Module 9 Study Guide PDF

Module 9 Study Guide Become familiar with the drug classes from the Module 9 drug tables on the Module 9 overview page. Understand the mechanisms of action, Indications, potential side effects, adverse effects, potential drug-to-drug interactions, contraindications, patient education, and use in pre...

Module 9 Study Guide Become familiar with the drug classes from the Module 9 drug tables on the Module 9 overview page. Understand the mechanisms of action, Indications, potential side effects, adverse effects, potential drug-to-drug interactions, contraindications, patient education, and use in pregnancy, lactation, children, and elderly for each class. Note any monitoring or follow-up indicated. Module 9 Unit A - Dermatologic: Skin Conditions © What are the common pathogens that cause skin infections? Staphylococcus aureus and streptococcus pyogenes (both are gram + bacteria) © When is a topical agent appropriate for a skin infection? When would you use a systemic? (How do we base treatment)? Topical: localized, mild infections Systemic: bacterial infections when topicals aren’t working Tx is based on severity of symptoms © What are the current treatment recommendations for a MRSA abscess? Incision and drainage, culture and sensitivity, education on wound care and hygiene, and follow-up in the absence of systemic symptoms, severe local symptoms, and immunosuppression © What are the pharmacological treatments for venereal warts? Look at indications, MOA, safety, and patient education for each. Podophyllin (podophyllum resin) (Podocon-25, Podofilm) * MOA: mixture of resins that inhibits DNA synthesis and mitosis leading =to cellular death and erosion of the wart * Safety: highly caustic and can lead to systemic absorption leading to toxicity. Should not be used in pregnancy or lactation * Pt education: soap and water should be used a few hours after application to reduce the risk of toxicity Bichloroacetic acid (BCA) and trichloroacetic acid (TCA) * MOA: Destroy warts by chemical coagulation * Safety: caution must be used as to not spread onto healthy tissue * Pt education: can be repeated weekly Imiquimod (Aldara, Zyclara) * MOA: does not have antiviral effects but Instead, it intensifies the immune response to HPV by stimulating the production of interferon-alpha, TNF, and several interleukins * Safety: can cause local irritation (Erythema, erosion, and flaking at the site of administration. Local itching, burning, and pain) but has minimal absorption so systemic effects are not a concern * Pt education: can be applied 1-3 times weekly for several weeks. Approved for pts 12 and older. Should be avoided in pregnancy Podofilox (Condylox) * MOA: inhibits mitosis * Safety: caustic and can lead to local irritation. Avoid in pregnancy and lactation Kunecatechins (Sinecatechins/Veregen) * MOA: unknown; Antioxidative effects, apoptosis, and telomerase inhibition are possible mechanisms of action * Safety: local irritation and discomfort are a possibility (Erythema, pruritus, burning, pain, erosion or ulceration, edema, induration, and rash). Has minimal systemic absorption. Safety in pregnancy is unknown. Caution in Immunocompromised, HIV-infected pts, and genital herpes * Pt education: can be applied three times a day for up to 16 weeks © Review topical antifungal medications. Look at indications, MOA, and safety. “azoles” * Indications: first line therapy for most skin infections * MOA: Impair synthesis of ergosterol allowing for increased permeability and leakage of cellular components resulting in cell death * Usually treat from 2 to 4 weeks and then continue one week after lesions disappear * Safety: Most are OK for pregnancy and lactation © Review systemic antifungal medications. Look at indications, MOA, duration of treatment, any monitoring needed, and drug-to-drug interactions. “azoles” * Indications: tinea capitis and tinea unguium * MOA: work by inhibiting fungal CYP 450 * Duration of treatment: routine use of systemic antifungals should be avoided * Monitoring: LFTs * D2d interactions: Warfarin, theophylline, macrolides, statins * Safety: hepatotoxicity, QT prolongation (itraconazole and fluconazole), d2d interactions © What is the effect of topical creams or ointments on condoms and diaphragms? Use of topical creams for treatment of yeast infections that are oil based can weaken condoms and diaphragms © Review medications used in the treatment of acne. Look at indications, MOA, and safety. Benzoyl Peroxide: * Indications: First line drug for mild to moderate acne; both an antibiotic and keratolytic * MOA: suppressing the growth of P. acnes; release of active oxygen; reduces inflammation and promote keratolysis (peeling of the horny layer of the epidermis) * Safety: caution in asthmatic patients Isotretinoin (Accutane): * Indications: severe nodulocystic acne vulgaris * MOA: decreases sebum production, sebaceous gland size, inflammation, and keratinization; decreasing the availability of sebum, a nutrient of p. acnes; lowers the skin population of this microbe * Safety: caution in liver disease and hyperlipidemia * d2d interactions with tetracyclines and vitamin A Adapalene (Differin): * Indications: considered the cornerstone of acne therapy (mild to moderate) * MOA: they can unplug existing comedones and prevent development of new ones; reduce inflammation and improve penetration of other topical agents; modulates inflammation, epithelial keratinization, and differentiation of follicular cells * Results in a reduction of formation of comedomes and inflammatory lesions COC (YAZ, Estrostep, Ortho Tri-cyclin, Beyaz) * Indications: approved for managing acne in those born with a uterus and ovaries * Must be at least 15, have reached menarche, want contraception, and have not responded to topical agents * MOA: suppression of ovarian androgen production and increased production of sex hormone-binding globulin (binds to androgens to render them inactive) * By decreasing androgen availability, estrogens decrease production of sebum * Safety: contraindicated in renal impairment, adrenal insufficiency, high risk of arterial or venous thrombotic diseases, undiagnosed abnormal uterine bleeding, current diagnosis or hx of breast cancer, liver tumors (benign or malignant), use of hep c drug combos (ombitasvir, paritaprevir/ritonavir (with or without dasabuvir) – d/t possible ALT elevations)) * Warnings: cigarette smoking increases the risk of serious cardiovascular events from COC. This risk increases with age, particularly in women over 35 and with the number of cigarettes smoked. Should not be used by women who are over 35 and smoke Spironolactone (Aldactone): * Indications: acne, especially women with PCOS and those passed their teenage years * MOA: blocks a variety of steroid receptors, including those for aldosterone and sex hormones; blockade of aldosterone receptors underlies the drug’s use as a diuretic as well as it’s use in heart failure; blockade of androgen receptors underlies benefits to those born with a uterus and ovaries with acne * Safety: contraindicated in pts with hyperkalemia, Addison’s disease, and concomitant use of eplerenone * D2d interactions: drugs that increase K+ (ACE inhibitors, ARBs, NSAIDS, heparin (and low molecular weight heparin), trimethoprim), lithium, digoxin, cholestyramine, acetylsalicylic acid © What acne treatments are appropriate in pregnancy? What acne treatments are contraindicated in pregnancy? Appropriate: benzoyl peroxide Contraindicated: differin, COC, Aldactone Most topical antibiotics are safe in pregnancy Avoid systemic treatment in the 1st trimester if possible Antibiotics safe in pregnancy- penicillins, cephalosporins, erythromycin and other macrolides Tetracyclines and tretinoins are all contraindicated during pregnancy © Review patient education in regard to managing expectations for acne treatment. When should they expect results for acne treatments? The first-line non-pharmacologic approach is washing the face gently two or three times daily with a mild soap. Avoiding oil-based facial products and cosmetics, using earbuds when talking on a cell phone, and changing the pillowcase regularly are all daily practices that help prevent exposure to excess oils and the development of acne. First line treatments (comedolytic bactericidal agent (Benzoyl peroxide), comedolytic agent (Retinoic Acid), or a topical antibiotic (Clindamycin 2% or Erythromycin 2-3%)): 4-6 weeks for significant improvement Oral antibiotics (tetracyclines, clindamycin, and erythromycin): 6 weeks for skin to turn over to see significant improvement COC (YAZ, Estrostep, and Ortho Tri-cyclen): 4-6 months for improvement © How is acne rosacea treated? initially treated with topical metronidazole (Flagyl, Metro-Gel) Other topical or oral antibiotics may be used if that fails, including oral metronidazole © What are the differences in medication delivery systems? Compare ointments, creams, lotions, and solutions. Ointments: tend to be thick and greasy and they can have Vaseline as a base. Not only is an ointment going to be good for dry skin, but good for areas where skin is really thick, such as the soles of your feet Creams: made of oil and water and are not typically as thick as ointments, but they're going to be thicker than a lotion Lotions: mostly water-based and they probably won't have much if any oil in them Solutions: Used for dry lesions but disappear quickly and are less occlusive than solutions but more than gels Gels: typically made of a solution and a thickening agent + alcohol. Disappears quickly. Choice for acne. © Review topical steroid use. What are the adverse effects of long-term use of topical steroids? Prolonged use can cause skin atrophy, ecchymosis, striae, telangiectasia, acne, hypertrichosis, cataract formation or glaucoma with prolonged use around the eye © How long should topical steroids be used with children? Adults? Children: one week Adult: two weeks © What are the appropriate areas of use for low potency steroids? High potency steroids? Low potency: face and the intertriginous areas (skin on skin – under the breasts, under the pannus, and between the thighs) High potency: reserved for the extremities and the torso * effective for smaller outbreaks and they're safer than systemic corticosteroids © How do systemic corticosteroids work? Inhibit cytokine and mediator release Attenuate mucus secretion Up-regulate beta-adrenergic receptors, inhibit Ige synthesis, decrease microvascular permeability Suppress influx of inflammatory cells Anti-inflammatory and immunosuppressant © What are the adverse effects of systemic corticosteroids? Can mask infection, cause GI upset and strip the stomach of its protective barrier, prolonged use can lead to GI bleed, mood changes, sleep disturbances, weight gain (d/t increased appetite) © Review systemic corticosteroids. What are the indications for use in derm? What are the potential common and serious side effects? Indications: severe disease - pemphigus, psoriasis. Seborrheic dermatitis, contact dermatitis, exfoliative dermatitis Serious side effects: severe infection, mania, psychosis, delirium, suicidal thoughts, depression, heart failure, peptic ulceration, DM, avascular necrosis of the hip Module 9 Unit B – Ophthalmic Drugs © What is blepharitis, and how is it treated? Blepharitis is an infection and/or irritation of the eyelid margin For mild-to-moderate symptoms, management consist of warm compresses, lid massage, lid washing with something gentle, maybe like Johnson's baby shampoo and artificial tears moderate to severe cases of blepharitis, you can use bacitracin ointment or erythromycin ointment. Topical antibiotics such as these are usually first line for this moderate to severe cases if the patient is not improving after several weeks or if at any time the condition worsens, refer them to an ophthalmologist © What are the classes of drugs used to manage bacterial conjunctivitis? antibacterial ophthalmic drops or ointment © How should bacterial conjunctivitis be managed in a PT who wears contact lenses? Contact lens wearers with bacterial conjunctivitis should be treated with antibiotics due to the increased risk of keratitis and/or infection with gram-negative organisms Fluoroquinolones are the preferred treatment for bacterial conjunctivitis in contact lens wearers due to the high incidence of Pseudomonas infection Patients should stop wearing contact lenses until treatment and symptoms are resolved © What are the classes of drugs used to manage allergic conjunctivitis? What are their mechanisms of actions? Allergic conjunctivitis may be treated with mast cell stabilizers (cromolyn sodium, lodoxamide), topical antihistamines, a combination of antihistamine and mast cell stabilizers, or oral antihistamines * Mast cell stabilizers: prevent release of inflammatory mediators * Topical antihistamines: block h1 receptors * Oral antihistamines: block h1 receptors © What is the expected time of therapeutic relief for allergic conjunctivitis with mast cell stabilizers? Antihistamines? Mast cell stabilizers: several weeks to see a benefit Antihistamines: immediate symptom relief © What medications are used for dry eyes? How do they work? What are the adverse effects? artificial tear substitutes and ocular lubricants * isotonic solutions employed as substitutes for natural tears * no adverse effects are associated with the daily and continuous use of preservative-free solutions Topical cyclosporine ophthalmic emulsion (Restasis) is prescribed for dry eyes due to inflammation * suppresses the immune response, thereby promoting resumption of tear production * Adverse effects are eye discomfort (burning, stinging, foreign body sensation), pruritus, conjunctival hyperemia, and blurred vision. © What are ocular decongestants, and what are they used for? weak solutions of adrenergic agonists applied topically to constrict dilated conjunctival blood vessels * phenylephrine, naphazoline, oxymetazoline, brimonidine, and tetrahydrozoline used to reduce redness of the eye caused by minor irritation © When are glucocorticoids used in the eye? When is it appropriate for the APRN to prescribe glucocorticoids? used to treat inflammatory disorders of the eye (e.g., uveitis, iritis, and conjunctivitis)  prescribing should be done in consult with an ophthalmologist or other specialist with the equipment to verify that symptoms are not caused by an underlying viral or fungal infection © What are the classes of drugs used to treat open-angle glaucoma? beta-blockers, prostaglandin analogs, and alpha-adrenergic agonists © What are the adverse effects of ophthalmic beta-blockers? What type of monitoring is necessary? Nonselective: heart block, bradycardia, bronchospasm; beta-Selective: heart block, bradycardia, hypotension * Transient ocular stinging, Conjunctivitis, blurred vision, photophobia, dry eyes, Bradycardia, atrioventricular heart block, bronchospasm, heightened brown pigmentation of the iris and eyelid Monitoring: pulse rate © Who is not a candidate for ophthalmic beta-blockers? contraindicated for use in patients with bradycardia, AV block, or cardiogenic shock caution in those with heart failure or on systemic beta blockers © What is the risk of ophthalmic beta-blockers given with oral beta-blockers? they have an additive effect Module 9 Unit C – Otic Drugs © What are the recommended antibacterial drugs used for AOM? amoxicillin 80-90 mg/kg/day (in 2 divided doses) for a child with AOM who (AAP Strong recommendation, Grade B) * has not received amoxicillin in the past 30 days * does not have concurrent purulent conjunctivitis * is not allergic to penicillin (cephalosporins are recommended for most children with penicillin allergy) amoxicillin-clavulanate 90/6.4 mg/kg/day if any of (AAP Strong recommendation, Grade C) * amoxicillin received in the past 30 days * concurrent purulent conjunctivitis * history of recurrent AOM unresponsive to amoxicillin © Are antibacterial drugs always recommended for AOM? Prescribing antibiotics for all children should be discouraged because most (over 80%) of AOM episodes resolve spontaneously within a week © What are the recommended antibacterial drugs used for acute otitis externa? Fluoroquinolone eardrops with or without a steroid are the mainstay of treatment, as 90% of cases are bacterial © What class of antibiotics are FDA approved for use in treating acute otitis externa when the tympanic membrane is ruptured? Selected fluoroquinolone drops may be used with perforation of the TM and/or pressure equalization (P.E.) tubes * ciprofloxacin/dexamethasone (Ciprodex) and ofloxacin (Floxin) © What pain medications are safe for use in the treatment of pain for acute otitis externa when the tympanic membrane is ruptured? Topical analgesics should not be used if there is a chance of tympanic membrane perforation Oral acetaminophen or ibuprofen is helpful for pain relief © What class of topical antibiotic is approved for use in treating children with acute otitis externa who have ruptured tympanic membrane? There is minimal systemic absorption of fluoroquinolones from the ear canal, so they may be used in treating AOE in pediatric patients © What is the role of topical otic steroids in treating acute otitis externa? Reduces pain by reducing inflammation and edema © Can topical otic steroids be used in the presence of a ruptured tympanic membrane? no © What could happen if you use otic steroids in the presence of herpes zoster? Use of otic steroids in presence of herpes zoster can lead to disseminated varicella © What patient education should be given for the use of otic preparations? Pt education: * Drops should be room at temperature * Pull auricle or pinna up to instill in adults, down to instill in children (Think “Grown-up”) * No swimming until infection is cleared, ie. 7 days Prevention: * Use acetic acid/alcohol combination (ratio of 1:3) * Before and after swimming (do not use in children less than 3 years of age) * Do not put anything in your ear that is smaller than your elbow Module 9 Unit D – Dermatologic Infestations © What are the pediculicides/scabicides used in treating lice and scabies? Scabies: * Apply permethrin cream 5% over the entire body starting at the neck down to covering the soles of the feet * Oral ivermectin (Stromectol) should be reserved for patients with scabies who do not improve with permethrin 5% cream (Elimite) Lice: * First line treatment: permethrin 1% and nit combing * Second line: Malathion lotion (Ovide) * For parents who do not want pediculicides: benzoyl alcohol (Ulesfia), not as effective as malathion * Lindane is neurotoxic so is rarely used * Do not use with history of a seizure disorder- FDA has cautioned against use © Are there any Black Box Warnings or cautions for these medications? Ovide: flammable Lindane: neurotoxic (seizures/death) Ivermectin: Category C in pregnancy © Why is it important to know if the medication is ovicidal? It is essential to understand which medications are ovicidal because non-ovicidal therapies for pediculosis should be applied twice, seven to 10 days apart, to kill hatching mites © How do we treat lice/scabies in pregnancy? Permethrin (Category B) is considered safe in pregnancy and lactation. With small amounts of topical applications, very little is absorbed. Permethrin is also rapidly metabolized, further reducing infant exposure © How do we treat lice/scabies in children? Scabies; * Topical permethrin 5%- Provide treatment to everyone in a household greater than 2 months, even if they are asymptomatic * Oral ivermectin- in patients greater than 5 years and more than 15kg * Topical lindane- used for patients greater than 2 years old who can not tolerate first line therapy Lice: * Permethrin 1% and nit combing * Pyrethrins with piperonyl butoxide (RID) * Occlusive agents (petroleum jelly) - for young children * Ivermectin- only in greater than 15kg © What are the important patient teaching elements when prescribing these drugs? Permethrin: * at night apply a thin, uniform layer to ALL skin surfaces (entire trunk and extremities) from neck to toes (including soles of feet), all skin folds, and brush under fingernails and toenails; scalp and face included when treating infants * avoid contact with eyes and mucous membranes * remove cream after 8-14 hours by bathing or showering * repeat in 1 week as permethrin is not considered to be ovicidal Ivermectin: * Instruct the patient using a tablet to rise slowly from a sitting/supine position, as the drug may cause orthostatic hypotension. * Advise patient to take tablets on an empty stomach with water. Lindane: * Wait for≥ 1 hour after bathing or showering before applying lindane lotion * Be sure to take a bath or shower before applying the medicine. Massage onto clean, dry skin. It must remain on the skin for 8 to 14 hours. * Apply the medicine from the neck to the toes. This includes all skin between your neck and toes — the skin around nails, the crease between buttocks, and the skin between toes. Infants, children, and the elderly often need to treat their scalp, temples, and forehead. Never apply medicine to the nose, lips, eyelids, or around the eyes or mouth. * If you wash your hands after applying the medicine, be sure to reapply the medicine to your hands. Mites like to burrow in the hands, so it is essential to treat the hands. Be sure to apply the medication to the skin between your fingers. * When you start treatment, wash your clothes, bedding, towels, and washcloths. Mites can survive for a few days without human skin. If a mite survives, you can get scabies again. You must wash clothes, sheets, comforters, blankets, towels, and other items to prevent this.