NAPLEX PREP QUESTIONS

Do not shake these medications

hormones proteins albumin alteplase immune globulins insulins monoclonal antibodies rasburicase vaccines (zoster)

PART A

hospital

The plan of a SOAP note includes

how the problem will be solved/addressed - diagnostic referrals - lab tests - patient education

These topical based formulations pull water from the atmosphere to moisturize the skin, can be sticky-feeling.

humectants (ex. glycerin, glycerol, PEG, urea, hyaluronic acid)

What is the most commonly used excipient?

lactose

USP specifies refrigeration for what type of compounds?

water-containing oral formulations

Etiology for NSTEMI/STEMI in more than 90% of patients is

atherosclerotic plaque rupture (plaque rupture causes imbalance between myocardial oxygen demand and supply)

Diagnosis of hypertension

average of >2 BP readings at >2 clinical encounters - make sure you have the appropriate sized BP cuff for the patient - 4 categories of hypertension: normal prehypertension stage 1 stage 2

Zepatier (elbasvir/grazoprevir)

- 1 Tablet daily, no regard to food - C/I in mod-severe hepatic impairment, use with strong inducers of CYP3A4, OATP1B1/3 inhibitors and efavirenz - warnings: LFTs increased (>5 ULN) w/in 4 weeks of tx, significant DDI potential - screen for NS5A polymorphism recommended when genotype 1A

Lactulose (hepatic encephalopathy)

- 1st line for both acute and chronic (prevention) therapy - nonabsorbable disaccharide - MOA: converts ammonia produced by intestinal bacteria to polar ammonium AND enhances diffusion of ammonia into colon for excretion - Enema = q4-6hrs PRN - prevention = 30-45ml (20-30g) PO TID-QID to produce 2-3 poops/day - C/I: low galactose diet - SE: gas, diarrhea, dyspepsia, abdominal discomfort, dehydration, Increased Na+/ decreased K+ - Monitoring: mental status, bowel movements, ammonia, fluid status, electrolytes

What patients are at high risk for low health literacy?

- >65 yo - immigrant population - low income - chronic mental and/or physical health conditions

Vaccination is a common missed primary prevention intervention. Your clinic has recently decided to incorporate vaccine discussions at each visit to make sure all patients are up-to-date on their schedules. What resources would be great to assist in developing this program?

- ACIP (via CDC) with updates given via MMWR - Pink Book (via CDC) with epidemiology and vaccine-preventable disease info - Immunization action coalition

Vasopressin (Vasostrict) for Variceal bleeds

- ADG analog - infusion: 0.2-0.4 units/min IV x max 24hrs - *not 1st line (usually used w/ nitroglycerin IV to prevent MI)* - SE: chest pain, MI, decreased CO, increased BP, N/V - Monitoring: BP, HR, ECG, fluid balance

NON-PHARM TX FOR HF

- ADHERENCE AND DIET - K+ consumption - (if ischemic heart disease --> suggest low cholesterol diet) - exercise - surgery (LVAD vs. hibernating myocardium vs. transplant) - biventricular pacing (once in, decrease drug maintenance)

Penicillin-beta lactamase inhibitors Unasyn (ampcillin/sulbactam) --> GI diverticulitis Timentin (ticarcillin/ clavulanic acid) Augmentin (amox/clavulanic acid) --> bites Zosyn (piperacillin/ tazobactam)

- ADRs: allergic reactions, seizures in renally compromised, neutropenia, hepatitis

Drugs with boxed warning for liver damage

- APAP high doses - amiodarone - isoniazid - ketoconazole (PO) - MTX - nevirapine - NRTIs - propylthiouracil - tipranavir - valproic acid

Where do I find information on *drug adverse reactions*?

- ASHP drug-induced Dx - FDAble - MedWatch (FAERS = FDA Safety Info + AE Reporting) - VAERS (vaccines) - MAUDE (reporting for medical devices) - Safety reporting portal - Meyler's SE of drugs

Spontaneous bacterial peritonitis

- acute infection of ascitic fluid - bacterial target: *Streptococci* and *enteric gram-NEG* - TX: 1) Ceftriaxone (or equivalent) x 5-7 dys 2) Albumin 1.5g/kg + 1g/kg day 3 (increases survival) *Pts who survive episode of SBP, should receive 2ndary prophylaxis with PO CIPRO or BACTRIM*

binders

- add cohesion to powders to allow tablets to stick together - improve stability and strength - ex: acacia, starch paste, sucrose syrup

Fish oils Lovaza 4 caps QD or 2 caps BID Vascepa 0.5caps 4 BID w/ food OR 1g CAPS 2 BID w/food

- adjunct to diet with TG >500mg/dl - Icosapent ethyl (vascepa) --> rec for ASCVD risk decrease risk - SE: burping (eructation), dyspepsia, taste perversions (Lovaza), arthralgias (Vascepa) - Monitor: LFTs and LDL - only Rx forms of omega-3 fatty acids: Lovaza, Vascepa - Stop prior to elective surgery d/t increased risk of bleeding - decrease TG 45%, increase HDL ~9%, can increase LDL up to 44% with Lovaza/ no increase with Vascepa - Monitor INR if on warfarin

Morphine in ACS 2-4mg IV bolus, may be repeated in 5-15 min PRN to relieve SX

- administered early in STEMI for pts with refractory angina as an analgesic and venodilator that lowers preload and afterload - can decrease myocardial oxygen demand - limited to certain patients and requires BP monitoring

MMR vaccine info

- adults born before 1957 are generally immune to measles and mumps - store MMR in freezer OR fridge - MMRV (ProQuad = + Varicella) = store in FREEZER - given SubQ

Cirrhosis

- advanced scarring / fibrosis, usually irreversible - most common causes: HCV and alcohol - as scar tissue replaces healthy tissue, blood flow in tissues is impaired --> complications: portal HTN, varices, ascites, and hepatic encephalopathy

TNKase dosing

- all over 5 second bolus Wt (kg) Dose (mg) <60 --> 30 60-69.9 --> 35 70-79.9 --> 40 80-89.9 --> 45 >90 --. 50

Common drugs that need decreased dose or increased interval in CKD

- aminoglycosides ( dosing interval) - beta-lactam abx (EXCEPT anti-staph penicillins/ceftriaxone) - fluconazole - quinolones (except moxifloxacin - hepatically cleared) - vanco - LMWH - rivaroxaban, apixaban, dabigatran (AFIB Only) - H2RAs (famotidine, ranitidine) - metoclopramide - bisphosphonates - lithium

T/F Live vaccines can interfere with tuberculin skin tests (PPD) and cause a false negative.

True

Drug treatment for HCV

Tx options and duration depend on: 1) genotype 2) presence of cirrhosis 3) tx-naive or tx-experienced Preferred: 2 DAAs for 8-12 weeks Ritonavir = not HCV active, boosts PI activity Use AASLD guidelines CURATIVE!!

Drugs normally colored:

anthracyclines - red - discolors sweat/urine rifampin - red - discolors body fluids/teeth methotrexate/ multivitamin infusions - yellow tigecycline - yellow/orange - teeth discoloration mitoxantrone - blue - discolors skin/eyes/urine iv iron - brown - discolors urine

immunity

antibodies are produced naturally to provide immunity against antigens immunoglobulin = medical term for antibody

What is the interval between antibody-containing products and MMR or varicella-containing vaccines?

antibody-containing --> vaccine: 3-11 months vaccine --> antibody-product: 2 weeks Find further details in Pink Book

Drugs that decrease blood pressure

antihypertensives vasodilators opioids benzodiazepines anesthetics PDE inhibitors

The negative pressure technique should be used with what medications when drawing from a vial?

any hazardous medications - do not put air into the vial, use the negative pressure technique to create a vacuum to draw out medications

Lomitapide (Juxtapid) 5-60mg

decrease apoB (main part of LDL + VLDL) MOA: binds and inhibits MTP approved for HoFH only available through REMs d/t hepatotox C/I: pregnancy, active liver dx $>500,000/year

Vitamin B 12 >200 pg/ml

decrease: PPIs, metformin, colchicine, chloramphenicol

Drug-induced kidney disease (DIKD) - risk factors/ drugs that cause

decreased renal blood flow and increased age = risk factors multiple nephrotoxic agents: 1) aminoglycosides 2) ampho B 3) cisplatin 4) cyclosporine 5) loops 6) NSAIDs 7) polymyxins 8) contrast dye 9) tacrolimus 10) vanco

Wetting surfactants

decreases tension b/w liquid and solids (ie. powder into suspension)

Folic acid (folate) 5-25 mcg/L

suppositories in women of childbearing age and alcoholism B12 and folate ordered for workup of macrocytic anemia decrease: phenytoin, phenobarb, primidone, MTX, bactrim, sulfasalazine

How does temperature affect surface tension?

surface tension decreases with increase in temperature

These two types of formulations requiring shaking to re-disperse compounds prior to administering.

suspensions and emulsions

1st Gen Cephalosporins Cephalexin (Keflex) 500mg q6hrs PO Cefazolin (Ancef) 1g q8hrs IV

- cephalexin = pregnant females with mild infections - cefazolin = surgery ppx to prevent SSTIs, covers E. coli

Non-sterile compounding is helpful for:

- changing formulation of a med (solid - liquid) - avoid an excipient patient cannot tolerate - prepare a dose/formulation not commercially available - add a flavor

Thiazides and dosing

- chlorothiazide (diuril) only once IV and PO -chlorothalidone (hygroton) 12.5-25mg - HCTZ (Microzide -capsule/ hydrodiuril- tablet) 12.5-25mg - Indapamine (lozol) 1.25mg - 2.5mg - Metolazone (Mykrox) 0.5-1mg/ (Zaroxolyn) 2.5-5mg

Hyperphosphatemia

- chronically elevated PTH (secondary hyperparathyroidism) - must be treated to prevent bone disease and fractures

Dalbavancin (dalvance) 1000mg IV single dose, followed by 500mg single dose 1 wk later new single dose regimen: - Crcl >30/ regular HD 1500mg - crcl <30/ not on regular HD 1125mg

- class: lipoglycopeptide - MOA: inhibits bacterial cell wall synthesis by binding with C-terminal D-alanyl- D-alanine of growing peptidoglycan chains - Place in tx: acute bacterial skin infections - Coverage: MRSA, streptococcus - renal dose adj: CrCl >30 = none CrCl <30 = 750mg single dose, then 375mg single dose 1 wk later ESRD = pts receiving intermittent hemodialysis no change - Admin: infuse over 30 min, mix and flush line w/ D5W - ADRs: N/D, HA, red man syndrome

Oritavancin (orbactiv) 1200mg IV single dose over 3 hours

- class: lipoglycopeptide - place in therapy: skin and soft tissue infections - coverage: MRSA, streptococcus species, vanco-susceptible E. faecalis - Admin: must be diluted in 1000ml of D5W - ADRs: infusion rxns, HA, N/V/D, limb and subQ abscesses, artificial increases in coagulation tests (effects on aPTT for 48hrs after admin and PT/INR for 24hrs after admin --> use anti-Xa test for heparin monitoring

Bactrim (trimethoprim/sulfamethoxazole) 160mg TMP: 800mg SMX q12 x 10-14 days IV for severe gram- NEG 8-10mg/kg/day in 2-4 equal divided doses

- combo abx in 1:5 ratio TMP:SMX - drug of choice for PJP (PCP), nocardia, and S. maltophilia infections - coverage: MRSA, PJP, nocardia, S. maltophilia - ADRs: N/V/D, anorexia, hypersensitivity (rash), hyperkalemia, SJS and aplastic anemia (RARE) - avoid in pregnancy and breastfeeding - DDI: potentiation of warfarin and phenytoin = increased bleeding risk - dose adjust for renal impairment - place in tx: respiratory tract infections, UTIs, GI, selected nosocomial infections - dose based on TMP

Homocysteine is...

- common amino acid in your blood - get it from eating meat - high levels = early development of heart disease - associated with low levels of vitamin B6, B12 and folate and renal disease - it can be recycled back into methionine using vit-b12 related enzymes - homocysteine --> B12 --> methionine (important for integrity of myelon on neurons)

Heart failure defined

- complex clinical syndrome resulting from any structural of functional cardiac disorder that impairs ability of ventricles to fill or eject blood - Systolic dysfunction = issue with contractility (EF <40%- HFREF) - Diastolic dysfunction = issue with relaxation (EF >40%)

Why is extended 24hr interval dosing possible with aminoglycosides?

- concentration-dependent killing (high peak serum concentration) - postantibiotic effect = still inhibiting bacterial growth even when drug concentration < MIC

PATHOPHYS: Hyperkalemia in CKD

- concerning once K >5 - renal K+ excretion is increased by: 1) hormone aldosterone 2) diuretics (loops >thiazides) 3) high urine flow 4) negatively charged ions in distal tubule (bicarb) - high dietary K+ dose not cause hyperkalemia unless kidney damage **normal kidney function: acute rise in K from meal would be offset by release of insulin --> causes K+ to shift into cells** Pts w/ DM at higher risk because insulin deficiency reduces ability to shift K+ into cells Mostly ASYMPTOMATIC, could have muscle weakness, bradycardia, fatal arrhythmias

Suppository compounding considerations

- consider partition coefficient - fat soluble drug will release slowly from fatty base whereas released more rapidly from water soluble base (opposites will repel)

Glycoprotein IIb/IIIa inhibitors - Abciximab (Reopro) 0.25mg/k IV bolus, followed by 0.125mcg/kg/min (max 10mcg/min) x 12 hrs - Eptifibatide (Integrilin) 180mcg/kg IV bolus x 2 (10 min apart) [max 22.6mg], following by infusion of 2mcg/kg/min - Trofiban (Aggrastat) 25mcg/kg IV bolus, then 0.15mcg/kg/min

-MOA: block final step of platelet aggregation, inhibits GP IIb/IIIa on activated platelets to prevent binding of fibrinogen or vWF and platelet cross-linking - Role in PCI to prevent early in-stent thrombosis following stent deployment - Reopro = MG dosing!!, platelet inhibition lasts 24-48hrs - ADRs: thrombocytopenia - TIP: Integrillin and Aggrestat have reversible inhibition and may be better option for patient who may need emergent CABG

Fondaparinux ppx = 2.5mg SC QD tx = 5-10mg SC QD

-MOA: heparin pentasaccharide, only binds AT3 to inhibit factor Xa - Indications: DVT ppx, VTE tx, alternative to UFH/LMWH for UA/NSTEMI/STEMI - CI: active bleeding, thrombocytopenia, CrCl <30

Ticagrelor (Brilinta) 180mg LD, then 90mg BID use 60mg BID after 12 months

-MOA: reversible concentration dependent inhibitor of P2Y12 receptor - NOT a prodrug --> rapidly absorbed, one active metabolite - can crush and make into a suspension - patient taking ticagrelor should not get >>81mg per day of ASA - indication: ACS managed medically or with PCI - Major ADRs: bleeding, dyspnea, bradycardia - Metabolism: CYP3A4, 2B6, 2C9, 2D6

Clindamycin (cleocin)

-Spec: Staph, Strep, anaerobes, MSSA, some MRSA - Dosing: 150-450mg q6hr (PO)/ 300-900mg q8h (IV) - NO RENAL DOSE ADJUST (hepatically cleared) - ADRs: (po admin) N/V/D, abdominal pain, esophagitis - HIGH RISK FOR C.DIF - place in tx: aspiration pneumonia, intraabdominal and pelvic infections, diabetic foot and decubitis ulcers, osteomyelitis, peritonsillar abscesses

HCV Med class: NS5A Replication Complex Inhibitors

-asvir Ledipasvir Ombitasvir Pibrentasvir Velpatasvir

HCV Med class: NS5B Polymerase Inhibitors

-buvir Dasabuvir Sofosbuvir

3rd gen cephalosporins ceftriaxone (rocephin) 1-2g IV q12-24hrs Ceftazidime (Fortaz) 1-2g q8h

-ceftriaxone meningitis 2g q12hr most other infections are 1g q24h NO RENAL DOSE ADJUST - ceftazidime covers pseudomonas

Continous data

- logical order - values continuously increase or decrease by SAME amount 1) INTERVAL - no meaningful 0, Ex temperature scales - 0 does not mean no temperature 2) RATIO - meaningful 0, age/ht/wt/time/BP --Ex: if HR = 0, heart is not beating

Risk levels of compounds for bacterial growth

- low, medium, high - used to determine beyond use date

Antibiotic classes that target "bacterial protein synthesis"

- macrolides - aminoglycosides

Capsules 101

- made of gelatin (pork-derived) or hypromellose (plant-derived) - human use sizes range from 000 (largest) - 5 (smallest)

Primary endpoint

- main result measured - separate and distinct singular item

Drug dosing and removal in dialysis

- many antibiotics are removed - either give after dialysis or need to give supplemental dose after dialysis Factors affecting drug removal in dialysis: 1) molecular weight/size = smaller is more dialyzable 2) Volume of distribution = large Vd is less dialyzable 3) protein-binding = more bound is less dialyzable Dialysis factors: 1) membrane = high-flux (large pore size) and high efficiency (large surface area) HD filters remove more substances 2) blood flow rate = higher rate means more drug removal over a time interval

Diuretic ADRs

dizziness, orthostasis dry mouth ototoxicity (IV loops) muscle cramps photosensitivity (thiazides)

Eosinophils 0-5%

increase: drug allergy, asthma, inflammation, parasitic infection

Basophils 0-1%

increase: inflammation, hypersensitivity rxn, leukemia

Lymphocytes 20-40%

increase: viral infections, lymphoma decrease: bone marrow suppression, HIV, systemic steroids

Phosphate levels (normal 2.3-4.7 mg/L) in the blood can be lowered by...

phosphate binders, oral Calcium

AMINOGLYCOSIDES HINTS

"mean old mycin" --treats mean, resistant, gram-negative infections - Ototoxicity = think mice --> ears --> ototox - Nephrotoxicity = Human ear is shaped like a kidney, Cr best indicator of kidney function (24hr CrCl) - TAPs - trough, administer, peak - get trough 30 min before next IV dose

gels made of poloxamer have this characteristic that let's them be ____ at room temp and _______ when cold.

"thermo-reversible" solid at room temp liquid when cold BUD is no more than 30 days

Diuretics

#1 - thiazides - don't work with poor renal function *Use loop diuretics when CrCl <30* - MOA: increase excretion of Na & Cl by inhibiting certain ion pumps in kidney - Thiazides = inhibit Na/Cl pumps, early distal tubule - Loops = inhibit reabsorption of Na/Cl, ascending loop of Henle (most potent) - Potassium sparing = inhibit Na/K exchange, distal renal tubule

Loop of Henle

(DOWN loop) = water reabsorbed into blood (UP loop) = Na and Cl reabsorbed into blood this is where 25% of sodium is filtered if ADH (vasopressin) works here, water is reabsorbed into the blood, less excreted in urine Loop diuretics cause less Ca reabsorption --> hypocalcemia (long-term use can cause decreased bone mineral density)

Criteria for HIGH-intensity and MODERATE-intensity statins

*HIGH INTENSITY: Rosuva 20-40, Atorva 40-80* - clinical ASCVD (TIA, stroke, PAD) - LDL >190 - DM, 40-75yrs old, LDL 70-189, w/ multiple ASCVD risk factors - 40-75yo, LDL 70-189, ASCVD >20% *MODERATE INTENSITY: Atorva 10-20, Rosuva 5-10, Simva 20-40, Prava 40-80, Lova 40* - DM, 40-75yo, LDL 70-189, regardless of ASCVD risk - 40-75yo, LDL 70-189, ASCVD 7.5% -19.9% Low intensity includes Simva 10, Prava 10-20, Lova 20

Hazardous compounding requirements

*containment* is a major part of precautions - C- PEC = sterile hoods for HD - C-SEC = buffer room, hood is located here - Storage: separate from non-H in an externally ventilated, negative-pressure room - ACPH: least 12 - External exhaust required OR Redundant HEPA filters if EE not allowed - dedicate equipment to HD only and sanitize after use

Tenofovir disoproxil fumarate (Viread) 300mg QD for HBV

*preferred* - Warnings: renal toxicity --Fanconi syndrome, osteomalacia, and decreased bone mineral density - SE: renal impairment, N/V/D, increased LFTS/CPK, HA, depression - dispense in OG container - DDI: didanosine, adefovir (increased risk of virologic failure)

Warfarin DDIs

- Abx/antifungals: 1) decrease flora in GI = decreased vitamin K production 2) hepatic CYP metabolism - Analgesics (NSAIDs) - Anticonvulsants/antiarrhythmics 1) extensive CYP2C9 and/or other CYP metabolism - Alcohol (hepatic metabolism)

ZIKA VIRUS

- Aedes species mosquitoes - transmission: sexual and possible blood transfusion - most asymptomatic, sx include fever, maculopapular rash, arthralgia, red eyes - birth defect: microcephaly if mother infected during pregnancy - NO VAX YET. avoid mosquito bites

You are working at a compounding pharmacy and need to find the recipe for a new patient's medication. Where can I look?

- Allen's - ASHP - Safety Data Sheets (SDS) - Merck Index - Remington - Trissel's - Handbook of Pharmaceutical Excipients

Tacrine Rivastigmine (exelon) Donepezil (aricept) Galantamine (razadyne)

- Alzheimer's - cholinesterase inhibitors

Stomach acid is required for Vosevi, Harvoni, Epclusa -->avoid these med classes

- Antacids - H2RAs - PPIs *decrease concentrations of ledipasvir and velpatasvir Separate antacids by 4hrs Take H2RAs at the same time or separate by 12 hrs (Use famotidine <40 mg BID) - DO NOT use PPIs

Lithium hints

- BPD - SE: the 3 Ps (peeing =polyuria, pooping = diarrhea, paresthesia = sign of electrolyte imbalance) - keep hydrated - monitor sodium levels as related

Typhoid Fever

- Bacteria salmonella tyhpi - life-threatening - high-risk areas: East/southeast asia, Africa, Caribbean, Central/South America - transmission: fecal/oral in food/water - spread via person w/ acute infection or chronic asymptomatic carrier - incubation period 6-30 days - presentation: fatigue, increasing fever over 3-5 days, HA, malaise, anorexia, enlargement of liver/spleen, rash - Fatal: intestinal hemorrhage or perforation 2-3 weeks later - vaccines are only 50-80% effective 1) Vivotif - oral, live, attenuated, complete >1 week before trip (no if <6yo) 2) Typhim Vi - inactivated, IM injection, complete >2 wks before travel (no if <2yo)

Type 2 Errors: false - negatives

- Beta - error: null accepted (when it should have been rejected) - Beta set by investigators during study design - typically 0.1 or 0.2 (risk of error 10% -20%) - risk increases if sample size is too small --> to decrease risk, power analysis performed

Warnings for all DAAs for HCV

- Black box warning: risk of reactivating HBV (test all pts for HBV prior to starting tx) - SE: well tolerated (HA, fatigue, D/N) - Monitor: LFTs (including bilirubin), HCV-RNA - hypoglycemia can occur with insulin use --> DAAs improve glucose metabolism

Sevelamer carbonate (Renvela) tablet/powder 800-1600mg TID Sevelamer HCl (Renagel) tablet only

- C/I: bowel obstruction - Warnings: can decrease dietary absorption of vitamins D, E, K and folic acid - consider using powder if dysphagia - BENEFIT: can lower TC and LDL by 15-30% - SE: N/V/D (>20%), dyspepsia, C, abdominal pain, gas - Monitor: Ca, PO4, HCO3, Cl, PTH -DDIs: 1) quinolones 2 hours before or 6 hrs after 2) give mycophenolate, tacrolimus, levothyroxine several hours before this

Tedizolid (Sivextro) IV/PO 200mg QD x 6 days

- Class: oxazolidinone - place in tx: acute bacterial skin and skin structure infections - Coverage: gram-POS - no renal or hepatic dose adjustments - ADRs: N/V/D, HA, dizziness - DDIs: inhibits MAO

Quinupristin/dalfopristin (Synercid)

- Coverage: abx-resistant gram-POS, VRE, MRSA, VISA, abx-resistant strep pneumo - ADRs: arthralgias, IV site pain, thrombophlebitis, increased LFTs - DDI potential: inhibits CYP3A4 - dosing: 7.5mg/kg q8hrs (VREF)/ 7.5mg/kg q12hr (SSTI) - fecal elimination (dose adj not needed/ not removed by dialysis) - not really used

Tetracyclines Doxycycline 100mg BID (IV or PO) Minocycline 100mg BID

- Coverage: aerobic, anaerobic, ricekttsiae, chlamydia, mycoplasmas, spirochetes - TIP: some strains of MRSA susceptible - TIP: if its difficult to pronounce, probably covered - ADRs: photosensitivity, teeth discoloration - C/I during pregnancy and breastfeeding, C/I in age <8yrs old - DDIs: chelation with milk/dairy, antacids, iron supps - Place in therapy: pneumonia, rocky mountain spotted fever, SIADH (treat hyponatremia), malignant pleural effusions (doxy), acne (mino/ doxy)

Metronidazole (flagyl) 500mg IV q6-8hrs 250mg -1g po q6-12hr colitis 500mg QID x 7-10 days

- Coverage: anaerobes (B. fragilis, Fusobacterium, C. dif, C. perfringens, Eubacterium), protozoan coverage (entamoeba histolytica, trichomoniasis vaginalis, Giardia lambia) - ADRs: metallic taste, GI upset, CNS effects, peripheral neuropathy (long-term use), dilsufiram-like reactions (wait 48hrs before alcohol), reversible neutropenia, dark urine - DDIs: inhibits metabolism of warfarin - Place in therapy: anaerobic infections, C. dif, bacterial vaginosis, H. pylori, acne roasacea

Macrolides Azithromycin Z-pak = 500mg 1st day, then 250mg days 2-5 Tri-pak = 500mg QD x 3 days Zmax (susp) = 2g dose 1 time - CAP = 500mg IV x 2 days, then PO 500mg QD to complete 7-10 days of therapy

- Coverage: atypicals (L. pneumophila, M. pneumo, Chlamydia, C. pneumo), S. pneumo, M. catarrhalis, Mycobacterium avium, B. burgdorferi, H. pylori - NO anaerobes/MRSA - ADRs: N/V/D, cramping, HA, metallic taste (secreted through salivary glands) - DDIs: erythromycin + clarithromycin inhibit metabolism of CYP3A4 - place in tx: respiratory infections, STDs, PID, sinusitis, MAC, lymes, endocarditis, tonsilitis

Chloramphenicol

- Coverage: broad-spec, aerobic, anaerobic, gram-POS, gram-NEG, staph aureus, enterococci, enterobacteriaciae, spirochetes, rickettsia, mycoplasma, chlamydia - ADRs: aplastic anemia, bone marrow suppression, Gray baby syndrome, optic/peripheral neuritis - Dosing: 50-100mg/kg/day given in divided doses q6hrs - exclusively used as alternative for VRE tx

Do not use these meds with Mavyret

- Efavirenz - HIV protease inhibitors - ethinyl estradiol-containing meds - cyclosporine

TCAs Hints

- Elavil, Tofranil, Desyrel - SE: anticholinergic - take 2-4weeks before full onset

Peripheral Vasodilators Hydralazine (Apresoline) 10-50mg PO QID/ 5-10mg IM/IV Minoxidil (Ioniten/ Rogaine OTC) 5-10mg QD --may need to add furosemide for fluid accumulation

- Indications: HTN, HF (hydralazine + isordil dinitrate/mononitrate) - MOA: decrease PVR through vasodilation - CI: CAD, mitral valve rheumatic heart dx - ADRs: HA, anorexia, N/V/D, palpitations, tachycardia

Peripheral Alpha-1 Receptor Blockers Doxazosin (cardura) Prazosin (Minipress) Terazosin (hytrin)

- Indications: high BP (not first line), BPH, Raynaud's, Scleroderma, pheochromocytoma, *PTSD (prazosin)* - MOA: relax certain muscles and keep small blood vessels open which improves blood flow and lowers BP - helps to improve urine flow in BPH - ADRs: first dose effect (take at bedtime), HA, pounding heartbeat, N, weakness, weight gain, small decrease in LDL, floppy iris syndrome (tell eye surgeon!!), priaprism - DDIs: CCBs, BBs, ED drugs - TIP: if HTN and BPH, give flomax and ACE/ARB

General dyslipidemia treatment guidelines 2018 ACC/AHA cholesterol management

- Lowering LDL by 1% = decreasing risk of heart dx/stroke by 1% - ASCVD risk estimate: risk of having a 1st cardiovascular event during next 10 years 1) INCLUDES: gender, age, race, TC, HDL, SBP and yes/no to antihypertensives, diabetes, smoking status 2) reassess every 4-6 years if low risk (<7.5%)

Adolescents recommended vaccines

- MCV4 (Menactra/Menveo) - 2 dose series started age 11-12 with 2nd dose at 16yo [ required first year of college if not previously done] - HPV - 3 doses started at age 11-12yrs *prevents 90% of cervical cancers and genital warts *If given before 15yo --> 2 doses (6-12 mon apart) *if given after 15yo --> 3 doses (2nd dose 1-2 mon later, then 3rd 6 months later) * CAUTION: FAINTING! * start at age 9 for anyone w/hx of sexual abuse - Tdap - >11yrs old

These are the 7 vaccines that need to be stored in the FREEZER

- MMRV (PROQUAD) -varicella (chicken pox) - Zostavax - COVID-19 - oral cholera - Ebola - smallpox

Colistin 2.5-5mg/kg/day IV divided into 2-4 doses 75-150mg 2-3x/day inhaled

- MOA: bactericidal polypeptide that disrupts cell membrane of gram-NEG bacteria - Coverage: multiple drug-resistant gram-NEG, pseudomonas, acinetobacter baumannii - ADRs: nephrotoxicity, neurotoxicity - Renally dose adjust!!!

Bile Acid sequestrants Colesevelam (Welchol) 625mg T or 3.75g packet

- MOA: bind intestinal bile acids to form complex that's fecally excreted --> removes cholesterol from enterohepatic recirculation - used for glycemic control in DM too - C/I: bowel obstruction, TG >500 - SE: constipation, abdominal pain, cramping, bloating, gas, increases TG - option in pregnancy!! - least DDIs, Take these meds 4 hrs before: cyclosporine, sulfonylureas, levothyroxine, olmesartan, phenytoin, COC w/ ee + NOR - *can decrease absorption of fat-soluble vitamins (ADEK), folate, and iron --> take MV but separate*

Aldosterone Receptor Antagonists Spironolactone (aldactone) Eplerenone (Inspra)

- MOA: competes with aldosterone for receptor sites in distal renal tubules = Increases NaCl and H20 excretion while conserving K+ and H+ ions - very effective for resistant hypertension and cirrhosis w/ edema/ascites - CI: anuria, acute renal failure, hyperkalemia, Addison's dx - TIP: if SCr >2.5 and K>5 = DO NOT USE - Warnings: renal impairment/hyperkalemia, CNS effects (somnolence/dizziness), gynecomastia - Monitoring: BP, Na/ K+, renal function

Dabigatran (Pradaxa) 150mg PO BID - PE/DVT ppx in hip replacement: 110mg 1-4h post-op, then 220mg PO QD for 28-35 days

- MOA: competitive direct thrombin inhibitor --> only inhibits Factor 2 - Indications: stroke ppx in afib (non-valvular), ppx and tx VTE - CI: active bleeding, mechanical valve, CrCl <15 - special consideration: risk of intracranial bleed or TE stroke lower in Dabigratran, but higher risk of GI bleed than warfarin. - rapid onset - t1/2 12-17hrs - renal elimination - no routine monitoring - Pgp substrate --> DDI potential - DO NOT CRUSH - KEEP IN OG CONTAINER

Beta-blockers

- MOA: decreased renin, CO, peripheral resistance, and aldosterone --> decreased sodium and water resistance = decreased blood volume - Metoprolol tartrate (Lopressor) = immediate release BID dosing (IV dose much lower than PO) - Metoprolol succinate ER (Toprol XL) = QD dosing, do not crush - Counseling: 1) don't protect against stroke 2) used in afib 3) don't abruptly D/C = rebound HTN/tachycardia if using BB and clonidine, titrate very slowly - Biggest ADR: fatigue!!!!

IVABRIDINE (Corlanor) for HF

- MOA: funny channel inhibitor - Does NOT alter: ventricular repolarization, myocardial contractility, or BP - ROLE: reduce risk of hospitalization for worsening HF - For pts with: 1) stable symptomatic HF 2) LVEF <35% 3) in sinus rhythm 4) resting HR >70 5) on max dose BB or cannot take BB Dosing: 5mg PO BID w/ hx of conduction defects = 2.5mg PO BID **adjust dose to reach resting HR b/w 50-60bpm Max dose: 7.5mg BID ADRs: Afib, bradycardia, conduction disturbances, phosphenes (transient enhanced brightness in limited area of visual field) C/I: acute decompensated HF, resting HR <60, SA block or 3rd degree block, sick sinus syndrome, severe hepatic impairment, pacemaker, taking CYP3A4 inhibitor

Heparin VTE dosing: PPX: 5000U SQ q8-12hrs TX: 80 U/kg IV bolus, then 18U/kg/hr OR 333 U/kg SC, then 250U/kg BID ACS dosing: 60-70U/kg IV bolus (max 5000U), then 12-15 U/kg/hr (max 1000U/hr)

- MOA: inactivates thrombin and factor Xa - indications: VTE ppx, PE, DIC, VTE tx - reversal agent: Protamine 1mg IV per 100U heparin to be neutralized - Monitoring: platelet count (QOD) aPTT (3-4x day 1, then daily) activated clotting time (ACT) PT/INR H/H

NRTIs general info

- MOA: inhibit HBV replication by inhibiting HBV polymerase - all approved as monotherapy - TIP: before starting tx, test all patients for HIV --> decreases risk of HIV resistance - If CrCl <50, reduce dose or frequency ---> Vemlidy (TAF): do not use if CrCl <15 - HBV exacerbations can occur upon D/C *BOXED WARNING* - lactic acidosis and severe hepatomegaly w/ steatosis (fatal!!) ~this has been downgraded to just a warning for TDF, TAF, lamivudine

Calcium Channel Blockers Dihydropyridines: Amlodipine 2.5, 5, 10mg Nifedipine (Adalat CC, Procardia XL) 30 ,60mg Nicardipine SR (Cardene) IV/PO Non-dihydropyridines: Diltiazem IR and ER PO/IV 0.25mg/kg over 2 minutes, 0.35mg/kg over 2 min repeated in 15 min, continuos infusion 5-15mg/hr Verpamail IR and ER PO/IV --> IV dosing 5-10mg bolus over 2 min

- MOA: inhibit influx of calcium through slow channels in vascular smooth muscles and myocardial tissue during depolarization, result = systemic and coronary artery vasodilation/decreased myocardial contractility, SA an AV nodal depression - Indications: angina, supraventricular arrhythmias (afib, aflutter, PSVT), brain aneurysm complications, migraine (verapamil), Raynaud's, pulmonary htn - Certain XL tablets have special release mechanisms and leave a "ghost tablet" in stool --drug has been released -CI: 2nd or 3rd degree heart block, Wolfe-Parkinson-White syndrome, sick sinus syndrome, symptomatic hypotension, systolic HF - Precautions/ADRs: AV heart block, peripheral edema, HA, dizziness, constipation (Verapamil) - DDI: felodipine and grapefruit juice

DIGOXIN for HF

- MOA: inhibits Na/K+ ATPase --> increased intracellular Ca = increased contractility - Role in HF: 1) improve sx 2) modest reduction in hospitalization 3) rate control in Afib -NO IMPROVEMENT IN SURVIVAL - Trials: Proved, Radiance, Dig Trial - Very large Vd --> be careful when sampling serum concentrations --> wait at least 12 hours after dose OR at trough before next dose - ADRs: GI (N/V/D/ anorexia), dysrhythmias, blue green haloes, CRAZY - Renal function and PK: normal = 1.5 days 60ml/min = 2 days 35ml/min = 2.5 days 15ml/min = 3 days anephric = 5 days

Dipyrimadole ER 200mg + ASA 25mg BID

- MOA: inhibits platelet uptake of adensonine, ADP platelet aggregation then blocked - Indications: arterial thromboembolism ppx in pts with prosthetic valves, valve disease, CABG / secondary ppx for ischemic stroke - ADRs: HA (reason why patients d/c), dizziness

WARFARIN

- MOA: inhibits vitamin K dependent coag factors 2,7,9,10 and protein C & S - indications: ppx, tx of VTE/PE, thromboembolic complications from AFib or valve replacement, reduce risk of death, recurrent MI, thromboembolic events - TIP: has a pro-coagulant effect before anticoag effect because of different t1/2 of inhibition of clotting factors--> REASON WHY BRIDGE TX NEEDED - ADRs: bleeding, skin necrosis, alopecia, feeling "chilly" - Teratogen - CI: risk of hemorrhage > benefits, pregnancy, blood dyscrasias, traumatic surgery, senile, AUD, psychosis, patients unreliable to check INR

FIBRATES

- MOA: peroxisome proliferator receptor alpha (PPARa) activators, upregulate apoC2 (increase lipase activity) and apoA1 (decreases VLDL and TG) - TIP: In presence of high TG, fibrate tx can lead to increased LDL - c/I: severe liver disease, gallbladder dx, CrCl <30, breastfeeding - SE: dyspepsia (gemfibrozil), Increased LFTs - reduce dose if CrCl 31-80ml/min (fenofibrate) - decreases TG 20-50%, increases HDL 15%, decreases LDL 5-20% - DDI: can increase effect of sulfonylureas and warfarin

PCSK9 inhibitors: Alirocumab (Praluent) 75 or 150mg/ml once q2wks OR 300mg monthly Evolocumab (Repatha) 140mg/ml once q2wks OR 420mg monthly (HoFH dose is only 420mg)

- MOA: proprotein convertase subtilisin kexin Type 9 inhibitors, acts to increase LDL receptor expression - EXPENSIVE subQ injection - SE: injection site reactions - monitor: LDL baseline, 4-8wks to assess response - store in fridge, can be at room temp for 30 days - before injection, let come to RT for at least 30 min - LDL reduction ~60%

Vorapaxar (Zontivity) 2.08mg QD in combo with aspirin and/or plavix

- MOA: protease activated receptor-1 (PAR-1) antagonist - indications: secondary ppx for hx of MI or established PAD - C/I: hx of TIA/stroke of intracranial hemorrhage, active pathologic bleeding - ADRs: bleeding - Monitor Hgb and Hct

Bivalirudin (Angiomax) 0.75mg/kg IV bolus, followed by 1.75mg/kg/h infusion during procedure and up to 4 hours post-op --> continue 0.2mg/kg/hr for 20 hours HIT: 0.15-0.2 mg/kg/hr

- MOA: reversible direct thrombin inhibitor that prevents conversion of fibrinogen to fibrin - renally dose adjust if CrCl 10-29ml/min: decrease infusion rate to 1mg/kg/ hr - *drug of choice for PCI in HIT patients* - ADRs: bleeding - indications: HIT (off-label), PCI, UA - Adjust infusion for HIT to aPTT 1.5-2.5x baseline - CI: active bleeding

Argatroban VTE: d/c heparin for baseline aPTT 2mcg/kg/min IV continuous ACS: 25mcg/kg/min IV continuous AND bolus 350mcg/kg admin via large bore IV line over 3-5min

- MOA: reversible direct thrombin inhibitor, blocks fibrinogen conversion to fibrin - indications: PCI, HIT, VTE ppx/tx - not recommended in ACS as first line, use bivalirudin instead - Test aPTT 2 hours after start for VTE, goal is 1.5-3x baseline/ dose adjustments not to exceed 10mcg/kg/min - FOR ACS: check ACT 5-10 min after bolus, can bolus again if ACT <300s (150mcg/kg) AND increase infusion by 30mcg/kg/min

Portal HTN and Variceal Bleeding

- Mechanism: when blood flow through liver is blocked by scar tissue, it backs up and flows into smaller blood vessels --> these vessels can balloon out and bleed if they break open - Acute variceal bleeding can be fatal!! --> pts are stabilized with supportive tx

Antibiotic classes that target *bacterial cell wall biosynthesis"

- beta-lactams - penicillins - cephalosporins *bind to PBP on cell wall

BETA BLOCKERS for HF

- Metoprolol Succinate = B1 selective, less BP lowering - Carvedilol = better HTN control - Bisoprolol (Zebeta) Role: 1) increase density of B1 receptors 2) inhibit cardiotox of catecholamines 3) decrease neurohormonal activation 4) decrease HR 5) antiischemic, antihypertensive, antiarrhythmic, antioxidant, antiproliferative When to start: when patient is stable with no fluid retention and no need for vasoactive drugs

Clinical presentation of Cirrhosis

- N, loss of appetite, V, D, malaise, pain in upper right quadrant - yellowed skin and whites of eyes - darkened urine - white or clay-colored stool

Drugs that can be precipitating factors of HF

- NSAIDs -Actos (fluid accumulation) - negative ionotropic drugs (flecainide, propafenone) - antiarrhythmics [ 2 are beneficial: amiodarone, dofetilide] - high Na+ content drugs - corticosteroids - etanercept, infliximab - herbal/natural products - alcohol or illicit drugs - viral myocarditis

FIRST ADD ON TO STATIN TX: ZETIA

- Only 10mg - MOA: inhibits absorption of intestinal cholesterol - C/I: active liver dx, preggo/BF - SE: myalgias, diarrhea, URTI, arthralgias - Monitor: LFTs at baseline - Lipid effects as monotx: decrease LDL 18-23%, increase HDL 1-3%, decrease TG 5-10% - DDI: gemfibrozil

Interferon Alfa (SUBQ)

- PEGylated extends half life, dosing is then once weekly - no longer recommended - use only in tx-resistant to DAA - flu-like side effects, CVD events, neuropsychiatric disorders - HORRIBLE.

Beta-Blockers: Role in ACS

- PO BB should be initiated within 1st day in pts without cardiogenic shock -* Metoprolol 5mg IV push (over 1-2min), repeated every 5 minutes for a total of 15mg, followed in 1-2 hrs by 25-50mg by mouth every 6 hrs* - target resting HR of 50-60bpm - continue for at least 3yrs in pts without LV dysfunction (if LV dysfunction, continue lifelong!!)

Rifaxamin (hepatic encephalopathy)

- PPX: 550mg PO BID - MOA: decreased ammonia production by bacteria - SE: peripheral edema, dizziness, fatigue, N, HA, ascites, gas - Monitor: mental status, ammonia

Vaccines recommended in HIV

- Pneumonia: Prevnar 13 x 1 dose, then PPSV23 1st dose 8 weeks later, then 2nd dose 5 years later - Menactra - HAV - HBV

Spread (variability) of data

- RANGE: difference b/w highest + lowest values - STANDARD DEVIATION: how spread out data is, to what degree it's dispersed away from the mean EX: large # of data values close to mean = small SD, highly dispersed data = larger SD - GAUSSIAN (normal) DISTRIBUTION: large data sets of continuous data, symmetrical bell-curves *When data is normally distributed: 1) mean = median = mode = center pt of curve 2) 68% of values fall within 1 SD of mean and 95% fall within 2 SDs - SKEWED DISTRIBUTIONS: when sample size is small and/or data has outliers *when there are a small # of values, outlier has larger impact on mean --> data becomes skewed --> MEDIAN is better measure of central tendency here **distortion of central tendency from outliers is decreased by collecting more values

Insulin Hints

- REGULAR = onset 1hr, peak 2hr, duration 4hr, clear in bottle (solution) so can be IV, R = rapid and run - NPH = onset 6hr, peak 8-10hr, duration 12hr, intermediate acting, cloudy = suspension (no IV!! -can lead to brain death), N = not so fast/not in the bag - 1,2,4,6,8,10,12 A) 124 = regular (2 is peak) B) 681012 = NPH (8-10 is peak) Exercise is like another shot of insulin, take a snack with you on runs/long exercise endeavors

Aliskerin (Tekturna) 150-300mg QD

- Renin inhibitor - MOA: blocks conversion of angiotensinogen to angiotensin 1 - place in tx: HTN alone or in combo w/ other agents - CI: concomitant ACEi/ARB in DM, pregnancy - Precautions: renal impairment, hyperkalemia, hypotension, serious skin reactions (SJS, TENS)

Prozac (fluoxetine) hints

- SE: anticholinergic - causes insomnia (give before noon)

Nitroglycerin in ACS

- SL NTG followed by IV NTG should be given to patients with ACS and ongoing ischemia, HF or uncontrolled high BP - Do not use in right-sided infarcts - avoid concomitant use w/ PDE-5 inihibitors - ADRs: transient HA, N/V, dizziness, flushing, rapid pulse - keep tabs in original glass bottle

What are the drug references for antibiotics?

- Sanford Guide - Brigg's pregnancy + Lactation - Trissel's compatibility guide

Older adults vaccine recommendations

- Shingrix 2 doses 2-6 months apart (>/= 50 years old) - Pneumonvax23 - wait at least 1 year after PCSV13 if >/=65 **Zostavax recommended >60 yrs old, but shingrix now preferred

Carbapenems - imipenem/cilastatin (Primaxin) - Meropenem (Merrem) - Ertapenem (invanz) - doripenem (doribax)

- Spectrum: poly-microbial, gram-POS, gram-NEG, anaerobic - NOT MRSA, VRE - ADRs: infusion-site problems, N/V/D (3-4%), rash, drug fever (3%), seizures from renal impairment drug accumulation - Place in tx: sepsis, nosocomial pneumonia, SSTI, complicated UTI, intraabdominal (diverticulitis), osteomyelitis, neutropenic pts, obstetric and gyno infections

These are the 10 vaccines that must be stored in the fridge

- TDAP - Hib - HAV - HBV - Gardasil (HPV) - Flu - MMR - Menactra/ meningitis - Prevnar13 - Rotarix

Pregnancy vaccine recommendations

- Tdap x 1 with each pregnancy preferably between weeks 27-36 **also vaccinate all close contacts of baby!!** - Flu (okay in any trimester)

Platelet P2Y12 inhibitors (thienopyridines) Ticlopidine (Ticlid) 250mg BID Clopidogrel (Plavix) - 600mg LD, then 75mg QD or - 300mg LD, if within 24hrs of thrombolytic Prasugrel (effient) Ticagrelor (Brilinta)

- Ticlid = ADR: cytopenia/neutropenia and skin reactions limit use, need to check CBC q2wks - Effient/Brilinta = only indicated for ACS - Plavix: - need a loading dose --> delayed onset - indications: ACS, recent MI or stroke, PAD - metabolism: 2C19, 3A, 2B6, 1A2 - plavix resistance in Asian population via genetic polymorphism - DDI: clopidogrel + omeprazole/esomeprazole - D/C 7 days prior to surgery

Tenofovir alafenamide (Vemlidy) 25mg QD

- WITH FOOD - SE: nausea, HA, abdominal pain, fatigue, cough, decreased BMD, increased LFTs - dispense in OG container - less renal and bone toxicity - DDI: (P-gp susbstrate!!) oxcarbazepine, phenytoin, phenobarb, etc

Metabolic Acidosis in CKD

- ability of kidney to reabsorb bicarb decreases as CKD progresses - Tx initiated when serum Bicarb <22

Order of a published clinical trial

- abstract (brief summary) - introduction - study methods (variables, outcomes) - statistical methods - results (figures, tables, graphs) - conclusion, interpretation of results/implications for practice

Octreotide (Sandostatin) for Variceal Bleeds

- analog of somatostatin w/ greater potency and longer duration of action - Bolus: 25-100 mcg IV (usually 50 mcg) --repeat in 1 hr if bleeding still present - Infusion: followed by 25-50 mcg/hr continuous x 2-5days - SE: bradycardia, cholelithiasis, biliary sludge, etc - Monitor: blood glucose, HR, ECG

ENTRESTO (sacubitril/valsartan)

- angiotensin receptor neprilysin inhibitor - Dose: 24/26mg, 49/51mg, 97/103 mg (103mg valsartan in entresto = 160mg valsartan alone) - ROLE: 1) reduce risk of CV death 2) reduce HF hospitalizations (HFrEF only) - MOA: neprilysin enzyme breaks down BNP to decrease hypertrophy, decrease sympathomimetic effort on heart - ADRs: hypotension and hyperkalemia (cough 11%, increase Scr 3%, angioedema 0.5%) - DO NOT USE in pregnancy or with another ACE/ARB - DDIs: K-sparing diuretics, aldosterone antagonists (increased risk of hyperkalemia)

Sterile compounding requirements:

- anteroom - buffer area (SEC) = cannot contain water sources/flood drains - primary engineering control (PEC) or segregated compounding area - surfaces must be smooth, impervious, non-shedding, easy to clean (stainless steel, molded plastic) - walls of durable material with locked sealed panels - floors = wide sheet vinyl flooring with head-welded seams

Utilize the hospital's ________ (map of area susceptibility) and _______________(list of covered / stocked medications) to select an appropriate antibiotic.

- antibiogram - formulary

Bempedoic Acid (Nexletol)

- approved 2/2020 - MOA: inhibits cholesterol synthesis in liver by inhibiting ACL - approved for HeFH and ASCVD requiring more LDL decreases

Durlaza

- aspirin ER - indicated for secondary prevention of stroke and acute cardiac events - 162.5mg of active aspirin

Hepatotoxic drug: NSAIDs

- avoid in pts with cirrhosis - can lead to decompensation, including bleeding

Meningococcal meningitis disease and vaccine

- bacteria N. meningitidis -MEDICAL EMERGENCY!! - fever, severe and unrelenting HA, nausea, stiff neck (nuchal rigidity), mental status changes - diagnosis via lumbar puncture - spread via respiratory secretions - high risk regions: meningitis belt of Africa during Dec- June - Vaccine required by government of Saudi Arabia for travel during annual Hajj and Umrah pilgrimages

Cholera

- bacteria, Vibrio cholerae - high-risk areas: Africa, Southeast Asia, Haiti - range from mild/asymptomatic --> profuse D/V, dehydration - WATERY DIARRHEA (Rice-water stools) - Vaccine: Vaxchora - live, attenuated, single, PO dose given >10 days before travel, good for 18-64 yo

HEMODIALYSIS:

- blood pumped to dialyzer and runs through semipermeable dialysis filter to remove waste products, electrolytes, excess fluid - 3-4hr process TIW - pts who do it at home can do it more frequently (5-6x/wk)

hypertonic solutions (>0.9%)

- can be fatal - range from 3% for hyponatremia to 23.4% for parenteral nutrition

Hepatotoxic drug: ACETAMINOPHEN

- can be used by patients with cirrhosis for a limited time and at lower doses - pts with alcoholic cirrhosis and actively drinking and/or are malnourished are at increased risk of further damage

Inactivated vaccines

- can be whole virus/bacterium or fractions - immunity can decline over time and a booster may be needed - use killed version of virus - cannot replicate!! - 3 types: 1) Polysaccharide 2) Conjugate 3) Recombinant

What should you watch out for when starting ACE/ARB in renal disease?

- can see a bump in Scr by 30% - if more than 30%, discontinue.

Odds ratio

- case-control studies, cohort and cross-sectional studies require this calculation for risk assessment - in order to estimate risks associated with a tx or intervention, the odds of unfavorable events are calculated Case-control studies: - enroll pts with clinical outcome or dx that already occurred - med charts are review retrospectively to look for possible common exposure that increased risk - odds ratio is used to calculate odds of outcome occurring with an exposure, compared to odds of outcome w/out exposure OR = AD / BC Ex: OR = 1.23 --> means some exposure is associated with 23% increased risk of outcome

Discrete Data

- categorical data 1) NOMINAL - subjects in arbitrary categories, gender/ethnicity/mortality --> YES/NO data 2) ORDINAL - ranked data w/ logical order, categories do NOT increase by same amount, EX: NYHA class 1-4, pain scale 0-10 --> 2 is not half the pain as 4

Hepatic Encephalopathy

- caused by acute or chronic hepatic insufficiency - symptoms: musty odor of breath/urine, changes in thinking/confusion/forgetfulness, mood changes, poor concentration, worsening handwriting, hand tremor (asterixis) - *Sx result from accumulation of gut-derived ammonia and glutamate*

Warfarin Dosing

- counsel on DDIs, vitamin K intake - Obtain baseline PT/INR, Hgb/Hct - Initial dose largely empiric (no longer give large LD) - most people get 5mg/day, older patients get 2.5mg/day, younger patients get 7.5mg/day - if treatment is urgent: give 2 doses roughly 2.5mg higher than maintenance dose

Penicillins Pen G aminopenicillins antistaph penicillins (dicloxacillin PO only, nafcillin IV) antipseudomonal penicillins (pipericillin)

- coverage: gram-POS, aerobic, some anaerobic - TIP: ampcillin and amoxicillin >> gram-neg >>>penG - nafcillin = hepatically cleared, short t1/2 - dose q4hr

AMINOGLYCOSIDES

- coverage: severe gram-NEG; aerobic gram-neg bacilli, enterococci, staphylococci, certain mycobacteria -MOA: works intracellularly by binding to 50S unit ribosome; bactericidal - ADRs: dose and tx-dependent nephrotox, ototoxicity (irreversible), neuromuscular block - dosing: normal is q8hrs, extended q24hrs - draw serum concentrations at *3rd dose* - with 30 min infusion, get PEAK 30 min after, get trough 30 min before next dose - place in therapy: UTI (severe), neutropenia, intra-abdominal and nosocomial infections

Secondary (acquired) hypercholesterolemia

- d/t poor diet, lack of physical activity that results in central adiposity - hypothyroidism and diabetes can also cause dyslipidemia - severe LDL >190 and TG >500 are very high risk and MUST BE TREATED

Niacin

- decreases rate of hepatic synthesis of VLDL (decreases TG) and LDL - nicotinic acid or Vitamin B3 other names - C/I: active liver dx, active PUD, arterial bleeding - Warnings: rhabdo w/ >1g doses + statin, heptatox, increases BG/uric acid, decreases phosphate - SE: flushing, itching, V/D, gout - check LFTs at baseline --> q6-12 weeks 1st year - IR = more flushing/itching, reduce w/ ASA 325 or Advil 200 30-60min before dose - CR/SR = less itching, more hepatotox - BEST choice: ER Niaspan (less itch, less hepatotox, most expensive) - "flush-free" NOT effective (niacinamide/nicotinamide) - increase HDL 15-35%, decrease TG 20-50% - DDI: take 4-6hrs after bile acid sequestrants

Requirements in the EHR

- demographic data - admission sheet - service agreement form - page describing patient's rights (JCO requirement) - advance directive to document patient's wishes concerning med tx - lab tests, med admin records

Hepatorenal syndrome

- development of renal failure in patients with advanced cirrhosis - result of renal vasoconstriction mediated by RAAS activation and SNS through feedback mechanism "hepatorenal reflex" - Ways to prevent: 1) Treat stages of cirrhosis appropriately 2) Avoid nephrotoxins and renal hypoperfusion -Treatment: 1) Albumin 2) Octreotide 3) midodrine

PERITONEAL DIALYSIS

- dialysis solution (usually with glucose) is pumped into peritoneal cavity - peritoneal membrane acts like semipermeable membrane - solution left in abdomen to "dwell" then is drained - cycle repeated throughout the day, everyday --done at home

Diluents/fillers

- dilute or bulk up to add size to very small doses - fillers: lactose, mannitol, sorbitol, starches, Ca salts, gelatin, bentonite, powdered cellulose - liquid: water, glycerin, alcohol - topicals: mineral oil, petrolatum, lanolin

Coombs Test, Direct (negative)

- direct antiglobulin test - used to determine cause of hemolytic anemia (autoimmune vs. drug-induced) and for transfusion compatibility POSITIVE: penicillins, cephalosporins, dapsone, isoniazid, levodopa, methyldopa, methylene blue, nitrofurantoin, pegloticase, primaquine, quinidine, rasburicase, rifampin, sulfonamides *if positive, discontinue offending drug*

Warfarin dose adjustments, do not exceed...

- do not exceed 25-30% of prior weekly dose

Benzos hints

- do not take short-acting long term (>90 days/ 3weeks-3 mos) - Anticholinergic SE

Vanco dosing

- dosing: use actual body weight Wt (kg) Dose(mg) <50 750 50-74 1000 75-90 1250 >90 1500 interval based on CrCl >50ml/min = q12hrs 30-50 ml/min = q24hrs <30 ml/min = q12hrs x 2 (random) *check TROUGH just prior to 4th dose*

SPIRONOLACTONE for HF

- effective through decreased aldosterone effects on heart, NOT VIA DIURETIC EFFECT

Low molecular weight heparin (LMWH) standard: 1mg/kg Sc q12hrs Renally adjusted: 1mg/kg SC q24hrs (CrCl <30) Age >75: 0.75mg/kg SC q12hrs Supplemental dose 0.3mg/kg IV prior to PCI is last dose 8-12hrs prior to PCI

- enoxaparin (lovenox) most common - do not use in: 1) active bleeding 2) HIT 3) CrCl <15 4) CABG planned

Reasons to hospitalize a patient for ADHF

- evidence of severe decompensation - dyspnea at rest - hemodynamically significant arrhythmia - ACS - worsened congestion - s/s pulmonary congestion - major electrolyte disturbance - comorbidities (septic, uncontrolled DM) - ICD firings

Populations with high risk of bleeding with warfarin

- excessive anticoagulation - first 30 days of warfarin tx - acute illness: HF - changes in other meds d/t DDIs (CYP2C9 metab) - dietary changes limiting vitamin K intake - dental surgery - biopsy or other surgery - trauma

Recombinant vaccines

- gene segment of a protein from the organism is inserted into gene of another cell (ie. yeast) where it replicates - GARDASIL9, FLUBLOK QUAD

Primary (familial) hypercholesterolemia

- genetic defects that cause severe cholesterol elevations - heterozygous or homozygous - categorized by Fredrickson classification

Prevnar13 specific recs

- give in any patients >/= 6 years old if immunocompromised - optional if >65

lubricants

- glidants or anti-adherents - prevent sticking - improve powder flowability in tabs/caps by decreasing interparticle friction ex. mag stearate, colloidal silica, calcium, PEG, glycerin

Sick Days in DM

- glucose goes up when sick, regardless of food intake - TAKE INSULIN - take sips of water = avoid dehydration

Levigating agent

- glycerin (aqueous) or mineral oil (lipophilic) - aids in grinding down particles *trituration = dry grinding of particles

Unfractionated heparin (UFH) 60u/kg IVP (max 4000U), then 12 U/kg/hr (max 1000U/hr), to target aTT of 50-70s

- gold standard injectable anticoag for pts with STEMI to prevent reclusion of an infarct artery - may have to use higher doses if no GP 11b/111a inhibitor used - monitor with ACT during PCI - contraindicated in HIT - ADR: bleeding --> reversed with *protamine*

Disintegrants

- helps break up tablets after PO admin (in GI tract) - tablets must dissolve to be absorbed - *alginates* = absorb water, tablet swells and bursts - ex. aliginic acid, polacrilin, potassium (amberlite), compressible sugar (nu-tab)

Hypertriglyceridemia and ASCVD

- high ASCVD risk - >500mg/dL also increases risk of acute pancreatitis

Statins for ACS what are the 2 options?

- high-intensity statin should be given Rosuvastatin 40mg Atorvastatin 80mg *use regardless of prior lipid-lowering therapy to reduce frequency of periprocedural MI following PCI

REPERFUSION THERAPY: Alteplase (Activase) Reteplase (Retavase) Tenectaplase (TNKase)

- if STEMI is diagnosed primary goal is to open vessel in shortest time possible with either fibrinolysis or PCI - MOA: fibrinolysis catalyze conversion of endogenous plasminogen to plasmin, which degrades fibrin and results in lysis of thrombus - *standard is door to needle time of <30min* - ADR: bleeding - Relative C/I: chronic/uncontrolled HTN, traumatic or prolonged CPR (>10min), major surgery within 14-21 days, internal bleeding within 2-4 weeks, noncompressible vascular punctures, pregnancy, active peptic ulcer, concurrent use with oral anticoags - ABSOLUTE CI: any hx of intracranial hemorrhage, known malignant intracranial neoplasm, ischemic stroke within 3 months, suspected aortic dissection, active bleeding, significant closed-head or facial trauma w/in 2 months, major surgery within 14 days

Phenothiazines

- immediate onset - Thorazine, Compazine - large doses = psychotic symptoms - small doses = N/V - SE: anticholinergic (blurred vision, constipation, drowsiness), EPS, photosensitivity

What happens if you miss your interval for a multi-dose vaccine series?

- increased interval between doses in a series does NOT diminish effectiveness of vaccine after series completion - only may delay more complete protection - decreased interval between vaccine doses in a series can interfere with antibody response and protection

VTE/DVT TRAVEL PREVENTION

- increased risk d/t limited movement on long flights - wear compression stockings - perform lower leg exercises when sitting

Relative risk reduction

- indicates how much the risk is reduced in the treatment group - RRR = (% risk control - % risk tx group) / % risk in control group - RRR = 1- RR decimal EX: RRR = 1- 0.57 = 0.43 --> Metoprolol-tx patients were 43% less likely to have HF progression than placebo-tx patients RR = % as likely (vs control) RRR = % less likely (vs. control)

Centrally Acting A2 Agonists Clonidine 0.1-0.2mg --> patch is once weekly Methyldopa (Aldomet) PO/IV Reserpine PO Guanfacine (Tenex) PO

- indications: HTN, hot flashes, alcohol drug withdrawal, ADHD, tourette's - MOA: negative feedback, prevent brain from sending signals to nervous system to speed up HR - ADRs: FATIGUE, DRY MOUTH, drowsiness, dizziness, impotence, constipation, HA, weight gain, depression - DDIs: may have synergistic effect w/ alcohol, barbs - Monitor: HR when taken with BB, CCB, digoxin

Factor Xa inhibitors Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa)

- indications: stroke ppx in non-valv afib, tx of DVT/PE - indications (Apixaban/rivaroxaban): ppx DVT/PE general and knee/hip arthroplasty - Rivaroxaban = high PO bioavailability (>80%), renal elimination, no lab monitoring, onset 2-4hrs

STATINS *Equivalent doses*: Pitavastatin 2mg Rosuvastatin 5mg (range 5-40mg ) Atorvastatin 10mg (10-80mg) Simvastatin 20mg (10-40mg - take PM) Lovastatin 40mg (20-80mg - Altoprev QHS) Pravastatin 40mg (10-80mg) Fluvastatin 80mg (20-80mg - take PM) (Rharmacists Rock At Saving Lives and Preventing Fatty deposits)

- inhibit rate-limiting step of cholesterol synthesis (HMG-CoA reductase inhibitors) - SE: may cause liver damage --do not use if AST or ALT are >3x ULN, muscle weakness/pain/rhabdo - C/I: pregnancy, breastfeeding, liver dx, CYP3A4 inhibitors (simva/lova) - Higher risk myalgias w/ higher doses, age >65, niacin, CYP3A4 inhibitors, hypothyroidism, renal impairment - MONITOR: check lipid panel 4-12 wks after start - SPECIAL POP: start w/ 5mg Rosuva in Asian patients (AUC higher) - Rosuva + Prava = least DDI potential - max out statin before using another medication

Why would we use de-escalation therapy?

- initiate broad-spec abx for infection risk or suspection --> get culture --> narrow spectrum of abx tx 1) helps to shorten exposure of unnecessary antibiotics 2) prevents resistance mechanisms from occurring

ACE inhibitors for HF

- inpatient use Captopril (short half life) - outpatient transition to low-dose Lisinopril - can cause drug-induced hyperkalemia - titrate to good maintenance dose - role in HF: 1) improve symptoms 2) reduce remodeling/ progression 3) reduce hospitalization 4) improve survival

Lokelma (sodium zirconium cyclosilicate) 10g PO TID

- instructions: empty packet into cup w/ at least 3 tbsp water, stir well and drink stat - warnings: can worsen GI motility, edema, contains Na - separate from other drugs 2 hrs before and after - SE: peripheral edema - NOT FOR EMERGENCY, store at room temp

Patiromer (Veltassa) 8.4g PO QD, max daily 25.2mg

- instructions: measure 1/3 cup water --pour 1/2 in an empty cup --add Veltassa packet and stir --add remaining water and stir. Drink STAT - mix should be cloudy - warnings: can worsen GI motility, hypomagnesemia - Separate from all meds by at least 3 hrs before or after - SE: C, N, D - Monitor: K, Mg - NOT FOR EMERGENCY USE - store powder in fridge, only good 3 months if kept at room temp

peer review

- intended to assess design and methods of research, value of results and conclusions to field of study, how well manuscript is written, and whether it's appropriate for journal audience

Why is vancomycin given IV for MRSA and PO for C.diff?

- it's a very difficult to kill bacteria with traditional antibiotics - vanco is a very large polar molecule that does not digest easily - vanco that treats colitis is double the dose and given PO so it can hit the GI system at site of action

Its OK to give a vaccine in the following specific scenarios

- mild acute illness (slight fever, diarrhea) - current abx treatment (except varicella, zoster, oral typhoid) - previous local skin reaction - allergies: birds, penicillin, products NOT in vaccines - pregnancy (except live), breastfeeding, preterm birth - immunosuppressed person in household, recent exposure to disease - fam hx of ADR

Absolute risk reduction

- more useful than RR/RRR - it includes reduction in risk AND incidence rate of outcome - if risk of N is low, but risk was small to begin with, the large RRR has little practical benefit - ARR = % risk in control group - % risk in tx group EX: ARR is 12%, 12 out of every 100 pts benefits from tx

YELLOW FEVER

- mosquitoes in tropical/ subtropical Africa and Central/South America - PPX: decrease exposure! - mostly asymptomatic w/ ~15% progressing to more toxic form w/ risk of shock/bleeding/organ failure - TX: no specific meds 1) symptomatic relief w/ fluids, analgesics, and antipyretics -->can NOT use aspirin or other NSAIDs d/t risk of bleeding - PPX: 1) YF-vax - live, attenuated, given ICVP yellow card which is only valid if completed w/in 10 days of arrival * c/i if egg allergy * recommended only to pts if high-risk or need proof to enter country

What is the rule for administering multiple vaccines in a single day?

- most live or inactivated vaccines can be administered simultaneously (on same day or at same visit) - for children: simultaneous admin is important to improve compliance and increase probability child will be fully immunized at appropriate age

Factor Xa Considerations

- no antidotes - no weekly monitoring - compliance with short t1/2 lives = patient loses entire anticoag effect if noncompliant and misses a dose (unlike warfarin with longer t1/2) - EXPENSIVE - Pt populations not studied (ie. cancer --> warfarin studied in cancer and more specific populations)

Kayexalate (SPS) PO = 15g 1-4x/day, Rectal = 30-50g q 6hrs

- non-absorbed cation-exchange resin - warnings: electrolyte disturbances, fecal impaction, GI necrosis - SE: N/V/D/C - Monitor: K, Mg, Na, Ca - do not mix oral powder with fruit juices containing K

Number needed to Treat

- number of patients who need to be treated for a certain period of time in order for ONE patient to benefit - ALWAYS round UP! NNT = 1 / (risk in control - risk in tx) = 1/ ARR ARR 12% --> NNT = 1/0.12 = 8.3 (round up to 9) --9 pts need to be treated for 1 year for 1 person to benefit

Diuretics in HF

- only if symptomatic - preferred goal is to obtain normal ventricular filling pressures - look at baseline weight - PE: JVD, rales, pulmonary edema - contraindications: sulfonamide allergies, anuria - Precautions: hepatic coma, severe electrolyte depletion, cirrhosis, gout, diabetes

Prasugrel (Effient) 600mg load, 10mg QD pts <60kg: 30mg load, 5mg QD,

- only indication: ACS managed with PCI - pro-drug activated by CYP3A4 and 2B6 - onset of action 0.5-1hr, t1/2 ~7hrs - ADRs: major bleeding *Contraindicated in pts >75, <60kg, prior TIA/stroke (risks>>>benefits)* - not used in elective PCI - D/C 7 days prior to surgery

Aztreonam (Azactam)

- only monobactam - covers gram-NEG (NOT active against gram + or anaerobes) - not stable in presence of ESBLs - Dosing: 1-2g IV q8h --> RENAL DOSE ADJUST - PO equivalent: Fluoroquinolones - ADRs: rash, D/N/V, increased LFTs, pseudomembranous colitis - no DDIs - place in therapy: UTI, pelvic and peritoneal infections, neutropenia, gram-NEG sepsis, nosocomial pneumonia, penicillin/cephalosporin allergy

Linezolid (Zyvox)

- oxazolidinone - Spectrum: MSSA, MRSA, VSE, VRE, strep - MOA: binds 50S ribosomal subunit - ADRs: D/N, headache, rash, thrombocytopenia (check platelets if tx >1 week), peripheral / optic neuropathy (reported blurred vision), arrhythmias - DDIs: MAO inhibitors, SSRIs --> serotonin syndrome - Dosing: 600mg IV or PO (excellent oral absorption) - Give dose after dialysis - Place in tx: VREF, nosocomial pneumonia, complicated skin and soft tissue (MRSA) - inhibits PVL MRSA production - *good for ICU patients with fluctuating renal fxn*

Fidaxomicin (Dificid) 200mg PO BID x 10 days

- poorly absorbed macrolide - coverage of C.Dif - ADRs: N/V, abdominal pain, GI hemorrhage, anemia, neutropenia - pregnancy category B - place in tx: lower risk of recurrence and more simplified dosing compared to PO vanco

NARxCheck scores

- predict unintentional overdose death potential - narcotic score of 650 = threshold equivalence to the 99th scoring percentile in NARxCheck

Aspirin in ACS

- preferred antiplatelet - hospital quality performance measure in MI - MOA: IRREVERSIBLY inhibits formation of thromboxane A2 through COX inhibition --> inhibits platelet aggregation - Counseling: at onset of chest pain, chew and swallow non-enteric coated 162-325mg of aspirin (1st dose chewed to achieve high blood concentration and platelet inhibition rapidly - Daily maintenance dose: 75-162mg (81mg) - TIP: low dose ASA preferred in patients on ticagrelor (PLATO) - TIP: D/C NSAIDs/ celecoxib at time of ACS - ADRs: dyspepsia, nausea, gastritis (dose-dependent) - TIP: need to hold 10 days prior to surgery for platelets to build back up

Polio

- present in Afghanistan, Burma (Myanmar), Guinea, Laos, Nigeria, Madagascar, Pakistan, Ukraine - CDC rec: single lifetime booster dose of inactivated poliovirus vaccine at least 4 weeks before travel to above areas for adults previously vaccinated as children - Vaccine is documented on "international certificate of vaccination or prophylaxis (ICVP) [ also records Yellow fever]

HCV Med class: NS3/4A PROTEASE INHIBITORS

- previr glecaprevir grazoprevir paritaprevir voxilaprevir TAKE WITH FOOD except Zepatier (elbasvir/grazoprevir) taken w/out regard to food

Study power

- probability a test will reject null hypothesis correctly - Power = 1 - Beta - determined by: 1) number of outcome values 2) difference in outcome rates 3) significance (alpha) level EX: beta 0.2, study has 80% power

Measures of central tendency

- provide simple summaries of data - MEAN: average, preferred for continuous data, normally distributed - MEDIAN: middle value when values arranged low-high, preferred for ordinal or skewed continuous data - MODE: most frequent value, preferred for nominal

Suspending agents

- solid dispersed into liquid - prevents solid particles from settling - shake to resuspend (suspensions) - can be a dispersant or plasticizer ex. sorbitol plasticizer for gelatin capsules ex. ora-plus and ora-sweet slightly acidic to prevent degradation

Confidence intervals

- provides same info about significance as p-value PLUS PRECISION - CI = 1 - a *if alpha is 0.05, study reports 95% CI if alpha is 0.01, study reports 99% CI Difference data (Means) --> based on subtraction, statistically significant if CI range does NOT include O Ratio data (relative risk, odds, hazard) --> based on division, statistically significant if CI does NOT include 1

ADHF clinical syndromes

- pulmonary or systemic volume overload - low CO - acute pulmonary edema

Sterile compounding is most common for hazardous and non-H IV drugs because they must be contaminant free. What other formulations is sterile used?

- radiopharmaceuticals - eye drops - irrigation rinses - pulmonary inhalations

Hazard ratio (HR)

- rate at which unfavorable event occurs in tx group vs. control group within a short period of time - used in survival analysis of death or disease progression - HR = HR in tx group / HR in control group

CCBs in ACS

- recommended in pts with ongoing ischemia who are already taking adequate doses of nitrates and BB OR in patients with C/I to BB - Diltiazem/ Verapamil preferred - continue indefinitely if CI to PO BB persists - should be avoided in acute management of all ACS unless clear symptomatic need or CI to BB

aPTT

- reflects alterations in intrinsic and common pathways of clotting cascade - highly variable test - no therapeutic range and more institution specific

Fluoroquinolones Cipro Levo Moxifloxacin

- renally dose adjust CIPRO and LEVO - Moxiflox hepatically cleared, not good for UTIs - Levo and Moxi = good for CAP with strep pneumo - Cipro is good with HAP (gram-NEG pathogens) - Levo = respiratory, good for UTIs - ADRs: GI, allergies, impaired cartilage development, and CNS toxicity - HIGH C. DIF RISK - achilles tendon rupture --> if taking prednisone chronically and strenuous athletes - place in tx: bone/joint infections, typhoid fever, infectious diarrhea, pneumonia, sinusitis

DIALYSIS in ESRD/ Stage 5 CKD

- required in all patients without transplant

4th gen cephalosporins Cefepime (maxipime) 1-2g q8-12h

- sometimes given as 4hr infusion

Hepatitis B disease and vaccine

- risk is low for travelers who do not engage in high-risk behavior - incubation period ~90 days - chronic disease: liver cancer/ liver disease - recommended to traveler's who: 1) plan to receive medical care 2) volunteer to provide medical work 3) have unprotected sexual encounters w/ new partners 4) piercings or tattoos abroad *if traveler unable to complete full 6 mon series before departure, complete as many doses as possible then complete when they return

Flavorings

- salty and sweet mask bitter - mint and spices mask poor flavor - acids enhance fruit flavors - ex: aspartame, saccharin, suralose, glycerin, dextrose, lactose, mannitol, sorbitol, phenylalanine, stevia, xylitol

Number needed to harm

- same formula as NNT - always round DOWN - number of patients treated for time period before one experiences harm

Clozaril (clozapine) hints

- second gen atypical - no Anticholinergic SE - SE: AGRANULOCYTOSIS (requires WBC monitoring prior to dispensing)

Specific populations recommended to receive HBV vaccine

- sexually active adults not in monogomous relationships - DM age 19-59 - household contact - IV drug use - HIV or chronic liver disease - healthcare workers - ESRD - incarcerated **Heplisav-B is 2 doses 1 month apart, not for pregnancy or children**

LMWH Enoxaparin (Lovenox) PPX = 30mg SC BID or 40mg SC QD TX = 1mg/kg SC BID or 1.5mg/kg SC QD Dalteparin (Fragmin) PPX = 2500 - 5000IU SQ QD TX = 200IU/kg SC QD

- similar to UFH, more specific for factor Xa >>IIa (4:1) - Indications: VTE ppx/ Tx - Monitoring: Anti- Xa (chromogenic assay), measure PEAK activity levels obtained 3-4hrs after SC dose, empiric dose adj made to maintain 0.5-1 U/mL - TIP: not necessary to monitor anticoag effect (maybe in obese) - TIP: No PTT therapeutic range - Also monitor: CBC, platelets, stool for occult blood - CI: active bleeding, thrombocytopenia, spinal hematoma, pts w/ epidurals

ARBs Candesartan (Atacand) 8mg Losartan (Cozaar) 50mg Valsartan (Diovan) 80mg Irbesartan (Avapro) 150mg Telmisartan (Micardis) 40mg Eprosartan (Teveten) 600mg Olmesartan (Benicar) 20mg

- site of action: AT1 receptor in kidney --> this redirects ACE2 to bind to AT2 receptor and that causes vasodilation to lower BP - CI: concurrent use w/ aliskerin in DM, 2nd/3rd trimester - Precautions: angioedema, hyperkalemia, hypotension, renal fxn deterioration - ADRs: angioedema, hyperkalemia, worsening renal function, dizziness, orthostasis - Monitoring: BP, BUN/Scr, serum K, urinalysis for protein

Preservatives

- slow/prevent microorganism growth - commonly have "benz" or "cetyl" or "phenyl/ols" or parabens in the name - ex. eyedrops with multiuse doses have these - do not use in neonates ex. chlorhexidine, povidone iodine, sodium benzoate/benzoic acid, sorbic acid/potassium sorbate, methyl/ethyl/propyl parabens, benzalkonium chloride, EDTA

QUICK START MALARIAL PROPHYLAXIS

- start 1-2 days before travel - avoid in pregnancy - cause NAUSEA 1) Atovaquone + Proguanil (Maldrone) - stop 1 week after travel, take daily - not for breastfeeding or severe renal impairment 2) Doxycycline (Doryx, Vibramycin) - stop 4 weeks after travel, take daily - causes photosensitivity - NOT for <8yo - good for hiking/camping b/c covers Rickettsia/leptospirosis 3) Primaquine (most effective for P. vivax) - stop 1 week after travel, taken daily - NOT for G6PD deficiency (cause hemolytic anemia), breastfeeding

HCV drugs (DAAs) have DDIs with...

- strong inducers of CYP3A4 (carbamazepine, oxcarbazepine, phenobarb, rifampin, rifabutin, SJW) - most increase statin concentrations and increase myopathy risk - insulin and antidiabetic meds = increase risk of hypoglycemia

Polysaccharide vaccines

- sugar molecules taken from outside layer of encapsulated bacteria - Do NOT produce a good immune response in children <2 - PNEUMOVAX23

Muscle conditions from statins

- symmetrical myalgias on legs/back/arms (muscle soreness, tiredness, weakness) --usually w/in 6 wks but can occur anytime - CoQ10 may provide benefit with myalgias/muscle pain - myopathy = muscle weakness + CPK elevations - myositis = muscle inflammation - MAJOR SE: rhabdo = muscle sx + CPK >10,000 + muscle protein in urine (myoglobinuria) --> can lead to acute renal failure Managing myalgias: 1) hold statin, check CPK 2) after 2-4 weeks: rechallenge w/ same or different statin at lower dose 3) if myalgias return, stop statin. 4) once symptoms resolve, use low dose of another statin

Entecavir (Baraclude) nucleoside-tx naive 0.5mg QD 3TC resistant 1mg QD

- take on EMPTY stomach - SE: peripheral edema, pyrexia, ascites, increased LFTs, hematuria, increased SCR, nephrotox - TIP: food decreases AUC by 18-20%, take 2 hrs before or after a meal

ADVANCED STARTS FOR MALARIAL PROPHYLAXIS

- taken weekly - safe in kids and pregnancy - choice depends on resistance 1) Chloroquine - start 1-2 wks before travel, stop 4 wks after, take weekly - patients taking chronic hydroxychloroquine are covered - SE: exacerbation of psoriasis, retinal toxicity/vision changes, blue-gray skin pigmentation - DO NOT use if resistance 2) Mefloquine - start >/= 2 wks b4 travel, stop 4 wks after, take weekly - DO NOT use in underlying psych conditions, seizures, arrhythmias, areas w/ resistance 3) Tafenoquine (Arakoda) - Loading dose 3 days b4 travel, take daily - maintenance: 7 days after LD, take weekly - Terminal: single dose after last maintenance dose - can use for </= 6 months - DO NOT use: G6PD deficiency, pregnancy/BF, underlying psych conditions

Aldosterone Receptor Antagonists in ACS

- to decrease mortality consider adding within first 7 days post-MI in pts: 1) already on ACEi/ARB 2) on a BB 3) LVEF <40% 4) either HF symptoms or DM - aldosterone plays a role in post-MI remodeling - Spironolactone can decrease all cause mortality in pts with stable, severe HF

Testing hypothesis for significance

- to show significance, trial needs to demonstrate that null hypothesis is NOT true (should be rejected) AND alternative hypothesis should be accepted NULL HYPOTHESIS: no statistically significant difference b/w groups, researcher tries to disprove/reject ALTERNATIVE HYPOTHESIS: there IS a statistically significant difference, this is what researcher hopes to prove/accept

Dengue

- transmitted via Aedes aegypti and Aedes albopictus mosquitoes - ~75% of infections asymptomatic - up to 5% can be severe, life-threatening shock, bleeding, or organ failure TX: Supportive care (no specific meds) PPX: dengvaxia and prevent bites! - live attenuated recombinant vaccine - only give to those with previous infection

Malaria

- transmitted via Anopheles mosquito - Dx lifecycle: multiplies in liver --> RBCs destroyed - Sx: shaking, chills, high fever, flu-like - Endemic in: Asia, Latin america, North Africa, Eastern Europe, South Pacific - Most common species: 1) Plasmodium vivax (MOST COMMON) 2) P. falciparum (MOST DEADLY) 3) P. malariae 4) P. ovale - PPX highly recommended and must be started before travel and continued once returned --> can cause NAUSEA --take with food/water or milk

Traveler's Diarrhea

- transmitted via contaminated food/water - most common travel-related illness - highest risk areas: Asia, Middle East, Africa, Mexico, Central and South America - if blood is mixed with stool = dysentery - symptoms begin w/in 6-72hrs if bacterial/viral --> *more than 80% of cases are E.Coli* - *Primary pathogens: E. coli, campylobacter jejuni, shigella, salmonella* - duration: 3-7 days - persistent: >14 days, more often with bacterial and protozoal species

Japanese Encephalitis

- transmitted via mosquitoes - usually asymptomatic --> can become encephalitis w/ rigors, seizures - can progress to coma and/or death - high risk: rural agricultural areas - Best PPX: protection from bites! - Vaccine: IXIARO --> rec for travel to Asia/ parts of Western Pacific, use in >2 months old, extended outdoor exposure or >/=1 month trip

Populations recommended to receive HAV vaccine

- travel to 3rd world countries - close contacts to infected - liver disease - hemophilia - MSM - people who inject drugs - homeless -HIV *HAV can last up to 6 months* Vax recommended for most places EXCEPT canada, western europe, scandinavia, japan, new zealand, Australia

"My patch is not sticking to my body no matter what I try!" Counsel. If fentanyl/ butrans patch? If Catapres?

- unfortunately, most cannot be covered with tape - Fentanyl/ Butrans: can cover with permitted adhesive films (bioclusive/tegaderm) --hold 30 sec when applying - Catapres: comes with it's own adhesive cover

Low risk

- use 1-3 components - longest BUD - 48hrs room temp, 14 days fridge, 45 days in freezer - low non-HD/HD: 12 hrs RT, 12hrs fridge

ACEi/ARBs in ACS

- use in all patients post-MI to: 1) decrease mortality 2) decrease reinfarction 3) prevent development of HF - indications: HF, LV dysfunction and EF<40%, T2DM, CKD - ACEi >>>>ARBs in ACS because more data

Conjugate vaccines

- use sugar molecules from outside layer of bacteria and join the molecules to carrier proteins - Conjugation increases immune response in infants - PREVNAR13, MENACTRA

Severe cases of ascites

- used paracentesis - large volume (removal of >5L) is associated with dramatic fluid shifts - Addition of albumin 6-8g/L removed is recommended to prevent circulatory dysfunction and progression to HRS

Dissolution rate

- used to determine the time it will take for the solute to dissolve - calculated using Fick's First Law of Diffusion

ACT

- used to monitor heparin during procedures w/ high-dose heparin - can be run every few minutes - normal adult 80-130s - adequate heparinization would prolong 200-300s

Altitude Sickness

- usually at 8,000 feet - sx: dizziness, HA, tachycardia, SOB - primary prophylaxis: Acetazolamide (Diamox) 125mg BID started day before - SE: polyuria, taste alteration, dehydration, photosensitivity, urticaria - C/I with sulfa allergy

Herd immunity

- vaccinated people protect unvaccinated and make them less likely to become infected *if vaccination rates drop below 85-95%, VPDs can become a threat again

Influenza

- vaccine given annually to account for ANTIGENIC DRIFT. - influenza A has subtypes based on HEMAGLUTININ and NEURAMINIDASE. - duration: 3-7 days, cough/ malaise for up to 2 weeks - Vaccine specifics: 1) age >6 mon, <8 yrs old never vaccinated: 2 doses 1 mon apart 2) egg allergy: can receive Flublok 3) only for >65 yo: Fluzone high dose, Fluad

INSECT BITE DISEASES...

- vectors = insects who transmit disease - reservoir = any place a dx can live and multiply - MOSQUITOES are #1 insect vector Prevention of bites: 1) stay/sleep in screened or air-conditioned room 2) use bed net 3) cover exposed skin 4) use 20-50% DEET repellant on exposed skin (also good for ticks) 5) use Permethrin on Clothing, bedding, gear (NOT SKIN) 6) other skin mosquito repellants: picaridin, oil of lemon, eucalyptus, or IR3535

Zostavax and Shingrix spacing

- wait >/= 8 weeks after Zostavax (if received) for shingrix 1st dose

Hydrophilic solvents

- water = purified via distillation, deionization, reverse osmosis - bacteriostatic water for sterile preps - alcohols = high miscibility with water, IPA 70% (benzyl alcohol) - glycols = low freezing points, high boiling points, water-soluble (PEG)

Live attenuated vaccines

- weakened - produced by modifying wild virus or bacterium in lab - can grow and produce immunity but NOT ILLNESS - most similar to actual disease and provide strong immune response to vaccine - DO NOT use in immunocompromised and pregnancy

Passive immunity

- when antibodies are provided from someone else 1) Mother --> baby: copy of Ig given shortly before birth, these decrease over time as child's own antibody production increases 2) IVIG: provides already made antibodies, can be used for quick immunity after exposure to antigen (rabies)

Surface tension and surfactants

- when surface tension is HIGH --2 substances will separate (ie. salad dressing) - adding a surfactant (amphiphilic substances) will lower surface tension and keep phases from separating as quickly

Type 1 errors: false-positives

- wrong: alternative was accepted and null rejected - CI = 1 - a (type 1 error) - when alpha is 0.05, p <0.05 = significant with probability of type 1 error <5%. You are 95% confident your results are correct

Ceftolozane/tazobactam (zerbaxa) 1.5g (1g/0.5g) IV q8h w/ CrCl >50 and 18yrs old

-class: cephalosporin + beta-lactamase inhibitor - place in tx: complicated intra-abdominal infections (+ metronidazole), complicated UTI (pyelonephritis) - renal dose adjustments: crcl 30-50 750mg q8h crcl 15-29 375mg q8h crcl<15 and no dialysis not studied ESRD w/ HD 750mg x 1 dose, followed by 150mg q8h - tip: give dose immediately after dialysis on dialysis days - ADRs: N/D, HA, pyrexia, hypersensitivity rxns, C.dif diarrhea - Monitor CrCl daily in pts with changing renal function, adjust dose as needed

Tigecycline (tygacil) 100mg initially, then 50mg q12h IV

-class: glycycline, related to tetracyclines - MOA: interacts with 30S subunit, inhibits protein synthesis --stops bacterial growth - place in therapy: complicated skin and skin structure, complicated intra-abdominal - coverage: broad-spec, gram-POS, gram-NEG, anaerobes, atypicals - NO PSEUDOMONAS COVERAGE - NO RENAL DOSE ADJ or for pts on dialysis - ADRs: N/V, photosensitivity, pancreatitis, antianabolic action - DDIs: warfarin - pregnancy category D

Ceftazidime/ avibactam (Avycaz) 2.5g q8h if Crcl >50

-class: injectable beta-lactam + cephalosporin in a 4:1 ratio with avibactam - place in tx: complicated intra-abdominal (+metronidazole), complicated UTIS (pyelonephritis) - Renal dose adjustments: Crcl 31-50 1.25g q8h 16-30 0.94g q12h 6-15 0.94g q24h <5 0.94g q48h - ADRs: V/ N/C, anxiety, skin and subQ tissue disorders, seizures in patients, C. dif diarrhea - decreased efficacy w/ CrCl 30-50 at baseline - pregnancy category B

5th Gen cephalosporins Ceftaroline fosamil (Teflaro) 600mg IV q12h

-coverage: MRSA (gram-pos), gram-neg - NO PSEUDOMONAS - place in tx: acute bacterial skin and skin structure infections, CAP - renally dose adjust CrCl 30-50 - 400mg IV q12h CrCl <30 - 300mg IV q12h ESRD or HD - 200mg IV q12h - ADRs: N/V/D/C, increased transaminases, hyperkalemia, rash - DDIs: B- lactam allergy, C.dif concerns, pregnancy category B

Vancomycin

-coverage: gram-POS, resistant S. epidermis/ S. aureus, ampcillin-resistant eneterococcus - ADRs: Red Man's syndrome (infusion rxn) TIP: if giving >1g, give over at least 1 hour -nephrotoxicity, ototoxicity, chemical thrombophlebitis, reversible neutropenia and thrombocytopenia - check trough sooner than 5 days if: CNS infection, endocarditis, persistant gram-POS bacteremia, change in SCr >0.5mg/dL - place in tx: serious MRSA infections, S. aureus/enterococci/streptococci in pts intolerant to beta-lactams, C. dif (PO)

ASCITES

-fluid in peritoneal space - can lead to development of spontaneous bacterial peritonitis (SBP) and hepatorenal syndrome (HRS) - most often d/t portal hypertension - TREATMENT: 1) reduce dietary sodium intake to <2g/day 2) avoid Na-retaining meds (NSAIDs) 3) use diuretics to increase fluid loss **fluid restrict ONLY if serum Na <120** **all patients with cirrhosis and ascites should be considered for liver transplant**

ACE Inhibitors Captopril Lisinopril Benazepril Fosinopril (monopril) Ramipril Quinapril Moexipril (Univasc) Trandolapril (Mavik) Perindopril (Aceon) Enalapril

-indications: HTN, HF, CAD, post-MI w/systolic dysfunction, CKD - MOA: prevent ACE1 --> ACE2 conversion which stops vasoconstriction and Na/H20 reabsorption - CI: angioedema, concurrent use of aliskerin in pts w/ DM, 2nd / 3rd trimester - Precautions: mod-severe renal impairment, pts with hx of bilateral renal artery stenosis, drug-induced hyperkalemia - TIP: Titrate ACE dose up to help dilate efferent arteriole and provide kidney benefit - TIP: when first starting ACE there is bump in Cr, if >30% of baseline SCr, there could be damage --use lower dose and try again - ADRs: COUGH, ANGIOEDEMA, hypotension, hyperkalemia - Monitor: BP, BUN/Scr, serum K, urinalysis for protein

Ribavirin 400-600mg BID for HCV

-inhibits RNA and DNA replication - NEVER monotherapy - TIP: tolerability increases with food - *aerosolized used for RSV (Virazole) - DO NOT crush, chew, or open capsule - **When hemoglobin <10, decrease dose (AVOID if HGB <8.5) - C/I: *pregnancy, male partners of pregnant women --AVOID CONCEPTION FOR 6 MONTHS AFTER* --hemoglobinopathies, CrCl <50, autoimmune hepatitis - SE: hemolytic anemia that can worsen CVD (DO NOT USE IN UNSTABLE CARDIAC DX), fatigue, HA, insomnia, N/V/D..... - Monitor: CBC w/ dif, PLTs, electrolytes, LFTs/Billi, HCV-RNA, TSH, monthly pregnancy - DDIs: didanosine (fatal hepatic failure/peripheral neuropathy/ pancreatitis), NRTIs (increase hepatotoxic effects/ lactic acidosis), zidovudine *BOXED WARNING* significant teratogenicity and hemolytic anemia within 4 weeks of tx

Buffers

-pka determines how much of a compound is ionized vs. how much non-ionized when placed into a solution w/ a set pH - ionized = more polar = water soluble - ex. potassium phosphate/metaphosphate, sodium acetate/citrate, HCl/NaOH, potassium phosphate/water

EMOLLIENTS

-softens and soothes the skin

Model for End-Stage Liver Disease (MELD)

0-40 scale higher numbers = greater risk of death within 3 months

The lowest hypotonic solution that should enter the body alone is

0.45%

Heparin-induced thrombocytopenia (HIT)

4 T score: 1) thrombocytopenia 2) Timing around doses of heparin 3) thrombosis 4) lack of alternative causes *if this occurs, switch therapy to fondaparinux or bivalirudin

IM needle size

1" (adults) 22-25 gauge EXCEPTION: Women <130lbs = 5/8" Men >260lbs/ women > 200lbs = 1.5"

Mainstays for chronic maintenance therapy for HF

1) ACEi (ARB if cough intolerable) 2) Beta blocker 3) diuretic (if symptomatic)

Treatment for alcohol-associated liver diseases

1) ALCOHOL CESSATION: - benzodiazepines for alcohol w/d inpatient - anticonvulsants for w/d outpatient 2) Naltrexone (Vivtrol) 3) Acamprasate (Campral) 4) Disulfiram (Antabuse) used to prevent relapse 5) Proper nutrition: Vitamins A, D, B1 (thiamine), folate, pyridoxine, zinc

Vaccine Safety Concerns

1) Autism = no evidence to support, genes play a role in autism 2) Thimerosal = mercury-containing preservative, no evidence it leads to autism esp since it was removed from childhood vaccines and rates of autism continued to rise 3) Gelatin = porcine-derived, for observant Muslisms, Jews, and 7th Day Adventists who fast from pork may have concerns --> most religious leaders have approved the use in vaccines as it's being injected/not ingested

You can make non-sterile hazardous in a C-PEC inside a C-SEC if:

1) C-SEC maintains ISO-7 2) separate sterile and non-sterile C-PECs 1 meter apart 3) particle-generating activity cannot be done at same time as another 4) Negative air pressure in C-PEC protects staff at hood, in C-SEC air exits room

Treatment for Gonorrhea

1) Ceftriaxone 500mg IM single dose OR 2) Cefixime 800mg PO single dose

What are the two most common causes of renal disease?

1) DM 2) hypertension

INOTROPES in ADHF

1) DOPAMINE 5-20mcg/kg/min: HF and hypotension (SBP <90), highest tachycardia risk/high proarrhythmia 2) DOBUTAMINE 2.5-20mcg/kg/min: positive inotrope for acute HF, monitor BP/HR/sx relief/urine output, ADRs: tachycardia, ventricular arrhythmias --> LOWER BP 3) MILRINONE 50mcg/kg IV bolus followed by continuous infusion --renally dose adjust

Traveler's Diarrhea TREATMENT

1) HYDRATION!! (increase fluids and NaCl intake with oral rehydration) 2) if non-severe, non-cholera: no medications are needed 3) *#1 choice: LOPERAMIDE (Immodium) 4mg after 1st stool, 2mg after each subsequent* which can decrease frequency and urgency - (Max dose 16mg/day Rx or 8mg/day OTC) - only use for up to 2 days, consult Dr. if >48hrs w/sx - do NOT use: <2yo (<6 if OTC), or if bloody diarrhea 4) Bismuth Subsalicylate: - salicylate part is antisecretory/antidiarrheal - SE: black tongue/stools, Reye's syndrome in children 5) Mod-Severe: add antibiotics! QUINOLONES, AZITHROMYCIN, RIFAXAMIN) - can shorten duration of diarrhea to <24hrs ***if dysentery: Azithromycin preferred*** *Rifaxamin and Rifamycin NOT used in C. jejuni or Salmonella suspected cases!!

Drugs/Conditions that contribute to or raise LDL/TG

1) INCREASE LDL AND TG - diuretics - efavirenz - steroids - immunosuppressants (cyclosporine) - atypical antipsychotics - protease inhibitors 2) INCREASE LDL ONLY: fish oils (except Vascepa) 3) INCREASE TG ONLY: - IV lipid emulsions - propofol - bile acid sequestrants 4) CONDITIONS THAT INCREASE: - obesity - hypothyroidism - alcoholism - smoking - renal/hepatic dx

PATHOPHYS: Anemia in CKD (anemia of chronic disease)

1) Kidneys produce less erythropoietin (EPO) 2) leads to decreased RBC production in bone marrow 3) anemia Hgb <13g/dL Primary problem: decreased EPO production = decreased RBC stimulation/production

Non-drug treatment for dyslipidemia

1) LIFESTYLE MODIFICATIONS!!! BMI 18.5-24.9 balanced diet consume fish limit saturated fat intake, trans fat aerobic activity 3-4x/week for ~40min *(can lower LDL by 3-6mg/dl)* 2) Red yeast rice --NOT REALLY 3) OTC fish oils can be used to lower TG, but can increase LDL

TREATMENT OPTIONS FOR ADHF

1) LOOP diuretics = reduce fluid volume (start with individualized dose, titrate to response, reduce once controlled 2)vasodilators (Nitroprusside, nitroglycerin, nesiritide (Natrecor) = decrease preload and afterload 3) inotropes (Dopamine, dobutamine, maybe milrinone) = augment contractility, routine use NOT indicated, used for cardiogenic shock, refractory decompensation, bridge to transplant, or palliative care 4) Natriuretic peptide = decrease preload/afterload, decreases fluid volume (fallen out of favor)

Tx-naive patients w/out cirrhosis HCV (all genotypes)

1) Mavyret (Glecaprevir/ pibrentasvir) x 8 weeks TAKE WITH FOOD 2) Epclusa (sofosbuvir/velpatasvir) x 12 weeks

VASODILATORS for ADHF

1) NITROPRUSSIDE 0.1-0.5mcg/kg/min: acute HF for afterload reduction, monitor BP/HR/sx/renal fxn, ADRs hypotension, thiocyanide toxicity --- VERY COSTLY 2) NITROGLYCERIN 5-10mcg/min: symptomatic relief, preload reduction, can be increased by increments of 10-20mcg/min every 5 min 3) nesiritide has no benefit > placebo

Tx for Metabolic Acidosis in CKD - Bicarb replacement

1) Sodium bicarb (Neut) = can cause fluid retention, monitor sodium, use caution in pts w/ HTN or CVD 2) Sodium citrate/citric acid solution (Cytra-2, Oracit, Shohl's solution) = monitor sodium, metabolized to bicarb in liver --may not work in liver dx or liver failure

Diuretics for ascites

1) Spironolactone (monotherapy) 50-100mg (max 400mg) OR 2) Spironolactone 100mg + Furosemide 40mg to maintain K+ *NEVER LOOPS MONOTX*

Simplified MOA of antilipidemia drugs

1) Statins - decrease FORMATION of cholesterol 2) Zetia - decreases FREE cholesterol ABSORPTION 3) Bile acid sequestrants - block enterohepatic recycling

Unsure if a formulation exists? Ask yourself these two questions:

1) What patient populations typically use this drug? 2) Would there be a reason to have this type of formulation for this patient population?

What are 7 helpful things to consider when preparing patient materials?

1) aim for 6th grade reading level 2) focus on key points 3) use non-medical terms or lay language 4) use shorter sentences 5) bullets, not paragraphs 6) PICTURES 7) Flesch-Kincaid Method = MS word that shows readability stats

What two parameters are used to determine severity of / stage kidney disease?

1) albuminuria (amt of albumin in urine) 2) GFR GFR <60 and/or albuminuria >30 indicate CKD

Traveler's Diarrhea Prevention

1) boil it, cook it, peel it, or leave it 2) avoid buffets and ICE 3) eat raw fruit and veg if peeled and/or washed in clean water 4) drink bottled water only 5) *Prophylaxis: bismuth subsalicylate (Pepto-Bismol)* which reduces risk by 50% --> Do NOT use: aspirin allergy, pregnancy, renal insufficiency, gout, or taking anticoags/probenecid/or MTX 6) *IF HIGH RISK/IMMUNOCOMPROMISED: Prophylax with Rifaxamin* (or Azithromycin or rifamycin)

advantages of surfactants

1) by keeping drug dispersed, provides consistent dose of drug delivered 2) helps with gut absorption of lipophilic drugs by forming micelles

Basic recommendations to Travelers

1) carry list of all medical conditions and medications 2) Store Rx meds in original containers 3) pack medications and medical supplies in carry-on 4) the Yellow Book by the CDC has more information on travel health info

Treatment of Hyperkalemia

1) d/c all potassium sources 2) CALCIUM GLUCONATE - stabilize myocardial cells to prevent arrhythmias (if severe) 3) ALBUTEROL - move K+ intracellularly, monitor for chest pain/tachycardia 4) BICARB - use when metabolic acidosis 5) INSULIN - shifts K+ intracellularly 6) GLUCOSE - stimulates insulin secretion, does not shift K on its own CABIG

Treatment for Hepatic encephalopathy

1) decrease dietary ammonia (limit amount of animal protein to 1-1.5g/kg a day 2) LACTULOSE 30-45ml (20-30g) PO Qhr until poop, then same dose 3-4x/day to produce 2-3 poops/day 3) Rifaxamin (xifaxan) 400mg PO q8h x 5-10 days 4) Zinc 220mg BID can also decrease ammonia

How to: Modifying Drug Treatment in Renal Disease

1) drug is renally eliminated = dose reduce or extend dosing interval 2) drug can cause or worsen CKD (nephrotoxic) = D/C 3) drug becomes less effective as kidney function declines (ie. thiazides, nitrofurantoin) = use alternative drug (ie. loops instead) 4) drug in C/I at a threshold of kidney fxn becuase A - drug accumulation is unsafe B - drug can cause more damage (NSAID) C - more harmful effects than usual when kidneys are normal (ie. hyperkalemia with spironolactone)

What are some factors that can decrease the accuracy of CG equation?

1) fraily, elderly - low muscle mass (can overestimate renal function) 2) obesity 3) liver disease 4) pregnancy 5) high muscle mass

Liver disease further classifications made by lab values

1) hepatocellular: increased ALT and AST 2) cholestatic: increased AlkPhos and Total Billi 3) mixed: elevated everything 4) hepatic encephalopathy: increased ammonia 5) jaundice: increase Tbili 6) alcoholic liver dx: increased gamma glutamyl transpeptidase (GGT) and AST>ALT

HEPATITIS B TX

1) interferon alfa --approved as monotherapy 2) NRTIs (tenofovir- TDF or TAF)

Drug therapy for HTN

1) lifestyle mods 2) stage 1: single agent 3) stage 2: combo/dual drug therapy *choice of initial agent depends on degree of BP elevation and presence of other comorbidities / compelling indications

Drug-induced liver injury (DILI)

1) primary tx: stop offending drug!! - hepatotoxic drugs typically D/C'd when LFTs are 3x ULN - ref: livertox.nih.gov

TREATMENT for hyperphosphatemia

1) restrict dietary phosphate (dairy, cola, chocolate, nuts) 2) phosphate binders - taken just before each meal A) aluminum -based = AlOH susp 300-600mg TID (rarely used d/t aluminum toxicity/dialysis dementia) *B) Ca-Based = first line* C) Aluminum and calcium free

Therapeutic goals for ADHF patients

1) reverse acute hemodynamic abnormalities - reverse decompensation - achieve euvolemia or optimal fluid status - optimal CO 2) Alleviate congestive sx - improve oxygenation - reduce subjective symptoms 3) initiate treatment to slow disease progression/ improve survival - reduce los and rate of hospitalization - reduce patient morbidity

Chronic consumption of alcohol results in these biological changes

1) secretion of pro-inflammatory cytokines (TNF-a, IL6) 2) oxidative stress 3) lipid peroxidation 4) acetylaldehyde toxicity --> cause inflammation, apoptosis, fibrosis of hepatocytes If a patient stops drinking, the liver can possibly regenerate to some extent

Counseling points for ACE inhibitors

1) start with very low dose and titrate 2) increase dose only if well tolerated 3) monitor renal function and serum K after 1-2 weeks 4) avoid hypovolemia (concurrent aggressive diuretic use) 5) do not take K+ supplements without approval 6) monitor for angioedema and orthostasis

What are the three functions of cholesterol?

1) structural component of cell walls 2) precursor in hormone synthesis 3) production of bile acid

What does the severity of the liver disease (Child-Turcotte-Pugh score A - C) predict about a patient?

1) survival 2) surgical outcomes 3) risk of complications A - mild - <7 B - moderate - 7-9 C - severe - >10

What are the 4 colligative properties?

1) vapor pressure lowering 2) boiling point elevation (pure water 100C) 3) freezing point depression (pure water 0C) 4) osmotic pressure

Ex: Olanzapine IR tablet and also an *ODT* and *short-acting injectable* and *long-acting injectable*...for what reasons?

1. (ODT) To dissolve quickly and prevent "cheeking" or patients hiding doses then spitting out 2. (short-acting) if a patient is agitated, works really quickly 3. (long-acting) for poor adherence

Certain granules/powders require specific instructions for administration. Describe administration for: 1. Cambia (diclofenac potassium powder) 2. Questran (cholestyramine) 3. Vyvanse 4. Singulair granules

1. Cambia (diclofenac potassium powder) - water 2. Questran (cholestyramine) - 2-6oz water or carbonated liquid 3. Vyvanse - water, yogurt, OJ 4. Singulair granules - 5ml baby formula/breast milk, spoonful applesauce/carrots/rice/ice cream

What are four reasons to use an ODT? Ex: Lamictal, Remeron, Soltab, Zyprexa, Zuplenz film Important counseling point for admin.

1. Dysphagia (stroke, old age, swelling, Parkinson's) 2. Children who can't swallow pills 3. nausea 4. non-adherence (ie. antipsychotics) Peel back foil, do not try to push tablet through foil.

What are 4 reasons for using a nasal spray formulation? Use the following medications as hints: Imitrex Afrin (oxymetazoline) Flonase

1. Faster onset than GI route 2. Useful for acute conditions that should be treated quickly (ie. migraine) 3. Bypass gut absorption (proteins that would be destroyed by gut) 4. Needed to treat localized symptoms (flonase)

These three organizations set criteria to measure quality of care

1. Joint Commission 2. Pharmacy Quality Alliance (PQA) 3. Agency for Healthcare Research and Quality (AHRQ)

When marketing a new OTC product, a manufacturer has two possible pathways to go through for approval.

1. NDA - through FDA CDER and this will then be an FDA-approved drug 2. OTC monograph process - labeling can be on the container itself (ie. vitamins)

4 mechanisms of antimicrobial resistance

1. Porin channels - Ex. imipenem with pseudomonas bacteria 2. Efflux pump - Ex. macrolides, fluoroquinolones, recognized as foreign by bacteria and pumped out of cell 3. Abx degrading enzyme 4. ESBLs - Ex. use carbapenems

Important counseling points for administering eye drops/ointments

1. Shake few times in bottle, invert gels and shake once 2. bend neck back and pull down lower eyelid 3. place drop into pocket 4. press on inner eye to keep med in --hold at least 1 minute (less likely to have side effects) wait 5 minutes between drops wait 5-10 minutes between different medications wait 10 minutes after drops to place in gel

Sublingual and buccal drug formulations that are placed under the tongue are extremely helpful for these 2 reasons... Ex: Edluar/ Intermezzo (Zolpidem), Nitrostat, Subsys/Actiq/Fentora (fentanyl)

1. Super fast onset 2. bypasses 1st pass metabolism and gut degradation to preserve more of the drug

Common drug pairings with incompatibility at Y-sites:

1. Zosyn + acyclovir 2. Ceftriaxone + Calcium-containing soln (lactated's ringer) 3. Heparin + Nitroglycerin/Alteplase/Hydromorphone 4. Calcium + phosphate 5. amphoB + anything 6. sodium bicarb + anything

Ways to prevent hydrolysis reactions

1. adsorbants (desiccants) 2. lyophilized powders (freeze-dried) 3. chelating agents 4. hygroscopic salt (water-absorbing) 5. prodrug formulation (release active drug via hydrolysis - aspirin) 6. control temp (*hydrolysis occurs more rapidly in higher temps*) 7. control pH

CCB Overdose Protocol

1. calcium 2. glucagon 3. vasopressors (dopamine, EPI, NE) 4. high-dose insulin/euglycemia therapy 5. lipid emulsion therapy **cardiac pacing may be required

These 4 characteristics make drugs "hazardous"

1. carcinogenic potential 2. teratogenic potential 3. organ toxicity at low doses 4. genotoxic (damage DNA)

Dosing frequencies for following PATCH medications: 1. Nicoderm/Ritigotine/ Selegiline 2. Testosterone 3. Nitroglycerin 4. Diclofenac 5. Clonidine (catapres) 6. Estradiol (climara)

1. daily 2. nightly 3. on 12-14hrs, then off 10-12hrs 4. twice a day 5. weekly 6. weekly continuous or 3 weeks on/1 wk off

Treatment goals for acute coronary syndromes

1. differentiate b/w events 2. STEMI/NSTEMI: - restore blood flow - prevent death and complications - prevent reocclusion - relief of ischemic chest discomfort 3. unstable angina --> prevent occlusion and MI 4. Long-term outcomes: - control CV risk factor - prevent additional CV events - improvement in quality of life

A patient comes in complaining of a rash on her abdomen where she last put her selegiline patch. Counsel her on what to do.

1. do not put patch on irritated skin 2. alternate sites 3. put hydrocortisone on after patch has been removed

Central access allows for drugs to be quickly diluted and is a way to have secure, long-term vascular access. It is required for:

1. highly concentrated drugs (KCL >20mEq/100ml) 2. long-term antibiotics 3. vesicants (vasopressors, anthracyclines-doxorubicin, vinca alkaloids, digoxin, nafcillin,mannitol, mitomycin, promethazine, foscarnet 4. pH or osmolality not close to blood's (ie. parenteral nutrition) 5. patients with poor peripheral venous access 6. administering high volumes 7. can use faster infusion rates

Long-acting injectables can be helpful for what 2 reasons? Ex: abilify maintena, haldol, invega sustenna, invega trinza (paliperidone), lupron depot (leuprolide), risperdal, vivitrol, zyprexa, relprevv

1. improve adherence (antipsychotics) 2. decreases need for more frequent (painful) injections

Ways to increase dissolution rate

1. larger surface area 2. stir preparation 3. use heat

Ways to prevent REDOX reactions

1. light protection 2. temp control (ie. with fridge) 3. chelating agents (tie up catalyst to prevent rxn - EDTA) 4. antioxidants (inhibit free radicals) 5. control pH (maintain pH with buffer)

There are 2 very important records required for compounding:

1. master formula record = recipe for a compound 2. compounding record = logbook of all products made at pharmacy

Key things to remember for SOAP notes

1. military time 2. measurements in metric 3. Use a systematic approach to complex med regimens

USP emphasizes 3 types of chemical reactions that cause most drug degradation

1. oxidation-reduction 2. hydrolysis 3. photolysis

what are 2 other buffer systems present in the body?

1. phosphate 2. protein

What are the two most important CMS quality control measures based on how expensive and avoidable they are?

1. rate of hospital-acquired infections 2. rate of hospital's readmission rates

What is USP's role in compounding?

1. sets standards for compounding preps (strength, quality, purity of human and animal products) NOT determining which drugs are hazardous

sterility testing can be 1 of 2 tests

1. tryptic soy broth 2. fluid thioglycollate medium

How much extra should you measure out prior to compounding?

10% excess to account for lost drug

The maximum BUD for CSPs made in an isolator in a SCA or a C-SCA is...

12 hours

Diagnosis of acute coronary syndromes

12 lead ECG Biochemical markers/cardiac enzymes (troponin) chem7 baseline CBC and coagulation tests (aPTT/PT/INR)

Oral solutions made with water as the solvent have a max BUD of...and should be refrigerated.

14 days

Pathophys of hyperphosphatemia in CKD

1a) increased PO4 because kidneys cannot clear it 1b) vitamin D is not activated by kidneys which decreases dietary calcium absorption 2) increased release of PTH 3) Ca pulled from bones (bone demineralization and increased fractures) 4) persists in CKD, no corrective homeostasis mechanisms work 5) calcification and cardiovascular disease develop

Daptomycin (cubicin)

2 fda-approved indications: 1) complicated skin infections - 4mg/kg IV q24 2) bacteremia/endocarditis - 6mg/kg IV q24 - class: cyclic lipopeptide antibiotic - coverage: resistant gram-pos - concentration-dependent killing - elimination: glomerular filtration (renal) - ADRs: GI disorders, injection site rxns, HA, insomnia, rash, increased CPK levels (muscle toxicity) - NOT FOR PNEUMONIA

Goal INR for warfarin

2-3 tx ppx VTE, PE 2.3-3.5 mechanical valve, post-MI

which ARBs have been studied for HF?

2nd line if ACEi not tolerated hold off and try ACE first - Candesartan, Losartan, Valsartan

HPV vaccine can be given in individuals up to the age of...

45 yrs old

Sub Q needle size

5/8" 23-25 gauge

Recommended temperature in SEC

68F / 20C or cooler

lifespan of platelets?

7-10 days -- reason you have to hold aspirin 10 days prior to surgery

What is the beyond use date for a medication needed STAT?

<1 hour

Secondary hypertension

<10% of patients, related to renal disease CKD, obstructive sleep apnea, hyperthyroidism, primary aldosteronism, pheochromocytoma

Medicaid

<133% federal poverty level

emulsifiers

>2 liquids that are immiscible (ie. oil and water)

Medicare includes

>65, ESRD, <65 with disability

What are the categories in the ACC/AHA heart failure classification?

A - high risk, but no structural changes B - structural changes, asymptomatic C - Structural changes, prior or current symptoms (most people) D - refractory, requiring specialized interventions

What can happen if long-acting capsules are chewed/crushed?

A fatal dose of the medication can be released at once.

Menactra vs. Menveo

Menactra - given to 9mon-55yrs old Menveo - given to 2 mon-55 years Quadrivalent: includes serogroups A, C, W, Y

Patch locations and dosing frequency for the following drugs: A. Exelon (rivastigmine) B. Butrans C. Lidoderm D. Daytrana (methyphenidate) E. Transderm Scop F. Duragesic G. Xulane (ethinyl estradiol/norelgestromin) H. Oxybutynin I. Vivelle-Dot (estradiol)

A. chest/back (upper/lower)/ upper arm, DAILY B. chest/back/upper arm/sides of chest, WEEKLY C. where pain is, 1-3 patches 12hrs on, 12hrs off D. hip, alternate right and left, DAILY (2hrs before school) E. behind the ear, 4hrs before needed, alternate q72hrs F. q72hrs, if wears off after 48hrs --switch to this G. back/abdomen/butt, WEEKLY X3 - then off 1 week H. abdomen/hip/butt, TWICE WEEKLY I. lower abdomen, TWICE WEEKLY

Elevate or reduce serum concentrations of potassium? A. Corticosteroids B. ACEi/ARBs/aliskerin C. Canagliflozin D. Albuterol E. Loops F. Insulin G. Bactrim H. Immunosuppressives (cyclosporine/ tacrolimus)

A. lower B. elevate C. elevate D. lower E. lower F. lower G. elevate H. elevate

Match up the correct USP number to the topic covered. USP: 797, 795, 800, NF A. Sterile B. hazardous drug handling in healthcare settings C. non-sterile D. monographs for drugs, dosage forms, compounded preps, excipients

A. sterile = 797 B. hazardous drug handling = 800 C. non-sterile = 795 D. monographs = USP-NF

Match the organization to the population/ disease state guidelines A. CHEST guidelines B. ADA guidelines/ AACE C. COPD D/ HIV and CAP guidelines E. ACOG F. GINA G. ACIP H. AAP I. Renal guidelines J. STIs

A. stroke prevention and VTE B. diabetes C. GOLD D. IDSA E. Women's health F. Asthma guidelines G. Immunization recommendations (via CDC) H. Pediatrics I. KDIGO J. CDC

Preferred first line drugs for hypertension

ACE inhibitors ARBs CCBs

9 Drugs/ drug classes that cause hyperkalemia

ACEi ARB Potassium supplements Beta blockers NSAIDs spironolactone/eplerenone salt substitutes (KCl) Bactrim Heparin **usually occurs from using multiple medications in this group at one time

Drugs that increase potassium levels

ACEi / ARBs Aldosterone receptor antagonists (spironolactone) aliskiren canagliflozin drosperinone-containing COCs K- containing IV fluids (parenteral nutrition) K-supps Bactrim transplant meds

advantages and limitations of peripheral access

ADV: simpler, less expensive, bedside insert Limitations: phlebitis, venous thrombosis, interstitial fluid extravasation

This organization has a detailed guidance on implementing USP standards

ASHP

IV Drug Compatibility and Stability Drug references

ASHP's handbook on injectable drug's King's Guide Trissel's (available on Lexi, Micromedex, ClinPharm)

The following products can be sprinkled onto *applesauce* for administration which is helpful for: 1. older adults and children who cannot swallow tablets 2. in hospitals when IV therapy is more expensive or not available

Adderall XR Coreg CR Dexilant (dexlansoprazole) Focalin XR (dexmethylphenidate) Namenda XR Nexium Ritalin LA (methylphenidate) Pancreatic enzymes (Creon, pancrelipase) Depakote sprinkles Kadian (morphine) Xtampza ER Micro-K [or pudding]

What organization recommends who and when to get vaccines?

Advisory committee on immunization practices (ACIP)

Which of the following are included in the package insert? A. Indications B. Black box warnings C. Drug cost D. Major changes in safety E. Dosing administration F. Drug strengths and formulations G. ADRs and DDIs H. Mechanism of Action I. Contraindications J. Specific trial results from clinical trials

All of the above EXCEPT C. Drug cost and off-label indications not on package insert --it is an FDA-approved item part of the drug labeling. only FDA-approved indications included

Which resource would you go to first if doing an in-depth research paper on off-label indications of duloxetine?

American Hospital Formulary Service (AHFS) - can find on Lexicomp - no pill ID, no pricing, no natural products

Drugs that can ONLY go in SALINE (no dextrose)

Ampcillin Daptomycin (cubicin) infliximab ampcillin/sulbactam (unasyn) capsofungin (cancidas) ertapenem (invanz) phenytoin A DIAbetic Can't Eat Pie (no sugar- D5W)

What alpha 2 agonist can you use for hypertension in pregnancy?

Methyldopa

Treatment for Chlamydia

Azithromycin 1 g PO single dose OR Doxycycline 100mg PO BID x 7 days

Lamivudine (Epivir HBV) 100mg QD if co-infected with HIV 150mg BID or 300mg QD

BOXED WARNING: do not use for HIV, lower dose than HIV tx - SE: HA, N/V/D - DDI: bactrim (increased 3TC levels)

BP Equation

BP = CO x PVR BP = (HR x SVR) x PVR

Essential hypertension

BP elevated for unknown reasons

Drugs that can ONLY go in DEXTROSE (no saline)

Bactrim Oxaliplatin AmphoB Synercid (quinupristin/dalfopristin) BOAS will strangle pharmacists who put these in saline

What medications elevate serum magnesium? normal 1.3-2.1 mEq/L

Mg-containing antacids, laxatives in renal impairment

You are on rotation at a women's health clinic for the next month and want to know what would be good resources to have on hand.

Brigg's CDC website Hale's Mother's Milk LactMed (NLM Toxnet) Micromedex Reprotox/ Reprorisk MotherToBaby

Converting celsius to fahrenheit

C = (F-32)/1.8 F = (C x 1.8) + 32

Precipitating factors for HF

CARDIO: ischemia (MI) arrhythmia valvular disease uncontrolled HTN pulmonary embolism progression of disease METABOLIC: infection anemia thyroid disorders renal insufficiency

What organization approves recommendations and publishes them?

CDC publishes in MMWR (morbidity and mortality weekly report) and in PINK BOOK

Patient's are constantly wanting to get involved in their care and take responsibility for their disease states by learning more information on their own (DREAM WORLD). What are some recommendations of sites/resources that have appropriate lay language?

CDC (infectious diseases, vaccines, travel) Drugs.com/ RX List MayoClinic Medline Plus (NLM) - videos, images, etc WebMD - pill ID, DDI checker FDA for Consumers US DHHS SafeMedication through ASHP

Information included in the SUBJECTIVE section of a note:

CHIEF COMPLAINT HPI PMH social history family history allergies med use (RX, otc, vitamins)

Calcium based phosphate binders

Calcium acetate 1,334 mg PO TID Calcium carbonate (TUMS) 500mg TID SE: hypercalcemia, Constipation, nausea Monitor: Ca, PO4, PTH ***hypercalcemia can be problematic w/ concomitant use of Vit D as it increases Calcium absorption ***total daily calcium should be <2000mg from diet/sup

What are the 3 ARBs that can be used for pts with ACS?

Candesartan Valsartan Losartan

This is the only IV Platelet P2Y12 inhibitor

Cangrelor (Kengreal) 30mcg/kg LD, then 4mcg/kg/min continuous

What are the only two ACE inhibitors not activated by liver?

Captopril (Capoten) and Lisinopril (Prinivil, Zestril)

What is the preferred ACE inhibitor to be started in hospital?

Captopril d/t short half life (2 hr) --> once stable and patient is discharged, switch to lisinopril

Ear drop administration technique for adults vs. children Is temperature of the drops important?

Children - pull earlobe down and back Adults - pull earlobe up and back Do not administer cold ear drops --can cause dizziness and discomfort

The following patches need to be removed prior to an MRI to avoid skin burning.

Clonidine Diclofenac (flector) estrogen rotigotine (neupro) Scopolamine testosterone **some vary by manufacturer so check label!

Making Emulsions - 2 methods

Continental Gum method = dry gum, 4 (oil):2 (water):1 (emulsifier) ratio, acacia used; titurated by shaking until a loud cracking sound hear, mix is creamy white English Gum method = wet gum, 4:2:1 ratio but titurate emulsifier and water first to create a mucilage (thick and sticky) then add oil slowly

Cephalosporin Coverage per generation

Coverage: 1st gen: staph, strep, K. pneumoniae, P. mirabilis, E. coli 2nd gen: less gram-pos, MORE GRAM-NEG, anaerobes 3rd gen: enhanced gram NEG, pseudomonas, can penetrate BBB 4th gen (cefepime): enhanced gram-neg, pseudomonas, decent gram-pos

At what CrCl do renal dose adjustments usually begin?

CrCl <60ml/min

Renal dose adjustments/ dosing facts for aminoglycosides

CrCl > 60 = 5mg/kg q24hrs CrCl 30-59 = 5mg/kg q48hrs dose based on actual or adjusted body weight Max dose 500mg ICU patients = 6mg/kg Only check TROUGH everyday to monitor drug accumulation

Cockroft-Gault Equation

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

Donning Order

Dirty side of anteroom: hair and face coverings Line of demarcation: one shoe covering at a time as you step over Clean side of anteroom: handwashing, gown Hand sanitizing --> gloves sanitize gloves (70% IPA)

Vitamin D info

D3 = cholecalciferol --> synthesized in skin from sun D2 = ergocalciferol --> plants, primary dietary source

DKA vs. HHS/HONK

DKA = tx is insulin HONK = tx is IV fluids

HTN Comorbidities selecting dual-acting/dual-purpose medications

DM: ACEi or ARB HF: ACEi + BB Post-MI: BB + ACEi Angina: BB or non-DHP CCB Essential tremor: non-selective BB (inderal) Migraine PPX: BB or CCB Hyperthyroid: BB

There are four locations to find the package insert. List 2

Daily Med Drugs@FDA manufacturer website attached to box/printed

Do not refrigerate these IV drugs

Dexmedetomidine (Precedex) Bactrim Phenytoin (crystallizes) furosemide (crystallizes) metronidazole moxifloxacin enoxaparin APAP (ofirmev) acyclovir (crystallizes) levetiracetam valproate

Key therapeutics information references?

DiPiro's Handbook of Non-Rx Drugs Koda-Kimble's The Merck Manual UpToDate

There are many free resources that can be accessed. These are:

Drug info portal (National Library of Medicine - includes DailyMed, LactMed, Pillbox) Epocrates (Plus offers ICD codes for billing at a fee) Prescriber's Digital reference (drugs, vaccines, biologics) Drugs.com RxList

Your hospitalist calls and asks if a certain antibiotic is available to treat this patient's ESBL infection. You know that this medication has been on shortage before but you are not sure of it's current status. How do you find out?

Drug shortage compendia: - ASHP - FDA - AHFS CDI [CDC for vaccines]

What is the only IV ACE inhibitor?

Enalapril (Vasotec) IV form is active drug enalaprilat

Acute coronary syndromes are diagnosed using these lab biomarkers and tests

ECG (STEMI or NSTEMI) Troponin CK-MB

This is the preferred route for drug delivery

Enteral - GI (if the gut works, use it!)

Approved regimens for HIV and HCV co-infection

Epclusa Harvoni Mavyret

What is the relative potencies of estrogen components?

Estradiol = most potent Estriol = least potent

Mavyret

Glecaprevir/ pibrentasvir *3 tablets daily WITH FOOD* - C/I in mod-severe hepatic impairment or hx of decompensation

What organization approves vaccines?

FDA - based on safety and efficacy data

797, 795, 800 are the minimum acceptable standards for compounding defined by these three organizations

FDA, State Board of Pharmacy, Joint Commission

T/F You must correct calcium every time you get a value for serum calcium.

False, ionized calcium does not need to be corrected. Corrected Ca = Reported Ca + [(4-albumin) x 0.8]

Examples of subcutaneous injections:

Forteo (teriparatide) Imitrex Insulins Lovenox Tymlos (abaloparatide) Etanercept

Treatment of Hyperkalemia - Ways to eliminate K+ from body

Furosemide - 5 min onset, eliminates K in urine, monitor volume status Kayexalate (sodium polystyrene sulfonate) - onset 1 hr, binds K in GI tract, use rectal in emergency Patiromer (PO) - onset ~7hrs, binds K in GI tract Lokelma (sodium zirconium cyclosilicate) (PO) - onset 1 hr, binds K in GI tract Hemodialysis - onset immediately, removes K from blood, used with other tx

Gentamycin Tobramycin Amikacin

G = used for gram-POSITIVE T = lower MIC for pseudomonas (good thing!) A = reserved for complicated infections *peaks/ troughs of tobra/gent much lower than amikacin

7 Common drugs with Filter requirements

Golimumab (simponi) amiodarone lorazepam (not needed with IV push) Phenytoin (not needed with IV push) lipids (1.2 microns) AmphoB (5 microns) taxanes (NOT docetaxel)

The pharmacology "bible"

Goodman and Gilman's Another is Katzung's

Simultaneous administration of vaccine and Ig antibody is recommended for post-exposure prophylaxis of:

HAV HBV rabies tetanus

Most inactivated vaccines for children are given after 2 months. what is the only vaccine given at birth?

HBV

Healthcare professionals recommended vaccines

HBV - if no documentation from childhood Tdap 1 dose if up to date, get every 10 years Varicella - if no hx of vaccination or illness MMR - if no hx of vaccine or blood test showing immunity

Infants/children vaccines and time to get it

HBV - started at birth, 3-doses @ 0, 1-2, 6-18 months prevnar13 - 2 months Dtap - 2 months Hib - 2 months (up to 15 mon) Polio - 2 months rotavirus (live) - 2 months MMR - 12 months varicella - 12 months HAV - 2 doses at 12 months & 6-18 month later **no polysaccharide before age 2

Goal levels for cholesterol components

HDL >40 for men, >50 women Non-HDL <130 LDL <100 (<70 for DM) TG <150 **get lipid panel after 9-12 hour fast**

Relationship of ASCVD and HDL, LDL

HDL protects from ASCVD risk LDL/VLDL contribute to risk

What is the strongest predictor of a person's health status?

HEALTH LITERACY

HTN Agents recommended per indication

HFREF = diuretic + ACE/ARB + BB (stage 4 -aldosterone antagonist) Post MI = BB + ACE/ARB CAD = BB + ACE/ARB (can do CCB or thiazide) DM = ACE/ARB (can go to CCB, thiazide) CKD = ACE or ARB with caution Recurrent stroke ppx = thiazide or thiazide/ACEi

Menactra/Menveo specific recs if not up-to-date

HIV travel military recruits 1yr college

What two drug references are go-to's for drug interactions?

Hansten and Horn's Facts and Comparisons

A 4 year old gets a new prescription for an antibiotic and her mother is asking you if it's appropriately dosed. What references could you refer to check?

Harriet Lane Handbook Red Book by AAP

UFH vs. LMWH

Heparin: - less expensive - more effectively reversed with protamine - more risk of thrombocytopenia - more continuous monitoring - continuous infusion or dosing BID/TID LMWH: - greater anticoag response predictability - more expensive - renally cleared - longer T1/2 - no reversal agent

Viruses that damage the liver

Hepatitis A through E Herpes virus CMV Epstein-Barr Adenoviruses

Sickle Cell Dx/ Asplenia vaccine recommendations

Hib Prevnar13 and Pneumovax23 **before age 65: 1 dose PCSV13, then 2 doses PPSV23 **give PCSV13 1st, then 1st PPSV23 >8 weeks later **2nd PPSV23 5 years later Menactra/Menveo Bexsero/Trumenba (MenB)

HYDRALAZINE/NITRATES in HF

Hydralazine 25-100mg TID Imdur 30-120mg daily together = BiDil preferred in patients who cannot take ACEi d/t renal dysfunction or hyperkalemia

What type of injection is an EpiPen: IM, SubQ, or intra-articular?

IM - thigh admin

What organization makes a "Do Not Crush list"?

ISMP

Tx anemia in CKD - Dialysis

IV Iron given at dialysis center d/t low iron in ESRD

Sterile compounding includes these two main formulations

IV drugs and eye drops

compounded sterile products

IV drugs in bags

neomycin indication and formulation

IV toxicity so not used IV used PO only for hepatic encephalopathy

Dabigatran reversal agent

Idarucizumab (Praxbind) 5g IV (1 dose)

Anaphylactic-reactions to vaccines

IgE mediated occur within minutes of getting vaccine use EpiPen

Pneumovax23 specific recs

In patients 2-64 years old: - 1 dose given: if heart/lung/liver disease, diabetes, AUD, smoker - 2 doses given: if immunocompromised

ISO requirements in compounding areas

Inside sterile hood: 5 SEC: 7 anteroom positive pressure SEC: 8 **ISO6 is not used in pharmacy**

This organization sets standards to air quality determined by number and size of particles per volume of air

International Standards Organization (ISO) lower the particle count, cleaner the air

You are volunteering at a refugee community center in your city to do a brown bag event with individuals. A lot of the medications being taken are from Venezuela, Peru, Colombia and your Spanish is not helping you out today. How can you be sure which medications patients are taking?

International drug names compendia Index Nominum Martindale's USAN (USP Dictionary) Lexicomp

What two equations calculate GFR?

MDRD and CKD-EPI these are used to stage CKD

Friedewald Equation if LDL not reported

LDL = TC - HDL - TG/5 *not used when TG >400 **If not fasting, TG level could be falsely elevated which can cause an incorrect LDL calculation

Diuretics for HF Which is the best class?

Loops best choice!! - NOT proven to improve survival - preferred goal: obtain normal ventricular filling pressures - Physical exam will reveal: JVD, rales, pulmonary edema that indicate diuretics should be used - STAY AT DRY WEIGHT - start with variable dose, titrate to achieve dry weight - reduce dose when fluid retention controlled - teach pt when and how to change dose --> significant weight gain = double dose - TIP: to overcome diuretic resistance, can give metolazone before loop diuretic to keep efferent arteriole dilated - TIP: CHECK MAG and K+ --> hypomag and hypokalemia very common

7 Vaccines given SubQ

MMR MMRV Varicella Zostavax Yellow fever Dengue Smallpox

The Institution for Safe Med Practices (ISMP) has a specific reporting program for ....with a sister organization at the FDA....

Med errors (MERP) ......MedWatch

Heart Failure Pathophysiology

Myocardial injury / fall in LV performance ---> activation of RAAS + SNS (increase in endothelin, AVP, cytokines) ---> remodeling and progressive worsening of LV function PATH 1) myocardial toxicity/ change in gene expression --> morbidity and mortality PATH 2) peripheral vasoconstriction/ sodium and water retention --> HF symptoms

Rolapitant

N/V, similar to aprepitant for cancer-associated N/V

Chemotherapy and hazardous drugs require precise handling and careful precautions. Where can you find information on protocols to stay safe?

NIOSH

This organization determines which drugs are hazardous

NIOSH

Diagnostic testing for HF

NO SINGLE TEST CONFIRMS DIAGNOSIS USE A COMBINATION OF CLINICAL S/SX

Secondary prevention for variceal bleeding

NON-SELECTIVE BB 1) Nadolol (Corgard) 40mg PO QD 2) Propranolol (Inderal) 20mg PO BID *BOXED WARNING* - Do not abruptly d/c, taper gradually over 1-2 weeks to avoid acute tachycardia, HTN, ischemia Monitor: HR and BP MOA: reduce portal pressure by decreasing portal venous inflow by 1) decreased CO 2) decreased splanchnic blood flow by vasoconstriction *titrate to target HR of 55-60 bpm and continue indefinitely

Rivaroxaban dosing

NON-VALV AFIB: 20mg PO QPM w/ dinner CrCl 15-50: 15mg ORTHOPEDIC SURGERY: 10mg PO QD post-op day 1 CrCl <30 = contraindicated VTE TX: 15mg PO BID x 3 weeks, then 20mg QD

Apixaban dosing

NON-VALV AFIB: 5mg PO BID if 2 of 3 of following: 2.5mg BID - >80yo - BW <60kg - Scr >1.5 - strong CYP3A4 or Pgp inhibitor ORTHO KNEE: 2.5mg BID 12 days ORTHO HIP: 2.5mg BID 35 days DVT/ PE TX: 10mg BID x 7 days, then 5mg BID x 6 months (can extend to 12 months if dosing 2.5mg BID)

METHOTREXATE subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

NOT refrig abdomen, thigh dosed: weekly

ENOXAPARIN/ FONDAPARINUX subcutaneous injection Ref/not? Room temp? injection sites? dose frequency?

NOT refrig admin >1 inch from navel Dose: QD or BID

SUMATRIPTAN (IMITREX, ZEMBRACE, SYMTOUCH) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

NOT refrig upper arm, thigh PRN use

Vaccines recommended in diabetes

Pneumovax23 --> 1 dose before age 65 HBV --> 19-59 yrs

These 2 substances act as delivery vehicles AND surfactants, both are amphiphilic

Polyethylene glycol (PEG) and poloxamer (topical gels)

Beyond use dates for commonly compounded products

Non-aqueous (in petrolatum) = 6 months, RT Water-containing oral = 14 days, fridge water-containing topicals (creams/lotions) = 30 days RT

Air Changes per hour (ACPH) required in hazardous drug compounding

Non-sterile : 12 Sterile: 30

NYHA Functional Class for Heart Failure

None - no limitations 1 - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea (shortness of breath). 2 - Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea (shortness of breath). 3 - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea. 4 - Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

Atomoxetine

Norepinephrine reuptake inhibitor - ADHD med

Cinacalcet (Sensipar)

ONLY DIALYSIS PATIENTS - MOA: calcimimetic --> mimics actions of Ca on parathyroid gland --> reduces PTH

OR vs. HR interpretation

OR or HR = 1 --> event rate same, no adv to tx/ no harm in exposure OR or HR > 1 --> event rate in tx group higher than event rate in control **HR = 2 means there are twice as many events (deaths) in treatment group vs. control** OR or HR < 1 --> event rate in tx group << rate in control, treatment is beneficial!

soft lozenges have this as their base

PEG

What medications / disease states lower serum magnesium? normal 1.3-2.1 mEq/L

PPIs, diuretics, amphoB, echinocandins Diarrhea, chronic alcohol use disorder

You get a call from a Dr. about to discharge a patient from the hospital who just had a GI ulcer bleed. The doctor is asking what formulations are available for this patient's maintenance medications because he is afraid oral tablets will be too harsh. What references do you check?

Package inserts Any drug monograph - Lexi, Micromedex, ClinPharm, Facts and Comparisons

This method of drug delivery includes anything outside the gut

Parenteral (IV, IM, SQ, transdermal, intra-articular, intra-thecal

Patients with an allergy should not ingest substances with this sweetener.

Phenylalanine (dangerous for patients with phenylketonuria)

There has been a recent update by the Supreme Court, ruling in favor of pharmacists being recognized and labeled as healthcare providers. What specific reference can you expect to find further information about this? Or if there was a big pharmaceutical merger that just went public?

Pink Sheet - news reports on regulatory, legislative, legal and business information

What is the assessment?

Provider's thought process of possible causes of current situation

What are two tests given to test health literacy?

REALM - rapid estimate of adult literacy in medicine - 1-2 min test, easy to give - not measure of comprehension - measure of pronunciation and word recognition TOFHLA - test of functional health literacy in adults - 20-25min test - assesses reading comprehension and numerical skills (Eng/Spa) - 0-11 score

Pediatric drug references

Red book (AAP) Harriet Lane Handbook Teddy bear book (injectables) Neofax (micromedex)

You are working in the pharmacy basement when a doctor calls and asks roughly how much a medication will cost for a patient as she wants to make sure the patient can afford it before prescribing. What two resources offer drug pricing?

Redbook (Micromedex) Medi-Span Price Rx

HTN Main treatment goal

Reduce morbidity and mortality

ADALIMUMAB (Humira) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

Refrigerated 14 days room temp abdomen, thigh dose: every other week

Glatiramer (copaxone) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

Refrigerated 30 days room temp stomach, arm, hip, thigh dose: daily or 3x/week

"I am concerned that my three month old puppy will find my patch in the garbage. How can I dispose of it safely?"

Remove and fold adhesive sides together Throw away in lidded container OR flush down toilet DEFINITELY WANT TO FLUSH: Duragesic, Butrans, Daytrana

Why should metformin not be used within 48hrs of receiving IV iodinated contrast? Reason patients are taken off metformin while first in the hospital

Renal impairment --> lactic acidosis

Risk and Relative Risk

Risk = probability of an event when intervention is given risk = # with unfavorable event / total # of subjects Relative risk = ratio of risk in exposed group / ratio risk in control group RR = risk in tx group / risk in control group RR = 1 --> no difference in risk RR >1 --> greater risk in Tx group of outcome RR <1 --> treatment reduces risk of outcome/ lower risk w/ tx

Most live vaccines are withheld until a child is 12 months. What is the only live vaccine given before that?

Rotavirus

Common clinical signs of HF

S3 gallop pleural effusion cheyne-stokes respiration tachycardia cardiomegaly edema

What two lab values will increase with renal dysfunction?

SCr BUN

Which diabetes drug class works at the proximal tubule?

SGLT2 inhibitors

Drug contraindicated in CKD when GFR < 30

SGLT2 inhibitors - Canagliflozin, Dapagliflozin, Empagliflozin Metformin (do not start if GFR <45)

What two commonly used medications are dose via GFR instead of the more commonly use CrCl?

SGLT2 inhibitors and Metformin

NSTEMI

ST depression T wave inversion elevated cardiac enzymes

STEMI

ST elevation elevated cardiac enzymes

These are a series of safety documents required by OSHA, providing guidance on PPE, first aid procedures, spill clean-up procedures, compounding cautions for each drug

Safety data sheets (SDS)

What is the primary ID "bible"?

Sanford's

Signs of warfarin overdose/ management

Signs: - blood in stool/urine - excessive menstrual bleeding - bruising - excessive nose bleeds/bleeding gums - persistent oozing from superficial injuries - bleeding from tumor, ulcer, lesion Management: - hold warfarin dose - give vitamin K (reversal agent) - replace clotting factors w/ plasma or plasma concentrates (fresh frozen plasma)

Approved HCV regimens for children >/=12

Sovaldi Harvoni if genotype covered

TX of Vitamin D deficiency/2nd parahyperthyroidism in CKD

Step 1: hyperphosphatemia correction with phosphate binders Step 2: hyperphos tx with vitamin D [Vitamin D deficiency occurs when kidney is unable to hydroxylate vit D to active form 1,25-dihydroxy vit D] Use oral supp of D2 (ergocalciferol) in early CKD (stages 3 or 4)

Tx for Variceal Bleeding

Supportive: 1) Blood volume resuscitation 2) mechanical ventilation 3) correction of coagulopathy 4) attempts to stop bleeding --> A- band ligation B - sclerotherapy 5) meds to vasoconstrict splanchnic (GI) circulation A - Octreotide (Sandostatin) B - Vasopressin 6) LAST LINE: surgery - balloon tamponade or transjugular intrahepatic portosystemic shunt (TIPS) 7) Short-term Abx for 7 days to reduce bacterial infections and mortality A - Ceftriaxone B - quinolone

Drug contraindicated in CKD when CrCl < 30

TAF-containing (Biktarvy, Genvoya, Descovy, Odefsey, Symtuza) NSAIDs Dabigatran/rivaroxaban (DVT/PE only)

Skewed refers to direction of ...

TAIL - more LOW values and outliers are HIGH --data skewed RIGHT (positive) - more HIGH values w/ low outliers --> left skewed (negative)

Drug contraindicated in CKD when CrCl < 50

TDF- containing meds (stribild, complera, atripla, symfi) voriconazole IV (d/t vehicle drug is in)

vanco dose modifications based on...

TROUGH <15 = increase dose to next level 15-20 = leave dose as is >20 = double dosing interval (extend time b/w doses) >25 = HOLD dose, check levels randomly

What is the cheapest formluation?

Tablets

Graduated and non-graduated USP grade droppers

USP criteria is that each drop weighs 45-55mg when held vertically

Recommended substances and compounding ingredients listed in:

USP-NF and Food Chemicals Codex (FCC) *preferably get from a FDA-registered facility if not, get a certificate of analysis that confirms specifications and quality

The osmotic release oral system acts by absorbing water in the gut into a tablet via osmosis to then push drug out through a small manufactured hole. It combines a fast drug delivery system with an ER version in one. What is a good counseling point for this drug formulation to tell patients? Ex: Concerta, Cardura XL, Procardia XL, Asacol HD, Delzicol

There can be a *ghost tablet/capsule shell in your stool!* This is normal, don't worry the medication has been released.

Moxifloxacin (avelox) is cleared hepatically. What site of action would not be appropriate to use this abx in (where renally cleared quinolones work great)?

UTIs --would not reach site of action

Ex. Ondansetron comes in IR tablet, oral solution, ODT, oral film, short-acting injectable...For what reasons?

This med is used for N/V so need to have a formulation that will get and stay in the body. Used for chemo-induced N/V so if a patient has an esophageal tumor needs oral solution, actively vomiting - ODT, etc

Influenza tri vs. quad vaccine

Tri: H1N1, H3N2 and 1 flu B strain Quad: 2 Flu A types and 2 flu B types

A very concerned father rushes into your pharmacy after finding a small white pill on his daughter's bedroom floor. He asks you to identify the medication. How would you go about doing this if you didn't recognize the tablet?

Use the Drug ID tool on Micromedex, Lexicomp, Pillbox, Ident-A-Drug **only source without pill ID = AHFS

Edoxaban dosing

VTE: 60mg QD after 5-10 days of parenteral anticoag if weight <60kg of CrCl <15 : 30mg NONVALV AFIB: 60mg QD if CrCl 15-50: 30mg Avoid if CrCl >95 --> drug is cleared too quickly and not effective

What is required by federal law to be provided to patients with each vaccine?

Vaccine information statements (VIS) - BEFORE the vaccine is given

This class of medications cannot be given intra-thecally as there is a risk of extravasation and necrosis.

Vesicants (vincristine, vinblastine)

ADHF treatment algorithm with cardiac index and PCMP

WARM + DRY = normal WARM + WET = pulmonary congestion (65% of pts) COLD + DRY = hypoperfusion, needs fluids! COLD + WET = cardiogenic shock wet = PCMP > 18 dry = PCMP <18 warm = cardiac index >2.2 cold = cardiac index <2.2

Your community pharmacy is located right by an international airport so you are constantly getting questions about travel and preparations for medications. What resources would be useful to help answer patients' travel questions?

WHO website Yellow book = via CDC, international travel Traveler's health (via CDC)

WHO, WHAT, WHY, HOW of ACE/ ARBs for proteinuria

WHO: all pts with albuminuria WHAT: decreases pressure in glomerulus, decreases albuminuria, CVD protection WHY: prevent disease progression HOW: RAAS inhibition --> efferent arteriole dilation

Sofosbuvir-containing regimens

Warning: SERIOUS BRADYCARDIA when taken with amiodarone *all 1 tablet daily* Epclusa - sofos + velpatasvir Harvoni - sofos + ledipasvir Vosevi - sofos + velpat + voxilaprevir (take with food) - protect from moisture, dispense in original container - avoid or minimize acid-suppressive tx

Al and Ca -Free Phosphate binders 1) Sucroferric oxyhydroxide (Velphoro) chewable 500mg TID 2) Ferric citrate (Auryxia) 2 tabs (420mg) TID

Warnings for ferric citrate: iron absorption, keep away from children SE of both: D, C, discolored black poop Monitoring of both: iron, ferritin, TSAT (ferric citrate), PO4, PTH DDIs sucroferric: do NOT use with levothyroxine, take Doxy 1 hr before DDIs ferric citrate: separate Cipro by 2 hours, take Doxy 1 hour before

class 3 recall

Where a product is not likely to cause adverse effects (ie. inconsistent coloring on tablets)

Do not crush or chew any drug with the following suffixes: (14 answers)

XL XR ER LA SR CR CRT SA TR TD 24 timecaps sprinkles cont

Brand name of capecitabine

Xeloda (xenicol is orlistat - a weight loss prescription med)

With this allergy, it's contraindicated to give the HBV and HPV vaccine

Yeast allergy

Define "myelosuppression"

a reduction in all hematopoietic cells (RBCs, platelets, leukocytes)

Sensitivity refers to

a test with a *true positive* result *if a test is sensitive, it helps a researcher rule out disease when the result is negative.* SNOUT.

Vitamin D analog - Calcitriol (Rocaltrol)

active vitamin D3 for late stage CKD (does not need to be activated) SE: hypercalcemia Others: Paricalcitriol, doxercalciferol = less hypercalcemia

enteric-coating

acid-resistant ex. gelatin, cellulose, bentonite, agar, various gums, starches

Hepatitis B and C

acute and chronic illness cirrhosis of liver, liver failure/cancer infectious blood and body fluids transmission (HCV direct blood into blood) HBV first line: NRTI tenofovir HCV 1st line: DAA combo

How do you stabilize two liquids that are generally immiscible?

add surfactant

Tdap booster is typically given after what age and at what time interval?

after 11yrs old given every 10 years **for deep or dirty wounds, give a dose if >/=5yrs since last dose

Geometric dilution

allows for homogenous mixing, everything is evenly mixed throughout

potassium sparing diuretics and dosing

amiloride (midamor) triamterene (dyrenium) Triamterene/HCTZ (dyazide) capsule 37.5/25mg Triamterene/HCTZ (Maxzide) tablet 37.5/25mg or 75/50mg

Reticulocyte count 0.5-2.5%

amount of immature RBCs being made by bone marrow increase: blood loss decrease: untreated anemia, bone marrow suppression

Green book?

animal drug products

Conditions that cause hypotension

anaphylaxis blood loss infection (sepsis) dehydration

Neutrophils 45-73% Bands 3-5%

assess liklihood of acute infection AKA polymorphonuclear (polys) and segs bands - immature neutrophils released from bone marrow to fight infection (left shift)

When working inside a sterile hood, one must be how far in?

at least 6 inches

Effectiveness of antibiotics and relationship to MEC and MTC

below MEC = no response above MTC = toxic to patient

What preservative in eye drops is it recommended to remove contact lenses prior to administration?

benzalkonium chloride (BAK)

drugs that decrease HR

beta blockers non-dihydropyridines CCBs digoxin clonidine, guanfacine antiarrhythmics opioids sedatives anesthetics neuromuscular blockers acetylcholinesterase inhibitors

purple book

biosimilars, interchangeables, biologics

use a porcelain mortar and pestle for

blending powders

How does a salicylate overdose affect the body's acid-base balance?

body enters alkalosis

Prior to monoclonal antibody injections, it's important to ...and NOT to...

bring to room temp prior to injection and NOT shake

Loops and dosing

bumetanide (bumex) 0.5 - 2mg PO/ IV furosemide (lasix) 20-80mg PO/ IV torsemide (demadex) 2.5-10mg PO/IV ethacrynic acid (edecrin) PO/IV - for patients with sulfonamide allergies, check if pharmacy has it stacked Loop IV:PO Conversion furosemide 40mg: 80mg bumetanide 1mg:1mg torsemide 10mg:10mg *as renal function declines, need to give bigger doses of loop diuretics to work.

Ways to prevent photolysis degradation

light protection bags/vials

Medications that reduce extracellular sodium concentrations (normal 135-145mEq/L)

carbamazepine, oxcarbazepine, SSRIs, diuretics

What buffer system dose the body use to maintain homeostasis pH?

carbonic acid-bicarbonate

Adefovir (Hepsera) 10mg

caution in renal impairment

What 2 cephalosporins cover B. fragilis?

cefoxitin and cefotetan

2nd gen cephalosporins Cefoxitin (mefoxin) 1-2g q6-8h Cefuroxime (Ceftin - acetyl, Zinacef - sodium)

cefoxitin is used for C-sections

This is the common arm vein for peripheral IV access

cephalic vein

Class 2 biological safety cabinet (HD only)

chemo hood for sterile chemo

Noninvasive testing used for HF

chest x-ray assessment of ventricular function ECF (could have afib also) cardiopulmonary testing (stress test)

Chewable formulations like Singulair are helpful when dealing with what specific patient population? Ex: Lamictal CD, Suprax (cefixime), Lanthanum (Fosrenol- phosphate binder activated once chewed to bind in gut)

children who cannot swallow pills

coloring

correlates with flavor ex. D +C red no3, yellow no6, caramel,, ferric oxide (red)

Determine if the following scenarios are safe to use: chlorpromazine - slight yellow dobutamine - slightly pink dopamine - slight yellow nitroprusside - orange norepi - yellow/orange

chlor- potency retained, okay to use dobu- oxidation occurred, potency not lost dop - potency retained, okay to use nitropruss - do not use norepi - normal color, okay to use

DO NOT USE THESE DRUGS WITH COLOR CHANGE

chlorpromazine - darker than slight yellow dacarbazine - pink dopamine - darker than slight yellow epinephrine - pink, then brown isoproterenol - pink or darker morphine- dark nitroprusside - orange / brown / blue (complete dissociation to cyanide) norepi - brown tigecycline- green/black

Common LIVE vaccines

cholera oral typhoid zostavax yellow fever intranasal flu varicella rotavirus MMR *COZY IV RM*

Macrolides

clindamycin azithromycin erythromycin

Proximal tubule

closest to Bowman's capsule much of Na, Cl, Water reabsorbed here back into body

Drug-induced agranulocytosis caused by what drugs?

clozapine, propylthiouracil, methimazole, procainamide, carbamazepine, bactrim, isoniazid

What medications DECREASE serum calcium?

corticosteroids, long-term heparin, loops, bisphosphonates, cinacalcet, topiramate, calcitonin

Eutectic mixture

combination of ingredients that will melt at a lower temperature than either component alone Good: penetrates skin better Bad: could burn if hot plate too high, solid powders alone could melt when mixed if solid at room temp alone

Composite endpoint

combines multiple endpoints - Caution: all endpoints must be similar in magnitude and have SIMILAR meaningful IMPORTANCE to PATIENT. (decrease BP does not equal decrease in MI/stroke) - Use composite value NOT sum of individual endpoints

hypodermic syringes

come with cannulas (needles) attached or separate to screw on

P - value

compared to alpha if alpha is 0.05 and p-value is <0.05, null hypothesis is rejected = statistically significant if alpha 0.05, p-value >0.05, null accepted, study failed to prove difference

most common manufactured tablet

compressed

Collecting duct

connect nephrons in each kidney to ureter involved in water and electrolyte balance *ALDOSTERONE* works here to increase water and sodium, decrease K+ reabsorption (*spironolactone/eplerenone* block this)

Metal spatulas cannot be used with what drugs?

containing metal ions

This is the leading cause of premature chronic disability in the US

coronary heart disease (CHD)

These topicals are form normal to dry skin and contain about 50/50 water-oil.

creams

For what lab values does JCO require a specific institution protocol?

critical lab values and in that protocol, physicians are required to have a time frame to manage them

This anticonvulsant can increase ammonia levels

depakote ER

Hydrophilic-lipophilic balance

determines type of surfactant required to make an emulsion - 0-20 scale surfactants <10 HLB = lipophilic, water-in-oil, for topicals (ex. span 65, glyceryl monostearate) surfactants >10 HLB = hydrophilic (water-soluble), oil-in-water, oral medications (ex. PEG400, Tween 85)

Active immunity

develops when person's own body and immune system produces antibodies to fight infection or in response to vaccine lasts a lifetime (often)

Aprepitant is approved in combination with what 2 medications for CINV?

dexamethasone (corticosteroid) and 5-HT3 antagonist (ondansetron)

Impella device for ADHF --what medication to use at the same time?

dextrose and heparin infusion

white blood cells (leukocytes) 4000-11,000 cells/mm3

diagnose and monitor infection/inflammation increase: acute phase reactant (systemic rxn to inflammation), systemic steroids, CSFs, EPI decrease: clozapine, chemotx, carbamazepine, cephalosporins, immunosuppressants (DMARDS, biologics), procainamide, vancomycin

Case of antimicrobial stewardship: Patient admitted with infection. Empiric therapy is started as cefepime (gram-neg) and vanco (gram-pos). Cultures come back with primary organism being MRSA. How do you proceed?

discontinue cefepime. continue vanco as primary treatment

use a wedgwood mortar and pestle for

dry crystals/hard powders

What is an important counseling point for after an anticoagulant injection (enoxaparin/fondaparinux)?

do not rub the site, it can cause bruising

Lab testing for HF baseline

electrolytes, blood glucose (DM?) BUN/Scr, CBC CPK, troponin (ischemic heart disease?) thyroid function test (cause of HF?) fasting lipid profile urinalysis (rule out infection and nephrotic syndrome) toxicology screen

Two medications form foam and need to be reconstituted by gentle swirling

enbrel and synercid

How should you select your measuring device

equal to or slightly larger than what you need - this is most accurate wider the mouth = less accurate

What is the only carbapenem without pseudomonas coverage?

ertapenem

Tx: Anemia in CKD

erythropoiesis-stimulating agents (ESAs) epoetin alfa (Procrit, Epogen, Retacrit) darbopoetin alfa (Aranesp) = longer lasting - decreases/prevents need for blood transfusions - precautions: increased BP, thrombosis - *only use when Hgb <10* --> discontinue STAT when Hgb >11 as risk of VTE, stroke, MI increases - *only effective if body has adequate iron available to make Hgb* --> assess iron panel and provide supp if needed

What estrogen component has highest risk for breast cancer?

estrone

Acute Decompensated Heart Failure (ADHF)

exacerbation of HF pt has new or worsening s/sx require hospital or ED visit

HTN lifestyle modifications

excess body weight sodium and alcohol intake smoking poor diet overall *lifestyle mods can slow development and progression of HTN, enhance drug efficacy, and decrease CV risk

Activated partial thromboplastin time (aPTT, PTT) 22-38 sec

false increase: oritavancin, telavancin

What drug is indicated for hypoactive sexual desire disorder in women?

filbanserin (addyi)

You must use this type of needle when drawing from an ampule

filter needle

Glomerulus

filtering unit MW <40,000 Da passes through to be excreted in urine afferent arteriole = blood in efferent arteriole = blood out has proteins

Class of antibiotics that targets "bacterial DNA replication - topoisomerase and DNA gyrase"

fluoroquinolones

foaming agent

forms foam by lowering surface tension of water ex. non-sterile compounding use non-foaming simethicone

Nephron

functional unit of kidney, controls concentration of Na and water, regulates blood volume --> regulates BP

Sorbitol sweeteners can produce some unpleasant side effects. There are...

gas, bloating, cramping - especially in IBS

Orange book

generic substitution therapeutic equivalence = AB rating

When would a CMP be helpful?

getting baseline electrolyte labs and liver function tests in one blood draw

Compounding aseptic isolator

glove box containment isolator for HD

chewable lozenges have this as their base

glycerin or gelatin

What equation is used to calculate pH?

henderson-hasselbalch

Mohr Pipette

graduated pipette for compounding

HEPA FILTERS 101

high efficiency particulate air filters > 99.97 efficient in removing particles >/=0.3microns vertical airflow/ biological safety cabinet = HEPA on top horizontal laminar airflow: HEPA at back must be re-certified by specialist every 6 mon or if moved

What type of needle is used to transfer drugs and additives into IV bags?

hypodermic or parenteral syringes

Diuretic electrolyte disturbances

hypokalemia hypomagnesemia hyponatremia hypocalcemia (loops lose) hypercalcemia (thiazides)

Common symptoms of LOW PERFUSION (HF)

hypotension cool extremities narrow pulse pressure sleepiness increase BUN, increase Cr hyponatremia

Glidants or lubricants for powders

improve flowability of the powders ex. mag stearate

Role of PO4 in the body...

in bone metabolism, helps to buffer acid-base balance

ointment mills and grinders decrease particle size which helps to:

increase surface area and rate of drug absorption

Mean corpuscular volume (MCV) 80-100 fL

increase: B12 or folate deficiency decrease: iron deficiency

Red Blood Cells Male: 4.5-5.5 x 10^6 cells/uL Female: 4.1-4.9 x 10^6

increase: ESAs, smoking, polycythemia decrease: chemotx, low production, blood loss, deficiency anemias (B12, folate), hemolytic anemia, sickle cell anemia

Electrolyte imbalances/ changes resulting from renal impairment are:

increased phosphate increased BUN increased Scr

Drugs that increase temperature

inhaled anesthetics (malignant hyperthermia) antipsychotics (neuroleptic malignant syndrome) topiramate

Hemoglobin male: 13.5-18 g/dl female: 12-16

iron-containing protein, carries O2 increase: ESAs decrease: anemias, bleeding (risk with anticoags, antiplatelets, P2Y12 inhibitors, fibrinolytics)

For pharmacists to be reimbursed and established as healthcare providers...

interventions require documentation since quality of care is tied to payment

adsorbants

keep powders dry ex. mag oxide, mag carbonate, kaolin

LVP

large volume parenteral >100ml - often 1 L for fluids

ICD Codes

length of inpatient procedure codes will increase each procedure code from 3-4 digits to 7 alpha-numeric characters

This drug was the first to be FDA-approved using zipdose technology

levetiracetam (Keppra/ Spirtam)

Use a glass mortar and pestle for:

liquids and oily compounds

How is cirrhosis definitively diagnosed? What labs are usually abnormal?

liver biopsy for diagnosis LABS: - increased: AST, ALT, AlkPhos (ALP), total bili, lactate dehydrogenase (LDH), prothrombin time (PT) - decreased: albumin TIP: higher the AST/ALT more active or acute the liver disease TIP: albumin and PT/INR markers of synthetic (production ability) liver function --> likely altered in chronic dx

When does stability become a concern with Zosyn?

longer infusion times and compatibility

drugs with leaching/sorption issues:

lorazepam amiodarone tacrolimus taxanes (paclitaxel) insulin nitroglycerin Leach Absorbs To Take In Nutrients

These topicals are mostly made of water and are good for oily skin.

lotions

Some drug formulations are helpful because they act locally to treat disease/illnesses. One example is Mycelex (clotrimazole) that is dissolved into the oral mucosa. This drug formulation is...

lozenge

Beyond use dates when repackaging

manufacturer's exp. date or 1 year from repackaging date --whichever is earlier

PART B

medical

Which carbapenem can be used for meningitis?

meropenem

When the anion gap is elevated above 5-12 normal range, what is the body's metabolic state?

metabolic acidosis

What is CKD-MBD?

mineral and bone disorder that affects almost all dialysis patients associated with fractures, CVD, increased mortality advanced disease be sure to monitor: PTH, phosphorus, Ca, Vit D

Examples of hazardous drugs

misoprostol chloramphenicol warfarin fluconazole, voriconazole cidovoir, ganciclovir, valganciclovir isotretinoin dronedarone dutasteride, finasteride paroxetine exenatide clobazam, clonazepam divalproex, phenytoin topirmate colchicine spironolactone ribavirin hormones ziprasidone transplant meds

The most common compounded tablet

molded

Prothrombin time (PT) 10-13 sec/ INR <1.2

monitor warfarin Increase: INR w/out warfarin, liver disease false increase: daptomycin, oritavancin, telavancin

Anti xa activity 1.0-2.0 IU/mL

monitors treatment with LMWH obtain a PEAK anti-xa 4hrs after SC LMWH dose monitoring recommended in pregnancy

surfactants for powders

neutralize static charge ex. sodium lauryl sulfate

Filters are used for drugs with risk of particulates, precipitates, crystals, contaminants or entrapped air. What filter is used for most products? What is needed for lipids?

most : 0.22 microns (calcium-phosphate precipitates) lipids: 1.2 microns 1 micron = 1/1000mm

These are the three white blood cells (leukocytes) classified further as granulocytes

neutrophils, basophils, eosinophils

Lanthanum carbonate (Fosrenol) chewable/powder 500mg TID

must CHEW THOROUGHLY!! - C/I: GI obstruction, fecal impaction, ileus - warnings: GI perforation - SE: N/V/D/C, abdominal pain - Monitoring: Ca, PO4, PTH -DDIs: 1) Al, Ca, Mg antacids separate 2 hours 2) Quinolones should be given 1 hr before or 4 hrs before 3) levothyroxine separate by >2hrs

CI and Precision information

narrow = high precision wide = poor precision CI indicates you are 95% confident that the true value of an outcome for the general (or true) population lies somewhere within range of ____% - _____%

Telavancin (vibativ) 10mg/kg IV QD, infusion 60 min

new abx, derivative of vanco - coverage: gram-pos - class: lipoglycopeptide - MOA: inhibits bacterial cell wall synthesis AND disrupts bacterial cell membrane function - place in therapy: complicated skin infections - dose adjust for renal impairment crcl 30-50 = 7.5mg/kg IV q24hrs crcl 10-29 = 10mg/kg IV q48hrs - ADRs: taste disturbances, N/V, foamy urine - false increase in coagulation monitoring tests - no ddi - pregnancy category C - DO NOT NEED TO MONITOR SERUM

Drug contraindicated in CKD when CrCl < 60

nitrofurantoin

Light exposure to this drug causes photo-degradation and increased toxicity

nitroprusside

Unstable angina

non-specific ECG changes normal cardiac enzymes

what are the statistical tests for CONTINUOUS data?

normal distribution = parametric tests skewed distribution = nonparametric 1) T-Tests - parametric test for continuous, normally distributed data A) one-sample T-test = data from single sample group compared with known data from general population B) paired t-test = single sample group used for pre-/post-measurement C) student t-test = when study has 2 independent samples, treatment and control groups = UNPAIRED 2) Analysis of variance (ANOVA) [F-test]: used to test for statistical significance w/ continuous data w/ 3 OR MORE SAMPLES/ groups

Information included in the OBJECTIVE section of a note:

obtained by clinician via observation or analysis vital signs (HR, RR, BP, temp) diagnostic tests lab results med list (if obtained not from patient)

This oil-based topical forms a protective barrier to prevent loss of water from epidermis. They are 80-100% oil, 0-20% water.

occlusive ointment (ex. petroleum jelly, cocoa butter, beeswax, paraffin)

hydrophobic solvents

oils and fats ex. mineral oil, omega-3, omega-6

torsion balances

old balances Class A or Class 3 sensitivity requirement is ~6mg

Streptomycin indication

only TB

drugs that decrease RR

opioids, sedatives

Common symptoms of CONGESTION (HF)

orthopnea paroxysmal nocturnal dyspnea neck vein distention (JVD) ascites, edema hepatic tenderness hepatojugular reflex rales (pulmonary)

Tonicity and osmolality

osmolality = all solutes tonicity = only solutes that do not cross vasculature

PLO gels are best for what type of drug delivery?

p = pluronic poloxamer - 2 joined compounds l = lecithin o = oil TRANSDERMAL

What is a PICC?

peripherally inserted central catheter starts in smaller vein and ends in superior vena cava easier to insert than directly into central vein

Photosensitive Drugs that need to be covered during administration

phytonadione (vit k) epoprastenol (flolan) nitroprusside (nitropress) micafungin (mycamine) doxycycline Protect Every Necessary Med from Daylight

What is a good base for vaginal suppositories and why?

polyethylene glycol - stable chemically - does not melt at body temp - dissolves slowly to provide prolonged release of tx

Drugs with leaching/sorption issues need to be placed in 1 of these 3 containers:

polyolefin polypropylene glass

Main intracellular cation that's normal range is 3.5-5mEq/L?

potassium

Shingrix vaccine is contraindicated in

pregnancy and lactation

Name three examples of at-home tests that can be purchased OTC?

pregnancy, ovulation, HIV, herpes, fecal occult blood, drug tests

coatings

prevent degredation ex. shellac, gelatin, gluten

ACEi and ARBs are used in renal disease to..

prevent progression of disease in patients with CKD, DM and/or hypertension if albuminuria is present

Definition: PEC

primary engineering control sterile hood

IV push

providing quick bolus dose into a vein directly or through catheter

Limulus ameboycte lysate (LAL)

reagent for bacterial endotoxins test

Which of the following are the most accurate temperature methods? A. axiliary B. rectal C. temporal D. Oral

rectal and oral

Communition (2 categories)

reduce particle size by grinding, crushing, milling, vibrating, etc 1. trituration = mix thoroughly, grind into fine powder 2. levigating = same but with liquid agent

What is an advantage to topical locally acting medications like bactroban and voltaren?

reduces incidence of systemic side effects

ETANERCEPT (Enbrel) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

refrigerated 14 days room temp thigh is preferred dose: weekly

ABALOPARATIDE (TYMLOS) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

refrigerated 30 days room temp abdomen dosed daily

GOLIMUMAB (Simponi) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

refrigerated 30 days room temp thigh, lower abdomen, upper arm monthly

CERTOLIZUMAB PEGOL (Cimzia) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

refrigerated 7 days room temp abdomen, thigh dose: every 2-4 weeks

TERIPARATIDE (FORTEO) subcutaneous injection Ref/not? room temp? injection sites? dose frequency?

refrigerated stays in fridge thigh, abdomen dosed daily

Distal convoluted tubule

regulates K, Na, Ca, pH *thiazide diuretics* inhibit Na Cl pump here (cause Ca reabsorption = hypercalcemia)

HIPAA (Health Insurance Portability and Accountability Act)

requires security protections for all individually identifiable health info (PHI) access to info must be limited by PINS and passwords info encrypted so unauthorized users can't see ** all employees and personnel are responsible for security of information.

Alcohol-associated liver disease

risk increased with amount consumed, women >>men 1) FATTY LIVER (steatosis): - chronic alcohol ingestion over long period of time - occurs because fat deposition in hepatocytes - REVERSIBLE - self-limited if drinking stopped or leads to fibrosis and cirrhosis 2) ALCOHOLIC HEPATITIS: acute, poor short-term survival 3) HEPATITIS OR CIRRHOSIS: only 15-20% of all chronic heavy drinkers get here

medium risk

risk increases each time the bag is entered - >3 components - parenteral nutrition, batch meds - 30hrs RT, 9 days fridge, 45 days freezer

Definition: SEC

secondary engineering control buffer room

Hepatitis A

self-limiting acute fecal-oral transmission 1st line- supportive care

Class 1 recall

serious adverse health consequences or death (ie. microbial growth in intrathecal injection)

SVP

small volume parenterals </= 100ml often "piggybacked" off large volume parenterals

which degrades / decomposes faster: solutions or solids?

solutions

Conditions that increase HR

some arrhythmias hyperthyroidism anemia dehydration anxiety, stress, pain hypoglycemia infection drug withdrawal serotonin syndrome

Luer Locks

special screw in tip on syringes not for Oral meds

Platelets: 150,000-450,000/mm3

spontaneous bleeding can occur when patients <20,000/ mm3 - decrease: heparin, LMWHs, fondaparinux, linezolid, valproic acid Antibody testing is used to confirm diagnosis of HIT. If ELISA test is positive, a positive SRA is confirmatory

Alpha

standard for significance max permissible error margin threshold for rejecting null hypothesis a = 5% or 0.05

Due to bacterial resistance, penicillins no longer cover this organism

staphylococcus

Drugs that increase heart rate

stimulants decongestants beta agonists theophylline anticholinergics bupropion antipsychotics excess caffeine, nicotine, illicit drug use vasodilators (nitrates, hydralazine, dihydropyridine CCBs)

Drugs/ conditions that increase RR

stimulants conditions: asthma, copd anxiety, stress ketoacidosis pnuemonia

Three central insertion central IV access

superior vena cava jugular vein femoral vein

Hard lozenges have this as their base

sucrose or syrup

class 2 recall

the product may cause temporary but reversible adverse effects, or in which there is little likelihood of serious adverse effects

Ex. Granisetron comes in a patch (Sancuso)...why?

this med used for chemo-induced nausea/vomiting can put patch on before chemo to prevent and will help for up to 7 days

Why is it important for IV solutions to match the body's pH 7.35-7.45, tonicity of 0.9%NaCl and osmolality of ~285mOsm/L?

to prevent fluid transfer across biological semipermeable membranes and RBCs/other cells from shrinking by fluid leaving cells to dilute incoming fluids or bursting by absorbing incoming fluids to dilute

G6PD 5-14 units/g

used to see if hemolytic anemia (result will be low) drugs that should have this tested prior to use: - dapsone, nitrofurantoin, pegloticase, primaquine, rasburicase, sulfonamides

high risk

uses non-sterile ingredients end product needs to be sterilized ex. code blue, stat meds - 24hrs RT, 3 days fridge, 45 days freezer

If a patient has "IV access", this has been inserted for fluid and drug delivery

venous catheter

What three populations should you not use CG equation in?

very young children ESRD unstable renal function where SCr is fluctuating

Syringes are good for what type of medication?

viscous ie. glycerin, mineral oil

What medications increase serum calcium ?

vitamin D, thiazides

What is the color tag for medical oxygen?

yellow

Tare

zero out on balance

The highest acceptable osmolality for peripheral IV administration

~900mOsm/L (>900 should be given via central line because it can be quickly diluted)