Pharmacology Exam 5

Front 1

Immunologic mechanisms are required to elim viable organisms during the treatment with ____antimicrobial agenets?

Back 1

Bacteriostatic*

So DON'T GIVE to IMS!!

Front 2

Broad spectrum antibiotics are more likely to cause ____?

Back 2

Superinfection: eradicating organisms of normal flora

Front 3

What are the 3 PK/PD parameters that predict efficacy?

Back 3

Time above the MIC

Dose/Peak above the MIC

24h AUC/amt of drug

Front 4

If a bacterial MIC is above the serum concentration, what is this called?

Back 4

RESISTANCE to the drug

Front 5

Five patients populations that should be treated w/prophylaxic Abx?

Back 5

IMS
Cancer
Surgical (bowel)
bacterial endocarditis
bacterial meningitis

Front 6

What has a thinner cell wall, OUTER MEMBRANE, and cytoplasmic membrane?

Back 6

GM NEGATIVE!

(gm pos is thick cell wall and cyto memb)

Front 7

CELL WALL INHIB:

B lactams MOA, MOR

Back 7

block prod cell wall by binding PBP's and inhib transpeptidation

**NO CROSS LINKING WALL**

bacteriocidal b/c bad wall causes lysis

MOR = inactiv b lactam ring, mutate PBP/pores, more efflux *high cross resistance for all Blactams*

**Blactams have most ALLERGIC rxns

Front 8

Most widely used, short half, poor absorb, widely distib (not CNS), against gram pos cocci

Back 8

Penicillins*


Pen G (IV) most strep, enterococc, pneumococi

Pen V (PO) minor inf, poos avail so 4x day!

Front 9

Antistaphococcal penicillin?

Back 9

Methicillin
tx serious b-lactamase prod staph inf

*extended spectrums: amox/(ampill + aminogly tx serious) against gm - can penetrate outer memb to tx UTI's/ear/resp

Front 10

Antipseudomonal penicillin?

Back 10

ticarcillin, piperacillin***
(pseuodomonas aeruginosa and other gm - rods and gm pos)

Front 11

Cephalosporin (Cell wall and B lactam) Generations

Back 11

1) gm + LEXIN, FAZOLIN
2) gm +, some - FOXITIN, FUROXIME
3) gm -, some + FTRIAXONE, FTAZIDIME
4) gm - FEPIME

Front 12

CEFAZOLIN is the DOC for....

Back 12

surgical prophylaxis, and alt to penicill

FIRST GEN CEPH against gm +
also cephalexin
no BBB cross
skin infect

Front 13

CEFUOXIME can treat...

Back 13

community acquired pnuemonia
*only 2nd gen ceph that crosses BBB!

Front 14

CEFTRIAXONE are less susceptible to...

Back 14

B lacatamases and can cross BBB
3rd gen, expanded gm - coverage

can lead to c.diff infect

Front 15

CEFEPIME is more resistant to...

Back 15

hydrolysis by beta lactamases.
4th gen **Has gm + coverage of 1st gen and gm - coverage of 3rd gen

Front 16

Two bad side effects of cephalosporins?

Back 16

HYPOPROTHROMBINEMIA
(treat w/vitamin K)

DISULFIRAM-LIKE RXN
(if take w/etoh)

Front 17

Most common MOR of B lactam abx?

Back 17

BETA LACTAMASES

**clavulanic acid (Beta Lactamase Inhibitors) increases effectiveness of B lactams to counteract!**

Front 18

What is a monobactam (blactam) that penicillin allergic patients can tolerate?

Back 18

AZTREONAM against gm -

(se: bone marrow supp induced leuko)

Front 19

Example of carbapenems (blactam)?

Back 19

imipenem/meropenum IV tx nosocom

*inactiv by renal dyhydropep so admin an inhib of that enz ( cilastatin)

Front 20

Inhib cell wall synth by binding D-ala-D-ala term of peptidogly backbone (non-blactam)?

Back 20

VANCOMYCIN
against gm +
R* vanco, R* all

OTOTOXICITY (vestib + coch)
RED MAN SYNDROME (thrombophlebitis)

Front 21

Inhib early stage of cell wall form (non blactam)? And treats UTI's.

Back 21

FOSFOMYCIN
gm+, -
synergizes w/blact, aminogly, fluoroq,

R* by decreased transport of drug in

Front 22

Inhib cell wall synth by blocking lipid carrier molecule that transfers peptidoglyc molecules subunits to wall (non blactam)?

Back 22

BACITRACIN
gm +

Tx topically b/c too nephrotoxic**

Front 23

Inhib cell wall b/c structural analog of D-ala and inhib incorp into peptidoglycan (non blactam)? And treats multidrug resist TB?

Back 23

CYCLOSERINE

CNS side eff

Front 24

30S:
Cause misreading of genetic code, so wrong tRNA binds and wrong aa inserted?

Back 24

AMINOGLYCOSIDES
-amikacin (-)
-gentamicin
-neomycin (creams w/bacitr)
-streptomycin (plague, tb)
-tobramycin (-)

*combine w/blactams to get past cell wall
*IV/IM only
*SE = RENAL, VESTIB OTO, NEUROMUSC (MS)

Front 25

30S:
Block tRNA from binding to A site

*DOC

Back 25

TETRACYCLINES
-tetracycline
-doxycycline
-minocycline

**DOC for Rocky mtn spotted fever (RICKETTSIA) & Lyme dis (BORRELIA)

*broad spectrum bacteriostatic, R* increasing: CONJUGATION EFFLUX
*have selective toxicity b/c actively pumped in bact cells

*SE: discolor teeth-no kids/preg, phototoxicity, block cation absorp, cause SJ if past expire date

Front 26

50S:
Block PEPTIDYL TRANSFERASE that catalyzes the formation of peptide bond between peptide and aa in A site? "Translocation Step"?

Back 26

MACROLIDES
-azithromycin
-erythromycin
-clarithromycin
-telithromycin

*Tx: upper and lower RESPIRATORY inf
*SE: few, but long QT, inhib P450s (drug interactions)
*MOR: efflux, decrease binding 50S

Front 27

50S:
BLOCK PEPTIDYL TRANSFERASE?
COMPLEX MOA?
BINDS P SITE, BLOCKS tRNA BIND?

Back 27

OTHERS

-CHLORAMPHENICOL (BBB- tx meningitis & typhoid 3rdW, but bone marr supp)
SE: Kidney inactiv by gluc, newborns low = GRAY BABY, also IDIO APLASTIC ANEMIA

-STREPTOGRAMINS: syner/cidal, tx VRE, $$$$$

-OXAZOLIDINES: tx VRE, nocosom, complic skin
*SE: block MAO (Ser synd)

Front 28

MOR for prot synth inhib (aminoglycosides)?

Back 28

ADENYLATE, ACETYLATE, PO4

-mut rib prot
-decreased transport aminoglyc

Front 29

Folic A inhib?

Back 29

Sulfonamides: inhib Dihydropteroate synthase (no dihydrofolate)
Tx: UTI's resp, otitis (diaz burn, tamide trachoma//conjunct)
SE: stones, A/N/V, hypersens, anemia, TOXIC ENCEPH NEWB

Trimethoprim: inhib DHFR (no tetrahydrofolic acid)

MOR* dyhydrop synth/DHFR mut, porins, PABA

Front 30

Combine TMP-SMX treats:

Back 30

bacterial prostatis/vaginitis
(wk base conc in acidic tiss)

enterobacter: UTI's (both cleared from kidney quickly-sim half lives), otitis media, bronchitis

Front 31

DNA Gyrase/topoisom Inhib

(bacteriostat, but if can't repair enz = becomes bacteriocidal)

Back 31

Quinolones: Nalidixic A

Fluorquinolones: Norfluox,
cipro-2nd gen most -
levo- 3rd gen most +

SE: GI, cations, CNS, phototox
Cxx: kids/preg
MOR: no plasmid yet! (gyrase/topo, porins efflux)

Front 32

"OTHER ABX"

Back 32

METRONIDAZOLE:

RIFAMPIN

NITROFURANTOIN

MUPIROCIN:

DAPTOMYCIN:

POLYMIXIN B:

Front 33

Trich vag (protozoal and anaerobic) drug activated by pyruv-ferred oxidored and free rad disrupts DNA****************

other abx

Back 33

metronidazole

Front 34

Inhib growth gm +/-, but fast R*, inhib DNA dep RNA* POL, Red Orange problem.
Tx: Tb and meningococcal

other abx

Back 34

rifampin

Front 35

Prophlyx UTI, b/c quickly excrete from kidneys
Tx: -! (some +) and cause GI prob

other abx

Back 35

nitrofurantoin

Front 36

Isoleucine analog competes w/bact isoleuc tRNA synthetase, blocks form tRNA
Tx: staph/strep incld MRSA

other abx

Back 36

mupirocin

Front 37

Cyclic lipopeptie disrupts plasma memb fxn in gm +, use to tx MRSA/VRSA/VRE $$

other abx

Back 37

daptomycin

Front 38

Creams and ointments, interacts w/PO4 comp of cell memb (-), but nephrotoxic

other abx

Back 38

polymyxin

Front 39

Does Giardiasis invade tissues?

Back 39

NO
adheres to lumen

(amebiasis does invade)

Front 40

What is the only parasitic STD?

Back 40

Trichomoniasis!

Front 41

How does Metronidazole work and what parasites does it treat?

Back 41

attacks parasitic pyruvate ferredox oxiored (PFOR) which converts pyruvate to acetyl coA

Treats Giardia-90% success, Entamoeba #1 DOC for sxs dis and extraintest (not cyst), Trichomonas *sex partners tx too! (anaerobic lumen reduced by PFOR, so active sops of electrons and forms reactive intermediates that disrupt DNA)

**avoid alcohol "disulfram like eff"

*R rare!

Front 42

Iodoquinol treats?

Back 42

Cyst Form! amebiasis in lumen intest b/c drug is poorly absorbed

not eff against trophoz in tiss

SE: OPTIC atrophy and perm vision loss and annoying 20D tx after metron

Front 43

Paromomycin treats?

Back 43

eliminates trophoz and cyst of e.hist/amebiasis in Lumen intest (not tiss forms)

Only 7D tx, less toxic than iodoquinol

Front 44

3 opportunitisic infections of AIDS

Back 44

Crytosporidium parvum-water D, healthy self limit, 1/4 AIDS D
Tx: nitazoxanide stops PFOR (anaer E metab) also tx giard 1+yrs

Pneumocystis jirovecii: TMP-SMX

Toxoplasma gondii-Pyrimethamine sulfadiazine

Front 45

Antiparasitic drugs (2) that also inhib bact?

Back 45

Folate synth inhib: sulfonamides (PABA analog stop dihyropteroate synthase) and diaminopyrimidines (inhib DHFR at lower conc than us)

Toxo: sulfon
Pnem Jirovecii TMP-SMX-high dose active, low maint, R* dev

SE: sulf rash, folic A def

Front 46

Choloquine, quinine, mefloquine tx which form of Malaria?

Primaquine?

Back 46

-Merozoite/RBC

-Liver hypnozoite, dormant

Front 47

Cholorquine mech?

Back 47

interfere with ability to detoxify compounds from degrade of hemoglobin-HIGH R* (P.falc)

-elim all rbc stages of plasmodium

Front 48

Quinine?

Back 48

localiz to dig vac, interfere w/hemoglob degrade/detox. Rbc all plasmodium, R* Asia

MOST TOXIC: cinch, hypoglyc (rel insulin and already low gluc)

Front 49

Mefloquine?

Back 49

proph/tx (deriv of quin)

Some neuropsych rxns in .5% pts receiving mefloquine for tx

Front 50

Primaquine?

Back 50

ONLY drug active against LIVER/HYPNOZOITE forms of p.vivax/ovale

SE: TOXIC! RBC lysis if G6PD def

*req host metab and interferes w/mitochondiral e-transport/pyrimidine synth

Front 51

Malarone?

Back 51

combination of atovaquone/proguanil
-atov lipoph, proguan inhib DHFR

tx/prophlyx p.falc (newer antimalarial)

Front 52

Doxycylcline?

Back 52

disrupt prot synth plasmodium, cheap!

SE: photosensitivity (no kids/preg)

Front 53

Thiabendazole?

Back 53

Most absorbed antehelmintic/benzimidazole

*Tx stronglyoidiasis (int/tiss) and topical cut larval migrans***

most toxic (GI, CNS). Cxx preg/under 2yrs

Front 54

Albendazole/Mebendazole?

Back 54

Ascariasis, pinworm, hookworm, whipworm

Front 55

Ivermectin?

Back 55

hyperpol muscle cells = paralysis, tx intest/extraintest

#1 choice strongyloid!

Front 56

Pyrantel Pamoate?

Back 56

choling nic rec for depol musc block

#1 choice pinworms! Whole house!

poor absorb/intest tx only

Front 57

Praziquantel?

Back 57

Tapeworm(Cest) and Fluke (trema)

-increase ca+ perm/depol, allows imm detect and paralysis trema

-flukes 3x/one day
-tape 1x
-cysticercosis 2wks

-rxn to dying worms

Front 58

Transmission of myco tub bacilli is mainly by:

Back 58

Respiratory* (inhale, mult wks, implant high O2)
overcrowd and poor hygiene
-Asia, Africa, Latin America

MOST INF ARE REACTIV/2nd

fever, dyspnea, cough/blood, tb+sputum/xray

Front 59

What does M. tuberculosis look like?

Back 59

GRAM POS ACID FAST BACILLI IN SPUTUM, L OR V SHAPED IN SMALL CHAINS/MASSES

*caseous lesions form

Front 60

Five first lines against TB?

Back 60

INH, Rifampin, ethambutol, pyrazinamide, sterptomycin

Front 61

DOC TB?

Back 61

Isoniazid (INH)

-inhib biosynth mycolic A, selective b/c activ by myco catalase perox
-increase membrance pores-death

-increase R* with mut KATG
-tx for two yrs! multidrug (mono-prophx)

-wide distrib(cns), 1/3 pop SLOW acetyl so periph NEURITIS, B6 inact AND SLE

***if fast acetyl? Drug induced HEPATITIS (monitor ALT/AST)

Front 62

Ethambutol?

Back 62

Tx M. tub or MAC if R* Rx or HIV

Color vision change

only take in combo

Front 63

Pyrazinamide?

Back 63

Tx active m.tub (activated/converted by myco to pyrazinoic A) inhib bact growth by lowering amb intracell pH and cant synth FA with FA synth1

part of oral multi drug tx +INH/rifamp

Front 64

Rifampin?

Back 64

bact specific, inhib dna dep RNA POL in bact, not us

all myco and prophx AIDS/INR R*

LFT q 2-4 weeks, red orange fluids
combine INH/pyraz but $3 tab!

Front 65

Rifabutin?

Back 65

Primary tx MAC

tx HIV, prophyx, in comb

Front 66

Aminoglycosides-streptomycin?

2nd line

(amikacin, kanamycin, capreomycin, viomycin)

Back 66

first Rx TB, IV/IM

less effective, pts w/R* to first line

oto/nephrotoxic

Front 67

M. leprae tx?

Back 67

Dapsone (mult drug mo-yrs): bacteriostatic inhib of folic A synth, also n-acteyl metab (SLE)

Clofazimine: bacteriostatic m.lep
AND MAC (anti-infl and pro imm)
tx: eyrth nod lep!!! lipophill 70D

Thalidomide: Terato! tx eyrth nod

Front 68

Biological basis of cancer is the accum of _____

Therefore, Cancer is a _____disease

Back 68

Mutations in your DNA

GENETIC

Front 69

ONCOGENES (kras)

TUM SUPPRESSORS (p53)

need min of 4 mut in same cell, over a long time (adds growth advantage)

200 genes identified out of 25,000 as onco or tum supp

cancer cells lose ability to stop and repair damage before completing DNA synth or mitosis

Back 69

Genes that activate when mutated are...

Genes that become inactive when mutated are....

Front 70

Chemotherapeutics work on ____ORDER KINETICS?

Back 70

FIRST!

each tx kills a constant PERCENTAGE of cells, not #

-so combine therapies to maximize 99.9-->99.99999

Front 71

Most common rate limiting toxic effect (limits how much drug dose you can give)?

Back 71

BONE MARROW SUPPRESSION


(also stomach lining-n/v, and hair loss)

Front 72

Class 1, 2, 3 agents?

Back 72

1:effects on prolif/non-prolif, kill all

2: kill cells in ONE spec cell cycle phase

3: Cell cycle NON SPECIFIC killers
**Most drugs here***

Front 73

Methotrexate?

Back 73

DNA synth inhib: FOLATE ANTAG
"S phase Class 2"

-INHIB DHFR
-MOST MYELSUPPRESSION!!!!!!!!!!

Front 74

Thioguaninine?

Back 74

DNA synth inhib: Purine ANTAG
"S phase Class 2"

-deriv of purine guanine, req activ to inhib PRPP

Front 75

5FU?

Back 75

DNA synth inhib: Pyrimidine ANTAG
"S phase Class 2"

-activ by THF to inhib thymidylate synthase/affects transrip

-HAND FOOT SYN, CARDIAC SXS AND CHEST PAINS *MUST WARN

Front 76

Hydroxyurea?

Back 76

DNA synth inhib: Ribonuctide Red Inhib
"S phase Class 2"

Front 77

Mechlorethamine, hydrochloride, cyclophosphamide?

Camustine?

Cisplatin?**

Busulfan?

Back 77

DNA alkating: Nitrogen Mustards
"Class 3"-all crosslink DNA!!

-nitrogen mustards

-nitrosourea

-platinum**WORST nephrotoxic

-other

Front 78

TOPOtecan?

Back 78

Topoisomerase 1 inhib

block topo 1 from religating DNA after single/dbl breaks

Front 79

eTOPOside?

Back 79

Topoisomerase 2 inhib

allows topo 2 to break dbd strand, but prevent unwind and religate

Front 80

Doxorubicin?

Back 80

DNA intercalating Drugs (commonly used)

-flat planar molec fit in DNA grooves
-convert to free rads = breaks
-inhib topo 2

Front 81

Vincristine?

Back 81

Microtubule POLYM inhib

*nephrotoxic (NOT bone marr supp)
-so give more of two drugs with two different toxicities

Front 82

Paclitaxel?

Back 82

Microtubule DEPOLYM inhib

*neurotoxic/hypersensitivity
(dexameth + antihist to prevent)

Front 83

Rituximab?
Trastuzumab?
bevacizumab?
panitumumab?

Back 83

Targeted Therapies: Monoclonal AB!

ritu: antiCD20
trast: anti HER2/neu
beva: anti VEGF
panitumumab: anti EGF

Targets surface or in blood
NOT IN CELL OR CROSS BBB!
-opsiniz, inhib fxn, block gf rec

Front 84

Imantinib?

Erlotinib?

Back 84

Tyr Kin Inhib: BCR-ABL

Tyr Kin Inhib: EGF rec

Front 85

Bortezimid?

Back 85

Protease inhib: Inhib 26S proteasome used to degrade ubiq proteins

Front 86

How do growth factor drugs help in tx chemo?

Back 86

help with adverse sxs

Front 87

Tamoxifen?

Fluatimde?

Back 87

block estrog bind to ER
SE: menopausal, masculiniz

block test bind to androg rec
SE: feminiz, hot flash, gynecomast, nipple pain, galactorrhea, impotence

Front 88

Acquired Resistance to Antivirals involves?

Back 88

VIRAL THYMIDINE KINASE (TK)

HSV/VZV use TK to PO4 host nucleosides needed for viral replic

Virus can make TK mutants to drug can work on it!!!

Front 89

Amantadine?

Back 89

TX PARKINSON'S!!! block Ach rec (nic) CAREFUL (avoid CNS toxic)

**influenza A ONLY!* recover fast
prophylx CV, old, kids over 10

VIRAL BLOCK ACIDIFIC! binds M2 membrane protein/H+channel to inhib fusion viral/endosome membranes, inhib later release!

Front 90

Oseltamivir?

Back 90

inhib neuraminidase influenza A and B!
-H binds sialic acid and clumps/no rel

-reduce length illness if within 48hrs
-tx sxs pts, high risk cx (young, old, BMI, preg, chronic, IMS)

Front 91

Acyclovir?

Back 91

Prodrug activ by herpes TK
*viral TK binds 200x more to drug than host TK will

*High dose/freq tx HSV/VZV

tirphosphorylated form incorp in viral DNA POL and DNA chain term

Front 92

Ganciclovir?

Back 92

sim acyclovir but LOWER SAFETY!
-prodrug activ by viral PO4
-SE: BLOOD DYSCR (granulo,thrombo), TERATO/EMBRYOTOXIC

Tx HSV/CMV (retinitis in IMS)
-lifelong to prevent relapse

Front 93

famiciclovir?

valacyclovir?

Back 93

-HSV tx if R* acyclovir (other TK dep)

-herpes zoster/genital, but CXX IMS b/c TTP-HUS SYNDROME!!!!!!!!!!

Front 94

cidofovir?

foscarnet?

Back 94

-ONLY approved tx for CMV retinitis pts with AIDS
************IV 1/wk******************

-tx cmv, hsv1/2, vzv, cmv retinitis AIDS acycl R*
******************IV only************

Front 95

idoxuridine?

Back 95

first gen antivirals, nuc analogs thymidine/adenosine

prodrugs activ by Thy/Adeno Kinases and act as antimetab that stop DNA synth and POL

TX TOPICAL HSV/HPV

Front 96

Ribarvarin?

Back 96

prodrug PO4, disrupts purine metab, CAUSING DEF GTP, and RNA/DNA synth is markedly inhib

TX: RSV nasal aerosol (inf, kids, adults*) HCV in combine w/IFNa

SE: HEMOLYTIC ANEMIA MOST COMMON, TERATO, Nasal Cx (apnea, peumothorax, CV, resp fxn)

Front 97

IFN ALPHA?

Back 97

-family of inducible proteins, prod by B/T, macros, fibros in response to viruses and cytokines

Disrupt MANY points in viral life cycle

Tx: Hep B, C
SE: flu-like (fever, fatige, myalgia, HA, chills)

Front 98

NRTI

(nucleoside analogs irrev inhib RT)
*early terminate viral DNA chain synth

AFFECT NAIVE

Back 98

abacavir
didanosine
emtricitabine
lamivudine
tenofovir
zidovudine

Front 99

NNRTI

Non nucleoside

AFFECT NAIVE

Back 99

efavirenz
nevirapine

Front 100

Protease Inhib (antiretroviral tx)

AFFECT ALREADY INFECTED

Back 100

ATAZANAVIR
FOSAMPRENAVIR
LOPINAVIR
RITONAVIR

****se: N, V, D***

Front 101

Standard combine therapy for HIV/AIDS?

Back 101

1 Protease inhib
2 nucleoside analags

***NNRTI BASED: 1NNRTI + 2 NRTI

***PI BASED: 1-2PI + 2 NRTI

Front 102

Fusion entry inhib?

Back 102

Enfuvirtide targets GP 41!!!

tx: R* pts to other drugs

Front 103

Cyclosporine A?

Tacrolimus?

Back 103

Calcineurin Inhib!

CSA: inhib prod IL2/prolif of Tcell, acute and ongoing txp
CXX-->tacro, OKT3, ATGAM, GRAPEFRUIT, TROPICAL (nephro/hypoMG)

Tacro: same moa, prophylx txp
CXX: Grapefruit (nephrotx, hypergly!***********************)

Front 104

Azathriprine?

Mycophenolate?

Back 104

Antimetab (antiprolif)

Aza: prodrug to 6Mp, inhib T prolif
****inactiv by xanth oxid CXX allopurinol/gout tx************
-SE: blood related, preg D, LFTs

MMF: produg to MPA, inhib B/T, given prophyx txp (combine decreases SE = decrease dose needed of other drugs!)
CXX: preg C

Front 105

ATGAM?

OKT3?

Basiliximab?

Daclizumab?

Sirulimus?

Back 105

Antilymphocytes

ATGAM: horse, reduce T fast (anaphlyx use antihist)

OKT3: mouse mono Ab, reduce T, but marked susc inf, hypersens, CRS

Basilix: chim Ab IL2 rec antag, no stim T, prophylx txp and combine

daclizumab: chim Ab IL2 antag, hypersens

Sirolimus: Easter bacteria, suppress cytokines (ILL2, 4, 15) driven T prolif by inhib G1-S of cell cycle!!!!!!!!!!!!!!!

Front 106

Corticosteroids as IMS?

Back 106

Poweful!
Prednisone
MethylPrednisolone

*Non spec, broad IMS for acute reject by T prolif through inhib IL1 & 6 in macros, AND reduce inflam eicos IL2, 4, IFgamma

MARKED HYPERGLY, HYPOKAL*CV

Front 107

Inf and Noninf cx of post TPX?

Back 107

Inf: CMV, HSV, PCP
-CMV 90% IMS tx pts
***CMV immGLOB***Ab to reduce CMV


NonInf: high BP, lipds, GI ulcer, liver dis, lymphoma
***Give Mg+ if low b/c tacro/CSA increase excr in renal tub (sxs may be neuromusc, CV, metab)