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161 Cards in this Set
- Front
- Back
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What is the initial treatment choice for Chronic Bronchitis/COPD?
(Group A patient, low risk, less symptoms) |
First Choice: -Short-acting anticholinergic (ipratroprium bromide [Atrovent]) PRN or -Can use a SA beta2-agonist (albuterol [Ventolin HFA, Proventil HFA]) PRN
Second Choice: -Add a short-acting beta2-agonist (albuterol) to SA anticholinergic, or both drugs combined (Combivent) or -Can use a LA anticholinergic (tiotropium [Spiriva]) or -Can use a LA beta2-agonist (salmeterol [Serevent])
Alternative Choice: Theophylline (can be used alone or in combination w/ meds from 1st and 2nd choice categories)
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If symptoms of chronic bronchitis/COPD are not better w/ treatment with ipratroprium bromide (Atrovent), what is the next step?
(Group B patient, low risk, more symptoms) |
First Choice: -use a LA anticholinergic (tiotropium [Spiriva]) or -use a LA beta2-agonist (salmeterol [Serevent])
*Provide consistent bronchodilation now
Second Choice: -use a LA anticholinergic (tiotropium [Spiriva]) AND a LA beta2-agonist (salmeterol [Serevent])
Alternative Choice: -SA beta2-agonist (albuterol [Ventolin HFA, Proventil HFA]) AND/OR Short-acting anticholinergic (ipratroprium bromide [Atrovent])
-Theophylline (d not use w/ roflumilast) |
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What is the treatment for a COPD patient who is high risk, but has less symptoms (Group C patient)? |
First choice: -ICS (fluticasone, budesonide) + LA beta2-agonist (salmeterol, formoterol [Advair, Symbicort]) or -LA anticholinergic (tiotropium [Spiriva])
Second choice: same as Group B -use a LA anticholinergic (tiotropium [Spiriva]) AND a LA beta2-agonist (salmeterol [Serevent])
Alternative Choice: -PDE-4 inhibitor (roflumilast [Daliresp] (Severe and very severe COPD assoc. w/ chronic bronchitis who have a h/o exacerbations. Not an bronchodilator and not for relief of acute bronchospasm)
-SA beta2-agonist (albuterol [Ventolin HFA, Proventil HFA]) AND/OR Short-acting anticholinergic (ipratroprium bromide [Atrovent])
-Theophylline (d not use w/ roflumilast) |
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What is the treatment for a COPD patient who is high risk, and has more symptoms (Group D patient)? |
First choice: same as group C -ICS (fluticasone, budesonide) + LA beta2-agonist (salmeterol, formoterol [Advair, Symbicort]) or -LA anticholinergic (tiotropium [Spiriva]) |
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What is the difference between ICS and LABA? |
ICS - give control of airway inflammation
LABA - give control of bronchospams; get rid of sxs plus minimize risk of flare |
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What is the definition of a COPD exacerbation? |
An exacerbation of COPD is an event in the natural course of the disease characterized by a change in the patient's baseline dyspnea, cough, and/or sputum beyond day-to-day variability sufficient to warrant a change in management |
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How should a COPD exacerbation be treated? |
Use of bronchodilators -short-acting beta2-agonist and/or anticholinergic (ipratropium, tiotropium bromide) as needed
-Consider adding long-acting bronchodilator (salmeterol, formoterol, tiotropium bromide) if patient not current using one
If baseline FEV1 < 50% of predicted, add a systemic corticosteroid such as prednsione 40 mg/d x 5-10 days
*Recent study supports shorter (5 day) course equally effective w/ fewer adverse effects than longer (10 day) course.
-Consider adding inhaled corticosteroid if not currently using
-Encourage smoking cessation |
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When is antimicrobial therapy indicated in COPD exacerbation? |
Likely indicated in the presence of 3 cardinal symptoms: increased dyspnea, increased sputum volume, and increased sputum purulence, though evidence varies |
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For a more severe COPD exacerbation/acute exacerbation of chronic bronchits, what antibiotics should be used if antimicrobial therapy is deemed necessary? |
-Amoxicillin-Clavulanate -Cephalosporin -Azithromycin -Clarithromycin -Fluoroquinolone w/ activity against DRSP (moxifloxacin, levofloxacin)
*Both amox-clav and cephalosporins cover gram-positive organisms and are stable in the presence of beta-lactamase
*Clarithromycin - Potent CYP 450 inhibitor |
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What antibiotic class is potentially associated w/ QT prolongation and increased risk of CV death during use, particularly in those w/ highest CV risk? |
-Macrolides |
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What antibiotic class is associated w/ potential tendon rupture, particularly when taken w/ systemic corticosteroids? |
-Respiratory Fluoroquinolones (moxifloxacin, levofloxacin) |
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Which is consistent w/ the diagnosis of all stages of COPD?
A) FEV1:FVC ratio < 0.70 B) Dyspnea on exertion C) Hypoxemia D. Orthopnea |
A) FEV1:FVC < 0.70 is the correct answer
DOE and hypoxemia are sometimes later findings in COPD
Orthopnea suggests HF and is rarely respiratory in origin. Most of the time it is cardiac in origin |
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What is the first-line treatment for Strep throat?
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-Penicillin V potassium (Penicillin VK) PO QID |
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What is the first-line treatment for Otitis media?
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-Amoxicillin BID to TID |
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What is the first-line treatment for Syphilis?
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-Benzathine penicillin G IM |
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What is the first-line treatment for Cellulitis not caused by MRSA, impetigo and erysipelas? |
-Dicloxacillin PO QID |
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What other antibiotics can be used to treat infections mainly caused by gram-positive bacteria such as cellulitis (not caused by MRSA) and mastitis?
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-First-generation cephalosporins such as cephalexin (Keflex) PO QID; cefadroxil, cefazolin
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What is the first-line treatment for Gonorrheal infections?
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-Rocephin (ceftriaxone) IM |
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What is the first-line treatment for Chlamydial infections (i.e., cervicitis, PID, atypical pneumonia [C. pneumoniae]) and other atypical bacterial infections such as non-gonococcal urethritis?
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-Doxycycline |
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What is the first-line treatment for atypical pneumonia?
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-Macrolide: azithromycin (Z-Pack) 500 mg on day 1, then 250 mg daily from day 2 to day 5
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What is the first-line treatment for uncomplicated HTN and Heart failure?
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-Thiazide diuretics |
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-Either trimethoprim-sulfamethoxazole (Bactrim BID) or clindamycin TID. Treat for at least 5-10 days |
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For mild acne not responding to OTCs, what is the next step for treatment?
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-Trial of prescription topicals (erythromycin and benzoyl peroxide [Benzamycin], tretinoin [Retin A]) |
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If a patient with moderate acne is not responding to topical prescriptions after 2-3 months, what treatment can be considered?
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-Consider adding tetracycline (best to take on an empty stomach
**Photosensitivity reaction from minimal sunlight exposure; esophageal ulcerations – swallow w/ full glass of water; throw away expired tetracycline pills, they degenerate and may cause neuropathy or Fanconi syndrome) |
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What is the first-line treatment for Moderate-severe acne and Rosacea?
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-Tetracycline |
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What is the first line treatment for Raynaud’s Phenomenon?
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-Calcium channel blockers |
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What are the likely causative pathogens in Community Acquired Bacterial Pneumonia? |
-No. 1: Streptococcus pneumoniae (gram-positive)
-Moraxella cararrhalis (gram-negative), Staphylococcus aureus (gram-positive), others
Cystic fibrosis: No. 1 bacteria is Pseudomonas aeruginosa (gram-negative)
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Pneumonia caused by H. influenza is predominantly a disease of what group of people?
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-Tobacco users |
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What is the most commonly reported S/E of calcium channel blockers?
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-Constipation
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Which type of CCB can worsen proteinuria in patients w/ nephropathy?
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-Dihydropine calcium channel blockers (i.e., Amlodipine, Nifedipine) |
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-Non-dihydropines (i.e., diltiazem, verapamil) cause less tachycardia due to their having minimal vasodilatory effects compared to dihydropines
-Sometimes when dihydropine CCBs are used to treat angina, the vasodilation and hypotension can lead to reflex tachycardia, which can be detrimental for patients w/ ischemic sxs b/c of the resulting increase in myocardial oxygen demand |
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When starting a patient on a CCB, what education would you provide to limit risk of toxicity from increased drug levels?
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-Avoid grapefruit juice – toxicity results as it will increase drug level |
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-HTN |
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What are the indications for use of an ACEI or ARB?
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-HTN, DM (renal), CKD |
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What black box warning has the FDA given ACEIs and ARBs? |
-Discontinue ACEIs and ARBs immediately if pregnant. These meds can cause death/injury to the developing fetus during the 2nd and 3rd trimesters
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What is the first-line drug for HTN in diabetics and for patients w/ proteinuric CKD? |
-ACEI or ARB |
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-ACEI cough occurs w/in the first few months of treatment. It is dry and hacking (w/o other sxs of URI)
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What are possible S/E’s of ACEIs and ARBs? |
-Angioedema and anaphylactoid reactions; ACEI cough; Hyperkalemia |
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-HTN |
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In what patients are Beta-Blockers contraindicated? |
-Patients with Asthma, COPD, Chronic bronchitis, Emphysema, Bradycardia, and AV-block (2nd- to 3rd-degree heart block) |
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What are S/Es of beta-blockers?
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-Bronchospasm |
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What are possible adverse effects of Aldosterone Antagonists (i.e., spironolactone)?
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-Galactorrhea, gynecomastia and hyperkalemia |
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What black box warning has the FDA given to Aldosterone Antagonists? |
-Increases risk of both benign and malignant tumors |
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What are treatment indications for Aldosterone Antagonists (i.e., spironolactone, eplerenone)?
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-Hirsuitism
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-Decrease or discontinue use of potassium supplements when starting therapy w/ AA’s |
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-Monitor serum potassium concentrations and renal function w//in 3 days and 1 week after the initiation or dose titration of an aldosterone antagonist; thereafter, potassium concentrations and renal function should be monitored monthly for the first 2 months and then every 3 months |
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What black box warning has the FDA issued regarding use of potassium sparing diuretics (i.e., Triamterene, Amiloride)?
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-Hyperkalemias, which can be fatal. Higher risk w/ renal impairment, DM, elderly, severely ill |
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What are the indications for use of a potassium-sparing diuretic (i.e., Triamterene, Amiloride)?
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-HTN |
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What are indications for use of thiazide diuretics (e.g., HCTZ, Chlorthalidone, Indapamide)?
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-Uncomplicated HTN (first-line), Heart Failure (first-line), Edema
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-Hyperglycemia (careful w/ diabetics) |
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What is an alternative treatment option to thiazide diuretics for patients w/ serious sulfa allergies? |
-Potassium-sparing diuretics such as triamterene and amiloride are the alternative options for these patients |
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-Rate control in Atrial fibrillation and A-Flutter (not first-line; beta-blockers and/or CCBs are a better first choice)
*Not a first-line drug for these conditions, used when conditions not controlled by other medications |
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What are signs and symptoms of digoxin overdose?
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-Initial sxs are gastrointestinal (anorexia, N/V, abdominal pain) |
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What are contraindications to use of Digoxin?
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-Digoxin should not be used in patients with ventricular fibrillation (a heart rhythm disorder of the ventricles, or lower chambers of the heart that allow blood to flow out of the heart)
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-Severe toxicity is treated w/ digoxin-binding antibodies (Digibind) |
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-Order a digoxin level, electrolytes (Potassium, magnesium, calcium), creatinine, and serial EKGs |
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What are considered critical Potassium values (adult to elderly)?
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-Critical: < 2.5 or > 6.5 mEq/L -Normal: 3.5 to 5.0 mEq/L |
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For what conditions is warfarin sodium (Coumadin), an anticoagulant, indicated? |
-Prevention/Treatment of thrombosis/thromboembolism
*Warfarin has been used occasionally after MIs, but is far less effective at preventing new thromboses in coronary arteries. Prevention of clotting in arteries is usually undertaken w/ antiplatelet drugs, which act by a different mechanism from warfarin (which normally has no effect on platelet function)
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For Atrial Fibrillation, what is the target INR while on warfarin?
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-2.0-3.0 |
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What is the most severe, common adverse affect of clindamycin, a lincosamide?
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-Clostridium difficile-associated diarrhea (the most frequent cause of pseudomembranous colitis)
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How is Clostridium difficile-associated diarrhea (CDIFF) treated?
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-Metronidazole (Flagyl) PO TID x 10-14 days |
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What are safety issues/considerations with Statins?
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-Do not mix w/ grapefruit juice
-Rhabdomyolysis (destruction of muscle cells) which in turn can result in life-threatening kidney injury
-CK levels go up (clinical measure of muscle damage and widely used to monitor the safe use of statins)
-Statins may increase risk of diabetes by 9%, with higher doses appearing to have larger effect
-Drug-induced hepatitis or rhabdomyolysis higher if mixed w/ azole antifungals -High-dose Zocor (80 mg) has the highest risk of rhabdomyolysis (muscle pain/tenderness) |
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-Jaw pain (jaw necrosis) |
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What instructions would you give to a patient who you are starting on a bisphosphonate? |
-Take alone upon waking w/ an 8 oz. glass of water (not juice) before breakfast |
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What are safety issues/considerations with use of Atypical antipsychotics (risperidone, olanzapine, quetiapine)?
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-High risk of weight gain, metabolic syndrome, and type 2 DM |
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-TSH, lipids, weight/BMI |
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What is the black box warning on Atypical antipsychotics (risperidone, olanzapine, quetiapine)?
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-Higher mortality in elderly patients |
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What black box warning has been given to Thiazolidinediones (TZDs) (e.g., pioglitazone [Actos])?
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-Cause or exacerbate CHF in some patients |
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-Stop if the patient c/o dyspnea, weight gain, cough (heart failure) |
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The use of which of the following antibiotics is most likely to reduce effectiveness of combined oral contraceptives? |
-The correct answer is D. Rifampin. Rifampicin is an effective liver enzyme-inducer, promoting the upregulation of hepatic cytochrome P450 enzymes (such asCYP2C9 and CYP3A4), increasing the rate of metabolism of many other drugs that are cleared by the liver through these enzymes. As a consequence, rifampicin can cause a range of adverse reactions when taken concurrently with other drugs
-The first 3 are more likely to cause spotting while taking the abx w/ COC, but effectiveness of COC is not decreased
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What is required for diagnosis of COPD? |
-Spirometry is required for diagnosis.
*When possible use age-related values to avoid over-diagnosis in elders
-An FEV1:FVC < 0.70 post-bronchodilator confirms persistent airflow limitation/COPD |
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How is classification of severity in COPD determined? |
Classification of severity is determined by FEV1 |
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What is the gold standard for diagnosing CAP? |
-Chest X-ray is the gold standard for diagnosing CAP. Repeat w/in 6 weeks to document clearing
-CXR shows lobar consolidation in classic bacterial pneumonia |
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What are objective findings in CAP? |
-Auscultation: rhonchi, crackles and wheezing
-Percussion: dullness over affected lobe
-Tactile fremitus and egophany: Increased
-Abnormal whispered pectoriloquy (whispered words louder) |
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What is the preferred treatment for CAP in a person with no comorbidities (previously healthy and no risk factors for DRSP)? |
Macrolides are preferred -Clarithromycin (Biaxin) BID x 10 days -Azithromycin (Z-Pack) daily x 5 days -Erythromycin QID x 10 days
or
Tetracyclines -Doxycycline 100 mg BID x 10 days |
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What is the preferred treatment for CAP in a person with comorbidity (i.e., alcoholism, CHF, chronic heart, lung, liver, or kidney disease, antibiotics previous 3 months, DM, splenectomy/asplenia, etc...)? |
Respiratory fluoroquinolone as ONE drug therapy -Levofloxacin [Levaquin] 750 mg qd x 5 days -Gatifloxacin [Tequin] 400 mg qd x 10 days -Moxifloxacin [Avelox] 400 mg qd x 10 days
OR
Beta-Lactam PLUS a macrolide -Preferred: high dose of amox (e.g., 1-3g TID) OR amox-clav (Augmentin) BID x 10-14 days PLUS a macrolide
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What are objective findings in atypical pneumonia (aka "Walking Pneumonia")? |
Auscultation: wheezing and diffuse crackles/rales
Nose: clear mucus (may have rhinitis of clear mucus)
Throat: Erythematous w/o pus or exudate
CXR: Diffuse interstitial infiltrates (up to 20% have pleural effusion)
CBC: may have normal results |
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How is acute bronchitis treated? |
Typically viral, treatment is symptomatic |
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What is the most infectious stage of pertussis? |
-The most infectious period is early in the disease (Catarrhal stage) up to 21 days of cough (if not treated w/ appropriate abx)
2nd and 3rd stages are, respectively, paroxysmal and convalescent) |
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What labs are indicated for suspected pertussis? |
-Nasopharyngeal swab for culture and polymerase chain reaction (PCR)
-Pertussis antibodies by ELISA (enzyme-linked immunnosorbent assay)
-CBC: Elevated WBCs and marked lymphocytosis (up to 80% lymphocytes in WBC differential)
-CXR should be negative. If positive, due to secondary bacterial infection |
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What is first line treatment in Pertussis? |
Macrolides: -Azithromycin (Z-Pack) 500 mg on day 1, then 250 mg daily from day 2 to day 5 -Clarithromycin (Biaxin) BID x 7 days |
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What is the recommended first-time treatment for COPD? |
Start with an anticholinergic, ipratropium bromide (Atrovent).
Add LA Beta2-agonist (salmeterol [Serevent]) if poorly controlled |
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What is the treatment for Reactivated or Active TB disease (infectious)? |
-Reportable disease
-All active TB pts should be tested for HIV infection
-Initial regimen for suspected TB before C&S results are available. Use 4 drugs: -isonicotinylhydrazine (Isoniazid) (INH) 300 mg qd -rifampin, ethambutal, pyrazidamide 3x/week
-Narrow down number of meds after C&S results reveal most effective drugs |
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How are recent PPD converters and latent TB infections treated? |
-Assess for signs and sxs of TB (cough, nightsweats, weight loss)
-Order CXR (make sure no hilar cavitations and mediastinal adenopathy
-HIV-negative: Isoniazid (INH) 300 mg/day x 9 months -HIV-positive: Isoniazid (INH) 300 mg/day for at least 12 months
-Check baseline liver function tests and monitor
*Generally, preventative treatment for latent TB infections is encouraged for those < 35 y/o. After age 35, much higher risk of liver damage from INH chemoprophylaxis |
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What is the first step in the treatment of asthma? |
For mild, intermittent asthma (FEV1/PEF > 80% predicted & symptoms < 2 days/week)
-Albuterol (Ventolin) metered-dose inhaler PRN |
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If albuterol is not sufficient to control asthma symptoms, and patient is having symptoms > 2 days per week, what is the next step in treatment? |
Step 2 in the treatment of asthma - Mild persistent Asthma (FEV1/PEF > 80% of predicted & Symptoms > 2 days/week)
-Albuterol (Ventolin) metered-dose inhaler PRN
PLUS
-Low-dose Inhaled corticosteroid (ICS) is preferred
Alternative: Cromolyn, montelukast, nedocromil, or theophylline |
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What is the 3rd step in the treatment of asthma, when the patient is experiencing daily symptoms? |
Step 3 - moderate persistent asthma (FEV1 or PEF 60%-80% of predicited & daily symptoms
-Albuterol (Ventolin) metered-dose inhaler PRN
PLUS
Alternative: low-dose ICS plus leukotriene inhibitor (Singulair), theophylline, or zileuton |
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What is the preferred treatment for a patient with severe persistent asthma and symptoms most of the day? |
Step 4 - severe persistent asthma (FEV/PEF < 60% predicted & symptoms most of the day)
-Albuterol (Ventolin) metered-dose inhaler PRN
PLUS
-High dose ICS plus long-acting B2-agonist (LABA) plus oral steroid (prednisone) daily is the preferred treatment
Examples of LABAs: -salmeterol (Serevent) BID -formoterol (Foradil) BID -salmeterol + fluticasone (Advair) BID
Examples of ICS: -triamcinolone (Azmacort BID) -fluticasone (Flovent HFA) BID |
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List examples of Long-acting Beta2-agonists and the associated side effects |
Examples of LABAs: -salmeterol (Serevent) BID -formoterol (Foradil) BID
Combo LABA + ICS: salmeterol + fluticasone (Advair) BID
S/E & A/E: -Warn patients of increased risk of asthma deaths w/ use of LABA
-LABAs are not to be used as rescue drugs
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List examples of Inhaled corticosteroids and the associated side effects |
Examples of ICS: -triamcinolone (Azmacort) BID -fluticasone (Flovent HFA) BID
Side effects/Adverse effects: -Oral thrush (gargle or drink water after use) -HPA axis suppression -Glaucoma -others
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What are the leukotriene inhibitors and what are the associated side effects w/ their use? |
Examples of leukotriene inhibitors: -montelukast (singulair) QD -zileuton (Zyflo) QD
Side effects/Adverse effects: -Neuropsychological effects (agitation, aggression, depression, etc)
-Monitor LFTs (zileuton) |
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What are the mast cell stabilizers and what are the associated side effects w/ their use? |
Examples of mast cell stabilizers: -cromolyn sodium (Intal) QID -nedocromil sodium (Tilade) QID
Side effects/Adverse effects: -works better in children -cough, sneezing
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What is an example of a methylxanthine and what are its associated side effects? |
Example: Theophylline (not used often) -Theo-24 capsules daily to bid -Starting dose 300 mg/day bid
Side effects/Adverse effects: -sympathomimetic. Avoid w/ seizures, HTN, stroke -Several drug interactions: macrolides, FQs, Cimetidine, anticonvulsants such as phenytoin, carbamazepime (Tegretol)
-Check blood levels: normal is 12-15 mg/dL |
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What is an example of an immunomodulator and what are its associated side effects? |
Example: -Omalizumab (anti-IgE) monoclonal antibody
Side effects/Adverse effects: Be equipped and prepared to treat anaphylaxis when starting this drug |
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What are objective findings in asthma? |
Lungs: wheezing w/ prolonged expiratory phase. As asthma worsens, the wheezing occurs during both inspiration and expiration
CV: tachycardia, rapid pulse |
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How does use of a spacer or chamber help with the delivery of medication to the lungs? |
Use of a "spacer" or "chamber" (Aerochamber) is encouraged. It will increase delivery of the aerosolized drug to the lungs and minimizes oral thrush (for inhaled steroids) |
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How is asthma diagnosed? |
Asthma is diagnosed based on the history, symptoms (wheeze, dyspnea, cough) and reversible expiratory airflow obstruction (spirometry, pulmonary function tests) |
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In asthma treatment, which drugs require lab monitoring? |
-Theophylline requires serum concentration monitoring
-Zileuton (Zyflo), must monitor liver function |
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How should Exercised-Induced Asthma be treated? |
-Premedicate 10 to 15 mins before the activity w/ 2 puffs of a short-acting Beta2-agonist (SABA; albuterol [Ventolin], levalbuterol [Xopenex], pirbuterol [Maxair]).
-Effect will last up to 4 hours |
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Asthma treatment in a nutshell... |
-Every patient should be on a SABA (albuterol) PRN
-Next step is ICS. Dose depends on asthma stage
-Then add on LABA (salmeterol) or use combination drug (salmeterol + fluticasone [Advair])
-Add leukotriene inhibitors, sustained-release theophylline, or mast cell stabilizer |
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What might a PEF result be during an asthma exacerbation? |
PEF < 40% |
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How is an asthma exacerbation treated? |
Give nebulizer treatment: -albuterol or levalbuterol/saline solution by nebulizer. -May repeat every 20 mins (for 3 doses) -If unable to use inhaled bronchodilators, give epinephrine IM
After neb tx: -listen for breath sounds. If inspiratory and expiratory wheezing is present, a good sign (signals opening up of airways). -If there is lack of breath soudns or wheezing after a neb tx, a bad sign (pt is not responding), call 911
Discharge: -Medrol dose pack or prednisone tabs 40 mg/day x 4 days (no weaning necessary if 4 days or less). Continue medications and increase dose (or add another controller drug)
Referral to ED (Call 911): -Poor to no response to neb treatment (peak expiratory flow (PEF) less than 40% of expected) -Impending respiratory arrest: give Epi-Pen STAT. Call 911
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What is the treatment for an uncomplicated Chlamydia infection? |
-Azithromycin 1g PO in a single dose (directly observed treatment [DOT] preferred)
OR
-Doxycycline 100 mg BID x 7 days (S/E: abdominal pain, must take with water. Esophagitis if tablet gets stuck in throat; Nausea, GI upset, photosensitivity, CAT D (stains growing tooth enamel)
*No test of cure necessary for azithromycin or doxycycline regimen
*Sex partners should be treated with Azithromycin 1g PO in a single dose |
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How should a complicated Chlamydial infection (Pelvic inflammatory disease) be treated? |
-Ceftriaxone (Rocephin) 250 mg IM x 1 dose PLUS doxycycline PO BID x 14 days
-With or without metronidazole (Flagyl) PO BID x 14 days |
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What laboratory testing should be done for both Gonorrhea and Chlamydia? |
-Nucleic acid amplification tests (NAAT) are highly sensitive tests for both gonorrhea and chlamydia. Swab samples can be collected from the urine, cervix, urethra, oral and rectal sites for both males and females
-Urine samples - collect the first part of the urine stream (15-20 mL)
-Pharynx and/or rectal samples: swab using a NAAT test (do not use the GenProbe)
-GenProbe: Use only for the cervix or urethra (not for pharynx or rectum
*Chlamydial cultures are not used in primary care |
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What is the antibiotic of choice for the treatment of Streptococcus pneumoniae pneumonia? |
Penicillin
Alternative choices are: erythromycin and clindamycin |
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What is the antibiotic of choice for the treatment of infections caused by Staphylococcus aureus? |
Dicloxicillin |
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What is the antibiotic of choice for the treatment of infections caused by Mycoplasma pneumoniae? |
Erythromycin |
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What is the antibiotic of choice for the treatment of infections caused by Moraxella catarrhalis? |
Ampicillin Clavulanate |
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What is a treatment option for psoriasis vulgaris? |
Vitamin D derivative cream |
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What is a treatment option for Herpes Zoster? |
-oral valcyclovir |
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What is a treatment option for Scabies? |
-Permethrin lotion |
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What is a treatment option for Verruca vulgaris? |
Imiquimod cream |
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What is a treatment option for Tinea pedis? |
Topical ketoconazole |
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What is a treatment option for Rosacea? |
Topical metronidazole |
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What is a treatment option for Keratosis pilaris? |
Ammonium lactate lotion |
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What is normal range for TSH? |
0.4 - 4.0 mIU/L |
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After initiating or changing a levothyroxine dose, when should TSH be checked again? |
-2 months b/c levothyroxine has a long half-life |
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Which of the following represents the best choice of abortive migraine therapy for a 55-year-old woman with angina pectoris?
A) Verapamil B) Ergotamine C) Ibuprofen D) Almotriptan |
C) Ibuprofen - best answer. Safety trumps all else
-Verapamil has nothing to do with HAs -Ergotamine and Almotriptan have vasoconstrictive properties
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When considering EBP recommendations for the use of prophylactic migraine treatment, which of the following is the preferred agent?
A) Propranolol B) Ergotamine C) Rizatriptan D) Verapamil |
A) Propranolol
Ergotamine and Rizatriptan are considered abortive therapies
Verapamil is no longer on the list for HA prophylaxis |
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When choosing a pharmacologic intervention to prevent recurrence of duodenal ulcer, you prescribe:
A) A proton pump inhibitor B) Timed antacid use C) Antimicrobial therapy D) A histamine-2 receptor antagonist |
C) Antimicrobial therapy - H. pylori causes duodenal ulcers |
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For a patient with DRSP risk and dx with CAP which of the following is the best choice?
The patient is currently on ICS, LABA, ACEI w/ thiazide diuretic, a statin, low-dose ASA, and a SABA
A) 7-day course of clarithromycin B) 5-day course of levofloxacin C) 10-day course of doxycycline D) 14-day course of cefpodoxime
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B) 5-day course of levofloxacin - has DRSP coverage, atypical pathogen coverage, No D/D interactions. Course is long enough
Clarithromycin is a bad choice. No DRSP coverage and lots of D/D interactions
Amox-Clav - no coverage of atypical pathogens
Cefpodoxime - covers H. influenzae and S. pneumoniae, but not atypicals |
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For which of the following diagnosis(es) would you prescribe Clotrimazole cream?
A. Candida Vulvovaginitis B. Trichomoniasis C. Bacterial vaginosis |
Clotrimazole cream is an appropriate intervention for Candida vulvovaginitis |
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For which of the following diagnosis(es) would you prescribe Oral Metronidazole?
A. Candida Vulvovaginitis B. Trichomoniasis C. Bacterial vaginosis |
Oral Metronidazole is an appropriate treatment for trichomoniasis and bacterial vaginosis |
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For which of the following diagnosis(es) would you prescribe Metronidazole gel?
A. Candida Vulvovaginitis B. Trichomoniasis C. Bacterial vaginosis |
Metronidazole gel may be used to treat Bacterial vaginosis |
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For which of the following diagnosis(es) would you prescribe Clindamycin cream?
A. Candida Vulvovaginitis B. Trichomoniasis C. Bacterial vaginosis |
Clindamycin cream may be used to treat bacterial vaginosis |
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What are the most common adverse effects seen with use of a cholinesterase inhibitor? |
-Nausea and diarrhea
GI upset severely limits their effectiveness Many older adults just can't tolerate these drugs |
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Which of the following drugs (BEERS Criteria) is associated with a lack of efficacy in impaired renal function w/ CrCl < 60 mL/min (1 mL/s)?
A. Nitrofurantoin (Macrodantin, Macrobid) B. Zolpidem (Ambien) C. Amitriptyline (Elavil) D. Diclofenac (Voltaren) E. Sertraline (Zoloft) |
A. Nitrofurantoin (antibiotic commonly used to treat UTIs) |
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Which of the following drugs (BEERS Criteria) is associated with significant risk of orthostatic hypotension?
A. Nitrofurantoin (Macrodantin, Macrobid) B. Zolpidem (Ambien) C. Amitriptyline (Elavil) D. Diclofenac (Voltaren) E. Sertraline (Zoloft) |
C. Amitriptyline (Elavil) |
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Which of the following drugs (BEERS Criteria) is associated with an increase in fall and fracture risk?
A. Nitrofurantoin (Macrodantin, Macrobid) B. Zolpidem (Ambien) C. Amitriptyline (Elavil) D. Diclofenac (Voltaren) E. Sertraline (Zoloft) |
B. Zolpidem (Ambien)
*Any of the sleep aids and Benzos will increase risk |
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Which of the following drugs (BEERS Criteria) is associated with a potential to promote fluid retention?
A. Nitrofurantoin (Macrodantin, Macrobid) B. Zolpidem (Ambien) C. Amitriptyline (Elavil) D. Diclofenac (Voltaren) E. Sertraline (Zoloft) |
D. Diclofenac (Voltaren), as well as all other NSAIDs |
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Which of the following drugs (BEERS Criteria) is associated with an increased risk for hyponatremia
A. Nitrofurantoin (Macrodantin, Macrobid) B. Zolpidem (Ambien) C. Amitriptyline (Elavil) D. Diclofenac (Voltaren) E. Sertraline (Zoloft) |
E. Sertraline (Zoloft)
Monitor sodium |
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Insulin - broad concepts |
-Rapid-acting insulin covers one meal at a time
-Regular insulin lasts "from meal to meal"
-NPH insulin lasts "from breakfast to dinner" (can be given once or twice/day)
-Lantus is "once a day" |
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A type 1 diabetic is on regular insulin and NPH insulin (not premixed, but separate) injected 2x/day.
The first dose is injected before breakfast and the second dose is injected at bedtime.
The blood sugar results from the patient's diary (fasting, before lunch, dinner, and bedtime) show that the lunchtime values are higher than normal.
Which insulin dose should be increased or decreasesd? |
In this case, the NPH component of the morning dose should be increased. Regular insulin peaks between breakfast and lunch (most of it is gone by lunchtime).
In contrast, NPH insulin peaks between 6 and 14 hours. Therefore, it will cover the post-prandial spike after lunch |
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What is the rate of use of dietary supplements in the older adult? |
Approx. 50%
Appears to increase over time and w/ advancing age |
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What herbal supplement products have a potential antiplatelet effect? |
-The three "G's" --> Ginko Biloba, ginseng, garlic; problematic w/ prescription antiplatelet meds, solo, or in combination |
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What herbal supplement is a CYP450 3A4 inducer? |
St. John's Wart is a CYP450 3A4 inducer and has the potential for serotonin syndrome when taken w/ SSRI |
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Which herbal supplement is potentially hepatotoxic? |
Kava |
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Which herbal supplement is a GABA agonist, and should not be used with benzodiazepines, alcohol or sedative-hypnotics? |
Valerian root: GABA agonist, sedating; not to be used with benzodiazepines, alcohol or sedative-hypnotics |
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What are the short-term indications for use of a PPI? |
-Gastrointestinal, duodenal ulcers, GERD sxs, part of H. pylori treatment |
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What are the longer-term indications for use of a PPI? |
-Severe GERD, erosive esophagitis, NSAID-induced ulcers prevention, Zollinger-Ellison syndrome |
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What are the potential consequences of long-term PPI use? |
-Rebound hypersecretion (consider tapering med w/ reducing dose, followed by QOD use, H2RA (Ranitidine), antacid use for sxs
-Potential decrease in absorption of select micronutrients requiring acid stomach environment (Iron, Vit. B12; supplementation need not established)
-Increased fracture risk in epi studies, noted in M&F (25% incr in overall fxs, 47% incr in spinal fxs in postmenopausal women)
-Calcium Citrate absorption LESS affected by altered gastric acidity
-Magnesium absorption (increase risk hypomagnesemia noted w/ Mg depleting medication such as thiazide and loop diuretics; Digoxin toxicity risk increased w/ low Mg) |
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What are symptoms of hypomagnesemia w/ PPI use? |
-Muscle cramps, heart palps, dizziness, tremors, seizures
-24-hour urine magnesium is the more accurate lab diagnosis (over serum mag) |
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How does PPI use affect efficacy of Clopidogrel? |
PPI inhibition CYP450 2C19
-Clopidogrel (Plavix), CYP 2C19 required for conversion to active metabolite
-When used w/ omeprazole, antiplatelet activity reduced by 20-40%
*Potential to increase CV risk events |
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Which PPIs are CYP450 2C19 inhibitors? |
-Lansoprazole (Prevacid) -Omeprazole (Prilosec) -Pantoprazole (Protonix) -Raberprazole (AcipHex) -Esomeprazole (Nexium)
*As the presence of PPIs and clopidogrel is short lived, separation by 12-20 hrs should in theory prevent competitive inhibition of CYP metabolism and minimize any potential, though unproven, clinical interaction |
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Age-related decline in CNS function leads to exaggerated response to which medications? |
CNS-active medications -Benzos -Anesthetics -Opioids |
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1) Age-related changes in vascular, pulmonary, and cardiac tissue lead to a decrease in effect of which medications?
2) What are additional therapeutic choices w/ less age-related impact? |
1) Decrease in effect of beta-adrenergic agents
-Beta2-agonists such as albuterol (SABA), salmeterol (LABA)
-Beta antagonists such as metoprolol, carvedilol
2) Additional options: -Inhaled anticholinergics (tiotropium, ipratropium bromide)
-CCBs (Dihydropines such as amlodipine or Non-Dihydropines such as verapamil, diltiazem [some evidence of increased sensitivity to PR-pronlonging effects in elder]) |
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72 y/o woman with UTI and mild renal insufficiency; urine culture results = 100K colonies of E. coli -
What is the best therapeutic option? |
Sensitive: -Nitrofurantoin (first drug off list if patient has kidney trouble; wont hurt pt, but may not clear infection); *Dose adjustment CrCl ≥ 50 mg/dL: standard dosing; If CrCL < 50 mg/dL: Avoid use -Ciprofloxacin: CrCl ≥ 30 mL/min: no change w/ doses 250-750 mg BID; CrCL < 30 mL/min: required dose Q 24
Resistant: -TMP-SMX (CrCl < 30: No change, 1 DS tab bid; CrCl 15-30: 1 DS tab 24hr or 1 SS tab q 12hr; CrCl < 15: avoid if possible or use 1 tab SS or DS q24hr -Ampicillin (E. coli laughs at ampicillin) |
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What antibiotics are likely effective for treatment of infections with extended spectrum beta-lactamase-producing strains (most often K. pneumoniae, E. coli, Acinetobacter) |
-Likely effective antimicrobials include nitrofurantoin and fosfomycin (Monuril)
*See previous caution on nitrofurantoin use in renal impairment
*T1/2 fosfomycin increases to 50 h in renal impairment |
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For patients w/ a UTI who also have DM, symptoms > 7 days, recently used antimicrobials (w/in past 3 mos), age ≥ 65 yrs, or male, what meds and length of therapy are required? |
7 day regimen -oral TMP-SMX -Fluoroquinolone -cefixime 400 mg qd -cefpodoxime 100-200 mg qd -other cephalosporins as appropriates |
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CrCl vs. GFR |
CrCl approximates GFR but might overestimate due to: -Creatinine secreted by proximal tubule -Filtered by glomerulus
Equation less accurate at GFR estimates > 60 mL/min/1.73 m2
W/ eGFR < 60, equation accurate for most of average body size and muscle mass |
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What factors affect Serum Creatinine Concentration? |
-Musclular bulk: increased muscle generation due to increased muscle mass +/- increased protein intake
-Malnutrition, muscle wasting, amputation: reduced creatinine generation due to reduced muscle mass +/- reduced protein intake
-Vegetarian Diet: decrease in Cr generation
-Ingestion of cooked meats: Transient increase in Cr generation; however, might be blunted by transient increase in GFR
-Older age: Reduction in Cr generation due to age-related decline in muscle mass
-Female sex: Reduced Cr generation due to reduced muscle mass
-Obesity: No change, excess mass is fat, not muscle mass and does not contribute to increased creatinine generation |
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When should a 24-hour urine collection for CrCl be performed? |
Indications for Clearance measurement when Serum Creatinine is possibly inaccurate:
-Extremes of age and body size -Severe malnutrition or obesity -Disease of skeletal muscle -Paraplegia or quadriplegia -Veg diet -Rapidly changing kidney fxn -Pregnancy |
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What is the impact of aging on the kidney? |
-Renal blood flow decreases related to reduction in cardiac output
Result: less reserve, increased risk of drug-induced nephrotoxicity |
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What are the risks associated w/ use of Cholinesterase inhibitors in older adults with dementia? |
Increased rates of: -syncope -bradycardia -pacemaker insertion -hip fracture
Risk of these previously under-recognized serious events must be weight carefully against the drugs' generally modest benefits |
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The Second Generation Antipsychotics boxed warning states that most of the deaths in elderly patients w/ dementia were due to what causes? |
-CV (e.g., HF, sudden death)
-Infectious (e.g., pneumonia) |
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What is the maximum dose of citalopram that may be given? |
-For all, not recommended above 40 mg/day
-Causes too large an effect on QT interval and confers no add'l benefit; Prolongs QT and increases risk for ventricular rhythm disturbances
-Use not recommended w/ congenital long QT syndrome, bradycardia, hypokalemia, or hypomagnesemia, recent acute MI, or uncompensated HF
-In patients who are taking other drugs that prolong the QT interval (e.g., macrolides) |
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In which patients should citalopram dose not exceed 20 mg/day? |
-Do not exceed 20 mg/day: -age> 60, -hepatic impairment, -CYP2C19 poor metabolizers, or -patients who are taking concomitant cimetidine (Tagamet) or another CYP2C19 inhibitor including many PPIs |
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You see an older woman with valvular heart disease who is taking warfarin. She also is seeking treatment for a longstanding depression.
What should you consider in prescribing an SSRI? |
-Half-life, anticholingeric effects
-paroxetine (Paxil): has shortest half-life (21h) but highest anticholingeric effect (OUT)
-Citalopram (Celexa): Bad choice, T1/2 = 33 hrs; see previous card
-fluoxetine (Prozac): Dont Consider, T1/2 = 84 hrs, metbolite = 7-15 days
Best options are:
-Sertraline (Zoloft): possible, T1/2 = 26 hr
-Escitalopram (Lexapro): T1/2 = 27-32 hr |
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True or false -
Fluoroquinolone antibiotics (-floxacin suffix) should not be taken w/in 2 hrs of oral calcium supplements or antacids? |
True. B/c of chelation effect |
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True or false -
Enteric-Coated iron preparations use results in AUCs less that 30% of AUC for oral solution or tablet? |
True
*Avoid enteric-coated products, particularly in the older adult b/c all enteric coated products are said to release in the jejunum and very often pH in jejunum in older adult is not sufficient to dissolve the enteric coating.
Plus, enteric coated iron is not a good idea in any age group b/c duodenum is the spot where most of the iron is picked up |
