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