Transcript Spring 2014 Exam 1 OMSI CLIs 2-7

Spring 2014 exam 1
OMSI CLIs
Mosby’s
Alkaline Phosphatase *
assigned pages wrong
• Normally 25-160 IU/L
• Increased:
• Liver disease
• Biliary obstruction
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ALP in cells (Kupffer) lining biliary collecting system
Excreted in the bile
Increased in :
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Extra- and intra-hepatic obstructive biliary disease
Cirrhosis
Bone tumors
Healing fracture
Hyperparathyroidism
Hyperthyroidism
• Decreased:
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Malnutrition
Excessive vitamin D intake,
Pernicious anemia,
Zinc deficiency
Alkaline phosphatase
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Used to detect and monitor diseases of the liver or bone
Test explanation
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Highest concentration found in
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Liver
Biliary tract epithelium
Bone
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Intestinal mucosa
Placenta
Liver disease
• Hepatic tumors, hepatotoxic drugs, and hepatitis increase levels
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Most sensitive test to detect tumor metastasis to the liver
New bone growth elevates ALP
• Osteoblastic metastatic (breast, prostate) tumors
• Paget, healing fractures, RA, hyperparathyroidism, and normal growing
bones are sources of elevated ALP
• ALP1 is liver origin and is heat stable
• ALP2 is inactivated by heat and is bone
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ALP 5’ nucleotidase are elevated in diseases of the liver
ALP
• Interfering factors:
• Recent ingestion of a meal can increase levels
• Young children with rapid bone growth
• Compounds that Increase ALP:
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Albumin made from placental tissue, allopurinol, antibiotics, azathioprine, colchicine,
fluorides, indomethacin, isoniazid, methotrexate, methyldopa, nicotinic acid,
phenothiazine, probenecid, tetracycline, and verapamil
• Compounds that Decrease ALP:
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Arsencials, cyanides, fluorides, nitrofurantoin, oxalates, and zinc salts
Serum amylase p. 60-62
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Ordered frequently to:
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Detect and monitor the clinical course of pancreatitis
When a patient presents with acute abdominal pain
Test explanation
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Most specific for pancreatitis
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Damage to acinar or obstruction of duct by carcinoma or gallstones causes
outpouring into intrapancreatic lymph and free peritoneum
Abnormal levels rise within 12 hours of the onset of the disease
It is rapidly excreted by kidneys
Persistence = pathology
Non-pancreatic diseases that can elevate:
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Amylase is normally secreted from pancreatic acinar cells into pancreatic duct and into
duodenum
Aids in the digestion of carbs
Can be elevated for bowel perforation, penetrating peptic ulcer, duodenal
obstruction, salivary gland infection, ectopic pregnancies, severe diabetic
ketoacidosis
Patients with chronic pancreatic necrosis due to tumor or massive hemorrhage
may cause low amylase levels
Serum amylase
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Interfering factors
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Serum lipidemia factitiously decreases amylase
IV dextrose lowers amylase
Aminosalicylic acid, aspirin, azathioprine, corticosteroids, dexamethasone, ethyl alcohol, glucocorticoids, iodine
containing contrast medium, loop diuretics, methyldopa, narcotic analgesics, oral contraceptives, prednisone
• Increased levels
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Acute pancreatitis, chronic relapsing pancreatitis, penetrating
peptic ulcer into the pancreas
GI disease
Acute cholecystitis
Parotiditis (mumps)
Ruptured ectopic pregnancy
Renal failure
Diabetic ketoacidosis
Pulmonary infarction
After endoscopic retrograde pancreatography
Antinuclear antibody (ANA) p. 9092
• Used to diagnose systemic lupus erthematosus (SLE) and
other autoimmune disease
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Drug-induced SLE
Scleroderma
Rheumatoid Arthritis
Sjogren syndrome
Dermatomyotosis
Polyarteritis
• ANA is a group of protein antibodies that react against cellular
nuclear material
• Normal findings negative at 1:40 dilution.
• Used to rule out SLE, negative results probably not SLE.
Erythrocyte sedimentation rate
(ESR) p. 234-235
• Non-specific test used to detect illnesses associated with acute and
chronic infection, inflammation, advanced neoplasm, and tissue
necrosis or infarction
• Routine test for patient with vague symptoms
• ESR lags behind other indicators early in an infection. May stay
elevated longer in the convalescent stage of a disease or infection.
• Especially helpful for inflammatory autoimmune disease
• Measure rate at which RBC settle in saline solution or plasma per
unity time
• RBC will settle faster with illness due to increased plasma proteins
(fibrogen)
• Westergren Method
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Male up to 15 mm/hr
Female up to 20 mm/hr
Child up to 10 mm/hr
New born 0-2 mm/hr
GGT p. 259-260
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Sensitive to hepatobiliary disease, also an indicator pf heavy and
chronic alcohol use
Test explanation
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Enzyme participates in the transfer of amino acids and peptides across the
cell membrane
Highest concentrations found in liver and biliary tract
Smaller concentrations found in kidney, spleen, heart, intestine, brain, and
prostate gland
Detect liver cell dysfunction highly accurate in indicating even slightest
degree of cholestasis
Detects biliary obstruction, cholangitis, or cholecystitis
Parallels elevation of ALP but more sensitive
Not increased in bone disease
Elevated in 75% of patients that chronically drink
Elevated with MI
Interfering factors
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May decrease late in pregnancy
Drugs that increase: alcohol, phenobarbitol, and phenytoin
Drugs that decrease: clofibrate and oral contraceptives
Gliadin antibodies
Anti-gliadin IgA/IgG; Anti-endomysium IgA; Antitissue transglutaminase IgA p. 263-265
• Endomysial IgA, gliadin IgA, tissue transglutaminase TG-ab
• Diagnose celiac disease and sprue by identifying ab to gliadin
and gluten in affected patients
• Crohn, colitis, and severe lactose intolerance may increase
levels
• Test explanation
Gladin and Gluten are found in wheat products. Patients
cannot tolerate ingestion of gliadin and gluten which are toxic
to intestinal mucosa
• Patients experience severe malabsorptive symptoms
• Gliadin and gluten cause direct mucosal damage and Ig appear
in gut mucosa and in serum
Growth Hormone (aka. GH,
Somatotropin hormone) p. 283-285
• Used to evaluate:
• Dwarfism, adolescents with short stature, delayed sexual maturity, or other
growth deficiencies. (decreased)
• Gigantism (kids) , or Acromegaly [occurs after closer of long bones].
(increased)
• Screening for pituitary hypofunction.
• Produced in acidophil cells in anterior pituitary
• GH is secreted during sleep, exercise, and ingestion of protein and in
response to hypoglycemia (if glucose levels are high, GH should be low,
oral glucose tolerance test used to see if levels suppressed)
• Secretion is episodic GH should be drawn 60-90 minutes after deep sleep. Or
after strenuous exercise for 30 minutes
• GH plays a role increasing protein synthesis, increasing breakdown of
fatty acids in adipose tissue, and increasing the blood glucose level.
• Insulin-like growth factor-1 (IGF-1) or somatomedin C provide a more
accurate reflection for the mean plasma concentration of GH.
• A person with normal IGF-1 almost never has acromegaly.
Lactose tolerance test *
assigned pages wrong
• Used to diagnose lactose intolerance caused by lactase
insufficiency, intestinal malabsorption, maldigestion, or bacterial
overgrowth in small intestine. In enterogenous diarrhea (lactose
broken down but not absorbed due to damaged gut)
• Test explanation:
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Glucose plasma will not rise after the ingestion and the small bowel
is flooded with a high lactose load
Bacterial catabolism occurs in the intestine creates flatus and
hydrogen
Symptoms include flatulence, abdominal cramping, bloating,
diarrhea, and failure to thrive in infants
Lactose load is given and if lactase is absent then the serum
glucose will not rise
Given glucose tolerance test to isolate lack of lactase
Hydrogen Breath test in which expelled air is analyzed for
hydrogen content (goes up) for when bacteria are exposed to
undigested food
Rheumatoid factor (RF) p. 471472
• Negative <60 units/mL
• Used in the diagnosis of RA
• RA:
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morning stiffness for 6 weeks
pain in at least one joint
swelling in at least 1 joint
symmetric bilateral joint swelling,
presence of subcutaneous nodules
radiographic changes
• Abnormal IgG made in synovial joints, act as “antigens”
• IgG and IgM along with Fc attack abnormal IgG
• Immune complexes are activated and joint destruction begins
RF
• Tests mainly for identification of IgM (Reactive IgM and
sometimes IgG and IgA make up Rheumatoid Factor)
• Approximately 80% of pts with RA have positive RF titers
• Must be found in greater than 1:80 dilution
• SLE may also give false positive (dilution usually less than 1:80)
• Other autoimmune dzs, tuberculosis, chronic hepatitis, infectious
mononucleosis and subacute bacterial endocarditis may give
false reading
• Does not disappear in remission, ANA does
• False negatives 20% of time, so negative test not used to rule
out RA.
Somatomedin C (aka insulin like
growth factor-1, IGF-1) p.483-484
• Used to screen:
• Patients with growth hormone deficiency, Pituitary insufficiency,
acromegaly.
• Levels depend on GH levels
• Somatomedins stimulate somatostatin and should feedback to decrease
pituitary.
• Test explanation:
• GHRH (from hypothalamus) -> GH (from anterior pituitary) ->
Somatomedin C/IGF-1 (mostly from liver)
• GH secretion varies widely throughout the day.
• Insulin-like growth factor-1 (IGF-1) provides a more accurate
reflection for the mean plasma concentration of GH.
• Not used to ddx GH deficiency (additional testing needed)
• A person with normal IGF-1 almost never has acromegaly.
IGF-1
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Gigantism
Acromegaly
Stress
Major sugery
Hypoglycemia
Starvation
Deep-sleep state
Exercise
• Decreased:
• GH deficiency (more
tests to ddx)
• Pituitary insufficiency
• Dwarfism
• Laron type dwarfism
(GH receptor
insensitivity)
• Hyperglycemia
• Hypothryoidism
• Etc…
Free Thyroxine Index p 512513
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Evaluate thyroid function
Corrects for changes in thyroid hormone binding serum proteins that can affect T4
Diagnose hypothyroidism and hyperthyroidism esp. in patients with abnormal thyroxinbinding globulin or evaluation during pregnancy (TBGs go up).
Measures the amount of free thyroxine T4 which is only 1% unbound goes into cells and is
activated
Not affected by thyroxin-binding globulin (TBG ) abnormalities so it correlates more
closely to hormonal status than total T4 and T3
If TBG is increased, the T3 uptake decreases and corrects for the increased T4 association
TBG proteins.
If TBG is normal and T4 is elevated, FT4 will be elevated indicating true hyperthyroidism
Low FT4 indicates hypothyroidism
Increased levels:
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primary hyperthyroidism,
acute thyroiditis,
facticious hyperthyroidism,
struma ovarii
Decreased:
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hypothyroidism,
pituitary insufficiency,
Hypothalamic failure
iodine insufficiency
Total Thyroxine p. 15-516
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Diagnose thyroid function and to monitor replacement and suppressive
therapy
Measures T4, both free and protein bound
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T4 is 90% of secreted hormone from thyroid.
Nearly all T3 and T4 are bound by serum proteins (eg TBG, albumin)
TRH (hypothalamus) -> TSH (Pituitary) -> Thyroid hormones
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TSH stimulates thyroid to secrete thyroid hormone
High levels of hormone inhibit TRH
High levels indicate hyperthyroid, low is hypothyroid
TBG affects results (When T4 is bound it is not metabolically active, so
increased binding causes increased secretion of hormones, without
metabolic abnormalities)
Interfering factors:
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increased after iodinated contrast x-ray, pregnancy causes increased levels, amphetamines, clofibrate, estrogens,
heroin, iodinated contrast media, iodine, methadone, and oral contraceptives increase
Decrease levels:
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anabolic steroids, androgens, anti-inflammatory drugs, antithyroid drugs, barbituates, furosemide, nonsteroidal lithium
phenytoin, propranolol, propylthiouracil
Total Thyroxine
High:
• Primary Hyperthyroidism
• Acute thyroiditis,
• Familial dysalbuminemic
hyperthyroxemia*
• facticious hyperthyroidism,
• Struma ovarii,
• TBG increase *
*=difference from Free T4
test
Low:
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Hypothyroidism
pituitary insufficiency
hypothalamic failure
protein malnutrition and
other protein depleted
states*
• iodine insufficiency
• non-thyroid illness
Uric Acid, blood p. 536-537
• Used to evaluate gout or recurrent urinary calculus (Kidney
stones).
• Test explanation:
• Uric acid is a waste product of purine catabolism, made primarily
by liver.
• 75% of uric acid is excreted by the kidneys, 25% by intestinal tract
• Uric acid is poorly soluble and with elevations (hyperuricemia)
crystals can from in kidney’s or ureters or synovium of joints (esp.
distal lower extremity (Gout). Soft tissue deposition are called
tophi.
• Causes of hyperurcemia can be overproduction (eg tumor lysis
syndrome in chemotherapy, enzyme deficiencies) or decreased
excretion (e.g. kidney failure). Many cases are idiopathic
Uric Acid
Increased
• Increased production
• Increased ingestion of purines (foods
such as liver, breads, kidney, anchovies)
• Genetic inborn error in purine
metabolism
• Metastatic cancer
• Multiple myeloma
• Leukemias
• Cancer Chemotherapy
• Hemolysis
• Rhabdomyelysis
• Decreased excretion
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Idiopathic
Chronic renal disease
Acidosis
Hypothryroidism
Alcoholism
Shock or chronic blood volume depletion
states
Decreased
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Wilsons disease
Faconi syndrome
Lead poisoning
Yellow atrophy of the liver
Sigmoidoscopy p. 654-656
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Direct visualization of rectum and sigmoid colon (lower GI is difficult to visualize
on radiography)
Recommended for patients with a change in bowel habits or obvious or occult
blood or abdominal pain
Routine screening for ppl over 50 every 3-5 years in no colorectal cancer risk.
During procedure can remove found polyps, reduce volvulus, obliterate
hemorrhoids
Poor bowel prep may obscure visualization, rectal bleeding may obstruct lens
Contraindications:
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Pts who are uncooperative, with diverticulitis (risk of causing rupture), painful
anorectal conditions, severe GI bleeding or suspected perforation
Detect:
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colorectal cancer,
colorectal polyps,
ulcerative proctitis (Ulcerative colitis frequently involves rectum charateristic, not
found in crohns),
pseudomembranous colitis,
intestinal ischemia (ischemia first causes darkening in the mucosa)
Arthrocentesis p 673-674
• Normal findings:
• Synovial fluid – clear and straw colored with few WBCs, no crystals, and
good mucin clot
• Indications:
• Ddx joint infection, arthritis, crystal-induced arthritis (gout and
pseudogout), synovitis, or neoplasms involving the joint
• Monitor chronic arthritic dzs, inject steroids
• Can be performed on any major joint (examples: knee, shoulder,
hip, elbow, wrist or ankle)
• Adding acetic acid to aspirated joint fluid, should clot
• Poor clot quality in in presence of inflammatory disease.
• If bleeding has occurred into the joint, it may clot spontaneously,
but this is abnormal.
Arthrocentesis p 673-674
• Septic Arthritis:
• Resulting from either penetrating trauma or blood-borne infection (during bacteremia)
• Joint is usually red, warm, swollen, and painful
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Reduced glucose, increased WBCs, increased Protein, Increased lactate.
Gram stain and culture
• Osteoarthritis:
• Non gouty crystals or other degenerative changes can cause chronic and acute flare up.
• Synovitis:
• Inflammatory or infectious
• Neoplasm:
• Protein levels elevated, microcopy may reveal malignant cells
• Joint effusion:
• Fluid in the joint, fluid analyzed to determine source of swelling
• Systemic lupus erythematous, Rheumatoid Arthritis:
• Autoimmune or collagen-vascular dzs can be ass with immunogenic arthritis
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Reduced complement level, increased WBCs, increased protein
• Gout, pseudogout:
• Cystral-induced arthritis with urate crystals or calcium pyrophosphate crystals are deposited
into joint-surrounding structures and joint surface cartilage.
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Inflammation (up WBCs in synovial fluid)
• Trauma:
• Joint effusion or bleeding into joint may occur
Cardiac Nuclear Scanning p.
831-834
• Evaluates myocardial ejection fraction, cardiac flow, cardiac
muscle function, coronary perfusion. Sometimes used in
conjunction with stress testing.
• Screening of adults for past and recent infarction
• Evaluation of ventricular function in patients with myocardial
disease or in patients receiving cardiotoxic drugs
• Evaluation of patients with chest pain and unclear EKG results
(pts with certain medications, bundle branch blocks, ventricular
hypertrophy)
• Evaluation of myocardial perfusion before and after therapy
(examples - bypass, or stents)
Cardiac Nuclear Scanning
• Non-invasive, detects left ventricular muscle function and coronary
artery distribution
• Compounds used most often
• Technetium-99m pertechnetate, (ischemic and infarcted area does
not take up material shows up dark, profusion scan)
• thallium-201, (ischemic and infarcted area does not take up material
shows up dark, profusion scan)
• Technetium-99m pyrophosphate (binds to calcium in a recent
infarcted area (hotspot), myocardial infraction scan, very useful in
delayed diagnoses of MI 5-10days before visit. Ischemic areas do not
wash out material, show up as hotspots)
• IV admin and radiation placed over heart produces an image of the
heart that can be recorded
• Cardiac flow studies inject into jugular or anticubital vein and uses
first pass through heart. Very useful in suspected ventricular septal
defects.
Quantitative fecal/stool fat p.
893-895
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Confirm diagnosis of steatorrhea, when patient has large, greasy, and
foul-smelling stools
Total output of fecal fat per 24 hours in a 3-day stool collection provides
the most reliable measurements.
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Abnormally high fat content confirms diagnosis
Fat retention coefficient is used in infants and children. Coefficient should be
at least 95%.
Increases in fecal fat:
• Cystic Fibrosis:
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Children with CF have obstructed pancreatic ducts so they cannot be expelled
into the intestine
Any condition that causes malabsorption (sprue, Crohns, Whipple,
gallstones, tumor, duct obstructions)
Short gut: causes higher fecal fat
Enemas and laxatives may increase fat
Barium and fiber laxatives decrease
Increased: CF, malabsorption due to celiac, sprue, whipple, crohns or
radiation enteritis, short gut
Stool for occult blood p. 898901
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Screening for colorectal cancer
Test explanation
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Tumors of the intestine grow into the lumen and are subjected to repeat
trauma by the fecal stream
The friable neovascular tumor ulcerates and bleeds
Guaiac chemistry (most common) performed on the stool to detect blood
peroxidase-like activity of hgb, which catalyzes reaction of peroxide and a
chromogen forming ortholidine, producing a blue color.
OB can be detected by immunochemical methods called fecal
immunochemical test (FIT) or immunochemical fecal occult blood test,
these are not affected by red meats or plants like Guaiac, but may fail to
recognize upper GI blood
DNA stool sample test is twice as sensitive as guaiac for colorectal
precancerous, benign or malignant tumors because some polyps don’t shed
blood
Benign, malignant GI tumors, ulcers, inflammatory bowel disease,
arteriovenous malformations, diverticulosis, hematobilia all cause OB
Also Hemorrhoids and swallowed blood result in OB
Stool hemoccult
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Interfering factors
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Bleeding gums following dental procedure or disease
Animal hemoglobin of ingested animal meat
Peroxidase rich vegetables (turnips, horseradish, artichokes, mushrooms, radishes, broccoli, bean
sprouts, cauliflower, oranges, bananas, cantaloupes, grapes)
Anticoags, aspirin, colchicine, iron, nonsteroidal antiarthritics, and steroids
drugs that instigate peroxidation reaction Boric acid, bromides, colchicine, iodine, iron, rauwolfia
Vitamin C inhibits peroxidation reaction causing false negatives
• Results and significance: Can detect occult blood with as little as
5mL lost per day
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GI tumor and polyps
Peptic disease (esophagitis, gastritis, and ulceration)
Varices (from portal hypertension)
IBD (Ulcerative colitis, Crohn disease)
Ischemic bowel disease
GI trauma or surgery
Hemorrhoids and other anorectal problems
Urine amylase p. 953-954
• Normal value up to 5000 somogyi units
• Used to assist in making the diagnosis of pancreatitis although
other nonpancreatic diseases can cause elevated urine amylase
levels
• Levels rise later than blood amylase levels
• Several days after the onset of disease serum may be normal but
urine levels are significantly elevated, useful for detecting
pancreatitis late in the disease course
• Test explanation:
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Kidneys clear amylase, disorders that affect pancreas cause
increased amylase levels in urine
Serum levels rise transiently after resolution of acute phase of
disease, urine levels remain elevated 5-7 days after onset
Not specific for disorders: parotiditis, cholecystitis, perforated
bowel, peptic ulcer, ectopic pregnancy and renal disease
See Serum amylase for test result significance
Toxicology p. 995-997
• Toxicology is used to evaluate for drugs of abuse, overdose, or poisoning
Prescribed drugs (and alochol) Include:
Acetaminophen
Acohol
Amobarbital
Butabarbital
Carbon dioxide
Glutethimide
Lead
Lithium
Meprobamate
Pheobarbital
Phenytoin
Salicylate (aspirin)
Amphetamine
Dextroamphetamine
Methamphetamine
Phenmetrazine
Toxicology
• Drugs last in urine longer than in blood
• Commonly abused drugs
• Marijuana
• THC in urine. Most labs detect carboxy-THC and use 100ng/mL as cut off. Detectable in
urine 1 hour afterwards and persist for 1-3 days afterwards.
• Editorial comment: THC can linger on average up to 10 days for a casual user, two to
four weeks for a people who use marijuana often, and more than a month for people
who use more frequently.
• Cocaine (including crack)
• Metabolite benzoylecgonine detectable in urine 1-4 hours afterwards and for 2-3days
• Phencyclidine (PCP)
• PCP or one of its metabolites detectable in urine 6-18 hours after use and lasts as long as
3 days.
• Amphetamines (esp. Meth)
• In urine about 3 hours after use and last for 1-2 days. Note that OTC cold remedies and
weight loss products often contain amphetamine analogs.
• Morphine and other narcotic alkaloids
• Enter urine in glucuronide conjugated forms 2 hours after use and for 2-3 days. Some
OTC cough syrup can produce positive results.
• Barbituates
• Detected in blood ,urine ,or gastric contents by direct immunoassay
Toxicology
• Common toxins
• Lead
• Delta-ALA accumulates in blood and urine
• Other heavy metals
• Mercury, Arsenic, Bismuth, and Antimony can be identified in urine
• Abuse or use of nonprescription drugs: Urine most useful
• Heave metals and lead poisoning: Blood, urine, CSF, Tissue
specimens
• Suicide attempts: Determination of toxic levels of drugs is
much more accurately determined with blood tests, although
urine may also be used.
Barium enema p.1047-1052
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Visualize colon, distal small bowel, and appendix (BE, Lower GI x-ray series)
Indicated when:
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Determines presence of polyps, tumors, and diverticula also anatomic
abnormalities
Assess filling of the appendix - failure to fill means appendicitis
Affects diseases of ileum like Crohn, IBS, and fistulas
Air contrast can be sufflated to increase accuracy –esp. helpful with small polyps
Contraindicated:
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Abdominal pain
Obvious or occult blood in the stools
IBD
Suspected cancer
Volvulus
Obstruction
with suspected perforation
non cooperative – pts must consciously hold barium in side rectum
Megacolon – barium may worsen condition
May cause perforation, fecal impaction
Residual stool, spasm, and old barium may affect study
Barium enema
Detect:
• Malignant tumor – evident as filling defect “apple core” appearance.
• Polyps – round filling defects, however stool can create same effect
• Diverticula – outpouchings. Diverticulitis is inflammation of these defects in the wall and
may show narrowing
• Inflammatory bowel disease - evident as narrowing of colon
• Ulcerative colitis – may produce cobblestone-like patterns a result of inflammation
surrounding the colon (do not confuse with cobblestone appearance inside lumen!)
• Crohn disease- areas devoid of contrast are classic finding. Rectum is usually involved in
crohn, but spared in Ulcerative colitis. Fistulas may be evident
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Colonic stenosis secondary to ischemia – “non-apple core” like narrowing
Perforated colon – leakage of contrast. Most common cause is cancer or diverticulitis
Colonic fistula– leakage to another organ (example : urinary bladder)
Appendicitis- lack of filling, 30%-60% of normal appendixes do not fill.
Extrinsic compression of colon from extracolonic tumor or absecess – convexity
Malrotation of gut- congenital abnormality cecum usually in RLQ, appears in LUQ
Colon Volvulus – cut off of flow
Intussusception – flow of barium stops at the tip of the intussuceptum.
Hernia – seen inside gut lumen outside abdomen
Bone Densitometry p 10551057
• Findings:
• Normal = <1 SD below normal
• Osteopenia = 1.0-2.5 SD below normal
• Osteoporosis = >2.5 SD below normal
• DEXA = Dual Emission X-ray Absorptiometry
• Dual photons used in x-ray spectrum, can measure density of bones
• [THIS WAS A BONUS QUESTION LAST YEAR]
• Important causes of reduced bone density
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Postmenopausal women, esp. with early menopause
Hyperparathyroidism
Chronic renal insufficiency (vitamin D is activated in kidney and phosphate levels regulated)
GI malabsorption (Vit D is fat soluble, calcium not absorbed)
Anorexia
Certain cancers
Corticosteroid use longer than 3 months
Certain endocrinopathies (eg Cushing syndrome)
Chronic Heparin therapy
Chronic immobility
CBC
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Measures RBC
Hemoglobin
Hematocrit
RBC Indices
WBC count
Blood smear
Platelet count
Mean platelet volume
CBC
• Mean corpuscular volume ( MCV)
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Average volume or size of a single RBC
Divide hematocrit by total RBC count
Large: folic acid or B12 deficiency
Small: iron deficient anemia or thalassemia
• RBC
• # circulating RBC
• Normal life span 120 days
• Lysed and extracted from circulation by spleen
CBC
• Mean corpuscular hemoglobin
• Measure of average weight of hemoglobin within RBC
• Mean corpuscular hemoglobin concentration
• Average concentration or % of hemoglobin within RBC
• RBC distribution width
• Indicates variation of size of RBC
• Important in classifying anemias
CBC
• Blood smear
• Information concerning drugs and diseases that affect RBCs and
WBCs
• Examines RBC, platelet, and WBC
• White count
• Neutrophils, basophils, eosinophils, monocytes, lymphocytes
CBC
• Platelet count
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Number of platelets formed in bone marrow of megakaryocytes
Adult/child 150,000-400,000
Newborn/ premature infant: 100,000-300,000
Infant 200,000-475,000
• Mean platelet volume
• Measure volume of large number of platelets to evaluate platelet
disorders especially thrombocytopenia
Cause of Increased Differentials
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Basophils: Leukemia, s/p spleenectomy
Eosnophils: Allergies, asthma, parasites
Lymphocytes: Viral infections, leukemia
Monocytes: Bacterial infections, protozoan infections,
ulcerative colitis
• Neutophils: Bacterial infection, noninfectious tissue damage,
metabolic disorders
Chem-7
•
•
•
•
•
•
•
Sodium
Chloride
Potassium
Bicarbonate or Carbon dioxide
BUN
Creatinine
Glucose
BMP vs. CMP
• BMP/Chem-7:
•
•
•
•
•
•
•
Sodium
Chloride
Potassium
CO2/Bicarbonate
BUN
Creatinine
Glucose
• CMP/Chem-12:
• Same as BMP plus:
•
•
•
•
•
AST
ALT
Albumin
Bilirubin
Alkaline Phosphatase
Sodium (Na)
• Normally 125-145 mmol/l
• Collect in red top tube
• Increased: Diabetes inspidius, exessive sweating, Cushing’s
syndrome
• Decreased: Excess body water (CHF, renal failure, small cell
lung cancer, brain disorders), hypothyroidism, vomiting,
diarrhea, pancreatitis
Chloride (Cl)
•
•
•
•
Normally 97-107 mEq/L
Collect in tiger top tube
Increased: Diarrhea, hyperalimentation
Decreased: Vomiting, renal disease, diabetic ketoacidosis
Potassium (K)
•
•
•
•
Normally 3.5-5 mEq/L
Collect in red or tiger top tube
Hemolysis may falsely elevate level
Increased: Renal failure, Addison’s disease, dehydration, ACE
inhibitors, Spironolactone
• Decreased: Diuretics, NG suctioning, vomiting, diarrhea,
metabolic alkalosis
Carbon Dixoide (CO2)
•
•
•
•
•
Normally 23-29 mmol/L
Collect in tiger tube top; don’t expose to air
CO2 excreted into blood as bicarbonate
Increased: COPD, severe vomiting
Decreased: Starvation, diabetic ketoacidosis, diarrhea,
dehydration
Blood Urea Nitrogen
•
•
•
•
•
•
Normally 5-20 mg/dl
Collect in tiger top tube
Increased: Renal failure, CHF, aminoglycosides
Decreased: Starvation, liver failure
BUN:Creatinine >20 suggests dehydration
BUN:Creatinine >30 suggests GI bleed
Creatinine
•
•
•
•
Normally <1.1 mg/dl
Collect in tiger or red top tube
Measures blood flow through kidneys
Increased: Renal failure, false positive seen in diabetic
ketoacidosis
• Decreased: Muscle wasting, liver disease
Glucose
•
•
•
•
Normally 80-140 mg/dl
Collect in red or tiger top tube
Slight increase normal with aging
Increased: DM, Cushing’s syndrome, pancreatitis, thiazide
diuretics
• Decreased: Liver disease, malnutrition, sepsis, endocrine
tumors
Arterial blood gases
• Monitor patients on ventilators, monitor critically ill
nonventilator patients, establish preoperative baseline
parameters, and regulate electrolyte therapy
• pH –log[H+]
• Acids normally found in blood: carbonic, dietary, lactic and
ketoacids
• Elevated indicates alkalosis
• Decreased indicates acidosis
Blood gases
• PCO2
•
•
•
•
•
Measure of partial pressure of carbon dioxide in the blood
Measure of ventilation
10% free floating in plasma, 90% carried by RBCs
Respiratory component of acid-base determination
Co2 and pH are inversely proportional
Blood gases
• HCO3- or CO2 content
• Measure of the metabolic component of the acid-base
equilibrium
• Regulated by the kidney
• Directly proportional to pH
• In alkalosis kidneys excrete more into the urine to lower pH
• PO2
•
•
•
•
Pressure of oxygen dissolved in plasma
Indirect measure of O2 content
Determines effectiveness of oxygen therapy
Determines the force of oxygen to diffuse across the pulmonary
alveoli membrane
Blood gases
• Oxygen saturation
• Percentage of hemoglobin saturated with oxygen
• As PO2 decreases so does saturation of hemoglobin
• Oxygen content
• The amount of oxygen in the blood
• Nearly all of it is bound to hemoglobin
• Base excess/deficit
•
•
•
•
Amount of
anions in the blood, bicarbonate being the largest
Also hemoglobin, proteins, phosphates
Negative base excess indicates acidosis, positive alkalosis
Urinalysis
•
•
•
•
Bilirubin: Jaundice, hepatitis, fecal contamination of sample
Blood: Stones, BPH, infection, Foley cath
Glucose: DM, pancreatitis, steroids
Ketones: Starvation, high fat diet, diabetic ketoacidosis,
vomiting, diarrhea, aspirin overdose
• Leukoesterase: UTI
• Leukoesterase plus nitrates: 75% of UTI
• Neither LE or nitrates: 92% not UTI
• Protein: Renal failure, CHF
• Glucose, Ketones, Leukoesterase and bilirubin in urine is never
normal
urinalysis
•
Normal:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Appearance: clear
Color: amber yellow
Odor: aromatic
pH 4.6-8
Protein 0-8 mg/dL
Nitrites none
Crystals none
Bilirubin none
Urobilinogen 0.1-1
Casts none
Glucose none
WBC 0-4 low power field
RBC <2
RBC casts none
Specific gravity 1.005-1.030
Leukocyte esterase negative
Ketones none
Ua
• Indications: used as part of routine diagnostic and screening
evaluations can give info on kidneys, performed on essentially
everyone
• Test explanation: divided one is sent to UA the other half is
cultured
• Lab exam:
• Color: clear, cloudy indicates WBC, RBC or bacteria, color
indicates concentration of urine and varies specific gravity,
abnormal color may indicate bleeding from kidney (dark red)
bleeding from lower UT (bright red)
• Dark yellow indicates urobilinogen or bilirubin
• Pseudomonas could cause green urine
UA
• Odor:
• Diabetics have strong, sweet smell of acetone
• UTI causes foul odor
• Fecal odor could be a fistula
• pH
• Alkaline indicates alkalemia, bacteria, UTI or citrus fruits or
vegetables, common after eating
• Acidic urine: dehydration, high meats and cranberries,
• Alkaline causes calcium carbonate, phosphate and magnesium
phosphate stones
UA
• Protein
•
•
•
Indicates if glomerular membrane is intact like in
glomerularnephritis, protein then seeps into urine and can lead to
hypoproteinemia which decreases capillary oncotic pressure
causing edema called nephrotic syndrome
Proteinuria indicates renal disease or preeclampsia
Indicates complications of DM, glomerularnephritis, amyloidosis,
multiple myeloma
• Specific gravity
•
•
•
•
•
High indicates concentrated urine
Low is dilute urine
Weight of urine compared to that of pure water
Chronic diseases associated with low specific gravity measure of
hydration status
Dehydration causes it to be really high
• Leukocyte esterase
•
Positive indicates UTI
UA
• Nitrites
•
Screening for UTI, bacteria produce reducase converting nitrates to
nitrites
• Ketones
•
Poorly controlled diabetes and hyperglycemia, massive fatty acid
catabolism
• Bilirubin and urobilinogen
•
Conjugated bilirubin is water soluble, indicates disease affecting
bilirubin affecting bilirubin metabolism after conjugation or defects
in excretion indicate previously suspected liver disease, gallstones,
or drug toxicity
• Crystals
•
•
•
Indicate renal stone formation is imminent
Can be with high serum uric acid levels
Parathyroid causes high phosphate and calcium crystals
UA
•
Casts
•
•
Rectangular clumps that form renal distal and collecting tubules, pH must be acidic and urine
concentrated
Hyaline
•
•
Cellular
•
Granular
•
•
•
•
•
Conglomerations of degenerated cells
•
After exercise and renal disease, result from disintegration of cellular material into granular particles
within a WBC
•
Some diseases epithelial cells desquamate into renal tubule fatty droplets become free oval fat bodies or
incorporated into proteins associate with nephrotic syndrome or nephrosis, fatty emboli or bone
fractures
Fatty
Waxy
•
•
Conglomerations of protein, proteinuria
Cell, hyaline, renal failure or further degeneration of granular casts, associated with chronic renal disease
and renal failure or diabetic nephropathy, malignant hypertension, and glomerularnephritis
Epithelial
•
•
Shed from bladder from tumor, infection, or polyps
Tubule epithelial casts indicate glomerulonephritis
•
•
•
Five or more indicate UTI involving bladder, kidneys, or both
Inflammatory nephritis, glomerulonephritis
pyelonephritis
•
Bladder, urethral, and ureteral disease, tumor, trauma stones infection, glomerloneprhitis, renal infarct,
goodpasture, vasculitis, sickle cell, interstitial nephritis, tubular necrosis, pyelonephritis
WBC
RBC
Lipoproteins
• Lipoproteins Should be collected after a 12-14 hour fast.
• Measured and classified by their density.
• Interfering Factors: smoking and alcohol ingestion decrease HDL,
binge eating alter lipoproteins, HDL values are age and sexdependent, HDL values (similar to cholesterol) decrease for 3
months post-MI, elevated HDL in hypothyroid, high triglyceride
levels make LDL calculations inaccurate.
• General Categories:
• Chylomicrons-carry TAGs from the intestine to liver, skeletal muscle, adipose
tissue
• VLDLs- carry newly synthesized TAGs from liver adipose tissue. VLDLs are the
predominant carriers of triglycerides. To a lesser degree, VLDLs are also
associated with increased risk of CAD because they can be converted to LDL
by lipoprotein lipase in skeletal muscle.
• IDLs- intermediates between VLDLs and LDLs, not detectable in blood
• LDLs- carry cholesterol from liver cells of the body. “bad cholesterol”
• HDLs- collects cholesterol from the body’s tissues and brings it back to the
liver, protective effect against heart disease. Out of the 5 subclasses of HDL,
only 2b is cardioprotective
Lipoproteins, pp. 356-361
• Risk for Coronary Heart Disease Based on Ratio of Cholesterol to
HDL
• High levels of LDLs are atherogenic…target levels vary according to
risk profile of patient (see p. 359). LDL= total cholesterol- ((TGs/5)HDL). SGGE divides LDL into 7 classes based on particle size. IIIa and
IIIb are the most commonly elevated forms, IVa and IVb are
associated with aggressive arterial plaques (nearly all patients with
IVa and IVb levels greater than 10% of total LDL have a
cardiovascular events within months!)
• LDL patterns have been identified to assess risk of CAD:
• (LDLs can be lowered with diet, exercise, and statins)
• LDL Pattern A: mostly large LDL particles, no increased risk for coronary
artery disease (CAD)
• LDL Pattern B: mostly small LDL particles associated with increased risk for
CAD
• Intermediate pattern: small and large LDL molecules, carries an intermediate
risk.
Lipoproteins (356 – 360)
• Lipoproteins- accurate predictor of heart disease
• -Proteins in the blood whose main purpose is to transport
cholesterol, triglycerides, and other insoluble fats
• -Used as markers to indicate the levels of lipids
Risk of CHD
Male
Female
½ the average
3.4
3.3
Average (3:1)
5.0
4.4
2x average (moderate)
10.0
7.0
3x average (high)
24.0
11.0
Risk for Heart Disease
Male
Female
High
60 mg/dL
70 mg/dL
Moderate
45 mg/dL
55 mg/dL
Low
25 mg/dL
35 mg/dL
Drugs
Drug
Uses
Side effects
Contraindications
Therapeutic
considerations
Alendronate
Class: Bisphosphonate
Mech: Decreases bone
reabsorption by osteoclasts;
blocks a step in the
mevalonate pathway
Indications:
•
Osteoporosis
prevention and
treatment
•
Paget’s disease
•
Jaw osteonecrosis in
cancer patients
•
•
•
Extended skeletal
effects,
•
Cessation of bone
remodeling
•
•
unclear how to
define overdose
•
Gastroesophageal pain
•
IV dose corrects
hypercalcemia in
days
all secreted by kidney
Calcitonin
(Salmon)
Mech: binds to and
activates a G-protein
coupled receptor on
osteoclasts to decrease
resorptive activity
Indications:
•
Hypercalcemia
•
Paget’s disease
•
Postmenopausal
osteoporosis
•
•
•
•
Raloxifene
Class: Selective estrogen
receptor modulator (SERMs)
Mech: Estrogen receptor
agonist in bone, estrogen
receptor antagonist against
endometrium and breast
Indication:
• Osteoporosis prevention
• Retinal vascular
occlusion
• Venous
thromboembolism
• Pulmonary embolism
• Hot flashes
• Leg cramps
Delayed gastric emptying
Inability to sit up for 30
minutes after taking drug
hypocalcemia
•
Flushing
Nausea
Diarrhea
Tachyphylaxis
• Hypersensitivity
• Nasal spray or
subcutaneous
• Subcutaneous lowers
blood calcium over
hours
• Pregnancy
• History or presence of
venous thromboembolism
• Decreases breast
cancer incidence
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
Enalapril
Class: ACE Inhibitors
Mech: Decreases
conversion of angiotensin
(AT) I to AT II, which
decreases
vasoconstriction of
arterioles, aldosterone
synthesis, renal proximal
tubule NaCl reabsorption,
and ADH release; also
inhibit degradation of
bradykinin, which
increases vasodilation
Indications:
• Hypertension
• heart failure
• diabetic nephropathy
• MI
• Angioedema (more
frequent in black
patients)
• Agranulocytosis
• Neutropenia
• Cough,
• Edema
• Hypotension
• Rash
• Gynecomastia
• Hyperkalemia
• Proteinuria
• History of
angioedema
• Bilateral renal artery
stenosis
• Renal failure
• Pregnancy
• Ester prodrug activated
in plasma
• Bradykinin causes cough
and edema; angioedema
can be potentially lifethreatening
• Delays progression of
cardiac contractile
dysfunction in HF and
after MI; delay diabetic
neuropathy
• Co-admin with
allopurinol may
predispose to
hypersensitivity rxn
including Steven Johnson
syndrome
Amlodipine
(Dihydropyridine)
Class: Calcium channel
blocker
Mech: calcium channel
blocker
Indication:
• Exertional angina
• Unstable angina
• Coronary spasm
• Hypertension
• Hypertrophic
cardiomyopathy
• Pre-eclampsia
•
•
•
•
•
•
•
•
• Preexisting
hypotension
• Arteriolar dilation
greater than venous
• High vascular to cardiac
selectivity
• Less depression of
myocardial contractility,
minimal effects on nodal
conduction
• Higher bioavailability,
longer time to peak
plasma concentration,
and slower hepatic
metabolism
Increased angina,
Rare MI
Palpitations
Peripheral edema
Flushing
Constipation
Heartburn
Dizziness
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
Naproxen
Propionic acid
(NSAID)
pseudoporphyria,
See Ibuprofen
•
•
•
Mech: See Ibuprofin
mild to moderate
pain, fever,
osteoarthritis, RA,
dysmenorrhea, gout
Ketorolac
Acetic acid (NSAID)
See Ibuprofen
See Ibuprofen
Stomach upset or
pain, constipation,
diarrhea, nausea or
vomiting
Diabetes, infants,
may upset ulcers,
not to be take with
thalassemias, may
irritate IBS
See Ibuprofen
FeSO4
Iron supplement for
anemia due to blood
loss and iron
insufficiency
Longer half life,
20x more potent
than ibuprofen,
causes fewer GI
adverse affects
Analgesia in
postsurgical patients,
used for no more
than 3-5 days
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
Donepezil
Class: Antiacetylcholinesterase
Diarrhea, nausea,
vomiting, cramps,
anorexia, vivid dreams
Treatment
associated liver
function test
abnormalities
Modest symptomatic
benefits
ACHe inhibitors
Same as
omeprazole
Given as IV
Mech: Increases ACh
by blocking breakdown
in synapse
=symptoms of
hyperactive
parasympathetics
Mild to moderate
Alzheimer’s/Dementia
Pantoprazole
Same as omeprazole
Same as omeprazole
-erosive esophagitis
-bleeding ulcer
Omeprazole
Proton pump inhibitor:
decrease acid secretion by
irreversibly inhibiting H+/K+
ATPase on parietal cells
Peptic ulcer disease, GERD,
erosive esophagitis, gastic
acid hypersecretion
h. Pylori GI tract infection
Pancreatitis, hepatotoxicity,
interstitial nephritis, may
affect effects of clopidigrel
increased risk of hip, wrist
and spine fracture, hospital
acquired pneumonia, and
enteric infections including
clostridium difficile,
salmonella, E. coli,
headache, rash, GI
discomfort, diarrhea,
anorexia, asthenia, back pain
hypersensitivity
Proton pump inhibitors
metabolized in liver by
CYP2C19 and CYP3A4 drug
interaction with ketoconazle
or itraconazle due to acid
environment needed to
absorb azole drugs
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
Aluminum
hydroxide
Symptomatic relief of
dyspepsia associated with
peptic ulcer disease, GERD
or hiatal hernia
Phosphate depletion (severe
weakness, malaise anorexia),
constipation, osteomalacia
in patients with renal failure
hypersensitivity
All antacids can potentially
increase or decrease the
rate or extent of absorption
of concurrently administered
oral drugs by changing
transit time or by binding
the drug
Magnesium
hydroxide
Same as above
Diarrhea, hypermagnesemia
in patients with renal failure
Hypersensitivity
Same as above
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
levothyroxine
Hormone,
T4, for hypothyroidism,
myxedema coma
Replaces missing hormone
Hyperthyroidism,
osteopenia, pseudotumor
cerebri, seizure, myocardial
infarction
Acute MI, uncorrected
adrenal cortical
insufficiency
Untreated
thyrotoxicosis
Cholestyramine and sodium
polystyrene sulfonate
decrease absorption of
synthetic thyroid hormone
Rifampin and phenytoin
increase metabolism
T4 desirable because of its
longer half life
Hydrocortisone
• Corticosteroid
•
Replacement therapy
for primary and
secondary adrenal
insufficiency
•
Reduces inflammation
Cushing syndrome, reduces
bone density with chronic
use
Fungal infection
Verapamil
(Phenylalkylamine)
Class: Calcium channel blocker
Mech: block voltage-gated Ltype calcium channels &
prevent influx of calcium that
promotes actin-myosin crossbridge formation
Indications:
• Prinzmetal or variant
angina or chronic stable
angina
• Hypertension
• A fib or flutter, paroxysmal
SVT
•
•
•
•
•
•
•
•
• IV is contraindicated
in patients with
ventricular
tachycardia and
patients receiving IV
beta blockers
• Sick sinus syndrome
or 2nd or 3rd AV block
• SVT associated with
bypass tract
• Left ventricular failure
• Hypotension
• Acute MI
Rare cardiac arrhythmia
AV block
Bradyarrhythmia
Exacerbation of heart failure
Peripheral edema
Syncope
Gingival hyperplasia
Dizziness
• Low ratio of vascular to
cardiac selectivity
• Depresses both SA and AV
node conduction velocity
• Raises serum
carbamazepine levels which
may cause toxicity
• Avoid using with beta
blockers
• Greater suppressive effect
on cardiac contractility
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
Acetominophen
Class: NSAID
Mech Weak inhibitor of peripheral
cyclooxygenases; predominant
effect may be inhibition of
cyclooxygenase-3 (COX-3) in the
CNS
Indications: Fever
Mild to moderate pain
Hepatotoxicity,
nephrotoxicity (rare)
Rash, hypothermia
Hypersensitivity to
acetaminophen
•
Ibuprofen
Class: Propionic acids:
Mech: Inhibit cyclooxygenase-l (COXI) and cyclooxygenase-2 (COX-2),
decreasing the biosynthesis of
downstream eicosanoids and thereby
limiting the inflammatory response
Indications:
•
Mild to moderate pain
•
Fever
•
Osteoarthritis, rheumatoid
arthritis
•
Dysmenorrhea
•
Gout
Gastrointestinal
hemorrhage,
ulceration,
perforation;
nephrotoxicity;
Stevens-Johnson
syndrome;
Gastrointestinal
disturbance, tinnitus
Gastrointestinal or
intracranial
bleeding
Coagulation defects
Asthma, urticaria, or
allergic-type
reactions after
taking NSAIDS,
due to risk of severe,
even fatal,
anaphylactic
reactions
Significant renal
insufficiency
N-Acetylcystine
Mech: Supplies cysteine to replenish
glutathione
Indications:
• Acetominophen Overdose
Although acetaminophen has
analgesic and antipyretic effects
similar to aspirin, the anti inflammatory effect of
acetaminophen is insignificant
because of its weak inhibition of
peripheral cyclooxygenases
•
Acetaminophen overdose is a
leading cause of hepatic failure
• Antidote for acetaminophen
overdose is N-acetylcysteine
ANTIDOTE FOR
ACETOMINAPHEN OD
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
Celecoxib
Class: COX-2 inhibitor (NSAID)
Mech: Selectively inhibits COX-2
Indications:
•
Osteoarthritis, rheumatoid
•
arthritis in adults, and
•
ankylosing spondylitis
•
Primary dysmenorrhea
•
Acute pain in adults
•
Familial adenomatous
polyposis
Myocardial infarction, ischemic
stroke, heart failure;
gastrointestinal bleeding,
ulceration, perforation;
renal papillary necrosis;
exacerbation of asthma
Gastrointestinal disturbance,
peripheral edema
Hypersensitivity to
sulfonamides
Hypersensitivity to
celecoxib
Asthma, urticaria, or
allergic-type
reactions after taking
NSAIDs,
due to risk of severe, even
fatal,
anaphylactic reactions
Pain associated with
coronary
artery bypass graft surgery
•
Class: carboxylated imidazole
Mech appears to facilitate GABAminergic neurotransmission
by increasing the number of
available GABA receptors, possibly
by displacing endogenous inhibitors
of GABA binding
Indications:
IV anesthesia
intubation
Can cause adrenal insufficiency,
can cause seizure activity
Labor / Imminent Delivery
Class: Opioid agonist
Mech: activates u-recptor in GI
tract, specifically in the myenteric
plexus, reduces muscle tone and
decreases parastalis
Indications:
• Diarrhea
•
•
•
•
•
Only COX-2
inhibitor still
on market!
Etomidate
Loperamide
OTCImodium
Septic shock
dry mouth
dizziness
drowsiness
vomiting
stomach pain, discomfort,
or distention (enlargement)
•
constipation
•
fatigue
-anticholenergic effects (turns
off parasympathetics)
Under two years of age
Paralytic ileus
•
•
Decreases efficacy of ACE
inhibitors
Incidence of gastropathy
and nephropathy may be
less than that associated
with NSAIDs, but may still
be significant
Valdecoxib and rofecoxib
recently withdrawn from
U.S. market due to
possible increase in
cardiovascular mortality
Drug
Uses
Side effects
Contraindications
Therapeutic considerations
Ranitidine
Class: H2 RECEPTOR
ANTAGONISTS
Mech: Decrease acid
secretion by inhibiting
histamine binding to H2
receptors on parietal cells
Indications:
•
Peptic ulcer disease
•
Gastroesophageal reflux
disease (GERD)
•
Erosive esophagitis
•
Gastric acid
hypersecretion
Necrotizing enterocolitis in
fetus or newborn,
pancreatitis
Headache, dizziness, arthralgia,
myalgia,
constipation, diarrhea
Hypersensitivity
•
Class: Nicotinic receptor
agonist
Mech: Stimulate opening of
nicotinic ACh receptor
channel and produce
depolarization of the cell
membrane; succinylcholine
persists at the neuroeffector
junction and activates the
nicotinic receptor channels
continuously,
which results in inactivation
of voltage-gated sodium
channels so that they cannot
open to support further
action potentials (sometimes
called "depolarizing
blockade‘)
Indications:
• Induction of
neuromuscular blockade in
surgery
• intubation
Bradyarrhythmia, cardiac
arrest, cardiac arrhythmia,
malignant hyperthermia,
rhabdomyolysis, respiratory
depression Skeletal muscle
myopathies Muscle rigidity,
myalgia, raised intraocular
pressure
Succinylcholine
•
Personal or family history
of malignant
hyperthermia
Skeletal muscle
myopathy
Ranitidine can be given IV
to treat hypersecretory
conditions or to treat
patients who are not able
to tolerate the oral
formulation
Bioavailability of
nizatidine is higher than
that of other H2 receptor
antagonists
Short duration of action makes
succinylcholine
in surgery drug of choice for
paralysis during intubation
Causes transient fasciculations
Upper motor neuron
injury
Extensive denervation of
skeletal muscle