6020 all

Herpes Zoster: shingrix

Live attenuated For healthy 50 yo or older, 2x doses Contraindicated: -immunocompromised -pregnancy -age younger than 50 yrs Drug interactions -high-dose steroids -antivirals

FDA BBW for all antidepressants

Suicidality

Macrolides other info

Potential DDIs w/ some other common drugs High resistance in some areas

Nitrofurantoin

Potential adverse effect of pulmonary toxicity such as pulmonary fibrosis

How drug absorption works

Pass via plasma and cell membrane -active or passive transport -depends on the absorbing surface

Nicotine Replacement Products

Patch Gum Nasal Spray Inhaler Lozenge

HMG CoA reductase inhibitors/ Statins

*Primarily ↓ LDL, effects on TG and HDL less pronounced Exemplars -Lovastatin, Pravastatin, Simvastatin, Fluvastatin, Atorvastatin, Rosuvastatin ***Avoid*** -Pregnancy or planning pregnancy -Active liver disease

Guttate psoriasis

"Little drops"

Older adults (DM)

"Start low and go slow" is a good principle to follow when starting any new medications in this population A1c goals often more relaxed - Avoidance of hypoglycemia high priority Groups at higher risk: - polypharmacy, functional disabilities, cognitive impairment, high fall risk Safety - Be cautious with medication dosing - Consider drug‐drug interactions - Remember considerations with renal function

H. Pylori tx

"Triple therapies": PPI plus 2 antibiotics - Clarithromycin, amoxicillin and tetracycline Effective and well tolerated first-line regimens. Alternatives: high-dose, prolonged dual regimen with a PPI and amoxicillin or quadruple therapy consisting of a PPI, bismuth subsalicylate (BSS), tetracycline, and metronidazole. Bismuth in bismuth subsalicylate (BSS) exerts microbicidal activity against H. pylori. -SE: tongue and stool black and can cause tinnitus. PPI + clarithromycin (Biaxin®) + either amoxicillin or metronidazole - Prevpac® costing ~$290 BSS + metronidazole + tetracycline - Helidac® costing ~$30. Biskalcitrate (a bismuth type agent) + metronidazole + tetracycline - Pylera®. 2 weeks - duration of therapy 90% effective

Inactivated vaccine principles

"killed virus" May be coadministered w/ other vaccines No need to restart series if pt gets off schedule (use catch-up schedule)

Sulfonamides avoid

"sulfa" allergy (due to sulfamthoxazole component); consider potential cross-sensitivity w/ non-antimicrobial sulfonamides During certain stages of pregnancy

Non-FDA approved alternatives (smoking)

(May have some benefit over placebo in RCT's) Nortriptyline Clonidine *SSRI's lack any evidence of efficacy Acupuncture Hypnosis Financial Incentives

Evidence Based Guidelines for Smoking

(US Dept. HHS/Public Health Service Guidelines) Aggressively motivate patients to quit Identify and assess tobacco use status Assess readiness to change -Theoretical stages of change Set quit date Multifaceted approach -Pharm and behavioral therapy/changes

Baseline BP 20/10 mmHg or more above goal

*ACE (or ARB) + long-acting dihydro CCB* OR ACE (or ARB) + thiazide diuretic

Niacin AE

*Common AE: Flushing -Aspirin given 30 minutes before niacin dose may prevent or reduce flushing Other potential ADRs -pruritus, headache, fatigue, GI -Hepatotoxicity (risk may outweigh any lipid benefit) -Impaired glucose control -Increase uric acid concentrations (gout) Caution for possible interactions in combination with other lipid therapies -Statins, fibrates: increases risk of hepatotoxicity and/or myalgias

Pregnancy & hypothyroidism

*Early/constant euthyroid status very important!!! Levothyroxine is used during pregnancy. A specialist can manage- there are some differences in treating pregnant women Approximately 75 to 85 percent of women with preexisting hypothyroidism need a higher dose of T4 during pregnancy to maintain normal TSH secretion. There are trimester-specific reference ranges for TSH during pregnancy. The TSH can be measured sooner during pregnancy, such as 4 weeks after any change and at least once a trimester. When the dose is increased in pregnancy, the dose should be reduced to the prepregnancy maintenance dose postpartum.

Topical corticosteroid potency

*For the same medication, ointment potency > cream > lotions

ARB

*No bradykinin-mediated cough like ACEI Considered alternative if intolerant of ACEi or becomes resistant Generics now available for some -Cost of generic ACE inhibitors advantage over branded ARBs Many combined with thiazide diuretic (HCTZ) -**Do not combine ARB with ACEI

MME opioids

*Use caution when prescribing opioids at any dosage and prescribe the lowest effective dose. Use extra precautions when increasing to ≥50 MME per day* such as: -Monitor and assess pain and function more frequently -Discuss reducing dose or tapering and discontinuing opioids if benefits do not outweigh harms -Consider offering naloxone Avoid or carefully justify increasing dosage to ≥90 MME/day.*

HTN Urgency ED

*Usually to ED* The patient with severe HTN, even if asymptomatic, is usually managed in the ED since: -exclusion of acute end-organ damage requires laboratory testing -and administration of meds and observation can take several hours Some tx that may be considered for adults with severe HTN: -nifedipine (dihydro-CCB), captopril (ACEi), clonidine (centrally-acting agent), hydralazine (vasodilator)

K-sparing Diuretics AE

*hyperkalemia, hyperuricemia Monitor: -Cr/eGFR; -electrolytes (esp potassium), -BP

Nodulocystic

+ inflamed nodules/cysts

Papulopustular

+ pustules

Papular

+ red inflamed papules

Metformin MOA

- *Decreases hepatic glucose production - Improves insulin sensitivity ---increases peripheral glucose uptake and utilization

TZD MOA

- *Increase insulin receptor sensitivity - Decreases hepatic glucose production - Enhance glucose uptake in muscle cells

T1DM med

- Insulin

SGLT2 benefits

- Low hypoglycemia risk - Weight loss - Mild BP reduction - Demonstrated efficacy in CV event risk reduction when added to standard care - Benefit in diabetic kidney disease with albuminuria - Benefit in heart failure, HFrEF

T2DM med

- Oral medications - Non‐insulin injectables - Insulin

Metformin benefits

- Works well/good A1c lowering - Favorable effect on serum lipids - Usually mild weight loss - Does not cause hypoglycemia as monotherapy

Class I topical steroid potency

-Betamethasone diproprionate (Diprolene) -clobetasol propionate (Temovate) Never on Face or Skin folds

The highest risk for non-adherence are pts w/...

-Complex regimens -Asymptomatic diseases such as HTN -Cognitive impairment -Psychiatric illness Higher risk -Chronic conditions (especially > 3) -Multiple providers -Recent hospital discharge

Class II topical steroid potency

-Flucinoninde (Lidex) -Amcinonide (Cyclocort) Never on Face or Skin folds

IM injections

-HIB -HepA -HepB -HPV -Influenza -Meningococcal -PCV13 -PPSV23 (also SQ) -Polio (also SQ) -Tetanus/tetanus booster

Class VII steroid potency

-Hydrocortisone -safe on the face & skin folds

Class III topical steroid potency

-Triamcinolone acetonide (aristocort) -Amcinonide (Cyclocort) -Halcinonide (Halog) Never on Face or Skin folds

Intestinal flora modifiers

1) Lactinex 2) Bacid 3) "Probiotics" such as Probiotica -Several mechanisms of action have been proposed to explain how probiotics could have beneficial effects. Acetic, lactic and propionic acid produced by Lactobacillus can lower intestinal pH and inhibit growth of pathogenic bacteria such as Escherichia coli and Clostridium.

Digestion aid

1). pancrelipase (Pancrease, Cotazym, Ku-Zyme, Viokase, Creon, Ultrace) - Used in several digestive disorders related to pancreatic insufficiency of lipase, such as steatorrhea, to breakdown fat. - May also be used for cystic fibrosis and to unclog feeding tubes. 2). lactase (Lactaid, Dairy Ease, Lactase) - For lactose intolerance 3). alpha-galactosidase (Beano®) - to aid digestion of carbohydrates to reduce gas

Basic Pharmacokinetic Process

1. Absorption 2. Distribution 3. Metabolism 4. Elimination

FDA & dietary supplements

1. Ensure safety 2. Maintain product integrity 3. Facilitate informed decision-making

Improve Adherence HF

1. Look for opportunities to facilitate adherence 2. Consider the patient's perspective -Start with the goals of therapy (feeling better and living longer) and then discuss how specific actions (medication initiation, intensification, monitoring, and adherence) support those goals -Ask patient how they learn best and provide education accordingly 3. Simplify medication regimens whenever possible 4. Consider costs and access 5. Communicate with other clinicians involved in care 6. Educate using practical, patient-friendly information -Provide a written explanation of the purpose of each med prescribed -Pharmacist visits can also help with complex medication regimens -Use the "teach back" principle to reinforce education 7. Recommend tools that support adherence in real time (pill boxes, alarms, apps) 8. Consider behavioral supports (such as motivational interviewing) 9. Anticipate problems -Communicate common side effects -Provide instructions on when to call for refills or problems 10. Monitor adherence and target patients at risk -Ask patients directly (e.g., "How many times in a week do you miss taking your medications?" "Have you run out of your medications recently?")

Thiazide Diuretics

1st line HTN option Commonly combined with other antihypertensives A thiazide may have additional benefit in osteoporosis; may be avoided with gout Chlorthalidone and indapamide (thiazide-like), longer-acting, significantly more potent than HCTZ Other: Metolazone: more commonly used in HF-associated edema than HTN Exemplars: Hydrochlorothiazide (HCTZ), chlorthalidone, indapamide

Select ACE Inhibitors ("pril")

1st line HTN option Lisinopril (very commonly used) Benazepril Captopril (is short-acting) Enalapril Fosinopril Ramipril Quinapril

CCBs

1st line HTN option Two major classes -Dihydropyridines (used more often for HTN) -Nondihydropyridines Typically very effective for those of black ethnicities, older adults May also be used for angina Dihydropyridine CCB may also be better option for patient with Asthma or COPD

2 groups of stimulants

1. Methylphenidate 2. Drugs containing amphetamine Note: Both appear to be equally effective and have similar adverse effect profiles

2 groups of complementary approaches

1. Mind & body 2. Natural products

3 Phases of Drug Action

1. Pharmaceutical phase 2. Pharmacokinetic phase 3. Pharmacodynamic phase

Schema for advising pts about herbal products

1. Quality 2. Efficacy 3. Safety

Use of Empowering Language (diabetes)

1. Use language that is neutral, nonjudgmental, and based on facts, actions, or physiology/biology; 2. Use language that is free from stigma; 3. Use language that is strength based, respectful, and inclusive and that imparts hope; 4. Use language that fosters collaboration between patients and providers; 5. Use language that is person centered (e.g., "person with diabetes" is preferred over "diabetic").

7 tips for Clinicians for Health Literacy

1. Use plain language 2. Limit information (3-5 key points) 3. Be specific and concrete, not general 4. Demonstrate, draw pictures, use models 5. Repeat/summerize 6. Teach-back (confirm understanding) 7. Be positive, hopeful, empowering

HIV life cycle

1. binding 2. fusion 3. reverse transcription 4. integration 5. replication 6. assembly 7. budding

Assessment of COPD

1. spirometrically confirmed diagnosis -Post bronchodilator (FEV1/FVC < 0.7) 2. Assessment of airflow limitation -GOLD 1 (>80) -GOLD 2 (50-79) -GOLD 3 (30-49) -GOLD 4 (<30) 3. Assessment of sx/Risk of exacerbations

TB

10 million people infected and 1.5 million deaths worldwide in 2018 attributed to TB -One‐third of the world population is infected. Resistance is a growing problem. -Acquired resistance to TB medications stems from inadequate or inappropriate prescribed treatment regimens or from patient noncompliance. -Multidrug‐resistant TB is becoming more of a problem.

Anxiety common drugs

11. Gabapentin (Neurontin) 14. Sertraline (Zoloft) 20. Escitalopram (Lexapro) 21. Alprazolam (Xanax) 23. Bupropion (Wellbutrin) 26. Citalopram (Celexa) 30. Trazadone • 31. Fluoxetine (Prozac) 34. Clonazepam (Klonopin) 46. Duloxetine (Cymbalta) 49. Venlafaxine (Effexor) 50. Zolpidem (Ambien) (60. Lorazepam)

INGC bioavailability

1st gen -Beclomethasone -Flunisolide -Triamcinolone -Budesodine -(10-50% bioavailability) 2nd gen -Fluticasone propionate (<2%) -mometasone furoate (undetectable) -fluticasone furoate (<1%) Total bioavailability (oral & nasal) of 2nd gen is lower -what does this mean?? ---Lower risk of systemic effects

Antihistamine potential AE

1st gen much > than 2nd gen Anticholinergic -dry mough, eyes (1st or 2nd gen) -impotence -urinary hesitancy -glaucoma -constipation CNS (>20% occurence) -sedation (most common, esp. 1st gen, some 2nd gen) -Paradoxical stimulation (usually children, 1st gen) -dizziness, confusion , falls (older pts, 1st gen) -cognitive impairment (rare- hallucination, psychosis; most 1st gen) Misc -weight gain

Smoking cessation order of therapy

1st line -NRT or -Chantix or -Xyban 2nd line (combo) -Patch + Gum -or- Patch + Nasal Spray -or- -Patch + Zyban 3rd line (only for people who fail 1st and 2nd line) -Clonidine, notriptyline

ARB (Angiotensin II Receptor Blockers)

1st line HTN option "sartan" Losartan (commonly used) Valsartan Irbesartan Olmesartan Telmisartan

Duloxetine (Cymbalta)

A selective serotonin and norepinephrine reuptake inhibitor with CNS activity. Has the largest evidence base to support analgesic efficacy FDA approved for: diabetic neuropathy, fibromyalgia, chronic low back pain, OA (in addition to depression and anxiety)

HIV combination therapy

2 NRTIs (backbone therapy) + a 3rd agent (either INSTI, NNRTI, or PI) + A "boosting" agent may also be added

Sulfonylureas

2nd line option • Oldest class of oral hypoglycemic agents 2nd generation preferred -Glimepiride -Glipizide (shortest‐acting) -Glyburide One of the most commonly prescribed (and one of the least expensive options)

Sulfonamide allergy & potential cross-sensitivity

2ndmost frequent cause of allergic drug reactions, after the beta-lactams (penicillinsand cephalosporins)

Physiologic changes during pregnancy and their impact on drug disposition and dosing

3rd trimester-renal blood flow doubled and renal excretion accelerated (lithium) Increased hepatic metabolism (phenytoin) Tone and mobility of bowel decrease -Prolonged transit-increase in absorption

SQ injections

45 degree angle muscles to inject: -anterolateral thigh -upper outer Tricpe area -upper buttock -abdomen (avoiding 2" radius around umbillicus Needle size: 23-25G, 5/8" needle -MMR -PPSV23 (also IM) -Polio (also IM) -varicella -Zoster (shingles)

Nonadherence is complex

5 interacting dimensions of adherence 1. Healthcare system/team factors 2. Pt related factors -physical factors -psychological factors 3. Therapy related factors 4. Condition-related factors 5. Social and economic factors One or more dimensions may contribute to a pt's medication non-adherence Many factors are not exclusive to one dimension and may overlap

Acute Bronchitis

95% of acute bronchitis caused by viral infections Supportive therapy - increase fluids, analgesics/antipyretics Cough suppressants -controversy regarding efficacy, codeine preparations discouraged SABA -no evidence supporting improvement in cough, may be useful for pts with wheezing/history of airway obstruction OTC combinations -evidence variable regarding effectiveness of OTC drugs with guaifenesin, antihistamine/decongestants Antibiotics -Not recommended!!! Should only be considered for at risk patients (heart, lung, liver, renal disease, immunosuppression, frailty)

First-order elimination

A constant proportion of the drug is eliminated per unit of time. Each half-life 50% of the drug is eliminated

Log dose-effect curve

A graph of the relationship between dose of a drug and the response

Romosozumab

A monoclonal anti-sclerostin antibody Newer anabolic agent approved for treatment of osteoporosis in postmenopausal women at high risk for fracture. At this time, not considered as initial therapy for most patients, may be considered for severe or high-risk cases or no other options appropriate? Careful patient selection for this drug, as it may increase the risk of MI, stroke and CV death Injected once monthly Induces a great BMD response, but max duration of therapy is one year; duration of use should be limited to 12 monthly doses.

e-cigs & vaporizers

A nicotine delivery device that mimics a real cigarette Has a battery that heats a cartridge which holds a liquid containing nicotine. Heated liquid is changed into a vapor which is inhaled. Flavors sometimes added. Very addictive. Liquid pod contains same amount of nicotine as 20 cigarettes. One pod can be consumed in less than an hour, causing nicotine toxicity. Contain fewer toxins than cigarettes (7,000) but still not safe

Graded dose-effect curve

A plot of the dose of the drug v. the intensity of the effect

Considerations for adults w/ ADHD

A systematic review and meta-analysis recommends preference for amphetamine over methylphenidate as initial therapy for adult patients (when appropriate). Another non-stimulant option: Bupropion (Wellbutrin) -Off-label -May be considered for adult with ADHD and comorbid depression

Which generation of antihistamines is preferred for the majority of pts?

A. 1st B. 2nd C. all have equivalent safety and efficacy profiles Answer: B

Which drug class is highly anticholinergic (which increases the AE profile)?

A. 1st gen antihistamine B. 2nd gen antihistamine C. Intranasal cortiocsteroid D. Intranasal cromolyn

The FDA recommends against use of OTC cold products for children under-------yrs of age

A. 6 B. 18 Answer: 6

Which is important pt education for use of intranasal glucocorticoids?

A. Always blow nose immediately after use B. Spray away from the nasal septum C. Spray toward the nasal septum Answer: B

Which is *NOT* a risk factor to consider when selecting antimicrobial therapy for outpt bacterial sinusitis?

A. Antibiotic therapy in the past 6 months B. Antibiotic therapy in the past month C. Daycare attendance D. Recent hospitalization

What can long-term use of topical pthalmic antihistamine/decongestant cause?

A. Antihistamine resistance B. Rebound red eye C. Severe eye pain D. Permanent vision loss Answer: B

Which drug has a caution due to its potential to cause dream abnormalities, insomnia, anxiety, depression, sucicidal thinking, & in rare cases, suicide. Therefore it is not recommended for pts w/ active, pre-existing anxiety, depression, or sx that suggests psychiatric disorders

A. Cetirizine (zyrtec) B. Cromolyn nasal (nasalcrom) C. Loratadine (Claritin) D. Montelukast (Singulair)

Which is thought to be somewhat more sedating than other 2nd gen antihistamines?

A. Cetirizine (zyrtec) B. Fexofenadine (Allegra) C. Loratadine (claritin) Answer: A

Which topical otic therapy is considered an ototoxic agent?

A. Ciprofloxacin/dexamethasone otic B. Neomycin/polymyxin B/Hydrocortisone otic Answer: B

You would be most concerned that new neuropsychiatric symptoms in a child, such as depression, aggression, or nightmares could possibly be related to...

A. Diphenhydramine (Benadryl) B. Loratadine (Claritin) C. Montelukkast (Singulair) Answer: C

Which medication can be attributed to development of rhinitis medicamentosa?

A. Fexofenadine (allegra) B. Oxymetazoline nasal (Afrin) C. Pseudoephedrine (sudafed) Answer: B

Which is a dietary supplement or herb that a pt may take for depression which has been associated w/ many drug-drug interactions

A. Glucosamine B. Echinacea C. Saw palmetto D. St. John's Wart Answer: D

Which would BEST treat nasal congestion in AR?

A. Intranasal glucocorticoid B. Nasal ipratropium bromide C. Nasal mast cell stabilizer D. Oral antihistamine Answer: A

A pt asks about use of guaifenesin (Mucinex) for a symptomatic relief of viral URI. The NP knows that it's important to educate the pt on the importance of...

A. Limiting fluid intake to reduce volume of secretions B. Always taking w/ an antihistamine for full effect C. Increasing fluid intake to ensure mobilization of secretions D. Increasing K to prevent myalgia Answer: C

Use Sanford guide to identify the best option for a first-line treatment for a 6yo w/ streptococcal pharyngitis. He is otherwise healthy, and has not allergies or recent abx use.

A. Penicillin V-K B. Azithromycin C. Doxycycline D. Levofloxacin Answer: A

Which oral decongestan's demonstrated efficacy is similar to placebo?

A. Phenylephrine B. Pseudoephedrine Answer: A

St. John's Wart x Clarithromycin =

A. clarithromycin will increase the lvl or effect of St. John's wort B. The dose of the St. John's wort should be doubled while taking clarithromycin C. St John's wort will decrease the lvl or effect of clarithromycin D. St John's wort will increase the lvl or effect of clarithromycin Answer: C.=

The compat methamphetamine epidemic act, which is part of the 2006 U.S.Patriot Act.

A. requires all providers to screen their pts for methamphetamine use @ every visit B. Restricts concurrent prescribing of amphetamines & cold products C. Restricts the sales of drugs that contain methamphetamine precursors, such as ephendrine, pseudoephedrine, and phenylpropanolamine, including a daily and 30-day limit on sale Answer: C

Which would you expect to be used for AR?

A. systemic cortiocosteoid B. Topical nasal corticosteroid C. Inhaled corticosteroid? C

ACEi indications

ACEI therapy (or ARB) are preferred for certain conditions (evidence for major improvement in outcome independent of BP): -Proteinuric CKD -HFrEF -Post-MI

Non-Emergent Pediatric HTN

ACEi or ARB (avoid if pregnancy risk) CCB Thiazide diuretic is an option -Ex: HCTZ, chlorthalidone -And no evidence of hyperglycemia, hyperlipidemia, or hyperuricemia -Also may be used as add-on therapy May consider: ACEi or ARB, CCB, thiazide -Note: not all drugs within these classes are approved for use in pediatrics Another 2nd /3rd line option- Beta blocker -Not recommended as initial therapy in children -Because of expanded AE (eg, impaired glucose tolerance and interference in lipid metabolism)

ADHD termination stage

ADHD symptoms may improve with time, but for many symptoms persist into adulthood. After several years of medication, it may be reasonable to offer children and adolescents who have had stable improvement in ADHD symptoms and target behaviors a trial off of medication with close monitoring to determine whether medication is still necessary.

Allylamine (antifungal) AE & monitoring

AE -AST, ALT elevations (rare cases of hepatic failure) -GI -photosensitivity Monitoring -Cr, LFT baseline

Systemic "azoles" (antifungal) AE and monitoring

AE -GI (abd pain/N/V/D) -photosensitivity -hepatoxicity -neg inotropic effects (black box warning in heart failure) Monitoring -see recommendation when prescribing

Metronidazole AE and warnings

AE -Generally well tolerated -metallic taste (pretty common) -GI (N/V/abd pain) Black box -carcinogenic in mice and rats (avoid unnecessary use) Avoid ETOH -during treatment and @ least 72 hrs post

Acetaminophen

AE -Hepatotoxicity -The risk of harm of acetaminophen is usually higher with increasing dose but may also occur at therapeutic doses, including: ---gastrointestinal bleeding ---liver toxicity ---renal failure ---cardiovascular disease Patients should be educated on the maximum safe dose due to potential liver toxicity. -Consider it is also a component of many OTC meds Total dosing of acetaminophen from all sources needs to be determined. -Max dose? ---Less than 3‐4 grams in 24 hours? ---Less than 2 g per day in frail patients, those > 80 years of age?

Systemic Corticosteroids AE

AE -anaphylaxis -adrenal insufficiency -Cushing syndrome -edema -hypokalemia Short-course "burst" treatment -Can be administered without tapering -Continued until peak expiratory rate is 80% or symptoms resolved

MMR adverse rxns & drug interactions

AE: fever 7-12 days after vaccine DI -immune globulin -high dose corticosteroids -chemotherapy

Diagnostic criteria for AIDS

AIDS-defining condition CD4 count <200

ART & pregnancy

ART given in pregnancy to reduce perinatal transmission

Sinus disease

AVRS= acute viral rhinosinusitis -consider bacterial if not improved (within 3 days children; 7 days adult) ABRS= acute bacterial rhinosinusitis Uncomplicated AVRS -General characteristics ---Symptom duration < 10 days ---Absence of high fever (102 F) -Supportive therapy is cornerstone of viral treatment

Insulin Admin

Absorption rate may vary among injection sites - Fastest in abdomen, slowest in leg, buttocks - Increased by exercise - Decreased by smoking Educate patients on proper technique - Periodically observe and look at injection sites

Acne Vulgaris oral agent tx

Abx Retinoid -isotretinoin) Spironolactone -uncommonly used Oral contraceptives (low progesterone) -Yasmin, Orthotricyclen -Only for adjunctive therapy

Acne Vulgaris oral agent tx

Abx Retinoid -isotretinoin) Spironolactone -uncommonly used Oral contraceptives (low progesterone) -Yasmin, Orthotricyclen -Only for adjunctive therapy

AGIs (term)

Acarbose (Precose)

AGIs (Alpha‐Glucosidase Inhibitors)

Acarbose (Precose); Miglitol (Glyset) Anticipated A1c reduction (0.5‐0.8%) *Primary adverse effect: GI - Cramping, flatus, diarrhea - Avoid cirrhosis, IBD, obstruction, malabsorption syndromes Not commonly used due to - Poorer tolerance - Frequent dosing (TID) - Less value (efficacy, cost) compared with alternatives

Drugs can affect bone metabolism

Accelerate Bone Loss: Chronic glucocorticoid use (defined as ≥ 5 mg prednisone for ≥ 3 months) Medroxyprogesterone acetate (depo provera) -Some experts recommend max 2 years; encourage recommended intake of calcium and vitamin D; evaluate BMD after 2 years of use Some cancer drugs Excess thyroid hormone And some other drugs have been also been implicated: TZDs, PPIs, anticonvulsants, SSRIs, some SGLT2 inhibitors, ART, loop diuretics, and more One class that can minimize bone loss: thiazide diuretic

Choosing btw Methylphenidate & Amphetamine stimulant

According to a study, although amphetamines may be slightly more efficacious, methylphenidate is usually better tolerated. A systematic review and meta-analysis recommends preference for methylphenidate over amphetamine as initial therapy for pediatric patients (when appropriate) At least ½ that don't respond to one will respond to the other type

Statins

According to literature, 4 Statin Benefit Groups -Secondary Prevention, ASCVD ---H/o MI, CVA/TIA, PAD, Angina -Primary prevention, age >21 years and LDL > 190 -Primary prevention, diabetes, age 40-75 years, LDL 70-189 -Primary prevention, age 40-75 years, LDL 70-189, estimated 10-year ASCVD risk of >7.5% Consider primary/secondary prevention ASDVD Risk Calculator/ Mobile App gives recommendations

Renal adjustment (abx)

Know where to find renal dosing info -Drug Prescribing Information -Epocrates -Sanford Guide Some common adjustment strategies: -Lower dose -Increase dosing interval

Mild Analgesics

Acetaminophen (typical first choice); NSAID is alternative Symptomatic treatment (myalgias, HA, sore throat, ear pain) -response within 60 min, peaks in 3-4 hrs Ped considerations -Avoid aspirin in < 21 yrs due to risk of Reyes syndrome Boxed warning for NSAIDs in CV dz -lowest effective dose for shortest duration Pregnancy -There is insufficient evidence regarding adverse effects of acetaminophen use, but acetaminophen is currently the pain reliever & antipyretic of choice during pregnancy when short-term drug therapy is indicated -There are potential risks with use of NSAIDs during pregnancy Educatate -Potential for overdose, esp in children

Types of Pain

Acute and Chronic Pain Nociceptive, Inflammatory, Neuropathic, Central

Tramadol (Ultram)

Acute pain Opiate analgesic (codeine analog) with weak mu‐receptor binding Inhibits serotonin and norepinephrine reuptake -Risk of serotonin syndrome when combined with other serotonergic agents Option for severe or refractory pain, usually short‐term Marketed as having low abuse and addiction potential -However, tolerance, withdrawal, and drug‐seeking behavior can occur. Controlled (Schedule IV). Cautions: -Seizure disorder or increased seizure risk factors -Has risks pregnancy, lactation -Strong cautions for children, contraindicated under 12 years of age and cautions for all pediatric patients

Endonuclease inhibitor (baloxavir)

Acute, uncomplicated influenza; not FDA-approved for prophylaxis One single dose (>12 years of age); dose depends on weight Avoid co-administration of with dairy products, calcium-fortified beverages, antacids, or oral supplements (e.g., calcium, iron, magnesium, selenium, or zinc). May be more expensive than alternative

Nicotine Pathophysiology

Addictive substance in cigarettes A ganglionic cholinergic receptor agonist Activation of these receptors: -relaxation -decreases stress and anxiety -improves concentration and reaction times Also increases: -Dopamine levels in CNS -Respiratory stimulation -Epinephrine release by adrenal medulla -Blood pressure -Heart rate -Carbon monoxide -Oxygen consumption

Ca & vit D

Adequate calcium intake is a fundamental aspect of any osteoporosis prevention or treatment program and part of a lifestyle for healthy bones at any age. This vitamin plays a major role in calcium absorption and bone health and may be important in muscle performance, balance, and risk of falling

Penis

Adrenergic Receptor: Alpha 1 Response: ejaculation/contraction

Genitourinary, Bladder sphincter, Sphincers

Adrenergic Receptor: alpha 1 Response: constriction

Cardiovascular & blood vessels

Adrenergic Receptor: alpha 1 & beta 2 Response: constriction/dilation

Uterus

Adrenergic Receptor: alpha 1 & beta 2 Response: contraction/relaxation

AV Node & SA Node

Adrenergic Receptor: beta 1 Response: Increased HR

Cardiac Muscle

Adrenergic Receptor: beta 1 Response: Increased contractility

Gastrointestinal Muscle

Adrenergic Receptor: beta 2 Response: decreased motility

Respiratory bronchial muscles

Adrenergic Receptor: beta 2 Response: dilation/relaxation

Antidiarrheals

Adsorbents and Demulcents - Adsorb toxins and other substances that produce diarrhea Antimotility/Antispasmodics - Anticholinergic and "opiate" type effect. - Do not use in invasive bacterial diarrhea and PMC, or in preschool children. Intestinal flora modifiers Antibiotics

ICS/LABA combo therapy

Advair (Fluticasone/Salmeterol) -Pregnant/Lactating: caution advised, fetal risk low/unknown caution advised Symbicort (Budesonide/Formoterol) -Pregnant/Lactating: caution advised, fetal risk low/unknown caution advised

Pseudoallergic or "nonimmune hypersensitivity" drug rxns

Adverse drug reaction Mimic immunologic drug allergies Complete mechanisms underlying most of them unknown Difficult to distinguish clinically Similar in presentation to true allergic reactions Diagnosis, prognosis, and prevention of pseudoallergy may be different from true allergy Refer to explore further testing, desensitization

Drug allergy

Adverse drug reaction caused by an immunologic reaction elicited by a drug Potentially life-threatening Classification ofImmunologic drug rxns Type I -Immediate in onset (seconds-1hr) and caused by immunoglobulin E (IgE)-mediated activation of mast cells and basophils; Common Clinical features of Type 1 reaction: anaphylaxis, angioedema, bronchospasm, or urticarial (hives)

Levothyroxine AE

Adverse effects of T4 replacement (levothyroxine) are rare as long as the correct dose is given. It is possible to cause hyperthyroidism if the levothyroxine dose is too high. -Potential risks of over-replacement: Skeletal, cardiac effects (such as arrhythmia, angina, accelerated bone loss

ACEi info

African Americans may not have substantial BP lowering affect with ACEi -May be used in combo with CCB or diuretic if comorbidity -May be used if patient has other compelling indication People of African descent have up to 5x greater risk of angioedema -Pt education ---Stop this med and go to ER if you experience swelling of your lips, tongue, face, or airway.

Antidepressant Removal

After first lifetime depressive episode, reasonable to trial off agent after 6 months-1 year. When and whether to trial off may be dictated by patient comfort/preference. -Taper off slowly for comfort (pace may depend on dose, duration of therapy, patient factors, etc) -Follow closely for symptom worsening Individuals with several lifetime episodes may choose to continue SSRI/SNRI/NDRI long term

AOM considerations

Age Severity Duration of disease Co-morbidities Allergy Recent abx use

Types of SABA

Albuterol -MDI ProAir, Ventolin, Proventil 90mcg/spray ---2 puffs q 4-6 hrs PRN wheezing ---Exercise induced: 2 puffs inhaled 5-30 mins before exercise -Nebulizer ---2.5mg/3mL -Oral: less potent bronchodilation Levalbuterol (xopenex)

Renin inhibitor

Aliskiren (Tekturna)

Placental drug transfer

All drugs can cross the placenta Some can cross more easily than others

Vit D

All exclusively breastfed infants should receive 400 IU per day of Vitamin D supplementation started within the first few days of life. Many patients require vitamin D supplementation as it is difficult to achieve goals with diet alone. -A Vitamin D level can be ordered. An individual's vitamin D status in this situation is assessed by measurement of serum 25(OH)D—not by measurement of 1,25- dihydroxyvitamin D. -Vitamin D supplementation: cholecalciferol (Vitamin D3) or ergocalciferol (Vit D2) ---Vitamin D3 (cholecalciferol) rather than vitamin D2 is recommended for replacement in adults.

Prescribing Guidelines (smoking)

All first-line agents approved by the FDA can be used -Select the agent most appropriate for the patient based on preference or previous history of quitting attempts, depression, or weight gain -Always consider 2nd line when contraindications or failures of 1st line occur

secondary prevention (anticoagulation)

All patients post‐MI and post‐stroke should take ASA for secondary prevention Lower doses just as effective as higher doses

Insulin

All patients with T1DM Many patients with T2DM - Indications for unstable T2DM ---Insulin need may not be permanent (esp if new‐onset T2DM) ----- High A1c (start thinking over 8.5%, definitely >10%) ----- Fasting plasma glucose >250 mg/dL, or ----- Random glucose > 300mg/dL Primary AE: Hypoglycemia, weight gain

Antiadrenergic Drugs (sympatholytics)

Alpha blockers -HTN Beta-blockers -Beta-blockers selectively or preferentially block beta 1 in the heart, with less effect on beta 2 in the lungs

Clonidine (Kapvay)

Alpha-2-adrenergic agonists Non-Stimulants Treatment Options As a class, they are less effective than stimulants. Not controlled They usually are used when:-children respond poorly to a trial of stimulants or atomoxetine-have unacceptable side effects-have significant coexisting conditions---May consider with coexisting tic disorder; emotional or behavioral condition Select AE: bradycardia, hypotension/orthostasis, sedation, dizziness— Guanfacine seems to have better AE profile than this drug Monitor BP, HR Dosing: Start low and go slow to minimize AE; dosing can be more complicated, so may be directed by a specialist Can take up to 2 weeks for initial response Taper over several weeks when DC'd

Guanfacine ER (Intuniv)

Alpha-2-adrenergic agonists Non-Stimulants Treatment Options As a class, they are less effective than stimulants. Not controlled They usually are used when:-children respond poorly to a trial of stimulants or atomoxetine-have unacceptable side effects-have significant coexisting conditions---May consider with coexisting tic disorder; emotional or behavioral condition Select AE: bradycardia, hypotension/orthostasis, sedation, dizziness— this drug seems to have better AE profile than clonidine (Kapvay) Monitor BP, HR Dosing: Start low and go slow to minimize AE; dosing can be more complicated, so may be directed by a specialist Can take up to 2 weeks for initial response Taper over several weeks when DC'd

Adrenergic Drugs

Alpha-stimulants or agonists (Alphamimetic) -Vasoconstrictor for hypotensive shock -nasal decongestant Beta-only stimulants or agonist(Betamimetic) -selective or preferential agonists for beta 1 or beta 2 -bronchodilation for COPD (beta 2) -Cardiac stimulant (beta 1) -Tocolytic (uterine relaxant) Alpha and Beta (mixed) stimulants or agonists

Drug eruptions: drug induced exanthems

Also called morbilliform eruptions Erythematous macules and papules that predominantly involve the trunk and proximal extremities Prompt withdrawal of the offending drug is the mainstay of treatment Most common cutaneous reactions to drugs -Responsible for about 75% of all drug rashes Antibiotics (esp sulfonamides) are implicated in most cases Topical corticosteroids and oral antihistamines may be considered for pruritis

Stimulant AE

Anorexia, weight loss, reduced height? -Deceleration may occur (over first couple years?), appears to attenuate over time, adult height does not appear to be affected Sleep disturbance Jitteriness Emotional lability -Rare reports of psychotic symptoms, such as hallucinations, delusional thinking, mania Increased heart rate and blood pressure Headache, dizziness Gastrointestinal symptoms Tics (new or worsening) Priapism- rare, but is a medical emergency*

Zyban SR (bupropion SR)

Also known as Wellbutrin SR First non-nicotine product approved for smoking cessation -Good for patients with co-existing depression, ADHD or both 27% of patients are abstinent at 6 months compared to 16% of placebo Patient needs to set a "stop date" for at least 1 week (but not more than 2 weeks) from date of starting medication. Patient continues to smoke for 1 week before attempting to quit smoking. If patient has not made significant improvements by week 7 of treatment, the attempt is unlikely to be successful and medication should be discontinued.

Pitted nails of psoriasis

Also think of -Psoriatic nail disease -psoriatic arthritis (more radial)

Pharmacotherapy (obesity)

Alters fat digestion -Orlistat (Alli, Xenical) GLP‐1 RA -Liraglutide (Saxenda) Sympathomimetic drug -Phentermine Combination drugs -Sympathomimetic + anticonvulsant (Phentermine + Topiramate, Qsymia) -Antidepressant + opioid receptor antagonist (Bupropion‐Naltrexone, Contrave)

Orlistat (Xenical® , Alli®) MOA

Alters fat digestion by inhibiting pancreatic and gastric lipases

antacids

Aluminum, magnesium and calcium-containing antacids MOA: Neutralize gastric acid and the pH of gastric contents. Increases lower esophageal sphincter pressure and decreases the activation of pepsinogen. Indications: Relieve symptoms of duodenal ulcers, effective for dyspepsia and "heart-burn." Dosing/Titration Info: -Provide prompt (almost immediate) relief of symptoms -Short duration of action (20 - 40 minutes on an empty stomach) -Require frequent dosing -Do not use for more than two weeks before more evaluation of symptoms Ingredients Aluminum hydroxide - Constipating - Used in dialysis since it binds phosphates Magnesium hydroxide (MOM) - Has a laxative effect in higher doses - Often combined with aluminum hydroxide to offset the constipating effects of the aluminum hydroxide Calcium carbonate, in Tums®, Children's Pepto®, etc. - Also used to treat/prevent osteoporosis Sodium bicarbonate - systemic absorption - "rebound" effect - used IV for treating metabolic acidosis - causes excess "sodium load" in clients with CHF Alginate (alginic acid) - an "anti-refluxant" in Gaviscon® - it reacts with sodium bicarbonate and saliva to form a viscous solution of sodium alginate that floats on the surface of the gastric contents and serves as a mechanical barrier to reflux - useful for GERD (gastroesophageal reflux disease) Side effects: Constipation or diarrhea Cautions: Interactions with other medications

Hypothyroidism goal of tx

Amelioration of symptoms Normalization of TSH secretion -serum TSH within the normal reference range (approximately 0.5 to 5.0 mU/L) Reduction in size of goiter if present Avoidance of overtreatment (iatrogenic thyrotoxicosis)

Tobramycin

Aminoglycoside w/ a black box waring for neurotoxicity/ototoxicity, nephrotoxicity, neuromuscular blockade

Drugs that cause hypothyroidism

Amiodarone Expectorants (eg, guaifenesin) Lithium

Dihydrophyridine Calcium Channel Blocker

Amlodipine

CAP

Amxocillin, doxycycline, fluoroquinolones are agents of choice for outpatient treatment No comorbidities, no recent antibiotic use -Amoxicillin -Doxycycline Comorbidities, antibiotic use within past 3 months -Levaquin 750mg daily X 5 days -[Augmentin OR Cefpodoxime OR Cefuroxime ] + Azithromycin OR Clarithromycin

6.6 A1C

An A1C goal for many nonpregnant adults of <7% (53 mmol/mol) is appropriate -Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes selfmanagement education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin

Nociceptive pain

An adaptive (protective) pain; pain sensed by pain receptors Somatic pain‐ MSK pain Visceral pain‐ pain from organs Might feel sharp, dull, throbbing, aching depending on condition Non-opioid meds -NSAIDs -Muscle relaxants (cyclobenzaprine, tizanidine, baclofen) -Acetaminophen Oral or topical NSAIDs are the first‐line therapy for many chronic nociceptive pain conditions. If usual treatment is ineffective for patients who are thought to have nociceptive pain? Consider the pain may be neuropathic or central and consider other treatments?

Inflammatory pain

An adaptive (protective) pain; results from local inflammation (such as arthritis, infection, tissue injury) Might throb or ache Non-opioid med -NSAIDs (ex: ibuprofen po, naproxen po, meloxicam po, ketorolac IM/po, diclofenac topical gel) -Systemic steroid oral/IM/intraarticular

Cefdinir

An ex of a 3rd gen cephalosporin

Types of Allergic Drug Rxns

Anaphylaxis/Anaphylactoid Angioedema/Urticaria Serum Sickness or serum sickness-like Stevens-Johnson Syndrome Toxic epidermal Necrosis (TEN) Fixed Drug eruptions

GLP‐1 Agonists

Another incretin therapy Injectable (SC) in a pen delivery system Dosing options: Once daily/once weekly/ BID Benefits -Good A1c lowering ---Many affect both FBG and PPBG (PPBG>FBG) -Low hypoglycemia risk -Increased satiety/ decrease Weight ---Liraglutide has dual indication for T2DM (Victoza) and obesity (Saxenda‐ higher dose than Victoza) -Cardiovascular benefits ---So far established CV benefits for liraglutide (Victoza), semaglutide (Ozempic), dulaglutide (Trulicity) Exenatide (Byetta, inj BID), Liraglutide (Victoza, inj QD), Exenatide ER (Bydureon, inj weekly), Dulaglutide (Trulicity, inj weekly), Semaglutide (Ozempic, inj weekly; Rybelsus, daily oral)

Opioid tx agreement

Another practice intended to decrease the risk for misuse Prior to starting a long‐term opioid Documents: -shared decision‐making -treatment goal‐setting -informed consent including potential risks/benefits/alternatives -defines the monitoring plan Can be a useful means of standardizing this step across patients and prescribers and discuss some potential issues before they occur When discussing the agreement, emphasize how its provisions are intended to protect patient safety Common information that is included: -Potential risks and benefits of opioid therapy -Clinical guidance that opioids may not improve pain or function -Prescribing and/or practice policies (e.g., dose limits, only one prescriber, only one pharmacy, refill policy‐ such as not refilling early, request refills at least 3 business days in advance) -Methods of monitoring opioid use (e.g., urine drug tests‐ will they be done at random or scheduled?, periodic visits, providers will check PDMP routinely) -Behaviors expected of the patient

Methimazole

Anti thyroid drug (Thioamides) (M) Tx option for Graves' hyperthyroidism for achieving euthyroid status

Propylthiouracil

Anti thyroid drug (Thioamides) (P) Tx option for Graves' hyperthyroidism for achieving euthyroid status

Avoid drugs in HF

Anti-inflammatory medications -Glucocorticoids: Sodium retention (particularly with fludrocortisone, hydrocortisone) -NSAIDs: Sodium retention and peripheral vasocontriction; blunted response to diuretics and angiotensin converting enzyme inhibitors Cardiovascular medications -Calcium channel blockers (but amlodipine or felodipine appear to be safe if needed for coexisting HTN) ---Negative inotropy; neurohumoral activation Diabetes medications -Metformin: Lactic acidosis (higher risk among patients with HF requiring pharmacologic management, esp those with unstable or acute HF at risk of hypoperfusion and hypoxemia) -Thiazolidinediones: Sodium retention

Topical corticosteroids

Anti-inflammatory response by variety of mechanisms Induce cutaneous vasoconstriction commensurate w/ their potency

Step 5 abx

Antibiotic stewardship Create and foster a unified clinical culture of excellence

Hepatotoxicity (abx)

Antibiotics have been found to be the most common drugs leading to hepatotoxicity Ex. abx •Augmentin •Penicillin •Ciprofloxacin •Erythromycin •Nitrofurantoin •Sulfonamides •Tetracycline Also "azole" antifungals •Fluconazole •Itraconazole •Ketoconazole

Aspirin

Anticoagulant MOA: irreversibly modifies and binds COX enzyme; this modification has the effect of inhibiting prostaglandin synthesis SE: dyspepsia, heartburn, tinnitus Notes about gastric effects: -Most significant adverse event is GI bleed (factor into risk/benefit analysis - taking ASA increases upper GI bleed risk 2‐to‐4‐fold) -Enteric coated no better for bothersome GI effects or ADE prevention

Apixaban (Eliquis)

Anticoagulant MOA: -Factor Xa inhibition Indications: non‐valvular AF, VTE (DVT, PE) Dosing: fixed (5 mg BID or 2.5 mg BID if meets 2: age >=80, weight <= 60 kg, Cr>=1.5; contraindicated for CrCl<30) Reversal agent: Andexanet (Andexxa)

Rivaroxaban (Xarelto)

Anticoagulant MOA: -Factor Xa inhibition Indications: non‐valvular AF, VTE (DVT, PE), DVT prophylaxis knee/hip replacement Dosing: varies based on indication, renal dosing required, contraindicated for CrCl < 15. Administer with meal. Reversal agent: Andexanet (Andexxa)

Dabigatran (Pradaxa)

Anticoagulant MOA: directly and reversibly inhibits thrombin Indications: -non‐valvular AF, VTE (DVT, PE) Dosing: fixed (150 mg BID for CrCl > 30 or -75 mg BID for CrCl 15‐30) Reversal agent: idarucizumab (Praxbind)

Stroke prevention in a-fib

Anticoagulation risk benefit analysis -Clinicians tend to overestimate bleed risk CHA2DS2VASC for patients with AF -Score of >=2 (men) and >=3 (women) on CHA2DS2Vasc indication for long term anticoagulation therapy There are apps that help you quantitatively balance risk -CHA2DS2VASC vs. HAS‐BLED

Adsorbents & demulcents

Antidiarrhea • MOA: Adsorb water and help solidify loose stools 1) Bismuth subsalicylate (Pepto-Bismol®, Kaopectate®, Maalox Total Stomach Relief®) -Nonspecific diarrhea and prophylactic treatment of traveler's diarrhea. -SE: ---black tarry stools and darkening of the tongue 2) calcium polycarbophil (FiberCon, Equalactin, Mitrolan) -hydrophilic, polyacrylic resin that is insoluble in water and can absorb 60 times its weight in water. -Free of toxic effects, unabsorbed and pharmacologically inactive. -Take with at least 8 ounces of water

IBS tx

Antidiarrheals - loperamide (Imodium), diphenoxylate (Lomotil) PPIs and H-2 antagonists Antispasmodics - dicyclomine (Bentyl), hyoscyamine (Levsin) - Bentyl - Levsin Bulk-forming laxatives/Fiber (Citrucel, FiberCon, Metamucil) Peppermint oil - Enteric-coated form. - Combination peppermint oil and caraway oil SSRIs - Prozac, Celexa, Paxil®, Zoloft Selective 5-HT3 serotonin antagonist - granisetron (Kytril) and ondansetron (Zofran). Nonabsorbed antibiotics, e.g. neomycin, rifaximin Tx for IBS-C -Lubiprostone (Amitiza) -Linaclotide (Linzess) Tx for IBS-D -Viberzi

Fluconazole

Antifungal drug that may have many drug interactions related to the CYP450 system

Digoxin

Anti‐arrhythmic drug Not included in Vaughan Williams taxonomy Works at AV node, may provide rate control in AF Positive inotrope: can be good fit with HF Relatively narrow therapeutic window (0.8 - 2.0 ng/mL or 0.5 - 1.0 ng/mL for EF<40%) Toxicity s/sx: heart block, ventricular arrhythmias, visual disturbance, dizziness, weakness, N/V/D, anorexia Toxicity affected by metabolism (frequent drug/drug interactions) and elimination (renal - caution with chronic or acute renal insult)

Sotalol (Betapace)

Anti‐arrhythmic drug (class III) Treats supra‐ and ventricular arrhythmias and may reduce arrhythmia and device discharge in ICD patients Significant QT prolongation‐ follow EKGs between cardiology appointments and avoid agents which may further elongate QT interval Renally eliminated‐ follow renal function and electrolytes (potassium/magnesium) closely, particularly with concomitant diuretics

Amiodarone (Cardorone)

Anti‐arrhythmic drug (class III) • Used for supra‐ventricular and ventricular arrhythmias, safe for structural heart disease • Patients undergo "loading" inpatient, then take maintenance doses Drug can accumulate and cause adverse effects systemically (suspect amiodarone as cause when "something isn't right") -Check TSH, LFTs q6 months; PFTs if symptoms arise Many drug‐drug interactions (inhibits several major CYPs), including warfarin (↑INR up to 200%) ‐ check carefully prior to all Rx'es

Anxiety goals of therapy

Anxiety may have short and long term goals. Long term goal: anxiety is less frequent, less severe (unlikely to remit completely). -**Therapy likely to play a big role in long term outcomes** Short term goal: focus on function- what are they having difficulty doing right now? Do they need help to do those things RIGHT NOW?

Buspirone (BuSpar)

Anxiety tx Non-benzo, non-habit forming anxiolytic for GAD and/or panic MOA: -unknown, likely hits multiple receptor sites, including partial serotonin 1A agonist May work well for benzo-naïve patients Takes 1-2 weeks to achieve therapeutic effect. ("This is not like Tylenol or Advil...") Starting dose: 5-10 mg BID to TID Max dose: 60 mg daily divided Short-term therapy

Fluid & electrolyte replacement

Are Pedialyte and related products really better than water or juices to treat and prevent dehydration in children? Sports drinks, broths, juice, and plain water Recommend a commercial oral rehydrating solution such as Pedialyte, Infalyte, Oralyte, etc. - 2 to 4 oz of a rehydrating solution for children under 22 pounds, or 4 to 8 oz for heavier kids, for each episode of vomiting or diarrhea. - Give small, frequent volumes: spoonfuls or small sips for toddlers, or small volumes in bottles for infants.

Papular Acne Therapy (acne vulgaris)

As per comedonal acne Add oral abx if moderately severe or if chest & back are involved *continue oral abx for @ least 6-8 wks then slowly decrease daily dose to avoid flare-ups *Do not abandon a given therapy until a 6 wk trail has been completed

Papulopustular/Nodulocystic Acne Tx (Acne Vulgaris)

As per papular Acne If severe consider Isotretinoin -recommend dermatology referral -all other acne tx is stopped -contraceptive counseling important. Oral contraceptives are safe w/ isotretinoin

Anxiety principles

As with depression, some anxiety is normal (and can even be adaptive). Some people's "off-button" becomes difficult to find or push

Strategy for health literacy: Review Medications

Ask pt to bring in all medicine bottles to the appt Go through each bottle and ask the pt -How do you take this medicine -when do you take it? -What do you take it for?

Antiplatelet tx (angina)

Aspirin 81‐162 mg OR Plavix if cannot take ASA or if patient has another compelling indication OR Anticoagulant warfarin or DOAC if patient has another compelling indication (note: these are not anti‐platelet agents, but they may take the place of or be added to anti‐platelet therapy)

Asthma Management Cycle

Assess -Confirm diagnosis -Symptom control and modifiable risk factors -Comorbidities -Adherence and Inhaler techniques Adjust Tx -Treatment of modifiable risk factors and comorbidities -Non-pharm strategies -Asthma medications Review Response -Symptoms -Exacerbations -Side effects -Lung function -Patient/parent satisfaction

Dyslipidemia

Atherosclerosis major cause of coronary artery disease Lipid panel in primary care -Total cholesterol -Low density (LDL) -Triglycerides -High density (HDL)

Affinity: Pharmacodynamic

Attraction of drug to receptor

Olanzapine

Atypical Antipsychotics (O) promote weight gain (histamine receptor effect)-Mechanism is felt to involve increased hunger-Encourage patients to modulate portion size (easier said than done!) Further underlying pathophysiology r/t atypical antipsychotics suspected Severity depends on degree of histamine effect -This drug has a greater histamine effect than Quetiapine

Quetiapine

Atypical Antipsychotics (Q) promote weight gain (histamine receptor effect)-Mechanism is felt to involve increased hunger-Encourage patients to modulate portion size (easier said than done!) Further underlying pathophysiology r/t atypical antipsychotics suspected Severity depends on degree of histamine effect

Mirtazapine (Remeron) (sleep)

Atypical antidepressant (alpha-2 antagonist) Less is more for sleep (7.5 mg, 15 mg). May assist with depression/anxiety. Non-habit forming. These lower doses may cause significant weight gain. If using for depression, doses 45 mg and higher typically used to avoid weight gain. Lower doses: sleepy, hungry, and a little happier Higher doses: activated and happy

Atypical Antipsychotics metabolic effect

Atypical antipsychotics promote weight gain (histamine receptor effect) -Mechanism is felt to involve increased hunger -Encourage patients to modulate portion size (easier said than done!) Further underlying pathophysiology r/t atypical antipsychotics suspected Severity depends on degree of histamine effect of the agent -Olanzapine > Quetiapine > Risperidone/Paliperidone > Aripiprazole = Ziprasidone = Lurasidone

Beta blocker caution

Avoid -Bronchospastic disease (Asthma, COPD) ---All beta blockers should be avoided in patients with severe or decompensated bronchospastic disease ---Non-cardioselective beta blockers should generally be avoided ---Even cardioselective BB should be considered with caution Bradycardia 2 nd/3rd degree AV block Uncompensated HF Caution: DM (may mask hypoglycemia, may cause impaired glucose tolerance and increased risk of new onset diabetes) DDI: Potential negative additive CV effects of BB + Non-dihydro CCB

Therapy of dermatophyte skin infections

Avoid combination products Has caused permanent skin atrophy due to the strong topical steroid Topical steroids cause localized immunosuppression which promote fungal growth Widespread skin involvement consider oral antifungal agents -Terbinafine (drug of choice) -Itraconazole

Tetracycline warnings

Avoid in pregnancy Avoid taking w/ calcium-containing foods or drugs (absorption)

NSAID special populations

Avoid in pregnancy Older adults -Brief course? -Lowest effective dose? -Careful titration and monitoring for adverse effects -Sometimes other treatment options are explored due to safety concerns.

Doxycycline

Avoid in pregnancy and young children, has potential to discolor teeth

Avoid in pregnancy (DM)

Avoid potentially teratogenic medications (ex: ACE inhibitors, statins) in sexually active women of childbearing age who are not using reliable contraception.

Epocrates (sulfonamide)

Avoid use -Sulfamethoxazole (as in TMP-SMX) -Thiazide diuretics -Celecoxib Caution advised w/ -loop diuretics -sulfonylureas

BB in HFrEF

BB are initiated soon after the patient is started on ACEi, ARNI, or ARB BB that are specifically recommended in HFrEF: -Carvedilol -Extended-release metoprolol succinate -Bisoprolol Begin at very low doses with titration to optimal doses as tolerated Be careful with dosing and monitor, as initiation of BB may lead to increase in symptoms for 1-2 wks before improvement is noted Monitor -BP, HR ---Avoid heart rate <50-60 (and consult cardiology) -Weight ---Increased diuretic dose or lower BB dose may be warranted

Obesity tx

BMI ≥30 kg/m2 BMI of 27‐29.9 kg/m2 with 1+ comorbidities, who have not met weight loss goals (loss of at least 5% of total body weight at 3‐6 months) with a comprehensive lifestyle intervention -Hypertension -T2D -Dyslipidemia -Other

total peripheral resistance (HTN)

BP = cardiac output x total peripheral resistance Angiotensin-converting enzyme inhibitors (ACEIs) Angiotensin II receptor blockers (ARBs) Direct renin inhibitors Beta blockers Alpha agonists Calcium channel blockers Diuretics Sympatholytics Vasodilators

Cardiac output (HTN)

BP = cardiac output x total peripheral resistance Beta blockers Calcium channel blockers Diuretics

HTN Older Adult goals

BP goals may not be easy to achieve in older adults -particularly in those with systolic pressure > 160 mmHg (isolated systolic hypertension has been defined as systolic pressure >160 and diastolic <90 mmHg) Another potential limitation to achieving goal BP: potential impairment of mental function -Reduce dose and allow systolic pressure to rise to a level in which symptoms resolve Another potential concern is low diastolic pressure from therapy for isolated systolic HTN may possibly increase CV risk

Resistant HTN

BP not controlled despite adherence to an appropriate 3-drug regimen (including a diuretic); BP requires at least 4 medications for control Consider if there is a secondary cause -Most common: obstructive sleep apnea, primary aldosteronism, renal artery stenosis Triple combo option -ACE or ARB, + a long-acting dihydropyridine CCB (usually amlodipine), + a long-acting thiazide diuretic (consider chlorthalidone) is often effective and generally well tolerated A MRA, such as spironolactone, can be helpful add-on therapy for some patients Referral to a hypertension specialist -Referral recommended: if a specific secondary cause is suspected or if BP remains elevated despite 6 months of more intensive treatment -For patients who remain resistant, a direct vasodilator, such as hydralazine for women or minoxidil for men, may be considered by a specialist

HTN w/o emergency or urgency (older adult)

BP reduction should be gradual, such as over 3-6 months If no indication for a specific drug, consider: -Thiazide-type diuretic ---Start low-dose ---Generally good efficacy -Long-acting calcium channel blocker ---Dihydropyridine generally preferred for efficacy -ACEi or ARB ---Lower dose if combined diuretic, close monitoring

Types of STI

Bacterial Pathogens -Syphilis -Gonorrhea -Chlamydia -Chancroid Viral Pathogens -Herpes Simplex types 1 and 2 Protozoan Pathogen -Trichomoniasis Human Papillomavirus Other Ectoparasitic Pathogens -Pubic Lice Bacterial Vaginosis Vulvovaginal Candidiasis

Initiating Insulin Therapy

Basal insulin (glargine or detemir) -Initial dose: 0.1‐0.2 units/kg/day ---Or 10 units per day -Monitor and adjust primarily per FBG -Can increase dose gradually if suboptimal BG ---About 10% every 4‐7 days ---Decrease dose by about 20% if hypoglycemia (40% decrease if severe hypo, such as BG <40)

Intesnsive Insulin therapy

Basal insulin + Rapid‐acting insulin with all meals

Intensive Insulin Therapy (MDI/Basal-bolus regimine)

Basal insulin + rapid acting insulin w/ all meals

Ex of ICS

Beclomethasone Budesonide (Pulmicort) Ciclesonide (Alvesco Fluticasone (Flovent) Mometasone (asmanex)

Opioid evaluation of risk

Before initiating opioid therapy: -Assess patients for risks of overdose, misuse, and opioid use disorder -Risk may be described as low, moderate, and high. Consider specialist referral with elevated risk. Assess for: -personal or family history of substance misuse -mental health Review state prescription drug monitoring program (PDMP) -Allows clinical to review the patient's history of controlled substance prescriptions to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. -CDC: review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months. Baseline urine drug test to assess for any current use of opioids/illicit substances prior to providing any opioid prescriptions.

ART treatment recommendations

Begin as soon as possible after diagnosis of HIV After diagnosis of acute or early HIV infection is made, pts should ideally be referred to a provider w/ experience in HIV management At this time, once treatment for HIV is initiated, ART is continued indefinitely

ADHD maintenance stage

Begins once the optimal dose and frequency of medication have been determined. Continued monitoring of treatment progress and adverse effects is necessary during the maintenance phase. Decisions regarding discontinuation of stimulant medication on weekends or school vacations must be made on a case by case basis. The duration of pharmacologic therapy is highly individualized; ongoing evaluation of the risks and benefits of medication is necessary for each patient

Powder (Topical corticosteroids)

Benefit -Absorb moisture -decrease friction Basic ingredient

Oils (Topical corticosteroids)

Benefit -Emollient -occlusive properties Basic ingredient

Liquids (Topical corticosteroids)

Benefit -Provide cooling, -soothing sensation -Help exudative lesions to dry Basic ingredient

Niacin

Benefit vs risk? -Not used very often Many mechanisms, decreases hepatic LDL and VLDL production Effects on lipids -Lower TC, LDL, TG, and elevate HDL Over-the counter doses are not sufficient to lower LDL

Primary prevention of ASCVD & events

Benefits: -A little ASCVD/MI/stroke reduction -A little cancer prevention, particularly colorectal Risks: -GI bleed (ASCEND trial in diabetics found that risk of GI bleed cancelled out primary prevention of CV event benefits - NEJM August 2018) -Beer's criteria for patients over 80 y/o due to bleed risk and uncertain benefit

Alprazolam (xananx)

Benzodiazepine (A) Patients should always be warned about: -Addictive potential -Tolerance -Withdrawal If patient requires long term benzos, they must be seen at least q3 months (probably by mental health specialist!).Weaning may be a long, slow process. Check your controlled substance databases!

Clonazepam (Klonopin)

Benzodiazepine (C) Patients should always be warned about: -Addictive potential -Tolerance -Withdrawal If patient requires long term benzos, they must be seen at least q3 months (probably by mental health specialist!).Weaning may be a long, slow process. Check your controlled substance databases!

Lorazepam (Ativan)

Benzodiazepine (L) Patients should always be warned about: -Addictive potential -Tolerance -Withdrawal If patient requires long term benzos, they must be seen at least q3 months (probably by mental health specialist!).Weaning may be a long, slow process. Check your controlled substance databases!

Chronic pain

Best pain control for chronic pain: targeted to the type of pain -Ex: neuropathic pain should be distinguished from nociceptive pain since treatments differ Treatment for chronic pain : non‐medication options, non‐opioid medications if needed, and opioids may need to be considered for moderate‐to‐severe episodes Discuss goals of therapy and potential risks and benefits thoroughly with the patient. Chronic daily use of opioids puts patients at risk of: -tolerance -dependence -substance use disorder -worsened pain (i.e. opioid induced hyperalgesia) -dose‐escalation resulting in adverse events such as overdose Chronic pain management can be complex and nuanced, it is appropriate to seek a consult from a pain management.

Graves' hyperthyroidism relieving sx

Beta blocker, such as atenolol, metoprolol, or propranolol -Treats symptoms, and unless contraindicated, is recommended for all patients until euthyroidism is achieved by thionamides, radioiodine, or surgery. -Monitor BP, pulse with BB

Common Migraine Prophylaxis

Beta blockers Calcium channel blockers TCAs/SSRIs/SNRIs (primary or secondary MOA?) Anticonvulsants (valproate, gabapentin, topiramate)

Metformin

Biguanide class Glucophage, Glucophage ER, Fortamet (ER), Glumetza (ER), Riomet (liquid) *First line therapy for T2DM (without contraindications) - May also be used for prevention of T2DM/prediabetes (but doesn't have FDA approval for this; see discussion in ADA Standards of Care)

Bile Acid Sequestrants

Bind to intestinal bile acids and then excreted in the feces; increase uptake of LDL Lower TC, LDL, and increase HDL -May increase TG Exemplars: Colestipol, Colesevelam, Cholestyramine Not metabolized by the liver Avoid if bilary obstruction AE: *GI: constipation, abdominal pain, flatulence, N/V, dyspepsia, belching.... (can be adherence issue) Drug interactions -Interfere with absorption of other medications -May reduce absorption of folic acid and fat-soluble vitamins such as vit A, D, and K

HIV step 1

Binding (also called attachment): HIV binds to receptors on the surface of the CD4 cell Drugs -CCR5 antagonist -post-attachment inhibitors

Macrolides MOA

Binds 50s ribosomal submit and prevents protein synthesis

Drug Agonist: Pharmacodynamic

Binds to a receptor and causes and effect

Alendronate (Fosamax)

Bisphosphonate (A) First line tx for osteoporosis For most postmenopausal women with osteoporosis -These may be taken daily or weekly, some are monthly.

Risedronate (Actonel)

Bisphosphonate (R) First line tx for osteoporosis For most postmenopausal women with osteoporosis -These may be taken daily or weekly, some are monthly.

Men w/ osteoporosis

Bisphosphonates, denosomab, teriparatide are primary considerations at this time and others may be approved in the future. If osteoporosis is due to another condition, the underlying cause would be treated.

HMG CoA reductase inhibitors/ Statins MOA

Block synthesis of cholesterol in the liver by competitively inhibiting HMG CoA reductase activity. Inhibit conversion of HMG-CoA to L-mevalonic acid and subsequently cholesterol

Antihistamine Nasal Spray

Blow nose to clear nostrils Keep head tilted downward when spraying Insert applicator into nostril, keep bottle upright, and close off the other nostril Breath in through nose While inhaling, press pump to release spray Alternate sparys btw nostrils After each use, wipe the spray tip w/ a clean tissue or cloth

Atnolol-Verapamil

Bradycardia

Liraglutide (Saxenda)

Brand that is FDA approved for obesity is Saxenda -Liraglutide brand for T2DM is Victoza Option for initial treatment, particularly in patients with T2DM and CVD -Pros: demonstrated benefits with regard to cardiometabolic risk factors, glycemia, and quality of life -Cons: GI effects (nausea, vomiting), injectable, cost Avoid h/o pancreatitis Contraindicated -Pregnancy -Patients with personal or family history of medullary thyroid cancer or multiple endocrine neoplasia (MEN) (see BBW)

Proper use of inhaler

Breathe in slowly and depress the canister Continue breathing for 3-5 seconds until lungs are full

Asthma: Quick relief

Bronchodilators -short-acting beta2-agonists ---Recommended in conjunction w/ ICS for management of asthma-related sx -Antimuscarinics/Anticholinergics ---Less effective than inhaled beta agonist- slower onset of action & achieves less bronchodilation Systemic corticosteroids Inhaled corticosteroid (ICS) + formoterol

HPV

By age of 50, > 80% of women will have contracted at least 1 strand Most asymptomatic HPV 6 and 11- low risk, cause 90% of genital warts HPV 16, 18, 31, 33, and 35- high risk, associated with cervical neoplasia May be infected with multiple types Treatment possibly reduces, but not eliminate HPV Surgical referral- difficult to treat due to size, # of warts, ineffective response to topicals or location

Hepatic first-pass effect

Bypass via parenteral, transdermal, rectal delivery

Morbidity & Mortality (smoking)

CDC estimates smoking accounts for approximately 443,000 premature deaths annually (CDC, 2015) Smoking accounts for at least 30% of all cancer deaths and nearly 90% of all lung cancer deaths Smoking increases risk of cancer of: nasopharyngeal tract, esophagus, stomach, pancreas, bladder, and cervix. Smoking increases risk factors for ischemic heart disease, aortic aneurysms, cerebrovascular disease, peripheral artery disease, acute respiratory infections, and COPD. Smoking just 1-4 cigarettes a day doubles the risk of dying from heart disease 70% say they want to quit 50% say they have tried to quit in last year -Only 3-6% of smokers who made unaided attempt are abstinent at 1 yr -With optimal treatment, that number raises to 30%

Drugs and the Nervous System

CNS Peripheral Nervous System (PNS) Divisions of PNS -Voluntary (somatic) -Involuntary (autonomic) ---Sypathetic (adrenergic):"fight or flight" ---Parasypathetic (cholinergic): "rest and digest"

Oral decongestant: AE

CV -tachycardia -palpitations -HTN Psych -nervousness -irritability -anxiety -insomnia -hallucinations Neuro -tremors -HA GU/GI -urinary hesitancy (avoid BPH, obstruction) -decreased appetitie, nausea Prescribe cautiously d/t AE profile

Antidepressant titration & pharmacogenomics

CYP2C19 and CYP2D6 enzymes are commonly used by antidepressants -Can determine whether patients are ultra-rapid vs. typical vs. poor metabolizers ---Ultra-rapid metabolizer = medication quickly metabolized and the active formulation does not have time to work, so LESS clinical effect ---Poor metabolizer = medication metabolized very slowly, so lots of active floats around the system, so MORE clinical effect -Due to cost, genetic panels are often reserved for patients who have failed (or responded atypically to) multiple agents Kinetics are half the puzzle...dynamics studies are emerging! If you run one of these reports, COMMUNICATION IS KEY.

Antidepressant Cheap "life hack"

CYP2D6 agents: -Fluoxetine (Prozac) -Paroxetine (Paxil) -Venlafaxine (Effexor) -Plus several tricyclics CYP2C19 agents -Citalopram (Celexa) -Escitalopram (Lexapro) If you're moving away from one of these agents because it's not working (you're thinking, "maybe they're an ultra-metabolizer") or they have excessive side effects (you're thinking, "maybe they're a slow metabolizer"), pick an agent that uses a different CYP. No genetics report required...

Gabapentin (Neurontin) & Pregabalin (Lyrica)

Calcium channel antagonists, block release of neurotransmitters Pregabalin is controlled (requires DEA) and gabenpetin is controlled in many states Indicated in treatment of neuropathic pain -ex: diabetic peripheral neuropathy, postherpetic neuralgia, and fibromyalgia

Adverse rxns during pregnancy

Can adversely affect both mother and fetus Some unique effects -heparin causes osteoporosis -prostaglandins stimulate uterine contraction -certain pain relivers used during delivery can depress respiration in the neonate

Intranasal antihistamine (2nd gen)

Can be considered 2nd line or add-on to nasal steroid for AR; may be more helpful than oral antihistamine Ex. -Dymista (combo antihistamine + steroid spray) -Azelastine -Olopatadine Can relieve rhinorrhea, sneezing, nasal pruritis Can improve nasal congestion (but not as effective as INGC) Pro: effectiveness, rapid onset (15 min) Cons: Increased cost relative to oral antihistamines, epistaxis, local adverse effects *Consider proper use w/ any nasal spray

e-cigs & vaporizers info

Can cause "popcorn lung" (bronchiolitis obliterans) which damages the lungs alveoli. Relatively new product = not much long term data. 39 deaths directly linked to e-cigarettes as of 11/2019 In November, 2019 CDC found (additive) Vitamin E acetate may be the causative factor in e-cigarette lung damage

Sacubitril-valsartan (Entresto)

Can improve symptoms and reduce mortality in HFrEF Alternative to ACE inhibitor or ARB -Do NOT combine sacubitril-valsartan with an ACE inhibitor (or another ARB, or a direct renin inhibitor/aliskiren) -*Must be off ACE at least 36 hours before starting ARNI Some potential AR: -hypotension, hyperkalemia, renal impairment Monitor -BP, renal function, potassium Avoid -History of angioedema -Pregnancy/lactation

HPA (Hypothalamic-pituitary-adrenal) axis suppression

Can occur w/ oral or topical steroids w/ as little as 2 wks of use Leads to adrenal atrophy, loss of cortisol secretory capability Risks of HPA suppression -High-potency -chronic/long duration of use -childen -application to highly permeable areas -tx of large areas -occlusion -poor skin integrity -liver failure

Truvada (PrEP)

Can reduce the risk of HIV transmission by great than 90% Contraindication -HIV+ -CrCl < 60 -Possible HIV exposure in past 72 hrs Requires follow-up visit

Sulfonylurea + Basal insulin

Combinations with Cautions Discontinuing sulfonylurea is often recommended with insulin use AE -Glucose lowering‐ high -Hypoglycemia‐ highest risk (additive effects) -Weight‐ gain (additive effects) -Cost‐ variable :/

Stability of Insulin

Can search drug prescribing information Generally - Unopened insulin‐ store in refrigerator - Once "open" or "in‐use" ---keep at room temperature (59 to 86°F) Be aware: Stability differs per product - 28 days‐ insulin glargine (Lantus®) - 42 days‐ insulin detemir (Levemir®) - There is a chart in the unit with more information

Naloxone

Can successfully resuscitate opioid overdose patients. Providers should discuss availability of naloxone with all patients who receive opioid prescriptions. Specifically consider co‐prescribing naloxone for patients who are increased risk: -take benzodiazepines or other CNS depressants -have a history of prior opioid overdose -have household members at risk for accidental ingestion The patient and members of the household should be educated on the signs of overdose and use of naloxone.

Common anti-seizure medications

Carbamazepine (Tegretol) Gabapentin (Neurontin)**- may help neuropathy -very few drug-drug interactions Lamotrigrine (Lamictal)- mood stabilization Levetiracetam (Keppra)** -very few drug-drug interactions Oxcarbazepine (Trileptal)- follow Na+ levels Phenytoin (Dilantin)* -highly protein bound, requires monitoring to ensure therapeutic levels Topiramate (Topamax)- weight loss, confusion Valproate (Depakote)*- mood stabilization -highly protein bound, requires monitoring to ensure therapeutic levels

Beta Blockers types

Cardioselective -Atenolol, Bisoprolol, Metoprolol, Esmolol, Acebutolol Non-Cardioselective -Propranolol, Timolol, Nadolol, Nebivolol, Pindolol, Carteolol, Penbutolol Mixed alpha/beta-blocker -Carvedilol, labetalol

Inflammatory bowel disease

Caused by exaggerated immune response against normal bowel flora Crohn's disease - Characterized by transmural inflammation - Usually affects terminal ileum (can impact all parts of GI tract) Ulcerative colitis - Inflammation of the mucosa and submucosa of the colon and rectum - May cause rectal bleeding - May require hospitalization Tx Not curative - may control disease process Aminosalicylates -Sulfasalazine -Mesalamine (Pentasa, Asacol, Lialda, Apriso) -Olsalazine -Balsalazide (Colazal) (Giazo) Glucocorticoids (hydrocortisone) Immunosuppressants (azathioprine) Immunomodulators -Inflixamab (Remicade) -Adalimumab (Humira) -Certolizumab (Cimzia) -Natalizumab (Tysabri) Antibiotics (metronidazole)

GLP-1 RA Black box warning

Causes thyroid C‐cell tumors in rats and mice - It is unknown if it causes thyroid C‐cell tumors, including medullary thyroid carcinoma (MTC), in humans - Many in this class are contraindicated in patients with a personal or family history of MTC and in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). - Routine monitoring with serum calcitonin or thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with GLP‐RA.

Pregnancy/Lactation Considerations

Caution in pregnancy -definitive safety profile unknown -if tx is needed ---use of low to mid potency topical corticosteroids does not seem to increase the risk of adverse outcomes for mother & the fetus -Limited data ---Some concerning findings (low birth weight, especially w/ high potency preparations) -Caution in lactation ---safety profile unknown

ceftaroline

Cephalosporins (Beta-lactam antibiotic) -5th gen MOA -interfere with bacterial cell wall synthesis Treat -upper respiratory infections -otitis media -skin infections -UTI -CAP AE -Hypersensitivity reaction -GI -Hemolytic anemia Generally safe and well-tolerated potential cross-sensitivity b/w PCN and cephalosporin

cefepime

Cephalosporins (Beta-lactam antibiotic) -4th gen MOA -interfere with bacterial cell wall synthesis Treat -upper respiratory infections -otitis media -skin infections -UTI -CAP AE -Hypersensitivity reaction -GI -Hemolytic anemia Generally safe and well-tolerated potential cross-sensitivity b/w PCN and cephalosporin

cefuroxime axetil (Ceftin)

Cephalosporins (Beta-lactam antibiotic) (C) MOA -interfere with bacterial cell wall synthesis Treat -upper respiratory infections -otitis media -skin infections -UTI -CAP AE -Hypersensitivity reaction -GI -Hemolytic anemia Generally safe and well-tolerated potential cross-sensitivity b/w PCN and cephalosporin

cephalexin (Keflex)

Cephalosporins (Beta-lactam antibiotic) (K) MOA -interfere with bacterial cell wall synthesis Treat -upper respiratory infections -otitis media -skin infections -UTI -CAP AE -Hypersensitivity reaction -GI -Hemolytic anemia Generally safe and well-tolerated potential cross-sensitivity b/w PCN and cephalosporin

cefdinir (Omnicef)

Cephalosporins (Beta-lactam antibiotic) (O) MOA -interfere with bacterial cell wall synthesis Treat -upper respiratory infections -otitis media -skin infections -UTI -CAP AE -Hypersensitivity reaction -GI -Hemolytic anemia Generally safe and well-tolerated potential cross-sensitivity b/w PCN and cephalosporin

ceftriaxone (Rocephin)

Cephalosporins (Beta-lactam antibiotic) (R) MOA -interfere with bacterial cell wall synthesis Treat -upper respiratory infections -otitis media -skin infections -UTI -CAP AE -Hypersensitivity reaction -GI -Hemolytic anemia Generally safe and well-tolerated potential cross-sensitivity b/w PCN and cephalosporin

CAP peds

Children under age 5 years -Amoxicillin -Azithromycin Infant (4‐16 wks) with suspected chlamydial pneumonia -Azithromycin OR -erythromycin (EryPed)

CAP children

Children under age 5 years -Bacterial pneumonia (S. pneumoniae) ---Amoxicillin ---Azithromycin Infant (4‐16 wks) with suspected chlamydial pneumonia -Azithromycin OR erythromycin (EryPed)

Chlamydia

Chlamydia trachomatis Most commonly reported STI in US Women and men are often asymptomatic Rate in women is almost twice that of men Patients often co-infected with gonorrhea Sexual partners must be treated Tx Adults/Adolescents - Azithromycin 1 g orally X 1 dose or doxycycline Pregnancy - Azithromycin or amoxicillin

Hiccups tx

Chlorpromazine (Thorazine) - The only FDA approved treatment for hiccups Haloperidol (Haldol) Metoclopramide (Reglan) Anticonvulsants: ("Regular" anticonvulsant doses) - Gabapentin (Neurontin) - Phenytoin (Dilantin) - Valproate (Depakote) - Carbamazepine (Tegretol)

AOM treatment

Choice of strategy depends of age and severity of illness -Adults: treat -Children: abx therapy or watchful waiting? ---< 2 yrs treat, >2 years observe Most pts improve within 48-72 hrs of abx tx Pain -mild analgesic Amoxicillan-clav (most common)

Donepezil (Aricept)

Cholinesterase Inhibitors (dementia) Tx of Alzheimer's dz MOA -Inhibits acetylcholinesterase thereby reducing amount of acetycholine breakdown in brain Common SE: GI-May present as overt dyspepsia, or may present as anorexia/weight loss

Asthma

Chronic inflammatory disease of the airway External stimuli causes inflammatory cells to release mediators (histamine, leukotrienes) causing sx

Gels

Combine therapeutic advantages of ointments w/ cosmetic advantages of creams Useful in tx of acne Beneficial for oily or hairy areas

COPD

Chronic lung disease characterized by small airway obstruction in reduction in expiratory flow rate -Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation Chronic bronchitis-excessive mucous production, cough >3 months or longer Emphysema- permanent enlargement of the air spaces distal to the terminal bronchiole

Consideration w/ chronic use of steroids on skin

Chronic use increases risk of AE -increased risk of tolerance to therapy -chronic use may induce eruptions ---sensitivity rxn ---acneiform eruption ---dry, scaly eruption w/ scattered follicular pustules around the mouth (perioral dermatitis) ---Facial eruption that is indistinguishable from rosacea Tx includes discontinuation of steroid therapy w/ gradual taper Consider intermittent use for chronic conditions Suggest derm referral for guidance

Economic burden (smoking)

Cigarette manufactures spent approx. $1 billion in 2016 on advertising. -$27 thousand per day In US the total economic burden of smoking is estimated at $326 billion annually. -Nearly $170 billion for direct medical care for adults -More than $156 billion in lost productivity, including $5.6 billion in lost productivity due to secondhand smoke exposure

Potency classification

Class I -very high potency Class II, III - high potency Class IV, V -medium potency Class VI -low potency Class VII -lowest potency

Vaughan Williams Classification for AAD (anti-arrhythmic drugs)

Class I - sodium channel blockers (uncommonly used for outpatient maintenance, outside scope of this course) Class II - beta blockers Class III - potassium channel blockers -Amiodarone (Cordarone), Sotalol (Betapace) Class IV - calcium channel blockers (specifically non‐DHPs)

Choosing among stimulants (ADHD)

Clinician and family partner to determine the initial stimulant medication. In choosing among the various stimulants, duration of action is a primary consideration. -A stimulant may be short or long-acting- duration can range from about 3-12 hours. The onset for many stimulants is usually about 30-60 minutes. Another consideration is whether or not the child can swallow pills (since some formulations cannot be crushed, split, or opened). -Variety of formulations: tablets, capsules, ODT (orally disintegrating tablet), patch, suspension.

Clinical Assessment of smoking

Clinician interventions as brief as 3 minutes can increase the cessation rate significantly Patients who use tobacco and are willing to quit should be treated using the 5 "A's" -Ask (every patient about tobacco use) -Advise (every tobacco user to quit) -Assess (the patient's willingness to make an attempt to quit) -Assist (those willing to quit by offering medication or referring for counseling) -Arrange (for follow-up contact within the first week after the quit date)

Centrally-acting agents: Alpha Agonists

Clonidine, Guanfacine Not indicated as first-line antihypertensive Clonidine can produce robust BP lowering -Use for acute hypertension urgency is off-label Select potential ADR: -*Drowsiness, fatigue, hypotension, bradycardia, dizziness, headache Caution elderly: on Beers List -CNS AE, bradycardia, orthostatic hypotension Also used in tx of ADHD Monitor -BP, HR, baseline serum creatinine Avoid abrupt withdrawal -Withdrawal sx, rebound HTN if abrupt DC; taper to D/C

common anticoagulants

Clopidegrel Aspirin*** Warfarin (down 10 from prior year) Abixapan (up 30 from prior year!) Rivaroxaban

Comedonal

Closed & open comedones

The Fate of the Closed comedo

Closed comedo ("Time bomb of acne") -Rupture & inflammation --->potent chemoattractant for neutrophils or -Open comedo

Caution: Cold preparations in ped populations

Combination cough/cold/fever products -lack proven efficacy -potential serious toxicity The FDA advisory committee recommends -against the use of OTC cough & cold medications in children < 6 yrs -and not recommended up to 12 yrs Important education for caregivers

Phentermine/Topiramate (Qsymia)

Combination of older drugs -Phentermine ---sympathomimetic -Topiramate ---anticonvulsant, migraine therapy Controlled substance requiring DEA‐ Schedule IV drug Topiramate is teratogenic -negative pregnancy test prior to and during treatment and 2 forms of contraception necessary for women of child‐bearing potential

TZD + Basal insulin

Combinations with Caution if used, use lower dose TZD AE -Glucose lowering‐ high -Hypoglycemia‐ high risk -Weight‐ gain (additive effects) -Other major side effects‐ edema (additive effects) -Cost‐ variable :/

Allergic rhinitis

Common condition -Seasonal > perennial -AR linked w/ several conditions Pharm addresses symptoms -Most pts require pharmacotherapy + allergen avoidance for satisfactory symptom control -Sneezing, rhinorrhea, nasal congestion, postnasal drip, itching of the eyes & nose

Actinic Keratosis

Common growth Gritty or sand-paper-like rough macule or thin papule Sun exposed skin AK ----> SCC (1:100 to 1:1000 risk) Tx: -liquid nitrogen -5-fluoruracil cream -imiquimod cream

Seborrheic Keratosis

Common growths Stuck-on usually brown to black thin papules to plaques Trunk & head & neck > extremities Benign Tx -not necessary -if irritated----> liquid nitrogen

Penicillins (beta-lactam antibiotic)

Common primary care indications -streptococcal pharyngitis -otitis media -sinusitis Generally safe and well-tolerated

Depression follow-up

Common scenario: Patient presents for routine visit, mood seems fine; their med list includes a low/moderate dose antidepressant How often should we check in on their mental health? Ideas for interview questions: -Remind me why you're taking sertraline? -How well is sertraline working for you? -How long have you been taking sertraline? Have you taken it continuously, or have you had periods where you didn't take it?

Antibiotics GI effects

Common w/ many abx common abx -erythromycin -clarithromycin -amoxicillin-clavulanate -doxycycline Diarrhea -related to changes in normal flora

CNS medication overuse HA

Commonly associated with Acetaminophen, butalbital-caffeine-ASA (Fiorinal), butalbital-caffeiene-acetaminophen (Fioricet), ASA, Ergotamine Can occur with any agent Rescue meds (from any class) should not be used >10d/month Preventive therapy is the mainstay for patients requiring more frequent rescue medication to avoid MOH

Radioactive Iodine (RAI-131) thyroid ablation therapy

Commonly used option for the treatment of hyperthyroidism that is endocrinology-directed Induces extensive tissue damage, resulting in ablation of the thyroid within 6 to 18 weeks. Patients who receive this med have the potential to contaminate their home and household contacts via saliva, urine, or radiation emitting from their neck, so patients will be educated on many post-treatment precautions. This med often induces hypothyroidism, so thyroid function is monitored routinely.

Before prescribing ADHD med

Complete history and physical exam Baseline height, weight, BP, and heart rate Co-morbidities? -CV is a focus ---Aim: identify underlying cardiac disease that may predispose the patient to serious CV events -Psych and Neuro ---Refer as needed for further evaluation -Substance abuse in patient or family? ---Influences drug selection ---Stimulants have a black box warning for abuse and dependence Pretreatment baseline for common potential adverse effects of ADHD drugs

Charts for asthma in children

Components of severity 1. Impairment based on -sx -nighttime awakenings -SABA use for sx control -Interference w/ normal activity -Lung function (Age 5-11) -Validation questionnaires (age 12 & >) 2. Risk -exacerbations requiring oral systemic corticosteroids -tx related AE -Reduction in lung growth (age 5-11) -Tx-related AE (age 5-11) Classification of asthma severity -Intermitent -Persistent ---Mild ---Moderate ---Severe Recommended Action of Tx

SGLT2 cons/AE

Con: Absence of long‐term efficacy and safety data Potential AE - Primary: genital, GU tract infections; others: dehydration, hypotension Be aware: Post‐marketing reports of DKA with SGLT2i - May not present typically, BG may be only minimally elevated - Check serum ketones if N/V, abdominal pain, malaise (DC SGLT2i if acidosis is confirmed)

Levofloxacin

Concerns regarding use during pregnancy and for children and youth < 18 yrs of age due to potential for adverse articular effects

Dermatology referral

Confirmation of diagnosis Inadequate response to tx Significant impact on quality of life Advanced tx regimens Widespread, severe disease

DRESS

Confluent morbiliform skin eruptions w/ oc-occuring systemic effecs including hematologic abnormalities, lymphadenopathy, and renal & hepatic invovment

Combo caution (DM): TZD + Basal insulin

Consider benefits/risks w/ this combo- if used, use lower dose TZD Glucose lowering - high Hypoglycemia -high risk Weight -gain (additive effects) Other major side effects -edema (additive effects) Cost -variable

Baseline BP 20/10 mmHg or more above goal?

Consider combo therapy: 2 drugs from different classes -May increase likelihood that target BP are achieved in a more reasonable time period -Ex: *ACE (or ARB) + long-acting dihydro CCB* (This combo preferred) OR ACE (or ARB) + thiazide diuretic -Be cautious in patients at increased risk for orthostatic hypotension (such as older adults)

Referral Considerations (DM)

Consider endocrinology referral for T1DM, insulin pumps, and continuous glucose monitoring (CGM) Consider the training and support needed for insulin pumps and CGM When prescribing devices, robust diabetes education, training, and support are required for optimal CGM device implementation and ongoing use

Levothyroxine starting dose

Consider individual patient factors and use clinical decision-making when selecting a dose. The range of required doses is wide, can vary from 50 to >200 mcg/day. T4 requirements correlate better with lean body mass than total body weight. 50-75 mcg daily for a non-pregnant adults? -Older patients and those with coronary heart disease should be started on a lower dose, such as 25 mcg daily. Initial dose may be calculated, but consider factors, such as the patient's age, disease severity, and health status (including cardiovascular and bone). -Calculating the initial dosing using 1 mcg/kg/day, or the full anticipated dose of 1.6 mcg/kg/day, in young, healthy patients may be considered. (Note the levothyroxine dose is mcg/micrograms, not mg/milligrams.)

Paroxetine (Paxil)

Depression drug, SSRI Downsides: -Difficult to titrate off -Uncomfortable if dose is missed -Highest potential for weight gain -Pregnancy category D No reason to start anyone on this in primary care (unless they did particularly well with it in the past). If someone is doing well with it, continue!

Precaution when using QT prolonging drugs

Consider individualized risk-benefit analysis and alternative agents Also consider if the patient is taking other meds that can prolong the QT interval Avoid use of more than one QT prolonging drug when possible Monitoring-EKG Instruct patients being treated with QT-prolonging drugs to report any new sx -palpitations, syncope, or near-syncope

Step 4 prescribing antibiotics

Consider potential risks -AE -pregnancy, lactation -older adults -peds -renal impairment -resistance

Tx HTN pregnancy

Consider the risks and benefits for both mother and fetus The level of BP is the most important factor: -Severe ---Defined as systolic BP ≥160 mmHg and/or diastolic BP ≥110 mmHg ---Prompt treatment is recommended (to reduce the risk of maternal stroke and other serious maternal complications); ER/IV meds -Moderate ---Defined as systolic 150-159 mmHg, diastolic 100-109 mmHg -Mild ---Defined as systolic 140-150 mmHg, diastolic 90-100 mmHg

ADHD considering tx

Consider the values & preferences of the patient and family Consider age of the child -School-aged children (≥6 years) and adolescents who meet diagnostic criteria for attention deficit hyperactivity disorder (ADHD) can be treated with drug therapy. -Pharmacotherapy for a child younger than 6 years of age should be managed by or in consultation with a specialist since there are additional considerations and the effects of stimulants on preschool children are unpredictable.

Stimulant considerations & strategies for AE

Considerations Patients may have unique responses Many AE are mild, of short duration Consider how can be reversed with adjustment to dose or timing Strategies Change the class -Ex: Methylphenidate vs Amphetamine or Stimulant vs Non-stimulant Change to another drug within that class (ex: Ritalin LA to Concerta) Change the dose - Ex: reduce the dose if increased anorexia, insomnia, or irritability

Metabolic Syndrome (atypical antipsychotic)

Constellation: -Abdominal obesity (35in women, 40in men) -With 2 of 4: ---Elevated triglyceride level ---Reduced high-density lipoprotein ---Elevated blood pressure ---Elevated fasting blood glucose Commonly results in development of DM2 and CV disease

Opioids AE

Constipation, nausea, vomiting Sedation, impaired psychomotor function; cognitive effects may impair ability to drive Urinary retention Sleep‐disordered breathing Risk of misuse, respiratory depression, and overdose Opioid‐induced hyperalgesia -patients treated with opioids can become more sensitive to certain painful stimuli Long‐term opioid use has been linked with: hypogonadism, immunosuppression, and increased risk of MI Neonatal abstinence syndrome (NAS), is most commonly associated with opioid exposure -Neonatal Opioid Withdrawal Syndrome (NOWS): withdrawal symptoms in newborns

COVID & asthma

Continue prescribed medications particularly ICS and OCS Written asthma action plan Avoid nebulizer in clinic whenever possible Avoid spirometry in patients with confirmed or suspected COVID-19

Nitrates off time

Continuous nitrate use results in tolerance‐ smooth muscle of periphery and coronary vessels stop responding/dilating. Tolerance prevention: -Rapidly change blood nitrate levels in a 24 hour period -Common goal: 10‐12 hours nitrate free per 24 hours Examples: -Isosorbide mononitrate at 7am and 3pm (off time through the night) -Nitroglycerin ointment dosed at bedtime and rinsed off in the morning (off time through the day)

ICS caution/AE

Contraindications/Caution -acute attacks -use w/ caution in children -avoid: Cushing's disease -caution in: ocular herpes, TB, oral/nasal trauma, untreated URI AE -Usually well tolerated -Oropharyngeal candidiasis (thrush): rinse after use -hoarseness, xerostomia & dysgeusia -cough -HA -Growth suppression

Seizure Tx goals

Control seizure activity Avoid treatment side effects Restore quality of life

Successful use of Topical corticosteroids

Correct Diagnosis Lesion type & location being treated Potency Vehicle (base the active med is delivered) Application methods -consider absorption inflamed skin-faster absorption -For optimal absorption of most topical drugs, apply them to moist skin either immediately after bathing/wet soak -Occlusion enhances drug absorption

Treating Mild to Moderate Ecema

Correct diagnosis! Rule out allergic or irritant contact dermatitis, dermatophyte infections, drug rxn, etc Good skin care: mild superfatted skin cleansers (unscented Dove, Basis, etc.), lukewarm not hot showers, lubricate skin frequently w/ unscented or fragrance free lotions/creams

Barriers to medication non-adherance

Cost Complexity of Regimen -Multiple medications -Frequent dosing Lack of Symptoms Trust/Mistrust Knowledge deficit Health Beliefs Self-efficacy (perceived ability to perform action) Misunderstanding -the need for the medicine -the nature of side effects -how to take the medication -the expected time it will take to see results

DPP4‐I cons

Cost? Relatively weak effects on A1C (0.5‐0.9%) Longterm safety? -Postmarketing reports of acute pancreatitis ---Avoid for patients with a h/o pancreatits -Possible link with severe joint pain (FDA report 2015) -Heart failure risk (saxagliptin and alogliptin, FDA warning, 2016)

Macrolides Potential AE

GI (N/V/D/abd pain) Hepatoxocity/drug-induced hepatitis Prolonged QT interval (consider other drugs that can have additive effects)

Cough suppressants (antitussives)

Cough - a physiologic response---> suppression may cause retention of secretions MOA -Act on the cough center to depress cough reflex No OTC products have been proven effective in treating cough Dextromethorphan -Not routinely recommended for acute cough d/t the common cold -Lack of consistent important benefit in published studies -Potential for adverse effects from misuse, may be toxic in children -May cause hallucinations, may interact w/ some psychotropic drugs Codeine -controlled substance -NOT recommended in URI -Controlled studies have not supported its use as an effective antitussive -Risk for neonatal withdrawl, resp depression for babies of women who took codeine near delivery

Benzonatate (Tessalon perles)

Cough suppressant Peripherally-acting non-narcotic antitussive MOA -Anesthetize respiratory stretch receptors in lungs & pleura May help nonproductive cough Onset 15-20 min, duration 3-8 hrs No drug interactions in Epocrates Potential adverse psychiatric effects -isolated cases of abnormal behavior reported (mental confusion, visual hallucinations) NOT approved for use in children < 10 yrs

Cockroft-Gault Equation

CrCl= (140-age) x Wt (kg)/ 72 x SCr **x 0.85 if female**

HTN Treatment

Current conclusion about monotherapy: Amount of BP reduction is the major determinant of CV risk reduction, not the choice of antihypertensive drug In some cases, co-morbidity may guide selection of a specific agent -Ex: ACE or ARB for HFrEF, prior MI, and proteinuric CKD Main classes for treatment of primary hypertension in primary care according to current evidence: -ACE inhibitor or Angiotensin II receptor blocker (ARB) -Thiazide or thiazide-like diuretic -Calcium channel blocker (long-acting, usually dihydropyridine)

Do not combine

DPP‐4 inhibitor/ GLP‐1 agonist or Meglitinide/sulfonylurea

(DOACs) Direct Oral Anti‐Coagulants or (NOACs) Novel Oral Anti‐Coagulants

Dabigatran (Pradaxa) Apixaban (Eliquis) Rivaroxaban (Xarelto) Edoxaban (Savaysa) Note: Briefly, there is now a fairly robust body of evidence suggest equivocal (researcher‐speak for equal) or superior outcomes for DOACs/NOACs as warfarin, and they have definitely panned out to be easier to dose and take, and their side effects have been a mix of superior and similar as well. In 2019, an update to the AHA/ACC atrial fibrillation guidelines was released, and it actually favors this class over warfarin for thrombus prevention in AF.

Abx stewardship

Decide -appropriately determine when abx are indicated Act -only give abx when indicated -accurate prescribing (drug, dose, duration) Empower & educate -create a unified prescribing environment

Psoriasis

Defined -A chronic eruption of scaly plaques on the extensor surfaces that may involve the scalp & nails Types -Vulgaris, guttate, pustular, erythrodermic, scalp, palmoplantar, nail Primary lesion -well-defined plaque w/ thick silvery scale Keys to dx -distribution -pitting of nails

Acne Vulgaris & Rosacea

Defined -Chronic papulopustular eruption affecting the pilosebaceous units of the face & trunk Types -Comedonal -papulopustular -nodulocystic -conglobata -fulminans -rosacea Primary lesions -red papule/nodule -pustule -comedones (white & black heads) Keys to Dx -age -flushing?

Eczema

Defined -Inflamed, pruritic skin (dermatitis) not due, exclusively, to external factors (allergens, sunlight, cold, heat, fungus, etc) Types -atopic, asteatotic, hand, numular, stasis (dermatitis) Primary Lesion -ill-defined scaly red patch Keys to Dx -rule out external factors as the sole cause of the eruption

Pyoderma

Defined -bacterial infections of the skin usually due to staphylococci/streptococci Types -folliculitis -impetigo -furunculosis Primary lesions -pustule or crusted erosion Keys to dx -follicular-based pustules, honey-colored crusts, tender red nodules

Scabies infestation

Defined -infestation of the skin due to the ectoparasite sarcoptes scabei Types -nodular -crusted (Norwegian) Primary lesion -linear burrow -excoriated papule Keys to dx -scabies prep, others itching, head & neck spared, hands & waistline involved

Dermatophyte Infection

Defined -superficial fungus infections of the skin caused by dermatophyte fungi Types -Tinea corporis (body), capitis, cruris, manuum (hand), pedis, unguium (nail) Primary lesion -scaly red patch or yellowish nail w/ subungual crumbling Keys to dx -identification of hyphae on KOH exam or fungus culture

Types of Anemia

Definition - a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues. Often manifests in patients as fatigue. Iron Deficiency Anemia (IDA) Folic Acid Deficiency Anemia (FDA) Pernicious Anemia (PA) Anemia of Chronic Disease (ACD) Thalassemia

Type II drug rxn

Delayed in onset (days-weeks) and caused by antibody (usually IgG-mediated cell destruction); Uncommon Clinical features: -Hemolytic anemia -thrombocytopenia -neutropenia

Type III drug rxn

Delayed in onset (days-weeks) and caused by immune complex; Uncommon Clinical features: -Serum sickness -vasculitis -drug fever -acute glomerulonephritis

Type IV drug rxn

Delayed in onset (varies, 24 hours-months) and T cell mediated Some morbilliform reactions, severe exfoliative dermatoses (ex: Stevens Johnson Syndrome), DRESS, interstitial nephritis, drug-induced hepatitis Any re-exposure contraindicated

Withdrawal from nicotine

Depressed mood Irritability Difficulty concentrating Anxiety Weight gain

Fluoxetine (Prozac)

Depression drug Most activating of SSRIs. Can be great for patients with low energy. Least likelihood for weight gain. Due to activating effects, most likely to aggravate panic or anxiety symptoms (particularly spontaneous panic). Can still use with these patients- start low, go slow. Starting dose: 5-20 mg Upper primary care dose*: 80 mg *The doses in this lecture listed as "Upper primary care dose" are the highest recommended doses on the package inserts. Psychiatric providers often use higher doses.

Escitalopram (Lexapro)

Depression drug, SSRI Last to go generic. Designed to have less sexual side effects (anecdotally, this goal may not have been achieved...) Racemic isomer of citalopram Starting dose: 5-10 mg Upper primary care dose: 20 mg

Sertraline (Zoloft)

Depression drug, SSRI Typically weight neutral. -A note on weight gain with SSRIs in general- very individualized whether a patient will gain weight. Often difficult to tease out whether weight changes are effect of med or symptom change. Effect may be cumulative. Used commonly (has been generic the longest) Starting dose: 12.5-50 mg Upper primary care dose: 100(+?) mg

Therapy of Severe & Widespread eczema

Dermatology referral Oral or intramuscular steroids Phototherapy Oral methotrexate

Pathologic‐ Neuropathic & Central Pain

Described as a maladaptive pain; damage or dysfunction of nervous system (such as with diabetes, nerve injury, central pain disorders) Ex: diabetic neuropathy, Fibromyalgia Might feel electric, burning, pins and needles, tingling, shooting Non-opioid med -Anticonvulsants (gabapentin, pregabalin) -SNRIs (duloxetine, milnacipran) -TCAs (amitriptyline, nortriptyline) -Topical agents: lidocaine or capsaicin

Pharmacogenomics

Development and use of medications

Some causes of immunodeficiency

Diabetes HIV/AIDS ESRD Cirrhosis Medications (steroids, chemotherapy, radiation)

Criteria for pharmacotherapy peds ADHD

Diagnostic assessment is complete & confirms diagnosis of ADHD Child is age 6 yrs or older -Children younger than 6 yrs should be managed by or in consultation w/ a specialist since the effects of stimulants on preschool children are unpredictable Parents accept medication as a contribution to management School will cooperate in administration & monitoring -It is not safe to permit the child or adolescent to take his or her own medication to school No previous sensitivity to the chosen medication Child has normal HR & BP Child is seizure free -Children w/ these conditions should be managed by, or in consultation w/, a specialist Child does not have Tourette syncrom -Children w/ these conditions should be managed by, or in consultation w/, a specialist Child does not have pervasive developmental delay -Children w/ these conditions should be managed by, or in consultation w/, a specialist Child does not have significant anxiety Substance abuse among household members is not a concern (for children who will be teated w/ immediate-release stimulants)

Calcium

Dietary history to assess calcium intake prior to supplementation is important. Dietary intake of calcium is encouraged. Average daily calcium intake among American adults is about half of what is recommended. Those who are getting adequate calcium from dietary intake alone do not need to take calcium supplements. If dietary intake is inadequate, consider calcium supplementation. Total intake of calcium (diet + supplements) should not routinely exceed 2,000 mg/day • There is some disagreement among experts regarding optimal intake and utility of calcium supplements. Calcium carbonate or calcium citrate Avoid excess supplementation, avoiding calcium doses over 500-600 mg at one time.

Discontinue PPI

Difficult to discontinue without developing symptoms. Discontinuation of PPI successful for ~ 1/3 long-term PPI users GERD patients more difficulty than non-GERD patients

Therapeutic Drug monitoring

Digoxin 0.8-2 mg/L Gentamicin, Tobramycin & Netilmicin: -Peak 4-8 mg/L; Trough <2 mg/L Lidocaine 1-5 mg/L Lithium carbonate 0.6-0.8 mEq/L (trough) Phenytoin 10-20 mg/L Theophylline 5-20 mg/L Valproic acid 50-100 mg/L Carbamazepine 4-12 mg/L

Non-Dihydropyridine calcium channel blocker

Diltiazem (cardizem)

HTN Adherence

Potential adverse effects Drug costs -Generics? $4 list? Complexity of drug regimen -Use of combined drugs can facilitate adherence (but may be more costly)

1st gen antihistamines

Diphenhydramine (Benadryl) -common ingredient in OTC allergy and sleep products Hydroxyzine (atarax, vistaril) -Sometimes used in primary care for pruritis/itching -some psychiatri providers use for anxiety Promethazine (phenegran) -sometimes used in primary care of N/V Chlorpheniramine Brompheniramine

Inactivated vaccines

Diptheria, tetanus, & pertussis vaccine Haemophilus B conjugate vaccine Inactivated poliovirus vaccine Hepatitis B virus vaccine Hepatitis A virus vaccine HPV vaccine Influenza vaccine Pneumococcal vaccine Meningococcal polysaccharide vaccine -Lyme disease vaccine -Typhoid vaccine -Cholera vaccine -Japanese encephalitis virus vaccine -plague vaccine -rabies vaccine

Cholinergic Agonist Drugs

Direct-Acting -Acts like acetylcholine Indirect-Acting -inhibits acetylcholinesterase

Combo caution (DM): Sulfonylurea + Basal insulin

Discontinuing sulfonylurea is often recommended w/ insulin use glucose lowering -high Hypoglycemia - highest risk (additive effects) Weight -gain (additive effects) Cost - variable

PUD (peptic ulcer disease)

Disorder that involves the upper GI tract Duodenal and gastric ulcers - most common 4 etiological groups: - Acid hypersecretion - Drug-induced - "Stress" ulcers following surgery - Infections - bacilli Helicobacter pylori

Systemic "azoles" (antifungal) MOA

Disrupt biosynthesis of a vital component of the cellular membrane of fungi, resulting in cell lysis and death CYP450 inhibitors---> increased drug interaction potential!

HTN considerations

Diuretics ACE inhibitors (angiotensinconverting enzyme inhibitors) ARB (angiotensin II receptor blockers) CCB (calcium channel blockers) -Dihydropyridine -Non-dihydropyridine Others -Potassium-sparing diuretics -Beta blockers -Direct renin inhibitor -Peripherally-acting agents ---Alpha blockers -Centrally-acting agents ---Alpha agonists

Cephalosporins (beta-lactam antibiotic)

Divided into "generations" based on their spectrum of activity Some 1-3rd generations of commonly used options in primary care 4th generation, cefepime, 5th generation, ceftaroline, are IV

Travelers' diarrhea prophylaxis

Do not generally recommend prophylaxis Fluoroquinolone, e.g., Cipro or Levaquin for a maximum of three weeks is ~90% effective. Rifaximin - 72% effective. Bismuth salicylate (Pepto-Bismol, Kaopectate, Maalox Total Stomach Relief) - Tless effective than antibiotics (~65%). - Use 2 tablets every 30 minutes for up to 8 doses for TREATMENT.

Was medication non-adherence non-intentional?

Does the person have cognitive impairment? Do they believe that the medication was discontinued or replaced? Did they not understand how long it was to be continued? Di they not understand that a "cure" was not possible?

ED50: Pharmacodynamic

Dose produces a half maximal response

LD50: Pharmacodynamic

Dose produces a half toxic response

Factors affecting tx: dosing & duration

Dosing schedule -often 1-2x daily Duration is important -goal: shortest duration required to achieve desired effect -consider condition & steroid potency ---primary care use of higher potency (max 3 wks) ---medium potency (not on face/intertriginous areas) < 6 wks ---Facial, intertriginous, genital dermatose shorter- max 1-2 wks ---peds: typically max 1-2 wks

Pharmacokinetics

Drug absorption, distribution, binding affinity, metabolism, and excretion

DRESS (drug eruptions)

Drug reaction with eosinophilia and systemic symptoms Severe and potentially life-threatening Characteristics -Confluent morbilliform skin eruption, hematologic abnormalities, lymphadenopathy, renal and hepatic involvement Common causes -Some antiepileptic agents,allopurinol, and the sulfonamides

Side Effect of Anticholinergic Drugs

Dry mouth Blurred vision Urinary retention Constipation Flushing Tachycardia Confusion, amnesia, hallucinations

Inhaled Insulin: Afrezza

Dry‐powder formulation of rapid‐acting insulin -Many patients will still need to inject long‐acting insulin Indicated for use in adults ≥ 18 years - NOT indicated children or pregnancy Literature currently supports subcutaneous rapid‐ acting insulin over inhaled insulin More limited dosing options than SQ insulin - Cartridges of 4, 8, and 12 unit options - Administered as a single inhalation per cartridge - If a patient needs a dose exceeding 12 units, inhalations using multiple cartridges are necessary (eg, a patient requiring 16 units with dinner will need two different inhalations of the 8‐unit cartridge).

Considerations for initiating ADHD med in peds

Duration Ability to swallow pills or capsules Time of day when the target symptoms occur Potential adverse effects History of substance abuse in patient or household member Preference of the child/adolescent and his/her parent/guardian Preferences regarding administration at school Expense

HTN principes

Each of the antihypertensive agents is roughly equally effective in lowering BP There is wide interpatient variability Many patients will respond well to one drug but not to another, but it can't always be predicted Ex: Those of black ethnicities and older patients generally respond better to a thiazide diuretic or CCB and relatively poorly to an ACE inhibitor or beta blocker -But...they may still have a specific indication for an ACE or ARB (such as HFrEF, MI, CKD)

Acne Pathophysiology (Formation of the Comedo)

Early microcomedo: -sebaceous canal distends w/ sticky corneocytes Late microcomdeo -colonization w/ Propionibacterium acnes Mature close comedo (white heads) -densely packed corneocytes, solid masses of P. acnes, few small hairs Open comedo (black head) -sticky corneocytes, bacteria, oxidized lipids

Fibrates: Fibric Acid Derivatives

Effect on lipids -**Primarily decreases triglycerides (TG) -Some decrease total serum cholesterol (TC), LDL, and some increase HDL *Often used if TG level >500 -Risk of pancreatitis Select exemplars -Fenofibrate ---May be preferred over gemfibrozil -Gemfibrozil ---Less expensive ---Tends to have more drug interactions Avoid hepatic impairement, eGFR <30 Not recommended lactation, avoid pregnancy Select potential ADRs: GI effects, cholelithiasis, phototoxicity, increase LFTs

NSAIDs

Effective for treatment of acute and chronic painful and inflammatory conditions. Nonselective -Ibuprofen -Naproxen -Meloxicam -Indomethacin -Ketorolac Selective COX-2 inhibitor -Celecoxib

Cold/URI treatment

Effective therapies in adults -analgesics -antihistamine/decongestant combo -intranasal/inhaled cromolyn sodium -intranasal ipratropium bromide Therapies w/ minimal or uncertain benefits -dextromethorphan -decongestants -saline nasal spray -expectorants -herbal products -zinc Ineffective therapies -antibiotic therapy -antihistamine -antivral therapies

Use of Steroid Nasal Sprays

Efficacy is linked w/ appropriate admin -Clean nose -Goal: medication in nose instead of throat -Head positioning (note: differes per formulation) ---aqueous delivery system: chin slightly tucked ---"Dry" aerosol delivery system: tilt head back slightly -Lightly sniffing -Some prefer holding the nostril closed w/ a finger from the opposite hand -Spray should be directed AWAY from the nasal septum -Avoid blowing nose for 15 mins after use

Initiating Drug Therapy (smoking)

Goal of drug therapy is long-term cessation and reduced likelihood of relapse The most effective treatment of tobacco dependence requires the use of multiple modalities

Lithium (mood disorder)

Electrolytes (may alter Na, K, Mg, P levels) Renal function (nephrotoxicity) Thyroid panel q~6 months Lithium levels for therapeutic dosing Special considerations: -Tetratogenic in first trimester -Elderly require lower doses for therapeutic response -NSAIDS, ACE-Is, diuretics, CCBs may cause increased plasma levels

Summary: Lipid Management in Adults

Elevated LDL-C, non-HDL-C, TG, TC/HDL-C ratio, ApoB, LDL particles -Statin = treatment of choice -Can consider bile acid sequestrant, niacin, or cholesterol absorption inhibitor if statin is contraindicated or not tolerated TG ≥500 mg/dL -Use fibrate or high-dose omega-3 fatty acid to reduce TG and risk of pancreatitis

Denosumab duration

Emerging concerns about an increased risk of vertebral fracture after stopping, the need for indefinite administration (up to 10 years?) of this med (or transition to another therapy when DC'd) should be discussed with patients prior to its initiation.

HTN reccomendations

Emphasis on multiple therapeutic agents at lower doses (rather than one agent at max dose) -After the initial dose, going to higher doses may produce on average relatively small further reductions in BP with risk of an increasing rate of adverse effects. Changes definitions of control for elders to allow higher values to avoid orthostatic falls and increase adherence Beta blockers no longer first-line drugs

Identify the pathogen (antibiotic)

Empiric therapy = choosing the antibiotic based on most likely pathogen -commonly used in primary care -When culture is not available/feasible to guide selection -based on epidemiology of suspected infection -in general, most likely organism is based on the suspected site of the infection -Evidence-based resources can help guide drug selection

Pyoderma therapy

Empiric tx before culture results -Clindamycin -erythromycin Topical mupirocin (bactroban) has excellent staphylococci/streptococci action

Metabolite

End product of metabolism. Either active or inactive

Yellow fever vaccine

Endemic of Sub-Saharan Africa & tropical South America Certification required to enter some countries Vaccinate all persons over 9 months of age traveling to endemic areas -Use cautiously in pts over 60

Mechanisms of Drug Interactions

Enhanced or inhibited absorption Protein binding displacement Enzyme induction Enzyme inhibition Inhibition or induction of the drug efflux transporter P-glycoprotein (P-gp)

Sulfonylureas MOA

Enhances insulin secretion/ "secretagogue"

Resources to check for Drug-Drug Interactions (DDIs)

Epocrates interaction checker University of Liverpool (free online app)

DOACs vs. warfarin

Equivalent clot prevention (some studies find DOACs superior) Fewer bleeding events with DOACs, particularly fewer intracranial bleeds. 2019 ACC/AHA guideline suggest DOACs/NOACs be used as first line therapy for thrombus prevention in atrial fibrillation

Drug-induced exanthermes/Morbiliform eruptions

Erythematous macules and papules that predominantly involve the trunk & proximal extremities

Medication Adherence counseling

Establish -trust -bi-directional communication Provide -simple explanations & education about meds & adherence Support -adherence-identify & address barriers to adherence Monitor -medication adherence in a non-judgmental manner

principle 4 (depression)

Establish therapeutic relationship LISTEN PARTNER! Move forward in agreement. Discuss realistic goals. Encourage communication of symptom progress and side effects. "You are the best therapeutic tool that you have - just your genuine self. Monkeys can learn to prescribe. It's the connecting piece - that's what we do. To just be able to sit with someone in their pain - not to run and fix it but just to sit and listen to them - they'll tell you all kinds of things."

Smoking demographics

Estimated 43.4 million smokers in US Men > Women smokers 16.7% of adult males smoke in US 13.6% adult females smoke in US Asian-Americans have the lowest rate of smoking in US American Indian and Alaskan natives have the highest rates Smoking in US high school students is estimated to be 9.3 % in 2015 (down from 36.4% in 1997). Estimated that every day approximately 3,200 children and adolescents smoke their first cigarette

Psoriasis: Pathophysiology

Etiology unknown: -possible genetic, environmental, physical factors Main defect: -rapid turnover of epidermal maturation (differentiation) ***Normal epidermal transit time = 30 days ***Psoriasis epidermal transit time = 7-14 days T cell mediated cytokine release (TNF alpha) TH1 cytokines

Eczema: Pathophysiology

Etiology unknown: -genetic & environmental factors play a strong role Histology -Spongiosis = intercellular edema within the epidermis. Acute & chronic inflammatory cells T cell mediated cytokine release (TH2 type)

Antidepressant titration

Every person is different. Most will see some symptom movement in 2 weeks, and by 4 weeks, they'll have seen most of the benefit of that dose. 4 week follow up: "Do you feel like there's room for you to feel better?" Typically, doses are increased ~q4wks by doubling or by adding increments of the starting dose. Doubling example: Prozac 10mg, 20mg, 40mg, 80mg Incremental example: Prozac 10mg, 20mg, 30mg, 40mg, etc. Start low or medium low. Go at the pace that seems to work for the patient. There is not a standardized "target dose." Treat to effect. Sometimes there are reasons to go slower or faster with dose adjustments- you will pick up this "art" as you go. The rate an individual metabolizes an anti-depressant may determine dose to a greater degree than their symptom severity. Keep the goal (RECOVERY) in mind. Do not be satisfied with remission/partial remission! Most common PCP mistake: trying low doses of several agents instead of maximizing a single agent. Remind patient that dose is partially based on how they metabolize, not how sick they are

Who should not take Triptans

Evidence is poor because we've always avoided use in these patients. Avoid use in: -History of ischemic stroke -History of ischemic heart disease -Prinzmetal's angina -Uncontrolled hypertension Pregnancy Familial hemiplegic migraine Basilar migraine (vertigo, tinnitus, other neuro sx) Patients taking MAOIs Not within 24 hours of Ergots Note about serotonin syndrome: -Recall that this class should be incorporated into your estimate of total serotonin burden. -Probably safe to use triptans with SSRIs/SNRIs/antipsychotics as these agents act on the 1a/2/3 receptor sites.

Factors to consider when selecting an antibiotic

Evidence of drug for the specific infection Spectrum of coverage Pt allergy Patterns of resistance Recent antibiotic exposure (approx. past 3 months) Cost Adverse effects Adherence Convenience (BID vs q 6) Formulation Pt characteristics Age, pregnancy, co-morbidities, Immune status

Stepwise Approach (asthma)

Evidence-based resource: Expert Panel Report 3 (NHLBI) Goal of persistent asthma therapy: suppress inflammation and prevent exacerbations Dose, number of meds, frequency of administration -increase as necessary, decrease when possible

Fluoroquinolones examples & uses

Ex -Ciprofloxacin -levofloxacin Uses -pyelonephritis -opthalmic infections (drops)

Antimicrobial sulfonamide

Ex -TMP-SMX -silversulfadiazine/silvadene cream Chemical structure believed central to the pathogenesis of hypersensitivity reactions

SUlfonamides uses and ex

Ex (combo of 2 drugs) -Trimethoprim/sulfamethoxazole (TMP/SMX;bactrim) Uses -UTI -skin infections

Macrolides examples and uses

Ex. -Azithromycin -Clarithromycin -Erythromycin Uses -Community acquired pneumonia (CAP) -Pharyngitis as alternative to PCN -STD -H. Pylori

Allylamine (antifungal) ex and uses

Ex. -Terbinafine Uses: -dermatophytes (onychomycosis) -tinea versicolor

Systemic "azoles" (antifungal) ex and uses

Ex. -Triazoles -Imidazoles Uses -Tinea -dermatophytes -tinea versicolor -candida

Metronidazole (Flagyl) ex and uses

Ex. -antiprotozoal -antibacterial Uses -Bacterial vaginosis -mild c. diff -H. pylori

Non-antimicrobial sulfonamides

Ex. -diuretics -hypoglycemics -anti-inflammatories -antihypertensives Associated w/ fewer immunologic rxns

Tetracyclines examples and uses

Ex. -Doxycycline -Minocycline Uses -Lyme disease -RMSF -PID -acne vulgaris

Leukotriene Receptor Antagonist

Ex. Montelukast (singulair) Indicated to treat both AR & asthma NOT recommended 1st line for AR: less effective overall in symptomatic tx, but is alternative if INGC is not an option -monotherapy or combined w/ 2nd gen antihistamine Potential, rare adverse effect: Neuropsychiatric events -Dream abnormalities, insomnia, anxiety, depression, hallucinations, suicidal ideations -Avoid in adults & children w/ active/pre-existing, or suspected psychiatric disorders -Inform all pts prior -DC if mood effects

Dosage Forms Affect Drug Concentration

Ex. enteric-coating Do not crush enteric-coated tablets or sustained-release products

DPP‐4 Inhibitors

Ex: Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta) Benefits - Oral - Overall well tolerated ---Doesn't cause hypoglycemia ---Weight neutral

TCAs

Ex: amitriptyline, nortriptyline None carry FDA label primary indication for pain management Amitriptyline has been the most widely studied TCA in chronic pain (and is the most sedating) Associated with multiple undesirable adverse effects, depending on agent. -Adverse effects tend to be dose‐related, recommend start at low dose

MRA (Mineralocorticoid receptor antagonist)/Aldosterone antagonist in HFrEF

Ex: spironolactone, eplerenone Have relatively weak diuretic activity, but offers other benefits Check baseline potassium and renal function before starting Primary potential AE: hyperkalemia -Other potential AE: gynecomastia, menstrual abnormalities, impotence, decreased libido Eplerenone is an alternative if excessive endocrine AE with spironolactone, but more expensive -Given the relative cost differences, spironolactone may be considered first for initial MRA therapy, with switch to eplerenone if endocrine side effects occur. Monitor -Serum renal function, electrolytes, particularly potassium -Such as 1-2 weeks after starting or uptitrating and 1-3 months thereafter Avoid in pregnancy

Fibrates: Fibric Acid Derivatives MOA

Exact MOA unknown -Inhibits triglyceride synthesis

Pre‐Mixed Insulin Therapy for T2DM

Examples: 70/30, 75/25 Changing from basal insulin, the premixed insulin is dosed at the current basal dose Administer twice daily with meals ‐ Before breakfast and evening meal Titration per BG ‐ Can increase about 10% every 4‐7 days if suboptimal BG ‐ Cut back about 20% if hypoglycemia (40% decrease if severe, such as BG <40)

Atypical Antipsychotics

Heterogenous group with complex receptor affinities -Dopamine -Serotonin -Norepinephrine -Histamine -Acetylcholine

MRA (Mineralocorticoid Receptor Agonist)

Exemplars: Spironolactone, Eplerenone -Selective aldosterone blocker ---Off-label- acne, hirsutism -Primary potential AE: hyperkalemia -Other potential AE: gynecomastia, menstrual abnormalities, impotence, decreased libido ---Eplerenone may be better tolerated and have less endocrine effects, but may be more expensive Warning- spironolactone -Tumorigenic in rats, avoid unnecessary use (Lexicomp) Monitor -Serum creatinine/eGFR, electrolytes (esp potassium)

Dihydropyridines (CCB)

Exemplars: amlopidine (Norvasc), nifedipine (Procardia), felodipine (Plendil) -Long-acting agents preferred ---Short-acting options are generally avoided d/t potential reflex tachycardia

Nondihydropyridines (CCB)

Exemplars: diltiazem (Cardizem), verapamil (Calan) -May also be used for rate control in atrial fibrillation

Teach-Back Method: Health Literacy Strategy

Explain Assess Clarify Understanding

Uticaria: pathophysiology

Exposure of allergens to lungs, gut, or skin Type I Hypersensitvity rxn -IgE mediated mast cell degranulation -release of histamine & other chemical mediators -increased capillary permeability & tissue edema

Generic Bioequivalence

FDA requirements for Bioequivalence: Not less than 80% but not more than 125% more

FDA SGLT2

FDA review of new data: removed the Boxed Warning about amputation risk from the diabetes medicine canagliflozin prescribing information Cases of a rare but life‐threatening bacterial infection of the genitals and area around the genitals have been reported - called necrotizing fasciitis of the perineum, or Fournier's gangrene

Fibromyalgia

Fibromyalgia is in the central pain category. Pregabalin (Lyrica)? -First drug FDA approved to treat fibromyalgia -May help with pain and sleep quality or Gabapentin (Neurontin)? -Not FDA approved for fibromyalgia -Some date show improvements in pain and sleep quality Duloxetine (Cymbalta)? -Serotonin‐norepinephrine reuptake inhibitor (SNRI) -FDA approved for fibromyalgia -Has been shown to help with pain, depression, and global functioning after 12 weeks. Milnacipran (Savella)? -Serotonin‐norepinephrine reuptake inhibitor (SNRI) -FDA approved for fibromyalgia -Has been shown to help with pain, fatigue, and cognition in patients with fibromyalgia. ---May be more potent for the management of both neuropathic and centralized pain conditions. Amitriptyline? -Historically, has been the first‐line pharmacologic treatment for fibromyalgia, although it is not approved by the FDA for this indication. -Patients may have short‐term improvement in pain and sleep, but less benefit in the long‐term. -Start with a low dose and titrate up if needed. Cyclobenzaprine (Flexeril) -Is not FDA approved but has been used in practice. Some patients have short‐term improvement in pain and sleep, but no long‐term benefit over placebo. Literature suggests these are not expected to be effective in treating fibromyalgia: -NSIADs -Steroids -Opiates -Benzodiazepines

TB tx

First -Line Drugs -Isoniazid (INH) -Rifampin (RIF) -Rifabutin -Rifapentine -Pyrazinamide (PZA) -Ethambuton (EMB) Second Line Drugs -Cycloserine -Ethionaminde -Moxifloxacin -Gatifloxacin

Non-Nicotine Products

First Line -Zyban (bupropioin) -Chantix (varenicline) Second Line -Clonidine -Nortyiptyline

BB (angina)

First line ↓ cardiac workload, ↓ myocardial O2 demand May be particularly helpful for exertional angina/exercise tolerance Complimentary to long acting nitrates ‐ potentiate MOA and help correct rebound tachycardia Mortality benefit for post‐MI and CAD Available formulations: non‐selective, selective, non‐selective/alpha blocking May cause or potentiate bradycardia, hypotension, fatigue/depression/ED Caution in heart failure exacerbation; pulmonary disease (avoid non‐ selective/higher dose selective, particularly in asthma) Avoid abrupt discontinuation

Recommended Order Of Therapy (smoking)

First line (agent plus counseling) -Nicotine Replacement (patch, gum, lozenge, spray, inhaler) - or -Chantix (varenicline) -or -Zyban (bupropion SR) Second line -Combo therapy -Patch + Gum -or- Patch + Nasal Spray -or -Patch + Zyban Third line (only for people who fail 1st and 2nd line) -Clonidine -notriptyline

Bisphosphonates

First line tx for osteoporosis For most postmenopausal women with osteoporosis, either alendronate (Fosamax) or risedronate (Actonel) is usually considered as the initial choice of oral . -These may be taken daily or weekly, some are monthly. -Less support overall for oral ibandronate (Boniva) due to less anticipated efficacy

Initiating therapy (smoking)

First step in any cessation program = set a specific "quit date" with patient. Non-pharmacologic Approaches: -Individual and Group behavioral interventions -Self-Management (remove ashtrays, avoid smoke- filled places, brush teeth often, chewing gum) -Nicotine Fading - a slow decrease in intake of nicotine per day -Aversion Therapy - Induce a large amount of nicotine at one time which can cause aversion to nicotine (not recommended by the US Dept. of Health)

Acetaminophen/Paracetamol

First‐line treatment in the management of mild persistent pain -May be more safe than some other options Lacks significant antiinflammatory properties, making it less effective for inflammatory pain than NSAIDs May be used in appropriate doses with the older adult Lower risk for pregnancy and lactation -Details noted in "pregnancy/lactation" tab in Epocrates When administered at appropriate doses, acetaminophen is relatively safe.

5 common herbs & supplements

Fish oil/Omega-3 fatty acids Glucosamine or chondronitin Melatonin Probiotics Coenzyme Q10

Food-Drug Interactions

Foods may also affect the P-450 system Ex. Grapefruit juice interactions -inhibits intestinal CYP3A4, P-glycoprotein & furanocoumarin -Other problem citrus fruits: tangelos, limes and Seville oranges. -No problem w/ most other citrus fruits: sweet oranges, lemon, tangerines, and citrons

Opioids & acute pain

For acute non‐cancer pain, consider the shortest duration and the lowest milligram morphine equivalent (MME) dose that is deemed effective to manage the condition. Per CDC guidelines, 3 days of opioid therapy is often sufficient and >7 days is rarely needed for acute pain.

Monitoring bone density

For patients starting on therapy, a follow-up dual-energy x-ray absorptiometry (DXA) of the hip and spine is commonly done after two years, and if BMD is stable or improved, less frequent monitoring thereafter. The finding of a clinically significant BMD decrease or a new fracture in a treated patient should trigger additional evaluation for contributing factors. Complex, non-responding, or concerning cases can be referred to a bone specialist, such as a rheumatologist or endocrinologist for further evaluation and treatment.

If a bisphosphonate is not selected

For patients who cannot receive or are intolerant of oral and IV bisphosphonates, the choice of agent depends on -risk of fracture (eg, history of prior fragility fractures, BMD T-scores, comorbidities) -Efficacy -Adverse effect profile -Patient preferences

Diuretics for HF

For treatment of HF, loop diuretics are generally preferred -Furosemide (Lasix), bumetanide (Bumex), torsemide (Demadex) -May cause hypokalemia -Careful monitoring of potassium and renal function is recommended BBW (furosemide, bumetanide) -"fluid and electrolyte depletion- potent diuretic in excessive amounts can cause profound diuresis with water/electrolyte depletion; individualize dose and schedule with medical supervision"

Drug Distribution

Free or bound to plasma proteins such as albumin -Bound portion = inactive until released to the free form Highly plasma protein bound drugs Ex. warfarin (coumadin)

IBS

Functional bowel disorder Alteration in bowel pattern and abdominal discomfort 10-15% prevalence in North America 4:1—females:males

HIV step 2

Fusion: the HIV envelope and the CD4 cell membrane fuse which allows HIV to enter the CD4 cell Durg -Fusion inhibitors

Sulfonamides potential AE

GI (N/V) Photosensitivity Hypersensitivity rxn (rash/ urticarial) Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis Pancreatitis

GLP‐1 Agonists SE

GI (N/V) Increased satiety, weight loss

Antiviral AE

GI (N/V)(oral Tamiflu> inhaled Relenza) -A little nausea possible with baloxavir/Xofluza? -Headache (Tamiflu) Post-marketing reports of sporadic, transient neuropsychiatric effects (neuraminidase inhibitor) Bronchospasm (inhaled Relenza)Relenza Contraindications: -Asthma, COPD

Orlistat (Xenical® , Alli®) AE

GI are common -Oily spotting -Flatus with discharge -Fecal urgency and incontinence Increased risk of kidney stones (increased urinary oxalate) Consideration: Reduces fat‐soluble vitamins -Education: Take multivitamin at bedtime Avoid: -Malabsorption syndrome -Cholestasis -Pregnancy

Depression med side effects

GI effects and headache typically resolve within 2 weeks. Constipation - increase water intake, try a stool softener, walk Sexual side effects - loss of libido, difficulty achieving orgasm, anorgasmia -How bothersome are the symptoms? Degree of bother will vary widely... -Consider trial on lower dose after 6-12 months or consider another class Side effects are real. Just because it's not listed on the package insert does not mean the patient is not experiencing it. Because serotonin receptors are fairly ubiquitous throughout the body, patients may feel/report a variety of sensations. Assess tolerability, safety.

COVID & GOLD

GOLD recognizes people with COPD are amongst the worst affected by COVID19 No evidence to support that inhaled (or oral) corticosteroids should be avoided in patients with COPD during the COVID19 epidemic COPD patients should maintain their regular therapy Oxygen therapy should be provided if needed following standard recommendations

HFmrEF

General management measures for HFmrEF are similar to those in patients with HFrEF -Lifestyle modification -Management of associated conditions -Serial routine assessment with additional f/u as needed ---evaluate and manage changes in symptoms or signs of HF -Medical therapy similar to HFrEF ---available evidence suggests that patients with HFmrEF respond to medical therapy in a manner more similar to HFrEF (than HFpEF) but the therapy is not exactly the same as HFrEF ---some that may be considered: diuretic, ARNI/ACE/or ARB, Beta blocker, MRA, hydralazine + nitrate if elevated BP, if digoxin is indicated?

GAD

Generalized anxiety disorder (GAD) is characterized by excessive worry and anxiety that are difficult to control and that cause significant distress and impairment. Between 35 and 50 percent of individuals with major depression may meet criteria for GAD.

Multiple drug therapy (HTN)

Generally required to achieve BP targets Fixed-dose, combination medication products -may reduce pill burden and improve medication adherence (also consider $) Some recommendations to take at least one med PM (not diuretic) Some literature suggest that 2 or 3 drugs at half-standard doses might have better outcomes with greater antihypertensive efficacy and less toxicity -compared to 1 drug at standard or twice-standard doses

Cephalosporin potential AE

Generally safe & well tolerated Hypersensitivity rxn (maculopapular rash, urticaria) GI (N/V/D; usually transient) Hemolytic anemia LFT elevations (AST, ALT Caution: -potential cross-sensitivity btw PCN and cephalosporin

Herpes

Genital herpes- incurable, recurrent with exacerbation and remission HSV-1 and HSV-2 Can shed the virus without being symptomatic Episodic therapy can shorten duration of outbreak if taking during prodromal phase or within 24 hours of outbreak Suppressive therapy recommended if > 6 outbreaks/year Tx Acyclovir

ABRS: high risk considerations

Geographic regions w/ high endemic rates of S. pneumonia Risk factors for abx resistance -daycare attendance/close contact -recent hospitalization/close contact healthcare environment -abc use within the past month -failure of prior abx therapy -smoking/close contact w/ smoking Other considerations for higher risk -age <2 or >65 -Immunocompromised -multiple co-morbidites -severe infection

Major 2nd line agents (DM)

Glucagon-like peptide-1 receptor agonists Sodium-glucose cotransporter-2 inhibitors Dipeptidyl peptidase-4 inhibitors Thiazolidinediones Sulfonylureas

AR tx options

Glucocorticoid nasal spray Oral antihistamines Antihistamine nasal spray Mast cells tabilizer Leukotriene modifier Intranasal anticholinergic *avoid systemic steriods & topical decongestants for routine tx of AR

Metformin (term)

Glucophage

considerations for T2DM meds

Glucose level and pattern • A1c • When is the BG high? Anticipated glucose lowering effect of drug Safety considerations • Age • Renal/hepatic function • Other co‐morbidities Cost Adverse effects/ Tolerability • *Especially hypoglycemia, weight gain Complexity of regimen Patient preferences

Sulfonylureas (term)

Glyburide (Diabeta) Glipizide (Glucotrol) Glimepiride (Amaryl)

T2DM Summary

Glycemic targets & BG‐lowering therapies must be individualized, based on a variety of patient and disease characteristics. Diet, exercise, & education: foundation of any T2DM therapy program. Unless contraindicated, metformin is 1st line. After metformin,see ADA and AACE algorithms. -Combination therapy with 1‐2 other oral/injectable agentsisreasonable. -Try to minimize side effects and complexity of regimen. All treatment decisions should be made in conjunction with the patient (focusing on his or her preferences, needs, & values). Comprehensive CV risk reduction is a major focus of therapy.

CAP Goals of Tx

Goal is to eradicate the offending pathogen Return to baseline respiratory status. Fever resolves in 2 to 4 days. Leukocytosis resolves by day 4 of treatment. Chest x-ray may take 4 weeks or more to return to normal.

principle 3 (depression)

Goals of therapy Response- significant reduction (>50%) of depressive symptoms -A START BUT NOT THE GOAL! Remission- period of >2 weeks and <2 months with no clinically significant depressive symptoms -ON THE ROAD, NOT THERE YET! RECOVERY- asymptomatic period of more than two months -THE GOAL!

Streptococal pharyngitis

Goals of therapy (GAS) -reduction in duration and severity of sx -prevent spread to others -reducing incidence of complications ---ARF, Glomerulonephritis, PANDAS syndrome Mild analgesics for pain -NSAIDs, Acetaminophen

Tapering Steroid therapy

Gradual taper of steroids if used > 2 wks permits recovery of HPA axis function Can prevent rebount, systemic effects Gradual reduction of potency & dosing ---over several days-couple wks

Propranolol, Atenolol

Graves' Hyperthyroidism relieving sx Treats symptoms, and unless contraindicated, is recommended for all patients until euthyroidism is achieved by thionamides, radioiodine, or surgery. Monitor BP & pulse since they are BB

Tetracyclines common AE

Gray-brown discoloration of teeth -avoid in children <8 yrs (exception: doxycycline-AAP ok'd < or = 21 days) GI (abd pain, N/V) Photosensitivity Rare: hepatotoxicity

Expectorant

Guaifenesin -Mucinex, Robitussin (OTC), Organidin MOA -increase mucus production & thin respiratory secretions to make secretions easier to expel Value for cough? AE: mild GI irritation Education: give w/ plenty of water Max use 1 wk Not recommended for children: no proven benefit

Beta blocker consideration

HFrEF (certain BB) chronic stable angina migraine prevention hyperthyroidism essential tremor rate control in patients with atrial fibrillation

Types of HIV

HIV-1 -responsible for the majority of HIV infections worldwide HIV-2

Drug Therapies for Dyslipidemias

HMG CoA reductase inhibitors ("statins") -Lovastatin, pravastatin, simvastatin, fluvastatin, atorvastatin, rosuvastatin Ezetimibe (Zetia) PCSK9 inhibitors Bile acid sequestrants -Cholestyramine, colestipol, colesevelam Niacin -Less common, may cause more problems than help Fibrates: fibric acid derivatives -Gemfibrozil, micronized fenofibrate, clofibrate Omega 3 Fatty Acids

Cozaar (losartan)

HTN therapy ARBs ("sartan") 1st line HTN option MOA: -Prevents binding of A-II to receptors in kidney, brain, heart, and arterial walls, blocking action of angiotensin II -Inhibits the renin-angiotensin-aldosterone system (RAAS) and cause fall in peripheral resistance Benefits -*No bradykinin-mediated cough like ACEi -Lower incidence of angioedema -Enhanced uric acid secretion in gout AE -Hyperkalemia (similar to ACEi) -Hypotension (more than ACEi) -Changes in renal function, including acute renal failure -Teratogenic (avoid in pregnancy) Can be combined with thiazide diuretic -**Do not combine with ACEi

Trandate (labetalol)

HTN therapy Beta Blockers (Mixed alpha/beta-blocker) MOA -Selectively antagonizes beta-1 adrenergic receptors AE -Hypotension -Bradycardia -Associated with impaired glucose tolerance and increased risk of new onset DM -Alteration of lipids (serum triglyceride, HDL) BBW -"Avoid Abrupt Cessation" -Could precipitate CV event -Taper if DC over a few weeks Avoid -Bronchospastic disease (Asthma, COPD) -Bradycardia -2 nd/3rd degree AV block -Uncompensated HF -DM: may mask hypoglycemia

Inderal (propranolol)

HTN therapy Beta Blockers (Non-Cardioselective) MOA -Selectively antagonizes beta-1 adrenergic receptors AE -Hypotension -Bradycardia -Associated with impaired glucose tolerance and increased risk of new onset DM -Alteration of lipids (serum triglyceride, HDL) BBW -"Avoid Abrupt Cessation" -Could precipitate CV event -Taper if DC over a few weeks Avoid -Bronchospastic disease (Asthma, COPD) -Bradycardia -2 nd/3rd degree AV block -Uncompensated HF -DM: may mask hypoglycemia

HCTZ (hydrochlorothiazide)

HTN therapy Thiazide Diuretics 1st line HTN option MOA: -inhibits distal convoluted tubule sodium and chloride resorption AE -Hypokalemia, -hyperuricemia -hyponatremia -hypotension -hyperlipidemia -hyperglycemia -hypercalcemia -hypomagnesemia

Aldomet (methyldopa)

HTN therapy (A) Centrally-acting agents: Alpha Agonists MOA: -Stimulates alpha-2 adrenergic receptors AE: -Sedation (common), -orthostatic hypotension, -bradycardia, -headache, -blood dyscrasias *Not widely used outside of pregnancy

Accupril (quinapril)

HTN therapy (Ac) ACEi ("pril") 1st line HTN option MOA: -inhibits angiotensin converting enzyme, interfering with conversion of A-I to A-II AE -cough (up to 20%), -hyperkalemia, angioedema -hypotension Avoid: -**Pregnant or planning pregnancy ---BBW: fetal toxicity -H/O angioedema Monitor: -Baseline and periodic BP, -serum Cr, -electrolytes (esp potassium) Renal effects -can cause increase in serum creatinine -Potential reduced eGFR African Americans -may not have substantial BP lowering affect with ACEi -have up to 5x greater risk of angioedema

Altace (Ramipril)

HTN therapy (Al) ACEi ("pril") 1st line HTN option MOA: -inhibits angiotensin converting enzyme, interfering with conversion of A-I to A-II AE -cough (up to 20%), -hyperkalemia, angioedema -hypotension Avoid: -**Pregnant or planning pregnancy ---BBW: fetal toxicity -H/O angioedema Monitor: -Baseline and periodic BP, -serum Cr, -electrolytes (esp potassium) Renal effects -can cause increase in serum creatinine -Potential reduced eGFR African Americans -may not have substantial BP lowering affect with ACEi -have up to 5x greater risk of angioedema

Catapres (clonidine)

HTN therapy (C) Centrally-acting agents: Alpha Agonists AE -*Drowsiness -fatigue -hypotension -bradycardia Caution Elderly -CNS AE -bradycardia orthostatic hypotension Avoid abrupt withrawl -taper to d/c

Calan (verapamil)

HTN therapy (Cal) CCBs: Nondihydropyridines -1st line HTN option MOA: -Lower calcium influx into smooth muscles -Are somewhat less potent vasodilators than dihydropyridines, but have a greater depressive effect on cardiac conduction and contractility -Affect conduction through the AV node and have negative chronotropic effects AE -*constipation (up to 25%) -*bradycardia -worsening cardiac output -hepatotoxicity -AV block ---Avoid: HFrEF, sick sinus syndrome, and second- or third-degree AV block Typically very effective for those of black ethnicities, older adults Long-acting agents preferred -Short-acting options are generally avoided d/t potential reflex tachycardia

Cardizem LA (Diltiazem Hydrochloride ER)

HTN therapy (Car) CCBs: Nondihydropyridines -1st line HTN option MOA: -Lower calcium influx into smooth muscles -Are somewhat less potent vasodilators than dihydropyridines, but have a greater depressive effect on cardiac conduction and contractility -Affect conduction through the AV node and have negative chronotropic effects AE -*constipation (up to 25%) -*bradycardia -worsening cardiac output -hepatotoxicity -AV block ---Avoid: HFrEF, sick sinus syndrome, and second- or third-degree AV block Typically very effective for those of black ethnicities, older adults Long-acting agents preferred -Short-acting options are generally avoided d/t potential reflex tachycardia

Lopressor (Metoprolol tartrate)

HTN therapy (L) Beta Blockers (Cardioselective) MOA -Selectively antagonizes beta-1 adrenergic receptors AE -Hypotension -Bradycardia -Associated with impaired glucose tolerance and increased risk of new onset DM -Alteration of lipids (serum triglyceride, HDL) BBW -"Avoid Abrupt Cessation" -Could precipitate CV event -Taper if DC over a few weeks Avoid -Bronchospastic disease (Asthma, COPD) -Bradycardia -2 nd/3rd degree AV block -Uncompensated HF -DM: may mask hypoglycemia

Norvasc (amlodipine)

HTN therapy (N) CCBs: *Dihydropyridines* -1st line HTN option MOA -lower calcium influx into smooth muscles, potent vasodilators that have little or no negative effect upon cardiac contractility or conduction -Does not affect conduction through AV node AE -*peripheral edema (up to 20%) -lightheadedness -flushing Typically very effective for those of black ethnicities, older adults Long-acting agents preferred -Short-acting options are generally avoided d/t potential reflex tachycardia

Procardia XL (Nifedipine ER)

HTN therapy (P) CCBs: *Dihydropyridines* -1st line HTN option MOA -lower calcium influx into smooth muscles, potent vasodilators that have little or no negative effect upon cardiac contractility or conduction -Does not affect conduction through AV node AE -*peripheral edema (up to 20%) -lightheadedness -flushing Typically very effective for those of black ethnicities, older adults Long-acting agents preferred -Short-acting options are generally avoided d/t potential reflex tachycardia

Tenormin (atenolol)

HTN therapy (Te) Beta Blockers (Cardioselective) MOA -Selectively antagonizes beta-1 adrenergic receptors AE -Hypotension -Bradycardia -Associated with impaired glucose tolerance and increased risk of new onset DM -Alteration of lipids (serum triglyceride, HDL) BBW -"Avoid Abrupt Cessation" -Could precipitate CV event -Taper if DC over a few weeks Avoid -Bronchospastic disease (Asthma, COPD) -Bradycardia -2 nd/3rd degree AV block -Uncompensated HF -DM: may mask hypoglycemia

Toprol (Metoprolol succinate)

HTN therapy (To) Beta Blockers (Cardioselective) MOA -Selectively antagonizes beta-1 adrenergic receptors AE -Hypotension -Bradycardia -Associated with impaired glucose tolerance and increased risk of new onset DM -Alteration of lipids (serum triglyceride, HDL) BBW -"Avoid Abrupt Cessation" -Could precipitate CV event -Taper if DC over a few weeks Avoid -Bronchospastic disease (Asthma, COPD) -Bradycardia -2 nd/3rd degree AV block -Uncompensated HF -DM: may mask hypoglycemia

Zestril (lisinopril)

HTN therapy (Z) ACEi ("pril") 1st line HTN option MOA: -inhibits angiotensin converting enzyme, interfering with conversion of A-I to A-II AE -cough (up to 20%), -hyperkalemia, angioedema -hypotension Avoid: -**Pregnant or planning pregnancy ---BBW: fetal toxicity -H/O angioedema Monitor: -Baseline and periodic BP, -serum Cr, -electrolytes (esp potassium) Renal effects -can cause increase in serum creatinine -Potential reduced eGFR African Americans -may not have substantial BP lowering affect with ACEi -have up to 5x greater risk of angioedema

Chancroid

Haemophilus ducreyi Endemic to certain areas of US Diagnosis difficult because lack of sensitive testing Tender lesions- rule out syphilis and HSV Tx -Azithromycin or -Ceftriaxone (do not use < 18 yrs or pregnant or lactating women) or -Erythromycin

Drug Excretion Concepts

Half-life (T 1/2) Hepatic first-pass effect "Prodrug" or progenitor drug Metabolite Zero-order Elimination First-order elimination

Anxiety reduce diversion & abuse

Have a controlled substance policy, and post it where it is highly visible. (for instance: This office does not prescribe controlled substances for new patients.) Reserve use to lowest necessary dose, for shortest amount of time, and only in patients in whom it is necessary to preserve function.

HF classifications

Heart Failure with Reduced Ejection Fraction (HFrEF) EF ≤40% Heart Failure with mid-range Ejection Fraction (HFmrEF) EF 41-49% Heart Failure with Preserved Ejection Fraction (HFpEF) EF ≥50%

Benefits of Smoking Cessation

Heart disease risk is cut in half just 1 year after quitting AND continues to drop over time. Even quitting at age 50 cuts your risk in half for early death from a smoking related disease Lung cancer risk drops by half 10 years after quitting Cancers of the mouth, throat, and esophagus risks are halved within 5 years after quitting Bladder cancer risk is halved within 5 years of quitting Reduced risk for infertility in women of childbearing age

Folic Acid Deficiency

High Risk Groups -Alcoholics -Vegetarians/Vegans -Infants who are fed powdered or goat's milk -Pregnant women-increased requirements -Diseases- Celiac disease, Crohn's, giardia, short bowel syndrome -Drugs- phenytoin, carbamazepine, methotrexate*, INH, triamterene, trimethoprim Prevention -Adequate dietary intake -Supplementation in pregnancy 0.4-0.8 mg/day Treatment -Oral folic acid 1-2 mg/day for 4-5 weeks Monitoring -Hgb levels begin to rise within one week -H&H at regular intervals- can monitor after 2 weeks then monthly until stable

Lvls of risk for c. diff (abx)

High risk abx -Clindamycin -2nd/3rd gen cephalosporins -quinolones Intermediate risk abx -Macrolides Low risk abx -Trimethoprim -tetracyclines -aminoglycosides -vancomycin

Absorption

High risk areas -face -groin -intertriginous -axillae consider potential AE -ex. thinning/atrophy of skin, systemic effects

Dx of primary hypothyroidism

High serum thyroid-stimulating hormone (TSH) and low serum free thyroxine (T4)

Decrease Serum K

Hydrochlorothiazide Furosemide Torsemide Bumetanide

Direct Renin Inhibitor: Aliskiren (Tekturna) AE

Hyperkalemia Hypotension Angioedema Changes in renal function, including acute renal failure Teratogenic Avoid Pregnancy -BBW: fetal toxicity

Ramipril-spironolactone

Hyperkalemia, renal impairment

Lisinopril-Losartan

Hyperkalemia, renal impairment, dual blocakde of renin-angiotensin-aldosterone system

Penicillin potential AE

Hypersensitivity rxn -Potential cross sensitivity PCN - cephalosporins GI (N/V/D) Hematologic (rare) LFT elevations (AST, ALT)

AE antibiotics

Hypersensitivity/allergic rxns Drug side effects Superinfections -vaginal candidiasis -c.diff

Sulfonylurea info

Hypoglycemia -Moderate/Severe Weight -gain Renal/GU -More hypo risk with renal impairment (concerns with glyburide use for older adult) GI -neutral Cardiac/HF -neutral Bone -neutral Ketoacidosis -neutral

AGIs Info

Hypoglycemia -neutral Weigh -neutral Renal/GU -neutral GI AE -Moderate Cardiac -neutral Bone -Neutral Keotacidosis -neutral

TZD info

Hypoglycemia -neutral Weight -gain Renal/GU -Neutral; bladder cancer risk (pioglitazone) GI -neutral Cardiac/HF -Contraindicated HF Bone -moderate Ketoacidosis -neutral

GLP-1 RA info

Hypoglycemia -neutral Weight -loss Renal/GU -Avoid exenatide CrCl <30; renal dosing required for some GI -moderate Cardiac/HF -neutral Bone -neutral Ketoacidosis -neutral

SGLT2 info

Hypoglycemia -neutral Weight -loss Renal/GU -Potential genital mycotic infections; avoid eGFR <45; potential benefit DKD (canagliflozin) GI -neutral Cardiac/HF -HF benefits in studies: dapagliflozin, canagliflozin, empagliflozin Bone -mild fracture risk Ketoacidosis -Associated with a small but significantly increased risk of DKA

DPP4‐I info

Hypoglycemia -neutral Weight -neutral Renal/GU -renal dose adjustment for some GI -neutral Cardiac/HF -potential risk saxagliptin, alogliptin Bone -Neutral Ketoacidosis -neutral

Metformin info

Hypoglycemia -neutral Weight -slight loss Renal/GU -Contraindicated if eGFR <30, considerations for eGFR 30‐45 GI -moderate Cardiac/HF -Neutral (avoid in unstable or hospitalized patients with HF) Bone -Neutral Ketoacidosis -neutral

Thiazide Diuretics AE

Hypokalemia, hyperuricemia, hyponatremia. hypotension, hyperlipidemia Others: hyperglycemia (impaired glucose tolerance), hypercalcemia, hypomagnesemia, photosensitivity High dose therapy has increased risk of AE, so try to use lower to mid-doses to mitigate AE -Chlorthalidone and HCTZ typical dosing is low/medium12.5 or 25mg daily Monitor -Serum Cr; electrolytes (esp K and Na); BP

Beta blockers AE

Hypotension Bradycardia Associated with impaired glucose tolerance and increased risk of new onset DM Alteration of lipids (serum triglyceride, HDL) Depression? (some research shows no increased risk) Fatigue (lower risk?) Sexual dysfunction (lower risk?) Monitor -Baseline and regular BP and HR, baseline and periodic serum Cr and BG BBW: "Avoid Abrupt Cessation" -Could precipitate CV event -Taper if DC over a few weeks

ACEi pt education

Hypotension most common adverse effect -Monitor BP outpatient and keep log We can discuss if you develop a cough

Topical Steroid Potency Rankings (I-III)

I = Strongest VII = weakest Class I -Betamethasone diproprionate (Diprolene) -clobetasol propionate (Temovate) Class II -Flucinoninde (Lidex) -Amcinonide (Cyclocort) Never on Face or Skin folds Class III -Triamcinolone acetonide (aristocort) -Amcinonide (Cyclocort) -Halcinonide (Halog)

Topical Steroid Potency Rankings (IV-VII)

I = Strongest VII = weakest Class IV -Hydrocortisone valerate (Westcort) -Halcinonide (Halog) Class V -Triamcinolone acetonide (aristocort) -Betamethasone valerate (Valisone) Class VI -Desonide (Desowen) -Triamcinolone acetonide (Aristocort) Class VII -Hydrocortisone -safe on the face & skin folds

Referral to Cardiologist

I NEED Help I: IV inotropes N: NYHA IIIB/IV or persistently elevated natriretic peptides E: end-organ dysfunction E: Ejection fraction <35% D: defibrillator shocks H: Hospitalizations > 1 E: Edema despite escalating diuretics L: Low BP pressure, high HR P: Prognostic medication- progressive intolerance or down-titration of GDM

Alvesco (Ciclesonide)

ICS (Al) MOA -Reduce eosinophils and mast cells in the airways -Reduce airway hyperresponsiveness by reducing inflammation -Reduce responsiveness to histamine, exercise, allergens, irritants Onset -2 weeks of continuous therapy for maximum effectiveness AE -Usually well tolerated -Oropharyngeal candidiasis (thrush)-rinse after use -Hoarseness, xerostomia and dysgeusia -Growth suppression Contraindicated -Acute attacks -Use with caution in children -Avoid- Cushing's Disease Pregnancy -Pulmicort drug of choice Reduce symptoms, reduce exacerbations, reduce use of SABA, improve pulmonary function

Asmanex (Mometasone)

ICS (As) MOA -Reduce eosinophils and mast cells in the airways -Reduce airway hyperresponsiveness by reducing inflammation -Reduce responsiveness to histamine, exercise, allergens, irritants Onset -2 weeks of continuous therapy for maximum effectiveness AE -Usually well tolerated -Oropharyngeal candidiasis (thrush)-rinse after use -Hoarseness, xerostomia and dysgeusia -Growth suppression Contraindicated -Acute attacks -Use with caution in children -Avoid- Cushing's Disease Pregnancy -Pulmicort drug of choice Reduce symptoms, reduce exacerbations, reduce use of SABA, improve pulmonary function

Flovent (Fluticasone)

ICS (F) MOA -Reduce eosinophils and mast cells in the airways -Reduce airway hyperresponsiveness by reducing inflammation -Reduce responsiveness to histamine, exercise, allergens, irritants Onset -2 weeks of continuous therapy for maximum effectiveness AE -Usually well tolerated -Oropharyngeal candidiasis (thrush)-rinse after use -Hoarseness, xerostomia and dysgeusia -Growth suppression Contraindicated -Acute attacks -Use with caution in children -Avoid- Cushing's Disease Pregnancy -Pulmicort drug of choice Reduce symptoms, reduce exacerbations, reduce use of SABA, improve pulmonary function

Pulmicort (Budesonide)

ICS (P) MOA -Reduce eosinophils and mast cells in the airways -Reduce airway hyperresponsiveness by reducing inflammation -Reduce responsiveness to histamine, exercise, allergens, irritants Onset -2 weeks of continuous therapy for maximum effectiveness AE -Usually well tolerated -Oropharyngeal candidiasis (thrush)-rinse after use -Hoarseness, xerostomia and dysgeusia -Growth suppression Contraindicated -Acute attacks -Use with caution in children -Avoid- Cushing's Disease Pregnancy -Pulmicort drug of choice Reduce symptoms, reduce exacerbations, reduce use of SABA, improve pulmonary function

Qvar (Beclomethasone)

ICS (Q) MOA -Reduce eosinophils and mast cells in the airways -Reduce airway hyperresponsiveness by reducing inflammation -Reduce responsiveness to histamine, exercise, allergens, irritants Onset -2 weeks of continuous therapy for maximum effectiveness AE -Usually well tolerated -Oropharyngeal candidiasis (thrush)-rinse after use -Hoarseness, xerostomia and dysgeusia -Growth suppression Contraindicated -Acute attacks -Use with caution in children -Avoid- Cushing's Disease Pregnancy -Pulmicort drug of choice Reduce symptoms, reduce exacerbations, reduce use of SABA, improve pulmonary function

Advair (Fluticasone/Salmeterol)

ICS/LABA Combo (A)

Symbicort (Budesonide/Formoterol)

ICS/LABA Combo (S)

Supratherapeutic INRs

INR 3‐5 without symptoms: hold warfarin, restart in 24‐48 hours at lower dose INR 5‐9 without symptoms: hold warfarin, monitor closely, restart at lower dose during downward trend OR low dose oral Vit K INR 9+ without symptoms: Oral Vit K, recheck in 24 hours Significant bleeding symptoms, regardless of INR: ED

INGC systemic effects

IOP, bone loss? Increased risk fo fractures, glaucoma, or cataracts? Consider bioavailability Inform pts of potential risks & consider individual's benefit/risk ratio Impact on growth in children -there is a potential risk -consider potency -QD agents preferred -consider additive effects of multiple steroid preparations (nasal, inhaled, topical, etc.) -Administer lowest effective dose once controlled -Monitor growth w/ any glucocorticoid-containing medication prescribed to a child

Zoledronic acid (Reclast)

IV bisphosphonate, for pt's who cannot take oral form may be administered once a year for treatment of postmenopausal osteoporosis.-It is the only IV of this med that has demonstrated efficacy for fracture prevention.

Care of an adolescent w/ T2DM

Ideally, should be managed by a multidisciplinary team - Including an endocrinologist, nurse educator, dietitian, mental health professional, and sometimes an exercise physiologist. - However, in locations where these resources are not available, patients can be managed by primary care clinicians, following guidelines. • Patients who do not achieve good glycemic control on metformin monotherapy should be managed by or in consultation with an endocrinologist and diabetes educator, if possible. • Family involvement is essential to initiate and support the lifestyle changes required in the management of a pediatric patient with T2DM.

Uticaria Therapy

Identification of allergen & avoidance: drugs, pollen, chemicals, food, bacteria, preservatives, malignant tumor, etc Antihistamine (Avoid systemic steroids): -Ioratadine, certirizine, fexofenadine (OTC) -Hydroxyzine (atarax) If chronic (>6 wks) consider adding: -cimetidine (tagamet)

Step 1 of prescribing antibacterials

Identify the enemy What are the most likely pathogens? Consider -Site of infection -pt's symptoms -pathogen's previous environment

Alternative

If a non-mainstream practice is used in place of conventional medicine

Intensifying Insulin for T2DM

If basal insulin monotherapy isn't working after some titration (ex: fasting BG better but postmeal BG still high) - Consider adding GLP‐1 RA If basal + GLP‐1 RA not working, rapid‐acting prandial insulin can be added - Such as with largest meal - Ex: 4 units with meal (or no more than 10% of basal dose)

Low Vit D

If low on this vitamin, may consider 5,000 IU of vitamin D3 daily x 8-12 weeks to get level >30 ng/mL, then can lower supplement dose to maintenance level, such as 800-2,000 IU per day. Specific decisions regarding supplementation dose should be individualized, considering each person's clinical situation, including labs and dietary intake. A max of 4,000 IU/day has been noted as the safe upper limit in the general population. Potential effects of excess of this vit: -Hypercalcemia -Hypercalciuria -Kidney stones

Pyoderma therapy

If possible obtain a swab culture for bacterial identification & antimicrobial sensitivites Empiric tx before culture results -Clindamycin -erythromycin Topical mupirocin (bactroban) has excellent staphylococci/streptococci action

Statin Intolerance/Myopathies?

If they occur, muscle symptoms and/or signs usually begin within weeks to months after initiating statin therapy Cautiously combining statins with fibrates Avoid drug interactions Check Vitamin D level For those who have a mild or moderate intolerance to statins, another statin may be tried before progressing to evidence-based non-statin therapies -Pravastatin or Fluvastatin may be better tolerated Try lower dose or dosing every other day -Alternate-day dosing appears to have equal LDL-C lowering efficacy and can reasonably be tried in patients unable to tolerate daily statin therapy There is currently inadequate evidence to recommend CoQ10 supplementation for prevention of statin-induced muscle toxicity.

HTN pregnancy perspective

If you see high BP in a pregnant person. Keep in mind there are several major hypertensive disorders that may occur in pregnancy: -Preeclampsia and eclampsia -Chronic (preexisting) hypertension -Preeclampsia-eclampsia superimposed upon chronic hypertension -Gestational hypertension Age indications and dosing varies -See Epocrates for details Start at lower end of known effective dose and titrate as needed, following BP and checking for AE -May need to consider adding 2nd drug in some cases

Immodium abuse

Immodium is an opioid agent and it helps to bind receptors in the brain and cause a similar euphoria or high Reasons for abuse: Low cost, easy access, over the counter FDA- safety warning for cardiovascular event

Omalizumab (Xolair)

Immunomodulators MOA -prevents IgE from binding to mast cells and basophils leading to a decease in mediators AE -Anaphylaxis, -URI, -headache, -bruising at injection site Contraindicated -Acute attack Should be prescribed and administered by specialist

Systemic effects of topical corticosteroids

Immunosuppression Impaired wound healing Hyperglycemia, unmask DM Other possible systemic effects -glaucoma, cataracts -HTN -Necrosis of femoral head

Pitfalls of Topical corticosteroid tx

Improper diagnosis Suboptimal med use -inaccurate med strength, improper vehicle Lack of patient adherence -inadequate pt education -adverse drug events Use of combination steroid/antifungal formulations Drug interactions Disregard for medication costs

Capabilities of ART

Improve immune function Eliminate the risk of AIDS-related complications but does not restore full health

HFrEF pharmacotherapy

Improve sx -Diuretic (typically a loop) -Beta blocker -ACE inhibitor, ARB, or ARNI -SGLT2i (ex: dapagliflozin, empagliflozin) -Hydralazine + nitrate -Ivabradine -Digoxin -Mineralocorticoid receptor antagonist (MRA; aldosterone antagonist) Note: Only 1 of these renin- angiotensin system inhibitors should be taken (don't combine) Prolongation of survival -Beta blockers -ARNI -ACE inhibitors -ARB -SGLT2i (ex: dapagliflozin) -Hydralazine + nitrate -MRA -Diuretic therapy (limited available evidence of survival benefit)

HFrEF goal of tx

Improve symptoms (including risk of hospitalization) Slow or reverse deterioration in myocardial function Reduce mortality

e-cigs teens

In 2018, when surveyed, more than 3 million middle & high school students had used ecigarettes within the last 30 days. (26% of all students) - (CDC) In 2018, 1 in 20 middle school and 1 in 5 high school students report using e-cigarettes in last 30 days. (CDC) 31% of e-cigarette teens start smoking within 6 months Two times as many male teen use e-cigarettes than female teens

T2DM and CVD

In patients with T2DM and established ASCVD or high CV risk, consider these options that have an additional indication for CV event risk reduction: -empagliflozin, canagliflozin (SGLT‐2s) -liraglutide (Victoza), semaglutide (Ozempic), dulaglutide (Trulicity) (injectable GLP‐1 RAs)

Causes of hypothyroidism

In the vast majority of cases, hypothyroidism is caused by thyroid disease (primary hypothyroidism). -One condition: Hashimoto's thyroiditis Thyroidectomy Radioactive iodine therapy Iodine Drugs

DTAP

Inactivated vaccine Contraindications -anaphylactic rxn -progressive neurological disease -high temp or seizure after previous DTaP dose (not Tdap) Adverse drug rxns -pain @ injection site -low grade fever -aches -HA Give antipyretics to children w/ hx of febrile seizures

Haemophilus b Conjugate Vaccine

Inactivated vaccine Protects against invasive H. flu Contraindicated -allergy to components of vaccine -moderate to severe illness -only given to children younger than age 6 yrs Adverse drug rxns -injection site pain & redness

Rabies vaccine

Inactive vaccine Contraindications -moderate to severe illness Adverse drug rxns -mild local & systemic rxns -serum sickness may occur Drug interactions -chloroquine -immunosuppressants -rabies IG

Teratogenesis

Incidence and causes of congenital anomalies -less than 1% of all birth defects caused by drugs Identification of teratogens very difficult

Cephalexin

Included in 1st generation of its class, potential for cross-sensitivity in pts w/ penicillin allergy

Amoxicillin + Clavulanate (Augmentin)

Includes a beta-lactamase inhibitor, which is used to treat beta-lactamase producting organisms

Levothyroxine titration

Increase -If the TSH is mildly elevated, consider increase of 12 to 25 mcg/day -If the TSH is >10mU/L 50, an increase 25 to 50 mcg/day may be necessay Decrease -If the TSH is mildly low, you can decrease by about 12 to 25 mcg/day or skip one pill per week. ---If the TSH further suppressed, a greater reduction may be needed, and measuring the free T4 can help determine the estimated dose reduction.

Diarrhea

Increase in frequency of the stools and loose watery stools Prevalence: -211 million people a year

Side effects of Adrenergic Drugs

Increased BP Increased HR Stroke Mydriasis Cardiac arrhythmias Increased BG Uterine relaxation

COPD Exacerbations

Increased airway inflammation, increased mucous production Symptoms -Dyspnea -Increased sputum purulence and volume -Increased cough and wheeze Classification -Mild- treated with short acting bronchodilators (SABDs) -Moderate- treated with SABDs plus antibiotics and/or oral corticosteroids -Severe- patient requires hospitalization or ER visit (may be associated with acute respiratory failure)

Drug Therapy in Elderly

Increased sensitivity in elderly due to: -Immature state of 5 pharmacokinetic processes ---Absorption, protein binding of drugs, blood-brain barrier, hepatic metabolism, renal drug excretion

Drug Therapy in Neonates and Infants

Increased sensitivity in infants due to: -Immature state of 5 pharmacokinetic processes ---Absorption, protein binding of drugs, blood-brain barrier, hepatic metabolism, renal drug excretion

Cholinesterase Inhibitors (dementia)

Indicated for mild-moderate AD Inhibits acetylcholinesterase thereby reducing amount of acetycholine breakdown in brain -Aricept (donepezil) ---Also has FDA approval for late AD -Exelon (rivastigmine) (patch) -Razadyne (galantamine) Common SE: GI -May present as overt dyspepsia, or may present as anorexia/weight loss Dosing: -Begin with low dose, titrate by intervals weekly until treatment dose is reached (e.g., Aricept 5 mg, then 10 mg, then 23 mg) Treatment goals: -Low rate of short term improvement -Moderate rate of stabilization -Primary goal is of less than expected decline Benefits: -Don't give families false hope Decision to discontinue: -Cost -Uncertain/diminished benefit? -Side effects -If discontinuation is appropriate, use slow taper -Some patients continue on CI's indefinitely

Trimethoprim + Sulfamethoxazole (TMP-SMX)

Indicated to treat UTI but should be avoided in pt w/ an antimicrobial sulfonamide allergy

Antimuscarinic Antagonists (COPD)

Indication: Treatment of COPD MOA: -relax brachial muscles causing bronchodilation, decrease mucus production, prevent release of mediators Contraindication/Caution -Allergy to atropine, soy, peanuts -Acute bronchospasm - Caution in narrow-angle glaucoma, BPH, pregnancy, and lactation AE: -restlessness, -dizziness, -HA, -GI, -blurred vision, -cough, -urinary obstruction

Step 2 of prescribing antibiotics target the enemy

Kill the bad bacteria, spare the good bacteria Aim for most narrow spectrum of activity necessary

Methylxanthines

Indication: -Alternative treatment for adolescents and adults with mild persistent asthma MOA -inhibits phosphodiesterase, preventing breakdown of cAMP causing smooth muscle to relax and preventing release of histamine and leukotrienes Contraindications -Allergy to corn products -Not recommended <12 years -Acute asthma exacerbations AE -Arryhthmia (life threatening), headache, N/V/D, restlessness, seizures, palpitations ---Toxicity:nausea, vomiting, diarrhea, headache, insomnia, and irritability

Systemic Corticosteroids (asthma)

Indication: -Treatment in acute moderate/severe asthma exacerbation MOA: -Inhibit cytokine and mediator release, inhibit IgE synthesis, suppress inflammatory process, suppress airway inflammation inhibiting mucus production/edema Onset of Action: Peak concentrations reached 1-2 hrs; 5 day-2 week course recommended Contraindications/Caution -untreated infections, lactation, alcohol intolerance -DM: increase BG; with quinolones-tendon rupture

LABA (long acting beta agonist) (athma)

Indication: -Used in combination with ICS for treatment of moderate persistent asthma MOA: -Activates adenylate cyclase and increases cAMP thereby relaxing smooth muscles and relieving bronchoconstriction Contraindication/Caution -Ischemic heart disease, HTN, arrhythmia, seizure disorder and hyperthyroidism -Caution with tricyclics, MAO inhibitors; antagonized by beta blockers AE -tachycardia, tremor, hypokalemia, hyperglycemia, headache, dizziness

SABA (short-acting beta2 agonist)

Indication: Tx of acute bronchospasm MOA: Activates adenlylate cyclase & increase cAMP thereby relaxing smooth muscle & relieving bronchoconstriction Onset: 5 min Contrandications/Caution -ischemic heart disease, HTN, arrhythmia, seizure disorder, & hyperthyroidism -Caution w/ tricyclics, MAO inhibitors; antagonized by beta blockers Adverse events: tachycardia, palpitations, tremor, hypokalemia, hyperglycemia, HA, dizziness

Leukotriene Modifiers (asthma)

Indication: alternative tx option for mild persistent asthma, adjunct w/ ICS 12 yrs & older MOA -Blocks binding of leukotrienes to receptors reducing contraction of smooth muscle, vascular permeability, mucus secretions & activation of inflammatory cells Contraindication/Caution -Contraindicated for the reversal of acute bronchospasms -Increased bleeding risk with Coumadin and Aspirin AE -Headache >10%, dizziness, weakness, GI, myalgias, fever

Oral decongestants

Indication: nasal congestion (not helpful for sneezing, rhinorrhea, or nasal itching) Ex. -Phenylephrine - value? -Pseudoephedrine (sudafed) Some antihistamine (2nd gen/decongestant combos) -loratadin/pseudoephedrine (claritin D) -cetirizine/pseudoephedrine (zyrtec D) -Fexofenadine/pseudoephedrine (allegra D) Limit use d/t AE profile Children & elderly - more sensitive to effects Avoid in children < 12 yrs -lack of proven benefit & potential for serious adverse effects -Risk: dosing errors-potential OD

Nasal Saline

Indications: -AR -Sinusitis -cold Effective for mild symptoms? Generally safe May not be tolerated in pediatric pts Should be used properly -AE: nasal burning & irritation -CAUTION: use distilled, sterilized, or previously boiled water due to reports of amebic encephalitis due to tap water rinses

Monitoring obesity

Individual drug considerations Baseline assessment -BP, HR, Wt, waist circumference, CV/Pulmonary exams Baseline labs -Dependent on drug -Women of childbearing age: pregnancy tests (contraindicated in pregnancy) Consistent f/u visits -Discuss lifestyle at EVERY visit Re‐evaluate -DC drug if wt loss < 4‐5% after 12‐16 wks Frequent pt follow up is key -best weight loss outcomes occur w/ frequent face-to-face visits (16/year)

osteoporosis tx

Individualize plans through shared-decision making Consider: -Anticipated efficacy of various options -Safety -Cost -Convenience -Other patient-related factors (preferences, co-morbidities, risk factors, etc)

Uncomplicated ABRS

Infection is probably bacteria if -persistent symptoms or signs lasting for >7-10 days w/o any evidence of clinical improvement OR -severe symptoms or signs ---High fever (> 102) ---Purulent nasal discharge, nasal congestion & facial pain lasting for at least 3 consecutive days OR -Worsening s&s after initial improvemnt (new onset fever, HA, or increase in nasal dischage following a typical viral URI that lasted about 5-6 days & initially improved "double sickening")

Constipation

Infrequent or difficult evacuation of stool Prevalence: 12-20% of population experience constipation Preferred therapy vs. actual therapy

Thalassemia

Inherited blood disorders characterized by too little hemoglobin Most often in Mediterranean, Middle Eastern, & South Asian populations Two types -Alpha Thalassemia -Beta Thalassemia (often misdiagnosed as IDA) Microcytic, Hypochromic These people have too much iron in their bodies -Don't give iron supplement! Treatment: Alpha Thalassemia -Usually no therapy -Low iron diet -Iron chelation therapy for iron overload Beta Thalassemia -Avoid iron supplements -Severe -> Blood transfusion

Other tx for postmenopausal osteoporosis

Inhibit bone resorption -Denosumab (Prolia) -Raloxifene (Evista) -Estrogen-Progestin? Anabolic agents -Teriparatide (Forteo), Abaloparatide (Tymlos) -Romosozumab (Evenity)

Bisphosphonates MOA

Inhibit bone resorption- slow down excessive bone loss, stabilize BMD and reduce fracture risk For the initial treatment of osteoporosis in postmenopausal women, oral bisphosphonates are often preferred as initial therapy because of their: -efficacy -favorable cost -availability of long-term safety data

Raloxifene (evista): Estrogen agonist/antagonist

Inhibits bone resorption Alternate therapy for postmenopausal women, may be considered particularly in women at high risk for breast cancer Less effective than bisphosphonates and denosumab. Reduces risk of vertebral fractures, but no demonstrated benefit for other fracture reduction

Ezetimibe (Zetia)

Inhibits cholesterol absorption at small intestine Has been shown to reduce total cholesterol, LDL, and TG while increasing HDL-C Alternative if statin intolerance and sometimes combined with statin therapy Not for children younger than 10 years Avoid in pregnancy

HFrEF Therapy

Initial- 3 types of pharmacologic agents: -Diuretic therapy (as needed to relieve symptoms and signs of volume overload, such as dyspnea and peripheral edema) -An angiotensin system blocker (ARNI, ACE inhibitor, or ARB) -A beta blocker Note: Choose 1 of these BB: carvedilol, metoprolol succinate, or bisoprolol

Sulfonylureas AE/caution

Initially very effective in lowering A1c Common AE - Moderate hypoglycemia, weight gain -Increased risk of hypo in combo with other DM meds (consider MOA) Caution -sulfonamide allergy, renal/hepatic impairment

Dexamethasone/ Triamcinolone

Injection option Severe dermatoses Face, groin, axillae, intertriginous areas AE -systemic

Digoxin for HFrEF

Inotropic effect, increases myocardial contractility -May also be used for treatment of A-fib Can provide clinical benefits in HFrEF, but use remains controversial -Previously a mainstay of HF management, but its role diminished with less evidence Can have toxic effects -Monitor serum drug level is in therapeutic range Individualized dosing -Based on many factors, such as renal function, ideal body weight, and concomitant meds that may affect digoxin levels *Narrow therapeutic index drug -Toxicity potential -Potential drug-drug interactions can upset narrow therapeutic index Monitor -Serum drug levels, Cr, potassium, electrolytes, HR (can cause bradycardia) Select potential AE: -GI most common (anorexia, N/V/D) -Toxicity ---arrhythmias, conduction disturbances, and, in severe cases, constitutional symptoms such as nausea, vomiting, and visual disturbances (yellow vision and green halos around lights) Risk factors for toxicity include: -low body weight, advanced age, renal impairment, hypokalemia, hypercalcemia, hypomagnesemia -hypothyroidism Note: a digoxin level is best determined as a trough concentration (obtained immediately before administering the next dose; otherwise > 6 hours after administration of last dose)

Prescribing older adults (DM) 2

Insulin - If A1c significantly above goal (such as>9%), FBG >250, RBG >300, ketonuria - May consider if other DM meds not an option for some reason - Consider how you can keep it safe and simple GLP‐1 agonists - Affect on appetite/ weight loss may be an issue for some, may be helpful for others - Safety? - One with additional CV indication for those with CVD? Sodium‐glucose co‐transporter 2 (SGLT2) inhibitors - Safety? - One with additional CV indication for those with CVD? TZD (pioglitazone) - There are some considerations for an older adults, such as risks of fluid retention; weight gain; avoid if heart failure; potential osteoporotic fracture risks All meds have advantages/disadvantages; individualize therapy

Basal Insulin Analogues

Insulin glargine (Lantus), insulin detemir (Levemir) are commonly used Generally considered 24‐hour insulins - May be dosed q 12 hours (esp Levemir) *Cannot be mixed in syringe with other insulin Expensive

Pediatric Diabetes Therapy

Insulin used for -T1DM (MDI or insulin pump) -Sometimes insulin for T2DM -If severe hyperglycemia/ symptoms/ ketosis ---Emergency Department Approved pharm options for T2DM -Metformin (T2DM age >10 years) -Liraglutide (GLP‐1 RA, T2DM age >10 years) -Insulin ---Consider basal insulin for T2DM, such as glargine (Lantus) or detemir (Levemir) Liraglutide (GLP‐1 RA) can be added for T2DM - as a 2nd agent for patients who fail monotherapy with metformin, or - as a 3rd agent for those who fail combination therapy with metformin and basal insulin Recommend co‐manage DM with pediatric endocrinology

DM in Pregnancy

Insulin, rather than oral anti‐hyperglycemic agents, is recommended during pregnancy - High efficacy - more safety data for some types - many pregnant women need it at some point - oral agents lack long‐term safety data ADA Standards of Care in Diabetes has details - published annually in Diabetes Care

Pharmacodynamics

Interactions within body tissue

Antibacterial drug targets

Interfere w/ cell wall synthesis Interfere w/ protein synthesis Interfere w/ various DNA processes Inhibit folate synthesis Bind to beta-lactamase enzymes

Insomnia

Interview to determine symptom timing (early, middle, late) Discuss symptom impact on function Screen for substance use (stimulants, depressants, etc) Rule out medical causes Implement non-pharm interventions

Methylphenidate (Ritalin, Concerta, Metadate)

Is a stimulant is usually better tolerated than amphetamines

Ritalin (methylphenidate)

Is a stimulant -Short-acting is usually better tolerated than amphetamines

Metadate (methylphenidate)

Is a stimulant -intermediate/long-acting is usually better tolerated than amphetamines

Concerta (methylphenidate)

Is a stimulant -long-acting is usually better tolerated than amphetamines

Types of Hypersensitivity rxns (sufonamide)

Isolated cutaneous rxns Morbiliform rash w/ fever & systemic symptoms Immediate type allergy & anaphylaxis SJS/TEN Minimal evidence of cross-reactivity between sulfonamide antimicrobials and non-antimicrobials

Increase serum K

Klor-Con Spironolactone Lisinopril Eplerenone Losartan

NSAID risks & AE

It is difficult to name a "safest" NSAID. Ibuprofen? -It is is quite safe when the drug is used at the lowest possible dose. Increasing the dose of any NSAID is associated with an increased risk of most related toxicities. Nonselective NSAIDs reversibly inhibit platelet functioning and can alter cardioprotective effects of aspirin. AE -There is a potential for an increased risk of GI bleeding with NSAID use -When used long term, consider gastro‐prophylaxis, such as PPI. -Consider dose‐ and age‐related risk of GI effects. -May cause or worsen renal impairment. ---Avoid NSAIDs in patients with renal insufficiency (CrCl <60). -Most renal effects of NSAIDs should be apparent in the first month. Routinely monitor serum creatinine and if there is a change in the dose of NSAID therapy Prescribe at the lowest effective dose for the shortest duration possible

Formoterol (Performist)

LABA (F) COPD maintenance therapy BBW -Increase risk of asthma related death Should be used as an adjunct with ICS Should not be used as monotherapy

Salmeterol (serevent)

LABA (S) COPD maintenance therapy BBW -Increase risk of asthma related death Should be used as an adjunct with ICS Should not be used as monotherapy

Exacerbations (COPD) pharm management

LABA/LAMA or LABA/ICS if on monotherapy -LABA/ICS hx of asthma or eos >300 On LABA/LAMA, escalate to LABA/LAMA/ICS (eos) or add roflumilast or azithromycin (former smoker) On LABA/ LAMA/ICS, add roflumilast or azithromycin (former smoker)

Tiotropium (Spiriva)

LAMA COPD maintenance therapy Alt -Aclidinium (Tudorza) -Glycopyrronium (Seebri) -Umeclidinium (Incruse) Caution -pregnancy -lactation

Therapeutic Index: Pharmacodynamic

LD50/ED50

Agents to Avoid in URI

Lack of evidence to support use or safety concerns -antibiotics -antihistamine monotherapy ---some benefit when combined w/ decongestant -INGCs -Cough suppressants ---codeine ---benzonatate -OTC combination cough/cold medications (children < 12) -Vit C, Echinacea (lack of evidence) -zinc (uncertain benefits and known toxcities)

HFpEF Tx

Largely governed by management of associated conditions, symptoms, and co-morbidities -Ex: HTN, CAD, obesity, DM, kidney disease, anemia Diuretics -Used to treat volume overload -Take care to avoid volume depletion May consider MRA, such as if HFpEF and BNP or N-terminal proBNP is elevated -but the recommendation for use in HFpEF is weaker than for use in HFrEF -may be dosed more cautiously

MAOIs

Last resort occasionally employed by psychiatry -Drug-drug interactions -Drug-food interactions Very effective

Important factors in vehicle selection

Lesion quality -moist vs dry Location -hairy vs nonhairy

6.8 A1C

Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes selfmanagement education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin

Accolate (Zafirlukast)

Leukotriene Modifier (A) MOA -Blocks binding of leukotrienes to receptors reducing contraction of smooth muscle, vascular permeability, mucus secretions and activation of inflammatory cells AE -Headache >10%. -dizziness, weakness, GI, myalgias, fever Caution -Contraindicated for the reversal of acute bronchospasms -Increased bleeding risk with Coumadin and Aspirin

Singulair (Montelukast)

Leukotriene Modifier (S) MOA -Blocks binding of leukotrienes to receptors reducing contraction of smooth muscle, vascular permeability, mucus secretions and activation of inflammatory cells AE -Headache >10%. -dizziness, weakness, GI, myalgias, fever Caution -Contraindicated for the reversal of acute bronchospasms -Increased bleeding risk with Coumadin and Aspirin

Levothyroxine monitoring

Levothyroxine has a long half-life (about 7 days) After initiation of T4 therapy, the patient should be reevaluated and serum TSH should be measured in 6 weeks. Then the dose can be adjusted accordingly. The serum TSH should be remeasured 6-8 weeks after any change in dose.

Therapeutic Index and Bioequivalence

Levothyroxine is a narrow therapeutic index drug, so small dose changes can make a big difference. Either a generic or a brand-name formulation is acceptable and multiple are available. It is optimal for patients to remain on the same formulation of T4. -If the decision is made for the brand, one option is to write "Brand only" on the prescription and sign on the dispense as written line. Another consideration is a 90- day prescription, which provides a 3-month supply from the same manufacturer. When there is a concern regarding equivalent efficacy of the preparations, a serum TSH can be measured 6 weeks after changing preparations to document that the serum TSH is still within the therapeutic target.

Pediatric levothyroxine

Levothyroxine is the recommended therapy for pediatric patients with primary hypothyroidism, but there are some different dosing considerations and many other elements of the work up. The goals of treatment are to restore normal growth and development. Pediatric Endocrinology Referral -There are additional evaluation, treatment, dosing, and monitoring considerations for thyroid dysfunction in a pediatric patient, so these patients may be immediately referred to a pediatric endocrinologist for further evaluation and treatment.

Dyslipidemia in peds

Lifestyle counseling important Consider lifestyle + pharmacotherapy if: -LDL > 130 and high-risk (such as DM) without adequate response to lifestyle changes without lifestyle response -LDL > 160 and moderate- or at-risk -LDL > 190 and no CV risk -Refer to pediatric lipid specialist for LDL > 250 or TG > 400 LDL goal <100 (high-risk) <130 for other risk groups

ACEi (ex)

Lisinopril ('pril)

Influenza (flumist)

Live attenuated Contains 2 strains of influenza A and 1 strain of influenza B Administered intranasally Live vaccine replicates in nasal mucosa Contraindicated: -egg allergy (anaphylactic rxn) -asthma -immunocompromised -pregnancy

Oral Polio

Live attenuated Not used in the US since 2000 but still used throughout the world Effective, easy to administer Virus lives in GI tract for 4-6 wks after administration Rare risk of vaccine-associated paralytic poliomyelitis -pt and household contacts (shed in feces)

Rotavirus vaccine

Live attenuated Orally administered & replicates in small intestine Contraindicated -Immunocompromised -Febrile illness Adverse rxns: -mild GI upset -no risk of intussusception in new vaccines Spread in feces

Attenuated Live Vaccines

Live attenuated influenza vaccine (LAIV) Measles, mumps, & rubella vaccine (MMR) Oral poliovirus vaccine Rotavirus vaccine Varicella virus vaccine Herpes zoster vaccine Typhoid Yellow fever vaccine Bacillus Calmetta-Guerin vaccine

MMR vaccine

Live attnuated 2 doses 99% effective in providing immunity for measles (88% mumps) Contraindicated: -neomycin allergy -pregnancy -immunosuppression -febrile illness ---ok w/ egg allergy ---may give to breastfeeding women

AE: Topical corticosteroids

Local effects -burning -pruritis -erythema Skin changes -skin atrophy ---depressed, shink, wrinkled skin w/ prominent telanglectasis ---may recover within wks to months if therapy is DC'd as soon as skin change occurs -Ecchymosis, purpura -Striae -Aceneiform eruption -Hypo/hyperpigmentation -Hypertrichosis (excessive hair growth) -Hypersensitivity rxn to vehicle or drug Photsensitization Promotion of fungal growth In general, there is increased risk of AE when topical corticosteroids are used > 3 wks

INGC: potential AE

Local irritation of the nasal mucosa -drying & burning -Tip: aqueous preparations may be less irritating Bad taste & discomfort from run-off into the throat -Tip: Dry powder formulations may be better tolerated Epistaxis -Frank epistaxis- may have to DC permenently -scant blood-try avoiding that nostril for a few days Nasal septal perforation -rare -direct away from septum

N/V tx

Locally acting agents 1) phosphorylated carbohydrate solution (Emetrol®, Emecheck®) - Dextrose/fructose/phosphoric acid -For children 2-11 years old the dose is 5-10 ml PO q 15 min prn nausea -For patients greater than 12 years old the dose is 15-30 ml PO q 15 min prn 2) carbonated soft drinks, e.g., Sprite, Coke or "Coke syrup" 3) bismuth subsalicylate (in Pepto-Bismol® and Kaopectate®) Centrally acting agents -Phenothiazine Antihistamines -Anticholinergics -Non-Phenothiazine Antihistamines -Cannabinoids -Serotonin Antagonists -Corticosteroids -Miscellaneous

Teriparatide (Forteo) & abaloparatide (Tymlos) long term safety

Long-term safety? Approved length of therapy: Max 2 years, so would need to consider what to do about therapy after that (such as bisphosphonate or denosomab) Theoretical risk of carcinogenicity; black box warning: osteosarcoma

Abx and pregnancy/lactation

Look up pregnancy/lactation safety information in an evidence-based reference -Prescribers should consult the product labeling of an antibiotic to review the risk summary and clinical considerations for use in pregnancy and lactation. In general, research is limited, so antimicrobial agents should be prescribed with caution. -Fluoroquinolones and tetracyclines are examples of classes that are generally avoided When possible, avoid fetal drug exposure-especially the 1st trimester since it is the major period of organogenesis

If a pt is allergic to sufonamide abx they may have cross-sensitivity to...

Loop diuretics, sulfonylureas, thiazide diuretics

Travelers' diarrhea tx

Loperamide (Imodium) or other antispasmodics, plus a three- day course of a fluoroquinolone - Relieves the symptoms in less than 24 hours. In pregnancy, azithromycin (Zithromax) Azithromycin (Zithromax®) 1 gram for one dose is effective, including some cases resistant to quinolones. Xifaxan (rifaximin) due to E. coli. Probiotics (Lactobacillus, etc.) not effective for treatment, but modest benefit for prevention. Oral rehydration salts to maintain fluid balance.

Angiotensin receptor blocker (ARB)

Losartan (Cozaar)

Tolerance: Pharmacodynamic

Loss of receptor response & drug effect

Antidepressant efficacy

Lots of studies with lots of different designs have tried to estimate how often antidepressants help. Most studies find that antidepressants help somewhere in the neighborhood of half the time. Lingering questions: -Could we use best practices to improve on that number? Maybe... -What happens to the other 50%? Don't forget to advise nonpharm...

Overt primary hyperthyroidism

Low -serum thyroid-stimulating hormone (TSH) and Elevated -thyroid hormones

Moderate-Intensity Statin Therapy

Lowers LDL by 30 - <50% Atorvastatin 10-20 mg Rosuvastatin 5-10 mg Simvastatin 20-40 mg Pravastatin 40-80 mg Lovastatin 40 mg Fluvastatin XL 80 mg Most benefit from statin therapy occurs with moderate-dose therapy

High-Intensity Statin Therapy

Lowers LDL by ≥50% Atorvastatin 40-80 mg Rosuvastatin 20-40 mg

Classification of hypoglycmia

Lvl 1 -glucose < 70, >54 Lvl 2 -glucose <54 Lvl 3 -A severe event characterized by altered mental &/or physical status requiring assistance for treatment of hypoglycemia

Antidepressant interactions

MAOIs: Serotonin syndrome Reported higher incidences of GI bleed and increased bleeding time when taken with NSAIDS, Coumadin, Plavix. Taking these agents is not a contraindication for use of SSRI, but important to be aware of the potential (cumulative) effects.

MAT & OUD (medication addiction tx, opioid use disorder)

MAT -improve retention in addiction treatment -suppress illicit drug use -improve quality of life -reduce mortality among patients with opioid use disorder (OUD) MAT ex: -methadone -buprenorphine‐naloxone -naltrexone

Suvorexant (Belxomra) (sleep)

MOA - orexin-receptor antagonist which blocks the binding of neuropeptides orexin A & B to receptors OX1R and OX2R, which is thought to suppress the wake drive Indication - insomnia characterized by difficulty with sleep onset and/or sleep maintenance age >=18 $$$ Similar concerns as non-benzo hypnotics- odd behavior, dependence/tolerance, Schedule 4

Zyban MOA & SE

MOA -Unknown. Commonly used as an antidepressant -Thought to affect dopaminergic or noradrenergric properties SE -HA -dry mouth -insomnia Contraindications -Seizures -eating disorders -do not give to pts who are currently taking Wellbutrin

Misoprostol (cytotec)

MOA: -This is a prostaglandin analog that decreases gastric acid from being secreted. Indication: -"at risk" for GI bleed including older clients with a history of GI bleed from NSAIDs and/or have been on a corticosteroid (e.g., prednisone). Dosing: -100 mcg or 200 mcg tablets PUD: -for NSAID AGI ulcer prevention this medication is dosed at 100-200 mcg PO QID. Contraindicated: -pregnancy; is an abortifacient. Side Effects: Causes diarrhea, so "start low and go slow" in dosing. • Combined with diclofenac (an NSAID) as Arthrotec

Amitiza (lubiprostone)

MOA: -Activates chloride channels in the gut, leading to increased intestinal fluid secretion and improved motility. Indications: -patients who aren't helped by fiber or laxatives for chronic constipation. SE: -nausea (30% of patients) - may be decreased by taking it with food or by reducing the dose from twice a day to once a day.

Bulk producing laxatives

MOA: -Bind to fecal contents and pull water into the stool Onset of Action: -12-24 hours up to 3 days Good for long-term prevention/treatment Encourage fluids with all of these. 1) bran (soluble and insoluble) 2) psyllium (Metamucil®, Fiberall®, Serutan®) 3) methylcellulose (Citrucel® powder and tablets) 4)calcium polycarbophil (FiberConâ Equalactinâ, Mitrolanâ))—provides ~225 mg of calcium per tablet. 5)malt soup extract (Maltsupexâ)

Non-phenothiazine antihistamine

MOA: -Block acetylcholine receptors in the vestibular center. SE: -drowsiness. dimenhydrinate (Dramamine) cyclizine (Marezine) meclizine (Antivert, Bonine, Dramamine II)

Saline or hyperosmotic laxatives

MOA: -Draws water into the intestine through osmosis and increases intestinal motility Onset of Action: -oral 30 minutes to 3 hours; rectal (sodium phosphate enema) 5 to 15 minutes Saline or Hyperosmotic Agents Used for "Traditional" Constipation 1) magnesium hydroxide (MOM) 2) low volume (PEG) polyethylene glycol (MiraLax®)—OTC in 2007 3) lactulose (Chronulac®, Kristaloseâ)— also used to ↓ blood ammonia levels SE: -Watch for dehydration!

Emollients or stool softeners

MOA: -Reduces the surface tension of the liquid contents of the bowel, allows for liquid in the stool and easier defecation Onset of Action: -1 to 3 days for docusate products, 6 - 8 hours for mineral oil Efficacy data is lacking, but is used for long-term prevention/treatment and in pregnancy since not systemically absorbed. mineral oil -may cause lipoidal pneumonia if aspirated -leaks from the anal sphincter -absorbs fat soluble vitamins causing deficiency of vitamins A, D, E , & K. docusate sodium [DSS] (Colace®) docusate calcium (Surfak®) docusate potassium (Dialose®)

Sucralfate (carafate)

MOA: Aluminum hydroxide complex of sucrose forms a polysaccharide "coating" over the ulceration May also stimulate prostaglandin mediated mucosal protection. Indication: -Stress ulcer prophylaxis and duodenal ulcer healing Dosing: 1 g and 1g/10 ml suspension PUD: 1g PO QID. Give before meals and before bedtime Side effects: rare, constipation most common. Dissolve the tablet to make a slurry prior to consumption. Mouth (aphthous) ulcer - additional indication

Edoxaban (Savaysa)

MOA: Factor Xa inhibition Indications: non‐valvular AF, VTE (DVT, PE) Dosing: varies based on indication, renal dosing required for CrCl<50, do not use for CrCl>95 (yes, you read that right - greater than 95) Reversal agent: Andexanet (Andexxa)

Linzess (linaclotide)

MOA: activate colonic neurons and increases smooth muscle contractions, promoting a bowel movement Indication: -Approved for IBS-C in adults, and chronic constipation Contraindicated < 6 yo Side Effects: -Diarrhea most common (20%)

PPI

MOA: bind to the H+/K+/ATPase enzyme on the surface of gastric parietal cells, inhibiting secretion of hydrogen ions into the gastric lumen. Inhibit >90% of 24-hour acid secretion - takes few days of therapy Short serum half-lives - one dose acts > 24 hrs Slight activity against H. pylori making this effective in treatment of PUD AE diarrhea Indications -Treatment of active duodenal or benign gastric ulcer for 4 to 8 weeks -Maintenance of duodenal or gastric ulcer healing up to one year -Relief of GERD symptoms up to 4 weeks -Erosive esophagitis for 4 to 8 weeks -Maintenance of esophageal healing up to one year -Massive acid hypersecretion, e.g., Zollinger-Ellison syndrome (ZE) -Approved for children 1-11 years of age with GERD and erosive esophagitis. Ex. 1. omeprazole sodium (Prilosec) 2. Zegrid 3. lansoprazole (Prevacid) 4. rabeprazole (AcipHex) 5. pantoprazole (Protonix) 6. Esomeprazole (Nexium) * Best PPI 7. Dexlansoprazole (Dexilantâ)

Nitrates (angina)

MOA: Relaxation of vascular smooth muscle resulting in vasodilation. Affects peripheral arteries, peripheral veins, coronary arteries -Peripheral venous dilaƟon results in less blood return to heart, ↓ preload, ↓ cardiac workload -Coronary artery dilaƟon results in ↑ blood flow to myocardium Classification by onset and duration of action: -Rapid acting for immediate relief of acute angina attacks -Long acting for prevention of symptoms SE -Headache, flushing, dizziness, weakness, orthostasis Caution -Avoid within 24 hours of PDE‐5's (Viagra, Levitra, Cialis, etc) due to potential for profound hypotension -Hypotensive effect may be cumulative‐ use caution in patient on anti‐ hypertensives Considerations -Patient should mark date of first use on the bottle; discard 6 months‐ 1 year after opening? -Store in dark container, room temp

K-sparing Diuretics

MRA has other indications (HF) and may be used for resistant HTN Relatively weak diuretic activity Often combined with a loop or thiazide Exemplars: -Triamterene, amiloride -spironolactone, eplerenone (MRA)

Clarithromycin

Macrolide that interacts w/ the antidepressant citalopram/ raises citalopram lvls risk of QT prolongation, cardiac arrhthmia, serotonin syndrome

INGCs

Main benefit: efficacy -Decreased nasal congestion, rhinorhea, nasal itching, and sneezing, post nasal drip Limitations -longer response time frame -more effective when taken regularly Several preparations available -consider cost, pt preference -options for pediatrics, pregnanacy, lactation available

Metformin AE

Main: GI -Nausea, diarrhea, abd pain Strategies to decrease GI side effects -ER version -Take with food -Gradual titration Vitamin B12 deficiency -Check if anemia, peripheral neuropathy -Periodically monitor serum B12 levels Contraindicated in patients with factors predisposing to lactic acidosis

Beta blocker

Metoprolol

Migraines: Triptans

Mainstay of rescue migraine treatment MOA- Serotonin (5-HT) 1b/1d -Receptor Agonists • Inhibit release of vasoactive peptides, promoting vasoconstriction • Block pain pathways in the brainstem • Inhibit transmission to the trigeminal nucleus caudalis Dosing ex -Oral Imitrex available 25 mg, 50 mg, 100 mg; cannot exceed 200 mg/24 hours -For each migraine event: Can take 1 dose (of any strength) followed by a second dose (typically of the same strength as the first dose) 2 hours later if symptoms persist First migraine event: -Usually recommended to start at moderate dose, repeat same moderate dose after 2 hours if needed -If no relief after 2nd dose, consider titration up to maximum dose for next migraine event Second migraine event: -If no relief after 2nd dose of max dosed agent, consider different agent for next event Third migraine event: -If no relief with 2 doses of different agent, refer Ex. -Sumatriptan (Imitrex)- SC, NS, PO, non-generic TD patch -Sumatriptan + Naproxen preparation -Zolmitriptan (Zomig)- NS, PO -Naratriptan (Amerge)- PO -Rizatriptan (Maxalt)- PO ---Propranolol increases Maxalt concentration by 70% -Almotriptan (Axert)- PO -Eletriptan (Relpax)- PO -Frovatriptan (Frova)- PO

Non-pharm cold/URI treatments

Maintain adequate hydration Honey? -option for treating cough in children > 1 yr w/ the common cold The AAP suggests that cough lozenges or hard candy may be used to coat the irritated throat for children older than 6 yrs Cool mist humidifier/vaporizer

Goals of asthma therapy

Maintain control of asthma w/ the least amount of medication in an effort to minimize risk of adverse events Control viewed in 2 domains 1. Reducing impairment -prevent chronic sx -infrequent use of SABA -maintain near normal PF (pulmonary fx) -maintain normal activities -meet pts/families satisfaction w/ care 2. Reducing risk -Prevent exacerbations, ED visits & hospitalizations -Prevent loss of lung function/growth -optimal tx w/ little to no adverse events

COPD: Pharm Therapy

Maintenance - Beta2- Agonists (SABA, LABA) -Anticholinergics/Antimuscarinics (short-acting, longacting) - Phosphodiesterate-4 Inhibitors -ICS Exacerbations -Short-acting bronchodilators -Systemic corticosteroids - Antibiotics

H2RA/PPI combo tx

Makes little sense pharmacologically Bedtime H-2 antagonists PPIs work best to reduce acid secretion triggered by meals during the day. H-2 antagonists reduce acid secretion during the day and night without regard to meals. Combination is less expensive than BID PPIs

Plain Language: Health literacy strategy

Making written and oral information easier to understand Key elements -Most important points come first -Break up complex information -Use simple language -Define technical terms

Seizure Disorder

Managed by neurology Reasonable that PCP refill meds when seizures are well controlled. Refer back to neurology: -Poor tolerance of medications -Breakthrough seizure activity

Non-Emergent Pediatric HTN info

Management decisions are dependent upon: -severity of HTN -underlying cause -presence of other risk factors for cardiovascular disease

Cream (Topical corticosteroids)

Management of inflammatory dermatoses Options -face -intertriginous areas Ointment more potent, but more potent than lotion

Combinations (DM)

Many DM meds are commonly combined Consider combination therapy in patients with higher A1C and lack of result with monotherapy (see evidence‐based algorithms) Most of the various classes can (and often should be) used in combination as therapy is intensified Differing MOA + Additive glucose lowering effects Better result Do not combine: -DPP‐4 inhibitor/ GLP‐1 agonist or -Meglitinide/sulfonylurea

GLP-1 RA cons

Many are injectable, but there is also a newer oral option -Semaglutide is available oral (Rybelsus) or injectable (Ozempic) $ $ $ Expense *GI effects -May be transient Long‐term safety profile still largely unknown -FDA continuing to follow potential precancerous findings with incretin drugs (GLP‐1 and DPP4, FDA warning 2013) Avoid: h/o pancreatitis (or high risk), gastroparesis

Clonidine

Non-Nicotine Product 2nd line agent Non-FDA Approved Good at reducing withdrawal symptoms Tapering is very important to avoid rebound hypertension

Cromolyn (asthma)

Mast cell stabilizer Indication: -Alternative therapy in children for step 2; preventive exercise induced asthma MOA: -block chloride channels and modulate mast cell mediator release No contraindications, caution in renal/hepatic impairment AE -Unpleasant taste, rash, sore throat, cough Pregnant/Lactating: -no known risk/safety unknown

Cromolyn

Mast cell stabilizer MOA -block chloride channels and modulate mast cell mediator release AE -Unpleasant taste -rash -sore throat -cough Indication -Alternative therapy in children for step 2; preventive exercise induced asthma

Cromolyn sodium (nasalcrom)

Mast cell stabilizer -MOA: decreases allergic inflammation, inhibits mast cell release of histamine & other inflammatory medicators Most effective in prevention of nasal sx -better than placebo, but less effective than other options -Episodic use: 30 mins prior to exposure ---For best results tart 1-4 wks prior to exposure Benefits -overall safety, well tolerated overall, rare AE -OTC -Options for ped pt Limitations -lower comparable efficacy -short duration of action, frequent dosing

Dementia Tx goals

Maximize: Function Independence Quality of life -Individual with dementia -Caregivers Time before institutionalization is needed

Efficacy: Pharmacodynamic

Maximum effect of a drug

Hydralazine + Nitrate (isosorbide dinitrate)

May be particularly helpful for patients with persistent hypertension despite compliance with other drug therapies for HFrEF. Use has been limited by generally poor adherence -inconvenient dosing (large number of tablets and frequency of administration) -higher risk of potential adverse reactions Monitoring -Consider baseline ANA (antinuclear antibody) level due to risk of druginduced lupus ---prior to initiation and periodically during prolonged therapy, ---or if the patient develops symptoms such as arthralgia, fever, chest pain, or persistent malaise -CBC (due to potential for blood dyscrasias)

Hyperthyroidism causes

May be related to: -Graves' disease (autoimmune) -Thyroiditis Drugs? -Overreplacement with excess levothyroxine -Amiodarone is just one example Referral -An endocrinologist can perform a more in-depth evaluation regarding the cause of the hyperthyroidism. -Can urgently refer pregnant and pediatric patients because of additional evaluation and treatment considerations.

Denosumab AE

May cause hypocalcemia- check and correct calcium prior As with bisphosphonates, rarely may be associated with ONJ (osteonecrosis of the jaw) and atypical femur fractures.

Hip fractures & PPIs

May interfere with calcium absorption PPI therapy associated with an increased risk of hip fracture. Elders users of PPI > 1yr = Increased risk for hip fx Increased risk with higher doses Men > drug-associated risk vs women

Phototoxic eruptions (abx)

May occur with many drugs -Common antibacterials: Tetracyclines, Sulfonamides, Fluoroquinolones -Antifungals: Terbinafine, Itraconazole, Griseofulvin Typically appears as an exaggerated sunburn, often with blisters Avoid prolonged sunlight while taking these agents Use sun protective clothing, sunscreen with UVA protection if must be outdoors

Opioid Withdrawal

May present with a constellation of signs and symptoms, including: -Restlessness, anxiety -Dilated pupils, tearing, runny nose -Tachycardia -Nausea, vomiting, diarrhea, abdominal cramping -Muscle and joint pain -Sweating, goose bumps, yawning, tremors Medications aimed at these symptoms: -clonidine (an alpha‐2 agonist that decreases norepinephrine release) -antiemetics -antidiarrheals -antispasmodics -other non‐opioid analgesics

Muscle Relaxants

May provide some analgesia and a degree of skeletal muscle relaxation or relief of muscle spasm. Primary adverse effects (sedation, dizziness) relate to their CNS and anticholinergic activity; may be particularly problematic in older patients. May take only at bedtime due to sedation.

Repaglinide, Nateglinide

Meglitinides/Glinides Short‐acting secretagogue Pro - Alternative to sulfonylurea if sulfa allergy - Less hypoglycemia, weight gain than sulfonylureas Cons -Dosed TID with meals - AE: hypoglycemia, weight gain

Trichomoniasis

Men often asymptomatic Men can harbor Trichomonas for years if left untreated Women-malodorous, yellow-green discharge with irritation Tx -Metronidazole or Tinidazole

Teriparatide (Forteo): possible candidates

Men or postmenopausal women with severe osteoporosis Patients with osteoporosis who are unable to tolerate bisphosphonates or who have contraindications to oral bisphosphonates Patients who fail other osteoporosis therapies (fracture with loss of BMD in spite of compliance with therapy)

ART AE

Metabolic effects are not uncommon Bleeding events Bone density effects Cardiac conduction effects etc.

Zero-order Elimination

Metabolized at a constant amount per unit of time, regardless of the conc.

Prescribing older adults (DM)

Metformin - Can use - Consider renal status Shorter‐acting secretagogues (glipizide or repaglinide) - Hypoglycemia still a potential risk - Glipizide is shorter‐acting (or glimepiride) and better option than glyburide - Repaglinide principally excreted by liver/ <10% renal DPP‐4 inhibitors - Some recommendation to consider this - Long‐term safety? Cost? - Consider renal dosing for some

Thioamides MOA

Methimazole, Propylthiouracil Inhibits thyroid hormone synthesis (both) • Inhibits the conversion of T4 à T3 (only PTU)

Theophylline

Methylxanthines MOA -inhibits phosphodiesterase, preventing breakdown of cAMP causing smooth muscle to relax and preventing release of histamine and leukotrienes. AE -Arryhthmia (life threatening), headache, NVD, restlessness, seizures, palpitations ---Toxicity-nausea, vomiting, diarrhea, headache, insomnia, and irritability Contraindications -Allergy to corn products -Not recommended <12 years -Acute asthma exacerbations Indication -Alternative treatment for adolescents and adults with mild persistent asthma

Monoclonal antibody therapies (migraines)

Migraine prophylaxis first class approved exclusively for migraine prevention (2018) Monthly (or q3 month) self-injection -Erenumab (Aimovig) -Fremanezumab (Ajovy) -Galcanezumab (Emgality)

Sx of Hypoglycemia

Mild -50-70 -neurogenic: palpitations, tremor, hunger, sweating, anxiety, paresthesia Moderate -50-70 -Neuroglycopenic: behavioral changes, emotional lability, difficulty thinking, confusion Severe hypoglycemia - <50 -Severe confusion, unconsciousness, seizure, coma, death -requires help form another individual

Statins Monitor

Monitor LFT, consider renal function -Baseline AST, ALT, monitor as clinically indicated thereafter, considering individual risk factors -Caution: renal disease, see Epocrates for individual drug/dosing info Monitor LDL -Can check 6-8 weeks after initiating statin therapy -Then about q 3 months until at an appropriate level, repeat every 12 months thereafter, or as the clinical situation dictates; a primary reason to periodically check LDL-C in treated patients is to evaluate compliance Active liver disease is a contraindication Some interact with some common drugs -Ex: Warfarin, non-dihydro CCB, antibiotics, antifungals, fluoxetine, protease inhibitors

ACEi

Monitor: Baseline and periodic BP, serum Cr, electrolytes (esp potassium) May start ACE at lower dose (50%) if on concurrent diuretic, volume depleted, or elderly DC with progressive and/or significant deterioration of renal function -For example, DC if serum Cr increases more than 30% above the baseline value, recheck -Nephrology referral

ARBs monitoring/pt education

Monitoring -BP, serum Cr, electrolytes (esp potassium) -Small, benign increases in serum Cr may occur ---DC with progressive and/or significant deterioration of renal function ---Starting dose should be reduced 50% in patients who are on a diuretic, volume depleted, or elderly Patient education -Monitor BP outpatient

DiureticsGeneral Info

Monitoring (initially, periodically, and with changes) -BP -Electrolytes (esp potassium) -Cr/BUN/eGFR Monitor Patient education -Taking earlier in the day can help with managing effects of increased urination

Pts w/ low health literacy

More likely to visit ER Have more hospital stays Less likely to follow treatment plans Have higher mortality rates

Inhaled insulin

Most common adverse effect: transient cough Safety: Concern about pulmonary toxicity - Avoid in patients who smoke, or quit in past 6 months - Avoid in patients with active/history/risk of lung cancer - Use contraindicated in patients with chronic lung disease, such as asthma or COPD Monitoring: Pulmonary function testing with spirometry - baseline, after 6 months, and annually thereafter (sooner if pulmonary symptoms, such as wheezing, persistent cough)

Penicillin allergy

Most common antibiotic allergy Only 10-15% of pts w/ a hx of penicillin allergy have evidence of IgE mediated positive skin test Potential to cross-reactivity PCN - Ceph -3-10% -avoid cephalosporins if Type 1 PCN allergy -Risk appears highest in 1st gen cep -Lower risk w/ cephalosporin w/ different side chain from offending agent

Nicotine replacement therapy

Most common first-line therapy Aims to control nicotine levels in bloodstream so withdrawal does not occur while patient adjusts to new lifestyle Primary Mechanism of Action: -To maintain plasma nicotine levels that relieve or prevent withdrawal without peaks -Once abstinence is achieved, the patient can taper off the nicotine by gradual reduction -Main benefit of NRT - not exposing patient to carcinogens and other toxins in smoke

Nortriptyline

Non-Nicotine Product 2nd line agent Non-FDA Approved SE -sedation -dry mouth Contraindicated in people with arrhythmias

Mass immunizations

Vaccinate susceptible populations Effective in reducing vaccine preventable disease Disease #'s increase when vaccination rates go down

Anemia of Chronic Disease

Most common form of anemia in older adults Normocytic, normochromic (80%) Microcytic, hypochromic (20%) Causes -Osteomyelitis, TB, rheumatoid diseases, hepatitis, carcinoma, myeloma, lymphoma, leukemia -Renal failure- occur secondary to erythropoietin deficiency -Endocrine disorders- reduce bone marrow responsiveness by not stimulating erythropoietin secretion Chronic renal failure or zidovudine treated HIV -treat underlying cause

Iron Deficiency Anemia

Most common type Occurs when iron loss exceeds iron intake & iron stores become depleted Microcytic, hypochromic Most common causes -Blood loss -Occult malignancy -Aspirin use -Poor iron absorption -Impaired RBC production Pharm Treatment- Ferrous Sulfate (FeSO4) Adverse Reactions -NVD, constipation*, dark stools* Patient education -Administration -Take on empty stomach if tolerated -Three times daily is best -Vitamin C helps increase absorption -May require stool softener Monitoring -Hgb, Hct, Ferritin- 4 weeks -Reticulocyte count if severe- check in 5-10 days Non-Pharm Diet rich in foods containing iron -Organ meats (liver) -Red meat -Beans -Green leafy vegetables -Whole grains

AR: Intranasal glucocorticoids (INGCs)

Most effective single maintenance therapy for AR 1st line treatment for adults w/ moderate-severe AR symptoms MOA -anti-inflammatory effect at many lvls in the nose -down-regulate inflammatory responses

HTN Older Adult

Most older adults (age >65 years), goal BP 120-135/70-80 mmHg Less aggressive systolic BP goals (130-140 mmHg?) may be appropriate in certain cases, such as: -patients >75 years -high burden of comorbidity -diastolic BP <55-60 mmHg (studies have found increased risk with lower diastolic pressures, particularly <60 mmHg) -postural hypotension Individualize goals and shared decision-making, rather than targeting one of the BP goals mentioned above, with particular consideration for: -severe frailty -dementia -limited life expectancy -non-ambulatory -reside in a skilled nursing facility

Pediatric considerations (abx)

Most pediatric drug dosing is guided by age and weight Sanford Guide has pediatric recommendations for various conditions and dosing recommendations for drugs Epocrateshas a pediatric dosing tab for drugs Potential risks: tetracyclines (<8 years), fluoroquinolones

Bacterial Vaginosis

Most prevalent vaginal infection Not considered an STI- increased prevalence in sexually active women Overgrowth of bacteria- Prevotella spp., Mobiluncus spp., Gardnerella vaginalis, or Mycoplasma hominis Diagnosis- white discharge, pH > 4.5, +whiff test, presence of clue cells Relapses and recurrences are common Tx -Metronidazole -Tinidazole

SSRI or SNRI

Most providers will start an antidepressant-naïve patient on SSRI first. (Why hit 2 receptors when 1 might work?) Cymbalta may be preferred in the presence of pain (though cost often prohibitive). If patient has history of poor or underwhelming response to SSRIs, or if they have had success with SNRI, that is a compelling indication to begin with SNRI.

Behavioral Counseling

Most studies demonstrate increasing quit rates with increasing behavioral support Specialty clinic or smoking cessation program Free telephone quitline (1-800-QUITNOW) - for follow-up support & counseling In United States, insurance plans are required to cover tobacco cessation, including behavioral counseling

H2 receptor antagonists

Most widely used OTC anti-ulcer agents Inhibit 50% to 80% of 24-hour acid secretion MOA: Competitively and reversibly binding to H-2 receptors on the parietal cell, thereby inhibiting binding of histamine to the receptors and diminishing histamine-stimulated production of gastric acid. Indication: GERD or PUD Dosing/Titration Info: -Take p.c. and/or h.s., or continuous infusion if I.V. -Provide rapid pain relief -usually after one nocturnal dose. -Quicker acting than PPIs - not as fast as oral antacids. Side Effects: -Headache, constipation, diarrhea, nausea -Cimetidine (Tagamet®)- dyskinesia and possible impotence Adverse Reactions: Thrombocytopenia, neutropenia, bradycardia, confusion, and depression Cautions: Cimetidine with other medications due to interactions. Ex: 1. Cimetidine (Tagamet®, Tagamet HB®) 2. Ranitidine (Zantac®, Zantac 75® 3. Nizatidine (Axid®, Axid AR®) 4. Famotidine (Pepcid®, Pepcid AC®)

Basic Principles of Therapeutics

Multiple actions and effects Biological variation All drugs are toxic; only the doses differ Toxicity may occur after months or years Placebo effect is real and important Drugs to treat drug-induced problems

Cholinergic Recptors

Muscarinic -M1, M2, M3, M4, M5 Nicotinic

Namenda XR

N-methyl-D-asparate (NMDA) antagonist -Blocks action of glutamate -Interactions: ---Use cautiously with NMDA antagonists such as amantidine or dextromethorphan ---Monitor closely with coadministration of HCTZ, triamterene, metformin, cimetidine, ranitidine, quinidine & nicotine -----Use the same renal cationic system & can result in elevated plasma levels of medications. Common SE: -constipation, headache, dizziness, pain Dosing -Starting dose: 7 mg daily, titrate up weekly or more slowly as tolerated -Target dose: 28 mg daily • Severe renal disease (CrCl 5-29 mL/min) -Target dose: 14 mg BID

Anticholinergics

N/V MOA: -Block acetylcholine receptors in the vestibular center. a) scopolamine (Transderm-SCOP®) -A transdermal formulation generally worn behind the ear. -Best used prior to travel or when motion sickness is expected. -Also approved for post-surgical nausea and vomiting. ---Place patch prior to surgery. -Motion Sickness: Apply one patch every 3 days prn -SE: Dizziness, somnolence

Serotonin antagonists

N/V MOA: -work centrally in the chemoreceptor trigger zone and also peripherally in the upper GI tract Ondansetron (Zofran) - SE: constipation, headache, fatigue

Bupropion (Wellbutrin)

Non-Stimulant, NDRI Alternate option for adults (usually refer for this use, off-label for ADHD) Blocks reuptake of norepinephrine and dopamine May be considered for adult with ADHD and comorbid depression Modest efficacy for ADHD? Takes several weeks for clinical effects to appear Select AE: hypertension, weight loss, insomnia BBW: suicidality, neuropsychiatric symptoms CI seizures, bulimia/anorexia Monitoring: BP, HR, weight, mental status

Phenothiazine antihistamine

N/V MOA: involves dopamine receptor blockade in the chemoreceptor trigger zone a) promethazine (Phenergan) -It is an H1-antagonist with considerable anticholinergic, sedative, and antiemetic effects and some local anesthetic properties. -Given orally, rectally, or parenterally. When given I.V., any extravasation can cause severe irritation and necrosis. -Not be used age 2 years SE: drowsiness, dizziness, blurred vision Pregnancy Category C b). prochlorperazine (Compazine®) contraindicated in children <2 years of age. Associated with EPS in some clients. SE: drowsiness, dizziness, and headache

Clindamycin potential AE and warning

N/V/D Major disadvantage: propensity to cause antibiotic-associated diarrhea Black box warning -C. diff associated diarrhea -should be reserved for serious infections when less toxic antimicrobial agents are inappropriate

Acne Rosacea tx considerations

NO COMEDONES: -No place for topical comedolytics (tretinoin, benzoyl peroxide) P. acnes bacteria not important: - topical erythromycin & clindamycin not helpful Vascular instability leads to flushing

Ibuprofen

NSAID used to tx migraine may also cause stomach or intestinal bleeding

Indomethacin

NSAID, non-selective considered more commonly with gout

Ketorolac

NSAID, non-selective for adults, usually administered IM (off‐label for peds) alternative to narcotic analgesic, for moderately severe acute pain requires analgesia at opioid level, not indicated for minor or chronic painful conditions *do not use longer than 5 days oral is indicated as continuation treatment following IM (or IV) dosing of ketorolac, if necessary should not be added to another NSAID BBW‐ appropriate use; GI/CV/Renal/Bleeding/Labor & Delivery Risks; Hypersensitivity reaction avoid if hypersensitivity to aspirin or NSAID

Meloxicam

NSAID, non-selective long duration of effect; slow onset

Ibuprofen, Naproxen

NSAID, non-selective short‐to‐moderate acting are commonly used, commonly suggested in literature, also available OTC

Celecoxib

NSAID, selective a selective COX‐2 inhibitor, relative reduction in GI toxicity compared with nonselective NSAIDs

NSAID CV consideration

NSAIDs can increase BP and diminish efficacy of antihypertensive drugs. Thus, it is recommended to avoid NSAIDs in patients with difficult‐to‐control hypertension and reduced cardiac output.

Symptomatic Treatment: Uncomplicated acute rhinosinusitis

Nasal steroid/INGC? -likely most beneficial w/ underlying AR Mild analgesic (NSAIDs or Acetaminophen) Oral decongestant? (if eustachian tube dysfunction? limited use d/t AE profile & questionable benefit) Intranasal decongestant? (max 3 days if needed to improve nasal patency) Guaifenesin? (thin secretions, not much research to support use) Saline irrigation? (limited evidence, possible benefit?) NOT recommended: Antihistamines (drying), systemic steroids (benefits < risks, AE profile)

Antidepressant and potential pregnancy

National Birth Defects Prevention Study - >30,000 cases and >10,000 controls -First trimester SNRIs associated with more birth defects - venlafaxine had the highest rate. -First trimester SSRIs and bupropion associated with lower frequency of birth defects - and escitalopram had no higher rate than control - could be a good option for someone who is intending to conceive.

Gonorrhea

Neisseria gonorrhoeae Transmitted through urethra, rectum, pharynx, vagina or eye Men often symptomatic, women often asymptomatic Patients often co-infected with chlamydia Sexual partners must be treated Tx *Treat for both Gonorrhea and Chlamydia* Adults/Adolescents - Ceftriaxone plus azithromycin or doxycycline - Alternative: Cefixime plus azithromycin or doxycycline *Do not use Cefixime for pharynx* Conjunctivitis: Cetriaxone 1 g IM X 1 dose plus azithromycin 1 g orally X 1 dose Cephalasporin allergy - Azithromycin 2 g orally X 1 dose

Anitiviarls: Influenza A & B

Neuraminidase inhibitors Endonuclease inhibitor Shorten duration of sx by approximately 0.5-3 days when administered within 48 hrs of illness onset

Atomoxetine (Strattera)

Non-Stimulant Treatment Options It does have some efficacy; may be less than stimulants; is generally well tolerated -Some potential AE: fatigue and somnolence, decreased appetite, nausea, vomiting, abdominal pain, weight loss, hypertension, tachycardia; priapismmedical emergency -Black box warning, you can view in Epocrates: suicidality for children and adolescents, especially during the first months of treatment -Caution if hypertension or tachycardia -Monitor: BP, HR, weight, mental status Not controlled. May be more appropriate if concern about abuse or diversion, or preference against stimulant medication. Dosing depends upon the child's weight. Effects take longer than stimulants- may not be apparent for one to two weeks, and max effects may take 6-12 weeks. Make not adjust dose as quickly as with a stimulant, may consider adjustment after about 4 weeks. Metabolized through the cytochrome P450 (CYP2D6) enzyme pathway -Interacts with some drugs, such as CYP2D6 inhibitors -There are additional considerations for patients who are CYP2D6 PMs (poor metabolizers)

SGLT2 inhibitors (Sodium-glucose co‐transporter 2)

Newer class (2013) Ex: Canaglifozin (Invokana), Dapaglifozin (Farxiga), Empagliflozin (Jardiance)

nicotine transdermal patch

Nicoderm CQ Do not smoke while using patch Available OTC Side Effects -Skin irritation -GI disturbance -dizziness -HA Instructions -Patch worn for 16-24 hours -Wear at night only if awakening with cravings

Nicotine Gum

Nicorette -Available OTC Dosing -2 mg most common (also available as 4 mg) -Chew 1 piece of gum Q 1-2 hours -Chew at least 9 pieces per day during first 6 weeks to increase chances of success -Max dose 24 pieces per day Side effects -Jaw soreness, -hiccups -belching -throat irritation -nausea Do not smoke while using gum

Nicotine Lozenge

Nicorette -Available OTC -Delivers 25% more dose than gum Side effects -hiccups -dyspepsia -dry mouth -irritation/soreness of mouth

Nicorette (Nicotine Lozenge)

Nicotine Replacement Therapy (NRT) SE -Hiccups -dyspepsia -dry mouth -irritation/soreness of mouth Available OTC Delivers 25% more dose than gum

Nicorette (Nicotine gum)

Nicotine Replacement Therapy (NRT) SE -Jaw soreness -hiccups -belching -throat irritation -nausea Available OTC Do not smoke while using

Nicotrol NS (Nicotine Nasal Spray)

Nicotine Replacement Therapy (NRT) SE -Nose and throat irritation -rhinitis -sneezing -coughing -watery eyes Available by prescription Fastest absorption Indicated for patient who fail gum and patch

Nicoderm CQ (Transdermal patch)

Nicotine Replacement Therapy (NRT) SE -Skin irritation, -GI disturbance, -dizziness, -headache Do not smoke while using Available OTC Worn for 16-24 hrs Wear at night only if awakening with cravings

Nicotrol Inhaler (Nicotine Inhaler)

Nicotine Replacement Therapy (NRT) SE -Throat irritation -dizziness -headache -cough 2 mechanisms -Mimics hand-to-mouth ritual of cigarette smoking -Produces sensation of inhaled smoke on back of throat Available by prescription

Nicotine Inhaler

Nicotrol Inhaler -Available by prescription -Thought to work by 2 different mechanisms: ---Mimics hand-to-mouth ritual of cigarette smoking ---Produces sensation of inhaled smoke on back of throat Side effects -throat irritation -dizziness -HA -cough

Nicotine Nasal Spray

Nicotrol NS -Available by prescription - Fastest absorption -Indicated for patient who fail gum and patch Side effects -Nose & throat irritation -rhinitis -sneezing -coughing -watery eyes

Choosing Triptan

No differences identified in head to head studies Consider insurance coverage Route of administration (SC or NS for patients with prominent/early nausea/vomiting) Education: Take at the first sign of pain

Estrogen-Progestin therapy

No longer a first-line approach for the treatment of osteoporosis in postmenopausal women -because of increased risk of breast cancer, stroke, venous thromboembolism (VTE), and perhaps coronary disease Possible indications for this med therapy in postmenopausal women include persistent menopausal symptoms and women with an indication for antiresorptive therapy who cannot tolerate the other drugs.

Acne Vulgaris oral isotretinoin tx

Nodulocystic acne or refractory acne Teratogenicity, extreme xerosis, increased liver function tests & triglycerides, etc. March 1, 2006: FDA iPledge Begins -to prevent use in pregnant women -Pt, MD, & pharmacist must register w/ FDA -all women of child bearing age must list 2 forms of contraception to register No strong evidence to support increased risk of depression & suicide Increased risk of colitis

Zyban SR (bupropion SR)

Non-Nicotine Product 1st line therapy AKA Wellbutrin SR MOA -Unknown. Commonly used as an antidepressant -Thought to affect dopaminergic or noradrenergric properties SE -Headache -dry mouth -insomnia Contraindicated -Seizures, eating disorders -Do not give to patients who are currently taking Wellbutrin Good for patients with co-existing depression, ADHD or both Patient needs to set a "stop date" for at least 1 week (but not more than 2 weeks) from date of starting medication. Patient continues to smoke for 1 week before attempting to quit smoking.

Chantix (varenicline)

Non-Nicotine Product 1st line therapy MOA -Binds to nicotinic acetylcholine receptor -Blocks nicotine's effects in the brain -Alleviates withdrawal symptoms SE -Suicidal ideations, nausea, constipation, abnormal dreams -Can cause neuropsychiatric symptoms Contraindicated -Preexisting psychiatric conditions -STOP IMMEDIATELY IF EXPERIENCE ANY CHANGES IN MOOD OR BEHAVIOR Start taking 1 week before quit date 43% of patients quit using this compared to 29% with Zyban

Alpha-2-adrenergic agonists

Non-Stimulants Treatment Options Guanfacine ER (Intuniv); Clonidine ER (Kapvay) As a class, they are less effective than stimulants. Not controlled They usually are used when: -children respond poorly to a trial of stimulants or atomoxetine -have unacceptable side effects -have significant coexisting conditions ---May consider with coexisting tic disorder; emotional or behavioral condition Select AE: bradycardia, hypotension/orthostasis, sedation, dizziness — Guanfacine seems to have better AE profile than Clonidine Monitor BP, HR Dosing: Start low and go slow to minimize AE; dosing can be more complicated, so may be directed by a specialist Can take up to 2 weeks for initial response Taper over several weeks when DC'd

Zolpidem (ambien)

Non-benzodiazepine hypnotics (sleep) Schedule IV Potential for amnesia with odd behaviors -If patient trialing agent for the first time, can suggest that bed partner watch for any oddities; put keys somewhere out of the usual to reduce risk of driving while sleeping. May be great for PRN use With regular use, patients may note: -Dependence (difficulty sleeping without the medication) -Tolerance (dose no longer provides desired effect) Thus, not recommended for long term daily use

Glucophage (metformin)

Non-insulin therapy 1st line therapy for T2DM MOA -*Decreases hepatic glucose production -Improves insulin sensitivity ---increases peripheral glucose uptake and utilization Benefits: -Works well/good A1c lowering -Favorable effect on serum lipids -Usually mild weight loss -Does not cause hypoglycemia as monotherapy AE -GI -Vit B12 deficiency -contraindicated in pt w/ lactic acidosis ---Anorexia ---N/V ---Abd pain Renal impairment (eGFR 30-45) -initiating is not recommended -If eGFR falls in this range during therapy: ---*Assess the benefits and risks of continuing treatment ---*Reduce the metformin dose by ½ (max 1g/day)

Precose (acarbose)

Non-insulin therapy AGIs MOA -delays glucose digestion and absorption which leads to reduce PP BG AE -GI Not commonly used due to - Poorer tolerance - Frequent dosing (TID) - Less value (efficacy, cost) compared with alternatives

Januvia (sitagliptin)

Non-insulin therapy DPP4i MOA -Inhibits the intestinal enzyme, DPP‐4 which increases endogenous incretins which leads to glucose‐dependent release of insulin; suppression of glucagon Benefits -Oral - Overall well tolerated ---Doesn't cause hypoglycemia ---Weight neutral Cons -Cost? -Relatively weak effects on A1C (0.5‐0.9%) -Longterm safety?

Actos (pioglitazone)

Non-insulin therapy Thiazolidinediones (TZD) MOA -*Increase insulin receptor sensitivity - Decreases hepatic glucose production - Enhance glucose uptake in muscle cells AE -*Weight gain -*Edema -*Increased risk of fractures -Anemia -Hepatotoxicity (rare, periodically monitor LFTs) Contraindicated in HF & bladder cancer Weight gain

Byetta, Bydureon (Exenatide)

Non-insulin therapy (B) GLP‐1 RA MOA -mimics GLP‐1 action: glucose‐dependent release of insulin, suppression of glucagon --- *Additional MOA: Delays gastric emptying, suppresses appetite Benefits -Good A1c lowering -Low hypoglycemia risk -Increased satiety/less Weight -Cardiovascular benefits Cons -Many are injectable, but there is also a newer oral option -$ $ $ Expense - *GI effects BBW -Causes thyroid C‐cell tumors in rats and mice SE -GI (N/V) - Increased satiety, weight loss Avoid -h/o pancreatitis -h/o gastroparesis Injectable (SQ)

Farxiga (dapagliflozin)

Non-insulin therapy (F) SGLT2i MOA: -promotes urinary excretion of glucose by preventing glucose reabsorption Benefits: - Low hypoglycemia risk - Weight loss - Mild BP reduction - Demonstrated efficacy in CV event risk reduction when added to standard care - Benefit in diabetic kidney disease with albuminuria - Benefit in heart failure, HFrEF Cons: -Absence of long‐term efficacy and safety data AE -Fouriner's gangrene (genitals) -GU tract infections; others: dehydration, hypotension -Post‐marketing reports of DKA

Invokana (canagliflozin)

Non-insulin therapy (I) SGLT2i MOA: -promotes urinary excretion of glucose by preventing glucose reabsorption Benefits: - Low hypoglycemia risk - Weight loss - Mild BP reduction - Demonstrated efficacy in CV event risk reduction when added to standard care - Benefit in diabetic kidney disease with albuminuria - Benefit in heart failure, HFrEF Cons: -Absence of long‐term efficacy and safety data AE -*Fouriner's gangrene (genitals) -GU tract infections; others: dehydration, hypotension -Post‐marketing reports of DKA

Jardiance (empagliflozin)

Non-insulin therapy (J) SGLT2i MOA: -promotes urinary excretion of glucose by preventing glucose reabsorption Benefits: - Low hypoglycemia risk - Weight loss - Mild BP reduction - Demonstrated efficacy in CV event risk reduction when added to standard care - Benefit in diabetic kidney disease with albuminuria - Benefit in heart failure, HFrEF Cons: -Absence of long‐term efficacy and safety data AE -Fouriner's gangrene (genitals) -GU tract infections; others: dehydration, hypotension -Post‐marketing reports of DKA

Ozempic, rybelsus (Semaglutide)

Non-insulin therapy (O) GLP‐1 RA MOA -mimics GLP‐1 action: glucose‐dependent release of insulin, suppression of glucagon --- *Additional MOA: Delays gastric emptying, suppresses appetite Benefits -Good A1c lowering -Low hypoglycemia risk -Increased satiety/less Weight -Cardiovascular benefits Cons -Many are injectable, but there is also a newer oral option -$ $ $ Expense - *GI effects BBW -Causes thyroid C‐cell tumors in rats and mice SE -GI (N/V) - Increased satiety, weight loss Avoid -h/o pancreatitis -h/o gastroparesis Injectable (SQ)

Diabeta (glyburide)

Non-insulin therapy (Sulfonylurea) 2nd line option for T2DM MOA: -Enhances insulin secretion/ "secretagogue" AE: -Moderate hypoglycemia, weight gain -Increased risk of hypo in combo with other DM meds Initially very effective in lowering A1c

Amaryl (glimepiride)

Non-insulin therapy (Sulfonylurea) 2nd line option for T2DM MOA: -Enhances insulin secretion/ "secretagogue" AE: -Moderate hypoglycemia, weight gain -Increased risk of hypo in combo with other DM meds Initially very effective in lowering A1c CV safety comparable to DPP4i

Trulicity (dulaglutide)

Non-insulin therapy (T) GLP‐1 RA MOA -mimics GLP‐1 action: glucose‐dependent release of insulin, suppression of glucagon --- *Additional MOA: Delays gastric emptying, suppresses appetite Benefits -Good A1c lowering -Low hypoglycemia risk -Increased satiety/less Weight -Cardiovascular benefits Cons -Many are injectable, but there is also a newer oral option -$ $ $ Expense - *GI effects BBW -Causes thyroid C‐cell tumors in rats and mice SE -GI (N/V) - Increased satiety, weight loss Avoid -h/o pancreatitis -h/o gastroparesis Injectable (SQ)

Victoza (Liraglutide)

Non-insulin therapy (incretin therapy) (V) GLP‐1 RA MOA -mimics GLP‐1 action: glucose‐dependent release of insulin, suppression of glucagon --- *Additional MOA: Delays gastric emptying, suppresses appetite Benefits -Good A1c lowering -Low hypoglycemia risk -Increased satiety/less Weight -Cardiovascular benefits Cons -Many are injectable, but there is also a newer oral option -$ $ $ Expense - *GI effects BBW -Causes thyroid C‐cell tumors in rats and mice SE -GI (N/V) - Increased satiety, weight loss Avoid -h/o pancreatitis -h/o gastroparesis Injectable (SQ)

Glucotrol (Glipizide)

Non-insulin therapy (shortest-acting Sulfonylurea) 2nd line option for T2DM MOA: -Enhances insulin secretion/ "secretagogue" AE: -Moderate hypoglycemia, weight gain -Increased risk of hypo in combo with other DM meds Initially very effective in lowering A1c

Complementary

Non-mainstream practice is used together w/ conventional medicine

Decrease levothyroxine

Normal aging Postpartum Weight loss of roughly more than 10 percent of body weight Initiation of androgen therapy Withdrawal of interacting substance -Drugs -Some substances that can decrease absorption of T4: ---ferrous sulfate, cholestyramine, colestipol, colesevelam, calcium carbonate, raloxifene, omeprazole, lansoprazole, and possibly other medications that impair acid secretion

Ipratropium bromide nasal (Atrovent Nasal spray)

Not 1st line for AR Primary effect: reduce rhinorrhea MOA -Antagonizes acetylcholine receptors -Decreases nasal discharge via anticholinergic activity -Localized action--->Inhibits serious & seromucous gland secretions Benefits: -Quick onset Generally well-tolerated ---SE: epistaxis, nasal dryness, HA Limitations -Limited efficacy -Short duration of action, requires more frequen dosing

Nortriptyline (2nd line agent)

Not FDA approved for smoking cessation Available RX only Must be titrated up to target dose of 75 to 100mg day for 12-24 weeks May double the chances of cessation compared to placebo Contraindicated in people with arrhythmias Common side effects: sedation and dry mouth

Live vaccine principles

Not administered to immunocompromised pts Usually not given if pt has febrile illness If pt needs 2 live vaccines -give both the same day OR -Administer at least 4 weeks apart Not administered in pregnancy -Pregnancy should be avoided for 1 month after vaccination Drug interaction -antiviral drugs

Benzodiazepine pearls

Not advised for use >12 weeks. Increases mortality risk when combined with opioids. Can be useful tool during titration of antidepressant. -May be scheduled or PRN - tailor to the patient's anxiety pattern Wonderful long term PRN tool for patients with panic (low dose alprazolam best due to short onset) -How many tablets do they need? (I tend to write for 5-10 tablets - I'm hoping this lasts them several months - if it doesn't, then they need adjustment to their long acting meds, either with me or with a mental health specialist.) Patients should always be warned about: -Addictive potential -Tolerance -Withdrawal If patient requires long term benzos, they must be seen at least q3 months (probably by mental health specialist!). Weaning may be a long, slow process. Check your controlled substance databases!

Clonidine (2nd line agent)

Not approved by FDA for smoking cessation Available RX only Good at reducing withdrawal symptoms Given as oral medication -or- transdermal patch and titrated up (typical 0.75mg daily in divided doses) Tapering is very important to avoid rebound hypertension Common side effects: drowsiness, dizziness, sedation

Bupropion‐Naltrexone (Contrave)

Not recommended as 1st line therapy Combination -Bupropion ---norepinephrine‐dopamine reuptake inhibitor indicated for depression and for use in prevention of weight gain during smoking cessation. Naltrexone -Opioid‐receptor antagonist used to treat alcohol and opioid dependence -Reward‐center of brain; may have fewer cravings -Thus, avoid for patients on opioids

Direct Renin Inhibitor: Aliskiren (Tekturna)

Not used as often -does not appear to have the same renal protective properties as ACEI *Do not combine with ACEI or ARB (or ARNI that's used for HF) Monitor -BP, Serum Cr, electrolytes (esp K)

pitfalls of therapy for acne vulgaris

Not waiting 6-8 wks to establish a response to starting therapy Ignoring the impact of cosmetics, skin cleansers, hair lubricans, picking, OCPs, occupational exposures, stress, & hormones on a pt's acne Poor pt education on how to counteract the drying effects of topical therapy

Pitfalls of Acne Rosacea Therapy

Not waiting 6-8 wks to establish a response to starting tx Ignoring the impact of cosmetics, skin cleaners, skin care products, topical steroids, stress, & other triggers on a pt's rosacea

COVID in primary care setting

Novel Coronavirus (SARS-CoV-2) Patients should be managed remotely via telehealth when appropriate Infection control is imperative Antipyretic/Analgesic - Acetaminophen first line; Anti-inflammatories if contraindicated or no response Supportive Therapy -Increase hydration -Cough suppressants (dextromethorphan of Benzonatate) Notify patients when to report to ED!

ART drug classes

Nucleoside/Nucleotide reverse transcriptase inhibitors (NRTIs) Non-nucleoside reverse transcriptase inhibitors (NNRTIs) Protease inhibitors (PIs) Integrase strand transfer inhibitors (INSTIs) Entry inhibitors Pharmacokinetic (PK) Enhancers

Vulvovaginal Candidiasis (VVC)

Pathogen- several yeast species, Candida albicans most common Not an STI- increased risk for sexually active women 75% of women will have at least 1; 40-45% will have at least 2 Diagnosis- wet prep, Gram's stain or culture Tx -azoles

Orlistat (Xenical® , Alli®)

OTC= Alli® 60mg TID with meal; Rx: Xenical® 120mg TID Acts locally in the GI tract Good CV safety profile and beneficial lipid effects Approved for long‐term tx of obesity Recommend well‐balanced meal with < 30% calories from fat

Approach to Drug allergy

Obtain a detailed history from the patient on the type of reaction•Classify the reaction as non-life threatening versus anaphylactic There is usually an acceptable, unrelated alternative drug Refer for further testing to if there is a need to determine true allergy/desensitization -Remember: Any re-exposure is contraindicated with some drug reactions

BP Methods

Obtain after 5 minutes of rest Avoid caffeine, exercise, and smoking for at least 30 minutes before measurement Don't talk during measurement Sit with feet on ground and legs uncrossed -or in a semi-reclining position with back supported Arm should be supported and at heart level An appropriately sized cuff should be used -Large adult cuff when indicated -Sometimes a thigh cuff is needed

Antidepressant-induced mania or hypomania

Occasionally, use of an unopposed antidepressant may unmask a bipolar disorder (precipitate a first episode of hypomania or mania) Often, if you carefully go back through these patients' histories, you can find a prior hypomania. What does that mean for us as prescribers of antidepressants? -Screen for hypomania in new med users. For instance, can ask: "Have you ever had a period of time in your life when you weren't sleeping but weren't feeling tired?"

Creams

Oil + water Pts may prefer for cosmetic reasons Moisturizing & cooling for exudation -management of inflammatory dermatoses Options -face -intertriginous areas Can was off w/ water Pt education -rub in until disappears For the same medication, ointment potency > cream > lotions

Ointments

Oil-based Excellent lubricant For the same med, ointment potency > creams Semiocclusive ----> enhanced medication absorption ---> increased potency

Obesity summary

Older obesity pharmacotherapies (such as phentermine) are often limited by -tolerability and dependence issues -generally approved only for short‐term use (≤12 weeks) Newer weight loss agents are typically -better tolerated -have better safety profiles, and -approved for chronic weight management/ maintenance Pharmacotherapy for overweight and obesity should be used as an adjunct to lifestyle therapy and not alone.

Immunomodulators (asthma)

Omalizumab (Xolair) MOA: -prevents IgE from binding to mast cells and basophils leading to a decease in mediators Contraindication: -Acute attack AE: Anaphylaxis, URI, headache, bruising at injection site Should be prescribed and administered by specialist

6.7 A1C

On the basis of provider judgement and patient preference, achievement of lower A1C levels (such as <6.5%) may be acceptable if this can be achieved safely without significant hypoglycemia or other adverse effect of treatment

GERD

One of the most prevalent conditions of the GI tract Reflux of stomach contents into the esophagus Cause: Relaxation of the lower esophageal sphincter Symptoms: Heartburn, belching, hoarseness, nausea, cough, epigastric pain

Opioid for chronic pain

Opioid therapy for the treatment of chronic non‐cancer pain is controversial -long‐term efficacy? -risk of serious harm‐ opioid addiction and overdose epidemic Opioid therapy should not be used as a first line option for chronic non‐cancer pain, but some cases of chronic moderate‐to‐severe pain may require prolonged use of opioids. *Always consider laws, regulations, and policies related to your practice and your state before prescribing opioids. • Careful assessment prior to opioid initiation is important. Consider if the patient: -is at low risk for substance abuse, and -has insufficient pain relief with trials of other potentially effective and safer therapies, and -pain is adversely affecting a patient's function and/or quality of life, and -has potential benefits that outweigh the risks Some populations have increased risks with the use of opioids: -older patients -kidney or liver disease -sleep apnea -mental health disorders

Teriparatide (Forteo) & Abaloparatide (Tymlos)

Parathyroid hormone analog, unique anabolic MOA -stimulates bone formation and activates bone remodeling (rather than just decreasing resorption) SQ injection daily Likely more expensive than oral bisphosphonate Select potential AE: hypercalcemia/calciuria

Combining NSAID + Acetaminophen

Option for pain -Such as more severe cases? There is data to support that NSAID + Acetaminophen provided similar analgesia to opioid for musculoskeletal complaints. May decrease opioid requirements for patients with acute pain.• Comparison of NSAID + Acetaminophen vs Opioid + Acetaminophen -No clinically important difference

Medrol

Oral option Severe dermatoses Face, groin, axillae, intertriginous areas AE -systemic

Antihistamines

Oral, Nasal spray Oral: 1st, 2nd gen MOA -down-reulate H1 receptor activity -inverse agnoists that shift the equilibrium from the active form of H1 receptor to inactive form Reduce itching, sneezing, & rhinorrhea, w/ less impact on nasal congestion -Minimal relief of nasal congestion

Antihistamine primary factors in selection

Overall similar efficacy AE potential Cost Dosing frequency (duration of action)

Management of Exacerbations (COPD)

Oxygen- O2 indicated with SaO2 ≤88% Bronchodilators- SABA ± SAMA Systemic Corticosteroids -Prednisone -Recommended for patients with exacerbations of more than mild severity Antibiotics -Increased dyspnea, volume of sputum, purulence of sputum (former/current smokers) -Augmentin, macrolides or tetracycline are used for empirical treatment standard 5-7 days

Anxiety before prescribing

PARTNER! Discuss goals. Encourage communication of symptom progress and side effects. Ask for a 6 month to 1 year commitment to antidepressant.

Dementia

PCP can evaluate for dementia onset and distinguish which type of dementia May have support from neurology during diagnostic phase May have support from mental health specialist for management of associated behavioral symptoms

Roflumilast (Daliresp)

PDE4 COPD maintenance therapy MOA -Inhibits PDE4 causes increase in cAMP within inflammatory cells important in pathogenesis of COPD, reduces inflammation, pulmonary remodeling AE -diarrhea -nausea -weight loss -HA Caution -Hepatic impairment; -w/ depression, -suicidal ideation Indication -Severe COPD associated w/a history of recurrent exacerbations

NSAID gastroprotection

PPIs to decrease NSAID-induced upper GI ulcers - Conflicting research findings. Prevacid® NapraPAC® esomeprazole (Nexium®) for prophylactic - Reduce dyspepsia & prevent endoscopically detected ulcers - Do not prevent serious NSAID-related GI complications long term. Gastroprotection needed ->76 years of age -Significant comorbidities -History of NSAID-related GI complications -Taking warfarin COX-2 inhibitors vs NSAIDs. PPIs reduced recurrent GI hemorrhage

Chronic pain & CE

Pain management specialists‐ methadone or buprenorphine for treatment of chronic non‐cancer pain and opioid use disorder. Buprenorphine is a mu‐opioid receptor agonist. Methadone and fentanyl should only be prescribed by providers familiar with these medications. In the United States, Risk Evaluation and Mitigation Strategies (REMS) were created by the FDA for clinicians who prescribe ER/LA opioids.

Pathophysiology of HTN

Pathogenesis is not fully understood Primary or "essential" (95%) Secondary (5%) -Medications (RX or OTC) ---Oral contraceptives ---NSAIDs, particularly chronic use ---Antidepressants ---Glucocorticoids ---Decongestants (ex: pseudoephedrine) ---Weight loss medications ---Stimulants for ADHD -Illicit drug use ---Ex: methamphetamines, cocaine Other conditions -Such as hyperthyroidism, primary renal disease, pheochromocytoma, primary aldosteronism, Cushing's syndrome

Antidepressant pt education

Pathophys reminders (normalize and de-stigmatize) Goals of therapy (feel more like "you"; coping mechanisms work again) Early expectations ("This is not Tylenol or Advil" -Eydie Cloyd, PMHNP; will take 4 weeks) Side effects -Early (mostly GI; will subside in 7-14 days - power through or cut tablet in half) -Long term (mostly sexual; warn re: SI) Prepare for the follow-up appt ("Could you feel better?"; dose is due to metabolism, not disease severity; what do your support people think?) How long will medication therapy last (6-12 months or indefinitely) How can they communicate with me

Initial Pharm Therapy for Stable COPD

Patient Group A -SA antimuscarinic (MA) or SA beta2-agonist (BA) Patient Group B -LAMA or LABA (both with severe breathlessness) Patient Group C -LAMA Patient Group D -LAMA or -LAMA + LABA (highly symptomatic CAT> 20) or -ICS + LABA (if eosinophil >300 or hx of asthma)

Antidepressants & pregnancy

Patient education for "What to do if you discover you're pregnant while taking an antidepressant": -SNRI: Stop the medication immediately. You can discuss alternatives at your first prenatal visit with your pregnancy care provider. If you decide you intend to conceive, call me so we can proactively change you to a different medication pre-conception. -SSRI or bupropion (Wellbutrin): It is safe to continue taking the medication until your first prenatal appointment. At that visit, your pregnancy care provider will help you consider the risks associated with both medication continuation and discontinuation.

Ca & vit D bone health

Patients treated with pharmacologic therapy should have normal serum calcium and Vitamin D-25(OH) levels prior to starting therapy. Vitamin D insufficiency and inadequate calcium intake are common in patients with osteoporosis. In the majority of osteoporosis treatment trials, calcium and vitamin D supplements were also administered.

IV bisphosphonate

Patients who cannot take an oral for of this med may be appropriate for intravenous (IV) of this med therapy. Zoledronic acid (Reclast) may be administered once a year for treatment of postmenopausal osteoporosis. -It is the only IV of this med that has demonstrated efficacy for fracture prevention.

Population IBD (inflammatory bowel disease)

Pediatrics: -Diagnosed in 20s and 30s -Caution with medications in pediatrics Pregnancy: -IBD is treated aggressively in pregnant women to monitor nutrition, monitor for anemia and dehydration -Preconception counseling is important

Population specifics in GERD

Pediatrics: -GERD is common in healthy infants! Geriatrics: -Watch sodium and aluminum containing antacids! -PPI to watch in geriatrics is pantoprazole Women: -GERD is common in pregnancy!

Population specifics in PUD

Pediatrics: -H. pylori generally not until children are 5 Geriatrics: -H.Pylori prevalence increases with age -Atypical presentation Women: -GERD is common in pregnancy!

Population specifics for IBS

Pediatrics: -Hard to diagnose Geriatrics: -Rare to have initial presentation in those greater than 50 yo -Colonoscopy? Women: -Likely to seek care for IBS

Population specifics in constipation

Pediatrics: -Manual evacuation -Controversial Geriatrics: -Self reported constipation increases with age -Overuse of laxatives Women: Pregnancy= docusate

Populations specifics for diarrhea

Pediatrics: -Oral rehydration Geriatrics: -Rehydration! -Watch interactions with other medications Women: -No loperamide for pregnant women -Lomotil and Loperamide are excreted in breast milk

Public Lice

Pediculosis pubis Treated differently based on location Commonly affects teenagers and young adults Resistance is common Tx -Permethrin -Malathion

GAS tx

Penicillin V-K: drug of choice -Amox tastes better -may consider injection if concern w/ adherence to oral therapy

Common Antibacterial Classes Used in Primary care

Penicillins Cephalosporins Macrolides Tetracyclines Fluoroquinolones Other -Lincosamide -Nitrofuran -Nitroimidazole

Amoxicillin

Penicillins (Beta-lactam antibiotic) (A) MOA -inhibition of bacterial cell growth by interference with cell wall synthesis Treats -Streptococcal pharyngitis -otitis media -sinusitis AE -Hypersensitivity reaction -GI Generally safe and well-tolerated Avoid Cephalosporins if Type 1 PCN allergy

Amoxicillin/Clavulantate (Augmentin)

Penicillins (Beta-lactam antibiotic) (AC) MOA -inhibition of bacterial cell growth by interference with cell wall synthesis Treats -Streptococcal pharyngitis -otitis media -sinusitis AE -Hypersensitivity reaction -GI Generally safe and well-tolerated Avoid Cephalosporins if Type 1 PCN allergy

Penicillin V

Penicillins (Beta-lactam antibiotic) (P) MOA -inhibition of bacterial cell growth by interference with cell wall synthesis Treats -Streptococcal pharyngitis -otitis media -sinusitis AE -Hypersensitivity reaction -GI Generally safe and well-tolerated Avoid Cephalosporins if Type 1 PCN allergy

SGLT2 MOA

promotes urinary excretion of glucose by preventing glucose reabsorption

Scabies Infestation Therapy

Permethrin (elimite) -applied to all skin sparing face for 8-12 hours as a single application. May repeat in 1 wk -All personal contacts should be treated Ivermectin -repeat in 2 wks Topical steroids: class III-IV Oral antihistamines -It may take 3-4 wks for itching to completely resolve

Stimulant pharmacogenic testing

Pharmacogenetic testing before prescribing medication for ADHD does not currently have broad recommendation. This is an active area of research. There has been some progress, but prospective studies confirming benefits (eg, improved initial or dose titration, decreased adverse events or cost) are lacking at this time. At this time, the US FDA and the American Academy of Pediatrics state that results of pharmacogenetic tests that are directly marketed to consumers (eg, for genetic variants that may be associated with medication metabolism) should not be used to make decisions about the appropriateness of a particular medication or dosing of a particular medication.

Applied and Clinical Pharmacokinetics and Pharmacodynamics

Pharmacokinetics: what the body does to the drug Pharmacodynamics: What the drug does to the body

Dyslipidemia in peds tx

Pharmacotherapy should not be used in children <10 years of age (there may certain high risk cases and a pediatric lipid specialist is consulted) Can use statins (monotherapy) for children > 10 years of age for increased LDL -Start with low doses -Lovastatin, simvastatin, pravastatin, rosuvastatin, and atorvastatin are approved by the US FDA for use in children -More info in chart- link in Brightspace Gemfibrozil or fenofibrate (monotherapy) may be used for elevated TG (>400)

What does not treat the infectious process, but can be prescribed to relieve dysuria ssociated w/ UTI?

Phenazopyridine (pyridium)

Opioid terms

Physical dependence upon an opioid -a physiological consequence of chronic use and not necessarily indicative of behavioral patterns of misuse or substance use disorder -patient can experience withdrawal symptoms when the drug is abruptly DC or dose rapidly decreased Aberrant opioid use, or opioid misuse -any use that is contrary to what is recommended Opioid use disorder -a problematic pattern of opioid use that causes significant impairment or distress -Addiction‐ primary, chronic and relapsing brain disease characterized by pathologically pursuing reward and/or relief by substance use

Barriers to ART adherence

Pill burden Frequency of dosing Adverse drug effects Treatment fatigue

TZD (term)

Pioglitazone (Actos)

TZDs (Thiazolidinediones)

Pioglitazone (Actos‐ more commonly prescribed of this class) Rosiglitazone (Avandia‐ significant restrictions 2010‐2013) *Contraindicated in heart failure

Classification of Topical Corticosteroids

Potency principles 1. remember: topical corticosteroids induce cutaneous vasoconstriction commensurate w/ their potency 2. Potency measurements correlate well w/ clinical anti-inflammatory efficacy 3. Occlusion can enhance topical corticosteroid potency by as much as 100-fold 4. USA classification system divides into 7 potency groups

Acquired QT prolongation

Potential increased with some antimicrobials -Fluoroquinolones, Macrolides, Azole antifungals (certain drugs may have more/less risk) Increased risk with with hypokalemia and hypomagnesemia Increased risk when drugs capable of prolonging QT are taken concomitantly (additive effect)

CCB interactions

Potential negative additive CV effects of BB + Nondihydropyridine CCB

ACEi eGFR

Potential reduced eGFR, including acute renal failure Some individuals at higher risk: -Bilateral renal artery stenosis, hypertensive nephrosclerosis, polycystic kidney disease, HF, or CKD -Also patients with acute volume loss due to vomiting and/or diarrhea may be susceptible

Serotonin Syndrome

Potentially life threatening; severity may vary widely -If minor symptoms, can con't single serotonergic agent, do not add others or increase dose. -True serotonin syndrome (toxicity) develops rapidly over 24 hrs Symptoms: -mental status changes (anxiety, agitated delirium, restlessness, and disorientation) -autonomic hyperactivity (diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, and diarrhea) -neuromuscular abnormalities (tremor, muscle rigidity, myoclonus, hyperreflexia, and bilateral Babinski sign) Potentiated by all serotonin agents: SSRIs, SNRIs, MAOIs, trazadone, atypical antipsychotics, triptans, tramadol, linezolid (Zyvox), dextromethorphan, meperidine (Demerol) Tell patients what to watch for if they are taking more than one agent from the above list; keep this syndrome in the back of your mind when patients taking multiple agents present "just not doing right"

Vehicle: basic ingredients

Powders -absorb moisture -decrease friction Oils -emollient -occlusive properties Liquids (e.g. water) -provide cooling, soothing sensation -help exudative lesions to dry

PrEP/PEP HIV prevention

PrEP: pre-exposure prophylaxis nPEP: non-occupational post-exposure prophylaxis Goal: reduce the acquisition of HIV infection PEP/nPEP should be continued for 4 wks

Other P2Y12 receptor blockers

Prasugrel (Effient) Ticagrelor (Brilinta) Ticlopidine (Ticlid) All indicated for stent‐related thrombus prevention post‐stenting Alternative for patients with poor anti‐platelet activity with Plavix? Other benefits?

Lactic Acidosis Risk factors (metformin)

Predisposing factors/contraindications: - Impaired renal function (eGFR <30 mL/min) - Active alcohol abuse - Concurrent active or progressive liver disease - Unstable or acute heart failure at risk of hypoperfusion and hypoxemia - Decreased tissue perfusion or hemodynamic instability due to infection or other causes - Past history of lactic acidosis during metformin therapy Stop if pt develops a condition associated with hypoxemia, dehydration, or sepsis

Increasing levothyroxine

Pregnancy Weight gain -Such as more than 10 percent of body weight Interacting medication -Some drugs can cause increased rate of thyroid hormone metabolism (therapy with rifampin, phenytoin, or phenobarbital) Estrogen therapy -Data suggest that serum TSH should be measured approximately 6-12 weeks after starting estrogen therapy in postmenopausal women receiving levothyroxine therapy to determine if an increase in dose is needed. Also recheck for younger hypothyroid women starting oral contraceptives?

Avoid herbal therapies for...

Pregnancy and lactation

ICS special populations

Pregnant/lactating -all should be used w/ caution: risk of fetal adrenal suppression -Limited data in lactation -exception pulmicort: drug of choice

Drug Metabolism

Prepares the drug for excretion -Not all drugs undergo biotransformation Not water-soluble -Must be biotransformed Cytochrome P450 enzymes -Found in the liver, intestines, lungs, and other organs -An isoform -Can either be induced or inhibited by chemicals in drugs and food Anticipate and manage drug interactions May predict or explain an individual's response Pharmacogenomics can effect metabolism -Ex. BiDil, Crestor, Warfarin

Risk factors of abx resistance

Prescribers -Prescribing ---Exposure to agent gives bacteria information they can use to change ---Overprescribing a particular agent -Inappropriate prescribing ---Wrong drug, dose, or duration ---Prescribing antibacterial agents for conditions that don't warrant it Pts Not adhering to prescriber directions -stopping med too early -Talking old meds -taking meds not prescribed for them

Stimulant pt education

Pretreatment education includes an explanation of: -rationale for medication treatment -benefits and potential risks of medication -process of determining the optimal regimen When to call When to follow-up

CDC: prevent abx resistance

Prevent infections, preventing spread -promote healthy immune system -vaccines -safe food preparation -clean environment -wash hands Improving use of abx -humans -animals Tracking resistance patterns -ABCs: active bacterial core surveillance Developing new abx & diagnostic tests

ARB MOA

Prevents binding of A-II to receptors in kidney, brain, heart, and arterial walls, blocking action of angiotensin II Inhibits the renin-angiotensin-aldosterone system (RAAS) and cause fall in peripheral resistance

Statins considerations

Price differs among options -Some generic, some $4 Timing recommendations varies -Take short-acting options HS (most LDL-C synthesis occurs during nighttime hours) ---Simvastatin ---Pravastatin ---Lovastatin ---Fluvastatin -Long-acting can be taken when convenient for the patient Monitoring -Lipid levels after 6 weeks of therapy then every yearly once at goal dose unless needed more often for some reason

Anticoagulation indications

Primary and secondary prevention of heart attack and stroke Arrhythmia - stroke prevention -Note: annual failure rate of rhythm/rate control can be as high as 35‐60% ‐ so even if a patient with atrial fibrillation SEEMS to be rhythm/rate controlled, they should still be anticoagulated. Mechanical heart valve/valvular disease Thromboembolism (active vs. clotting disorder vs. history of clot) Post‐stenting

Drug Excretion (clearance)

Primary excretory mechanism is renal Excretion also via: breast milk, feces, sweat Ex. Urinary elimination of amphetamines

Board spectrum antibiotic

Pro -Active against both gram-positive & gram-negative organisms Con -Misuse linked w/ increased ADE & resistance

Mechanisms of antimicrobial resistance

Production of enzymes that inactivate the drug -Ex: Beta-lactamases Acquisition of efflux pumps that expel the drug from the organism Alteration of cell membranes that prevent drug entrance -Ex: Porin deletion/mutation Modification of antibiotic targets Mutation inhibiting target binding Genetic transfer via transduction, transformation, or conjugation

Metoclopramide (Reglan)

Prokinetic agents MOA: - increase esophageal motility and gastric emptying rate and perhaps some effects to increase LES resting pressure SE -May cause dystonic (extrapyramidal or EPS) or tardive dyskinesia (TD) reactions. Other indications -diabetic gastroparesis and an anti-emetic in cancer chemotherapy.

Baclofen (Lioresal)

Prokinetic agents Muscle relaxant that has been shown to increase LES pressure SE: -Drowsiness, hypotension and dizziness

Side effects of Beta blockers

Prolongs and masks symptoms of hypoglycemia (will still sweat) Increase BG Increase Blood lipids Bradycardia Fatigue Bronchoconstriction

PCSK9 Inhibitors

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors Examples: Alirocumab, Evolocumab *Powerful LDL lowering, even greater than statins *Require subcutaneous self-injection Newer option, more expensive at this time -There are options for special approval for individuals meeting certain criteria May be indicated for select subgroups of patients -Ex: adjunct to maximally tolerated statin therapy for patients with familial hypercholesterolemia Overall levels of adverse reactions and discontinuation very low -Possible local injection site reactions Avoid in pregnancy

Orlistat (Xenical® , Alli®) pros/cons

Pros: -effective for weight loss -demonstrated benefits to glycemia, lipids, and BP ---studies show its cholesterol lowering benefits appear independent of its weight reducing effect -long‐duration trials (4 years) -reassuring safety profile Cons: -high prevalence (15‐30%) of unpleasant GI effects which may not be tolerated (can be avoided by not exceeding 30 percent fat with meal) -absorption of fat‐soluble vitamins may be reduced

Immune Globulin (IG) serums

Provide passive immunity to infectious disease Derived from the pooled plasma of adults, processed by cold ethanol fractionation Contraindications -do not give within 3 months of live vaccine Adverse drug rxn -mild local & systemic rxn Drug interactions -live virus vaccines

Measuring pt medication adherance

Pt reports Pill counts Refill records Clinical outcomes Biological and chemical markers -laboratory tests or vital signs Measure medication adherence w/ scales -Ex. Morisky simplified self-reported measure of adherence

Fluoroquinolones caution

Pts > 60 yrs In general avoid - < 18 yrs -pregnancy, lactation -usually safer option available -potential for musculoskeletal toxicity in developing fetuses & children Avoid prescribing systemic fluoroquinolones to -Pts who have other treatment options for ---Acute bacterial sinusitis ---acute bacterial exacerbation of chronic bronchitis ---Uncomplicated urinary tract infections Risks > benefits But...appropriate for serious bacterial infections

How common is medication non-adherence

Pts do not take their medicine as prescribed about half the time

ICS (inhaled corticosteroids) (asthma)

Reduce sx, reduce exacerbations, reduce use of SABA, improve pulmonary function Indication: Mild & persistent asthma MOA -reduce eosinophils & mast cells in the airway -reduce airway hyperresponsiveness by reducing inflammation -reduce responsiveness to histamine, exercise, allergens, irritants Onset of action -2 wks of continuous therapy for max effectiveness

Bisphosphonates caution & AE

Pts who have esophageal disorders, gastrointestinal intolerance to this med, or an inability to follow the dosing requirements of this med, should NOT be treated w/ this med AE GI effects (oral) Atypical femur fractures? -Appears related to longer duration of use > 5 years -DC if occurs Osteonecrosis of the jaw? -Consider risk factors: IV administration, cancer therapy, higher dose and longer duration of exposure, dental extractions, dental implants, poorly fitting dentures, glucocorticoids, smoking, diabetes, and preexisting dental disease -Refer for dental exam before starting therapy and routinely during (for bisphosphonate and denosumab) ---Maintain good oral hygiene and regular oral exams, notify oral surgeon about therapy pre-procedure, and delay initiation of therapy if an invasive dental procedure is planned ---DC if occurs

Nitrofurantoin AE

Pulmonary fibrosis (potentially irreversible) GI (N/V) Hepatotoxicity Renal -contraindicated for CrCl< 60

Denosumab (prolia)

RANK Ligand inhibitor Inhibits osteoclast formation, decreases bone resorption, and increases bone mineral density SQ injection every 6months Higher cost option at this time

Chantix (varenicline)

RX supplied as "Starting Pack" & "Maintenance Pack" Start taking Chantix 1 week before quit date SE -suicidal ideations -nausea -constipation -abnormal dreams -Can cause neuropsychiatric sx Contraindications -Preexisting psychiatric conditions -STOP IMMEDIATELY IF EXPERIENCE ANY CHANGES IN MOOD OR BEHAVIOR

Tachyphylaxis: Pharmacodynamic

Rapid development of tolerance

HTN Urgency goal

Rapidity with which BP should be brought to safe levels is controversial and not based upon high-quality medical evidence There are many factors to be considered. In general: In the absence of symptoms, a gradual reduction is suggested over a period of several hours to several days. Ex: The shorter-term goal is to reduce the BP to ≤160/≤100. -There are additional potential risks if lowered by >25-30% over the first 2- 4 hours -Then longer-term, decrease toward target BP over following days (

Lactic Acidosis Risk (metformin)

Rare but serious, high mortality rate Symptoms may be vague or severe -Anorexia -N/V -Abd pain -Lethargy -Hyperventilation -Hypotension

Migraines

Reasonable that PCPs prescribe first line therapy Frequent, severe, protracted, disabling, or refractory headaches best managed by neurology **FIRST**: Nonpharm- migraine diary to identify triggers; consider "migraine diet" trial (broad elimination, wash out, reintroduce one thing at a time) Many patients will require pharmacological intervention -Rescue -Preventive

ABRS: Treatment failure

Reasons for tx failure -resistant pathogens -inadequate dosing -structural abnormalities Indication for alt tx strategy -failure to show some improvement in 3-7 days OR -worsening of sx after 3 days of therapy If failed 1st line: select a drug from another class If failed 2nd line: consider referral for further evaluation

6.9 A1C

Reassess glycemic targets over time based on the criteria in Fig. 6.2 or, in older adults

Beta blockers

Recently not commonly recommended for initial therapy in the absence of a specific indication for use -particularly for many >60 yrs of age Compared with other options, beta blockers may be associated with: -inferior protection against stroke risk -small increase in mortality (particularly over 60 years)

GINA (Global initiative for asthma) Asthma Treatment Strategies

Recommendations updated in 2019 Major Changes -No longer recommends starting with SABA treatment only -Recommends all adults and adolescents receive ICScontaining controller -Low dose ICS-formoterol used intermittently OR low dose ICS used with SABA for symptom relief

Metformin w/ Renal Impairment

Recommended shift in monitoring from serum creatinine to eGFR (to better estimate kidney function) - Obtain eGFR at baseline and then at least annually in all patients taking metformin, more frequently for those with increased risk (such as elderly). Avoid metformin with eGFR < 30 mL/minute/1.73 m2 If eGFR is 30‐45 mL/minute/1.73 m2: - Initiating metformin is not recommended - If eGFR falls in this range during therapy: ---*Assess the benefits and risks of continuing treatment ---*Reduce the metformin dose by ½ (max 1g/day) Usually held for patients undergoing contrast‐dye procedures until renal function reassessed

Goals of COPD therapy

Reduce Symptoms -Relieve symptoms -Improve exercise tolerance -Improve health status Reduce Risk -Prevent disease progression -Prevent/treat exacerbations -Reduce mortality

SGLT2 (Sodium-glucose cotransporter 2) inhibitors

Reduce blood glucose by increasing urinary glucose excretion; other myocardial and vascular effects have been proposed Randomized trials found that SGLT2i (such as dapagliflozin, empagliflozin, or canagliflozin) reduced the risk of heart failure hospitalization in adults with T2 DM Can also reduce the risk of progression of diabetic kidney disease Considered among secondary therapies for HFrEF in patients with T2DM and some may also be considered for those with HF without T2DM (dapagliflozin or empagliflozin) Avoid SGLT2i with -risk factors for diabetic ketoacidosis -symptomatic hypotension -severely impaired or rapidly declining kidney function

Neuraminidase Inhibitor (Tamiflu)

Reduce influenza viral shedding Oseltamivir is preferred for treatment of pregnant and breastfeeding women and those with severe or complicated influenza) Also approved for prophylaxis (within 48 hours of exposure) Dosing specifics for txand prophylaxis and age are in Epocrates)

AR: Goals of treatment

Reduce or minimize frequency & severity of sx Improve quality of life Minimize AE Prevent complications Minimize impact on co-morbid disorders Decision to tx -severity of sx? -Pt tolerance of sx? -Tx duration?

Goals of drug therapy (obesity)

Reduce weight -Weight loss of 4‐8% is typical (6‐12 months) -When drug therapy is discontinued, weight is expected to rise. -Weight loss should: ---exceed 1 pound/wk during the first month of drug therapy ---fall more than 4‐5% below baseline between 3‐6 months ---remain at this level to be considered effective Improve health status -physical function, -comorbidities, and/or -sense of well‐being Minimize adverse effects

Elderly Insulin risks

Reduced dexterity, impaired vision, cognitive deficits -Assess individual's ability to draw up and give injection and monitor BG -Assess nutrition habits --- Types and timing of foods, eating on a regular schedule, snacks, etc -Assess hypoglycemia risk --- Presence of sx and knowledge of appropriate tx -Consider simpler insulin regimens with fewer injections

HTN Facts

Reducing BP reduces -HF (50%) -Stroke (30-40%) -MI (20-25%) ~50% of HTN pts do not have adequate BP control Stage 1 - >120 systolic OR - >80 diastolic Stage 2 - >140 systolic OR - >90 diastolic

Location affects absorption

Regional differences reflecting % of the total dose absorbed across the body Sole of foot 0.05% Palm 0.1% Forearm 1% Scalp 3.5% Forehead 6% Face 7% Eyelids & genitalia 30%

Smoking relapse

Relapse prevention should be part of every encounter Give positive feedback to all who quit or who attempt to quit 22% relapse within 3 months

Grave's hyperthyroidism goal tx

Relieve symptoms Achieve stable euthyroid state Prevent long-term adverse sequelae

Abx tx: Uncomplicated ABRS

Reminder -some abx that are unusually avoided in pregnancy: Tetracyclines, Fluroquinolones, clarithromycin Adult & peds recommendations Also includes recommendations for penicillin allergy

Meglitinides/Glinides

Repaglinide (Prandin), Nateglinide (Starlix) Short‐acting secretagogue Pros: - Alternative to sulfonylurea if sulfa allergy - Less hypoglycemia, weight gain than sulfonylureas Cons: - Dosed TID with meals - AE: hypoglycemia, weight gain

e-cig data

Research has shown e-cigarettes may help people quit smoking traditional cigarettes. However, evidence is inconclusive due to the low quality of published research (Cochran Review) Researchers feel this may be a "gateway drug" leading nonsmokers and teens to use tobacco In 2016, e-cigarettes became the most commonly used nicotine delivery system among youth, surpassing conventional cigarettes.

Acne Vulgaris topical agent tx

Retinoids: -tretinon -adapalene -comedolytic -shrink sebaceous glands -Should not be used in pregnant women Abx -Clindamycin & erythromycin -sulfur-containing products Benzoyl Peroxide -antibacterial -comedolytic

Acne Vulgaris topical agent tx

Retinoids: -tretinon -adapalene -comedolytic -shrink sebaceous glands -Should not be used in pregnant women Abx -Clindamycin & erythromycin -sulfur-containing products Benzoyl Peroxide -antibacterial -comedolytic

Follow-up Pharmacological Management (COPD)

Review -Review symptoms (dyspnea) and exacerbation risks Assess -Asses inhaler technique and adherence Adjust -Adjust pharm treatment, including escalating and de-escalating

A-Fib: Rate vs Rhythm control

Rhythm vs. Rate control -Equivalent mortality -Equivalent thromboembolism (this was a surprise) -Equivalent quality of life Rhythm control -Drugs are associated with significant AE's, and some require frequent monitoring Rate control -Beta blockers and non‐DHP CCBs are mainstays -Often preferred - since outcomes are similar, decision often made based on how "easy" the medications are to prescribe/take/tolerate - and rate control drugs can be simpler to prescribe/take

Lovastatin- Gemfibrozil

Risk of myopathy, rhabdoylosis

TB info

Risk stratification -High risk: children under age 4 years, HIV/AIDS patients, transplant patients, foreign-born patients Drug therapy principles 1. Treatment regimens must contain multiple drugs to which the organisms are susceptible. 2. The drugs must be taken regularly. 3. Drug therapy must continue for a sufficient period of time. Two phases of treatment -Initiation phase is for first 2 months. -Continuation phase lasts 4 to 7 months.

PDE4 (Phosphodiesterase-4 Inhibitors) (COPD)

Roflumilast (Daliresp) Indication: Severe COPD associated w/a history of recurrent exacerbations MOA: Inhibits PDE4 causes increase in cAMP within inflammatory cells important in pathogenesis of COPD, reduces inflammation, pulmonary remodeling Contraindication/Caution -Hepatic impairment; caution w/ depression, suicidal ideation AE: diarrhea, nausea, weight loss, HA, back pain, dizziness, loss of appetite Pregnancy: caution advised; lactation safety unknown, caution advised

principle 1 (depression)

Role of Medication for Depression MANY factors may contribute to mood - neurotransmitters, hormones, life stressors, etc. We use coping mechanisms (health and unhealthy) to manage these things. Biologic and life factors accumulate and activate our genetic predispositions - to depression, anxiety, mania, thought disorders, or some combination of these. There are times when our coping mechanisms cease to work like they used to. -Symptoms persist -Function is impaired Medication may be useful support for biologic factors.

Asthma management

Routine monitoring of sx & lung function Pt education Reduction in triggers Pharmacological therapy

Monitoring stimulant

Routinely monitor for efficacyimprovement in core symptoms and adverse effects and the medication dose adjusted as indicated May use parent and teacher feedback and/or ADHD rating scales Routine (may be weekly, then monthly, then every 3 months) -BP -Pulse -weight -height (pediatric)

Hand Eczema

Rule out other things first

Common pathogens: ABRS

S. pneumonia H. Influenzae M. Catarrhalis Abx tx goals -speed resoluton of infection -prevent bacterial complications -avoid chronic sinus disease

CAP

S. pneumoniae most common pathogen Amxocillin, doxycycline, fluoroquinolones are agents of choice for outpatient treatment -No comorbidities, no recent antibiotic use ---Amoxicillin ---Doxycycline -Comorbidities, antibiotic use within past 3 months ---Levaquin ---[Augmentin OR Cefpodoxime OR Cefuroxime ] + Azithromycin OR Clarithromycin

Levalbuterol (Xopenex)

SABA MOA -Activates adenlyate cyclase and increases cAMP thereby relaxing smooth muscles and relieving bronchoconstriction AE -tachycardia -palpitations -tremor -hypokalemia -hyperglycemia Caution -Ischemic heart disease, HTN, arrhythmia, seizure disorder and hyperthyroidism -with tricyclics, MAO inhibitors; antagonized by beta blockers

MDI ProAir (Albuterol)

SABA MOA -Activates adenlyate cyclase and increases cAMP thereby relaxing smooth muscles and relieving bronchoconstriction AE -tachycardia -palpitations -tremor -hypokalemia -hyperglycemia Caution -Ischemic heart disease, HTN, arrhythmia, seizure disorder and hyperthyroidism -with tricyclics, MAO inhibitors; antagonized by beta blockers

Proventil 90 mcg/spray (Albuterol)

SABA MOA -Activates adenlyate cyclase and increases cAMP thereby relaxing smooth muscles and relieving bronchoconstriction AE -tachycardia -palpitations -tremor -hypokalemia -hyperglycemia Caution -Ischemic heart disease, HTN, arrhythmia, seizure disorder and hyperthyroidism -with tricyclics, MAO inhibitors; antagonized by beta blockers

Ventolin (Albuterol)

SABA MOA -Activates adenlyate cyclase and increases cAMP thereby relaxing smooth muscles and relieving bronchoconstriction AE -tachycardia -palpitations -tremor -hypokalemia -hyperglycemia Caution -Ischemic heart disease, HTN, arrhythmia, seizure disorder and hyperthyroidism -with tricyclics, MAO inhibitors; antagonized by beta blockers

Combivent Respimat (Ipratropium/Albuterol)

SAMA/SABA combo COPD maintenance therapy Can use in pregnancy, lactation unknown

Desvenlafaxine (Pristiq)

SNRI (antidepressant) Expensive at this time (even the generic). Extended release formulation Starting dose: 50 mg Upper primary care dose: 100 mg

Levomilnacipran (Fetzima)

SNRI (antidepressant) Expensive at this time. Extended release formulation Larger dose range: 20-120 mg

Venlafaxine (Effexor and Effexor XR)

SNRI (antidepressant) Fairly commonly used in primary care Generic AND cheap Starting dose: 37.5-75 mg Upper primary care dose: 150 mg or higher?

Duloxetine (Cymbalta)

SNRI (depression med) Carries indication for pain. Has a generic, but it's still pretty pricey Starting dose: 30-60 mg Upper primary care dose: 120 mg

Anxiety long term therapy

SSRIs, SNRIs all have FDA indication for anxiety Same principles of initiation and titration apply. Sometimes, a higher dose may be required to achieve symptom control. Initial dosing may be patient driven- anxious patients may prefer lower starting doses and slower upward titration. Affirm them for sticking with the med, let them have input into how often and by how much you increase the dose. Watch for activation-related side effects of antidepressants (paradoxical effect- antidepressant making them feel worse - usually temporary, if they can tolerate it) If this occurs, decrease dose or start with new med (not necessarily new class) at lower dose. Be particularly cautious with patients who have a history of panicstart low and go slow.

Side Effects of Cholinergic Drugs

Salivation Lacrimation Urination Defecation Gastrointestinal distress Emesis

LABA (COPD)

Salmeterol (Serevent) -Peds: exercise induced bronchospasms >4 yo 1 puff 30-60 min before exercise Formoterol (Performist) -Foradil: Discontinued Nov 2015 Pregnancy: caution advised; lactation safety unknown, caution advised

Fagerstom Tolerance Test for Nicotine Dependence

Score 7 or greater suggests physical dependence to nicotine

Long Acting Nitrates (angina)

Second Line Maintain vasodilation for continuous workload reduction Start with low dose, advance dose q1‐2 weeks until symptoms improved or side effects intolerable (i.e., +symptoms OR SBP<100 OR bump in HR 10bpm); slow downward titration at end of therapy to avoid rebound angina/HTN Same cautions and side effects as short acting nitrates; some SE's will abate after 1‐2 weeks of therapy -Plus: some folks may experience rebound tachycardia Isosorbide Dinitrate (oral) -Take on an empty stomach (1‐2 hrs after food) Isosorbide Mononitrate (Imdur) (oral) -Extended release, less frequent dosing -Take on an empty stomach (1‐2 hrs after food) Nitroglycerin (transdermal patch or ointment) -See package dosing guidelines

CCB (angina)

Second Line Relaxation of smooth muscle, primarily of arteries (does not ↓ preload) May also assist with exertional angina/exercise tolerance Avoid in heart failure Watch for edema Watch for cumulative bradycardia effect with BBs

HFrEF Tx

Secondary -MRA -SGLT2i (such as dapagliflozin) -Hydralazine + nitrate -Ivabradine -Digoxin

Limitation of 1st gen antihistamin

Sedation & other CNS effects common -Lipophilic--->cross BBB -AE on intellectual and motor function ---older adults: more susceptible to thir anticholinergic effects ---children: impaired school performance ---prohibited for some transportation workers (pilots, bus drivers, etc) Not 1st line due to AE profile

ARB pros/cons

Select Potential AE -Hyperkalemia (similar to ACEi) -Hypotension (more than ACEi) -Changes in renal function, including acute renal failure -Teratogenic Some benefits -Typically no problem with cough (ARB may be better than ACEi for patients with Asthma, COPD) -Lower incidence of angioedema -Enhanced uric acid secretion in gout (losartan) Avoid Pregnancy -BBW: fetal toxicity

Peripherally-Acting Agents: Alpha Blockers AE

Select potential AE: orthostatic hypotension, dizziness, fatigue, somnolence, dry mouth -Caution elderly: on Beers List (high risk of orthostatic hypotension) Patient Education -Give first dose at bedtime -Rise from sitting or lying down slowly to minimize risk of orthostatic hypotension Titrate slowly -If upward titration is needed, it should be done over several weeks

Antidepressants Types

Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Norepinephrine Dopamine Reuptake Inhibitors (NDRIs) Tricyclic Antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Atypicals (Serotonin Partial Agonist Reuptake Inhibitor, etc) All similarly effective for symptoms, differences lie in side effects

Ivabradine (Corlanor)

Selective sinus node inhibitor Decreases heart rate May be considered for HFrEF -patients with an LVEF ≤35% in sinus rhythm with a resting heart rate ≥70 -and who are either on a max tolerated dose up to target of beta blocker or have a contraindication to beta blocker use Monitoring -Heart rate -ECG -Symptoms and signs of HF (esp. evidence of volume overload) Note: There are also many CI/Cautions that should be considered before prescribing Ivabradine

Beta Blockers MOA

Selectively antagonizes beta-1 adrenergic receptors

Ointments (Topical corticosteroids)

Semiocclusive properties lead to enhanced medication absorption which leads to increased potency More potent than cream or lotion Treats -Tx lichenified lesions, crusted lesions, mounded scales -Dry, scaly areas Not useful on large or hairy areas

Potency: Pharmacodynamic

Sensitivity of receptor to drug

C. diff (w/ abx)

Serious, potentially life-threatening infection Cause of pseudomembranous colitis Sx: watery diarrhea, abdominal cramping Abx disrupts normal flora leading to C. diff opportunistically flourishes

Trazadone (sleep)

Serotonin receptor antagonist and reuptake inhibitor Non-addictive; may have depression/anxiety effect, cheap. Use for insomnia is off label. Indication is for depression. Depression doses (150-300 mg) much higher than sleep doses (25-75 mg). Half life 3-6 hours (good for early or middle insomnia) Note: some patients report minimal effectiveness (particularly those who have benzo exposure in the past) Generally well-tolerated; may cause vivid nightmares; rare priapism

Methods for Determining Renal Function

Serum creatinine Creatinine clearance Glomerular filtration rate (GFR) -Recommended by the National Kidney Foundation (NKF) Most package inserts still base dosing on creatinine clearance

Geriatric considerations (abx)

Serum creatinine level alone is not completely reflective of kidney function -Calculate creatinine clearance Patients >65 years are likely to have some degree of renal impairment •Adjust renally when indicated -Renal dosing info can be found in Sanford Guide and at bottom of adult dosing tab in Epocrates

Oral/Parenteral steroids

Severe dermatoses Face, groin, axillae, intertriginous areas Options -medrol dose pack -oral prednisone -injectable: dexamethasone/triamcinolone Consider potential AE (systemic effects even more profound than topical) Caution in certain populations

HTN Urgency

Severe hypertension (≥180/≥120 mmHg) in asymptomatic patients without acute end-organ damage More common in clinical practice -Especially among patients with known HTN who are not fully adherent to medications

CDC recommendation for antiviral

Severe, complicated, or progressive illness; hospitalized Higher risk for complication -children < 2 and adults > 65 -pregnant women or postpartum -extremely obese

Stevens-Johnson syndrome (drug eruption)

Severe, potentially life-threatening disorder of the skin and mucous membranes Usually a rxn to a medication -Strongly associated with antimicrobial sulfonamides drugs, but there are many others Be aware of S/S Medical emergency ---> Hospital!

Ipratropium (Atrovent)

Short-Acting Antimuscarinics (SAMA) COPD maintenance therapy MOA -relax brachial muscles causing bronchodilation, decrease mucus production, prevent release of mediators AE -restlessness -dizziness -HA -GI Contraindication -Allergy to atropine, soy, peanuts -Acute bronchospasm -Caution in narrow-angle glaucoma, BPH, pregnancy, and lactation

Ex of Antimuscarinics (COPD)

Short-Acting Antimuscarinics (SAMA) -Ipratropium (Atrovent) -Use in pregnancy; lactation safety unknown, caution advised Combination Ipratropium/Albuterol -Combivent Respimat -DuoNeb -Use in pregnancy*; lactation safety unknown, caution advised Long-Acting Antimuscarinics (LAMA) -Tiotropium (Spiriva) ---HandiHaler ---Respimat -Aclidinium (Tudorza) -Glycopyrronium (Seebri), Umeclidinium (Incruse) -Caution advised in pregnancy; lactation safety unknown, caution advised

Stimulants Duration of Action

Short-acting forms (duration of action less than 4 hours) Intermediate- or long-acting forms (duration more than 4 hours) -In children older than 6 years of age, a longer-acting preparation may be used initially, starting at the lowest dose and titrating up. -Intermediate or long-acting preparations generally are indicated for children who require a duration of action >4 hours or in whom the administration of medication every 4 hours is inconvenient, stigmatizing, or impossible. -Long-acting medications have additional benefits that they may improve adherence and are potentially less likely to be misused.

Migraine prophylaxis

Should be considered for patients with: -Frequency -Long lasting -Significant disability/QoL impairment Neurologist driven; PCP may continue neurologist's recommended agent(s)

LABA info

Should be used as an adjunct with ICS Should not be used as monotherapy Does not replace ICS Should not be used for acute symptoms or exacerbations Increase lung function, decrease symptoms but controversy over chronic use Black Box Warning -Increase risk of asthma related death

Antiflatulents

Simethicone (Mylicon Drops, Gas-X, Phazyme, Maalox Anti-Gas) - Another example of re-formulation: Mylicon tablets now contain calcium carbonate. Charcoal (CharcoCaps®, Flatulex®) Alpha-galactosidase (Beano®)

Measles, Mumps, rubella, & varciella (MMRV)

Similar to MMR Contraindications same as MMR -caution in pts w/ hx of cerebral injury, seizures, or where physiological stress due to fever should be avoided AE: -Fever > 102 F -increased risk of febrile seizures

Pregnancy (DM)

Similar to the targets recommended by ACOG (the same as for GDM), the ADA-recommended targets for women with type 1 or type 2 diabetes are as follows: • Fasting glucose <95 mg/dL (5.3 mmol/L) and either • One-hour postprandial glucose <140 mg/dL (7.8 mmol/L) or • Two-hour postprandial glucose <120 mg/dL (6.7 mmol/L)

Pharmacotherapy Obesity

Single‐drug option recommended over combo drug as initial option Not every drug works for every patient, individual responses vary widely Liraglutide (1st line) Orlistat (2nd line if changing from liraglutide, or if liraglutide is not an option)

DPP‐4 Inhibitors (term)

Sitagliptin (Januvia)

Clindamycin indications

Skin and soft tissue infections MRSA infections An alternative agent for other various infectious processes

Choosing a Thiazide Diuretics

Some evidence suggests chlorthalidone is the preferred thiazide diuretic in patients with primary HTN (indapamide is alternative) -Shown to provide greater efficacy and reduce CV events and mortality -HCTZ is less potent and shorter-acting -However, HCTZ is still used frequently, and whether one is preferred over the other remains controversia

Pregnancy Insulin

Some experts prefer NPH (intermediate‐acting insulin) in pregnancy - Good data over decades supporting its safety and effectiveness in pregnancy - Doses can be adjusted quickly in response to changing requirements in pregnant women Longer‐acting insulin analogs: ex: detemir (Levemir), glargine (Lantus) Epocrates states for NPH, Levemir, Lantus - "No known risk of fetal harm based on human data"

Migraine analgesics

Some individuals may respond to OTC analgesics for rescue -Acetaminophen -Aspirin -NSAIDS (ibuprofen, naproxen) -Excedrin migraine (Acetaminophen 250 mg - ASA 250 mg - Caffeine 65 mg) (about the same amount of caffeine as 2 diet cokes or 1 cup of coffee)

Ex of Stimulants

Some methylphenidate options: — Ritalin- short-acting — Ritalin LA- intermediate/long-acting — Metadate CD- intermediate/long-acting -Aptensio XR- long-acting, -Quillavant XR suspension- long-acting, — Concerta- long-acting, -Jornay PM- long-acting; unique in that it is taken at night and onset is about 12 hours later -Daytrana patch- long-acting, onset slower than others Some amphetamine options: — Amphetamine-dextroamphetamine (Adderall) - short-acting — Adderall XR- long-acting, immediate and continuous release — Lisdexamfetamine (Vyvanse)- long-acting

Opioid for Pain

Some painful conditions may require use of opioids. When starting opioid‐naïve patients on an opioid, consider an immediate‐release/short‐ acting (IR/SA) agent at the lowest effective dose. Opioids are controlled Consider laws, regulations, and policies related to prescribing State BON websites provide more information regarding state laws

Raloxifene AE

Some significant concerns: -Hot flashes, leg cramps, peripheral edema, increased risk of blood clots -Black box warnings: Venous thromboembolism risk, fatal stroke risk Avoid with active/previous venous thromboembolism Caution: -CV disease/risk, stroke history/risk

Topical decongestants

Sprays, drops, pumps Phenylephrine, oxymetazoline (Afrin) MOA -stimulates alpha-adrenergic receptors--->vasoconstriction of nasal mucosa Indications -nasal congestion or obstruction, significatn altitude change Intranasal more efficacious than oral in decreasing nasal congestion Efficacious, quick onset (about 10 mins) Caution: rebount congestion -Rhinitis medicamentosa ---Tx: DC use, use intranasal steroids -educate! restrict to 3 day use SE: burning, epistaxis, drying of nasal mucosa Lower risk of systemic effect, but consider similar oral cautions

5 step stages to change

Stage 1 - Pre-contemplation: the patient has no intention to quit Stage 2 - Contemplation: interested in quitting, but has no definite plans Stage 3 - Preparation: planning to quit within the next few months and has made a failed attempt is the previous year Stage 4 - Action: the smoker makes a serious effort to quit by modifying his/her behavior. During this stage the patient has abstained from 1 day to 6 months. After 6 months of abstinence, the patient enters final stage. Stage 5 - Maintenance

INGC dosing recommendations

Start w/ max dose for age Look @ options -Is there a QD option? Step Down therapy? -once sx controlled, steop down @ 1-week intervals to lowest effective dose Daily? -Chronic, severe sx PRN? -May work for mild or episodic sx

Warfarin (Coumadin) initiating therapy

Start with ~4‐5 mg First check 3‐5 days; titrate to target INR Constant adjustment throughout treatment required When considering dose adjustments, can help to think in terms of total weekly dose

Statins and Diabetes Onset?

Statins are generally first-line for individuals with DM and dyslipidemia or high CV risk (consider ASCVD risk calculator) New-onset diabetes is increased in individuals treated with statins It is dose-related, occurs primarily in individuals with metabolic syndrome Appears to be less common with pravastatin Occurs overall to a lesser extent than the associated decrease in ASCVD

Other strategies for Medication adherance

Step 1: Ask Think about underlying factors K.I.S. = keep it simple -Simplify the regimine -Impart Knowledge -Modify pt belief and behavior -Provide communication and trust -Leave the bias -Evaluate adherance

Lisdexamfetamine (Vyvanse)

Stimulant (ADHD tx) Amphetamine -Long Acting (4 hr duration) Long-acting medications have additional benefits that they may improve adherence and are potentially less likely to be misused.

Dextroamphetamine/Amphetamine (Adderall)

Stimulant (ADHD tx) Amphetamine-Short-acting Short-acting forms (duration of action less than 4 hours)

ADHD Tx options peds

Stimulant (various types; IR, ER) Strattera Alpha-2-adrenergic agonists

Dosing a stimulant

Stimulant medications usually are started at the lowest dose that may produce an effect and increased gradually (such as every 1-3 weeks?) until core symptoms improve or adverse effects become unacceptable. Ex: At least a 40-50% improvement in core symptoms has been suggested in literature as reasonable result from pharmacotherapy

Methyldopa (Centrally-acting agents: Alpha Agonists)

Stimulates alpha-2 adrenergic receptors *Not widely used outside of pregnancy Milder antihypertensive with slower onset of action Select potential AE -Sedation (common), orthostatic hypotension, bradycardia, headache, blood dyscrasias Monitoring -BP, HR -CBC; may check direct Coombs test baseline and after 6-12 months (hemolytic anemia) -LFTs are checked more frequently first 6-12 weeks and if fever occurs Contraindicated with hepatic disease

Metformin Benefits

Strong efficacy Low hypoglycemia risk Doesn't cause weight gain Long term safety data Low cost

Rapid acting NTG (nitroglycerine)

Sublingual (under the tongue) to avoid first pass effect ( inactivated by hepatic metabolism) Onset 1‐5 minutes, half life 3‐4 minutes, duration of action 30‐60 minutes -Can hasten onset by sitting, leaning forward, breathing deeply, Valsalva (i.e., bearing down as if for bowel movement)

principle 2 (depression)

Successful treatment is more than an Rx How can we provide patients with resources? How useful is a prescription alone?

Bupropion‐Naltrexone (Contrave) BBW

Suicidality (black box warning) Contraindicated in patients with -uncontrolled hypertension -seizure disorder -eating disorder -use of other bupropion‐containing products -chronic opioid use -pregnancy or breastfeeding

General potency considerations

Super high potency corticosteroids -severe dermatoses over nonfacial/nonintertriginous areas -possible palms & soles Medium to high potency strength preparations -mild to moderate nonfacial/nonintertriginous dermatoses Low potency topical corticosteroids -face, eyelid, intertriginous, & genital dermatoses -large areas (low-medium strength preparations) -consider likelihood for systemic absorption

Acute bronchitis

Supportive therapy -increase fluids -analgesic/antipyretics Abx not recommended

Goals of ART

Suppress -viral suppression Restore -restore immune function Improve -Improve quality of life Tailor -consider efficacy, tolerance, pt preference Prevent -prevent HIV transmission to others Preserve -preserve future treatment options

Benefits of ART adherence

Sustained viral suppression Reduced risk of drug resistance Better overall health Improved quality of life Decreased risk of HIV transmission

Phentermine

Sympathomimetic Increase norepinephrine, dopamine release Only approved for *short‐term* use -Max 12 weeks -Related to amphetamines ---Controlled substance requiring DEA‐ Schedule IV drug -----Abuse potential ---Contraindicated in pt with h/o abuse

Tx peds HTN

Symptomatic HTN -eg, headache, seizures, changes in mental status, focal neurologic complaints, visual disturbances, and CV complaints indicative of heart failure Stage 2 HTN Hypertensive end-organ damage Any stage of HTN for patients with CKD Any stage of HTN for patients with DM Stage 1 HTN without evidence of end-organ damage and persisting despite a trial of 4-6 months of nonpharmacologic therapy

Prednisone

Systemic Corticosteroid MOA -Inhibit cytokine and mediator release, inhibit IgE synthesis, suppress inflammatory process, suppress airway inflammation inhibiting mucus production/edema AE -anaphylaxis, -adrenal insufficiency, -Cushing syndrome, -edema, -hypokalemia Indication -Treatment in acute moderate/severe asthma exacerbation Onset -1-2 hrs; -5 day-2 week course recommended

Syphilis

Systemic disease caused by Treponema pallidum Primary-ulcer/chancre at infection site Secondary-rash, adenopathy and neuro complications Tertiary (early latent)- cardiac, neuro, ophthalmic, auditory Tx *Benzathine penicillin G is the treatment for ALL stages* Primary/Secondary/Tertiary - Adults: 2.4 million units IM as single dose - Children 50,000 units/kg IM times one dose up to adult dose Latent or unknown - Adults: 2.4 million units IM weekly X 3 weeks - Children: 50,000 units/kg IM weekly X 3 weeks Penicillin allergy - Nonpregnant: Doxy 100mg BID X 14 days or tetracycline 500 mg daily X 14 days - Pregnant/children: desensitization

Tx dermatophyte hair infection

T. capitis (usually trichophyton tonsurans) Topical agents are ineffective Oral griseofulvin suspension -children Terbinafine -adults Selenium sulfide -reduces infectivity

Tx of dermatophyte nail infection

T. unguium (usually trichophyton rubrum) Topical agents are ineffective Terbinafine or itraconazole pulse therapy

Tx for hypothyroidism

T4 (levothyroxine) -tx of choice for correction of hypothyroidism T3 (liothyronine)? Combo T3 + T4? -Liotrix -Desiccated thyroid (port or beef origin)

Amitriptyline (Elavil)

TCA -Antidepressant Very effective. Not a mainstay of treatment because: -Bothersome SE's - blurred vision, constipation, urinary retention, dry mouth, weight gain, sedation, dizziness. -Life threatening SE's- paralytic ileus, lower seizure threshold, arrhythmias, tachycardia, sudden death, hepatic failure, increased intraocular pressure.

NTG (nitroglycerine) Admin

Take at first sign of pain 5 minutes later, if still having pain, take a second dose, call EMS? 5 minutes later, if still having pain, take a third dose, call EMS More doses? (due to short half life, if continuous dilation is desired, continuous doses are required...)

Taking oral Bisphosphonates

Take on an empty stomach First thing in the morning With 8 oz of plain water Must remain upright for 30 minutes (60 min with Boniva), during which time cannot eat or drink anything else Can discontinue if symptoms of esophagitis develop and look for another option outside of this med

Migraine rescue agents

Taken to abort a migraine Typically more helpful when taken sooner after symptom onset Single larger dose more helpful than multiple smaller doses

Pt Education (smoking)

Talk about cessation at every visit Counseling + pharm therapy = greater chance of success Educate patient on possible S/E of medication AND withdrawal effects (irritability, weight gain, dreams) Continually offer encouragement about quitting, even if they do not succeed with multiple attempts

Narrow-spectrum antibiotics

Targeted Primarily useful against particular species of microorganisms

Stimulants

Tend to be the preferred treatment over other medications for several reasons. -Stimulants have a rapid onset of action, long record of data, and established efficacy in improving core symptoms of ADHD. -At least 80% of school-aged children and adolescents will respond to one of the stimulants if the stimulants are tried in a systematic way. -The response rate to a specific stimulant is approximately 70%. -Exact MOA of stimulants? ---Stimulation of CNS activity, NE and dopamine have roles

Fluoroquinolones (ex. levofloxacin) have a BBW regarding

Tendon eruption

Fluoroquinolones potential AE

Tendon rupture -increased risk >60 yrs, concomitant steroid, renal dz; often achilles tendon rupture Peripheral Neuropathy (may be permanent) Dysglycemia in DM (hypo or hyper) CNS effects -HA -dizziness QT prolongation -can lead to Torsades de pointes & V fib -consider potential of additive effect w/ other drugs capable of prolonging the QT interval Photosensitivity GI (N/D) Pseudomembranous colitis - C. diff infection

Anabolic agents

Teriparatide or Abaloparatide Romosozumab -In contrast to antiresorptive agents, this med stimulate bone formation and activate bone remodeling. -At this time, this med can only be used for a limited amount of time, such as maximum of 1-2 years, depending on drug.

Anxiety half life & therapeutic goals

Test practice: arrange these agents by onset/half life: -Alprazolam (Xanax) -Clonazepam (Klonopin) -Diazepam (Valium) -Lorazepam (Ativan) What might be the therapeutic applications of these different onsets/half lives? -Clonazepam 0.25 mg PO BID for the patient with anxiety around the clock -Alprazolam 0.25 mg PO PRN for the patient with panic attacks

Acne Vulgaris oral abx tx

Tetracycline -photosensitivity -GI upset (empty stomach) Doxycycline -photosensitivity -$$ Minocycline -dizziness -skin pigmentation -$$$ Erythromycin -GI upset Trimethoprim/sulfamethoxazole -photosensitivity -renal effects

Abx (diarrhea)

Tetracycline, metronidazole (Flagylâ) and fluoroquinolones. Particularly useful in treating/preventing "Traveler's Diarrhea." Antibiotics cause diarrhea. - Clostridium difficile most common - ampicillin, second and third generation cephalosporins, clindamycin and fluoroquinolones.

Not all combinations have been found equal in high-risk patients

The ACCOMPLISH Trial -BP reductions -Time to primary endpoint

Adherence

The active, voluntary, and collaborative involvement of the pt in a mutually acceptable course of behavior to produce a therapeutic result

Health Literacy

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

Acetylcholine (dementia)

The enzyme responsible for synthesizing acethylcholine's two components is decreased by 58-90% in Alzheimer's Disease, impairing the cholinergic system in the brain.

Titrating Stimulant

The optimal dose and frequency of medication are determined. The optimal dose is the dose at which target outcomes are achieved w/ minimal side effects Usually lasts about 1-3 months Requires close monitoring ---core symptoms ---target outcomes ---adverse effects

Antidepressant prescribing challenges

The patient who presents as extremely ill but is very resistant to pharmacotherapy On the other end of that spectrum, the patient who seems to think that a pill will fix everything

Insulin Therapy in T2DM

The progressive nature of T2DM should be regularly & objectively explained to T2DM patients. Avoid using insulin as a threat, describing it as a failure or punishment.

What is Medication Adherence?

The pt's conformance w/ the provider's recommendation w/ respect to medication: -Timing -Dosage -Frequency -Duration for the prescribed length of time

Pharmacotherapy of Obesity

The role of drug therapy has been questioned because of concerns about -Efficacy -Safety -Body weight loss slows and then plateaus with continued treatment -Most patients regain weight when their weight loss drugs are stopped

Pathophysiology Reminder (depression)

The serotonin (aka 5HT) system is very complex: -Receptors throughout the body (brain, lungs, heart, kidneys, GI tract, etc) 7 known receptor groups, for instance: -5HT 1A: buspirone (Buspar), vilazodone (Viibryd) -5HT 1B & D: Triptans -5HT 2A: Atypical antipsychotics antagonize (fun fact: hallucinogens are agonists) -5HT 1A, 2&3 groups: SSRIs/SNRIs enhance the synaptic activity at these sites -5HT 3 group: Anti-emetics antagonize

Cannabis and cannabinoids (pain)

The use of cannabis and cannabinoids for chronic pain is controversial Mixed and varied legal status of these substances in various locations. State laws vary; every state has laws dictating the use of medical marijuana Federal level: marijuana is classified as a Schedule I substance under the Controlled Substances Act. Thus, a Schedule I drug cannot be legally "prescribed". There is additional training available regarding certifying medical marijuana for a qualifying condition. The long‐term adverse effects of medical cannabis use are not known. Short‐term adverse effects of cannabis and cannabinoids: -dizziness, dry mouth, nausea, vomiting, fatigue, drowsiness, euphoria, confusion, hallucination, and loss of balance Many trials have reported mixed results on efficacy for chronic pain. Cannabidiol (Epidiolex) Dronabinol (Marinol, and generics) is a synthetic form of THC, the main psychoactive constituent of cannabis. Nabilone (Cesamet) Uses: -Both dronabinol and nabilone are approved for treatment of nausea and vomiting associated with cancer chemotherapy. -Dronabinol is also approved for anorexia associated with weight loss in patients with AIDS. -Cannabidiol (Epidiolex) is approved for Lennox‐Gastaut syndrome and Dravet syndrome

Ex of Methylxanthines

Theophylline -Pregnant/Lactating ---Caution, no known human risk/probably safe

Stopping opioids

Therapy may be discontinued for a variety of reasons, such as: -Ineffectiveness -development of intolerable side effects or opioid‐induced hyperalgesia, -development of opioid use disorder (OUD), -diversion Gradually tapered off of opioids and consider other nonopioid therapies. -The longer the duration of previous opioid therapy, the longer the taper may take. Example of a taper: dose reduction of 5% to 20% every 4 weeks

Opioid & benzodiazepines

There are strong cautions against the concomitant use of a benzodiazepine and opioid. Box warnings regarding the serious risks associated with combined use of opioids and benzodiazepines.

Effects of glucocorticoid therapy

There is a variety of potential AE related to glucocorticoid therapy It is important to be aware of all these potential effects, so providers monitor appropriately & recognize them if they develop

Meds & weight loss

They do not "work on their own" Medications amplify the effect of behavioral changes to produce consumption of fewer calories Addition of a weight loss med to a lifestyle program will likely result in greater weight loss

Metronidazole

This abx may be used to treat c. diff and pts should be educated to avoid alcohol during use

Clindamycin

This antibiotic has a black box warning for C. diff associated diarrhea

Pregnancy Overview (DM)

Tight glycemic control and intensive management There are key differences among types - Pre‐existing T1D or T2D vs Gestational DM Insulin needs change throughout pregnancy DM in pregnancy is complex! - Insulin resistance varies throughout pregnancy - OB provider manages, sometimes high‐risk OB

GLP-1 RA Prescribing

Titrate to reduce GI side effects -Start at lowest dose -See Epocrates for guidance on starting dose, titration, and other administration details ---Ex: oral semaglutide (Rybelsus) has specific administration instructions -You can titrate even more slowly if needed -Pick the dose that works best for that patient

what is abx stewardship?

To measure antibiotic prescribing To improve antibiotic prescribing by clinicians & use by pts so that abx are only prescribed & used when needed To minimize misdiagnoses or delayed diagnoses leading to underuse of abx To ensure that the rt drug, dose, & duration are selected when an abx is needed

Anemia tx goal

To provide adequate oxygen transport to body tissues by restoring hemoglobin and RBC count Note: Anemia can be temporary or long term. Treatments differ based on type.

Common adherence issues

Took less often Smaller doses Stopped sooner Delayed fill Failed to fill

Tx of dermatophyte skin infections

Topical Antifungal cream -miconazole -clotrimazole -econazole $$ -ketoconazole $$$ -Terbinafine $$$$ Topical nystatin has no effect on dermatophyte fungi, only candida spp

Tx of dermatophyte skin infections (usually trichophyton rubrum)

Topical Antifungal cream -miconazole -clotrimazole -econazole $$ -ketoconazole $$$ -Terbinafine $$$$ Topical nystatin has no effect on dermatophyte fungi, only candida spp

Limited Plaque Psoriasis Therapy

Topical Steroids -class I or II for short term (14 days) control -Class III-IV for daily maintenance therapy Topical calcipotriene (dovonex) -Apply 2x daily +/- topical steroids Topical tazarotene (Tazorac) -Should not be used in pregnant women -Apply 1x daily +/- topical steroids Topical tar containing ointments -Short contact therapy

Tx dermatophyte hair infection

Topical agents are ineffective Oral griseofulvin suspension -children Terbinafine -adults Selenium sulfide -reduces infectivity

Psoriasis Tx modalities

Topical steroid creams & ointments Topical calcipotriene cream & ointment Topical tazarotene (retinoid) gel Phototherapy (UVB & PUVA) Oral methotrexate, acitretin (retinoid), or cyclosporine Injectable biologic response modifiers -TNF -IL 12/23 -IL-17A (human IgG1) -IL-17A (human IgG4)

Therapy of mild to moderate eczema

Topical steroids only for flares -Class I or II for short term (14 days) control of severe flares in adults. Class III or IV for children -Class IV-VII for mild flares in adults. Class VI or VII in children Consider topical or oral abx if crusted Consider topical tacrolimus or topical pimecrolimus ($$$) for refractory disease -both are calcineurin inhibitors that inhibit T cell proliferation -NO SKIN ATROPHY -FDA is concerned about long term use (skin cancers, lymphomas???) -Dermatologists are not concerned

Comedonal acne therapy (Acne vulgaris)

Topical tretinoin cream or gel @ bedtime *apply a small amount (pea-sized) to affected regions of face *apply to dry face, not wet *Try applying every other night if irritating Consider adding a topical abx or topical benzoyl peroxide in the morning

Therapy of Acne Rosacea

Topicals -metronidazole cream or gel -azelaic acid cream or gel -ivermectin -sulfacetamide w/ sulfur If moderately severe add oral abx -doxycycline, minocycline -erythromycin

Statin Potency Also Varies

Total cholesterol and LDL reduction -Rosuvastatin -Atorvastatin -Lovastatin -Simvastatin -Pravastatin -Fluvastatin Triglyceride reduction -Atorvastatin -Rosuvastatin -Simvastatin -Lovastatin -Pravastatin -Fluvastatin HDL increase -Rosuvastatin - Lovastatin -Simvastatin -Pravastatin -Atorvastatin -Fluvastatin

VTE

Traditional practice -ED for Lovenox to warfarin Current standard -Can use Lovenox followed by DOAC or warfarin -Or can use DOAC in office (WOAH!!) Duration of therapy: -First event - 3 months -First event, idiopathic or cancer - >3 months -Recurrent - indefinite?

Oral typhoid vaccine

Travelers to South or South east Asia, Africa, Carribbean, Central & south America Oral capsule for age 6 yrs and up Revaccinate every 5 yrs

Lotion (Topical corticosteroids)

Treat -Acute inflammatory and exudative lesions -Ex: contact dermatitis, tinea pedis, tinea cruris Provide cooling and drying action as it evaporates -Making it useful for moist dermatoses and/or pruritis Easy to apply to hairy skin, large areas Less potent

Foams (Topical corticosteroids)

Treat -Consider with inflamed skin, scalp dermatoses. hairy area May contain flammable ingredients May cost more than other formulation

Solutions (Topical corticosteroids)

Treat -Management of psoriasis or seborrhea of scalp -Hairy area Less potent Contain alcohol or propylene glycol -Tend to be drying -Provide coolness and aid in drying exudative lesions

Fish oil

Treat Hypertriglyceridemia

St. John's wort

Treat depressions Is an inducer of the CYP enzymes, and thus can cause increased metabolism of other drugs, which leads to decreased conc. & therapeutic effect

Smoking overview

Treat tobacco abuse as a chronic disease Many cycles throughout lifetime Leading cause of preventable morbidity and mortality Economic burden

Stimulant tx failure

Treatment failure has been described as lack of 40-50% improvement or intolerable adverse effects. -If one stimulant doesn't work, may consider trying the other type (with a similar titration process). -Consider if there may be absorption issues? (ex: high fat meal and vitamin C can affect absorption for some stimulants) -Review of the initial presentation and diagnosis is warranted for children who do not respond to a second stimulant at the maximum dose. The following possibilities should be considered: ---Lack of adherence to the medication regimen ---The possibility of medication diversion (eg, giving or selling the medication to others) ---Whether the expectations are realistic ---Whether there is a comorbid psychiatric diagnosis

Consequences of non-adherence

Treatment failures Deaths Increased costs -nonadherence to medications is one of the largest and most expensive disease categories

ART primary care principles

Treatment is complex---> collaborative care w/ specialists who care for HIV pts Many antiretroviral medications from several classes are currently available Combination therapy is cornerstone of management

Multimodal approach to pain

Treatment of pain is more effective when more than one method is used (multmodal analgesia). Non‐medication treatments for pain have been recommended first for many conditions because they are typically low risk with potential for great benefit and ultimate recovery. Non‐opioid pain medications can be considered as well and should be used to avoid the need for opioids, or to reduce the need for high dose or prolonged use of opioids.

Graves' hyperthyroidism achieving euthyroid status

Treatment options: -Antithyroid drugs- Thioamides: ---Methimazole ---Propylthiouracil (PTU) -Radioactive Iodine (RAI-131) -Surgery

TB

Treatment regimens must contain multiple drugs to which the organisms are susceptible. First line -Isoniazid (INH) -Rifampin (RIF) -Rifabutin Second line -Cycloserine -Ethionaminde -Moxifloxacin

Other Concentrated Insulins

Tresiba (Insulin degludec) -U100 or U200 insulin pens ---U200 delivers the same dose in ½ the volume - Longer‐acting insulin - Starting dose T2DM: 10 units SC once daily - Option for higher dosing per injection ---Up to 80 units in U100 pen ---Up to 160 units in U200 pen Regular U500 - Very concentrated - For severely insulin‐resistant patients (eg, requiring more than 200 total units of insulin daily) - Recommend reserving for endocrinology

Depression pearls

Trial and error! (it's not as scientific as we wish it were- yet!) Maximize one drug's potential before changing drugs or adding another drug -You wouldn't start lisinopril 5 mg, decide it "wasn't working", and change to amlodipine 2.5 mg. Meds plus counseling = best outcome Know when to refer. Patients for whom we might consider starting on the low end of the dosing range: -Older adults -Frail or underweight adults -Adolescents (with additional advice about potential for suicidal thoughts) -Med anxiety (either on the part of the patient or the provider) (It's ok to be anxious at first!) When to try a different agent? -No symptom movement after 2 dose adjustments AND patient is still safe (if not safe, refer) When to try a different class? -No symptom movement after 2 dose adjustments AND patient is still safe (if not safe, refer) -Bothersome SEs with any class

Sumatriptan (Imitrex)

Triptan used to tx migraine MOA Serotonin (5-HT) 1b/1d -Receptor Agonists -Inhibit release of vasoactive peptides, promoting vasoconstriction -Block pain pathways in the brainstem -Inhibit transmission to the trigeminal nucleus caudalis

It is recommended that OTC cough & cold medications be avoided in children < 6 yrs & using OTC cough & cold meds in children btw 6-12 yrs of age is not recommended

True False Answer: True

Glucocorticoid nasal sprays have been described as 1st line & most effective single agent maintenance therapy for allergic rhinitis, particularly persistent moderate-to-severe sx

Ture False Answer: True

Dyspnea (COPD) pharm management

Two long acting bronchodilators recommended for persistent breathlessness or exercise limitation if on monotherapy Persistent breathlessness or exercise limitation on ICS/LABA, add LAMA Investigate other causes

Seborrheic Keratosis

Tx -not necessary -if irritated----> liquid nitrogen

isotretinoin

Tx acne vulgaris -Nodulocystic acne or refractory acne Teratogenicity, extreme xerosis, increased liver function tests & triglycerides, etc. March 1, 2006: FDA iPledge Begins -to prevent use in pregnant women -Pt, MD, & pharmacist must register w/ FDA -all women of child bearing age must list 2 forms of contraception to register No strong evidence to support increased risk of depression & suicide Increased risk of colitis

Porcine thyroid

Tx hypothyroidism w/ natural product made from animal thyroid glands (usually a pig's)

Liothyronine (T3)

Tx of hypothyroidism

Levothyroxine (T4)

Tx of hypothyroidism -tx of choice for correction of hypothyroidism

Actinic Keratosis

Tx: -liquid nitrogen -5-fluoruracil cream -imiquimod cream

Sanford guide sinusitis

Usually start Amox/Clav for peds; Epocrates also has info on lower-dose options for mild-moderate cases for some ages Notice duration for peds is longer than adults High-dose Amox/Clav may be considered if risk factors for resistance If not concered about resistance plain Amox is option

SNRI

Types -Duloxetine (Cymbalta) -Venlafaxine (Effexor and Effexor XR) -Desvenlafaxine (Pristiq) -Levomilnacipran (Fetzima) Venlafaxine (IR and ER), duloxetine, desvenlafaxine have generics; venlafaxine on some $4 lists. MOA -Boost neurotransmitters serotonin, norepinephrine/noradrenaline, and dopamine. -Blocks serotonin reuptake pump. -Blocks norepinephrine reuptake pump. -Desensitizes serotonin 1A receptors and beta adrenergic receptors. Side effects Same as SSRIs PLUS: -Sweating, tremors, sedation, urinary retention Norepinephrine effect may raise BP and HR (especially Effexor which has strongest NE effect). Effect can be cumulative. Short half lives; missing a single dose may cause patients to report withdrawal type symptoms- body aches, stomach ache, "electric jolts" Notes: Renal impairment - lower dose 25-50% Hepatic impairment - lower dose 50%

NDRI (Norepinephrine/Dopamine Reuptake Inhibitor)

Types Bupropion (Wellbutrin, Wellbutrin XL, Wellbutrin SR) Generic Extended release preferred by most patients due to ease of dosing and less sleep disturbance MOA boosts neurotransmitters norepinephrine, noradrenaline, and dopamine. Blocks reuptake pumps.

SSRI

Types Fluoxetine (Prozac) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Note: All generic; all (except escitalopram) $4 MOA -Boosts neurotransmitter serotonin. -Blocks serotonin reuptake pump. -Desensitizes serotonin receptors, especially serotonin 1A autoreceptors. All effective! Which one to choose? -Which one worked in the past, for the patient or their first degree family member? -If they are new to SSRIs, there are some nuances...

Concentrated Insulins: Toujeo

U300 is longer‐acting Concentrated insulins may be more comfortable for the patient and may improve adherence for patients with insulin resistance who require large doses of insulin. Solostar pen adjusts volume dispensed - delivers 1/3 of a unit with each click A higher daily dosage of Toujeo may be required to achieve the same level of glycemic control as with Lantus (glargine U100)

Cephalosporin potential uses in primary care

URI Otitis media Skin infections UTI CAP

Nitrofurantoin (Macrobid) uses

Uncomplicated UTIs -only used for treatment of lower UTIs b/c adequate drug conc. are found only in urine

pro/cons SGLT2

Unfavorable -genital infections -diabetic ketoacidosis -amputations -fractures Favorable -prevention of heart failure -preservation of renal function -reduction in major adverse CV events -reduction in BP -weight loss -improvement in glycamia

Pts w/ angina sx

Universal: -Anti‐platelet therapy -Short acting nitroglycerin for relief of acute episodes First line: Beta blocker if no contraindication (BB especially useful for the patient with compelling indications: prior MI, heart failure) Second line: If symptoms persist or there is contraindication to beta blockade, add/substitute CCB and/or long acting nitrate Third line: Ranolazine (Ranexa) - antianginal which inhibits late sodium current; significant drug‐drug interactions

Combo therapy not recommended (osteoporosis)

Until the effect of combination therapy on fracture risk is better understood, AACE does not recommend concomitant use of these agents for prevention or treatment of postmenopausal osteoporosis

CDC: inappropriate abx use

Up to 50% of antibacterial agents are NOT necessary. Antibiotics are the only drug where use in one patient can impact the effectiveness in another. If everyone does not use antibiotics well, we will all suffer the consequences.

Risk factors hypoglycemia

Use of insulin secretagogues Impaired kidney or hepatic fx Longer duration of diabetes Frailty & older age Cognitive impairment Impaired counterregulatory response, hypoglycemia unawareness Physical or intellectual disability that may impair behavioral response to hypoglycemia Alcohol use Polypharmacy

Long term asthma control

Used to control sx -Inhaled corticosteroids -leukotriene modifiers -Cromolyn -Methylxanthines -Long-acting Beta2-agonists -immunomodulators

Tuberculin purified protein derivative: PPD

Used to screen asymptomatic individuals for infection w/ M. tuberculosis Contraindications -tuberculin-positive reactors -immunodeficiency Adverse drug rxns -in highly sensitive people -vesiculation, ulceration, & necrosis @ admin site Drug interactions -live virus vaccine -Bacillus Calmette-Guerin -Immunosuppressants

Topical corticosteroids

Used to treat -Contact dermatitis -Atopic dermatitis/Eczema -Psoriasis MOA -Induce cutaneous vasoconstriction commensurate with their potency Need -***Correct diagnosis -***Lesion type and location being treated -* Consider absorption -*Occlusion enhances drug absorption -For optimal absorption of most topical drugs, apply them to moist skin either immediately after bathing/ wet soak. AE -***Skin atrophy -Photosensitization -Promotion of fungal growth -*In general, there is increased risk of AE when topical corticosteroids are used > 3 weeks Systemic AE -Immunosuppression -Impaired wound healing -Hyperglycemia, unmask DM -HPA axis suppression

Acetaminophen

Used to treat migraine Tends to be overused for HA Is an analgesic and antipyretic

Omega-3 Fatty Acids

Useful for patients with high triglycerides (TG) -Alternative to fibrate therapy Omega-3-acid ethyl esters can increase LDL-C levels May prolong bleeding time Monitor ALT and AST levels periodically Potential GI effects Avoid if hypersensitivity to fish and/or shellfish

Gels (Topical corticosteroids)

Useful in treating acne Beneficial for oily or hairy areas Combine therapeutic advantages of ointments with cosmetic advantages of creams

HTN pregnancy considerations

Usually BP >150/100 is treated Referral/Specialist-led treatment Most widely used medications: -Methyldopa (alpha agonist; milder agent, may cause sedation) -Labetalol (alpha/beta blocker) -Nifedipine, extended-release (dihydro CCB) Consider: -All antihypertensive drugs cross the placenta -There are no data from large well-designed randomized trials on which to base a strong recommendation for use of one drug over another. *Avoid* -ACEI, ARB, direct renin inhibitors, mineralocorticoid receptor antagonists (spironolactone, eplerenone)

Mood Stabilization

Valproate (Depakote) -Caution- liver impairment -Watch: platelets, LFTs, plasma levels (baseline, at 1 month, q6 months) Carbamazepine (Tegretol) -Caution- liver impairment, aplastic anemia, agranulocytosis, multiple potential drug-drug interactions -Watch: platelets, WBCs, LFTs, renal, thyroid (baseline, at 1 month, q6 months) Oxcarbazepine (Trileptal) -Caution- Increased risk of developing hyponatremia, interference with hormonal contraceptives -Watch: Sodium (baseline, monthly x3, q6 months) Lamotrigine (Lamictal) -Caution - Stevens Johnson Syndrome

Pharmacogenetics

Variability in drug response/toxicity due to genetic factors

Pharyngitis

Various pathogens -Group A strep (GAS) ---most common bacterial cause -Other potential pathogens (C. diptheriae, C. pneumoniae) -Viral: influenza, IM -Consider evaluation for primary HIV infection in pts w/ pharyngitis, painful mucosal ulcers, or risk factors for HIV Consider classic symptoms of GAS

Glycemic Goals

Vary among individuals - Age (pediatric/adult/geriatric) - Co‐morbidities - Pregnancy

TCAs

Very effective. Not a mainstay of treatment because: -Bothersome SE's - blurred vision, constipation, urinary retention, dry mouth, weight gain, sedation, dizziness. -Life threatening SE's- paralytic ileus, lower seizure threshold, arrhythmias, tachycardia, sudden death, hepatic failure, increased intraocular pressure.

SPARI

Vilazadone (Viibryd) -Serotonin 1A partial agonist reuptake inhibitor (dual MOA of partial agonist and reuptake inhibitor) Still fairly new (expensive) The partial agonist action was designed to limit some of the SSRI brain side effects. Early nausea and diarrhea sometimes intolerable

Common Cold/URI

Viral causes most common General tx principles -advise pt the usual course & duration of URI -Symptomacti tx Inform pts of risks & benefits of symptomatic management Acute bacterial rhinosinusitis is a potential (but not frequent) complication For most people, sx are self-limited Symptomatic therapy remains the mainstay of common cold tx -cough suppression -nasal symptoms -pain (HA, ear pain, muscle & joint pain) Advise pts when to return for re-evaluation

AOM (acute otitis media)

Viral etiology relatively common Abx when indicated -most common bacterial pathogens ---streptococcus pneumoniae ---Haemophilus influenzae ---M. Catarrhalis -Decision to treat varies

Cholecalciferol, ergocalciferol

Vit D3 & Vit D2 Vit D3 rather than vitamin D2 is recommended for replacement in adults.

Pernicious Anemia

Vitamin B12 deficiency that is autoimmune or linked to heredity Other causes -Vegetarian/Vegan (pregnant women) -Crohn's -Gastric Bypass Prevention -Adequate dietary intake (breakfast cereal*) -Diet- Mollusks (clams), fortified breakfast cereals, liver, salmon, milk, eggs Treatment -Oral, IM, and intranasal Vitamin B12 preparations -Nutritional deficit: 1,000 mcg/day cobalamin (oral) until normal B12 levels -Pernicious anemia: 1,000 mcg IM daily for 1 week followed by 1,000 mcg IM weekly for a month Monitoring -Reticulocytes, H&H, B12 monitored before therapy, after 7 days and at regular intervals -K+, LFTs

Serotonin Modulator & Stimulator

Vortioxetine (Brintellix) -Similar MOA to vilazadone (Viibryd), plus action at several other serotonin sites Being used with some good success by psych providers, but typically only after patients have failed SSRI/SNRI or found the SE bothersome Significant GI effects- may abate some after 2 weeks. Take with food. Very new, very expensive, even with insurance (high copay)

PT w/ SIHD (stable ischemic heart disease)

• Anti‐platelet therapy Address modifiable risk factors: -Smoking cessation -Weight loss -Exercise Optimize therapy for: -HTN -Dyslipidemia -Diabetes

Changing ADHD med

Warranted for children who do not have improvement in core symptoms at the maximum recommended dose or who have intolerable side effects There are some dosing references regarding switching from one stimulant to another -Tip: Dose of amphetamines is expected to be about half of methylphenidate dose; ex: Methylphenidate (Ritalin) 20mg approx. equivalent to Amphetamine-dextroamphetamine (Adderall) 10mg; can still start at a lower dose and titrate according to response.

Pediatric considerations for steroid therapy

Watch potency! -generally lower potency (classes 4-7) -avoid potent (high, super-high) in children under age 12 yrs -consult derm for severe cases Shorter durations -generally max 1-2 wks Lower quantities -based upon calculation of mean body surface area

Lotions

Water-based (powder + water or other liquid) When to use -acute inflammatory & exudative lesions -ex: contact dermatitis, tinea pedis, tinea cruris Provide cooling & drying action as lotion evaporates -making it useful for moist dermatoses &/or pruritis Easy to apply to hairy skin, large areas Less potent Pt education -shake container before each application

Drug Absorption

Weak acids or weak bases -weak acid drug in acidic media (nonionized), better absorption wise -weak acid drug in basic media (ionized) -weak basic drug in acid media (ionized) -weak basic drug in basic media (nonionized) Water-soluble -Cannot pass through cell memebranes Lipid soluble -more readily pass through cell membranes

Which antidepressant should I choose?

What has worked (or not worked) for the patient in the past? Match cost with insurance/payment ability Match symptoms and side effect profiles Listen to any patient biases or fears

Insomnia pharm Tx

What have they tried over the counter? -Tylenol PM -Melatonin How helpful was it? Most folks who present to our offices for help have tried these things, but if they haven't, it's completely reasonable to suggest a trial of OTC first. Nonbenzodiazepine sedatives -Trazadone -Remeron -Ambien (and related agents) Melatonin agonists Primary mechanism of action for alternate disorder with side effect of drowsiness

HIV treatment failure

When an antiretroviral regimen is unable to control HIV infection. Factors that can contribute to HIV treatment failure include drug resistance, drug toxicity, or poor adherence to antiretroviral therapy

HTN pregnancy

When hypertension is diagnosed in a pregnant woman, the major issues are: -establishing a diagnosis -deciding the BP at which treatment should be initiated and the target BP -avoiding drugs that may adversely affect the fetus

FRAX (Fracture Risk Assessment Tool)

When making pharmacologic decisions, a score using this may be considered in addition to DXA results. • Estimates the 10-year probability of major osteoporotic fracture (clinical spine, forearm, hip or shoulder fracture) AND hip fracture for untreated patients between 40-90 years • Offers additional information about fracture risk for those with osteopenia (bone loss) and osteoporosis.

Duration of bisphosphonate tx

When medication therapy stops, benefit decreases (some minimal potential residual benefit with bisphosphonate, but not others) This class has been implicated in several potentially dangerous side effects that are linked with longer duration of use (as mentioned above) Consider risk Patients who take this med for 5 years and still have high fracture risk (prior fx, older age, frail, high fall risk, etc): -Continue med and reconsider a "med holiday" after 6-10 years (6 years IV Zoledronic acid). -Teriparatide or raloxifene may be considered during the holiday for higher risk patients. Patients who take this med for 5 years, have stable BMD, no prior fx, and low risk for fracture: -Consider a "med holiday" at 5 years (3 years IV Zoledronic acid). -Continue to monitor BMD; if it decreases, can restart med.

Solutions

When might you use? -management of psoriasis or seborrhea of scalp -hairy area Convenient to apply Less potent Contain alcohol or propylene glycol -tend to be drying -provide coolness & aid in drying exudative lesions

Ointment info

When to use -Tx lichenified lesions, crusted lesions, mounded scales (ex. psoriasis) -dry, scaly areas Not useful on large or hairy areas Pt acceptance may be lower "greasy, stick" Pt education: moisten skin prior to use; rub in until disappears

Foams

When to use? -consider w/ inflamed skin, scalp dermatoses, hairy area Easy to apply Cosmetically acceptable Most cost more than other formulation May contain flammable ingredients -pt education: avoid fire, flame, &/or smoking during & immediately following application Use -spray a small quantity into the cap or on a saucer & then apply w/ a fingertip

Case: UTIW.P. is a 27-year-old female presenting with dysuria, urinary frequency, and cloudy urine for 2 days. She has no fever, n/v, flank pain, CVA tenderness, allergies, or current medications. LMP 2 weeks ago. She is diagnosed with uncomplicated UTI (acute cystitis).

Which drug(s) could be considered as first-line therapy for W.P.? Which drug would notbe considered 1stline? a. Fosfomycin b.Ciprofloxacin c.Nitrofurantoin d.Trimethoprim-sulfamethoxazole Which drug is not an antibiotic, but is a urinary analgesic, and may be used for a couple days to help reduce discomfort from dysuria? If W.P. had fever, nausea, and CVA tenderness, and was diagnosed with pyelonephritis, is the first-line treatment for pyelonephritis the same for UTI? (Outlined in Sanford Guide)

Abx resistance

Widespread and inappropriate use-single most important cause of drug resistance Issue in community, long-term care, and hospital settings Negative impacts on patients, healthcare system, and society

Depression when to refer

With treatment, we are expecting either: -Full resolution of symptoms. (keep same dose) -Partial resolution of symptoms. (increase dose) -No change yet, but no worse either. (increase dose) We are not expecting: -Symptoms worsening (refer) -New suicidal ideation (refer, possibly emergently) -New mania or hypomania (see next slide) -No symptom change after 1-2 dose increases (refer)

Angina

Work‐up for reversible angina conducted in cardiology setting; irreversible angina worked up in ED. Mainstays of work‐up and initial treatment may include: -Stress test -Catheterization -Intervention (e.g., stenting, bypass, etc) Myocardial O2 demand exceeds supply (reversible ischemia) Stable angina resolves with rest and/or nigroglycerin

Activia (bifidobacterium animalis)

Yogurt product Promoted for bowel regularity. Contains a probiotic "Bifidus regularis" - Strain of Bifidobacterium animalis. Insufficient evidence to recommend Activia® over other yogurts Probably a good choice for patients who want a yogurt with live and active cultures.

Ex of Leukotriene Modifiers

Zafirlukast (accolate) -Pregnant: Caution advised/no known risk for teratogenicity -Lactating: Possibly unsafe Montelukast (Singulair) -Pregnant: Caution advised; congenital risk inconclusive -Lactating: Safety unknown

Non-benzodiazepine hypnotics (sleep)

Zolpidem (Ambien, AmbienCR, Intermezzo), Zaleplon (Sonata), Eszopiclone (Lunesta) Schedule IV Potential for amnesia with odd behaviors -If patient trialing agent for the first time, can suggest that bed partner watch for any oddities; put keys somewhere out of the usual to reduce risk of driving while sleeping. May be great for PRN use With regular use, patients may note: -Dependence (difficulty sleeping without the medication) -Tolerance (dose no longer provides desired effect) Thus, not recommended for long term daily use

Partial agonist: Pharmacodynamic

a drug that binds to a receptor and causes a response that is less than that caused by a full agonist

Drug Antagonist: Pharmacodynamic

a drug that blocks another drug from combining with a receptor

Direct Renin Inhibitor: Aliskiren (Tekturna) MOA

also works on RAAS Decreases plasma renin activity interfering with conversion of angiotensinogen to A-I

Methadone

reduces opioid cravings and withdrawal and blunts or blocks the effects of opioids

Clopidogrel (Plavix)

anticoagulant Class: -P2Y12 receptor blocker MOA: -Inhibits adenosine disphosphate (ADP), which promotes platelet receptor binding Dosing: -75 mg PO daily SE: dyspepsia, N/D Considerations Dual antiplatelet therapy with ASA and clopidogrel: -Post‐ percutaneous coronary intervention, and particularly if there is stenting, either with both bare metal stents (BMS) or drug eluting stents (DES) for 12 months or more (at 12 months, they should revisit the cardiology provider who completed their procedure for consideration of discontinuation of therapy) -Secondary prevention of acute coronary syndrome/stroke? Clopidogrel alone: -Secondary prevention of acute coronary syndrome/stroke? Concerns Concomitant use with PPIs -Observational studies observed an increased incidence of coronary events in patients taking PPI with their clopidogrel. -However, RCTs have failed to support this relationship‐ they find reduced incidence of GI bleed, but no change in coronary events. -Current theory is that confounding variables caused the observational association, rather than a true interaction. Pharmacogenomics -What to do with patients with High on treatment Platelet Reactivity (HPR)? Genetic screening (probably not)? Substitute prasugrel (Effient)?

Warfarin (Coumadin)

anticoagulant MOA: -competitively binds to vitamin K, inhibiting vitamin K dependent coagulation (reversible with antidote: Vitamin K) Pharmacokinetics/pharmacodynamics: -Foods with Vitamin K can decrease effectiveness‐ consume steady amount -Highly protein bound -Metabolism has genetic variation and is impacted by numerous agents -Narrow therapeutic index Thus, frequent monitoring important: -Blood levels (International Normalized Ratio ‐ INR) -Patient adherence to medication/diet -Risk of bleeding vs benefit INR targets: -Atrial fibrillation, history of VTE: INR 2.0‐3.0 -Most prosthetic heart valves: INR 2.5‐3.5 Due to pharmacokinetics/NTI, some patients may benefit from branded product for consistency Dose at bedtime to minimize drug/food interactions Contraindicated: -Pregnancy -Recent hemorrhage -Risk of major bleed -Recent trauma Relative contraindications: -See HAS‐BLED score (older age, uncontrolled HTN, hx GI bleed, alcohol use, etc)

Buproprion (Wellbutrin (XL)

antidepressant Who shouldn't take it: History of seizures Alcohol users (cumulatively lower seizure threshold; "how much is too much" alcohol will therefore vary by person; package insert advises "caution") -Note: Tramadol also reduces seizure threshold History of panic (due to activation, this may be exacerbated) Underweight (may cause further weight loss) Who is a good candidate: Vegetative depression Weight neutral - good for patients who have experienced weight gain with SSRIs/SNRIs or are particularly worried about potential weight gain with SSRIs/SNRIs Less sexual side effects - may be preferred for patients for whom SSRIs/SNRIs have been problematic or for patients who are particularly concerned about SSRI/SNRI-related sexual SEs Attempting smoking cessation SE -**Seizures** -Tinnitus -Less smoking? -Interferes with sleep if taken close to bedtime- dose in the morning -Anxiety (usually won't cause it, but if it was already there, may make it worse)

Antimotility/antispasmodics

antidiarrhea diphenoxylate (Lomotil®) - Schedule V controlled loperamide (Imodium®, Kaopectate II®, Maalox Antidiarrheal®, Pepto Diarrhea Control®) - Available OTC difenoxin (Motofen®) - The active metabolite of diphenoxylate - Schedule IV related to atropine

Maintenance doses

are administered at prescribed intervals to maintain a therapeutic drug response

Herbs

are not regulated by the FDA as food or drugs, but they fall under the category of "supplements" which is more limited

Naltrexone

blocks the euphoric and sedative effects of opioids and prevents feelings of euphoria

ACEi renal

can cause increase in serum creatinine -May be benign or significant -Monitor serum creatinine- within 4 weeks after initiating therapy...or sooner? ---Some sources recommend 1 week ---Sooner, within 1-2 weeks if combined with a diuretic -----reduce starting dose by 50% if taking diuretic ---Sooner, within 3-5 days, if high risk for renal artery stenosis

Antiretroviral therapy (ART)

can prevent destruction of the immune system and progression to AIDS

SJS

characterized by prodrome of flue-llike sx, erythematous macules & plaques, blistering of mucous membranes & sloughing

Step 3 of prescribing antibiotics

consider the options

ABC obesity

risk assessment -Abdominal obesity (waist circumference) -BMI -CV risk factors ---hypertension, diabetes, dyslipidemia -Co‐morbidities ---sleep apnea, nonalcoholic fatty liver disease

Irritants or stimulants

constipation MOA: -Increase peristalsis through effects on smooth muscle and promoting fluid accumulation in the colon/small intestine Onset of Action: -oral 6 to 12 hours; rectal 15 to 60 minutes Bisacodyl (Dulcolax®, Correctol®)—enteric coated tablets and suppositories. - Do not administered with milk or antacids Glycerin suppositories - Local irritating and hyperosmolar effect - Not systemically absorbed Sennosides, e.g., senna (Senokot®, Ex-Lax®) -

ACE inhibitors AE

cough (up to 20%), hyperkalemia, angioedema, hypotension, teratogenicity, photosensitivity Others less common: pancreatitis, SIADH, blood dyscrasias Avoid -**Pregnant or planning pregnancy ---BBW: fetal toxicity -H/O angioedema

Nummular eczema

crusting

Muscle relaxant examples

cyclobenzaprine (Flexeril, commonly considered first) methocarbamol (Robaxin) carisoprodol (Soma, concerns about abuse potential; controlled) baclofen metaxalone (Skelaxin) tizanidine (Zanaflex)

AGIs MOA

delays glucose digestion and absorption which reduce PP BG

Citalopram (Celexa)

depression drug, SSRI FDA blackbox warning that doses over 20 mg may prolong QT interval in persons over 60 y/o. If patient chooses to stay on higher doses, document conversation discussing potential for cardiac effects. Starting dose: 10 mg Upper primary care dose: 40 mg for up to 60 y/o; 20 mg > 60 y/o

"Prodrug" or progenitor drug

drug (either active or inactive) metabolized to another active drug

Zetia (ezetimibe)

dyslipidemia therapy MOA -Inhibits cholesterol absorption at small intestine Has been shown to reduce total cholesterol, LDL, and TG while increasing HDL-C Alternative if statin intolerance and sometimes combined with statin therapy Not for children younger than 10 years Avoid in pregnancy

Niaspan (Niacin)

dyslipidemia therapy MOA -Many mechanisms, decreases hepatic LDL and VLDL production AE -Flushing ---Aspirin given 30 minutes before niacin dose may prevent or reduce flushing Caution -possible interactions in combination with other lipid therapies ---Statins, fibrates: increases risk of hepatotoxicity and/or myalgias Benefit vs risk? -Not used very often Lower TC, LDL, TG, and elevate HDL Over-the counter doses are not sufficient to lower LDL

Lovaza (Omega-3 fatty acid ethyl esters)

dyslipidemia therapy Useful for patients with high triglycerides (TG) Avoid -if hypersensitivity to fish and/or shellfish can increase LDL-C levels May prolong bleeding time

Crestor (rosuvastatin)

dyslipidemia therapy (C) HMG CoA reductase inhibitors/ Statins MOA -Block synthesis of cholesterol in the liver by competitively inhibiting HMG CoA reductase activity. -Inhibit conversion of HMG-CoA to L-mevalonic acid and subsequently cholesterol AE -Rhabdomyolysis rare but possible -myalgia -fatigue ***Avoid*** -Pregnancy or planning pregnancy -Active liver disease 4 Benefit groups -Secondary Prevention, ASCVD ---H/o MI, CVA/TIA, PAD, Angina -Primary prevention, age >21 years and LDL > 190 -Primary prevention, diabetes, age 40-75 years, LDL 70-189 -Primary prevention, age 40-75 years, LDL 70-189, estimated 10-year ASCVD risk of >7.5% *Primarily ↓ LDL, effects on TG and HDL less pronounced Statins are generally first-line for individuals with DM and dyslipidemia or high CV risk

Lopid (gemfibrozil)

dyslipidemia therapy (L) Fibrates: fibric acid derivatives MOA -exact unknown ---Inhibits triglyceride synthesis AE -avoid pregnancy -Avoid hepatic impairement, eGFR <30 **Primarily decreases triglycerides (TG) -Some decrease total serum cholesterol (TC), LDL, and some increase HDL *Often used if TG level >500 -Risk of pancreatitis

Lipitor (atorvastatin)

dyslipidemia therapy (L) HMG CoA reductase inhibitors/ Statins MOA -Block synthesis of cholesterol in the liver by competitively inhibiting HMG CoA reductase activity. -Inhibit conversion of HMG-CoA to L-mevalonic acid and subsequently cholesterol AE -Rhabdomyolysis rare but possible -myalgia -fatigue ***Avoid*** -Pregnancy or planning pregnancy -Active liver disease 4 Benefit groups -Secondary Prevention, ASCVD ---H/o MI, CVA/TIA, PAD, Angina -Primary prevention, age >21 years and LDL > 190 -Primary prevention, diabetes, age 40-75 years, LDL 70-189 -Primary prevention, age 40-75 years, LDL 70-189, estimated 10-year ASCVD risk of >7.5% *Primarily ↓ LDL, effects on TG and HDL less pronounced Statins are generally first-line for individuals with DM and dyslipidemia or high CV risk

Mevacor (lovastatin)

dyslipidemia therapy (M) HMG CoA reductase inhibitors/ Statins MOA -Block synthesis of cholesterol in the liver by competitively inhibiting HMG CoA reductase activity. -Inhibit conversion of HMG-CoA to L-mevalonic acid and subsequently cholesterol AE -Rhabdomyolysis rare but possible -myalgia -fatigue ***Avoid*** -Pregnancy or planning pregnancy -Active liver disease 4 Benefit groups -Secondary Prevention, ASCVD ---H/o MI, CVA/TIA, PAD, Angina -Primary prevention, age >21 years and LDL > 190 -Primary prevention, diabetes, age 40-75 years, LDL 70-189 -Primary prevention, age 40-75 years, LDL 70-189, estimated 10-year ASCVD risk of >7.5% *Primarily ↓ LDL, effects on TG and HDL less pronounced Statins are generally first-line for individuals with DM and dyslipidemia or high CV risk

Pravachol (pravastatin)

dyslipidemia therapy (P) HMG CoA reductase inhibitors/ Statins MOA -Block synthesis of cholesterol in the liver by competitively inhibiting HMG CoA reductase activity. -Inhibit conversion of HMG-CoA to L-mevalonic acid and subsequently cholesterol AE -Rhabdomyolysis rare but possible -myalgia -fatigue ***Avoid*** -Pregnancy or planning pregnancy -Active liver disease 4 Benefit groups -Secondary Prevention, ASCVD ---H/o MI, CVA/TIA, PAD, Angina -Primary prevention, age >21 years and LDL > 190 -Primary prevention, diabetes, age 40-75 years, LDL 70-189 -Primary prevention, age 40-75 years, LDL 70-189, estimated 10-year ASCVD risk of >7.5% *Primarily ↓ LDL, effects on TG and HDL less pronounced Statins are generally first-line for individuals with DM and dyslipidemia or high CV risk

Questran (Cholestyramine)

dyslipidemia therapy (Q) Bile Acid Sequestrants MOA -Bind to intestinal bile acids and then excreted in the feces; increase uptake of LDL AE -*GI Lower TC, LDL, and increase HDL Not metabolized by the liver Avoid if bilary obstruction

Tricor (fenofibrate)

dyslipidemia therapy (T) Fibrates: fibric acid derivatives MOA -exact unknown ---Inhibits triglyceride synthesis AE -avoid pregnancy -Avoid hepatic impairement, eGFR <30 **Primarily decreases triglycerides (TG) -Some decrease total serum cholesterol (TC), LDL, and some increase HDL *Often used if TG level >500 -Risk of pancreatitis

Welchol (Colesevelam)

dyslipidemia therapy (W) Bile Acid Sequestrants MOA -Bind to intestinal bile acids and then excreted in the feces; increase uptake of LDL AE -*GI Lower TC, LDL, and increase HDL Not metabolized by the liver Avoid if bilary obstruction

Zocor (simvastatin)

dyslipidemia therapy (Z) HMG CoA reductase inhibitors/ Statins MOA -Block synthesis of cholesterol in the liver by competitively inhibiting HMG CoA reductase activity. -Inhibit conversion of HMG-CoA to L-mevalonic acid and subsequently cholesterol AE -Rhabdomyolysis rare but possible -myalgia -fatigue ***Avoid*** -Pregnancy or planning pregnancy -Active liver disease 4 Benefit groups -Secondary Prevention, ASCVD ---H/o MI, CVA/TIA, PAD, Angina -Primary prevention, age >21 years and LDL > 190 -Primary prevention, diabetes, age 40-75 years, LDL 70-189 -Primary prevention, age 40-75 years, LDL 70-189, estimated 10-year ASCVD risk of >7.5% *Primarily ↓ LDL, effects on TG and HDL less pronounced Statins are generally first-line for individuals with DM and dyslipidemia or high CV risk

Stimulant (ADHD)

first-line agent when clinician, patient, and caregiver(s) agree to a trial of medication for ADHD in a school-aged child or adolescent, per the literature

Inactivated influenza vaccine

inactivated vaccine 3 strains of influenza: 2 type A, 1 type B Strains change annually based on predicted circulating strains Contraindications -anaphylaxis to eggs or influenza vaccine -Guillain-Barre syndrome within 6 wks of influenza vaccine -febrile illness Adverse drug rxns -local rxn -mild systemic effects Drug interactions -immunosuppressants -theophylline -phenytoin -warfarin

Serogroup B meningococcal vaccine

inactivated vaccine Btw 63% and 94% of adolescents and young adults vaccinated demonstrated a protective immune response 1 month after completing the series Contraindications -febrile illness Adverse drug rxns -local rxn Drug interactions -none

HPV vaccine

inactivated vaccine Contraindications -allergic rxn Adverse drug rxn -syncope -injection site pain/redness

Inactivated poliovirus vaccine

inactivated vaccine Contraindications -allergy to neomycin -streptomycin -polymyxin B Drug interaction -immunosuppressants

Meningococcal vaccine

inactivated vaccine Contraindications -febrille illness Adverse drug rxns -local rxn Drug interactions -none

Hep A virus vaccine

inactivated vaccine Provides 100% protection w/ 2 doses Contraindications -severe rxn to HAV -moderate illness -younger than 12 months Adverse drug rxns -soreness @ injection site

PCV13 (pneumococcal conjugate) vaccine

inactive vaccine Contraindicated -moderate to severe febrile illness Adverse drug rxns -local rxn -mild systemic effects

PPV23 (pneumococcal polysaccharide) vaccine

inactive vaccine Contraindications -moderate to severe febrile illness -give 10 to 14 days before splenectomy, organ transplant, or chemotherapy -No PPV in children less than 2 yrs Adverse drug rxns -local rxn -mild systemic effects Drug interactions -immunosuppressants (give 10 to 14 days before)

Hep B virus vaccine

inactive vaccine Stimulates antihepatitis B surface antigen antibodies Contraindications: -yeast allergy -moderate or severe illness -immunosuppression Adverse drug rxn -local rxn -fever -malaise

Bacteriostatic drugs

inhibit or delay bacterial growth and replication Generally slower than bactericidal agents Requires adequate immune system

Penicillin MOA

inhibition of bacterial cell growth by interference w/ cell wall synthesis

Fluoroquinolones MOA

inhibits DNA gyrase Bactericidal, broad-spectrum

Allylamine (antifungal) MOA

inhibits a key enzyme in sterol biosynthesis of the fungal cell wall, resulting in fungal cell death (primarily fungicidal)

ACE inhibitors MOA

inhibits angiotensin converting enzyme, interfering with conversion of A-I to A-II

Thiazide Diuretics MOA

inhibits distal convoluted tubule sodium and chloride resorption

NPH (Novolin N)

insulin therapy Intermediate‐acting

Lantus, Basaglar (insulin glargine U-100)

insulin therapy Long‐acting basal

Levemir (insulin detemir U-100)

insulin therapy Long‐acting basal *Cannot be mixed in syringe with other insulin If basal insulin monotherapy isn't working after some titration (ex: fasting BG better but postmeal BG still high) - Consider adding GLP‐1 RA If basal + GLP‐1 RA not working, rapid‐acting prandial insulin can be added - Such as with largest meal

insulin NPH/regular (Novolin 70/30)

insulin therapy Mixture of intermediate and short acting

Novolog, Humalog (insulin aspart)

insulin therapy Rapid‐acting

Afrezza (inhaled insulin)

insulin therapy Rapid‐acting AE -transient cough -Concern about pulmonary toxicity ---Avoid in pt who smoke & COPD

regular (Novolin R)

insulin therapy Short‐acting

Cephalosporin MOA

interfere w/ bacterial cell wall synthesis

Loading dose

is administered to reach a therapeutic response lvl rapidly

ADHD

is one of the most common neuropsychiatric disorders of childhood and adolescence

Thioamides: Methimazole

is used more commonly than PTU (Propylthiouracil) -It has a longer duration of action and better efficacy than PTU, and it tends to have a lower incidence of adverse effects than PTU. -PTU is often reserved for those who cannot tolerate other options. It is used during certain trimesters of pregnancy. Rare, but potential adverse effects: agranulocytosis and hepatotoxicity

Bactericidal drugs

kill target organisms Also preferred in cases of serious infections such as endocarditis and meningitis, to achieve rapid cure

Varicella vaccine

live attenuated 2 doses 98.3% effective Contraindication -neomycin allergy -febrile illness -immunocompromised -high-dose steroids -pregnancy Adverse rxns -fever -rash -injection site rxn

Herpes Zoster: zostavax

live attenuated Shingles caused by reactivation of varicella virus Admin 1 dose for pts age 60 or older Contraindicated: -neomycin or gelatin allergy -immunocompromised -pregnancy -acute illness -age younger than 60 yrs Drug interactions -high dose steroids -antivirals

Dihydropyridines (CCB) MOA

lower calcium influx into smooth muscles, potent vasodilators that have little or no negative effect upon cardiac contractility or conduction Do not affect conduction through AV node

Bowel preparation for colonoscopy

magnesium citrate (Citrate of Magnesia) large volume PEG (polyethylene glycol) solutions - (GoLYTELYâ, NuLYTELYâ, CoLyteâ, MiraLaxâ, TryLite®,) Small volume PEG solutions (2L) - (HalfLytely®, MoviPrep®) sodium phosphate monobasic monohydrate and sodium phosphate dibasic anhydrous sodium phosphate (Visicolâ, OsmoPrep®) -Prepopik®, and Suprep®

Phentermine/Topiramate (Qsymia) AE

may cause neuropsychiatric side effects (depression, anxiety, inattention -Monitor for depression or suicidal thoughts Paresthesia and dry mouth -Seems to limit tolerance to increased dose Tachycardia DC if ineffective by 12 weeks with gradual taper -Tapering of dose over at least 1 week using every other day dosing -Abrupt DC leads to seizures Contraindications -Pregnancy -Hyperthyroidism -Glaucoma

GLP‐1 Agonists MOA

mimics GLP‐1 action: glucose‐dependent release of insulin, suppression of glucagon - *Additional MOA: Delays gastric emptying, suppresses appetite

Contrave (Bupropion-Naltrexone)

obesity therapy BBW -suicidality Contraindicated -uncontrolled HTN -seizure disorder -eating disorder -chronic opioid use -pregnancy Not recommended 1st line therapy Antidepressant + opioid receptor antagonist Approved for long term use

Adipex-P (Phentermine)

obesity therapy MOA: -Increase norepinephrine, dopamine release Schedule IV drug -c/o in pt w/ hx of abuse Only approved for short term use Sympathomimetic drug

Xenical/Alli (Orlistat)

obesity therapy Pros -effective for weight loss -demonstrated benefits to glycemia, lipids, and BP ---studies show its cholesterol lowering benefits appear independent of its weight reducing effect -long‐duration trials (4 years) -reassuring safety profile Cons -high prevalence (15‐30%) of unpleasant GI effects which may not be tolerated (can be avoided by not exceeding 30 percent fat with meal) -absorption of fat‐soluble vitamins may be reduced MOA: Alters fat digestion by inhibiting pancreatic and gastric lipases AE -GI are common ---Oily spotting ---Flatus with discharge ---Fecal urgency and incontinence -Increased risk of kidney stones Avoid -Malabsorption syndrome -Cholestasis -Pregnancy 2nd line if changing from liraglutide, or if liraglutide is not an option Alters fat digestion Approved for long term use

Saxenda (Liraglutide)

obesity therapy Pros: -demonstrated benefits with regard to cardiometabolic risk factors, glycemia, and quality of life Cons -GI effects (nausea, vomiting), -injectable, -cost Avoid h/o pancreatitis pregnancy -BBW medullar thyroid cancer and multiendocrine neoplasia Option for initial treatment, particularly in patients with T2DM and CVD 1st line GLP‐1 RA Approved for long term use

Qsymia (Phentermine-Topiramate)

obesity therapy Schedule IV drug Avoid -pregnancy (teratogenic), need 2 forms of contraception -Hyperthyroidism -glaucoma AE -neuropsychiatric SE (anxiety, depression) -Paresthesia & dry mouth -Tachycardia Gradually taper off if not working Sympathomimetic + anticonvulsant Approved for long term use

ABRS

observation (watchful waiting)? -an option for immunocompetent pts w/ uncomplicated ABRS who can have good follow-up -watchful waiting may not be appropriate for all pts ---Age ---General state of health ---comorbidities

Osteoporosis

occurs most commonly in postmenopausal women. The majority of postmenopausal women with this disease have bone loss related to estrogen deficiency and/or age. It is recommended that postmenopausal women with established disease (T-score ≤-2.5) or fragility fracture be treated with a pharmacologic agent.

Adjustment disorder

per DSM 5: the development of emotional or behavioral symptoms in response to an identifiable stressor(s) -Symptoms typically present within 3 months of the stressor and may persist until 6 months after the stressor is terminated. -The adjustment disorder may be designated as acute if the duration of symptoms has been 6 months or less and chronic if symptoms persist past 6 months. -Adjustment disorders are coded as having depressed mood, anxiety, or a mix of depression or anxiety. may be particularly pertinent during the COVID19 pandemic -Increased prevalence (as much as 3-fold) of stress, depression, anxiety symptoms across age groups -Persons with lower income, less savings, and greater exposure to stressors may experience the greatest symptom burden There is a paucity evidence for successful pharmacologic or nonpharmalogic management strategies for adjustment disorder. If symptoms are interfering with function, it could be reasonable to initiate therapy according to the associated mood effects (depression vs. anxiety vs. mixed).

2nd gen antihistamines

preferred over 1st gen for allergic rhinitis (due to AE profile of 1st gen) Ex. -Loratadine -certirizine (most sedating 2nd gen) -fexofenadine (least sedating) -desloratadine -levocertirizine Appropriate as monotherapy for intermittent or mild sx (esp sneezing, nasal or eye itching) Benefit: longer acting, lipophobic---> fewer CNS effects for all, lower cost/many OTC Quick onset of action Some are approved for peds as young as 6 months of age

Antimuscarinics/Anticholinergics (asthma)

short & long acting Used most frequently in COPD Ipratropium-albuterol combination (combivent) is a second-line quick relief medication in the tx of asthma Several studies demonstrate increase in FEV1, but not supported by NAEPP or GINA guidelines

Levothyroxine pt education

should be taken on an empty stomach, ideally 30 to 60 minutes before breakfast, coffee, other medications, vitamins, and supplements to avoid interference with med absorption. Symptoms may begin to resolve after 2-3 weeks, but steady-state TSH concentrations are not achieved for at least 6 weeks.

Adverse drug rxns

side effects does not equal drug allergy

Buprenorphine

suppresses and reduces cravings for opioids

Drug Therapy During pregnancy: Teretogenesis

teras= a Greek word meaning "monster" Teratogenesis= literally, "to produce a monster" Birth defects -gross malformation ---Cleft palate, clubfoot, and hydrocephalus -Neurobehavioral and metabolic anomalies

Half-life (T 1/2)

time for the plasma conc. of drug to b reduced by 50%

Probiotic

treat antibiotic-associated diarrhea

Ginko biloba

treat dementia

Coenzyme Q10

treat heart failure

CCB AE

vary with type and dose Dihydropyridines- *peripheral edema (up to 20%), lightheadedness, flushing -Tip: Using CCB/ACE combination decreases peripheral edema by 50% vs CCB high-dose alone -Monitoring: BP Non-dihydropyridines- *constipation (up to 25%), *bradycardia, worsening cardiac output, hepatotoxicity, AV block -Avoid: HFrEF, sick sinus syndrome, and second- or third-degree AV block -Monitoring: BP, HR, LFTs, ECG

Palmoplantar psoriasis

well defined edge (psoriasis in general)

TZD AE

• *Weight gain • *Edema • *Increased risk of fractures • Anemia • Hepatotoxicity (rare, periodically monitor LFTs) Avoid - Increased fx risk - Active or hx of bladder cancer (Pioglitazone) - Active liver disease

child or adolescent with T2DM

• Achieve and maintain near‐normal glycemic control • Improve insulin sensitivity and potentially improve insulin secretion, which results in improved glycemic control • Identify and treat, if necessary, comorbidities such as hypertension, dyslipidemia, and nonalcoholic fatty liver disease • Prevent vascular complications of T2DM • Avoid unplanned pregnancies in young women with T2DM, due to high risk of adverse outcomes

CVD considerations (DM)

• Albuminuria? Consider ACE or ARB • HTN? Consider ACE or ARB + CCB and/or thiazide as needed to get to goal BP • Dyslipidemia: usually a statin, consider ASCVD risk calculation that was discussed previously

Peripherally-Acting Agents: Alpha Blockers

• Exemplars: Doxazosin, Prazosin, Terazosin •Not first-line antihypertensive • *May be considered with co-morbid HTN and symptomatic BPH • Careful BP monitoring is required in all patients. • Examples of other uses by psychiatric providersPTSD, nightmares (off-label, prazosin)

Orthostatic hypotension (older adult HTN)

• Is a potential limiting factor to the use of antihypertensive drugs • Increases fall risk, which increases risk of hip fracture

"Let me out!", the very hot raccoon and zebra yelled

• Live attenuated influenza vaccine (LAIV) • Measles, mumps, and rubella vaccine (MMR) • Oral poliovirus vaccine • Typhoid vaccine • Varicella virus vaccine • Herpes zoster vaccine • Rotavirus vaccine • Zostavax vaccine • Yellow fever vaccine

Nondihydropyridines (CCB) MOA

• Lower calcium influx into smooth muscles • Are somewhat less potent vasodilators than dihydropyridines, but have a greater depressive effect on cardiac conduction and contractility • Affect conduction through the AV node and have negative chronotropic effects

Initiating combo DM therapy

• Metformin is the preferred first-line agent for the treatment of T2D1,2 • Patients on metformin monotherapy who do not achieve glycemic targets should be started on combination therapy with additional agents, including insulin2 • Combination therapy is often required and should include therapeutic agents with complementary mechanisms of action2 • For patients with A1C >7.5% who are not on antihyperglycemic agents, metformin plus another agent in addition to lifestyle therapy should be initiated2 • Although a medication's efficacy declines somewhat when added as a third agent, the addition may be required to ensure effective treatment2 • Symptomatic patients with A1C >9% are likely to achieve great benefit from the addition of insulin, although maximum doses with 2 or 3 other agents may be adequate if the patient has no significant symptoms2

FDA long-term tx (obesity)

• Orlistat (Xenical) • Liraglutide 3mg (Saxenda) • Phentermine/Topiramate ER (Qsymia) • Naltrexone ER/Bupropion ER (Contrave) Keep in mind, for patients wishing to use an anti‐obesity medication for longer than 4 years, the lack of longer‐term safety (and efficacy) data should be made known

Write RX for DM Supplies

• RX for glucometers and test strips and brand‐ specific. • Consider how many times the patient needs to check his/her BG daily (+ prn) and round up to the nearest box size for the monthly RX. • Do the same for lancets. Lancets may be more interchangeable. • Insurances often cover testing supplies - They often prefer certain brands, so a patient may have to change brands if new insurance coverage. • Self‐pay option - Patients can also buy testing supplies at the pharmacy if they don't have insurance. Store‐ brand meters are much lower priced than brand name. They don't need a RX for self‐pay of these

Statins AE

• Select potential ADR: myalgia, fatigue, GI intolerance, flu-like symptoms, HA Rhabdomyolysis rare but possible -Myalgias and myopathy occur with a frequency of 2-11% ---Some agents more likely; more likely with higher doses ---Will discuss strategies on following slide -May check baseline serum creatinine kinase and repeat if s/s ---Routine monitoring not recommended ---Patients can experience statin-induced myalgias without an elevation in CK -Increased risk with some drug interactions ---Avoid gemfibrozil and statins ---Caution fenofibrate and statins

HTN Emergency

• Severe hypertension (≥180/≥120 mmHg) with evidence of acute end-organ damage • *Can be life-threatening and require immediate emergency tx • *Tx usually with parenteral (IV) meds in monitored setting (ED) for hours to days

Angina tx goals

• Short term: -Nitrates -Relief of acute angina Long term: -Nitrates, BBs, CCBs, antiplatelet -Prevention of anginal episodes -Prevent progression of athroschlerosis -Reduce risk of MI -Improve functional capacity -Prolong survival

Diuretics

• Thiazide, thiazide-like (preferred for HTN) • Potassium-sparing, MRA • Loop

Arrhythmia

• Work‐up and treatment driven by cardiology and may occur in an inpatient setting -Correct primary problems causing secondary arrhythmias -Hemodynamic stabilization -Consider chemical or electrical cardioversion -Consider pharmacotherapy for maintenance -Anticoagulation often initiated before or simultaneous with other interventions

Hydralzine (HTN urgency)

• direct arterial vasodilator • most commonly reserved for refractory HTN despite modest doses of >3 agents • direct vasodilator (directly relax arterial smooth muscle and reduce peripheral vascular resistance); may produce profound peripheral vasodilation • often cause adverse effects (i.e. peripheral edema and reflex tachycardia) • typically combined with a β-blocker and a loop diuretic