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Why would we not want to give antihistamines and sympathomimetics to a patient suffering from acute bronchitis?
They dehydrate secretions which may prolong symptoms
If our patient has had persistent symptoms of bronchitis, which antibiotics could we give them?
Doxy for mycoplasma atypical coverage
OR
Macrolides
OR
Fluroquinolones (last resort)
When should we draw blood and sputum cultures when suspected for community acquired pneumonia?
Before giving Antibiotics!!
Which antibiotic treatments would we give to a patient experiencing community acquired pneumonia with no risk of resistant Strep Pneumonia?
Macrolide (1st line)
OR
Doxycycline (2nd line)
Which antibiotic treatments would we give to a patient experiencing community acquired pneumonia with RISK of resistant strep pneumonia?
How about if they have an allergy?
Beta lactam + macrolide (NKDA)
OR
Fluroquinolone (with beta lactam allergy)
What is the best way to treat Community acquired pneumonia inpatient non-ICU? NKDA
IV ceftriaxone (beta lactam) + macrolide (IV/oral)
If our patient is suspect for MRSA community acquired pneumonia, what do we use?
Vancomycin
What antibiotic coverage must we always cover for in Nosocomial Pneumonia ?
Pseudomonas and MRSA
Which antibiotic trio would we give for broad spectrum empiric coverage against nosocomial pneumonia?
HINT --> We need two antipseudomonal and gram-positive MRSA coverage
Antipseudomonal Beta lactam (cefepine, meropenum, zosyn)
PLUS
Antipseudomonal fluroquinolone (Levo) or Aminoglycoside
PLUS
Vancomycin or linezolid
NOTE--> Do not use vanco and aminoglycosides together if the patient has renal issues!! (ototoxicity & nephrotoxicity)
What is our combo therapy we use for treating Tuberculosis for the first 2 months?
Then what for 4 months after?
Rifampin
Isoniazid
Pyrazinamide
Ethambutol
Rifampin and Isoniazid (4 months after)
What is the purpose of isoniazid in our combo therapy for TB?
Inhibits the waxy cell coat of TB in order for the other drugs to go in.
NOTE --> Secreted as acetylated metabolite (which patients could have shorter or longer half-lives for it)
What MUST we give to patients taking isoniazid in order to prevent seizures and CNS affects due to pyridoxine deficiency?
Vitamin B6 (Pyridoxine)
Which allergic reaction can be caused from isoniazid?
Lupus like syndrome (butterfly rash)
Rifampin is considered a CYP450 INDUCER, what could that mean for patients taking long term HIV meds or women taking oral contraceptives?
Those meds will be excreted and metabolized much much quicker leading to low levels of them in the body
What is a side affect of rifampin that we must warn our patients about?
HINT: has to do with secretions
Warn them that their tears, sweat, and urine could turn orange
What is a major adverse effect of taking ethambutol?
Decreased red/green discrimination (partial color blindness)
and decreased visual acuity
What is the function of pyrazinamide used in TB infections?
Lowers the pH so bacteria cant grow
What is an adverse affect to taking pyrazinamide in TB infections?
Gout or kidney stones
If our patient is having an anaphylactic reaction, what solution are we gonna give in order to increase blood pressure due to our histamine lowering it during the anaphylaxis?
HINT: know the dosing for this one too :(
IV crystalloids 0.9% (normal saline)
20mL/kg bolus (1-2 L at a time)
for severe cases use 4-8 L
Which drug are we gonna give in order to vasoconstrict and relax bronchial smooth muscles when our patient is experiencing anaphylaxis?
Epinephrine (IM/SC or IV )
What can we give to block histamine during an anaphylactic reaction?
HINT: There's two types, tell me which one has cutaneous and which has systemic effects?
H1 blocker (diphenhydramine or hydroxyzine) --> cutaneous
H2 blocker (famotidine) --> blocks systemic vasodilation
How does albuterol have an effect on smooth muscle?
Beta 2 agonist so it relaxes the smooth muscle
Which drugs act on all aspects on anaphylaxis but take time to work?
HINT: don't use these for acute reactions
Corticosteroids (methylprednisolone IV, or prednisone)
Which drug would we give a patient to provoke a bronchial reactivity (smooth muscle contraction) to assess if the patient indeed has asthma?
methacholine
Fun fact: 20% drop in FVE1 means they have asthma
What are considered quick relief medications for asthma?
HINT: 3 classes
SABAs
Anticholinergics
Systemic corticosteroids
What are considered long term controllers for asthma?
HINT: be broad, just give some classes, there's alot of them
LABAs
Inhaled corticosteroids
Leukotriene modifiers
Mast cell stabilizers
Anti-IgE antibodies
Methylxanthines (theophylline)
Which drug increases cAMP, relaxes smooth muscle and tends to increase heart rate while treating asthma?
beta 2 agonist
Which drugs can we never never never use alone for asthma?
LABAs such as formoterol or salmeterol
How many weeks do inhaled corticosteroids take to work at full effect?
8 weeks
How do we use our LABAs if we cant use them alone?
we use a LABA plus a corticosteroid
What kinds of drugs are effective in aspirin-induced asthma?
Leukotriene modifiers
What are some major weird side effects of omalizumab (xolair) used to prevents degranulation of mast cells?
Neutralizing antibodies may develop and gets rid the drug making it ineffective (could cause anaphylaxis)
Why would we ever use methylxanthines such as theophylline in real life?
-Theophylline is a phosphodiesterase inhibitor btw
To treat bad status asthmaticus
NOTE: can cause arrhythmias and convulsions (not a good drug tbh)
Which two systemic corticosteroids can be given parenterally?
Methylprednisolone and Dexamethasone
What is one downfall to using a nebulizer for inhaled meds?
You get such high does of the drug which could amplify side effects
How long should we wait in between puffs when using an
inhaled beta 2 agonist?
15-30 seconds
Which 4 drugs do we normally give to patients experiencing status asthmaticus?
Continuous albuterol nebulized
Steroids
Magnesium
Ketamine
What is the mechanism of action of bupropion SR for those needing to cut down on smoking/nicotine consumption?
What kind of patients do we avoid giving this too?
bupropion indirectly activates epinephrine and dopamine by binding to the receptors
avoid giving to those with seizure disorder, MAOI's (antidepressants), and nonadrenergic antidepressants
What could nicotine poisoning cause?
Tachyarrhythmias and hypertension
What is a major major side effect of varenicline (Chantix)?
Could cause neuropsychiatric events (depression, suicidal ideations)
Why should we educate our patients to not drink grapefruit juice with Apixaban (eliquis)?
Eliquis is metabolized via CYP3A4
Could lead to adverse bleeding
What is unique about the Oral factor inhibitor Edoxaban (savaysa)?
If the patient's creatinine clearance is >95mL/min (great) then the drug will clear too quickly and could lead to strokes from underlying afib
What is the only apoprotein of LDL in which it binds to LDL and its receptor?
ApoB-100
What is the mechanism of action for HMG-CoA reductase inhibitors (STATINS)
Inhibits HMG-CoA reductase which reduces intracellular cholesterol and upregulates LDL receptors to uptake more non-HDL particles from circulation
What are three statins that are metabolized by CYP3A4?
Atorvastatin, Lovastatin, and Simvastatin
Which organ should we monitor the most when having patients taking statins?
Liver
What adverse reactions can be caused from using statins?
Myalgia (muscle pain) or rhabdomyolysis (breakdown leading to kidney dysfunction)
NOTE: measure CPK in labs
Can we give statins to pregnant patients?
NOOOO
Which drug is an example of a cholesterol absorption inhibitor?
What area of the body is this working on?
Can this be added with a statin?
Ezetimibe (zetia)
Intestines to inhibit cholesterol absorption
Yes, can be an add on with a statin
What kind of drug interactions can we see with ezetimibe (zetia)
Fibric acid derivatives --> liver/bile duct problems
Bile acid sequestrants --> decrease concentration
Antacids --> decrease concentration
Cyclosporin --> increases concentration
What is the main function of Fibric acid derivatives (fibrates)?
Good reduction in triglycerides
Good at raising HDL
NOTE: Fibrates activate PPAR-alpha --> lowers TG
and
Increase expression of ApoA-1--> raises HDL
If we have a patient with a familial history of just high triglycerides or low HDL, which drug class would be of choice?
Fibrates
Should we pair statins and fibrates?
No, myopathy would be more likely to occur
Note: Fibrates have interactions with most cholesterol drugs and also warfarin
Can we given Fibrates the pregnant women?
How about those with gallbladder disease?
No and No
What's the purpose of bile action sequestrants (resins)?
How does it reduce LDLs?
They bind to bile acids in the GI system and prevent the recirculation of cholesterol, excreting it in the feces
--> This causes the liver to secrete more bile acids and make more LDL receptors --> lowering LDLs
Can we use bile action sequestrants for pregnancy?
Yes!! Does not get absorbed
Note: GI upset is bad, really depends on the patient's choice
Does increasing the dose of bile acids sequestrants help make it more effective?
Nope, just increases the side effects
When should we tell our patients to take bile acid sequestrants?
Hint: with food/without food/ in the morning? which one is it?
Within 1 hr of a meal
What can bile acid sequestrants increase?
Triglycerides
Not good for those who already have high triglycerides
How would we avoid bile acid sequestrants from interacting with alot of cardio drugs?
We either have the patient take the cardio meds 1 hour before taking the Bile acid sequestrant
OR
Have them take the cardio meds 4 hours after taking the bile acid sequestrant
How does Niacin work?
Decreases hepatic production of VLDL and apo B
--> decreases Triglycerides
--> Increases HDL
What is the extended release Niacin supplement called?
Niaspan
How can we prevent patients from obtaining a cutaneous flushing rash that Niacin can create?
Give aspirin prophylactically
Can Niacin mess with glucose and uric acid levels?
Yes, monitor them
Note: Don't advise patients to take niacin if they have a Hx of diabetes, hyperuricemia, PUD, or liver disease
Can you drink alcohol when using niacin?
Nope, advise not too due to the flushing
How do PCSK9 inhibitors work?
Why aren't they used often?
Monoclonal antibodies that block enzymes which keep LDL receptors active longer
Not used because it's only an injectable and expensive
What are two high intensity statins?
Atorvastatin (CYP450/ GRAPEFRUIT JUICE)
Rosuvastatin
How do loop diuretics work?
Which specific carrier does it inhibit?
Stops the reabsorption of sodium in the ascending loop of henle which keeps water in the lumen
Inhibits the Na-2Cl-K carrier
Where would aldosterone have the most affect in the kidney?
Distal tubule
Where would potassium sparing diuretics have the most affect in the kidney?
Collecting duct
What electrolytes are typically excreted when we give a patient loop diuretics
Hint: There's 3 main ones
Calcium, magnesium, and potassium
What is the main loop diuretic used in clinical practice?
Furosemide (Lasix) (MAIN GO TO)
Just have an idea about the ones below
Note: Bumetanide (bumex)
Torsemide (demedex)
Ethacrynic acid (edecrin)
Would we want to give loop diuretics to a patient with diabetes?
No, hyperglycemia can occur with this drug
Which type of patients could benefit from loop diuretics?
HINT: Think about the kidney specifically
Those in renal failure and have a creatinine clearance of below 30ml/min
Name some adverse affects for Loop diuretics?
Hypokalemia
Hyperglycemia
Hyperuricemia
Ototoxicity
Azotemia (BUN increases)
Why would we not want to give NSAIDS with patients on diuretics?
NSAIDS block prostaglandin which constricts the afferent arteriole to the glomerulus, thus reducing GRF and urine output. --> counteracts diuretics
Where do thiazide diuretics work in the kidney?
What transporter do they affect?
Work in the distal tubule
Blocks sodium/chloride channel
What is a BIG difference we see in electrolytes when we compare thiazide diuretics vs Loop diuretics?
Thiazide diuretics hold onto CALCIUM!! (less calcium excretion)
NOTE: GOOD for those experiencing calcium kidney stones because the body will reabsorb it from the lumen (the body can handle high calcium levels)
What diuretic should we give to those experiencing chronic kidney stones?
Thiazide Diuretics
What is the chronic use of thiazide diuretics?
To decrease sodium retention leading to less vasoconstriction in the arteriole walls
We know that loop diuretics are better for those with a low creatinine clearance, but which thiazide diuretic is the exception?
Metolazone
Can make a rock pee
Which class of diuretics can cause:
Hypercalcemia
Constipation
Sexual Dysfunction
Thiazide diuretics
Can we combine potassium sparing diuretics with loop or thiazide diuretics?
Yes!
What are the two potassium sparing diuretics?
Amiloride (midamor)
Triamterene (dyrenium)
If our patient has a high potassium lab value (>5) , which diuretics are contraindicated?
Potassium sparing ones (amiloride, triamterene)
AND
Aldosterone Antagonists (spironolactone, eperenone)
What are our two Aldosterone antagonists?
Spironolactone
Eplerenone
Which aldosterone antagonist has significant causes for menstrual irregularities, hirsutism, and gynecomastia?
Spironolactone
NOTE: Use eplerenone instead!
What are our three carbonic anhydrase inhibitors?
Acetazolamide (diamox)
Dichlorphenamide (daramide)
Methazolamide (Glauctabs)
What would we expect our URINE pH to be when taking carbonic anhydrase inhibitors?
How about our serum (blood) pH to be?
Increases in urine (more alkaline)
Decreases in blood (metabolic acidosis)
What CNS condition can carbonic anhydrase treat?
Epilepsy, because carbonic anhydrase inhibitors make the blood more acidic which reduces seizure risk
What do all ACE inhibitors have at the end of their name?
HINT: this is how you distinguish them
PRIL
What types of comorbidities can be benefitted from ACE inhibitors?
Diabetes
HTN
CHF (specifically LV dysfunction)
What is a very common side effect of ACE inhibitors?
Dry cough (due to bradykinin accumulation in lungs)
NOTE: bradykinin accumulation could rarely cause angioedema
Which electrolyte imbalance can occur from using ACE inhibitors?
Hyperkalemia
NOTE: be careful putting patients on ACE inhibitors and spironolactone--> high levels of K+
Can we give ACE inhibitors or ARBS to pregnant patients?
NO! could cause birth defects
Which specific angiotensin pathway do ARBS block?
Angiotensin 1
All ARBS end in ..........
Sartan
What are the affects of calcium channel blockers on arterial and venous tone?
Ineffective at decreasing venous tone but work on arterial smooth muscle best
--> This can decrease afterload and have no effect on preload
Which types of calcium channel blockers work on the myocytes of the heart and which do not?
Non-DPH works on the heart and slows AV conduction --> (diltiazem and verapamil)
DPH (dihydropyridine) does not affect the heart/AV node
Can we give patient's with Heart block or Heart Failure calcium channel blockers?
No