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192 Cards in this Set
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|
sources of fungal disease
|
just unlucky
world travel AIDS-opportunistic diseases pt's resistance is decreased: antibiotic therapy |
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|
antifungal agents -cell membrane
|
polyenes
imidazoles triazoles |
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main use of nystatin
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candida
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nystatin activity against
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yeast, fungi
no antibacterial activity |
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MoA of nystatin
|
--increased permability of membrane
|
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sterols
|
important
sterols in media confer resistance of sensitivity of fungus to agent |
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nystatin -selectivity
|
not used systemically --> RBC hemolysis and kidney damage
no resistance oral (negligible absorption) mainly topical use (no toxicity) |
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tx place of nystatin
|
candida (ointment)
moniliasis -skin (topical), GI tract |
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uses of amphotericin B
|
fungal penumonia
bone infections disseminated fungal infections fungal meningitis cryptococcal meningitis used to be 100% fatal before AmpB |
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amphotericin B
|
binds to fungal membranes
ions leak out of cells --forms pores in membrane |
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MoA of polyene agents
|
forms pores in fungal cell membrane
|
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sterols in the media confer
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resistance or sensitivity
interconversion between sensitivity and resistance in presence and absence of choletserol |
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selectivity of action of amp B
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lysosomal membranes
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resistance of amp B
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not serious problem
|
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pharmacokinetics of amp B
|
poorly absorbed from GI tract-never oral
IV (thrombophlebitis) |
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amp B toxicities - idiosyncratic/intrathecal
|
idiosyncratic: fevers, chills, shock, thrombocytopenia, cardiac fibrillation and arrest
intrathecal (fungal meningitis): chemical meningitis, corticosteroids? |
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amp B toxicities - blood
|
anemia (75%)
hematocrit 27 decrease production of erythroid proteins treat with epogen |
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amp B toxicities -RENAL
|
DO NOT EXCEED 4 grams total
increase bun/serumcreatinine decreased urea clearance, decrease ability of kidney to conentrate deposition of Ca2+ in kidney renal tubular alkalosis hypokalemia --Rhabdomolysis MUST KNOW RENAL FUNCTION BEFORE GIVE AMP B -do all renal tests MUST MONITOR |
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is renal toxicity reversible?
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depends on time and dose
if too much, too long --> will destroy kidneys |
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amphotericin B administration
|
IV slowly
wait 4 hrs mild rx 0.3 mg/kg severe rx give less five maintenance dose must treat for long periods of time hi dose --> 6-10 wks low dose --> 12-16 wks |
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new formulations amp B
|
lipid vehicles
very expensive but LESS TOXIC less kidney damage |
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ketoconazole
|
oral antifungal agent
broad spectrum systemic infection less toxic DECREASED P450 activity --> toxicity of other drugs inexpensive |
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MoA of ketoconazole
|
inhibits ergosterol synthesis
|
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toxicities of ketoconazole
|
GI
CNS (headache) liver |
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major prob with ketoconazole -why not used systmically
|
inhibits cytc P450
interferes w/ biosynthesis of steroid hromones (gynecomastia) alteras metabolism of many other drugs not used much systemically used TOPICALLY in shampoo for dermatophytosis, candidiasis, seborrheic dermatitis |
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itraconazole MOA
|
inhibits ergosterol synthesis
related to ketoconazole MORE EXPENSIVE |
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toxicities of intraconazole
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GI distress
hypokalemia liver damage hypertension |
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voriconazole
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IV OR ORAL
oral LOW P450 INHIBITION |
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voriconazole is effective for
|
aspergillosis
|
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miconazole
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broad spectrum
inhibits ergosterol synthesis |
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toxicities of miconazole (when used systemically)
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hyponatremia, phlebitis
lowers hematocrit cardiac arrhythmias nausea acute psychosis (rare) |
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uses of miconazole
|
topical: candida albicans (skin/vaginal infections)
tinea: pedis, cruris, versicolor |
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fluconazole --good antifungal agent for AIDS patient
|
water soluble IV or oral
GOOD CSF PENETRATION inhibits ergosterol synthesis |
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toxicities of fluconazole
|
GI distress
teratogenic Rash in AIDS pt stevens-johnson syndrome liver thrombocytopenia AIDS DOES NOT TOLERATE WELL |
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drug-drug interactions of fluconazole
|
increased phenytoin
increased sulfonylureas increased warfarin increased cyclosporin Fluconazole increases levels of above drugs |
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fungi can be resistant to what antifungal agent?
|
fluconazole
|
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uses of fluconazole
|
oral/esophageal candidiasis (AIDS)
cryptococcal meningitis relapse after amp B (AIDS) coccidoidal meningitis |
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MoA griseofulvin
|
INHIBIT FUNGAL mitosis
fungicidal in vitro fungistatic iin pt |
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|
spectrum of griseofulvin
|
ringworm: microsporum, trichophyton, epidermophyton
candida albicans |
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|
pharmacokinetics of griseofulvin
|
oral
absorption is better w/ FATTY meal peak is at 4 hrs |
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|
time scale of griseofulvin
|
skin/hairs wks
palms/sole 6-8 wks fingernails 3-6 mo toe nails 6-12 mo |
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Griseofulvin toxicities
|
headache - should pass
memory loss photosensitive (rare) teratogenic, carcinogenic (animals) at high doses --usually contraindicated in pregnancy |
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therapeutic place of griseofulvin
|
athlete's foot
fungal infections of skin and nails fungistatic (long term) |
|
|
5-flurocytosine (pro-drug) pyrimidine
fungus converts this to w/ what enzyme? |
5-FU by cytosine deaminase
this is called lethal synthesis! |
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|
primary mechanism of action of 5-FC
|
FdUMP thymidylate synthase
disrupt dUMP --> dTMP in DNA synthesis |
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|
GU binds what?
|
G and A
produces fradulent proteins |
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|
spectrum:
|
C. ablicans
cryptococcosis neoformans** chromoblastomycosis |
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MoA griseofulvin
|
INHIBIT FUNGAL mitosis
fungicidal in vitro fungistatic iin pt |
|
|
spectrum of griseofulvin
|
ringworm: microsporum, trichophyton, epidermophyton
candida albicans |
|
|
pharmacokinetics of griseofulvin
|
oral
absorption is better w/ FATTY meal peak is at 4 hrs |
|
|
time scale of griseofulvin
|
skin/hairs wks
palms/sole 6-8 wks fingernails 3-6 mo toe nails 6-12 mo |
|
|
Griseofulvin toxicities
|
headache - should pass
memory loss photosensitive (rare) teratogenic, carcinogenic (animals) at high doses --usually contraindicated in pregnancy |
|
|
therapeutic place of griseofulvin
|
athlete's foot
fungal infections of skin and nails fungistatic (long term) |
|
|
5-flurocytosine (pro-drug) pyrimidine
fungus converts this to w/ what enzyme? |
5-FU by cytosine deaminase
this is called lethal synthesis! |
|
|
primary mechanism of action of 5-FC
|
FdUMP thymidylate synthase
disrupt dUMP --> dTMP in DNA synthesis |
|
|
GU binds what?
|
G and A
produces fradulent proteins |
|
|
spectrum:
|
C. ablicans
cryptococcosis neoformans** chromoblastomycosis |
|
|
5-FC resistance
|
HIGH -problem
|
|
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pharmacokinetics of 5-FC
|
oral, well absorbed
|
|
|
toxicites of 5-FC
|
low
severe diarrhea (rare) SERIOUS BONE MARROW DEPRESSION more toxic in AIDS pt |
|
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potentiation w/ Amp B
|
use low dose amp B (disrupts membrane) with some other antifungal (allowed to enter membrane)
|
|
|
topical agents -undecenylic acid/tolnaftate -tx
|
cutaneous mycoses
topical agents athlete's foot ringworm |
|
|
MoA of allylamines-terbinafine
|
inhibit squalene epoxidase
|
|
|
SE of terbinafine
|
GI
headache abdominal pain changes in taste patterns elevation of liver enzymes |
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|
tx uses (oral) of terbinafine
|
trichophyton
epidermophyton microsporum species |
|
|
glucan
|
major fungal cell wall component
|
|
|
glucan synthesis inhibitors (echinocandins)
|
block cell wall synthesis
inhibit 1,3-beta glucan synthase |
|
|
echinocandins:
caspofungin SE |
GI
flushing elevated liver enzymes |
|
|
uses of casofungin
|
INVASIVE aspergillosis**
mucocutaneous candidiasis candidal bloodstream infections |
|
|
micafungin
|
phase 2 trails
esophageal candidiasis (HIV+pts) |
|
|
V-echinocandin
|
anidulafungin
USE: aspergillus species |
|
|
phenobarbital + griseofulvin
|
absorption effect
lowers serum levels of griseofulvin |
|
|
griseofulvin induces
|
microsomal enzymes
decreases wargarin gamma-aminolevulinic acid synthetase (porphyria) |
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ketoconazole affects steroid biosynthesis other drug metabolism
|
decreases cytochrome P450
changes in sex hormones not used systemically |
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|
major agents of anti-tuberculosis
|
INH
ethambutol rifampin pyrazinamide streptomycin |
|
|
secondary agents of antituberculosis
|
cycloserine
viomycin vanamycin capreomycin ethionamide |
|
|
chemotherapy of tuberculosis --tests
|
skin test
blood test (new): antigen based, more reliable than skin test, more expensive, cheaper in long run? |
|
|
chemotherapy of TB-RULE
|
see at frequent intervals
notify health department AT LEAST 2 DRUGS! |
|
|
standard tx of TB
|
6 month treatment:
INH + rifampin + pyrazinamide (2 mo) INH + rifampin (4 mo) combination of INH + rifampin --> 9 months |
|
|
major agents of anti-tuberculosis
|
INH
ethambutol rifampin pyrazinamide streptomycin |
|
|
4 drug regimen
|
INH
rifampin pyrazinamide ethambutol or streptomycin |
|
|
multiple drugs with MoA given will decrease
|
resistance development
|
|
|
secondary agents of antituberculosis
|
cycloserine
viomycin vanamycin capreomycin ethionamide |
|
|
what TB chemotherapy is safe for pregnancy?
|
INH + RIFAMPIN + ETHAMBUTOL - SAFE
|
|
|
chemotherapy of tuberculosis --tests
|
skin test
blood test (new): antigen based, more reliable than skin test, more expensive, cheaper in long run? |
|
|
major agents of anti-tuberculosis
|
INH
ethambutol rifampin pyrazinamide streptomycin |
|
|
4 drug regimen--when do you need to use this?
|
IRPE/S
ASIANS (SE Asia) hispanics recent immigrants miliary TB: nodules = millet seed in size disseminated TB or Extrapulmonary disease pts w/ TB meningitis extensive pulmonary disease HIV infection |
|
|
chemotherapy of TB-RULE
|
see at frequent intervals
notify health department AT LEAST 2 DRUGS! |
|
|
secondary agents of antituberculosis
|
cycloserine
viomycin vanamycin capreomycin ethionamide |
|
|
after tx, what is expected?
|
results within 2 wks
reduction of fever decreased cough gain in weight feel better radiologic improvement |
|
|
standard tx of TB
|
6 month treatment:
INH + rifampin + pyrazinamide (2 mo) INH + rifampin (4 mo) combination of INH + rifampin --> 9 months |
|
|
chemotherapy of tuberculosis --tests
|
skin test
blood test (new): antigen based, more reliable than skin test, more expensive, cheaper in long run? |
|
|
chemotherapy of TB-RULE
|
see at frequent intervals
notify health department AT LEAST 2 DRUGS! |
|
|
4 drug regimen
|
INH
rifampin pyrazinamide ethambutol or streptomycin |
|
|
standard tx of TB
|
6 month treatment:
INH + rifampin + pyrazinamide (2 mo) INH + rifampin (4 mo) combination of INH + rifampin --> 9 months |
|
|
multiple drugs with MoA given will decrease
|
resistance development
|
|
|
what TB chemotherapy is safe for pregnancy?
|
INH + RIFAMPIN + ETHAMBUTOL - SAFE
|
|
|
4 drug regimen
|
INH
rifampin pyrazinamide ethambutol or streptomycin |
|
|
multiple drugs with MoA given will decrease
|
resistance development
|
|
|
4 drug regimen--when do you need to use this?
|
IRPE/S
ASIANS (SE Asia) hispanics recent immigrants miliary TB: nodules = millet seed in size disseminated TB or Extrapulmonary disease pts w/ TB meningitis extensive pulmonary disease HIV infection |
|
|
what TB chemotherapy is safe for pregnancy?
|
INH + RIFAMPIN + ETHAMBUTOL - SAFE
|
|
|
after tx, what is expected?
|
results within 2 wks
reduction of fever decreased cough gain in weight feel better radiologic improvement |
|
|
4 drug regimen--when do you need to use this?
|
IRPE/S
ASIANS (SE Asia) hispanics recent immigrants miliary TB: nodules = millet seed in size disseminated TB or Extrapulmonary disease pts w/ TB meningitis extensive pulmonary disease HIV infection |
|
|
after tx, what is expected?
|
results within 2 wks
reduction of fever decreased cough gain in weight feel better radiologic improvement |
|
|
prophylaxis - when?
what? what type of pt? |
no apparent disease but exposed
positive TB test HIV patient give INH for 9 months! |
|
|
MoA of INH
|
increased hydrogen peroxide --> death
decrease mycolic acid synthesis decreases --> cell wall damage no effect on gram + and - |
|
|
does isoniazid grow slow or fast?
|
slow!
long delay before resumption of growth do not have to treat every day COMPLIANCE? |
|
|
isoniazid resistance
|
1. MYCOLIC ACID BIOSYNTHESIS IS ALTERED (INHIBITED)***
2. catalase-peroxidase mutation 3. INH uptake is reduced |
|
|
pharmacokinetics of isoniazid
|
aborbed well orally
good distribution **inactivated by metabolism** |
|
|
determine fast vs. slow acetylators
dependent on race, influenced by gender or age |
measure plasma levels of INH
or half life |
|
|
high acetyltransferase activity (FAST)
|
inhertied as autosomal dominant
heterozygous and homozygous dominants |
|
|
Clinical significance of slow acetylators
|
pyrodoxine deficiency B6
intermittent tx dephenyhydantoin toxicity (INH inhibits metabolism) |
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|
toxicities of isoniazid
|
peripheral neuropathy
CNS-euphoria, memory loss hepatic toxicity: prophylaxis infant/adolescents -treat prophylactically >36: higher rate of hepatitis --> dont treat 21-35: disagreement |
|
|
what can increase toxicity of INH?
|
alcohol
|
|
|
why does INH cause liver necrosis?
|
INH-->acetylhydrazine-->active acetyl group--> covalent binding to macromolecules --> hepatic necrosis
if also taking rifampin-->1/30,000 death to hepatitis |
|
|
hematologic toxicities of isoniazid
|
agranulocytosis
eosinophilia thrombocytopenia anemia also: arthritic symptoms-pain in joints convulsions (rare unless have epilepsy) |
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|
prophylaxis of TB
|
ONLY DRUG USED
6-1 yr usually 9 mo adults and children |
|
|
MoA of ethambutol
|
may inhibit BOTH RNA and MYCOLIC ACID
no antibacterial action |
|
|
pharmacokinetics of ethambutol
|
oral and absorbed from GI
excreted in urine/feces partially oxidized |
|
|
pharmacokinetics of ethambutol
|
oral and absorbed from GI
excreted in urine/feces partially oxidized |
|
|
pharmacokinetics of ethambutol
|
oral and absorbed from GI
excreted in urine/feces partially oxidized |
|
|
pharmacokinetics of ethambutol
|
oral and absorbed from GI
excreted in urine/feces partially oxidized |
|
|
Toxicities of ethambutol
|
****RETROBULBAR Neuritis -high doses
loss of visual acuity red-green color blindness Contraindicated in youn kids -must check visual function before administration |
|
|
Toxicities of ethambutol
|
****RETROBULBAR Neuritis -high doses
loss of visual acuity red-green color blindness Contraindicated in youn kids -must check visual function before administration |
|
|
Toxicities of ethambutol
|
****RETROBULBAR Neuritis -high doses
loss of visual acuity red-green color blindness Contraindicated in youn kids -must check visual function before administration |
|
|
Toxicities of ethambutol
|
****RETROBULBAR Neuritis -high doses
loss of visual acuity red-green color blindness Contraindicated in youn kids -must check visual function before administration |
|
|
ethambutol replaces
|
PAS
|
|
|
ethambutol replaces
|
PAS
|
|
|
ethambutol replaces
|
PAS
|
|
|
ethambutol replaces
|
PAS
|
|
|
uses of rifampin
|
systemic TB
TB meningitis eradication of memingococcal carrier state +++GRAM POSITIVE INFECTIONS activity against DNA viruses cancer chemotherapy anti-fungal + amphotericin B |
|
|
uses of rifampin
|
systemic TB
TB meningitis eradication of memingococcal carrier state +++GRAM POSITIVE INFECTIONS activity against DNA viruses cancer chemotherapy anti-fungal + amphotericin B |
|
|
uses of rifampin
|
systemic TB
TB meningitis eradication of memingococcal carrier state +++GRAM POSITIVE INFECTIONS activity against DNA viruses cancer chemotherapy anti-fungal + amphotericin B |
|
|
uses of rifampin
|
systemic TB
TB meningitis eradication of memingococcal carrier state +++GRAM POSITIVE INFECTIONS activity against DNA viruses cancer chemotherapy anti-fungal + amphotericin B |
|
|
MoA of Rifampin
|
Binds to RNA polymerase
**blocks initiation of RNA synthesis enzyme is composed of 4 subunits one specific subunit conveys resistance against rifampin |
|
|
MoA of Rifampin
|
Binds to RNA polymerase
**blocks initiation of RNA synthesis enzyme is composed of 4 subunits one specific subunit conveys resistance against rifampin |
|
|
MoA of Rifampin
|
Binds to RNA polymerase
**blocks initiation of RNA synthesis enzyme is composed of 4 subunits one specific subunit conveys resistance against rifampin |
|
|
MoA of Rifampin
|
Binds to RNA polymerase
**blocks initiation of RNA synthesis enzyme is composed of 4 subunits one specific subunit conveys resistance against rifampin |
|
|
selectivity of action - Rifampin
|
no effect on mammalian DNA
dependent RNA polymerase does not bind except in mitochondria (high doses) |
|
|
selectivity of action - Rifampin
|
no effect on mammalian DNA
dependent RNA polymerase does not bind except in mitochondria (high doses) |
|
|
selectivity of action - Rifampin
|
no effect on mammalian DNA
dependent RNA polymerase does not bind except in mitochondria (high doses) |
|
|
selectivity of action - Rifampin
|
no effect on mammalian DNA
dependent RNA polymerase does not bind except in mitochondria (high doses) |
|
|
toxicity of rifampin is LOW
|
hepatitis (rare)
ORANGE STAIN* FLU-LIKE symptoms* |
|
|
toxicity of rifampin is LOW
|
hepatitis (rare)
ORANGE STAIN* FLU-LIKE symptoms* |
|
|
toxicity of rifampin is LOW
|
hepatitis (rare)
ORANGE STAIN* FLU-LIKE symptoms* |
|
|
toxicity of rifampin is LOW
|
hepatitis (rare)
ORANGE STAIN* FLU-LIKE symptoms* |
|
|
therapeutic place of rifampin
|
*active TB
*meningococcal carrier state (rifampin high insaliva) TB meningitis staph endocarditis/osteomyelitis (beta-lactam/vancomycin) |
|
|
therapeutic place of rifampin
|
*active TB
*meningococcal carrier state (rifampin high insaliva) TB meningitis staph endocarditis/osteomyelitis (beta-lactam/vancomycin) |
|
|
rifampin is a potent
|
INDUCER OF LIVER MICROSOMAL ENZYMES
decreases half life of many drugs KNOW ORAL CONTRACEPTIVES!! M |
|
|
therapeutic place of rifampin
|
*active TB
*meningococcal carrier state (rifampin high insaliva) TB meningitis staph endocarditis/osteomyelitis (beta-lactam/vancomycin) |
|
|
therapeutic place of rifampin
|
*active TB
*meningococcal carrier state (rifampin high insaliva) TB meningitis staph endocarditis/osteomyelitis (beta-lactam/vancomycin) |
|
|
rifampin is a potent
|
INDUCER OF LIVER MICROSOMAL ENZYMES
decreases half life of many drugs KNOW ORAL CONTRACEPTIVES!! M |
|
|
main toxicity of pyrazinamide
|
HEPATIC
Huperuricemia |
|
|
rifampin is a potent
|
INDUCER OF LIVER MICROSOMAL ENZYMES
decreases half life of many drugs KNOW ORAL CONTRACEPTIVES!! M |
|
|
rifampin is a potent
|
INDUCER OF LIVER MICROSOMAL ENZYMES
decreases half life of many drugs KNOW ORAL CONTRACEPTIVES!! M |
|
|
main toxicity of pyrazinamide
|
HEPATIC
Huperuricemia |
|
|
main toxicity of pyrazinamide
|
HEPATIC
Huperuricemia |
|
|
main toxicity of pyrazinamide
|
HEPATIC
Huperuricemia |
|
|
will resistance occur w/ pyraxinamides?
|
yes if used alone 6-8 wks
|
|
|
uses of pyrazinamide
|
effective in initial therapy regimens
retreatment of reinfection *TOXICITY tolerable for SHORT DURATIONS |
|
|
streptomycin -toxicity
|
ototoxicity
nephrotoxicity |
|
|
cycloserine toxicity
|
peripheral neuropathy
CNS system dysfunction grand mal/petit mal convulsions ALL exacerbated by alcohol |
|
|
cycloserine is contraindicated in
|
epilepsy
severe depression severe anxiety give w/ pyridoxine (B6) ameliorates neurologic toxicity |
|
|
toxicity of ethionamide
|
GI problems
mental depression neurological: blurred vision, diplopia, dizziness, paresthesia, headache |
|
|
toxicity of capreomycin - cyclic peptide
|
auditory
renal -not severe |
|
|
toxicity of kanamycin
|
AG: nephrotoxicity
ototoxic |
|
|
PAS - aminosalicylic acid
|
rarely used
GI probs hypersensitivity compliance |
|
|
MoA of PAS
|
inhibits coupling enzyme -FOLIC ACID
|
|
|
what inactivates PAS?
|
acetylation
excretion-weak acid |
|
|
INH + rifampin -->
|
increases hepatotoxicity
|
|
|
Rifampin + aminosalicyclic acid -->
|
absorption problems
|
|
|
rifampin + Oral contraceptives
|
decrease half life and activity of oral contraceptives
|
|
|
Dapsone
|
related to sulfa drugs
inhibit folic acid synthesis: compete w/ PABA |
|
|
toxicities of dapsone
|
GI
blood dyscrasias (anemia, methheamoglobinemia, Fe3+) |
|
|
dapsone is used for
|
LEPROSY
|
|
|
thalidomide
|
sleeping pill that can cause phocomelia
|
|
|
anti-leprosy drugs
|
clofazimine
rifampin thalidomide (sleeping potion)--> erythema nodosum leprosum-complication of leprosy; cannot prescribe, need permission ethionamide |
|
|
combination chemotherapy
|
reduce resistance
decrease time of use DAP, RIF, Clofazimine |
|
|
usual tx minimal time is
|
2 years
relapses are possible |
|
|
Dapsone
|
related to sulfa drugs
inhibit folic acid synthesis: compete w/ PABA |
|
|
mycobacterium avium complex
|
rifabutin (rifampin deriv)
macrolides fluoroquinolones clofaximine amikacin |
|
|
toxicities of dapsone
|
GI
blood dyscrasias (anemia, methheamoglobinemia, Fe3+) |
|
|
mainly micobacterium avium complex more common in
|
HIV pts
<100 T-cell count |
|
|
dapsone is used for
|
LEPROSY
|
|
|
tx mycobacterium avium complex
|
single-agent therapy--> resistance dev
clarithromycin/azithromycin + ethambutol/rifabutin, clofazimine, fluroquinolones ethionamide are added |
|
|
thalidomide
|
sleeping pill that can cause phocomelia
|
|
|
anti-leprosy drugs
|
clofazimine
rifampin thalidomide (sleeping potion)--> erythema nodosum leprosum-complication of leprosy; cannot prescribe, need permission ethionamide |
|
|
combination chemotherapy
|
reduce resistance
decrease time of use DAP, RIF, Clofazimine |
|
|
usual tx minimal time is
|
2 years
relapses are possible |
|
|
mycobacterium avium complex
|
rifabutin (rifampin deriv)
macrolides fluoroquinolones clofaximine amikacin |
|
|
mainly micobacterium avium complex more common in
|
HIV pts
<100 T-cell count |
|
|
tx mycobacterium avium complex
|
single-agent therapy--> resistance dev
clarithromycin/azithromycin + ethambutol/rifabutin, clofazimine, fluroquinolones ethionamide are added |
