Offer treatment for the opioid disorder.<\/li>\n<\/ol>\n\n\n\nUS Drug Enforcement Administration description of the scheduled drugs
\u2026<\/p>\n\n\n\n
Treatment of Chronic Pain<\/p>\n\n\n\n
o Example: How should something like osteoarthritis be treated?
Salicylates: 3.6-5.4 g\/day Use of pregabalin- can help relieve neuropathic pain. Acute pain (sharp, darting
pain) is especially responsive, although other forms of neuropathic pain
(cramping pain, aching pain, and burning pain) also respond.
-Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for
chronic pain. Clinicians should consider opioid therapy only if expected benefits for both
pain and function are anticipated to outweigh risks to the patient. If opioids are used, they
should be combined with nonpharmacologic therapy and nonopioid pharmacologic
therapy, as appropriate.<\/p>\n\n\n\n
Risk factors for Opioid Use Disorder
history of overdose, history of substance use
disorder, higher opioid dosages (\u226550 MME\/day), or concurrent benzodiazepine use<\/p>\n\n\n\n
Methadone<\/p>\n\n\n\n
o Black Box Warning
QT prolongation and severe respiratory depression<\/p>\n\n\n\n
Methadone<\/p>\n\n\n\n
o Benefits of use in opioid use disorder
Maintenance and suppressive therapy<\/p>\n\n\n\n
Creates tolerance -> patient less likely to seek out illicit drugs because no desirable effects<\/p>\n\n\n\n
Buprenorphine and Naloxone<\/p>\n\n\n\n
o Benefit of using this combination
Discourages IV use<\/p>\n\n\n\n
Makes risk for withdrawal low<\/p>\n\n\n\n
Treatment of chronic pain<\/p>\n\n\n\n
o Use of pregabalin
For seizures and neuropathic pain<\/p>\n\n\n\n
Regulated as a controlled substance<\/p>\n\n\n\n
Effects similar to diazepam when given with other sedative-hypnotic drugs<\/p>\n\n\n\n
Treatment of chronic pain<\/p>\n\n\n\n
o Use of pregabalin Side effects
o Sedation, dizziness, and ataxia are more commonly linked to pregabalin. Gastrointestinal bleeding may be caused by COX-2 inhibitors and NSAIDs.<\/p>\n\n\n\n
WEEK 3
\u2026<\/p>\n\n\n\n
How to treat hypertension
o Order HTN medications are typically prescribed in
ACEs, ARBs, thiazides, calcium channel blockers<\/p>\n\n\n\n
How to treat hypertension<\/p>\n\n\n\n
Which is best for someone with diabetes
ACE -> ARB -> calcium channel blocker -> diuretic<\/p>\n\n\n\n
How to treat hypertension<\/p>\n\n\n\n
Best approach or drug to use during pregnancy or someone wishing to become pregnant
Labetolol, nifedipine, and methyldopa (little mama)<\/p>\n\n\n\n
How to treat hypertension<\/p>\n\n\n\n
The therapeutic action of drug classifications used<\/p>\n\n\n\n
How to treat hypertension<\/p>\n\n\n\n
Ethnic groups impacted by certain drug classifications
African Americans- African americans do not
respond well to ACE-I or ARBs. First line would be thiazide diuretics and then
CCB’s.<\/p>\n\n\n\n
Prescribing considerations when carbamazepine is prescribed with warfarin
Decreases effects of warfarin – consider increasing dosage<\/p>\n\n\n\n
Beta-blockers<\/p>\n\n\n\n
o Their use with nitroglycerin and tachycardia
May mask common signs of hypoglycemia<\/p>\n\n\n\n
Can help suppress nitro-induced tachycardia<\/p>\n\n\n\n
Beta-blockers<\/p>\n\n\n\n
Know examples
Cardioselective examples include:
Atenolol (Tenormin\u00ae), bisoprolol
(Bystolic\u00ae), metoprolol (Lopressor\u00ae) and metoprolol succinate (Toprol-XL\u00ae)<\/p>\n\n\n\n
Non-selective beta blockers-
Carvedilol (Coreg\u00ae), labetalol (Trandate\u00ae), nadolol
(Corgard\u00ae), propranolol (Inderal\u00ae) and Sotalol (Betapace\u00ae<\/p>\n\n\n\n
Beta-blockers<\/p>\n\n\n\n
Risk of stopping them abruptly
tachycardia<\/p>\n\n\n\n
Beta-blockers<\/p>\n\n\n\n
What happens when given to someone with asthma?
May cause dry cough from constriction of the bronchi<\/p>\n\n\n\n
Diuretics action
decreases preload on the heart (what’s coming back to the heart) by diuresing fluid volume and vasodilation<\/p>\n\n\n\n
-decrease blood volume, venous pressure, and preload<\/p>\n\n\n\n
Blocks sodium-chloride channel in the kidney<\/p>\n\n\n\n
Diuretics Contradictions to thiazide diuretics
Sensitivity to sulfa drugs<\/p>\n\n\n\n
Sensitivity to thiazides<\/p>\n\n\n\n
Hepatic coma<\/p>\n\n\n\n
Diuretics Monitoring needs
Daily weights, edema<\/p>\n\n\n\n
BP and HR<\/p>\n\n\n\n
Signs of hypokalemia<\/p>\n\n\n\n
Heart failure<\/p>\n\n\n\n
o What to prescribe in response to fibrotic changes
ACEIs<\/p>\n\n\n\n
Heart failure<\/p>\n\n\n\n
Effects of cardiac glycosides (digoxin)
Positive inotropic effect on the heart -> increases cardiac output -Increase myocardial contractility
and CO by inhibiting Na+ K+<\/p>\n\n\n\n
Heart failure
Quinidine and digoxin<\/p>\n\n\n\n
o What happens when they are combined?
Quinidine increases digoxin levels by decreasing excretion of digoxin, altering distribution of digoxin, or both<\/p>\n\n\n\n
Atherosclerotic Cardiovascular Disease (ASCVD) Risk Score<\/p>\n\n\n\n
o What is it?
Cholesterol guideline with 4 categories of patients who would benefit from statin treatment<\/p>\n\n\n\n
ASCVD) Risk Score<\/p>\n\n\n\n
When is it used?
Based on\u2026
The presence or absence of ASCVD<\/p>\n\n\n\n
Number of risk factors an individual has<\/p>\n\n\n\n
10-year ASCVD score<\/p>\n\n\n\n
Hyperlipidemia<\/p>\n\n\n\n
o Statin Drugs
At what age can they be prescribed
Over 10 years old<\/p>\n\n\n\n
Hyperlipidemia<\/p>\n\n\n\n
o Ezetimibe (Zetia)<\/p>\n\n\n\n
What is it?
Reduces plasma cholesterol, LDL,<\/p>\n\n\n\n
Blocks cholesterol absorption in the small intestine<\/p>\n\n\n\n
Can produce a small increase in HDL<\/p>\n\n\n\n
Hyperlipidemia<\/p>\n\n\n\n
o Ezetimibe (Zetia)<\/p>\n\n\n\n
When would it be used?
Adjunct to diet modification<\/p>\n\n\n\n
Approved for monotherapy and combined
use with statin<\/p>\n\n\n\n
Hyperlipidemia<\/p>\n\n\n\n
o Pharmacological option to minimize side effects<\/p>\n\n\n\n
In other words, how would you treat high cholesterol if someone was concerned about or experiencing side effects from other medications?
Which drug classification would be a good choice?
Usually statins at lowest dose then bile acid sequestrants<\/p>\n\n\n\n
Angina
o Therapeutic action of organic nitrates
Acts directly on vascular smooth muscle to promote vasodilation<\/p>\n\n\n\n
Angina<\/p>\n\n\n\n
o Contraindications for ranolazine
Pre-existing QT prolongation<\/p>\n\n\n\n
Hepatic impairment<\/p>\n\n\n\n
Taking drugs that inhibit CYP3A4 (most calcium channel blockers EXCEPT for amlodipine)<\/p>\n\n\n\n
WEEK 4
\u2026<\/p>\n\n\n\n
Most appropriate treatment approach for OA<\/p>\n\n\n\n
o Pharmacological
NSAIDS, corticosteroids, colchicine<\/p>\n\n\n\n
Most appropriate treatment approach for OA<\/p>\n\n\n\n
o Non-Pharmacological
Exercise<\/p>\n\n\n\n
Gout<\/p>\n\n\n\n
o Complications of untreated gout
EROSION, irreversible joint damage, renal calculi<\/p>\n\n\n\n
Gout<\/p>\n\n\n\n
o Treatment of acute flare with colchicine
Patient education
Adverse effects
Adverse effects: GI toxicity -> nausea and vomiting, diarrhea and
abdominal pain and bone marrow suppression Patient edu- If GI effects occur then colchicine must be d\/c immediately.<\/p>\n\n\n\n
Gout<\/p>\n\n\n\n
o Long-term use of allopurinol
What condition can be developed?
Formation of cataracts with long-term use more than 3 years<\/p>\n\n\n\n
Gout<\/p>\n\n\n\n
o Drug interactions with allopurinol
Warfarin – inhibits hepatic drug-metabolizing enzymes, delays interaction
of this drug; dosage should be reduced<\/p>\n\n\n\n
Mercaptopurine and azathioprine – accumulate to toxic levels, reduce dosage<\/p>\n\n\n\n
Theophylline – should not be combined<\/p>\n\n\n\n
Ampicillin – high incidence of rash<\/p>\n\n\n\n
Gout<\/p>\n\n\n\n
o What should be co-administered with febuxostat?
Prophylactic NSAIDs or colchicine for up to 6 months because of gout flare-up<\/p>\n\n\n\n
NSAIDS<\/p>\n\n\n\n
o Black Box Warning
thrombotic events, GI ulceration, bleeding<\/p>\n\n\n\n
NSAIDS<\/p>\n\n\n\n
o Drug interactions
Warfarin, heparin, and other anticoagulants – increases risk for bleeding<\/p>\n\n\n\n
Glucocorticoids – promotes gastric ulceration<\/p>\n\n\n\n
ACEI – increases risk for renal impairment<\/p>\n\n\n\n
Other NSAIDs – can negate effects of ASA<\/p>\n\n\n\n
Vaccines – may blunt immune response to vaccines<\/p>\n\n\n\n
NSAIDS<\/p>\n\n\n\n
o Therapeutic action
Provides rapid relief, anti-inflammatory<\/p>\n\n\n\n
NSAIDS<\/p>\n\n\n\n
o Mechanism of action
Non-selective inhibitor of cyclooxygenase<\/p>\n\n\n\n
COX 1 – protection against MI and ischemic stroke<\/p>\n\n\n\n
COX 2 – reduces inflammation, pain, and fever<\/p>\n\n\n\n
DMARDs<\/p>\n\n\n\n
o What baseline diagnostics are needed for all DMARDs
Liver enzymes
creatinine
LFTs, kidney function, and bone marrow function, WBC, and pregnancy test (Can be hard on
the liver and kidneys)<\/p>\n\n\n\n
DMARDs<\/p>\n\n\n\n
o Therapeutic response of methotrexate
Reduces joint destruction and SLOWS disease progression<\/p>\n\n\n\n
Osteoporosis<\/p>\n\n\n\n
o Alendronate
Patient education
Remain upright for 30 min.<\/p>\n\n\n\n
Take on empty stomach<\/p>\n\n\n\n
Take in AM<\/p>\n\n\n\n
Osteoporosis<\/p>\n\n\n\n
o Ibandronate
Which dietary supplement can interfere with absorption?
Antacids, calcium, vit D, or other vitamin supplements<\/p>\n\n\n\n
Remain upright for 60 min.<\/p>\n\n\n\n
Don’t eat\/drink for 60 min.<\/p>\n\n\n\n
Rheumatoid Arthritis<\/p>\n\n\n\n
o Treatment during pregnancy
Biologic DMARDs:
-TNF antagonists are US Food and Drug Administration (FDA) Pregnancy Risk Category B.
-Rituximab and abatacept are Pregnancy Risk Category C.
-Nonbiologic DMARDs: Azathioprine is teratogenic. Both leflunomide and methotrexate can cause fetal death and congenital abnormalities.
-Hydroxychloroquine may cause fetal ocular toxicity; however, in some conditions, such as maternal lupus or malaria, the drug decreases the fetal risk associated with the conditions it treats.
-Sulfasalazine is Pregnancy Risk Category B.<\/p>\n\n\n\n
Rheumatoid Arthritis<\/p>\n\n\n\n
Which drugs have highest risk vs which ones are the safest
NSAIDs and DMARDS are highest risk<\/p>\n\n\n\n
Corticosteroids are safest option<\/p>\n\n\n\n
Hydrocodone\/Acetaminophen (Lortab)<\/p>\n\n\n\n
\n- directions for use<\/li>\n\n\n\n
- indication<\/li>\n\n\n\n
- common doses<\/li>\n\n\n\n
- Directions: take 2.5 mg po every 4-6 hours<\/li>\n\n\n\n
- Indication: moderate-severe pain<\/li>\n\n\n\n
- Dose: 2.5-10 mg po q4-6 prn<\/li>\n<\/ol>\n\n\n\n
Lisinopril<\/p>\n\n\n\n
\n- directions for use<\/li>\n\n\n\n
- indication<\/li>\n\n\n\n
- common doses<\/li>\n\n\n\n
- Directions: take 10 mg po daily
Check HR and BP before taking medication
Monitor for symptoms -> dry, productive cough
First-dose hypotension<\/li>\n\n\n\n - Indication: hypertension<\/li>\n\n\n\n
- Dose: 10-40 mg po daily<\/li>\n<\/ol>\n\n\n\n
Colchicine<\/p>\n\n\n\n
\n- directions for use<\/li>\n\n\n\n
- indication<\/li>\n\n\n\n
- common doses<\/li>\n\n\n\n
- Directions: take 1.2 mg po then 0.6 mg one hour after (acute)
Take 0.6 mg po 3x daily for 1.8 mg max dose<\/li>\n\n\n\n - Indication: acute gout flare-up and prophylaxis<\/li>\n\n\n\n
- Dose: 1.2 mg initial dose then 0.6 mg one hour after or 0.6 mg 3x, should not exceed 1.8 mg<\/li>\n<\/ol>\n\n\n\n
Amlodipine (Norvasc)<\/p>\n\n\n\n
\n- directions for use<\/li>\n\n\n\n
- indication<\/li>\n\n\n\n
- common doses<\/li>\n\n\n\n
- Directions: take 5 mg po daily (2.5 mg if elderly) visit the provider to evaluate the dose adjustment in 1-2 weeks
Check HR and BP before taking medication<\/li>\n\n\n\n - Indication: hypertension<\/li>\n\n\n\n
- Dose: start at 5 mg po daily, adjust the dose in 1-2 weeks<\/li>\n<\/ol>\n\n\n\n
Which medications are schedule II drugs, select all that apply:<\/p>\n\n\n\n
\n- valium & Ativan<\/li>\n\n\n\n
- Oxy<\/li>\n\n\n\n
- Fentanyl<\/li>\n\n\n\n
- Methadone<\/li>\n\n\n\n
- Oxy<\/li>\n\n\n\n
- Fentanyl<\/li>\n\n\n\n
- Methadone<\/li>\n<\/ol>\n\n\n\n
(also includes Adderall- requires monthly visit including drug and tox screening)<\/p>\n\n\n\n
Which medications are schedule III drugs, select all that apply:<\/p>\n\n\n\n
\n- Xanax<\/li>\n\n\n\n
- Tramadol<\/li>\n\n\n\n
- <90mg of codeine<\/li>\n\n\n\n
- Anabolic steroids<\/li>\n\n\n\n
- <90mg of codeine<\/li>\n\n\n\n
- Anabolic steroids<\/li>\n<\/ol>\n\n\n\n
What is the abuse potential with schedule III drugs?
Moderate to Low potential for abuse<\/p>\n\n\n\n
Which medications are schedule IV drugs, select all that apply:<\/p>\n\n\n\n
\n- Ativan<\/li>\n\n\n\n
- Tramadol<\/li>\n\n\n\n
- Methadone<\/li>\n\n\n\n
- Adderall<\/li>\n\n\n\n
- Ativan<\/li>\n\n\n\n
- Tramadol<\/li>\n<\/ol>\n\n\n\n
An 82-year-old male visits the clinic complaining that his pain meds “Take forever” to work after he takes his pill. What are possible reasons you can explain to him?<\/p>\n\n\n\n
\n- Perhaps we need to increase your dose.<\/li>\n\n\n\n
- Sometimes as you get older, absorption may be slower resulting in a delayed response.<\/li>\n\n\n\n
- As we get older the gastric acid decreases making it harder to break up the med, causing a slower absorption.
-Sometimes as you get older, absorption may be slower resulting in a delayed response.<\/li>\n<\/ol>\n\n\n\n