Shared Flashcard Set

Details

Exam 3 Cards
Therapeutics Exam 3
272
Pharmacology
Graduate
11/03/2011

Additional Pharmacology Flashcards

 


 

Cards

Term
Reduction in the concentration of hemoglobin that results in a reduced oxygen-carrying capacity of the blood??
Definition
Anemia
Term
Common Causes of Anemia?
Definition
Blood Loss
Decreased RBC production
Increasd RBC destruction
Combination
Term
What is essential for successful anemia management??
Definition
Determining underlying cause
Term
Side effects of anemia:
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
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
200 mg elemental/day
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
2-3 equal doses daily
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
Vitamin C
Yes, GI SE
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
Dose for iron dextran??
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
Iron dextran ADR??
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
Intrinsic factor
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
Megablastic
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
ADR of folic acid??
Definition
Flushing
Malaise
Rash
Term
Drug interaction of folic acid??
Definition
Phenytoin
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
Long Term effects of OP?
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
Skeletal disorder
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
Women >> 65
Men >> 70
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
Falls prevention:
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
May correct it as well
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
Lead
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
ADR of calcium??
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
800-1000mg
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
Bisphosphonates
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
Osteonecrosis
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
Hormones in OP??
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
Vertebral
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
20 mcg given once daily
Term
When is terapartide CI??
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
Denosumab usal dose?
Definition
SubQ 60 mg every 6 months
Term
Denosumab administration?
Definition
SubQ upper arm, thigh, abdomen
Term
Denosumab ADR??
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
Men bisphosphonates??
Definition
Alendronate. (primary)
Secondary-Treat cause
Term
What type of drug can induce OP??
How?
Definition
Glucocorticoids
Increase bone resorption and inhibit formation.
Term
Glucocorticoids
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
ED
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
Sacral nerve reflex
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
Organic dysfunction
Definition
Actual problem w/ something internal
Term
Psycogenic dysfunction
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
NP treatment of ED??
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
SE of VED??
Definition
Cold/disoolored/lifeless penis w/ hingle like feel.
Term
Prosthesis??
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
Decreased.
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
SE of PDE 5 inhibitors??
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
NAION
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
Vardenafinil
Term
Alprostadil Mechanism
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
Papaverine
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
Phentolamine
Definition
Comprehensive alpha adrenergic antagonist that increases arterial inflow by opposing constriction.
Non-FDA
Rarely used alone. Sometimes mixed w/ alprastadil
Term
Yohimbine
Definition
INdole alkaloid in the bark of yohimbe trees.
Inhibit Alpha 2 in the brain (libido/erection)
Not recommended bc so little info
Term
Yohimbine ADR?
Definition
Nausea
Irritability
Headache
Anxiety
Tachycardia
Hxn
Term
What is the first choice for treatment of hypogonadism??
Definition
Testosterone
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
IM testosterone adimin?
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
SE of testosterone??
Definition
Caused by absorption enhancers
Term
Oral testosterones??
Definition
Poor bioavailability.
1st pass metabolism
Try to fix w/ alkylated:
Methyltstosterone
Fluoxymesterone
Makes hepatotoxic
Term
Buccal Testosterone
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
Testosterone SE??
Definition
Gynecomastia
Dyslipidemia
Polycythemia
Acne
Weight gain
Hxn
Edema
Exacerbatiosns of CHF
BPH/prostate evaluation
Term
Complaint of leakage of urine??
Definition
UI
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
No. Rare
Term
What are the factors responsible for SUI?
Definition
Not completely understood. Loss of tropic effects of estrogen.
Term
Risk factors for SUI:
Definition
Pregnancy
Vaginal childbirth
Menopause
Cognitive impairment
Obesity
Increasing age
Term
SUI in males??
Definition
Rare. But usually happens after a surgery. Prostatectomy, prostate--BPH
Term
Diagnostic tests for SUI??
Definition
Observation of urethral meatus opening while patient coughs/strains
Term
What happens during Urge UI??
Definition
Detruser/Bladder is overactive and contracts inappropriately during the filling phase. (amount lost can be large bc bladder can empty completely)
Term
Nocturia/Enuresis during UUI?
Definition
Yes.
Term
Cause of UUI?
Definition
Often unknown
Term
Risk Factors for UUI?
Definition
Hysterectomy
Recurrent UTI's
Increasing age
Bladder outlet obstruction (BPH/malignancy)
Neurologic disorders (stroke, parkinsons disease, MS, spinal cord injury)
Term
In UUI, what is the origin of overreactivity??
Definition
Myogenic
Neurogenic
Mix of both
Term
Do you always have an "urge" in UUI?
Definition
No
Term
Diagnostic tests for UUI:
Definition
Urodynamic studies. Goldstandard
Urinalysis/urine culture should be - (rule out UTI as cause)
Term
What happens in overflow UI?
Definition
Bladder if filled @ all tims, but cannot empty, so urine leaks out episodically.
Term
OUI can be 2 types of activity, what are they??
Definition
Underactivity
Overactivity
Term
OUI under-activity mechanism:
When is this seen clinically?
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)
Term
Signs of overflow UI w/ underactivity?
Definition
High post void urine volume
Term
OUI overactivity
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)
Term
Functional UI:
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
Term
PE components in UI??
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
Term
Desired outcomes of UI treatment:
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
Term
NP treatment UI:
Definition
Surgery
Lifestyle
Scheduled voiding regimen
PFMR
anti-incontinence devices
supportive interventions
Term
What is first line NP therapy for UI?? Which UI? What do these require?
Definition
Behavioral treatments (SUI, UUI, Mixed)
Require motivation
Term
Which NP treatments for UI are the only significant ones? Which has been shown to be better than anticholinergic in UUI?
Definition
PFMR (better)
Behavorial
Term
Is surgery first line??
Definition
Rarely.
Usually considered when degree of bother/lifestyle compromise is sufficient
Term
Overactivity or underactivity?? which can be managed w/ surgery?
Definition
Overactivity.
Underactivity cannot be surgicaly managed
Term
What type of UI is surgery best management? What does this do?
Definition
SUI.
Stabalize urethra/bladder neck and augment urethral resistance uring periurethral collagen and other injectables.
Term
In males, how is SUI best treated??
Definition
Implanting an artificial sphincter.
Term
What is first line therapy for UUI?
Definition
Anti-cholinergic/antipasmotic
Term
What is the major problem with use of anti-cholinergics for UUI?
Definition
Lack of selectivity for bladder. So you get SE of dry mouth, constipation, blurred vision, cognitive, tachycardia
Term
Oxybutynin: how does it work??
SE?
Definition
Alpha receptor blockade.
Orthostasis/Sedation/Weight gain (histamine h1 block)
Term
What is better in terms of tolerability?? Tolteridine IR, oxybutynin IR??
Definition
Tolteridine>>Oxybutynin
Term
For UI, are ER or IR better?? Why?
Definition
ER
Safety and efficacy
Term
In UI, what DF is preferred? Oral. Dermal.
Definition
Oral>>Dermal
Term
What medication would you use in a male with presumed non-obstructive BPH and UUI?? (treat UUI)
Definition
Tolteradine LA (monotherapy or combine w/ alpha antagonist)
Term
Can you use 2 anti-cholinergics to lower the dose of each??
Definition
No. No rationale.
Term
How would you treat a woman with mixed UI(UUI + SUI) and atrophic vaginitis and or urethritis
Definition
Benefit form PV estrogen and anticholinergic therapy
Term
DDVAP??
Definition
Decrease UUI symptoms by up to 8 hours after monitoring doses
Also used in pediatrics
Term
Duloxetine for UUI??
Definition
Short term benefit
Bladder capacity < 400 mL
Term
Goals of SUI treatment:
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.
Term
Treatment of SUI??
Definition
Usually not pharmacologic but NP.
Sometimes duloxetine + PFMR
Term
SUI and surgery??
Definition
Frequently curable
Term
SUI estrogen effect?
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
Term
SUI estrogen use??
SE?
Definition
Local only
SE: mastodynia, uterine bleeding, nausea, thromboembolism, cv events, ischemia, increase breast/endometrial cancer risk
Term
SUI Alpha Agonists:
Definition
Pseudophedrine. Mild-moderate.
Monotherapy fails.
Combine w/ estrogen
Term
Alpha agonist SE:
Definition
HXN
headache
Dry mouth
nausea
insomnia
restlessness
Term
Drug calsses for SUI
Definition
Alpha agonists
Duloxetine
Estrogens
Term
Duloxetine for SUI:
Mechanism
Similar to?
Approved for?
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.
Term
Duloxetine in males??
Definition
After radical prostatectomy
Term
Overflow UI (interactivity) treatment
Urospecificity?SE?
Definition
Bethanichol (cholinomimetic)
Not urospecific:
Muscle/abdominal cramps
hypersalivationdiarrhea
potentially life threatening bradycardia
bronchospasm
Term
What can also benefit overflow UI?? How?
Definition
Alpha antagonists, relax the bladder.
Term
Overflow UI bc of obstruction. treatment?
Definition
remove the obstruction
Term
What urinary symptoms are associated w/ BPH?
Definition
Consistent with impaired emptying of urine from and storage of urine in the bladder
Term
Risk factors for BPH:
Definition
Androgens (testosterone->DHT by 5 alpha reductase) make prostate grow
Age
Term
2 types of tissue in the prostate:
Definition
Glandular/Epithelial: Secretions (including PSA)
Stromal/Muscle: can contract urethra
Term
Androgens effect on growth/stromal tissue?
Definition
+ effect on growth.
No effect on stromal tissue (effected by estrogen, which testosterone->estrogen. indirect effect)
Term
What receptors are located on stromal cells? What do these do when stimulated?
Definition
Alpha 1A
Stimulate/contract around urethra, narrow it.
Obstructive voiding symptoms.
Term
What does detrusor instability cause?
Definition
Irritating voiding. Urgency/Frequency.
Term
Where are detrusor fibers located?
Definition
Alpha 1D receptors.
Term
In an enlarged gland? What is the epithelial/stromal ratio??
Definition
1:5
Term
Obstructive BPH symptoms:
Definition
Failure to empty while full
Decrease force of urinary stream
Urinary hesitation
Dribbling
Straining
Term
Irritative BPH symptoms:
Definition
Failure to store until full
Bladder outlet obstruction-detrusor muscles hypertrophy (increased pressure)
irritable and contracts with abnormally in small urine amounts
Term
What are BPH complications if untreated??
Definition
Acute refractory Urinary retantion
Renal failure
UTI
UI
Bladder stones
Large bladder diverticuli
Recurrent gross hematuria
Term
Treatment goals of BPH
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
Term
How often DRE / AVA scoring in BPH patinet?
Definition
DRE-1 year
AVA-3 months.
Term
Surgical effects on BPH:
Definition
Can be good, but can result in significant morbidity: ED, retrograde ejaculation, UI, bleeding, UTI
Term
Gold Standard BPH surgery?? How is it performed?
Definition
Prostatectomy: transurethrally (less invasice, many options)or open surgery (transpubically, retropubic)
Term
Why do some patients benefit from alpha antaginist + 5 alpha reductase inhibitor?
What specific drugs?
Disadvantages/
Definition
Decreased need for prostatectomy (decrease BPH complications)
Specifically doxazosin + finasteride
More expensive, more ADR
Term
NP therapy for BPH
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
Term
What is a secondary mechanism of action in alpha antagonist monotherapy?
Definition
Induce prostatic apoptosis. (shrink prostate)
Term
Onset of alpha antag: BPH
Definition
Days-weeks
Term
Which BPH med stops progression better?
Definition
5 alpha reductase inhibitors
Term
ADR of alpha antagnists BPH? What meds?
Definition
Hypotension
Syncope
IR terazosin, doxazosin
Less common in ER doxazosin, alfuzosin
Term
What is first line for moderate-severe BPH??
Definition
Alpha antagonists
Term
1st generation alpha antagonists:
Definition
Ex. phenoxybenzamine:
Block pre- and post- synaptic andrenergic receptors
Post=BPH.
Pre=undesirable. Leads to catechol release, tachycardia
Term
2nd generation alpha antagonists:
Definition
Block postsynaptic alpha receptors in the bladder nec, prostate, and peripheral vasculature.
Hypotensive=dose related. common
Terazosin, doxazosin, alfuzosin.
Term
3rd generation alpha antagonists:
Definition
Tamsulosin, sildosin
Selectively block post synaptic alpha 1A which are in high [] in the prostate.
Hypotensive less common
Term
Uroselectivity
Definition
Selective inhibition of alpha 1A and alpha 1D receptors which predominate in stroma and detrusor muscles.
Term
Only functional uroselective??
Definition
Alfuzosin ER tablets
Term
What happens if you give high doses of alfuzosin, tamsulosin??
Definition
Systemic effects
Hypotension
Term
What BPH meds are in need for up-titration of daily dose??
Definition
-IR terazosin, Doxasosin
Minimally ER doxasosin, tamsulosin
Not required ER Alfuzosin, sildosin
Term
Absorption of IR terazosin, doxazosin?? Plasma Peaks?
What about Modified/ER doxazosin, alfusasin, tamsulosin??
Definition
IR=absorbed quickly. High plasma peaks.
ER/MR=absorbed more slowly. lower peak levels. remain @ therapeutic levels in the plasma.
Term
When do you give first dose alpha blocker? Why?
Definition
Before bed to avoid hypotensive effects.
Term
How long should you wait before increasing the dose of an alpha blocker??
Definition
3-7 days.
Term
With what alpha blocker is retrograde ejaculation most common?
Definition
Tamsulosin.
Term
Rhinitis, Malaise alpha blocker??
Definition
Extension of alpha block.
Become tolerant to these effects
No need to d/c
Term
What can continuous use of anticholinergic anti-histamines cause in BPH??
Definition
Urinary retention
Term
Floppy iris syndome:
What drug is most common?
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
Term
What BPH drus has been linked to 2 cases of hepatitis?
Definition
Alfuzasin
Term
Alpha blocker drug interactions?
Definition
Add to anti-hypertensive effects of diuretics, a-hxn, PDE inhibitors
Term
alpha blocker to treat BPH + HXN?
Definition
No. not a good idea.
Term
What are the 2 substypes of 5alpha reductases?
Definition
Majority is type 2, minority is type 2
Term
what type induce apoptosis?
Definition
5 alpha reductases
Term
onset of 5 alpha reductases?
Definition
slow. 6 months.
Term
CV effects of alpha 5 reductases?
Definition
None
Term
Symptom relief of 5 alpha reductases?
Definition
Moderate. but reduce progression
Term
Metabolism of 5 alpha reductases? dose adjustments?
Definition
Hepatically. No dose adjustments.
No dose adjustments in renal
Term
ADR of 5 alpha reductases?
Definition
Decreased libido
Ed
Retrograd ejaculation
gynocomastia
breast tenderness
Term
5 alpha reductases in pregnant females?
Definition
CI. Do not even handle unless gloves. Feminize male fetus
Term
Finasteride
Definition
Selective for type 2 reductase.
Term
Dutasteride
Definition
Type 1 and 2 5 alhpa reductase inhibitor.
Faster working.
More complete inhibition.
Term
Finasteride vs dutasteride
Definition
Dustasteride is faster and more complete.
Therapeutically exchangable.
Term
How can 5 alpha reductases prevent developmnt of prostate cancer?
Definition
Decrease levels of DHT which is linked to prostate cancer.
Term
Combination therapy in BPH?
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.
Supporting users have an ad free experience!