Term
| What is a chronic inflammatory disorder of the pilosebaceious unit? |
|
Definition
|
|
Term
| sebum production is primarily driven by what? |
|
Definition
|
|
Term
| What are the 4 primary factors involved in the formation of acne lesions? |
|
Definition
1. Increased sebum production
2. Follicular hyperproliferation and abnormal desquamation
3. Bacterial Growth
4. Inflammation |
|
|
Term
| what is the major bacteria in acne? |
|
Definition
|
|
Term
| Classification of P. acnes |
|
Definition
|
|
Term
| What are the potential causes of acne inflammation? |
|
Definition
-increased sebum productions, keratinocyte sloughing, and bacterial growth
-P.acnes can trigger by producing biologically active mediators and promoting proinflammatory cytokine release |
|
|
Term
| blackhead: opened or closed? |
|
Definition
Open-color due to melanin
whitehead is closed |
|
|
Term
| where on the body does acne usually occur? |
|
Definition
Face
Back
Upper chest
Shoulders
--Where sebaceous glands are most predominant |
|
|
Term
| Non-inflammatory vs. Inflammatory lesions |
|
Definition
Non-inflammatory:
-open and closed comedones
Inflammatory:
-papules, pustules, and maybe nodules
-Scars are a common result |
|
|
Term
| Acne Severity: mild, moderate, and severe |
|
Definition
Mild: non-inflammatory lesions (few to numerous open and closed comedones)-no scarring
Moderate: inflammatory papules and pustules with some non-inflammatory-possible scarring
Severe: Inflammatory and non-inflammatory lesions-extensive scarring |
|
|
Term
| Medications that can cause acne |
|
Definition
corticotropin
androgens
barbiturates
corticosteroids
cyclosporine
disulfiram
isoniazid
lithium
phenytoin
psoralens-used in PUVA
vitamin B2, B6, B12 |
|
|
Term
| Exacerbating Risk Factors for Acne |
|
Definition
-occlusive products (oil based cosmetics, hair dyes, clothing, helpemts)
-genetics
-heavy sweating
-high humidity
-mechanical trauma (scrubs)
-excessive rubbing/picking
-stress
-occupational exposure-dirt, cooking oil
-diet-controversial/not proven |
|
|
Term
| T or F: additional testing is usually done to diagnose acne |
|
Definition
| F-usually just physical exam |
|
|
Term
| T or F: nonpharmacological therapies are very efficacious in treating acne |
|
Definition
| F-none drastically effective |
|
|
Term
| T or F: tea tree oil is well tolerated and effective in treating acne |
|
Definition
| T, but it has a slower onset of action than other topical therapies |
|
|
Term
| T or F: dietary restriction is effective in managing acne. |
|
Definition
|
|
Term
| T or F: when starting a new treatment acne may worsen. |
|
Definition
| T: may worsen at first because it takes 8 weeks for a microcomedo to mature and treatments usually target new eruptions |
|
|
Term
| Dosage forms best for oily skin |
|
Definition
|
|
Term
| Dosage forms best for normal skin |
|
Definition
| gels, solutions, lotions, creams |
|
|
Term
| Dosage forms best for dry skin |
|
Definition
|
|
Term
| What type of dosage form is good for hair-bearing areas? |
|
Definition
|
|
Term
| What is the gold standard for mild to moderate acne? |
|
Definition
| Topical retinoids (helps minimize antibiotic use) |
|
|
Term
| What are some topical retinoids? |
|
Definition
1. Tretinoin (Atralin, Avita, Renova, Retin-A)
2. Adapalene (Differin)
3. Tazarotene (Tazorac) |
|
|
Term
| what is the benefit of a microsphere formulation in topical retinoids? |
|
Definition
| It is more tolerable, no increase in efficacy |
|
|
Term
| how long does it take to see an effect from topical retinoids? |
|
Definition
| ~3 months--stick with it! |
|
|
Term
| Safety concerns with topical retinoids |
|
Definition
1. photosensitivity
2. AVOID USE IN PREGNANCY-women use contraception
3. skin irritation, dryness, flaking (less with microsphere) |
|
|
Term
| What other drug are topical retinoids synergistic with? |
|
Definition
| topical antibiotics and benzoyl peroxide (with minimal to increased side effects) |
|
|
Term
| T or F: topical retinoids show no improvement in hyperpigmentation |
|
Definition
| F-accelerates resolution of post-inflammatory hyperpigmentation (good for control maybe not everyday) |
|
|
Term
| Counseling points of topical retinoids |
|
Definition
1. transient (2-4 week) worsening of symptoms--stick with it
2. Not for spot treatment-apply to entire face
3. skin should be DRY when applying
4. Use sunscreen (15 SPF)
5. Skin will become extremely sensitive to weather (wind, cold)
6. BE AWARE if pt taking other photosensitizing meds |
|
|
Term
| Which topical retinoid is the best? |
|
Definition
Mostly equally effective, but
adapalene (differin) best tolerated
tazarotene (Tazorac) may be more effective BUT most irritating |
|
|
Term
| what is the most cost effective therapy for acne? |
|
Definition
|
|
Term
| what is the most effective benzoyl peroxide: 2.5%, 5%, or 10%? |
|
Definition
efficacy in 2.5% and 5%
-minimal additional efficacy in 10% with increased ADRs |
|
|
Term
| T or F: Benzoyl peroxide has comparable efficacy to antibiotics |
|
Definition
T- and they dont cause resistance
ALSO decreases antibiotic resistance when used in combo with antibiotics |
|
|
Term
| Counseling points with Benzoyl peroxide |
|
Definition
1. was away drug after a few hours when first initiating therapy to help skin tolerate it
2. Dont use with topical tretinoin because BPO oxidizes T and makes it less effective--if use both: use BPO in the AM and Tretinon (Top Ret) at night
3. Apply to dry skin to minimize irritation |
|
|
Term
|
Definition
Azelaic acid 20% cream
aka Azelex |
|
|
Term
| Which is more effective Finacea or Tretinoin? |
|
Definition
| Tretinoin-finacea is less irritating though |
|
|
Term
| Which agent is REALLY good at decreasing hyperpigmentation? |
|
Definition
| Finacea (Azelaic Acid)--reports of being too effective |
|
|
Term
| Which is least irritating: Topical retinoids, Azelaic Acid Cream, BPO? |
|
Definition
|
|
Term
| T or F: Azelaic acid has NO likelihood of bacterial resistance, systemic ADR, or photosensitivity. |
|
Definition
|
|
Term
| Which is more effective: once or twice daily dosing of azelaic acid? |
|
Definition
| Both are equally effective |
|
|
Term
| For most topical acne medications how do you apply them? |
|
Definition
| to a dry clean face (1-2 times per day depending) |
|
|
Term
| T or F: using dapsone 5% gel (Azone) increases the risk of hemolytic anemia in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. |
|
Definition
False-there is an incresaed risk with the ORAL form
-so testing in unnecessary for gel use |
|
|
Term
| What topical acne agents cause photosensitivity? |
|
Definition
Topical retinoids
Benzoyl peroxide
dapsone 5% gel |
|
|
Term
| dapsone 5% gel - what patient population might need to be monitored |
|
Definition
| Anemics -questionable decrease in hemoglobin (not likely) |
|
|
Term
| If using dapsone and benzoyl peroxide together what could occur? |
|
Definition
temporary yellow/orange skin and hair discoloration
should space these products (one in am the other in pm) |
|
|
Term
| Greatest improvement is seen in __________ lesions with dapsone 5% gel use |
|
Definition
| inflammatory lesions (unknown MOA) |
|
|
Term
| Dapsone and sulfa allergy patients |
|
Definition
it is a sulfone derivative
so not contraindicated in patients with a sulfa allergy |
|
|
Term
| Dosing and administration of dapsone gel |
|
Definition
BID x 12 weeks
apply pea-sized amount to skin and gently rub in
patients may notice gritty appearance to particles after application |
|
|
Term
| Can you get salicylic toxicity with topical salicylic acid? |
|
Definition
| Yes, if repeated widespread use on highly permeable skin (inflamed/abraded) |
|
|
Term
| What class is salicylic acid? |
|
Definition
|
|
Term
| Why is salicylic acid considered second line? |
|
Definition
| not as potent comedolytic properties |
|
|
Term
| Dosing and Strength of Salicylic acid |
|
Definition
QD-TID
0.5%-2%
**Medication is only active as long as product is on the skin |
|
|
Term
| When using an antibiotic for acne what must be given with it? Why? |
|
Definition
| benzoyl peroxide, to prevent/decrease resistance |
|
|
Term
| Efficacy of topical (and oral) antibiotics is increased with what other agents? |
|
Definition
|
|
Term
| What agents come in combination with topical antibiotics? |
|
Definition
benzoyl peroxide (+ Clind or +Ery)
tretinoin (+Clind) |
|
|
Term
| What are bad or controversial agents for acne |
|
Definition
Sulfur and resorcinol
Aluminum chloride
topical zinc--ineffective alone
sulfacetamide (+sulfa allergy) |
|
|
Term
| First line agents in mild to moderate acne |
|
Definition
| topical retinoids and benzoyl peroxide |
|
|
Term
| second line agents in mild to moderate acne |
|
Definition
salicylic acid
dapsone
topical antibiotics
azelaic acid |
|
|
Term
| If taking two topical acne agents, is it okay for them to be applied at the same time? |
|
Definition
|
|
Term
| T or F: you can use macrolides for acne when pregnant? |
|
Definition
|
|
Term
| T or F: you can use tetracyclines for acne when pregnant? |
|
Definition
| F-fetal and infant toxicity |
|
|
Term
| T or F: you can use bactrim for acne when pregnant? |
|
Definition
| F-fetal and infant toxicity |
|
|
Term
| ADR and Contraindications of Tetracyclines |
|
Definition
tooth discoloration
enamel hypoplasia
reduced bone growth in children <8 y/o and pregnant women
fetal and infant toxicity
photosensitivity
GI issues |
|
|
Term
|
Definition
fetal and infant toxicity
bone marrow suppression
SJS
TEN (toxic epidermis necrolysis)
photosensitivity |
|
|
Term
|
Definition
bacterial resistance (worst with Erythromycin)
GI upset
pseudomembranous colitis
photosensitivity |
|
|
Term
| Which oral antibiotics use to treat acne can cause vaginal candidiasis? |
|
Definition
All of them
-tetracyclines
-macrolides
-bactrim |
|
|
Term
| T or F: by combining with topical retinoids, oral antibiotics have less resistance. |
|
Definition
| F- no less resistance, but will be able to decrease the duration of use because it will be more efficacious |
|
|
Term
| which oral antibiotic is most efficacious for moderate to severe acne? |
|
Definition
Minocycline
(then doxy and tetra) |
|
|
Term
| what are the possible agents that can be used for moderate to severe acne? |
|
Definition
PO Antibiotics (Tetracyclines, macrolides, TMP-SMX)
Isotretinoin (Clavaris)
OC (estrogen)
Spironolactone
Corticosteroids-limited/only short use |
|
|
Term
| How long should you use oral antibiotics for acne treatment? |
|
Definition
| 12-18 weeks (improvement generally within 6-10 weeks) |
|
|
Term
| which is the least photosenitizing tetracycline? |
|
Definition
minocycline
but can cause vertigo, skin discoloration, and lupus-like syndrome |
|
|
Term
| What oral antibiotic has the most reports of resistance? |
|
Definition
|
|
Term
| When should erythromycin (PO) be considered for acne treatment? |
|
Definition
| when patient cant use a tetracycline-->pregnant or <8 y/o |
|
|
Term
| What is the order in which oral antibiotics should be considered for use in treating acne? |
|
Definition
| minocycline > doxycycline > tetracycline > erythromycin/clindamycin > bactrim |
|
|
Term
| what is the cheapest option for moderate to severe acne treatment? |
|
Definition
|
|
Term
| what can patients do to help minimize occurrence of vaginal candidiasis |
|
Definition
|
|
Term
| which tetracyclines can be given with food and drink? |
|
Definition
minocycline and doxycycline --even though still will separate with divalent cations
can help to decrease GI ADRs |
|
|
Term
| What drug for acne treatment is pregnancy category X |
|
Definition
| isotretinoin (Amnesteem, Claravis) |
|
|
Term
| T or F: only women have to enroll in the iPledge program |
|
Definition
|
|
Term
|
Definition
teratogenic
suicidal ideation
pancreatitis
pseudotumor cerebri
photosensitivity
elevated cholesterol and TGs
bone abnormalities
Drying of oral, nasal, and ocular mucosa--VERY COMMON
MANY ADRs and are often DOSE RELATED |
|
|
Term
| Relative CI with isotretinoin |
|
Definition
hyperlipidemia
diabetes mellitus
severe osteoporosis
Pregnancy is absolute CI |
|
|
Term
| what is the most effective sebosuppressive agent? |
|
Definition
|
|
Term
| how many forms of contraception are required when taking isotretinoin? |
|
Definition
Two
there is a drug interaction with OCs making them less effective |
|
|
Term
| what should you do if someone gets pregnant when taking isotretinoin? |
|
Definition
| refer them to a reproductive toxicity specialist for evaluation |
|
|
Term
| how long is isotretinoin used? |
|
Definition
| up to 20 weeks, or d/c sooner if acne resolution is 70% or greater |
|
|
Term
| T or F: any prescriber can write a prescription for isotretinoin. |
|
Definition
| F-the prescriber must be registered with the iPledge program |
|
|
Term
|
Definition
|
|
Term
| psoriasis is most prevalent in what racial group |
|
Definition
|
|
Term
| what immune cell plays a key role in psoriasis |
|
Definition
T-lymphocytes
1. hyperproliferation and abnormal differentiation of the epidermis
2. immune mediated mechanisms |
|
|
Term
| Important cytokines in psoriasis? |
|
Definition
IFN: alpha, beta, gamma
IL-2
TNF-alpha
IL-8 |
|
|
Term
|
Definition
cold
stress
obesity
alcohol and smoking
infections
sits of injury (chronic rubbing, mechanical pressure)--KOEBNER Phenomenon
Medications: lithium carbonate, beta blockers, antimalarial, NSAIDs, ACE inihibtors, Tetracyclines, interferons |
|
|
Term
|
Definition
| punctuate bleeding caused by removal of a 'scale' of psoriasis |
|
|
Term
|
Definition
most common (80-90%)
extensor surfaces (elbows and knees) + scalp, trunk, butt, limbs |
|
|
Term
|
Definition
"Dew-drop-like"
kids and young adults
on trunk and proximal extremities
how plaque psoriasis initially presents
strong association with group A beta-hemolytic strep infections |
|
|
Term
|
Definition
collection of neutrophils in stratum corneum
localized (more common and less severe) or generalized
usually on palms and soles of feet |
|
|
Term
|
Definition
intertriginous area (skin folds)
moisture-minimal scales
Frequently misdiagnosed as a fungal infection |
|
|
Term
|
Definition
rare and life threatening
high risk of infections, sepsis, electrolyte imbalances
generalized erythema
Inpatient management |
|
|
Term
|
Definition
few to multiple tiny pits scattered over nail plate
yellow/tan/brown color (oil drop sign)
many with psoriatic arthritis
confused often with onychomycosis (check with fungal scraping |
|
|
Term
| T or F: psoriasis patients have a higher incidence of MI |
|
Definition
|
|
Term
Classification of Psoriasis
Mild, Moderate, Severe |
|
Definition
Mild: <5% BSA
Moderate: 5-10%
Severe: >10% OR involvement of hands, feet, genitals, facial region OR major interference in daily life |
|
|
Term
|
Definition
psoriasis area and severity index
measure of overall severity and coverage |
|
|
Term
| Goals of psoriasis therapy |
|
Definition
PASI 50= 50% decrease in severity from baseline-clinically relevant point when assessing
PASI 75-for biologics |
|
|
Term
| First line for mild to moderate psoriasis? |
|
Definition
| topical therapy or targeted phototherapy |
|
|
Term
|
Definition
| used when dosing for topical (from last joint to tip of finger-can cover ~2% BSA) |
|
|
Term
| T or F: emollients can be used to treat psoriasis |
|
Definition
F-they can be used as ADJUNCTS to keep skin soft and minimize itching, tenderness, keep hydrated, prevent irritation (prevent Koebnerization)
use after shower
MOST effective: ointments/thick creams |
|
|
Term
| T of F: patients can use short course steroid when starting isotretinoin |
|
Definition
| T (like with topical retinoids) |
|
|
Term
| What must be monitored with isotretinoin? |
|
Definition
1. ADR: neurologic, ophthalmologic, GI, metabolic (monthly)
2. LFTs and Lipids (at weeks 0, 4, and 8)
3. Screen for psychiatric disorders and depression before and during treatment
4. CPK (creatinine phosphokinase), glucose, CBC with diff
5. pregnancy tests (monthly) |
|
|
Term
| Must fill isotretinoin Rx by when? |
|
Definition
| 7 days after it was written. |
|
|
Term
| T or F: topical retinoids cause more sunburn risk than systemic retinoids? |
|
Definition
| F-equal chance of sunburn |
|
|
Term
| How many refills can be on an isotretinoin Rx? |
|
Definition
|
|
Term
| What drugs should you not use when on isotretinoin? |
|
Definition
Tetracylcines and tigecycline--increases chances of pseudotumor cerebri
increased Cl of Carbamazepine
decreased effectiveness of OC (so need 2 forms) |
|
|
Term
| How long before and after using isotretinoin must patients remain on TWO forms of birth control? |
|
Definition
|
|
Term
| T or F: any type of OC can decrease acne |
|
Definition
F-must be low androgen
use 1st or 3rd generation progestins (nogestimate, norethindrone acetate, desogestrel)
drosperinone has anti-androgenic activity
low to moderate dose of ethinyl estradiol (20-35 mcg) is target dose |
|
|
Term
| How long does it take to see a significant effect with OC for acne treatment? |
|
Definition
|
|
Term
| Who is OC for acne a good choice for? |
|
Definition
| women with excess androgen production, severe seborrhea, androgenic alopecia, late-onset acne |
|
|
Term
|
Definition
may take upto 3-6 weeks
anti-androgenic (blocks androgen receptor)
-gynecomastia in men and menstrual irregularity/breast tenderness/HA in women
Reserved usually for patients with PCOS
monitor potassium and BP |
|
|
Term
| T or F: Oral corticosteroids can be used to treat acne |
|
Definition
T, but there is limited effectiveness data
may be helpful for severe inflammatory acne but only use very short bursts of high dose
Good choice for adrenal hyperandrogenism (low doses)
helpful in reducing flare ups with retinoids |
|
|
Term
| T or F: topical therapies must have failed in combination for the patient to use systemic acne treatment. |
|
Definition
T
exception is OC-can be used in women regardless of severity (especially if for other purposes too) |
|
|
Term
| What should you look at during a skin assessment? |
|
Definition
1. location
2. size
3. distribution
4. arrangement
5. lesion type (ex: macular)
6. shape
7. margination
8. color of skin and lesion |
|
|
Term
|
Definition
| Cutaneous Adverse Drug Reaction |
|
|
Term
| what must be excluded when determining if a drug caused a cutaneous reaction? |
|
Definition
| a viral rash--commonly mistaken for drug allergies in children |
|
|
Term
| What do you give to treat a cutaneous adverse drug reaction? |
|
Definition
|
|
Term
| T or F: Warfarin necrosis occurs in people who are allergic to warfarin |
|
Definition
not an allergy
usually occurs if load on warfarin and there is not bridge therapy with heparin/lovenox |
|
|
Term
| First line for mild to moderate psoriasis? |
|
Definition
|
|
Term
| Which is a more potent steroid: Class 1 or Class 7 |
|
Definition
|
|
Term
| ADRs of topical steroid use for psoriasis |
|
Definition
skin atrophy (esp if after skin returned to normal)
exacerbation of infections (dermatologic)
rebound psoriasis symptoms with abrupt stop of steroid
hyperesthesia-increased sensitivity to pain
telangiectasias and purpura (b/c affects blood vessels) |
|
|
Term
| Can you use topical steroids on intertriginous areas? |
|
Definition
| NOT the ultra potent steroids or ointments |
|
|
Term
| If vitamin D analogs and topical corticosteroids are equally effective, why are corticosteroids usually first line? |
|
Definition
less skin irritation
+ultra potent are actually more efficacious |
|
|
Term
| how long can you use a ultra potent corticosteroid? |
|
Definition
|
|
Term
| Can you use occlusive therapies with corticosteroids |
|
Definition
| Yes-to help boost efficacy |
|
|
Term
| Potential ADRs with topical vitamin D analogs |
|
Definition
1. hypercalcemia
2. photosensitivity
3. skin irritation-MAJOR effect |
|
|
Term
| What vitamin D analog is associated with less skin irritation? |
|
Definition
Calcitriol (compared to calcipotriene)
so better for sensitive areas (skin folds) |
|
|
Term
| what is the onset of action for a topical vitamin D analog? |
|
Definition
12 weeks
tazarotene (topical retinoid) is also 12 weeks, but corticosteroids are 8 weeks |
|
|
Term
| Which has a longer disease free period: topical steroid or vitamin D analog? |
|
Definition
| Vitamin D analog (but takes longer to see an effect) |
|
|
Term
| Vitamin D analog vs Topical steroid |
|
Definition
Vit D Analog:
1. longer onset-take 3 months
2. longer duration
3. more irritating
4. less toxic |
|
|
Term
| Can you use topical steroids and vitamin D analogs together? |
|
Definition
yes-to increase efficacy and decrease risk of atrophy
Combo product (taclonex) available-$$$ |
|
|
Term
| T or F: topical retinoids are contraindicated in pregnancy |
|
Definition
|
|
Term
| Which topical retinoid can be used for psoriasis |
|
Definition
Tazarotene
recommended to be used with topical steroid to increase efficacy and tolerability |
|
|
Term
| What are second line agents of mild to moderate psoriasis? |
|
Definition
coal tar
salicylic acid
calcineurin inhibitors (tacrolimus, pimecrolimus)
anthralin |
|
|
Term
|
Definition
keratolytic
ADR: photosensitivity, greasy, stains, odor
Most useful as adjunct to topical steroids
NOT for use in acute exacerbations (will worsen psoriasis)--use after plaque formation
Cheap |
|
|
Term
| names of Calcineurin inhibitors |
|
Definition
| tacrolimus and pimecrolimus |
|
|
Term
|
Definition
MOA: inhibits T cell activation and release of inflammatory cytokines
Do NOT use in patients under 2 y/o or Immunocompromised
increased risk for lymphoma and skin cancer
BID for <6 weeks (not on broken skin or infections)
Well tolerated
First line option in intertriginous, facial, genital areas or inverse psoriasis
-only marginally effective in plaque psoriasis |
|
|
Term
| Salicylic acid in psoriasis |
|
Definition
Keratolytic (like coal tar)--best for thick scales
avoid use in big areas to prevent salicylism (N/V, tinnitus, hyperventilation)
use in addition to topical steroids or immunosuppressive agents for additive effect
-enhances penetration of other agents
-do NOT combo with phototherapy (decreased efficacy) |
|
|
Term
|
Definition
Dritho-Scalp, Psoriatec
apply at increasing contact intervals starting at 1 minute and increasing as tolerated
STAINS everything!!!
-takes 1-2 weeks to disappear after stopping therapy |
|
|
Term
| What is the next treatment option if topical therapy for psoriasis fails? |
|
Definition
| Phototherapy (PUVA) in Dr. office |
|
|
Term
| T or F: systemic therapy is usually used in combinations for psoriasis because monotherapy does not provide optimal outcomes |
|
Definition
T-allows for lower doses=less ADRs
can use different treatment plans
rotational-use different agents with different MOAs back to back
Sequential: rapid clearance of psoriasis with aggressive therapy then switch to less potent therapy for maintenance |
|
|
Term
| What is the gold standard for systemic psoriasis therapy? |
|
Definition
|
|
Term
| T or F: methotrexate is CI in pregnancy? |
|
Definition
T-teratogenic
d/c 3 months before conception |
|
|
Term
| MTX can increase the risk of what (multiple)? |
|
Definition
infection
cancer/malignancy
hepatotoxicity |
|
|
Term
| MTX should NOT be used in patients with... |
|
Definition
CrCl < 30 mL/min
Platelet count <50,000/mm^3
WBC count <3000/mm^3
LFTs > 2x Upper limit of normal (ULN)
**WBC >10,000-12,000 indicates infection-so dont use either |
|
|
Term
|
Definition
GI issues
pulmonary fibrosis
hepatotoxicity (increased LFTs)
stomatitis, mucosal ulceration
bone marrow suppression and infections |
|
|
Term
| What is the most cost effective systemic drug therapy for psoriasis? |
|
Definition
|
|
Term
|
Definition
initiate at 7.5-15 mg/week and increase incrementally by 2.5 mg Q2-4weeks until response is evident
Max dose ~25 mg/week
IV, SQ, IM
OKAY long term |
|
|
Term
| What must be given with MTX |
|
Definition
Folic acid 1-5 mg per day
protects against stomatitis, nausea, macrolytic anemia (not pulmonary tox)
NOTE: use of other meds that interfere with folic acid can increase MTX toxicity (ex: sulfa) |
|
|
Term
| Risk factors for hepatotoxicity from MTX |
|
Definition
Hx of moderate EtOH consumption
Persistently elevated LFTs
Hx of liver disease (Hep B or C)
Family Hx of inherited liver disease (hemochromatosis)
Hx of sig exposure to other hepatotoxic drugs and chemicals
diabetes (especially if UNCONTROLLED)
obesity (fatty liver disease)
hyperlipidemia
No folate supplementation |
|
|
Term
| Monitoring for patients on MTX without risk factors for hepatotoxicity |
|
Definition
draw LFTs Q1-3 Months
Perform liver biopsy if:
-if 5+/9 LFTs are increased over 12 months or inf Alb decreased
-cumulative dose of 3.5-4 g of MTX given (or switch to another agent) |
|
|
Term
| Monitoring for patients on MTX with risk factors for hepatotoxicity |
|
Definition
use other agent if not CI
if decide to use MTX anyways-perform liver biopsy within 2-6 months of starting
repeat liver biopsy every 1-1.5 g of cumulative MTX (~2-6 months) |
|
|
Term
| Cyclosporine is toxic to what? |
|
Definition
kidney-nephrotoxic
keep dose under 5 mg/kg/day
-monitor Serum Cr regularly |
|
|
Term
| what psoriasis agents can you NOT use with phototherapy |
|
Definition
salicylic acid
cyclosporine |
|
|
Term
| what psoriasis agent has major interactions with sulfa drugs? |
|
Definition
|
|
Term
| how is cyclosporine usually used with psoriasis? |
|
Definition
on short term to gain quick control
bridge therapy during the beginning (other meds take longer to have effect)
-cyclosporine's onset is 4-8 weeks |
|
|
Term
| What are some major issues with cyclosporine use? |
|
Definition
HTN-monitor BP
Infection-Incereased LFTs
Cancers (immunosuppressive)
nephrotoxic (dont use in patients with renal insufficiency)
hypertriglyceridemia (TG>750)
hypoMg
hyperK
gingival hyperplasia
flu-like sx
MANY DRUG INTERACTIONS |
|
|
Term
| what other psoriasis agents can you NOT use with cyclosporine |
|
Definition
Coal tar
other immunosuppressives
PUVA |
|
|
Term
| Who should not take cyclosporine? |
|
Definition
renal insufficiency
poorly controlled HTN
malignancy
major infection
poorly controlled diabetes |
|
|
Term
| How long can cyclosporine be used continuously? |
|
Definition
1 year
should taper up and once gain control, taper to lower dose for maintenance |
|
|
Term
| Acitretin brand name and class |
|
Definition
|
|
Term
| how many forms of birth control and for how long with acitretin |
|
Definition
category X-with toxic metabolite staying in system long time
start 2 forms of BC 1 month before therapy and must continued both forms for 3 years after stopping drug
--female patients should not have EtOH during and 2 months post-therapy because it increases toxic metabolite formation
-CanNOT donate blood for 3 years post-thearpy |
|
|
Term
| Issues/ADRs with Acitretin |
|
Definition
hypervitaminosis A (drying and conjunctivitis)
hepatotoxicity
skeletal changes-dont use in kids
Elevated TGs (treat with fibrates)
"unstable psoriasis"-like rxn ("retinoid dermatitis")
teratogenic |
|
|
Term
| which systemic psoriasis treatment is most effective: MTX, cyclosporine, Acitretin? |
|
Definition
Cyclosporine > MTX > Acitretin (used more of an adjunct)
should titrate all when first starting |
|
|
Term
| What is an advantage of acitretin over cyclosporine and MTX? |
|
Definition
it is not immunosuppressive (so can use in AIDS, cancer patients)
and little cumulative toxicity
can also use in phototherapy |
|
|
Term
|
Definition
| start with 25 mg QOD and increase to 50 mg QD WITH main meal (increases absorption) |
|
|
Term
| What must be monitored with acitretin therapy |
|
Definition
Lipid profile (at baseline, at 1-2 weeks, then intervals of 4-8 weeks)
LFTs (baseline and then until stable)
Glucose in diabetes
Bone abnormalities (with long-term use) |
|
|
Term
| Second line systemic agents for psoriasis |
|
Definition
azathioprine
hydroxyurea
leflunomide
mycophenolate mofetil
sulfsalazine
tacrolimus
6-thioguanine |
|
|
Term
| Black box warning on ALL TNF-alpha blockers |
|
Definition
| increased risk of malignancies and infections, activation of latent infections (TB, RA) |
|
|
Term
| T-cell inhibitor used for psoriasis |
|
Definition
alefacept (Amevive)
IM ONLY--given in dr office
$$$$$$ |
|
|
Term
|
Definition
elevated LFTs (hepatotoxicity)
hypersensitivity rxns
infections, latent infection reactivation (TB test annually)
flu-like sx
local inj site rxn
lymphopenia |
|
|
Term
| what is considered the least effective biologic |
|
Definition
alefacept
HOWEVER for patients it does work well in there is a long remission associated with it |
|
|
Term
|
Definition
IM weekly for 12 weeks
monitor CD4s
if worked well then can repeat after 12 weeks if the patient has good CD4 counts |
|
|
Term
| pregnancy category of alefacept |
|
Definition
|
|
Term
| interleukin-12/23 inhibitor |
|
Definition
|
|
Term
|
Definition
increased body weight = decreased efficacy (diff doses above and below 100 kg)
SQ-self administration (week 0, 4, then q12 weeks) |
|
|
Term
| which biologic has the best and fastest treatment of psoriasis? |
|
Definition
|
|
Term
| safety issues with ustekinumab |
|
Definition
rare-adverse CV events
increased risk of infection/malignancy
inj site rxn |
|
|
Term
| Testing and monitoring for ustekinumab |
|
Definition
do a TB (PPD) test before starting
all immunization should be UTD
-while on drug dont give live vaccines
-do NOT give BCG (TB) vaccine 1 year before/after and during therapy
monitor CBC, LFTs, and hepatitis profiles + yearly PPD |
|
|
Term
| what are the TNF-alpha blockers? |
|
Definition
etanercept (Enbrel)
infliximab (Remicade)
Adalimumab (Humira)
golimumab (Simponi) |
|
|
Term
| T or F: all TNF-alpha blockers are considered equally effective |
|
Definition
T-for PsA,
but for cutaneous psoriasis according to phase 3 trials infliximab > adalimumab > etanercept >golimumab |
|
|
Term
| What disease condition are TNF-alpha blockers linked to specifically |
|
Definition
new or worsening heart failure
-dont use in class III CHF
-for Class I or II do a ECHO, if EF<50% avoid TNF-alpha blockers
***Also should not be used in patients with demyelinating diseases (MS) or in patients who are first degree relatives of those with MS |
|
|
Term
| all biologics are what pregnancy category |
|
Definition
|
|
Term
| what is the drug of choice of PsA |
|
Definition
| TNF-alpha blockers-all shown to be equally effective |
|
|
Term
| why does efficacy tend to decrease for TNF-alpha blockers over time |
|
Definition
development of antibodies
add MTX, phototherapy, or switch to diff biologic |
|
|
Term
| What are TNF-alpha blockers combined with to lessen the likelihood of developing resistance to therapy |
|
Definition
|
|
Term
| What must be done before starting TNF-alpha blockers and what must be monitored |
|
Definition
Immunizations UTD
PPD performed (+yearly)
No use of live vaccines during therapy
-inactive or recombinant vaccines may be considered although the immune response of these vaccines could be compromised
monitor CBC and LFTs |
|
|
Term
|
Definition
|
|
Term
|
Definition
only humanized TNF-alpha blocker (minimizes immunogenicity)
ONLY one studied for psoriasis in kids-but not an FDA indication yet
SQ |
|
|
Term
|
Definition
|
|
Term
|
Definition
TNF-alpha blocker
Fastest acting
IV---$$$$
no need to adjust in renal or hepatic impairment |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
Newest TNF-alpha blocker
indicated for PsA but NOT cutaneous psoriasis (b/c didnt study in these patients) |
|
|
Term
| Agents good for facial or intertriginous areas for psoriasis |
|
Definition
Class VI or VII topical steroids-sparingly
Topical tacrolimus/pimecrolimus (slower)
Calcitriol
Locaclized phototherapy |
|
|
Term
| Agents good for Guttate psoriasis |
|
Definition
| phototherapy (PUVA) +/- medium potency topical steroids |
|
|
Term
| agents good for localized pustular psoriasis |
|
Definition
hard to treat
systemic retinoids first line
topical potent steroids or PUVA |
|
|
Term
| Agents good for erythrodermic psoriasis |
|
Definition
topical potent steroids
oral retinoid
MTX
cyclosporine
biologics with rapid onset-infliximab |
|
|
Term
| Agents for Nail psoriasis |
|
Definition
VERY hard to treat
potent class I or II topical steroids with calcipotriene or intralesional steroids
systemic therapy, phototherapy, and biologics are more effective than topical
8-12 months to generate new nail-slow |
|
|
Term
| mild psoriatic arthritis treatment |
|
Definition
NSAIDs
if no response after 2-3 months-MTX |
|
|
Term
| moderate to severe psoriatic arthritis treatment |
|
Definition
1st line: MTX +/-TNF-alpha blocker (Golimumab)
2nd line: ustekinumab +/- MTX |
|
|
Term
| which is most efficacious: ustekinumab or TNF-alpha blockers |
|
Definition
| TNF-alpha blockers are more effective for psoriasis |
|
|
Term
| MOA of intranasal steroids |
|
Definition
binds to glucocorticoid receptors in inflammed cells
1. decreases mediator release
2. decreases neutrophil chemotaxis
3. decreases intracellular edema (causes mild vasoconstriction)
4. inhibits mast cell mediated late-phase rxn |
|
|
Term
| What is the best agent of perennial rhinitis? |
|
Definition
intranasal steroids
especially people with predominate nasal congestion |
|
|
Term
| T or F: all intranasal steroids are equally efficacious |
|
Definition
| T, but bioavailability decreases/less ADRs and longer half-life from 1st to 3rd generation |
|
|
Term
| 3rd generation intranasal steroids |
|
Definition
Fluticasone (Flonase, Veramyst)
Mometasone (Nasonex)
2 sprays each nostril daily |
|
|
Term
| T of F: intranasal steroids can cause stunted growth in kids |
|
Definition
|
|
Term
| T or F: intranasal steroids can be additive to other steroid preparations |
|
Definition
|
|
Term
| Dosing of Intranasal steroid |
|
Definition
usually prefer QD dosing
start with max dose, taper down to least effective
-peak response in 2-3 weeks
-can use decongestant first to open up nasal passages then steroid
can cause local Candida infections (rare) |
|
|
Term
| When should antihistamines be used? |
|
Definition
| 1-2 hours before exposure (better at PREVENTING rather than reversing actions of histamine) |
|
|
Term
| First generation antihistamines |
|
Definition
diphenhydramine
chlorpheniramine
hydroxyzine (Rx)
brompheniramine |
|
|
Term
| Most significant ADR with 1st generation antihistamines |
|
Definition
Sedation
-paradoxical in kids
+anticholinergic in elderly |
|
|
Term
| Who should be cautious when using first generation antihistamines |
|
Definition
patients with incresaed IOP
hyperthyroidism
CV disease |
|
|
Term
| Second generation compared with first generation antihistamines |
|
Definition
peripherally selective (vs non-selective)
little anticholinergic effects
Non/less sedating (cetirizine somewhat sedating) |
|
|
Term
| 3rd generation antihistamines |
|
Definition
fexofenadine
desloratidine (clarinex)
levocetirizine (xyzal) |
|
|
Term
|
Definition
olopatadine (pataday, patanol)
-patanase (nasal)
azelastine (optivar)
-astelin,astepro (nasal) |
|
|
Term
| 2nd generation antihistamines are a better choice for: |
|
Definition
children
elderly
patients concerned about sedation
patients with NO cost concerns |
|
|
Term
|
Definition
-vasoconstrition
-little/no systemic absorption
-good for PRN (NOT routine) use
-can cause rhinitis medicamentosa (so dont use over 5 days)
Phenylephrine HCl
Napazoline, Terahydrozoline
Oxymetazoline (Afrin), Xylometazoline |
|
|
Term
| T or F rhinitis medicamentosa is a concern for all decongestants. |
|
Definition
| F-not with systemic therapy |
|
|
Term
| ADRs of systemic decongestants |
|
Definition
elevated BP
CNS stimulation
tremor
nervousness |
|
|
Term
| systemic decongestants are contraindiciated in: |
|
Definition
people taking MAOIs and Ergot derivatives
-can cause HTNive crisis |
|
|
Term
|
Definition
Mast cell stabilizer
MOA: inhibits allergin triggered mast cell degranulation (release of mediators including histamine)
NO direct antihistamine, anticholinergic, or anti-inflammatory properties
good for immediate and late phase rxns
-starts working within 30 min (must coat entire nasal passage)
QID dosing |
|
|
Term
|
Definition
Singulair
MOA: inhibits inflammatory mediator release from mast cells
more effective for sneezing and itching than for congestion
less effective than nasal steroids
better in combo with 2nd gen antihistamine than any agent alone
usually used in patients who have epitaxis or intolerance to nasal steroids or azelastine or nasal polyps |
|
|
Term
|
Definition
Atrovent
anticholinergic NS--best for rhinorrhea
caution in patients with glaucoma and BPH
ADRs: HA, epistaxis, and nasal dryness |
|
|
Term
| For children over 3, what is the first recommendation for allergic rhinitis? |
|
Definition
intranasal steroid
Fluticasone furoate (veramyst) okay in kids 2+ but propionate must ben 4 y/o |
|
|
Term
| What does a typical adult toxic ingestion look like |
|
Definition
multiple, intentional, unknown, delayed recognition
OD or suicide |
|
|
Term
| what does a typical child toxic ingestion look like |
|
Definition
| single agent, known, promptly recognized |
|
|
Term
| what does a typical elderly toxic ingestion look like |
|
Definition
| chronic overmedication (polypharm) |
|
|
Term
| most commonly ingested products in kids |
|
Definition
1. plants
2. cleaning supplies
3. cough/cold products
4. perfume/cologne
PRETTY AND SMELL NICE |
|
|
Term
| what are the first 3 questions you should ask when someone presents with toxic ingestion |
|
Definition
Subastance?
How much?
Route? |
|
|
Term
| You should always assume ________ with a toxic ingestion |
|
Definition
|
|
Term
| Mydriasis is a indication of what type of toxicity |
|
Definition
| sympathomimetic, anti-cholinergic, adrenergic |
|
|
Term
| what is the antidote to rhabdomylysis? |
|
Definition
IV Bicarb-prevents ppt of protein
-indicated by increased CPK (creatine phosphokinase) |
|
|
Term
| what should NEVER be given for a TCA OD |
|
Definition
| BZD antagonist - flumazenil (sp?) |
|
|
Term
| Why is thiamine given with EtOH OD |
|
Definition
| if give sugar (in D5W) and thiamine deficient then can cause encephalopathy (wernickes) |
|
|
Term
|
Definition
has 2 compounds (emetine and cephalin)
both are local GI irritants and work to stimulate the CTZ
*only good 60-90 min post ingestion |
|
|
Term
| Contraindications for syrup of ipecac |
|
Definition
Absolute:
1. unconscious
2. kids < 6 months
3. seizing
4. corrosive substances (liquid plumber)
Relative:
1. seizure inducing drugs
2. rapid coma inducing drugs
3. pregnancy (can cut off blood to baby because blood being sent to GI)
4. hydrocarbons (grease)-can get in to lungs and coat them and aspirate
5. severe bradycardia (to throw up will be bradycardic before the event) |
|
|
Term
| what should always follow syrup of ipecac |
|
Definition
| lots of water--need vehicle |
|
|
Term
|
Definition
| the event itself is stressful, but beforehand it causes bradycardia and other SNS depression because of cholinergic surge needed |
|
|
Term
| what should follow gastric lavage |
|
Definition
| activated charcoal after pumping up what was pumped in |
|
|
Term
| Why should you avoid using water for gastric lavage in children |
|
Definition
| to avoid hyponatremia-use saline |
|
|
Term
| what is an absolute contraindication to gastric lavage |
|
Definition
unprotected airway
relative CI: hydrocarbons and corrosive substances |
|
|
Term
| what are the most common complications of gastric lavage |
|
Definition
| aspiration pneumonia and bradycardia |
|
|
Term
| Why cant you give activated charcoal to someone with an ileus? |
|
Definition
can cause toxic megacolon-->perforated-->all colon contents spill into body
check for bowel sounds first |
|
|
Term
| What is activated charcoal not effective for? |
|
Definition
Alcohols
Heavy metals
Hydrocarbons
Cyanide |
|
|
Term
| If giving activated charcoal and ipecac what should you use first |
|
Definition
| ipecac because charcoal will adsorb to ipecac too |
|
|
Term
| what is the most common ADR with activated charcoal |
|
Definition
constipation-so it is formulated with sorbitol
**Turns stool black |
|
|
Term
| what is usually used if a kid swallows a battery |
|
Definition
|
|
Term
| what are the two types of cathartics? |
|
Definition
saline (Mg) and saccharides (sorbitol)
PEG most common |
|
|
Term
| what are carthartics contraindicated for |
|
Definition
|
|
Term
| When should a cathartic be used for toxic ingestion? |
|
Definition
| when the substance is post-pyloric |
|
|
Term
| peritoneal dialysis is good at removing what? |
|
Definition
Alcohol-but almost never used for toxic ingestion treatment
for renal failure
over 24 hours
toxins diffuse across mesenteric capillaries and peritoneal membrane into dialysate |
|
|
Term
| what is the advantage of hemofiltration over hemodialysis |
|
Definition
toxins with larger molecular weights (aminoglycosides, metals) can be removed
highly protein bound toxins are also more rapidly removed |
|
|
Term
|
Definition
|
|
Term
| antidote for acute dystonic rxns to anti-psychotics |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| N-Acetylcysteine (Mucomyst) |
|
|
Term
| antidote to beta blockers |
|
Definition
|
|
Term
|
Definition
|
|
Term
| antidote to organophosphates |
|
Definition
|
|
Term
|
Definition
|
|
Term
| antidote to methanol/treatment of OD |
|
Definition
ethanol
Folinic acid (leukovorin) will enhance conversion of formic acid to CO2 and water
4-MP (Fomepizole) can block alcohol dehydrogenase without causing intox BUT $$$$$
HD for more severe cases-good at removing alcohol
avoid activated charcoal and ipecac |
|
|
Term
| antidote to ethylene glycol/ Treatment of OD |
|
Definition
ethanol--IMMED
thaimine, pyridoxine, and folate to increase conversion to water and CO2
Gastric lavage in first 4 hours
treat sx supportively
4-MP (Fomepizole) is an alternative to EtOH |
|
|
Term
| antidote to isoniazid (TB drug) |
|
Definition
|
|
Term
| antidote to alpha-1 antagonist (decongestant) |
|
Definition
|
|
Term
| What are the three parts of lethal injection |
|
Definition
1. Anesthetic-Thiopental or Pentabarbital (Quick and short acting)
2. NMJ Blocker: paricuronium-paralyzes all skeletal muscle (diaphragm)
3. KCl-very toxic stops heart (asystole) |
|
|
Term
| If suspect CO poisoning what is the first thing to do? |
|
Definition
| give supp 100% oxygen and if needed place in hyperbaric chamber |
|
|
Term
| why does CO poisoning cause metabolic acidosis |
|
Definition
| anaerobic respiration-->lactic ACID builds up = decreased pH |
|
|
Term
| T or F: cocaine is lethal by all routes of administration |
|
Definition
|
|
Term
| What are common major issues with cocaine OD |
|
Definition
CVAs
Intracerebral and subarachnoid hemorrhages
seizures
rhabdo
chest pain associated with MI |
|
|
Term
|
Definition
NE--last resort to raise BP
"leaves you dead" |
|
|
Term
| What is given for seizures from toxic ODs? |
|
Definition
1. diazepam to stop seizure
2. phenytoin to prevent another
3. do a CT skan to check for cerebral hemorrhage (ex: cocaine) |
|
|
Term
| T or F: with cocaine OD you should assume they have intracranial hemorrhage until proven otherwise |
|
Definition
|
|
Term
| what should be given for sinus tachycardia (ex: with cocaine OD) |
|
Definition
| diazepam (it is from the anxiety) |
|
|
Term
| what should be given for HTN associated with cocaine OD? |
|
Definition
labetalol (not a pure beta-blocker)
blocks beta-1, beta-2, and alpha-1 (so antagonizes alpha-1 which causes vasoconstriction--so lower BP this way) |
|
|
Term
| what are two other drugs that should be treated like TCAs in OD? |
|
Definition
carbamazepine and cyclobenzaprine
because structurally similar |
|
|
Term
| Clinical presentation of TCA OD |
|
Definition
T: tonic-clonic seizures
C: cardiac arrhythmias
A: anti-cholinergic (sedation, tachycardia, dry) |
|
|
Term
| How does Bicarbonate work in TCA OD |
|
Definition
1. increased plasma protein binding of TCAs
2. Stabilization of fast Na+ channels (protect agst arrhythmia)
within seconds of starting bicarb drip QRS returns to normal |
|
|
Term
| What is the first thing you should think of when you see QRS prolongation? |
|
Definition
|
|
Term
| Classic Triad of opioid intoxication |
|
Definition
1. Miosis
2. respiratory depression
3. depressed level of consiousness |
|
|
Term
| Can you give naloxone down ET tube? |
|
Definition
|
|
Term
| How is naloxone usually given in opioid OD? |
|
Definition
| 2 mg (starting dose) and repeated dosing or continuous infusion may be necessary since all opioids have longer half-life than naloxone |
|
|
Term
| For what agents might you have to give as much as 10-20 mg of naloxone to reverse toxicity? |
|
Definition
pentazocine
codeine
methadone |
|
|
Term
| drugs you can give down ET tube: |
|
Definition
NAVEL
naloxone
atropine
valium
epi
lidocaine |
|
|
Term
| Presentation of beta-blocker toxicity |
|
Definition
bradycardia
depression of inotropy (contractility)-->focus of treatment |
|
|
Term
| Treatment of beta-blocker toxicity |
|
Definition
glucagon to increase inotropy (contraction)--does not compete with beta-receptors (circumvents pathway)
-AND helps manage hyperglycemia
-IV and may follow with infusion
Atropine may be needed for pacing |
|
|
Term
| What is the major risk of hydrocarbon ingestion |
|
Definition
aspiration (resulting in pneumonitis)
with large ingestion--cardiac, GI, CNS tox |
|
|
Term
|
Definition
1 (greases) and 2 (kerosene and gasoline) are most commonly ingested
3 (benzene) and 4 (chlorinated hydrocarbons) are most commonly seen in factory workers |
|
|
Term
| What should you do with a hydrocarbon toxic ingestion? |
|
Definition
| monitor unless coughing/spitting up |
|
|
Term
| T or F: OP toxicity is species specific. |
|
Definition
| F-it is NOT species specific (remember the sheep on island) |
|
|
Term
| What are the 3 drugs soldiers carry with them? |
|
Definition
1. atropine
2. 2-PAM
3. Morphine |
|
|
Term
| What do some organophosphates smell like? |
|
Definition
|
|
Term
| Who do you mostly see OP poisoning in? |
|
Definition
| victims of war and farmers |
|
|
Term
| Symptoms of OP poisoning? |
|
Definition
1. parasympathetic (SLUDGE)
2. Nicotinic (muscle weakness, tetany of diaphragm)
3. CNS (confusion, respiratory depression) |
|
|
Term
|
Definition
1. remove clothing/decontaminate skin (so no more exposure)
2. atropine-reverse muscarinic and CNS effects), use until dry mouth
3. 2-PAM-use within 24 hours |
|
|
Term
| Are barbiturates acidic or basic |
|
Definition
acidic
can alkalinize urine (only with PB) with bicarb |
|
|
Term
| Presentation and treatment of barbiturate OD |
|
Definition
Respiratory depression, hypotension, decreased level of consiousness (may appear dead)
Tx: support (intubation) and GI elimination (forced diuresis and activated charcoal) |
|
|
Term
| T or F: death from BZD OD is common |
|
Definition
F-Rare unless combined with EtOH/other CNS depressants
dont have narrow TW |
|
|
Term
| Why should you not induce emesis in Benzo OD (especially if known to be short acting) |
|
Definition
can progress to unconsciousness very quickly (no gag reflex)
midazolam, traizolam, temapzepam)
use activated charcoal instead |
|
|
Term
| What is the antidote for BZD OD |
|
Definition
| flumazenil (only if PURE BZD OD) |
|
|
Term
| What are the two most toxic alcohols? |
|
Definition
| methanol and ethylene glycol |
|
|
Term
| What is the metabolic sequence of methanol? |
|
Definition
| Methanol- (alcohol dehydrogenase) -> formaldehyde -(aldehyde dehydrogenase) -> formic acid (which is TOXIC) - (folate dep mechanism)-> CO2 and H2O |
|
|
Term
| What does methanol toxicity cause? |
|
Definition
blindness (formic acid in optic nerve)
metabolic acidiosis |
|
|
Term
| ethylene glycol is found where? |
|
Definition
|
|
Term
| what should you check for with methanol and ethylene glycol OD? |
|
Definition
| ASA/APAP levels and methanol/EG (for both toxicities) |
|
|
Term
| Metabolism of Ethylene glycol |
|
Definition
EG- (alcohol dehydrogenase)-> glycoaldehyde -(aldehyde dehydrogenase)->glycolic acid ->glycoxylic acid->oxalic acid
Glycoxylic acid->CO2 and H2O
Oxalic acid->calcium oxalate crystals |
|
|
Term
| Presentation of Ethylene glycol toxicity |
|
Definition
Acidosis (from glycoxylic acid and oxalic acid)
Renal tube damage (glycolic acid)
calcium oxalate crystals ->renal failure (oxalic acid) |
|
|
Term
| Conversion of ethylene glycol to inactive metabolites (water and CO2) is dependent on what? |
|
Definition
|
|
Term
| What is the quickest way to check for ethylene glycol ingestion? |
|
Definition
|
|
Term
| what is isopropyl alcohol and who usually ingests this? |
|
Definition
rubbing alcohol
alcoholics |
|
|
Term
| What is ingestion of isopropyl alcohol confirmed by? |
|
Definition
ketosis (sweet odor on breath)
metabolized by alcohol dehydrogenase to acetone
GI irritation
NO emesis, mainly supportive care |
|
|
Term
|
Definition
| ethanol -(alcohol dehydrogenase)-> acetaldehyde -(aldehyde dehydrogenase)->acetyl CoA-->CO2 and Water |
|
|
Term
| what does chloral hydrate do to alcohol? |
|
Definition
| inhibits alcohol dehydrogenase (very sedating) |
|
|
Term
| what does flagyl inhibit? |
|
Definition
aldehyde dehydrogenase
the acetaldehyde is what makes you feel sick so why metronidazole makes you feel sick with EtOH too! |
|
|
Term
| Treatment of EtOH toxicity is mainly supportive, what else may be given? |
|
Definition
protect airway
thiamine (must be given with glucose to protect against wernickes), glucose, naloxone
HD removes EtOH well, but is rarely needed |
|
|
Term
| What is the metabolism of APAP? |
|
Definition
Mainly by liver
90% conjugated to glucouronide and sulfate metabolites
<5% to N-aetyl-p-benzo-quinoneimine (NAPQI)-->inactivated by conjugation with glutathioine |
|
|
Term
| What gets depleted with BIG APAP ingestion? |
|
Definition
glutathione (cant detoxify NAPQI
extra bad because in OD more metabolism gets shifted to NAPQI pathway |
|
|
Term
| 4 phases of APAP toxicity |
|
Definition
1. (first 24 hours) Extreme GI upset
2. (24-72 hr) asymptomatic/LFTs on rise
3. (>72 hr) Hepatic dysfunction, PT/INR elevate, increased ammonia levels-->hepatic encephalopathy and death
4. (5-14 day) Either resolution of hepatic impairment or death |
|
|
Term
| When are APAP levels obtained following ingestion? |
|
Definition
4 hours
the plotted on Rumack-Matthew Nomogram
Harder to use with ER products |
|
|
Term
| What can be used to treat an APAP overdose |
|
Definition
NAC-replenishes glutathione stores
has many -SH groups (bad odor)
Mucomyst (PO)
-bad taste (mix with juice)
-originally for CF patients
- 17 doses (if vomit one up, must repeat)
-can use metoclopramide, ondansetron, NG tube to decrease chance of vomiting
-charcoal also binds to NAC--controversial to use
Acetadote (IV) (admin with D5W)
-higher incidence of anaphylaxis
-but less N/V
Cimetidine being studied
-MOA-inhibits CYP450-shunts pathway away from NAPQI formation
DONT USE IPECAC |
|
|
Term
| What is the hallmark sign of NSAID OD? |
|
Definition
|
|
Term
| What should you do in the case of chronic NSAID OD? |
|
Definition
Bicarb (increases renal excretion)
supportive care |
|
|
Term
| What is the most toxic salicyclate? |
|
Definition
| methyl-salicyclate (oil of wintergreen) |
|
|
Term
| What drug has a cyanide group in it? |
|
Definition
sodium nitroprusside
(amiodarone) |
|
|
Term
| Where is cyanide most significantly found? |
|
Definition
| FIRES (from organic materials) |
|
|
Term
| What does cyanide do? aka why is it bad? |
|
Definition
inhibits cytochrome oxidase system (aka stops aerobic respiration) so induces anaerobic respiration
1. formation/accumulation of lactic acid
2. decreased oxygen metabolism |
|
|
Term
| What smell is associated with cyanide poisoning? |
|
Definition
|
|
Term
| What is in the lilly cyanide antidote kit? |
|
Definition
OVERALL: trying to induce metHB (even though it has less Oxygen bindability, it has even less ability to bind CN)
1. amyl nitrite pearls: put under nose while IV access is secured
2. Sodium Nitrite (IV)
3. Sodium Thiosulfate: acts as a sulfur donor group to the endogenous enzyme rhodanse (detoxifies CN) to cause CN--> thiocyanate |
|
|
Term
| Amphetamine toxicity is similar to what other toxicity? |
|
Definition
|
|
Term
| what does the treatment of amphetamine OD consist of? |
|
Definition
Supportive treatment
HTN and seizure management |
|
|
Term
| what plant does digoxin come from? |
|
Definition
|
|
Term
| what is seen in digoxin OD? |
|
Definition
yellow/green haze
halo vision
AV block, bradycardia, N/V, mental status changes, hyperkalemia
Use digibind (cant use HD) |
|
|
Term
| Does giving calcium solve calcium channel blocker toxicity? |
|
Definition
Not completely
only helps with depression of cardiac contractility, but no sinus node effects or peripheral vasodilation effects
GIVE GLUCAGON too
HD not effective |
|
|
Term
| Who usually presents with an Fe OD? |
|
Definition
| Children--look like candy |
|
|
Term
| In general, what does iron toxicity result in? |
|
Definition
| corrosive effects and maybe cellular dysfunction with acidosis |
|
|
Term
|
Definition
1. Immediate: corrosive effects, emesis, bloody diarrhea
2. Latency: improvement over 12 hours
3. Relapse: abrupt coma, shock, SEIZURES, coagulopathy, HEPATIC FAILURE, and death
4. Late: SCARRING, STRICTURES, OBSTRUCTIONS |
|
|
Term
| Serum Fe > TIBC means what |
|
Definition
iron toxicity
the serum iron exceeds the transferrin iron binding capacity |
|
|
Term
| How should Fe toxicity be treated |
|
Definition
Deferoxamine IV
aim to change orange to pink urine (chelation or Fe with deferoxamine)
stop when serum Fe is normal or urine color is normal
cant do HD or charcoal |
|
|
Term
|
Definition
|
|
Term
How do you recognize a brown recluse?
Why is it deadly |
|
Definition
violin on back
NE-like toxin (potent vasoconstrictor)
Tx: dapsone can help within 24 hours, no anti-venom |
|
|
Term
| What is a potential issue with anti-venom? |
|
Definition
because it is an antibody from a horse, can get allergic rxn to anti-venom
more likely if get more than once-dont be dumb and get bit by the same snake twice! |
|
|
Term
| What should you use to treat BPH without massive prostate? |
|
Definition
|
|
Term
| what should you use to treat BPH with massive prostate? |
|
Definition
| alpha blocker + 5-alpha reductase inhibitor |
|
|
Term
| Club drugs vs designer drug |
|
Definition
Club drug: innovator
Designer: similar effects that avoid regulatory control |
|
|
Term
|
Definition
lipophilic=long half-life
hyperstimulation of DA, NE, 5-HT neurons
tachyphylaxis-quick resistance
Acute: euphoria, HTN, hyperthermia, rhabdo, seizures, tachycardia
Long-term: paranoia, meth mouth, cardiomyopathy, hallucinations, weight loss |
|
|
Term
|
Definition
NO ANTIDOTE--supportive care
CV: anti-arrhythmics, anti-HTN
Agitation: IV Lorazepam, Haloperidol
Rhabdo: IV Bicarb |
|
|
Term
| what are synthetic cathinones? |
|
Definition
| bath salts (plant food, herbal incense) |
|
|
Term
| Main synthetic cathinones |
|
Definition
mephedrone
methylenedioxylpyrovalerone (MDPV)
look like methcathinone (amphetamine-like alkaloid) |
|
|
Term
| Desired and undesired effects from synthetic cathinones |
|
Definition
Desired: CNS stimulation and hallucinations (superior high to cocaine)
Undesired: tachycardia, agitation, tremor, HTN, hyperthermia, paranoia (similar to Meth) |
|
|
Term
| MOA of synthetic cathinones |
|
Definition
| inhibit reuptake of NE, 5-HT, DA |
|
|
Term
| Treatment of synthetic cathinon OD |
|
Definition
NO ANTIDOTE
CV support: anti-arrhythmics, anti-HTN
Agitation: IV Lorazepam, haloperidol
minimize stimulation
tox screen requires GC-MS |
|
|
Term
| what is methylenedioxylmethamphetamine? |
|
Definition
|
|
Term
| T or F: MDMA is legal only in Europe |
|
Definition
| F-ecstasy inst legal anywhere |
|
|
Term
| why is MDMA an ideal club drug? |
|
Definition
NO hangover effect (only 3-6 hours)
-energy, talkativeness, open-mindedness, feelings of intimacy
-increased libido
-distorted sense of time
-decreased fear/aggression/defensiveness
-mild hallucinations
hard to detect with tox screen |
|
|
Term
|
Definition
|
|
Term
| what is the most serious complication and hallmark sign of MDMA use |
|
Definition
| hyperthermia (they drink lots of water even though have a diminished thirst) |
|
|
Term
| Treatment of OD on ecstasy |
|
Definition
Agitation: IV lorazepam
HTN: nitroprusside or labetalol
Hyperthermia: cool quickly
Serotonin Syndrome: dantrolene
Rhabdo: IV bicarb
Anti-arrhythmics |
|
|
Term
| How can SIADH occur with MDMA? |
|
Definition
| users drink lots of water because they know they will have decreased thrist and hyperthermia --> drink so much and they hold on to in all --> SIADH--> hyponatremia which can affect brain |
|
|
Term
| What control class is ketamine? |
|
Definition
|
|
Term
| what illicit drug is ketamine related to? |
|
Definition
|
|
Term
|
Definition
| interacts at NMDA receptor and is short acting (upto 45 min) |
|
|
Term
|
Definition
Desired: hallucinations, out of body experiences
Undesired: respiratory depression, seizures, arrhythmias (where it can be problematic, but not typical unless really high doses) |
|
|
Term
| What to do wiht a Ketamine OD? |
|
Definition
Note: very acute on/off so acute OD not usually seen
NO ANTIDOTE
monitor and support BP, heart rate, respiratory rate
BZD to sedate
minimize stimuli
unlikely to find on tox screen |
|
|
Term
| what control class is GHB and what is it used for? |
|
Definition
C-II
(but C-I if possessed without Rx)
narcolepsy/cataplexy |
|
|
Term
|
Definition
| endogenous NT GABA (CNS depressant) |
|
|
Term
| What do guys often take with ecstasy? |
|
Definition
| viagra (because vasoconstriction inhibits erection) |
|
|
Term
|
Definition
NO ANTIDOTE
GI decontamination if recent ingestion
Airway protection with supp oxygen (b/c PROFOUND VOMITING and respiratory depresson)
atropine-for bradycardia
BZD-for suspected seizures |
|
|
Term
|
Definition
| epidermis detaches from dermis (life threatening cutaneous rxn) |
|
|
Term
| what is the most common CADR (cutaneous ADR) |
|
Definition
morbilliform Rxn--looks viral
-itchy, papules that can grow together
Big diff b/w this and viral:
Viral: start on face first
Drug: start on trunk first |
|
|
Term
| Treatment for morbilliform rxn (CADR) |
|
Definition
benadryl, corticosteroids if needed
determine cause |
|
|
Term
|
Definition
hives
large wheals or red papules that itch
Tx: antihistamine, steroids, epipen if anaphyllaxis |
|
|
Term
|
Definition
Similar to urticaria but usually extensive tissue
swelling, with involvement of the deeper dermal and subcutaneous
tissue, especially areas with loose subcutaneous tissue such as eyelids
or lips
Tx: antihistamine, steroids, epipen if anaphyllaxis |
|
|
Term
| What is the hallmark or cutaneous vasculitis? |
|
Definition
palpable purpura
Lesions DO NOT BLANCH
may also involved kidney, liver, GI tract, joints, and
CNS and can be life-threatening
GO TO ER-steroids/immunosuppressants |
|
|
Term
| Erythema Multiforme (EM) Minor |
|
Definition
usually limited to palms/distal areas
bull's eye lesions
can be from Lyme disease, drug, or virus (HSV)<-treat this with acyclovir |
|
|
Term
| Erythema Multiforme (EM) Major is also known as what? |
|
Definition
| Stevens Johnson's Syndrome |
|
|
Term
| Stevens Johnson's Syndrome |
|
Definition
ALWAYS with mucous membrane involvement
sloughing skin = big infection risk = steroids might not be helpful
10-20% BSA
starts with prodrome
target shaped, blisters |
|
|
Term
|
Definition
toxic epidermal necrolysis
most severe CADR
lots of pain, prodrome with flu-like sx
GO to ER-burn unit |
|
|
Term
|
Definition
SJS: <10% epidermal detachment
SJS/TEN overlap: 10-30 % epidermal detachment
TEN: >30% epidermal detachment |
|
|
Term
| Which is more common: phototoxic or photoallergic photosensitivity |
|
Definition
Phototoxic
treat like exaggerated sunburn and d/c drug, antihistamines
Dose related rxn
confined exclusively to areas exposed to light |
|
|
Term
| photoallergic photosensitivity |
|
Definition
usually with topical drugs
rash on both sun exposed and non-sun exposed areas
Tx: oral antihistamines |
|
|
Term
| What is another name of atopic dermatitis? |
|
Definition
eczema
"the itch that rashes"
Tx: topical steroid
common in infants and kids |
|
|
Term
|
Definition
pre-malignant lesions
tx: topical 5-FU |
|
|
Term
| Basal Cell Carcinoma (BCC) |
|
Definition
most common type of skin cancer
usually on chronic sun exposed areas
Tx: surgical removal usually works |
|
|
Term
| Squamous Cell Carcinoma (SCC) |
|
Definition
2nd most common skin cancer
potential to metastasize
Tx: usually surgical removal |
|
|
Term
|
Definition
most dangerous skin cancer
incidence is increasing but so is survival rate |
|
|
Term
|
Definition
Arava
DMARD (non-biologic) for RA
MOA: inhibits pyrimidine synthesis--> decreasing lymphocyte proliferation
-similar efficacy to MTX
-uses loading dose (100 mg x 3d, 20mgQD)
-monitor LFTs, CBC (monthly-->Q6-8 weeks)
Toxicities: HAIR LOSS (women dont like), hepatitis, N/V/D |
|
|
Term
|
Definition
DMARD (non-biologic) for RA
MOA: reduce formation of peptide-MHC complex, decrease presentation of CD4+ T Cells
200-300 mg BID
Monitor: EYE EXAMS-watch for vision changes and rash
Takes 6 WEEKS to see initial effect, WAIT 6 MONTHS TO SEE IF EFFECTIVE (RA agent that takes the longest)
-no hepatic or renal toxicities (big benefit) |
|
|
Term
|
Definition
DMARD (non-biologic) for RA
pro-drug
unknown MOA
effects within 2 months
500 mg BID-->1 g BID max
monitor CBC baseline->weekly -> monthly
Limited use due to ADRs: N/V/D, anorexia, rash
-CAN CHANGE SKIN AND URINE YELLOW-ORANGE
-interacts with Fe supp and warfarin |
|
|
Term
| T or F: minocycline can be used to treat RA |
|
Definition
|
|
Term
| Alternative agents for RA (DMARDs) |
|
Definition
Azathioprine
Cyclosporine
Cyclophosphamide
D-Penicillamine
Auranofin |
|
|
Term
| which RA biologic is also indicated for psoriatic arthritis? |
|
Definition
|
|
Term
|
Definition
TNF inhibitor for RA
humanized antibody to TNF
SQ |
|
|
Term
| why is infliximab the most antigenic? |
|
Definition
| it is a chimeric mouse/human IgG (others are humanized) |
|
|
Term
|
Definition
mAb against CD20 (B cells)
depletes peripheral B cells
IV
give methylprednisolone before infusion to decrease infusion rxn
-no monitoring
-give concurrent MTX
-if/when disease reactivates must do retreatment
-no live vaccines |
|
|
Term
| What are the cytokine inhibitors used used in RA? |
|
Definition
tocilizumab (IL-6 inhibitor)
IV
Monitor: LFTs, CBC, and lipids
use alone or with MTX
anakinra (not recommended anymore) |
|
|
Term
| Features of RA poor prognosis |
|
Definition
functional limitations
extraarticular disease (nodules, RA lung disease, secondary Sjogren's syndrome, RA vasculitis)
+RF
+ACCP
bony erosion on radiography |
|
|
