CMPC Study Guide exam with complete solutions 2024, Exams of Sports Psychology

Download CMPC Study Guide exam with complete solutions 2024 and more Exams Sports Psychology in PDF only on Docsity! Advanced jPharmacology jNSG j533 jexam jwith jcomplete jsolutions j2024 EP jis ja j38-year-old jfemale jpatient jthat jcomes jin jfor jdiabetes jeducation jand jmanagement. jShe jwas jdiagnosed j12 jyears jago jand jstates jlately jshe jis jnot jable jto jcontrol jher jdiet jalthough jshe jcontinues ja j1600 jcalorie jdiet jwith jappropriate jdaily jcarbohydrate jintake j(per jdietitian jprescription) jand jwalks j40 jminutes jevery jday jof jthe jweek. jShe jstates jcompliance jwith jall jmedications. jShe jdenies jany jhistory jof jhypoglycemia jdespite jbeing jable jto jidentify jsigns jand jsymptoms jand jdescribe jappropriate jtreatment jstrategies. PMH: jT2DM, jHTN, jobesity, jdepression, js/p jthyroidectomy jdue jto jthyroid jcancer FmHx: jNoncontributory SHx: j(−) jSmoking, jalcohol juse, jpast jmarijuana juse jwhile jin jhigh jschool Medications: jMetformin j850 jmg jtid, jglipizide j20 jmg jbid, jlisinopril j20 jmg jdaily, jsertraline j100 jmg jdaily, jmultivitamin jdaily Vitals: jBP j128/82 jmg jHg; jP j72 jbeats/min; jBMI j31 jm/kg2 Laboratory jtest jresults: jNa j134 jmEq/L, jK j5.4 jmEq/L, jCl j106 jmEq/L, jBUN j- jANSWER✓✓-Exenatide j- jExenatide j(Bydureon) jonce jweekly jhas jbeen jable jto jdemonstrate jweight jloss jand jdecrease jA1C% jby j0.7% jto j1.2% jin jclinical jtrials; jhowever jit jis jcontraindicated jfor jEP jdue jto jthe jself-reported jhistory jof jthyroid jcancer. Dapagliflozin j- jDapagliflozin j(Farxiga) jis jcontraindicated jin jthis jpatient jdue jto jhyperkalemia jwhich jcould jbe jmade jworse jby jthis jdrug. jThe jpackage jinsert jdoes jnot jindicate ja jspecific jpotassium jconcentration jcut joff jto jno jlonger juse jthis jmedication; jhowever, jthere jare jbetter jchoices jin jthis jpatient. Sitagliptin j- jSitagliptin j(Januvia) jis jable jto jobtain jan jA1C jgoal jof jless jthan j7% jbased jon jclinical jtrials jand jcurrently jthe jpatient jdoes jnot jhave jany jcautionary jobjective jmeasures jto jnot juse jthis jmedication. jDPP-IV jinhibitors jare jweight jneutral. jDPP-IV jinhibitors jcan jbe jused jin jpatients jtaking jsulfonylureas; jhowever, jit jmay jbe jrecommended jto jreduce jor jstop jthe jsulfonylurea jdose. Acarbose j- jAcarbose j(Precose) jis jnot jrecommended jfor jinitial jmanagement jand jis jassociated jwith jsignificant jGI jside jeffects. jMore jinformation jwould jbe jneeded jregarding jfasting jand jpost-prandial jnumbers. jIn jaddition, jadding jacarbose jwould jonly jlower jA1c jby j0.8% jat jbest jand jtherefore jwould jnot jachieve jthe jdesired jA1C jgoal jof j<7% JR jis ja j68-year-old jAfrican jAmerican jman jwith ja jnew jdiagnosis jof jT2DM. jHe jwas jclassified jas jhaving jprediabetes j(at jrisk jfor jdeveloping jdiabetes) j5 jyears jbefore jthe jdiagnosis jand jhas ja jstrong jfamily jhistory jof jtype j2 jdiabetes. jJR's jblood jpressure jwas j150/92 jmm jHg. jHis jlaboratory jresults jrevealed jan jA1C jof j8.1%, jnormal jcholesterol jpanel, jand jnormal jrenal/hepatic jfunction jwere jnoted jwith jtoday's jlaboratory jtest jresults. Past jmedical jhistory: jHypertension j(diagnosed j4 jy jago) jHyperlipidemia j(diagnosed j2 jy jago) jPancreatitis j(idiopathic) j(acute jhospitalization j3 jy jago) Family jhistory: jType j2 jdiabetes Medication: jHCTZ j25 jmg jdaily, jsimvastatin j10 jmg jdaily Allergies: jSMZ/TMP Vitals: jBP: j150/92 jmm jHg jP: j78 jbeats/min jRR: j12 jrpm jWaist jCircumference: j46 jin jWeight: j267 jlb jHeight: j5 j′ j6 j″ jBMI: j43.1 jkg/m j2 Despite jimprovements jin jthe jpast jsix jweeks jdue jto jlifestyle jchanges jand jexercise, jdrug jtherapy jis jto jbe jstarted jfor jJR's jdiabet j- jANSWER✓✓-Metformin jis jthe jdrug jof jchoice jrecommended jfor jmost jpatients jwith jdiabetes jin jaddition jto jlifestyle jmodifications jassuming jno jcontraindications jor jintolerabilities jare jpresent jupon jevaluation. jMetformin jhas jalso jshown jto jprovide jpositive jweight jneutral/loss jeffects jin jobese jpatients. jIt jis jcrucial jto jknow jthe jrenal jstatus jof jpatients jcommencing jmetformin jtherapy jto jlimit jthe jrisk jof jlactic jacidosis j(JR jis jwithout jcontraindication). Since jhis jentry jA1C jis j>7.5%, jdual jtherapy jis jindicated. jThere jare jseveral jpotential jchoices. jThe jsecond jstep jcan jbe ja jdipeptidyl jpeptidase-4 jinhibitor, jit jcan jbe ja jglucagon-like jpeptide-1 j(GLP-1) jreceptor jagonist, jit jcan jbe ja jTZD, jit jcan jbe ja jsulfonylurea jagent, jit jcan jbe ja jSGLT2 jinhibitor, jor jit jcould jbe jbasal jinsulin. jAnything jnext jcan jbe jtried jdepending jon jwhat jsuits jthe jcircumstance DPP4 jinhibitors jare jweight jneutral jbet jrelatively jbenign jside jeffect jprofile. jSitagliptin jhas jbeen jassociated jwith jcase jreports jof jpancreatitis, jso jthis jspecific jagent jshould jbe javoided. j$$$ GLP-1 janalog jand jhas jdata jto jsupport jan jA1C jreduction jnecessary jto jgain jglycemic jcontrol jand jmay jassist jwith jweight jloss jgoals jfor jthis jpatient. jNew jinformation jsuggests jthese jagents jmay jprovide jbenefits jin jthose jwith jASCVD. jJR jhas ja jpast jhistory jof jpancreatitis jand jGLP-1 janalogs jare jnot jrecommended jdue jto jthis jcontraindication TZDs jhave jdata jto jsupport jan jA1C jreduction jnecessary jto jgain jglycemic jcontrol, jbut jare jassociated jwith jweight jgain, jnegative jeffects jon jlipids jand jincreased jrisk jof jfracture. jUntil jrecently, jTZDs jhave jalso jbeen jlinked jto jincreased jCV jevents jand juse jhas jfallen jout jof jfavor Sulfonylureas jprovide jexcellent jA1C jlowering, jbut jare jalso jassociated jwith jweight jgain. jThey jalso jhave jthe jpotential jto jcause jhypoglycemia, jso jpatient jeducation jis jcrucial. jBecause jof jhis jallergies jto j"sulfa", juse jwould jbe jcontr -previous jexposure jto jmacroglide jantibiotics Strongest jReccomendation: -Bismuth jQuadruple jTherapy j10-14 jdays *do jnot jdrink jalcohol jw/ jmetronidazole* -Salvage jregimen jshould jbe jdifferent jthan jfirst jregimen Who jwould jbe ja jcandidate jfor jprophylaxis jof jNSAID jinduced julcer jand jwhat jagents jare jappropriate? jWhat jif jthe jpatient jis jon jcardio-protective j(low jdose) jaspirin? jWhat jif jan jNSAID jinduced julcer jdoes jdevelop. jHow jshould jit jbe jtreated? j- jANSWER✓✓-Candidate: -Candidates: jChronic jNsaid jUse, jHx julcers, jZollinger-Ellison Prevention jTreatment- jPPI, jstandard jdoses j(most jeffective j& jbest jtolerated), jMisoprostol j(better jthan jH2RA's, jNo jPregnancy) What jif jan jNSAID jinduced julcer jdoes jdevelop. jHow jshould jit jbe jtreated? j- jANSWER✓✓-Ulcer jTreatment- -PPI j(most jeffective) -H2RA j(Famotidone j40mg jdaily) -Sucralfate j(binding jpaste, jrequires jmultiple jdoses, jadverse jmed jreactions, jabdominal jside jeffects) Who jis ja jcandidate jfor jstress julcer jprophylaxis j(SUP)? j- jANSWER✓✓--ICU jpatients -Trauma, jincluding jspinal jcord jinjuries -Mechanical jventilation -Thermal jinjuries j>35% j(almost jhalf jthe jbody) Of jthe jagents javailable jto jcontrol jthe jcomplications jof jdiabetes jmellitus, jcardiovascular jdrugs, jand jparticularly jACE jinhibitors, jhave ja jpre-eminent jplace. jExperimental jand jepidemiological jdata jsuggest jthat jactivation jof jthe jrenin-angiotensin-aldosterone jsystem jplays jan jimportant jrole jin jincreasing jin jthe jmicro- jand jmacrovascular jcomplications jin jpatients jwith jdiabetes jmellitus. jNot jonly jare jACE jinhibitors jpotent jantihypertensive jagents jbut jthere jis ja jgrowing jbody jof jdata jindicating jthat jalso jthey jhave ja jspecific j'organ- protective' jeffect. jFor jthe jsame jdegree jof jblood jpressure jcontrol, jcompared jwith jother jantihypertensive jagents, jACE jinhibitors jdemonstrate jfunction jand jtissue jprotection jof jconsidered jorgans. jACE jinhibitors jhave jbeen jreported jto jimprove jkidney, jheart, jand jto ja jlesser jextent, jeye jand jperipheral jnerve jfunction jof jpatients jwith jdiabetes jmellitus. jThese jfavorable jeffects jare jthe jresult jof jinhibition jof jbo j- jANSWER✓✓- There jis ja j"compelling" jindication jin jpatients jwith jhypertension jand jDM. jThese jshould jbe jthe j1st jclass jof jantihypertensive jmedications jused jin jthose jwith jDM j+ jHTN Recommended jfor jthe jtreatment jof jthe jpatient jwith jCKD j(modestly jelevated j(30-299 jmg/24 jh) jor jhigher jlevels j(>300 jmg/24 jh) jof jurinary jalbumin jexcretion), jeven jin jthose jwithout jDM Delay jprogression jof jnephropathy jin jType j1 jwith jor jwithout jHTN jand jany jdegree jof jalbuminuria j Delay jprogression jof jnephropathy jin jType j2 jwith jor jwithout jHTN jand jmicroalbuminuriaReduce jdevelopment jof jmicroalbuminuria j(kidney jdisease) jin jType j2 jwith jor jwithout jHTN ARBs jare jconsidered ja jreasonable jalternative jfor jthose jintolerant jof jACEI j- jANSWER✓✓- Cardioprotective jdose jASA j(IE jbaby jaspirin jor jclopidrogel jas jalternative)For jSECONDARY jPREVENTION jof jCV jEvents- jUse jin jALL jdiabetics jwith jCV jdiseaseFor jPRIMARY jPREVENTION jof jCV jEventsUSE jin: jhigh jCV jrisk jpatients j(10-yr jCV jrisk j> j10%) j- jTypically: jmale j> j50 jyo jor jfemale j>60 jyo jwith j1 jadditional jmajor jrisk jfactor j(FH jof jCVD, jHTN, jsmoker, jdyslipidemia jor jalbuminuria)MAY jconsider: jintermediate jCV jrisk jpatrients j10-yr jCV jrisk jof j5- 10%) j- jyounger jpatients jwith j1 jor jmore jrisk jfactors, jolder jpatients jwith jno jrisk jfactorsNOT jrecommended: jlow jCV jrisk jpatients j- jmen j<50 jyo jor jwomen j<60 jyo jwithout jmajor jCV jrisk jfactors jor j10-yr jCV jrisk j< j5%Note j- jMany jauthorities jconsider jDM jto jbe jan jASCVD jrisk jequivalentThis jis jbasically jeveryone jwith jDM j- jANSWER✓✓- What jare jthe jgoals jset jby jACE j/ACCE jand jare jthey jwritten jin jstone jfor jall jpatients? j- jANSWER✓✓-Primary jtarget jfor jglycemic jcontrol jis jHbA1C Individualize jHbA1C jgoal j- jbased jon...Duration jof jDMAge/life jexpectancyComorbid jconditions Known jCVD jor jadvanced jcomorbid jconditionsHypoglycemic junawareness Individual jpatient jconsiderations Please jnote jwhen jtransitioning jfrom joral jtherapy jfor jtype jII jDM jto jinsulin, jmetformin jis jretained! jSecretagogues jare jdiscontinued jpossibly jwhen jbasal jinsulin jis jinitiated, jbut jdefinitely jwhen jprandial j(fast/rapid) jinsulin jis jto jbe jadded j- jANSWER✓✓-Options jto jadd jto jbasal jinsulin jfor jprandial jcoverage... Fast-acting jinsulin DPP-4 jinhibitors Incretin jmimetics Glinides Alpha-glucosidase jinhibitors Colesevelam What jare jthe jvarious jtypes jof joral jand jnon-insulin jmedications jand jwhat jrepresents ja jrational jcombination jof jmedications? j- jANSWER✓✓-Combinations jshould jhave jdifferent jmechanism jof jaction Combinations jshould javoid joverlapping jADRs Combinations jshould jideally jbe jselected jbased jon jneed jfor jbetter jbasal jvs jpost-prandial jcontrol Selection jshould jaccount jfor jpatient jspecific jconcerns j(eg. jweight, jCVD jrisk, jetc) What jantidiabetic jmedications jhave jcompelling jindications: j- jANSWER✓✓-for jthose jwith junderlying jASCVD jor jat jhigh jrisk jfor jCVD for jthose jwith jCKD for jthose jwith ja jcompelling jneed jto javoid jhypoglycemia for jthose jwhere jweight jis jan jimportant jconsideration j(ie jwhich jare jassociated jwith jweight jloss, jgain jor jare jweight jneutral) What jare jthe jvarious jinsulins jand jdescribe jthe jpharmacokinetics j(onset, jpeak, jduration)and jhow jare jthey jused j(eg jbasal, jbasal-bolus, jsplit-mixed, jsliding jscale j(..Ask jif jyou jdon't junderstand)). j- jANSWER✓✓-Basal-bolus j(long jacting jbasal j+ jrapid/fast jacting jbolus) jprovides jthe jgreatest jflexibility jand jcontrol jof jall jregimens Sliding jScale jShould jNOT jbe jused Difficult jto jdo jin jhome jsetting, jrequires jeducation jand junderstanding jof jpatient jand jcaregiver Allows jpatient jto jbecome jhyperglycemic, jbetter jto jschedule jdosing jand jprevent jrises jin jBG Requires jfrequent jblood jglucose jmonitoring, j$$$ jand jcompliance jissues Can jbe jused jas jmonotherapy jor jas jadd-on jtherapy jfor jT2DM j.. jPresenting jA1C jof j9 j+ jsymptoms jor jfailure jto jachieve jgoal jA1C jon jadequate jtrial jof j2-3 jagents jat jmaximally jtolerated jdoses j- jANSWER✓✓-Often jstarting jwith ja jlong jacting jinsulin When jglycemic jgoals jaren't jreached jdespite jbasal jinsulin j(Good jFBG jand jpre- prandial jBG, jbut jelevated jHbA1C), jConsider jprandial jtherapy jwith jfast-acting jinsulin. jBegin jfast-acting jinsulin jbefore jlargest jmeal.Variation jexists jbetween jADA jand jACCE jin jtheir jrecommendations If jHbA1C jstill jelevated, jadd jfast-acting jto janother jmealSulfonylurea jcan jcontinue jup juntil jthe jpoint jwhere jprandial j(rapid) jinsulin jis jaddedMetformin jcan j/ jshould jcontinue j!! Note jthere jis jno jsignificant jdifference jin jefficacy jamong jthe jPPIs jwhen jgiven jat jequipotent jdoses Food jmay jaffect jabsorption. jGiven j30-60' jbefore ja jmeal. jMore jflexibility jin jterm jof jdosing jwith jnewer jagents j(eg. jdexlansoprazole)Delayed jonset: j3-4 jdays jfor jfull jinhibition Duration jof jaction jup jto j24 jhours jdue jto jcovalent, jirreversible jinhibition jof jproton jpump j- jANSWER✓✓- Patients jwith jknown josteoporosis jcan jremain jon jPPI jtherapy. jConcern jfor jhip jfractures jand josteoporosis jshould jnot jaffect jthe jdecision jto juse jPPI jlong-term jexcept jin jpatients jwith jother jrisk jfactors jfor jhip jfracture j- jANSWER✓✓- Final jthoughts jon jGERD: j- jANSWER✓✓-◦Therapy jfor jGERD jother jthan jacid jsuppression, jincluding jprokinetic jtherapy jand/or jbaclofen, jshould jnot jbe jused jin jGERD jpatients jwithout jdiagnostic jevaluation. ◦For jpatients jwith jpartial jresponse jto jonce jdaily jtherapy jwith ja jPPI, jtailored jtherapy jwith jadjustment jof jdose jtiming jand/or jtwice jdaily jdosing jshould jbe jconsidered jin jpatients jwith jnight-time jsymptoms, jvariable jschedules, jand/or jsleep ◦In jpatients jwith jpartial jresponse jto jPPI jtherapy, jincreasing jthe jdose jto jtwice jdaily jtherapy jor jswitching jto ja jdifferent jPPI jmay jprovide jadditional jsymptom jrelief. ◦ jMaintenance jPPI jtherapy jshould jbe jadministered jfor jGERD jpatients jwho jcontinue jto jhave jsymptoms jafter jthe jPPI jis jdiscontinued, jand jin jpatients jwith jcomplications jincluding jerosive jesophagitis jand jBarrett's jesophagus ◦Histamine-receptor jantagonists j(H2RA) jtherapy jcan jbe jused jas ja jmaintenance joption jin jpatients jwithout jerosive jdisease jif jpatients jexperience jheartburn jrelief. jBedtime jH2RA jtherapy jcan jbe jadded jto jdaytime jPPI jtherapy jin jselected jpatients jwith jobjective jevidence jof jnight-time jreflux jif jneeded, jbut jmay jbe jassociated jwith jthe jdevelopment jof jtachyphylaxis jafter jseveral jweeks jof jusage Peptic julcers j(gastric jand jduodenal) jare jdefects jin jthe jGI jmucosa jthat jextend jthrough jthe jmuscularis jmucosa. jCausal jrelationships jassociate jwith jH. jPylori jinfection, jNSAIDs jand jSRMD. j- jANSWER✓✓-Therapy jincludes jnon- pharmacological jinterventions j(similar jto jGERD) jand jpharmacological jwith jacid jsuppression j(antacids, jH2RAs, jPPIs) jand/or jmucosal jprotection j(sucralfate, jcolloidal jbismuth, jmisoprostol), jand jif jpresent, jH jPylori jeradication Acid jsuppression j- jsee jtreatment jmodalities junder jGERD j(Duration j/ jdosages jmay jbe jdifferent jbased jon jindication) Mucosal jprotectionSucralfate j- jIn jacid jenvironment jit jturns jinto ja jviscous, jsticky jpolymer jthat jbinds jselectively jto julcers jand jerosions jcreating ja jprotective jlayerEfficacy jcomparable jto jH2RAsChemically, jcontains jAl(OH)3, jthus jbehaves jas jAluminum jas jfar jas jADRs j(eg jconstipation), jDIs j(eg jchelation)Bismuth j- jMOA junclearBismuth jcoats julcers jand jerosions, jcreating ja jprotective jlayer jagainst jacid jand jpepsinIt jmay jstimulate jPG jand jmucus jsecretionIt jbinds jbacterial jendotoxins jand jhas jdirect jantimicrobial jactivity jagainst jpylori H jPylori jeradication j- jBecause jof jthe jcritical jrole jof jH. jPylori jin jthe jpathogenesis jof jpeptic julcer, jeradication jof jthis jinfection jis ja jstandard jcare jin jpatients jwith jgastric jor jduodenal julcers All jregimens jinclude j2 jantibiotics j& jAcid jsuppression jtherapy j(PPI jor jH2RA)May jinclude jBismuth jpreparation Note jespecially jduration jand jcomments jsections jof jthe jtable jbelow! j- jANSWER✓✓- In jpatients jaged j55 jyr jor jyounger jwith jno jalarm jfeatures, jthe jclinician jmay jconsider jtwo japproximately jequivalent jmanagement joptions: j(i) jtest jand jtreat jfor jH. jpylori jand ja jtrial jof jacid jsuppression jif jeradication jis jsuccessful jbut jsymptoms jdo jnot jresolve jor j(ii) jan jempiric jtrial jof jacid jsuppression jwith ja jproton jpump jinhibitor j(PPI) jfor j4-8 jwk j- jANSWER✓✓- NSAID jinduced julcers Prevention: j- jANSWER✓✓-Misoprostol jor jPPI. jH2RAs jnot jrecommended jfor jprophylaxis.COX-2 jinhibitors jare jassociated jwith ja jsignificantly jlower jincidence jof jgastric jand jduodenal julcers jwhen jcompared jto jtraditional jNSAIDs. jHowever, jthis jbeneficial jeffect jis jnegated jwhen jthe jpatient jis jtaking jconcomitant jlow- dose jaspirin. jThe jusefulness jof jthese jagents jhas jalso jbeen jreduced jby jtheir jassociation jwith jmyocardial jinfarction jand jother jthrombotic jCV jeventsCOX-2 jinhibitors jand jNSAIDs jto jbe jdiscussed jin jmore jdetail jlater jin jthe jsemester Candidate jfor jprophylaxis Candidate jfor jprophylaxis j- jANSWER✓✓-History jof jprior jgastrointestinal jevent Age jover j60 j(5x jgreater jrisk) High jNSAID jdosage Concurrent juse jof jcorticosteroids j(4x jgreater jrisk) Concurrent juse jof janticoagulants, jantiplatelets jor jlow jdose jASA j(12x jgreater jrisk) Treatment: jDiscontinue jNSAID jIf jpossibleEradicate jH jPylori jif j(+)H2RAs jor jPPIsPPIs jheal jNSAID-related julcers jmore jeffectively jas jcompared jwith jH2RAs jand jare jtherefore jthe jantisecretory jdrug jof jchoice jfor jtreating jNSAID-related julcers, jespecially jwhen jNSAIDs jare jcontinuedPatients jwith jNSAID-associated julcers jshould jbe jtreated jwith ja jPPI jfor ja jminimum jof jeight jweeksSucralfate jis jan joption jfor jhealing jonly jif jNSAID jwill jbe jstopped Constipation j- jANSWER✓✓-Approach jto jtreatment jshould jbegin jwith jdetermination jof jcause(including jmedications ja jpatient jmay jbe jon jtable j21- 1)OpiatesAnticholinergics j(eg. jtricyclic jantidepressant j(amitryptiline), jdiphenhydramine, jbenztropine, jetc.)NDHP-CCB j(eg jverapamil)Oral jiron jpreparationsCalcium jor jaluminum jantacidsNSAIDsClonidineDiuretics Constipation jtreatment j- jANSWER✓✓-Non-pharmacological jinterventions jfirst j(diet j(fiber), jexercise, jfluids)Probiotics j- jlimited jdata jBest jPract jRes jClin jGastroenterol. j2011;25:119-126 PharmacologicalBulk jforming jagents j(eg. jmethylcellulose j(Citrucel*))Administer j240 jmL jof jwater jwith jeach jdose jto jprevent jesophageal j/ jGI jobstruction jand jworsening jsymptomPhysical jbinding jof jother jsubstances jincluding jmedicationsSafe jin jpregnancyEmollients j(softeners) j(eg. jdocusate j(Colace*)Facilitate jmixing jof jaqueous jand jfatty jmaterials jin jthe jintestinal jtractUsed jfor jprevention, jNOT jtreatment. jCommonly jprescribed jwith jmedications jthat jmay jcause jconstipation j(chronic jopiate juse, jiron jsupplementation)Safe jin jpregnancyLubricant jlaxative j(mineral joil j/ jcastor joil)Coats jstool jto jallow jeasy jpassage j/ jPrevents jcolonic jwater jabsorptionSystemic jabsorption j- jcan jgenerate jimmune jresponseAspiration j- jmay jlead jto jlipoid jpneumoniaDecreases jabsorption jof jfat-soluble jvitamins jà jDO jNOT juse jin jpregnancyHyperosmotics j(eg. jpolyethylene jglycol j(Miralax*))Osmotic jeffects jto jretain jfluid jin jGI jtractSafe jin jpregnancySaline jlaxatives j- jComposed jof jrelatively jpoorly jabsorbed jions j(Mg+ j- jsulfate, j- jphosphate, j- jcitrate)(eg. jMOM*)Osmotic jeffects jto jretain jfluid jin jGI jtractMay jbe jused joccasionally jto jtreat jconstipation jin jotherwise jhealthy jadultADRs: jfluid jand jelectrolyte jdisturbances: jMg j(renal jdysfunction) jor jNa j(CHF) jaccumulationStimulant jlaxatives j(Senna, jBisacodyl) j(eg jSennokot*, jDulcolox*)Only jrecommended jfor jintermittent juse j- jdaily juse jstrongly jdiscouragedNew jagents javailable jfor jspecific juse jONLY j(eg. jIBS-C, jOIC)NOT jdiscussed jin jthis jcourse Summary jof jconstipation jrecommendations j- jANSWER✓✓-Slow jTransit jConstipationHyperosmotic jlaxativesSenna, jBisacodyl jand jother jstimulants jare jsecond jline Those jwho jneed jto javoid jstraining j(eg jhemorrhoids, jhernia, jMI)Stool jsofteners jor jPEG ChildrenDiet, jfluid jexerciseAvoid junder j6 jyears jwithout jevaluationGlycerin jsuppository, jdocusate Sedative jand janti-anxiety jeffects j→ jreduce janticipatory jN/V jassociated jwith jchemotherapy jADRs j- jCNS j- jsedation, jhallucinations, jeuphoria; jCV j- jhypotension CINV j- jEvaluate jemetogenic jpotential jof jregimen Mono jtherapy jfor jchemotherapy jwith jlow jand jmoderate jemetogenic jrisk Aggressive j(combination jof jagents jwith jdifferent jmechanisms) jantiemetics jfor jhighly jemetogenic jregimens jand jdelayed jCINV jExamples Dexamethasone j+ jmetoclopramide j+ jdiphenhydramine j+ jlorazepam jOndansetron j+ jdexamethasone jOndansetron j+ jmetoclopramide jMetoclopramide j+ jdexamethasone jOndansetron j+ jdexamethasone j+ jprochlorperazine Ondansetron j+ jdexamethasone j+ japrepitant Erectile jdysfunction j-"The jinability jto jattain jor jsustain jan jerection jadequate jfor jsexual jstimulation" j- jANSWER✓✓-Can jbe jthe jresult jof jage jrelated jchanges j(e.g. jdiminished jtestosterone, jaltered jresponse jto jNO, jetc), jcomorbidities j(e.g. jDM, jBPH, jdepression, jetc j.. jTable j51-1), jand jmedications j(e.g. j5-alpha jreductase jinhibitors, jbeta-blockers, jTCAs, jetc. j.. jTable j51-2) Before jinitiating jtreatment jfor jED j- jANSWER✓✓-a jphysical jexamination jand jthorough jmedical, jsocial, jand jmedication jhistories jwith jemphasis jon jcardiac jdisease jmust jbe jtaken jto jassess jfor jability jto jsafely jperform jsexual jactivity jand jto jassess jfor jpossible jdrug jinteractions Diagnosis jshould jinclude jPE j(including ja jcheck jfor jsigns jof jhypogonadism), jmedication jreview, jHx, jand jlabs j( jHbA1C, jPSA, jFLP, jtestosterone) ED jtreatment jshould jinclude: j- jANSWER✓✓-Non-pharmacological jinterventions Reduce jfat jand jcholesterol jin jdiet Decrease jor jlimit jalcohol jconsumption Eliminate jtobacco juse jand jsubstance jabuse Weight jloss jif jappropriate Regular jexercise Co-morbidity j(DM, jHTN, jetc.) jmanagement j- jincluding j(if jpossible) jremoval jof jcausal jmedications If ja jmedication jis jremoved, jconsider jthat jit jprobably jwill jhave jto jbe jreplaced jwith ja jreasonable jalternative j- jANSWER✓✓-Examples: SSRIs jare ja jpotential jcause jof jED. jA jreasonable jreplacement jmight jbe jbupropion j(assuming jno jcontraindications) Dutasteride j(for jBPH) jis ja jcommon jcause jof jED. jTardenafil jas ja jreplacement jfor jor jin jcombination jwith ja j5-alpha jreductase jmight jbe jreasonable j(assuming jno jcontraindications) ED jNote: j- jANSWER✓✓-There jare joccasions jwhere jan joffending jmedication jcan jNOT jbe jdiscontinued jbecause jof ja jcompelling jindication jand j/ jor jlack jof ja jreasonable jalternative j(eg jBeta-blockers jin jheart jfailure jor jSIHD). PDE5Is j- jOften jconsidered jdrug jof jchoice jwhen jpharmacotherapy jis jnecessary. jThere jis jno jconvincing jevidence jthat jone jagent jin jthis jclass jis jsuperior jto janother. jChoice jmay jbe jbased jon jpatient jpreference, jcost, jand jformularies j- jANSWER✓✓-There jis jno jdrug jeffect jwithout jsome jtype jof jsexual jstimulation jbecause jthese jdrugs jdo jnot jcause jpenile jerections; jthey jonly jprovide jthe jability jof jthe jpenis jto jrespond jto jsexual jstimulation. Varying jduration jof jaction j(most j4-5 jh, jtadalafil j36h). Headache jand jflushing jmost jcommon jADRs. jSerious jcardiac jevents jpossible Significant jDIs jexist j- jANSWER✓✓-+) jnitrates j- jsevere jhypotensionIn jan jemergent jsituation, ja jpatient jwho jhas jtaken jsildenafil jmay jbe jgiven ja jnitrate jafter j24 jhours; jfor jtadalafil, jafter j48 jhours. j Vardenafil jdoes jnot jhave ja jsuggested jtime jinterval, jbut jblood jpressure jand jheart jrate jdid jnot jchange jwhen jthe jdrug jwas jtaken j24 jhours jbefore jnitrate jadministration. jThese jsuggested jintervals jare ja jdirect jcorrelation jto jhalf-life jand jduration jof jaction Prolonging jof jQT jinterval Serious jcardiovascular jevents jhave jbeen jassociated jwith jPDE5 jinhibitors; jtherefore, jthey jshould jnot jbe jused jin jpatients jin jwhom jsexual jintercourse jis jinadvisable jbecause jof jpoor jcardiac jstatus. Testosterone jreplacement j(Low-T) j- jANSWER✓✓-Testosterone jreplacement jregimens jshould jnever jbe jadministered jto jmen jwith jnormal jserum jtestosterone jlevels, jor jin jpatients jwith jisolated jerectile jdysfunction jas jthe jonly jsign jof jhypogonadism. Before jinitiating jany jtestosterone jreplacement jregimen jin jpatients j40 jyears jand jolder, jpatients jshould jbe jscreened jfor jbreast jcancer, jbenign jprostatic jhyperplasia, jand jprostate jcancer. jAll jare jtestosterone-dependent jconditions jand jtheoretically jcould jbe jworsened jby jexogenous jadministration jof jtestosterone Alprostadil j- jPgE1 janalog jadministered jby jintracavernosal jinjection j& jintraurethral jinserts j- jANSWER✓✓-Because jPGs jbypass jmany jsteps jin jthe jerectile jcascade, jthey jare jquite jeffective jat jproducing jan jerection, jeven jin jcases jwhere jPDE5 jinhibitors jcannot jdo jso. Most jinvasive jand jlow jpatient jacceptance. jReserved jas jsecond jor jthird jline jtreatment BPH j- jANSWER✓✓-BPH jincreases jurethral jresistance, jresulting jin jcompensatory jchanges jin jbladder jfunction. jObstruction-induced jchanges jin jdetrusor jfunction, jincluding jsmooth jmuscle jhypertrophy, jcompounded jby jage- related jchanges jin jthe jfunctioning jof jthe jbladder, jlead jto jurinary jfrequency, jurgency, jand jnocturia, jthe jmost jbothersome jBPH-related jcomplaints. jNot jall jpatients jwith jLUTS jhave jBPH jand jnot jall jmen jwith jBPH jhave jLUTS. BPH jdiagnosis j- jANSWER✓✓-Diagnosis jincludes jcomponents jsuch jas jsymptom jassessment j(AUA jscore), jPE jand jPSA PSA jis jpresent jin jsmall jquantities jin jthe jserum jof jmen jwith jhealthy jprostates, jbut jis joften jelevated jin jthe jpresence jof jprostate jcancer jor jother jprostate jdisorders. jPSA jis jnot juniquely jan jindicator jof jprostate jcancer, jbut jmay jalso jdetect jprostatitis jor jBPH. jPSA jcorrelates jwith jprostate jsize jand jcan jbe jused jas ja jprognostic jmarker Non-pharmacologic jinterventions jfor jBPH j- jANSWER✓✓-Lifestyle jmodification j- jlimiting jEToH, jcaffeine, javoid jcertain jmedications j(Table j52-4)(e.g. jdecongestants, jandrogens, jetc) jas jwell jas jaddressing jco-morbidities j(weight jloss, jetc) Watchful jwaiting jis jthe jmost jconservative japproach jfor jpatients jwith jmild jsymptoms jor jthose jwith jmoderate jsymptoms jwithout jbother ◦Appropriate joption jfor jpatients jwith jmild jsymptoms j(AUA-SI jscore j≤ j7), jand jfor jmany jwith jmoderate jto jsevere jsymptoms j(AUA-SI j≥ j8) jif jthey jare jnot jbothered ◦Behavior jmodification jincludes jrestricting jfluids jclose jto jbedtime, jminimizing jcaffeine, jsweetened jdrinks jand jalcohol jintake, jfrequent jemptying jof jthe jbladder jduring jwaking jhours j(to javoid joverflow jincontinence jand jurgency), jand javoiding jdrugs jthat jcould jexacerbate jvoiding jsymptoms j(e.g. jantihistamines, jdecongestants). ◦At jeach jvisit, jassess jthe jpatient's jrisk jof jdeveloping jacute jurinary jretention jby jevaluating jthe jpatient's jprostate jsize jor jusing jPSA jas ja jsurrogate jmarker jof jprostate jenlargement The jlevel jof jsymptom jdistress jthat jindividual jmen jare jable jto jtolerate jis jvariable Alpha-blockers j- jANSWER✓✓-fairly jrapid jonset j(2-4 jweeks) jwith jrelatively jrapid jsymptom jresolution j, jdurable jeffect j(years) jwith jAUA jsymptom jindex j(AUASI) jimproving j30-45%. jNo jeffect jon jprostate jsize j(PSA) jor jdisease jprogression. For jmen jwith jlow jpost-void jresidual jurine jvolumes jand jirritative jsymptoms j(e.g., jfrequency, jurgency) jthat jpersist jduring jtreatment jwith jan jalpha- adrenergic jantagonist, jcombination jtreatment jwith jan janticholinergic jagent jcan jbe jtried ◦Improved jstorage jvoiding jparameters jand jfrequency jcompared jwith jalpha-1- adrenergic jantagonist jtherapy jalone ◦For jpatients jwho jpoorly jtolerate janticholinergic jadverse jeffects, jan jalternative jis jMirabegron The jrisk jof jside jeffects, jincreased jpost-void jresidual jurine jvolume, jdecreased jmaximal jurinary jflow jrate, jor jacute jurinary jretention jis jlow BPH jcombination jtherapy j- jANSWER✓✓-◦ ja-blocker jand jPDE-5Is For jmen jwith jmoderate jsymptoms jof jBPH jand jerectile jdysfunction, jtreatment jwith jdaily jtadalafil j(5 jmg/day) jalone jor jin jcombination jwith jtamsulosin j(0.4 jmg/day) jcan jbe jconsidered Addition jof jPDE-5Is jto jalpha jblockers jmay jimprove jlower jurinary jtract jsymptoms ◦PDE-5i jand j5a-RIs Addition jof jPDE-5i jto j5a-RIs jcan joffset jerectile jdysfunction jcommonly jseen jwith j5a-RIs Red jFlag jmedications jin jpregnancy j - jCommonly jused j/ jteratogenic j- jANSWER✓✓-Warfarin, jPhenytoin, jValproic jAcid, jCarbamazepine, jLithium, jACE jinhibitors/ARBs, jThalidomide, jEthanol, jstatins j.. jetc Considerations jmust jbe jgiven jto jnot jonly jthose jwho jARE jpregnant, jbut jall jwomen jof jchild jbearing jyears jwhere jpregnancy jis jpossible j(planned jor jun- planned) Note: jthis jis jNOT ja jcomprehensive jlist, jbut ja jgood jrepresentation jfor jexam jpurposes Combined jOral jContraception: j- jANSWER✓✓-choosing ja jformulation jbased jon jfertility jgoals, jpatient jpreference, jdiscussion jof jrisk/benefits, jHx j(to jrule jout jcontraindications j.. jsee jUS jMEC jattached) World jHealth jOrganization jand jthe jFood jand jDrug jAdministration jrecommend jusing jthe jlowest jdose jpill jthat jis jeffective j(as jnoted jbelow, jefficacy jcan jbe jimpacted jby jseveral jfactors j.. jincluding jother jmedications. jThus, jthe jlowest jdose javailable jis jnot jalways jthe jlowest jmost jeffective jdose) Combined jOral jContraceptives j- jANSWER✓✓-Risks jcan jinclude, jbut jnot jlimited jto jcancers, jCV jevents/HTN, jVTE, jdrug jinteractions Concomitant juse jof jbroad jspectrum jantibiotics jand jcombination jcontraceptives jmay jresult jin jdecreased jcontraceptive jefficacy; jhowever jthis jis jCategory j1 junder jUS jMEC If ja jtypical jfailure jrate jof j1% jto j3% jis ja jconcern jfor jthe jpatient, jconsider jadditional jor jalternative jforms jof jbirth jcontrol Concomitant juse jof jP450 jenzyme jinducers j(rifampin, jphenytoin, jcarbamazepine, jphenobarbital) jmay jresult jin jdecreased jcontraceptive jefficacy If juse jCOC j- juse jhigher jdoses j(at jleast j35 jmcg jEE) j+ jhigh jprogestin, jshorten jhormone jfree jinterval jto j4 jdays jor jless Avoid jlow jprogestin j- jthe jpatch, jPOP Consider jadditional jor jalternative jforms jof jbirth jcontrol Concomitant juse jof jAnti-HIV jprotease jinhibitors jcan jeither jincrease jor jdecrease jserum jlevels jof jestrogens jand jprogestins j- jmay jneed jbackup jmethod Drospirenone jcan jcause jhyperkalemia, jespecially jif jused jwith jother jagents jthat jcan jincrease jpotassium j(ACEIs, jheparin, jaldosterone jantagonists, jetc) Benefits jcan jinclude jfavorable jeffect jon jbone, jmenstrual jeffects, jimproved jacne, jimproved jPMDD, jetc Managing jhormone jconcerns j- jANSWER✓✓-Estrogen Excess j- jN/V, jcervical jmucorrhea, jhypertension, jheadache, jbreast jtenderness, jedema, jmelasma, jbloating Deficiency j- jEarly jor jmid-cycle jbreakthrough jbleeding, jincreased jspotting, jhypomenorrhea, jvasomotor jsymptoms Progestin Excess j- jbreast jtenderness, jheadache, jfatigue, jchanges jin jmood Deficiency j- jLate jbreak jthrough jbleeding, jhypermenorrhea, jdysmenorrhea Androgen Excess j- jincreased jappetite, jweight jgain, jacne, joily jskin, jhirsutism, jdecreased jlibido, jincreased jbreast jsize, jbreast jtenderness, jincreased jLDL, jdecreased jHDL Amenorrhea j- jrule jout jother jcauses. jCan jincrease jto jmore jestrogenic jformulation jor jto jtriphasic jformulation jto jdecrease jamenorrhea.Not ja jconcern jif jpatient jis jhappy. Acne/ joily jskin/ jhirsutism j- jRule jout jother jcauses. jSwitch jto jless jandrogenic jformulation jof jprogestin j(or jdecrease jprogestin jcontent)3rd jgeneration jDesogestrel, jnorgestimate4th jgeneration jdrospirenone Dienogest Managing jhormone jconcerns j- jANSWER✓✓-GI- jtypically jresolves jin j1-3 jmonths. jDecrease jestrogen jcomponent jwill jhelp jwith jnausea. jDecrease jprogestin jcomponent jto jhelp jwith jbloating jand jconstipation Bleeding j/spotting j- jCommon j(30-50%) jwhen jfirst jinitiated. jOften jresolves jby j3rd jor j4th jcycle Other jmanipulations jof jestrogen jand jprogestin jdepend jat jthe jpoint jof jthe jcycle jbleeding j/ jspotting joccurs First jrule jout jother jcauses jincluding jmedications j(eg. jMedications jthat jincrease jmetabolism)If jspotting jor jbleeding jbefore jcompleting jactive jpills j(late jcycle j(days10-21)) j- jincrease jprogestin jto jenhance jendometrial jsupport Monophasic jwith jhigher jprogestin jor jtriphasic jwith jing jprogestin If jspotting jafter jwithdrawal jbleeding j(early jcycle j(days j1-9))- jincrease jestrogen jor jdecrease jprogestin jin jthe jearly jpills(triphasic)If jmid-cycle jspotting/bleeding j- jincrease jboth jestrogen/progestin jmidcycle Headaches j- jIf jheadaches jstart jor jworsen jafter jstarting jOC, jneed jto jrule jout jother jcauses j(take jBP, jask jabout jheadache, jany jfocal jneurologic jsymptoms)If jrelated jto jOC juse jand jare jnot jserious j- jDiscontinue jOC, jLower jestrogen jdose, jLower jprogestin, jEliminate jpill jfree jinterval j(only jif jHA joccur jduring jpill jfree jinterval) Decreased jLibido Ask jabout jdepression If jdue jto jdecrease jin jvaginal jlubrication, jswitch jto jvaginal jring jcontraception Increase jestrogen Hypertension j- jCOCs jcan jcause jsmall jincreases j(i.e., j6 jto j8 jmm jHg) jin jblood jpressure, jregardless jof jestrogen jdosage Low j-dose jCOCs jis jacceptable jin jwomen jyounger jthan j35 jyears jwith jwell- controlled jand jfrequently jmonitored jhypertension Discontinuing jthe jCOC jusually jrestores jblood jpressure jto jpretreatment jvalues jwithin j3 jto j6 jmonths VTE j/ jThromboembolism Estrogens j- jincrease jhepatic jproduction jof jfactor jVII, jfactor jX, jand jfibrinogen jin jthe jcoagulation jcascade, jtherefore jincreasing jthe jrisk jof jthromboembolic jevents Progestins Newer j3rd Progestin jOnly joral jcontraceptives j- jANSWER✓✓-- jindicated jin jBreastfeeding j(post-partum jphase), jolder jwomen, jwomen jwho jcannot jtake jestrogen The jfailure jrate jis jhigher jthan jother jprogestin-only jmethods jor jCOCs Effectiveness jis jlowered jwhen jtaken jas jlittle jas ja jfew jhours jlate DM jI/II/GDM jin jpregnancy: j- jANSWER✓✓-DM jI j/ jII j/ jGDM TreatmentADA jdiet Insulin j- jdrug jof jchoice Regular jinsulin jor jNPH Insulin jlispro j(Humalog) Insulin jaspart j(Novolog)◦Insulin jrequirements jwill jincrease jbeginning jaround j28 jweeks jgestation jand jcontinue jto jincrease jdue jto jplacental jhormones Increasing jdata jon jsafety jof jinsulin jglargine jin jpregnancy