Terms in this set (512)
Size of drug that crosses placenta
400-600 daltons (most drugs 250-400 daltons)
Fluconazole pregnancy category
Methimazole pregnancy category
Lithium pregnancy category
Corticosteroids pregnancy category
Docusate pregnancy category
TCAs pregnancy category
Acetaminophen pregnancy category
Cetirizine pregnancy category
Penicillins pregnancy category
Cephs pregnancy category
Drugs that decrease milk supply
Androgens, bromicriptine, ergots, estrogen, levodopa, maois, nicotine, sympathomimetics
Drugs that increase milk supply
Amoxapine, antipsychotics, cimetidine, methyldopa, metoclopramide, reserpine
Don't use ortho evra in women above this weight
When do you add beta blocker in heart failure?
Only when hf symptoms are stable and pts are euvolemic
How do you increase beta blocker doses
Double dose q2 weeks
Can you consider bb in pts with reactive airway disease or asymptomatic bradycardia
Which would you decrease first in heart failure with hypotension?
Reduce ace first then beta blocker
Target dose candesartan in hf
Target dose losartan in hf
Valsartan target dose in hf
Bisoprolol target dose in hf
Carvedilol target dose in hf
25 mg bid
Met succinate target dose in hf
chemo Drugs that may cause hf
Anthracyclines, high dose cyclophosphamide, fluorouracil, trastuzumab
Most common cause of hfpef
Most common cause of hfref
Ethacrynic acid equivalent dose
How to increase ace dose
Double dose every 1-4 weeks
Captopril target dose in hf
50 mg tid
Enalapril target dose in hf
10 mg bid
Lisinopril goal in HF
When are aas indicated in hf
Class 2-4 with ef 35% or less to reduce morb and mortal
Scr guidelines for adding on aldosterone antagonist
<2.5 men and <2 women
Benefit of dig in hf
Reduced hospitalizations, exercise tolerance, symptoms
Do you load dig in pts with hf?
Goal dig in hf
Signs of dig tox
N/v, vision changes
Place in therapy for bidil
In addition to ace and bb in African Americans with stage 3 or 4 hf
Adjusting aa dose based on hyperkalemia
Decrease dose by 50% or discontinue if k >5.5
Only anti arrhythmics that can be used in HF
Amiodarone and dofetilide
Spontaneous self termination within 7 days
Lasts more than 7 days
2 or more episodes
Afib ecg findings
No p waves, irregularly irregular
Afib heart rate goals
Normal ef= less than 110. Low ef= less than 80 at rest and less than 100 with exercise
Digoxin has little effect in...
Exercise. Minimal effectiveness with sympathetic activation.
After opening dabigatran use within this time period
Convert parenteral to noac
Start 0-2 hours before next dose of parenteral drug
Warfarin to noac
Start noac when inr<2
Rivaroxaban and apixiban drug interactions
Is a substrate of 3a4 and p glycoprotein x
Trial that demonstrated no benefit of rhythm control vs rate control
This cannot be present for cardioversion
Atrial thrombus. TEE rule out or 3 weeks of therapeutic anticoag required if duration unknown or >48 hrs.
How long to anti coagulate post cardioversion
4 weeks full dose
What are the three criteria to reduce apixiban dose?
Age 80+, weight <60 kg, scr 1.5+. Dose should be 2.5 mg bid
Antiarrhythmics for pts without structural heart disease
Flecainide and propafenone
Amio loading in afib
400 mg bid to tid for 2 weeks than 400 mg daily. Load to 10g.
Half life of amio
Amio + dig dose adjustment
Lower dig dose by 50%
Amio + Warfarin dose adjustment
Lower warfarin dose by 25%
Amio + simvastatin dose max
20 mg simva
Monitoring with amio
Lfts, thyroid, chest radiography + Pfts (pulmonary fibrosis), ophthalmic eval (optic neuritis), skin (blue), neuropathy
In hospital x3 days
Hf, crcl <40, qtc > 440 msec, sinus Brady, 2nd or 3rd degree av block
Dronedarone difference from amio
Lacks iodine moiety that contributes to thyroid, pulmonary, hepatic, and ocular toxicity
Anti arrhythmics in cad
Dofetilide, dronedarone, sotalol. Amio second line.
Requirement to diagnose htn
Avg of readings at 2 separate visits
Sodium rec for htn
<2.4g per day
Avoid thiazides in
4 statin benefit groups
1.cad, stroke, pad
2. ldl 190+
3. Diabetes 40-75 with ldl 70-189
4. 10 yr risk 7.5% or greater
Age when consider moderate intensity statin
Diabetes category of risk you do...
Moderate intensity statin unless 10 yr risk is >7.5%
High intensity statins lower ldl how much
Moderate intensity statins Lower ldl how much
Low intensity statins lower ldl how much
Low intensity statins
Simva 10, Prava 10-20, lova 20, fluva 20-40, pitava 1
What is included in 10 yr ascvd risk score?
Sex age race total cholesterol Hdl sbp on treatment for Htn diabetes smoker
Ck monitoring with statins
Baseline. Then only again if myopathy.
Statins that go thru 3a4
Simva lova atorva (less though)
Statin with minimal drug interactions
Grapefruit juice amount
1 quart per day
Dilt, verapamil, dronedarone dose with simva
Max 10 mg
Amlodipine dose with simva
Max 20 mg
Most hepatotoxic form of niacin
For hyper trig
For homozyg familial hyperchol
Lfts, flu like sx
200 mcg sq weekly
For homozyg familial hyperchol
Why is dipyramidole bad?
Increased exercise induced myocardial ischemia, no benefit over aspirin
Use this for prinzmetal angina
When to use scheduled nitrates in cad
In conjunction with beta blocker or non dhp Ccb (blunts sympathetic reflex tone from nitrates)
Time needed between nitrates and pde5 inhibitors
24h sildenafil and vardenafil, 48h tadalafilm
((Sbp -dbp)/3) + dbp
70-100 mm hg
Map is a measure of...
Pressure in thoracic vena cava near right atrium. Reflects preload and measure of fluid responsiveness. Inaccurate in mv pts requiring peep.
Indirect measure of cardiac function related to left ventricular volume
5-12 mm hg
Normal cardiac output
Cardiac index equation
CO/BSA, normal is 2.5-4 L/min
Lactate is a measure of...
Oxygen transport and use. Lactic acid produced in anaerobic metabolism. In hypo perfusion tissues receive less blood and therefore less oxygen.
Difference between cvo2 and svo2
Cvo2 is higher because had not mixed with venous blood from coronary sinus
Normal oxygen extraction from arterial to venous circulation
Normal cvo2 and svo2
In hypo perfusion s will be less than 70%
Normal pco2 and bicarbonate for acid base
Respiratory or metabolic compensation occurs immediately
Respiratory. Metabolic is slowly in kidneys.
Anion gap equation
Na - (cl + bicarb)
Normal anion gap
8-12 mm hg
Anion gap metabolic acidosis mnemonic
Methanol, uremia, dka, prop glycol, intox/infxn, lactic acidosis, ethylene glycol, salicylate/sepsis
There is something else present!
Non anion gap metabolic acidosis
F- used cars
Fistula, uteroenteric conduits, saline, endocrine, diarrhea, carbonic anhydrase inhib, rta, spironolactone
High co but low pcwp and svr. Leaky capillaries but hyper dynamic
Low co, high wedge pressure and svr. Insufficient forward flow causes venous congestion (pcwp). This causes increased svr to try to improve perfusion.
Low co, low pwcp, high svr. Trying to constrict to improve perfusion.
____ before pressors
T>38 or <36
Wbc>12 or <4
SIRS + infection
Sepsis + organ dysfunction
Hypotension persists despite fluid resuscitation
What time period for early goal directed therapy
6 hours. Meeting resusc goals within 6 hours associated win improved survival.
Goals in early goal directed therapy
Uop >0.5 ml/kg/hr
Cvo2 >70% or svo2> 65%
Why is HES not recommended for fluid resuscitation in sepsis
Initial pressor of choice
Drug of choice for pressor extravasation
Phentolamine (alpha antagonist)
Need to start abx within ______ of recognizing septic shock or severe sepsis
Doses for this pressor are not titrated
0.03-0.04 units/min. This is a physiologic replacement dose.
0.5-8 MCG/kg/min. Common max is 300 MCG/min
Trial that showed steroids should not be used in sepsis stabilized with fluids and pressure
AHA change from ABC to ____
CAB. Reduces time to compressions.
Atropine in ACLS
0.5 mg q3-5 min up to 3 mg for bradycardia
How to give drugs endotrachaeally
Give 2.5-3x the IV dose diluted in 5-10 ml sterile water
Drugs that can be given endotrachaeally
32 to 34 degrees for 12-24 hrs asap after cardiac arrest for neuro recovery and mortality. No later than 10 hrs after arrest. Sedate to treat shivering. Don't necessarily need paralytics.
Agitation sedation scale. -5 to +4
Primary cause of agitation
Drug clearance is ____ in hypothermia
Reduced. Can also impair distribution of drugs to site of action (propofol)
Glucose is _____ during hypothermia
Elevated. Opposite when rewarming.
Potassium is _____ during hypothermia.
Elevated. Opposite when rewarming.
Propofol and dexmedetomidine cause ______ when bolused
Lorazepam iv dosing
1 mg/hr. 1 mg/kg/day can result in prop glycol toxicity. Intermittent= 1-4 mg q2-6hr
5 MCG/kg/min, titrate q5 min
PRIS related to infusions at this dose
50 MCG/kg/min. Metabolic Acidosis, cardiac failure, arrhythmias, hyperkalemia, kidney failure
Does dexmedetomidine cause respiratory depression?
No but can cause loss of oropharyngeal muscle tone leading to airway obstruction
Should you load dexmedetomidine?
No, not in icu pts due to risk of bradycardia and hypotension
Paralytics that don't accumulate renally or hepatically
Indications for SUP
Mv > 48 hours
Coagulopathy: plt<50,000, inr >1.5, aptt 2x control
Early neonatal sepsis
Within 72 hours of birth
Most common infxn in late neonatal sepsis
Csf findings in peds bacterial meningitis
Wbc > 1000
Neutrophils > 50
lab findings in peds viral meningitis
Wbc 100-500- elevated but less than bacterial
This should not be reported with ordinal data
Means and standard deviations
Mean should only be reported with ...
Continuous and normally distributed data
Mean is sensitive to...
Outliers. Tend toward the tail which had the outliers
This is not sensitive to outliers
Mode can be used for what types of data
All- nominal ordinal or continuous
When there is more than one mode it is known as
Bimodal, trimodal, etc
Standard deviation is a measure of...
Variability around the mean
How do you calculate std deviation
Square root of variance (-avg squared difference of each observation from the mean)
What percent of values are within 1 std deviation?
68%, 95% within 2, 99% within 3
When you have the 75th percentile it means...
75% of other values are smaller
Used to summariE and describe data collected or generated on research studies
Conclusions made about a population from a study of the sample of the population
An educated statement about an unknown population
Inferences made by estimation and hypothesis testing
Gaussian distribution is another word for...
x in statistics
s in statistics
Sample std deviation
Population std deviation
Hints for when data is continuous and normally distributed
Population mean is 0 and population sd is equal to 1
Mean and median will be about equal for...
Normally distributed data. This is practical and easy to use. This is challenging when reading a paper bc most don't report median and mean or all of the data
Normally distributed population
Likelihood event will occur given all possible outcomes
All values within the confidence interval are statistically plausible
Do you need to show a p value and a confidence interval
No difference between groups compared
There is a difference between groups compared
2 symptoms must have 1 of for depression
depressed mood, marked decreased interest in usual activities. must have 5/9 x2 weeks
50% decrease in score
meds that may cause depression
interferons, bzds, barbiturates, alcohol, cns depressants, lipid soluble bbs, withdawal from stimulants, cocaine
sx of atypical depression
hypersomnia, hyperphagia, mood reactivity. maois prticularly ood for this
psych drugs with minimal cyp interactions
venlafaxine, desvenlafxine, mirtazepine, levomilnacipran
why avoid tyramine
precipitates hypertensive crisis
washout period for maoi
2 weeks. 6 weeks for fluoxetine
Emsam (selegiline patch)- how often change?
q24 hours, once hit 9 mg/24 hrs need to start maoi diet
paroxetine max dose
50 mg, 60 mg anxiety
fluoxetine max dose
most sedating ssris
sx of serotonin syndrome
confusion, hypomania, restlessness, myoclonus, hyperreflexia, diaphoresis, shivering, tremor, diarrhea, incoordination
withdrawal is most common with this ssri
citalopram max dose 20 mg/day recommended in
hepaic impairment, >60 years, poor cyp2c19 metabolizers
venlafaxine, desvenlafaxine, duloxetine, levomilnacipran
this snri has a dose related effect on NE
venlafaxine. Primarily serotonin at doses <150 mg
milnacipran is approved for...
fibromyalgia. levomilnacipran approved for depression.
levomilnacipran side effects
hyponatremia, increased bleeding risk
snri + serotonin 2a antagonist. Minimal effects on sexual function, orthostatic hypo less likely than w/ trazodone. given BID
dopamine and NE reuptake inhibitor. parent drug blocks dopamine, metabolite blocks NE.
minimize seizure risk w/ bupropion
IR: keep to 150 mg/dose max, ER: max 450 mg/day
lithium's role in depression augmentation
helps in treatment-resistant depression.
levothyroxine depression augmentation dose
frequently 25 mcg/day
when to consider augmentation in depression
when pts are partial responders
only lasts 4 days, not severe enough to warrant hospitalization, does not impair social or occupational fnctioning, is not associated w/ psychosis. mania = 7+days
lithium effect onset
anti-mania 1-2 weeks. antidepressant may take 6-8 weeks. most psychiatrists use bzds, antipsychotics
initial lithium dose
lithium goal concentration
0.8-1.2 acute mania, 0.6-1 maintenance, measure at steady state ~5 days. order troughs.
vpa in bipolar disorder
not as effective for depressive episodes, goal 50-125, percent unbound increases as concentrations approach 100-125
Bioavailability of extended release VPA pdt
80% of other pdts
when to evaluate complete effect of cbz autoinduction
after 4-5 weeks
SJS w/ cbz, do not use cbz if positive, should screen asians
timing of lamotrigine rash
within 2-8 weeks, note also may cause aseptic meningitis
antidepressants with greatest risk of causing switch to manic phase in bipolar
SNRIs and TCAs. do not use antidepressants as monotherapy.
high potency first generation antipsychotics
fluphenazine, thiothixene, haloperidol. These have lowest anticholinergic, sedation, hypotension risk of FGAs. Highest EPS risk though.
low potency first generation antipsychotics
Treatment or parkinsonims and dystonia EPS symptoms
antipsychotic that does not cause tardive dyskinesia
clozapine. supplementation with vitamin e may also be helpful
these antipsychotics can cause pigmentary deposis on the retina and corneal opacity
thioridazine and chlorpromazine (low potency)
Risperdal consta dosing frequency
Q2 weeks, requires 3 week oral bridge. Establish oral tolerability before starting.
Preferred antipsychotic in concomitant Parkinson's
Antipsychotic that must be taken with food
Duration for anxiety diagnosis
Tolerance to this bZd effect occurs within. Days
It is generally recommended to restrict bzds to this time period
3-4 months. To avoid dependence.
Time to onset for buspirone
Adjuncts for anxiety
Pregabalin, qtp, olz, risp
Used for ocd
First line ssris for ptsd
Fluoxetine sertraline paroxetine. Bzds are not effective. Anticonvulsants for aggression, anger, and depression.
Short acting bZd for sleep
Intermediate bzds for sleep
Long acting bzds for sleep
More common when discontinued abruptly. Better with tapering. Worse with short and intermediate acting bzds.
When delirium tremens occurs
When seizures may occur in alc withdrawal
Loading dose protocol in alc withdrawal
Diazepam 10-20 mg q1-2 hours until symptoms alleviated
Treatment for stress incontinence
Alpha agonists, topical estrogens, duloxetine
Treatment for overflow incontinence
Alpha antagonists, 5alpha reductase inhibitors, bethanechol, tadalafil. Incomplete emptying. Post void residual >300 ml
Most common adrs of urinary agents
Dry mouth, constipation, dizziness
5 alpha reductase facilitates conversion of testosterone to dht resulting in prostate growth
When to consider surgery for bph
Persistent gross hematuria, bladder stones, recurrent utis, renal insufficiency
Concern with all alpha blockers, especially tamsulosin
Intraoperative floppy iris syndrome. All should be asked about planned cataract surgery.
Reserve finasteride and dutasteride for...
Those with large prostrate volume (40g). 6 months to efficacy.
American urological association symptom index
0-7: watchful waiting
8-19: consider therapy
20+: assess for surgery
Max dose apap in liver disease
Are ppis superior to h2ras for ulcer prevention with NSAIDs?
Timing for Asa and NSAIDs
Take aspirin 30 minutes before nsaid to avoid reductions in Asa efficacy
Limited efficacy in OA
Capsaicin, diclofenac gel, lidocaine patch
500 mg tid. Prevents joint degradation and relieves pain.
Difference between OA and RA
RA affects small joints of hands, feet, and wrists. Stiffness in morning.
First line agents in RA
Methotrexate, hydroxychloroquine, sulfasalazine, leflunomide. Takes 3 months to see effect. NSAIDs do not affect disease progression. Steroids used as a bridge to dmard effect.
Main hydroxychloroquine toxicity
Main sulfasalazine side effect
Oral polio vaccine
Vaccines that contain neomycin
Inactivated polio, mmr, varicella
If had recent immune globulin avoid giving these vaccines
Guillan barre and vaccines
Meningococcal, association not proven
Immunize preterm infants according to this age
Postpone this vaccine to age 30 days if pt is less than 2 kg
Hep b. Reduced immune response.
Vaccines to avoid in households with immunocompromised children
Oral polio. Other lives are fine.
Live vaccines okay at this dose of prednisone
<2mg/kg/day. If higher, delay at least one month after discontinuing the high dose.
Drug of choice for peds focal seizures
Vpa, cbz, pht. Same for tonic clonic.
Drug of choice for myoclonic
Drug of choice for peds absence
Lennox gastaut drug of choice, peds
Vpa, topiramate, ltg
Drug of choice infantile spasms
ACTH (adrenocorticotropic hormone)
Some ADHD symptoms should be present before this age
7. Also present in 2 or more settings.
Avoid these adhd products in patients with structural heart defects
Duration of action
Duration of action
Concerta duration of action
Apply to hip 2 hours before needed. Remove 9 hours after application. May be worn up to 16 hours. Duration of effect 3 hours after removal. Swimming or exercising okay.
Adderall xr duration of action
10 hours, 6 hours ir
Vyvanse duration of action
More than 20 minutes or does not regain consciousness in between
Dosing still q12h
Sjs allele with cbz
Hlab*1502. Test in Asians.
Hepatotoxicity, aplastic anemia, guardian must sign consent form
1 mg phenytoin = _____ mg fosphen
Indications for gabapentin er
Postherpetic neuralgia, rls
Drugs of choice for atonic seizures
Max dose lacosamide
300 mg/day. Schedule 5.
Avoid lacosamide in...
First degree av block
Cbz vs oxcarb
More blood dyscrasias, less hyponatremia
Perampanel side effects
Neuropsych, weight gain, gait disturbance
Max infusion rate phenytoin
50 mg/ min. Only in NS
Primidone metab to...
Give with food. Shortens qt. available as oral solution.
Angle closure glaucoma, hyperthermia (decreased perspiration)
Nystagmus, tremor, blurred vision. Vision loss with higher dose and longer duration. Restricted distribution program.
Carbonic anhydrase inhibitor, avoid in sulfa allergy, depression, psychomotor slowing, kidney stones, blood dyscrasias, hyperthermia
Max dose cbz
Max dose clonazepam
Max dose ltg
200 mg/day with vpa
375 mg without inducer
500 mg with inducer
Keppra max dose
Phenobarb max dose
Phenytoin max dose
Pregabalin max dose
Topiramate max dose
Vpa max dose
Lorazepam dose in status
0.1 mg/kg up to 4 mg, rate 2 mg/min
Phenobarb, phenytoin, vpa dose in status
All 20 mg/kg!
Must be on ventilator for these status meds
Pentobarbital, thiopental, propofol
Aeds have no effect on these contraceptive methods....
Levonorgestrel iud, depot shots
This common aed has no effect on contraceptive meds
When to consider withdrawing aeds:
Seizure free x2-5 yrs, single type, eeg normalized on treatment
Improved sexual function with these aeds
Fda warning and med guide for aeds required because of risk of..
Dose reduce Pradaxa to 75 bid with these concomitant meds...
Why shouldn't Pradaxa capsule be opened
Reduced bioavailability by 75%
Don't use heparin in acute stroke treatment because
Increased risk of hemorrhagic conversion
Avoid streptokinase in acute stroke because
0.9 mg/kg (max 90 mg), 10% given immediately, then rest over 1 hr
Notable exclusions to tpa
Surgery/head trauma/stroke 3 months, surgery or serious trauma 2 weeks, bp >185/110, glucose <50 or >400, lp within 1 week, inr >1.7, plt <100,000
Asa dose post stroke
75-100 mg. no benefit with increased dose. Don't use Asa + clopidogrel for secondary stroke prevention.
Cilostazol CI in
CHF. inhib plt agg, 100 bid on empty stomach
Insomnia. Metab to amphetamine
List direct dopamine agonists
Pramipexole, bromocriptine, rotigotine, apomorphine (short acting)
Treat apomorphine nausea with
Trimethobenzamide 300 mg tid x3 days before initiating and for 6 weeks after initiating
Risk with apomorphine
Hypotension. Also hallucinations.
Anticholinergics used in Parkinson's for
Tolcapone restricted because of
Hepatotoxicity. Must sign consent form.
With carbidopa levodopa in stalevo. Prevents breakdown of dopamine. Orange urine discoloration, hallucinations, diarrhea
When to do migraine ppx
Recurrent and interfere with daily routine, frequent, ineffective abortive therapy
Do not have faster onset, not absorbed SL
CAD, stroke, uncontrolled htn, pvd, ischemic bowel, pregnancy. Same for ergots.
Migraine attack >72 hours. Headache free <4 hours (sleep not included). Treat with iv steroids, iv dhe, iv sodium valproate
Tension headache ppx
Cluster headache ppx
Verapamil, melatonin, lithium
Oxygen-100% at 6-12l/hr, intranasal lidocaine, octreotide and 10% cocaine
May repeat in 4 hours
Treatment for acute ms relapse
Corticosteroids. 1g/day methylpred x3-5 days
Dimethyl fumarate adrs
Skin flushing, GI, decrease lymphocytes
Bradycardia, macular edema, lfts, Htn decrease lymphocytes, respiratory
Selegiline loses Mao-b selectivity at doses greater than ...
Bradycardia. Hr returns to baseline with 1 month continued dosing. Must monitor for 6 hours after first dose. If miss two weeks need to be remonitored. Macular edema, av delays, avoid live vaccines, avoid pregnancy
Must fail multiple ms agents before starting this one due to cardio toxicity, therapy related leukemia
Risk of pml increases with this duration on natalizumab
2 years or more
This ms drug has long half life, takes 3 months to reach steady state, and takes average 8 months to eliminate from body
Teriflunomide. Preg x, neutropenia, alopecia, hepatotoxicity
Symptoms of ms
Fatigue, spasticity, urinary invontinence, pain, depression, cog impairment, fecal invontinence, sexual dysfunction
Drug for walking impairment in ms
Dalfampridine. 10 mg bid, k channel blocker. CI in history of seizures.
Delayed onset n/v with chemo
After 24 hours
Classic chemo delayed n/agent
Mild emetogenic radiation
Head and neck or extremities
Moderate emetogenic radiation
Upper abdomen or pelvis or craniospinal
Highly emetogenic radiation
Total body, total nodal, upper half body
3 drug antiemetic should always be used with this regimen
AC. Doxorubicin or epirubicin with cyclophosphamide
Drugs with high emetic risk
Cisplatin, high dose cyclophosphamide, dacarbazine, doxo, ifos high dose, carmustine
All mabs are this emetic risk
Common chemo that is minimal emetic risk
These three antiemetics equal at equivalent doses
Granisetron, ondansetron, dolasetron
Apply 24-48 hours before chemo. Max duration 7 days.
This serotonin antagonist is preferred by nccn guidelines
125 mg day 1, 80 mg days 2 and 3. Fos is 150 mg on day 1 only.
Drug interactions with aprepitant
Ocs, warfarin (decrease inr)
Consider modifying pain regimen when...
Pt requires more than 2 breakthrough in 24 hours
Avoid these in heme pts due to plt inhibition
High bioavailability with this form of fentanyl
Buccal. Compared to transmucosal.
Pts with breast cancer and bone Mets and mm pts with lytic lesions should receive this
Pamidronate or zometa. Continue until substantial decline in performance status. Take ca + d to prevent hypocalcemia.
Nadir post chemo
10-14 days. Recovers 3-4 week after.
Wbc x (seg + band)
General counts needed to give cheno
Wbc > 3, anc > 1500, plt 100
Plt life span
Temp for fn
101 or 100.4 over 1 hour
Csfs should only be used in
6 mg dose 24 hours after cheno
5mcg/kg x 11 doses
Drug that prevents severe thrombocytopenia
Oprelvekin. Daily sq injection 6-24 hours after chemo. Used to maintain dose intensity of chemo.not used.
Starts esas at this hemoglobin
<10. Goal 8-10.
Prevent nephrotoxicity from Cisplatin
Detoxifies acrolein implicated in hemorrhagic cystitis. Always ifos sometime cyclophos
Must be present when acrolein present in bladder
0.8(4-alb) + ca
Tx for spinal cord compression
Dex and radiation or surgery
Rasburicase. 5-10x more soluble in urine. Approved 0.2 mg/kg x5 doses
When to use leucovirin rescue
Mtx greater than 100 mg/m2
3rd space fluid, pcn, NSAIDs, ppis
Leucovirin with fluorouracil
Colorectal cancer to enhance activity
Tx of toxic mtx (>1) with delayed clearance due to renal function. 50 units/kg.
Doxo dauno epi
Vinblastine, vincristine, vinorelbine
Meclorethamine extrav treatment
Vinca extrav treatment
Doxo dauno Ida epi extrav treatment
Acute irinotecan diarrhea
Atropine. Within 24 hours.
Chemo drugs renal adjustment.
Mtx carbo cis etop bleo topo lenalidomide
Chemo drugs hepatic adjustment
Doxo dauno vincristine vinblastine, docet pacli sorafenib pazopanib
Lifestyle modifications only recommended in select groups for this condition
Duration of therapy for erosive esophagitis
8 weeks. Ppis more effective. B
When to consider bid ppis
Partial response or nighttime symptoms
Do not use oral solution of this ppi for ng/og
What to do about fracture risk and ppis
Fracture concern should not affect decision. Pts with osteo may remain on ppis.
This ulcer is relieved by eating
Duodenal. Also worse at night.
Most common cause of gastric ulcer
H pylori, nsaids
Less GI toxic nsaids
Ibuprofen, diclofenac, nabumetone. Piroxicam and ketorolac highest risk.
Rapid urease test
Detects presence of ammonia in sample generated by h pylori urease activity
Elisa serologic test for h pylori
Cannot differentiate between active and past exposure
Urea breath test
Used to make diagnosis and test for eradication. Wait until 4 weeks after treatment.
Treatment of choice h pylori
Ppi+ amoxicillin, clarith, metronidazole (3 drugs)
Quad therapy for h pylori
Tetracycline, bismuth, ppi, metronidazole. 14 days.
Only NSAID that does not appear to increase cv risk
Elective endoscopy should be deferred...
For one year after DES
Asa + ppi is superior to...
Separation of ibuprofen and aspirin
Take ibu 30 min after or 8 hours before aspirin
No thermal method for GI bleed is better than another
High risk stigmata
Active bleeding, adherent clot, non bleeding visible vessel
Effect of ppis in GI bleeds
Re bleeding, mortality, need for surgery in active bleed with successful endoscopic intervention
Long term ppi therapy recommended for these ulcers
Those without obvious cause- NSAIDs, h pylori
Mv > 48 hours
Inr > 1.5, plt < 50
Severe head or spinal cord
GI bleed last year
Patchy cobblestone appearance
Toxic mega colon with chrons or uc?
Uc. Also risk factor for colorectal cancer. Pseudopolyps common.
Phases of uc
Severe >6/day, blood, esr, tenderness
Fulminant >10 with continuous blood
Max loperamide ibd
Cholestyramine in ibd
Possibly for Nike salt induced diarrhea after ikeal resection
Active drug in sulfasalazine
5amino salicylate. Colonic activation.
Secretory diarrhea in 25% of patients
Distal ileum, colon
Small bowel, colon
Lialda, apriso, Olsalazine, balsalazide
Budesonide is 15x more potent than
Prednisone. Releases in terminal ileum.
Meds to be concerned with for tpmt deficiency
Azathioprine, 6mp. Determine genotype before initiating. Risk of hepatosplenic T cell lymphoma
Mab that may cause hf exacerbations
Infliximab. Do not exceed 5 mg/kg/dose in chronic hf
Stool antigen test
Polyclonal or monoclonal antibody tests that detect presence of h pylori in stool
Duration of treatment for h pylori
7-14 days. 14 preferred for acg guidelines
Infliximab + azathioprine or 6mp =
Bb warning for increased risk of hepatosplenic T cell lymphoma. Mostly in teen males with Crohns or uc
Oral + topical medals mine is more effective than either alone
Budesonide may be used for
Up to 3 months
Components of child pugh
Serum ascites albumin gradient
Calculate by subtracting ascites albumin from serum albumin. >1.1 means ascites is secondary to portal htn
Furosemide + spironolactone
This should be present in liver pts! 40 mg fur per 100 mg spir
Albumin for paracentesis
6-8 g/L fluid removed if >5 removed
Add on to diuretics in liver pts
Midodrine 7.5 mg tid
Neomycin in hepatic encephalopathy
3-6 g/day in 3-4 divided doses
Treatments for acute variceal bleeds
Vasopressin 0.2-0.4 unit/min + ntg 40-400 mcg/min. Or octreotide (causes hyperglycemia). Or somatostAtin
Abx in variceal bleeds
Ciprofloxacin oral x7 days or ctx 1g/day. Reduced mortality.
Pharmacotherapy recommended to prevent variceal formation
Est/progest reduce hip fractures by _____ and vertebral fractures by ______
Risk of endometrial cancer is related to _____ of estrogen solo use
Duration. Not recommended in h/o breast cancer
Progesten vs progestin
Progestin = synthetic
Hrt main effects
Decrease cvd in young pts. May increase risk in older women.
Decreased colon cancer
May increase lung cancer in h/o smoking
Recs for hrt post hysterectomy
Estrogen daily without interruption
Estrogen plus cyclic progesten
Similar to normal cycle
Estrogen plus continuous progestin
Irregular cycle for first 8-12 months
Vaginal rings for estrogen hrt dosing frequency
1 tab daily for 2 weeks then 1 tab twice weekly
Climara patch dosing frequency
1 patch weekly. Others are twice weekly.
Divigel estrogen gel
Apply to one leg daily
Apply from wrist to shoulder
1 spray on forearm daily. Can increase to 2-3 sprays.
Combo patch. Doses once weekly.
Prempro vs premphase
Pro= like ocs. Same dose of pro and est daily.
Phase= 14 days estrogen then 14 days combo
Prometrium vs provera
Prometrium= micronized progesterone in peanut oil
Provera= medroxyprog acetate
SERM indicated for menopause. If uterus also need progestin.
Conjugated estrogens plus bazedoxifene
Estrogen + SERM (instead of progestin). Tx of vasomotor symptoms, prevent osteoporosis. May be used with intact uterus. Throat neck muscle pain.
Effexor dose for vasomotor symptoms
75 mg once daily
Fluoxetine dose for vasomotor symptoms
Paroxetine dose for vasomotor symptoms
Sertraline dose for vasomotor symptoms
No evidence for use of this herb for HRT
Evening primrose oil
Main risk of black cohosh
Evaluating SD of young adult mean
Before age 45
Ca/vit d recs
1000 mg 600units
Usefulness of FRAX score
Determine if osteopenia requires treatment (most useful for low bmd of hip). Treat if 10 yr probability greater than 20%.
When to screen for osteoporosis
Women over 65 men over 70.
Wait 60 minutes for food for this osteoporosis med
Ibandronate. Others 30 minutes. Studies only show decreased risk vertebral fracture. Not approved for men
Benefit of zoledronic acid
No GI side effects. CI in crcl <35. Q2 yrs for prevention.
1200 mg calcium in this age
Women over 51+, men 70+. 800 units d 70+
Alendronate prevention vs treatment
Raloxifene efficacy in osteoporosis
Not reduce hip fractures
Useful for bone pain caused by vertebral compression fractures
Calcitonin. One nostril, alternate daily.
Recombinant human parathyroid hormone. Does not reduce hip fractures. Osteosarcoma in rats. Increased risk dig tox.
Denosumab approved for
Postmen women with osteo or bone loss assoc with prostate or breast cancer. Not CI in renal dys. REMS
Anticoag in pregnancy required when...
History of dvt
Prosthetic heart valve
Deficiency of clotting factor
Anti phospholipid antibodies
Dc heparin this far in advance of c section or vaginal delivery
First line insulin in preg
Regular and nph
Preg induced htn
After 20 weeks. If before 20 weeks it already existed before pregnancy
Htn plus proteinuria
Tonic clonic seizures
60 mg aspirin from weeks 24-28 until labor
Between weeks 37 and 40
Prevention of pre term labor
17 hydroxyprogedterone 250 MCG Im q week from 16 to 36 weeks
Avoid terbutaline use beyond this duration
48 hours. To prevent preterm labor.
Pharmacotherapy recommended to prevent variceal formation
Vaginal ph becomes more _____ in menopause
Basic. More favorable for bacterial colonization.
Primary inducing agent
Ergots and pregnancy
Used to terminate early pregnancies or decrease postpartum or post abortion bleeding.
1st half of menstrual cucle
Estrogen, then progesterone
fsh and lh secreted by...
Ocs approved for acne
Estrostep, ortho tri cyclen, yaz, beyaz
CIs for ocs
Less than 21 days postpartum, less than 42 days postpartum with dvt risk factors, bp greater than 160/100
Want to treat acne with OCs-
Pick product with lower androgenic activity of higher estrogen
High dose estrogen oc
Low 30-50 MCG
Very low <30 mcg
2 days placebo and 5 days estrogen only instead of 7 days placebo
Ortho evra less effective for women above this weight
Ortho evra patch has fallen off for 30 hours
Reapply new patch if off for > 24 hours. Now new day 1, Use BUM for 7 days.
Nuvaring has been out for 6 hours
Reinsert and use bum until continuous use of ring x 7 days. Ring causes decreased libido.
Missed dose of POP
>3 hours. Must then use backup for 48 hours. No hormone free days with these
Bone loss with depot shot
Risk after 5 years use, almost completely reversible
Missed dose of depot shot
Delayed return of fertility with depot shots
Up to 18 months
Disadvantage of copper iud
Increased monthly blood loss by 35%. Increased infxn risk for 20 days after insertion
Avoid implanon in women > ______% IBW
If vomiting within _____ of taking EC, retake dose
Clomiphene given on these days cycle
2 - 5
Both FSH and LH. comes from urine of postmenopausal women. Give on day 2-3 and continue 7-10 days.