PC707 - FINAL EXAM ALL MODULES QUESTIONS & Answers 100% Correct

What is prescriptive authority? - Answer Legal right to prescribe drugs Is the Physicians Desk Reference a reliable source to use when prescribing drugs? - Answer No--it is not evidence-based and it is not updated What is the sunshine act? - Answer -part of the affordable care act -limits providers on accepting gifts from pharmaceutical companies -reduces bias What is pharmacology? - Answer -study of the drugs and their actions and effects on living things -legal drugs, illegal drugs, prescription drugs, OTC drugs How does the FDA define drugs that they approve? - Answer -chemicals that have been proved for safety and efficacy What must providers consider when prescribing? - Answer -the dose -the route of administration -indications -side effects of consequence -adverse effects -contraindications -significant drug-drug interactions -appropriate monitoring -treatment of side effects if necessary What is pharmacokinetics? - Answer -how drugs move in the body and what the body does with it How does pharmacokinetics influence prescribing? - Answer -the route -the dosage needed -dosing intervals What are the 4 aspects of pharmacokinetics? - Answer -absorption -distribution -metabolism -excretion What affects bioavailability the most? - Answer PO administration What is a pro-drug? - Answer -a drug that needs to be metabolized to become "activated" What is the major organ of metabolism? - Answer -Liver -Uses enzymes called "CYPs" -these enzymes can induce or inhibit metabolism What is protein-binding? - Answer -drugs that have a high affinity for proteins will bind with them and therefore become unable to bind to receptor sites -in order to activate receptors they must be free circulating molecules What is the half-life of a drug? - Answer -how long it takes for a drug at its original amount to be reduced by 50% Why is it important to know the half-life of a drug? - Answer -to help determine dosing intervals to maintain therapeutic levels What is the first-pass effect? - Answer -alteration of the drug dose by metabolism before it reaches systemic circulation -only happens with PO medications What are the genetic variances of metabolism? - Answer -poor metabolizers (certain enzymes are little to none) -intermediate metabolizers -extensive metabolizers (NORMAL) -ultra-rapid metabolizers (duplicate genes to make extra enzymes) What is the primary organ of excretion? - Answer kidneys What are other methods of excretion? - Answer -saliva -sweat -breastmilk -skin -lungs Why would the elderly have a smaller first-pass effect? Why is this important to know? - Answer -decreased liver mass -decreased enzymes -->this is important because with a smaller first pass effect higher drugs levels will reach circulation What does the rate of excretion depend primarily on? - Answer -renal blood flow -glomerular filtration rate Can side effects be negative AND positive? - Answer Yes What is an adverse effect? - Answer -negative side effect -undesirable -unintended What are contraindications? - Answer -do not give -the risks outweigh the benefits What are relative contraindications? - Answer -the consideration that there are rare exceptions to the rule -the risk of NOT taking the medication potentially is greater than the risk of taking it What are precautions? - Answer -"warnings" -clinically significant -providers must weight the risks vs benefits What is a black box warning? - Answer -a potential adverse effect is serious enough that the risk must be thoughtfully considered OR -a potential adverse effect that can be reduced or eliminated by appropriate use OR -FDA has approved with restrictions to assure safe use If a drug has a high protein affinity--the protein binding sites must saturated in order for what to happen? - Answer -free drug to be able to circulate and activate receptors When taking two different drugs that are both highly protein bound, how does stopping or starting a drug affect the levels of the other drug? - Answer -if one drug is suddenly stopped it opens up protein binding sites for the other drug to bind to--reducing plasma drug levels -if a new drug is started--it will replace some of the protein binding sites--which then increases the plasma drug levels of the drug that was already present What sources should providers use when prescribing? - Answer -whenever possible you must utilize the highest levels of evidence -OR trusted experts in the field (ACOG, CDC, American Cancer Society, etc.) What is an enzyme inhibitor? - Answer -inhibits the enzyme action causing decreased metabolism -this can increase the drug levels -it can affect all drugs that utilize the same metabolic pathway What is an enzyme inducer? - Answer -increases the enzymes that induces metabolism -this decreases drug levels -it can affect all drugs that utilize the same metabolic pathway What is an agonist? - Answer -a drug that binds to AND activates a receptor What is a partial agonist? - Answer A drug that binds to and activates a receptor but produces a smaller effect at full dosage than a full agonist What is an antagonist? - Answer -A molecule that binds to a receptor but does NOT activate it--it blocks the activating drug from binding to the receptor When is a drug-drug interaction risk the greatest? - Answer -when a patient is taking multiple medications (poly-pharmacy) What is the most common cause of ER visits from an adverse drug reaction? - Answer -bleeding from anticoagulants Why must a person limit or discontinue use of grapefruit juice when taking certain drugs? - Answer -it inhibits metabolism -this can increase drug levels--potentially to dangerous levels -one cup of juice can inhibit metabolism for up to 72 hours! Rule of safe prescribing? - Answer AVOID M pneumonic--Ask and Consider A-Allergies V-Vitamins & Herbs O-old drugs, new drugs, over the counter drugs I-interactions D-dependence M- Mendel "genetics" --family history of drug reactions Type 1 allergic reaction? - Answer -IgE mediated -Immediate hypersensitivity -antigen exposure--B cells stimulated--antibodies produced -future exposure--antibodies bind to mast cells & basophils -potential anaphylactic degranulation -vasodilation, leaky vessel walls, smooth muscles spasm, itchy wheals, rash, edema, bronchospasm, decreased blood pressure -re-exposure is necessary -epinephrine needed -may need glucocorticoids, H1 blockers, bronchodilators What is the difference between type 1 allergic rash and morbilliform rash? - Answer -type 1 allergic rash--hives, wheals, itchy, type 1 hypersensitivity -morbilliform rash--most likely due to a drug reaction, looks like the measles, "drug eruption", type IV delayed hypersensitivity What is a type 2 hypersensitivity? - Answer -IgG or IgM mediated -Ex: heparin induced thrombocytopenia -will resolve when the drug is stopped What is type 3 hypersensitivity? - Answer -Immune complex mediated -Ex: serum sickness -will resolve when the drug is stopped What is type 4 hypersensitivity? - Answer -Cell mediated (cytotoxic t cells) -delayed response -diffuse, bilateral, symmetrical -Ex: drug rash, contact dermatitis, steven-johnson syndrome What is a pseudo allergy? - Answer -mast cell degranulation by a non-IgE mediated mechanism -Ex: opiate analgesic causes direct mast cell activation--causing itching What does the QT interval represent? - Answer ventricular depolarization and repolarization A longer QT interval increases the risk of what? - Answer -ventricular dysrhythmias (particularly Torsades de pointe) -sudden cardiac death Who is at an increased risk of a long QT interval? - Answer -females -electrolyte imbalances (hypokalemia, hypomagnesemia, hypocalcemia) -renal or hepatic problems -taking multiple drugs that can prolong QT interval -grapefruit juice that might inhibit metabolism of drugs that prolong QT interval -diuretic use (reduces electrolytes) -bradycardia -underlying cardiac disease -digitalis therapy -family history of long QT syndrome -congenital long QT syndrome What factors can impact pharmacokinetics, pharmacodynamics, drug efficacy and likelihood of drug reactions? - Answer -age, sex, weight, genetics, diet, co-existing diseases, etc. Why are pharmaceutical companies less likely to research children? - Answer -ethical risks -health risks -cost Why are infants at a higher risk of adverse effects from drugs? - Answer -organ immaturity -under-developed blood brain barrier -variable peristalsis -variable blood flow to muscles -increased total % body water (affects distribution) -reduced metabolism What is polypharmacy? - Answer use of multiple medications Number of drug reactions is closely related to number of drugs a person is taking. True or false? - Answer True What are some prescribing issues with the elderly? - Answer -polypharmacy -disease-drug reactions (Ex: cirrhosis and tylenol) -physiologic changes (Ex: renal & hepatic dysfunction) -multiple prescriptions from different specialities -poor adherence What is the Beers criteria? - Answer -lists potentially inappropriate drugs that lead to adverse effects in the elderly -particularly in those greater than 65 years old -not applicable to those in hospice or palliative care -a tool not a guideline--must use your own clinical judgment What is a START and STOP criteria? - Answer START--criteria to help determine the right tx for the elderly STOP--criteria to help determine medications to stop -these are tools not guidelines--must use your own clinical judgment If a patient presents with a new symptoms or worsening of a condition what is appropriate to ask regarding medications? - Answer -have you recently started a new medication? Why are the elderly at risk of adverse drug reactions? - Answer -decreased renal function -decreased muscle mass -decreased total body water (decreased distribution) -decreased liver mass & enzymes -increased gastric pH -slower peristalsis Must prescribe to the pregnant or breastfeeding patient with caution because? - Answer -most evidence is inconclusive on safety Whenever prescribing, a woman of childbearing age should always assumed to be pregnant until proven otherwise. True or false? - Answer True What are teratogens? What is the criteria to be considered a teratogen? - Answer -any agent that harms the embryo or fetus 3 criteria: -must cause a characteristic set of malformations -must act only during a specific window of vulnerability -incidence of increase with increasing dosage and duration of exposure Reasons for lack of adherence? - Answer -lack of affordability -lack of understanding directions -troublesome side effects -inconvenient drug dosing -pt decides they do not need to take it How is prophylactic treatment different from acute treatment? - Answer -action is taken to PREVENT disease Number of refills are based on what? - Answer -when you want them to come back for follow-up Reconciling of medications must occur with every patient at every encounter. True or false? - Answer True Can you send an electronic prescription for a schedule II drug? - Answer No--a written prescription is required. In a prescription, what is the "Sig"? - Answer -means "to write" -your directions on how to take the medication Does a generic substitution contain the same amount of active drug as the brand name drug? - Answer -Yes -They are "essentially similar" -They have bioequivalence -The generic drug has to be within 80-125% of the same pharmacokinetics as the brand drug Do generic drugs and brand name drugs have the same bioavailability? - Answer No, just because they are bioequivalent (they have the same amount of the active drug) does not mean they have the same bioavailability (the rate and extent that the active drug is absorbed and becomes available at the target site) When would a brand name be medically necessary? - Answer -certain chronic diseases -drugs with a narrow therapeutic index and consistency in the medication is important What is pharmacogenomics? - Answer -the study of how genes affect a person's response to drugs -"personalization" of drug therapy What is a very important aspect of genetic variations to consider when prescribing? - Answer -variations of genes that code for metabolism -is the person a poor, intermediate, extensive, or ultra-rapid metabolizer? What happens if a person who is a ultra-rapid metabolizer takes a "pro-drug"? - Answer Since the pro-drug needs to be metabolized to become active, the ultra-rapid metabolizer will quickly activate the medication and the person will experience a quicker than normal drug response What happens if a person who is a poor metabolizer takes a "pro-drug"? - Answer Since the pro-drug needs to be metabolized to become active, the poor metabolizer will most likely not be able to activate the medication and the person will not experience a drug response What is ethnopharmacology? - Answer -understanding the specific impact of cultural factors on patient drug response -does not 100% predict a specific outcome based on racial or cultural factors--but can predict a potential risk for a particular response Patient teaching for women of child-bearing age is important to: - Answer -keep good communication so the patient tells you as soon as they are pregnant or plan to become pregnant Things to remember when prescribing to pregnant and lactating women: - Answer -start low and increase dose only if necessary -avoid medications whenever possible -use drugs with the safest profile and have been studied the longest -use one drug rather than many -make sure dating of the pregnancy is accurate -try to avoid medications during the first trimester -try to pick topical over systemic -shared decision making is very important! What is the "all or none" period? - Answer -in the preimplantation period--a teratogen will either cause a miscarriage or will survive How does a teratogen affect the embryogenesis or "organogenesis" period? - Answer -most critical period of high sensitivity and susceptibility of potential complications from exposure -the first trimester -will cause gross malformations -usually already established once they find out they are pregnant How does a teratogen affect the fetal period? - Answer -starts after the first trimester (week 11) -exposure during this period usually just alters growth and function of tissues and organs -ex: growth restrictions, alteration in size and functional ability of organs, developmental & behavioral abnormalities Lack of proof of teratogenicity does not equal safety AND proof of teratogenicity does not mean every exposure causes a defect. True or false? - Answer True In order to safely prescribe to pregnant women, what should the provider assume? - Answer -assume that ANY drug could reach the fetus and cause potential problems What is the most effective defense against illness and disease for infants? - Answer -breastmilk -weaning or stopping is almost never necessary For breastfeeding women, what types of medications should be prescribed in order to reduce infant exposure and potential side effects? - Answer -oral medications -low bioavailability Tips for prescribing to breastfeeding mothers: - Answer -start with non-pharm remedies whenever possible -breastfeed before taking the medication or take the medication before the infants longest nap -avoid extra, maximum, XR, long acting etc. -start slow and low -avoid medications with multiple ingredients -use less versus many -be extremely careful with newborns and preterm--less effective metabolizers (increases risk of toxicity) -teach mothers warning signs and to monitor for side effects (changes in sleep, feeds, void, alertness/wakefulness) For a medication to be considered OTC: - Answer -must be considered safe & low mis-use risk -patients can self-diagnose in order to take it -condition can be self-managed All OTC's are safe. True or false? - Answer False -there is still the potential for adverse effects, drug interactions, and potential for abuse Commonly used OTC: - Answer -NSAIDS -Aspirin (ASA) -Acetaminophen (APAP) -Antacids -Decongestants -Topical nasal decongestants -Antihistamines All complementary and alternative medicines are considered safe and effective. True or false? - Answer False -they are not all safe -they do not require FDA approval for "safety and efficacy" -potential for drug interactions exist What are RDAs? - Answer -Recommended Dietary Allowance -nutrient intake goals for individuals that meets the needs of nearly all healthy people What is the general recommendations for RDAs? - Answer -do not take more than 150% of the RDA What are water-soluble vitamins? - Answer -Vitamin B and C -water soluble--easily excreted by the kidneys -not stored in large amounts so need to ingest frequently What are fat-soluble vitamins? - Answer -A, D, E, K -stored in the liver and fatty tissue Vitamin A in high doses is: - Answer -highly teratogenic What is chelation? - Answer -bonding of drug molecules to metal ions -chelation can reduce drug absorption -if a patient is taking "metals" like iron, magnesium, calcium, aluminum--make sure they space their medications at least 2 hours apart in order to decrease chance of chelation -this is why patients taking tetracyclines should not take milk products with it because of the potential chelating effect of "calcium" What is absorption? - Answer -movement of a drug from site of administration into the blood Distribution? - Answer -movement from blood to interstitial space of tissues and into the cells Metabolism? - Answer -enzymes changing the drug structure -usually into an "inactive form" to be excreted, but sometimes metabolism is needed to produce active metabolites (pro-drugs) The rate of absorption determines: - Answer -how soon effects will begin -the amount absorbed determines how intense the effects are Why are malnourished individuals at risk for drug toxicity? - Answer -they have reduced nutrients and co-factors available for proper metabolism -this decreases metabolism and allows for drug levels to build up in the body What types of drugs are excreted more often in the breastmilk? - Answer -Lipid soluble drugs Although plasma drug levels are not able to tell us the actual drug levels available at the target sites, they are highly predictive of: - Answer -therapeutic and toxic responses What is the therapeutic index? - Answer -"therapeutic range" -the range between the minimum effective concentration and the toxic concentration -drugs with a narrow range are hard to administer safely--need to monitor carefully -drugs with a wide range are considered much safer What happens when a loading dose of a medication is given? - Answer -to quickly achieve therapeutic level -then can be maintained with maintenance doses What is the potency of a drug? - Answer -The amount of a drug that must be given in order to produce a particular response -the more potent the drug, the less is needed to produce the desired response -potency implies nothing about it's maximal efficacy--this is patient dependent--match the intensity of the response to the patient needs When drugs are toxic to specific organs, what must the provider do? - Answer -monitor the function of these organs Why might medications need to be increased in the third trimester of pregnancy? - Answer -increased renal blood flow--so drug levels might be reduced -might need to increase the dosage What is the current labeling system for pregnancy and lactation? - Answer -Categories of A, B, C, D, X -vague and not fully understood--some overlapping of categories -hard to determine risks versus benefits -C, D, X are considered "potential for fetal risk or positive evidence of fetal risk" -this system is being phased out and replaced with the new labeling system PLLR Sometimes NOT taking a drug during pregnancy causes more harm to the fetus. True or false? - Answer True -ex: not taking albuterol for asthma What is the PLLR system? - Answer -the new labeling system for drugs in pregnancy and lactation -contains a pregnancy exposure registry -categories for pregnancy, lactation, females and males of reproductive potential -provides risk summaries, clinical considerations, data -easier to navigate -helps the provider to weigh risks versus benefits Antioxidants help to: - Answer -neutralize free radicals (normal by-products of metabolism that can cause tissue injury or "oxidative stress") What is an off-label use? - Answer -using a medication for a purpose other than what it was FDA approved for -just because labeling is lacking for a specific age group or condition does not mean it is unsafe or improper to use--it just means there is insufficient evidence for approval at this time -many drugs are utilized as "off-label" for children--because ethically, there are limited evidence for children When a drug is used "off-label" what should the provider make sure to do? - Answer -Shared decision making -Informed consent -Document these in the medical chart What is an anticholinergic reaction? - Answer -when a drug produces effects caused by opposing of acetylcholine -dry mouth, blurry vision, constipation, drowsiness, trouble urinating etc. -elderly patients are most at risk because of the changes from aging Ace inhibitors in pregnancy: - Answer -contraindicated -known teratogens -especially in the first trimester -must use a hypertension medication with a safer profile Accutane in pregnancy: - Answer -contraindicated -teratogen -category X Can you prescribe to family members or friends? - Answer -every person deserves the same level of care in a professional setting -must have a bona-fide patient provider relationship -some states deem it illegal -it can be unethical to do so -avoid whenever possible Can you write a prescription for a patient and change the directions in order for the patient to save money? - Answer -no, you must write the prescription exactly as you want the patient to take it -you can potentially write a prescription for a higher mg and have the patient take half of it in order to save money--but you must indicate exactly the amount the patient will be taking and for exactly how many days the dosage will provide What are the main components on a prescription? - Answer -patient name, address, birth date -date of issuance -name, strength, dosage, and quantity of the medication -Sig (directions for use) -refills authorized -prescribers signature -DEA number when applicable -for controlled substances always write numbers out -if a brand name is indicated--make sure to write why WHO's six step model of rational prescribing: - Answer -define the patient problem -specify the therapeutic objective -choose the treatment -start the treatment -educate the patient -monitor effectiveness Why are children more at risk of overdose or toxicity? - Answer -higher rate of metabolism (if given a pro-drug May increase amounts) -drugs are usually less protein bound -higher concentration of body water--medication distributed more widely in the body SMP-TMX and warfarin may cause: - Answer -serious adverse reactions--leading to hospitalization Ayurvedic herbs and some traditional Chinese herbs have the potential to cause: - Answer -lead poisoning Anti-histamines may cause confusion in who? - Answer -elderly Due to a chelating effect with tetracyclines and thyroid medications what patient education is important to include: - Answer -space these medications from metal containing products such as "iron, magnesium, calcium, aluminum" What kind of medications are excreted more in breastmilk? - Answer Lipid-soluble drugs Avoid what kind of foods when taking MAOI's? Why is this important? - Answer -tyramine containing foods such as aged cheese, wine, cured meats, yeast extracts -it can increase blood pressure to dangerous levels--causing hypertensive crisis Sulfa drugs can cause what: - Answer -kernicterus Vitamin B6 should be avoided when taking what medication? - Answer -levodopa Who should avoid probiotics? - Answer -those who are immunosuppressed -those who are taking medications to treat things like HIV, cancer, TB Kava and Comfrey are alternative therapies that should be used with extreme caution or should be avoided because they can cause: - Answer -severe liver damage Cranberry juice may cause what: - Answer -increased bleeding in those taking warfarin St johns wort should be used with caution because it can: - Answer -can induce metabolism and increase other drugs to dangerous levels -cause serotonin syndrome when taking with other serotonin increasing drugs Glucocorticoids can cause what in children? - Answer -growth suppression Drug accumulation secondary to reduced renal excretion is the most important cause of what in older adults? - Answer -adverse drug reactions and side effects Extreme caution must be taken with iron and children because it may cause: - Answer -iron poisoning and death How much vitamin D is recommended? - Answer - IU/day -good reference for therapeutic level is 30-50 ng/mL Contributing factors to abx resistance - Answer Antibacterial soaps, abx prescribed for viral illness, incorrect dose, wrong duration, low compliance, use of abx used by humans also used in animals How to minimize abx resistance - Answer Prescribe the right medicine appropriately, right dose, right duration, know anti-infectives to target harmful bacteria, use clinical resources Antibiogram - Answer Local antibiotic resistance listed by drug names, organisms, and % resistance Type I allergy - Answer IgE mediated, immediate hypersensitivity; affects cardio and respiratory systems Type II allergy - Answer Antibody dependent cytotoxicity Type III allergy - Answer Immune complex hypersensitivity Type IV allergy - Answer Cell-mediated or delayed hypersensitivity Pseudo allergy - Answer Probably mast cell degranulation by a non-IgE mediated mechanism Cross reactivity - Answer If a patient has a drug allergy with a specific chemical structure they will be allergic to a different drug that has the same structure. Ex: PCN + cephalosporins Signs and symptoms of sulfanomide allergic reaction - Answer Rash, fever, early 1-3 days > Stop drug Narrow spectrum - Answer Antimicrobial that acts against a single or limited group of microorganisms Extended spectrum - Answer Agents that are effective again Gram+ organisms and a significant number of Gram- organisms. Ex: ampicillin Broad spectrum - Answer Antimicrobials that are effective against a wide variety of microbial species. Ex: tetracycline Bacteriostatic - Answer Arrests the growth or inhibits replication but does not kill the organism. Depends on the host immune system for eradication of the organism. Bacteriocidal - Answer The drug kills the organism Selecting antibiotic therapy - Answer First consider the infecting organism, sensitivity of organism to microbial agents, site of infection, status of host defenses, pharmacokinetics, renal and liver function, clinical evaluation of abx's effectivness Gram positive microbes - Answer Staph, strep, enterococci (above umbilicus) Gram negative microbes - Answer Everything else (below umbilicus) Abx therapy for unknown pathogen - Answer Diagnose, obtain specimens for lab, formulate microbiologic dx, determine need for therapy, choose abx, consider safety of abx and cost Symptom when amoxicillan is given to a patient with mononucleosis - Answer Rash Name a drug-drug interacton for HMG-CoA reductase inhibitors. Ex. lovastatin, simvastatin - Answer Do not use with larithromycin Name a drug-drug interacton for clarithromycin - Answer Do not use with calcium channel blockers Drug-drug interactions for warfarin - Answer TMP-SMX, erythromycin, fluconazole, ketoconazole, itraconazole, metronidazole. Drug-disease interactions for warfarin - Answer Potential for serious bleeding effents, monitor INR Drug-drug interactions for TMP-SMX - Answer Angiotensin converting inhibitors, angiotensin receptor blockers may result in hyperkalemia, sudden cardiac death esp in patients with kidney disease or elderly Betalactamase - Answer An enzyme produced by bacteria that breaks down betalactam in penicillins; resistance Chelation - Answer Metals (Fe, Ca, Mg, Al) bind with tetracycline making it ineffective. Do not take within 2 hours of dairy. MRSA management - Answer Incision & drainage; pt education on hygiene, wound care; abx therapy for abscesses with extensive/systemic/rapid progression, extremes of age, in area difficult to drain; betalactamase abx 1st choice if no allergy; obtain blood cultures 2-4 days after +cultures until infection is clear Clostridium difficile (C.diff) - Answer Adverse effect of certain broad spectrum abx that kill gut flora. Abx responsible for C.diff - Answer Imipenem, ceftazidime, clindamycin, moxifloxacin Proper hand hygiene for C.diff - Answer Soap and water, not hand gel or foam C.diff treatment (mild to moderate) - Answer Metronidazole 500 mg PO TID, 10-14 days C.diff treatment (severe) - Answer Injectable vancomycin PO, fidaxomic ($3000 for 10 day course) Contraindication for probiotics - Answer Do not give in patients with immunosuppression Category B antibiotics - Answer PCN, macrolides, cephalosporins Category C antibiotics - Answer Sulfonamide: avoid in 1st and 3rd trimesters. Use only if nothing else works Category D antibiotics - Answer Tetracyclines: causes IUGR, teeth discoloration Treatment for bacterial vaginosis during pregnancy - Answer Metronidozole, category B, use during any trimester Timing of TDaP in pregnancy - Answer 27-36 weeks gestation What kind of immunization is contraindicated in pregnancy? - Answer Live viruses Contraindications to immunization - Answer Encephalopathy, T > 105F, convulsions, continuous crying > 3 hours, anaphylactic allergy to egg products Do not administer MMR vaccine if they have a history of this reaction - Answer Anaphylaxis due to latex or gelatin Contraindications for PCN - Answer Type I reaction PCN spectrum of activity - Answer Gram+ PCN pregnancy rating - Answer Category B PCN moa - Answer Disrupts cell wall synthesis Beware of using this antibiotic class in those with PCN Type I hypersensitivity - Answer Cephalosporins Cephalosporin spectrum of activity - Answer 1st: Gm+; 2nd: Gm+, Gm-; 3rd: weak Gm+, Gm-, beta lactamase; 4th: extended 3rd gen Pregnancy safety of cephalosporins - Answer Catergory B: 1st and 2nd generation safe Fluoroquinolones moa - Answer Interferes with DNAgyrase, bactericidal Pregnancy safety of fluoroquinolones - Answer Contraindicated Fluoroquinolones spectrum of activity - Answer 2nd: weak Gm+, Gm-, pseudomonas; 3rd: Gm+, Gm-, B lactasmase, DRSP, anaerobes, pseudomonas; 4th: Gm+, Gm-, atypical, B lactamase, DRSP, MRSA, anaerobes, pseudomonas Fluoroquiolones BLACK BOX WARNING - Answer Increased risk for tendon rupture especially in pts > 60 years, taking corticosteroids, hx of organ transplant Fluoroquinolones side effects - Answer Anticholinergic effects, GI effects, abd pain, candida, crystaluria, restlessness Fluoroquinolones adverse effects - Answer CNS effects (seizures, confusion), hepatotoxicity, peripheral neuropathy, hemotologic conditions, anxiety, depression Fluoroquinolones contraindications - Answer Contraindicated in those with CNS or renal pathology, do not use for children, pregnancy, hypersensitivity Fluoroquinolone safety during lactation - Answer Use cipro only Fluoroquinolone uses - Answer UTI, bones, joints, soft tissues Macrolide uses - Answer Chlamydia, Legionnaire's disease, microplasma, pneumonia Macrolide MOA - Answer Inhibition of protein synthesis, bacteriostatic Macrolide spectrum of activity - Answer Early gen: Gm+, atypicals; Late gen: Gm+, Gm-, atypicals Macrolide side effects - Answer GI upset Macrolide patient education - Answer Take on an empty stomach with a full glass of water Macrolide adverse effects - Answer Ototoxicity, prolonged QT intervals Macrolide contraindications - Answer Do not use with other drugs that prolong QT intervals or ototoxic drugs Macrolide drug-drug interactions - Answer Clarithromycin, erythromycin, telithromycin Macrolide safety profile pregnancy - Answer Category B Macrolide safety profile lactation - Answer Use azithromycin Tetracycline uses - Answer Typhus, Q fever, Rocky mountain spotted fever, lyme disesase, chlamydia Tetracycline MOA - Answer Obstructs protein synthesis by competing for RNA ribosomes, bactericidal Tetracycline spectrum of activity - Answer Gm-, MRSA, atypicals Tetracycline side effects - Answer Decreases effectiveness of oral contraceptives, N/V/D, photosensitivity, CNS (lightheadedness, dizziness, vertigo, vestibular neuronitis), fatty infiltration of liver Tetracycline patient education - Answer Drink lots of water Tetracycline contraindications - Answer Do not take with metals, not for pregnancy or children under 8 Tetracycline pregnancy safety rating - Answer Category D, causes IUGR, bone+teeth problems Tetracycline use during lactation - Answer Controversial, short-term use < 3 weeks Sulfonamide uses - Answer UTI, PCP, URI, sinusitis, protozoans Sulfonamide MOA - Answer Inhibits folate production, bacteriostatic Sulfonamide spectrum of activity - Answer Gm-, MRSA Sulfonamide side effects - Answer GI (abd pain, n/v/d, mild reversible pancreatitis), CNS (headache, vertigo, somnolence, tinnitus), cardiac (palpatations, chest pain) Sulfonamide patient education - Answer Minimum of 8-10 glasses of water daily, protect from sun Sulfonamide adverse effects - Answer SJS, urticaria, flushing, vertigo, photosensitivity, stomatitis, glossitis, peripheral neuronitis, oliguria, anuria, crysturia, uric acid kidney stones Sulfonamide contrindications - Answer Kidney problems, recent gout attach, PUD, kids < 2 months, HIV pts Sulfonamide use in pregnancy - Answer Category C, avoid during 1st and 3rd trimesters, use only if nothing else works Sulfonamide use during lactation - Answer Contraindicated in infants with hyperbilirubinemia, G6PD deficiency Lincosamide example - Answer Clindamycin Lincosamide side effect - Answer Diarrhea Metronidazole uses - Answer BV, trichomoniasis Metronidazole spectrum of activity - Answer Anti-protozoan, anti-bacterial Metronidazole patient education - Answer No alcohol ingestion including cough syrups and herbal tinctures for 24-48 hours after last dose Metronidazole pregnancy safety - Answer Safe (oral or vaginal routes) Rifampin use - Answer TB Rifampin patient education - Answer Use a backup form of contraception Glycopeptide example - Answer Vancomycin GLycopeptide spectrum of activity - Answer Narrow spectrum: Gm+ resistant to 1st line meds, MRSA Oxszolidinone example - Answer Linezolid Oxszolidinone uses - Answer Pneumonia, complicated skin infections, vanco-resistance Oxszolidinone spectrum of activity - Answer Gm+ Oxszolidinone side effects - Answer N/D, headache Oxszolidinone patient education - Answer Do not use within 2 weeks of MAOIs Oxszolidinone adverse effects - Answer Lactic acidosis, peripheral neuropathy, optic neuropathy is used longer than 28 days What is natural immunity? - Answer -"innate" -physical barriers, natural killers cells, phagocytes -non-specific What is acquired immunity? - Answer -acquired -specific -after exposure to an antigen -T cells & B cells are involved What is cell-mediated immunity? - Answer -does not involve antibodies -activation of antigen-specific cytotoxic t cells (these help the infected cells cause apoptosis "cell death") -release of various cytokines What is humoral immunity? - Answer -b cells, helper t cells, macrophages, dendritic cells all help faciliate the production of antibodies What cells does HIV attack? - Answer -helper t-cells -these cells are vital to producing a humoral response--which is why people infected with HIV become severely immunocompromised What is a live or attenuated vaccine? - Answer -contains a "live" form of the organism but is NON-infective -altered to produce a low chance of causing the disease -increased chance for long-term immunity -MAY cause the disease What is a killed or in-attenuated vaccine? - Answer -contains dead portions of the organism but is antigenically active -WON'T cause the disease -protection is more short term -will need more boosters What are precautions with vaccinations? - Answer -temp greater than 105 within 48 hours of a vaccine -continuous crying greater than 3 hours -convulsions What are the contraindications for giving vaccinations? - Answer -true egg allergy-- "anaphylactic reactions" (those with mild egg reactions are ok) -no "live" vaccines in pregnancy -encephalopathy -experienced GBS (guillain barre syndrome) When is TDAP given in pregnancy? Why is this timing important? - Answer -27-36 weeks gestation -this is to ensure the mother has adequate time to develop antibodies in order to pass them on to the fetus AND for there to be adequate protection to the infant until they can get their routine DTaP vaccination -it is safe to be given sooner for extenuative circumstances such as a "whooping cough outbreak" or potential tetanus exposure Who should we consult for up-to-date evidence-based prescribing practices regarding flu vaccinations? - Answer -the CDC -local health department Is acyclovir okay to give in pregnancy? What would it be used for? - Answer -Yes it is safe -It can be used as "suppressive" therapy during pregnancy to help prevent vertical transmission of herpes simplex virus to the infant during vaginal delivery What are the two FDA approved medications approved antivirals used for influenza? - Answer -oseltamivir (Tamiflu)--oral form -zanamivir (Relenza)--inhaled form -these inhibit neuraminidase--a viral enzyme required for viral replication -these both have activity against influenza A & B -only effective if given within 48 hours of onset of symptoms How are viruses different than bacteria in relation to illness in humans? How does this impact anti-viral medications? - Answer -they rely on host cells for metabolism and replication -most anti-virals only REDUCE viral shedding & reproducing until the body can use it's own defense to decrease the viral load and ultimately clear the virus from the body -most anti-virals can potentially reduce the severity of symptoms, duration of illness, and risk of complications--but does not cure it -it is important to provide comfort & supportive care education Who is most at risk of complications with influenza? - Answer -children less than 2 years old -elderly greater than 65 years old -pregnant or postpartum women -less than 18 years old on long-term aspirin (ASA) therapy -people with chronic conditions -American Indians -Alaskan Natives -morbidly obese individuals -residents of long term care facilities -immunocompromised What is the main drug used for prevention and treatment of CMV? - Answer -Ganciclovir -suppresses viral replication of viral DNA -advise against becoming pregnant -inform males about sterility -educate patients to report symptoms of bone marrow suppression Flu anti-virals, flu vaccine, and acyclovir while breastfeeding? - Answer -limited data -data suggests the medication is not absorbed much into the breastmilk -benefits of continuing breastfeeding outweigh the potential risks -low levels most likely will not cause harm What is the main concern with oral "azole" antifungals? - Answer -they cause inhibition of CYP450 enzyme system for metabolism -this can cause a decreased metabolism of drugs that also use this pathway What is is contraindicated when taking oral azole antifungals? - Answer -Statins -they can cause the increase of blood levels of statins--which can potentially cause liver damage or rhabdomyolysis What is the "azole" drug category? - Answer -broad-spectrum -anti-fungal -lower toxicity -can be oral or topical -inhibits CYP450 enzyme metabolism Which "azole" is not considered an anti-fungal? - Answer -metronidazole (Flagyl) -anti-protozoal & anti-bacterial Is oral fluconazole (Diflucan) safe in pregnancy and lactation? - Answer -yes--in lower doses and short exposure -high doses & long-term exposure is associated with congenital anomalies -the amount of drug that enters breastmilk is lower than the considered "safe" amount to give to a neonate What is a safe treatment for oral candidiasis in infants? - Answer -nystatin (Mycostatin)-- a "polyene antifungal" -second line would be fluconazole (Diflucan) 2 Black Box Warnings: Ketoconazole - Answer 1) severe liver harm can occur -only used orally if absolutely needed and only for systemic purposes 2) contraindication to use with other drugs that prolong QT interval -can lead to fatal cardiac dysrhythmias Which "azole" antifungal should be avoided by breastfeeding women? - Answer -ketoconazole --increased potential for hepatotoxicity What is the precaution for elderly when taking oral azole antifungals? - Answer -watch for potential increase in other drugs they are taking such as warfarin, oral hypoglycemics, etc.-contraindicated if they are taking statins Which "polyene" antifungal can be used for systemic fungal infections? - Answer -amphotericin B What is amphotericin B? - Answer -polyene anti-fungal -broad-spectrum -drug of choice for systemic -can be HIGHLY toxic -only used when infections are progressive & fatal -given by IV infusion -complete elimination from the body takes a long time -nephrotoxic -may cause hypokalemia & hematologic effects -*can reduce risk of toxicity if combined with flucytosine (antifungal) in order to be be able to give low dose amphotericin B--this combination is equivalent to a high dose of amphotericin B Black Box Warning: amphotericin B? - Answer -due to toxicity risk--only use in the setting of potentially life-threatening infection What are the two most common anti-tuberculosis drugs used? What could be used as second line? - Answer -isoniazid (INH) -rifampin (Rifadin) -second line use--fluroquinolones What supplement should be considered for those taking isoniazid (INH)? Why? - Answer -vitamin B6 -this is important for those who are at risk of low B6 levels (HIV, diabetes, pregnant, lactating) -this drug competes with vitamin B6 in certain enzyme reactions What does rifampin (Rifadin) potentially interfere with? - Answer -the absorption of oral contraceptives -ensure the patient has a back-up method What is important to remember when treating patients with TB? - Answer -need to use multiple drugs in order to decrease risk of developing drug resistance What are the most common protozoans seen in primary care? What is the most common drug used to treat these? - Answer -trichomonas vaginalis (STI) -giardia lamblia (hikers diarrhea) -metronidazole (Flagyl) metronidazole (Flagyl) ? - Answer -can be used to treat protozoa, parasites, amoebas, anaerobic bacteria -bactericidal -disrupts synthesis of nucleic acid & disrupts DNA structure--causing cell death -can be second line choice for C-Diff -resistance is rare -important to use another drug in combination if the infection also involves aerobic bacteria (it does not work against these)