Midterm Flashcards
1
Q
What are the CYP450 inhibitors?
A
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Ciprofloxacin
Erythromycin
Cranberry juice/grapefruit juice
Omeprazole
Metronidazole
2
Q
What are the CYP450 inducers?
A
Barbituates
St John’s Wort
Carbazempam
Rifampin
Alcohol
Phenytoin
Griseofluvin
Phenobarbital
Sulfonylureas
3
Q
What does Beer’s Criteria include?
A
Potentially Inappropriate Medication (PIM) for older adults due to
• medication-disease or medication-syndrome interactions that may exacerbate the disease or syndrome
• medications to be used cautiously in older adults
• clinically significant drug interactions that should be avoided in older adults
• medications to be avoided or dosage decreased in the presence of impaired kidney function in older adults
4
Q
At what age does gastric absorption and emptying reach adult values?
A
6-8 months
5
Q
At what age does gastric acidity reach adult values?
A
2 years
6
Q
How are IM drugs absorbed in early infancy?
A
During early infancy, IM absorption is slow and erratic due to early low blood flow.
7
Q
How does the speed of IM absorption compare in neonates to adults?
A
IM drugs are absorbed more rapidly in neonates than adults
8
Q
How does the speed of transdermal absorption compare in neonates to older children and adults?
A
Transdermal drugs are absorbed more rapidly and more completely in neonates than in older children and adults due to thin skin and increased blood flow. This increases risk for toxicity.
9
Q
At what age does hepatic metabolization reach adult levels?
A
the capacity of the liver to metabolize many drugs increases rapidly about 1 month after birth and approaches adult levels a few months later with complete maturation of the liver by 1 year
10
Q
At what age does renal drug excretion reach adult levels?
A
renal drug excretion is significantly reduced at birth due to renal blood flow, glomerular filtration, and active tubular secretion; adults levels of renal function are achieved by 1 year
11
Q
How does the speed of hepatic drug metabolism in children compare to adults?
A
drugs are metabolized faster by children until 2 years old when it gradually declines until puberty when a sharp decline occurs to reach adult levels of metabolism
12
Q
What act prevents discrimination based on genetic testing results?
A
In 2008, the Genetic Information Nondiscrimination Act was passed
13
Q
To what drug class do levorphanol tapentadol belong?
A
Pure opioid agonists
14
Q
What are examples of opioid agonist/antagonists?
A
pentazocine
nalbuphine
butorphanol
buprenorphine (can prolong QT)
15
Q
What are examples of selective opioid antagonists?
A
methylnaltrexone
naloxegol
naldemedine
These selectively block opioid receptors in the GI tract to prevent opioid-induced constipation.
16
Q
What controlled substance schedule does codeine belong to?
A
Schedule II, III, or IV depending on dosage. Dosing with > than 90mg of codeine are schedule II while doses <90mg of codeine per dosing unit are in schedule III. Cough preparations with less than 200mg of codeine or per 100ml (Robitussin AC) are in schedule V.
Other schedule II meds include midazolam, cocaine, methamphetamine, methadone, hydromorphone, oxycodone, fentanyl, meperidine, dexedrine, adderall, Ritalin
Other schedule III meds include ketamine, anabolic steroids, and testosterone.
Other schedule V meds include Lomotil, Motofen, Lyrica, Parepectolin.
17
Q
What controlled substance schedule does tramadol belong to?
A
Schedule IV along with xanax, valium, ativan, ambien, tramadol, talwin, soma, darvon and darvocet
18
Q
What controlled substance schedule does lyrics belong to?
A
Schedule V along with cough preparations with less than 200 mg of codeine per 100 ml, lomotil, morofen, lyrica, parepectolin
19
Q
What is the black box warning for methadone?
A
QT prolongation
20
Q
In which order should antihypertensives be ordered?
A
Thiazide Diuretics
ACEIs
ARBs
CCBs
21
Q
What is the preferred antihypertensives for a patient with DM?
A
ACEIs or ARBs are renal protective in DM.
22
Q
What antihypertensives is indicated in pregnancy?
A
Labetalol
23
Q
What interaction can occur between Warfarin and Carbazepime?
A
Carbazepime is a CYP450 inducer which will increase the rate of metabolism of warfarin requiring larger doses to maintain a therapeutic range.
24
Q
What side effect of nitroglycerin can be treated with beta-blockers?
A
Reflex tachycardia can result due to dilating arterioles causing sympathetic stimulation of the heart which can be treated by beta-blockers.
25
What adverse event can result from abrupt cessation of beta-blockers?
Long term use of beta-blockers can sensitize the heart to catecholamines so if a beta blockers are withdrawn abruptly, anginal pain or ventricular dysrhythmias may develop. This is referred to as rebound excitation. Therefore, beta blockers should be tapered over 1-2 weeks.
26
Which class of medications should be avoided in patients with asthma?
Nonselective beta-blockers can cause bronchospasm in patients with asthma
27
What is the mechanism of action for thiazide diuretics?
Thiazide diuretics block sodium and chloride reabsorption in the distal convoluted tubule increasing renal
excretion of sodium, chloride, potassium, and water; increases serum calcium level by increasing calcium reabsorption in exchange for sodium
28
What med class is cross-sensitive with thiazide diuretics?
Sulfas
29
What drug interactions can occur with thiazide diuretics (chlorthalidone, hydrochlorothiazide)
Concurrent use of lithium may result in increased serum lithium concentrations and lead to lithium toxicity which will result in weakness, tremor, excessive thirst, and confusion.
Concurrent use of thiazides and digoxin can precipitate dig toxicity due to hypokalemia which will result in nausea, vomiting, arrhythmias, xanthopsia (yellow halos around lights)
30
What monitoring is needed for thiazides?
Electrolytes (sodium, potassium, calcium), urate
Thiazides can cause hyponatremia,hypokalemia, hypercalcemia, and increased serum urate.
31
Which drug is contraindicated while taking digoxin?
Quinidine will decrease clearance of digoxin and lead to digitalis toxicity.
32
What is an ASCVD Risk Score
An Atherosclerotic Cardiovascular Disease Risk is a measure of the risk of having a cardiac event. The 2018 ACC/AHA cholesterol guideline defines high ASCVD risk as 20% or greater. Patients with existing clinical ASCVD are placed in a “very-high risk” category, despite their screening percentage. For all other people, 10-year risk must be calculated. The instrument employed most often is the Framingham Risk Prediction Score, which takes five factors into account
•age
•total cholesterol
•HDL cholesterol
•smoking status
•systolic blood pressure
33
Which diabetic patients should be a statin according to the American College of Physicians?
The American College of Physicians recommends a statin for
(1) all patients with type 2 diabetes plus diagnosed ASCVD, even if they don't have high cholesterol; and
(2) all adults with type 2 diabetes plus one additional risk factor (e.g., hypertension, smoking, age older than 55 years), even if they don't have high cholesterol.
Taken together, these guidelines suggest that most patients with diabetes should receive a statin.
34
What elements are required for a written prescription?
-Prescriber Name, License #, Contact Information
- NPI or DEA #
- Patient Name
- Patient DOB
- Allergies
- Medication
- Dose and Frequency
- Route
- Indication
- Number of Tablets to Dispense
- Number of Refills
35
What is the dose, frequency and indication for hydrocodone /acetaminophen?
Hydrocodone/Acetaminophen (Lortab)
- Dose
- • 5mg/325mg, 7.5mg/325mg, 10mg/325mg
Directions
- • take every 4-6 hours
Indication
• moderate to moderately severe pain.
36
What is the dose, frequency and indication for lisinopril?
Dose
- • 2.5mg, 5mg, 10mg, 20mg, 30mg, 40mg
Directions
- • take once daily
Indication
• hypertension, heart failure, acute MI
37
What is the dose, frequency and indication for amlodipine?
Dose
- • 5mg, 10mg
Directions
- • take once daily
Indication
• hypertension
38
What is the dose, frequency and indication for colchicine?
Dose
- • 0.6-1.2mg
Directions
• acute flare — take 1.2mg at the first sign of gout flare, followed by 0.6mg 1 hour later
- • prophylactic — take 0.6 mg once or twice daily
Indication
• prophylaxis and treatment of acute gout flare
39
What medications should be avoided in neonates and pediatrics?
Tetracycline — can stain teeth
Sulfinamides — kernicterus
Aspirin — Reye’s syndrome
Glucocorticoids — growth supression
40
What pharmacological changes occur in geriatrics?
Decreased Absorption
-increased gastric ph
-decreased gastric acid
-delayed gastric emptying
Altered Distribution
-increased body fat
-decreased lean muscle mass
-decreased total body water
-decreased cardiac output
-decreased albumin
Decreased Metabolization
-decreased hepatic function
Decreased Excretion
-decreased renal function
41
What are examples of CYP450 substrates?
Amiodarone
Aliskeren
Nifedipine
Statins
Colchicine
Naloxogel
Epelranone
Ranazoline
Rivaroxoban
Warfarin
42
Which are some examples of teratogenic drugs?
isotretinoin (accutane) vitamin A in large doses
fluroquinolones
tetracyclines
warfarin
DOACs
DMARDs
anticonvulsants
43
Are opioids safe in pregnancy?
No, opioids taken in early pregnancy can increase risk for congenital heart defects, spina bifida, and gastroschisis
44
How should something like osteoarthritis be treated?
NSAIDs
45
What is tramadol approved for?
moderate to moderately severe pain
46
What schedule is tramadol?
Schedule 4 controlled substances are drugs with a low potential for abuse and low risk for dependence such as xanax, valium, ativan, ambien, tramadol, pentazocine (talwins), soma, darvon, darvocet
47
What drugs should be avoided with tramadol?
benzos
CNS depressants
SSRIs
SNRIs
triptans
tricyclic antidepressants
alcohol
MAOIs — hypertensive crises
48
In what condition should tramadol be avoided?
epilepsy
49
What are examples of pure opioid agonists?
morphine, fentanyl, methadone, hydromorphone, oxymorphone, levorphanol, codeine, oxycodone, tapentadol
50
What are examples of pure opioid antagonists?
naloxone, naltrexone
51
What are examples of agonist-antagonists?
pentazocine, nalbuphine, butorphanol, buprenorphine
52
What are examples of selective opioid antagonists?
methylnaltrexone, naloxegol, naldemedine
53
What is codeine approved for?
Treatment of mild to moderate pain
54
What is the black box warning for codeine?
Respiratory depression; deaths have also occurred in breastfeeding infants after being exposed to high concentrations of morphine because the mothers were ultra-rapid metabolizers.
55
What medications should be avoided with opioids?
benzos
barbituates
alcohol
CNS depressants
antihistamines
thiothixene
anesthetics
sedatives
atropine-like drugs
tryciclic antidepressants
anticholinergic drugs — constipation
MAOIs — hyperexia coma
56
How would you know when to refer someone to a pain specialist for pain management?
when 120 MME are used
57
What schedule does heroin belong to?
Schedule 1 controlled substances are drugs with no accepted medical use and high potential for abuse such as heroin, LSD, ecstacy, methaqualone, peyote
58
What schedule does adderall being to?
Schedule 2 controlled substances are drugs with high potential for abuse, with use potentially leading to severe psychological or physical dependance.
products with less than 15 mg of hydrocodone per dosage unit, cocaine, methamphetamine, methadone, hydromorphone, oxycodone, fentanyl, meperidine, dexedrine, adderall, ritalin
59
What schedule do anabolic steroids belong to?
Schedule 3 controlled substances are drugs with a moderate to low potential for psychological and physical dependence such products containing less than 90 mg of codeine per dosage unit, ketamine, anabolic steroids, testosterone
60
What schedule does ambien belong to?
Schedule 4 controlled substances are drugs with a low potential for abuse and low risk for dependence such as xanax, valium, ativan, ambien, tramadol, talwin, soma, darvon, darvocet
61
What schedule does lyrica belong to?
Schedule 5 controlled substances are drugs containing limited quantities of certain narcotics, generally for antitussives, antidiarrheal, analgesic purposes, cough preparations with less than 200 mg of codeine per 100 ml, such as lomotil, morofen, lyrica, parepectolin
62
What are the top 5 priorities of the HHS in regard to the opioid epidemic?
improve access to treatment and recovery services
promoting the use of overdose reversing drugs
strengthening our understanding of the epidemic through better public health surveillance
providing support for cutting edge research on pain and addiction
advancing better pain management practices
63
What provisions were made to the guidelines for prescribing opioids to non-cancer patients?
Only using opioids after nonopioids or more conservative options failed.
Discuss the benefits and risks of long term opioids
Use only one prescriber and one pharmacy
Comprehensive follow up to ensure efficacy and to assess for side effects of treatment.
Stopping opioids after an attempt at rotation has produced inadequate benefit.
Fully documenting the entire process of the opioid prescription process.
64
What can methadone be used for?
Maintenance and suppression therapy for opioid use disorder.
65
What is the black box warning for methadone?
prolonged QT
66
What baseline monitoring is indicated for methadone?
ECG
67
Why is buprenorphine safer to use than methadone?
It has a ceiling to respiratory depression
68
What is the black box warning for vicodin?
vicodin (hydrocodone/acetaminophen) has a black box warning for hepatotoxicity
69
What drug interactions can occur with furosemide?
lithium — increased effects of lithium
digoxin — increased risk for dig toxicity in hypokalemia
aminoglycocides (gentamycin) — increased risk for ototoxicity
NSAIDS — increased risk for prerenal kidney injury, can decrease efficacy and intensify toxicity
70
What adverse reaction can result from furosemide?
ototoxicity, hyperglycemia, hyperuricemia, decreased HDL, increased LDL and triglycerides
71
What baseline monitoring is indicated for loop diuretics?
creatinine
electrolytes
72
Are loop diuretics safe in pregnancy?
No, animal studies have demonstrated maternal death, abortion, and fetal resorption
73
What are adverse effects of thiazide diuretics?
hyperglycemia, hyperuricemia, dig toxicity, lithium toxicity
74
What is the black box warning for spironolactone?
Has been shown to be tumorigenic in rats.
75
What are side effects of spironolactone?
gynecomastia, menstrual irregularities, impotence, hirsutism, deepening of the voice
76
What is considered normal blood pressure?
SBP <120 & DBP <80
77
What is considered elevated blood pressure?
SBP 120-129 & DBP <80
78
What is considered stage I hypertension?
SBP 130-139 & DBP 80-89
79
What is considered stage II hypertension?
SBP ≥140 & DBP >90
80
What is the role of aldosterone?
inhibits renal excretion of sodium and water in exchange for excretion of potassium and hydrogen increasing blood volume and blood pressure; promotes remodeling and cardiac fibrosis
81
What is an adverse effect of ACEIs?
renal insufficiency in bilateral renal artery stenosis, neutropenia
82
Are RAAS blockers safe in pregnancy?
No, RAAS blockers should be avoided, especially in the second and third trimester
83
What is the black box warning for ACEIs?
Fetal injury in pregnancy, especially in the second and third trimesters
84
What drug interactions can occur with ACEIs?
Lithium — ACEIs can cause lithium to accumulate to toxic levels
NSAIDs — NSAIDs can reduce the antihypertensive effects of ACEIs and intensify toxicity
85
What baseline data is needed for ACEIs and ARBs?
renal function (creatinine)
86
What monitoring is needed for ACEIs and ARBs?
renal function (creatinine) should also be checked 2-4 weeks after starting
87
What drug class is indicated for cardiac fibrosis?
ARBs
88
What are contraindications for ACEIs?
pregnancy, renal artery stenosis
89
What is the only approved direct renin inhibitor?
aliskiren
90
What should be avoided with administration of a direct renin inhibitor?
administration with a high fat meal
91
To which drug class does eplerenone belong?
aldosterone antagonist
92
What inhibitors will lead to toxic levels of eplerenone?
CYP3A4
93
What are adverse effect of CCBs?
constipation, gingival hyperplasia, chronic rash, facial flushing, headache, ankle or feet edema
94
Verapamil can increase the serum
concentration of which drug by 60%?
Digoxin
95
What food should be avoided with CCBs?
Grapefruit juice
96
What medications can increase toxicity of nifedipine?
CYP3A4 inducers
97
What are contraindications for CCBs?
HF, SSS, AVB
98
What medication can cause acute rheumatoid syndrome (muscle pain, joint pain, fever, nephritis, pericarditis, and the presence of antinuclear antibodies) that closely resembles lupus.
Hydralazine
99
What adverse reaction can occur from hydralazine and monoxide?
blood volume expansion from sodium and water retention
100
What is the black box warning for minoxidil?
Pericardial effusion and cardiac tampanode. Therefore, it should be reserved for hypertensive patients who do not respond adequately to maximum therapeutic doses of a diuretic and 2 other antihypertensive agents.
101
At what age can statins be prescribed?
≥ 10 years old
102
What is the acceptable level for total cholesterol?
<170
103
What total cholesterol level is considered borderline?
170-190
104
What are total cholesterol level is considered elevated?
≥200
105
What is the acceptable level for LDL cholesterol?
<110
106
What LDLl cholesterol level is considered borderline?
110-129
107
What are LDL cholesterol level is considered elevated?
≥130
108
What are normal values for HDL?
>40 for men and >50 for women
109
What are normal values for triglycerides?
<150
110
Who will benefit from statins according to the American College of Cardiology / American Heart Association Blood Cholesterol Guidelines
individuals with ASCVD
individuals with LDL ≥190
individuals aged 40-75 with diabetes and LDL 70-189 an estimated 10-year ASCVD risk of 7.5% or higher
individuals aged ≥40 with diabetes
111
What are the components of metabolic syndrome?
hypertriglyceridemia (>150)
low HDL (<40)
hyperglycemia (>100 fasting)
hypertension (>135/85)
waist circumference (>40 men and >35women)
112
What is the initial treatment for hyperlipidemia after therapeutic lifestyle changes have been ineffective?
Statins are first-line and if ineffective, bile acid sequestrates (cholestyramine, niacin) can be added to the regimen
113
What are examples of HMGCoA reductase inhibitors?
Statins
114
In what patient population are statins contraindicated?
pregnant women
115
For what conditions are statins contraindicated?
liver disease, hepatitis, alcoholism
116
Statins can have potentiating adverse from which inhibitors?
CYP3A4
117
Rosuvastatin reaches abnormally high levels in people of what heritage?
Asian
118
When should statins be taken?
At night as they are more effective
119
What are adverse reactions of atorvastatin?
myopathy, rhabdo, headache, rash, GI upset, hepatotoxicity, new onset diabetes?
120
What drug interactions can occur when taken with statins?
Colchicine — increases risk for myopathy/myoisitis
Amiodarone — can increase levels of statin
Cyclosporine — can increase levels of statins
Statins are CY3A4 substrates so inhibitors such as grapefruit juice and macrolids (erythromycin, azithromycin) should be avoided
121
What baseline monitoring is needed for atorvastatin?
liver function, lipid panel
122
What cholesterol lowering medications can be used in pregnancy?
ezetimibe (Zetia)
fenofibrate
123
What are the safest lipid-lower medications?
bile acid sequestrates are not absorbed from the GI tract and doe not have any systemic effects
124
What drug interactions can occur with bile acid sequestrates (colesevelam, cholestyramine)?
bile acid sequestrates can bind with and prevent absorption of thiazides, digoxin, warfarin, ezetimibe, leflunomide, and some antibiotics so these drugs should be administered either an hour before or four hours after bile acid sequestrates.
125
What are common side effects of bile acid sequestrates such as Colesevelam?
constipation (can be minimized by dietary fiber and fluid), bloating, nausea,
*decreases fat absorption and therefore, decreases absorption of fat soluble vitamins as well
126
What are adverse effects of ezetimibe (zetia)?
myopathy, rhabdo, hepatitis, pancreatitis, and thrombocytopenia
127
What drug interactions can occur with ezetimibe (zetia)?
Statins — can increase risk for hepatotoxicity and myopathy; these drugs can be given together but transaminase levels should be monitored
Fibrates (gemfibrozil/fenofibrate) — can increase the risk for gallstones and myopathy
Bile acid sequestrates (cholestyramine) — can significantly decrease the absorption of ezetimibe so ezetimibe should be administered at least 2 hours before or 4 hours after a bile acid sequestrate
Cyclosporine — can greatly increase levels of ezetimibe
128
What is gemfibrozil used to treat?
hypertriglycerideemia, also raises HDL, but no effect on LDL
*fibrates should not be combined with ezetimibe (zetia) as the risk for gallstones and myopathy is increased
129
What are adverse effects of fibrates (gemfibrozil)?
gallstones, myopaty, hepatotoxicity
130
What is a major drug interaction of gemfribrozil?
Warfarin is displaced from plasma albumin by gemfibrozil, increasing its concentration, increasing anticoagulant effects
131
For which conditions are fibrates (gemfibrozil) contraindicated?
liver disease, gallbladder disease
132
What is an example of a type I antidysrhythmic?
Type I antidysrhythmics are sodium channel blockers such as quinidine, lidocaine, and mexiletine
133
What is an example of a type II antidysrhythmic?
Type II antidysrhythmics are beta blockers such as propanalol
134
What is an example of a type III antidysrhythmic?
Type III antidysrhythmics are potassium channel blockers such as amiodarone
135
What is an example of a type IV antidysrhythmic?
Type IV antidysrhythmics are calcium channel blockers such as verapamil
136
What is the therapeutic range for digoxin?
0.5-0.8
137
What are the indications for digoxin?
The primary indication for digoxin in heart failure but it can also be used for supra ventricular dysrhythmias. It is not effective against ventricular dysrhythmias.
138
What drug interactions can occur with digoxin?
quinidine — can increase serum digoxin levels and increase risk for toxicity
amiodarone — can increase serum digoxin levels and increase risk for toxicity
verapamil/diltiazem — can increase serum digoxin levels and increase risk for toxicity
diuretics — can increase risk for arrhythmias from hypokalemia
139
How can renal insufficiency affect digoxin?
renal impairment can lead to toxic accumulation of dig due to reduced renal excretion
140
What baseline monitoring in needed for digoxin?
ECG, serum electrolytes, renal function
141
What drug interactions can occur with quinidine?
amiodarone — can increase the serum levels of quinine
digoxin — quinidine can double serum levels of digoxin
142
What are adverse effects of quinidine?
headache, nausea, vertigo, visual disturbances, tinitus, sinus arrest, AV block, ventricular tachydysrhythmias, asystole
143
What is the black box warning for quinidine?
increased mortality for Afib or Aflutter
144
What is the black box warning for mexiletine?
increased mortality for non-life threatening arrhythmias
145
Amiodarone can increase levels of which drugs?
digoxin
quinidine
warfarin
statins
phynetoin
cyclosporins
146
What drugs increase the levels of amiodarone?
CYP3A4 inhibitors by decreased metabolism
147
What drugs decrease the levels of amiodarone?
cholestyramine by decreased absorption and CYP3A4 inducers by increased metabolism
148
What are the adverse effects of amiodarone?
QT prolongation, QRS widening, PR prolongation, pulmonary fibrosis, optic neuropathy and optic neuritis (visual impairment), thyroid toxicity (hypothyroidism or hyperthyroidism), photosensitivity reactions (skin reactions)
149
What is the black box warnings for amiodarone?
pulmonary toxicity — hypersensitivity pneumonitis, interstitial/alveolar pneumonitis, pulmonary fibrosis
liver toxicity
150
What are side effects of
nondihydropyridine CCBs?
bradycardia, AV block, HF
151
What drug interactions can occur with nondihydropyridine CCBs (verapamil and diltiazem)?
digoxin — verapamil and diltiazem can elevate levels of digoxin and increase risk for toxicity
152
What drugs should be avoided in heart failure stage C and up?
antidysrhythmics — can worsen heart failure by cardiosupression (only amiodarone and dovetailed [tikosyn] have been proved not to reduce survival)
CCBs — can worsen heart failure by cardiosupression (only amlodipine has been proved not to reduce survival)
NSAIDs — can worsen heart failure by sodium retention and peripheral vasoconstriction, additionally they can reduce the efficacy and intensify toxicity of diuretics and ACEIs
153
What are examples of MRAs (aldosterone antagonists)?
spironolactone, eplerenone
154
What are contraindications for beta blockers?
HF, SSS, AVB; use caution in asthma, DM
155
What can occur with abrupt cessation of beta blockers?
Long term use of beta blockers can sensitize the heart to catecholamines so if a beta blocker is withdrawn abruptly, anginal pain or ventricular dysrhythmias may develop. This is referred to as rebound excitation. Therefore, beta blockers should be tapered over 1-2 weeks.
156
At what point in renal insufficiency do thiazide diuretics become ineffective?
creatinine clearance <40-50
157
What med classes are used to treat angina?
nitrates, CCBs, beta-blockers, ranazoline
158
What CCB is widely used for angina and is approved for both vasospastic angina and angina of effort?
verapamil
159
What can trigger stable angina?
exercise, stress, large meals, cold exposure
160
What causes variant angina?
coronary artery spasms
161
What are contraindications for ranozoline?
QT prolonging drugs, hepatic impairment, CYP3A4 inhibitors
162
What drug interactions occur with ranozoline?
CYP3A4 inhibitors and inducers and verapamil/diltiazem can increase levels of ranolazine
163
What meds are contraindicated with nitrates?
PDE5 inhibitors (sildenafil)
164
How long of a nitrate free interval is necessary to prevent tolerance to nitrates?
8 hours
165
In what patient population is warfarin contraindicated?
pregnant women, breastfeeding women
166
What is the preferred anticoagulant in pregnancy?
heparin is the preferred anticoagulant in pregnancy because it does not cross the placenta
167
What is the black box warning for heparin?
spinal or epidural hematoma in patients undergoing spinal puncture or epidural anesthesia
168
What drugs interact with warfarin?
aspirin, NSAIDs, acetaminophen, sulfonamides, glucocorticoids, digoxin, CYP3A4 inhibitors and inducers
169
What is the target range for INR while on warfarin?
2.5-3.5
170
What drugs increase the effects of warfarin?
acetaminophen, aspirin, NSAIDs, acetaminophen, gemfibrozil, antifungals, amiodarone, cephalosporins CYP3A4 inhibitors
171
What drugs decrease the effects of warfarin?
vitamin K and CYP3A4 inducers
172
What drugs affect therapeutic levels of rivaroxaban?
CYP3A4A inhibitors and inducers and PGP inhibitors and inducers
173
For what conditions should rivaroxaban be avoided?
renal insufficiency (CrCl 30-50), and hepatic impairment
174
What drugs inhibit metabolism and activation of the prodrug clopidogrel?
CYP2C19 inhibitors — cimeditdine, fluoxitine, fluvoxamine, fluconazole, ketoconazole, voriconazole, etravirine, felbamate, and ticlopidine
175
What are the four goals of treatment for RA?
relieving symptoms
maintaining joint function
minimizing systemic involvement
delaying disease progression
176
What would you expect to find in the synovial fluid of a patient with OA?
leucocytes
177
How long do patients with OA generally experience stiffness?
≤ 30 min
178
What lab value would you expect to be elevated in RA?
ESR
179
How long do patients with RA generally experience stiffness?
≥ 60 min
180
What would you expect to find in the synovial fluid of a patient with OA?
leucocytes, cloudy
181
What drug classes are used to treat RA?
NSAIDs
corticosteroids
conventional DMARDs (methotrexate, leflunomide, sulfasalazine, hydroxychloroquine)
biologic DMARDs (etanercept, certolizumab, golimumab, adalimumab)
targeted DMARDs (tofacitinib, barcitinib)
182
What baseline data is needed before starting any DMARDs?
CDC w/ diff, LFTs (AST/ALT), pregnancy test, check for infection (HBV, TB) or malignancy (skin assessment)
183
What baseline assessment is needed for hydroxychloroquine?
cardiac exam (ECG), ophthalmic exam, and the usuals for DMARDs — CDC w/ diff, LFTs (AST/ALT), pregnancy test, check for infection (HBV, TB) or malignancy (skin assessment)
184
What is the mechanism of action for methotrexate?
inhibits dihydrofolate reductase; inhibits lymphocyte proliferation (folate antagonist), providing immunosuppression
185
What are contraindications to methotrexate?
pregnancy, breast feeding, blood dyscrasias, liver disease, immunodeficiency
186
What are adverse effects of methotrexate?
hepatic fibrosis, myelosupression, GI ulceration, pneumonitis
*consider dosing with folic acid to reduce GI and hepatic toxicity
187
What monitoring in indicated for methotrexate?
periodic liver function, renal function, and CBC
188
How soon should methotrexate be initiated after diagnosis of RA?
within 3 months
189
What routine monitoring is needed for methotrexate?
liver and renal function
190
Is methotrexate safe in pregnancy?
No, it can cause congenital abnormalities and fetal demise
191
What is the black box warning for methotrexate?
fatal toxicities of the bone marrow, liver, lungs, and kidneys
192
What drug interactions can occur with leflunomide?
NSAIDs — leflunomide can inhibit metabolism of certain NSAIDs
Rifampin — can increase levels of leflunomide by 40%
cholestyramine — can decrease decrease of leflunomide
193
Is leflunomide safe in pregnancy?
No, leflunomide is teratogenic; therefore, it is contraindicated in pregnancy. Patients desiring pregnancy must follow a three-step protocol that includes stopping leflunomide, taking cholestyramine to chelate the leflunomide, and ensuring that leflunomide drug levels are below 20 μg/L before getting pregnant;
194
What is the most significant adverse reaction from hydroxychloroquine?
retinal damage, QT prolongation
195
What is the best option for treating RA in pregnancy?
Hydroxychloroquine is probably the safest DMARD for RA in pregnancy?
196
Can targeted DMARDs be combined with methotrexate?
Yes, targeted DMARDs can be combined with methotrexate, but cannot be combined with biologics or other immunosupressants
*do not combine biologics with conventional DMARDs
197
After how many gout flares are drugs for hyperuricemia indicated?
3 or more per year
198
What drugs are used in the treatment of acute gout?
NSAIDs, corticosteroids, colchicine
199
What are adverse effects of colchicine?
nausea, vomiting, diarrhea, abdominal pain, myelosupression, myopathy, rhabdo
200
What drugs intact with colchicine?
statins — can increase risk for myopathy
CYP inhibitors and inducers
PGP inhibitors and inducers
201
What drugs are used in the treatment of chronic gout?
xanthine oxidase inhibitors (allopurinal, febuxostat), uricosuric agents (probenecid)
202
What is the mechanism of action of xanthine oxidase inhibitors?
inhibits xanthine oxidase, interfering with conversion of hypoxanthine and xanthine to uric acid
203
What are common side effects of allopurinol?
hypersensitivity syndrome (rash, pruritus, urticaria, eosinophilia, fever, liver dysfunction, and renal dysfunction), severe subcutaneous adverse reaction (SCAR) syndrome more likely in patients of Korean, Chinese, and Thai ancestry, cataracts with prolonged use
204
What drug interactions can occur with allopurinol?
warfarin — allopurinol can increase levels of warfarin
theophylline
205
Is allopurinol safe in renal insufficiency?
allopurinol is the drug of choice for patients with renal insufficiency
206
What should be co-administered with febuxostat?
NSAIDs and colchicine should be co-administered with febuxostat to prevent gout flare.
207
What drug interactions can occur with probenecid?
aspirin and salicylate interfere with the uricosuric action of probenecid and should be avoided
208
What are common side effects of colchicine?
nausea, vomiting, diarrhea, myelosupression, and myopathy
209
What drugs are contraindicated with colchicine.
Statins increase the risk of myopathy when taken with colchicine, PGP inhibitors, and CYP3A4 inhibitors — macrocodes (erythromycin, clarithromycin, gentamicin), protease inhibitors
210
What is the recommended dietary intake of calcium?
1000mg/day for women ≤50
1200mg/day for women >50
211
What is the recommended dietary intake of vitamin D?
600IU/day for women ≤ 70
800IU/day for women >70
212
What diagnostic criteria is required for osteoporosis?
T-score of ≤ -2.5 at the femoral neck or spine
213
Who should be treated for osteoporosis according to the American Association of Clinical Endocrinologists?
a hip or vertebral frature
T-score of ≤ -2.5 at the femoral neck or spine
T-score of -1 to -2.5 at the femoral neck or spine plus either a 10-year probability of a hip fracture of 3% or more or a 10-year probability of another major osteoporosis-related fracture of 20%
214
What types of fracture is seen most commonly in severe osteoporosis?
hip and vertebral fractures
215
What is the first-line treatment for osteoporosis?
Bisphosphonates
additionally, vitamin D and calcium supplements are indicated
216
What baseline monitoring is indicated prior to initiating bisphosphonates?
DXA, height, serum calcium, serum 25(OH)D, serum creatinine, pregnancy status, dental examination
217
What continued monitoring is indicated while on bisphosphonates (alendronate)?
DXA every 1-2 years until stable then every 2 years, periodic serum calcium, serum 25(OH)D, serum creatinine
218
What patient education is needed for biphosphonates?
Take on an empty stomach with a full glass of water and remain upright for 30 minutes (60 minutes with ibandronate) then avoid ingesting anything for at least 30 min (60 min with ibandronate). Avoid ingesting antacids, calcium, iron, or magnesium supplements for 2 hours.
219
What are adverse effects of bisphophonates?
atypical fractures and osteonecrosis of the jaw
220
What is the mechanism of action for bisphosphonates?
inhibits osteoclast activity, reducing bone resorption and turnover
221
When are bisphosphonates contraindicated?
dysphagia, patients who cannot sit or stand for at least 30-60 min, esophagitis, GFR < 30-35 mL/min; low serum calcium and vitamin D (should be corrected before instituting therapy)
222
What is the black box warning for raloxifine?
increased risk for venous thromboembolic events and increased risk for CVA when given to postmenopausal women who have had history or risk for CAD
223
What electrolyte imbalance does denosumab increase the risk for?
hypocalcaemia and hypophosphataemia
224
What baseline monitoring is indicated prior to initiating RANKL inhibitors (denosumab)?
DXA, height, serum calcium, serum 25(OH)D, pregnancy status, dental examination
225
What are adverse effects of denosumab?
musculoskeletal pain, hypercholesteralemia, UTI, immunosuppression, severe infections, hypocalcemia (higher in patients with renal impairment, hypoparathyroidism, thyroid surgery, malabsorption syndromes, excision of the small intestines), osteonecrosis of the jaw
226
What baseline monitoring is indicated prior to initiating Selective Estrogen Receptor Modulators (SERMs) (raloxifine)?
axial DXA, height, serum calcium, serum 25(OH)D, pregnancy status, mammogram
