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Pharmacology Update

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Title: Pharmacology Update


1
Pharmacology Update
2
Which of the following is TRUE about using
testosterone in older men?ltgt A.Testosterone
might improve energy, strength, and
libido.ltgt B.There are concerns about a possible
increased risk of prostate cancer.ltgt C.Oral
methyltestosterone should be tried
first.ltgt D.Both A and B
3
Answer
  • D.Both A and B

4
Before starting testosterone you should check
what blood tests?
  • A. PSA
  • B. Hemoglobin
  • C. Liver Function
  • D. Hemoglobin A1C
  • E. A, B, C
  • F. All of the above

5
Answer
  • E. A, B, C

6
What level of testosterone is low and what level
is therapeutic in mg/dl?
  • A. 200/400
  • B. 300/500
  • C. 300/600
  • D. 400/ 700

7
Answer
  • C. 300/600

8
Which of the following is TRUE about chronic use
of proton pump inhibitors?ltgt A.PPIs lower the
risk of fractures.ltgt B.PPIs lower the risk of
pneumonia.ltgt C.Tapering the PPI when stopping
may help reduce acid rebound symptoms.ltgt D.PPIs
increase calcium absorption.
9
Answer
  • C.Tapering the PPI when stopping may help reduce
    acid rebound symptoms.ltgt

10
Which of the following is TRUE about the
interaction between clarithromycin and inhaled
salmeterol (Advair, Serevent)?ltgt A.Clarithromycin
can lower salmeterol levels and make it less
effective.ltgt B.Clarithromycin can boost
salmeterol levels and cause adverse cardiac
effects.ltgt C.A similar interaction is seen with
azithromycin and salmeterol.ltgt D.A similar
interaction is seen with clarithromycin and
formoterol (Foradil).
11
Answer
  • B.Clarithromycin can boost salmeterol levels and
    cause adverse cardiac effects.ltgt

12
Which of the following is TRUE about using
beta-blockers in patients with chronic
obstructive pulmonary disease?ltgt A.Beta-blockers
are usually avoided due to fears of
bronchoconstriction.ltgt B.New evidence suggests
that beta-blockers might decrease COPD
exacerbations.ltgtC.Cardioselective beta-blocker
(metoprolol, etc) are preferred for COPD
patients.ltgt D.All of the above
13
Answer
  • D.All of the above

14
Most states now have Prescription Drug Monitoring
Programs for controlled drugs. Which of the
following is TRUE?ltgt A.These programs are proven
to reduce diversion.ltgt B.Information can't be
shared with other states.ltgt C.Prescribers can
find out if patients are getting controlled drugs
from other prescribers or pharmacies.ltgt D.The
information is only available by phone.
15
Answer
  • C.Prescribers can find out if patients are
    getting controlled drugs from other prescribers
    or pharmacies.ltgt

16
Which of the following is TRUE about drug
allergies?ltgt A.Hydrocodone can be used in a
patient with a true allergy to codeine.ltgt B.Cross
-sensitivity usually isn't a problem between
sulfa antibiotics and other sulfonamides.ltgt C.Abo
ut 10 of patients allergic to penicillin are
allergic to cephalosporins.ltgt D.People allergic
to sulfa drugs also need to avoid drugs or foods
with sulfur, sulfites, or sulfates.
17
Answer
  • B.Cross-sensitivity usually isn't a problem
    between sulfa antibiotics and other sulfonamides

18
Opioids.
  • Most reactions are side effects or
    "pseudoallergies"...and AREN'T immune mediated.
    Pseudoallergies are due to histamine release and
    can lead to hives, itching, etc. In this case,
    try a lower dose...a different opioid...or
    pretreat with an antihistamine.     For a true
    opioid allergy, use one from a different class. 
       Patients allergic to codeine CAN usually take
    fentanyl, meperidine, or methadone...but NOT
    morphine, hydrocodone, or oxycodone.     Avoid
    tramadol or tapentadol if opioid reactions were
    severe

19
Sulfas.
  •  Cross-sensitivity usually is NOT a problem
    between sulfa antibiotics and other
    sulfonamides...thiazides, loops, sulfonylureas,
    etc.     If patients need a diuretic and must
    avoid sulfas, use amiloride, triamterene,
    spironolactone, or ethacrynic acid. And yes,
    ethacrynic acid IS available again...after being
    gone a few years ago.     Tell patients allergic
    to sulfas that they CAN have foods or drugs with
    sulfur, sulfites, or sulfates. Explain these
    DON'T cross-react.

20
Penicillin.
  •      Experts used to think about 10 of patients
    allergic to penicillin were allergic to
    cephalosporins...and 47 to imipenem. But
    actually the risk is only about 1.     Consider
    using another beta-lactam if the penicillin
    allergy is mild...but avoid beta-lactams if the
    reaction to penicillin is severe.     If in
    doubt about a reaction and the drug is critical,
    consider drug allergy testing...and
    desensitization if necessary.

21
What works for Leg Cramps?
  • A. Quinine
  • B. Magnessium
  • C. Calcium
  • D. Requip
  • E. Gateraid
  • F. Nothing works well

22
Answer
  • F. Nothing works well

23
Leg Cramps
  • Patients are still looking for something that
    works for nocturnal leg cramps. Almost half of
    elderly patients have frequent leg cramps with no
    obvious cause. The problem is there are no proven
    treatments.     First look for possible causes
    such as diuretics or beta-agonists. Also check
    serum potassium, magnesium, and calcium.   
     Advise patients to try simple measures...calf
    stretches, hot or cold packs, hydration with
    electrolytes (Gatorade, etc).     Recommend
    acetaminophen or ibuprofen for pain relief...but
    explain they won't prevent cramps.     Some
    experts suggest B-complex vitamins, low-dose
    diltiazem, or magnesium...but there's only weak
    evidence of a possible benefit.     Don't use
    vitamin E and gabapentin...evidence suggests that
    they DON'T work for muscle cramps.     Other
    anticonvulsants and baclofen are sometimes tried
    for severe cramps, but they aren't proven to
    help. Don't use them routinely.     Don't rely
    on clonazepam or ropinirole for leg cramps,
    either. These can be helpful for restless legs
    syndrome...but there's no evidence that they
    prevent leg cramps.     Of course the 800-pound
    gorilla is quinine.     Don't recommend Hyland's
    Leg Cramps with Quinine or similar homeopathics.
    Their quinine content is miniscule and not proven
    to work.      Tonic water has only 20 mg
    quinine/cup...not enough to help.     Rx quinine
    is still used a lot. But FDA questions its
    efficacy and says the risks are too high for leg
    cramps.     Qualaquin is the only approved
    quinine. But its labeling warns not to use it for
    leg cramps...and it costs about 5 per cap.   
     It's okay to prescribe Qualaquin off-label for
    leg cramps, but consider the risk of
    thrombocytopenia, arrhythmias, etc. Consider
    using our quinine consent form if you're
    concerned about legal exposure.

24
Qualaquin 324 mg
  • Do not use this medication if you have ever had
    an allergic reaction to quinine or similar
    medicines such as mefloquine (Lariam) or
    quinidine (Cardioquin, Quinidex, Quinaglute)
  • Do not use if you have a history of "Long QT
    syndrome"
  • glucose-6-phosphate dehydrogenase (G-6-PD)
    deficiency
  • myasthenia gravis or
  • optic neuritis (inflammation of the optic nerve).
  • If you have any of these other conditions, you
    may need a dose adjustment or special tests to
    safely take quinine
  • heart disease or a heart rhythm disorder
  • low potassium levels in your blood (hypokalemia)
    or
  • kidney or liver disease.

25
How long patients should take aspirin PLUS
clopidogrel (Plavix) OR prasugrel (Effient) after
a coronary stent.
  • A. One month
  • B. One year
  • C. Depends on the stent

26
Answer
  • C. Depends on the stent

27
Which of the following is TRUE about antiplatelet
therapy after a coronary stent?ltgt A.Dual
antiplatelet therapy is usually given for at
least one year after placement of a drug-eluting
stent.ltgt B.Aspirin should be stopped at the same
time as clopidogrel.ltgt C.Drug-eluting stents
have a lower risk of thrombosis than bare-metal
stents.ltgt D.Patients who miss one dose of
clopidogrel should get another loading dose.
28
Answer
  • A.Dual antiplatelet therapy is usually given for
    at least one year after placement of a
    drug-eluting stent.

29
Preventing Thrombosis
  • Patients should get aspirin indefinitely after a
    stent.     But how long patients should take
    clopidogrel or prasugrel depends on the type of
    stent and the indication for the stent.   
     Bare-metal stents are quickly coated with
    endothelial cells which help prevent stent
    THROMBOSIS.     But cell overgrowth can block
    the stent and cause RESTENOSIS.     For
    bare-metal stents, use dual therapy with aspirin
    plus clopidogrel or prasugrel for at least one
    month for stable patients...and 12 to 15 months
    for patients with acute coronary syndrome.   
     Drug-eluting stents are coated with meds to help
    prevent cell overgrowth and restenosis. But the
    stent metal is exposed longer which can increase
    the risk for stent thrombosis.     Therefore
    patients with drug-eluting stents usually need
    dual antiplatelet therapy longer to prevent clots
    than patients with bare-metal stents.     Some
    evidence suggests one year of dual antiplatelets
    is enough for drug-eluting stents...but
    thrombosis risk may persist for years

30
Which of the following patients are good
candidates for carrying TWO doses of injectable
epinephrine (EpiPen, etc) for allergic
reactions?ltgt A.Children under age 6 years
oldltgt B.People who will be in remote
areasltgt C.Patients who have had a prior severe
or hard to treat allergic reactionltgt D.Both B
and C
31
Answer
  • D.Both B and C

32
Epinephrine
  • Many people get two pens...to keep at different
    locations.     Now some experts recommend
    carrying two doses at a time.     Up to 20 of
    patients get a second dose to treat
    anaphylaxis.     A second dose is more likely to
    be needed in patients over age 10...and those
    with a previous severe reaction.     Tell
    patients to carry two doses if they will be in a
    remote area...or they have had a more severe or
    hard to treat reaction.     Prescribe two
    auto-injectors (EpiPen, Adrenaclick)...or
    one Twinject. Twinjectcosts less than two
    auto-injectors...but the second dose is given
    manually so it can be more difficult to use.   
     Advise patients to head to the emergency room
    after the first dose...and use the second dose 10
    minutes after the first one if symptoms persist
    or return.

33
What drug interactions do you have with OxyContin?
34
Which of the following is TRUE about drug
interactions with oxycodone (OxyContin,
etc)?ltgt A.Oxycodone levels can be increased by
clarithromycin, ketoconazole, or
ritonavir.ltgt B.Oxycodone levels can be decreased
by carbamazepine, phenytoin, or
rifampin.ltgt C.Similar interactions are not seen
with codeine, hydromorphone, or
morphine.ltgt D.All of the above
35
Answer
  • D.All of the above

36
Answer
  • A new black box warning for OxyContin (oxycodone)
    about interactions with CYP3A4 drugs.     CYP3A4
    is a major pathway for metabolizing oxycodone,
    therefore 3A4 inhibitors or inducers can affect
    oxycodone levels.     INCREASED oxycodone
    levels can be seen when it's combined with 3A4
    INHIBITORS...macrolides (clarithromycin, etc),
    azole antifungals (ketoconazole, etc), or
    protease inhibitors (ritonavir, etc).     For
    example, voriconazole (Vfend) can almost double
    oxycodone peak levels and prolong its effects. 
       DECREASED oxycodone levels can be seen if it's
    combined with 3A4 INDUCERS...carbamazepine,
    phenytoin, rifampin, St. John's wort, etc.   
     Rifampin decreases oxycodone peak levels by more
    than 50.     Monitor patients if they need to
    combine oxycodone with a 3A4 inhibitor or
    inducer...and adjust doses if needed.   
     Observe the same precautions with other
    oxycodone products...Percodan,Percocet, etc.   
     Keep in mind that 3A4 inducers or inhibitors are
    likely to interact with fentanyl...and possibly
    with hydrocodone, tramadol, and propoxyphene.   
     Methadone can interact with some 3A4 inhibitors
    or inducers...but probably through a different
    pathway.     To avoid 3A4 interactions,
    prescribe morphine, codeine, hydromorphone, or
    tapentadol (Nucynta).

37
What can be added to Lactulose to prevent Hepatic
Encephalopathy?
38
Answer
  •  Xifaxan (rifaximin) now comes in a 550 mg tablet
    to prevent hepatic encephalopathy due to chronic
    liver disease

39
Rifaximin
  • Rifaximin is a nonabsorbable antibiotic that
    originally came on the market for treating
    traveler's diarrhea.     Rifaximin helps prevent
    hepatic encephalopathy by killing bacteria in the
    gut that produce ammonia and other toxins.   
     Adding rifaximin to lactulose reduces the risk
    of recurrent hepatic encephalopathy and
    hospitalization by 50. One additional episode is
    prevented for every 4 patients treated for 6
    months.     The downside is that rifaximin costs
    1200 per month.     Some clinicians use
    metronidazole, neomycin, or vancomycin to TREAT
    hepatic encephalopathy. But there's not enough
    evidence to recommend these antibiotics for
    prevention...and there are concerns about
    long-term toxicity.     Consider using rifaximin
    when lactulose alone is not enough to prevent
    recurrent hepatic encephalopathy.

40
CoQ10 may help with which of the following
  •  A. Statin myalgia.  B.  Heart failure.  C.
    Hypertension.  D.  Type 2 diabetes.  E.
    Migraines.
  • F. All of the above

41
Answer
  • F. All of the above

42
CoQ10
  •  Statin myalgia. There's conflicting evidence
    about CoQ10's effectiveness for statin-induced
    myopathy...but it's safe, well tolerated, and
    many people swear by it.     Don't use it for
    myalgia unless there is a strong reason...for
    example, if providing it helps keep your patient
    on a statin. In that instance, try 100 mg/day. 
       Heart failure. Some evidence suggests that 60
    to 300 mg/day improves quality of life and
    decreases symptoms and hospitalization.   
     Consider it only as an add-on for patients not
    well controlled on traditional heart failure
    meds...and explain it might not help.   
     Hypertension. Some small studies suggest using
    100 to 120 mg daily to lower blood pressure...but
    tell people not to rely on it.     Type 2
    diabetes. Some evidence suggests that 100 to 200
    mg/day can slightly lower A1C...but other studies
    show no benefit. Tell patients not to rely on
    it.     Migraines. Preliminary evidence suggests
    that CoQ10 might reduce migraine frequency. If
    patients want to try this, suggest 100 mg
    TID...and advise them it can take up to 3 months
    to see if it helps.     CoQ10 doses up to 3000
    mg/day are quite safe...but might cause nausea or
    diarrhea. If needed, suggest dividing doses over
    100 mg

43
 Propylthiouracil (PTU) for hyperthyroidism now
has a black box warning because of?
  • A. Renal Failure
  • B. Hepatic Failure
  • C. Severe Nausea and Vomiting
  • D. Severe Headaches
  • E. Severe Myalgias

44
Answer
  • B. Hepatic Failure

45
Propylthiouracil
  • The risk of acute liver failure with
    propylthiouracil (PTU) is about 1 case per 10,000
    in adults...and 1 case per 2,000 for children. 
       Liver toxicity is not dose-related and can
    happen anytime after starting therapy.     Liver
    function tests don't help detect it
    earlier...because it comes on suddenly and
    progresses rapidly.     Use methimazole
    (Tapazole) instead for most patients who need a
    drug to reduce thyroid hormone synthesis.   
     Save propylthiouracil for patients who can't
    tolerate other options...methimazole, radioactive
    iodine, or surgery.     Also use
    propylthiouracil for women trying to get pregnant
    and during the first trimester...because
    methimazole is associated with birth defects. But
    use methimazole after the first trimester.   
     And use propylthiouracil for thyroid storm
    because propylthiouracil inhibits conversion of
    T4 to T3...methimazole doesn't.     Advise
    patients taking propylthiouracil to stop the drug
    and alert you if they get symptoms of liver
    toxicity.     Keep in mind that both methimazole
    and propylthiouracil can cause RARE cases of
    agranulocytosis within a few months of starting
    therapy. Tell patients to report symptoms of
    infection. If this occurs, check a differential
    white blood cell count.

46
Hormone Therapy in women is associated with which
of the folowing?
  • A. Lung cancer B. Breast cancer C.
    Endometrial cancer D. Colorectal cancer E.
    Ovarian cancer 
  • F. A, B, C.

47
Answer
  • F. A, B, C.

48
Hormone therapy" (HT) and Cancer
  •    Women still ask if hormone therapy increases
    cancer risk.     Note the politically correct
    term "hormone therapy" (HT) instead of "hormone
    replacement therapy" (HRT). Authorities don't
    want people to think these doses "replace"
    hormones to their premenopause level.   
     Hormone therapy helps menopausal symptoms and
    decreases the risk of osteoporosis and
    fractures...but it's associated with some
    cancers.     Lung cancer is the newest cancer
    linked with hormone therapy.     Estrogen and
    progestin MIGHT increase the risk of developing
    lung cancer...especially when used for 10 or more
    years.     It might also promote the growth of
    existing lung cancer...especially in older women
    who smoke...possibly because some lung cancer
    tumors have hormone receptors.     Breast
    cancer risk may increase after about 3 years on
    estrogen plus progestin...instead of 5 years like
    experts used to think.     But explain that the
    risk is very small... 8 more cases of breast
    cancer per 10,000 women using combo therapy for 5
    years or longer.     And the risk starts to
    decline 2 to 3 years after stopping hormone
    therapy.     Endometrial cancer risk is 5 times
    higher for women taking estrogen ALONE for more
    than 3 years. Continue to add a progestin to an
    estrogen for a woman with an intact uterus.   
     Colorectal cancer risk was thought to go down
    based on the initial Women's Health Initiative
    report. But longer follow-up now suggests that
    hormone therapy doesn't prevent colorectal
    cancer.     Ovarian cancer risk due to hormone
    therapy is very small...if any at all. Tell women
    that using hormone therapy for less than 5 years
    is NOT associated with a higher risk for ovarian
    cancer.     Continue to recommend caution with
    hormone therapy...and use small doses for the
    shortest time and only when needed

49
Which of the following is TRUE about the new
statin, pitavastatin (Livalo)?ltgt A.Pitavastatin
lowers LDL more than higher doses of atorvastatin
(Lipitor) or rosuvastatin (Crestor).ltgt B.Pitavast
atin lowers LDL more than 60.ltgt C.Pitavastatin
doses over 4 mg/day are associated with more
rhabdomyolysis.ltgt D.Pitavastatin has a high risk
for CYP450 drug interactions.
50
Answer
  • C.Pitavastatin doses over 4 mg/day are associated
    with more rhabdomyolysis

51
Livalo (LIV-al-o, pitavastatin).
  • Reps will promote its high potency and low risk
    for interactions...but don't get excited.   
     It's true, Livalo IS more potent than other
    statins...but realize this is just marketing
    fluff. It refers to Livalo's lower doses...only 1
    to 4 mg/day.     But higher potency does NOT
    mean it's more effective.     Livalo 2 to 4 mg
    lowers LDL 38 to 45...similar
    to Lipitor (atorvastatin) 10 to 20 mg
    or Crestor (rosuvastatin) 5 mg.     Higher doses
    of Lipitor and Crestor can lower LDL about 60. 
       But don't push Livalo doses over 4 mg/day.
    Researchers originally started with higher
    doses...but these were associated with more
    rhabdomyolysis.     And there's no proof
    that Livalo prevents cardiovascular events.   
     Livalo does have a low risk for CYP450
    interactions...similar to Crestor, pravastatin,
    or fluvastatin.     Don't use Livalo at this
    time.     Start with a generic statin for most
    patients. If using simvastatin, watchsimvastatin
    doses and drug interactions.     Go
    to Lipitor or Crestor for greater
    LDL-lowering...or Crestor or pravastatin for
    fewer drug interactions.     Keep in mind
    that Lipitor is going generic in 2011.

52
How much will 40 mg of Simvastatin lower your LDL
Cholestrol?
  • A. 20
  • B. 30
  • C. 40
  • D. 50
  • E. 60

53
Answer
  • C. 40

54
What are the relative potency of the Statins?
55
Answer you get 40 LDL reduction of Cholesterol
with the following drugs
  • Livalo (LIV-al-o, pitavastatin) 2mg
  • Simvastatin (Zocor) 40 mg
  • Lovastatin (Mevacor) 80 mg
  • Pravastatin (Pravochol) 80 mg
  • Lipitor (Atorvastatin) 20 mg
  • Crestor (Resuvasatin) 5mg
  • All lower Cholesterol by about 40 LDL reduction

56
If you double the dose of the Statin you get
_____ more reduction in Cholestrol?
  • A. 4
  • B. 6
  • C. 8
  • D. 10
  • E. 12

57
Answer
  • B. 6

58
Increasing Simvasatin from 40 to 80 mg lowers LDL
just 6 more but increases myopathy _____ times.
  • A. 2x
  • B. 4x
  • C. 6x
  • D. 8x

59
Answer
  • C. 6x

60
Simvastatin
  • Keep in mind that going from 40 to 80 mg lowers
    LDL just 6 more but increases myopathy 6
    times.     If a patient needs more LDL-lowering
    than you can get from simvastatin 40 mg, consider
    using Lipitor or Crestor instead.     When you
    use simvastatin, be careful to use an appropriate
    dose.     Don't exceed 10 mg with cyclosporine,
    danazol, or gemfibrozil. Use fenofibrate instead
    of gemfibrozil to lower myopathy risk.     Don't
    exceed 20 mg with amiodarone or verapamil.   
     Don't exceed 40 mg with diltiazem...or in
    patients of Chinese descent who are also taking
    niacin 1 gram or more/day.     Don't use
    simvastatin while patients are taking strong
    CYP3A4 inhibitors...erythromycin, clarithromycin,
    telithromycin, itraconazole, ketoconazole, HIV
    protease inhibitors, or nefazodone

61
What drugs do you need to monitor blood tests?
62
Answer
  • We're often asked what lab tests are needed for
    certain drugs.     We know potassium should be
    checked with diuretics, ACE inhibitors, and
    ARBs...and liver function when starting statins.
  • liver function with diclofenac
  • thyroid function with amiodarone also check PFTs
  • glucose and lipids with atypical antipsychotics
    (Zyprexa, etc)
  • CBC with carbamazepine
  • platelets with valproate
  • lipids withAccutane.

63
What works as Insect Repellent?
  • A. DEET 10 and 30 B. Picaridin 20 C. Lemon
    eucalyptus oil D. Soybean oil E. Supplements 
  • F. A, B, C, D.

64
Answer
  • F. A, B, C, D.

65
Answer
  •   DEET is safe when used as labeled...despite
    many people's fears.     Recommend up to 30
    DEET for adults and kids over 2 months.   
     Higher concentrations last longer...but there's
    not much more benefit after 30. DEET 10 lasts
    about 3 hrs and 30 about 6 hrs.   
     Picaridin 20 works up to 8 hours for mosquitoes
    and ticks...and it isn't as smelly or oily as
    DEET. Recommend up to 20 picaridin (Natrapel,
    etc) for adults...and 5 to 10 for kids over 6
    months.     Lemon eucalyptus oil repels
    mosquitoes and ticks for up to 6 hours. Don't use
    it for kids under 3 years...since it hasn't been
    tested on them.     Soybean oil (Bite Blocker,
    etc) protects up to 4 hours for mosquitoes and 2
    hours for ticks...and can be used at any age.   
     Don't recommend citronella oil...it needs to be
    applied every hour. And explain that oil
    impregnated arm bands haven't been shown to
    work.     Skin So Soft Bug Guard Plus has
    repellents (picaridin, etc)...but tell people not
    to rely on the plain version.   
     Supplements are often tried such as garlic,
    brewer's yeast, or B vitamins. Don't recommend
    them...there's no proof that they work

66
Which of the following is TRUE about intensive
treatment of blood pressure and lipids in
patients with type 2 diabetes?ltgt A.Most
cardiovascular outcomes are similar when systolic
BP is less than 140 mmHg compared to under 120
mmHg.ltgt B.Intensive BP lowering INCREASES the
risk of stroke.ltgt C.Fenofibrate plus simvastatin
is associated with better outcomes than
simvastatin alone in diabetes patients.ltgt D.Most
diabetes patients should have an LDL goal less
than 70 mg/dL.
67
Answer
  • A.Most cardiovascular outcomes are similar when
    systolic BP is less than 140 mmHg compared to
    under 120 mmHg.ltgt

68
BP and Lipids in DM
  • Experts hoped intensive treatment would lower
    cardiovascular risk.     But recent evidence
    suggests this may NOT be the case.     Blood
    pressure. The current thinking is to aim for a
    systolic BP less than 130 mmHg for diabetes
    patients...instead of under 140 mmHg.     But
    there's no proof this lower BP goal is
    beneficial.     Now evidence shows similar
    cardiovascular outcomes when systolic BP is under
    140 mmHg compared to under 120 mmHg...in older
    patients with long-standing diabetes and high CV
    risk.     One exception is stroke...but the
    benefit is modest. Intensive therapy prevents 1
    more stroke for every 89 patients treated for 5
    years.     These findings will likely impact
    future guidelines.     In the meantime, feel
    comfortable with a systolic goal less than 140
    mmHg and APPROACHING 130 mmHg in most diabetes
    patients.     Consider going for a systolic
    UNDER 130 mmHg in patients at high risk for
    stroke...and in those with kidney disease WITH
    proteinuria.     And aim for a DIASTOLIC less
    than 80 mmHg...but over 60 mmHg.     Lipids.
    Researchers also hoped that more intensive lipid
    therapy for diabetes would improve outcomes...but
    this didn't pan out, either.     Adding
    fenofibrate to simvastatin DOESN'T improve
    cardiovascular outcomes compared to simvastatin
    alone...in diabetes patients at high CV risk with
    an average triglyceride level of 164 mg/dL.   
     Continue to use a statin first for diabetes
    patients.     Aim for an LDL less than 100 mg/dL
    in most diabetes patients.     If triglycerides
    are over 199 mg/dL, check the secondary lipid
    goal of "non-HDL" cholesterol...just total
    cholesterol minus HDL.     Aim for a non-HDL
    goal 30 mg/dL higher than the LDL goal.     To
    lower non-HDL, increase the statin...or add
    niacin or fish oil. Save fenofibrate for when
    these aren't tolerated. Monitor glucose more
    closely when using niacin in a diabetes patient.

69
What Drug for BPH has just gone Generic?
  • A. Avodart
  • B. Doxasosyn
  • C. Tamsulosin
  • D. Finasteride

70
Answer
  • C. Tamsulosin

71
Tamsulosin is the latest generic alpha-blocker
for benign prostatic hyperplasia (BPH). Which of
the following is TRUE?ltgt A.All alpha-blockers
have similar efficacy for BPH.ltgt B.Tamsulosin is
more selective for the bladder and prostate than
doxazosin or terazosin.ltgt C.Selective
alpha-blockers cause less dizziness and
hypotension, but more abnormal ejaculation.ltgt D.A
ll of the above
72
Answer
  • D.All of the above

73
Flomax (tamsulosin)
  •   Flomax (tamsulosin) is the first SELECTIVE
    alpha-blocker for benign prostatic hyperplasia
    (BPH) to go generic.     This will lead to a
    round of switching as patients and payors take
    advantage of better prices or fewer side
    effects.     Expect similar efficacy from all
    alpha-blockers used for BPH.     Choose one
    based on cost and side effects.   
     Doxazosin and terazosin generics are still the
    cheapest...but they're NOT selective so they
    cause more dizziness and hypotension.   
     Tamsulosin and Rapaflo (silodosin) are more
    selective for the bladder and prostate...and
    cause less dizziness and hypotension.     But
    their drawback is more abnormal ejaculation.   
     Uroxatral (alfuzosin ER) and Cardura
    XL (doxazosin ER) are NOT more selective
    drugs...but their extended-release formulas
    reduce dizziness and hypotension similar to
    tamsulosin.     The first generic tamsulosin
    costs about 120 per 30 caps... compared to about
    140 for Flomax. But expect the price to drop
    much more soon when additional generics come on
    the market.     When switching patients, start
    with the lowest dose of tamsulosin 0.4 mg daily
    and increase if needed after 2 to 4 weeks.

74
Which of the following is TRUE about using
long-acting beta-agonists for asthma?ltgt A.Long-act
ing beta-agonists should be used as monotherapy
for asthma.ltgt B.Long-acting beta-agonists are
still risky when used with an inhaled
steroid.ltgt C.It's usually better to prescribe a
combo inhaler (Advair, Symbicort) instead of
giving a long-acting beta-agonist and inhaled
steroid separately.ltgt D.Long-acting beta-agonists
should not be used for chronic obstructive
pulmonary disease.
75
Answer
  • C.It's usually better to prescribe a combo
    inhaler (Advair, Symbicort) instead of giving a
    long-acting beta-agonist and inhaled steroid
    separately.

76
Asthma and Long-acting beta-agnonists
  •   Experts agree that long-acting beta-agonists
    shouldn't be used ALONE for asthma...due to the
    risk of severe exacerbations. In fact, these
    drugs are now CONTRAINDICATED as monotherapy for
    asthma.     The FDA also makes a controversial
    recommendation...to limit using long-acting
    beta-agonists for the shortest time possible for
    asthma.     This goes against the current
    guidelines.     Asthma patients often do better
    when a long-acting beta-agonist is added to a
    low-dose inhaled steroid as the next step. And
    there's concern that stopping the beta-agonist
    will precipitate an exacerbation.     There's no
    evidence that long-acting beta-agonists are still
    risky when used with an inhaled steroid.   
     Continue to start with an inhaled steroid for
    persistent asthma.     If a low-dose inhaled
    steroid is not enough, consider trying an
    intermediate-dose steroid before adding a
    long-acting beta-agonist or montelukast
    (Singulair).     When adding a long-acting
    beta-agonist, prescribe a combo
    inhaler...Advair(fluticasone/salmeterol)
    or Symbicort (budesonide/ formoterol)...so
    patients keep getting the steroid.     When
    stepping down therapy, the evidence supports
    decreasing the steroid dose as a first step
    before stopping the long-acting
    beta-agonist...but feel comfortable doing either
    as a first step.     Document your reasons for
    continuing a long-acting beta-agonist long-term
    such as inadequate control or concern about
    exacerbations.     Keep in mind this new FDA
    recommendation DOESN'T apply to treating chronic
    obstructive pulmonary disease with long-acting
    beta-agonists... they haven't been shown to be
    risky in these patients.

77
Pennsaid is a new topical diclofenac solution.
Which of the following is TRUE?ltgt A.Pennsaid seem
s to work about as well as oral diclofenac for
knee osteoarthritis.ltgt B.Topical diclofenac has
a similar risk of GI problems as oral
diclofenac.ltgt C.About 50 of a Pennsaid dose is
absorbed systemically.ltgt D.Pennsaid is applied
just once a day.
78
Answer
  • A.Pennsaid seems to work about as well as oral
    diclofenac for knee osteoarthritis.

79
Many drugs can cause QT prolongation. Which of
the following has a high risk of causing
torsades?ltgt A.Clarithromycinltgt B.Methadoneltgt C.
Levofloxacinltgt D.Both A and B
80
Answer
  • D.Both A and B

81
Torsades.
  •  Many drugs prolong the QT interval, but not all
    cause torsades.     Give special attention to
    interactions with high-risk drugs... quinidine,
    disopyramide, sotalol, clarithromycin,
    erythromycin, haloperidol, thioridazine,
    chlorpromazine, and methadone.     Lower risk
    drugs can prolong the QT interval, but aren't
    likely to cause torsades. These include
    amiodarone, azithromycin, quinolones
    (levofloxacin, etc), SSRIs, venlafaxine, and
    ziprasidone (Geodon).     But these lower risk
    drugs can tip the balance towards torsades if
    they're combined with riskier drugs in a
    high-risk patient.     Some drug combos are a
    "double whammy" because they increase the QT
    interval...AND interact to increase drug
    concentrations.     For example, avoid combining
    amiodarone with clarithromycin or other strong
    3A4 inhibitors...especially when there are other
    patient risk factors. Use another antibiotic
    instead.     And watch for patients on laxatives
    or diuretics...these increase the risk of low
    serum potassium and magnesium.     Use an
    alternate med when high-risk drugs are
    involved... especially in a high-risk patient. 
       If there aren't suitable alternatives, monitor
    ECG at baseline, when doses are significantly
    increased, and then every year.     Change drugs
    if the QT interval is greater than 500 ms...or
    increases more than 60 ms from baseline

82
How can you reduce the Fall risk in the elderly?
83
How can you reduce Fall risk in the elderly
  • 1. Reduce psychoactive medications.  Fall risk
    can double with every psychoactive med added.   
     Consider the total psychoactive med
    load...antidepressants, hypnotics,
    benzodiazepines, narcotics, antipsychotics,
    muscle relaxants, metoclopramide, older
    antihistamines, etc.     Watch for opportunities
    to lower doses or discontinue meds.     But
    don't abruptly stop antidepressants,
    anticonvulsants, antipsychotics, or benzos. Taper
    these by 25 per week...or slower for chronic
    benzos, paroxetine, or venlafaxine.2. Check for
    orthostatic hypotension. Change meds if systolic
    BP drops more than 20 mmHg or diastolic drops
    more than 10 mmHg.3. Try to avoid chronic Rx
    sleep meds...zolpidem, etc.     But explain that
    OTC sleep meds (diphenhydramine, etc) aren't
    safer than Rx ones. The OTCs may be more
    dangerous because their anticholinergic effects
    can worsen cognition.4. Try to avoid
    propoxyphene. It's associated with more falls
    than tramadol or morphine...and may not work any
    better than acetaminophen.     If acetaminophen
    alone isn't enough, try a low-dose
    codeine/acetaminophen combo or tramadol
    instead.5. Recommend at least 800 IU/day of
    vitamin D...it may help prevent falls by
    increasing muscle strength.
  • 6. Increase muscle strength, by exercising when
    you are sedentary. Stand up and walk in place 15
    seconds at a time while holding on to something.
    Work up to 100 a day
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