UAMS P3 - Therapeutics 2 E3 Study Guide

Symptoms most Commonly associated with the Cold

Sore Throat, Aches, Fatigue

Symptoms most Commonly associated with the Flu

Aches, Fatigue, Fever

Symptoms most Commonly associated with the COVID

Difficulty Breathing, Fatigue, Sore Throat

Symptoms most Commonly associated with RSV

Wheezing, Fever, Difficulty Breathing

Oseltamivir (Tamiflu) Class

Neuraminidase Inhibitor

Zanamivir (Relenza) Class

Neuraminidase Inhibitor

Peramavir (Rapivab) Class

Neuraminidase Inhibitor

Baloxavir (Xofluza) Class

Endonuclease Inhibitor

Amantadine Class

Adamantanes

Rimantadine Class

Adamantanes

Neuraminidase Inhibitors has activity against which Influenza Viruses

A and B

Endonuclease Inhibitors has activity against which Influenza Viruses

A and B

Adamantanes has activity against which Influenza Viruses

A only

(THIS CLASS NO LONGER RECOMMENDED FOR TREATMENT OF INFLUENZA)

When administered within 48hrs of onset of illness, _____________ may reduce duration of illness by approximately 1 day

Neuraminidase Inhibitors

Influenza Antiviral Therapy should begin within _____________ of symptom onset

48 hours

Reasons Antivral Therapy for Influenza should begin ASAP (even if > 48hrs):

Hospitalized,

Severe/Complicated illness,

Higher risk for Influenza Complications

In Severe Influenza disease, Recommended treatment:

Oral or Enteric Oseltamivir

(NO zanamivir, paramivir, or baloxavir)

Renal dose adjustment for Oseltamivir

CrCl < 60 mL/min

Which Influenza Medication is preferred in pregnant or severe patients?

Oseltamivir

Oseltamivir ADEs

N/V,

Headache,

Neuropsychiatric events,

Gasping syndrome in neonates

(only for formulations containing benzyl alcohol)

Zanamivir should be avoided in patients with

underlying respiratory disease or allergy to milk protein

Zanamivir ADEs

Sore throat (inhalation admin),

Cough (inhalation admin),

Sporadic Transient Neuropsychiatric events

Oral suspension of Oseltamivir should be avoided in patients with _____________ due to ___________ content

fructose intolerance; sorbitol

Peramivir Renal dose adjustment when:

CrCl < 50 mL/min

Peramivir ADEs

Diarrhea (more common)/Constipation/V,

Neuropsychiatric events

Baloxavir should be avoided with

polyvalent cation-containing products

Baloxavir ADEs

Diarrhea, Vomitting

Which Influenza therapy agent can result in reduced susceptibility to Influenza A for younger patients due to gene mutations of polymerase acidic protein?

Baloxavir

Antiviral chemoprophylaxis is generally not recommended if more than __________ has elapsed since first exposure to individual with influenza

48 hours

Oseltamivir Treatment and Chemoprophylaxis Duration

Treatment: 5 days

Chemoprophylaxis: 7 days if vaccinated, 14 days if not

Zanamivir Treatment and Chemoprophylaxis Duration

Treatment: 5 days

Chemoprophylaxis: 7 days

Which Influenza therapy is inhaled?

Zanamivir

Peramivir Treatment and Chemoprophylaxis Duration

Treatment: 1 day

Chemoprophylaxis: Not recommended

Baloxavir Treatment and Chemoprophylaxis Duration

Treatment: 1 day

Chemoprophylaxis: 1 day

All patients __________________, besides patients with contraindications, is recommended to get the flu vaccine

>= 6 months

Flu Vaccine: Children 6 Months to 8 years should get

2 vaccine doses >= 4 weeks apart with 1st vaccination

Flu Vaccine: Adults >= 65 years should get vaccines

3-4x the amount of antigen as standard dose

2025 Influenza Vaccines are all

trivalent (2 Type A, 1 type B)

Inactivated Vaccine Brand Names for pts < 65

Alfuria (egg based), F

luarix (egg based),

FluLaval (egg based),

Fluzone (egg based),

Flucelvas (egg free)

Recombinant Vaccine Brand Names for pts < 65

Flublock (egg free)

Live Vaccine Brand Names for pts < 65

FluMist

Recombinant Vaccine Brand Names for pts >= 65

Flublock (egg free)

Adjuvanted Vaccine Brand Names for pts >= 65

Fluad (egg based)

High Dose Vaccine Brand Names for pts >= 65

Fluzone HD (egg based)

Higher Risk for Severe COVID-19

Age >= 50,

Mental health disorders,

Obesity,

Pregnancy and recent,

Smoking current and former

COVID-19 Outpatient Antiviral Treatment Agents

Ritonavir/Nirmatrelvir (Paxlovid),

Remdesivir (Veklury),

Molnupiravir (Lagevrio)

COVID-19 Drug that is a peptidomimetic inhibitor of COVID protease leading to inhibition of viral replication (brand name)

Paxlovid

COVID-19 Drug that is a inhibitor COVID RNA polymerase leading to inhibition of viral replication (brand name)

Veklury

COVID-19 Drug that is a causes viral genome errors by incorporating NHC-TP in COVID RNA and inhibits replication

Lagevrio

Paxlovid should be used in patients...

12 and up

Lagevrio should be used in patients...

18 and up

Veklury should be used in patients...

any age

Which COVID-19 treatment agent should be avoided in pregnant patients

Lagevrio

Paxlovid Considerations

Renally dosed,

Monitor for Liver ADEs,

Lots of Drug-Drug interactions (CYP450 inhibitor)

Paxlovid ADEs

Change in taste, Diarrhea, Muscle Pain

Veklury Considerations

Monitor ALT for liver inflammation signs

Lagevrio Considerations

Avoid in pregnancy, Weak evidence for effectiveness

COVID-19 Inpatient Treatment Options

Dexamethasone,

Remdesivir (Veklury),

Baricitinib (Olumiant),

Tofacitinib (Xeljanz),

Tocilizumab (Actemra),

Sarilumab (Kevzara)

Which COVID-19 Treatment can be used in both Inpatient and Outpatient setting?

Veklury

Dexamethasone Considerations for COVID-19 Use

associated with reduced mortality with hypoxia/requiring O2

MOA of Baricitinib (Olumiant)

Inhibits JAK enzyme which reduces cytokine storm helping block virus entry

MOA of Tofacitinib (Xeljanz)

Inhibits JAK enzyme which reduces cytokine storm helping block virus entry

Xeljanz and Olumiant Considerations

do NOT initiate if absolute lymphocyte/neutrophil counts are below certain thresholds,

BBW: serious infection/thrombosis,

monitor ALT for liver inflammation signs,

Renal Dose adjustments

Olumiant should be used in patients...

2 and up

Xeljanz should be used in patients...

2 and up

Actemra should be used in patients...

2 and up

Kevzara should be used in patients...

18 and up

Tocilizumab (Actemra) MOA

Interleukin-6 (IL-6) antagonist leading to reduced cytokine and acute phase reactant production

Sarilumab (Kevzara) MOA

Interleukin-6 (IL-6) antagonist leading to reduced cytokine and acute phase reactant production

Actemra and Kevzara Considerations

do NOT initiate if absolute neutrophil/platelets below certain threshold,

do NOT initiate if ALT/AST are above certain thresholds,

BBW regarding risk for serious infection,

Monitor ALT for signs of liver inflammation

COVID-19 Outpatient Mild-to-Moderate severity treatment should be

Paxlovid x5 days (ORAL),

Veklury x3 days (IV)

COVID-19 Hospitalized Mild-to-Moderate severity treatment should be

High risk for progession within 7 days: Veklury x3 Days (IV)

(Steroids do not show benefit)

COVID-19 Hospitalized Severe severity treatment not needing oxygen should be

Dexamethasone x10days or until discharge,

Veklury x5days IV,

Tocilizumab (Actemra) or Baricitinib (Olumiant)

COVID-19 Hospitalized Severe severity treatment needing oxygen should be

Dexamethasone x10days or until discharge,

Tocilizumab (Actemra) or Baricitinib (Olumiant)

COVID-19 Hospitalized Severe severity treatment needing ECMO should be

Dexamethasone x10days or until discharge,

Tocilizumab (Actemra) or Baricitinib (Olumiant)

Signs of possible Pneumonia infection in pts with Uncomplicated Bronchitis

HR >= 100,

RR >= 24,

Oral Temp > 38C (100.4F)

Therapy for Uncomplicated Bronchitis

Cough suppressants,

First-gen Antihistamines,

Decongestants

Which assessment tool is preferred for use to assess severity of illness in patients with Pneumonia?

PSI (PORT)

What risk factors does the CURB-65 Assessment Tool for Pneumonia Severity consider?

Confusion,

BUN >= 20,

RR > 30,

SBP <= 90 OR DBP <= 60,

Age >= 65

PSI Risk Class 1 (<50pts) should be treated as

Outpatient

PSI Risk Class 2 (51-70pts) should be treated as

Outpatient

PSI Risk Class 3 (71-90pts) should be treated as

Outpatient or Inpatient

PSI Risk Class 4 (91-130pts) should be treated as

Inpatient

PSI Risk Class 5 (>130pts) should be treated as

Inpatient

Community Acquired Pneumonia Outpatient Comorbidities

Chronic Heart, Lung, Liver, Renal diseases;

DM;

Alcoholism;

Malignancy;

Asplenia

Community Acquired Pneumonia Outpatient Treatment WITHOUT Co-morbidities

Amoxicillin,

Doxycycline,

Azithromycin,

Clarithromycin

(choose 1)

Community Acquired Pneumonia Outpatient Treatment WITH Co-morbidities

Beta-lactam + Macrolide;

Beta-lactam + Doxycycline;

Respiratory Fluoroquinolone (Levofloxacin, Moxifloxacin)

Beta-Lactam options for Outpatient Community Acquired Pneumonia

Augmentin, Cefpodoxime, Cefuroxime

Macrolide options for Outpatient Community Acquired Pneumonia

Azithromycin, Clarithromycin

Factors for High Quality Sputum Culture

0-5 Epithelial cells;

Moderate, marked, or many WBCs (purulent);

Moderate or Heavy Growth of typically one organism

_______________ recommended when empirically treating with Vanc or Linezolid for Community Acquired Pneumonia

MRSA PCR Nasal Screen

Negative MRSA PCR Nasal Screen would indicate to

stop/de-escalate Vanc or Linezolid for MRSA coverage

Positive MRSA PCR Nasal Screen would indicate to

Continue MRSA coverage with Vanc or Linezolid

Severe Community Acquired Pneumonia defined as having ____ major or ______ minor Criteria

1; >= 3

Major Criteria for CAP

Septic Shock with need for vasopressors,

Respiratory failure requiring mechanical ventilation

Minor Criteria for CAP

RR >= 30,

PaO2 ratio <= 250,

Multilobar infiltrates,

Confusion,

Uremia (BUN >= 20),

Leukopenia (WBC < 4k),

Thrombocytopenia (Plts < 100k),

Hypothermia (Temp < 36C),

Hypotension

CAP Treatment for Standard Inpatient Non-Severe Therapy

Beta-lactam + Macrolide,

Respiratory Fluoroquinolone (Levofloxacin or Moxifloxacin)

Beta-Lactams for Inpatient Treatment for CAP (both severe and non-severe)

Ampicillin-Sulbactam,

Cefotaxime,

Ceftriaxone,

Ceftaroline

Macrolides for Inpatient Treatment for CAP

Azithromycin,

Clarithromycin

Alternative Agent for Macrolides in CAP treatment

Doxycycline