Test your Knowledge: Final Exam

4. What ADRs may occur with central acting skeletal muscle relaxants? What education would you provide to a patient when prescribing.

(Baclofen, Soma, Paraflex, Flexeril, Robaxin, Zanaflex, benzodiazepines) Sedative effect; may increase risk of falls. Baclofen may cause decrease in seizure control. Soma may cause physical dependence. Cyclobenzaprine=serotonin syndrome, also has anticholinergic effects-avoid with urinary retention and increased ocular pressure. . Do not drive or use any other CNS sedating med concurrently. Many are on the BEERS list in the elderly.

b) What is the diagnostic criteria for diagnosing Type II diabetes mellitus?

- Acute Symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dL. (Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes are polyuria, polydipsia, and unexplained weight loss) - Fasting plasma glucose ≥126 mg/dL. (Fasting is defined as no caloric intake for at least 8 hrs. - 2 hours postload plasma glucose in an oral glucose tolerance test ≥200 mg/dL. The test using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. - A1c ≥ 6.5%

d) What patient education should be provided regarding the use of an SSRI or antidepressant medication?

- Drugs may take as long as 3 to 4 weeks until their full therapeutic benefit become evident and that the initial adverse reactions, commonly including nausea, intermittent light-headedness, sedation, muscle restlessness and sleep disruptions, should be minor and transient. - Assess the level of sedation the drug can initially cause before engaging in hazardous activities - DO NOT miss a dose or prescription run out (withdrawal syndrome) - Avoid alcohol, OTC meds that stimulate, insomnia or drowsiness.

19. In the treatment of diabetes mellitus, understanding criteria perimeters for diagnosis is important. For diabetes mellitus, answer the following: a) What is the diagnostic criteria for diagnosing Impaired Fasting Glucose (IFG) also known as pre-diabetes?

- Fasting plasma glucose 100-125 mg/dL (IFG) or - Plasma glucose 140-199 mg/dL (IGT) 2 hr post ingestion of standard glucose load (75 g) or - A1c 5.7-6.4%

34. What are the goals of treatment in GERD?

1). Reduce or eliminate symptoms 2). Heal esophageal lesions 3). Manage or prevent complications such as stricture, barretts or CA, prevent relapse-lifestyle mod and meds

c) What is the time to response for the effectiveness of the drug to work?

3 to 4 weeks

37. Nursing mother should take medication

30 minutes post breastfeeding.

d) Thiazolidinediones (TZDs) Common Agent: Pioglitazone (Actos), Rosiglitazone (Avandia) reduce HbA1c approximately by 0.5- 1.5% MOA: Improve target cell response to insulin by activating receptor cell proteins that improve insulin action. - Increases utilization of insulin by liver and muscle cells and reduces liver glucose production. Black Box Warnings: Cardiotoxicity/ CHF & Heart failure CONTRAINDICATED in patients with NYHA class III-IV HF

ADRs: CV: edema, URI, headache, fatigue Watch for signs of CHF, use with caution with pt's with elevated liver enzymes - Increased risk of bladder cancer with pioglitazone use contraindication: Chronic liver disease (heavy liver processing) - Fluid retention: exacerbates heart failure - FDA loosening of restrictions, but still dangerous drug. - Pregnancy Category C - Not approved for children younger than age 18 Monitoring: liver enzymes (ALT) @ the start of the therapy, HbA1C Special consideration/ pt education: Female patients using oral contraceptives for birth control and premenopausal anovulatory patients should be informed about the possible need to increase the dose of oral contraceptive or choose an alternative birth control method. Advise the patient to report immediately any signs of hepatic dysfunction such as nausea, vomiting, abdominal pain, fatigue, anorexia, jaundice, or dark urine. - once daily dosing

e) Dipeptidyl Peptidase-4 inhibitors (DPP-4) : "Gliptins" Common Agent: Sitagliptin (Januvia), saxaglipin (Onglyza) Reduce HbA1C by 0.4-0.6 % MOA: Inhibits dipeptidyl peptidase-4 (DPP-4). DPP-4 breaks down GLP-1 and GIP which are released in response to a meal - Leads to an increase in the secretion of insulin and suppress the release of glucagon by the pancreas - Promotes pre- and postprandial glucose levels - Promotes mild weight loss in obese diabetics

ADRs: GI, headache, URI symptoms, joint pain. Increased risk of acute pancreatitis Contraindication : Renal dysfunction Pregnancy Category B Not approved in children ACE inhibitors: increased risk of angioedema Monitoring: Renal function at baseline and annually. HbA1C every 3 months Special consideration/ pt education: once daily in the AM, don't double if for a missed dose Monotherapy or in combination with other anti-diabetic drugs. Cost: expensive Administration: taken once daily in the morning

f) Glucagon-like Peptide-1 Agonists (GLP-1) Common Agent: Injectable agents (referred to as GLP-1 agonists) Exenatide (Byetta - BID dosing; Bydureon - once weekly), liraglutide (Victoza) Newer agents: albiglutide (Tanzeum), dulaglutide (Trulicity) MOA: Binds to GLP-1 receptors; promotes insulin release from pancreatic beta cells in the presence of elevated glucose Mimics natural incretin hormones Slows glucose absorption from the gut; promotes satiety Clinical use only for Type II DM Add-on therapy is typical in combination with other diabetes agents § Only GLP-1 FDA approval for obesity - liraglutide (Saxenda)

ADRs: Injection site reactions, GI: nausea, vomiting, diarrhea. Weight loss contraindication: Acute pancreatitis noted in post marketing surveillance Severe GI disease (colitis, Crohn's disease) Pregnancy Category C Renal impairment <30 GFR contraindicated; 30-50 adjust dose Increased INR if administered with warfarin & Digoxin Monitoring: Glycemic control and GI distress Renal functions - baseline and q3-6 months Not recommended for use in patients with a personal or family history of medullary thyroid cancer (MTC)- Black Box warning Special consideration/ pt education: Administration SC injection for rapid release 60 minutes before meals. If BID, dose at least 6 hours apart. Lifestyle diet/exercise

g) Meglitinides (short-acting insulin secretagogues Common Agent: Nateglinide (Starlix), Repaglinide (Prandin) MOA: Increases insulin release from beta cells by closing K+ channels which leads to the opening of Ca+ channels and it is the influx of Ca+ that releases the insulin. - Time in plasma is short < 2 hours, so they only lower postprandial BG levels (they don't directly affect fasting BG level or any of the other defects in metabolism seen in DM II - More expensive that SU agents

ADRs: hypoglycemia in vulnerable populations Contraindication: hepatic impairment, Pregnancy Catagory C, not approved in pediatrics. Caution in severe renal impairment and adrenal/pituitary impairment b/c these drugs may exert more glucose-lowering effects. Antifungals (ketoconazole) and antimicrobials (erythromycin) inhibit metabolism, increasing the risk for hypoglycemia. Monitoring: Get baseline HbA1C and recheck in 3 mos. Special consideration/ pt education: administer no more than 30 minutes before a meal, hold if not eating. If extra meals are eaten, an extra dose should also be taken

c) Sulfonylurea's Common Agent: Glipizide (Gluctrol), glyburide (Diabeta), glimepiride (Amaryl)-- All are second generation. Patient education: take it at the time each day, preferably before or with morning meal.

ADRs: hypoglycemia, GI, derm rashes, SIDH, hemolytic anemia, leukopenia, thrombocytopenia, weight gain. Contraindication/ Precaution: Cross-sensitivity with sulfonamides or thiazide diuretics ( potentiate effects of anti-diuretic hormone) - Pregnancy Category C: avoid in pregnant women - Older adults more sensitive due to hypoglycemia - Pediatric: use in children 10-18 but it is unlabeled All sulfonylureas should be used with extreme caution for patients with hepatic or renal impairment, and liver and renal function should be monitored frequently if they must be used. Monitoring: baseline HgA1C, then every 3 mo while adjusting, then every 6 months - CBC & renal function at onset then 6-12 month annual unless more if sx's

6. What risks are associated with the concurrent use of acetaminophen (Tylenol) and analgesics containing acetaminophen? Provide some examples of analgesics that contain acetaminophen.

Acute hepatic necrosis, poisoning. 10 grams in adults may be toxic. Alcohol and acetaminophen=toxicity. Tylenol with codeine, Butalbital, Fioricet, Midrin all contain acetaminophen.

2. What medications are used in the treatment of gouty arthritis for an acute exacerbation? How about for prevention of gout flare-ups?

Acute: colchicine; initial dose is 1.2mg at 1st sign of flare, then 0.6mg 1 hr later. Prevention: allopurinol-mild:200-300mg, moderate: 400-600mg. Also colchicine: less than 1 flare/year=0.6mg/day 3-4x/week, more than 1 flare/year=0.6mg daily.

b) What is the mechanism of action of SSRI drugs?

Affect the serotonin neurotransmitter in the synaptic cleft by blocking the serotonin transporters from returning remaining serotonin to the presynaptic cell. Bottom line: inhibits serotonin reuptake without significantly affecting norepinephrine, muscarinic, histamnic or alpha adrenergic receptors.

3. In the treatment of urticaria with a generalized rash or symptoms, what medication(s) would be considered in the treatment plan?

Antihistamines, clemastine. Hydroxyzine is good for itching with urticaria. Cetirizine, desloratadine, and loratadine may also be used. (Ch 17, pg 403).

11. What are the goals of treatment for migraine prevention? List medication option(s) for a simple migraine abortive therapy? Goal: Minimize impact on QL & avoid medication overuse FYI: a drug of choice in pregnancy is Opioids such as Acetaminophen with codein

Avoid triggers and prophylaxis for frequent migraines. Abortive meds: OTC analgesic: NSAID (Ibuprofen or naproxen) or Migraine formulas ( Excedrin Migraine or Advil Migraine) Midrange analgesics: Butalbital/ASA or APAP (Fiorinal/Fioricet), Midrin( Isometheptene/Tylenol/dichloralphenazone), High range analgesics: opioids, Codeine combined with ASA or APAP, IM meperidine, internasal butorphanol. Ergot derivatives (vasoconstrictors), Pregnancy X Triptans: Serotonin receptor agonists such as Imitrex

14. List some antimicrobial choices to treat Staph or Strep skin infections or skin abscess. If Methicillin-resistant Staphyloccocus (MRSA) is suspected, which antimicrobial would be of consideration? What education would you provide to a patient with suspected or confirmed MRSA infection?

Bacitracin: 2 to 5 times a day until clear Double abx: bacitracin and polymixin B Triple abx: bacitracin, neomycin & polymixin B MRSA suspected TX systemicly with Clindamycin, TMP/SMZ, doxycycline Pt education: Hand washing. Do not share towels or utensils. Wash with antibacterial soap

21. Functioning beta-cells are required for this pharmacological class to be effective in type-2 diabetes. Name the class and the pathophysiology of why functioning beta-cells are necessary.

Biguanide Sulfonylurea Meglitinides Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) DPP-4 inhibitors Sodium-glucose co-transporter 2 inhibitors (SGLT2) All these drugs don't produce insulin, just stimulate the B-cells to make insulin

22. What drug is a first-line oral agent in type 2 diabetes according to evidence-based guidelines?

Biguanide: Metformin

e) metronidazole (Flagyl)

Cat B; Bacterial vaginosis & trichomoniasis (may be used in pregnancy per CDC and treat partner), H. pylori, Divertic (+ TMP-SMX or Cipro or Levo) ADR: Use with caution in seizures, liver disease, warfarin and do not drink ETOH during and 48 hours after last dose

c) Fluoroquinolones (in the treatment of UTI)

Cat C not safe in pregnancy; Use only in complicated UTI or pyelonephritis: Cirp is first line 500mg BID 7-14d ADR: Tendon rupture exac by steroids, age, transplant; Cdiff, FQAD-multi-organ rxn-muscles and tendons; Increased QT

c) Floroquinoline

Cipro 250 BID for 3 days uncomplicated; Levofloxacin 250mg 10 days complicated Remember Black Box Warning

b) Clindamycin ??? Safe in pregnancy; Strep and Staph infections; MRSA skin infections; MRSA pneumonia and MRSA osteomyelitis ADR: Cdiff

Class: Macrolide Indication: Strep and Staph infections; MRSA skin infections; MRSA pneumonia and MRSA osteomyelitis ADRs/contraindication: Pregnancy: B

27. For the following antimicrobial, identify the indication for use, the class of pharmacological agent, potential ADRs/contraindication, pregnancy or any other considerations in prescribing. a) Amoxicillin/ clavulanate (Augmentin)

Class: PCN Indication: Sinusitis, Pneumonia ( in DRSP), acute exacerbation of chronic bronchitis, AOM; Skin infections: Non-MRSA UTIs as a 2 nd line in allergy to sulfa or pregnancy ADRs/contraindication: diarrhea Pregnancy: B

23. Complete the chart by listing the mechanism of action for each class of diabetes medications, some common agents (names), potential ADRs/contraindications, monitoring, and any special considerations/patient education. a) Basal insulin (long-acting)

Common Agent : ADRs/contraindication : Monitoring : Special consideration/ pt education :

d) Do the treatment goals differ in older adult/elderly individuals? How so, what considerations would there be in older adults/elderly individuals?

Comorbidities such as liver/kidney disease affect regimen. Elderly increased risk of hypoglycemia. Wt loss increases morbidity and mortality. Exercise = positive results. Higher A1C is acceptable with comorbidities. Start low and go slow. Don't prescribe metformin if GFR <30

5. For the following, list potential concerns with regarding to excessive use, toxicity/overdose. Include if a reversal agent exists. If any associated routine monitoring should be performed, include as well. a) Tricyclic antidepressants (ie. Elavil) Hight risk of OD & death Weight gain & autonomic side effects Less than a week's worth of meds can produce life-threatening cardiac arrhythmia, hypotension, seizures, extreme sedation & death can occur Supportive care for OD: No reversal agent

Contraindicated in all CV disorders-concurrent use with SSRI, cannabis, sympathomimetics increase CV toxicity); use caution on glaucoma, epilepsy, BPH urinary issues due to blockage of acetylcholine. No reversal agent. SI must be monitored along with EKG prior to and 3 weeks post first dosage. Check plasma levels.

b) Biguanides Common Agent: Metformin, first-line of therapy, reduce HbA1c approximately by 1.5% MOA: Decreases glucose production in the liver, decreases GI glucose absorption and improves insulin sensitivity by increasing peripheral glucose uptake and utilization. - It doesn't stimulate insulin release for beta cells - Inhibits platelet aggregation and reduces blood viscosity - Also does not cause weight gain; often patients lose weight. ADRs: GI usually resolve in 2 weeks after starting dose - Lactic acidosis is rare except in dehydration episodes - Renal disease: watch patients at risk for metabolic acidosis - Liver disease: increased risk for lactic acidosis

Contraindication: Renal or haptic disease or major dysfunction - Metabolic acidosis - The ADA is recommending using eGFR above 30 ml/min - Withhold drug 48 hrs before and after procedures involving iodine-based contrast mediums and temporarily withheld from pt undergoing a surgical procedure in which fluid will be withheld b/c of a risk of dehydration and hypoperfusion that may result in lactic acidosis - Watch patients with B12 anemia/deficiency - Pregnancy Category B (not recommended) - No recommendation for children < 10 years of age Monitoring: Assess renal function, ketones, HbA1C before starting dose and q 3 months while titrating, then q3-6 months Special consideration/ pt education: report diarrhea > 2 days, take medication at the same time every day, swallow medication whole, don't cut, crush or chew. If you miss a dose, take it as soon as you remember unless it time for the next dose, don't double dose

26. In the treatment of thyroid disorders, respond to the following: a) What are the goals of treatment?

Correction of hypometabolicstate with return to euthyroidstate

d) Milk of Magnesium (MOM)

Do not use in renal insufficiency/ failure. May cause diarrhea.

9. Which antidepressants may be used in neuropathic pain with concurrent depression?

Duloxetine (Cymbalta)

30. Discuss the step-wise approach (refer to power point and textbook). Include appropriate treatment including examples of medication names for GERD.

Dyspepsia or mild GERD 1. Antacids and lifestyle modification GERD Triggers, Alcohol, weight, smoking, mints, coffee, citrus fruits) 2. Histamine2 receptor agonists for 4 to 8 weeks • If better:continue for 12weeks then wean off Moderate to severe GERD • Proton pump inhibitors for 8 weeks If better wean off PPI If symptoms not improved:refer to GI Moderate to Severe GERD • Symptoms not relieved increase PPI to BID for 4 to 8 weeks •If symptom free for 4weeks then step down to once a day PPI and reassess in 6 to12 months • Symptoms not relieved after 8 weeks: refer

28. What are the goals in the treatment of urinary tract infection (UTIs)?

Eradication of causative organism! Relief of symptoms and educate to prevent recurrent infections

d) Aspirin

Excessive use (Toxicity/od): Ototoxicity, GI irritation & bleeding (prolong bleeding time) Reversal agent: No antidote, supportive care like platelet transfusion & GI tract decontamination, and reduction of the body's salicylate burden Monitoring: At a low dose, no monitoring is needed, serum creatinine level before starting, random salicylate level 7-10 days after. CBC,Urine pH, renal function frequentely Symptom of toxicity is Tinnitus

c) Acetaminophen (recommended daily dose is 3g per day)

Excessive use (Toxicity/od:): severe hepatotoxicity, a leading cause of drug-induced acute liver failure Reversal agent: N- Acetylcysteine & gastric lavage Monitoring: LFT? For example, pt on Propranolol, acetaminophen clearance is decreased

e) NSAIDs

Excessive use: (toxicity/od): GI bleed Symptom: convulsions, metabolic acidosis, coma, and acute renal failure Reversal agent: no antidotes Monitoring: required only for long-term therapy, renal function ( creatinine) & CBC before initiating & annually

b) Warfarin Drug interaction: NSAID, Cimetidine, Antifungal & oral Abx ( all increase the effect of warfarin) Drugs that decrease the effect of Warfarin: Barbiturates, griseofulvin, Vit K, cholestyramine, Carbamazepine , birth control, Colestipol

Excessive use: Fetal bleeding Toxicity/od: Reversal agent: Vitamin K/FFP Monitoring: Daily INRs are done initially. Once the therapeutic range is achieved for at least 2 consecutive days. The testing 2 or 3 times weekly for 1 or 2 weeks. If the INR results remain stable, testing is reduced to q 6 weeks.

c) Calcium Cardonate (Tums)

First line for GERD, adjunct with PUD tx and also used routinely for CA deficiency in CRF and postmenopausal, osteoporosis. Do not take with oxalic acid (spinach & rhubarb), dairy. Contraindicated in hypercalcemia, renal calculi; may cause constipation

d) Pencillin drugs Pregnancy: if allergy to PCN-use Cephalexin 500mg BID

First line in pregnancy or sulfa allergy: Augmentin 500 BID 3-5 Days ADR: Diarrhea

b) Trimethoprim/ sulfamethoxazole

First line tx; uncomplicated; depending on resistance levels in the area; 1 tab BID for 3 days; upper UTI BID 14 days ADR: (SULFA) Steven Johnson Syndrome; blood dyscrasias, hepatotoxicity, hemolysis in G6PD deficiency

29. List pharmacological agents used in the treatment of UTI's (first-line + second-line/treatment failure options). Discuss length of treatment, potential ADRs/contraindications, and use in complicated/uncomplicated UTI. a) Macrobid: Nitrofurantoin

First line tx;uncomplicated: 100mg BID for 5-7 days (some areas have shown resistance to TMP-SMZ) can also use for prophylaxis if UTI > 3xyr. ADR: pulm fibrosis, peripheral neuropathy, can use if allergy to PCN/Sulfa

7. The use of the following medications includes a Black Box Warning for: a) NSAIDs

GI bleed, cardiovascular events

24. Name a couple sulfonylurea's and list potential considerations when prescribing these drugs (include older adult/elderly considerations).

Glipizide(Glucotrol), glyburide (Diabeta), glimepiride (Amaryl) All potentiate effects of anti-diuretic hormone Elderly more sensitive to these drugs, hypoglycemic effects, cheaper, interact w thiazide diuretics

c) When might long-acting basal insulin (e.g. insulin glargine, insulin detemir) be added to a medication regime?

HbA1C > 9%

32. Discuss the indication(s) for use, potential ADRs/contraindications, and any major medication interactions for each med listed below: a) Cimetidine (Tagamet)

Highly selective H2 blocker used for GERD, Reduce gastric acid secretion by 35-50% Not a first line in its class, less potent than Ranitidine (Zantac) & Famotidine (Pepcid) Decrease hepatic metabolism of many drugs (has many drug interactions - inhibits CYP450) • Rarely used due to inhibition of cytochrome pathways • Effective for allergic reactions-blocks histamine (histamine is a mediator in allergic reactions)

20. What factors would be helpful in knowing when prescribing a medication regime for a patient with diabetes? (ie. lifestyle, activities of daily living, etc.)

Hypoglycemia is more likely with when caloric intake is reduced. Alcohol can mask signs and symptoms of hypoglycemia. Exercise can also affect sugar. Beta-blockers also mask hypoglycemia

35. Tx for gonorrhea and chlamydia:

IM ceftriaxone and po azithromycin

38. Estrogen SEs:

Increased risk for endometrial CA; CHD risk with combo HRT-may be related to onset and length of therapy, Increased risk of stroke/thromboembolic events

c) GLP-1 Agonists (ie. Victoza)

Increased risk of heart failure, thyroid c-cell tumors.

b) Proton Pump Inhibitors (e.g. Protonix, Nexium, Prilosec...) Interaction: • Decrease the effectiveness of atazanavir (Reyataz), indinavir (Crixivan), and nelfinavir (Viracept)— antiretroviral (HIV) • PPIs interfere with absorption of drugs dependent on an acidic gastric pH to be effective • Increased monitoring of INR if taking with warfarin • Clopidogrel (Plavix) has a black box warning regarding interactions with omeprazole

Indication: Tx gastric condition characterized by hyperacidity. Used for erosive gastritis, GERD, & Zollinger-Ellison syndrome, as part of multidrug regimen for short-term tx of PUD, duodenal ulcers caused by H.pylori Contraindications: cautiously in patients with hepatic dysfunction and the elderly Pregnancy Category B or C (Congenital anomalies have been reported) ADRs: Risk for significant nutrient deficiencies: iron, vitamin B12, & calcium Long-term PPI use increase risk for osteoporosis & increased hip fractures: Clostridium difficile, salmonella & camphylobacter infections Increased risk of pneumonia

e) Carafate

Indications: Duodenal ulcer and maintenance of (caused by NSAID or other medication) Binds to necrotic tissue and creates barrier to acid, pepsin, bile salts; stimulates prostaglandins for essential and maintenance of protective mucosa. Give 2 hours apart from other drugs; 1 hour prior to meals and bedtime, works within 2 weeks; maintenance dose BID

25. In a diabetic patient, what type of oral agent(s) should a patient hold if skipping a meal? What class does the medication belong to? Oral agents; Short-acting glucose-lowering drugs for type 2 diabetes, Short-acting; rapid onset Cost -more expensive than SU agents

Meglitinides: Nateglinide (Starlix), Repaglinide (Prandin)

10. To learn more about SSRI's and antidepressants, respond to the following questions: a) What are common sides effects of serotonin reuptake inhibitors (SSRI)? 4 S's 1.Sick ( nausea: 90% of serotonin is found in the gut) 2. Shit ( diarrhea) 3. Sex 4. Sleep ( insomnia) 5. Sore head ( HA)

Nausea, sometimes vomiting, HA, light-headedness, dizziness, dry mouth, increased sweating, weight gain or loss, exacerbation of anxiety, agitation, sexual side effect up to 35%: diminished, delayed or absent orgasm, decreased libido - Watch with warfarin, may potentiate bleeding FluoxetINE (Prozac) ParoxetINE (Paxil) SertralINE ( Zoloft) FluvoxamINE (Luvox) CitaloPRAM (Celexa) EscitaloPRAM ( Lexapro)

d) Trimethoprim/ sulfamethoxazole

Not safe in pregnancy; first line UTI (after nitrofurantoin, depending on area resistance); Chronic bronchitis, Divertic (+ Metronidazole) ADR: Steven-Johnson syndrome; hemolysis in G6PD deficiency, hepatotoxicity, blood dyscrasias

d) In hyperthyroidism, which medication(s) have a risk of hepatotoxicity?

PTU: Propylthiouracil BLACK BOX WARNING

e) What considerations are there with the risk of suicidality when treating depression with SSRIs or antidepressants (in general).

Patient needs to be monitored closely during the first 2 to 3 weeks on initiation of SRI's. There should be at least telephone contact on a weekly basis with an agreement to notify the prescriber immediately if suicidal thoughts occur or persist

31. How does a duodenal ulcer differ from a peptic ulcer? (Hint: see ppt presentation). Include considerations to Helicobacter pylori (H.pylori) infections.

Peptic ulcers are duodenal or gastric; Duodenal are 95-100% H. Pylori +; Gastric are 75-85% H. Pylori +. Try antacids and lifestyle mod first; Test for H. Pylori. Tx is 10 days-4 weeks with abx and PPI per CDC. Low risk can end therapy; High risk: consider chronic supportive therapy with PPI or H2RA: Smokers, COPD, CAD, Bleeding or Perf Ulcer, NSAID use. Complicated-Bleeding-send to GI for endo, tx H. Pylori and repeat endo.

f) Reglan (Prokinetics) Indication: GERD (short term), PUD, Heartburn, Acid indigestion, "Sour Stomach" & Gastroparesis stimulate the motility of the upper GI tract without stimulating gastric, biliary, or pancreatic secretions Accelerates GI emptying Has antiemetic properties * Patients with Creatinine Cr below 40 mL/min should have their therapy initiated at approximately half the recommended dosage

Precautions/Contraindications • Black box warning due to risk of developing tardive dyskinesia • Contraindicated in GI hemorrhage, mechanical obstruction, new surgery on the GI tract, or perforation • Use cautiously in patients with a history of depression • Depression may occur, including suicidal ideation ADRs: tardive dyskinesia, depression, dizziness, diarrhea • hypoglycemia in patients with diabetes • Rare: galactorrhea, amenorrhea, gynecomastia, impotence secondary to hyperprolactinemia Interaction: Additive CNS depression occurs with other CNS depressants • Increased risk of EPS occurs with other drugs that have the potential for EPS • Drugs with anticholinergic effects reverse the action of metoclopramide

1. What are some red flags of chemical dependency?

Prescription forgery, selling, stealing or borrowing prescription drugs, requesting specific drugs, resistance to change in therapy, concurrently using illicit drugs, obtaining the same drug from multiple providers, need for increased doses. Scammers goal is to obtain more meds, more potent or higher dosages, or a drug that is high in street value.

c) When adjusting hypothyroidism therapy, what is an optimal length of time before reassessing a laboratory test?

Recheck TSH 4-6 weeks; titrate dose accordingly

d) Warfarin

Risk of fatal bleeding. Meds and food that affect it, green leafy veggies. Cipro can increase plasma level of warfarin. Clarithromycin increases plasma levels

12. Discuss the principles associated with anti-depressant therapy including SSRI's and anti-anxiety agents (e.g. Valium, Xanax, Klonopin). In use of SSRI's, what are the benefits over use of benzodiazepine agents (e.g. consider dependence)? What indications are SSRI's used as treatment for?

SSRIs inhibit reuptake of serotonin. SSRIs are 1st line for depression and anxiety (lLONG TERM). Benzodiazepines (xanax, valium) are 1st line for ACUTE symptoms. They bind to GABA receptors; increase the action and decrease excitability. SSRIs are much safer, will not cause dependence like benzo's. SSRIs are used for depression, anxiety, OCD, PTSD, panic disorders, and migraines.

16. In osteoporosis, what is the most common bone(s) affected with bone demineralization? By using treatment modalities such as bisphosphonates, what type of activity is inhibited relative to pharmacodynamics? What are some of the ADRs of bisphosphonate drugs?

Spine; hip and wrist; Osteoclastic activity is inhibited: inhibits normal and abnormal bone resorption; ADR: musculoskeletal pain, osteonecrosis of jaw, afib, GI upset

8. Although rare, glucose-6 phosphate dehydrogenase deficiency (G6PD) may occur. What drugs can precipitate hemolysis in G6PD-deficient individuals?

Sulfonamides (more common), rarely with nitrofurantoin and trimethoprim.

b) What lab test(s) should be monitored in hypothyroidism?

TSH and free T4 levels Every 4 to 6 weeks until euthyroid Closely monitor thyroid levels during pregnancy and after delivery

15. When prescribing iron supplementation (ferrous sulfate) in anemia, what education would you provide to the patient for the most optimal absorption? What information would you give on the length of treatment?

Take iron pills on empty stomach, may add Vit C, to increase absorption. Avoid calcium & antacids they inhibit iron absorption. Treatment is for 3-4 months AFTER hgb/hct normalize

b) Fluoroquinolones

Tendonitis/tendon rupture, increased risk if age greater than 60 or concurrent use with corticosteroids, or if kidney, heart, or lung transplant.

17. List medications that may negatively affect bone health resulting in osteopenia or osteoporosis.

Thyroid meds; aromatose inhibitors; steroids, PPI's, SSRIs

18. Briefly describe the difference between Type I and Type II diabetes in terms of pathophysiology?

Type 1 diabetes: Results from b-cell destruction, leading to absolute insulin deficiency: Need insulin Type I Pathophysiology - Autoimmune destruction of the pancreatic beta cells - Genetic susceptibility - Long preclinical period Type 2 diabetes: Results from a progressive insulin secretory defect or insulin resistance: B-cell makes insulin

e) Complicated vs. Uncomplicated

Uncomplicated-simple lower UTI Complicated: predisposed reason: neurogenic bladder, stricture, BPH, Stones, catheter, pregnancy, having increased urinary symptoms-flank pain, rigors, hospital stay within past 2 weeks-get UC to help guide tx

13. List the treatment for pernicious anemia and length of treatment intervention.

Vitamin b12 IM injection daily x1 week then weekly, then 1000mg IM weekly for a month Once b12 value normalizes, PO b12 1000 mcg daily and B12 1000mcg monthly IM 500 mcg b12 weekly via Nasal route Tx is Life Long