Term
Reduction in the concentration of hemoglobin that results in a reduced oxygen-carrying capacity of the blood?? |
|
Definition
|
|
Term
|
Definition
Blood Loss Decreased RBC production Increasd RBC destruction Combination |
|
|
Term
What is essential for successful anemia management?? |
|
Definition
Determining underlying cause |
|
|
Term
|
Definition
Fatigue Lethargy SOB Headache Edema Tachycardia |
|
|
Term
Anemia: Men vs women. Blacks vs. Whites??? |
|
Definition
Women of child bearing age>>Men Non-hispanic blacks>>Whites |
|
|
Term
Other diseases that are often accompanied by anemia?? |
|
Definition
Chronic Kidney Disease Cancer+Chemotherapy |
|
|
Term
Types of anemia that result from a decreased production of RBC? |
|
Definition
Nutritional (iron, b12, folic acid) Cancer+CKD (hypoproductive anemia) Anemia of chronic disease |
|
|
Term
Why does CKD cause anemia? |
|
Definition
EPO formed by the kidney. (pluripotent stem cells) GM-CSF/IL2 are also formed These cells often differentiate into reticulocytes. If this can't happen, then you can't form blood cells. Anemia |
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|
Term
What type of anemia does a deficiency in B12 cause? |
|
Definition
Hypoproliferative. Not enough intrinsic factor. Pernicious anemia. |
|
|
Term
What is pernicious anemia? What type of diseases can also cause this problem?? |
|
Definition
Not enough vitamin B12 will cause a low amount of intrinsic factor. You cannot absorb iron from diet.
Intestinal diseases can also cause this problem. |
|
|
Term
Why does cancer chemotherapy cause anemia? |
|
Definition
It kills rapidly dividing cells (plouripotent stem cells), no RBC produciton |
|
|
Term
How does anemia of chronic disease cause anemia (inflammation)?? |
|
Definition
There is a decrease in epo production, a decrease in epo response, and a decrease in iron homeostasis (keeping it in stores, and away from the rest of the body) |
|
|
Term
What are the goals of anemia therapy: |
|
Definition
Increase hgb level Increase O2 carrying capacity Treat the underlying cause |
|
|
Term
What are the NP therapies for anemia? |
|
Definition
Blood transfuction Diet (iron, b12, folic acid) |
|
|
Term
How much elemental iron is necessary for pharmacological treatment of anemia? |
|
Definition
|
|
Term
What does pharmacological iron therapy do to the iron in the body?? How long does it take to be effective? |
|
Definition
replaces iron stores in the body necessary for RBC production/maturation. Takes 7-10 days if treated properly. |
|
|
Term
When giving iron therapy, how often should the patient be re-assessed? and for what value?? |
|
Definition
2-3 weeks. iron should increase by 2g/dL in 3 weeks |
|
|
Term
Is it better to give 1 dose of iron daily or use 2-3 equal doses? |
|
Definition
|
|
Term
When should you give oral iron? |
|
Definition
On an empty stomach (1hr before, 2 hours after) |
|
|
Term
When is it appropriate to give iron on a full stomach? What does this do to properties of the drug? |
|
Definition
When taking it on an empty stomach causes upset. Will decrease absorption. |
|
|
Term
Besides taking it on an empty stomach, what can increase absorption of iron? Can this cause SE? |
|
Definition
|
|
Term
What happens with iron toxicity?? |
|
Definition
Abdominal pain Nausea Heartburn Constipation Black Stools |
|
|
Term
Drugs that interact with iron? How do they interact? How to prevnent? |
|
Definition
-Flouroquinalones, Tetracyclines, Phenytoin -Decrease absorption of the drug by binding with the iron -Seperate doses by 2-43 hours |
|
|
Term
When is parentral iron therapy appropraiate? |
|
Definition
When patient is unable to tolerate oral form bc low response, compliance, toxicity |
|
|
Term
What are the formulations for parentral iron? What are the indications for each?? |
|
Definition
Iron Dextran (IDA w/ dont tolerate oral) Ferric Gluconate (CKD anemia, contraversial) Iron Sucrose (CKD anemia, contraversial) |
|
|
Term
|
Definition
(0.0442(desired hgb-observed hgb)*weight)+ (0.26*weight) |
|
|
Term
How should iron dextran be given? |
|
Definition
100 mg aliquotes over 4-6 hours |
|
|
Term
What must happen before a dose of iron dextran?? |
|
Definition
Iron dextran test must be given to avoid anaphylaxis |
|
|
Term
|
Definition
Arrythmia, Arthralgia, Hypotension, Flushing, Pruritis |
|
|
Term
Cyancoblamin/B12 DF? Which is most common? Why? |
|
Definition
Oral/Parentreral. (parenteral more common bc increasd bioavailabilty) |
|
|
Term
What test may you need to pursue if treating a patient for B12 deficiency? |
|
Definition
|
|
Term
Onset of action: B12/Cyancobalmin? What results are seen? |
|
Definition
Quick. Within Days. See diminish of neurologic and megablastic cells disappear |
|
|
Term
B12 deficiency has what type of RBC? |
|
Definition
|
|
Term
Drug intractions of B12? ADR?? |
|
Definition
Omeprazole, Absorbic acid (Decreases oral) Minimal ADR (injection pain, pruritis, rash) |
|
|
Term
Response time for folic acid treatment?? |
|
Definition
Fast usually ~2 weeks. 2-4 months for complete response |
|
|
Term
What is max dose of folic acid?? What happens after that? What is usual anemia dose? |
|
Definition
5mg/day max. Can't absorb anymore. 1mg/day usually sufficient for anemia |
|
|
Term
|
Definition
|
|
Term
Drug interaction of folic acid?? |
|
Definition
|
|
Term
Conditions causing anemia of chronic disease?? |
|
Definition
CKD Cancer+Chemo Inflammatory diseases |
|
|
Term
What labs can be distorted w/ folic acid deficiency?? |
|
Definition
Methylmalonic acid can be normal. Homocysteine can be high |
|
|
Term
What are some lab values of B12 deficiency? |
|
Definition
Methylmalonic acid and homocysteine can be high |
|
|
Term
Monitoring parameters for anemia? |
|
Definition
Monitor symptoms, labs, hgb, adr, CBC MCV, Iron, Reticulocytes |
|
|
Term
If you have a high MCV, what values should you next look at to determine that cause of anemia? How do you proceed from there? |
|
Definition
Look @ B12, Folate. If Low folate, than you have a folic acid def. If you b12, you need to do schilling test to see if normal intrinsic factor -Normal intrinsic: investigate GI -Low intrinsic=pernicious anemia. |
|
|
Term
Who has the highest risk for developing OP? What are the common sites of fracture? |
|
Definition
Postmenopausal women Sites: Hip, Vertebral, wrist |
|
|
Term
|
Definition
Chronic Pain Loss of Mobility Depression Nursing Home Death |
|
|
Term
What can multiple vertebral fractures lead to in OP? |
|
Definition
restrictive lung disease/alter abdominal anatomy |
|
|
Term
When is mortality common in OP? |
|
Definition
1 year after hip fracture |
|
|
Term
OP is the most common what (type of disorder) |
|
Definition
|
|
Term
Primary vs Secondary OP?? |
|
Definition
Primary-No known cause Secondary-Caused by another condition (disease, drugs) |
|
|
Term
Why do women have a higher chance of OP?? |
|
Definition
Lose estrogen after menopause. Lose protective effect |
|
|
Term
AA, Caucasion, Asian, Hispanic women prevalence of OP?? |
|
Definition
cauc>>Asian>>Hispanic>>African americal |
|
|
Term
Relationship between bone density and fracture risk?? |
|
Definition
Decrease density=Increased risk |
|
|
Term
Secondary causes of OP in men?? What is most common. |
|
Definition
Hypogonadism, Glucocorticoid use***, alcoholism |
|
|
Term
2 types of bone: characteristics. (trabecullar, cortical) |
|
Definition
Trabedulcar-spongelike on inner surfaces Cortical-dense, compact. responsible for bone strength. outside of long bone. |
|
|
Term
What type of cells help undergo skeleton remodeling?? How do they do so?? |
|
Definition
Osteoblasts(build) Osteoclasts (Take bone away and put into blood) |
|
|
Term
Osteoblasts/clasts in OP?? |
|
Definition
Blast activity will be decreased Clast activity will be increased. |
|
|
Term
Diagnosis of OP?? What sites?? How performed?? |
|
Definition
Decreased bone density and weakening of associated tissues Central-Hip/Spine Peripheral-Heel/forearm/hand DXA scan |
|
|
Term
Is central or peripheral DXA scan more accurate?? |
|
Definition
Central. Recommended by WHO bc inconsistencies w/ peripheral. |
|
|
Term
Why do a peripheral DXA scan?? |
|
Definition
Cheaper, Easier (access, portible) |
|
|
Term
What is a T score? What is a Z score? |
|
Definition
T score is standard deviations away from mean bone density Z score is essentially the same thing but corrected for age. |
|
|
Term
Osteoporosis T score? Osteopenia? |
|
Definition
-2.5=osteoporosis -1, -2.5=osteopenia |
|
|
Term
What ages is DXA routine?? |
|
Definition
|
|
Term
What is the purpose of FRAX?? |
|
Definition
Calculate 10 year risk for OP fractures (major, hip). Also do T score, age, and other factors. |
|
|
Term
What are some secondary causes of OP? |
|
Definition
Hyperparathyroidism Low Vitamin D Hyperthyroid Hypogonasism Cancer |
|
|
Term
What are the treatment goals of OP? |
|
Definition
1.Prevent fractures and their complications -Maintain and/or increase bone mineral density -Prevent secondary causes -Decrease morbidity and mortality associated w/ bone loss |
|
|
Term
What are some risk factors for OP that can be modified? |
|
Definition
Decrease smoking Increase Ca intake Nutrition Inactivity Heavy alcohol use Vitamin D deficiency |
|
|
Term
What is calcium good for in OP?? what are a few good sources of it? |
|
Definition
Bone mass/density. Dairy, Juice, Cruciferous veggies, salmon, sardines |
|
|
Term
what is vitamin D good for in OP? what are some sources?? |
|
Definition
Calcium absorption. Sunlight, egg yolks, saltwater fish, liver |
|
|
Term
Exercise in OP?? Weight bearing and Muscle strengthening?? |
|
Definition
Beneficial to bone health. weight bearing builds and maintains strength Muscle strenghs will increase/maintain strength and resistance to decrease falls |
|
|
Term
What are some medications that are "balance altering" |
|
Definition
Benzo's Antipsychotics Tricyclic AD Sedative/Hypnotics Anti-cholinergics Corticosteroids CV/Anti-hypertensives (orthostatic) |
|
|
Term
|
Definition
Balance training Muscle strengthening Remove hazards from home D/C presdisposing meds |
|
|
Term
What happens when serum ca is low?? |
|
Definition
It is taken away from bone to maintain serum levels |
|
|
Term
What is calcium's effect on hyperparathyroidism?? |
|
Definition
|
|
Term
What is the max recommended elemental Ca/day?? Who is recommended to receive this? |
|
Definition
1500 mg daily Post menopausal women |
|
|
Term
What do some calcium supplements contain?? |
|
Definition
|
|
Term
What is the max amount of Ca/dose?? What is the toxic dose/day? |
|
Definition
500-600 elemental ca for adequate absorption? 2500/day |
|
|
Term
When should calcium carbonate be administered? What may decrease this absorption?? What salt is not altered by these? |
|
Definition
With food. H2/PPI may alter the absorption of these bc acid is needed to dissolve. Calcium citrate does not need acid to be absorbed. |
|
|
Term
|
Definition
Constipation Bloating Cramps Flatulence |
|
|
Term
What can calcium alter the absorption of?? |
|
Definition
Some iron supplements, some anti-biotics (flouroquinalones, tetracyclines) |
|
|
Term
what is the recommended vitamin D dose?? |
|
Definition
|
|
Term
Why are some people at risk for vitamin d deficiency?? |
|
Definition
Malabsorption Renal Other chronic diseases elderly-less sunlight |
|
|
Term
What is the first line therapy in OP?? |
|
Definition
|
|
Term
How do bisphosphonates work? |
|
Definition
Decrease bone resorption by building bone matrix. Inhibit osteoclast activity |
|
|
Term
Where are bisphosphonates stored? |
|
Definition
They remain in bone and are slowly released. |
|
|
Term
|
Definition
Loss of blood supply to the bones. Happens in the jaw w/ bisphospnates Higher risk in IV bisphosphonates Risk factors: chemo, radiotherapy, corticosteroids, infection, pre-existing dental disease |
|
|
Term
What 2 serious ADR's are bisphosphonates linked to?? |
|
Definition
Atraumatic fractures Osteonecrosis |
|
|
Term
what are some milder SE of bisphosphonates? ADR?? |
|
Definition
N/V Esophageal irritation Dyspepsia
Esophageal ulceration. Erosions w/ bleeding, perforation, structure, esophagitis Abdominal pain |
|
|
Term
Zoledronic (injection) ADR? |
|
Definition
A-fib Increased SCR Infusion related reaction |
|
|
Term
How is a patient supposed to take bisphosphonates? |
|
Definition
Empty stomach (as soon as awake) 30-60 minutes before each meal W/ 6-8 oz H2O Swallow whole No other meds/supplements Sit upright |
|
|
Term
Who is not recommended to take bisphosphonates?? |
|
Definition
Hypocalcemia renal insufficiency esophageal abnormalites |
|
|
Term
What is a solution for people unable to tolerate oral bisphosphonates?? |
|
Definition
IV bisphosphonates. Zoledronic Acid |
|
|
Term
SERM drug? How do they work? |
|
Definition
Raloxefine. Tamoxifen. Toremiphene. Work by having estrogen like activity on bones and cholesterol. Reduce bone resorption and decrease turnover |
|
|
Term
What is special about tamoxifen and toremiphene |
|
Definition
Partial agonist/antagonist activity Breast cancer only b/c too many ADR for OP |
|
|
Term
Raloxifene effects?? Bone. Fracture. Breast. CV. Stroke. ADR |
|
Definition
Increase bone density Decrease fractures antagonistic tissues in breasts No change in CV Increase in fatal stroke ADR: Hot flash, leg cramps, increased risk of venous thromboembolism. |
|
|
Term
|
Definition
Estrogen either alone or w/ progestin. No longer recommended |
|
|
Term
How does calcitonin work in OP? |
|
Definition
Naturally occurring hormone. Major role in Ca levels. Binds to osteoclasts and inhibits resorption. |
|
|
Term
What is the synthetic calcitonin product, what are DF? How is it administered? |
|
Definition
Calcitonin-salmon IV and Intranasal SubQ or IM every other day |
|
|
Term
What are SE of calcitonin-salmon? |
|
Definition
Flushing Urinary Frequency N/V Abdominal cramp Irritaiton (IV site) |
|
|
Term
Calcitonin intranasal vs IM?? |
|
Definition
Nasal-preferred. easy. low ADR (local only) |
|
|
Term
What type of fracture is most effected by calcitoniin? |
|
Definition
|
|
Term
What is terapartide? what is is used for? |
|
Definition
Recombinant human parathyroid. Moderate-severe op |
|
|
Term
How does terapartide work? |
|
Definition
Stimulates osteoblastic activity |
|
|
Term
How is terapartide given?? |
|
Definition
|
|
Term
|
Definition
Osteosarcoma Hyperglycemia |
|
|
Term
What are some useful combination therapies in OP?? What is an un useful combination? |
|
Definition
-Bisphosphonates + Estrogen/raloxifene -estrogen + Calcitonin BAD: Bisphosphonates + Anabolic agents (terapartide) |
|
|
Term
Strontium ralenate PTH (1-84) |
|
Definition
Experimental PTH is inj. pth w/ mixed results Strontium is oral w/ anti respoptive properties. useful in decreasing vertebral fractures |
|
|
Term
Denosumab mech of action? |
|
Definition
Binds to RANKL, which overall inhibits osteoclast activity. Decreases resorption |
|
|
Term
|
Definition
SubQ 60 mg every 6 months |
|
|
Term
Denosumab administration? |
|
Definition
SubQ upper arm, thigh, abdomen |
|
|
Term
|
Definition
CNS symptoms (fatigue, headache) Dermatologic (dermatitis, eczema, rash) Endocrine and metaolic (hypophosphatemia, hypocaclemia) Gastrointestinal (nausea, diarrhea) Neuromusclular & skeletal (weakness, arthralgia, limb pain, back pain) Respiratory (dyspnea, cough) |
|
|
Term
OP Alternatives/Herbals? What did they make worse? CYPS?? |
|
Definition
Isoflavavones (soy/red clover) OTC Actually made lymphocytopenia worse CYP1A2, 2C9 |
|
|
Term
|
Definition
Alendronate. (primary) Secondary-Treat cause |
|
|
Term
What type of drug can induce OP?? How? |
|
Definition
Glucocorticoids Increase bone resorption and inhibit formation. |
|
|
Term
|
Definition
Prednisone Hydrocortisone Methylprednisolone Dexamethasone |
|
|
Term
Glucocorticoid affect on Ca?? Osteoblasts. Estrogen/testosterone? |
|
Definition
Increase excretion Ca Decrease absorption Ca Inhibit osteoblasts Less estrogen/testosterone produced |
|
|
Term
Inability to achienve and maintain an erection suffienct for sexual intercourse?? |
|
Definition
|
|
Term
What are the 3 components of a penis? |
|
Definition
2 dorsolateral copora cavernosa (blood filled sinusoidal, surrounded by trabecullar SM and tunical olbuginea, a sheath that supplies blood) Ventral corpus spongiosum-surrounds penile urethra, distally forms gland penis |
|
|
Term
What is responsible for a flaccid penis? |
|
Definition
Alpha 2 adnreergic receptors mediate contraction of arterial/cavernosal SM |
|
|
Term
PNS activty or SNS activity= erection?? How does this work? |
|
Definition
Increased PNS activity. Blood flows into tissue. |
|
|
Term
What is responsible for an erection while sleeping? |
|
Definition
|
|
Term
Describe process of erection? |
|
Definition
-ACH mediated activity leads to NO production, which increases CGMP -Vasoactive peptice+ PGE1/E2 stimulate increased camp =Increased CAMP+CGMP will decrease Ca w/in SM. Relaxed Sinusoidal spaces engorged Intracavernosal pressure increases Subtuincal venules compressed Penis is rigid and elongated |
|
|
Term
When does detumescence occur?? |
|
Definition
W/ SNS discharge after ejaculation. Reduction of parasympathetic |
|
|
Term
What is testosterone responsible for in ED?? |
|
Definition
-Albeit complex role -Libido -Stabilize intracavernosal levels of NO synthetase |
|
|
Term
|
Definition
Actual problem w/ something internal |
|
|
Term
|
Definition
No response to physiological erousal. |
|
|
Term
What disease is ED related to?? Another?? |
|
Definition
Cerebrovascular disease Diabetes |
|
|
Term
What is the primary goal of ED treatment? What is ideal?? |
|
Definition
To achieve erection suitable for intercourse and improve the patient quality of life. (ideal has minimal SE, convenient, quick onset, few interactions) |
|
|
Term
|
Definition
Lifestyle modifications VED Prosthesis |
|
|
Term
What are lifestyle modifications for ED treatment? |
|
Definition
Diet Physical activity Weight loss Smoking Cessation Decrease alcohol intake D/C ilicit drug use |
|
|
Term
VED's Mechanism Line of therapy? Onset? CI?? |
|
Definition
- pressure draws blood into penis by dilating arterines and engorging cavernosa -Maintain w/ constriction band -1st line non invasive -30 minute onset (slow) -SI w/ Sickle Cell disease -Caution w/ anti-coag. priapism |
|
|
Term
|
Definition
Cold/disoolored/lifeless penis w/ hingle like feel. |
|
|
Term
|
Definition
Insert a semi rigid malleable or inflatable rod into cavernosa Rod=always rigid Inflatable-pump in scrotum Release button when done Invasive Rods interfere w/ urination Replace every 10-15 years |
|
|
Term
Pharmacologic treatment of ED?? |
|
Definition
Phosphodiesterase 5 inhibitors |
|
|
Term
How do PDE 5 inhibitors work?? |
|
Definition
Inhibit PDE type 5, which breaks down CGMP (SM relax is induced-->erection) |
|
|
Term
When are PDE-5 inhibitors effective?? |
|
Definition
Only in presence of sexual stimulation |
|
|
Term
Response rate to PDE 5 inhibitors in prostatectome, diabetes, vascular disease?? |
|
Definition
|
|
Term
Tadalafil Preference. Action. Response. |
|
Definition
Higher preference Higher response Longer Acting "weekend drug" |
|
|
Term
T1/2 of Todalafil. Dildafinil. Vardenalfil. |
|
Definition
Todalafil-18 hours Dildafinil/Cardenalfil: 3-4 hours |
|
|
Term
|
Definition
Headache Flushing Nasal congestion Dyspepsia Myalgia Back pain Priapism (rare) |
|
|
Term
What PDE 5 can have difficulty discriminating blue from green?? Why?? |
|
Definition
Vardenafil and sildenafil Cross reactivity w/ PDE-6 in retina |
|
|
Term
|
Definition
Rare. Blood flow is blocked to optic nerve If using PDE-5, and sudden decrease in vision. call Dr. Immediately. |
|
|
Term
CV disease and ED? Which meds are CI/Cautious? |
|
Definition
Use of meds is contraversial. They can lead to hypotension. Pt. w/ nitrates cannot use any PDE-5 Caution w/ alpha blockers |
|
|
Term
What PDE-5 label has caution about possible QT elongation?? |
|
Definition
|
|
Term
|
Definition
Prosteglandin E1 analog Induces erection by stimulating adenylyl cyclase (increase SM relaxation) |
|
|
Term
Alprostadil DF?? What line of therapy?? |
|
Definition
Intracavernosal injection-more effective Transurethral supp (MUSE)--w/ an applicator 2nd line therapy (invasive) |
|
|
Term
Onset of alprostadil MUSE?? Effective?? |
|
Definition
5-10 minutes effective 30-60 minutes |
|
|
Term
SE of alprostadil? SE of partner?? |
|
Definition
Aching in penis, t3sticles, legs, perineum, warmth/buring sensation in urethra, minor urethral bleeding/spotting -Priapism -Lightheadedness
Vaginal itch/Burn |
|
|
Term
Alprostadil vs. PDE-5 inhibitors |
|
Definition
More expensive Not as effective ADR Compicated insertion CI if pregnant partner |
|
|
Term
What is the only FDA approved ED injection? |
|
Definition
Alprostadil. Must be titrated in physicainas office (to acheive no >>1 hour erection) |
|
|
Term
How do you administer alprostadil?? |
|
Definition
Inject into the side and massage the penis to distribute the drug |
|
|
Term
ADR of alprostadil injection? Caution/CI?? |
|
Definition
Pain w/ injection Fibrosis Priapism Caution w/ sickle cell disease Caution w/ anti-coags. |
|
|
Term
|
Definition
Non selective PDE inhibitor that induces an erection by relaxing SM and increasing blood flow Rarely used alone. Sometimes mixed w/ alprastadil. Non-FDA |
|
|
Term
|
Definition
Comprehensive alpha adrenergic antagonist that increases arterial inflow by opposing constriction. Non-FDA Rarely used alone. Sometimes mixed w/ alprastadil |
|
|
Term
|
Definition
INdole alkaloid in the bark of yohimbe trees. Inhibit Alpha 2 in the brain (libido/erection) Not recommended bc so little info |
|
|
Term
|
Definition
Nausea Irritability Headache Anxiety Tachycardia Hxn |
|
|
Term
What is the first choice for treatment of hypogonadism?? |
|
Definition
|
|
Term
What can testosterone supplementation correct? |
|
Definition
Decreased libido Fatigue Muscle Loss Sleep disturbances depressed mood |
|
|
Term
Testosterone DF?? What is cheapest. |
|
Definition
Oral, IM, Topical patch/gel, implanted pellet buccal tablet Cheapest- Injectable esters. |
|
|
Term
What testosterone supp has the longest duration and is preferred? |
|
Definition
Testosterone cypionate/ethanthate |
|
|
Term
|
Definition
Every 2-4 weeks Will see hormone levels w/ in 2 days [] decline, dip below physiologic before next dose |
|
|
Term
Topical tesosterone advantages?? Disadvantages |
|
Definition
Convenient Expensive Admin Daily |
|
|
Term
What must you do after using testosterone gel? |
|
Definition
Wash hands Avoid shower/bath 5-6 hours after |
|
|
Term
|
Definition
Caused by absorption enhancers |
|
|
Term
|
Definition
Poor bioavailability. 1st pass metabolism Try to fix w/ alkylated: Methyltstosterone Fluoxymesterone Makes hepatotoxic |
|
|
Term
|
Definition
Alternate to oral Delivered to systemic Bypass 1st pass Upper gum 2x daily Cost similar to patch/gel SE oral irritation, bitter teste, gum edema |
|
|
Term
|
Definition
Gynecomastia Dyslipidemia Polycythemia Acne Weight gain Hxn Edema Exacerbatiosns of CHF BPH/prostate evaluation |
|
|
Term
Complaint of leakage of urine?? |
|
Definition
|
|
Term
Who is most likely to get UI?? |
|
Definition
Menopausal age women. (50) Drop after (55-60) Increase again (60+) |
|
|
Term
What happens in stress UI? What are incidences where this increases) |
|
Definition
Urethra/urethral sphincters cannot generate enough resistance to impede urine flow when pressures are elevated. (activities such as exercise, running, lifting, coughing, sneezing) |
|
|
Term
Nocturia/Enuresis in SUI?? |
|
Definition
|
|
Term
What are the factors responsible for SUI? |
|
Definition
Not completely understood. Loss of tropic effects of estrogen. |
|
|
Term
|
Definition
Pregnancy Vaginal childbirth Menopause Cognitive impairment Obesity Increasing age |
|
|
Term
|
Definition
Rare. But usually happens after a surgery. Prostatectomy, prostate--BPH |
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Term
Diagnostic tests for SUI?? |
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Definition
Observation of urethral meatus opening while patient coughs/strains |
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Term
What happens during Urge UI?? |
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Definition
Detruser/Bladder is overactive and contracts inappropriately during the filling phase. (amount lost can be large bc bladder can empty completely) |
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Term
Nocturia/Enuresis during UUI? |
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Definition
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Term
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Definition
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Term
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Definition
Hysterectomy Recurrent UTI's Increasing age Bladder outlet obstruction (BPH/malignancy) Neurologic disorders (stroke, parkinsons disease, MS, spinal cord injury) |
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Term
In UUI, what is the origin of overreactivity?? |
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Definition
Myogenic Neurogenic Mix of both |
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Term
Do you always have an "urge" in UUI? |
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Definition
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Term
Diagnostic tests for UUI: |
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Definition
Urodynamic studies. Goldstandard Urinalysis/urine culture should be - (rule out UTI as cause) |
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Term
What happens in overflow UI? |
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Definition
Bladder if filled @ all tims, but cannot empty, so urine leaks out episodically. |
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Term
OUI can be 2 types of activity, what are they?? |
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Definition
Underactivity Overactivity |
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Term
OUI under-activity mechanism: When is this seen clinically? |
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Definition
Detursor muscle is weak. CAN lose ability to voluntarily contract Cannot be emptied. Large residual volumes remain. Seen clinically-Chronic Bladder Obstruction due to BPH/malignancy. May also be manifestation of neurogenic bladder (often in diabetics, lower spinal injury, MS, radical pelvic surgery) |
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Term
Signs of overflow UI w/ underactivity? |
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Definition
High post void urine volume |
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Term
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Definition
Urethra/Sprinctors cannot overcome detrusor contractility -In long term bladder outlet obstruction -Rare in females (can be seen as a result from cystocele formation) -Neurologic disorders (both sexes) |
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Term
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Definition
Generally not caused by intrinsic, but by extrinsic factors like: immobility Lack of access to toilet Cognitive impairmnt UTI Postmenopausal atrophic urethritis/vaginitis -Diabetes mellitus/insipidus -Pelvic malignancy -Constipation/Fecal impaction -Congenital malformations -CNS disorder -Depression |
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Term
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Definition
Abdominal exam. Neurologic eval of perineum/lower extremities for nerve fxn DRE, Reflexes, pelvic muscle contraction -Pelvic exam -Genital prostate exam -Direct obv of opening of urethral meatus -Reineal exam |
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Term
Desired outcomes of UI treatment: |
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Definition
Restoration of continence Decrease UI episodes and frequency of nocturia Prevent disease complications (derm, skin breakdown, delay institutionalism) -Avoid/minimize ADR -Minimize Costs -Improve quality of life |
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Term
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Definition
Surgery Lifestyle Scheduled voiding regimen PFMR anti-incontinence devices supportive interventions |
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Term
What is first line NP therapy for UI?? Which UI? What do these require? |
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Definition
Behavioral treatments (SUI, UUI, Mixed) Require motivation |
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Term
Which NP treatments for UI are the only significant ones? Which has been shown to be better than anticholinergic in UUI? |
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Definition
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Term
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Definition
Rarely. Usually considered when degree of bother/lifestyle compromise is sufficient |
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Term
Overactivity or underactivity?? which can be managed w/ surgery? |
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Definition
Overactivity. Underactivity cannot be surgicaly managed |
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Term
What type of UI is surgery best management? What does this do? |
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Definition
SUI. Stabalize urethra/bladder neck and augment urethral resistance uring periurethral collagen and other injectables. |
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Term
In males, how is SUI best treated?? |
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Definition
Implanting an artificial sphincter. |
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Term
What is first line therapy for UUI? |
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Definition
Anti-cholinergic/antipasmotic |
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Term
What is the major problem with use of anti-cholinergics for UUI? |
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Definition
Lack of selectivity for bladder. So you get SE of dry mouth, constipation, blurred vision, cognitive, tachycardia |
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Term
Oxybutynin: how does it work?? SE? |
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Definition
Alpha receptor blockade. Orthostasis/Sedation/Weight gain (histamine h1 block) |
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Term
What is better in terms of tolerability?? Tolteridine IR, oxybutynin IR?? |
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Definition
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Term
For UI, are ER or IR better?? Why? |
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Definition
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Term
In UI, what DF is preferred? Oral. Dermal. |
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Definition
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Term
What medication would you use in a male with presumed non-obstructive BPH and UUI?? (treat UUI) |
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Definition
Tolteradine LA (monotherapy or combine w/ alpha antagonist) |
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Term
Can you use 2 anti-cholinergics to lower the dose of each?? |
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Definition
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Term
How would you treat a woman with mixed UI(UUI + SUI) and atrophic vaginitis and or urethritis |
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Definition
Benefit form PV estrogen and anticholinergic therapy |
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Term
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Definition
Decrease UUI symptoms by up to 8 hours after monitoring doses Also used in pediatrics |
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Term
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Definition
Short term benefit Bladder capacity < 400 mL |
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Term
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Definition
Increase closure mechanism by one of the following: -Stimulate alpha receptors in SM -Enhance supportive structures underlying the urethral mucosa -Enhance the + effects of serotonin and NE in the afferent/efferent path of micturiction reflex. |
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Term
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Definition
Usually not pharmacologic but NP. Sometimes duloxetine + PFMR |
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Term
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Definition
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Term
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Definition
Trophic effect on uroepithelial cells and underlying collagen subq tissue enhancement of local micro-circulation by increase the number of peripheral blood vessels. and enhance sensitivity of alpha andrenocpetors |
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Term
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Definition
Local only SE: mastodynia, uterine bleeding, nausea, thromboembolism, cv events, ischemia, increase breast/endometrial cancer risk |
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Term
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Definition
Pseudophedrine. Mild-moderate. Monotherapy fails. Combine w/ estrogen |
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Term
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Definition
HXN headache Dry mouth nausea insomnia restlessness |
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Term
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Definition
Alpha agonists Duloxetine Estrogens |
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Term
Duloxetine for SUI: Mechanism Similar to? Approved for? |
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Definition
Selective serotonin-NE reuptake inhibitor. Controls serotonogenic and adrenergic tone which is involved in ascending and descding control of urethral SM, sphinctors. Similar to venlafaxine Approveed for depression, painful diabetic neuropathy, fibromyalgia, anxiety disorder. SUI is off label. |
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Term
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Definition
After radical prostatectomy |
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Term
Overflow UI (interactivity) treatment Urospecificity?SE? |
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Definition
Bethanichol (cholinomimetic) Not urospecific: Muscle/abdominal cramps hypersalivationdiarrhea potentially life threatening bradycardia bronchospasm |
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Term
What can also benefit overflow UI?? How? |
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Definition
Alpha antagonists, relax the bladder. |
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Term
Overflow UI bc of obstruction. treatment? |
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Definition
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Term
What urinary symptoms are associated w/ BPH? |
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Definition
Consistent with impaired emptying of urine from and storage of urine in the bladder |
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Term
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Definition
Androgens (testosterone->DHT by 5 alpha reductase) make prostate grow Age |
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Term
2 types of tissue in the prostate: |
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Definition
Glandular/Epithelial: Secretions (including PSA) Stromal/Muscle: can contract urethra |
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Term
Androgens effect on growth/stromal tissue? |
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Definition
+ effect on growth. No effect on stromal tissue (effected by estrogen, which testosterone->estrogen. indirect effect) |
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Term
What receptors are located on stromal cells? What do these do when stimulated? |
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Definition
Alpha 1A Stimulate/contract around urethra, narrow it. Obstructive voiding symptoms. |
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Term
What does detrusor instability cause? |
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Definition
Irritating voiding. Urgency/Frequency. |
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Term
Where are detrusor fibers located? |
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Definition
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Term
In an enlarged gland? What is the epithelial/stromal ratio?? |
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Definition
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Term
Obstructive BPH symptoms: |
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Definition
Failure to empty while full Decrease force of urinary stream Urinary hesitation Dribbling Straining |
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Term
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Definition
Failure to store until full Bladder outlet obstruction-detrusor muscles hypertrophy (increased pressure) irritable and contracts with abnormally in small urine amounts |
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Term
What are BPH complications if untreated?? |
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Definition
Acute refractory Urinary retantion Renal failure UTI UI Bladder stones Large bladder diverticuli Recurrent gross hematuria |
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Term
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Definition
Slow disease progression (BUN, Creatinine)--should improve, stabailze, decrease to normal values. Prevent disease complications, decrease need for surgical intervention. Avoid/minimize ADR Provide economical therapy Maintain/improve quality of life |
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Term
How often DRE / AVA scoring in BPH patinet? |
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Definition
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Term
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Definition
Can be good, but can result in significant morbidity: ED, retrograde ejaculation, UI, bleeding, UTI |
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Term
Gold Standard BPH surgery?? How is it performed? |
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Definition
Prostatectomy: transurethrally (less invasice, many options)or open surgery (transpubically, retropubic) |
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Term
Why do some patients benefit from alpha antaginist + 5 alpha reductase inhibitor? What specific drugs? Disadvantages/ |
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Definition
Decreased need for prostatectomy (decrease BPH complications) Specifically doxazosin + finasteride More expensive, more ADR |
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Term
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Definition
Stop fluids and void before sleep (nocturia) Daytime-avoid caffeine _ alcohol Avoid OTC's that worsen BPH (antihistamines/decongestants) Toilet mapping Lose weight (T-->Estrogen in fat) Herbals: Pygeum, secale cereale, hypoxis roopen, saw pimento |
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Term
What is a secondary mechanism of action in alpha antagonist monotherapy? |
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Definition
Induce prostatic apoptosis. (shrink prostate) |
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Term
Onset of alpha antag: BPH |
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Definition
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Term
Which BPH med stops progression better? |
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Definition
5 alpha reductase inhibitors |
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Term
ADR of alpha antagnists BPH? What meds? |
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Definition
Hypotension Syncope IR terazosin, doxazosin Less common in ER doxazosin, alfuzosin |
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Term
What is first line for moderate-severe BPH?? |
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Definition
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Term
1st generation alpha antagonists: |
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Definition
Ex. phenoxybenzamine: Block pre- and post- synaptic andrenergic receptors Post=BPH. Pre=undesirable. Leads to catechol release, tachycardia |
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Term
2nd generation alpha antagonists: |
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Definition
Block postsynaptic alpha receptors in the bladder nec, prostate, and peripheral vasculature. Hypotensive=dose related. common Terazosin, doxazosin, alfuzosin. |
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Term
3rd generation alpha antagonists: |
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Definition
Tamsulosin, sildosin Selectively block post synaptic alpha 1A which are in high [] in the prostate. Hypotensive less common |
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Term
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Definition
Selective inhibition of alpha 1A and alpha 1D receptors which predominate in stroma and detrusor muscles. |
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Term
Only functional uroselective?? |
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Definition
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Term
What happens if you give high doses of alfuzosin, tamsulosin?? |
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Definition
Systemic effects Hypotension |
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Term
What BPH meds are in need for up-titration of daily dose?? |
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Definition
-IR terazosin, Doxasosin Minimally ER doxasosin, tamsulosin Not required ER Alfuzosin, sildosin |
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Term
Absorption of IR terazosin, doxazosin?? Plasma Peaks? What about Modified/ER doxazosin, alfusasin, tamsulosin?? |
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Definition
IR=absorbed quickly. High plasma peaks. ER/MR=absorbed more slowly. lower peak levels. remain @ therapeutic levels in the plasma. |
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Term
When do you give first dose alpha blocker? Why? |
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Definition
Before bed to avoid hypotensive effects. |
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Term
How long should you wait before increasing the dose of an alpha blocker?? |
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Definition
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Term
With what alpha blocker is retrograde ejaculation most common? |
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Definition
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Term
Rhinitis, Malaise alpha blocker?? |
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Definition
Extension of alpha block. Become tolerant to these effects No need to d/c |
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Term
What can continuous use of anticholinergic anti-histamines cause in BPH?? |
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Definition
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Term
Floppy iris syndome: What drug is most common? |
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Definition
Often w/ tamsulosin iris dilator muscle erlaxes If patient underegoes cataract surgery, iris can becom flaccid, billow out or become floppy. Surgical complications Pt must inform dr. still do surgery. but use different technique |
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Term
What BPH drus has been linked to 2 cases of hepatitis? |
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Definition
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Term
Alpha blocker drug interactions? |
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Definition
Add to anti-hypertensive effects of diuretics, a-hxn, PDE inhibitors |
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Term
alpha blocker to treat BPH + HXN? |
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Definition
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Term
What are the 2 substypes of 5alpha reductases? |
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Definition
Majority is type 2, minority is type 2 |
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Term
what type induce apoptosis? |
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Definition
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Term
onset of 5 alpha reductases? |
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Definition
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Term
CV effects of alpha 5 reductases? |
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Definition
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Term
Symptom relief of 5 alpha reductases? |
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Definition
Moderate. but reduce progression |
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Term
Metabolism of 5 alpha reductases? dose adjustments? |
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Definition
Hepatically. No dose adjustments. No dose adjustments in renal |
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Term
ADR of 5 alpha reductases? |
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Definition
Decreased libido Ed Retrograd ejaculation gynocomastia breast tenderness |
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Term
5 alpha reductases in pregnant females? |
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Definition
CI. Do not even handle unless gloves. Feminize male fetus |
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Term
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Definition
Selective for type 2 reductase. |
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Term
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Definition
Type 1 and 2 5 alhpa reductase inhibitor. Faster working. More complete inhibition. |
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Term
Finasteride vs dutasteride |
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Definition
Dustasteride is faster and more complete. Therapeutically exchangable. |
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Term
How can 5 alpha reductases prevent developmnt of prostate cancer? |
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Definition
Decrease levels of DHT which is linked to prostate cancer. |
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Term
Combination therapy in BPH? |
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Definition
Alpha block + 5 alpha reductase inhbitor considered in symptomatic patient w/ high risk of bph complications (P>30 and PSA >1.5) Discuss advantages and disadvantages w/ patient. Alpha antag can be dropped after 6-12 months. Another management: addition of anti-cholinergic for irritative symptoms -added pharmacologic effect on releiving symptoms -no cases of urinary retention reported. |
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