Podcast
Questions and Answers
Initial dose of aspirin
Initial dose of aspirin
325 mg PO Q4 hours as needed for pain; dispense #30
Initial prescription for ibuprofen
Initial prescription for ibuprofen
800mg PO every 8 hours as needed for pain, dispense #30
Initial prescription of celecoxib
Initial prescription of celecoxib
200 mg PO daily; dispense #30
Initial Acetaminophen
Initial Acetaminophen
Calcium Carbonate initial
Calcium Carbonate initial
Cholecalciferol initial
Cholecalciferol initial
Alendronate initial
Alendronate initial
Baclofen initial
Baclofen initial
Cyclobenzaprine initial
Cyclobenzaprine initial
What is the mechanism of action (MOA) for Baclofen?
What is the mechanism of action (MOA) for Baclofen?
What is the indication of Baclofen?
What is the indication of Baclofen?
What is the primary mechanism of action of diazepam in managing muscle spasms?
What is the primary mechanism of action of diazepam in managing muscle spasms?
Which of the following is a contraindication for the use of dantrolene?
Which of the following is a contraindication for the use of dantrolene?
A patient is prescribed cyclobenzaprine for muscle spasms. What common adverse effect should the patient be educated about?
A patient is prescribed cyclobenzaprine for muscle spasms. What common adverse effect should the patient be educated about?
Which of the following medications is most associated with the risk of rhabdomyolysis if its intrathecal pump fails?
Which of the following medications is most associated with the risk of rhabdomyolysis if its intrathecal pump fails?
What is the primary indication for using dantrolene?
What is the primary indication for using dantrolene?
A patient taking diazepam is also prescribed an opioid for pain management. Which interaction is most important to monitor for?
A patient taking diazepam is also prescribed an opioid for pain management. Which interaction is most important to monitor for?
Which of the following is a known interaction of cyclobenzaprine?
Which of the following is a known interaction of cyclobenzaprine?
A patient with muscle spasticity also has cirrhosis. Which medication should be avoided or used with extreme caution?
A patient with muscle spasticity also has cirrhosis. Which medication should be avoided or used with extreme caution?
What is the mechanism of action of cyclobenzaprine?
What is the mechanism of action of cyclobenzaprine?
Which medication is most likely to cause anterograde amnesia as an adverse effect?
Which medication is most likely to cause anterograde amnesia as an adverse effect?
A patient reports experiencing dizziness and increased confusion after starting baclofen. What is the most appropriate initial action?
A patient reports experiencing dizziness and increased confusion after starting baclofen. What is the most appropriate initial action?
Which of the following is a therapeutic indication for diazepam?
Which of the following is a therapeutic indication for diazepam?
In what clinical scenario is dantrolene most commonly used?
In what clinical scenario is dantrolene most commonly used?
What is a key patient education point for individuals prescribed medications such as baclofen, diazepam, or cyclobenzaprine?
What is a key patient education point for individuals prescribed medications such as baclofen, diazepam, or cyclobenzaprine?
What is the primary mechanism of action of baclofen?
What is the primary mechanism of action of baclofen?
A patient taking baclofen reports a sudden high fever, altered mental status and muscle rigidity. What life-threatening condition has the patient most likely developed?
A patient taking baclofen reports a sudden high fever, altered mental status and muscle rigidity. What life-threatening condition has the patient most likely developed?
Which of the following is a contraindication for cyclobenzaprine use?
Which of the following is a contraindication for cyclobenzaprine use?
When educating a patient about dantrolene, what is the most important potential adverse effect to discuss?
When educating a patient about dantrolene, what is the most important potential adverse effect to discuss?
Which of these medications used for muscle spasms/spasticity has a mechanism of action that directly affects calcium release within muscle cells?
Which of these medications used for muscle spasms/spasticity has a mechanism of action that directly affects calcium release within muscle cells?
A patient is prescribed diazepam for muscle spasms. What other medication on their list would prompt you to reduce the dose of diazepam?
A patient is prescribed diazepam for muscle spasms. What other medication on their list would prompt you to reduce the dose of diazepam?
A patient with spasticity due to cerebral palsy is being treated with baclofen. Which non-pharmacological intervention is also essential when caring for the patient?
A patient with spasticity due to cerebral palsy is being treated with baclofen. Which non-pharmacological intervention is also essential when caring for the patient?
Which of the following drugs is most likely to cause anticholinergic side effects?
Which of the following drugs is most likely to cause anticholinergic side effects?
In a patient experiencing muscle spasms, which of the following underlying conditions is least likely considered as a factor?
In a patient experiencing muscle spasms, which of the following underlying conditions is least likely considered as a factor?
When advising a patient about the use of cyclobenzaprine, what is the most crucial information regarding its duration of use?
When advising a patient about the use of cyclobenzaprine, what is the most crucial information regarding its duration of use?
Which of the following best describes the mechanism behind muscle spasms depicted in the image?
Which of the following best describes the mechanism behind muscle spasms depicted in the image?
Which of the following pharmacologic treatments is commonly used postoperatively in patients with muscle spasm?
Which of the following pharmacologic treatments is commonly used postoperatively in patients with muscle spasm?
What potentially life-threatening adverse effect requires vigilant monitoring in patients receiving dantrolene?
What potentially life-threatening adverse effect requires vigilant monitoring in patients receiving dantrolene?
Which of the following best summarizes the actions taken to treat cancer pain?
Which of the following best summarizes the actions taken to treat cancer pain?
What is the fundamental approach to providing cancer management?
What is the fundamental approach to providing cancer management?
In cancer pain management, what is the first step in the analgesic ladder approach?
In cancer pain management, what is the first step in the analgesic ladder approach?
Which of the following issues acts as a major impediment to effective cancer pain management?
Which of the following issues acts as a major impediment to effective cancer pain management?
A cancer patient is on Step 2 and still has pain. What classification of medications should be used?
A cancer patient is on Step 2 and still has pain. What classification of medications should be used?
Which step of cancer pain management involves interventional methods as well as opioids?
Which step of cancer pain management involves interventional methods as well as opioids?
A cancer patient is not getting pain relief from lower level pain medications. After evaluation, what should care providers reassure the patient?
A cancer patient is not getting pain relief from lower level pain medications. After evaluation, what should care providers reassure the patient?
Cancer patients sometimes struggle to do what?
Cancer patients sometimes struggle to do what?
The oncologist is looking to provide the patient information for breakthrough pain. What can this include?
The oncologist is looking to provide the patient information for breakthrough pain. What can this include?
What is the primary goal of initial assessment with ongoing evaluation in the management strategy of cancer?
What is the primary goal of initial assessment with ongoing evaluation in the management strategy of cancer?
Which is a non-pharmacologic treatments help with muscle spasms?
Which is a non-pharmacologic treatments help with muscle spasms?
What are potential reasons that lead to cancer related pain?
What are potential reasons that lead to cancer related pain?
What class of medications cause anterograde amnesia, CNS depression, and paradoxical reactions?
What class of medications cause anterograde amnesia, CNS depression, and paradoxical reactions?
What is the primary difference between medications used to treat muscle spasms versus those used for muscle spasticity?
What is the primary difference between medications used to treat muscle spasms versus those used for muscle spasticity?
Which of the following is a key difference in the treatment approach between muscle spasms and muscle spasticity?
Which of the following is a key difference in the treatment approach between muscle spasms and muscle spasticity?
How does the mechanism of action of cyclobenzaprine differ from that of dantrolene?
How does the mechanism of action of cyclobenzaprine differ from that of dantrolene?
Which of the following best describes the difference in the primary targets of baclofen and diazepam?
Which of the following best describes the difference in the primary targets of baclofen and diazepam?
A patient with muscle spasms requires a medication that acts directly on the skeletal muscle. Which of the following medications is most appropriate?
A patient with muscle spasms requires a medication that acts directly on the skeletal muscle. Which of the following medications is most appropriate?
Which of the following is a key difference in the mechanism of action between opioids and NSAIDs in the management of pain?
Which of the following is a key difference in the mechanism of action between opioids and NSAIDs in the management of pain?
How do adjuvant analgesics differ from opioids and NSAIDs in their primary mechanism of action for pain relief?
How do adjuvant analgesics differ from opioids and NSAIDs in their primary mechanism of action for pain relief?
What is the primary difference in how opioids and acetaminophen alleviate pain?
What is the primary difference in how opioids and acetaminophen alleviate pain?
In the treatment of persistent cancer pain, what distinguishes nerve blocks from opioid medications?
In the treatment of persistent cancer pain, what distinguishes nerve blocks from opioid medications?
When managing persistent cancer pain, how do radiation therapy and surgery differ from pharmacologic approaches like opioids and NSAIDs?
When managing persistent cancer pain, how do radiation therapy and surgery differ from pharmacologic approaches like opioids and NSAIDs?
Which of the following is a common etiology of cancer pain directly related to the disease process?
Which of the following is a common etiology of cancer pain directly related to the disease process?
What is a recommended treatment approach for a cancer patient experiencing neuropathic pain?
What is a recommended treatment approach for a cancer patient experiencing neuropathic pain?
A cancer patient reports constant bone pain that worsens with movement. Besides pharmacological options, which of the following interventions is most appropriate?
A cancer patient reports constant bone pain that worsens with movement. Besides pharmacological options, which of the following interventions is most appropriate?
A cancer patient on Step 1 of the analgesic ladder is not experiencing adequate pain relief. What is the most appropriate next step according to the WHO analgesic ladder?
A cancer patient on Step 1 of the analgesic ladder is not experiencing adequate pain relief. What is the most appropriate next step according to the WHO analgesic ladder?
Why is a multimodal approach important in acute pain management?
Why is a multimodal approach important in acute pain management?
When transitioning from acute to chronic pain management, what is one of the MOST important steps?
When transitioning from acute to chronic pain management, what is one of the MOST important steps?
Which intervention is most appropriate for breakthrough cancer pain?
Which intervention is most appropriate for breakthrough cancer pain?
7-year-old child with cerebral palsy presents with increased leg stiffness, making walking difficult. What medication is typically considered first-line for managing spasticity in children with cerebral palsy?
7-year-old child with cerebral palsy presents with increased leg stiffness, making walking difficult. What medication is typically considered first-line for managing spasticity in children with cerebral palsy?
A 35-year-old female complains of sudden lower back pain after lifting a heavy box. She describes the pain as cramping and reports muscle stiffness. Which initial treatment is most appropriate?
A 35-year-old female complains of sudden lower back pain after lifting a heavy box. She describes the pain as cramping and reports muscle stiffness. Which initial treatment is most appropriate?
A 45-year-old male presents to the emergency department with severe muscle spasms in his lower back and neck after lifting a heavy object. He has already taken over-the-counter NSAIDs and cyclobenzaprine without relief. What medication would be most appropriate to consider next?
A 45-year-old male presents to the emergency department with severe muscle spasms in his lower back and neck after lifting a heavy object. He has already taken over-the-counter NSAIDs and cyclobenzaprine without relief. What medication would be most appropriate to consider next?
A 58-year-old woman undergoing chemotherapy for stage 2 breast cancer reports a mild, dull ache in her lower back. She rates the pain as 3/10 and finds it worsens in the evening. Which of the following is the most appropriate initial step in her pain management?
A 58-year-old woman undergoing chemotherapy for stage 2 breast cancer reports a mild, dull ache in her lower back. She rates the pain as 3/10 and finds it worsens in the evening. Which of the following is the most appropriate initial step in her pain management?
A 65-year-old man with lung cancer is receiving chemotherapy and radiation. He reports moderate, throbbing pain in his right shoulder, rated 5/10, which worsens with physical activity and at night. He is currently prescribed 10mg TID IR oxy, with 20mg SR oxy in AM. What adjustments to his medications should be considered?
A 65-year-old man with lung cancer is receiving chemotherapy and radiation. He reports moderate, throbbing pain in his right shoulder, rated 5/10, which worsens with physical activity and at night. He is currently prescribed 10mg TID IR oxy, with 20mg SR oxy in AM. What adjustments to his medications should be considered?
A 72 year old woman has advanced ovarian cancer and intense pain at 8-10. She has has been prescribed morphine but it is not providing adequate relief. What non-pharmacologic and interventions should be part of the care?
A 72 year old woman has advanced ovarian cancer and intense pain at 8-10. She has has been prescribed morphine but it is not providing adequate relief. What non-pharmacologic and interventions should be part of the care?
What is the MOST important reason to educate the patient to avoid alcohol if they are prescribed medications like diazepam or cyclobenzaprine?
What is the MOST important reason to educate the patient to avoid alcohol if they are prescribed medications like diazepam or cyclobenzaprine?
What factors differentiate muscle spasms from muscle spasticity?
What factors differentiate muscle spasms from muscle spasticity?
Which of the following best describes the treatment approach of hyperkyphosis?
Which of the following best describes the treatment approach of hyperkyphosis?
Which of the following is MOST appropriate for management of persistent cancer pain?
Which of the following is MOST appropriate for management of persistent cancer pain?
A patient has been prescribed dantrolene. What important point should be discussed with the patient?
A patient has been prescribed dantrolene. What important point should be discussed with the patient?
What are the types of medications in step 1 of cancer pain relief?
What are the types of medications in step 1 of cancer pain relief?
A patient undergoing chemotherapy is experiencing nausea. What can be used to help address the feeling?
A patient undergoing chemotherapy is experiencing nausea. What can be used to help address the feeling?
When is diazepam the most appropriate medication considering side effect profile?
When is diazepam the most appropriate medication considering side effect profile?
Why should movement be a part of a patient's regular activities?
Why should movement be a part of a patient's regular activities?
Which of these medications is most commonly used for muscle spasms?
Which of these medications is most commonly used for muscle spasms?
A patient is taking cyclobenzaprine. What medications should be avoided while undergoing treatment with cyclobenzaprine?
A patient is taking cyclobenzaprine. What medications should be avoided while undergoing treatment with cyclobenzaprine?
Which of these is an adverse effect of cyclobenzaprine?
Which of these is an adverse effect of cyclobenzaprine?
A patient is taking baclofen via intrathecal pump. What is a life threatening condition they can get?
A patient is taking baclofen via intrathecal pump. What is a life threatening condition they can get?
What medication is typically first in treatment to help patients with muscle spasticity?
What medication is typically first in treatment to help patients with muscle spasticity?
Which of these drugs can be used to provide immediate relief of breakthrough pain.
Which of these drugs can be used to provide immediate relief of breakthrough pain.
Which of the following is least appropriate for patients with breakthrough pain or cancer pain?
Which of the following is least appropriate for patients with breakthrough pain or cancer pain?
A patient of European descent is prescribed tamoxifen for breast cancer prevention. What pharmacogenetic consideration is most relevant regarding the drug's efficacy?
A patient of European descent is prescribed tamoxifen for breast cancer prevention. What pharmacogenetic consideration is most relevant regarding the drug's efficacy?
A clinician is considering prescribing carbamazepine to a patient who reports being of Asian descent. What genetic test is most important to conduct before initiating treatment?
A clinician is considering prescribing carbamazepine to a patient who reports being of Asian descent. What genetic test is most important to conduct before initiating treatment?
Which of the following represents a barrier to the widespread implementation of pharmacogenomics in clinical practice?
Which of the following represents a barrier to the widespread implementation of pharmacogenomics in clinical practice?
A cardiologist is planning treatment for a patient with a recent myocardial infarction who is also a CYP2C19 poor metabolizer. Which antiplatelet medication should the cardiologist consider, given the patient's genetic profile?
A cardiologist is planning treatment for a patient with a recent myocardial infarction who is also a CYP2C19 poor metabolizer. Which antiplatelet medication should the cardiologist consider, given the patient's genetic profile?
What is the primary focus of precision medicine?
What is the primary focus of precision medicine?
Which of the following genetic variations is known to increase the risk of toxicity in patients taking warfarin?
Which of the following genetic variations is known to increase the risk of toxicity in patients taking warfarin?
What is a key consideration when using genetic testing to guide warfarin dosing?
What is a key consideration when using genetic testing to guide warfarin dosing?
A patient is prescribed a beta-1 (B1) adrenergic receptor antagonist. If the patient has a genetic variant that causes B1 receptors to be hyperresponsive, what outcome is most likely?
A patient is prescribed a beta-1 (B1) adrenergic receptor antagonist. If the patient has a genetic variant that causes B1 receptors to be hyperresponsive, what outcome is most likely?
A health care provider is using genetic testing to optimize drug selection. Which resource offers guidelines to assist providers?
A health care provider is using genetic testing to optimize drug selection. Which resource offers guidelines to assist providers?
A patient is about to start on Abacavir treatment for HIV. What genetic testing is important before starting?
A patient is about to start on Abacavir treatment for HIV. What genetic testing is important before starting?
What is the definition of pharmacogenomics?
What is the definition of pharmacogenomics?
Which of the following describes how adverse drug reactions are ranked as cause of death in the U.S.?
Which of the following describes how adverse drug reactions are ranked as cause of death in the U.S.?
When genetic variants commonly modify drug responses, what are the ways that it modifies?
When genetic variants commonly modify drug responses, what are the ways that it modifies?
A patient with cancer needs a medication. They have a genetic variant that means they can't convert the drug to its active form. What will this cause?
A patient with cancer needs a medication. They have a genetic variant that means they can't convert the drug to its active form. What will this cause?
What does the Genetic Information Nondiscrimination Act (GINA) protect?
What does the Genetic Information Nondiscrimination Act (GINA) protect?
Which of the following is the most critical consideration when prescribing medication to a pregnant patient?
Which of the following is the most critical consideration when prescribing medication to a pregnant patient?
Teratogenicity refers to which of the following drug effects?
Teratogenicity refers to which of the following drug effects?
Why is it essential to understand the FDA pregnancy risk categories when prescribing medications to pregnant women?
Why is it essential to understand the FDA pregnancy risk categories when prescribing medications to pregnant women?
When choosing a medication for a breastfeeding mother, what is a crucial factor to consider to minimize infant exposure?
When choosing a medication for a breastfeeding mother, what is a crucial factor to consider to minimize infant exposure?
Which factor primarily determines the amount of drug exposure a breastfeeding infant receives?
Which factor primarily determines the amount of drug exposure a breastfeeding infant receives?
What is the primary goal when prescribing medications to breastfeeding mothers?
What is the primary goal when prescribing medications to breastfeeding mothers?
Why are drugs with a short half-life often preferred in breastfeeding mothers?
Why are drugs with a short half-life often preferred in breastfeeding mothers?
What is a key consideration when prescribing medications classified as 'category X' during pregnancy?
What is a key consideration when prescribing medications classified as 'category X' during pregnancy?
How does pregnancy affect drug distribution in the mother's body?
How does pregnancy affect drug distribution in the mother's body?
What is the significance of considering a drug's molecular weight when prescribing to a breastfeeding mother?
What is the significance of considering a drug's molecular weight when prescribing to a breastfeeding mother?
Why is it important to counsel breastfeeding mothers about timing medication doses relative to breastfeeding?
Why is it important to counsel breastfeeding mothers about timing medication doses relative to breastfeeding?
Which of the following best defines teratogenesis?
Which of the following best defines teratogenesis?
What is a critical factor to consider regarding drug absorption during pregnancy?
What is a critical factor to consider regarding drug absorption during pregnancy?
A medication's high protein-binding capacity during pregnancy suggests which of the following?
A medication's high protein-binding capacity during pregnancy suggests which of the following?
Why might a medication with a long half-life pose a greater risk to a breastfeeding infant?
Why might a medication with a long half-life pose a greater risk to a breastfeeding infant?
What is the primary reason certain medications are considered absolutely contraindicated during breastfeeding?
What is the primary reason certain medications are considered absolutely contraindicated during breastfeeding?
Which of the following is a key consideration when assessing the risk of drug transfer into breast milk?
Which of the following is a key consideration when assessing the risk of drug transfer into breast milk?
What information is provided by resources like LactMed?
What information is provided by resources like LactMed?
When should a breastfeeding mother ideally take medication to minimize infant exposure?
When should a breastfeeding mother ideally take medication to minimize infant exposure?
Why is monitoring the infant important when a breastfeeding mother is taking medication?
Why is monitoring the infant important when a breastfeeding mother is taking medication?
Which of the following physiological changes in pregnancy can affect drug metabolism?
Which of the following physiological changes in pregnancy can affect drug metabolism?
What is the most prudent approach when prescribing medications during pregnancy, considering the potential for teratogenic effects?
What is the most prudent approach when prescribing medications during pregnancy, considering the potential for teratogenic effects?
What is the primary significance of a drug's volume of distribution (Vd) during pregnancy?
What is the primary significance of a drug's volume of distribution (Vd) during pregnancy?
In the context of prescribing for breastfeeding mothers, what does the term 'relative infant dose' (RID) refer to?
In the context of prescribing for breastfeeding mothers, what does the term 'relative infant dose' (RID) refer to?
What is the primary factor influencing drug distribution in neonates compared to older children?
What is the primary factor influencing drug distribution in neonates compared to older children?
Which developmental factor in infants (under 1 year) has the MOST impact on drug metabolism?
Which developmental factor in infants (under 1 year) has the MOST impact on drug metabolism?
In children aged 1-12 years, what change in drug metabolism is typically observed compared to adults?
In children aged 1-12 years, what change in drug metabolism is typically observed compared to adults?
Which of the following pharmacokinetics variables is LEAST likely to be affected by the aging process in older adults?
Which of the following pharmacokinetics variables is LEAST likely to be affected by the aging process in older adults?
An older adult experiences a significant decline in renal function. How will this MOST likely affect the excretion of a drug primarily eliminated by the kidneys?
An older adult experiences a significant decline in renal function. How will this MOST likely affect the excretion of a drug primarily eliminated by the kidneys?
Which of the following physiological changes in older adults has the MOST significant impact on the volume of distribution of lipophilic drugs?
Which of the following physiological changes in older adults has the MOST significant impact on the volume of distribution of lipophilic drugs?
What is a crucial consideration when prescribing medications for older adults related to changes in drug metabolism?
What is a crucial consideration when prescribing medications for older adults related to changes in drug metabolism?
What common prescribing strategy can help reduce the risk of adverse drug reactions in older adults, considering pharmacokinetic changes?
What common prescribing strategy can help reduce the risk of adverse drug reactions in older adults, considering pharmacokinetic changes?
What is a key consideration for medication use in palliative care at the end of life, given potential alterations in drug pharmacokinetics?
What is a key consideration for medication use in palliative care at the end of life, given potential alterations in drug pharmacokinetics?
How might the altered absorption and metabolism of medications in a terminally ill patient impact treatment decisions?
How might the altered absorption and metabolism of medications in a terminally ill patient impact treatment decisions?
Which aspect of drug therapy requires the MOST careful adjustment in an elderly patient at the end of life?
Which aspect of drug therapy requires the MOST careful adjustment in an elderly patient at the end of life?
Why is there an increased vulnerability to medication-related adverse effects among older palliative care patients?
Why is there an increased vulnerability to medication-related adverse effects among older palliative care patients?
A patient is identified as a CYP2C19 poor metabolizer. How does this MOST likely affect the efficacy of clopidogrel?
A patient is identified as a CYP2C19 poor metabolizer. How does this MOST likely affect the efficacy of clopidogrel?
For a patient of Asian descent, what is the primary reason for screening for HLA-B*1502 allele before starting carbamazepine treatment?
For a patient of Asian descent, what is the primary reason for screening for HLA-B*1502 allele before starting carbamazepine treatment?
Prior to prescribing tamoxifen, what pharmacogenomic consideration is most relevant for a patient to ensure the drug's efficacy?
Prior to prescribing tamoxifen, what pharmacogenomic consideration is most relevant for a patient to ensure the drug's efficacy?
What is the primary benefit of using genetic or traditional testing when initiating warfarin therapy?
What is the primary benefit of using genetic or traditional testing when initiating warfarin therapy?
A patient with a known genetic variant demonstrates an exaggerated response to beta-1 adrenergic agonists. What is a likely clinical implication?
A patient with a known genetic variant demonstrates an exaggerated response to beta-1 adrenergic agonists. What is a likely clinical implication?
What is a measurable parameter that signifies the presence of a specific physiological phenomenon, and can relate to drug responses?
What is a measurable parameter that signifies the presence of a specific physiological phenomenon, and can relate to drug responses?
Which factor presents a significant challenge to the widespread use of pharmacogenomics in clinical practice?
Which factor presents a significant challenge to the widespread use of pharmacogenomics in clinical practice?
According to the provided FDA Stand on Genetic Testing, which drug requires that clinicians use genetic testing to determine proper usage?
According to the provided FDA Stand on Genetic Testing, which drug requires that clinicians use genetic testing to determine proper usage?
When prescribing medications to a pregnant patient, what is the MOST significant initial consideration?
When prescribing medications to a pregnant patient, what is the MOST significant initial consideration?
What is the primary concern when prescribing a medication categorized as 'Category X' during pregnancy?
What is the primary concern when prescribing a medication categorized as 'Category X' during pregnancy?
Which pharmacokinetic factor is MOST altered during pregnancy, potentially requiring dosage adjustments for certain medications?
Which pharmacokinetic factor is MOST altered during pregnancy, potentially requiring dosage adjustments for certain medications?
When choosing a medication for a breastfeeding mother, what drug characteristic helps minimize exposure to the infant?
When choosing a medication for a breastfeeding mother, what drug characteristic helps minimize exposure to the infant?
Which of the following resources is most helpful for a clinician seeking information on drug transfer into breast milk and potential infant adverse effects?
Which of the following resources is most helpful for a clinician seeking information on drug transfer into breast milk and potential infant adverse effects?
During pregnancy, which type of drugs can MOST easily cross the placenta?
During pregnancy, which type of drugs can MOST easily cross the placenta?
A pregnant patient is taking a medication known to cause osteoporosis as an adverse effect. Which of the following medications is MOST likely the culprit?
A pregnant patient is taking a medication known to cause osteoporosis as an adverse effect. Which of the following medications is MOST likely the culprit?
Which of the following is MOST likely to result from aspirin use near term in pregnant patients?
Which of the following is MOST likely to result from aspirin use near term in pregnant patients?
A medication's effect during the embryonic period of pregnancy is MOST likely to cause:
A medication's effect during the embryonic period of pregnancy is MOST likely to cause:
What is the MOST likely outcome when teratogens affect a pregnancy during the preimplantation period?
What is the MOST likely outcome when teratogens affect a pregnancy during the preimplantation period?
During which period of pregnancy is a fetus MOST susceptible to structural malformations caused by teratogens?
During which period of pregnancy is a fetus MOST susceptible to structural malformations caused by teratogens?
Which of the following medications is associated with causing tooth and bone abnormalities if taken during pregnancy?
Which of the following medications is associated with causing tooth and bone abnormalities if taken during pregnancy?
Which medication can cause premature closure of the ductus arteriosus if taken during pregnancy?
Which medication can cause premature closure of the ductus arteriosus if taken during pregnancy?
Which of the following is associated with causing Neonatal Hypoglycemia?
Which of the following is associated with causing Neonatal Hypoglycemia?
A pregnant patient is prescribed a medication labeled as Pregnancy Category X. What does this signify?
A pregnant patient is prescribed a medication labeled as Pregnancy Category X. What does this signify?
Following confirmation of teratogen exposure during pregnancy, what is the FIRST step?
Following confirmation of teratogen exposure during pregnancy, what is the FIRST step?
Which of the following characteristics makes a drug LEAST likely to be transferred into breast milk?
Which of the following characteristics makes a drug LEAST likely to be transferred into breast milk?
A breastfeeding mother requires an analgesic. Which of the following is GENERALLY considered a drug of choice?
A breastfeeding mother requires an analgesic. Which of the following is GENERALLY considered a drug of choice?
Which type of medication is contraindicated for breastfeeding mothers?
Which type of medication is contraindicated for breastfeeding mothers?
Why is the consideration of a drug's half-life important when prescribing to breastfeeding mothers?
Why is the consideration of a drug's half-life important when prescribing to breastfeeding mothers?
Which description applies to why physiologic changes should be considered when prescribing to a pregnant patient?
Which description applies to why physiologic changes should be considered when prescribing to a pregnant patient?
What is the KEY cause of adverse drug reactions (ADRs) in the geriatric population?
What is the KEY cause of adverse drug reactions (ADRs) in the geriatric population?
During the reduction in lean body mass and total body water in older adults, how can they impact medications?
During the reduction in lean body mass and total body water in older adults, how can they impact medications?
Which is the recommendation that is used when accounting for pharmacokinetics and pharmacodynamic changes that occur when a patient ages?
Which is the recommendation that is used when accounting for pharmacokinetics and pharmacodynamic changes that occur when a patient ages?
Which of the following factors presents the GREATEST challenge when prescribing to older adult patients?
Which of the following factors presents the GREATEST challenge when prescribing to older adult patients?
What action should providers take when prescribing to a patient who is facing end of life concerns?
What action should providers take when prescribing to a patient who is facing end of life concerns?
The Beers Criteria for Potentially Inappropriate Medication should be avoided for what reason?
The Beers Criteria for Potentially Inappropriate Medication should be avoided for what reason?
Which of the following drugs used for end-of-life respiratory secretions is an anticholinergic?
Which of the following drugs used for end-of-life respiratory secretions is an anticholinergic?
Which dosage is recommended to start therapy for pharmacokinetic and pharmacodynamic changes?
Which dosage is recommended to start therapy for pharmacokinetic and pharmacodynamic changes?
In pediatric patients, what does the blood-brain barrier impact?
In pediatric patients, what does the blood-brain barrier impact?
What is the gastric emptying rate for neonates aged 0-28 days?
What is the gastric emptying rate for neonates aged 0-28 days?
What is the gastric emptying rate for an infant that is 1 month to 2 years?
What is the gastric emptying rate for an infant that is 1 month to 2 years?
What can be used to convert an adult dosage to a pediatric dosage for a med?
What can be used to convert an adult dosage to a pediatric dosage for a med?
Which medication could cause a patient who is prematurely going through puberty to have reduced adult height?
Which medication could cause a patient who is prematurely going through puberty to have reduced adult height?
What possible adverse reaction can be caused by the use of fluoroquinolones?
What possible adverse reaction can be caused by the use of fluoroquinolones?
A patient with chickenpox can experience what adverse reaction if they take Aspirin or other salicylates?
A patient with chickenpox can experience what adverse reaction if they take Aspirin or other salicylates?
What important steps can we take to promote adherence, particularly for children?
What important steps can we take to promote adherence, particularly for children?
When administering the pediatric dose via weight, how do you determine the BSA Dosage?
When administering the pediatric dose via weight, how do you determine the BSA Dosage?
What are important pharmacokinetic considerations when prescribing to a pediatric patient?
What are important pharmacokinetic considerations when prescribing to a pediatric patient?
What can happen to a neonate exposed to sulfonamides?
What can happen to a neonate exposed to sulfonamides?
What can happen to a child exposed to Tetracyclines?
What can happen to a child exposed to Tetracyclines?
What can happen to a child that uses promethazine?
What can happen to a child that uses promethazine?
What can happen to a child exposed to Hexachlorophene?
What can happen to a child exposed to Hexachlorophene?
Can aspirin and other salicylates lead to severe intoxication in children?
Can aspirin and other salicylates lead to severe intoxication in children?
When is it safe to prescribe new drugs with pregnant patients?
When is it safe to prescribe new drugs with pregnant patients?
What is one unique, pregnancy related adverse effect for Prostaglandins (like misoprostol)?
What is one unique, pregnancy related adverse effect for Prostaglandins (like misoprostol)?
A pregnant woman with a history of alcohol use is MOST at risk for:
A pregnant woman with a history of alcohol use is MOST at risk for:
What is a potential adverse drug reaction (ADR) of prostaglandins (misoprostol) when used in pregnancy?
What is a potential adverse drug reaction (ADR) of prostaglandins (misoprostol) when used in pregnancy?
What is one of the potential impacts of teratogens during the preimplantation period?
What is one of the potential impacts of teratogens during the preimplantation period?
What is a potential impact of teratogens during the embryonic period?
What is a potential impact of teratogens during the embryonic period?
Flashcards
Baclofen: Class & MOA
Baclofen: Class & MOA
Skeletal muscle relaxant. Inhibits transmission of mono/polysynaptic reflexes, leading to hyperpolarization of afferent fibers.
Baclofen: Indications
Baclofen: Indications
Muscle spasms/pain and spasticity.
Baclofen: Adverse Effects
Baclofen: Adverse Effects
Confusion, dizziness, and sedation.
Baclofen: Contraindications
Baclofen: Contraindications
Hypersensitivity to baclofen.
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Baclofen: Major Interactions
Baclofen: Major Interactions
Alcohol, hydroxyzine, opioids, and zolpidem.
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Baclofen: Patient Education (intrathecal)
Baclofen: Patient Education (intrathecal)
Monitor for altered mental status, fever, rigidity, rhabdomyolysis, and death if pump fails.
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Diazepam: Class & MOA
Diazepam: Class & MOA
Benzodiazepine. Binds at postsynaptic GABA neuron, enhances GABA effect.
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Diazepam: Indications
Diazepam: Indications
Muscle spasms/rigidity.
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Diazepam: Adverse Effects
Diazepam: Adverse Effects
Anterograde amnesia, CNS depression, paradoxical reactions.
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Diazepam: Contraindications
Diazepam: Contraindications
Hypersensitivity to diazepam.
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Diazepam: Major Interactions
Diazepam: Major Interactions
Opioids, alcohol, hydroxyzine, valproic acid, and zolpidem.
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Diazepam: Clinical Pearls
Diazepam: Clinical Pearls
Can be helpful in acute settings or severe spasms, but not for long-term management.
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Dantrolene: Class & MOA
Dantrolene: Class & MOA
Skeletal muscle relaxant. Interferes with calcium release.
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Dantrolene: Indications
Dantrolene: Indications
Spasms, malignant hyperthermia.
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Dantrolene: Adverse Effects
Dantrolene: Adverse Effects
CNS depression, hepatotoxicity, muscle weakness.
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Dantrolene: Contraindications
Dantrolene: Contraindications
Cirrhosis, hepatitis, when spasticity is needed to maintain function.
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Dantrolene: Major Interactions
Dantrolene: Major Interactions
Alcohol, hydroxyzine, opioids, and zolpidem.
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Dantrolene: Clinical Pearls
Dantrolene: Clinical Pearls
Usually used for malignant hyperthermia; rarely for muscle spasms/pain.
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Cyclobenzaprine: Class & MOA
Cyclobenzaprine: Class & MOA
Skeletal Muscle Relaxant. Influences activity of alpha and gamma motor neurons.
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Cyclobenzaprine: Indications
Cyclobenzaprine: Indications
Muscle spasm/pain, post-op.
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Cyclobenzaprine: Adverse Effects
Cyclobenzaprine: Adverse Effects
Anticholinergic effects, CNS, serotonin syndrome.
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Cyclobenzaprine: Contraindications
Cyclobenzaprine: Contraindications
Hypersensitivity, MAO use, hyperthyroidism, heart block, acute recovery of MI, heart failure.
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Cyclobenzaprine: Major Interactions
Cyclobenzaprine: Major Interactions
Alcohol, opioids, hydroxyzine, and zolpidem.
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Cyclobenzaprine: Clinical Pearls
Cyclobenzaprine: Clinical Pearls
Similar medications like methocarbamol and tizanidine are also used; cyclobenzaprine is said to be most sedating.
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Spasm/Spasticity: Patient Education
Spasm/Spasticity: Patient Education
Caution alcohol use, caution combination with benzodiazepines/opioids, driving.
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Muscle Spasm
Muscle Spasm
Involuntary and forceful muscle contraction; also known as Charley Horse or muscle cramp.
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Muscle Spasm: Pathophysiology
Muscle Spasm: Pathophysiology
Aberrant afferent input and/or non-physiological motor axonal transmission leads to sustained muscle contraction and cramps.
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Muscle Spasms: Common Causes
Muscle Spasms: Common Causes
Includes dehydration, electrolyte imbalances, overuse, and underlying medical conditions.
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Muscle Spasm: Differential Diagnosis
Muscle Spasm: Differential Diagnosis
Physiologic, metabolic, neuromuscular, and other neurological conditions.
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Muscle Spasm: Treatment Approaches
Muscle Spasm: Treatment Approaches
Pharmacologic (e.g., cyclobenzaprine, diazepam, dantrolene) and non-pharmacologic (heat, stretching, PT, massage).
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Muscle Spasticity
Muscle Spasticity
A condition characterized by increased muscle tone, stiffness, and exaggerated reflexes due to upper motor neuron damage.
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Muscle Spasticity: Pathophysiology
Muscle Spasticity: Pathophysiology
Damage to motor cortex and CST pathways leads to a loss of cortical inhibition, resulting in spasticity and hyperreflexia.
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Muscle Spasticity: Treatment
Muscle Spasticity: Treatment
Pharmacologic (e.g., baclofen, diazepam, dantrolene) and non-pharmacologic (heat, stretching, PT, massage). Movement helps.
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Specific Spasticity Treatments
Specific Spasticity Treatments
Baclofen is often used intrathecally; dantrolene can help with baclofen withdrawal.
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Treatments for Muscle Spasms
Treatments for Muscle Spasms
Pharmacologic: Cyclobenzaprine and diazepam can be used. Non-pharmacologic: Heat, stretching, PT, massage. Movement helps..
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Cancer Pain: Direct Causes
Cancer Pain: Direct Causes
Tumor burden, metastatic invasion, and visceral pain.
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Cancer Pain: Treatment-Related Causes
Cancer Pain: Treatment-Related Causes
Chemotherapy, radiation, and surgery.
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Cancer Pain Management: Step 1
Cancer Pain Management: Step 1
Starts with non-opioid analgesics and adjuvant therapies.
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Cancer Pain Management: Step 2
Cancer Pain Management: Step 2
Escalates to low-dose opioids with non-opioid analgesics and adjuvants.
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Cancer Pain Management: Step 3
Cancer Pain Management: Step 3
Utilizes strong opioids with non-opioid analgesics and adjuvants; consider route and tolerance.
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Cancer Pain Management: Step 4
Cancer Pain Management: Step 4
Considers interventional techniques like epidural/intrathecal, surgery, nerve blocks, ultrasound, and ablation.
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Cancer Pain: Patient Education
Cancer Pain: Patient Education
Reassure manageability, encourage honest reporting, provide a written plan including breakthrough pain management.
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Barriers to Pain Control
Barriers to Pain Control
Poor pain assessment, under-reporting, opioid fears, tolerance, and cultural beliefs.
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Multimodal Pain Control
Multimodal Pain Control
Scheduled acetaminophen, NSAIDs, lidocaine patches, nerve blocks, gabapentin, muscle relaxers.
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Genetics
Genetics
Examination of the passing of genetic traits from one generation to another through human genes.
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Genome
Genome
All of a person's genes.
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Genomics
Genomics
The study of the genome, including gene interactions with each other and the environment.
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Pharmacogenomics
Pharmacogenomics
The study of how genes affect a person's response to drugs.
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Precision Medicine
Precision Medicine
Finding effective treatment strategies for patient groups based on genetic, lifestyle, and environmental factors.
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Pharmacogenomic Biomarker
Pharmacogenomic Biomarker
A measurable indicator that suggests the presence of a specific phenomenon such as gene characteristics related to drug responses.
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Genetic Variants and Drug Metabolism
Genetic Variants and Drug Metabolism
Genetic variations commonly modify drug responses by accelerating or slowing the metabolism of many drugs, or by reducing their benefits and/or increasing toxicity.
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CYP2C19 and Clopidogrel
CYP2C19 and Clopidogrel
The cytochrome that can reduce the benefits of clopidogrel (Plavix) because it is needed to convert the drug to its active form. About 25% of patients have a variant of the enzyme
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CYP2C9 and Warfarin
CYP2C9 and Warfarin
Cytochrome variants can increase toxicity when metabolizing this drug, so it's inactived by this one, those with variants will metabolize slow and causes it to accumulate
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CYP2D6 and Tamoxifen
CYP2D6 and Tamoxifen
The cytochrome that convert tamoxifen to it's active form and a deficiency can reduce the benefits of tamoxifen, leading to a drug related risk for endometrial canacer
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Pharmacogenomic Resources
Pharmacogenomic Resources
CDC Genomics and Precision Health, US FDA Precision Medicine, and CPIC (Clinical Pharmacogenetics Implementation Consortium)
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Barriers to Pharmacogenomic Implementation
Barriers to Pharmacogenomic Implementation
Limited reimbursement, delay to be available, lack of clinician education, limited guidelines and standardization, and ethical/privacy concerns
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Practical Applications of Genetic Testing
Practical Applications of Genetic Testing
Can predict drug response and adverse effects, guides personalized medication selection and dosing, and are useful in oncology, psychiatry, cardiology, and pain management
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Variants VKORC1 and Warfarin
Variants VKORC1 and Warfarin
Variants genes produce a form of the enzyme that can be easily inhibited by warfarin which allow for anticoagulation with a reduced dosage.
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Altered Immune Response
Altered Immune Response
Increases the risk of severe hypersensitivity reactions with certain drugs such as Carbamazepine (Tegretol) used for epilepsy, bipolar
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Teratogenic Drugs
Teratogenic Drugs
Medications known to cause birth defects.
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FDA Pregnancy Categories
FDA Pregnancy Categories
A system used to classify medications based on their potential risk to a developing fetus.
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Pregnancy Category A
Pregnancy Category A
Controlled human studies demonstrate no risk to the fetus.
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Pregnancy Category B
Pregnancy Category B
Animal studies show no fetal risk, but no controlled human studies exist OR animal studies show risk, but controlled human studies do not.
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Pregnancy Category C
Pregnancy Category C
Animal studies show fetal risk, but potential benefits may outweigh risks in certain situations
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Pregnancy Category D
Pregnancy Category D
Definite fetal risk exists, benefits may outweigh risk in life-threatening situations.
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Pregnancy Category X
Pregnancy Category X
Studies demonstrate fetal abnormalities; risk clearly outweighs any benefit.
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Teratogenic Antihypertensives
Teratogenic Antihypertensives
ACE inhibitors, ARBs, and Renin Inhibitors
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Teratogenic Anticoagulant
Teratogenic Anticoagulant
Warfarin
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Teratogenic Acne Medication
Teratogenic Acne Medication
Isotretinoin
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Teratogenic DMARD
Teratogenic DMARD
Methotrexate
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Teratogenic Immunomodulatory Drug
Teratogenic Immunomodulatory Drug
Thalidomide
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Teratogenic Anticonvulsant
Teratogenic Anticonvulsant
Valproic Acid
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Teratogenic Mood Stabilizer
Teratogenic Mood Stabilizer
Lithium
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Teratogenic Antiviral
Teratogenic Antiviral
Ribavirin
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Teratogenic Prostaglandin
Teratogenic Prostaglandin
Misoprostol
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Teratogenic 5-alpha-reductase inhibitor
Teratogenic 5-alpha-reductase inhibitor
Finasteride
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Pediatric Dosage Formulas
Pediatric Dosage Formulas
Clark's Rule: (Weight in lbs / 150) x Adult Dose = Pediatric Dose. Young's Rule: (Age / (Age + 12)) x Adult Dose = Pediatric Dose.
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Beers Criteria: Anticholinergics
Beers Criteria: Anticholinergics
Anticholinergics (e.g., diphenhydramine, oxybutynin). Cause confusion, dry mouth, constipation, and urinary retention. Alternatives: Non-anticholinergic antihistamines (loratadine), behavioral interventions for urinary issues.
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Beers Criteria: Benzodiazepenes
Beers Criteria: Benzodiazepenes
Benzodiazepenes (e.g., diazepam, lorazepam). Increased risk of cognitive impairment, delirium, falls, and fractures. Alternatives: Non-benzodiazepine anxiolytics (buspirone), SSRIs, behavioral therapies.
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Beers Criteria: NSAIDs
Beers Criteria: NSAIDs
NSAIDs (e.g., ibuprofen, naproxen). Increase risk of GI bleeding, renal impairment, and cardiovascular events. Alternatives: Acetaminophen, topical analgesics, non-pharmacologic pain management.
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Beers Criteria: Opioids
Beers Criteria: Opioids
Opioids. Increased risk of falls, constipation, respiratory depression, and cognitive impairment. Alternatives: Non-opioid analgesics, multimodal pain management strategies.
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Beers Criteria: Sliding Scale Insulin
Beers Criteria: Sliding Scale Insulin
Sliding scale insulin. High risk of hypoglycemia. Alternatives: Scheduled insulin with adjustments, consistent carbohydrate intake.
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Beers Criteria: First Gen. Antihistamines
Beers Criteria: First Gen. Antihistamines
First-generation antihistamines (e.g., diphenhydramine). Anticholinergic effects, sedation, increased fall risk. Alternatives: Second-generation antihistamines (loratadine, cetirizine).
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Beers Criteria: Nitrofurantoin
Beers Criteria: Nitrofurantoin
Nitrofurantoin: Risk of pulmonary toxicity, peripheral neuropathy, especially with long-term use, safer alternatives available. Alternatives: Other antibiotics based on culture and sensitivity.
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Pregnancy: Physiologic Changes
Pregnancy: Physiologic Changes
Changes in GI can lead to prolonged transit time affecting drug absorption. Renal blood flow doubles, increasing drug clearance. Liver metabolism increases.
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Placental Drug Transfer
Placental Drug Transfer
Lipid-soluble drugs cross the placenta easily. Ionized, water-soluble, highly polar, or protein-bound drugs cross with difficulty.
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ADRs Unique to Pregnancy
ADRs Unique to Pregnancy
Heparin can cause osteoporosis/compression fractures. Prostaglandins can cause abortion. Aspirin can suppress contractions in labor and increases the risk for serious bleeding.
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Preimplantation Period Effects
Preimplantation Period Effects
Teratogens result in death of the conceptus or have no negative impact.
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Embryonic Period Effects
Embryonic Period Effects
Teratogens cause structural malformations during this period.
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Fetal Period Effects
Fetal Period Effects
Teratogens affect organ function and development.
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Drugs causing Internal Organ Defects
Drugs causing Internal Organ Defects
Thalidomide, Isotretinoin, Vitamin A derivatives
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Drug causing Vaginal Carcinoma
Drug causing Vaginal Carcinoma
Diethylstilbestrol
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Drugs causing Premature closure of Ductus Arteriosus
Drugs causing Premature closure of Ductus Arteriosus
NSAIDs, Warfarin
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Pregnancy: Drug Caution
Pregnancy: Drug Caution
Caution with all new drugs and in pregnant patients. Lack of teratogenicity in animals is not proof of safety in humans.
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FDA Pregnancy Risks
FDA Pregnancy Risks
A indicates remote risk, X indicates high risk. Risk increases from A to X.
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Teratogen Exposure Protocol
Teratogen Exposure Protocol
Determine gestational age, identify common malformations linked to the drug, use ultrasound, and consider options.
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Drugs Contraindicated: Breastfeeding
Drugs Contraindicated: Breastfeeding
Amphetamine, Cocaine, Heroin, Marijuana, Phencyclidine are unsafe. Cyclophosphamide, Cyclosporine, Doxorubicin, Methotrexate are also unsafe.
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Drugs contraindicate in breastfeeding
Drugs contraindicate in breastfeeding
Substances like Amphetamine, Cocaine, Heroin, Marijuana and Phencyclidine
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Breastfeeding: Safe Meds
Breastfeeding: Safe Meds
Acetaminophen, ibuprofen, sertraline, loratadine, penicillins, propylthiouracil are generally safe.
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Breastfeeding: Analgesics of Choice
Breastfeeding: Analgesics of Choice
Preferred analgesics include acetaminophen, ibuprofen, mefenamic acid, sumatriptan, and morphine.
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Breastfeeding : Anticoagulant Drugs of Choice
Breastfeeding : Anticoagulant Drugs of Choice
Warfarin, acenocoumarol, and heparin (unfractionated).
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Capital of France (example flashcard)
Capital of France (example flashcard)
Paris
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Pharmacotherapy Across the Lifespan: Pregnancy
- GI tone and motility decrease during pregnancy, leading to prolonged transit time; this can affect drug levels.
- Renal blood flow doubles in pregnant patients, which increases glomerular filtration rate, leading to faster clearance of some drugs.
- Hepatic metabolism increases in pregnant patients; this has implications for some medications.
- Lipid-soluble drugs cross the placenta easily.
- Drugs that are ionized (water soluble), highly polar, and protein-bound are difficult to cross the placenta.
- It is generally assumed that any drug taken during pregnancy will reach the fetus.
- Heparin can cause osteoporosis, leading to compression fractures.
- Prostaglandins (e.g., misoprostol) can cause abortion.
- Aspirin near term can suppress contractions in labor and increases the risk for serious bleeding.
- Teratogens during the preimplantation period (weeks 1-2) either result in death of the conceptus or have no negative impact.
- Exposure to teratogens during the embryonic period (weeks 3-8) can cause structural or gross malformations. High sensitivity period.
- Teratogens during the fetal period (week 9 to birth) can impact function.
- If teratogen exposure is confirmed, determine how far along the pregnancy was when the drug was taken.
- If teratogen exposure is confirmed, identify what malformations are common with that drug.
- If teratogen exposure is confirmed, perform an ultrasound (at least twice) to evaluate.
- If teratogen exposure is confirmed, consider termination of pregnancy if the malformation is severe.
Drugs That Can Cause Teratogenic Effects
- Cyclophosphamide and Methotrexate can cause CNS malformations.
- Methotrexate and Thalidomide can cause limb malformations.
- Carbamazepine, Valproic acid, Tetracycline and Trimethoprim-sulfamethoxazole, Angiotensin-converting enzyme inhibitors, HMG CoA reductase inhibitors, NSAIDs, and Warfarin can cause cardiovascular malformations.
- Diethylstilbestrol and 5-α-reductase inhibitors can cause genital malformations.
- Carbamazepine, Valproic acid, Trimethoprim-sulfamethoxazole, HMG CoA reductase inhibitors, Isotretinoin and other vitamin A derivatives can cause craniofacial defects.
- Angiotensin-converting enzyme inhibitors can cause renal malformations.
- Carbamazepine, Phenytoin, Topiramate, Valproic acid, Trimethoprim-sulfamethoxazole, HMG CoA reductase inhibitors and Warfarin can all cause neural tube defects.
- Thalidomide, Isotretinoin and other vitamin A derivatives can cause internal organ defects.
- Phenytoin and Topiramate cause growth delay.
- Carbamazepine and Valproic acid can cause Hypospadias.
- Diethylstilbestrol can cause vaginal carcinoma.
- Tetracycline can cause tooth and bone anomalies.
- Nicotine replacement products can cause Orofacial Clefts and Intrauterine Growth Restriction.
- Alcohol can cause Stillbirth, Spontaneous Abortion, Low Birth Weight and Intellectual Disabilities.
- NSAIDs and Warfarin can cause Premature closure of Ductus Arteriosus.
- Oral hypoglycemic drugs can cause Neonatal Hypoglycemia.
- HMG CoA reductase inhibitors can cause Facial Malformations and Single-lobed Brain (Holoprosencephaly).
- Lithium can cause Epstein Anomaly.
- A lack of teratogenicity in animals is not proof of safety in humans, even if the FDA has approved it.
- Exercise caution with all new drugs and pregnant patients.
FDA Pregnancy Risk Categories
- Category A: Remote risk – Studies in women show no harm during the first trimester, and no evidence of risk later in pregnancy.
- Category B: Slightly more risk – Animal studies show no risk, or show risk only in later trimesters, but no human studies have been done.
- Category C: Greater risk – Animal studies show risk, but no human studies have been done.
- Category D: Proven risk – Studies in women show fetal damage, but benefits may outweigh risks for life-threatening conditions; a statement on risk will appear in the WARNINGS section of drug labeling.
- Category X: High risk – Studies show clear risk for fetal abnormalities, outweighing any potential benefits, these drugs are not recommended during pregnancy; a statement on risk will appear in the CONTRAINDICATIONS section of drug labeling.
- While these categories are being phased out, they’re still frequently referenced, highlighting the spectrum from high to low risk.
Pharmacotherapy Across the Lifespan: Breastfeeding
- Amphetamine, Cocaine, Heroin, Marijuana, and Phencyclidine are contraindicated during breastfeeding.
- Cyclophosphamide, Cyclosporine, Doxorubicin, and Methotrexate are contraindicated during breastfeeding.
- Atenolol, Bromocriptine, Ergotamine, Lithium, Nicotine, and radioactive compounds (temporary cessation) are contraindicated during breastfeeding.
- Acetaminophen, ibuprofen, flurbiprofen, ketorolac, mefenamic acid, sumatriptan, and morphine are drugs of choice for breastfeeding mothers when used as analgesic drugs.
- Warfarin, acenocoumarol, and heparin (unfractionated) are drugs of choice for breastfeeding mothers when used as anticoagulant drugs.
- Sertraline, paroxetine, and TCAS are drugs of choice for breastfeeding mothers when used as antidepressants.
- Carbamazepine, phenytoin, and valproic acid are drugs of choice for breastfeeding mothers when used as antiepileptic drugs.
- Loratadine and fexofenadine are drugs of choice for breastfeeding mothers when used as antihistamines.
- Penicillins, cephalosporins, aminoglycosides, macrolides are drugs of choice for breastfeeding mothers when used as antimicrobial drugs.
- Labetalol, metoprolol, and propranolol are drugs of choice for breastfeeding mothers when used as beta-adrenergic antagonists.
- Propylthiouracil, insulin, levothyroxine are drugs of choice for breastfeeding mothers when used as endocrine drugs.
- Prednisolone and prednisone are drugs of choice for breastfeeding mothers when used as glucocorticoids.
Pharmacotherapy Across the Lifespan: Pediatric Populations
- Pediatric populations are categorized by:
- Premature infants (less than 36 weeks gestational age).
- Full-term infants (36 to 40 weeks gestational age).
- Neonates (first 4 postnatal weeks).
- Infants (postnatal weeks 5 to 52).
- Children (1 to 12 years).
- Adolescents (12 to 16 years).
Pediatric Patients: Pharmacokinetic Considerations
- Drug absorption depends on gastric and intestinal variability and gastric acidity.
- Protein binding of drugs depends on low albumin and binding competition.
- The blood-brain barrier is not fully intact in the first month.
- Hepatic drug metabolism has an impact on drug levels/toxicity.
- Renal drug excretion depends on low renal blood flow, glomerular filtration, and tubular secretion.
Pediatric Patients: Neonates (0-28 days)
- Absorption:
- Gastric pH: Higher pH, decreased acid secretion.
- Gastric emptying: Slower rate, prolonged drug absorption.
- Distribution:
- Total body water: Higher proportion.
- Protein binding: Reduced due to low albumin levels.
- Metabolism:
- Enzyme activity: Immature hepatic enzyme systems.
- Elimination:
- Renal function: Reduced glomerular filtration rate and tubular secretion.
Pediatric Patients: Infants (1 month to 2 years)
- Absorption:
- Gastric pH: Gradual decrease to adult levels.
- Gastric emptying: Faster rate, variable absorption.
- Distribution:
- Total body water: Decreasing proportion.
- Protein binding: Increasing but may still be reduced compared to adults.
- Metabolism:
- Hepatic enzyme activity: Rapid maturation but still lower than adults.
- Elimination:
- Renal function: Improving but still lower than adults.
Pediatric Patients: Children (2 years and older)
- Absorption:
- Gastric pH: Similar to adults.
- Gastric emptying: Comparable to adults.
- Distribution:
- Total body water: Approaching adult levels.
- Protein binding: Similar to adults.
- Metabolism:
- Hepatic enzyme activity: Approaching adult levels.
- Elimination:
- Renal function: approaching adult levels.
Pediatric Patients: Calculations
- Adult dose can be converted to a pediatric dose by multiplying the adult dose with the child’s weight (kg) / 70.
- Adult dose can be converted to a pediatric dose by multiplying the adult dose with the child’s BSA (m^2)/ 1.73.
- To calculate accurately, determine the child’s weight (kg) or body surface area (BSA, m²), where BSA is more precise, if available.
- Apply the formula using the given adult dose while adjusting based on clinical judgment and medication-specific guidelines.
- Always verify with pediatric dosing references when available before prescribing.
Pediatric Patients: Unique Adverse Drug Reactions (Part 1)
- Androgens in pediatric patients can cause premature puberty in males and reduced adult height from premature epiphyseal closure.
- Aspirin and other salicylates in pediatric patients can cause severe intoxication from acute overdose and Reye syndrome in children with chickenpox or influenza.
- Chloramphenicol in pediatric patients can cause gray syndrome (neonates and infants).
- Fluoroquinolones in pediatric patients can cause tendon rupture.
- Glucocorticoids in pediatric patients can cause growth suppression with prolonged use.
Pediatric Patients: Unique Adverse Drug Reactions (Part 2)
- Hexachlorophene can cause central nervous system toxicity in infants.
- Nalidixic acid can cause cartilage erosion.
- Phenothiazines can cause sudden infant death syndrome.
- Promethazine is known for its pronounced respiratory depression in children younger than 2 years.
- Sulfonamides can cause Kernicterus (neonates).
- Tetracyclines can cause staining of developing teeth.
Pediatric Patients: Promoting Adherence Strategies
- Considerations to promote adherence in children:
- Simplify Regimens: Use the fewest number of doses and medications possible.
- Palatable Formulations: Choose easy-to-swallow formulations with acceptable taste.
- Education: Explain the purpose of the medication and the importance of adherence to both the child (if age-appropriate) and caregivers.
- Caregiver Involvement: Ensure caregivers understand the medication schedule and administration techniques.
- Dosing Devices: Provide accurate measuring devices like syringes or droppers.
- Behavioral Techniques: Use rewards, charts, or other techniques to encourage adherence.
- Timing with Activities: Associate medication administration with regular activities like meals or bedtime.
- Open Communication: Encourage questions and address concerns promptly.
- Consider School or Daycare: Coordinate medication administration with school or daycare personnel.
Pharmacotherapy Across the Lifespan: Older Adults
- Use inclusive language and avoid terms like seniors, elderly, the aged, aging dependents, old-old, and young-old. Terms like older persons, older people, older adults, older patients, older individuals, persons 65 years and older, or the older population are preferred.
- Considerations and Concerns for older adults include pharmacokinetics, multiple co-morbidities, polypharmacy, and adherence.
Older Adults: Pharmacokinetics
- Absorption: Increased gastric pH, decreased absorptive surface area, decreased splanchnic blood flow, decreased gastrointestinal motility, and delayed gastric emptying.
- Distribution: Increased body fat, decreased lean body mass, decreased total body water, decreased serum albumin, decreased cardiac output.
- Metabolism: Decreased hepatic blood flow and mass, and decreased activity of hepatic enzymes.
- Excretion: Decreased renal blood flow, decreased glomerular filtration rate, decreased tubular secretion, and decreased number of nephrons.
- Changes vary greatly and may be lesser in those who are physically fit.
- There is an increase in body fat. Soluble drugs (e.g., propranolol), plasma levels decrease.
- There is a decrease in lean body mass and total body water. Water-soluble drugs (e.g., ethanol) are distributed in a smaller volume concentration, effects of the drugs increase.
- There is a decrease in albumin levels. Levels of free drug increase.
- Drug accumulation secondary to reduced renal excretion is the most important cause of ADRs in older adults.
Older Adults: Challenges in Pharmacotherapeutics
- Challenges for Older adults include:
- Drug accumulation secondary to reduced renal function.
- Polypharmacy (treatment with multiple drugs).
- Greater severity of illness.
- Presence of comorbidities.
- Use of drugs that have a low therapeutic index (e.g., digoxin, a drug for heart failure).
- Increased individual variation secondary to altered pharmacokinetics.
- Inadequate supervision of long-term therapy.
- Poor patient adherence.
Older Adults: Reducing Adverse Drug Reactions
- Measures to reduce adverse drug reactions in older adults:
- Medication Review: Regularly review all medications (including over-the-counter and supplements) to identify potential interactions or unnecessary drugs.
- Start Low, Go Slow: Initiate medications at low doses and gradually increase as needed, monitoring for adverse effects.
- Simplify Regimens: Reduce the number of medications and doses whenever possible via deprescribing or using combination products.
- Avoid Polypharmacy: Limit the use of multiple medications to minimize the risk of drug interactions and adverse effects.
- Assess Renal and Hepatic Function: Adjust doses based on kidney and liver function to prevent drug accumulation.
- Consider Age-Related Changes: Understand how changes in body composition and organ function affect drug pharmacokinetics and pharmacodynamics.
- Monitor for Adverse Effects: Closely monitor older adults for any new or worsening symptoms that could be related to medications.
- Educate Patients and Caregivers: Provide clear, written instructions and counseling on medication use, potential adverse effects, and what to do if they occur.
- Use Beers Criteria: Consult the Beers Criteria to identify potentially inappropriate medications for older adults.
- Regularly Reassess Necessity: Re-evaluate the continued need for each medication at regular intervals.
- Optimize Non-Pharmacological Therapies: Use lifestyle modifications, physical therapy, and other non-drug approaches whenever feasible.
- Employ the simplest medication regimen possible.
- Monitor for drug-drug interactions and iatrogenic illness.
- Periodically review the need for continued drug therapy and discontinue medications as appropriate.
- Encourage the patient to dispose of old medications.
- Take steps to promote adherence.
- Avoid drugs included in Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
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