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58 Cards in this Set

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Name some contraindications for hormone replacement therapy
Abnormal, undiagnosed genital bleeding
Breast cancer
DVT or PE
Estrogen-dependent neoplasia
Pregnancy
Stroke or MI in past year
Thromboembolic disorder/ thrombophlebitis
Estrogen & Progestin - Patient education
AE's may be diminished by starting with low dose and may be alleviated by changing products (transdermal, continuous to cyclic regimen, etc.)
Contact physician if any occur:
- Abdominal tenderness, pain, or swelling
- Coughing up blood
- Disturbances of vision or speech
- Dizziness or fainting
- Lumps in the breast
- Numbness or weakness in an arm or leg
- Severe vomiting or headache
- Sharp chest pain or SOB
- Sharp pain in the claves
Estrogen & Progestin - AE's
Increased risk for venous thromboembolism, stroke, coronary heart disease, & breast cancer
Beneficial effects include reduction in fractures & colorectal cancer
Estrogen - Main AE's
Breast tenderness, heavy bleeding, headache, nausea
Progestin - Main AE's
Depression, headache, irritability
Estrogen & Progestin - Drug-disease interactions
Esrogen may exacerbate depression, diabetes (glucose intolerance), hypertriglyceridemia, hepatic adenoma, thyroid disorder (increase dose of supplement), impaired hepatic function (poor metabolism of estrogens), cardiovascular disorders (coronary heart disease & venous thromboembolism risk increased)
Estrogens - Drug-drug interactions
Decreased estrogen effect:
- CYP450 3A4 inducers (barbituates, carbamazepine, rifampin, St. John's wort), hydantoins, topiramate

Decreased effect of:
- hydantoins, thyroid hormones, oral anticoagulants

Increased effect of:
- corticosteroids, TCAs

Increased estrogen effect:
- CYP450 3A4 inhibitors (itracoazole, ketoconazole, macrolide antibiotics, ritonavir, grapefruit)
Progestins - Drug-drug interactions
Aminoglutethimide may increase metabolism of medroxyprogesterone

Rifampin may increase metabolism of norethindrone
Estrogens & Progestins - Monitoring parameters
Labs not required
Androgens (testosterone) - MOA
Precursor hormones to estrogen production by ovaries & peripheral sites
Act at androgen receptor sites or exhibit action following conversion to estrogen
Replaces androgen to improve deficiency-related symptoms (decreased sexual desire, decreased energy, diminished well-being)
Androgens - Patient education
Testosterone therapy given only to postmenopausal women who are receiving concurrent estrogen therapy
Androgens - Contraindications (relative)
Fluid retention, possible undesirable changes in lipid profile, virilization (lower HDL)
Androgens - Monitoring parameters
Labs not required
Phytoestrogens (isoflavones, lignans, coumestans)
Food sources: soybeans, flaxseed, alfalfa sprouts
Some studies have shown improvement in vaginal symptoms
No evidence supportin gimprovement in other symptoms of menopause (hot flashes, depression, anxiety, headache, myalgia)
May have beneficial effects on lipids
Name the oral HRT formulations
Premarin (conjugated estrogen)
Esradiol, Estrace, Gynodiol (micronized estradiol)
Estropipate, Ortho-Est, Ogen (estrone sulfate)
Estratab, Menest (esterified estrogens)
Estradiol
Synthetic conjugated estrogen
Name the transdermal ERT formulations
Estraderm (estradiol transdermal system)
Alora, Climara
Esclim, Vivelle, Vivelle-DOT
Name the injectable ERT formulations
Estrace vaginal cream
Ogen vaginal cream
Premarin vaginal cream
Estring vaginal ring
Vagifem vaginal tablet
Name the combination estrogen-progestin products
Activella
femHRT
Estring
Prempro
Premphase
Climara Pro (transdermal patch)
Combipatch (transdermal patch)
Name the combination estrogen-androgen products
Estratest H.S., Syntest H.S.
Estratest, Syntest D.S.
What are the benefits to using Progestin-only contraception?
Appropriate for use in breastfeeding women
Efficacy is less than that of COCs
Free of cardiovascular risks associated with estrogen-containing products
What is estrogen's MOA in contraception?
Prevents development of a dominant fllicle by suppression of FSH
Does not block ovulation
What is progestin's MOA in contraception?
Blocks ovulation
Contributes to production of thick and impermeable cervical mucus
Contributes to inovlation and atrophy of the endometrium
Contraception - Patient Education
Efficay is high but dependent on proper scheduled use
Does not prevent transmisison of STDs
Warning signs of important complications:
- severe abdominal pain, severe chest pain, shortness of breath, coughing up blood, severe headache, eye problems (blurred vision, flashing lights, blindness), severe leg pain in calf or thigh
Expect changes in characteristics of menstrual cycle
Use a back-up if mor than one dose is missed per cycle
Contraception - AE's
Nausea and vomiting - usually resolves within 3 months, breakthrough bleeding, spotting, amenorrhea, altered menstrual flow, melasma, headache, migraine, weight change, edema
Serious and less common:
- venous thrombosis, pulmonary embolism, MI, coronary thrombosis, arterial thromboembolism, cerebral thrombosis
Contraception - Drug-drug & drug-disease interactions
Decreased effect of contraceptive:
- ampicillin, griseofulvin, sulfonamides, tetracycline, anticonvulsants (barbiturates, carbamazepine, felbamate, phenytoin, topiramate), NNRTIs, PIs, pioglitazone, phenytoin, rifampin, theophylline
Increased plasma level of contraceptives:
- atorvastatin, vitamin C, 3A4 inhibitors
Decreased effect of:
- anticoagulants, benzodiazepine tranquilizers, beta blockers, hypoglycemics (tolbutamide, Diabinese, Orinase, Tolinase), methyldopa, phenytoin
Increased effect of:
- TCAs, benzodiazepine tranquilizers, beta blockers, theophylline
Increased toxicity of cortisone
Contraception - Monitoring parameters
Signs of serious complications
Labs not required
Name the progestin-only oral contraceptives
Ortho Micronir, Errin, Nor-QD, Nora-BE, Camila, Ovrette
Name the contraindications for combined oral contraceptive use
Breast cancer, current history of DVT, PE, CVA, or ischemic heart disease
Diabetes with nephropathy, enuropathy, retinopaty, or other vascular disease
Headaches
Hypertension >160/100 or with vascular disease
Lactation <6 weeks postpartum
Liver disease
Pregnancy
Surgery with prolonged immobilization or any surgery on the legs
Smoker (>20/day) >35yrs old
Structural heart disease complicated by pulmonary hypertension, atrial fibrillation, or history of acute bacterial endocarditis
T scores - when to initiate therapy
T score < -2 and no risk factors

T score < -1.5 with risk factors
Osteopenia - T score definition
T score -1 to -2.5 SD below young adult mean
Osteoporosis - T score definition
T score < -2.5 SD below the young adult mean
Name the risk factors for osteoporosis
Advanced age, amenorrhea, anorexia, cigarette smoking, current low bone mass, estrogen deficiency as a result of menopause, ethnicity (Caucasian or Asian), excessive alcohol use, family history of osteoporosis or history of fracture in a primary relative, female, history of fracture over age of 50, inactive lifestyle, long-term use of corticosteroids or anticonvulsants, low lifetime calcium intake, low testosterone in men, thin or small frame
Name the medical conditions associated wiht increased risk of osteoporosis
aIDS, Cushing's disease, eating disorders, hyperparathyroidism, inflammatory bowel disease, Type I DM, lymphoma and leukemia, malabsorption syndromes, rheumatoid arthritis
Name the drugs assoicated with an increased risk of osteoporosis
Anticonvulsants (phenobarbital, phenytoin), cytotoxic drugs, glucocorticoids, immunosuppressants, lithium, long-term heparin use, progesterone (parenteral and long-acting), supraphysiologic thyroxine doses, tamoxifen (premenopausal)
What are the recommendations for screening for osteoporosis?
Screen all women >65, postmenopausal women <65 with family history or clinical risk factors, and women with fracture history unrelated to trauma
Calcium - Patient education
Only ~500mg absorbed from GI tract at at time, separate doses
Calcium carbonate contains highest level of elemental calcium - take with food to increase absorption
Calcium citrate - with or without food
Calcium - AE's
GI upset (nausea, vomiting, cramping, flatulence)
Headache, hypophosphatemia, hypercalcemia
Calcium - drug-drug & drug-disease interactions
May decrease bioavailability of fluoroquinolones or tetracyclines
Calcium - Monitoring parameters
Labs not required
Bisphosphonates - MOA
Binds to bone (hydroxyapatite) and incorporates into bone to increase and stabilize bone mass
Bisphosphotanes - Patient education
Must be taken with a full glass of water (8 ounces) 30 minutes prior to the first meal of the day
Remain in upright position for at least 30min following ingestion
Take med on regularly scheduled basis
Compliance may be increased by once-weekly dosing
Bisphosphonates - AE's
GI - abdominal pain, dyspepsia, constipation, diarrhea, flatulene, nausea, acid regurgitation, gastritis
CNS - headache
Bisphosphonates - Drug-drug & drug-disease interactions
Decreased effect of bisphosphonates:
- Calcium supplements, antacids - separate by 1 hour
Incrased effect of bisphosphonates:
- ranitidine (IV may double bioavailability of alendronate)
Increased toxicity of:
- Aspirin (alendronate >10mg/d may increase risk of upper GI AE's of ASA)
Evista - MOA
Raloxifene
Selective estrogen receptor modulator
Estrogen receptor agonist at skeleton - decreases resorption of bone and overall bone turnover
Estrogen replacement therapy for osteoporosis treatment - MOA
Replaces natural estrogen in postmenopausal women to restore protective skeletal benefits
Estrogen replacement therapy for osteoporosis treatment - Patient education
Benefits must outweigh the risks
Estrogen replacement therapy for osteoporosis treatment - Contraindications
History of thromboembolism, breast, or endometrial cancer
Undiagnosed abnormal genital bleeding
Pregnancy
Estrogen replacement therapy for osteoporosis treatment - AE's
Genitourinary - vaginal bleeding or spotting
Other - breast enlargement & tenderness, increased weight
Cardiovascular - increased triglycerides
Estrogen replacement therapy for osteoporosis treatment - Drug-drug & drug-disease interactions
Decreased concentration of estrogen:
- rifampin
Incrased toxicity of:
- hydrocortisone, anticoagulants (increased potential for thromboembolic events)
Evista - Patient education
With or without food
Concomitant use with estrogen not recommended
Will not treat symptoms of menopause
In the event of prolonged immobilization, discontinue raloxifene 3 days prior to and during the immobile period when possible
Evista - AE's
Cardiovascular - hot flashes, chest pain, syncope
GI - nausea, diarrhea, vomiting
Musculoskeletal - arthralgia, myalgia
CNS - insomnia, neuralgia
Skin - rash, sweating
Evista - Drug-drug & drug-disease interactions
Decreased effect of raloxifene:
- ampicillin, cholestyramine (do not give together)
Decreased effect of:
- warfarin (PT decreased up to 10%)
Miacalcin - MOA
Calcitonin
Participates in regulation of calcium and bone metabolism
Inhibits bone resorption by binding to osteoclast receptors
Miacalcin - Patient education
Injection form given in upper arm, thigh, or buttocks
Nasal spray - use alternating nostrils every day, store in refrigerator until time for use, warm spray to room temp before 1st use, then store at room temp
Miacalcin - AE's
Skin - facial flushing and hand flushing
GI - nausea, diarrhea, vomiting, abdominal pain
Taste disorder - salty taste
Genitourinary - nocturia, urinary frequency
Nasal - rhinitis, nasal dryness, irritation, itching, congestion
Ophthalmic - blurred vision, abnormal lacrimation
Miacalcin - Drug-drug & drug-disease interactions
Decreased effect of:
- lithium
Forteo - MOA
Teriparatide (parathyroid hormone)
Increases rate of bone formation by increasing birth rate of osteoblasts and preventing apoptosis, resulting in improved bone mineral density
Forteo - AE's
Musculoskeletal - pain, arthralgia
CNS - paresthesias
GI - nausea, diarrhea, abdominal cramps
Taste disorder - metallic taste
Skin - injection pain, urticaria