Advanced Pharmacology Final Exam

Parkinson's disease, pharmacotherapy, patient teaching - - symptom journaling (on and off times, dyskinesia, mood/memory changes, nausea/constipation from medication SE -food consistency changes for swallowing issues, increased fluid and fiber for constipation -take medication with food (initially) to avoid nausea/anorexia -limit dietary protein to 3-4 ounces per meal (size of a deck of cards) due to interference with levodopa (take med in morning, eat protein food in evening) -avoid taking levodopa with meals or within 2 hours of iron -avoid tyramine rich foods (aged cheese, soybean, cured meats) with MAO-B inhibitors (rasagaline, selegiline, safinamide) to avoid serotonin syndrome -inc. calcium, vitamin d, weight bearing exercise -patient education sources: PD foundation, Michael J fox foundation Alzheimer's disease, pharmacotherapy, goals of treatment - -maintain/maximize patient functional ability and quality of life while minimizing AE and cost of drugs -multidisciplinary team approach -drug therapy choices for cognitive symptoms: cholinesterase inhibitors & memantine -no cure for AD; goal of treatment is to slow disease progression and manage symptoms (Increasing length of time of self-sufficiency, delaying need for nursing home placement, reducing burden on the caregiver) Alcohol use disorder, pharmacotherapy, side effects - Naltrexone (not to be used in hepatic dysfunction/opioid use or active withdrawal/drinking) SE- usually well tolerated, may cause HA, nausea, injection site reaction, hepatic toxicity in alcohol-dependent pt, may have CV effects but not common Acamprostate (not to be used in renal dysfunction/sulfite sensitivity) SE- diarrhea, insomnia, nausea, pruritus, asthenia, anxiety/depression, CV effects Disulfiram (deterrent producing effects if taken even with slight amount of alcohol like mouthwash) AE of drug- drowsiness, fatigue, HA, hepatic dys., peripheral/optic neuropathy, metallic/garlic taste, rash/acne ADHD, stimulants, side effects - Neuro: insomnia, HA, dizziness, abuse potential, growth retardation (high doses), seizure activity, agitation, nervousness, tics, dyskinesia GI: loss of appetite, weight loss, N/V Cardiac: palpitations, tachycardia, hypertension, arrythmias may be able to minimize SE with "drug holidays" summers/weekends without drug Insomnia, pharmacotherapy, first line agents - -Benzodiazepines: alprazolam, estazolam, flurazepam, lorazepam, quazepam, temazepam, triazolam (END IN LAM AND PAM) -BZRA: zolpidem, zaleplon, escitalopram -ramelteon -1st gen. antihistamine: doxylamine succinate (only agent approved for pregnancy) -Flurazepam and quazepam assist with falling asleep, while Temazepam helps stay asleep due to longer half-life Depression, pharmacotherapy, treatment order: First line- - First Line: SSRIs and SNRIs - Fluoxetine and sertraline for patients with somnolence Paroxetine may be good for patients with insomnia. Selection of agents should be based on patient's past experiences, medications and drug interactions/cost If the patient is taking drugs metabolized by CYP3A4, then avoid fluoxetine (Prozac) If depression-related symptoms include sexual dysfunction, SSRIs and SNRIs should be avoided If weight gain needs to be avoided, then bupropion better option than SSRIs (like paroxetine, which has the greatest potential for weight gain) or mirtazapine Combining psychotherapy with pharmacotherapy, in patients with psychosocial stressors, leads to better short-term outcomes compared to single-option treatment Depression, pharmacotherapy, treatment order: Second line- - -An inc. in dose may be needed if some clinical benefit from first line therapy OR -adding another agent to first line therapy (augmentation) with lithium, thyroid hormone or stimulant medication (not common anymore though) -if pt gets no benefit from SSRI or SNRI or cannot tolerate the drug another drug can be chosen from same class -Atypical antidepressants considered second line (bupropion, mirtazapine) -combination therapy with: trazodone, bupropion (though this is often used as initial therapy), mirtazapine, buspirone, and the atypical antipsychotics (AAPs) Depression, pharmacotherapy, treatment order: Third line- - -TCAs or MAOIs -inexperienced practitioners should not prescribe MAOI drugs due to dangerous side effects, food/drug interactions Antiarrhythmics, pharmacotherapy, expected EKG findings with treatment (Quinidine) - prolonged QT interval and a slightly prolonged QRS complex on the ECG Antiarrhythmics, pharmacotherapy, expected EKG findings with treatment (Procainamide) - widens the QRS complex, prolongs the QT interval, and slightly prolongs the PR interval Antiarrhythmics, pharmacotherapy, expected EKG findings with treatment (Disopyramide) - Prolonged QT interval and a slightly prolonged QRS complex Antiarrhythmics, pharmacotherapy, expected EKG findings with treatment (Flecainide) - Because of the slowed cardiac conduction, increases in the PR interval and QRS duration may be seen on the EKG Antiarrhythmics, pharmacotherapy, expected EKG findings with treatment (Beta blockers) - sinus bradycardia, consisting of a normal or slightly prolonged PR interval and occasional shortening of the QT interval Antiarrhythmics, pharmacotherapy, expected EKG findings with treatment (Class 3 AADs) - increased ventricular ectopy and changes in PR interval, QRS duration, and QT interval Antiarrhythmics, pharmacotherapy, choosing appropriate drug - AFib or Aflutter + hemodynamically UNstable (sev. hypotension, syncope, HF/angina) 1st line tx is immediate DCC if hemodynamically stable + rapid ventricular rate, need to treat rate in Afib with IV diltiazem, IV verapamil or an IV beta blocker if pt LV systolic function (LVEF) is > 40% *use beta blocker if pt is post op/hyperthyroidism digoxin has a slow onset of action so not preferred in high adrenergic states (exercise) If pt comes in with HFrEF (LVEF <40%) an IV beta blocker or IV digoxin is preferred *avoid BB in pts showing signs of decompensated HF For pt with worsening HF symptoms, IV digoxin/IV amiodarone is 1st line for controlling ventricular rate if pt has contraindications to BB, diltiazem, or verapamil and is in Afib can tx with IV amiodarone for rate control Pts with Afib >48 hours at risk for thrombo. event if conversion to SR occurs in absence of anticoagulation, so if pt not adequately anti-coagulated, avoid IV amiodarone or cardioversion CHF, pharmacotherapy, second line management in HFrEF - -ACE-I or ARB or ARNI (Entresto) and beta blocker with a diuretic -Patients with HF and signs of volume overload should be started immediately on a diuretic in addition to an ACE-I -Mild HF or concomitant hypertension ->thiazide diuretics -Loop diuretics: preferred in most patients, particularly those with renal impairment or marked fluid retention Potassium-sparing diuretic or potassium supplement should be used for patients with serum potassium concentrations less than 4.0 mEq/L. Patients with persistent volume overload despite initial medical management may require more aggressive administration of the current diuretic (e.g., IV administration), more potent diuretics, or a combination of diuretics (e.g., furosemide and metolazone, or furosemide and spironolactone) CAD, nonpharmacologic interventions/education - The practitioner must assess the patient's modifiable risk factors and work with him or her to reduce the risk for or progression of CHD -Modifiable risk factors: smoking, HTN, dyslipidemia, diabetes, obesity -provide dietary counseling, patients should consume a low-fat, low-cholesterol diet, patients should engage in regular aerobic exercise -practitioner should emphasize that nonpharmacologic therapy and lifestyle modifications supplement drug therapy and should continue indefinitely HTN, pharmacotherapy, diuretics and contraindications (Thiazide drugs) - Thiazides- Chlorthalidone, hydrochlorothiazide, Chlorothiazide (Diuril), indapamide, and metolazone contraindications: -anuria -not recommended in patients with creatinine clearance less than 30 mL/min -renal decompensation -hypersensitive to thiazides or sulfonamides -high doses are not recommended in patients with hyperlipidemia, gout, and diabetes HTN, pharmacotherapy, diuretics and contraindications (Loop diuretics) - contraindications: -anuria -hepatic coma/severe electrolyte depletion -ethacrynic acid contra. in infants -furosemide, bumetanide, torsemide contra. in sulfonylureas sensitivity instead use ethacrynic acid HTN, pharmacotherapy, diuretics and contraindications (potassium sparing) - Can cause hyperkalemia and hyponatremia and therefore should be avoided in patients with serum potassium levels of more than 5 mEq/L contraindiacted if: -Addison Disease -Anuria -Patient taking Eplerenone HTN, pharmacotherapy, side effects (Thiazide diuretics) - -hypokalemia, hypomagnesemia -HYPERcalcemia, HYPERurecemia (can worsen gout) and HYPERglycemia (risk of getting diabetes) -tinnitus, paresthesia, abd. cramps, N/V, diarrhea, muscle cramps, weakness, sexual dys. HTN, pharmacotherapy, side effects (Loop diuretics) - -may be same SE as thiazide diuretics but not as significant in terms of serum lipid/glucose -hypocalcemia (opposite of thiazide SE) -electrolyte & volume depletion greater b/c short duration -ototoxicity in high doses (more common in ethacrynic acid) -loop diuretic reserved mainly for HTN pt w/renal dysfunction