Correct Answer:
decreases effects of oral contraceptives
provider may need to increase oral contraceptive dosage or switch to
another form of oral contraception
pramipexole adverse effects
Correct Answer:
Nausea, dizziness, daytime somnolence, insomnia, constipation, weakness,
hallucinations, impulse control disorders
When is pramipexole most effective in treating PD?
Correct Answer:
early stages- used alone (significant improvement in motor performance)
advanced stage- combined with levodopa
COMT inhibitors when to use\/prescribe
Correct Answer:
ex. entacapone
only for use with levodopa, inhibits the metabolism of levodopa in the
intestine and peripheral tissues. This prolongs the plasma half-life of
levodopa and thereby prolongs the time that levodopa is available to brain
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<\/a><\/figure>\n\n\n\nA person with what type of condition should not take echinacea?
Prolonged use should be avoided in those who are immunocompromised including HIV, cancer, drug therapy for TB, RA, and SLE<\/p>\n\n\n\n
Therapeutic effect of coenzyme Q-10
Antioxidant that serves a vital role in cellular energy production
Structurally similar to vitamin K, not used with warfarin<\/p>\n\n\n\n
What is the dietary supplement act of 1994 (DSHEA)?
Categorizes botanical products (herbal supplements), vitamins, minerals as dietary (food) supplements rather than drugs. By classifying products as dietary supplements the DSHEA excepts them from undergoing FDA scrutiny and approval before marketing. DSHEA does impose restrictions with labeling. All herbal products must be labeled as dietary supplements.<\/p>\n\n\n\n
Ginkgo Biloba adverse effects
stomach upset, headache, dizziness, vertigo. Some reports of spontaneous bleeding. Incorrect ingestion can lead to seizures and fatalities (if you eat seeds)<\/p>\n\n\n\n
Kava adverse effects
can cause severe liver injury (ABSOUTELY contraindicated in hepatotoxicity.<\/p>\n\n\n\n
Patient education about administration\/consumption about flaxseed
Flaxseed can reduce absorption of conventional medications so it should be taken 1 hour before or 2 hours after these drugs<\/p>\n\n\n\n
Therapeutic effect of feverfew (dietary supplement)
Used primarily for migraine prophylaxis, seasonal allergies, asthma, RA, and psoriasis<\/p>\n\n\n\n
St. Johns wort adverse effects
insomnia, vivid dreams, restlessness, anxiety, agitation, irritability, abdominal pain, dry mouth, headache<\/p>\n\n\n\n
Ginger root adverse effects
CNS depression and cardiac dysrhythmias. Excessive doses can cause GI side effects<\/p>\n\n\n\n
Current good manufacturing practices (CGMP) ruling of 2007
This ruling ensures that a product contains what the label proclaims – the package contains ingredients that are listed and does not lack any.
Set of standards to regulate the manufacturing and labeling of dietary supplements set for by the FDA. Designed to ensure that dietary supplements be devoid of adulterants, contaminants, and impurities and tha package labels accurately reflect the identity, purity, quality, and strength of what is inside. In addition, the label should indicate not only active ingredients but also inactive ingredients. Also mandates that mfr establish quality-control procedures with the objective of preventing mislabeled, underfilled, or overfilled formulations, variations in tablet size, color, or potency; and contamination with drugs, bacteria, pesticides, glass, lead, and other potential contaminants.<\/p>\n\n\n\n
Dietary supplement and non-prescription drug consumer protection act of 2006
mandates the reporting of serious averse events for non-prescription drugs and dietary supplements. The following should be reported: deaths, hospitalizations, life-threatening experiences, persistent or significant disabilities and birth defects<\/p>\n\n\n\n
First line treatment for primary, secondary, or early latent syphilis
Benzathine penicillin G 2.4 million units IM once<\/p>\n\n\n\n
First line treatment for bacterial vaginosis (BV)
Metronidazole 500 mg PO BID X 7 days<\/p>\n\n\n\n
First line treatment for genital herpes (first clinical episode)
acyclovir 400 mg PO TID x 7-10 days or acyclovir 200 mg PO 5 times a day for 7-10 days or famciclovir 250 mg PO TID\/day for 7-10 days or valacyclovir 1G PO 2 times\/day for 7-10 days<\/p>\n\n\n\n
Patient teaching and response to delayed onset of therapeutic effect for dutasteride
“I cannot donate blood while taking this medication” (men should not donate blood for at least 6 months after stopping to avoid transmission to women through administration of blood product)<\/p>\n\n\n\n
Long half life (about 5 weeks)
reduces ejaculate volume and libido in some men and causes decline in PSA in all men
Teratogenic
absorbed through skin – pregnant women should not handle<\/p>\n\n\n\n
Terazosin – how to know its working?
symptom improvement and increased urinary flow develop rapidly
“urine stream wasn’t as delayed and the urine flow was a lot stronger”<\/p>\n\n\n\n
Major drawback of progestin only oral contraceptives
Irregular bleeding
slightly safer than combination but less effective and more likely to cause irregular bleeding, spotting, amenorrhea, inconsistent cycle lengths, variations in volume and duration of monthly flow<\/p>\n\n\n\n
Outpatient treatment with pelvic inflammatory disease (PID)
doxycycline 100 mg PO BID x 14 days plus either cefoxitin 2 G IM once or ceftriaxone 250 mg IM once with or without metronidazole 500 mg PO BID x 14 days<\/p>\n\n\n\n
Benefits of prescribing medroxyprogesterone acetate
reduces risk of endometrial cancer
No increase in the risk for cervical, ovarian, or breast cancer<\/p>\n\n\n\n
How does carbamazepine impact oral contraceptives?
decreases the effectiveness of oral contraceptives
must advise patient of the risks and need for additional contraceptives if pregnancy is not desired<\/p>\n\n\n\n
Nexplanon (etonogestrel subdermal implant) benefits
safe to use while breastfeeding and has no effects on quality or quantity of milk produced<\/p>\n\n\n\n
benefits of alprostadil various routes
Two routes: transurethral and intracavernous
benefits intracavernous: response is rapid and injections are relatively painless. Provides an erection sufficient enough for intercourse but does not last longer than 1 hour. SHould be used no more than 3 times a week and no more than once in 24 hours
Benefits transurethral: approved for twice daily use and is inserted into the urethral. Erection develops within 5-10 minutes after drug insertion and lasts 30-60 minutes
fewer side effects<\/p>\n\n\n\n
Various routes of estrogen therapy
oral, transdermal preparations (emulsion, spray, gels, patches), intravaginal (creams, inserts, rings)<\/p>\n\n\n\n
When is oral estrogen route used
convenience<\/p>\n\n\n\n
When is parental estrogen route used
for emergency heavy uterine bleeding<\/p>\n\n\n\n
When is transdermal estrogen route used
total dose of estrogen is greatly reduced bc liver is bypassed
less NV
blood levels of estrogen fluctuate less
lower risk for DVT, PE, and stroke<\/p>\n\n\n\n
When is intravaginal estrogen route used
local effects primarily for treatment of vulval and vaginal atrophy associated with menopause
vaginal ring used for systemic effects (hot flashes and night sweats) as well as local effects (vulval and vaginal atrophy)<\/p>\n\n\n\n
Papaverine plus phentolamine patient education
erection develops within 10 minutes and lasts 2-4 hours
priapism can occur
development of painless fibrotic nodules in the corpus cavernosum is common
Adverse effects: orthostatic hypotension with dizziness, transient paresthesia’s ecchymosis, and difficulty in achieving orgasm or ejaculation
injection not oral<\/p>\n\n\n\n
First line treatment for uncomplicated gonococcal urethritis
ceftriaxone 250 mg IM once plus azithromycin 1G PO once<\/p>\n\n\n\n
When is androgen therapy appropriate vs. not needed related to puberty
Needed: if delayed puberty is a result of true hypogonadism, long term replacement therapy is indicated, off label use is indicated if psychological pressures of delayed sexual maturation are causing boy significant distress
Not needed: if puberty fails to occur at usual age (before 15), Most often due to familial pattern of delayed puberty and does not indicate pathology
delayed puberty in boys,use in menopausal women to alleviate<\/p>\n\n\n\n
Common side effects of doxazosin
hypotension, dizziness, fainting, somnolence, and nasal congestion<\/p>\n\n\n\n
First line treatment for chlamydia for adults and adolescents
azithromycin 1 G PO or doxycycline 100 mg PO BID for 7 days<\/p>\n\n\n\n
adverse effects of androgen therapy
Virilization in women,girls and boys- most common complication
premature epiphyseal closure ( radiographic exam should be done of wrist and hand every 6 months),
hepatotoxicity,
effect cholesterol levels(increase LDL and decrease HDL),
promote growth of prostate cancer -contraindicated for med dx w\/prostate cancer)
edema,
risk for abuse,
risk for thromboembolic events<\/p>\n\n\n\n
When are progestin contraindicated
undiagnosed vaginal bleeding, active thrombophlebitis or history of thromboembolic disorder, active liver disease, and carcinoma of breast
women who have undergone hysterectomy<\/p>\n\n\n\n
When is it appropriate to increase the dose of donepezil?
after 1-3 months (minimize side effects)<\/p>\n\n\n\n
What is abortive therapy?
eliminate headache pain and suppress associated nausea and vomiting<\/p>\n\n\n\n
When is abortive therapy used?
treatment should begin at earliest sign of attack
limit to 1-2 days per week. more frequent use can lead to medication overuse headache (MOH)<\/p>\n\n\n\n
abortive therapy for mild symptoms
NSAID (asa or naproxen may work)<\/p>\n\n\n\n
abortive therapy for moderate to severe symptoms
migraine-specific drug such as serotonin agonist-less frequently used- an ergot alkaloid. If these fail an opioid analgesic (butorphanol) may be needed<\/p>\n\n\n\n
Cholinesterase inhibitors side effects
dizziness, orthostatic hypotension, weight loss, falls d\/t bradycardia, N\/V\/D, insomnia<\/p>\n\n\n\n
First line treatment for migraine prevention
beta blockers (propranolol)<\/p>\n\n\n\n
How to know someone would be appropriate for preventative therapy for migraines
indicated for patients who have frequent attacks (3 or more a month), attacks that are especially severe or attacks that do not respond to abortive therapy<\/p>\n\n\n\n
Which medication would be given for someone with epilepsy needing adjunctive therapy for partial seizures with or without secondary generalization?
gabapentin<\/p>\n\n\n\n
When on medications for Alzheimer’s disease (AD) and symptoms increase, better to increase AD medication than to add things like herbal medications, vitamins, or NSAIDS
true<\/p>\n\n\n\n
You have determined that a patient is a candidate for opioid analgesic therapy for migraines. Which opioid analgesic would be most appropriate?
Butorphanol nasal spray<\/p>\n\n\n\n
Common side effects of phenytoin
CNS effects such as sedation
gingival hyperplasia
dermatologic effects (stevens-johnson syndrome and toxic epidermal necrolysis)
Drug reaction with eosinophilia and systemic symptoms (dress)
effects in pregnancy – teratogen- can cause cleft palate, heart malformations, and fetal hydantoin syndrome
cardiovascular effects
hirsutism
interference with vitamin D metabolism<\/p>\n\n\n\n
How can phenytoin affect birth control
decreases effects of oral contraceptives
provider may need to increase oral contraceptive dosage or switch to another form of oral contraception<\/p>\n\n\n\n
pramipexole adverse effects
Nausea, dizziness, daytime somnolence, insomnia, constipation, weakness, hallucinations, impulse control disorders<\/p>\n\n\n\n
When is pramipexole most effective in treating PD?
early stages- used alone (significant improvement in motor performance)
advanced stage- combined with levodopa<\/p>\n\n\n\n
COMT inhibitors when to use\/prescribe
ex. entacapone
only for use with levodopa, inhibits the metabolism of levodopa in the intestine and peripheral tissues. This prolongs the plasma half-life of levodopa and thereby prolongs the time that levodopa is available to brain<\/p>\n\n\n\n
MOA sumatriptan
binds to 5-HT receptors on sensory nerves of the trigeminal vascular system. Suppresses the release of CGRP, a compound that promotes release of inflammatory neuropeptides and thereby diminishes perivascular inflammation. Both actions- vasoconstriction and decreased perivascular inflammation- help relieve migraine pain<\/p>\n\n\n\n
Bromocriptine – how to manage side effects?
to minimize adverse effects, dosage should be low initially then gradually increased<\/p>\n\n\n\n
Sleep attacks associated with PD treatment
sleep attacks are overwhelming and irresistible sleepiness that comes on without warning, adverse effect of pramipexole<\/p>\n\n\n\n
Contraindications for triptans
ischemic heart disease, myocardial infarction, uncontrolled HTM, or other heart disease<\/p>\n\n\n\n
The first dose of any triptan should be under direct supervision in case of any unknown underlying cardiac disease
true<\/p>\n\n\n\n
First line treatment for generalized anxiety disorder
SSRI (paroxetine and escitalopram)
SNRI (venlafaxine and duloxetine)<\/p>\n\n\n\n
First line treatment for panic disorder (PD)
SSRIs – three approved (fluoxetine, paroxetine, sertraline)<\/p>\n\n\n\n
Lithium drug-drug interactions
NSAIDS, diuretics, and anticholinergic drugs<\/p>\n\n\n\n
Lithium therapeutic drug levels
below 1.5
range from 0.4 to 1 (0.6 to 0.8)<\/p>\n\n\n\n
Which sleep medication would help patients fall asleep if they don’t have trouble staying asleep?
zolpidem (ambien), zapelon (sonata), ramelteon (rozerem), triazolam (halcion)<\/p>\n\n\n\n
Memantine – what to do when someone has an elevated creatine clearance?
dosage adjustment for patients with renal impairment having creatine clearance of less then 30 mL\/min<\/p>\n\n\n\n
Black box warning for antidepressants
antidepressants especially early on, risk of suicide may actually increase. these concerns apply mainly to children, adolescents, and adults younger than 25<\/p>\n\n\n\n
Benzodiazepine-like drugs examples
zolpidem (ambien), zaleplon (sonata), eszopiclone (linesta)<\/p>\n\n\n\n
Melatonin-receptor- agonist examples
Ramelteon (rozarem)<\/p>\n\n\n\n
Which is the first line drug class for treating sleep disorders?
Benzodiazepines (xanax, librium, ativan, valium)<\/p>\n\n\n\n
Depression treatment options
SSRIs, SNRIs, TCAs, MAOIs, and atypical anti-depressants<\/p>\n\n\n\n
drug of choice for depression
SSRIs, SNRIs, bupropion, and mirtazapine<\/p>\n\n\n\n
What if the drugs of choice don’t work or aren’t tolerated by the patient?
older antidepressants (TCAs and MAOIs) have more adverse effects and are less well tolerated than the first line agents and are generally reserved for patients who have not responded to the first line drugs<\/p>\n\n\n\n
Benzodiazepine drug examples
-pam
Xanax (alprazolam), valium (diazepam), lorazepam (ativan), librium (chlordiazepoxide)<\/p>\n\n\n\n
MAOI baseline data
Monitor blood pressure
therapeutic doses can cause hypotension also in combination with tyramine foods can cause hypertensive crisis<\/p>\n\n\n\n
Dietary restriction MAOIs
avoid foods with tyramine
avoid avocados, figs, bananas, meats, fermented foods, most cheese (except cottage and cream cheese), yeast extract, imported beer, shrimp, soy sauce, protein dietary supplements
Have a lot of drug interactions, consult with provider before taking new medications or supplements<\/p>\n\n\n\n
What condition is MAOIs the drug of choice for
atypical depression, often reserved for patients who do not respond well to SSRIs or TCAs
examples: isocaboxazid (marplan), phenelzine (nardil), selegiline (emsam)<\/p>\n\n\n\n
TCAs baseline data
prior to starting a TCA an EKG should be done
especially in patients with known dysrhythmias or older than 40<\/p>\n\n\n\n
side effects of progestin’s
Spotting, amenorrhea, breakthrough bleeding, inconsistent cycle length, variations in volume and duration of monthly flow<\/p>\n\n\n\n
long term progestin use is approved for
protection against endometrial cancer<\/p>\n\n\n\n
Recommended hormone therapy for women with an intact uterus
estrogen plus progesterone (EPT)<\/p>\n\n\n\n
recommended hormone therapy for women without a uterus
estrogen therapy should be used<\/p>\n\n\n\n
Patient education for transdermal testosterone
Apply to shoulder, upper arm, or abdomen.
wash hands with soap and water
Blood levels of testosterone should be measured 14 days after the initiation
radiographs every 6 months
principal adverse effect is a rash<\/p>\n\n\n\n
Touching undried topical testosterone is extremely dangerous for which two patient populations
Pregnant women and children
can cause virilization (male physical characteristics) and fetal harm<\/p>\n\n\n\n
Androgens (testosterone) contraindicated
Those with known prostate cancer and breast cancer<\/p>\n\n\n\n
An erection lasting longer than what is an medical emergency
4 hours<\/p>\n\n\n\n
When is it safe to prescribe progestin
required for women that have an intact uterus and have undergone hormone therapy
For lactating patients give progesterone meds, cannot have estrogen
Approved for long-term only for protection against endometrial cancer<\/p>\n\n\n\n
Not safe to prescribe progestin’s
contraindicated in women that have had hysterectomies
irregular bleeding major drawback of progestin as an oral contraceptive
progestin contraindicated in undiagnosed vaginal bleeding, active thrombophlebitis or history of thromboembolic disorders, active liver disease, and carcinoma of the breast<\/p>\n\n\n\n
How might carbamazepine impact which oral contraceptive is prescribed?
increase OC dose or use other form of contraceptive (condoms)<\/p>\n\n\n\n
Testosterone gels
main concerns if skin to skin contact can transfer drug
apply to clean site on shoulder, upper arm, or abdomen<\/p>\n\n\n\n
Testosterone pellets
indicated for male hypogonadsim and delayed puberty
implanted under skin near hip or abdomen<\/p>\n\n\n\n
testosterone buccal tablets
steady blood levels of drug
not affected by eating, drinking, or brushing teeth
alternate side of mouth (gums)<\/p>\n\n\n\n
How to monitor antiepileptic drugs for effectiveness
Using a frequency chart kept by the patient of family can be useful in monitoring effectiveness. No medication should be considered ineffective until treatment has been tested in sufficiently high doses.
plasma drug levels and patient adherence<\/p>\n\n\n\n
absence seizures drug effectiveness
Since these happen so often- seizure stops dosage is sufficient if not need higher dosage<\/p>\n\n\n\n
Performance anxiety first line treatment
beta blockers (propranolol)<\/p>\n\n\n\n
social anxiety disorder first line treatment
sertraline and parozetine (SSRIs)<\/p>\n\n\n\n
How long should it take for antidepressant to work?
“this medication takes about 1-3 weeks to notice a difference”
12 weeks for max response
therapeutic trial should not be considered failure until drug has been taken for at least 1 month without success<\/p>\n\n\n\n
Rivastigmine patient teaching
cholinesterase inhibitor (this drug has highest rate of cholinergic effects) Wh
treats AD and dementia of parkinson’s
Falls are more likely to occur as a result of bradycardia and other cardiac changes
to prevent weight loss, encourage nutritional supplements (boost) and snacks between meals
Most adverse effects (N, D, insomnia) are dose related and can be decreased by starting with lower doses and increasing gradually<\/p>\n\n\n\n
What should be included in patients seizure frequency chart
date, time, and nature of all seizure events<\/p>\n\n\n\n
first line treatment for acute, mild, and moderate migraine without N\/V
-triptans<\/p>\n\n\n\n
Levodopa\/carbidopa in treatment\/diagnosis of parkinson’s
If bothering symptoms are ONLY MOTOR related, than levodopa\/carbidopa is preferred. Reduces symptoms by increasing dopamine synthesis in striatum
Taken without food
reduce N by taking with low-fat and low-protein meals such as fruits and vegetables<\/p>\n\n\n\n
First generation Antipsychotics adverse effects
extrapyramidal reactions: TD, acute dystonia, parkinsonism, akathisia (movement disorder that makes it hard to stay still)
Neuroleptic malignant syndrome (NMS) – rare, primary symptoms are “lead pipe” rigidity, sudden high fever, sweating, autonomic instability, BP fluctuations
Anticholinergic effects- orthostatic hypotension, sedation, neuroendocrine effects, seizures, sexual dysfunction, agranulocytosis, severe dysrythmias<\/p>\n\n\n\n
First generation antipsychotics
end in -ine (zine, pine), Haldol<\/p>\n\n\n\n
patient education antipsychotics
Patients should be informed about signs and symptoms of hypotension (lightheadedness and dizziness) and advised to sit or lie down if these occur. In addition, patients should be informed that hypotension can ve minimized by moving slowly when assuming an erect posture. Patient’s should be warned against participating in hazardous activities (driving) until sedative effects diminish.<\/p>\n\n\n\n
SSRI examples
lexapro, prozac (fluoxetine), paroextine (paxil), sertraline (zoloft)<\/p>\n\n\n\n
Adverse effect with SSRI and MAOI
serotonin syndrome, stop MAOI 14 days before SSRI<\/p>\n\n\n\n
SSRI’s common adverse effects
nausea, agitation, sexual dysfunction, and insomnia, headache, nervousness, anorexia, sweating, somnolence<\/p>\n\n\n\n
Drug interactions with SSRIs
MAOIs and other serotonergic drugs (other anti-depressants- SNRIs, MAOIs, TCAs, triptans), tramadol, and linezolid (antibiotic), st johns wort<\/p>\n\n\n\n
baseline data for SSRI and SNRI
serum NA on older adults and patients on diuretic therapy<\/p>\n\n\n\n
SSRI adverse effects
sexual dysfunction, weight gain, headache, nausea, nervousness, insomnia, and anxiety<\/p>\n\n\n\n
Strategies to minimize adverse effects – SSRI and SNRI
Reduce dosage, “drug holidays” (take a break on friday and saturday), add drug to help problem, or switch to another anti-depressant, taper dose (discontinued abruptly cause withdrawal symptoms), signs of suicide<\/p>\n\n\n\n
TCA patient education
orthostatic hypotension
Patients should be informed that they can minimize orthostatic hypotension by moving slowly when assuming an upright posture. In addition, patients should be instructed to sit or lie down if symptoms (dizziness, lightheadedness) occur
Anticholinergic effects
sedation – advised to avoid hazardous activities if sedation is prominent
EKG
Risk for suicide<\/p>\n\n\n\n
MAOIs patient education
Patients should be informed about signs of hypotension (dizziness, lightheadedness) and advised to sit or lie down if these occur. Also, they should be informed that hypotension can be minimized by moving slowly when assuming an erect posture
Avoid tyramine-rich foods
symptoms of hypertensive crisis and seek medical attention if these develop<\/p>\n\n\n\n
Serotonin withdrawal
dizziness, headache, nausea, sensory disturbances, tremor, anxiety, and dysphoria, altered mental status, myoclonus hyperflexia, excessive sweating, fever<\/p>\n\n\n\n
Minimized by tapering slowly<\/p>\n\n\n\n