Therapy 5 Final Exam Big Concepts

Annovera: > 2 hours - Insert ring asap and keep same keep in place until scheduled ring removal day - Use back-up method for 7 days

A patient calls your pharmacy and explains that she had taken her Annovera ring out a little over two hours ago and was planning to re-insert it right away but forgot. What should you advise the patient to do?

First week: Apply asap, new patch change day - Use back-up for 7 days

A patient calls your pharmacy and says she forgot to apply her Twirla patch. It is the first week of her cycle. What should you instruct her to do?

Primary Amenorrhea: - Absence of menses by age 16 in presence of normal secondary sexual development OR - Absence of menses by age 14 in the absence of normal secondary sexual development

How is primary amenorrhea defined?

Secondary Amenorrhea: - Absence of menses for 3 cycles or 6 months in a previously menstruating woman

How is secondary amenorrhea defined?

Depot medroxyprogesterone acetate 150 mg (DMPA) (Depo-Provera®) - Administered IM in gluteal or deltoid muscle every 3 months - First dose given only within 5 days of start of period, or within 5 days postpartum if not breastfeeding (BF), and 6th week postpartum if BF - No back-up method needed

How is the intramuscular progestin-only contraceptive Depot medroxyprogesterone acetate (Depo-Provera®) administered?

What else do you want to know? - Time of ingestion; was it ingested all at once or spread out? What are your recommendations? - NAC IV - 150 mg/kg (max 15 g) over 60 minutes, followed by 50 mg/kg (max 5 g) over 4 hours, followed by 100 mg/kg (max 10 g) over 16 hours (21 hours total)

1. What else do you want to know? 2. What are your recommendations?

1. Stromal (smooth muscle) 2. Epithelial (glandular) 3. 5:1

1. Which type of prostate tissue is embedded with α-1A adrenergic receptors? 2. Androgens stimulate which type of tissue? 3. What is the ratio of stromal to epithelial tissue in BPH?

Tamsulosin and Silodosin Good choice in patients with: - Low BP or well controlled HTN on agents other than α-antagonists - Those in which dose titration would be complicated

3rd generation α-adrenergic blocking agents are a good choice for what type of patients?

Detachment < 24 hours: Re-apply or apply new patch asap and keep same patch change day - No back-up required

A patient calls the pharmacy and explain that her transdermal contraceptive patch fell off sometime within the last 8 hours. What should you instruct her to do?

Delayed Application (2nd or 3rd week) ≥ 48 hours: Apply asap; new patch change day - Use back-up for 7 days

A patient calls your pharmacy Friday night and says she forgot to apply her Xulane patch. She tells you it's the 2nd week of her cycle and she normally applies a new patch on Tuesdays. What should you tell the patient?

Delayed Application (2nd or 3rd week) < 48 hours: Apply asap - No back-up required

A patient calls your pharmacy Friday night and says she forgot to apply her Xulane patch. She tells you it's the 3rd week of her cycle and she normally applies a new patch on Thursdays. What should you tell the patient?

Remember: 1. APAP 2. Antibiotics/Anti-Tb 3. Complimentary & Alternative Medicines 4. Anti-Epileptics 5. Statins DILI-ALF from herbal/supplements a growing trend: ~21% of all DILI cases - Particularly noted with weight-loss and body building products

What 5 medications/classes did Dr. Morgen want us to be able to recall that may cause DILI?

- Increase in urinary frequency (irritative) - Urinary hesitancy (obstructive)

What BPH symptoms is GM experiencing?

- Unknown risk of medullary thyroid carcinoma (MTC) in humans - Personal or family history of medullary thyroid carcinoma or Multiple Endocrine Neoplasia syndrome type 2

What Black Box Warning is associated with Liraglutide (Saxenda®)?

Black Box Warning: Teratogenic - Increased risks of first trimester pregnancy loss and congenital malformations - Any woman of childbearing age must be on birth control while using Mycophenolate

What Black Box Warning is associated with Mycophenolate (Cellcept®, Myfortic®)?

Suicidal behavior and ideation

What Black Box Warning is associated with Naltrexone/bupropion ER (Contrave®)?

Black Box Warning: Osteosarcoma - Paget's, alkaline phosphatase elevations, pediatric patients, prior radiation therapy, children/young adults with open epiphyses

What Black Box Warning is associated with Parathyroid Hormone Analogs?

Boxed warning: - Increased risk of VTE/stroke - May still cause endometrial stimulation (despite antagonism) Boxed warning in PI: Prescribe progestin (intact uterus); not clinically recommended* CI: Unexplained bleeding, breast/endometrial cancer

What Black Box Warnings are associated with Ospemifene (Osphena®)?

a. "Standard," "General," or "Polymeric" - Intact macronutrients

What EN formulation composition is appropriate for most patients with minimally impaired digestion? a. "Standard," "General," or "Polymeric" b. "Oligomeric," "Elemental," or "Defined" c. Specialized d. Simple Macronutrients

Orlistat (Xenical®, Alli®)

What FDA approved agent for obesity utilized peripheral activity as part of its MOA?

a. Administer intrapartum Clindamycin - If the isolate is sensitive to both Clindamycin and Erythromycin, we'll use Clindamycin

What GBS prophylaxis should be administered? a. Administer intrapartum Clindamycin b. Administer intrapartum Erythromycin c. Administer intrapartum Vancomycin

e. Need more information - Severe penicillin allergy - Need to know more about the isolate to choose between Clindamycin and Vancomycin

What GBS prophylaxis should be administered? a. Administer intrapartum Penicillin b. Administer intrapartum Cefazolin c. Administer intrapartum Clindamycin d. Administer intrapartum Vancomycin e. Need more information

1. Dose is 2 x 105 mg prefilled syringes subcutaneously once monthly by a health care provider - Refrigerated - Expensive treatment: $1900 per month 2. Maximum of 1 year (12 months) of treatment 3. Use bisphosphonates or Denosumab sequentially

What are 3 clinical pearls regarding the use of Romosozumab?

1. Phentermine (Apidex-P) - Short-term therapy only (up to 12 weeks) 2. Phentermine/topiramate ER (Qsymia®) 3. Naltrexone/bupropion (Contrave®) 4. Liraglutide (Saxenda®)

What are the four FDA Approved agents for obesity that utilize CNS activity as part of their MOA?

1. Treat underlying cause: - Weight gain and psychotherapy in cases of anorexia - Reduction in exercise if excessive 2. Increase calcium/vitamin D in diet to reduce risk of osteoporosis (prevent bone loss)

What are the non-pharmacologic treatment options for Amenorrhea?

Pharmacotherapy Goals: - Eradication of the infection - Prevention of spread to others

What are the pharmacotherapy goals for the treatment of Chlamydia?

Pharmacotherapy Goals: - Eradication of the infection - Prevention of spread to others

What are the pharmacotherapy goals for the treatment of Gonorrhea?

Cell culture and PCR

What are the preferred HSV tests for persons who seek medical treatment for genital ulcers or other mucocutaneous lesions?

Infant: Oral Nystatin Suspension 100,000 units QID x 10 days - 0.5 mL in each side of the mouth if < 30 days old - 1 mL in each side of mouth if > 30 days old - Paint suspension into recesses of the mouth Mom: Nystatin cream/ointment on nipples 3-4 times daily

What are the recommendations for both the Mother and the Infant for Candidiasis (thrush), a yeast infection of the nipple and infant's mmouth?

• Acyclovir 400mg orally 3x/day for 7-10 days, or • Famciclovir 250mg orally 3x/day for 7-10 days, or • Valacyclovir 1gm orally 2x/day for 7-10 days

What are the recommended regimens for Genital Herpes First Clinical Episode?

• Valacyclovir 1gm orally 1x/day • Acyclovir 400mg orally 2x/day • Famciclovir 250mg orally 2x/day • Valacyclovir 500mg orally 1x/day (Decreased efficacy compared to other regimens if >10 episodes/yr)

What are the recommended regimens for Genital Herpes Suppressive Therapy?

• Impaired fasting blood glucose • Excessive facial hair, Acanthosis nigricans • Insulin resistance with the acanthosis • Weight gain • Irregular periods • Increased FH:LSH ratio (usually 1:1), hers is more around 3:1 • Rule Out: Thyroid (good), Testosterone WNL

What are the s/sx indicating ZM has PCOS?

Ibandronate, Raloxifene

What are the second-line therapy options for spine fracture prevention?

"ACHES" A - Abdominal pain C - Chest pain (SOB, coughing) H - Headache (severe HA, dizziness) E - Eye problems (seeing double, blurry vision) S - Severe leg pain (calf or thigh)

What are the severe side effects associated with Combined Hormonal Contraceptives (CHC)?

MOA: Inhibit myometrial (uterine) contractions Goals: - Stop preterm labor contractions - Prolong gestation (Administered ~ 48 hrs.)

What are the therapy goals for Tocolytic agents?

Symptoms: Nausea, Vomiting, High gastric residual volumes (GRV) Management: - Reduce feeding rate - Add motility agent (i.e., Metoclopramide) - Advance gastric tube to post-pyloric

What are the three steps to managing EN intolerance?

Management: 1. Ensure adequate hydration 2. Consider a stool softener and laxative 3. Add or reduce fiber (with additional hydration)

What are the three steps to managing constipation due to Enteral Nutrition (EN)?

Main reasons for discontinuation: - Excessive bleeding and spotting - Infections - Pain

What are the top 3 reasons for discontinuation of a LNG-IUD?

Treatment options: - Plasmapheresis - Intravenous immunoglobulin (IVIG) - Rituximab - Bortezomib

What are the treatment options for Antibody Mediated Rejection (B-cell mediated)?

Treatment options: - Antithymocyte globulin - Pulse steroids

What are the treatment options for Cellular Rejection (T-cell mediated)?

1. Irritative: Due to bladder muscle hypertrophy from long-standing obstruction → hypersensitivity - Small amounts of urine initiate bladder emptying response - Urinary Frequency - Urinary Urgency - Nocturia 2. Obstructive: Due to static and dynamic factors reducing bladder emptying/voiding - Urinary retention - Incomplete emptying - Urinary hesitancy and straining - Weak urine stream - Bladder always feels full

What are the two classifications of BPH symptoms?

1. Static ("physical block") 2. Dynamic (↑ smooth muscle tone)

What are the two factors leading to BPH pathogenesis?

1. Advancing age 2. Normal testicular function (testosterone & DHT)

What are the two main risk factors for BPH?

- Control signs/symptoms - Prevent transmission to sexual partners

What are the two primary goals for genital herpes pharmacotherapy treatment?

Primary: 1. Type 1 - Postmenopausal - Increased cortical and trabecular (cancellous) bone loss 2. Type 2 - Senile - Occurs in men and women 75 years of age and older - Ratio of female/male 2:1

What are the two types of Primary Osteoarthritis?

Extracorporeal Albumin Dialysis (AD) - MARS©: Molecular Adsorbent Recirculating System - In contrast to hemodialysis, initial dialysate is 16% albumin

What is FDA-approved for treatment of ALF due to drugs or toxins and also used off-label for Acute on Chronic Liver Failure, Post-Transplant or Post-Surgical failure, bridge to transplant, etc.?

Preterm Premature Rupture of Membranes (PPROM) - The breaking of amniotic sac ("water breaks") before labor begins occuring before 37 weeks gestation

What is PPROM?

Place in therapy: Patients who failed bisphosphonates or have severe osteoporosis with high fracture risk - Treatment only, not used for prevention - Monoclonal antibody that inhibits sclerostin: Increased bone formation; Decreases bone resorption

What is Romosozumab's place in Osteoporosis treatment therapy?

a. Class A - 6 points: • No ascites, no encephalopathy • Bilirubin - 4 (3 points) • Albumin - 3.4 (2 points) • INR - Normal (1 point)

What is ST's Child-Pugh Score? a. Class A b. Class B c. Class C

Myrbetriq® (Mirabegron)

What is a newer medication for UUI that is a β-3 receptor agonist in bladder → relaxation of detrusor smooth muscle during urine storage phase → ↑ bladder capacity, but should be avoided in patients with severe or uncontrolled hypertension?

Ginger (raw root ginger): - Dose: 1-2 g/day, divided into 3-4 doses - ACOG recommends 250mg PO TID plus another dose before bed

What is a non-prescription pharmacologic treatment that may be beneficial for N/V in pregnancy?

Hot flashes

What is a problematic ADE associated with Ospemifene (Osphena®)?

Depot medroxyprogesterone acetate 104 mg (Depo-subQ Provera®): - Injected subcutaneously into the anterior thigh or abdomen every 12 - 14 weeks - FDA-approved for preventing pregnancy and treatment of endometriosis - Same effectiveness as IM formulation

How is the subcutaneous progestin-only contraceptive Depot medroxyprogesterone acetate 104mg (Depo-subQ Provera®) administered?

Illness lasts 5-10 days - Prodromal symptoms are common (localized tingling, irritation) and begin 12-24 hours before lesions erupt - Symptoms tend to be less severe than in primary infection - Usually, no systemic symptoms

How long does a recurrent genital herpes infection without treatment typically last?

c. 684 kcal - 4 hours of EN lost for each medication administration time - 3 medication administration time x 4 hours = 12 hours of EN infusion lost - 12 hours x 38 mL/hour = 456 mL - 456 x 1.5 kcal/mL = 684 kcal - From earlier patient, 1375 kcal/day needed → we lose approximately ½ of our intended/needed calories

How many calories are lost in a 24-hour period of time if EN is held 2 hours before and after a medication that is administered three times daily, assuming a goal rate of 38 mL/hr. of a 1.5 kcal/mL EN formula? a. 152 kcal b. 456 kcal c. 684 kcal d. 1375 kcal

c. Six 1. Female 2. Family history 3. Low calcium intake 4. Underweight (< 127 lbs.) 5. Age (66 y/o) 6. Caucasian

How many risk factors for osteoporosis does PB have? a. One b. Three c. Six d. Eight

- If T-score is > -1, repeat in 5 years or as appropriate - If T-score is -1.1 to -2.4, repeat in 2 years or as appropriate - Once patient is being treated with prescription therapy, repeat every 1-2 years

How often should DEXA scan be performed?

Women with pre-existing HYPOthyroidism should be instructed to increase dose of Levothyroxine by 20-30% upon conception - Increase weekly dose by 2 additional tablets (9 tablets per week instead of 7 tablets per week, giving a 29% increase) - Increase daily dose by 25-30%

How should women with pre-existing hypothyroidism be instructed to take their Levothyroxine upon conception?

1. Testosterone cypionate IM/SubQ 50-100 mg/week 2. Testosterone enanthate IM/SubQ 50-100 mg/week 3. Testosterone patch 4-8 mg/day 4. Testosterone 1.62% topical gel 40.5-103.25 mg/day 5. Testosterone 1% topical gel 50-100 mg/day 6. Testosterone 2% axillary gel 60-120 mg/day

Identify 2-3 masculinizing medication therapy regimens:

- Initial: Spotting or BTB - Longer Term: Irregular (8% with absence of bleeding at 6 months in norethin.)

Identify the most common bleeding patterns associated with the following hormonal contraception method: Progestin-only pills - Initial: - Longer Term:

1. Everolimus (Zortress®) 2. Sirolimus (Rapamune®)

What 2 Mammalian Target of Rapamycin Inhibitors (mTORi) agents are utilized for immunosuppressive maintenance therapy?

- Denosumab - Parathyroid hormone analogs - Romosozumab

What 3 agents are reserved for patients with very high fracture risk or who have failed bisphosphonate therapy?

Raloxifene (Evista®) - Selective estrogen receptor modulator (SERM) - Estrogen agonist on bones - Estrogen antagonist on breast and uterus

What is a second-line Osteoporosis medication for women only that improves lumbar spine/femoral neck BMD (less than bisphosphonates, though), does not reduce non-vertebral fractures or hip fractures, and can be used for prevention or treatment?

- Occurs when T. pallidum invades the CNS - May occur at any stage of syphilis - Can be asymptomatic Early neurosyphilis occurs a few months to a few years after infection - Clinical manifestations include acute syphilitic meningitis, meningovascular syphilis, ocular involvement

What is characteristic of early neurosyphilis?

- Dose-Related; predictable - Stereotypical Reaction; Reproducible in animal models - Short latency period - Most Common - Ex: APAP

What is characteristic of intrinsic DILI?

- Occurs when T. pallidum invades the CNS - May occur at any stage of syphilis - Can be asymptomatic Late neurosyphilis occurs decades after infection and is more rare - Clinical manifestations include general paresis, tabes dorsalis, ocular involvement

What is characteristic of late neurosyphilis?

- Host suppresses infection - No lesions are clinically apparent - Only evidence is positive serologic test - May occur between primary and secondary stages, between secondary relapses, and after secondary stage Categories: - Early latent: <1 year duration - Late latent: ³1 year duration

What is characteristic of latent syphilis?

1. Infrequent Menstruation: - Menstrual cycle > 35 days - Generally light flow, but can occasionally be heavy 2. Caused by dysfunction of hypothalamic-pituitary-ovarian axis - Not critical enough to cause amenorrhea - Most common cause is anovulation 3. PCOS is most common cause of oligomenorrhea 4. Most common menstrual problem in women with hyperthyroidism

What is characteristic of oligomenorrhea?

Prevention is key! - Head of bed (HOB) elevation - Gastric residual volumes every 4-6 hours

What is key to mitigating aspiration secondary to EN?

c. Weight loss - She is underweight; down 27 kg (~60 lbs.) from a year ago - BMI 16.9 kg/m2: Underweight (moderate thinness)

What is likely the reason for CJ's amenorrhea? a. Pregnancy b. Uterine obstruction c. Weight loss d. PCOS

1. Calcineurin minimization/withdrawal - Declining renal function due to CNI 2. Infections 3. Cancer - Anti-neoplastic effect

What is mTORi's place in immunosuppression therapy?

Iodide supplementation (iodized salt): - Recommend at least 220 mcg/day during pregnancy - 290 mcg/day for lactating women

What is recommended during pregnancy to aid in healthy brain development of the baby? What is the recommendation for lactating mothers?

Lactulose - Dosing: PO or NG - Starting Dose: 45mL (30g) hourly until laxative effect achieved - Upon bowel movement change to 15-45mL (10-30g) q 8 to 12 hours titrated to 2-3 stools daily - Patients may need long-term prophylactic dosing

What is the 1st Line Therapy Hepatic Encephalopathy (HE) Grades II - IV?

Biopsy is Gold Standard: - Cellular rejection: Infiltration of allograft by T lymphocytes, inflammatory cells - Antibody mediated rejection: Positive C4d staining

What is the Gold Standard for diagnosing rejection?

Aqueous crystalline penicillin G 18-24 million units per day, administered as 3-4 million units IV every 4 hours or continuous infusion for 10-14 days

What is the Gold Standard treatment regimen for neurosyphilis? What is the duration of treatment?

• Identify patients with DILI, and work with the healthcare team to determine causality when necessary • Institute hepatic dosing adjustments for patients with liver dysfunction or receiving extracorporeal albumin dialysis • Educate patients regarding appropriate APAP usage and Herbal/Dietary supplements

What is the Pharmacist's Role in Liver injury?

1. Rule out differential diagnosis 2. Assess possibility of DILI • Assess likelihood of association per LiverTox database or 1° Lit Search • Characterize pattern of liver injury per labs and R-Value • Calculate RUCAM 3. Draw conclusions and develop treatment plan

What is the Pharmacist's role in DILI Assessment?

Drug of choice: Penicillin G given during labor - Only want to consider an alternative to Penicillin G if they truly have a severe allergic reaction

What is the anti-infective of choice for GBS prophylaxis? When is it administered?

Initial dose titration/ADEs: q2-3 weeks until at appropriate dose (efficacy/ADEs) - Efficacy and adverse effects Q 6 months (maintenance phase)

What is the appropriate F/U monitoring recommendations for ET/EPT for menopause?

b. 600-1,000 IU daily

What is the appropriate dose of Vitamin D to recommend for a postmenopausal woman? a. 400 IU daily b. 600-1,000 IU daily c. 2,000 IU daily d. None

First Line = Combination diuretics - Spironolactone 100 mg po daily: To counteract RAAS activation - Anti-aldosterone effects require higher doses, up to 400 mg/day - Furosemide 40 mg po daily: For potent diuresis and prevention of hyperkalemia - Refractory = Large-volume paracentesis + albumin then diuretics

What is the first-line pharmacologic treatment for ascites? What is the dosing?

Anticholinergics/Antimuscarinics and B3-adrenergic agonists

What is the first-line pharmacologic treatment option for Urge Urinary Incontinence?

Bisphosphonates - First-line therapy for both men and women - Decrease bone resorption; Inhibit osteoclast activity - Long biologic half-lives - Oral bioavailability of 1-5%

What is the first-line therapy for Osteoporosis for both men and women?

a. Weight loss

What is the first-line therapy for ZM? a. Weight loss b. Combined hormonal oral contraceptive c. Spironolactone 25mg PO once daily d. Metformin 500mg PO once daily, titrate as tolerated

Osmotic Laxative (Polyethylene Glycol) - First-line therapy

What is the first-line therapy for constipation treatment during pregnancy?

Octreotide (Sandostatin®) - Dose: 50 mcg IV x1, then 25 - 50 mcg/hr. IV drip - Duration: 2-5 days, stop when free of bleeding for >24 hr.

What is the first-line therapy to to slow or stop bleeding due to an acute variceal hemorrhage?

First-line treatment for PUI is non-pharmacologic - Urge, Stress, Overflow: Lifestyle modifications (i.e., smoking cessation, constipation prevention, weight reduction, etc.); Bladder Diary

What is the first-line treatment recommendation for Persistent Urinary Incontinence (PUI)?

Pelvic Floor Muscle Rehabilitation - 1st line treatment for stress UI

What is the first-line treatment recommendation for Stress Urinary Incontinence?

Vaginal delivery of baby

What is the goal of inducing labor?

Indication: Moderate-severe dyspareunia - Option for women who prefer a non-estrogen, oral treatment for GSM

What is the indication for Ospemifene (Osphena®)? For whom would it be a good therapy choice for?

These patients do not need pharmacologic treatment - Counsel on removal of risk factors for disease progression

What is the recommended pharmacologic primary prophylaxis treatment for patients with cirrhosis but without gastric esophageal varices?

Pharmacologic Therapy: - Octreotide - Antibiotic prophylaxis

What is the recommended pharmacologic treatment for an acute variceal hemorrhage?

Therapy for Primary, Secondary, and Early Latent Syphilis: - Benzathine penicillin G 2.4 million units IM in a single dose (Bicillin L-A®)

What is the recommended pharmacotherapeutic regimen for the treatment of primary, secondary, and early-latent syphilis? What is the duration of treatment?

Pregnancy: Azithromycin 1gm orally in a single dose - Alternate: Amoxicillin 500mg orally 3x/day for 7 days

What is the recommended regimen for the treatment of Chlamydia during pregnancy?

Benzathine penicillin G 2.4 million units IM once weekly x 3 weeks (7.2 million units total)

What is the recommended therapy for Late Latent Syphilis, Latent Syphilis of Unknown Duration, and Tertiary Syphilis without neurologic involvement? What is the duration of treatment?

Mastitis: Dicloxacillin 500mg QID x 10-14 days

What is the recommended therapy for mastitis, and infection of the breast tissue that usually presents as erythemma, pain, and/or a fever?

IV N-Acetylcysteine (NAC; Acetadote©) - Based on Rumack-Matthew Nomogram; but when in doubt, treat!

What is the recommended treatment for APAP DILI?

Low-dose combination OCs (20-35 mcg ethinyl estradiol)

What is the specific pharmacologic recommendation for Menorrhagia for adolescents up to age 18 years?

Low-dose combination OCs or progestin only therapy

What is the specific pharmacologic recommendation for Menorrhagia for women aged 19-39 years?

- Cyclic progestin, low-dose OCs, levonorgestrel IUD, or cyclic hormonal therapy - Therapies may also relieve perimenopausal symptoms

What is the specific pharmacologic recommendation for Menorrhagia for women aged 40 years to menopause?

Goal is to increase hemoglobin, with a corresponding increase in oxygen-carrying capacity and reduction of symptoms - Therapy should be titrated to resolution of symptoms - Severe complications can be avoided by maintaining hemoglobin > 7 g/dL

What is the therapeutic goal for anemia treatment?

• Both oral and IV formulations available • Treatment typically is sufficient with oral supplementation • Folic acid 1 mg/day is typically effective

What is the treatment for Folate Deficiency Anemia?

Combined Hormonal Contraceptives

What is the treatment of choice for women wanting menstrual cyclicity, relief of acne and hirsutism, and pregnancy prevention in PCOS treatment?

• Mild symptoms - Watchful Waiting • Patient assessed at regular intervals (3-6 months) • Drug therapy considered if symptoms progress

What is the treatment recommendation for patients with mild BPH symptoms (AUA Symptom Index Score <7)?

a. Less than 7 days

What is the typical timeline for the development of hepatic encephalopathy after the onset of jaundice for "hyperacute" acute liver failure? a. Less than 7 days b. 7-21 days c. Greater than 21 days, but less than 26 weeks d. Greater than 26 weeks

Only infects people who also have HBV infection!

What is unique about a Hepatitis D infection?

a. Initiate Letrozole 2.5mg PO daily

What is your next course of action for ZM? a. Initiate Letrozole 2.5mg PO daily b. Initiate Metformin 500mg PO BID, titrate as tolerate c. Initiate a combined oral contraceptive d. Initiate Clomiphene + Metformin

Prostate-specific Antigen (PSA) at baseline, 6 months, and annually thereafter

What lab must be monitored at baseline, 6 months, and annually thereafter with 5-α-Reductase Inhibitor use?

Intranasal Calcitonin - Dose is 200 units intranasally daily - Alternating nares every other day

What medication is a salmon-derived, third- or fourth-line therapy agent for Osteoporosis?

If missed green (inert) pill, skip it and continue as scheduled until pack is finished

What should you tell a patient who has missed a green pill from her Drospirenone 4 mg (Slynd®) pack?

a. Alendronate - Stops the osteoclasts so bone doesn't get reabsorbed, low bioavailability, lasts a long time

What would you prescribe for PB? a. Alendronate b. Raloxifene c. Teriparatide d. Denosumab e. Intranasal Calcitonin

d. Assess adherence

What would you recommend? a. Increase the Alendronate to 140mg weekly b. Add Denosumab c. Add Teriparatide d. Assess adherence

Preferred in men with moderate to severe BPH with enlarged prostate glands of at least 30 g (newest AUA guideline update) or PSA ≥ 1.5 ng/dL (which indicates prostate gland likely ≥ 30 g)

When are 5-α-Reductase Inhibitors preferred in BPH treatment?

Use when refractory symptoms after lifestyle modifications and antacid use, or when frequency of heartburn warrants a medication to prevent symptoms versus treating them when they happen

When are H2 Receptor Antagonists (Famotidine or Cimetidine) indicated for heartburn for a woman during pregnancy?

Proton-Pump Inhibitors: - Recommended in those with complicated GERD that is refractory to other therapies - Usual doses of Omeprazole and other PPIs are not a major teratogenic risk and safe to use in pregnancy

When are PPIs indicated for women during pregnancy?

Diagnostic paracentesis: 1. PMN < 250 cells/mm3, but S/Sx of infection or culture positive 2. PMN > 250 cells/mm3

When are empiric antibiotics indicated for SBP?

*Determine if ovulatory or anovulatory* - will help us determine which treatment to use - Age, cycle length, progesterone level during midluteal phase

When assessing Menorrhagia, what determination will help us determine which treatment to use?

Can be used as first line if T score is < 3.5 or patient has severe osteoporosis

When can Parathyroid Hormone Analogs be used as a first-line treatment option?

b. Day 1 start - Starting on the first day of period, so hypothetically, backup would never be required

Which COC start method does not require backup upon initiation regardless of when the period started? a. Sunday start b. Day 1 start c. Quick start d. Natazia®

Dextromethorphan appears to be safe

Which Cough Suppressant/Expectorant appears to be safe for use during pregnancy?

d. Avanafil (Stendra®) - 15-30 minutes - Sildenafil (Viagra®): 30-60 minutes - Vardenafil (Levitra®): 30-60 minutes - Tadalafil (Cialis®): 60-120 minutes

Which PDE-5 Inhibitor has the quickest onset of action? a. Sildenafil (Viagra®) b. Vardenafil (Levitra®) c. Tadalafil (Cialis®) d. Avanafil (Stendra®)

a. Sildenafil (Viagra®) c. Tadalafil (Cialis®)

Which PDE-5 Inhibitor(s) require a dosage adjustment for renal impairment? a. Sildenafil (Viagra®) b. Vardenafil (Levitra®) c. Tadalafil (Cialis®) d. Avanafil (Stendra®)

b. Vardenafil (Levitra®) d. Avanafil (Stendra®)

Which PDE-5 Inhibitor(s) should not be used in renal dialysis patients? a. Sildenafil (Viagra®) b. Vardenafil (Levitra®) c. Tadalafil (Cialis®) d. Avanafil (Stendra®)

b. Vardenafil (Levitra®)

Which PDE-5 inhibitor is contraindicated for use with Class 1 and/or Class 3 antiarrhythmic agents due to QT prolongation? a. Sildenafil (Viagra®) b. Vardenafil (Levitra®) c. Tadalafil (Cialis®) d. Avanafil (Stendra®)

Darifenacin (Enablex®) - ER formulation

Which UUI agent has its bioavailability affected by formulation, CYP2D6 polymorphism, dose, and race (↑ in Caucasians; ↑ in heterozygous CYP2D6 extensive metabolizers)?

Azathioprine AZA (Imuran®) - TPMT (thiopurine methyltransferase) testing

Which agent utilized in immunosuppression maintenance therapy requires TPMT testing prior to its use?

d. Liraglutide (Saxenda®)

Which agent would be an inappropriate pharmacologic choice for obesity for a patient with FH of medullary thyroid carcinoma? a. Phentermine (Apidex-P) b. Phentermine/topiramate ER (Qsymia®) c. Naltrexone/bupropion (Contrave®) d. Liraglutide (Saxenda®) e. Orlistat (Xenical®, Alli®)

Fesoterodine Fumarate (Toviaz®) - Also, dose adjust for CrCl <30 mL/min or in patients taking potent CYP3A4 inhibitors

Which anticholinergic for the treatment of UUI is not recommended in patients with severe hepatic impairment?

c. Insomnia d. Hot flashes

Which of the following are vasomotor menopause-related symptoms? Select all that apply. a. Osteoporosis b. Mood disturbances (such as depression or irritability) c. Insomnia d. Hot flashes e. Vaginal dryness

b. It causes QT prolongation

Which of the following characteristics makes Vardenafil unique among the PDE-5 inhibitors? a. It can be dosed once daily on a scheduled basis b. It causes QT prolongation c. It is generically available d. It comes as an oral solution for those who have difficulty swallowing

a. Duration of therapy c. Stage of the pregnancy d. Dose of the medication

Which of the following characteristics should be considered when choosing a medication for a woman who is pregnant? Select all that apply. a. Duration of therapy b. Sex of the fetus c. Stage of the pregnancy d. Dose of the medication e. The woman's parity

b. Secondary Syphilis - Nickel-dime lesions - Benzathine penicillin G 2.4 million units IM in a single dose

Which of the following correctly describes the stage of syphilis - symptom - treatment? a. Primary Syphilis - Chancre - Benzathine penicillin G 2.4 million units IM x 3 doses b. Secondary Syphilis - Nickel-dime lesions - Benzathine penicillin G 2.4 million units IM in a single dose c. Tertiary (late) Syphilis - Gummatous lesions - Benzathine penicillin G 2.4 million units IM in a single dose

e. All of the above

Which of the following current FDA approved weight loss medications is pregnancy category X? a. Naltrexone/bupropion (Contrave®) b. Phentermine/topiramate (Qsymia®) c. Orlistat (Xenical®, Alli®) d. Liraglutide (Saxenda®) e. All of the above

d. Patient has a low testosterone level

Which of the following describes an instance when Testosterone would be an appropriate therapy for the treatment of a patient with ED symptoms? a. Patient prefers treatment with a local, topical therapy b. Patient has decreased libido c. Patient has contraindications to the use of PDE-5 inhibitors d. Patient has a low testosterone level

c. Oxybutynin TD

Which of the following has the lowest incidence of anticholinergic side effects? a. Darifenacin b. Oxybutynin IR c. Oxybutynin TD d. Tolterodine

b. Regular cycle - Regular cycle indicates ovulatory cycle because they are having the normal transition from the follicular phase to the luteal phase with ovulation occurring

Which of the following indicates an ovulatory cycle? a. Irregular cycle b. Regular cycle c. Heavy bleeding d. Light bleeding

d. FSH:LH ratio of 1 - No, LH:FSH is usually 3:1 - Alopecia: Androgenism, so yes - Blood glucose of 108 mg/dL - FBG, so yes - Oligomenorrhea - Yes

Which of the following is NOT a characteristic of PCOS? a. Alopecia b. Blood glucose of 108 mg/dL c. Oligomenorrhea d. FSH:LH ratio of 1

Higher Scores = Higher likelihood of drug cause (DILI)

A higher RUCAM Score =

b. False

Alpha-adrenergic antagonists are used to treat static factors that lead to BPH. a. True b. False

c. Increase free water flushes • Hypernatremia is potentially the sign of a metabolic disturbance - she is potentially dehydrated • EN is not present to meet fluid requirements, we still need to give free water flushes unless the patient is able to drink water orally

(Recall TM) Three days after initiation of EN, TM begins to have some new altered mental status and develops hypernatremia. Which of the following intervention should be considered? a. Change EN formulations to have more fiber b. Elevate the head of bed c. Increase free water flushes d. Rule out infection

a. Increased facial hair growth within one month d. Risk for painful intercourse due to vaginal atrophy e. Lowering of voice frequency/pitch within one month

A 24-year-old patient is starting testosterone cypionate 50 mg IM once weekly for masculinization. Which of the following do you educate them for expectations of therapy? [Select all that apply.] a. Increased facial hair growth within one month b. Reduced fertility long-term c. Increase in body fat within one year d. Risk for painful intercourse due to vaginal atrophy e. Lowering of voice frequency/pitch within one month

b. Labetalol - 1st Line along with Methyldopa (However, Methyldopa is dosed 2-3x/day) - Atenolol - 2nd Line - Lisinopril - Do not use; Contraindicated - Nifedipine - 2nd Line

A 28-year-old, pregnant woman has a blood pressure of 154/102 mmHg at 28 weeks' gestation, despite dietary changes. The physician refers her to you for treatment, what do you recommend? a. Atenolol b. Labetalol c. Lisinopril d. Nifedipine

a. PMN < 250 and culture negative

A cirrhotic patient presents with fever and chills and is at risk for SBP. A diagnostic paracentesis is completed. Which of the following would indicate that the patient does not need antibiotic therapy for SBP? a. PMN < 250 and culture negative b. PMN < 250 and culture positive c. PMN > 250 and culture positive d. PMN > 250 and culture negative

NuvaRing/EluRyng: > 3 hours - If ring removal occurred in 3rd week: Discard ring, insert a new ring immediately, starting new 21-day cycle - Use back-up method for 7 days

A patient calls your pharmacy around 6pm and explains that she had taken her EluRyng ring out this morning and was planning to re-insert it right away but forgot. She tells you that it's the third week of her cycle. What should you advise the patient to do?

NuvaRing/EluRyng: > 3 hours - Insert ring asap and keep same keep in place until scheduled ring removal day - Use back-up method for 7 days

A patient calls your pharmacy around 6pm and explains that she had taken her NuvaRing ring out this morning and was planning to re-insert it right away but forgot. She tells you that it's the second week of her cycle. What should you advise the patient to do?

Detachment ≥ 24 hours: Apply new patch asap, new patch change day - Use back-up for 7 days

A patient calls your pharmacy on Wednesday at 8pm frantic because she noticed her Xulane patch was no longer on her arm. She got home from work yesterday at 5pm and changed quickly before heading back to campus to study. Her mom sends her a picture of the sweater she was wearing and sure enough, her Xulane patch was stuck to the inside. What should you instruct her to do?

d. Too much androgen

A patient complains of an abnormal amount of hair falling out recently. She started a new OCP 1.5 months ago. What is likely the problem? a. Too much estrogen b. Too little estrogen c. Too much progesterone d. Too much androgen

c. Apply patch ASAP, no backup is necessary

A patient forgot to change her Twila patch yesterday morning. This is week 2. What do you tell her? a. Apply patch on next patch change day, use backup for 7 days b. Apply patch on next patch change day, no backup is necessary c. Apply patch ASAP, no backup is necessary d. Apply patch ASAP, use backup for 7 days

c. Take it as soon as you can. Continue pack as usual. Use backup x 48 hours.

A patient forgot to take their Norethindrone 0.35mg tablet this morning (~8am). It's now 6:15pm. What do you tell her? a. Take is as soon as you can. Continue pack as usual. No backup necessary. b. Take it as soon as you can. Continue pack as usual. Use backup x 7 days. c. Take it as soon as you can. Continue pack as usual. Use backup x 48 hours. d. Skip missed tablet. Take Tomorrow's pill as usual. Use backup x 7 days

These symptoms indicate too much estrogen - Decrease estrogen

A patient is experiencing breast tenderness, HA, nausea, and cyclic weight gain with her current CHC, what do you recommend?

These symptoms indicate too much progesterone - Decrease progesterone

A patient is experiencing fatigue, depression and non-cyclical weight gain with her current CHC, what do you recommend?

These symptoms indicate too much androgen - Switch to a CHC with less androgenic effect; want to decrease androgen

A patient is experiencing hair loss, acne, and hirsutism with her current CHC, what do you recommend?

These symptoms indicate not enough estrogen - Increase estrogen

A patient is experiencing unscheduled bleeding during pill days 1-9 of her cycle and light menses with her current CHC, what do you recommend?

These symptoms indicate not enough progesterone - Increase progesterone

A patient is experiencing unscheduled bleeding during pill days 10-21 of her cycle with her current CHC, what do you recommend?

a. Ferrous sulfate 325 mg po one tablets three times daily

A patient is newly diagnosed with IDA. Which of the following is an appropriate initial oral iron regimen? a. Ferrous sulfate 325 mg po one tablets three times daily b. Ferrous gluconate 325 mg po one tablets three times daily c. Ferrous fumarate 100 mg po one tablets three times daily

a. Folate • Not iron deficiency because the MCV would be decreased • Increased homocysteine levels may indicate either folate or vitamin B12 deficiencies • Increased methylmalonic acid levels may indicate a vitamin B12 deficiency • In this case, the MMA levels are normal

A patient presents with a low H/H and an elevated MCV. Further workup shows an elevated homocysteine level and a normal MMA level. What deficiency is likely present? a. Folate b. Iron deficiency c. Vitamin B12 d. No deficiency is present

• Increased abdominal distension • Shifting flank dullness • Fluid wave

A patient with ascites is likely to present with what 3 clinical signs/symptoms?

d. Progesterone

A version of this hormone can be given by mouth for 10-14 days to induce withdrawal bleeding in patients with amenorrhea: a. Androgen b. Estrogen c. Luteinizing hormone d. Progesterone

a. True

ACOG discourages Misoprotol/Dinoprostone use with previous cesarean delivery or major uterine surgery a. True b. False

c. In the 2 years after the final menstrual period

According to the STRAW staging system, when are vasomotor symptoms "Most likely" to occur in a woman's life? a. In the late remaining lifespan of a woman postmenopause b. In the 1-3 years after the final menstrual period c. In the 2 years after the final menstrual period d. In the very early part of the menopausal transition

Labs: Renal function, liver function, QTc interval, testosterone level, FLP, Hgb A1c, TSH

After a brief conversation with MN, the MD makes the diagnosis of erectile dysfunction and requests the PharmD's advice for pharmacologic therapy. What are some more questions you should ask the patient or provider?

Indication: Off label use for induction and rejection treatment in renal, heart, and lung transplant - No longer available in the U.S.

Alemtuzumab (Campath®), a monoclonal depleting agent, is indicated for:

Calcineurin Inhibitor (Tacrolimus) + Antiproliferative (Mycophenolate) + Corticosteroid (Prednisone)

Although the maintenance immunosuppression regimen is transplant center-specific, the most common regimen is:

Induction immunosuppression: - Methylprednisolone AND - Basiliximab OR Thymoglobulin OR Alemtuzumab

Although the typical regimen can vary based on graft, patient's PMH, risk of rejection, history of rejection, infections, etc., what does a typical induction immunosuppression regimen consist of?

Maintenance immunosuppression: - Tacrolimus AND - Mycophenolate AND - Prednisone

Although the typical regimen can vary based on graft, patient's PMH, risk of rejection, history of rejection, infections, etc., what does a typical maintenance immunosuppression regimen consist of?

b. Advance the NG to an NJ • We have emesis, a sign of intolerance and now an aspiration risk • Want to advance the tube and make it post-pyloric • Tolerance of naso access is fine (no need for percutaneous)

An NG is placed for your 84 y/o female s/p CVA. After EN is initiated, she has two episodes of emesis. EN is held. What can be done with the EN access to help the patient tolerate the EN? a. Remove the NG and attempt to let her eat normally b. Advance the NG to an NJ c. Remove the NG and place a PEG d. Remove the NG and place a PEJ

a. True

An erection is primarily the result of increased blood flow to erectile tissue due to nitric oxide mediated smooth muscle vasodilation and relaxation. a. True b. False

a. Estrogen

An increase in which hormone stimulates the surge of LH? a. Estrogen b. Progesterone c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH)

d. BMI > 29 kg/m2 Annovera®: Not studied in women with BMI > 29 kg/m2

Annovera® was not studied in women with which of the following characteristics? a. > 70 kg (154 lbs.) b. > 90 kg (198 lbs.) c. BMI > 30 kg/m2 d. BMI > 29 kg/m2

Not studied in women with BMI > 29 kg/m2

Annovera™ (EE 13 mcg + Segesterone acetate 0.15 mg) has insufficient data showing efficacy in which patient population?

- Uncontrolled narrow-angle glaucoma - Gastric retention - Severely decreased GI motility

Anticholinergics/Antimuscarinics and B3-adrenergic agonists for the treatment of Urge Urinary Incontinence is contraindicated in patients with:

Indication: - Renal transplant (induction and rejection) - Off-label use for induction and rejection treatment in heart, intestine, and lung transplants

Antithymocyte globulin (Thymoglobulin®), a polyclonal lymphocyte depleting agent, is indicated for:

b. False - NOT interchangeable - ATGAM not used very often - Thymoglobulin: Inject human thymocytes (precursor to T cells) into rabbits - ATGAM: Inject human thymocytes into horses

Antithymocyte globulin formulations, Thymoglobulin and ATGAM are interchangeable. a. True b. False

- Phentermine (Apidex-P) - Phentermine/topiramate ER (Qsymia®)

Appetite suppressant (CNS activity) is associated with which FDA approved agent(s) for obesity?

- Yes, Mom and Baby are stable - Also, she is experiencing contractions - She's at < 32 weeks gestation, so we would want to utilize Indomethacin

Are tocolytics indicated for SH? If yes, what tocolytic would you suggest for SH?

1. Influenza (inactivated) 2. COVID-19 If indicated: Hep B, Hep A, Meningococcal

Aside from Tdap, what are two additional vaccines that are recommended by the CDC to receive during pregnancy?

1. Gabapentin 900 mg PO daily in divided doses (or Pregabalin 150-300mg/day) 2. Clonidine 0.1 mg PO daily/TD weekly

Aside from antidepressants, what are two additional non-hormonal therapies for moderate to severe vasomotor symptoms (neither are effective for GSM)?

- Prenatal vitamin + Calcium and Vitamin D + DHA Supplementation - Also, ensure she is receiving the recommended Iodide

Aside from the Prenatal Vitamin, is there anything else OS should be taking?

d. Citracal 500mg by mouth twice daily - Has 500mg of Calcium per serving

Assuming PB gets 500mg of Calcium from food each day, how would you supplement her calcium intake? a. No supplement is needed b. Tums Chewable 350mg - 2 tablets by mouth once daily c. Multivitamin by mouth once daily d. Citracal 500mg by mouth twice daily

b. 24 to 33 weeks' gestation

At what gestational age are PPROM antibiotics indicated? Select all that may apply. a. < 23-24 weeks' gestation b. 24 to 33 weeks' gestation c. 34 to 36 weeks' gestation

1. Allopurinol 2. Febuxostat

Azathioprine AZA (Imuran®) has notable DDIs with which medications?

Induction (Options): Methylprednisolone and Basiliximab (Simulect®) or Thymoglobulin or Alemtuzumab (Campath®) - Methylprednisolone (corticosteroid); Basiliximab (non-depleting agent); Thymoglobulin (depleting agent); Alemtuzumab (depleting agent) - Can utilize Methylprednisolone and Basiliximab (Simulect®) for an induction regimen since JD is a low immunological risk Maintenance (Options): Tacrolimus (Prograf®) and Mycophenolate (Myfortic®, Cellcept®) and Prednisone (Deltasone®) - Tacrolimus (calcineurin inhibitor); Mycophenolate (antiproliferative); Prednisone (corticosteroid)

Based on JD's immunologic risk, what induction agent will you recommend to the transplant surgeon?

- Hormonal IUD, implant: 2 menstrual cycles - Copper IU: 2 menstrual cycles - Oral contraceptive pill, vaginal ring: 3 menstrual cycles - TDS patch: 4 menstrual cycles - Injectable: 5-8 menstrual cycles

Based on the 2020 Pegravid Contraceptive Use and Fecundability prospective cohort study (BMJ. 2020;371:m3966), n = 17,954 women planning pregnancy, identify the time to normal fertility for the following contraceptive methods: - Hormonal IUD, implant: - Copper IU: - Oral contraceptive pill, vaginal ring: - TDS patch: - Injectable:

Indication: Renal transplant induction - Off label use: Heart, liver, and lung transplant induction

Basiliximab (Simulect®), a monoclonal non-depleting agent, is indicated for:

Liver transplant

Belatacept (Nulojix®) is not recommended in which type of organ transplant due to increased risk of graft loss and death?

Hormonal contraceptives +/- Eflornithine +/- Spironolactone; also, laser treatment

Broadly speaking, what agents should be used for dermatologic symptoms of hyperandrogenism secondary to PCOS?

Letrozole preferred, next Clomiphene

Broadly speaking, what agents should be used for infertility/ovulation induction secondary to PCOS?

Hormonal contraceptives

Broadly speaking, what agents should be used for menstrual abnormalities secondary to PCOS?

Insulin sensitizer - Metformin

Broadly speaking, what agents should be used for metabolic/glycemic abnormalities/insulin resistance secondary to PCOS?

Rifamycins (rifampin, rifabutin)

CHC has a pertinent DDI with which class of medications?

1. Postpartum: - CHCs should be avoided in this population < 21 days postpartum as a woman is in a hypercoagulable state - Usually not recommended until 4-6 weeks post-partum (follow-up appointment) 2. Breastfeeding: - CHCs are not recommended initially for women who are breastfeeding - Estrogen is thought to decrease milk production - Infant may not receive enough calories due to the decrease in milk production - Infant may receive hormones in the breast milk - May be started without significant effect once milk flow is well established and adequate

CHCs are not recommended/should be avoided in which two special populations due to worry that an infant may not receive enough calories/the woman is in a hypercoagulable state?

b. False

Cellcept (mycophenolate mofetil) tablets can be crushed for NG tube administration. a. True b. False

Cellcept (MMF): Stomach Myfortic (MPA): Small intestine

Cellcept® and Myfortic®, two different formulations of Mycophenolate, are released where in the body, respectively?

d. The recommended CDC treatment regimen is Ceftriaxone 1g IM x 1 for a patient weighing > 150 kg

Choose the statement below that is TRUE about gonorrhea infection. a. Most women with gonorrhea are symptomatic and have severe cervicitis or mucopurulent urethritis b. Patients with gonorrhea should also empirically be treated for syphilis c. The goal of treatment is symptom suppression, as gonococcal infections cannot be cured/eradicated d. The recommended CDC treatment regimen is Ceftriaxone 1g IM x 1 for a patient weighing > 150 kg

b. Presence of HBV surface antigen (HBsAg) for > 6 months

Chronic hepatitis is defined as: a. Presence of symptoms such as jaundice and abdominal pain b. Presence of HBV surface antigen (HBsAg) for > 6 months c. Presence of HBV surface antibody (anti-HBs) d. Evidence of liver cirrhosis

1. Not recommended in patients: - With hepatic impairment - With renal impairment (not studied) - >75 years of age (not studied) 2. Use "cautiously"/avoid in women with BMI >27 kg/m2 - Increased risk of endometrial hyperplasia d/t decreased BZA exposure 3. Increased VTE/stroke risk (CEE & class effect with ERAAs)

Conjugated Estrogen/Bazedoxifene (Duavee®) is not recommended/should used cautiously in what patient populations?

Caution in renal dysfunction - CrCl less than 30 mL/min

Denosumab (Prolia®, Xgevia®) should be used cautiously in patients with what level of renal dysfunction?

Women: - Majority are asymptomatic - Local signs of cervicitis, when present, include: - Mucopurulent endocervical discharge - Edematous cervical ectopy with erythema and friability - Local symptoms of urethritis, when present, include dysuria, frequency, pyuria (presence of pus in the urine) Men: - >50% will be asymptomatic - Urethritis symptoms/signs if present: mucopurulent, mucoid or clear urethral discharge, dysuria (painful urination)

Describe the typical clinical presentation for Men and for Women who may present with a Chlamydial infection:

Women: - Most are ASYMPTOMATIC - Can have cervicitis or urethritis - May not present until severe infection, such as pelvic inflammatory disease - Can lead to infertility Men: - Most are SYMPTOMATIC - Urethritis with mucopurulent discharge - Epidydimitis; typically, unilateral testicular swelling and pain

Describe the typical clinical presentation for Men and for Women who may present with a Gonorrheal infection:

Ceftriaxone 1 gram IV daily - Maximum 7 days of therapy (or less if hemorrhage/need for vasoactive therapy resolves) - Alternatives: Ciprofloxacin 500mg BID or Sulfamethoxazole-Trimethoprim 800mg-160mg BID

Due to patients being at a high risk for SBP secondary to an acute variceal hemorrhage, what antibiotic should be given prophylactically?

High immunologic risk → Depleting agent - Thymoglobulin - Alemtuzumab

Each transplant center has its own immunosuppression protocol induction protocol, but per the lecture, a patient that is considered a high-immunologic risk should receive:

Low immunologic risk → Non-depleting agent - Basiliximab

Each transplant center has its own immunosuppression protocol induction protocol, but per the lecture, a patient that is considered a low-immunologic risk should receive:

- Liraglutide (Saxenda®) - Phentermine/topiramate ER (Qsymia®)

Enhanced satiety (CNS activity) is associated with which FDA approved agent(s) for obesity?

a. True

Erectile Dysfunction (ED) is a marker of CV disease. a. True b. False

a. True - Little systemic absorption

Estring® (Estradiol Vaginal Ring) can be used for GSM. a. True b. False

a. True

Estrogen levels are higher than progesterone levels during the follicular phase. a. True b. False

Menorrhagia: Menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy.

How is menorrhagia defined?

4

Extended use of COCs (continuous use) allows for how many withdrawal bleeds per year?

- Labor occurring before 37 weeks gestation - Normal process, just early

How is premature labor defined?

b. False Indicated for hot flashes and vaginal atrophy: - Systemically absorbed - Do not use if only treating for GSM - ET only: Not for women with intact uterus

Femring© (Estradiol acetate Vaginal Ring) can be used for GSM only. a. True b. False

b. False

Flushing is a rare side effect that can occur with all PDE-5 inhibitor medications. a. True b. False

a. True

For DMPA, it is important to consider the patients weight because it may cause weight gain in women who are already overweight/obese. However, a patients weight has no impact on efficacy. a. True b. False

1. Vancomycin 2. Vancomycin 3. Vancomycin

For GBS prophylaxis, given the patient meets the severe allergy criteria, what regimen would you administer based on the following isolate tests? 1. Resistant to Erythromycin and Clindamycin: 2. Resistant to Erythromycin and inducible resistance to Clindamycin: 3. Resistant to Erythromycin and sensitive to Clindamycin:

Large doses of corticosteroids IV given intra-operative for induction: • Methylprednisolone IV (Medrol®) - Induction • Dexamethasone IV (Decadron®) - Induction • Prednisone PO (Deltasone®) - Induction/Maintenance

For the following Corticosteroid agents, indicate whether they would be utilized in induction or maintenance immunosuppression therapy: - Methylprednisolone IV (Medrol®): - Dexamethasone IV (Decadron®): - Prednisone PO (Deltasone®):

- Mild: ≤ 7 - Moderate: 8-19 - Severe: ≥ 20

For the following categories of BPH Severity, identify the associated AUA Symptom Index Score: - Mild: - Moderate: - Severe:

Hyper Acute ALF: - Typical timeline of HE after onset of Jaundice: < 7 days - Typical Causes: APAP - Presentation: Severe (Cerebral Edema and HE) - Prognosis - Likelihood of Tx-Free Survival: High Acute ALF: - Typical timeline of HE after onset of Jaundice: 7-21 days - Typical Causes: Viral Hepatitis - Presentation: Cerebral edema - Prognosis - Likelihood of Tx-Free Survival: Low Sub-Acute ALF: - Typical timeline of HE after onset of Jaundice: >21 Days but < 26 weeks - Typical Causes: Drug-induced - Presentation: More mild - Prognosis - Likelihood of Tx-Free Survival: Low

For the following classifications of ALF, identify the following: Typical timeline of HE after onset of Jaundice, Typical Causes, Presentation, and Prognosis - Likelihood of Tx-Free Survival: - Hyper Acute ALF: - Acute ALF: - Sub-Acute ALF:

They need to have their results confirmed with a treponemal test

For the following scenarios regarding syphilis, what is the next step in treatment? - Patients with clinical symptoms and a negative non-treponema test - Patients with a positive non-treponemal test

- Urge: Frequency and/or urgency; Bladder overactivity - Stress: UI during activities; Urethral underactivity - Overflow: Straining to void, interrupted urine stream; Urethral overactivity and/or bladder underactivity - Functional: Unable/unwilling to reach toilet; N/A

For the following types of urinary incontinence, identify (briefly) the typical clinical presentation and whether its due to Urethral/Bladder Overactivity/Underactivity: - Urge: - Stress: - Overflow: - Functional:

b. Prednisone

For which of the following maintenance immunosuppressants is a serum trough level NOT indicated as part of therapeutic drug monitoring? a. Tacrolimus b. Prednisone c. Everolimus d. Cyclosporine

c. A woman with vaginal dryness and dyspareunia unrelieved with topical estrogen - For A) PMH of breast cancer - For B) Recent PE can increase risk for VTE; ADE associated with Ospemifene is increased VTE risk - For C) Correct Answer - GSM symptoms refractory to topical estrogen - For D) Vaginal itching and pain we could help, but the presence of vasomotor symptoms (hot flashes) could be exacerbated with Ospemifene because the medication can actually cause hot flashes

For which patient is Ospemifene therapy most appropriate? a. A woman with GSM complaints who is receiving therapy for breast cancer b. A woman with recent PE and severe dyspareunia with no relief from topical lubricants c. A woman with vaginal dryness and dyspareunia unrelieved with topical estrogen d. A woman with bothersome hot flashes and complains of vaginal itching and pain

GnRH analogues: - Leuprolide depot IM 3.75-7.5mg/month - Histrelin implant 50mg/12 months

Gender dysphoria can worsen at onset on puberty. Patients can start a puberty-blocking therapy once they have entered puberty at Tanner stage G2/B2. What are two GnRH analogues that may be utilized?

b. Cyclosporine

Gingival hyperplasia is a unique adverse effect of which maintenance immunosuppression? a. Prednisone b. Cyclosporine c. Tacrolimus d. Belatacept

- Glecaprevir/Pibrentasvir (Mavyret®): 3 tablets PO QD w/food x 8 weeks - Sofosbuvir/Velpatasvir (Epclusa®): 1 tablet PO QD x 12 weeks

How are the direct acting oral antivirals for the treatment of Hepatitis C dosed? - Glecaprevir/Pibrentasvir (Mavyret®): - Sofosbuvir/Velpatasvir (Epclusa®):

- Hep A: Fecal-oral route - Hep B: Blood, semen, body fluids - Hep C: Blood (common with IV drug use) - Hep D: Mainly percutaneous, but also mucosal with infectious blood/body fluid (must have Hep B co-infection!) - Hep E: Fecal-oral route (contaminated water in developing countries); HEV found in certain mammals, undercooked meat/organs can lead to food-borne transmission

How are the following Hepatitis infections transmitted? - Hep A: - Hep B: - Hep C: - Hep D: - Hep E:

On the basis of the R-value at presentation - Hepatocellular: Hepatocyte damage - Cholestatic: Issues with gallbladder ducts or flow - Mixed: Both types - R value = (ALT/ALT ULN) ÷ (Alk Phos/Alk Phos ULN)

How can DILI be categorized?

Hyperandrogenism - Hirsutism (60-70% of women with PCOS) - Acne (15-25%) - Alopecia (5%) Menstrual or ovulatory disturbances - Oligo- or anovulation - 60-85% have oligomenorrhea or amenorrhea Possibly obesity (30-60%) - Central or abdominal obesity Insulin resistance (50-70%) - Impaired fasting glucose - Type 2 Diabetes - Independent of weight

How do a majority of the patients with PCOS present clinically?

BMI = weight (kg) ÷ height^2 (meters) or BMI = weight (lb) ÷ height^2 (inches) * 703.

How do you calculate BMI?

- APAP DILI = Intrinsic, HyperAcute - Dose-dependent and predictable - Typically, associated with doses > 4g/day, common if > 10 g/day (or 150 mg/kg) in adults - Short latency; Hepatic injury generally starts 24 - 72 hours after the ingestion

How is APAP DILI characterized?

Acute Liver Failure (ALF): 1. RAPID deterioration of the liver within < 26 weeks (no pre-existing cirrhosis) 2. Coagulopathy (INR > 1.5) AND Hepatic Encephalopathy

How is Acute Liver Failure (ALF) defined?

Clomiphene citrate 50 mg PO once daily x 5 days on days 5-9; max 100 mg daily x 6 cycles - Discontinue after 3 cycles if no ovulation occurs or if 3 ovulatory cycles occur without pregnancy

How is Clomiphene citrate dosed for ovulation induction?

Drug-Induced Liver Injury (DILI) - Broad term applied to any injury to liver by an RX, OTC, or CAM therapy - Spectrum from asymptomatic liver test elevations to ALF - Trials and registries use many different definitions/thresholds

How is DILI defined?

Letrozole 2.5 mg PO once daily x 5 days on days 3-7 (or 4-8 or 5-9), can take for up to 5 cycles and increase dose up to 7.5 mg/day

How is Letrozole dosed for ovulation induction?

Metrorrhagia: An increased duration of menstrual flow beyond 7 days and continuous with the cycle. Intermenstrual bleeding occurs between menses, discontinuous with the cycle.

How is Metrorrhagia defined?

Highly effective (< 1% failure rate): - LARCs (implant, IUD) - Permanent sterilization Moderately effective (4 - 7% failure rate): - DMPA - CHCs (pill, patch, ring) Less effective (≥ 13% failure rate): - Barrier methods - Withdrawal - Fertility-awareness-based methods - Spermicides

Identify methods that would be categorized under the following levels of effectiveness: - Highly effective (< 1% failure rate): - Moderately effective (4 - 7% failure rate): - Less effective (≥ 13% failure rate):

Select contraindications: - Current PID or STI (purulent cervicitis or chlamydial infection or gonorrhea) or at risk for PID - Uterine structural abnormalities - Current breast, endometrial or cervical cancer - Unexplained vaginal bleeding - Post-septic abortion or postpartum endometritis - Liver tumors (benign or malignant) or liver disease

Identify some LNG-IUD Contraindications:

1. 17-β estradiol - a bioidentical form of estrogen: - 4-8 mg/day (PO or sublingual) - 100-400 mg/day (transdermal) 2. Estradiol valerate IM 10-20 mg/week 3. Estradiol cypionate IM 1-2.5 mg/week 4. Antiandrogen therapy: - Spironolactone PO 100-400 mg/daily (Qday or divided BID) - Finasteride PO 1-5mg/day or dutasteride PO 0.5 mg/day - GnRH analogues (Leuprolide depot, Histrelin)

Identify some feminizing medication therapies:

- Breast development (3-6 months) - Suppressed sperm motility and counts - Possible increase of VTE risk (studies used older estrogens and didn't control for other risk factors) - Possible increased risk of breast and prostate cancers - No significant change to facial structure, Adam's apple, chest/hip dimensions, and voice unless started hormones at onset of puberty

Identify some feminizing therapy outcomes:

- High Dose EE: 50 mcg - Low-Dose EE: 30-35 mcg - Very Low-Dose EE: 20-25 mcg

Identify the amount of Ethinyl estradiol (EE) that is associated with the following: - High Dose EE: - Low-Dose EE: - Very Low-Dose EE:

Cefazolin 2g IV initial dose, then 1g IV every 8 hours until delivery

Identify the appropriate GBS prophylaxis regimen given the following patient information: - Document penicillin allergy - Did not experience anaphylaxis, angioedema, respiratory distress, or urticaria

Vancomycin 1g IV every 12 hours until delivery

Identify the appropriate GBS prophylaxis regimen given the following patient information: - Document penicillin allergy - Severe reaction (Anaphylaxis, angioedema, respiratory distress, or urticaria) - Isolate not susceptible to Clindamycin or Erythromycin

Clindamycin 900mg IV every 8 hours until delivery

Identify the appropriate GBS prophylaxis regimen given the following patient information: - Document penicillin allergy - Severe reaction (Anaphylaxis, angioedema, respiratory distress, or urticaria) - Isolate susceptible to Clindamycin or Erythromycin

Penicillin G, 5 million units IV initial dose, then 2.5-3 million units every 4 hours until delivery Alternative: Ampicillin 2g IV initial dose, then 1g IV every 4 hours until delivery

Identify the appropriate GBS prophylaxis regimen given the following patient information: - Not allergic to Penicillin

Consider estrogen (+/- progestin therapy)

Identify the appropriate pharmacologic agent for the treatment of amenorrhea given the following patient information: - Negative pregnancy test - Underlying cause: Anorexia/Excessive exercise (Hypothalamic suppression) - Refractory to psychotherapy

Dopamine agonist

Identify the appropriate pharmacologic agent for the treatment of amenorrhea given the following patient information: - Negative pregnancy test - Underlying cause: Hyperprolactinemia

Progestin to induce withdrawal bleeding and then continued or followed by estrogen + progestin combination therapy (if no contraindications)

Identify the appropriate pharmacologic agent for the treatment of amenorrhea given the following patient information: - Negative pregnancy test - Underlying cause: Other/Unknown

- Xulane®: EE 35 mcg + 0.15 mg Norelgestromin delivered per day - Twirla®: EE 30 mcg + 0.12 mg Levonorgestrel delivered per day

Identify the components of the following Transdermal Contraceptive Patches: - Xulane®: - Twirla®:

- NuvaRing®/EluRyng™/generic: EE 15 mcg + Etonogestrel 0.12 mg delivered daily - Annovera™: EE 13 mcg + Segesterone acetate 0.15 mg delivered daily - Good for access issues; patients receive the prescription, and the vaginal ring is good for the year

Identify the components of the following contraceptive vaginal rings: - NuvaRing®/EluRyng™/generic: - Annovera™:

- U.S. RDA: 0.8 g/kg/day - Minor Distress, Hospitalized: 1-1.2 g/kg/day - Moderate Distress: 1.2-1.5 g/kg/day - Severe Distress: 1.5-2 g/kg/day

Identify the estimate protein requirements based on the following degrees of stress: - U.S. RDA: - Minor Distress, Hospitalized: - Moderate Distress: - Severe Distress:

- 1 month: Reduced voice functional frequency or pitch; increased facial hair growth; acne - 6 months: Cessation of menses - First year: 3% body weight increase, 9% body fat decrease, 10% increase in lean body mean mass - Not sure when: Facial structure changes, breast size decreases, vaginal atrophy, preserved fertility

Identify the following masculinizing therapy outcomes based on duration: - 1 month: - 6 months: - First year:

- Initial: Spotting or unscheduled bleeding (BTB) - Longer Term: Regular menses (except with continuous use)

Identify the most common bleeding patterns associated with the following hormonal contraception method: COCs, Ring, Patch - Initial: - Longer Term:

- Initial: Spotting or BTB - Longer Term: 40-50% with absence of bleeding at 12 months

Identify the most common bleeding patterns associated with the following hormonal contraception method: DMPA - Initial: - Longer Term:

- Initial: Spotting or BTB - Longer Term: Lessens over time (<20% with absence of bleeding at 24 months)

Identify the most common bleeding patterns associated with the following hormonal contraception method: Implant - Initial: - Longer Term:

- Initial: Spotting or BTB - Longer Term: Lessens over time (~20% with absence of bleeding at 12 months)

Identify the most common bleeding patterns associated with the following hormonal contraception method: LNG-IUD - Initial: - Longer Term:

1. No Stress - Confined to bed: 1.2 - Out of bed - Normal activity: 1.3 2. Mild Stress - Postoperative recovery - Uncomplicated surgery: 1.0 - Trauma (Mild) i.e., long bone fracture: 1.2 3. Moderate Stress - Sepsis (moderate): 1.3 - Trauma (CNS, sedated): 1.3 - Trauma (moderate-severe): 1.5 4. Severe Stress: - Sepsis (Severe): 1.6 - Trauma (CNS, severe): Up to 2 - Burns (proportionate to burned area): Up to 2

Identify the numerical stress factor value associated with each Harris-Benedict stress condition: - No stress (2): - Mild Stress (2): - Moderate Stress (3): - Severe Stress (3):

- Mildly Stress, Hospitalized: 20-25 kcal/kg - Moderate Stress or Malnourished: 25-30 kcal/kg - Severe Stress, Critically Ill: 30-40 kcal/kg

Identify the simplistic weight-based estimation for daily requirement of caloric intake based on the following patient states per the ASPEN method: - Mildly Stress, Hospitalized: - Moderate Stress or Malnourished: - Severe Stress, Critically Ill:

Stage of Obesity: Stage 1 - Moderate severity PCOS - BMI (28.9) Most Appropriate Medication: Phentermine/topiramate ER (Qsymia®) - Orlistat is a no because of IBS - Liraglutide is a no because she is afraid of needles - Contrave is a twice-a-day regimen (patient only wants a once daily regimen) Counseling: Breakthrough bleeding (although contraceptive effectiveness is still maintained)

Identify what WHO Stage this patient is in and what medication would be the most appropriate to initiate.

T-score: • > -1: Normal bone mass • -2.4 to -1: Osteopenia • < -2.5: Osteoporosis • < -2.5 with one or more fractures: Severe or established osteoporosis

Identify what the following DEXA scan T-score's indicate: - ( > -1 ): - ( -2.4 to -1 ): - ( < -2.5 ): - ( < -2.5 w/ one or more fractures):

- ND/OD or - NJ/OJ

If EN is needed for < 4 weeks (short term) and the patient is an aspiration risk or has decreased gastric motility, what are the routes of access?

NG or OG

If EN is needed for < 4 weeks (short term) and the patient is not an aspiration risk and gastric motility is WNL, what are the routes of access?

J or G-J

If EN is needed for > 4 weeks (long term) and the patient is an aspiration risk or has decreased gastric motility, what are the routes of access?

G or PEG

If EN is needed for > 4 weeks (long term) and the patient is not an aspiration risk and gastric motility is WNL, what are the routes of access?

b. Yes, if her FRAX risk of hip fracture is >3% - She hasn't had a fracture so she couldn't be treated by T-score alone

If PB's T-score is -2.2, should we treat her for osteoporosis? a. No, it's not < -2.5 b. Yes, if her FRAX risk of hip fracture is >3% c. Yes, if her FRAX risk of any major fracture is >10%

Pseudoephedrine > Phenylephrine if needed (avoid in first trimester)

If a decongestant is absolutely needed during pregnancy, what is the recommendation?

a. True High rate of reinfection (especially in women): - Subsequent infections associated with higher risk of complications - Re-screen patients 3 to 4 months after initial treatment

If a first-line regimen was used for the treatment of Gonorrhea, immediate post-treatment test of cure is not necessary unless reinfection suspected. If persistent symptoms, culture & send for susceptibility testing. a. True b. False

Transgender men who use testosterone or GnRH therapy: - May still be able to get pregnant - Recommend LNG-IUD, DMPA, progestin-only implants, POPs - Estrogen may interact with testosterone

If a hormonal contraceptive method is needed for a transgender man who uses testosterone or GnRH therapy, what should be recommended?

- Inject 300 mcg IM at 28 weeks' gestation (Protection lasts about 12 weeks) - Injected again IM within 72 hours of delivery

If a mother is indicated for Rho(D) Immune Globulin, when/how is it administered?

1. Medroxyprogesterone acetate 5-10 mg PO once daily x 5-10 days during luteal phase OR for 12-14 days each month or on cycle days 5-26 2. Norethindrone acetate 2.5-10 mg/day PO for 5-10 days during luteal phase or 5mg TID on cycle days 5-26 - Usual dose 5mg TID

If anovulatory, what cyclic progesterone monotherapy regimens are available for the treatment of Menorrhagia?

Albumin - 1.5 g/kg IV x 1 within 6 hours of detection AND 1 g/kg IV x 1 on day 3 if: - Scr >1 mg/dL - or BUN >30 mg/dL - or Tbili >4 mg/dL

In addition to empiric antibiotics, what should also be included in therapy for SBP?

c. BMI > 30 kg/m2 NuvaRing®: One study showed lower EE concentration in women with BMI > 30 kg/m2 - Unclear if that affects effectiveness

In one NuvaRing® study, it was shown that there was a lower EE concentration in women with which of the following characteristics? a. > 70 kg (154 lbs.) b. > 90 kg (198 lbs.) c. BMI > 30 kg/m2 d. BMI > 29 kg/m2

Basal Metabolic Rate (BMR*): Energy (kcal) expended in the post-absorptive state approximately 2 hours after a meal (~10% greater than BEE) - BEE: Basal Energy Expenditure

In reference to energy expenditure, what does BMR stand for?

If not on Prenatal Vitamin: 1. Folic acid 600 (400-800) mcg PO daily 2. Iron, 27 mg elemental iron PO daily 3. Calcium 1,000 mg/day PO 4. Vitamin D 600 units PO daily 5. Omega-3s (DHA), fish or algae based, 300mg DHA PO daily 6. Iodide at least 220 mcg/day

In regard to pregnancy, if a patient is not taking a prenatal vitamin, what 6 vitamins/minerals should they be receiving daily and what is the RDA?

1. NSAIDs 2. Combination oral contraceptives 3. Progesterone

What are 3 categories of medications that may be utilized in the treatment of Menorrhagia?

Masculinizing therapy - Testosterone - Increases masculine characteristics - Reduces feminine characteristics Feminizing therapy - Estradiol, antiandrogen therapy - Breast development, reduce sperm motility/counts Puberty-blocking therapies - GnRH analogues (Leuprolide, Histrelin) - To postpone/halt puberty until ready for GAHT

In summary, broadly determine what agent(s) are used for the following therapies and why: - Masculinizing Therapy: - Feminizing Therapy: - Puberty-Blocking Therapy:

- HB: Harris-Benedict - MSJ: Mifflin-St Jeor - Ve: Minute ventilation (L/min) - Tmax: Maximum temperature in prior 24 hours in degrees C

In the Penn State Equation, what do each of these variables stand for? - HB: - MSJ: - Ve: - Tmax:

a. Hepatitis A b. Hepatitis B

In the United States, which of the following have a vaccination available to prevent disease? Select all that apply. a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D e. Hepatitis E

b. Hepatitis A and B

In the United States, which of the following have a vaccine approved for use to prevent disease? a. Hepatitis A b. Hepatitis A and B c. Hepatitis C d. Hepatitis D e. Hepatitis E

c. Females and Males of Reproductive Potential

In which section would you find information about whether a patient should be using contraception while using the drug? a. Pregnancy b. Lactation c. Females and Males of Reproductive Potential

a. Folate b. Vitamin B12 - May indicate either a Folate of Vitamin B12 deficiency

Increased homocysteine levels in the blood may indicate what type of nutritional deficiency? a. Folate b. Vitamin B12 c. Vitamin D d. Magnesium

b. Vitamin B12

Increased methylmalonic acid levels may indicate what type of nutritional deficiency? a. Folate b. Vitamin B12 c. Vitamin D d. Magnesium

d. BB plus EVL

Once ST's esophageal variceal hemorrhage has been stabilized with octreotide and EVL, what should be recommended for ongoing therapy? a. BB alone b. None, patient had shunt procedure for his acute bleed c. EVL alone d. BB plus EVL e. Nitrate alone

b. Yes, it's used to determine risk of fracture in certain patients

Is FRAX® used in the diagnosis or management of osteoporosis? a. Yes, it will be replacing the DEXA b. Yes, it's used to determine risk of fracture in certain patients c. No, FRAX® is a made up tool

- Total cPRA (tcPRA) is 2 (low) - T Cell and B Cell crossmatch is negative - Patient is low immunologic risk

Is patient high or low immunologic risk?

Not in United States. However, there is one approved in China

Is there a vaccine available for Hepatitis E?

Yes, the patient could benefit from an enteral feeding tube: - Existing malnutrition (not able to meet nutrition needs via oral intake) - lost 11 kg over 3 months - Likely further decreases in oral intake due to mucositis, nausea, and vomiting from chemo radiation (PO intake will be difficult for him) - GI tract is functional

Is this patient a candidate to receive enteral feeding?

a. Ovulatory - She has regular periods with 31 to 33 day cycles (she is ovulating)

Is this patient ovulatory or anovulatory? a. Ovulatory b. Anovulatory

- Monitor Tacrolimus trough level; Take Tacrolimus after blood draw morning of appointment - Take Prednisone with food

JD is started on maintenance immunosuppression regimen of Tacrolimus 2 mg twice daily [goal 10-12 ng/mL], Mycophenolate 1000 mg twice daily, and a prednisone taper. What are some counseling points to tell JD about his medications?

d. Not enough progestin - There's not enough progestin to maintain the uterine lining

JH is a 23-year-old female that complains of unscheduled bleeding during week 3 of her birth control pack. An excess or lack of which hormone is likely causing the breakthrough bleeding (BTB)? a. Too much estrogen b. Not enough estrogen c. Too much progestin d. Not enough progestin

c. Oral estrogen/progestogen therapy (EPT) 1. First, look at if the patient has symptoms - Patient is experiencing vasomotor symptoms (hot flashes) and GSM (vaginal dryness) - We need systemic therapy (to treat both the vasomotor symptoms and GSM) 2. Second, look at PMH (for contraindications) - She has had no prior surgeries and no significant PMH - So, she has a uterus and EPT is indicated for women with an intact uterus 3. Duavee could also be an option - Estrogen + Bazedoxifene (BZE takes the place of the Progestogen)

JL is a 53 y/o woman, postmenopausal x 1 year, complaining of hot flashes and vaginal dryness that are intolerable. She has no notable PMH and no prior surgeries. What would be the most appropriate treatment? a. HT is contraindicated b. Oral estrogen therapy (ET) c. Oral estrogen/progestogen therapy (EPT) d. Vaginal/localized ET (not Femring®) e. Transdermal ET

c. Overflow UI • Likely due to BPH • "feeling like his bladder is always full" → indicative of an outflow UI

JS a 70-year-old male comes into the pharmacy complaining of frequent urination, a weak urinary stream, and "feeling like his bladder is always full". What type of urinary incontinence matches this patient's symptoms? a. Urge UI b. Stress UI c. Overflow UI d. Functional UI

c. Stress incontinence

LT is a 78 y/o female complaining of leaking urine when she runs or coughs. Based on LT's symptoms, how would you classify her incontinence? a. Mixed incontinence b. Overflow incontinence c. Stress incontinence d. Urge incontinence

b. Oxybutynin ER - Mirabegron could be a good option, but it can elevate BP. This patient has been admitted for a hypertensive crisis recently. Also, the medication is brand name only so it may be expensive/not on formulary

LT is a 79-year-old man complaining of urgency and frequency. He could not tolerate oxybutynin IR due to dry mouth. PMH includes hypertension for which he was recently admitted for Hypertensive Emergency. Which would be the MOST appropriate therapy for LT's UI symptoms? a. Duloxetine b. Oxybutynin ER c. Mirabegron d. Oxybutynin TD OTC

Commonly secondary to nutritional deficiencies: - Folic Acid - Vitamin B12

Macrocytic Anemia (MCV >100 fL) is commonly secondary to what two nutritional deficiencies?

Sirolimus: - Increased risk for infections/malignancy - De novo use in liver transplants associated with mortality and graft loss - De novo use in lung transplants caused bronchial anastomotic dehiscence

What are the U.S. Black Box Warnings associated with Sirolimus (mTORi)?

Contraindications: Current breast cancer

What are the contraindications for a hormonal subdermal implant?

d. The time of the final menstrual period in a woman's life

Menopause is: a. The 12 months following a woman's final menstrual period b. The phase of life after a woman's final menstrual period through death c. The time when irregular menstrual cycles start through one year after the final menstrual period d. The time of the final menstrual period in a woman's life

1. Cholestyramine - Interferes with enterohepatic recirculation 2. Cyclosporine - Interferes with enterohepatic recirculation

Mycophenolate (Cellcept®, Myfortic®) has notable DDIs with which two medications?

Drug-drug interactions: 1. Opiates 2. Bupropion is metabolized by CYP2B6 - 2B6 inducers: Ritonavir - 2B6 inhibitors: Ticlopidine, Clopidogrel 3. Bupropion and its metabolites inhibit CYP2D6 - 2D6 substrates: Beta-blockers, SSRIs, SNRIs, TCAs, Antipsychotics

Naltrexone/bupropion ER (Contrave®) has what DDIs?

c. BMI > 30 kg/m2 Natazia®: Not studied in women with BMI > 30 kg/m2

Natazia® was not studied in women with which of the following characteristics? a. > 70 kg (154 lbs.) b. > 90 kg (198 lbs.) c. BMI > 30 kg/m2 d. BMI > 29 kg/m2

> 70 kg (154 lbs.)

Norethindrone POP should be used with caution in women:

BMI ≥ 30 kg/m2

NuvaRing®/EluRyng™/generic (EE 15 mcg + Etonogestrel 0.12) showed decreased EE concentrations in women with what BMI? Although, it is unknown if efficacy was effected.

- Yes, she isn't eating very much - The Prenatal vitamin and additional supplementation is important for fetal development and prevention of adverse outcomes with pregnancy

OS states she has been having trouble taking her prenatal vitamin since she has been so nauseous. She wonders if she must continue taking it. What would you tell her?

- If the biological father's blood type is Rho(D)+ or unknown, then yes. - Would give the RhoGAM at 28-weeks gestation and within 72 hours after delivery - If the Dad is positive and the Mom is negative, there is a 75% chance the baby will be positive

OS tells you she was told during her pregnancy with her son that she is Rho(D)- ....is she a candidate for Rho(D) Immune Globulin?

Anovulation - Anovulation happens when an egg (ovum) doesn't release from your ovary during your menstrual cycle.

Oligomenorrhea caused by a dysfunction of the hypothalamic-pituitary-ovarian axis is most commonly caused by:

- Alendronate, Risedronate, Zoledronic acid for women & men - Denosumab (may be 2nd line due to cost)

What are the first line therapies for Hip and Spine fracture prevention?

a. Add Lactulose Starting Dose: 45mL (30g) hourly until laxative effect achieved - Upon bowel movement change to 15-45mL (10-30g) q 8 to 12 hours titrated to 2-3 stools daily

One month later, ST's friend brings him in to the emergency department because he has significantly altered mental status. Which of the following should be recommended at this time? a. Add Lactulose b. Add Octreotide c. Increase dietary protein d. Stop the BB

Corticosteroids - Corticosteroids stimulate the synthesis and release of surfactants into the alveolar spaces

What class of agents are used to treat Fetal Lung Immaturity?

a. Yes - The Major Osteoporotic score indicates things are out of whack per the FRAX Calculation Tool: - Major Osteoporotic: 27% (Treat if > 20%) - Hip Fracture: 1.5% (Treat if > 3%)

PB had a FRAX® analysis done and it yielded the following results: BMI: 23.5 10-Year Probability of Fracture: - Major Osteoporotic: 27% - Hip Fracture: 1.5% Should we offer treatment to RT? a. Yes b. No

Nitrates: - PDE-5 inhibitors are contraindicated with regular or intermittent use of organic nitrates in any form via any route - Do NOT use nitrates within 24 hrs. of Sildenafil, Vardenafil, Avanafil or within 48hrs of Tadalafil

PDE-5 inhibitors are contraindicated with regular or intermittent use of what medications?

1. Hemoglobin < 7 g/dL 2. Down trending hemoglobin with active blood loss

Packed red blood cells (PRBCs) are considered for treatment for what two cases?

Not to be used in premenopausal women of child-bearing potential

Parathyroid Hormone Analogs should not be used in which specific patient population?

Paroxetine DDI w/Tamoxifen (CYP2D6) which can decrease Tamoxifen concentrations

Paroxetine has a pertinent DDI with which medication, subsequently decreasing its serum concentrations?

Chlamydia - Patients should receive therapy to eradicate BOTH organisms concurrently UNLESS a rapid test can rule out co-infection.

Patients infected with gonorrhea are often co-infected with:

"PAINS" P = Period late A = Abdominal pain or pain with intercourse I = Infection, abnormal or odorous vaginal discharge N = Not feeling well, fever, chills S = String (missing, shorter, longer)

Patients with a LNG-IUD should seek medical care if experience any of these problems:

b. Arterial vasodilation and venous occlusion

Penile erection develops from which of the following? a. Arterial occlusion and venous vasodilation b. Arterial vasodilation and venous occlusion c. Arterial and venous vasodilation d. Arterial and venous occlusion

ACOG Recommendation: May induce if Bishop score ≥ 6 - The higher the Bishop score, the more likely to experience a successful delivery

Per the Bishop Scoring System and per ACOG Recommendation, at what score may labor be induced?

CDC Guidelines: All pregnant women screened between 35-37 weeks gestation

Per the CDC Guidelines, all pregnant women should be screened for Group B Streptococcus (GBS) when?

Only contraindication per MEC is current breast cancer

Per the MEC, the only current contraindication to the intramuscular progestin-only contraceptive Depot medroxyprogesterone acetate (Depo-Provera®) is?

High Risk according to NYHA: • Unstable or symptomatic angina despite treatment • Uncontrolled hypertension • Severe congestive heart failure (NYHA Class III or IV) • Recent myocardial infarction or stroke within past 2 weeks • Moderate or severe valvular heart disease • High risk cardiac arrhythmia • Obstructive hypertrophic cardiomyopathy

Per the NYHA, what factors would make a patient a high risk for sexual intercourse and thus be contraindicated to PDE-5 (Phosphodiesterase - 5 Inhibitor) therapy and sexual intercourse should be deferred?

If not effective, add Metformin or Dexamethasone or use another ovulation induction agent

Per the PCOS Treatment Algorithm, what is the preferred agent for infertility refractory to TLCs and Letrozole (or Clomiphene)?

If no pregnancy desired, add CHC or Metformin

Per the PCOS Treatment Algorithm, what is the preferred treatment for amenorrhea or oligomenorrhea that is refractory to 3-6 months of lifestyle modifications for an obese patient that does not desire pregnancy?

Reduce dextrose to 50% of requirement with initial PN bag

Per the Pharmacotherapy V Protocol, how should dextrose be adjusted if the patient is at risk for refeeding syndrome?

- 8.1: Pregnancy (includes labor and delivery) - 8.2: Lactation (includes nursing mothers) - 8.3: Females and Males of Reproductive Potential

Per the Pregnancy and Lactation Labeling Rule (PLLR), identify what the following sections are about: - 8.1: - 8.2: - 8.3:

1. Ovulatory dysfunction (oligo- or anovulation) 2. Clinical and/or biochemical hyperandrogenism 3. Polycystic ovaries (seen via U/S or other imagine technique) - AND exclusion of other known disorders (hyperprolactinemia, thyroid abnormalities, and congenital adrenal hyperplasia)

Per the Rotterdam Criteria for diagnosis of PCOS, there must be 2 of the 3 following criteria present for a diagnosis:

1. Underweight: <18.5 2. Normal weight: 18.5-24.9 3. Overweight: 25-29.9 4. Obesity: > 30 - Obesity Class I: 30-34.9 - Obesity Class II: 35-39.9 - Obesity Class III (morbidly obese): > 40

Per the World Health Organization (WHO), what BMI is associated with the following weight classifications? 1. Underweight: 2. Normal weight: 3. Overweight: 4. Obesity: - Obesity Class I: - Obesity Class II: - Obesity Class III (morbidly obese):

Severe Allergic Reaction - Anaphylaxis - Angioedema - Respiratory distress - Urticaria

Persons with a history of what type of reaction after receiving penicillin or a cephalosporin would be eligible for either Vancomycin or Clindamycin depending on whether or not the isolate is susceptible to Clindamycin and Erythromycin?

Antihypertensives: ACE/ARB are preferred, possibly less with B1 selective drugs

What class of antihypertensive medication is preferred for those with sexual dysfunction?

Recommended for a woman in a stable, mutually-monogamous relationship and without history and risks of STIs/PID - Levonorgestrel IUD 52 mg (Mirena®, Liletta®) - Levonorgestrel IUD 19.5 mg (Kyleena®) - Levonorgestrel IUD 13.5mg (Skyla™)

Progestin intrauterine devices are recommended for:

Women who are lactating - May be initiated immediately postpartum for those not lactating - Can be initiated immediately postpartum for those lactating (benefits outweigh risks) and some wait 4-6 weeks (no restrictions per U.S. MEC)

Progestin-Only Pill (POP) are most commonly used among women who:

d. Estradiol (Estring®) - Not experiencing any vasomotor symptoms, just GSM symptoms. So, we can use a localized therapy - Femring is systemically absorbed - Femring is the only localized, non-systemically absorbed product out of these options

RD is a 56 y/o woman complaining of severe vaginal itching and dyspareunia x 6 months. PMH: HTN, CAD, cholecystectomy and hysterectomy. What would you recommend for RD? a. CEE (oral ET) b. Combipatch (transdermal EPT) c. Estradiol (Femring©) d. Estradiol (Estring®)

a. Too much estrogen - Starting out with too much estrogen, stops the hormonal pills, starts the placebo pills, and then is experiencing headaches; essentially experiencing a withdrawal - Could lower the estrogen content of the hormonal pills or find a product that has a small concentration of estrogen in the placebo pills

RW is a 26-year-old female with more headaches during her period than she had before starting birth control pills. An excess or lack of which hormone is likely causing her headaches? a. Too much estrogen b. Not enough estrogen c. Too much progestin d. Not enough progestin

Naltrexone/bupropion (Contrave®)

Reduced cravings (CNS activity) is associated with which FDA approved agent(s) for obesity?

Black Box Warning for Cardiac Disorders: - May increase risk of MI, stroke, CV death - Do not use within 1 year of MI, stroke

Romosozumab has a Black Box Warning for:

b. Stress UI - PMH of 2 vaginal deliveries → indicative risk factor that this would be Stress UI

SL a 50-year-old female approaches you at the pharmacy counter wondering what she can do for these embarrassing symptoms she is having. SL reports urinating when she laughs or sneezes. PMH reveals 2 vaginal deliveries. What type of urinary incontinence match this patient's symptoms? a. Urge UI b. Stress UI c. Overflow UI d. Functional UI

c. Add furosemide 40mg AND spironolactone 100mg PO QD

ST comes back to your clinic for a 3-month follow-up from his hospitalization. On physical exam, it is noted that he now has significant ascites present. Which of the following should be recommended at this time? a. Increase BB dose b. Add furosemide 40mg PO QD c. Add furosemide 40mg AND spironolactone 100mg PO QD d. Add furosemide 100mg AND spironolactone 40mg PO QD e. Recommend dietary salt restriction only

d. Add Albumin + Norepinephrine Expand intravascular volume: - Albumin 1 g/kg IV QDay PLUS - Vasopressors (Norepinephrine)

ST is hospitalized for treatment of hepatic encephalopathy, which is severe enough to require intubation. During his hospitalization, it is noted that his SCr has increased to 6. Which of the following should be recommended at this time? a. Increase the BB b. Start iHD c. Add Albumin d. Add Albumin + Norepinephrine

a. Start Ceftriaxone IV daily

ST presents to the emergency department with complaints of general fatigue, fever, and chills. A diagnostic paracentesis is done which shows 300 PMNs and no bacteria. Which of the following should be recommended at this time? a. Start Ceftriaxone IV daily b. Start Bactrim DS tablets PO QD c. No antibiotic therapy is indicated at this time

- BEERs List medications to potentially avoid in the elderly - Extensive hepatic metabolism (avoid w/ severe impairment)

Second generation α-adrenergic antagonists (i.e., Terazosin, Doxazosin, & Alfuzosin) should be avoided in what patient population(s)?

a. Yes, she has several risk factors for osteoporosis

Should PB have a DEXA scan done? a. Yes, she has several risk factors for osteoporosis b. No, she's not 70 years old c. No, we already know she has osteoporosis

- Yes (No cirrhosis or Hep B infx) - Glecaprevir/pibrentasvir 100/40mg (Mavyret®) or Sofosbuvir/velpatasvir 400/100mg (Epclusa®) - Up-to-date medication list, insurance coverage, patient preference

Should this patient be eligible for simplified HCV treatment? If so, which pangenotypic regimens would be options? If selecting a regimen, what else needs to be considered?

No • She should still be monitored • Her ALT is normal • Her HBV DNA is low • Fibroscan is normal

Should this patient be prioritized for HBV treatment?

Yes • Hep B surface antigen is reactive • HBV DNA is detectable (> 20,000) • ALT is elevated • Fibroscan shows F1 (mild fibrosis/scanning)

Should this patient be prioritized for HBV treatment?

Alemtuzumab strong depleting agent → increased risk for infections - Utilized in steroid avoidance or CNI minimization maintenance immunosuppression - No longer available in the U.S.

Since Alemtuzumab (Campath®) is a strong depleting agent, patients are at an increased risk for?

Drospirenone 4 mg (Slynd®) - Progestin-Only Pill (POP) - Failure Rate: 4% - Return to Fertility: Rapid

Slynd® is the brand name for?

a. True - Annually reassess/discuss need for continued suppressive therapy

Suppressive therapy for recurrent genital herpes reduces but does not eliminate subclinical viral shedding. a. True b. False

Tamsulosin (Flomax®): - Avoid in severe sulfa allergy (rare, but avoid use if severe reaction) - Avoid with potent CYP3A4 inhibitors and severe hepatic impairment

Tamsulosin (Flomax®) should be avoided in which two patient scenarios?

a. Nonselective Type I and Type II 5-α-Reductase Inhibitor - Dual inhibitor - Finasteride (Proscar®, Propecia®): Selective type II 5-α-Reductase Inhibitor

The 5-α-Reductase Inhibitor, Dutasteride (Avodart®), is: a. Nonselective Type I and Type II 5-α-Reductase Inhibitor - Dual inhibitor b. Selective type II 5-α-Reductase Inhibitor

- Class A = 5 to 6 points (least severe liver disease) - Class B = 7 to 9 points (moderately severe liver disease) - Class C = 10 to 15 points (most severe liver disease)

The Child-Turcotte-Pugh Class is obtained by adding score for each parameter (total points), for each Class determine the Cirrhosis severity and associated score: - Class A: - Class B: - Class C:

Etiology geographically dependent: Developing Countries: Viral hepatitis (A, E) cases more common Developed Countries: Toxin-related cases (APAP)

The etiology of ALF is geographically dependent. What is the most common etiology in developing countries? In developed countries?

- Cyclosporine: 50-350 ng/mL - Tacrolimus: 3-15 ng/mL

The goal trough level for Calcineurin inhibitors (i.e., Cyclosporine and Tacrolimus) are dependent on the type of transplant, time after transplant, infection, history, and other factors. Generally speaking, are the goal trough levels for Cyclosporine and Tacrolimus?

- Sirolimus goal: 6-12 ng/mL - Everolimus goal: 3-8 ng/mL

The goal trough level for mTORi's (i.e., Sirolimus and Everolimus) are dependent on the type of transplant, other immunosuppression, how far out from transplant, and other factors, generally speaking, are the goal trough levels for Sirolimus and Everolimus?

c. Dutasteride and Tamsulosin Indication for Combo Therapy: - Moderate to severe symptoms - Enlarged prostate gland > 30 g (42 g) - PSA > 1.5ng/mL (1.6 ng/mL)

The medical resident is wondering what medication/s you recommend be initiated in this patient? a. Finasteride b. Doxazosin c. Dutasteride and Tamsulosin d. Oxybutynin and Doxazosin

a. Patient D - WBC 2.6, Hgb 7.2, Hct 22.0, Plt 60k

Thymoglobulin dosing should be modified for which of the following patients and their current hematologic parameters? a. Patient D - WBC 2.6, Hgb 7.2, Hct 22.0, Plt 60k b. Patient C - WBC 7.7, Hgb 12, Hct 35.7, Plt 107k c. Patient A - WBC 8.0, Hgb 8.0, Hct 24.1, Plt 79k d. Patient B - WBC 9.8m Hgb 11.0, Hct 33.5, Plt 99k

b. False - Tocolytics do NOT directly improve neonatal outcomes - Give us time to administer meds/make interventions that can! - Tocolytics are contraindicated (i.e., in general, would not use...) if there are maternal or fetal risks to prolonging the pregnancy

Tocolytics directly improve neonatal outcomes. a. True b. False

DDIs: CYP 3A4 and 2D6 inhibitors (Fluoxetine, Sertraline, etc.)

Tolterodine (Detrol®), used for the treatment of UUI, has what pertinent DDIs?

- Women with a BMI ≥ 30 kg/m2 (reduced effectiveness, possible increased VTE risk) - Women 35+ who smoke (VTE risk)

Transdermal Contraceptive Patches are contraindicated in what patient population(s)?

a. True - 5 days for Ulipristal acetate (UPA) - 3 days for Plan B (Levonorgestrel)

Ulipristal acetate (UPA) is effective in preventing pregnancy up to 5 days after unprotected intercourse. a. True b. False

a. Desogestrel 0.15 mg + EE 30 mcg (high p, int e, low a)

Using the information from the Facts & Comparisons Contraception Progestin/Endometrial/Androgen Activity table, which of the following COC options would you recommend? a. Desogestrel 0.15 mg + EE 30 mcg (high p, int e, low a) b. Norethindrone 0.5 mg +EE 35 mcg (low p/e/a) c. Norethindrone acetate 1 mg + EE 20 mcg (int/high p, low e, int/high a) d. Norgestrel 0.5 mg + EE 50 mcg (high p/e/a)

Indication: GSM

Vaginal (Cream, ring, tablet) estrogen formulations are indicated for:

c. HCV Antibody reactive, HCV RNA detected - HCV Antibody: Non-reactive - No current or past HCV infection (unless exposed within the last 6 months) - HCV Antibody: Reactive - Current or past HCV infection - HCV RNA: Detected - Current HCV infection - HCV RNA: Not detected - No current HCV infection

What HCV labs would indicate current, active HCV infection? a. HCV Antibody non-reactive, HCV RNA not detected b. HCV Antibody reactive, HCV RNA not detected c. HCV Antibody reactive, HCV RNA detected d. Not sure, need more lab work

HVPG > 10mm Hg: Clinically Significant Portal Hypertension (Predictive of complications of cirrhosis)

What Hepatic Venous Pressure Gradient (HVPG) value indicates clinically significant portal hypertension and is predictive of complications of cirrhosis?

PDE-5 inhibitors: - Sildenafil (Viagra®) - Vardenafil (Levitra®) - Tadalafil (Cialis®) - Avanafil (Stendra®)

What PDE-5 inhibitors are available as first-line pharmacologic treatment options for ED?

Belatacept (Nulojix®) Administration: - Infused over 30 minutes central or peripheral line - Does not require pre-medication - Round to the nearest 12.5 mg

What T Cell Costimulation Blocker may be utilized in immunosupprresive maintenance therapy?

Adverse effects with oral bisphosphonates: - N/V/D - Dyspepsia, Abdominal pain, Esophageal reflux - Esophageal irritation/GI bleeding/Perforation/Ulceration - Mainly related to incorrect administration - Severe bone, joint, muscle pain

What adverse effects are associated with oral bisphosphonates?

Floppy Iris Syndrome Iris dilator muscle relaxes: - Becomes a complication during cataract surgery - Patients should notify their ophthalmologist

What adverse reaction involving the α-1A receptors located in the iris dilator is most commonly associated with Tamsulosin?

"H's and N's" - CSA: Cyclosporine; FK: Tacrolimus H's - Hypertension (CSA > FK) - Hypercholesterolemia (CSA > FK) - Hyperkalemia/Hypomagnesemia (FK > CSA) - Hyperplasia (gingival) (CSA only) - Hirsutism (CSA only) or hair loss (FK only) N's - Neurotoxicity (FK > CSA) - Tremors, headache, seizures - Neoplasms - New onset diabetes after transplant (FK > CSA) - Nephrotoxicity

What adverse reactions are associated with Calcineurin inhibitors, i.e., Cyclosporine (Gengraf®, Neoral®, Sandimmune®) and Tacrolimus (Prograf®, Astagraf®, Envarsus®)?

Eflornithine hydrochloride cream 13.9% (Vaniqa®) - Takes 4-8 weeks for maximal effectiveness, usually in conjunction with laser hair removal

What agent is FDA-approved for reducing unwanted hair from face and adjacent areas under chin in females ≥ 12 years old?

Doxylamine - Add to Pyridoxine if needed - Available OTC - Dose: 12.5 mg with Pyridoxine every 8 hours - The combination of Pyridoxine and Doxylamine is associated with a 70% reduction in NVP and recommended by ACOG (Level A Evidence)

What agent is added to Vitamin B6 (Pyridoxine) if needed for additional treatment of N/V in pregnancy?

Thymoglobulin: 1.5 mg/kg 3-5 doses

What agent is typically utilized as the treatment for steroid-resistant or moderate/severe acute cellular rejection?

Children: Pamidronate (cancer hypercalcemia therapy)

What agent is used in children, notably as a cancer hypercalcemia therapy?

Oxytocin (Pitocin®) - Uterotonic agent - Increases frequency, force and duration of contractions - Endogenous polypeptide hormone

What agent is utilized to help stimulate contractions and increase uterine activity. It is given exogenously for artificial induction and augmentation of labor usually if the prostaglandin agents just aren't cutting it. Given via continuous infusion and titrated to effect.

Add Metformin for Clomiphene resistance: - 1500-2000mg/day, divided

What agent that can be added to Clomiphene for Clomiphene resistance reduces circulating insulin levels to help normalize follicular development in women with PCOS and has shown best effectiveness in overweight or obese women?

- Management of Cerebral Edema: Mannitol - Management of Infection: Prophylactic Abx for severe cases - Management of Coagulopathies: Empiric Vitamin K

What agents are recommended for supportive care for ALF for the the following: - Management of Cerebral Edema: - Management of Infection: - Management of Coagulopathies:

Prostaglandins: Induce labor - Misoprostol (PGE1) vaginal tablet - Dinoprostone (PGE2) vaginal gel or insert

What agents may be utilized for cervical ripening/induction of labor?

Oxybutynin IR oral - Generally, 1st line therapy due to low cost - Strongest anticholinergic side effects: Caution in elderly, monitor ADEs - 2.5-5mg BID/TID, Max: 5mg 4x/day - Start low, go slow with elderly

What anticholinergic medication is generally utilized first-line for UUI due to cost?

Paroxetine (Brisdelle®): 7.5mg PO QHS - FDA approved for moderate to severe vasomotor symptoms - Others: Citalopram, Desvenlafaxine, Escitalopram, Fluoxetine, Paroxetine*, Sertraline, Venlafaxine* - Not effective for genitourinary symptoms (GSM)

What antidepressant, non-hormonal therapy is the drug of choice (others are 2nd line) for moderate to severe vasomotor symptoms (not effective for GSM)?

Silodosin (Rapaflo®): - Dose adjust for renal dysfunction: Contraindicated in CrCl <30 mL/min - Avoid with potent CYP3A4 inhibitors and severe hepatic impairment

What are 2 dosing pearls for Silodosin (Rapaflo®)?

1. Rapid Plasma Reagin (RPR) - tests for antibodies to syphilis 2. Venereal Disease Research Laboratory (VDRL) - tests for antibodies to syphilis

What are 2 non-treponemal tests that test for antibodies to syphilis in the blood?

1. Mavyret® (Glecaprevir/pibrentasvir) 2. Epclusa® (Sofosbuvir/velpatasvir)

What are 2 pangenotypic options for HCV simplified treatment?

1. Male condom 2. Spermicide (N-9) 3. Sponge - Nulliparous - Parous Perfect Use: Male condom (2%) Typical Use: Nulliparous Sponge (12%)

What are 3 Non-Prescription Barrier Contraceptive Methods? Which offers the lowest failure rate with perfect use and typical use?

1. Internal condom 2. Diaphragm (with spermicide) 3. Cervical cap - Nulliparous - Parous Perfect Use: Internal condom (5%) Typical Use: Diaphragm (with spermicide) (12%)

What are 3 Prescription Barrier Contraceptive Methods? Which offers the lowest failure rate with perfect use and typical use?

1. Allow 5 minutes for gel to dry before dressing 2. Avoid water contact as long as possible (swimming) 3. Alcohol based gel: Avoid smoking until the gel has dried (fire hazard) 4. Do not apply sunscreen for at least 60 minutes after application AND avoid applying for 7 or more consecutive days - May increase absorption of transdermal estrogen gel

What are 4 important counseling pearls for Hormonal Transdermal Gels?

1. Immediate cessation of ETOH 2. APAP < 2 g/day 3. Vaccination against Hep A and Hep B 4. Sodium restriction (< 2 g/day) to reduce ascites

What are 4 non-pharmacologic treatment recommendations for cirrhosis?

1. Abstinence 2. Fertility awareness methods (FAMs) & Natural family planning (NFP) 3. Fertility awareness app 4. Coitus interruptus 5. Lactation amenorrhea method (LAM) Perfect Use: Fertility awareness methods (FAMs) & Natural family planning (NFP) - 0.4-5% Typical Use: Lactation amenorrhea method (LAM) - 4-7%

What are 5 Behavioral Contraceptive Methods (Natural Family Planning)? Aside from abstinence, which offers the lowest failure rate with perfect use and typical use?

CNS Activity: 1. Phentermine (Apidex-P) - Short-term therapy only (up to 12 weeks) 2. Phentermine/topiramate ER (Qsymia®) 3. Naltrexone/bupropion (Contrave®) 4. Liraglutide (Saxenda®) Peripheral activity: 5. Orlistat (Xenical®, Alli®)

What are 5 FDA approved agents for obesity?

• Severe, active liver disease • Untreated HTN • Estrogen-dependent tumor • Hypersensitivity to HT • Pregnancy

What are 5 additional systemic hormonal therapy (HT) contraindications?

1. Modified-Release (DR, CR, ER, LA, XR, SA etc.) - Over-dosages, fatalities! - Exception: Some/Rare capsules w/ microencapsulated pellets can be opened, and intact pellets administered via large-bore feeding tubes 2. Enteric-Coated - Stomach irritation, altered absorption, clogging of tubes 3. Carcinogenic / Teratogenic 4. Poor Palatability - Bitter (if still taking PO), Irritating, numbing 5. Altered efficacy d/t Gastric vs. Intestinal Delivery - Require gastric pH (Itraconazole) - Local site of action (Ex: Antacids, Bismuth, Sucralfate) - Proximal absorption (Fluoroquinolones, iron)

What are 5 categories of medications that cannot be crushed (from EN lecture)?

1. Calcineurin inhibitors: - Cyclosporine (Gengraf®, Neoral®, Sandimmune®) - Tacrolimus (Prograf®, Astagraf®, Envarsus®) 2. Antiproliferative: - Azathioprine (Imuran®) - Mycophenolate (Myfortic®, Cellcept®) 3. Corticosteroids: - Methylprednisolone/Prednisone 4. Mammalian target of Rapamycin inhibitors: - Everolimus (Zortress®) - Sirolimus (Rapamune®) 5. T cell costimulation blocker: - Belatacept (Nulojix®)

What are 5 categories of medications that may be utilized in maintenance immunosuppression therapy?

1. Diarrhea 2. Constipation 3. Intolerance 4. Aspiration 5. Metabolic alterations 6. Intestinal ischemia

What are 6 complications of Enteral Nutrition (EN)?

Contraindications: - Hypocalcemia - Pregnancy - Hypersensitivity to Denosumab

What are CIs to Denosumab (Prolia®, Xgevia®) use?

Contraindications: - Pregnancy - Active or previous VTE - Male

What are CIs to Raloxifene (Evista®) use?

- Age (72 y/o); normal testicular function

What are GM's risk factors for BPH?

Place in therapy: Patients who failed bisphosphonates or have severe osteoporosis with high fracture risk - Can be used as first line if T score is < 3.5 or patient has severe osteoporosis - Preferred over Raloxifene in patients who have had a low-trauma fracture

What are Parathyroid Hormone Analogs place in Osteoporosis treatment therapy?

- Cost-effective - Safe - Approved for 10 continuous years - Highly effective: 0.8% typical use - Can be used as post-coital contraceptive when inserted within 5 days of unprotected intercourse (<1% pregnancy rate) - Immediate return to fertility

What are advantages to the non-hormonal long-acting reversible contraceptive (LARC) Copper T 380A IUD?

1. Phenytoin 2. Carbamazepine 3. Fluoroquinolones 4. Warfarin

What are four medications that are notorious for interacting with EN?

1. Bisphosphonates 2. NSAIDs 3. Products containing sorbitol 4. ER or CR formulations

What are four medications that should be avoided in gastric bypass?

Adverse effects: 1. Cardiac disorders 2. Hypocalcemia - Must take Calcium and Vitamin D during therapy; More concern in renal dysfunction: CrCl less than 30 mL/min 3. Osteonecrosis of the jaw 4. Atypical femur fractures

What are four pertinent AEs associated with Romosozumab?

1. Diclegis® (Doxylamine 10 mg + Pyridoxine 10 mg DR) - Dose: 2 tabs PO in the evening on empty stomach, if needed may add 3rd tablet in the morning on day 3, then 4th tablet in mid-afternoon on day 4 2. Bonjesta® (Doxylamine 20 mg + Pyridoxine 20mg CR) - Dose: 1 tab PO at bedtime on day 1; may increase to 1 tab AM, 1 tab HS on day 2 if sxs persist; max 2 tabs/day 3. Zofran® (Ondansetron) - Dose: 4-8 mg Q 8 hours PO or IV 4. Reglan® (Metoclopramide) - Dose: 5-10 mg PO TID

What are four prescription-only agents utilized for N/V in pregnancy?

Must receive IM injection every 13 weeks: - Sufficient dosage to last 15 weeks, so have 2-week grace period - If more than 1 week overdue, will need to do a pregnancy test and use back-up method for 7 days after injection DMPA has delayed return to fertility: - Ovulation will not return for 5-8 months after last injection and up to 18-22 months for some women (median 10 mos.) - Not recommended for any woman wanting to conceive within a year

What are important counseling points for Depo-Provera in regards to frequency of dosing and return to fertility?

Risk factors: - Increasing age - Bladder outlet obstruction (tumors, stones) - Neurologic disorders (stroke, dementia, PD, SCI) - Infection (UTI, urethritis)

What are risk factors associated with Urge Urinary Incontinence (UUI)?

1. Oxybutynin (Ditropan®, Oxytrol®, Gelnique®) 2. Tolterodine (Detrol®) 3. Fesoterodine (Toviaz®) 4. Trospium (Sanctura®) 5. Solifenacin (Vesicare®) 6. Darifenacin (Enablex®)

What are six anticholinergics for the treatment of Urge Urinary Incontinence?

Everolimus: - Increased risk for infections/malignancy - Renal graft thrombosis - Nephrotoxicity when used in combination with standard doses of Cyclosporine - Increased mortality in heart transplant within first 3 months associated with serious infections

What are the U.S. Black Box Warnings associated with Everolimus (mTORi)?

Advantages: 1. Fewer periods a year 2. Reduces menstrual-related problems, anxiety, fluid retention, breast tenderness, bloating, menstrual migraines Disadvantages: 1. Increases risk of unscheduled bleeding - As much as 41% had BTB in first few months of Lybrel® - May take hormone-free interval for 3-4 consecutive days, but not more than once/month or during first 21 days of use - May subside after several months (give it up to 6 months)

What are some advantages and disadvantages of extended use COCs?

If the Gut Works, Use it! 1. EN: Better preservation of gut barrier function - ↓ infectious complicaitons 2. EN: Better overall safety profile - ↓ Severe complications 3. EN: Less expensive 4. EN: Greater convenience 5. EN: Offers enteral access for medications

What are some advantages to Enteral Nutrition (EN) over Parenteral Nutrition (PN)?

Side effects: Common: Headache, flushing, indigestion, congestion Rare: Priapism, visual disturbances

What are some common and rare side effects associated with PDE-5 inhibitors?

Contraindications: - Pregnancy - Carcinoma of the breast - Undiagnosed abnormal vaginal bleeding - Acute liver disease (including malignant or benign liver tumors)

What are some contraindications to progestin-only contraceptive use?

- Saline irrigation - Also, exercise, humidifier, raising the head of the bed, external nasal dilator

What are some non-pharmacologic treatment options for symptoms associated with the common cold or allergic rhinitis during pregnancy?

• Medication use (HCTZ, SSRI, Opioid) • Hypertension, hyperlipidemia, depression • Smoking • Age (> 50 y/o) • Diabetes

What are some of the risk factors MN has for ED?

1. Lifestyle: - Age > 50 - Smoking - Obesity - Sedentary 2. Trauma (e.g., spinal cord injury) 3. Surgical procedures 4. Specific medications (antihypertensives, antidepressants, antipsychotics, anticonvulsants, 5 alpha reductase inhibitors, opioids)

What are some organic risk factors associated with sexual dysfunction?

• Performance anxiety • Loss of attraction • Relationship difficulties • Stress • Depression • Schizophrenia • Specific medications (antihypertensives, antidepressants, antipsychotics, anticonvulsants, 5 alpha reductase inhibitors, opioids)

What are some psychogenic risk factors associated with sexual dysfunction?

Risk factors: - Pregnancy/vaginal childbirth - Age - Lower urinary tract surgery/injury - Men: prostate surgery (damage to urethra) - Obesity - Menopause (estrogen deficiency)

What are some risk factors associated with Stress Urinary Incontinence (SUI)?

Clinical guideline recommendations for initiating pharmacologic therapy: 1. BMI of ≥ 27 kg/m2 and the presence of weight-related complications 2. BMI >30 kg/m2 3. If no clinical improvement after a trial of 12 weeks, consider dose adjustment or try another agent

What are the 3 clinical guideline recommendations for initiating pharmacologic therapy for obesity?

1. Stop offending agent 2. N-Acetylcysteine (NAC) - Lack of strong evidence for other treatments (Anti-HIS, steroids) - Some drugs have specific treatments that may be of benefit - Ex: Carnitine for valproate hepatotoxicity; cholestyramine for terbinafine 3. Life-long ADR; Never Re-Challenge! - Add to Allergy list - Re-exposure strongly discouraged, especially if initial injury was significant - Exception: Life-threatening situations where there is no suitable alternative

What are the 3 steps to effective DILI management?

FDA-approved indications: 1. Prevent pregnancy - Typical failure rate of 9% - Return to fertility: Average is 3 months 2. Reduce acne (Estrostep®, Ortho-Tri-Cyclen®, YAZ®, Beyaz®) 3. PMDD (YAZ®, Beyaz®) 4. Heavy menstrual bleeding (Natazia®)

What are the 4 FDA approved indications for Combined Hormonal Contraception (CHC)?

1. Treat the underlying cause! - Stop any offending drugs - Treat infection 2. Supportive care: get through the acute event! - ICU Admission, Early transfer to Transplant Center - Fluid management, hemodynamic support, close monitoring of labs - Management of cerebral edema - Mannitol - Management of infection - Prophylactic Abx for severe cases - Management of coagulopathies - Empiric Vitamin K 3. Pharmacotherapy - Drug-specific therapy - N-AC 4. Transplant

What are the 4 steps to effective ALF treatment?

1. Rule out infection-related diarrhea 2. Rule out medication-related diarrhea - Are patients on any pro-kinetic agents (something that increased GI motility)? i.e., Metoclopramide, Erythromycin, etc. oGet rid of these agents if they are on board 3. Change EN formula type 4. Add fiber 5. Add an antidiarrheal (e.g., Loperamide, Diphenoxylate, Paregoric, Octreotide, etc.) 6. Continue EN as tolerated and initiate PN to complete delivery of nutrients

What are the 6 steps to managing diarrhea related to Enteral Nutrition (EN)?

1. Acyclovir 800mg orally 2x/day for 5 days 2. Acyclovir 800mg orally 3x/day for 2 days 3. Famciclovir 1gm orally 2x/day for 1 day 4. Famciclovir 500mg once, followed by 250mg 2x/day for 2 days or, Famciclovir 125mg 2x/day for 5 days or, Valacyclovir 500mg orally 2x/day for 3 days or, Valacyclovir 1gm orally 1x/day for 5 days

What are the CDC Recommended Regimens for Episodic Genital Herpes Therapy?

1. Regimen for uncomplicated gonococcal infections of the cervix, urethra, or rectum: Ceftriaxone 500mg IM as a single dose for persons weighing < 150kg (300 lb.) - For persons weighing >150kg (300 lb.): 1gm of IM Ceftriaxone should be administered - If chlamydial infection has not been excluded, providers should treat for chlamydia with Doxycycline 100mg orally twice daily for 7 days - During pregnancy, Azithromycin 1gm as a single dose is recommended to treat chlamydia

What are the CDC Recommended regimens for uncomplicated gonococcal infections of the cervix, urethra, or rectum (2020)?

Recommended regimen for uncomplicated gonococcal infections of the pharynx: 1. Ceftriaxone 500mg IM as a single dose for persons weighing < 150kg (300 lb.) - For persons weighing > 150kg (300 lb.), 1gm of IM Ceftriaxone should be administered - If Chlamydia co-infection is identified when pharyngeal gonorrhea testing is performed, providers should treat for chlamydia with Doxycycline 100mg orally twice a day for 7 days - During pregnancy, Azithromycin 1gm as a single dose is recommended to treat chlamydia

What are the CDC Recommended regimens for uncomplicated gonococcal infections of the pharynx (2020)?

If 1 white pill is missed, take asap, continue as scheduled

What should you tell a patient who has missed 1 white pill from her Drospirenone 4 mg (Slynd®) pack?

1. S/p bariatric surgery 1a. Restrictive procedure (band or sleeve) - All methods are appropriate 1b. Malabsorptive procedure (Roux-en-Y gastric bypass or biliopancreatic diversion) -Non-oral methods are preferred - Avoid oral methods (COC, POP = 3 on MEC chart) 2. Renal impairment: Non-hormonal contraception is encouraged 3. Hepatic impairment: CHC may be poorly metabolized, use is contraindicated in presence of hepatic tumors or disease

What are three additional special populations (aside from postpartum and breastfeeding) in which CHCs are not recommended/should be avoided?

1. Warm water (10 - 30 mL) 2. Pancrelipase tablet (Viokace®) and Sodium Bicarbonate tablet - Crush 1 pancrealipase tablet - Crush 1 HCO3 324 mg tablet - (Activates pancrealipase enzymes and raises pH) - Dissolve in 5 mL H2O and allow to dwell 30 - 60 min in tubing 3 .Replacement of feeding tube

What are three strategies to managing feeding tube clogging?

1. Indomethacin (Indocin®) - NSAID 2. Nifedipine (immediate release) - Calcium channel blocker 3. Terbutaline (Bricanyl®) - β2-adrenergic agonist

What are three tocolytic agents that may be utilized to inhibit myometrial (uterine) contractions?

• Patient must sit or lay down • Expensive treatment: ~$1400-1700 per month • Maximum of two years of treatment 1. Abaloparatide: - Dose is 80 mcg subcutaneously once daily - Refrigerated pen with 30 doses 2. Teriparatide: - Dose is 20 mcg subcutaneously once daily - Refrigerated pen with 28 doses

What are two Parathyroid Hormone Analogs available for Osteoporosis treatment therapy? What is the maximum duration of treatment with these agents?

Direct acting antivirals (Tenofovir, Entecavir) - Well-tolerated

What are two agents that can be utilized for HBV treatment?

1. Azathioprine AZA (Imuran®) 2. Mycophenolate MPA/MMF (Myfortic®, Cellcept®)

What are two antiproliferative agents that are utilized in maintenance immunosuppression therapy?

1. Scheduled Voiding 2. Urge Suppression Techniques

What are two bladder training techniques for Urge Urinary Incontinence?

1. Depleting agents: - Antithymocyte globulin (ATGAM®, Thymoglobulin®) - Alemtuzumab (Campath®) 2. Non-depleting agent: - Basiliximab (Simulect®)

What are two classes of medications utilized for immunosuppression induction?

Treponemal test: - Fluorescent Treponemal Antibody Absorption (FTA-ABS) - T. pallidum particle agglutination (TPPA)

What are two examples of syphilis treponemal tests?

- Functional GI tract - Oral intake is unsafe, insufficient, or impossible

What are two indications for which Enteral Nutrition (EN) should be used?

1. Balloon Tamponade Procedures: - Balloon-occluded Retrograde Transvenous Obliteration (BRTO) of gastric varices 2. Surgical Shunting Procedures: - Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure for gastric or esophageal varices

What are two non-pharmacologic treatment options for an acute variceal hemorrhage?

1. Malignancy - Post transplant lymphoproliferative disorder (PTLD) - Contraindicated in EBV serostatus negative or unknown serostatus due to increased risk of developing PTLD 2. Infections

What are two notable adverse reactions associated with Belatacept (Nulojix®)?

Regimen: - Betamethasone 12mg IM Q24h x 2 doses, OR - Dexamethasone 6mg IM Q12h x 4 doses - May use a single repeat course which reduces neonatal morbidity (Betamethasone)

What are two regimens commonly employed for Fetal Lung Immaturity treatment? Which can be repeated?

1. Atypical fractures: - Subtrochanteric and femoral shaft - Transverse or short oblique orientation - Spontaneous or minimal trauma 2. Osteonecrosis of the jaw: - More common with high-dose intravenous bisphosphonates or therapy over 2 years in length - Seen after tooth extraction, mouth trauma, or oral surgery - Risk factors include concomitant glucocorticoid therapy, pre-existing dental disease, chemotherapy, radiotherapy, infection

What are two severe, but less common, ADEs associated with bisphosphonates?

Treatment for moderate to severe BPH: - Do NOT reduce prostate size - Reduce the dynamic factor (relieve prostate contraction around urethra) Onset of Action: Days to weeks

What are α-adrenergic blocking agents place in BPH therapy? What is their onset of action?

IV doses: - Ibandronate 3 mg IV push every 3 months - Zoledronic acid 5 mg IV over 15 minutes every 12 months

What bisphosphonate medications are available IV?

Add Dexamethasone to Clomiphene - Suppresses adrenal androgen

What can be added to Clomiphene citrate for ovulation induction to suppress adrenal androgen?

Jarisch-Herxheimer Reaction - Self-limited reaction to anti-treponemal therapy (Fever, malaise, nausea/vomiting; may be associated with chills and exacerbation of secondary rash) - Occurs within 24 hours after therapy initiation - Not an allergic reaction to penicillin - More common in those who have early syphilis, presumably because bacterial burdens are higher

What can be incorrectly classified as a penicillin allergy after administration of Benzathine penicillin G 2.4 million units IM for the treatment of primary, secondary, or early-latent syphilis?

Supplement Thiamine (co-factor for glucose metabolism) - 100 mg/day (1st dose prior to nutrition support); PO/enteral multivitamin

What can be supplemented to help prevent refeeding syndrome with EN?

1. Ovulation prediction kits (OPKs) - Measures LH surge in urine - Ovulation expected within 12-48 hours after LH surge (highest fertility next 1-3 days and peaks at 36 hours) 2. Basal body temperature (BBT) - Chart resting body temperature - Measures thermogenic property of progesterone; Look for biphasic pattern indicating ovulation occurred 3. Mid-luteal serum progesterone level - Measured 1 week after ovulation - Level of ≥ 3 ng/mL consistent with ovulation

What can be utilized to assess ovulation factor?

Management should include: Reducing the feeding rate, consider adding motility agent, consider advancing gastric tube to post-pyloric. Prevent aspiration: HOB elevation, continued monitoring of GRVs and GI assessments

What can we do to manage this potential EN complication?

Static and Dynamic factors reducing bladder emptying/voiding

What causes obstructive BPH symptoms?

α-adrenergic antagonists - Terazosin (Hytrin®) - 2nd Gen. Periphery + Prostate - Doxazosin (Cardura®) - 2nd Gen. Periphery + Prostate - Alfuzosin (Uroxatral®) - 2nd Gen. Periphery + Prostate - Tamsulosin (Flomax®) - 3rd Gen. Prostate-specific - Silodosin (Rapaflo®) - 3rd Gen. Prostate-specific

What class of medications act on the dynamic factors causing BPH by relaxing periphery and/or prostate smooth muscle?

5α-reductase inhibitors: - Finasteride (Proscar®, Propecia®) - Dutasteride (Avodart®) - Dutasteride/Tamsulosin (Jalyn®)

What class of medications act on the static factors causing BPH by interfering with testosterone's effect on prostate gland enlargement?

1. Medroxyprogesterone 10-20 mg PO once daily continuously - No contraceptive effects 2. Norethindrone 0.35mg PO 1 tab once daily 3. Depot medroxyprogesterone acetate 150 mg IM q 3 months - 25-43% achieved amenorrhea after 6 months and 76% had irregular bleeding 4. Levonorgestrel IUD for 3-6 years - 95% reduction after 12 months; also, antifibrinolytic in endometrium)

What continuous progesterone monotherapy regimens for women with ovulatory or anovulatory cycles; and/or desires pregnancy prevention, are available to reduce menstrual bleeding secondary to Menorrhagia?

1. Rule out cirrhosis 2. Accurate medication list 3. Labs: - Within 6 months of start - CBC, hepatic function panel (AST, ALT, albumin, total and direct bilirubin), calculated GFR - Anytime prior to start - HCV RNA viral load, HIV test, Hepatitis B surface antigen (HBsAg)

What do we need prior to initiating simplified HCV treatment?

a. Pyridoxine 10 mg PO TID +/- Doxylamine 12.5 mg PO TID-QID

What do you recommend for JT? a. Pyridoxine 10 mg PO TID +/- Doxylamine 12.5 mg PO TID-QID b. Diclegis 2 tablets PO QPM c. Ondansetron 4 mg PO Q8hrs d. Promethazine 12.5 mg PO Q4-6hrs

If missed dose by more than 3 hours: - Take as soon as remembered and use back-up method for next 48 hours - Consider emergency contraception if unprotected sex occurs - Continue pack as scheduled - Same instructions if vomiting or severe diarrhea occurs

What do you tell a patient who has missed their Norethindrone 0.35mg dose by more than 3 hours?

- The patient is likely experiencing steroid-psychosis due to the Prednisone that was prescribed post-transplant as a part of his immunosuppression regimen (i.e., agitation, insomnia, mood swings) - First, instruct RG's spouse to continue the transplant medications as prescribed. - Inform the spouse that the Prednisone component of the transplant medication regimen is not a permanent fixture to his medications and the goal is for RG to be tapered off of the steroids - Inform the spouse that RG's symptoms should resolve after the Prednisone has been tapered to discontinuation

What do you tell her? Is there any reassuring information you can give to RG's bewildered spouse?

T-score: - Compares measured bone mineral density (BMD) to mean BMD of healthy, young, sex-matched white reference population - Expressed as number of standard deviations from the mean of the reference population - Every standard deviation decrease in BMD in women is 10-12% decrease in bone mass and 1.5-2.6-fold increase in fracture risk

What does a DEXA scan T-score tell us?

Z-score: - Compares measured bone mineral density (BMD) to mean BMD of healthy, age-matched, sex-matched white reference population - Usually low when secondary causes of osteoporosis are present

What does a DEXA scan Z-score tell us?

Requires initiation of therapy within 1 day of lesion onset

What does episodic treatment for recurrent genital herpes require?

a. INR Value

What else do you need to know to diagnose ALF? a. INR Value b. LFTs c. Liver biopsy results d. Presence of portal HTN

Etiology determines prognosis and treatment!

What factor determines ALF prognosis and treatment?

BMI: 16-18.5 kg/m2 Weight loss: 5% in 1 month Caloric intake: None or negligible oral intake for 5-6 days or <75% of estimated energy requirement for >7 days during an acute illness or injury or <75% of estimated energy requirement for >1 month Loss of subcutaneous fat: Evidence of moderate loss Loss of muscle mass: Evidence of mild or moderate loss Higher-risk comorbidities (moderate disease): Chronic alcohol/drug use disorder, Dysphagia and esophageal dysmotility, Eating disorders, Food insecurity and homelessness, Hyperemesis gravidarum, Cancer, etc. Electrolytes: Minimally low levels or normal current levels and recent low levels necessitating minimal or single-dose supplementation

What factors put a patient at moderate risk for refeeding syndrome?

BMI: <16 kg/m2 Weight loss: 7.5% in 3 months or >10% in 6 months Caloric intake: None or negligible oral intake for > 7 days or <50% of estimated energy requirement for >5 days during an acute illness or injury or <50% of estimated energy requirement for >1 month Loss of subcutaneous fat: Evidence of severe loss Loss of muscle mass: Evidence of severe loss Higher-risk comorbidities (severe disease): Chronic alcohol/drug use disorder, Dysphagia and esophageal dysmotility, Eating disorders, Food insecurity and homelessness, Hyperemesis gravidarum, Cancer, etc. Electrolytes: Moderately/significantly low levels or minimally low or normal levels and recent low levels necessitating significant or multiple-dose supplementation

What factors put a patient at significant risk for refeeding syndrome?

1. ABO Blood typing 2. Human Leukocyte Antigen (HLA) 3. Panel Reactive Antibody (PRA) - Flow Crossmatch - Virtual Crossmatch

What immunologic testing must have been performed in order to say that LC's close family friend is a "match?"

Use of PPIs

What increases the incidence of SBP secondary to bacterial translocation into peritoneal cavity?

Beclomethasone or Budesonide are preferred

What intranasal corticosteroids are recommended and effective for use during pregnancy?

Women with postmenopausal symptoms and intact uterus - Moderate-severe hot flashes/vaginal atrophy (CEE) - Prevention of postmenopausal osteoporosis May be a good choice with women concerned about breast tenderness/density or uterine bleeding - Bleeding patterns similar to placebo

What is Conjugated Estrogen/Bazedoxifene (Duavee®) place in hormonal therapy for menopause?

Delivery of nutrition via the GI tract - Includes normal PO intake - "Tube feedings": Nutrition via tube, catheter, or stoma that delivers nutrients distal to the oral cavity

What is Enteral Nutrition (EN)?

c. Plasmapheresis (PP) QOD x3 days + IVIG 0.1 g/kg QOD x2 doses after PP followed by IVIG 1 g/kg x2 doses after last PP - Pulse steroids - Target T-cells - Thymoglobulin - Target T-cells - Plasmapheresis - Want to utilize Plasmapheresis plus something else to help prevent the rebounding of the antibodies • Increase in SCr (from 1.5 to 3.1); increased a little more than double • Urine output has decreased • Tacrolimus trough is far below goal • Renal biopsy is C4d positive (indicative of antibody-mediated rejection)

What is an appropriate treatment? a. Pulse steroids b. Thymoglobulin c. Plasmapheresis (PP) QOD x3 days + IVIG 0.1 g/kg QOD x2 doses after PP followed by IVIG 1 g/kg x2 doses after last PP d. Plasmapheresis

Low-dose: Oxytocin start at 1-2 milliunit/min IV and increase by 1-2 milliunit/min q15-30min until effective contractions q2-3min High-dose**: Oxytocin start at 6 milliunit/min IV and increase by 3-6 milliunit/min q15-30min until effective contractions q2-3min - Max dose of 25 milliunit/min

What is an example of a low-dose and a high-dose Oxytocin (Pitocin®) titration regimen for labor induction?

a. Immunologic cure - Immunologic cure - Lose HBsAg and suppress HBV DNA - The transcriptional template of HBV in hepatocytes still poses reactivation risk - Virologic cure: Eradicate virus, including template (cccDNA) - NOT attainable

What is attainable with Hepatitis B treatment? a. Immunologic cure b. Virologic cure

Continuous Infusion: Usually over 24-hours, most common administration - Post-pyloric feeding ("D" or "J" tube) - Pump used for administration - controlled rate improves tolerance - Common in hospitals: critically ill, intubated, risk for refeeding syndrome, poor glycemic control - Initiated at 10-20 mL/hr. and titrated up every 4 to 8 hours until goal rate is achieved

What is characteristic of EN administered via continuous infusion?

Cyclic Feeding: Larger volume of EN is administered over a shorter period of time (e.g., 8-12 hours, often overnight) - Common in long-term care facilities or home care - Decreases time attached to pump (more freedom!)

What is characteristic of EN administered via cyclic feeding?

Intermittent/Bolus feeding: - Requires a "G" tube given large volume; the "G" tube terminates in the stomach - 240-480 mL (1-2 8oz cans of formula) administered over 15-60 minutes - Administered 3-8 times per day via pump or gravity (via syringe or feeding bag) - Common for patients on chronic EN at home

What is characteristic of EN administered via intermittent/bolus feeding?

• High MCV (macrocytic) - > 100 fL • Normal B12 • Decreased Folate

What is characteristic of Folate Deficiency Anemia?

Functional - not due to bladder or bladder outlet: - Secondary to chronic impairment of physical and/or cognitive functioning - Caused by cognitive, functional, or mobility difficulties that impair patients' ability get to the bathroom - Linked to the primary disease vs bladder/bladder outlet

What is characteristic of Functional Incontinence?

- Unpredictable; Less related to dose/route/duration - Varied Presentation - Longer/Variable latency - Typically occurs within ~6 months of new drug initiation - Less Common - Ex: Amoxicillin/Clavulanate

What is characteristic of Idiosyncratic DILI?

- Low MCV (microcytic) - < 80 fL - Low Serum Ferritin

What is characteristic of Iron Deficiency Anemia (IDA)?

Overflow Incontinence: - Urethral overactivity (too much tone/resistance) and/or bladder underactivity (weak detrusor contractions) - Bladder is filled to capacity, but unable to empty - Urinary retention

What is characteristic of Overflow Incontinence?

• High MCV (macrocytic) - > 100 fL • Decreased B12 • Normal Folate • Schilling Test → Decreased intrinsic factor

What is characteristic of Pernicious Anemia?

Stress Urinary Incontinence: - Urethral underactivity (too little tone in sphincter, pelvic floor weakness) - Occurs during exertional activities (stress): Exercise, jumping, running, lifting, coughing, sneezing

What is characteristic of Stress Urinary Incontinence?

- Approximately 30% of untreated patients progress to the tertiary stage within 1 to 20 years - Rare because of the widespread availability and use of antibiotics Manifestations: - Gummatous lesions (i.e., Serpiginous Gummata of Forearm; Ulcerating Gumma) - Cardiovascular syphilis

What is characteristic of Tertiary (Late) Syphilis?

Urge Urinary Incontinence: - Bladder overactivity (involuntary contraction of detrusor muscle)

What is characteristic of Urge Urinary Incontinence?

• High MCV (macrocytic) - > 100 fL • Decreased B12 • Normal Folate

What is characteristic of Vitamin B12 deficiency?

• Jaundice/Scleral icterus • Spider angiomas on face and upper chest, caput medusae • Palmar erythema • Clotting abnormalities: Bleeding/bruising, GI bleeding • Increased abdominal girth and peripheral edema • Mental status changes • Sex hormone changes (gynecomastia, testicular atrophy, amenorrhea) • Heightened sensitivity to hepatically cleared medications/toxins

What is characteristic of a late (decompensated) clinical presentation of cirrhosis?

- Primary lesion or "chancre" develops at the site of inoculation Chancre: - Progresses from macule to papule to ulcer - Typically painless, indurated, and has a clean base - Highly infectious - Heals spontaneously within 1 to 6 weeks - 25% present with multiple lesions Regional lymphadenopathy: Classically rubbery, painless, bilateral

What is characteristic of a primary syphilis infection?

- Secondary lesions occur 3 to 6 weeks after the primary chancre appears; may persist for weeks to months - Primary and secondary stages may overlap - Mucocutaneous lesions most common Manifestations: - Rash (75%-100%) i.e., Nickel/Dime lesion, Palmar/Plantar Rash, Papulosquamous Rash - Lymphadenopathy (50%-86%) - Malaise - Mucous patches (6%-30%) - Condylomata lata (10%-20%) - Alopecia (5%) Serologic tests are usually highest in titer during this stage

What is characteristic of a secondary syphilis infection?

• Cachexia and weight loss • Weakness • Fatigue

What is characteristic of an early clinical presentation of cirrhosis?

If 2+ white pills are missed, take last missed dose asap, continue as scheduled and use backup x 7 days

What should you tell a patient who has missed 2+ white pills from her Drospirenone 4 mg (Slynd®) pack?

b. Initiate a combined oral hormonal contraceptive - Not only for inducing withdrawal bleeding but because she is sexually active - Condoms aren't the most effective option for preventing pregnancy

What is the appropriate next step in therapy for the treatment of CJ's amenorrhea? a. Initiate Cabergoline 0.25mg PO twice weekly b. Initiate a combined oral hormonal contraceptive c. Initiate conjugated estrogen 1.25mg PO once daily d. Refer for psychotherapy

Vitamin B12 (cyanocobalamin) is available both orally and parenterally - Oral dosing: 1,000 - 2,000 mcg/day - IM dosing: 800-1,000 mcg/day x 1-2 weeks, followed by 100-1,000 mcg/day until HgB normalizes with monthly maintenance doses

What is the appropriate treatment recommendation for Vitamin B12 Deficiency if a Schillings Test has been performed?

Vitamin B12 (cyanocobalamin) - IM dosing: 800-1,000 mcg/day x 1-2 weeks, followed by 100-1,000 mcg/day until HgB normalizes with monthly maintenance doses

What is the appropriate treatment recommendation for Vitamin B12 Deficiency in the absence of a Schillings Test?

b. Add Metformin to Clomiphene

What is the best next step? a. Add Dexamethasone to Clomiphene b. Add Metformin to Clomiphene c. Ovarian drilling d. Switch to gonadotropins

Sirolimus: Once daily administration Everolimus: Twice daily administration

What is the different in administration frequency between the two mTORi's Sirolimus and Everolimus?

Starting dose: 20mg po BID - Titrate every 2-3 days to goal - Maximum daily dose of 320 mg daily

What is the dose of Propranolol for GEV primary prophylaxis?

Estrogen: - Estrogen x 21-25 days - Estradiol valerate 1-2 mg PO once daily - Conjugated estrogen 1.25 mg PO once daily Progestin: - Progestin on last 10-14 days of estrogen therapy (on days 10 to 20-24) - Medroxyprogesterone acetate 5 mg PO once daily - Norethindrone acetate 2.5-10 mg PO once daily Note: Estrogen + Progestin as separate pills do not provide contraception

What is the dosing regimen for Estrogen + Progestin Therapy to induce monthly uterine withdrawal bleeding in women with primary or secondary amenorrhea?

Oral: - Loading Dose: 140 mg/kg x 1 dose - Maintenance Dose: 70 mg/kg every 4 hours x 17 doses (72 hours total) IV: - 150 mg/kg (max 15 g) over 60 minutes, followed by 50 mg/kg (max 5 g) over 4 hours, followed by 100 mg/kg (max 10 g) over 16 hours (21 hours total)

What is the dosing regimen, per the Prescott Protocol, for N-Acetylcysteine (NAC) treatment of APAP DILI?

Iron Sucrose - 1,000 mg total dose is recommended to replete iron stores - Typically, administered in divided doses: 200 mg IV daily for 5 days

What is the dosing strategy for IV Iron Sucrose for the treatment of Iron Deficiency Anemia (IDA)?

Progestin Challenge Test: 7-10 days - Medroxyprogesterone 10 mg PO once daily - Norethindrone acetate 2.5-10 mg PO once daily - Micronized progesterone 400 mg PO once daily - Withdrawal bleed expected within 3-7 days after Maintenance Therapy: Take 10-14 days each month - NOT a contraception - If it is not successful, amenorrhea may be caused by outflow tract obstruction or hyperandrogenic anovulation (e.g., PCOS)

What is the dosing strategy for progesterone monotherapy in the treatment of secondary amenorrhea (to unknown cause)?

Insulin - 1st drug of choice - Weight-based, mixed multidose regimen

What is the drug of choice for gestational diabetes?

1st line: 1. Methyldopa has been drug of choice (strong evidence and experience) - Dosed 2-3x/day - Slow onset, associated fatigue 2. Labetalol (more rapid-onset) - Avoid in women with asthma, heart disease, HF

What is the drug of choice for gestational hypertension?

DOT: Continue until s/sx of coagulopathy and HE resolves and APAP undetectable - Based on clinical outcome NOT by time or APAP levels; May extend WELL beyond 72 h - Could hang NAC for days

What is the duration of treatment, per the Prescott Protocol, for N-Acetylcysteine (NAC) treatment of APAP DILI?

Etiologic agent: C. trachomatis - Gram negative, obligate intracellular human pathogen - Infects columnar epithelial cells - Survives by replication that results in the death of the cell

What is the etiologic agent behind Chlamydia?

Etiologic agent: Neisseria gonorrhoeae • Gram-negative intracellular diplococcus • Infects mucus-secreting epithelial cells • Evades host response through alteration of surface structures

What is the etiologic agent behind Gonorrhea?

Organism: Treponema pallidum - Gram negative spirochete - Often grows in clusters

What is the etiologic agent behind Syphilis?

b. NSAIDs - Would not use NSAIDs for MG, however, because she has a documented allergy

What is the first line therapy for ovulatory menorrhagia? a. COCs b. NSAIDs c. Progesterone therapy d. Danazol

a. Increase BMI - Amenorrhea likely due to weight loss - There is a critical value of adipose tissue (body fat) required to start your period and keep periods regular - She is underweight; down 27 kg (~60 lbs.) from a year ago - BMI 16.9 kg/m2: Underweight (moderate thinness)

What is the first step in this patients therapy for amenorrhea? a. Increase BMI b. Start a combined oral hormonal contraceptive c. Initiate Cabergoline 0.25mg PO twice weekly d. Initiate medroxyprogesterone acetate 10mg PO once daily on cycle days 14-25

d. Will you please this pregnancy test? - Condoms have about an 82% success rate (~18% failure rate)

What is the first thing you are going to ask KH? a. How old were you when you first got your period? b. How much are you exercising each week? c. How much weight have you lost in the last couple of months? d. Will you please this pregnancy test?

First line: Third-generation Cephalosporins - Cefotaxime: 2g IV q 8 hours - Ceftriaxone: 1g IV q 24 hours Treatment duration: 5 days - Treat organism (narrow when appropriate)!

What is the first-line empiric antibiotic therapy for SBP? What is the duration of treatment?

First line treatment for acute cellular rejection "Pulse steroids": - Methylprednisolone 250-1000mg 3-5 days - Followed by Prednisone taper

What is the first-line pharmacologic agent for acute cellular rejection?

Vitamin B6 (Pyridoxine) - Available OTC - Dose: 10-25 mg every 8 hours - Doses up to 100 mg or 500mg have been used

What is the first-line pharmacologic therapy option for N/V in pregnancy?

Initial treatment of IDA is oral iron therapy with a goal of 200 mg elemental iron daily - Divide in to two or three doses daily - Administer on an empty stomach - Taking oral iron supplements with food can decrease iron absorption by about 50% - Iron absorption increases in an acidic environment (so, patients should take with something like orange juice)

What is the initial pharmacologic treatment for Iron Deficiency Anemia (IDA)?

Quantitative nontreponemal serologic tests should be repeated at 6, 12, and 24 months - 4-fold decrease or greater in titer suggests clinically significant response

What is the last step in Syphilis treatment after the regimen has been completed?

Mainstay of Treatment: Non-selective beta blockers - Reduce portal pressure via drugs that act by causing splanchnic vasoconstriction - Non-selective β-blockers: Nadolol, Propranolol, Carvedilol

What is the mainstay of treatment for portal hypertension?

No more than 600 mg per dose

What is the maximum amount of Calcium recommended per dose?

d. Until symptoms of acute liver failure resolves and the Acetaminophen level is negligible

What is the most appropriate duration of treatment for N-acetylcysteine following Acetaminophen overdose? a. 48 hours b. 72 hours c. 24 hours after the initial ingestion of Acetaminophen d. Until symptoms of acute liver failure resolves and the Acetaminophen level is negligible

a. Sildenafil 50mg PO once daily PRN

What is the most appropriate initial therapy for MN's ED? a. Sildenafil 50mg PO once daily PRN b. Vardenafil 25mg PO once daily PRN c. Avanafil 100mg PO once daily PRN d. Tadalafil 25mg PO once daily e. Alprostadil 25mcg intracavernosal injection once PRN

Polycystic ovary syndrome (PCOS)

What is the most common cause of Oligomenorrhea?

a. Acetaminophen

What is the most common cause of acute liver failure within the USA? a. Acetaminophen b. Viral hepatitis c. Cancer d. Alcohol

a. Hot flashes

What is the most common menopause-related symptom? a. Hot flashes b. Insomnia c. Mood disturbances d. Vaginal dryness

Normal MMA Level: 0 - 0.4 µmol/L blood - Vitamin B12 is needed to convert methymalonyl coenzyme A to succinyl coenzyme A - Increased methylmalonic acid levels may indicate a vitamin B12 deficiency

What is the normal Methylmalonic Acid (MMA) level in the body?

Normal Homocysteine Level: 4.4 - 10.8 µmol/L blood - Both folate and vitamin B12 are needed for the conversion of homocysteine to methionine - Increased homocysteine levels may indicate either folate or vitamin B12 deficiencies

What is the normal homocysteine level in the body?

Eradicate organism

What is the number one pharmacotherapeutic goal for the treatment of Syphilis?

Expand intravascular volume: - Albumin 1 g/kg IV QDay PLUS - Vasopressors (Norepinephrine)

What is the pharmacologic recommendation to expand intravascular volume for patients with Hepatorenal Syndrome (HRS)?

Oral bisphosphonates preferred - Alendronate or Risedronate - Then IV bisphosphonates, Teriparatide, Denosumab, Raloxifene

What is the preferred Osteoporosis therapy for patients taking glucocorticoids?

Spironolactone: 50-200mg divided BID x 6-12 months - Reduces hair growth by 40-88%, may take 6-9 months for improvement

What is the preferred treatment and dose for reducing hair growth associated with hirsutism secondary to PCOS?

Adults and Adolescents: Doxycycline 100mg orally 2x/day for 7 days - Alternate: Azithromycin 1gm orally in a single dose or Levofloxacin 500mg orally 1x/day for 7 days

What is the recommended Adults and Adolescents regimen for the treatment of Chlamydia?

Children aged >8 years (nasopharynx, urogenital, and rectal): - Azithromycin 1gm orally in a single dose or - Doxycycline 100mg orally 2x/day for 7 days

What is the recommended Chlamydia treatment regimen for children aged >8 years (nasopharynx, urogenital, and rectal)?

Children who weigh >45kg (nasopharynx, urogenital, and rectal): - Erythromycin base, 50 mg/kg body wight/day orally divided into 4 doses daily for 14 days or - Ethylsuccinate 50 mg/kg body weight/day orally, divided into 4 doses daily for 14 days

What is the recommended Chlamydia treatment regimen for children who weigh >45kg (nasopharynx, urogenital, and rectal)?

Neonates (Ophthalmia and pneumonia): - Erythromycin base, 50 mg/kg body weight/day orally, divided into 4 doses daily for 14 days or - Ethylsuccinate, 50 mg/kg body weight/day orally, divided into 4 doses daily for 14 days - Alternative: Azithromycin suspension 20 mg/kg body weight/day orally, 1x/day for 3 days

What is the recommended Chlamydia treatment regimen for neonates (Ophthalmia and pneumonia)?

Add-On Therapy: Antibiotic Therapy - 1st Choice Abx: Rifaximin - Eradicates urease-producing bacteria from GI tract - May be more effective and better-tolerated than Lactulose, more data needed - Dose: 550mg PO BID - Not orally bioavailable (systemic absorption of 0.4%) - Limited drug-drug interactions; Limited adverse effects - Can be very expensive - Alternatives: Neomycin, Metronidazole

What is the recommended add-on antibiotic therapy for Hepatic Encephalopathy (HE) Grades II - IV?

Per guidelines: Use empiric Vitamin K supplementation (Phytonadione 5-10 mg IV PRN)

What is the recommended agent and dose for the management of coagulopathies in ALF supportive care?

Regimen: - Ampicillin 2gm IV Q6hrs & Azithromycin IV 500mg daily x 48hrs, then Amoxicillin 500mg PO Q8hrs & Azithromycin 500mg PO daily x 5d Alternatives: Cefazolin/Clindamycin/Gentamicin/Vancomycin used in place of Ampicillin for PCN allergies Rationale: Empiric coverage of amniotic cavity organisms

What is the recommended antibiotic regimen for Preterm PROM (PPROM)?

1. Non-selective β-blockers: 1st Line (Nadolol, Propranolol): ↓ bleeding and ↓ mortality - Carvedilol 2nd line due to alpha-1 antagonism/vasoconstriction - Duration of therapy is lifelong 2. Endoscopic Variceal Ligation (EVL, aka "banding") and sclerotherapy - EVL: Strictures (rubber bands) around varices - Sclerotherapy: Inject varices with substances to reduce blood flow

What is the recommended pharmacologic primary prophylaxis treatment for patients with Gastroesophageal Varices?

a. Ampicillin 2gm IV q6h b. Betamethasone 12mg IM q24h x 2 doses c. Azithromycin 500mg IV daily - Specifically, looking at PPROM for SH - Would not give Indomethacin at this point (it is a tocolytic) and she has no indication of contractions at this point

What medication(s) would you suggest to improve maternal and neonatal outcomes? Select all that apply. a. Ampicillin 2gm IV q6h b. Betamethasone 12mg IM q24h x 2 doses c. Azithromycin 500mg IV daily d. Indomethacin 100mg PO x 1, then 25mg q6h

- HCTZ (polyuria) - Benadryl - Antihistamine (interfering with urinary frequency)

What medications could be contributing to GM's symptoms?

Discharge on oral meds (Metoclopramide + Hydroxyzine or Doxylamine + Pyridoxine)

What medications would you discharge a patient with after inpatient treatment for Hyperemesis Gravidarum?

Black cohosh (Cimicifuga racemosa): - Serotonergic effect vs Estrogenic effect - Mixed results in clinical studies - 2012 Cochrane review deemed insufficient evidence to recommend for VMS - 20mg PO BID - not studied beyond 12 months

What natural/herbal product may be an option for women who prefer a non-estrogen, natural therapy for the treatment of hot flashes?

Gemtesa® (Vibegron)

What newer medication, FDA approved in December 2020, for UUI, is not associated with clinically significant changes in blood pressure?

Absorbent products (pads, diapers)

What non-pharmacologic anti-incontinence & supportive devices are appropriate for all types of UI (Urge, Stress, Overflow, Functional)?

Therapeutic Paracentesis: Remove large volume of ascitic fluid - Albumin IV post-paracentesis (6-8 g per L removed) if > 5L removed

What non-pharmacologic therapy is recommended for ascites treatment?

Pseudoephedrine 15-30mg BID/TID

What non-selective alpha-adrenergic agent that works by stimulating α-adrenergic receptors in the smooth muscle of the proximal urethra and bladder neck has been utilized off-label for Stress Urinary Incontinence?

Duloxetine (Cymbalta®) 40-80 mg/day in one or two doses

What pharmacologic agent has been used for Stress Urinary Incontinence even though it is not FDA approved for this indication and has shown only a modest efficacy?

Antihistamines: Chlorpheniramine is recommended - Loratadine, Cetirizine are acceptable

What pharmacologic is first-line for allergic cold/rhinitis symptoms during pregnancy?

Sodium ferric gluconate - FDA approved for IDA in hemodialysis patients - The recommended adult dosage is 10 mL (125 mg of elemental iron) diluted in 100 mL of 0.9% sodium chloride administered by intravenous infusion over 1 hour per dialysis session or undiluted as a slow intravenous injection (at a rate of up to 12.5 mg/min) per dialysis session.

What product is FDA approved for Iron Deficiency Anemia (IDA) in hemodialysis patients? What is the dosing strategy?

Risk Factor: African American Manifestation: Elevated serum creatinine, decline in UO, edema, fever

What risk factor for rejection does LC have? If rejection were to occur, how would this manifest after transplantation?

Denosumab (Prolia®, Xgevia®) 1. Second line therapy but some providers using first line 2. Monoclonal antibody against RANKL - Inhibits osteoclast activity - Decreases bone resorption

What second-line therapy for Osteoporosis treatment (not used for prevention) inhibits osteoclast activity, decreases bone resorption, reduces vertebral/nonvertebral/hip fracture, and improves lumbar spine/femoral neck BMD?

Omega-3s (DHA): - Dietary sources: Vegetable oils, two low-mercury fish servings per week - Supplements (fish oil or algae-based docosahexaenoic acid-DHA); 300 mg DHA

What should be consumed during pregnancy due to it being critical for fetal neurodevelopment and also that it may be important for timing of gestation and birth weight?

Renal function tests

What should be monitored 2-3 times weekly with PN?

• Weight • Vital signs • PO nutritional intake • Fluid balance (intake and output) • Blood glucose • Serum electrolytes

What should be monitored at least daily with PN?

• Liver function tests • Serum triglycerides • Nitrogen balance

What should be monitored at least weekly with PN?

b. Initiate BB therapy

What should be recommended? a. EVL b. Initiate BB therapy c. No therapy is indicated at this time

Iron: 27 mg elemental PO per day

What should be taken during pregnancy to help prevent anemia, spontaneous abortion, premature delivery, and low birth weight?

- Finish hormonal pills in the pack and start a new pack (omitting hormone- free interval) - Use back-up method for 7 days

What should you instruct a patient to do if 2 or more COC pills are missed in week 3 of their cycle?

If 2 or more consecutive pills are missed (≥48 hours since last scheduled dose): Take most recently missed pill asap and discard other missed pill(s), take remaining pills at usual time - Use back-up method for 7 days

What should you instruct a patient to do if 2 or more consecutive COC pills are missed and its been ≥48 hours since last scheduled dose?

If missed one pill: Take it as soon as remembered and next dose at usual scheduled time (may take 2 pills in one day) - No back-up method required

What should you instruct a patient to do if they tell you they missed a dose of one of their COCs and its been 24 to <48 hours since their last scheduled dose?

b. Increase dose to 112 mcg PO once daily once pregnant - Increase dose of Levothyroxine by 20-30% upon conception - Equates to a 27% dose increase (want 20-30% increase), check TSH levels 1-month after dose change, and then every 4-6 weeks thereafter

What should you tell PG about her Levothyroxine? a. Decrease dose to 50 mcg PO once daily once pregnant b. Increase dose to 112 mcg PO once daily once pregnant c. Increase dose to 175 mcg PO once daily once pregnant d. Leave dose as is and check TSH once pregnant

If vomiting/diarrhea within 3-4 hours of dose: Take next tablet asap (within 12 hours of scheduled dose), if 2+ tabs are missed, follow above instructions; use back-up if v/d > 1 day.

What should you tell a patient who has been experiencing N/V within 3-4 hours of her last Drospirenone 4 mg (Slynd®) white pill?

- Vasomotor flushes, hot flashes, vaginal dryness (~10%) - Abdominal or pelvic pain, ovarian enlargement, headaches, nausea, mood swings (<10%) - Visual disturbances (<2%); Should notify prescriber, may need to stop med - Multiple births (twins-5%, triplets-1-2%) - Reduced endometrial proliferation, decreased quality and quantity of cervical mucus - Increased risk for ovarian cancer if used > 12 mos. - Monitor for effectiveness (ovulation, pregnancy), side effects

What side effects are associated with Clomiphene citrate use?

Folic acid 600 (400-800) mcg PO daily

What supplement should be taken at least one month before conception through the first three months of pregnancy to prevent neural tube defects?

Symptoms: - Urine leakage with physical activity - No UI with inactivity - No nocturia

What symptoms are commonly associated with Stress Urinary Incontinence (SUI)?

Symptoms: - Urinary frequency (voiding > 8 times during waking hours) - Urinary urgency - Nocturia (> 1 awakenings in the night to urinate) - Nocturnal incontinence

What symptoms are commonly associated with Urge Urinary Incontinence (UUI)?

Symptoms: - Lower abdominal fullness - Sense of incomplete bladder emptying - Hesitancy - may also have urgency and frequency - Dribbling - leaking small amounts of urine - Straining to void - Decreased force of stream

What symptoms would a patient typically present with for Overflow Urinary Incontinence?

Testing: - First catch urine or - Cervical or male urethral swab for nucleic acid amplification test (NAAT)

What tests can be utilized to test for Chlamydia?

c. Octreotide - Hematemesis: Blood in vomit - Octreotide will actively reduce the bleeding

What therapy should be recommended first? a. Antibiotic b. BB c. Octreotide d. EGD

b. Hyper-Acute Hyper Acute ALF: - Typical timeline of HE after onset of Jaundice: < 7 days - Typical Causes: APAP - Presentation: Severe (Cerebral Edema and HE) - Prognosis - Likelihood of Tx-Free Survival: High

What type of ALF is LK's presentation most consistent with? a. Acute b. Hyper-Acute c. Sub-Acute d. Shock Liver

PEG tube - Expected duration > 4 weeks (about to undergo 6 weeks of chemotherapy) - Percutaneous gastrostomy over nasoenteric feeding - No clear aspiration risk or decreased GI motility

What type of EN access is appropriate?

c. NG • OG/OJ require sedation (would need to be intubated) • Needs it for < 4 weeks, so an NG tube would be appropriate • No mention of aspiration risk or decreased GI motility

What type of EN access would be appropriate for a non-intubated 84 y/o female s/p CVA with anticipated EN needs for the next 3 weeks? a. OG b. OJ c. NG d. PEG

a. Terazosin e. Stress - Terazosin (an alpha blocker) can cause urethral relaxation → stress urinary incontinence

What type of UI is SL presenting with and which medication is most likely to be exacerbating her UI? a. Terazosin b. Sertraline c. HCTZ d. Tramadol e. Stress f. Urge g. Overflow h. Functional

Vaginal estrogen (non-systemically absorbed) preferred treatment if only GSM symptoms are present - Localized, vaginal, non-systemically absorbed HT does not treat vasomotor symptoms (hot flashes, night sweats, etc...)

What type of hormonal therapy would you recommend for a patient needing only GSM symptom relief?

Systemic Hormonal Therapy (HT) - PO, TD formulations equally effective

What type of hormonal therapy would you recommend for a patient needing vasomotor symptom relief and GSM symptom relief?

- Estrogen-progestogen therapy (EPT): "Combined HT" - Estrogen + ERAA

What type of hormone therapy (HT) for menopause women is prescribed for women with a uterus?

Estrogen therapy (ET)

What type of hormone therapy (HT) for menopause women is prescribed for women without a uterus?

b. Hepatocellular - R = 21.2

What type of liver injury is present? a. Cholestatic b. Hepatocellular c. Mixed d. No injury

c. Mixed - R = 2.8

What type of liver injury is present? a. Cholestatic b. Hepatocellular c. Mixed d. No injury

- Progesterone monotherapy - Estrogen/progestin combination therapy

What types of pharmacologic therapies are recommended for the treatment of Amenorrhea?

1. To provide a format that is helpful for patient counseling 2. To allow a method to transfer clinical information without providing a scripted protocol for the health care provider that may be come outdated as new data are discovered 3. Designed to help provide patient-specific therapy and improve the overall standard of care

What were 3 goals of the Pregnancy and Lactation Labeling Rule (PLLR), "The Rule," that went into effect June 30, 2015?

1. Intrauterine pregnancy 2. Ectopic pregnancy 3. Miscarriage 4. Polycystic Ovary Syndrome (PCOS)

What were four highlighted potential causes of Abnormal Uterine Bleeding (AUB) indicated in lecture?

- Diabetes - Hypertension

What were the most likely causes of patient's ESRD that led to kidney transplantation?

a. Yaz (Drospirenone 3mg + EE 20mcg) - Not NuvaRyng because she is uncomfortable with that area - Not Xulane because of her family history of hypertension and stroke - Not Loestrin Fe 1.5/30 b/c of her acne concern

What would be the best contraceptive option for AN? a. Yaz (Drospirenone 3mg + EE 20mcg) b. Loestrin Fe 1.5/30 (Norethindrone 1.5mg + EE 30mcg) c. Xulane (Norelgestromin 0.15mg + EE 35mcg) d. NuvaRing (Etonogestrel 0.12mg + EE 20mcg)

a. Combined oral contraceptive 1 tablet PO daily - Documented NSAID allergy (NSAIDs are considered first-line)

What would be the best therapeutic option for MG? a. Combined oral contraceptive 1 tablet PO daily b. Medroxyprogesterone acetate 10mg PO once daily x 5 days c. Depot MPA 150mg IM q3months d. Levonorgestrel IUD for up to 7 years

b. 38 mL per hour 1. Moderate Stress →25 kcal/kg = 1375 kcal 2. Jevity 1.5 → 1.5 kcal/mL 3. 916.7 mL Jevity 1.5 to meet total energy requirement 4. (916.7 mL Jevity) / (24 hours) → 38.2 mL/hr

What would be the goal continuous EN rate for this patient? a. 20 mL per hour b. 38 mL per hour c. 46 mL per hour d. 52 mL per hour

Indication: Kidney transplant in combination with Basiliximab, Mycophenolate, and corticosteroids - Off label: de novo use lung transplant, conversion from calcineurin inhibitor in renal transplant Place in Therapy: - Low risk kidney transplant recipients - Conversion in kidney transplant recipient with CNI toxicity/compliance issues - Not recommended in liver transplant patients due to increased risk of graft loss and death

When is Belatacept (Nulojix®), a T Cell Costimulation Blocker, indicated for immunosuppressive therapy?

To induce monthly uterine withdrawal bleeding in women with primary or secondary amenorrhea

When is Estrogen + Progestin Therapy used in the treatment of Amenorrhea?

Indomethacin (Indocin®): - Gestational age 24-32 weeks - 50-100mg PO load, then 25mg q6h x 48hrs

When is Indomethacin (Indocin®) indicated for use as a tocolytic agent? What is the dose?

Nifedipine IR: - Gestational age > 32 weeks - 10-30mg PO load, then 10-20mg q6h x 48hrs - Risks when used with magnesium sulfate - Mg Sulfate given intrapartum for other indications: Neuroprotection in 24-32-week neonates; Seizure prophylaxis for maternal preeclampsia

When is Nifedipine IR indicated for use as a tocolytic agent? What is the dose?

Terbutaline (Bricanyl®): - May be used to treat hyperstimulation seen with induction of labor - Dose: 0.25mg SC q20min PRN tachysystole

When is Terbutaline (Bricanyl®) indicated for use as a tocolytic agent? What is the dose?

Only treat if testosterone levels are low! - Morning serum total testosterone level < 300 ng/dL on 2 occasions - Only using this when the testosterone levels are low!

When is Testosterone (Depo-Testosterone®, Testoderm®, AndroGel®) utilized in erectile dysfunction therapy?

- Back-up not necessary if it's been ≤ 5 days since the first day of last menstrual period - If > 5 days, abstain or use back-up method for 7 days

When is backup necessary when initiating a CHC?

Start the Sunday following first day of period - Yes, for first 7 days (unless ≤ 5 days since period started

When is backup needed for a Sunday Start for a COC?

"Long term prophylaxis" indicated in patients who survive SBP or w/ low-protein ascites, and: - Scr ≥1.2mg/dL, or - BUN ≥ 25mg/dL, or - Serum Na ≤ 130mEq/L, or - Child-Pugh score of ≥9 with bilirubin ≥3 Duration: Therapy is indefinite until transplantation or death Regimen: PO Ciprofloxacin 500mg QD or Sulfamethoxazole-Trimethoprim DS QD

When is long-term SBG prophylaxis indicated? How long is treatment? For these patients, what is the recommended regimen?

b. Age 30 - By age 30, but it's usually in your early 20's)

When is peak bone mass attained? a. Age 10 b. Age 30 c. Age 40 d. Age 50

To induce monthly uterine withdrawal bleeding in women with secondary amenorrhea (to unknown cause)

When is progesterone monotherapy used in the treatment of Amenorrhea?

Treatment indicated if: - At risk of preterm birth within 7 days AND - Between 24-34 weeks gestation (routine) OR between 34-36 weeks gestation (consider)

When is treatment for Fetal Lung Immaturity indicated?

Hypertriglyceridemia - Reduce frequency of IVFE when TG trending up - When TG > 400 mg/dL, hold IVFE (note risk of essential fatty aid deficiency)

When should IVFE be adjusted during PN administration?

Avoid when CrCl is less than 35 mL/min (30 mL/min for Ibandronate or Risedronate)

When should bisphosphonates be avoided in Osteoporosis treatment?

2nd Gen. (Periperhy + Prostate) - Terazosin (Hytrin®) - Doxazosin (Cardura®) - Alfuzosin (Uroxatral®) Dose: At bedtime d/t dizziness, hypotension, 1st dose syncope (less with Alfuzosin) MOA: Not selective → alpha blockade in peripheral vasculature → vasodilation = symptoms above

When should second generation α-adrenergic antagonists be dosed, and why?

Monitor trough level: - Draw 30 minutes-60 minutes prior to AM dose

When should the trough levels for Calcineurin inhibitors, i.e., Cyclosporine and Tacrolimus be drawn?

Monitor trough levels: - Drawn 30 minutes prior to daily dose

When should trough levels for mTORi's, i.e., Sirolimus and Everolimus, be drawn?

c. Female patient aged 60 with a T-score of -1.9

When would you want to perform a FRAX analysis? a. Female patient aged 50 with a T-score of -0.5 b. Female patient aged 30 with a T-score of 1 c. Female patient aged 60 with a T-score of -1.9 d. Female patient aged 70 with a T-score of -2.9

Start: • Naso- (nares) "N" • Oro- (mouth) "O" (requires intubation) • -ostomy: Artificial excretory opening (endoscopic, radiographic, or surgical incision in abdominal wall) End: • -Gastric (stomach) "G" • Post-Pyloric: -Duodenal (more proximal small intestine) "D" -Jejunal (more distal small intestine) "J"

Where does EN access start? Where does EN access end?

Trospium chloride (Sanctura®) IR, ER - Quaternary ammonium muscarinic agent with relative selectivity for M2 and M3 receptors - ER formulation should be avoided in CrCl <30 mL/min

Which anticholinergic for the treatment of UUI must be taken on an empty stomach and has fewer CNS adverse events in the general population due to its hydrophilic properties that minimize passage through the blood-brain barrier?

Antidepressants: Bupropion is associated with less ED than others

Which antidepressant is associated with less erectile dysfunction than others?

- Mycophenolate is more common antiproliferative utilized - Less rejection episodes with Mycophenolate compared to Azathioprine in kidney transplant recipients - Azathioprine utilized in pregnant patients or trying to get pregnant; or in patients unable to tolerate Mycophenolate

Which antiproliferative agent is more commonly used, Mycophenolate or Azathioprine? What is the rational behind this?

All of them a. Acetaminophen b. Antibiotics c. Herbals d. Antiepileptics e. Statins

Which are the most common instigators of drug-induced livery injury (DILI) as described in lecture? Select all that apply. a. Acetaminophen b. Antibiotics c. Herbals d. Antiepileptics e. Statins

Combined Oral Contraceptives (COCs) - Dose: Same doses as for contraceptive use - For active heavy menstrual bleeding, may take 1 tablet 2-4 times a day until the bleeding stops, then continue 1 tablet daily

Which class of medications is utilized to reduce bleeding (40-50%), prevent pregnancy, and is indicated for women with ovulatory or anovulatory cycles; and/or desires pregnancy prevention for the treatment of Menorrhagia?

NSAIDs Begin first day of period and for duration of period - Mefenamic acid: 500mg PO 3-4/day - Naproxen: 500 mg PO x 1, then 250 mg PO TID - Ibuprofen: 600-1200 mg/day, divided

Which class of medications is utilized to reduce menstrual bleeding (20-50% reduction) and is considered first line for women with ovulatory cycles, when patient prefers no hormones, or desires to become pregnant for the treatment of Menorrhagia?

b. Progesterone

Which hormone is responsible for maintaining the endometrial lining? a. Estrogen b. Progesterone c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH)

d. Luteinizing hormone (LH)

Which hormone surges to cause ovulation? a. Estrogen b. Progesterone c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH)

Tdap

Which immunization is recommended for all pregnant women with every pregnancy, regardless of history between 27-36 weeks' gestation or immediately postpartum at the very latest?

Solifenacin Succinate (Vesicare®) - Dose adjust in CrCl < 30 mL/min or moderate hepatic impairment - Avoid in severe hepatic impairment

Which medication that can be utilized in the treatment of UUI has a dose-related ADE of increased risk of QT interval prolongation?

Tadalafil (Cialis®) - 2.5-5mg/day

Which medication was FDA approved for BPH in 2012 and should be considered in men with both BPH and erectile dysfunction?

c. Denosumab

Which medication would be contraindicated in a patient with hypocalcemia? a. Abaloparatide b. Calcitonin c. Denosumab d. Raloxifene

a. Alendronate

Which medication would be contraindicated in a patient with severe kidney disease (CrCl is less than 30 mL/min)? a. Alendronate b. Calcitonin c. Raloxifene d. Teriparatide

e. All the above

Which medication(s) has/have been associated with ED? a. Finasteride b. Hydrocodone c. Citalopram d. HCTZ e. All the above

a. Paroxetine c. HCTZ - Paroxetine: Contraindicated in Pregnancy (Category D), so discontinue, can increase risk of cardiac malformations; Can consider Sertraline, Citalopram - HCTZ: Diuretic, consider discontinuing HCTZ; Monitor BP; Consider adding on Labetalol or Methyldopa - Vitamin D: Fine - Metformin: She can continue to take Metformin

Which medication(s) require dose adjustment, discontinuation, and/or addition to her medication regimen now or upon conception? Select all that apply. a. Paroxetine b. Vitamin D c. HCTZ d. Metformin

a. Alfuzosin

Which of the following BPH medications would be MOST appropriate in an elderly male with a history of hypotension and frequent falls? a. Alfuzosin b. Doxazosin c. Prazosin d. Terazosin

b. Etonogestrel 0.12 mg + EE 20 mcg - Etonogestrel 0.12mg _ EE 20 mcg (NuvaRyng) - If she has eczema, she may want to avoid the patch

Which of the following CHC formulations do you suggest? a. Drospirenone 3 mg + EE 20 mcg b. Etonogestrel 0.12 mg + EE 20 mcg c. Norelgestromin 0.15 mg + EE 20 mcg d. Norgestrel 0.5 mg + EE 50 mcg

a. History of breast cancer c. History of pulmonary embolism d. History of ischemic stroke e. Current tobacco use

Which of the following are absolute contraindications to systemic HT? Select all that apply. a. History of breast cancer b. History of osteoporosis c. History of pulmonary embolism d. History of ischemic stroke e. Current tobacco use

a. Obesity b. Coronary artery disease c. Depression and the use of certain antidepressant medications e. Diabetes

Which of the following are risk factors for erectile dysfunction? Select all that apply. a. Obesity b. Coronary artery disease c. Depression and the use of certain antidepressant medications d. Increased amount of dopamine in the CNS e. Diabetes

b. Decreased number of ovarian follicles d. Decreased Estradiol e. Increased FSH

Which of the following are the correct physiologic changes occurring during the menopause transition? Select all that apply. a. Increased number of ovarian follicles b. Decreased number of ovarian follicles c. Decreased FSH d. Decreased Estradiol e. Increased FSH

a. Terbutaline can be used to treat uterine hyperstimulation caused by Misoprostol c. Misoprostol is lower cost compared to Dinoprostone inserts

Which of the following are true of misoprostol when used to induce labor contractions and ripen the cervix? [Select all that apply] a. Terbutaline can be used to treat uterine hyperstimulation caused by Misoprostol b. Misoprostol may be removed in the event of hyperstimulation which then reverses hyperstimulation c. Misoprostol is lower cost compared to Dinoprostone inserts d. Oxytocin may be started within 30 minutes of the last dose of Misoprostol e. There is less risk of uterine hyperstimulation with Misoprostol when used at recommended doses compared to Dinoprostone

a. Period is late - A clot is more of a concern with a combination oral contraceptive pill (one that contains estrogen) - Leg pain/SOB; "ACHES" - Remember "PAINS" - Period late, abdominal pain/pain with intercourse, infection, not feeling well (fever, shiver, chills), string (missing, shorter, longer)

Which of the following is a reason a patient should seek medical care if they have an IUD? a. Period is late b. Shortness of breath c. Leg pain d. Nausea

b. Cigarette smoking

Which of the following is a risk factor for osteoporosis? a. African American race/ethnicity b. Cigarette smoking c. Daily weight bearing exercise d. Weight of 135 pounds

d. Rule out C. Diff infection - The first step is to rule out infection-related diarrhea

Which of the following is an appropriate initial step to address diarrhea in a patient receiving EN? a. Begin anti-diarrheal therapy b. Change the EN formula to have less fat c. Change the EN formula to have less fiber d. Rule out C. Diff infection

a. History of venous thromboembolism

Which of the following is considered an absolute contraindication to hormone therapy for menopause-related symptoms? a. History of venous thromboembolism b. Hypertriglyceridemia c. Obesity d. Gallbladder disease

b. The reaction is typically dose-related d. There is a short period between drug exposure and diagnosis of liver injury e. The classic example includes DILI induced by Acetaminophen

Which of the following is consistent with intrinsic drug-induced livery injury (DILI)? Select all that apply. a. The presentation is varied or unpredictable b. The reaction is typically dose-related c. The presentation and reaction are varied between patients d. There is a short period between drug exposure and diagnosis of liver injury e. The classic example includes DILI induced by Acetaminophen

d. Naproxen 500mg PO x 1, then 250mg PO TID for the duration of her period

Which of the following is first line of therapy for this patient to reduce menstrual blood loss? a. Depot Medroxyprogesterone acetate 150mg IM Q3mos. b. Ethinyl estradiol 35 mcg/Norethindrone 1 mg PO once daily c. Medroxyprogesterone 5mg PO on days 14-26 d. Naproxen 500mg PO x 1, then 250mg PO TID for the duration of her period

b. Famotidine 10mg PO twice daily at bedtime

Which of the following is the best option for her? a. Calcium antacids 500mg PO 1-2 tablets as needed b. Famotidine 10mg PO twice daily at bedtime c. Omeprazole 20mg PO once daily 30 minutes before breakfast d. Refer her to her obstetrician

b. COCs d. Continuous progesterone - Both will work well to reduce bleeding in anovulatory women (COCs and Continuous progesterone) - NSAIDs work best in ovulatory women - Cyclic progesterone will work in anovulatory women but she will get a period, and that's not what she's looking for

Which of the following is the best option to treat menorrhagia in an anovulatory woman who prefers not to have a period? a. NSAIDs b. COCs c. Cyclic progesterone d. Continuous progesterone

c. Therapeutic lifestyle changes - Therapeutic lifestyle choices are first, then we can add Letrozole or Clomiphene later if needed

Which of the following is the first-line of therapy for obese women with PCOS? a. Letrozole b. Combined hormonal contraceptive c. Therapeutic lifestyle changes d. Metformin

a. Venlafaxine b. Paroxetine c. Gabapentin e. Clonidine

Which of the following may be used as non-hormonal therapy for the treatment of menopause-related hot flashes based on clinical guidelines? Select all that apply. a. Venlafaxine b. Paroxetine c. Gabapentin d. Vaginal lubricant e. Clonidine

d. Oxycodone

Which of the following medications has the highest potential to aggravate urinary incontinence symptoms? a. Hydralazine b. Metoprolol tartrate c. Methocarbamol d. Oxycodone

a. Metformin - Does not have a great effect on hyperandrogenism symptoms

Which of the following medications is NOT effective for hirsutism? a. Metformin b. Spironolactone c. Eflornithine d. Combined hormonal contraceptives

d. HCV: Glecaprevir/Pibrentasvir

Which of the following medications is correctly paired to the viral hepatitis it treats? a. HAV: Tenofovir b. HBV: Sofosbuvir/Velpatasvir c. HCV: Entecavir d. HCV: Glecaprevir/Pibrentasvir

d. Phenytoin

Which of the following medications would be a risk factor for a patient developing osteoporosis? a. Aspirin b. Lisinopril c. Metformin d. Phenytoin

d. Furosemide and Spironolactone - Furosemide 40mg and Spironolactone 100mg PO QD

Which of the following medications would be appropriate to recommend for the treatment of a patient with ascites? a. Rifaxamin b. Octreotide infusion c. Octreotide SubQ injections d. Furosemide and Spironolactone

d. Lactulose

Which of the following medications would be appropriate treatment for hepatic encephalopathy? a. Albumin b. Non-selective beta-blocker c. Octreotide SubQ injection d. Lactulose

d. Nexplanon (0.05%) - best method aside from abstinence - Slynd: 4% - Depo-Provera: 0.3-3% - Mirena: <1%

Which of the following methods is the most effective (lowest failure rate)? a. Slynd b. Depo-Provera c. Mirena d. Nexplanon

a. Fertility awareness app (Natural Cycles) - 24% - Diaphragm: 12% - Male condom: 18% - Sponge: Nulliparous: 12%; Parous: 24%

Which of the following methods is the most effective in preventing pregnancy based on typical use? a. Fertility awareness app (Natural Cycles) b. Diaphragm c. Male condom d. Sponge

d. Weight loss goal of 5-10%

Which of the following non-pharmacologic therapy is most important to counsel your patient (BMI 28 kg/m2) about when they are presenting with a new diagnosis of PCOS? a. Diet of low-saturated fats, high fiber, low-glycemia index foods b. Moderate exercise, 150 minutes each week c. Use of a CPAP machine for obstructive sleep apnea d. Weight loss goal of 5-10%

b. Ovulation prediction kit - Measures LH surge in urine - Ovulation expected within 12-48 hours after LH surge (highest fertility next 1-3 days and peaks at 36 hours)

Which of the following ovulation assessment tests will be most helpful and easiest for ZM to use? a. Serum FSH b. Ovulation prediction kit c. Basal body temperature charting d. Serum progesterone

b. Blurry vision - Severe SEs of CHCs = "ACHES"

Which one of the following is a severe side effect of CHCs? a. Weight gain b. Blurry vision c. Nausea d. Hirsutism

a. A 22-year-old pregnant female who is Rh(-) and her husband's Rh status is not known

Which of the following patients is a good candidate for RhoGAM? a. A 22-year-old pregnant female who is Rh(-) and her husband's Rh status is not known b. A 23-year-old pregnant female who is Rh(-) and her husband is Rh(-) c. A 24-year-old pregnant female who is Rh(+) and her husband is Rh(+) d. A 25-year-old pregnant female who is Rh(+) and her husband's Rh status is not known

d. 27 y/o F, s/p pregnancy x4, weekly blood transfusions x 1 month, PRA Class I: 89%, Class II: 100%

Which of the following patients would be correctly identified as having the highest risk for rejection? a. 37 y/o F, s/p pregnancy x1, zero blood transfusions, PRA Class I: 4%, Class II: 0% b. 91 y/o M, zero blood transfusions, PRA Class I: 0%, Class II: 0% c. 56 y/o M, weekly blood transfusions x 1 month, PRA Class I: 0%, Class II: 0% d. 27 y/o F, s/p pregnancy x4, weekly blood transfusions x 1 month, PRA Class I: 89%, Class II: 100%

d. Conjugated estrogens alone

Which of the following products is appropriate for use in a woman experiencing menopause-related hot flashes who has had a hysterectomy? a. Conjugated estrogens/medroxyprogesterone acetate b. Conjugated estrogen/bazedoxifene (Duavee) c. Ospemifene (Osphena) d. Conjugated estrogens alone

a. Femring vaginal ring

Which of the following products is effective in treating menopause-related hot flashes? a. Femring vaginal ring b. Estring vaginal ring c. Estrace vaginal cream d. Vagifem vaginal tablet

a. Mirena® b. Liletta® - Levonorgestrel IUD 52 mg (Mirena®, Liletta®) - Levonorgestrel IUD 19.5 mg (Kyleena®) - Levonorgestrel IUD 13.5mg (Skyla™)

Which of the following progestin intrauterine devices contains the highest dosing of progestin (Levonorgestrel)? a. Mirena® b. Liletta® c. Kyleena® d. Skyla™

a. Mirena®: 7 years - Liletta®: 6 years - Kyleena®: 5 years - Skyla™: 3 years

Which of the following progestin intrauterine devices has the longest duration of efficacy? a. Mirena® b. Liletta® c. Kyleena® d. Skyla™

e. Nexplanon (0.05%) - Progestin-only pill (Norethindrone & Drospirenone): 9%; 4% - Levonorgestrel IUD: 0.2% - Depo-Provera (IM DMPA): 3% - Depo-SubQ Provera: 3%

Which of the following progestin-only contraceptives has the lowest typical use failure rate? a. Progestin-only pill (Norethindrone & Drospirenone) b. Levonorgestrel IUD c. Depo-Provera (IM DMPA) d. Depo-SubQ Provera e. Nexplanon

b. Menstruation, Follicular phase, Ovulation, Luteal phase

Which of the following shows the correct order of the phases of the menstrual cycle, beginning with day 1? a. Ovulation, Follicular phase, Luteal phase, Menstruation b. Menstruation, Follicular phase, Ovulation, Luteal phase c. Luteal phase, Follicular phase, Menstruation, Ovulation d. Menstruation, Luteal phase, Ovulation, Follicular phase

a. Cefazolin

Which of the following therapies is used for the prevention of vertical transmission of group B streptococcus in a woman who is allergic to penicillin but does not report a reaction of anaphylaxis, angioedema, respiratory distress, or urticaria? a. Cefazolin b. Vancomycin c. Erythromycin d. Clindamycin

d. All of the Above

Which of the following therapies may be indicated for LK? a. Mannitol b. N-AC c. Vitamin K d. All of the Above

c. A woman who experiences induced menopause from an oophorectomy

Which of the following women will most likely not experience perimenopause? a. A woman who experiences premature menopause not due to medical intervention b. A woman who experiences natural menopause c. A woman who experiences induced menopause from an oophorectomy

a. Non-selective beta-blocker monotherapy

Which of the following would be an appropriate therapy for the primary prophylaxis of esophageal varices hemorrhage in a patient with small non-bleeding varices present on EGD? a. Non-selective beta-blocker monotherapy b. Non-selective beta-blocker and nitrate combination therapy c. Nitrate monotherapy d. Octreotide infusion

c. Non-selective beta-blocker and EVL

Which of the following would be an appropriate therapy for the secondary prophylaxis of esophageal varices hemorrhage? a. Non-selective beta-blocker monotherapy b. EVL monotherapy c. Non-selective beta-blocker and EVL d. Nitrate monotherapy

c. Administer N-acetylcysteine 150 mg/kg IV x 1 over 15 minutes, followed by 50 mg/kg IV over 4 hours, followed by 100 mg/kg over 16 hours

Which of the following would be the most appropriate treatment option? a. Administer activated charcoal 50 mg orally x 1 dose b. Administer Octreotide 50 mcg IV x 1, then 25 mcg/hr. IV infusion c. Administer N-acetylcysteine 150 mg/kg IV x 1 over 15 minutes, followed by 50 mg/kg IV over 4 hours, followed by 100 mg/kg over 16 hours d. No medication therapy is indicated at this time; continue to monitor for signs and symptoms of toxicity and provide supportive care as needed

a. ALT > 3 times ULN and R-ration > 5

Which of the following would indicate a laboratory pattern supporting hepatocellular drug induced liver injury? a. ALT > 3 times ULN and R-ration > 5 b. Alk phos > 2x ULN and R-ratio < 2 c. Alk phos > 2x ULN and ALT > 3x ULN and R-ratio 2-5 d. None of the above

c. Alfuzosin (Uroxatral®)

Which of the following α-adrenergic blocking agents is functionally uroselective, but not pharmacologically? a. Terazosin (Hytrin®) b. Doxazosin (Cardura®) c. Alfuzosin (Uroxatral®) d. Tamsulosin (Flomax®) e. Silodosin (Rapaflo®)

c. Secondary Syphilis: Occurs 3 to 6 weeks after the initial lesion; often manifests as mucocutaneous lesions

Which of the statements accurately portrays the stage of syphilis listed? a. Latent Syphilis: Occurs when the organism invades the central nervous system and results in meningitis b. Primary Syphilis: The host suppresses the infection and there are no clinically apparent lesions c. Secondary Syphilis: Occurs 3 to 6 weeks after the initial lesion; often manifests as mucocutaneous lesions d. Tertiary Syphilis: The initial presentation of the chancre lesion

PB - PRA Class I: 28% - PRA Class II: 86% - Patient is a 2 of 6 antigen match with the identified deceased donor. - Transplanted organ contains many antigens - T cell recognition of 'non-self' antigens leads to T cell activation, antibody production, and graft rejection - RG would be the ideal candidate because he is at a decreased risk for rejection and is a better immunological match

Which of these two patients would you identify as having the higher immunologic risk for rejection should they receive the transplant? Why?

b. Acetaminophen toxicity with MELD score 40 - High MELD score (40 is the highest) higher likelihood of dying in the next 3 months - Non-compliance to medications could be a reason for a patient not being eligible for a transplant

Which patient is in the greatest need to receive a transplant as soon as possible? a. Alcohol hepatitis with MELD score 10 b. Acetaminophen toxicity with MELD score 40 c. Kidney transplant recipient from 2010 with graft loss due to medication non-compliance d. CKD stage IV with decreasing urine output

d. 22 y/o woman with migraines with aura - Patient is likely established with breast feeding at 6 months post-partum - CI in women with migraines with aura puts them at risk for stroke

Which patient is not a candidate for CHCs? a. 45 y/o woman who is a non-smoker b. 24 y/o woman with a FH of HTN c. 26 y/o lactating woman who is 6 months postpartum d. 22 y/o woman with migraines with aura

b. Organogenesis - Organogenesis is when we worry the most about medication effects because this when the majority of the organs are formed - GFR develops during fetogenesis - Renal insufficiency, pulmonary hypertension, neurologic deficiency can manifest during fetogenesis

Which phase of embryonic & fetal development do we worry about the most regarding medication effects because this is when the majority of the organs are formed? a. Implantation b. Organogenesis c. Fetogenesis d. Neonatal period

Etonogestrel 68 mg (Nexplanon®) - Contains barium sulfate 15 mg - MOA: Suppresses ovulation, thickens cervical mucus - Advantages: No reliance on patient compliance, rapid return to fertility, excellent effectiveness

Which progestin-only product is inserted subdermally on inside of upper arm, indicated to prevent pregnancy for up to 3 years, and has a failure rate of 0.05%?

Sofosbuvir/Velpatasvir (Epclusa®)

Which regimen has a concern for drug interaction with proton pump inhibitors?

a. Hepatitis A

Which viral hepatitis virus cannot become a long-term, chronic infection? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D e. None of the above - they all can become chronic

- Terazosin (Hytrin®) - Doxazosin (Cardura®)

Which α-adrenergic blocking agents can be useful in treating concurrent hypertension as well as dynamic factors of BPH?

Everyone! - All patients with acute or chronic HCV Except: - Short life expectancy not impacted by HCV therapy - Liver transplant or other curative therapy

Who do we treat for HCV?

Patients who survive active hemorrhage should receive therapy to prevent recurrence - Re-bleeding after initial hemorrhage control occurs ~60% (re-bleeding mortality ~33%) Best Option: Non-selective BB + Chronic EVL

Who is indicated for GEV secondary prophylaxis? What is the best therapeutic regimen option?

Who receives prophylaxis? 1. Moms +GBS during 35-37-week screening 2. GBS bacteriuria during any trimester of current pregnancy 3. Unknown mom GBS status, plus any of the following: - Preterm birth (< 37wk gestation) - Rupture of membranes ≥ 18 hours - Fever during delivery ≥100.4℉ - Previous infant with invasive GBS disease

Who receives Group B Streptococcus (GBS) prophylaxis treatment?

a. Inhibition of prostaglandin by Indomethacin may promote premature closure of fetal ductus arteriosus

Why is indomethacin restricted to use as a tocolytic from 24-32 weeks' gestation? a. Inhibition of prostaglandin by Indomethacin may promote premature closure of fetal ductus arteriosus b. Inhibition of prostaglandins by Indomethacin may increase the risk of maternal hypotension and tachycardia c. Indomethacin may also serve as neuroprotection to decrease the risk of cerebral palsy in premature infants d. Inhibition of prostaglandins by Indomethacin may promote an increase in amniotic fluid volume which increases the risk of fetal pulmonary hypertension

Denosumab has an ADE for Hypocalcemia/Hypophosphatemia

Why must Calcium and Vitamin D be taken with a Denosumab (Prolia®, Xgevia®) regimen?

a. True

Women who are perimenopausal should be advised to use contraception if pregnancy isn't desired. a. True b. False

b. > 90 kg (198 lbs.) Xulane®: Greater failure rate in women > 90 kg (198 lbs.)

Xulane® demonstrated a greater failure rate in women: a. > 70 kg (154 lbs.) b. > 90 kg (198 lbs.) c. BMI > 30 kg/m2 d. BMI > 29 kg/m2

c. BMI > 30 kg/m2 Xulane®, Twirla®: Contraindicated in women with BMI > 30 kg/m2

Xulane®, Twirla® are contraindicated in women: a. > 70 kg (154 lbs.) b. > 90 kg (198 lbs.) c. BMI > 30 kg/m2 d. BMI > 29 kg/m2

d. Iodide to prevent iodine deficiency e. Calcium to support bone growth

You have been asked to educate a woman who is trying to conceive about prenatal vitamins. Which of the following are important to check for inclusion in a prenatal vitamin? Select all that apply. a. Fenugreek to increase milk supply b. Vitamin K to prevent post-partum thromboembolism c. Docusate to reduce constipation d. Iodide to prevent iodine deficiency e. Calcium to support bone growth

c. Take Alendronate with food - We don't want to tell people to take it with food - it affects absorption

You recommend PB start Alendronate 70 mg by mouth once weekly for treatment of osteoporosis. After 2 months, PB tells you that she has severe dyspepsia after taking the Alendronate and doesn't want to take it anymore. Which of these is NOT a possible correct response to PB? a. Change Alendronate to Raloxifene b. Change Alendronate to another oral or IV Bisphosphonate c. Take Alendronate with food

d. Take Saturday's pill now, then resume usual dosing tonight, use back-up for 7 days

a. Take tonight's pill as usual, no back-up is needed b. Take tonight's pill as usual, use back-up for 7 days c. Take Saturday's pill now, then resume usual dosing tonight, no back-up is needed d. Take Saturday's pill now, then resume usual dosing tonight, use back-up for 7 days