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Quiz 7

GI/GU/Reproductive Study guide

QuestionAnswer
Antacid mechanism: direct buffering of stomach acid
Alginates create a layer of foam, (example Gaviscon)
Antacid dosing variable but generally qid prn
Adverse effects of Ca and Al antacids constipation
Adverse effects of magnesium antacids diarrhea
Adverse effects of electrolyte imbalance in renal impairment cognitive problems (aluminum and magnesium toxicity), osteomalacia, and tetany (hypercalcemia)
Drug interactions for antacids Quinolone/tetracycline antibiotics (separate by 2 hours), phenytoin, levothyroxine, iron supplements
H2 Antagonists famotidine (Pepcid) nizatidine (Axid) ranitidine (Zantac) cimetidine (Tagamet)
H2 antagonist mechanism block histamine H2 receptors on gastric parietal cells, decrease secretion of stomach acid
Famotidine dosing GERD 10-40 mg bid PUD 20-40mg qd
Nizatidine dosing GERD 75-100 mg bid PUD 150 mg qd- bid (300mg qd)
Ranitidine dosing GERD 75-300 mg bid (300 mg qd) PUD 150 mg qd bid
Cimetidine dosing GERD 200-800 mg bid (400 mg qid) PUD 400 mg qd-bid
Adverse effects of H2 Antagonists headache, dizziness, diarrhea/constipation, cognitive impairment/agitation
H2 antagonist drug interactions Ketoconazole/itraconazole (antifungals), calcium/iron, CYP1A2 and 2C9/19 substrates (Tagamet specifically, will affect theophylline and warfarin), CYP3A4 and 2D6 (cimetidine specifically) substrates with narrow therapeutic index
Cimetidine is the most potent enzyme inhibitor of the H2 antagonists T/F True- Famotidine least likely for drug interactions.
Off label use for Cimetidine Treatment of warts
Proton Pump Inhibitors (PPIs) omeperazole (Prilosec) lansoprazole (Prevacid) pantoprazole (Protonix) rabeprazole (Aciphex) esomeprazole (Nexium)
PPI Mechanism Irreversibly inhibits H/K ATPase (aka proton pump) Decreases production of stomach acid
PPI dosing for GERD usually once a day dosing is sufficient, may do twice a day dosing for nocturnal symptoms (severe cases only)
PPI dosing for PUD induced by H pylori Use twice day dosing because it enhances benefit of antibiotic
PPI adverse effects diarrhea/constipation, nausea/abdominal pain, pernicious anemia (low B12), and gastric carcinoma
PPI drug interactions Ketoconazole/itraconazole, calcium/Iron, CYP2C19 substrates (warfarin)
PPI onset 12-24 hours
Prokinetics (improve motility) Metoclopramide (Reglan), Erythromycin, Bethanechol
Prokinetic Mechanism Metoclopramide- dopamine antagonist centrally, potentiates Ach peripherally Erythromycin- Motilin receptor agonist Bethanechol- Ach agonist
Prokinetic dosing Before meals and hs
Adverse effects-Reglan Sedation, confusion, fatigue, nausea/vomiting, abdominal pain, diarrhea, extrapyramidal sx., pseudoparkinsonism, akathesia, increased prolactin (gynecomastia, impotence, breast enlargement, galactorhea), and neuroleptic malignant syndrome
Erythromycin adverse effects nausea/vomiting, abdominal pain, diarrhea (C-diff), rashes, urticaria, QT prolongation, drug resistance
Bethaechol adverse effects Cholinergic (hypersecretion, sweating bronchoconstriction, orthostasis, etc.) Contraindicated in asthmatics
Metoclopramide drug interactions Dopamine agonists/antagonists, anticholinergics, CNS depressants
Erythromycin drug interactions CYP3A4 substrates, anything with QT prolongation, anything with narrow drug range, such as: theophylline, warfarin, digoxin, lithium...
Bethanechol drug interactions anticholinergics, cholinesterase inhibitors (example: Aricept)
Why would you choose prokinetics All are reserved for symptomatic failure of acid-suppressing therapy. Reglan is generally chosen first, fewer GI side effects
Antibiotic combos for H pylori infection 3 drug regimin Clarithromycin, Amoxicillin, Lansoprazole (PrevPac) X 7-14 days Substitute metronidazole for PCN allergy
H pylori 4 drug regimen Metronidazole, tetracycline, bismuth, PPI X 10-14 days
Sequential therapy for H pylori Amoxicillin, PPI X 5days, then Clarithromycin (Biaxin), tinidazole, PPI X 5days (Reserve quinolones (levofloxacin) to avoid resistance)
Sucralfate (Carafate) mechanism reacts with stomach acid to form adherent paste, preferentially binds to damaged tissue (liquid bandaid)
Sucralfate dosing 1 g ac, hs; 1 g bid for maintenance
Carafate adverse effects Constipation, aluminum toxicity in severe renal patients, hypophosphatemia
Carafate drug interactions Similar to aluminum antacids, acid suppressants
Loperamide (Imodium) mechanism Inhibits peristalsis, opiate agonist, anticholinergic antagonist
Loperamide dosage may be used if afebrile and lacking bloody stools, 4 mg initially, then 2 mg after each loose stool, not to exceed 8-16 mg/day. Use less than 48-72 hours
Loperamide adverse reactions constipation, dizziness, drowsiness, fatigue (not recommended for children less than 2-6)
Bismuth Subsalicylate (Pepto) mechanism decreased prostaglandin production, mucosal protection
Pepto uses Can reduce number of stools by 50%, travelers diarrhea prevention
Pepto dosage 524 mg every 30 to 60 minutes not to exceed 8 doses
Pepto adverse reactions Caution in pregnancy and nursing, constipation, black tongue or stool (harmless)
Pepto interactions Salicylates *adverse effects increased, Reye's syndrome, not recommended under age 12
Diphenoxylate/Atropine Lomitil
Lomotil Mechanism Inhibits peristalsis, opiate agonist, anticholinergic only to limit abuse.
Lomotil dosage 5mg 3-4 times daily, reduce and/or discontinue ASAP, not recommended in children less than 2
Lomotil (diphenoxylate) adverse reactions nausea, constipation, dizziness, drowsiness, anticholinergic effects
Lomotil (diphenoxylate) drug interactions CNS depressants, anticholinergics, MAOIs
First line agent for diarrhea Loperamide Imodium
Fiber intake should be 20-30 grams/day
Bulk-forming fibers drug interactions Digoxin, warfarin
Emollients (stool softeners) Docusate salts
Docusate mechanism anionic surfactant, allows easier penetration of water into the stool
Docusate uses best for prevention, effect takes 1-3 days, used often in pregnancy and postpartum, post-cardiac surgery
Docusate dosing 50-250mg daily
Docusate interactions mineral oil
Mineral oil (lubricant) mechanism softens fecal content by coating, inhibits colonic resorption of water
Mineral oil uses fecal impaction (onset 6-8 hours)
Mineral oil dosing 15-45 ml
Mineral oil drug reactions Inflammatory reaction in intestines, liver and spleen, can be aspirated, not usually recommended
Mineral oil drug interactions fat soluble vitamins
Hyperosmotic/Saline Choices OTC- glycerin suppository, sorbitol oral, mag salts, Na Phosphate oral Rx- Sorbitol, Lactulose, Polyethylene glycol
Bedwetting is defined at what age Age 5 years and beyond
Imipramine Tofranil Tricyclic antidepressant
Tofranil (imipramine) First drug used to treat bedwetting, relaxes bladder muscle and may lighten sleep, success 10-50%, maximal effects achieved in a few days, relapse rate high when discontinued.
Tofranil (imipramine) considerations used in children over 6, only available in capsule or tablet form, inexpensive
Tofranil (imipramine) dosage 7-8 years (25 mg given one hour before bed 9 years and older (50 mg-75mg one hour before bed)
Imipramine side effects anxiety, irritability, insomnia, loss of appetite, tachycardia, blurred vision, dry mouth, constipation, weight gain, hypotension
Imipramine major danger accidental overdose (irreversible heart block) adult should administer and be kept out of child's reach
Desmopressin (DDAVP) Synthetic vasopressin- reduces urine production
DDAVP indication children 6 years and older with primary nocturnal enuresis.
DDAVP nasal spray banned in 2007- deaths due to hyponatremia
DDAVP response rate high (70-90%) good for episodic use such as summer camp, expensive and relapse rate is 95%
DDAVP dosage start with dose of .2mg and titrate up to a max of .6mg, titrate until child completely dry at night. Parent should not titrate until speaks to provider. Duration of medication is controversial but 6 months to 4-8 weeks.
DDAVP adverse effects headaches, facial flushing, nausea, hyponatremia
Stress incontinence first line treatment alpha adrenergic agonists
Stress incontinence second line treatment estrogen in postmenopaussal women- alone or together with alpha adrenergic agonists
Stress incontinence Cymbalta (duloxetine)
Urge incontinence first line treatment anticholinergics
Urge inontinence second line treatment estrogen in postmenopausal women
Mixed incontinence treatment agent that treats the predominant symptom
overflow incontinence treatment drugs are not indicated- surgery is indicated
antimuscarinics are also called: anticholinergics
Muscarinic action decrrease heart rate and force of contraction, constricts airways, dilates blood vessels, increase activity of he stomach, intestines, bladder, salivary, lacrimal, and sweat glands.
urge incontinence treated with muscarinic antagonists
Muscarinic antagonists adverse reactions (think of atropine) cognitive impairment, tachycardia, pupil dilation, blurred vision, restlessness, mouth dryness, urinary retention, increased salivary and respiratory secretions and perspiration
First Generation Muscarinic antagonists Oxybutynin (Ditropan, Ditropan XL) Tolterodine (Detrol, Detrol LA)
Second Generation Muscarinic antagonists Darifenacin (Enablix) Solifenacin (Vesicare) Trospium (Sanctura)
Oxybutynin (Ditropan) first drug of choice available in short release, extended release and transdermal patch
Ditropan indications improves total bladder capacity, neuropathic voiding dysfnction, and bladder filling pressure/ uaed to depress uninhibited detrusor contractions in patients with and without neurogenic bladder dysfunction.
Tolterodine (Detrol/Detrol LA)indications overactive bladder symptoms of urinary frequency or urge incontinence, as effective as oxybutynin
Detrol dosing twice daily dosing, fewer problems with dry mouth
Solifenacin (Vesicare) indications overactive bladder with symptoms of urinary incontinence
Vesicare adverse effects QT interval prolongation in patients on medications who also have this property
Darifenacin (Enablix) indications treatment of overactive bladder with symptoms of urinary incontinence, urgency, and frequency
Trospium chloride (Sanctura) indications management of overactive bladder and urge incontinence, has fewer cognitive effects
Tricyclic antidepressants effective for urge and mixed incontinence, increases urethral outlet resistance by adrenergic simulation of smooth muscle of the bladder neck and proximal urethra, assist urine storage by decreasing bladder contractility.
Tricyclic antidepressant drug of choice Imipramine (Tofranil) sedating effects, take at night
Tofranil contraindications may not use within 14 days of MAOI, death may occur
Tricyclic antidepressant adverse, effects: orthostatic hypotension, cardiac conduction abnormalities, dizziness, confusion, potentially life-threatening overdose. limit to individuals who have one or more medical indications
alpha adrenergic agonists for stress incontinence 1. bind with a receptor and initiate the same activity produced by endogenous substance 2. receptors regulate sympathetic innervation of the neck of the bladder 3. contract the smooth muscles of the GU tract
Alpha adrenergic agonist example pseudophedrine (Sudafed)
Sudafed dosage 15-30 mg TID only modestly effective
Sudafed contraindications Severe HTN, coronary artery disease, use with caution in HTN, DM, BPH, hyperthyroidis, increased intraocular pressure.
Alpha adrenergic agonists adverse effects hypertension, nausea, insomnia, rash, itching, headache, anxiety, and dizziness
Estrogen for stress incontinence adjunct therapy in stress incontinence and urethral underactivity
estrogen actions increases urethral vascularity and tone, enhances alpha adrenergic responsiveness of urethral muscle in postmenopausal women
Estrogen usage use only topical products, best justified if woman also has urethritis or vaginitis
Serotonin- Norepinephrine Reuptake Inhibitor SNRI- Duloxietine Cymbalta
Cymbalta used for stress incontinence
Cymbalta approved for depression and diabetic neuropathy, currently off-label for stress incontinence
Cymbalta action on urinary system increases urethral and external urethral sphincter muscle tone during storage phase
Cymbalta precautions avoid with severe renal or hepatic impairment, avoid in pregnant or breastfeeding, discontinue gradually, avoid in all patients who have taken MAO inhibitors within 14 days
Cymbalta adverse effects (CNS) suicidal thoughts, anxiety, agitation, aggressiveness, engaging in unusual or dangerous activities
Cymbalta adverse effects (Serotonin syndrome) rare Confusion, hallucinations, agitation, tachycardia, BP changes, arrhythmias, nausea, vomiting, diarrhea, overactive reflexes, fever, sweating, shivering, shakiness, seizures, coma
Cymbalta most common side effects nausea, vomiting, decreased appetite, drowsiness, headaches, dry mouth, diziness, insomnia, constipation or diarrhea, fatigue and weakness, cough, sore throat, or runny nose, sweating, decreased libido and other sexual adverse effects.
Vascular causes of Erectile dysfunction compromise of vascular flow such as HTN, PVD, arteriosclerosis
Neurologic causes of ED impaired nerve conduction to the bain or to penis
Hormonal causes of ED sub-physiologic levels of testosterone
Psychogenic causes of ED depression, performance anxiety, sedation, alzheimer's disease, hypothyroidism, mental disorders
Social causes of ED cigarette smoking, excessive alcohol intake because excessive alcohol intake can lead to (androgen deficiency, peripheral neuropathy, chronic liver disease)
anticholinergics that cause ED antihistamines, tricyclic antidepressants
Dopamine agonists that cause ED Reglan
Beta blockers that cause ED atenolol, metoprolol
centrally acting agents that cause ED clonidine, methyldopa
Other drugs that cause ED Digoin, peripherally acting sympatholytics (rarely ued) spironolactone (Aldactone)
Thiazide diuretics that cause ED HCTZ, chlorthalidone
Selective norepinephrine reuptake inhibitors that cause ED Cymbalta, Effexor
Antipsychotics that cause ED Thorazine, Prolixin, Haldol
Anticonvulsants that cause ED Dilantin Tegretol, and Lithium Carbonate
Other drugs that can cause ED Proscar, Avodart, alcohol, cimetidine (Tagamet), Opioids, Hormones, corticosteroids, estrogens, and anti-androgens
First line therapy for ED Sildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis)
PDE-5 inhibitor mechanism Nitric oxide is released during sexual stimulation, this enhances ability to produce cGMP, cGMP dilates vessels and enhances arterial flow to the corpora cavernosa and enhaces blood filling of cavernosal sinuses
Patient education on PDE-5 inhibitor take Viagra on an empty stomach at least 2 hours before meals, avoid fatty meals before taking Viagra or Levitra, try the drug 5-8 times before declaring failure.
Vardenafil (Levitra, sidenafil (Viagra) pharmacokinetics 1 hour onset of action short duration of action (4-5 hours) oral absorption delayed if taken within 2 hours of a fatty meal avoid alcohol due to orthostatic hypotension
Tadalafil (Cialis) pharacokinetics 2 hour onset of action,, prolonged duration of action up to 36 hours, food does not affect rate of absorption
PDE-5 Inhibitor dosing Take no more than is prescribed, take only once per day
PDE-5 Inhibitor dosing special considerations elderly patients, hepatic dysfunction, renal dysfunction, P450 3A4 inhibitors such as cimetidine, erythromycin, clarithromycin and ketoconazole
PDE-5 Inhibitor adverse effects (In order of frequency) headache, flushing, flu-like symptoms, dyspepsia, myalgia, abnormal vision, back pain, ischemic optic neuropathy (Lead to permanent vision loss)
Priapism Erection lasting longer than 4 hours (rare) associated with excessive doses or concomitant therapy
Vardenafil (Levitra) and sidenafil (Viagra) hypotension -decrease systolic 8-10 mm Hg and diastolic 5-6 mm Hg. -Starts 1 hour after dose -Lasts 4 hours -May cause clinical hypotensive problems in patients on multiple antihypertensives or nitrates.
Vardenafil (Levitra) and sidenafil (Viagra) temporary vision changes -Sensitivity to light -Blurred vision -Loss of blue-green color discrimination
Tadalafil (Cialis) adverse effects Lower back and limb pain- dose related
PDE-5 Inhibitor drug interactions Nitrates May cause severe hypotension Withhold for 24 hrs after sildenafil or vardenafil and for 48 hrs after tadalafil
PDE-5 inhibitor and treatment of angina use non-nitrate containing agents such as calcium channel blockers, beta blocker, or morphine
May prescribe PDE-5 inhibitors to: 1. symptomatic CV disease with less than 3 CV risk factors 2. Well controlled HTN 3. Mild, stable angina 4. Mild heart failure (Class 1) 5. Mild valvular heart disease 6. MI greater than 6 weeks ago
Diagnose low testosterone level by monitor first morning serum testosterone
Adverse effects of low testosterone Na retention and weight gain, exacerbation of HTN and heart failure, lipid profile changes
BPH benign prostatic hyperplasia
Prostate gland anatomy normal adult prostate- size of walnut, surrounds neck of bladder and urethra
Prostate function Secrete seminal fluid
Prostate enlargement affects half of men in their 60s and as many as 90% in their 70s and 80s.
As BPH worsens: the bladder wall becomes thicker and irritable, begins to contract even when it contains small amounts of urine, causing more frequent urination, eventually weakens and loses the ability to empty causing urinary retention.
AUA Symptom Score for BPH Score 1-7 mild score 8-19 moderate score 20-35 severe
AUA recommends that the symptom scale be used: at initial assessment and then to follow the course of illness and therapy along with PSA levels
Substances that exacerbate BPH Alcohol, coffee, high intake of butter and margarine
Substances that improve BPH Green tea, soy and high intakes of fruits
Medications that exacerbate BPH Decongestants, Antihistamines, diuretics, and antidepressants
Alpha adrenergic antagonists pharmacology antagonists stop or slow down the natural alpha adrenergic fight or flight reactions; constrict the blood vessels in the skin, digestive tract, and urinary tract; dec. activity of the stomach & intestines; & contract the smooth muscle in genital& urinary
Alpha Adrenergic Antagonists include terazosin (Hytrin) doxazosin (Cardura) prazosin (Minipress) tamsulosin (Flomax) (These are functional anti-hypertensives)
Alpha Adrenergic antagonist adverse effects orthostatic hypotenion, syncope, dizziness, should begin with a low dose and increase incrementally.
Side effects of Flomax tiredness, asthenia, ejaculatory dysfunction, flu-like symptoms, and nasal congestion
Dosage of Alpha Adrenergic antagonist one tablet qhs
5 (alpha) reductase inhibitors mechanism of action -testosterone is converted to DHT, which stimulates prostate growth -converion is facilitated by 5 alpha reductase -agents that suppress androgen action will induce prostate atrophy -reduction in volume and sx may not be for 12 months
5 alpha reductase inhibitors finesteride (Proscar) dutasteride (Avodart) flutamide (Eulexin) leuprolide (Lupron)
finasteride (Proscar) mechanism halts disease progression, decreases the size, increases urine flow in most patients, reduces risk for acute urinary retention and surgery, recommended for long term therapy
finasteride (Proscar) adverse effects does not affect libido or spermatogenesis
dutasteride (Avadart) has same indication and effects as Proscar: adverse effects impotence, decreased libido, ejaculation disorders, gynecomastia
flutamide (Eulexin) inhibits binding of androgen to its receptors: adverse effects nipple tenderness, decreased libido, diarrhea **use in patients unable to tolerate finasteride**
leuprolide (Lupron) adverse effects hot flashes, loss of potency **Reserved for patients with prostate cancer**
In the treatment of BPH what is the first line of choice drugs: Alpha adrenergic agonists, they are faster and more effective than a 5 alpha reductase inhibitor, more effective in reducing lower urinary tract sx., no effect on PSA, associated with less sexual dysfunction.
Which drug therapy is best for significantly enlarged prostate and people that cannot tolerate the cardiovascular side effects of alpha adrenergic antagonists 5 alpha reductase inhibitors
Combination therapy good first choice for: patients with an enlarged prostate greater than 40 grams and an elevated PSA greater than or equal to 1.4 ng/mL
Monitoring patients with BPH and medications -monitor BP during the first 2 wks of tx. -attend to subjective complaints of sexual dysfunction (biggest reason for non-compliance) -evaluate success of therapy by the reduction of symptoms
Main cause of UTI in children E-coli causes 85% of UTIs in children
Infants younger than 3 months with a UTI Refer for admission for parenteral antibiotics
First line antibiotics for 1st UTI in children Suprax 16mg/kg/day Day 1 BID, thereafter once daily
Cephalexin (Keflex) 25-100mg/kg/day low cost QID dosing
Sulfamethoxazole/Trimethoprim (Bactrim, Septra) 6-10mg/kg/day moderate cost BID dosing Use with caution in jaundiced infant (will refer anyway)
Amoxicillin is no longer recommended for UTI because increased incidence of resistance to E coli
Second line treatment of UTI in children less than 12 Nitrofurantoin (Macrodantin) Ciprofloxin (Cipro)
Nitrofurantoin (Macrodantin) 5-7mg/kg/day unpleasant taste low cost may be useful in older children
Ciprofloxin (Cipro) 20-30mg/kg/day approved as 2nd line for complicated UTI in children greater than 1 year High cost Causes antibiotic resistance Black box warning: high risk of tendinitis and tendon rupture.
Treatment of UTI in pregnancy After C & S First line (5 to 14 days)- Nitrofurantoin, cephalosporin Other drugs- sulfonamides (avoid in mothers with G6PD deficiency, avoid in late pregnancy (neonatal hyperbilirubinemia) **PCN no longer best choice due to E coli resistance**
Guidelines for treating uncomplicated UTI in non-pregnant women First line TMP-SMX DS (Bactrim, Septra) Trimethoprim Fluoroquinolone (Cipro) Macrodantin or Macrobid Fosfomycin tromethamine (Monural)
Bactrim, Septra BID for 3 days- check for sulfa allergy
Trimethoprim BID for 3 days- give this with sulfa allergy
Cipro (fluoroquinolone) BID for 3 days
Macrodantin or Macrobid 7 days
Fosfomycin tromethamine (Monural) single dose
Because of resistance do not use: 1st generation cephalosporin and amoxicillin
Once daily treatment for frequent UTIs nitrofurantoin, norfloxacin, ciprofloxacin, trimethoprim TMP-SMX DS (Bactrim/Septra)
How often do you re-evaluate the need to continue daily antibiotics in frequent UTI patients after 6-12 months
Pyridium Use with antibiotic to relieve discomfort NO benefit after 2 days Pregnancy category B
Pyridium dosage 200mg TID after meals Makes urine orange or red and may stain fabric May stain contact lenses
Acute bacterial prostatitis outpatient therapy all therapy is BIDD X 4 weeks
First line treatment for prostatitis Ciprofloxacin (Cipro) Ofloxacin (Floxin)
Treatment for prostatitis if allergic to quinolones TMP-SMX DS or TMP (Bactrim or Septra)
First line treatment for chronic prostatitis TMP-SMX other drugs used to treat: Norfloxacin Carbenicillin (Geocillin) Ofloxacin (Floxin) Minocycline Cephalexin
Acute epididymitis If caused by GC or chlamydia, follow CDC recommendations. If allergic to cephalosporins or tetracyclines: use ofloxacin or levofloxacin
Acute epididymitis- Ofloxacin BID for 10 days
Acute epididymitis- levofloxacin daily for 10 days
Timeline of Menstrual cycle Day 1-28
Day 1 Menstruation begins
Day 3-5 FSH rises, initiating follicle growth
Day 6-7 LH begins to rise, estrogen follows suit, endometrium begins to thicken
Day 10-12 Estrogen peaks
Day 13-14 FSH, LH spike (pre-ovulatory surge)
Day 14 Ovulation
Day 15-16 Estrogen and progesterone rise
Day 21-22 Corpus luteum begins to degenerate, estrogen peaks and begins rapid fall, progesterone begins slow fall
Day 27-28 Endometrium begins to degenerate
Created by: 1096147201
 

 



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