STRUGLE part 2

Menopause ->

Menopause treatment for vasomotor symptoms (± uterus)

estrogen

+progesterone if uterus is present (endometrial cancer risk)

Criteria for hormone therapy in menopause

symptomatic women within 10 years of menopause, ≤ 60 yo, no CI to use

Estrace

17-Beta-Estradiol

vaginal cream for vasomotor symptoms

Estring

17-Beta-Estradiol

vaginal ring for vasomotor symptoms

Vagifem

17-Beta-Estradiol

vaginal tablet for vasomotor symptoms

Premarin

Conjugated Equine Estrogens

vaginal cream for vasomotor symptoms

Climara, Vivelle Dot indication, BW, duration of application

Estradiol for postmenopause vasomotor symptoms

BW: endometrial cancer without progestin in women with uterus, dementia ≥ 65 yo, ⬆ VTE and stroke, breast cancer

Climara: once weekly

Vivelle-Dot: twice weekly

ClimaraPro

Transdermal patch

Pro = progestin

Estradiol + levonorgestrel for postmenopause vasomotor symptoms

CombiPatch

Estradiol and Norethindrone for postmenopause vasomotor symptoms

Prempro

Oral tabs

Conjugated Equine Estrogens and Medroxyprogesterone

• postmenopause vasomotor symptoms

Premphase

Oral tabs

Conjugated Equine Estrogens and Medroxyprogesterone

• postmenopause vasomotor symptoms

Provera

Medroxyprogesterone

• Oral tabs

• postmenopause vasomotor symptoms

Prometrium

Micronized progesterone

• oral tabs

• postmenopause vasomotor symptoms

Ospemifene (Osphena) indication

severe dyspareunia

• estrogen agonist/antagonist

SSRI for menopausal vasomotor symptoms

Paroxetine (Brisdelle)

Paroxetine DDI with warfarin and tamoxifen

Paroxetine is a 2D6 inhibitor will block effectiveness of tamoxifen or warfarin

Fezolinetant (Veozah) indication

Neurokinin B antagonist

• modulates neuronal activity in thermoregulatory center

• FDA approved for mod-severe vasomotor symptoms associated with menopause

Testosterone products are which schedule

CIII

AndroGel BW

Testosterone gel

BW: secondary exposure in children can result in virilization

Drugs that can cause erectile/sexual dysfunction

alcohol

antidepressants: SSRI/SNRI

antihypertensives: BB, clonidine, thiazides

antipsychotics: first gen- chlorpromazine

• prolactin-raising 2nd gen: risperidone, paliperidone

BPH meds: finasteride, dutasteride, silodosin (retrograde ejaculation)

PDE5 inhibitor warnings

hearing loss, vision loss, hypotension, color discrimination, priapism

High fat meal can increase or decrease efficacy in certain PDE5 inhibitors

decrease efficacy with sildenafil and vardenafil

Viagra starting dose

sildenafil 50 mg 1 hr before

reduce to 25 mg if ≥ 65 yo, using alpha blocker, 3A4 inhibitor, or severe renal/liver disease

Levitra

Vardenafil

Levitra starting dose

Vardenafil 10 mg 1hr before

5 mg if ≥ 65 yo, using alpha blocker, 3A4 inhibitor, or severe renal/liver disease

Cialis starting dose

tadalafil 10 mg 30 min before

5 mg if ≥ 65 yo, using alpha blocker, 3A4 inhibitor, severe renal/liver disease

Stendra

Avanafil

Stendra starting dose

Avanafil 100 mg 15-30 mins before

50 mg if ≥ 65 yo, using alpha blocker, 3A4 inhibitor, severe renal/liver disease

Addyi indication

Flibanserin- 5HT1A agonist and 5HT2A antagonist

premenopasual females for hypoactive sexual disorder

Vyleesi

Bremelanotide SC PRN ≥ 45 min before sexual activity

premenopasual females for hypoactive sexual disorder

CI: hypertension or known CV disease

Addyi BW/REMS

BW: contraindicated with alcohol due to increase risk of severe hypotension and syncope

REMS

Cialis counseling

Tadalafil

can cause back pain

Natural Products for benign prostatic hyperplasia

saw palmetto

First line treatment in BPH

alpha blockers

• cause relaxation of smooth muscle in prostate and bladder neck

• reduces bladder outlet obstruction and improves urinary flow

Cardura indication, class

Doxazosin qHS

Nonselective alpha1 blocker for BPH

Terazosin indication, class

qHS

nonselective alpha1 blocker for BPH

Flomax indication, class, dose

Tamsulosin

selective alpha1 blocker for BPH

0.4 mg daily

Uroxatral

Afluzosin

selective alpha1 blocker for BPH

Rapaflo

Silodosin

selective alpha1 blocker for BPH

Alpha1 blocker warnings

orthostatic hypotension/syncope

Intraoperative floppy iris syndrome during cataract surgery

Alpha1 blocker SE

dizziness, fatigue, headache, abnormal ejaculation

How long to determine beneficial effects of alpha1 blocks in BPH

4-6 weeks

Retrograde ejaculation is common in which alpha blocker

silodosin (Rapaflo)

Which BPH treatment is contraindicated with alpha1 blockers

tadalafil, instead can be used with finasteride if enlarged prostate present

When to use a 5 alpha reductase inhibitor in BPH

finasteride, dutasteride

• enlarged prostate

  • can be used in combination with alpha blocker to improve symptoms, decrease risk of urinary retention, decrease need for surgery

5 alpha reductase inhibitor in BPH CI

women of child bearing potential, pregnancy, children

5 alpha reductase inhibitor in BPH SE

impotence, decreased libido, ejaculation disturbances, breast enlargement and tenderness

Onset of 5 alpha reductase inhibitor in BPH

6 months for max efficacy

Entadfi

Finasteride + tadalafil

Avodart

Dutasteride

Jalyn

Dutasteride + tamsulosin

First line treatment for urinary incontinence

behavioral therapies, exercises

First line drugs for urinary incontinence

anticholinergics- oxybuytnin

Beta3 receptor agonist- mirabegron

Detrol indication

Tolterodine, anticholinergic for urinary incontinence

Vesicare

Solifenacin, anticholinergic for urinary incontinence

Oxybuytnin patch duration

twice weekly

Ditropan XL formulation

oxybutynin ER with ghost shell

Myrbetriq

Mirabegron

beta3 agonist for urinary incontinence- relaxes the detrusor muscle

less dry mouth

Myrbetriq warnings

mirabegron

• urinary retention when used with anticholinergic drug

• increase BP

Third line refractory treatment for urinary incontinence

Botox

Nocturia treatment

Desmopressin

• antidiuretic hormone that decreases urine production

DDAVP BW

Desmopressin

BW: hyponatremia

CI: fluid retention

Samsca

Arginine Vasopressin Receptor Antagonist

Tolvaptan

for hyponatremia

Samsca BW

Tolvaptan for hyponatremia

BW: initiated and re-initiated in a hospital

> 12 mEq/L/24h is associated with Osmotic Demyelination Syndrome: paralysis, seizures, death

Samsca warnings and SE

Tolvaptan for hyponatremia

Warnings: hepatotoxicity

SE: thirst, nausea, dry mouth, polyuria

Monitor rate of Na increase

Samsca limit

Tolvaptan

PO daily

max 30 days due to hepatotoxicity

KCl peripheral line max infusion rate and concentration

rate 10 mEq/mL

concentration 10 mEq/100 mL

Gammagard BW

IVIG- multiple sclerosis, myasthenia gravis, Guillain-Barre syndrome

BW: acute renal dysfunction can occur, thrombosis

Octagam

IVIG

Privigen

IVIG

IVIG treatment and vaccinations

impair response to vaccinations

APCHE II score

estimates ICU mortality risk

Dopamine low (renal) dose and receptors

1-4 mcg/kg/min
D1 agonist

Dopamine medium dose and receptors

5-10 mcg/kg/min

B1 agonist

Dopamine high dose and receptors

10-20 mcg/kg/min

Alpha1 agonist

Vasopressor BW/Warning

vesicants

What to treat extravasation with for vasopressors

phentolamine- alpha1 blocker

Epinephrine receptors

alpha1, beta1, beta2 agonist

Norepinephrine receptors

alpha1 agonist > beta1 agonist

Phenylephrine receptors

alpha1

Vasopressin receptors

vasopressin

Nitroglycerin low doses vs high doses

low dose: venous vasodilator

high dose: arterial vasodilator

Nitroglycerin effectiveness limited by

tachyphylaxis after 24-48 hours

Nitroglycerin administration

non-PCV container

Nipride

Nitroprusside

• mixed arterial and venous vasodilator Ni

Nipride BW

metabolism produces cyanide, administer with hydroxocobalamin to reduce the risk of thiocyanate toxicity

excessive hypotension, D5W preferred

Nipiride Warning and SE

Nitroprusside

Warning: increased ICP

SE: HA, tachycardia, thiocyanate/cyanide toxicity N=

Nitroprusside administration

requires light protection, use only clear solutions

Dobutamine receptors

Inotrope- beta1

some beta2 and alpha1 agonism

may turn pink due to oxidation, but potency is not lost

Milrinone receptors

PDE3 inhibitor in cardiac and vascular tissue; inotropic effects with vasodilation

MAP

[2*DBP + SBP]/3

ADHF volume overloaded sx and treatment

sx: edema, JVD, ascites

Treatment: loop diuretics, vasodilators (NTG, nitroprusside)

ADHF hypoperfusion sx and treatment

sx: AMS, decreased renal function, cool extremities

Treatment: inotropes (dobutamine, milrinone)

Precedex receptors

dexmedetomidine

alpha2 adrenergic receptor agonist

Precedex side effects

hypotension, bradycardia

Precedex storage

does not need refrigeration

Diprivan CI

Propofol

CI: hypersensitivity to eggs or soy products

Diprivan calories

1.1 kcal/mL

Ativan formulated with propylene glycol…

lorazepam

propylene glycol can cause acute renal failure and metabolic acidosis

Midazolam CI

3A4 inhibitors