Internal Medicine Floors Caveats Flashcards
(45 cards)
Naltrexone and acamprosate… Alcohol use disorder and liver disease
Naltrexone and acamprosate are both medications used to treat alcohol use disorder (AUD), but the key caveat for liver disease is that acamprosate is generally preferred over naltrexone because it is primarily metabolized by the kidneys, not the liver, making it safer for individuals with liver damage; while naltrexone should be used with caution in patients with severe liver disease due to potential hepatotoxicity (liver damage) concerns.
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Naltrexone - has GI effects, ONCE DAILY DOSING starting at 50mg …then if stable on it can increase to 100mg QD after a week
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Acamprostate - TID dosing
IV famotidine in renal dysfunction
Yes, famotidine intravenous can be used in patients with renal dysfunction, but dosage adjustments are necessary based on the degree of renal impairment.
Famotidine is primarily excreted by the kidneys, and its clearance is significantly reduced in patients with renal insufficiency. The U.S. Food and Drug Administration (FDA) recommends dosage adjustments for patients with moderate to severe renal impairment (creatinine clearance less than 60 mL/min) to avoid potential adverse effects, such as central nervous system (CNS) reactions and QT prolongation.[1]
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For patients with moderate renal impairment (creatinine clearance 30-60 mL/min), the maximum recommended dosage is 20 mg once daily or 40 mg every other day. For those with severe renal impairment (creatinine clearance less than 30 mL/min), the recommended dosage is 20 mg every other day.[1]
Rough workflow for SBM
- Look at unverified orders in Med Mang.
- Quick triage = anything we need to take care of now? (vanco labs coming back?, levels? electrolytes, vitals, INR? bleeding overnight?) then round
- Deep triage
- After rounds you can start working on Adhoc notes/ MPTL + documentations
- Look at other patients on servers to address everything
- Make sure to check med mang. thruout the day!
- Check insulin at 4PM
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NOTE: MAke sure to check for renal adjustments, DDI, IV -> PO
abx for gram negative bacteremia
CAP: Outpatient Treatment (Previously Healthy, No Risk Factors for Drug-Resistant Pathogens)
First-line Regimen (Macrolide):
Azithromycin 500 mg PO once, then 250 mg PO daily for 4 days
Clarithromycin 500 mg PO twice daily for 7-10 days
Alternatively: Doxycycline 100 mg PO twice daily for 7-10 days
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Alternative (For Risk of Penicillin-resistant S. pneumoniae or Comorbidities):
Amoxicillin 1 g PO three times daily + Azithromycin 500 mg PO once daily for 5-7 days
Or Doxycycline (for penicillin allergy) with alternative agents as needed
CAP: Outpatient Treatment (With Comorbidities or Risk of Drug-Resistant Pathogens)
First-line Regimen (Beta-lactam + Macrolide):
Amoxicillin-Clavulanate 875 mg/125 mg PO twice daily OR Cefuroxime 500 mg PO twice daily + Azithromycin 500 mg PO once daily for 5-7 days
Doxycycline can be an alternative to azithromycin
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Alternative (Respiratory Fluoroquinolone):
Levofloxacin 750 mg PO daily for 5-7 days
Moxifloxacin 400 mg PO daily for 5-7 days
CAP: Inpatient Treatment (Non-Severe CAP)
First-line Regimen (Beta-lactam + Macrolide):
Ceftriaxone 1-2 g IV daily + Azithromycin 500 mg IV daily
Alternatively: Cefotaxime 1-2 g IV every 8 hours + Azithromycin 500 mg IV daily
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Alternative (Respiratory Fluoroquinolone):
Levofloxacin 750 mg IV daily
Moxifloxacin 400 mg IV daily
CAP: Inpatient Treatment (Severe CAP, ICU)
Empiric Regimen (Beta-lactam + Macrolide or Fluoroquinolone):
Ceftriaxone 1-2 g IV every 24 hours OR Cefotaxime 1-2 g IV every 8 hours + Azithromycin 500 mg IV daily
Levofloxacin 750 mg IV daily or Moxifloxacin 400 mg IV daily may be substituted for the macrolide
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If Concern for Pseudomonas or MRSA:
Piperacillin-Tazobactam 4.5 g IV every 6 hours + Levofloxacin 750 mg IV daily
Or Cefepime 2 g IV every 8 hours + Levofloxacin 750 mg IV daily
Add Vancomycin or Linezolid for MRSA coverage
Aspiration Pneumonia
Amoxicillin-Clavulanate 875 mg/125 mg PO twice daily for 7-10 days
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Clindamycin 600 mg IV every 8 hours or Metronidazole 500 mg IV every 8 hours + Amoxicillin 1 g PO every 8 hours for 7-10 days
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For aspiration pneumonia, the additional microbial coverage required includes:
* Anaerobes: Commonly found in the oral cavity and gastrointestinal tract.
HF vs. Cirrhosis (ascites) diuresis - Pathophys
- Heart Failure (HF) and Diuresis:
In heart failure, the heart’s inability to pump blood efficiently leads to fluid buildup in the body. The primary issue in HF is impaired cardiac output, which leads to renal hypoperfusion. The kidneys respond by activating the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS), which ultimately increase sodium and water retention in an attempt to improve circulation. However, this exacerbates fluid overload, leading to symptoms like edema and pulmonary congestion.
Diuresis in HF: The goal of diuretic therapy in heart failure is to reduce the fluid overload, improve symptoms, and optimize cardiac function. Loop diuretics (e.g., furosemide, bumetanide, torsemide) are commonly used as they are potent and work directly at the loop of Henle to block sodium reabsorption and increase urine output.
Challenges: In HF, renal hypoperfusion can make the kidneys less responsive to diuretics. In addition, fluid retention may be exacerbated by the activation of RAAS and SNS. Diuretic resistance can develop, requiring higher doses or combination therapies to achieve adequate fluid removal.
- Ascites and Diuresis:
Ascites is primarily a complication of liver disease (e.g., cirrhosis), where increased portal hypertension leads to fluid accumulation in the peritoneal cavity. The liver’s impaired ability to produce albumin causes hypoalbuminemia, which reduces the effective circulating volume and promotes fluid leakage into the abdomen. In response to this, the body activates RAAS and SNS, similarly to HF, which promotes sodium and water retention, leading to ascitic fluid buildup.
Diuresis in Ascites: The goal of diuretic therapy in ascites is to balance fluid removal without causing electrolyte disturbances, especially in the setting of hypoalbuminemia. Diuretics used in ascites are typically spironolactone (a potassium-sparing diuretic) combined with furosemide (a loop diuretic). Spironolactone is particularly important as it blocks the effects of aldosterone, a key mediator of fluid retention in liver disease.
Challenges: Ascitic fluid tends to be more gradual in accumulation compared to the rapid fluid shifts seen in heart failure. In addition, because albumin is low, the body has a reduced ability to draw fluid back into the vascular space, so diuretics may be less effective compared to HF. Moreover, the balance between sodium retention and potassium loss is crucial in ascites, requiring careful monitoring to avoid hypokalemia or hyponatremia.
Why Diuresis is Not the Same:
Pathophysiology:
In HF, the problem is primarily cardiac dysfunction, which affects the kidneys indirectly through poor perfusion and increased fluid retention.
In ascites, the issue is liver dysfunction leading to portal hypertension and hypoalbuminemia, which affects the fluid distribution and the body’s ability to retain or remove sodium effectively.
Kidney Response:
In HF, despite renal hypoperfusion, diuretics can still be effective, but resistance often develops, necessitating higher or combined doses.
In ascites, the diuretic response is often slower and less robust, as the liver’s inability to produce sufficient albumin hampers the ability to remove fluid from the peritoneal cavity.
Electrolyte Imbalance:
In HF, electrolyte disturbances (especially hypokalemia and hyponatremia) can occur due to the use of loop diuretics, but the kidney usually maintains some compensatory function.
In ascites, diuretics like spironolactone help to prevent hypokalemia, but the combined use with furosemide requires careful monitoring of sodium and potassium levels due to the complex interplay of liver function, kidney response, and diuretic action.
HF vs Ascites Diuresis regimen
Diuretic Regimen for HF vs. Ascites
1. Heart Failure Regimen:
First-line therapy (acute exacerbation of HF):
Furosemide 20-40 mg IV (initial dose)
Adjust dose based on clinical response and urine output, typically up to 80-160 mg IV in severe cases.
Chronic management:
Furosemide 40-160 mg PO daily (or higher if needed)
Monitor for electrolyte imbalances, renal function, and fluid status.
Combination therapy:
Spironolactone 25-50 mg PO daily (if aldosterone antagonism is needed for refractory symptoms).
2. Ascites Regimen:
First-line therapy:
Spironolactone 100 mg PO daily
Furosemide 40 mg PO daily
Ratio of 100 mg spironolactone to 40 mg furosemide is commonly used to balance sodium retention and potassium loss. (can also do Spirno 50mg + Furo 20mg)
Adjustment:
Gradually titrate doses based on clinical response (e.g., urine output, reduction in abdominal girth).
In cases of resistant ascites, doses may be increased or a more aggressive diuretic regimen may be used, but careful monitoring is necessary.
Monitoring:
Watch for electrolyte disturbances, especially hyponatremia and hypokalemia.
Paracentesis may be required if ascites does not respond to diuretics or if there is discomfort or respiratory compromise from fluid accumulation.
When replenishing calcium..look at ionized calcium cuz thats more accurate
Less than 1? then can replenish
Tips for working up patients
- Read hand off notes…anything urgent to adress ? like new INR, animoglycoside levels, vanco level
- check vitals noting - BP, temp (are they afebrile?), O2 requirements
- Look CHEM7 and CBC note anything out of order/ look at trends - are they stable? or is this something that happened recently?
- Other labs - look at BUN, Scr, Glucose, anion gap? Liver func/ renal func — if messed up need to renally dose stuff!
- Look at radiology…any new bleed/ clots/ etc
- Look at Microbiology, any bugs? are they on atibiotics?
- Look at anticoag? treatment vs ppx?
- MAR Summary - what are they on? is it appropriate ?
- CLinical notes - why are they here, what are the issues
- Look at diet…NPO? or regular?
Meropenem vs Ertapenem
Meropenem - COVERS PEA (peudomonas, enterobacter, aciterbacter) BUT it’s dosed TID!
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Where as Ertapenem doesnt cover PEA but it’s a QD dosing!
Ceftriaxone for meningitis — dosing is unique
2 grams every 12 hours -higher doses and longer durations
When to get vanco levels in PD and HD patients
Usually get pre - HD level! However…if need to get after PD or HD? - need to get it 2-4 hours after HD becuase drug needs time to distribute in body!
Vancomycin in Peritonitis in PD patients
Bag is in peritoneal! so there’s a chance to get infection there! - Only in peritonitis…vancomycin is DIRECTLY injected into the PD bag so vanco can concentrate in the peritoneal area…for any other systemic infections? can do it thru central or peripheral line
How to look at UH outpatient PA/ co pay request
Pharmacy –> Outpt resource –> resource –> Tracking –> daily log sheet –> then control F the patient’s name
When looking for a starter packs - think apixaban and riva…
need to look for BRAND NAME !!! (eliquis vs xarlto)
If you want to check patient’s complaince to their DOAC (eliquis, riva, etc)
Get their Anti-Xa upon admission! if there is any levels…means they were prolly taking it
Medication list symbols and what they mean
Scroll - documented by the doctors
Pill bottles - previous RX –> modify without resending
Valporic Acid and the caveats
If indication is AGITATION - we can lower the dose if needed depending on the patient …if its long term/ psych is following? can get them involved
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If indication is SZ…. hesitate to mess with the dose!!! Need to get psych involved before touching dose.. can refer to psych consult notes!
Procalcitonin level and it’s importance
Non sepecific inflammation marker of bacterial infections
Ordering vancomycin lab (can be applied to tobra labs too)
Powerorder –> add –> vanco-lab and vancpmycin lab draw instruction
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Change it to the time you want (30 mins prior to next dose- check mar when next dose is due)… make it TIME STUDY (not random unless it’s CI)
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PICC line? nurse draw..if not? then lab draw
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FOR TOBRA - there will be 4 different orders - one is tobra peak, tobra trough, then 2 tobra lab draw instruction
