Pharm Module 6

Adverse effects of fludrocortisone (Florinef), a mineralocorticoid:

HTN, edema, cardiac enlargement, hypokalemia Inform patients about signs of sodium and water retention (e.g., unusual weight gain, swelling of feet or lower legs) and hypokalemia (e.g., muscle weakness, irregular heartbeat), and instruct them to notify provider if these occur

Many athletes use anabolic steroids to enhance athletic performance. Significant risks:

HTN, suppression of release of LH and FSH, testicular shrinkage, sterility, gynecomastia, acne, reduction in HDL, increase in LDL Hepatotoxicity with 17-alpha-alkylated compounds Renal damage Psychological effects on psychologically unbalanced individuals, can intensify aggression

Short duration, rapid acting insulin

10-30 minutes for onset 15-90 minutes for peak 3-6 hours for duration

Oral contraceptives

2 categories: combination OCs (estrogen + progestin) and progestin only (mini-pills) Almost all combo OCs use the same estrogen: ethinyl estradiol Eight difference progestins are used Contraindicated during pregnancy because they have no legitimate use during pregnancy

Combination OCs

3 subgroups: monophasic, biphasic, and triphasic Act primarily by inhibiting ovulation Can cause a variety of adverse effects, but serious events are rare HTN Cancer Stroke in patients with migraine Abnormal uterine bleeding Use in pregnancy and lactation: may cause bleeding in female infants Benign hepatic adenoma Glucose intolerance ACHES - could be signs of a serious disorder such as liver disease, gallbladder disease, stroke, blood clots, escalating BP, and/or heart disease. Patients must notify provider ASAP with ACHES Abdominal pain Chest pain Headaches (severe) Eye problems (blurry vision) Swelling and aching in upper and lower legs Thrombotic events with combo OCs are caused by the progestin as well as the estrogen The risk of thrombotic events is lowest with combo OCs that have a low dose of estrogen and contain a first generation progestin High risk with OCs that contain drospirenone or desogestrel Increased risk in women who smoke and those with thrombophilias Protect against ovarian and endometrial cancer and do not increase risk of breast cancer

Glucocorticoids for IBD

Hydrocortisone Used for UC and Crohn's Severe adverse effects (esp with long-term use) including adrenal suppression, osteoporosis, increased susceptibility to infection, cushingoid syndrome

List the primary glucocorticoids and mineralocorticoids used for hormone replacement in Addison's disease

Hydrocortisone = principal glucocorticoid Dexamethasone, prednisone and cortisone also used Fludrocortisone is a potent mineralocorticoid that also possesses significant glucocorticoid activity The only mineralocorticoid available and is drug of choice for chronic mineralocorticoid replacement

Adverse effects of GH

Hyperglycemia Neutralizing antibodies Over the course of treatment, patients may develop neutralizing antibodies that bind with GH and render the hormone inactive Carpal tunnel syndrome Fatality in patients with Prader-Willi Major risk factors are severe obesity, upper airway obstruction, sleep apnea, and respiratory infection Interactions Glucocorticoids can oppose the growth-promoting effects of GH

Tx of hypogonadism

Hypogonadism is a condition in which testes fail to produce adequate amounts of testosterone When complete hypogonadism occurs in boys, puberty cannot take place Long-acting parenteral preparation is given → voice deepens, growth is accelerated, penis is enlarged, and other secondary sex characteristics are expressed This occurs over several years

Describe the hypothalamic-pituitary-thyroid feedback loop

Hypothalamus releases thyrotropin releasing hormone (TRH) which stimulates release of TSH from anterior pituitary TSH stimulates all aspects of thyroid function, including release of T3 and T4 T3 and T4 act on the pituitary to suppress further TSH release

pancrelipase (Creon, Pancreaze)

Mixtures include lipases, amylases, proteases Dose is adjusted on an individual bases Determining factors include extent of enzyme deficiency, dietary fat content, and enzyme activity of the preparation selected Pancreatic enzymes should be taken with every meal and snack

Contraindications for vaccines

No live vaccines in pregnant people or immunocompromised people Live vaccines: MMR, varicella Absolute contraindications to vaccine administration in children include a hx of anaphylactic reaction to a specific vaccine or vaccine component, as well as the presence of moderate or severe illness with or without a fever

Drug interactions with metronidazole

Warfarin: increased bleeding Phenytoin, lithium, fluorouracil, cyclosporine: increased toxicity Cytochrome P450 Drugs that increase CYP450 activity (phenobarb, rifampin, phenytoin) decrease metronidazole levels Drugs that decrease CYP450 activity (ketoconazole, others) increase metronidazole levels

Vitamin C

Water soluble Action required for production of collagen and other compounds that bind cells together Part of the biochemical reaction for the synthesis of adrenal steroids Has antioxidant properties Facilitates iron absorption Deficiency: scurvy Sources: citrus fruits/juices, tomatoes, potatoes, strawberries, melons, spinach, broccoli

Signs and symptoms of Addison's Disease

Weakness Hypotension Emaciation Hypoglycemia, hyperkalemia, hyponatremia Increased pigmentation of skin and mucous membranes

NP identifies which of the following as most common laxative abused by the general public?

bisacodyl (Dulcolax) (stimulant laxatives)

big side effect of bismuth compounds

black tongue and stool

Adverse effects of progestin-only OCs

breast discomfort, HA, local irritation, nausea, menstrual cramps

Drug that have interactions with antacids

cimetidine, ranitidine, sucralfate

Adverse effects of antacids

constipation, diarrhea, sodium loading

Vitamin B12 (aka)

cyanocobalamin

Leishmaniasis treatment

liposomal ampho B, sodium stibogluconate

Niacin (aka)

nicotinic acid, nicotinamide

List drugs that increase levothyroxine metabolism

phenytoin carbamazepine rifampin sertraline phenobarbital

Important physiologic effects of androgens

pubertal transformation in males maintenance of adult male sexual characteristics promote muscle growth spermatogenesis stimulation of erythropoiesis

Vitamin B6 (aka)

pyridoxine

Vitamin A (aka)

retinol

Vitamin B2 (aka)

riboflavin

Tetracycline big side effect

staining of teeth -- avoid in pregnant people and people under age 8

Long-term high-dose therapy with metoclopramide (Reglan) can cause:

tardive dyskinesia

Vitamin B1 (aka)

thiamin

Short course for community-acquired UTIs

trimethoprim/sulfamethoxazole (Bactrim) Bacteriostatic; folic acid inhibitor BID x3days Risk of Stevens-Johnson Syndrome Hemolytic disease in G-6-PD deficiency Can be used in pregnancy until 36 weeks

Vitamin C (aka)

ascorbic acid

Toxic nodular goiter

(AKA Plummer's disease) Result of thyroid adenoma Clinical manifestations are similar to Graves' except exophthalmos Treatment: same as Graves' disease; if antithyroid drug is used, symptoms return rapidly when drug is withdrawn. Surgery and radiation are preferred.

3 major classes of worms

1. Nematodes (roundworms) Common intestinal worms :pinworms, hookworms, giant roundworms 2. Hookworms common in rural areas where hygiene is poor and people go barefoot Extraintestinal worms: pork roundworms Cestodes (tapeworms) Acquired from undercooked beef or pork that contains tapeworm larvae 3. Trematodes (flukes)

Big edu point with Flagyl

avoid alcohol

Contraindications to laxative use

**KNOW THIS** 1. Abdominal pan, nausea, cramps, or other symptoms of appendicitis, regoinal enteritis, diverticulitis, or UC 2. Acute surgical abdomen 3. Fecal impaction of bowel obstruction 4. Habitual use 5. Use with caution in pregnancy and lactation

Addison's Disease

= Primary Adrenocortical Insufficiency Secondary adrenocortical insufficiency results from decreased secretion of ACTH Tertiary insufficiency results from decreased secretion of CRH In both cases adrenal secretion of glucocorticoids is diminished and secretion of mineralocorticoids is usually normal

Cushing's syndrome - causes

= adrenal hormone excess Causes Hypersecretion of ACTH Hypersecretion of glucocorticoids Administration of glucocorticoids in large doses

Antacids

= alkaline compounds that neutralize stomach acid Principal indications: PUD and GERD Beneficial actions React with gastric acid to produce neutral salts or salts of low acidity Reduce destruction of gut wall by neutralizing acid May also enhance mucosal protection by stimulating production of prostaglandins Except for sodium bicarb, antacids do NOT alter systemic pH Use with caution in patients with renal impairment

The first half of the 28-day menstrual cycle

= follicular phase Estrogens produced by maturing ovarian follicles cause proliferation of the endometrium

Second half of menstrual cycle

= luteal phase Progesterone produced by the corpus luteum causes the endometrium to become more vascular and the endometrial glands to secrete glycogen Toward the end of the menstrual cycle, progesterone levels decline, causing breakdown of the endometrium, which results in menstrual bleeding

Vitamins

= organic compounds required in minute amounts that promote growth and health maintenance by participating in energy transformation and regulation of metabolic processes Do not serve as a source of energy Several vitamins are inactive in native form and must be converted to active compounds in the body

Minipill

= progestin only

Treatment of BPH

Alpha-reductase inhibitors (mechanical obstruction) Alpha 1-adrenergic antagonists (dynamic obstruction)

Passive immunity

A temporary immune state created by the administration of antibodies to a person not already immunized -Immune globulins -Breast milk -Placental transfer

Explain why multiple doses of a vaccine are given for a particular preventable infectious disease, rather than just a single dose.

A toxoid vaccine is a bacterial toxin that has been changed to a non-toxic form. Reimmunization is necessary -- this is why you need a tetanus booster every 5-10 years

Patient has chemotherapy-induced nausea. Which med would be most effective for this patient? A. ondansetron (Zofran) B. prochlorperazine (Compazine) C. dexamethasone (Decadron) D. promethazine (Phenergan)

A. zofran

calcium carbonate: 2 big adverse effects

ACID REBOUND constipation

fat soluble vitamins

ADEK

Albendazole (Albenza)

Absorbed better with fatty meal Giant roundworms

Radioactive Iodine (131I)

Absorbed by and concentrated in thyroid, radiation emitted and destroys thyroid gland Increased risk of hypothyroidism Category X in pregnancy Useful in thyroid cancer Must monitor TSH

Identify the main source of Vitamin B12 compared with other B Vitamins.

According to Google, vitamin B12 is naturally found in animal products including fish, meat, poultry, eggs, milk and milk products Generally not present in plant foods, but fortified breakfast cereals are a readily available source of vitamin B12 with high bioavailability for vegetarians

Toxoplasmosis

Acquired by eating undercooked meat In immunocompromised hosts, disease can progress to encephalitis and death Treatment: pyrimethamine + either sulfadiazine, clinda, or atovaquone

Bismuth compounds for PUD

Act topically to disrupt the cell wall of H. pylori, causing lysis and death May inhibit urease activity and prevent H. pylori from adhering to the gastric surface Can impart a harmless black coloration to tongue and stool

Omeprazole (Prilosec)

Actions: inhibits gastric secretion Ulcer prophylaxis is Indicated only for patients in an ICU and then only if they have an additional risk factor, such as multiple trauma, SCI, prolonged mechanical ventilation Adverse effects: HA, GI effects, PNA, fractures, hypomag, rebound acid hypersecretion, C. diff infection, gastric cancer

Muscarinic agonists for urinary retention

Activate muscarinic receptors of urinary tract Relax trigone and sphincter muscles Increase voiding pressure contracting detrusor muscle Useful in post-op and postpartum patients with urinary retention Approved agent: bethanechol (Urecholine) Direct-acting muscarinic agonist Administer 1-2 hours after meals

Praziquantel (Biltricide)

Administer with food, do not crush Tapeworms

Causes of Addison's disease

Adrenal glands are damaged and unable to make glucocorticoids 80% caused by autoimmune destruction of adrenal tissue Other causes are tuberculosis, other infections, hemorrhage, cancers, certain drugs (ketoconazole, rifampin)

Chlamydia treatment

Adults and adolescents Urethral, cervical, or rectal infections: azithromycin 1 gm oral dose or doxycycline PO BID x 7 days Pregnant women: azithromycin or amox Infants with PNA or ophthalmia Erythromycin Preadolescent children Erythromycin or azithromycin depending on age/weight >8yo: Azithromycin single dose PO or doxycycline x 7 days (avoid if possible because of staining of teeth) Lymphogranuloma venereum - more common in tropical countries → doxy x 21 days

List the adverse events for muscarinic agonist overdose

Adverse effects = SLUDGE and Killer Bs Salivation, lacrimation, urination, diaphoresis/diarrhea, GI cramping, and emesis Can progress to bronchospasm, bronchorrhea, blurred vision, bradycardia/tachycardia, hypotension, confusion and shock

List the side effects of anticholinergic drugs used for OAB

Adverse effects of anticholinergics for OAB: dry mouth, blurred vision, photophobia, tachycardia, URINARY RETENTION, constipation, anhidrosis

Describe the clinical implications of hyperaldosteronism

Aldosterone, the major mineralocorticoid, acts on the kidney to promote retention of sodium and water and excretion of potassium and hydrogen Aldosterone also acts directly on the heart and blood vessels, causing harm when levels are high Hyperaldosteronism Excessive sodium is retained Fluid retention and HTN Potassium is lost because of the sodium-potassium exchange pump As potassium is lost, there is an intracellular shift of potassium out of the cell and H+ into the cell resulting in metabolic alkalosis Results in: hypokalemia, metabolic alkalosis, HTN

Bowel-Cleansing Products for Colonoscopy

Allow for good visualization of the bowel Two kinds of bowel cleansers, both equally effective Sodium phosphate Hypertonic with body fluids Can cause dehydration and electrolyte disturbance Possibility of renal damage Polyethylene glycol (PEG) plus electrolytes (ELS) Isotonic with body fluids Requires ingestion of large volume of bad-tasting liquid

IBS drugs

Alosetron (Lotronex) Potentially hazardous Approved for women only and for severe IBS not responsive to other treatment GI toxicities can cause complicated constipation, leading to perforation and ischemic colitis Risk management program Lubiprostone (Amitiza) Approved for IBS-C in women over 18 Tegaserod (Zelnorm) Short-term therapy of IBS-C and chronic idiopathic constipation in women <55 who are free of CV disease

BPH drugs and HTN

Alpha 1 adrenergic antagonists very useful in patients with both HTN and BPH Be careful if patient is on antihypertensive drugs

Active immunity

An immune response with antibody formation to an infection through vaccines, toxoids, or natural exposure to a disease by activation of B and T lymphocytes

Different preparations of drugs used for treating OAB

Anticholinergics available in the following preparations: oral, immediate release, delayed release, transdermal patch, topical gel

Vitamin E

Antioxidant properties High-dose vitamin E (more than 200 IU/day) increases risk for hemorrhagic stroke Sources: fresh greens, seeds, oils, corn

Immunosuppressants for IBD

Azathioprine UC and Crohn's Major adverse effects: pancreatitis and neutropenia

Pt prescribed amox and tetracycline to treat PUD. NP will instruct patient that these meds will do what? A. Prevent GI infections that cause GI bleeding B. Destroy the bacteria in the stomach that are causing ulceration C. Reduce gastric acid production and alkalize the stomach fluids D. Reduce the secretion of pepsin in the stomach

B. Remember to use at least 2 abx!

NP identifies which of the following laxatives as having the added response of ridding the body of ammonia? A. polyethylene glycol (Miralax) B. lactulose C. lubiprostone (Amitiza) D. mineral oil

B. pts with liver failure or increased ammonia levels might take this into account

Benzodiazepines as antiemetics

Benefits: sedation, suppression of anticipatory emesis, production of anterograde amnesia

Identify the main groups of drugs that can interfere with diabetes therapy, whether by directly altering blood glucose levels or by interacting with the current antidiabetic drug or drugs.

Beta blockers can delay awareness of hypoglycemia by masking hypoglycemia-induced signs that are caused by activation of the sympathetic nervous system (e.g., tachycardia, palpitations) In addition, beta blockers inhibit the breakdown of glycogen to glucose and can thereby impede glucose replenishment

Identify the main groups of oral antidiabetic drugs (and a prototype in each). Compare and contrast their main mechanisms of action, their main adverse responses, and drug-drug interactions.

Biguanides Sulfonylureas Thiazolidinediones Glitazones Meglitinides GLP-1 Receptor agonists DDP-4 inhibitors GLP1 Agonists

Stimulant laxatives

Bisacodyl (Dulcolax) 2 effects on bowel: stimulate intestinal motility and increase amounts of water/electrolytes in intestinal lumen Widely used and abused Used for opioid-induced constipation and for constipation from slow intestinal transit

Alpha 1-adrenergic antagonists (dynamic obstruction)

Blockade of alpha 1 receptors relaxes smooth muscle in the bladder neck (trigone and sphincter) Preferred for men with relatively small prostates (dynamic obstruction) Do not decrease the size of prostate like 5-alpha-reductase inhibitors do Do not decrease PSA levels Examples Selective for alpha 1a in the prostate: tamsulosin (Flomax) and silodosin (Rapaflo) Less likely to cause the effects on smooth muscle like the nonselective agents since they have minimal effects on vascular smooth muscle Can cause abnormal ejaculation unlike the nonselective agents Non-selective alpha 1 blockers: alfuzosin (Uroxatral), terazosin (Hytrin) and doxazosin (Cardura) Block alpha 1 receptors in prostate AND in blood vessels → promote vasodilation and lower BP

Metoclopramide (Reglan) as an antiemetic

Blocks dopamine receptors in CTZ

Symptom control for DM

Blood glucose levels must be kept as close to normal as safely possible BP and lipids within acceptable range Physical activity and proper diet are central components of management

Hypoglycemia

Blood glucose of <60 mg/dL Results from error in insulin dose, failure to eat after taking med, increased exercise, stress (including illness) medication changes, loss of beta cell function (beta cells continue to die off over time) Symptoms: HA, difficulty in problem solving, disturbed or altered behavior, coma and seizures (may result in death), cool/clammy skin Insulin-induced hypoglycemia can be treated with a fast-acting oral sugar (glucose tablets, orange juice, sugar cubes), IV glucose, or parenteral glucagon

Pt with IBS is prescribed alosetron (Lotronex). Before it is administered, it is most important for the NP to do what? A. assess for abdominal bruits B. Check serum potassium and sodium levels C. Ask the patient about any problems with constipation D. Mix the powder in 8 oz of fruit juice

C Don't want to cause bowel perf

water soluble vitamins

C and B complex (thiamin, riboflavin, niacin, pyridoxine, pantothenic acid, biotin, folic acid, and cyanocobalamin)

Vitamin D

Critical role in regulation of calcium and phosphorus metabolism, and may help protect against the development of breast cancer, colorectal cancer, and type 1 diabetes and improve overall mortality Deficiency in children: Rickets Deficiency in adults: osteomalacia Sources: sunlight, fish, cereal, whole grains, cheese, butter, milk

What would you give a child or someone who is pregnant or a child with traveler's diarrhea?

azithromycin

Insulin lispro (Humalog)

Can be given immediately before eating or even after eating because of rapid action Administered subq injection or with an insulin pump Very similar to natural insulin with differences in 2 amino acids

Identify indications for the use of a laxative.

Can reduce painful elimination associated with episiotomy, hemorrhoids, and other anorectal lesions In patients with CV diseases, softening stool decreases amount of strain needed to defecate, avoiding dangerous elevation of BP In older patients, laxatives compensate for loss of tone in abdominal and perineal muscles Can be used for fresh stool sample, emptying bowel for treatment/procedure, expelling dead parasites after treatment Modify effluent from ileostomy or colostomy Constipation (including pregnancy-induced and opioid-induced) Fecal impaction in bedridden patients Remove poisons

Treatment of Cushing's syndrome

Carcinoma/adenoma: surgical removal of adrenal gland Replacement therapy with glucocorticoids and mineralocorticoids for bilateral adrenalectomy Drugs used as adjuncts to surgical treatment Most effective pharmacologic agent is ketoconazole (Nizoral) Antifungal that also blocks glucocorticoid synthesis Much higher dose than antifungal therapy

Hypothyroidism

Causes: Hashimoto's disease, iron deficiency in diet, surgical removal of thyroid or destruction with radioactive iodine, insufficient secretion of TSH (secondary hypothyroidism) or TRH (tertiary hypothyroidism) Signs/symptoms: pale/puffy face, cold/dry skin, brittle hair, hair loss, low HR, low temp, lethargy, fatigue, intolerance to cold, impaired mentation, possible thyroid enlargement Treatment: replacement therapy with thyroid hormones; in almost all cases this is lifelong

Irritable bowel syndrome

Characterized by cramping abdominal pain that cannot be explained by structural or chemical abnormalities May occur with diarrhea, constipation, or both Four groups of drugs used: antispasmodics, bulk-forming agents, antidiarrheals, tricyclic antidepressants Drugs: losetrone (Lotronex), lubiprostone (Amiiza), tegaserod (Zelnorm)

Who do you not give pepto bismol to?

Children (Reye's syndrome) or anyone with an aspirin allergy

Vitamin B12

Cyanocobalamin Essential factor in synthesis of DNA Deficiency: megaloblastic "pernicious" anemia, neurologic damage Sources: fish, cheese, red meat, shrimp, eggs

Explain why drugs that block M3 receptors are useful for OAB

Class of choice for OAB: anticholinergics Parasympathetic nervous system controls bladder contraction By blocking muscarinic receptors, bladder activity decreases Muscarinic receptor specificity is important to decrease side effects M1 = salivary glands, CNS M2 = Heart M3 = Salivary glands, bladder: detrusor, GI smooth muscle, and several functions in the eye Response to activation = contraction (increased pressure) Impact of blockade = relaxation (decreased pressure)

List the common symptoms of cystitis

Cystitis = lower UTI that occurs most often in women of childbearing age Clinical manifestations: dysuria, urinary urgency, urinary frequency, suprapubic discomfort, pyuria, and bacteriuria

List drugs that require additional monitoring when used concurrently with levothyroxine

Warfarin -- increased bleeding May need to increase insulin dose Observe for dysrhythmias if used with catecholamines

Considerations for choice of contraceptive methods

Combination OCs should be avoided by women with certain CV disorders, as well as women over 35 who smoke Women who are not in a mutually monogamous relationship (and are at risk for an STD) should not use an IUD

Progestins

Compounds that act like progesterone Produced by ovaries and placenta Therapeutic uses Postmenopausal hormone therapy Dysfunctional uterine bleeding (premenopause) Amenorrhea Obstetrics: prematurity prevention Endometrial carcinoma and hyperplasia

Contraindications of PDE5 inhibitors

Contraindicated in men taking organic nitrates d/t risk of life-threatening hypotension Contraindicated with other vasodilators, like alpha-adrenergic blockers

List the contraindications for muscarinic agonist use

Contraindications Patients with peptic ulcer disease, urinary tract obstruction, intestinal obstructions, hypotension, asthma, coronary insufficiency, and hyperthyroidism

Treatment of hyperaldosteronism

based on underlying cause Surgery Aldosterone antagonist (sprionolactone)

Sucralfate (Carafate)

Creates a protective barrier for up to 6 hours Therapeutic uses: acute ulcers and maintenance therapy Adverse effects: constipation (rare) Drug interactions: antacids

A patient who has been taking a long-acting morphine to treat severe pain for a few mos complains of constipation. NP prescribes which of the following? A. polycarbophil (FiberCon) B. mineral oil C. psyllium (Metamucil) D. senna (Senokot)

D

Which medication is used to promote gastric ulcer healing by providing a protective barrier? A. cimetidine B. misoprostol C. omeprazole D. sucralfate

D

Pt is prescribed bisacodyl. Which of the following should NP include in patient teaching? A. Urine will turn yellow-brown when taking this med B. Crush bisacodyl tablet and sprinkle it on your food C. Chew the bisacodyl tablet D. Do not take the bisacodyl with an antacid

D (or milk!)

Which statement about metoclopramide (Reglan) does the NP identify as true? A. High-dose therapy causes nervous excitability B. High-dose therapy cuase constipation C. Long-term high-dose therapy causes reversible tardive dyskinesia D. The drug is contraindicated in patients with GI obstruction, perforation, or hemorrhage

D. Remember that it can cause IRreversible TD

Non-contraceptive benefits of oral contraceptives

Decreases risks of ovarian cancer, endometrial cancer, ovarian cysts, pelvic inflammatory disease, benign breast disease, anemia, and acne Favorable effect on menstrual cycles: reduced cramps; lighter, shorter, more predictable flow

pellagra

Dermatitis characterized by scaling and cracking of skin in areas exposed to the sun GI disturbances CNS disturbances: irritability, insomnia, memory loss, anxiety and dementia

Therapeutic uses of ADH

Diabetes insipidus Cardiac arrest Post-op abdominal distension Abdominal radiography (to dispel gas shadows) Enuresis Hemophilia A Von Willebrand's disease

Adverse effects with metronidazole

Disulfiram reaction with ETOH Other adverse effects: metallic taste in mouth, stomatitis, rare CNS changes

Surfactant laxatives

Docusate sodium (Colace) Produces a soft stool several days after onset of tx Alters stool consistency Lowers surface tension Facilitates penetration of water into feces May also act on intestinal wall Inhibits fluid absorption Stimulates secretion of water and electrolytes into intestinal lumen Surfactant resemble stimulant laxatives

Most common cause of acute pyelonephritis

E coli

Identify the most common organism for community-acquired urinary tract infections (UTIs)

E. coli

Traveler's diarrhea

E. coli usually self limiting Possible therapies: ciprofloxacin, norfloxacin, azithromycin, rifaximin Consider age of patient and pregnancy

Drug interactions with oral contraceptives

Efficacy can be reduced by agents that induce hepatic drug-metabolizing enzymes (rifampin, phenobarb, ritonavir, St. John's wort) Drugs whose effects are can be DECREASED by OCs: warfarin, insulin, oral hypoglycemics Drugs whose effects are can be INCREASED by OCs: theophylline, TCAs, diazepam, chlordiazepoxide Drugs that elevate POTASSIUM should be avoided in patients on Yasmin, Bayaz and YAZ

Discuss the mechanisms by which emesis is triggered and the main neurotransmitters that participate in the triggering of signs and symptoms.

Emesis results from activation of the vomiting center, which receives its principal stimulatory inputs from the chemoreceptor trigger zone, cerebral cortex, and inner ear Serotonin antagonists are the most effective antiemetics available

Ivermectin (Stromectol)

Empty stomach with water Giant roundworms

Adverse effects of estrogens

Endometrial hyperplasia & carcinoma (if unopposed) Promotes growth of existing breast cancer Ovarian cancer CV events Nausea Teratogenic Other: Gallbladder disease, jaundice, HA, and chloasma

What is the principal endogenous estrogen?

Estradiol

Roles of estrogens

Estrogens are required for the growth and maturation of the uterus, vagina, fallopian tubes, and breasts Estrogens also control pigmentation of the nipples and genitalia Estrogens suppress bone mineral resorption and have a positive impact on bone mass Estrogens raise levels of HDL cholesterol and reduce levels of LDL cholesterol Promote and suppress blood coagulation Physiologic processes r/t repro: ductal growth in breast, thickening and cornification of vaginal epithelium, proliferation of the uterine epithelium, copious secretion of thickened mucus from endocervical glands

GLP1 Agonists

Exampes: exenatide (Byetta), liraglutide (Victoza) Work on several different organs to lower glucose levels Slow glucose absorption from the gut (type 1 and 2) Increase insulin secretion from pancreas when glucose is high Delay many drugs in gut Increase cases of pancreatitis Pregnancy category C Caution in renal impairment

Glucocorticoids as antiemetics

Exampes: methylprednisolone, dexamethasone Unknown MOA

GLP-1 Receptor agonists

Example: exenatide (Byetta, Soliqua, Trulicity) Injectable meds that cause glucagon suppression and delay gastric emptying Effective in reducing Hgb A1C ~1% Low risk of hypoglycemia Moderate weight loss Major side effects: GI side effects, injectable, more expensive

Biguanides

Example: glucophage (Metformin) Decreases glucose production by the liver and increases glucose uptake by muscle and adipose tissue Increased insulin sensitivity Main adverse effects: GI disturbances Decreased appetite, nausea, diarrhea Does NOT cause hypoglycemia when used alone Very rarely causes lactic acidosis, which can be fatal Increased risk with renal impairment, which decreases metformin excretion and thereby causes levels to rise rapidly Metformin is dosed based on renal function Check GFR Can be started in patients with GFR >45 can continue with GFR 30 Increases fertility Do not use ETOH

Butyrophenones as antiemetics

Example: haloperidol (Haldol) Block dopamine 2 receptors in CTZ

Serotonin receptor antagonists

Example: ondansetron (Zofran) Mechanism of action: blocks 3 serotonin receptors on afferent vagal nerve

Glitazones

Example: pioglitazone (Actos) Oral meds taken once daily with or without food Reduces insulin resistance -- insulin must be available Used with metformin, sulfonylurea, or insulin Monitor: fluid retention, liver toxicity, increased lipids, LFTs

Phenothiazines as antiemetics

Example: prochlorperazine (Compazine) Block dopamine 2 receptors in CTZ

Thiazolidinediones

Example: rosiglitazone (Avandia) Oral meds that sensitize peripheral tissues to insulin and decrease gluconeogenesis in liver Effective in reducing Hgb A1C Lower risk of hypoglycemia than sulfonylureas Major adverse effects: some weight gain, risk of edema and heart failure (because they promote water retention) More expensive

DDP-4 inhibitors

Example: sitagliptin (Januvia) Oral meds that work similarly to GLP-1 agonists Moderately effective in reducing Hgb A1C by 0.7-1.6% Low risk of hypoglycemia Weight neutral Few side effects More expensive

Cannabinoids

Examples: dronabinol (Marinol) and nabilone (Cesamet) Chemically related to marijuana MOA with emesis unclear

Sulfonylureas

Examples: glipizide, glyburide Oral med: take 30 min before meal Stimulate the release of insulin from pancreatic B cells Major adverse effects: hypoglycemia and weight gain Also nausea and vomiting Pros Effective in reducing Hgb A1C by 1.25% Inexpensive

Meglitinides

Examples: repaglinide, nateglinide Must have functioning pancreas Will not work in patients who don't respond to sulfonylureas Give 30 minutes before meals Skip dose if meal is skipped Add dose if added meal Do not exceed 4 doses/day Monitor: sweating, tachycardia, fatigue, hunger, tremors, hypoglycemia, nausea/diarrhea

Quantitative measurements for DM

Fasting blood glucose levels Blood drawn at least 8 hours after last meal Normal level less than 100 mg/dL Prediabetes: 100-125 Diabetes: 126 and higher Hemoglobin A1C Average blood glucose levels over previous 2-3 mos Level of 6.5% or higher is considered diagnostic

List risk factors and treatments associated with complicated UTIs

Female and male patients with structural or functional abnormality of urinary tract Prostatic hyperplasia, renal calculi, nephrocalcinosis, renal or bladder tumors, ureteric stricture, or indwelling catheter Obtain C&S before treatment Treatment: broad spectrum abx x 7-14 days

Excess PRL secretion

Females: amenorrhea, galactorrhea (excessive milk flow), infertility, possible delay of puberty Males: reduced libido and potency, galactorrhea, possible delay of puberty

Signs and symptoms of acute pyelonephritis

Fever Chills Flank pain Urinary frequency Urgency Pyuria Bacteremia

Methimazole (Tapazole)

First line drug Blocks synthesis of thyroid hormones Most dangerous side effect: agranulocytosis Avoid use in first trimester of pregnancy Must monitor TSH

Wet beriberi

Fluid accumulation in the legs CV complications (palpitations, ECG abnormalities, high-output heart failure) May progress to circulatory collapse and death With treatment: recovery dramatic with replacement therapy

Insulin resistance

For a given blood insulin level, cells in these tissues are less able to take up and metabolize the glucose available to them Insulin resistance appears to result from 3 causes: reduced binding of insulin to receptors, reduced receptor numbers, and reduced receptor responsiveness Drugs like GLITAZONES can be given to reduce insulin resistance

List the three classes of steroids produced by the adrenal cortex

Glucocorticoids Mineralocorticoids Androgens

IM medroxyprogesterone acetate (Depo-provera)

Good choice when adherence is a problem Active for 3 mos and is one of the most effective contraceptives available Prevents pregnancy mainly by suppressing ovulation Also thickens cervical mucus and alters the endometrium such that implantation is discouraged Adverse effects: menstrual irregularities, bone loss

Etonogestrel subdermal implants (Nexplanon)

Good choice when adherence is a problem Active for 3 years and are among the most effective contraceptives available Nexplanon has the same mechanism as progestin-only pills: production of thick, sticky mucus and involution of the endometrium Adverse effect: irregular bleeding

IUDs

Good choice when adherence is a problem Among the most reliable forms of reversible birth control Examples: Copper T 380A [ParaGard], Levonorgestrel-releasing intrauterine system [Mirena] Placed within 7 days of onset of menses Replacement can be inserted during any phase of the menstrual cycle ParaGard can remain in place for 10 years Mirena can remain in place for 5 years

Risks associated with hormone therapy

Greater than previously believed → HRT use has declined sharply Some risks include: CV events: MI, stroke, pulmonary embolism, DVT Endometrial cancer Breast cancer Ovarian cancer Gallbladder disease Dementia Urinary incontinence

Identify the hormones produced and released by the ANTERIOR PITUITARY

Growth hormone Adrenocorticotropic hormone Thyroid stimulating hormone Follicle stimulating hormone Luteinizing hormone Prolactin

Amoxicillin for PUD

H. pylori is highly sensitive to amox Rate of resistance low Kills bacteria by disrupting cell wall Antibacterial activity is highest at a neutral pH and thus can be enhanced by reducing gastric acidity with an antisecretory agent Most common side effect: diarrhea

Cimetidine (Tagamet)

H2 blocker for PUD Adverse effects: antiandrogenic effects, CNS effects, PNA, IV bolus can cause hypotension and dysrhythmias Drug interactions: warfarin, phenytoin, theophylline, lidocaine, antacids can reduce absorption of cimetidine (give at least 1 hour apart from antacids)

Ranitidine (Zantac)

H2 blocker for PUD More potent, fewer adverse effects and drug interactions Adverse effects: does not bind to androgen receptors, elevation of gastric pH may increase risk of PNA Actions of famotidine and nizatidine are very similar

What type of drugs are used for treatment of NSAID-induced ulcers?

H2 receptor blockers and PPIs

Adverse effects of prokinetic agents

High-dose therapy: sedation, diarrhea common Long-term high-dose therapy: can cause irreversible tardive dyskinesia

darifenacin (Enablex)

Highly M3 selective drug Expensive Minimal side effects

State the role of H2 blockers in the management of PUD.

Histamine2-receptor Antagonists are first choice drugs for treating gastric and duodenal ulcers Promote healing by suppressing secretion of gastric acid All agents (cimetidine, ranitidine, famotidine, nizatidine) are equally effective

Therapeutic uses for estrogen

Hormone therapy after menopause Female hypogonadism Acne

Immunomodulators for IBD

Infliximab Moderate to severe Crohn's Major adverse effects: infusion reactions and opportunistic infections

Tetracycline for PUD

Inhibitor of bacterial protein synthesis Highly active against H. pylori Resistance is rare Do NOT use in PREGNANT patients and YOUNG CHILDREN because it can stain teeth Not recommended below age 8

PDE-5 inhibitors and cytochrome p450 inhibitors

Inhibitors of cytochrome P450 can suppress metabolism of sildenafil

Treatment of diarrhea

Management: dx and treatment of underlying disease, replacement of lost water and salts, relief of cramping, reducing passage of unformed stools Two major groups of antidiarrheals: specific antidiarrheal drugs, and nonspecific antidiarrheal drugs (opioids, bismuth subsalicylate, bulk-forming agents, anticholinergic antispasmodics)

Two landmark studies r/t hormone therapy

Large, randomized, placebo-controlled trials Demonstrated that use of HT could increase, rather than prevent, cardiovascular events Women taking HT in the study had an increase in thromboembolic events such as DVT and stroke Based on the findings, everything is being re-evaluated, and some women in early menopause will still receive HT Women's Health Initiative Assessed the benefits of HT as primary prevention against heart disease and other disorders in healthy postmenopausal women Heart and Estrogen/Progestin Replacement Study and its follow up (HERS and HERS II) Assessed the benefits of HT as secondary prevention in women with established coronary heart disease

Thyroid hormone products

Levothyroxine (Synthroid) Synthetic preparation of T4 identical to the naturally occurring hormone Drug of choice for most patients requiring thyroid hormone replacement Liothyronine (Cytomel, Triostat) Synthetic preparation of T3 identical to the naturally occurring hormone Liotrix (Thyrolar) Synthetic T4 plus a synthetic T3 in a 4:1 fixed ratio Thyroid (Armour Thyroid, Nature-Throid, Thyroid USP) Dedicated animal thyroid glands Rarely used

Hyperthyroidism

Low TSH, High free T3/T4 Graves' Disease Low TSH, greater increase in T3 than T4 Graves' Disease signs/symptoms: rapid and strong heartbeat, possible dysrhythmias and angina, CNS stimulation → nervousness, insomnia, rapid thought flow, rapid speech; weak/atrophied skeletal muscles, increased metabolic rate, increased body temp, intolerance to heat, warm/moist skin, increased appetite, weight loss if caloric intake fails to match increase in metabolic rate All symptoms above are referred to as thyrotoxicosis Patients with Graves' disease also have exophthalmos Treatment: 1) surgical removal of thyroid tissue, 2) destruction of thyroid tissue with radioactive iodine 3) suppression of thyroid hormone synthesis with an antithyroid drug (methimazole or propylthiouracil) Radiation preferable for adults, antithyroid drugs preferred for younger patients Beta blockers and nonradioactive iodine may be used as adjunctive therapy Surgery or steroids for exophthalmos

List the indications and protocols for UTI prophylaxis

Low-dose nitrofurantoin (Macrodantin) PO at HS x6mos Low-dose trimethoprim PO at HS x6mos Low-dose TMP/SMX PO at HS x6mos

Describe the principal protozoal infections endemic to the United States and those seen in the United States because of world travel.

MALARIA: High fever, chills, profuse sweating Treatment : Moderate attack with chloroquine, Prophylaxis also with chloroquine Entamoeoba hystolytica,Trichomonas vaginalis and Giardia lamblia are most common organisms that cause protozoal infections outside of malaria Protozoal infections: amebiasis, cryptosporidiosis, giardiasis, leishmaniasis, toxoplasmosis, trichomoniasis

Missed doses of OCs

Missed dose with 28-day cycle schedule 1 or more pills missed in first week: take one pill ASAP and continue with pack, use additional form of contraception for 7 days 1-2 missed pills in 2nd or 3rd week: take one pill ASAP and continue with pack; skip placebo pills and go straight to new pack once all active pills have been taken. Use additional form of contraception for 7 days 3 or more missed pills 2nd or 3rd week: follow instructions given for missing 1-2 pills and also use additional form of contraception for 7 days Extended cycle and continuous schedules Up to 7 days can be missed with little or no increased risk of pregnancy, provided the pills have been taken continuously for the prior 3 weeks

Medications useful for the treatment of hyperthyroidism

Methimazole (Tapazole) Propylthiouracil (PTU) Radioactive Iodine (131I)

Antibiotics for IBD

Metronidazole Helpful with Crohn's, ineffective against UC

Clostridium difficile-associated diarrhea

Metronidazole, vancomycin Wash hands, wear gloves

Osmotic laxatives

Milk of mag (MOM) Laxative salts: poorly absorbed salts draw water into intestinal lumen, fecal mass softens and swells, peristalsis is stimulated Adverse effects: substantial water loss: dehydration, acute renal failure, sodium retention (exacerbated heart failure, HTN, edema)

Discuss the role of the certain antibacterial drugs used in PUD management.

Minimum of 2 abx to reduce risk of resistance, preferably 3 Clarithromycin-based triple therapy 1 Clarithromycin-based triple therapy 2 Bismuth-based quadruple therapy Sequential therapy Abx more effective when combined with a PPI or H2 receptor agonist (antisecretory agent) Eradication rates are good with 10-day course and better with 14-day

monophasic, biphasic, triphasic OCs

Monophasic: Even levels of estrogen and progestin provided through cycle days 1 to 21 Biphasic: Static level of estrogen with two different progestin rates that switch mid-cycle Triphasic: Varying estrogen and progestin levels through day 21 of the cycle

Goals of drug therapy for peptic ulcer disease

Most common cause of peptic ulcer disease is H. pylori, and #2 is NSAIDs 3 ways antiulcer drugs work: Eradicate H. pylori (abx) Reduce gastric acidity (antisecretory agents, misoprostol) Enhance mucosal defenses (sucralfate, misoprostol)

Mebendazole (Vermox)

Most common drug for helminthiasis tx Absorbed better with food Pinworms, roundworms, and hookworms

Rabeprazole (Aciphex)

Much like omeprazole and lansoprazole Uses: H. pylori eradication, duodenal ulcers, GERD, hypersecretory states (like Zollinger-Ellison syndrome) Action: reduces gastric acidity by inhibiting gastric H+, K+-ATPase

Vitamin A

Multiple functions in the eyes Deficiency: night blindness, xerophthalmia (dry, thickened condition of conjunctiva) and keratomalacia (degeneration of cornea with keratinization of corneal epithelium) Excess: birth defects, liver injury, bone abnormality Intake should not exceed 3000 mcg Food sources: carrots, papaya, meat, eggs, cheese, sweet potato, fish, broccoli, squash, mango, peppers, apricots, peaches, melon, avocado

Intermediate duration insulin

NPH insulin (Humalin N, Novalin N) Time course 60-120 min onset 6-14 hours for peak 16-24 hours for duration Prepared by conjugating regular insulin with protamine (a large protein), which decreases the solubility of NPH insulin and thus delays absorption CANNOT be given at mealtime to prevent postprandial hyperglycemia because of longer onset Given two or three times daily to provide glycemic control between meals and during the night This is the only longer-acting insulin suitable for mixing with short-acting insulins Subq injection only

Esomeprazole (Nexium)

Nearly identical to omeprazole Uses: erosive esophagitis, GERD, duodenal ulcers associated with H. pylori, prophylaxis of NSAID-induced ulcers Adverse effects: HA, nausea, flatulence, abd pain, dry mouth ,PNA, hypomag, osteoporosis, fractures

Dry beriberi

Neurologic and motor deficits No edema or CV symptoms Recovery slow

Substance P/ neurokinin1 antagonist

New class of drugs Example: aprepitant (Emend) Blocks neurokinin1-type receptors (for substance P) in the chemoreceptor trigger zone Prevents post-op nausea and chemo-induced N/V

Niacin

Nicotinic acid Vitamin B3 Both a vitamin and a drug When used as a drug (to reduce cholesterol levels), doses are much higher than when it is used to prevent or correct deficiency Adverse effects: vasodilation with flushing, dizziness, nausea Deficiency → pellagra Sources: vegetables, fruits, whole grains, dairy products, fish, beef, turkey, enriched grains, legumes, nuts, seeds

Cryptosporidiosis treatment

Nitazoxanide

Long course for community-acquired UTIs

Nitrofurantoin (Macrobid) Low concentrations: bacteriostatic High concentrations: bactericidal Uses: Lower UTIs, prophylaxis, recurrent lower UTIs BID x 7 days Adverse effects GI effects Pulmonary reactions (acute and subacute) Hematologic effects with G-6-PD deficiency Peripheral neuropathy Hepatotoxicity Birth defects

festerodine (Toviaz), tolerodine (Detrol) and trospium (Sanctura)

Non-selective drugs M3 blockers Inexpensive Greater side effects

Vaginal rings

NuvaRing One ring is inserted once each month, left in place for 3 weeks, then removed New ring is inserted 1 week later During the ring-free week, withdrawal bleeding occurs Most common adverse effects: vaginitis, HA, upper respiratory infection, leukorrhea, sinusitis, weight gain, nausea

Signs and symptoms of Cushing's syndrome

Obesity Hyperglycemia Lycosuria Hypertension Fluid and electrolyte disturbances

cimetidine and antacids together?

Ok, but administer 1 hour apart There was a question about being prescribed cimetidine and aluminum hydroxide (Maalox) and the answer was to wait an hour between them

Nonspecific antidiarrheal agents

Opioids Reduce intestinal motility, slow intestinal transit, allow more fluid to be absorbed, decrease secretion of fluid into small interesting and increase absorption of fluid and salt Most commonly used: diphenoxylate (Lomotil) and loperamide (Imodium)

Chlamydia: organism, symptoms

Organism: Chlamydia trachomatis Symptoms Can cause genital tract infections leading to PID and tubal damage resulting in ectopic pregnancy Can cause proctitis, conjunctivitis, LGV Ophthalmia, pneumonia in infants

Gonorrhea: organism, symptoms

Organism: Neisseria gonorrhoeae Symptoms May be asymptomatic in women In men: urethral burning with pus-like discharge

Pelvic inflammatory disease

Organism: Neisseria gonorrhoeae, Chlamydia trachomatis, or both Infection of uterus, fallopian tubes, and ovaries Symptoms: abdominal pain, vaginal discharge, fever Common drugs Ceftriaxone IM once WITH doxy PO BID x 14 days Inpatient: treated with IV abx

Syphilis

Organism: Treponema pallidum Symptoms Primary: chancre 1-4 weeks after exposure Secondary: 2-6 weeks after chancre heals; skin lesions, flu-like symptoms develop Tertiary: (5-40 YEARS after initial infection) almost any organ can be involved; infection of the brain common, heart valves, bones, joints, eyes Penicillin G remains drug of choice

Trichomoniasis

Organism: Trichomonas vaginalis Symptoms Men typically asymptomatic Women: green, frothy discharge Treatment: metronidazole

Nongonococcal urethritis

Organism: Ureaplasma urealyticum, Trichomonas vaginalis, and Mycoplasma urealyticum Common drugs Azithromycin or doxy If persistent, add metronidazole

Dexlansoprazole (Dexilant)

Reduces gastric acidity by inhibiting gastric H+, K+-ATPase Uses: tx and maintenance of healing of erosive esophagitis; treatment of symptomatic GERD Adverse effects: diarrhea, abd pain, nausea, vomiting, flatulence, URI, hypomag, osteoporosis, fractures

Define overactive bladder (OAB)

Overactive bladder = urgency incontinence 4 major symptoms: urinary urgency, urinary frequency, nocturia, and urge incontinence In most cases, urge incontinence results from involuntary contractions of the bladder detrusor (the smooth muscle component of the bladder wall), often referred to as detrusor instability or detrusor overactivity Don't confuse urge incontinence with stress incontinence, which is urinary leakage caused by activities that increase pressure within the abdominal cavity or overflow incontinence, which is the involuntary leakage of urine from an overly distended bladder

Identify the two hormones produced in the hypothalamus and released by the POSTERIOR PITUITARY

Oxytocin Antidiuretic hormone

What are the most effective drugs for suppressing secretion of gastric acid?

PPIs

What type of drug is used for prophylaxis of NSAID-induced ulcers?

PPIs

Treatment for thyroid storm

PTU or methimazole AND Lugol's solution, sodium iodide, propranolol, hydrocortisone

GH excess

Pediatric: gigantism (7-9 feet tall) Treatment: removal of pituitary gland Adults: acromegaly if epiphyses already closed Treatment: surgery, radiation or drugs

GH deficiency

Pediatric: short stature, slowed growth, mental function not impaired Treatment: replacement therapy with human GH Adults: reduced muscle mass

Short duration, slower acting insulin

Regular insulin (Humulin R, Novolin R) Time course 30-60 minutes for onset 1-5 hours for peak 6-10 hours for duration Administered via subq injection, insulin pump, IM injection, or IV Should be given before meals to control postprandial hyperglycemia

3 types of dopamine antagonists used as antiemetics

Phenothiazines Butyrophenones metoclopramide

Describe changes in drug therapy that may be required for pregnant women who are treated for type 1 or type 2 diabetes until delivery.

Placenta produces hormones that antagonize insulin's actions → increased need for insulin Production of cortisol (which promotes hyperglycemia) increases threefold during pregnancy → increased need for insulin Because glucose can pass freely from maternal circulation to fetal circulation, hyperglycemia in the mother will stimulate excessive secretion of insulin in the fetus → hyperinsulinism can have multiple adverse effects on fetus Metformin sometimes used in the setting of type 2 DM Women with type 2 DM who discontinue oral medications can resume oral therapy after delivery Gestational diabetes managed with diet and medication, blood glucose monitoring

Propylthiouracil (PTU)

Preferred in first trimester or pregnancy, then can switch to methimazole Most dangerous toxic effect: liver injury Must monitor TSH

oxybutynin (Dritropan, Oxytrol) and solifenacin (Vesicare) Less expensive

Primarily M3 selective drugs Minimal side effects

Indications of androgen therapy

Primary clinical application is management of androgen deficiency in males (only FDA-approved indication) Principal adverse effects are virilization and hepatotoxicity Also premature epiphyseal closure in children Contraindicated in pregnancy d/t risk for injury to the female fetus Therapeutic uses of androgens Male hypogonadism Replacement therapy Delayed puberty Breast cancer Replacement therapy in menopausal women Wasting in patients with AIDS Anemias

Function of prolactin

Produced by anterior pituitary Stimulates milk production after parturition Deficiency generally without symptoms except for disturbance of lactation Excess has lots of adverse effects

Oxytocin

Produced by hypothalamus, stored and released from posterior pit 2 roles: promotion of uterine contractions during labor and stimulation of milk EJECTION during breast-feeding

ADH roles

Promotes renal conservation of water Works on the collecting ducts of the kidney to increase their permeability to water Produced in the hypothalamus Released by the posterior pituitary

Describe the function of growth hormone (GH)

Promotion of growth (practically all organs and tissues) Promotion of protein synthesis Reduces glucose utilization, causing a tendency for plasma levels of glucose to rise

Bulk-forming laxatives

Psyllium (Metamucil) Function similarly to dietary fiber: swells with water to form a gel that softens and increases fecal mass Preferred temporary treatment of constipation Used for diverticulosis and IBS

Vitamin B6

Pyridoxine Coenzyme in the metabolism of amino acids and proteins Must be converted to active form: pyridoxal phosphate Deficiency → peripheral neuritis, seborrheic dermatitis, microcytic anemia, convulsions, depression, confusion Deficiency can result from inborn errors of metabolism Dietary deficiency is rare in US except in alcoholics Isoniazid (TB drug) prevents conversion of pyridoxine to its active form and can thereby induce pyridoxine deficiency Sources: fortified breakfast cereals, meat, fish, poultry, white potatoes, other starchy veggies, non-citrus fruits

Calcium carbonate (Tums)

Rapid acting High acid-neutralizing capacity Effects have long duration Acid rebound Principal adverse effect: constipation Combine with a magnesium-containing antacid to combat this Other adverse effects: eructation (belching), flatulence

Magnesium hydroxide (Milk of Magnesia)

Rapid acting High acid-neutralizing capacity Long-lasting effects Adverse effect: diarrhea Frequently used as a laxative Usually taken in combo with aluminum hydroxide Avoid in patients with undiagnosed abdominal pain Use in caution with renal failure

Amebiasis

Rare in US, seen in third-world Treatment: iodoquinol, paromomycin, metronidazole, tinidazole

Drugs that reduce levothyroxine absorption

Reduced absorption with food, histamine blockers, PPIs, sucralfate, cholestyramine, antacids, iron supplements, magnesium salts

Aluminum hydroxide (Mylanta, Maalox, Gaviscon)

Relatively low acid-neutralizing capacity Rarely used alone Widely used in combo with mag hydroxide Preparations contain significant amounts of sodium Drug interactions: tetracyclines, warfarin, digoxin May cause constipation

Benefits of menopausal hormone therapy

Relief of vasomotor symptoms Management of urogenital atrophy Prevention of osteoporosis and related fractures Cardioprotection Prevention of colorectal cancer Positive effect on wound healing Tooth retention Glycemic control

Describe the ways for treating recurrent UTIs

Repeat with 2-week course of therapy If treatment failure occurs, treat additional 4-6 weeks If treatment failure occurs, treat additional 6 mos

Provide a rationale for split dosing for therapy for Addison's disease

Replacement therapy should mimic normal patterns of corticosteroid secretion ⅔ in morning and ⅓ in afternoon Doses increased in times of stress

Treatment of Addison's Disease

Replacement therapy with adrenocorticoids Hydrocortisone is drug of choice Both glucocorticoid and mineralocorticoid

Vitamin K

Required for synthesis of prothrombin and other clotting factors Adverse effects: hypersensitivity reaction, hyperbilirubinemia in parenteral administration to newborns Deficiency: bleeding tendencies Severe deficiency: spontaneous hemorrhage Used to treat vitamin K deficiency and as an antidote for warfarin Sources: leafy greens, spinach, kiwi, prunes, avocado

Vitamin B2

Riboflavin Involved in numerous enzymatic reactions First must be changed to flavin adenine dinucleotide (FAD) or flavin mononucleotide (FMN) Can be used to treat migraine headaches

Progestin-only OCs

Safer because they lack estrogen Less effective and cause more menstrual irregularity Prevent pregnancy by causing production of thick, sticky mucus (which creates a barrier to migration of sperm) by suppressing endometrial growth (which discourages implantation) SAFE for use with BREASTFEEDING **Must be used continuously Adherence is very important as missing a scheduled dose by 3 hours constitutes a missed dose and requires a backup method More likely to cause breakthrough bleeding Great option for individual with CV issues, smokes or is older than 35 Transdermal patches Application: once weekly for 3 weeks, followed by 1 week off (to permit normal menstruation)

Describe the laboratory tests used for diagnosing and monitoring thyroid disease

Serum TSH is the most sensitive method for diagnosing hypothyroidism because anterior pit is really sensitive to changes in thyroid hormone levels Small reductions T3 and T4 can cause a dramatic rise in serum TSH Serum TSH can also be used to distinguish primary hypothyroidism from secondary hypothyroidism Primary: TSH is high Secondary: TSH is low, normal or high despite low levels of T3 and T4 Total T4 = bound plus free of free Free and T4 = only free; this is preferred T3 measurements can be free or total as well, and free is preferred

Insulin aspart (NovoLog)

Should be given 5-15 min before meals Administered subq injection or with an insulin pump Very similar to human insulin except position of one amino acid

Insulin glulisine (Apidra)

Should be given close to time of eating Administered subq injection or with an insulin pump Very similar to natural insulin except difference in 2 amino acids

Adverse effects of progestins

Teratogenic - esp in early pregnancy! Gynecologic effects (whatever that means) Breast cancer Remember: in combo with estrogen, there can be an increased risk of breast cancer in postmenopausal women Depression Breast tenderness

Describe signs and symptoms associated with acute prostatitis and list the drugs and treatment duration for acute prostatitis

Signs and symptoms: high fever, ,chills, malaise, myalgia, localized pain, dysuria, nocturia, urinary urgency, urinary frequency, urinary retention Mild: treat with PO ciprofloxacin x 2-4 weeks Severe: IV ciprofloxacin followed by 2-4 weeks of PO abx

Thyroid storm

Signs: profound hyperthermia, severe tachycardia, restlessness, agitation and tremor; laterL unconsciousness, coma, hypotension, heart failure Life-threatening and requires immediate treatment

Pantoprazole (Protonix)

Similar to other PPIs Treatment of GERD and hypersecretory states Adverse effects: diarrhea, nausea, dyspepsia, HA, dizziness, hypomag, osteoporosis, fractures

Ultra-long duration insulin

Subq injection once daily U-300 insulin glargine (Toujeo) Onset 360 min, no peak, >24h duration Insulin degludec (Tresiba) Onset 30-90 min, no peak, >24h duration

5-aminosalicylates for IBD

Sulfasalazine Reduces inflammation Mild to moderate UC Adverse effects: nausea, fever, rash, arthralgia, hematologic disorders

Prokinetic agents

Suppress emesis and increase upper GI motility Example: metoclopramide (Reglan) Blocks receptors for dopamine and serotonin in the CTZ Therapeutic uses PO: diabetic gastroparesis and suppression of GERD IV: suppression of post-op nausea and vomiting, suppression of CINV, facilitation of small bowel intubation, facilitation of radiologic exam of GI tract

Clarithromycin (Biaxin) for PUD

Suppresses growth of H. pylori by inhibiting protein synthesis Resistance is rising Side effects: nausea, diarrhea, distortion of taste

Treatment of hyperprolactinemia

Suppression of prolactin release with dopamine agonists Two agents: cabergoline (Dostinex) and bromocriptine (Parlodel) These drugs bind with dopamine receptors in the pituitary and thereby exhibit the same inhibitory influence on prolactin release as does dopamine released from the hypothalamus Cabergoline is generally preferred because it's better tolerated and dosing is more convenient

Herpes Simplex Virus

Symptoms Primary infection: great pain, high fever, multiple vesicular lesions and ulcers Secondary: less painful, fewer lesions, slight fever Treatment: valacyclovir, famciclovir

Wernicke-Korsakoff syndrome

Symptoms = confusion, loss of mental activity, vision changes, can lead to coma/death

acute pyelonephritis treatment

TMP/SMX BID x14 days Ciprofloxacin BID x 7-14 days Levofloxacin QD x 5-10 days Longer treatment is generally more effective than shorter treatment

Selective estrogen receptor modulator (SERM):

Tamoxifen (Nolvadex) Activates estrogen Breast cancer treatment: inhibits cell growth in breast Protects against osteoporosis Produces hot flashes Increases risk for endometrial cancer and thromboembolism Another SERM is raloxifene (Evista) Very similar to tamoxifen, but it doesn't activate estrogen receptors in the endometrium Big difference: it does not carry a risk of uterine cancer

Bacterial vaginosis

Technically not an STI Symptoms: malodorous (fishy-smelling) discharge, clue cells Caused by multiple organisms Common drugs Non-pregnant women: metronidazole PO BID x 7 days (must avoid alcohol) or 2% clindamycin cream at HS x 7 days Pregnant women: metronidazole PO BID x 7 days or clindamycin PO BID x 7 days

Describe the ACTH stimulation and dexamethasone suppression tests and discuss their indications

Testing of adrenocortical function Cosyntropin = Synthetic analog of ACTH Acts to stimulate synthesis and secretion of cortisol and other adrenal glucocorticoids ACTH is used primarily for diagnostic test: Plasma cortisol is measured Patient is given 250-mcg dose IM or IV Plasma cortisol is measured again 30-60 min after injection If cortisol level RISES above 20 mcg/dL, adrenal response is NORMAL and primary adrenal insufficiency can be rules out If cortisol level doesn't rise significantly, a diagnosis of primary adrenal insufficiency can be made

Misoprostol (Cytotec)

Therapeutic uses: only approved GI indication is prevention of gastric ulcers caused by long-term NSAID therapy Adverse effects: dose-related diarrhea, abd pain, contraindicated during pregnancy (category X)

PPIs: therapeutic uses and adverse effects

Therapeutic uses: short term tx of gastric/duodenal ulcers, GERD Adverse effects: fracture, increased risk of pneumonia, possible intestinal infection with C. difficile, rebound acid hypersecretion

Alpha 1a-blockers/5-alpha-reductase inhibitors

These drugs can be harmful to a male fetus -- should not be handled by a pregnant woman or a woman who plans to become pregnant 5-alpha-reductase inhibitors prevent conversion of testosterone to DHT Example: finasteride (Proscar) Most effective in patients with a very large prostate (mechanical obstruction) Also sold at lower dosages as Propecia for male-pattern baldness Adverse effects: decreases ejaculate volume and libido, gynecomastia, decreases levels of PSA

Vitamin B1

Thiamine Coenzyme for carbohydrate metabolism Requirements increased slightly during pregnancy and breastfeeding Severe deficiency → beriberi In US, occurs most often in people with chronic alcohol consumption -- manifests as Wernicke-Korsakoff syndrome rather than beriberi

Describe the changes in thyroid dosing during and after pregnancy

Thyroid binding globulin increases throughout pregnancy Therefore free T4 increases Levothyroxine (Synthroid) dosage must be increased incrementally Following delivery, TBG will return to pre-pregnancy levels Synthroid dose must be decreased Follow TSH every month

General recommendations re: hormone therapy

To balance benefits and risks, an individual risk profile should be compiled for every woman considering HT. All candidates should be informed of known risks. Women with multiple risk factors should consider alternative therapies. For most women, the benefits of long-term HT for disease prevention do not outweigh the risks, and hence long-term HT should be avoided. Conversely, the benefits of short-term therapy (less than 5 years) to treat menopausal symptoms often do justify the risks. To keep risk as low as possible, HT should be used in the lowest dosage and for the shortest time needed to accomplish treatment goals.

Thyroid hormones

Triiodothyronine (T3) = the active hormone Synthetic: liothyronine Thyroxine (T4) = precursor to triiodothyronine Synthetic: levothyroxine

Important concepts of hormone replacement therapy in menopause

Two regimens: estrogen monotherapy and estrogen + progestin The purpose of estrogen in both regimens is to control menopausal symptoms by replacing estrogen that was lost due to menopause Progestin is present ONLY to counterbalance estrogen-mediated stimulation of the endometrium (which can lead to endometrial hyperplasia and cancer) For women who have had a hysterectomy, the progestin is unnecessary!

Long duration insulin

U-100 insulin glargine (Lantus) and insulin detemir (Levemir) Subq injection twice daily at the same time each day Onset: 60-120 min, no peak, 18-24 hour duration

Gonorrhea treatment

Urethral, cervical and rectal infection Single dose of IM ceftriaxone If allergic, single 2 gram dose of azithromycin Pharyngeal infection Single dose of IM ceftriaxone Single 1 gram dose of azithromycin Conjunctivitis Single 1 gram dose of IM ceftriaxone Wash eye with normal saline once Disseminated gonococcal infection without endocarditis or meningitis: ceftriaxone IM or IV daily for 2 weeks Disseminated gonococcal infection with endocarditis or meningitis: ceftriaxone IM or IV q12h x 2 weeks Neonatal infection: prophylaxis with 0.5% erythromycin ointment Ceftriaxone single dose -- can cause blindness if not treated

Drugs that may cause significant adverse events when used with muscarinic blockers

Use very cautiously or not at all with antihistamines, tricyclic antidepressants, phenothiazine, antipsychotics

Radioactive iodine

Used in.. Graves' Disease to destroy thyroid tissue Thyroid cancer to destroy malignant thyroid cells Diagnostic use: can reveal the extent of thyroid activity Not recommended Contraindicated in pregnancy and lactation Not used in young children

GnRH

Used to treat prostate cancer and endometriosis and to induce ovulation CRH used to diagnose adrenal disorders Somatostatin used to treat acromegaly

Sodium bicarbonate

Useful for treating acidosis and for elevating urinary pH to promote excretion of acidic drugs after overdose Inappropriate for treating PUD Brief duration, high sodium content, can cause alkalosis Can exacerbate HTN and heart failure Can cause systemic alkalosis in patients with renal impairment

Giardiasis

Usually in upper small intestine Infestation by contact with contaminated objects or from drinking contaminated water Bloody diarrhea is common Treatment: metronidazole, tinidazole, nitazoxanide

Trichomoniasis (in antiprotozoal chapter)

Vaginitis in women, urethritis in men Usually transmitted by sexual contact Contaminated objects also infectious Treatment: metronidazole (drug of choice), tinadazole (tolerated better but more expensive)

Metronidazole (Flagyl) for PUD

Very effective against sensitive strains of H. pylori Over 40% of strains now resistant Avoid alcohol (disulfiram-like reaction) Avoid in pregnancy

Lansoprazole (Prevacid)

Very similar to omeprazole Adverse effects: diarrhea, abd pain, nausea, PNA, hypomag, osteoporosis, fx

Folic acid

Vitamin B9 Essential factor in synthesis of DNA Deficiency → megaloblastic "pernicious" anemia Deficiency in early pregnancy can cause neural tube defects All women with potential for becoming pregnant should consume 400-800mcg of supplemental folic acid every day Excess: high doses (more than 800mcg/day) associated with increased risk for certain cancers and should be discouraged Food folate vs. synthetic folate Synthetic form more stable FDA ordered synthetic folate to be added to all enriched grain products Foods high in folate: fortified bread, cereals, and rice; beans, OJ, spinach

Pyrantel pamoate (Pin-X)

With or without food, must be thoroughly chewed Pinworms, hookworms

Symptoms of menopause result from:

a decline in ovarian production of estrogen

Adverse effects of high-dose hydrocortisone therapy:

adrenal suppression, Cushing's syndrome Cushing's syndrome = hyperglycemia, glycosuria, fluid and electrolyte disturbances, osteoporosis, muscle weakness, cutaneous striations, and lowered resistance to infection Redistribution of fat to abdomen, face and posterior neck produces characteristic potbelly, moon face, and buffalo hump

What drug would you give to a woman with severe IBS that has lasted >6 mos that hasn't been responsive to other treatments?

alosetron (Lotronex)

Vitamin E (aka)

alpha-tocopherol

side effects of aluminum therapy and mag therapy

aluminum = constipation magnesium = diarrhea

Antacid families

aluminum compounds mag compounds calcium compounds sodium compounds

The menstrual cycle is regulated by

anterior pituitary hormones, FSH and LH

Drug of choice for nausea during pregnancy?

doxylamine (Unisom) + vitamin B6

In menstrual cycle, uterine changes are brought about under the influence of

estrogens and progesterone