NUR 613 Exam 6 part 2

Bacterial Vaginosis (BV)

(technically, not an STI) •Caused by multiple organisms •Produces malodorous, fishy-smelling discharge (worse in alkalotic environment such as after intercourse [alkaline semen])

Peptic Ulcer Disease

- Group of upper gastrointestinal (GI) disorders that cause degrees of erosion of the gut wall; Severe erosion can be complicated by hemorrhage and perforation; caused imbalance between mucosal and aggressive factors Most common cause - H. pylori is the most common cause of gastric and duodenal ulcers Second most common cause is NSAIDs

Define constipation.

-2 or fewer stools per week or -Passage of hard, pellet-like stools for at least 2 weeks Hard stools, infrequent stools, excessive straining, prolonged effort, sense of incomplete evacuation, unsuccessful defecation

C. diff treatment

-Flagyl for mild-moderate illness -Vancomycin for more severe symptoms (ototoxicity, nephrotoxicity, VRE) -Probiotics Prevention -1:10 bleach solution -soiled areas need to be cleaned immediately following an episode

Dutasteride (Avodart)

-TX for BPH •Inhibits 5-alpha-reductase Similar to finasteride but with three differences: •Reduction in circulating DHT is more complete •Harmful to a developing male fetus •Extremely long half-life (5 weeks) •These drugs (5-alpha reductase inhibitors) should NOT be handled by women who are pregnant or expect to get pregnant!!!

How do helminths enter the body?

-the worm gains entrance to the body through contaminated food, unwashed hands or through the skin

Pelt's hints in pink

:)

•Passive immunity

A temporary immune state created bythe administration of antibodies to aperson not already immunized •Immune globulins •Breast milk •Placental transfer

Aluminum Hydroxide(MylantaMaalox® Gaviscon®)

ANTACID Relatively low ANC, slow acting, effects have long duration Rarely used alone - Widely used in combination with magnesium hydroxide CAUTION: Significant amounts of sodium - May cause constipation Drug interactions -Tetracyclines -Warfarin -Digoxin

Contraindications to Laxative Use: IMPORTANT!

Abdominal pain Nausea Cramps Symptoms of appendicitis OR s/s of anything else Regional enteritis Diverticulitis ulcerative colitis Acute surgical abdomen Fecal impaction or bowel obstruction Habitual use Use with caution in pregnancy and lactation

Metronidazole

Active against •E. histolytica •G. lamblia •T. vaginalis Adverse effects •DISULFRAM REACTION with EtOH (Nausea/vomiting) •Metallic taste in the mouth •Stomatitis •RARE CNS changes: seizures, peripheral neuropathy •Resolve when medication is removed

Notes on immunity

Adaptive Immunity- •Activated once the INNATE immune response initiates the inflammatory process; antigen identification vaccines are antigens B cells differentiate into plasma cells which secrete antibodies CD4+ cells stimulate B cells to produce plasma cells that produce antibodies Primary and Secondary Memory Phaseand Response- Notice how the primary and secondary exposure to an antigen and how the cellular response and production of IgM and Igg are correlated (this is why it takes multiple doses of vaccine)

Vitamin A

Aka Retinol •Fat soluble •Multiple functions in the eyes Toxicity •Birth defects, liver injury, bone-related disorders Deficiency causes •Night blindness •Xerophthalmia •Keratomalacia •Blindness

Vitamin E

Aka alpha-tocopherol •Fat soluble •Antioxidant properties •Dietary sources—fresh greens, seeds, oils •Toxicity may increase risk for bleeding

Vitamin C

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

Metronidazole (and Tinidazole) Drug Interactions

Alcohol •Nausea/vomiting/possible psychotic reaction Warfarin •↑ bleeding - warfarin adjustment may be needed Phenytoin, Lithium, Fluorouracil, Cyclosporine •↑ toxicity - monitor drug levels Cytochrome P450 •Drugs that ↑ CYP450 activity ↓ metronidazole levels (Phenobarbital, rifampin, phenytoin, and others) •Drugs that ↓ CYP450 activity ↑ metronidazole levels (ketoconazole and others)

Irritable Bowel Syndrome (IBS) groups of drugs used

American College of Gastroenterology has concluded there is no proof of clinical benefit for most of these agents: - Antispasmodics - Bulk-forming agents - Antidiarrheals - Tricyclic antidepressants Studies suggest that antibiotics or an acid suppressant (PPI's or H2 receptor antagonists) may be effective for some patients.

Magnesium Hydroxide [Milk of Magnesia]

Antacid •Rapid acting, high acid-neutralizing capacity (ANC), produces long-lasting effects; •Frequently used as a laxative •Most prominent adverse effect is diarrhea •Usually taken in combination with aluminum hydroxide, an antacid that promotes constipation •AVOID in patients with undiagnosed abdominal pain •Use with caution in patients with renal failure

•Albendazole [Albenza®]

Anthelmintic drug •Absorption better with fatty meal »Giant roundworms (ascaris)

•Praziquantel [Biltricide®]

Anthelmintic drug •Administer with food - do not crush »Tapeworms

•Ivermectin [Stromectol®]

Anthelmintic drug •Empty stomach with water »Giant round worms

•Pyrantel pamoate [Pin-X®]

Anthelmintic drug •With or without food - must be thoroughly chewed »Pinworms, hookworms

Metoclopramide [Reglan®]

Antiemetic Blocks dopamine receptors in CTZ

•Substance P/neurokinin1 antagonists

Antiemetic •Aprepitant [Emend®] •Blocks neurokinin1-type receptors (for substance P) in the chemoreceptor trigger zone (CTZ) •Prevents postoperative nausea/vomiting and CINV •Prolonged duration of action

Serotonin receptor antagonists

Antiemetics Granisetron [Sancuso®] Dolasetron [Anzemet®] Palonosetron [Aloxi®] Ondansetron [Zofran®] be careful with SSRIs (serotonin syndrome)

Butyrophenones

Antiemetics Haloperidol [Haldol®] & droperidol [Inapsine®] - Block dopamine2 receptors in CTZ Side effects: similar to phenothiazines, may cause prolonged QT interval and fatal dysrhythmias Electrocardiogram (ECG) before administration

Dopamine antagonists

Antiemetics Phenothiazines - Prochlorperazine [Compazine®] Block dopamine2 receptors in CTZ Side effects: Extrapyramidal reactions, anticholinergic effects, hypotension & sedation- careful in elderly

A patient with IBS is prescribed alosetron [Lotronex]. Before this drug is administered, it is most important for the nurse practitioner to do what? Assess for abdominal bruits. Check serum potassium and sodium levels. Ask the patient about any problems with constipation . Mix the powder in 8 ounces of fruit juice

Ask the patient about any problems with constipation (increases constipation)

The nurse practitioner identifies which of the following laxatives as having the added response of ridding the body of ammonia? A) Polyethylene glycol [Miralax] B) Lactulose C) Lubiprostone [Amitiza] D) Mineral oil

B) Lactulose

Thiamin deficiency

Beriberi and Wernicke-Korsakoff syndrome

The nurse practitioner identifies which of the following as the most common type of laxative abused by the general public? Magnesium hydroxide [Milk of Magnesia] Docusate sodium [Colace] Bisacodyl [Dulcolax] Polyethylene glycol [MiraLax]

Bisacodyl [Dulcolax]

Metoclopramide [Reglan®] (Prokinetic Agent)

Blocks receptors for dopamine & serotonin in the CTZ Therapeutic uses PO: Diabetic gastroparesis and suppression of GERD IV: Suppression of postoperative nausea & vomiting, suppression of CINV, facilitation of small bowel intubation, & facilitation of radiologic examination of GI tract Adverse effects High-dose therapy: sedation, diarrhea common Long-term high-dose therapy: can cause irreversible tardive dyskinesia (TD)

Trimethoprim/sulfamethoxazole (TMP/SMZ)(Bactrim® DS) & pregnancy

Can be used in pregnancy up to 36 weeks •Why not in the last four weeks? - Generally, trimethoprim-sulfamethoxazole is not prescribed for newborns because the sulfamethoxazole component increases the risk of hyperbilirubinemia and kernicterus.

Describe the different stages of syphilis

Caused by the spirochete Treponema pallidum •Primary syphilis identified by chancer that develops 1 - 4 weeks after exposure •After healing, secondary syphilis develops; sx resolve in 6 - 8 weeks; may recur •Tertiary syphilis develops

•Disseminated Gonococcal Infection •With endocarditis or meningitis

Ceftriaxone 1 gm IM or IV every 12 hours up to 2 weeks

Diarrhea

Characterized by - stools of excessive volume & fluidity - increased frequency of defecation It is a symptom of GI disease and not a "disease" in itself, tx cause Causes: infection, maldigestion, inflammation, functional disorders of the bowel Complications - dehydration & electrolyte depletion

Irritable Bowel Syndrome (IBS)

Characterized by cramping abdominal pain (may be severe) that cannot be explained by structural or chemical abnormalities May occur with diarrhea, constipation, or both Considered IBS when symptoms have been present for 12 weeks over the past year

Malaria Treatment

Chloroquine mefloquine, atovaquone/proguanil (for blood schizont), primaquine (for liver hypnozoite)

Polyethylene Glycol - Electrolyte Solutions

CoLyte® GoLytely® •Large volume administered •Typically 4 L •Patients must ingest 250 to 300 mL every 10 minutes for 2 to 3 hours HalfLytely® MoviPrep® •Volume administered is cut in half •Most common adverse effects are nausea, bloating, and abdominal discomfort.

A patient is prescribed bisacodyl. Which of the following should the nurse practitioner include in patient teaching? A) Your urine will turn yellow‐brown when taking this medication. B) Crush the bisacodyl tablet and sprinkle it on your food. C) Chew the bisacodyl tablet. D) Do not take the bisacodyl with an antacid

D) Do not take the bisacodyl with an antacid (or milk)

A patient who has been taking a long‐acting morphine to treat severe pain for a few months complains of constipation. The nurse practitioner decides to prescribe which of the following medications for the patient? A) Polycarbophil [FiberCon] B) Mineral oil C) Psyllium [Metamucil] D) Senna [Senokot]

D) Senna [Senokot]

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

D) The drug is contraindicated in patients with GI obstruction, perforation, or hemorrhage IRREVERSIBLE TD

Pyridoxine deficiency

Deficiency •May result from poor diet, isoniazid use, inborn errors of metabolism Symptoms •Seborrheic dermatitis, microcytic anemia, peripheral neuritis, convulsions, depression, confusion •Dietary deficiency of B6 is rare in United States, except in alcoholics*

A patient is prescribed amoxicillin and tetracycline to treat peptic ulcer disease. The nurse practitioner will instruct the patient that these medications will do what? A) Prevent GI infections that cause gastric bleeding. B) Destroy the bacteria in the stomach that are causing ulceration. C) Reduce gastric acid production and alkalize the stomach fluids. D) Reduce the secretion of pepsin in the stomach.

Destroy the bacteria in the stomach that are causing ulceration.

Antihistamines for Motion Sickness

Dimenhydrinate [Dramamine®] Meclizine [Antivert®] Cyclizine [Cyclivert®] Adverse effects: - Sedation (H1 receptor blocking) - Dry mouth, blurred vision, urinary retention, constipation (muscarinic receptor blocking)

•Alprostadil (prostaglandin E1)

Drug for ED Treatment Administration •Injected directly into the corpus cavernosum •Increased arterial flow and decreased venous outflow in the penis •Should not be used more than 3 times per week or once in 24 hours Adverse effects •Burning sensations, prolonged erection, priapism, and penile fibrosis Transurethral—alprostadil pellets (Muse) •Do not use more than twice in 24 hours •No priapism or penile fibrosis

•Papaverine (smooth muscle relaxant) plus phentolamine (alpha-adrenergic blocking agent)

Drug for ED Treatment •Increased arterial flow and decreased venous outflow in the penis •Used to counteract impotence Administration •Injected directly into the corpus cavernosum (ouch!) Adverse effects •Priapism •Painless fibrotic nodules in the corpus cavernosum Orthostatic hypotension with dizziness

•Mifepristone (RU 486) with misoprostol

Drugs for Medical Abortion Blocks uterine progesterone receptors Adverse effects •Bleeding •Cramping •Nausea •Vomiting •Diarrhea •Headache

Scopolamine

Drugs for Motion Sickness Muscarinic antagonist Side effects: dry mouth, blurred vision, drowsiness can be a patch for motion sickness

Combination OCs: Drug Interactions

Drugs that elevate potassium should be avoided by pts on Yasmin, beyaz, yaz aka ethinyl estradiol/drospirenone Warfarin Anticonvulsants/antiepileptic drugs (e.g., phenytoin) Tetracycline antibiotics and ampicillin Theophylline

Testosterone •Effects

Effects on sex characteristics in males •Pubertal transformation •Spermatogenesis Effects on sex characteristics in females •Clitoral growth •Pubic hair growth Anabolic effects •Skeletal muscle Erythropoietic effects •Synthesis of erythropoietin •Men have greater hematocrit than women

Amebiasis

Entamoeba histolytica protozoa tx: metronidazole, tinidazole rare in US but seen in third-world •Iodoquinol and paromomycin are active only against amebas residing in the intestine. •Metronidazole and tinidazole are active against amebas that inhabit the intestine, liver, and all other sites.

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

Escherichia coli (E. coli) (80%)

•Traveler's diarrhea

Escherichia coli --> Usually self-limiting Possible therapies •ciprofloxacin [Cipro®] •norfloxacin [Noroxin®] •azithromycin [Zithromax®] •rifaximin [Xifaxan®] •Consider age of patient; remember pregnancy

Monophasic Oral Contraceptives

Exactly the same all the way through (ratio of drugs is the same)

Cannabinoids as antiemetics

Examples: Dronabinol [Marinol®] & nabilone [Cesamet®] Chemically related to marijuana MOA with emesis unclear Potential for abuse and psychotomimetic effects

Identify the risk factors for community and hospital-acquired UTIs

Female anatomy Sexual activity- Sexually active women tend to have more UTIs than do women who aren't sexually active. Having a new sexual partner also increases your risk. Certain types of birth control- Women who use diaphragms for birth control may be at higher risk, as well as women who use spermicidal agents. Menopause- After menopause, a decline in circulating estrogen causes changes in the urinary tract that make you more vulnerable to infection. Urinary tract abnormalities Blockages in the urinary tract A suppressed immune system- Diabetes and other diseases that impair the immune system — the body's defense against germs — can increase the risk of UTIs. Catheter use A recent urinary procedure

Ondansetron [Zofran®]

First approved for chemotherapy-induced nausea and vomiting (CINV) - Also used to prevent nausea and vomiting associated with radiotherapy and anesthesia MOA: Blocks type 3 serotonin receptors on afferent vagal nerve Adverse effects - Headache, diarrhea, dizziness, prolonged QT interval, risk of torsade de pointes be careful with SSRIs (serotonin syndrome)

Tamsulosin adverse effect

Floppy iris syndrome seen at time of cataract removal; post-op can cause increased pain and discomfort opthamologist must know about use of tamsulosin before cataract removal surgery to modify floppy iris syndrome

giardiasis

Giardia lamblia protozoa •Primary habitat of G. lamblia is the upper small intestine. •Infestation usually occurs by contact with contaminated objects or by drinking contaminated water. •Bloody diarrhea is common •Drugs of choice are metronidazole, tinidazole, and nitazoxanide.

•Disseminated Gonococcal Infection

Gonorrhea •Caused by gonococcal bacteremia •Petechial/pustular skin lesions •Arthritis/arthralgia/tenosynovitis •Meningitis •Rare endocarditis

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

H. pylori Treatment •Minimum of 2 antibiotics to reduce risk of resistance developing. •CLARITHROMYCIN-BASED TRIPLE THERAPY •BISMUTH-BASED QUADRUPLE THERAPY Amoxicillin, Tetracycline, Metronidazole [Flagyl®]

Discuss the difference in mechanism of action of an H2 receptor antagonist versus an antihistamine.

H1-antihistamines competitively block histamines from attaching to histamine receptors that are located on nerves, smooth muscle, endothelium, glandular cells, and mast cells. Since histamines causes vasodilation and increase vascular permeability which causes fluid to leak from the capillaries to the surrounding tissues, these H1-antihistamines will block these actions which will stop inflammation and other allergy symptoms. The second generation H1-antihistamines do not cross the blood brain barrier which is why it does not cause drowsiness such as the first generation. The H2-antihistamines block H2 histamine receptors that are found in the gastric acid producing parietal cells of the stomach. Therefore, these antihistamines will reduce the amount of gastric acid being secreted in the stomach.

NSAID-Induced Ulcers Treatment

H2 receptor blockers & PPIs are preferred. Discontinue NSAIDs if possible

Omeprazole [Prilosec®] AE

Headache GI effects Pneumonia Fractures Hypomagnesemia Rebound acid hypersecretion C. difficile infection Gastric cancer

Syphilis tx

Highly sensitive to penicillin (PCN) •PCN G remains drug of choice Dose depends upon stage of disease •Primary, secondary, latent < 1 year --> Single IM dose of benzathine PCN G - 2.4 million units for adults - 50,000 units/kg for children •Tertiary or neurosyphilis 18 - 24 million units daily (divided q 6 hours) for 10 - 14 days

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

Histamine2-Receptor Antagonists - First-choice drugs for treating gastric and duodenal ulcers Promote healing by suppressing secretion of gastric acid - All are equally effective. Cimetidine [Tagamet®] Ranitidine [Zantac®] Famotidine [Pepcid®] Nizatidine [Axid®]

Prostaglandins

In obstetrics, prostaglandins are indicated for: •Induction of abortion •Cervical ripening before induction of labor •Control of postpartum hemorrhage --> this can be lifesaving!

Oral Contraceptives Mechanism

Inhibition of ovulation (egg release)

Testosterone/Androgens warning

June 2014- FDA mandated for the manufacturers of testosterone products to add a general label warning concerning the increased risk for venous blood clots, including deep vein thrombosis and pulmonary embolism. •Testosterone product labels already caution in regards to the increased risk for venous blood clots as a result of polycythemia; however, additional postmarket reports of venous blood clots reveal no connection to polycythemia. Therefore, the FDA has decided to make the label warning on testosterone products more general.

Pediculosis

LICE •Head lice Pediculus humanus capitis (head louse) •Body lice Pediculus humanus corporis (body louse) •Pubic lice Phthirus pubis (pubic or crab louse)

Laxative Effect vs. Catharsis

Laxative effect produces soft, formed stool over a period of 1 or more days and is relatively mild Catharsis is a prompt, fluid evacuation of the bowel which is fast and intense

Gonorrhea tx •Preadolescent children

Legal implications are great •Diagnosis must be definitive •Obtaining a culture is an absolute requirement before treatment Treatment depends upon age and weight •Localized infection < 45 kg, single 125 mg IM dose ceftriaxone •> 45 kg, treat same as adults

•Subdermal etonogestrel implants [Nexplanon]

Long-acting Contraceptive •Among the most effective contraceptives available •Adverse effect: Irregular bleeding

•Intrauterine devices (IUDs)

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

•Depot medroxyprogesterone acetate (MPA)

Long-acting Contraceptive •Injected intramuscularly (IM) or subcutaneously (subQ), protects against pregnancy for 3 months or longer •Adverse effects: Menstrual irregularities, bone loss

Cimetidine [Tagamet®] drug interactions

MANY •Warfarin •Phenytoin •Theophylline •Lidocaine •Antacids can reduce absorption of cimetidine- •Administer at least 1 hour apart

Antiprotozoal Drugs

Metronidazole (Flagyl) tinidazole

Mineral oil

Mixture of indigestible and poorly absorbed hydrocarbons. Laxative action is produced by lubrication. Adverse effects -Lipid pneumonia -anal leakage -deposition of mineral oil in the liver

Proton Pump Inhibitors

Most effective drugs for suppressing secretion of gastric acid Therapeutic uses: Short term - Gastric/duodenal ulcers; GERD Selection of PPI is based on cost & prescriber's preference used long term & in high doses can increase the risk of serious adverse events -Fracture -Pneumonia -Acid rebound -Possible intestinal infection with C. difficile

•Immunization records

National Childhood Vaccine Act of 1986 requires a permanent record of each mandated vaccination •Date of vaccination •Route and site of vaccination •Vaccine type, manufacturer, lot number, expiration date •Name, address, title of person administering the vaccine Reason for record •To ensure appropriate vaccination •To avoid over-vaccination

Sodium Phosphate Products AE

Nausea, bloating, abdominal discomfort; risk of dehydration, electrolyte disturbances, and kidney damage Hyperphosphatemia - which can cause acute, reversible renal damage - possibly chronic, irreversible renal damage

Niacin other names

Nicotinic Acid Vitamin B3 nicotinamide

Sildenafil (Viagra) drug-drug interactions

Nitrates •Could cause life-threatening hypotension •24 hours in between these medications for safety Alpha blockers •Can cause symptomatic postural hypotension Inhibitors of cytochrome P450 (CYP3A4) •Can suppress metabolism of sildenafil •Absorption slowed by high-fat meals

Vardenafil (Levitra, Staxyn) •Drug interactions

Nitrates •Could cause life-threatening hypotension •Wait 24 hours in between taking these two medications!! •This is not to imply that you can take one drug today, the other tomorrow, the first drug the next day, etc.! Alpha blockers •Can cause symptomatic postural hypotension Inhibitors of cytochrome P450 (CYP3A4) •Can suppress metabolism of vardenafil •Use with caution!

Identify the drugs useful for long-term treatment for community-acquired UTIs

Nitrofurantoin (Macrobid®) •Low concentrations: Bacteriostatic •High concentrations: Bactericidal •Uses: Lower UTIs, prophylaxis, recurrent lower UTIs •BID x 7 days (most gynecologists use this regimen) •The text says 5 days but clinically 7 days is better

Drugs for IBD

Not curative; may control disease process 5-Aminosalicylates (sulfasalazine; 5-ASA) Glucocorticoids (hydrocortisone) Immunosuppressants (azathioprine) Immunomodulators (infliximab) Antibiotics (metronidazole)

Identify indications for the use of a laxative.

Obtain fresh stool sample Empty bowel before treatment or procedure Expel dead parasites after treatment (yuck!) Modify effluent from ileostomy or colostomy Constipation (multiple causes, including pregnancy and opioid use) Prevent fecal impaction in bedridden patients Remove poisons

A patient is experiencing chemotherapy‐induced nausea. Which prescribed medication would be most effective for this patient? Ondansetron [Zofran] Prochlorperazine [Compazine] Dexamethasone [Decadron] Promethazine [Phenergan]

Ondansetron [Zofran]

Most effective antidiarrheal agents

Opioids Activate opioid receptors in GI tract - Reduce intestinal motility - Slow intestinal transit - Allow more fluid to be absorbed - Decrease secretion of fluid into small intestine and increase absorption of fluid and salt Most commonly used: - diphenoxylate (plus atropine) [Lomotil®] - loperamide [Imodium®]

Treatment for ED

Oral agents: PDE5 inhibitors •Sildenafil (Viagra) •Vardenafil (Levitra, Staxyn) •Tadalafil (Cialis) Nonoral agents- 2nd-line therapy •Papaverine plus phentolamine •Alprostadil (Prostaglandin E1) [Caverject, Caverject Impulse, Edex, Muse]

Glycerin suppository

Osmotic agent that softens and lubricates hardened, impacted feces May stimulate rectal contraction Evacuation occurs about 30 minutes after suppository insertion Useful for reestablishing normal bowel function after termination of chronic laxative use hold it in as long as they can

Sodium Phosphate Products

Osmotic laxatives that draw water into intestinal lumen, which softens and swells fecal mass, which stretches intestinal wall to stimulate peristalsis

Pelvic Inflammatory Disease (PID) tx

Outpatient •Ceftriaxone 250 mg IM once WITH doxycycline 100 mg PO BID x 14 days Inpatient •Generally treated with IV antibiotics •See most recent protocols from CDC for drugs

Tadalafil (Cialis)

PDE5 inhibitor, approved in 2003 •Relaxes penile arterial and trabecular smooth muscle •Effects last up to 36 hours-much longer than with sildenafil or vardenafil; therefore, timing of dosing and sexual activity need not be tightly coupled (no pun intended!). •Now approved for daily dosing for men if activity is anticipated twice weekly. •Also used for benign prostatic hypertrophy (BPH) & pulmonary arterial hypertension (PAH)

Dexlansoprazole [Dexilant®]

PPI Reduces gastric acidity by inhibiting gastric H+,K+-ATPase Uses: Treatment and maintenance of healing of erosive esophagitis; treatment of symptomatic GERD Adverse effects: Diarrhea, abdominal pain, nausea, vomiting, flatulence, upper respiratory infection, hypomagnesemia, osteoporosis, fractures

Omeprazole [Prilosec®]

PPI Inhibits gastric secretion Short half-life (t ½) Ulcer prophylaxis is indicated only for patients in an ICU and then only if they have an additional risk factor, such as multiple trauma, spinal cord injury, or prolonged mechanical ventilation (>48 hours)

Rabeprazole[Aciphex®]

PPI; Much like omeprazole and lansoprazole in actions, uses, and adverse effects Uses: H. pylori eradication, duodenal ulcers, GERD, hypersecretory states (for example, Zollinger-Ellison syndrome) Mechanism of action: Reduces gastric acidity by inhibiting gastric H+,K+-ATPase

Esomeprazole [Nexium®]

PPI; Nearly identical to omeprazole [Prilosec] Uses: Erosive esophagitis, GERD, duodenal ulcers associated with H. pylori infection, prophylaxis of NSAID-induced ulcers Adverse effects: Headache, diarrhea, nausea, flatulence, abdominal pain, dry mouth, pneumonia, hypomagnesemia, osteoporosis, fractures

Lansoprazole [Prevacid®]

PPI; Very similar to omeprazole •Adverse effects: Diarrhea, abdominal pain, nausea, pneumonia, hypomagnesemia, osteoporosis, fracture

Oral ivermectin

Pediculosis and scabies usually treated with topical drugs. The only exception is ivermectin, which is dosed orally. ■ Oral ivermectin is highly active against mites and lice but should be reserved for patients who have not responded to permethrin and other traditional topical agents

Symptoms of cystitis

Pelvic pressure Lower abdomen discomfort Frequent, painful urination Blood in urine

NSAID-Induced Ulcers prophylaxis

Proton pump inhibitors (PPIs) are preferred Misoprostol is also effective but can cause diarrhea BLACK BOX WARNING IN PREGNANCY Antacids, sucralfate, & H2 receptor blockers are NOT recommended.

Calcium Carbonate(Tums®)

Rapid acting High ANC Effects have long duration Acid rebound/hyperacid state Principal adverse effect -Constipation -can be overcome by combining calcium carbonate with a magnesium-containing antacid Other adverse effects -Eructation (belching) -Flatulence

Discuss the mechanisms of action of antacids.

React with gastric acid to produce neutral salts or salts of low acidity Reduce destruction of gut wall by neutralizing acid May also enhance mucosal protection by stimulating production of prostaglandins Except for sodium bicarbonate, antacids do not alter systemic pH

Recurrent UTIs

Relapse •20% recolonization with the original infecting organism •Suggests structural abnormality of urinary tract, involvement of kidneys, or chronic bacterial prostatitis Reinfection •80% of recurrent UTIs in females •Usually involves lower urinary tract and may be related to sexual intercourse

Riboflavin Therapeutic Uses

Riboflavin deficiency Migraine headaches

Other Drugs for BPH

Saw palmetto •Used widely •Effectiveness not supported •Tolterodine (Detrol) •PDE5 inhibitors (cialis) •Botulinum toxin

Pantoprazole[Protonix®]

Similar to omeprazole and the other PPIs Uses: Treatment of GERD & hypersecretory states Adverse effects ØDiarrhea, nausea, dyspepsia, headache, dizziness ØLong-term use: Hypomagnesemia, osteoporosis, fractures

Gonorrhea tx •Urethral, cervical and rectal infection

Single 250 mg IM dose ceftriaxone (Rocephin®) •Mix with lidocaine for comfort •If allergic, single 2 gram PO dose of azithromycin •The advantage of ceftriaxone and azithromycin is chlamydia coverage

Which medication is used to promote gastric ulcer healing by providing a protective barrier? A) Cimetidine B) Misoprostol C) Omeprazole D) Sucralfate

Sucralfate

State the role of sucralfate (Carafate) in the management of PUD.

Sucralfate •Creates a protective barrier for up to 6 hours Used to tx acute ulcers and maintenance therapy AE: rare constipation drug interactions: antacids

Prokinetic Agents

Suppress emesis & increase upper GI motility Metoclopramide [Reglan®]

•Non-pharmacologic methods of contraception

Surgical sterilization (tubal ligation, vasectomy) Mechanical devices (condom, diaphragm, cervical cap) Avoiding intercourse during periods of fertility (calendar method, temperature method, cervical mucus method)

Anorectal Preparations

Symptomatic relief of hemorrhoids and other anorectal disorders -Local anesthetics -Hydrocortisone -Emollients -Astringents

Alpha1a-Blocker/ 5-Alpha-ReductaseInhibitor

TX for BPH Tamsulosin/dutasteride (Jalyn) Adverse effects - Decreased libido - Abnormal ejaculation (retrograde ejaculation)

Alpha1-Adrenergic Antagonists for BPH •Impact on blood pressure

Tamsulosin (Flomax) and silodosin (Rapaflo) •Selective for alpha1a receptors in the prostate Alfuzosin (Uroxatral), terazosin (Hytrin) & doxazosin (Cardura) •Nonselective alpha1 blockers •Block alpha1 receptors in the blood vessels PLUS alpha1a receptors in the prostate •Promote vasodilation and can lower blood pressure Very useful for patients with both HTN & BPH!!

what age can you give tetracycline

Tetracyclines are not recommended for treatment in children younger than 8 years of age

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

The vomiting centre is predominantly activated by three different mechanisms: By nervous impulses from the stomach, intestinal tract, and other portions of the body, resulting in a reflexive activation; By stimulation from the higher brain centres; By the chemoreceptor trigger zone (CTZ) sending impulses. The neurotransmitters implicated in the control of nausea and vomiting include acetylcholine, dopamine, histamine (H1 receptor), substance P (NK-1 receptor), and serotonin (5-HT3 receptor). There are also opioid receptors present, which may be involved in the mechanism by which opiates cause nausea and vomiting.

Identify the drugs useful for short-term treatment for community-acquired UTIs

Trimethoprim/sulfamethoxazole (TMP/SMZ)(Bactrim® DS) •Bacteriostatic; folic acid inhibitor •BID x 3 days (most urologists use this regimen)

Glucocorticoids as antiemetics

Unknown mechanism of action (MOA) as antiemetic Examples: Methylprednisolone, Dexamethasone Commonly used to suppress chemotherapy-induced nausea and vomiting (CINV) - this is not an application approved by the U.S. Food and Drug Administration (FDA) Effective alone and in combination with antiemetics

Chlamydia tx Adults and Adolescents

Urethral, cervical or rectal infections •Azithromycin 1 gm oral dose x one or •Doxycycline 100 mg PO BID x 7 days

Sildenafil (Viagra) cautions

Use with caution by men with the following: •MI, stroke, and life-threatening dysrhythmia within the last 6 months •Resting hypotension (BP below 90/50 mm Hg) •Resting hypertension (BP above 170/110 mm Hg) •Heart failure •Unstable angina CONTRAINDICATION: Sildenafil should not be used at all by men taking nitroglycerin or any other drug in the nitrate family (ex. isosorbide)! •WHY??? Could cause life-threatening hypotension

Discuss the cautions of antacids.

Use with caution in patients with renal impairment

Sodium Bicarbonate

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

Nongonococcal Urethritis (NGU) & tx

Very commonly seen as STI in younger population •Commonly seen in college student health centers •Caused by any organism OTHER than N. gonorrhoeae •Chlamydia, Ureaplasma urealyticum, Trichomonas vaginalis, and Mycoplasma urealyticum are common causes - Recommended treatments azithromycin 1 gm PO x one or doxycycline 100 mg PO BID x 7 days If persistent, two drugs recommended •Add metronidazole 2 gm PO once

Thiamin other name

Vitamin B1

•Cyanocobalamin

Vitamin B12

Riboflavin other name

Vitamin B2

pyridoxine

Vitamin B6 •Coenzyme in the metabolism of amino acids and proteins •Must first be converted to its active form: pyridoxal phosphate

State the overall functional role of vitamins in maintaining good health.

Vitamins •Organic compounds •Required in minute amounts for growth and maintenance of health •Do not serve as a source of energy •Essential for energy transformation and regulation of metabolic processes •Several vitamins are inactive in native form; must be converted to active compounds in the body

1. A patient is prescribed cimetidine [Tagamet] and aluminumhydroxide [Maalox] for the treatment of peptic ulcer disease. What should the nurse practitioner teach the patient to do? Drink an 8‐ounce glass of water when taking these medications. Take the medications together to enhance their effectiveness. Take the Tagamet 2 hours before the Maalox. Wait at least 1 hour between administration of the two medications

Wait at least 1 hour between administration of the two medications

wet vs dry beriberi

Wet beriberi - Cardiovascular complications - With treatment: recovery dramatic with replacement therapy Dry beriberi - no edema or cardiovascular symptoms - Recovery slow

Acute Bacterial Prostatitis tx

With inflammation*, response to ABX treatment is rapid •If mild, PO ciprofloxacin for 2 - 4 weeks •If severe, IV ciprofloxacin followed by 2 - 4 weeks oral TX * In chronic prostatitis where inflammation is minimal, treatment is less effective and may require months of treatment. (4-6 months)

Anthelmintic drugs metabolism

all in the liver

Vitamin B12 sources

animal products

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

animal sources

Stimulant Laxatives:

bisacodyl [Dulcolax®] Two effects on bowel - Stimulate intestinal motility - Increase amounts of water and electrolytes in intestinal lumen Widely used and abused for weight loss/eating disorders Legitimately used for opioid-induced constipation and for constipation from slow intestinal transit

Tertiary syphilis

can affect many different organ systems. These include the heart and blood vessels, and the brain and nervous system. Tertiary syphilis is very serious and would occur 10-30 years after your infection began. In tertiary syphilis, the disease damages your internal organs and can result in death.

Surfactant Laxatives:

docusate sodium [Colace®] Produces a soft stool several days after onset of treatment Alters stool consistency - lowers surface tension - facilitates penetration of water into feces May also act on intestinal wall - inhibits fluid absorption - stimulates secretion of water and electrolytes into intestinal lumen Surfactants resemble stimulant laxatives

Identify the two major vitamin groups or classifications and which vitamins are in each

fat soluble - Vitamins A, D, E, K water soluble - Vitamin B complex—thiamin, riboflavin, niacin, pyridoxine, pantothenic acid, biotin, folic acid, cyanocobalamin - Vitamin C

Trematodes

flukes (parasitic flatworms)

Biphasic Oral Contraceptives

have a change in ratio of estrogen to progestin at some point change is to mimic changes in normal estrogen cycle

Triphasic Oral Contraceptives

have two changes in ratio of estrogen to progestin at some point changes are to mimic changes in normal estrogen cycle

non-drug constipation treatment

high fluid, high fiber, exercise

Trichomoniasis tx

metronidazole single 2 gm PO or, if recurrent metronidazole 500 mg PO BID x 7 days •Can be used in pregnancy

Osmotic Laxatives

milk of magnesia (MOM) Laxative salts (sodium phosphate, magnesium hydroxide) •Poorly absorbed salts that draw water into intestinal lumen •Fecal mass softens and swells •Wall stretches •Peristalsis is stimulated •Low doses: Results in 6 to 12 hours •High doses: Results in 2 to 6 hours Adverse effects •Dehydration: Substantial water loss •Acute renal failure (ARF) •Sodium retention: Exacerbated heart failure, HTN, edema

Mebendazole [Vermox®]

most commonly used Anthelmintic •Absorption better with food »Pinworms, roundworms, and hookworms

What might be the best treatment for a child or someone pregnant that has Traveler's diarrhea? Would a fluoroquinolone such as ciprofloxacin be appropriate for either of them? Why or why not?

no

Primary syphilis

painless chancre that develops 1 - 4 weeks after exposure

Niacin sources

protein, peanuts, ready-to-eat cereals, chicken, rice, yeast, milk

Trichomoniasis

protozoa Trichomonas vaginalis - 8 million new cases in US/year •Usual site in genitourinary tract and rectum •Vaginitis in women; urethritis in men •Usually transmitted by direct sexual contact •Contaminated objects also infectious (e.g. dildos*) •Metronidazole is the traditional drug of choice; tinidazole better tolerated but MORE expensive

Nematodes

roundworms Common intestinal worms •Pinworms (Enterobius vermicularis) •Hookworms (Necator americanus) •Giant roundworms (Ascaris lumbricoides) Extraintestinal •Pork roundworms (Trichinella spiralis)

Trimethoprim/sulfamethoxazole (TMP/SMZ)(Bactrim® DS) uses

short-term treatment for community-acquired UTIs TMP/SMZ is also useful for treating Pneumocystis pneumonia (PCP)

Cestodes

tapeworms

Secondary syphilis

the second phase of syphilis, marked by a rash and fever

Products for Androgen Replacement Therapy in Hypogonadal Males

these are Schedule III drugs •Intramuscular testosterone ester •Transdermal testosterone patches •Transdermal testosterone gels •Implantable testosterone pellets •Testosterone buccal tablets

wet beriberi

vitamin B1 (thiamin) deficiency •Fluid accumulation in the legs •Cardiovascular complications (palpitations, ECG abnormalities, high-output heart failure) •May progress to circulatory collapse and death •With treatment: recovery dramatic with replacement therapy

•Dry beriberi

vitamin B1 (thiamin) deficiency •Neurologic and motor deficits, no edema or cardiovascular symptoms •Recovery slow

Combo OCPs •Missed Dose •28-day-cycle schedules

•1 or more pills missed first week: Take one pill as soon as possible (ASAP) and continue with the pack; use an additional form of contraception for 7 days •1 or 2 pills missed second or third week: Take one pill ASAP and continue with active pills in the pack; skip placebo pills and go straight to a new pack once all the active pills have been taken; use an additional form of contraception for 7 days •3 or more pills missed second or third week: Follow instructions given for missing 1 or 2 pills; also, use an additional form of contraception for 7 days

Plan B

•2 high-dose tablets of levonorgestrel (progestin) •Need to take first tablet within 72 hours after intercourse and the second tablet 12 hours after taking the first dose •Let the patient know that significant nausea is expected •If your patient cannot get Plan B at a pharmacy, consult Lehne, p. 763 and you can make your own!

Benign Prostatic Hyperplasia •Drug therapy

•5-Alpha-reductase inhibitors (mechanical obstruction) • Alpha1-adrenergic antagonists (dynamic obstruction) •Alpha1a-blockers/ 5-Alpha-reductase inhibitor

ACHES

•ACHES is a mnemonic that describes a set of side effects for hormonal contraceptives. •Abdominal pain (gallbladder) •Chest pain (cardiac) •Headaches (severe) (vascular dz) •Eye problems (blurry vision) (vascular dz) •Swelling and aching in the upper and lower legs (thromboembolism) •ACHES could be signs of a serious disorder such as liver disease, gallbladder disease, stroke, blood clots, escalating BP, and/or heart disease. •Individuals need to be educated to notify their healthcare provider immediately should they experience any sign of ACHES.

Bismuth Compounds

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

Wernicke-Korsakoff syndrome

•Alcoholism: most common cause of thiamin deficiency in United States; thiamine is metabolized poorly by heavy drinkers. •Given frequently in the ED when patients are intoxicated to assure sufficient Vitamin B1 is present Serious CNS disorder (neurologic and psychologic) •Nystagmus, diplopia, ataxia, inability to remember the recent past basically a form of dementia found in chronic alcoholics due to a deficiency of Thiamin (Vitamin B1)

Antacid families

•Aluminum compounds •Magnesium compounds •Calcium compounds •Sodium compounds

Chlamydia tx •Preadolescent children

•Always consider sexual abuse as cause of infection < 45 kg, erythromycin ethylsuccinate l2.5 mg/kg PO QID x 14 days •> 45 kg AND < 8 yo, azithromycin single 1 gm dose PO •> 8 yo, azithromycin single 1 gm dose PO or doxycycline PO BID x 7 days (issue here is staining of teeth; avoid if possible)

•Active immunity

•An immune response with antibodyformation to an infection throughvaccines, toxoids, or natural exposureto a disease by activation of B and Tlymphocytes

Cimetidine [Tagamet®] AE

•Antiandrogenic effects •CNS effects •Pneumonia •IV bolus: Can cause hypotension and dysrhythmias

Management of CINV (chemo induced nausea)

•Antiemetics are more effective in preventing CINV than suppressing CINV in progress •Give before chemotherapy drugs

•Transdermal contraceptive patch [Ortho Evra]

•Application: Once a week for 3 weeks, followed by 1 week off (to permit normal menstruation) •Adverse effects: Breast discomfort, headache, local irritation, nausea, menstrual cramps Not recommended for women who weigh >180 lbs

•Lubiprostone [Amitiza®]

•Approved for IBS-C in women age 18 years or older

Malaria

•Associated with high fever, chills, and profuse sweating Etiology Plasmodium vivax (P. vivax) •Most common •Disease is usually relatively mild Plasmodium falciparum •Less common •More severe - without treatment 10% mortality Therapeutic objectives •Tx acute attacks •Prevent relapse •Prophylaxis

Anthelmintic drugs

•Available Drugs: generally devoid of side effects •Mebendazole [Vermox®] - most commonly used •Albendazole [Albenza®] •Pyrantel pamoate [Pin-X®] •Praziquantel [Biltricide®] •Ivermectin [Stromectol®]

Chlamydia tx Pregnant women

•Azithromycin 1 gm oral dose x one or •Amoxicillin 500 mg PO TID x 7 days

Toxoid

•Bacterial toxin that has been changed to a nontoxic form •Re-immunization is necessary --> This is why you get your tetanus "booster" every 5-10 years

Alpha1-Adrenergic Antagonists for BPH MOA

•Blockade of alpha1 receptors relaxes smooth muscle in the bladder neck (trigone and sphincter) •Preferred for men with relatively small prostates (dynamic obstruction) •Do not decrease the size of the prostate like the 5-alpha-reductase inhibitors may do.

•Cyanocobalamin (vitamin B12) & folic acid

•Both essential factors in the synthesis of DNA •Deficiency of either manifests as megaloblastic "pernicious" anemia •Cyanocobalamin deficiency produces neurologic damage as well

Gonorrhea

•Caused by Neisseria gonorrhea (Gram negative diplococci) May be asymptomatic in women •May cause serious damage to the reproductive tract. •Men generally experience urethral burning with pus-like discharge

Inflammatory Bowel Disease (IBD)

•Caused by exaggerated immune response to normal bowel flora Crohn's disease •Characterized by transmural inflammation •Usually affects terminal ileum (can affect 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

Trichomoniasis organism and symptoms

•Caused by flagellated protozoan - Trichomonas vaginalis •Men are typically asymptomatic •Women may have frothy, green discharge

toxoplasmosis

•Caused by infection with Toxoplasma gondii protozoa •Infection is most commonly acquired by eating undercooked meat; may also be congenital. •In immunocompromised hosts, such as those with HIV/AIDS, the disease may progress to encephalitis and death. •The treatment of choice is pyrimethamine plus either sulfadiazine, clindamycin, or atovaquone.

•Disseminated Gonococcal Infection tx in the absence of endocarditis or meningitis

•Ceftriaxone 1 gm IM or IV every 24 hours up to 2 weeks

•Spermicides

•Chemical surfactants that kill sperm by destroying their cell membrane •Gel, jelly, suppository, vaginal film, and contraceptive sponge •All formulations can be purchased without a prescription •When used alone, only moderately effective Use with a diaphragm or condom increases efficacy

Antacids drug interactions

•Cimetidine •Ranitidine •Sucralfate

Thiamin actions

•Coenzyme for carbohydrate metabolism •Requirements increased slightly during pregnancy and breastfeeding

Oral Contraceptives •Classification (two main categories)

•Combination oral contraceptives (OCs) - Estrogen and progestin •Progestin-only OCs ("mini-pills")

who should avoid Combination oral contraceptives (OCs)

•Combination oral contraceptives (OCs) should be avoided by women with certain cardiovascular disorders, as well as by women over 35 years old who smoke.

Acute Uncomplicated Pyelonephritis

•Common in young children, older adults and women of childbearing age •Fever, chills, flank pain, urinary frequency, urgency, pyuria, and bacteremia •E. coli most common cause

Antacids AE

•Constipation: Aluminum hydroxide •Diarrhea: Magnesium hydroxide AC & MD^^ •Sodium loading

Emergency Contraception

•Contraception implemented after intercourse •Following rape, failed contraception, or failure to use contraception •Plan B

Noncontraceptive Benefits of OCs

•Decrease risks of ovarian cancer, endometrial cancer, ovarian cysts, pelvic inflammatory disease (PID), benign breast disease, iron deficiency, anemia, and acne Favorable effect on menstrual cycles •Reduced cramps •Lighter, shorter, more predictable flow

Finasteride (Proscar) AE

•Decreases ejaculate volume and libido •Gynecomastia •Decreases levels of prostate-specific antigen (PSA)

•Pancrelipase [Creon®, Pancreaze®]

•Deficiency of enzymes compromises digestion Commonly seen in Cystic Fibrosis and other pancreatic diseases given with meals Pancreatic enzyme for clinical use Mixtures include •Lipases •Amylases •proteases •Prepared from hog pancreas

Deficiency of folic acid during pregnancy

•Deficiency of folic acid during pregnancy can impair CNS development •Can result in certain, not all, neural tube defects, anencephaly, spina bifida •Important for any patient who may become pregnant to take additional folic acid

•Hyperemesis gravidarum

•Dehydration, ketonuria •Hypokalemia •loss of 5% or more of body weight •Doxylamine [Unisom®] plus vitamin B6 (Diclegis) FIRST LINE IN PREGNANCY, NOT ZOFRAN Other therapies •Prochlorperazine [Compazine®] •Metoclopramide [Reglan®] •Ondansetron [Zofran®] •Methylprednisolone may be tried as a last resort only after 10 weeks gestation

•Reporting vaccine-preventable disease

•Determine whether an outbreak is occurring •Evaluate prevention and control strategies •Evaluate the impact of national immunization policies and practices

Diarrhea •Management

•Diagnosis and treatment of underlying disease •Replacement of lost water and salts •Relief of cramping •Reducing passage of unformed stools

Ranitidine [Zantac®] AE

•Does not bind to androgen receptors •Elevation of gastric pH may increase risk of pneumonia

Erectile Dysfunction (ED)

•ED, also known as impotence •Persistent inability to achieve or sustain an erection suitable for satisfactory sexual performance •Affects up to 30 million men •ED is commonly associated with chronic illnesses. •Risk for ED increases with advancing age.

Discuss the goals of drug therapy for peptic ulcer disease (PUD).

•Eradicate H. pylori (antibiotics) Reduce gastric acidity •(antisecretory agents, misoprostol) Enhance mucosal defenses •(sucralfate, misoprostol) Minimize resistance to abx

Chlamydia tx Infants with pneumonia or opthalmia

•Erythromycin ethylsuccinate l2.5 mg/kg QID x 14 days

Estimated average requirement (EAR)

•Estimated average requirement (EAR) is the level of intake that will meet nutrition requirements for 50% of the healthy individuals in any life-stage or gender group

Alpha1-Adrenergic Antagonists for BPH •Drug interactions

•Exercise caution with other blood pressure-lowering medications •Organic nitrates, antihypertensive drugs, PDE5 inhibitors used for ED •Inhibitors of CYP3A4

Vitamin K

•Fat soluble •Action required for synthesis of prothrombin and other clotting factors •Deficiency produces bleeding Adverse effects •Hypersensitivity reaction •Hyperbilirubinemia in parenteral administration to newborns Therapeutic use •Warfarin overdose

Vitamin D

•Fat soluble •Regulates calcium and phosphorus •Deficiency causes rickets or osteomalacia

Complicated UTIs

•Female and male patients with structural or functional abnormality of the urinary tract - Prostatic hyperplasia, renal calculi, nephrocalcinosis, renal or bladder tumors, ureteric stricture, or indwelling catheter •Symptoms range from mild to severe - Patient may develop systemic illness manifesting as fever, bacteremia, and septic shock •Microbiology is unpredictable •Aggressive treatment is required •OBTAIN C&S BEFORE TREATMENT then treat empirically with broad spectrum ABX 7-14 days

pyridoxine sources

•Fortified breakfast cereals, meat, fish, poultry, white potatoes, other starchy vegetables, and noncitrus fruits

UTI Treatment Failure

•Frequent infections (> 3/year) If relapse occurs after short-course therapy •Repeat with 2-week course of therapy •If treatment failure occurs, treat additional 4 - 6 weeks •If treatment failure occurs, treat for 6 months

Bulk forming laxatives

•Function similarly to dietary fiber: Swells with water to form a gel that softens and increases fecal mass •Preferred temporary treatment of constipation •Used for diverticulosis and irritable bowel syndrome psyllium [Metamucil®]

•Nitrofurantoin (Macrobid®Ф) •Adverse effects

•Gastrointestinal effects •*Pulmonary reactions: Acute and subacute •Hematologic effects in patients with G-6-PD deficiency (males usually) •*Peripheral neuropathy: Demyelinization and nerve degeneration can occur and may be irreversible •*Hepatotoxicity •*Birth defects Ф Macrobid® is the more commonly used high-dose BID preparation of nitrofurantoin used for UTI therapy. Macrodantin® is the less commonly used low-dose QID preparation of nitrofurantoin used more commonly for prophylaxis. * Your instructor never observed this in 31 years of clinical practice - this was the drug of choice.

Alpha1-Adrenergic Antagonists for BPH AE

•Generally well tolerated! Tamsulosin (Flomax) and silodosin (Rapaflo) •Less likely to cause the effects on vascular smooth muscle like the nonselective agents do since they have minimal effects on vascular smooth muscle. •Can cause abnormal ejaculation unlike the nonselective agents Terazosin (Hytrin), alfuzosin (Uroxatral), and doxazosin (Cardura) •Hypotension, fainting, dizziness, somnolence, and nasal congestion •These drugs DO NOT decrease PSA levels!!

Tx Regimen for H. Pylori

•Goal: Minimize resistance! - Guidelines recommend using at least two antibiotics, preferably three •Antisecretory agent: A PPI or H2 receptor antagonist also should be used in combination with the antibiotics. •Eradication rates are good with a 10-day course and slightly better with a 14-day course

Amoxicillin

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

Vardenafil (Levitra, Staxyn) •Adverse effects

•Headache •Flushing •Rhinitis •Dyspepsia •Can prolong QT interval •Can lower blood pressure •Can also be associated with sudden hearing loss and vision loss from non-arteritic ischemic optic neuropathy (NAION)

Tadalafil (Cialis) •Adverse effects

•Headache, dyspepsia, back pain, myalgia, limb pain, flushing, & nasal congestion •Sudden hearing loss and vision loss from NAION

Acute Severe Pyelonephritis tx

•Hospitalization may be required •IV antibiotics generally required •Many options are available May switch ABX once culture results are known •Ampicillin plus gentamicin •Ampicillin/sulbactam •Ciprofloxicin •**Ceftriaxone •**Ceftazidime After control is assured for 24-48 hours, switch to PO meds **expensive and may require ID consult

Sildenafil (Viagra) •Adverse effects

•Hypotension •Priapism...WHAT IS THIS??? (If you have an erection lasting longer than 4 hours......) •Headache, dyspepsia, flushing, nasal congestion, diarrhea, rash, dizziness, mild transient visual disturbances, & intensification of obstructive sleep apnea Rare side effects •Non-arteritic ischemic optic neuropathy •Sudden hearing loss

•Adverse effects of immunization

•Immunocompromised children are at special risk from live vaccines...BE SURE TO KNOW WHICH VACCINES ARE LIVE!!! •Congenital immunodeficiency •HIV infection •Leukemia •Lymphoma •Generalized malignancy •Therapy with radiation •Cytotoxic anticancer drugs High-dose glucocorticoids MMR is live

Niacin •Therapeutic uses

•In capacity as a vitamin, used only as treatment for niacin deficiency If given in large doses, can decrease cholesterol

Pelvic Inflammatory Disease (PID)

•Infection of the uterus, fallopian tubes, and ovaries •N. gonorrhoeae, C. trachomatis, or both

Acute Bacterial Prostatitis

•Inflammation of the prostate caused by local bacterial infection High fever, chills, malaise, myalgia, localized pain, dysuria, nocturia, urinary urgency, urinary frequency, urinary retention •80% of cases caused by E. coli •Frequently associated with indwelling urethral catheter, urethral instrumentation, transurethral prostatic resection •Responds well to antimicrobial therapy

Tetracycline

•Inhibitor of bacterial protein synthesis •Highly active against H. pylori •Resistance is rare. •Do not use in pregnant patients and young children because tetracycline can stain developing teeth.

Finasteride (Proscar)

•Inhibits 5-alpha-reductase -TX for BPH •Most effective in patients with a very large prostate (mechanical obstruction) •Also sold at lower dosages as Propecia for male pattern baldness

Riboflavin actions

•Involved in numerous enzymatic reactions •First, must be changed to flavin adenine dinucleotide (FAD) or flavin mononucleotide (FMN)

For history of frequent UTIs, prophylaxis is often helpful

•Low-dose Nitrofurantoin (Macrodantin®**)PO at HS x 6 months •Low-dose trimethoprim PO at HS x 6 months •Low-dose TMP/SMX PO at HS x 6 months HS= at bedtime Why at HS rather than in the AM with breakfast? largest concentration of urine is produced at night, so urine will be in urinary tract for longer amt of time

Progestin-only Oral Contraceptives- dosing

•MUST BE USED CONTINUOUSLY Adherence with the progestin-only pills is very important as missing a scheduled dose by 3 hours constituents a missed dose and requires a backup method

Testosterone/Androgens •Therapeutic uses

•Male hypogonadism •Replacement therapy •Delayed puberty •Breast cancer •Replacement therapy in menopausal women •Wasting in patients with AIDS •Anemias

Testosterone •Biosynthesis and secretion

•Males: testosterone •Females: preandrogens

Androgen (Anabolic Steroid) Abuse by Athletes

•Many athletes use to enhance athletic performance Significant risks -HTN, suppression of release of LH and FSH, testicular shrinkage, sterility, gynecomastia, acne, reduction in HDL, and increase in LDL •Hepatotoxicity with 17-alpha-alkylated compounds •Renal damage Psychologic effects •Mentally healthy: minimal impact Psychologically unbalanced: could intensify aggression

Progestin-only Oral Contraceptives

•May also be referred to as "minipills" •Suppresses the endometrium •Maintains thick mucus plug as helpful barrier to sperm •MUST BE USED CONTINUOUSLY •Less effective than combination Ocs

•Inactivated vaccines

•Microorganisms or their antigenic products that have been killed or attenuated •Produce long-lasting antibody response without causing disease •Prevents disease or disease state is milder

Drugs for Medical Abortion

•Mifepristone (RU 486) with misoprostol •Methotrexate with misoprostol •Prostaglandins

Oral Contraceptives •Three major subgroups of combination OCs

•Monophasic •Biphasic •Triphasic

Chlamydia tx •Lymphogranuloma venereum

•More common in tropical countries •Doxycycline 100 mg PO BID x 21 days

Ranitidine [Zantac®]

•More potent, fewer adverse effects and drug interactions compared with cimetidine •Actions of famotidine [Pepcid] & nizatidine [Axid] are very similar to ranitidine.

Herpes Simplex Virus (HSV)

•Never cured but can be controlled •Primary infection develop 6 - 8 days following exposure •Great pain, high fever, multiple vesicular lesions and ulcers that may last 10 - 14 days •Secondary infection (recurrent) usually less painful, lesions fewer, slight fever; may last 3 - 5 days

Tadalafil (Cialis) •Drug interactions

•Nitrates •Alpha blockers (except tamsulosin [Flomax]) •CYP3A4 inhibitors can increase levels of tadalafil; therefore, should limit tadalafil dosage to 10mg every 72 hours if taking a CYP3A4 inhibitor.

Riboflavin AE

•None for humans, no UL

Benign Prostatic Hyperplasia (BPH)

•Nonmalignant prostate enlargement •Caused by excessive growth of epithelial (glandular) cells and smooth muscle cells

•Vaginal contraceptive ring [NuvaRing]

•One ring is inserted once each month, left in place for 3 weeks, and then removed; a new ring is inserted 1 week later. During the ring-free week, withdrawal bleeding occurs. •Most common adverse effects: Vaginitis, headaches, upper respiratory infection, leukorrhea, sinusitis, weight gain, and nausea.

State the role of misoprostol (Cytotec) in the management of PUD.

•Only approved GI indication is prevention of gastric ulcers caused by long-term NSAID therapy •Dose-related diarrhea and abdominal pain •Contraindicated during pregnancy: Category X

Pharmacologic methods of contraception

•Oral contraceptives •Etonogestrel implants •Injectable medroxyprogesterone acetate •Intrauterine devices •Vaginal rings •Transdermal patches

Vardenafil (Levitra, Staxyn)

•PDE5 inhibitor approved in 2003 •Relaxes arterial and trabecular smooth muscle in the penis

Niacin deficiency

•Pellagra: this was very common in the south "years ago" •Dermatitis characterized by scaling and cracking of the skin in areas exposed to the sun •GI disturbances •CNS - Irritability, insomnia, memory loss, anxiety, and dementia

Sildenafil (Viagra)

•Phosphodiesterase type 5 (PDE5) inhibitor •First oral agent for ED: introduced in 1998 •Still VERY EXPENSIVE! ~$25 per tablet! •NO GENERIC FORM Originally developed as cardiac medicine •Only enhances normal erectile response in the presence of stimuli. •No significant impact on men who do not have ED •Not approved for women •Approved in 2005 as Revatio to treat pulmonary arterial hypertension (PAH)

•Alosetron [Lotronex®]

•Potentially hazardous drug; IBS tx; approved for women only •Approved ONLY for women with SEVERE IBS-D which has lasted for > 6 months & has not responded to conventional treatment. •GI toxicities can cause complicated constipation, leading to perforation and ischemic colitis •Risk management program

•Attenuated live vaccines

•Produce long-lasting active immunity similar to natural exposure •Risk of use in pregnant women and the immunocompromised

Androgens

•Produced by the testes, ovaries, and adrenal cortex •Major endogenous androgen is testosterone. •Noted most for their ability to promote expression of male sex characteristics •Primary clinical application is management of androgen deficiency in males •Principal adverse effects are virilization and hepatotoxicity

Progestin-only Oral Contraceptives AEs

•Progestin-only preparations are less effective •More likely to cause irregular bleeding Acne, hirsutism, weight gain, mood changes, & libido changes

Gonorrhea tx •Neonatal infection

•Prophylaxis with 0.5% erythromycin ointment Neonatal opthalmia can cause blindness if untreated •Ceftriaxone 25 -50 mg/kg IM single dose not to exceed 125 mg

Immunizations

•Purpose is to protect against infectious diseases •Most effective method is to create a highly immune population •Universal vaccine is the goal •Vaccines carry risk, but risks of disease are much greater •"Herd" immunity

Recommended dietary allowances (RDAs)

•Recommended dietary allowances (RDAs) for vitamins are set by the Food and Nutrition Board of the National Academy of Sciences •RDAs represent the average daily dietary intake sufficient to meet the nutrient requirements of nearly all (97%-98%) healthy individuals in a particular life-stage or gender group

Drugs and herbs that reduce the effects of Oral Contraceptives

•Rifampin •Ritonavir •Antiepileptic drugs (e.g., phenytoin) •St. John's wort

Trimethoprim/sulfamethoxazole (TMP/SMZ)(Bactrim® DS) AE

•Risk of Stevens-Johnson Syndrome (very low) hemolytic disease in G-6-PD deficiency

Scabes

•Sarcoptes scabiei MITES

Chlamydia

•Screening recommended in all sexually active (SA) women < 25 and SA women > 25 with a new partner Can cause •Genital tract infections - Untreated may cause significant pelvic infection (PID) and tubal damage resulting in ectopic pregnancy •Proctitis •Conjunctivitis •Lymphogranuloma venerum (LGV) In infants •Ophthalmia Pneumonia

Drugs whose effects are increased by Oral Contraceptives

•Several agents, including theophylline, tricyclic antidepressants, diazepam, and chlordiazepoxide

•Tegaserod [Zelnorm®]

•Short-term therapy of IBS-C and chronic idiopathic constipation (CIC) in women < 55 years old who are free of cardiovascular (CV) disease

Progestin-only Oral Contraceptives- benefits

•Since they do NOT contain estrogen, minipills do not have most of the ADRs associated with combination OCs such as thromboembolic disorders, headaches, or nausea. •Slightly safer than combination OCs •Safe for use with breastfeeding •Great option for an individual who has cardiovascular issues such as HTN, smokes, or is older than 35 years

Gonorrhea tx •Conjunctivitis

•Single 1 gram IM dose ceftriaxone (Rocephin®) •Wash the eye with normal saline once

Gonorrhea tx Pharyngeal infection

•Single 250 mg IM dose ceftriaxone (Rocephin®) plus Single 1 gram PO dose of azithromycin

Niacin •Adverse effects

•Small doses devoid of adverse effects Large doses •Vasodilation with flushing, itching, dizziness, nausea

different bowel cleansing products used for colonoscopies.

•Sodium phosphate Hypertonic with body fluids •Can cause dehydration and electrolyte disturbance •Possibility of renal damage Polyethylene glycol (PEG) plus electrolytes (ELS) •Isotonic with body fluids •Requires ingestion of large volume of bad-tasting liquid!!! •Combination of sodium picosulfate, magnesium oxide, & citric acid

Be familiar with the names of the different bowel cleansing products used for colonoscopies.

•Sodium phosphate •Polyethylene glycol (PEG) plus electrolytes (ELS) •CoLyte® GoLytely® •HalfLytely® MoviPrep®

•Two major groups of antidiarrheals:

•Specific antidiarrheal drugs Nonspecific antidiarrheal drugs •Opioids •Bismuth subsalicylate- don't give to child or someone with aspirin allergy (related to aspirin) •Bulk-forming agents •Anticholinergic antispasmodics

Clarithromycin [Biaxin®]

•Suppresses growth of H. pylori by inhibiting protein synthesis •Unfortunately, rate of resistance is rising, exceeding 20% in some areas side effects: •Nausea •Diarrhea •Distortion of taste

Food folate vs. synthetic folate

•Synthetic form is more stable •FDA ordered synthetic folate to be added to all enriched grain products

Acute Uncomplicated Pyelonephritis tx

•TMP/SMX BID x 14 days •Ciprofloxacin BID x 7-14 days •Levofloxacin QD x 5-10 days •NOTE: Longer treatment is generally more effective than shorter treatment (this is an editorial comment by your instructor) **REMEMBER: no -floxacin in <18 y/o

Alpha1-Adrenergic Antagonists approved for the treatment of BPH:

•Terazosin (Hytrin) •Doxazosin (Cardura) •Tamsulosin (Flomax) •Alfuzosin (Uroxatral) •Silodosin (Rapaflo) •Above drugs have not been compared to see if one is more effective than another. The two newer agents, tamsulosin & silodosin, may be better tolerated than the older medications

Quadrivalent Influenza Vaccine

•The US Food and Drug Administration approved a quadrivalent influenza vaccine directed against 2 strains of influenza A (H3N2 and H1N1) and 2 strains of influenza B. This increased coverage should improve the odds of providing cross-reactive antibody against a greater proportion of circulating influenza B viruses. •Mild allergy to eggs is no longer a contraindication; however, persons with this allergy should receive the inactivated influenza vaccine as this is the form of the vaccine studied in this population

Describe where the most current STI treatment protocols can be obtained

•The most current CDC STI treatment protocols are found here: •https://www.cdc.gov/std/tg2015/default.htm

tolerable upper intake limit (UL)

•The tolerable upper intake limit (UL) for a vitamin is the highest average daily intake that can be consumed by nearly everyone without significant risk for adverse effects •The UL is an index of safety—not a recommendation to exceed the RDA

Combination OCs: Adverse Effects

•Thromboembolic disorders •Hypertension •Cancer •Stroke in patients with migraine •Abnormal uterine bleeding •Use in pregnancy and lactation: may cause bleeding in female infants (very scary for the parents) •Benign hepatic adenoma •Glucose intolerance

Bowel Cleansing Products for Colonoscopy- •Why does the bowel need to be "cleansed"?

•To allow for good visualization of the bowel during a procedure such as a colonoscopy

Combo OCPs •Missed Dose •Extended cycle and continuous schedules

•Up to 7 days can be missed with little or no increased risk of pregnancy, provided the pills had been taken continuously for the prior 3 weeks (because they are basically mimicking the 28 day cycle pill with the placebo week)

Benign Prostatic Hyperplasia (BPH) s/s

•Urinary hesitancy •Urinary urgency •Increased frequency of urination •Dysuria •Nocturia •Straining to void •Post-void dribbling •Decreased force and caliber of the urinary stream •Sensation of incomplete bladder emptying

•Benzodiazepines as antiemetics

•Used in combination regimens to suppress CINV Three primary benefits: •Sedation •Suppression of anticipatory emesis •Production of anterograde amnesia

Metronidazole [Flagyl®]

•Very effective against sensitive strains of H. pylori •AVOID ALCOHOL- •Disulfiram-like reaction can occur if metronidazole is used with alcohol; avoid for 3 days after stopping med - remember other things include alcohol besides alcohol!! ex. mouthwash, cold medicine •Avoid use during pregnancy

Testosterone/Androgens •Adverse effects

•Virilization- the development of male physical characteristics •Premature epiphyseal closure •Hepatotoxicity •Effects on cholesterol levels •Use in pregnancy •Prostate cancer •Edema •Gynecomastia •Abuse potential (athletic performance)

Drugs whose effects are decreased by Oral Contraceptives

•Warfarin •Insulin •Oral hypoglycemics

Vitamin B Complex

•Water soluble Includes: •Niacin (nicotinic acid) •Riboflavin (vitamin B2) •Thiamin (vitamin B1) •Pyridoxine (vitamin B6) •Cyanocobalamin (vitamin B12) •Folic acid

who should avoid an IUD

•Women who are not in a mutually monogamous relationship, and hence are at risk for a STD, should not use an IUD.

Bacterial Vaginosis (BV) tx in nonpregnant women

•metronidazole 500 mg PO BID x 7 days (works best)(must avoid alcohol to avoid SIGNIFICANT nausea/vomiting;warn of strong metallic taste) (Avoid alcohol for 3-5 days after completion of med) or 2% clindamycin cream at HS x 7 days

Bacterial Vaginosis (BV) tx in pregnant women

•oral only metronidazole 500 mg PO BID x 7 days or clindamycin 300 mg PO BID x 7 days

Herpes Simplex Virus (HSV) tx

•valacyclovir •famciclovir •With recurrent outbreak (> 2/month), suppress with daily valacyclovir

Pediculosis and scabies topical tx

■ The major topical drugs for pediculosis and scabies have minimal side effects. ■ Topical pediculicides include drugs with neurotoxic effects on lice (permethrin, pyrethrins, malathion, lindane, spinosad, and topical ivermectin) and drugs that suffocate the lice (benzyl alcohol). The AAP recommends 1% permethrin or pyrethrins for first-line therapy in children. ■ With the exception of malathion and topical ivermectin, the major drugs for mites and lice have low activity against ova or nymphs, and hence a second application is needed to kill ova that hatched after the first application.