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Pharmacology > Pharm III Final Exam > Flashcards

Pharm III Final Exam Flashcards

1
Q

what drugs are considered beta lactase?

A

penicillin, ampicillin, methicillin, piperacillin, azetreonam, impimenem and cephalosporins

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2
Q

what antibiotic classes target 30S inhibitors?

A

ahminoglycosides and tetracyclines

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3
Q

what antibiotic classes target 50S inhibitors?

A

macrolides, clindamycin, linezolid and chloramphenicol

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4
Q

what conditions are augmentin good for?

A

AOM, rhino sinusitis, pneumonia, UTI, GU, skin and soft tissue infections

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5
Q

what condition is zosyn good for?

A

abdominal infections

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6
Q

what are the adverse effects of beta lactase?

A

hepatotoxicity: agranulocytosis, thrombocytopenia, neutropenia

hepatotoxicity: DILI, cholestastic hepatic, acute hepatitis

neurotoxicity: seizures, status epilepticus, hallucinations, encephalopathy

nephrotoxicity: interstitial nephritis

mitochondrial toxicity

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7
Q

what antibiotics cross the BBB?

A

ceftriaxone, cefotaxime, vancomycin with rifampin

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8
Q

what is empiric therapy for community acquired disease in immunocompetent patients?

A

ceftriaxone or cefotaxime, if severe add vancomycin,

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9
Q

what is empiric therapy for community acquired disease in old or immunocompromised patients?

A

ceftriaxone or cefotaxime plus amoxicillin and vancomycin

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10
Q

what is empiric therapy for nosocomial disease?

A

vancomycin and ceftazidime or cefepime

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11
Q

treatment for otitis media?

A

amoxicillin, cefdinir, cefpodoxime, cefuroxime or ceftriazone

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12
Q

treatment of otitis media with beta lactam allergy?

A

doxycycline, azithromycin, clarithromycin

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13
Q

treatment of acute bacterial rhino sinusitis?

A

amoxicillin or augmentin

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14
Q

treatment of acute bacterial rhino sinusitis with penicillin allergy?

A

doxycycline or 3rd generation cephalosporin

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15
Q

outpatient treatment of CAP with no comorbidities

A

amoxicillin plus macrolide or doxycycline

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16
Q

outpatient treatment of CAP with comorbidities

A

augmentin cephalosporin with macrolide or doxycycline

or monotherapy fluoroquinolone

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17
Q

inpatient treatment of CAP with no comorbidites

A

beta lactam plus macrolide

or mono therapy fluoroquinolone

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18
Q

inpatient treatment of CAP with comorbidiites

A

linezolid plus pseudomonas coverage

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19
Q

triple treatment of H. pylori

A

PPI, amoxicillin, clarithromycin

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20
Q

quadruple treatment of H. pylori

A

PPI, bismuth, metronidazole, tetracycline

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21
Q

small intestinal bacterial overgrowth treatment

A

rifaximin, TMP-SMX, cipro, augmentin

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22
Q

treatment of uncomplicated UTI

A

cipro, levofloxacin, TMP-SMX

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23
Q

outpatient treatment of complicated UTI

A

ertapenem or ceftriazone with cipro, levofloxacin or TMP-SMX

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24
Q

inpatient complicated UTI treatment

A

ceftriaxone

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25
Q

prostatis treatment

A

fluoroquinolone or TMP-SMX

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26
Q

gonorrhea treatment

A

ceftriaxone

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27
Q

chlamydia treamtnet

A

doxycline

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28
Q

syphilis treatment

A

pen G

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29
Q

PID treatment

A

ceftriaxone, doxycycline and metronidazole

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30
Q

erysipelas treatment

A

penicillin, amoxicillin, cephalexin or cefadroxil

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31
Q

treatment of skin and soft tissue infection with sepsis or immunocompromised

A

vancomycin plus efepime

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32
Q

treatment of skin and soft tissue infection without MRSA risk

A

dicloxaacillin, cephalexin or cefadroxil

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33
Q

treatment of skin and soft tissue infections with MRSA risk

A

TMP-SMX, amoxicillin and doxycycline or linezolid

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34
Q

what are the fat soluble vitamins

A

ADEK

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35
Q

what are the water soluble vitamins

A

B complex and C

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36
Q

signs of B1 deficiency

A

beriberi: neuropathy, muscle weakness, cardiomegaly, edema, ophthalmoplegia, confabulation

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37
Q

signs of B2 deficiency

A

magenta tongue, stomatitis, seborrhea, cheilosis, ocular symptoms

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38
Q

sign of B3 deficiency

A

pellagra: dermatitis, red tongue, diarrhea, apathy, dementia, disorientation

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39
Q

signs of B6 deficiency

A

seborrhea, glossitis, convulsions, neuropathy, depression, confusion, microcytic anemia

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40
Q

signs of B9 deficiency

A

megaloblastic anemia, glossitis, depression, elevated homocysteine

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41
Q

signs of B12 deficiency

A

megaloblastic anemia, loss of vibration and proprioception, abnormal gait, demential, impotence, loss of bladder and bowel control, increased homocysteine and MMA

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42
Q

signs of vitamin C deficiency

A

scurvy: petechiae, ecchymosis, coiled hair, inflamed gums, join pain, poor wound healing

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43
Q

signs of vitamin A deficiency

A

MCC of blindness in developing countries

xerophthalmia, night blindness, bitot spots, follicular hyperkeratosis, impaired embryonic development, immune dysfunction

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44
Q

signs of vitamin D deficiency

A

rickets: skeletal deformity, rachitic rosary, bow legs, osteomalacia

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45
Q

signs of vitamin E deficiency

A

peripheral neuropathy, spinocerebellar ataxia, muscle atrophy, retinopathy

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46
Q

signs of vitamin K deficiency

A

elevated PTT, bleeding

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47
Q

what benefits does vitamin A provide?

A

vision and skin

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48
Q

what benefits does vitamin D provide?

A

bone health

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49
Q

who should be cautious when taking vitamin D?

A

hypercalcemia, renal failure, kidney stones, hyperphosphatemia

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50
Q

D3 is also known as what and it comes from what?

A

cholecalciferol, sun

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51
Q

D2 is also known as what and it comes from what?

A

ergocalciferol, food

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52
Q

what are the benefits of vitamin E?

A

antioxidant

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53
Q

what are the benefits of vitamin K?

A

synthesis of coagulation factors VII, IX, X, II

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54
Q

what is vitamin K1, K2 and K3?

A

K1: phytonadione
K2: menaquinone
K3: menadione

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55
Q

what are signs of calcium deficiency?

A

osteoporosis

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56
Q

what are signs of copper deficiency?

A

anemia, growth retardation, defective keratinization and pigmentation of hair, hypothermia, degemnative changes in aortic elastin, mental deterioration

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57
Q

what are signs of fluoride deficiency?

A

dental caries

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58
Q

what are signs of iodine deficiency

A

thyroid enlargement, low T4, cretinism

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59
Q

what are signs of iron deficiency?

A

pica, anemia, impaired cognitive development, muscle abnormalities, premature labor, increased perinatal maternal death

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60
Q

what are signs of phosphorus deficiency?

A

rickets, proximal muscle weakness, rhabdo, paresthesia, ataxia, seizures, confusion, HF, acidosis

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61
Q

what are signs of zinc deficiency?

A

growth retardation, decreased taste and smell alopecia, diarrhea, FTT, gonadal atrophy, congenital malformation

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62
Q

what vitamin can harm the baby during pregnancy?

A

A

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63
Q

what prenatal vitamin should be taken >1 month prior to conception or ASAP after conception and why?

A

folic acid, prevents neural tube defects

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64
Q

what nutritional deficiencies are associated with bariatric surgery?

A

B12, ADEK, calcium, iron

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65
Q

adverse effects of vitamin A?

A

dry skin, hyperpigmentation, alopecia, night sweats, anorexia, hepatomegaly, hyperlipidemia, polyuria, albuminuria, arthralgia, growth retardation, hypomenorrhea, increased ICP, ataxia, headache

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66
Q

adverse effects of vitamin D?

A

HTN, dysrhythmia, metallic taste, dry mouth, anorexia, bone pain, fatigue, headache

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67
Q

adverse effects of vitamin E?

A

n/v, flatulence, BUN elevation, weakness, increased bleeding, blurry vision, dizziness

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68
Q

adverse effects of vitamin K?

A

urticaria, hyperbilirubinemia, hemolytic anemia, headache, brain damage

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69
Q

adverse effects of B1?

A

angioedema, pruritus, cyanosis, CV collapse

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70
Q

adverse effects of B2?

A

urine discoloration

71
Q

adverse effects of B3?

A

hypotension, anxiety, dysrhythmia, peptic ulcer, hepatitis, hyperuricemia, hyperglycemia, flushing

72
Q

adverse effects of B6?

A

paresthesia, flushing, lethargy

73
Q

adverse effects of B12?

A

itching, diarrhea, fever, vascular thrombosis, optic nerve atrophy, flushing

74
Q

adverse effects of vitamin C?

A

abdominal cramping, renal stones

75
Q

calcium toxicity

A

renal insufficiency, nephrolithasis, impaired iron absorption

76
Q

fluoride toxicity

A

dental and skeletal fluorosis, osteosclerosis

77
Q

iron toxicity

A

GI, organ damage

78
Q

copper toxicity

A

n/v/d, hepatic failure, hemolytic anemia, mental deterioration

79
Q

zinc toxicity

A

gastritis, sweating, respiratory distress, pulmonary fibrosis

80
Q

risks of CAM

A

small amount of research, misses and harm can result due to increasing public use and inadequate communication

81
Q

pharmacological effects of echinacea

A

immune modulation: increased phagocytosis, monocytes, neutrophils and NK cells

anti-inflammatory: inhibits COX, 5-lipoxygenease and hyaluronidase, eczema benefit

antibacterial, fungal and antioxidant effects

82
Q

adverse effects of echinacea

A

unpleasant taste, GI upset, allergy

83
Q

pharmacologic effects of garlic

A

CV and metabolic: inhibits HMG-CoA reductase, reduces cholesterol and LDL

antimicrobial

antineoplastic: inhibits precarcinogens for colon, esophagus, lung, breast and stomach

possible systolic and diastolic reduction

84
Q

adverse effects of garlic

A

nausea, hypotension, allergy, odor, bleeding

85
Q

avoid garlic with

A

warfarin, aspirin, ibuprofen

86
Q

avoid echinacea with

A

compromised immune system, AI disorders, immunosuppresants

87
Q

pharmacological effects of ginkgo

A

CV: increased blood flow, reduces blood viscosity, vasodilation

CNS: cognition and ADL improvement with dementia and negative affects in schizophrenia

88
Q

adverse effects of ginkgo

A

nausea, headache, stomach upset, diarrhea, allergy, anxiety, insomnia

89
Q

avoid ginkgo

A

antiplatelets, anticoagulants, seizure disroders

90
Q

pharmacological effects of ginseng

A

cold prevention, lower postprandial glucose, cancer related fatigue

91
Q

avoid ginseng

A

psych patiens, estrogen or hypoglycemic medication, warfarin

92
Q

pharmacologic effect of St. John’s Wort

A

antidepressant

93
Q

adverse effect of St. John’s Wort

A

photosensitivity

94
Q

avoid St. John’s Wort

A

stimulants, decreases effective of: digoxin, OC, cyclosporine, HIV meds, warfarin, anticonvulsants

95
Q

pharmacological effects of saw palmetto

A

BPH: blocks conversion of testosterone to dihydrotestosteeon by 5 alpha reductase

96
Q

adverse effects of saw palmetto

A

abdominal pain, n/d, headache, fatigue, decreased libido, rhinitis

97
Q

what is coenzyme 10 used for?

A

HTN, CAD, chronic stable angina, prevention of statin induced myopathy, HF

98
Q

pharmacological effects of glucosamine

A

knee osteoarthritis
used to produce glycosaminoglycans and proteoglycans in articular cartilage

99
Q

adverse effects of glucosamine

A

mild diarrhea, abdominal cramping, nausea

100
Q

avoid glucosamine with

A

shellfish allergy, increases INR in warfarin

101
Q

pharmacological effects of melatonin

A

insomnia, sleep induction, jet lag, can reduce anxiety

102
Q

adverse effects of melatonin

A

drowsiness, fatigue, headache, irritability, depression, dysphoria, BP changes

103
Q

avoid melatonin with

A

NSAIDs, antidepressants, BB

104
Q

what drug is FDA banned due to counting ephedrine alkaloids causing unreasonable CV risks?

A

ephedra or Ma huang

105
Q

pharmacological effects if red yeast rice

A

statin activity

106
Q

describe homeopathy

A

symptoms are treated with a very dilute substance that would cause the same symptoms if given at a high dose, little to no active ingredient

107
Q

what is enteral nutrition?

A

any method of feeding that uses GI tract

108
Q

what is parenteral nutrition?

A

delivery of calories and nutrients through vein

109
Q

advantages of enteral nutrition

A

Maintains normal metabolic pathways
Allows delivery of a full range of nutrients
Triggers the release of cholecystokinin
Preserves hepatic lipid metabolism
Maintain normal intestinal pH and flora
Supports GI tract as an organ of the immune system
Promotes wound healing
Lowers cost
Reduces infectious complications

110
Q

indications of enteral nutrition

A

Poor oral intake: will not eat
Anorexia, depression, disability, eating disorder, early satiety, nausea, painful swallowing

Unsafe oral intake: can’t eat
Altered LOC, dysphagia, ET intubation, gastroparesis, impaired sucking swallowing, proximal intestinal obstruction

Elevated needs: can’t eat enough
Burns, open wounds, pressure ulcers, sepsis, trauma

111
Q

indications of parenteral nutrition

A

Anyone who cannot and will not eat or cannot maintain their fluid and/or nutritional status by oral eating or by tube feeding may be appropriate for IV nutrition

Conditions that impair nutrient absorption: Short bowel syndrome, enterocutaneous fistula, infectious colitis, radiation, chemotherapy effects, small bowel obstruction

Need for bowel rest: IBD, ischemic bowel, severe pancreatitis, chylous fistula, preoperative status, NPO

Motility disorders: Prolonged ileus, scleroderma, pseudo-obstruction visceral organ myopathy

Inability to achieve or maintain enteral access: Unstable clinical condition, hyperemesis gravidarum, eating disorder

112
Q

peripheral parenteral nutrition

A

mild to moderately stressed patient who is expected to have adequate GI function in 10-14 days, requires no fluid restriction, cannot require nutrients in large amounts

113
Q

central parenteral nutrition

A

preferred, for those who need nutrition 14+ days

114
Q

considerations for continuous PN administration

A

unstable patients with unstable fluid balance or glucose homeostasis

115
Q

considerations for intermittent PN administration

A

Generally given over 12-18 hours per day
Useful for hospitalized patients with limited venous access and infusion in interrupted by administration of other medications
May minimize incidence or reverse liver injury that can occur with continuous infusion
If patient receiving PN at home, allows a more “normal” lifestyle

116
Q

NHLBI Obesity Treatment Guidelines

A

25.0-26.9: diet, exercise, behavioral therapy

27.0-29.9: diet, exercise, behavioral therapy and pharmacotherapy with comorbidities

30.0-34.9 (class 1): diet, exercise, behavioral therapy, pharmacotherapy and lap band surgery with comorbidities

35.0-39.9 (class 2): diet, exercise, behavioral therapy, pharmacotherapy, surgery with comorbidities

> 40 (class 3): diet, exercise, behavioral therapy, pharmacotherapy, surgery

117
Q

central obesity

A

Correlates with high levels of intra-abdominal or visceral fat

Can be approximated by measuring waist circumference: Measured at narrowest point between last rib and top of iliac crest

High risk
>40 inches in men
>35 inches in women

118
Q

GLP-1 Receptor Agonist MOA

A

selective glucagon-like peptide-1 receptor agonist that increases glucose dependent insulin secretion, decreases inappropriate glucagon secretion, slows gastric emptying, also acts in the areas of the brain involved in regulation of appetite and caloric intake

119
Q

Liraglutide side effects

A

Nausea, hypoglycemia, diarrhea, constipation, vomiting, headache, decreased appetite, dyspepsia, fatigue, dizziness, abdominal pain, increased lipase

Black box: causes dose-dependent and treatment duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice, human effect is unknown

Serious Hypoglycemia

Heart Rate Increase

SI

Renal impairment

120
Q

Liraglutide contraindications

A

Personal or family history of medullary thyroid carcinoma or MEN 2

Pregnancy

121
Q

Semaglutide side effects

A

Abdominal pain, nausea, diarrhea, constipation, vomiting, decreased appetite

Black box: causes dose-dependent and treatment duration-dependent thyroid C-cell tumors at clinically relevant exposures in both genders of rats and mice, human effect is unknown

Cardiovascular effects: Increased resting heart rate has been observed in placebo-controlled trials.

Gallbladder disease: Use of GLP-1 agonists may increase risk of gallbladder and bile duct disease. Cholelithiasis has been reported in patients treated with semaglutide; substantial or rapid weight loss may increase risk.

pancreatitis, psychiatric, renal

122
Q

semalgutide contraindications

A

Personal or family history of medullary thyroid carcinoma or MEN 2

123
Q

orlistat MOA

A

reversibly inhibits gastric and pancreatic lipases, inhibits absorption of dietary fats by 30%

124
Q

orlistat side effects

A

Most common: Oily rectal leakage

Flatus with discharge, fecal urgency, fatty/oily stool, oily evacuation, increased defecation, and fecal incontinence

125
Q

orlistat contraindications

A

Chronic malabsorption syndrome

Cholestasis

Pregnancy

126
Q

Naltrexone/Bupropion side effects

A

nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth and diarrhea.

HTN, tachycardia, hepatotoxicity, acute angle closure glaucoma

127
Q

Naltrexone/Bupropion contraindications

A

Uncontrolled hypertension.

Seizure disorders, anorexia nervosa or bulimia, or undergoing abrupt discontinuation of alcohol, benzodiazepines, barbiturates, and antiepileptic drugs.

Use of other bupropion-containing products.

Chronic opioid use.

During or within 14 days of taking monoamine oxidase inhibitors (MAOI).

Pregnancy

128
Q

phentermine MOA

A

educes appetite most likely due to CNS effect

129
Q

phentermine side effects

A

Insomnia, increased heart rate, dry mouth, taste alteration, dizziness, tremors, headache, diarrhea, constipation, vomiting, gastrointestinal distress, anxiety, and restlessness

Primary pulmonary hypertension has been reported in use of phentermine with fenfluramine, development of tolerance, effects ability to engage in hazardous tasks, safety with serotonergic agents such as SSRIs has not been established

Indicated as short-term monotherapy

130
Q

phentermine contraindications

A

Pregnancy

History of cardiovascular disease or stroke

Use of MAO inhibitors

Hyperthyroidism

Glaucoma

Agitated states

Uncontrolled hypertension

History of drug abuse

Seizures

131
Q

phentermine/topiramate

A

long term use

Option for males and post-menopausal females without uncontrolled HTN or CAD
Use in caution in females with childbearing potential due to risk of fetal malformations

132
Q

phentermine/topiramate side effects

A

paresthesia, dizziness, dysgeusia, insomnia, constipation, and dry mouth.

Fetal Toxicity: Females of reproductive potential must obtain a negative pregnancy test before treatment and monthly thereafter; use effective contraception. (REMS program).
Increase in Heart Rate: Monitor heart rate in all patients, especially in cardiac or cerebrovascular disease.

Suicidal Behavior and Ideation: Monitor for depression or suicidal thoughts. Discontinue if develop.

Mood and Sleep Disorders: Consider dose reduction or d/c for clinically significant or persistent symptoms.

Cognitive Impairment: May cause disturbances in attention or memory. Caution patients about operating automobiles or hazardous machinery when starting treatment.

Metabolic Acidosis: Measure electrolytes before/during treatment.

Elevated Creatinine

133
Q

phentermine/topiramate contraindications

A

Glaucoma

Hyperthyroidism

During or within 14 days of taking monoamine oxidase inhibitors

Pregnancy

134
Q

Lorcaserin side effects

A

In non-diabetic patients: headache, dizziness, fatigue, nausea, dry mouth, and constipation.

In diabetic patients, most common adverse reactions are hypoglycemia, headache, back pain, cough, and fatigue.

Removed from market due to increased risk of cancer

135
Q

obesity monitoring

A

Every 6 weeks for all patients
Weight: if patient does not lose 4-5% of body weight after 12 weeks of therapy and max tolerated dose → taper and discontinue
BP and HR
Electrolytes with phentermine/topiramate
Ask about adverse effects

136
Q

herbal products not recommended for weight loss

A

Garcinia cambogia
Widely marketed for weight loss
Cases of acute hepatitis and acute liver failure resulting in need for liver transplant have been reported (thought to be associated with active ingredient, hydroxycitric acid)
Supplements can also be contaminated with a hepatotoxic substance (sibutramine)

Green Tea and Coffee Extract
Activity is due to caffeine

Chromium picolinate
Side effects mostly CNS (headache, mood changes)
Use with caution in renal and hepatic impairment, diabetes

137
Q

appetite stimulants in cancer patients

A

Dronabinol
Antiemetic, appetite stimulant, cannabinoid
Side effects of CNS effects, euphoria, tachycardia
Risk of substance abuse

Megestrol
Progestin hormone
Similar side effects to corticosteroids
Adrenal suppression, cushing syndrome, diabetes, thromboembolism

Cyproheptadine
Used off label for decreased appetite secondary to chronic disease
First generation H1 antagonist
MOA: potent antihistamine and serotonin antagonist with anticholinergic effects, competes with histamine for H1 receptor sites on effector cells in the GI tract, blood vessels and respiratory tract
Contraindicated in: newborns and infants, breastfeeding mothers, elderly, concurrent MAOI use, angle closure glaucoma, stenosing peptic ulcer, symptomatic prostatic hypertrophy, bladder neck obstruction pyloroduodenal obstruction

138
Q

appetite stimulation in elderly

A

Megestrol
Dronabinol: well studies but has significant CNS side effects
Mirtazapine: antidepressant
Ghrelin mimetics: growth hormone secretagogues: new, not well studied
Treat depression if present
Treat and manage dementia if present

139
Q

hepatitis B nucleoside analogs treatment options

A

MOA: incorporated into viral DNA causing chain termination

Entecavir, tenofovir disoproxil, tenofovir alafenamide
Drugs with a high barrier to resistance are preferred to ones with low barrier
Also have some activity against HIV
Generally, well tolerated with some fatigue, elevated CPK and GI disturbances

Limitations
Lamivudine: HBV resistance to drug is high

Adefovir: less effective

Entecavir
Effective against HBV strains that are resistant to other drugs
Once daily dosing
Dose adjustment with renal dysfunction
Should not be used with other renal toxic medications

Tenofovir
Tenofovir alafenamide → only indicated for HBV
Tenofovir disoproxil fumarate → indicated for HBV and HIV

140
Q

hepatitis B interferons treatment options

A

IFN-alfa and pegylated-IFN-alfa
Flu like symptoms, fatigue, depression
Dose limiting toxicity
Bone marrow suppression, severe fatigue, weight loss, neurotoxicity (somnolence and behavioral disturbances), AI disorders, cardiovascular problems
48 week treatment duration

141
Q

HCV treatment

A

Direct acting anti-HCV agents (DAAs)

NS3/4A protease inhibitors: -previr
NS5A inhibitors: -asvir
NS5B polymerase inhibitors: -buvir

142
Q

goals of treatment for portal HTN and varices

A

Resolution of acute complications
Tamponade of bleeding and resolution of hemodynamic instability for an episode of acute variceal hemorrhage
Prevention of complications through lowering of portal pressure with medical therapy and/or supporting abstinence from alcohol

143
Q

approach to treatment of portal HTN

A

Primary prophylaxis is to prevent first bleeding episode
Screen for varices upon diagnosis
Use nonselective beta adrenergic blocker therapy: propranolol, nadolol or carvedilol
MOA: decrease portal pressure by decreasing cardiac output and decreasing splanchnic blood flow
Continue indefinitely
Monitor for contraindications that may develop → renal impairment or hypotension
Carvedilol is believed to be better tolerate than the pure nonselective beta adrenergic blockers
Beta adrenergic blocker therapy is not indicated if varices are not present
Endoscopic vein ligation is an alternative

144
Q

management of varices

A

Specific interventions to control the acute hemorrhage and prevent complications

Initial treatment goals
Adequate resuscitate blood volume
Protect the airway from blood aspiration
Prophylaxis against spontaneous bacterial peritonitis (SBP) and other infections
Control bleeding
Prevent rebleeding
Preservation of liver function of HE
Acute kidney injury prevention
Start octreotide (antidiarrheal, somatostatin analog)
Start early to control bleeding and facilitate endoscopy
Initiate prophylactic antibiotics to prevent spontaneous bacterial peritonitis (SBP) in ALL patients upon admission

For patients with cirrhosis + acute variceal bleeding,
Ceftriaxone IV recommended and preferred due to high quinolone resistance
Other option: ciprofloxacin (oral)
Can also administer erythromycin IV before endoscopy
Accelerates gastric emptying of clots and improves visibility during endoscopy
Patients with advanced disease are more likely to fail octreotide and endoscopic variceal ligation (EVL) and need a transjugular intrahepatic portosystemic shunt (TIPS)

145
Q

management of ascites

A

Alcohol abstinence
Sodium restriction
Diuretics
Spironolactone and furosemide or spironolactone alone
Stop diuretics if
Uncontrolled or recurrent encephalopathy
Severe hyponatremia despite fluid restriction
Renal insufficiency
If tense ascites is present, perform paracentesis before diuretics and salt restriction
Consider liver transplant with refractory ascites

146
Q

treatment of spontaneous bacterial peritonitis

A

If documented or suspected SBP, Abx need to cover Escherichia coli, Klebsiella pneumoniae, and pneumococci.
Drug of choice- Cefotaxime, IV (or similar 3rd generation cephalosporin) x 5 days
Alternatives for community-acquired SBP: ceftriaxone or piperacillin/tazobactam
After recovery, patients should be on long-term, daily, oral antibiotic prophylaxis with ciprofloxacin

147
Q

how to lower ammonia with hepatic encephalopathy

A

Lactulose (lactitol)- can be administered orally or by retention enema
Encourages passage of ammonia in the stool
Polyethylene glycol- also effective for acute HE
Antibiotics
Rifaximin- when added to lactulose, is superior for recurrent HE
Zinc
Patients with HE are frequently deficient in zinc
Supplementation not recommended in absence of deficiency
Zinc can inhibit copper absorption which can lead to anemia
Flumazenil- used for short-term therapy in refractory HE with suspected or confirmed benzodiazepine intake

148
Q

treatment options for intestinal gas

A

simethicone, alpha-galactosidase, lactase replacement

149
Q

simethicone

A

Indicated for flatulence
MOA: defoaming agent: reduces surface tension of gas bubbled embedded in mucus in GI tract, as surface tension changes, gas bubbles are broken
No systemic absorption
Is often combined with antacids

150
Q

alpha-galactosidase

A

Indicated for flatulence
MOA: hydrolyzes oligosaccharides into smaller parts to be metabolized by intestinal bacteria
Enzyme is derived from aspergillus fungus
Used for treatment of intestinal gas produced by high fiber diets or foods containing oligosaccharides such as legumes and cruciferous vegetables
Must be taken before or within initial bite of food
Caution in DM patients
Avoid with mold allergy

151
Q

lactase replacement

A

MOA: lactase enzymes break down lactose, a disaccharide, into monosaccharides glucose and galactose
Aids in dairy digestion

152
Q

indications of intestinal gas with more severe disease

A

Intestinal gas symptoms that persist for more than several months or occur more often than occasionally (several times a month)
Severe, debilitating symptoms
Sudden change in location of abdominal pain, increase in the frequency of symptoms, or onset of symptoms in patients >40 years of age
Symptoms + significant abdominal discomfort or sudden change in bowel function
Symptoms + severe persistent diarrhea or constipation, GI bleeding, fatigue, unintentional weight loss, or frequent nocturnal symptoms

153
Q

glucocorticoids

A

Have metabolic activity
Bind to specific intracellular cytoplasmic receptors in target tissues which are widely distributed throughout the body
Dexamethasone, prednisone, fluticasone, betamethasone, methylprednisolone, prednisolone, triamcinolone

154
Q

mineralocorticoids

A

Have electrolyte regulating activity
Receptors are confined mainly to excretory organs, such as kidney, colon, salivary glands and sweat glands
Fludrocortisone, aldosterone

155
Q

corticosteroid activity

A

Bind to receptor
Receptors dimerize or pair up
Receptor-hormone complex recruits coactivator (or corepressor) proteins
Until translocates into nucleus
Attaches to gene promoter elements
Can serve as a transcription factor to turn genes on (when complexed with coactivators) or off (when complexes with corepressors) depending on tissue
Because of this mechanism, some effects of corticosteroids take hours to days to occur

156
Q

cortisol

A

Principle human glucocorticoid
Peaks in AM then declines → secondary smaller peak in late afternoon (diurnal production)
Stress and levels of circulating steroid influence secretion

157
Q

glucocorticoid activity

A

Receptors are spread throughout the body
Adverse effects can occur throughout the body

Stimulate gluconeogenesis and catabolism of proteins
Facilitate glucose production and breakdown of proteins into amino acids
Physiologic effect
Increase in liver glycogen levels
Increase in fasting blood glucose levels
Increase in urinary nitrogen output

158
Q

activity of all glucocorticoids

A

Promote normal intermediary metabolism
Increase resistance to stress
Alter blood cell levels in plasma
Possess anti-inflammatory action
Affect other systems

159
Q

use of glucocorticoids

A

Relief of inflammatory symptoms
Treatment of asthma and allergies
Acceleration of lung maturation
Replacement therapy for primary adrenal insufficiency
Replacement therapy for secondary or tertiary adrenal insufficiency
Diagnosis of cushing syndrome
Replacement therapy for congenital adrenal hyperplasia

160
Q

topical corticosteroids

A

Minimally absorbed when applied to normal skin
Long term occlusion with an impermeable film → enhances penetration
Penetration caries based on region of the body
Penetration increased several fold in inflame skin and in severe exfoliative diseases
Comes in various different preparations which can alter potency
Grade 1-7: super high potency to least potent
Least potent: hydrocortisone base and hydrocortisone acetate
Triamcinolone is commonly prescribe in the primary care setting
Lowest potency hydrocortisone is available OTC

161
Q

adverse effects of topical corticosteroids

A

All absorbable formulation have a risk of suppressing the HPA axis
Can lead to a severely impaired stress response
Prolonged use in large quantities → iatrogenic cushing syndrome
Local effects
Atrophy of skin
Hypopigmentation
Corticoid rosacea
Perioral dermatitis
Steroid acne
Hypertrichosis
Increased intraocular pressure
Allergic contact dermatitis

162
Q

glucocorticoid injections

A

Triamcinolone acetonide or kenalog
IM or intra-articular use
Indications
Acute gout flare
Inflammatory ot allergic condition
Acute MS exacerbation
Rheumatic condition
Can also be used for intralesional injections into dermatoses

163
Q

corticosteroids in allergies

A

Beneficial in treatment of allergic rhinitis, drug, serum or transfusion reactions
Fluticason is inhaled into the respiratory tract from an MDI for treatment of allergic rhinitis and asthma

164
Q

corticosteroids in asthma and COPD

A

ICS are recommended for daily use in all patients with asthma except those with intermittent asthma
ICS are indicates for group E COPD patients on GOLD criteria
Should be combined with LAMA and LABA
Oral glucocorticoid therapy has shown benefit in treating COPD exacerbations

165
Q

corticosteroids in lung maturation

A

Fetal cortisol is a regulator of lung maturation
Betamethasone or dexamethasone IM to mother within 48 hours prior to premature delivery → accelerate lung maturation in fetus to prevent respiratory distress syndrome

166
Q

corticosteroids for inflammation

A

Significantly reduces inflammation associated with
RA
Inflammatory skin conditions including redness, swelling, heat and tenderness
Agents that are important for symptom control in
Persistent asthma
Exacerbation of asthma
Exacerbations in IBD
Intra Articular corticosteroids may be used for treatment of an osteoarthritis flare
Corticosteroids are not curative in these disorders

167
Q

steroid burst

A

Short term of oral glucocorticoids lasting <2 weeks
Used for asthma or COPD exacerbations, inflammatory pain

168
Q

mineralocorticoid use and activity

A

Help control fluid status and concentration of electrolytes, especially with sodium and potassium

Increase rate of sodium, bicarbonate and water resorption

Increase rate of potassium excretion

Can help maintain normal sodium and potassium concentration in serum

Aldosterone acts on mineralocorticoid receptors in the distal tubules and collecting ducts in the kidney, causing reabsorption of Na+, HCO3- and H2O.

Aldosterone decreases reabsorption of K+, which, with H+, is lost in the urine.

Enhancement of Na+ reabsorption by aldosterone also occurs in gastrointestinal mucosa and in sweat and salivary glands.

Elevated aldosterone levels may cause alkalosis and hypokalemia, retention of sodium and water, and increased blood volume and blood pressure.
Hyperaldosteronism is treated with spironolactone

169
Q

why is prednisone preferred in pregnancy?

A

Fetal liver cannot convert it to active compound → prednisolone, any prednisolone made by mother is converted back to prednisone by placenta enzyme

170
Q

adverse effects of corticosteroids

A

Osteoporosis is the MC adverse effect with long term use

Glucocorticoids suppress intestinal calcium absorption, inhibit bone formation and decrease synthesis of sex hormones

Patients should take vitamin D and calcium

Bisphosphonates can be used to treat

Can increase appetite → use in cancer patients (prednisone0

Hyperglycemia → DM

Monitor blood glucose and adjust medication as needed

Cushing like signs: Body fat redistribution, moon facies, hirsutism, increased appetite
Cataract with long term use

Topical therapy: Skin atrophy, Ecchymosis, Purple striae

171
Q

corticosteroid discontinuation

A

If the HPA axis is suppressed, sudden discontinuation can have serious consequences including death.
Abrupt discontinuation of the corticosteroids àacute adrenal insufficiency that can be fatal
Risk of acute adrenal insufficiency + possibility that corticosteroid withdrawal could exacerbate the disease à dose must be tapered SLOWLY according to individual tolerance.
Patient must be monitored carefully.

172
Q

tapering does not need to be done when?

A

used for <3 weeks

173
Q
A

Pharmacology (4 decks)

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