Transcript 1 - RCRMC Family Medicine Residency

Pharmacology Update
Which of the following is TRUE about
using testosterone in older men?<>
A.Testosterone might improve energy,
strength, and libido.<>
B.There are concerns about a possible
increased risk of prostate cancer.<>
C.Oral methyltestosterone should be
tried first.<>
D.Both A and B
Answer
• D.Both A and B
Before starting testosterone you
should check what blood tests?
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A. PSA
B. Hemoglobin
C. Liver Function
D. Hemoglobin A1C
E. A, B, C
F. All of the above
Answer
• E. A, B, C
What level of testosterone is low
and what level is therapeutic in
mg/dl?
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A. 200/400
B. 300/500
C. 300/600
D. 400/ 700
Answer
• C. 300/600
Which of the following is TRUE
about chronic use of proton pump
inhibitors?<>
A.PPIs lower the risk of
fractures.<>
B.PPIs lower the risk of
pneumonia.<>
C.Tapering the PPI when stopping
may help reduce acid rebound
symptoms.<>
D.PPIs increase calcium absorption.
Answer
• C.Tapering the PPI when stopping may help
reduce acid rebound symptoms.<>
Which of the following is TRUE about the
interaction between clarithromycin and
inhaled salmeterol (Advair, Serevent)?<>
A.Clarithromycin can lower salmeterol levels
and make it less effective.<>
B.Clarithromycin can boost salmeterol levels
and cause adverse cardiac effects.<>
C.A similar interaction is seen with
azithromycin and salmeterol.<>
D.A similar interaction is seen with
clarithromycin and formoterol (Foradil).
Answer
• B.Clarithromycin can boost salmeterol
levels and cause adverse cardiac effects.<>
Which of the following is TRUE about using
beta-blockers in patients with chronic
obstructive pulmonary disease?<>
A.Beta-blockers are usually avoided due to
fears of bronchoconstriction.<>
B.New evidence suggests that beta-blockers
might decrease COPD exacerbations.<>
C.Cardioselective beta-blocker (metoprolol,
etc) are preferred for COPD patients.<>
D.All of the above
Answer
• D.All of the above
Most states now have Prescription Drug
Monitoring Programs for controlled drugs.
Which of the following is TRUE?<>
A.These programs are proven to reduce
diversion.<>
B.Information can't be shared with other
states.<>
C.Prescribers can find out if patients are
getting controlled drugs from other
prescribers or pharmacies.<>
D.The information is only available by
phone.
Answer
• C.Prescribers can find out if
patients are getting controlled
drugs from other prescribers or
pharmacies.<>
Which of the following is TRUE about drug
allergies?<>
A.Hydrocodone can be used in a patient with
a true allergy to codeine.<>
B.Cross-sensitivity usually isn't a problem
between sulfa antibiotics and other
sulfonamides.<>
C.About 10% of patients allergic to penicillin
are allergic to cephalosporins.<>
D.People allergic to sulfa drugs also need to
avoid drugs or foods with sulfur, sulfites, or
sulfates.
Answer
• B.Cross-sensitivity usually isn't a
problem between sulfa antibiotics and
other sulfonamides
Opioids.
• Most reactions are side effects or
"pseudoallergies"...and AREN'T immune
mediated. Pseudoallergies are due to histamine
release and can lead to hives, itching, etc. In this
case, try a lower dose...a different opioid...or
pretreat with an antihistamine.
For a true opioid allergy, use one from a
different class.
Patients allergic to codeine CAN usually take
fentanyl, meperidine, or methadone...but NOT
morphine, hydrocodone, or oxycodone.
Avoid tramadol or tapentadol if opioid
reactions were severe
Sulfas.
• Cross-sensitivity usually is NOT a problem
between sulfa antibiotics and other
sulfonamides...thiazides, loops, sulfonylureas, etc.
If patients need a diuretic and must avoid
sulfas, use amiloride, triamterene, spironolactone,
or ethacrynic acid. And yes, ethacrynic acid IS
available again...after being gone a few years ago.
Tell patients allergic to sulfas that they CAN
have foods or drugs with sulfur, sulfites, or
sulfates. Explain these DON'T cross-react.
Penicillin.
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Experts used to think about 10% of
patients allergic to penicillin were allergic
to cephalosporins...and 47% to imipenem.
But actually the risk is only about 1%.
Consider using another beta-lactam if the
penicillin allergy is mild...but avoid betalactams if the reaction to penicillin is
severe.
If in doubt about a reaction and the drug
is critical, consider drug allergy testing...and
desensitization if necessary.
What works for Leg Cramps?
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A. Quinine
B. Magnessium
C. Calcium
D. Requip
E. Gateraid
F. Nothing works well
Answer
• F. Nothing works well
Leg Cramps
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Patients are still looking for something that works for nocturnal leg cramps. Almost half of elderly
patients have frequent leg cramps with no obvious cause. The problem is there are no proven
treatments.
First look for possible causes such as diuretics or beta-agonists. Also check serum potassium,
magnesium, and calcium.
Advise patients to try simple measures...calf stretches, hot or cold packs, hydration with
electrolytes (Gatorade, etc).
Recommend acetaminophen or ibuprofen for pain relief...but explain they won't prevent cramps.
Some experts suggest B-complex vitamins, low-dose diltiazem, or magnesium...but there's only
weak evidence of a possible benefit.
Don't use vitamin E and gabapentin...evidence suggests that they DON'T work for muscle cramps.
Other anticonvulsants and baclofen are sometimes tried for severe cramps, but they aren't proven
to help. Don't use them routinely.
Don't rely on clonazepam or ropinirole for leg cramps, either. These can be helpful for restless
legs syndrome...but there's no evidence that they prevent leg cramps.
Of course the 800-pound gorilla is quinine.
Don't recommend Hyland's Leg Cramps with Quinine or similar homeopathics. Their quinine
content is miniscule and not proven to work.
Tonic water has only 20 mg quinine/cup...not enough to help.
Rx quinine is still used a lot. But FDA questions its efficacy and says the risks are too high for leg
cramps.
Qualaquin is the only approved quinine. But its labeling warns not to use it for leg cramps...and it
costs about $5 per cap.
It's okay to prescribe Qualaquin off-label for leg cramps, but consider the risk of
thrombocytopenia, arrhythmias, etc. Consider using our quinine consent form if you're concerned
about legal exposure.
Qualaquin 324 mg
• Do not use this medication if you have ever had an allergic
reaction to quinine or similar medicines such as
mefloquine (Lariam) or quinidine (Cardioquin, Quinidex,
Quinaglute)
• Do not use if you have a history of "Long QT syndrome";
• glucose-6-phosphate dehydrogenase (G-6-PD) deficiency;
• myasthenia gravis; or
• optic neuritis (inflammation of the optic nerve).
• If you have any of these other conditions, you may need a
dose adjustment or special tests to safely take quinine:
• heart disease or a heart rhythm disorder;
• low potassium levels in your blood (hypokalemia); or
• kidney or liver disease.
How long patients should take
aspirin PLUS clopidogrel
(Plavix) OR prasugrel
(Effient) after a coronary stent.
• A. One month
• B. One year
• C. Depends on the stent
Answer
• C. Depends on the stent
Which of the following is TRUE about antiplatelet
therapy after a coronary stent?<>
A.Dual antiplatelet therapy is usually given for at
least one year after placement of a drug-eluting
stent.<>
B.Aspirin should be stopped at the same time as
clopidogrel.<>
C.Drug-eluting stents have a lower risk of
thrombosis than bare-metal stents.<>
D.Patients who miss one dose of clopidogrel should
get another loading dose.
Answer
• A.Dual antiplatelet therapy is usually given
for at least one year after placement of a
drug-eluting stent.
Preventing Thrombosis
• Patients should get aspirin indefinitely after a stent.
But how long patients should take clopidogrel or prasugrel depends
on the type of stent and the indication for the stent.
Bare-metal stents are quickly coated with endothelial cells which
help prevent stent THROMBOSIS.
But cell overgrowth can block the stent and cause RESTENOSIS.
For bare-metal stents, use dual therapy with aspirin plus clopidogrel
or prasugrel for at least one month for stable patients...and 12 to 15
months for patients with acute coronary syndrome.
Drug-eluting stents are coated with meds to help prevent cell
overgrowth and restenosis. But the stent metal is exposed longer which
can increase the risk for stent thrombosis.
Therefore patients with drug-eluting stents usually need dual
antiplatelet therapy longer to prevent clots than patients with baremetal stents.
Some evidence suggests one year of dual antiplatelets is enough for
drug-eluting stents...but thrombosis risk may persist for years
Which of the following patients are good
candidates for carrying TWO doses of
injectable epinephrine (EpiPen, etc) for
allergic reactions?<>
A.Children under age 6 years old<>
B.People who will be in remote areas<>
C.Patients who have had a prior severe
or hard to treat allergic reaction<>
D.Both B and C
Answer
• D.Both B and C
Epinephrine
• Many people get two pens...to keep at different locations.
Now some experts recommend carrying two doses at a
time.
Up to 20% of patients get a second dose to treat
anaphylaxis.
A second dose is more likely to be needed in patients
over age 10...and those with a previous severe reaction.
Tell patients to carry two doses if they will be in a
remote area...or they have had a more severe or hard to
treat reaction.
Prescribe two auto-injectors (EpiPen, Adrenaclick)...or
one Twinject. Twinjectcosts less than two autoinjectors...but the second dose is given manually so it can
be more difficult to use.
Advise patients to head to the emergency room after the
first dose...and use the second dose 10 minutes after the
first one if symptoms persist or return.
What drug interactions do you
have with OxyContin?
Which of the following is TRUE about drug
interactions with oxycodone (OxyContin,
etc)?<>
A.Oxycodone levels can be increased by
clarithromycin, ketoconazole, or ritonavir.<>
B.Oxycodone levels can be decreased by
carbamazepine, phenytoin, or rifampin.<>
C.Similar interactions are not seen with
codeine, hydromorphone, or morphine.<>
D.All of the above
Answer
• D.All of the above
Answer
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A new black box warning for OxyContin (oxycodone) about interactions with
CYP3A4 drugs.
CYP3A4 is a major pathway for metabolizing oxycodone, therefore 3A4
inhibitors or inducers can affect oxycodone levels.
INCREASED oxycodone levels can be seen when it's combined with 3A4
INHIBITORS...macrolides (clarithromycin, etc), azole antifungals
(ketoconazole, etc), or protease inhibitors (ritonavir, etc).
For example, voriconazole (Vfend) can almost double oxycodone peak
levels and prolong its effects.
DECREASED oxycodone levels can be seen if it's combined with 3A4
INDUCERS...carbamazepine, phenytoin, rifampin, St. John's wort, etc.
Rifampin decreases oxycodone peak levels by more than 50%.
Monitor patients if they need to combine oxycodone with a 3A4 inhibitor or
inducer...and adjust doses if needed.
Observe the same precautions with other oxycodone
products...Percodan,Percocet, etc.
Keep in mind that 3A4 inducers or inhibitors are likely to interact with
fentanyl...and possibly with hydrocodone, tramadol, and propoxyphene.
Methadone can interact with some 3A4 inhibitors or inducers...but probably
through a different pathway.
To avoid 3A4 interactions, prescribe morphine, codeine, hydromorphone,
or tapentadol (Nucynta).
What can be added to Lactulose
to prevent Hepatic
Encephalopathy?
Answer
• Xifaxan (rifaximin) now comes in a 550 mg
tablet to prevent hepatic encephalopathy
due to chronic liver disease
Rifaximin
• Rifaximin is a nonabsorbable antibiotic that originally
came on the market for treating traveler's diarrhea.
Rifaximin helps prevent hepatic encephalopathy by
killing bacteria in the gut that produce ammonia and other
toxins.
Adding rifaximin to lactulose reduces the risk of
recurrent hepatic encephalopathy and hospitalization by
50%. One additional episode is prevented for every 4
patients treated for 6 months.
The downside is that rifaximin costs $1200 per month.
Some clinicians use metronidazole, neomycin, or
vancomycin to TREAT hepatic encephalopathy. But
there's not enough evidence to recommend these
antibiotics for prevention...and there are concerns about
long-term toxicity.
Consider using rifaximin when lactulose alone is not
enough to prevent recurrent hepatic encephalopathy.
CoQ10 may help with
which of the following
• A. Statin myalgia.
B. Heart failure.
C. Hypertension.
D. Type 2 diabetes.
E. Migraines.
F. All of the above
Answer
• F. All of the above
CoQ10
Statin myalgia. There's conflicting evidence about CoQ10's effectiveness
for statin-induced myopathy...but it's safe, well tolerated, and many
people swear by it.
Don't use it for myalgia unless there is a strong reason...for
example, if providing it helps keep your patient on a statin. In that
instance, try 100 mg/day.
Heart failure. Some evidence suggests that 60 to 300 mg/day
improves quality of life and decreases symptoms and hospitalization.
Consider it only as an add-on for patients not well controlled on
traditional heart failure meds...and explain it might not help.
Hypertension. Some small studies suggest using 100 to 120 mg
daily to lower blood pressure...but tell people not to rely on it.
Type 2 diabetes. Some evidence suggests that 100 to 200 mg/day
can slightly lower A1C...but other studies show no benefit. Tell
patients not to rely on it.
Migraines. Preliminary evidence suggests that CoQ10 might reduce
migraine frequency. If patients want to try this, suggest 100 mg
TID...and advise them it can take up to 3 months to see if it helps.
CoQ10 doses up to 3000 mg/day are quite safe...but might cause
nausea or diarrhea. If needed, suggest dividing doses over 100 mg
Propylthiouracil (PTU) for
hyperthyroidism now has a black
box warning because of?
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A. Renal Failure
B. Hepatic Failure
C. Severe Nausea and Vomiting
D. Severe Headaches
E. Severe Myalgias
Answer
• B. Hepatic Failure
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Propylthiouracil
The risk of acute liver failure with propylthiouracil (PTU) is about 1 case per
10,000 in adults...and 1 case per 2,000 for children.
Liver toxicity is not dose-related and can happen anytime after starting
therapy.
Liver function tests don't help detect it earlier...because it comes on
suddenly and progresses rapidly.
Use methimazole (Tapazole) instead for most patients who need a drug to
reduce thyroid hormone synthesis.
Save propylthiouracil for patients who can't tolerate other
options...methimazole, radioactive iodine, or surgery.
Also use propylthiouracil for women trying to get pregnant and during the
first trimester...because methimazole is associated with birth defects. But use
methimazole after the first trimester.
And use propylthiouracil for thyroid storm because propylthiouracil inhibits
conversion of T4 to T3...methimazole doesn't.
Advise patients taking propylthiouracil to stop the drug and alert you if they
get symptoms of liver toxicity.
Keep in mind that both methimazole and propylthiouracil can cause RARE
cases of agranulocytosis within a few months of starting therapy. Tell patients
to report symptoms of infection. If this occurs, check a differential white blood
cell count.
Hormone Therapy in women is
associated with which of the
folowing?
A. Lung cancer
B. Breast cancer
C. Endometrial cancer
D. Colorectal cancer
E. Ovarian cancer
F. A, B, C.
Answer
• F. A, B, C.
“Hormone therapy" (HT) and Cancer
Women still ask if hormone therapy increases cancer risk.
Note the politically correct term "hormone therapy" (HT) instead of "hormone
replacement therapy" (HRT). Authorities don't want people to think these doses
"replace" hormones to their premenopause level.
Hormone therapy helps menopausal symptoms and decreases the risk of osteoporosis
and fractures...but it's associated with some cancers.
Lung cancer is the newest cancer linked with hormone therapy.
Estrogen and progestin MIGHT increase the risk of developing lung
cancer...especially when used for 10 or more years.
It might also promote the growth of existing lung cancer...especially in older women
who smoke...possibly because some lung cancer tumors have hormone receptors.
Breast cancer risk may increase after about 3 years on estrogen plus
progestin...instead of 5 years like experts used to think.
But explain that the risk is very small... 8 more cases of breast cancer per 10,000
women using combo therapy for 5 years or longer.
And the risk starts to decline 2 to 3 years after stopping hormone therapy.
Endometrial cancer risk is 5 times higher for women taking estrogen ALONE for
more than 3 years. Continue to add a progestin to an estrogen for a woman with an intact
uterus.
Colorectal cancer risk was thought to go down based on the initial Women's Health
Initiative report. But longer follow-up now suggests that hormone therapy doesn't
prevent colorectal cancer.
Ovarian cancer risk due to hormone therapy is very small...if any at all. Tell women
that using hormone therapy for less than 5 years is NOT associated with a higher risk for
ovarian cancer.
Continue to recommend caution with hormone therapy...and use small doses for the
Which of the following is TRUE about the
new statin, pitavastatin (Livalo)?<>
A.Pitavastatin lowers LDL more than higher
doses of atorvastatin (Lipitor) or rosuvastatin
(Crestor).<>
B.Pitavastatin lowers LDL more than
60%.<>
C.Pitavastatin doses over 4 mg/day are
associated with more rhabdomyolysis.<>
D.Pitavastatin has a high risk for CYP450
drug interactions.
Answer
• C.Pitavastatin doses over 4 mg/day are
associated with more rhabdomyolysis
Livalo (LIV-al-o, pitavastatin).
•
Reps will promote its high potency and low risk for interactions...but don't get
excited.
It's true, Livalo IS more potent than other statins...but realize this is just
marketing fluff. It refers to Livalo's lower doses...only 1 to 4 mg/day.
But higher potency does NOT mean it's more effective.
Livalo 2 to 4 mg lowers LDL 38% to 45%...similar to Lipitor (atorvastatin)
10 to 20 mg or Crestor (rosuvastatin) 5 mg.
Higher doses of Lipitor and Crestor can lower LDL about 60%.
But don't push Livalo doses over 4 mg/day. Researchers originally started
with higher doses...but these were associated with more rhabdomyolysis.
And there's no proof that Livalo prevents cardiovascular events.
Livalo does have a low risk for CYP450 interactions...similar to Crestor,
pravastatin, or fluvastatin.
Don't use Livalo at this time.
Start with a generic statin for most patients. If using simvastatin,
watchsimvastatin doses and drug interactions.
Go to Lipitor or Crestor for greater LDL-lowering...or Crestor or
pravastatin for fewer drug interactions.
Keep in mind that Lipitor is going generic in 2011.
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How much will 40 mg of
Simvastatin lower your LDL
Cholestrol?
A. 20%
B. 30%
C. 40%
D. 50%
E. 60%
Answer
• C. 40%
What are the relative potency of
the Statins?
Answer you get 40% LDL
reduction of Cholesterol with the
following drugs
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Livalo (LIV-al-o, pitavastatin) 2mg
Simvastatin (Zocor) 40 mg
Lovastatin (Mevacor) 80 mg
Pravastatin (Pravochol) 80 mg
Lipitor (Atorvastatin) 20 mg
Crestor (Resuvasatin) 5mg
All lower Cholesterol by about 40% LDL
reduction
If you double the dose of the
Statin you get _____% more
reduction in Cholestrol?
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A. 4%
B. 6%
C. 8%
D. 10%
E. 12%
Answer
• B. 6%
Increasing Simvasatin from 40 to 80
mg lowers LDL just 6% more but
increases myopathy _____ times.
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A. 2x
B. 4x
C. 6x
D. 8x
Answer
• C. 6x
Simvastatin
• Keep in mind that going from 40 to 80 mg lowers LDL just 6% more
but increases myopathy 6 times.
If a patient needs more LDL-lowering than you can get from
simvastatin 40 mg, consider using Lipitor or Crestor instead.
When you use simvastatin, be careful to use an appropriate dose.
Don't exceed 10 mg with cyclosporine, danazol, or gemfibrozil. Use
fenofibrate instead of gemfibrozil to lower myopathy risk.
Don't exceed 20 mg with amiodarone or verapamil.
Don't exceed 40 mg with diltiazem...or in patients of Chinese
descent who are also taking niacin 1 gram or more/day.
Don't use simvastatin while patients are taking strong CYP3A4
inhibitors...erythromycin, clarithromycin, telithromycin, itraconazole,
ketoconazole, HIV protease inhibitors, or nefazodone
What drugs do you need to
monitor blood tests?
Answer
• We're often asked what lab tests are needed for
certain drugs.
We know potassium should be checked with
diuretics, ACE inhibitors, and ARBs...and liver
function when starting statins.
• liver function with diclofenac
• thyroid function with amiodarone also check
PFT’s
• glucose and lipids with atypical antipsychotics
(Zyprexa, etc)
• CBC with carbamazepine
• platelets with valproate
• lipids withAccutane.
What works as Insect Repellent?
• A. DEET 10% and 30%
B. Picaridin 20%
C. Lemon eucalyptus oil
D. Soybean oil
E. Supplements
• F. A, B, C, D.
Answer
• F. A, B, C, D.
Answer
•
DEET is safe when used as labeled...despite many people's fears.
Recommend up to 30% DEET for adults and kids over 2 months.
Higher concentrations last longer...but there's not much more benefit after
30%. DEET 10% lasts about 3 hrs and 30% about 6 hrs.
Picaridin 20% works up to 8 hours for mosquitoes and ticks...and it isn't as
smelly or oily as DEET. Recommend up to 20% picaridin (Natrapel, etc) for
adults...and 5% to 10% for kids over 6 months.
Lemon eucalyptus oil repels mosquitoes and ticks for up to 6 hours. Don't
use it for kids under 3 years...since it hasn't been tested on them.
Soybean oil (Bite Blocker, etc) protects up to 4 hours for mosquitoes and 2
hours for ticks...and can be used at any age.
Don't recommend citronella oil...it needs to be applied every hour. And
explain that oil impregnated arm bands haven't been shown to work.
Skin So Soft Bug Guard Plus has repellents (picaridin, etc)...but tell people
not to rely on the plain version.
Supplements are often tried such as garlic, brewer's yeast, or B vitamins.
Don't recommend them...there's no proof that they work
Which of the following is TRUE about
intensive treatment of blood pressure and
lipids in patients with type 2 diabetes?<>
A.Most cardiovascular outcomes are similar
when systolic BP is less than 140 mmHg
compared to under 120 mmHg.<>
B.Intensive BP lowering INCREASES the
risk of stroke.<>
C.Fenofibrate plus simvastatin is associated
with better outcomes than simvastatin alone in
diabetes patients.<>
D.Most diabetes patients should have an LDL
goal less than 70 mg/dL.
Answer
• A.Most cardiovascular outcomes are similar
when systolic BP is less than 140 mmHg
compared to under 120 mmHg.<>
BP and Lipids in DM
•
Experts hoped intensive treatment would lower cardiovascular risk.
But recent evidence suggests this may NOT be the case.
Blood pressure. The current thinking is to aim for a systolic BP less than 130 mmHg for diabetes
patients...instead of under 140 mmHg.
But there's no proof this lower BP goal is beneficial.
Now evidence shows similar cardiovascular outcomes when systolic BP is under 140 mmHg
compared to under 120 mmHg...in older patients with long-standing diabetes and high CV risk.
One exception is stroke...but the benefit is modest. Intensive therapy prevents 1 more stroke for
every 89 patients treated for 5 years.
These findings will likely impact future guidelines.
In the meantime, feel comfortable with a systolic goal less than 140 mmHg and APPROACHING
130 mmHg in most diabetes patients.
Consider going for a systolic UNDER 130 mmHg in patients at high risk for stroke...and in those
with kidney disease WITH proteinuria.
And aim for a DIASTOLIC less than 80 mmHg...but over 60 mmHg.
Lipids. Researchers also hoped that more intensive lipid therapy for diabetes would improve
outcomes...but this didn't pan out, either.
Adding fenofibrate to simvastatin DOESN'T improve cardiovascular outcomes compared to
simvastatin alone...in diabetes patients at high CV risk with an average triglyceride level of 164
mg/dL.
Continue to use a statin first for diabetes patients.
Aim for an LDL less than 100 mg/dL in most diabetes patients.
If triglycerides are over 199 mg/dL, check the secondary lipid goal of "non-HDL"
cholesterol...just total cholesterol minus HDL.
Aim for a non-HDL goal 30 mg/dL higher than the LDL goal.
To lower non-HDL, increase the statin...or add niacin or fish oil. Save fenofibrate for when these
aren't tolerated. Monitor glucose more closely when using niacin in a diabetes patient.
What Drug for BPH has just gone
Generic?
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A. Avodart
B. Doxasosyn
C. Tamsulosin
D. Finasteride
Answer
• C. Tamsulosin
Tamsulosin is the latest generic alpha-blocker
for benign prostatic hyperplasia (BPH).
Which of the following is TRUE?<>
A.All alpha-blockers have similar efficacy for
BPH.<>
B.Tamsulosin is more selective for the
bladder and prostate than doxazosin or
terazosin.<>
C.Selective alpha-blockers cause less
dizziness and hypotension, but more abnormal
ejaculation.<>
D.All of the above
Answer
• D.All of the above
Flomax (tamsulosin)
•
Flomax (tamsulosin) is the first SELECTIVE alpha-blocker for
benign prostatic hyperplasia (BPH) to go generic.
This will lead to a round of switching as patients and payors take
advantage of better prices or fewer side effects.
Expect similar efficacy from all alpha-blockers used for BPH.
Choose one based on cost and side effects.
Doxazosin and terazosin generics are still the cheapest...but they're
NOT selective so they cause more dizziness and hypotension.
Tamsulosin and Rapaflo (silodosin) are more selective for the
bladder and prostate...and cause less dizziness and hypotension.
But their drawback is more abnormal ejaculation.
Uroxatral (alfuzosin ER) and Cardura XL (doxazosin ER) are NOT
more selective drugs...but their extended-release formulas reduce
dizziness and hypotension similar to tamsulosin.
The first generic tamsulosin costs about $120 per 30 caps...
compared to about $140 for Flomax. But expect the price to drop much
more soon when additional generics come on the market.
When switching patients, start with the lowest dose of tamsulosin
0.4 mg daily and increase if needed after 2 to 4 weeks.
Which of the following is TRUE about using
long-acting beta-agonists for
asthma?<> A.Long-acting beta-agonists
should be used as monotherapy for
asthma.<> B.Long-acting beta-agonists are
still risky when used with an inhaled
steroid.<> C.It's usually better to prescribe a
combo inhaler (Advair, Symbicort) instead of
giving a long-acting beta-agonist and inhaled
steroid separately.<> D.Long-acting betaagonists should not be used for chronic
obstructive pulmonary disease.
Answer
• C.It's usually better to prescribe a combo
inhaler (Advair, Symbicort) instead of
giving a long-acting beta-agonist and
inhaled steroid separately.
Asthma and Long-acting beta-agnonists
•
Experts agree that long-acting beta-agonists shouldn't be used ALONE for asthma...due
to the risk of severe exacerbations. In fact, these drugs are now CONTRAINDICATED
as monotherapy for asthma.
The FDA also makes a controversial recommendation...to limit using long-acting
beta-agonists for the shortest time possible for asthma.
This goes against the current guidelines.
Asthma patients often do better when a long-acting beta-agonist is added to a lowdose inhaled steroid as the next step. And there's concern that stopping the beta-agonist
will precipitate an exacerbation.
There's no evidence that long-acting beta-agonists are still risky when used with an
inhaled steroid.
Continue to start with an inhaled steroid for persistent asthma.
If a low-dose inhaled steroid is not enough, consider trying an intermediate-dose
steroid before adding a long-acting beta-agonist or montelukast (Singulair).
When adding a long-acting beta-agonist, prescribe a combo
inhaler...Advair(fluticasone/salmeterol) or Symbicort (budesonide/ formoterol)...so
patients keep getting the steroid.
When stepping down therapy, the evidence supports decreasing the steroid dose as a
first step before stopping the long-acting beta-agonist...but feel comfortable doing either
as a first step.
Document your reasons for continuing a long-acting beta-agonist long-term such as
inadequate control or concern about exacerbations.
Keep in mind this new FDA recommendation DOESN'T apply to treating chronic
obstructive pulmonary disease with long-acting beta-agonists... they haven't been shown
to be risky in these patients.
Pennsaid is a new topical diclofenac
solution. Which of the following is
TRUE?<>
A.Pennsaid seems to work about as well
as oral diclofenac for knee
osteoarthritis.<>
B.Topical diclofenac has a similar risk of
GI problems as oral diclofenac.<>
C.About 50% of a Pennsaid dose is
absorbed systemically.<>
D.Pennsaid is applied just once a day.
Answer
• A.Pennsaid seems to work about as well as
oral diclofenac for knee osteoarthritis.
Many drugs can cause QT
prolongation. Which of the
following has a high risk of
causing torsades?<>
A.Clarithromycin<>
B.Methadone<>
C.Levofloxacin<>
D.Both A and B
Answer
• D.Both A and B
•
Torsades.
Many drugs prolong the QT interval, but not all cause torsades.
Give special attention to interactions with high-risk drugs... quinidine, disopyramide,
sotalol, clarithromycin, erythromycin, haloperidol, thioridazine, chlorpromazine, and
methadone.
Lower risk drugs can prolong the QT interval, but aren't likely to cause torsades.
These include amiodarone, azithromycin, quinolones (levofloxacin, etc), SSRIs,
venlafaxine, and ziprasidone (Geodon).
But these lower risk drugs can tip the balance towards torsades if they're combined
with riskier drugs in a high-risk patient.
Some drug combos are a "double whammy" because they increase the QT
interval...AND interact to increase drug concentrations.
For example, avoid combining amiodarone with clarithromycin or other strong 3A4
inhibitors...especially when there are other patient risk factors. Use another antibiotic
instead.
And watch for patients on laxatives or diuretics...these increase the risk of low serum
potassium and magnesium.
Use an alternate med when high-risk drugs are involved... especially in a high-risk
patient.
If there aren't suitable alternatives, monitor ECG at baseline, when doses are
significantly increased, and then every year.
Change drugs if the QT interval is greater than 500 ms...or increases more than 60 ms
from baseline
How can you reduce the Fall risk
in the elderly?
•
•
How can you reduce Fall risk in
the elderly
1. Reduce psychoactive medications. Fall risk can double with every psychoactive med
added.
Consider the total psychoactive med load...antidepressants, hypnotics,
benzodiazepines, narcotics, antipsychotics, muscle relaxants, metoclopramide, older
antihistamines, etc.
Watch for opportunities to lower doses or discontinue meds.
But don't abruptly stop antidepressants, anticonvulsants, antipsychotics, or benzos.
Taper these by 25% per week...or slower for chronic benzos, paroxetine, or venlafaxine.
2. Check for orthostatic hypotension. Change meds if systolic BP drops more than 20
mmHg or diastolic drops more than 10 mmHg.
3. Try to avoid chronic Rx sleep meds...zolpidem, etc.
But explain that OTC sleep meds (diphenhydramine, etc) aren't safer than Rx ones.
The OTCs may be more dangerous because their anticholinergic effects can worsen
cognition.
4. Try to avoid propoxyphene. It's associated with more falls than tramadol or
morphine...and may not work any better than acetaminophen.
If acetaminophen alone isn't enough, try a low-dose codeine/acetaminophen combo
or tramadol instead.
5. Recommend at least 800 IU/day of vitamin D...it may help prevent falls by increasing
muscle strength.
6. Increase muscle strength, by exercising when you are sedentary. Stand up and walk
in place 15 seconds at a time while holding on to something. Work up to 100 a day