pebc

• BETA BLOCKERS
• CARBONIC ANHYDRASE INHIBITORS
• ALPHA-2 AGONISTS (BOTH)

• A-2-AGONISTS
• BETABLOCKERS
• CHOLINERGIC AGONISTS
• PROSTAGLANDIN ANALOGUES
• CARBONIC ANHYDRASE INHIBITORS

• HTN
• ABNORMAL LIVER/RENAL - 2
• STROKE
• BLEEDING
• LABILE INR
• ELDERLY >65
• DRUGS/ALCOHOL - 2

PROSTAGLANDIN ANALOGUES (UVEOSCLERAL, EXCEPT FOR BIMATOPROST WHICH ALSO DOES TRABECULAR)

CHOLINERGIC AGONISTS (TRABECULAR)

ALPHA 2 AGONISTS (BOTH)

IC ANTIARRHYTHMICS (PROPAFENONE, FLECAINIDE)

AMIODARONE, SOTALOL

MG IV

• BBS
• ISDN/HYRALAZINE
• ACEI/ARB
• ENTRESTO
• MRA

RELY - DABIGATRAN SUPERIOR TO WARFARIN IN STROKE AND VTE

ROCKET AF - RIVAROX NONINFERIOR TO WARFARIN

AVERROES - APIXABAN SUPERIOR TO ASA

ARISTOTLE - APIXABAN SUPERIOR TO WARFARIN

AFIB + PCI OR RECENT ACS AND CHADS 2+

• PHOTOSENSITIVITY
• HYPERKALEMIA
• HYPER SCR
• HYPOGLYCEMIA
• HYPONATREMIA
• RENAL CRYSTALLIZATION
• RASH

• ARIPIPRAZOLE
• PALIPERIDONE
• (RISPERIDONE)

• METHYLDOPA
• LABETALOL
• NIFEDIPINE XL

• IF EF< 35%, AMIODARONE
• IF EF >35%, AMIODARONE OR SOTALOL

IF INEFFECTIVE -> CATHETER ABLATION

USE SOTALOL WITH CAUTION BETWEEN 35-40

ATRIAL FLUTTER

DRONEDARONE, FLECAINIDE, PROPAFENONE, SOTALOL

• IF INEFFECTIVE, CHOOSE 1 OF AMIODARONE OR CATHETER ABLATION
• (IF AMIODARONE INEFFECTIVE, ABLATE)

• CAN CONSIDER TARGET SBP <120 IN CERTAIN POPNS:
• CKD (<60)
• CVD
• FRS=>15%
• 75Y+

5X INCREMENTAL REDUCTION IN BP

ONLY IN REFRACTIVE HEART FAILURE

MI OR HF

IF SBP 20 OR MORE ABOVE TARGET OR DBP 10 OR MORE ABOVE TARGET

SERTRALINE

• DIURETICS (THIAZIDE)
• BB (ONLY IF <60, HF, MI)
• ACEI (NON BLACK W/UNCOMPLICATED HTN, DM, HF, MI, CKD)
• ARB (UNCOMPLICATED HTN, CKD, ISCHEMIC HEART DISEASE)
• CCBS (ELDERLY, BLACK ARE PARTICULARY RESPONSIVE)

• 1 GTT QHS (2 IF BIG NAIL)
• COURSE OF TX 48 WEEKS
• NO NEED TO DEBRIDE C.F. PENLAC
• CLIP UNINFECTED TOENAILS FIRST

RIVAROXABAN

• INDICATED FOR CHRONIC CONSTIPATION OR IBS
• QD 30 MIN AC 1ST MEAL
• INCREASES GI TRANSIT, SOFTENS STOOL, INCREASES BM FREQUENCY
• AE: DIARRHEA

INCREASES ABSORPTION

• VTE
• BREAST TENDER
• FLUID RETENTION
• NAUSEA
• SPOTTING (NORMAL X 3 CYCLE)
• BLOATING
• HEADACHE (DUE TO ESTROGEN DROP - CAN USE LOW DOSE ESTROGEN IN PLACEBO WEEK)

• MOOD 
• WEIGHT GAIN
• REDUCED LIBIDO 
• CONSTIPATION (LATE PREGNANCY)

THUS: MOOD, FOOD, NO BOOB, NO POO

ESTROGEN NOT HIGH ENOUGH

ESTROGEN TOO HIGH - INCREASE PROGESTIN

MAST CELL STABILIZER + ANTIHISTAMINE!

THUS WORKS FASTER THAN MAST CELL (WORKS IN FEW MINUTES AND FOR 12H C.F. MAST CELL ONSET OF DAYS)

NOTE DIFFERENCE BETWEEN PATANOL AND PATADAY

• FEVER >72H
• FEVER >40C
• FEVER <6 MONTHS OLD

• COUGH >3 WEEKS
• CONGESTION > 1 WEEK WITH PURULENT DISCHARGE OR JAW/FACIAL PAIN
• CROUP

• ASTHMA
• COPD
• TROUBLE BREATHING/CHEST PAIN WHEN BREATHING

• EXTREME IRRITABILITY
• EXCESSIVE FATIGUE

• SENSITIVITY TO LIGHT
• NECK STIFFNESS
• SEVERE HEADACHE

• DIFFICULTY SWALLOWING
• COUGHING WITH VOMITING

SKIN RASH

• ASTHMA
• COPD
• SSRIS/MAOIS (DM IS 2D6 METABOLIZED)
• PRODUCTIVE COUGH

• NOT FOR UNDER 12
• NOT FOR UNDER 18 IF TONSILS/ADENOIDS REMOVED

• BPH
• CVD
• DM
• GLAUCOMA (CLOSURE)
• HTN
• SEIZURE DISORDER
• THYROID

SALINE

• HISTORICALLY USED THIS WAY
• PETROLATUM WHEN ASPIRATED DURING SLEEP CAN ACCUMULATE IN LUNGS OVER TIME AND LEAD TO CHRONIC PNEUMONITIS (LEADS TO SOB, COUGH, REDUCED LUNG CAPACITY)

DEXAMETHASONE 0.6MG/KG X 1 DOSE

ANY OCP + CONDOMS

PREFERRED: DEPO-MEDROL OR IUD/IUS OR CONDOMS

• OFFICIAL: TX/ PREVENTION OF ULCERS
• UNOFFICIAL: ABORTION

• AVOID COC FOR 6 WEEKS POSTPARTUM AND USE WITH CAUTION IN 1ST 6 MONTHS (VTE RISK, POTENTIAL EFFECT ON MILK PRODUCTION)
• USE PROGESTIN ONLY (CAN USE IMMEDIATELY POST-PARTUM)

• ON INSULIN: 3000
• ON ORAL MEDS WITH HYPO RISK : 400
• ALL OTHER T2DM: 200

CO-TREAT FOR CHLAMYDIA TOO!

• 1ST LINE: CEFTRIAXONE 250MG IM + AZITHRO 1G (1 DOSE EACH)
• 2ND LINE: CEFIXIME 400MG + 1 G AZITHRO (1 DOSE EACH)
• 2ND LINE: SPECTINOMYCIN 2G IM + 1 G AZITHRO (1 DOSE EACH)
• 2ND LINE: AZITHRO 2 G (1 DOSE)

• 1ST LINE: AZITHRO 1 G
• 2ND LINE: DOXYCYCLINE 100MG BID X 7 DAYS

ALWAYS

CKD

DIABETES

GEMFIBROZIL

• >75Y
• FEMALE
• LOW BMI
• ETOH/DRUG ABUSE
• NMDS
• ASIAN

• TAMOX AES
• INEFFECTIVE TAMOX THERAPY
• COMPLETED TAMOX THERAPY

• ANTIANDROGEN (PROSTATE CANCER)
• DAILY, W/O REGARD TO MEALS
• FOR COMBO WITH LHRH ANALOGUE OR AFTER SURGICAL CASTRATION IN METASTATIC PROSTATE CANCER (START ON DAY OF OR AFTER SURGERY)
• AES: HOT FLASHES, GYNECOMASTIA, BREAST TENDERNESS

• CONSTELLA FOR CHRONIC CONSTIPATION OR IBS
• DAILY DOSE AC 1ST MEAL
• AE: DIARRHEA

• DICETEL: FOR IBS TOO, BUT LESS INCIDENCE OF DIARRHEA
• TID AC
• AE: LESS DIARRHEA

• ACTONEL : EMPTY STOMACH
• ACTONEL DR: WITH FOOD

ACTONEL DR: ALSO HAS DI WITH PPIS (NEEDS ACIDIC ENVIRONMENT)

• PSYLLIUM/DOCUSATE: 12-72H
• PEG: 2-4 DAYS
• PEG SUPP: 15-60 MINUTES
• LACTULOSE: 1-2 DAYS
• MILK OF MAGNESIA: 30 MIN - 6H
• SODIUM PHOSPHATE: 30 MIN -6H
• FLEET ENEMA: 2-15 MINUTES
• BISACODYL/SENOKOT: 6-12H
• BISACODYL SUPP: 15-60 MINUTES

• 1. BLEXTEN (BILASTINE) DAILY ON EMPTY STOMACH
• -FOR 12+YO
• -QT PROLONGATION

• 2. RUPALL (RUPATADINE) DAILY C/ OR C/O FOOD
•      -NO GRAPEFRUIT

• 1. ACUTE DYSTONIA (MUSCLE SPASMS OF FACE,NECK,BACK)
• 1-5 DAYS
• USE ANTI-PARKINSON AGENTS (BENZTROPINE)

• 2. AKATHISIA (RESTLESSNESS)
• 5-60 DYAS
• REDUCE DOSE OR CHANGE DRUG
• CLONAZEPAM/PROPRANOLOL MORE EFFECTIVE THAN ANTI-PD DRUGS

• 3. PARKINSONISM (BRAKINESIA, RIGIDITY, TREMOR)
• 5-30 DAYS
• DOSE REDUCTION, CHANGE MEDS, USE ANTI-PD DRUGS

• 4. NEUROLEPTIC MALIGNANT SYNDROME (EXTREME RIGIDITY, FEVER, UNSTABLE BP, CAN BE FATAL)
• WEEKS TO MONTHS AND CAN PERSIST FOR DAYS AFTER STOPPING ANTIPSYCHOTIC
• -STOP AP IMMEDIATELY, SUPPORTIVE CARE, BROMOCRIPTINE/DANTROLENE

• 5. TARDIVE DYSKINESIA (OROFACIAL)
• MONTHS-YEARS
• USUALLY IRREVERSIBLE

36H

• IMIQUIMOD
• WARTS
• APPLY 3/WEEK (MWF) QHS
• USE GLOVE, RUB IN
• DON'T COVER WITH BANDAGE
• WASH IN AM
• AE: BURNING, STINGING, REDNESS
• IF TOO BOTHERSOME, STOP 1 WK, RESTART

CI IN WEEKS 38-42, LABOUR AND DELIVERY (G6PD, HEMOLYTIC ANEMIA)

• NAUSEA, DROWSY, DIZZINESS (SUBSIDE OVER FEW MONTHS)
• START 0.25MG QHS (MAY NEED 1-4MG DAILY)
• TAKE DOSE 2H BEFORE ONSET OF SX AND INCREASE Q4-5 DAYS TO EFFECTIVENESS
• MAY DEVELOP COMPULSIVE BEHAVIOURS (GAMBLE, HYPERSEXUALITY- MORE LIKELY IN FEMALES)
• DON'T STOP ABRUPTLY
• AVOID CAFFEINE, ETOH, NICOTINE
• TRY EXERCISE, HOT BATHS
• SLEEP ATTACKS

• 300U/ML VS 100U/ML, THUS LESS VOLUME
• PEN ALSO HAS LESS SURFACE AREA THUS SLOWER RELEASE
• TOUJEO LASTS 6WK OUT OF FRIDGE (C.F. 4 WEEKS)
• STUDIES: MIMICS BASAL MORE, LESS HYPOGLYCEMIA
• PRIME WITH 3 UNITS CF. 2 UNITS FOR ALL OTHERS

• FIASP
• CAN DOSE 2 MIN AC TO 20MIN PC
• MORE CLOSELY MIMICS NATURAL PHYSIO INSULIN RESPONSE
• APPEARS IN BLOOD 2X FASTER THAN ASPART
• IMPROVED MEALTIME CONTROL IN T1 AND T2DM
• IMPROVED OVERALL CONTROL IN T1, SIMILAR OVERALL CONTROL IN T2
• NO SIG DIFF IN OVERALL RATE OF SEVERE/CONFIRMED HYPO
• HAS VITAMIN B3 TO INCREASE ABSORPTION

• PERIPHERAL EDEMA
• FATIGUE
• PULMONARY EDEMA
• (RESPECTIVELY)

• PREDIABETES:
• AIC 6-6.4
• FBG 6.1-6.9
• PPBG 7.8-11

• DIABETES:
• AIC 6.5+
• FBG 7+
• PPBG 11.1+
• RANDOM BG 11.1+
• IN ABSENCE OF SYMPTOMS, REPEAT WITH FBG OR PPBG (DON'T USE RANDOM FOR REPEAT)

• BETABLOCKERS
• CORTICOSTEROIDS
• IMMUNOSUPPRESSIVES
• NIACIN
• PROTEASE INHIBITORS
• SECOND GENERATION APS
• THIAZIDE AND LOOP DIURETICS

BEST <3H, CAN IF <4.5H

BEST IF <30MIN, BUT CAN GIVE <6H WITH SIMILAR BENEFIT, CAN GIVE <12H FOR SOME BENEFIT

90 MINUTES

• HELP WITH SYMPTOMS, EDEMA IN EARLY VT
• RELIEVE SX IN PATIENTS WHO DEVELOP POST-THROMBOTIC SYNDROME (BUT DO NOT PREVENT PTS!)
• *INAPPROPRIATE TO USE IN PATIENTS WITH PRE-EXISTING PVD

DEPENDS ON RISK OF RECURRENCE

• IF 1ST EPISODE WITH TRANSIENT RFS (E.G. SURGERY) OR 1ST UNPROVOKED DISTAL DVT (BELOW KNEE) - 3 MONTHS
• IF 2ND UNPROVOKED, IRREVERSIBLE RFS (CANCER) - CONSIDER INDEFINITELY 

*HIGHEST RISK IS IN MALES

• <10% OF PATIENTS
• RISK OF INTRACRANIAL HEMORRHAGE
• BEST RESULTS IF RECENT THROMBUS (<14 DAYS)
• DON'T CONSIDER IF SHORT LIFE EXPECTANCY OR POOR FUNCTIONAL STATUS
• GENERALLY: CONSIDER IF LIFE- OR LIMB-THREATENING THROMBOSIS AND NO BLEEDING CI

• ETOH-INDUCED HYPO
• MALNOURISHED PATIENTS

• INJ: FONDA, LMWH, UFH (UFH PREFERRED IN CRCL<30)
• PO: APIXABAN, RIVAROXABAN

DABIGATRAN CAN BE CONSIDERED FOR ONGOING THERAPY (APPROVED, BUT SHOULD BE USED FOLLOWING 5-10 DAYS OF PARENTERAL ANTICOAGULANT)

• PREFER LMWH (BABY IS A TUMOUR)
• IF UNAVAILABLE, USE UFH

LMWH HAS LESS BONE LOSS AND IS DAILY

BOTH DON'T CROSS PLACENTA

AVOID WARFARIN (TERATOGENIC)

CAN USE WARFARIN, UFH OR LMWH

APPROVED: ARGATROBAN, DANAPAROID

LIMITED DATA TO USE BIVALIRUDIN OR FONDAPARINUX

APIXABAN: 10MG BID X 7 DAYS, THEN 5MG BID FOR 3-6MONTHS

RIVAROXABAN: 15MG BID X 21 DAYS, THEN 20MG DAILY X 3-6MONTHS

DABIGATRAN: FIRST 5-10 DAYS OF PARENTERAL ANTICOAGULATION THEN 150MG BID (<80Y) OR 110MG BID (>80Y)

NONPHARMS KEY: MINIMIZE COLD EXPOSURE, WARMING EXERCISES, STOPE SMOKING, AVOID STRESS

• IF OVERLY SYMPTOMATIC:
• -DHP CCB (NIFEDIPINE, FELODIPINE) 30-60 MIN BEFORE COLD EXPOSURE, OR DAILY IN WINTER 
• -PRAZOSIN?

• 1-2 DAYS TO INCUBATE
• SHEDDING USUALLY WHEN SYMPTOMS START OR JUST BEFORE

• DOES NOT PREVENT
• 1G DAILY MAY REDUCE DURATION/SEVERITY OF SYMPTOMS

• KIDS 0-5: SALINE 
• KIDS 6-11: ORAL ANTIHISTAMINE/DECONGESTANT X 3 DAYS (THERE ARE NO TRIALS FOR TOPICALS IN THIS AGE RANGE)
• 12+: TOPICAL DECONGESTANT X 3 DAYS OR TOPICAL ANTICHOLINERGIC X 4 DAYS (IF NO RELIEF, USE ORAL DECONGESTANT OR ORAL DECONGESTANT/ANTIHISTAMINE)

• AIC =<8%
• FBG = 6-10

• AIC = < 7.5%
• FBG = 4-10

IF T2DM = FOLLOW USUAL GUIDELINES

• NO EVIDENCE TO SHOW THAT IR REDUCES INCIDENCE/SEVERITY OF COLDS 
• BUT IF USED UP TO 4 MONTHS, IT MAY REDUCE THE NUMBER OF DAYS WITH URTI BY 6 DAYS
• CONCLUSION: INSUFFICIENT EVIDENCE TO RECOMMEND IT

IF MACROVASCULAR END ORGAN DAMAGE (ISCHEMIA, PAD, CEREBROVASC/CAROTID DISEASE): STATIN + ACE + ASA (PLAVIX IF ASA-INTOLERANT)

IF MICROVASCULAR (RETINO/NEPHRO/NEUROPATHY) OR PT 55+ : STATIN + ACE

IF 40-54 OR PT 30+ AND HAS HAD DM FOR 15+ YEARS OR MEETS LIPID GUIDES FOR STATIN THERAPY: STATIN

6%

• NONRX: PSYLLIUM, OMEGA-3 FAS
• RX: D/C ALL LIPID LOWERING AGENTS EXCEPT FOR RESINS, BUT THEIR GI EFFECTS MAY LIMIT USE

LIPID-LOWERING AGENTS ARE NOT CURRENTLY RECOMMENDED DURING BREASTFEEDING

<4 DAYS OF DAYTIME SX OR <1 DAY OF NIGHTTIME SX AND <4 USES OF SABA WEEKLY

NOTE: SABA USES/WEEK INCLUDE THOSE USED TO TREAT OR PREVENT EXERCISE-INDUCED ASTHMA!

SYMBICORT (BUDESONIDE/FORMOTEROL)

• NOT ROUTINELY USED
• IPRATROPIUM ALTERNATIVE TO SABA IN PATIENTS SUSCEPTIBLE TO TREMOR/TACHYCARDIA (THOUGH DELAYED ONSET VS SABA, EFFECTS LAST LONGER)
• MAY ALSO BE USEFUL IN BB-INDUCED BRONCHOSPASM

NOTE: IN KIDS: USE OF IPRATROPIUM SHOULD BE RESTRICTED TO ADJUNCTIVE THERAPY IN SEVERE EXACERBATIONS

• FLUID RETENTION
• GLUCOSE INTOLERANCE
• HYPERTENSION
• INCREASED APPETITE
• MOOD ALTERATIONS
• WEIGHT GAIN

*MINIMIZE BY LIMITING TX TO 1-2 WEEKS

• ADRENAL AXIS SUPPRESSION
• AVASCULAR NECROSIS OF THE HIP
• CATARACTS
• DERMAL THINNING
• DIABETES
• GLAUCOMA
• HYPERTENSION
• MYOPATHY
• OSTEOPOROSIS

*MINIMIZE WITH ALTERNATE DAY DOSING

10-20%, THUS ADULT DOSES MAY BE REQUIRED IN CHILDREN

• NO RELIEF, OR RELIEF <2H (FROM ASTHMA IN KIDS CHAPTER IN TC)
• THESE PEOPLE MAY NEED A COURSE OF SYSTEMIC CS

• HELPFUL IN 6-11Y ON MODERATE DOSES OF ICS
• HELPFUL IN >12Y ON LOW ICS DOSES
• ROLE UNCERTAIN IN <6Y

SHOULD ALWAYS BE COMBINED WITH ICS!

12+

• DEXAMETHASONE PO
• IF CAN'T TAKE PO, CONSIDER PARENTERAL DEXAMETHASONE OR INHALED BUDESONIDE

SYMPTOMS RELIEVED 2-3 H LATER

• SHORTNESS OF BREATH
• ACTIVITY LIMITATION

• KIDS: FIRST LINE METHIMAZOLE
• PREGNANT: PTU IN 1ST TRIMESTER, THEN SWITCH TO MMI (MMI IS TERATOGENIC IN 1ST TRIMESTER, PTU HAS MORE HEPATOTOXICITY)

FEV1 < 80% AND FEV1/FVC < LOWER LIMIT OF NORMAL (USED TO BE < 0.7)

MAIN ROLE: COMBO WITH LABA IN MODERATE-SEVERE DISEASE

TORCH: SHOWED INCREASED MORTALITY WITH ICS MONOTHERAPY

• LIMITED AS MONOTHERAPY BECAUSE:
• LESS EFFECTIVE THAN TIOTROPIUM AND SLOWER ONSET VS SABA

• INCREASE 2 TABS / WEEK ONCE YOU GET A POSITIVE PREGNANCY TEST
• THEN BLOODWORK DETERMINES DOSING TITRATION

HYPO: WEIGHT GAIN, COLD INTOLERANCE, FATIGUE, IMPAIRED MEMORY, CONSTIPATION, DRY SKIN/HAIR, HTN, BRADYCARDIA

HYPER: WEIGHT LOSS, HEAT INTOLERANCE, PALPITATIONS, TACHYCARDIA, SWEATING, WARM/MOIST SKIN, DIARRHEA, EYELID LAG/STARE

• NAUSEA/DIARREA/WEIGHT LOSS IN THE FIRST FEW WEEKS OF TX
• NEUROPSYCH (ANXIETY, DEPRESSION, INSOMNIA, HA) - IF HX DEPRESSION, DON'T USE THIS

• 5 DAY COURSE OF 30-40MG DAILY IS SUFFICIENT (AND = TO 10-14 DAYS)
• TAPERING UNNECESSARY IF <2 WEEKS
• NO ROLE FOR ORAL STEROID MAINTENANCE THERAPY

• WHEN HAVE 2-3 OF: INCREASED DYSPNEA, INCREASED SPUTUM, INCREASED SPUTUM PURULENCE
• OR 
• SEVERE EXACERBATION: REQUIRING INVASIVE MECHANICAL VENTILATION

• 1. ADDRESS RFS 
• 2. PULMONARY REHAB
• 3. START SABA
• 4. LAMA *
• 5. LAMA/LABA COMBO
• 6. LAMA + ICS/LABA (IF 1 HOSP OR 2+ EXACERB REQUIRING PO STEROIDS)
• 7. ADD PULMONARY REHAB +/- ROFLUMILAST +/- AZITHROMYCIN (IF 1 HOSP OR 2+ EXACERB REQUIRING PO STEROIDS)
• 8. O2 THERAPY
• 9. SURGERY/TRANSPLANT

*CONSIDER ADDING PDE4 INHIBITOR

>1 MONTHS

STANDARDIAZED GINGER (ZINGIBER OFFINALE) CAN BE CONSIDERED AS ALTERNATIVE TO ESTABLISHED ANTIEMETICS IN MGMT OF PREGNANCY-INDUCED AND POST-OP N/V

• 2+ OF THE FOLLOWING IN LAST 3 MONTHS AND SX ONSET AT LEAST 6 MONTHS BEFORE DX:
• LUMPY >25%
• <3 BM/WEEK
• STRAIN >25%
• INCOMPLETE FEELING >25%
• OBSTRUCTIVE FEELING >25%
• MANUAL MANOUEVRES >25%
• LOOSE STOOLS NOT PRESENT

• BLOODY STOOL
• UNEXPLAINED WEIGHT LOSS
• FEVER
• FHX IBD/COLON CANCER
• ANEMIA
• SEVERE PAIN
• SUDDEN CHANGES IN BM >50
• PENCIL THIN STOOLS

• COGNITIVE IMPAIRMENT
• PT DOESN'T DRINK LOTS OF WATER
• PATIENT HAS OBSTRUCTION/ACUTE CONSTIPATION

• 1. NONPHARMS
• 2. BULK FORMING AGENTS
• 3. MG-CONTAINING LIQUID ANTACIDS
• SENNA/BISACODYL OK SHORT-TERM
• LACTULOSE/PEG IF REFRACTORY TO FIBRE/STIMULANTS

AVOID CASTOR OIL: CAN INDUCE PREMATURE CONTRACTIONS

• 1.NONPHARMS
• 2. BFAS
• 3. MILK OF MAGNESIA
• STIMULANTS SHORT TERM OK

• EFFECTIVE IN OPIOID-INDUCED CONSTIPATION
• MAY CONSIDER IN PATIENTS WITH RENAL OR CARDIAC DYSFXN (DOESN'T CONTAIN ELECTROLYTES)

• CALCIUM/ALUMINUM CONTAINING = CONSTIPATION
• MG-CONTAINING = DIARRHEA

• MENINGOCOCCAL
• PNEUMOCOCCAL
• ACT-HIB (HEMOPHILUS INFLUENZA)
• HEPATITIS B (FOR KIDS)

• BLOODY
• FEVER
• LONGER THAN 2 DAYS
• SEVERE PAIN
• 6+ BMS/DAY
• VOMITING
• DEHYDRATION
• <6 MONTHS OLD

• IN <65, THEY PREVENT ABX- AND C.DIFF- ASSOCIATED DIARRHEA
• ACUTE INFECTIOUS DIARRHEA
• NO EVIDENCE IN TRAVELLERS DIARRHEA

• FLORASTOR - SACCHAROMYCES BOULARDII (SACRE BLEU J'AI C. DIFFICILE!) MAY BE USED IN CONJUNCTION WITH ABX TREATMENT TO PREVENT RECURRENCE
• NO ROLE FOR PROBIOTIC MONOTHERAPY

FYI THIS IS A YEAST

NO MALFORMATIONS

BUT, TRANSMITTED IN BREASTMILK, SO HOLD OFF ON BREASTFEEDING DURING TX

SPECIFIC: CHOLESTYRAMINE

NONSPECIFIC: ANTIHISTAMINES (FOR SEDATION)

• NEUROTOXICITY (PERIPHERAL NEUROPATHY)
• PAINFUL

AVOID ALCOHOL X 3 MONTHS+ OR UNTIL COMPLETE NORMALIZATION OF LIVER ENZYMES AND HEPATIC FUNCTION

GENOTYPE 2, 3

GENOTYPE 1 IS DIFFICULT-TO-TREAT (UP TO 72% OF HCV INFECTIONS IN N.AMERICA)

H2RA, ALGINATES, ANTACIDS

PPI  (8 WEEK COURSE OF PPI)

• PPI:
• FOR MOD-SEVERE
• SUPERIOR SYMPTOM CONTROL, ESOPHAGITIS, PREVENTION OF RECURRENCES
• IRREVERSIBLE INHIBITION
• DAILY DOSING (PRN IS NOT SUITABLE)
• NO TACHYPHYLAXIS
• MAY BID DOSE IF PARTIAL RESPONSE
• PRODRUG (THUS TAKE 30-60MIN AC - EXCEPT FOR DEXILANT!)

• H2RA:
• FOR TRIVIAL-MILD
• UNSURE IF PREVENTS RECURRENCES
• QUICKER ONSET, THUS CAN USE PRN
• TACHYPHLAXIS
• CAN DOSE BID
• CAN USE AS ADJUNCT TO PPIS, DOSING IT QHS FOR NOCTURNAL SYMPTOMS

• CVE EVENTS
• C.DIFF AND ENTERIC BACTERIAL INFECTIONS
• CAP
• DEMENTIA
• GASTRIC DISEASE (FUNDAL GLAND POLYPOSIS)
• HYPOMAGNESEMIA
• CKD
• OSTEOPOROSIS FRACTURE

THUS, REASSESS NEED ANNUALLY THROUGH DISCONTINUATION OR TAPER

• HAVE TO BE OFF ABX FOR 1 MONTH+
• HAVE TO BE OFF H2RA/PPI FOR 1 WEEK+
• (CONCERNS ABOUT FALSE NEGATIVES)

• EITHER TEST FOR H.PYLORI AND TREAT
• OR TRIAL PPI 4-8 WEEKS

• 1. AMOX, CLARITHRO, PPI BID X 10-14 DAYS
• 2. METRO, CLARITHRO, PPI BID X 10-14 DAYS (IF PCN ALLERGY)
• 3. PPI BID, METRO, TETRACYCLINE, BISMUTH QID X 10-14 DAYS

#3 CAN BE FIRST LINE, OR USED IF FAILED TRIPLE THERAPY, INTOLERANT TO MACROLIDES, OR IF RESISTANCE TO BIAXIN IS HIGH

• OTHER SECOND LINES:
• 1. PPI + AMOX + BIAXIN + METRO X 10-14 DAYS
• 2. PPI + AMOX X 5-7 DAYS THEN PPI + METRO + CLARITHRO X 5-7 DAYS

• DAILY PPI
• MISOPROSTOL 200 MCG QID
• CHANGE NSAID TO COX-2 SELECTIVE

• STOP NSAID WHEN CAN
• PPI (H2RA, MISOPROSTOL LESS EFFECTIVE ALTERNATIVES)
• TX UNTIL 8 WEEKS AFTER D/C NSAID
• CONSIDER SWITCH TO COX-2 SELECTIVE
• NOTE: MAKE SURE TO TEST FOR H.PYLORI

• >50Y
• DYSPHAGIA
• ODYNOPHAGIA
• VOMITING
• WEIGHT LOSS
• ANEMIA
• BLEEDING

• CD: ALL GI TRACT
• UC: COLON
• ULCERATIVE PROCTOSIGMOIDITIS IS IN THE DISTAL COLON

• INDUCTION OF REMISSION AND PREVENTION OF RELAPSE IN MILD-MOD UC
• INEFFECTIVE FOR CROHN'S

CONTRAINDICATED; GIVE AT LEAST 3 WEEKS PRIOR TO INITIATION

• ROME III CRITERIA:
• RECURRENT ABDOMINAL PAIN/DISCOMFORT AT LEAST 3/MONTH FOR 3+ MONTHS, ASSOCIATED WITH 2 OF THE FOLLOWING:
• 1. ONSET ASSOCIATED WITH CHANGE IN STOOL CONSITENCY
• 2. RELIEF WITH DEFECATION
• 3. ONSET ASSOCIATED WITH CHANGE IN STOOL FREQUENCY

• APPROVED: HTN
• OFF-LABEL: NIGHTMARES IN PTSD, RAYNAUDS, SCORPION STINGS, BPH

• INTRAOPERATIVE FLOPPY IRIS SYNDROME (TELL EYE MD IF CATARACT SURGERY)
• RETROGRADE EJACULATION (5-10%)

DECREASED EJAC VOLUME OCCURS IN 90% OF MEN ON SILODOSIN AND IS UNCOMMON WITH ALFUZOSIN

• A-BLOCKERS:
• DYNAMIC COMPONENT
• DAYS-WEEKS
• IMPROVE FLOW RATES 1-3ML/SEC
• IMPROVE SX SCORES 1-3 POINTS

• 5-ALPHA-REDUCTASE INHBITORS:
• STATIC COMPONENT
• MONTHS-YEARS
• IMPROVE FLOW RATES 1-2 ML/SEC
• IMPROVE SX SCORES 1-2 POINTS
• WORKS BEST IF LARGE PROSTATE

NO DDIS (DUTASTERIDE: 3A4)

• 1. NONPHARMS: KEGELS, TIMED VOIDING
• 2. NO REAL PCT. COULD USE VAGINAL ESTROGEN IF POSTMENOPAUSAL WITH UROGENITAL ATROPHY. SECOND LINE IS DULOXETINE (OFF-LABEL).

• ANTICHOLINERGIC:
• DRY MOUTH
• DELIRIUM
• INCREASED IOP/WORSENING GLAUCOMA
• SLOW GASTRIC MOTILITY (CONSTIPATION)
• DECREASED SECRETIONS
• POTENTIAL FOR CHANGES IN HEART RHYTHM/RATE

NEWER ONES HAVE REDUCED AES: DARIFENACIN, SOLIFENACIN, TROSPIUM, OXYBUTYNIN PATCH

• B3 ADRENERGIC AGONIST
• EFFECTIVE VS. PLACEBO
• AE: HTN, TACHYCARDIA, NASOPHARYNGITIS, UTI (UNCOMMON = QTC)
• CONSIDER IF FAIL FIRST LINE (HIGH COST, LACK OF LONG-TERM DATA, POTENTIAL CV EVENTS)

• 1. NONPHARMS: KEGELS, TIMED VOIDING
• 2. ANTIMUSCARINICS FIRST LINE; MIRABEGRON 2ND; VAGINAL ESTROGEN IF POSTMENOPAUSAL WITH UROGENITAL ATROPHY

• 5Y+
• IF DAYTIME:
• OXYBUTYNIN FOR URGE SYNDROME
• OXYBUTYNIN + TOLTERODINE IF FAIL MONOTX

• IF ENURESIS:
• ENURESIS ALARM
• DESMOPRESSIN
• OXYBUTYNIN + DESMOPRESSION (IF SMALL BLADDER CAPACITY OR REFRACTORY TO DESMO MONOTX)

• ALARM: SUPERIOR BECAUSE ONCE DRY, LESS CHANCE OF RELAPSE
• HOWEVER, IT TAKES LONGER TO REDUCE BEDWETTING (DESMOPRESSIN IS IMMEDIATE)

• TABLETS OR MELTZ
• START WITH LOWEST DOSE
• IF NO RESPONSE, INCREASE BY 1 TAB Q3 DAYS UNTIL ACHIEVE DRYNESS
• AES: HA, ABD PAIN, WATER INTOXICATION, HYPONATREMIA-RELATED SEIZURES
• USE NONPHARMS TOO (LIMIT FLUIDS, ALARMS, DON'T DEFER MICTURITION, DO BLADDER TRAINING: KEGELS, SCHEDULED VOIDING)
• WITHHOLD IF ACUTE ILLNESS LEADING TO DECREASED FLUID INTAKE

• IUD:
• NON-HORMONAL - COPPER
• FAILURE 0.6-0.8% (BETTER THAN CONDOMS)
• LASTS 3-10 YEARS 

• IUS:
• LOW DOSE LEVONORGESTREL RELEASED AT LEAST 5 YEARS
• FAILURE <0.2 PREGNANCY RATE/YEAR
• NORMAL MENSTRUATION RETURNS WITHIN 1-3 MONTHS OF REMOVAL
• 20-30% OF WOMEN STOP HAVING PERIOD
• CAN REDUCE MENSTRUAL BLOOD LOSS, FIBROID GROWTH, DYSMENORRHEA, ENDOMETRIOSIS PAIN, REDUCE RISK OF DEVELOPING PRECANCEROUS CELLS IN UTERUS

• PROS:
• RELIEF FROM SEVERE DYSMENORRHEA, HEAVY FLOW, SOCIALLY UNDESIRABLE FLOW
• FEWER BLEEDING DAYS
• REDUCED SIDE EFFECTS (PELVIC PAIN, HA, BLOATING, SWELLING, TENDERNESS)

• CONS:
• IRREGULAR UNSCHEDULED BLEEDING
• MAY NOT REALIZE INADVERTENT PREGNANCY

• THICKENS CERVICAL MUCUS
• BACKUP X 48H
• IF MISS BY >3H, BACKUP REQUIRED
• CAN USE >25Y WHO SMOKE, WHO CAN'T TOLERATE ESTROGEN, HAVE AES TO COC, MIGRAINE HEADACHES WITH AURA, BREASTFEEDING

MAY NOT RESUME FOR UP TO 1 YEAR POST-LAST INJECTION

LEVONORGESTREL REDUCED EFFICACY 75-80KG, INEFFECTIVE >80KG

EVRA MAY BE INEFFECTIVE >90KG

CAN STILL GIVE PLAN B IRRESPECTIVE OF WEIGHT IF BENEFITS OUTWEIGH RISKS

• ABDOMINAL PAIN
• CHEST PAIN
• HEADACHES
• EYE PROBLEMS
• SEVERE LEG PAIN

• 1: NORETHINDRONE
• 2: LEVONORGESTROL
• 3: DESOGESTREL AND NORGESTIMATE (LESS ANDROGENIC = USEFUL IN ACNE)
• 4: DROSPIRENONE (YAZ) (ANTIANDROGENIC; MAY HAVE HIGHER RISK OF VTE; ALSO RELATED TO SPIRONOLACTONE, THUS CAN GET HYPERKALEMIA)

• DYSMENORRHEA: PAIN DURING MENSES (PG RELATED)
• ENDOMETRIOSIS: ECTOPIC GROWTH OF LINING

DICLOFENAC AND IBUPROFEN

3-6 MONTHS OF NSAIDS OR CHC TO DEMONSTRATE EFFICACY

START WITH NSAIDS/OPIOIDS FOR PAIN

• PERSISTENT MILD DISEASE:
• COC OR PROGESTIN-ONLY CAN BE USED FOR UNLIMITED TIME
• IF INEFFECTIVE, USE IUS, DANAZOL OR GNRH ANALOGUE + ADD-BACK X 6-12 MONTHS

• ADVANCED DISEASE:
• MPA, DANAZOL, GNRH ANALOGUE (FOR PAIN)

BASICALLY, SURGERY IS INEVITABLE

• REDUCE LH, FSH, THUS CAUSE HYPOESTROGENIC STATE:
• HOT FLASHES
• INSOMNIA
• MOOD CHANGES
• VAGINAL ATROPHY
• DECREASE BONE MINERAL DENSITY

THUS ADD ESTROGEN, MPA (ADD-BACK HORMONES) TO MITIGATE THESE

• <18Y (BONES HAVEN'T FULLY FORMED, IT CAN REDUCE BMD)
• RFS FOR OSTEOPOROSIS
• PLANNING TO HAVE CHILDREN AFTER STOPPING IT (TAKES UP TO 1 YEAR TO RETURN)

• HOT FLASHES (START 2Y BEFORE FINAL PERIOD; WORSE WITHIN 2Y AFTER LAST PERIOD; USUALLY SUBSIDE 6Y AFTER; SOME CONTINUE)
• NIGHT SWEATS
• VAGINAL DRYNESS,ITCHINESS,VAGINITIS, DYSPAREUNIA (THESE DON'T IMPROVE, UNLIKE HOT FLASHES)
• SLEEP DISTURBANCES
• MOOD (MDD, ANXIETY)

PATCH DOESN'T INCREASE TGS AND HAS LESS VTE RISK

DIET, EXERCISE, CA, VIT D

• IF VASOMOTOR SX, CAN USE HRT 1ST LINE
• IF NO VASOMOTOR SX, BISPHOSPHONATES OR SERMS

• ESCITALOPRAM, VENLAFAXINE
• (NOT PAROXETINE - WEIGHT GAIN)

• IF SYSTEMIC ESTROGEN - YES
• IF VAGINAL AND AT RECOMMENDED DOSES FOR 1Y OR LESS, AND NO RFS (DM, OBESE, LATE AGE NATURAL MENOPAUSE 52+, NULLIPARITY) - NO

• ABDOMEN, INNER THIGHS
• NOT BREASTS
• NO SITE ROTATION REQUIRED

• TADALAFIL - MOST WELL TOLERATED, LONGEST DURATION, MYALGIA
• SILDENAFIL - MOST EFFECTIVE, VISUAL AES, ABS DELAYED BY HIGH FAT MEALS
• VARDENAFIL - VISUAL AES

NOT TO BE GIVEN FOR 5 DAYS AFTER STOPPING

• DULOXETINE
• PREGABALIN

• OFF-LABEL: TRAMADOL, TCAS, SSRI (LESS EFFECTIVE THAN TCA BUT BETTER TOLERATED)
• -IT MAY BE THE SNRI EFFECT OF TRAMADOL THAT MAKES IT EFFECTIVE (OTHER OPIOIDS DON'T WORK)
• -SEDATION MAY PLAY A ROLE IN EFFICACY OF TCAS

• CLEAR ASSOCIATION
• PMR: ACHING/STIFF MUSCLES IN NECK, PECS, PELVIS, THIGH
• GCA: HA, JAW CLAUDICATION, VISUAL LOSS

• TX: SYSTEMIC CORTICOSTEROIDS (HIGHER DOSES FOR GCA)
• MOST NEED 1-2 YEARS OF TX, SOME 5-10Y OR INDEFINITELY
• STEROIDS CAN'T REVERSE VISION LOSS ONCE IT HAS OCCURRED
• -CO-RX BISPHOSPHONATES WHEN STARTING STEROIDS TO REDUCE OP RISK
• ALSO CONSIDER LOW DOSE ASA DAILY IF GCA DX (MAY LOWER RISK OF BLINDNESS)

• ASYMPTOMATIC HYPERURICEMIA
• ACUTE GOUTY ARTHRITIS
• INTERCRITICAL GOUT
• CHRONIC TOPHACEOUS GOUT

• NSAIDS
• COLCHICINE
• ORAL STEROIDS
• *WITHIN 24H OF ONSET
• *SPONTANEOUSLY RESOLVES 3-10 DAYS

• 1.2MG STAT
• 0.6MG 1 H LATER
• =TOTAL 1.8MG
• NOT RECOMMENDED IF PRESENT 36H+ AFTER ONSET

CAN START DURING ACUTE ATTACK AS LONG AS INFLAMMATORY DRUGS HAVE BEEN STARTED

• GOUTY ARTHRITIS WITH TOPHI
• 2+ ATTACKS PER YEAR
• CKD STAGE 2+ (<90ML/MIN)
• PAST UROLITHIASIS

• 100MG DAILY OR 50 IF CKD STAGE 4-5
• LOW TO REDUCE SEVERE HYPERSENSITIVITY RXN AND TO REDUCE CHANCES OF EXACERBATING ATTACK

• RASH MOST COMMON (CAN DESENSITIZE)
• HYPERSENSITIVITY (1/1000): CAN HAVE SJS, TEN OR SYSTEMIC DISEASES INCLUDING RASH, EXFOLIATIVE DERMATITIS, FEVER, VASCULITIS, EOSINOPHILIA, CYTOPENIA, MAJOR END ORGAN DISEASE
• MORTALITY IS 20-25%
• RFS: RENAL, THIAZIDE DIURETICS, HIGH DOSE, HLAB5801 (KOREAN, HAN CHINESE, THAI)

• SEVERE RENAL (MINOR RENAL CLEARANCE)
• 80MG SUPERIOR TO 300MG ALLOPURINOL

• FEBUX: CI IF ON AZATHIOPRINE, MERCAPTOPURINE (SEVERE TOXICITY)
• ALSO HIGHER RISK OF MI/STROKE VS ALLOPURINOL!

• START LOW, TITRATE
• USE NSAID/COLCHICINE (STEROID LAST RESORT) X 6MONTHS+ WHEN STARTING ANTIHYPERURICEMIC

• CIS:
• HEPATIC/RENAL IMPAIRMENT WHILE ALSO ON 3A4/PGP INHIBITORS

• DDIS:
• STATINS (MYALGIA)
• 3A4, PGP INHIBITORS (BIAXIN) CAN INCREASE COLCHICINE (FATALITIES HAVE BEEN REPORTED)
• GRAPEFRUIT

SULFA (CONTRAINDICATED)

• ANTICOAGULANTS/ANTIPLT (BLEED)
• ANTIHYPERTENSIVES (REDUCED EFFECT)
• LITHIUM 
• SSRIS (GI BLEED)

MOVEMENT

AGE, OBESITY, GENETICS

• VOLTAREN = ORAL NSAIDS
• LESS AES
• USE AS INITIAL THERAPY FOR 75Y+

• CAPSAICIN WAS SUPERIOR TO PLACEBO (BUT STUDY SUBJECTS WERE ABLE TO USE PO ANALGESICS)
• CAN CAUSE BURNING SENSATION

NAPROXEN

NAPROXEN

CELECOXIB

• 65Y+
• COMORBIDITIES
• HIGH DOSE NSAID
• MULTIPLE NSAIDS
• HX UPPER GI BLEED
• PRESENCE OF H.PYLORI

• 1. NONPHARMS + TOPICAL ANALGESICS
• 2. ACETAMINOPHEN
• 3. NSAIDS:
• IF NO RFS: LOW DOSE NSAID
• IF 1-2 RFS: LOW DOSE NSAID + PPI OR LOW DOSE COX-2 NSAID
• IF MULTIPLE RFS: LOW DOSE COX-2 INHIBITOR + PPI OR ALTERNATIVE (OPIOID, LOCAL INJECTIONS)
• 4. FULL-DOSE NSAID OR COX-2 INHIBITOR SUPPLEMENTED WITH OPIOIDS, LOCAL INJECTIONS
• 5. SURGERY

• LESS EFFECTIVE UNLESS WITH TYLENOL
• LESS RESP DEPRESSION AND ABUSE POTENTIAL BUT MORE NAUSEA

• BASELINE TX FOR MOST PATIENTS
• HYDROXYCHLOROQUINE/CHLOROQUINE
• HELPS WITH PHOTOSENSITIVITY RASHES, ARTHRITIS AND FATIGUE
• USUALLY IN COMBO WITH STEROIDS OR IMMUNOSUPPRESSANTS
• ALSO HELPS LOWER LIPIDS, GLC AND BLOOD CLOTS
• AES: EYE TOXICITY - REGULAR CHECKUPS

*NOTE: SMOKING DECREASES EFFICACY OF ANTIMALARIALS

• SUN AVOIDANCE
• SOME ARE ON CHRONIC STEROIDS (WITH CONCOMITANT IMMUNOSUPP/IMMUNOMODS/BIOLOGICS FOR STEROID SPARING)
• RECOMMEND BISPHOSPHONATES FOR THOSE TAKING ORAL CS 7.5MG+ DAILY FOR 3MONTHS+ (AS WELL AS VITAMIN D, CALCIUM)

• MTX 20-25MG WEEKLY X 3 MONTHS+ (WITH FOLIC ACID/FOLINIC ACID WEEKLY)
• OR IF MOD-SEVERE (3+ JOINTS): COMBO MTX WITH SULFASALAZINE OR HCQ
• IF CI TO MTX: LEFLUNOMIDE

SEVERE LIVER INJURY

• DURING ACTIVE INFECTION
• PRIOR TO SURGERY

• 3 MONTHS+ IN BOTH MALES, FEMALES
• GIVE FOLIC ACID

• UNDERGO DRUG ELIMINATION PROTOCOL:
• CHOLESTYRAMINE 8G TID OR ACTIVATED CHARCOAL 50G QID X 11 DAYS
• MEASURE PLASMA CONC OF ITS METABOLITE 2 TIMES AT LEAST 2 WEEKS APART
• ONCE CONFIRMED UNDER 0.02MG/L, WAIT 3 MONTHS (MALES) OR 1-3 CYCLES (FEMALES)
• WITHOUT DRUG ELIM, CAN TAKE UP TO 2 YEARS FOR PLASMA LEVELS TO DROP < 0.02

BLEEDING 7+ DAYS OR IN EXCESSIVE VOLUMES LEADING TO REDUCED QOL OR IRON-DEFICIENCY ANEMIA

• MAX 6 MONTHS
• CAN DO LONGER WITH ADD-BACK THERAPY OF ESTROGEN-PROGESTERONE TO PRESERVE BONE HEALTH

• CONTRACEPTION - DOSE EVERY DAY
• MENORRHAGIA - DOSE FOR 21 DAYS, TAKE 7 DAYS OFF

15-20 MINUTES AT LEAST QID FOR FIRST 48H (OR LONGER IF SWELLING CONTINUES)

• AGE
• STEROID USE (= PREDNISONE 7.5MG DAILY) >3 MONTHS
• HX FRAGILITY FRACTURE
• LOW BMD

• STEROIDS 3MONTHS+
• AROMATASE INHIBITORS
• GLITAZONES
• PPIS
• SSRIS
• ANTICOAGULANTS (UFH, LMWHS)
• ANTIRETROVIRAL THERAPY
• LOOP DIURETICS
• CYCLOSPORINE
• HIGH DOSES VITAMIN A

ONE THAT OCCURS WITH LOW TRAUMA E.G. FROM STANDING HEIGHT OR LESS

• AUTOMATIC HIGH RISK:
• 1. FRACTURE OF HIP OR SPINE WHEN POSTMENOPAUSAL OR >50Y (UNLESS IT HAPPENED DUE TO TRAUMATIC EVENT)
• 2. 2 FRAGILITY FRACTURES

• BUMP UP 1 CATEGORY:
• 1. FRAGILITY FRACTURE AT SITE OTHER THAN HIP/SPINE
• 2. STEROID THERAPY

• 10 YEAR RISK OF OP-RELATED FRACTURE
• LOW: <10%
• MOD: 10-20%
• HIGH: >20%
• USES AGE, BMD, EPIDEMIOLOGIC DATA

• HIGH RISK
• CONSIDER FOR MODERATE RISK

• DIET: PROTEIN, CALCIUM, VITAMIN D, ALCOHOL (>2/DAY) AND CAFFEINE (<4/DAY)
• EXERCISE: WEIGHT BEARING ESPECIALLY
• SMOKING CESSATION
• FALL PREVENTION: LIGHTING, GRAB BARS

• PROBABLY NOT
• EFFECTIVE FOR SECONDARY PREVENTION OF FRACTURES BUT PREVENTION IS LESS ROBUST VS OTHER BPS (NO DATA SHOWING PREVENTION OF NONVERTEBRAL FRACTURES)
• PROS: CHEAP, ONLY DOSED X 2 WEEKS EVERY 3 MONTHS (PACKAGED WITH 76 DAYS OF 500MG ELEMENTAL CALCIUM), SAFETY FOR 7 YEARS, NO REPORTS OF ONJ ON CYCLICAL REGIMEN

• RISEDRONATE AND ALENDRONATE
• BOTH REDUCE RISK OF ALL FRACTURES

• ADHERENCE (ONCE ANNUALLY)
• IF CANNOT TOLERATE GI AES OF PO BPS
• IF NOT RESPONDING TO PO BPS
• REDUCES RISK OF ALL OP-RELATED FRACTURES

• OSTEONECROSIS OF JAW (LOW RISK)
• ESOPHAGEAL ULCERATION (PO)
• ATYPICAL FEMORAL SHAFT FRACTURES (OUTWEIGHED BY REDUCTION IN HIP FRACTURES)

• WHEN TREATED WITH BPS FOR 2Y+ 
• IF OCCURS, STOP AND USE ANABOLIC AGENT TO INCREASE TURNOVER
• ONCE HEALED, CAN CONSIDER BP ALTERNATIVES

• PTS ON ALENDRONATE X 5 YEARS EITHER CONTINUED FOR ANOTHER 5Y OR PLACEBO
• PLACEBO: MODERATE BMD REDUCTION AND ONLY INCREASED VERTEBRAL FRACTURES
• PROVIDES EVIDENCE FOR SAFETY AND FURTHER FRACTURE PREVENTION IN HIGH-RISK PTS TAKING ALENDRONATE X 10 YEARS

• 1-3Y IF LOW-MOD RISK, ON ALENDRONATE 3-5Y
• 1-3Y IF LOW-MOD RISK, ON ZOLEDRONATE 3-5Y AND NO HX OF VERTEBRAL/HIP FRACTURE
• 1Y IF LOW-MOD RISK, ON RISEDRONATE (LOWER BONE AFFINITY VS ALENDRONATE)
• IF HIGH RISK AT TX ONSET BUT NO HX FRACTURE, FEMORAL BMD >-2.5, AND NO RFS FOR FRACTURE, CAN CONSIDER HOLIDAY AFTER 5 YEARS

• PROS:
• AGONIST AT BONE (INCREASES BMD, REDUCES VERTEBRAL FRACTURE RISK)
• ANTAGONIST AT BREAST/UTERINE TISSUES
• NO INCREASE CV RISK

• CONS:
• MODEST INCREASE IN DVT, PE IN POSTMENO
• MAY AGGRAVATE HOT FLASHES

• POSTMENO WITH:
• HX OP FRACTURE
• MULTIPLE RF FOR FRACTURE
• FAILED/INTOLERANT OF OTHER TX

• 24 MONTHS LIFETIME EXPOSURE
• THEN USE BISPHOSPHONATE OR OTHER ANTICATABOLIC TO PRESERVE GAINS

• REASONABLE TO USE ESTROGEN OR EST/PROGEST UNTIL NORMAL AGE OF MENOPAUSE (BALANCE VS RISK OF BREAST CANCER AND HEART DISEASE)
• IF MENOPAUSAL SX ARE NOT AN ISSUE, CAN USE RALOXIFENE (ANTAGONIST AT BREAST)

SEVERE CASES (MORE THAN 1 FRAGILITY FRACTURE, VERY LOW BMD)

• BP
• DENOSUMAB
• ESTROGEN
• TERIPARATIDE
• 2ND LINE: RALOXIFENE (BECAUSE OF ABSENCE OF NONVERTEBRAL FRACTURE DATA)

• FOSAMAX: ALENDRONATE DAILY OR WEEKLY
• FOSAVANCE: ALENDRONATE + VITAMIN D WEEKLY

• BPS
• DENOSUMAB

• NO MAKEUP
• LOW GLYCEMIC DIET?
• NO PICKING AT LESIONS
• GENTLE NON-SOAP CLEANSER
• DON'T OVER CLEANSE
• REDUCE STRESS
• SUN SCREEN/PROTECTION

• WITH TOPICAL ABX, IT REDUCES RESISTANCE
• WITH TOPICAL RETINOID, IT CAN REDUCE FLARE FROM RETINOID INITIATION

TOPICAL RETINOID

• CAN APPLY Q2-3DAYS
• CAN WASH OFF AFTER 1-3H
• *PEA SIZED AMOUNT FOR ENTIRE FACE
• NOTE: CAN WORSEN ACNE AT 1 MONTH, TAKE 2-3 MONTHS TO CLEAR UP

STOP AT LEAST 1 MONTH BEFORE TRYING TO CONCEIVE

• RETINOID ANALIGUE
• LESS IRRITATING AND PHOTOSENSITIZING

• SUN
• HEAT
• HOT BEVERAGES
• TOPICAL STEROIDS
• EMOTIONAL STRESS
• SPICY FOOD
• ALCOHOL
• ASTRINGENTS

• 1. ERYTHEMATOTELANGIECTATIC - FLUSHING, REDNESS, SPIDERVEINS
• TX: TOPICALS: METRONIDAZOLE, BRIMONIDINE, AZELAIC ACID

• 2. PAPULOPUSTULAR - PAPULES, PUSTULES, RED, EDEMA, PLAQUES
• TX: TOPICAL METRONIDAZOLE, AZELAIC ACID, IVERMECTIN OR SYSTEMIC TETRA/MINOC/DOXYCYCLINE OR LOW DOSE ISOTRETINOIN

• 3. PHYMATOUS - NASAL SX
• TX: SYSTEMIC ISOTRETINOIN

• 4. OCULAR - ITCHY, DRY, BLEPHARITIS, CONJUNCTIVITIS
• TX: TOPICAL EYE ABX, EYE CYCLOSPORINE OR ARTIFICIAL TEARS; SYSTEMIC TETRA/MINO/DOXYCYCLINE

• METRONIDAZOLE AND AZELAIC ACID TOPICAL SHOULD BE SAFE
• IVERMECTIN AND BRIMONIDINE UNKNOWN SAFETY - AVOID
• CI: CYCLINE ANTIBIOTICS, ISOTRETINOIN

• VIBRAMYCIN - NO RESTRICTIONS
• APPRILON (MODIFIED RELEASE) - EMPTY STOMACH

• UVA: PHOTOTOXICITY, PHOTOAGING, IMMUNOSUPPRESSION, SKIN CANCER 
• IN TANNING BEDS
• PENETRATES SKIN MORE DEEPLY

• UVB: SUNBURN 
• DOES NOT PENETRATE GLASS
• ALSO CAN CAUSE IMMUNOSUPP AND CANCER

TOXIC: DOSE-RELATED, OCCURS IN ALMOST ALL PEOPLE ON A HIGH ENOUGH DOSE OF PHOTOTOXIC DRUG AFTER SUN EXPOSURE, REACTION ON SUN-EXPOSED AREA

ALLERGIC: DELAYED HYPERSENSITIVITY AFTER SUN EXPOSURE, OCCURS RARELY, REACTION CAN EXTEND BEYOND SUN-EXPOSED BORDERS

• INORGANIC (PHYSICAL) SUNSCREENS OK FOR ALL AGES
• ORGANIC (CHEMICAL) SUNSCREENS OK FOR 6 MONTHS+

• SPF = LEAST AMOUNT OF ENERGY NEEDED TO PRODUCE ERYTHEMA WITH SUNSCREEN, DIVIDED BY THE LEAST AMOUNT OF ENERGY NEEDED TO PRODUCE ERYTHEMA WITHOUT SUNSCREEN
• RECOMMEND MINIMUM 15, IDEALLY AT LEAST 30

• CRITICAL WAVELENGTH IS AT LEAST 370NM
• = WAVELENGTH WHERE STILL CAN BLOCK OUT 90% OF UVA RAYS

AFTER 40 OR 80 MINUTES, DEPENDING ON THE PRODUCT

• 1ST: EPIDERMIS; RED PAINFUL; HEALS 1 WEEK (SUNBURN)
• 2ND SUPERFICIAL: EPIDERMIS AND UPPER DERMIS; BLISTERS; RED; VERY PAINFUL; HEALS 2-3 WEEKS (SCALD WITH WATER)
• 2ND DEEP: EPIDERMIS AND DEEP DERMIS; BLISTERS, BROAD EPIDERMAL SKIN LOSS; PAINFUL; HEALS 2+WEEKS WITH SOME SCARRING (FLAME, OIL)
• 3RD: EPIDERMIS THROUGH DERMIS TO SC FAT; SKIN PALE, PAINLESS, LEATHERY; WON'T HEAL, NEED SURGERY/GRAFTS (FLAME, HOT METAL)

• 2ND DEGREE >10% BSA IF <10Y OR >50Y
• 2ND DEGREE >20% BSA FOR ALL OTHERS
• 2ND DEGREE ON FACE, HANDS, FEET, OVER MAJOR JOINTS
• 3RD DEGREE >5% BSA
• INHALATION INJURIES
• CONCOMITANT TRAUMA
• PRE-EXISTING ILLNESS THAT CAN COMPLICATE RECOVERY

• AVOID:
• PRESSURE
• SHEARING FORCES (E.G. ON RECLINING BED)
• FRICTION
• EXCESSIVE MOISTURE
• DRY, FLAKY SKIN
• MALNUTRITION (IMPAIRED HEALING)
• IMMOBILIZATION
• SENSORY/CIRCULATORY COMPROMISE
• SMOKING

• ORAL RETINOIDS + PHOTOTHERAPY
• BIOLOGICS
• INTRALESIONAL STEROID INJECTIONS

• EMOLLIENTS, AVOIDING TRIGGERS
• STEROID TOPICALS (MOD-HIGH) ALONE OR WITH OTHER TOPICALS (ANTHRALIN, TAR, CALCIPITRIOL, TAZAROTENE)

*NOTE CALCINEURIN INHIBITORS ARE INDICATED FOR ATOPIC DERMATITIS BUT HAVE BEEN USED IN PSORIASIS ON FACE/FOLDS

• 1ST LINE: MOISTURIZERS 
• IF RED,SCALY,EXCORIATIONS: STEROID OR BARRIER REPAIR TX 
• IF UNRESOLVED IN 2 WEEKS, USE THE ONE NOT TRIED
• IF BOTH FAIL AND PATIENT IS >2YO: TRIAL OF CALCINEURIN INHIBITORS
• IF NO LUCK: CHECK FOR INFECTION, ADHERENCE, REFER TO DERM

• >2 YO
• 2ND LINE INTERMITTENTLY
• SOMETIMES 1ST LINE OFF LABEL FOR FACE/FOLDS IF CONCERNED ABOUT AMOUNT/FREQUENCY OF STEROID USE
• COMBO WITH STEROID DOESN'T APPEAR TO BE BETTER THAN STEROID ALONE
• PIMECROLIMUS: FOR MILD-MOD AD
• TACROLIMUS: FOR MOD-SEVERE AD

• 1ST GEN HELP WITH SLEEP
• PRURITIS IS NOT HISTAMINE MEDIATED THUS IT DOESN'T HELP WITH ITCH!

MAY CAUSE REDNESS AND BURNING AT APPLICATION SITE (NOT HARMFUL, RESOLVES IN HOURS)

• ONLY IF ITCHINESS CAUSED BY INFLAMMATORY SKIN CONDITION (VISIBLY RED, WITH ITCH/TENDERNESS)
• NOT FOR CHRONIC USE
• REFER: EXTENSIVE AREA, EROSIONS/BLISTERS PRESENT, ADVERSE QOL IMPACT

PUT IN FRIDGE BEFORE

48 H

• LICE: ONLY THOSE WITH LIVE LICE/NITS WITHIN 1 CM OF SCALP
• SCABIES: ALL CONTACTS EVEN IF ASYMPTOMATIC (ALL HOUSEHOLD CONTACTS WITHIN LAST MONTH)

SAFE AND EFFECTIVE OPTIONS:

• VIA NEUROTOXICITY:
• 1. PERMETHRIN (NIX, KWELLADA-P)
• 2. PYRETHRINS/PIERONYL BUTOXIDE (R&C)
• -CAN GET RESISTANCE TO THESE TYPES

• VIA DEHYDRATION:
• 3. ISOPROPYL MYRISTATE 50%/CYCLOMETHICONE 50% (RESULTZ)

• VIA ASPHYXIATION:
• 4. DIMETICONE (NYDA)
• 5. BENZYL ALCOHOL 5% LOTION (NOT YET MARKETED, BUT APPROVED)

• NOTE: LINDANE 1% NOT AVAILABLE IN CANADA
• CONCERNS OF NEUROTOXICITY AND BONE MARROW SUPPRESSION

• UNCONVENTIONAL:
• CETAPHIL CLEANSER
• PETROLEUM JELLY (BUT DIDN'T PREVENT EGG-LAYING)

• NOT ALL ARE RELIABLY OVICIDAL
• PLUS PATIENTS ARE NOT FULLY COMPLIANT WITH APPLICATION

• PREMETHRIN 5% CREAM SCALP AND LEFT ON FOR HOURS/OVERNIGHT
• ORAL SEPTRA WITH PERMETHRIN 1%
• CROTAMITON 10% TO SCALP X 24 HOURS
• ORAL IVERMECTIN, REPEAT IN 7-10 DAYS

• PERMETHRIN 1%
• PYRETHINS WITH PIPERONYL BUTOXIDE
• ORAL IVERMECTIN, REPEAT IN 2 WEEKS

NONPHARMS USUALLY SUFFICIENT (THEY LIVE IN CLOTHING, BED SHEETS)

• PERMETHRIN 5%
• ALTERNATIVELY: CROTAMITON, SULFUR, IVERMECTIN

GIVE SOMETHING FOR ITCH (PRURITIS MAY PERSIST FOR WEEKS): MOD TOPICAL STEROIDS, ANTIHISTAMINES, EMOLLIENTS

IF CRUSTED SCABIES: IVERMECTIN + TOPICAL PERMETHRIN

DON'T USE PERMETHRIN (NIX/KWELLADA-P) OR PYRETHINS/PIPERONYL BUTOXIDE (R&C)

• DON'T USE NIX/KWELLADA/R&C
• REMOVE LICE/NITS WITH TWEEZERS THEN:
• USE VASELINE BID-QID X 10 DAYS

• IMPETIGO, ERYSIPELAS, FOLLICULITIS
• FURUNCLE, CARBUNCLE
• CELLULITIS
• NECROTIZING FASCIITIS

NORMAL SALINE COMPRESSES 10-15MIN BID-TID TO REMOVE CRUSTS AND PROMOTE HEALING

• ACUTE ONSET INFXN OF DERMIS, SC TISSUE
• BRIGHT RED, EDEMA, WARM, TENDER
• SUSPECT H.INFLUENZA IN <5Y IF FACIAL CELLULITIS PRECEDED BY URTI PRODROME, ESPECIALLY IF CHILD IS WITHOUT ACT-HIB INJECTION

• ACUTE ONSET
• COMMONLY FACE AND LOWER EXTREMITIES
• VS CELLULITIS: ERYSIPELAS MORE SUPERFICIAL CUTANEOUS, PROMINENT LYMPHATIC INVOLVEMENT, HIGHER RECURRENCE RATE, S.PYOGENES, SHARPLY DELINEATED MARGINS/LOCATION

• ERYSIPELAS: LONGER: 2 WEEKS, UP TO 4-6 WEEKS
• BECAUSE OF LYMPHATIC INVOLVEMENT AND HIGHER RECURRENCE RATES
• CELLULITIS: 7-10 DAYS

• PENICILLIN
• (S.PYOGENES SUSPECTED CAUSE)

• CONSIDER SEPTRA
• VANCO IF CELLULITIS AND BETA-LACTAM ALLERGY AND CONFIRMED MRSA
• CLINDAMYCIN ALSO AN OPTION (ALSO AS FIRST LINE IF PENICILLIN ALLERGY)

• CLINDAMYCIN 
• NOTE RISK OF C.DIFF, COLITIS
• ALSO SAFE IN PREGNANCY (NOT RECOMMENDED IN BF - CAN ALTER FLORA OF BABY)

• SMALL ROLE
• ONLY IF GRAM NEGATIVES, OR MRSA, OR PSA

CLOXACILLIN

• CONTAGIOUS
• SOMETIMES SELF-LIMITING IN 2-3 WEEKS

• DISTAL LATERAL SUBUNGUAL ONCHO OR SUPERFICIAL WHITE ONCHO THAT IS:
• EARLY
• MILD
• LIMITED DISTAL INVOLVEMENT
• LUNULA NOT INVOLVED
• 1-2 NAILS
• NO FAILURE OF PREVIOUS THERAPY
• CI TO SYSTEMIC THERAPY

• NO NEED TO DEBRIDE
• NO NEED TO REMOVE PREVIOUSLY APPLIED SOLUTION WEEKLY

• IMMUNOCOMPROMISED (INCL DIABETES)
• MULTIPLE NAILS INVOLVED
• PRIOR CELLULITIS
• VENOUS INSUFFICIENCY
• NAIL PAIN
• COSMETIC APPEARANCE

• FINGER: 6 WEEKS
• TOE: 12 WEEKS

• ITRACONAZOLE
• PULSED DOSE PREFERRED (1 WEEK/MONTH X 2 MONTHS IF FINGER, X 3 MONTHS IF TOE)

• MEN: <135G/L
• WOMEN: <120G/L

• ENHANCE: VITAMIN C
• REDUCE: POLYPHENOLS/PHYTATES (COFFEE, TEA)

UP TO 3 MONTHS AFTER YOU REACH TARGET HB

20MG/DAY STARTED AT 20 WEEKS GESTATION

• MAY BE BETTER ABSORBED AND TOLERATED VS ORAL SALTS
• BUT LACKING EVIDENCE FOR EFFICACY IN FR-DEFICIENT ANEMIA
• E.G. PROFERRIN

NONE. AVOID THEM ALL. POORLY ABSORBED.

• ANEMIA
• NEUROLOGIC (DEMENTIA, WEAKNESS, SENSORY NEUROPATHY, PARESTHESIAS)
• GIVING FOLIC ACID WILL HELP ANEMIA ASPECT BUT NOT THE NEURAL SX

• DIETARY DEFICIENCY 
• ALCOHOLISM

MALABSORPTION (PERNICIOUS ANEMIA, GASTRECTOMY, CROHN'S, PPIS, METFORMIN

• FOLIC ACID: 
• PREVENTION: 200MCG DAILY
• TREATMENT: 1-5MG DAILY
• B12:
• PREVENTION: 6-9MCG DAILY
• TREATMENT: 1000MCG DAILY

• 2 MONTHS
• 6 MONTHS+ FOR FOLIC ACID TO CORRECT NEUROLOGIC DEFICITS

KNOWN HX OF DRUG ALLERGY DUE TO RISK OF SERIOUS HYPERSENSITIVITY (COULD BE FATAL)

• LESS FREQUENT DOSING
• NO PURE RED CELL APLASIA AS RARE SIDE EFFECT

• VOLUME DEPLETION: LOSS OF FLUID FROM INTRAVASCULAR SPACE
• DEHYDRATION: LOSS OF SALT AND WATER FROM EXTRACELLULAR (INTRAVASCULAR, INTERSTITIAL) AND INTRACELLULAR SPACES

• MILD: ORAL FLUIDS
• MOD-SEVERE: DEPENDS
• 1. IF DEHYDRATION - D5W (MOST GOES INTRACELLULAR)
• 2. IF VOLUME DEPLETION - CRYSTALLOID (NS 0.9% OR RINGERS)
• *BLOOD PRODUCTS EFFECTIVE IF HEMORRHAGIC HYPOVOLEMIA
• *COLLOIDS FALLING OUT OF FAVOUR (AES, LACK OF SUPERIORITY)

• <140/90 IF ACR<3
• <130/80 IF ACR 3+

• GLICLAZIDE
• SHORT HALF LIFE
• NO RENAL CLEARANCE
• THUS LESS HYPOGLYCEMIA

EVERYONE OVER 50 (WHO CARES WHAT LDL IS)

DOUBLE THE DOSE

SPIRONOLACTONE

• IF <50, FUROSEMIDE
• IF >50, HCTZ

• SULFA ALLERGY
• ALLERGY TO LASIX

• LOOP
• THIAZIDES ARE CI BECAUSE THEY IMPAIR CALCIUM EXCRETION

• 1ST LINE: BISPHOSPHONATES (PAMIDRONATE, ZOLEDRONIC ACID, CLODRONATE)
• 2ND LINE: DENOSUMAB

• PRIMARY HYPER-PTH IF NOT A CANDIDATE FOR PTH-ECTOMY
• SECONDARY HYPER-PTH IN CKD PATIENTS ON DIALYSIS

IT REDUCES CALCIUM

• CALCIUM GLUCONATE/CHLORIDE TO PROTECT THE HEART
• INSULIN TO SHIFT K INTO CELLS
• GIVE GLC TO PREVENT HYPO
• NAHCO3 IF ALSO METABOLIC ACIDOSIS
• SALBUTAMOL IS ALSO EFFECTIVE (USE IF OTHER FAIL)

• TO REMOVE K:
• ADD FLUID IF VOLUME RETRACTED
• LOOP DIURETICS TO REMOVE K
• HEMODIALYSIS IF LARGE AMOUNTS ARE TO BE REMOVED
• KAYEXYLATE (CATION-EXCHANGE RESINS) ARE DEBATABLE

OTALGIA

• <48H OF ILLNESS
• >6 MONTHS OLD
• NONSEVERE (<39C, MILD OTALGIA)
• UNCOMPLICATED 
• NO CRANIOFACIAL ANOMALIES, IMMUNODEFICIENCIES, CARDIAC/PULMONARY DISEASE, DOWN SYNDROME
• NO HX COMPLICATED AOM
• PARENTS CAN RECOGNIZE WORSENING SX AND CAN ACCESS CARE

• S.PNEUMO - PCN BINDING CELL WALL PROTEINS (THUS JUST DOUBLE THE DOSE OF AMOXI)
• H.INFLUENZAE - BETA-LACTAMASE (THUS ADD CLAVULIN)
• M.CATARRHALIS - BETA-LACTAMASE (THUS ADD CLAVULIN)

• 5 DAYS IF 2Y+
• 10 DAYS IF <2Y

• CLARITHROMYCIN OR AZITHROMYCIN
• CLINDAMYCIN ONLY COVERS S.PNEUMO

FOR 24H AFTER ANTIBIOTICS STARTED

• 10 DAYS 
• EXCEPT FOR ZPACK

• INFERIOR COVERAGE OF S.PNEUMO AND H.INFLUENZAE
• HIGHER RATE OF RESISTANCE TO S.PNEUMO COMPARED TO AMOX
• LESS EFFICACIOUS THAN AMOXICLAV (IN AOM - BUT THESE HAVE THE SAME PATHOGENS AS SINUSITIS)

• FLU SEASON: OCTOBER - APRIL
• VACCINE RECOMMENDED: OCT-MID NOV

• 65Y+
• 1-64Y WITH RFS/CHRONIC CONDITIONS
• IMMUNOCOMPROMISED

• OSELTAMIVIR FIRST LINE
• WORKS BEST IF TX ONSET <48H
• NOT APPROVED FOR <1Y

• ILL ENOUGH TO REQUIRE HOSPITALIZATION
• ILLNESS PROGRESSIVE, SEVERE OR COMPLICATED

INACTIVATED: CAN USE REGARDLESS OF PAST SEVERE ALLERGY TO EGGS IRRESPECTIVE OF IMMUNIZATION SETTING

INTRANASAL: CAN USE REGARDLESS OF PAST SEVERE ALLERGY TO EGGS IRRESPECTIVE OF IMMUNIZATION SETTING

• C: CONFUSION
• U: BUN >7
• R: RR 30+
• B: SBP <90 OR DBP <60
• 65: 65Y+

• EACH WORTH 1 POINT
• SCORE PREDICTS RISK OF DEATH
• 0: 0.6%
• 5: 57%

• VANCOMYCIN
• LINEZOLID

• 50+ IMMUNOCOMPROMISED PTS
• FOLLOWED BY PNEU-23
• (PNEU-13 SHOWN TO BE MORE IMMUNOGENIC IN SOME STUDIES)

• IF HEALTHY, NO RF FOR DRUG-RESISTANT STREP PNEUMO (<2, >65, COMORBIDITIES, ABX IN LAST 3 MONTHS, ALCOHOLISM, IMMUNOSUPP, EXPOSURE TO DAYCARE KIDS):
• -->MACROLIDE OR DOXYCYCLINE

• IF COMORBIDITY, USED ABX LAST 3 MONTHS:
• -->RESP FQ (LEVO, MOXI) OR AMOXICLAV +  MACROLIDE (NOT ERYTHROMYCIN B/C LOWER H.INFLUENZAE ACTIVITY)

• MEROPENEM/IMIPENEM
• CEFEPIME (4)
• CEFTAZIDIME (3)
• PIPTAZO
• CIPROFLOXACIN
• AMINOGLYCOSIDES

• 1ST LINE: ISONIAZID DAILY X 9 MONTHS
• 2ND LINE: INH X 6 MONTHS
• 2ND LINE: INH + RIFAMPIN X 4 MONTHS
• RIFAMPIN X 4 MONTHS (IF INH RESISTANT)

• INH + RIFAMPIN + PYRAZINAMIDE +/- ETHAMBUTOL DAILY FOR 2 MONTHS
• THEN INH + RIFAMPIN DAILY FOR 4 MONTHS

NOTE: ALWAYS GIVE PYRIDOXINE (B6) TO PREVENT PERIPHERAL NEUROPATHY FROM INH

ONLY ADDED IF KNOWN INH RESISTANCE OR PENDING RESULTS

• IF INTERRUPTION FOR 14DAYS+ IN INITIAL PHASE
• INTERRUPTION FOR 3MONTHS+ IN CONTINUATION PHASE

• AST > 3 X ULN IN SYMPTOMATIC (N/V/JAUNDICE/ABD PAIN)
• AST > 5 X ULN IN ASYMPTOMATIC PATIENTS

• CONTROVERSIAL RE: MALFORMATIONS
• IF GIVEN SHORTLY BEFORE DELIVERY, CAN CAUSE FLOPPY INFANT SYNDROME AND WITHDRAWAL AES

• PERIPHERAL NEUROPATHY 
• GIVE PYRIDOXINE (B6)

• ACTIVE TB
• AE: OCULAR TOXICITY, SKIN RASH, GI, NEUROLOGIC AES
• TB DRUG THAT DOES NOT CAUSE LIVER TOXICITY!

• DEXEDRIN
• RITALIN

NOTE: DEXEDRIN

• INH:
• ITIS (FATIGUE), NEUROPATHY (PERIPHERAL), HEPATOTOXICITY

• S.PNEUMO, H.INF, N.MENGITIDIS
• CEFTRIAXONE OR CEFOTAXIME + VANCO
• VANCO ADDED DUE TO INCREASED RESISTANCE TO S.PNEUMO

• SALINE-MOISTENED GAUZE OR HYDROACTIVE GEL DRESSING 
• THESE PROVIDE MOIST ENVIRONMENTS AND HELP DEBRIDE

S.AUREUS, B.HEMOLYTIC STREP

IF THE WOUND IS MALODOROUS OR NECROTIC, COVER GRAM NEGATIVE AND ANAEROBES TOO

• SEPTRA X 3 DAYS
• TRIMETHOPRIM X 3 DAYS
• NITROFURANTION BID X 5 DAYS
• FOSFOMYCIN 3 G X 1 DOSE

• SECOND LINE:
• FQ X 3 DAYS
• CEPHALEXIN X 7 DAYS

FQ X 7-14 DAYS

• 2ND LINE: 
• AMOXICLAV X 10-14 DAYS
• SEPTRA 10-14 DAYS
• TRIMETHOPRIM X 10-14 DAYS

• FQ X 7-10 DAYS
• SEPTRA X 7-10 DAYS
• MACROBID 7-10 DAYS

• 2ND LINE:
• AMOXICLAV X 7-10 DAYS
• CEPHALEXIN X 7-10 DAYS
• CEFIXIME X 7-10 DAYS

• CI IF <60ML/MIN
• NOT RECOMMENDED IN PYELONEPHRITIS
• RARE AE: PULMONARY/HEPATIC TOXICITY (USUALLY WITH LONG-TERM USE)

• AMG IV +/- AMPICILLIN FOR INITIAL
• STEP DOWN ONCE SENSITIVITIES
• TOTAL 10-14 DAY TX

• TREAT ASYMPTOMATIC BACTERIURIA AND SYMPTOMATIC CYSTITIS
• 3-7 DAY COURSE OF: AMOXICILLIN (IF SENSITIVE), AMOXI-CLAV, CEPHALEXIN, MACROBID OR FOSFOMYCIN

• PREGNANT WOMEN
• PRIOR TO TURP

• 2+ IN 6 MONTHS OR
• 3+ IN 1 YEAR

• 4-6 WEEKS
• CAN USE HOME IV THERAPY

• ITCHY: C, T
• ODOUR: T, BV
• DISCHARGE: C (WHITE, CLUMPY), T (OFF-WHITE/YELLOW, FROTHY), BV (GREY/MILKY, THIN, COPIOUS)
• PH: C IS NORMAL, T, BV ARE >4.5
• SEXUAL TRANSMISSION: T

• WAIT 5 HALF-LIVES FOR IRREVERSIBLE MAOI(PHENYLZINE)
• FLUOXETINE TAKES 5 WEEKS

• FROM IRREV MAOI: WAIT 14 DAYS 
• FROM MOCLOBEMIDE: WAIT 5 DAYS

• FLU-LIKE SX
• INSOMNIA
• NAUSEA
• IMBALANCE
• SENSORY DISTURBANCE
• HYPERAROUSAL (NOT SEX)

• METRONIDAZOLE
• CLINDAMYCIN

FROM 2 DAYS PRIOR TO RASH APPEARANCE UNTIL LAST LESION HAS CRUSTED

• NOTES:
• VIRAL LOAD < 50 AND CD4 > 200

• ECPS:
• <40COPIES/ML (PCR) OR
• <75COPIES/ML (BRANCHED DNA TEST)

FAILURE IS NOT HAVING VL < 200 BY EITHER ASSAY

• COMBINATION ANTIRETROVIRAL THERAPY
• 2 NRTIS + NNRTI OR
• 2 NRTIS + PROTEASE INHIBITOR WITH A BOOSTER (COCIBISTAT/LOW DOSE RITONAVIR) OR
• 2 NRTIS + INTEGRASE INHIBITOR

• PREFERRED NRTI COMBOS:
• TENOFOVOIR/EMTRICITABINE OR
• ABACAVIR/LAMUVIDINE
• ALTERNATIVE: TENOFOVIR/LAMUVIDINE

• PREFERRED NNRTI:
• EFAVIRENZ OR
• RILPIVIRINE

• PREFERRED PI:
• ATAZANAVIR OR
• DARUNAVIR

• PREFERRED II:
• DOLUTEGRAVIR OR
• ELTEGRAVIR OR
• RALTEGRAVIR

• PCP
• CD4 <200
• PREFERRED TX- SEPTRA
• ALTERNATIVE- DAPSONE, ATOVAQUONE OR MONTHLY INHALED PENTAMIDINE

• TOXOPLASMA GONDII (WITH POSITIVE SEROLOGY)
• CD4 < 100
• PREFERRED TX- SEPTRA
• ALTERNATIVE- ATOVAQUONE

• MAC, CMV, FUNGAL INFECTIONS
• CD4 <50
• MAC- USE MACROLIDE (AZITHRO, CLARITHRO)
• CMV- PROPHYLAXIS ISN'T COST-EFFECTIVE
• FUNGAL- FLUCONAZOLE

WHEN CD4 > 200 FOR 3 MONTHS+

• PAROXETINE
• SERTRALINE

• 6 WEEKS 
• MAY TAKE UP TO 12 WEEKS FOR SIGNIFICANT CHANGE IN SYMPTOMS

NOT RECOMMENDED DUE TO EFFECTS ON DISINHIBITION AND HIGH RATE OF SUBSTANCE ABUSE IN PTSD

4 WEEKS+

3+ UNFORMED STOOLS IN 24H PLUS AT LEAST ONE OF CRAMPING, TENESMUS, ABDOMINAL PAIN, NAUSEA, VOMITING, FEVER, BLOODY DIARRHEA

• PARASITIC
• COULD BE IBS

• BOIL
• CHLORINE (SODIUM HYPOCHLORITE)
• IODINE DROPS (DON'T USE >3 WEEKS)
• IODINE RESIN FILTERS ARE BETTER

IT PRODUCES BLACK STOOL - CAN CONFUSE WITH MELENA

• FQS (NOT FOR THAILAND, INDIA, NEPAL, INDONESIA)
• SEPTRA/DOXYCYCLINE NO LONGER RECOMMENDED DUE TO RESISTANCE
• BISMUTH CAN BE CONSIDERED BUT NOT OFTEN RECOMMENDED

• 3
• <3 AT RISK OF TOXIC MEGACOLON

• FEVER
• BLOODY DIARRHEA
• MALNOURISHED
• DEHYDRATED
• (CAN PROLONG INFECTION)

• NOT FQS
• AZITHROMYCIN

• PROPHYLAXIS IS NOT RECOMMENDED
• CARRY ORT SALTS
• DO NOT USE IODINE PREPARATIONS TO STERILIZE WATER
• IF TX NEEDED, USE AZITHROMYCIN
• SEPTRA OK IN EARLY PREGNANCY
• LOPERAMIDE OK TO USE PRN

• BASICALLY:
• NO PROPHYLAXIS
• AZITHRO + LOPERAMIDE OK FOR SEVERE

• 4 MG INITIALLY THEN 
• 2MG AFTER EACH LOOSE BM
• NO MORE THAN 16 MG (8 TABS) DAILY

• 500MG DAILY X 3 DAYS
• OR 1G X 1 DOSE

BENZOS, ALCOHOL (SEIZURES)

• MILD-MOD: SUPPORTIVE CARE AND IF NEEDED, LOW-DOSE, SHORT-DURATION BENZOS
• SEVERE: DIAZEPAM (AND/OR PHENOBARB IF RESISTANT)

• NO TX IS CONSISTENTLY EFFECTIVE
• CBT IS MOST EFFECTIVE

• MOST EFFECTIVE TX: METHADONE OR SUBOXONE
• CLONIDINE CAN BLUNT NEURADRENERGIC SX (CHILLS, FLUSHING)

DIAZEPAM/CLONAZEPAM

2 MONTHS+

• 4-6 H FOR DEET
• <1 H FOR CITRONELLA

• 1ST LINE: CHLOROQUINE (IF SUSCEPTIBLE)
• IF RESISTANT TO CHLOROQUINE: MEFLOQUINE
• IF RESISTANT TO CHLOROQUINE AND MEFLOQUINE: MALARONE, DOXYCYCLINE
• PRIMAQUINE IS AN ALTERNATIVE

• DEET HIGHLY RECOMMENDED (SAFE IN 2ND, 3RD TRIMESTER)
• CHLOROQUINE FIRST LINE 
• IF RESISTANT TO CHLOROQUINE: MEFLOQUINE
• THERE IS NO SAFE/EFFECTIVE OPTION IF MEFLOQUINE RESISTANCE
• AZITHRO IS AN OPTION BUT IS SUBOPTIMAL

• SEIZURES
• DEPRESSION
• PSYCHOSIS
• RECENT ANXIETY DISORDER
• CARDIAC CONDUCTION DISTURBANCE
• ADR TO MEFLOQUINE

THUS, USE MALARONE, DOXYCYCLINE OR PRIMAQUINE

• FEVER WITHIN 1 YEAR (MORE-SO WITHIN 3 MONTHS) OF RETURNING
• REGARDLESS OF CHEMOPROPHYLAXIS
• = MEDICAL EMERGENCY

• IF <8YO: DEFER TRAVEL OR USE MALARONE
• IF >8YO: MALARONE OR DOXYCYCLINE

• DAILY WITH FOOD
• START 1 DAY BEFORE
• CONTINUE FOR 1 WEEK AFTER

• WEEKLY
• START 1-2 WEEKS BEFORE
• CONTINUE FOR 4 WEEKS AFTER

• DAILY WITH FOOD
• START 1 DAY BEFORE
• CONTINUE FOR 3 DAYS AFTER

• DAILY WITH FOOD AND WATER
• START 1 DAY BEFORE
• CONTINUE FOR 4 WEEKS AFTER

• 5HT3R ANTAGONISTS (ONDANSETRON)
• NEUROKININ-1 RECEPTOR ANTAGONISTS (APREPITANT)

USUALLY COMBO WITH EACH OTHER AND WITH DEXAMETHASONE

CAN ALSO USE DOPAMINE ANTAGONISTS (PROCHLORPERAZONE AND METOCLOPRAMIDE FOR LOW EMETOGENIC CHEMO AND FOR RESCUE)

OLANZAPINE ALSO EFFECTIVE

• APREPITANT MODERATE 3A4 INHIBITOR
• THUS DOSE OF DEXAMETHASONE SHOULD BE DECREASED

• TYRAMINE RICH FOODS (AGED CHEESE, CURED MEAT, BEER, FOOD, SOY)
• IRREVERSIBLE MAOI (PHENELZINE): RESTRICT
• REVERSIBLE (MOCLOBEMIDE): NO RESTRICT UNTIL 600MG DAILY

• IF GROWTH SUPPRESSION (LOST >10% OF BODY WEIGHT)
• WHEN ASSESSING BENEFIT

TAKE 2-3 WEEKS IN THE SUMMER (OFF-SCHOOL) TO DETERMINE

NOT RECOMMENDED IF CHILD HAS MOD-SEVERE SYMPTOMS OR IS DOING VERY WELL ON STIMULANT

• STIMULANTS
• ATOMOXETINE

• 3 WEEKS
• SEVERE SYMPTOMS WILL USUALLY RESOLVE IN 3 DAYS OR LESS
• ONSET IS 1-7 DAYS AFTER STOPPING THE MED

• PEG: 
• GREATER IMPROVEMENTS IN STOOL FREQUENCY AND FORM
• RELIEF OF ABDOMINAL PAIN
• REDUCES THE NEED FOR ADDITIONAL LAXATIVES
• ALSO BETTER SAFETY PROFILE

• ORAL PEGYLATED NALOXONE DERIVATIVE
• FOR OPIOID-INDUCED CONSTIPATION WHO HAVE FAILED COMMON LAXATIVES

GRADUALLY OVER 3-4 WEEKS WHILE OPTIMIZING NONPHARMS

• GLYCERIN SUPPOSITORY
• LACTULOSE

(FYI DERIVED FROM MIRTAZAPINE)

• SUBLINGUAL BID
• SE: ORAL HYPOESTHESIA/PARESTHESIA (RESOLVES 1 H), HYPERSENSITIVITY HAVE OCCURRED

• RELATED TO INITIATION AND DOSE INCREASES
• OFTEN WORSE 2-3H POST-DOSE (TIME OF PEAK CONC)
• DOESN'T APPEAR TO RELATE TO ABSENCE/PRESENCE OF FOOD
• MANAGEMENT: LOWER/SPLIT THE DOSE OR GIVE IT QHS
• GINGER MAY HELP

• ASENAPINE
• ZIPRASIDONE CC

• PALIPERIDONE
• ARIPIPRAZOLE

• OLANZAPINE
• CLOZAPINE
• QUETIPAINE

• PALIPERIDONE
• RISPERIDONE

• OLANZAPINE
• CLOZAPINE
• THEN
• QUETIAPINE
• THEN
• RISPERIDONE
• PALIPERIDONE

• CLOZAPINE
• OLANZAPINE

• PALIPERIDONE
• RISPERIDONE

• CLOZAPINE (EVERYTHING)
• ZIPRASIDONE (QT)

• NRT BUT NOT BECAUSE THEY ARE BETTER THAN BUPROPION/VARENICLINE (THESE ARE NOT TECHNICALLY SECOND LINE)
• LIKELY DUE TO SAFETY CONCERNS OF RX OPTIONS VS NRT

• NASAL SPRAY
• SUBLINGUAL TABLET

50-70%

• PAST/CURRENT PSYCH ILLNESS
• BUT RECENT DATA SUGGESTS NO ASSOCIATION WITH NEUROPSYCH AES AND THAT IT IS SAFE AND EFFECTIVE IN PTS WITH STABLE SCHIZO

• CVD
• DATA SUGGESTS NO SIG INCREASE IN CV EVENTS BUT BE CAUTIOUS UNTIL FURTHER DATA

• VARENICLINE
• NRT PATCH + PRN
• NRT INHALER/LOZENGE/SPRAY
• NRT PATCH
• BUPROPION
• GUM

NOTE: NRT + BUPROPION MIGHT BE BETTER THAN BUPROPION ALONE

THOSE WITHOUT NICOTINE OR HEALTH CLAIMS

BUPROPION (ANOREXIANT PROPERTIES)

NRT/CHAMPIX LESS WEIGHT GAIN VS USING BEHAVIOURAL METHODS ALONE

• SMOKING INDUCES 1A2 THUS INCREASES CLEARANCE OF CAFFEINE
• QUITTING MEANS YOU NEED LESS CAFFEINE

0.5G

• DOSE-RELATED
• IDIOSYNCRATIC
• LONG-TERM EFFECTS

• DIZZINESS
• SEDATION
• FATIGUE
• ATAXIA
• COGNITIVE/PSYCHIATRIC
• NAUSEA

CAN REDUCE DOSE OR USE SLOW RELEASE FORMS INSTEAD OF IR

• SKIN RASH (PHENYTOIN, CARBAMAZEPINE, LAMOTRIGINE MOST LIKELY)
• MOST OFTEN OCCURS WITHIN 6 WEEKS BUT CAN OCCUR ANY TIME
• HAN CHINESE (HLAB-1502) MAY BE AT RISK
• IF DEVELOPS, STOP (CAN BE SJS, TEN)
• IF HX RASH, CHOOSE ONE WITH LOWER INCIDENCE OR JUST START LOW, GO SLOW

OTHERS: HEMATOPOESIS DISORDERS, HEPATOTOXICITY

LOW BONE DENSITY AND FRACTURES

SUPPLEMENT WITH VITAMIN D AND CALCIUM

• CARBAMAZEPINE
• ESLICARBAZEPINE
• OXCARBAZEPINE
• PHENOBARB
• PERAMPENEL
• PHENYTOIN
• PRIMIDONE
• RUFINAMIDE
• TOPIRAMATE

IMPORTANT ONES: ALL THE AZEPINES, ALL THE ONES STARTING WITH P, AND TO "TOP" IT OFF, TOPIRAMATE

• ATENOLOL
• DIURETICS (AVOID)
• SPIRONOLACTONE
• ACE/ARB

• 1: GI
• HYPER - N/V/D
• HYPO - CONSTIPATION/ILEUS

• 2: CVS
• HYPER - ARRYHTHMIA
• HYPO - ARRHYTHMIA, ARREST

• 3: NEURO
• HYPER - WEAKNESS, PARALYSIS, RESP FAILURE
• HYPO - WEAKNESS, LETHARGY, REDUCED REFLEXES

• ENTRESTO SUPERIOR TO ENALAPRIL IN REDUCING DEATH FROM CV, HF HOSPITALIZATION, DEATH FROM ANY CAUSE, IMPROVING QOL
• HAD LESS HYPERKALEMIA AND RENAL DYSFUNCTION
• BUT HAD HIGHER HYPOTENSION RATES
• ANGIOEDEMA WAS THE SAME

• IF HIGHLY SYMPTOMATIC
• MULTIPLE RECURRENCES
• ARRYTHMIA INDUCED CARDIOMYOPATHY
• EXTREME QOL IMPAIRMENT

• OTHERWISE TRY RATE CONTROL VIA BB/CCB
• IF THIS DOESN'T WORK, THEN ATTEMPT RHTYHM CONTROL

• 1 H BEFORE OR 
• 4-6 HOURS AFTER

INCREASED RISK OF STROKE AND DEATH WHEN USED FOR WEEKS-MONTHS

• NO ACTIVE METABOLITES
• METABOLISM UNCHANGED BY AGE

• NOT FOR LONGER THAN 4 DAYS
• SHOULD BE SHORT-ACTING AND USED PRN

• 3-4 WEEKS 
• BUT OFTEN SEEN IMPROVEMENTS IN 1ST WEEK

• 3 Y FOLLOW UP OF A STUDY SHOWED THAT KIDS ON STIMULANTS WERE ON AVERAGE 2CM SHORTER AND 2.7KG LESS VS NONMEDICATED KIDS
• MONITOR FOR GROWTH SUPPRESSION BASELINE AND MONTHLY

• SINGLE DAILY DOSING 
• IMPROVED ADHERENCE
• AVOIDING NEED TO MEDICATE AT SCHOOL
• DECREASED ABUSE POTENTIAL
• LESS REBOUND HYPERACTIVITY

EXAMPLES: ADDERALL XR, BIPHENTIN, CONCERTA, VYVANSE

1ST LINE: NONPHARMS

• IF SEVERE BEHAVIOURAL SX: USE ANTIPSYCHOTICS
• RISPERIDONE, OLANZAPINE, QUETIAPINE OR ARIPIRAZOLE
• IF PARKINSON, DON'T USE RISPERIDONE

IF SLEEP RELATED, USING TRAZODONE

IF SEVERE USE INJECTABLE (OLANZAPINE VS HALOPERIDOL)

CHOLINESTERASE INHIBITORS: DONEPEZIL, RIVASTIGMINE, GALANTAMINE

NMDA R ANTAGONIST: MEMANTINE

2-4 POINTS PER YEAR

THUS WE WANT TO DECLINE < 2 POINTS ANNUALLY ON TX = BENEFIT

DONEPEZIL

• ESICTALOPRAM
• MIRTAZAPINE
• SERTRALINE
• VENLAFAXINE

• ESCITALOPRAM
• SERTRALINE
• BUPROPION
• CITALOPRAM

• SUBSIDE: CNS, GI SIDE EFFECTS
• PERSIST: SEXUAL DYSFUNCTION (CAN INVOLVE IMPAIRED DESIRE, AROUSAL AND/OR ANORGASMIA/EJAC)

• MIRTAZAPINE
• BUPROPION (BEST OPTION)
• MOCLOBEMIDE
• VORTIOXETINE

• SAME SIDE EFFECTS
• SUPERIOR EFFICACY

• I: AT LEAST 1 CLEAR-CUT MANIC EPISODE, WITH OR WITHOUT DEPRESSIVE OR HYPOMANIC EPISODES
• II: HYPOMANIA + DEPRESSIVE EPISODES WITHOUT A FULL MANIC EPISODE

• LITHIUM
• DIVALPROEX
• 2ND GEN ANTIPSYCHOTIC
• 2 DRUG COMBO (LITHIUM OR DIVALPROEX + A SECOND GEN AP)

• USUALLY ADD-ON WHEN MOD-SEVERE EPISODE
• TREAT FOR 2 WEEKS TO SEE IF CHANGE IS NECESSARY

• LITHIUM
• LAMOTRIGINE
• LURASIDONE
• QUETIAPINE
• 2 DRUG COMBO (LITHIUM OR DIVALPROEX + SSRI/BUPROPION; LITHIUM + DIVALPROEX; OLANZAPINE + SSRI)

SWITCH IF INADEQUATE RESPONSE IN 2-4 WEEKS

• QUETIAPINE
• LITHIUM

2 MONTHS AFTER EPISODE AND NO RELAPSE

• ELIMINATE CAFFEINE
• REDUCE DOSE
• ADD BETA-BLOCKER (PROPRANOLOL/ATENOLOL)

MAINTAIN USUAL FLUID/SALT/CAFFEINE INTAKE

IF ACUTELY ILL/ELECTROLYTE LOSSES, STOP LITHIUM TEMPORARILY

• POSITIVE (HALLUCINATIONS, DELUSIONS)
• NEGATIVE (APATHY, ANHEDONIA)
• MOOD (ANXIETY, EMOTIONAL)
• COGNITIVE (IMPAIRED CONC, MEMORY, ATTN)

REPORTS OF CARDIAC AND RESPIRATORY PROBLEMS INCLUDING DEATH

4-8 WEEKS


IF TX RESISTANT AND USING CLOZAPINE, TRIAL IS 4-6 MONTHS

• ASENAPINE 5MG BID
• LURASIDONE 40MG DAILY

• ZIPRASIDONE
• XR QUETIAPINE

TO AVOID ADVERSE REACTIONS

• 1-2 YEARS
• CONSIDER 2-5 YEARS IF SEVERE ILLNESS, SLOWER RESPONSE, SUBSTANCE ABUSE, HX SUICIDAL BEHAVIOUR, AGGRESSIVE
• IF 2+ EPISODES, TREAT FOR 5 YEARS

• ANTIPSYCHOTICS
• CAN OCCUR AT ANY DOSE/TIME
• RF: DEHYDRATION
• CHARACTERIZED BY MUSCLE RIGIDITY, FEVER, AUTONOMIC DISTURBANCE, LABILE BP, FLUCTUATING LEVEL OF CONSCIOUSNESS, ELEVATED WBC AND CK

• LIMIT NAPS TO 30MIN
• AVOID CAFFEINE/NICOTINE/DRUGS
• REGULAR RELAXING BEDTIME ROUTINE
• MAKE SLEEP ENVIRONMENT PLEASANT
• AVOID SLEEPING IN
• EXERCISE DAILY
• AVOID LARGE EVENING MEALS
• TURN CLOCK FACE AWAY AND ALWAYS USE ALARM

• NITRAZEPAM
• FLURAZEPAM
• TEMAZEPAM
• TRIAZOLAM

• N,F: NOT RECOMMENDED PARTICULARLY IN ELDERLY (ACCUMULATION, HANGOVER EFFECTS (LONG HALF LIFE))
• TRIAZOLAM: FAST ONSET, SHORT DURATION THUS GOOD FOR INITIAL INSOMNIA BUT HAS ABUSE POTENTIAL! NOT FOR ELDERLY.

• CALDOT
• CLONAZEPAM
• ALPRAZOLAM
• LORAZEPAM
• DIAZEPAM
• OXAZEPAM
• TEMAZEPAM

• DIAZEPAM
• CLONAZEPAM

• ASK
• ADVISE
• ASSESS
• ASSIST
• ARRANGE FOLLOW UP

• SET TARGET QUIT DATE
• GET PROFESSIONAL HELP
• ENLIST SOCIAL SUPPORT
• USE MEDS TO QUIT
• USING PROBLEM-SOLVING METHODS OF COUNSELLING TO QUIT AND REMAIN SMOKE FREE

10

• NO ACIDIC FOOD/DRINK FOR 15 MIN BEFORE OR DURING
• (REDUCED ABSORPTION)

20 PIECES

• 0.5MG DAILY X 3 DAYS
• 0.5MG BID X 4 DAYS
• 0.5-1MG BID X 12 WEEKS
• TOTAL DURATION: 13 WEEKS

QUIT DATE: 1-2 WEEKS AFTER STARTING

VARENICLINE (INCREASED SIDE EFFECT RISK)

• 150MG DAILY X 3 DAYS
• 150MG BID X 7-12 WEEKS

QUIT DATE: 1-2 WEEKS AFTER STARTING

ANOREXIA: PROKINETICS (CHOOSE METOCLOPRAMIDE ONLY IF ANTI-NAUSEA EFFECT IS ALSO NEEDED)

BULIMIA: SSRI (VENLAFAXINE, FLUOXETINE, TRAZODONE) X 6-12 MONTHS

BENZTROPINE = COGENTIN = ANTICHOLINERGIC

BROMOCRIPTINE = ERGOT DOPAMINE AGONIST

• ANTIPSYCHOTICS (THINK, THEY CAN CAUSE PARKINSON)
• PROKINETICS (USED TO TREAT "LACKTATION")

• DOPAMINE AND PROLACTIN INVERSELY RELATED
• IN PARKINSON, DOPAMINE IS LOW AND ACETYLCHOLINE INCREASES

• MIDDLE-AGED TO ELDERLY
• SEVERE AND ABRUPT
• PROGRESSIVE SEVERITY/INCREASED FREQUENCY
• SIGNIFICANT CHANGE IN HA PATTERN
• STIFF NECK/FOCAL SIGNS/REDUCED CONSCIOUSNESS
• FEVER/APPEARS SICK

• NONOPIOIDS < 15 / MONTH
• OPIOIDS, TRIPTANS AND COMBO ANALGESICS < 10 / MONTH

SC SUMATRIPTAN

NARATRIPTAN (MAX EFFECT 4 H)

BUT IT'S ASSOCIATED WITH FEWER SIDE EFFECTS

• CARDIAC DISORDERS
• SUSTAINED HTN
• BASILAR/HEMIPLEGIC MIGRAINES

• CLUSTER = C = CALCIUM CHANNEL BLOCKERS (VERAPAMIL)
• TTHA = T = TCAS (NOR/AMITRIPTYLINE)

3 ATTACKS

MUST ALSO TRY 3 DIFFERENT TRIPTANS BEFORE MOVING ON TO NEXT STEP (NSAID + TRIPTAN)

• RIZA
• ZOLMI

• ZOLMI
• SUMA

• CONSIDER IN ADOLESCENTS WITH MOD-SEV MIGRAINE UNRESPONSIVE TO CONVENTIONAL ANALGESICS
• ALMOTRIPTAN IS ONLY APPROVED ONE (12-18Y)
• BEST EVIDENCE EXISTS FOR NASAL SUMATRIPTAN THOUGH

• NOT AFFECTED BY RENAL/LIVER DISEASE
• LONGER DURATION OF ACTION VS MEPERIDINE

• AMETHOCAINE: PROS
• SUPERIOR IN PREVENTING PAIN ASSOCIATED WITH NEEDLES IN KIDS
• APPLY 30 MIN BEFORE (EMLA 45-60)

• AMETHOCAINE VASODILATES (CAN CAUSE HYPERSENSITIVITY ON REPEAT)
• EMLA VASOCONSTRICTS, MAKING CANNULATION DIFFICULT

• 1. TCA OR GABAPENTIN/PREGABALIN
• 2. SNRI OR TOPICAL LIDOCAINE
• 3. TRAMADOL OR SR OPIOID
• 4. OTHER (CANNABINOID, METHADONE, LAMOTRIGINE, TOPIRAMATE, VPA/DIVALPROEX)

• PARTIAL/COMPLETE PARALYSIS FOR <7 DAYS
• IF 7DAYS+, MEDS WON'T HELP

• URGE TO MOVE LEGS
• BEGIN/WORSEN AT REST
• RELIEVED BY MOVEMENT
• WORSE IN EVENING

• INTERMITTENT: MANY ARE JUST FE-DEFICIENT - CHECK LEVELS
• INTERMITTENT USE OF LEVODOPA, LOW-POTENCY OPIOID, OR BENZO

• DAILY SX: DOPAMINE AGONIST 1ST CHOICE
• COULD ALSO TRY GABAPENTIN/PREGABALIN

REFRACTORY: SWITCH TO GABAPENTIN, HIGH-POTENCY OPIOID OR OTHER DOPAMINE AGONIST, ADD BENZO/LOW-POTENCY OPIOID/GABAPENTIN

NONPHARMS: NO COFFEE/ALCOHOL/NICOTINE; USE HOT BATH, MASSAGE, EXERCISE

• NONERGOLINE: MORE FAVOURABLE SE PROFILE
• BUT ASSOCIATED WITH MORE SUDDEN SLEEP ATTACKS AT HIGHER DOSES

ERGOLINE: PLEURAL FIBROSIS, PSYCHOSIS

• ONLY IF FUNCTIONAL IMPAIRMENT!
• IF MILD SX: RASAGILINE/SELEGILINE (MAOB)
• IF MOD-SEVERE AND <60Y: DOPAMINE AGONIST (IF THIS DOESN'T WORK, ADD LEVODOPA)
• IF MOD-SEVERE AND >60Y: LEVODOPA

• IMPROVES LEVODOPA INDUCED DYSKINESIA IN LATER STAGES
• NMDAR ANTAGONIST

• BENZTROPINE
• MAILY FOR TREMOR

• TOLCAPONE - ONLY VIA SAP (HEPATOTOXICITY)
• ENTACAPONE - NO LIVER TOX BUT SES ARE DIARRHEA (WEEKS TO MONTHS AFTER INITIATION) AND HARMLESS URINE DISCOLOURATION

• SIMILAR TO NEUROLEPTIC MALIGNANT SYNDROME
• POTENTIALLY FATAL
• USUALLY OCCURS WHEN ABRUPT D/C OF DOPAMINERGIC DRUGS
• DRUG HOLIDAYS NOT RECOMMENDED!

• INCREASE LEVODOPA FREQUENCY
• ADD COMT
• ADD DOPAMINE AGONIST
• ADD RASAGILINE
• CHANGE TO SR LEVODOPA

• ADD AMANTADINE
• INCREASE FREQ BUT SMALLER DOSES OF LEVODOPA
• DECREASE LEVODOPA/ DOPAMINE AGONIST

• ADD AMANTADINE
• DECREASE LEVODOPA
• D/C ANTICHOLINERGIC
• D/C SELEGILINE

COMPLEX PARTIAL

• TONIC-CLONIC
• ABSENCE

• CONSCIOUSNESS PRESERVED IN SIMPLE PARTIAL
• AND CONSCIOUSNESS "IMPAIRED" IN COMPLEX PARTIAL (MEMORY IMPAIRED BUT CAN PERFORM TASKS)

VALPROIC ACID/DIVALPROEX (TERATOGENIC)

• 1ST LINE: BETA-BLOCKER OR PROSTAGLANDIN ANALOG
• 2ND LINE: ADD OR SUBSTITUTE
• CARBONIC ANHYDRASE INHIBITOR
• PROSTAGLANDIN ANALOG
• ADRENERGIC AGONIST
• BETA-BLOCKER
• 3RD LINE: ADD
• ANY AGENT (INCLUDING CHOLINERGIC) TO A MAX OF 3 AGENTS!
• 4TH LINE: CAN ADD ORAL CARBONIC ANHYDRASE INHIBITOR

NOTE: CAN CONSIDER TRABECULOPLASTY 2ND LINE ONWARDS

• SYSTANE ULTRA
• REFRESH PLUS
• HYLO

ALSO CONTACT LENS COMPATIBLE!

ELDERLY (INCREASED RISK OF FRACTURE) AND CORONARY ARTERY DISEASE

• 1. RASH
• 2. HYPERSENSITIVITY
• 3. HEPATOTOXICITY (MORE WITH PTU)
• 4. SYMPTOMS OF INFECTION - CONTACT MD ASAP
• THESE MEDS CAN GRADUALLY CAUSE NEUTROPENIA (REGULARLY MONITOR WBC)

• PAIN
• PHOTOPHOBIA
• VISION DISTURBANCES
• TRAUMA
• FOREIGN BODY
• KERATITIS (CORNEAL INVOLVEMENT)
• MOD-SEVERE ON QOL

• 0-2: RECTAL DEFINITIVE; AXILLARY SECOND
• 2-5: RECTAL DEFINITIVE; AXILLARY/TYMPANIC SECOND
• 5+: ORAL DEFINITIVE; AXILLARY/TYMPANIC SECOND

• 38 IF RECTAL/TYMPANIC
• 37.5 IF ORAL
• 37 IF AXILLARY

• LOW (FACE/FOLDS): HC ACETATE, DESONIDE
• MOD (BODY): DIFLUCORTOLONE, PREDNICARBATE, FLUOCINOLONE, TRIAMCINOLONE, BETAMETHASONE VALERATE, HC VALERATE, CLOBETASONE BUTYRATE
• HIGH (THICK SKIN): BETAMETHASONE DIPROPIONATE, DESOXIMETASONE, MOMETASONE, FLUOCINONIDE, AMCINONIDE
• ULTRA HIGH (PALMS/SOLES): CLOBETASOL, HALOBETASOL, BETAMETHASONE DIPROPIONATE GLYCOL

DESLORATADINE