NAPLEX 72-page review guide | Complete Updated 2025 A+ Guide.

NAPLEX 72-page review guide | Complete Updated 2025 A+ Guide.ALLERGIC RHINITIS sneezing, itchy nose, eyes or throat, watery eyes, rhinorrhea (runny nose), nasal congestion, post-nasal drip. NON-PHARM Tx: DRUG Tx: 1. AVOID exposure to allergens. 2. IgE – mediated or Blood test. 3. Nasal irrigation – saline, propylene/polyethylene glycol 4. Neti Pot 5. Boiled/Distilled H2O – NEVER use faucet water. 1. Chronic, Mod-Severe rhinitis a. 1st LINE = Intranasal Corticosteroid 2. MILD sx = Oral Antihistamine a. Decongestants can be used or other agents for itchy eyes. Intranasal Corticosteroids *1st LINE = for mod-severe most effective class of med to decrease inflammation Have different names for allergy relief & asthma. GENERIC BRAND ADRs BBW COUNSELING NOTES Beclomethasone Beconase, Qnasl HA, dry nose, bad taste, epistaxis (nose bleed), and local infection. - Adrenal suppression w/ long-term use. - Delayed wound healing - Avoid if nasal ulcers or trauma. - Stunt growth in children - IOPÇ , open-angle glaucoma, cataracts. FLONASE & NASACORT Counseling: 1. Shake bottle 2. Flonase = Prime 7-days no use 3. Nasacort = Prime 14-days no use 4. Point away when priming 5. Tilt head forward & inhale while spraying in nose. 1. May take 1 week to get relief. 2. Pregnancy - Use Budesonide 3. Get nasal exams for long use. 4. AVOID contagious people 5. Shake well before use Budesonide Rhinort Aqua Fluticasone Flonase Mometasone Nasonex Triamcinolone Nasacort Ciclesonide Omnaris, Zetonna Flusinolide Oral Antihistamines 1st generation (more drowsiness) 1st LINE = Mild-Mod Sx. Effective relief of itching, sneezing, rhinorrhea, other immediate hypersensitivity rxns. Has little effect on nasal congestion. GENERIC BRAND ADRs BBW CONTRAINDICATIONS NOTES Diphenhydramine HCL Benadryl *Do NOT use 6 YO ADULTS = 25-50mg PO Q4-6H Somnolence, cognitive impairment, strong anticholinergic effects - AVOID use in elderly - Caution in CVD, - Prostate enlargement - Glaucoma - Asthma - Excessive sedation. - AVOID use in 2 YO Infants, lactating women, narrow-angle glaucoma, asthma, AVOID MAOi, symptomatic BPH, peptic ulcer Lactating women should use 2nd gen ALL should be D/C before allergy skin testing. 1st gen cause photosensitivity Clemastine Tavist, Dayhist Chlorpheniramine Chlor-Trimeton, Chlorphen Carbinoxamine Arbinoxa, Karbinal Oral Antihistamines 2nd generation (preferred due to less sedation & more cognitive function) Cetirizine Zyrtec Somnolence occasionally - CNS depression - Sedation w/ other sedating meds Levocetirizine w/ ESRD 1. Fexofenadine: Take w/ H2O 2. AVOID Al+/Mg+ products 3. PREGO - Loratadine/Cetirizine best Levocetirzine Xyzal Fexofenadine Allegra Loratadine Claritin Desloratadine Clarinex Intranasal Antihistamines Azelastine Astelin, Astepro Somnolence, bitter taste, Olopatadine Patanase HA, nosebleed Helps w/ Nasal congestion Oral Decongestants α-Adrenergic-Agonist Products containing "D" contain Phenylephrine or Pseudoephedrine Vasoconstriction of sinus vessels GENERIC BRAND ADRs BBW CONTRAINDICATIONS NOTES Phenylephrine HCL Sudafed PE CV + CNS stimulation - AVOID in 2 YO 14 Days w/ MAOi Phenylephrine: HTN, tachycardia Phenylephrine low BA PSE more effective Pseudophedrine Sudafed, Nexafed, ONSET 15-60 mins Zephrex-D Topical (Intranasal) Decongestants Oxymetazoline Afrin Stingy, burning, sneezing, dryness, rebound congestion after 3 days - AVOID in 2 YO - MAOi use Effective in 5-10 mins *Limit use to 3 days to potential rebound congestion. Naphazoline Privine Tetrahydrozolline Tyzine Other GENERIC BRAND MOA ADRs BBW CONTRAINDICATIONS NOTES Intranasal Cromolyn Nasalcrom MAST-cell Stabilizer Can be used as Tx + Px Ipratroprium Bromide Atrovent Anticholinergic GOOD for Rhinitis by drying nose out Montelukast Singulair leukotriene antagonist 10 mg PO QD, can be used as adjunctive tx Sublingual Immunotherapy Allergy Shots - 1st dose MUST be given in doctor's office w/ PT monitored 1st 30 mins *PT should get RX for Epinephrine PenCOLD Viral infxn of URT caused by Rhinovirus/Coronavirus. ÖTransmit through hands or by air. ÖPractice correct hand-washing technique. ÖSelf-limiting NON-PHARM Tx: DRUG Tx: 1. Zinc 2. Vitamin C (Absorbic acid) 3. Echinacea 1. Expectorants 2. Cough suppressants 3. Decongestants (refer to allergic rhinitis for drug chart) 4. Analgesics/Antipyretics Expectorant – removes phlegm GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Guaifenesin Mucinex, Robitussin N/V/D, dizzy, HA, rash, upset stomach Child 2 yo MAX = 2000 mg/day (Adult) Cough Suppressants DM = 5-HT + NMDA blocker Benzonatate = Topical anesthetic GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Dextromethorphan Delysm, DayQuil N/V, drowsiness, Serotonin Syndrome MAOi use 14 days DM = Dextromethorphan Must be 18 yo to buy Codeine N/V, sedation, constipation, hypotension BBW: Respiratory depression Child 12 yo Additive CNS effect w/ other CNS depressants Benzonatate Tessalon. Zonatuss Somnolence, confusion, hallucination *AVOID in child 10 yo Diphenhydramine Benadryl Combination Products Pediatric Concerns/Dosing for Cold medications GENERIC BRAND Cough/Cold Products Acetaminophen in Infants Ibuprofen in Infants Dextromethorphan/Promethazine Per FDA, don’t use • OTC meds in 2 yo • Codeine in child 12 yo Per manufacturer (relabeled) • NO child 4 yo Per AAP - NO child 6 yo Do NOT use Promethazine in 2 yo Use 1. Hydration, nasal bulbs, saline drop/spray 2. Ibuprofen or Acetaminophen a. Do NOT use ASA (Reyes Sx) {160mg/5mL} Dose: 10-15 mg/kg/dose Q4-6H PRN Max: 5 doses/24hr Drops: 50mg/1.25 mL Suspension: 100 mg/5 mL Dose: 5-10 mg/kg/dose Q4-6H PRN Max = 40 mg/kg/day Brompheniramine/PSE/DM BromFed DM Promethazine/Phenylephrine/Codeine Promethazine VC/Codeine GuaiFENesin/Codeine Robafen AC, Virtussin AC GuaiFENesin/Codeine/PSE Cheratussin, Mytussin DAC Chlorpheniramine/Hydrocodone TussiCaps, Tussionex, VituzASTHMA Inflammation & bronchoconstriction Ö Airway obstruction and low expiratory exhalation. Characteristics of Disease Control Risk Factors 1. Recurrent wheezing, breathlessness, chest tightness, & coughing. (Freq. at night & waking) 2. Reversible w/ meds. 3. Exacerbations can be mild-severe-fatal. 4. Triggered by environment & inflammatory mediators: Histamine, Leukotriene, Cytokines, Mast cells, Eosinophil, or genetics (IgE). Can be any of the following: a. Allergens, dust, smoke, chemicals, weather, b. Lifestyle (stress/exercise), respiratory infxns c. Meds: ASA, NSAIDs, BB's 5. Comorbidities: Allergy, GERD, Obesity, Sleep apnea, Anxiety, Depression. 1. Avoid Smoking 2. Avoid Triggers 3. Keep exercising (even if EIB) 4. Annual Flu shot 5. PPSV23: Age 2-64 yo 6. PCV-13: Age 6-18 yo Diagnosis Classification Assess Expiratory volume 1. Spirometry a. Test Forced Vital Capacity (FVC) in 1 second (FEV1) 2. Peak Expiratory Flow (PEF) a. use Peak Flow Meter measuring daily (see below) Impairment Criteria Intermittent Mild-Persistent Mod-Persistent Severe-Persistent Daytime Sx ≤ 2 days/wk 2 days/wk NOT daily Daily Throughout Day Night time awakenings ≤ 2x/month 3-4x/month 1x/wk NOT nightly Often 7x/wk Rescue Inhaler use ≤ 2 days/wk 2 days/wk OR 1x/day Daily Several times a day Activity Limitations none Minor Some Extreme Lung Fxn - FEV1% 80% 80% 60-80% 60% FEV1/FVC Normal Normal 5% Reduction 5% Reduction Risk Criteria Intermittent Mild-Persistent Mod-Persistent Severe-Persistent Exacerbations req. PO steroid 0-1 per year ≥2 per year Steps for Initiation STEP 1 STEP 2 STEP 3 – consider PO steroid STEP 4/5 – consider PO steroid Peak Flow Meter 1. Use every morning before any asthma meds. 2. Stand up straight Š Exhale 3. Inhale deeply then blow out HARD & FAST into PEFR & record the highest of 3 tries. 4. Clean 1x/wk GREEN Zone = 80-100% YELLOW Zone = 50-80% (Need Action Plan) RED Zone = 50% of personal best (Go to Emergency Room) Treatment Algorithm Effectiveness of Therapy General Information STEP 1 SABA PRN (ALL PTs must have SABA PRN) STEP 2 Low Dose ICS Alternate Tx: Cromolyn, LTRA, Theophylline STEP 3 Low-dose ICS + LABA or Med-dose ICS Alternate Tx: Zileuton, LTRA, STEP 4 Med-dose ICS + LABA Theophylline STEP 5 High-dose ICS + LABA Consider adding Tiotroprium for PTs 6 yo if Hx of STEP 6 High-dose ICS + LABA + PO steroid exacerbation. 1. Follow up in 2-6 wks 2. Check Adherence to meds 3. Counsel technique/cleaning 4. Control risks, triggers, comorbidities 5. Review action plan 6. Determine step-up/down Tx 7. Follow up 1-6 months if controlled. Well Controlled: 1. Sx/SABA use ≤ 2 days/wk 2. Nightime awake ≤ 2x/month 3. No limits to activity Maintain step/step down if controlled for 3 mons. Spacers: • Helps to coordinate inhalation w/ MDI into lungs & prevents thrush. • Clean 1x/wk soap water Nebulizer: • Turns liquid meds into fine mist. If prescribed 1 inhaler PT must wait 60 secs b/t each: • 1st: SABA • Any other Bronchodilator • LAST: ICS Exercise induced bronchospasms (EIB): • SABA is preferred 5-15 mins before exercise but Salmeterol (LABA) can be used unless it is being used for maintenance. Montelukast must be taken 2 hrs prior to exercise. • Rescue Inhalers: should last 12 months w/ good asthma control. NOT Controlled: 1. Sx/SABA use 2 days/wk 2. Nightime awake 1-3x/wk 3. Some limits to activity Step up 1 step POORLY Controlled: 1. Sx/SABA use several times/day 2. Nighttime awake ≥ 4x/wk 3. Extreme limits to activity Step up 1-2 stepsASTHMA Drug chart β Agonists - Relax smooth muscle Š Bronchodilation GENERIC BRAND ADRs BBW CONTRAINDICATIONS/CAUTIONS NOTES Albuterol (SABA) ProAir HFA ProAir RespiClick Ventolin HFA Proventil HFA Nervousness Tremor Tachycardia Palpitations Hyperglycemia K+ ¶ Caution w/ CVD, Glaucoma, Hyperthyroidism, Seizures, Diabetes - MDI's (HFA): Shake well before use - Albuterol inhalers = 200 puffs/inhaler o Except Ventolin HFA = 60 inhales - EIB: 2 inhales 5 min. before exercise Levabuterol (SABA) Xopenex Salmeterol (LABA) Serevent Diskus (DPI) ÇRisk of Asthma related death - ONLY used for PTs on ICS but symptoms not controlled - ADD on therapy to Medium dose ICS before increasing to High dose ICS - NEVER use NON-Selective β agonists Racepinepherine OTC (SABA) Inhaled Corticosteroids (ICS) – inhibits inflammation Beclomethasone QVAR Dysphonia (Hard to talk) Oral Thrush Cough URTI Hyperglycemia - Not used for primary Tx of Asthma or acute episodes of asthma - Adrenal suppression, risk of fractures, stunt child growth - 1st Line for ALL w/ Persistent Asthma - Rinse mouth w/ warm H2O or use spacer to prevent thrush. Budesonide Pulmicort Flexhaler Fluticasone Flovent HFA Arnuity Ellipta - DPI Mometasone Asmanex HFA -MDI Asmanex Twisthaler - DPI Ciclesonide Alvesco Flunisolide Aerospan Leukotriene Receptor Antagonists – reduces airway inflammation Montelukast Singulair Headache Dizzy Ab pain URTI LFTs Ç Neuropsychiatric events - Mostly used in Children - Montelukast: 10 mg PO QHS o Granules: must be used w/in 15 mins. - Zileuton: taken with food - Zafirlukast: taken on empty stomach Zileuton Zyflo Hepatic imp. Zafirlukast Accolate Anticholinergic Tiotropium Spiriva Respimat Hyperthermia Dry skin/dry mouth Mydriasis Constipation Urinary retention - Approved for 6 YO for Asthma w/ Hx of exacerbations despite ICS/LABA Tx. Xanthines - Blocks Phosphodiesterase Š ÇcAMP Š Bronchodilation Theophylline Theo-24 Theo-Cron Elixophyllin N/V/HA HR increase Insomnia Tremor/Nervous - CVD, Hyperthyroidism, PUD, Seizures - Small increase in dose → Large increase in concentration o Loading dose based on IBW - MANY DRUG interactions due to IA2/3A4/2E1 inhibition - Monitor Serum Conc. Š Tx Range = 5-15 mcg/mL o Measure PEAK - Active metabolites: Caffeine & 3-methylxanthine - Aminophylline → Theophylline: Multiply 0.8x Monoclonal antibody - inhibits IgE Omalizumab Xolair Injection site rxn Arthralgias Dizzy/Fatigue Anaphylaxis Given SC Q2-4 wks only in Hospital under medical supervision. Indication: Allergic asthma in PT 6 YO & positive allergen skin test & ICS isn’t enough. Interleukin-5 (IL5) Antagonist – inhibits IgE Mepolizumab Nucala Injection site rxn Arthralgias Dizzy/Fatigue Indication: 12 YO given SC route for Eosinophillic Asthma Reslizumab Cinqair Anaphylaxis IV onlyASTHMA Counseling Meter Dosed Inhalers (MDI) General 1. HFA, Respimat, or if there is Suffix (QVAR) 2. Aerosolized liquid med 3. HFA uses Propellant 4. Req. SLOW DEEP inhalation same time as pressing button. 5. SPACER can be used 6. SHAKE Well except for QVAR, Alvesco, Respimat DIRECTIONS FOR USE: 1. Shake 5 secs before spray 2. Exhale fully 3. Inhale slowly/deeply while pressing button. 4. Hold breath 10 secs or long as possible. Ventolin HFA PRIME: Spray 4x: into air while shaking between sprays. Prime if not used for 14 days or if dropped. CLEAN: ProAir HFA Remove metal canister (do not get wet) & rinse mouthpiece w/ warm H2O then AIR DRY (1x/wk). Flovent HFA PRIME: Spray 4x into air while shaking between sprays. Prime if not used for 7 days or 5 days for Dulera CLEAN: Use clean cotton swab to wipe mouthpiece then AIR DRY. Dulera CLEAN: Wipe mouthpiece w/ clean dry cloth. NEVER put in H2O. Symbicort PRIME: Spray 2x into air while shaking between sprays. Prime if not used for 7 days or ≥10 days for QVAR CLEAN: QVAR Wipe mouthpiece w/ clean dry cloth. NEVER put in H2O Dry Powder Inhalers (DPI) Soft Mist Inhaler/Inhalation Spray General 1. Diskus, Ellipta, Pressair, Handihaler, Neohaler, RespiClick. 2. Fine powder inhalation 3. NO Propellant 4. Req. forceful quick inhalation w/o pressing button same time 5. NO SPACERS 6. Do NOT Shake Combivent, Spiriva, Striverdi, Stiolto 1. Propellant free and delivers drug in fine mist 2. Better lung deposition and requires less inhalation effort 3. To use for first time (keep cap closed until step 5) a. Press safety catch and pull off clear base b. Insert cartridge into inhaler and push against surface c. Replace clear base d. Turn base in direction of arrow until you hear a click e. Flip open cap until it clicks into open position f. Point inhaler toward ground and press dose release button until a cloud is visible then repeat 3 more times before use 4. Daily use (T.O.P) a. Turn base in direction of arrow until you hear a click (keep cap closed) b. Open cap until it clicks into open position c. Close lips around inhaler and Press button while taking in a slow deep breath Advair Diskus 1. Pull Thumb-grip away til mouthpiece shows. 2. Slide lever until it clicks. 3. Exhale away from mouth. 4. Inhale quick/deep 5. HOLD long as possible or 10 sec 6. Rinse mouth w/ H2O & spit. Do NOT wash just AIR DRY Pulmicort Flexhaler 1. Twist off white cover while twisting brown base far as it will go in other direction til you hear a click. (Loaded) 2. Do NOT shake the inhaler. 3. Turn head away & exhale fully. 4. Inhale deep/forcefully. 5. Rinse out mouth and spit. Let AIR DRY no H2O Combination Products ICS/LABA Combos: Budesonide/Formoterol (Symbicort) Fluticasone/Salmeterol (Advair Diskus/HFA) Mometasone/Formoterol (Dulera) ProAir RespiClick AirDuo RespiClick 1. Open cap all the way til it clicks. a. Opening/Closing cap w/o inhaling wastes medication. 2. Exhale all the way away from inhaler. 3. Inhale deeply & HOLD long as possible or 10 secs NO PRIMING needed. Only use dry cloth NO H2O to clean.SMOKING CESSATION GENERAL INFORMATION The "5-A's" Model: 1. Providers must inquire about Tobacco use. 2. 1-800-QUIT-NOW 3. Counseling is just as important as medications. 4. Combination Tx can be used 1st LINE. 5. Meds are always recommended unless CI. 6. E-Cigs should not be recommended. 7. Counsel all pregnant women, children, & light smokers (10 cigs/day). 8. Smokers 19-64 YO need Flu + Pneumovax 23 vaccines. 9. Smoke induces CYP450-A12 → Supratherapeutic levels of med. 10. Women 35 YO should not take Oral Contraceptive (CVD risk) 1. ASK about tobacco use. 2. ADVISE to quit. 3. ASSESS willingness to quit. 4. ASSIST in quit attempt. 5. ARRANGE follow up. GENERIC BRAND ADRs BBW C/I NOTES Nicotine Patch NicoDerm CQ Nicotine Replacement Tx (mostly OTC) - ALL products; wait 15 mins after eating or drinking for use 1. HA/Dizzy 2. Insomnia 3. Nervousness *Patch: vivid dreams *Inhaler: throat irritation AVOID in post-MI, arrhythmias, angina, and pregnancy. 1. 18 yo + ID for purchase 2. Combo w/ short-acting = Most effective 3. Remove patch before MRI. 4. Gum/Lozenge (4mg) shown to reduce weight gain. Nicotine Polacrilex Gum Nicorette Nicotine Polacrilix Lozenge Nicorette Mini Nicotine inhaler Nicotrol inhaler (RX) Nicotine Nasal Spray Nicotrol Spray (RX) Other Medications GENERIC BRAND MOA ADRs BBW CONTRAINDICATIONS NOTES Buproprion SR Zyban Dopamine/NE Blocker tapering not needed 1. Dry mouth 2. Insomnia 3. Agitation 4. Headache Suicidal behavior in young pts like other Anti-depressants. 1. Seizure disorder 2. Anorexia/Bulimia 3. MAOi 14 days 4. Benzos, AEDs, Barbiturates - Do NOT use w/ other forms of Buproprion. - Start 1 week before quitting smoke. - MAX Dose = 300 mg/day - Wait 8 hrs if splitting dose. N/V/Dizzy, constipation, tremors, blurred vision, anxiety, tachycardia, sweating. Varenicline Chantix α-4-β-2 nicotinic agonist tapering not needed 1. Insomnia 2. Nausea 3. Abnormal dreams 4. Headache 1. Serious Psychiatric behavior 2. Seizures 3. Ç ETOH + Blackout risk 4. Sleep walking pts unable to quit immediately should cut smoking by 50% every 4 weeks. - START 1 week before quit date OR START and quit between 8-35 days. - Take after meal + glass of H20. - Decrease ETOH use. Constipation, vomiting, flatulence. - Caution serious rxns (facial swelling, rash, peeling skin) Counseling & Dosing DRUG COUNSELING DOSING Nicotine Patch 1. Apply new patch start of each day, dispose used in Pouch. 2. Apply to clean, dry, hairless skin & hold for 10 secs. 3. Wear the patch for 24 hrs. Only remove before sleep if abnormal dreams occur. 4. Fold inward & discard in pouch then place in trash. 5. Wash hands before/after use. 6. Rotate site of patch. Don’t use same site for 1 week. 7. NEVER cut patch or use 1 patch at a time. Cigarette use Week 1-6 Week 7-8 Week 9-10 10 cigs/day 21 mg patch 14 mg patch 7 mg patch ≤ 10 cigs/day 14 mg patch 7 mg patch No recommendation Nicotine Gum 1. Chew slowly til "tingle" or "flavored taste" then PARK gum in cheek. a. Repeat when tingle/flavor goes away 2. Use for 30 mins. 3. Use 1 piece Q1-2hrs No more than 24 pieces per day *Min 9 pieces/lozenges per day for the 1st 6 wks Chew/Dissolve 1 piece every: Smoke 1st cigarette Dose Weeks 1 – 6 Q1 – 2H 30min after waking 2mg Ö Weeks 7 – 9 Q2 – 4H ≤ 30 min after waking 4mg Weeks 10 – 12 Q4 – 8H Nicotine Lozenge 1. Place in mouth let DISSOLVE slowly 2. Move side to side for 20-30 mins. 3. NEVER use 1 at a time. No more than 20 lozenges per day Nicotine Inhaler 1. Puff inhaler in short/freq breaths + inhale deeply. 2. Each cartridge gives 20 minutes of continuous puffing. 3. Clean mouthpiece w/ soap + water regularly. 4. Keep at room temp (in pocket). Nicotine Nasal Spray 1. Spray once in each nostril while breathing through mouth. 2. Do NOT sniff, swallow, or inhale through nose 3. Wait 5 mins after use before driving or heaving machines.PULMONARY ARTERIAL HYPERTENSION (PAH) continuous high BP in the pulmonary arteries. PAH = mean PAP (mPAP) ≥ 25 mmHg. Signs & Symptoms Causes of Pulmonary Fibrosis: NON-PHARM Tx: DRUG Tx: Fatigue Dyspnea Chest pain Syncope Edema Tachycardia Amiodarone Methotrexate Nitrofurantoin Sulfasalazine 1. Sodium restrict 2.4 g/day 2. Flu/Pneumonia Vaccines 3. Avoid High Altitudes. 4. O2 Sat 90. 1. Anti-Coagulation w/ Warfarin: INR Goal = 1.5 - 2.5. 2. Loop Diuretics for volume overload. 3. Digoxin to improve CO or control HR. 4. Perform Acute Vasoreactive Testing. a. During which drugs are given to illicit a response. i. RESPONDER: mPAP falls by at least ≥10 to a value less than 40. 1. Give CCB: Nifedipine, Diltiazem, and Amlodipine. a. NOT Recommended = Verapamil. ii. NON-RESPONDERS: or PTs failing CCB Tx need ≥1 vasodilator. 1. Prostacyclins, ERAs, PDE-5, or sGC. Treatment Algorithm Prostacyclin Analogues (Prostanoids) - Potent Vasodilator + Inhibit platelet aggregation. WHO-FC: World Health Organization Functional Classification - Class I = patients with PH but without limitation of physical activity - Class II = patients with PH resulting in slight limitation of physical activity - Class III = patients with PH with marked limitation of physical activity - Class IV = patients with PH unable to be physically active and with signs of right heart failure GENERIC BRAND ADRs BBW C/I NOTES Epoprestenol Flolan (IV) Veltri (IV) Vasodilation Rxns - (Hypotension, HA, Dizzy, Flushing) N/V/D Jaw Pain Anxiety/Tremor Thrombocytopenia Infusion-site Pain Rebound PAH (Don't DC abruptly) IV infusions → Infections Heart failure - Parenteral = most potent. - Avoid interruption in Tx. - Avoid large/sudden dose reductions. - Epoprostenol = Protect from light - Flolan = reqs. ice packs for solution. - Avoid NSAIDs Trepostinil Remodulin (IV, SQ) Tyvaso (inhaled) Orenitram (ER tab) Hepatic imp. Iloprost Ventavis (inhaled) Selexipag Uptravi (tab) Endothelin Antagonist (ERA) - Blocks Endothelin vasoconstriction. GENERIC BRAND ADRs BBW C/I NOTES Bosentan Tracleer HA URTI Flushing Hypotension Fluid Retention ¶Hgb/Hct Embryo-Fetal toxicity - Women need Neg. Prego test before use & monthly. Bosentan = Hepatotoxicity (ALT/AST) Pregnancy - REMS Program Bosentan = ↓ effectiveness of Contraceptives. Ambrisentan Letairis Macitentan Opsumit PDE-5 inhibitor - Pulmonary relaxation/vasodilation. GENERIC BRAND ADRs BBW C/I NOTES Sildenafil Revatio HA Flushing Dyspepsia Extremity/Back pain Epitaxis Hypotension Hearing/Vision loss Priapism Use of Nitrates or Tadalafil Adcirca Riociguat. Soluble Guanylate Cyclase (sGC) GENERIC BRAND ADRs BBW C/I NOTES Riociguat Adempas Headache Bleeding Pulmonary edema Hypotension N/V/D Embryo-Fetal toxicity - Women need Neg. Prego test before use & monthly. - Pregnancy - use of PDE-5 or Nitrates - REMS Program - Space out o Sildenafil = 24 hrs o Tadalafil = 48 hrsGOUT Uric acid built up in joints – end-product of Purine metabolism. → PT may be Asymptomatic → Sx - painful, burning, swelling joint. → Typically starts in 1 joint (Big Toe) Risk Factors Treatment Pearls DRUG Tx • Male • Obese • Excess ETOH • HTN, CKD • Age • Meds 1. NEVER treat asymptomatic hyperuricemia. 2. ONLY Tx after Gout Attack. 3. GOAL = Uric acid 6mg 4. Drugs used to Tx different from ppx Acute Gout Attacks - Use NSAID, steroid, or Colchicine - Use meds at 1st sign of attack - Combination Tx w/ any 3 for severe attacks. - Ice packs or IA injection - Chronic urate-lowering Tx (ULT) should continue w/o interruption Chronic Urate-Lowering Treatment - ULT should be given to those w/ gout who had an attack, intermittent sx or tophi. - Gout ppx: NSAIDs or Colchicine - 1st LINE = Allopurinol (XOi) or Febuxostat - 2nd LINE = Probenecid (if XOi is C/I) or added if UA level isnt below 6mg/dL while maxed out on XOi. o Lesinurad is also 2nd Line taken w/ XOi. - Peglitocase - reserved for Severe Refractory dx Reduce risk: AVOID organ meats highfructose corn syrup, ETOH. Anti-gout = interference with migration of neutrophils GENERIC BRAND ADRs BBW C/I NOTES Colchicine Colcrys Mitigare NVD Myelosuppression Myopathy Neuropathy Cramping Loose stools Vit-B12 ¶ GI Sx Myopathy Myelosuppression Use w/ gemfibrozil, statins, non-DHP CCBs P-GP or CYP3A4 inhibitor 1. Start w/I 36 hrs of Sx onset. 2. Ppx dose should be held for 12 hrs AFTER Tx dose begins. 3. AVOID Cyclosporine - Dose: 1.2 mg PO (2x 0.6 mg) followed by 0.6 mg in 1 hr. o Do NOT Exceed 1.8mg/hr or 2.4mg/day. o Dose every 3 days (NO earlier) NSAIDs Indomethacin Indocin Refer to pain handout - AVOID use severe Renal Dx. - Celecoxib has most CVD risk Naproxen Naprosyn Celecoxib Celebrex Sulindac Clinoril Steroids – can be given PO, IV, IM, ACTH Prednisolone Prednisolone Hyperglycemia, HTN, insomnia, appetite increase Refer to steroids handout - 0.5 mg/kg/day 5-10 days OR 0.5 mg/kg/day 2-5 days followed by Methylprednisolone Medrol taper over 7-10 days Triamcinolone Xanthine Oxidase Inhibitors Allopurinol Zyloprim Rash, Nausea, Gout attacks, diarrhea, LFTs Ç Hepatotoxicity (in Asians HLAB*5801test prior) - Hypersensitivity (SJS/TEN) - Do not use for asymptomatic hyperuricemia - Didanosine - Mercaptopurine - Azathioprine - Peglitocase - Lower dose w/ CKD - Take w/ FOOD - 1st 3-6 mons. use w/ Colchicine or NSAID - AVOID Antacids use Febuxostat Uloric Rash, nausea, - Allopurinol - Start 100mg titrate up to 300mg divide BID arthralgia, LFTs Ç Hepatotoxicity, Thrombosis, Gout attack Uriosurics Probenecid Hypersensitivity Hemolytic Anemia Warning: CrCl 30 Hemolytic anemia in G6PD deficiency Do NOT with use ASA Blood dyscrasias, nephrolithiasis G6PD deficiency, child 2 yo - Combination with Colchicine available (Col-Benemid) - Probenecid can be used to Ç Beta-Lactam levels - Decrease clearance of ASA, PCNs, cephalosporins, carbapenems. - Decreases efficacy of Loop diuretics while increasing toxicity. Lesinurad Zurampic SCr Ç, renal failure, nephrolithiasis, HA Acute Renal failure CrCl 30, ESRD, Dialysis, Kidney Transplant - Take QAM w/ XOI + FOOD + H2O Recombinant Uriocase Pegloticase Krystexxa AB formation, gout flare, infusion rxn, nausea, skin probs Anaphylaxis – (premedicate w/ Anti-histamines & Steroids.) G6PD deficiency - Injection ONLY - Give NSAID or Colchicine 1 week prior to infusion for 6 months. - NEVER use w/ Allopurinol or Febuxostat Rasburicase Elitek Edema, HA, anxiety, rash, NV, ab pain, diarrhea, constipation Anaphylaxis ONLY USED FOR: Tumor Lysis Syndrome - Injection ONLY - PT's at risk for TLS should receive IV hydration - Monitor CBC - Life-threatening complication of Chemo-Tx or Cancer. Cells lyse open and purines are released quickly converting to uric Acid, aka "Acute Gout" attack causing electrolyte abnormalities. ACUTE TX CHRONIC TXMOTION SICKNESS Signs & Symptoms NON-PHARM Tx: DRUG Tx: 1. Nausea 2. Dizziness 3. Fatigue 1. Sea-Band (acupuncture) 2. Ginger Tea 3. Peppermint 1. Transderm Scop 2. Meclizine 3. Diphenhydramine (Benadryl) 4. Promethazine (not for children) 5. Cyclizine (Marezine) Anti-Histamine/Anti-Cholinergic MOST commonly prescribed NOT more effective than OTC GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Scopolamine 3-Day Patch Transderm Scop Dry mouth CNS effects (drowsy, dizzy, confusion) Eyes Stinging Pupil Dilation Risk of IOP Tachycardia (rare) Belladonna Allergy Angle Closure Glaucoma Applied behind EAR Lasts 3 days. Anti-Histamine GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Meclizine Dramamine Bonine Day-Less Drowsy Motion Time Travel Sickness Sedation Dry mouth Dry/Blurry Vision Tachycardia WARNING: CNS Depression Impairment Worsens BPH Sx Increase IOP Oral agents must be taken 30 - 60 mins prior. TRANSDERM SCOP – Counseling Instructions 1. Apply to clean, dry, hairless area behind the ear. 2. Press firmly for at least 30 seconds to seal edges of patch. 3. Apply 4 hrs. before needed effect 4. Wash hands w/ soap before & after. (Avoid Eyes) 5. Renew patch only every 3 days & only one at a time. 6. Causes drowsiness so avoid ETOH. 7. Remove patch before MRI.ERECTILE DYSFUNCTION Most commonly caused by reduced blood flow to penis. Common in CVD such as HTN, Atherosclerosis, or Diabetes. Psychological Causes NON-PHARM Tx DRUG Tx: Drugs Causing ED • Depression • Stress • Spinal cord injury • Stroke 1. Weight Loss 2. Quit smoking/ETOH 3. Yohimbe 4. L-Arginine 5. Panax Ginseng • 1st Line = PDE-5 inhibitors • 2nd Line = Alprostadil SSRIs/SNRIs Beta-Blockers Clonidine 1st Gen Anti-Psychotics • (Haloperidol, Fluphenazine, Chlorpromazine, Risperidone, Paliperidone) BPH Meds • Finasteride, Dutasteride, Silodosin PDE-5 Inhibitors Release NO Š cGMP increase Š Smooth muscle relaxation Š Increase BF to penis. GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Sildenafil Viagra Revatio (for PAH) HA/Dizzy Flushing Dyspepsia Blurred vision Tinnitus Photosensitivity Epistaxis Diarrhea Myalgia/Back pain • mostly Cialis WARNING: Color discrimination Hearing/Vision loss Hypotension Priapism Chest Pain - Refer to PCP Use w/ Nitrates or Riociguat Viagra/Cialis 50% dose reduction if: • ≥ 65 yo • Using Alpha-Blocker (HypoTN) • Using CYP3A4 inhibitor • Severe Renal/Liver Dx Start 50mg 1hr before sex. Tadalafil Cialis Adcirca (for PAH) Daily 2.5-5 mg PRN 5-20 mg Avanafil Stendra Vardenafil Levitra Staxyn ODT Prostaglandin E1 - vasodilator that allows blood to flow GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Alprostadil - (Injections) Caverject Edex Penile pain Priapism HA/Dizzy Penile implants Penile abnormalities Must refrigerate Alprostadil - (Urethral Pellets) Muse Conditions that predispose to priapism (sickle-cell anemia, myeloma, leukemia) 5-HT1A agonist/5-HT2A antagonist - does NOT enhance sexual performance GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Flibanserin Addyi Dizzy Somnolence Nausea Fatigue Dry mouth Insomnia • ETOH causes Hypotension + Syncope. • AVOID CYP3A4 inhibitors • Hepatic impairment ETOH Pregnancy • For premenopausal women ONLY • REMS Program • Treatment for hypo-active sexual desire disorder (HSDD): o Low sexual desire that is not caused by health condition or drugs.BENIGN PROSTATE HYPERPLASIA General Information Signs & Symptoms (LUTS) Drugs that Worsen BPH AUA Guidelines for Tx • Enlarged gland leads to Lower urinary tract Sx (LUTS) • Bladder outlet obstruction (BOO) + contractions lead to freq. urination. • DRE - Digital Rectal exam • Study urinalysis + Prostate specific antigen (PSA) • NOT associated with prostate cancer • Sx are similar to prostate cancer • UTI infections are uncommon Hesitancy Intermittency Weak stream of urine Urgency Leaking/Dribbling Incomplete emptying Frequency Nocturia Anticholinergic medications Antihistamines Caffeine Decongestants Diuretics Testosterone products SNRIs TCA's Phenothiazines • Depends on severity of Sx. • No natural product recs. 1. Alpha-blockers 2. 5α-reductase inhibitors a. Do NOT use in BPH w/o enlargement. 3. Tolterodine optional 4. PDE-5 inhibitors α-blockers - relax smooth muscle leading to improved urinary flow GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES COUNSELING Terazosin (Non-selective) Dizziness/HA Fatigue Abnormal Ejaculation Fluid retention Rhinitis Orthostatic hypotension Syncope Floppy Iris Syndrome Priapism Angina Silodosin/Alfuzosin + CYP3A4 Hepatic imp. (Child-Pugh C) Renal imp. • Non-selective α-blockers must be titrated • Usually taken at bedtime to avoid first dose effect of orthostatic HTN. • Alone or combo w/ 5-alpha • 1st Line for Mod-Sev Sx. • Non-selective = More side Fx. • Caution w/ PDE-5 inhibitors (BP) • Alpha-Blockers do NOT shrink prostate or alter PSA levels. • Counseling: 1. Caution standing up 2. CNS Fx 3. Avoid ETOH Doxazosin (Non-selective) Cardura Tamsulosin (Selective Alpha-1A Blocker) Flomax 0.4mg 30 min after same meal each day. Alfuzosin (Selective Alpha-1A Blocker) Uroxatral Do NOT use if risk for QT Prolongation. Silodosin (Selective Alpha-1A Blocker) Rapaflo Can cause retrograde ejaculation (reduced or NO semen) 5α-reductase inhibitors - blocks conversion of Testosterone Š DHT GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES COUNSELING Finasteride Proscar Impotence Libido Ejaculation disturbance Breast enlargement/tender Increase risk of Prostate cancer. Women of child-bearing age Pregnancy Children • Pregnant women should not handle/take. • Shrink prostate + ¶PSA level • Do NOT use Proscar in a PT using Propecia for hair loss. Only used in BPH + enlargement Dutasteride Avodart PDE-5 inhibitors GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES COUNSELING Tadalafil Cialis Adcirca HA/Dizzy Flushing Dyspepsia Blurred vision Myalgia Diarrhea Color discrimination Hearing loss Vision loss Hypotension Priapism Chest pain Do NOT use w/ nitrates or Riociguat 5mg daily same meal.OVERACTIVE BLADDER General Information NON-PHARM Tx DRUG Tx: How to Minimize Dry Mouth Sx • Urinary urgency w/ or w/o incontinence (lacking control). • Increased frequency + nocturia • M3-Muscarinic receptors via ACH trigger stimulation of detrusor muscles Š involuntary contractions. • 1st Line Tx = Behavioral therapy Non-Drug Tx is 1st line 1. Bladder training 2. Kegel exercises 3. Dietary changes 4. Weight loss Drug Tx is 2nd line Combo w/ Non-Pharm tx. 1. Anti-Cholinergics 2. B-3 Agonists 3. Onabotulinumtoxin-A • Avoid combo Anti-cholinergics • Try Extended-Release • Try Oxybutynin gel/patch • Mirabegron - less dry mouth Anticholinergics - block ACH binding to Muscarinic receptors. XR formulations are preferred (less dry mouth) GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Oxybutynin Ditropan Dizzy/Drowsy Xerostomia Constipation Blurred vision Urinary retention Agitation Confusion Drowsiness Angioedema Urinary retention Gastric retention Low gastric motility Narrow Angle Glaucoma Oxybutynin Patch/Gel = Less dry mouth. Trospium XR = Empty Stomach Oxybutynin Patch Oxytrol Tolterodine Detrol Trospium XR Sanctura XR Solifenacin Vesicare Darifenacin Enablex Fesoterodine Toviaz Beta-3 agonist - causes less dry mouth GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Mirabegron Myrbetriq HTN Nasopharyngitis UTI HA/Dizzy Constipation Angioedema Urinary retention in BPH Caution w/ Digoxin Inhibit ACH release – 3rd Line Tx GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Onabotulinumtoxin-A Botox UTI Urinary retention Dysuria Swallowing trouble Breathing trouble Infection at injection site Prophylaxis with abx before admin. Anti-Diuretic Hormone GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Desmopressin Noctiva DDAVP injection Hyponatremia Nasal conditions Risk for Hyponatremia Loop diuretics CKD SIADH Fluid retentionSICKLE CELL ANEMIA General Information NON-PHARM Tx: DRUG Tx: Immunizations • Inherited RBC genetic disorder (most common in Blacks) • PTs have abnormal hemoglobin called HgbS. • Give concave sickle shape of RBC shortening lifespan of RBCs to 10-20 days Š anemia & fatigue. • PTs lack O2 transport & clumping in blood vessels. • Sickle Cell Crises: o Vascular occlusion leads to ischemia + O2-deprivation. o Vaso-occlusive Crisis (VOC) aka Acute Pain Crisis. ▪ Leads to pain in lower back, abdomen, chest, & extremities. • Functional Asplenia: o Decreased or absence of spleen function. ▪ Spleen becomes fibrotic & shrinks in size. ▪ PT unable to recycle RBCs & store/produce WBCs. • PTS are risk for Infections. Should get immunizations, ABX. 1. Blood Transfusions: a. GOAL Hgb = 10 g/dL. b. Risk of Iron overload. 2. Chelation Therapy: a. Used to remove excess Iron. Only cure is bone marrow transplant but risky + cost. 1. Immunizations 2. ABX 3. Analgesics a. Mild-Mod Pain: i. Tx w/ NSAIDs or acetaminophen, rest, compresses. b. Severe Pain: i. IV Opioids ii. PT-Controlled Analgesia (PCA) 4. Chelation Tx 5. Hydroxyurea or L-Glutamine a. Reduce complications 1. Influenza Type B Vaccine (HiB) 2. Pneumococcal vaccine 3. Meningococcal vaccine. Stimulates Hgb-F production GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Hydroxyurea Droxia Hydrea LFTs Uric Acid BUN/SCr N/V/D Mouth ulcers Anorexia Hyperpigmentation Atrophy of Skin/Nails Low Sperm count Myelosuppression Leukemia/Skin cancer Embryo-Fetal toxicity Avoid Live Vaccines Skin ulcers Pancreatitis Macrocytosis Use Sun Screen to protect skin. • IND: ≥ 3 Mod-Sev Pain crises in 1 year • Contraception is required - During & up to 1 year after • Hazardous - Wash hands & wear Gloves • Supplement Folic Acid • Monitor: o CBC w/ Differential o ANC 2000 Unknown GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES L-Glutamine Endari Constipation Nausea HA Back/Extremity pain Cough Mix each dose in 8 oz. of COLD or ROOM temp. beverage OR in 4-6 oz. of food.BIPOLAR DISORDER General Information Mania Diagnosis DRUG Tx: • Mood disorder w/ fluctuations from extreme sadness or hopelessness Š abnormally elevated overexcitement or irritable mood called mania or hypomania. • Each episode is a drastic change in mood/behavior. • Bipolar PTs are more susceptible to Drug-Induced extrapyramidal symptoms (EPS) esp. with first generation antipsychotics • Abnormally elevated/irritable mood for 1 week OR any duration req. hospitalization. • Depression • Inflated Self-esteem • Talkative • One topic to next • Easily distracted • High risk activities 1st line: SGAs are preferred for Tx of Bipolar disorders. 1. Toxicology should be performed if due to illicit drug use. 2. GOAL: to stabilize mood w/o inducing fluctuations. 3. Anti-Psychotics: only used if PT has psychosis. 4. Anti-Depressants: NOT recommended - induce mania a. ONLY given if PT is already on Mood Stabilizer BIPOLAR 1: BIPOLAR 2: ACUTE Tx: MAINTENANCE Tx: • Severe Mania • Intense Depression • May be Psychotic/Delusional (may req. hospitalization) • Hypomania • Does NOT affect social/work • NO cause of psychosis • Intense Depression • PTs feel better during Mania so often misdiagnosed for only Depression during that phase. 1st line for manic state • Valproate + Anti-Psychotic • Lithium + Anti-Psychotic 1st line for bipolar depression • Lithium • Lamotrigine Bipolar Depression: • Lamotrigine Bipolar Mania: • Valproate • Carbamazepine (Equetro) Mania + Depression: • Lithium +/- SGA Mood Stabilizers Pregnancy Medication Guides Treatment for both mania + depression Lithium Valproate Lamotrigine • NOT used for acute mania due to slow titration & severe rash. Carbamazepine Avoid • Valproate o Causes fetal syndrome • Carbamazepine o Causes fetal syndrome • Lithium o Causes abnormalities SGAs = Preferred d Anti-Depressants • MedGuide for Suicide risk. Anti-Psychotics • MedGuide for Death risk in elderly PTs w/dementia-related psychosis GENERIC BRAND ADRs BBW C/I NOTES DOSING Lithium Lithobid GI upset • Nausea, Anorexia, Ab-pain Cognitive Fx Cogwheel Rigidity Tremor Weight gain Polyuria/Polydipsia Hypothyroidism Lithium toxicity ÇRisk of Serotonin Syndrome • SSRIs/SNRIs • Triptans • Linezolid ÇRisk of Neurotoxicity (Ataxia, tremor, nausea) • Non-DHP CCBs • Phenytoin • Carbamazepine • Mild-Mod Renal Imp. (Lithium is 100% renally cleared) INITIATION: 1. Titrate slowly Š QHS 2. Take w/ FOOD 3. Drink plenty of FLUIDS Factors affecting concentration ÇLithium levels • ¶ sodium intake • ACEi/ARBs • NSAIDs (use ASA) ¶Lithium levels • Ç sodium Intake • Caffeine • Theophylline Dose Correctly: • 5 mL Solution = 8 mEq • 300mg Tab/Cap = 8 mEq Therapeutic Range: 0.6 - 1.2ANXIETY General Information NON-PHARM Tx: DRUG Tx: Benzodiazepines 1. Continuous + Severe amount of great distress, fear, & worry. 2. Inability to focus at school/work. 3. Harmful to relationships. DSM-5 Classifcation of Major Types of Anxiety: General Anxiety Disorder (GAD) Panic Disorder (PD) Social Anxiety Disorder (SAD) Obsessive Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) Cognitive Behavioral Tx (CBT) AVOID Drug-induced Anxiety • Albuterol • Anti-Psychotics • Bupropion • Caffeine • Decongestants (PSE) • Illicit Drugs • Steroids • Stimulants • Levothyroxine • Theophylline 1st line = SSRI or SNRI • Escitalopram • Fluoxetine • Paroxetine • Sertraline • Duloxetine • Venlafaxine XR 1. Start at 1/2 initial dose 2. Slowly Titrate 3. Take 4-wks for relief 2nd line: • Buspirone o takes 2-4 wks • Amitriptyline (Elavil) • Imipramine (Tofranil) • Nortriptyline (Pamelor) • Hydroxyzine (Vistaril) o Sedating Anti-histamine o NOT used long-term • Pregabalin (Lyrica) o C5 - Tx anxiety + neuropathy • Propranolol (Inderal) Metabolism + Safety • Lorazepam • Oxazepam • Temazepam "L-O-T" are less harmful for PTs w/ Liver impairment since metabolized to inactive compounds (Glucuronides) 1. Used short-term & fast relief. 2. Used for acute-anxiety. 3. D/C after 1-2 wks. 4. ANTI-DOTE = Flumazenil GENERIC BRAND ADRs BBW CONTRAINDICATIONS NOTES Buspirone Nausea/Headache Dizziness Drowsiness • MAOi w/in 14 days • Avoid Serotonergic Meds (Serotonin Syndrome) Benzodiazepines (C4) GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Lorazepam Ativan Somnolence Dizziness Lightheadedness Weakness Ataxia BBW: Respiratory Depression Coma/Death WARNINGS: • Dependence/Tolerance in chronic use so must taper off (if using 10 days) • Amnesia • CNS depression • Abuse • 65 yo: safety risks. • Opioids • Pregnancy • AVOID other CNS Depressants ALPRAZOLAM: • C/I with Ketoconazole/Itraconazole (Strong CYP3A4) Diazepam: • Lipophilic • Fast Onset/Long Half-life • High Abuse potential Used for ETOH Withdrawal Sx: • Lorazepam • Diazepam • Chlordiazepoxide Alprazolam Xanax Clonazepam Klonopin Diazepam Valium Oxazepam Chlordiazepoxide Clorazepate Tranxene-T Temazepam Restoril NOT FOR ANXIETYALZHEIMER’S DISEASE General Information Signs & Symptoms Drugs that WORSEN Dementia: NON-PHARM Tx: DRUG Tx: • Cognitive decline Š dementia w/ noticeable memory loss. • Tx does very little for neurotic plaques & tangles. • DIAGNOSIS: Mini-Mental State Exam (MMSE Score 24) • ELDERLY PTs: o AVOID use of AntiCholinergics such as Diphenhydramine or Benztropine. • Memory loss • Difficulty communicating • Inability to learn • Difficulty planning or organizing • Poor coordination/ motor fxn • Personality changes • Paranoia/agitation/ hallucination • Anti-Histamines • Anti-Cholinergics • Anti-Emetics • Anti-Psychotics • Barbiturates • BZDs • Benztropine • Muscle Relaxants • Other CNS Depressants 1. Vitamin-E 2. Gingko Biloba (Çbleed risk) 3. Vitamin-D (helps memory) 4. Diet & Exercise • ACH inhibitors - slows progression o Donepezil - Take at bedtime. o Memantine - Alone or Adjunct to other meds • Anti-Psychotics/Anti-Depressants may be used but risk of: o Death in elderly (Psychotics) ACH Inhibitors - inhibit Acetylcholinesterase (ÇACH) GENERIC BRAND ADRs BBW CONTRAINDICATIONS NOTES Donepezil Aricept N/V/D Bradycardia Fainting Insomnia QT-Prolongation • Avoid drugs that ¶ HR due to risk of dizziness/falls. • Avoid Anti-Cholinergics = ¶efficacy • Give Donepezil at NIGHT to ¶ nausea. (5 - 10 mg QHS) Start at low dose Š Titrate Recommended: • Exelon Patch or Donepezil ODT o ¶ GI side fx. Donepezil + Memantine Namzaric Rivastigmine Exelon Galantamine Razadyne NMDA Blocker GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Memantine Namenda Dizziness Headache Constipation • Oral Solution available • ER Caps: Do not crush/chew • May sprinkle on applesauceSTEROIDS General Information Reduce Systemic Risks by Medrol Dose-Pak Dosing PO Dosing Equivalence • Steroids have stronger anti-inflammatory ability than NSAIDs. • Adrenal Insufficiency: endogenous steroids that the adrenal gland is not producing. • Cortisol - may be replaced by any steroid. • Steroids must be TAPERED off. • Addison's disease - adrenal gland not making enough cortisol. o Opposite of Cushing's syndrome o Treat with fludrocortisone ▪ Replacement therapy to mimic Aldosterone (Ç mineralocorticoid activity to balance H20 + electrolytes. • Every-Other-Day dosing • Taper Off • Use injections - drug stays local • Inhaled steroids - for asthma • Use low absorption • Lowest effective dose (21 x 4 mg Tabs) • DAY 1: 2 before breakfast, 1 after lunch, 1 after dinner, 2 QHS • DAY 2: 1 before breakfast, 1 after lunch, 1 after dinner, 2 QHS • DAY 3: 1 before breakfast, 1 after lunch, 1 after dinner, 1 QHS • DAY 4: 1 before breakfast, 1 after lunch, 1 QHS • DAY 5: 1 before breakfast, 1 QHS • DAY 6: 1 before breakfast. Cortisone 25 mg Short-acting Hydrocortisone 20 Prednisone 5 Prednisolone 5 Intermediate-acting Methylprednisolone 4 Triamcinolone 4 Dexamethasone 0.75 Long-acting Betamethasone 0.6 mg Cute Hot Pharmacists & Physicians Marry Together & Deliver Babies Steroids - ÇGlucocorticoid activity and Çanti-Inflammatory effect GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Cortisone SHORT-TERM FX: (1 Month) ÇAppetite Weight Gain Fluid Retention Mood Swings Insomnia Indigestion Bitter Taste ÇBP ÇBG LONG-TERM FX: Refer to Cushing's syndrome WARNING: Adrenal Suppression (HPA axis) Taper Off when use is 14 days Live Vaccines Serious Systemic Infections Strong Anti-Inflammatory effects • Cortisone = Pro-Drug of Cortisol • Prednisone - Pro-Drug of Prednisolone • Prednisolone used often for child Treatment Indications • Replacement therapy • Auto-Immune diseases • Post-Transplant • Asthma QD Dosing = Take 7am - 8am to mimic body cortisol release Betamethasone Celestone Soluspan Ready Sharp Dexamethasone DexPak 6-10-13 Day Double Dex Hydrocortisone Solu-Cortef Cortef Methylprednisolone Medrol Solu-Medrol A-Methapred Depo-Medrol Prednisone Deltasone Prednisolone Millipred Orapred ODT Prediapred Triamcinolone Kenalog Cushing’s Syndrome High Steroid Intake/Production SE Key Concepts • Adrenal gland produces too much cortisol, causing many side effects (refer to Š box) • Exogenous Steroids in high doses may also increase cortisol o ÇCortisol Š Negative FB Š ¶Cortisol • Ultimately causing HPA-axis Suppression - GI Bleed/Ulcers - Growth Retardation - Glaucoma/Cataracts - Psychiatric Changes - Poor Bone Health - Pink-Purples Stretch Marks - Moon Face - Acne - Buffalo Hump - Diabetes - Dysmenorrhea - Hypothyroidism - Muscle Wasting - Infection - Impaired Wound Heal - Women - Hirsutism • Immunosuppressed dosing = ≥2 mg/kg/day OR ≥20 mg/day of Prednisone or Prednisone-EQ for 2 weeks. • Immunosuppressed PT cannot get Live Vaccines & there is Ç risk of Infxn. • Taper off to reduce HPA-axis Suppression and ¶ chance of Addison's disease • Common Method = ¶ dose by 10 - 20% every few days (7 - 14 days)THYROID DISORDERS General Information Drugs that ¶ Thyroid hormone levels Levothyroxine Colors Thyroid Pathophysiology • T3 = Triiodothyronine • T4 = Thyroxine 1. Thyroid cells absorb Iodine/Tyrosine to make hormones. 2. Thyroid produces T3/T4. 3. TSH secreted by Pituitary gland in Hypothalamus. 4. µ T4 = ¶ TSH (Negative FB loop) 5. Active Form = Free T4 (FT4) Ca+, Fe+, Mg+, Al+3 (antacids) Multivitamins - ADEK, Folate Cholestyramine Orlistat (Xenical, Alli) Sevelamer Sucralfate Kayexalate Estrogen SSRIs BB's Amiodarone 25 mcg = Orange 100 mcg = Yellow 150 mcg - Blue 50 mcg = White 112 mcg = Rose 175 mcg - Lilac 75 mcg = Violet 125 mcg = Brown 200 mcg = Pink 88 mcg = Olive 137 mcg = Turquoise 300 mcg - Green Orangutans Will Vomit On You Right Before They Become Large Proud Giants Counseling 1. Different brands are not equal. 2. Safe in pregnancy + breastfeeding. 3. Take w/ H2O 60 mins before breakfast or 3 hrs after dinner. Hypothyroidism = ¶T4/µTSH (low Metabolism) Signs/Sx: Fatigue Weight gain Cold intolerance Muscle cramps Constipation Myalgias Bradycardia Coarse/Loss of hair Memory impairment Menorrhagia Goiter - due to iodine -------------------------------- Myxedema Coma: Occurs when pt is untreated for a long period of hypothyroidism. (Life-threatening emergency) Treatment: 1. Levothyroxine (T4) = 1st Line 2. Consistent preparation minimizing variability. 3. PTs who "don't feel right" may use other formulations. -------------------------------------------- Hashimoto's Disease: - Autoimmune - AB's attack Thyroid - Caused by conditions + drugs: o Amiodarone o Carbamazepine o Eslicarbazepine o Oxcarbazepine o Interferon o Lithium o Phenytoin o Tyrosine Kinase inhibitors (esp. Sunitinib) Diagnosis: ¶ FT4 | Normal = 0.9-2.3 µ TSH | Normal = 0.3-3.0 Screen at age 60 ----------------------------------- Monitor: Check TSH q4-6 wks til levels are normal then q4-6 months. Too high dose leads to Afib + fractures. ----------------------------------- Pregnancy: causes low birth weight, loss of pregnancy, premature birth, lower IQ in children Thyroid Replacement GENERIC BRAND ADRs BBW C/I NOTES DOSING Levothyroxine (T4) Synthroid Levoxyl Tirosint Unithroid Euthyroid = No Sx µµµ dose = hyperthyroidism sx. Not used for obesity/weight reduction - Acute MI - Thyrotoxicosis - Uncorrected Adrenal insufficiency - Decrease dose in CVD - IV to PO ratio = 0.75-1 - Levothyroxine is safe & recommended in pregnancy (requiring 30-50% increase in dose) - Full Dose = 1.6 mcg/kg/day (IBW) for healthy, young-middle age (50) - CAD = 12.5- 25 mcg/day Thyroid Desiccated USP (T3/T4) Armour Thyroid Liothyronine (T3) Cytomel Triostat Liotrix (T3/T4) Thyrolar Hyperthyroidism = µT4/¶TSH Signs/Sx: Treatment: Overview: Anti-Thyroid Medications GENERIC BRAND ADRs BBW C/I NOTES Beta-Blockers Used for Sx control: Palpitations, tremors, tachycardia. Propylthiouracil PTU GI upset HA Rash Hepatitis Agranulocytosis (rare) Liver failure (PTU) Pregnancy: 1st trimester = use PTU Methimazole Tapazole 2nd/3rd trimester = Methimazole Potassium Iodide Lugol's Solution Rash Metallic taste GI upset Hypersensitivity to Iodine Temporarily inhibits secretion of T4/T3 for only weeks Saturated K+ Iodide SSKI Thyroshield Heat intolerance Weight loss or gain Tremor Palpitations/Tachycardia Freq bowel movements Agitation, nervous, anxiety Fatigue/Muscle weakness Insomnia Thinning hair Goiter (possible) Exophthalmos Light/Absent menses 1. BB's for Sx control 2. PTU or Methimazole (temporary til surgery) 3. RAI-131(Takes 1-3 months of HIGHER doses to control Sx but later must REDUCE dose to avoid hypothyroidism) - Over-Production of thyroid hormones. - Mostly caused by Grave's disease (autoimmune in women 30-40's that stimulates too much T4) - Drugs that cause hyperthyroidism: o iodine o amiodarone o Interferon - Thyroid Storm - life-threatening emergency that is treated w/ PTU. o Fever ( 103), tachycardia, tachypnea, dehydration, sweating, agitation, delirium, psychosis, coma.TRAVELER’S DISEASES Traveler’s Diarrhea (TD) General Information 1. Travelers should carry a list of all medical conditions & medications (Rx/OTC). 2. Pack any medical supplies on Carry-On luggage. 3. "YELLOW Book" has all CDC travel information. 4. Consider food/H2O, blood/body fluids, & insects for transmission. 5. Dysentery TD occurs if blood in stool - Worse Sx. 6. Mostly caused by Bacterial (E. coli). Prevention 1. Cook it, peel it, or forget it! 2. Bismuth Subsalicylate (BSS) a. Pepto-Bismol b. Anti-Secretory Anti-Diarrheal c. S/E of black tongue/stool d. Caution: Reye’s Syndrome 3. ABX only used for HIGH risk. Treatment: 1. Hydrate (fluid/salt). 2. Loperamide (Imodium A-D) a. Primary Tx for acute diarrhea. b. Decreases freq/urgency 3. Macrolides, FQ's, or Rifaximin preferred. 4. Azithromycin = Severe TD or Dysentery TD. Prophylaxis 1. BSS - tabs/liquid dose 525-1050 mg QID w/ FOOD & QHS. 2. Rifaximin - preferred for pt at high risk. Mild TD • Loperamide PRN (NO ABX) Dose: 4mg after 1st loose stool. 2mg after for each loose stool. MAX Dose = 16 mg/day MAX Use = 2 days. Moderate TD • Loperamide PRN +/- ABX Severe/Dysentery TD • Azithromycin 1000mg x 1 dose +/- Loperamide Malaria General Information • Plasmodium Vivax is most common cause and resistant to drugs. • P. Faciparum - MOST deadly! • Prophylaxis is recommended and Tx varies depending on region. • Malaria drugs cause nausea & GI stress so need to be taken w/ FOOD + H2O/Milk. Insect Bites Transmitting Disease: • Vector is usually Mosquitoes: Japanese Encephalitis, Yellow Fever, Dengue, Malaria, Zika virus. • Protect from insect bites is key. • DEET 20-50% is the active ingredient in insect repellant. • Permethrin is used to Tx clothing. GENERIC BRAND WHEN TO USE CONTRAINDICATION NOTES QUICK START Px: Initiate 1-2 days prior to travel. Atovaquone/Proguanil Malarone Take daily & STOP 1 week after travel Pregnancy Breastfeeding Doxycycline Doryx ALL do not use in Pregnancy. Vibramycin Take daily & STOP 4 weeks after travel Child 8 yo Pregnancy Breastfeeding *Photosensitivity Primaquine Take daily & STOP 1 week after travel G6PD - Deficiency Pregnancy Breastfeeding ADVANCE Start Px: Start 1-2 weeks prior to travel. Chloroquine Taken WEEKLY ADRs: Skin Rxns Visual changes Blue/Grey skin pigmentation - Safe in children/pregnancy - Choice depends on regional resistance Mefloquine Lariam Psychiatric conditions Seizures Arrhythmias Other Diseases Cholera: - Vibrio Cholera - Food/H2O contaminants - Vaccine: Vaxchora (PO, Live) Polio: CDC recommends 1-Lifetime Booster dose 4 wks before travel for adults. Hepatitis-B: 1. Spread by Blood/Body fluids 2. Avoid high risk behaviors. 3. Dose vaccine 6 months to complete. Administer as MANY doses as possible before travel. Meningococcal Meningitis: 1. Neiserria meningitis 2. Fever, HA, stiff neck Sx req UREGENT care. 3. Spread by Respiratory secretions. 4. HAJJ & Umrah pilgrimages from Saudi Arabia to req vaccines during travel. Air Travel Compression stockings -------------------------- Acute Mountain Sickness Need Acetazolamide (CI = Sulfa allergy) Typhoid Fever: 1. Caused by Salmonella Typhi. 2. Spread by contaminated Feces. 3. Vaccines: Vivotif or Typhim Vi. (IM). Give ≥2 wks before travel. Dengue Fever: - NO vaccine available - AVOID Mosquitoes is crucial. Japanese Encephalitis: - AVOID Mosquitoes - Vaccine: Ixiaro Zika Virus: 1. Transmitted by Mosquitoes, sexual contact, or blood transfusions. 2. Causes Microcephaly 3. NO Vaccine 4. Use contraception w/ sex. Yellow Fever: - ASA/NSAIDs = Bleeding do NOT use. - LIVE Vaccine: YF-VAX. - Given certificate for vaccination & must be completed w/in 10 days before arrival. - C/I = Egg Allergy.WEIGHT LOSS AACE/ACE Guidelines = Exercise 150 mins/wk for 3-5 days/wk + resistance training. General Information Drugs that cause Weight Gain Drugs that cause Weight Loss Bariatric Surgery Caution/Avoid • Meds not appropriate for small weight loss. • ONLY indicated for BMI ≥30 OR BMI ≥27 +1 weight-related condition (DLD, HTN, and DM). • Rx meds only used adjunct to diet plan + exercise. • Drugs are selected based on PT’s comorbid conditions. • Older stimulant agents are ONLY used short-term to jump-start a diet. • Newer agents are used Long-term for maintenance. (Qsymia, Belviq, Contrave, Saxenda) • Weight loss drugs should be D/C if they don’t produce at least 5% weight loss at 12 weeks. • Insulin • Sulfonylureas • Glitazones • Anti-Psychotics • Steroids • Mirtazapine (Remeron) • Dronabinol (Marinol) • Megestrol (Megace) • Condition – Hypothyroidism • ADHD Stimulants (Ritalin, Concerta, Adderall, Vyvanse) • Exenatide (Byetta/Bydureon) • Liraglutide (Victoza) • Saxenda (at high dose) • Topiramate (Topamax) • BMI 40 or 30 + condition • Nutrient Deficiency: o Ca+ Citrate is preferred. o Vit-B12 & Iron supplements o Iron/Ca+ 2 hrs. before or 4 hrs. after antacids. o Supplement Vit-ADEK for LIFE. • Medication Concerns: • May need to crush, liquid, or transdermal for 2 months postsurgery • PT’s may need Ursodiol for gallstones. • AVOID GI irritants (NSAIDs + Bisphosphonates) • Pregnancy o Avoid all WL drugs • Depression o Contrave (contains bupropion) • Hypertension o Qsymia, Contrave • Opioid Use o Contrave • Seizures o Qsymia, Contrave GENERIC BRAND MOA ADRs BBW CONTRAINDICATION NOTES Phentermine/Topiramate Qsymia (C4) - Phentermine - Sympathomimetic stimulant amphetamine like µ NE. - Topiramate - GABA/Glutamate. Anxiety Depression Suicidal thoughts Tachycardia - Hyperthyroidism - Glaucoma - MAOi in 14 days Pregnancy Taper off due to seizure. Naltrexone/Buproprion Contrave Decreases cravings/appetite. N/V/C/HA Dizziness Dry Mouth - NOT approved for MDD - Suicidal ideation - Caution in psychiatric/seizures disorders. - Can µ HR/BP - Opioid use - Uncontrolled HTN - Seizure disorder - Bulimia/Anorexia - Bupropion-containing products Naltrexone - blocks opioids + buprenorphine Š blocking analgesia. Lorcaserin Belviq (C4) Serotonin 5HT-2C agonist (increasing satiety) Dizzy/HA Fatigue Nausea Dry mouth Serotonin Syndrome w/ other serotonergic agents Pregnancy Liraglutide Saxenda GLP-1 agonist Nausea/Vomiting Diarrhea/Constipation Dizzy/HA/Fatigue - Family Hx of Medullary Thyroid Carcinoma (MTC) - Hypoglycemia - µ HR Pregnancy - Victoza - for Diabetes. - Saxenda - REMS for MTC + Pancreatitis Phentermine (C4) Adipex-P Sympathomimetic Stimulants (Similar to amphetamines, increasing NE) Tachycardia Agitation µ BP Adipex-P: Avoid in Pregnancy - AVOID in HTN, PAH, Hyperthyroidism, or Glaucoma. - MAOi in 14 days - Stimulants are used for 12 weeks to jump start a diet. - Monitor - HR/BP Diethylproprion (C4) Tenuate Phendimetrazine (C3) Benzphetamine (C3) Regimex Orlistat Rx Xenical Lipase inhibitor - decreases fat absorption by 30% Gas w/ Discharge Fecal urgency Fatty stool - Liver damage - Cholelithiasis - Kidney Stones - Hypoglycemia - Pregnancy - Cholelithiasis - Malabsorption Syndrome - Take Vitamin ADEK + BetaCarotene at bedtime or separate by 2 hours. - Do NOT use Cyclosporine or separate by 3 hrs. - Separate Levothyroxine by 4 hrs. Orlistat OTC AlliMIGRAINE Chronic headaches causing pain for hours or days. General Information Diagnosis Treatment • Most cause N/V, sensitivity to light, or auras of flashing lights, blind spots or tingling in arms or legs. • May be due to NT's, especially Serotonin - 5HT • Identify and avoid migraine "triggers" (Female hormonal changes, food, stress, sleep pattern, weather) • Women who have migraine w/ aura = µ Stroke risk. o Should AVOID Estrogen-containing contraceptives. ≥5 attacks not attributed to other disorders with: • Last 4-72 hrs. + recur sporadically. • ≥2 characteristics: Unilateral location, pulsating, mod-severe pain, aggravated by physical activity. • If N/V, photophobia, or phonophobia occurs. NON-DRUG Tx: 1. Avoid Triggers 2. Stress management 3. Massage 4. Spinal manipulation 5. Cold compress/Ice pack 6. Acupuncture Natural Products: • Caffeine combo w/ ASA or Tylenol • Butterbur • CoQ-10 • Feverfew • Magnesium Peppermint • Riboflavin Prophylactic Tx: Used to decrease frequency of migraines. Consider 2-6 month use if: 1. Using Acute Tx ≥2 days/wk OR ≥3x/month. 2. If migraines decrease QOL. 3. If acute tx are ineffective or contraindicated. Ex. Beta-Blockers, Topiramate Valproic Acid, TCAs, Venlafaxine, or Botox (chronic migraines only) RX Options: - Triptans (5HT) - Ergotamine - Butalbital (barbiturate used for combo meds) o NOT recommended due to abuse/dependency & need to be tapered off due to worsening of headaches. o Fioricet: Acetaminophen/Butalbital/Caffeine o Fiorinal: ASA/Butalbital/Caffeine o BOTH are used in combo w/ Codeine = C3 - Opioids - Diclofenac OTC Tx: - Acetaminophen - Advil (Ibuprofen) - Excedrin (ASA + APAP + Caffeine) - Aleve (Naproxen) • Avoid Opioid, Tramadol, and Tapentadol for last line. • Some PTs benefit from OTC products + Triptan • Medication "Overuse" (MOH) = REBOUND Headaches: o Headaches that occur 10-15 days/month o MUST limit medication 2-3x/wk. & taper off Butalbital. GENERIC BRAND MOA ADRs BBW CONTRAINDICATION NOTES Sumatriptan Imitrex Onzetra Xsail Zembrace SymTouch Sumavel 5HT-1 Agonist Vasoconstriction of cranial blood vessels - Paresthesia (tingling/numbness) - Hot/Cold sensations - Dizzy/Somnolence - Dry mouth - Nausea - Chest pain/tightness - Triptan Sensations (Chest/Neck pressure or heaviness) - µ BP - Cardiac/CV events - Arrhythmias - Serotonin Syndrome - Medication Overuse HA (MOH) - Seizures (Sumatriptan ONLY) - Caution in Hepatic/Renal imp - CV Disease (Stroke/TIA) - Uncontrolled HTN - Ischemic Heart Dx - Peripher Vascular Dx Use w/in 24 hrs. of other Triptan or Ergotamine. AVOID Maxalt-ODT in Phenylketonuria (PKU) ALL injections are SQ (Lateral Thigh or Upper Arm) Protect from light. Sumatriptan + Naproxen (Child 12 yo) Treximet 1. 1st Line for Acute Tx 2. MUST take at 1st sign of Migraine 3. ODTs, nasal spray, injections are useful if PT has nausea. 4. Imitrex/Zomig Nasal spray (Do NOT Prime) 5. Frovatriptan/Naratriptan = Long-Acting but SLOWER onset. 6. D/I: SSRI, SNRI, MAOi, or CYP3A4 inhbitors. Almotriptan (Tab, Child 12 yo) Axert Eletriptan Relpax Frovatriptan Frova Naratriptan Amerge Rizatriptan (Child 6-17 yo) Maxalt Zolmitriptan (Nasal Spray, Child 12 yo) Zomig GENERIC BRAND MOA ADRs BBW CONTRAINDICATION NOTES Dihydroergotamine (Injection, Nasal Spray) DHE 45 Migranal Ergotamines: ONLY for PTs who get no relief from Triptans. Nasal Spray: Rhinitis Nausea/Dizziness Dysguesia (altered taste) Life-threaten Peripheral Ischemia Avoid CYP3A4 inhibitors CV/Cerebral Vascular events Uncontrolled HTN Ischemic Heart Dx Pregnancy Strong CYP3A4 inhibitors - Must PRIME 4x for nasal spray. - Do NOT inhale deeply Ergotamine + Caffeine - Let drug absorb into nose skin. (Tablet, Suppository) Cafergot Migergot GENERIC BRAND MOA ADRs BBW CONTRAINDICATION NOTES Propanolol Inderal LA Beta-Blockers Propranolol = MOST Lipophilic Propranolol + Timolol: Non-selective so avoid in COPD/Asthma Metoprolol Lopressor Toprol XL Timolol GENERIC BRAND MOA ADRs BBW CONTRAINDICATION NOTES Divalproex Depakote Depakene Valproic Acid Anti-Epileptics Liver Toxicity Pancreatitis Weight Gain Teratogenic Thrombocytopenia Pregnancy Topiramate Topamax Trokendi XR Weight LOSS Parasthesia Cognitive Impairment PregnancyATTENTION DEFICIT HYPERACTIVITY DISORDER General Information DSM-5 Diagnostic Criteria DRUG Tx Dosing Formulations • Chronic inattention, hyperactivity, & impulsivity. • Due to Dopamine + Norepinephrine. • 1st LINE Tx = Cognitive Behavioral Tx (CBT) • Non-Drug Tx = Fish Oils INATTENTION = 6 Sx HYPER-ACTIVITY & IMPULSIVE = 6 Sx 3 Conditions MUST Be Met: 1. Sx must be present before age 12 yo. 2. Sx must be present in 2 or more settings. 3. Sx interfere w/ functioning. 1st Line: Stimulants (C2) Concerta, Daytrana Patch, Ritalin, Vyvanse, Adderall • Dose in QAM • Titrate up every 7 days • No need to taper 2nd Line or Suspected Abuse Risk: Non-stimulants Strattera ADJUNCT/Alone: Intuniv, Kapvay Sleep Aids: Clonidine, Diphenhydramine LA Suspensions: • Quillivant XR o Shake bottle 10 secs. o Push plunger down. o Measure to white end. • Dyanavel XR Chewable Tabs: • Quillichew ER • Vyvanse ODT: • Contempla XR • Adzenys XR Sprinkle Capsules: • Focalin XR • Ritalin LA • Aptensio XR • Adderall XR • When SPRINK