PHA 651 Pharmacotherapy Final

RATG

"rabbit" antithymocyte globulin, Thymoglobulin more effective than ATG for graft survival; longer t1/2; duration 3w-6mo bind directly to CD4 receptors to deplete cells through direct cytotoxicity

*diagnosis prediabetes

A1C 5.7-6.4% FPG 100-125 OGTT 140-199

*GLP1RA overview

A1C-lowering efficacy: 1% glucose target: short-acting FPG and long-acting both cautions: CI gastroparesis, ESRD; pancreatitis benefit: CVD; wt loss high efficacy, no hypoglycemia, weight loss, liraglutide then semaglutide then ER exenatide benefit in ASCVD, high cost, SQ, liraglutide benefit in DKD, renal dose adjustment for exenatide and lixisenatide, caution when initiating or increasing dose due to potential risk of AKI, GI SE common, injection site reactions, acute pancreatitis risk (?) FDA black box: risk of thyroid C-cell tumors (liraglu-, albiglu-, dutaglu-, and ER exenatide) MOA: supraphysiologic GLP1 administration increases glucose-dependent insulin secretion; decreases glucagon; slows gastric emptying; promotes satiety 2nd or 3rd line GI SE most common; CI gastroparesis- acute pancreatitis; acute renal failure All SQ, semaglutide in an oral form is in development examples: exenatide (Byetta), exenatide ER (Bydureon), liraglutide (Victoza), dulaglutidde (Trulicity), semaglutide (Ozempic), lixisenatide (Adlyzin)

*second generation SU overview

A1C-lowering efficacy: 1.5-2% glucose target: FPG and PP cautions: hypoglycemia; wt gain; decreased beta cell fx high efficacy, hypoglycemia, weight gain, low cost, can be used second line, avoid glyburide in renal dysfunction glipizide and glimepiride initiate conservatively to avoid hypoglycemia FDA special warning: increased risk of cardiovascular mortality based on studies of first generation SU Good efficacy early in disease process; poor durability; do not exceed 1/2-2/3 daily dose glyburide used off-label in GDM examples glipizide (Glucotrol (XL)), glimepiride (Amaryl), glyburide (Diabeta, Glynase)

*insulin overview

A1C-lowering efficacy: highest glucose target: basal FPG, bolus PP cautions: hypoglycemia; wt gain benefit: decrease glucose toxicity highest efficacy, hypoglycemia (higher risk with human insulins), weight gain, low cost for human insulin and high cost for analogs, SQ, lower insulin doses required with decreases in eGFR-titrate per clinical response, injection site reactions

*ABO blood typing

A: A antigen and anti-B antibodies B: B antigen and anti-A antibodies AB: A and B antigen, no antibodies O: no antigens, A and B antibodies

steroid hormone pathway in zona reticularis

ACTH sensitive 1. 17-alpha-OH pregnenolone from zona fasciculata pathway converted to DHEA 2. DHEA converted to DHEA-S Also, 17-alpha-OH progesterone from zona fasciculata pathway converted to androstenedione

steroid hormone pathway in zona fasciculata

ACTH sensitive 1. pregnenolone from the zona glomerulus pathway is converted to 17-alpha-OH pregnenolone 2a. 17-alpha-OH pregnenolone converted to 17-alpha-OH progesterone 2b. OR progesterone from zona glomerulus pathway converted to 17-alpha-OH progesterone 3. converted to 11-deoxycortisol 4. converted to cortisol

*TZD ADMET

AE *-Weight gain; Fluid retention (usually with concomitant insulin, NSAIDs, glucocorticoids, or DHP-CCBs) -Heart failure exacerbation -Increased fracture rate in postmenopausal women* -Potential cause of bladder cancer (pio) ? -Rare hepatotoxicity; rare macular edema CI -ALT > 2.5x upper limit of normal -Class III and IV heart failure

doxycycline for acne

AE: candidiasis, GI upset, photosensitivity more effective when taken 30min before food favored drug in class for acne (intermittent azithromycin just as effective)

tetracycline for acne

AE: candidiasis, GI upset, phototoxic, intracranial HTN (cannot be combined with systemic retinoids) drug-food interactions: dairy, vitamins, calcium (erythromycin has similar efficacy)

*erythromycin topical for acne

AE: erythema, dryness, pruritis P. acnes resistance can occur (combo with BPO)

*TDM and IBD

AGA suggests therapeutic drug monitoring to guide tx changes in adults with IBD (confirmed by endoscopy or imaging) in maintenance phase on anti-TNF agents The frequency of repeat TDM and the optimal target trough are unknown for both Patients being started on thiopurines should receive TPMP testing (enzyme activity or genotype) regularly in addition to CBC and liver enzymes -clinically significant benefit only in pts homozygous for TPMT who are at increased risk for harm due to severe neutropenia and infection Reactive thiopurine metabolite monitoring suggested in patients with active IBD OR in pts with quiescent disease when thiopurine toxicity is suspected -optimal target in combo therapies unknown but monotherapy suggests a 6-TGN (thioguanine) level between 230-450 pmol/8x10^8 RBC suggested trough goals: infliximab-5, adalimumab-7.5, certolizumab pegol-20, golimumab-lack of evidence

*idiopathic T1DM

AKA Type 1B; no autoimmunity; rare; African or Asian ancestry; strongly inherited Insulinopenia (deficient pancreatic insulin secretion) Episodic ketoacidosis; varying degrees of insulin deficiency between episodes Requirement for insulin therapy may be intermittent

anterior pituitary

AKA adenohypophysis secretes GH, prolactin, ACTH, TSH, LH, and FSH release regulated by hypothalamus

*toxic adenoma

AKA autonomous thyroid nodule thyroid mass whose fx is independent of pituitary control

*bone remodeling

AKA bone metabolism-cyclic removal of mineralized bone by osteoclasts followed by formation of bone matrix through the osteoblasts purpose: adjust to meet changing mechanical needs, repair microdamages, prevent accumulation of old bone, maintain plasma calcium homeostasis

*neonatal diabetes

AKA congenital diabetes 85% of cases have underlying monogenic cause. All children diagnosed with diabetes in first 6 months of life should have immediate genetic testing. May be transient or permanent

*Grave's disease

AKA toxic diffuse goiter-most common HTR thyroid stimulation antibodies (TSAb) directed against thyrotropin receptor bind receptor and activate AC in the same manner as TSH

diet modification for constipation

ALWAYS suggest diet modification increase fluids (1/2 body weight in oz), fibers (20-30g/d) and exercise

*OTC treatment of dysmenorrhea

APAP, NSAIDs-inhibit COX1 and 2 to decrease PG synthesis -take one day before menses onset and for 2-3d after onset -naproxen (Aleve) 220mg q8-12h (consider 440mg LD), max 1100mg/d -ibuprofen (Advil) 400mg q4h, 3200mg/d limited efficacy among combo products containing pyrilamine (drowsiness), pamabrom, caffeine (e.g. Pamprin, Midol)

AP signs and symptoms

Abdominal pain-often sudden onset over 10-20 min of severe, "knife-like" -may last for several days and radiates to back (upper quad) -relief with fetal position -intensity and location of pain do not correlate with severity of disease N/V, epigastric tenderness, abdominal distention , fever, shock, jaundice, scleral icterus, diaphoresis

*ANC

Absolute Neutrophil Count ((%Neutrophils (PMN) + %Bands) x WBC)/100

*tx goals SLE

Achieve and maintain remission (symptom free) Prevention of "flares" Decrease disease progression and prevent organ damage Improve quality of life Minimize adverse drug events Prevent thromboembolic event Optimal patient outcomes are achieved through a team-based approach to care which includes, at a minimum, input from: -The Patient -*Family physicians -Nephrologists -Rheumatologists* -Pharmacists

adrenal hypofunction

Addison's disease-low aldosterone, sex hormones, and cortisol Hypoaldosteronism-only aldosterone is low

*DPP4i ADMET

Adverse effects: well tolerated -Upper respiratory infections, HA, joint pain, arthralgia -Rare—Pancreatitis, skin reactions -Saxa & allo—FDA warning—may increase risk of HF CI—hypersensitivity; DKA; T1D

*pharmacotherapy considerations for DM

Age Weight Comorbidities: CAD, HF, CKD, Liver dysfunction, Hypoglycemia

*Spironolactone

Aldactone, aldosterone antagonist, used for HF and HTN 100-400 mg/day (max), adjust if CrCl 10-50, CI if <10 block androgen and progesterone receptors in addition to aldosterone AE: hyper-K, GI discomfort, impotence, gynecomastia, hypoTN monitoring: Scr, K, BP

*complications osteomyelitis

Amputation Chronic osteomyelitis and bone necrosis

Pharmacist opportunities with PPIs

An estimated 30-50% of prescribed PPIs is believed to be inappropriate Many patients who would strongly benefit from a PPI are non-compliant due to fear of adverse effects Educate patients on the TRUE risks and benefits of PPIs Conduct routine DUR in order to: -Identify PPI prescriptions with no indication -Ensure patients are on the lowest effective dose of PPI for the shortest time necessary to treat diagnoses -Make recommendations to PCP regarding deprescribing PPIs when appropriate -Encourage appropriate follow-up with PCP for monitoring and evaluation

zona reticularis

Androgen production Testosterone and estradiol are the major products and influence the reproductive system and primary/secondary sex characteristics

Routine Monitoring Parametersfor Parenteral Nutrition

***Assess GIT function and medications*** baseline: CBC, albumin, renal and liver function tests, INR, TG daily: weight, VS, nutritional intake, fluid balance (input/output), electrolytes (for the first 3-4d), BG 2-3x/w: electrolytes, renal function test weekly: N balance, prealbumin or transferrin, TG, LFT, INR

*Infants and hypothyroidism

*10-15 mcg/kg/day* Monitor with FT4 for first 6 months of life

*empiric basal bolus dosing for T1DM

0.6 units/kg/day 0.3 during honeymoon

CP etiology

1. Heavy alcohol consumption 2. prolonged high TG e.g. obese for 15-20 years 3. postnecrotic pancreatitis

*tx variceal bleeding strategies

1. Primary Prophylaxis 2. Treatment of acute variceal hemorrhage 3. Secondary prophylaxis

*muscle glucose uptake plateau

10 mg/kg/min typically exceeded in T2DM

*Importance of Contraception

45% of US pregnancies are unintended and nearly half result in abortion 40% occur in couples claiming the use of contraception pregnancy can be risky in patients with certain medical conditions

Recommended Macronutrients Requirements for Enteral or Parenteral Nutrition

45-65% carbs; 20-35% fat; 10-35% protein

*Desiccated Thyroid Extract

4:1 mix of T4/T3, pork or beef origin, typical dose 90mg 1 grain (60mg) dessicated thyroid is equivalent to 100mcg T4 and should contain app 38 mcg T4 and 9 mcg T3

*Liotrix

4:1 mixture, Thyrolar T4 (75 mcg)/T3 (18.75 mcg)

*DM in older adults

65+yo-30% have T2DM and 40% have preDM, 1/3 are undiagnosed annual screening for early detection of cognitive impairment is indicated high priority population for depression screening and treatment avoid hypoglycemia, A1C goal 7.5%-8.5%, FPG 90-130 for the health, 90-150 for fall risk or complications, 100-180 for very poor health

*OP epidemiology

80% are female; women are 5x more likely to develop osteoporosis than men; women have twice the fracture rate of men 50% of women and 20% of men will have an ORF in their lifetime

Phytoestrogens in menopause tx

CAM with little data to support role plant stenols with weak estrogenic activity: soybeans (isoflavones), cereals, flaxseed oil (lignans), alfalfa sprouts (coumestans)

Black cohosh in menopause tx

CAM, herbal supplement, mixed results, no known estrogenic activity isolated reports of hepatitis, no safety trials beyond 6mo use

Alemtuzumab

Campathi-binds to CD52R to cause direct cytotoxicity 30mg IV single dose; t1/2 12d; pancreatic and kidney transplants monitoring: ANC

cirrhosis secondary to viral hepatitis

Chronic infection Hepatitis B or C Common in IV drug users Transmitted through sexual contact

*Hypothyroidism Epidemiology

Clinical & biochemical syndrome resulting from decreased thyroid hormone production. Overt hypo occurs in 1.5% to 2% of women and 0.2% of men; incidence increases with age.

*Patient Care Process: Hypothyroidism

Collect: patient characteristics (age, preg, etc.); PMH; s/s; meds; objective (lab—TSH, FT4, TPO antibodies, Scr, ALT, etc.) Assess: cause, identify and prioritize problem list, current meds that may contribute to/worsen hypo; current meds that may interact with thyroid hormone replacement; appropriateness/effectiveness of current thyroid hormone replacement regimen Plan: drug therapy & monitoring parameters including efficacy/safety Implement: pt education about plan, max. adherence Follow-up: 4-6 wks; 6-12 mo if stable

COC

Combined Oral Contraceptive

CD

Crohn's disease-transmural discontinuous inflammatory condition that can affect any area from mouth to anus-cobblestoning, fat wrapping, thickened wall abdominal pain, non-bloody diarrhea, often nocturnal, fecal incontinence, fatigue, N/V, weight loss severity doesn't correlate to intestinal involvement or degree of inflammation. modest increase in risk for bowel cancer; surgery rarely curative

Alpha-Adrenergic Antagonist and BPH

DOC for quick relief of LUTS (lower UT sx) 2nd gen (equally effective as 3rd): terazosin (Hytrin), doxazosin (Cardura) IR and ER, alfuzosin ER (Uroxatral-uroselective), prazosin (Minipress) *3rd gen: tamsulosin (Flomax-less hypoTN),* silodosin do not decrease prostate volume or affect PSA levels

*budesonide (Entocort EC)

DOC for remission induction for mild-mod CD localized to right colon or ileum 9mg qam for 8w, max 4 mo (no real clinical benefit beyond 3 mo systemic effect negligible and no taper required potential interactions with CYP3A4 metabolized drugs not likely significant

*Which drug class prolongs the half-life of endogenous GLP-1?

DPP4i

topical abx for acne

Decrease comedones, papules & pustules Combination products to decrease resistance issues -BenzaClin & Duac - BPO 5% & clindamycin 1% -Benzamycin - BPO 5% & erythromycin 3%

decreased blood flow to liver and cirrhosis

Decreased clearance and prolonged half-life of medications High-extraction drugs

Acromegaly - Diagnosis

Dx of acromegaly consists of failure of GH suppression <1 mcg/L following an OGTT in the presence of elevated IGF-1

Secondary dysmenorrhea

Endometriosis, uterine polyps, uterine fibroids Complications of IUDs, PID

alvimopan

Entereg to accelerate the time to GI recovery following partial large or small bowel resection SE: anemia, dyspepsia, hypokalemia, back pain, and urinary retention for short-term hospital use only; max 7 days or 15 doses whichever is less hospitals must register for EASE (Entereg Access Support and Education)

*Which Medication Formulations NOT to be Administered Via Enteral Tube

Enterically-coated Sustained-release Sublingual or buccal

*Additonal Services/Referral in DM

Eye care professional for annual dilated eye exam Family planning for women of reproductive age Registered dietitian/CDE for MNT DSMES (education and support) -Medicare pays for 10 hours the year of diagnosis and 2 hours thereafter Dentist for comprehensive dental and periodontal examination Mental health professional, if indicated

*insulin titration

FBG 2 units every 3 days prandial glucose 10-15% two times a week (1-2 units typically)

*Azelaic Acid in rosacea

Finacea-treats papules and pustules of mild to moderate rosacea (and acne) antimicrobial, anti-keratinizing, anti-inflammatory (bacteriostatic) no effect on sebum excretion hypopigmentation esp in dark skinnned as effective as metronidazole ADE: facial burning, stinging, and itching (more often than metronidazole, but also mild and tolerable)

*IV insulin to SQ insulin

First SQ insulin injection should be administered at least 1 hour prior to discontinuation of the IV insulin infusion

*SU examples

First generation—rarely used due to increased hypoglycemia risk (acetohexamide, chlorpropamide, tolazamide, tolbutamide) Second generation 1. Glipizide (Glucotrol, Glucotrol XL) -SU of choice in renal insufficiency; start with lower dose 2. Glyburide (DiaBeta, Glynase) -Avoid in renal insufficiency: active metabolites 3. Glimepiride (Amaryl)

*T2D Algorithm Review/Summary

First-line metformin + lifestyle Consider dual tx in newly diagnosed patient with A1C 1.5% above target ASCVD: GLP-1 RA (1st) (liraglutide > semaglutide > exenatide LAR) or SGLT2i (2nd) (empagliflozin > canagliflozin) HF/CKD: SGLT2i (1st) or GLP-1 RA (2nd) Minimize hypo: SGLT2i, GLP-1 RA, DPP4i, TZD Minimize weight gain/promote loss: GLP-1 RA, SGLT2i Cost: SU, TZD, non-analogue insulin

*BPH symptoms

Frequency Urgency Nocturia

*Control-to-Target (CTT) System (closed loop system)

Fully automated and requires no interaction except for calibration of the CGM Three subtypes are being investigated: insulin-only, bi-hormonal and hybrid. Bi-hormonal (insulin and glucagon)—mimics the glucose-regulating function of a healthy pancreas more closely than an insulin-only system. Hybrid system allows the patient to supplement insulin prior to a meal

*GI symptoms

Functional (no identifiable pathophysiology) in nature Indicative of non-functional GI disorders: GERD, PUD, IBD (CD and UC) Indicative of non-GI disorders -Gynecological causes (PID, pregnancy, dysmenorrhea, endometriosis) -Urinary causes -Cardiac causes Due to growing recognition of previously unknown gut pathophysiology, the term "functional disorder" is being replaced with "disorders of gut-brain interaction"

*functional GI disorders

Functional GI disorders account for about 40% of GI problems treated by physicians "Functional disorders" are characterized by symptoms rather than identifiable, underlying pathophysiology Examples of functional disorders include: N/V, chronic diarrhea, generalized abdominal pain, heartburn (not GERD), intestinal gas/bloating, IBS, chronic constipation

*Pregnancy Glycemic Targets

GDM & pre-existing type 1 or type 2 -Pre-prandial ≤ 95 mg/dL -One-hour postmeal ≤140 mg/dL or -Two-hour postmeal ≤120 mg/dL A1C goal in pregnancy < 6%

*What is the most common AE of metformin?

GI distress

*Clinically Significant Hypoglycemia

Glucagon should be prescribed for all patients at increased risk of clinically significant hypoglycemia *(BG < 54 mg/dL).* Raise glycemic targets of insulin-treated patients with hypoglycemia unawareness or an episode of clinically significant hypoglycemia for several weeks Reevaluate treatment regimen

zona fasciculata

Glucocorticoid production Cortisol is the principle end product Fat, carbohydrate and protein metabolism

*chemical-induced diabetes

Glucocorticoids, nicotinic acid, interferon alfa, diazoxide, HCTZ, atypical antipsychotics, protease inhibitors, pentamidine

GLM

Golimumab(GLM)—(Simponi), anti-TNF agent Indication: Moderate to highly active RA in combination with MTX SE: Rare (other than infection) Availability: SubQ injection (prefilled syringe or autoinjector) that can be given at home Counseling: Leave at room temperature for 30 minutes prior to administration. Rotate injection sites and never give injections into areas where the skin is tender, bruised, red, or hard. Do not pull the autoinjector away from the skin until you hear a first "click" sound and then a second "click" sound

CP diagnosis

H&P is not diagnostic but can identify common signs and symptoms imaging-atrophy, calcification, or dilated pancreatic duct 9US, EUS +/- FNP (fine-needle puncture), CT, MRI, MRCP (magnetic resonance cholangiopancreatography), ERCP (endoscopic retrograde) lab-secretin testing (gold standard), fecal elastase, serum trypsin

PDE5i AE and DI

HA, flushing, dyspepsia, nasal congestion, priapism (more rare) sildenafil and vardenafil-decrease BP, vision changes, NAION (non-arteritic anterior ischemic optic neuropathy) tadalafil-muscle pain DO NOT TAKE WITH NITRATES-hypoTN due to NO donors that stimulate GC and increase tissue levels of cGMP

if pregnancy occurs

HGC will tell the body to maintain progesterone and menses will not occur

*tissue typing

HLA I (MHC I): located on all nucleate cells - target for cytotoxic T cells -HLA-A, HLA-B, HLA-C HLA II (MHC II): macrophages, B lymphocytes, monocytes, activated T cells -HLA-DR, HLA-DQ, HLA-DP

ocular HTN

IOP 21+, normal vision fields, normal optic disc, open angles, absence of disease

*tx DKA and HHS

IV fluids, insulin, potassium, bicarbonate when pH <6.9, and sometimes phosphate Correct estimated fluid deficits within 24h. Hyperglycemia corrected faster than KA. KA will most likely correct after resolution of hyperglycemia. Do NOT initiate insulin infusion until serum K >3.5

antibody mediated acute rejection treatment

IV steroid, plasmapheresis, IVIG (immune globulin), optimize immunosuppressants

*cellular mediated acute rejection treatment

IV steroids, increase immunosuppressant initial appropriate immunosuppression regimen usually prevents this

nutrition and acid-base

If they are acidotic then electrolytes need to be in acetate form If they are alkalotic then electrolytes need to be in chloride form

missed doses with patches

If they forget to put it on for week 1: backup for 7 days and consider EC <24 hours due to detachment: reapply to same place and resume routine >24 hours: new patch as if starting anew, backup and consider EC <48 hours in week 2 or 3: apply new patch and resume routine >48 hours in week 2 or 3: new patch as if starting anew, backup and consider EC

Guselkumab

IgG1 monoclonal Ab that binds IL23 thereby reducing IL17 and IL22. Also decreases pro-inflammatory cytokines approved for moderate to severe plaque psoriasis AE: URT, HA, tinea, diarrhea

canakinumab and gout

Ilaris, off label IL1 inhibitor

*T1DM

Immune-mediated: defined by presence of autoimmune markers Cellular-mediated: autoimmune destruction of pancreatic β-cells; variable rate of destruction Autoimmune markers: islet cell autoantibodies, autoantibodies to GAD, insulin, tyrosine phosphatases, ZnT8 Strong HLA associations; linkage to DQA & DQB genes HLA-DR/DQ alleles can be predisposing or protective GAD—glutamic acid decarboxylase ZnT8—zinc transporter 8 HLA-DR (Human Leukocyte Antigen - antigen D Related)

loperamide for diarrhea

Imodium-preferred antimotility agent, OTC as 2mg capsule or 1mg/mL solution 4mg at onset then 2mg after each loose stool; max 16mg/d or 48h of treatment SE: post-treatment constipation high doses have euphoric effects but may lead to life threatening arrhythmias

*GERD treatment goals

Improve symptoms and quality of life Prevent relapse Promote healing of esophageal mucosa Prevent development of complicated disease

vaccinations in pregnant women

Inactivated influenza recommended for all pregnant women Tdap recommended during each pregnancy -Ideally between 27 and 36 weeks -If not given during pregnancy, give immediately postpartum Live, attenuated vaccines should generally be deferred during pregnancy

*TZD disadvantages

Induction of ovulation Periodic liver function test monitoring AE profile—fluid retention* (dose and DI related), weight gain, fracture risk, HF

*severe acne

Inflammatory lesions and scarring with some noninflammatory lesions Extensive papules, pustules, nodules and scarring

ondansetron

Is often given to treat vomiting in acute gastroenteritis because it does not cause significant drowsiness Usually only 1 dose is required May increase diarrhea acutely; constipation after several doses Improves response to oral rehydration Decreases need for IV rehydration therapy Decreases the rate of hospitalization due to dehydration Has a good safety profile with few drug interactions

*charcot foot

Joint dysfunction and foot drop caused by neuropathic arthopathy crushes the bones down. Much higher pressure and greater risk of injury

Amiloride

K sparing diuretic used for HTN; monitor: hyper-K, hypotension, N/V/D, HA MOA: blocks epithelial Na channels in the DCT and CD to inhibit Na reabsorption Decreases Na/K ATPase which leads to K retention and decreased Ca and Mg 20mg/d divided BID, max 30mg/d, adjust by 50% if CrCl <10-50

DI gout

K-wasting diuretics, ethambutol, levodopa, chemotherapy, nicotinic acid, ethanol, salicylates, pyrazinamide, cyclosporine, tacrolimus

*Clinical pearls HoTR

Keep TSH within normal RR 0.5-5 mIU/L If sx remain and TSH confirmed by repeat lab to be within the the upper limit, increase T4 dose and aim for TSH in lower half of normal range *age-adjusted upper limit higher for pts >70yo 6-8*

anakinra for gout

Keneret, off label IL1 inhibitor

salicylic acid for acne

Keratolytic, comedolytic, antiinflammatory, and mildly antibacterial AE: burning, irritation, peeling

drug inhibition of steroid hormone pathway

Ketoconazole inhibits cyp 17, 11-beta-hydoxylase, and 17 alpha-hydroxylase. Metyrapone and etomidate inhibit 11-beta-hydroxylase

sarilumab

Kevzara, IL6R antagonist for mod-severe active RA in pts who failed one or more DMARDs, may be used as monotherapy or in combo with other DMARDs BBW: serious infections SE: neutropenia, increased ALT, injection site erythema, URI, UTI, thrombocytopenia, GI perforation (risk increased with concurrent diverticulitis or NSAID or CS use) SQ q2w; refrigerate; room temp 30 min before administration hold dose and maybe lower upon reinitiation if ANC <2000/mm3, platelets<150, or liver transaminases above 1.5xULN do not use in breastfeeding, risk in pregnancy unknown

*anakinra

Kineret, IL1R antagonist, for mod-severe active RA in pts 18+yo who have failed 1 or more DMARD, use alone or in combo with DMARDs (not anti-TNF) SE: injection site reaction, worsening of RA, URI, HA, nausea, diarrhea 100 mg SQ daily; QOD in renal adjustment CI: Hypersensitivity to E. coli-derived proteins monitor: ANC q3mo until 1 year after d/c no live vaccines, may increase malignancy risk

*insulin regimens T1DM

LAI (glargine QD or detemir BID) and SAI (lispro, glulisine, aspart) for meal coverage

*glargine

LAI, U100 (Lantus) vial and pen-pH 4 (soluble) forms microprecipitates in neutral pH that slowly dissolve into dimers and monomers causing 24h DOA U100 (Basaglar)-pen, follow-on biologic, no autosubstitution U300 (Toujeo)-pen, longer DOA

*Thyroid Gland

Located in anterior neck Composed of left and right lobes with connecting branch (isthmus) Produces two iodine-containing hormones within thyroglobulin (TG) -Thyroxine or tetraiodothyronine (T4) -Triiodothyronine (T3)

ROME IV Diagnostic Criteria for Chronic (Functional) Diarrhea

Loose or watery stools, without predominant abdominal pain or bothersome bloating, occurring in >25% of stools for the last 3mo with initial sx 6+mo ago Do not use ROME IV when an underlying cause can be been identified

*primary prevention CVD in DM

MNT, glycemic control (early, aggressive intervention), HTN control, lipid control, antiplatelet if indicated, lifestyle management (tobacco cessation, weight control, 5-10% weight loss)

*nonpharmacologic treatment of DM

MNT, weight optimization, healthy diet 150 min of moderate-to-vigorous intensity physical activity per week spread over at least 3 days with no more than 2 consecutive days without activity 2-3 sessions/week of resistance training on nonconsecutive days limit sedentary time to no more than 30 minutes flexibility and balance training for older adults 2-3x/week DSME and DSMS

complications of PN

Mechanical -Catheter obstruction -Venous thrombosis -Venous thrombophlebitis Metabolic Infectious Catheter & systemic infections

*DM agents that cause weight loss

Metformin, SGLT2i, GLP1 RA, DPP4i (neutral)

PEG 3350

Miralax, Glycolax, DOC for occasional/acute or chronic constipation, IBS-C; Good choice post-surgery to decrease straining; Used off label for bowel prep 17 g in 8 oz. of liquid QD; OOA: 48 hours

*insulin pen advantages

More accurate (measurement, air bubbles) -Reduce need for dexterity and visual acuity -Lilly products have built-in magnifying lens, audible clicks; Novo products—large window, audible clicks More portable, discrete, less pain, more apt to be used

identifying and avoiding food intolerances in IBS

More than 60% of patients with IBS experience bloating and abdominal pain after eating certain foods Keep a dietary and symptom diary (2-3 weeks) to identify implicating foods and avoid them Possible culprits: fat, spicy foods, lactose, gluten, alcohol, artificial sweeteners (sugar alcohols), insoluble fibers (especially bran), fermentable carbs (fermentable oligosaccharide, disaccharide, monosaccharide, and polyols FODMAPS)

*Thyroid and Pregnancy

Most women with preexisting hypo need a higher dose of T4 during pregnancy as early as fifth week of gestation, plateauing by week 20

*Benefits of lactation

Mother: more rapid uterine recovery; decreased postpartum blood loss; decreased risk of breast and ovarian cancer Baby: decreased risk of gastroenteritis, severe RTIs, AOM, and SIDS Exclusive breastfeeding is recommended until 6 months of age

noloxegol

Movantik, PAMORA CI: Concomitant use with CYP3A4 inhibitors (clarithomycin, ketoconazole, etc.) take on an empty stomach at least 1 hour prior to the first meal of the day or 2 hours after, may be crushed and given via NG tube if needed, avoid grapefruit and grapefruit juice PEGylated derivative of naloxone prevents cross of BBB and potentiation of opioid withdrawal; Dispense with medication guide; Half dose in CrCL < 60 then increase dose slowly if tolerated

OTHER tx for PMS/PMDD

NSAIDs; diuretics in OTC meds are not effective; exercise, SNRIs (venlafaxine) alprazolam for those unresponsive to other agents (addiction potential) buspirone-reduces irritability GnRH agonists (leuprolide), danazol-generally reserved for severe PMDD unresponsive to other tx

DOC for treatment of gastric varices

NSBB and EVL

*screening recommendations for OP

PE, DXA, vertebral imaging, BTMs,

*prevention DKA and HHS

Patient contact with health care provider Insulin therapy -During illness -Educate on BG goals Treat fever and infection Family education of sick day management

Glucocorticoid secretion is regulated by

Pituitary hormone Adrenocorticotropic hormone (ACTH/corticotropin)

crossmatching

Positive cross-match: Cytotoxic IgG antibodies are present against donor tissue Strong contraindication to transplant

What happens if you take excess B vitamins?

Possible neuropathy in rare instances. Usually just get peed out though, water-soluble!

*Metformin Off-Label Use

Prediabetes (prevention of T2D)-particular benefit in women with previous GDM Antipsychotic-induced weight gain Polycystic ovary syndrome

systemic estrogens for menopause

Premarin (CEE-conjugated equine estrogens), Estrace (micronized 17beta-estradiol), Climara (once weekly patch), Vivelle-Dot (twice weekly patch), Evamist (spray), Estrogel, Estrasorb (emulsion), Femring (3 mo vaginal ring with SYSTEMIC absorption)

PONV

Prevention for high-risk pts only Prevention: Droperidol + dexamethasone (first 20 min) OR ondansetron (last 20 min) OR scopolamine patch (1 hr before) Treatment: phenothiazine, 5HT3 antagonist

*gatroparesis tx

Prokinetics (metoclopramide or erythromycin)

uncomplicated N/V tx

Promethazine, prokinetics, or 5HT3 antagonist

treatment goals of PUD

Relieve ulcer symptoms Heal ulcer Eradicate H. pylori (if positive) Prevent recurrence Reduce ulcer-related complications

*Which oral class is most likely to cause hypoglycemia?

SU

*BB and HTR

SYMPTOM CONTROL NOT CURATIVE Selective BB manage sympathetic symptoms and inhibit peripheral T4 conversion given to decrease thyrotoxic effects or prevent cardiac decompensation in susceptible pts AE: hypoTN, bradycardia, fatigue, masking hypoglycemia CI: asthma, COPD if non-selective benefits: -decrease HR (goal <90), BP, muscle weakness, tremors -improve degree of irritability, emotional lability, exercise tolerance propranolol 120-160 mg in 3 or 4 divided doses; max 640mg/day-preferred in lactation nadolol 80mg divided into 1 or 2 doses; max 320mg/day

*DPP4i examples

Sitagliptin (Januvia)--25-100mg daily, dose adjust for renal insufficiency Linagliptin (Tradjenta)--no dosage adjustment -Dose: 5 mg daily Saxagliptin (Onglyza) -Dose 2.5-5mg daily, avoid in HF Alogliptin (Nesina) -6.25mg, 12.5mg, 25mg once daily -Dose adjustment in renal impairment -Reduce by half (12.5) for pts with CrCl 30-60 -6.25mg for CrCl <30

*weight loss categories

Small loss: <5% of usual body weight (UBW) Potentially significant loss: 5-10% of UBW Significant loss: >10% of UBW

pegvisomant

Somavert, GH derivative used for acromegaly that blocks GH receptor and inhibits IGF-1 production *(does not actually inhibit GH)* loading dose 40mg SQ followed by maintenance of 10mg QD (max 30/mg/d) AE: injection site pain, GI symptoms, increased LFTs, infection, flu-like symptoms appears to be the most effective agent for normalizing IGF1

*nausea

Subjective feeling of needing to vomit including an unpleasant feeling in the mouth and stomach associated with salivation, sweating, dizziness, and tachycardia May be more bothersome than vomiting in some

*liothyronine

T3, Cytomel, typical dose 37.5mcg

*Threshold Suspend Device System (Sensor-augmented pump)

Temporarily suspends insulin delivery when the glucose level falls to a low glucose threshold—"low glucose suspend system." Serves as a back-up when patient is unable to respond to a hypoglycemic event. Partially closed loop system

*physical activity

There can be adrenaline-associated increases in BG but improved glucose utilization will decrease BG. BG may be affected up to 18h after activity due to the muscle replenishment of glycogen stores. Consider reduction in overnight basal following exercise to reduce risk of delayed exercise-induced hypoglycemia. *Decrease bolus insulin for planned activity for pts using MDI* or add carbohydrate. Decrease basal rate for pts using pump therapy.

*Artificial Pancreas Device Systems

Threshold Suspend Device System (Sensor-augmented pump) Control-to-Target (CTT) System (closed loop system)

*MNT to reduce CVD in DM

Total dietary fat intake 25-35%, monounsaturated or poly Fiber (14g/1000 calories) Alcohol limited Sodium 2300 mg/day

*motion sickness

Treatment : antihistamines, 5HT3 antagonist Prevention: scopolamine, meclizine, dimenhydramine

*degludec

Tresiba, ultra LAI, flex touch pen, once daily U100, 5 pens, 300 units each, max single dose 80 units U200, 3 pens, 600 units each, max single dose 160 units DOA >42h, t1/2 25h, SS 4d, stable 56d at room temperature lower rate of severe and nocturnal hypoglycemia than glargine and less day to day variability consider use in renal insufficiency insulin degludec/insulin aspart 70/30 (Ryzodeg) QD or BID TWF

diagnosis PUD

Upper endoscopy (EGD) with biopsy is Gold Standard-recommended in all patients with alarm symptoms and all patients ≥ 45 years old with suspected PUD -Detects 90% of peptic ulcers, permits direct inspection, visualization and biopsy -Biopsy is used for rapid urease test, histology and culture -Use of bismuths, H2RAs, and PPIs prior to biopsy may lead to false (-) urease test Radiography (less expensive)-if ulceration, endoscopy must follow for biopsy and histology to rule out malignancy

complications of BPH progression

acute urinary retention can lead to acute renal failure chronic renal failure for long-standing bladder outlet obstruction hematuria, urinary incontinence, recurrent UTI, bladder stones

*treatment overview atopic dermatitis

adequate moisture, low-moderate topical steroid, topical immunosuppressive, oatmeal based products, probiotics, watch for secondary infections

GH effects

antiinsulin effects on lipid and carbohydrate metabolism: decreases glucose uptake, increases lipolysis, increases muscle mass, increases HGP, decreases insulin-receptor sensitivity

intertriginous

armpits and under breasts especially in individuals with skin folds

*guidelines for oral abx use in moderate to severe acne

avoid abx monotherapy, combo topical retinoid and BPO to reduce resistance treat for 6-8w for minimum improvement reevaluate need for antibiotic at 12-18w with the same antibiotic for several courses before switching to another antibiotic add hormonal therapy for selected females

menopause tx

avoid triggers, personal cooling devices, layered clothing, stress reduction, HRT and non-hormonal alternatives

BEE

basal energy expenditure-predictive equation the amount of energy required to maintain the body's normal metabolic activity: respiration, maintenance of body temperature, etc. Harris-Benedict Equation (BEE) BEEmen (kcal/day) = 66 + (13.7 x Wt) + (5.0 x Ht) - (6.8 x Age) BEEwomen (kcal/day) = 655 + (9.6 x Wt) + (1.8 x Ht) - (4.7 x Age) Age in years Height in cm (***note: 1in=2.54cm) Weight in kg Don't need to memorize equations Multiply by stress factors

*RAI timing

before a meal ~10 minutes

*penis anatomy

blocking of the dorsalis penis artery on top can limit erection

minerals and bowels

calcium constipates magnesium moves

*common foot deformities

charcot foot hammer toes bunions prominent metatarsal heads

*long acting insulin only

check FBG once a day

*OTC allergy tx in pregnant women

chlorpheniramine, loratidine, cetirizine, diphenhydramine NOT ON EXAM

*cyst

closed cavity or sac lined by epithelium, especially one with liquid or semisolid material

*management of underlying psychological issues of IBS

cognitive behavioral therapies, hypnosis, medication, relaxation techniques, moderate physical activity for 30min/d, 5d/wk (vigorous may worsen sx)

CHC

combined hormonal contraceptive-synthetic estrogen and progestin types: COC (combined oral contraceptive), transdermal, or vaginal ring

*CGM

continuous glucose monitoring-measures interstitial glucose, new sensor q3-7d useful in hypoglycemic unawareness, nocturnal or frequent hypoglycemia most commonly paired with insulin pump therapy

EN infusion

continuous preferred in critically ill pts in a hospital setting as they are less likely to aspirate cyclic-at night bolus-long-term care facility intermittent

*CSII

continuous subcutaneous insulin infusion cannula inserted under the skin Pumps deliver RAI at a programmed rate mimicking basal insulin administration but can be manually operated to adjust for meals or correction doses Catheter insertion/tubing changed every 2-3 days

*nonpharmacological treatment of PUD

d/c NSAIDs (including ASA) and other exacerbating meds, smoking cessation, reduce stress (physical and psychological), consider probiotics (Lactobacillus 5-10 billion CFUs/d and Bifidobacterium 5 billion CFUs/d)

if at risk for aspiration

deliver EN to the small bowel instead of the stomach or use prokinetic agents like metoclopramide 10mg QID for normal renal fx and erythromycin 3-7mg/kg/d -both QT prolonging agents and metoclopramide can cause tardive dyskinesia intubated patients receiving EN should have the head of the bed elevated 30-45 degrees and use chlorhexidine mouthwash BID reduce level of sedation and analgesia minimize transport out of the ICU (e.g. diagnostic tests and procedures)

DMPA

depot medroxyprogesterone acetate

soluble fiber

dissolves and absorbs water to form a gel-like consistency bacterial degradation (fermentation) in the colon may cause gas supports good gut bacteria, slows digestion, prevents BG spikes, keeps you full longer, aids in weight loss, and lowers the risk of MI or heart disease e.g. oats, barley, beans, lentils, peas, some fruits and vegetables also methylcellulose, psyllium, wheat dextrin

fourth generation progestins

drospirenone, dienogest no estrogen activity, low progestin activity, and anti-androgenic

EVL

endoscopic variceal ligation-primary prophylaxis of variceal bleeds

progestin AE

excess: HA, fatigue, mood changes, breast tenderness; deficiency: late BTB

*LR

for aggressive hydration in AP; labs-Na, K, Cl, Ca CI: lactic acidosis, hypercalcemia, hyperkalemia, hyponatremia Caution: CHF, renal insufficiency, alkalosis, pulmonary or peripheral edema

*OP physical exam

for all persons-annual height, check for secondary causes, Medicare pays every 2 years, no warning signs for a fracture

*main insulin counterregulatory hormone

glucagon

avoid in heart failure

infliximab

*LH

luteinizing hormone, gonadotropin

*DPP4i

modest efficacy MOA: Inhibits DPP-4 from breaking down endogenous GLP-1 = increased endogenous incretin levels = glucose-dependent increase in insulin secretion & glucose-dependent inhibition of glucagon secretion; targets PPBG -Glucagon suppression results in decreased liver glucose production -Enhances insulin and amylin secretion from pancreas -Good durability (insulin present) Advantages—weight neutral, no hypoglycemia as monotx, possible CVD benefit

NSAID least likely to cause cardiovascular problems

naproxen

estradiol valerate

newest (Natazia) EE 20mcg

*main risk factor for T2DM

obesity

secum

pouch that forms the beginning of the large intestine

cupping

pressure thins outer rim of optic nerve

PA

primary aldosterone-65% caused by bilateral adrenal hyperplasia (BAH), 30% aldosterone-producing adenoma (APA-also Conn's syndrome) PA is present in 10% of the hypertensive population (secondary HTN) more common in women, 30-60yo, most asymptomatic remove the tumor for APA, pharmacological tx for BAH (aldosterone antagonists or amiloride) sx: resistant arterial HTN, hypokalemia, muscle weakness, fatigue, HA

Hyperprolactinemia

prolactin is normally secreted in a pulsatile fashion with the highest concentration while sleeping prolactin secretion regulated by DA hyperprolactinemia is a state of persistent prolactin elevations typically from benign prolactin-secreting pituitary tumors known as prolactinomas *diagnosed when >20mcg/L in women (usually reproductive age) and >25 in men*

prolactin

promotes lactation inhibited by *dopamine* and GABA

Avoid ophthalmic BB in patients with...

pulmonary diseases, sinus bradycardia, second- or third-degree heart block, CHF, atherosclerosis, DM, Myasthenia gravis, pts receiving oral BBs

*microvascular complications

retinopathy, nephropathy, neuropathy8

*aura

sensation warning a patient that they may have a migraine soon may see halos, may smell something, etc.

*Hypothalamic-pituitary-thyroid axis

sensitive to small changes in circulating thyroid hormone conc. alterations in thyroid hormone secretion maintain peripheral free thyroid hormone levels within a narrow range

*PEDIS Grade 4

severe-local infection with signs of SIRS 2+ of the following: temp >38 or <36, HR >90, RR >20, WBCs >12000 or <4000 tx duration: 2-3 wk of inpatient therapy IV-vancomycin and zosyn combo is really good. Zosyn has anaerobe coverage.

*acne treatment considerations

severity, lesion types, preference, costs, skin type, age, adherence, response to previous therapy, scarring, psychological effects, family hx persistent acne

*N/V signs and symptoms

simple: queasiness or discomfort, often self-limiting or only need sx therapy complex: weight loss, fever, abdominal pain. sx not relieved by antiemetics, fluid/electrolyte imbalance. usually associated with noxious agents or psychogenic events

SBP

spontaneous bacterial peritonitis-acute bacterial infection of ascitic fluid in the absence of intra-abdominal infection or intestinal perforation *most common-E. coli, K. pneumoniae, S. pneumoniae* paracentesis for all who develop sx or have lab abnormalities suggestive of infection (e.g. abdominal pain or tenderness, fever, encephalopathy, renal failure, acidosis, or peripheral leukocytosis) *>250 PMNs is diagnostic* no need to monitor once they leave the hospital

DMARDs for RA

start as soon as possible within 3 mo of sx onset and continue indefinitely even in periods of remission reduce inflammation, prevent joint damage, maintain joint function and integrity, prevent overall disease progression e.g. HCQ, SSZ, MTX, LEF

SSZ counseling

sun sensitivity

magnesium and PMS/PMDD

supplements may improve pain, fluid retention, and negative affect data is sparse, but 200-360mg for PMS sx is supported; SE: N/D

Role of DHT

testosterone and androstenedione are converted in the prostate to dihydrotestosterone by 5alpha-reductase type II. DHT causes epithelial tissue growth in the prostate. Estrogen causes stromal growth in the gland.

PO biologic

tofacitinib

systemic therapy for psoriasis

use when plaques are too extensive for topical therapy (>10% BSA) or when refractory to topical and phototherapy systemic glucocorticoids may lead to life-threatening pustular psoriasis when d/c oral: methotrexate, cyclosporine, acitrentin, apremilast biological: TNFalpha inhibitors-infliximab, etanercept, adalimumab, alefacept, ustekinumab, secukinumab, ixekizuman, brodalumab

statins with transplants

use with caution due to DDI especially with CNIs, increased risk of rhabdomyolysis, monitor CPK at baseline and every 6mo on statin do show benefit in heart transplant pts in preventing rejection due to immunomodulatory effects only CI in lovastatin and simvastatin

coal tar and psoriasis

used for over 100 years, but its use has decreased in the US poorly tolerated due to staining of clothes, skin, and tar odor SE: irritant contact dermatitis, sun sensitivity can be used short-term in pregnancy

MELD

used to assess cirrhosis severity

topical metronidazole in rosacea

widely used in tx of rosacea-exact mechanism of reducing erythema and inflammatory lesion is not known, may take several weeks for benefit AE: burning, dryness, rash, itching overall well-tolerated

IBD treatment factors

*location,* coexisting conditions, medication adherence, lifestyle factors, QoL *goals of therapy:* acute exacerbation, maintenance, remission

*methimazole summary

Initial treatment in severe cases or preoperative preparation Advantages: noninvasive, low initial cost, low risk of permanent hypothyroidism, possible remissions due to immune effects Disadvantages: low cure rate, ADR, drug compliance

*tx plan for EARLY RA

Initiate DMARD monotherapy over double or triple therapy (typically MTX) For ALL patients being initiated on DMARD therapy, consider a "bridge" with low-dose glucocorticoids until DMARD benefit can be realized. For patients with moderate or high disease activity despite double or triple DMARD therapy, consider adding low-dose glucocorticoids (defined as ≤10 mg/day of prednisone or equivalent) For patients experiencing a flare of RA, add a short-term glucocorticoid (< 3 months) Glucocorticoids should be continued at the lowest effective dose for the shortest period possible

*Comprehensive foot exam by a provider should include:

Inspection of skin Assessment of foot deformities 10 gauge monofilament testing Assessment of ankle reflexes Vascular assessment (esp. pulses in legs and feet)

Eplerenone

Inspra for HTN and HF MOA: selective AA with low affinity for androgen and progesterone receptors (less SE than spironolactone) 50mg BID; max 100mg/day CI: CrCl <30 AE: hyper-K (monitor), hypoTN (monitor), dizziness, HA, gynecomastia CYP 3A4 substrate-do not take with strong inhibitors

*ED diagnosis

International Index of ED-standardized questionaire to assess severity PMH-illness, surgical hx, Etoh, drug use, smoking Meds, lab tests (testosterone and PSA) PE-hypogonadism (gynecomastia, decreased body hair), DRE (BPH can cause ED), curved penis (Peyronie's disease-excessive scar tissue-treated with Potaba-potassium aminobenzoate-expensive)

*silent thyroiditis

Lymphocytic and postpartum variations

HRT duration in menopause tx

Shortest duration that achieves tx goal, limit to 3-5y of use, reassess q6-12mo recurrence of vasomotor sx occurs 50% of the time after d/c (now or later) -independent of age and duration of use -data inconclusive on tapering benefit (suggest if d/c makes the pt uneasy)

*Brodalumab for psoriasis

Siliq-binds IL17 inhibiting the IL17A pathway AE: infection (bronchitis, URT, UTI), fatigue, tinea, suicidal ideation

*indications for insulin

T1DM, GDM, pre-existing DM in pregnancy, DKA/HHS, glucose toxicity, acute illness/surgery, T2DM not at glycemic goal on non-insulin therapies

*levothyroxine

T4 Tablets: Levoxyl, Synthroid, Unithroid Soft gel: Tirosint Oral Soln: Tirosint-Sol avg adult dose 112-125mcg daily

*T1DM insulin dosing

TDD 0.4-1 units/kg/day (0.6 empiric) honeymoon phase 0.1-0.4 (0.3 empiric) CSII or MDI (4 injections) is ADA/AACE recommended regimen

*DM therapy choice with high TG

TG >1000, do not prescribe GLP1 because there is a high risk of pancreatitis

*Monitoring Combined Therapy in hypothyroidism

TSH 6 weeks after initiation FT4 may be useful in nonsteady-state conditions Converting combination to T4 monotherapy: T3 is 4 times more potent metabolically than T4 e.g. pt taking 12.5mcg T3 and 50mcg T4 should be taking 100mcg T4 as monotherapy

apomorphine

Uprima-promising drug in development-dissolves under tongue to stimulate dopamine and heighten sexual interest and sensation

*nephrolithiasis and gout

Uric acid stones, calcium oxalate stones, or mixed stones Dependent on serum and urinary uric acid concentrations and urinary pH (occurs at pH < 6)

*SGLT2i examples

Canagliflozin (Invokana) 100-300mg daily, CrCl <60 100mg, <45 not recommended, good for HF Dapagliflozin (Farxiga) 5-10mg daily, <60 not recommended Empagliflozin (Jardiance) 10-25mg daily, <45 not recommended, good for HF Ertugliflozin (Steglatro) 5-15mg daily, do not initiate <30

*OTC cough tx in pregnant women

guaifenesin dextromethorphan mentholated rubs numbing throat sprays cough drops Avoid sustained-release products. Avoid products containing > 1 active ingredient. Avoid liquid preparations containing alcohol. Use caution with agents containing supplements/herbs. NOT ON EXAM

*albumin and SBP

albumin addition necessary if Scr >1, BUN >30, or total bilirubin >4mg/dL albumin dosing: 1.5g/kg on admission and 1 g/kg on day 3 SBP is thought to enhance intravascular hypovolemia and organ hypoperfusion albumin dosing prevents HRS (hepatorenal syndrome)

APA

aldosterone-producing adenoma

ARR

aldosterone-renin ratio

alarm symptoms of PUD

anemia, melena, heme (+) stool, hematemesis, anorexia, weight loss, persistent epigastric pain radiating to back, change in the nature of pain, severe pain

Gaviscon

antacid, tablets will foam when chewed CI: hypersensitivity to seaweed (natural source of alginic acid)

*OTC heartburn tx in pregnant women

antacids ranitidine cimetidine famotidine Nonpharmacologic recommendations: smaller, more frequent meals; avoid eating/drinking before bedtime; avoid fatty foods, caffeine, spicy foods, mint, nicotine; elevate head of bed 4-6 inches. Antacids should be used first-line. Excessive magnesium-containing products may cause diarrhea. If not responsive to antacids, may use H2 blocker. Omeprazole may be considered but should generally be secondary to physician recommendation. NOT ON EXAM

biologic and small molecule DMARDs

anti-TNF biologics-adalimumab, etanercept, infliximab, golimumab, certolizumab non anti-TNF biologics-rituximab, tocilizumab, sarilumab, abatacept small molecule-tofacitinib

GERD pharmacological treatment

exclusions to self-care: alarm symptoms, severe or frequent (>2d/w) heart burn for over 3mo, sx that persist >2w despite appropriate OTC therapy infrequent mild-mod: self care with antacids, alginic acid, H2RA or combo frequent mild-severe: PPI atypical: endoscopy or ambulatory reflux monitoring to diagnose then PPI

Subdermal Implant

etonogestrel (Nexplanon) inserted on inner side of upper, nondominant arm insert in first five days of menses or use backup effective for up to 3y; fertility returns rapidly after removal

*POAG diagnosis

evaluation of the optic disk and retinal nerve fiber layer assessment of visual fields measure of IOP-does not have to be elevated for diagnosis

Top-down therapy for CD

evidence suggests biologics early in the disease course (w/in 2y of onset) have better long-term CD outcomes and may reduce steroid dependence. There is a concern of long-term complications like cancer.

hyperlipidemia and transplants

exacerbated by CS, CNIs, sirolimus, diuretics current guidelines recommend monitoring lipids 2-3 months after transplant and annually thereafter tx: statins, lifestyle modifications, BAS, fish oil, fibrates drug combos to avoid: -CsA+statin+fibrates -CsA+high dose statin -CsA+statin+azoles or macrolide (hold statin temporarily) -CsA+statin+Non-DHP CCB

androgen AE

excess: Weight gain, acne, oily skin, hirsutism, increased LDL, decreased HDL

*OTC constipation tx in pregnant women

bulk-forming laxatives docusate polyethylene glycol Nonpharmacologic recommendations: ≥ 8 glasses of water/day; regular exercise; increase dietary fiber. Bulk formers are preferred, especially for maintaining regularity. Stimulant laxatives (bisacodyl, sennosides) may be used in refractory constipation but are associated with stomach cramping. Ensure patients are drinking enough water. Frequent need for osmotic or stimulant laxatives should be referred to physician. NOT ON EXAM

*heartburn

burning sensation in the chest caused by acid regurgitation into the esophagus; Common symptom of gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), delayed gastric emptying, gallbladder disease, hiatal hernia, and other gastrointestinal (GI) disorders NOT THE SAME AS GERD (no damage to the esophagus)

ocular rosacea

burning, dryness, itching, ocular photosensitivity, blurred vision, telangiectasia of the sclera, periorbital edema generally responds well to topical agents but severe cases show a prompt response to oral abx and improvement with isotretinoin

Paregoric

camphorated tincture of opium,, 5-10mL up to QID PRN 0.4mg/mL morphine in 45% alcohol do not confuse with opium tincture which is 25x more potent

*Clinical Presentation HoTR

extreme fatigue, weight gain, depression, cold intolerance, dry skin/loss of hair/brittle nails, constipation, irregular heavy menses, decreased concentration, forgetfulness, bradycardia, HTN (diastolic), hypothermia, hoarseness, hyperlipidemia, puffy eyelids, goiter, muscle pain, weakness, decreased reflexes

*protein requirements

g/kg ABW/d; maintenance: 1-1.2; renal or hepatic failure: 1.2-2 (use dry weight); dialysis: 1.5-2.5; hepatic coma 0.6-0.8 (use dry weight)

*GERD

gastroesophageal reflux disease chronic upper gastrointestinal disorder that develops from the reflux of the acidic contents of the stomach into the esophagus (with or without esophageal injury). It can be subdivided in 3 phenotypes: -Nonerosive reflux disease (NERD)—60 to 70% of pts -Erosive esophagitis (EE)—20 to 30% of pts Major risk factor for BE -Barrett's esophagus (BE)—about 10% of pts

cardiotoxic drug for SLE

cyclophosphamide

psoriasis complications

joint disease (5-20%), injury and infection of skin, poor quality of life, anxiety and depression (25%), increased mortality from CVD, increased risk of lymphoma and non-melanoma skin cancer

*insulin administration

needle and syringe -NPH, SAI, or RAI can be mixed in single injection -smallest-31G and 6mm pens -disposable or reusable, portable -aspart and lispro offer half-unit delivery -smallest 32G and 4mm CSII

*DM agents that lower FBG

metformin and LAI

gout assessment

mild-mod attack: <=6 on the pain scale with only a few small or 1-2 large joints severe attack: >6 with polyarticular presentation or multiple large joints

*artificial tears

moisturize eyes PRN mineral oil, glycerin, propylene glycol, dextran, hypromellose

*Long-term Outcomes Hypothyroidism

neuromuscular and psychiatric symptoms may persist for months some studies document persistent defect in psychological well-being congenital HoTR in infants with inadequate tx may have permanent brain damage

*nausea and vomiting

not regurgitation or reflux, rumination ("chewing the cud"), dyspepsia (indigestion) acute N/V from infection (viral gastroenteritis), CNS causes (motion sickness), metabolic causes (pregnancy), DI (chemo), inflammation (toxins, appendicitis, pancreatitis) or iatrogenic causes complications: dehydration, electrolyte imbalance, malnutrition, aspiration pneumonia, esophageal tears

PRA

panel reactive antibodies formed from previous exposures e.g. transfusions, other transplants, pregnancy more than 20-50% PRA indicates higher risk for rejection

*inflammatory lesions of acne

papule, pustule, nodule

diagnosis of ascites

paracentesis for inpatients or those with clinically apparent new-onset ascites -fluid analysis, total protein, CBC with differential, cx if infection suspected -SAAG (serum ascites albumin gradient) >1.1g/dL = portal HTN paracentesis to either diagnose cirrhosis or pull of fluid to relieve sx gross assessment-push on one side of the abdomen and look for a fluid wave-positive for ascites

*Child-Pugh Classification

parameters: ascites, hepatic encephalopathy, bilirubin, albumin, prothrombin time Child A Class: 5-6 points, well compensated Child B Class: 7-9, significant functional compromise, may qualify for transplant Child C Class: 10-15, decompensated, may qualify for transplant

*alcohol and diabetes

particularly in T1DM In the fasting state, alcohol may cause hypoglycemia in persons using insulin or secretagogues Alcohol is a source of energy, but not converted to glucose; *interferes with gluconeogenesis "Dead in Bed"* Drinks should be limited to 1 drink a day (women) or 2 (men) To reduce risk of nocturnal hypoglycemia in PWD using insulin or insulin secretagogues, alcohol should be consumed with food InPWD, moderate alcohol consumption (when ingested alone) has no acute effect on glucose and insulin concentrations, but carbohydrate coingested with alcohol (as in a mixed drink) may raise blood glucose The body processes the body like fat and it breaks down the alcohol first. (Not good for weight loss)

comedo

plug of keratin & sebum in hair follicle open-blackhead (sebum and fatty acids oxidize and change color) closed-whitehead

immunization recommended in all RA pts

pneumococcal

tazarotene for acne

retinoid, prodrug of tazarotenic acid modulates differentiation and proliferation of epithelial tissue; exerts anti-inflammatory and immunologic activity AE: burning/stinging, pruritis, erythema, dry skin, rash, dermatitis, photosensitivity cleanse skin, apply thin film once daily in the evening

*early combination therapy for DM

should be considered if initial A1C is >1.5% above goal and they need to lose weight you would give them metformin and an additional agent that fit their needs (CVD risk, weight loss need, cost, etc.)

HRT and dementia in menopause tx

significant reduction shown in some studies, but an increased risk reported in women 65+yo with estrogen +/- progestin HRT is not indicated for the prevention of dementia

exacerbation of acne

stress, oil-based makeup, sunscreen, hair products, dirt, friction from tight clothing, athletic equipment, oils from cooking, *no correlation with diet* drugs: steroids, lithium, OCs (high progesterone), physical occlusants (zinc-oxide)

exacerbating factors of gout

stress, trauma, infection, surgery, alcohol, meds

*Empiric Osteomyelitis Regimens

vanc trough goal of 15-20 (usually only 10-15 but we want bone penetration) additional agents for GN coverage: Zosyn, Merrem, cetazadime (Fortaz), cefepime (Maxipime), Cipro

floppy iris syndrome

very specific to tamsulosin-almost irreversible really only occurs during cataract surgery-dc tamsulosin

*VAT

visceral adipose tissue-20% of total fat in men, 6% in women higher rate of lipolysis that other fat; produces adipocytokines like TNFalpha, IL6, angiotensinogen, plasminogen activator or inhibitor-1, and resisten which all contribute to insulin resistance, HTN, and hypercoagulability

*pustule

visible collection of pus within or beneath epidermis often in hair follicle, sweat gland

*hot flashes

warm feeling spreads from head to toe +/- visible flushing and sweating experienced by 50-85% esp during 2y after menopause may occur at night-night sweats, insomnia, sleep deprivation trigger: increased temperature; ingestion of hot liquids, caffeine, alcohol, spicy foods; mental stress

*viral and bacterial conjunctivitis

warm water compress to alleviate swelling and mild discomfort cool water compress for viral or allergic artificial tears to provide lubrication and reduce "gritty" feeling

monitoring of therapy in obese patients

weight (4-5% loss at 12w of tolerated max dose), vital signs, BG (may need to decrease insulin or secretagogue dose), SCr AE: neuropsychiatric (lorcaserin, P-T, B-N), acute pancreatitis (liraglutide), hyperchloremic nonanion gap metabolic acidosis (topiramate)

*weight loss and DM remission

weight loss of 15kg can lead to remission in those with DM for less than 6 years

*Radioactive Iodine (131I) Ablation

well absorbed orally and concentrates in the thyroid to disrupt hormone synthesis. Causes thyroid follicular necrosis over a period of weeks. Transient increase in TH secondary to release of preformed hormone *Pretreat elderly and patients with cardiac disease with MMI* Mosy patients are euthyroid within 6mo-1 year; HoTR often develops CI: pregnancy (or planning in the next 6mo), lactation, coexisting thyroid cancer

*T1DM summary

<30 yo, abrupt onset, lean, no insulin resistance, autoantibodies often, symptomatic, ketones present, immediate need for insulin complications-DKA, no microvascular at diagnosis and macrovascular are rare

missed doses Nuvaring

<3h removed-rinse with cool or lukewarm water then reinsert >3h removed-backup 7 days and consider EC ring in place >3 weeks-remove and insert new ring after ring-free interval, no backup needed

early danger signs with CHC

*A*bdominal pain (severe)-liver problem, gallbladder disease, blood clot *C*hest pain (severe), SOB, or hemoptysis-PE or MI *H*eadaches (severe)-stroke, HTN, migraine *E*ye problems-blurred vision, flashing lights, blindness *S*evere leg pain in calf or thigh-DVT

Drug Interactions

*BTB may be first sign of decreased hormone concentrations* CYP3A4 inducers: rifampin, rifabutin, rifapentine, grisofulvin, topiramate, phenobarbital, carbamazepine, oxcarbazepine, phenytoin, some HIV meds, St. John's Wort, etc. long-term use of inducer-DMPA or IUD (not affected) or COC with 50mcg EE CHCs decrease lamotrigine and effectiveness of thyroid replacement hormones *controversial risk of contraceptive failure with tetracyclines and penicillin-back up contraception for duration of therapy and until next withdrawal bleed

PUD risk factors

*H. pylori,* chronic diseases, viral infections, radiation, organ transplant physical stress (non-ambulatory), psychological stress (controversial), ZES, some foods will aggravate the ulcers but do not cause the ulcer or make the ulcer itself worse

*thyroid storm treatment

*PTU preferred* due to its ability to inhibit peripheral conversion of T4 to T3 iodide AFTER thioamide to block release of preformed hormone and inhibit iodide utilization BB (e.g. esmolol), glucocorticoids, acetaminophen for fever, and supportive tx

Avoid CAI in patients with...

*sulfa allergies,* sickle cell disease, respiratory acidosis, pulmonary disorders, renal calculi, electrolyte imbalance, hepatic disease, renal disease, DM, Addison's, concurrent use of diuretics or salicylates

*Pharmacodynamic interactions in hypothyroidism

*warfarin-higher doses in HoTR and lower doses in HTR digoxin-lower doses in HoTR and higher doses in HTR*

*HTR classification

Graves disease, toxic adenoma, Plummer's disease, thyroiditis, drug-induced, tumor

AP etiology

1. gallstone 2. alcohol 3. high TG 4. CF-genetic 5. iatrogenic e.g. ERCP 6. DI-valproic acid, Bactrim, tetracyclines, exenatide, DPP4, GLP1 agonists, opioids

*menstrual cycle step-wise

1. Low levels of estrogen stimulate FSH secretion (positive feedback) 2. FSH stimulates growth and development of follicles 3. One follicle becomes dominant and produces increasing amounts of estrogen a. Thickening of endometrial lining to prepare for implantation b. Increased production of thin, watery cervical mucus to facilitate sperm transport 4. Sustained estrogen elevation causes pituitary to release LH 5. LH surge stimulates ovulation 6. Remnants of follicle=corpus luteum, which secretes progesterone and estrogen a. Progesterone maintains endometrium and causes thickening of cervical mucus b. Progesterone and estrogen inhibit FSH and LH release (negative feedback) 7. Implantation occurs: HCG is produced and prevents degeneration of corpus luteum. Continued production of progesterone and estrogen maintains environment to support pregnancy a. Implantation does not occur: corpus luteum degenerates and declining progesterone and estrogen levels stimulate menses

*Common Microbes in Osteomyelitis

1. S. aureus, S. epidermis 2. Corynebacterium, Enterococcus, Proteus 3. Streptococci, Pseudomonas, E. coli, anaerobes, Morganella morganii

steroid hormone pathway in zona glomerulus

1. cholesterol to pregnenolone (rate-limiting step) 2. converted to progesterone 3. converted to 11-deoxycorticosterone 4. converted to corticosterone 5. converted to aldosterone

*N/V treatment

1. correct complication-dehydration, bleeding, etc. 2. H&P, PE, labs, imaging to identify underlying cause (may give empiric tx) 3. treat underlying cause 4. treat sx mild-mod uncomplicated-oral or rectal antiemetics severe or intractable-IV antiemetics acute gastroenteritis: no antiemetics because vomiting is self-limiting and it trying to get rid of toxic substances in the body-may be given to increase the success rate or ORT or to ease concern (only 1 dose necessary

stepwise approach to treating chronic idiopathic constipation

1. increase water intake, treat underlying cause 2. increase fiber intake 3. stool softeners 4. osmotic agent 5. stimulant laxative (consider using as a "rescue" during a 2-4w trial with increased fiber or osmotic agent if the pt has not had a BM for 3+ days) 6. chloride channel activators 7. GC-C agonist all of these are CI with GI obstruction

CHO tolerance problems in PN

1. may need to provide regular insulin, min dose 5-10 *U/bag* -supplement with ISS (insulin sliding scale), add 25 or 50% of ISS to PN next time -insulin is renally eliminated so only use ISS for those with renal dysfunction 2. may need to adjust amount of glucose provided 3. may need to use 50/50 CHO:FAT ratio

*hypoglycemia treatment

15/15 rule: 15g rapid-acting carb (1/2 cup juice/soda, 4 glucose tabs, 4-5 hard candies). Recheck in 15 minutes and repeat if BG <70. Once BG >70, if it is >1h before nect meal, consume a long-acting carb+protein. Glucagon SC, IM, or IV; OOA 6.5min; 0.25-0.5mg <5yo; 0.5-1mg 5-10yo; 1mg >10yo -for when pt is unconscious: call 911, avoid aspiration (left side), adjust insulin dose Glucose 25mg IV (dextrose 50%, 50mL), OOA 4min

Catabolism and UUN

24h UUN measurement-BEST assessmen of severity of the injury response -can't be used in oliguric or anuric renal failure

treatment for overweight or obese TDM2

25-27-lifestyle; 27+-add pharmacotherapy; 30+-consider metabolic surgery

POAG evaluation of treatment outcomes

25-30% reduction in IOP for most pts or IOP <21 (toxicity vs quality-of-life) monitoring: visual fields and disk changes q6-12mo or earlier if unstable

*Ginger and N/V

250mg up to QID for mild morning sickness SE: reflux and heartburn, increased risk for bleed if >2g/d

*weight loss goals

3-5% body weight reduction = reduction in some CVD risk factors Greater reduction = greater benefits Initial goal: 5% to 10% of baseline weight within 6 months

*IBS and celiac disease

5-15% of pts with Celiac disease (gluten allergy with intestinal damage called villous atrophy) were initially diagnosed (correctly ot incorrectly) with IBS sx of Celiac disease: diarrhea, weight loss, abdominal pain, fatigue Celiac disease 4x more prevalent in IBS population than general IBS pts often have predisposing genetic factors (HLA-DQ2/DQ8) for Celiac IBS pts may benefit from being tested for Celiac or a gluten-free trial

*alarm symptoms N/V

>55yo, unintended weight loss, progressive dysphagia, persistent vomiting, evidence of gastrointestinal bleeding, family history of GI cancer, AMS, abdominal pain, hematochezia, melena, focal neurologic defect

*DM case 2

A 68-year-old male with T2D, COPD, & recurrent UTI, presents for follow-up. Meds include metformin 500 mg twice daily & Tradjenta 5 mg daily. Current labs: A1C 9.1%; eGFR 30; FPG 170 mg/dL; BMI 26 kg/m2 Which of the following is best to add to this patient's regimen? a. Canagliflozin 100 mg orally once daily b. Exenatide XR 2 mg SQ once weekly c. U300 insulin glargine 10 units SQ daily d. U100 insulin glargine 10 units SQ daily & insulin lispro 3 units SQ ac Not indicated for meal-time insulin Canagliflozin not recommended for that GFR Exenatide is CI for that GFR U300 has less hypoglycemia-safe for elderly C is the answer

*induction therapy

A high level of immunosuppression during the transplant procedure perioperatively, initial coverage

*Individualization of A1C Goal

A1C < 7% appropriate for most patients (ADA) Monitor every 3 (not at goal)-6 (at goal) months Tighter targets (6.0 - 6.5 %) - younger, healthier Looser targets (7.5 - 8.0 % or more) - older, comorbidities, risk of hypoglycemia

pituitary disorders

Acromegaly-disorder of GH Short stature-GH deficiency Hyperprolactinemia-excessive prolactin Panhypopituitarism-depletion of at least one hormone if not several

phentermine

Adipex-P, sympathomimetic available as monotherapy for short-term use (<12w) schedule IV; 15-37.5mg/d (may be divided into 2 doses) CI: MAOI use within 14d, hx HF, CVD, arrhythmias, stroke, glaucoma,<16yo similar structure to fenfluramine which was removed from the market due to valvular heart disease and primary pulmonary HTN AE: tachycardia, elevated BP, dry mouth, constipation, insomnia, irritability

*OTC hemorrhoid tx in pregnant women

Anusol-HC (hydrocortisone) Preparation H (phenylephrine, pramoxine, glycerin, petrolatum) Tucks pads (witch hazel) Nonpharmacologic recommendation: soak in warm water ± baking soda; avoid sitting for prolonged periods; avoid straining (ameloriate constipation). Other medicated products may be appropriate, but ingredient lists should be evaluated before recommending. NOT ON EXAM

drug-induced hyperprolactinemia

Any agent that antagonizes DA or increases prolactin release: antipsychotic (likely), SSRIs, MAOIs, TCAs, Eletriptan (5HT agonist), metoclopramide, estrogen/progesterone in OC, verapamil

*metformin dosage

Available in 500mg, 850mg, 1000 mg; 500mg, 750mg, 1000 mg XR 500 mg once or twice daily (or 850 mg daily) with food to start; increase dose by 500 mg/day at weekly intervals. Max dose 2550 mg/day. Common dose: 1 g twice daily or 2 g at bedtime with XR. Liquid available—Riomet *500 mg/5 mL (approved for children 10 yoa +)* XR forms: Glucophage XR 500mg, 750mg; Glumetza 500 mg, 1000 mg; Fortamet 500, 1000 80% of glycemic-lowering effect seen at 1500mg; 2000mg/day max effective dose (If doctors prescribe up to 2550 don't call and bother them. Don't recommend higher than 2000 when asked though)

*CVD and CHC

Avoid CHCs in pts with multiple CVD RF (age, smoking, DM, HTN, dyslipidemia)

*physical activity T1DM

Avoid if severe hyperglycemia and ketosis *Recommend pre-exercise BG level of 100 mg/dL or higher* Frequent SMBG and/or CGM use Ready access to simple carbohydrates

moderate acne

inflammatory papules and pustules with some noninflammatory lesions, few nodules and possible scarring

*drugs that mask hypoglycemia

BB and clonidine

drugs to decrease production of aqueous humor

BB, CAI, alpha2 agonists

MSM

Believed to have anti-inflammatory and anti-oxidative activity SE: Bloating, constipation, decline in concentration, fatigue, headache, insomnia (all rare) CI: None

lorcaserin

Belviq-activates serotonin 2C receptor in hypothalamus resulting in increased satiety and decreased food consumption efficacy-decrease in waist circumference, BP, TG, DLD, TC, FPG 10mg BID with or without meals or 20mg ER daily AE: HA, dizziness, nausea, fatigue, nasopharyngitis, hypoglycemia in T2DM CI: MAOI within 14d; avoid in liver/renal failure and pregnancy Serotonin syndrome with SSRI, SNRI, MAOI, St. John's wort, triptans, bupropion DDI: dextromethorphan (CYP2D6 substrate) less insulin resistance! may need to adjust secretagogue and insulin doses

*hypoglycemia symptoms

BG<70 mild: tremor, palpitations, hunger moderate: HA, mood changes, irritable, drowsy, may need assistance to treat severe: unresponsive, unconscious, convulsions, needs assistanct nocturnal: HA, tingling lips and tongue, difficulty waking, nightmares, diaphoresis

Clinical Conditions Warranting Cautious Initiation of PN

BG>180, BUN>100, TG>200 (CI at >400), Na<130 or >150, K<3, Mg<1.3, Ca ionized<4.5, Phos <2

markers for excess body fat and body composition

BMI (most reliable), waist circumference, skin fold thickness, waist-to-hip ratio, waist-to-height ratio, bioelectrical impedance, and dual energy x-ray absorptiometry

*HTR PE

BP & HR increased Thyroid palpation and auscultation (size, nodularity, vascularity) Neuromuscular exam (tremor, brisk deep tendon reflexes) Eye exam (exophthalmos) Dermatologic CV exam Lymphatic (nodes and spleen—r/o lymphoma)

Proscar vs Propecia

BPH vs hair loss

Rosacea drugs that have been tried with some success but lack enough evidence of efficacy

BPO (stinging and erythema), clindamycin (clears some lesions), isotretinoin (delayed benefit >2mo, reserved for resistant rosacea) topical retinoids (any benefit delayed >2mo), topical steroids (EXACERBATION), topical calcineurin inhibitors (some benefit, use caution), permethrin (if follicular mites suspected)

*OTC diarrhea tx in pregnant women

BRAT diet; may trial avoidance of dairy for 24 hours. Reserve loperamide for use after 1st trimester and with physician consultation. NOT ON EXAM

*exogenous insulin

Basal Insulin (long-acting and intermediate-acting insulin) Mimics normal pancreatic insulin secretion with constant levels Suppresses glucose production in the fasting & postabsorptive period Bolus Insulin (rapid-acting and short-acting insulin) Also called prandial or meal-time insulin Mimics spikes of physiologic insulin secretion after eating

*Role of Thyroid Hormones

Basal metabolic rate Thermogenesis Carb, protein, lipid metabolism ANS regulation—HR and strength of contraction Growth & development -Neural and skeletal -Stimulates bone turnover Role in synthesis/clearance of hormones

*thioamides monitoring

Baseline: FT4, TSH, and WBC with differential TFTs every 4-6 weeks until euthyroid then every 3-6mo -Serum T3 and T4 levels should normalize first, but TSH may remain suppressed for several months Check for remission in Graves' patients after 6‐12 months

*belimumab and SLE

Benlysta, for active SLE in pts on standard therapy as an add on, onset 2-4mo blocks the binding of soluble BlyS, a B-cell survival factor, to its receptors on B-cells, inhibiting the survival of B-cells and reducing the differentiation of B cells into plasma cells 10mg/kg IV q2w for 3 doses then q4w, no monitoring SE: nausea, diarrhea, hypersensitivity, infusion reactions wait 4mo after d/c for conception-crosses the placenta

*Glucocorticoid Binding

Bound to one of three plasma proteins: CBG>albumin>alpha1-glycoprotein ≥95% of cortisol is protein bound and serves as a reservoir Concentration of plasma proteins determines the level of active cortisol so if your serum is low on proteins than cortisol and its effects are increased e.g. acute hypertension

Duavee for menopause

CEE+bazedoxifene-SERM-antagonist-reduces risk of endometrial hyperplasia increases BMD, improves depressive symptoms, and may decrease colon cancer risk acceptable alternative to use of progestin in women with intact uterus

*Fed state

CHO increases BG insulin released-suppresses HGP, stimulates uptake, suppresses glucagon release incretin hormones-insulin release and glucagon suppression

*insulin therapy in DKA and HHS

CIVI (preferred) or frequent SQ/IM Loading dose of 0.1 units/kg followed by continuous infusion of 0.1 units/kg/h OR 0.14 units/kg/h regular insulin as IV continuous infusion If glucose doesn't fall by 10% within first hour, give 0.14 unit/kg as IV bolus, then continue as above When BG <200 mg/dL (DKA) or 300 mg/dL (HHS), reduce insulin drip rate to 0.02-0.05 units/kg/hr

*drug interactions in SOT

CNI-CYP3A4 inducers and inhibitors prednisone-CYP3A4 inducers mycophenolate-OC proliferative signal inhibitors-CYP3A4 interactions; synergistic action between mTOR inhibitors and CNIs

celecoxib

COX2i, nontraditional NSAID 100mg BID or 200mg daily (max 200mg for OA and 400mg for RA) SE: GI discomfort, GI bleed (to a lesser degree than traditional NSAIDs), increased risk of cardiovascular events (stroke and MI) and renal insufficiency CI: Sulfa allergy; Post-CABG (within 14 days); DDI: may increase lithium levels

*Macrovascular complications

CVD-stroke, heart attack, PAD, etc.

intolerance of EN

CXR to ensure proper placement of tube check for intolerance daily: vomiting, diarrhea, reduced passage of flatus and stool, abdominal distension, complaints of discomfort, high NG output CI: GRV (gastric residual volume) >500mL/24h, routine checks not recommended -stomach is not emptying as it should -do not hold EN for GRV <500 unless there are other signs of intolerance, may slow rate of infusion first

Intracavernosal Alprostadil and ED

Caverject and Edex, more effective than MUSE PGE, stimulates AC to increase production of cAMP which causes vasodilation secondline to VED and PDE5i; 70% respond; 1/3 d/c therapy within 6-12mo

*Dawn Phenomenon

Characterized by a rise in BG levels in the early morning hours (3-8am) -Not caused by antecedent hypoglycemia -Nighttime hyperglycemia compounded by natural increase in BG overnight Results in pre-breakfast hyperglycemia Management: -Counsel patient to check 3 or 4 AM BG for a few days to r/o Somogyi -Review evening meal/snack -Correct by increasing basal insulin dose to decrease nighttime hyperglycemia

*DKA and potassium

Check potassium levels before giving insulin because it may cause hypokalemia and cause further damage

*SGLT2 inhibitor Place in Therapy

Combination therapy for T2D Adjunct therapy in T1D—off label BP-lowering effect Dual SGLT-2/SGLT-1 inhibitors in pipeline Efficacy based on entry-level A1C CV benefit—Empagliflozin & canagliflozin FDA approved for reducing cardiovascular death in patients with T2D and CVD

*amylin

Cosecreted from pancreatic beta cell with insulin Suppresses glucagon secretion Slows gastric emptying Central satiety

Secukinumab

Cosentyx-against IL17A monoclonal Ab-approved for moderate to severe plaque psoriasis in adults who are candidates for systemic therapy or phototherapy AE: HA, urticaria, GI, infection

combination therapy for POAG

Cosopt (timolol + dorzolamide) Combigan (timolol + brimonidine) Simbrinza (brinzolamide + brimonidine)

Depot Medroxyprogesterone Acetate

Depo-Provera; IM-delta or gluteus; SQ-upper thigh or abdomen if not initiated in the first 7d of menses, use backup x 7d given every 13 weeks, backup if 2+ weeks late, may be early if needed not affected by enzyme-inducing drugs amenorrhea common after 1y of use, 5lb/y weight gain BBW for decreased BMD for use 2+y but benefit usually outweighs risk may affect lipids-consider other progestin-only agents in CVD-risk pts median time to pregnancy after d/c is 10mo

*annual macrovascular assessment

Diabetes confers independent ASCVD risk ASVCD = CHD, cerebrovascular disease, PAD Known ASCVD—consider ACE/ARB T2D and ASCVD—empagliflozin or cana, liraglutide or sema or exenatide LAR Risk factors: HTN, DLD, smoking, family hx premature dx, CKD, albuminuria Address BP, lipids, albuminuria, antiplatelet Tighter glycemic control soon after dx may ↓ macrovascular complications Aggressive A1C goal in patients with long-standing disease without hx of tight control may not provide same benefit and may increase mortality

diagnosis AP

Diagnosis usually made in the presence of 2 of the following: 1. Abdominal pain consistent with pancreatitis 2. Serum amylase and/or lipase >3xULN (>5xULN in DM) 3. Characteristic findings from abdominal imaging (CT or MRI) for those with atypical presentation, unclear diagnosis, and patients who fail to improve clinically within the first 48 to 72h

constipation etiology

Disorders of the GI Tract (generally colon or rectum), DM, hypothyroidism, hyperparathyroidism, pregnancy, neurogenic causes (spinal cord injuries, MS, Parkinson's disease), poor diet, psychogenic

*ROME IV Diagnostic Criteria for Constipation

Do not use ROME IV when an underlying cause can be identified sx onset 6mo prior and must include 2+ of the following for the last 3mo: straining, BSFS 1-2 (hard stool), sensation of incomplete evacuation or anorectal blockage, manual maneuvers required to facilitate defecation in more than 25% of bowel movements, fewer than 3 spontaneous bowel movements each week insufficient to diagnose IBS (abdominal pain and bloating may occur but are not predominant)

determining if a drug is teratogenic

Drug testing in pregnant animals is required for FDA approval Data difficult to interpret Almost all drugs known to be teratogenic in humans are also teratogenic in at least one experimental animal

*pharmacological tx RA

Drug therapy selection is based on: Disease activity -Low -Moderate -High Disease duration -< 6 months -≥ 6 months Presence of high-risk comorbidities Other patient specific factors e.g. DMARDs, biologics

Resources for pregnancy and lactation drug advice

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk - Briggs, Freeman, Yaffe Mother to Baby - https://mothertobaby.org/ Medications and Mother's Milk - Hale LactMed - http://lactmed.nlm.nih.gov

*Autonomic neuropathy in DM

ED, urinary retention, diarrhea, hypoglycemic unawareness CV-orthostatic hypoTN, resting tachycardia gastroparesis-lifestyle, metoclopramide (short term only), erythromycin

*Placebo Substitutions

EE-minimizes effects of estrogen withdrawal (PMS/PMDD, HA), ferrous fumarate, levomefolate calcium such as Beyaz and Safyari (CHCs may lower folate)

*POAG patient education

ELC and NLO use of more than one drop per dose increases cost, does not improve response and may increase AE shake suspensions well; shake gels once to get the medication in the tip two different eye drops: wait 5-10 minutes between doses (gel 10 minutes) do not touch dropper bottle tip with eye, hand, or any other surface if the eye drop contains the preservative benzalkonium chloride, soft contacts must be removed and put back in 15 minutes later

PDE5i and ED

Effective for most despite etiology, nonresponders may need counseling -use of foreplay, empty stomach vs fatty meal, when to consider therapy failure NOT USED IN PTS WITH NORMAL ERECTILE FX!!! (priapism and tissue death) OOA: 30-60min and short DOA (tadalafil exception-36h- "weekend viagra") dosing adjustments for age, hepatic fx, and renal fx ethanol can result in orthostatic hypoTN sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis), avafanil (Stendra)

pathophysiology gout

Elevated levels of uric acid in the blood are due to: 1. Overproduction -Accelerated rate of purine breakdown in the body due to enzyme abnormalities (likely genetic) 2. Underexcretion -Decreased rate or extent of renal excretion of uric acid -In normal conditions, 2/3 of uric acid is excreted in the urine, while 1/3 is eliminated through the GI tract after enzymatic degradation by colonic bacteria -Most common cause of hyperuricemia and gout

*T2D Basal Insulin—Empiric Dose

Empiric dose for LAI (basal only therapy) 10 units or 0.1 units/kg/day 0.2 units/kg/day for obese; glucose toxicity *-Adjust based on FPG: titrate 2 units every 3 days*

*vedolizumab

Entyvio, integrin inhibitor for adults with mod-severe active UC or CD who have an inadequate response with, lost response to, or were intolerant to an anti-TNF agent or immunomodulator; or had an inadequate response with, were intolerant to, or demonstrated dependent on corticosteroids to induce (UC or CD) or maintain remission (UC only) 300mg IV at 0, 2, and 6 weeks then every 8 weeks thereafter REMS: Drug is NOT restricted. Drug must be dispensed with a medication guide, and manufacturer must conduct post marketing studies. . Does not cross the BBB so PML believed to be unlikely

lactulose

Enulose for chronic constipation and treatment and prevention of HE (Not recommended 1st line due to cost and not recommended for IBS-C due to bloating) Dose: 15 to 30 ml/day in divided doses; Onset: < 1 hour

mild-moderate PUD

Epigastric Pain -dull, burning, vague discomfort, abdominal fullness, or cramping -may come and go over several days or weeks -absence of pain does not preclude ulcers N/V, heartburn, belching, bloating, early satiety or feelings of fullness

crisoborole and atopic dermatitis

Eucrisa-novel agent for mild to moderate, PDE4i, results in increased cAMP levels which lower TNFalpha, IFN, IL2 which play a role in the inflammatory cascade AAA thin film BID ADEs-application site pain

*Persistent Symptoms Hypothyroidism

Evaluate for alternative causes of sx TSH may be slightly off due to circadian fluctuations so it should be confirmed before changing T4 dose

*DM choice of therapy

First-line treatment for glucose lowering in T2D in ASCVD is lifestyle intervention with diet and exercise; metformin is the drug of first choice. If patients have evidence for ASCVD, GLP-1RA or SGLT2i with proven cardiovascular benefit are recommended as an early part of glycemic management. If CHF predominates (adequate eGFR): SGLT2i with evidence of reducing CHF, or a GLP-1 RA.If CKD predominates, use metformin with dose adjustment & add GLP-1 RA (*caution in ESRD).

*acromegaly sx

GH level will be >1 mcg/L after an OGTT IGF-1 serum concentrations will be elevated Glucose intolerance ~50% HA Visual disturbances Excessive sweating Neuropathies Joint pain Paresthesias Coarsening of facial features Increase hand volume Increase shoe size Enlarged tongue Various dermatologic conditions

*incretin hormones

GIP (glucose-dep insulinotropic peptide) and GLP-1 (glucagon-like peptide) short half life (approximately 10 minutes) due to the removal of 2 N-terminal amino acids by DPP4 (brush border of intestine)

*Determining Etiology HTR

Graves' disease with new-onset ophthalmopathy, large non-nodular thyroid generally apparent If not obvious, diagnostic tests may be required

*HHS pathogenesis

Greater degree of dehydration secondary to osmotic diuresis Relative insulin deficiency, inadequate to facilitate glucose utilization in tissues, but adequate to prevent lipolysis and ketogenesis

*preeclampsia

HTN with proteinuria >20w OR HTN with thrombocytopenia, impaired liver fx, renal insufficiency, pulmonary edema, cerebral or visual disturbances may cause renal failure, death, preterm delivery, intrauterine growth, progression to eclampsia prevention: monitor BP, calcium 500mg BID, ASA 81mg at 12w if high RF present high RF: hx preeclampsia, multifetal, DM, chronic HTN, renal disease, autoimmune tx: bed rest, hospitalization, delivery if >37w if BP >160/110 give IV hydralazine or labetalol and MgSO4 for seizure prophylaxis

Many pts with acromegaly will develop

HTN, CHD (coronary heart disease), LVH, cardiomyopathy, LVH, osteoarthritis and joint damage (90%), respiratory disorders, sleep apnea, DM Also, increased risk for esophageal, colon, and stomach cancer

*HTR dx

HTR much less common than HoTR, women 3-4x more likely to have than men dx based on TFT -overt HTR: low TSH, high FT4 and/or T3 -Graves' disease or nodular goiter: greater increases in T3 than T4 -subclinical HTR: low TSH, normal FT4, T3, FT3 -TSH-induced (pituitary adenoma): normal or high TSH, high FT4 and T3

Thyroid Disorders

HTR: TSH <0.1 mIU/L diagnostic thyrotoxicosis: exposure to excessive TH from any cause including HTR HoTR: TSH >4.5 mIU/L diagnostic of primary HoTR *The great masquerader*

short stature sx

Height that is < 2 standard deviations of the mean Reduced growth velocity Delayed skeletal maturation Central obesity Prominence of the forehead Immaturity of the face *Peak GH conc <10 mcg/L following GH provocation test Reduced IGF-1 binding protein Hypothyroidism and hypoglycemia*

Cirrhosis Pathophysiology

Hep C, hep B, or alcohol hurts the liver-inflammation as a protective mechanism prolonged inflammation leads to the production of fibrotic tissue that doesn't stretch. This increases the pressure and can cause portal hypertension. Collateral blood vessels called varices in the esophagus and chest. These can burst as a complication. They can bleed out very quickly Abdominal cavity is typically a sterile environment-ascites increases the risk of infection. SBP-spontaneous bacterial peritonitis-recurrent bouts of infection in the abdominal cavity Loss of hepatocyte microvilli, activated stellate cells, deposition of scar matrix, loss of fenestrae, activation of Kuppfer cell Gut bacteria produce nitrogen in the form of ammonia. If this ammonia builds up it will hurt the brain. Can cause severe confusion. Main differential: encephalopathy or UTI

*DKA and HHS complications

Hypoglycemia Hypokalemia and hyperkalemia Pulmonary and cerebral edema Vascular thrombosis Recurrent ketoacidosis

*HPA introuction

Hypothalamus is a part of many axes HPA-hypothalamus, pituitary-adrenal HPT-hypothalamus, pituitary-thyroid CRH-corticotropic releasing hormone ACTH-adrenocorticotropic hormone CRH from hypothalamus CTH from ant pit All regulated by negative feedback

*Hypothalamic-Pituitary-Thyroid Axis Regulation

Hypothalamus releases TRH TRH binds to receptor on pituitary & regulates synthesis/secretion of thyrotropin (TSH) TSH binds to receptors on thyroid & regulates synthesis/secretion of thyroid hormones T4 & T3 exert negative feedback on TSH release

*HPG axis

Hypothalamus-pituitary-gonad axis, the negative feedback loop that regulates sex-hormone production.

IBS classification

IBS-D (most common) >25% loose/watery stools AND <25% hard/lumpy stools IBS-C >25% hard/lumpy stools AND <25% loose/watery stools IBS-M >25% loose/watery stools AND >25% hard/lumpy stools Unclassified (IBS-U) <25% loose/watery stools AND<25% hard/lumpy stools number of abnormal stools/total stools NOT % of days pts may experience long periods without sx which led to patients with IBS-D and IBS-C being inappropriately classified as IBS-U Constipation = Type 1 and 2 on the Bristol Stool Form Scale Diarrhea = Type 6 and 7 on the Bristol Stool Form Scale (and sometimes 5)

*IBW

IBWwomen (kg) = 45.5 + 2.3 x (Ht(in) above 5 ft)) IBWmen (kg) = 50 + 2.3 x (Ht(in) above 5 ft))

*calculating energy requirements

IC, simplistic formula, and predictive equations (less accurate in obese and underweight pts) re-evaluate energy expenditure more than once per week

*T1DM autoantibodies

ICA most common against insulin, glutamic acid decarboxylase 65, tyrosine phosphatases IA2 and IA2beta, and ZnT8 markers of disease and NOT mediators of beta cell destruction can be used to identify at risk individuals or evaluate how to slow progression of disease beta cell autoimmunity may precede disease by 13 years

*non-depleting antibodies

IL2R antagonist on activated T cells for pts at low risk for rejection basiliximab (Simulect) 20mg IVPB on Day 0 and 4; t1/2 7-10d; DOA: 30-45d SE less than polyclonal, no cytokine release syndrome. tachycardia, *hypertension (prominent)*, hypotension

*Insulin Intensification Strategies—T2D

If not at A1C target after basal titration or dose >1 unit/kg/day -Add 1 mealtime RAI with largest meal; empiric dose 4 units or 10% of basal dose Stepwise additional prandial doses (if needed) OR twice daily premixed D/C secretagogues when starting intensive (basal-bolus/prandial) insulin

*nutrition assessment

If nutritionally at risk - comprehensive nutrition assessment must be completed within 48-72 hrs; done by dieticians Nutrition intake and dietary habits, underlying pathology w/ nutritional effects, end-organ effects, GI surgery, corticosteroids, immunosuppressive agents, radiation, chemotherapy, estimation of nutrition needs, decreased B vitamin absorption in bariatric surgery (B1 or thiamine-helps the body utilize glucose to make ATP)

*Surgery for hypothyroidism

If patients can not resume oral intake in 5-7 days, give T4 IV 80% of the usual oral dose

*signs of a lupus disease flare coming

Increased fatigue or exhaustion New or high fever Increased pain Worsening of rash or hair loss Upset stomach Headache Dizziness or forgetfulness Development of new symptoms

obesity

Life long disease, weight loss is hard, but maintenance is harder 60-90 minutes of exercise most days of the week; goal weight loss is 1-2 lbs/week therapy + lifestyle changes have 3-5% greater weight loss than lifestyle alone even after the weight is lost there are still many changes caused by the adiposity leptin released from adipose cells so when someone loses weight, leptin goes down when leptin typically signals satiety. Leptin resistance can occur and the body will no longer recognize itself as full Assess at 3mo and decide whether or not we want to continue therapy BMI >25 considered at risk for HTN, DLD, T2D, CHD, OSA increased mortality risk from CVD, DM, kidney disease, and some cancers Class I obesity 30-34.9; Class II obesity 34-39.9; Extreme 40+

BB and POAG

MOA: block beta R in the ciliary epithelium of the eye lower IOP by decreasing aqueous humor production traditionally firstline therapy systemic AE: tachyphylaxis, bronchospasm, pulmonary edema, status asthmaticus, respiratory arrest, bradycardia, hypoTN, CHF exacerbation, depression, hyperlipidemia, mask symptoms of hypoglycemia local AE: stinging, conjunctivitis, keratitis, dry eyes, uveitis

IBD treatment goals

Maintain adequate nutritional status Prevent development of cancer Reduce the need for surgery or chronic corticosteroid use Relieve intestinal inflammation and dysfunction Complete relief of symptoms (remission) Complete mucosal healing Improve quality of life

*Peripheral Synthesis of T3

Majority of T3 formed by conversion of T4 in peripheral tissues Type I deiodinases: thyroid, liver, kidney Type II deiodinases: thyroid, pituitary, CNS, brown adipose tissue Type III deiodinases: placenta, skin, developing brain

MTX for RA

Methotrexate (MTX)—Trexall® or Rheumatrex® Indication: Drug of 1st choice when initiating therapy at any level of disease activity but may not be initiated first due to side effect profile; Recommended in combination with HCQ and SSZ for patients with moderate to high disease activity and poor prognosis regardless of disease duration Onset: 1-2 months SE: Diarrhea, hepatotoxicity, AKI, pneumonitis, severe dermatologic reactions, mucositis CI: Pregnancy, liver disease, immunodeficiency, blood dyscrasias Counseling: Supplement with folic acid 1mg daily Monitoring: CBC, LFTs, SCr at baseline and monthly for the first 6 months of therapy then every 1 to 2 months thereafter; Chest x-ray is recommended at baseline

Nonhormonal Treatment of Vulvovaginal Atrophy

Moisturizers like Replens and Vagisil are safe for daily use. May also decrease vaginal pH to premenopausal levels. Lubricants like KY Jelly and Astroglide decrease dyspareunia by decreasing friction. Nonhormonal agents are used for vasomotor sx and do not reverse preexisting atrophy nor improve atrophy sx.

primary prophylaxis of variceal bleeds

Monitor using EGD Small varices (< 5 mm) with NO criteria for increased risk of bleeding-NSBB can be used, but long term benefit is not confirmed Small varices plus risk factors for variceal hemorrhage-NSBB Medium to large varices-NSBB or EVL (reserved for pts who can't tolerate BB) Therapies not recommended for prevention of variceal hemorrhage: nitrates, shunt therapy, sclerotherapy

*Rx therapy dysmenorrhea

NSAIDs, hormonal contraceptives (CHCs, DMPA, LNG IUD) -inhibit endometrial proliferation, reduced PG secretion by edometrial tissue, reduced potential for progestin-induced PG release, may require 3+mo for relief

NLO

Nasolacrimal duct occlusion (NLO): gently pressing the corner of the eye by the side of the nose before and for at least 1-2 minutes after administering an eye drop to prevent nasolacrimal drainage of the drug.

*GLP1RA Risk/AE

Nausea, vomiting, diarrhea (transient) Pruritus; nodules (exenatide XR) May delay absorption of other medications; slows gastric emptying Acute renal failure and chronic renal failure exacerbation Tachycardia CI/caution -Hx pancreatitis--caution -Personal/family hx MTC--CI -Multiple endocrine neoplasia syndrome type 2--CI -Gastroparesis--CI

low FODMAP diet for IBS

Newest evidence suggests that FODMAPS in wheat rather than gluten leads to IBS sx in pts without Celiac Disease who report an improvement in IBS symptoms after discontinuing gluten-containing products >75% of IBS patients (all subtypes) feel better on the low FODMAP diet low FODMAP diet is not recommended long term as FODMAPs are prebiotics recommend patient reintroduce a few higher FODMAP foods slowly, as tolerated once symptoms are well controlled

*Things to consider before treating diabetic foot infections

No abx if there is no evidence of soft tissue or bone involvement initial regimen should target GPC broader spectrum if MDR and in chronic, previously treated, or severe infections treat like osteomyelitis if bone involvement can't be ruled out (MRI-best choice, but may take up to a week to be seen

*psoriasis prevention

No primary preventative measures known. Symptoms and flares can be reduced by: Keep skin moisturized Avoid cold, dry climates Avoid skin injuries Avoid beta blockers, and lithium Limit alcohol esp. in men

*mild acne

Noninflammatory lesions (open and closed comedones) Possible papules and pustules; no nodules No scarring

*Complications if Wound Left Untreated

Osteomyelitis (17-32% of ulcers) Amputation Bacteremia, sepsis, endocarditis-death risk Sepsis

elimination of comedones mechanisms

Normalization of follicular keratinazation Decrease in sebaceous gland activity, P. acnes, and inflammation Prevent formation of new lesions

eplerenone vs spironolactone

Not really any impotence in eplerenone Spironolactone causes more gynecomastia Eplerenone causes more hyperkalemia

*Combination T4 & T3 Therapy

Not typically recommended and not superior to T4 monotherapy possible benefit in pts with type 2 deiodinase polymorphism Candidates: thyroidectomy, ablative radioiodine therapy patients, patients with serum T3 at or below lower end of RR Discourage use in older patients, patients with CVD, pregnant women

*Belatacept

Nulojix-IV only-derived from abatacept (Orencia) used to treat RA 10mg/kg over 30min on days 0, 3, 14, 28 then week 8 and 12 then switch to maintenance dose of 5mg/kg every 4 weeks t1/2 11d; no renal/hepatic adjustments; induction and maintenance AE: anemia, neutropenia diarrhea, UTI, HA, peripheral edema, PML (progressive multifocal leukoencephalopathy) BBW: PTLD (post-transplant lymphoproliferative disease) in EBV naive patients CI in patients who are EBV-seronegative not firstline but may be used in those unable to tolerate CNIs only approved for kidney transplant, off-label for liver

vaginal ring

Nuvaring: EE+etenogestrel; one ring x 3w followed by ring-free week specific placement not required-if uncomfortable, likely not far enough discard in trash within protective pouch (counsel pts to keep it!) do not purposefully remove it for sex newly approved: Annovera: EE and segesterone acetate-insert ring for 3w, remove for 1w, reinsert and repeat for up to 13 cycles

hormonal therapy for androgen excess

OC-progestins with low androgenic activity (norgestimate, norethindrone, drospirenone) approved for acne spironolactone-antiandrogen-reduces sebum production

glucocorticoid metabolism

Occurs in the liver and is responsible for converting inactive steroids to active metabolites. Most exogenous steroid products are active; however, prednisone and cortisone must be metabolised to convert to the active form

*CP identifying cause

Often determined during diagnostic testing Consider genetic testing in patients < 25 years old with ICP (idiopathic chronic pancreatitis) and a family history of pancreatic disease Conduct a sweat test to rule out CF in children

baricitinib

Olumiant, JAKi, small molecule for mod-severe RA as monotherapy or in combination with a DMARD (NOT AZA, cyclosporine, or biologics) in the pipeline for SLE inhibits JAK enzyme which then reduces phophorylation and activation of signal transducers and activators of transcription decreasing certain intracellular activities including inflammation and immune function SE: nausea, URI, elevated LFTs, HPLD, herpes simplex and zoster monitoring: LFTs (at baseline), CBC, lipids, renal function not recommended if CrCl <60 Do not start during serious active infection or in severe hepatic impairment not recommended in pregnancy or lactation; stop 1w before conception BBW: severe infections (caution in DM), lymphoma, other malignancies, VTE (rare)

*DKD treatment

Optimize glucose & BP control Non-dialysis dependent DKD, dietary protein app. 0.8g/kg body wt/day In htn & diabetes with elevated UACR use ACEi or ARB -Reduces risk of progression to ESRD (established DKD & htn) & CV events -Maximize dose *Do NOT recommend ACEi/ARB for primary prevention of DKD in patients with normal BP, UACR and eGFR.* Specific antihyperglycemics may improve renal outcomes: empagliflozin, canagliflozin, liraglutide, semaglutide

phentermine/topiramate ER

Osyemia ER; efficacy 5-10% weight loss after 1y; renal and hepatic adjustment P-sympathomimetic, suppresses appetite: T-appetite suppression and satiety enhancement induced by augmenting GABA, voltage-gated ion channel modulation, glutamate receptor inhibition 3.75/23 qam x14d then increase for 12w if pt hasn't lost at least 3% of baseline either dc or increase dose x14d then increase again for another 12w if pt has not lost 5% of baseline at the top dose, taper (QOD for 1w) then dc AE: paresthesia, dizziness, dry mouth, constipation, insomnia, increase in HR and BP, *depression, anxiety, and disturbance in attention* CI: MAOI use, pregnancy, glaucoma HTR, depression, recent stroke/CV event; generally avoid in pts with HTN, CHD, hx of renal stones (topiramate) REMS to avoid use in pregnancy

*high insulin doses

Over-basalization, decreased satiety, and insulin resistance if > 48 units TDD Adding more insulin does not address the physiologic defect so consider the addition of GLP-1 RA, SGLT2i, metformin, TZD Other concerns: hypoglycemia, med errors, absorption issues

*Defining Hypothyroidism

Overt primary hypothyroidism: high serum TSH & low serum free T4 Highly variable clinical manifestations; nonspecific symptoms Subclinical hypo: high TSH & normal free T4; most patients asymptomatic Central hypothyroidism: hypothalamic or pituitary disease; low T4 & TSH that is not appropriately elevated (may be low, normal, slightly increased) Transient (subacute thyroiditis) or reversible (drug induced)

PA diagnosis

PAC-to-PRA ratio: plasma-aldosterone-concentration-to-plasma-renin activity An elevated ARR is very suggestive of PA; ARR cutoffs of 20-40 or 20 with an aldosterone level >15 ng/dl are most often used Following a positive ARR, confirmatory tests must be performed: oral sodium loading test, saline infusion test, FST, captopril challenge test

drugs to increase outflow of aqueous humor

PG analogs, cholinergic agonists, alpha2 agonists

*Preliminary Work-Up for Contraceptive Selection

PMH, SH, FH, current medications, and BP prior to initiation annual PE recommended but not required

*daily self foot exams

Palpation of foot every night Visual inspection with a non-breakable mirror (don't want to accidentally step on it and hurt themselves)

*GLP1RA action

Pancreas -↑ glucose-dependent insulin secretion -↓ glucose-dependent glucagon secretion Stomach -↓ gastric emptying Brain -↑ satiety

*organ defects T2DM

Pancreas: β-cell impairment and increased α cell secretion *Brain: impaired satiety; decreased dopamine, and impaired circadian rhythm* Liver: increased gluconeogenesis Peripheral tissue: decreased GLUT-4 transporters GI tract: decreased GLP-1, diminished effect *Adipose: decreased adiponectin; increased cytokines, IL-6, and TNF* Kidney: increased gluconeogenesis and SGLT2 upregulation

Copper IUD

Paragard, copper toxic to sperm, device may impair fertilization or implantation associated with *heavy menstrual flow* and dysmenorrhea may be used as emergency contraception if placed within 5d

bismuth subsalicylate

Pepto Bismol, Kaopectate, Maalox Total Relief-antisecretory agent for indigestion, abdominal cramps, diarrhea, and prevention of TD 524 mg q30-60min PRN; max 8 doses/d black stools and tongue; ringing of ears CI: <12yo due to risk of Reye's syndrome use caution with concomitant salicylates, sensitivities, or blood thinners

*PEDIS Diabetic Foot Wound Classification System

Perfusion Extent (size) Depth (tissue loss) Infection Sensation (neuropathy)

docusate/senna

Peri-Colace, combination stool softener and stimulant, PRN only, not long-term

*insulin resistance

Present in patients with T2DM; associated with obesity; increases risk for CVD Characterized by markers of metabolic syndrome: -Abdominal waist circumference (> 40 in. men and > 35 in. women) -HTN (BP ≥ 130/85) -Fasting BG ≥ 100-110 mg/dL -TG ≥ 150 mg/dL -Low HDL (≤40 males, ≤50 females) *Patients with T1D can be insulin resistant as well if they become overweight, etc.

tacrolimus

Prograf, TAC, FK506-BID, oral-forms complex with FKBP and inhibits calcineurin preferred over cyclosporine; lower target conc. reduces risk for toxicities avoid IV if possible due to risk of anaphylaxis Astagraf XL for kidney transplants; BBW: increased mortality in liver transplant Envarsus XL-oral, QD-for heart, liver, and kidney These are NOT interchangeable AE: diarrhea, nausea, nephrotoxicity, tremor, HA, insomnia, hyperBG, HLD, HTN

*prednisone

Rayos for inflammatory or immunosuppressive therapy 5-60mg QD (dose HS to improve AM symptoms, release begins 4h after taking) take with food; do not break or chew; do not dc abruptly DDI: barbiturates, phenytoin, TB drugs AE: glucose intolerance, *hyperglycemia,* hyperlipidemia, OP, adrenal axis suppression, increased appetite, *weight gain*, fluid retention, *irritability*, impaired wound healing, acne, swelling, anxiety, HTN, infection, PUD, GI bleeding, leukocytosis, *insomnia*

*PK insulin

RAI OOA 10-15 min, peak 1-2h, DOA 3-4h (5 for aspart) SAI OOA 0.5-1h, peak 2-3h, DOA 3-6h NPH OOA 2-4h, peak 4-6h, DOA 8-12h LAI-more variability -Levemir OOA 1h, DOA 14-24h -Lantus OOA 4-5h, DOA 22-24h -Toujeo OOA 6h, DOA 36h -degludec (Tresiba) OOA 30-90 min, DOA 42h

*Pharmacist's Role

Recommend contraception to patients and prescribers based on patient-specific needs Counsel patients regarding appropriate use of contraceptives, possible side effects, drug interactions, etc. Move towards making hormonal contraceptives available via pharmacist "prescribing," or even OTC -California, Colorado, Hawaii, Maryland, New Mexico, Oregon, Tennessee, Washington, Washington D.C.

*infliximab for RA

Remicade, anti-TNF agent for mod-high active RA in combo with MTX or alone SE: HA, N/V/D, cough infusion over 2 hrs premedicate with antihistamine, APAP, +/- CS to prevent infusion reaction Prep/Admin: Calculate the dose and select the appropriate number of vials. Reconstitute each vial with 10 ml sterile water. Swirl. Do not shake. Let solution stand for 5 minutes for bubbles to settle.

infliximab for IBD

Remicade, anti-TNF for induction of remission and maintenance in patients with moderate to severe CD and UC 5mg/kg infused over 2 hours at weeks 0, 2, 6, and every 8 weeks thereafter; may increase to 10mg/kg if no CHF REMS-dispense medication guide before each treatment

*GERD complications

Require immediate evaluation by a healthcare provider Esophageal erosions or erosive esophagitis -bloody stool, weakness, overly tired Esophageal strictures, Barrett's esophagus, Barrett's metaplasia, malignancy -severe pain, choking when eating

biologics and small molecule DMARDs

Reserve biological and small molecule drugs for patients who fail traditional DMARD therapy; Not superior 1st line Small Molecule Drug(s) Tofacitinib (Xeljanz®) Baricitinib—(Olumiant®) Biological DMARDs are divided into 2 groups: 1. Anti-TNF Agents* -Adalimumab (Humira®) -Certolizumab pegol (Cimzia®) -Infliximab (Remicade®) -Etanercept (Enbrel®) -Golimumab (Simponi®) 2. Non-anti-TNF Agents -Rituximab (Rituxan®) -Tocilizumab (Actemra®) -Sarilumab (Kevzara®) -Abatacept (Orencia®) -Anakinra—(Kineret®) *None found superior to another; Choice based on cost, insurance coverage, provider preferences, and patient specific factors

*Psychosocial Assessment

Routinely screen for depression, diabetes-related distress, anxiety, eating disorders, and cognitive impairment Older adults (aged ≥65 years) should be considered high-priority for depression screening and treatment. Annually screen people who are prescribed atypical antipsychotics for prediabetes or diabetes. Disordered eating

*hormone contraceptive AE

SE often improve/resolve spontaneously by 3mo AE: BTB, melasma, thromboembolism, HTN, stroke, MI, CVD, cancer, worsening gallbladder disease may decrease glucose tolerance in DM (due to androgenicity of progestin?)

*SSRI and IBS

SE: dry mouth, nausea, HA, diarrhea, insomnia, sexual dysfunction, weight gain/loss SSRIs may be inappropriate in IBS-D due to diarrhea side effects full effects may take 4-6 weeks e.g. citalopram, escitalopram, fluoxetine, paroxetine (anticholinergic effects)

integrin inhibitors

SE: risk of infection (e.g. URI), HA, arthralgia, injection site rxns, edema, PML (progressive multifocal leukoencephalopathy), dysmenorrhea, hepatotoxicity CI: history of PML or JVC (natalizumab only) do not shake, must be given IV do not combine with anti-TNF agents or other integrin inhibitors PML-disease of white matter of the brain caused by JCV (John Cunningham virus); mortality rate 30-50% and the survivors have neurological defects

Octreotide

Sandostatin, long-acting somatostatin analog used off-label for acromegaly more potent at inhibiting GH than endogenous somatostatin MOA: mimics somatostatin to decrease GH and IGF1 and also suppress LH 50 mcg TID IV/SQ titrated until GH <5ng/mL or IGF1 <1.9 units/mL in males and <2.2 in females long acting IM can be dosed qmonth should have at least *one week free period every year* AE: GI disturbances, malabsorption of fat, and flatulence

liraglutide

Saxenda, GLP1RA, for obesity, especially in the presence of DM efficacy-5.8kg lost after 16 weeks above lifestyle alone AE: N/V, pancreatitis, renal impairment, hypoglycemia, tachycardia CI: medullary thyroid cancer, multiple endocrine neoplasia type 2 hx, pregnancy start at 0.6 and go up 0.6 weekly with a goal of 3mg

Short Stature - Diagnosis

Several of the following: height >2.25 SD below mean, subnormal growth velocity, delayed bone age, low serum IGF1 or IGF1 binding protein 50+% of children with GH deficiency have normal levels in adulthood

golimumab for IBD

Simponi, anti-TNF for induction of remission or maintenance in mod-severe UC with intolerance or steroid-dep therapy 200 mg initially (in provider's office); 100mg at week 2 then q4w (at home) 50 and 100 mg prefilled syringes for SubQ injection, contains latex REMS: give medication guide each time dispensed

topical sulfa for acne

Sulfur is keratolytic, antifungal, and antiparasitic Sulfacetamide inhibits bacterial dihydrofolate synthetase & disrupts bacterial development

*conjunctivitis

Swelling, itching, burning, and redness of the conjunctiva Causes: virus, bacteria, an allergen, or from an ocular irritant In most cases, it causes only mild discomfort, will not harm vision, and will clear without medical treatment Characterized by diffusely reddened eye, purulent or serous discharge, itching, smarting, stinging, foreign body sensation

naldemedine

Symproic, 0.2mg tablet, PAMORA, structurally similar to naltrexone, schedule II, do not take with strong CYP3A5 inducers (e.g. rifampin). not recommended in pregnancy and lactation as it can precipitate withdrawal in the child

*T4 Formulations

Tablet—most commonly used Soft gel capsule—possible less dependent upon gastric pH than tab; may consider for patients with poor absorption (atrophic gastritis) Generic vs brand: either is acceptable (Not recommended to switch often because you have to recheck the TSH in 6 weeks)

cimetidine

Tagamet, H2RA SE: Reversible gynecomastia and impotence in men Cytochrome P-450 inhibition leading to potentially severe drug interactions (ex. theophylline, lidocaine, phenytoin, quinidine, and warfarin) Antacids decrease absorption of cimetidine

Ixekizumab

Taltz-humanized IgG4 monoclonal Ab that selectively binds with IL17A cytokine approved for moderate to severe plaque psoriasis in adults AE: neutropenia, infection, URI, nausea, tinea, thrombocytopenia

*Diabetes screening children

Test at 10yo or at puberty (whichever comes first) in overweight children (BMI in 85th percentile) Risk factors: maternal history DM, GDM during gestation, T2DM in first or second degree relative, ethnicity, clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans, HTN, dyslipidemia, PCOS, or low birth weight)

*RA "treat to target"

The American College of Rheumatology (ACR) recommends "treating to target" to ensure optimal patient outcomes "Treat to Target" requires an objective measure of current "disease activity" in order to "target" a lower degree of "disease activity" or remission ACR endorses 6 tools (beyond the scope of this lecture) for the assessment of RA e.g. inflammation, joint involvement, duration of sx, etc.

management of patients with moderate/large varices that have not bled

propranolol, nadolol, carvedilol, EVL

*general principles in choosing drugs for pregnant women

Try nonpharmacologic therapies first Avoid medication use during the first trimester, if possible Use single agents when possible Use lowest dose possible Avoid use of newer drugs Fewer adverse effects ≠ less potential to cause fetal harm Discourage patients from using OTC products without consulting with a healthcare provider No amount of alcohol is safe during pregnancy Encourage preconception planning

*OC tips

Try to keep estrogen and progestin activity the same and avoid androgen activity Try to keep the number of periods the same Zovia-50mcg EE-pts need to be on 35 or less!!!

Bristol Stool Chart

Type 1: Separate hard lumps, very constipated Type 2: Lumpy and sausage like, slightly constipated Type 3: Sausage shape with cracks on surface, normal Type 4: Smooth, sausage or snake like, normal Type 5: Soft blobs with clear cut edges, lacking fiber Type 6: mushy consistency with ragged edges, inflammation Type 7: Liquid consistency with no solid pieces, inflammation

natalizumab

Tysabri, integrin inhibitor for induction and maintenance of remission in mod-sever active CD in adults who have not had adequate response to anti-TNF 300mg IV q4w; test for anti-IC virus Ab before initiation and q6mo *do not give with immunomodulators*; d/c steroids within 6w of initiation REMS: drug is restricted. pts must enroll in TOUCH (Tysabri Outreach Unified Committment to Health). tx must be reauthorized q6mo.

*regular human insulin U-500

U500 (20 mL vial or pen)-duration acts more like intermediate vs U100 (10 mL) OOA 30 min, DOA 24h

*SGLT2 AE/Risk

Urinary tract infections Mycotic genital infections Bone fracture Decreased BP Osmotic diuresis CI in patients with impaired renal function Hyperkalemia Euglycemic DKA: absolute risk low Lower limb amputation Necrotizing fasciitis

afluzosin

Uroxatral-expensive, rarely used, uroselective, long-acting, no titration required less likely to cause cardiac symptoms than other 2nd generations and can be given without regard to meals or bedtime

*Yuzpe method

Use (levo)norgestrel-containing COCs-number of pills depends on hormone content e.g. 6 yellow pills of Lybrel associated with more N/V than progestin-only EC

poor respiratory reserve and RA

Use caution in patients with a history of poor respiratory reserve (asthma or COPD) -Consider rituximab or abatacept 1st line in patients with interstitial lung disease

*General Nutrition Guidelines for DM

Use the Dietary Guidelines for Americans as a basis for meal planning http://www.choosemyplate.gov/MyPlate Emphasize fruits, vegetables, whole grains, lean protein, low-fat or nonfat dairy There is NO specific diet for patients with diabetes Sodium to 2,300 milligrams a day Saturated fat to < 10% of calories/day Added sugars to < 10% of calories/day

PO abx in rosacea

Used for antiinflammatory properties when topical tx is not enough indicated for when pt has ocular symptoms

Hypoaldosteronism

Usually caused by adrenocortical insufficiency Pts will usually present with hyponatremia, hyperkalemia, or both -Usually present with hyperchloremic metabolic acidosis Treatment: Fludrocortisone 0.1-0.3 mg daily until adrenal recovery

*Hypothyroidism Overview

Usually requires lifelong treatment via HRT Goal: TSH in normal RR 0.5-5 mU/L, reduce symptoms and size of goiter, avoid iatrogenic thyrotoxicosis

*T-score

WHO Criteria I-BMD SD from "normal" (healthy 30yo of the same sex) of 0 Use Z-score instead in men <50yo, children, and premenopausal women

*GLP1RA benefits

Weight loss* (Saxenda = liraglutide) Low risk of hypoglycemia Efficacy Blood pressure/lipid improvement β-cell preservation Good durability CV benefit (lira, exenatide ER, sema) DKD benefit (lira)

Risks of HRT for menopause tx

Women's Health Initiative (WHI)-large prospective study of estrogen therapy (ET) and estrogen/progestin therapy (EPT) in postmenopausal women looked ar CVD and incidence of breast cancer ended early due to risks in EPT group and lack of benefit on CVD breast cancer may have increased in EPT, but the CI crosses 1 increased risk of CHD, stroke, ad PE in EPT increase in stroke risk for ET (all other CI cross 1) reanalysis of data in 23 trial meta-analysis-HRT recommended <60yo and <10y since menopause (lower risk of CVD)

contraceptive transdermal patch

Xulane: EE+norelgestromin-can be cyclic, extended-cycle, or continuous increased failure rate in pts 90+kg BBW: VTE, higher estrogen exposure (60% more than OC) apply to buttock, abdomen, upper arm, back-check daily (not breasts!!!) do not use supplemental adhesives or use topical products in that location irritated skin-use new patch at alternate location until next change patch day fold sticky sides together and put in trash (NOT toilet-not filtered out of water)

lesinurad and gout

Zurampic, used in combo with XOI for gout in pts who failed XOI monotherapy inhibits the function of URAT-1 (transporter protein) involved in uric acid reabsorption in the kidney 200mg QD, no dose adjustment required SE: HA, flu, increase in SCr, GERD CI: CrCl <45 mL/min, kidney transplant recipient, tumor lysis syndrome or Lesch-Nyhan syndrome caution: may increase cardiovascular events, not recommended in hepatic impairment, assess renal function before initiating therapy take in the morning with food and plenty of water

low potency topical corticosteroids

aclometasone, desonide 0.05%, fluocinolone 0.01%, hydrocortisone 0.05-2.5%

avoid in uncontrolled COPD

abatacept

*CP Clinical Presentation

abdominal discomfort, steatorrhea, N/V/D, malnutrition, weight loss, jaundice, radiation of pain to back (upper quad), epigastric tenderness, normal or mildly elevated pancreatic enzymes only steatorrhea dx: 72h analysis on a high fat diet (>15g/d of fat excreted in stool) DM and steatorrhea are late manifestations of disease. (10+y even) pts may experience malnutrition and weight loss in the absence of steatorrhea

*sx DKA and HHS

abdominal pain, N/V (DKA), polyuria, polydipsia, dehydration, tachycardia, orthostasis, dry mucus membranes, Kussmaul breathing (DKA), fruity smelling breath from acetone, confusion, coma (more common HHS)

Mifepristone

abortifacient and also used in Cushing's syndrome MOA: PR and GR antagonist that inhibits dexamethasone suppression and increases endogenous cortisol and ACTH levels 600-1200mg/d (max), 600mg/d max in renal/hepatic impairment AE: hypo-K, nausea, fatigue, peripheral edema, and endometrial hyperplasia monitoring: K, pregnancy test, pelvic US effective for reversing hyperglycemia, HTN, and weight gain from Cushing's CI: lovastatin, simvastatin, cyclosporine, PREGNANCY, hx unexplained vaginal bleeding

contraindications to EN

absolute: mechanical obstruction (SBO), necrotizing enterocolitis relative/challenges: severe diarrhea, protracted vomiting, enteric fistula, severe GIB, intestinal dysmotility

ascites tx

abstinence from alcohol, diuretics (mainstay of tx), d/c NSAIDs, monitor BP and renal function, and consider transplant if the prognosis is pure attain negative Na balance-salt restriction <2000mg/d (mainstay of treatment), fluid restriction <1.5L/d not necessary unless serum sodium is <120-125, increase sodium excretion to >78 mmol/d, Na>K in urine concentration ACEI/ARB may be harmful with patients with cirrhosis and ascites if the kidneys are hypoperfused due to low BV (vasodilation of efferent arterial)

*endocrinopathy

acromegaly and Cushing's syndrome

Kwashiorkor

adequate calories but inadequate protein intake e.g. trauma, infection, burns skeletal muscle and albumin wasting, edema, 6mo-3y, subcutaneous fat is preserved, edema and enlarged fatty liver, lethargic, only mild muscle wasting is present, poor appetite, only needs proteins (no increase in fats and carbs)

*adiponectin

adipocytokine that improves insulin sensitivity, decreases HGP, and increases FFA oxidation in muscle level decreases with increased obesity

GERD treatment failure

after 8w, make sure the pt is making lifestyle modifications optimize dose and administration time (30-60min before a large meal) consider BID, improve compliance

IBD and vaccines

all IBD pts should receive flu shot pneumococcal for adult pts with IBD receiving immunosuppressive therapy should receive both PCV13 and PPSV23 in accordance with national guidelines consider herpes zoster for adults >50yo with IBD especially if immunosuppressed varicella for adults with IBD before immunosuppressive therapy initiated meningococcal for adolescents with IBD with routine vaccinations hep B for adults with IBD before starting anti-TNF therapy adults with with IBD receiving immunosuppressive therapy should avoid live vaccines; family members can receive them with certain precautions Tdap, HAV, HBV, and HPV administered per ACIP like usual

clinical presentation cirrhosis

asymptomatic (5-10+y), fatigue/weakness, malaise, anorexia, weight loss, pruritus, palmar erythema, spider angiomata, hyperpigmentation, jaundice (one of the first physical signs), scleral icterus, tea-colored urine, caput medusae (bulging distended superficial epigastric veins), PERSISTENT itching or rash (will go away with Benadryl and then come right back), ascites, edema, pleural effusion, and respiratory difficulties, gynecomastia, reduced libido, hepatomegaly (class B or C), splenomegaly, encephalopathy, N/V, hematemesis, melena, hematochezia, fever, chills, abdominal pain, abnormal bleeding or bruising

prenatal vitamins

at least 0.4mg/d of folate for neural tube development Ca for bone mineralization; iron to increase maternal BV consider omega-3 fatty acid in pregnant women with inadequate intake

*insulin response

basal-1 unit/h Biphasic insulin response to a constant glucose stimulus. The peak of the first phase in humans is 3 to 5 minutes; the second phase begins at 2 minutes and continues to increase slowly for at least 60 minutes or until normoglycemia Diabetes loses that first phase insulin release first

*Preferred Insulin Therapy in T1D

basal-bolus AKA MDI (multipe daily injection), intensive insulin therapy 50% total daily dose (TDD) basal and 50% bolus divided among 3 meals upon f/u bolus may vary depending on preprandial BG, anticipated activity, anticipated carb intake

pharmacological management of prophylaxis and ULT

begin ULT only after acute attack has resolved 1. titrate XOI over 2-5w + initiate anti-inflammatory prophylaxis with NSAID or colchicine -*Continue prophylaxis 6-12mo -if they are <5mg/dL continue drug therapy and reassess in 6mo -if they are >5mg/dL add uricosuric agent and titrate to max dose --if they are <5mg/dL continue drug therapy and reassess in 6mo --if they are >5mg/dL d/c other meds and initiate pegloticase (combination with urate lowering drugs not recommended, but is used in practice)

*BPH

benign prostatic hyperplasia enlargement of the gland compression of the urethra and compromise of urinary flow (BOO-bladder outlet obstruction)

BPO for acne

benzoyl peroxide-kills P. acnes and reduces oil production 2.5% is just as effective as 10% and causes less irritation *some consider it a comedolytic because it loosens follicular plug structure* apply to dry skin after washing to decrease irritation *Use sunscreens*

depleting antibodies in induction

binds to T cell receptors and HLA-cytotoxic for pts at high risk for refection e.g. young, African American, kidney transplants, sensitization to HLA antigens due to exposure to blood products polyclonal Ab like antithymocyte globulin (Atgam, Thymoglobulin) and monoclonal like alemtuzumab (Campath)

*BMD

bone mineral density-measured by DEXA (dual energy XR absorptiometry) central DEXA-gold standard for OP dx, measures BMD in hip and spine peripheral DEXA-measures at wrist or heel, point of care device, alternative in pts who cannot afford central DEXA

*BTB

breakthrough bleeding-bleeding in between menstrual periods that is enough to require a pad or tampon early or mid-cycle: starts on or before 14d or never ceases after menses late cycle: starts after 14d

Neuromodulatory Agents

can be used in Cushing's disease but have terrible AE and limited efficacy cyproheptadine, ritanserin, ketanserin, bromocriptine, cabergoline, valproic acid, octreotide, lanreotide, rosiglitazone, and tretinoin cyproheptadine is a potent antihistamine and 5HTR blocker that is normally used for allergic rhinitis; has strong anticholinergic SE (sedation, weight gain, dizziness, blurred vision) which limits its use; can also be used for pesticide OD

*scars in acne

can result from inflammatory lesion

kahoot tips

can't reverse nodules anti-CCP more selective for rheumatoid arthritis avoid in pts with severe CHF-infliximab (anti-TNF) asthma and RA-good agent-rituximab

indications for EN

cancer or inability to eat due to cancer or radiation, organ failure, hypermetabolic states, GI disease, neurologic impairment, AIDS, anorexia, geriatric pts, transplants pts, acute pancreatitis

TPN

central venous access e.g. superior vena cava next to R atrium hyperosmotic 1300-1800mOsm/L-*more concentrated than PPN* concentrated for fluid restricted pts and still provides sufficient calories/protein preferred in pts that will require PN for longer than 7-14d

*polymorphisms on chromosome 6 and diabetes

certain polymorphisms can put an individual at increased risk for T1DM while others are protective

*CZP

certolizumab pegol (Cimzia), SQ, anti-TNF agent, for mod-high active RA as monotherapy or in combo with MTX SE: Headache, N/V leave at room temperature for 30 minutes prior to administration, latex free

atopic dermatitis

chronic skin disorder with inflammation and intense pruritis, subtype of eczema 20% of infants have sx and 60% of those continue to have sx in adulthood increased IgE synthesis hallmark sx: itch-scratch-rash-itch "the itch that rashes) xerosis-dry skin worsens sx adequate moisturizing -emollients most effective after bathing, limit soap and use warm not hot water control pruritis: antihistamines like hydroxyzine, mild sedation may limit -nonsedating antihistamines are generaly ineffective mid-potency topical steroid-secondline to emollient -use low potency on face and intertriginous areas to minimize skin atrophy

Environmental factors involved in psoriasis development

climate, stress, alcohol, smoking, infection, trauma drugs: lithium, beta blockers, NSAIDs, tetracycline, and antimalarials

rate limiting step to HPA hormone synthesis

conversion of cholesterol to pregnenolone

*EC

copper IUD within 5d, LNG 1.5mg x 1 dose, Yuzpe method, Ella 30mg x 1 dose

*OA nonpharmacologic treatment

cornerstone of OA management-promotes healing and decreases inflammation education, psychosocial interventions, exercise, weight loss, heat therapy, PT or OT, assistive devices (walker, cane), joint unloading devices (braces, shoes) -mod intensity aerobic for 30min 5x/w or vigorous for 20min 3x/w -muscle strengthening at least 2x/w -aquatic exercises for knee OA

CBG

corticosteroid binding globulin

HRT and ovarian cancer in menopause tx

data is inconsistent, possible increase with >10y of estrogen use only

*Hyperprolactinemia - Treatment

dc any offending drugs pharmacological tx preferred over surgery because microadenomas tend to be small and not easily removed DA agonists link bromocriptine and cabergoline

*surgery in pancreatic necrosis

debridement recommended in all pts, but if stable should complete a course of antibiotics first minimally invasive procedures preferred but may not be able to use them in early disease. Must be walled off before laparoscopic procedures can be used

perimenopause

declining ovarian fx and irregular menstrual cycles

*Drug Interactions for Hypothyroidism Treatment

decrease T4 absorption (take T4 1-2h before or 4-6h after): cholestyramine, calcium, ferrous sulfate, sucralfate, AlOH, magnesium, zinc, MVI (calcium) increase T4 metabolism (requires TSH recheck): rifampin, phenobarbital, sertraline

gout dx

definitive dx requires aspiration of synovial fluid and identification of crystals in practice, usually made with monoarthritis and hyperuricemia and when the pt has a positive response to colchicine deterine whether the pt is an overproducer or an underexcretor -overproduction if >600mg in urine over 24h after a purine free diet for 3-5d or >1000mg on a regular diet

*thioamides

delayed effect (weeks), often used before RAI tx or surgery, 18-24mo in Graves inhibit organification and coupling, PTU also inhibits peripheral conversion to T3 DDI: increase in warfarin dose needed as pt becomes euthyroid MMI 30-60mg/d in 1-2 doses-PREFERRED in most pts PTU-preferred during 1st trimester, lactation, or thyroid storm

*PN

delivery of nutrients via central or peripheral line; most complex Rx drug PPN-peripheral venous infusion TPN-total-central venous infusion-subclavian, internal jugular, PICC, Hickman, Groshong

*LAI in children

detemir (Levemir)—studied in children as young as 2 yoa; vial or pen glargine (Lantus SoloStar, solution; Basaglar KwikPen)—U100 -children 6 yo glargine (Toujeo)—U300 -not approved for use in children degludec (Tresiba)—U100, U200 -not approved for use in children

preventing OP and calcium consumption

dietary calcium is superior to supplementation calcium carbonate with meals-40% elemental calcium calcium citrate with or without food-20% elemental calcium -preferred in pts with a history of bariatric surgery, decreased GI absorption, concurrent PPI use, etc. to improve absorption -more expensive, higher pill burder than carbonate option divided doses increase absorption but fiber impairs it separate from quinolones and TCN for 2+h too much can increase risk for hypercalciuria, hypercalcemia, and kidney stones 20% increased CVD deaths in men who took >1000mg daily

*pharmacological therapy SLE

disease management: CS, antimalarials, biologics, immunomodulators adjunct management: sx management with NSAIDs, osteoporosis prevention, anti-HTN meds, statin therapy -low dose ASA for primary prevention thrombosis, preeclampsia and pregnancy loss, and associated nephropathy -heparin, enoxaparin, or warfarin for secondary prevention of thrombosis

*progestin in CHC

dominant, provides majority of contraceptive benefit suppresses LH release to prevent ovulation thickens cervical mucus to delay sperm transport, prevent sperm penetration, and slow ovum transport induces endometrial atrophy to prevent implantation

organ transplantation overview

donors both living and deceased are on the rise for 6 consecutive years but the demand for transplantation is also on the rise one organ donor can save 8 lives transplanted organs in order of decreasing prevalence: kidneys (4+y wait), liver (1y wait), heart (6mo wait), lung, pancreas

*DILE

drug induced lupus erythematosus, may arise months-years after tx with causative drug and sx resolve within days-months of stopping the medication pharmacotherapy rarely needed, but low dose CS in severe cases most likely in 50-70 caucasians, equal risk among the genders e.g. *hydralazine, procainamide,* quinidine, isoniazid, minocycline

teratogenic drug transfer

drugs may be present in maternal circulation (systemic absorption) transfer generally occurs via passive diffusion into placenta factors effecting placental transport: -maternal blood concentration (dose) -MW (<500 cross easily, >1000 generally do not cross) -half-life (longer t1/2 means increased opportunity for transfer) -lipid solubility (crossing biological membranes) -ionization at physiological pH (unionized crosses readily) -plasma protein binding (only unbound can cross)

*monogenic diabetes syndromes

e.g. neonatal or MODY

AP lab findings

early AP: breakdown in the synthesis secretion coupling of pancreatic digestive enzymes, but synthesis continues despite blockade of secretion. As a result, digestive enzymes leak out of acinar cells through the basolateral membrane to the interstitial space and then enter the systemic circulation Not specific to pancreatitis

GERD diagnosis

empiric acid suppression challenge test: 1-2w trial with a PPI upper endoscopy-primary method for evaluating esophageal injury used after a failed PPI trial or with alarm symptoms 24h continuous pH monitoring useful after a failed PPI trial in which PPI is held for 7d and a dairy diary is kept radiologic testiing (barium esophagram/swallow)-noninvasive and less expensive than endoscopy, but is no longer recommended for GERD diagnosis esophageal manometry-preoperative evaluation of LES pressure and esophageal peristalsis, but has no role in GERD diagnosis

Acute Adrenal Insufficiency

endocrine emergency caused by HPA axis suppression causes: abrupt withdrawal of steroids, stressful situations, surgery, infection, trauma DOC: hydrocortisone-binds MR and GR 100mg IV rapid infusion followed by CIVI for 24-48 hours IV converted to oral hydrocortisone 50mg q6-8h and then tapering

enteral formula

energy provided kcal/g -carb 4, protein 4, fat 9 macronutrients only

PACG risk factors

family hx of angle-closure, age >60yo, female, hyperopia, certain meds, pseudoexfoliation, Inuit and Asian ancestry

*Advantages of Fiasp

faster absorption good for children and elderly or other people who have an unpredictable carb intake because the insulin can be dosed at the completion of the meal

retinoids for acne

firstline in both noninflammatory and inflammatory acne CORNERSTONE of therapy e.g. tretinoin, adapalene, tazarotene

*enzymes for diarrhea

for diarrhea due to lactose intolerance, available OTC No SE, CI, or DI e.g. Lactaid or lactase containing food products

anti-TNF agents

for pts who fail monotherapy and combo therapy with MTX in early RA warning: serious infections (caution in active infection, DM, AIDS, etc.) CI: mod-severe CHF or severe, recurrent, or untreated infection refrigerate; do not freeze or shake; protect from light onset days-weeks; monitoring: CBC, TB, HBV, LFTs not for pts with demyelination disease (e.g. MS) d/c if demyelination occurs and do not rechallenge with any anti-TNF agent

cannabinoids and N/V

for refractory CINV SE: euphoria, dizziness, paranoia, somnolence do not take with alcohol, sedatives, hypnotics or other psychomimetics do not drive or operate machinery dronabinol (Marinol)-CI to sesame oil allergy, dose adjust in renal impairment nabilone (Cesamet)-CI history of psychosis, caution in severe hepatic impairment

topical NSAIDs

for relief of OA pain e.g. ankle, elbox, foot, knee, hand, wrist locally inhibits PG by inhibiting COX1 and 2 SE: itch, rash, contact dermatitis, dry skin, tingling, burning; CI: oral NSAIDs

*budesonide (Uceris)

for remission induction in pts with active, mild to moderate ulcerative colitis 9mg daily in the morning for 8 weeks; do not crush or chew no taper needed but drug has not been studied for more than 3mo potential interactions with CYP3A4 metabolized drugs-likely not significant mostly local, not effective in systemic disease e.g. asthma designed to target delivery throughout the full length of the colon

*Rome IV

functional bowel disorders IBS, constipation, diarrhea, abdominal bloating/distension, unspecified functional bowel disorder, opioid-indiuced constipation

*GnRH

gonadotropin releasing hormone

*The Prostate Gland

heart shaped walnut-sized gland, weighs 4-20g secrete fluid as part of ejaculate that carries sperm and makes the vaginal canal less acidic (possibly antibacterial due to high concentration of zinc) three tissue types: epithelial, stromal, capsule

*clinical presentation HTR

heat intolerance, sweating, tremor, tachycardia, systolic HTN, anxiety, frequent BM or diarrhea, lighter menses, fatigue and muscle weakness, thyroid enlargement (Graves), weight loss despite increased appetite, exophthalmos, pretibial myxedema, insomnia, irritability apathetic HTR (elderly)-minimal SNS sx

short stature syndrome

height >2 SD below population mean and lower than third percentile for height 1.8 million children in US cause: GH deficiency, intrauterine growth restriction, consitutional growth delay, malnutrition, malabsorption of nutrients, genetic syndromes like Turner's

*Contraceptive Failure Rates

highly effective even with typical use-levonorgestrel implant, vasectomy, levonorgestrel IUS, copper IUD, tubal litigation highly effective with perfect use, but increases 6-9% with typical use-DMPA, pill, vaginal ring, patch male condom-perfect use 2% to typical use 18%

when to test pts for H. pylori

history of PUD, low grade gastric MALT lymphoma, history of long-term aspirin use), initiation of chronic NSAID therapy, unexplained iron deficiency anemia, ITP (idiopathic thrombocytopenic purpura) consider non-endoscopic testing if dyspepsia, <60yo, and without alarm sx

*nodules in HTR

hot nodules (5%) typically benign, 10% cold nodules are malignant

DOC mild lupus

hydroxychloroquine

*steroid dependence or resistance

inability to achieve remission with steroids OR inability to taper without experiencing recurrent active disease sx or full relapse withing 3mo immunomodulators have "steroid-sparing" effects to improve response to steroids and allow a taper

decreased protein binding in cirrhosis

increased fraction of unbound drug in the serum; increased t1/2; decreased metabolic activity especially phase I reactions; Vd increased

vaccinations in RA

influenza-research is underway to determine if high-dose influenza vaccine provides additional benefit in patients with RA pneumococcal -Recommend PCV13 in all RA patients (19 to 64 yo) who have not received previous vaccination with PCV13. Follow PCV13 vaccine with PPSV23 vaccine at least 8 weeks later. -Give PPSV23 booster 5 years later. -Recommend PPSV23 vaccine in all RA patients (19 to 64 yo) who have previously received PCV13.Give PPSV23 booster 5 years later. hep B-if RF present **IV drug abuse, multiple sex partners in previous 6 months, health care personnel herpes zoster (live) -Recommended for patients ≥ 50 years old at least 2-4 weeks before starting biologic or tofacitinib for RA -Do not give to patients already receiving biologic or tofacitnib therapy varicella zoster (live) -Consider varicella zoster virus antibody test to anyone who cannot remember having chickenpox. If test is negative and no CI, offer varicella zoster vaccine before starting biologics *All vaccinations should be completed at least 2 weeks prior to initiation to immunomodulators therapies whenever possible Avoid live vaccines while receiving active treatment with biologic DMARDs

AE monoclonal antibodies

infusion rxns (fever, chills, hypoTN, dyspnea-pretreat with diphenhydramine, APAP, and methylprednisolone), neutropenia, anemia, thrombocytopenia

*drugs causing hypothyroidism

inhibit thyroid synthesis or release: thionamide, lithium, thalidomide, iodine, amiodarone, radiographic agents, SSKI decrease absorption T4: BAS, AlOH, CaCO3, sucralfate, iron, PPI

cyclosporine and psoriasis

inhibits Tcell fx and proliferation involved in psoriasis bridge or intervention therapy (interval and long-term) CI: abnormal renal fx, uncontrolled HTN, malignancy, other immunosuppressives AE: renal dysfx, HTN, hyperK, hyperlipidemia

*Diabetes Treatment in Transplant

insulin preferred in many pts, needed if FPG>200 glipizide, meglitinides, TZDs, caution with metformin optimizing immunosuppressant therapy

*primary pathophysiologic defect in T2DM

insulin resistance

*GIP

insulin sensitizer in adipocytes Glucose-dependent insulinotropic polypeptide Secreted by K cells in the jejunum and proximal duodenum Inactivated by dipeptidyl peptidase-4 (DPP4)

*DM agents-weight gain

insulin, SU, TZD

*Thyroid Hormone Synthesis

iodide enters into the thyroid follicular cell and is oxidized to iodine by TPO these iodines bind to tyrosine residues on TG TG-large glycoprotein synthesized in the thyroid cell whose iodinated tyrosine residues (MIT and DIT) bind together to form active T4 (90%) and T3 (10%) proteolysis releases TH from TG into the bloodstream Most T3 is formed from the breakdown of T4-catalyzed by the enzyme 5′-monodeiodinase in peripheral tissues; *T3 is as much as 5x more active than T4*

(drug-induced thyrotoxicosis

iodide-containing contrast dyes amiodarone-interferes with type 1 5' deiodinase iodide release may contribute to excess iodine

If the primary role of estrogens is to stabilize the endometrial lining and provide cycle control, what do you think is the most common side effect of progestin-only contraception?

irregular menstrual bleeding

cirrhosis

irreversible, progressive replacement of hepatic cells with fibrous scar tissue end-stage of any chronic liver disease, 8th leading cause of death in US US: mostly alcoholic liver disease and hep C; worldwide: mostly hep B

DI cirrhosis

isoniazid, methyldopa, amiodarone, MTX, PPU (propylthiouracil for HTR)

psoriasis

lesions are characterized by sharply demarcated erythematous papules and plaques often covered by silver-white scales psoriatic arthritis (5-20%), pruritis (25%) type: plaque, pustular, scalp, guttate (spots), inverse (skin folds), erythrodermic most common is psoriasis vulgaris (scalp) or plaque (80%)

AE polyclonal antibodies

leukopenia, anemia, thrombocytopenia, skin rash, serum sickness (worse with ATG) cytokine release syndrome (fever, chills, malaise-premedicate with diphenhydramine and APAP)

*thyroid storm

life-threatening medical emergency-decompensated thyrotoxicosis fever (often >103), tachycardia, tachypnea, dehydration, delirium, coma, N/V/D precipitating factors: infection, trauma, surgery, radioactive iodine, withdrawal from antithyroid drugs

*DM drug therapy if considering oral therapy in combination with injectable therapies

metformin: continue TZD: stop when commencing insulin or reduce dose SU: stop or reduce by 50% when basal insulin initiated, consider stopping if prandial or premix insulin initiated SGLT2i: consider adding if pt has established CVD, as weight reduction aid, or if A1c above target. Beware DKA, instruct on sick-day rules, and do not down-titrate insulin over-aggressively DPP4i: stop if GLP1RA initiated

*PEDIS Grade 2

mild Local infection involving only the skin and the subcutaneous tissue Erythema 0.5 - 2 cm around the ulcer Other causes for inflammation must be ruled out Treatment duration: 1-2 weeks of outpatient therapy PO-Kefflex in pts who are not at high risk for MRSA (haven't been in the hospital or recent infections) then jump to Bactrim or Augmentin for those at risk for MRSA

*thioamides AE

mild AE (dose-dep): rash, fever, arthalgia severe AE: agranulocytosis (check WNC at initiation), hepatitis, vasculitis

*mild acute pancreatitis

mild and self-limiting, absence of organ failure, no complications, no necrosis, usually not recurrent, requires brief hospitalization (ICU not required) 85% interstitial edematous and 15% necrotizing

UC assessment

mild disease: <4 stools/d +/- blood, no signs of systemic toxicity, normal ESR moderate: 4+ stools/d +/- blood, minimal evidence of systemic toxicity severe: 6+ bloody stools/d with signs (fever, tachycardia, anemia, ESR >30) fulminant: 10+ stools/d with continuous bleeding, systemic toxicity, abdominal tenderness, and colonic dilation requiring transfusion proctitis-UC of rectum only that usually presents with diarrhea or constipation patients who require corticosteroids to achieve clinical wellbeing are said to be steroid dependent not in remission

*analgesia in AP

mild pain (1-4 on pain scale): NSAIDs, APAP severe pain (8-10): opioids (morphine, meperidine, hydromorphone, fentanyl) -morphine and spasm of the sphincter of Oddi-may worsen pain -fentanyl use is increasing due to safety profile and role in renal impairment, but it can cause respiratory depression and will require monitoring -hydromorphone > meperidine (not recommended CrCl <60) > morphine -meperidine-active metabolite build up causes seizures especially in kidney dysfx

simplistic formula

mild stress: 20-25 kcal/kg/day, hospitalized patient moderate stress: 25-30 kcal/kg/day, typical ICU patient or malnourished severe stress: 30-40 kcal/kg/day, extensive burn, severe trauma, hypermetabolic and hypercatabolic Use dry or usual body weight for normal weight patients; use IBW for obese patients.

ascites

most common complication of cirrhosis protuberant abdomen, shifting dullness, fluid wave, bulging flanks, pain caused by sodium and water retention, decreased albumin production (reduced osmotic pressure), leakage of lymphatic fluid develops at a 5y cumulative rate of 30% in compensated liver disease

hypothyroidism tx in pregnant women

mother is responsible for fetal needs until 10-12w levothyroxine preferred-30-50% increase in dose generally; monitor q4-6w

*UTI tx in pregnant women

nitrofurantoin-possible assoc with birth defects in first trimester and avoid after 36w (esp in mothers with G6PD deficiency)-hemolytic anemia risk SMZ-risk kernicterus-avoid after 32w; TMP-folate antagonist-avoid in 1st trimester

*OP and calcitonin

no longer recommended due to risk of cancer do have indications for Paget's disease with a maximum of 3mo and in pts with hypercalcemia due to cancer for a maximum of 2-4 weeks

salicylic acid and psoriasis

no specific FDA indication-limited effectiveness alone but when added to mometasone or tacrolimus the overall efficacy increases CI: renal and hepatic dysfx appears to be safe in pregnancy

gout RF

obesity, malignancy, metabolic syndrome, alcohol abuse, high purine diet, medications, lead poisoning, genetic factors

Primary dysmenorrhea

occurs primarily with ovulatory cycles and generally begins 1-2y after menarche prevalence/intensity decreases with age, onset of sexual activity, after childbirth sx: cramping pain, nausea, diarrhea, HA, appetite loss increased PG secretion, more intense contractions, uterine hypoxia, vasodilation

OIC

opioid induced constipation tolerance to constipation does not occur unlike most of the SE of opioids traditional treatment for constipation is NOT effective OIC pts will need stimulant or prokinetic avoid bulk forming laxatives and fiber supplements-too much fiber could lead to obstruction diet and lifestyle modifications alone are not believed to prevent or improve OIC stool softener often prescribed prophylactically but is not effective alone and should be combined with a stimulant laxative

OP treatment guidelines

oral bisphosphonates firstline upper GI stuff: try injectable bisphosphonates hip fracture and non-vertebral fracture not studied in ibandronate teriparatide-didn't technically measure hip fracture denosumab is pretty good hip wasn't studied in abaloparatide (Tymlos)

*OGTT

oral glucose tolerance test Administration of 75 grams of glucose to a fasting patient. Blood glucose level is checked 2 hours after "glucose load." Blood glucose curves of a patient with normal glucose tolerance and a person with diabetes after oral administration of 1 g of glucose/kg body weight. Note the initial raised concentration in the individual with diabetes. A criterion of normality is the return of the curve to the initial value within 2 hours.

ORT in diarrhea

oral rehydration therapy-fluid and electrolyte balance mild-mod dehydration: Gatorade diluted 1:1 with water or Pedialyte (preferred) which is balanced with sodium 60-75 mEq/L and glucose 75-90 mmol/L

allograft

organ or tissue transplanted from a genetically non-identical member of the same species

*supportive therapy for IBD

pain relief, diarrhea control (loperamide or lomotil-CI in obstruction or toxicity)

Dysmenorrhea

painful cramping up to 12h before menses, increases in intensity for 24h then decreases in intensity for 24-72h

PFD

pelvic floor dysfxn AKA outlet constipation-inability to relax muscles to have BM straining, incomplete evacuation, need for manual or positional maneuvers for BM possible urinary problems (urgency, incomplete evacuation, pain), lower back pain, pressure in pelvis or rectum, muscle spasms in the pelvis, and discomfort during intercourse (women only) cause: childbirth, trauma history, surgery, radiation in pelvic region, obesity less responsive to traditional therapies (fiber and laxatives) muscle relaxers may be beneficial in some preferred treatment: biofeedback (via PT) or bowel retraining

alpha1 location

periphery and prostate

*menopause

permanent cessation of menses; occurs after 12mo consecutively median age of onset 51y; may be asymptomatic vasomotor sx: hot flashes, night sweats vulvovaginal atrophy: dryness, itching, pain, dyspareunia others: mood swings, poor concentration, HA, urinary frequency, sexual dysfx

*Papulopustular rosacea

persistent central facial erythema with transient papules and/or pustules usually responds easily to topical abx (DOC tetracyclines) and azelaic acid alternatives: macrolides, metronidazole; second line: oral abx full dose tetracyclines can be used in severe cases then tapered down as improvement is seen

*Cushing's Treatment

pharmacological tx in preoperative pts or as adjunctive therapy in postoperative awaiting response (most need 4wk). If tumor is inoperable choose 2 agents. NOT monotherapy in most settings. types: steroidogenesis inhibitors, adrenolytic agents, neuromodulators of ACTH release, GR blockers

PSA

prostate specific antigen will decrease with use of 5alpha reductase inhibitors, but not PDEis.

*key concepts of SOT

pts generally receive 2-4 immunosuppressants in order to minimize individual toxicities as well as block different aspects of the immune response while the CNI tacrolimus and cyclosporine, inhibitors of IL2 and thus activation, are the backbone of therapy, they are also associated with severe AE like nephrotoxicity and neurotoxicity (TDM used to reduce occurrence) CS are a key component in most strategies because they block the initial steps in allograft rejection (1stline); significant AE lead to steroid-minimizing. AZA and mycophenolate inhibit proliferation by altering purine synthesis; most significant AE is bone marrow suppression sirolimus and everolimus inhibit the mTOR (mammalian target of rapamycin) receptor which alters T cell response to IL2; AE: leukopenia, thrombocytopenia, anemia, hyperlipidemia most lymphocyte depleting Abs are associated with significant infusion-related reactions while nondepleting are generally better tolerated long-term allograft and pt survival is limited by chronic rejection, CVD, infection, and long-term immunosuppressive complications such as malignancy

*SU advantages

quick onset , high initial response rate, inexpensive

*Short Stature - Treatment

recombinant GH is the mainstay of therapy-all somatropin analogs recombinant IGF1-mecasermin (Increlex)

*rejection

rejection can take place at any time -hyperacute, acute (cell mediated or Ab mediated), chronic

vaginal estrogen for tx of vulvovaginal atrophy

reverses epithelial thinning, decreases pH, and improves atrophy sx low-dose preferred in those with atrophy alone. More effective than oral. Addition of progestin generally unnecessary, annual surveillance or progestin withdrawal considered in some women Evaluate any vaginal bleeding-endometrial buildup or malignancy Estrace (cream) and Vagifem (tablet) QD for 1-2w then decreased to 1-3x/week Estring in place for 3 mo Apply creams at least 12 hours before sexual activity *SE: irritation, candidiasis, vaginal bleeding, breast tenderness*

GnRH analogs and endometriosis

second line agents e.g. Nafarelin, leuprolide, goserelin, Orlissa (elagolix) bind to GnRH receptors in pituitary to downregulate HPO axis decrease release FSH and LH and decrease estrogen levels (cause amenorrhea) similar efficacy to OC, progestins, and danazol increased cost and AE profile (menopausal-like symptoms, decreased BMD) Estrogen add-back therapy (plus progestin)-theory that certain level of estrogen exacerbates endometriosis; below that level estrogen decreases AE without affecting disease itself-initiate with GnRH therapy OR at least if use GnRH >6mo

*DI OP

secondary causes, long-term use of 3+ mo aluminum (in antacids), heparin and LMWH, barbiturates, cytotoxic chemo, cyclosporine A, tacrolimus, DMPA, glucocorticoids (>5mg prednisone equivalents), MTX, PPI, SSRI, tamoxifen, TZD, excessive thyroid replacement, GnRH antagonists and agonists

*first generation SU overview

secretagogue, hypoglycemia, weight gain, low cost, *increased CV mortality,* long half-life, caution in elderly, CI in SJS e.g. chlorpoparamide (Diabinese), tolazamide, tolbutamide

chloride channel activators

secretagogues for chronic constipation, IBS-C in adult women, and OIC SE: N/V/D, abdominal pain and distension OOA <24h; take with food to decrease N/V decrease dose with Child Pugh class B or C drug is not effective if pt is taking methadone reserved for pts who have failed other treatment e.g. lubiprostone (Amitiza)

*alpha cells

secrete glucagon

*beta cells

secrete insulin and amylin

*aqueous humor

secreted by ciliary epithelium and leaves through trabecular meshwork

*adrenal medulla

secretes catecholamines

*Additional Considerations for Optimal Care for Gout

seek tx immediately when an attack begins rest, elevate, and apply ice to affected joints add a PPI in pts at risk for GI bleed on high dose NSAIDs do not use diuretics to treat HTN if at all possible losartan and fenofibrate and vit C (500mg/d) should not be primary ULT but have weak uricosuric effect when used to manage HTN and DLD and deficiencies

STC

slow transit constipation-decreased motility and increased transit time infrequent BMs, bloating, abdominal discomfort, decreased urge leading to soiling of clothes, feeling of incomplete evacuation cause believed to be neuropathic-genetic or acquired (DM), non-curative less responsive to traditional therapies -fiber may worsen constipation -traditional laxatives may soften and increase BMs but do not help other sx -some need enemas for complete evacuation -promotility/prokinetic agents beneficial -may require surgical intervention

N/V and dehydration

small amounts of ORS (oral rehydration solution) may be given if vomiting oral antiemetics may be considered to increase success of rehydration, but those with anticholinergic effects (e.g. antihistamines) may worsen dehydration refeedin should begin with complex carbs and protein as soon as tolerable (bread, rice, potatoes, chicken) breastfed infants should continue to feed as tolerated

*nodule

small solid boss or node that can be detected by touch

*Choosing glycemic control goals

small vessel disease progression can be prevented with tighter control, but in patients with established vascular complications a tighter control is not going to control the vascular disease.

*papule

small, circumscribed, superficial solid elevation less than 1 cm in diameter

firstline interventions to prevent fractures

smoking cessation, fall prevention, decrease alcohol consumption, start bisphosphonate therapy

*GERD risk factors

smoking, tight fitting clothes, supine position, obesity, heavy exercise, alcohol abuse, fatty foods, spicy foods, mints, chocolate, caffeine, citrus fruits and juices, tomatoes and tomato juice, carbonated beverages, onions, garlic, pregnancy, scleroderma, nasogastric tube intubation, gastroparesis, ZES, hiatal hernia

SOT

solid organ transplantation

*combination therapy for OP

some studies show greater increase in BMD but no decrease in actual fractures PTH + bisphosphonates not recommended, but *should be followed by an antiresorptive agent (bisphosphonate) to prevent bone loss* denosumab and teriparatide can be given together safely, benefit unknown estrogen and bisphosphonates can be given together safely, benefit unknown

pharmacological treatment of CD

some sx improvement should be evident within 2-4 weeks and complete remission within 12-16 weeks Maintenance-combo of immunomodulators with infliximab more effective than either as monotherapy mild-moderate: budesonide (local action only-distal ileum and proximal colon) for remission then observe for maintenance moderate-severe: oral steroids for remission and AZA or 6-MP for maintenance (or MTX for steroid-dependent CD) and add biologic if needed severe/fulminant: IV steroids and infliximab for remission then infliximab for maintenance

gout

spectrum of diseases including hyperuricemia (>6.8 mg/dL), recurrent attacks of acute arthritis, tophi (monosodium urate crystal deposition into nodules), interstitial renal disease, and uric acid nephrolithiasis "disease of kings"-associated with overindulgence sx usually appear at levels >6 in women and >7 in men; however, pts may be asymptomatic and some may experience sx at lower levels in symptomatic pts, levels <6 were associated with less flares gout is the most common inflammatory arthritis in US men 7-9x more likely to develop gout than women, incidence higher in postmenopausal women than premenopausal, incidence increases with age and then peaks between 30-50yo

*drospirenone

spironolactone derivative, antiandrogenic and antimineralocorticoid activity potential DI with agents that increase potassium-monitor for 1mo e.g. Yaz, Yasmin

*reasons for undernutrition

starvation, impaired absorption (e.g. IBD), altered metabolism (e.g. HTR, sepsis)

preventative services and IBD

studies suggest IBD pts fo not receive preventative services at the same rate as the general population; receive better care in a team-based approach PCPs may not be aware of extensive and unique needs of IBD pts vaccines, screenings, smoking cessation (esp CD)

*glycerin suppositories

subcategory of osmotic agents for intermittent treatment of constipation OOA 15 to 30 min; SE: Rectal irritation lubricate suppositories with a water based lubricant and insert gently. Cut suppository lengthwise to create appropriate dose from adult or pediatric suppositories Enemas or suppositories preferred for patients with fecal impaction.

saline laxatives

subcategory of osmotic agents used for acute evacuation of the bowel for diagnostic procedures, after poisoning, or to eliminate parasites; PRN (every few weeks) to treat constipation, and IBS-C; rectal administration for impaction OOA 3h for oral and <30min for rectal SE: fluid/electrolyte imbalance, AKI, hypoTN, hyperphosphatemia accumulation of Mg in pts with renal dysfx and accumulation of Na in patients with CHF; use with caution in the elderly and pts with CHF or renal dysfx e.g. MgOH, Mg citrate, Mg supplements, Na phosphates (Fleet Enema) max 1 dose daily (may lead to AKI); PRN use only

ejaculatory physiology

sympathetic stimulation

*albumin

t1/2 18-20 days, maintains plasma oncotic P, transporter increased: dehydration, anabolic steroids, insulin, infection decreased: fluid overload, edema, kidney dysfunction, nephrotic syndrome, poor dietary intake, impaired digestion, burns, HF, cirrhosis, trauma, sepsis, thyroid/adrenal/pituitary hormones

*prealbumin

t1/2 2-3d; binds T3/4, retinol protein carrier increased: kidney dysfx; decreased: cirrhosis, hepatitis, stress, surgery, inflammation, hypothyroidism, CF, burns, Zn deficiency

mAb therapy and OA

tanezumab-investigational, selectively inhibits NGF (nerve growth factor) which may prevent pain signal from reaching the spinal cord and brain

SLE

systemic lupus erythematosus progressive, systemic, autoimmune disease that can affect any part of the body Disease severity can range from mild to fatal Lupus is a "cyclic" disease with periods of remission and subsequent "flares" While it can effect anyone, SLE its largest impact is on young women SLE is a relatively rare disorder Prevalence and severity vary by sex, race, ethnicity, and socioeconomic factors Prevalence was 2.3x higher in African Americans than Caucasians -African American patients were diagnosed at earlier ages and had greater proportions of renal disease and progression to ESRD than Caucasians Prevalence was 10x higher in females than in males Most women with SLE develop symptoms during the childbearing years (age 15-45). -Disease severity varies with pregnancy and menstrual cycle with "flares" more common before menstruation and during pregnancy when estrogen levels are highest Because the symptoms of SLE often overlap with other disease, the average time to diagnosis may be between 2 and 5 years. The incidence of SLE is believed to be increasing, likely due to: -Improved diagnostics -Reduced mortality (still higher than general population) While there is no cure for lupus, 80 to 90% of patients receiving appropriate lupus therapies can expect an average life expectancy The worst prognosis is seen with renal or CNS involvement A patient may have active SLE, quiescent SLE (no disease activity while on medication, or may be in remission (no disease activity off of medication) Patients may have periodic or cyclic flares Clinical presentation may vary by age, sex, trigger, race, and ethnicity Disease manifestations fluctuate with periods of remission, flares, and progression Disease may manifest in almost any organ system Antibody titers may correspond with symptomology "SLE can have literally hundreds of manifestations related to autoimmunity...In addition to cellular immune activation, it is the hallmark of the disease that manifestations are due to various antibodies and often to immune complexes consisting of autoantigen and autoantibodies."

Cushing's diagnosis

tests: urine cortisol (most common), late night serum, salivary concentration, low-dose dexamethasone test (suppression test) negative results rules out Cushing's; positive results-start to rule out other causes: starvation, hydration from water loading (5L/d), alcoholism, acute stress, medications (topical steroids, carbamazepine, fenofibrate) renal impairment of <60 mL/min can LOWER urine cortisol levels

*TZD

thiazolidinedione (or glitazones) MOA: peroxisome-proliferator-activated receptor gamma (PPAR-γ) agonist; results in an increase in insulin-dependent glucose disposal (insulin sensitivity) in skeletal muscle and adipocytes (primarily) and a decrease in hepatic glucose production (secondarily, through decreased insulin resistance). PPAR-y stimulation (fat, vascular cells) increases GLUT-4 transporter production (glucose into peripheral tissue) Efficacy: -Reduces A1C by 1-1.5%; Lowers FBG (60-70 mg/dL) and PP (FBG > PP) -Good durability; *Delayed onset (max effect 8-12 weeks); Requires insulin to be effective* Metabolism: CYP2C8 DI: strong inducers or inhibitors of CYP2C8 (gemfibrozil or rifampin)

*acanthosis nigricans

thickening and darkening of skin near axillary region or neck

*Phymatous rosacea

thickening skin, irregular surface nodules, and enlargement typically on nose, chin, forehead, cheeks, and ears generally nonresponsive to oral or topical therapy isotretinoin may halt progression and shrink overall nose size surgical or laser ablation is usually necessary

Levonorgestrel IUS

thickens cervical mucus; inhibits sperm movement; reduces sperm survival; thins lining of the uterus; device itself may damage ovum, disrupt ovum transport, and/or damage the embryo *Does not appear to be affected by enzyme-inducing drugs* amenorrhea common

uncomplicated malnutrition

thin, severe muscle wasting, minimal body fat, thin hair and skin, bony prominences, temporal wasting, lower body temp, lower HR, hypoTN, changes in hair or nail appearance

*Drug Overview HTR

thioamides: MMI and PTU iodides: SSKI, Lugol solution (KI and I2; 6mg/drop), radiocontrast (Telepaque/Oragrafin/Hypaque) BB: propranolol, nadalol, atenolol (preferred-once daily)

*TNA, 2-in-1

total nutrient admixture infused over 24h D + AA + electrolytes + trace elements IVFE 10% or 20% infused separately over <12h (prevent microbial growth)

topical dapsone for acne

thought to interfere with neutrophil migration and interrupt inflammatory cascade AE: oiliness/peeling, dryness, and erythema d/c if signs and sx of hemolytic anemia (esp G6PD deficiency) DI: BPO if applied at the same time can discolor skin (yellow/orange)

maintenance immunosuppression triangle

three sides to balanced immune suppression: organ rejection (immune activation), medication adverse effects, infection

Lab abnormalities in cirrhosis

thrombocytopenia (decreased platelet production or splenic sequestration), anemia (hypersplenism, variceal bleeding, decreased erythrocyte production), increased blood ammonia (no longer broken down by liver), increased Scr (HRS)

*Maintenance Dose Adjustment for Hypothyroidism

times to increase dose: pregnancy, weight gain >10%, impaired acid secretion or GI disorders (e.g. celiac disease), nephrotic syndrome (increased TH excretion), increased TH metabolism (rifampin, carbamazepine, phenytoin, phenobarb) If TSH slightly elevated (5-15) or slightly below normal (0.05-0.3): increase/decrease T4 dose 12-25mcg/d FT4 helpful when TSH very high or very low remeasure TSH 6wk after any change in dose times to decrease dose: aging, weight loss >10%, androgen therapy In longstanding overtreatment, stepwise reduction in dose over 3-4mo

TZB

tocilizumab (Actemra), SQ weekly, IL6R antagonist used as monotherapy or in combo with non-biological DMARDs in mod-severe active RA BBW: risk of serious infection (esp with MTX or CS)-hold dose during infection then resume once infection is controlled SE: nausea, diarrhea, HA, dyspepsia, URI, UTI, nasopharyngitis, hepatotoxicity, hypercholesterolemia (can be serious) CI: ANC<2000, platelets<100,000, or AST or ALT >1.5x ULN not recommended in pregnancy or lactation, wait 3 mo after d/c to conceive assess lipids at 4 and 8 weeks then q2y, *does NOT exacerbate HF*

agents for mild to moderate plaque psoriasis

topical corticosteroids, vitamin D analogs, tazarotene, anthralin, coal tar

isotretinoin in acne

treatment course for 20w, reduction of initial dose reduces initial flaring approved for severe nodular tx resistant acne reduces sebaceous gland size, reduces sebum production, inhibit P. acnes growth, regulates cell differentiation and proliferation, inhibits inflammation BIG GUNS to gain control and then switch back to topical baseline CBC and chemistry, fasting lipid panel

*DKA

triad: uncontrolled hyperglycemia, metabolic acidosis, increased ketones evolves in <24h; prognosis is worse at extremes of age in presence of coma, hypoTN, severe comorbidities most 18-44yo and T1DM; absolute insulin deficiency increases ketogenesis most common cause of death in children/adolescents with T1DM, half <24yo

VED

vacuum erection device-negative pressure to increase blood flow, OOA: 3-20m use with PDE5i or alprostadil even more effective CI: sickle cell disease, warfarin use

*pharmacological treatment of PUD

typical: d/c NSAID then start PPI if sx do not resolve if NSAID must be continued: give with PPI or misoprostol to prevent ulcers previous H. pylori tx: endoscopy alarm sx: endoscopy then test for H. pylori if an ulcer is present ulcer without H. pylori: d/c NSAID and start PPI at the same time

*Clinical Presentation of GERD

typical: pyrosis (heartburn), burning of esophagus, water brash (regurgitation) atypical: chronic cough, asthma, laryngitis, hoarseness, sore throat, loss of dental enamel, belching, bloating, hiccups, early satiety, dyspepsia, N/V rule out: MI; GI bleed (may present as weakness from anemia); esophageal, throat, or stomach cancers alarm: dysphagia, choking, odynophagia, bloody vomit or stools, unexplained weight loss, anemia

*Other Treatments for wound care (Not currently supported by IDSA guideline)

typically in addition to abx hyperbaric O2 therapy-kills anaerobes, increases perfusion topical negative pressure e.g. vacuum-assisted closure-increases perfusion collagen-more common in developed countries that are not the US growth factors including granulocyte colonizing factor maggot larvae-used in third world countries to eat the dead tissue, infection risk

*chronic NSAID use and PUD

ulcers develop in 15-30% of chronic NSAID users systemic inhibition of protective PG in the gastric mucosa, direct irritation, and decreased platelet aggregation (excludes COX2) lead to GI damage

HRT and endometrial cancer in menopause tx

unopposed estrogen increases the risk of endometrial cancer in women with an intact uterus. Progestin should be used for a minimum of 10-14d per month. Duavee (CEE+bazedoxifene(SERM)) is an acceptable alternative

refractory ascites

unresponsive to sodium restriction and high dose diuretics or recurs rapidly consider d/c BB and ACEI/ARB due to risk of systemic hypoTN consider adding midodrin, serial paracentesis, TIPS (transjugular intrahepatic portosystemic shunt, peritoneovenous shunt, or liver transplant

*complications of PUD

upper GI bleed (most common)-melena, hematemesis, occult, Hct and Hgb low perforation into abdominal cavity-most common with NSAIDs in pts >60yo -sudden, sharp, severe pain in epigastric but quickly spreading through upper abdominal area ulcer penetration, stricture at ulcer site, obstruction (least common)

*UACR

urine albumin-to-creatinine ratio

*NSAIDs and SLE

use cautiously as NSAIDs may cause renal impairment, fluid retention, and interstitial nephritis. LN increases the risk for NSAID induced ARF SLE pts have an increased sensitivity to GI SE of NSAIDs, consider PPI use use more selective NSAIDs or celecoxib to decrease risk of bleeding

antidepressants in obesity

used off label SSRIs-fluoxetine, sertraline have been successful in binge-eating -dose generally higher than in MDD Bupropion-inhibits DA and NE reuptake, also in combo with naltrexone

immunosuppression in transplants

without immunosuppression the immune system will reject the transplant allograft multiple immunosuppressant therapies in combo as several immune cells are involved in the cellular and humoral responses that result in rejection DDI can be strategically used to lower doses required for individual medications

OP RF

women 65+yo, men 70+yo, caucasian or asian, tobacco use, family hx, fracture hx as an adult, estrogen deficiency before 45yo, long term glucocorticoids, fragility fracture in close relative, low lifelong calcium or vitamin D, sedentary lifestyle, testosterone depletion in men, low body weight, alcohol >2-3 drinks daily, increased likelihood to fall, high salt intake, excess vit A, gastric bypass or other GI surgery

*Split-mixed Calculation Example

wt 80 kg, T1D of long duration, prefers 2 injections 80 kg x 0.6 units/kg/day (empiric dose) = 48 units TDD 2/3 of TDD in am; 1/3 TDD pm = 32 units am and 16 units pm NPH:REG ratio 2:1 in am = 21 units NPH; 11 units regular NPH:REG ratio 1:1 in pm = 8 units NPH; 8 units regular

CMV

cytomegalovirus vaganciclovir (Valcyte) as prophylaxis; duration for 100d for all risk pts, 6mo for high-risk kidney transplant recipients, 12mo for high-risk dose adjustment required for renal dysfunction; also provides coverage for EBV AE: myelosuppression, thrombocytopenia; monitor: CBC, SCr

antibiotics for IBS

for IBS-D ≥ 12 years old 550mg TID x 14 days (repeat up to 2x if recurrence) SE: HA, nausea, peripheral edema (RARE) Rifaximin (Xifaxan)

nutrition screening

within 2-4h of admission by nurses in the hospital; rescreening every 3-7d up to 50% of critically ill have preexisting nutritional disorders and others can develop disorders rapidly due to metabolic demands of healing, rapid fluid shifts, loss of specific vitamins and trace elements RF for undernutrition: recent unintended weight loss, presence of acute or chronic illness, drug and/or other tx, socioeconomic factors MST (malnutrition screening tool) and SGA (subjective global assessment)-food and alcohol consumption, ease to prepare food, weight history, medical and surgical procedures, drug therapies, hx of EN or PN

hyperacute rejection

within minutes-tissue damage can be mediated through Ab-dependent, cell-mediated cytotoxicity, or through activation of the complement cascade -ischemic damage to the microvascular rapidly results in tissue necrosis treat with supportive care and retransplantation if possible (appropriate matching will help)

XOI and gout

xanthine oxidase inhibitors, firstline for long-term ULT in both underexcretors and overproducers inhibits uric acid synthesis by impairing the conversion of hypoxanthine to xanthine and xanthine to uric acid e.g. allopurinol (DOC recurrent nephrolithiasis, inexpensive), feboxustat (Uloric)

systemic CAI and POAG

acetazolamide (Diamox), methozolamide (Neptazane) reserved as thirdline due to AE: N/D. loss of appetite and taste, transient myopia, paresthesia, renal stones, and hematologic problems

*pharmacological tx of CP

analgesia, antisecretory drugs, pancreatic enzyme replacement, somatostatin analogs, corticosteroids, antioxidants

*OA and CAM

for OA of the knee that has failed all pharmacological and nonpharmacological therapies and are not candidates for surgery or have severe pain -acupuncture, duloxetine, opioid

*Hypothyroidism Treatment Dosing

*Initial dose 1.6 mcg/kg/d (112mcg for the average adult)* Requirements correlate better with lean body mass than ABW those with CHD-initial tx 25mcg T4/d; >50-60yo-initial tx 50mcg T4/d; increase dose by 25mcg/d q3-6w until normal TSH or cardiac sx; TH increases myocardial oxygen demand-small risk of inducing arrhythmias, angina pectoris, or MI in older pts

*laboratory assessment hypothyroidism

*Screen q5years in those >35yo, reference ranges vary by age* TSH - highest sensitivity and specificity Free T4 (FT4) may increase diagnostic accuracy Total T4 and/or Total T3 may be useful in some patients

*Which GLP-1RA is CI in ESRD?

*exenatide* is CI <30 with caution 30-50 lixisenatide is CI <15 with caution 15-30

*Laboratory Assessment of Thyroid Function

*normal: Total T4 4.5-10.9, Free T4 0.8-2.7, Total T3 60-181, TSH 0.5-5* hyperthyroid-increased Total T4, Free T4, and Total T3, decreased TSH hypothyroid-opposite

CP treatment goals

*relieve pain,* improve pancreatic function, and prevent/manage complications

*resolution criteria for DKA and HHS

Blood glucose <200 mg/dL PLUS Two of the following: -Serum bicarbonate ≥15 mEq/L -Venous pH >7.3 -AG ≤12 mEq/L

*semaglutide (Ozempic)

0.25 or 0.5mg once a week wash hands check pen to make sure its the right one make sure the liquid is almost colorless new needle tear of paper tab screw needle on pen remove both caps select flow check symbol-only when you start a new pen press and make sure a dose appears. turn the dose counter once the counter reaches 0 slowly count to 6 unscrew the needle and place it in a sharps container If the flow check fails try a few more times. Then change needles and try again. if you don't have a sharps container place it in an empty sturdy container with a lid

teratogenic periods

1-2weeks-all or nothing-either the cells are replaced or prenatal death-don't know they're pregnant usually anyways 3-8weeks embryo-major morphological abnormalities 9-38 weeks-functional defects and minor morphological abnormalities

steroid hormone pathway in testis

1. DHEA from zona reticularis pathway converted to androstenedione or androsta-5-ene-3b,17b-diol 2. Both of these products converted to testosterone

first steps in making a TPN

1. Determined if it is indicated 2. Determine the type of access

*identifying cause AP

1. Assess for gallstones (cholethiasis) in all AP patients 2. Assess alcohol consumption 3. Assess TG if no gallstones or chronic alcohol use; considered causative if > 1000 mg/dl Evaluate for tumors if >40yo Consider genetic testing in patients <30 years old with AP of unknown cause (idiopathic acute pancreatitis or IAP) and a family history of pancreatic disease

*four stages of gout

1. Asymptomatic hyperuricemia -Patients have elevated serum uric acid but no symptoms -Pharmacological intervention is not recommended 2. Acute gout or acute gouty arthritis -Hyperuricemia has led to deposits of uric acid crystals in joint space(s) leading to sudden, intense pain and swelling in joint(s) --Synovitis or gout flare -Attacks may subside within 3 to 10 days without treatment -Pharmacological intervention is recommended -Prophylaxis may or may not be indicated 3. Interval or intercritical gout -Period between acute attacks in which no symptoms are present 4. Chronic tophaceous gouty arthropathy (CTGA) -Develops over several years -Disease may have caused permanent damage to affected joints -Disease may have caused permanent damage to kidneys -With treatment, most patients do not progress to this stage

*four types of lupus

1. Systemic lupus erythematosus (SLE) accounts for about 70% of all lupus cases -About 50% of all patients with SLE will have severe disease activity at some time in their life 2. Cutaneous lupus affects ONLY the skin and accounts for about 10% of lupus cases 3. Drug-Induced lupus is not true lupus. It accounts for about 10% of "lupus" presentations .4 Neonatal lupus

bismuth quadruple therapy

10-14 days PPI QD or BID OR H2RA BID, bismuth subsalicylate QID, metronidazole QID, tetracycline QID

concomitant therapy

10-14d, PPI BID, clarithromycin BID, amoxicillin BID, metronidazole BID

levofloxacin triple therapy

10-14d, PPI BID, levofloxacin QD, amoxicillin BID

markers of liver function

1. bilirubin 2. albumin-decreased due to loss of synthetic ability of the liver 3. PT-INR-elevated due to loss of clotting factor synthetic ability -e.g. INR 1.7 without warfarin. Still give anticoagulants like usual when indicated.

Etiologic Factors of Acne

1. increased sebum production that can be a hyperresponsiveness to androgen 2. alteration in the keratinization process -abnormal keratinization primary event in formation of comedo -clumping and plugging of follicle 3. bacterial growth and colonization e.g. P. acnes 4. inflammation and immune response-increased sebum, keratinocute sloughing, and bacterial growth cause inflammation

step-wise OA

1. lifestyle modifications and APAP for 1mo -go straight to NSAID for hands 2. maximize APAP and/or add capsaicin 3. initiate NSAID for 1mo -Can do tylenol and NSAIDs together 4. Different NSAID for 1mo 5. Tramadol for 1mo -normally d/c to limit pill burden, but can use APAP/tramadol -If the patient needs an opioid, consider combining opioid and nsaid to keep opioid dose as low as possible 6. Consider duloxetine, opioid analgesics, acupuncture, or surgery

*8.2 Lactation

1. risk summary: presence of drug and/or active metabolites in human milk, effects on breastfed child, effects on milk production 2. clinical considerations: minimizing exposure and monitoring for adverse reactions 3. data

Asthma tx in pregnant women

1/3 will experience worsening asthma preferred SABA: albuterol; preferred ICS: budesonide If medium ICS insufficient, add LABA (salmeterol preferred)

Calories Provided by Propofol

10% fat emulsion administered continuously, 10mg/mL, 1.1 kcal/mL

diuretics in ascites

100 spironolactone to 40 Lasix, max 400 and 160 (maintains potassium amiloride 10-40 mg/d may be substituted in pts with tender gynecomastia no limit to weight loss if significant edema is present then 0.5kg/d once resolved d/c if HE, active GI bleed, severe hyponatremia, or renal insufficiency

OP treatment

1000-1200mg/d Ca, 800-1000IU/d vit D; moderate activity 30+ min/d most days do not exceed 1500mg of calcium due to increased risk of kidney stones, cardiovascular disease and stroke vit D supplements when <30ng/dL

*HTR tx

131I-most common, CI in pregnancy and nursing mothers very high risk of HoTR, used when definitive tx sought surgery-TOC for thyroid cancer and pts with respiratory/swallowing difficulties, HTR will follow drugs-used for Graves, noninvasive, minimize risk of HoTR, nor definitive, potential for AE, require long-term adherence

clarithromycin triple therapy

14 days-PPI BID, clarithromycin BID, and amoxicillin BID

Severe acute pancreatitis

15-20% of AP patients, defined entirely on presence of organ failure that fails to resolve within 48h may take up to 72h after presentation for severe AP to be evident early (within 1 week), late phase characterized by local complications

NSAIDs for gout

1st line for acute gout and prophylaxis Indication: Short term management of acute gouty attacks Dosing: Initiate with maximum dosage at onset of symptoms and continue for 24 hours after symptom resolution and taper quickly over 2-3 days Specific agents: (Selection made based on patient factors) Indomethacin 25-50 mg QID x 3 days, then BID for 4-7 days Naproxen 500 mg BID x 3 days then 250-500 mg QD for 4-7 days Sulindac 200 mg BID for 7 to 10 days No NSAID found superior in the treatment of acute gouty attacks

corticosteroids

1st line for mod-severe UC and for all CD (40-60mg prednisone for 1-2 weeks) to induce remission; long-term steroids implicated in more complicated courses of CD including abscesses and fistulas SE: HTN and high BG, emotional instability, insomnia, mood swings, edema, appetite stimulation, peptic ulcers, OP (initiate prophylaxis per guidelines) avoid live or live attenuated vaccines taper by 5-10mg per week until 20mg then by 2.5-5 weekly take with food and do not take at bedtime may increase effects of natalizumab may increase bleeding risk with NSAIDs and anticoagulants e.g. prednisone, methylprednisolone, budesonide ER (oral only)

misoprostol

Cytotec, synthetic PG for prevention of NSAID induced ulcers SE: dose-dep diarrhea and cramping (severe), N/V, flatulence, headaches CI: pregnancy (unless to induce labor after a miscarriage, etc.) diclofenac/misoprostol (Arthrotec)

*prognosis osteomyelitis

2.8% overall mortality rate 31% overall recurrence rate 46% pharmacological treatment failure rate

cirrhosis secondary to alcohol abuse

2/3 of adult Americans drink some alcohol >10 years of daily ingestion of 80 g of ethyl alcohol (6 to 8 drinks/day) Risk Factors: -The amount of alcohol ingested -The type of alcohol consumed -Women -Malnutrition -Viral Hepatitis Every time you get drunk it hurts the liver just a tad. It typically can regenerate from that, but it can be overwhelmed with repetitive acute insults Women can't hold their alcohol as well and are more sensitive to cirrhosis Malnourishment-decreases your albumin and hurts your liver

*purine

2/3 of purines are produced naturally by the body by biosynthesis or salvage 1/3 comes from a diet of processed meat, red meat, beer, alcohol, fatty fish, seafood, mushrooms, yeast degraded by xanthine oxidase into uric acid

Controversies in Osteoporosis Management

2017 American College of Physicians Guidelines (endorsed by the American Academy of Family Physicians) recommended against use of all agents (including vit D, calcium, and exercise) except: alendronate, risedronate, zoledronic acid, or denosumab

Step-up therapy for CD

2018 guidelines support initiation of corticosteroids and adding immunomodulators and biologics later in the treatment course 1. steroid to induce remission (improvement should be evident in 2-4w) 2. continue until remission or lack of improvement over 12-16w 3. lack of remission (steroid-dep) should warrant addition of an alternative therapy (steroid-sparing agent) 4. once remission is achieved, steroid should be tapered and maintenance therapy continued (steroid-sparing agent or adjunct agent already used)

*Duration of Active Hormone

21 active pills then 7d off or 21 active then 7 placebo or 24 active and 4 placebo extended cycle: 84 active pills and 7 placebo-Quasense, Seasonique noncyclic-continuous active hormone --> amenorrhea e.g. Amethyst any CHC can be used as cyclic or continuous-monophasic preferred in COC continuous use may be beneficial in those with anemia, dysmenorrhea, menorrhagia, endometriosis, PMS/PMDD, or other conditions brought on by hormone fluctuations or withdrawal BTB and spotting more common with extended-cycle and continuous use

5-HT4 Receptor Agonist

2mg daily for CIC in adults SE: HA, abdominal pain, dizziness, diarrhea, flatulence, fatigue decrease dose to 1mg daily with CrCl <30 CI: intestinal obstruction or perforation, IBD, toxic megacolon or megarectum warning: suicidal ideation and behavior e.g. prucalopride (Motegrity)-no increase in CV events compared to placebo

Alpha1 Blocker SE and DI

2nd gen SE: dizziness, muscle weakness, hypoTN, and orthostatic hypoTN 3rd gen SE: tiredness, dizziness, ejaculatory dysfx, flu-like sx, nasal congestion, floppy iris syndrome, orthostatic hypoTN tamsulosin 0.4 is as effective as 0.8 with less AE DI: antihypertensive medications

*regular insulin timing

30 minutes before meal

*daily fluid requirements

30-35mL/kg/d; give 2-2.5L/d in ICU pts, more in sepsis, 1-1.5L for fluid restriction increased: fever, diuretics, vomiting, NG suction, fistula drainage, diarrhea, hyperventilation, excessive sweating, HTR, diabetes insipidus decreased: fluid overload, HF, decreased UO, kidney failure, SIADH

topical therapy psoriasis

80% have mild to moderate disease and can be treated with safe topical therapy used adjunctively for resistant lesions wih UV light or systemic therapy monotherapy is not recommended in extensive or resistant disease

*acne vulgaris

80% of persons 11-30yo experience, persist in 10-20% risk factors: hormones (androgen excess), environment, genetic predisposition

*pituitary gland

AKA hypophysis, referred to as "master gland", small region at base of the brain receives autonomic input and regulates: limbic functions, food and water intake, body temperature, cardiovascular fx, respiratory fx, diurnal rhythms

*posterior pituitary

AKA neurohypophysis secretes oxytocin and vasopressin release stimulated by direct nervous stimulation

Pyridoxine (B6) and PMS/PMDD

50-100mg daily, may reduce sx of depression, d/c if neuropathy occurs

fungal infections

50-90% systemic fungal infections are by Candida 25% of pts infected, mortality rates up to 82% prophylaxis in lung and heart-lung transplant recipients Nystatin (Mycostatin) 400,000 U/4mL; swish and swallow QID for at least 1 month azole antifungals (caution DDI), echinocandins, amphotericin B

*basal bolus calculation example

60 kg x 0.6 unit/kg/day (empiric dose) = 36 units of insulin/day 36 units x 0.5 (50% basal) = 18 units insulin glargine (U-100) SQ daily 30 units x 0.5 (50% bolus) = 18 units for bolus—divide among meals 18 units RAI/3 = 6 units insulin lispro SQ 10 minutes before meals

*Thyroid Hormone Transport

99% protein bound: TBG, transthyretin (TTR), and albumin

*statins in DM

<40yo without ASCVD-no need <40 with ASCVD-high 40+ without ASCVD-moderate 40+ with ASCVD-high ASCVD risk >20% or multiple risk factors-high

*hypoglycemia in older adults

> 50% higher rates of severe hypoglycemia Earlier and more severe deterioration of psychomotor coordination Impaired awareness of neurogenic (autonomic) warning symptoms Risk is higher in cognitively impaired

diarrhea

>3/d and decreased consistency of fecal discharge than usual Acute diarrhea: ≤ 14d, abrupt onset, AKA gastroenteritis, usually infectious -Usually self-limiting (frequently ≤ 72 hours) e.g. cholera—acute watery diarrhea and dysentery—acute bloody diarrhea Persistent diarrhea: > 14 days Chronic diarrhea: > 30 days

*T2DM summary

>30yo, gradual onset, history of obesity, insulin resistance, rarely autoantibodies, often asymptomatic, no ketones, rarely immediate need for insulin (usually years after diagnosis) complication-HHS, microvascular and macrovascular at diagnosis common

Addison's disease

AKA primary adrenal insufficiency involves destruction (typically autoimmune) of all regions of the adrenal cortex deficiency in cortisol, aldosterone, and androgens compensatory increase in CRH and ACTH

*short-acting insulin

AKA regular human insulin U100 Humulin *R*, Novolin R (ReliOn) for bolus- inject 30-60 min before meals due to delayed OOA -possible hypoglycemia due to prolonged DOA *(dose-dependent)* IV administration -1 unit/mL insulin drip; t1/2=9 min Humulin R U500 (20mL vial), Humulin R U500 Kwikpen (3 mL) -PK similar to NPH, OOA=15 min

acupuncture and OA

A technique of traditional Chinese medicine that stimulates certain points on the body through the strategic insertion of thin needles into the skin Studies have found acupuncture to ease pain from certain chronic pain conditions including low-back pain, neck pain, and osteoarthritis pain May also reduce the frequency of tension and migraine headaches Acupuncture should be offered in adjunct to other standard therapies Acupuncture needles are regulated by the FDA as medical devices for use by licensed practitioners Needles must be sterile, nontoxic, and labeled for single use only

*GERD nonpharmacological treatment

Avoid foods and beverages known to trigger symptoms Avoid large and high fat meals and alcohol Avoid eating within 2-3 hours of laying down Avoid medications that can relax the LES or have irritant effect Wear loose fitting clothing Smoking cessation Raise head of bed 6 to 8 inches (not w/ pillows) Sleep on left side Lose weight (for patients overweight or with normal BMI but recent weight gain)

azelaic acid and acne

Azelex, Finacea for mild to moderate acne in pts not able to tolerate BPO antibacterial, antiinflammatory, comedolytic activity AE: itching, stinging, and tingling NO PHOTOSENSITIVITY 15% usually for rosacea, 20% usually for acne

*diagnosis diabetes

A1C 6.5+% FPG 126+ OGTT 200+ RPG 200+ with symptoms of hyperglycemia

*DM in hospital setting

A1C for all patients with DM/HG if not performed in prior 3 months Insulin—initiate for persistent HG (≥180 mg/dL) with target range of 140-180 mg/dL

*DPP4i overview

A1C-lowering efficacy: 0.8% glucose target: PP cautions: HF-saxagliptinalogliptin; pancreatitis benefit: no increase in MACE intermediate efficacy, no hypoglycemia, neutral weight change, saxagliptin and alogliptin increased risk CHF(saxa-, alo-), high cost, renal dose adjustment (sita-, saxa-, and alogliptin), can be used in renal impairment, no dose adjustment for lina-, potential risk of acute pancreatitis, joint pain class: incretin mimetic MOA: inhibits DPP4i to prolong incretin action; results in increased insulin secretion and decreased glucagon secretion 2nd or 3rd line, joint pain, acute pancreatitis do not administer with GLP1RA examples: sitagliptin (Januvia), linagliptin (Tradjenta), saxagliptin (Onglyza), alogliptin (Nesina)

*SGLT2i overview

A1C-lowering efficacy: 1% glucose target: FPG cautions: hypotension; CI renal dysfx, UTI, mycotic dysfx benefit: HF; wt loss, decrease in glucose toxicity intermediate efficacy, no hyperglycemia, weight loss, empagliflozin and canagliflozin benefit in ASCVD and CHF and DKD, high cost, renal dose adjustment for all FDA black box: risk of amputation with cana- Other risks: bone fractures (cana-), DKA, genitourinary infections, volume depletion, hypotension, increased LDL, and Fournier's gangrene MOA: blocks SGLT2 R in proximal tubule (about 90% of filtered glucose load), preventing renal reabsorption of glucose, results in glycosuria and lowered BG examples: canagliflozin (Invokana), empa- (Jardiance), dapa- (Farxiga), ertu- (Stegiatro)

*metformin overview

A1C-lowering efficacy: 1.5-2% glucose target: FPG cautions: renal, hypoxic, GI AE benefit: targets IR high efficacy, no hyperglycemia, neutral weight change, potential benefit for ASCVD, firstline, low cost, CI <30, GI SE common, potential for B12 deficiency, BBW lactic acid (rare): hypoxic conditions Notes: Slow titration to minimize GI AE, effective dose 1500-2000 mg/day; benefit in pre-DM; off-label GDM class: biguanide MOA: inhibition of hepatic gluconeogenesis; increased insulin sensitivity (sensitizer); decreased GI glucose absorption Brand: *Glucophage,* Glucophage XR, Fortamet, Glumetza, Riomet

*AAO screening recommendations

AAO-American Academy of Opthalmology With Risk factors for glaucoma-comprehensive eye exam ~ every 1 to 2 years Without risk factors for glaucoma-comprehensive eye exam ~ every 5 to 10 years in pts <40, more frequently in those >40

*Pre-Transplant Lab Work-up

ABO blood typing, tissue typing, PRA (panel reactive antibodies), lymphocyte cross-match

*proven teratogens

ACEI/ARB-fetal kidney toxicity, hypocalvaria (skull hypoplasia) warfarin-fetal warfarin syndrome (nasal and extremity hypoplasia, developmental delay, etc.), death carbamazepine-NTDs, craniofacial defects, nail hypoplasia, developmental delay phenytoin-fetal hydantoin syndrome (facial defects, VSD, mental retardation) lithium-Ebstein's anomaly-tricuspid defect (low risk) tetracyclines-permanent tooth discoloration TMP-NTDs, CV defects retinoids-microtia (absence of pinna of eternal ear), thymic aplasia, CV defects diethylstilbestrol, genital defects in boys, vaginal-cervical cancer in girls thalidomide-phocomelia (flipper babies) valproic acid-facial defects, NTDs (not overcome with folic acid)

Regulation of Hormone Secretion

ACTH released in response to CRH from the hypothalamus. To a minimal extent, vasopressin and oxytoxin can stimulate ACTH production. NE and 5HT can stimulate CRH or ACTH but in amounts that are rarely clinically significant When cortisol or androgens reach sufficient concentrations, they are terminated through a negative feedback loop. Adrenal androgen release is increased during puberty and decreases with age and fasting states (anorexia) Aldosterone mediated via RAAS. Renin production is stimulated by a drop in BP, erect posture, Na, depletion, adrenergic stimulation, and CNS excitation. Renin production inhibited by salt loading, AgII, ADH, K, Ca, BP increases, and drugs. When Na, water retention, and BP increase, renin shut off via negative feedback.

*DM goals

ADA: A1C <7%, preprandial (FBG) 80-130, PPG (2 hours after the beginning of the meal) <180

*vasopressin

ADH, potent, nonselective vasoconstrictor, multiple SE (BP spike) no longer firstline for variceal bleeding

minocycline

AE: hypersensitivity, discoloration of skin, hyperpigmentation (blue), vestibular toxicity, GI upset, photosensitivity (more than others in class) *food does not significantly alter serum concentrations unlike other tetracyclines*

*polyclonal antibodies monitoring

CBC with differential (decrease dose 50% if WBC<5000), PLT (decrease dose by 50% if PLT 50,000-100,000), CD3 count (goal<20 cells/mm3), vitals during administration

diagnostic criteria in SLE

At least 4 of SOAP BRAIN MD S-serositis (pleuritis, pericarditis) O-oral ulcers A-arthritis P-photosensitivity B-blood (anemia, leukopenia, thrombocytopenia) R-renal (protein) A-ANA I-immunologic (dsDNA) N-neurologic (psych, seizures) M-malar rash D-discoid rash

normal uric acid levels

Females: 2.4-6.0 mg/dL Males: 3.4-7.0 mg/dL

*RA assessment

CDAI score (range 0-76) levels: remission, low, moderate, high early RA <6mo; established RA 6+mo poor prognosis with any 1 of the following: functional limitations, extra-articular disease, positive RF, positive anti-CCP, bony erosion on xray prognosis no longer recommended as a factor in RA therapy selection

*T2DM progression

Compensatory hyperinsulinemia, beta cell hyperplasia Increased beta cell apoptosis/decreased regeneration Progressive decrease in the beta cell mass Long-standing insulin resistance leading to beta cell exhaustion Chronic HG can induce beta cell desensitization—glucotoxicity Chronic elevation of FFAs can cause toxicity to beta cells—lipotoxicity Progressive β cell dysfunction is the norm Progressively more intense trmt needed

*T1DM pathogenesis

Autoimmune process; destruction of pancreatic β cells triggered in genetically susceptible individual and mediated by macrophages and T lymphocytes Autoantibodies—markers of disease; > 90% of newly dx pts Strong genetic linkages to DQA & B genes, HLAs; polymorphisms (chromosome 6) assoc. with development or protection β-cell autoimmunity precedes by 9-13y → hyperglycemia when 10-20% remain first lose first phase insulin release honeymoon phase—transient remission with ↓ insulin requirement common autoimmune: Hashimoto's thyroiditis, Graves' disease, Addison's

*nephropathy and gout

ARF-blockage of urine flow secondary to crystals in CDs and ureters, commonly associated with cytotoxic drug therapy chronic renal failure-long-term deposition of crystals in renal parenchyma -decreased renal clearance will be the earliest pathophysiological disturbance followed by HTN and nephrosclerosis

Composition of the adrenal gland

Adrenal medulla (10%) Adrenal Cortex (90%) -Zona glomerulosa (15%) -Zona fasciculata (60%) -Zona reticularis (25%)

*Subacute thyroiditis

After viral infection; pt presents with fever and neck pain

*screening recommendations for diabetes

Annual screening for pts on atypical antipsychotics Use FPG for those with HIV. Screen 6-12mo prior to ARV initiation, 3 mo after every ARV change, then annually. (q6mo for those with comorbid prediabetes)

*secondary prevention CVD in DM

Antiplatelet Statin Empagliflozin, Canagliflozin Liraglutide, sema, exenatide LAR

*DM Comprehensive Care Needs Summary

Antiplatelet therapy Dental examination Depression screening Diabetes self-management education/support Dilated eye examination Foot examination Annual influenza vaccination Pneumococcal vaccination Hepatitis B vaccination Smoking cessation counseling Urine test for albumin-to-creatinine ratio eGFR

topical CAI and POAG

MOA: decrease production of aqueous humor caution in sulfa allergy, secondline, BID or TID (usually) AE: stinging (dorzolamide), blurred vision (brinzolamide), conjunctivitis (rare) brinzolamide (Azopt), dorzolamide (Trusopt)

diarrhea prevention strategy in all pts

Appropriate immunizations and schedule Rotavirus—oral vaccine recommended for all infants -RotaTeq (RV5) given in 3 doses at 2, 4, and 6 months OR -Rotarix (RV1) given in 2 doses at 2 and 4 months Typhoid—recommended for travelers visiting some countries in Asia, Africa, and Latin America (available in oral or injectable) Cholera—recommended for travelers visiting areas with active cholera transmission ex. Yemen (present), Haiti (2010-13), etc.

*ABCs of DM

A—A1C (every 3 months if not at goal; 6 months if at goal) Antiplatelet therapy -ASA 72-162 mg/day secondary prevention (DM & ASCVD history) -ASA 72-162 mg/day primary prevention (patients at increased risk) -Previous guidance: 50 yoa with one additional risk factor (family hx of CVD, HTN, tobacco use, dyslipidemia, albuminuria) for primary prevention Blood pressure (every visit) -Blood pressure goal < 140/90 for most patients; < 130/80 in patients with greater risk Cholesterol -Moderate to high intensity (existing ASCVD) statin Cessation of tobacco

steroidgenesis inhibitors

Block the production of cortisol: metyrapone, ketoconazole, etomidate, aminoglutethimide

*Osteomyelitis

Bacterial or fungal infection of the bone 17-32% of diabetic foot ulcers progress to osteomyelitis

liver transplant

Before transplant pts with advanced disease died within months to years Extended survival with liver transplant Deceased donor or living donor There are currently over 16,000 Americans on the waiting list for a liver transplant The donated and the remaining part of the donor's liver will grow to the size the body needs in weeks Nearly 75% of liver transplant patients are alive five years after their transplants

*foot care

Comprehensive foot evaluation annually Sensory loss or prior ulceration/amputation = every visit. Prior hx: ulceration, amputation, Charcot foot, angioplasty, tobacco use, retinopathy, renal disease, neuropathy symptoms (pain, burning, tingling) and vascular disease (leg fatigue, claudication). Neurological assessment (monofilament + pinprick, vibration, or temp) Vascular assessment—claudication or decreases/absent pedal pulses—refer for ABI Refer to specialist—patients who smoke, hx of lower extremity complications, LOPS, structural abnormalities or PAD

*Use of Premixed Insulin

CAUTION, biphasic suspension (mix well-rolling or pens end to end) Humulin or Novolin 70/30-70% NPH + 30% Regular Humalog 75/25, Humalog 50/50 and Novolog 70/30 -NPH + RAI Usually BID especially in T1DM Used for convenience; not flexible; not easy to adjust

*exocrine disease

CF, pancreatitis, neoplasia

celecoxib for gout

COX2i for short-term management of flares in pts with contraindications to NSAIDs, 800mg initially then 400mg q12h for 1 week or until pain resolves

CNI DDI

CYP3A4 inhibitors like non-DHP, azoles, macrolides (clari>ery>azi), and grape fruit juice increase CNI levels; CYP3A4 inducers like rifampin, rifabutin, isoniazid, phenytoin, carbamazepine, and St. John's Wort decrease CNI levels

sucralfate

Carafate for prevention or treatment of peptic ulcer, OOA 1-2h, DOA 6h SE: constipation and bloating, hypophosphatemia (binds dietary phosphate), gastric bezoar (glob formed by unabsorbed drug) bioavailability of oral FQ, warfarin, digoxin, phenytoin, levothyroxine, quinidine, ketoconazole, amitriptyline, and theophylline may be reduced give other medications 2 hrs before or 6 hrs after sucralfate caution: minimal systemic absorption occurs but avoid long term use in renal insufficiency due to aluminum content safe in both pregnancy and lactation; take on an empty stomach

*surgery in gallstone pancreatitis

Cholecystectomy is recommended within first 48h of hospitalization, but may be delayed to a later time in the typically prolonged hospitalization ( > 2 weeks) in moderate-severe AP

certolizumab pegol for IBD

Cimzia, anti-TNF, *latex free* for induction of remission and maintenance in pts with mod-severe CD 400mg initially and at weeks 2 and 4 then q4w 200mg/mL prefilled syringe for home use REMS-give medication guide each time dispensed

topical clindamycin for acne

Cleocin-inhibits P. acnes, comedolytic, antiinflammatory AE: dryness, burning, pruritis, erythema, hypersensitivity, C. diff (rare) resistance-use BPO in combination

Risk factors for NSAID-induced ulcers and complications

Confirmed prior ulcer or ulcer-related complication History of H. pylori infection Age > 65 Multiple or high-dose NSAID use Concomitant use of aspirin (including low dose) Concomitant use of anticoagulants, corticosteroids, bisphosphonates, antiplatelet drugs, or SSRIs Selection of NSAID

*nonpharmacological treatment of IBS

Consider eating smaller, more frequent meals Stick to a normal eating pattern each day -Eat 3 meals daily + 1 or 2 small snacks -Do not skip meals -Avoid large meals -Chew food thoroughly -Do not eat late at night Limit alcohol consumption -Max 1 drink per day for women -Max 2 drinks per day for men

*DM drug therapy if intensifying to injectable therapies

Consider if A1C>10% or >2% above target on dual/triple therapy GLP1RA prior to insulin in most but consider if GLP1RA not appropriate or if A1C >11% or signs of catabolism (weight loss, polyuria, polydipsia-suggests insulin deficiency) If further intensification: basal insulin initiation and titration If further intensification: prandial insulin initiation and titration usually as one dose with largest meal If further intensification: increase prandial frequency If further intensification: proceed to FULL basal-bolus regimen with basal and prandial insulin at each meal If further intensification: DSMEs

*DM and autoimmune

Consider testing individuals with T1D for antithyroid peroxidase & antithyroglobulin antibodies soon after dx. Measure TSH soon after dx of T1D; recheck every 1-2 yrs if normal Consider screening individuals with T1D for celiac disease soon after dx T2D in children/adolescents: autoantibodies to exclude possibility of autoimmune T1D

*pharmacotherapy combinations for DM

Consider the following when selecting dual/triple or adjunctive agents Target different pathophysiologic defects Combine agents that work at different sites Drugs that target fasting and PP glucose Patient goals, e.g., weight loss AE profile

constipation

Constipation is not a disease, but a symptom Decrease in frequency of fecal elimination characterized by passage of hard, painful stools Normal bowel function varies among patients (3/day to 3/week), and failure to have daily bowel movements does not constitute constipation or require laxative use

constitutional symptoms

Constitutional refers to a plethora of symptoms effecting many different body systems including fever, weight loss, malaise, fatigue, chronic pain, etc.

naltrexone/bupropion ER

Contrave-beta-reuptake inhibitor of DA and NE; N-opioid antagonist efficacy 4.8%; max dose 32mg/360mg 2 tablets QID AE: N/V/C, HA, dizziness; CI: uncontrolled HTN, seizure disorders, anorexia nervosa or bulimia, chronic opioid use, MAOIs, pregnancy

*AP treatment goals

Control inflammatory process Minimize systemic complications Prevent pancreatic necrosis and infection Decrease morbidity and mortality

nonpharmacological treatment of motion sickness

Ride in the middle of vehicle Semi recumbent position Fix vision on the horizon Avoiding reading Closing eyes Acupressure at P6 point of the wrist (Seaband®) Ginger Ale (or ginger supplements 250 mg QID)

*tazarotene for psoriasis

Tazorac-synthetic retinoid-hydrolyzed to active form tazarotenic acid best used in combo with corticosteroids more irritating that calcipotriene do not use on >20% BSA SE: lesion irritation and sun sensitivity d/c if pruritis, burning, redness or peeling pregnancy category X

Addison's - Diagnosis

Distinguish between Addison's and secondary insufficiency. Weight loss, dehydration, hyperpigmentation, hypo-Na, hyper-K, and elevated BUN are common in Addison's. Aldosterone secretion is preserved in secondary. Short corticotropin stimulation test-Pts are given 250mcg of synthetic ACTH IV or IM. Cortisol levels are drawn at baseline and 30-60min after injection. Cortisol levels 18+ rules out adrenal insufficiency.

cyclophosphamide and SLE

Cytoxan-off label for severe SLE, *SOC for LN when combined with steroids* prevents cell division by cross-linking DNA strands and decreasing DNA synthesis onset 6w; SE: alopecia (3-6w), severe N/V, sterility, acute hemorrhagic cystitis (can be fatal) or urinary fibrosis, flushing, HA, rash (mild-severe), bladder toxicity (increase normal fluid intake to decrease risk) CI: pregnancy, lactation, bone marrow suppression; warning: cardiotoxicity (esp in high doses or CHF), increased infection and malignancy risk do not give with biologics or live vaccines; renal and hepatic dose adjustment must be discarded with hazardous waste; prodrug metabolized in the liver monitor: CBC with differential, BUN, UA, electrolytes, SCr

*Hypothyroidism in Pregnancy

DOC: levothyroxine. There are TSH levels specific to pregnancy. increased dosage requirement due to degradation by placental deiodinase, increased TGB, increased T4 pool size, and increased demand (fetal requirements)

oral abx for acne

DOC: tetracyclines-bacteriostatic by inhibiting bacterial protein synthesis on multiplying organisms only SE: teratogen (inhibit skeletal growth), stains teeth <8yo, photosensitivity Use sunscreen!!!

adrenal hyperfunction

Cushing's-most common, characterized by cortisol excess hyperaldosteronism-low K, high Na, resistant HTN

*duloxetine and OA

Cymbalta, SNRI, off label for OA mod-severe pain despite NSAID optimization SE: nausea, dry mouth, somnolence, constipation, fatigue, dizziness, decreased appetits, hepatotoxicity (rare); CI: MAOIs or uncontrolled narrow angle glaucoma warning: suicidal ideation when initiating therapy, not recommended in severe renal impairment or hepatic impairment or history of alcohol abuse taper slowly to avoid withdrawal (depression, insomnia, neuropathic pain, severe headache "zaps", tremor, ringing ears, nightmares)

*Correction Factor (CF) OR Insulin Sensitivity Factor (ISF)

Correct for high premeal levels, OR sick day management Rule of thumb value 50 (adults) 1800 rule (rapid-acting insulin); 1500 rule regular human insulin 1800/current TDD = mg/dL change provided by 1 unit RAI

coagulation disorders and cirrhosis

Correct in patients who are actively bleeding Platelet transfusions for thrombocytopenia Fresh frozen plasma for prolongation of the PT to replace clotting factors

*insulin pen tips

DON'T REUSE PEN NEEDLES!!! They get dull, the insulin can get clogged, and there is increased risk of infection. prime with 2 units every time you use it!!! 90 degree angle (45 in some kids) leave the needle in place for 10 seconds! Wash hands 2 inches from belly button-rotate site alcohol swab top of the pen dial to 2 units to prime pinch up the skin and fat, make sure you don't pinch muscle straight in 90 degrees Let go of the pinch and then push the plunger Count to 10 Don't store with the pen needle on it or reuse the needle Store the box in the fridge, but the open pen you are using can be at room temperature. It will be good for the number of days on the box. Lantus is 30.

Calories Provided by Clevidipine

DHP administered as a continuous infusion that is in a 20% fat emulsion Cleviprex 0.5mg/mL provides 2kcal/mL

What to recommend in a woman on CYP3A4 inhibitors that can not be dc'd?

DMPA or levornorgestrel IUS

ASPEN Practice Recommendations for Meds Administration Via Enteral Tube

DO NOT add/mix meds directly to enteral feeding formula. DO NOT mix meds together, but do dilute them appropriately prior to administration (risk of incompatibility, altered therapeutic drug response, tube obstruction). Each medication to be administered separately. When available, liquid dosage forms to be used. Administer as fine powder and mix w/ sterile water Prior to administering meds, stop TF and flush the tube w/ at least 15 ml warm water. Dilute and administer in an oral syringe. Flush the tube again w/ at least 15 ml warm water. Note: dilution/flush volume should be less for peds doses. Restart TF. ONLY hold the feeding by 30 min or more when separation is indicated to avoid altered drug bioavailability.

*acne tx algorithm

DOC mild comedonal: topical retinoid DOC mild papular/pustular: topical retinoid + BPO or BPO/abx DOC moderate papular/pustular: topical retinoid + oral abx +/- BPO DOC moderate nodular: same as above OR oral isotretinoin severe nodular: oral isotretinoin alternatives for females: hormonal + topical retinoid +/- BPO or BPO/abx maintenance therapy: topical retinoid + BPO or BPO/abx

Rocephin vs Cefotaxime in SBP

DOC-Rocephin for 5 days, but cefoaxime is preferred in children (Rocephin causes kernicterus) or if nearby organs are damaged (e.g. gall bladder and bile ducts-Rocephin has a SE for bilirubin sludging)

*Beginning a New Regimen

Day 1 start: take first tablet on first day of menses Backup contraception generally not necessary with the exception of Natazia (use backup contraception for 9 days) Sunday start: take first tablet on first Sunday after start of menses - use backup contraception x 7 days Quick start: take first tablet as soon as possible - use backup contraception x 7 days Consider recommending backup contraception for the first month with all new starts

*key points DM

Diabetes confers independent ASCVD risk; many PWD have additional risk factors: htn, DLD, obesity, physical inactivity, CKD, & tobacco use Clinical approach: include novel agents that effectively lower ASCVD events/risk Lifestyle: MNT, PA, weight loss, tobacco cessation, psychological support Glycemic control = reduction in onset & progression of microvascular disease HbA1c target for most adults ≤ 7 % Individualize treatment based on patient preferences, costs, goals, risk of AE, and patient characteristics (e.g., frailty, comorbidity). GLP-1RAs & SGLT2i's improve CV outcomes, HF & CKD progression.

*pharmacotherapy decision for DM

Diabetes duration Blood glucose level out of range Degree of A1C-lowering needed to achieve goal Adverse effects/tolerability Comorbid conditions Good efficacy β-cell protective Minimize weight gain Minimize hypoglycemia Cardiovascular benefit Minimize AE/DI

diclofenac 2% solution

Diclofenac 2% (Pennsaid® Solution)—RX only Counseling: Apply to clean, dry skin. Dispense 40 mg (2 pump actuations) directly onto the knee or first into the hand and then onto the knee and spread evenly around front, back and sides of knee BID. Wash hands completely after applying. Wait until the area is completely dry before covering with clothing or applying sunscreen, insect repellent, cosmetics, topical medications, etc. Protect exposure area from sunlight. Availability: Each bottle is 112 grams. Each pump actuation delivers 20 mg of diclofenac sodium in 1 gram of solution. One bottle per knee per month. Can use sunscreen as long as you wait for it to dry first

*obesity in critical illness

EN recommended within 24-48h of ICU admission *AdjBW not recommended*, calculate BMI, identify obesity class, measure waist circumference, evaluate biomarkers of metabolic syndrome (BG, TG, cholesterol) evaluate for micronutrient and trace minerals deficiency implement high-protein hypocaloric feeding BMI 30-50: 11-14kcal/kg *ABW* daily need; >50: 22-25kcal/kg *IBW* daily need -energy goal should not exceed 65-70% of goal as measured by IC as weight-based equations represent 65-70% of measured energy expenditure BMI 30-40: 2g/kg *IBW* daily need protein; BMI>40: up to 2.5g/kg *IBW*

IBD labs

ESR, CRP, BMD, CBC + differential, stool sample, occult blood, fecal caprotectin (new stool test-helpful tool in differentiating between IBD and IBS-protein released by neutrophils as a sign of inflammation)

*Meal Planning Considerations for DM

Eat 3 meals per day Eat snacks only as part of a balanced food plan (100-150 kcal) Achieve balance of carbohydrates throughout the day Eat consistent amount of CHO at meals and snacks from day to day Consume concentrated sweets in moderation on special occasions Include protein and fat with each meal and snack

*DM treatment goals

Eliminate/ameliorate symptoms -Hyperglycemia contributes to poor wound healing, compromises WBC fxn, & alters capillary fxn Prevent acute complications -Hypoglycemia -Diabetic ketoacidosis (DKA) -Hyperglycemic hyperosmolar state (HHS) Prevent chronic complications Attain glycemic goal—individualize

Ulipristal acetate

Ella-SPRM-prevents/delays ovulation if taken within 120h of unprotected sex may also alter endometrial lining, preferred in overweight/obese and more effective than LNG EC SE: nausea and irregular bleeding *hormonal contraception shouldn't be started or resumed for 5d as it could decrease effectiveness-use barrier contraception as backup

*etanercept

Enbrel, anti-TNF agent for mod-high active RA 60mg SQ weekly with or without MTX SE: HA, injection site rxn, N/V, abdominal pain may increase hypoBG risk in those on antidiabetic meds, decrease dose leave at room temperature for 30min prior to administration

choosing an NSAID for OA

For patients receiving low dose ASA therapy for cardiovascular protection -Use a non-selective NSAID other than ibuprofen OR -Take aspirin 30 min before or 8 hrs after ibuprofen to avoid interaction -Naproxen has the best cardiovascular safety profile For patients ≥ 75 yo in need of NSAID therapy -Topical products are preferred For patients with CKD with eGFR < 30 cc/min, avoid NSAIDs For patients with CKD with eGFR 30-59 cc/min, consider risk and benefit before initiating an NSAID Risk factors for NSAID-related GI complications: -History of previous GI ulcer -Age ≥ 65 yo -Concomitant use of anticoagulants, corticosteroids, other NSAIDS (including low dose ASA), or SSRIs -High dose NSAID therapy -Concurrent, chronic debilitating disorders, especially CVD -Concurrent h. pylori infection --ACG recommends testing (and treating if positive) before initiating long term NSAIDs Evaluating Risk of GI Complications with NSAID Use: -Low Risk—no predisposing risk factors -Moderate Risk—1 or 2 risk factors -High Risk—3 or more risk factors OR a history of complicated ulcer

*Prevention/Delay of Onset of T2DM

For patients with IGT, IFG, or A1C 5.7-6.4% -target weight loss of 7% of body weight -increase physical activity to at least 150 min/week of moderate activity *Consider metformin for prevention of T2DM -BMI ≥ 35 kg/m2 -Age < 60 -Women with previous GDM* At least annual monitoring for DM development Screen/treat modifiable risk factors for CVD Refer to Diabetes Prevention Program (DPP)

*vomiting

Forceful expulsion of the stomach contents through the mouth preceded by relaxation of the esophageal sphincter, contraction of the abdominal muscles, and temporary suspension of breathing body's natural means of ridding itself of poisons or certain infections Purposeful induction of vomiting is no longer recommended when a known poison has been ingested

teriparatide

Forteo, PTH analog, SQ daily, max 2y, for those with severe OP (may be firstline if T<-3), increased fracture risk, GC-induced OP binds PTH Rs with same affinity as PTH and stimulates bone formation on trabecular and cortical bone surfaces by preferential stimulation of osteoblasts *(REBUILDS BONE)* SE: hyper-Ca, leg cramps, nausea, dizziness, orthostatic hypoTN within 4h BBW: osteosarcomas in animals Refrigerate. Protect from light. Discard after 28d.

*acromegaly

GH excess that only effects ~50 adults in a million gigantism-even more rare, excess GH prior to epiphyseal closure in children *2-3x increased mortality from cardiovascular, respiratory, or neoplastic disease* most pts are middle-aged at dx, effects both genders equally 90% caused by GH-secreting pituitary adenoma symptoms develop gradually over time so it may take 7-10 years to diagnose pts experience soft-tissue overgrowth that effect many body systems

*DM agents-weight loss/neutral

GLP-1 Agonists DPP4 Inhibitors (neutral) SGLT2 Inhibitors Metformin (neutral) Pramlintide Alpha glucosidase inhibitors (mild)

IBD etiology

Genetic predisposition -psychological or stress factors trigger flares -NOD2/CARD15 gene Environmental factors -smoking, diet, abx, NSAIDs, ASA, appendicitis Immune system disturbance -microbiota, mucosal defense

*pregnancy basics

Gestational age is calculated from the date of the last menstrual period Average pregnancy = 40 weeks Pre-term if born at < 37 weeks Pregnancy is divided into 3 trimesters, each comprised of 14 weeks Embryo vs. fetus - not called a fetus until 10 weeks gestation Organogenesis occurs in the first trimester second and third trimesters are growth and development

*Acromegaly - Treatment

Goals: reduce GH to <1 mcg/L after an OGTT with normal IGF-1 TOC: transsphenoidal surgical resection of the GH-secreting adenoma -Post-surgical cure rates range from 50-90% -Complications of resection: meningitis, DI, pituitary failure Radiation is also a possible option but could take years to relieve symptoms Pharmacological treatment (backup plan) -dopamine agonists like bromocriptine and cabergoline (more selective and much longer half-life, more expensive) -Somatostatin analogs like octreotide and lanreotide -GH receptor antagonists like pegvisomant (Somavert) Small studies have suggested that combination tx may be better

gout relationship with other diseases

Growing evidence shows a causal relationship between hyperuricemia and cardiovascular disease -Evidence shows that hyperuricemia increases risk for chronic kidney disease and thus may be a secondary cause of hypertension -A number of small, independent trials suggest that ULT therapies reduce the risk of these adverse outcomes but more study is warranted Some evidence suggests hyperuricemia may be a protective factor against Alzheimer's and Parkinsons' -The neuroprotective relationship between uric acid and CNS disorders is a new concept and not understood

HRT and VTE in menopause tx

HRT is associated with an increased risk for VTE within 1-2 years after initiation Incidence increases with increase in age, obesity, and thrombogenic mutations Smoking further increases risk but is not considered to be a contraindication to HRT HRT is contraindicated in patients with previous idiopathic or current VTE

*Hypothyroidism: Etiologies

Hashimoto thyroiditis: autoimmune(anti-thyroid gland or anti-TPO), most common iatrogenic: radiation (e.g. for HTR), thyroidectomy, excess thionamides medications: amiodarone, lithium, IFN, radiocontrast dye miscellaneous: iodine deficiency or excess, postinflammatory thyroiditis, postpartum thyroiditis, pituitary or hypothalamic disease (secondary)

*HbA1C

HbA1c—glycated hemoglobin correlates with a patient's avg blood glucose level over a span of 2-3 months Used to diagnose, assess control and guide treatment decisions eAG—translates A1C test results into estimated average glucose eAG familiar to patients who test their BG at home sickle cell anemia and hemoglobin pathologies skew results

*diabetes

Heterogeneous group of metabolic disorders Abnormalities in carbohydrate, fat & protein metabolism Characterized by hyperglycemia Defect in insulin secretion, action, or both Chronic complications—microvascular, macrovascular Cardiovascular disease (CVD) is the leading cause of death in patients with T1D of long duration; accounts for nearly 70% of deaths in patients with T2D; largest contributor to the direct & indirect costs of diabetes. Leading cause of blindness and ESRD in adults; 73,000 LL amputations 29.1 million people (14%) diagnosed: 86 million at high risk

*adalimumab

Humira, anti-TNF agent Indication: Moderate to highly active RA in combination with MTX or as monotherapy SE: Headache, rash, injection site reaction Availability: SubQ injection (prefilled pen or syringe) that may be given at home Admin: Leave at room temperature for 30 minutes prior to administration. Inject entire contents of pen/syringe. Rotate injection sites and do not give in areas where skin is tender, bruised, red, or hard. Discard in sharps container. Needle cover contains latex.

adalimumab for IBD

Humira, anti-TNF for induction of remission and maintenance in pts with mod-severe CD and UC, 160mg (4 40mg injections in 1d or 2 on 2 consecutive days) initially the second dose 2 weeks later (80mg); begin maintenance dose of 40mg every other week thereafter; can be given at home REMS: dispense med guide each time dispensed; contains latex

What plays a huge role in GH regulation?

IGF1! When IGF1 goes up, GH follows after a short lag time.

IVFE and pancreatitis

IVFE does not stimulate pancreatic exocrine function so it is safe in pancreatitis as long as the TG<400 with continuous lipid infusion (<250 when checked 4 hours after the infusion)

*anti-dsDNA for SLE

If ANA test shows a 1:40 titer or higher, more specific tests should be performed including anti-dsDNA (present in about 70% of patients with SLE and less than 1% of patients without SLE), anti-Smith, anti-RNP, anticardiolipin, and beta-2 glycoprotein antibodies as well as lupus anticoagulant Elevated levels of any one or more of the above increase likelihood of SLE Over dozen autoantibodies have been associated with SLE at different degrees of sensitivity and selectivity The development of MULTIPLE autoantibodies is more indicative of SLE than ANA

breast cancer in menopause tx

If a risk increase exists it appears to be small and isolates to older women with longer exposures. Hormones influence tumor growth but it is questionable if they induce malignant tumor formation. May be a lower risk with micronized progestin over MPA and with avoidance of combined continuous therapy.

*nonpharmacological tx gout

Implement in asymptomatic and symptomatic patients Avoid organ meats Avoid foods containing high-fructose corn syrup* Limit (1-2 drinks daily) or eliminate alcohol* Limit meats, seafood, fruit juices, sugar, desserts, and salt* Increase intake of low-fat or nonfat dairy and vegetables* Weight loss (in overweight patients) and exercise (in all patients)* Smoking cessation* Drink 8 to 16 (8 oz) glasses of water daily -Maintain urine output of 2 to 3 L per day Apply ice to affected joints (only symptomatic pts) Some studies have shown Vitamin C supplementation modestly reduced serum urate levels. Not clinically significant compared to placebo. 2017 Guidelines question benefit of dietary changes

*azathioprine

Imuran, AZA-prodrug cleaved to 6MP which is incorporated into DNA, halting replication; also inhibits cellular purine synthesis, which are required for the function of macrophages, lymphocytes, and neutrophils ineffective for hyperacute rejection; avoid live vaccines AE:*bone marrow suppression* (leukopenia >50%) thrombocytopenia, dose-dependent pancytopenia, hepatotoxicity, pancreatitis, N/V/D, alopecia monitor: WBC 3000-5000 decrease dose by 50%; <3000 d/c until resolution; PLT <100,000 decrease dose by 50%; <50,0000 d/c until resolved

*Injectable Therapy in T2D

In most patients we would use GLP1RA instead of basal insulin Basal first if A1C >11%, catabolic symptoms (weight loss, etc.), or T1DM Add prandial if A1C above goal with FPG at target OR a basal dose >1 unit/kg/day Consider initial combo injectable tx if A1C >10% and 2% above target -Options: GLP1RA + basal or prandial/basal insulin

*Additional ADA Lipid Recommendations

Increase omega-3 fatty acids, viscous fiber, and plant stanols/sterols; weight loss (if indicated); and increase physical activity Intensify lifestyle therapy and optimize glycemic control for patients with elevated TG and/or low HDL For patients with fasting TG levels >/= 500 mg/dL, consider therapy to reduce risk of pancreatitis.

*children and adolescents with DM

Increasing incidence of T2D in adolescents; may present with DKA Obesity, physical inactivity Metformin: labeled for use in children ≥ 10 yoa Sulfonylureas commonly used Other agents used off-label T1D: A1C goal < 7.5% T2D: A1C < 7% T1D or T2D: 60 min/day or more of moderate- or vigorous intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week

Mecasermin

Increlax, recombinant IGF1 used for short stature in children d/t severe primary IGF-1 deficiency (ht SD <-3 plus basal IGF-1 SD <-3 plus normal or elevated GH) MOA: Stimulates the synthesis and secretion of IGF-1 Dose: 0.04-0.12 mg/kg SQ BID Must monitor closely for hypoglycemia; administer with a snack or meal AE: hypoglycemia, injection site rxns, tonsillar hypertrophy, retinal edema, HA, arthralgia's

mycophenolate and SLE

Indication: Off label for the treatment of severe SLE, specifically lupus nephritis (LN); MOA: Exhibits cytostatic effects on T and B lymphocytes, suppressing immunity Dosing: 1 gram BID x 6 months in combination with glucocorticoid THEN 0.5 to 3 grams daily thereafter Onset: 6-8 weeks SE: Hypertension, peripheral edema, tachycardia, headache, insomnia, dizziness, anxiety, rash, hyperglycemia, hypercholesterolemia, electrolyte changes, abdominal pain, N/V, blood dyscrasias, and many others Black Box Warning: Increased risk of infection, may be serious or fatal. Increased risk of lymphoma and skin malignancies. CI: Pregnancy (Category D), Counsel: Women planning to become pregnant must DC at least 6 weeks before conceiving; Not recommended in breast feeding; Counsel women on mycophenolate not to become pregnant; "Hazardous drug", dispose of in hazardous waste Monitor: CBC weekly for 1 month then twice monthly for 1-2 months then monthly thereafter x 1 year; Scr, BUN, and LFTs periodically; Monitor for s/s of infection or lymphoma, blood pressure, fluid and weight, and glucose in patients with diabetes Note: Do not combine with biologicals Mycophenolate is preferred over Cyclophosphamide to date because it has a better side effect profile but still not a good side effect profile; Mycophenolate is considered standard of care for LN (lupus nephritis) now.

*immunizations in DM

Influenza—annual (≥6 months of age) Hepatitis B-unvaccinated adults 18-59 yoa; consider in adult > than 59 yrs PCV13 recommended for children before age 2 yrs People with diabetes ages 2-64 yrs should also receive PPSV23 PPSV23 for adults ≥65 years of age (regardless of vaccination hx)

tx plan for ESTABLISHED RA

Initiate DMARD monotherapy over double or triple therapy (typically MTX) add additional agents e.g. GC or biologics in combo with MTX, not monotherapy when possible

*fluid therapy DKA or HHS

Initiate NS 1-1.5 L/hr during first hour Then calculate corrected serum sodium Na corrected = Na measured + 0.016 x (Serum glucose - 100) Once BG corrected to 200-250 mg/dL, add D5W to current IV fluid at 150-250 ml/hr Subsequent infusion rate of NS or 1/2NS (250-500 mL/hr) depends on hydration state.

*NSAIDs for RA

Inititate at dx for 1-2w trial at a moderate or high dose for up to 3mo then prn for pain and swelling do not affect disease progression, just treat the sx

GH regulation

Insulin Growth Factor (IGF) - also known as somatomedins, mediates GH IGF-1-regulates growth to some extent before birth, but mainly after birth IGF-2-primarily regulates growth in utero Has a very short half-life (~30 min) GH concentrations are lowest through the day -Levels pulse after meals, after exercise, or during periods of stress GH secretion is highest during the night within the first 1-2 hours of slow-wave sleep GH secretion is lowest during infancy, increases slightly during childhood, reaches its peak during adolescence, and gradually declines during middle age

*T2DM pathogenesis

Insulin resistance (muscle, fat, liver) Insulin secretory dysfunction (relative deficiency) Decreased amylin secretion Increased endogenous (hepatic) glucose production Neuroendocrine dysfunction Impaired incretin effect Increased gastric emptying rate Deranged adipocyte biology (accelerated lipolysis) Increased renal glucose reabsorption

*SGLT2i benefit

Insulin‐independent action Associated with calorie loss; weight loss Low risk of hypoglycemia Complementary action to other agents Can be used regardless of disease duration Decreased BP Oral, once daily; available in combination CVD benefit (empa, cana) DKD (diabetic kidney disease) benefit (empa, cana) Lowers fasting and PP glucose

Prasterone for tx vulvovaginal atrophy

Intrarosa-moderate to severe dyspareunia in postmenopausal women inactive endogenous steroid converted into active androgens and/or estrogens CI in undiagnosed vaginal bleeding, cancer in hx of breast cancer 6.5mg vaginal insert HS; empty bladder first SE: vaginal discharge (14.2%) and abnormal Pap (2.1%)

*Causes for End-Stage Organ Dysfunction

Kidney: HTN, DM, CKD Liver: Cirrhosis due to alcohol or Hepatitis B or C Heart: Ventricular failure, viral infections Lung: COPD, idiopathic pulmonary fibrosis Pancreas: DM Small bowel: Short bowel syndrome, functional disorders

pegloticase and gout

Krystexxa Indication: Management of gout when patient has had inadequate response to XOI and uricosuric agents, in severe disease with > 7 attacks/year in the absence of tophi, > 2 attacks per year with tophi, and patients with CTGA MOA: Catalyzes oxidation of uric acid to allantoin, an inert water soluble purine metabolite excreted in the urine, and lowering serum uric acid Dose: 8mg in 250 ml NS or ½NS IV infusion over 2 hours every 2 weeks; No dose adjustments required SE: Gout flare (prevent with anti-inflammatory prophylaxis with NSAID or colchicine for first 6 months of therapy), CHF exacerbation, N/V, confusion, nasopharyngitis, constipation, and chest pain CI: Hypersensitivity, Glucose-g-phosphate dehydrogenase (G6PD) deficiency Black Box Warning: Anaphylaxis and infusion reactions have been reported during infusion and within 2 hours post infusion and are life threatening Caution: Patients of African or Mediterranean descent should be screened for G6PD deficiency before initiation of therapy due to risk of hemolysis and methemoglobinemia Monitor: Monitor serum uric acid levels. DC if levels increase above 6 mg/dL on two consecutive occasions while receiving this medication Note: DC other uric acid lowering drugs. Pegloticase must be given in the healthcare setting. Pre-medication with corticosteroids and antihistamines decrease risk of infusion reactions and anaphylaxis. Start prophylaxis with NSAID or colchicine 1 week prior to infusion.

*glargine (Toujeo)

LAI, U300, *daily dosing*, t1/2 23 hours, SS in 4d, DOA 36h offers smaller depot surface area leading to a reduced rate of absorption provides flatter and prolonged PK and PD profiles and more consistency *Less nocturnal hypoglycemia than U100* SoloStar (1.5mL) delivers 80 unit dose Max SoloStar (3 mL) delivers 160 unit dose Can forget a dose and still be covered by 36h 1:1 conversion to U100, but may need 10-20% to provide same glycemic control EDITION trials: similar A1C lowering efficacy and weight effects vs U100

*GI tract

Large hollow organs extending from the mouth to the anus Muscle movements (peristalsis) and strategic hormones and enzymes release allow digestion and movement of food

*detemir

Levemir, LAI, U100 Binds interstitial albumin at the injection site; once dissociates from interstitial albumin, enters capillary, where it again binds to albumin, prolonging action Dose-dependent DOA; dosed every 12-24 hours If giving less than 0.4units/kg/day consider BID instead of QD

*obesity and DM

Lifelong disease Weight loss is difficult, maintenance is even more challenging Maintenance of weight loss—60-90 minutes physical activity most days of week Goal weight loss 1-2 lb per week; caloric deficit 500-750 kcal/day T2D: Recommend use of GLP1 RA or SGLT2 inhibitor in addition to the first-line agent metformin*

*nonpharmacological tx SLE

Lifestyle counseling is recommended for all SLE patients at at diagnosis (or if SLE is suspected) Smoking cessation Weight management* Regular exercise* Eat a healthy diet* Healthy coping/stress management Minimization of sun exposure *=to reduce comorbid conditions

*selection of NSAID and PUD risk

Listed in order of decreasing risk 1. Salicylates-aspirin, salsalate 2. nonselective NSAIDs (ibuprofen, naproxen, indomethacin, ketorolac) 3. partially selective NSAIDs (etodolac, diclofenac, meloxicam, nabumetone) 4. Selective COX-2i (celecoxib) Ketorolac is highly ulcerogenic-20 pills or 5d limit celecoxib is actually protective for about 2 years

*iodides and HTR

MOA: block thyroid hormone release, inhibit organification, inhibit peripheral conversion of T4 to T3, decrease gland size/vascularity AE: allergic reactions, metallic taste, "escape" phenomenon (resumption of normal iodine organification and normal TPO fx) dose-related toxicity: thirst, diarrhea, weakness, convulsions CI: pregnancy, before RAI tx, nodular goiter or adenomas decreased inorganic iodine inside thyroid follicle below critical threshold secondary to down-regulation of NIS tissue autonomous-will use the iodine as a substrate for additional TH synthesis *most commonly used for Graves disease before surgery and in thyroid storm*

Diphenoxylate/Atropine

Lomotil, antimotility agent, 2.5-5mg PO TID to QID PRN, max 20mg/d SE: blurred vision, dry mouth, urinary hesitancy CI: severe liver dz, jaundice, or narrow-angle glaucoma atropine has no effect on tx but was added to discourage abuse

alosetron

Lotronex, 5HT3 antagonist for IBS-D SE: constipation, bowel obstruction, and ischemic colitis; bowel perforation and death (rare) CI: hx of constipation, bowel obstruction, ischemic colitis, IBD, or thromboembolic disorder d/c if constipation or sx of ischemic colitis (new or worsening abdominal pain or blood in stool) occur

*Lab evaluation in HTR

Low TSH (in rare cases can be high in secondary disease), high TT4, high FT4, high TT3, thyroid autoantibodies (TSH receptor antibody and thyroid-stimulating immunoglubulin), RAIU (CI in pregnancy), thyroid scan (131I or 99mTc)

*TZD advantages

Low risk of hypoglycemia as monotherapy Favorable metabolic effects—increases HDL-C (pio and rosi) and lowers TG (pio) Can use in renal insufficiency Excellent insulin sensitizer Potential beta cell-sparing Induce ovulation in PCOS

*SGLT2i

MOA: Inhibit glucose (& Na) reabsorption; non-insulin MOA ↓ renal glucose threshold =↑urinary glucose excretion Glucose loss of 80-100 g/day = 320-400 kcal/day Low risk of hypoglycemia, Weight loss; BP & CVD/HF benefit ↑ GU infxn; osmotic diuresis; hyperkalemia; bone loss*; amputation risk; euglycemic DKA; CI: severe renal dysfunction SGLT2 inhibitors may reduce CKD progression; should not be used with more than mild CKD (avoid with eGFR <45). Normal renal fxn—180 grams glucose filtered daily In normoglycemia, all filtered glucose is reabsorbed SGLT2 mediates 90% of filtered glucose reabsorption SGLT1 mediates 10% Hyperglycemia increases SGLT2 and maximal capacity; excess glucose returns to bloodstream SGLT2i blocks reabsorption and increases glycosuria, reducing plasma glucose

*macrolides and diarrhea

for TD in pts who have failed rifamycin prophylaxis or who are traveling in areas where FQ resistance is common SE: N/V, diarrhea, QT prolongation e.g. azithromycin (Zpak, Tpak, Zmax), clarithromycin (Biaxin)

*alpha agonists and POAG

MOA: decrease production of aqueous humor and increases uveoscleral outflow systemic AE: dry nose and mouth, hypoTN, decreased pulse, lethargy local AE: allergic conjunctivitis, hyperemia, ocular pruritis, foreign-object sense Apraclonidine (lopidine)-only used short term after ocular surgery brimonidine (Alphagan P)-secondline, contains purite (preservative which facilitates drug delivery), possible neuroprotective properties can be used in addition to BB or PG analog avoid ophthalmic alpha agonists in patients with CVD, renal dysfx, DM, cerebrovascular disease, concomitant drugs (cardiovascular, antihypertensives, MAOIs, and TCAs)

*PG analogs and POAG

MOA: increase outflow of aqueous humor through uveoscleral pathway increasingly chosen over topical BB and other meds as initial therapy. It is just as effective, but it has less systemic SE than BB. Also, it is only once daily. AE: conjunctival hyperemia, stinging on instillation, eye changes (iris darkening, eyelash thickening and lengthening, eyelid darkening) undesirable in one eye

cholinergic agonists and POAG

MOA: increase outflow of aqueous humor through uveoscleral pathway significant SE: miosis, myopia fourthline-contraction of ciliary muscle and ocular pearl: high doses are frequently needed for pts with darkly pigmented eyes direct acting: pilocarpine (Isopto Carpine, Pilocar), carbachol (Isopto Carbachol, Carboptic) indirect acting: echothiophate iodide (phospholine iodide), inhibits cholinesterase

metyrapone

MOA: inhibits 11 beta-hydroxylase (11-deoxycortisol to cortisol) sudden decrease in cortisol within hours prompts rise in ACTH concentrations. As ACTH increases and cortisol blockage persists, precursors are shunted toward androgen production. Metyrapone also blocks aldosterone synthesis and a buildup of precursors that only exhibit weak mineralocorticoid activity. 1-2g/day divided q4-6h, max 6g/d AE: hirsutism and acne from extra androgens, BP and electrolyte abnormalities from lack of aldosterone (monitor K, Mg, Na, etc.) CYP3A4 inducer only available through manufacturer as *LAST RESORT*

*meglitinides overview

MOA: secretagogue infrequently used 2n line, hypoglycemia, weight gain, caution in renal dysfx administer w/i 30 min prior to each meal; skip dose if meal skipped examples: netaglinide (Starlix), repaglinie (Prandin)

*meglitinides

MOA—non-SU secretagogues; short-acting stimulation (1/2 -4 hrs) Efficacy—↓ A1C 0.5-1% (Repag > Nateg) -Reduces PP BG -TID (mealtime) dosing may ↓adherence; skip dose if meal is skipped -Short durability AE—Hypoglycemia; weight gain (< SU) CI—DKA, T1D, hypoglycemic unawareness -Repaglinide use with gemfibrozil or conivaptan (vasopressin antagonist) Repaglinide (Prandin)—0.5-1 mg at 1-15 min before meals; max DD 16 mg, 4 mg QID Nateglinide (Starlix) 60 or 120 mg before meals

*amylin analog

MOA—synthetic analog of human amylin causes glucose-dependent inhibition of glucagon secretion, reduced rate of gastric emptying, increased satiety Efficacy—0.5-0.7% A1C decrease; lowers PPBG AE—N/V, hypoglycemia CI—Gastroparesis, hypoglycemic unawareness, A1C > 9%, unwilling to SMBG DDI—may delay absorption of other medications; slow gastric emptying advantages: weight loss, *PP control* disadvantages: *GI AE,* Reduce rate and extent absorption of pain relievers, antibiotics, oral contraceptives pramlintide (Symlin)

*progestins for menopause

MPA: Provera; micronized progesterone: Prometrium; norethindrone: Aygestin Mirena-endometrial protection equivalent to continuous progestin

DMARD superior regardless of disease severity or prognosis

MTX

Alprostadil Intraurethral

MUSE (medicated urethral system for erection) PGE, stimulates AC to increase production of cAMP which causes vasodilation 90% absorbed by urethra and corpus spongiosum in less than 10min, peak 20-25 20% of dose reaches the corpora cavernosum Any absorbed systemically is rapidly metabolized in the lungs Dose 125-1000mcg, no more than 2 doses/d (penile injury) empty bladder completely before administration AE: urethra injury or pain, partner pain (acidic and sometimes falls into vagina) pellets are about an inch long and the width of a typical catheter

stem cell therapy and OA

Mesenchymal stem cells harvested from umbilical cords donated following normal, healthy births are injected into joint space to stimulate cartilage regeneration and decrease inflammation Controversial and costly procedure being performed in clinics across the US FDA warns that "lack of evidence for unapproved stem cell treatment is worrisome" Laws and approval requirements for stem cell therapies is still evolving

*potassium in DKA and HHS

Mild-to-moderate hyperkalemia is common Insulin therapy, correction of acidosis, volume expansion decrease K Maintain between 4-5 mEq/L -20-30 mEq/L fluid Hypokalemia-Begin with fluid therapy, delay insulin until K is > 3.3 mEq/L

zona glomerulus

Mineralocorticoid production Aldosterone is principle end product Responsible for K+ and Mg++ secretion and Na+ reabsorption

missed doses OC

Miss 1 dose anytime in pill pack, 2 doses the following day, no backup needed. (exception Netazia) 2+ missed doses, 7 days of backup when they resume, consider EC MUST DISPENSE A PACKAGE INSERT and counsel pts

*metformin ADMET

Most common AE—GI distress (take with food, try XR, split dose) -Rare: Lactic acidosis (serious), megaloblastic anemia -Other less common—metallic taste, macrocytic anemia, B12 deficiency DI—cimetidine (competes for renal tubular secretion)—increases metformin conc. Avoid use with alcohol (lactic acidosis) Monitoring—A1C, SCr, B12 Contraindications: hypersensitivity, acute/chronic metabolic acidosis (shock, acute MI, septicemia); DKA -Severe hepatic, pulmonary, renal disease; decompensated HF -IV contrast (48 hrs post admin)

SLE pathophysiology

Multiple, complex alterations in the balance of immune factors leads to an abnormally functioning immune system -T and B lymphocyte activation and signaling are altered -Apoptotic cell clearance is decreased -Plasma cells, which produce antibodies, are increased -Immune complexes deposit in various organs, triggering complement and other mediators of inflammation

OA txs NOT recommended

Muscle relaxants are not beneficial for the management of OA pain Viscosupplementation, intra-articular injection of sodium hyaluronate into the joint space to lubricate the joint, is still FDA approved and available in the US -Hyaluronate products are classified as "medical devices" rather than drugs in the US -Hyaluronate may have some clinical benefit and few side effects -It is no longer recommended in guidelines Glucosamine—may lengthen time to surgical requirement; Evidence: Weak Chondroitin sulfate—conflicting evidence S-adenosylmethionine (SAM-e)—no benefit as monotherapy Hydroxychloroquine (Plaquenil™) used in the treatment of rheumatoid arthritis and sometimes off label in OA no more effective than placebo in reducing OA pain

nitrogen balance

N found only in protein, N is lost in urine in the form of urea UUN (urine urea nitrogen) 10-12g/d in healthy individuals; 16-24g/d in the critically ill loss of 16g N as urea=loss of 1 lb of skeletal muscle/LBM each day; rapid development of malnutrition excess protein breakdown during critical illness leads to negative nitrogen balance and functional impairment-respiratory failure, heart failure, diarrhea 1. determine nitrogen lost by a 24h UUN 2. add 4 to account for non-urinary losses of nitrogen 3. determine intake by dividing protein intake by 6.25 4. calculate the difference

*pregnancy-induced conditions

N/V, heartburn/reflux, constipation, UTI, preeclampsia

recommendations for BMD testing

NOF recommends q2y, no general consensus, but new evidence suggests every year in women with advanced osteopenia, 5y with moderate osteopenia, 15y with mild osteopenia or normal BMD

*T1D Conventional (Split-mixed)—rare

NPH and bolus insulin before breakfast and dinner OR premixed insulin best for pts with consistent meal schedule, physical activity, carb intake difficult to attain tight control; lack of flexibility 2/3 TDD in am and 1/3 in pm

*NPH vs LAI

NPH-has a peak, shorter duration, and thus hypoglycemia risk LAI-less peak, longer duration, lower risk of hypoglycemia (glargine U300, degludec U100 and U200 are especially good at reducing nocturnal hypoglycemia)

nutritional support in AP

NPO for at least 48h in mild AP-oral feeds as soon as N/V and severe abdominal pain resolve -low fat diet is as safe as clear liquids in mod-severe AP-enteral nutrition is recommended -NG preffered, and continuous EN preferred over bolus -parenteral to be avoided as TPN has been associated with fungal complications -probiotics are no longer recommended with enteral nutrition and may even increase mortality in severe AP

*AGI advantages

No hypoglycemia as monotherapy Weight neural Best used in early disease or pre-diabetes (increased GI motility)

*types of glaucoma

OAG and PACG Both can be inherited, congenital, or secondary to disease, trauma, or drugs and can lead to serious complications Both primary and secondary glaucomas may be caused by a combination of open-angle and closed-angle mechanisms.

FDA Risk Categories

OLD A-controlled studies in women fail to demonstrate fetal risk B-no controlled studies in women, but animals fail to demonstrate fetal risk C-animal studies show an AE OR studies in animals and women not available D-positive evidence of human fetal risk, but benefits might outweigh risk X-positive evidence of human fetal risk, risk clearly outweighs benefit

ophthalmic preservatives and OSD

OSD-ocular surface disease OSD will often manifest secondary to glaucoma therapy as superficial punctate keratitis, tear-film instability, or allergy Patients with medication-related OSD may try treatment with artificial tears, anti-inflammatory therapy, or possibly preservative-free therapy if feasible

predisposing medications of AACG

OTC decongestants, motion sickness meds, adrenergic agonists, antipsychotics, antidepressants, anticholinergics, antihistamines

*T1DM presentation

Onset seems to be abrupt; extensive preclinical period Progressive fasting hyperglycemia Glucosuria results in osmotic diuresis, producing polyuria with compensatory polydipsia Weight loss occurs as calories are lost in the urine and body fat and protein stores are broken down Liver begins to metabolize FFA that are released in response to epinephrine and low insulin conc. Absolute lack of insulin may cause excessive mobilization of FFAs to the liver, where they are metabolized to ketones—ketonemia, ketonuria, ketoacidosis

*diabetic neuropathy

Optimize glycemic control Screening: T2D assess for diabetic peripheral neuropathy at dx,T1D 5 years after dx; annually thereafter Assessment of distal symmetric polyeneuropathy: Temperature or pinprick sensation and vibration sensation; 10-g monofilament testing (assess loss of protective sensation) Assessment of foot pulses, testing for loss of protective sensation (LOPS) annually Assess s/s autonomic neuropathy in patients with microvascular complications Initial pharmacotherapy (ADA): pregabalin (Lyrica), duloxetine (Cymbalta), or gabapentin; other agents off-label Daily self-foot exam, foot hygiene, footwear

*abatacept

Orencia, T cell modulator, monotherapy or in combo with traditional DMARDs for RA with high disease activity and poor prognosis despite traditional DMARD use or those who with mod-severe TA who have failed a TNFalpha inhibitor *No BBW and no monitoring*, weekly SQ not recommended in pregnancy or lactation interacts with BG testing strips so may alter BG readings on the day of injection SE: *COPD exacerbation,* HA, nausea, diarrhea

Ospemifene for tx vulvovaginal atrophy

Osphena-SERM for moderate to severe dyspareunia unique vaginal effect comparatively: improved vaginal pH, dryness, and hormonal environment. with no cases of VTE, endometrial hyperplasia, or carcinoma most common SE: proliferative endometrium and/or hot flashes in 10% risks associated with estrogen use-CI in undiagnosed vaginal bleeding; hx DVT, PE or arterial thromboembolic disease; estrogen-dep malignancies

*Metformin & Lactic Acidosis

Overall risk of metformin-associated lactic acidosis is low DC when: -eGFR < 30 mL/min or -Clinical situations in which there is an increased risk of lactic acidosis (sepsis, hypotension, and hypoxia), or -High risk of acute kidney injury resulting in a worsening of GFR, such as administration of radiocontrast dye in those with eGFR < 60 mL/min

erection physiology

PSNS, NO release, GC activation, cGMP production, smooth muscle relaxation of corpus cavernosum, increased blood flow to penis

abaloparatide

PTHrP analog, Tymlos, safety unsure after 2y for OP in postmenopaisal women at high risk of fracture binds to and stimulates PTH1R resulting in activation of cAMP signaling pathway in target cells leading to increases in BMD and content SE: orthostatic hypotension, hypercalcemia, hypercalciuria, urolithiasis, nausea, HA, mild injection site rxns, tachycardia BBW: osteosarcomas in animals SQ; have pt sit or lie down in case of orthostatic hypotension; refrigerate, do not freeze; store for up to 30d refrigerated after opening

*hepatotoxicity and thioamides

PTU BBW: fulminant hepatic necrosis-risk is higher in children Baseline LFTs, monitor for pruritic rash, jaundice, acholic (putty-colored) stools, dark urine, abdominal pain

*POEM

Patient Oriented Evidence that Matters Guiding principles should be clinically relevant to the patient Differences in recommendations may be based on risk/benefit, differences in patient populations studied/targeted, perceived health literacy, cost, convenience, age, disease severity, specialty perspective, etc.

*When to do a IV to SQ Insulin Conversion

Patient tolerating at least a full liquid diet BG <200 mg/dL Serum bicarbonate ≥15 mEq/L Venous pH >7.3 AG ≤12 mEq/L

*T1DM treatment

Patients require insulin to sustain life: basal (long or intermediate) & bolus (meals) Pramlintide (amylin analog) may be used in those who continue to have erratic postprandial control

*T2DM presentation

Patients tend to present without overt symptoms Usually diagnosed after unrelated blood work Typically overweight 3Ps blurred vision glycosuria fatigue slow wound healing vision changes

*nocturnal GERD

Patients who complain of nighttime symptoms despite optimal PPI dosing may benefit from -Elevate head of bed -Avoid eating within 2-3 hours of bedtime -Avoid sleeping in right decubitus position in bed -BID PPI dosing -Switching once daily PPI to dinner time -Add a bedtime dose of H2RA

*glaucoma suspects

Patients with consistently high IOP, or patients with clinical findings suspicious of early glaucomatous changes

*iodide examples

SSKI (saturated solution KI) or Lugol solution for 10 days before surgery Also, radiographic iodinated contrast agents

PAMORAs

Peripherally Acting Mu-Opioid Receptor Antagonist for OIC in adults with chronic, non-cancer pain (except Entereg®) SE: abdominal pain, nausea, diarrhea, hyperhidrosis (excessive sweating), flushing, flatulence, dizziness, chills must have been on opioid for at least 4 weeks before initiation of PAMORA d/c if opioid is stopped or if severe or persistent diarrhea occurs d/c all maintenance laxative therapy and opioid antagonists before initiation noloxegol (Movantik) 25mg QD (1/2 dose if not tolerated) methylnaltrexone (Relistor) 12mg SQ QD or 450 mg (3 tablets) QD 30 minutes before first meal naldemedine (Symproic) 0.2 mg tablet daily without regard to meals alvimopan (Entereg) 12 mg tablet given 30 min to 5 hours preoperatively, then BID beginning 1 day post-surgery for max of 7 days or 15 doses (whichever is less) Increased risk of opioid withdrawal with "disruption of the blood brain barrier" Not recommended in pregnancy or lactation but likely safe

Traveler's Diarrhea Prevention Strategy

Pre-travel counseling about food, water, sanitation, hygeine boil it, cook it, peel it, or forget it bismuth subsalicylates prophylactic for TD for those >12yo -2 tablets or 2 tbsp QID for up to 3w -CI: IBD or HIV due to potential for excessive systemic absorption prophylactic antibiotics ONLY in high-risk pts for up to 3w -HIV+, cytotoxic chemotherapy, secretory IgA deficiency -do not protect against parasites or replace good hygeine -rifaximin (Xifaxan)—PREFERRED and FQ (increasing resistance) IgA protects against infections in the mucous membranes of GIT and respiratory evidence not does NOT support use of probiotics, prebiotics, or synbiotics all travelers to endemic areas should pack an antimotility or antisecretory agent to manage symptoms and an antibiotic, just in case. Travelers should NOT utilize these products unless problematic diarrhea occurs (interferes with activities) abx for treatment: rifamixin, rifamycin, FQ, macrolides (preferred in Southeast Asia to cover resistant Campylobacter) for 1-3d

*Diabetic Foot Ulcer Prevention

Proper nail and skin care Feet should be kept clean and dry Daily self foot exams Proper shoe selection -Well fitting walking or athletic shoes may be adequate for most -People with bony deformities may need extra wide or deep shoes -People with Charcot foot may require custom molded shoes No barefoot walking-not even in your house

*diagnosis osteomyelitis

Probe-to-bone (PTB) test (probe makes a clinking noise when it hits) MRI (Study of Choice) Bone culture and histology Bone biopsy

tacrolimus and SLE

Prograf, off label for SLE (esp LN) in combo with steroids, noninferior to mycophenolate with fewer AE, inhibits T cell activation, onset 6-12w SE: increased risk of infection, skin malignancies, lymphoma, and DM; HTN; HA; insomnia; nausea; electrolyte changes; abdominal pain; anemia CI: castor oil allergy (vehicle) do not combine with other immunosuppressants, take live vaccines, or drink grape fruit juice; must be disposed of in hazardous waste monitor: trough 10-20 ng/mL, SCr, BUN, LFTs, electrolytes, BG, BP, infusion rxn safe in pregnancy and breastfeeding

denosumab

Prolia-for postmenopausal women with OP at high risk of fracture or failed firstline tx or receiving aromatase inhibitor therapy (breast cancer-exemestane, anastrazole, letrozole); men at high risk for fracture receiving ADT for nonmetastatis prostate cancer some evidence of atypical fractures, pancreatitis, ONJ, cellulitis, rashes CI: hypocalcemia; caution in pts with CrCl<30 or requiring dialysis not recommended in pregnancy or those with concurrent immunosuppressants Warm to room temp for 15-30 minutes before administration. SQ every 6mo Xgeva for bone metastasis every 4 weeks SQ

*insulin action summary

Promotes uptake of glucose, FA, AA and their conversion to storage forms in tissues Inhibits hepatic glucose production by suppressing glucagon secretion from pancreatic α cells In muscle, promotes the uptake of glucose and its storage as glycogen & stimulates the uptake of AAs and their conversion to protein Prevents breakdown of triglycerides to free fatty acids (lipolysis) Facilitates conversion of glucose to glycogen and TG synthesis in the liver

preventing OP and fall risk

Providers should evaluate fall risk at least annually Implement fall prevention strategies Homes safety assessments Balance training exercises Avoidance of medications that can increase risk for falls Refer to PT (AACE/ACE 2016) Utilize hip protectors in high risk pts (AACE/ACE 2016) Annual eye exams and appropriate eyewear -Ex. Bifocals may increase falls

*DM case 1

R.T., a 46-year-old woman, is newly diagnosed with T2D with an A1C of 9.1%. BMI is 31 kg/m2; eGRF 45 mL/min. She is insured & has a robust support system. Which of the following do you recommend for R.T.? A. Monotherapy with metformin B. Monotherapy with liraglutide C. Metformin plus glipizide D. Metformin plus U-100 glargine E. Metformin plus dulaglutide F. Metformin plus empagliflozin F is contraindicated for GFR A1C more than 1.5% of goal so we need dual therapy Glipizide not ideal due to weight gain Insulin not indicated Answer is E

RA diagnosis (qualitative)

RA can be difficult to diagnose as early signs may mimic signs of various other diseases including osteoarthritis, Lupus, Lyme disease, gout, or fibromyalgia If a patient exhibits any signs or symptoms of RA, the physician should: -Gather information about the patient's: --Personal medical history, esp. history of autoimmune disease --Severity and length of recent and current symptoms indicative of RA --Family history regarding RA or other autoimmune disorders -Conduct a physical exam to --Evaluate each joint for tenderness, swelling, warmth and painful or limited movement -- -Inflammation levels (not definitive for RA but indicative of inflammatory disease) --Erythrocyte sedimentation rate (ESR or "sed rate") --C-reactive protein (CRP) -Identify biomarkers for RA --Ex. Antibodies --Rheumatoid factor (RF) is an antibody found in about 80% of patients with RA (but may occur in other autoimmune diseases, too) --Anti-cyclic citrullinated peptide (anti-CCP) occurs primarily in patients with RA, is present in 60-70% of patients with RA and can appear before symptoms present -X-rays, ultrasound, or MRI can be used to visualize joint damage --Imaging performed in early stages of the disease may show little to know damage to joints Identify rheumatoid nodules

*RA vs fibromyalgia

RA: inflammation comes and goes, can last for 6w, damages joints fibromyalgia: constant widespread muscle and tissue pain, lasts 3mo, doesn't damage tissues

stroke and CHC

RF: age, smoking, HTN (greatest risk in hypertensive smokers 35+yo), migraines migraine with aura or 35+yo-avoid CHC d/c CHC if pts develop new-onset or worsening migraines

*physical activity cautions in DM

Retinopathy: vigorous-intensity aerobic or resistance exercise may be CI Neuropathy: caution, walking usually acceptable

*herbal products and OA

Reduce pain and decrease progression of OA of the knee e.g. glucosamine, chondroitin, sAMe, MSM Glucosamine, chondroitin, SAMe, and MSM are all available alone or in combination with one another. All these herbal products work better when given with glucosamine. No current practice guidelines recommend the use of any of these products.

glucosamine and OA

Reduces pain and joint space narrowing and improves mobility by providing essential building blocks for cartilage regeneration and increase hyaluronic acid production SE: GI upset (diarrhea, heartburn, N/V) and itch CI: Shellfish allergy

*insulin storage

Refrigerate unopened insulin -Do not freeze -Avoid temperature extremes Use unopened insulin by manufacturer's expiration date Opened insulins expire based on type & delivery device -May be kept at room temperature (15-30˚C or 59-86˚F) Inspect before use for clumping, precipitates, discoloration, etc.

*general insulin dosing considerations

Regimen should be individualized for patient Assess patient's readiness, goals, support (financial and otherwise), schedule, cognitive ability, confidence prior to initiation

methylnaltrexone

Relistor, PAMORA for OIC in pts with advanced illness receiving palliative care when reponse to laxative therapy is insufficient rotate injection sites, store at room temperature, protect from light dosing is weight based and given every other day use loaded syringe within 24h; be in close proximity to toilet when injecting restricted ability to cross BBB due to quaternary amine structure dispense with medication guide half dose in CrCl <30 safety not established past 6mo

*T1DM screening

Routine screening not recommended Blood glucose rather than A1C Screening for T1D with panel of autoantibodies currently recommended only in setting of research trial

*I:CHO (Insulin to Carbohydrate) Ratio

Rule of 500: 500/TDD=I:CHO ratio e.g. 500/50 units=10 (1 unit RAI for every 10g carb to be consumed) *Replaces empiric bolus calculation to give greater flexibility in meal planning* Rule of thumb value for adults is 1:15

GBS prophylaxis in pregnant women

S. agalactiae, universal prenatal screen at 35-37w vertical transmission during birth associated with neonatal infection (bacteremia, pneumonia, meningitis) and death DOC-PCN G q4h; alternatives: ampicillin, cefazolin, clindamycin, vancomycin

*obesity case application 1

S.B, a 47-year-old female with a prior hx of substance abuse, presents for chronic disease management. Her BMI is 30. She has OSA and T2D of 2-year duration (current A1C 7.5 %); she takes metformin 1000 mg twice daily. S.B. has been consistent in caloric restriction (app. 1500 kcal/day) and physical activity (walking 30 minutes daily 6 days per week) for the past 6 months. She is frustrated that her weight loss efforts have plateaued. Which of the following is the best intervention for S.B.? A. Begin Saxenda® (liraglutide) 0.6 mg SQ daily; titrate weekly to 3 mg SQ daily. B. Intensify physical activity as pharmacotherapy for obesity is not indicated. C. Begin Contrave®(naltrexone/bupropion) 8mg/90mg one tablet twice daily. D. Begin Xenical® (orlistat) 120 mg three times daily. A is preferred. D will work. B is probably okay, but it might be hard for her to implement it when she's already exercising regularly. C is a definite no due to her past history of substance abuse.

5-HT3 Receptor Antagonist and diarrhea

SE: HA, fatigue, constipation, dizziness, QT prolongation reduce dose with hepatic impairment (CP-C) reduced frequency of stools and bloating but did not relieve pain significant improvement was seen within 7 days of onset most benefit was decrease in urgency sx resolution not prolonged after d/c less benefit seen in patients with h/o severe diarrhea appears to be more beneficial in women (likely due to difference in gene expression and Cyp1A2 activity), men may need higher doses e.g. ondansetron -(Zofran®) -PO tabs and sublingual tabs; only one available in generic -(Zuplenz®)—oral soluble film (new formulation)

SNRIs and IBS-D

SE: dry mouth, nausea, HA, dizziness, insomnia, sexual dysfxn, loss of appetite, night sweats, constipation (may be inappropriate for IBS-C), HTN full effects may take 4-6w, may be beneficial in pts with more severe pain e.g. desvenlafaxine (Pristiq), duloxetine (Cymbalta), venlafaxine (Effexor)

osmotic agents

SE: flatulence, nausea, diarrhea, cramps, and electrolyte imbalance e.g. lactulose, sorbitol, PEG, saline laxatives, glycerin suppositories

Anti-TNF agents

SE: increased risk of infection (reactivation of latent TB or Hep B) and malignancy, HA, N/V/D, abdominal pain, cough, pharyngitis, HTN, fatigue, rash, CHF exacerbation, arthralgias CI: untreated TB infection, history of chronic infections (Hep B), MS, severe CHF, hx of histoplasmosis (assess for all before initiation) injection rxns may be decreased by antihistamines, APAP, or corticosteroids do not take with other anti-TNF agents or natalizumab do not take with live or live attenuated vaccines (decrease vaccine effectiveness) e.g. infliximab (Remicade-biosimilar CT-P13, IV only, infuse over 2h), adalimumab (Humira-biosimilar adalimumab-adbm, SQ), certolizumab pegol (Cimzia, SQ) biosimilars-as safe and effective as their reference drug, but no evidence if switching to a biosimilar from the reference is a good idea

*antibiotics in AP

SIRS is common in AP and signs/symptoms resemble those of infection Indicated for the management of: 1. Extra pancreatic infections such as pneumonia, cholangitis, bacteremia, UTI, etc. -May be HAI increased potential for resistance and increase in mortality 2. Infected necrosis (pancreatic or extrapancreatic)-usually monomicrobial -Most common originate in GI flora-usually GNR like E. coli (most infections between neck and genitals), klebsiella, pseudomonas, and enterococcus If patient deteriorates or fails to improve after 7-10d use abx that penetrate pancreatic necrosis: carbapenems, quinolones, and metronidazole

super simplified diagnosis SLE

SLE likely with positive ANA (or ENA or anti-dsDNA Ab) in addition to at least two independent SLE organ sx not otherwise explained

SLE dx

SLE should be suspected in any patient with symptoms presenting in any 2 of the following organ systems: -Constitutional -Musculoskeletal -Skin -Renal -Neuropsychiatric -Hematologic -Cardiac -Pulmonary -Gastrointestinal -Reticuloendothelial Once SLE is suspected, the initial evaluation should be the antinuclear antibody (ANA) test If ANA test shows a 1:40 titer or higher, more specific tests should be performed including anti-dsDNA (present in about 70% of patients with SLE and less than 1% of patients without SLE), anti-Smith, anti-RNP, anticardiolipin, and beta-2 glycoprotein antibodies as well as lupus anticoagulant Tests to evaluate overall health status that should be performed include: urinalysis, CMP, CBC, and direct Coombs test (test for autoimmune hemolytic anemia) Evaluate erythrocyte sedimentation rate (ESR or "sed" rate) and C-reactive protein to measure degree of inflammation and disease activity

*insulin PK

SQ kinetics dependent on onset, peak, and DOA; absorption depends on source, concentration, additives (e.g. protamine), blood flow to area, and injection site NPH absorption from rapid to slowest: *abdominal fat, posterior upper arms, lateral thigh area, superior buttocks area* insulin is degraded in the liver(25-50%), muscle and kidney (15-20%)

Nonhormonal Alternatives for menopause tx

SSRI-Brisdelle (paroxetine) 7.5mg HS; SNRI-(des)venlafaxine -initiate at lowest effective dose, increase after 2-3w if needed -do not d/c abruptly; may cause sexual dysfx gabapentin, pregabalin-may cause drowsiness, dizziness, impaired balance, memory and concentration (pregabalin) clonidine-do not d/c abruptly; may cause lightheadedness, hypoTN, HA

*DM agents that cause weight gain

SU, insulin (notorious), TZD (decreases insulin resistance so may decrease belly fat, but has dose-related edema)

*DM monitoring

Self-monitoring of blood glucose (SMBG)—measures plasma glucose with finger stick blood sample; frequency depends upon treatment Intensive insulin regimens (multiple-dose insulin or insulin pump) -At least prior to meals/snacks, occasionally postprandially (PP), at bedtime, prior to exercise, when low BG is suspected, after treating low BG, prior to critical tasks (driving) A1C lowering efficacy ? -SMBG may help guide treatment decisions/self-management for patients taking less frequent insulin or noninsulin therapies Testing sites—fingertip most accurate

Marasmus/Kwashiorkor

Severe protein-calorie malnutrition Skeletal muscle + albumin + SQ fat wasting Ex. chronically ill pts

*acitretin in psoriasis

Soriatane,retnioid for severe plaque psoriasis in adults with UV therapy dose decrease of 30-50% CI: pregnancy, liver or kidney dysfx, abnormal lipid values DI: alcohol (teratogenic metabolite), methotrexate, tetracycline (intracranial HTN), vit A derivatives, contraceptives (reduces effectiveness) no breastfeeding up to 30d after d/c

AKI in PN

Standard EN: 25-30 kcal/kg/day and 1.2-2g/kg/day of protein (2.5 HD or CRRT) Consider specialty formulas low in phosphate, K, and Na Might need to concentrate formula in those with dialysis Consider amount of UO

*Diabetes screening adults

Start at age 45 Also those with BMI 25+ (23+ in Asian Americans) with one additional risk factor Risk factors include: first degree relative with DM, ethnicity, CVD history, HTN, HDL 35+, TG 250+, PCOS, physical inactivity, clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans) Test at least every 3 years in non-diagnosed individuals and those who have previously had GDM. Test annually in those with prediabetes.

ustekinumab

Stelara for mod-severe active CD in adults who have failed treatment with immunomodulators or corticosteroids, but never failed with anti-TNF, or who failed tx with one or more anti-TNF agent SE: increased risk of infection and reactivation of latent infections (TB or Hep B) and malignancy, vomiting, HA, and injection site reaction CI: active or latent TB (pre-treat) single, weight based infusion (institutional) followed by 90mg SQ at home q8w refrigerate; do not freeze; protect from light; do not shake

Ustekinumab for psoriasis

Stelara-against IL12 and IL23 (upstream from 17) consider d/c in any pt without response in 12w AE: infection, HA, fatigue, depression, carcinoma, etc.

CD treatment controversy

Step-up therapy vs. top-down therapy

*direct action of insulin

Stimulation of tissue glucose uptake Suppression of hepatic glucose production Suppression of FFA release (lipolysis)

*pramlintide

Symlin 60 mcg, 120 mcg prefilled pens; up to three times daily before meals, titrate—GI Indicated for patients using mealtime insulin -Reduce dose of mealtime insulin dose by 50% -Basal insulin dose may be reduced if FBG close to goal Dose—T1D -Initiate at 15 mcg SQ with meals daily, and increase by 15 mcg per dose every 3-7 days as tolerated; max of 60 mcg with meals Dose—T2D -Initiate at 60 mcg with meals, and increase to 120 mcg with meals in 3-7 days as tolerated Administration—subcutaneous injection in abdomen or thigh; variable absorption with arm injection

*T2DM treatment

Symptomatic patients may initially require treatment with combination injectable or oral therapy Treatment frequently necessitates use of multiple therapeutic agents (oral agents, non-insulin injectables, and/or insulin) Look AHEAD trial (Look Action for Health in Diabetes) -Reported no decrease in CV outcomes from intensive lifestyle change in patients with T2D after 10 years of follow-up -Intensive lifestyle was not able to obtain intensive glycemic control in majority of patients -Highlights need for early medication use in conjunction with diet and physical activity

*Iatrogenic Subclinical Hyperthyroidism

T4 overreplacement causes subclinical hyperthyroidism or overt hyper -Subclinical = normal T4 & T3, low TSH Atrial fibrillation is main risk -3x more often in older patients with TSH < 0.1 mU/L Accelerated bone loss (particularly postmenopausal women) Increased risk of arrhythmia and fractures with TSH < 0.03 mU/L

*Timing of Thyroid Dose

T4 should be administered on empty stomach with water, ideally an hour before bkfst Consider bedtime admin in patients unable to wait before eating in am Do not administer with -Bile acid resins -Calcium carbonate -Ferrous sulfate -PPI

APA-dependent aldosteronism

TOC: laparoscopic resection of the adenoma 100% have BP improvements and 30-70% are permanently cured APA are small and can occur in multiples, resection should target the entire gland

*Replacement Therapy for Hypothyroidism

TOC: levothyroxine-prohormone with little intrinsic activity, app 80% T4 absorbed T4 t1/2 7d-QD tx results in near constant serum T4 and T3 conc when SS reached synthetic TH: L-thyroxine, liothyronine, liotrix; natural: dessicated thyroid BBW against use for weight reduction

*HTR diagnostic testing

TRAb-thyrotropin receptor antibodies-positive confirms Graves, but it may not be positive in mild graves Determination of radioactive iodine uptake-distinguish toxic multinodular goiter and toxic adenoma from Graves' (diffuse increased uptake) US to measure thyroidal blood flow

*Tai chi and OA

Tai Chi is a traditional style of martial arts that features slow, rhythmic movements to induce mental relaxation and enhance balance, strength, flexibility, and self-efficacy Improves physical strength and mobility and promotes a sense of well-being Studies have shown that patients with OA of the knee who participate in Tai Chi twice weekly had less pain and better physical function than participants in other exercise programs Tai Chi improves muscle strength and coordination leading to improved joint stability Tai Chi promotes mental-calmness which may interfere with pain perception

MTX and SLE

Trexall® or Rheumatrex® Indication: Management of severe SLE alone or in combination with other agents Onset: 1-2 months SE: Diarrhea, hepatotoxicity, AKI, pneumonitis (presents as dry, persistent cough), severe dermatologic reactions, mucositis CI: Pregnancy, liver disease, immunodeficiency, blood dyscrasias Counseling: Supplement with folic acid 1mg daily Monitoring: CBC, LFTs, SCr at baseline and monthly for the first 6 months of therapy then every 1 to 2 months thereafter; Baseline chest x-ray is recommended.

diagnosis H. pylori

UBT (urea breath test)-most accurate noninvasive test for confirming eradication-most accurate 4w after completion of tx -bismuth, H2RAs, and PPIs may lead to false - test Ab detection test-not effective for confirming eradication FAT (fecal antigen test)-cheaper and easier than UBT

Endoscopic and Radiographic Abnormalities in Cirrhosis

US-small nodular liver with increased echogenicity or ascites CT and MRI-liver nodularity, atrophic and hypertrophic changes, ascites, varices, portal vein patency (CT) EGD-varices all of these are not enough for dx-need liver biopsy

*phototherapy for psoriasis

UVA & UVB rays increased efficacy when used in combo with other treatments PUVA - psoralen (UV sensitizer) & ultraviolet light A treatment -Increases risk of skin cancer with long term use -Highly effective for psoriasis

feboxustat and gout

Uloric, superior to allopurinol but more recurrent flares (esp high dose) 40mg daily, may change to 80 mg after 2w, 120mg in refractory gout caution in renal impairment SE: diarrhea, abdominal pain, musculoskeletal pain, LFT abnormalities, and N/V monitoring: LFTs 2 and 4mo after initiation; sx of CVS, MI, and stroke

*RA etiology

Unknown, likely multifactorial Genetic susceptibility -Over 21 genes potentially involved Environment -Smoking, infection, trauma -Parental history of substance abuse Hormones Diet

ED pathophysiology

Vascular- Atherosclerosis, Penile Raynaud's phenomenon Neurologic- CVA, Spinal cord damage, Autonomic neuropathy ( diabetes), Peripheral neuropathy Endocrine- DM, Hypogonadism, prolactinomas, hyper or hypothyroidism Iatrogenic- Pelvic radiation (can destroy nerves), surgery of spine, pelvic area, prostate, etc Medical conditions-most common DM and HTN

tofacitinib

Xeljanz for mod-severe active UC, 1st and only oral biologic for severe UC SE: HA, diarrhea, elevated cholesterol, nasopharyngitis, herpes zoster, increased CPK, rash and URI, bone marrow suppression, hepatotoxicity, GI perforation, severe hepatic impairment, serious infections monitor: LFTs if liver disease suspected, CHC at baseline and 4-8w then q3mo, lipids 4-8w later, s/s of TB even if initial test is negative do not crush or chew; do not start durring serious active infection or severe hepatic impairment; not recommended in pregnancy or lactation; stop for 4w before trying to become pregnant; do not take immunomodulators or other biological agents counsel DM pts about increased infection risk; inert tablet shell left in stool BBW: increased risk of TB, invasive fungal infections, and others; increased risk of lymphoma and other malignancies including EBV associated with PTLD for kidney dose adjust in mod-severe renal impairment or moderate hepatic impairment d/c if Hgb <8 or ANC <500

tofacitinab

Xeljanz, JAKi, small molecule for mod-severe active RA as monotherapy or combo with other DMARDs, but NOT AZA or cyclosporine or biologics inhibits JAK enzyme which leads to activation of transcription and regulation of gene expression and intracellular activity SE: HA, diarrhea, nasopharyngitis, URI, bone marrow suppression, hepatotoxicity, GI perforation, VTE, stroke monitoring: CBC at baseline and at 4-8w and q3mo after; lipids at 4-8w not recommended in pregnancy or lactation, stop 4w before conception BBW: serious infections (caution in DM), lymphoma and malignancy risk, risk of EBV-associated PTLD after kidney transplant renal and hepatic dose adjustment hold or d/c if Hgb<8 or ANC<500

*Fixed Ratio combinations

Xultophy -Degludec (Tresiba m) & liraglutide -Each dose step equals 1 unit degludec & 0.036 mg liraglutide -Max dose: 50 units degludec and 1.8 mg liraglutide Soliqua -Glargine (Lantus) & lixisenatide -Each dose step equals 2 units glargine and 1 mcg lixisenatide -Max 60 units (insulin glargine 60 units/lixisenatide 20 mcg)/day

ZES

Zollinger-Ellison Syndrome-tumors in pancreas and duodenum

*allopurinol and gout

Zyloprim, take with food, increase water intake 50-100mg daily and titrate over 2-5w to reach <5-6mg/dL, max 800 -max 200 if CrCl <60, max 100 if <30 SE: GI upset (diarrhea, nausea), rash (severe-d/c immediately) DDI: skin rash with amoxicillin or ampicillin; enhanced bone marrow suppression with cyclophosphamide and other cytotoxic drugs; AKI with didanosine; reduce AZA by 25% when given together

*OTC pain tx in pregnant women

acetaminophen Occasional use of NSAIDs in 1st and 2nd trimester generally considered safe but should generally be secondary to physician recommendation. NOT ON EXAM

*acute osteomyelitis

absence of necrotic bone; usually monomicrobial (stepping on a nail all the way to the bone); generally presents with systemic sx within 2wk of infection

IBD and intestinal microbiome

abx disrupt microbiome leading to increased intestinal inflammation abx may induce SE that mimic symptomology of IBD pts with IBD may have an increased risk of C. difficile infection risks of abx do not outweigh benefits (when truly indicated)

*osteomyelitis treatment

abx for 4-6w. Surgery may be required if abx fail or the pt has chronic osteomyelitis with necrotic bone and soft tissue. May treat with abx for 6mo or even lifetime if there is a chronic infection and surgery is CI.

*AGI agents

acarbose (Precose)-25mg with first bite of meal once daily for a week, then twice daily for a week, then three times daily. 100mg max for those >60kg. 50mg max or those <60kg miglitol (Glyset)-25-100mg TID, renal elimination

NSAID least likely to cause GI bleed

acetaminophen-does NOT cause GI bleeds

rosacea

acneiform disorder occuring in midlife, symmetrical rash on central part of face fair skinned who blush have tendency to get rosacea more common in women, more severe in men triggers: anything hot, emotional or irritating to the skin types: erythematotelangiectatic, papulopustular, phymatous, ocular

immunosuppressive agents in transplantation

act on resting T lymphocyte: monoclonal and and polyclonal depleting antibodies, co-stimulatory signal inhibitor early activation: steroids, calcineurin inhibitors late activation: IL2R antagonist proliferation: proliferative signal inhibitors active cells: antimetabolite agents

psoriasis patho

activated Tcells in skin, secrete cytokines, cytokines will influence keratinocytes and other cells to produce changes characteristic of psoriasis TH1 profile-INFgamma, TNFalpha, IL2 once stimulated by cytokines, epidermal cells will proliferate sevenfold faster than normal cells

RAAS system

activated by drop in blood pressure to release renin which converts angiotensinogen to angiotensin I. ACE converts AgI to AgII. Then AgII leads to an increase in aldosterone

Combined Oral Contraceptives

active pills may be consistent (monophasic) or vary (multiphasic) Always ONE estrogen and ONE progestin

alternative therapy for psoriasis

acupuncture and fish oil supplements-no clinical evidence

AACG

acute angle-closure glaucoma rapid increase in IOP (40-70), sudden onset of eye pain (usually one), HA, blurry vision, halos around lights, N/V, red/infected conjunctiva, mid-dilated pupil that reacts poorly to light, corneal edema may be triggered by sudden pupillary dilation from darkness, sympathetic arousal, or medications

Diarrhea: Evaluation & Treatment: A Stepwise Approach

acute community acquired diarrhea does not require pharmacological tx in pts with non-severe diarrhea without signs of toxicity -maintain appropriate hydration or rehydrate if necessary -symptomatic therapy may decrease sx or shorten length of disease: antimotility drugs like loperamide and antisecretory drugs like bismuth subsalicylate -if severe, bloody, or signs of toxicity or sepsis stool diagnosis is required --provide supportive care if needed and give abx if appropriate TD (form of acute): antimotility or antisecretary drugs +/- short course of abx persistent diarrhea:antimotility or antisecretory drugs based on lab findings -likely protozoan if recent travel, but could be post-antibiotic diarrhea due to upset of normal flora or C. diff chronic diarrhea: antimotility or antisecretory drugs based on lab findings -could be protozoan, post-abx, or C. diff but most likely post-TD IBS

*clinical features AP

acute onset of persistent, severe epigastric abdominal pain (maybe RUQ and rarely confined to left side) Gallstone pancreatitis: -Pain is well localized and onset of pain is rapid -changing positions does not relieve the pain -pain reaching maximum intensity in 10-20 minutes Alcoholic pancreatitis -Pain is less abrupt and pain may be poorly localized (50% radiate to back) -changing positions does relieve some pain -Pain can persist for several hours to days ~90% of patients will have N/V lasting several hours severe: may have dyspnea due to diaphragmatic inflammation 5-10% of patients with acute severe pancreatitis may have painless disease or unexplained hypotension

*AP

acute pancreatitis, highest rate in middle aged, men w/ heavy alcohol consumption (>50g/d for 5+y), and gallbladder disease (e.g. obesity -->gallstones) incidence likely increasing due to diet, but mortality is decreasing especially in those with severe often necrotizing pancreatitis mortality usually due to SIRS and organ failure in first 2 weeks, after 2 weeks it is likely due to sepsis and its complications acute onset of persistent, often severe epigastric pain and elevated pancreatic enzymes in the blood usually mild, and self-limiting to 3-5d without complication, but 20% has a severe course and 30% of these die rarely progresses to CP

pharmacological tx gout

acute: NSAIDs, CS, colchicine for 10-14d, initiated within 24h if possible -CS have less SHORT-TERM SE than NSAIDs prophylaxis (prevent flare during initiation of ULT): colchicine, NSAIDs for 6+mo ULT (prevent progression of gout and long-term complications): probenecid, losartan and fenofibrate (off label), allopurinol, febuxistat, pegloticase -does not reduce risk of flare during the first 6mo, use prophylaxis!

*adjusting insulin

address unexplained hypoglycemia starting with FPG, then PPG look for patterns (generally 3 out of range in a row) if prelunch out-of-range, fix prebreakfast insulin if predinner out-of-range, fix prelunch insulin or morning NPH if bedtime out-of-range, fix predinner insulin *if early morning out-of-range, fix LAI or evening NPH*

Mitotane

adenolytic agent used in adrenocortical carcinoma and Cushing's cytotoxic drug resembles DDT inhibits 11-hydroxylation of 11-deoxycortisol and 11-deoxycorticosterone in the cortex to cause adrenal cortical atrophy 1-4g/day; max 12g/day; TAKE WITH FOOD; weeks to months for full effect even with antiemetics on board this drug can be rough on the stomach AE: GI upset, diarrhea, lethargy, somnolence, CNS disturbances suppression can be severe and cortisol suppression can continue for long periods of time after dc so exogenous steroids may be necessary monitoring: UFC (urine free cortisol), serum K

viral conjunctivitis

adenovirus most common cause, but may also be a more severe viral infection like herpes zoster, herpes simplex, HIV tx: no topical, just let the infection run its course (several days to several weeks)

*benzodiazepines and N/V

adjunct to CINV tx, beneficial for anticipatory CINV SE: sedation, respiratory depression, depression CI: pregnancy, severe respitatory insufficiency, sleep apnea caution with other drugs that cause respiratory and CNS depression

*Chronic Constipation: Nonpharmacological Treatment

adjust bowel habits-reserve adequate and regular time for BM -do not ignore the urge to defecate EVER!!! -consider more physiologically effective position correct underlying causes, d/c or decrease causative medications if possible surgery indicated in chronic malignancy or GI obstruction

*nonpharmacologic treatment of dysmenorrhea

aerobic exercise increases blood flow; endorphin release heat therapy better than APAP or ibuprofen alone -caution continuous heat therapy in diabetics -if sleeping use a hot water bottle which will cool off slowly and not burn patient tobacco cessation omega-3 polyunsaturated fatty acids-may decrease intensity and duration high frequency TENS-stimulates endogenous pain relief mechanisms -need to try for days, maybe weeks to find individual "sweet spot"

POAG risk factors

age, African descent, nearsightedness, family hx, elevated IOP hx of eye surgeries and DM may also be contributory

ED risk factors

age, CVD, obesity, metabolic syndrome, DM, hormonal control, smoking, alcohol meds (25%)-antipsychotics, antidepressants, antihistamines, antiHTN, 5alphaRI

*AP management

aggressive hydration, analgesia, antibiotics, nutrition

*macrovascular complication prevention

aggressive mgmt. of traditional CV risk factors

gout medicine that reduces risk of kidney stones

allopurinol

AHS

allopurinol hypersensitivity syndrome life threatening , immunologic reaction. It is dose related and occurs most commonly in the presence of renal insufficiency and/or individuals with the HLA-B*5801 allele Presentation: Fever, worsening renal function, eosinophilia, leukocytosis, hepatotoxicity, severe rash (Steven Johnson's Syndrome (SJS), toxic epidermal necrolysis (TEN), erythema multiforme, or exfoliative dermatitis ) Risk factors: -Female gender -Renal impairment -Diuretic use -High dose allopurinol or fast titration -Asian decent Pharmacogenetics: Consider screening for HLA-B*5801 allele in high risk individuals including Koreans and patients with Chinese or Thai ancestry with CrCl < 60 mL/min; New evidence suggests African Americans may benefit from screening for HLA-B*5801 allele Prevention: Utilize desensitization protocols for gout patients who have had previous reactions to allopurinol (except AHS)

DI GERD

alpha and beta agonists, anticholinergics, aspirin, barbiturates, benzodiazepines, narcotics, tetracycline, zidovudine, nitrates, NSAIDs, progesterone, potassium, PG, theophylline, quinidine, CCB, dopamine, estrogen, isoproterenol, iron, bisphosphonates, TCAs

*Combination Therapy for BPH

alpha blockers and 5alphaRI useful in men with severe sx and large prostate anticholinergic agents for irritative voiding sx PDE5i-do not use with alpha blockers, <26w if using 5alphaRI

BPH tx

alpha blockers-relax prostatic smooth muscle 5alphaRI-interere with androgen stimulated growth combo product-Jalyn (dutasteride+tamsulosin) phytotherapy (herbal) not recommended by FDA

*AGI

alpha-glucosidase inhibitors MOA: inhibits small intestine enzyme α-glucosidase, responsible for breakdown of complex carbs into glucose, thus delaying & reducing PPBG levels. Note: use simple sugar or skim milk to treat hypoglycemia AE: GI effects like flatulence, bloating, abdominal discomfort, and diarrhea are very common; elevated serum aminotransferase levels (rare) CI: IBD, intestinal obstruction, malabsorption; SCr >2 or CrCl < 25; cirrhosis

*retching

also called dry heaving, is the act of vomiting without producing any vomit

rifamycin and diarrhea

alternative therapy for TD (travelers' diarrhea) not complicated by fever or bloody stool caused by E. coli; local with little systemic effect warning: if fever or bloody stool, rifamycin may worsen diarrhea and prolong illness; d/c if diarrhea worsens, does not improve w/in 48h, or C. difficile occurs rifaximin (Xifaxan) 200mg TID x 3d for TD, preferred prophylaxis if needed -SE: HA, nausea (rare); also for IBS-D rifamycin DR (Aemcolo) 388mg (2 tabs) BID x 3d; SE: HA, constipation -take with a glass of liquid-NOT alcohol; swallow whole

Factors That Influence Calcium & Phosphorus Compatibility in PN Formulation

amino acid concentration and composition, pH, calcium salt form, dextrose concentration, temperature, order of mixing

*aromatase inhibitors and endometriosis

anastrozole, letrozole-inhibition of aromatase blocks the conversion of androstenedione to estrone and testosterone to estradiol. Decrease secretion and production of estrogen by endometrial tissue, but do not reduce ovarian estrogen. Use in combo with CHC, progestin, or GnRH agonist SE: mild HA, N/D, less frequent menopausal SE compared to GnRH agonist estrogen add-back therapy is appropriate reserve for severe endometriosis who have failed other therapies

Sodium Sulfacetamide 10% / Sulfur 5% for rosacea

antibacterial and antiinflammatory effects not much evidence for efficacy over metronidazole and azelaic acid CI: sulfa allergy, kidney disease AE: contact dermatitis, irritation, itching sometimes used in combo with metronidazole

conjunctivitis treatment

antibiotic eye drop if bacteria suspected NSAID for mild inflammation; steroid eye drops for severe inflammation artificial tears to help with "gritty" feeling and alleviate dryness

*drug-induced PCAG

anticholinergic or sympathomimetic properties sulfonamides can cause lens swelling

Drugs That Decrease Milk Supply

anticholinergics, smoking, diuretics, dopamine agonists, estrogens, sympathomimetic vasoconstrictors

Stages of CD4 T cell activation and cytokine production

antigen-MCH II complexes are responsible for initating the activation of CD4 T cells. TCR (T cell receptor) complex recognized MHC complex and co-stimulatory signal initiates signal transduction and activation of second messengers like calcineurin. Calcineurin removes phosphates from NFAT (nuclear factor of activated T cells) which allows NFAT to enter the nucleus. NFAT binds to IL2 promoter gene and causes IL2 production. IL2 induces CD4 cell proliferation and cytokine production

SLE tx with no major organ involvement

antimalarials, low-dose steroids, AZA, MTX

IBS-D: Pharmacological Treatment

antimotility, antispasmodic/anticholinergic, 5HT3 antagonist, opioid agonist, abx, antidepressants

ANA

antinuclear antibody Autoantibodies to nuclear self antigen or ANA is a hallmark of SLE diagnosis Highly sensitive test Test is positive in 94% of patients with SLE May be negative in early onset SLE May be positive in patients without SLE

ATG

antithymocyte globulin "equine", Atgam, 0.1mL of 1:1000 dilution for skin test duration 2 weeks-binds directly to CD4 Rs to deplete cells-cytotoxic

PMS and placebos

any amount of improvement in PMS symptoms should be considered a success sometimes the amount of control the pt feels helps in the management of their symptoms

disease states and OP

any disease state that contributes to bone loss or a lack of absorption of vitamin D and calcium e.g. IBD, ESRD, hyperthyroidism

malignancy and transplants

appear an average of 5y after transplantation and increase with length and level of immunosuppression risk of de novo malignancy (not genetics) increased 3-5x uncommon in general population but occur much higher in transplant recipients: -PTLD, Kaposi sarcoma, renal carcinoma, in situ carcinomas of the uterine cervix, hepatobiliary tumors, anogenital carcinoma

topical diclofenac

apply to joint and massage gently; do not wash off for one hour wash hands immediately afterward and avoid eyes do not cover with occlusive dressing or moisturizers protect from light with clothing, not sunscreen remind patients to keep the application card to more accurately measure doses pts may need 3-5 100mg tubes each month

classic clinical presentation SLE

arthritis, butterfly rash (malar rash, "wolf bite"), fatigue, depression, anxiety, arthralgia, malaise, fever, anorexia, infection, muscle weakness, Raynaud's phenomenon, alopecia, discoid rash (mostly areas exposed to sun), symmetrical polyarthropathy without joint destruction

*DI PUD

aspirin, anticoagulants, antiplatelets, bisphosphonates, chemo. corticosteroids, iron supplements, *NSAIDs*, potassium, SNRI, SSRI

*evaluation and response to therapy in OP

assess fall risk at every visit, annual height measurement, biennial BMD evaluation, vertebral imaging when indicated, evaluate adherence in tx failure

*SLE screening recommendations

assess for HTN, HLD, depression, anxiety, and bone loss vit D deficiency common in SLE-worsening fatigue and increased OP risk

AP Initial Assessment & Risk Stratification

assess hemodynamic status at presentation assess for organ failure with Modified Marshal Score identify clinical findings associated with severe course: 55+yo, AME, BMI >30, comorbid diseases, SIRS lab findings-BUN >20 (or lower but rising), HCT >44% (rising), elevated SCr radiology findings: pleural effusions, pulmonary infiltrates, multiple or extensive pancreatic collections

*HRT recommendations in menopause tx

assess pts for risk/benefit, use lowest effective dose for shortest period of time localized HRT for vulvovaginal sx without vasomotor sx *reserve systemic HRT for moderate to severe vasomotor sx* *consider transdermal estrogen to minimize estrogen exposure*

atopic triad

asthma, atopic dermatitis, allergic rhinitis

T2DM and obesity

at initiation of insulin (basal firstline) add at least one of the following: metformin, pramlintide (bolus only), GLP1RA, and consider SGLT2 HTN: ACEI, ARBs, CCBs rather than BB OC preferred over injectables NSAIDs and DMARDs instead of corticosteroids less sedating antihistamines gabapentin contributes to weight gain

*drugs that impact glycemic control

atypical antipsychotics, corticosteroids, ARV, sympathomimetics, estrogen/OC, niacin, diuretics

*euglycemic DKA

atypical: normal or slightly elevated BG -SGLT2i on board=glucosuria elevated ketones, high anion gap metabolic acidosis potential triggers: lowered insulin dose, acute illness, infection, surgery, reduced calorie/fluid intake

high potency topical corticosteroids

augmented betamethasone 0.05%, clobetasol 0.05%, fluocinonide 0.05-0.1%, halobetasol 0.05%, amcinonide 0.1%, betamethasone 0.05-0.1%, desoximetasone 0.05-0.25%, diflorasone 0.05%, halcinonide 0.1%, triamcinolone 0.05%

*hallmark of T1DM

autoimmune

*additional comorbidities in DM

autoimmune (T1DM), cancer, cognitive impairment/dementia, fatty liver disease, pancreatitis, fractures, hearing impairment, HIV, low testosterone (men), OSA, periodontal disease, psychosocial/emotional disorders

dietary management of diarrhea

avoid caffeine and juice high in unabsorbable sugars mod-severe: d/c solid foods and dairy for 24h or administer a low-residue diet -low residue prolong transit time, ideally reducing the number and volume of stools e.g. BRAT (banana, rice, applesauce, toast) -diarrhea should resolve if it is osmotic in nature if vomiting is not controlled by antiemetics: NPO (liquids and saltines) for 24h

General Considerations for medicine in pregnant women

avoid unnecessary medication use consider ability of infant to metabolize and eliminate drug monitor infant SE that are most likely to occue breastfeeding d/c is rarely necessary but temporary d/c may be possible for short-term use of medications (pump and dump)

CP nonpharmacological treatment

avoidance of alcohol, smoking cessation, and dietary invention -low fat diet (50-75g/d) with smaller, more frequent meals surgical procedures for refractory pain, symptomatic pseudocysts and asymptomatic >5cm, pancreatic ulcers, cholethiasis, obstruction, and pancreatic cancer

AZA and SLE

azathioprine, Imuran, steroid sparing agent useful in maintenance after successful induction, onset 1-2mo SE: generally less severe than other immunosuppressants, myelosuppression, hepatotoxicity; CI: pregnancy; monitor: CBCs, LFTs

*HGP

hepatic glucose production

most common reason for combined oral contraception discontinuation

intermenstrual bleeding

baseline testing and recommendations for RA

baseline for DMARDs and biologics: CBC, CrCl/eGFR, aminotransferase, albumin, TB skin test, hep B and C screening, CXR rituximab: IgA, IgG, and IgM before each cycle tocilzumab: lipid profile q3mo, neutrophils and AST/ALT before each dose biologics not to be used in pts with serious infection or cancer with the exception of basal cell carcinoma

*RAI timing preference

before the meal is preferred but within a few minutes of starting the meal is okay. With children may need to give at the end of the meal because it is hard to determine how many carbs a child will consume if they do not finish their meal, etc.

*pharmacological tx OIC

begin prophylaxis with start of the opioid osmotic laxative (Miralax) recommended first-titrate to soft stool, not runny stimulant laxatives recommended after patient fails osmotic (benefit vs risk) stool softeners and lubricants make BM less painful, but do not move bowels -add to stimulant laxative to make BM more comfortable use enema or suppository if impaction occurs try stimulant and osmotic combo before adding prescription consider PAMORA or intestinal secretagogue (chloride channel activator) next -AGA recommends naldemedine, naloxegol, or methylnatrexone in refractory but makes no recommendations for lubiprostone, prucalopride, or GC-C agonists

*radioactive iodine summary

best tx for toxic nodules and toxic multinodular goiter advantages: cure, lowest cost before adjustment for quality of life disadvantages: permanent, hypothyroidism almost inevitable, might worsen ophthalmology, pregnancy must be deferred 6-12mo with no breastfeeding, small potential risk of exacerbation of HTR

ophthalmic BB

betaxolol (Betoptic-S)-selective, suspension-less systemic AE but slightly less effective than timolol in IOP reduction carteolol (Ocupress) partial beta agonist activity with no clinical difference in cardiovascular and pulmonary function effects levnobunolol (Betagan), metipranolol (OptiPranolol)-limited use as it causes more ocular burning and stinging; granulomatous anterior uveitis timolol (Timoptic)-most common, XR-once daily dosing of ion-activated gelatin prolongs precorneal residence time and increases ocular bioavailability

*metformin

biguanide, Fortamet, Glucophage (XR), Glumetza, Riomet primarily inhibits HGP; also acts as an insulin sensitizer in hepatic and peripheral (muscle) insulin resistance; may also decrease intestinal absorption of glucose AMPK activation and partial inhibition of mitochondrial respiratory chain t1/2 17h (effects last >24h), OOA-days, max effect 2 weeks optimal firstline agent; primarily reduces fasting glucose

mifeprestone blocks

binding of cortisol and progesterone

proliferative signal inhibitors

binds FKBP12 to form a complex that inhibits mTOR, a kinase critical in IL2 mediated cell-cycle progression maintenance immunosuppression 3mo after transplant that can be used synergistically with CNIs to maximize CNI dose and reduce toxicity do not use in liver or lung transplants and avoid live vaccines e.g. sirolimus (Rapamune), everolimus (Zortress Afinitor) AE: leukopenia, thrombocytopenia, HLD, delayed wound healing monitoring: sirolimus trough 10-20ng/mL, BMP, CBC, lipid, BP, CXR

*TNF-α Inhibitors and Psoriasis

binds TNF cytokines that regulate immune responses to infection & inflammation CI: live vaccine (2w before or 3mo after therapy) and active infection; CHF caution: renal, asthma, hx of blood dyscrasias, CNS demyelinating disease and history of chronic recurrent infections AE: may develop or worsen autoimmune (MS, drug-induced lupus), vasculitis etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), certolizuman (Cimzia)

IBD complications

both: strictures, growth failure in children, malnutrition and/or deficiencies (B12, iron, K, Zn), hypoalbuminemia mainly CD: fistula, OP mainly UC: obstruction, hemorrhage, perforation, toxic megacolon, hemorrhoids, anal fissures, and/or perirectal abscesses toxic megacolon-segmental or total colonic distension of greater than 6cm with acute colitis and signs of systemic toxicity stricture-abnormal passage between organs or to the outside of the body pseudopolyp-projecting mass of granulation tissue that may develop in UC and become covered in regenerating epithelium

N/V dietary recommendation

breastfeeding infants should continue to nurse children and adults who are not dehydrated can eat a regular diet as tolerated but will likely have a decreased appetite and should avoid sugary juices gastroparesis-eat small frequent meals very low in fat and insoluble fiber

*melasma

brown or gray-brown patches on the face or other areas that are exposed to a lot of sun

NSAID most likely to cause cardiovascular problems

celecoxib

NSAID least likely to cause bleeding

celecoxib followed by diclofenac

*metabolic syndrome

central obesity plus 2 of the following: abnormal glucose, abnormal lipid, or abnormal BP

screenings and IBD

cervical cancer-women on immunosuppressants need annual pap smears OP-BMD testing at dx and periodically for pts with conventional risk factors depression and anxiety-screen all pts skin cancer- screening for melanoma independent of the use of biologic therapy colon cancer-after 8-10 years of UC begin, annual or biannual colonoscopy with multiple biopsies at regular intervals. HGD (High grade dysplasia) is indication for colectomy

Conditional Recommendations for IBS

caffeine <400mg/d and limit spicy foods (in pts with sensitivity only) rule out fructans in onion and garlic as culprits in food sensitivities limit fat intake to 40-50g/d gradually increase soluble fiber to 20-30g/day (not insoluble) -pts with IBS-C should consider adding up to 2 tbsp flaxseeds (linseeds) to daily diet for a 3-6mo trial avoid carbonation and increase water uptake to 12 cups daily if lactose intolerant, avoid lactose or take lactase supplements

CNI

calcineurin inhibitors for post-transplant prevention of acute or delayed rejection inhibit dephosphorylation of NFAT which decreases synthesis of IL2 and mediates monoclonal T cell proliferation and activation unique mechanism: cyclosporine forms a complex with cyclophilin and tacrolimus forms a complex with FKBP lipophilic, highly protein bound, do NOT use as monotherapy

topical vit D analogs for psoriasis

calcipotriene, calcitriol-active form of vit D, taclonex-do not apply to >30% BSA SE: lesion irritation, sun sensitivity, high dose may suppress HPA axis and thin skin

prevention of OP

calcium and vitamin D supplement recommendations go up at the age of 50 moderate activity 30+ min on most days of the week weight bearing (running, jogging, lifting weights) at least 3x/w -improves agility, strength, posture, and balance

Cannabinoid Hyperemesis Syndrome

cannabinoids can both tx N/V and make it worse CHS (cannabinoid hyperemesis syndrome) caused by long term use recurrent nausea, severe vomiting, abdominal pain, bathing or showering relieves symptoms; cyclic pattern q4-8w; pathogenesis unknown

teratogenicity

capability of causing developmental toxicity e.g. structural anomalies (birth defects), growth restriction, functional-neurobehavioral deficits, death organogenesis-greatest vulnerability *NTDs before 44d; cleft lip before 50d, cleft palate before 12w CNS and urogenital system sensitive to late injury* Most birth defects are NOT caused by drugs; baseline risk 5-6%; caused by genetics, chromosomal abnormalities, multifactorial inheritance, or environment defects confined to a group of malformations that are specific to that teratogen not confined to first trimester, developmental toxicities throughout pregnancy

bacterial conjunctivitis

cause: S. aureus, Strep pneumo, H. influenzae, Moraxella catarrhalis N. gonorrheae-tx with ceftriaxone, cipro or ofloxacin if allergic to cephalosporins Chlamydia-tx azithromycin or doxycycline for adults, erythromycin for neonates topical abx eye drops or ointments-azithromycin (Azasite-store in fridge, 14d at RT), cipro (Ciloxan), ofloxacin (Occuflox), trimethoprim/polymyxin B (Polytrim)

constipation tx in pregnant women

caused by delayed gastric emptying and prolonged intestinal transit time, exacerbated by iron increase water and dietary fiber intake, exercise firstline: bulk-formers (psyllium, methylcellulose, Ca polycarbophil), docusate secondline: laxatives (polyethylene glycol, bisacodyl)

*topical corticosteroids for atopic dermatitis

children BID x 7d; adults BID x 14d can be used with PO antihistamines-common self care combo Chronic use of high potency (fluorinated) steroids on face can cause thinning & acne-like complications Epidermal atrophy presents with ecchymoses, striae, shiny, thin skin and/or telangiectases with prolonged use

hep C and RA

chronic HCV on effective antiviral therapy can be treated as usual untreated HCV must have antiviral therapy before initiating immunosuppressants -if antiviral therapy is inappropriate, treat RA with DMARDs rather than anti-TNF

*IBS

chronic disorder of the fxn of the GIT characterized by abdominal pain that is accompanied by change in the bowel habits (diarrhea or constipation), that occur together, but with one symptom predominating sx: gas, bloating, heartburn, fatigue, depression, insomnia, and/or poor QoL IBS does NOT cause damage to the GIT or increase risk of malignancy

CP

chronic pancreatitis-prevalence varies widely with geographic, etiologic, environmental, and genetic factors highest incidence in middle aged, men with 10+y history of alcohol (most common) or heavy alcohol consumption (>50g/d for 5+y) characterized by progressive inflammation and long-standing pancreatic injury leading to the replacement of parenchyma with fibrotic connective tissue periods of intractable upper abdominal pain (min sx)-early CP may resemble AP pathophysiology not well understood

*PUD

chronic peptic ulcer disease is an upper GI disorder characterized by periods of epigastiric pain/discomfort followed by periods of remission defects in the gastric mucosa (gastric ulcers-rend to be aggravated on empty stomach and relieved by eating

Marasmus

chronic prolonged undernutrition, skeletal muscle and subcutaneous fat wasting, weight loss >10% e.g. cancer pts, anorexia, major depression, malabsorption common <1mo, alert and irritable, severe muscle wasting, voracious feeder, needs adequate macronutrients

general hygiene for acne

clean face 2-3x/d with mild cleanser or soap (not for removal of surface oil) light exfoliation can be beneficial to some scrubbing or popping lesions can cause more inflammation use only water-based makeup and be careful with hair products UV light is controversial

probiotics in IBS

clinical evidence for benefit in IBS-reduce global sx, flatulence, bloating, abdominal pain-optimal microbe, duration, and dose are unknown IBS pts should be advised to select one product at a time for a minimum of 4 weeks and document symptoms some probiotics appear to have anti-inflammatory properties or appear to modulate visceral hypersensitivity via unknown mechanisms little research on PREbiotics and SYNbiotics for IBS prebiotics: food sources for probiotics or gut flora e.g. inulin which are present in FODMAPS (some concern that low FODMAP diets may negatively alter flora) -prebiotics showed no benefit for CIC synbiotics: prebiotics + probiotics with potentially synergistic action -synbiotics show benefit in CIC but not IBS sx as of yet.

pituitary gland and hypothalamus

closely connected-communication between brain and body's endocrine organs hypothalamus sends nerve and metabolic signals to control pituitary secretion neurons in the hypothalamus produce vasopressin and oxytocin median eminence is found at the bottom of the hypothalamus-rich in nerve axons and blood vessels that provide physical and chemical connections

CAM for IBS

cognitive & behavioral therapy, hypnotherapy (documented long term response and reduced healthcare use), acupuncture (sx relief in some, similar QoL)

*development of varices

collateral vessels develop in esophagus, stomach, and rectum in response to increased resistance (HVPG of 8-10) to divert blood back to systemic circulation weak superficial vessels prone to rupture and bleed (HVPG >12) screening EGD (esophagogastroduodenoscopy) for dx recommended when cirrhosis or portal HTN is discovered NSBB (propranolol and nadalol preferred)-beta2 receptors in liver-vasodilation! increased risk of bleeding in decompensated cirrhosis (Class B and C) large varices have a higher risk of hemorrhage

CHF (Class III or IV) and RA

combo DMARD therpy or non anti-TNF biologic or tofacitinib may consider anti-TNF in compensated CHF if all other options have failed -if anti-TNF makes CHF worse do NOT try another one

noninflammatory lesions of acne

comedo (NOT papule)

*amylin deficiency

commonly seen in T1DM amylin usually decreases glucagon, slows gastric emptying, and increases satiety

complications of SOT

comorbidities are the primary cause of mortality in pts with a functioning graft for 5 or more years after transplantation rejection, infection, HTN, DM, HLD, malignancy

*EMPA-REG OUTCOME trial

compared empagliflozin to placebo in addition to standard medical treatment for diabetes. Empagliflozin significantly lowered risk of CV mortality, CHF hospitalization, and all-cause mortality with a very modest reduction in HbA1c.

*diabetes and atherosclerosis

compensatory mechanism to overcome impaired insulin signaling via MAPK cascade may contribute to atherosclerosis

*Panhypopituitarism

complete or partial loss of anterior and posterior pituitary fx and results in at least one hormone deficiency: (ACTH, gonadotropin, GH, TH) or hyperprolactinemia etiology: primary pituitary tumors, ischemic necrosis of the pituitary, surgical trauma, irradiation, CNS infections tx: lifelong replacement of glucocorticoids, TH, sex steroids, or GH

surgery and endometriosis

conservative surgery-ablation removal of implants, adhesions followed by drug therapy-preserves fertility definitive surgery-hysterecotomy, bilateral salpingo-oophorectomy, removal of all visible endometriosis (difficult to remove it all-recurring pain not uncommon)

*high risk for infection and RA

consider using etanercept or abatacept as first line biologics

*sick day rules

continue basal insulin at normal dose* and cover hyperglycemia with RAI by dosing q4-6h to keep BG <250 8-12 oz of fluid with calories per hour, SMBG q2h If BG >250 check ketones q4h call provider if vomiting with BG >500 or mod-large urine ketones

*transplant contraindications for the recipient

continued substance abuse, poor family/social/financial support, BMI >35, malignancy, pregnancy, uncontrolled infection, confirmed medical noncompliance, uncontrolled psychiatric disorder

combined hormonal contraceptives and endometriosis

continuous COC preferred, if non-oral Nuvaring > Xulane sx improvement from atrophy of endometrial implants; inhibition of ovulation, reduce menstrual flow; decrease hormone levels

*topical steroids for psoriasis

cornerstone of tx for majority of psoriasis pts classified based on ability to produce vasoconstriction local cutaneous SE-more common on face and intertriginous areas-atrophy (long term), telangiectasia, striae distensae, acne, purpura systemic SE: Cushing's, osteonecrosis of femoral head, cataracts, glaucoma, HPA axis suppression (rare) low-potency agents are preferred for the face, axillae, and groin rarely induce a remission, may lose effectiveness over time

luteal phase

corpus luteum produces progesterone to maintain the fertilized blastocyst implanted in the uterus. Negative feedback decreases LH and FSH which prevents follicle growth, breast, increased progesterone for 14d, increased fat depot, PGs released by endometrium PG properties: platelet aggregation, vasodilation (N/V/D, HA, appetite loss), uterine contraction-endometrial sloughing

drug-induced POAG

corticosteroids (especially ophthalmic)

combo topical regimens for psoriasis

corticosteroids and salicylic acid or vit D or tazarotene tacrolimus and salicylic acid UVB light and coal tar or anthralin UVA light with oral or topical psoralen (UV sensitizer)

Cushing's pathophysiology

cortisol release should follow a circadian rhythm with levels peaking around 8am and declining 60-80% to reach nadir around 3am. Cushing's patients only 3% will have normal values late at night because the decline is not as severe if present. *midnight serum cortisol >7.5mcg/dL* is highly sensitive and midnight salivary is an effective alternative to avoid hospital admission.

topical analgesics for OA

counterirritants-depletion of substance P, onset 2-6w temporary relief of minor pain due to strain, sprain, bruising, cramps, or arthritis capsaicin (Zostric, SalonPas) from chili pepper, apply 3-4x daily -paradoxical pain-relief, pain on skin masks musculoskeletal pain -SE: burning and stinging (wear gloves) topical lidocaine OTC and and Rx patches may help, but has limited absorption to deep tissues and joints

*T1DM triggers

cow milk, virus, dietary or environmental factors

Visceral Proteins and Assessment of Lean Body Mass (LBM)

critical illness-production of inflammatory cytokines that will inhibit albumin synthesis proteins can be low for many reasons hypercatabolic because they are critically ill in sepsis, the pt could be malnourished and still have high pre-albumin because in AKI the kidney is not able to excrete efficiently prealbumin has a shorter half-life compared to albumin visceral proteins reflect the presence of inflammation more than malnutrition in many cases none are accurate nutritional markers

*CHC CI

current breast cancer, malignant liver tumor, severe cirrhosis, increase risk for stroke or cardiac event, increased risk for thromboembolism

combined regimens for menopause

cyclic progestin for 10-14d each cycle -Premphase: CEE x 14d, CEE+MPA x 14d -preferred during perimenopause for those with intact uteruses -may be preferred throughout menopause to decrease hormone exposure -generally produces a regular withdrawal bleed continuous estrogen and progestin -more common in those 2+y past menopause onset -spotting common in first 6 mo, most amenorrheic in 1y -Prempro (oral), Combipatch, Bijuva (oral-bioidenticals) CHC in perimenopausal may serve dual benefit

SLE tx with major organ involvement

cyclophosphamide IV, mycophenolate, CNIs (not standard in US yet), biologics, clinical trial

*hazardous waste

cyclophosphamide, mycophenolate, tacrolimus NOT MTX

*CsA

cyclosporine A: Sandimmune (USP, non-modified, PO-absorption issues); Neoral (micro-emulsion); Gengraf (micro-emulsion) forms a complex with cyclophin to inhibit calcineurin and decrease IL2 AE: *hyperlipidemia, nephrotoxicity, tremor, HA, HTN*, hyperBG, gingival hyperplasia, hirsutism, diarrhea, vomiting

CNI monitoring

cyclosporine trough: 150-400mcg/L; tacrolimus trough: 5-20mcg/L hepatic and renal function, BG, BP, electrolytes

DST

dexamethasone suppression test Administer 1mg at 11pm and then check fasting plasma cortisol at 8am In normal pts this dose would suppress cortisol production via negative feedback Cushing's pts don't have this negative feedback, cortisol would be normal or high Be mindful of CYP3A4 inhibitors/inducers that alter dexamethasone metabolism

PACG management

emergency, patient is placed supine, sx relief with analgesics and antiemetics 1. timolol 0.5%, wait 1 minute 2. apraclonidine 1%, wait 1 minute 3. pilocarpine 2%, wait 15 minutes 4. pilocarpine 2%, wait 1 minute 5. prednisolone 1% q15min-4 doses acetazolamide 500mg (IV preferred) if IOP remains significantly elevated (40+) 30 min later and an ophthalmologist is not immediately available to assume care, give mannitol 1-2g/kg IV

*tumor and HTR

excessive pituitary TSH

secondary aldosteronism

excessive stimulation of zona glomerulosa by extraadrenal factor, usually RAAS excessive K intake, CHF, cirrhosis, renal artery stenosis, Bartter's syndrome, OC, pregnancy, and menses can promote aldosterone secretion DOC: spironolactone

Vulvovaginal Atrophy

decrease in estrogen leads to thinning and drying of vaginal mucosa (does not diminish over time), decreased blood flow, and increased pH regular sex decreases extent of atrophic vaginal changes

*FFA effect on glucose

decreased FFA in blood increases glucose uptake by muscles, decreases HGP increased FFA in blood impairs insulin secretion and leads to resistance excess lipolysis interferes w/ insulin signaling; beta cell apoptosis via FFA products; increased HGP; proinflammatory cytokines; decreased glucose uptake

*T2DM ominous octet

decreased incretin effect increased lipolysis increased glucose reabsorption in kidney decreased glucose uptake NT dysfunction increased HGP increased glucagon secretion decreased insulin secretion

pathophysiology of PUD

decreased mucosal defense mechanisms: blood flow, bicarbonate secretion, cell restitution, and epithelial cell renewal increased aggressive factors: gastric acid, pepsin, bile salts, H. pylori, NSAIDs

*high dose IV steroids

decreases IL2 production through receptor inhibition and decreased gene expression universal agent used in almost all transplants in addition to other agents used or as a single induction methylprednisolone 500mg IVPB-reverses 75% of acute rejection episodes but DO NOT USE in pancreatic transplants

tretinoin

decreases cohesiveness of follicular epithelium and decreases microcomedone formation. Stimulates mitotic activity and increases turnover of follicular epithelial cells causing extrusion of the comedones (eliminates lesions present). AE: dryness, erythema, pruritis, photosensitivity, *initial flare-up*, edema, blistering, stinging, peeling start low and go slow, *Use sunscreen!!!*

*chronic osteomyelitis

defined as presence of necrotic bone Usually polymicrobial Patients typically have a previous history of osteomyelitis

FRAX tool

developed by WHO for 40-90yo only, country specific, computerized integrates clinical risk factors and BMD to calculate 10y probability of hip fracture or major ORF (spine, forearm, hip, shoulder)

cirrhosis complications

development of coagulopathies and synthetic failure decreased thrombopoetin and thus thrombocytopenia or macrocytic anemia from folate and vit B12 deficiency

*DKD

diabetic kidney disease Clinical dx-albuminuria (persistent elevated urinary albumin excretion) and/or reduced eGFR; 20-40% of patients; may be present at dx of T2D May progress to ESRD; markedly increases cardiovascular risk Risk factors for progression: elevated BP, glycemia, albuminuria Treat to the highest tolerated dose of ACEI/ARB as possible especially if there is albuminuria Nephropathy screening—annually—urine albumin/creatinine ratio (spot UACR) & eGFR in all patients with T2D, and patients with T1D of 5 yr duration -Increased urinary albumin excretion: micro- (> 30-299) and macroalbuminuria (> 300)

Calories Provided From CRRT Dialysate

dialysate 1.5-2.5% rich in glucose and about 1/2 of the calories get absorbed

contraception additional information

diaphragms should NOT be used as backup contraceptions be careful not to remove ring with tampons discard and replace disconnected rings refrigerate prior to dispensing-room temperature for 4 mo

*traditional DMARDs

disease-modifying antirheumatic drugs-start within 3mo of RA dx e.g. HCQ, LEF, MTX, SSZ

PPIs-fake news

do NOT increase risk of death, may or may not increase dementia, long term risk of OP but no fracrures (fractures kill you not OP) aspirin+PPI does not prevent esophageal cancer PPIs decrease acidic environment and make it harder to absorb iron and Mg PPI and kidney disease-jury still out on this one GERD medications affect absorption of chemo-just increase chemo dose PPI does increase the risk of C diff, but when IV in the hospital long-term PPI dose use linked to pneumonia in older adults within 3mo of taking it-TRUE-changes the normal flora and that bacteria can be aspirated into the lungs

pulmonary failure in PN

do not recommend high-fat/low-CHO formulations to reduce CO2 production in pts with acute respiratory failure avoid rapid infusion of IVFE (no faster than 10h) use fluid-restricted energy-dense EN formulations phosphate monitoring and appropriate replacement

rescue or salvage therapies for H. pylori

do not repeat previously used abx (even if new infection-assume resistance) failed clarithromycin-based therapy, use bismuth quadruple therapy OR levofloxacin salvage regimen failed bismuth quadruple therapy, use clarithromycin (should be avoided as salvage) or levofloxacin-containing salvage regimen

Summary of Guideline Recommendations for Obesity

do not stop tx after goal is achieved T2DM-consider GLP1RA, SGLT2i in addition to metformin CVD-avoid sympathomimetics, use lorcaserin or orlistat HTN-avoid sympathomimetics (phentermine and diethylpropion)

ovulation phase

dominant follicle releases ovum due to brief LH surge; body temp raises for 36h, cervical secretions promote spermatozoa transit

*metformin use in renal impairment

eGFR > 45 mL/minute/1.73 m2: No dosage adjustment necessary; monitor renal fxn annually. eGFR 30 to 45 mL/minute/1.73 m2: Preexisting impairment: in the absence of active kidney disease or conditions that predispose to hypoperfusion/hypoxemia (acute heart failure, dehydration) tx may be initiated at 250 mg/day with close monitoring and titration (max: 1,000 mg/day) If eGFR falls between 30 to<45 mL/minute/1.73 m2 during therapy: Consider benefits/risks of continuing therapy. If continuing tx, dosage reduction of 50% (maximum: 1,000 mg/day) and monitoring of renal function every 3 months. eGFR <30: Use CI

*microvascular complication prevention

early treatment with near-normoglycemia and *attain blood pressure goal*

*macrolides in rosacea

effective for papulopustular rosacea used in those tolerant to tetracyclines 2nd generation tend to work faster (erythromycin, azithromycin, clarithromycin)

CVD in menopause tx

effects of estrogen and progesterone on vascular tissue appear to be dependent on age, time from menopause, and preexisting CVD HRT may be cardioprotective when prescribed early in menopausal transition potential risk particularly with EPT in women >60yo and/or >10y since menopause MPA may be more likely to adversely affect CV risk HRT shouldn't be initiated or continued for primary of secondary prevention CAD

*retrograde ejaculation

ejaculatory dysfunction seen with tamsulosin in which the sperm goes backward into the bladder of the man contributes to fertility issues

*Subclinical Hypothyroidism

elevated TSH, normal FT4, 4-15%; risk factors: age, female most have chronic autoimmune (Hashimoto's) thyroiditis with high anti-TPO Ab *Treat when TSH 10mU/L or higher*

endometriosis

endometrial activity outside uterine cavity-causes pain, infertility, dyspareunia pain not limited to menses, short cycle, prolonged flow generally occurs many years post menarche implanted tissue capable of estrogen biosynthesis, abnormally increased aromatase activity, decrease in inactivation of estrogen 1. estrogen/progesterone withdrawal 2. lesion bleeding 3. inflammation in adjacent tissues 4. scar tissue and adhesion development

*ERCP

endoscopic retrograde cholangiopancreatography pts with pancreatis due to common bile duct stones should have ERCP ASAP within 24h of admission (not indicated in cholecystitis-cystic duct stone) elevated bilirubin and LFTs in pts with bile duct stones EUS (endoscopic US) for MRCP (magnetic resonance CP) indicated by cholecystectomy (gall bladder removal) AP is a common complication of ERCP-risk can be decreased with guided wire cannulation, pancreatic duct stents, and *rectal NSAIDs* (e.g. diclofenac and indomethacin placed prior to procedure

IBD imaging

endoscopy (traditional) + biopsy or chromoendoscopy (preferred if h/o dysplasia) -lower endoscopy: colonoscopy or sigmoidoscopy +/- biopsy (UC and CD) effective in diagnosis and assessing severity of inflammation -upper endoscopy or EGF (esophagogastroduodenoscopy) (CD and only if upper GI sx are present) barium enema or swallow CT (computerized tomography-3D)

Endoscopic Interventions of Acute Variceal Hemorrhage

endoscopy within 12h EVL-more effective, preferred form of endoscopic therapy sclerotherapy if EVL is technically difficult tissue adhesives like cyanoacrylate for gastric varices SBP prophylaxis-DOC is IV ceftriaxone 1g/24h for a max of 7d -also norfloxacin and ciprofloxacin

sAMe

enhances native proteoglycan synthesis and secretion in chondrocytes in the cartilage, also has antidepressant effect which may decrease pain perception SE: N/V/D, dizziness, anxiety, irritability, sweating; CI: bipolar

EN

enteral nutrition-delivery of nutrients by tube into stomach (most common) OR duodenum or jejunum NG, OG (orogastric), nasoduodenal, nasojejunal-temporary and can be done at bedside -Note that sometimes these are placed for medicine administration and are not necessarily for EN unless specifically stated. esophagogostomy/pharyngostomy, gastrostomy, jejunostomy-requires trip to the OR and a longer intended duration (4-6w) Better to start at a low rate and then up the dose -if they cannot tolerate that goal rate a doctor may order a parenteral supplement. You need to be able to calculate needs to discover if that supplement is necessary

*ED

erectile dysfx; 53% of men 53-90yo; most likely sx of condition or medication failure to achieve a penile erection adequate for satisfactory sexual intercourse psychogenic-anxiety, depression stress organic-vascular, neurologic, hormonal, medical or pharmacologic

Fat Emulsion: Essential Fatty Acids

essential-must get from exogenous sources Omega-6 fatty acid (alpha-linoleic acid) & Omega-3 fatty acid (linolenic acid) Deficiency s/sx: dermatitis, alopecia, impaired wound healing, growth failure, thrombocytopenia, anemia Occurs w/: prolonged use of lipid-free parenteral nutrition, severe fat malabsorption, very-low-fat diets/enteral feeding formulations, severe malnutrition

Imvexxy for tx vulvovaginal atrophy

estradiol, ultra low-dose vaginal insert, mod-severe dyspareunia from menopause sx improvement within 12w, insert with smaller end up, approximately 2 inches

stimulates the thickening of the endometrial lining

estrogen

Hormonal Contraception MOA

estrogen and progestin exert negative feedback on FSH and LH release work primarily to inhibit ovulation

*thromboembolism and CHC

estrogen increase coagulability in dose-dep fashion RF: underlying hypercoagulability, >35yo, obesity, personal hx, prolonged immobility d/c CHC 4+ weeks before predisposing elective surgery and 2w after risk slightly increased with transdermal patch, vaginal ring, and COC containing drospirenone and desogestrel

*Estrogen Therapy for hypothyroidism

estrogens increase serum TBG and may increase need for T4 TSH should be measured app. 12 wk after starting estrogen tx in postmenopausal women to determine if an increase in T4 is needed whether younger hypothyroid women with OC need dose adjustments is unclear

BP and CHC

estrogens may increase SBP by 8 and DBP by 6mmHg If HTN well-controlled and no other CV RFs, may consider trial of CHC if pt does not want to use alternatives avoid CHC in those with uncontrolled HTN and/or vascular disease

*EE

ethinyl estradiol 50mcg-high-rarely used unless DI require higher levels of estogen 30-35mcg-low-common particulary in women with BTB due to low estrogen 10-25mcg-very low-common, minimized estrogen exposure and estrogen SE

HTN and transplants

exacerbated or caused post-transplant by corticosteroids, cyclosporine, tacrolimus, or impaired graft function cyclosporine increases endothelin production and stimulates SNS and RAAS CCB are traditionally firstline for post-transplant HTN -DHP preferred due to less DDI, nonDHP are CYP3A4i that alter CNI levels ACEI/ARB possible-caution in kidney transplant -if SCr increases >30% 1-2 weeks after initiation, use another agent Adjunctive therapy includes central-acting agents (guanfacine, clonidine, methyldopa) and diuretics

*Genetic factors involved in psoriasis development

exact mode of inheritance unknown, number of loci identified most psoriasis pts have at least one immediate relative with psoriasis

*Cushing's Syndrome

excess in cortisol from supraphysiologic levels of glucocorticoids from either exogenous administration or endogenous overproduction ACTH-dep: overproduction of ACTH by the pituitary (80%) which chronically stimulates the adrenal glands causing bilateral adrenal hyperplasia (BAH) -85% from pituitary adenomas (Cushing's disease) -may also be ectopic ACTH-secreting tumors (pancreas, thyroid, lungs) ACTH-indep: adrenal adenomas/carcinomas-majority are benign; most in children

*estrogen AE

excess: nausea, bloating, HA, breast tenderness, melasma; deficiency: early or mid-cycle BTB or spotting

*Preexisting DM & Pregnancy

eye exams before pregnancy or in first trimester of those with preexisting DM monitor every trimester and for 1 year postpartum preconception couseling should be incorporated into routine care for all girls of childbearing potential and how glycemic control reduces congenital anomaly risk ACEI and statins CI in pregnancy low dose ASA from the end of the first trimester until the baby is born in order to lower the risk of preeclampsia

ELC

eyelid closure: closing the eye for 5min after instillation of an eye drop. It may improve drug response, reduce AE, and allow less frequent dosing and the use of lower drug concentrations

*Advantages of RAI vs regular human insulin

faster acting-imitates body's natural mealtime insulin

clinical presentation RA

fatigue, weakness, low-grade fever, weight loss, joint pain and stiffness (lasts >6w, worse after holding still for long periods of time), tenderness and warmth, swelling in 3+ joints, symmetrical, rheumatoid nodules labs: RF (rheumatoid factor), anti-CCP (anticyclic citrullinated peptide), elevated ESR, elevated CRP, joint fluid aspiration (high WBC but no infection or crystals) OA pain in shoulder only if pitcher; RA pain in shoulder almost always OA in big toe and major hand joints; RA in all joints of hands and feet OA pain in back; RA pain in elbowa

SLE risk factors

female, 15-40yo, African American, Hispanic, Asian, family hx, genetic variance, sun exposure, smoking, stress, viral exposure (EBV, CMV, herpes zoster), silica, mercuty, OC, HRT (estrogen is "immunoenhancing")

hyperprolactinemia sx

female: oligomenorrhe, amenorrhea, galctorhhea, infertility, decreased libido, hirsutism, acne male: decreased libido, infertility, reduced muscle mass, galactorrhea, gynecomastia

FODMAP

fermentable (undigested carbs), oligosaccharides (fructans and GDS found in wheat, rye, onions, garlic, legumes), dissacharides (lactose), monosaccharides (fructose in honey, apples), polyols (sorbitol and mannitol (some fruit and veggies))

IBD systemic signs and symptoms

fever, malaise, fatigue, anemia (CD<UC), tachycardia and toxic megacolon (UC) toxic megacolon-occurs when extensive inflammation causes colon dilation, delaying GI transit and causing gas and feces to build up. May be life threatening esp if rupture occurs -high fever, high WBC, inflammation, distention, pain, dehydration, +/- bleeding consider hospitalization of patients with severe pain or diarrhea (>8x/d) +/- bleeding, dramatic weight loss, fever, or other systemic symptoms

IBS-C: Pharmacological Treatment

fiber supplementation when dietary fiber is insufficient -psyllium-only fiber shown to improve IBS (all subtypes) but does not reduce pain -insoluble fibers may worsen IBS symptoms patients who fail fiber therapy should consider sx relief with: osmotic laxatives, PRN stimulant laxatives, chloride channel activators, GC-C agonist, 5HT3R agonists, antidepressants

*IBS risk factors

fibromyalgia, interstitial cystitis, chronic fatigue, migraines, previous case of TD (IBS-D) psychiatric disorders-enhance response to stress e.g. major depression, generalized anxiety -patients with history of physical or sexual abuse and PTSD have an increased incidence of IBS

stellate cells

fibrotic tissue comes from these cells in response to chronic inflammation lose vit A, become highly proliferative, synthesize fibrotic scar tissue, loss of hepatocyte microvilli, loss of sinusoidal fenestrae, deterioration of hepatocyte fx

function of the liver

filters blood from the digestive tract, detoxifies chemicals and metabolizes drugs, secretes bile, storage of vitamins and minerals, glycogenesis, makes proteins for blood clotting and other functions (albumin to maintain BV)

OA and NSAIDs

firstline for hand, secondline for those who fail NSAIDs SE: GI discomfort, PUD, GI bleed, increased cardiovascular events, renal insufficiency, photosensitivity (naproxen, diclofenac, meloxicam, celecoxib, ketoprofen, and nabumetone only); CI: NSAIDs or ASA allergy, asthma (conditional), w/i 14d of CABG, first trimester and last few weeks of pregnancy DDI: may block effects of ASA if taken first; may increase lithium levels -*take NSAIDs 30 minutes after ASA or 8h before* BBW: increase in cardiovascular events, PUD, gastric or intestinal perforation (esp elderly, no warning, unpredictable) e.g. salsalate, etodolac, diclofenac, indomethacin, ketorolac, nabumetone, ibuprofen, naproxen, ketoprofen, oxaprozin, piroxicam, meloxicam

OA and APAP

firstline for pain management in OA (except hands), 325-650 q4-6h NOT PRN avoid in hx of alcoholism (max 2g/d) or liver disease (hepatotoxicity SE) chronic APAP may increase INR (increased warfarin effects) APAP alone does not increase risk for bleeding

bisphosphonates and OP

firstline for prevention and tx; duration: 3-5y, sometimes more; t1/2 of some >1y; takes 12-24mo to see benefits in BMD but may see decrease in fractures interferes with osteoclast-mediated bone resorption SE: GI disturbances, esophagitis, musculoskeletal pain, HA, rash, ONJ(osteonecrosis of the jaw), and atypical fractures CI: Hypocalcemia, CrCl<30ml/min should take Ca and vit D supplementation SEPARATELY use caution in patients with hx upper GI disorders if able to reach a T-score > -2.5 may be able to discontinue drug therapy for 3-5y ONJ in patients receiving chemotherapy and concurrent high-dose IV bisphosphonate, or dental surgery e.g. alendronate, ibandronate, risedronate, zoledronic acid (for bone degeneration during chemo)

H. pylori eradication

firstline: bismuth regiment unless CI (due to increasing resistance to clarithromycin) clarithromycin triple therapy in areas where resistance is low and it pts with no exposure to macrolides for ANY reason takes years for H. pylori to replicate to a degree to cause clinical sx consider adding a probiotic with therapy to decrease GI intolerance to meds combo products: Prevpac, Helidac, Pylera

*obesity pearls

firstline: lorcaserin amd liraglutide lorcaserin and orlistat have similar efficacy, but lorcaserin has a better AE profile -beneficial effects on glycemia and kidney fxn, benefit in CVD or those at risk liraglutide-DOC in T2DM particularly those wtih CVD; GI SE, high cost, injectable orlistat-not firstline, GI SE; benefits glycemia, lipids, BP phentermine-topiramate: best efficacy but more AE/CI for men or postmenopausal women w/o HTN, CHD, or sleep apnea -increased HR, depression, anxiety, cognition, fetal malformations (topiramate) bupropion-naltrexone: similar efficacy to lorcaserin, but more AE/CI

*OA tx

firstline: nonpharmacological therapy -● Patient education ● PT/OT ● Exercise (sp. Tai Chi) ● Assistive devices ● Weight loss ● Joint unloading devices ● Heat/Cold therapy ● Psychosocial interventions secondline for hands: -Oral NSAIDs ● Topical NSAIDs ● Topical capsaicin ● Tramadol (CIV) secondline for knee and hip: -APAP ● Oral NSAIDs ● Topical NSAIDs (Knee only) ● Tramadol (CIV) ● Intra-Articular Steroid lastline: surgery and CAM Tramadol (CIV) and intra-articular steroids should be reserved for patients who have failed other therapies and who have moderate to severe pain

FST

fludrocortisone suppression test-most reliable PA diagnosis but requires hospitalization. Normally fludrocortisone will decrease aldosterone levels, but in PA this negative feedback is reduced.

Acute Variceal Hemorrhage

fluid resuscitation with LR or NS first to prevent damage from hypoperfusion correction of significant coagulopathy and/or thrombocytopenia with FFP and platelets BP is a direct measure of intravascular volume recommendation: pharmacologic + endoscopic therapy combo -pharmacologic: octreotide (local, splanchnic-relating to the viscera or internal organs, especially those of the abdomen) or vasopressin (systemic-many SE) -endoscopic: EVL or sclerotherapy

*chemical conjunctivitis

flush out irritant w/ saline and treat inflammation w/ NSAIDs or steroid eye drops if contacts caused it, they should not be used until the conjunctivitis has healed

Erythematotelangiectatic Rosacea

flushing and persistent erythema with or without telangiectasia (vascular lesion formed by blood vessel dilation) most difficult to treat-most effective is laser or light therapy not much evidence to support oral or topical abx isotretinoin may have transient effects

*FSH

follicle stimulating hormone, gonadotropin

5-HT3 Antagonists and N/V

for CINV and PONV prevention and tx, severe or intractable N/V SE: HA, fatigue, constipation, dizziness, QT prolongation work best on a scheduled basis rather than PRN reduce dose with hepatic impairment (CP-C) ondansetron (Zofran, PO and SL) (Zuplenx-film), granisetron (Kytril), dolasetron (Anzemet), palonosetron (Aloxi)

Mu-Opioid Receptor Agonist

for IBS-D in adults, schedule IV, e.g. eluxadoline (Viberzi) 100mg BID with food or 75mg in pts without a gallbladder, have mild-mod hepatic impairment, or who cannot tolerate 100mg SE: constipation (d/c if severe >4d) , abdominal pain, nausea, euphoria (dose-dep) CI: biliary duct obstruction, sphincter of Oddi disease or dysfx, >3 drinks/d, history of pancreatitis or pancreatic duct obstruction, severe hepatic impairment, constipation, GI obstruction

*adapalene gel and acne

for acne vulgaris-binds to retinoid receptors, *results may take 8-12w* less irritating than tretinoin-most irritation subsides after 1 mo AE: erythema, dryness, pruritis, burning, photosensitivity, *acne flares*, dermatitis, hyperpigmentation apply once daily at bedtime Use sunscreen!!!

antimotility agents

for acute and chronic diarrhea, IBS-D SE: N/V, dizzinss, drowsiness, itching, dry mouth, miosis, and constipation CI: pts at risk of bacterial enteritis with E. coli, Shigella, or Salmonella (toxin producing), children <2yo, hypersensitivity, diarrhea accompanied by fever or bloody stool addiction potential with long-term use (excludes loperamide); avoid alcohol e.g. loperamide, Lomotil, Paregoric

butyrophenones and N/V

for anticipatory/acute CINV, PONV SE: agitation, restlessness, sedation, QT prolongation, anticholinergic effects caution: combination with other drugs that cause CNS depression or QT prolongation e.g. droperidol (Inapsine), haloperidol (Haldol)

glucocorticoid use and OP

for any pt expected to be on a GC for 3+mo complete clinical fracture risk assessment and BMD screening within 6 mo of starting GC-repeat assessment annually and repeat BMD at least every 3y assessment includes: history and details of GC use, evaluation of falls and fractures, evaluation for frailty, identify RF for fractures (malnutrition, significant weight loss or low body weight, hypogonadism, history of hip fracture, history of alcohol abuse or smoking), identify comorbidities, PE (including wt and ht without shoes), test of muscle strength, assess clinical findings of undiagnosed fracture (spinal tenderness, deformity, reduced space b/w lower ribs and upper pelvis)

topical calcineurin inhibitors for psoriasis

for atopic psoriasis esp facial or intertriginous in pts >2yo, off label pimecrolimus (Elidel) and tacrolimus (Protopic) not super effective: lymphoma-controversial

GC-C agonist

for chronic constipation, IBS-C, OIC SE: diarrhea, abdominal pain, flatulence; CI: <18yo d/c if severe diarrhea occurs; may decrease absorption of oral meds (e.g. OC) keep in original package; protect from light and moisture e.g. linaclotide (Linzess-30min before breakfast), plecanatide (Trulance)

*Emollients/Surfactants/Stool Softeners

for constipation prevention-not effective as tx OOA 1-3d; 200-500mg QD in 1-4 divided doses; safe for long-term use SE: N/V, diarrhea, cramping (rare) may increase absorption of mineral oil frequently given post-operatively to prevent straining and in conjunction with drugs that are known for causing constipation e.g. docusate sodium (Colace), docusate calcium (Surfak)

colchicine and gout

for flares when pt is intolerant to or has failed NSAID ONLY EFFECTIVE WITHIN 36-48h IN FLARE DOC for prophylaxis-decreases inflammation related to urate crystals renal dose adjustment prophylaxis: 0.6 BID; treatment: 1.2mg then 0.6mg one hour later, then 0.6mg QD or BID until gout resolves SE: GI upset (diarrhea), neutropenia, axonal neuromyopathy; CI: hypersensitivity, blood dyscrasia, severe cardiac or GI disease, hepatic failure, renal failure (<10) excretion of colchicine is reduced by macrolides-may be fatal!!! low dose and high dose are just as effective

sorbitol

for funtional constipation in cognitively intact patients (rarely used) 30-150mL (70% solution) PO or 120mL (25-30% solution) PR daily onset: 24-48h

prokinetics and N/V

for gastroparesis, CINV, PONV, and morning sickness; never first line due to SE SE: EPS (akathisia, dyskinesia, dystonia, pseudoparkinsonism), drowsiness, hyperprolactinemia, seizures, diarrhea CI: history of seizures, concurrent use of drugs that may cause EPS or seizures max 12w due to increased risk of irreversible tardive dyskinesia long-term shortened gastric transit time may reduce absorption of some medications decrease dose with CrCl <40 e.g. metoclopramide (Reglan)

lesinurad/allopurinol combo and gout

for gout in pts who failed XOI monotherapy

Aminosalycilates

for induction of remission and maintenance in mild-mod UC SE: HA, abdominal pain, nausea, pharyngitis (lowest incidence with suppository and enema) CI: hypersensitivity caution in renal or hepatic impairment Do not crush or chew. Administer enema and suppository HS and maintain for 8 and 3 hours, respectively. Some pts may require rectal and oral concurrently sulfasalazine (Azulfidine)-combines sulfonamide with mesalamine, SE of sun sensitivity and impaired folate absorption mesalamine: Rowasa enema for distal colon and rectum, Canasa suppository DOC for proctitis, Apriso for colon maintenance only, Pentasa for distal stomach to rectum, Lialda for distal ileum and colon olsalazine (Dipentum) for colon, SE diarrhea balsalazine (Colazol) for colon

fluoroquinolones for diarrhea

for infectious diarrhea due to bacteria; 1st line for empiric therapy if indicated, no longer recommended for prophylaxis separate from vitamins and calcium-containing products by 2 hours CDC reports increased evidence of Shigella isolates with reduced susceptibility to ciprofloxacin and azithromycin

*stimulant laxatives

for intermittent (every few weeks) tx of constipation; not indicated for routine tx due to strong purgative action SE: cramping, diarrhea, fluid/electrolyte imbalances with chronic use e.g. bisacodyl HS (Dulcolax-also for bowel preparation), senna or sennosoids HS (Senokot), castor oil

*uricosuric drugs and gout

for long-term gout in pts with underexcretion (<800mg on regular diet or <600 on purine restricted diet) increase renal clearance of uric acid by inhibiting post secretory renal proximal tubular reabsorption of uric acid SE: GI upset, GI bleed, rash, hypersensitivity, flare, kidney stones CI: gout due to overproduction (will cause stones), current flare, pts with blood disorder, children <2yo not recommended 1st line in pts with hx renal stones or CrCl <=50 salicylates decrease effect of uricosuric drugs (use <325 daily) start at low dose, increase water intake, alkalize urine with potassium citrate to avoid marked uricosuria and possible stone formation probenecid (Benemid)-may inhibit tubular secretion of other agents increasing plasma concentrations of penicillins, cephalosporins, sulfonamides, indomethacin, ketorolac, heparin, zidovudine, nitrofurantoin

*phenothiazines and N/V

for migraine, motion sickness, CINV or PONV, severe or intractable N/V, vertigo SE: EPS (extrapyridimal symptoms-dystonia, tardive dyskinesia), orthostatin hypoTN, sedation, seizures, anticholinergic effects, hallucinations (elderly) CI: <2yo, intra-arterial or SQ (given IM or slow IV push) Caution: Beers Criteria for the elderly, combination with other drugs that cause respiratory or CNS depression e.g. promethazine (Phenergan), prochlorperazine (Compazine)-antipsychotic

*antacids

for mild GERD or occasional heartburn, OOA <1h, DOA 30 min SE: constipation, diarrhea, cramping, acid rebound, acid-base disturbances, electrolyte imbalance, hypophosphatemia (with aluminum) CI: hypersensitivity, CrCl <30 (and caution in renal insufficiency) DOC in pregnancy and breast feeding -Ca containing products are considered safest -d/c Mg containing antacids in 3rd trimester -high levels of aluminum can be neurotoxic to fetus *antacids decrease the absorption of drugs that require an acidic environment for dissolution and absorption (e.g. phenytoin, isoniazid, ketoconazole, itraconazole, iron products) and increase bioavailabiluty of others (e.g. digoxin, nifedipine) -may bind tetracyclines and quinolones, separate by 2h -citrate products and aluminum containing antacids should not be mixed as it increases the absorption of aluminum shake liquids and be sure to chew all chewable tablets thoroughly e.g. CaCO3 (Tums, Rolaids), MgOH (milk of magnesia), AlOH/MgOH +/- simethicone (Maalox, Mylanta), Gaviscon

*H2RA

for mild to moderate GERD, PUD, dyspepsia, stress ulcer prevention (ranitidine) fast OOA (30-45min) and longer DOA (6-10h) SE: HA, dizziness, tiredness, confusion, diarrhea, constipation CI: hypersensitivity pregnancy: famotidine preferred, nizatidine avoided lactation: famotidine preferred, cimetidine CI tolerance may occur due to upregulation at the H2 receptor site e.g. cimetidine (Tagamet-lots of DDI), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid-many DDI, may increase effects of aspirin)

*CS and SLE

for mild-severe SLE, alone or in combo for initial control of severe SLE and maintenance after disease suppression, generally reserved for pts with involvement in vital organs pulse therapy-short term, high dose for life-threatening disease (nephritis, CNS, hemolytic)

antidepressants in IBS

for mod-severe or continuous abdominal pain or underlying depression or anxiety disorders (lower doses for IBS than depression) e.g. TCAs, SSRIs, SNRIs 3mo trial at standard is recommended before therapeutic failure is confirmed

*Surgery for BPH

for moderate or severe sx not responsive to drugs gold standard, minimaly invasive -transurethral microwave procedure or needle ablation -water-induced thermotherapy surgical tx-turp, tuip, open surgery, laser surgery

5-Alpha Reductase Inhibitors

for moderate to severe BPH and off-label for prostate cancer prevention finasteride (Proscar) inhibits Type II, intraprostatic DHT 80-90%, serum 70% dutasteride (Avodart)-nonselective, quicker, intraprostatic 100%, serum 90% SE: impotence (esp first 6mo), weakness, gynecomastic, ejaculation disturbances pregnancy category X-don't even let women touch it disadvantages: may take up to 6mo to notice change and 12mo to reach peak 6mo of treatment at normal doses can reduce PSA 50%

topical immunosuppressants for atopic dermatitis

for moderate to severe atopic dermatitis when pt (>2yo) cannot use topical steroids, atrophy concerns (do not thin skin), unresponsive to tx act on T cells by suppressing cytokine transcription DO NOT USE WITH OCCLUSIVE DRESSING (increases systemic absorption) AE: transient burning and pruritis pimecrolimus (Elidel) and tacrolimus (Protopic)

Combination Antihistamine and Vitamin B6 analog

for morning sickness in those who do not respond to conservative management SE: anticholinergic effects, drowsiness (especially in combo with sedating drugs) CI: concurrent use of MAOIs 2 tablets at bedtime (1 in the morning + 1 mid morning + 2 hs = max of 4) not PRN, take on an empty stomach with water; do not drive e.g. doxylamine 10mg/pyridoxine 10mg (Diclegis) DR formerly "Bendectin" which was voluntarily withdrawn from the market in 1983 due to a lawsuit alleging teratogenicity; No evidence supported this

lubricants for constipation

for occasional/acute constipation, OOA: 6-8h SE: aspiration pneumonia, decreased absorption of fat soluble vitamins with chronic use, pruritus, and soiling of clothes decreases absorption of digoxin; increases systemic toxicity risk with docusate CI: bedridden, cognitively impaired pts, pregnancy e.g. mineral oil OTC, liquid, or enema

corticosteroids and N/V

for preventing delayed CINV or PONV; not effective for gastroenteritis or PRN; severe morning sickness after 10w (risk of oral cleft) SE: HTN and high BG, edema, mood swings, agitation, weight gain, appetite increase, sleep disturbance, peptic ulcer CINV dosing does not require taper; may be given on day 1 of chemo only or QD depending on emetogenic level of chemo and other iatiemetics; doses vary

Combination Neurokinin 1 (NK1) Receptor Antagonists and 5-HT3 Antagonist

for prevention of acute and delayed CINV SE: HA, asthenia, dyspepsia, fatigue, constipation, and erythema CYP3A4 inducers decrease plasma concentration of netupitant, do not combine CYP3A4 inhibitors can lead to increased plasma concentrations of netupitant for up to 4 days, use with caution. give 1 hour before chemotherapy with or without food, followed by dexamethasone 30 minutes later. not for severe renal or hepatic impairment Netupitant 300mg /palonosetron 0.5 mg (Akynzeo) capsule Fosnetupitant235 mg/palonosetron 0.25 mg (Akynzeo) injection

NK1 receptor agonists and N/V

for prevention of delayed CINV or PONV SE: fatigue, hiccups, HA, constipation or diarrhea, weakness decreases steroid metabolism by as much as 50% enhances the metabolism of warfarin (decreases INR), paclitaxel, etoposide, irinotecan, imatinib, vinca alkaloids, oral contaceptives (back up contraception), itraconaozle, tergenadine and phenytoin (additional monitoring) e.g. aprepitant (Emend-oral), fosaprepitant (Emend-IV prodrug)

anticholinergics for N/V

for prevention of motion sickness and PONV, adjunct to CINV prophylaxis SE: dry mouth, drowsiness, blurred vision, confusion, fatigue, tachycardia apply behind ear 4-12h before travel and every 72h while traveling apply behind ear 1h before surgery and remove 24h after surgery wash hands after applying and remove prior to MRI as it may contain metal

*Constipation: Signs & Symptoms

hard, small, dry stools, bloating, cramping, straining, sensation of blockade, fatigue, HA, N/V if alarm sx-colonoscopy or radiological exam should be conducted to identify and also rule out any secondary causes -hematochezia, anal bleeding, significant unintended weight loss, family hx cancer, anemia, changes in bowel behaviors or form

raloxifene

for treatment and prevention of OP, reduces bone resorption and rate of bone turnover through estrogen agonist activity at estrogen receptors on bone decrease risk of invasive breast cancer in postmenopausal women at high risk (strong family history or those undergoing tx) SE: PE, VTE, chest pain, palpitations, tachycardia, and vasodilation, hot flashes CI: pregnant or may become pregnant, hx VTE DDI: warfarin and other highly bound protein drugs

*bulk-forming agents

for tx and prevention of chronic constipation, preferred for management in pregnancy, IBS-C; OOA 3-5d SE: flatulence, abdominal distension common increase water consumption to prevent obstruction; avoid in pts with difficulty swallowing when bedridden, cognitively impaired pts-lowest dose and frequency to maintain 3 stools/week e.g. psyllium hydrophilic colloids (Metamucil), methylcellulose (Citracel), wheat dextrin (Benefiber), polycarbophil (FiberCon)

*antihistamines and N/V

for tx or prevention of N/V due to migraine, motion sickness, or vertigo SE: drowsiness, anticholinergic effects, respiratory and/or CNS depression caution when combining with other drugs that cause respiratory or CNS depression or have anticholinergic effects diphenhydramine (Benadryl), dimenhydrinate (Dramamine), meclizine (Bonine, Antivert, Less Drowsy Dramamine), hydroxyzine (Vistaril)

*normal erection requires

functioning vascular system, nervous system (spinal damage, etc.), and hormonal system (HPA axis) in addition to psychological factors

*injection technique

gather insulin supplies-vials and fresh syringe-doublecheck expiration date NPH and premixed-mix by rolling or turning pen end to end draw in an amount of air equal to your insulin dose push the air in, draw the desired amount out, check for bubbles

young person with ED

generally secondary to another medical condition (The CEO of Roman had a life-threatening heart problem and his first sx was ED.)

*atopy

genetically determined state of hypersensitivity to environmental allergens. Associated with the IgE antibody.

*OP etiology

genetics, diet, lifestyle (smoking and drinking), exercise, hormone status, disease states, medications

*GDM

gestational diabetes mellitus; 9% of all pregnancies Up to 50% will later develop T2DM Offspring at greater risk of T2D development Lifestyle intervention; medications added if needed Insulin DOC-Detemir and NPH; oral agents used off-label Risk to neonate—macrosomia, hypoglycemia (can lead to respiratory distress and electrolyte imbalances), jaundice

pancreas

glandular organ in ULQ that is part of the endocrine and digestive systems endocrine: Islets of Langerhans (group of cells)-beta cells secrete insulin; alpha cells secrete glucagon; delta cells secrete somatostatin exocrine: acinar cells-hormones such as secretin (SC) and cholecystokinin (CCK) regulate exocrine pancreatic secretion of isotonic fluid containing electrolytes, inhibitors, and pancreatic enzymes

*eye disorders

glaucoma sty blepharitis conjunctivitis dry eye age-related macular degeneration ocular emergencies

*fasting state

glucagon release-HGP and glycogenolysis glucose production-85% liver and 15% kidneys glucose uptake-75% non-insulin dependent in brain, insulin-dep in liver & muscle

*GLP1

glucagon-like-peptide-1 secreted from L cells in distal intestinal and colon mucosa when glucose levels >90mg/dL. Slows gastric emptying, stimulates insulin secretion, and increases satiety. Inactivated by DPP4

CAM that improves OA outcomes

glucosamine

*psoriasis treatment

goals: skin normalization, patient acceptability, reduce toxicity PASI (severity), PGA, and NPF-PS assessments ketatolytics (salicylic acid), emollients, topical therapy, systemic therapy

H. pylori

gram -, spiral shaped, flagellated bacillus, microaerophilic produces urease which neutralizes stomach pH resides between mucus layer and surface epithelial cells in the stomach infection usually occurs during childhood RF: low socioeconomic status, number of siblings, infected parent in developing countries it can be spread in the water, in the US it is generally spread from one family member to another with some speculation of genetic predisposition. susceptibility testing is only completed with biopsy. 4-5 biopsies are taken (2 from the antrum 2 cm from the pylorus and 1 from the anterior and posterior corpus. patient must be off abx and PPIs for 2 weeks prior to biopsy. Treat all patients with a positive H. pylori test regardless of symptomatology MALT lymphoma is caused by H. pylori. In early stage disease, lymphoma can be cured by h. pylori eradication alone. ITP, also known as immune thrombocytopenia, is a disorder of low platelet count that presents as the appearance of tiny bruises all over the body, excessive menstrual bleeding, etc. ITP increases a patient's risk of developing a GI bleed

*agranulocytosis and thioamides

granulocyte count < 500—0.5-6% Fever > 101°F x 1-2 days, malaise, sore throat, gingivitis, oropharyngeal infxn If experience symptoms, notify MD and d/c until get WBC with differential If confirmed agranulocytosis, patient should not receive thioamides

*MI and CHC

greater concern due to higher hormone doses in CHCs (very low risk if no RF) RF: smoking, >35yo, HTN, hypercholesterolemia, morbid obesity, DM

*HRS

hepatorenal syndrome-functional renal failure in the setting of cirrhosis result of intense renal vasoconstiction -extreme systemic vasodilation, sodium retention, and oliguria development: hemodynamic alterations, neurohumoral dysregulation, effects on renal fxn, ascites (SBP, bleeding, paracentesis without albumin) d/c diuretics and other meds that decrease BV expand intravascular volume with IV albumin at 1g/kg up to a max of 100g bridge to transplant-arterial vasoconstrictors (midodrine or terlipressin) plus octreotide and albumin liver transplant is the only definitive therapy and only therapy that will prolong survival

BBW ketoconazole

hepatotoxicity

*SGLT2

high capacity, low affinity transporter that absorbs 90% of filtered glucose in a normal individual the renal threshold is typically 180 mg/dL but in those with T2DM this increases to 220-240. This is likely due to SGLT2 receptor over expression

*TZD overview

high efficacy, no hypoglycemia, weight gain, potential benefit ASCVD (pioglitazone), all increase risk CHF, low cost, no dose adjustment required but not recommended in renal impairment due to potential for fluid retention, benefit in NASH, risk of bone fractures, bladder cancer (pioglitazone), increased LDL (rosiglitazone) FDA black box: CHF (pioglitazone and rosiglitazone) MOA: improves target cell (lipid) response to insulin, without increasing pancreatic insulin secretion (sensitizer). Selective agonist for PPAR gamma. Activation of PPARgamma Rs influence production of gene products involved in glucose and lipid metabolism infrequent second line due to AE examples: pioglitazone (Actos), rosiglitazone (Avandia)

waist circumference

high risk >40cm in men and >35cm in women less predictive if BMI >35 and/or ht <5ft more likely to lead to CVD, insulin resistance, T2DM, HLD, HTN

*infectious conjunctivitis

highly contagious, common in young children, and usualy self-limiting counseling: hand hygeine, don't touch eyes, change towel and washcloth daily, discard eye cosmetics, particularly mascara bacterial contagious for 48h after therapy begins, viral contagious for up to 14d refer if symptoms do not improve in 48h

HRT

hormone replacement therapy estrogen only-women with hysterectomy (otherwise endometrial hyperplasia) estrogen and progestin (e.g. Duavee) localized HRT improves vulvovaginal atrophy

*GLP1RA examples

human GLP1 based: liraglutide (Victoza), albiglutide (Tanzeum-no longer marketed), dulaglutide (Trulicity), semaglutide (Ozempic) extendin-4 based: exenatide (Byetta), exenatide LAR (Bydureon), lixisenatide (Adlyxin)

HLA

human leukocyte antigen

*HPV

human papillomavirus

Acute Antibody-Mediated Rejection

humoral rejection characterized by the presence of antibodies against HLA antigens present on the donor vascular endothelium Ab activate complement which creates a membrane attack complex that directly damages the organ and attracts inflammatory cells to the allograft generally occurs in the first 3-6mo and has an increased fatality rate biopsy of the transplanted organ needed to delineate which acute rejection is occurring

*HRT CI in menopause tx

hx breast cancer, estrogen-sensitive malignancies, undiagnosed vaginal bleeding, untreated endometrial hyperplasia, hx idiopathic VTE, recent arterial thromboembolic disease, untreated HTN, *active liver disease* if any of these are even suspected, rule them out before starting HRT

CHC and increased risk for thromboembolism

hx of DVT/PE and not on anticoagulant; known thrombogenic mutations Major surgery with prolonged immobilization; less than 21 days postpartum SLE (systemic lupus erythematous) with positive aPLa (antiphospholipid antibody)

Contraceptive Selection: Patients with risk factors

hx of breast cancer: copper IUD preferred DM with vascular complications, neuropathy, or duration >20y: avoid CHCs and DMPA hx of VTE: avoid CHCs hyperlipidemia: minipill, implant, or IUD preferred -If controlled, can consider COC with low androgenic progestin -If high TGY while on CHC, use progestin-only agent or copper IUD HTN: minipill, implant, or IUD preferred -If controlled, can consider COC with monitoring smoker: avoid CHCs in those 35+yo migraines: avoid CHCs in those with aura and/or 35+yo -women on CHCs with worsening migraines should d/c menstrual migrianes: CHC on extended-cycle, continuously, or EE not placebo -associated with estrogen withdrawal nonmigraine headaches: any agent is acceptable

*malignancy and RA

hx of skin cancer: DMARDs over biologics or tofacitinib hx lymphoma, leukemia, multiple myeloma: -firstline: rituximab -secondline: combo DMARDs or abatacept or tocilizumab NOT anti-TNF solid organ cancer: treat like usual

*CHC and increased risk for stroke and/or cardiac event

hx of stroke, moderate to severe impairment of cardiac fx, ischemic heart disease, BP >160/100, migraines with aura, smoking 15+ cigarettes a day when 35+yo

*Risk Factors for Diabetic Foot Ulcers

hx of ulcers or amputations, foot deformities, peripheral neuropathy with LOPS, pre-ulcerative callus or corn, PAD, no palpable pedal pulses (5-fold increase in risk), poor glycemic control, visual impairment, diabetic neuropathy (esp if on dialysis), cigarette smoking, onychomycosis (3x risk)

Addison's - Treatment

hydrocortisone-starting dose: 15-25 mg/day; cortisone-starting dose: 25-37.5 mg/day; prednisone-starting dose: 2.5 mg/day; should be used BID to mimic the body's natural diurnal cycle with 2/3 of dose is in the morning and the remainder of the dose given 6-8 hrs later; should be dosed at the minimal effective dose. Fludrocortisone acetate can be used to supplement mineralocorticoid loss

HCQ for RA

hydroxychloroquine (Plaquenil) Indication: Monotherapy for RA in patients with good prognosis and low disease activity and disease duration < 24 months; In combination with MTX for moderate to high disease activity regardless of prognosis or disease duration; With SSZ for patients with high disease activity and good prognosis and disease duration between 6 and 24 months Onset: 3-6 months SE: Retinopathy (Increased risk with doses > 800mg/day and patients >60), GI upset CI: Renal impairment Counseling: Take with food Monitoring: Baseline eye exam for patients ≥ 40 or patients with family history of eye disease with annual follow up pretty mild drug for those with mild symptoms

*HCQ and SLE

hydroxychloroquine, Plaquenil-SOC in mild SLE, safe in pregnancy, OOA 3-6mo SE: retinopathy (esp >800mg/d and >60yo), GI upset; CI: renal impairment take with food; eye exam annually for those 40+yo with family hx of eye disease

Metabolic Abnormalities Associated with Parenteral Nutrition

hyperglycemia (most common)-excessive dextrose administration, metabolic stress, infection, corticosteroids, pancreatitis, DM, peritoneal dialysis hypoglycemia-abrupt dextrose withdrawal, excessive insulin excess CO2 production-excess dextrose hyperTG-metabolic stress, familial HLD, pancreatitis, excess or rapid IVFE abnormal LFT-metabolic stress, infection, excess dextrose administration, excess caloric intake, long-term PN therapy azotemia-excessive protein, caution in pts with renal or hepatic disease refeeding syndrome-severe hypophosphatemia, hypomagnesemia, hypokalemia. steatosis-hepatic fat accumulation cholestasis-impaired bile secretion or biliary obstruction gallbladder stones-stasis

*DKA pathogenesis

hyperglycemia with metabolic acidosis (high anion gap) resulting from ketones in response to insulin deficiency and elevated counter-regulatory hormones increased counterregulatory hormones: cortisol, GH, glucagon, EPI Liver-converts fatty acids into ketone bodies and gluconeogenesis

*HHS

hyperosmolar hyperglycemic state characterized by severe hyperglycemia, hyperosmolality profound dehydration in absence of ketoacidosis mortality rate 5-20%, generally T2DM, relative insulin deficiency, absent or minimal ketogenesis, evolves over several days to weeks

*HTR

hyperthyroidism

*SU disadvantages

hypoglycemia (elderly), weight gain, high secondary failure rate, may inhibit ischemic preconditioning

*insulin AE

hypoglycemia, weight gain, hypoK, edema, injection site rxns, lipodystrophy/atrophy, hypersensitivity

*HPG

hypothalamic-pituitary-gonad

*glucose homeostasis

ideal maintenance 55-140 40-60 necessary to fuel CNS; maintained by glycogenolysis, gluconeogenesis, and the reduction of glucose uptake in insulin-dependent tissues GLUT1: insulin-independent, present in CNS GLUT4: insulin-dependent, muscle and fat counter-regulatory hormones of insulin: glucagon, EPI (shaky feeling from low BG), GH, cortisol

guidelines for tx of HE

identify and treat precipitating factor lactulose-DOC for both tx and prevention of recurrence of episodic OHE (overt) rifaximin is an effective add-on therapy for prevention of OHE recurrence neomycin and metronidazole are alternatives for OHE treatment

*overt hepatic encephalopathy

identify and treat precipitating factors reduce ammonia blood concentration with diet and drugs dietary restrictions-protein limitation for acute HE until sx resolve then increase gradually to 1-1.5g/kg/d (vegetable or dairy protein preferred) lactulose lowers ammonia by laxative effect, bacterial uptake of ammonia and reduction of ammonia production by small intestine -30-45mL qh until 3 loose BM/d (not .necessarily diarrhea)=CATHARSIS -alternative retention enema (300mL in 700mL held for 60 min -gut bacteria converts lactulose to lactic acid and acetic acid-one of these compounds will donate H to ammonia (reduction). Ammonium can get pooped out but ammonia can not maintenance lactulose 15-45mL q8-12h titrated to produce 2-3 soft stools/d abx: neomycin, metronidazole, rifaximin

*identifying the cause of OP

identifying secondary causes: measure 25-OHvitamin D, calcium, creatinine, TSH

hep B and RA

if active infection effectively being treated with antiviral therapy, treat as usual if natural immunity, treat as usual, but monitor viral load if chronic untreated use antiviral therapy before starting immunosuppressants

*Antibiotic Treatment After Amputation

if all infected tissue has been surgically removed: abx for 2-5d if persistent infection or necrotic bone: abx for 4+ weeks

*bicarbonate in DKA and HHS

if pH < 6.9, dilute bicarb 100mmol in 400 mL H2O + 20 mEq KCL, infuse for 2 hours until venous pH >7.0

physiological changes during critical illness

imbalanced hormones (catecholamines, cortisol, glucagon, growth hormone, insulin), excess liver glucose production, insulin resistance, excess catabolism, increased production of proinflammatory cytokines raised blood sugar whether they are diabetic or not; FPG 140-180 is acceptable in critically ill pts

ketoconazole

imidazole antifungal, strong 3A4 inhibitor MOA: inhibits steroidogenesis by inhibiting CYP17 pathway Also inhibits 11 beta-hydroxylase, and 17 alpha-hydroxylase and can lower cholesterol levels 200-1200mg/d divided into 2 doses (max 1600mg/day) AE: GI upset, dermatologic reactions, liver transaminase, gynecomastia, hypogonadism (testes atrophy) BBW: hepatotoxicity; monitor LFTs benefits unseen for several weeks

Emergency Contraceptive Pills

repeat dose if you vomit within 3h, consider meclizine pretreatment next cycle may be early/late and lighter/heavier if no withdrawal bleed within 3w, take pregnancy test 3A4 inducers will decrease LNG and ulipristal concentrations.

Etomidate

imidazole derivative only available in parenteral formulation and limited to pts with acute hypercortisolemia requiring emergency tx MOA: inhibition of 11-beta-hydroxylase 0.2-0.6mg/kg over 30-60 seconds for hypertensive crisis, high doses can be fatal AE: N/V, pain at injection site, myoclonus, transient skeletal movements, uncontrolled eye movements, hiccups when used as anesthesia it can increase mortality due to lack of cortisol monitor cardiac and BP only way to cure hiccups-Thorazine-KNOW FOR NAPLEX

*MTX

immunomodulator 25mg IM or SQ weekly in combo with CD pts resistant to steroids OR 15-25mg for maintenance of remission OR 15mg with biologic to reduce immunogenicity SE: N/V, stomatitis, hepatotoxicity, AKI, dermatological reactions (skin cancer) monitoring: CBC, LFTs, SCr (baseline, monthly for 6mo then every 2mo), CXR at baseline counseling: folic acid can prevent stomatitis and N/V; men whose partner is trying to conceive should stop MTX for 3mo prior (make completely new sperm)

*thiopurines

immunomodulator e.g. AZA (azathiopurine), 6MP (mercaptopurine) for maintenance therapy for UC and CD for pts in remission or in combo with biologics to reduce immunogenicity (lower dose) NEVER used to induce remission as its onset is 8-12 weeks SE: allergic reactions, pancreatitis, N/V, myelosuppression, hepatotoxicity, infection, and malignancy esp non-melanoma skin cancers and lymphoma

*T2DM triumvirate

impaired insulin secretion, decreased glucose uptake, increased HGP

*Noncontraceptive Benefits of CHCs

improve menstrual regularity, decrease dysmenorrhea, decrease blood loss from menses, improve hormone-mediated conditions (acne, hirsutism, endometriosis, PCOS, etc.), manage perimenopause sx decreased incidence/risk of: ovarian cysts, benign breast disease, ovarian cancer (benefit at 1y of use and decreases risk 7-9% each subsequent year), endometrial cancer (benefit begins at 1y of use and increases with duration)

*antisecretory drugs and CP

improve response to pancreatic enzyme replacement and decrease gastric acid secretion e.g. H2RAs (DOC), PPIs(addon if steatorrhea not decreased with H2RA)

*metformin advantages

improved micro/macro outcomes with early aggressive tx reduced all-cause mortality and stroke risk vs SU or insulin no hypoglycemia as monotherapy, weight loss neutral/loss, high response rate, positive lipid effects, inexpensive, reasonable durability may lower risk of pancreatic, colon, and breast cancer in T2DM

SBP prophylaxis

in cirrhosis pts with a GI bleed with 7 days only of ceftriazone or norfloxacin in those with SBP hx-long-term daily norfloxacin or Bactrim in low protein ascites (<1.5g/dL) with either impaired renal function (SCr>1.2, BUN >25, Na <130) or liver failure (Child-Pugh >9 with bilirubin >3)-norfloxacin 400mg QD or Bactrim

*POAG treatment

in pts with IOP >25 or IOP >18 with cupping and field loss or pts at high risk for visual field degradation (may be monocular tx)-target 25% reduction emphasize compliance since disease is largely asymptomatic current therapy is directed at altering the flow and production of aqueous humor *firstline: BB or PG analog; secondline: brimonidine (Alphagan P-alpha agonist), topical CAI; thirdline: oral CAI; fourthline: direct-acting cholinergic agent* other options: laser therapy, surgery tx often a combination older drugs require TID or QID; newer drugs only QD or BID, but can be costly does not correct vision loss, but slows progression

*Myxedema Coma

inability to compensate for hypothyroidism markedly reduced deiodinase activity hypothermia, progressive mental detioration, high mortality rate *aggressively treat with IV levothyroxine or liothyronine* and supportive care

Steroid AE

increase BG, weight gain (2-3x appetite increase), increase WBC (12-15, 20 is more likely an infection), adrenal suppression, immunosuppression, thinning of skin and bone (chronic use), fluid retention/elevation in BP, mood swings (avoid in those with certain CNS abnormalities), CNS stimulation (avoid after 6pm), increased risk of infections

steroid effect on BP

increase BP via vasoconstriction and Na/water retention

portal HTN

increase in portal pressure gradient due to increased portal blood flow and increased resistance to blood flow through the portal vein likely due to lack of stretch due to fibrotic tissue normal HVPG (hepatic venous pressure gradient) 3-5mmHg, portal HTN 10-12+ to counteract increased gradient: systemic and splanchnic vasodilation leading to a drop in BP and increased splanchnic blood flow

heartburn/reflux tx in pregnant women

increased abdominal pressure; relaxation of gastroesophageal sphincter; delayed gastric emptying nonpharmacologic: smaller, more frequent meals; avoid eating/drinking within 3h of bedtime; avoid fatty foods, caffeine, spicy foods, mint, nicotine; elevate the head of the bed 4-6in *firstline: antacids (calcium carbonate, AlOH, MgOH)* *secondline: ranitidine, famotidine, sucralfate, metoclopramide* *third line: omeprazole*

calcium and PMS/PMDD

increased estrogen leads to hyperparathyroidism and increased Ca demands may improve mood, behavior, pain, water retention, and food cravings recommend 600mg BID in women with PMS who do not have adequate intake

*GLP1RA

increased incretin levels cause increased insulin and inhibition of glucagon secretion (glucose-dep), slowed gastric emptying, and increased satiety

IOP

increased intraocular pressure is thought to play an important role in the pathogenesis, but is NOT a diagnostic criterion for glaucoma. IOP varies with pulse, BP, forced expiration or coughing, neck compression, caffeine intake, posture, gender, general health, and lifestyle (smoking). Circadian variation has the highest values upon wakening and the lowest at about 6pm. Median IOP 13-18 mmHg, abnormal >22 20-30% of pts with glaucomatous visual field loss have an IOP <21

liver cancer and CHC

increased risk for benign liver tumors hepatocellular carcinoma-rare in US; risk may increase with use >5y

cervical cancer and CHC

increased risk in use >5y, most due to HPV, annual exam and Pap recommended

HRT and stroke in menopause tx

increased risk statistically significant at the nominal but not at the adjusted levels (look at individual instance of the repeat measures) Nurses' Health Study showed dose-dependent increase in risk with CEE 0.625+

IC

indirect calorimetry-gold standard accuracy affected by air leaks, chest tubes, supplemental oxygen, ventilator settings, CRRT, anesthesia, PT, excessive movement

Treatment of endometriosis

individualized, relieve symptoms, improve fertility (if desired) hormonal contraception, GnRH analogs, aromatase inhibitors, danazol Recurrence possible with all treatment options, including definitive surgery

immunosuppression in cell

induction immunosuppression: IL2 (Basiliximab), CD4 (Afgam, thymoglobulin), CD52 (Alemtuzumab), IL2 gene (steroids) maintenance immunosuppression: IL2R (sirolimus, everolimus), cell cycle (AZA), CD80 and 86 (belatacept), calcineurin (tacrolimus, cyclosporine), de novo purine synthesis (mycophenolate)

*SOT immunosuppression model

induction-potent, immediate immunosuppression maintenance-prevent rejection while minimizing drug-related toxicity

SOT immunosuppressive agents

induction: depleting antibodies, nondepleting antibodies HD IV steroids maintenance: CNIs, CS, antimetabolites, proliferation and co-stimulatory signal inhibitors

*characteristics of poop

infants have frequent BM that decline after 2y and become predictable after 4y light, white, or clay colored-barium swallow, barium enema, lack of bile, possible sign of liver or gall bladder disease yellow-common in babies, but if it's greasy and smells bad it can be a sign of fat in the stool; may be a sign of celiac disease, pancreatitis, or lactose intolerance green-food coloring, green veggies, iron supplements black-babies' first poops are black and thick, bleeding in upper GIT, bismuth subsalicylate, iron supplements, black licorice, blueberries red-lower GI bleed, hemorrhoids, inflammation or polyps in the colon or cancer, iif bright red (otherwise could be food coloring, beets, or tomatoes)

*precipitating factors DKA and HHS

infection (most common), inadequate insulin, pancreatitis, MI, CVA, drugs (corticosteroids, sympathomimetics, thiazides, pentamidine), new onset T1DM or T2DM in elderly, eating disorders

8IBD differential diagnosis

infectious diarrhea, diverticulitis, Celiac disease (IgA tTG), IBS, colon cancer

*pancreatitis

inflammation of the pancreas with variable involvement of regional tissues or remote organ systems AP (acute) or CP (chronic)

lupus nephritis

inflammation that can lead to kidney failure requiring dialysis and/or transplant 35% present with LN sx at diagnosis, 60% will develop within 10y

IBD

inflammatory bowel disease-group of chronic, idiopathic, relapsing GIT disorders believed to be the result of dysregulation of the mucosal immune system e.g. UC and CD

*residual hyperpigmentation

inflammatory lesions can trigger hyperpigmentation-persists for weeks to months

orlistat

inhibits GI lipase activity (stomach and pancreas, decreases fat absorption 60 (Alli OTC) or 120mg (Xenical Rx) TID with fat containing meals 30% of ingested fats excreted in feces; recommended to eat low fat meals AE: ADEK absorption decreased, soft stools, rectal leakage, choleslithiasis, nephrolithiasis (oxalate-induced kidney stones) consistent, modest weight loss, LDL and BP improvement DDI: cyclosporine; action on vit K may potentiate warfarin CI: chronic malabsorption syndrome, cholestasis, Ca oxalate stones, pregnancy

methotrexate and psoriasis

inhibits replication and fx of T and B cells and suppresses secretion of cytokines folate supplementation on the 6d of the week you don't take methotrexate AE: loss of appetite, stomatitis, fatigue, hepatotoxicity, lung disease, severe skin rxns, opportunistic infection, tumor lysis syndrome BBW: bone marrow depression

infusion rate PN

initiate PN gradually over 12-24h to desired rate d/c in a stepwise fashion: 1/2 one hour prior to d/c (may add another step for 1h) -abrupt stop can cause hypoglycemia because the pancreas is pumping insulin -if the pt needs a test that can't wait an hour or two, use D10 at the same rate cyclic PN infusion (compression PN)-12h infusions for those that go home on PN

*ULT

initiate with any one of the following: tophi, 2+ attacks/yr, CKD stage 2+, hx stones pts may choose not to initiate ULT, reassess that choice with subsequent attacks target <5-6 mg/dL, monitor q2-5w during dose titration, q6mo once at target DOC: XOI (if pt fails one try the other one) secondline: uricosuric agents: probenecid, fenofibrate, losartan thirdline (severe gout in refractory pts): pegloticase, d/c other therapy

*diabetic agents

injectables: insulin, amylin mimetic, GLP1RA oral agents: SU, AGI, meglitinides, biguanides, SGLT2i, TZD, dopamine agonist, BAS, DPP4i

SLE classification

instruments are often expensive and time consuming, may require training unlike CDAIs for RA and CD, there is no preferred instrument mild: skin rashes, HA, fatigue, mild pain moderate: higher amounts of above sx plus thrombocytopenia and/or anemia severe: major organ damage e.g. LN

nonpharmacological treatment Cushing's

transsphenoidal (TOC) or irradiation for a tumor chemo for cancerous tumor

deprescribing PPIs

intermittent and on-demand dosing not recommended on PPI use PPU to heal the esophagus and treat sx while the pt implement lifestyle modifications to reduce risk of recurrence should f/u 4-12w and 6-12mo after deprescribing to assess for sx recurrence deprescribing should not occur in pts with a history of Barrett esophagitis, severe esophagitis, bleeding ulcers, and GI prophylaxis deprescribing should be attempted at least once a year in most adults

aloprostadil injection tips

into corpora cavernosa at a 90 degree angle with the skin on the upper side of the penis. Do not inject near the underside or the very top where the vessels are. Alternate sides for injection and do not use constantly to prevent plaque formation

corticosteroids and OA

intra-articular injection Indication: Short-term symptomatic relief of OA pain of the knee MOA: Inhibit accumulation of inflammatory cell lines, reduce prostaglandin synthesis, inhibit leukocyte secretion from synovial cells, and decrease interleukin secretion by the synovium SE (local): Infection, osteonecrosis, tendon rupture, and skin atrophy Caution: Injections should be limited to 3-4 times annually Counseling Points: Minimize activity and stress on the joint for several days after injection. Pain relief will be seen 24-72 hours after injection. Specific Drugs: All corticosteroids have equal efficacy at equipotent doses; Drug choice is based on provider preference/experience. -Triamcinolone acetonide (Kenalog®) -Betamethasone (Celestone Soluspan®) -Methylprednsolone (Depo-Medrol®)

*indications for parenteral nutrition

intractable vomiting (severe acute pancreatitis), diarrhea (enteral feeding intolerance, Graft vs Host disease, severe IBD flare), mucositis (chemo), ileus (severe trauma/major abdominal surgery, EN not possible for 7d, s/p Whipple or sepsis), small bowel obstruction (secondary to CA), malabsorption (severe mucosal injury, short bowel syndrome, radiation enteritis), enteral feeding intolerance (high gastric residuals), severe malnutrition before elective surgery (minimum of 10-14d of TPN which is the time to restore cellular immunity and serum proteins) initate ASAP in high nutritional risk; low risk should wait 7-10d before initiating or supplementing EN if unable to meet 60% energy and protein requirements

*IUD

intrauterine device

*IUS

intrauterine system

*factors contributing to fall risk

intrinsic factors: balance and gait problems, visual impairments, impaired cognition extrinsic factors: inappropriate footwear, inappropriate medications environmental factors: bad lighting, loose rugs or uneven floors, lack of railing or safety equipment

liver biopsy

invasive, ONLY way to diagnose cirrhosis definitively

*Energy Provided by Parenteral Nutrition Macronutrients

kcal/g, dextrose 3.4, aminoacids 4, IVFE 10 (due to addition of glycerol) IV dextrose infusion rate <5 mg/kg/min (4-7 depending on hospital) IVFE available as soybean or safflower/soybean emulsions in 10%, 20%, 30%. These IVFE products differ in phospholipid (PL) and TG concentrations. 10%: 1.1 kcal/ml (higher PL:TG ratio); 20%: 2 kcal/ml; 30% 3 kcal/ml CI: egg allergy

*nail care advice for diabetes

keep them short, but not short enough to risk cutting yourself cut them straight across clean and dry-no lotion!

NSAID most likely to cause GI bleed

ketorolac

NSAID most likely to cause PUD

ketorolac

*NSAIDs and conjunctivitis

ketorolac (Acular, Acular LS, Acuvail), flurbiprofen (Ocufen), bromfenac, diclofenac

acute rejection by organ

kidney: 20% in the first 6mo; liver: 18% in the first year; heart: 16% in the first year; lung: 36% in the first year

nonpharmacological treatment IBD

lactose intolerant should avoid milk products or supplement with lactase small-bowel strictures should avoid citrus fruits and nuts smoking cessation (exacerbates disease activity and recurrence in CD; Nicotine appears protective in UC) avoid alcohol (may exacerbate symptoms) avoid NSAIDS in CD (may exacerbate disease activity) assess and manage stress, depression, and anxiety which are associated with poor adherence and decreased health related quality of life (CD) enteral (preferred method if needed)-may facilitate induction of remission in CD parenteral-preferred in severe CD and severe UC when bowel rest is indicated or to improve nutritional status prior to surgery -may facilitate induction of remission in UC -beneficial (short term) in children and adolescents with growth retardation probiotics have shown effectiveness in maintaining remission in UC surgery

*Factors Affecting Infant Drug Exposure

largely via passive diffusion through capillary walls into mammary gland high bioavailability, low protein binding, and higher doses-more available to cross long t1/2-more time for drug to cross weak bases-drug may become trapped in milk high lipid solubility and MW <300-drug more readily crosses e.g. CNS drugs *preterm and newborns-most susceptible-immature metabolism and excretion, unstable RBC membrane (hemolysis from nitrofurantoin, phenazopyridine), immature BBB (increased sensitivity to CNS depressants)*

*continuous pt assessment in RA

medication review q6mo all biologics d/c in severe infection then restarted once infection has resolved d/c if PML develops (mostly rituximab-anti-TNF) closely monitor for TB or HBV

ophthalmic PG analogs

latanoprost (Xalatan)-store in fridge and protect from light, RT for 6 weeks bimatoprost (Lumigan)-approved cosmetic use of solution (Latisse) travoprost (Travatan Z)-local irritation may be less because it is free of the preservative benzalkonium chloride tafluprost (Zioptan)-preservative free, fridge required, care in handling the single-use packages to minimize risk of infection, immediately discard unused solution

DI diarrhea

laxatives, Mg-containing antacids, chemotherapy, gold salts, metformin, tetracyclines, sulfonamides, broad-spectrum antibiotics, reserpine, colchicine, methyldopa, misoprostol, PPIs, H2RAs, ACEIs, bethanechol, neostigmine, quinidine, digoxin, NSAIDs

*diabetic retinopathy

leading cause of adult-onset blindness Optimize glycemic, BP, and lipid control (reduce risk/slow progression) Screening: T1D—Comprehensive (dilated) eye exam within 5 yrs dx; T2D—at dx; before pregnancy or in first trimester in preexisting diabetes Repeat annually if retinopathy present; well controlled glycemia consider 1-2 yrs Trmt: referral ophthalmologist; laser photocoagulation or intravitreous anti-vascular endothelial GF

LEF for RA

leflunomide (Avara), firstline at any stage/severity (esp when MTX intolerated) recommended in combo with MTX in pts with high disease regardless of prognosis with a disease duration of 6+mo onset 1-2mo; SE: hepatotoxicity, diarrhea; CI: pregnancy, chroic liver disease baseline: CBC, LFTs, TB, and pregnancy test CBC and LFTs monthly for 6mo than q6-8w thereafter

breast cancer and CHC

levonorgestrel IUS increased risk but did not increase with duration of use results inconsistent among other progestin-only methods after d/c risk was still higher for 5+y 1 extra breast cancer dx for every 7690 women using CHC for 1y varied with age: 1 for every 50,000 women <35 did not account for breastfeeding, alcohol consumption, or physical activity is the data generalizable? only white women meta-analyses have shown 8-24% inccreased risk risk difference between users and nonusers is small must consider noncontraceptive benefits-decreased ovarian, endometrial, and colon cancer so the overall cancer risk may be slightly lower in users consider pregnancy risk-2015 maternal mortality 26 deaths per 100,000 women8

LNG

levonorgestrel, Plan B One-Step, Aftera, EContra EZ, My Way, Next Choice One Dose, Take Action, Opcicon One-Step, React 88% effective if taken within 72h; moderately effective within 120h inhibit or delay ovulation, does not appear to impair implantation Available OTC without age or point-of-sale restrictions Decreased effectiveness in overweight and obese patients SE: nausea and irregular bleeding

*IUDs

levonorgestrel-Mirena (5y), Liletta (5), Kyleena (5), and Skyla (3-smaller and better for women before childbirth) copper IUD (10y)

ED tx

lifestyle changes-diet, exercise, tobacco, ETOH psychotherapy as monotherapy or as adjunct to specific therapies VEDs, PDE5i, alprostadil, surgical therapy, testosterone for hypogonadism last line: penile prostheses (inflatable pump in scotum, usually for those with radical prostectomy)

management of NODAT

lifestyle modifications, reducing steroids if possible switch from TAC to cyclosporine go directly to insulin therapy if FPG>200 (40% of pts) use metformin with caution as there is a risk of lactic acidosis in those with moderate renal impairment

antispasmodics/anticholinergics

limited use in diarrhea due to SE profile management of abdominal pain and/or bloating associated with IBS-D SE: dry eyes, dry mouth, urinary retention, constipation, drowsiness, etc. use with caution in the elderly (Beers Criteria) hyoscyamine (Levsin, Levbid, HyoMax) 0.25-0.5mg IV, IM, or SubQ Q4H PRN (Max 4 doses/24 hours) or 0.375-0.5mg ER PO Q12H PRN (Max 1.5 mg/24 hours) or 0.125-0.25 PO or SL Q4H PRN (Max 1.5mg/24 hours) -for GI spasm, adjunct in IBS, etc. Atropine, Hyoscyamine, Scopolamine, and Phenobarbital (Donnatal®) Dosage: 1-2 IR tablets or 1-2 teaspoons PO 3-4 times daily or 1 ER tablet Q8 to 12 hours PRN Indication: Adjunct in treatment of IBS Chlordiazepoxide/Clidinium (Librax) Availability: Rx only Dosage: 1-2 capsules PO 3 to 4 times daily before meals and at bedtime Indication: Treatment of IBS, spastic colon, anxiety disorders, etc. Dicyclomine (Bentyl®) Availability: Rx only; IM, PO (tabs or syrup) Dosage: 20 mg QID increasing to 40mg QID Indication: Treatment of functional disturbances of GI motility including IBS Note: Lose efficacy with long term, scheduled use. Use PRN only. Meta-analyses found these drugs ineffective in IBS yet they are still prescribed. Peppermint Oil Capsules (OTC) Dose: 1 capsule BID Availability: OTC capsule Data: One small clinical trial showed that 25% of patients who took peppermint oil capsules for 3 months continued to have IBS symptoms compared to 65% of those that received placebo SE: Heartburn, N/V

*probiotics

live, non-pathogenic microorganisms that adhere to epithelial cells in the GIT and produce antimicrobial substances that modulate immunity and influence metabolic activities in the GIT indicated for diarrhea due to imbalance in intestinal flora, prophylaxis with antibiotics (diarrhea as SE), and IBS e.g. lactobacillus (Lactinex, Flora-Q, Culturelle, also in yogurt), bifidobacterium (Align, SimlyBiotix), combination (Nexbiotic, Probiotic by ZenWise) No sustained benefit after d/c; requires continual use for benefit evidence is lacking for acute, infectious diarrhea

*LFT

liver function tests: aminotransferases (ALT and AST), alkaline phosphatase, GGT ALT more specific for liver injury but may be normal in cirrhosis pt AST 2-6x ULN in severe alcoholic hepatitis AST/ALT ratio >2 is suggestive of alcohol liver damage alkaline phosphatase and GGT elevated together suggests hepatic disease and will need further investigation to decide if it is acute or indicative of cirrhosis

*What is metformin's main site of pharmacologic activity? Which BG level is targeted?

liver-inhibits HGP affects FPG

OA characteristics

location: Weight-bearing joints (knees, hip, low back, hands)—Asymmetrical but may be symmetrical in some cases Non-inflamed joints, narrowing of joint space, restructuring of bone and cartilage (resulting in joint deformities—late stage), possible joint swelling, +/- joint enlargement, limited range of motion (ROM), crepitus Dull join pain relieved by rest, joint stiffness < 20-30 min (worse upon waking and after sitting long periods, alleviated by motion), tenderness Insidious development over many years Genetic, metabolic, and environmental factors exacerbating factors: Obesity (unless in hands only), lack of activity, heavy physical activity, repetitive movements, trauma modifying factors: Continuous exercise (light-to-moderate activity as tolerated), weight loss, oral analgesic medication, topical pain relievers

*LAI

long-acting insulin analogues-mimic basal insulin secretion; Lower risk of hypoglycemia than intermediate-acting insulins e.g. glargine, detemir, degludec

*Contraceptive Selection: No Risk Factors or Specific Issues

long-term: DMPA, implant, or IUD short-term: COC, monophasic with placebo days preferred, *20-25mcg EE and 1st or 2nd generation progestin,* patch and ring appropriate also prefer fewer or no withdrawal bleeds: extended or continuous use

*antimotility drugs for IBS-D

loperamide, DOC, consider pretreatment (2mg or 4mg) before leaving home diphenoxylate/atropine (Lomotil)-2nd line cholestyramine (Questran) for refractory IBS-D when bile acid malabsorption suspected/confirmed; 4g QD to BID (max 24g/d) SE: Decrease absorption of fat soluble vitamins (A, D, E, and K) and folic acid mix with liquid and drink quickly (tastes bad) and may cause tooth discoloration and decay; may decrease absorption of concurrent medications so give other medications 1 hour before or 4 to 6 hours after

*T2DM

lose 5-7% beta cell function each year possibly due to glucose toxicity, lipotoxicity, insulin resistance, age, genetics, or incretin deficiency low mitochondial function and density increased glucagon release due to GLP1 or insulin resistance/deficiency Peripheral insulin resistance Relative insulin deficiency—insufficient to normalize plasma glucose levels Progressive loss of β cell mass & function (not autoimmune) Overweight, abdominal obesity, HTN, DLD, and elevated plasminogen activator inhibitor-1 (PAI-1) levels; 90-95% Strong genetic predisposition; polygenetic More common in all ethnic groups other than those of European ancestry Prevalence increases with age Increased risk of developing CVD

medication effect on body weight

loss: anticonvulsants (topiramate, zonisamide, lamotrigine), antidepressants (bupropion, venlafaxine, desvenlafaxine), antipsychotics (ziprasidone) neutral: antipsychotics (haloperidol, aripiprazole) gain: antidepressants (MAOI, TCA, SSRI, mirtazipine), antipsychotics (olanzapine, risperidone, clonzapine, quetiapine), antidiabetics (insulin, SU, TZD, meglitinide), glucocorticoids, progestins, divalproex, mood stabilizers (lithium, carbamazepine, gabapentin, valproate), cyproheptadine, alpha blockers, BB

*choosing an NSAID for CV and GI risk

low CV risk and low GI risk: NSAID alone (least ulcerogenic at lowest effective dose) low CV risk and moderate GI risk: COX2, NSAID+PPI, NSAID+misoprostol low CV risk and high GI risk: COX2+PPI, COX2+misoprostol, CAM high CV risk and low-mod GI risk: naproxen+PPI, naproxen+misoprostol high CV risk and high GI risk: avoid NSAID and COX2 and use alternative high CV risk defined as needing ASA for CV benefit

*corticosteroids for RA

low dose oral steroids upon diagnosis for up to 3mo to control sx of pain and synovitis until DMARDs can take effect ("bridging") high dose PO or IM or IV steroid "bursts" followed by a rapid taper (po only) intra-articular injections- at least 3mo between injections, max 3x/year DDI: may increase risk of bleeding with anticoagulants or NSAIDs short term SE: elevated BP and BG, emotional instability, insomnia, mood swings, edema, appetite stimulation long term SE (>6mo): OP, weight gain, T2DM, cataracts, HTN, CHF, increased infection risk, impaired wound healing divided doses in the evening may cause sleep disturbances but prevent morning stiffness-patient preference taper by 5-10mg every week until 2omg then 2.5-5mg weekly until d/c prednisone (oral, IV), methylprednisolone (oral, IM, intra-articular, IV) triamcinolone (IM or intra-articular)

*anthralin and psoriasis

lower efficacy than topical corticosteroids or retinoids as monotherapy limit application to affected areas; can cause skin irritation and staining (black)

*LES

lower esophageal sphincter decrease in muscle tone can lead to reflux of stomach acid into the esophagus

analgesia in CP

lowest effective dose of least potent analgesic most effective when given before meals opioid only if pancreatic enzyme replacement failed to control pain consider transdermal with severe maldigestion, malabsorption, or with increasing pill burden consider adjunct therapy with antidepressants (TCAs, SSRIs, SNRIs), gabapentin or pregabalin which may affect pain and potentiate opioid analgesic effects least potent to most potent: APAP, tramadol, hydrocodone, meperidine, morphine, oxycodone, hydromorphone, fentanyl

hyaluronic acid and OA

lubricant injection, no longer recommended

severe complication of SLE

lupus nephritis Atherosclerosis and coronary artery disease Pericarditis or endocarditis Pleurisy, pulmonary embolism, or pulmonary edema Pancreatitis, peritonitis, enlarged liver or spleen Anemia or thrombocytopenia Antiphospholipid antibody syndrome (APS) -Leading to severe clotting complications (ie. DVT, stroke, miscarriages and pregnancy complications) Neurological problems (ie. Memory loss, alterations in thinking and judgment, neuropathies, seizures, strokes, etc.) Mental health problems (Ranging from mild anxiety/depression to severe psychosis, delusions or hallucinations, or mania)

tetracyclines for rosacea

mainstay of oral abx therapy in rosacea for its anti-inflammatory effects highly effective in papulopustular subtype with only 3-4 weeks of therapy Use in combo with topical agent and then taper after control is reached some patients require long-term low-dose oral abx doxycycline-high dose for 14d then moderate for one month then low dose for 3-5mo. <50mg/d is sub-antibacterial and therefore less likely to induce bacterial resistance Use suncreen!!!

chronic rejection

major cause of graft loss persistent perivascular and interstitial inflammation common in kidney, liver, heart unlike acute rejection, chronic is not reversible with any immunosuppressants

*MHC

major histocompatibility complex

*delivering an injection

make sure the skin is clean and free of any scarring pinch the skin and push the needle straight in at a 90 degree angle Inject the insulin at a moderate steady pace and leave the needle in for 10 seconds rotate sites-if you don't rotate enough your skin can swell and thicken. Then that spot will be harder to inject in the future

CP complications

maldigestion/malnutrition, chronic pain, steatorrhea, T3DM, pancreatic cancer, OP and fractures (vit D and E deficiency)

diarrhea complications

malnutritions, diminished growth, impaired cognitive development, death, fluid/electrolyte imbalance, acid-base disturbance, cardiovascular collapse

*DM management in older adults

manage: hyperglycemia, RF, comorbidities, drug safety avoid: hypoglycemia, hypoTN, polypharmacy, DDI older adults may have more neuroglycopenic manifestations (dizzinesss, weakness, delirium, confusion) that may be misconstrued as TIA may increase risk of MACE and cardiac autonomic dysfunction severe episodes require hospitalization assoc. with increased risk of dementia falls with mild episodes may lead to long-term care placement Use secretagogues (SU and meglitinides) and insulin with caution

bilirubin

marker of liver function-product of breakdown of hemoglobin molecules elevation indicates defects in transport, conjugation, and excretion by the liver (pretty much the only thing that does break it down). Normal level is 3-5. 6.5-7 is when we worry. Double digits merits full investigation. Causes the yellowing of skin.

follicular phase

maturation of the dominant follicle, increased FSH, estradiol, endometrium, and coagulation factors; estradiol peaks midcycle, ovum, 6-14d

*MODY

maturiry onset diabetes of the young, autosomal dominant, usually <25yo impaired insulin secretion with minimal defects in insulin action genetic testing recommended as mutation directs treatment *SU recommended for the most common variant*

disease/trauma-related malnutrition

may appear thin or normal with peripheral edema, ascites, or anasarca some muscle wasting but retention of some body fat pale face, hair, and skin delayed wound healing

*osteopenia

may be a precursor to OP, but is not a disease lesser degree of bone loss; T-score between -1 and -2.5

Chasteberry (chastetree) and PMS/PMDD

may be effective for irritability, mood alteration, HA, and breast fullness SE: nausea, heartburn, hypermenorrhea, diarrhea, GI upset

SLE etiology

may be related to alternations in DNA methylation and histone modifications that can lead to changes in gene expression men with Klinefelter's (XXY) and women with Turner's (XO) increased risk smoking, tanning, infections, medications (vaccines, biologics), psychological or physical stress, silica dust, petroleum, solvents, cleaners, dyes, pesticides, imbalance within the gut microbiome Ruminococcus gnavus linked to increased incidence of SLE and LN more common in women than men trigger type impacts the site of predominant symptom

*pump advantages

may permit tighter control and greater flexibility can do basal-bolus with a single insulin more precise dosing (0.025 units/h) that can be adjusted hourly requires intensive self-care consider for pts with hypoglycemic unawareness concurrent CGM use

morning sickness

meclizine, promethazine, pyridoxine (B6) +/- doxylamine, ginger, ondansetron; [Thiamine (B1) is given to patients with hyperemesis gravidarum to prevent Wernicke Encephalopathy]

*surgery for obesity

metabolic surgery for those >40 or BMI>35 with comorbid conditions that have failed behavioral/pharmacologic tx -complications: nausea, stomach ulceration, anemia, nutritional deficiencies (iron, B12, folate, C, A) laparascopic adjustable gastric banding for BMI 30-40 with at least one obesity-related comorbidity-decreased m/m 20-30kg weight loss maintained for 5y; good likelihood for DM remission but have to continue the lifestyle modifications or the weight and the DM could come back

*SU ADMET

metabolism: liver CYP2C9; glyburides active metabolites, renally excreted AE: hypoglycemia, weight gain, rash, photosensitivity, dyspepsia, nausea, HA, hemolytic anemia, GI upset, cholestasis CI: hypersensitivity, DKA, T1DM, severe liver or kidney disease, hypoglycemic unawareness caution in sulfa allergy, G6PD deficiency

antimetabolites

metabolized to active form, noncompetitively and reversibly inhibits inosine monophosphate dehydrogenase (IM PDH), decreasing the proliferation of B and T lymphocyte used in conjunction with CNIs and CS-allows for lower CNI doses to reduce associated toxicities avoid live vaccines e.g. mycophenolate, AZA (azathioprine)

*DM drug therapy if need to minimize hypoglycemia

metformin firstline If A1C above target: DPP4i, GLP1RA, SGLT2i, or TZD If further intensification: combination of agents above If further intensification: consider basal insulin or SU

*DM drug therapy if need to promote weight loss

metformin firstline If A1C above target: GLP1RA or SGLT2i If further intensification: add the other class If further intensification: DPP4i if not on GLP1RA If DPP4i CI or intolerated: cautious addition of SU, TZD, or basal insulin

*DM drug therapy when ASCVD predominates

metformin firstline If A1C above target: GLP1RA or SGLT2i (if eGFR adequate). If further intensification or intolerant: add the other class, DPP4i if not on GLP1RA, basal insulin (degludec or glargine), TZD, or SU

*DM drug therapy if HF or CKD predominates`

metformin firstline If A1C above target: SGLT2i CI or intolerated: GLP1RA If further intensification: Avoid TZD but consider DPP4i (not saxa- if HF) if not on GLP1RA, basal insulin, or SU

*DM drug therapy if cost is a major issue

metformin firstline If A1C above target: SU or TZD If further intensification: add other class If further intensification: basal insulin, DPP4i, or SGLT2i

CD assessment

mild-mod: ambulatory with oral feedings without signs of systemic toxiciy mod-servere: fever, weight loss, abdominal pain, N/V, significant anemia severe fulminant: persistent sx despite standard therapy or with signs of severe systemic toxicity remission: endoscopic, clinical (weeks-years without sx), surgical CDAI (marker of CD) used more as an academic or research tool than in practice

pharmacological management of acute gout attack

mild-moderate: monotherapy with NSAID, systemic CS, or colchicine -if adequate response continue for 24h then dc/taper -if <20% pain improvement in 24h or <50% after 24h, switch to alternate monotherapy or use combination severe: colchicine + NSAID (+/- intra-articular steroid) or colchicine + oral CS (+/- intra-articular steroid) -if adequate response continue for 24h then dc/taper -if <20% pain improvement in 24h or <50% after 24h, consider alternate diagnosis

acute pancreatitis

mild: specialized nutrition is not recommended unless unable to advance to oral diet within 7d moderate to severe: start EN at a low-volume rate within 24-48h of admission and advance to goal as tolerated-consider use of probiotics with severe on EN -if EN not feasible, use PN after 1 week from the onset of symptoms

CREDIT

mnemonic device to identify source of exposure and infection in SOT patient C - Community acquired R - Reactivation E - Epidemiologic exposure D - Donor derived I - Iatrogenic T - Travel related

*PEDIS Grade 3

moderate Local infection with erythema >2 cm OR involving structures deeper than skin and subcutaneous tissue AND with no systemic involvement (No SIRS signs) Treatment duration: 2-3 weeks of outpatient vs. inpatient therapy Choose inpatient if the infection is limb-threatening or potentially life threatening IV-Vancomycin with good gram positive coverage. Merepenem is good because its once daily, but it's expensive.

nonpharmacological tx RA

moderate rest, PT, OT, assistive devices (orthotics, splints), weight reduction, heat/cold therapies, emotional support, smoking cessation, exercise (cycling, swimming, water aerobics, walking), surgery (not curative)

macrolides for acne

moderate to severe acne in young patients, pregnant females, or pts with tetracycline hypersensitivity or resistance high rate of resistance compared to tetracyclines-combo with BPO AE: GI upset, candidiasis

apremilast and psoriasis

moderate-severe plaque psoriasis, expensive PDE4i that provides regulation of multiple inflammatory mediators AE: nausea, diarrhea, weight loss; DI: major substrate 3A4

*other causes diabetes

monogenic diabetes syndromes exocrine disease chemical induced endocrinopathies

Combined hormonal contraception for PMS/PMDD

monophasics used continuously may provide most benefit (PREFERRED) superiority of any one agent has not been shown Yaz/Beyaz-beneficial for mood, physical, and behavioral sx

bismuth salts

monotherapy for dyspepsia or combo to treat H. pylori SE: black stools and tongue, ringing of ears CI: hypersensitivity, children <=12 caution: renal impairment may decrease elimination; use in caution in pts with concomitant salicylates or those with salicylate sensitivities e.g. Pepto Bismol, Kaopectate, Maalox Total Relief

Cushing's clinical presentation

moon face, central adiposity, buffalo hump (dorsocervical fat pads), supraclavicular fat pads, abdominal striae, HTN in 75%, glucose intolerance in 60% central obesity can lead to metabolic syndrome-higher risk for DM and CVD If untreated, those with Cushing's die within 5 years from cardiovascular causes

Medications Known to Interact with EN

phenytoin, warfarin, FQs, TCN, antacids, PPI should NEVER go down NG or OG tube!!!

*Common microbes in diabetic foot infections

most DM foot infections are chronic and polymicronial. They may start with Staph from stepping on a nail and then it creates an environment for GNR to join aerobic GPC most common-Staph and Strep aerobic GNR-Proteus, E. coli, Pseudomonas obligate anaerobes-ischemic or necrotic wounds-Bacteroides, Peptococcus

diarrhea etiology

most acute diarrhea (gastroenteritis, stomach flu) cases are infectious and self-limiting caused by inflammation of the lining of the stomach and intestines typically 1-3d for viral, 3-7d for bacterial, and weeks-months for protozoa transmission: food, water, objects, person-to-person often accompanied by N/V, fever, abdominal pain or cramping, bloody stools, tenesmus or fecal urgency, bloating/flatulence bacterial (80-90% traveler's) cause more serious diarrhea e.g. Salmonella, Campylobacter, E. coli, Shigella, Vibrio cholerae, C. difficile common viral culprits e.g. calciviruses (norovirus and sapovirus) and rotavirus -responsible for 1/3 of all diarrhea hospitalizations -norovirus is the most common cause in adults and school-aged children -rotavirus is the most common cause in infants and children-can also infect adults exposed to a child with the virus

Acute Cellular Rejection

most common in the first 3-6mo-mediated by alloreactive T-lymphocytes that appear in the circulation and infiltrate the allograft through vascular endothelium -local release of lymphokines attracts and stimulates macrophages pain, tenderness, lethargy, fever, increase in SCr, proteinuria, increase in BP biopsy needed to dilineate what type of acute reaction is occuring

*progestin-only SE

most common is irregular menstrual bleeding (usually lighter)-some amenorrhea HA, weight gain, acne, breast pain, formation of ovarian cysts is possible worsening depression-not usually a problem unless severe or uncontrolled -can still be put on ORAL progestin so that it can be dc'd quickly

HRT SE for menopause tx

most common with EPT (estrogen-progestin therapy): resumption of vaginal bleeding, breast tenderness; also nausea, weight gain, edema, HA, PMS-like sx, increased vaginal discharge, BP changes possible (monitor)

NSAIDs and ulcers

most ulcerogenic (safer for heart)-salicylates lke aspirin and salsalate nonselective NSAIDs-ibuprofen, naproxen, indomethacin, ketorolac partially selective: etodolac, diclofenac, meloxicam, nabumetone least ulcerogenic (less safe for heart)-selective COX2i celecoxib

isotretinoin AE

mucocutaneous effects-drying of mouth, nose, eyes (avoid contacts), skin, rarely genito-anal mucosa SE and treatment: pain (NSAIDs), photosensitivity (sunscreen), lipid disturbances and liver fx (reversible), acne flare at initiation of therapy (counsel, start low), alopecia (reversible), depression (counseling, antidepressants) BBW: aggressive behavior can cause premature closure of epiphyses

*HTN management in DM

multiple drug therapy usually required: ACEI (max tolerated dose 1stline in pts with DM esp with albuminuria), ARBs, thiazides, DHP

*mycophenolates

mycophenolate mofetil (CellCept, MMF, IV, PO), mycophenolate sodium (Myfortic, MPA), NOT interchangeable, 1000 MMF=720 MPA take on empty stomach early in post-transplant period efficacy of OC may decrease with therapy-2 forms of BC 4 weeks before and 6 weeks after if pregnancy occurs, DO NOT STOP TAKING without talking to MD AE: N/V/D, dose-dependent abdominal pain, leukopenia, thrombocytopenia, anemia, pancytopenia, HTN, first trimester congenital malformations

*opportunistic infections and transplant

natural consequence of immunosuppression usual signs and symptoms may be absent in intensive regimens most occur during the first 6mo after transplantation CMV, VZV, EBV, T. gondii, P. jiroveci, and Mtb

fiber

natural, complex carb in plants, either soluble or insoluble, both necessary cannot be absorbed by digestive system and insead slows digestion and makes your stools softer and easier to pass

*How do diabetic foot ulcers occur?

neuropathy, poor circulation, foot deformities, irritation, trauma wound healing is complicated by vascular disease and poor glycemic control lack of blood flow thus decreased WBC migration and angiogenesis

*NPH

neutral protamine hagedoen; intermediate; Humulin *N*, Novolin N milky suspension that mimics basal insulin secretion and provides a more labile glucose response *BID in T1DM and for best control in T2DM (may be QD until pt loses fx in beta cells)* mix well-roll or turn end to end for a pen addition of protamine (NPL-lispro protamine suspension, aspart protamine suspension) delays onset, peak, and duration of insulin effect

What could be the issue behind intermenstrual bleeding (breakthrough bleeding, spotting)? How should we counsel our patients who are experiencing this?

new birth control?-ride it out for 2 or 3 months before considering a change drug interaction?-reevaluate meds hormone disorder? (e.g. pituitary issues)-fix disorder if possible non-compliance?-set a timer, make a schedule

NODAT

new-onset DM after translantation (5-30%) CNIs inhibit insulin production and decreases secretion (CsA<tacrolimus) mTOR inhibitors impair beta cell response and increase insulin resistance CS induce insulin resistance and impair peripheral glucose uptake

*Somogyi Effect

nighttime hypoglycemia which causes a release of counterregulatory hormones leading to pre-breakfast hyperglycemia and symptoms such as diaphoresis, HA, nightmares, and tingling around the mouth. Check 3am BG for a couple of days to confirm hypoglycemia Decrease nighttime basal insulin dose or change NPH dose from supper to bedtime (You've overdone the insulin and the hormones are overcompensating)

pain tx in pregnant women

nonpharmacological treatment first when appropriate mild to moderate-firstline APAP; single doses of ibuprofen unlikely to cause harm, but avoid NSAIDs in 3rd trimester (PG inhibitors can close fetal duct from aorta to pulmonary artery) severe-short term opioids, if pts are opioid dependent they should generally d/c

first generation progestins

norethindrone, norethindrone acetate, ethynodiol diacetate estrogen, progestin, and androgen activity

third generation progestins

norgestimate, desogestrel very little to no estrogen activity, progestin activity, and androgen activity

*second generation progestins

norgestrel, levonorgestrel (most androgenic) no estrogen activity, high progestin and androgen activity

*Provider Foot Exam Schedule

normal exam-repeat annually loss of sensation only-q6mo recommend soft molded shoe insoles loss of sensation and PAD, deformities or onchyomycosis-q3mo and insoles

SSRIs and PMS/PMDD

normal hormone fluctuation may trigger reductions in 5HT and other NTs TOC for PMDD and severe PMS (FDA: fluoxetine, sertraline, paroxetine CR) reduces irritability, depressed mood, dysphoria, psychosocial fx, bloating, breast tenderness, appetite changes may experience relief within the first cycle of use continuous or intermittent during luteal phase SE: insomnia, fatigue, decreased libido, nausea, dry mouth

NTC

normal transit constipation AKA functional constipation or CIC (chronic idiopathic constipation)-most common type of primary constipation colinic motility unaltered and pelvic muscle function is normal generally respond well to increased fiber, water, and laxatives

preventing OP and vitamin D

normal vit D 20-40ng/mL, goal 30 fortified milk, liver, fatty fish, fortified cereals, ricotta cheese, orange juice, egg yolk, COD liver oil, mushroom, caviar only 20 min of sunlight 3x/w is enough to synthesize sufficient vit D in most do not exceed more than 4,000 IU/day-increased athersclerosis, MI, and mortality in pts with serum vit D >36 ng/mL renal or hepatic disease may require Rx supplementation Rx capsules vit D3 (Cholecalciferol) OTC-available in combo with calcium vit D2 (Ergocalciferol) Rx 50,000 IU capsules of 8000 IU/mL solution 1 capsule once or twice a week for vitamin D deficiency

*testosterone

not indicated in OP, used off label in men with low testosterone levels stimulate bone formation (androgen effect) and slow bone loss (estrogen effect) more benefit from estrogen effect studies have shown that replacing testosterone which is then converted to estrogen in men with low levels can increase BMD (NOT if testosterone WNL) effect on fracture risk not evaluated SE: N/V, HA, oily skin, hair loss, acne, injection site rxn, mood changes if at high risk for fracture also add bisphosphonate or teriparatide should not be used for men with prostate cancer

opioids for RA

not really an indication, sometimes prescribed for mod-severe pain despite trying all other appropriate therapies; not shown more effective than NSAIDs lowest dose to achiieve pain control, most will not acheive full aleviation may lead to hyperalgesia

*glaucoma

ocular disorders that lead to an optic neuropathy characterized by changes in the optic nerve head (optic disk) associated with loss of visual sensitivity and field

Cipro

off label for CD management SE: N/V/D, tendon rupture (not recommended for children) CI: may potentiate effects of tizanidine and lead to life threatening hypoTN may take with food but separate from dairy products and vitamins decrease dose with CrCl <30mL/min

metronidazole

off label for CD management SE: diarrhea, constipation, metallic taste, peripheral neuropathy, disulfiram rxn CI: 1st trimester pregnancy; avoid alcohol for 3d after d/c; dose adjust in CrCl <10 and/or severe hepatic disease

*laryngopharyngeal reflux

often called "silent reflux"-refluxate in esophagus and back of the throat and mouth without esophageal sx like hearburn damages larynx and vocal cords, increases risk of pneumonia pts may associate sx with allergies or colds e.g. hoarseness, throat irritation, continual throat clearing, chronic cough, SOB, chronic sinus infections, asthma exacerbation, etc.

*PPI interactions

omeprazole-inhibits CYP2C19, decreasing clearance of diazepam, phenytoin, and warfarin -prevents transformation of clopidogrel to active form lansoprazole-induces CYP1A and increases the metabolism of theophylline rabeprazole-increases risk of serotonin syndrome when taken with citalopram -increases risk of hypomagnesemia, etc., when taken with tacrolimus pantoprazole-increases risk or serotonin syndrome when taken with citalopram -increases risk of hypomagnesemia, etc., when taken with tacrolimus esomeprazole,available in IV-interactions same as omeprazole dexlansoprazole (Dexilant)-can be taken without regard to meal times

*conversion formulas

once daily NPH (T2DM only) to glargine 1:1 BID NPH to glargine and degludec-reduce NPH 20% NPH to detemir 1:1 See resource

*dulaglutide (Trulicity)

once weekly 0.75 or 1.5/5mL helps encourage body to increase its own insulin like its supposed to can be unrefrigerated for up to 2 weeks wash hands check expiration make sure its not cloudy uncap the pen place against skin and unlock press until you hear a click and hold until you hear a second click you can tell its done because you can see the grey plunger put it in a sharps container

antibiotics and CD

once widely used off-label for CD, abx are NOT effective to induce remission or mucosal healing abx should be reserved for tx of perianal fistulas and after surgical draining of intrabdominal abscess to reduce recurrence

*PN Compression

only for patients going home on PN e.g. home health Day 1: infuse total daily volume over 20hrs Day 2: infuse total daily volume over 16hrs Day 3: infuse total daily volume over 12hrs

testosterone replacement

only in pts with symptomatic hypogonadism as confirmed by the presence of decreased libido and low serum concentrations of testosterone

premature ovarian failure

onset of menopause before age 40 Not all of the treatments for menopause apply to them and they always get HRT because it is abnormal for them to have menopause this early.

lupus exacerbating factors

physical and/or emotional stress, poor adherence, exposure to UV, overworked, infection, injury, surgery, pregnancy, childbirth, allergens, certain meds and vaccines

Chronic HTN tx in pregnant women

physiological decline in BP typically during 1st and 2nd trimester tx if BP >160/105 or evidence of end organ damage (BP goal <140/90) methyldopa 0.5-3g/d divided BID or TID-may not be effective for severe HTN labetalol 200-2400mg/d divided BID or TID-well-tolerated nifedipine ER 30-120mg/d-avoid IR and sublingual secondline: thiazides

*TZD examples

pioglitazone (Actos)-once daily, 15, 30, 45mg rosiglitazone (Avandia)-once or twice daily, 2, 4, 8mg

DI constipation

polystyrene sodium sulfonate, antacids with calcium or aluminum, non-potassium sparing diuretics, phenothiazines, TCAs, anticholinergics, CCBs, clonidine, antihistamine, opiates, NSAIDs, iron containing products, antiparkinson agents, PG inhibitors, succinylcholine, barium sulfate

*symptoms of hyperglycemia

polyuria, polyphagia, polydipsia

Pathophysiologic mechanisms for diarrhea

osmotic—Poorly absorbed substances retain intestinal fluids (e.g. certain foods, sugar alcohols, or Mg-containing products). Another cause is malabsorption such as lactose intolerance or Celiac disease. secretory—stimulating substance increases secretion or decreases absorption of large amounts of water and electrolytes (some medications, most common in TD e.g. toxin from cholera that alters the function of chloride channel proteins) exudative—inflammatory disease of the GI tract discharges mucus, serum proteins, and blood into the gut (CD, UC, or infection) motility—increase in intestinal motility does not allow adequate exposure to mucosal epithelium and brush border enzymes to allow absorption of fluid and electrolytes. (e.g. psychogenic, some medicines, HTR, pepper, cinnamon, alcohol)

*OA

osteoarthritis also known as degenerative joint disease (DJD) is characterized by irreversible degeneration of cartilage and underlying bone within a joint and bone overgrowth leading to joint disfiguration, stiffness, and pain OA is the most common of the rheumatic diseases OA is the most common form of arthritis worldwide OA affects over 30 million Americans compared to the nearly 1.3 million Americans with rheumatoid arthritis OA of the knee is the leading cause of musculoskeletal pain in adults in the US OA is the fifth leading cause of disability in older Americans after cardiovascular, cerebrovascular, and pulmonary diseases The annual cost of OA in America is believed to be as high as $89.1 billion—more than asthma or COPD and more than all renal and neurologic diseases combined

OP

osteoporosis-epidemic affecting 150million worldwide characterized by low bone mass and microarchitectual deterioration of bone tissue, leading to enhanced bone fragility and increase in fracture risk dx: T-score less than -2.5; severe: <-2.5 AND history of fragility fracture 1 SD decrease in BMD leads to a 1.5-3x increase in fracture risk

*malnutrition

overnutrition or undernutrition

N/V tx in pregnant women

peak 8-12w, generally resolves by 16-20 weeks smaller and more frequent meals; avoid triggers; ginger; low-fat bland, dry diet firstline: pyridoxine (vit B6) and/or doxylamine (Diclegis-10mg/10mg) (take at night because doxylamine is a sedating antihistamine) adjuncts B6: diphenhydramine, dimenhydrinate, promethazine, prochlorperazine alternatives: metoclopramide, ondansetron (may be associated with increased risk for oral cleft and/or cardiac defect) refractory: methylprednisolone

cortisol circadian rhythm

peak a little at meals and snacks, but it the highest at 8am and the lowest at 3am (nadir-lowest point)

*PPN

peripheral PN via peripheral venous access for supplemental calories only max osmolality 900 mOsm/L, max D10% and AA 3-5% *not a desirable option in fluid restricted pts* not for more than 2 weeks

Contraceptive Selection: Specific Needs

poor compliance: consider DMPA, implant, or IUD; avoid progestin-only pill acne: estrogen component of CHC may be beneficial, 3rd or 4th progestin androgenic issues: COC with 4th generation progestin epilepsy: avoid CHCs with lamotrigine; DMPA or IUDs with inducing antiepileptics endometriosis: continuous CHC firstline (want low estrogen, high progestin, high androgen); progestin only may be effective estrogen withdrawal: extended, continuous, or agents with EE in lieu of placebos bariatric surgery: avoid OC if malabsorptive surgery e.g. Roux-en-Y bypass, all types used in restrictive procedures obesity: hormonal contraceptives may be less effective; consider COC with up to 35mcg EE; consider extended or continuous; consider progestin-only or copper IUD if pt is >35yo and/or has other RF for thrombosis

*AGI disadvantages

poorly tolerated, modest efficacy, slow titration, multiple daily dosing

*Cirrhosis complications

portal HTN, HE, HRS, SBP, ascites, varices

constipation prevention

post-operatively, during pregnancy, and postpartum preferred drugs: stool softeners and bulk-forming laxatives (fiber supplements-NOT with opioids)

*HTR surgery summary

potential choice in pregnancy if antithyroid drugs cause major SE possible complications: recurrent laryngeal nerve damage, hypoparathyroidism advantages: rapid, effective tx especially in pts with large goiters disadvantages: most invasive, quality-of-life adjustment, permanent hypothyroidism, pain, scar

*Parenteral Formula Composition

potential precipitation of Ca and Phos which can be life-threatening formulas which contain vit K will affect the INR of pts on warfarin dextrose and lipid emulsion-energy substrate, amino acids-anabolic substrate, electrolytes (Na, K, Ca, Mg, PO4, Cl, acetate), MVI (C, B1, 2, 3, 5, 6, B12, biotin, folic acid, A, D, E, and sometimes K), trace elements (Zn, Cu, chromium, manganese, selenium), possible additives (famotidine, regular insulin)

*Which drug is indicated for use with prandial insulin?

pramlintide

TCAs in IBS

preferred in IBS-D; may take up to 8w for benefit SE: anticholinergic (dry mouth and eyes, urinary retention), QT prolongation, constipation, dizziness, drowsiness, and weight gain e.g. amitriptyline-more SE, *nortriptyline, desipramine*

Progestin-Only Contraceptives

preferred in breastfeeding, long-acting contraception, and estrogen-related SE CI in pts with current breast cancer avoid in breast cancer hx, acute liver disease, and undiagnosed vaginal bleeding inconsistent inhibation of ovulation, thicken cervical mucus, induce endometrial atrophy (prevent implantation) "mini pills" all contain norethindrone 0.35mg in 28d packs with no placebos (Ortho Micronor, Jolivette, Heather, Errin) take at the same time qd. Use backup if >3h late or quick start

*CI of Mifepristone

pregnancy and statin use (specifically simvastatin and lovastatin)

*8.1 Pregnancy

pregnancy exposure summary, risk summary, human and animal data clinical considerations: -disease-associated maternal/embryo/fetal risk -dose adjustments during pregnancy and postpartum -maternal and fetal/neonatal AE -labor and delivery

*Contraception Postpartum

pregnancy increases VTE risk and remains elevated postpartum minimum 21d to start CHC, 6w preferred progestin-only can start anytime, but wait 3-6w if breastfeeding estrogens may decrease milk supply

*8.3 Females and Males of Reproductive Potential

pregnancy test, contraception, infertility

aminoglutethimide target

pregnenolone

PMDD

premenstrual dysphoric disorder-mood and mental health sx, higher level of dysfx, patho not well understood, related to cyclic hormonal changes

*PMS

premenstrual symptoms-occur prior to menses and resolve with menses onset symptoms: depression, irritability, anxiety, confusion, social withdrawal, breast tenderness, bloating, HA, swelling of extremities MUST adversely affect social relationships or work to be considered true PMS

*aspiration RF

presence of nasoenteric enteral access device, mechanical ventilation, 70+yo, reduced level of consciousness, poor oral care, inadequate nurse: patient ratio, supine position, neurologic defecit, GERD, transport out of ICU (best to stop temporarily), bolus intermittent EN If on the way to surgery, no EN for 24h before

*preventing post-surgical infections in RA

preventing post-surgical infections with the brief d/c of a biologic should be weighed against the risk of a post-surgical RA flare consider planning surgery after at least one dosing interval has elapsed -for RTX ideally stop 3-6mo before surgery -for TCZ IV should be stopped 4w before and SQ 2w before

estrogens and OP

prevention (NOT tx of ORF) in pts with significant menopausal sx requiring estrogen therapy (and transgender women transitioning) e.g. estradiol, Estraderm-applied twice weekly use lowest dose for shortest period of time to treat vasomotor sx decreases bone loss and lower fracture risk CI: pregnancy, VTE, MI or stroke within the last year, undiagnosed abnormal genital bleeding, suspected breast cancer or estrogen-dependent neoplasma, or liver disease serious SE: VTE, stroke, CAD, gallbladder disease, dementia, breast cancer estrogen only: N/V, dizziness, weight gain, breast tenderness and enlargement, resumed cyclic or breakthrough vaginal bleeding estrogen/progestin: edema, rash, acne, hirsutism, alopecia, HA, irritability, fatigue, depression, mood swings, plus the above for estrogen to a lesser degree

indications for drug therapy in OP

prevention: T-score <-1 + 10y probability risk of hip fracture >3% or major ORF >20% tx: T-score <-2.5, patients with hip or vertebral fracture (even if asymptomatic

*PACG

primary angle closure glaucoma 5-10% of primary glaucoma, more prevalent in people of Asian descent patho: mechanical obstruction of aqueous humor outflow and very high IOP acute PACG is a medical emergency! It requires urgent intervention (laser or surgical intervention) to prevent permanent vision loss

POAG

primary open angle glaucoma, 2.8 million in US in 2010 (on the rise) decreased OUTFLOW of aqueous humor outflow due to degenerative process in the trabecular meshwork onset-gradual and asymptomatic; early stage-decrease in visual field, late stage-loss of peripheral vision mean progression rate from a full field to blindness takes 25y in untreated pts

OP classification

primary type 1: postmenopausal presents in the first 3-6y after menopause-associated with increased bone resporption primary type 2: senile osteoporosis presents at 75+yo, women:men::2:1, greatest risk for hip, pelvic, and vertebral fractures secondary: induced by certain lifestyle factors, disease states, and/or medications

classifying chronic constipation

primary, idiopathic, or functional constipation (ROME IV says OIC is functional) secondary e.g. PFD (pelvic floor dysfxn), NTC, STC, and OIC

PPI

prodrugs-require acid environment and actively secreting proton pump thus more effective when taken 30 to 60 minutes before a meal on an empty stomach OOA: 2-3h, peak: 3d SE: N/V/D, HA, dizziness, rash, elevated LFTs, thrombocytopenia, increased risk of infection in the first several weeks (pneumonias, enteric infections, acute nosocomial infections in the critically ill), increased risk of OP, B12 deficiency, hypomagnesemia with long term use (>1 yr), decreased iron absorption, C. difficile infection CI: Hypersensitivity Pregnancy: Believed to be safe in pregnancy but no studies have been conducted Lactation: Avoid; Risk of growth retardation dose reduction is recommended in patients with severe hepatic impairment prophylactic use of PPIs recommended in pts receiving concomitant dual antiplatelet therapy with aspirin and clopidogrel to reduce the risk of upper GI bleed. May lead to decreased effectiveness of clopidogrel and increased risk of cardiovascular events. Avoid coadministration of omeprazole, omeprazole/sodium bicarbonate, or esomeprazole with clopidogrel although clinical data has not shown an increased risk of cardiovascular events in patients receiving concomitant dual antiplatelet therapy with these PPIs. *All PPIs can increase methotrexate levels, a potentially severe interaction.

maintains the endometrial lining

progesterone

*FSH

promotes follicle development/stimulated estradiol and progesterone inhibited by *estradiol,* inhibin, and *fasting*

ACTH

promotes glucocorticoid effects inhibited by increase in cortisol

GH

promotes growth in all tissues inhibited by *dopamine,* glucocorticoids, and progesterone

TSH

promotes iodine uptake/TH synthesis inhibited by *thyroxine,* somatostatin, glucocorticoids, *dopamine*

LH

promotes ovulation/maintains corpus luteum inhibited by *estradiol,* testosterone, and *fasting*

P. Jiroveci Pneumonia

prophylaxis with Bactrim double strength 3x/w or daily for 6-12mo -also effective against T. gondii and N. asteroides AE: myelosuppression, hyperkalemia, rash monitor: SCr, electrolytes, CBC, skin renal dose adusment

*NSBB in cirrhosis

propranolol and nadolol reduce portal pressure by decreasing cardiac output (beta1) and producing splanchnic vasoconstriction (beta2) Titrate to reduce the HR 25% or with a goal of 55-60bpm only cost effective form of prophylactic therapy and should be continued indefinitely to reduce bleeding and decrease mortality in pts with known varices f/u surveillance EGD is unnecessary

Types of Nutrition Deficiencies

protein and calories-Marasmus, Kwashiorkor single nutrients: water soluble (B1-thiamine, B2-riboflavin, pantothenic acid, niacin, B6-pyridoxine, folic acid, B12-cyanocobalamin, biotin, C-ascorbic acid), fat soluble nutrients (A-retinol, D-ergocalciferol, E-alpha-tocopherol, K-phytonadione), trace elements (chromium, copper, iodine, iron, manganese, molybdenum, selenium, zinc)

*factors of hepatic drug clearance

protein binding, metabolic enzyme activity, hepatic blood flow

major pancreatic exocrine enzymes

proteolytic: trypsinogen and chymotrypsinogen are secreted as zymogens, inactive enzymes that are activated in the lumen of the duodenum. This prevents these enzymes from damaging the pancreas. Amylolytic: amylase Lipolytic: lipase, PLA2, etc. Nucleolytic-(deoxy)ribonuclease other: trypsin inhibitor

hydration for AP

provides circulatory support and helps decrease risk of serious complications (ex. necrosis) esp first 24-48 hours -start immediately and reassess q6h -d/c after 6-12 hours if no improvement evident LR may reduce the incidence of SIRS compared to NS -Contains Na+, K+, Cl-, and Ca++ -lactate helps with alkalinization and prevention of SIRS -250-500 ml/hr but in severe volume depletion manifested as hypotension and tachycardia, more rapid replenishment may be required -caution in patients with history of CHF, edema, renal disease (fluid overload risk)

*OTC N/V tx in pregnant women

pyridoxine (vitamin B6) doxylamine Emetrol Nonpharmacologic recommendations: smaller, more frequent meals; low-fat, bland, dry diet; sip water throughout the day; avoid triggers; ginger extract; take prenatal vitamins at night. Acupressure (Sea-Bands) may be helpful. NOT ON EXAM

*RAI

rapid-acting insulin, SQ or IV, OOA 10 min, peak 1-2h, DOA 3-5h lispro (Humalog)-U100 vial, cartridge, pen or U200 pen lispro (Admelog) -- U100, vial, pen aspart (NovoLog)—U100, vial, cartridge, pen aspart (Fiasp)--U100, vial, pen (niacinamide = faster abs) glulisine (Apidra)—U100, vial and pen Uses: bolus, CD, CSII More physiologic insulin replacement than regular human insulin -faster absorption, shorter duration -superior PP glucose lowering compared to regular human insulin

pancreatic enzyme replacement and CP

recommended for all CP with steatorrhea and/OR malabsorption may reduce pain even in the absence of steatorrhea replaces pancreatic enzymes and allows the pancreas to rest more effective when given with antisecretory drugs before initiation: nutritional status, weight, BMI, CBC with differential, CMP, INR, albumin, prealbumin, carotene, vitamin D, and BMD should be performed ~90,000 USP units of lipase per meal for appropriate fat absorption even in advanced disease, the pancreas still produces some lipases so 90,000 units are usually not actually requested

diarrhea alarm symptoms

rectal bleeding (in the absence of hemorrhoids), fever, signs of systemic inflammation, unexplained weight loss, nocturnal diarrhea, recent abx, high volume (>250mL/d), very frequent >6-10x/d, evidence of malnutrition family history of IBS, Celiac or GI malignancy -colonoscopy for all patients 50+yo (45 for African Americans) any of these warrant further evaluation-colonoscopy and/or EGD with biopsy, CBC, CRP, TSH, molecular stool analysis, etc.

*ROME IV Diagnostic Criteria for IBS

recurrent abdominal pain an average of 1+ d/wk in the last 3 mo, associated with 2+ of the following: 1. related to defecation 2. associated with a change in stool frequency 3. associated with a change in stool form in the absence of other structural or biochemical explanation for sx

Secondary Adrenal Insufficiency

reduced glucocorticoids usually due to a drug-induced decrease in ACTH cause: steroids, mirtazapine, progestins (medroxyprogesterone, megestrol)

chondroitin and OA

reduces pain and improves mortality possibly through anti-inflammatory properties and by providing cartilage elasticity SE: constipation or diarrhea, heartburn, edema, rash, asthma exacerbation CI: bovine, pork, or fish/shark allergy (depending on source)

refractory heartburn

reflux sx that have not responded after 8w after BID PPI dosing most of these do not have GERD but rather have underlying psychological comorbidities leading to functional heartburn or reflux hypersensitivity if refractory with evidence of reflux via diagnostic testing like endoscopy or pH test: continue BID PPI and add H2RA HS or Baclofen 5-20mg TID (off label)

transplant contraindications for the donor

relative: age, hep B or C antigen, BMI >35, untreated sepsis absolute: current IVDU (drug user), uncontrolled HTN, HIV, prolonged ischemia of organ, current malignancy

*insulin

required for T1DM and recommended for T2DM with glucose toxicity or lack of glycemic control on oral agents DOC in pregnancy originally from bovine and porcine pancreas but now exclusively human insulin from rDNA technology in the USA (more consistent OOA, DOA, and absorption)

Pregnancy and Lactation Labeling Rule

requires changes to content and format of info presented in prescription labeling applies to prescription drugs and biologics, does not apply to OTC drugs removes pregnancy letter categories and requires frequent label updates assist healthcare providers in assessing risk-benefit Prescription Drug Labeling Sections 8.1-8.3

*tense ascites

requires therapeutic paracentesis and albumin infusion if volume removed is >5L -6 to 8 g/L of fluid removed sodium restriction and oral diuretics should then be initiated

Surgery and IBD

resection of segments of intestine, complication correction, abscess drainage non-curative but indicated for CD when: -medical management fails -incapacitation occurs due to disease or drug therapy -retarded growth or development in children -intestinal obstruction, fistula, or abscess formation -toxic megacolon, perforation, hemorrhage, carcinoma indicated for UC when: -medical management fails or uncontrolled drug-related complications -impaired QoL from disease or drugs -complications including carcinoma of the rectum or colon -retarded growth or development in children -UC >10y or who demonstrate premalignant changes on rectal biopsy

insoluble fiber

resists fermentation and moves through GIT relatively unchanged as "roughage" draws water into the stool, increasing stool bulk and softening stool so its easier to pass and decreases transit time e.g. whole grains, bran, nuts, green leafy vegetables, other fruits and veggies (esp stalks, skin, and seeds), calcium polycarbophil

RA

rheumatoid arthritis, chronic systemic inflammatory disorder characterized by deforming symmetric polyarthritis and a wide spectrum of extra-articular manifestations such as cardiovascular complications, rheumatoid nodules, pulmonary fibrosis, Sjogren's syndrome (dry, itchy eyes), Felty's syndrome (splenomegaly and neutropenia) 2x increased risk of CVD, CVD is the cause of death of half 22% more likely to be diagnosed with cancer mortality used to be 40% higher but is now the same as general population most common autoimmune in US; 3rd most common arthritis (OA and gout) 2-3x more common in women, but usually more severe in men onset usually 30-40yo, prevalence increases with age

*rifamixin and overt hepatic encephalopathy

rifaximin (Xifaxan)-new and extremely expensive-combo with lactulose decreases hospital length of stay and decreases readmittance rates COSTLY, but COST-EFFECTIVE; systemic absorption very low tx of HE: 400mg q8h for 5-7d OHE recurrence reduction: 550mg BID

lipase in AP

rises within 4-8 hours of onset of symptoms and peaks @ 24h. then returns to normal within 8-14 days (normal <100 IU/L) more sensitive when pancreatitis is d/t alcohol more specific to acute pancreatitis than amylase, but non-pancreatic diseases (renal disease, appendicitis, and cholecystitis) may raise lipase levels, as well.

*amylase in AP

rises within 6-12h and returns to normal in 3-5d so dx may be missed if >24h 3xULN for diagnosis, normal 25-115 IU/L may remain WNL in alcohol-induced and high TG induced pancreatitis

*iPLEDGE

risk management program for isotretinoin prescribers, pts, wholesalers, and manufacturers must register and comply 2 pregnancy tests before initial rx, 2 forms of contraception 30d before and after another pregnancy test every month and contraception confirmation from doctor pharmacy must obtain authorization number prior to dispensing

avoid in JCV

rituximab

indicated for RA and lymphoma

rituximab

RXB and SLE

rituximab (Rituxan), anti-B cell therapy, off label for LN (lupus nephritis) refractory to conventional therapies, some studies think it should be used early in the disease course to allow for decreases in steroid dose SE: mild infusion rxn (fever, HA, chills, hypotension, rash) OOA 2-16w, premedicate with IV methylprednisolone 100mg 30 min before each infusion, d/c antihypertensive meds 12h before to avoid transient hypoTN, if rxn occurs slow the infusion rate by half monitor: CBC and HBV; *does NOT exacerbate HF*

RXB

rituximab, anti-B cell therapy, for combo with MTX for pts with mod-severe active RA who have failed with at least one anti-TNF BBW: fatal infusion reactions (most common with first infusion) pts with JCV infection are at an increased risk for PML and death SE: infusion reactions (fever, HA hypotension, chills), rash, neutropenia premedicate with IV methylprednisolone 100mg and APAP 30 min before each infusion to prevent infusion reactions d/c antihypertensive medication 12h before to avoid transient hypotension *does not exacerbate HF*

Evaluation/Diagnosis BPH

rule out: stricture, bladder neck contracture, carcinoma of prostate or bladder, bladder caliculi, UTI, prostatitis, neurogenic bladder med hx: antihistamines, decongestants, opiate diuretics, TCAs DRE, AUA sx score index (0-7 is mild sc, 8-35 is bothersome, moderate to severe), labs (UA, BUN, SCr, PSA)

*OTC congestion tx in pregnant women

saline nasal drops or spray oral decongestants limited to 2nd and 3rd trimesters-pseudoephedrine (preferred), phenylephrine. Not for pts with HTN. nasal decongestants or corticosteroids secondary to physician recommendation NOT ON EXAM

*Risk Factors for Progression to Osteomyelitis

sausage toe-swollen deformed toe bone visible or palpable when probed infected ulcer with an ESR of >70 mm/h (normal 0-22 male, 0-29 female) non-healing ulcer after weeks of appropriate care and off-loading of pressure radiologically evident bone destruction beneath ulcer ulcer area >2cm2 or more than 3mm deep ulceration presents over bony prominence for 2+ weeks ulceration with unexplained *leukocytosis*

fingertip method

scalp-3 fingertip units face and neck-2.5 one whole hand-1 entire arm and hand-4 elbow/knee-1 one whole foot-1.5 entire leg and foot-8 buttocks-4 trunk ONE SIDE-8 genitalia-0.5

Modified Marshal Score

score of 2 or more in any system is considered organ failure respiratory, renal, cardiovascular 30-40% increase in SCr indicates kidney dysfunction

Co-Stimulatory Signal Inhibitor

selective co-stimulation blocker that binds costimulatory ligands (CD80 and 86) on APCs, preventing interaction with CD28 on T cells and thus preventing T cell activation and proliferation e.g. Belatercept (Nulojix)

*Selenium

selenium is required for deiodinase activity deficiency-exacerbate both autoimmune thyroid disease and endemic cretinism supplementation reduces Ab levels, improves US structure of thyroid, and reduces occurrence of postpartum thyroiditis in pregnant women with TPO Ab literature does not show improvement in thyroid fx when given in HoTR

bromocriptine

semisynthetic ergot alkaloid and DA receptor agonist used for acromegaly, hyperprolactinemia, Parkinson's disease, and T2DM (lots of SE-rarely done now) 1.25mg HS; increase by 1.25mg increments q3-4d until 20-30mg/d in 3-4 doses AE: HA, lightheaded, dizzy, nervous, fatigue, rhinitis, GI symptoms TAKE WITH FOOD. AE mostly seen in the beginning and may go away in time

cabergoline

semisynthetic ergot alkaloid used in acromegaly and hyperprolactinemia long-acting DA agonist, *take with food* 0.5mg twice weakly, increase 0.5mg every other day up to 7mg/wk AE: HA, lightheaded, dizzy, nervous, fatigue, rhinitis, hypoTN (not seen much with bromocriptine), GI symptoms AE more likely at the beginning of course, may go away with time

*CS for gout

short term management when NSAIDs and cochicine are contraindicated or there is a lack of response to these agents or for pts with polyarticular involvement 0.5mg/kg/d for 2-5d followed by 7-10d taper can be used intra-articular in 1-2 large joints used adjunct to oral Medrol is a reasonable choice-ease of use and availability

*DM agents that lower PPG

short-acting GLP1RA, DPP4i, RAI, AGI, meglitinides, pramlintide

*Contraindications to Peripheral Parenteral Nutrition (PPN)

significant malnutrition, severe metabolic stress, large nutrient or electrolyte needs (K is a strong vascular irritant), fluid restriction, need for prolonged PN (>14d), renal or liver insufficiency

*OTC gas tx in pregnant women

simethicone NOT ON EXAM

*factors contributing to ORF

skeletal factors: impaired bone quality and low bone density nonskeletal factors: propensity to fall, fall mechanics, etc.

avoid biologics in pts with

skin cancer

*combo topicals for rosacea

sodium sulfacetamide and sulfur-antiinflammatory, keratolytic, antibacterial CI: kidney disease and sulfa sensitivity Rosula=above+urea (helps sooth and relieve erythema and inflammation)

octreotide

somatostatin analog that works by inhibition of vasodilatory peptides (glucagon), local vasoconstrictive effect, and preventing postprandial hyperemia initiate therapy early, when variceal hemorrhage is suspected assess for cardiac conduction abnormalities and monitor BG (usually hyper) *IV bolus dose of 50mcg, CIVI 50mcg/h for 3-5d until the bleeding stops*

*recombinant GH

somatropin analog used in GHD that promotes growth of linear bone, skeletal muscle, and other organs 1mg contains 2.6 IU of GH; 0.3mg/kg/wk starting dose for children AE: injection site pain, arthralgia's, fatigue, hyperglycemia, gynecomastia (50% of pts on long-term tx)

secondary prophylaxis variceal hemorrhage

start APAP following acute bleed after there is no bleeding for at least 24 hours and before patient is discharged from the hospital for all pts unless shunt surgery or TIPS performed need transplant if candidate: Child Pugh score > 7 and MELD score > 15 firstline: NSBB and chronic EVL combo: NSBB + isosorbide mononitrate for patients unable to undergo EVL alternatives: surgical or interventional shunting-higher incidence of HE

SBP tx

start broad spectrum (target gram negative) abx therapy if PMN counts > 250 or if PMN counts < 250 with s/s of infection (temp > 100 F, abdominal pain/tenderness) firstline: 3rd gen cephalosporins-cefotaxime (2 g every 8-12 hours for 5d) or ceftriaxone (2 g/day for 5d intravenously) or other agents such as ciprofloxacin IV 400 mg BID for 5d if oral administration is not possible

Pathophysiology of BPH

static factors-anatomic enlargement of the prostate gland due to androgen and estrogen stimulated growth, as well as, urine outflow reduction and blockade dynamic factors-increased alpha-adrenergic tone in stromal tissue of prostate leading to reduced urethra lumen and urine outflow

strange but true about OP

statins have long been associated with bone anabolism

*drugs causing hyperthyroidism

stimulation of synthesis or release-iodine, amiodarone

*Drugs That Increase Milk Supply

suckling is the most effective stimulus-recommend more frequent nursing first metoclopramide 10 mg PO TID x 1-2w, OOA: 2-5d, persists after d/c herbal agents: fenugreek (may cause hypoglycemia), milk thistle

SSZ for RA

sulfasalazine (Sulfadine, Azulifidine) for monotherapy in low active RA regardless of stage/prognosis or in combo with other DMARDs for mod-high active RA regardless of stage/prognosis or MTX with poor prognosis no matter stage OOA: 1-2mo; SE: GI upset, sun sensitivity, low folate levels, blood dyscrasias (rare); CI: sulfa allergy supplement with 1mg folic acid daily, monitor CBC q2-4w then q3mo thereafter

*SU

sulfonylureas, secretagogue MOA: binds SU receptors on beta cells, closing KATP channels, which depolarizes cell membranes & opens a Ca channel, with the resulting increase in intracellular Ca conc. causing insulin to be released, regardless of ambient glucose level. 50% of max dose accounts for 80% of efficacy; max effective dose is app. 75% stated max Start with lower end of dosing range; titrate dose weekly on basis of BG response 5-10% primary failure rate (glucose toxicity or LADA); 5-10%/year secondary failure rate Poor durability

EN preferred over PN

supports structural integrity of the gut which reduces bacterial challenge, risk of systemic infections, and risk of multiple-organ dysfunction initiate EN within 24-48h to lower risk of metabolic and infectious complications bowel sounds are not required for initiation initiate in the stomach unless there is a high risk for aspiration or intolerance hold EN in hemodynamically unstable pts

estrogen in CHC

suppresses FSH and LH release to prevent ovulation, accelerates ovum transport, primary role is to stabilize endometrial lining and provide cycle control

danazol and endometriosis

suppresses secretion of FSH and LH which decreases estrogen levels may directly inhibit ovarian steroidogenesis and increase the metabolic clearance of estradiol and progesterone causes atrophy of endometrial implants poorly tolerated: weight gain, voice changes, edema, acne, hot flashes, vaginal dryness, hirsutism, liver disease, increased cholesterol teratogenic-masculination of females and possible ambiguous reproductive organ-structure, use barrier contraception refractory for all other pharmacotherapy, limit to 6mo

*progestin-only contraceptives and endometriosis

sx improvement d/t endometrial atrophy-minipill, DMPA, levonorgestrel IUD

*hepatic encephalopathy

sx: decreased cognition, confusion, changes in behavior, asterixis asterixis is hallmark (hand flapping syndrome)-caused by build up on ammonia in the brain that affects fine motor control false neurotransmitters-increased levels of aromatic amino acids, GABA, and endogenous benzodiazepines precipitating factors-infections, variceal hemorrhage, renal insufficiency, electrolyte abnormalities, increased dietary protein summary-gut bacteria produces nitrogen which is converted to NH3 and then NH4 in the liver so it can be eliminated.

*Monitoring & Dose Adjustments for Hypothyroidism

symptom improvement in 2-3wk and complete recovery in months steady-state TSH achieved in about 6 wk (why we measure q6wk until euthyroid) If TSH above RR, increase T4 dose by 12-25mcg/d; can check in 3wk if sx persist doses >2mcg/kg/day suggest T4 malabsorption or poor adherence measure TSH annually after establishing maintenance dose

progestin-only

synthetic progesterone only, oral tablets (minipill), depot injections, subdermal implant, IUS

*transferrin

t1/2 8-9d, binds Fe in plasma and transports it to bone increased: Fe deficiency, pregnancy, hypoxia, chronic blood loss, estrogens decreased: Chronic infection, cirrhosis, burns, nephrotic syndrome, cortisone, testosterone, intestinal problems

*GDM screening

test for undiagnosed DM at the first prenatal visit in pts with RFs test for GDM at 24-28wk; ACOG and NIH recommend two-step testing screen women with hx of GDM for T2DM using OGTT 4-12wk postpartum *screen women with hx GDM for preDM q3y* women with history of GDM with preDM should receive lifestyle intervention or metformin to prevent progression

menarche

the first menstrual period

refeeding syndrome

titrate nutrition in those who are severely malnourished. If not, the body will start pumping out insulin which will trigger the shift of K, Mg, Phos intracellularly

*TNA, 3-in-1

total nutrient admixture, infuse over 24h, lower pH in the 3-in-1 dextrose + AA + IVFE + electrolytes + trace elements 30% IVFE ONLY used for TNA preparation & NOT directly IV infused

*Plummer's disease

toxic multinodular goiter

tramadol and mortality

tramadol may be associated with higher risk of all cause mortality in pts with OA compared to commonly prescribed NSAIDs (maybe they were given tramadol because they were sicker!)

opioid analgesics and OA

tramadol-pts with mod-severe pain who have failed other therapies CII-failed tramadol or who do not qualify for surgery with mod-severe pain bind to opiate receptors in CNS to inhibit ascending pain pathways, altering perception, and response to pain SE: dizziness, drowsiness, N/V, constipation, hepatotoxicity (esp with APAP), addiction potential, CNS and respiratory depression may be used in combo with NSAIDs and COX2i initiated at lowest effective dose for shortest duration possible some studies say NSAIDs are just as good as CIIs (tramadol not studied)

*transgender pts and OP

transgender women=male at birth; transgender men=female at birth agonadal states increase risk of OP transgender women preexisting RF before gonadectomy or hormones: reduced physical activity, low muscle mass and grip strength, low vit D levels transgender men who use Depo-Provera to stop periods may experience a decrease in BMD

Moderately severe acute pancreatitis

transient organ failure <48h +/- necrosis, hospitalization usually 7-10d

UC

ulcerative colitis-shallow, continuous inflammatory condition of the mucosa and submucosa confined to rectum and colon significant increase in risk for bowel cancer surgery usually curative ulceration, pseudopolups, loss of haustria, abdominal pain and weight loss (rare), diarrhea (bloody and mucus tinged), tenesmus, constipation (when rectum only) types: proctitis (rectum), proctosigmoiditis (add sigmoid colon), distal colitis (add descending colon), extensive colitis (add transverse colon), pancolitis (entirety)

*pharmacological treatment of UC

ulceritis in the rectum-always use 5ASA suppository to put them in remission mild-mod (low risk for complications) give oral ASA as long as they respond moderate with complication risk-skip ASAs and try one of the following: -anti-TNF +/- thiopurine (not in HF), vedolizumab +/- immunomodulator (thiopurine or MTX), oral steroids + thiopurine (least SE-keep thiopurine for maintenance and taper steroid) high risk of complications-IV steroids or infliximab or cyclosporine or colectomy -for maintenance after infliximab just add thiopurine -for maintenance after any other switch to options from previous level

*PEDIS Grade 1

uninfected, <=1 of the following sx of infection: local swelling or induration, erythema, local tenderness or pain, local warmth, purulent discharge does not require systemic abx treat by keeping clean, offloading pressure, and the use of topical antibiotics if indicated

IBS alarm symptoms

unintentional weight loss, rectal bleeding, nocturnal sx, onset 50+yo, abdominal or rectal mass, iron deficiency anemia, inflammatory markers, fever family hx of GI cancer, IBD, or Celiac disease

*correction dose

units RAI to correct out-of-range pre-meal BG CD=(BG now-BG goal)/CF

alphablocker vs 5alpha reductase inhibitor

unlike 5alpha reductase inhibitors, alpha blockers treat symptoms but do nothing to PSA levels or the size of the prostate

hepatic failure and PN

use dry weight to determine energy and protein requirements might need fluid and Na restriction but avoid resticting protein standard EN is preferred (no evidence of benefit of branched-chain AA or coma grade in pts with encephalopathy)

steroids and conjunctivitis

use short-term to decrease inflamation and reduce the risk of increased IOP should not be used with HSV conjunctivitis dexamethasone (Maxidex, Ozurdex), loteprednol (Alrexm Lotemax susp, ointment, gel), fluorometholone (Flarex, FML Forte, FML Liquifilm suspension, ointment), *prednisolone (Pred Forte)*

Aminoglutethimide

used in adrenal suppression such as Cushing's, fallen out of favor lately If used it should be combined with another steroidogenesis inhibitor MOA: inhibits conversion of cholesterol to pregnenolone which inhibits the production of cortisol, aldosterone and androgens (thus lots of SE) 1g/d divided q6h (max 2g/d) AE: drowsiness (severe sedation-monitor), rash, N/V, hirsutism, ataxia

*OTC vaginal yeast infection tx in pregnant women

vaginal miconazole or clotrimazole for 7d NOT ON EXAM