NAPLEX Material Overview PDF

ALLERGIC RHINITIS sneezing, itchy nose, eyes or throat, watery eyes, rhinorrhea (runny nose), nasal congestion, post-nasal drip. 1. 2. 3. 4. 5. NON-PHARM Tx: AVOID exposure to allergens. IgE – mediated or Blood test. Nasal irrigation – saline, propylene/polyethylene glycol Neti Pot Boiled/Distille...

ALLERGIC RHINITIS sneezing, itchy nose, eyes or throat, watery eyes, rhinorrhea (runny nose), nasal congestion, post-nasal drip. 1. 2. 3. 4. 5. NON-PHARM Tx: AVOID exposure to allergens. IgE – mediated or Blood test. Nasal irrigation – saline, propylene/polyethylene glycol Neti Pot Boiled/Distilled H2O – NEVER use faucet water. *1st LINE = for mod-severe GENERIC BRAND Beclomethasone Beconase, Qnasl Budesonide Rhinort Aqua Fluticasone Flonase Mometasone Nasonex Triamcinolone Nasacort Ciclesonide Omnaris, Zetonna Flusinolide 1st LINE = Mild-Mod Sx. GENERIC BRAND Benadryl Diphenhydramine HCL HA, dry nose, bad taste, epistaxis (nose bleed), and local infection. 2. Chronic, Mod-Severe rhinitis a. 1st LINE = Intranasal Corticosteroid MILD sx = Oral Antihistamine a. Decongestants can be used or other agents for itchy eyes. - Adrenal suppression w/ long-term use. - Delayed wound healing - Avoid if nasal ulcers or trauma. - Stunt growth in children - IOP , open-angle glaucoma, cataracts. Have different names for allergy relief & asthma. COUNSELING NOTES FLONASE & NASACORT Counseling: 1. Shake bottle 2. Flonase = Prime 7-days no use 3. Nasacort = Prime 14-days no use 4. Point away when priming 5. Tilt head forward & inhale while spraying in nose. Oral Antihistamines 1st generation (more drowsiness) Effective relief of itching, sneezing, rhinorrhea, other immediate hypersensitivity rxns. ADRs BBW CONTRAINDICATIONS *Do NOT use <6 YO Somnolence, cognitive impairment, strong anticholinergic effects Carbinoxamine Cetirizine Levocetirzine Fexofenadine Loratadine Desloratadine Zyrtec Xyzal Allegra Claritin Clarinex Somnolence occasionally Azelastine Olopatadine Astelin, Astepro Patanase Somnolence, bitter taste, HA, nosebleed Chlorpheniramine 1. Intranasal Corticosteroids most effective class of med to decrease inflammation ADRs BBW ADULTS = 25-50mg PO Q4-6H Tavist, Dayhist Chlor-Trimeton, Chlorphen Arbinoxa, Karbinal Clemastine DRUG Tx: - AVOID use in elderly Caution in CVD, Prostate enlargement Glaucoma Asthma Excessive sedation. AVOID use in <2 YO Infants, lactating women, narrow-angle glaucoma, asthma, AVOID MAOi, symptomatic BPH, peptic ulcer 1. 2. 3. 4. 5. May take 1 week to get relief. Pregnancy - Use Budesonide Get nasal exams for long use. AVOID contagious people Shake well before use Has little effect on nasal congestion. NOTES Lactating women should use 2nd gen ALL should be D/C before allergy skin testing. 1st gen cause photosensitivity Oral Antihistamines 2nd generation (preferred due to less sedation & more cognitive function) - CNS depression - Sedation w/ other sedating meds Levocetirizine w/ ESRD 1. 2. 3. Fexofenadine: Take w/ H2O AVOID Al+/Mg+ products PREGO - Loratadine/Cetirizine best Intranasal Antihistamines Helps w/ Nasal congestion Oxymetazoline Naphazoline Tetrahydrozolline Afrin Privine Tyzine Oral Decongestants Products containing "D" contain Phenylephrine or Pseudoephedrine ADRs BBW CONTRAINDICATIONS 14 Days w/ MAOi CV + CNS stimulation - AVOID in <2 YO Phenylephrine: HTN, tachycardia Topical (Intranasal) Decongestants Stingy, burning, sneezing, - AVOID in <2 YO dryness, rebound - MAOi use congestion after 3 days GENERIC Intranasal Cromolyn Ipratroprium Bromide Montelukast BRAND Nasalcrom Atrovent Singulair MOA MAST-cell Stabilizer Anticholinergic leukotriene antagonist α-Adrenergic-Agonist GENERIC BRAND Phenylephrine HCL Sudafed PE Sudafed, Nexafed, Pseudophedrine Zephrex-D Sublingual Immunotherapy ADRs Other BBW CONTRAINDICATIONS Allergy Shots - 1st dose MUST be given in doctor's office w/ PT monitored 1st 30 mins Vasoconstriction of sinus vessels NOTES Phenylephrine low BA PSE more effective ONSET 15-60 mins Effective in 5-10 mins *Limit use to <3 days to potential rebound congestion. NOTES Can be used as Tx + Px GOOD for Rhinitis by drying nose out 10 mg PO QD, can be used as adjunctive tx *PT should get RX for Epinephrine Pen COLD Viral infxn of URT caused by Rhinovirus/Coronavirus. Transmit through hands or by air. Practice correct hand-washing technique. Self-limiting NON-PHARM Tx: 1. 2. 3. 1. 2. 3. 4. Zinc Vitamin C (Absorbic acid) Echinacea GENERIC Guaifenesin BRAND Mucinex, Robitussin DRUG Tx: Expectorants Cough suppressants Decongestants (refer to allergic rhinitis for drug chart) Analgesics/Antipyretics Expectorant – removes phlegm ADRs BBW N/V/D, dizzy, HA, rash, upset stomach CONTRAINDICATION Child < 2 yo NOTES MAX = 2000 mg/day (Adult) Cough Suppressants GENERIC Dextromethorphan DM = 5-HT + NMDA blocker BRAND Delysm, DayQuil Codeine Benzonatate Tessalon. Zonatuss Diphenhydramine Benadryl ADRs BBW N/V, drowsiness, Serotonin Syndrome N/V, sedation, constipation, hypotension Somnolence, confusion, hallucination Combination Products GENERIC BRAND Dextromethorphan/Promethazine Brompheniramine/PSE/DM BromFed DM Promethazine Promethazine/Phenylephrine/Codeine VC/Codeine GuaiFENesin/Codeine Robafen AC, Virtussin AC GuaiFENesin/Codeine/PSE Cheratussin, Mytussin DAC TussiCaps, Tussionex, Chlorpheniramine/Hydrocodone Vituz BBW: Respiratory depression Benzonatate = Topical anesthetic CONTRAINDICATION NOTES DM = MAOi use 14 days Dextromethorphan Must be > 18 yo to buy Additive CNS effect w/ Child < 12 yo other CNS depressants *AVOID in child < 10 yo Pediatric Concerns/Dosing for Cold medications Cough/Cold Products Acetaminophen in Infants Per FDA, don’t use • OTC meds in < 2 yo • Codeine in child < 12 yo Per manufacturer (relabeled) {160mg/5mL} • NO child < 4 yo Per AAP - NO child < 6 yo Dose: 10-15 mg/kg/dose Do NOT use Promethazine in < 2 yo Q4-6H PRN Use 1. 2. Hydration, nasal bulbs, saline drop/spray Ibuprofen or Acetaminophen a. Do NOT use ASA (Reyes Sx) Max: 5 doses/24hr Ibuprofen in Infants Drops: 50mg/1.25 mL Suspension: 100 mg/5 mL Dose: 5-10 mg/kg/dose Q4-6H PRN Max = 40 mg/kg/day ASTHMA Inflammation & bronchoconstriction  Airway obstruction and low expiratory exhalation. Characteristics of Disease Recurrent wheezing, breathlessness, chest tightness, & coughing. (Freq. at night & waking) Reversible w/ meds. Exacerbations can be mild-severe-fatal. Triggered by environment & inflammatory mediators: Histamine, Leukotriene, Cytokines, Mast cells, Eosinophil, or genetics (IgE). Can be any of the following: a. Allergens, dust, smoke, chemicals, weather, b. Lifestyle (stress/exercise), respiratory infxns c. Meds: ASA, NSAIDs, BB's 5. Comorbidities: Allergy, GERD, Obesity, Sleep apnea, Anxiety, Depression. 1. 2. 3. 4. Diagnosis Peak Flow Meter 1. Use every morning before any asthma meds. 2. Stand up straight  Exhale 3. Inhale deeply then blow out HARD & FAST into PEFR & record the highest of 3 tries. 4. Clean 1x/wk GREEN Zone = 80-100% YELLOW Zone = 50-80% (Need Action Plan) RED Zone = < 50% of personal best (Go to Emergency Room) Avoid Smoking Avoid Triggers Keep exercising (even if EIB) Annual Flu shot PPSV23: Age 2-64 yo 6. PCV-13: Age 6-18 yo Impairment Criteria Daytime Sx Night time awakenings Rescue Inhaler use Activity Limitations Lung Fxn - FEV1% FEV1/FVC Intermittent ≤ 2 days/wk ≤ 2x/month ≤ 2 days/wk none > 80% Normal Mild-Persistent > 2 days/wk NOT daily 3-4x/month > 2 days/wk OR > 1x/day Minor > 80% Normal Mod-Persistent Daily > 1x/wk NOT nightly Daily Some 60-80% 5% Reduction Severe-Persistent Throughout Day Often 7x/wk Several times a day Extreme < 60% 5% Reduction Risk Criteria Exacerbations req. PO steroid Intermittent 0-1 per year Mild-Persistent Mod-Persistent ≥2 per year Severe-Persistent Steps for Initiation STEP 1 Treatment Algorithm STEP 1 SABA PRN (ALL PTs must have SABA PRN) STEP 2 Low Dose ICS STEP 3 Low-dose ICS + LABA or Med-dose ICS STEP 4 Med-dose ICS + LABA STEP 5 High-dose ICS + LABA STEP 6 High-dose ICS + LABA + PO steroid Follow up in 2-6 wks Check Adherence to meds Counsel technique/cleaning Control risks, triggers, comorbidities 1. 2. 3. 4. 5. Classification Assess Expiratory volume 1. Spirometry a. Test Forced Vital Capacity (FVC) in 1 second (FEV1) 2. Peak Expiratory Flow (PEF) a. use Peak Flow Meter measuring daily (see below) 1. 2. 3. 4. Control Risk Factors Alternate Tx: Cromolyn, LTRA, Theophylline Alternate Tx: Zileuton, LTRA, Theophylline Consider adding Tiotroprium for PTs > 6 yo if Hx of exacerbation. 5. Review action plan 6. Determine step-up/down Tx 7. Follow up 1-6 months if controlled. STEP 2 Effectiveness of Therapy Well Controlled: 1. Sx/SABA use ≤ 2 days/wk 2. Nightime awake ≤ 2x/month 3. No limits to activity Maintain step/step down if controlled for 3 mons. NOT Controlled: 1. Sx/SABA use > 2 days/wk 2. Nightime awake 1-3x/wk 3. Some limits to activity Step up 1 step POORLY Controlled: 1. Sx/SABA use several times/day 2. Nighttime awake ≥ 4x/wk 3. Extreme limits to activity Step up 1-2 steps STEP 3 – consider PO steroid STEP 4/5 – consider PO steroid General Information Spacers: • Helps to coordinate inhalation w/ MDI into lungs & prevents thrush. • Clean 1x/wk soap water Nebulizer: • Turns liquid meds into fine mist. If prescribed >1 inhaler PT must wait 60 secs b/t each: • 1st: SABA • Any other Bronchodilator • LAST: ICS Exercise induced bronchospasms (EIB): • SABA is preferred 5-15 mins before exercise but Salmeterol (LABA) can be used unless it is being used for maintenance. Montelukast must be taken 2 hrs prior to exercise. • Rescue Inhalers: should last 12 months w/ good asthma control. ASTHMA Drug chart GENERIC Albuterol (SABA) Levabuterol (SABA) Salmeterol (LABA) BRAND ProAir HFA ProAir RespiClick Ventolin HFA Proventil HFA Xopenex Serevent Diskus (DPI) ADRs β Agonists - Relax smooth muscle  Bronchodilation BBW CONTRAINDICATIONS/CAUTIONS NOTES - Nervousness Tremor Tachycardia Palpitations Hyperglycemia K+  Risk of Asthma related death Caution w/ CVD, Glaucoma, Hyperthyroidism, Seizures, Diabetes - MDI's (HFA): Shake well before use Albuterol inhalers = 200 puffs/inhaler o Except Ventolin HFA = 60 inhales EIB: 2 inhales 5 min. before exercise ONLY used for PTs on ICS but symptoms not controlled ADD on therapy to Medium dose ICS before increasing to High dose ICS NEVER use NON-Selective β agonists Racepinepherine OTC (SABA) Inhaled Corticosteroids (ICS) – inhibits inflammation Beclomethasone Budesonide Ciclesonide Flunisolide QVAR Pulmicort Flexhaler Flovent HFA Arnuity Ellipta - DPI Asmanex HFA -MDI Asmanex Twisthaler - DPI Alvesco Aerospan Montelukast Zileuton Singulair Zyflo Zafirlukast Accolate Fluticasone Mometasone Dysphonia (Hard to talk) Oral Thrush Cough URTI Hyperglycemia Headache Dizzy Ab pain URTI LFTs  - Not used for primary Tx of Asthma or acute episodes of asthma - Adrenal suppression, risk of fractures, stunt child growth Leukotriene Receptor Antagonists – reduces airway inflammation Neuropsychiatric events Hepatic imp. Tiotropium Spiriva Respimat Anticholinergic Hyperthermia Dry skin/dry mouth Mydriasis Constipation Urinary retention Xanthines - Blocks Phosphodiesterase  cAMP  Bronchodilation Theophylline Theo-24 Theo-Cron Elixophyllin N/V/HA HR increase Insomnia Tremor/Nervous Omalizumab Xolair Injection site rxn Arthralgias Dizzy/Fatigue Mepolizumab Nucala Reslizumab Cinqair - CVD, Hyperthyroidism, PUD, Seizures - Small increase in dose → Large increase in concentration o Loading dose based on IBW - 1st Line for ALL w/ Persistent Asthma Rinse mouth w/ warm H2O or use spacer to prevent thrush. - Mostly used in Children Montelukast: 10 mg PO QHS o Granules: must be used w/in 15 mins. Zileuton: taken with food Zafirlukast: taken on empty stomach - - Approved for > 6 YO for Asthma w/ Hx of exacerbations despite ICS/LABA Tx. - MANY DRUG interactions due to IA2/3A4/2E1 inhibition Monitor Serum Conc.  Tx Range = 5-15 mcg/mL o Measure PEAK Active metabolites: Caffeine & 3-methylxanthine Aminophylline → Theophylline: Multiply 0.8x - Monoclonal antibody - inhibits IgE Anaphylaxis Given SC Q2-4 wks only in Hospital under medical supervision. Indication: Allergic asthma in PT > 6 YO & positive allergen skin test & ICS isn’t enough. Interleukin-5 (IL5) Antagonist – inhibits IgE Injection site rxn Arthralgias Dizzy/Fatigue Indication: >12 YO given SC route for Eosinophillic Asthma Anaphylaxis IV only ASTHMA Counseling Meter Dosed Inhalers (MDI) General Ventolin HFA ProAir HFA Flovent HFA Dulera Symbicort QVAR General Advair Diskus 1. 2. 3. 4. 5. 6. HFA, Respimat, or if there is Suffix (QVAR) Aerosolized liquid med HFA uses Propellant Req. SLOW DEEP inhalation same time as pressing button. SPACER can be used SHAKE Well except for QVAR, Alvesco, Respimat PRIME: Spray 4x: into air while shaking between sprays. Prime if not used for 14 days or if dropped. PRIME: Spray 4x into air while shaking between sprays. Prime if not used for >7 days or >5 days for Dulera PRIME: Spray 2x into air while shaking between sprays. Prime if not used for 7 days or ≥10 days for QVAR 1. 2. 3. 4. 5. 6. Dry Powder Inhalers (DPI) Diskus, Ellipta, Pressair, Handihaler, Neohaler, RespiClick. Fine powder inhalation NO Propellant Req. forceful quick inhalation w/o pressing button same time NO SPACERS Do NOT Shake 1. 2. 3. 4. 5. 6. Pull Thumb-grip away til mouthpiece shows. Slide lever until it clicks. Exhale away from mouth. Inhale quick/deep HOLD long as possible or 10 sec Rinse mouth w/ H2O & spit. Do NOT wash just AIR DRY Pulmicort Flexhaler 1. Twist off white cover while twisting brown base far as it will go in other direction til you hear a click. (Loaded) 2. Do NOT shake the inhaler. 3. Turn head away & exhale fully. 4. Inhale deep/forcefully. 5. Rinse out mouth and spit. Let AIR DRY no H2O ProAir RespiClick AirDuo RespiClick 1. 2. 3. 4. 1. Open cap all the way til it clicks. a. Opening/Closing cap w/o inhaling wastes medication. 2. Exhale all the way away from inhaler. 3. Inhale deeply & HOLD long as possible or 10 secs NO PRIMING needed. Only use dry cloth NO H2O to clean. DIRECTIONS FOR USE: Shake 5 secs before spray Exhale fully Inhale slowly/deeply while pressing button. Hold breath 10 secs or long as possible. CLEAN: Remove metal canister (do not get wet) & rinse mouthpiece w/ warm H2O then AIR DRY (1x/wk). CLEAN: Use clean cotton swab to wipe mouthpiece then AIR DRY. CLEAN: Wipe mouthpiece w/ clean dry cloth. NEVER put in H2O. CLEAN: Wipe mouthpiece w/ clean dry cloth. NEVER put in H2O Soft Mist Inhaler/Inhalation Spray Combivent, Spiriva, Striverdi, Stiolto 1. Propellant free and delivers drug in fine mist 2. Better lung deposition and requires less inhalation effort 3. To use for first time (keep cap closed until step 5) a. Press safety catch and pull off clear base b. Insert cartridge into inhaler and push against surface c. Replace clear base d. Turn base in direction of arrow until you hear a click e. Flip open cap until it clicks into open position f. Point inhaler toward ground and press dose release button until a cloud is visible then repeat 3 more times before use 4. Daily use (T.O.P) a. Turn base in direction of arrow until you hear a click (keep cap closed) b. Open cap until it clicks into open position c. Close lips around inhaler and Press button while taking in a slow deep breath man in now dozes Combination Products ICS/LABA Combos: Budesonide/Formoterol (Symbicort) Fluticasone/Salmeterol (Advair Diskus/HFA) Mometasone/Formoterol (Dulera) ambivert respimat SMOKING CESSATION GENERAL INFORMATION 1. 2. 3. 4. 5. GENERIC Nicotine Patch Nicotine Polacrilex Gum Nicotine Polacrilix Lozenge Nicotine inhaler Nicotine Nasal Spray GENERIC Buproprion SR Varenicline 6. 7. 8. 9. 10. Providers must inquire about Tobacco use. 1-800-QUIT-NOW Counseling is just as important as medications. Combination Tx can be used 1st LINE. Meds are always recommended unless CI. BRAND NicoDerm CQ Nicorette Nicorette Mini Nicotrol inhaler (RX) Nicotrol Spray (RX) BRAND Zyban Chantix tapering not needed α-4-β-2 nicotinic agonist tapering not needed DRUG Nicotine Patch 1. 2. 3. 4. 5. 6. 7. 1. ADRs 1. HA/Dizzy 2. Insomnia 3. Nervousness Nicotine Replacement Tx (mostly OTC) - ALL products; wait 15 mins after eating or drinking for use MOA Dopamine/NE Blocker The "5-A's" Model: E-Cigs should not be recommended. Counsel all pregnant women, children, & light smokers (<10 cigs/day). Smokers 19-64 YO need Flu + Pneumovax 23 vaccines. Smoke induces CYP450-A12 → Supratherapeutic levels of med. Women > 35 YO should not take Oral Contraceptive (CVD risk) 1. Dry mouth 3. Agitation 2. Insomnia 4. Headache N/V/Dizzy, constipation, tremors, blurred vision, anxiety, tachycardia, sweating. 3. Abnormal 1. Insomnia dreams 2. Nausea 4. Headache Constipation, vomiting, flatulence. Suicidal behavior in young pts like other Anti-depressants. 1. 2. 3. 4. Serious Psychiatric behavior Seizures  ETOH + Blackout risk Sleep walking Counseling & Dosing COUNSELING Apply new patch start of each day, dispose used in Pouch. Apply to clean, dry, hairless skin & hold for 10 secs. Wear the patch for 24 hrs. Only remove before sleep if abnormal dreams occur. Fold inward & discard in pouch then place in trash. Wash hands before/after use. Rotate site of patch. Don’t use same site for 1 week. NEVER cut patch or use > 1 patch at a time. 2. 3. 1. 2. 3. Place in mouth let DISSOLVE slowly Move side to side for 20-30 mins. NEVER use > 1 at a time. Nicotine Inhaler 1. 2. 3. 4. Puff inhaler in short/freq breaths + inhale deeply. Each cartridge gives 20 minutes of continuous puffing. Clean mouthpiece w/ soap + water regularly. Keep at room temp (in pocket). Nicotine Nasal Spray 1. 2. 3. Spray once in each nostril while breathing through mouth. Do NOT sniff, swallow, or inhale through nose Wait 5 mins after use before driving or heaving machines. Nicotine Lozenge No more than 20 lozenges per day ASK about tobacco use. ADVISE to quit. ASSESS willingness to quit. ASSIST in quit attempt. ARRANGE follow up. C/I AVOID in post-MI, arrhythmias, angina, and pregnancy. Other Medications BBW Chew slowly til "tingle" or "flavored taste" then PARK gum in cheek. a. Repeat when tingle/flavor goes away Use for 30 mins. Use 1 piece Q1-2hrs No more than 24 pieces per day Nicotine Gum BBW *Patch: vivid dreams *Inhaler: throat irritation ADRs 1. 2. 3. 4. 5. CONTRAINDICATIONS 1. Seizure disorder 2. Anorexia/Bulimia 3. MAOi 14 days 4. Benzos, AEDs, Barbiturates pts unable to quit immediately should cut smoking by 50% every 4 weeks. NOTES 1. >18 yo + ID for purchase 2. Combo w/ short-acting = Most effective 3. Remove patch before MRI. 4. Gum/Lozenge (4mg) shown to reduce weight gain. NOTES - Do NOT use w/ other forms of Buproprion. Start 1 week before quitting smoke. MAX Dose = 300 mg/day Wait 8 hrs if splitting dose. - START 1 week before quit date OR START and quit between 8-35 days. - Take after meal + glass of H20. - Decrease ETOH use. - Caution serious rxns (facial swelling, rash, peeling skin) DOSING Cigarette use > 10 cigs/day ≤ 10 cigs/day Week 1-6 21 mg patch 14 mg patch Week 7-8 14 mg patch 7 mg patch Week 9-10 7 mg patch No recommendation *Min 9 pieces/lozenges per day for the 1st 6 wks Chew/Dissolve 1 piece every: Smoke 1st cigarette Dose Weeks 1 – 6 Q1 – 2H > 30min after waking 2mg  Weeks 7 – 9 Q2 – 4H 4mg Weeks 10 – 12 Q4 – 8H ≤ 30 min after waking PULMONARY ARTERIAL HYPERTENSION (PAH) continuous high BP in the pulmonary arteries. PAH = mean PAP (mPAP) ≥ 25 mmHg. Signs & Symptoms Fatigue Dyspnea Chest pain Syncope Edema Tachycardia Causes of Pulmonary Fibrosis: Amiodarone Methotrexate Nitrofurantoin Sulfasalazine NON-PHARM Tx: 1. 2. 3. 4. DRUG Tx: 1. 2. 3. 4. Sodium restrict < 2.4 g/day Flu/Pneumonia Vaccines Avoid High Altitudes. O2 Sat > 90. Treatment Algorithm GENERIC Epoprestenol Trepostinil Iloprost Selexipag GENERIC WHO-FC: World Health Organization Functional Classification - Class I = patients with PH but without limitation of physical activity - Class II = patients with PH resulting in slight limitation of physical activity - Class III = patients with PH with marked limitation of physical activity - Class IV = patients with PH unable to be physically active and with signs of right heart failure Prostacyclin Analogues (Prostanoids) - Potent Vasodilator + Inhibit platelet aggregation. BRAND ADRs BBW C/I NOTES Flolan (IV) Parenteral = most potent. Heart failure Vasodilation Rxns Veltri (IV) - Avoid interruption in Tx. - (Hypotension, HA, Rebound PAH - Avoid large/sudden dose Remodulin (IV, SQ) Dizzy, Flushing) (Don't DC reductions. Tyvaso (inhaled) Hepatic imp. N/V/D abruptly) - Epoprostenol = Protect Orenitram (ER tab) Jaw Pain from light IV infusions → Anxiety/Tremor Ventavis (inhaled) - Flolan = reqs. ice packs for Infections Thrombocytopenia solution. Infusion-site Pain - Avoid NSAIDs Uptravi (tab) BRAND Bosentan Tracleer Ambrisentan Letairis Macitentan Opsumit GENERIC BRAND Sildenafil Revatio Tadalafil Adcirca GENERIC Riociguat Anti-Coagulation w/ Warfarin: INR Goal = 1.5 - 2.5. Loop Diuretics for volume overload. Digoxin to improve CO or control HR. Perform Acute Vasoreactive Testing. a. During which drugs are given to illicit a response. i. RESPONDER: mPAP falls by at least ≥10 to a value less than <40. 1. Give CCB: Nifedipine, Diltiazem, and Amlodipine. a. NOT Recommended = Verapamil. ii. NON-RESPONDERS: or PTs failing CCB Tx need ≥1 vasodilator. 1. Prostacyclins, ERAs, PDE-5, or sGC. Endothelin Antagonist (ERA) - Blocks Endothelin vasoconstriction. ADRs BBW C/I NOTES Embryo-Fetal toxicity HA - Women need Neg. URTI - REMS Program Prego test before use & Flushing Pregnancy Bosentan = ↓ effectiveness monthly. Hypotension of Contraceptives. Fluid Retention Bosentan = Hepatotoxicity Hgb/Hct (ALT/AST) PDE-5 inhibitor - Pulmonary relaxation/vasodilation. ADRs BBW C/I HA Flushing Dyspepsia Extremity/Back pain Epitaxis Hypotension Hearing/Vision loss Priapism Use of Nitrates or Riociguat. Soluble Guanylate Cyclase (sGC) BBW C/I BRAND ADRs Adempas Headache Bleeding Pulmonary edema Hypotension N/V/D Embryo-Fetal toxicity - Women need Neg. Prego test before use & monthly. NOTES - Pregnancy - use of PDE-5 or Nitrates NOTES - REMS Program - Space out o Sildenafil = 24 hrs o Tadalafil = 48 hrs GOUT Uric acid built up in joints – end-product of Purine metabolism. → PT may be Asymptomatic → Sx - painful, burning, swelling joint. → Typically starts in 1 joint (Big Toe) Risk Factors • Male • Obese • Excess ETOH Treatment Pearls • HTN, CKD • Age • Meds Reduce risk: AVOID organ meats highfructose corn syrup, ETOH. GENERIC BRAND Colcrys Mitigare Indomethacin Naproxen Celecoxib Sulindac Indocin Naprosyn Celebrex Clinoril Prednisolone Methylprednisolone Triamcinolone Prednisolone Medrol ADRs NVD Myelosuppression Myopathy Neuropathy Cramping Loose stools Vit-B12  Chronic Urate-Lowering Treatment - ULT should be given to those w/ gout who had an attack, intermittent sx or tophi. - Gout ppx: NSAIDs or Colchicine - 1st LINE = Allopurinol (XOi) or Febuxostat - 2nd LINE = Probenecid (if XOi is C/I) or added if UA level isnt below <6mg/dL while maxed out on XOi. o Lesinurad is also 2nd Line taken w/ XOi. - Peglitocase - reserved for Severe Refractory dx Acute Gout Attacks - Use NSAID, steroid, or Colchicine - Use meds at 1st sign of attack - Combination Tx w/ any 3 for severe attacks. - Ice packs or IA injection - Chronic urate-lowering Tx (ULT) should continue w/o interruption 1. NEVER treat asymptomatic hyperuricemia. 2. ONLY Tx after Gout Attack. 3. GOAL = Uric acid < 6mg 4. Drugs used to Tx different from ppx Anti-gout = interference with migration of neutrophils BBW C/I NOTES 1. Start w/I 36 hrs of Sx onset. GI Sx 2. Ppx dose should be held for 12 hrs AFTER Tx dose begins. Myopathy 3. AVOID Cyclosporine Myelosuppression P-GP or CYP3A4 inhibitor - Dose: 1.2 mg PO (2x 0.6 mg) followed by 0.6 mg in 1 hr. Use w/ gemfibrozil, o Do NOT Exceed 1.8mg/hr or 2.4mg/day. statins, non-DHP CCBs o Dose every 3 days (NO earlier) NSAIDs - AVOID use severe Renal Dx. Celecoxib has most CVD risk - 0.5 mg/kg/day 5-10 days OR 0.5 mg/kg/day 2-5 days followed by taper over 7-10 days Xanthine Oxidase Inhibitors - Hypersensitivity (SJS/TEN) - Do not use for asymptomatic hyperuricemia - Didanosine - Mercaptopurine - Azathioprine - Peglitocase Uriosurics - Lower dose w/ CKD Take w/ FOOD 1st 3-6 mons. use w/ Colchicine or NSAID AVOID Antacids use Allopurinol - Start 100mg titrate up to 300mg divide BID Do NOT with use ASA Blood dyscrasias, nephrolithiasis G6PD deficiency, child <2 yo - Combination with Colchicine available (Col-Benemid) Probenecid can be used to  Beta-Lactam levels Decrease clearance of ASA, PCNs, cephalosporins, carbapenems. Decreases efficacy of Loop diuretics while increasing toxicity. - Take QAM w/ XOI + FOOD + H2O - Injection ONLY Give NSAID or Colchicine 1 week prior to infusion for 6 months. NEVER use w/ Allopurinol or Febuxostat - Injection ONLY PT's at risk for TLS should receive IV hydration Monitor CBC Life-threatening complication of Chemo-Tx or Cancer. Cells lyse open and purines are released quickly converting to uric Acid, aka "Acute Gout" attack causing electrolyte abnormalities. Refer to pain handout ACUTE TX Colchicine DRUG Tx Steroids – can be given PO, IV, IM, ACTH Hyperglycemia, HTN, insomnia, appetite increase Allopurinol Zyloprim Rash, Nausea, Gout attacks, diarrhea, LFTs  Febuxostat Uloric Rash, nausea, arthralgia, LFTs  Probenecid Hepatotoxicity (in Asians HLAB*5801test prior) Hepatotoxicity, Thrombosis, Gout attack Warning: CrCl <30 Hemolytic anemia in G6PD deficiency Lesinurad Zurampic SCr , renal failure, nephrolithiasis, HA Acute Renal failure Pegloticase Krystexxa AB formation, gout flare, infusion rxn, nausea, skin probs Anaphylaxis – (premedicate w/ Anti-histamines & Steroids.) Rasburicase Elitek Edema, HA, anxiety, rash, NV, ab pain, diarrhea, constipation Anaphylaxis CrCl <30, ESRD, Dialysis, Kidney Transplant Recombinant Uriocase G6PD deficiency ONLY USED FOR: Tumor Lysis Syndrome CHRONIC TX Hypersensitivity Hemolytic Anemia Refer to steroids handout MOTION SICKNESS Signs & Symptoms 1. 2. 3. Nausea Dizziness Fatigue NON-PHARM Tx: 1. Sea-Band (acupuncture) 2. Ginger Tea 3. Peppermint DRUG Tx: 1. 2. 3. 4. 5. Transderm Scop Meclizine Diphenhydramine (Benadryl) Promethazine (not for children) Cyclizine (Marezine) Anti-Histamine/Anti-Cholinergic MOST commonly prescribed NOT more effective than OTC GENERIC BRAND ADRs BBW CONTRAINDICATION NOTES Dry mouth CNS effects (drowsy, dizzy, confusion) Belladonna Allergy Scopolamine 3-Day Transderm Applied behind EAR Eyes Stinging Angle Closure Patch Scop Lasts 3 days. Pupil Dilation Glaucoma Risk of IOP Tachycardia (rare) GENERIC Meclizine BRAND Dramamine Bonine Day-Less Drowsy Motion Time Travel Sickness ADRs Sedation Dry mouth Dry/Blurry Vision Tachycardia Anti-Histamine BBW CONTRAINDICATION WARNING: CNS Depression Impairment Worsens BPH Sx Increase IOP TRANSDERM SCOP – Counseling Instructions 1. 2. 3. 4. 5. 6. 7. Apply to clean, dry, hairless area behind the ear. Press firmly for at least 30 seconds to seal edges of patch. Apply 4 hrs. before needed effect Wash hands w/ soap before & after. (Avoid Eyes) Renew patch only every 3 days & only one at a time. Causes drowsiness so avoid ETOH. Remove patch before MRI. NOTES Oral agents must be taken 30 - 60 mins prior. ERECTILE DYSFUNCTION Most commonly caused by reduced blood flow to penis. Psychological Causes • • • • NON-PHARM Tx 1. 2. 3. 4. 5. Depression Stress Spinal cord injury Stroke GENERIC Sildenafil Tadalafil Avanafil Vardenafil GENERIC Alprostadil (Injections) Alprostadil - (Urethral Pellets) Weight Loss Quit smoking/ETOH Yohimbe L-Arginine Panax Ginseng DRUG Tx: • • 1st Line = PDE-5 inhibitors 2nd Line = Alprostadil Drugs Causing ED SSRIs/SNRIs Beta-Blockers Clonidine 1st Gen Anti-Psychotics • (Haloperidol, Fluphenazine, Chlorpromazine, Risperidone, Paliperidone) BPH Meds • Finasteride, Dutasteride, Silodosin PDE-5 Inhibitors Release NO  cGMP increase  Smooth muscle relaxation  Increase BF to penis. BRAND ADRs BBW CONTRAINDICATION HA/Dizzy Viagra Use w/ Nitrates or Riociguat Flushing Revatio (for PAH) WARNING: Dyspepsia Viagra/Cialis Color discrimination Cialis Blurred vision 50% dose reduction if: Hearing/Vision loss Adcirca (for PAH) Tinnitus • ≥ 65 yo Hypotension Photosensitivity Priapism • Using Alpha-Blocker Epistaxis Stendra Chest Pain Refer to (HypoTN) Diarrhea PCP • Using CYP3A4 inhibitor Myalgia/Back pain Levitra • Severe Renal/Liver Dx • mostly Cialis Staxyn ODT BRAND Caverject Edex Muse GENERIC Flibanserin Common in CVD such as HTN, Atherosclerosis, or Diabetes. BRAND Addyi Prostaglandin E1 - vasodilator that allows blood to flow ADRs BBW CONTRAINDICATION Penile implants Penile abnormalities Penile pain Priapism Conditions that predispose HA/Dizzy to priapism (sickle-cell anemia, myeloma, leukemia) 5-HT1A agonist/5-HT2A antagonist - does NOT enhance sexual performance ADRs BBW CONTRAINDICATION Dizzy Somnolence Nausea Fatigue Dry mouth Insomnia • ETOH causes Hypotension + Syncope. • AVOID CYP3A4 inhibitors • Hepatic impairment ETOH Pregnancy NOTES Start 50mg 1hr before sex. Daily 2.5-5 mg PRN 5-20 mg NOTES Must refrigerate NOTES • For premenopausal women ONLY • REMS Program • Treatment for hypo-active sexual desire disorder (HSDD): o Low sexual desire that is not caused by health condition or drugs. BENIGN PROSTATE HYPERPLASIA General Information • • • • • • • Signs & Symptoms (LUTS) Enlarged gland leads to Lower urinary tract Sx (LUTS) Bladder outlet obstruction (BOO) + contractions lead to freq. urination. DRE - Digital Rectal exam Study urinalysis + Prostate specific antigen (PSA) NOT associated with prostate cancer Sx are similar to prostate cancer UTI infections are uncommon GENERIC BRAND Terazosin (Non-selective) Doxazosin (Non-selective) Cardura Tamsulosin (Selective Alpha-1A Blocker) Flomax Alfuzosin (Selective Alpha-1A Blocker) Uroxatral Silodosin (Selective Alpha-1A Blocker) Rapaflo GENERIC Finasteride Dutasteride BRAND Avodart Tadalafil BRAND Cialis Adcirca AUA Guidelines for Tx Orthostatic hypotension Syncope Floppy Iris Syndrome Priapism Angina Silodosin/Alfuzosin + CYP3A4 Hepatic imp. (Child-Pugh C) Renal imp. • • Depends on severity of Sx. No natural product recs. 1. 2. Alpha-blockers 5α-reductase inhibitors a. Do NOT use in BPH w/o enlargement. Tolterodine optional PDE-5 inhibitors 3. 4. α-blockers - relax smooth muscle leading to improved urinary flow BBW CONTRAINDICATION Dizziness/HA Fatigue Abnormal Ejaculation Fluid retention Rhinitis NOTES • Non-selective α-blockers must be titrated • Usually taken at bedtime to avoid first dose effect of orthostatic HTN. 0.4mg 30 min after same meal each day. Do NOT use if risk for QT Prolongation. Can cause retrograde ejaculation (reduced or NO semen) ADRs Impotence Libido Ejaculation disturbance Breast enlargement/tender Proscar GENERIC ADRs Hesitancy Intermittency Weak stream of urine Urgency Leaking/Dribbling Incomplete emptying Frequency Nocturia Drugs that Worsen BPH Anticholinergic medications Antihistamines Caffeine Decongestants Diuretics Testosterone products SNRIs TCA's Phenothiazines ADRs HA/Dizzy Flushing Dyspepsia Blurred vision Myalgia Diarrhea 5α-reductase inhibitors - blocks conversion of Testosterone  DHT BBW CONTRAINDICATION Increase risk of Prostate cancer. BBW Color discrimination Hearing loss Vision loss Hypotension Priapism Chest pain Women of child-bearing age Pregnancy Children PDE-5 inhibitors CONTRAINDICATION Do NOT use w/ nitrates or Riociguat NOTES • Pregnant women should not handle/take. • Shrink prostate + PSA level • Do NOT use Proscar in a PT using Propecia for hair loss. NOTES 5mg daily same meal. COUNSELING • • • • • Alone or combo w/ 5-alpha 1st Line for Mod-Sev Sx. Non-selective = More side Fx. Caution w/ PDE-5 inhibitors (BP) Alpha-Blockers do NOT shrink prostate or alter PSA levels. • Counseling: 1. Caution standing up 2. CNS Fx 3. Avoid ETOH COUNSELING Only used in BPH + enlargement COUNSELING OVERACTIVE BLADDER General Information • • • • Urinary urgency w/ or w/o incontinence (lacking control). Increased frequency + nocturia M3-Muscarinic receptors via ACH trigger stimulation of detrusor muscles  involuntary contractions. 1st Line Tx = Behavioral therapy GENERIC Oxybutynin Oxybutynin Patch Tolterodine Trospium XR Solifenacin Darifenacin Fesoterodine BRAND Myrbetriq GENERIC Onabotulinumtoxin-A GENERIC Desmopressin DRUG Tx: Non-Drug Tx is 1st line Drug Tx is 2nd line Combo w/ Non-Pharm tx. Bladder training Kegel exercises Dietary changes Weight loss 1. 2. 3. Anti-Cholinergics B-3 Agonists Onabotulinumtoxin-A How to Minimize Dry Mouth Sx • • • • Avoid combo Anti-cholinergics Try Extended-Release Try Oxybutynin gel/patch Mirabegron - less dry mouth Anticholinergics - block ACH binding to Muscarinic receptors. XR formulations are preferred (less dry mouth) BRAND ADRs BBW CONTRAINDICATION NOTES Ditropan Oxytrol Dizzy/Drowsy Agitation Urinary retention Detrol Xerostomia Oxybutynin Patch/Gel = Less Confusion Gastric retention Sanctura XR Constipation dry mouth. Drowsiness Low gastric motility Blurred vision Trospium XR = Empty Stomach Vesicare Angioedema Narrow Angle Glaucoma Urinary retention Enablex Toviaz GENERIC Mirabegron 1. 2. 3. 4. NON-PHARM Tx BRAND Beta-3 agonist - causes less dry mouth ADRs BBW HTN Nasopharyngitis UTI HA/Dizzy Constipation ADRs Angioedema Urinary retention in BPH Inhibit ACH release – 3rd Line Tx BBW UTI Urinary retention Dysuria Botox BRAND Noctiva DDAVP injection ADRs Swallowing trouble Breathing trouble Anti-Diuretic Hormone BBW Hyponatremia Nasal conditions CONTRAINDICATION NOTES Caution w/ Digoxin CONTRAINDICATION Infection at injection site CONTRAINDICATION Risk for Hyponatremia Loop diuretics CKD SIADH Fluid retention NOTES Prophylaxis with abx before admin. NOTES SICKLE CELL ANEMIA General Information NON-PHARM Tx: • Inherited RBC genetic disorder (most common in Blacks) • PTs have abnormal hemoglobin called HgbS. • Give concave sickle shape of RBC shortening lifespan of RBCs to 10-20 days  anemia & fatigue. • PTs lack O2 transport & clumping in blood vessels. • Sickle Cell Crises: o Vascular occlusion leads to ischemia + O2-deprivation. o Vaso-occlusive Crisis (VOC) aka Acute Pain Crisis. ▪ Leads to pain in lower back, abdomen, chest, & extremities. • Functional Asplenia: o Decreased or absence of spleen function. ▪ Spleen becomes fibrotic & shrinks in size. ▪ PT unable to recycle RBCs & store/produce WBCs. • PTS are risk for Infections. Should get immunizations, ABX. GENERIC Hydroxyurea GENERIC L-Glutamine BRAND Droxia Hydrea BRAND Endari ADRs LFTs Uric Acid BUN/SCr N/V/D Mouth ulcers Anorexia Hyperpigmentation Atrophy of Skin/Nails Low Sperm count ADRs Constipation Nausea HA Back/Extremity pain Cough DRUG Tx: 1. Blood Transfusions: a. GOAL Hgb = < 10 g/dL. b. Risk of Iron overload. 2. Chelation Therapy: a. Used to remove excess Iron. Only cure is bone marrow transplant but risky + cost. 1. Immunizations 2. ABX 3. Analgesics a. Mild-Mod Pain: i. Tx w/ NSAIDs or acetaminophen, rest, compresses. b. Severe Pain: i. IV Opioids ii. PT-Controlled Analgesia (PCA) 4. Chelation Tx 5. Hydroxyurea or L-Glutamine a. Reduce complications Stimulates Hgb-F production BBW CONTRAINDICATION Myelosuppression Leukemia/Skin cancer Embryo-Fetal toxicity Avoid Live Vaccines Skin ulcers Pancreatitis Macrocytosis Use Sun Screen to protect skin. Unknown BBW Immunizations CONTRAINDICATION 1. Influenza Type B Vaccine (HiB) 2. Pneumococcal vaccine 3. Meningococcal vaccine. NOTES • IND: ≥ 3 Mod-Sev Pain crises in 1 year • Contraception is required - During & up to 1 year after • Hazardous - Wash hands & wear Gloves • Supplement Folic Acid • Monitor: o CBC w/ Differential o ANC < 2000 NOTES Mix each dose in 8 oz. of COLD or ROOM temp. beverage OR in 4-6 oz. of food. BIPOLAR DISORDER • • • General Information Mood disorder w/ fluctuations from extreme sadness or hopelessness  abnormally elevated overexcitement or irritable mood called mania or hypomania. Each episode is a drastic change in mood/behavior. Bipolar PTs are more susceptible to Drug-Induced extrapyramidal symptoms (EPS) esp. with first generation antipsychotics BIPOLAR 1: • Severe Mania • Intense Depression • May be Psychotic/Delusional (may req. hospitalization) • • • • • Mania Diagnosis • Abnormally elevated/irritable mood for 1 week OR any duration req. hospitalization. • Depression • Inflated Self-esteem • Talkative • One topic to next • Easily distracted • High risk activities BIPOLAR 2: Hypomania Does NOT affect social/work NO cause of psychosis Intense Depression PTs feel better during Mania so often misdiagnosed for only Depression during that phase. Mood Stabilizers BRAND ADRs 1st line: SGAs are preferred for Tx of Bipolar disorders. 1. Toxicology should be performed if due to illicit drug use. 2. GOAL: to stabilize mood w/o inducing fluctuations. 3. Anti-Psychotics: only used if PT has psychosis. 4. Anti-Depressants: NOT recommended - induce mania a. ONLY given if PT is already on Mood Stabilizer ACUTE Tx: 1st line for manic state • Valproate + Anti-Psychotic • Lithium + Anti-Psychotic 1st line for bipolar depression • Lithium • Lamotrigine Lithium Lithobid Bipolar Depression: • Lamotrigine Bipolar Mania: • Valproate • Carbamazepine (Equetro) Mania + Depression: • Lithium +/- SGA Medication Guides Avoid • • • Valproate o Causes fetal syndrome Carbamazepine o Causes fetal syndrome Lithium o Causes abnormalities • • Anti-Depressants MedGuide for Suicide risk. Anti-Psychotics MedGuide for Death risk in elderly PTs w/dementia-related psychosis SGAs = Preferred d BBW C/I Risk of Serotonin Syndrome • SSRIs/SNRIs • Triptans • Linezolid Risk of Neurotoxicity (Ataxia, tremor, nausea) • Non-DHP CCBs • Phenytoin • Carbamazepine NOTES DOSING INITIATION: 1. Titrate slowly  QHS 2. Take w/ FOOD 3. Drink plenty of FLUIDS Lithium toxicity GI upset • Nausea, Anorexia, Ab-pain Cognitive Fx Cogwheel Rigidity Tremor Weight gain Polyuria/Polydipsia Hypothyroidism MAINTENANCE Tx: Pregnancy Treatment for both mania + depression Lithium Valproate Lamotrigine • NOT used for acute mania due to slow titration & severe rash. Carbamazepine GENERIC DRUG Tx: • Mild-Mod Renal Imp. (Lithium is 100% renally cleared) Factors affecting concentration Lithium levels •  sodium intake • ACEi/ARBs • NSAIDs (use ASA) Lithium levels •  sodium Intake • Caffeine • Theophylline Dose Correctly: • 5 mL Solution = 8 mEq • 300mg Tab/Cap = 8 mEq Therapeutic Range: 0.6 - 1.2 ANXIETY General Information NON-PHARM Tx: Cognitive Behavioral Tx (CBT) 1. 2. 3. Continuous + Severe amount of great distress, fear, & worry. Inability to focus at school/work. Harmful to relationships. DSM-5 Classifcation of Major Types of Anxiety: General Anxiety Disorder (GAD) Panic Disorder (PD) Social Anxiety Disorder (SAD) Obsessive Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD) GENERIC BRAND BRAND Lorazepam Ativan Alprazolam Xanax Clonazepam Klonopin Diazepam ADRs Nausea/Headache Dizziness Drowsiness Buspirone GENERIC AVOID Drug-induced Anxiety • Albuterol • Anti-Psychotics • Bupropion • Caffeine • Decongestants (PSE) • Illicit Drugs • Steroids • Stimulants • Levothyroxine • Theophylline Valium Oxazepam Chlordiazepoxide Clorazepate Tranxene-T Temazepam Restoril ADRs DRUG Tx: 1st line = SSRI or SNRI • Escitalopram • Fluoxetine • Paroxetine • Sertraline • Duloxetine • Venlafaxine XR 1. Start at 1/2 initial dose 2. Slowly Titrate 3. Take 4-wks for relief BBW 2nd line: • Buspirone o takes 2-4 wks • Amitriptyline (Elavil) • Imipramine (Tofranil) • Nortriptyline (Pamelor) • Hydroxyzine (Vistaril) o Sedating Anti-histamine o NOT used long-term • Pregabalin (Lyrica) o C5 - Tx anxiety + neuropathy • Propranolol (Inderal) Metabolism + Safety • • • Lorazepam Oxazepam Temazepam "L-O-T" are less harmful for PTs w/ Liver impairment since metabolized to inactive compounds (Glucuronides) 1. Used short-term & fast relief. 2. Used for acute-anxiety. 3. D/C after 1-2 wks. 4. ANTI-DOTE = Flumazenil CONTRAINDICATIONS NOTES CONTRAINDICATION NOTES • MAOi w/in 14 days • Avoid Serotonergic Meds (Serotonin Syndrome) Benzodiazepines (C4) BBW BBW: Respiratory Depression Coma/Death Somnolence Dizziness Lightheadedness Weakness Ataxia Benzodiazepines WARNINGS: • Dependence/Tolerance in chronic use so must taper off (if using > 10 days) • Amnesia • CNS depression • Abuse • > 65 yo: safety risks. • Opioids • Pregnancy • AVOID other CNS Depressants ALPRAZOLAM: • C/I with Ketoconazole/Itraconazole (Strong CYP3A4) Diazepam: • Lipophilic • Fast Onset/Long Half-life • High Abuse potential Used for ETOH Withdrawal Sx: • Lorazepam • Diazepam • Chlordiazepoxide NOT FOR ANXIETY ALZHEIMER’S DISEASE General Information Signs & Symptoms • Cognitive decline  dementia w/ noticeable memory loss. • Tx does very little for neurotic plaques & tangles. • DIAGNOSIS: Mini-Mental State Exam (MMSE Score < 24) • ELDERLY PTs: o AVOID use of AntiCholinergics such as Diphenhydramine or Benztropine. GENERIC Donepezil • • • • • • • • • Anti-Histamines Anti-Cholinergics Anti-Emetics Anti-Psychotics Barbiturates BZDs Benztropine Muscle Relaxants Other CNS Depressants Rivastigmine Exelon Galantamine Razadyne BRAND Namenda NON-PHARM Tx: 1. Vitamin-E 2. Gingko Biloba (bleed risk) 3. Vitamin-D (helps memory) 4. Diet & Exercise DRUG Tx: • ACH inhibitors - slows progression o Donepezil - Take at bedtime. o Memantine - Alone or Adjunct to other meds • Anti-Psychotics/Anti-Depressants may be used but risk of: o Death in elderly (Psychotics) ACH Inhibitors - inhibit Acetylcholinesterase (ACH) ADRs BBW CONTRAINDICATIONS • Avoid drugs that  HR due to risk of dizziness/falls. • Avoid Anti-Cholinergics = efficacy • Give Donepezil at NIGHT to  nausea. (5 - 10 mg QHS) Aricept Namzaric Memantine Memory loss Difficulty communicating Inability to learn Difficulty planning or organizing • Poor coordination/ motor fxn • Personality changes • Paranoia/agitation/ hallucination BRAND Donepezil + Memantine GENERIC • • • • Drugs that WORSEN Dementia: N/V/D Bradycardia Fainting Insomnia QT-Prolongation ADRs Dizziness Headache Constipation NMDA Blocker BBW NOTES Start at low dose  Titrate Recommended: • Exelon Patch or Donepezil ODT o  GI side fx. CONTRAINDICATION NOTES • • • Oral Solution available ER Caps: Do not crush/chew May sprinkle on applesauce STEROIDS General Information Reduce Systemic Risks by Medrol Dose-Pak Dosing • Steroids have stronger anti-inflammatory ability than NSAIDs. • Adrenal Insufficiency: endogenous steroids that the adrenal gland is not producing. • Cortisol - may be replaced by any steroid. • Steroids must be TAPERED off. • Addison's disease - adrenal gland not making enough cortisol. o Opposite of Cushing's syndrome o Treat with fludrocortisone ▪ Replacement therapy to mimic Aldosterone ( mineralocorticoid activity to balance H20 + electrolytes. • Every-Other-Day dosing • Taper Off • Use injections - drug stays local • Inhaled steroids - for asthma • Use low absorption • Lowest effective dose (21 x 4 mg Tabs) GENERIC • • • • • • PO Dosing Equivalence DAY 1: 2 before breakfast, 1 after lunch, 1 after dinner, 2 QHS DAY 2: 1 before breakfast, 1 after lunch, 1 after dinner, 2 QHS DAY 3: 1 before breakfast, 1 after lunch, 1 after dinner, 1 QHS DAY 4: 1 before breakfast, 1 after lunch, 1 QHS DAY 5: 1 before breakfast, 1 QHS DAY 6: 1 before breakfast. 25 mg 20 5 5 4 4 0.75 0.6 mg Short-acting Intermediate-acting Long-acting Cute Hot Pharmacists & Physicians Marry Together & Deliver Babies Steroids - Glucocorticoid activity and anti-Inflammatory effect ADRs BBW BRAND Cortisone Hydrocortisone Prednisone Prednisolone Methylprednisolone Triamcinolone Dexamethasone Betamethasone CONTRAINDICATION NOTES Cortisone Betamethasone Celestone Soluspan Ready Sharp Dexamethasone DexPak 6-10-13 Day Double Dex Hydrocortisone Solu-Cortef Cortef Methylprednisolone Medrol Solu-Medrol A-Methapred Depo-Medrol Prednisone Deltasone Prednisolone Millipred Orapred ODT Prediapred Triamcinolone Kenalog Appetite Weight Gain Fluid Retention Mood Swings Insomnia Indigestion Bitter Taste BP BG WARNING: Adrenal Suppression (HPA axis) Taper Off when use is >14 days LONG-TERM FX: Refer to Cushing's syndrome Cushing’s Syndrome • Adrenal gland produces too much cortisol, causing many side effects (refer to  box) • Exogenous Steroids in high doses may also increase cortisol o Cortisol  Negative FB  Cortisol • Ultimately causing HPA-axis Suppression Strong Anti-Inflammatory effects SHORT-TERM FX: (<1 Month) High Steroid Intake/Production SE - GI Bleed/Ulcers Growth Retardation Glaucoma/Cataracts Psychiatric Changes Poor Bone Health Pink-Purples Stretch Marks Moon Face Acne - Buffalo Hump Diabetes Dysmenorrhea Hypothyroidism Muscle Wasting Infection Impaired Wound Heal Women - Hirsutism • Cortisone = Pro-Drug of Cortisol • Prednisone - Pro-Drug of Prednisolone • Prednisolone used often for child Live Vaccines Serious Systemic Infections Treatment Indications • Replacement therapy • Auto-Immune diseases • Post-Transplant • Asthma QD Dosing = Take 7am - 8am to mimic body cortisol release Key Concepts • Immunosuppressed dosing = ≥2 mg/kg/day OR ≥20 mg/day of Prednisone or Prednisone-EQ for >2 weeks. • Immunosuppressed PT cannot get Live Vaccines & there is  risk of Infxn. • Taper off to reduce HPA-axis Suppression and  chance of Addison's disease • Common Method =  dose by 10 - 20% every few days (7 - 14 days) THYROID DISORDERS General Information Thyroid Pathophysiology • T3 = Triiodothyronine • T4 = Thyroxine 1. Thyroid cells absorb Iodine/Tyrosine to make hormones. 2. Thyroid produces T3/T4. 3. TSH secreted by Pituitary gland in Hypothalamus. 4.  T4 =  TSH (Negative FB loop) 5. Active Form = Free T4 (FT4) Drugs that  Thyroid hormone levels Ca+, Fe+, Mg+, Al+3 (antacids) Multivitamins - ADEK, Folate Cholestyramine Orlistat (Xenical, Alli) Sevelamer Sucralfate Kayexalate Estrogen SSRIs BB's Amiodarone Levothyroxine Colors 25 mcg = Orange 50 mcg = White 75 mcg = Violet 88 mcg = Olive 100 mcg = Yellow 112 mcg = Rose 125 mcg = Brown 137 mcg = Turquoise 150 mcg - Blue 175 mcg - Lilac 200 mcg = Pink 300 mcg - Green Orangutans Will Vomit On You Right Before They Become Large Proud Giants 1. 2. 3. Counseling Different brands are not equal. Safe in pregnancy + breastfeeding. Take w/ H2O 60 mins before breakfast or 3 hrs after dinner. Hypothyroidism = T4/TSH (low Metabolism) Signs/Sx: Fatigue Weight gain Cold intolerance Muscle cramps Constipation Myalgias Bradycardia Coarse/Loss of hair Memory impairment Menorrhagia Goiter - due to iodine -------------------------------Myxedema Coma: Occurs when pt is untreated for a long period of hypothyroidism. (Life-threatening emergency) Treatment: 1. Levothyroxine (T4) = 1st Line 2. Consistent preparation minimizing variability. 3. PTs who "don't feel right" may use other formulations. -------------------------------------------Hashimoto's Disease: - Autoimmune - AB's attack Thyroid - Caused by conditions + drugs: o Amiodarone o Carbamazepine o Eslicarbazepine o Oxcarbazepine o Interferon o Lithium o Phenytoin o Tyrosine Kinase inhibitors (esp. Sunitinib) Diagnosis:  FT4 | Normal = 0.9-2.3  TSH | Normal = 0.3-3.0 Screen at age 60 ----------------------------------Monitor: Check TSH q4-6 wks til levels are normal then q4-6 months. Too high dose leads to Afib + fractures. ----------------------------------Pregnancy: causes low birth weight, loss of pregnancy, premature birth, lower IQ in children GENERIC Levothyroxine (T4) BRAND Synthroid Levoxyl Tirosint Unithroid Thyroid Desiccated USP (T3/T4) Armour Thyroid Liothyronine (T3) Cytomel Triostat Liotrix (T3/T4) Thyrolar Thyroid Replacement BBW ADRs Euthyroid = No Sx  dose = hyperthyroidism sx. Not used for obesity/weight reduction C/I NOTES DOSING - Acute MI - Thyrotoxicosis - Uncorrected Adrenal insufficiency - Decrease dose in CVD - IV to PO ratio = 0.75-1 - Levothyroxine is safe & recommended in pregnancy (requiring 30-50% increase in dose) - Full Dose = 1.6 mcg/kg/day (IBW) for healthy, young-middle age (<50) - CAD = 12.525 mcg/day Hyperthyroidism = T4/TSH Signs/Sx: Treatment: Heat intolerance Weight loss or gain Tremor Palpitations/Tachycardia Freq bowel movements Agitation, nervous, anxiety Fatigue/Muscle weakness Insomnia Thinning hair Goiter (possible) Exophthalmos Light/Absent menses 1. BB's for Sx control 2. PTU or Methimazole (temporary til surgery) 3. RAI-131(Takes 1-3 months of HIGHER doses to control Sx but later must REDUCE dose to avoid hypothyroidism) - - Overview: Over-Production of thyroid hormones. Mostly caused by Grave's disease (autoimmune in women 30-40's that stimulates too much T4) Drugs that cause hyperthyroidism: o iodine o amiodarone o Interferon Thyroid Storm - life-threatening emergency that is treated w/ PTU. o Fever (> 103), tachycardia, tachypnea, dehydration, sweating, agitation, delirium, psychosis, coma. GENERIC Beta-Blockers Propylthiouracil BRAND PTU Methimazole Tapazole Potassium Iodide Lugol's Solution Saturated K+ Iodide SSKI Thyroshield ADRs Anti-Thyroid Medications BBW C/I NOTES Used for Sx control: Palpitations, tremors, tachycardia. GI upset HA Rash Hepatitis Agranulocytosis (rare) Rash Metallic taste GI upset Pregnancy: 1st trimester = use PTU 2nd/3rd trimester = Methimazole Liver failure (PTU) Hypersensitivity to Iodine Temporarily inhibits secretion of T4/T3 for only weeks TRAVELER’S DISEASES Traveler’s Diarrhea (TD) General Information 1. Travelers should carry a list of all medical conditions & medications (Rx/OTC). 2. Pack any medical supplies on Carry-On luggage. 3. "YELLOW Book" has all CDC travel information. 4. Consider food/H2O, blood/body fluids, & insects for transmission. 5. Dysentery TD occurs if blood in stool - Worse Sx. 6. Mostly caused by Bacterial (E. coli). Prevention 1. Cook it, peel it, or forget it! 2. Bismuth Subsalicylate (BSS) a. Pepto-Bismol b. Anti-Secretory Anti-Diarrheal c. S/E of black tongue/stool d. Caution: Reye’s Syndrome 3. ABX only used for HIGH risk. 1. 2. 3. 4. Treatment: Hydrate (fluid/salt). Loperamide (Imodium A-D) a. Primary Tx for acute diarrhea. b. Decreases freq/urgency Macrolides, FQ's, or Rifaximin preferred. Azithromycin = Severe TD or Dysentery TD. 1. 2. Prophylaxis BSS - tabs/liquid dose 525-1050 mg QID w/ FOOD & QHS. Rifaximin - preferred for pt at high risk. Dose: 4mg after 1st loose stool. 2mg after for each loose stool. MAX Dose = 16 mg/day MAX Use = 2 days. Mild TD • Loperamide PRN (NO ABX) Moderate TD • Loperamide PRN +/- ABX Severe/Dysentery TD • Azithromycin 1000mg x 1 dose +/- Loperamide Malaria GENERIC General Information • Plasmodium Vivax is most common cause and resistant to drugs. • P. Faciparum - MOST deadly! • Prophylaxis is recommended and Tx varies depending on region. • Malaria drugs cause nausea & GI stress so need to be taken w/ FOOD + H2O/Milk. Insect Bites Transmitting Disease: • Vector is usually Mosquitoes: Japanese Encephalitis, Yellow Fever, Dengue, Malaria, Zika virus. • Protect from insect bites is key. • DEET 20-50% is the active ingredient in insect repellant. • Permethrin is used to Tx clothing. QUICK START Px: Initiate 1-2 days prior to travel. BRAND Atovaquone/Proguanil Malarone Doxycycline Doryx Vibramycin Take daily & STOP 4 weeks after travel Take daily & STOP 1 week after travel Primaquine ADVANCE Start Px: Start 1-2 weeks prior to travel. WHEN TO USE Take daily & STOP 1 week after travel Chloroquine Taken WEEKLY Mefloquine CONTRAINDICATION Pregnancy Breastfeeding Child < 8 yo Pregnancy Breastfeeding *Photosensitivity ALL do not use in Pregnancy. G6PD - Deficiency Pregnancy Breastfeeding ADRs: Skin Rxns Visual changes Blue/Grey skin pigmentation Psychiatric conditions Seizures Arrhythmias Lariam NOTES - Safe in children/pregnancy - Choice depends on regional resistance Other Diseases Cholera: - Vibrio Cholera - Food/H2O contaminants - Vaccine: Vaxchora (PO, Live) Polio: CDC recommends 1-Lifetime Booster dose 4 wks before travel for adults. Hepatitis-B: 1. Spread by Blood/Body fluids 2. Avoid high risk behaviors. 3. Dose vaccine 6 months to complete. Administer as MANY doses as possible before travel. Meningococcal Meningitis: 1. Neiserria meningitis 2. Fever, HA, stiff neck Sx req UREGENT care. 3. Spread by Respiratory secretions. 4. HAJJ & Umrah pilgrimages from Saudi Arabia to req vaccines during travel. Air Travel Compression stockings -------------------------Acute Mountain Sickness Need Acetazolamide (CI = Sulfa allergy) Typhoid Fever: 1. Caused by Salmonella Typhi. 2. Spread by contaminated Feces. 3. Vaccines: Vivotif or Typhim Vi. (IM). Give ≥2 wks before travel. Dengue Fever: - NO vaccine available - AVOID Mosquitoes is crucial. Japanese Encephalitis: - AVOID Mosquitoes - Vaccine: Ixiaro Zika Virus: 1. Transmitted by Mosquitoes, sexual contact, or blood transfusions. 2. Causes Microcephaly 3. NO Vaccine 4. Use contraception w/ sex. Yellow Fever: - ASA/NSAIDs = Bleeding do NOT use. - LIVE Vaccine: YF-VAX. - Given certificate for vaccination & must be completed w/in 10 days before arrival. - C/I = Egg Allergy. WEIGHT LOSS AACE/ACE Guidelines = Exercise > 150 mins/wk for 3-5 days/wk + resistance training. General Information Drugs that cause Weight Gain • Meds not appropriate for small weight loss. • ONLY indicated for BMI ≥30 OR BMI ≥27 +1 weight-related condition (DLD, HTN, and DM). • Rx meds only used adjunct to diet plan + exercise. • Drugs are selected based on PT’s comorbid conditions. • Older stimulant agents are ONLY used short-term to jump-start a diet. • Newer agents are used Long-term for maintenance. (Qsymia, Belviq, Contrave, Saxenda) • Weight loss drugs should be D/C if they don’t produce at least 5% weight loss at 12 weeks. GENERIC Phentermine/Topiramate BRAND Qsymia (C4) • • • • • • • • Drugs that cause Weight Loss Insulin Sulfonylureas Glitazones Anti-Psychotics Steroids Mirtazapine (Remeron) Dronabinol (Marinol) Megestrol (Megace) • ADHD Stimulants (Ritalin, Concerta, Adderall, Vyvanse) • Exenatide (Byetta/Bydureon) • Liraglutide (Victoza) • Saxenda (at high dose) • Topiramate (Topamax) • Condition – Hypothyroidism MOA - Phentermine Sympathomimetic stimulant amphetamine like  NE. - Topiramate GABA/Glutamate. ADRs Bariatric Surgery Caution/Avoid • BMI > 40 or >30 + condition • Nutrient Deficiency: o Ca+ Citrate is preferred. o Vit-B12 & Iron supplements o Iron/Ca+ 2 hrs. before or 4 hrs. after antacids. o Supplement Vit-ADEK for LIFE. • Medication Concerns: • May need to crush, liquid, or transdermal for 2 months postsurgery • PT’s may need Ursodiol for gallstones. • AVOID GI irritants (NSAIDs + Bisphosphonates) • Pregnancy o Avoid all WL drugs • Depression o Contrave (contains bupropion) • Hypertension o Qsymia, Contrave • Opioid Use o Contrave • Seizures o Qsymia, Contrave BBW Anxiety Depression Suicidal thoughts Tachycardia CONTRAINDICATION - Hyperthyroidism - Glaucoma - MAOi in 14 days Pregnancy NOTES Taper off due to seizure. Naltrexone/Buproprion Contrave Decreases cravings/appetite. N/V/C/HA Dizziness Dry Mouth - NOT approved for MDD - Suicidal ideation - Caution in psychiatric/seizures disorders. - Can  HR/BP Lorcaserin Belviq (C4) Serotonin 5HT-2C agonist (increasing satiety) Dizzy/HA Fatigue Nausea Dry mouth Serotonin Syndrome w/ other serotonergic agents Pregnancy GLP-1 agonist Nausea/Vomiting Diarrhea/Constipation Dizzy/HA/Fatigue - Family Hx of Medullary Thyroid Carcinoma (MTC) - Hypoglycemia -  HR Pregnancy - Victoza - for Diabetes. - Saxenda - REMS for MTC + Pancreatitis Sympathomimetic Stimulants (Similar to amphetamines, increasing NE) Tachycardia Agitation  BP - AVOID in HTN, PAH, Hyperthyroidism, or Glaucoma. - MAOi in 14 days - Stimulants are used for 12 weeks to jump start a diet. - Monitor - HR/BP - Pregnancy - Cholelithiasis - Malabsorption Syndrome - Take Vitamin ADEK + BetaCarotene at bedtime or separate by 2 hours. - Do NOT use Cyclosporine or separate by 3 hrs. - Separate Levothyroxine by 4 hrs. Liraglutide Saxenda Phentermine (C4) Diethylproprion (C4) Phendimetrazine (C3) Benzphetamine (C3) Orlistat Rx Adipex-P Tenuate Orlistat OTC Regimex Xenical Alli Lipase inhibitor - decreases fat absorption by 30% Gas w/ Discharge Fecal urgency Fatty stool Adipex-P: Avoid in Pregnancy - Liver damage Cholelithiasis Kidney Stones Hypoglycemia - Opioid use Uncontrolled HTN Seizure disorder Bulimia/Anorexia Bupropion-containing products Naltrexone - blocks opioids + buprenorphine  blocking analgesia. MIGRAINE Chronic headaches causing pain for hours or days. General Information Diagnosis • Most cause N/V, sensitivity to light, or auras of flashing lights, blind spots or tingling in arms or legs. • May be due to NT's, especially Serotonin - 5HT • Identify and avoid migraine "triggers" (Female hormonal changes, food, stress, sleep pattern, weather) • Women who have migraine w/ aura =  Stroke risk. o Should AVOID Estrogen-containing contraceptives. GENERIC Sumatriptan ≥5 attacks not attributed to other disorders with: • Last 4-72 hrs. + recur sporadically. • ≥2 characteristics: Unilateral location, pulsating, mod-severe pain, aggravated by physical activity. • If N/V, photophobia, or phonophobia occurs. BRAND Imitrex Onzetra Xsail Zembrace SymTouch Sumavel Sumatriptan + Naproxen (Child >12 yo) Treximet Almotriptan (Tab, Child >12 yo) Axert Eletriptan Relpax Frovatriptan Frova Naratriptan Amerge Rizatriptan (Child 6-17 yo) Maxalt Zolmitriptan (Nasal Spray, Child >12 yo) Zomig GENERIC Dihydroergotamine (Injection, Nasal Spray) BRAND DHE 45 Migranal Ergotamine + Caffeine (Tablet, Suppository) Cafergot Migergot GENERIC Propanolol Metoprolol BRAND Inderal LA Lopressor Toprol XL Treatment 1. 2. 3. 4. 5. 6. NON-DRUG Tx: Avoid Triggers Stress management Massage Spinal manipulation Cold compress/Ice pack Acupuncture Natural Products: • Caffeine combo w/ ASA or Tylenol • Butterbur • CoQ-10 • Feverfew • Magnesium Peppermint • Riboflavin MOA 5HT-1 Agonist MOA Ergotamines: ONLY for PTs who get no relief from Triptans. MOA Consider 2-6 month use if: 1. Using Acute Tx ≥2 days/wk OR ≥3x/month. 2. If migraines decrease QOL. 3. If acute tx are ineffective or contraindicated. Ex. Beta-Blockers, Topiramate Valproic Acid, TCAs, Venlafaxine, or Botox (chronic migraines only) ADRs - Vasoconstriction of cranial blood vessels