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CK E3
| Question | Answer |
|---|---|
| digoxin has ___ compartment model | 2 |
| are digoxin loading doses recommended in HF? | NO |
| what is digoxin used for? | controlling ventricular rate in AFib |
| are Digoxin loading doses given all at once and why? | because 2 compartment model, long distribution phase a large Vd |
| what is the initial Digoxin loading dose and the following doses? | 0.25-0.5 then 0.25 q6h for total of 0.75-1.5 |
| what is the absolute max loading dose? | 1.5 |
| does obesity have impact on Digoxin? | no, because it distributes into lean tissues |
| what weight is used for digoxin? | IBW, unless Actual is less than IBW then use TBW |
| what happens to the loading dose if pt has impaired renal function? | decrease total LD by 50% |
| what are lab abnormalities that make pt more sensitive to Digoxin and what should you do? | Hypokalemia, hypomagnesemia, hypercalcemia. lower doses used |
| what is the oral maintenance dose for adults with normal renal function? | 0.125-0.25 mg po qd |
| what are the steps for determining dose in HF pts? | CrCl--> IBW --> Daily dose |
| safety monitoring for Digoxin? | BMP: Scr, K, Ca, Mg |
| when to get digoxin levels? | -initially starting, annually for stable pts, acute illness, concern for toxicity, change in renal function, drug interactions |
| what is the digoxin half life and when is steady state reached? | half life is 36hr, Steady state is reached in 3-5 t1/2= 108-180 hrs -5-7 days for normal renal function pts -2-3 wks for significant renal dysfunction |
| what happens if level is draw before SS? | falsely low |
| what happens if level is draw before the distributions phase had ended? | falsely high, wait at least 8 hours until after dose is given |
| what is digoxin's therapeutic range for HF | 0.5-0.9 |
| what is digoxin's therapeutic range for Afib | 0.5-2 (1.2 is ideal because higher than that has been associated with increased mortality) |
| s/sx of digoxin toxicity | GI: N/V CNS: confusion, vertigo, dizziness Vision: yellow/ green halos Cardio: Vent Tachy Electrolytes: hyperkalemia |
| digoxin toxicity can occur in pts with____ | normal therapeutic range usually in those with low K, Mg |
| risk factors for D tox | elderly, impaired renal function, hypokalemia, hypomagnesemia |
| digoxin toxicity antidote | DigiFab , Digoxin immune Fab |
| what are two types of D toxicity | acute, chronic |
| what are two DigiFab indications? | D conc above 10 after distribution phase OR >15 at any time Acute ingestion >10mg for adults |
| should digifab bw given to pt without s/sx of acute toxicity? | no, unless there is confirmed acute ingestion |
| DDI: NDH-CCB | V & D increases digoxin |
| DDI: amiodarone | increase D 2-3x above baseline--> decrease D dose by 20-50% if adding amiodarone |
| DDI: erythromycin, clarithromycin, tetracycline | increase D conc |
| DDI: Al containing products | decrease D absorption --> separate by 2 hours |
| DDI: cholestyramine | decrease D absorption |
| DDI: NSAIDs | increase D conc |
| DDI: Loop diuretics | increase risk for D toxicity |
| is amiodarone therapeutic monitoring routinely recommended? | no |
| amiodarone is the DOC in ___ pts | HF |
| consider d/c Amio | if hepatic enzymes are >3x UNL |
| is amio renally adjusted | NO |
| amiodarone organ system toxicity | pulmonary, hepatic, cardiac, renal |
| amiodarone is contraindicated in which population | ***iodine allergy 2/3rd degree heart block bradycardia causing syncope cariogenic shock |
| amiodarone monitoring | LFT, PFT, CxR, eye exam, TSH, EKG |
| amiodarone is a common _____ inhibitor | CYP |
| PD interactions with amiodarone | other drugs that decrease HR, prolong QTc |
| amiodarone DDI: digoxin | increase D, decrease D by 25-50% |
| amiodarone DDI: warfarin | increase W, decrease W dose by 30-50% |
| amiodarone DDI: simvastatin and lovastatin | increase statin, max simvastatin dose is 20, max love is 40 |
| amiodarone DDI: GFJ | increase Amio conc, avoid use together |
| Lithium shares properties of | physiological cations (Na/K) |
| changes in fluids and Na balance | can effect PK and drug interactions |
| what is lithium half life | ~5 days |
| is lithium renally dose adjusted ? | yes |
| what is the acute mania lithium levels? | 0.8-1.5 |
| what is the maintenance lithium levels? | 0.6-1 |
| when do you obtain trough conc for lithuim | right before the next dose after SS has been reached |
| Lithium SE | GI upset N/D, cogwheel rigidity, fine hand tremor, weight gain, hypothyroidism |
| what are lithium levels for mod toxicity | 1.5-2.5 |
| what are lithium levels for severe toxicity | >2.5 |
| Lithium DDI: thiazide | increase L conc --> inc risk of L toxicity |
| Lithium DDI: loop diuretics | may inc or dec L conc |
| Lithium DDI: ACE/ARB/ARNI | increases L conc --> inc risk of L toxicity |
| Lithium DDI: decreased salt intake/ dehydration | increase L conc --> inc risk of L toxicity |
| Lithium DDI: NSAID | increase L conc --> inc risk of L toxicity (only NSAID that can be used with L is sulindac) |
| Lithium DDI: theophylline | dec L conc |
| Lithium DDI: increased salt or caffeine intake | dec L conc |
| theophylline is structurally similar to what | caffeine |
| is theophylline distributed into fatty tissues | no! (IBW is used unless TBW is less, then TBW is used) |
| is theophylline renally eliminated | no |
| how long is the half life for theophylline | 1-2 days |
| ciprofloxacin (strong cyp inhibitor) does what to theophylline | increase T conc |
| strong cyp inducers does what to theophylline | decrease T conc |
| what is the conversion factor when converting from aminophylline to theophylline | multiply A by 0.8 |
| theophylline levels | 5-15 |
| do you measure peak levels with theophylline | yes, after SS, typically wait at least 2 days |
| theophylline toxicity symptoms | N/V, tachycardia/ palpitations, tremors |
| what is phenytoin loading dose | 20mg/kg |
| can phenytoin IV/PO doses be given all at once | IV can be given at once, oral not all at once because it is rate-limited GI absorption or oral phenytoin |
| what is the max phenytoin oral dose to be administered at once | 400 mg, given in multiple doses separated by 2 hours |
| what is the total phenytoin therapeutic conc | 10-20 (both bound and unbound) |
| what is the total free phenytoin therapeutic conc | 1-2 mg measures only FREE drug |
| when to draw phenytoin levels | -after loading dose (IV-wait at least 2 hr after end of infusion) (PO- wait at least 24 hours after last dose-Loading dose is administer over 6-8hrs) -after mtn dose initiation (trough q3-4 days until stable) -when there is a chance in status of pt |
| when to draw phenytoin trough levels for stable pts | 3-12 months |
| what are some factors that can alter phenytoin protein binding | -hypoalbuminemia (liver disease, burn,trauma,malnourishment, elderly) -displacement by endogenous cmpds(hyperbilirubinemia, ESRD) -displacement by exogenous cmpd (warfarin, valproic acid) |
| what happens to phenytoin in altered conditions | conc increase in the extravascular space |
| who should FREE phenytoin levels be recommended for? | -when the pt has altered protein binding (especially when change is first noted--> after can obtain total level is acceptable) -total P levels don't correlate with clinical status -critically ill with suspected PB |
| what is the serum albumin for hypoalbuminemia | <3.5 |
| phenytoin toxic conc | ->20 nystagmus ->30 ataxia, N/V ->40 mental status change and CNS depression |
| phenytoin DDI: valproate | increases P conc |
| phenytoin DDI: oral contraceptive | dec oral contraceptive conc, recommend alternative contraception method |
| phenytoin DDI: carbamazepine | can inc or dec P conc dec carb conc |
| phenytoin DDI: warfarin | inc or dec anticoagulant effect, inc P conc |
| phenytoin DDI: lamotrigine | dec lamotrigine conc |
| what gene do we test for carbamazepine? | HLAB *1502 |
| if the pt is postive for HLAB *1502, what do you do | AVOID carbamazepine |
| what is unique about carbamazepine weekly doses | increase dose every week |
| what is carb therapeutic levels | 4-12 mg/L |
| when to draw carbamazepine levels | -w/i 3-5 days after starting drug -again after auto induction is complete (3-5 wk) -change in status (DDI, pt status, or dosing) |
| when to draw carbamazepine levels in stable pt | 3-12 m |
| carbamazepine DDI: valproate | increases carb active metabolite conc |
| carbamazepine DDI: oral contraceptive | dec oral contraceptive effectiveness |
| carbamazepine DDI: phenytoin | inc or dec phenytoin conc dec carb conc |
| carbamazepine DDI: warfarin | dec anticoagulant effect (dec INR) |
| carbamazepine DDI: lamotrigine | dec lamotrigine conc |
| when calculating dose for valproate what body weight is used | actual body weight |
| how do you titrate dose for valproate | increase dose weekly |
| how long until the mtn dose is reached | 4-6 weeks after initiation |
| in what pt population do we avoid valproate | severe liver disease |
| what is valproate therapuetic level | 50-100 |
| when to draw valproate levels | -pt is at SS on mtn dose (reached in about 2-4d after mtn dose is achieved) -morning levels drawn right before next dose (level fluctuation AM/PM) -when there is a change in pt status |
| when to draw valproate levels in stable ambulatory pts | 3-12 m |
| what are factors that affect valproate protein binding | -hypoalbuminemia (liver disease, burn,trauma,malnourishment, elderly) -displacement by endogenous cmpds(hyperbilirubinemia, ESRD) -displacement by exogenous cmpd (warfarin, phenytoin) |
| pt with altered protein binding on VA would be expected to have ___ and be at risk ____ | higher free conc ; for toxicity even with normal total conc |
| valproate toxicity | 75-100 ataxia, sedation 100-175 tremor >175 stupor, coma |
| valproate DDI: lamotrigine | inc lamotrigine conc |
| valproate DDI: estrogen- containing contraceptive | dec in VPA conc |
| beta-lactam pk/pd parameters | % time over MIC |
| what is aminoglycosides PK/PD | Cmax/MIC |
| what is vancomycin PK/PD | AUC/MIC |
| what is BL PK/PD | time /MIC |
| what is PK/PD target for cefepime | 60% >MIC |
| what is PK/PD target for ertapenem | 40%> MIC |
| what is PK/PD target for ampicillin-sulbactam | 50%>MIC |
| for BL free drug conc must remain ___ MIC to effectively kill pathogens | above |
| what two infusion methods are recommended for BL | extended and continuous |
| for example: zosyn is primarily adminstered through the | extended infusion |
| what happens when you inc dose of BL | higher risk for ADR which are peak dependent |
| what happens when you give BL more frequently | increases efficacy with lowest risk for ADR |
| which BL require NO renal dose adjustment | ceftriaxone, oxacillin |
Created by:
reynaaltayawi