Term
| GERD is one of the most common chronic conditions in US which patients take _____ meds. |
|
Definition
|
|
Term
| What is dyspepsia greek for? what does it mean? |
|
Definition
bad digestion
discomfort in the upper abdominal area |
|
|
Term
| The LES relaxes to do what? And then contracts to do what? |
|
Definition
-allow food to enter stomach
-prevent reflux |
|
|
Term
| Resting LES pressures are ______ gastric baseline pressure. |
|
Definition
above
-normal to have some reflux multiple times each day due to transient relaxation of LES |
|
|
Term
| According to Wick, the stomach is usually the size of what and can get up to 10x this size. |
|
Definition
|
|
Term
| What 3 lines of defense must be impaired for GERD to develop? |
|
Definition
-LES barrier impaired
-decreased clearance of refluxed materials from esophagus
-decreased esophageal mucosal resistance |
|
|
Term
| What is dysphagia? What is odynophagia? |
|
Definition
-difficulty swallowing
-pain swallowing |
|
|
Term
| What symptoms of GERD warrant immediate referral and probable endoscopy? |
|
Definition
Dysphagia (difficulty swallowing food)
Odynophagia (pain upon swallowing food)
Bleeding (obviously)
Vomiting blood
Anemia
Tarry, black stools
Unexplained weight loss
Choking
Chest pain: both atypical symptom and alarm system |
|
|
Term
| When do you use an endoscopy when suspect GERD? |
|
Definition
| in patients who fail to respond to 6-8 wks of prescription therapy |
|
|
Term
| Of the 50% of people insured who uses 90% of the resources? |
|
Definition
|
|
Term
| Why is the camera pill possibly a good diagnostic tool in the cause of GERD? |
|
Definition
|
|
Term
| What 2 things can cause tarry or black stool other than GERD? |
|
Definition
Ppeto-Bismol
Iron supplements |
|
|
Term
| What factors can decrease LES pressure to make GERD worse? |
|
Definition
*Ethanol *Obesity
and
Foods (chocolates, garlic, onions, caffeine…)
Drugs (CCB, *ETHANOL, Estrogen, Theophylline…)
Smoking
Certain movements (bending over, exercise)
Tight fitting clothes
Mint (really bad for you if you’re having indigestion bc they cause secretion)
*Obesity |
|
|
Term
| What drugs can lower the LES pressure? |
|
Definition
Calcium channel antagonists
Narcotics ( meperidine, morphine)
Oral contraceptives |
|
|
Term
| What are the 3 phases of treatment of GERD? |
|
Definition
I- Lifestyle changes, pt directed therapy with OTC meds
II- Pharmocologic intervention (anti-secretory intervention)
III- Pt's who fail I and II need surgical intervention |
|
|
Term
| What are good empirical therapies of GERD if the pt has no prior hx of GERD? How long should pts self medicate? |
|
Definition
-Initial trial of appropriate Acid suppression with antacids, H2RAs (histamine 2 receptor antagonists) or PPIs
*Patients should not self medicate for longer than 14 days without further evaluation |
|
|
Term
| What is Wick's favorite PPI? |
|
Definition
| Omeprazole (Prilosec-OTC) |
|
|
Term
| What is the most effective first like option when treating GERD/? |
|
Definition
| Acid suppression via PPIs |
|
|
Term
| When is long term therapy beneficial with PPIs? When should pPIs be taken? |
|
Definition
in chronic and complicated GERD
30 to 60 minutes prior to other meds, breakfast, or the evening meal. |
|
|
Term
| Why are colas bad for GERD? |
|
Definition
| HAVE CAFFEINE AND CARBONATION AND ARE THEREFORE ACIDIC |
|
|
Term
| When should promotility agents such as Metoclopramide be used? |
|
Definition
for severe GERD
-should only be used as an adjunct therapy to PPIs or H2RAs to get to the root of the cause of GERD
-have poor side effects |
|
|
Term
| What are examples of H2RAs? |
|
Definition
*Ranitidine (Zantac ®)
*Famotidine (Pepcid ®)
-these work but Wick thinks PPIs work much better |
|
|
Term
|
Definition
Histamine acts on the parietal cells which triggers GASTRIC ACID.
--so the histamine receptor is blocked
--have very low side effects |
|
|
Term
| How long should pt take oTCs before getting a script? how often do OTCs work with GERD? |
|
Definition
|
|
Term
| What are the 2nd generations to H2RAs? |
|
Definition
|
|
Term
| How can the use of PPIs cause N/V/D and vitamin B12 deficiencies? |
|
Definition
| bc aren't absorbing the vitamin B12 |
|
|
Term
| In what type of environment do PPIs degrade rapidly? What should your patients never do to pPIs? |
|
Definition
acidic environments
*Make sure your patients do not crush or chew delayed release tablets |
|
|
Term
| What is under research with PPIs? |
|
Definition
| Their possible inhibition of CYP enzymes causing antiplatelet interactions |
|
|
Term
| What should you use for mild GERD? severe? |
|
Definition
For mild GERD- use H2 or PPI
Moderate to severe- use PPI |
|
|
Term
| In how many GERD pts is symptomatic relief achieved with PPIs? what ae healing rates? |
|
Definition
82%
78% after 8 wks
H2s were only 50% |
|
|
Term
| Which antacids are popular, cost-effective and easy to use? can they be chewed? What might they cause? |
|
Definition
*Calcium Carbonate (Tuns, Rolaids)
-can be chewed
-Ca may cause constipation |
|
|
Term
| Ca causes constipation and Mg causes what? |
|
Definition
diarrhea
-is an antacid but doubles as a laxative |
|
|
Term
| With antacids what requires monitoring for long term use? |
|
Definition
| Calcium carbonate (Hypercalcemia) |
|
|
Term
| What does Sucralfate (Carafate) do? |
|
Definition
Protects ulcerated tissue area by coating it
@ pH 2-2.5 binds to damaged tissue and forms a barrier
~also binds bile salts which prevents bile adis from irritating the sotmach |
|
|
Term
| Which drug is referred to as a synthetic prostaglandin and is a "big boy" (not a first line) when treating GERD? |
|
Definition
|
|
Term
| Aside from Wick's preference what are the pecking orders of GERD tx? |
|
Definition
| antacids-->prilosec--.H2RA--->PPI |
|
|
Term
| What can you develop if take too many antacids (CalciuM carbonate) |
|
Definition
Hypercalcemia
-so requires monitoring for long term use
-whereas you would not even use Sodium carbonate for long term use. |
|
|
Term
| Antacids should be taken one hour before or two hours after other medications... what are three important DDIs with these? |
|
Definition
Tetracycline- binds with antacids and will go right through the gut and not be absorbed.
Fluoroquinolones
Quinidine |
|
|
Term
| What treatments can you use for PUD? |
|
Definition
PPI, antacids, Bismuth or H2 antagonists for symptoms
Metronidazole or tetracycline for underlying bacteria if is H.Pylori PUD |
|
|
Term
|
Definition
|
|
Term
| What is the gold standard for dxing PUD? |
|
Definition
|
|
Term
| There are 2 types of PUD, what are they and who gets which? |
|
Definition
Gastric- older pts
Duodenal- 20-50 |
|
|
Term
| How can PUD be caused by NSAIDS? |
|
Definition
due to NSAID long term use
-direct irritation to gastric epithelium
-inhibits Cox-1
--which decreases protective prostaglandins that protect the stomach |
|
|
Term
| What is an empirical method to reduce NSAID PUD? |
|
Definition
Ween them off the NSAID to see if pt still needs it
-also stop smoking |
|
|
Term
| What is the acute tx for PUD? |
|
Definition
*PPI 4 wks or H2 antagonist for 6-8 wks
*Treat H.pylori
*D/C NSAID if can |
|
|
Term
| What is the ideal treatment for H. pylori? |
|
Definition
two antibiotics + PPI or bismuth at least 7 days, preferably 14 days handout
known as a Prevpack |
|
|
Term
| What abx can be used for H. pylori? |
|
Definition
| Clarithromycin, metronidazole, tetracycline, amoxicillin |
|
|
Term
| What exactly is in a Prevpack? |
|
Definition
Lansoprazole (Prevacid) –(#2) 30mg
Amoxicillin (penicillin antibiotic)- (#4) 500mg
Clarithromycin (macrolide antibiotic) (#2) 500mg
take for 10-14 days |
|
|
Term
| What are the 4 types of antacids? |
|
Definition
CAMS
Calcium Carbonate
Magnesium (Hydroxide/Chloride)
Aluminum (Hydroxide/Phosphate)
Sodium Bicarbonate |
|
|
Term
| so. what are the general pharmacologic txs of PUD? |
|
Definition
Antacids
H2RA
PPI
Abx tx of H.pylori |
|
|
Term
| Constipation is going how many days without a BM? |
|
Definition
3 days
acute: <3 mos
chronic: >3 mos |
|
|
Term
| Whay are some medications that cause constipation? |
|
Definition
*Calcium
*Analgesics (opiods, NSAIDS)
*Anticholinergics
*Iron
CCB
Clonidine
TCA (Elavil) |
|
|
Term
| Since non-pharmacologic is ALWAYS the first line, what is the first line non-pharmacologic therapy for constipation? |
|
Definition
-increase dietary fiber 20-35 grams/d
-increased fluid intake
-exercise
-heed the urge |
|
|
Term
| What is the pharmacologic therapy of constipation? |
|
Definition
1st line:
-Bulk-forming (metamucil) (short and long term)
-Emollients: Colase (stool softeners)
-Lubricants: mineral oil
2nd line:
-Osmotic laxatives (GoLYTELY) long term
-Hyperosmotics (glycerin)
-Saline (Citrate of Mg, MOM)
-Enema (short term only)
3rd line
-Stimulants (Bisacodyl) |
|
|
Term
| What is the difference in Metamucil and colase? |
|
Definition
| Metamucil might bind things up. |
|
|
Term
| What do emollients prevent? (Colase- Docusate sodium) |
|
Definition
| constipation and straining |
|
|
Term
| What are the adverse effects of lubricants such as mineral oil? |
|
Definition
Decreases fat absorption of fat-soluble vitamins (A,D,E&K)
Tastes bad
Taken orally and can be aspirated (lipid pneumonia)
Systemically absorbed |
|
|
Term
| In what pts should you be cautious when using laxatives? |
|
Definition
|
|
Term
| What is used for relief of constipation before a colonoscopy? |
|
Definition
|
|
Term
| What new drug is approved for chronic idiopathic constipation? |
|
Definition
New class: chloride channel activators (CCAs)
New drug: Lupiprostone (Amitza)
-opens the flood gates |
|
|
Term
| What are the 6 alarm of constipation? |
|
Definition
worsening of constipation
blood in the stool
weight loss
fever
anorexia
N/V |
|
|
Term
| What constipation treatments should be used for chronic use? |
|
Definition
Docusate or bulk
NO LAXATIVES |
|
|
Term
| What is a good non-pharmacologic treatment plan for diarrhea in adults? children? What is a good diet to use if you have diarrhea? |
|
Definition
-discontinue solid food and dairy products x 24 hrs.
-children: continue feeding children with acute diarrhea (decreased morbidity and mortality)
-BRAT: bananas, rice, applesauce, toast |
|
|
Term
| What non-pharmacologic therapy for diarrhea saves lives and is the preferred tx for mild-moderate diarrhea? |
|
Definition
ORT (oral rehydration therapy)
-especially in children and third world countries
-a pack hat you put in water |
|
|
Term
| What are two antimotility agents that can be used for diarrhea? |
|
Definition
Loperamide (Immodium)
Diphenoxylate/ atropine (lOMOTIL |
|
|
Term
|
Definition
stimulates mu-opiod receptors located on intestinal circular muscles
-->slows motility to allow absorption of electrolytes and water |
|
|
Term
| When should Loperamide be used? |
|
Definition
Traveler's diarrhea, nonspecific acute
-when pt has low grade fever and no bloody stools. |
|
|
Term
| How does Kaolin work? Who should this not be used in? |
|
Definition
MOA: adsorption
do not use <12 |
|
|
Term
| What is an antisecretory agent that is a good treatment for the relief of mild, nonspecific diarrhea? |
|
Definition
| Bismuth subsalicylate (Pepto-Bismol, Kaopectate) |
|
|
Term
| What type of stools might be caused by bismuth salicylate? |
|
Definition
|
|
Term
| There are strong ties between IBS and _________. |
|
Definition
|
|
Term
| Is IBS constipation or diarrhea? |
|
Definition
|
|
Term
| What are some non-pharmacological treatments of IBS? |
|
Definition
-diet, lifestyle, psychological therapy
*increase dietary fiber to 25 g/day, increase slowly to avoid bloating. |
|
|
Term
| IBS tx should include drugs to reduce diarrhea or constipation and what? |
|
Definition
Antispasmodics:
-dicyclomine (Bentyl)
--has a narrow therapeutic window
--will also reduce short term pain |
|
|
Term
| What is the 5-HT3 Antagonists that can be used with IBS with diarrhea? |
|
Definition
Alosteron (Lotronex)
-must be prescribed through a program and by a GI due to risk of Ischemic colitis. |
|
|
Term
| What kind of IBS can TCA (tricyclic antidepressants) be used for? |
|
Definition
long term reduction of symptoms
-has various side effects |
|
|
Term
| What is the mechanism of action of Simethicone for the tx of gas? |
|
Definition
-defoaming agent
-reduces surface tension of gas bubbles and more easily pass gas
-*NOT ABSORBED
-*DNE 500mg/day |
|
|
Term
| Activated charcoal has absorbent effects for intestinal gas, it is best used when combined with simethicone, what are it's 3 downfalls? |
|
Definition
*not approved or shown effective for gas
-very messy
-bad taste |
|
|
Term
| Within the brainstem, what are the 2 anatomically and functionally distinct units that control vomiting? |
|
Definition
vomiting center
chemoreceptor trigger zone (CTZ) |
|
|
Term
| These centers in the brainstem receive stimuli from 4 diffent sources, what are the 3 stimuli that stimulate the extramedullary ceters in the brain? |
|
Definition
*psychological stimuli: odors, fear
*vestibular disturbances: motion sickness
*cerebral trauma |
|
|
Term
| What OTC tx is great for all ages? |
|
Definition
| Ginger ale- over ice and sip slowly |
|
|
Term
| What H2RAa are good to use for N/V? Which one SHOULD NOT BE USED due to DDIs? |
|
Definition
*Ranitidine (Zantac®)
*Famotidine (Pepcid®)
**Cimetidine (Tagamet) |
|
|
Term
| What is okay to be used as N/V therapy in pregnant women? |
|
Definition
*vitamin B6 (pyridoxine)
2nd line is doxylamine (antihistamine) if B6 does not work alone. |
|
|
Term
| What pharmacologic tx is great for children and is OTC? |
|
Definition
| Phosphorylated carbonate solution (Emetrol, nauzene) |
|
|
Term
| What are the 5 types of emetics? |
|
Definition
antidopaminergic
anticholinergic
serotonin antagonists
cannabinoid agonists (marijuana)
neurokinin receptor antagonists: |
|
|
Term
| What are some examples of antidopaminergic antiemetics? |
|
Definition
*Phenazothiazines: Prochlorperazine (Compazine), Promethazine (Phenergan)
*Benzamides: Metaclopramide (Reglan) |
|
|
Term
| What are some examples of anticholinergic antiemetics? |
|
Definition
*Meclizine (antivert))
Rx patches: Scopolamine (Transderm- Scop) and Dimenhydrinate (Dramine) |
|
|
Term
| What are serotonin antagonist antiemetics? |
|
Definition
|
|
Term
| What drugs are useful for post-operative N/V? What is best for chemo induced nausea? |
|
Definition
Antidopaminergics
*antihistaminic and anticholinergic make them good for motion sickness
*not as effective as metoclopramide and ondansetron for chemotherapy-induced nausea |
|
|
Term
| There are 2 types of antidopaminergics: butyphenones and phenothiazines, what are two examples of phenothiazines? |
|
Definition
prochlorperazine (compazine)
promethazine (phenergan)
**good after surgery when anesthesia may cause N/V |
|
|
Term
| what is an example of dopamine receptor antagonists used for N/V? What type of nausea? |
|
Definition
Metoclopramide (Reglan)
-standard drug for treating chemotherapy induced nausea |
|
|
Term
| Why should metoclopramide not be used everyday? |
|
Definition
|
|
Term
| Which antihistamines are used for N/V? |
|
Definition
| only those that cross the BBB |
|
|
Term
| What type of nausea are antihistamines used for? What are they and which cannot be used in children? |
|
Definition
-motion sickness
-dimenhydrinate (Dramamine), diphenhydramine (Benadryl) and meclizine (Antivert)
Diphenhydramine cannot be used in children under 6
Meclizine cannot be used in children under 12 |
|
|
Term
| Anticholinergiv N/V medicine, Scopolamine (scopoderm) is used for what type of nausea? |
|
Definition
motion sickness
NOT for chemotherapy nausea
used back in the day as a truth serum |
|
|
Term
| Serotonin antagonists, Ondansetron (Zofran), is a serotonin antagonist used for what type of nausea? |
|
Definition
NV associated with chemotherapy
new and is taken before chemo for prevention
Reglan is then used after chemo. |
|
|
Term
| If the zofran and reglan did not work for acute and delayed chemotherapy nausea, then what? |
|
Definition
Neurokinin receptor antagonist: Aprepitant (Emend)
Used for prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV) in combination with standard antiemetic regimens (5HT3 antagonist plus a corticosteroid) |
|
|
Term
| What has not been shown to be optimal as monotherapy for CINV? |
|
Definition
Aprepitant
-adverse reactions |
|
|
Term
| What is the rationale for multi-drug therapy for CINV? |
|
Definition
cytotoxic agents produce emesis by multiple mechanisms
*reduces individula doses
*reduces adverse effects |
|
|
Term
|
Definition
|
|
Term
| What diseases is caused by having too little Niacin or Tryptophan in the diet? |
|
Definition
Pellagra
-vitamin fortified bread therefor saved lives.
-went from 2000 deaths to 500 from the 40s to the 50s |
|
|
Term
| What are the fat-soluble vitamins? |
|
Definition
A (retinoid)
D (Ergocalciferol D-2 & Cholecaliferol D-3) "Sunshine"
K
E
*these vitamins can be toxic because they build up in the body.. other vitamins that are water soluble are not stored. |
|
|
Term
|
Definition
vision
cell and gene regulation
think of keratin in carrots |
|
|
Term
|
Definition
| Calcium homeostasis and bone metabolism |
|
|
Term
|
Definition
membrane antioxidant
-in lotions, though not absorbed well that way |
|
|
Term
|
Definition
| blood clotting ad calcium metabolism |
|
|
Term
|
Definition
| Metabolism of drugs and steroids |
|
|
Term
| Where do we get a lot of minerals? |
|
Definition
| fluorinated water supply- found this out bc people without fluoride in the water did not have tooth decay |
|
|
Term
| Minerals are 4-5 % of body weight... of this, what is 50%? 25%? |
|
Definition
|
|
Term
| What are the MACROvitamins needd for human health? |
|
Definition
| C, B-1, B-2, Niacin, B-6, Folic Acid, Biotin, pantothenic acid and B-12 |
|
|
Term
| Who is at risk for not having the healthy amount of vitamins needed? |
|
Definition
Elderly, infant, developing fetus or Pregnancy
Polypharmacy (with more than one provider)
Existing malnutrition
Patients with a chronic disease (long-term therapy) or GI disease
Poor patient compliance (too little or too much)
*Drug disposition (may cause N/V, diarrhea)
Lean or obese patients |
|
|
Term
| Why does the AMA think that people need to take vitamins now? |
|
Definition
|
|
Term
| Should you store vitamins in high temperatures or buy them in bulk? |
|
Definition
|
|
Term
| Can too many vitamins be a bad thing? |
|
Definition
| Yes, don't want ot form a bug lump in stomach |
|
|
Term
| What makes Alendronate (Fosamax) negligible? What reduces it by 60%? |
|
Definition
-if taken with food
-if taken with coffee or orange juice
Wick-"And people wonder why they have osteoporosis" |
|
|
Term
| What can not be properly distributed (aDme) if protein intake is inadequate (bc is protein bound)? |
|
Definition
Warfarin
Phenytoin
*especially in elderly, low albumin levels may cause excessive bleeding and toxic levels of phenytoin |
|
|
Term
| How can food both inhibit and enhance metabolism of drugs? |
|
Definition
| By altering the enzyme system |
|
|
Term
| Metabolism example: What increases the hepatic metabolism of theophylline? What can inhibit the intestinal metabolism of Ca Channel Blockers (CCB)? |
|
Definition
-diet with high protein and low carbohydrates
-grapefruits (can last up to 72 hours) |
|
|
Term
| More metabolism examples: What drugs compete with food for metabolism in the liver and intestine? |
|
Definition
|
|
Term
| What food and nutrients can alter the reapsorption of drugs from the renal tubule by altering pH? admE |
|
Definition
| milk, most fruits and juices |
|
|
Term
| What do loop diuretics increase the excretion of? |
|
Definition
K, Mg, Na, Cl, Ca
-->need to be careful to not cause hyponatremia that could show up as mental confusion in older patients. |
|
|
Term
| What do thiazide diuretic increase the excretion of? decrease? |
|
Definition
K & Mg
Ca (may result in hypercalcemia, which might be good in pt's with osteoporosis) |
|
|
Term
| What are 2 K sparing diuretics, and what do they increase excretion of? How can there be adverse effects of this (2)? |
|
Definition
Spironolactone (Aldactone) or Triamterene (Dyrenium)
-Na, Cl and Ca
1. Blood levels of K could rise to dangerous levels if they are also taking K supplements.
2. If used with an ACE inhibitor (enalopril or Fosinopril) can cause hyperkalemia |
|
|
Term
| Long term corticosteroids (prednisone) can do what to Na excretion levels? |
|
Definition
decrease it.
-leads to water and Na retention.
-ALSO: Ca is lost in the urine and corticosteroids may impair intestinal Ca absorption |
|
|
Term
| What are some drugs that alter taste or the smell of foods? |
|
Definition
Anti-infectives
*Docusate Na (Colace)
Antihistamatics
Antineoplastics
CNS drugs such as Phenteramine |
|
|
Term
| Osteomalacia develops in adults whose epiphyseal closures make that portion of the bone resistant to vitamin D. how can this be prevented? |
|
Definition
| Vitamin D3 (Cholecalciferol), Ca and P |
|
|
Term
| Why does precipitation occur in the joints and extremities? |
|
Definition
-Synovial fluid is a poorer solvent than plasma
-Extremities are cooler therefore solubility is less |
|
|
Term
| Why was gout associated with aristocracy? |
|
Definition
|
|
Term
| What are the non-pharmacologic things you want to push first when treating gout? |
|
Definition
| push lots of water (so are getting rid of excess uric acid) |
|
|
Term
| Where does gout show up first? |
|
Definition
|
|
Term
| Why does necrosis happen in gout? |
|
Definition
| Inflammation makes lots of pressure and kills stuff. |
|
|
Term
| What is gout an inflammatory response to? |
|
Definition
uric acid in the blood and tissues.
-due to reduced uric acid clearance by the kidneys
-caused by purine metabolism abnormalities (PRPP, HGPRT) |
|
|
Term
| What is gouty arthritis the result of? |
|
Definition
uric acid reaching high levels in the blood and crystalizing to form insoluble precipitates
-these crystals then aggregate in the joints and cause inflammation |
|
|
Term
| What are tophi? Where do they occur? |
|
Definition
Deposits of monosodium urate crystals -appear as white nodules
-Occur in areas with less bloodflow (earlobes, extremities) |
|
|
Term
|
Definition
|
|
Term
| What are 1000 times more prevalent in patient's with gout? |
|
Definition
| kidney stones... can lead to renal damage |
|
|
Term
| What medicines do you use to treat acute gout? |
|
Definition
*colchicine
NSAIDs
*Naproxen
*Indomethacin |
|
|
Term
| What meds do you use to eat chronic gout? |
|
Definition
|
|
Term
| Colchicine has been the primary therapeutic agent for years. How does it work? |
|
Definition
inhibits tubulin pollymerization and cell replication
Prevents proliferation and migration of leukocytes.
STOP THE INFLAMMATION- STOP THE PAIN |
|
|
Term
| Why isn't colchicine used for long term gout treatment? What has it been replaced with? |
|
Definition
Due to GI side effects of diarrhea.
*NSAIDs and Indomethacin is commonly used.
-Now colchicine only available in it's generic form (Colcrys) |
|
|
Term
| What are the common side effects of colchicine? the rare ones? |
|
Definition
-Diarrhea, abdominal cramps, nausea, vomiting
-Bone marrow suppression, neuropathy and myopathy
*Severe diarrhea is the rate limiting factor that makes it not able to be used for chronic gout. |
|
|
Term
| What uricosuric agents can you use for gout? Which type of gout? |
|
Definition
Probenecid, Sulfinpyrazone
-tophaceous gout or in patients with increasing frequency fo gout |
|
|
Term
| How does Probenecid work on the kidney? Why was it invented? |
|
Definition
-decreases reuptake of uric acid so it will remain in the urine and be eliminated.
-invented to prevent elimination of penicillin and increase half life. |
|
|
Term
| What might excess uric acid secretion predispose patients to and how might this be prevented (2)? |
|
Definition
stone formation
-prevented by maintaining fluid intake and urine output
-alkalinize urine (>6.0) to enhane solubility of uric acid) |
|
|
Term
| When is allopurinol used? |
|
Definition
in the CHRONIC treatment of gout
-so cochicine is used for acute attacks (inflammation) and stopped once uric acid levels are normalized
AND then allopurinol is used for uric acid levels. |
|
|
Term
| What are the adverse effects of allopurinol? |
|
Definition
GI intolerance, N/V/D
Stevens-Johnson |
|
|
Term
|
Definition
| anti-cancer drugs: azathioprine and 6-mercaptopurine |
|
|
Term
| What is the first new gout drug in 40 years? |
|
Definition
Febuxostat (Uloric)
-generally more effective at reducing uric acid levels than allopurinol |
|
|
Term
| Besides allopurinol, what else can be used prophylactically for gout? |
|
Definition
|
|
Term
| What else is added to Febuxostat initially to prevent acute flareups of gout? |
|
Definition
|
|
Term
| Along with colchezine, what is the first line tx of gout? |
|
Definition
|
|
Term
| What is more important than NSAID type? |
|
Definition
|
|
Term
| Which NSAID is used most for gout? |
|
Definition
|
|
Term
| Besides endomethacin, what is an NSAID used for the alleviation of gout symptoms? |
|
Definition
Naproxen (Aleve)
-can be OTC, but usually prescribed at a strength of 500mg
-20x more potent than aspirin (half life=12 hours) |
|
|
Term
| NSAIDs are __________ and therefore when you take them you need to be careful to no bump off other drugs that are also ____________. |
|
Definition
protein bound
protein bound |
|
|
Term
| What foods should you not intake when trying to treat gout? |
|
Definition
| foods that cause uric acid levels to rise: red meats, caffeine, alcohol (especially beer) |
|
|
Term
| Besides avoiding certain foods, what other non-pharmacological treatments can help? |
|
Definition
patient education!
weight control
drink lots of water |
|
|
Term
|
Definition
|
|
Term
So in general, when treating gout:
REDUCE URIC ACID LEVELS:
-Inhibit uric acid production by xanthine oxidase (2 examples)
-Promote uric acid excretion by the kidneys with uricosurics (1 example)
STOP INFLAMMATORY CASCADE:
-NSAIDS (2 examples, no aspirin)
-antimicrotubular agent that prevents proliferation and migration of leukocytes (1 example)
-corticosteroids |
|
Definition
-allopurinol, febuxostat
-probenacid
-naproxen, indomethacin
-colchicine |
|
|
Term
| Why don't you take aspirin (ASA) for gout? |
|
Definition
| -an acid, so will make it worse |
|
|
Term
|
Definition
|
|
Term
What percent of the world's population has RA?
Women ______ times more common than men
What is the peak age of onset? |
|
Definition
|
|
Term
What is it currently believed that RA is currently triggered by?
(This is why it's more common in females) |
|
Definition
combination of:
genetics
environmental
hormonal
reproductive factors |
|
|
Term
| How does RA usually affect joints? |
|
Definition
|
|
Term
| Between OA and RA, what is the difference in duration of time? |
|
Definition
OA: less than 30 mins
RA: greater than 30 mins (in pain all the time) |
|
|
Term
| Between OA and RA, what is the difference in joint location? |
|
Definition
OA: DIP, PIP, hips (asymmetrical)
RS: PIP, MCP, wrist, elbow, MTP (symmetrical) |
|
|
Term
| Between OA and RA, what is the difference in the labs? |
|
Definition
OA: no change in ESR
RA: elevated ESR |
|
|
Term
| A patient has RA if have four of the following 7 S/S? |
|
Definition
Morning stiffness
arthritis of 3 or more joints
arthritis of hand joints
symmetric arthritis
RA
Serum Rheumatoid Factor
Radiographic changes |
|
|
Term
| What is the non-pharmacologic tx of RA? |
|
Definition
rest
OT and PT
assistive devices
weight loss
surgery |
|
|
Term
For the tx of RA, what do you start with?
-within 3 mos of dx?
-if side effects are intolerable?
-last alternative? |
|
Definition
-NSAIDs or glucocorticoids in mild dz then use adjunctive therapy
-DMARD
-another biological agent
-surgery |
|
|
Term
|
Definition
Celebrex, ASA
-fast acting
Also:Naproxen and ibuprofen |
|
|
Term
| What will people with RA probably be on for the rest of their life? |
|
Definition
|
|
Term
| What NSAID gel can be rubbed on RA joints? |
|
Definition
|
|
Term
| What should be started quickly due to ability to induce a long term effect? |
|
Definition
|
|
Term
| Methotrexate has side effects, so anytime you can down the dosage do it. How should you do this? |
|
Definition
| taper up and taper down... 7.5-20 mg/ week or over 36 hours. |
|
|
Term
| What are adverse effects of MTX related to? |
|
Definition
|
|
Term
| What 2 other things must be taken when taking methotrexate? |
|
Definition
folic acid (should not be dispensed together)
birth control |
|
|
Term
| What 2 other things must be taken when taking methotrexate? |
|
Definition
folic acid (should not be dispensed together)
birth control |
|
|
Term
| Leflunomide controls inflammation in RA, what are it's adverse side effects? |
|
Definition
*liver toxicity, diarrhea, alopecia, rash, immunosuppression
*Patient MUST use effective contraception |
|
|
Term
| When is Etanercept (Enbrel) useful in treating RA? |
|
Definition
-in early RA
-in pts who have failed other DMARDs |
|
|
Term
| What must Infliximab (Remicade) be used in combination with to slow radiographic progression of RA? |
|
Definition
|
|
Term
| What is the most common type of joint dz? |
|
Definition
Osteoarthritis
-'wear and tear'
-progression erosion of articular cartilage |
|
|
Term
| What % of people have evidence of OA by the time they are 65? |
|
Definition
80-90%
-can occur younger with injuries |
|
|
Term
| So, OA leads to the erosion of articular cartilage, what occurs secondary to this? |
|
Definition
inflammation
-sclerosis (underlying bone is thickened)
-formation of bone spurs (osteophytes) |
|
|
Term
| OA is ________ of the joint, not in the space surrounding. |
|
Definition
|
|
Term
| OA is *not systemic, typically what is involved? |
|
Definition
Only one or a few joints:
-hips
-knees
-lower lumbar and cervical spine
-hands (DIP, PIP)
-1st tarsometatarsal joint |
|
|
Term
| Heberden nodes in OA are characteristic in ______. |
|
Definition
women, not men.
-are osteophytes on DIP |
|
|
Term
| What are the osteophytes called on PIPs? |
|
Definition
|
|
Term
| Dx of OA includes symptoms and radiologic images. Symptoms include difficulty walking, crepitus, stiffness that decreases with motion and pain. Describe the pain early and late. |
|
Definition
early: associated with activity
late: pain with both activity and rest |
|
|
Term
| Dx of OA includes symptoms and radiologic images. Symptoms include difficulty walking, crepitus, stiffness that decreases with motion and pain. Describe the pain early and late. |
|
Definition
early: associated with activity
late: pain with both activity and rest |
|
|
Term
| What are the oral OTC agents for treating OA? |
|
Definition
Glucosamine/Chondroitin/MSM
-takes about 2 mos to load into joints
-must have fxning chondrocytes
Tylenol (First line therapy)
Ibuprofen and Naproxen (NSAIDs may cause GI upset) |
|
|
Term
| What are the topical OTC agents for treating OA? |
|
Definition
Capsaicin or Arnica
-TID-QID
-can induce stinging sensation (made from red pepper) |
|
|
Term
| What are the oral Rx agents for treating OA? |
|
Definition
NSAIDs
-800 mg ibuprofen (Max 3.2 g/day)
-Naproxen, diclofenac, indomethacin
Opiate analgesics
-hydrocodone/acetominophen (Lortab)
-oxycodone/ acetominophen (Percocet) |
|
|
Term
| What are the topical Rx agents for OA tx? |
|
Definition
|
|
Term
| When using viscosupplementation to tx OA, what is used? |
|
Definition
| hyaluronate injected into joint to help lubricate it |
|
|
Term
| Once you get to a certain point, what kind of surgery can you have? |
|
Definition
|
|
Term
| OA is more in athletes, what is Osteoporosis more associated with? |
|
Definition
| not taking enough calcium or Vitamin D |
|
|
Term
|
Definition
| Bone density + Bone quality |
|
|
Term
| What's the problem in ostoporosis? |
|
Definition
|
|
Term
| What is the most common type of metabolic bone dz? |
|
Definition
|
|
Term
| Osteoporosis: __________ suffer from it more, but _______ have more fractures. |
|
Definition
|
|
Term
| What are the most susceptible bone in osteoporosis? |
|
Definition
|
|
Term
| What are the most susceptible bone in osteoporosis? |
|
Definition
|
|
Term
| Osteoporosis is an imbalance of what? |
|
Definition
| osteoblast and osteoclast activity |
|
|
Term
| What are the modifiable risk factors for osteoporosis? |
|
Definition
*low body weight (<125 lbs)
low calcium/ vitamin D
sedentary lifestyle
alcohol excess
cigarette smoking
caffeine (increases calcium excretion)
corticosteroid use
recurrent falls
RA |
|
|
Term
| What are the nonmodifiable risk factors? |
|
Definition
sex
race (Caucasian, Asians at high risk)
advanced age (postmenopausal and >65)
female
history of 1st degree relative
early menopause
small thin frame |
|
|
Term
| What are the primary types of osteoporsis? |
|
Definition
postmenopausal
age related |
|
|
Term
| What are the 3 secondary types of osteoporosis? |
|
Definition
chronic disease states
drug therapy (STEROIDS)
lifestyle |
|
|
Term
| On the PE for osteoporosis, what test should you do to get a baseline? |
|
Definition
|
|
Term
| What kind of onset does osteoporosis have? |
|
Definition
gradual onset that occurs over the years
-most likely first presented with a fracture with minimal trauma |
|
|
Term
| Less than __% of women 75 years and older receive bone density screenings. |
|
Definition
10
-sad, bc not hard to screen non-invasive and cheap |
|
|
Term
| What is associated with 20-40% reduced risk of hip fracture? |
|
Definition
|
|
Term
| When do you need to use Fosamax for osteoporosis? |
|
Definition
wrist... no
hip... maybe
spine... yes! |
|
|
Term
| What is the recommended daily dose of Calcium? |
|
Definition
|
|
Term
| How much Ca can be absorbed at one time? |
|
Definition
|
|
Term
| Besides dairy products and food, where can you get calcium? |
|
Definition
Calcium citrate (Citracal)- taken without food
Calcium carbonate- taken with meals (cheaper) |
|
|
Term
| What are adverse effects of calcium? |
|
Definition
*constipation
bloating
cramps
flatuence |
|
|
Term
| Vitamin D can be obtained from egg yolks, fish, liver and supplements and UV exposure, sunscreens SPF or higher blocks _____% of Vitamin D production |
|
Definition
|
|
Term
| How much sun exposure is necessary for healthy amounts of Vitamin D? |
|
Definition
|
|
Term
| What supplements can give you Vitamin B12? |
|
Definition
|
|
Term
| When it comes to vitamin D and Calcium levels, at what age will we mostly be treating? When these people hit age 50, how many mgs do you increase each by? |
|
Definition
19-50 yoa
200 mg
D- 600mg --> 800
Ca- 1000mg -->1200 (women) 1000 (men) |
|
|
Term
| Why is estrogen useful in the prevention of osteoporosis? |
|
Definition
increases osteoblast activity
-so extrogen protects them until menopause
-after menopause HRT used to be used. |
|
|
Term
| Why is HRT no longer recommended for the prevention of bone fractures? |
|
Definition
| found an increase in invasive breast cancer, nonfatal stroke, venous thromboembolism and nonfatal MI |
|
|
Term
| Why is HRT no longer recommended for the prevention of bone fractures? |
|
Definition
| found an increase in invasive breast cancer, nonfatal stroke, venous thromboembolism and nonfatal MI |
|
|
Term
| Why do you want to give HRT in small doses and need to titrate it up and down? |
|
Definition
women are still cycling even though they are no longer menstruating
also due to fluctuations with diet and exercise |
|
|
Term
| Raloxifine (Evista) is a SERM (Selective Estrogen Receptor Modulator) how does it work in the breasts? bones? |
|
Definition
bones= estrogen agonist
breasts= estrogen antagonist |
|
|
Term
| So, why would one use Raloxifene rather than a conjugated estrogen? |
|
Definition
Raloxifene's side effects are not as bad
decreases estrogen receptor positive breast CA |
|
|
Term
| How much does raloxifine reduce vertebral fracture in postmenopausal women? |
|
Definition
|
|
Term
| What is the most commonly used treatment for osteoporosis? |
|
Definition
Bisphosphonates
(Alendronate sodium (Fosamax), Risedronate sodium (Actonel))
2nd line: Ibandronate sodium (Boniva) |
|
|
Term
| What does Wickeizer think about bisphosphanates? |
|
Definition
A lot of people are depressed and can't take these things
-not for everybody, don't use for every little fracture.
-come with a lot of instructions. |
|
|
Term
| Which bisphosphanate is most effective for pt's with previous fracture? |
|
Definition
Alendronate sodium (Fosamax)
70 mg/week |
|
|
Term
| How do bisphosphonates work? |
|
Definition
| decrease bone resorption by causing osteoclast apoptosis and decreased fxn |
|
|
Term
| Where are bisphosphonates administered? |
|
Definition
at the physician's office
-not for self injection
-useful in patient's unable to take oral injection
-can be taken orally: 150 mg once monthly for tx and prophylaxis (expensive, most patients switch over to Fosamax) |
|
|
Term
|
Definition
inhibitor of bone resorption (inhibits osteoclasts)
is the last line therapy only for osteoporosis |
|
|
Term
| Which type of calcitonin is inhibited by gastric fluid? |
|
Definition
| Miacalcin (nasal spray or injection) |
|
|
Term
| Recombinant parathyroid increases the number and action of osteoblasts, what osteoporosis is it specifically used for? |
|
Definition
| postmenopausal with high risk for fracture |
|
|
Term
| What does recombinant parathyroid's (Teriparatide) warning label say? |
|
Definition
Increased risk of osteosarcoma
-use is limited to 2 years. |
|
|
Term
| What is the only thing Denosumab (Prolia) is approved for? |
|
Definition
Only approved for tx of postmenopausal osteoporosis in women with high risk of fracture
-reduces formation, action and lifespan of osteoclasts |
|
|
Term
| What can you take concurrently with Calcium and Vitamin D when Calcium and vitamin D are not enough? |
|
Definition
Fosteum
-is a natural approach to therapy (medical food)
-need a Rx and is kind of expensive. |
|
|
Term
| What are some causes of men with osteporosis? |
|
Definition
*Low levels of testosterone
Hypogonadism
Lack aromotase |
|
|
Term
| What puts one at HIGH risk for Type 2 Osteoporosis? |
|
Definition
| older than 75 with poor Ca absorption |
|
|
Term
| What are 4 preventative methods againt OA? |
|
Definition
wt bearing exercise
Ca/vit D/ P intake
no smoking
limit alcohol use |
|
|
Term
| What are currently the first line drugs of OA? how should they be taken? |
|
Definition
Biphosphonates (Fosamax, Actonel, Boniva)
-taken on an empty stomach and pt must sit for 1/2 hour |
|
|
Term
| What SERM is used to treat OA? |
|
Definition
Raloxifene (Evista)
-reduces resorption of bone |
|
|
Term
| What may interfere with the absorption of bisphosphonates? |
|
Definition
Antacids (Ca, Al, Mg)
-avoid for 2 hours. |
|
|
Term
| What is an inflammatory disorder of the bursa caused by overuse or trauma? |
|
Definition
|
|
Term
| For tendonitis, since tendons take a looong time to grow back, if NSAIDs and cutting back on exercise don't work, what should be done? |
|
Definition
| steroid injection and referral to a PT as to not make them a lot worse |
|
|
Term
| What should be done for muscle spasms before starting pt on muscle relaxants? |
|
Definition
NSAIDs
reduced exercise
rest
*want to wait bc of side effects and risk of abusing these drugs. |
|
|
Term
| How long should muscle relaxants be used? |
|
Definition
Should not be used longer than a week
-if chronic should be treated with PT |
|
|
Term
| Antispasmodics are CNS depressants, which one is key and is most commonly used? |
|
Definition
|
|
Term
| Which antispasmodic reduces tonic somatic motor activity and is useful in TMJ? |
|
Definition
Cyclobenzaprine (Flexeril)
-a relative of TCAs |
|
|
Term
| Do you use antispasmodics for injuries? |
|
Definition
|
|
Term
| What is another antispasmodic? (2) |
|
Definition
|
|
Term
| What is the only benzodiazepam indicated for both skeletal muscle relaxant AND for muscle spasms? |
|
Definition
|
|
