Transcript Therapeutics IV - 4-2

Therapeutics IV Tutoring
Lisa Hayes
[email protected]
April 2, 2016
Outline
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GI Lab/Procedures
Upper GI Bleed
Stress Related Mucosal Damage/SUP
GERD
Peptic Ulcer Disease
Adult Liver Disease
Pediatric Liver Disease
Drug-Induced Liver Disease
Hepatitis
Pancreatitis
GI LAB/PROCEDURES
Which of the follow is not a “warning
symptom” that requires further workup?
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A – intractable vomiting
B – weight loss
C – constipation
D – anemia
E – dysphagia
Which of the following are used in the
diagnosis of pancreatitis?
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A – AST/ALT
B – Amylase/lipase
C – Ammonia
D – PT/INR
Which liver marker has the longer half
life?
• A – AST
• B – ALT
Which drug is not known to cause
gastric mucosal irritation?
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A – NSAIDs
B – iron
C – potassium
D – cetirizine
Which antibiotic is known to cause
esophagitis?
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A – cephalexin
B – ciprofloxacin
C – doxycyline
D – metronidazole
Which drug can contribute to GERD?
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A – HCTZ
B – lisinopril
C – metoprolol
D – nifedipine
UPPER GI BLEED
What are the 3 types of injection
therapy that can be used in endoscopy
to treat a UGIB?
• A – 1:1000 epinephrine + isotonic saline +
absolute alcohol
• B – 1: 10000 epinephrine + isotonic saline +
70 % ethanol
• C – 1: 1000 epinephrine + hypertonic saline +
70% ethanol
• D – 1: 10000 epinephrine + hypertonic saline +
absolute alcohol
BB is a patient with a UGIB. She presents with vomiting bright
red blood. She has a history of afib, osteoarthritis, and
depression. She is waiting for endoscopy. What should you
recommend at this time?
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A – Octreotide drip alone
B – Zantac 50mg IV q8h
C – Protonix 8mg/hr, 80mg bolus IV
D – Protonix 8mg/hr, no bolus
FK is a patient with advanced cirrhosis who presents to the ED with his
second GI bleed in 3 months. His last GIB was determined to be a result of a
variceal bleed. Which would be best for the management of his variceal bleed
today?
• A – Vasopressin 0.03units/min
• B – Vasopressin 0.4 units/min
• C – Octreotide 50mcg bolus + Octreotide
10mcg/hr
• D – Octreotide 25mcg bolus + Octreotide
50mcg/hr
The attending wants to know if there is anything he can
prescribe for FK to help prevent further variceal
bleeding. What do you tell him?
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A – Imdur 20mg daily
B – Propranolol 20mg BID
C – Nadolol 40mg TID
D – Metoclopramide 10mg ACHS
STRESS RELATED MUCOSAL
DAMAGE/SUP
TH is a patient in your ICU. She was in a car accident 7 days ago where her
face/head was badly damaged in addition to a severe femur fracture. She has
been on mechanical ventilation since her arrival. Today her BP has dropped
significantly with an increase in HR. Additionally, on the AM labs, you have
noticed her Hgb has dropped by 2.5g/dl. Her Hgb had stabilized before
today’s reading. It appears she has developed SRMD. What should have been
done to prevent her development of this disease?
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A – enteral feeding
B – PPI prophylaxis
C – H2B prophylaxis
D – enteral feeding + PPI prophylaxis
TH is a patient in your ICU. She was in a car accident 7 days ago where her
face/head was badly damaged in addition to a severe femur fracture. She has
been on mechanical ventilation since her arrival. Today her BP has dropped
significantly with an increase in HR. Additionally, on the AM labs, you have
noticed her Hgb has dropped by 2.5g/dl. Her Hgb had stabilized before
today’s reading. It appears she has developed SRMD. Her BP is 95/70. What
should be done now to treat the patient?
• A – octreotide infusion
• B – protonix infusion
• C – dopamine infusion
SH is a patient in your ICU after a ATV accident where he had a severe brain
bleed and broke his pelvis. He is currently on enteral feeds; he is tolerating
these well. He was admitted to the ICU 48 hours ago. He only required
mechanical ventilation for 24 hours after his admission to the ICU. What is
your recommendation for SUP at this time.
• A – Add PPI IV once daily
• B – no additional recommendations at this
time
• C – Add H2B IV once daily
CH is a patient in your ICU who presented 4 days ago with sepsis. He has advanced
cirrhosis with a history of GI bleed 8 months ago. Labs were WNL this AM except for
INR = 1.7. He has been ventilated since his admission. He has been receiving enteral
feeds with a BCAA formulation since day 2 of his admission. What is your
recommendation for SUP?
• A – Add PPI IV Qday
• B – no additional SUP required
• C – Add sucralfate down NG tube QID
GERD
The LES and meds/other agents that act on it can contribute to GERD.
Determine the number of factors that could be acting on the LES in the
following case: AA is a patient who has 2 cups of coffee daily in addition to
her glass of wine each night with dinner. She enjoys tomato based pastas and
laying down in bed to watch television right after dinner. She drinks 1 diet
coke with lunch each day. Her BMI is currently 35. Her favorite meal is buffalo
wings with extra spicy sauce.
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A–4
B–5
C–6
D–7
WR has been diagnosed with erosive esophagtitis as a result of
not being properly counseled on her tetracyline for acne
prevention. How long should we recommend use of PPI?
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A – 2 weeks
B – 4 weeks
C – 8 weeks
D – 12 weeks
Which medication irreversibly blocks
the H/K/ATPase system?
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A – Rantidine
B – Sucralfate
C – Nexium
D – Misoprostol
BY is a patient who had a stent placed 3 months ago and has been on Plavix therapy
since that time. The patient has some GERD symptoms and the physician would like to
try a short course of PPI. He wants to know which would be the best to choose as he
heard a lot of controversy about the combination of these 2 medications.
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A – Omeprazole, cheapest option
B – Protonix, less drug interactions
C – Nexium, available OTC now
D – doesn’t matter, just pick one
TW is a 73 year old AA female who has been on PPI therapy for 2 years. She
refuses to come off her PPI for fear of GI symptoms. You perform a point of
care bone density exam on her and discover she has some osteopenia and
you want to recommend a calcium supplement. What would be the best
choice.
• A – Calcium citrate
• B – Calcium carbonate
VA is a mom who has brought her baby to clinic for increased
reflux symptoms. VA wants to try non-pharmacologic things for
the reflux before any medications as her son is only 2 months old
and she is scared to give him any medications routinely unless it
is absolutely necessary. What would you recommend to VA?
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A – elevate HOB
B – smaller, more frequent feedings
C – optimize burping
D – thicken formula with rice cereal
JH is a patient with mild symptoms of
GERD. What would you recommend
for him.
• A – lifestyle changes only
• B – lifestyle changes + antacids PRN
• C – lifestyle changes + antacids PRN +
omeprazole 40mg daily
• D – lifestyle changes + antacids PRN + Zantac
75mg daily
PEPTIC ULCER DISEASE
In therapy for PUD, what cell do we
focus our efforts on?
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A – parietal cells
B – chief cells
C- foveolar cell (mucus neck cells)
D – G cells
PPIs are drugs that are used to treat PUD. Common PPIs are
omeprazole and pantoprazole. What are common SE of chronic
use of these drugs?
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A – hypokalemia and increased risk for CDiff
B – hypomagnesemia and B12 deficiency
C – low bicarbonate and hyperkalemia
D – B12 deficiency and hyponatremia
What are some issues associated with
H2Blockers (Rantidine, Famotidine,
etc)?
• A – drug, drug interactions + cost
• B – cost + BID dosing
• C – drug, drug interactions + not comparable
between agents
• D – tachyphylaxis + drug interactions
1. What is the drug class of Misoprostol?
2. What are SE that most often warrant its discontinuation by
patients?
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– 1. PPI
– 2. cramping, diarrhea
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– 1. prostaglandin
– 2. cramping, diarrhea
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– 1. H2 blocker
– 2. pregnancy
A patient, EQ, has been diagnosed with H. pylori infection with a urea breath
test. It has been decided he needs treatment for eradication of this infection.
Which of the following regimens would you recommend given he has not yet
undergone any treatment for this infection. He is allergic to Zosyn–
anaphylaxis.
• A – PPI daily, Clarithromycin 500 BID,
Metronidazole 500 BID
• B – PPI BID, Pepto 525mg QID, Metronidazole
500mg QID, Tetracycline 500mg QID
• C – PPI BID, Clarithromycin 500 BID,
Metronidazole 500 BID
• D – PPI BID, Clarithromycin 500 BID,
Amoxicillin 1gm BID
EQ came back for follow up after completion of the regimen you
recommended. On follow-up, he is still experiencing symptoms and it is
discovered he still has active H. pylori infection. The attending asks you to
recommend a proper second course of antibiotic eradication therapy.
• A – Repeat prior course. Ensure compliance
• B – PPI BID on days 1-10; Amoxicillin 1gm on
days 1-5; Metronidazole 500mg BID on days 610; Clarithromycin 500mg on days 6-10
• C – PPI BID, Pepto 525mg QID, Metronidazole
500mg QID, Tetracycline 500mg QID
• D – PPI BID; Pepto 525mg QID; Levofloxacin
250mg BID; Tetracyclin 500mg QID
EW is a 67 year old patient who has been using diclofenac sodium 100mg BID
for treatment of his osteoarthritis. Other pertinent history includes: 1ppd
smoker, 3 OH drinks/wk. Meds: 81mg ASA for heart health, 20mg paxil for
depression. He presents to clinic with complaint of increased heartburn and
GI discomfort. It is determined that he has a ulcer. You as an astute
pharmacist notify the team that is likely secondary to the NSAID use. What is
your recommendation?
• A – Add PPI in addition to diclofenac indefinitely
• B – Add PPI for short term healing of ulcer (2-4
wk) and continue diclofenac after PPI course
• C – Add PPI for short term healing of ulcer (2-4
wk) + change to APAP for treatment of OA
• D – Add PPI for short term treatment of ulcer (24wk). Add misoprostol to diclofenac regimen
indefinitely
Adult Liver Disease
Which of the following hepatic markers can help
tell the severity of liver disease?
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A – ALT/AST
B – Tbili
C – INR
D - AlkPhos
HT presents as a 16beer/day drinker. It is determined he has
severe ALD. He has AMS (indicative of hepatic encephalopathy –
increased NH3 levels on lab report) and his MDF score is 42.
Which of the following therapies would be appropriate at this
time?
• A – no therapy indicated since severe dz
• B – Lactulose enema til AMS resolves
• C – Prednisone 40mg/day for 28 days, then
taper
• D – Pentoxifylline 400mg TID
HG has portal hypertension and a history of variceal
bleeding as a result of his cirrhosis. Which of the
following would be appropriate prophylaxis for repeat
bleeding?
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A – Nadolol 40mg BID, goal HR 55-60
B – Propranolol 10mg TID, goal HR 55-60
C – Nadolol 20mg daily, goal HR 65-70
D – Propranolol 20mg TID, goal HR 65-70
HG does not take your recommendation for prophylaxis for
bleeding and is admitted to your ICU for bleeding of his varices.
The attending asks if there is anything that should be added to
his regimen besides Ocreotide, fluids, and the propranolol he
wasn’t taking before. What do you recommend?
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A – Ciprofloxacin 400mg IV daily for 7 days
B – Ceftriaxone 1gm IV daily for 7 days
C – Ceftriaxone 1gm IV daily for 14 days
D – Norfloxacin 400mg IV BID for 14 days
Determine if HG’s ascites is due to
portal hypertension. Serum albumin
2.7gm/dL. Ascitic albumin: 1.5gm/dL
• A – yes, due to portal hypertension
• B – no, not due to portal hypertension
Since HG’s ascites is due to portal hypertension, the
attending asks for a recommendation on appropriate
diuretics. What do you recommend?
• A – Use bumetaminde preferrentially as single
agent
• B – Use furosemide in combo with
spironalactone; no recommended ratio
• C – use furosemide in combo with
spironalactone; recommended ratio 40:100
• D – use thiazides preferentially over loops
Despite appropriate treatment with diuretics, HG required a
therapeutic paracentesis. The medical student wants to know if
he should recommend albumin replacement to the resident. 4.5L
of fluid were removed during the procedure.
• A – no replacement required
• B – yes, give 30g of 5% albumin
• C – yes, give 30g of 25% albumin
HG is discharged home 1 week later but returns at the end of the
month and it is discovered he has developed spontaneous
bacterial peritonitis. The PMN count on his recent ascitic fluid
was 350. SCR 1.8mg/dL today. Recommend appropriate therapy
at this time.
• A – Start abx – Cefotaxime 1gm IV q8h.
• B – Start albumin – 1.5g/kg on day 1 + 1g/kg
on day 3
• C – Start abx – ceftriaxone 1gm IV q12h
• D – start albumin – 6-8g/L of fluid removed
The physician wants to know if there is anything
he can to do to prevent HG from getting SBP
again. What do you say?
• A – Bactrim DS TIW
• B – Cipro 500mg daily
• C – Bactrim DS daily
• D – Cipro 750mg weekly
Which of the following is the DOC for
hepatic encephalopathy?
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A – neomycin
B – rifaximin
C – lactulose
D – flumazenil
Pediatric Liver Disease
What is the DOC for treating neonatal
jaundice?
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A – exchange tranfusion
B – pentoxifylline
C – phototherapy
D – exclusive breast feeding
Which drug is not known to displace biliribuin
from albumin and is considered safe in
neonates?
• A – ceftriaxone
• B – sulfonamide
• C – lipid emulsion
• D – cefotaxime
Parenteral Nutrition Associated Liver Disease (PNALD)
is common in pediatric patients receiving long term PN.
Which of the following medications can be used to
treat PNALD?
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A – increase rate of PN
B – remove lipids from PN
C – omega-3 fatty acids
D – wait to introduce enteral nutrition
Acholic stools are most often a sign of
what disease when presenting in the
pediatric population?
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A – neonatal jaundice
B – biliary atresia
C – PNALD
D – Alagille’s syndrome
Which medication used to treat sclerosing cholangitis in children
has not been shown to have efficacy in the same disease state in
adults?
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A – ursodeoxycholic acid
B – azathioprine
C – prednisone
D – CCK
What drug can be used to chelate copper
in patients with Wilson’s disease?
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A – ursodiol
B – ascorbic acid
C – exjade
D – penicillamine
Drug-Induced Liver Disease
Which drug is it important to reduce the dose
for renal function to prevent hepatic injury?
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A – sulfonamides
B – allopurinol
C – nitrofurantoin
D – isoniazid
Cytotoxic (hepatocellular) damage is evident by an
increase in what hepatic markers?
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A – INR
B – AST
C - AST and ALT
D – ALT
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Age over 50 years is a risk factor for hepatic
injury when taking which of the following
medications?
A – allopurinol
B – nitrofurantoin
C – isoniazid
D – acetaminophen
Which drug is associated with both
chronic and acute hepatic injury?
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A – nitrofurantoin
B – allopurinol
C – acetaminophen
D – sulfa drugs
Acetaminophen overdose results in
which of the following?
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A – significant rise in ALT
B – significant rise in AST
C – normal AST
D – normal ALT, increased INR
Inhibition of which enzyme may increase the
toxicity of acetaminophen overdose?
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A – CYP3A4
B – CYP2E1
C – CYP2D6
D – CYP1A2
Hepatitis
Which hepatic virus is there treatment
but no vaccine for?
• A – Hepatitis A
• B – Hepatitis B
• C – Hepatitis C
Which of the following serological profiles is that of a patient
who is immune to the HBV virus due to natural infection?
• A – HBsAG negative; antiHBc positive; antiHBs
positive
• B – HBsAg negative; antiHBc negative; antiHBs
positive
• C – HBsAg negative; antiHBc negative; antiHBs
negative
Which of the following is the serological profile of a
patient who is chronically infected with HBV?
• A – HBsAg – positive; Anti-HBc positive; IgM
antiHBc – positive; anti-HBs – negative
• B - HBsAg – positive; Anti-HBc positive; IgM
antiHBc – negative; anti-HBs – negative
BF has been stuck by a needle after administering a flu vaccine
because he did not follow the proper protocol. It is determined
that the patient has HBV. BF is not up to date on his HBV vaccine.
What should he receive as post-exposure prophylaxis?
• A – HBIG alone if no more than 7 days have
passed since exposure
• B – HBV vaccine + HBIG
• C – HBIG alone
• D – HBV vaccine alone
What is used for treatment of
autoimmune hepatitis?
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A – prednisolone
B – prednisone + azathioprine
C – ursodiol
D – medrol
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What is the general duration of
treatment for HCV if no cirrhosis is
present?
A – 24 weeks
B – 16 weeks
C – 12 weeks
D – 8 weeks
Pancreatitis
What is the most common cause of
acute pancreatitis?
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A – alcohol
B – medications
C – hyperparathyroidism
D – gallstones
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Which of the following causes of pancreatitis
(acute) is most likely to progress to chronic
pancreatitis?
A – alcohol
B – medications
C – hypertriglyceridemia
D – gallstones
PK presents to the ED with epigastric pain that he reports is constant.
Pancreatitis is suspected and amylase and lipase levels are drawn. His
amylase is WNL but his lipase is 300units/L. On CT scan, a collection of fluid is
noted outside the pancreas. The attending asks you for a recommendation
regarding PK’s condition given the odd lab results.
• A – Recommend treating for pancreatitis
• B – Recommend looking for other causes of dx
You have correctly chosen to treat PK
for pancreatitis. What should you
recommend first line?
• A – Abx (broad spectrum) for his fluid
collection
• B – Fluids for hypovolemia
• C – enteral nutrition to prevent mortality
• D – pain medication
LT is a chronic alcoholic and presents to the ER with his 5th case
of pancreatitis in the last year. He is diagnosed with chronic
pancreatitis. What can be done to manage his pain and
discomfort?
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A – insulin
B – pancreatic enzymes
C – welchol
D – increase fiber in diet
BONUS!
IRRITABLE BOWEL SYNDROME
A patient presents to your clinic with a history of IBS. Today her symptoms include the
following: chronic constipation mixed with intermittent diarrhea, pain that is relieved
with defecation, and a recent weight loss of 10kg. Current patient weight of 80kg.
What should be your course of action?
• A – consider change in medication to rectify
constipation/diarrhea picture
• B – refer, symptoms not consistent with IBS
• C – recommend increased fiber intake
HG is a patient who has recently been diagnosed with diarrhea predominant
IBS. He would like some non-pharmacologic options to try before beginning a
medication regimen as he does not have good prescription drug coverage.
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A – Avoid lactose containing foods
B – increase dietary fiber
C – avoid gas-producing foods
D – consider food allergies
The previous pt, HG, has tried nonpharmacologic
methods with no success. Which of the follow
pharmacologic agents would be a good choice for him?
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A – Alosetron (Lotronex)
B – Loperamide (Imodium)
C – Lubiprostone (Amitiza)
D – Linactolide (Linzess)
JY is a pt with constipation predominant IBS. Which
agent should be avoided in his regimen as you design
it?
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A – Linaclotide (Linzess)
B – Amitriptyline (Elavil)
C – Lubiprostone (Amitiza)
D – Tegaserod (Zelnorm)
A patient presents to your clinic. She is a 2nd year pharmacy student who has
been experiencing anxiety secondary to working 35 hours a week and going
to school full time. She is worried about her grades. She has been
experiencing abdominal pain relieved by defecation, intermittent constipation
mixed with diarrhea, and overall nausea. Which medication is indicated in this
patient?
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A – loperamide
B – alprazolam
C – linactolide
D – citalopram