Final Exam Flashcards by Nicole Gaudreau

Gent and tobra dose

7 mg/kg

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Amikacin dose

15 mg/kg

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When to draw AG peak

0.25 - 1 hour after 1 hour infusion

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When to draw AG trough

30 minutes or less before the next dose

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When to draw random AG

If drawn after 1st dose, should be at least one 1/2 life from the peak concentration
If drawing after dialysis, wait at least 2 hours for redistribution to take place before drawing a concentration

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When to draw Vanc peak

At least 1-2 hours after the end of infusion

Avoids distributional phase which may result in erroneous calculations

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When to draw Vanc trough

Less than 1 hour before next dose

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When to draw Vanc random

At least one anticipated t1/2 from previous level obtained

To ensure accuracy in calculating elimination rate constant

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What causes AG-induced nephrotoxicity

When the trough is too high

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When does AG-induced nephrotoxicity occur

w/in 4-5 days

High risk associated w/long duration

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Is AG-induced nephrotoxicity reversible?

Yes

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AG-induced RF

other disease states, age, other nephrotoxic drugs

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What happens to the urine production in AG-induced nephrotoxicity?

Non-oliguric

Will still be producing urine

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What factors increase AG Vd

Ascites/pancreatitis
Cancer
CF
Intensive caare
Post-op/mechanical ventilation
Post partum
Surgery

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What factors increase AG CL?

Burns
CF
Fever
HD/PD

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What factors decrease AG half-life?

Burns
CF
HD/PD

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What is oral vanc used for

Pseudomembraneous colitis

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Are IM vanc injections considered?

No d/t severe pain

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Vanc distribution

Widely into body tissues

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What type of compartment model is used for Vanc?

1, 2 is most realistic

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Vanc metabolism

Little to none

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Vanc IV excretion

80-100% recovered in urine in first 24 hours in normal adults

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Vanc in HD/PD

minimally removed

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Vanc pts with increased clearance

Obese
Pediatrics
Burn pts

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CAPD

Peritoneal dialysis Moves along a fluid gradient Less efficient than HD Drugs can be added to PD

GFR in pts on CAPD

10-20

CAVH/CVVH

continuous renal replacement | Removes larger molecules than any other types of dialysis

GFR in pts on CAVH/CVVH

Concentration dependent abx

Amount of microbial killing depends on the max concentration of drug above the MIC

Concentration dependent abx PK/PD parameters

Peak MIC

Concentration dependent abx examples

AGs FQs Daptomycin Metronidazole

Time dependent abx

Amount of microbial killing depends on the time the drug stays above the MIC

Time dependent abx PK/PD parameters

T > MIC

Time dependent abx examples

``` Beta-lactams Macrolides Clindamycin Vanc Linezolid ```

Post-abx effect

Continued expression of bacterial growth after a short exposure to abx agents

Drugs that increase risk of nephrotoxicity w/CSA/TAC

AGs Amphotericin B Vanc NSAIDs

Enzyme inducers and immunosuppressants

Prospectively increase CSA/TAC/EVR daily dose by 25% | Monitor CSA/TAC/EVR trough levels 4-7 days after initiation

Conversion of PO TAC to IV TAC

IC TAC is 1/3 dose of PO dose

Harvoni and Epclusa are not recommended with

Amiodarone Rifampin, St. John's wort Carbamazepine, phenytoin, phenobarb, oxcarbazepine Rosuvastatin (Harvoni only)

Viekiera is C/I with

Carbamazepine, phenytoin, phenobarb Rifampin, St John's wort Lovastatin, simvastatin Sildenafil

Zepatier is C/I with

Carbamazepine, Phenytoin Rifampin St. John's wort CsA

Zepatier is not recommended with

3A4 inducers: nafcillin | 3A4 inhibitors: ketoconazole, cobi

EFV/NVP + rifampin PK result and recommendation

decreased EFV/NVP | Increase EFV dose

EFV/NVP + statins PK result and recommendation

Decreased statins | Monitor cholesterol closely

RPV + PPIs PK result and recommendation

Decreased RPV | Avoid PPIs

ETV + unboosted PIs PK results

decreased PIs

ETV + warfarin PK result and recommendation

Increased warfarin | Monitor INR carefully

PI + rifampin PK result

Decreased PI, increased rifampin

PI + St John's Wort Pk result

Decreased PI

PI + (midaz/triaz)/ergot/statin/pimozide

Increased second drug

PI contraindicated with

``` Rifampin Midaz/triaz Lova/simva ergot St John Wort Pimozide ```

ATV + PPI PK result and recommendation

Decreased ATV Max omep 20 mg/day Always boost

PI + amiodarone PK result and recommendation

Increase amiodarone Avoid if possible TDM

PI + trazodone PK result and recommendation

Increased trazodone | Use lowest dose

PI + immunosuppressants PK result and recommendation

Increased immunosuppressants | TDM

PI + statins PK result and recommendation

Increased statins | Prava/atorv preferred

PIs + fluticasone

Increased fluticasone | Use alternative inhaled/nasal glucocorticoid

RAL + rifampin PK result and recommendation

Decreased RAL | Double RAL dose

RAL + phenytoin/phenobarb PK result and recommendation

Potential decreased RAL | Use caution

DTG + dofetilide PK result and recommendation

Increased dofetilide | C/I

DTG + rifampin

decreased DTG | Increase DTG

DTG + cations

Decreased DTG | Take DTG 2hrs before or 6 hours after cations

Amiodarone level

0.5-2 mg/ml | Peak level at 3-7 hours

Amiodarone MOA

Class III antiarrhythmic | Has properties of all classes

Amiodarone absorption

Very slow | 50-70%

Amiodarone distribution

Mainly to lipophilic tissues | Tissue concentration 10-400x higher

Amiodarone compartment model

Amiodarone major metabolism site

Liver | 3A4

Amiodarone active metabolite

Desmthylamiodarone

Amiodarone DDI by cyp enzymes

``` Warfarin - decrease dose by 25% Digoxin - decrease dose by 50% HMG-CoA reductase inhibitors Phenytoin - increase phenytoin by 50% Grapefruit juice may increase oral absorption - separate by 2 hours ```

Amiodarone DDI by AV node conduction

NDH CCB BB Dig

Amiodarone elimination

Biliary

Adjustment of theophylline dosing based on ss concentration

For every 1 mg/kg of theophylline, blood concentrations will rise 2 mg/L

Factors affecting drug absorption in the elderly

``` CV CNS Renal GU Endocrine GI Musculoskeletal Immunology/hematology ```

Absorption changes associated with aging

Intestinal permeability Gastric acid secretion GI motility Transdermal/IM

Distribution changes associated with aging

Protein binding | Body fat and body water

Metabolism changes associated with aging

40% reduction of blood flow to the liver and reduction in liver mass Phase 1 metabolism reduction

Elimination changes associated with aging

Kidney mass decreases | Physiologic changes

The aged kidney has...

Decreased ability to maximally concentrate or dilute urine Decreased response to inadequate dietary daily Impaired handling of potassium

Final Exam Flashcards

(79 cards)