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Therapeutics III '13

Pain, UTI, Skin Infections, Hepatitis, Cirrhosis, HIV, PUD/GERD

QuestionAnswer
Pain is: an unpleasant sensory and emotional experience associated with actual or potential tissue damage
Which type of pain has a biological function? Nocioceptive
Which type of pain does not have a biological function? Neuropathic
What is nocioceptive pain? stimulation of peripheral pain receptors that can be somatic (musculoskeletal) or visceral (internal)
What is neuropathic pain? dysfunction of peripheral or central nervous system
How do we describe neuropathic pain? tingling, burning, shooting, numbing, electric
How do we describe nocioceptive pain? sharp, dull, aching, stabbing, throbbing
Which type of pain commonly has a psychological component? chronic
What are common features of acute pain? anxiety, sympathetic hyperactivity, occurs less than 1 month
What are common features of chronic pain? fatigue, anger, depression, insomnia, social disruption, occurs greater than 1 month
Activation of nerves that do not transmit pain signals then interfering with signals from pain fibers to inhibit the perception of pain is called what? Gate Control Theory
What are some things that close the gate control theory and therefore help alleviate pain? drugs, counter-stimulation, increased interest in activities, intense concentration, relaxation, happiness, rest, isolation
What are some things that open the gate to pain, making it worse? injury, tension, anger, anxiety, worry, depression, boredom, inappropriate physical activity, focusing on pain
What are the 2 goals of pain management? reduce average pain score by 30% and improve quality of life
Is pain managed best with opioids? No
Is there any objective way to measure pain? No
Is patient usually under or over-treated? under-treated
What drugs fall into the category that you should should try first line (1)? APAP, NSAIDs, anticonvulsants, antidepressants
What drugs fall into the category that you should try if category 1 drugs do not work for pain (2)? tramadol, hydrocodone/APAP (vicodin), codeine/APAP
What drugs should you use if category 1 or 2 drugs don't work for pain (3)? morphine, oxycodone, hydromorphone, fentanyl, methadone
APAP dosing Max 1000mg every 6 hours
Pregabalin dosing 50 mg TID, then titrate up to 100 mg TID in one week
Gabapentin dosing 300 mg TID, but goal dose is 600 mg TID for 4 weeks Avg dose: 2400mg/day and max 3600mg/day
Nortriptyline dosing 25 mg HS (10 if elderly), then titrate up by increments of 10-25 mg/day every 3-7 days; usual effective dose is 75-100mg/day
Amitriptyline dosing 25 mg HS (10 if elderly), then titrate up by increments of 10-25 mg/day every 3-7 days; usual effective dose is 75-100mg/day
What are some non-pharmacologic options for treating pain? hot/cold compress, PT, exercise, behavioral therapy, e-stim, biofeedback, relaxation, coping, group therapy, massage, pilates, yoga, water therapy
Does APAP have anti-inflammatory properties? NO
Can APAP be used to treat both chronic and acute pain? yes
Can you give APAP if patient has chronic kidney disease? yes
What is the most common cause of acute liver failure? APAP
When should you avoid APAP? greater than 3 alcoholic beverages per day or severe chronic liver disease
What is the max daily dose of APAP? 4 grams/day
Does ibuprofen have anti-inflammatory properties? yes
Can ibuprofen be used to treat both chronic and acute pain? no only acute
What are the 4 cons to using ibuprofen? GI bleeds, Increased bleeding risk due to platelet dysfunction, renally toxic, cardio risk
If patient has bleeding gastric ulcer, what NSAID should be given? Celecoxib (celebrex) because it is cox-2 selective and will not effect the GI, or salsalate
Avoid all NSAIDs in patients with what? Kidney problems
If giving ASA and NSAID, how do you dose? give ASA, then 30 minutes later, give NSAID; 8 hours after NSAID was given is when you can give next ASA dose
Why do we not recommend ASA for pain? high risk of bleeding
What is capsaicin especially good for? neuropathic, localized pain
What is lidoderm good for? neuropathic or nocioceptive localized pain
Can lidoderm patches be cut? yes
Absorption is non-linear and saturable for which pain drug? gabapentin
Which drug is first line for neuropathic pain? lyrica
What are the main cons of lyrica? expensive, C-5, must be renally adjusted
Which class of TCAs has less adverse effects and more NE reuptake? secondary amines like desipramine and nortriptyline
Which class of TCAs has more adverse effects and more anticholinergic activity? tertiary amines like amitriptyline, doxepin, imipramine
Why are TCAs good for neuropathic pain? Because they are also good for concurrent insomnia or depression
What are the major cons of the TCAs for pain? lots of drug intxs, adverse effects, caution in elderly, seizure, cardiac, dementia, constipation, BPH, glaucoma, urinary retention because these are all going to exacerbate anticholinergic effects BUT they are inexpensive
Which SNRI is probably the most likely to be used for pain? Cymbalta because it is approved for diabetic neuropathic pain, fibromyalgia, and chronic musculoskeletal pain
Should muscle relaxants be used for chronic pain? NO
Morphine dose: Max daily dose is 120 mg unless patient has been on it for a long time and it has been slowly titrated up
Hydromorphone dose:
Oxycodone dose:
Methadone dose:
Hydrocodone dose: usually 5-10 mg every 4-6 hours, do not exceed APAP daily max
Tramadol dose: 25-50 mg every 6 hours, then can titrate up to 100 mg every 6 hours; change dosing interval to BID if renal or liver disease
Fentanyl dose:
T/F: Opioids have a high rate of adverse effects (80%) T
Who receives benefit from opioid use? Chronic cancer pain, short-term treatment of nocioceptive pain (<90 days), and neuropathic pain after trying non-opioid methods
Which 4 opioids have max daily doses (ceiling doses)? tapendatol, tramadol, codeine, hydorcodone/APAP
Which opioid has the lowest potential for abuse? tramadol
If patient has kidney problems and low CrCl, which is the safest opioid to use? fentanyl
Which opioid should you avoid using in children? codeine
Which opioid should you never use an equianalgesic chart to dose for? codeine
Which opioid also inhibits the reuptake of serotonin and norepinephrine? tramadol
If patient has seizure disorder, can you use tramadol? no
What is the #1 prescribed pain med in America? hydrocodone
What is the preferred opioid for acute and chronic pain in most patients? morphine
T/F: morphine has a lower risk for euphoria than oxy or hydromorphone. T
What is the most common of all infections? skin and soft tissue
What 3 things would help to diagnose if a patient has SSTI and systemic toxicity? fever/hypothermia, tachycardia, hypotension
What lab tests help to diagnose SSTI with systemic toxicity? blood culture, CBC w/ differential, basic metabolic panel, CRP
When should we recommend ABX on top of incision and drainage for an SSTI? severe or extensive disease, rapid progression of cellulitis, s/s of systemic illness, comorbities/immunosuppression, extremes of age, if the abscess is on the face, hands or genitalia, any association with septic phlebitis, or if it worsens after I and D
What are some normal skin flora? yeast, bacillus, micrococcus, diphtheroids, streptococcus spp, staphylococcus aureus, staphylococcus epidermidis
What is the most common bacterial contaminant in cultures? staphylococcus epidermidis
What are 3 examples of hematogenous spread? measles, chickenpox, meningitis petechiae
What is a hematogenous spread? the bacteria or virus spreads from another site to the skin
What are some examples of uncomplicated SSTIs? gram +, superficial infections like impetigo, extending into dermis and subQ fat, folliculitis, furuncles, carbuncles
What classifies a complicated SSTI? gram + or -, polymicrobial, involves deep tissues including subQ fat, needs significant surgical intervention, involves perianal area, significant coexisting diseases like DM, obesity, or immunocompromised
What are some examples of a complicated SSTI? diabetic foot infxn, surg site infxn, decubitus ulcer, necrotizing fasciitis
What are 2 examples of diffuse areas of infection? cellulitis, necrotizing fasciitis
What are 2 examples of local areas of infection? impetigo, abscess
What are some examples of acute SSTIs? cuts, burns, bites, trauma, surgery (any break in intact skin)
What are some examples of chronic SSTIs? diabetic foot infections, pressure sores, venous stasis ulcers (any underlying mechanism that could cause infection)
Patient has a localized, pus-producing boil, abscess, or carbuncle. What type of organism and what type of infection? uncomplicated staph (clusters of cocci)
Patient has a diffuse, cellulitis, erysipelas, or lymphangitis. What type of organism and what type of infection? uncomplicated strep (chains)
What skin pathogen is associated with recurrent hospital admissions, contact sports, boils or abscesses? MRSA
What skin pathogens are associated with diabetes? S. aureus, streptococci, gram (-) bacilli, anaerobes
What pathogen do we associate with cat bites? pasturella
What pathogen do we associate with water exposure? vibrio most commonly
How would you describe a non-bullous impetigo? fluid filled vesicles break open aka honey crusts
How would you describe bullous impetigo? ruptured lesions give a "varnished" look to the skin
What population do we most commonly see impetigo? 2-5 year olds
What are the 2 common pathogens of impetigo? staph aureus and strep pyogenes
How do we treat impetigo? mupirocin for 5-10 days (one application TID for kids and adults)
What skin infection is caused by strep pyogenes aka Group A Strep and is red, tender, fiery, and painful? erysipelas
How do we treat erysipelas? penicillin IV or PO
What pathogen usually causes a furuncle (boil)? staph aureus
What is a furuncle aka 'boil'? infection of the hair follicle
What is a carbuncle? when the furuncle extends ito several adjacent follicles and forms a larger inflammatory mass with pus from multiple follicles; usually on the back of the neck and in diabetic patients
Do we need to treat carbuncles and furuncles with ABX? no, just moist heat and I&D if large
What are some S/S of cellulitis? fever, tachycardia, confusion, hypotension, and leukocytosis
How would you diagnose a diffuse, spreading skin infection affecting the deeper dermis and subQ fat that presents as either vesicles, bullae, petechiae, or ecchymoses? cellulitis
Is aspiration of the skin helpful for cellulitis? no, not is 80% of cases
How do we treat cellulitis? elevate to drain edema, give ABX (first line is nafcillin/oxacillin, cefazolin, or clinda/vanc if they have penicillin allergy
How long to treat cellulitis with ABX? 5-10 days
Should we use IV or Oral ABX for cellulitis? either but can start with oral
What is the drug of choice for treating MSSA SSTIs? IV nafcillin/oxacillin or PO dicloxacillin
Which cellulitis antibiotic has inducible MRSA resistance? clinda
What is the drug of choice for treating MRSA cellulitis? vanco
What are 2 oral options for treating MRSA cellulitis? doxy and bactrim
What SSTI is deep and devastating and is usually secondary to trauma or surgery? necrotizing fasciitis
What are some S/S of necrotizing fasciitis? subQ tissue will feel hard, broad erythematous tract along the skin, and probing the edges of the wound will allow viewing down to fascia
What are some common organisms that cause necrotizing fasciitis? strep pyogenes, vibrio, aeromonas hydrophila
What are 3 risk factors for a polymicrobial necro fasciitis infection? post-op infection, decubitus ulcers, PVD/DM
Patient has severe, constant pain with skin bruising, necrosis, rapid spread of infection while on ABX, fever, delirium, renal failure, gas in the tissue, and cutaneous anesthesia. Do they have cellulitis or necrotizing fasciitis? NF
What is the mainstay of treatment for NF? Penicillin + clindamycin (because strep pyogenes is very sensitive to PCN)
Why do we use clindamycin in addition to penicillin to treat NF? clinda reduces toxins and inflammatory mediators released by these bacteria
If you are bitten by a cat or a dog, which two vaccines should you consider? rabies and tetanus
How do we treat cat/dog bites? Augmentin (amox/clav)
What is more serious, a dog/cat bite or a human bite? human bite
What pathogens are common to a human bite? 1)anaerobic are fusobacterium, peptostreptococcus, prevotella 2)aerobic are streptococci, staph aureus, eikenella corrodens
How do we treat human bite infections? ampicillin-sulbactam, cefoxitin, ertapenem
What bacteria is only found in our mouths? eikenella
For both human bites and animal bites, what is the mainstay of treatment? amoxicillin or ampicillin
If patient has had contact with an animal but you don't know if they have anthrax, tularemia, or yersinia, what do you empirically treat with? doxy or cipro
What is the most common source of fever 48 hours post surgery? surgical site infection
What type of surgeries most commonly cause polymicrobial infections? nonsterile tissue surgeries like colon, biliary, respiratory, and vaginal
How do you know when to treat a surgical site infection? if temp> 38.5 C or HR> 110 bpm you should treat with ABX and open the suture line
At least 1 of 4 of these criteria must be present to diagnose a surgical site infection? purulent incisional drainage, positive wound culture results, pain/tenderness/swelling/erythema at incision site, or diagnosis by attending surgeon or physician
For surgical site infections, what type of coverage are we looking for? gram (-) and anaerobic
If a surgical operation is clean, non-intestinal or genital procedure, what are the 2 most common organisms? streptococcus and staph aureus
What is the primary therapy of a surgical site infection? open the incision, remove the infected material, and continue to change dressing until the wound completely heals
DM causes a reduction in immune function and therefore more incidence of foot infections. What is the serum glucose level when this immune impairment begins? >150 mg/dL
What are the 4 steps in the pathophysiology of a diabetic foot infection? neuropathy-> deformity-> minor trauma-> ulceration
To classify a diabetic foot infection, you must have at least 2 of the following? local swelling or induration, erythema, local tenderness/pain, local warmth, purulent discharge
What is the most common pathogen causing diabetic foot infections? staph (aerobic gram +); you might see anaerobes if the tissue is already dead
Consider MRSA infection if..... patient had MRSA in the last year, the prevalence is high (30-50%), or if it is a severe infection
Consider P. aeruginosa if..... if it is a severe infection, patient failed non-pseudomonal agents, patient soaks feet or has frequent exposure to water, lives in a warm climate (only if there are risk factors because it is often a colonizer)
Consider ESBL (klebsiella or e.coli) if.... patient lives in warm southern climate like India, if infection is associated with neuropathy, osteomyelitis, ulcer >4 cm squared, poor glycemic control, or the need for surgery
WWhat do we treat an ESBL (klebsiella or e.coli) with? carbapenem
What is the common trough level we should aim for with vanco? 15-20 mcg/mL
Which antibiotic does not cover pseudomonas? ertapenem
How long do we give ABX for a mild SSTI? 1-2 weeks
How long do we give ABX for a moderate SSTI? 1-3 weeks
How long do we give ABX for a severe SSTI? 2-4 weeks
How do we diagnose HIV (vs. AIDS)? positive HIV antibodies on ELISA confirmed with a western blot
How do we diagnose AIDS (vs. HIV)? HIV + with 1 or more of the following: CD4 < 200 or AIDS defining illness
What is the CONFIRMATORY test for HIV? western blot
How long does it take to develop antibodies for HIV? 3-4 weeks to up to 6 months
How long does the acute retroviral syndrome last? 3-14 days
How long does clinical latency of HIV last? many years
Why do we care about CD4 count? tells us about disease progression and whether we need to start drug therapy or not, opportunistic infections
What is an adequate CD4 response for patients on ART? increase by 50-150 cells per year (but in first 3 months is better)
Why do we care about viral load? good indicator of transmission, it shows if patient is responding to ART, maybe they need new therapy
How often should viral load be measured and when do we expect to achieve suppression? monitor every 4 weeks and it should take 12-24 weeks to suppress viral load
What is the goal viral load for HIV? undetectable (not zero but so low that we can't find it on assay)
Has life expectancy for HIV patients increased or decreased? increased by quite a bit
When should ART be initiated for HIV patient? it depends, CD4 count is the best determiner
What is unique about stribild? it is quadruple therapy
What are the treatment goals that drive the decision to start ART? decrease viral load, increase CD4, increase life expectancy, prevent transmission, improve QOL
What are the 5 predictors of virologic success? 1) adherence 2) starting early 3) low viral load 4) high CD4 counts 5) high potency ARV
Which HIV drug should pregnant women not take? truvada
Which HIV drug should pregnant women take? Reyataz/ritonavir + Combivir
Which class of HIV drugs inhibit viral RNA being transcribed into DNA via reverse transcriptase? NRTIs and NNRTIs
What are the 2 most preferred (backbone) NRTIs according to Fox? Truvada and Combivir (for prego)
Which drug has produced FATAL hypersensitivity reactions and specific HLA-B screening is required? Ziagen (abacavir)
Which class of HIV drugs have minimal drug interactions? NRTIs
Which ART drugs need to be renally dosed? NRTIs
What are some disadvantages to NNRTIs? conferred resistance to whole class if you become resistant to just one, and drug interactions by CYP450
What is the liklihood that a person will contract a virus resistant to one medication? 6-16%
What is the most common NNRTI that can be dosed once daily? Sustiva
Which NNRTI is contraindicated with PPIs? the new drug Edurant
What is the most common side effect of Sustiva? CNS like dizziness and confusion (also teratogenic)
What is the most common integrase inhibitor? Isentress
What is the dosing of Isentress and possible disadvantage? twice daily unlike others which are once daily
What is a big advantage of Integrase inhibitors? no food effect and fewer drug interactions
Which integrase inhibitor is contraindicated with any and all drugs that are metabolized by 3A4? Stribild (quad therapy)
Can you use Stribild if a patient has kidney problems? no
What are the two most common protease inhibitors that we use? Reyataz and Prezista
Which ART class is more forgiving of non-adherence? PIs
All of this drug class are INHIBITORS of CYP 450? PIs
What is the big disadvantage of PIs? really bad long-term effects like diabetes, increased lipids, other difficult things to treat
What drug classes do we give to treatment experienced patients? fusion inhibitors and CCR5 antagonists (fuzeon and selzentry)
Which drug is dosed depending on drug interactions? Selzentry
Which drug has a black box warning for hepatotoxicity? Selzentry
Which drug is given as an injection for ART and added as salvage therapy? Fuzeon
What is the % of doses that must be taken to achieve full viral suppression? 95%
How many days can you miss of a 30 day regimen to still suppress your viral load? only 1 (only 3 in a 3 month period)
Which adverse effect is common in Retrovir? peripheral neuropathy
What is the preferred regimen of ART? 2 NRTIs + INSTI
Intelence (etravirine) NNRTI
Retrovir (zidovudine) NRTI
What is a common adverse effect of Intelence (NNRTI)? skin rash
Sustiva (efavirenz) NNRTI
Reyataz (atazanavir) PI
Truvada (tenofovir/emtricitabine) NRTI (double)
Isentress (raltegravir) integrase inhibitor
Norvir (ritonavir) PI
Trizivir (zidovudine, lamivudine, abacavir) combo of NRTIs
Fuzeon adverse effect? injection site reaction
Ziagen (abacavir) adverse effect? fatal hypersensitivity
What are the defense mechanisms for a UTI (6)? 1. micturition 2. acidic pH of urine 3. osmolality of urine 4. high concentration of urea 5. prostatic secretions 6. high organic acid concentration
What are S/S of cystitis (bladder UTI)? dysuria, frequency, urgeny, suprapubic pain, hematuria
Are vaginal irritation and discharge indicative of a UTI? no
What are S/S of pyelonephritis (kidney infection)? fever > 38C, chills, flank pain, N/V, with or without S/S of cystitis, costovertebral angle tenderness
What are some S/S that elderly might have when they have a UTI? GI symptoms, change in eating habits, altered mental status, no specific urinary symptoms
What parts of the urinalysis are most important for dx a UTI? blood, nitrites, leukocyte esterases, clarity
What does a positive nitrite level on UA tell us? that there are enterobacteria in the urine
On microscopy of urine, what two things are we looking for to dx a UTI? WBC >10 and bacteria > 10 to the fifth
When do we do a urine culture? 1. complicated, lower UTI 2. upper UTI 3. uncharacteristic symptoms 4. persisting symptoms after treatment 5. recurring UTI less than 1 month after treatment 6. prostatitis
If a young, healthy woman has classic UTI symptoms and a positive dipstick, do we need to do a urine culture? no
What are some potential bacteria that cause uncomplicated UTIs? E. coli (most common), staph saprophyticus, Klebsiella pneumoniae, proteus
What is a common contaminant bacteria that could be seen but is not the cause of UTI? staph epi
Which bacteria that causes complicated UTIs is very resistant to treatment? pseudomonas aeruginosa
Which bacteria is the most common cause of both complicated and uncomplicated UTI? E. coli
Which bacteria is the second most common cause of complicated UTI if patient is in the hospital? Enterococcus spp
When do we recommend follow-up cultures for an uncomplicated UTI? if symptoms are persisting even after 2-3 days of ABX, or they have recurring symptoms within a few weeks after treatment
When do we recommend topical estrogen for a UTI? if postmenopausal with 3 or more recurrent UTIs and they must not be on an oral estrogen
Should we recommend lactobacilli or cranberry juice for a UTI? no, there is inconclusive evidence (but it won't hurt)
When would you not recommend nitrofurantoin for a UTI? 1) if it is pyelonephritis or 2) if CrCl <60 because it works specifically in the urine
When would you not recommend Bactrim for a UTI? 1) if local resistance rates are >20% or 2) if patient has taken it in last 6 months
What is the duration of therapy for fosfomycin for a UTI? one dose
What is the duration of therapy for Bactrim (TMP-SMZ) for a UTI? 3 days
What is the duration of therapy for nitrofurantoin for a UTI? 5 days
What are second line options for treating an uncomplicated UTI? fluoroquinolones (3 days) or beta-lactams (3-7 days)
How long do we generally treat a complicated UTI for (as compared to uncomp)? 5-14 days
What is the first line treatment for complicated UTI? fluoroquinolones like levofloxacin, cipro, cipro ER
What is the class of treatment that is second line for uncomplicated but first line for complicated UTI? fluoroquinolones
When can you switch patient with comp UTI from IV to oral meds? When they are afebrile for 24-48 hours
When do we always perform a urine culture? if patient has pyelonephritis
What are the 3 oral treatment options for pyelonephritis? fluoroquinolones, TMP-SMX, beta-lactams
What are the IV treatment options for pyelonephritis? levofloxacin, ceftriaxone, ertapenem, gentamicin, ampicillin-sulbactam
How do we diagnose a catheter-associated UTI? 1) midstream voided urine when catheter has been removed within 48 hours OR 2) 10 to the third or more bacteria and one or more bacteria present in the catheter urine specimen PLUS 3) UTI symptoms
What are the 7 s/s of a CA-UTI? fever, chills, malaise, altered mental status, flank pain, pelvic discomfort, costovertebral angle tenderness (other urinary symptoms may not be present)
What 3 things are NOT diagnostic of a CA-UTI? cloudy urine, odorous urine, pyuria (pus) in the urine
Do we do UA or urine culture if the patient has a suspected CA-UTI? no because there will always be bacteria present in that case (only do it if the patient is symptomatic)
When do we do a urine culture for a catheter patient? when they have UTI symptoms, prior to treatment, and from a fresh catheter
How do we treat a CA-UTI? just like a complicated UTI; 7-14 days (fluoroquinolones or cipro)
How do we dx a male with asymptomatic bacteruria? 1) one urine sample with one bacterial species > 10 to the fifth cfu/mL or 2) one catheterized urine sample with one bacterial species >10 to the second cfu/ml
How do we dx a female with asymptomatic bacteruria? 1) two consecutive voided urine samples with the same bacterial species >10 to the fifth cfu/ml or 2) one catheterized urine sample with one bacterial species >10 to the second cfu/ml
When do we screen for a UTI? pregnant women (once early on) and prior to urologic procedures
When do we not recommend screening for asymptomatic bacteruria? pre-menopausal, non-pregnant women, diabetic women, older adults, spinal cord injuries, catheterized patients
When do we treat asymptomatic bacteruria with pyuria as a symptom? childre, pregnancy (treat 3-7 days), TURP urologic procedure patients, catheter-acquired bacteruria lasting 48 hours after catheter is removed
If a pregnant woman gets a UTI or asymptomatic bacteruria and fails to treat it, what are the consequences? stillbirth, low birth weight, prematurity
Which drug class is absolutely contraindicated for treating a UTI during pregnancy? fluoroquinolones
What are the first line treatments for pregnant women with UTIs? nitrofurantoin, augmentin (amox/clav), cephalosporins (keflex, cefpodoxime); there are no special warnings or considerations with augmentin so probably choose that one
What is the difference between a relapse and a reinfection when talking about UTIs? Reinfection: caused by different bug; usually happens more than 14 days after the last UTI Relapse: caused by the same organism; usually occurs within 14 days
If a patient is reinfected with UTI within 1-2 weeks, what do we do? treat with a broader spectrum ABX
If a patient is reinfected with a UTI within 1 month to within 6 months, what do we do? treat with first line short course therapy and do not use the original agent again
What are the biologic mediators that can prevent reinfection of UT? cranberry, d-mannose, topical estrogen
What are the behavioral changes that can help prevent a UTI reinfection? avoid tight-fitting panties, wipe front to back, avoid douching and spermicides, fluids, pee after sex, reduce or stop sex
When do we allow patients to use drugs for prophylaxis of a UTI? -3 or more UTIs in the past year -2 or more UTIs in the past 6 months - one of those must have been confirmed by culture -when non-pharmacologic measures fail
What are the regimens for single dose prophylaxis of a UTI (4)? 1) TMP 100 mg once 2) TMP-SMX Bactrim 1/2 SS tab once 3) Nitrofurantoin 50-100 mg once 4) Keflex 250 mg once
What is more effective- single dose prophylaxis or continuous prophylaxis? single dose
What is the duration for a continuous prophylaxis of a UTI? 6 months
What are the 4 regimens for continuous UTI prophylaxis? 1) TMP-SMX 1/2 SS tab daily or 3 times/week 2) Levofloxacin 500 mg daily 3) Nitrofurantoin 50-100 mg daily 4) TMP 100 mg daily
When UTIs relapse, what other issues should we consider? renal involvement, prostatitis, or structural abnormality
If a woman is experiencing UTI relapse, what do we do? up treatment time to 2 weeks; then if still relapsing, up treatment time to an additional 2-4 weeks; if still relapsing 6 weeks out, perform urology exam
What are the s/s of acute prostatitis? cloudy urine, dysuria, pelvic or perianal pain, myalgia, malaise, chills, fever, edematous or tender prostate
What is the most common bug to cause prostatitis? E. coli
Do we order urine cultures for prostatitis or not? yes (and a UA)
How long do we treat prostatitis for (either inpatient or outpatient)? 2-6 weeks
What are the treatment options for prostatitis on an outpatient basis? fluoroquinolones and Bactrim
What are the treatment options for inpatient prostatitis? treat empirically with broad spectrum beta-lactams, a cephalosporin, and + or - an aminoglycoside (adjust according to culture results)
How do we choose ABX for cystitis and pyelonephritis? -severity of infection -site of infection -classification of infection -patient factors -resistance factors
Screening and treatment for asymptomatic bacteruria is only recommended for whom? pregnant women and patients undergoing urological procedures
Is PUD more common in men than women? no; same prevalence
What are some risk factors for getting PUD? genetic predisposition, tobacco, stress, diet
What are some causes of PUD? H. pylori, NSAIDs, idiopathic, Zollinger-Ellison syndrome where acid is hypersecreted
What are some aggressive factors for PUD? gastric acid, pepsin, bile, H. pylori
What are some protective factors for PUD? bicarbonate, mucus, mucosal blood flow
Which part of the GI tract usually harbors the most H. pylori? duodenum
NSAID-induced PUD is most common in which part of the GI tract? gastric (stomach)
Stress-related mucosal damage leading to PUD is most common in which part of the GI tract? gastric (stomach)
Cardio protective doses of _____ might be gastrotoxic and cause PUD? aspirin
What are some risk factors for serious complications with PUD when using an NSAID? advanced age, concurrent corticosteroid use, concurrent anticoag use, prior hx of PUD or upper GI bleed, using other NSAIDs concurrently
Do COX-2 specific NSAIDs cause PUD? no but the risk is not zero
Does adding low dose aspirin to a COX-2 regimen harm or help the risk of PUD? it negates the benefit of taking a COX-2
How do we treat idiopathic ulcers? H2RA or PPI for 4-8 weeks
What type of bacteria is H. pylori? gram (-) spiral shaped rod
How does H. pylori cause an ulcer? it attaches to the gastric mucosa, produces large amounts of urease which hydrolyze gastric juices and convert it to ammonia and CO2
How do we acquire H. pylori? person to person transmission either fecal to oral or oral-oral
How do we dx a duodenal ulcer and gastric ulcer concurrently that are caused by gastrin-secreting tumors? serum gastrin level and secretin test
What is the gold standard for dx an ulcer? endoscopy
If receiving an endoscopy, how do we counsel patients on what to do with their PPI and/or ABX? d/c abx and bismuth prior to procedure; d/c PPI 1 week prior to procedure
What are some common causes of refractory or recurrent ulcers? noncompliance, smoking, ASA/NSAID use, presence of H. pylori
What are the typical symptoms of an ulcer? epigastric abdominal pain that is burning, discomforting, fullness, or cramping, heartburn, belching, bloating -N/V, anorexia common with gastric ulcer -nocturnal pain that awakens patient between 12 am and 3am -can be more common in spring and fall
What is a common sign of ulcer? weight loss associated with N/V and anorexia; bleeding ulcer, perforation, penetration, or obstruction
What are some common side effects of H2RAs? HA, depression, sedation, agitation, confusion, decreased platelets, galactorrhea, gynecomastia, impotence -cimetidine is the worst one because of intxns with warfarin, theo, phenytoin, propanolol
Are H2RAs safe in pregnancy? yes
Who should be cautioned before taking an H2RA? elderly, hepatic or renal dysfunction
What do we have to watch for if we recommend Zegerid OTC? metabolic alkalosis or hypocalcemia because it contains sodium bicarbonate
What are side effects of PPIs? HA, dizziness, somnolence, diarrhea, constipation, B12 deficiency, risk of fracture, possible low magnesium levels
Are PPIs safe to use in pregnancy? yes
What CYP are PPI mostly metabolized by? 2C19, some 3A4
What drugs might PPI inhibit? warfarin, diazepam, phenytoin, plavix -effects ketoconazole and tetracycline due to changes in pH
When should a patient take a PPI? on an empty stomach in the morning because that is when the gastric acid surge occurs
What kind of ulcer can we use misoprostil for? duodenal and gastric
What is misoprostil? prostaglandin analogue
What are the side effects of misoprostil? diarrhea (30-40%), abdominal pain, spontaneous abortion, infantile diarrhea if nursing mother
Who should be treated with misoprostil? -patient on NSAID and corticosteroid -patient with history of DU/GU, with or without complications, and when NSAIDs cannot be stopped
What are the disadvantages of sucralfate? need to take on empty stomach, multiple dosing, large tablet, constipation, decreases warfarin/ketoconazole/phenytoin/dig/theo/etc
What is the MOA of sucralfate? adheres to defective mucosal barrier to protect, neutralizes acid, inhibits pepsin, binds to bile salts, stimulates the production of mucus, might stimulate prostaglandin synthesis and release
What is the dosing of sucralfate? 1-2 grams 4 times daily (1 hour after meals and at bedtime)
What are side effects of antacids? hypercalcemia, hypermagnesemia, constipation (aluminum and calcium products), diarrhea (magnesium), gas (sodium bicarb), aluminum toxicity, sodium increase, hypophosphatemia, constipation is most significant
Are antacids okay to use in pregnancy? yes
What are some common drug interactions with antacids? phenytoin, warfarin, fluoroquinolones, thyroxine
What is the triple therapy regimen to eradicate H. pylori? 1) omeprazole 20 mg BID 30-60 min before meals 2) clarithromycin 500 mg BID 3) amoxicillin 1 gram BID, OR if penicillin allergy use metronidazole 500 mg BID with meals **Can use PrevPak for 7-14 days if available (amox + lansoprazole + clarithromycin)
What is the quadruple therapy regimen to eradicate H. pylori? 1) omeprazole 20 mg BID before meals 2) metronidazole 250-500mg QID with meals 3) tetracycline 500 mg QID 4) bismuth salicylate 2 tabs (524 mg) QID with meals and HS **treat for 10-14 days
What are two combo products that can be used to eradicate H. pylori? pylera and helidac
How do probiotics help with H. pylori? help control the colonization, may reduce adverse effects *lactobacillus and bifidobacterium
What are the 6 things to consider when choosing an eradication regimen for H. pylori? 1. compliance 2. cost 3. safety 4. efficacy 5. local resistance 6. prior patient exposure to abx
What are some non-pharmacologic measures for ulcers? reduce stress, reduce NSAID use, lower NSAID dose, add antacids, avoid spicy food, coffee, alcohol
What are some foods that exacerbate GERD by decreasing LES tone? peppermint, spearmint (carminatives), chocolate, fatty meals, coffee, coke, tea, citrus juices, tomato juice
What is something we can do to actually increase LES tone, thereby reducing GERD? eat high protein meals
What are drugs that decrease LES tone and cause GERD? barbituates CCB caffeine, ethanol, nicotine meperidine morphine nitrates, theo, dopamine, diazepam estrogen, progesterone
What are drugs that increase LES tone and help prevent GERD? cisapride, metoclopramide, norepinephrine, phenylephrine
What are some hormones/other substances that might cause GERD by decreasing LES tone? estrogen, progesterone, glucagon, prostaglandins
What are the 3 types of GERD? typical, atypical, complicated
What are the symptoms of typical GERD? waxing and waning heartburn, hypersalivation, belching, regurgitation, all common after a fatty meal, lying down, bending over, or shortly after eating
What are the symptoms of an atypical GERD? nonallergic asthma, chronic cough, hoarseness, pharyngitis, chest pain that mimics angina
What are symptoms of compicated GERD? continuous pain, dysphagia, odynophagia, severe esophagitis
What are some non-pharmacologic treatments for GERD? smaller meals, less fatty meals, high protein meals, don't lie down right after a meal, cut alcohol and other food factors, lose weight, control diabetes
If antacids and lifestyle changes do not relieve GERD symptoms, what are 2 other alternative regimens? 1) H2RA BID for 6-12 weeks 2) PPI QD for 4-8 weeks
What are the 4 clinical complications that we run into if we don't properly treat GERD? 1) obstructions due to stricture formation 2) chronic, low grade bleeding 3) ulcer causing perforation 4) cancer due to development of columnar lining (Barrett's esophagus)
Created by: laellagem6