UC, Crohn's, IBS, Insomnia, Testosterone, Derm, Transplant, Hair loss

IBD vs IBS

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Ulcerative colitis

• Distal colitis

Crohn’s disease

IBD vs IBS

IBD → has inflammation → steroids

IBS → no inflammation

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Ulcerative colitis (inflammation confined to intestines) → blood in stool, pain better after passing a stool

• Distal colitis (left sided) → contained to rectum and sigmoid colon → treat with enema/suppository

  • Mesalamine (Canasa, Rowasa) → suppository, enema respectively

Crohn’s disease (inflammation deeper) → no blood in stool pain in lower right quadrant, constant pain

Class for indication

• Lialda, Asacol HD, Delzicol, Pentasa, Apriso, Canasa, Rowasa → generic

• Colazal → generic

• Dipentum → generic

• Azulfidine → generic, avoid in…allergy

Avoid all in…allergy

Class for Indication

• Lialda, Asacol HD, Delzicol, Pentasa, Apriso, Canasa, Rowasa → Mesalamine

• Colazal → Balsalazide

• Dipentum → Olsalazine

• Azulfidine → Sulfasalazine, avoid in sulfa allergy

Avoid all in salicylate allergy

-

Salicylates (Mesalamine, Colazal, Olsalazine, Sulfasalazine) → Mild-Moderate

Budesonide (Ucertis, Entocort EC) → Mod-severe

TNF alpha blockers and Immunosuppressants → Mod-severe Crohns, Refractory UC

Generic

• Lialda, Asacol HD → formulation

• Delzicol, Pentasa, Apriso → formulation

  • Apriso DDI → do NOT take with

• Indication, dosing timing

  • Canasa → formulation

  • Rowasa → formulation

Mesalamine

• Lialda, Asacol HD → DR tabs

• Delzicol, Pentasa, Apriso → CR caps

  • Apriso DDI → do NOT take with antacids (need it to release in large intestine, not stomach)

• For distal colitis, QHS

  • Canasa → rectal suppository

  • Rowasa → rectal enema

-

Salicylates (Mesalamine, Colazal, Olsalazine, Sulfasalazine) → Mild-Moderate

Budesonide (Ucertis, Entocort EC) → Mod-severe

TNF alpha blockers and Immunosuppressants → Mod-severe Crohns, Refractory UC

Generic

• Uceris → indication

• Entocort EC → indication

Budesonide

• Uceris → mod-severe UC

• Entocort EC → mod-severe Crohn’s

Could also give other steroids (prednisone, hydrocortisone, etc) but least systemic issues

-

Salicylates (Mesalamine, Colazal, Olsalazine, Sulfasalazine) → Mild-Moderate

Budesonide (Ucertis, Entocort EC) → Mod-severe

TNF alpha blockers and Immunosuppressants → Mod-severe Crohns, Refractory UC

Indication

Class

• Remicade → generic, formulation, mixing rule

• Humira → generic

• Cimzia → generic, only for what indication

• Simponi → generic

Immunosuppressants

• Imuran → generic

• 6-mercaptopurine

Immunosuppressants for Refractory UC or Mod-serve Crohn’s

TNF alpha blocker

• Remicade → Infliximab, comes IV, used with NON-PVC tubing

• Humira → Adalimumab

• Cimzia → Certolizumab, only for CD

• Simponi → Golimumab

Immunosuppressants

• Imuran → Azathioprine

• 6-mercaptopurine

-

Salicylates (Mesalamine, Colazal, Olsalazine, Sulfasalazine) → Mild-Moderate

Budesonide (Ucertis, Entocort EC) → Mod-severe

TNF alpha blockers and Immunosuppressants → Mod-severe Crohns, Refractory UC

Abx for Crohn’s

Metronidazole

Ciprofloxacin

Generic (C-… med)

Indications →

• Women →

• Men →

Formulation

IM

• Given only in the…

• BBW →

Natesto → formulation

Striant → formulation

Androderm → formulation, changed…

Testosterone (C-3 med)

Indications →

• Women → breast cancer

• Men → delayed puberty, hypogonadism

Formulation

IM

• Given only in the gluteal muscle

• BBW → pulmonary oil microembolism

Natesto → nasal spray

Striant → buccal

Androderm → transdermal patch, change daily

Generic (C-… med), Formulation

• Axiron → location

• Testim → location

• AndroGel 1% and 1.62% → location

• Fortesta → location

Indications →

• Women →

• Men →

Comments →

Testosterone (C-3 med), Gel and solution

• Axiron (solution) → Axilla (armpit)

• Testim → shoulder, upper arm

• AndroGel 1% and 1.62% → shoulder, upper arm, abdomen

• Fortesta → Front / inner thigh

Indications →

• Women → breast cancer

• Men → delayed puberty, hypogonadism

Comments → alcohol based, flammable

Cystic acne

1st step →

2nd step →

• Benzamycin → generic

• BenzaClin, Duac, Acanya → generic

3rd step →

• Doxycycline

• Minocycline

4th step →

1st step → Benzoyl peroxide

2nd step → Topical Abx + Benzoyl peroxide

• Benzamycin → Benzoyl peroxide + Erythromycin

• BenzaClin, Duac, Acanya → Benzoyl peroxide + Clindamycin

3rd step → Oral Abx + Benzoyl peroxide

• Doxycycline

• Minocycline

4th step → Isotretinoin

Generic

• Absorica

• Amnesteem

• Clarvis

• Myorisan

• Zenatane

Indication →

Pregnancy

iPLEDGE → for both male and female

• 2

Has…(time) window to fill Rx with…(day) supply, refills?

Regards to food, exception

ADE

• 5

Every visit check labs (3)

DDI

• 3

Isotretinoin

• Absorica

• Amnesteem

• Clarvis

• Myorisan

• Zenatane

Indication → severe cystic acne

Pregnancy Category X

iPLEDGE → for both male and female

• 2 forms of contraception starting 1 month before, during and after therapy

• 2 neg urine/blood tests every month

Has 7 day window to fill Rx with 1 months supply, no refills → go in every month to retest

All taken with food EXCEPT for Absorica

ADE

• Dry skin, cheilitis (cracked corner of lips) → skin gets worse before it gets better

• Sun sensitivity

• Psych

• Hepatotoxicity

• Bone marrow suppression

Every visit check CBC, LFT, pregnancy test

DDI

• Tetracyclines (decrease efficacy of estrogen, increase risk of preg)

• Progesterone only pill (not enough for contraception)

• St Johns wort (increase risk of pregnancy)

Atopic dermatitis 1st line →

Mild →

Moderate →

Atopic dermatitis 1st line → steroids

Mild → Desonide, Hydrocortisone

Moderate → Triamacinolone, Fluoricinolone, Betamethasone

Elidel → generic

Protopic → generic

• Prograf, Envarsus XR, Astagraf XL → indication

Indication →

Frequency →

Potential risk for…

Elidel → Pimecrolimus

Protopic → Tacrolimus

• Prograf, Envarsus XR, Astagraf XL → transplant drug

Indication → 2nd line for atopic dermatitis, after steroids

Frequency → BID

Potential risk for cancer

Psoriasis

…condition → treat with…

• DOC →

• Alt →

• Mild →

Chronic autoimmune condition → treat with immunosuppressants

• DOC → Methotrexate

• Alt → Cyclosporine, TNF alpha blocker

• Mild → Topic steroids, Vitamin D analog, Topical retinoid

Abreva

Generic

OTC vs Rx

…times daily for max…days

MOA →

Docosanol

the only OTC antiviral cream

5 times daily for max 10 days

MOA → inhibits viral fusion (prevent entry)

Aldara

Generic

Indication → Frequency (2)

Up to…weeks

Wash off after…

Imiquimod

Indication → Frequency (2)

• Genital worts → 3 times weekly

• Actinic keratosis → twice weekly

Up to 16 weeks

Wash off after 8 hrs

Indication →

5-FU → ADE

Aldara → generic, frequency up to…weeks

Solaraze → generic, use for…days

Indication → actinic keratosis (precancerous skin growth)

5-FU → remember hand-foot syndrome, increase INR and photosensitivity

Aldara → Imiquimod, twice weekly up to 16 weeks

Solaraze → Diclofenac, use for 60-90 days

Transplant drugs → Class

Generic (Formulation: 3)

• Prograf

• Envarsus XR, Astagraf XL → formulation

  • Regards to food

  • Avoid…

• Protopic → formulation, indication

Generic → (Formulation: 3)

• Gengraf, Neoral →

• Sandimmune → formulation

• Retasaiss, Cequa, Verkazia, Vevye → formulation, indication

IV formulation made with…

ADE → 4

• Cyclosporine specific → 1

DDI → 1

Transplant drugs → Calcineurin inhibitors

Tacrolimus (Formulation: oral (IR, ER), IV, topical)

• Prograf

• Envarsus XR, Astagraf XL → ER formulation

  • Take on empty stomach

  • Avoid alcohol

• Protopic → topical tacrolimus for atopic dermatitis

Cyclosporine → (Formulation: oral, IV, ophthalmic)

• Gengraf, Neoral → equivalent (but not to Sandimmune)

• Sandimmune → IV

• Retasaiss, Cequa, Verkazia, Vevye → ophthalmic cyclosporine for dry eyes

IV formulation made with non-PVC tubing

ADE → nephrotoxicity, HTN, hyperkalemia, hyperuricemia

• Cyclosporine specific → gingivitis hyperplasia

DDI → CYP3A4 substrate

CellCept

Myfortic

Generic

• Regards to food

• Don’t use in…

Compounding

MycophenoLATE (antimetabolite for transplant just like Azathioprine) →

• Eat LATEr → Empty stomach

• Get pregnant LATEr → don’t use in pregnancy

  • 2 forms of contraception 4 weeks prior and during

  • DC for at least 6 weeks before trying to get pregnant

Hazardous meds → double glove, gown, preparation in Class 2 biological cabinet

Class, indication

• Rapamune →

  • Formulation

  • Storage

• Zortress →

  • Afinitor → indication

mTOR inhibitors as transplant drug

• Rapamune → Sirolimus

  • Oral solution

  • Protect from light and refrigerate

• Zortress → Everolimus

  • Afinitor → cancer

Formulation, Indication

Simulect → generic

Nulojix → generic

Thymoglobulin → ADE

IV Transplant Drug

Simulect → Basiliximab

Nulojix → Belatacept

Thymoglobulin → infusion reactions (premedicate)_

Class for Indication (C-…)

MOA →

Generic

• Ambien, Ambien CR

• ZolipMist →

• Edluar →

• Intermezzo →

  • Women seniors, hepait impairment, patients on opioids →

  • Male →

Sonata → Generic

Short acting non-BZD hypnotic agents for Insomnia (C-4 just like orexin receptor antagonists)

MOA → works on GABA (just like BZD)

Zolpidem

• Ambien, Ambien CR

• ZolipMist → oral spray ON tongue

• Edluar → SL tab UNDER tongue

• Intermezzo → SL tab taken for middle of the night wakening only if 4 hrs remaining before wake time

  • Women seniors, hepait impairment, patients on opioids → 1.75 mg

  • Male → 3 mg

Sonata → Zaleplon

• Shortest t½ and rapid acting

Restoril

Generic

Class for Indication

C-…

Temazepam

BZD for Insomnia

C-5

Orexin receptor antagonist and non-BZD hypnotics → C-4

Indicated for…

OTC

• Benadryl → generic

• Unisom → generic

Silenor → generic

Herb → 1

Non-controlled meds indicated for insomnia

OTC

• Benadryl → Diphenhydramine

• Unisom → Doxylamine

Silenor → Doxepin

Herb → Valerian Root

Class for Indication

Rozerem →

Hetlioz →

• Indication →

Good for…, not for…

Melatonin for Insomnia

Rozerem → Ramelteon

Hetlioz → Tasimelteon

• Indication → non-24 hr sleep wake disorder in totally blind patients

Good for initiating sleep, not for maintaining sleep

Class for Indication

C-…

Belsomra →

• CYP

DayVigo →

Quviviq →

Orexin receptor antagonist for insomnia (oxrein receptors active during wakefulness)

C-4 (non-BZD hypnotics C-4, BZD C-5)

Belsomra → Suvorexant

• CYP3A4 substrate

DayVigo → Lemborexant

Quviviq → Daridorexant

N/V for 1st trimester

1st line → (2)

• Diclegis → generic

Alt 1st line → (2)

2nd line → (1) (risk of…(2))

1st line →

• Vitamin B6 (pyridoxine)

• Diclegis → Doxylamine + Pyridoxine

Alt 1st line → OTC Benadryl, Dramamine

2nd line → 5HT3 inhibitors (risk of heart defects, prolonged QT)

• dolasetron (anzemet) granisetron (sancuso) ondansetron (zofran, zuplenz oral soluble film), palonsetron (aloxi)

Pregnancy DOC

Pain →

GERD →

Constipation →

Rhinitis → →

UTI → (2)

Preeclampsia/Eclampsia → (3) → to prevent seizures (but worry about…)

Pain → acetaminophen

GERD → lifestyle changes, antacids (Mag helps with preg constipation), H2 blocker (ranitidine), PPI (except Prilosec)

Constipation → milk of magnesium

Rhinitis → saline spray → antihistamine

UTI → macrobid (except CI in near term, aka after 38 weeks), Beta lactam

Preeclampsia/Eclampsia → labetalol, nifedipine, hydralazine → Magnesium sulfate IV to prevent seizures (but worry about resp depression)

Indicated for…

Rogaine → generic

Propecia (…mg) → generic

• Proscar (…mg) for indication

Indicated for hair loss

Rogaine → Minoxidil

Propecia (1 mg) → Finasteride

• Proscar (5 mg) for BPH

Generic, class for indication

• Ditropan →

• Gelnique 10% →

• Oxytrol → formulation (OTC/Rx for gender, changed…every…)

ADE → (3)

Oxybutynin, anticholinergics for overactive bladder

• Ditropan → ER tabs

• Gelnique 10% → gel

• Oxytrol → transdermal patch (OTC for women changed twice weekly every 4 days)

ADE → dry mouth, constipation, somnolence (less in Oxytrol)

Mirabegron (Myrbetriq) -> beta 3 adrenergic agonist

Myrbetriq

Generic

Class for Indication

ADE →

• Advantage

Mirabegron

Beta-3 adrenergic agonist for overactive bladder

ADE → uncontrolled HTN (think BB for HTN)

• Advantage → No anticholinergic ADE like Oxybutynin (Ditropan, Gelnique, Oxytrol)

Zanaflex

Generic, class (avoid in…)

MOA → … (just like…)

• Same ADE →

Tizanidine, muscle relaxant (avoid in alcohol and elderly)

MOA → alpha 2 agonist (just like clonidine)

• Same ADE → hypotension, dry mouth, sedation, dizziness

Unique → CYP1A2 substrate (CYP1A2 inhibitors like cipro, fluvoxamine, cimetidine will increase levels)

Amrix

Fexmid

Generic, class (avoid in…)

…like structure → watch out for…

CI with…

Cyclobenzaprine, muscle relaxant (avoid in alcohol and elderly)

TCA / carbamazepine / amitriptyline like structure → watch out for anticholinergic ADE

CI with MAOIs

Class (avoid in…)

Soma → generic (C-…)

Lioresal → generic

• MOA →

• Formulation available →

Methocarbamol

Metaxalone

Chlorzoxazone

Muscle relaxant (avoid in alcohol and elderly)

Soma → Carisoprodol (C-4)

Lioresal → Baclofen

• MOA → GABA agonist

• Formulation available → intrathecal

Dantrium

Generic, class (avoid in…(2))

• Same med used to treat…

Dantrolene, muscle relaxant (avoid in alcohol and elderly)

• Same med used to treat Neuroleptic Malignant Syndrome to treat muscle rigidity

Class for Indication

• Imodium →

  • Max dose → OTC…, Rx…

• Viberzi → … (C-…)

  • Regards to food

  • ADE →

• Antidotes →

Opoid receptor agonist for diarrhea

• Imodium → Loperamide

  • Max → OTC 8 mg, Rx 16 mg

• Viberzi → Eluxadoline (C-4)

  • Take with food

  • ADE → hepatoxicity, pancreatitis (similar ish to VPA)

• Antidotes → Naloxone

Alosetron (Lotronex), Rifaxamin (Xifaxan)

Lotronex

Generic

MOA →
Indication →

DDI → → CI with…

Alosetron (think ondansetron)

MOA → 5-HT3 receptor antagonist
Indication → IBS-diarrhea ONLY for women who failed other options

DDI → substrate → CI with fluvoxamine (CYP1A2 inhibitor)

Loperamide (Imodium), Eluxadoline (Viberzi)

Rifaxamin (Xifaxan)

Xifaxan

Generic

Indication →

Rifaximin

Indication

• IBS-diarrhea

• Remember traveler’s diarrhea, prevention of hepatic encephalopathy

Loperamide (Imodium), Eluxadoline (Viberzi)

Rifaxamin (Xifaxan)

Amitiza

Generic

MOA →

Indication →

• (3)

Regards to food

Lubiprostone

MOA → Cl channel activator

Indication →

• Chronic idiopathic constipation (CIC)

• IBS-constipation for female at least 18 yo

• Opioid induced constipation

Take with food

Linaclotide (Linzess), Plecanatide (Trulance) → Guanylate cyclase-C agonist

• CIC, IBS-C

• Empty stomach

Class

• Linzess →

  • CI in…(age)

• Trulance →

  • CI in…(age)

Indication →

• (2)

Regards to food

Guanylate cyclase-C agonist

• Linzess → Linaclotide

  • CI in < 2 yo

• Trulance → Plecanatide

  • CI in < 6 yo

Indication →

• Chronic idiopathic constipation (CIC)

• IBS-constipation

Empty stomach

Lubiprostone (Amitizia) → Cl channel activator

• CIC, IBS-C for female at least 18 yo

• With food