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1
Q

What is the difference between Reclast and Zometa which are both zolendronic acid?

A

Same ingredient, different uses: Reclast - osteo, pager’s disease; Zometa - cancer

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2
Q

What is the brand for Fidaxomicin and what is this medication used for?’

A

Dificid. Used to treat C.diff. Used as first line agents in patients with no fulminant infection.
*reduces risk for recurrent infection, has GI side effects, expensive

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3
Q

What is the brand name for bezlotoxumab? And what is it used for?

A

Zinplava. C.diff. Recommendation is to be used for recurrent infections and patients who has had infection in the last 6 months.

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4
Q

What two lab values show kidney injury?

A

Creatinine and BUN. They are waste products that are eliminated by the kidney. As their levels rise in the blood, it can be indicated that the kidney is not functioning properly. BUN/Creatinine ratio tends to go up as GFR falls.

*BUN (Blood Urea Nitrogen) can be falsely low in patients with liver impairment since liver is unable to adequately convert ammonia to urea

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5
Q

What are the two types of acute kidney injuries?

A

Intrinsic: damage to function units of kidney (nephrons), caused by infection, toxic agents, drugs (aminoglycosides, vancomycin, chemotherapy, etc)

Postrenal: obstruction (stone, BPH, tumor), drugs that can form crystals and stones (acyclovir, Indian or, methotrexate)

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6
Q

What medications treat AKI?

A

None. Dialysis in emergency situation to filter blood.
Otherwise treat underlying cause and/or remove offending agent: infection with a/b, dehydrations with fluid replacement etc
Fluid overload with diuretics
Treat electrolyte imbalances caused by AKI: hyperkalemia with SPS (GI side effects), or in emergency situations insulin can be used to push K+ out of cells.
Severe acidosis: sodium bicarbonate

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7
Q

What drugs are known to cause/contribute to AKI?

A

Aminoglycosides
Vancomycin
NSAIDS
ACEI/ARB
Contrast dye
Amphotericin B
Chemo agents (platinum compounds)
Diuretics via dehydration risks
Anti rejection agents

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8
Q

What is Addison’s disease?

A

Opposite of Cushing. Too little cortisol. Aldosterone could be in short supply.

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9
Q

How do you treat Addison’s disease?

A

Steroid replacement: hydrocortisone, prednisone
Mineralcorticoid replacement may be necessary to help hyponatremia: fludrocortisone, avoid spironolactone which can exacerbate hyperkalemia and hyponatremia as well as oppose effects of mineralcorticoid
Adrenal crisis management through fluid and electrolyte replacement, monitor blood glucose and give dextrose as needed, IV hydrocortisone, fludrocortisone as needed

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10
Q

What medications can likely cause angioedema?

A

ACEI/ARB
NSAIDS
Penicillins

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11
Q

What is and how do you treat angioedema?

A

Swelling of the loose tissue like lips, mouth, throat, and genitals etc.

Epi-pen 0.3mg (response may be blunted by being on Betablockers)
Glucagon for patients on beta-blockers
Antihistamines
Glucocorticoids
Respiratory bronchodilators

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12
Q

What organisms are targeted for a/b prophylaxis and what medications are used?

A

Gram (+) mostly, staph and strep (mostly using 1st or 2nd generation cephalosporins (ie. cefazolin), penicillin type (ampicillin)
Concerns for MRSA, use vancomycin or Clindamycin for resistant gram (+)
GI surgery may need to cover gram (-) and anaerobes (use metronidazole or clindamycin for anaerobes), quinolones for gram (-)
Urologic procedure use quinolones (levo, cipro); smz/tmp

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13
Q

What is the max dose of Zyrtec for patients >77yo?

A

5mg QD

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14
Q

What are some side effects associated with common systemic decongestants like pseudoephedrine and phenylephrine?

A

Increase in blood pressure, contribute to urinary retention in patients with BPH, increases anxiety/insomnia

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15
Q

What is the black box warning for montelukast?

A

Psychiatric events such as aggression, suicide, and depression

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16
Q

When do you increase or decrease dose for ESAs?

A

Monitor Hb, if increases more than 1g/dL in two weeks, decrease dose by 25%.
If no increase of Hb of 1g/dL in 4 weeks, then increase dose by 25%.
*black box of cardiovascular events

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17
Q

What is the most potent for of oral iron supplementation?

A

Ferrous fumurate (33%), sulfate (22%), gluconate (12%)
*constipation stomach upset dependent on dose and iron content
*watch for cation interaction with other meds
*take with vitamin C to help with absorption
*polyscaccharide iron complex can be option is absorption not enough from standard therapy

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18
Q

How do you treat pernicious anemia?

A

Supplement with B12, oral not readily absorbed
Injection = 1,000mcg weekly until goal is reached, then maintain with monthly injection

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19
Q

Hemoglobin and hematocrit ranges for male and female

A

Hemoglobin
Female: 12-16 g/dL
Male: 14-18 g/dL

Hematocrit
40-54%
36-48%

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20
Q

What should you ask burn patients before using silver sulfadiazine?

A

Are you allergic to sulfa?

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21
Q

Why shouldn’t burn patients use topical corticosteroids?

A

It can possibly increase infection risk and healing may be impaired

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22
Q

What is the order of potency in corticosteroid creams?

A

Lowest to highest
Hydrocortisone —> fluocinonide, betamethasone valerate —> triamcinolone —> clobetasol, betamethasone diproprionate
*skin thinning
*enlarged blood vessels

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23
Q

What are topical calcineurin inhibitors?

A

Tacrolimus (Protopic) pimecrolimus (Elidel)

*adverse effects profile better than topical corticosteroids for atopic dermatitis
*boxed warning of rare cases of malignancy

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24
Q

What is bacterial peritonitis and what are common agents to treat it?

A

Infection of the peritoneum, occurs in patients with portal hypertension which is typically as a result of cirrhosis, lupus
*Target gram (-), 3rd gen cephalosporins = cetriaxone, cefotaxime
*If gram (+) concerns, ampicillin can be used
*ProphylaxisL cipro, Bactria

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25
What are common eye drops for bacterial/viral eye infections?
Gentamicin Erythromycin Polymixin/trimethoprim Moxifloxacin Sulfacetamide *adenovirus most common cause of viral infection *most common bacteria: staph, strep, m.cat, h.flu
26
What is cholelithiasis and what medication treats it?
Gallstones; Ursodiol (Actigall), dissolves cholesterol which can be important component in gallstones, monitor liver function *Allopurinol for prevention if Uric acid based stones *pain in upper right quadrant, commonly associated with fatty meals
27
What is a sign of cirrhosis that involves INR?
Elevation on INR due to liver making clotting factors even when patient is not on anti coagulation
28
Why is bleeding a risk in cirrhosis?
If liver is damaged, clotting factors may not be properly made causing thin blood, esp in even there is esophageal varies that rupture due to portal hypertension
29
What happens when liver can not break down waste products?
Hepatic encephalopathy. Build of of ammonia causing risk of confusion, sedation, seizure, delirium *drugs that can cause this - carbamazepine, valproic acid *Treat underlying causes, obesity, hepatitis, alcoholism *Portal hypertension: non-selective beta blocker- propranolol, Nadia lol Encephalopathy: lactulose, rifaximin (Xifaxen) *Manage ascites: aldosterone antagonist, spironolactone (may be used with loops to remove excess fluid), appropriate target is 40mg furosemide to 100mg spironolactone to maintain stable K+
30
When is red man syndrome not a concern when taking Vanc?
When given orally. Only indication for oral vanc is c.diff since systemic absorption is poor, infection in GI so not an issue
31
What are medications and disease states that can cause constipation?
Opioids, anticholinergics, calcium channel blockers, iron supplements, calcium supplements Parkinson’s, MS, diabetes, hypothyroidism, stroke
32
What is the CIWA-AR test for?
Scale for withdrawal scored up to 67, the higher the score the more likely the patient needs meds for the withdrawal
33
Alcoholics are usually deficient in what vitamins?
B12, thiamine (B1), folic acid In Wernicke’s encephalopathy patients can have delirium and typically due to lack of dietary thiamine (B1)
34
What meds are used for alcohol withdrawal?
Naltrexone (monthly injection, once daily tablet): GI sides effects, inc LFTs *pt should be opioid free for 7-14 days Acamprosate: *rec to start after abstaining from alcohol, Contraindicated in CrCl <30, diarrhea is predominant side effect, dosing TID Disulfiram: mechanism is disulfram reaction causing dysphoric, headache, flushing, and GI symptoms when alcohol is ingested, need to take med for it to work
35
What meds are used for opioid use disorder?
Methadone, suboxone, naltrexone Methadone, full mu agonist, very long half life, will cause sedation and other opioid like effects, Qtc interactions, has to be dispensed via special treatment program, sched 2 Suboxone, combo of partial mu agonist and opioid mu antagonist, prevents reward from opioid agonists, sched 3 Naltrexone: mu antagonist, needs to be taken regularly, monthly injection, or once daily tab, can precipitate withdrawal so maintenance therapy must not be started until withdrawal is finished Naltrexone can precipitate withdrawal, suboxone may precipitate withdrawal, methadone can be started prior to full withdrawal
36
Why is it usually not recommended to give elderly patients mineral oil?
Increase risk for pneumonitis (aspiration risk)
37
What are the normal levels of uric acid?
2.5-6 mg/dL
38
What are some risk factors for gout?
Alcohol Metabolic disease/obesity Seafood (foods high in purine) Family history Male gender Loop/thiazide diuretics can decrease uric acid excretion Niacin, cyclosporine, and tacrolimus can raise uric acid levels
39
What are some important things to note about allopurinol?
Reduces the PRODUCTION of uric acid, prevents making more does not remove what’s already there Side effects of rash and GI Test for HLA-B5801 in AA and SE asians descent prior to starting Can raise azathioprine levels Loop/thiazide and PCN use may increase risk for allergic reaction Dose adjust with worsening kidney function
40
What is a major limiting factor with using colchicine?
Side effect of diarrhea (low does has similar efficacy to high does in acute treatment of flares with reduced side effects)
41
Is colchicine used for prevention or treatment?
Both. Watch for CYP3A4 inhibitors like grapefruit juice which will increase serum levels. May inc risk of myopathy/rehab do in patients on statins
42
Is indomethacin the only NSAID for gout flares?
No, can use other NSAIDs. Indomethacin has high incidence of GI side effects, possibly will see GI protection with its use Needs to watch with patients that have CHF, renal impairment, or on anticoagulants
43
What can be used for pain in gout flares if NSAIDs and colchicine can not be used?
Corticosteroids. Acute flare management only, first line alternative.
44
What is febuxostat used for?
Uloric or febuxostat is very similar to allopurinol. Meant for prophylaxis as well, FDA warning for cardiovascular death, so only used last line.
45
What does probenecid do?
Removes uric acid in the body by increasing kidney excretion. Need adequate renal function for this medication to work.
46
What is the main side effect of probenecid?
GI upset.
47
The serum levels of which medications can be raised by taking probenecid?
PCN, quinolones, cephalosporins, NSAIDs, nitrofurantoin, methotrexate Thus, probenecid can be seen used with PCNs to prolong plasma-life and increase serum concentrations.
48
What is a GAD-7 scale used for?
7 questions about ANXIETY Each question scored from 0-3, total max score of 21 0-4 minimal anxiety, 15-21 severe
49
What is flumazenil?
The reversal agent for benzos
50
What is the shortest acting benzo? Longest?
Triazolam Diazepam, flurazepam, chlordiazepoxide
51
What is the advantage of using buspirone for anxiety? And disadvantage?
Non-controlled. Multiple times a day dosing
52
What medications can exacerbate GERD?
Corticosteroids,bisphosphonates, NSAIDs
53
What medications must be look out for that interact with antacids?
Quinolones, tetracyclines, levothyroxine
54
Do we dose adjust H2 blockers for GERD?
Yes. Also watch for possible accumulation that could cause rare CNS problems that are more likely in CKD Avoid cimetidine due to many interactions CYP3A4, also carries gynecomastia risk
55
How many hours do you have to separate sulcralfate and other medications?
Take sucralfate 2 hours after other meds
56
What are eye vitamins usually composed of?
Vitamin A, C, E, Lutein, copper, zinc, zeanthin
57
What VEGF inhibitor is used for macular degeneration and what does it do?
Cancer med Avastin, bevacizumab, can be injected into the eye to reduce the growth of abnormal blood vessels
58
What are the outpatient treatments for COVID-19?
1. Paxlovid (nirmatrelvir/ritonavir): mild to moderate patients oral admin, initiate within 5 days of symptom development Strong CYP3A4 inhibitor so can interact with many medications (be careful with polypharmacy geriatric patients) 2. Remdesivir: alternative to paxlovid, IV admin for 3 days 3. Bebtelovimab: (best against omicron strains), single IV Inj 4. Lagevrio (Molnupiravir): oral med, 50% reduction in hospitalization and death
59
What are inpatient options for COVID-19?
In patients that do not need oxygen: remdesivir In patients that need oxygen: Dexamethasone + remdesivir In patients that have worsening condition and inc oxygen requirements: dexamethasone + baricitinib or tocilizumab (can also consider adding remdesivir as supplies allow)
60
What is flumazenil?
Benzo reversal Black box warning or seizure risk
61
What are the routes of halo one?
IV IM SC Intranasal
62
How do you treat diverticulitis?
Treat infection + Pain management Look for infection, if so, gram (-) and anaerobic coverage is primary initial focus Cipro or Bactrim + metronidazole Plus pain management, use acetaminophen as opioids and NSAIDs can exacerbate condition
63
What are medications for “failure to thrive”?
No medication to treat FTT. Treat underlying disease state Avoid minimize medications that can contribute
64
What are some environmental conditions to help prevent falls in the older patients?
Poor lighting Hazardous object in hallways etc Bathroom bedroom conditions Avoid steps and stairs Support rails as appropriate
65
What can we do to help prevent fails with patients with diabetes and HTN?
Relax doses of BP meds (hypotension) and diabetic meds (hypoglycemia)
66
What are some risk factors for diabetic ketoacidosis?
Non-adherence to insulin Poor management of blood sugars Type-1 diabetes
67
How to treat diabetic ketoacidosis?
Fluid replacement, electrolyte abnormalities (ie potassium), insulin, NaBicarb (reserved for severe acidosis state) Fluid replacement as often hypovolemic (ie. normal saline) Identify and address electrolyte abnormalities: K should be given BEFORE insulin if low K+ (<3.3-3.5), K can be given with insulin if normal K+ -Insulin causes an intracellular shift of K+ out of cells that could lead to potential profound hypokalemia if potassium stores are already low
68
What is first line and second line treatment for PAD?
Lack or inadequate blood flow to legs, extremities caused by claudication with symptoms of pain and cramping in legs, atherosclerosis is usually the cause First line: statins, treat HTN, manage diabetes, anti platelet therapy aspirin or clopidogrel (if ASA contraindicated) 2nd: cilostazol, take on empty stomach, contraindicated in heart failure, pentoxifylline, give with food, might not be beneficial 3rd: bypass surgery
69
How do you treat valvular heart disease?
Control HTN, lipids ABx if needed Valve replacement *Anticoag afterwards, bridge with LMWH and then long term warfarin * Warfarin goal for MITRAL MECHANICAL valve 2.5-3.5 with aspirin * Warfarin goal for AORTIC MECHANICAL valve 2.0-3.0 with aspirin unless with risk factor goal = 2.5-3.5 (prev clot, LV dysfunction, hypercoaguable state, older type valve) *Warfarin goal for BIOPROSTHETIC mitral or aortic valves 2-3 with aspirin
70
What medications are used to treat VERTIGO?
Symptomatic management with: Meclizine, benzos, ondansetron, promethazine/metoclopramide/procloperazine
71
When do you use midodrine?
For orthostasis. Opposite of alpha blocker, clamps on vessels to cause pressure Should not be used in BPH, can cause exacerbation
72
What is CAD?
CAD IS PLAQUE BUILDUP WITHIN THE WALLS OF THE CORONARY ARTERIES CORONARY HEART DISEASE
73
What are some common drugs associated with SJS?
allopurinol lamotrigine carbamazepine barbituates pheytoin nsaids, APAP sulfa, pcn
74
What genetic testing shows increase risk for SJS from antiseizure medicaitons? gout medications like allopurinol?
HLA-B 1502 inc risk for sjs from carbamazepine, phenytoin, and phenobarbital, more common in asian descent (chinese, indian) HLA-B*5801 inc risk for severe cutaneous reactions in asian descent (korean, han chinese, and thai) and also african
75
What can sleep apnea cause?
Resistant HTN, must rule out before increasing antihypertensive meds
76
T/F: no meds treat sleep apnea?
True, Treat underlying cause nasal steroids for nasal congestion nasal saline for nasal dryness CPAP, weight loss, smoking cessation
77
What medications can exacerbate sleep apnea?
Opioids, Benzos Seizure meds Older anticholinergics/antihistamines Drugs that can contribute to weight gain (SU, mirtazapine, etc)
78
What are the 5 As for reviewing readiness for smoking cessation?
1. Ask about smoking at each visit 2. Advise the patient to quit 3. Assess readiness to quit 4. Assist those patient who are ready to quit (counseling and medication management) 5. Arrange follow-up visits, contact, phone calls as the patient begins their smoking cessation journey
79
What does the American Thoracic Society recommend for smoking cessation?
Chantix (Varenicline) recommends over other therapy but can use nicotine replacement, varenicline, buproprion are all considered primary options based on cost, coexisting conditions, patient preference etc 2nd line options: clonidine, nortriptyline
80
What is varenicline?
Chantix Partial nicotine agonist, 12 week course which can be doubled to 24 for certain patients *patients can still smoke in first week *notorious adverse affect of vivid dreams *possible risk of psych changes * insomnia *nausea/vomitting
81
What are the types of nicotine replacement products?
Patch, Gum, inhaler, lozenge, nasal spray
82
What are the different dosages for NRT patches?
21, 14, and 7 mg start with 21mg for patients using 10 or more cig per day and 14 mg patch for those using less than 10 cig per day
83
What are the doses for NRT gum options? lozenge?
2 mg and 4 mg (max 24 pieces a day, q2h) 4 mg dose for patient that has their first cigarette within the first 30 min of awakening Lozenge: same as gum strengths (max 20 pieces a day)
84
What is the limiting factor of the inhaler type NRT?
Must puff inhaler for 20 minutes for best relief of craving (max of 16 cartridges per day)
85
How do you use the nasal spray for NRT?
2 sprays (1 in each nostril) = 1 dose, 1mg of nicotine (Max 40 doses per day, 80 individual sprays)
86
What are some symptoms of serotonin syndrome?
CNS changes, neuromuscular overactivity HTN, Tachycardia Tremor, fever Diarrhea Ataxia (impaired balance or coordination)
87
What are some offending drugs for serotonin syndrome?
SSRI, SNRI, TCA, MAOI, buspirone Tramadol Triptans Linezolid
88
How to treat serotonin syndrome?
Remove offending agent, can use benzo to help agitation and tremor Cyproheptadine, first generation antihistamine, typically reserved for moderate to severe cases (has antiserotonergic activity) *Patient will likely need inpatient management, fluids, cardiac status, oxygen
89
What are the two GLP-1s used for weight loss?
Saxenda (Liruglatide) and Wegovy (Semaglutide), larger doses for weight loss than for diabetes
90
What are the cutoffs for obesity with BMI?
normal is 18.5-25 overweight is 25-30 moderate obesity 30-35 severly obese 35-40 very severyly obese 40+
91
Which equation is now used for eGFR that excludes race as a risk factor?
CKD EPI 2021
92
What are some risk associated with menopause?
Osteoporosis, CV disease, UI, and sexual dysfunction (dec libido, vaginal dryness)
93
What are the risk for hormone replacement therapy?
Breast cancer DVT/PE Heart disease Stroke
94
T/F: for patients with intact uterus, they will need to use progestin if estrogen is going to be used to lower the risk of uterine cancer
True.
95
What is duavee?
Bazedoxifene/estrogen combination “Tissue selective estrogen complexes” TSEC SERM combined with estrogen Potential option to avoid progestin risks/side effects
96
What are non-hormonal therapy for menopausal symptoms?
SNRI: velafaxine SSRI: paroxetine, citalopram Anticonvulsants: Gabapentin
97
How do you calculate ANC?
ANC = WBC * ((Segs/100) + (Bands/100)) ANC = 1.0 k/uL x (0.32 + 0.42) = 740
98
Explain time dependent vs concentration depended pharmacokinetics
-T>MIC: the pharmacodynamics outcome that is correlated with efficacy for time dependent drugs; increased bacterial killing is based on the percentage of time the concentration exceeds the MIC. Drugs reach a saturable killing rate, therefore, increasing drug concentrations more will not affect the bacterial activity. Example of drugs: Penicillins, cephalosporings, monobactmas, clindamycin, macrolides, linezolid, tetracyclines. -Peak/MIC: the pharmacodynamics outcome that is correlated with efficacy for concentration depend drugs. The rate and extend of killing of bacteria will increase with increased drug concentrations relative to the MIC. Administer higher doses with a decreased frequency of administration. Examples of drugs: aminoglycosides, floroquinolones, ketolide, metronidazole, oritavancin. -AUC/MIC: the pharmacodynamics outcome that is correlated with efficacy for concentration depend drugs. It measures the AUC relative to the MIC of the organisms. Administer higher doses with a decreased frequency of administration. Example of drugs: floroquinolones, macrolides, tetracyclines, vancomycin.
99
T/F: the CAGE questionnaire is used to assess alcohol use
True
100
What is associated with Wernicke’s encephalopathy?
B1 thiamine deficiency
101
What happens if you do not treat the reversible disorder fo Wernicke encephalopathy?
It can evolve to a non reversible disorder called Korsakoff syndrome memory loss, amnesia, confabulation Treatment IV thiamine 500mg bid-tid
102
What is CIWA used to assess?
Clinical Institute withdrawal assessment for alcohol scale scored up to 67 higher the score, the more the patient need medication for withdrawal to be decided —> monitor or benzo indicated
103
What is the assessment scale used for opiate withdrawal?
Clinical opiate withdrawal scale COWS
104
What are some medications used to manage opioid withdrawal symptoms?
Clonidine: helps overall symptoms, sweats, tearing, piloerction trazodone, loperamide ondandsetron ibuprofen dicyclomine: GI cramping
105
What medications are best for isolated systolic elevated bp?
CCB and thiazide diuretics
106
What drug is primidone metabolized to?
Phenobarbital.

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