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PHARM II WEEK 4 ALL CONTENT ELABORATED.
DMARDs onset & use Accurate Answer - 4-8 weeks; use for RA with NSAIDs, corticosteroids (for symptom relief first) gold standard for RA tx Accurate Answer - methotrexate name the drug class: methotrexate, leflunomide, sulfasalazine, hydroxychloroquine Accurate Answer - DMARDs common AE of DMARDs Accurate Answer - hepatitis, myelosuppression, GI intolerance MTX CI Accurate Answer - alcohol use, pregnancy which DMARD is safe to use during pregnancy? Accurate Answer
- sulfasalazine key AE of hydroxychloroquine Accurate Answer - retinopathy- need annual eye exams what are "biosimilars"? Accurate Answer - "generic" of the original FDA approved biologic; not identical, but no clinically meaningful differences what drug class is FDA approved to treat these conditions: RA, PsA, AS, Crohn's, hidradenitis suppurativa, JIA, UC, plaque psoriasis, uveitis Accurate Answer - TNF inhibitors MOA of the following drugs: etanercept, adalimumab, certilozumab pegol, golimumab, infliximab Accurate Answer - TNF inhibitors which TNF inhibitors can be given IV? Accurate Answer - infliximab, golimumab
TNF inhibitors black box warnings Accurate Answer - increased risk of respiratory & opportunistic infections, malignancy (lymphoma & lung CA) rituximab MOA & use Accurate Answer - b-cell inhibitor; given IV for RA, granulomatosis w/polyangitis abatacept MOA & use Accurate Answer - T-cell inhibitor; RA, polyarticular JIA, PsA anakinra, canakinumab MOA Accurate Answer - IL-1 inhibitors tocilizumab, sarilumab MOA Accurate Answer - IL-6 inhibitors patient taking tocilizumab or sarilumab must have labs monitored frequently for what? Accurate Answer - anemia, neutropenia, elevated lipids, elevated liver enzymes secukinumab, ixekizumab MOA Accurate Answer - IL- inhibitor guselkumab, risankizumab-rzaa, ustekinumab MOA Accurate Answer - IL-23 inhibitor apremilast MOA Accurate Answer - PDE-4 inhibitor (small molecule) tofacitinib, baricitinib, upadacitinib MOA & ROA Accurate Answer
- small molecule JAK inhibitor; oral med once daily which med is FDA approved for SLE treatment? MOA? Accurate Answer - belimumab; inhibits b-cell activation = inhibits inflammation
pharm regimen for group B COPD (0-1 exacerbations, significant symptoms) Accurate Answer - LABA + LAMA pharm regimen for group E COPD (2+ exacerbations, 1+ hospitalization) Accurate Answer - LABA + LAMA when should you consider adding ICS to LABA+LAMA regimen in COPD? Accurate Answer - if blood eos ≥ 300 mainstay of treatment for COPD Accurate Answer - bronchodilators (act on airway smooth muscle); beta agonists or antimuscarinic agents when are short-acting VS long-acting meds used for COPD? Accurate Answer - short-acting for "rescue"; long-acting used as maintenance therapy list drugs in the following classes:
- SABA
- LABA
- SAMA
- LAMA Accurate Answer - - SABA: albuterol, salbutamol, levalbuterol
- LABA: formoterol, salmeterol, vilanterol
- SAMA: ipratropium bromide
- LAMA: tiotropium, umeclidinium indications for inhaled corticosteroids (ICS) Accurate Answer - significant symptoms, recurrent exacerbations, blood eos > indications & CI for systemic steroids Accurate Answer - - indication: acute exacerbation
- CI: chronic management of COPD
supportive (non-pharm) therapy for COPD Accurate Answer - smoking cessation, immunizations, pulmonary rehab indications for home O2 therapy in COPD Accurate Answer - pO2<55 on RA, or 56-59 w/cor pulmonale or sec. polycythemia improves QOL in patients with chronic hypoxemia; if O2 only drops with exertion, O2 will help with symptoms but doesn't improve long term presentation of COPD acute exacerbation Accurate Answer - AMS, can only speak with single words at a time, silent chest, use of accessory muscles, labored breathing, paradoxical breathing ↓pH, ↓pO2, ↑pCO in a COPD patient who presents with acute exacerbation, what other concurrent conditions should you evaluate for? Accurate Answer
- pneumonia, pneumothorax, CHF, PE management of COPD acute exacerbation Accurate Answer - short-acting inhaled beta agonist + systemic steroids + abx what is the preferred ventilation for COPD exacerbation? Accurate Answer - non-invasive ventilation what ECG rhythm is associated with COPD? Accurate Answer - multifocal atrial tachycardia (MAT) if a young (<45yo) patient presents with emphysema in the absence of a recognized risk factor, what do you need to test for? Accurate Answer - alpha-1 antitrypsin deficiency group 1 VS group 2 PAH Accurate Answer - - group 1: pulmonary arteries
- improves functional capacity
- decreased "death from any cause", lung transplants, hospitalizations in severe PAH non-pharm for rhinitis Accurate Answer - avoid allergies, daily nasal saline irrigation what is the most effective single therapy for mod-severe rhinitis? Accurate Answer - intranasal corticosteroid sprays (inhibits allergic inflammation of nose) if intranasal corticosteroid spray doesn't work for a patient with rhinitis, what is next line? Accurate Answer - intranasal antihistamines- astelin, astepro, patanase indication for combo glucocorticoid/antihistamine sprays in rhinitis:
- azelastine-fluticasone
- olopatadine-mometasone Accurate Answer - - azelastine- fluticasone: >6yo
- olopatadine-mometasone: >12yo how do H1 antihistamines work? Accurate Answer - inverse agonists that downregulate H are 1st or 2nd gen H1 antihistamines preferred and why? list examples of each Accurate Answer - 2nd gen are preferred bc less sedating
- 1st gen: diphenydramine (benadryl), doxepin, hydroxyzine
- 2nd gen: loratadine (claritin), fexofenadine, cetirizine how should dosing change for 2nd gen antihistamines in kidney or hepatic insufficiency? Accurate Answer - - cetirizine: reduce dose by 1/
- loratidine: dose every other day
- fexofenadine: reduce to 60mg/day
antihistamines AE Accurate Answer - anticholinergic (dry), sedation, prolonged QT, hypersensitivity, weight gain, ventricular arrhythmias why are decongestants helpful in treating rhinitis/how do they work? Accurate Answer - alpha adrenergic agonists = constrict BV = relieve congestion list the decongestants Accurate Answer - oxymetazoline, phenylephrine, pseudoephedrine what are potential AE of decongestants to be aware of? (3) Accurate Answer - HTN, insomnia, anxiety how long should decongestants be used for? Accurate Answer - short-term ONLY, prolonged use can cause rhinitis medicamentosa (rebound symptoms) when should leukotriene blockers be used? MOA? Accurate Answer - add-on med for rhinitis or if patient has asthma; block mucous secretion/congestion/inflammation list the leukotriene blockers Accurate Answer - montelukast, zafirlukast > zileuton black box warning for montelukast Accurate Answer - neuropsych changes, suicide first line therapy for nasal polyps Accurate Answer - 1. daily nasal saline irrigations
- intranasal corticosteroid sprays
treatment for rhinosinusitis Accurate Answer - 1. intranasal corticosteroid
- intranasal decongestant (short term)
- abx IF symptoms worsen/don't improve in 7d, or complicated acute 1st line abx for rhinosinusitis Accurate Answer - augmentin (amoxicillin-clavulanic acid) 7-10d if penicillin allergy → doxycycline treatment of mild external otitis Accurate Answer - topical acetic acid-hydrocortisone combo for 7d treatment for moderate external otitis with intact TM Accurate Answer - abx + corticosteroid combo for 7d ex: ciprofloxacin + hydrocortisone ex: neomycin + polymyxin B + hydrocortisone treatment for moderate external otitis with NON-intact TM Accurate Answer - JUST antibiotic drop (ciprofloxacin or ofloxacin) for 7d treatment for severe external otitis Accurate Answer - topical combo of abx (against S. aureua & P. aeruginosa) + glucocorticoid if integrity of TM is not confirmed in a patient with severe external otitis, what meds should be avoided due to potential ototoxicity? what abx SHOULD you use? Accurate Answer - - avoid neomycin- polymyxin B-hydrocortisone, meds containing aminoglycosides
- use cipro/ofloxacin 1st line abx for OM in adults VS children Accurate Answer - - adults: augmentin
- children: amoxicillin
when is abx treatment recommended for strep? which abx? Accurate Answer - any patient who has a positive microbiologic test for GAS; penicillin what patient education should you provide for ENT meds? Accurate Answer - - abx instructions (or why you didn't prescribe them abx)
- SE
- decongestants (rebound congestion)
- avoiding allergies what are required roles of a derm drug vehicle? Accurate Answer
- maintain solubility & stability of the drug
- let the drug penetrate, permeate through SC
- diffusion into epidermis
- keep the drug at target location for long enough ointment is the best vehicle for _________ Accurate Answer - dry, thick, lichenified skin cream is the best vehicle for ___________ Accurate Answer - acute dermatitis, and when ointments aren't tolerated (hot and humid, intertriginous) gel is the best vehicle for ___________ Accurate Answer - facial & hair bearing areas derm "rule of thumb" Accurate Answer - if it is wet, dry it; if it's dry, wet it how do the 4 drug vehicles rank for wetting vs drying? Accurate Answer - wet → dry:
- ointments → creams → lotions → gels
why is salicylic acid good for treating warts? Accurate Answer - keratolytic; increases solubilization of stratum corneum retinoids MOA Accurate Answer - - binding to AND activating retinoic receptors (RAR ɑ, RAR β, RAR 𝝲)
- keratolyic, comedolytic, anti-inflammatory, reduce sebum production what can retinoids treat? Accurate Answer - acne, psoriasis, skin aging, skin cancer common AE of retinoids Accurate Answer - teratogenic, pruritis, erythema, xerosis, sun sensitivity indications, AE for tretinoin Accurate Answer - - acne, wrinkles
- pregnancy category C, unstable with sun exposure indications, AE for adapalene Accurate Answer - - acne
- pregnancy category C isotretinoin MOA, indication Accurate Answer - - reduces size of sebaceous glands, inhibits fn
- severe acne that's resistant to other tx key AE of isotretinoin Accurate Answer - significant teratogenesis (category X)- accutane providers, pharmacies, and patients admistering/taking isotretinoin must enroll in what program to ensure safety? Accurate Answer - iPLEDGE tazarotene indications, AE Accurate Answer - - acne, psoriasis
- teratogenic & photosensitivity
treatment regimen for mild acne vulgaris Accurate Answer - benzoyl peroxide OR topical retinoid OR combo (bp + retinoid + abx) treatment regimen for moderate acne vulgaris Accurate Answer - topical combo (benzoyl peroxide + topical retinoid) OR topical combo + abx treatment regimen for severe acne vulgaris Accurate Answer - oral abx + topical combo (benzoyl peroxide + retinoid) OR isotretinoin (accutane) initial treatment approach for psoriasis over small body surface area Accurate Answer - topical therapy what class of topical corticosteroids should be used for face & intertriginous areas VS palms & soles? Accurate Answer - - face/intertriginous: low potency (hydrocortisone)
- palms/soles: high potency (clobetasol) what is tachyphylaxis & how can it be prevented? Accurate Answer - decreased benefit when high potency corticosteroids are applied daily for 2w; prevent this with alternate day applications topical AE of topical corticosteroids Accurate Answer - atrophy, acne, fungal infection, decr wound healing, contact dermatitis, glaucoma/cataracts, hypopigmentation systemic AE of topical corticosteroids Accurate Answer - hypothalamis-pit axis suppression, cushing, growth retardation indication & MOA of calcipotriene Accurate Answer - - vit D receptor agonsit; inhibits cell proliferation & redcues inflammation
pharmacological uses of estrogen (4) Accurate Answer - 1. hypogonadism
- hormone therapy
- contraception (neg feedback on HPG)
- acne treatment how is estrogen beneficial to use for hormone therapy? Accurate Answer - maintains bone density, suppresses hot flashes & urogenital atrophy how can estrogen treat acne? Accurate Answer - inhibit steroidogenesis, decrease free testosterone concentrations according to the results from the women's health initiative RCT, what are increased VS decreased risks of estrogen + progestin therapy? Accurate Answer - - increased risk: CAD, stroke, PE, invasive breast cancer
- decreased risk: colorectal cancer, hip fracture when estrogen is given for HT, there is no increased risk for breast cancer within what time period? Accurate Answer - immediately after menopause for first 5-7 years estrogen AE related to physiological effects Accurate Answer - breast tenderness, endometrial hyperplasia, increased blood coagulation other estrogen AE Accurate Answer - nausea, cholestasis, migraine, bloating estrogen monotherapy has increased risk of what cancer? Accurate Answer - endometrial cancer contraceptive therapy has reduced risk of what cancers? Accurate Answer - ovarian, endometrial, colorectal cancer
list the progestins Accurate Answer - MPA, norethindrone, norgestrel, levonorgestrel, norgestimate pharmacological uses of progestins (4) Accurate Answer - 1. contraceptive agent
- HRT
- dysmenorrhea
- endometriosis why are progestins a good choice for HRT? Accurate Answer - they decrease risk of endometrial hyperplasia caused by estrogens how do progestins treat dysmenorrhea? Accurate Answer - decrease endometrial mass, decr PG production how do progestins treat endometriosis? Accurate Answer - inhibit endometrial proliferation (growth) & stimulate endometrial differentiation progestin AE related to physiological effects Accurate Answer - breakthrough bleeding, impaired glucose tolerance, changes in lipid metabolism other progestin AE Accurate Answer - acne, hirsutism hormonal birth control MOA (4) Accurate Answer - 1. inhibits ovulation
- inhibits follicle development
- disrupts normal endometrial growth/development
- changes viscosity of cervical mucus what are the available ROA for hormonal birth control? Accurate Answer - oral, parenteral, insertable
what medications interact with hormone birth control? Accurate Answer - - HIV drugs, anticonvulsants, st johns wort
- antibiotics lower contraceptive effectiveness what are SERMs/how do they work? Accurate Answer - bind to estrogen receptors & alter transcriptional activity, but effects are dependent on tissue/location how do SERMs affect bone? Accurate Answer - agonist; suppress resorption how do SERMs affect endometrium? Accurate Answer - partial agonist; proliferation how do SERMs affect hypothalamus, pituitary, breast? Accurate Answer - antagonist; cause hot flashes & inhibit breast proliferation tamoxifen, toremifene, raloxifene MOA Accurate Answer - selective estrogen receptor modulator (SERM) compare tamoxifen, toremifene, raloxifene clinical use Accurate Answer - - all: breast cancer
- raloxifene: ALSO postmenopausal bone loss tamoxifen/toremifene VS raloxifene AE Accurate Answer - - both: hot flashes, n/v
- tamoxifen/toremifene: ALSO endometrial CA clomiphene MOA & clinical use Accurate Answer - - inhibits estrogen feedback to increase FSH & ovulation (ER partial agonist)
- fertility drug clomiphene AE Accurate Answer - multiple births, hot flashes, ovary enlargement
danazol MOA & clinical use Accurate Answer - - ↓ LH, FSH, steroidogenesis, endometriotic implant growth
- ↑ testosterone
- endometriosis & breast fibrocytic disease is danazol an aromatase inhibitor? Accurate Answer - no danazol AE Accurate Answer - weight gain, edema, oily skin, acne, hirsutism, hot flashes think: increase all androgen effects anastrozole, letrozole MOA & clinical use Accurate Answer - - aromatase inhibitor
- breast cancer anastrazole, letrozole AE Accurate Answer - GI, hot flashes, lethargy mifepristone MOA Accurate Answer - PRM, blocks progesterone
- inhibits progesterone receptors
- uterine contractions
- sheds uterine lining
- opens cervix mifepristone clinical use Accurate Answer - abortifacent for <10 weeks gestation
- admin of mifepristone
- admin of misoprostol 24-48h later mifepristone, misoprostol AE Accurate Answer - - mifepristone: vaginal bleeding 8-17d
- misoprostol: cramps, n/v/d
