q
What is the preferred antimetabolite?
What is it MOA?
A
- Mycophenolate
- Inhibits IMDPH which inhibits cell cyle replication
7
Q
Dosing for Atgam?
A
10-15 mg/kg/day
for 7-10 days
8
Q
If pt is on IR tacrolimus 2 mg BID how would you convert them to Envarsus XR?
A
- Once daily dose 70-80% of total IR dose
- So 3 mg daily would work
9
Q
What is the Number one cause of death after any transplant
A
Cardiovascular Dx
10
Q
mTOR inhibitors two
notes about them?
A
- Sirolimus
- Everolimus
- One or other not both
- Used in place of calcineurin inhibitors or anti-metabolite
11
Q
Dibigatran
A
WIthin 2 houts activated charcoal
Idarubaccizumab first line
second like PCC4
12
Q
What are the 9 exclusion criteria for Alteplase
A
- Current intracranial Hemorrhage
- Bleeding diathesis
- Active internal bleeding
- Recent intracranial hemorrhage or intraspinal surgery or serious head trauma (<=3 mos)
- Current severe uncontrolled HTN (SBP>= 185 mm hg or DBP >= 110) (can treat and then try)
- Subarachnoid hemorrhage
- Intracranial process that may increase bleeding risk
- Actively on warfarin with INR > 1.7 or other oral anticoag (pretty much automatically exclude these pts if theyre on one)
- Suspected aortic arch dissection
13
Q
Hemorrhagic Stroke
Risk factors Modifiable and non
A
- HTN, smoking, alcohol use, DM, anticoag/antiplat use(most common cause)
- Nonmod: Cerebral amyloid angiopathy, asian
14
Q
Common induction regimen?
A
- INDUCTiON
- Thymo or basiliximab
- Plus high dose corticosteroids
- MAINTENANCE
- Tacro and mycophenolate with or without prednisone
15
Q
Post stroke care management
What should be administered? 1st and 2nd line
What should be initiated or resumed?
Smoking Cessation
A
- Antiplat started immediately unless alteplase is administered
- 1st ASA 325 PO daily
- 2nd- Clopidogrel 300 mg 1 then clopidogrel 75 mg PO daily
- Used for ASA allergic pts. Or ASA failure
- High intensity statin should be inititiated or resumed
- Atorvastatin 80
- Smoking cessation
16
Q
Adverse effects of Corticosteroids?
5
A
- Elevated WBC w higher doses (this can mask the picture if looking for infection)
- Wt gain 2/2 fluid retention and increased appetite
- Mood changes
- Insomnia
17
Q
CNIs vs mTORs
Advantage to chose CNIs?
A
- Reduced hypercholesterolemia
- Less impaired wound healing
18
Q
2 types of CMV
A
- Infection
Invasive: CMV that actually causes organ damage CMV induced colitis most common
19
Q
Tacrolimus dosing information
What is more potent? Cyclo or Tacro?
What is the dosing interval?
What are the ranges?
What levels are monitored? what is the range?
IV?
A
- 50 x more potent than cyclo
- BID q12h, XR-XL are qd
- 0.5->10mg BID
- Get a 12 hour trough to monitor levels
- 5-15 ng/mL
- IV isnt a 1:1
20
Q
If you think someone had a stroke what studies need to be given prior to giving ____ drug
A
Alteplase
- Non-contrast CT-this will also rule out hemorrage
- Finger stick blood glucose hypoglycemia can mimic
- Oxygen sat hypoxia can mimic
21
Q
mTOR AEs
A
- Slow wound healing
- Increased protein in urine (stop drug it stops)
- Increased cholesterol and TGs(realy)
- Myelosuppression
- Pulmonary toxicity (sirolimus only)
22
Q
Drug interactions with FK/Cyclo
Whats the way and the 8 drugs that increase level?
A
- Antifungal azoles
- Erythromycin, Clarithromycin, Azithromycin
- Lopinavir/Ritonavir
- Diltiazem and verapamil
- CYP3A4 inhibitors
23
Q
Clinical presentation for Hemorrhage usually take longer and symptoms are more drawn out.
A
24
Q
IV admin of Alteplase
Dose?
If these 5 things develp stop infusiong and get CT
What to monitor?
What Bp range do we want to maintain and how?
What repeat testing? Before starting what?
A
- 0.9 mg/kg max 90 mg first 10% given as a bolus over one minute then rest over 60 min
- Severe HA, N/V, acute HTN, worsening neuro exam Dc alteplase and get CT scan
- Monitor BP
- <180, <105 use anti HTNs to maintain
- Follow up CT or MRI, scan at 24 hour after IV atleplase before starting anticoagulant therapt
25
What are the risk factors for infection?
6
* Technical/Surgical comp
* Most commonly occur during 1st month
* Net state of immunosuppression
* Use of Antilyphocyte prep
* Comorbidities
* REcipient exposure
* Donor organ
* Nosocomial
* Community
26
Adverse effects and Administration of Rituximab
8 AEs
Admin?
* Fever, chills, nausea, dizziness, hypotension, bronchospasms, hypoxia, cytopenias
* Premedicate:APAP, Antihistamines, corticosteroids
27
Sirolimus what is it?
Dose? and when?
What levels need to be taken and when? what is the range?
Important to note when making dose adjustments?
* 2-5 mg per day in the AM
* 24 hour trough before taking, 5-15 ng/mL
* Need to wait 1-2 weeks before adjusting dose (biggest downfall)
28
Adverse effects of Mycophenolate and how to alleviate them?
Teratogenicity?
* N/V/D can lead to colitis
* Take with food
* Preg Cat D black box for teratogenicity dont take when pregnant, not recommended in breast feeding
* Use contraception for at least 6 weeks before trying to conceive
29
Who would you use Acyclovir on and why?
Dosing?
* Low risk patient because it only covers HSV not CMV
* Dose adjustement for renal dysfunction
30
Thymo rabbit one
Dose and length
Adjust in?
What is its place in therapy?
1.5 mg/kg/day for 3-5 doses
Polyclonal depleting
- Induces depletion of cells from circulation
Adjust dose if leuko/thrombocytopenia
* Induction in pts with high immune risk pt and those at increased risk of delayed graft function
* For rejection
31
What are the immediate release formualtions of Tacrolimus?
What is the dosing interval?
* Generic Tacro and Prograf, you can switch between the two no problem
* BID every 12 hours
32
Cardiovascular Risks
First one: what drugs are causing it?
* HTN: caused by CNIs and Roids
* ACEI/ARB still the best choice might have to wait if doing a renal transplant.
* CCB cna be good not verap or dilt
33
What are the two extended release formulations of Tacro? how are they dosed?
* Astagraf XL
* Envarsus XR
* Both taken onces daily in the morning
34
rATG Adverse effects?
1. Cytokine release syndrome which causes fever and chill
2. Infection (higher than basilix)
3. Leukopenia
4. Malignancy
5. Thrombocytopenia
35
WHat medications need to be given premedication prior to taking them? What are the meds?
* Atgam
* Thymo
* APAP/Diphenhydramine/steroids (prednisone methylprednisolone) or something similar
36
What is the clinical presentatin of a acute ischemic stroke?
* Sudden numbness or weakness in Face, arms, speech, trunk
* Visual impairment
* Dizziness, loss of balance, HA
37
rATG
Positive points 4
Less immunogenic
FEwer rejection episodes within 1 year
Less recurrent rejection
Higher rates of rejection reversal
38
IVIG AEs
Dose adjustements?
* Infusion rxn premedication
* Renal insufficiency: only sucrose free preps should be used
* BBwaring risk of acute renal failure
* Carimune NF cantains sucrose all others dont
39
Di FK/CYA
Drugs that decrease levels? 6
* Nafcillin
* Rifampin
* Efavirenz
* Carbamazepine
* Phenytoin
* Phenobarbital
* CYP 3A4 inducers
40
Basaliximab AEs
Infection and Malignancy
Infection is higher in rATG
41
3-4.5 hours since symptom onset
5 things for inclusion criteria for Alteplase
* ischemic stroke with neuro deficit
* \>= 18 \<=80 w/o history of DM and prior stroke
* NIHSS score \<=25
* Without imaging evidence of ischemic injury involving \> 1/3 of MCA territory
42
Whats a situation where you would switch someone from prograf to CYA?
* The big thing with Tacro (also hair loss) is neuronal effects so it can cause bad shaking and if thats the case you could switch to CYA (hairgrowth) but over all FK is better.
43
If pts bp is \>180-230 or \>105-120
Treat with?
Labetolol infusion dont fuck around!
44
Treating Bp and you might need longer or more controll what two drugs?
* Nicardipine
* Clevidipine
45
Calcineurin Inhibitors
What are the two?
MOA?
What are the brand names? of each?
* Cyclosporine, CSA, Sandimmune, Neoral, Gengraf
* Tacrolimus- Prograf, Envarsus, Astagraf XL
* Tacro is more common cant be on both at the same time
* Inhibits calcineurin which suppresses T cell activation by inhibiting **signal 3**
46
If you use this medication instead of the newer one you made the wrong mothafuckin choice
Atgam older shitier version of thymo
47
Fusion protein?
Betacept only one thats IV
48
If pt is on IR tacrolimus 2 mg BID how would you convert them to Astagraf XL?
Are Astagraf and Envarsus interchangable?
* It is a 1:1 conversion with daily dose
* So you would give them Astagraf XL 4 mg in the morning
* NO they are different
49
Side effects of Tacro and CYA?
* FK
* Hair loss
* Post transplant DM (both)
* HTN(both)
* Hyper lipids (both)
* Hypomagnesemia (**both but more here)**
* Hypophas (**both but more here)**
* Hyperkal (**both but more here)**
* **Both very nephrotoxic**
* **More neurotox here (tremor, cns)**
* **CYA- Hair growth**
50
For the most part depending on what the pt looks like you can still go ahead and do a SOT but what is the exception where you will not do it?
+ cross match
51
If pts only need prophylaxis for Candidiasis what 2 drugs can they get?
Nystatin
or
Clotrimazole (inhibit CYP3A4)
52
Sirolimus vs Everolimus
* Siro
* Longer t 1/2 harder for dose adjustment usually a week
* More issues with wound healing
* Once daily dosing
* Ever
* Shorter t1/2 usually BID but as once daily
* Can make dose adjustments earlier
53
What is the reason for the acid form of mycophenolate?
* Formulated because Gi effects from mefetil were so bad they needed to make a formulation that didnt need to be activated in the stomach.
54
MOA of mTORs
Bind to FK bind protein and inhibit cell cycle replication
55
When do trough levels need to be taken for FK/CYA?
Before the morning dose has been taken
56
The two things we can try and change so we can give alteplase are HTN and blood glucose what are the ranges we want for glucose?
If hyperglycemic treat with?
Hypo?
140-180
Insulin 5-10 units followed by infusion
Hypo- D50W x 1 repeat blood glucose level 15 minutes after tx
57
Risk factors for Hyperactute rejection?
* ABO incompatable
* High PRA (preg,blood tranfusion, previous transplant)
* + cross match
*
58
Precautions when giving alteplase
Glucose levels?
current malignancy and expected to live for?
Something within the last something
9 things total
* \<50 or \>400- usually treat
* Current malignancy and life expectancy is less than 6 months dont treat
* Ischemic stroke in the last 3 months
* Major surgery or trauma within last 14 days
* Recent GI/GU bleed
* \>77
* Acute pericarditis or left heart thrombus
* end stage renal dx with elevated aPTT
* Pregnant
59
Treatment for B cell (antibody) mediated rejection
Rituximab, IVIG
60
Other DI with FK/CYA
what do you need to tell the patient? What med is fine to use?
* Statins-inform the pt and monitor for myopathies dont need to stop therapy but need to watch
* Pravastatin doesnt have this interaction so its preferred
61
Tx Anticoag reversal
Drugs?
INR goal?
Vit K
First line 4-factor PCC + Vit K 5-10 mg IV
25 INR 2
50 units \>6
\<=1.4
62
Which drug needs dose adjustments for pts with leukopenia/thrombocytopenia?
Antithymocyte globulin
Both of them
63
Transplant pts cant use?!
NSAIDs
64
What would be the advantage of taking Azathioprine over Mycophenolate?
* LEss GI
* Pts with like colitis or some shit
* Otherwise myco is better
65
What is the dose range of Cyclosporine?
* 25 BID- \>400 mg BID
66
Everolimus newer one
Dosed?
Trough range and when? Dose adjustments?
* 0.75 BID q 12 h
* 12 hour trough
* Range 3-12 ng/mL
* Wait a week to adjust dose
* Not equiv to affinitor
67
What are the two antimetabolites?
What is there place in therapy which one is preferred?
* Azathioprine
* Mycophenolate (newer)
* Maintenance
68
2 types of CMV prevention
* Pre-emptive: Arent using drugs just monitoring
* Once virus is detected you treat
* Prophylaxis
* Consider coverage for most CMV and herpes
69
DIs with the mTORs
* Decrease levels CYP3A4
* Azole antifung
* Erythromycin, clarithromycin, azithromycin
* Verapamil, Diltiazem
* Cyclosporine
* Increase levels
* Carbamazepine
* Nafcillin
* Rifampin
* Efavirenz
* Phenytoin
* Phenobarb
70
What is the conversion between Mycophenolate Mofetil (MMF) and Mycophenolate Acid (MPA)
What is the dose range?
What is the usual dose?
* 500 mg MMF= 360 mg MPA
* 250-1500 BID q 12 h
* 1,000 mg every 12 hours
71
Primary prophylaxis for CMV?
What is in?
What dose and for how long?
* Valganciclovir- prodrug
* 450-900 qday for 3-6 mos
* AE
* Neutropenia, anemia, GI disturbances
72
Rituximab uses in SOT? 3
* B cell (antibody) mediated rejection
* desenitization regimens (pre-transplant)
* Post transplant lymphoproliferative disorders
73
Oral Direct Xa `Reversal
Rivaroxaban, apixaban, edoxaban
Try to give a bunch of different factor to over ride MOA
If within two hours of taking Anti coag and give charcoal
4-PCC
74
CMV
What puts you at high risk, moderate and low risk?
* D+/R-
* D-/R+
* D-/R-
*
75
What does Rituximab do?
Depletes Bcells
76
mTOR inhibitors? 2
Sirolimus and Everolimus
77
Inclusion Criteria for Alteplase
0-3 hours since symptom onset
* Diagnosis of Ischemic stroke causing measurable neurologic effects
* Age \>= 18 G t G
78
Ganciclovir
WHen?
IV form used rarely seen all drugs cause penias
requires dosage adjustment in renal
Rarely used
79
Managment of BP during and after alteplase therapy when its =\<180/105?
* Monitor bp every 15 minutes for 2 hours after alteplase therapy then q 30 min for 6 hours, then every hour for 16 hours
80
Azathioprine
Dose?
What is the preparation?
AEs? 6
DI?
MOA?
* 50-150 mg qday
* Only comes in 50 mg tablets
1. Leukopenia, Thrombocytopenia, anemia
2. Skin cancer
3. Pancreatitis, lymphoma (rare)
DI
* Xanthine Oxidase inhibitors (allopurinol)
* Increases the concentrations of Azathio and dose reduction is needed
* Sulfasalazine- Inhibit TPMT
Converted into 6-MP and prevents cell cycle replication
81
Treatment for Ischemic Stroke
* Time is brain tissue
* Perform detail pt hx
* _______ assessment within ___ min on ED arrival. Completion of what?
* ____ of the head ___ min of ED arrival to rule out?
* What should be given within 60 minutes?
* Neurologic within 25 minutes NIHSS
* CT scan within 45 minutes to rule out hemorrhage
* IV TPA / Alteplase need to be given within 60 minutes
82
What are the two calcineurin inhibitors? Which one is preferred and what is their place in therapy?
Tacrolimus (preferred), Cyclosporine
Used for maintenance
83
What blood levels are drawn for Cyclosporine?
* 12 hour trough levels with a range of 75-300 ng/mL
84
PCP and PJP Prophylaxis
What drug? What forms? for how long? Dosage adjustments? AEs? 2
* 3-12 months
* SMX/TMP
* DS 800/160 mg
* 1 tab once daily 3 days per week
* SS 400/80 1 tab once daily
* Rash, Sun sensitivity
* Renal dysfunction reduce dose
85
What is the dose and administration of thymo?
* Infusion given over 4-6 hours via central line
* Need a 0.22 micron filter
* 1.5 mg/kg/day for 3-5 DOSES
* Pts also need to be premedicated; APAP, diphenhydramine, steroids
86
How long will pts be on antirejection therapy?
What is a pearl of this?
* Pts will be on this forever and its important for them to be adherent and not miss dose
* If a patient is like super sick then you could possibly hold it for a few days.
87
Hyperlipidemia Cardiovascular risk in SOT
Culprits? 5
Tx? What is preferred
Monitor?
What reduces absorption
* Sirolimus, Everolimus, Cyclosporine, Tacrolimus, Steriod
* Statin therapy:pravastatin is preferred
* Monitor liver function tests
* Bile acid sequestrants
88
Basiliximab
What type of antibody?
MOA:?
What is its indication?
Dose?
Administration?
* Chimeric (70% human 30% Murine) monoclonal antibody
* Binds to CD25 (this is alpha subunit of IL2 receptor on surface of activated T cells) Inhibiting IL-2 mediated effects
* **Used for induction only not used for the tx of rejection**
* 20 mg IV on post op day 0 and post op day 4
* SHort infusion time
* Can be given peripherally
## Footnote
**Also known as a Non-depleting IL2 receptor antagonist**
89
Which type of stroke has highest risk of mortality?
* Brain stem
* Loss of respiratory stimulation, heart function, temp reg, ability to chew or swallow
90
Corticosteroids
Methylprednisolone (IV)
Prednisone Oral
91
What are the risk factors for pts to have a higher PRA?
* Pregnancy
* blood transfusion
* previous transplant
92
What acute rejection is harder to treat?
What are the two types?
* Antibody/HUmoral
93
Primary ICH most common basically dont know what it is
Secondary: Something we can take out
94
Corticosteroids
Whos gonna be on roids?
What is the most common agent?
What are the doses and when?
Following transplant what will people do?
What are the maintenance doses?
* Some will be on some wont
* Prednisone
* 5 mg daily - 60 mg daily qAM for insomnia
* Many pts will be on taper
* Maintenance doses are usually \<10 mg daily
95
NODAT
Culprit?
tx?
5
* Tacrolimus B-cell tox, Steroids (insulin resistance)
* Immunosuppression changes: Antidiabetic agents may require dose adjustments as immunosuppression changes
* Insulin is the best 40% of pts are on it
* Glipizide is preferred due to liver metabolism but mostly avoided due to renal and risk of hypoglycemia
* Metformin Monitor renal
* DDPT4 renal function
96
Mycophenolate
Administration
DIs?
* Do not cut crush or chew either
* DI
* Pantoprazole not clinically significant
* Cyclosporine- youll have to increase the dose of MMF if you are taking both
97
Prothrombin Complex Concentrates?
* 4-factor PCC Kcentra II,VII, IX, X and proteins C and S
* If they have an allergy to heparin then you need to use FEIBA
98
If someone has had a TIA Transient Ischemic Attach what is the give away?
* No Radiographic evidence of infarct or tissue damage
99
Fresh frozen plasma
SLow admin and large volume
PCC\>FFP
100
What brand name cannot be interchanged with any of the other products?
* Sandimmune (non-modified version) cannot be interchanged no equivalent has erradic absorption
* Neoral, Gengraf
101
If you have an IV formulation of cyclosporine and want to switch them to oral what is the conversion?
IDK but its not 1:1
102
What is another drug for PCP/PJP prophylaxis? What do you need to test for?
Dapsone
G6PD testing- if defficient pt at risk for methemoglobinemia
103
Anticholinergic antidote
What is the indication?
Pts with agitated delirium and no significant QRs QT prolongation.
104
Tx for I and II
PCN allerrgy?
MRSA?
Duration
* Cefazolin
* Clinda
* Vanco
* 24 hours
105
III open fracture with no gross contamination Tx
* Ceftriaxone
* Allergy Clinda + metro
* Add vanc for MRSA
* 48 hours or 24 hours after wound healing
106
LEthal triad
* Hypoxia
* Hypothermia
* Acidosis
107
