Flashcards in pharm cases Deck (147):
Case 1: 32 y/o woman in urgent care with viral gastroenteritis of two days associated with diarrhea. Lo estrin FE 1/20. mild discomfort to palpation without organomegally. Folic acid. Multivitamin. Na 136mEq/L (135-145); K 4mEq/L (3.3-4.9) ; BUN 15mg/dL (8-25).
3 DOC you could use in her?
3. dietary fiber
Case 2: 75 y/o who has had a partial gastrectomy for gastric cancer. his chronic diarreah is not relieved by fiber or loperamide therapy. AMI. COPD. CKD stage 3. Hyperlipidemia. Allergies ASA. Metoprolol succinate 50 mg, albuterol MDI PRN, atorvastatin 40 mg. bowel sounds active. no palpable organs. discomfort to deep palpation. eGFR 32 ml/min; BUN 20 mg/dL (8-25); Na 132 mEq/L (135-145); K 4 mEq/L (3.3-4.9)
DOC? watch for?
since on BB watch for hypotension since there is Dx-Dx interaction
**monitor her for gallstones because this is a SE of this medication!**
what is the drug class for loperamide?
what is the MOA of loperamide?
inhibition of presynaptic cholingergic nerves in colonic submucosal and mysenteric plexsus and slows transit time
what is the drug class for koalin-pectin?
what is the MOA of koalin pectin?
a clay (koalin) that is a plant polysacchride (pectin) that absorbs fluids and bacterial toxins
what is the drug class for dietary fiber?
what is the MOA of dietary fiber?
absorbs and binds fluids, provides stool bulk
what is the drug class for octreotide?
synthetic somatostatin analogue
what are 3 SE you need to monitor really carefully in a patient taking octreotide for diarreah?
1. gallstones with longterm use--occur in 50% if people
2. hypoglycemia if diabetic!!
3. bradycardia if taking BB or CCB!!
what is a drug drug interaction with octreotide?
BB and CCB
what does octreotide cause?
delayed gastric entry
case 3: 30 y/o with ulcerative colitis txed with mesalamine or 5-ASA. she is fatigued and you discover a macrocytic anemia. Loestrin 1.5/30. mesalamine 1 gm Q6. non palpable organs, no pain. BS active. No neuropathy. H&H 10.5/32.
what two labs do you want to check?
Tests: order B12/folate levels!! **suspect anemia here**
Mesalamine can inhibit folate absorption so want to check and see if her folate or B12 levels are down, need to check one becasue they can mask each other!!
B12 deficient anemia has....
what is the drug class of mesalamine?
what is the MOA of mesalamine?
local colon anti-inflammatory action and systemic prostaglandin inhibittion
what is a SE of mesalamine used for anti-inflamatory?
can inhibit folate absoprtion.....so consider supplementation if levels low!
when should you bring someone back when treating macrocytic anemia with both B12 or folate?
3-4 weeks should start to see results!!
Case 4: 35 y/o has chrohns disease that was initially controlled with sulfasalazine, however she was recently referred to a gastroenterologist because she needed more steroids to control her sxs. she comes to see you after being started on azathioprine. Crohns. Depoprovera 150 mg Q3 months, sulfasalazine 1 gm BID, azathioprine 100 mg daily. folic acid 1 mg daily. what should she be watching for?
azathioprine is a IMMUNOSUPPRESSANT so needs to watch out for increased risk of infections
what is the drug class of azathiopurine?
purine analogue immunosuppressant
what is the MOA of azathiopprine?
inhibits synthesis of DNA, RNA, and proteins
what are the 3 SE you need to keep in mind when prescribing azathioprine?
1. pancreatitis (statorreah)
2. hepatotoxiticiy (jaundice)
3. bone marrow toxicitiy
how long does it take to get the full effect of azathiorine?
Case 5: 85 y/o man who is bedbound and has constapation that hasn’t responded to increased fluids, fiber, or dietary modifications. he hasn’t had a BM in 4 days and his last BM was dry hard and small. Dementia. HTN. COPD. Constapation. Amlodipine 5 mg, atrovent MDI PRN. BUN 30mg/dL (8-25); eGFR 25 mL/min; Na 138mEq/L (135-145); K 4.5 mEq/L (3.3-4.9).
acute: PEG 3350
Chronic: senokot and docusate Na
DO RECTAL EXAM TO MAKE SURE NOT IMPACTED!!!
**keep in mind the reason fiber didn't work well for him was because you have to have a lot of fluids and in elderly it is hard to get them to take the adequate amouth?***
why might a small dose of fiber not work well for an elderly person for constapation?
Fiber is difficult for an elderly person because they often do not drink enough. Cannot rely on him to drink enough.
what drug would you typically use for acute constipation since it is for short term use?
what is the drug class for PEG 3350?
what is the MOA of PEG3350?
causes water retention in stool and increased stool frequency
what is the drug class for senokot?
what is the MOA of senokot?
stimulate enterocytes, neuros, and GI smooth muscle causing low grade inflamation and intestinal motility
what is the drug class for docusate Na?
what two drugs might you combine for chronic tx of eldery constapation?
docusate Na and senokot
Case 6: 55 y/o who presents with coffee ground emesis x 1 day. Cirrhosis hx and pt has had prior episode of UGI bleed secondary to esophageal caricies and portal HTN. Alcohol abuse, cirrhosis, portal HTN, COPD, tobacco abuse, HTN. Albuterol MDI, Lisinopril. liver edge palpable, hard. H&H 12/35; BUN 20mg/dL (8-25); K 4.6 mEq/L (3.3-4.9); Na 143mEq/L (135-145)
ADMIT THIS PATIENT!! ESOPHAGEAL VARICES!!!
DOC1: octreotide--constricts the splanchnic arterioles
since this pt is already vomiting, osctreotide will stop the bleeding but has the SE Of nausea...so give onsansetron (zofran) to help with the nausea
what is the drug class for ondansetron?
what is the MOA of ondansetron?
periphreal and CRTZ 5-HT3 receptor blockade
what is the typically indication for ondansetron?
only for post op, radiation, and chemotherapy induced N/V
what is the MOA of octreotide?
splanchnic arteriole constriction
synthetic analog of somatostatin
Case 7: 25 y/o dxed with chronic hep C, genotype 1. His specialist has recommended a tx but he is hesitant to accept his advice and seeks your advice. specialist recommended a standard regimen of an injectable and two oral medications. Heroine abuse, chronic hep C. anti-HCV antibodies pos with genotype 1. He wants to know goals of tx and if there are any other alternative txs that are easier to take with few SE.
what is 3 drug regimen?
what is an alternative?
1. PEG interferon
Although ledipasvir/sofosbuvir (harvoni) is more effective at treating hep C geneotype 1...what is the downside?
super expensive and unrealistic for many!!
~40,000 for 90 tabs!!!
what is the drug class for ledipasvir/sofosbuvir?
direct acting antiviral RNA polymerase inhibitor
what is the MOA of ledipasvir/sofosbuvir?
inhibits the HCV protein needed for repliation aka RNA polymerase
what is the percent efficacy at ERRIDICATION of Hep C when using ledipasvir/sofosbuvir?
94% but the down side is it is super expensive!
Case 8: 75 y/o with PMH of liver failure who is admitted for abrupt change in cognition. Hx of chronic hepatitis where se refused care after failing tx on interferon/ribavirin. She was found on the floor semiconcious. liver failure, HTN, DMT2, CKD4, anemia of chronic dxs, easy bruising, chronic hepatitis. lisinopril 40 mg, glargine insulin 30 units daily, metforming 500 mg BID. she has portal-systemic encepalopathy.
2 DOC for portal system encephalopathy?
CHRONIC LIVER FAILURE causes the build up of toxins like ammonia in the blood
when digested by the bacterial in the gut, it produces acid which takes the ammonia NH# and converts it to NH4 , which cant cross gut wall and also ENHANCES DIFFUSION OF NH3 from serum into gut!!
DOC2 if first not working: RIFAXIMIN abx
this kills off the bacterial because these help in the conversion of ammonia
what are the two DOC for portal encephalopathy?
what is the drug class for lactulose?
what is the MOA of lactulose? 3
1. synthetic dissachride laxative
2. bacterial digestion of lactulose produces acid pH converting NH3 to NH4, which can't cross the gut wall (inactives ammonia and precents it from being absorbed)
3. enhances diffusion of NH3 from serum into gut lumen
what is the MOA for rifaximin?
inhibits bacterial RNA-synthesis by binding to bacterial RNA polymerase
what is the is the drug class for rifaximin?
Case 9: 65 y/o with chronic pancreatitis who has noted an increase in steatorrhea over the past month. alcohol abuse, chronic hepatitis, tobacco use, COPD, HTN, CKD stage 3. albuterol MDI, lisinopril 20 mg, pancrlipase 35,00 units per meal.
3 DOC options?
pancreatitis means that he isn't produce enough pancreatic enzymes to break down the fats, so you must supplement
DOC1: increase dose of pacrelipase (increase supllemental enzymes)
DOC2: switch to the enteric coated version of this drug that are microspheres called creon
DOC3: add a PPI to decrease the aciditiy so these capsules can make it down to the duodenum where they do their work
what is the drug class for pancrelipase?
what is the MOA of pancrelipase?
supplemental enzymes (lipase, amylase, protease)
how can pancrelipase be taken?
sprinkle microspheres capsule on soft, low pH, no chew foods
what can interfere with pancrelipase?
dairy products because of the high pH
what are pancrelipase derived from? why important?
derived from pork, so don't use in someone with a pork sensitivity
if someone has statorhhea, what does that suggest?
they don't have enough pancreatic enzymes because this is what breaks down fat!!
what should you do if you are nontherapeutic on a pancreatic enzyme supplement? pancrelipase
INCREASE THE DOSE!!!!
what should the max fat intake be for someone with pancreaititis or taking pancrelipase?
how should you initiate a pancrelipase?
start with a non-enteric coated option and then switch to an enteric coated option if that doesn't work
case 10: 80 y/o man who is recovering from a left hip repair from MVA. he is 1 day post op and has experienced an abrupt onset of confusion and has now had a seizure. HTN. lisinopril 10 mg, meperidine via PCA at 0.2 ml of 10 mg/mL solution with 5 min lockout between doses (max 600mg hours). eGFR 45 ml/min
what to do?
STOP THE MEPERIDINE!!!!
***THIS IS CONTRA IN ELDERLY AND CAN CUASE CONFUSION AND SEIZURES DUE TO THE TOXIC METABOLITE***
what is the drug class for merperidine?
opiod analgesic synthetic
what is the MOA of merperidine?
binds to mu opoid receptors in the CNS and inhibits ascending pain pathways
what is the toxic metabolite produced by merperidine?
normeperidine so only use for short term LESS THAN 48 H
who is merperidine contraindicated in? why?
causes confusion and seizures as a SE from toxic metabolite!!!
what are the two indications for merperidine?
peri-op and acute pancreatitis
Case 11: 29 y/o with substernal discomfort that wakes him up 2-3 times per week, esp after a stressful night at work. Gets to sleep around 2 am after working at a restaurant.He doesn't have insurance. antacids relieve his sxs for about a hour or so and then they recur and wake him. obesity. BMI 36.
when should you take ranantadine?
~6pm because the most acid production occurs at 7pm
what are the most effective drug class for tx of nocturnal dyspepsia?
H2 receptor blockers
should pts be on a PPI long term?
what should you do for someone who has GERD?
endoscopy to look for barretts esophagus
how is ranantadine used?
what is the drug class for ranantadine?
H2 receptor blocker
what is the MOA of ranatadine?
competitive inhibition of H2 receptor of gastric parietal cells and reduce basal stimulated acid production
what is the MOA of the two PPIs/
shuts down the pumps!!
inhibits basal and stimulated parietal cells protein pump secretions
what are the two PPI?
how long does it take for the PPIs omeprazole and pantoprazole to become effective? why?
3-5 days since only ~10% of PP are active at a time so takes longer to knock out the active pumps
how long can the PPIs be used?
12 weeks or 3 months
what is the SE you need to be concious of when taking omeprazole long term?
gastric atrophy with long term use
what are the 3 indications to stop taking omprezole?
1. GERD-reevaluate every 3-6 months and try to down titrate the dose, always use lowest effective dose
2. duodenum ulcers: after 4 weeks
3. gastric ulcers: after 6-8 weeks`
what is used to convert clopidegrel to the active form and why does this influence the use of PPI Omeprazole?
so does PPIs!
so they are fighting over the resources to use this pathway and there isn't enough for both so you decrease the effectiveness when using the PPI omprezole
Case 12: 55 y/o with epigastric discomfort, excessive burping day and night and a bitter taste in her mouth 4-5 tims a week. 20 pack year smoking hx. no blood or mucous in stool. Obesity, tobacco abuse, afib,COPD. BMI 44.ALLERGIES: ASA (bronchospasm), warfarin (hives), dabigitran (hives) MEDS: clopidigrel. new chest xray showing hyperinflated and diaphragm flattened bilaterally.
2 DOC options?
normaly omeprazole, but since using clopidrel this drug is contradindicated
NEW DOC: pantoprazole
which should you use first H2 or PPI?
H2 receoptor inhibitor
what is a unique instance you might see a PPI be used that is untraditional?
in surgeries because this is a stressful situation and so the body increases acid production so this helps with that
what is the drug class for sucralfate?
what is the MOA of sucralfate?
forms a paste that forms barrier by binding selectively to gastric mucosal ulcers
what is the indication for sucrafactant?
duodenal or gastric ulcers
what is the drug class for misoprostol?
mucosal NSAID protectant
what is the MOA of misoprostol?
synthetic prostaglandin E1 analog replaces protective prostaglandin inhibited by the NSAID therapy
what is the indication of rmisoprotostol?
NSAID induced gastric ulcers
when do you use sucrafactant and misprostol?
in already existing ulcers
when should you take prantoprazole?
take half hour to one hour prior to breakfast meal and other meds!!!
what is the responsible agent for pud?
what are the choices for DX in a patient with gastric ulcer and suspecting H. pylori?2
1. GOLD STANDARD: ENDOSCOPY AND BX
2. breath test to smell for urea
what is the drug class for ranitidine?
what is the MOA of ranitidine?
competitive H2 receptor of parietal cells
what are the two indications for ranitidine?
Case 13: 75 y/o lady with 3 days history of mild aching, LLQ abdominal discomfort and constipation. HTN. Amlodipne 5 mg daily. mild discomfort to LLQ palpatation. moveable fusiform mass, BS intact. DRE neg for blood. CBC w/diff: WBC 10,000 (4,000-10,000), segs 70% (50-65%)
DOC: cipro and metronidazole
TOC: CT with contrast unless BMI over 30
what do you now want to mix metronidazole with? why?
alcohol creates a disulfram like reaction with profuse vomiting
Case 14: 75 y/o lady treated for the past week with IV primaxim for MRSA pneumonia. Her pneumonia is better but now she has 8-10 fluid stools per day without blood or mucous. Pneumonia-MRSA, T2Dm, HTN, CKD 4. IV primaxim, amlodipine. diffuse discomfort to palpation in LLQ w/o palpable mass.
DOC1? if that didn't work?
DOC2: vancomycin if that didn't work, treats Cdiff and MRSA so she is getting double treatment
STOP THE PRIMAXIN since causing the c.diff
when thinking about txing c.diff, what two drugs should you think of?
1. metronidazole first
2. vancomycin 2nd (mrsa)
what can primaxim be used to tx?
pseudomonas intestinal infection
Case 15:58 y/o presents with gnawing epigastric discomfort for past month without hematemesis. awakes at night 2x per week. nausea but no vomiting. He does not smoke, take NSAIDS, or drink. Transiently relieved by antacids. UGI endoscopy reveals a small duodenal ulcer and bx is pos for H. pylori.
two DOC regimens?
Triple: PPI, Clarithromycin, Amox or Metronidazole x 14 days
Quadruple: PPI, Tetracycline, Metronidazole, Bismuth
what is the eradication of H. pylori when using quadrouple therapy?
Case 16: 26 y/o with daily intermittent crampy abdominal pain with multiple loose stools a day. No mucous or blood in stools. wants to reduce the number of stools a day so it doesn’t interfere with his work.
what do you need to be careful when txing patient with crohns colitis/inflammation dxs?
using an antidiarreal since increases the risk for bowel obstruction or toxic megacolon
Case 17: 55 y/o with recurring episodes of gout in 1st metatarsal. you are starting on allopurinol to control his sxs and using ibuprofen as bridge therapy. he gets a small bleed. GOUT. UGIB. allopurinol 100 mg daily. ibuprofen 800 mg TID.
STOP THE NSAIDS!!!
DOC1: use COX2 selective celecoxib short term
DOC2: start PPI at high dose, consider with H2
DOC3: misoprotosol-proection against NSAID
DOC4: sufrafate-coats the ulcer
what two DOC should you think of if a patient already has an ulcer?
misoprostol- protection against NSAID
Sucrafate- mucosal protectant
what is the drug class for misoprostol?
what is the drug class for sucrafate?
surfactant producing agent that coats the ulcer
why do NSAIDS cause mucosal irritation?
inhibit prostaglandins that have a protective effect on the stomach lining
Case 18: 28 y/o male who had persistent nausea and vomiting while working on a boat. symptomatic on boat, however, just won a cruise. He wants to know what can help him on this 1 week cruise and prevent his vomiting.
2 DOC options?
2. SCOP patch (taken 4 hours prior)
**don't drink if taking scop patch because it is an anticholinergic and alcohol with increase the effects of this!!**
what is the drug class for ondansetron (sozfran)?
what is the indication for ondansetron?
only for post op radiation and chemotherapy
what is the MOA of ondanestron?
periphreal and CRTZ 5-HT3 receptor blockade
what is the drug class for dronabinol? 3 things
what are the two indications for dranabinol?
anti-emetic for chemo
what is the drug class for scopolamine?
what are the SE of scopolamine?
NO PEE SO SEE NO SHIT NO SPIT
what are the two drugs you should think about when thinking of preventing motion sickness?
how often and when do you use scopolamine?
1 patch 4 hours before and leave on f0r 72 hours
Case 19: 55 y/o patient receiving radiation therapy for laryngeal carcinoma. he gets nausea following his txs and is scared he might commit and have trouble with his airway. what can you recommend for him for prevention of vomiting?
Case 20: 38 y/o lady who got chem for breast cancer. she was nausea and vomiting after each tx. She wants to know what she can take for post chemo N/V. POP daily. BMI 24.
2 DOC combinations to consider
COMBO 1: dexamethasone plus aprepitant
(dexamethasone increases the efficacy of aprepitant so OFTEN used together)
COMBO2: odansatron plus aprepitant
***caution in her because aprepitant decreases efficacy of OCPS and she is taking POP***
what can prepitant used for chemc nausea do?
decrease the efficacy of OCPs/POPs!
what is the MOA of aprepitant?
blocks central NK1 receptors
what is the drug class for aprepitant?
what is the drug class for dexamethasone?
what is the MOA of dexamethasone?
enhances effect of 5-HT3 receptor
agonist of CRTZ
Case 21: 40 year old female has T2DM and persistent feelings of bloating and satiety after even small meals or snacks. her T2DM is well controlled and her postprandial sxs are making her very uncomfortable. SHe wants to know what else she can take for these sxs. T2DM, depression. Metformin 1000 mg BID. Venlafaxine XR 150 mg daily. (depression). BMI 30.
DRUG DRUG INTERACTION WITH VENLAFAXINE so watch out for this
**monitor for extrapyrimidal signs like terative disconesia**
drug does metoclopromide for daibetic gastroparesis interact with?
what do you give to calm a patient down if the are going crazy from SE of medication?
Case 22: 75 y/o with gastric reflux that makes it difficult for him to sleep at night. Trial of H2 blocker wasn’t successful.you have reccomended a proton pump inhibitor. He wants to know what SE he may experience if he uses this medication long term (over 2 months). HF. COPD. Fx left hip. furosemide 20 mg. symbicort 160/4.5 MDI 2 inh daily. Proventil HFA, ranitidine 3000 mg nightly (GERD).
what are 5 things you can be at increased risk for with long term PUD or with long term PPI use?
Accelerated gastric atrophy
incr CV risk
accelerated osteoporosis (since gastric atrophy prevents absorption of Ca)
C Difficile (CDAD)
what is one SE you need to keep in mind with PPI if patient taking other medications?
inhibit absorption effets of other medications they are on
what do you take a PPI?
PPI: take 30-60 mins prior to meal
when do you take a H2?
H2: give in evening at 6pm
what are 2 alarm sxs that should indicate the need for endoscopy?
1. coffee ground emesis
if a person is taking clopidigrel, what ppi can they use?
pantoprazole!!! KNOW THIS!!!
Case 23: 27 y/o with PMH of drug abuse and alcoholism. He also now has chronic hep C genotype 2. Drug abuse (MJ, cocaine, alcohol), tobacco use. mild RUQ discomfort. what are his tx options?
Sofosbuvir plus Ribavarin x 12 weeks
what is the tx for chronic hep genotype 1? time length
ledipasvir/sofosbuvir for 12 weeks
what is the tx for any other hep besides just chronic genotype 1?
+/- Peglated interferon
for 24 weeks
what drug is a tetragenic and therefore requires monthly pregancy tests?
what drugs should a parthner not take if there wife is pregnant?
ribavarin because it is extremely stong tetragenic
Case 24: 28 y/o female with IBS constipation predominant which has not responded to OTC laxatives, fiber, and fluids. SHe is miserable with adominal cramps and asks for tx. IBS-C. Lo-ovral.
2 DOC for IBS?
what are the two DOC for someone with IBS-C?
Case 25: 65 y/o male who is scheduled for screening colonoscopy and needs to have a bowel prep. what should you give him?
POLYETHYLENE GLYCOL FOR BOWEL PREP
what is the compound in bowel prep?
what must you do when taking someone off a PPI?
down titrate because they might get a passive production of acid!!! don't want this to happen and spark their sxs all over again!!!