Pharmacology Update

1
Pharmacology Update
2
Which of the following is TRUE about using
testosterone in older men?ltgt A.Testosterone
might improve energy, strength, and
libido.ltgt B.There are concerns about a possible
increased risk of prostate cancer.ltgt C.Oral
methyltestosterone should be tried
first.ltgt D.Both A and B
3
Answer

• D.Both A and B

4
Before starting testosterone you should check
what blood tests?

• A. PSA
• B. Hemoglobin
• C. Liver Function
• D. Hemoglobin A1C
• E. A, B, C
• F. All of the above

5
Answer

• E. A, B, C

6
What level of testosterone is low and what level
is therapeutic in mg/dl?

• A. 200/400
• B. 300/500
• C. 300/600
• D. 400/ 700

7
Answer

• C. 300/600

8
Which of the following is TRUE about chronic use
of proton pump inhibitors?ltgt A.PPIs lower the
risk of fractures.ltgt B.PPIs lower the risk of
pneumonia.ltgt C.Tapering the PPI when stopping
may help reduce acid rebound symptoms.ltgt D.PPIs
increase calcium absorption.
9
Answer

• C.Tapering the PPI when stopping may help reduce
  acid rebound symptoms.ltgt

10
Which of the following is TRUE about the
interaction between clarithromycin and inhaled
salmeterol (Advair, Serevent)?ltgt A.Clarithromycin
can lower salmeterol levels and make it less
effective.ltgt B.Clarithromycin can boost
salmeterol levels and cause adverse cardiac
effects.ltgt C.A similar interaction is seen with
azithromycin and salmeterol.ltgt D.A similar
interaction is seen with clarithromycin and
formoterol (Foradil).
11
Answer

• B.Clarithromycin can boost salmeterol levels and
  cause adverse cardiac effects.ltgt

12
Which of the following is TRUE about using
beta-blockers in patients with chronic
obstructive pulmonary disease?ltgt A.Beta-blockers
are usually avoided due to fears of
bronchoconstriction.ltgt B.New evidence suggests
that beta-blockers might decrease COPD
exacerbations.ltgtC.Cardioselective beta-blocker
(metoprolol, etc) are preferred for COPD
patients.ltgt D.All of the above
13
Answer

• D.All of the above

14
Most states now have Prescription Drug Monitoring
Programs for controlled drugs. Which of the
following is TRUE?ltgt A.These programs are proven
to reduce diversion.ltgt B.Information can't be
shared with other states.ltgt C.Prescribers can
find out if patients are getting controlled drugs
from other prescribers or pharmacies.ltgt D.The
information is only available by phone.
15
Answer

• C.Prescribers can find out if patients are
  getting controlled drugs from other prescribers
  or pharmacies.ltgt

16
Which of the following is TRUE about drug
allergies?ltgt A.Hydrocodone can be used in a
patient with a true allergy to codeine.ltgt B.Cross
-sensitivity usually isn't a problem between
sulfa antibiotics and other sulfonamides.ltgt C.Abo
ut 10 of patients allergic to penicillin are
allergic to cephalosporins.ltgt D.People allergic
to sulfa drugs also need to avoid drugs or foods
with sulfur, sulfites, or sulfates.
17
Answer

• B.Cross-sensitivity usually isn't a problem
  between sulfa antibiotics and other sulfonamides

18
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

19
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.

20
Penicillin.

•      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 beta-lactams 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.

21
What works for Leg Cramps?

• A. Quinine
• B. Magnessium
• C. Calcium
• D. Requip
• E. Gateraid
• F. Nothing works well

22
Answer

• F. Nothing works well

23
Leg Cramps

• 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.

24
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.

25
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

26
Answer

• C. Depends on the stent

27
Which of the following is TRUE about antiplatelet
therapy after a coronary stent?ltgt A.Dual
antiplatelet therapy is usually given for at
least one year after placement of a drug-eluting
stent.ltgt B.Aspirin should be stopped at the same
time as clopidogrel.ltgt C.Drug-eluting stents
have a lower risk of thrombosis than bare-metal
stents.ltgt D.Patients who miss one dose of
clopidogrel should get another loading dose.
28
Answer

• A.Dual antiplatelet therapy is usually given for
  at least one year after placement of a
  drug-eluting stent.

29
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 bare-metal stents.     Some
  evidence suggests one year of dual antiplatelets
  is enough for drug-eluting stents...but
  thrombosis risk may persist for years

30
Which of the following patients are good
candidates for carrying TWO doses of injectable
epinephrine (EpiPen, etc) for allergic
reactions?ltgt A.Children under age 6 years
oldltgt B.People who will be in remote
areasltgt C.Patients who have had a prior severe
or hard to treat allergic reactionltgt D.Both B
and C
31
Answer

• D.Both B and C

32
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
  auto-injectors...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.

33
What drug interactions do you have with OxyContin?
34
Which of the following is TRUE about drug
interactions with oxycodone (OxyContin,
etc)?ltgt A.Oxycodone levels can be increased by
clarithromycin, ketoconazole, or
ritonavir.ltgt B.Oxycodone levels can be decreased
by carbamazepine, phenytoin, or
rifampin.ltgt C.Similar interactions are not seen
with codeine, hydromorphone, or
morphine.ltgt D.All of the above
35
Answer

• D.All of the above

36
Answer

• 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).

37
What can be added to Lactulose to prevent Hepatic
Encephalopathy?
38
Answer

•  Xifaxan (rifaximin) now comes in a 550 mg tablet
  to prevent hepatic encephalopathy due to chronic
  liver disease

39
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.

40
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

41
Answer

• F. All of the above

42
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

43
 Propylthiouracil (PTU) for hyperthyroidism now
has a black box warning because of?

• A. Renal Failure
• B. Hepatic Failure
• C. Severe Nausea and Vomiting
• D. Severe Headaches
• E. Severe Myalgias

44
Answer

• B. Hepatic Failure

45
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.

46
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.

47
Answer

• F. A, B, C.

48
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
  shortest time and only when needed

49
Which of the following is TRUE about the new
statin, pitavastatin (Livalo)?ltgt A.Pitavastatin
lowers LDL more than higher doses of atorvastatin
(Lipitor) or rosuvastatin (Crestor).ltgt B.Pitavast
atin lowers LDL more than 60.ltgt C.Pitavastatin
doses over 4 mg/day are associated with more
rhabdomyolysis.ltgt D.Pitavastatin has a high risk
for CYP450 drug interactions.
50
Answer

• C.Pitavastatin doses over 4 mg/day are associated
  with more rhabdomyolysis

51
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.

52
How much will 40 mg of Simvastatin lower your LDL
Cholestrol?

• A. 20
• B. 30
• C. 40
• D. 50
• E. 60

53
Answer

• C. 40

54
What are the relative potency of the Statins?
55
Answer you get 40 LDL reduction of Cholesterol
with the following drugs

• 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

56
If you double the dose of the Statin you get
_____ more reduction in Cholestrol?

• A. 4
• B. 6
• C. 8
• D. 10
• E. 12

57
Answer

• B. 6

58
Increasing Simvasatin from 40 to 80 mg lowers LDL
just 6 more but increases myopathy _____ times.

• A. 2x
• B. 4x
• C. 6x
• D. 8x

59
Answer

• C. 6x

60
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

61
What drugs do you need to monitor blood tests?
62
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 PFTs
• glucose and lipids with atypical antipsychotics
  (Zyprexa, etc)
• CBC with carbamazepine
• platelets with valproate
• lipids withAccutane.

63
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.

64
Answer

• F. A, B, C, D.

65
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

66
Which of the following is TRUE about intensive
treatment of blood pressure and lipids in
patients with type 2 diabetes?ltgt A.Most
cardiovascular outcomes are similar when systolic
BP is less than 140 mmHg compared to under 120
mmHg.ltgt B.Intensive BP lowering INCREASES the
risk of stroke.ltgt C.Fenofibrate plus simvastatin
is associated with better outcomes than
simvastatin alone in diabetes patients.ltgt D.Most
diabetes patients should have an LDL goal less
than 70 mg/dL.
67
Answer

• A.Most cardiovascular outcomes are similar when
  systolic BP is less than 140 mmHg compared to
  under 120 mmHg.ltgt

68
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.

69
What Drug for BPH has just gone Generic?

• A. Avodart
• B. Doxasosyn
• C. Tamsulosin
• D. Finasteride

70
Answer

• C. Tamsulosin

71
Tamsulosin is the latest generic alpha-blocker
for benign prostatic hyperplasia (BPH). Which of
the following is TRUE?ltgt A.All alpha-blockers
have similar efficacy for BPH.ltgt B.Tamsulosin is
more selective for the bladder and prostate than
doxazosin or terazosin.ltgt C.Selective
alpha-blockers cause less dizziness and
hypotension, but more abnormal ejaculation.ltgt D.A
ll of the above
72
Answer

• D.All of the above

73
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.

74
Which of the following is TRUE about using
long-acting beta-agonists for asthma?ltgt A.Long-act
ing beta-agonists should be used as monotherapy
for asthma.ltgt B.Long-acting beta-agonists are
still risky when used with an inhaled
steroid.ltgt C.It's usually better to prescribe a
combo inhaler (Advair, Symbicort) instead of
giving a long-acting beta-agonist and inhaled
steroid separately.ltgt D.Long-acting beta-agonists
should not be used for chronic obstructive
pulmonary disease.
75
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.

76
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
  low-dose 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.

77
Pennsaid is a new topical diclofenac solution.
Which of the following is TRUE?ltgt A.Pennsaid seem
s to work about as well as oral diclofenac for
knee osteoarthritis.ltgt B.Topical diclofenac has
a similar risk of GI problems as oral
diclofenac.ltgt C.About 50 of a Pennsaid dose is
absorbed systemically.ltgt D.Pennsaid is applied
just once a day.
78
Answer

• A.Pennsaid seems to work about as well as oral
  diclofenac for knee osteoarthritis.

79
Many drugs can cause QT prolongation. Which of
the following has a high risk of causing
torsades?ltgt A.Clarithromycinltgt B.Methadoneltgt C.
Levofloxacinltgt D.Both A and B
80
Answer

• D.Both A and B

81
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

82
How can you reduce the Fall risk in the elderly?
83
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