Can Jackie Chan be on carbamaipine to control his tonic clonic seizure?
Maybe. Should check a HLA-B1502 allele prior to starting carbamazepine d/t high risk of SJS or TEN
Carbamazipine levels can INCREASE with???
Propoxyphene
Cimetidine
Erythromycin
Clarithromycin
Verapamil
Hydantoins
Carbamazipine levels can DECREASE with?
Beta blockers
Warfarin
Doxycycline
Succinimides
Haloperidol
Oral Contraceptives
What patient should you use CAUTION with when prescribing Carbamazipine?
pt w/increased intraocular pressure (it has mild anticholinergic effect)
Who should you NEVER prescribe Carbamazipine to?
Those w/hypersensitivity to carbamazipine or TCAs
history of bone marrow suppression (blood dyscraisa risk!)
Concurrent MAOIs
(and Asians)
Your patient on carbamazipine for partial seizures comes in for 3M follow up with a fever, sore throat, & weakness. Are you concerned?
YES! It cn cause bone marrow depression! (onset within 1st 3M of tx)
TRUE or FALSE. Carbamazipine can cause liver damage or impair thyroid function
TRUE!
Side effects of carbamazpine
Drowsiness, dizziness, blurred vision, N/V, dry mouth, diplopia, HA
(hint: give dose at bedtime)
Ethosuximide (Zarontin) is a succinidmide used to treat what type of seizure?
ABSENCE seizure in kids/adults
When should you check drug level of Ethosuximide (Zarontin)?
Check levels 1-3weeks after iniation of treatment. (want 40-100mcg/ml)
Michelle Duggar has absence seizures and has started on ethosuximide (Zarontin), what should she be aware of?
18 is enough kids!!!
Use a back up of birth control because Ethosuximide can decrease the effectiveness of birth control.
What is a serious problem with taking Ethosuximide for absence seizures?
Agranulocytosis, aplastic anemia, & granulocytopenia. Blood dyscrasias uncommon but can be fatal.
(Absense seizure & Agranulocytosis/aplastic anemia for Ethosuximide!)
Beside checking for a therapeutic level after 1-3weeks of treatment, what other baseline and intermitent lab should you get for Ethosuximide?
CBC (can cause blood dyscrasias). Look for sore throat, fever, pallor, weakness, infection, easy bruising, etc.
What is the MOST common ADR of Ethosuximide?
GI symptoms & Somnolence
Topiramte is used as ADJUNCTIVE therapy for what two types of seizures?
partial and primary generalized tonic clonic seizures
(Not sure if this helps but To(o) = adjunct)
What are some ADRs of Toprimate?
Weight loss (stabilizes 2-3yr)
Impaired cognition (dose related, reversible)
Parethesias
Depression & mood problems
Decreased sweating (heat intolerance & hyperthermia in kids)
What are serious ADRs of Toprimate?
Metabolic acidosis (measure bicarb at baseline and 2-4M)
Myopia and secondary angle glaucoma
Your patient is taking Topriamte as an adjunct for partial seizures. He exhibits a change in level of consciousness unexplained lethargy, and is vomiting. What should you do?
Besides the ABCs....check a serum ammonia level!
Your 20 year old patient is starting Topiramte as an adjunct to primary generalized tonic clonic seizures. What should you warn about?
There is a risk of suicidal behavior and ideation. Tell family and patient about potential neuropsychiatric ADR!
Gabapentin is indicated for what two types of seizures?
Partial seizures (add on for refractory partial seizures)
Secondary generalized seizures
What to warn pt (and family) of w/Gabapentin?
Neuropyschiatric events of kids 3-12yr
Increased risk of suicide
Serious reaction of Gabapentin?
Leukopenia or Thrombocytopenia
Common reactions of Gabapentin
Dizziness, somnolence, weight gain
So you're dizzy, tired, and fat..but you are seizing...awesome
What type of monitoring should you do for your patient on Gabapentin?
CBC for leukopenia/thrombocyopenia
NO ROUTINE MONITORING (no monitoring of drug levels)
Avoid ___ ___ for Gabapentin
abrupt withdrawl, can get withdrawal status epilepticus
Keppra (Levetiracetam) is used for what 3 types of seizures?
What should you tell your patient who is taking Fluoroquinolones?
Take with full glass of water (not food-it will delay absorption)
Stay hydrated to avoid crystal urea (avoid urine alkalizers, such as citrus drinks, baking soda, & antacids
Tendon tenderness occurs STOP med & notify
TRUE or FALSE. If your patient has a reaction to a penicillin, you should try another type of penicillin.
FALSE! Any patient allergic to penicillin will be allergic to all other penicillins risk for cross allergy to related drugs (cephalosporins & betalactamase inhibitors)
What are PCNs used for?
Commonly prescribed for infections seen in PCP office
Acute Otitis media & sinusitus (amoxicillin)
Steptococcal pharyngitis
Infection following bites (Augmentin)
Upper Resp Infections
Erythromycin is used for what 5 things?
Community acquired pneumonia
Chlamydia
Pertussis
H. Pylori
Chronic Bronchitis
If your patient is allergic to PCN, what type of med may you use?
Sulfonamides cross hypersensitivity can occur with which meds?
Sulfonylureas, thiazides, loop diuretics, and sunscreens w/PABA
Avoid sulfonamides in _____ deficiency
G6PD deficiency. Inherited disorder results in body lacking enzyme that normally protects RBC from toxic chemicals.Certain drugs can cause RBC breakdown and anemia.
Sulfanomides are structurally similar to ______ and act as a competitive inhibitor
PABA
TRUE or FALSE. Sulfanomides are no longer the 1st choice in infectious disease but they are used as low cost alternative for pregnancy, kids, and those w/PCN allergy.
TRUE
TRUE or FALSE. Resistance is not a problem with Sulfonamides
FALSE! Resistance is an issue.
Long term use of Sulfonamides, you need to check ____
Suppresses FSH so don't develop dominant follicle. also helps with cycle control (decreases break through bleeding)
When prescribing birth control, what should you take into consideration?
Pt knowledge & commitment
medical hx
current medications
prior experience w/methods
SE (migraines, dysmenorrhea, n/v)
pt weight
price
progestin sensitivyt, weight gain, fatigue, varicose veins
Benefits of OCs
reduces benign breast disease
reduces endometrial cancer
reduces ovarian cancer
reduces PID
reduces menstrual issues (anemia, dysmenorrhea)
Risks (of combined OCs)
VTE
MI
CVA
Benign liver tumors
retinal & mesentaric artery thrombosis
gall bladder disease
Increased cholesterol
Raises BP
Increased risk of VTE is most common risk of combined OCs, what part of the OC is it related to?
Estrogen. Increases blood viscosity, increases adhesiveness of plts, increases level of clotting factors, decreases AT3 activity.
So D/C 4 wk prior to surgery/immbolity
Use CAUTION when prescribing OCs to
postpartum<6wk
Breastfeeding 6wk-6mo
undx vag/uterine bleeding
past hx of breast ca w/no evidence in <5yr
meds that affect LFTs
gall bladder & sickle cell disease
HTN
DM w/out vascular dz in women <35yr
OC is ABSOLUTELY CONTRAINDICATED in
DVT/PE or hx of one
CVA, CAD, (or hx)
Structual cardiac dz
subacute bacterial endocardiits
breast ca
DM w/vascular dz or ≥20yr hx of
Breastfeeding ≤6wk
Liver dz or abnl LFTs
HA w/neuro sx
HTN w/vascular dz (or BP ≥1601/100)
Major surgery w/immbolity
≥35yr old smoker
Common OC SE
BTB (spotting)
HA
N/V, breast tenderness
Mood swings (happens more w/progestin only)
What are the OC "ACHES"
Abodminal pain (abd artery throbmosis, GB, liver)
Chest pain & SOB ( MI)
HA (CVA, HTN, migraines)
Eyes (visual changes, retinal artery thrombosis)
Severe leg pain (VTE)
Check every visit and document!
How do progestin only pills prevent pregnancy?
Thickens cervial mucus (primary effect)
Endometrial changes
Ovulation inhibition (less predictable than combined OCs)
Progestin only is good for what patient population?
Those who have contraindication to estrogen. good for smokers. Thrombosis is less of an issue. BP changes are usually not a problem.
Why do you need to have GREAT compliance on progestin only birth control?
Its a low hormone level. Effect is strongest @ 2-4hrs then decreases at 22hr. If taken late, use a back up for 48hrs.
What patient education do you need to do w/progestin only pill?
Need good compliance!
No placebo pill, active only!
Nuvaring advantages
Ease of use
Limited remembering
Better cycle control, less BTB than OCs by releasing steady hormones
Who is Nuvaring contraindicated in?
Those w/ cystocele, rectocele or uterine prolapse
What are the SE of Nuvaring?
Same as oral combined OCs
Also: vaginitis, leukorrhea, "feeling it", or expulsion
How long can the Nuvaring be out before a back up method of birth control is needed?
3 hr
TRUE or FALSE. The Nuvaring works immediately, no back up method needed while starting on it.
FALSE, need back up for 1 week
TRUE or FALSE. Plan B is an abortifacient
FALSE. It is used to prevent ovulation or implantation.
Plan B is _______ only.
Progestin Only
How do you instruct the patient to take Plan B?
2 tables, PO Q12hr x1
Plan B can be taken up to ______ hrs post sexual intercourse
120hrs (3-5days)
What are the SE of Plan B?
Same as oral OCs
Generally N/V, BTB/spotting
What patient education is needed w/plan B?
Risk/Benefits, SE/use
consent
Menses within 4-6weeks
UHCG if no menses
Can take up to 4x/yr but need to talk about changing method, STDs/HIV
What is the only contraindication to Plan B
Pregnancy. Need to test before prescribing.
What is the goal of HRT?
Tx of mod-severe vasomotor symptoms
Tx of mod-severe vulvar/vaginal atrophy
Prevention of postmenopausal osteoporosis
HRT: without a uterus get what type?
Estrogen only. Progestin is used to balance estrogen hyperstimulation of endometrium (and increased endometrial ca risk). No uterus = no need for progestin!
HRT is to use ______ _____ of hormone for the _______ duration possible.
lowest dose for shortest duration. (2yrs in lecture, book says 5, waiting from Nancy to find out which to know)
Your patient on HRT complains it is not working at 4 weeks, should you increase the dose?
No, it takes 6-8weeks to reach a max effect. No dose increases until then.
How often should you review risks/benefits with your patient on HRT?
Every year. Explain non-pharmacological things too, like weight loss, smoking cessation, reduced alcohol intake, regular exercise, and healthy diet.
ERT and HRT is contraindicated in those with ....
history of breast ca (& those w/1st degree relative w/breast ca) or those w/gynecologic ca.
(HRT/ERT does decrease risk of colon ca though!)
Risks of HRT
MI/Stroke
DVT/PE
Breast Ca
Dementia
Gall bladder dz
urinary incontinence
Risks of ERT
Stroke/DVT
Ovarian/Uterine Ca
Gall bladder dz
urinary incontinence
?Breast ca & dementia
Benefits of HRT/ERT
vasomotor symptom suppression (no hot flashes)
preserves urogenital tract
preserves bone mineral density & osteoporotic fx
decreases risk of colorectal ca (not estrogen alone)
HRT studies
Womens Health Initiative (WHI)
Heart & Estrogen/progestin Replacement Study (HERS)
What should you monitor for your patient on HRT/ERT?
annual exam & complete hx
mammogram
LFTs & lipids @ baseline & annually if abnormal
women 45yr+ for adult onset DM
When starting HRT, when should you follow up
Follow up at 3M, 6M then follow closely. Get the patient through the hump of menopause then taper off (again 2-5years is max, waiting on final answer...)
Vaginal estrogen is used for?
Symptom management. Vaginal application of estrogen thickens and revascularizes the vaginal epithelium increasing the number of superficial cells and reverses vaginal atrophy (improvement seen in 2 weeks)
FDA recommends vaginal estrogen (topical preparations) for ______ _____.
urogenital symptoms
Risk factors for osteoporosis
Family hx
Age 62yr in women or 70yr in men
Estrogen deficiency <45yr
slight build
fair complexion
age
low calcium &/or vitamin D diet
minimal sun exposure
weight <70kg
sedentary lifestyle
smoking & alcohol use
Diseases and drugs that increase risk of osteoporosis
glucocorticoid use (>5mg/day >3M)
anticonvulsants
long-term PPI
Heavy tobacco or alcohol use
AA women have a higher bone density, how are they at risk for osteoporosis
AA women tend to have lower Ca intake (and more likely to be lactose intolerant per the book).
Risk increases with age
Asians are high risk for osteoporosis, why?
They consume inadequate calcium (and per book are more likely to be lactose intolerant)
Hispanic women have same risk as white women for osteoporosis. True or False?
True
________ prevents bone resorption action of PTH
Estrogen (Why hormone replacement therapy can be good for osteoporosis)
Name a SERM used for osteoporosis
Raloxifene (Evista) has estrogen EFFECTS on bone. It is 2nd line therpa, decreases risk of vertebral fx. Can get hot flashes (main cause to d/c)
Also protective against Breast Ca
__________ reduce bone resorption by inhbiting osteocast activity
Bisphosphonates.
Bisphosphonates are used in what patient populations.
primary prevention in women >70yrs w/risk factors or >65yr with vertebral fx
1st line therapy for post menopausal women w/osteoporosis
1st line therapy for men older than age 70yr w/osteoporosis
_______balances PTH by increasing osteoblastic activity. (also has analgesic effect on bone pain)
Calcitonin
What patient population is calcitonin good for?
Women >65yr w/hx of vertebral fx
NOT for prevention of bone loss
(Intranasal administration)
Before starting tx for osteoporosis, what should you rule out?
Other disorders that may cause low BMD
Hyperparathyroidism
Vit. D deficiency
Hyperthyroidism
Renal disease
What lab work should you get for a osteoporosis work up?
serum Ca+ & albumin
25 Hydroxy Vit. D
TSH
Serum creatinine level
(to r/o other disorders)
DEXA measure BMD. ____% loss = double fx risk
10% loss equals double the fracture risk
Buspirone (Buspar) is used for what disorders?
Generalized anxiety disorder
Social phobia
Augments SSRIs or SNRIs for agitated or anxious depression
______ is good because it does not have a tolerance or dependency. No CNS depression or sedation either!
Buspirone (Buspar)
How long before Buspar takes effect?
Takes 2 weeks to reach therapeutic effect (up to 6wks for max effect)
How often is Buspar dosed?
Multiple daily dosing
BUSPAR is contraindicated in _______ & __________.
panic attacks and severe hepatic/renal disease
Adverse Drug Effect of Buspar
Few ADR and they resolve with continued use. Light headedness, HA, insomnia, nausea, nervousness, & dry mouth. Akathesia & involuntary movements (rare)
*No congnitive impairment of BZDs*
What kind of drug interactions can happen with Buspirone (Buspar)?
Serotonergic drugs (MAOIs & SSRIs) can cause serotonin syndrome
Excitalopram is a cleaned up version of Citalopram (Celexa). what does this mean?
No sedation properties like Celexa
What would you use Fluoxetine (Prozac) for?
OCD
Panic disorder
Bulimia nervosa
(lastly for depression)
What would you use Escitalopram (Lexapro) for?
Major depression
GAD
SSRI like Escitalopram or Fluoxetine are contraindicated iwth concurrent use of ______
MAOIs (or within 14 days of MAOIs)
When should you use caution with SSRIs like Fluoxetine or Escitalopram?
Severe hepatic or renal impairment & should be avoided in the 1st and 3rd trimester of pregnancy
ADRs with SSRIs (like Fluoxetine or Escitalopram)
N/V, HA, light headedness, dizziness, dry mouth, increased sweating, weight gain/loss, exacerbation of anxiety & agitation
What is a MAJOR side effect of SSRI
Sexual dysfunction (change to different SSRI or decrease the dose)
_________ can cause insomnia so you should give it in the morning.
Fluoxetine (Prozac)
_____ are common w/Prozac
GI disturbances
Do NOT prescribe more than _____ weeks of an SSRI.
Four weeks max, want to see patient at 4weeks and if you give 3M supply, that may not happen
What is a serious ADR of SSRI
serotonin syndrome. Rapid onset (2-72hrs after start of tx), can be fatal, N/D, chills, sweating, hyperthermia, HTN, myoclonic jerking, tremor, agitation, ataxia, disorientation, hyperreflexia, fever, confusion, & delerium
To prevent serotonin syndrome, you should avoid __________.
adjunctive combination of serotonergic agents
How much time should you wait when changing from one serotonergic agent to another?
2 weeks should elapse after d/c MAOI before starting SSRI
5-6 weeks should elapse between d/c SSRI before starting MAOI
How do you taper SSRI off?
allow 5 1/2 lives per dose decrease
Medications associated with serotonin syndrome
Antidepressants
Amphetamines
analgesics
antibiotics
anticonvulsants
antiemetics
antimigraine
bariatric
drugs of abuse (LSD, MDMA)
Herbal drugs & supplements
OTCs
What is the ONLY SSRI you do not need to taper?
Fluoxetine, it has active metabolites.
There is a risk of _____ with SSRIs. This risk is increased with the concommitant use of ASA or NSAIDs.
Risk of bleeding.
Elderly on SSRI: watch for _____
electrolyte disturbances
How long does it take before you see therapeutic effects of SSRIs
4-6 weeks
Pharmacokinetics of Fluoxetine (Prozac)
peak 6-8hr
1/2 life ~16hr
significant 1st pass in liver & is metabolized by CYP450. Parent drug has 1/2 life of 1-3 days but its 1st metabolite has additional 1/2 life of 4-16days so overall 1/2 life is 4-26hrs)
Single dose of _______ can be helpful in last step of tapering off SSRI and avoiding withdrawal.
Fluoxetine (Prozac)
How would you d/c Escitalopram (Lexapro)
1/2 life is 27-32hr. Allow FIVE 1/2 lives per dose decrease (so 5.5-6.5 days), decrease by 50% each time but may need to go slower. Can show withdrawal symptoms after 1 missed dose
Escitalopram (Lexapro) acts only on _________
serotonin
What are the general steps for diagnosing depression?
Step 1: rule out medical disorders (CBC, Chem 10, LFTs, Lipids, UA, TSH, lead toxicity)
Step 2: screen for substance abuse
Step 3: Prenancy test
*Need to assess suicidal risk*
What is the tx algorithm for SSRI therapy
week 1-3 Monotherapy
week 4-6 increase dose (or switch if SE)
week 6-8 (if not enough increase dose, or if at max then titrate back down and make switch)
week 8-10 (increase dose if needed)
continuation period
12-18M later, taper off (unless hx of 3 episodes then continue)
TRUE or FALSE.
SSRI tx: monotherapy at lowest dose, adequate 8 week trial (@ max dose), if not effect, taper and switch to another SSRI, if not effect then try SNRI, if no effect REFER!
TRUE!
When prescribing an SSRI, when should you follow up?
Follow up in 1 week. First 3 weeks there can be suicidal ideation so need to check in
anxiety, agitation, irritability, confusion, and slowed thinking
Phenelzine (Nardil) is a ______
MAOI
What is a huge risk for interaction w/Phenelzine (Nardil)
Interaction w/tyramine & phenylethylamine. Can get rapid extreme HTN
Phenelzine (Nardil) with concurrent use of anticholinergic, sympathomimetics, & stimulants can cause a ____ ____.
HTN crises
Your patient on Phenelzine (MAOI) took an anticholinergic and now has a HA, palpiation, stiff/sore neck, chest tightness, ↑HR, sweating, & dilated pupils. What do you do?
Having a HTN crisis. Tx immediately with phentoiamine (Regitine) 5mg IV, then 0.25-0.5mg IM Q4-6hr
What lab test should you monitor for your patient on Pehnelzine (Nardil)?
Monitor LFTs, d/c if abnormal
Why is Clonzapam preferred over Xanax or Serax?
It has longer half life and daily dosing
A benefit of Serax (oxazepam) is...
good for detox, easy on the liver
What are BZDs used for?
Anxiolytic (anxiety & insomnia)
Many other uses: muscle relaxant, pre-anesthesia sedation, prevention/tx of panic attacks, acute agitation, dystonia, emergent tx of seizures, restless leg syndrom, IBS, chemo induced N/V
Bad part about Alprazolam (Xanax)
More likely to cause dependence bc high potency & rapid short term action
Alprazolam (Xanax) drug interactions
Cimetidine, omeprazole, macrolide abx, disulfiram, grapefruit juice (decreases metabolism so inc. effect of xanax), & Ketoconazole (contraindicated concurrent use)
TRUE or FALSE. To wean off BZD, Clonazepam (Klonopin) is good to substitute (an equivalent dose) in place of short acting BZD then titrate down.
TRUE
TRUE or FALSE. Clonazepam (Klonopin) is not good for panic disorders because it takes time to work.
FALSE. Long acting BZD are 1st choice for panic disorders because taking them prior to anticipatory event to PREVENT panic attack rather than tx as needed.
TRUE or FALSE. After 1 week of controlled symptoms on BZD, it is time to switch to SSRI. So you would increase SSRI while decreasing BZD (like Clonazepam).
TRUE. (if needed Clonazepam can be used as adjunctive tx)
What is a drug interaction with Clonazepam (Klonopin)?
Lithium (increased sexual dysfunction)
______ ______ potentiates Oxazepam (Serax)
smoking cessation
Elderly may need ______ dose of BZD.
Lower
when are BZD contraindicated?
Pregnancy & Lactation
Hepatic & Renal disease
Not for kids under 6yr
Acute narrow angle glaucoma
What are some ADRs of BZDs
CNS depressant (sedation)
CV or Resp. depression
Common SE: dizziness, confusion, blurred vision, & hypotension
