Module 3: Chapters 18-26 Flashcards
1
Q
What select drugs cause kidney disease?
A
-Aminoglycosides
-Amphotericin B
-Cisplatin
-Cyclosporine
-Loop diuretics
-NSAIDs
-Polymixins
-Radioactive contrast dye
-Tacrolimus
-Vancomycin
2
Q
What are the criteria for confirming CKD? (3)
A
1- eGFR < 60 ml/min/1.73
2- albuminuria equivalent to urine albumin excretion rate > 30mg/24 hr or urine albumin to creatinine ratio > 30
3- decreased eGFR or albuminuria has occurred for greater than 3 months (to distinguish from AKI)
3
Q
Delaying progression of CKD: ACEi & ARBs for albuminuria
A
-who: rec in pts with HTN and albuminuria
-why: to prevent kidney disease progression
-how: inhibit renin-angiotensin-aldosterone system, causing efferent arteriolar dilation
-what: reduce pressure in the glomerulus, decrease albuminuria and provide cardiovascular protection
4
Q
DM management in CKD
A
-SGLT2i (canagliflozin, dapaliflozin, and empagliflozin) have demonstrated a reduction in cardiovascualr events and CKD progression (if they cannot take- GLP1 can be used)
–> Finerenone: a nonsteroidal mineralocorticoid receptor antagonist, is indicated to reduce CKD progression and cardiovascular risks; it can be added to an SGLT2 inhibitor and maximally-tolerated dose of an ACE or ARB in pts with eGFR > 25
5
Q
Drugs that require adjustment in CKD: anti-infectives
A
**increase dosing interval
-aminoglycosides
-beta-lactams (except antistaphyloccal oenicillins and ceftriaxone)
-fluconazole
-quinolones (except moxifloxacin)
-vancomycin
6
Q
Drugs that require adjustment in CKD: Cardiovascular drugs
A
-LMWH (enoxaparin)
-Rivaroxaban
-Apixaban
-Dabigatran
7
Q
Drugs that require adjustment in CKD: Gastrointestinal Drugs
A
-H2RAs (famotidine, ranitidine)
-Metoclopramide
8
Q
Select drugs that are CI on CKD: CrCl < 60 ml/min
A
nitrofurantoin
9
Q
Select drugs that are CI on CKD: CrCl < 50 ml/min
A
-tenofovir disoproxil fumarate containing products ( complera, delstrigo, stribild, symfi)
-voriconazole IV
10
Q
Select drugs that are CI on CKD: CrCl < 30 ml/min
A
-tenofovir alafenamide containing products (Biktarvy, Descovy, Genvoya, Odefsey, Symtuza)
-NSAIDs
-Dabigatran
-Rivaroxaban
-avanafil
-bisphosphonates
-duloxetine
-fondaparinux
-potassium-sparing diuretics
-tadalafil
-tramadol ER
11
Q
Select drugs that are CI on CKD: CrCl GFRv < 30
A
metformin (do no initiate if GFR < 45)
12
Q
Select drugs that are CI on CKD: others
A
-meperidine
-SGLT2i
-dofelitide
-edoxaban
-glyburide
-sotalol
13
Q
Phosphate binders: Aluminum hydroxide suspension
A
-300-600 mg PO TID w/ meals
-SEs: aluminum intoxication, “dialysis dementia”, osteomalacia, constipation, nausea
-monitor: Ca, PO4, PTH, s/sx of aluminum toxicity
14
Q
Phosphate binders: calcium acetate (phoslyra)
A
*1st line
-1334 mg PO TID w/ meals, titrate based on PO4 levels
-SEs: hypercalcemia, constipation, nausea
-monitor Ca, PO4, PTH
-binds more dietary phosphorus than calcium carbonate
15
Q
Phosphate binders: calcium carbonate (tums)
A
*1st line
-500 mg po TId w/meals, titrate based on PO4 levels
-SEs: hypercalcemia, constipation, nausea
-monitor: Ca, PO4, PTH
16
Q
Phosphate Binder: Sucroferric oxyhydroxide (velphoro)
A
-500 mg PO TID w/ meals
-SE: diarrhea, constipation, discolored poop
-monitor: PO4, PTH
*absorption is minimal
17
Q
Phosphate Binders: Ferric citrate (Auryxia)
A
-2 tabs (420 mg) PO TID w/ meals
*iron absorption occurs, dosage reduction of IV iron may be necessary
-SE: diarrhea, constipation
-monitor: PO4, PTH, iron, ferritin, TSAT
18
Q
Phosphate Binders: Lanthanum carbonate (Fosrenol)
A
-500 mg PO TID with meals *must chew tablet throughly to reduce risk of severe GI AEs
CI: GI obstruction, fecal impaction, ileus
-warnings: GI perforation
-SEs: N/V, diarrhea, constipation, abdominal pain
-monitor: Ca, PO4, PTH
19
Q
Phosphate Binders: Sevelamer Carbonate (Renvela) and Sevelamer hydrochloride (Renagel)
A
-800-1600 mg PO TID w/ meals
-CI: bowel onstruction
-Warnings: can reduce dietary absorption of vitamins D, E, K and folic acid
-SEs: N/V, diarrhea, dyspepsia, constipation, abdominal pain, flatulence
-monitor: Ca, PO4, HCO3, PTH
*can lower cholesterol and LDL by 15-30%
20
Q
Phosphate binder interactions
A
**important to separate the administration of phosphate binders from levothyroxine, quinolones and tetracyclines
21
Q
Cholecalciferol
A
-vitamin D3
-synthesized in the skin after exposure to sunlight
22
Q
Ergocalciferol
A
-vitamin D2
-produced from plant sterols and is the primary dietary sourced of vitamin D
23
Q
Vitamin D analog: Calcitriol (Rocaltrol)
A
–> active form of vitamin D : take with food or shortly after a meal to dec GI upset
-CKD: 0.25-0.5 mcg PO daily
-Dialysis: 0.25-1 mcg PO daily ot 0.5-4 mcg IV 3x weekly
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D
24
Q
Vitamin D analog: Calcifediol (Rayaldee)
A
–> prodrug of calcitriol
-CKD stage 3 or 4: 30 mcg PO QHS
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D
25
Vitamin D analog: Doxercalciferol
CKD: 1-3.5 mcg PO daily
Dialysis: 10-20 mcg PO 3x weekly or 4-14 mcg IV 3x weekly
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D
26
Vitamin D analog: Paricalcitol (Zemplar)
CKD: 1-2 mcg PO daily or 2-4 mcg PO 3x weekly
Dialysis: 2.8-7 mcg IV 3x weekly
CI: hypercalcemia, vitamin D toxicity
Warnings: digitalis toxicity potentiated by hypercalcemia
SEs: hypercalcemia, N/V/D
27
Calcimimetic drugs
-increases sensiticity of the calcium-sensing receptor in the parathyroid glad, which causes dec PTH, Ca, and PO4
28
Calcimimetic drugs: Cinacalcet (Sensipar)
-mimics the actions of calcium on the parathyroid gland and causes a further reduction in PTH
-Dialysis: 30-180 mg PO daily w/ food, take tablet whole- do not crush or chew
CI: hypocalcemia
Warnings: caution in pts w/ hx of seizures
SEs: hypocalcemia
Monitoring: Ca, PO4, PTH
29
Calcimimetic drugs: Etelcalcetide (Parsabiv)
-Dialysis: 2.5-15 mg IV 3x weekly
Warnings: hypocalcemia
SEs: muscle spasms, paresthesia
Monitoring: Ca, PO4, PTH
30
Anemia of CKD * as kidney function declines, EPO production decreases*
-ESAs work like EPO to produce more RBCs and can prevent the need for blood transfusions
ex: epoetin alfa (Procrit, Epogen, Retacrit) and darbepoetin alfa (Aranesp)
--> ESAs have risk of inc BP, thrombosis
**only be used with hemoglobin is < 10 and d/c or held if hemoglobin exceeds 11 g/dL
-only affective if iron is available, IV iron is used
(daprodustat (Jesduvroq) option for CKD pts that have been recieving dialysis for 4 months, used to increased erythropoietin levels)
31
Select drugs that raise potassium levels
-ACE/ARBs
-aldosterone receptor antagonists
-aliskiren
-canagliflozin
-drospirenone-containing COCs
-potassium-containing IV fluids
-potassium supps
-bactrim
-cyclosporine, everolimus, tacrolimus
-chronic heparin use
-glycopyrrolate
-NSAIDs
-Pentamidine
32
Treating Severe Hyperkalemia: 1- stabilize the heart
-calcium gluconate: IV, 1-2 min onset
-does not. decrease potassium but stabilizes myocardial cells to prevent arrthythimas
33
Treating Severe Hyperkalemia: 2- shift K intracellularly (4 options)
1: regular insulin: IV, 30 min onset --> co-adminstered with glucose ot dextrose to prevent hypoglycemia
2: dextrose: IV, 30 min onset --> stimulates insulin secretion, but does not shift K intracellularly on it own
3: Sodium bicarbonate: IV, 30 min onset --> used when metabolic acidosis is present
4: albuterol, nebulized, 30 min onset --> monitor for tachycardia and chest pain
34
Treating Severe Hyperkalemia: 3- elimiate K from the body (5 options)
1: furosemide, IV, 5 min onset --> eliminates K in the urine, monitor volume status
2: sodium polystyrene sulfonate (SPS): oral or rectal, 2-24 hr onset --> binds K. in the GI tract, due to GI necrosis, used for emergency situations only
3: Patiromer: oral, ~7 hrs onset --> binds K in the GI tract, delayed onset limits use in emergencies
4: Sodium zirconium cyclosillicate: oral, 1 hr onset --> binds K in GI tract, potassium binder with fastest onset of action = preferred for emergency situations.
5: hemodialysis: meh
35
Treating Severe Hyperkalemia: Sodium polyrtyrene sulfonate/ SPS (kayexalate)
-15 g 1-4 qd po
Warnings: electrolyte disturbances, fecal impaction, GI necrosis, can bind other oral medications
SEs: N/V, constipation or diarrhea
Monitoring: K. Mg, Na, Ca
*do not mix oral products with fruit juices containing K
--> due to risk of GI necrosis, limit use to specific situations (life-threatening hyperkalemia etc)
36
Treating Severe Hyperkalemia: Patiromer (Veltassa)
-8.4 gm PO once daily, MDD 25.2 mg
Warnings: can worsen GI motility, hypomagnesemia, binds to many oral drugs, separate by at least 3 hours before or 3 hours after
SEs: constipation, N/D
Monitoring: K, Mg
--> delayed onset of action, limits the use in life threatening hyperkalemia
-store powder in fridge, must be used within 3 months if stored at room temp
37
Treating Severe Hyperkalemia: Sodium zirconium cyclosilicate (lokelma)
-10 g PO TID for up to 48 hrs
Warnings: can worsen GI motility, edema, contains sodium, can bind to other drugs; separate by at least 2 hours before and 2 hours after
SEs: peripheral edema
-generally the preferred potassium binder due to fastest onset of action
-store at room temp
38
Metabolic acidosis and drugs to treat it (2)
-when bicarbonate is < 22 mEq/L
1- sodium bicarbonate: sodium load can cause fluid retention, monitor sodium level and use caution in patients with hypertension or cardiovascular disease
2- sodium citrate/citric acid (Cytra-2): monitor sodium levels, metabolized to bicarbonate by the liver; may not be affective in pts with liver failure
39
Factors affecting drug removal during dialysis:
1) molecular weight/size
2) Volume of distribution
3) Protein-binging
1) MW: smaller molecules are more readily removed by dialysis
2) Vd: drugs with a large Vd are less likely to be removed by dialysis
3) Pb: highly protein-bound drugs are less likely to be removed by dialysis
40
Factors affecting drug removal during dialysis:
1) membrane
2) blood flow rate
1) M: high-flux (large pore size) and high-efficiency (large surface area) HD filters remove more substances than conventional/low-flux filters
2) BFR: higher dialysis blood flow rates increase drug removal over a given time interval
41
Hepatitis A facts
-acute
-fecal-oral transmission
-has a vaccine
-1st line tx: supportive
42
Hepatitis B facts
-can be acute or chronic
-blood, body fluids transmission
-has a vaccine
-1st line tx: PEG-INF or NRTI (tenofovir or entecavir)
43
Hepatitis C facts
-can be acute or chronic
-blood, body fluids transmission
-does NOT have a vaccine
-1st line tx:
--> tx niave: DAA combination
--> others: Diret acting antivirals + robavirin
44
what are the 2 medication regimens that are recommended for treatment naive Hep C pts without cirrhosis:
-Glecaprevir/pibrentasvir (Mavyret)
-Sofobuvir/velpatasvir (Epclusa)
45
Drug tx for Hep C: NS3/4A protease Inhibitors
Name clues: -previr (P for Pl)
- Glecaprevir
-Grazoprevir
-Voxilaprevir
**Protease Inhibitors & Grub (PIG): take with food!!
46
Drugs tx for Hep C: NS5A Replication Complex Inhibitors
Name clues: -asvir (A for NS5A)
- Elbasvir
-Lediopasvir
-Pibrentasvir
-Velpatasvir
47
Drug tx for Hep C: NS5B Polymerase Inhibitors
Name clues: -buvir (B is for NS5B)
-Sofosbuvir
48
Safety profile for all Direct acting antivirals (DAAs)
-BBW: risk of reactivating HBV; test all patient. for HBV before starting a DDA
-warnings: for sofosbuvir-containing regimens, to NOT use amiodarone - as serious symtomatic bradycardia has been reported
-SEs: well tolerated, HA, fatigue, D/N
-monitoring: LFTs (including bilirubin), HCV-RNA
49
DAA: Glecaprevir/pibrentasvir (Mavyret)
-3 tabs once daily WITH food
-CI: moderate to severe hepatic impairments (childs pugh B or C) or hx of hepatic decompensation, use with strong CYP3A4, use with ethinyl products
-approved for all 6 genotypes for treatment naive patients and for 8 week course of therapy in select pts
50
DAA: Sofosbuvir/velpatasvir (Epclusa)
- 1 tablet daily w/ or w/o food
-approved for all 6 genotypes for treatment naive patients
51
All DAA drug interactions
-CI with strong inducers of CYP3A4
-most DAAs inc statin concetration and myopathy risks
-dec BG can occur with insulin and other diabetic medications
52
DAA Drug interactions: Mavyret
-do not use with strong CYP3A4 inducers, ethinyl estradiol-containing products, lovastatin, simvastatin or cyclosporine
53
DAA Drug interactions: Epclusa, Harvoni and Vosevl
-contains sofosbuvir; do not use with amiodarone due to the risk of bradycardia
-antiacids, H2RAs and PPIs can dec concentrations of ledipasvir and velpatasivir
--> seperate from antiacids by 4 hours
--> take H2Ras at the same time or seperated (~12 hours) and use famotidine < 40 mg BID
--> PPIs are not recommended with Epclusa
54
DAA Drug Interactions: Zepatier
-do not use with efavirenz, HIV protease inhibitors or cyclosporine
-not rec with nafcillin, ketoconazole, bosentan, tacrolimus, etravirine, Stribild, Genvoya and modafinil
55
Ribavirin (used with DAAs for HCV tx)
-400-600 mg BID
BBW: significant teratogenic, not effective as monotherapy, hemolytic anemia
CI: pregnancy
SEs: hemolytic anemia
* need 2 relaible forms of BC during tx and 6 months after tx
56
Nucleoside/tide reverse transcriptase inhibitors (NRTIs) used for monotherapy in HBV
-inhibit HBV replication
-decrease dosing for CrCl < 50
BBW: lactic acidosis and severe hepatomegaly with steroids, exacerbation of HBV can occur upon d/c
57
NRTIs: Tenofavir disoproxil fumarate, TDF (Viread)
*preferred therapy
-300 mg daily
Warnings: renal toxicity, fanconi syndrome, osteomalacia and dec bone mineral density
SEs: renal impairment, dec bone mineral density
--> dispense in original contianer
58
NRTIs: Tenofivir alafenamide, TAF (Vemlidy)
*preferred therapy
-25 mg daily with food (crcl < 15 = not rec)
Warnings: renal toxicity, fanconi syndrome, osteomalacia and dec bone mineral density
SEs: nausea
--> TAF is associated with dec renal and bone toxicity
--> only approved for treating HBV (not HIV)
59
NRTIs: Entecavir (Baracclude)
*preferred therapy **take on empty stomach
-tx niave: 0.5 mg daily
-lamivudine-resistant: 1 mg daily
SEs: peripheral edema, ascites, inc LFTs
-food recuded AUC by 18-20%; take on an empty stomach (2 hours before or after a meal)
60
NRTIs: Lamivudine (Epivir HBV)
-100 mg daily (150 mg BID or 300 mg daily if co-infected with HIV)
BBW: do not use Epivir HBV for tx of HIV - can result in HIV resistance
SEs: headache, N/V/D, fatigue, insomnia, myalgias
61
NRTIs: Adefovir (Hepsera)
-10 mg daily
BBW: caution in pts with renal impairment or those at risk of renal toxicity
SEs: headache, weakness, abdominal pain, hematuria, rash
62
Interferon Alfa for the tx of chronis HBV: Pegylated interferon-alfa-2a (Pegasys)
SC dose weekly
BBW: can cause or exacerbate neuropsychiatric, autoimmune, ischemic or infectious disorders, if use with ribavirin, teratogenic/anemia risk
CI: autoimmune hepatitis, decompensated liver disease in cirrhotic pts, infants/neonates
SEs: CNS effects, GI upset, inc LFTs, myelosuppresion, flu-like symptoms; pre-treat with APAP and an antihistamine
63
Lab tests for liver disease
-acute liver toxicity: inc AST/ALT
-chronic liver disease: inc AST/ALT, alk phos, Bili, LDH, PT/INR, dec albumin
-alcoholic liver disease: inc AST > inc ALT, inc gamma-glutamyl transpeptidase (GGT)
-Hepatic encephalopathy: inc ammonia
-Jaundice: inc Tbili
64
Childs-Turcotte-Pugh classification of liver disease
Class A (mild disease): < 7
Class B (moderate disease): 7-9
Class C (severe disease): 10-15
--> the model for end stage liver disease (MELD) ranges from 6-40
65
What is a natural product used in tx of liver disease?
-Milk thistle
66
Select drugs with a Boxed warning for liver damage
-Acetaminophen (high doses, acute or chronic)
-amiodaraone
-isoniazid
-ketoconazole (oral)
-methotrexate
-nefazodone
-nevirapine
-NRTIs
-Propylthiouracil
-valporic acid
67
Alcohol associated liver disease tx
-can include fatty liver, alcoholic hepatitis and chronic hepatitis
--> chronic consumption of alcohol results in the secretion of TNF-alpha, IL-6, and IL-8 = inflammation, apoptosis and eventually fibrosis of liver cells
TX: naltrexone, acamprostate, thiamine, folate
68
Vasoconstricting medications for bleeding varices: Octreotide (Sandostatin)
-bolus: 25-100 mcg IV can repeat in 1 hour if hemorrhage not controlled
-continuous infusion: 25-50 mcg/hr x 2-5 days
SEs: bradycardia, cholelithiasis, biliary sludge
Monitoring: blood glucose, HR, ECG
69
Vasoconstricting medications for bleeding varices: Vasopressin (Vasostrict)
-infusion: 0.2-0.4 units/min IV, max duration 24 hrs
SEs: arrthythmias, chest pain, MI, dec cardiac output, inc BP, N/V
Monitor: BP, HR, ECG, fluid balance
70
Non-selective beta blockers for portal hypertension
nadolol (40 mg) and propranolol (20 mg BID) are used for primary and secondary prevention of variceal bleeding --> help to reduce portal pressure
71
Hepatic Encephalopathy
Symptoms: musty odor of breath or urine, changes in thinking, confusion, forgetfullness
--> a result of accumulation of gut-derived nitrogenous substances in the blood (ammonia, glutamate)
-tx includes reducing blood ammonia levels through diet and drug therapy
-first line: lactulose
-second line: rifaximin
72
Hepatic Encephalopathy tx: Lactulose
*1st line tx
-tx: 30-45 ml/hour until stool evacuation. PO 3/4 times a day, titrate to produce 2-3 soft BMs daily
-prevention: 30-45ml PO 3-4 times a day, titrate until 2-3 soft BMS a day
CI: low galactose diet
SEs: flatulance, diarrhea, dyspesia, abdominla pain
Monitor: BMs, ammonia
73
Hepatic Enephalopahty tx: Rifaximin
*2nd line tx
-TX: 400 mg PO Q8h x5-20 days
-Prevention: 550 mg PO BID
SEs: peripheral edema, dizziness, fatigue, nausea, ascites
monitor: mental status, ammonia
74
Ascites
-fluid accumulation within the peritoneal space that can lead to the development of bacterial peritonitis (SBS) and hepatorenal syndromw (HS)
-pts with ascites due to portal HTN should limit dietary sodium intake to <2 grams/day
75
Ascites treatment
-diuretic therapy: spironolactone monotherapy or w/ combination of furosemide
-in severe cases- abdominal paracentesis is needed to directly remove ascitic fluid
76
Spontaneous Bacterial Peritonitis (SPS)
-an acute infection of the ascitic fluid
-target streptococci and enteric gram - pathogens with ceftriaxone for 5-7 days
-pts who have survived an episode of SBP should receive secondary prophylaxis with oral cipro or bactrim
77
What are the common live vaccines? (MICRO-VY)
MMR
Intranasal influenza
Cholera
Rotavirus
Oral Typhoid
Varicella
Yellow fever
(TB, dengue, smallpox, ebola)
78
General rules for all vaccines
-vaccines can usually be given on the same day or spaced 4 weeks apart
-multiple vaccine series requires > 1 dose, the intervals between doses can be extended without restarting the series, but they should not be shortened in most cases
79
Live vaccines and antibody general rules
-MMR and varicella-containing vaccines require separation from antibody containing products (blood transfusion, IVIG)
--> vaccine - 2 weeks - antibody containing product
--> antibody containing product - 3 months or longer - vaccine
-simultaneous administration of vaccine and antibody is recommended for post-exposure prophylaxis of certain diseases
80
vaccinations can be given, if indicated, in the following situations:
-mild acute illness (slight fever, mild diarrhea)
-current antimicrobial treatment
-previous local skin reaction from a vaccine
-allergies: bird feathers, penicillin, allergies to products not in the vaccine
-pregnancy (except live vaccines), breastfeeding, preterm birth
-recent tuberculin skin test
-immunosuppressed person in the household, recent exposure to the disease or convalescence
-family hx of AEs to the vaccine
81
Vaccines for infants and children
- 3 dose hep B vaccine started at birth
-other vaccines started at 2 months: PCV13 or PCV 15, DTaP, Hib, polio, rotavirus
-live vaccines started at > 12 months: MMR, varicella
-no polysaccharide vaccines before age 2
82
Vaccines for healthcare professionals
-annual influenza
-hep B
-Tdap: 1 dose, if not up to date, then Td or Tdap every 10 years
-Varicella
-MMR
83
Vaccines for adolescents and young adults
-MCV4 (Menactra, Menveo, or MenQuadfi)
--> 2 doses, 1 dose at age 11-12 and 1 dose at age 16
--> first year college students
-HPV
--> rec at age 11-12, 2 or 3 doses depending on age started
-Tdap: first dose at age 11-12
84
Vaccines for those with sickle cell disease and other causes of asplenia
-H. influenzae type b (Hib) vaccine
-pneumococcal vaccine (19-64 y/o) with either
--> PCV20 x1
--> PCV15 x1 then PPSV23 x1 > 8 weeks later
-Meningococcal vaccines
--> menactra, menveo or menQuadfi
--> Bexsero or Trumenba
85
Vaccines for pregnancy
-live vaccines are contraindicated
-Influenza vaccine, inactivated can be given in any trimester
-Tdap x1 with each pregnancy (weeks 27-36)
86
Vaccines for immunodeficiency
-live vaccines are contraindicated
-pneumococcal vaccine (19-64 y/o) with either
--> PCV20 x1
--> PCV15 x1 then PPSV23 x1 > 8 weeks later
-herpes zoster vaccine (shingrix): > 19 y/o, 2 doses, 2-6 months apart
-vaccines with pts with HIV:
--> menactra, menveo or menquadfi
--> Hep A and Hep B
87
Vaccines for older adults
-shingrix, age > 50: 2 doses, 2-6 months apart
-Pneumococcal vaccine ( > 65 y/o), give:
--> PCV20 x1
--> PCV15 x1, then PPSV23 x1 > 12 months later (or > 8 weeks if immunocompromised)
88
Vaccines for people with diabetes
-Pneumococcal vaccine ( > 65 y/o), give:
--> PCV20 x1
--> PCV15 x1, then PPSV23 x1 > 12 months later (or > 8 weeks if immunocompromised)
-Hep B (age > 60)
89
Vaccinations for adults
-influenza
-Tdap,Td: Tdap x1 if not gotten previously then TD or Tdap q 10 years
-Shingles: all adults > 50 or > 19 yrs if immunocompromised
-HPV: < 26 y/o
-Hep A. Hep B
-meningococcal
-pneumococcal
90
Influenza vaccine tips
- can be given annually to all pts > 6 months
-6 months - 8 yrs (not previously vaccinated) : give 2 doses ( 4 weeks apart)
-egg allergy?
--> can receive age appropriate inactivated
--> egg free = Flublok (> 18 y/o), and Flucelax (> 6 months)
--> do not give the live vaccine (FluMist)
-Pregos: can recieve age appropriate inactivated
91
SC vaccine administration
-yellow fever
-Dengue
-Smallpox
-Monkeypox
92
IM or SC vaccine administration
-MMR
-MMRV
-Varicella
-PPSV23
-Polio
93
Intranasal vaccine administration
-FluMist (live vaccine)
94
PO vaccine administration
-Typhoid
-cholera
-rotavirus
95
What drugs are used for prophylaxis for travelers diarrhea?
-Bismuth subsalicylate 524-1050 mg PO 4 times a day (with meals and at bedtime)
-antibiotics (rifaximin preferred) --> only if there is a high risk of complication from TD
96
what drugs are used for tx of travelers diarrhea?
Mild TD: loperamide or bismuth subsalicylates
Moderate TD: loperamide +/- antibiotic
--> azithromycin or a quinolone
--> Rifaximin is an alternative
Severe TD: antibiotics +/- loperamide
--> azithromycin preferred
--> quinolones or rifazimin as alt
97
what are the inactivated travel vaccines?
-Hep A (Havrix, VAQTA)
-Hep B (Engerix-B, Heplisav-B)
-Hep A/B (Twinrix)
-Menigoccous (Menactra, Menveo, MenQuadfi)
-Polio (POL)
-Typhoid-IM (Typhim Vi)
98
What are the activated/live travel vaccines?
-Cholera-PO (Vaxchora)
-Typhoid-PO (Vivotif)
-Yellow Fever-SC (YF-VAX)
99
What medications should be started 1-2 days prior to travel?
-Doxycycline: take daily, stop 4 weeks after travel (prevents rickettsial infections and leptospirosis; preferred in hiking/camping) - causes photosensitivity
--> do not use in pregos and kids under 8 (tooth development/discoloration)
100
What medications should be started 1-2 weeks prior to travel?
-Chloroquine: stop 4 weeks after travel, take weekly,
--> SEs: retinol toxicity and vision changes, do no use in areas wehre chloroquine or mefloquine resistance
101
What medication is used for altitude sickness and motion sickness?
-Acetazolamine: take as prophylactic day prior to travel (125 mg BID) or on the day of the ascent.
--> SEs: polyuria, photosensitivity, taste alteration
CI: with sulfa allergy
102
What does a gram + organism show on stain?
thick cell walls and stain purple/blue
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What does gram - organisms show on stain?
think cell wall and stain pink/reddish color
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what are examples of gram + Cocci in clusters?
-staphyloccus spp. including MSSA or MRSA
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What are examples of gram + cocci in pairs and chains?
-streptococcus pneumoniae (diplococci)
-streptococcus spp. (inclusing S. pyogenes)
-enterococcus spp (VRE)
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What are examples of gram + rods?
-Listeria
-monocytogenes
-corynebacterium spp.
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What are examples of gram + anaerobes?
-peptostreptoccus
-propionibacterium acnes
-clostridioides difficile
-clostridium spp.
108
What are examples of atypical bacteria?
-do not stain!
-Chlamydia spp.
-Legionella spp.
-Mycoplasma pneumoniae
-Mycobacterium tuberculosis
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What are examples of gram - cocci?
Neisseria spp.
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What are examples of gram - Anaerobes?
-Bacteroides fragilis
-prevotella spp.
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What are examples of gram - coccobacilli?
-acinetobacter baumannil
-bordetella pertussis
-Moraxella catarrhalis
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what are examples of gram - rods that colonize the gut (enteric)?
-proteus mirabilis
-escherichia coli
-klebsiella spp.
-serratia spp.
-enterobacter cloacae
-citrobacter spp.
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What are examples of gram - rods that do NOT colonize the gut?
-Pseudomonas aeruginosa
-Haemophilus influenzae
-Providencia spp.
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What are examples of gram - bacteria that are curved or spiral shaped rods?
-H. pylori
-Campylobacter spp
-Treponema spp
-borrelia spp
-leptospira spp
115
What is MIC?
Minimum inhibitory concentration: the minimum concentration of each antibiotic that inhibits bacterial growth
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what are the common resistant pathogens? (Kill Each And Every Strong Pathogen)
K: klebsiella pneumoniae (extended spectrum beta lactamase (ESBL) & carbapenem resistant enterobacterales (CRE)
E: e. coli (ESBL, CRE)
A: acinetobacter baumannii
E: enterococcus faecalis, enterocooccus faecium (vancomycin resistant enteroccus (VRE)
S: staph aures (MRSA)
P: pseudomonas aeruginosa
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What antibiotics come with a warning of C.diff?
-all do but highest risk with:
-broad spectrum penicillins and cephalosporins
-quinolones
-carbapenems
-clindamycin (BBW)
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What are the hydrophilic abx and their properties?
-Beta-lactams, aminoglycosides, vancomycin, daptomycin, polymyxins
1- small volume of distribution = less tissue penetration
2- mostly renally eliminated = drug accumulation and SEs can occur if not dose adjusted
3- low intracellular concentrations = not active against atypical pathogens
4- poor-moderate bioavailability = IV:PO ratio is NOT 1:1
119
what are lipophilic agents and their properties?
-quinolones, macrolides, rifampin, linezolid, tetracyclines
1- large volume of distribution = better tissue penetration
2-mostly hepatically metabolized = potential for hepatotoxicity and DDIs
3- achieve intracellular concentrations = active against atypical pathogens
4- excellent bioavailability = IV;PO
120
Cmax:MIC (concentration dependent) dosing of abx
-aminoglycosides, quinolones, daptomycin
Goal: high peak (inc killing), low trough (dec toxicity)
Dosing strategies: large dose, long interval
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AUC:MIC (exposure-dependent) dosing of abx
-vancomycin, macrolides, tetracyclines, polymixins
Goal: exposure over time
Dosing strategy: variable
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Time > MIC (time-dependent) dosing of abx
-Beta-lactams (penicillins, cephalosporins, carbapenems)
Goal: maintain drug level > MIC for most of the dosing interval
Dosing strategy: shorter dosing interval, extended or continuous infusion
123
how do beta-lactam abx work?
ex: penicillins, cephalosporins and carbapenems)
-have a chemical structure that is characterized by a beta lactam ring
-they inhibit bacterial cell wall synthesis by binding to penicillin-binding proteins = prevents the final step of peptidoglycan synthesis in bacterial cell walls
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Safety/SE/Monitoring of penicillin class abx
-BBW: pen G benzathine (IM ONLY) - not for IV use, can cause cardiorespiratory arrest and death
-CI: CrCl < 30- do not use ER oral formulations of amoxicillin and augmentin XR or the 875 mg of augmentin
-SEs: seizures (w/ accumulation), GI upset, diarrhea, hemolytic anemia
-Monitor: renal function
125
Natural Penicillins
- Pen V potassium: PO
-Pen G aqueous (Pfizerpen): IV
-Pen G benzathine: IM (1.2-2.4 million units x 1)
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Anti-staphylococcal Penicillins
-Dicloxacillin PO
-Nafcillin IV/IM
-Oxacillin IV
--> preferred for MSSA soft tissue, bone and joint, endocarditis and bloodstream infections
--> no renal dosing adjustments
--> Nafcillin is a vesicant: admin through a central line is preferred; if extravasation occurs, use cold packs and hyaluronidase injections
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Aminopenicillins
-Amoxicillin PO
-Amoxicillin/Clavulanate: PO
-Ampicillin: PO/IV/IM
-Ampicillin/Sulbactam (Unasyn): IV
--> ampicillin PO is rarely used due to poor PO biavailability: amoxicillin PO is preferred if switching from IV ampicillin
--> amox/clauv: use a 14:1 ratio to dec diarrhea cause by the clauv part
--> IV ampicillin and ampicillin/sulbactam must be diluted in NS only
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Extended - Spectrum Penicillins
-Piperacillin/Tazobactam (Zosyn) IV
--> contains 65 mg Na per 1 gram of piperacillin
129
Penicillin Drug Interactions
-Probenecid can inc the level of beta lactams by interfering with renal excretion, this combination is sometimes used in severe infections to inc antibiotic levels
-Penicillin can inc the serum concentrations of methotrexate
-Beta-lactams (except nafcillin and dicloxacillin) can enhance the anticoagulant effect of warfarin be inhibiting the production of vit K
-nafcillin and dicloxacillin can inhibit the anticoagulant effect of warfarin
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Class features of penicillins
-all penicillins should be avoided in pts with a beta-lactam allergy
--> exception: tx of syphilis during pregnancy (all pts) or in pts with poor compliance/follow-up = desensitize and treat with pen G benzathine
-all penicillins increase the risk of seizure if accumulation occurs
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Key features of Penicillins: outpt (oral therapy)
-Pen VK: 1st line tx for pharyngitis (strep throat) and mild non-purulent skin infections (no abscess)
-Amoxicillin: 1st line tx for acute otitis media (ped dose = 80-90 mg/kg/day)
--> drug of choice for infective endocarditis prophylaxis before dental procedure ( 2 g PO x 1, 30-60 mins before)
--> used in H. pylori tx
-Amox/Clauv: 1st line tx for acute otitis media (ped dose = 90 mg/kg/day) and bacterial sinusitis --> use the lowest dose of clauv to decrease diarrhea
-Dicloxacillin: covers MSSA only (no MRSA) and no renal dose adjustment needed
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Key features of penicillins (Parenteral therapy)
-Pen G Benzathine: drug of choice for syphilis (2.4 million units IM x1), not for IV use = can cause death
-Nafcillin/Oxacillin:covers MSSA only (no MRSA) and no renal dose adjustment needed
-Pip/tazo (Zosyn): only penicillin active against Pseudomonas, extended infusions (4 hrs) can be used to maximize T > MIC
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1st generation cephalosporins
-excellent activity against gram + cocci and preferred for MSSA
-Cefazolin IV/IM
-Cephalexin (Keflex): used for skin infections (MSSA) or strep throat: PO 250-500 mg q6-12 hrs
(cefadroxil)
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2nd generation cephalosporins
-Cefuroxime: cover staphlocci, S. pneumonae, haemophilus, neidderia, proteus, E. coli and klebsiella (PO/IV/IM) --> PO use for acute otitis media, CAP
-Cefotetan & Cefoxitin: (IV/IM) added activity against gram - anaerobes (B. fagilis)
135
3rd generation cephalosporins (group 1)
-cover resistant streptococci (s. pneumoniae and viridans), MSSA, gram + anaerobes and resistant strains of HNPEK
-cefdinir (PO)- used for acute otitis media
-ceftriaxone (IV/IM)
-cefotaxime (IV/IM)
-cefixime (PO)
-cefpodoxime (PO)
136
3rd generation cephalosporins (group 2)
-lacks gram + activity but covers pseudomonas
-Ceftazidime (IV/IM)
137
4th generation cephalosporins
-cefepime: has broad gram - activity (HNPEK, CAPES, and pseudomonas) and gram + activity similar to ceftriaxone
138
5th generation cephalosporins
-ceftaroline: has gram - activity similiar to ceftriaxone, but broad gram + activity
-only beta-lactam that covers MRSA
--> common uses: CAP, skin and soft tissue infections
139
Cephalosporin drug interactions
-insoluble precipitates may form when ceftriaxone is administered in the same line as calcium-containing IV fluids
-drugs that decrease stomach acid can decrease the bioavailability of some oral cephalosporins
--> cefuroxime, cefpodoxime and cefdinir should be seperated by 2 hours from short acting antiacids --> avoid H2RAs and PPIs
140
1st gen cephalosporin inpatient use
-cefazolin: surgical prophylaxis
141
2nd gen cephalosporin inpatient use
-cefotetan and cefoxitin:
-anaerobic coverage (B. fragilis)
-common uses: surgical prophylaxis (GI procedures)
--> cefoteran can cause a disulfiram-like reaction with alcohol ingestion
142
3rd gen cephalosporin inpatient use
-ceftriaxone and cefotaxime
-common uses: CAP, meningitis, spontaneous bacterial peritonitis, pyelonephritis
--> ceftriaxone: no renal dosing needed, do not use ceftriaxone in neonates (age 0-28 days)
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Carbapenems do NOT cover
atypicals, VRE, MRSA, C. diff, stenotrophomonas
--> ErtAPenem does not cover PEA: pseusomonas, enterococcus, acinetrobacter
144
Cabapenem drugs: Meropenem and Ertapenem
M: IV
E: IV/IM: stable in NS only
CI: anaphylaxtic reactions to beta-lactams
-Warning: do no use with PCN allergy, CNS effects like seizures
-SEs: diarrhea, rash/DRESS, bone marrow suppression with prolonged use
-Monitor: renal function
--> Imipenem is combined with cilastatin to prevent drug degradation by renal tubular dehydropeptidase
(E:commonly used for diabetic foot infections)
145
Carbapenem class effects
-all active against ESBL-producing organisms and (except E) pseudomonas
-do not use with penicillin allergy
-seizure risk (with higher doses & failure to renally dose)
146
Carbapenems common uses
-polymicrobial infections (diabetic foot infections)
-empiric therapy when resistant organisms are suspected
-ESBL-positive infections
-resistant pseudomonas or acinetrobacter infections
--> all are IV only, ertapenem must be diluted in normal saline
147
Monobactam: Aztreonam
-inhibits bacterial cell synthesis by binding to penicillin binding proteins --> which prevent the final step of peptidoglycan synthesis in bacterial cell walls
-covers many gram - organisms: pseudomonas and CAPES
**used when there is an penicillin allergy
148
Key features of aminoglycosides
-kill gram - pathogens, are synergistic with beta-lactams from some gram + organisms and have low resistance and drug cost
-gentomycin and streptomycin are used for synergy, in combo with a beta-lactam or vancomycin, when treating gram + infections
-have notable toxicity that require monitoring nephrotoxicity and ototoxicity, which may be irreversible
149
Aminoglycosides dosing
-traditional dosing = uses lower doses more frequently
-extended interval dosing = higher doses less frequently --> less accumulation of drug, loer risk of nephrotoxicity and decreased cost (also gives time for the kidney to recover between doses
150
Amino glycoside: Gentamicin
-IV, IM, opthalmic, topical: 1-2.5 mg/kg/dose
-crcl > 60: q 8hr
-extended iv dosing: 4-7 mg/kg/dose
151
Aminoglycosides: SEs,/Safety/Monitoring
BBW: nephrotoxicity, ototoxicity, neuromuscular blockade
SEs: use caution in pts with renal disease or elderly and those taking other nephrotoxic drugs (amphotericin B, cisplatin, polymixins, cyclosporine, loop diuretics, NSAIDs, radiocontrast dye, tacrolimus and vanco)
-Monitor: drug levels, renal function,
--> draw a trough level immediately before (30 min) the 4th dose; draw a peak level 30 min after the 30 min infusion for the 4th dose
152
Aminoglycosides: Tobramycin
-IV, IM, opthalmic, inhaled (for CF)
-T IV dosing: 1-2.5mg/kg/dose
-E IV dosing: 4-7 mg/kg/dose
-crcl > 60 = q 8 hrs
153
Aminoglycosides: Amikacin
-IV, IM
5-7.5 mg/kg/dose q 8 hr
154
Quinolones: Safety, SEs, Monitoring
BBW: tendon inflammation and/or rupture, peripheral neuropathy, seizures (has CNS effect)
CI: cipro and tizanidine
Warnings: QT prolongation (highest with moxi), hypo/hyperglycemia, psychiatric disturbances, avoid systemic quinolones in children and prego/breastfeeding, photosensitivity
SEs: N/V/D, headahce, dizziness, SJS/TEN
155
Quinolones: Ciprofloxacin
*anti-pseudomonal (including pneumonias)
-PO: 250-750 mg q 12
-IV: 200-400mg q8-12
(crcl 30-50 = q 12, crcl < 30 = q 18-24)
CI: cipro & concurrent admin of tizanidine
--> Cipro oral suspension: shake well, do not administer thru NG or feeding tube
--> can cruch immediate release tabs, mix with water and give via a feeding tube, hold tube feedings at least 1 hr before and 2 hrs after the dose
156
Quinolones: Levofloxacin
*anti-pseudomonal (including pneumonias)
*respiratory quinolones (s. pneumoniae activity)
*IV:PO = 1:1
PO/IV: 250-750 mg qd
-CrCl: < 50 = Q 48hrs or dec dose
157
Quinolones: Moxifloxican
*only drug in class that is not renally adjusted (do not use for UTIs)
*IV:PO = 1:1
-IV/PO: 400 mg q 24 h
158
Quinolones: drug drug interactions
-antacids and other polyvalent cations can chelate and inhibit quinolone absorption & should not be taken at the same time
-lanthanum and sevelamer can dec the serum concentration or oral quinolones ; separate admin by at least 2 hrs before & after
-can inc affects of warfarin
-inc effects of sulfonylureas, insulin & other hypoglycemic drugs
-qt-prolonging
-Probenecid and NSAIDs can inc quinolone levels
-cipro is a strong CYP1A2 inhibitor = inc levels of caffine, theophylline and tizanodine by redusing metabolism
159
Macrolides: random facts
-bind to the 50s ribosomal subunit
-excellent coverage of atypical (legionella, chlamydia) but utility against S. pneumoniae, haemophilus, chlamydia and morexella
160
Macrolides: Azithromycin
-zpack: 500 mg day 1, 250 mg days 2-5
-IV: 250-500mg daily
-no renal dose adjustments needed
*Used for: COPD exacerbations, pertussis, chlamydia (in pregos), prophylaxis for mycobacterium avium complex, severe traverlers diarrhea
161
Macrolides: Safety/Side effects/ Monitoring
CI: hx of cholestatic juandice/hepatic dysfunction w/ prior use
*do not use clarithromycin and erythromycin with lovsatatin or simvastatin
Warnings: QTc prolongation (E > A> C), hepatotoxicity,
SEs: GI upset
162
Macrolides: Clarithromycin
PO: 250-500 mg q 12 or 1 g (ER) qd
-used in H. pylori tx regimens
-caution in pts with CAD
163
Macrolides: Erythromycin
-dosing depends on product
-increases gastric motility and is used for gastroparesis
*highest risk of qtc prolongation
164
Macrolides: drug drug interactions
-E and C are major substrates of CYP3A4 and are inhibitors --> CI with lova and simva
-caution with CVD, dec potassium and magnesium & other QTc prolonging drugs
165
Tetracyclines:
