Nonpharmacologic Management Essay Examples
Know presentation, DX and Management
Diagnoses List
Acute bronchitis-
DESCRIPTION
Acute cough due to inflammation of the bronchioles, bronchi, and trachea; usually follows an upper respiratory infection or exposure to a chemical irritant.
ETIOLOGY
Adenovirus
Rhinovirus
Influenza A and B
Parainfluenza
RISK FACTORS
Upper respiratory infection
Air pollutants
Smoking and/or secondary exposure
Reflux esophagitis
Allergy
Chronic obstructive pulmonary disease
Acute and chronic sinusitis
Infants
Older adults
Immunosuppression
ASSESSMENT FINDINGS
Cough: dry and nonproductive, then productive; may be purulent
URI symptoms
Fatigue
Fever due to bacterial infection; more common in smokers and patients with COPD
Fever due to viral cause (unusual after first few days)
Burning sensation in chest
Crackles, wheezes
Chest wall pain
Nonpharmacologic Management Essay Examples
DIFFERENTIAL DIAGNOSIS
Pneumonia
Tuberculosis
Asthma
DIAGNOSTIC STUDIES
Decision criteria for chest radiographs: tachypnea, hypoxia, fever, abnormal lung exam
Only consider chest X-ray if high index of suspicion for pneumonia or superimposed heart failure
Consider PPD: expect negative results
PREVENTION
Smoking cessation
Avoid known respiratory irritants
Treat underlying conditions that contribute to risk (asthma, gastroesophageal reflux disease, etc.)
Influenza immunization for high-risk populations
NONPHARMACOLOGIC MANAGEMENT
Increase fluid intake
Use humidifier
Rest
Smoking cessation
Consider honey in children older than 1 year
Patient education about disease, treatment, expected cause of cough, and emergency actions
PHARMACOLOGIC MANAGEMENT
Cough suppressants for nighttime relief
Avoid antihistamines
Antibiotics if organism is bacterial
Antivirals if influenza diagnosed
Decongestants and antihistamines are ineffective unless sinusitis or allergy is underlying
Bronchodilators if wheezing or prior history of asthma
Although antibiotics are commonly prescribed, they are NOT recommended.
ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Cough Suppressants
Suppress cough in the medullary center of the brain
dextromethorphan/guaifenesin
Adult
: 10 mL q 4 hr
Max
: 4 doses in 24 hours
Children 6-12 years:
5 mL q 4-6 hr;
Max
: 4 doses in 24 hr
Children <6 years:
not recommended
Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor
Contraindicated in Parkinson’s disease
Potential drug interaction with some SSRIs
Avoid in patients who are having difficulty clearing secretions
Robitussin DM
various generics
Dextromethorphan 10 mg/5 mL
Guaifenesin 100 mg/5 mL
dextromethorphan
Adult and ≥12 years:
10 mL q 6-8 hr prn for cough
Max
: 4 doses in 24 hr
Children 6-12 years:
5 mL every 6-8 hr prn for cough
Max
: 4 doses in 24 hr
4-6 years:
2.5 mL every 6-8 hr prn for cough
Max
: 4 doses in 24 hr
Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor
Contraindicated in Parkinson’s disease
Potential drug intervention with some SSRIs
Avoid in patients who are having difficulty clearing secretions
Do not use if on a sodium restricted diet
Delsym
Dextromethorphan 15 mg/5 mL (alcohol free/orange or grape flavor)
Adult
: 10 mL q 12 hr
Children 6-12 years:
5 mL q 12 hr
Children 4-6 years:
2.5 mL q 12 hr
codeine/guaifenesin
Adults and children ≥ 12 years:
10 mL q 4 hr prn cough
Max
: 6 doses in 24 hr
Children
6-12 years:
5 mL q 4 hr prn cough
Max
: 6 doses in 24 hr
Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor
Contraindicated in Parkinson’s disease
Potential drug interaction with some SSRIs
Schedule V medication
Avoid in patients who are having difficulty clearing secretions
Avoid narcotic cough suppressants in patient with COPD or asthma
May be habit forming
May aggravate constipation
Robitussin AC
Each 5 mL contains
100 mg guaifenesin and
10 mg codeine
Antitussives
Topical anesthetic effect on the respiratory stretch receptors
benzonatate
Adults and children > 10 years:
100-200 mg TID prn cough
Max: 600 mg daily
Do not break or chew capsule – can produce local anesthesia and may reduce patient’s gag reflex
Monitor for dizziness, drowsiness and visual changes
Begins to act in 15-20 minutes and lasts for 3-8 hours
Avoid use in patients sensitive to or taking agents with PABA – possible adverse CNS effects
Tessalon
Caps: 100 mg, 200 mg
Expectorants
guaifenesin
Adult
: 200-400 mg PO q 4 hr prn
Max:
2400 mg/day
Children
2-5 years:
50-100 mg. PO q 4 hr prn
Max:
600mg/ day
Children 6-11 years:
100-200 mg PO q 4 hr prn
Max:
1200 mg/day
Children ≥12 years:
200-400 mg PO q 4 hr prn;
Max:
2400 mg/day.
Caution if nephrolithiasis
Caution in patients under 6 years
Take with plenty of water; do not cut/crush/chew ER tab
Short-Acting Bronchodilators
albuterol
Inhalation
:
Adult Dose:
metered-dose inhaler (MDI) or dry powder inhaler (90 mcg/actuation): 2 inhalations q 4 to 6 hr as needed
Metered-dose inhaler (100 mcg/actuation):
Acute treatment:
1 to 2 inhalations; additional inhalations may be necessary if inadequate relief however patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment
Maintenance (in combination with corticosteroid therapy):
1 to 2 inhalations TID-QID
Max: 8 inhalations daily
Dry powder inhaler (200 mcg/inhalation):
Acute treatment:
1 inhalation (200 mcg) as needed;
Max:
4 inhalations (800 mcg)/day; patient should be advised to promptly consult health care provider or seek medical attention if prior dose fails to provide adequate relief or if control of symptoms lasts <3 hr
Maintenance (in combination with corticosteroid therapy):
1 inhalation (200 mcg) q 4-6 hr;
Max
: 4 inhalations (800 mcg)/day
Nebulization solution:
2.5 mg TID-QID as needed; Quick relief: 1.25 to 5 mg q 4-8 hr as needed (NAEPP 2007)
Pediatric: Inhalation:
Metered-dose inhaler or dry powder inhaler (90 mcg/actuation)
quick relief: refer to adult dosing for all ages
Metered-dose inhaler (100 mcg/actuation):
Children 6 to 11 years:
Acute treatment:
1 inhalation; additional inhalations may be necessary if inadequate relief; however, patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment
Maintenance (in combination with corticosteroid therapy):
1 inhalation; may increase to maximum of 1 inhalation QID
Children ≥12 years and adolescents:
refer to adult dosing
Inhalation:
Metered-dose inhalers: Shake well before use; prime prior to first use, and whenever inhaler has not been used for >2 weeks or when it has been dropped, by releasing 3 to 4 test sprays into the air (away from face). HFA inhalers should be cleaned with warm water at least once per week; allow to air dry completely prior to use. A spacer device or valved holding chamber is recommended for use with metered-dose inhalers.
Storage
Metered-dose inhalers (HFA aerosols): Store at 15°C to 25°C (59°F to 77°F). Do not store at temperature >120°F. Do not puncture. Do not use or store near heat or open flame.
Ventolin HFA: Discard when counter reads 000 or 12 months after removal from protective pouch, whichever comes first. Store with mouthpiece down.
Use with caution in patients with impaired renal disease, hyperthyroidism, diabetes, glaucoma
CONSULTATION/REFERRAL
Refer to pulmonologist if symptoms not improved after 4 weeks
FOLLOW-UP
7 days if not improved or if condition worsens
High-risk groups (i.e., those with co-existing disease) warrant quicker follow-up
EXPECTED COURSE
Shorter symptom duration if causative agent is rhinovirus or coronavirus
Symptoms may persist 3-4 weeks
POSSIBLE COMPLICATIONS
Pneumonia
Chronic cough
Acute laryngopharyngitis
DESCRIPTION
An acute inflammation of the pharynx/tonsils. The most common cause of acute pharyngitis is viruses. Accurate diagnosis and treatment of Strep pharyngitis is important to prevent rheumatic fever, poststreptococcal glomerulonephritis, to reduce transmission, and to limit complications, such as peritonsillar abscess, lymphadenitis, and mastoiditis
ETIOLOGY
Causes
Viral*
Bacterial
Rhinovirus
Adenovirus
Parainfluenza
Epstein-Barr virus (mononucleosis)
Respiratory syncytial virus
Group A beta-hemolytic
Streptococcus**
Haemophilus influenzae
Mycoplasma pneumonia
Chlamydia pneumoniae
Neisseria gonorrhoeae
No pathogen can be
isolated in many cases
* Most common etiology
** Common depending on time of year
INCIDENCE
Prevalent in school age population, but occurs in all age groups (5-18 years most common)
Occurs in 5-15% of adults and 20-30% of children
More common during winter months
RISK FACTORS
Age
Exposure during Group A beta-hemolytic
Streptococcus
(GABHS) infection outbreaks
Family history of rheumatic fever places higher risk if GABHS is untreated
ASSESSMENT FINDINGS
Sore throat and pharyngeal edema
Tonsillar exudate and/or enlarged tonsils
Malaise
Clinical findings are not specific for diagnosis of bacterial or viral illness. The signs and symptoms of strep pharyngitis and other etiologies overlap, and an accurate diagnosis based on clinical findings alone is difficult
Suggestive of Strep:
Cervical adenopathy
Fever >102° F (38.8° C)
Absence of other upper respiratory findings (cough, nasal congestion, etc.)
Petechiae on soft palate
“Beefy red” tonsils
“Sandpaper” rash (bridge of nose, neck, and/or torso)
Abdominal pain, headache
Streptococcal tonsillitis has a distinct odor
Suggestive of viral infection:
Concurrent conjunctivitis, nasal congestion, hoarseness, cough, diarrhea or viral rash
Modified Centor Clinical Prediction Rule for Group A Strep infection
Tonsillar exudates
+1 point
Tender anterior chain cervical adenopathy
+1 point
Fever by history
+1 point
Age <15 years
+1 point
Age 15-45
0 points
Age >45
-1 point
Cough (almost always excludes
Streptococcus
)
-1 point
3-4 points: treat empirically for Strep
infection
2 points: rapid Strep
test, treat if positive
1 point: unlikely Strep
0 or -1 points: do not test or treat
DIFFERENTIAL DIAGNOSIS
Upper respiratory illness
Tonsillitis
Mononucleosis
DIAGNOSTIC STUDIES
Rapid antigen strep test (95-99% specific).
The swab should be taken from the tonsils, tonsillar fossa, and the posterior pharyngeal wall. Good specimen is essential
In children and adolescents, negative rapid antigen test should be confirmed with a throat culture. Confirmation not necessary in adults due to lower risk for the development of acute rheumatic fever
10% of patients with mononucleosis have concomitant Strep infection
Antistreptolysin (ASO) titer should not be ordered to diagnose acute infection (ASO detects past infection)
PREVENTION
Avoid contact with infected people during outbreaks
Good hand washing, especially during cold weather months
Teach patients not to share drinking glasses, eating utensils, etc.
Prompt treatment of patients with family history of rheumatic fever
NONPHARMACOLOGIC MANAGEMENT
Gargling with warm salt water
Increased fluid intake
Patient education about disease, course and treatment
Change toothbrush after treatment
PHARMACOLOGIC MANAGEMENT
Antipyretics/analgesics (acetaminophen, ibuprofen) are adjunctive treatment for fever and throat pain
Empiric treatment of asymptomatic household contacts of strep pharyngitis patients is not routinely recommended
For Strep pharyngitis, amoxicillin and penicillin V (10 days) are drugs of choice. For penicillin-allergic children, cephalexin/cefadroxil/clindamycin (10 days) or macrolides (5 days) are recommended
Antibiotics no benefit in treatment of nonstrep pharyngitis infections. Exceptions are
Corynebacterium diphtheriae
,
Neisseria gonorrhoeae
, and others
Medication (based on patient’s age or weight)
Treatment
Penicillin G
One IM injection
Penicillin V
Amoxicillin
Requires 10 days of treatment
First-generation
cephalosporins
Requires 10 days of treatment
Second-generation
cephalosporins
5 days of treatment
Azithromycin (for PCN allergy); limited efficacy against Streptococcal infection and should only be used for patients with documented history of PCN anaphylaxis or hives
12 mg/kg dose daily x 5 days
Clindamycin 7 mg/kg TID x 10 days for resistant/chronic recurrent Streptococcal infection
Mupirocin BID-TID to nasal mucosa for carrier
STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Penicillin Bacterial;
Bactericidal: inhibits cell wall mucopeptide synthesis; inhibits beta-lactamase
General comments
Indicated for infections caused by penicillinase-sensitive microorganisms
Generally well tolerated; watch for hypersensitivity reactions
Clavulanate broadens spectrum of coverage
Consider amoxicillin/clavulanate if failure after 72 hours
Give in divided doses
Amoxicillin and Penicillin V are considered first-line agents in most cases, unless other antibiotic exposure in the last 90 days
The course of treatment is 10 days for all beta-lactam antibiotics, but FDA has approved 5-day course of cefdinir and cefpodoxime
penicillin V potassium
Adult:
500 mg 2-3 times daily for 10 days
Children:
250 mg PO BID-TID for 10 days
Adolescents:
500 mg PO BID for 10 days
Lactation: Safe
Give 1 hour before and 2 hours after meals
Pen V K
Tablet: 250 mg, 500 mg
Oral Solution: 125 mg/5 mL, 250 mg/5 mL
penicillin G benzathine
Adult:
1.2 million units IM for 1 dose
<27 kg:
0.6 million units IM for 1 dose
≥27 kg:
1.2 million units IM for 1 dose
Lactation: Safe
Do not confuse Bicillin L-A with Bicillin C-R
Do not confuse penicillin G benzathine with penicillamine or penicillin G procaine. They are NOT interchangeable
Very painful injection if not combined with Penicillin G procaine (Ex. 900,000 units of Penicillin G benzathine + 300,000 units of Penicillin G procaine = 1.2 million units)
Bicillin L-A
Injection: 600,000 units/mL, 1.2 million units/2 mL
NOT FOR IV USE
amoxicillin
Adult:
500-875 mg PO q 12 hr for 10-14 days
(higher dosing for severe infections)
Children:
>40 kg:
dose for 10 days
50 mg/kg once daily for 10 days
Max:
1 g/day
Alternate:
25 mg/kg BID for 10 days
Max:
500 mg/dose
GI side effects
Amoxicillin is not stable in the presence of beta lactamase producing organisms
DO NOT USE IF HISTORY OF HIVES OR ANAPHYLAXIS TO PENICILLIN
Decrease dose for renal impairment
Children’s dose of amoxicillin should never exceed maximum adult dose
Amoxil
Caps: 250 mg, 500 mg
Tabs: 500 mg, 875 mg
Suspension: 250 mg/5 mL;
400 mg/5 mL
Pediatric drops: 50 mg/mL
Moxatag
775 mg ER Tab daily for 10 days
continued
STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Macrolides
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest
General comments
Effective treatment for
S. pyogenes
in the presence of penicillin allergy
Associated with higher rates of GI side effects
Age, weight and severity of infection determine dose in children
Local antibiotic resistant rates should be considered prior to prescribing.
azithromycin
Adult:
Usual
: 500 mg daily for 3 days
Alternative:
2 g as a single dose or 500 mg on day 1 and 250 mg days 2-5
Children >6 months old:
Usual:
10 mg/kg once daily for 3 days or 10 mg/kg on day 1 and 5 mg/kg days 2-5
Max:
500 mg daily
Lactation: Safety Unknown
First-line for penicillin allergic (Type I allergic reaction)
Consider clindamycin, if failure after 48-72 hours
Avoid concomitant use of aluminum or magnesium containing antacids
Cautious use if renal or hepatic impairment
Hypersensitivity reactions may recur after initial successful symptomatic treatment
Zithromax
Tabs: 500 mg, 250 mg
Powder: 2 g/bottle
Suspension: 100 mg/5 mL,
200 mg/5 mL
clarithromycin
Adult:
250 mg PO q 12 hr for 10 days
Children 6 months and older:
15 mg/kg/day PO divided q 12 hr for 10 days
Max:
250 mg/dose
Cautious use in patients with either renal or hepatic dysfunction
Clarithromycin may be involved in drug reactions involving CYP 450 system; special care when prescribing concurrently with 3A4 substrate medications
Common side effect is an abnormal taste in mouth while taking tablet or suspension
Biaxin
Coated tabs: 250 mg, 500 mg
Biaxin XL
Coated tabs extended release: 500 mg
Other Antibacterials
Bacteriostatic or bactericidal, inhibits protein synthesis
General comments
Half-life is 2.4-3 hours
Carries a black box warning for
C. difficile
associated diarrhea
clindamycin
Adult:
300 mg PO q 8 hr for 10 days
Children:
7 mg/kg/day PO divided q 8 hr for 10 days
Max:
300 mg/dose
Adolescents:
150-300 mg PO q 6 hr
Max
300 mg per dose
Lactation: Probably Unsafe
May cause exfoliative dermatitis
Caution in hepatic dysfunction
Only use if other antibiotics have been unsuccessful
Use in patients with initial bacterial failure who are penicillin/cephalosporin allergic with Type I reaction; consider use in patients who failed therapy with ceftriaxone (used in conjunction with tympanocentesis)
continued
STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Cleocin
Injection: 150 mg/mL
Tabs: 75 mg, 150 mg, 300 mg
Capsule: 150 mg, 300 mg
Solution: 75 mg/5 mL
Granules for solution: 75 mg/5 mL
Cautious use in patients with hepatic, renal impairments, colitis
Side effects include pseudo-membranous colitis,
C. difficile
diarrhea
Take with a full glass of water
First Generation Cephalosporins
Arrests bacterial growth by inhibiting bacterial cell wall synthesis
General comments
Caution if recent antibiotic associated colitis
cephalexin
Adult:
500 mg PO q 12 hr for 10 days
Children >1 year of age:
25-50 mg/kg/d in 2-4 divided doses for 10 days
Max
: 500 mg q 12 hr
Cautious use in patients with history of hives or anaphylaxis to penicillin
Dosage reduction needed for renal impairment
Give without regard to meals
PT should be monitored in patients at risk: renal or hepatic impairment, poor nutritional state
After mixing suspension, store in refrigerator for up to 14 days
Keflex
Caps: 250 mg, 500 mg, 750 mg
Tablets: 250 mg, 500 mg
Suspension: 125 mg/5 mL,
500 mg/5 mL
cefadroxil
Adult:
1 g PO daily in divided doses q 12 hr for 10 days
Children:
30 mg/kg PO divided q 12 hr for 10 days
Cautious use in patients with history of hives or anaphylaxis to penicillin
Dosage reduction needed for renal impairment
No dosage reduction needed for geriatric patients
Duricef
Caps: 500 mg, 1000 mg,
Tabs: 1000 mg
Suspension: 250 mg/5 mL,
500 mg/5 mL
CONSULTATION/REFERRAL
Evidence of acute renal failure and reddish, tea-colored urine (2-3 weeks post infection) may indicate acute poststreptococcal glomerulonephritis
Tonsillar edema and upper airway obstruction
Peritonsillar abscess
Tonsillectomy is not recommended to reduce the frequency of Strep pharyngitis
FOLLOW-UP
None usually needed
Patient no longer considered contagious after 24 hours on antibiotic
Follow-up culture not recommended, may be done to assure compliance
EXPECTED COURSE
Peak fever and pain on days 2 and 3
Lasts 4-10 days
POSSIBLE COMPLICATIONS
Upper airway obstruction
Acute post-Strep glomerulonephritis after Streptococcal infection
May develop sloughing of skin on fingertips and toes in weeks following Strep infection
Acute maxillary sinusitis
DESCRIPTION
Also known as: (Acute Rhinosinusitis, Recurrent Acute Rhinosinusitis, Chronic Rhinosinusitis)
Inflammation of at least one paranasal sinus due to bacterial, viral, or fungal infection; or allergic reaction. Annually, acute bacterial rhinosinusitis costs more than $3 billion and accounts for more outpatient antibiotic prescriptions than any other diagnosis. The terms
sinusitis
and
rhinosinusitis
are used interchangeably because inflammation of the sinus cavities and nasal cavities are usually concurrent.
Classification
Acute rhinosinusitis (ARS): symptoms <12 weeks
Recurrent ARS (RARS): at least three episodes of acute bacterial rhinosinusitis in a year
Chronic rhinosinusitis (CRS): symptoms of varying severity >12 weeks. Further classified with or without nasal polyps; abnormal findings on CT scan or nasal endoscopy
ETIOLOGY
Bacterial
Acute
sinusitis
Streptococcus pneumoniae
species (most common)
Haemophilus influenza
(common in smokers)
Moraxella catarrhalis
Viral
Rhinovirus
Coronavirus
Influenza A and B
Parainfluenza virus
Respiratory syncytial virus
Chronic
sinusitis
Gram-negative more likely
Staphylococcus aureus
Pseudomonas aeruginosa
Anaerobic organisms
Vast majority of rhinosinusitis cases are due to viruses, NOT bacteria. Viral URIs usually precede bacterial infections of the sinuses. It is the persistence of symptoms that suggests sinusitis.
INCIDENCE
Common in all ages
Men = Women
Common in early fall and early spring
13% of adults annually
A majority of patients with rhinosinusitis seek care from their PCPs
RISK FACTORS
Allergies, asthma
Tooth abscess (25% of chronic sinusitis is due to tooth abscess)
Cigarette smoking
URIs, cystic fibrosis, immune deficiencies
Swimming in contaminated water
Any condition that results in swollen nasal mucous membranes, such as common cold and allergic rhinitis
Anatomical abnormalities that prevent normal mucosal drainage, such as ciliary dyskinesia, nasal polyps and deviated septum
Asthma, GERD, and otitis media are often comorbid with CRS
ASSESSMENT FINDINGS
Fever (may or may not be present)
Persistent symptoms of URI (>10-14 days)
Nasal congestion and/or discharge (may be purulent and/or bloody)
Headache
Sore throat from persistent postnasal discharge
Pain/pressure over cheeks and upper teeth (suggests maxillary sinus involvement)
Pain/pressure and tenderness over eyebrows (suggests frontal sinus involvement)
Pain/pressure and tenderness behind and between eyes (suggests ethmoid sinus involvement)
Cough
Anosmia
Halitosis
Postnasal discharge, throat clearing
Periorbital edema
Bacterial infection more likely if: symptoms >10 days, worsening of symptoms after initial improvement, persistent purulent nasal discharge, fever, unilateral face or tooth pain.
DIFFERENTIAL DIAGNOSIS
Viral URI
Allergic rhinitis
Nonallergic rhinitis (triggered by strong odors or change in temperatures)
Dental abscess
Headaches
Nasal foreign body
Wegener’s granulomatosis
DIAGNOSTIC STUDIES
CBC: elevated WBC count if bacterial infection
Sinus X-rays: opaque areas on radiographs; air-fluid levels
CT scan: most useful tool to evaluate recurrent sinusitis but unable to differentiate viral from bacterial infection. Required before surgery or when complications of sinusitis are suspected
Imaging recommended with unilateral CRS to exclude tumor, anatomical defect, or foreign body. MRI is superior to CT for soft tissue imaging
Transillumination: opacification with air-fluid levels if sinus cavity is infected
Allergen-specific IgE testing for respiratory allergens for RARS or CRS
Evaluate for immune deficiency if CRS is resistant to treatment: quantitative IgG, IgA, IgM; pneumococcal antibody; complement function and T-cell number and function
Consider culture and sensitivity for treatment resistant infections
Consider evaluating for cystic fibrosis in a child with CRS with nasal polyps, especially if
Pseudomonas aeruginosa
is cultured from the sinuses
PREVENTION
Promote drainage by avoiding irritants that increase swelling in mucous membranes and cause retention of sinus exudate
Blowing, rather than “sniffing” nose
Good hand washing to prevent URIs
Management of allergic rhinitis
NONPHARMACOLOGIC MANAGEMENT
Avoid environmental irritants (cigarette smoke)
Manage allergic rhinitis appropriately
Humidified air can improve mucus clearance
Look for the presence of otitis media when evaluating a patient with rhinosinusitis (and vice versa)
Increase fluid intake
Sleep with head of bed elevated to aid with drainage
Patient education regarding disease, treatment options, etc.
PHARMACOLOGIC MANAGEMENT
Current data support watchful waiting of acute infections for 10 days; start antibiotic therapy if symptoms extend beyond 10 days.
Antibiotics: for acute infections and patients with moderate to severe infection
Amoxicillin-clavulanate is first-line antibiotic
Doxycycline, levaquin, or moxifloxacin if PCN allergy
Macrolides no longer recommended due to high rate of resistance
Amoxicillin not recommended;
M. catarrhalis
and
H. influenzae
can produce ß-lactamase and are resistant to amoxicillin
If
no
improvement occurs within 3-5 days, consider an alternate antibiotic that broadens coverage or covers resistant bacteria.
If
partial
response, consider additional 10-14 days with same or different antibiotic. If no substantial improvement or resolution in 21-28 days, refer to specialist
Decongestants: oral route preferred over topical, however, may use
oxymetazoline
q 12 hours for 1-3 days for ARS. Neither oral nor topical are beneficial for CRS
Analgesics for headache, antipyretics for fever
Topical intranasal steroids as monotherapy or in conjunction with antibiotics, especially in children and/or adults with underlying allergies. May consider a 3- to 6-week course of topical antibiotics for CRS (
mupirocin
,
gentamicin
,
tobramycin
nebulized or irrigations). Low systemic absorption. Studies demonstrate 82% improvement
CRS: oral antibiotic plus short course of oral steroids. Antibiotics of greater benefit for patients without nasal polyposis. Antibiotic therapy beyond 10-14 days is recommended. Oral steroids should be prescribed for patients with nasal polyps to decrease polyp size. Nasal steroids should be prescribed for patients with and without polyps; CRS is an inflammatory condition
Patients with asthma who develop rhinosinusitis should be treated aggressively, since successful treatment will improve asthma
Saline irrigation may be used as adjunctive therapy, using distilled or boiled tap water only. Patients should be instructed to clean the delivery device to avoid contamination. Squeeze bottles are superior to saline sprays, nebulizers, or devices (Neti pot)
In
children
, ARS is self-limiting, and antibiotic treatment facilitates improvement and resolution. Nasal steroids are a useful adjunct, however, nasal irrigation, antihistamines, decongestants, and mucolytics have not been proven beneficial for ARS in
children
.
In
children
with CRS, the mainstay of treatment is medical; surgery less frequently needed
Limited data support antibiotic therapy
Intranasal steroids should be prescribed, and antibiotics should be used for acute exacerbations
Surgery is an infrequent treatment for CRS in children; when needed, adenoidectomy with or without antral maxillary irrigation is used
Risk for resistance should be evaluated prior to determining antibiotic therapy. Risk factors for resistance include: age <2 years or >65 years, recent antibiotic use, hospitalization within the past 5 days, presence of co-morbid conditions, immunocompromised state.
ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT
Reserve antibiotics for persistent, unimproved symptoms >10 days or severe symptoms for >3-4 days
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Penicillin
Inhibits cell wall synthesis of gram-positive bacteria (Staph, Strep) and are most effective against organisms with rapidly dividing cell walls
General comments
Indicated for infections caused by penicillinase-sensitive microorganisms
Generally well tolerated; watch for hypersensitivity reactions
May have high rates of resistance depending on geographic region
amoxicillin
Adult:
500 mg-875 mg PO q 12 hr for 5-7 days
Children:
>40 kg:
dose as adult
<3 months:
20-30 mg/kg/day PO divided q 12 hr for 48-72 hr
>3 months:
25-45 mg/kg/day PO divided q 12 hr
>2 years old:
80-90 mg/kg/day PO divided q 12 hr for 5-7 days; do not exceed max adult dose
DO NOT USE IF HISTORY OF HIVES OR ANAPHYLAXIS TO PENICILLIN
Ineffective against beta lactamase-producing organisms
Decrease dose for renal impairment
Children’s dose of amoxicillin should never exceed maximum adult dose
Consider high-dose amoxicillin for severe sinusitis or likelihood of drug-resistant
Streptococcus pneumoniae
Amoxil
Caps: 250 mg, 500 mg
Tabs: 500 mg, 875 mg
Suspension: 250 mg/5 mL;
400 mg/5 mL
Pediatric drops: 50 mg/mL
Moxatag
Extended-release tabs: 775mg
Extended-Spectrum
Penicillin
Inhibits cell wall synthesis of gram-positive bacteria (Staph, Strep) and are most
effective against organisms with rapidly dividing cell walls
General comments
Addition of clavulanic acid (as potassium) extends antimicrobial spectrum (covers many gram-negative organisms) and protects PCN molecule if the organism produces beta lactamase
Clavulanic acid is known to cause diarrhea
amoxicillin/clavulanic acid
(as potassium)
Adult:
500/125 mg PO TID or 875/125 mg PO q 12 hr for 5-7 days
Alternative
: 2000 mg or 90 mg/kg PO q 12 hr for 10 days for
S. pneumoniae
or at risk for resistance
Children:
>40 kg:
dose as adult
<3 months:
30 mg/kg/day PO q 12 hr for 7-10 days
>3 months and older and <40 kg:
25-45 mg/kg/day PO q 12 hr
DO NOT USE IN PATIENTS WHO HAD HIVES OR ANAPHYLAXIS TO PENICILLIN
Children:
base dose on amoxicillin component
Monitor for PCN hypersensitivity
Take with meals to minimize gastrointestinal side effects
Contraindicated in severe renal impairment (CrCl <30 mL/min), dialysis, or history of Augmentin-associated cholestatic jaundice, hepatic dysfunction
Chew tabs contain phenylalanine
Augmentin
Tabs: 250/125 mg, 500/125 mg, 875/125 mg
Elixir: 125/31.25/5 mL; 250/62.5/5 mL
XR: 1000/62.5 mg
Tetracycline
Bacteriostatic, inhibits bacterial protein synthesis by disruption of RNA at ribosomal sites
General comments
May alter GI flora
doxycycline
Adult:
100 mg PO q 12 hr or
200 mg PO daily for 5-7 days
Children:
not recommended
Caution in hepatic impairment and recent colitis associated with antibiotic use
Associated with diarrhea
continued
ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT
Reserve antibiotics for a) Persistent and not improving symptoms > 10 days or b) Severe symptoms for > 3-4 days
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
May lead to permanent yellowing or graying of the teeth in children <8 years old.
Vibramycin
Tabs: 100 mg
Elixir: 25 mg/5 mL, 50 mg/5 mL
Cephalosporins
Third generation
Provides broader coverage
of gram-negative organisms; beta-lactamase-producing organisms
General comments
Recommended in combination with clindamycin for children with penicillin allergy. Not indicated as monotherapy for treatment of sinusitis
For patients who had skin rash to penicillin, OK to use third-generation cephalosporin
Generally well tolerated
cefpodoxime
Adult ≥12 years: Sinusitis:
Usual:
200 mg q 12 hr for 10 days
Children (2 months to 12 years):
Usual
: 5 mg/kg q 12 hr for 10 days
Max:
200 mg/dose
NOT likely to cause an adverse reaction in patients with history of IgE response to penicillins; use caution
Decrease dose for renal impairment
Children’s dose should not exceed adult dose
Cefpodoxime: take tabs with food; suspension may be given without regard to food
Vantin
Tabs: 100 mg and 200 mg
Suspension: 50 mg/5 mL,
100 mg/5 mL
Various generics
cefdinir
Adult > 13 years:
Usual
: 300 mg q 12 hr (or 600 mg q 24 hr) for 10 days
Children 6 months-12 years:
Usual:
7 mg/kg q 12 hr or 14 mg/kg daily for 10 days
Max:
300 mg per dose
Separate medication by at least 2 hours when giving with iron supplements (except iron fortified cereals)
Omnicef
Tabs: 300 mg
Suspension: 125 mg/5 mL,
250 mg/5 mL
Various generics
Cefixime
Children 6 months to 11 years:
Usual:
8 mg/kg/day for 10 days
Max
: 400 mg/day
Suprax
Other Antibacterials
Bacteriostatic or bactericidal, inhibits protein synthesis
General comments
Half-life is 2.4-3 hours
Carries a black box warning for
C. difficile
associated diarrhea
Clindamycin
Adult:
300 mg PO q 8 hr x 10 days
Children:
10-25 mg/kg/day PO q 6-8 hr
Max:
1.8 g/day
Adolescents:
150-300 mg PO q 6 hr
Max:
1.8 g/day PO
May cause exfoliative dermatitis
Caution in hepatic dysfunction
Cleocin
Tabs:
75 mg, 150 mg, 300 mg
Elixir: 75 mg/5 mL
Macrolides
Inhibit protein synthesis by binding to the 50S ribosomal subunit
General comments
Macrolides are not recommended for empiric treatment due to high rates of resistance. May consider as alternative to PCN in pregnancy, if allergic to PCN
Avoid concomitant aluminum- or magnesium-containing antacids
azithromycin
Adults:
Usual
: 500 mg daily for 3 days
Alternative:
2 g as a single dose or 500 mg on day 1 and 250 mg days 2-5
Children >6 months old:
Usual:
10 mg/kg once daily for 3 days or 10 mg/kg on day 1, and 5 mg/kg days 2-5
Max
: 500 mg daily
Azithromycin 2-g single dose MUST be taken on an empty stomach; multiday doses may be taken without regard to food
Cautious use in patients with either renal or hepatic dysfunction
Zithromax
Tabs: 500 mg, 250 mg
Powder: 2 g/bottle
Suspension: 100 mg/5 mL,
200 mg/5 mL
Various generics
continued
ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT
Reserve antibiotics for a) Persistent and not improving symptoms > 10 days or b) Severe symptoms for > 3-4 days
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Quinolones
Inhibit the action of DNA gyrase, which is essential for the organism to replicate itself
General comments
Broad-spectrum antimicrobial agents
Monitor for QT prolongation and photosensitivity
Avoid in ages <18 years, pregnant women, due to potential impairment in bone and cartilage formation
Monitor for hypoglycemic reactions
levofloxacin
Adult >18 years:
Usual:
500 mg once daily for 10-14 days
Alternative:
750 mg daily for 5 days
Children:
not recommended
Reduce dose for impaired renal function
Avoid drugs that prolong QT interval
Absorption significantly decreased by dairy products, multivitamins, and calcium containing products
Possible increased risk of tendinitis or tendon rupture
Causes photosensitivity
Levaquin
Tabs: 250 mg, 500 mg, 750 mgOral solution: 480 mL
moxifloxacin
Adult:
Usual:
1 tablet once daily for 5-7 days
Children:
not indicated
Avelox
Tabs: 400 mg
PREGNANCY/LACTATION CONSIDERATIONS
Sinusitis may be aggravated by physiologic nasal congestion due to pregnancy
Mild decongestant use considered safe for short-term use, but not proven effective
Avoid antibiotics unless absolutely necessary
Avoid tetracyclines, quinolones during pregnancy or lactation
CONSULTATION/REFERRAL
Refer to ENT for recurrent infections or treatment-resistant infections. May require endoscopic surgical intervention
Consider immediate referral for periorbital cellulitis
Emergency care if meningitis suspected
FOLLOW-UP
Indicated until clinically free of infection
If unresolving/worsening symptoms after 3-5 days of antibiotic therapy
EXPECTED COURSE
Good prognosis for acute sinusitis
Chronic sinusitis often recurs unless causative factor is treated (e.g., allergic rhinitis, drainage problems) or eliminated (e.g., mechanical obstruction)
POSSIBLE COMPLICATIONS
Abscess
Meningitis
Periorbital cellulitis
Allergic rhinitis
DESCRIPTION
Inflammatory IgE-mediated disease of the mucous membranes of the nasal tract with subsequent mucosal edema, clear discharge, sneezing, and nasal stuffiness. It may be seasonal, perennial, or episodic. The diagnosis is made when the patient presents with history and physical consistent with an allergic cause and one or more of the following is present: nasal congestion, rhinorrhea, itchy nose, or sneezing.
ETIOLOGY
Results from any substance or condition that causes an IgE-mediated response characterized by rupture of mast cells and release of histamines, leukotrienes, prostaglandins and other substances
Most common seasonal allergens are pollens from grass, trees, weeds
Most common perennial allergens are mold, animal dander, dust mites, smoke
INCIDENCE
10-20% of children
20-30% of adolescents
Usually diminishes with age
Most common age of onset is 10-20 years
RISK FACTORS
Family history
Other atopic diseases (e.g., asthma, atopic dermatitis, allergic conjunctivitis, food allergy)
Repeated exposure to the allergic substance
Nonadherence to treatment
ASSESSMENT FINDINGS
“Allergic shiners:” dark, discolored areas beneath the lower eyelids resulting from impeded lymphatic and venous drainage
Conjunctival injection, watery eyes
Pale, boggy nasal mucosa with congestion and clear rhinorrhea
Transverse crease on tip of nose due to “allergic salute:” long-term wiping of nose in an upward direction due to itch/tickle
Mouth breathing and dry lips
Sore throat/dry mouth upon waking
Palpable lymph nodes
Enlarged tonsils and adenoids
Document presence of associated conditions: sleep-disordered breathing, otitis media, rhinosinusitis, conjunctivitis, asthma, atopic dermatitis
DIFFERENTIAL DIAGNOSIS
Vasomotor rhinitis
Rhinitis medicamentosa
Infection
Tumors
Nasal foreign body
Common cold
DIAGNOSTIC STUDIES
Usually none
CBC: eosinophilia if acute reaction
Consider cultures if infection is suspected
Sinus films are not recommended
CT scan primary imaging study
Allergy testing for patients who do not respond to empiric treatment. Note: antihistamines will suppress reaction to skin allergy testing (usually stop antihistamines 1 week prior to testing)
Diagnostic allergen prick/droplet tests (usually performed by allergist)
RAST (RadioAllergoSorbent Test): allergen-specific IgE test (ImmunoCAP) used in patients in whom a severe reaction is possible. Blood test to detect specific IgE antibodies. Benefit: venous blood testing; may be done by PCP; no need to stop antihistamines prior to testing
PREVENTION
Minimize continuous exposure to commonly known allergens
Remove offending allergens/avoid exposure
Adherence to pharmacological regimen
Avoidance of allergen is first line of treatment
NONPHARMACOLOGIC MANAGEMENT
Avoidance/elimination of allergens. Examples: frequent vacuuming, dusting; removal of feather pillows; frequent air filter changes; removal of house plants; pet control; removal of carpet and stuffed animals; use of hypoallergenic pillow/mattress covers; no smoking in home)
If pharmacologic therapy does not reduce symptoms, offer immunotherapy or refer
In cases of nasal airway obstruction and enlarged inferior turbinates that don’t respond to medical therapy, refer to ENT
Referral for acupuncture for patients interested in nonpharmacologic therapy
PHARMACOLOGIC MANAGEMENT
Saline nasal spray helps to “wash” offending particles trapped in airways
Antihistamines (nonsedating and sedating available)
Nasal steroids (preferred agent for most cases)
Nasal antihistamine sprays (for seasonal, perennial, or episodic allergic rhinitis)
Combination therapy when monotherapy doesn’t achieve adequate response
Systemic steroids (avoid if possible and use only short-term)
Topical cromolyn (mast cell stabilizer)
Leukotriene modifier more common if patient has other allergies based on diagnosis (e.g. asthma), but not recommended as primary therapy
Decongestants, oral or topical
ALLERGIC RHINITIS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
diphenhydramine
Adult:
25-50 mg q 4-6 hr
Max:
300 mg/day
Children:
<6 years:
individualize
6
–
12 years:
12.5-25 mg q 4-6 hr
Max:
150 mg/day
Cautious use in patients with glaucoma, difficulty urinating due to an enlarged prostate gland, COPD
Avoid alcohol within 6 hours of dose
May cause profound drowsiness in some patients
Benadryl
Chew tabs: 12.5 mg
Tabs: 25 mg
Liquid: 12.5 mg/5 mL
Injection: 50 mg/mL
hydroxyzine
Adult:
25 mg TID-QID
Children:
<6 years:
50 mg daily in divided doses
>6 years:
50-100 mg daily in divided doses
Unable to establish safety during pregnancy
May produce drowsiness in any dose. Appropriate care advised
If used in older patients, should administer a low dose and monitor carefully
Atarax
Caps: 25 mg, 50 mg
Vistaril
Suspension: 25 mg/5 mL; available in 4 oz.; 1 pt
Antihistamines
Second Generation
General comments
Does not typically produce drowsiness (except cetirizine) and usually dosed once daily
Recommended for patients with primary complaints of sneezing and itching nose
cetirizine
Adults and children ≥12 years:
5-10 mg daily
Children:
6
–
11 years:
5-10 mg based on symptom relief
2
–
6 years:
2.5 mg daily or BID
Caution with activities requiring mental alertness; produces drowsiness because of its affinity for H1 receptors
Dosage adjustment needed for ages 77 and older, renal and hepatic impairment
Take without regard to food
Consider taking in the evening
Zyrtec
Tabs: 10 mg
Chew tabs: 5 mg; 10 mg
Syrup: 1 mg/mL; 4 oz bottle
levocetirizine
Adults and children ≥12 years:
5 mg once daily in the evening
Children:
6
–
11 years:
2.5 mg once daily in the evening
6 months
–
5 years:
1.25 mg once daily in the evening
Adjust dose for renal impairment; contraindicated in children 6 months to 11 years with renal impairment
Avoid engaging in activities requiring mental alertness
Avoid concurrent alcohol or CNS depressants
Xyzal
Tabs: 5 mg scored
Oral Solution: 0.5 mg/mL
fexofenadine
Adults and children ≥12 years:
180 mg daily or 60 mg BID
Children 2
–
11 years:
30 mg
BID
Shake bottle well before use
Reduce dose for renal impairment
Allegra ODT contains phenylalanine (other Allegra products do not)
Avoid aluminum- and magnesium-containing antacids
Less effective if taken with fruit juices; take with water
Do not expect sedation
Allegra
Tabs: 30 mg, 60 mg, 180 mg
ODT tab: 30 mg
Suspension: 6 mg/mL
loratadine
Adults and children
≥6 years:
10 mg daily
Children 2-5 years:
5 mg once daily
Children use RediTabs or syrup
Adjustment needed for renal or hepatic impairment
Do not expect sedation
continued
ALLERGIC RHINITIS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Claritin
Chew Tabs: 5 mg
Redi Tabs: 10 mg
Syrup: 1 mg/mL
desloratadine
Adult:
5 mg daily
Children 6 months-11 months:
1 mg (2 mL) daily
1-5 years:
1.25 mg (2.5 mL) daily
6-11 years:
2.5 mg (5 mL) daily
>12 years:
5 mg daily
Children use RediTabs or syrup
Do not expect sedation
Clarinex
Tabs: 5 mg
RediTabs: 2.5 mg
Syrup: 0.5 mg/mL
Topical nasal steroids
Exert glucocorticoid activity on the nasal mucosa and thus have local anti-inflammatory effects
General comments
Indicated for perennial, seasonal allergic rhinitis
Symptoms usually improved after 2 weeks but most benefit after a few days
Discontinue if no improvement in symptoms after 3 weeks
Use lowest dose possible, especially in children due to systemic side effects
Epistaxis may occur if mucous membranes become dried or injured from use
Mechanics of use important
budesonide
Adult:
Starting dose:
1 spray (32 mcg) per nostril daily
Usual:
2-4 sprays per nostril
daily
Max:
4 sprays per nostril daily
Children 6-12 years:
Initial:
1 spray per nostril daily
Usual:
1-2 sprays per nostril daily
Max:
2 sprays per nostril daily
Gently shake container prior to use
Individualize dosage for symptoms
Even with minimal systemic absorption of intranasal steroids, possible vertical growth impairment in pediatric patients
Rare risk of glaucoma, increased intraocular pressure, cataracts
Avoid exposure to chickenpox or measles
Rhinocort AQ
8.6 g (120 metered sprays)
fluticasone
Adult:
2 sprays (50 mcg/spray) each nostril daily or 1 spray per nostril 2 times daily
Children >4 years:
Initial
: 1 spray each nostril daily
Max:
2 sprays each nostril daily
Individualize dosage for symptoms
Even with minimal systemic absorption of intranasal steroids, possible vertical growth impairment in pediatric patients
Rare risk of glaucoma, increased intraocular pressure, cataracts
Avoid exposure to chickenpox or measles
Improvement in symptoms may occur as soon as 12 hours but may not be achieved for several days
Flonase
16-g container, 120 sprays;
dose as above age 4 to adult
Veramyst
Adult:
2 sprays each nostril daily
Children 2-12 years:
Initial: 1 spray each nostril daily
Max: 2 sprays each nostril daily
mometasone
Adults and children ≥12 years:
2 sprays (50 mcg/spray) each nostril daily
Children 2-11 years:
1 spray per nostril daily
Individualize dosage for symptoms
Even with minimal systemic absorption of intranasal steroids, possible vertical growth impairment in pediatric patients
Rare risk of glaucoma, increased intraocular pressure, cataracts
Avoid exposure to chickenpox or measles
No change in dosage required for older patient
Nasonex
17 g, 120 sprays
continued
ALLERGIC RHINITIS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
triamcinolone
Adult:
2 sprays (55 mcg/spray) per nostril daily
Children
:
6-12 years:
Initial:
1 spray each nostril per day
Max:
2 sprays each nostril once daily
2-5 years:
1 puff each nostril daily
Individualize dosage for symptoms
Even with minimal systemic absorption of intranasal steroids, possible growth retardation when used in pediatric patients
Rare risk of glaucoma, increased intraocular pressure, cataracts
Avoid exposure to chickenpox or measles
Shake well before each use
Improvement in symptoms may occur as soon as 12 hours but may not be achieved for several days
Nasacort (OTC)
16.5 g, 120 sprays
ciclesonide
(Omnaris)
Adults and children >6 years:
2 puffs each nostril daily
beclomethasone
HFA delivery, similar to delivery system of asthma inhaler, penetrates deep into nasal cavity
Beconase AQ
42 mcg/inhalation
Children 6-12 years:
Initial:
1 spray per nostril daily
Usual:
1-2 sprays per nostril daily
Max:
2 sprays per nostril daily
Qnasl
40 and 80 mcg/spray
Children 4-11 years:
1 spray 40 mcg/inhalation each nostril daily
>12 years:
1 spray 80 mcg/inhalation each nostril daily
Antihistamine/ Corticosteroid combination
May be used for patients who do not get relief with corticosteroid spray alone
azelastine/ fluticasone
Adults and children >6 years:
1 spray each nostril daily
Dymista
Leukotriene Receptor Antagonist
Oral agents may be used as adjunct in combination with other oral antihistamines and inhaled corticosteroids
Should not be offered for primary therapy
Also beneficial in asthma
montelukast
Children 6-24 months:
4 mg granules daily in evening
Children 2-6 years:
4-mg chewable tablet daily
Children 6-15 years:
5-mg chewable tablet daily
Children >15 years:
10-mg tablet daily
Granules may be sprinkled on any food, such as applesauce or yogurt
Singulair
Granules: 4 mg
Chewable tabs: 4 and 5 mg
Tablets: 10 mg
CONSULTATION/REFERRAL
Allergist for testing beyond allergen-specific IgE (ImmunoCAP) when symptoms persist despite treatment
Allergist may recommend allergen immunotherapy (injection or sublingual)
ENT for sinus-related etiologies or nasal polyposis
Emergency department for severe allergic response to allergens
FOLLOW-UP
2-4 weeks after initial evaluation and then every 3-6 months depending on patient and symptom severity
EXPECTED COURSE
Allergies tend to diminish in severity as people age
Allergic response is heightened each time allergen is contacted
Allergic response usually not seen at first exposure
Risk for developing asthma or atopic dermatitis (“allergic triad”)
POSSIBLE COMPLICATIONS
Otitis media
Secondary infections of sinuses, tonsils, pharynx
Sinusitis
Epistaxis
Facial changes (e.g., persistent transverse crease due to allergic salute; allergic shiners; chronic dry lips; chronic nasal flaring)
Snoring (sleep apnea/obstructed breathing)
Anxiety
DESCRIPTION
Psychic and physical experience of dread, foreboding, apprehension, or panic in response to emotional or physiologic stimuli; may be acute or chronic. Many anxiety disorders develop in childhood and tend to persist if untreated.
Common types of anxiety disorders included in the DSM-5 are: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder (social phobia), panic disorder, panic attack specifier, agoraphobia, generalized anxiety disorder, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, other unspecified anxiety disorder, and unspecified anxiety disorder.
ETIOLOGY
Behavioral theory: anxiety is the conditioned response to specific environmental stimuli
Genetic component (first-degree relative increases likelihood eightfold)
Biologic theories
Norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) are poorly regulated
The autonomic nervous system inappropriately responds to stimuli
Functional cerebral pathology causes anxiety disorder symptoms
Hypothalamic pituitary adrenal (HPA) axis highly implicated
INCIDENCE
7.7% lifetime prevalence in U.S. population
Women > Men
Most prevalent in 20- to 45-year-olds
Average age of onset 11 years old
Separation anxiety is the most common reason given for school refusal (mean age 9 years)
Anxiety is the most common psychiatric disorder in the United States.
RISK FACTORS
Organic causes:
Organic syndromes: endocrinopathies, cardiorespiratory disorders, anemia
Use of or withdrawal from medications and substances
Alcohol
Antihypertensives
Caffeine, including analgesics containing caffeine
Cocaine, marijuana, hallucinogens, synthetics
Corticosteroids
Lidocaine
Oral contraceptives
Nonsteroidal anti-inflammatories
Withdrawal from selective serotonin reuptake inhibitors (SSRIs)
Family history
Psychosocial stressors:
Marital discord
Medical illness
Job and/or school-related stress
Financial problems
Psychiatric disorders:
Major depressive disorder (MDD)
Post-traumatic stress disorder (PTSD)
Personality disorders
Schizophrenia and other psychotic disorders
ASSESSMENT FINDINGS
Children:
Excessive anxiety about separation after age 3-4 years
Note:
DSM-5 states that separation anxiety may be present in adulthood
Unrealistic worry about harm to self or family
Persistent worry about past behavior, competence, or future events
Adults:
Complaints of apprehension, restlessness, edginess, distractibility
Insomnia
Somatic complaints:
Fatigue, headaches
Paresthesia, near syncope, derealization, dizziness, diaphoresis
Palpitations, tachycardia, chest pain/tightness
Dyspnea, hyperventilation
Nausea, vomiting, diarrhea
Excessive rumination
DIFFERENTIAL DIAGNOSIS
Obsessive compulsive disorder
Oppositional defiant disorder
Personality disorders
Depression
Bipolar disorder
Attention deficit disorder
Cognitive disorder such as delirium
Substance intoxication or withdrawal
Posttraumatic stress disorder
Any medical condition that involves stimulation of the sympathetic nervous system
Arrhythmias, MI, valvular disease
Endocrinopathies: hyperthyroidism, Cushing syndrome, hypoglycemia, electrolyte imbalances, menopause
Medication/substance reactions and/or withdrawals
Anemia
Asthma, COPD, pulmonary embolism, pneumothorax
DIAGNOSTIC STUDIES
TSH
CBC, urinalysis
Urine drug screen
Focus on medical conditions for which patient is already being treated
Direct attention toward arrhythmias, hyperthyroidism, drugs
Evaluate prominent constellation of symptoms
Psychologic testing
Patient-Reported Outcome Measurement Information System (PROMIS) for emotional distress-anxiety: available for adults, adolescents and children
Hamilton Anxiety Scale
Zung Anxiety Self-Assessment
NONPHARMACOLOGIC MANAGEMENT
Psychotherapy
Education about diagnosis, treatment plan, and prognosis
Support and empathic listening
First-line treatment for children and adolescents
Relaxation techniques
Cognitive behavioral therapy
Reconditioning: exposure to feared stimuli in controlled setting to develop tolerance and eventually eradicate the anxiety response
General measures
Regular exercise and healthy diet
Adequate sleep and limit caffeine intake
Serial office visits
Advise patients to avoid alcohol consumption because this increases the risk of drug interactions and is associated with high rates of abuse and rebound anxiety.
PHARMACOLOGIC MANAGEMENT
Benzodiazepines should be of limited duration, with intent of allowing patient to benefit from behavioral treatments
Drugs should play an adjunctive role, except in panic disorder
Drugs reduce—not eradicate—symptoms
Long-term use of SSRIs or other serotonergic agents may be required
Selective serotonin reuptake inhibitors (SSRIs) may not achieve therapeutic response for 2-4 weeks. Full anti-anxiety response may take 12 weeks or more. Consider starting with lower doses.
Use of benzodiazepines until an SSRI or SNRI becomes effective is a common short-term strategy; expectations of use and duration should be discussed with the patient at the time treatment is initiated.
Specific phobia
Benzodiazepines: short-term use only, up to 1-3 months with planned taper
Works well but concerns with addiction in long-term use
Generalized anxiety disorder
First-line treatment
Selective serotonin reuptake inhibitors (SSRIs)
Selective norepinephrine reuptake inhibitors (SNRIs)
Buspirone (BuSpar)
Adult
: 7.5 mg PO BID-TID; usual range 20-30 mg/day
Children <6 years
: not recommended
6-17 years:
7.5-30 mg PO BID
Tabs: 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg
Panic disorder
First-line treatment: SSRIs and SNRIs
Tricyclic antidepressants (TCAs): Perform risk assessment; can be lethal in overdose
Benzodiazepines
Beta blockers may also be helpful, particularly with panic associated with specific stimuli
Be aware of the boxed warning about risk for increased suicidality in children, adolescents, and young adults who take SSRIs.
ANXIETY PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Benzodiazepines (BNZs)
binds at stereospecific receptors at several sites in the CNS
General comments
CNS depressant activity is produced, ranges from mild impairment to hypnosis. Do not engage in activities that require mental alertness while taking
All BNZs have
abuse potential
Do not mix with other CNS depressants (like alcohol); sedative effect is enhanced
Tolerance
develops with daily use
Lowest effective dose should be used
Use for short periods of time (2-4 weeks)
All BNZs are
Schedule IV
Lower dosages in older adults
Monitor for seizures during withdrawal
Withdrawal symptoms can occur with abrupt withdrawal, especially after 12 weeks
Preference is to use BNZs with shorter half-life in older adults, to avoid cumulative toxicity
DO NOT MIX WITH
ketoconazole, itraconazole
Caution in patients with renal, hepatic, alcohol use, or pulmonary dysfunction; may cause respiratory depression
Contraindicated in acute narrow-angle glaucoma
Contraindicated in patients with history of substance misuse
alprazolam
Immediate Release
Adult >18 years:
Initial
: 0.25-0.5 mg PO TID
Max
: 4 mg PO daily in divided doses
Older or debilitated:
0.25 mg PO BID-TID
Extended Release
Adult:
0.5-1 mg PO daily in the AM; increase at intervals of at least 3-4 days
Usual
: 3-6 mg/day
Max
: 10 mg/day
May increase dose at intervals of 3-4 days. Do not increase by more than 1 mg daily
Most addictive of this class
due to short half-life and rapid onset
Xanax
Tabs: 0.25 mg, 0.5 mg, 1 mg, 2 mg
Xanax XR
Extended-release tabs: 0.5 mg, 1 mg, 2 mg, 3 mg
clonazepam
Adult > 18 years:
Initial:
0.25-0.5 mg PO BID-TID
Max:
4 mg PO daily in divided doses
Older or debilitated:
start at lowest dose and slowly titrate up
Less addictive due to long half-life
Boxed Warning:
Be aware of prescribing opiates and benzodiazepine together; higher incidence of respiratory failure and death when combined
Klonopin
Tabs: 0.5 m, 1 mg, 2 mg
ODT: 0.125 mg, 0.25 mg, 0.5 mg,1 mg, 2 mg
diazepam
Adult:
Initial
: 2-10 mg PO BID-QID depending on severity of symptoms
Older or debilitated:
2-2.5 mg PO 1 or 2 times initially; increase gradually as tolerated
Less addictive due to long half-life
Valium
Tabs: 2 mg, 5 mg, 10 mg
lorazepam
Adult
:
Initial
: 2-3 mg/d PO given BID-TID
Older or debilitated
: 1-2 mg/d PO in divided doses
Preferred BNZ for patients with compromised hepatic functioning due to avoiding the first pass
Common BNZ utilized to assist with detox from alcohol; short-term use in monitored environment
Ativan
Tabs: 0.5 mg, 1 mg, 2 mg scored
continued
ANXIETY PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Selective Serotonin
Reuptake Inhibitors (SSRIs)
General comments
May increase the risk of suicidal thinking and behavior in patients with major depressive disorder, especially
in children, adolescents and young adults
Monitor patient closely for clinical worsening, suicidality, unusual changes in behavior, especially during initial months of therapy. Ideally, patient should be seen within 2 weeks of initiating or changing the dose of an antidepressant
Full effect may be delayed 4 weeks or longer
May increase risk of bleeding, especially in combination with aspirin, NSAIDs, warfarin
Do not abruptly stop usage
Monitor for hyponatremia
Drug interactions may occur with many medications given in combination with SSRIs. Check compatibility
**Use of SSRIs in the treatment of
anxiety disorders could be indefinite
fluoxetine
*FDA indication for the treatment of panic disorder
Adult:
20 mg PO once daily.
May increase dose after several wk if insufficient clinical response. Doses >20 mg may be administered in single dose or BID
Max
: 80 mg daily
Children 8-17 years:
Initial:
10-20 mg PO daily. If started on 10 mg/day, increase after 1 wk to 20 mg/day
Lower weight children:
start at 10 mg/day PO; may increase after several wk to 20 mg/day
Avoid in patients with uncontrolled narrow-angle glaucoma
No dosage adjustment recommended for renal dysfunction or older patients. However, older adults may have greater sensitivity
Monitor for weight change during treatment
May alter glycemic control (hypoglycemia during use, hyperglycemia after discontinuing)
Discontinuation should take place gradually rather than abruptly
Prozac
Tabs: 10 mg, 20 mg, 40 mg
Solution: 20 mg/5 mL
escitalopram
*FDA indication for treatment of generalized anxiety disorder
Adult
: 10 mg PO once daily. May increase in 1 to 2 wk
Max Adults:
20 mg PO daily
Max Older Adults:
10 mg PO daily
Note:
requires gradual tapering to discontinue
Children >12
: dosing is same as adult dosing except increase should be delayed until after 3 weeks
Not approved for patients <12 years old
Avoid in patients with uncontrolled narrow-angle glaucoma
No dosage adjustment recommended for renal dysfunction or older adults. However, older adults may have greater sensitivity
Prolongs the QT interval
Watch for hyponatremia
Discontinuation should take place gradually rather than abruptly
Lexapro
Tabs: 5 mg, 10 mg, 20 mg
Liquid: 5 mg/5 mL
paroxetine
*FDA indication for the treatment of panic disorder, social anxiety disorder, and generalized anxiety disorder
Adult
:
Initial
: 20 mg PO in morning; may increase dose in 10-mg increments at 1-week intervals
Max
: 50 mg daily
Older or debilitated
:
Initial
: 10 mg PO
Max
: 40 mg PO daily
At least 14 days should elapse between MAO inhibitor and administration of paroxetine
Avoid in patients with uncontrolled narrow-angle glaucoma
Cautious use in history of seizures
Discontinuation should take place gradually rather than abruptly; consider 10 mg/d at wkly intervals before discontinuing
Sedation is common complaint; consider dosing at bedtime.
Monitor for weight gain; not uncommon
Paxil
Tabs: 10 mg, 20 mg, 30 mg, 40 mg
Suspension: 10 mg/5 mL
Paxil CR
Adult
:
Initial
: 25 mg PO daily; adjust
by 12.5 mg/d PO at wkly intervals
Max
: 62.5 mg/d
Older or debilitated
:
Initial
: 12.5 mg/d PO
Max
: 50 mg/d PO
Serotonin and Norepinephrine Reuptake
Inhibitors (SNRIs)
General comments
Antidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment.
Monitor BP before beginning SNRIs and regularly during treatment; could increase BP.
duloxetine
*FDA indication for treatment of generalized anxiety disorder
Adult
: 60 mg PO once daily
Alternative
: 30 mg PO once daily for 1 wk, then increase to 60 mg once daily
Max
: 120 mg PO but no evidence doses >60 mg PO confer greater benefit
At least 14 days should elapse between MAO inhibitor and administration of citalopram
Avoid in patients with uncontrolled narrow-angle glaucoma
Cymbalta
Caps: 20 mg, 30 mg, 60 mg caps
venlafaxine
*FDA indication to treat panic disorder and social anxiety disorder
Adult
:
37.5-375 mg PO daily in divided doses with food; should taper over a minimum of 2 wk
venlafaxine ER
Adult
:
75-225 mg PO daily with food; taper dose by no more than 75 mg/wk PO to discharge
Effexor XR
Caps: 37.5 mg, 75 mg, 150 mg caps
continued
ANXIETY PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Anxiolytic; Serotonin 1A partial agonist; serotonin stabilizer
General comments
Slower onset than benzodiazepines; optimum effect requires 3 to 4 weeks of therapy.
Do not use with MAOIs; caution with itraconazole, cimetidine, nefazodone, erythromycin, and other CYP3A4 inhibitors
buspirone
Adult:
7.5 mg PO BID-TID, usual range 20-30 mg/day
Max: 60 mg daily
Children 6-17 years:
7.5-30 mg PO BID
Not approved for use in children <6 years old
Buspar brand discontinued in U.S.
Not recommended for severe renal or hepatic impairment
Monitor for signs/symptoms of serotonin syndrome, especially in combination with other serotonin modulators
Avoid large quantities of grapefruit juice
No FDA indication for children aged 6-17 years; use would be off-label
Buspar
Tabs: 5 mg, 7.5 mg 10 mg, 15 mg, 30 mg
PREGNANCY/LACTATION CONSIDERATIONS
BNZs contraindicated in pregnancy and lactation
TCAs contraindicated in pregnancy
SSRIs contraindicated in first trimester but may be continued by midwife/obstetrician
CONSULTATION/REFERRAL
Parent/child or family intervention
Evidence of substance abuse
Disabling symptoms
Symptoms that worsen despite treatment
FOLLOW-UP
Regular follow-up visits are important to reinforce education about nonpharmacologic management and proper use of medications
Avoid prescribing anxiolytics by telephone
Remain alert to signs of medication misuse
Tricyclic antidepressants require periodic serum levels along with baseline and follow-up EKGs
EXPECTED COURSE
Anxiety in children can be a precursor to agoraphobia or panic disorder in adulthood
Treatment of medical cause usually, but not always, initiates improvement
Short-term anxiety disorders usually respond well to treatment
Obsessive compulsive disorder requires long-term pharmacologic therapy and psychotherapy
Generalized anxiety disorder is a chronic disease with many exacerbations and relapses.
Exacerbations are more common during times of stress.
Relapses more common in the first year if medication is discontinued.
POSSIBLE COMPLICATIONS
Work- and school-related difficulties
Self-medication leading to alcohol abuse, benzodiazepine dependence
Social impairment
Cardiac arrhythmias related to TCA use
Falls due to sedating effects of medications, especially in older adults
Suicide
Asthma
DESCRIPTION
A chronic inflammatory disorder of the respiratory system that causes airway constriction and hyperresponsiveness of the bronchi. Airway narrowing increases mucus production,
reversible
airway obstruction, inflammation, and airway hyperresponsiveness. Symptoms range from occasional and mild to severe and debilitating.
A consistent definition of asthma is elusive because symptoms vary among patients. It is helpful to think of asthma as an inflammatory disorder of the airways. The WHO defines asthma as a disease characterized by “recurrent attacks of breathlessness and wheezing that vary in severity and frequency from person to person.”
ETIOLOGY
Inflammation of the bronchial mucosa and spasm of the bronchial smooth muscle leads to narrowing of the small and, occasionally, the large airways
Produces characteristic cough and wheezing
INCIDENCE
In the United States, 18.4 million adults and 7.2 million children are affected by asthma
1 in 11 children and 1 in 12 adults have asthma
Asthma is responsible for almost 500,000 hospitalizations and 1.9 million ED visits per year
Most common noncommunicable disease of early childhood; half of cases develop during childhood
Leading cause of missed school days and work, with an estimated annual cost of $56 billion in lost productivity, medical care, and death
RISK FACTORS
Comorbid conditions:
Adults:
URI, COPD, GERD, obesity, obstructive sleep apnea, chronic sinusitis
Children:
URI, viral respiratory infection in susceptible people, cystic fibrosis, obesity
Respiratory irritants:
tobacco smoke, wood smoke, perfumes, pollution, cockroaches, dust mite exposure
History of atopy and allergen exposure
Exercise
Residing in an urban area
Family history
Female sex: women account for nearly 65% of asthma deaths overall
Black race/ethnicity: black people are three times more likely to die from asthma than people of other races. Black women have the highest asthma mortality rate of all groups, more than 2.5 times higher than white women
A personal or family history of asthma or other atopic diseases is suggestive of asthma in a patient with symptoms of asthma.
ASSESSMENT FINDINGS
Between attacks, patients with asthma are generally free from symptoms
Initially, airway constriction causing expiratory wheezing
Shortness of breath
Tachypnea
Tachycardia
A nonproductive cough
Chest tightness
Hyperresonance
Prolonged expiration
Accessory muscle use in severe asthma attack
Sudden nocturnal dyspnea
Decreased exercise tolerance
Normal growth and development in children, even with frequent steroid use
Classification of Asthma Severity
Mild
intermittent
Symptoms ≤2 days per week
or
≤2 nights per month;
Exacerbations brief
Mild
persistent
Symptoms ≥2 times per week, but <1 time per day
or
<2 nights per month
Moderate persistent
Daily symptoms
or
more than 3-4 nights per month
Severe
persistent
Continual symptoms
or
frequent nighttime symptoms >1 night per month
Source: National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma
DIFFERENTIAL DIAGNOSIS
Respiratory infections
Heart failure
Gastroesophageal reflux disease
Habitual or nonasthma-related cough
COPD
Tuberculosis
Foreign body aspiration, especially in children
A diagnosis of asthma requires the presence of respiratory symptoms such as intermittent dyspnea, cough, wheezing, and variable expiratory airflow obstruction.
DIAGNOSTIC STUDIES
Spirometry
Pulmonary function tests
Consider allergy testing
Peak flow monitoring
Methacholine challenge test
PREVENTION
Identify and minimize known asthma triggers by avoiding allergens and irritants
Take prescribed asthma medications daily
Learn early signs and symptoms of asthma exacerbation
Implement an asthma action plan, a preplanned medication plan for asthma exacerbations
Influenza and pneumococcal pneumonia immunizations
Monitor peak flow values
Learn correct use of inhalers, spacers, and other medications: about half of people using inhalers do so incorrectly
An asthma action plan can be based on a patient’s peak expiratory flow rate, but symptom-based plans appear equally effective.
NONPHARMACOLOGIC MANAGEMENT
Peak flow monitoring
Avoidance of asthma triggers if possible
Ongoing patient and family education about disease, treatment, trigger avoidance, asthma management, and emergency actions can minimize asthma severity
Use of asthma action plan and proper use of peak flow meter can reduce ED visits and hospitalizations
PHARMACOLOGIC MANAGEMENT
Inhaled corticosteroids (ICSs) are the mainstay of treatment and are indicated for all categories of persistent asthma
Among ICS molecules, fluticasone has greater systemic side effects than other steroids, and budesonide has a better systemic adverse effect profile
Newer ICSs, such as ciclesonide, might be more beneficial in reducing systemic effects
All patients with persistent asthma must have a rescue medication (short acting bronchodilator), like albuterol, to use when bronchoconstrictive episode occurs.
Mild Intermittent
Short-acting bronchodilator:
for exacerbations
Mild
persistent
Preferred treatment:
low-dose ICS
Short-acting bronchodilator for exacerbations
Alternative treatment:
cromolyn, leukotriene
OR
sustained-release theophylline (serum concentration 5-15 mcg/mL)
Consider leukotriene blocker (Singulair, Accolate)
Moderate persistent
Preferred treatment:
low- to medium- dose ICS and long-acting inhaled bronchodilator
Short-acting bronchodilator for exacerbations
Alternative treatment:
low- to medium-dose inhaled corticosteroid and leukotriene blocker OR theophylline
Severe persistent
Preferred treatment:
high-dose ICS and long-acting inhaled bronchodilators
AND
, if needed, oral corticosteroids (2 mg/kg/d not to exceed 60 mg/d)
Short-acting bronchodilator for exacerbations
Omalizumab is an option when other asthma medications are ineffective. It is an expensive anti-IgE medication given as an injection every 2 to 4 wk to prevent reactions from allergic triggers
Source: National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma
For infants and children <5 years of age:
Cromolyn (Intal) preferred over steroids if provides adequate symptom management. Nebulized bronchodilator preferred over metered-dose inhaler. Use spacer/holding chamber and face mask
Mild intermittent
Short-acting bronchodilator:
for exacerbations
Mild persistent
Preferred treatment:
low-dose ICS
Short-acting bronchodilator for exacerbations
Alternative treatment:
cromolyn, leukotriene
Consider leukotriene blocker (Singulair)
Moderate persistent
Preferred treatment:
low-dose ICS and long-acting inhaled bronchodilator OR medium-dose inhaled corticosteroid
Short-acting bronchodilator for exacerbations
Alternative treatment:
low-dose ICS and leukotriene blocker OR theophylline
Severe persistent
Preferred treatment:
high-dose ICS and long-acting inhaled bronchodilators
AND
, if needed, oral corticosteroids (2 mg/kg/day not to exceed 60 mg/day)
Short-acting bronchodilator for exacerbations
Source: National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma
ASTHMA PHARMACOLOGIC MANAGEMENT
Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Short-Acting Bronchodilators
Stimulate beta 2 receptors in the lungs, causing bronchodilation. Used as rescue inhalers
General comments
Paradoxical bronchospasm can result from use of bronchodilators; may be life-threatening
Increased use of albuterol can signify deteriorating asthma. Give special consideration to anti-inflammatory treatment (corticosteroids)
albuterol
(inhaled or nebulized)
Adult and ≥12 years:
Usual:
2 puffs q 4-6 hr prn for bronchospasm
Alternative:
1 puff q 4-6 hours
Children <4 years:
not
recommended
≥4 years:
2 puffs q 4-6 hours; 1 puff q 4 hours may suffice
Prevention of exercise-induced asthma:
≥4 years:
2 puffs q 15-30 min before exercise
Each puff: albuterol 90 mcg
Can increase heart rate and blood pressure, cause QT prolongation and ST segment depression
Cautious use in patients with cardiac arrhythmias, convulsive disorders, hyperthyroidism
Use extreme caution in patients on MAO inhibitors, beta blockers
May cause hypokalemia, especially if in conjunction with potassium-wasting medications. Consider monitoring potassium levels
Possible decreases in digoxin levels
Shake well before each spray
Ventolin HFA
17-g canister contains
200 actuations
albuterol
Adult and ≥12 years:
Usual:
2 puffs q 4-6 hr
Children ≥4 years:
2 puffs q 4-6 hr; 1 puff q 4 hr may be sufficient for some patients
Each puff: albuterol 90 mcg
ProAir HFA
8.5 g canister/200 actuations
Long-Acting
Bronchodilators
Stimulate beta 2 receptors in the lung: maintenance meds that do not treat an acute asthma attack
General comments
Paradoxical bronchospasm can result from use of bronchodilators and may be life-threatening
Long-acting bronchodilators increase the risk of asthma-related death. Do not use in patients with asthma unless accompanied by a long-term asthma control medication, such as an inhaled steroid
salmeterol
Adult:
1 puff q 12 hr
Only for use in conjunction with a long-term asthma control medication, such as an inhaled steroid
Do not use long-acting agents to treat acute symptoms. These agents take 15-20 minutes to produce bronchodilation
Tolerance develops with prolonged use
Significant drug interactions with ketoconazole, erythromycin, clarithromycin
Can increase heart rate, blood pressure, and cause QT prolongation and ST segment depression
Cautious use in patients with cardiac arrhythmias, convulsive disorders, hyperthyroidism
Use extreme caution in patients on MAO inhibitors, beta blockers
May cause hypokalemia, especially if in conjunction with potassium-wasting medications. Consider monitoring potassium levels
Serevent Diskus
Each puff:30 mcg
salmeterol
60 actuations
continued
ASTHMA PHARMACOLOGIC MANAGEMENT
Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Xanthines
Cause bronchodilation by relaxing smooth muscle of the bronchi and pulmonary blood vessels
General comments
Used as an alternative in asthma treatment; not first line
Toxicity is a general concern with theophylline. Activated charcoal used to manage acute and chronic toxicity
theophylline
Adult:
Initial:
300-400 mg daily for 3 days; if tolerated, increase dose to 400-600 mg daily; after 3 more days, if tolerated and needed, increase dose to blood level
Max:
400 mg daily for patients with impaired clearance or age
>60 years
12-15 years:
16 mg/kg
Max:
400 mg/day PO
The xanthenes are central respiratory stimulants and reduce fatigability in patients with COPD
Must monitor levels (10-20 mcg/mL is desirable). Common symptom of toxicity is repetitive vomiting
Elevated levels predispose patient to ventricular arrhythmias, seizures. Use is ill advised in patients with active peptic ulcer disease, seizure disorders, cardiac arrhythmias
Monitor for tremors, anxiety, jitteriness
Many food-drug interactions involving CYP 450 system
No dosage adjustment for renal impairment; need adjustment for hepatic insufficiency, heart failure
Smoking increases clearance of theophylline
High-fat meal increases absorption of theophylline
Do not crush or chew extended-release tablets
Aminophylline is converted to theophylline
Theo-24
Tabs: 100 mg, 200 mg,
Extended-Release Caps: 300 mg, 400 mg
Anticholinergics (Short-Acting)
Block action of acetylcholine and thus cause mild bronchodilation and prevent bronchoconstriction
General comments
No used first line in asthma
Monitor for signs of worsening narrow-angle glaucoma, worsening GI/GU obstruction
ipratropium
Adult:
2 puffs QID
Max:
12 puffs/24 hr solution for nebulizer
Adult:
500 mcg TID-QID
Not indicated for relief of acute bronchospasm
Works well in conjunction with a bronchodilator
Atrovent HFA canister does not require shaking, but it does need to be primed
Atrovent HFA
17 mcg/puffs
12.9 g/200 puffs
Solution: 2.5 mL/vial (25)
Inhaled Corticosteroids
Glucocorticoids decrease activity of inflammatory cells and mediators
General comments
Steroid activity is local (in the lungs) and is associated with minimal systemic absorption
Decreases in bone density can occur with steroids; monitor
May cause immunosuppression; possible increased risk of pneumonia, worsening of existing infections. Cautious use with concurrent 3A4 inhibitors
fluticasone propionate
Adult:
Previously on bronchodilators:
Initial:
88 mcg inhaled BID
Max:
440 mcg inhaled BID
Previously on inhaled steroids:
Initial:
88-220 mcg inhaled BID
Max:
440 mcg inhaled BID
Previously on oral steroids:
Initial:
440 mcg inhaled BID
Max:
880 mcg inhaled BID
Slowly wean patients on oral steroids to inhaled steroids
Abrupt withdrawal of oral steroids can cause symptoms of adrenal insufficiency (fatigue, weakness, hypotension)
Inhaled glucocorticoids have fewer and less severe adverse effects than orally administered glucocorticoids.
Clinicians should aim for the lowest dose possible to avoid systemic adverse effects on hypothalamo-pituitary-adrenal axis, bone density and growth
Flovent HFA
44 mcg/actuation (10.6 g)
110 mcg/ actuation (12 g)
220 mcg/actuation (12 g)
continued
ASTHMA PHARMACOLOGIC MANAGEMENT
Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Monitor for increased intraocular pressure, glaucoma and/or cataracts
Rinse mouth well after use to prevent thrush
budesonide
Adult:
Initial:
360 mcg inhaled BID
Alternative:
Some patients may respond to 180 mcg inhaled BID
Max:
720 mcg inhaled BID
Inhaled steroids do not cause systemic effects
Monitor for symptoms of fungal infection in the mouth and pharynx
Pulmicort Flexhaler
Available: 180 mcg/actuation, 120 doses
mometasone
Previously on bronchodilators alone or inhaled steroids
Initial:
220 mcg once in the PM
Max:
440 mcg daily as single dose or divided
Previously on oral corticosteroids (wean gradually)
Initial:
440 mcg inhaled BID
Max:
880 mcg inhaled daily
Asmanex Twisthaler
Inhalations-20 g; 240 actuations
Combination Inhaled Corticosteroid/Long-Acting Bronchodilator
Glucocorticoids decrease activity of inflammatory cells and mediators
Steroid activity is local (in the lungs) and is associated with minimal systemic absorption
General comments
Paradoxical bronchospasm can occur with combo medications
Close monitoring for glaucoma and cataracts is warranted
Possible metabolic effects: hypokalemia, hyperglycemia
Rinse mouth well after use to avoid thrush
fluticasone/salmeterol
Adults and children ≥12 years:
Not previously on inhaled steroid:
1 puff 100/50 or 250/50 daily
Already on inhaled steroid:
see literature
If insufficient response after 2 wk use next highest strength
Max:
1 puff 500/50 BID
Children 4-11 years:
1 puff 100/50 BID
Monitor for symptoms of fungal infection in the mouth and pharynx
NOT indicated for the relief of acute bronchospasm
Increased risk of pneumonia
Risks associated with inhaled steroids and long-acting bronchodilators are identical in these combination products, as in individual products
Base initial dose on asthma severity
Advair Diskus
100/50, 250/50, 500/50
Diskus (60 blisters)
budesonide/formoterol
Adults and children ≥12 years:
2 puffs 80/4.5 or 160/4.5 BID (AM and PM)
If inadequate response after 1-2 wk of 80/4.5, increase to 2 puffs 160/4.5
Max:
2 puffs 160/4.5
Monitor for symptoms of fungal infection in the mouth and pharynx
NOT indicated for the relief of acute bronchospasm
Increased risk of pneumonia in patients
Risks associated with inhaled steroids and long-acting bronchodilators are identical in these combinations products, as in individual products
Symbicort
Available: 80/4.5, 160/4.5 60, 120 actuations
continued
ASTHMA PHARMACOLOGIC MANAGEMENT
Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Leukotriene antagonists
Block the action of leukotrienes which are released from mast cells and eosinophils and are associated with airway edema, increased inflammatory activity and smooth muscle contraction
General comments
These agents are NOT substitutes for bronchodilators or inhaled steroids
Take daily
Monitor for drug interactions with zafirlukast
montelukast
Adults and children >15 years:
10 mg
Children 6-14 years:
5 mg chew tab PO daily;
Children 2-5 years:
1 4-mg chew tab PO daily;
Children 12-23 months:
1 4-mg granule packet PO daily
For prevention of exercise-induced asthma: take at least 2 hr before exercise
Cautious use in hepatic dysfunction
Not for use as lone product in severe asthma
Chew tab contains phenylalamine
Leukotriene antagonists are helpful in managing allergic component
Singulair
Tabs: 10 mg
Chew tabs: 4 mg, 5 mg
Oral granules: 4 mg
omalizumab
Adult and children ≥12 years:
Initiate dosing according to Table 1 or 2 (next section)
Table 1: Subcutaneous Xolair doses q 4 wk for patients ≥12 years:
Pretreatment serum IgE ≥30-100 IU/mL:
30-60 kg, >60-70 kg, >70-90 kg, dose 150 mg; >90-150 kg, dose 300 mg
Pretreatment serum IgE >100-200 IU/mL:
30-60 kg, >60-70 kg, >70-90 kg, dose 300 mg
Pretreatment serum IgE >200-300 IU/mL:
30-60 kg, dose 300 mg
Higher body wt and serum IgE levels, move to biwkly dosing (below)
May be appropriate when other asthma meds are ineffective; anti-IgE medication given IM every 2-4 weeks to prevent reactions from allergic triggers
FDA indication for moderate to severe persistent allergic asthma
First monoclonal antibody with FDA indication to treat chronic idiopathic urticaria in adults and adolescents who remain symptomatic despite H1 antihistamine treatment
Xolair is a subcutaneous injection administered in office by a healthcare provider
Provider must be prepared to manage anaphylaxis that can be life-threatening
Indication is for moderate to severe persistent asthma in patients ≥6 years who have a positive skin test or in whom symptoms are inadequately controlled with inhaled corticosteroids
Limitations of use: not indicated for treatment of urticarial or other allergies and does not treat acute bronchospasm or status asthmaticus
Xolair
Table 2: Subcutaneous Xolair doses q 2 wk for patients ≥12 years:
Pretreatment serum IgE >100-200 IU/mL:
>90-150 kg, dose 225 mg
Pretreatment serum IgE >200-300 IU/mL:
>60-70 kg, >70-90 kg, dose 225 mg; >90-150 kg, dose 300 mg
Pretreatment serum IgE >300-400 IU/mL:
30-60 kg, >60-70 kg, dose 225 mg; >70-90 kg, dose 300 mg
Pretreatment serum IgE >400-500 IU/mL:
30-60 kg, >60-70 kg, dose 300 mg; >70-90 kg, dose 375 mg; higher wt, do not dose
Pretreatment serum IgE >500-600 IU/mL:
30-60 kg, dose 300 mg; >60-70 kg, dose 375 mg; higher wt, do not dose
Pretreatment serum IgE >600-700 IU/mL:
30-60 kg, dose 375 mg; higher wt, do not dose
Patients 6 to <12 year:
Subcutaneous Xolair doses 2 q 2 or 4 weeks for pediatric patients with asthma who begin Xolair between ages 6 and <12 years:https://www.gene.com/downlo ad/pdf/xolair_prescribing.pdf
PREGNANCY/LACTATION CONSIDERATIONS
Stress importance of prevention
Poor control can result in low birth weight infants, premature labor/delivery, increased risk of fetal mortality
Aggressive treatment of symptoms with steroids, bronchodilators, and theophylline if needed
CONSULTATION/REFERRAL
Allergist/pulmonologist for patients with severe persistent asthma, a life-threatening exacerbation, or hospitalization for asthma, and patients who required more than two rounds of oral steroids in a year or who are candidates for immunotherapy
FOLLOW-UP
As needed to educate patient, parent, caregiver about disease and management
Every 3-6 months for stable disease
EXPECTED COURSE
Excellent with adherence to asthma action plan
Small percentage of patients have poor control, even with proper medication use
Risk of mortality increased by nocturnal symptoms, history of intubation for asthma, history of hospitalization/ICU admission for asthma, more than three ED visits annually for asthma, and oral steroid dependence
Adult women, black people, and older adults have the highest death rates
POSSIBLE COMPLICATIONS
Respiratory failure/death from unrelieved bronchospasms
Steroid dependence
Back pain-
DESCRIPTION
Activity intolerance due to lumbar pain that involves an intervertebral disc. Referral of pain to the buttocks, posterior thighs, and/or down one or both legs (radiculopathy) is common.
Low back pain is generally mechanical in nature and attributed to degenerative changes.
Radiculopathy is a disorder of the spinal nerve roots due to compression, inflammation, or tearing of nerve roots at the site of entry into the vertebral canal.
Back pain can be further classified into three categories
Acute: less than 6 weeks’ duration
Subacute: 6 weeks to 3 months’ duration
Chronic: symptoms for more than 3 months or on more than half of days in the prior 6 months
ETIOLOGY
Often unclear; stretching or tearing of nerves, muscles, tendons, ligaments, or fascia of back secondary to trauma or chronic mechanical stress
Compression or irritation of a nerve root is a common cause
The vertebral discs most commonly affected in low back pain are L4-L5 and L5-S1.
INCIDENCE
>85% of U.S. population affected at some point
Most common musculoskeletal problem worldwide
Second most common reason to seek healthcare
Common cause of hospitalizations and subsequent surgeries
Overall prevalence is 38% of the U.S. population
Prevalence of chronic low back pain is about 15%
Men = Women
RISK FACTORS
Obesity
Sedentary lifestyle, inadequate conditioning
Cigarette smoking
Preexisting psychological conditions
Chronic occupational strain, improper lifting techniques
Exaggerated lumbar lordosis, chronic poor posture
Leg length discrepancy
Age >65 years
ASSESSMENT FINDINGS
Pain in back, buttocks and/or one or both thighs that is aggravated by movement, rising from seated position, standing, and flexion; may be relieved by rest, repositioning, or reclining
Muscle spasm may be present over lumbosacral area due to soft tissue involvement (ligaments, muscles)
Pain may radiate down leg and below the knee
Assess rectal tone in patients describing cauda equina syndrome
Motor, sensory, and reflex examinations are imperative
Observe gait, assess lower extremity strength and bulk of muscles, pulses
Deep tendon reflexes (DTR)
Patellar: tests nerves at roots L2-L4
Achilles: tests nerves at roots S1-S2
DTR responses are graded as follows:
0: no response
+1: diminished response
+2: normal response
+3: increased response
+4: hyperactive response
Diminished DTR responses may imply myopathies, decreased muscle mass, and nerve root impairment. DTR responses greater than normal are characteristic of pyramidal tract disease, electrolyte imbalance, hyperthyroidism, or other endocrine abnormalities.
New-onset radicular pain in older patients is often a sign of spinal stenosis.
Straight leg raise test; elevation of affected leg in supine position will elicit pain at 20-30° for severe disease, 30-60° for moderate disease.
Crossed leg raise test: elevating unaffected leg produces pain in affected leg.
DIFFERENTIAL DIAGNOSIS
Low back strain
Herniated intervertebral disc
Prostatitis, pyelonephritis
Vascular occlusion at level of bifurcation; abdominal aneurysm
Carcinoma if bony metastasis occurs
Endometriosis, fibromyoma
Depression, hysteria
Malingering
Compression fracture, osteoporosis
Osteoarthritis
Ankylosing spondylitis
Cauda equina syndrome
Hip or pelvic pathology
DIAGNOSTIC STUDIES
Routine imaging is not recommended for patients with acute or nonspecific back pain. Red flag symptoms (below) or lack of clinical improvement in 4-6 weeks warrants consideration of plain film imaging
Neurologic deficits
History of cancer
Accompanying unexplained weight loss
Substance abuse: steroids, alcohol, drugs
History of significant trauma
Patient involved in litigation, desiring compensation
Consider additional studies only for patients who have severe or progressive neurologic deficits or symptoms of underlying conditions
MRI
CBC, ESR, serum calcium, alkaline phosphatase, serum immunoelectrophoresis
Urinalysis
Many patients have bulging discs but do not experience symptoms.
PREVENTION
Education about proper lifting techniques, body mechanics
Conditioning exercises
Maintenance of appropriate weight for height
Avoid cigarette smoking
NONPHARMACOLOGIC MANAGEMENT
Patient education and reassurance (80-90% recover by 6 weeks), NSAIDs, acetaminophen and muscle relaxers for nonspecific acute low back pain (AAFP evidence rating A)
Avoid bed rest or restrict to no more than 1-2 days
Physical therapy (McKenzie method), core strengthening exercises after acute injury to decrease recurrence (Evidence rating B)
Chiropractor/spinal manipulation not more effective than medical treatment (Evidence rating B)
No substantial benefit with steroids, acupuncture, massage, traction, lumbar supports or exercise program (Evidence rating A)
Gradually resume activities as tolerated and include gradually increasing low-stress aerobic exercises
Physical modalities
Cryotherapy for 20-30 minutes several times up to 48 hours after onset
Apply heat for 20-30 minutes several times a day after the first 48 hours
Exercise: isometric tightening of abdominal and gluteal muscles after acute pain subsides; lumbar hyperextension exercises
Education about preventive measures
Shoe insoles, shoe lifts recommended for leg length discrepancies >2 cm
Conservative measures are usually recommended for the first 6 weeks, unless neurological deficits or severe pain is present.
PHARMACOLOGIC MANAGEMENT
NSAIDs reduce pain and inflammation and promote healing
Acetaminophen reduces pain but is more effective in combination with a narcotic analgesic or NSAID
Muscle relaxants have NOT been proven more effective than NSAIDs either alone or concomitantly, but they are helpful for spastic conditions
Short-term use of opioid analgesics for pain relief has NOT been proven more effective than NSAIDs; opioids are associated with potential for physical dependence
Consider epidural steroid injections to reduce inflammation and pain if conservative treatments fail
CONSULTATION/REFERRAL
Findings that indicate neurological involvement
Recurrent or chronic pain unresponsive to therapy
Physical therapy initially if pain is moderate and conservative treatment has not provided relief
FOLLOW-UP
Return for repeat evaluation in 24-48 hours if pain is severe, and in 7-10 days if pain is moderate; follow every 2-4 weeks until able to resume lifestyle
Ongoing education and support about lifestyle changes
If unable to tolerate activities despite no serious underlying pathology, explore psychosocial factors
EXPECTED COURSE
In 80% of cases, symptoms resolve in 4-6 weeks
POSSIBLE COMPLICATIONS
Prolonged disability associated with physical, psychological, social, and economic factors
BPH
DESCRIPTION
Benign enlargement of the prostate gland that narrows the urethral lumen and leads to increased prostatic smooth muscle tone. Pathophysiology associated with various lower urinary tract symptoms.
ETIOLOGY
Exact cause unknown, but strong evidence supports age-related hormonal changes and an androgen/estrogen imbalance
Epithelial ratio changes secondary to aging increase the number of prostatic stem cells and decrease cell death
The presence of androgens is necessary for the development of benign prostatic hyperplasia (BPH)
INCIDENCE
Uncommon age younger than 40
42% of men aged 51-60 years
82% of men by age 70-80 years
Responsible for $1.1 billion in healthcare costs annually and 4.4 million office visits annually
RISK FACTORS
Elevated PSA levels, increased physical activity
Increasing age
Family genetics
Black men more likely to be affected than other patient populations
Asian men less likely than any other patient population to be diagnosed with BPH
Cigarette smoking, male-pattern baldness, and metabolic syndrome are now considered weak risk factors for BPH
ASSESSMENT FINDINGS
Weak urinary stream
Hesitancy and postvoid dribbling
Incomplete emptying of bladder
Frequency and urgency
Nocturia
Urinary incontinence
Urinary retention
Hematuria: gross or microscopic
Firm, smooth, symmetrically enlarged prostate
The size of the prostate in a man with benign prostatic hyperplasia (BPH) does not always correlate with symptoms.
DIFFERENTIAL DIAGNOSIS
Prostatitis
Prostate cancer
Urethral stricture
Neurogenic bladder
Effect of medications (e.g., sympathomimetics, opiates, antihistamines, anticholinergics)
Urinary tract infection
Malignancy (bladder or prostate)
DIAGNOSTIC STUDIES
Initial evaluation with American Urological Association Symptom Index, a self-administered tool that asks seven questions about symptoms of prostatism: incomplete emptying, frequency, intermittency, urgency, a weak stream, hesitancy, and nocturia. The index is scored from 0-35 depending on symptoms:
Mild symptoms: score of 0-7
Moderate symptoms: score of 8-19
Severe symptoms: score of 20-35
May also use International Prostate Symptoms Score (IPSS)
Urinalysis: pyuria if residual urine present
Creatinine for assessment of renal function
Postvoid residual urine measurement (>100 mL)
Prostate-specific antigen (PSA): may be elevated, but <10 ng/mL
Ultrasound of prostate (not necessary for routine evaluation of the gland)
Needle biopsy
IVP, CT or MRI of the prostate
Optional testing: maximal urinary flow rate, postvoid residual urine volume, urine cytology
NONPHARMACOLOGIC MANAGEMENT
Lifestyle modifications may provide relief of mild symptoms (AUA score 0-7)
Limit fluids before bedtime
Frequent voiding
Avoid sympathomimetic or anticholinergic medications (e.g., decongestants) due to increased risk of urinary retention
Avoid caffeine, alcohol, and other beverages that produce diuresis
Sitting to urinate vs. standing may reduce symptoms
Surgical options for patients with moderate to severe symptoms:
Transurethral resection of the prostate (TURP): gold standard for relief of symptoms related to urinary retention in men with low surgical risk, or those desiring long-term benefit
Transurethral incision of the prostate (TUIP), radiofrequency ablation and microwave therapy are all viable options for younger men who cannot tolerate TURP or photoselective vaporization (PVP) surgeries
Photoselective vaporization (PVP) is an ablative procedure generally performed on an outpatient basis. PVP removes less prostate tissue and produces less blood than TURP. HoLEP and ThuLep are variations of photolaser surgery that are synonymous with open prostatectomy
Open prostatectomy may be necessary for very large prostates (>100 g)
A normal prostate gland in a young man weighs about 20 grams.
Indications for surgery: severe symptoms, refractory urinary retention, recurrent urinary tract infections, recurrent hematuria, bladder stones, renal insufficiency due to BPH
PHARMACOLOGIC MANAGEMENT
Pharmacologic therapy is indicated in mild to moderate disease (AUA score >8)
Mild to moderate symptoms warrant treatment with an alpha-1 adrenergic antagonist as monotherapy; provides immediate therapeutic benefits
5-alpha reductase inhibitors should be used long term for maximum efficacy: 6-12 months of treatment may be required for symptom improvement
In men with severe symptoms, it is acceptable to initiate therapy with a combination of alpha-1 adrenergic antagonists and a 5-alpha reductase inhibitor
BENIGN PROSTATIC HYPERPLASIA PHARMACOLOGIC MANAGEMENT
Prior to initiating therapy, appropriate evaluation is necessary to identify conditions such as infection, prostate cancer, stricture disease, hypotonic bladder or other neurogenic disorders that might mimic BPH
Class
Drug
Generic name
(Trade Name)
Dosage
How supplied
Comments
Alpha 1 adrenergic antagonists
Blockade of the alpha adrenergic receptors causes relaxation of smooth muscle in the prostate and neck of the bladder
General comments
May cause orthostatic hypotension
Use with caution in patients taking erectile dysfunction medications
Seek medical attention for priapism
doxazosin
Adult:
Initial:
1 mg PO daily
Usual:
titrate for effect
Max:
8 mg PO daily
Extended Release
Adult:
Initial:
4 mg PO daily
Usual:
titrate for effect
Max:
8 mg PO daily
Drug therapy must be individualized
Increase immediate-release dose at 7- to 14-day intervals; increase extended-release dose at 3- to 4-week intervals
Extended-release form contraindicated in patients with hepatic dysfunction
Extended-release form should be taken daily with breakfast
Do not crush or chew extended-release form
Cardura
Tabs: 1 mg, 2 mg, 4 mg, 8 mg scored
Cardura XL
Extended-release tabs: 4 mg, 8 mg
tamsulosin
Adult:
Initial:
0.4 mg PO daily
Max:
0.8 mg PO daily
Dose daily at consistent time
May increase dose after 2-4 weeks
If higher doses are held for extended periods, resume at lower dose and titrate down
Flomax
Caps: 0.4 mg caps
terazosin
Adult:
Initial:
1 mg PO/day at HS
Usual:
titrate for effect
Max:
20 mg PO/day
Syncope most likely timed with dosage administration
If higher doses are held for extended periods, resume at lower dose and titrate down
Hytrin
Tabs: 1 mg, 2 mg, 5 mg, 10 mg
Caps: 1 mg, 2 mg, 5 mg, 10 mg
Alfuzosin
Adult:
Initial/Max:
10 mg PO daily
Uroxatral
Tabs: 10 mg
silodosin
Adult:
Initial:
8 mg PO daily
CrCl of 30-50: 4 mg PO daily
CrCl <30: contraindicated
Max:
8 mg PO daily
Rapaflo
Tabs: 4 mg, 8 mg
BENIGN PROSTATIC HYPERPLASIA PHARMACOLOGIC MANAGEMENT
Prior to initiating therapy, appropriate evaluation is necessary to identify conditions such as infection, prostate cancer, stricture disease, hypotonic bladder or other neurogenic disorders that might mimic BPH
Class
Drug
Generic name
(Trade Name)
Dosage
How supplied
Comments
5-Alpha Reductase Inhibitors
Inhibit conversion of testosterone to DHT
Enlargement of the
prostate gland is caused by DHT
General comments
Pregnant women should not handle product
May take 6-12 months to assess benefit of therapy
PSA levels will decrease while on this therapy
dutasteride
As Monotherapy:
Adult:
Initial:
0.5 mg PO daily
Max:
0.5 mg PO daily
As Combination Therapy
Initial:
0.5 mg PO daily
Max:
0.5 mg PO daily in combination with tamsulosin (0.4 mg) daily
Do not crush or chew
If higher doses are held for extended periods, resume at monotherapy dose and titrate back
Avodart
Caps: 0.5 mg
finasteride
As Monotherapy:
Adult:
Initial:
5 mg PO daily
Max:
5 mg PO daily
As Combination Therapy:
Adult:
Initial:
5 mg PO daily
Max:
5 mg PO daily in combination with doxazosin daily
Do not crush or chew
May be taken without regard to meals
May decrease amount of ejaculation
Proscar
Tabs: 5 mg
Phosphodiesterase-5 (PDE-5) Inhibitors
Inhibit phosphodiesterase type 5 (PDE-5), enhance effects of nitric oxide, and increase cGMP, resulting in relaxation of smooth muscle
General comments
Use cautiously in patients with BP of 90/50 mm Hg, CAD with MI and CABG or revascularization in the last 6 months, retinal disorders, or bleeding risks
Not safe to be administered with nitrates or long-acting nitrates
Transient hypotension may occur
Obtain baseline creatinine level
Patients should be urged to report sudden changes in vision
Priapism lasting greater than 4 hours should be evaluated
tadalafil
Adult:
Initial
: 2.5 mg PO daily
Max:
5 mg PO daily
CrCl <30: contraindicated
Avoid concomitant use of nitrates
Use caution if patient on alpha blocker
May be taken without regard to meals
Use with caution in patients with recent MI, CVA
May use lower starting dose in older adults or patients with diminished renal or hepatic function
Cialis
Tabs: 2.5 mg, 5 mg, 10 mg, 20 mg
5-alpha reductase inhibitors decrease PSA. For purposes of screening for prostate cancer, PSA value must be doubled in order to compare with premedication result.
CONSULTATION/REFERRAL
Refer for urological evaluation if refractory to treatment, evidence of renal complications, or if surgery indicated
FOLLOW-UP
Annual digital rectal exam
PSA annually
Review possible side effects of medications and screen for erectile dysfunction
Patient should be encouraged to keep a log of symptoms and voiding patterns, including volume of urination, for review at follow-up
EXPECTED COURSE
Symptoms improve or stabilize in 70-80% of patients
20-30% of patients require treatment due to worsening of symptoms
POSSIBLE COMPLICATIONS
Acute urinary retention
Urinary incontinence (nocturnal is common)
Nocturia
Urinary tract infection
Prostatitis
Hydronephrosis
Erectile dysfunction from pharmacologic or surgical treatment
Depressive disorder
DESCRIPTION
Depression is a constellation of signs and symptoms that have multifactorial causes including life circumstances, biological predisposition, and epigenetic influences. Disturbances in cognitive, emotional, behavioral, and somatic regulations are involved. Depressed mood and anhedonia are the major symptoms.
Anhedonia is a loss of pleasure or interest in things that previously provided joy or pleasure. To be diagnosed with depressive disorders, the patient must exhibit depression and/or anhedonia along with other specifiers.
ETIOLOGY
Still not well understood
Impaired synthesis and/or metabolism of norepinephrine, serotonin, dopamine and/or other neurotransmitters
Gamma-aminobutyric acid (GABA)/glutamate, N-methyl-D-aspartate (NMDA) and other neurotransmitters affecting the structural integrity of the brain are thought to be possible factors or contributing factors in depression.
Evidence indicates genetic predisposition (30-40%)
60-70% of cases are related to specific environmental factors including adverse events in childhood and ongoing or recent stress due to interpersonal adversities. Examples include: childhood sexual abuse, other lifetime trauma, decreased or absent social support, and marital issues
Serotonin produces calmness and relaxed state
Norepinephrine and dopamine enhance productivity, ambition, concentration and ability to feel pleasure
GABA exerts effects on feelings of calmness
NMDA is an excitatory neurotransmitter
INCIDENCE
Major depressive disorder affects 16 million adults annually in the United States
Will affect 5-20% of the U.S. population at some time
1.5-3 times more common among people with an affected first-degree relative
Affects 2% of preadolescents and 5% of adolescents in the U.S.
The World Health Organization expects depression to be the leading cause of disability worldwide by 2020
RISK FACTORS
Female sex
Psychosocial stressors
Postpartum period
Physical or chronic illness, especially migraines and back pain
Prior episodes of depression and suicide attempts
Family history of suicide
Alcohol or substance abuse
Children with a history of being bullied or experiencing other forms of abuse
Retirement, aging, significant losses (death of a spouse, loss of job, divorce, etc.)
ASSESSMENT FINDINGS
Children:
Anorexia
Sleep disturbance
Apathy and sluggishness
Developmental delay
Anxiety, irritability, cries easily, restlessness
Aggression, hyperactivity
School problems
GI or other somatic complaints
Poor self-esteem
Cognitive dulling
Suicidal thoughts or self-injury
Withdrawal or increased clinging behaviors
Adolescents:
Similar to adults
Impulsivity
Fatigue
Hopelessness
Substance abuse
Adults:
Depressed mood for 2 weeks or longer and/or anhedonia; at least one of these MUST be present
Decreased or increased appetite
Weight loss or gain
Sleep disorder
Psychomotor agitation or retardation
Fatigue, loss of energy
Feelings of worthlessness, inappropriate guilt
Recurrent thoughts of death
Difficulty thinking/concentrating or indecisiveness
In adults, depression is likely if the patient experiences anhedonia or depression and any four or more of the following: change in appetite, sleep pattern, fatigue, psychomotor retardation or agitation, poor self-image, concentration difficulty, or suicidal ideation.
DIFFERENTIAL DIAGNOSIS
Children:
Bipolar disorder
Attention deficit disorder
Separation anxiety
Chronic physical illness
Conduct disorder
Physical or sexual abuse
PTSD
Substance misuse
Organic causes
Adults:
Bipolar disorder
Substance misuse
Physical illness: organic brain diseases, diabetes, liver, or renal failure
Grief reaction; important to distinguish
Other psychiatric disorders
Medication abuse/use
Medication withdrawal
Hypothyroidism, B12 deficiency
Dementia
DIAGNOSTIC STUDIES
Structured interviews/questionnaires:
The Children’s Depression Inventory
Children’s Depression Scale
Depression Self-Rating Scale
Hamilton Depression Scale
DSM-5 cross cutting tools for depression (PROMIS) in children (ages 6-17), adolescents (ages 11-17) and adults
Patient Health Questionnaire 9 (PHQ-9; available in a modified form for adolescents)
Beck’s Depression Inventory
Child Behavior Checklist for ages 4-18 years
Pediatric symptom checklist
Zung self-rating depression scale
Geriatric depression scale
Laboratory studies do not diagnose depression but are used to rule out other conditions.
Laboratory studies:
TSH to rule out hypothyroidism
Urine drug screen for substance use disorders
ECG as baseline to rule out arrhythmias or heart block before instituting tricyclic antidepressants
Consider fasting blood sugar, vitamin D, vitamin B12 and folate levels
Some genetic testing is available to help with selection of specific psychotropic medications that are metabolized via the CYP 450 system. This is especially important in patients who have not responded adequately to multiple trials of antidepressants
TCA may provoke arrhythmias in patients with subclinical sinus node dysfunction.
PREVENTION
Maintain a high index of suspicion in adolescents and adults with family or personal history of depression, suicide attempts (especially within the previous 5 years), chronic illness and/or recent loss
Ask patients suspected of suicide intent about plan, lethality and availability of method
Routine questioning about use of alcohol and drugs starting during adolescence and extending into the lifespan. Consider including any school-aged child in questioning about alcohol and drugs as well
NONPHARMACOLOGIC MANAGEMENT
Identify suicidal risk, plan, lethality, availability and intent
Establish safe environment: ensure patient safety in least restrictive environment
When suicidal urges are present, obtain a “commitment to treatment” statement with a crisis response plan directed at planned responses to addressing behaviors
Provide community resources, suicide hotline
Suicide threats should be interpreted as a communication of desperation and are to be taken seriously; know your state’s involuntary commitment laws and APRN scope of practice
Psychoeducation
Ongoing information about illness, symptoms, prognosis, and therapy
Include interpersonal relationships, work, other health-related needs
Discourage major life changes while in a depressive state
Help set realistic, attainable, concrete goals
Educate about importance of avoiding alcohol
Psychotherapy
The treatment of choice with or without pharmacological interventions in mild to moderate depression
Pharmacological treatment works best when accompanied by psychotherapy
Establish and maintain a supportive therapeutic relationship
Remain available during times of crisis
Maintain vigilance for signs of destructive impulses
Strengthen expectations of help and hope for the future
Enlist support of others in patient’s social network
Electroconvulsive therapy (ECT)
Indicated for depression in which a rapid antidepressant response is imperative: depression coupled with psychotic features, catatonic stupor, mania, severe suicidality, suicidality in pregnancy, or severe nutritional compromise
Indicated for patients who prefer this method of treatment, or who have responded unsatisfactorily to antidepressant medication in the past
High rate of therapeutic success
Chief side effects are transient postictal confusional state and memory impairment that resolve in a few days
Light therapy
Particularly effective for seasonal affective disorder
Exposure to bright white artificial light for 30 minutes or more in morning and/or evening
May be used along with pharmacotherapy
Transcranial magnetic stimulation (TMS)
Used in resistant depression
Side effects are significantly reduced
Treatment is 4-5 times a week for 4-6 weeks
Vagus nerve stimulation (VNS)
Approved for adult patients with long-term or recurrent major depression
Requires surgical implantation of a stimulator that runs from the collarbone to the vagus nerve in the neck
In moderate to severe depression, psychotherapeutic interventions in conjunction with pharmacologic therapy are superior to either approach used alone.
PHARMACOLOGIC MANAGEMENT
Determine coexisting substance use disorders and general medical conditions
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin norepinephrine reuptake inhibitors (SNRIs)
Novel antidepressants
Tricyclic antidepressants (TCAs)
Monoamine oxidase inhibitors are not used first or second line because of numerous food and drug interactions. These drugs are usually prescribed by psychiatric specialists
Atypical antipsychotics may be used to augment poor response to antidepressants alone. These are powerful medications and should be monitored for side effects common to all antipsychotics
TCAs and SSRIs/SNRIs are equally efficacious, but SSRIs have a better side effect profile and would not be fatal if a month’s supply were taken at once.
All antidepressants carry a boxed warning about suicidal thoughts and urges in children, adolescents and young adults.
ANTIDEPRESSANT PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
Selective Serotonin Reuptake Inhibitors (SSRIs)
General comments
Considered first-line treatment for depression
May increase the risk of suicidal thinking and behavior in patients with major depressive disorder, especially
in children, adolescents and young adults
Monitor patient closely for clinical worsening, suicidality, or unusual changes in behavior, especially during the initial months of therapy. Ideally patient should be seen within 2 weeks of initiating or changing the dose of an antidepressant
Write prescription for smallest practical amount
Full effect may be delayed for 4
weeks or longer
May increase risk of bleeding, especially in combination with
aspirin, NSAIDs, warfarin
Do not abruptly stop usage
Monitor for hyponatremia
Drug interactions may occur with many medications given in combination with SSRIs; check compatibility
Treatment should be sustained for
6-18 months with the first episode
of major depression
Avoid alcohol when taking SSRIs
May cause decrease in libido
Do not administer to patients within 5 weeks of taking MAO inhibitors; high risk of serotonin syndrome when coadministered. Monitor for other serotonergic agents and educate about increased risk for serotonin syndrome
fluoxetine
Adult:
20 mg PO once daily. Increase dose after several weeks if insufficient clinical response. Doses >20 mg may be administered once daily or BID
Max:
80 mg daily
Children 8-17 years:
Initial:
10-20 mg PO daily. If started on 10 mg/day, increase after 1 wk to 20 mg/day
Lower weight children:
start at 10 mg/day PO; may increase after several wks to 20 mg/day
Avoid in patients with uncontrolled narrow-angle glaucoma
No dosage adjustment recommended for renal dysfunction or older adults. However, older adults may have greater sensitivity
Monitor for weight change during treatment
May alter glycemic control (hypoglycemia during use, hyperglycemia after discontinuing)
Discontinuation should take place gradually rather than abruptly
Prozac
Tabs: 10 mg, 20 mg, 40 mg
Solution: 20 mg/5 mL
Prozac weekly
Caps: 90 mg e-c delayed release pellets
Used in maintenance phase
Start 7 days after last dose of fluoxetine 20 mg when switching from daily dose
See fluoxetine for precautions
citalopram
Adult:
20 mg PO once daily. May increase to 40 mg PO daily after at least 1 wk in between dose increases
Older adult and hepatic impairment:
20 mg PO daily; 40 mg/day PO only for non-responding patients
Max:
60 mg daily
At least 14 days should elapse between MAO inhibitor and administration of citalopram
Avoid in patients with uncontrolled narrow angle glaucoma
No dosage adjustment necessary for renal impairment
Discontinuation should take place gradually rather than abruptly
Keep dose at lowest effective dose secondary to QT prolongation
Celexa
Tabs: 10 mg, 20 mg, 40 mg
escitalopram
Adult:
10 mg PO once daily. May increase in 1 to 2 wk
Max Adults:
20 mg PO daily
Max Older adults:
10 mg PO daily
Note:
Requires gradual tapering to discontinue
Children >12 years:
dosing is same as adult dosing, except increase should be delayed until after 3 wk
Not approved in patients younger than 12 years
Avoid in patients with uncontrolled narrow-angle glaucoma
No dosage adjustment recommended for renal dysfunction or older adults. However, older adults may have greater sensitivity
Prolongs the QT interval
Watch for hyponatremia
Discontinuation should take place gradually rather than abruptly
Lexapro
Tabs: 5 mg, 10 mg, 20 mg
Liquid: 5 mg/5 mL
paroxetine
Adult:
Initial:
20 mg PO in morning; may increase dose in 10-mg increments at 1-wk intervals
Max:
50 mg daily
Older adults, debilitated:
Initial:
10 mg PO
Max:
40 mg PO daily
At least 14 days should elapse between MAO inhibitor and administration of paroxetine
Avoid in patients with uncontrolled narrow-angle glaucoma
Cautious use in history of seizures
Discontinuation should take place gradually rather than abruptly; consider 10 mg/day at weekly intervals before discontinuing
Paxil
Tabs: 10 mg, 20 mg, 30 mg, 40 mg
Suspension: 10 mg/5 mL
Paxil CR
Adult:
Initial:
25 mg PO daily; adjust
by 12.5 mg/day PO at wkly intervals
Max:
62.5 mg/day
Older adults, debilitated:
Initial:
12.5 mg/day PO
Max:
50 mg/day PO
sertraline
Adult:
50 mg PO daily in AM or PM; may increase at 1-wk intervals
Max:
200 mg/day PO
At least 14 days should elapse between MAO inhibitor and administration of citalopram
Avoid in patients with uncontrolled narrow-angle glaucoma
No dosage adjustment necessary for renal impairment
Need dosage adjustment for hepatic dysfunction
Dilute oral concentrate in 4 oz water, ginger ale, lemon/lime soda, or orange juice before administering
Zoloft
Tabs: 25 mg, 50 mg, 100 mg
Oral concentrate: 20 mg/mL
Vilazodone
Adult:
40 mg PO once daily
Advise patient to take with food for adequate absorption
Not approved for children
No dosage adjustment necessary for patients with renal impairment
Viibryd
Tabs: 10 mg, 20 mg, and 40 mg
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)
General comments
Antidepressants increase risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment
duloxetine
Adult:
60 mg PO once daily
Alternative:
30 mg PO once daily for 1 wk, then increase to 60 mg once daily
Max:
120 mg PO but no evidence doses >60 mg PO confer greater benefit
May increase the risk of suicidal thinking and behavior in patients with major depressive disorder
Do not administer to patients taking MAO inhibitors
Avoid in patients with uncontrolled narrow-angle glaucoma
May be given without regard to meals
Increased risk of bleeding with NSAIDs, aspirin, warfarin
Do not prescribe for patients with substantial alcohol use
Monitor for orthostatic hypotension and syncope within first week of therapy
Cymbalta
Caps: 20 mg, 30 mg, 60 mg
venlafaxine
Adult:
37.5-375 mg PO daily in divided doses with food; should taper this medication over at least 2 wk
venlafaxine ER
Adult:
75-225 mg PO daily with food; taper dose by no more than 75 mg PO per wk to discharge
Effexor XR
Caps: 37.5 mg, 75 mg, 150 mg
desvenlafaxine
Adult:
Initial:
50 mg PO daily;
Max:
100 mg daily
Pristiq
Extended-release tabs: 50 mg, 100 mg
Tricyclic Antidepressants
General comments
Antidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment
TCAs should never be prescribed to children due to risk of sudden death
According to Halter (2018), patients must take therapeutic doses of TCAs for 10-14 days or longer before they begin to work. Full effects may not be seen for 4 to 8 weeks
amitriptyline
Adult:
75 mg PO in divided doses in late afternoon or HS
Alternate:
50-100 mg HS. May increase by 25-50 mg
Max:
150 mg/day
Older adults and adolescents:
10 mg PO TID
Alternate:
20 mg PO HS
Prescribe smallest amount feasible. Deaths may occur from overdosage with this class of medications
May cause sedation; give HS
Do not administer to patients taking MAO inhibitors
Cautious use in patients with cardiovascular disorders. May cause sinus tachycardia, prolonged QT interval, or arrhythmias
Close supervision if given to patients with hyperthyroidism
When possible, discontinue prior to elective surgery
Fluctuations in blood sugar are possible
Cautious use in patients with hepatic dysfunction
Periodically monitor drug level
Elavil
Tabs: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
Norepinephrine and Dopamine Reuptake Inhibitors
General comments
Antidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment
bupropion
Adult:
150 mg PO initially, with target of 300 mg daily given in the AM. If tolerated, can increase to 300 mg as soon as 4 days after starting dose
Full antidepressant effect may not be seen for 4 weeks
Dosage adjustment in patients with renal or hepatic dysfunction
Contraindicated in seizure disorder, current or prior diagnosis of bulimia
Contraindicated in patients undergoing abrupt cessation of alcohol or benzodiazepines
Known to assist with sexual side effects of other antidepressants
At least 14 days should elapse between MAO inhibitors and bupropion
When switching patients from Wellbutrin tablets or from Wellbutrin SR tablets, give the same total daily dose as a single dose of Wellbutrin XR
Wellbutrin XL
Tabs: 150 mg, 300 mg
Wellbutrin SR
Adult:
150 mg PO given in AM initially. Target of 300 mg PO daily given in divided doses. Must separate BID doses by 8 or more hr. If tolerated, can increase to 300 mg in divided doses as soon as 4 days after starting 150-mg dose
Max:
200 mg BID
Serotonin Antagonists and Reuptake Inhibitors
(SARIs)
General comments
Trazodone should be used with
caution in patients with hepatic
impairment
Can be used as adjunct to the treatment of residual anxiety and insomnia with other antidepressants
Useful for patients concerned about sexual side effects and weight gain from other antidepressants
trazodone
Adult: Depression as monotherapy:
Initial:
150 mg/daily in divided doses; can increase every 3-4 days by 50 mg/day as needed for a maximum of 400 mg/day
Desyrel
Scored Tabs: 50 mg, 100 mg, 150 mg, 300 mg
Noradrenaline and Specific Serotonergic agents (NaSSAs)
General comments
Sedation and weight gain are common with mirtazapine
Breaking a 15-mg tablet in half and administering 7.5 mg dose may increase sedation
Adding mirtazapine to venlafaxine or SSRIs may reverse drug-induced anxiety, insomnia, and GI complaints
mirtazapine
Adult:
15 mg-45 mg HS
Initial:
15 mg q HS; increase 1-2 wk until desired efficacy is reached; max is generally 45 mg/day
Remeron
Tabs (scored):15 mg, 30 mg, 45 mg
SolTab disintegrating tabs: 15 mg, 30 mg, 45 mg
Other
General comments
Known as a multimodal antidepressant that works on multiple neurotransmitters, including serotonin, glutamate, acetycholine, dopamine, norepinephrine, and histamine
Formerly named Brintellix
Tablet should not be crushed, divided, or dissolved
Shown effective in older adult population
Early results suggest more robust pro-cognitive actions than other antidepressants
vortioxetine
Adult:
5 mg-20 mg daily
Initial:
10 mg once daily; can decrease to 5 mg daily or increase to 20 mg daily depending on patient response
Max:
20 mg daily
Trintellix
Tabs: 5 mg, 10 mg, 15 mg, 20 mg
CONSULTATION/REFERRAL
Psychiatrist or psychiatric APRN if patient has suicide plan, or for ECT if severe major depression is coupled with psychosis, nutritional compromise, or suicidality. Make appointment and referral at time of visit
Indications for inpatient psychiatric treatment:
Unable to adequately care for self or cooperate with outpatient treatment
Has suicidal or homicidal ideation and plan, particularly if method is violent
Lack of psychosocial support
Complicating psychiatric or medical conditions that make outpatient treatment unsafe
Coexistence of substance use disorder
In older adults, depression often coexists with dementia or can even be misdiagnosed as dementia.
FOLLOW-UP
Within 2 weeks after initiating medication or sooner if patient’s condition dictates
For a first episode of depression, antidepressant medications should be continued for at least 4-6 months after complete remission of symptoms. Second episodes of depression should be treated for 2 years; three or more episodes may warrant lifetime treatment
Antidepressant medications should be tapered rather than abruptly discontinued
Patients with multiple prior episodes of depression may require long-term pharmacologic management
After recovery from a suicide attempt, explore frame of mind to determine whether suicidal thoughts persist
Educate about constructive methods of seeking help for future problems
Further explore sudden, noticeable recovery from major depressive disorder; could be a warning sign of upcoming suicide
EXPECTED COURSE
60-70% response rates to antidepressants of all classes
4-6 weeks required to fully respond to medication management
The most common reason for antidepressant failure in primary care is an inadequate dosage, inadequate trial or inadequate length of time on the medication. If some symptom relief is achieved within the first few weeks, continue to push the medication dosage up slowly until the maximum dosage is reached before adding anything else. If no response by 3-4 weeks, switching agents is suggested. After three or more attempts at finding an antidepressant that is efficacious, specialist referral should be considered
Depression should be treated to remission, not some degree of symptom relief
High relapse rate during the first 8 weeks after resolution of symptoms
POSSIBLE COMPLICATIONS
Suicide: overdose of tricyclics is potentially lethal
Bizarre behavior may endanger social relationships and reputation
Increased risk of suicide at start of antidepressant therapy; weekly follow-up appointments needed; closely monitor for suicidal ideations
Complicating psychiatric or medical conditions
Serotonin syndrome when combining several medications
Substance abuse resulting from attempts to self-medicate
Most patients with bipolar disorder present with depressive symptoms, not with mania. Careful screening is critical, since antidepressants can cause mania.
Diabetes Type II-
DESCRIPTION
Complex chronic metabolic illness characterized by abnormal insulin secretion, resistance to insulin in target tissues, and/or a decrease in insulin receptors.
ETIOLOGY
Influenced by genetics as well as environmental factors
High body mass with central obesity is strongest environmental factor
Inactivity
Drug- or chemical-induced: glucocorticoids, highly active antiretroviral therapy
INCIDENCE
30 million (9.4%) of U.S. population
Incidence rising in all age groups; especially among those born later than 2000
Increased rates in people with black, American Indian, Hispanic, or Pacific Islander ethnicity
Men and women affected equally
RISK FACTORS
BMI >25 kg/m2
History of gestational diabetes
History of delivery of macrosomic infant
Family history of Type 2 diabetes (T2DM)
Conditions associated with insulin resistance (polycystic ovarian syndrome, acanthosis nigricans)
HDL-C <35 mg/dL to/- TG >250 mg/dL
Hypertension or treatment for hypertension
History of cardiovascular disease
Hemochromatosis
Impaired fasting glucose
Sedentary lifestyle
BMI cut point for screening overweight/obese Asian patients for prediabetes and T2DM is 23 kg/m2.
ASSESSMENT FINDINGS
Usually discovered on routine examination
Chemistry panel and urinalysis: glucosuria, proteinuria, hyperglycemia
Obesity
Polydipsia, polyuria, polyphagia
Fatigue
Blurred vision
Chronic skin infections
Balanitis sometimes seen in men older than 65 years
Chronic candidal vulvovaginitis in women
May present with hyperosmolar state or coma
Long Term Effects of Hyperglycemia
Hypertension
Diabetic kidney disease
Coronary artery disease, myocardial infarction
Peripheral neuropathy
Cerebrovascular accident
Severe peripheral vascular insufficiency
DIFFERENTIAL DIAGNOSIS
Diabetes mellitus Type 1 (T1DM)
Prediabetes
Gestational diabetes
Cushing’s syndrome
Pheochromocytoma
Acromegaly
Corticosteroid use
DIAGNOSTIC STUDIES
American Diabetes Association
Diagnostic Criteria
Fasting Plasma Glucose
≥126 mg/dL, confirmed on different day
Random Plasma Glucose
≥200 mg/dL with symptoms
OR
2-hour plasma glucose ≥200 mg/dL on OGTT with 75-g glucose load
OR
≥200 mg/dL, confirmed on different day
Prediabetes (impaired fasting glucose)
Fasting glucose between 100 mg/dL and 125 mg/dL, confirmed on different day
OR
A1C 5.7-6.4%
OR
OGTT 140-199 mg/dL
Hgb A1C
≥6.5%
*OGTT, oral glucose tolerance test
Screening: ADA recommends adults ≥45 years be screened every 3 years, and more often if fasting plasma glucose close to 126 mg/dL
ADA recommends screening patients with history of gestational diabetes at 6-12 weeks’ gestation with OGTT and every 3 years after that for life
Type 1 distinguished from Type 2: C peptide levels are below normal in T1DM and normal or above normal in T2DM
A patient with A1C range of 5.7-6.4% has a diabetes risk similar to someone who has T2DM. These patients should be counseled on ways to aggressively reduce their risk for development of T2DM.
PREVENTION
Weight loss to reach and maintain normal BMI
Exercise 150 minutes or more/week (no more than 2 consecutive days without activity); resistance training 2-3 times/week on nonconsecutive days
Reduce length of sedentary intervals by interrupting prolonged sitting every 30 minutes
Focus on education about obesity, low-fat, low-calorie diet, exercise, sequelae, treatments
Increase awareness; screen for social determinants of health:
Financial ability to afford medication
Access to healthy foods
Food insecurity
Community support
NONPHARMACOLOGIC MANAGEMENT
Weight loss: primary goal for all obese patients with T2DM; even modest weight loss of 5-10 lbs can help increase insulin sensitivity
Nutrition plan:
Three visits with registered dietitian at diagnosis, plus ongoing follow-up visits semiannually to annually
An individualized medical nutrition program, preferably one developed by a registered dietitian
Avoid alcohol
Avoid smoking, including e-cigarettes
Exercise
Increases insulin secretion, glucose utilization and HDL levels
Endurance exercise is optimal (e.g., walking)
Perform stress test first if older than 35 years and diagnosed with diabetes
Periodic physical examinations:
Blood pressure and cardiac assessment
Funduscopic and vision examination at time of diagnosis, then every 2 years, or if vision problems occur
Oral examination
Thyroid palpation
Skin examination
Neurological examination
Abdominal examination
Examine feet for pulses, cleanliness, odor, swelling, mobility, nail thickness, bruises, pressure points; include sensory evaluation at every visit
Psychosocial screening and follow-up for symptoms of distress, depression, anxiety, eating disorders, cognitive capacity
PHARMACOLOGIC MANAGEMENT
Initiate metformin at diagnosis unless contraindicated
First-line drug classes: biguanides (metformin), sulfonylureas, thiazolidinediones, GLP-1, dipeptidyl peptidase-4 (DDP-4)
Second-line drug classes: insulin, meglitinides, diphenylalanine derivatives, bile sequestrants, SGLT2 inhibitors, alpha-glucosidase inhibitors
TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How supplied
Comments
Biguanides
Decrease production of glucose in the
liver; decrease absorption of glucose in the intestine, and improve insulin sensitivity by increasing peripheral glucose uptake and utilization
General comments
Lactic acidosis is rare but serious metabolic complication
Does not produce hypoglycemia
unless caloric intake is deficient, strenuous exercise without caloric compensation occurs, or, in older adults, debilitation or malnourishment
May produce weight loss,
improved lipid profiles
May be used as monotherapy or in combination with TZD, insulin, sulfonylureas
Metformin should be temporarily discontinued in patients undergoing radiologic studies involving
intravascular administration of
iodinated contrast materials because
use of such products may result in
acute alteration of renal function
metformin
Immediate Release
Adult:
Metformin 500 mg BID; increase in increments of 500 mg wkly
Max
: 2000 mg daily in 2 divided doses
Alternate
: 850 mg once daily with meals. Increase in increments of 850 mg every 2 wk
Max
: 2550 mg/ day in divided doses except Glumetza 2000 mg/day
Children 10-16 years:
500 mg BID, given with meals. Increase in increments of 500 mg wkly
Max
: 2000 mg daily in divided doses
DO NOT USE XR in children
Pregnancy: no evidence of risk
Dose with food
Avoid in binge drinkers
Careful use in patients with heart failure, renal or hepatic dysfunction
Diarrhea, flatulence are common initial side effects; usually resolves by 2 weeks
Goal is to decrease fasting plasma glucose and Hgb A1C levels to norm or near norm
Monitor blood glucose to determine lowest effective dose
Extended Release
Adult:
500 mg once daily with evening meal. Increase in 500-mg increments, not sooner than once wkly
Max
: XR 2000 mg/day
Give once daily with evening meal
Swallow whole, never crush or chew
Do not use in children
Glucophage, various generics
Tabs: 500 mg, 850 mg, 1000 mg
Glucophage XL, various generics
Extended-release tabs: 500 mg, 750 mg, 1000 mg
continued
TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How supplied
Comments
Thiazolidinediones (TZDs)
Inhibit gluconeogenesis in the liver,
improve insulin liver sensitivity in the
skeletal muscle and adipose tissue, and consequently reduce circulating insulin
levels in hyperinsulinemic patients
General comments
Can exacerbate or precipitate heart failure
Not recommended in patients with symptomatic heart failure
Contraindicated in patients with
Class III or IV heart failure
Depends on the presence of insulin for its action
May be used as monotherapy or in combination with metformin, insulin, sulfonylureas
pioglitazone
Adult
>
18 years:
Initial:
15 mg or 30 mg once daily
Usual:
individualized
Max: 45 mg/day
Children
: not established
Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks
Monitor ALT prior to initiation, then periodically per clinical judgment
Do not initiate in patients with hepatic dysfunction
If ALT increases >3 times the upper limits of normal and remains elevated, discontinue pioglitazone
Monitor for fluid retention; may exacerbate heart failure
No adjustment necessary for renal dysfunction
May increase risk of fractures in menopausal women
Can be taken without regard to meals
Actos
Tabs: 15 mg, 30 mg, 45 mg
Meglitinides
Potentiate insulin secretion from pancreas (short-acting secretagogue)
General comments
Do not use with insulin
May be used as monotherapy or with metformin
repaglinide
Adult:
0.5 mg within 30 min of meal or at mealtime BID to QID for patients not previously treated or with Hgb A1C <8%
Titrate by doubling dose at intervals of at least 1 wk
Max
: 16 mg/day
Alternate:
in patients previously treated with antidiabetic agents and Hgb A1C >8%, initially 1-2 mg with 2-4 meals daily. Titrate by doubling dose at intervals of at least 1 wk
Max:
16 mg/day
Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks
Preprandial dosing only
If a meal is skipped (or added), skip (or add) a repaglinide dose
Should not be used with sulfonylureas
Use with caution in hepatic failure, age >65, or debilitated patients; may be sensitive to hypoglycemic effects of repaglinide
Dose adjustment recommended for renal dysfunction
Do not take with gemfibrozil
Prandin
Tabs: 0.5 mg, 1 mg, 2 mg
Alpha glucosidase inhibitors
Delay absorption of carbohydrates
following a meal, resulting in a smaller rise
in glucose elevation
General comments
Contraindicated in patients with inflammatory bowel disorders
May be used as monotherapy, with a sulfonylurea, or with insulin
miglitol
Adult:
give one tablet 30 min before meals
Initial
: 25 mg TID; may start at 25 mg daily and gradually increase to TID. Increase to 50 mg TID after 4-8 wk
Usual
: 50 mg TID
Max
: 100 mg TID
Children
: not recommended
Pregnancy: animal studies have failed to demonstrate a risk to fetus; no adequate studies in pregnant women
These agents do NOT enhance action of insulin
Dosage adjustment needed for renal dysfunction; no adjustment needed for hepatic dysfunction
If hypoglycemia results, do NOT administer sucrose (absorption will be delayed); instead, administer dextrose
Flatulence and diarrhea are common side effects
Glyset
Tabs: 25 mg, 50 mg, 100 mg
continued
TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How supplied
Comments
acarbose
Adult:
25 mg TID; take with first bite of main meal; increase at 4- to 8-wk intervals
Max
: 100 mg TID
Max
<60 kg: 50 mg TID
Max
>60 kg: 100 mg TID
Pregnancy: animal studies have failed to demonstrate a risk to fetus; no adequate studies in pregnant women
Patients with low body weight may be at increased risk for elevated serum transaminases
Contraindicated in inflammatory bowel disease
Cautious use in renal dysfunction
Initially monitor blood glucose 1 hour postprandially during titration, then glycosylated hemoglobin
Monitor serum transaminases every 3 months during first year and periodically thereafter
Precose
Tabs: 25 mg, 50 mg, 100 mg
DDP IV Inhibitors
Dipeptidyl-peptidase-4 (DDP-IV) inhibitors enhance biologically active GLP-1 to increase insulin secretion and suppress glucagon secretion. Preserve
beta cell potentia; weight neutral
General comments
Boxed Warning
May cause or exacerbate CHF. Watch closely after initiation or dose increase. Contraindicated in patients with NYHA Class III-IV CHF and not recommended in patient with symptomatic CHF
May be used in combination with metformin, TZD, sulfonylurea,
insulin
sitagliptin
Adult:
Initial
: 100 mg daily
Usual
: 100 mg once daily
Max
: 100 mg daily
Children <18 years:
not recommended
Pregnancy: animal studies have failed to demonstrate risk to fetus; no adequate studies in pregnant women
Dosage adjustment needed for moderate or severe renal dysfunction
Take with or without food
Monitor renal function prior to initiation and periodically
May need to initially lower dose of sulfonylurea
Caution with digoxin; monitor pulse rate
Monitor for pancreatitis
Januvia
Tabs: 25 mg 50 mg, 100 mg
saxagliptin
Adult:
may use 2.5-5 mg once
daily
Initial
: 2.5 mg or 5 mg once
daily taken without regard to meals
Usual
: 5 mg
Max
: 5 mg daily
Pregnancy: animal studies have failed to demonstrate risk to fetus; no adequate studies in pregnant women
May need to initially lower dose of sulfonylurea
Dosage adjustment needed for moderate or severe renal dysfunction; no adjustment needed for hepatic dysfunction
Take with or without food
Monitor for drug interactions with 3A4/5 inhibitors
Onglyza
Tabs: 2.5 mg, 5 mg
SGLT2 Inhibitors
Boxed Warning
Lower limb amputation: twofold increased risk of leg and foot amputations with use of canagliflozin. Prior history of PVD, neuropathy, or diabetic foot ulcers may increase risk. Monitor for infection, new pain or tenderness, sores or ulcers involving the lower limb
canagliflozin
Adult
: 100 mg PO daily; give with first meal of day
Max
: 300 mg daily
Renal Dosing:
eGFR 45-59:
100 mg daily
eGFR 30-44:
avoid use
eGFR <30:
contraindicated
D/C if eGFR is persistently <45
Peds dosing:
not applicable
Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks
eGFR at baseline
Lipid panel
Potassium level if renal impairment or hypokalemia risk
Caution in older patients
Caution in T1DM
Caution hypotension
Invokana
Tabs: 100 mg, 300 mg
dapagliflozin
Adult:
5 mg PO q am
Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks
Caution in older adults
Caution with hyperlipidemia
Active bladder cancer
eGFR <60
Contraindicated in T1DM
Farxiga
Tabs: 5 mg, 10 mg
continued
TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How supplied
Comments
empagliflozin
Peds dosing:
not applicable
Pregnancy: NO adequate studies to show safety
Caution with insulin or sulfonylurea
Caution with renal impairment; discontinue if GFR falls below 45 mL/min
Caution with hyperlipidemia
Increased risk for UTI
Caution with diuretics; may cause volume depletion
Increased risk for genital mycotic infections
Caution with older adults and with renal impairment
Contraindicated in T1DM
Jardiance
Tabs: 10 mg, 25 mg
Glucagon-Like Peptide (GLP-1)
Promotes release of insulin from pancreatic beta cells in the presence of elevated
glucose concentrations
General comments
Boxed Warning
Thyroid C-cell Tumor Risk:
contraindicated in patients with medullary thyroid carcinoma history or patients with family history
May be used with metformin, sulfonylurea, or a TZD
Weight loss is desired side effect
exenatide
Adult:
Initial
: 5 mcg BID subcutaneously within 60 min before morning and evening meals (at least 6 hr apart). After 1 month, may increase to 10 mcg
Usual
: 10 mcg BID
Max
: 10 mcg BID
Pregnancy: no well-controlled studies in humans, but potential benefits may warrant use
Cautious use in patients with end-stage renal disease
No dosage adjustment needed for hepatic dysfunction
Must be refrigerated prior to first dose, then kept at room temperature
Administer SC injection in thigh, abdomen, or upper arm within 60-minute period before morning and evening meals. Do not administer after a meal
If dose missed, resume as prescribed with the next dose
Common side effect is nausea and anorexia
May decrease effectiveness of oral contraceptives
Byetta
Forms: 5 mcg /1.2 mL prefilled pen (60 doses); 10 mcg/2.4 mL prefilled pen (60 doses)
dulaglutide
T2DM
Start 0.75 mg SC q wk: max 1.5 mg/wk
Pedi: no dosage available
Boxed Warning:
thyroid C-cell tumor risk
Contraindicated in patients with medullary thyroid carcinoma history or with family history
Caution
T1DM
Diabetic ketoacidosis
Pancreatitis history
Gastroparesis
Renal impairment
Reactions
Angioedema
Decreased appetite
Abdominal pain
Tachycardia
PR prolongation
Amylase & lipase increase
Pregnancy & lactation: inadequate information at this time
Trulicity
INJ Pen: 0.75 mg/0.5 mL per injection, 1.5 mg/0.5 mL per injection
Sulfonylurea Agents
Stimulate release of insulin fromfunctioning pancreatic beta cells
Secondary failure may occur withextended therapy
General comments
Sulfonylureas may be potentiated by
many drugs: NSAIDs, quinolones, highly protein-bound drugs, beta-blocking agents, thiazides, others
glimepiride
Adult:
Initial
: 1-2 mg once daily with breakfast or first main meal. After reaching dose of 2 mg, increase by up to 2 mg at 1- to 2-mg intervals if needed
Usual
: 1-4 mg once daily
Max
: 8 mg/day
Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks
Cautious use with renal or hepatic dysfunction, age >65 or debilitated
Once 8 mg has been reached and fasting glucose is >150 mg/dL, insulin may be recommended
Monitor blood glucose for 1-2 weeks when transferring patient from a longer-acting sulfonylurea to glimepiride
Amaryl
Tabs: 1 mg, 2 mg, 4 mg
continued
TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How supplied
Comments
glipizide
Adult:
Initial:
5 mg before breakfast. Increase by 2.5-5 mg every few days
Max:
15 mg once daily dose
Max:
40 mg daily in divided doses 30 min before meals
Older adults, debilitated, hepatic impairment
Initial
: 2.5 mg daily
Adult:
Initial
: 5 mg with breakfast
Usual
: 5-10 mg once daily
Max
: 20 mg once daily
Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks
Cautious use in renal or hepatic dysfunction
Glucotrol
Tabs: 5 mg, 10 mg
Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks
Do not crush, chew or divide
Glucotrol XL
Extended-release tabs: 5 mg,
10 mg
EXAMPLES OF COMBINATION DRUGS
Combination Type
Fixed-Dose Combination, mg
Trade Name
DPP IV and biguanide
Sitagliptin-metformin (50/500, 50/1000)
Janumet
Meglitinide and biguanide
Repaglinide and metformin (1/500, 2/500)
PrandiMet
Sulfonylurea and biguanide
Glipizide and metformin (2.5/250, 2.5/500, 5/500)
Metaglip
Glyburide and metformin (1.25/250, 2.5/500, 5/500)
Glucovance
TZD and biguanide
Pioglitazone and metformin (15/500, 15/850)
Actoplus Met
Rosiglitazone and metformin (2/500, 4/500, 2/1000, 4/1000)
Avandamet
TZD and sulfonylurea
Rosiglitazone and glimepiride (4/1, 4/2, 4/4)
Avandaryl
DPP IV, Dipeptidyl peptidase-4 inhibitor; TZD, thiazolidinediones
Some drug combinations are available in multiple fixed doses. Each drug is reported in milligrams
INSULINS
Insulin Preparation
Onset in hours
Peak in hours
Duration hours
Novolog
< 0.25
1-3
3-5
Levemir
1
0
24
Lantus
1.1
0
> 24
Apidra
0.25
1
2-4
Humalog
< 0.25
1
3.5-4.5
Humalog mix 75/25
< 0.25
0.5-1.5
24
Humalog mix 50/50
< 0.25
1
16
Novolin R
0.5
2.5-5
8
Humulin 70/30
0.5
2-2
24
Humulin 50/50
0.5
3-5
24
Novolin 70/30
0.5
2-12
24
Humulin N
1-2
6-12
18-24
Novolin N
1-5
4-12
24
Toujeo
Develops more than 6 hours after administration
0
24
Insulin
Recommended early in course of oral therapy, but often used when oral agents have been exhausted
0.1-0.2 units/kg/day or 10 units daily of peakless insulin recommended as initial insulin therapy
If unable to achieve glycemic goals, administer mealtime insulin
Other Pharmacologic Therapy
Antihypertensive treatment for blood pressure >140/90 mm Hg (130/80 mm Hg considered); no deference to ACE inhibitor or ARB as first-line agent
HMG-CoA reductase inhibitors (statins)
Moderate LDL-lowering capacity for hyperlipidemia in T2DM patients ages 40-75; LDL 70-189 mg/dL without additional CV risk factors (primary prevention)
High LDL-lowering capacity for hyperlipidemia in any patient who has cardiovascular event or LDL >190 mg/dL (secondary prevention)
Focus on education about self-care, low-fat/carb/calorie diet, regular exercise, sequelae, treatments
PREGNANCY/LACTATION CONSIDERATIONS
Oral agents are generally avoided; however, metformin has been used to treat pregnant women with pregestational diabetes (T1DM or T2DM that existed prior to conception)
Sulfonylureas are avoided because they cross the placenta and can cause fetal hyperinsulinemia
Universal screening at 24 to 28 weeks’ gestation for detection of gestational diabetes. If glucose >140 mg/dL 1 hr after 50 g oral glucose load, 3-hr GTT is recommended
Refer to registered dietitian and diabetes educator
Addition of insulin if glucose >90 mg/dL fasting or ≥120 mg/dL on two or more occasions in a 2-week period
Self-monitoring of glucose four times a day or more
Women with gestational diabetes have increased risk for later development of T2DM, thus follow-up is warranted
Increased risk of maternal and fetal complications:
Pregnancy accelerates development of retinopathy and pregnancy-induced hypertension
Increased risk of spontaneous abortion, stillbirth, and congenital anomalies
Increased risk of macrosomia resulting in shoulder dystocia
Screen women with gestational diabetes 6-12 weeks
postpartum and continue surveillance throughout
lifetime.
CONSULTATION/REFERRAL
Endocrinologist
Registered dietitian
Certified diabetes educator
Ophthalmologist
Early referral to foot specialist when needed
FOLLOW-UP
Guidance for follow-up is detailed in Standards of Medical Care in Diabetes 2018, Comprehensive Medical Evaluation and Assessment of Comorbidities (Chapter 3, Table 3.1): https://doi.org/10.2337/dc18-S003
EXPECTED COURSE
Dependent on glucose control; poor control results in increased risk for vascular complications
Complications typically develop 10-15 years after onset but can present earlier if DM undetected for years before diagnosis
POSSIBLE COMPLICATIONS
Diabetic kidney disease, renal failure
Peripheral neuropathy
Retinopathy
Cardiovascular and peripheral vascular disease
Glaucoma, cataracts, blindness
Skin ulcerations, gangrene of lower extremities; limb amputations
Charcot foot
Diabetic ketoacidosis
Gastroparesis
Eczema
DESCRIPTION
Chronic pruritic skin eruption presenting as a patchy plaque-like rash with inflammation. Acute exacerbations appear in characteristic sites. “Eczema” is often used interchangeably with “atopic dermatitis,” but the term eczema describes acute symptoms associated with atopic dermatitis. Eczema occurs most frequently in children, but it affects many adults.
Commonly seen in patients with other atopic illnesses (e.g., asthma, allergic rhinitis).
ETIOLOGY
Multifactorial: genetic, physiological, immunologic and environmental factors
Elevated serum IgE levels
Personal family history of allergies, asthma, allergic rhinitis
INCIDENCE
Affects almost 10% of children
60% first experience symptoms between infancy & age 12 years
Begins after age 2 months, resolves by age 3 years
90% have remission by puberty
Affects both sexes equally
More common in black and Asian patients
RISK FACTORS
Family history of atopic diseases
Skin infections
Stress
Temperature extremes
Contact with irritating substances (wearing new clothing prior to washing, harsh soaps, skin products with perfumes)
ASSESSMENT FINDINGS
General: pruritus, erythema, dry skin, facial erythema, infraorbital folds (Dennie-Morgan folds); antecubital fossa, posterior patella areas; scalp area
Infants
:
Lesions on flexural surfaces of arms, legs, on trunk, face (especially cheeks)
Lesions are erythematous and papular
Vesicles may ooze, form crusts
Children
:
Lesions common on wrists, ankles and flexural surfaces
Presence of scales and plaques; lichenification occurs as a result of scratching
Adults
:
Flexural surfaces are common sites (dorsa of the hands and feet)
Often reappears in adulthood after absence since childhood
Lichenification and scaling are typical
DIFFERENTIAL DIAGNOSIS
Contact dermatitis
Seborrheic dermatitis
Scabies
Psoriasis
DIAGNOSTIC STUDIES
Usually none needed
Skin biopsy to rule out other skin disorders
80% of patients may have eosinophilia during episodes of disease activity
Serum allergy testing is available
PREVENTION
Liberal use of emollients to prevent dry skin
Avoid known precipitating factors (stress, wool clothing, detergents with fragrance, etc.)
Wash clothing with fragrance-free detergents, fabric softeners and dryer sheets
Keep environments as free of dust as possible
Use of air purifiers and humidifiers
Eliminate carpets; clean bedding weekly; use mattress protectors to reduce dust mites
Wash bedding in water that is 120 to 130 degrees F
Humidity in home should be no more than 50%
Serum allergy testing reveals that dust mites in the environment pose a high threat for skin allergies.
Dermatophagoides farinae:
American dust mite
Dermatophagoides pteronyssinus:
foreign dust mites
NONPHARMACOLOGIC MANAGEMENT
Bathing is recommended; moisturizer should be applied 1 to 3 minutes after patting skin dry, while skin is slightly moist (pores are open only 1 to 3 minutes)
Superfatted soaps are best; nonsoap cleansers should have a neutral or low pH
Prevent skin trauma (sunburns, etc.)
When possible, soak in warm water for 20 minutes before applying emollient
Apply cool wet compresses (Burow’s solution) if lesions are weeping or oozing
Wet wrap therapy for moderate to severe atopic conditions
Avoid ointments for oozing atopic dermatitis, to allow lesions to dry. Promotes healing
Sunshine or UVB treatments
Bleach baths: 3 times weekly (1/4 cup of household bleach in a full tub of water; soak 2-3 minutes). Atopic patients are predisposed to skin infections
Patient education about disease process, self-care, and precipitating factors, as well as importance of hydrating the skin with moisturizers 1-2 times daily, or as often as needed to keep skin moist
PHARMACOLOGIC MANAGEMENT
Topical corticosteroids (creams are preferred) are the mainstay of therapy (use lowest potency that controls symptoms)
Antihistamines (oral and topical) for itching
Emollients 2-3 times per day or as needed to correct dry skin (Eucerin, Lubriderm, Cetaphil, Vaseline). Steroid-sparing emollients recommended
Oral corticosteroids may be used for severe cases. Due to the chronic nature of this disease, use only in short bursts
Intralesional steroid injections
Topical calcineurin inhibitors: Elidel cream 1% or Tacrolimus ointment 0.03% and 0.1%; maintenance dosing twice weekly for 12 months, use moisturizers on other days. This proactive approach may reduce or delay exacerbations
Dry skin treated with corticosteroid therapy will exhibit minimal response; however, use for 7 days or less may ease symptoms of erythema and pruritus.
ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT
Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients due to larger ratio of skin surface area to body weight. Limit use to lowest effective potency and time.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Low-Potency Steroids
exert their anti-inflammatory effect through mechanical, chemical, microbiological and immunological means
General comments
Use lowest potency that produces desired effect
Skin atrophy and changes in skin color are possible with long term use
Areas with greatest absorption are the face, groin, and axillae. Consider lowest potency steroids in
these areas or avoid prolonged use
Systemic absorption is usually minimal, but broken skin absorbs significantly more steroid
Topical steroids will worsen skin infections
alclometasone
dipropionate 0.05%
Adults and children >1 years:
apply thin film, massage in BID to TID
For external use only
Do not use longer than 3 weeks
No dosage adjustment needed for geriatric patients
Do not occlude or use under diaper
Aclovate
Cream, oint: 15 g, 45 g,60 g
fluocinolone acetonide 0.01%
Adults and children:
apply thin film BID to QID
0.01% solution
0.025% cream 15 g, 60 g
For external use only
Do not use longer than 3 weeks
No adjustment in dosage needed for geriatric patients
Synalar solution
Cream/ointment: 15 g, 60 g
Solution: 60 mL, 90 mL
hydrocortisone butyrate 0.1%
Adult and Children > 2 years:
apply thin film BID to QID
For external use only
Do not use longer than 3 weeks
Locoid
Cream/Ointment: 15 g, 30 g, 45 g
continued
ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT
Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients because of larger skin surface area to body weight ratio. Limit use to lowest effect potency and time.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Medium-Potency
Steroids
exert their anti-inflammatory effect through mechanical, chemical, microbiological, and immunological means
General comments
Use lowest potency that produces desired effect
Skin atrophy and changes in skin color are possible with long term use
Areas with greatest absorption are the face, groin, and axillae. Consider lowest potency steroids in these areas or avoid prolonged use
Topical steroids will worsen skin infections
triamcinolone
acetonide 0.025% or 0.1%
Adults and children:
apply thin film BID to QID
Intended for external use only
Caution with use longer than 2 weeks; may change skin pigmentation
Caution in pediatric patients
Aristocort cream
Kenalog cream, lotion, ointment
Ointment: 0.1% (medium), 0.025% (medium/low) 15 g, 80 g
Cream: 0.1%, 0.025%, 15 g, 80 g
Lotion: 0.1% 60 mL
Spray: 0.0147%
desoximetasone 0.05%
Adults and children >10 years:
apply thin film BID
Intended for topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Topicort LP cream
Cream: 15 g, 60 g
flurandrenolide 0.025%
Adults and children:
apply BID to TID
Intended for topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Cordran
Cream/ointment: 30 g, 60 g
fluticasone propionate 0.05%
Adult
: apply thin film BID
Children
>
3 months
: apply a thin film once daily or BID
Intended for topical use only
Safety of use in pediatric patients for more than 4 weeks has not been established
No dosage adjustment recommended for geriatric patients
Cutivate
Cream: 15 g, 30 g
Lotion: 60 mL, 120 mL
hydrocortisone valerate 0.2%
Adult
: apply thin film BID to TID
Children
: Pediatric dosing not available
Intended for topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Westcort
Cream/ointment: 15 g, 45 g, 60 g
continued
ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT
Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients due to larger ratio of skin surface area to body weight. Limit use to lowest effective potency and time.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
mometasone furoate 0.1%
Adults and children >2 years:
apply thin film once daily
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
DO NOT USE WITH AN OCCLUSIVE DRESSING
Elocon
Cream/ointment: 15 g, 45 g
Lotion: 30 mL, 60 mL
desoximetasone 0.05%
*Cream = medium potency
Adults and children >10 years:
apply thin film BID
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Topicort
*Ointment = medium potency
Cream/ointment: 15 g, 60 g, 100 g
High-Potency
Corticosteroids
Exert anti-inflammatory effect through mechanical, chemical, microbiological, and immunological means
General comments
Use lowest potency that produces desired effect
Skin atrophy and changes in skin color are possible with long term use
Areas with greatest absorption of steroid are the face, groin, and axillae. Consider lowest potency steroids in these areas
Topical steroids will worsen skin infections
Do not use more than 50 g/week
amcinonide 0.1%
Adult
: thin film BID to TID
Children
: Pediatric dosing not available
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Cyclocort
Cream/ointment: 15 g, 30 g, 60 g
Lotion: 30 mL, 60 mL
betamethasone
dipropionate 0.05%
Adult and children > 13 years
: apply thin film once daily to BID
Max
: 2 consecutive wk
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Studies demonstrate HPA axis suppression in some children
No dosage adjustment recommended for geriatric patients
Diprolene AF
Ointment/cream: 15 g, 50 g
desoximetasone 0.05% gel, 0.25% cream/ointment
Adults and children >10 years:
apply thin film BID
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Research shows HPA axis suppression in some children
Topicort gel
Cream/gel: 15 g, 60 g
Ointment: 30 mL, 60 mL
continued
ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT
Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients due to larger ratio of skin surface area to body weight. Limit use to lowest effective potency and time.
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Super High Potency
Exert anti-inflammatory effect through mechanical, chemical, microbiological, and immunological means
General comments
Use lowest potency that produces desired effect
Skin atrophy and changes in skin color are possible with long term use
Areas with greatest absorption of steroid are the face, groin, and axillae. Consider lowest potency steroids in these areas or avoid prolonged use
Topical steroids will worsen skin infections
Do not use more than 50 g/week
betamethasone dipropionate augmented 0.05%
Adults and children >13 years:
apply thin film once daily to BID
Max
: 2 consecutive wk
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Research shows HPA axis suppression in some children
No dosage adjustment recommended for older adults
Diprolene
Ointment: 15 g, 45 g, 60 g
Lotion: 30 mL, 60 mL
Gel: 15 g
clobetasol propionate 0.05%
Adults and children ≥12 years:
apply thin film BID
Max
: 50 g/wk
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Research shows HPA axis suppression in some children
No dosage adjustment recommended for older adults
Temovate cream, gel, ointment, scalp, emollient
Clobex, Cormax
Cream/Ointment: 15 g, 30 g, 45 g, 60 g
Solution: 50 mL
Foam: 100 g
Scalp emollient: 50 mL
flurandrenolide 4 mcg/ sq cream
Adult:
Cream
: apply a thin film BID to TID
Tape
: Apply tape to clean, dry skin; replace every 12 to 24 hr
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Change tape every 12 hours
Cordran
Cream
: 60g, 120g
Tape
: 3” x 24” and 3” x 80”
halobetasol propionate 0.05%
Adults and children >12 years:
apply thin layer BID
Max: 50 g/wk
Topical use only
Caution with use longer than 2 weeks; may change skin pigmentation
Do not use with occlusive dressings
No dosage adjustment recommended for geriatric patients
Ultravate
Cream/Ointment: 15 g, 45 g
CONSULTATION/REFERRAL
Dermatology specialist
Allergy specialist
FOLLOW UP
Initial treatment and at 2 weeks, then 6 to 8 weeks
Follow-up is important to assure that patient is improving and steroid medication is not being overused for prolonged periods. Education is important for parents/patients. If flare is severe, prescribe a stronger steroid for 2 weeks and then decrease potency, or change to topical calcineurin inhibitors such as Elidel or Protopic. Daily moisturization is important
EXPECTED COURSE
Waxes and wanes; expect flaring
POSSIBLE COMPLICATIONS
Secondary infection: (excoriations in child likely need treatment for skin infection; eczema slow to improve if infection is not treated)
Steroid atrophy
Fibromyalgia / myositis
ASSESSMENT FINDINGS
Burning, stiffness or aching pain at multiple sites (radiating low back, neck and upper posterior shoulder tightness)
Stiffness on arising
Fatigue
Poor sleep, frequent awakenings with inability to fall asleep again
Sensation of swollen joints and paresthesias
Memory problems, headaches, light-headedness, dizziness
Anxiety and/or depression
Symptoms are triggered or aggravated by temperature changes, lack of sleep, and physical and/or mental stress
Widespread pain for at least 3 months
Bilateral pain above and below the waist
Symptoms are common and nonspecific. Therefore, the physical examination may be unremarkable.
CONSULTATION/REFERRAL
Pain management
Rheumatology
Psychiatry
Refer nonresponders to a pain specialist or rheumatologist.
DESCRIPTION
Fibromyalgia is a complex, idiopathic, chronic neurologic condition characterized by widespread heightened pain sensitivity, sleep disturbance, fatigue, headache, cognitive difficulties, digestive problems, paresthesias and psychological distress.
DIAGNOSTIC STUDIES
Structured interviews/questionnaires:
American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia: 3-month history of pain and symptoms of fatigue, awakening fatigued, cognitive problems; no other health problem explains pain/symptoms
Laboratory studies:
Complete blood count
Complete metabolic panel with renal function and liver function
Urinalysis
Erythrocyte sedimentation rate
Rheumatoid factor, if patient has suggestive symptoms
Antinuclear antibody, if patient has suggestive symptoms
Thyroid-stimulating hormone, T3, T4
Creatinine phosphokinase
Vitamin D, (25-hydroxy)
Vitamin B12
Iron studies: TIBC, ferritin, iron
Magnesium
CRP
Additional tests are not recommended for diagnosis unless clinically indicated
X-rays, scans and muscle biopsy are normal
Laboratory studies are not diagnostic but are necessary to rule out other disorders.
DIFFERENTIAL DIAGNOSIS
Chronic fatigue syndrome
Hypothyroidism
Metabolic and inflammatory myopathies (especially in patients taking statins)
Polymyalgia rheumatica
Myofascial pain syndrome
Osteoarthritis
Rheumatoid arthritis
Systemic lupus erythematosus (SLE)
ETIOLOGY
Unknown, but likely involves nervous system
EXPECTED COURSE
Fluctuating, chronic course
FOLLOW-UP
Variable and depends on symptom severity, coping abilities, and patient resources
Within 2 weeks after initiating medication
INCIDENCE
Fibromyalgia affects approximately 5 million U.S. adults
Women > Men
Can affect children and adolescents
NONPHARMACOLOGIC MANAGEMENT
The goal of treatment is to improve function and reduce pain
Complementary and Alternative Therapy
Stress Management:
cognitive behavioral therapy, relaxation training, group therapy, biofeedback, mindfulness, meditation
Exercise:
low-impact cardiovascular exercise (walking, swimming, bicycling), strength and aerobic conditioning, flexibility and balance; research shows exercise is most effective treatment
Alternative Therapies:
Chinese herbal tea, acupuncture, tai chi, yoga, hypnosis, chiropractic therapy, massage therapy, magnetic therapy, trigger point injections
Patient Education:
Avoid changes in diet
Avoid highly processed foods
Avoid tobacco smoke exposure
Exercise as prescribed: don’t increase without consulting provider
Avoid unnecessary life changes
Pace activities
Provide community resources
Helpful websites:
The Arthritis Foundation
http://www.arthritis.org
The Fibromyalgia Network Web
http://www.fmnetnews.com
American College of Rheumatology
http://www.rheumatology.org
National Fibromyalgia Awareness Campaign
National Fibromyalgia Association
National Fibromyalgia Partnership, Inc.
http://www.fmpartnership.org
American Chronic Pain Association
http://theacpa.org
Establish and maintain a supportive therapeutic relationship
Psychotherapeutic interventions in conjunction with pharmacologic therapy are superior to either used alone.
PHARMACOLOGIC MANAGEMENT
Determine coexisting substance use disorders and general medical conditions
Strongly recommended to avoid opioid narcotic medication, which may worsen the pain. If patient is already on opioids, recommended gradual withdrawal over 2-3 weeks
Tramadol may be used short term if needed
Acetaminophen and NSAIDs are not effective, except to treat other pain triggers (arthritis)
Benzodiazepines and nonbenzodiazepine sleep agents (zolpidem) are not recommended for sleep
FIBROMYALGIA PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
Selective Serotonin Reuptake Inhibitors (SSRIs)
General comments
May increase the risk of suicidal thinking and behavior in patients with major depressive disorder
Monitor patient closely for clinical worsening, suicidality, unusual changes in behavior, especially during initial months of therapy
Write Rx for smallest practical amount
Full effect may be delayed for 4 weeks or longer
May increase risk of bleeding, especially in combination with aspirin, NSAIDs, warfarin
Do not abruptly stop usage
Monitor for hyponatremia
Drug interactions may occur with many medications given in combination with SSRIs. Check compatibility
Treatment should be sustained for several months
Avoid alcohol when taking SSRIs
May cause decrease in libido
fluoxetine
Adult:
20 mg once daily.
Increase dose after several weeks if insufficient clinical response.
Doses >20 mg may be administered once or twice daily
Max:
80 mg daily
Children 8-17 years:
Initial:
10-20 mg daily.
If started on 10 mg/day, increase after 1 week to 20 mg/day. Lower weight children, start at 10 mg/day; may increase after several weeks to 20 mg/day
No adequate human fetal studies; evaluate benefits vs. risks
Do not administer to patients within 5 weeks of taking MAO inhibitors
Avoid in patients with uncontrolled narrow-angle glaucoma
No dosage adjustment recommended for renal dysfunction or age >65; older adults may have greater sensitivity
Monitor for weight change during treatment
May alter glycemic control (hypoglycemia during use, hyperglycemia after discontinuing)
Discontinuation should take place gradually, not abruptly
Prozac
Tabs: 10 mg, 20 mg, 40 mg
Solution: 20 mg/5 mL
Prozac weekly
Caps: 90 mg e-c delayed-release pellets
No adequate human fetal studies; evaluate benefits vs. risks
Used in maintenance phase
Start 7 days after last dose of fluoxetine 20 mg when switching from daily dose
See fluoxetine for precautions
paroxetine
Adults:
Initial:
20 mg in morning; may increase dose in 10-mg increments at 1-week intervals
Max
: 50 mg daily
Older adults, debilitated:
Initial:
10 mg
Max
: 40 mg daily
Evidence of human fetal risk
At least 14 days should elapse between MAO inhibitor and administration of paroxetine
Avoid in patients with uncontrolled narrow-angle glaucoma
Cautious use with history of seizures
Discontinuation should take place gradually rather than abruptly; consider 10 mg/day at weekly intervals before discontinuing
Paxil
Tabs: 10 mg, 20 mg, 30 mg, 40 mg
Susp: 10 mg/5 mL
Paxil CR
Adults:
Initial:
25 mg daily; adjust
by 12.5 mg/day at weekly intervals
Max:
62.5 mg/day
Older adults, debilitated:
Initial:
12.5 mg/day
Max:
50 mg/day
See paroxetine
Alpha-2 Delta Ligand
General comments
Potentiates CNS depression with alcohol, other CNS depressants
Additive edema, weight gain with thiazolidinediones
pregabalin
Adults:
Initial:
75 mg BID; may increase to 150 mg BID within 1 wk as tolerated;
max 450 mg/day
Renal impairment
(CrCl <60 mL/min): reduce dose
No adequate human fetal studies; Nursing not recommended
Avoid abrupt cessation; taper over 1 wk
Discontinue if angioedema, hypersensitivity reactions, myopathy or markedly elevated creatine kinase levels
HF: ocular conditions
Diabetes: monitor skin integrity
Monitor suicidal tendencies
Lyrica
Capsule: 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg
Solution: 20 mg/mL
Alpha-2 Delta Ligand
General comments
Off-label use
Potentiates CNS depression with alcohol, other CNS depressants
Give 2 hours after antacids
May antagonize hydrocodone
May interfere with some urine protein tests
gabapentin
Adults:
Initial:
300 mg daily x 1 day, then 300 mg BID x 1 day, then 300 mg TID, then titrate to effect.
Max 2400 mg/day
No adequate human fetal studies. Nursing not recommended
Avoid abrupt cessation; taper over 1 wk
Monitor for DRESS/multiorgan hypersensitivity, anaphylaxis, angioedema; discontinue if occurs
Neurontin
Capsules: 100 mg, 300 mg, 400 mg
Tablets: 600 mg, 800 mg
Oral Solution: 250/5mL
Serotonin and Norepinephrine Reuptake
Inhibitors (SNRIs)
General comments
Antidepressants increase risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment
May increase risk of suicidal thinking and behavior in patients with major depressive disorder
Monitor patient closely for clinical worsening, suicidality, unusual changes in behavior, especially during initial months of therapy
May increase risk of bleeding, especially in combination with aspirin, NSAIDs, warfarin
Do not abruptly stop usage
Avoid alcohol when taking SNRIs
duloxetine
Adults:
60 mg once daily
Alternative: 30 mg once daily for 1 wk, then increase to 60 mg once daily
Max:
120 mg but no evidence doses >60 mg confer greater benefit
No adequate human fetal studies; evaluate benefits vs. risks
May increase risk of suicidal thinking and behavior in patients with major depressive disorder
Do not administer to patients taking MAO inhibitors
Avoid in patients with uncontrolled narrow-angle glaucoma
May be given without regard to meals
Increased risk of bleeding with NSAIDs, aspirin, warfarin
Do not prescribe for patients with substantial alcohol use
Monitor for orthostatic hypotension and syncope within first week of therapy
No adequate human fetal studies; evaluate benefits vs. risks
May increase risk of suicidal thinking and behavior in patients with major depressive disorder
Do not administer to patients taking MAO inhibitors
Avoid in patients with uncontrolled narrow-angle glaucoma
May be given without regard to meals
Increased risk of bleeding with NSAIDs, aspirin, warfarin
Do not prescribe for patients with substantial alcohol use
Monitor for orthostatic hypotension and syncope within first week of therapy
Cymbalta
Caps: 20 mg, 30 mg, 60 mg caps
milnacipran
Adults:
Day 1: 12.5 mg once
Days 2-3: 12.5 mg BID
Days 4-7: 25 mg BID
After day 7: 50 mg BID
Max:
100 mg BID
Severe renal impairment (CrCl 5-29 mL/min: maintenance 25 mg BID; Max 50 mg BID
Older adults and adolescents:
20 mg HS
Savella
Tabs: 12.5 mg, 25 mg, 50 mg, 100 mg
Muscle Relaxants
General comments
Increased risk of serotonin syndrome with other serotonergic drugs
Potentiates anticholinergics, alcohol, and other CNS depressants
May antagonize clonidine
Tramadol increases seizure risk
cyclobenzaprine
Adults:
Start 10 mg at bedtime. May increase to 40 mg/day divided daily to TID
Max dose: 40 mg daily
Potential benefits may warrant use; no risk shown in animal studies
May cause drowsiness
Moderate to severe hepatic impairment
Note with glaucoma: increased intraocular pressure
Contraindicated in acute post MI, arrhythmias, heart block, HF, hyperthyroidism
Avoid MAOIs within 14 days
Flexeril
Tabs: 5 mg, 7.5 mg, 10 mg
Tricyclic Antidepressants
General comments
Antidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment
amitriptyline
Adults:
25-50 mg HS
Max:
150 mg/day
Older adults and adolescents:
20 mg HS
Nonpharmacologic Management Essay Examples
No adequate fetal studies in humans; evaluate benefits vs. risks
Prescribe smallest amount feasible; deaths may occur from overdosage with this class of medications
May cause sedation; administer at bedtime if feasible
Do not administer to patients taking MAO inhibitors
Cautious use in patients with cardiovascular disorders. May cause sinus tachycardia, prolonged QT interval, or arrhythmias
Close supervision if given to patients with hyperthyroidism or being treated for hyperthyroidism
When possible, discontinue prior to elective surgery
Fluctuations in blood sugar are possible
Cautious use in patients with hepatic dysfunction
Elavil
Tabs: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
POSSIBLE COMPLICATIONS
Chronic pain
Chronic work loss
Marked functional impairment
Severe depression and anxiety
PREVENTION
No specific prevention known
RISK FACTORS
Female sex
Age 20 to 50 years
Genetics
Infections
Physical or emotional trauma
Rheumatic disease (osteoarthritis, lupus, rheumatoid arthritis, ankylosing spondylitis)
Nonpharmacologic Management Essay Examples
Hyperlipidemia
DESCRIPTION
Elevated levels of blood lipids: cholesterol, cholesterol esters, phospholipids, and/or triglycerides.
ETIOLOGY
Inherited disorder of lipid metabolism
High intake of dietary lipids
Obesity, sedentary lifestyle
Diabetes mellitus
Hypothyroidism
Anabolic steroid use
Hepatic disorders: hepatitis, cirrhosis
Renal disorders: uremia, nephrotic syndrome
Stress
Drug-induced: thiazide diuretics, β-blockers, cyclosporine
Alcohol and caffeine
Metabolic syndrome: characterized by hypertension, glucose intolerance, obesity, dyslipidemia, and/or coagulation abnormalities
INCIDENCE
Hypercholesterolemia >200 mg/dL: 100 million people in U.S.
Hypercholesterolemia >240 mg/dL: 35 million people in U.S.
Men = Women, but onset is 10-15 years later in women
Incidence increases as age increases
Familial Hypercholesterolemia (FH)
2% or 1:200 with LDL >190 have mutation in one or more genes
Need early preventive therapy to reduce cumulative and chronic LDL exposure that leads to early heart disease
RISK FACTORS
Family history of CHD [type 2 familial hypercholesterolemia (FH)]
Physical inactivity
Smoking
Age: men > 45 years, women > 55 years or premature menopause without estrogen replacement
Obesity
Diet high in saturated fat
Diabetes mellitus
ASSESSMENT FINDINGS
Few physical findings
Xanthomata
Xanthelasma
Corneal arcus prior to age 50
Bruits
Angina pectoris
Myocardial infarction
Stroke
DIFFERENTIAL DIAGNOSIS
Consider secondary causes: hypothyroidism, pregnancy, diabetes, nonfasting state
DIAGNOSTIC STUDIES
Fasting lipid profile (9-12 hours of fasting)
Nonfasting sample: total cholesterol, LDL and
HDL values minimally affected by eating; triglycerides elevated by eating
Glucose
Urinalysis, creatinine (for detection of nephrotic syndrome, which can induce dyslipidemia)
TSH (for detection of hypothyroidism, which may secondarily cause hypercholesterolemia)
PREVENTION
1% decrease in cholesterol decreases CHD risk by 2%
Adults and children >2 years: reduce dietary intake of fats to <30% of total calories; <7% should be from saturated fat (10% reduction in LDL with this diet)
Total cholesterol intake <200 mg/day
Minimize use of trans fatty acids
Increase intake of fiber, vegetables, fruits, and other whole grains
Decreased intake of fat is not recommended for children <1 year old
Identify and eliminate risk factors in children and adults
Encourage active lifestyle in children to reduce obesity risk
Adults should exercise at least 2.5 hours per week (sustained aerobic activity increases HDL, decreases TC)
Weight control and avoidance of tobacco products
Appropriate management of systemic diseases (e.g., diabetes mellitus, hypothyroidism, hypertension)
NONPHARMACOLOGICAL MANAGEMENT
Therapeutic lifestyle changes (TLC): nutrition, weight reduction, increased physical activity (See Prevention)
Patient education about risk factors, lifestyle modifications, diet, exercise, etc.
INDICATIONS FOR PHARMACOLOGICAL MANAGEMENT
Three risk categories (demographics, labs, personal history) delineate treatment options based on ASCVD 10-year risk calculation and/or presence of major risk factors. See tool at http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
Primary lipid target is LDL
Nonpharmacologic Management Essay Examples
STATIN INTOLERANCE
If statin intolerance suspected, temporarily discontinue statin therapy, decrease dosage, and re-challenge with 2-3 statins of differing metabolic pathways and intermittent (1-3x weekly) dosing of long half-life statins
2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults
Groups Who Benefit From Statin Use
History of CHD or stroke
Patients with LDL ≥190 mg/dL
DM (no evidence of ASCVD), 40-75 years old with LDL 70-189 mg/dL
No evidence of ASCVD or DM; LDL 70-189 mg/dL PLUS estimated 10-year ASCVD risk ≥7.5%
Lipid Screening Recommendation
When increased risk for CHD is present, screen men at ages 20-30 and women after age 20
Screen men without risk factors beginning at age 35
Optimal screening interval and age to stop screening are unknown
Source: U.S. Preventive Services Task Force Guide to Clinical Preventive Services, 2014.
Pediatric patients
Total Cholesterol <170 mg/dL
Desirable
LDL Cholesterol <110 mg/dL
Desirable
Major Risk Factors
Age (men ≥45 years, women ≥55 years)
Family history of premature CHD (first-degree relatives, CHD in men <55 years, in women <65 years)
Cigarette smoking
Hypertension (BP ≥140/90 mm Hg or on antihypertensive therapy)
HDL <40 mg/dL, triglycerides >200 mg/dL
Metabolic syndrome
Established CHD (history of MI, stable/unstable angina, previous CAD interventions)
CHD risk equivalents (peripheral artery disease, abdominal aortic aneurysm, carotid disease, diabetes mellitus)
Source: Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) by the National Cholesterol Education Program (NCEP), 2004.
Summary of 2013 ACC/AHA Updated Guidelines
Risk
Demographics
Lipid Goals/Pharmacologic Intervention
High
Secondary prevention in adults >75 years old
Primary prevention in adults with LDL ≥190 mg/dL
Primary prevention in adults 40-75 years old with LDL 70-189 mg/dL PLUS estimated ASCVD risk of ≥7.5%
Primary prevention in DM aged 40-75 years with LDL 70-189 mg/dL PLUS estimated ASCVD risk ≥7.5%
Goal: 50% reduction in LDL with statin (atorvastatin 40 mg or 80 mg daily; rosuvastatin 20 mg or 40 mg daily)
Moderate
Secondary prevention in adults >75 years old
Primary prevention in adults 40-75 years old with LDL 70-189 mg/dL PLUS estimated ASCVD risk ≥7.5%
Primary prevention in DM 40-75 years old PLUS estimated ASCVD risk of ≥7.5%
Goal: 30-49% reduction in LDL with statin (atorvastatin 10 mg or 20 mg daily; fluvastatin 40 mg BID, 80 mg daily; lovastatin 40 mg daily; pitavastatin 2 mg or 4 mg daily; pravastatin 40 mg or 80 mg daily; rosuvastatin 5 mg or 10 mg daily; simvastatin 20 mg or 40 mg daily)
PHARMACOLOGIC MANAGEMENT
SUMMARY OF LIPID LOWERING AGENTS
DRUG CLASS
↓ LDL
↑ HDL
↓ TRIGS
Statins
19-54%
5-15%
7-30%
Bile Acid Sequestrants
15-30%
3-5%
Insignificant
Nicotinic Acid
5-25%
15-35%
20-50%
Fibric Acids
5-7%
10-20%
20-50%
Cholesterol Absorption Inhibitor
15-18%
3-3.5%
Insignificant
PCSK9 inhibitors
52.8%
–
–
LIPID LOWERING AGENTS
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
HMG-CoA Reductase
Inhibitors (Statins)
Inhibit HMG-CoA, the enzyme that is partly responsible for cholesterol synthesis; decrease total cholesterol, LDL; minimal increase in HD
L
General comments:
Considered first line therapy
Perform liver function tests before initiating therapy, at 4-6 and 12 weeks, and after each dose increase, then periodically (or per manufacturer’s recommendations)
To be used in conjunction with diet, exercise, & weight reduction in overweight patients
Watch for myopathy, rhabdomyolysis
Watch for drug interactions, especially with grapefruit juice and lovastatin, simvastatin, atorvastatin
Not safe during pregnancy
atorvastatin
LDL-C reduction < 45%
Adult:
Initial:
10 or 20 mg/day
Usual:
10-80 mg/day
Max:
80 mg/day
LDL-C reduction > 45%
Initial
: 40 mg/day
Usual:
40-80 mg/day
Max:
80 mg/day
Heterozygous Familial
Hypercholesterolemia
Children:
< 10 years:not recommended
10-17 years:
Initial:
10 mg/day
Usual:
10 mg/day
Max
: 20 mg/day
If concomitant use with gemfibrozil, maximum dose should not exceed 10 mg/day
If concomitant use with clarithromycin, itraconazole, or protease inhibitors, maximum dose should not exceed 20 mg/day
Lipitor
Tabs: 10 mg, 20 mg, 40 mg, 80 mg
fluvastatin
LDL-C reduction < 25%
Adult:
Initial:
20 mg in evening
Usual:
20-80 mg/day
Max:
80 mg/day
LDL-C reduction > 25%
Adult:
Initial
: Lescol XL 80 mg in PM
OR
40 mg Lescol daily or BID daily or twice daily
Usual:
80 mg/day
Max
: 80 mg/day
Children:
not recommended
Avoid in patients with substantial alcohol consumption
Avoid concomitant fibrates, cyclosporine
May be taken without regard to meals
Lescol
Tabs: 20 mg, 40 mg
Lescol XL
Extended-release tabs: 80 mg
continued
LIPID LOWERING AGENTS
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
lovastatin
CrCl > 30 mL/min
Adult:
Initial:
10-20 mg (evening)
Usual:
10-80 mg/day in single or divided doses
Max:
80 mg day (single or divided dose)
CrCl >30 mL/min
Adult:
Initial:
10-20 mg/day
Usual:
10-20 mg/day
Max:
20 mg day
Heterozygous Familial
Hypercholesterolemia
Children:
< 10 years:
not recommended
10-17 yrs:
Initial:
10-20 mg/day
Usual:
10-40 mg/day
Max:
40 mg/day
Take with evening meal
Patients on amiodarone or verapamil should not exceed 40 mg/day
Start with lower doses if patient on cyclosporine or danazol; do not exceed 20 mg/day
For patients on fibrates or high-dose niacin, do not exceed 20 mg/day
Nonpharmacologic Management Essay Examples
Mevacor
Altocor
Tabs: 10 mg, 20 mg, 40 mg
pravastatin
Normal Renal/Hepatic Function
Adult:
Initial:
10 mg/day
Usual:
20-40 mg/day
Max
: 80 mg/day
Children:
< 8 years:
not recommended
8-13 years:
20 mg/daily
14-18 years:
40 mg/daily
Impaired Renal/Hepatic Function
Adult:
Initial:
10 mg/day
Usual:
20 mg/day
Max:
20 mg/day
May adjust dose after 4 weeks
Take at bedtime
Pravachol
Tabs: 10 mg, 20 mg, 40 mg, 80 mg
continued
LIPID LOWERING AGENTS
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
rosuvastatin
CrCl > 30mL/min
Adult:
Initial
: 10 mg/day
Usual:
5-20 mg/day
Max:
40 mg/day
CrCl < 30mL/min
Adult:
Initial
: 5 mg/day
Max:
10 mg/day
Heterozygous Familial Hypercholesterolemia
Children:
< 10 years: not recommended
10-17 yrs:
Initial:
5-10 mg/day
Usual:
5-20 mg/day
Max:
20 mg/day
May be taken without regard to meals
Maximum dose reserved only for patients who do not achieve LDL-C goal
In Asian patients, initiate therapy at 5 mg/day
In patients taking cyclosporine, maximum dose is 5 mg/day
In patients taking antiviral agents, maximum dose is 10 mg/day
Crestor
Tabs: 5 mg, 10 mg,
20 mg, 40 mg
simvastatin
Normal risk of CHD
event
Adult:
Initial
: 20-40 mg HS
Usual
: 40 mg HS
Max
: 40 mg HS
High risk of CHD event
Adult
:
Initial
: 40 mg HS
Usual
: 40-80 mg HS
Max
: 80 mg HS
Heterozygous Familial
Hypercholesterolemia
Children
:
<10 years
: not recommended
10-17 years:
Initial
: 10 mg HS
Usual
: 10-40 mg HS
Max
: 40 mg HS
Dosage adjustments at intervals of 4 weeks or more
If concomitant use with gemfibrozil, simvastatin maximum dose should not exceed 10 mg/day
Start with lower doses if patient on cyclosporin or danazol; do not exceed 10 mg/day
Patients on amiodarone or verapamil should not exceed 20 mg/day
Patients on diltiazem should not exceed 40 mg/day
Zocor
Tabs: 5 mg, 10 mg,
20 mg, 40 mg, 80mg
continued
LIPID LOWERING AGENTS
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Bile Acid Sequestrants
Bind bile acids in the intestine which prevents their absorption. These insoluble bile acid complexes are excreted in the feces
General comments
In conjunction with diet, used to decrease total cholesterol, LDL
May prevent absorption of fat soluble vitamins A, D, E & K
Watch for constipation, flatulence
May reduce absorption of many oral medications
cholestyramine
Adult:
Initial:
one packet with food or fluids 1-2 times a day
Usual:
2-4 packets divided in 2 doses daily
Max:
6 doses/day
Do not administer with other medications
Mix only with noncarbonated liquids
Questran
Carton: 60 pkts
Can: 378 g
Questran Light
Carton: 60 pkts
Can: 268 g
colesevelam
Adult:
Initial
: 3 tabs BID
OR
1 packet 3.75 g/day
OR
1 packet 1.875 g BID
Usual:
same as initial
Max:
same as initial
Children:
< 10 years:
not recommended
10-17 years:
same as adult, but use powder form
Use with caution in pregnancy due to binding of other nutrients
If powder, mix in 4-8 oz water
Take with meals
Contraindicated in patients with history of bowel obstruction
Contraindicated in patients with serum triglycerides >500 mg/dL
Caution in patients with history of pancreatitis
Welchol
Tabs: 625 mg
Pkt: 1.875 g, 3.75 g
colestipol
Adult:
Initial:
1 packet
OR
1 scoop/day
OR
2-4 g/day
Usual:
1-6 packets
OR
1-6 scoops
OR
2-16 g (per day or divided doses)
Max:
6 packets
OR
6 scoops
OR
16 g (per day or divided doses)
Children:
not recommended
Use with caution in pregnancy due to binding of other nutrients
Do not crush tablet formulation
Titrate dose upward weekly to achieve max
Chronic use can lead to increased bleeding tendency (vitamin K depletion)
Nonpharmacologic Management Essay Examples
Colestid
Carton: 30 packet, 90 packet
Powder: 300 g, 500 g
Colestipol
Tab: 1 g
continued
LIPID LOWERING AGENTS
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Fibric Acids
Increase lipolysis and elimination of triglyceride-rich particles from plasma. Results in lowering of triglycerides, LDL
General comments
Concomitant use of gemfibrozil and statins can produce rhabdomyolysis and acute renal failure
Increases gallstone formation risk
Monitor liver function studies and glucose during therapy; both may be elevated
gemfibrozil
Adult:
Initial:
1.2 g daily in 2 divided doses, 30 min AC
Usual:
same as initial
Max:
same as initial
Children:
not recommended
Concomitant therapy with cerivastatin increases risk of myopathy and rhabdomyolysis
Avoid in patients with pre-existing gallbladder disease
Discontinue after 3 months if lipid response is inadequate
Avoid concomitant therapy with HMG-CoA reductase inhibitors
Lopid
Tabs: 600 mg
fenofibrate
Normal Triglycerides
Adult:
Initial:
145 mg/day
Usual:
same as initial
Max:
same as initial
Elevated Triglycerides
Initial
: 48 mg/day
Usual
: 48-145 mg/day
Max:
145 mg/day
Children:
not recommended
Contraindicated in patients with severe renal or hepatic dysfunction
Avoid in patients with pre-existing gallbladder disease
Caution in patients with warfarin-type anticoagulants
Adjust at 4-8 week intervals; discontinue after 2 months of max dose if not favorable lipid response
TriCor
Tabs: 48 mg, 145 mg
fenofibric acid
Mixed Hyperlipidemia
Adult:
Initial:
135 mg/day
Usual:
same as initial
Max:
same as initial
Hypertriglyceridemia
Adult:
Initial:
45 mg/day
Usual:
45-135 mg/day
Max:
135 mg/day
Renal Impairment
Adult:
Initial:
45 mg/day
Usual:
45 mg/day
Max:
45 mg/day
Children:
not recommended
As mono therapy, targets severe hypertriglyceridemia
As combination therapy (with HMG-CoA reductase inhibitors, targets mixed hyperlipidemia
Contraindicated in patients on dialysis
Trilipix
Caps: 45 mg, 135 mg
continued
LIPID LOWERING AGENTS
Class
Drug
Generic name
(Trade name®)
Dosage
How supplied
Comments
Niacin
Not well understood but thought to decrease hepatic VLDL production. VLDL is converted to LDL. Also, may decrease lipoprotein production in the liver; increases HDL
General comments
Monitor liver function studies before initiation of treatment, at 6 and 12 weeks after treatment, with each dosage increase, and periodically
Poorly tolerated. Causes flushing and hypotension. Take at bedtime with an aspirin to improve tolerability
Monitor for myalgias and rhabdomyolysis
niacin (nicotinic acid)
Adult:
Initial:
250 mg with evening meal; increase every 4-7 days until 1.5-2 g/day
Usual:
1.5-3 g/day (may be in 3 divided doses)
Max:
6 g/day
Children
: not recommended
Upward titration of dose required
Avoid taking on empty stomach
Do not interchange immediate release dosage form with extended release dosage form
Niacor
Tabs: 500 mg
niacin (nicotinic acid),
extended release
Adult:
Initial:
500 mg/HS, wk 1-4; then 1000 mg/HS wk 5-8; then 1500 mg/HS wk 9-12; then 2000 mg/HS wk 13-16
Usual:
1000-2000 mg/HS
Max:
2000 mg/HS
Children
: not recommended
Upward titration should not exceed 500 mg in a 4-week period
If therapy interrupted, resume on titration schedule
Women may require lower doses than men
Use with caution in patients with renal or hepatic dysfunction
Do not interchange immediate-release dosage form with extended-release dosage form
Niaspan
Tabs: 500 mg, 750 mg, 1000 mg
Cholesterol Absorption Inhibitor
Inhibits absorption of cholesterol by the small intestine. Does not inhibit cholesterol synthesis (statins) or increase bile acid excretion
ezetimibe
Adult:
Initial:
10 mg/day
Usual:
same as initial
Max:
same as initial
Children:
> 10 years:
Initial
: 10 mg/day
Usual:
same as initial
Max:
same as initial
Alone or in combination with statin
No evidence of myopathy when used alone
Not necessary to monitor hepatic function unless patient on other therapy that requires monitoring
GI complaints are most common
Nonpharmacologic Management Essay Examples
Zetia
Tabs: 10 mg
PCSK9 inhibitors
Mechanism of action is attaching to the PCSK9 proteins, which are responsible for destruction and recycling of LDL-C receptors located on the liver
alirocumab
Subcutaneously every 2 wk; if LDL-C response is inadequate, increase dosing to 150 mg every 2 wk
Evolocumab dose based on type of FH being treated
For heterozygous FH, evolocumab 140 mg subcutaneously every 2 wk or 420 mg once per month
Considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher-risk patients with clinical ASCVD or familial hypercholesterolemia
Not recommended for use in primary prevention patients in the absence of familial hypercholesterolemia
Measure LDL-C every 2-6 weeks after initiation or adjustment of therapy
Praluent
Injection: 75 mg/mL
PREGNANCY/LACTATION CONSIDERATIONS
Cholesterol levels are usually elevated during pregnancy
Measurement is not recommended
Treatment contraindicated
CONSIDERATIONS FOR SPECIAL POPULATIONS
Older adults: benefits with total cholesterol and LDL reduction
Statins typically well tolerated by older adults
Diabetes: aggressive management of hyperlipidemia needed
The ACC/AHA writing committee supports consideration of adding ezetimibe 10 mg daily as the first non-statin agent for many higher-risk patient groups. However, the committee does not recommend niacin as an additional non-statin therapy for the situations discussed in the document. Consistent with the 2013 guideline, the panel recommends looking first at lifestyle issues, including diet, exercise and smoking, followed by statin therapy.
CONSULTATION/REFERRAL
Dietitian
Refer children with hyperlipidemia that does not respond to dietary and conservative measures; specialist intervention needed
FOLLOW-UP
Evaluate lipid values every 5 years starting at age 20 if normal values obtained
After initiation of lipid lowering therapy, monitor lipids every 6-8 weeks until goal attained; then every 6-12 months to evaluate compliance
EXPECTED COURSE
Depends on etiology and severity of disease
1% decrease in LDL value decreases CHD risk by 2%
POSSIBLE COMPLICATIONS
Coronary artery disease
Cerebrovascular disease
Peripheral vascular disease
Arteriosclerosis
Hypertension-
Systolic and/or diastolic blood pressure that is higher
than expected for age or pregnancy status. A presumptive diagnosis can be made if the average of two measurements is abnormal on two separate visits. Hypertension (HTN) is classified as primary (essential) or secondary. Isolated systolic hypertension is common in older adults. Nonpharmacologic Management Essay Examples
ACC/AHA guidelines emphasize link between hypertension and cardiovascular disease. The ASCVD Risk Calculator should be used to make treatment decisions: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/. Available as a mobile app: ASCVD Risk Estimator Plus
ACC/AHA Classification of HTN
BP Category
Systolic BP
Diastolic BP
Normal
<120 mm Hg
and
<80 mm Hg
Elevated
120-129 mm Hg
and
<80 mm Hg
HTN stage 1
130-139 mm Hg
or
80-89 mm Hg
HTN stage 2
≥140 mm Hg
or
≥90 mm Hg
ACC/AHA Target BP Goal
Classification of patients
Goal
For adults with confirmed HTN and known CVD or 10-year ASCVD event risk of 10% or higher
<130/80 mm Hg
For adults with confirmed HTN, without additional markers of increased CVD risk
<130/80 mm Hg may be reasonable
Source: 2017 ACC/AHA guidelines
ETIOLOGY
ADULT
Causes of Primary Hypertension
No known cause in 90% of cases
Causes of Secondary Hypertension
Renal
Acute glomerulonephritis
Chronic renal failure
Polycystic kidney disease
Pyelonephritis
Vascular
Coarctation of the aorta
Renal artery stenosis
Endocrine
Primary hyperaldosteronism
Pheochromocytoma
Cushing’s syndrome
Neuroblastoma
Hyperthyroidism
Neurologic
Increased intracranial pressure
Sleep apnea
Pharmacological
Oral contraceptives
Corticosteroids
Cocaine
NSAIDs
Decongestants
Sympathomimetics
PEDIATRIC
Causes of Primary Hypertension
In children >10 years, HTN is usually primary. However, secondary causes must be ruled out.
Causes of Secondary Hypertension
Approximately 10% of cases of HTN
Renal
Most common cause (80%)
Vascular
Coarctation of the aorta (5-10% due to this)
Endocrine
Adrenal dysfunction
Hyperaldosteronism
Hyperthyroidism
Neurologic
Increased intracranial pressure
Sleep apnea
Nonpharmacologic Management Essay Examples
Pharmacological
Oral contraceptives
Corticosteroids
Cocaine
NSAIDs
Decongestants
Sympathomimetics
INCIDENCE
85 million U.S. residents have HTN; in 45.9% of them, HTN is uncontrolled
Reported rates of HTN in children vary from 2-13% (highest in black and Asian children)
Black adults have higher incidence than general population
Men > Women
Initially appears between 30-55 years
Increased prevalence in older adults
5-10% of all pregnancies
RISK FACTORS
Modifiable risk factors:
Cigarette smoking (including secondhand)
Diabetes mellitus
Dyslipidemia/hypercholesteremia
Overweight/obesity (obesity is single most important factor in children; important in adults as well)
Physical inactivity/low fitness
Unhealthy diet
Excessive dietary intake of sodium
Excessive alcohol consumption
Relative fixed risk factors:
CDK
Family history
Increased age (>55 years male; >65 years female)
Low socioeconomic
Low educational status
Male sex
Obstructive sleep apnea (OSA)
Psychosocial stress
Pregnancy
ASSESSMENT FINDINGS
Most patients are asymptomatic
Occipital headaches
Headache on awakening in morning
Blurry vision
Exam of optic fundi: look for AV nicking, arteriolar narrowing, hemorrhages, exudates, and papilledema
Left ventricular hypertrophy (after longstanding hypertension)
Pregnancy with hypertension and proteinuria, edema, and excessive weight gain
Perform exam of symmetrical pulses, auscultate for carotid and abdominal bruits, auscultate over kidneys for bruits
Nonpharmacologic Management Essay Examples
Pediatric Classification of HTN
Age 1-13 Years
Age ≥13 Years
Normal BP:
<90th percentile
Normal BP:
<120/80 mm Hg
Elevated BP:
≥90th-95th percentile or 120/80 mm Hg to <95th percentile (whichever is lower)
Elevated BP:
120/<80 to 129/<80 mm Hg
Stage 1 HTN:
≥95th percentile to <95th percentile +12 mm Hg or 130/80 to 139/89 mm Hg (whichever is lower)
Stage 2 HTN:
≥130/80 mm Hg
Stage 2 HTN:
≥95th percentile + 12 mm Hg or ≥140/90 mm Hg (whichever is lower)
Stage 2 HTN:
≥140/90 mm Hg
DIFFERENTIAL DIAGNOSIS
Secondary hypertension
White coat hypertension (artificially elevated BP due to anxiety in medical environment)
DIAGNOSTIC STUDIES
Urinalysis: may reveal proteinuria
Electrolytes, creatinine, calcium
Fasting lipid profile
Fasting blood glucose
Electrocardiogram (ECG)
Other studies depending on history and physical exam
Measure BP twice, 5 minutes apart
Patient should be seated and proper cuff size and application used (ALWAYS assess contralateral arm to confirm elevated reading)
Consider using ambulatory BP monitoring and home BP monitoring to aid in diagnosis and management
Goal of diagnostic studies is to identify target organ damage, any underlying cause, and/or additional risk factors.
PREVENTION
Maintenance of healthy weight and BMI
Smoking cessation
Regular aerobic exercise
Alcohol in moderation (<1 oz/day)
Stress management
Adherence to medication regimen
NONPHARMACOLOGIC MANAGEMENT
If Stage 1, no hx of CVD, and risk score <10%, initiate lifestyle changes first
Stage 2, lifestyle + medication
Lifestyle changes can reduce systolic BP by 4-11 mm Hg
Implement DASH (Dietary Approaches to Stopping Hypertension) eating plan
Reduce dietary sodium and increase potassium (except with CKD and certain medications)
Nonpharmacologic Management Essay Examples
Increase fruits, vegetables, whole grains
Reduce saturated fat intake
Obtain ideal body weight; 1 mm Hg BP reduction for every 1 kg reduction in body weight
90-150 mins of aerobic exercise and/or three sessions of isometric resistance exercise per week
Reduce alcohol intake: 2 or < drinks per day for men and 1 or < drinks per day for women
Identification and management of stressors
Counseling about elimination of other cardiovascular risks (e.g., smoking cessation)
Treatment of underlying disease, if applicable
Twice-weekly BP checks during pregnancy, if elevated
Do not restrict salt intake during pregnancy
Patient education about disease, treatment, prevention of complications, long-term implications, diet changes, and lifestyle modifications
Self-monitoring patients should:
Use valid instruments for accurate measurements
Position themselves correctly with the bottom of the cuff above the bend of the elbow
Take two readings 1 minute apart each morning before medication and each evening before dinner
Weekly readings for 2 weeks after treatment changes and the week before the clinic visit
Average home readings on two or more occasions
PHARMACOLOGIC MANAGEMENT
Start Medication:
Primary prevention of CVD
is recommended for adults without history of CVD AND a 10-year ASCVD risk of ≥10% or higher and Stage 1 HTN OR a 10-year ASCVD risk <10% with SBP 140 mm Hg or higher or a DBP 90 mm Hg or higher
Secondary prevention of CVD
with history of clinical CVD AND Stage 1 HTN
If Stage 2
, start
TWO
BP-lowering medications
In black patients, two or more medications recommended: thiazide and calcium channel blockers are the most effective
A variety of agents may be used in adult, pediatric, and nonpregnant patients:
Diuretics: may decrease renal function in patients with chronic renal failure and in patients with renal insufficiency
Angiotensin-converting enzyme inhibitors (ACE inhibitors)
Angiotensin II receptor blockers (ARBs)
Do NOT use ACE and ARB together
Beta blockers (NOT first line)
Calcium channel blockers
Vasodilators
Combination of above
In pregnant patients:
Vasodilators
Beta blockers
Methyldopa (Aldomet)
Calcium channel blockers
Avoid ARBs and ACE inhibitors
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Thiazide Diuretics
Increase excretion of sodium and chloride and thus water; decrease circulating plasma volume
General comments
Monitor for hypokalemia (check potassium level about 2 weeks after initiation and with increase in dose)
Maintain potassium 4-5 mmol/L
May worsen gout and elevate blood glucose and lipids
hydrochlorothiazide (HCTZ)
Adult:
Initial:
25 mg/day
Usual:
12.5-50 mg/day
Max:
50 mg/day
Children:
Initial:
1-2 mg/kg/day in 1-2 divided doses
<6 months:
max 3 mg/kg/day
6 months-2 years:
max 37.5 mg/day
2-12 years:
max 100 mg/day
Relatively inexpensive
Careful use in sulfonamide allergy
Contraindicated in patients with anuria
Various generics (Esidrix, HCTZ, HydroDIURIL, Microzide, Oretic, thiazide)
Caps: 12.5 mg
Tabs: 25 mg, 50 mg, 100 mg
chlorthalidone
Adult:
Initial:
12.5-25 mg/day
Usual:
12.5-50 mg/day
Max:
50 mg/day
Children:
not recommended
Preferred thiazide
Chlorthalidone provides more consistent 24-hour BP control than HCTZ
Hygroton
Tabs: 25 mg, 50 mg
chlorthalidone
Adult:
Initial:
15 mg/day
Usual:
30-45 mg/day
Max:
50 mg/day
Children:
not recommended
Do not interchange between trade and generic due to bioavailability differences
Higher doses predispose patients to hypokalemia
Thalitone
Tabs: 15 mg (trade)
Tabs: 30 mg, 50 mg (generic)
Loop Diuretics
Inhibit absorption of sodium and chloride in proximal/distal tubules and loop of Henle
General comments
More potent diuretic action than thiazides
Monitor for dehydration, electrolyte imbalances and hypotension
May be used for patients who develop fluid overload
Increases calcium excretion
Nonpharmacologic Management Essay Examples
furosemide
Adult:
Initial:
20-40 mg BID
Usual:
Individualized for effect
Max:
320 mg (split in 2-3 doses); do not exceed maximum adult dose
Children:
Initial
: 2 mg/kg
Max
: 6 mg/kg
Second-line therapy after thiazides
Use lower doses in older adults
Diuretic of choice in reduced Cr Cl patients
Risk of ototoxicity
Lasix
Tabs: 20 mg, 40 mg, 80 mg
Solution: 10 mg/mL, 40 mg/mL
torsemide
Adult:
Initial:
5 mg daily
Usual:
5-10 mg/day
Max:
10 mg (either daily or split between doses)
Children:
not recommended
Second-line therapy after thiazides
Contraindicated in patients with sulfonylurea allergy
May take without regard to meals
Risk of ototoxicity
Demadex
Tabs: 5 mg, 10 mg
Potassium-Sparing Diuretics
Enhance the action of thiazide and loop diuretics and counteract potassium loss by these agents
spironolactone
Adult:
Initial
: 12.5 mg/day (single or split dose)
Usual
: 25-50 mg daily
Max
: 200 mg/day (single or split dose)
Children:
not recommended
Usually not first-line agent
Requires at least 2 weeks of therapy to determine effectiveness
Contraindicated in patients with anuria, acute renal insufficiency, hyperkalemia
Aldactone
Tabs: 25 mg, 50 mg, 100 mg
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
triamterene
Adult
:
Initial
: 100 mg BID after meal
Usual
: 100 mg BID
Max
: 300 mg/day
Children:
not recommended
If taking another diuretic or anti-HTN agent, must lower starting dose
Patients should not be receiving potassium supplementation
Dyrenium
Caps: 50 mg, 100 mg
Angiotensin-Converting
Enzyme (ACE) Inhibitors
Inhibit the action of angiotensin-converting enzyme (ACE), which is responsible for conversion of angiotensin I to angiotensin II; angiotensin II causes vasoconstriction and sodium retention. Prevents breakdown of bradykinin
General comments
First-line agent
End in “pril”
Dry cough is common side effect; monitor for first-dose hypotension,
hyperkalemia, acute renal failure
Angioedema is rare but more common in black patients
Monitor for renal failure and worsening chronic heart failure
Preferred in patients with diabetes and heart failure
Avoid use in patients with bilateral renal artery stenosis
benazepril
Patients NOT on Diuretics
Adult:
Initial:
10 mg/day
Usual
: 20-40 mg/day
Max
: 80 mg/day
Children: >6 years:
Initial
: 0.2 mg/kg/day
Max:
0.6 mg/kg/day (or 40 mg)
Patients On diuretics
Adult:
Initial:
5 mg/day
Usual:
20-40 mg/day
Max:
80 mg/day
Patients with renal
impairment (glomerular filtration < 30mL)
Initial:
5 mg/day
Usual:
20-40 mg/day
Max:
40 mg/day
Little additional effect noted at doses >40 mg
Considered MONOTHERAPY in children
Avoid in children with glomerular filtration rates <30 mL/min
Lotensin
Tabs: 5 mg, 10 mg, 20 mg, 40 mg
captopril
Patients NOT on diuretics
Adult:
Initial
: 25 mg BID or TID
Usual
: 25-50 mg/day
Max
: 450 mg/day
Children
: not recommended
Patients on diuretics
Adult:
Initial
: 6.25-12.5 mg BID or TID
Usual
: 25-150 mg BID or TID
Max
: 450 mg/day
Patients with renal impairment (glomerular filtration <30 mL)
Initial
: 6.25-12.5 mg BID or TID
Usual
: 12.5-75 mg/day
Capoten
Tabs: 12.5 mg, 25 mg, 50 mg, 100 mg
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
enalapril maleate
Patients NOT on diuretics
Adult:
Initial
: 5 mg/day
Usual
: 10-40 mg/day (single or split doses)
Max
: 40 mg/day
Patients ON diuretics
Adult
:
Initial
: 2.5 mg/day
Usual
: 10-40 mg/day (single or split doses)
Max:
40 mg/day
Patients with renal impairment (glomerular filtration <30 mL)
Initial
: 2.5 mg/day
Usual
: 10-40 mg/day (single or split doses)
Max
: 40 mg/day
Children
: not recommended
Avoid potassium supplements
Use with caution in patients on lithium
Recommend holding diuretics 3 days prior to starting, if appropriate for patient
If patient on diuretic, must monitor for 2 hours after initial dose
If patient on dialysis, give only 2.5 mg on days of dialysis
Vasotec
Tabs: 2.5 mg, 5 mg, 10 mg, 20 mg
lisinopril
Patients NOT on Diuretics
Adult:
Initial:
10 mg/day
Usual:
20-40 mg/day
Max:
80 mg/day
Children ≥6 years:
Initial:
0.07 mg/kg
Usual:
Individualize
Max:
0.61 mg/kg –
do not exceed maximum adult dose
Patients on diuretics OR with renal
impairment (glomerular
filtration < 30mL)
Adult:
Initial:
2.5 mg/day
Usual:
2.5-5 mg/day
Max:
5 mg/day
Recommend holding diuretics 3 days prior to starting, if appropriate for patient
Doses at 80 mg may not produce significantly greater effect compared to 40 mg
Prinivil
Tabs: 2.5 mg, 5 mg, 10 mg, 20 mg, 40 mg
Zestril
ramipril
Patients NOT on diuretics
Adult:
Initial
: 2.5 mg/day for 7 days; 5 mg/day for 21 days; then 10 mg/day
Usual
: 2.5-20 mg/day (single or split dose)
Max
: 20 mg/day
Children
: Not recommended
Patients on diuretics OR with renal impairment (Cr Cl <40 mL/min)
Initial
: 1.25 mg/day for 7 days; 2.5 mg/day for 21 days; then 5 mg/day
Usual
: 2.5-5 mg/day (single or
split dose)
Max
: 5 mg/day
Requires initial titration of dosage schedule
May increase lithium levels
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Altace
Caps 1.25 mg, 2.5 mg, 5 mg, 10 mg
Tabs 1.25 mg, 2.5 mg, 5 mg, 10 mg
Angiotensin II Receptor Blockers (ARBs)
Block vasoconstriction and sodium retention effects of AT II (angiotensin II) found in many tissues
General comments
End in “sartan”
Does not affect bradykinin; therefore, no cough as with ACE inhibitors. Good renoprotective action; therefore, good alternative in patients with diabetes who cannot tolerate ACE inhibitors
Monitor for hypotension and possible renal failure
candesartan cilexetil
Patients NOT on diuretics, not volume depleted
Adult
:
Initial
: 16 mg/day
Usual
: 8-32 mg/day (single or split dose)
Max
: 32 mg/day
Children:
<1 year:
not recommended
1-6 years:
Initial
: 0.2 mg/kg/day
Usual
: 0.05-0.4 mg/kg/day
Max
: do not exceed max adult dose
6-17 years:
Weight <50 kg;
Initial
: 4-8 mg/day
Usual
: 2-16 mg/day
Max
: 16 mg/day
Weight >50 kg;
Initial
: 4-8 mg/day
Usual
: 2-16 mg/day
Max
: 4-32 mg/day
Dose is individualized for effect
Nonpharmacologic Management Essay Examples
Initial response seen in ~2 weeks, full response in 4-6 weeks
If patient has volume depletion or impaired renal function, consider lower dose and provide close supervision
Atacand
Tabs: 4 mg, 8 mg, 16 mg, 32 mg
eprosartan mesylate
Patients NOT on diuretics, not volume depleted
Adult:
Initial
: 600 mg/day
Usual
: 400-800 mg/day (single or split dose)
Max
: 800 mg/day
Children
: not recommended
In severe renal impairment, do not exceed 600 mg/day
Volume or salt-depleted patients must be closely monitored when initiating treatment
Teveten
Tabs: 400 mg, 600 mg
losartan
Patients NOT on diuretics, not volume depleted
Adult:
Initial
: 50 mg/day
Usual
: 25-100 mg/day (single or split dose)
Max
: 100 mg/day
Children:
<6 years:
not recommended
>6 years:
Initial
: 0.7 mg/kg/day
Usual
: 0.7-1.4 mg/kg/day
Max
: 1.4 mg/kg/day;
do not
exceed maximum adult dose
Patients on diuretics or volume depleted
Adult
:
Initial
: 25 mg/day
Usual
: 25-100 mg/day (single or split dose)
Max
: 100 mg/day
Children
: not recommended
Initial effect within 1 week, may take 3-6 weeks for maximum effect
Cozaar
Tabs: 25 mg, 50 mg, 100 mg
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
olmesartan medoxomil
Patients NOT on diuretics, not volume depleted
Adult
:
Initial
: 20 mg/day
Usual
: 20-40 mg/day
Max
: 40 mg/day
Children
:
Weight >20 and <35 kg:
Initial
: 10 mg/day
Usual
: Individualize
Max
: 20 mg/day
Weight >35 kg:
Initial
: 20 mg/day
Usual
: Individualize
Max
: 40 mg/day
Taken without regard to food
Doses must be individualized
Clinical effect within 2 weeks
Caution when initiating in patients with hepatic or severe renal impairment
At doses >40 mg, addition of diuretic recommended
Benicar
Tabs: 5 mg, 20 mg, 40 mg
valsartan
Patients NOT on diuretics, not volume depleted
Adult:
Initial
: 80 mg/day
Usual
: 80-320 mg/day
Max
: 320 mg/day
Children:
<6 years:
not recommended;
6-16 years:
Initial
: 1.3 mg/kg/day
Usual
: Individualize
Max
: 160 mg/day
Taken without regard to food
Clinical effect within 2 weeks; maximum effect in 4 weeks
Caution when initiating in patients with hepatic or severe renal impairment
At doses >80 mg, addition of diuretic recommended
Diovan
Caps: 80 mg, 160 mg
Tabs: 40 mg, 80 mg, 160 mg, 320 mg
Cardioselective
Beta Blockers
Decrease sympathetic stimulation by beta blockade in the heart
General comments
Consider post-MI, in heart failure, ischemic heart disease
Should be avoided (or used cautiously) in patients with airway disease, heart block
Should be used with caution in patients with diabetes (may mask symptoms of hypoglycemia) and in patients with peripheral vascular disease
May cause exercise intolerance
acebutolol
Adult:
Initial
: 400 mg/day (single or split dose)
Usual
: 200-800 mg/day
Max
: 1200 mg/day
Children
: not recommended
DO NOT ABRUPTLY STOP DRUG
BID dosing more effective than single dose
Has intrinsic sympathomimetic activity
Sectral
Caps: 200 mg, 400 mg
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
atenolol
Adult:
Initial
50 mg/day
Usual
: 50-100 mg/day
Max
: 100 mg/day
Children
: not recommended
>65 years or patients with renal impairment
CrCl 15-35 mL/min
Initial
: 25 mg/day
Max
: 50 mg/day
CrCl <15 mL/min
Initial
: 25 mg/day
Max
: 25 mg/day
DO NOT ABRUPTLY STOP DRUG
May titrate dose upward after 1 week
Patients on dialysis should be monitored under hospital supervision for dosages given post-treatment
Tenormin
Tabs: 25 mg, 50 mg, 100 mg
bisoprolol fumarate
Adult:
Initial
: 5 mg/day
Usual
: individualize
Max
: 20 mg/day
Patients with renal or hepatic dysfunction
Initial
: 2.5 mg/day
Usual
: individualize
Max
: 20 mg/day
Children
: not recommended
DO NOT ABRUPTLY STOP DRUG
Individualize for patient effect
Advance from 5 mg to 10 mg to 20 mg as needed
Zebeta
Tabs: 5 mg, 10 mg
metoprolol succinate, extended release
Adult:
Initial:
25-100 mg/day
Usual:
100-400 mg/day
Max:
400 mg/day
Children:
not recommended
DO NOT ABRUPTLY STOP DRUG; must be tapered over 2 weeks
NOTE DIFFERENT DOSAGE FORMS; extended release form preferred for HTN control
Individualize for patient effect
Advance dosage at weekly intervals
Lopressor
Extended-release tabs: 25 mg, 50 mg, 100 mg, 200 mg
Toprol-XL
Extended-release tabs: 25 mg, 50 mg, 100 mg, 200 mg
metoprolol tartrate
Adult:
Initial:
100 mg/day (single or
divided dose)
Usual:
100-400 mg/day (single or divided dose)
Max:
450 mg/day (single or
divided dose)
Children:
not recommended
DO NOT ABRUPTLY STOP DRUG; must be tapered over 2 weeks
NOTE DIFFERENT DOSAGE FORMS; extended-release form preferred for HTN control;
Single immediate doses may not offer 24-hour coverage
Individualize for patient effect
Titrate dosage at weekly intervals
Should be given with meals
Lopressor
Tabs: 25 mg, 50 mg, 100 mg, 200 mg
Toprol-XL
Tabs: 25 mg, 50 mg, 100 mg, 200 mg
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Non-Cardioselective
Beta Blockers
Block stimulation of both beta1 (heart) and beta 2 (lungs) receptors, causing decreased heart rate, blood pressure, and cardiac output (beta1), as well as decreased central motor activity, inhibition of renin release from the kidneys, reduction of norepinephrine from neurons, and mild bronchoconstriction (beta 2)
General comments
End in “lol”
Contraindicated in patients with bronchoconstrictive disease (i.e., asthma, COPD, etc.)
Cautious use in patients with diabetes due to masking signs and symptoms of hypoglycemia (tachycardia, blood pressure changes)
Nonspecific beta blockade helpful in patients with tremors, anxiety and
migraine headaches
nadolol
Adult:
Initial
: 20-40 mg/day
Usual:
40-80 mg/day
Max:
320 mg/day
Children
: not recommended
Special dosing schedule in
renal impairment
Initial
: 20 mg
CrCl >50:
24 hr
CrCl 31- 50:
24-36 hr
CrCl 10- 30:
24-48 hr
CrCl <10:
40-60 hr
DO NOT ABRUPTLY STOP DRUG; may take 2 weeks to withdraw drug while patient is closely monitored
Individualize therapy
Taken without regard to meals
Note dosing schedule for renal dysfunction
Corgard
Tabs: 20 mg, 40 mg, 80 mg, 120 mg, 160 mg
penbutolol
Adult:
Initial:
20 mg/day
Usual:
20-40 mg/day
Max:
80 mg/day
Children:
not recommended
DO NOT ABRUPTLY STOP DRUG; may take 2 weeks to withdraw drug while patient is closely monitored
Full effect within 2 weeks
Levatol
Tabs: 20 mg
pindolol
Adult:
Initial:
5 mg BID
Usual:
10-30 mg/day
Max:
60 mg/day
Children:
not recommended
DO NOT ABRUPTLY STOP DRUG
Individualize therapy; adjust dose every 1-2 weeks
Has intrinsic sympathomimetic activity
Contraindicated with thioridazine
Visken
Tabs: 5 mg, 10 mg
propranolol
IMMEDIATE RELEASE
Adult:
Initial:
40 mg BID
Usual:
120-240 mg/day
Max:
640 mg/day
Children:
Initial:
1 mg/kg/day (in two divided doses)
Usual:
2-4 mg/kg/day (in two divided doses)
Max:
16 mg/day (in two divided doses) or 640 mg/day
EXTENDED RELEASE
Adult:
Initial:
80 mg/day
Usual:
120-160 mg/day
Max:
640 mg/day
DO NOT ABRUPTLY STOP DRUG
Extended-release form has different kinetics; CANNOT switch between dosage forms on a 1:1 mg basis
Titrate for effective BP; titration may vary from a few days to several weeks
Do not crush or chew tablets
Contraindicated with thioridazine
Inderal
Tabs: 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
Inderal LA
Extended-release caps: 60 mg,
80 mg, 120 mg, 160 mg
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Calcium Channel Blockers
Dihydropyridine (DHP)
Inhibit movement of calcium ions across the cell membrane and vascular smooth muscle, which depresses myocardial contractility and increases cardiac blood flow
General comments
End in suffix “pine”
Does not cause bradycardia
Monitor for hypotension and worsening of heart failure, ankle edema
Good choice in patients with isolated systolic hypertension, for migraine prophylaxis, and in patients with stable angina
Serious drug interactions with grapefruit juice
Long-acting DHP calcium channel blockers preferred for isolated systolic hypertension
amlodipine besylate
Adult:
Initial
: 5 mg/day
Usual
: 5-10 mg/day
Max
: 10 mg/day
>65 years, renal or hepatic patients:
Initial
: 2.5 mg/day
Children: > 6 years:
Initial
: 2.5 mg/day
Usual
: 2.5-5 mg/day
Max
: 5 mg/day
Titrate for effect; increase doses at 7- to 14-day intervals; must reassess patient after each titration
Nonpharmacologic Management Essay Examples
Norvasc
Tabs: 2.5 mg, 5 mg, 10 mg
felodipine
Adult:
Initial
: 2.5-5 mg/day
Usual
: 2.5-10 mg/day
Max
: 10 mg/day
>65 years or hepatic patients:
Initial
: 2.5 mg/day
Children
: not recommended
Titrate for effect; increase dose after minimum 2-week interval
Do not crush or chew tablets
Bioavailability affected by
meals; take on empty stomach
Plendil
Extended-release tabs: 2.5 mg,
5 mg, 10 mg
nicardipine HCL
Immediate-Release Formulation
Adult:
Initial
: 20 mg TID
Usual
: 20-40 mg TID
Max
: 120 mg/day
Children
: not recommended
Sustained-Release Formulation
Adult
:
Initial
: 30 mg BID
Usual
: 30-60 mg BID
Max
: 60 mg BID
Children
: not recommended
Individualize treatment
Lower doses required if impaired hepatic function
Effective response requires peak and trough BP measurements
Titrate dose after 3 days
Additional monitoring required if changing between dose formulations
Cardene
Caps: 20 mg, 30 mg
Cardene SR
Sustained-release caps: 30 mg, 45 mg, 60 mg
nifedipine
Adult:
Initial:
30-60 mg/day
Usual:
30-60 mg/day
Max:
120 mg/day
Children:
not recommended
Individualize treatment; advance doses at 1- or 2-week intervals
Use extended-release formulations for HTN control
Take on empty stomach
Do not crush or chew extended-release formulations
Must be withdrawn slowly if discontinued
Procardia XL
Extended-release tabs: 30 mg,
60 mg, 90 mg
Adalat CC
Extended-release tabs: 30 mg,
60 mg, 90 mg
nisoldipine
Adult:
Initial
: 17 mg/day
Usual
: 8.5-34 mg/day
Max
: 34 mg/day
>65 years OR with hepatic
dysfunction
Initial
: 8.5 mg/day
Children
: not recommended
Individualize treatment; advance doses at 1- to 2-week intervals
Take on empty stomach
Do not crush or chew
continued
HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Sular
Extended-release tabs: 8.5 mg,
17 mg, 25.5 mg, 34 mg
Calcium Channel Blockers: Non-Dihydropyridine
(Non-DHP)
Inhibit movement of calcium ions across cell membrane and vascular smooth muscle, which depresses myocardial contractility and increases cardiac blood flow
General comments
Watch for conduction defects
Decreases heart rate
Use cautiously or avoid with β-blockers
Monitor for worsening of heart failure, hypotension, bradycardia, constipation
Consider in patients with atrial fibrillation with rapid ventricular
Grapefruit juice may increase serum
concentration of CCB
diltiazem
Adult:
Initial
: 120-240 mg/day
Usual
: 240-360 mg/day
Max
: 480-540 mg/day*
>60 years:
Initial: 120 mg/day
Children
: not recommended
*See prescribing information for maximum dose limits
Use extended-release formulations for HTN control
Available in multiple formulations (tablets and capsules) and strengths
Individualize therapy; titrate biweekly
Start with lowest dose possible, especially patients >65 years
Do not crush or chew
Incidence of side effects increases as dose increases
Cardizem LA
Extended-release tabs: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
Cardizem CD
Extended-release caps: 120 mg,
180 mg, 240 mg, 300 mg, 360 mg
Dilacor XR
Extended-release caps: 120 mg
180 mg, 240 mg (administer on empty stomach)
Tiazac
Extended-release caps: 120 mg
180 mg, 240 mg, 300 mg, 360 mg, 420 mg
verapamil
Adult:
Initial
: 180 mg/day
Usual
: 180-240 mg/day
Max
: 360 mg/day (must be in divided doses)*
Children:
not recommended
*Refer to prescribing information for additional guidelines
Use extended-release formulations for HTN control
Available in multiple formulations (tablets and capsules) and strengths; refer to specific product for additional guidelines
Individualize therapy; titrate at biweekly intervals
Older adults or small stature people may require lower starting dose
Calan SR
Caps: 120 mg, 180 mg, 240 mg
Covera HS (give at bedtime)
Extended-release tabs: 120 mg,
240 mg
Isoptin SR
Sustained-release tabs: 120 mg, 180 mg, 240 mg
Verelan PM (give at bedtime)
Extended-release caps: 100 mg, 200 mg, 300 mg
Direct Renin
Inhibitor
Decreases plasma renin activity (PRA) and inhibits conversion of angiotensinogen to Angiotensin I
General comments
Monitor K+ levels in patients with diabetes
Caution with maximum doses of ACE inhibitors
May be potentiated by statins and ketoconazole
aliskiren hemifumarate
Adult:
Initial:
150 mg/day
Usual:
150-300 mg/day
Max:
300 mg/day
Children:
not recommended
Individualize therapy; adjust dose after 2 weeks
Take on empty stomach
Use with caution in patients with renal impairment
Use with caution in patients with volume and/or salt depletion
Tekturna
Tabs: 150 mg, 300 mg
COMBINATION DRUGS FOR HYPERTENSION
Combination Type*
Fixed-Dose Combination, mg†
Trade Name
ACEIs and CCBs
Amlodipine-benazepril hydrochloride (2.5/10, 5/10, 5/20, 10/20)
Lotrel
Enalapril-felodipine (5/5)
Lexxel
Trandolapril-verapamil (2/180, 1/240, 2/240, 4/240)
Tarka
ACE inhibitors and diuretics
Benazepril-hydrochlorothiazide (5/6.25, 10/12.5, 20/12.5, 20/25)
Lotensin HCT
Captopril-hydrochlorothiazide (25/15, 25/25, 50/15, 50/25)
Capozide
Enalapril-hydrochlorothiazide (5/12.5, 10/25)
Vaseretic
Fosinopril-hydrochlorothiazide (10/12.5, 20/12.5)
Monopril/HCT
Lisinopril-hydrochlorothiazide (10/12.5, 20/12.5, 20/25)
Prinzide, Zestoretic
Moexipril-hydrochlorothiazide (7.5/12.5, 15/25)
Uniretic
Quinapril-hydrochlorothiazide (10/12.5, 20/12.5, 20/25)
Accuretic
ARBs and diuretics
Candesartan-hydrochlorothiazide (16/12.5, 32/12.5)
Atacand HCT
Eprosartan-hydrochlorothiazide (600/12.5, 600/25)
Teveten-HCT
Irbesartan-hydrochlorothiazide (150/12.5, 300/12.5)
Avalide
Losartan-hydrochlorothiazide (50/12.5, 100/25)
Hyzaar
Olmesartan medoxomil-hydrochlorothiazide (20/12.5,40/12.5,40/25)
Benicar HCT
Telmisartan-hydrochlorothiazide (40/12.5, 80/12.5)
Micardis-HCT
Valsartan-hydrochlorothiazide (80/12.5, 160/12.5, 160/25)
Diovan-HCT
BBs and diuretics
Atenolol-chlorthalidone (50/25, 100/25)
Tenoretic
Bisoprolol-hydrochlorothiazide (2.5/6.25, 5/6.25, 10/6.25)
Ziac
Metoprolol-hydrochlorothiazide (50/25, 100/25)
Lopressor HCT
Nadolol-bendroflumethiazide (40/5, 80/5)
Corzide
Propranolol LA-hydrochlorothiazide (40/25, 80/25)
Inderide LA
Timolol-hydrochlorothiazide (10/25)
Timolide
Centrally acting drug and diuretic
Methyldopa-hydrochlorothiazide (250/15, 250/25, 500/30, 500/50)
Aldoril
Reserpine-chlorthalidone (0.125/25, 0.25/50)
Demi-Regroton, Regroton
Reserpine-chlorothiazide (0.125/250, 0.25/500)
Diupres
Reserpine-hydrochlorothiazide (0.125/25, 0.125/50)
Hydropres
Diuretic and diuretic
Amiloride-hydrochlorothiazide (5/50)
Moduretic
Spironolactone-hydrochlorothiazide (25/25, 50/50)
Aldactazide
Triamterene-hydrochlorothiazide (37.5/25, 75/50)
Dyazide, Maxzide
*Drug abbreviations: BB, beta-blocker; ACE inhibitor, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker.
†Some drug combinations are available in multiple fixed doses. Each drug dose is reported in milligrams.
PRESCRIBING STRATEGIES
Thiazide diuretics: chlorthalidone is preferred over HCTZ; stop if eGFR <30
Initial selection of agent depends on underlying disease
Consider ACE inhibitors or ARBs in patients with diabetes, proteinuria, heart failure; avoid during pregnancy
Beta blockers no longer recommended first line for uncomplicated hypertension, but consider in patients with heart failure, first 2-3 years post MI (to prevent remodeling), ischemic heart disease, and migraine headaches
Calcium channel blockers (dihydropyridine; DHP) encouraged in isolated systolic hypertension, asthma, migraines, ischemic disease; consider for stroke prevention
If Stage 2, initiate therapy with two drugs
Selection of antihypertensives in children is similar to adults
CONSULTATION/REFERRAL
Refer to cardiologist: children with significant or severe hypertension
Refer as needed for secondary causes of hypertension
FOLLOW-UP
Inquire about compliance, medication side effects
Monthly, until patient reaches goal; then every 3-6 months as appropriate
EXPECTED COURSE
Only 25% of patients who are treated for hypertension are actually at goal; expect complications if inadequately managed
Most patients require more than one medication to reach goal
POSSIBLE COMPLICATIONS
Stroke
Coronary artery disease
Myocardial infarction
Renal failure
Heart failure
Eclampsia (seizures)
Pulmonary edema
Hypertensive crisis
Hypothyroidism
DESCRIPTION
Clinical state that results from a reduction in circulating free thyroid hormone or from resistance to the action of thyroid hormone.
ETIOLOGY
Majority of cases are due to primary thyroid gland failure resulting from autoimmune destruction (Hashimoto’s thyroiditis)
Ablative therapy for hyperthyroidism
Other causes are congenital, secondary or tertiary, due to pituitary or hypothalamic disease
INCIDENCE
Predominant age is >40 years
Women > Men
Common in adults >65 years
RISK FACTORS
Increasing age
Family history
Postpartum
Pituitary disease
Hypothalamic disease
Autoimmune diseases
History of head or neck irradiation
Treatment of hyperthyroidism
Treatment with lithium or iodine-containing amiodarone
ASSESSMENT FINDINGS
Clinical symptoms range from asymptomatic to myxedema coma
Lethargy, delayed deep tendon reflexes
Mild weight gain, swelling of hands and feet, macroglossia, periorbital edema
Nonpharmacologic Management Essay Examples
Intolerance to cold
Constipation
Menstrual irregularities, decreased libido, infertility
Memory loss, dull facial expression, depression
Muscle cramps, arthralgias, paresthesias
Coarse dry skin, hair loss from body and scalp, brittle nails
Bradycardia, enlarged heart
Reduced systolic BP and increased diastolic BP
Anemia
Hyponatremia
Atrophic or enlarged thyroid
Decreased sweating
Depression
Hoarseness
Pubertal delay
Expect lipid levels to be elevated in patients who have hypothyroidism. Treat lipids if still elevated after TSH <10 mIU/L.
DIFFERENTIAL DIAGNOSIS
Depression
Dementia
Congestive heart failure
Kidney failure
Many others; presenting symptoms are usually vague
DIAGNOSTIC STUDIES
Serum TSH is increased in thymoprivic (rare) and goitrous hypothyroidism (often >20 mIU/mL); normal or undetectable in pituitary or hypothalamic hypothyroidism
T
4
decreased most commonly; occasionally T
3
decreased
Free T
4
index ↓ = T
3
resin uptake x total serum T
4
Subclinical hypothyroidism: slightly elevated TSH and nonspecific symptoms; monitor TSH every 3 months. Treatment increases risk of osteopenia/osteoporosis.
PREVENTION
Periodic monitoring of thyroid hormone levels for patients treated for hyperthyroidism
Identification of risk factors
Newborn thyroid screening at 2-6 days of age
Congenital hypothyroidism: educate parents about etiology, treatment with L-thyroxine to prevent intellectual disabilities, and need for follow-up care.
NONPHARMACOLOGIC MANAGEMENT
Educate parents that children may manifest behavioral problems at the beginning of treatment
Assess growth and development in children
High-fiber diet to prevent constipation
If obese, diet for weight loss/body fat reduction
Educate about need for lifelong adherence to thyroid replacement medication and need to report signs of toxicity, infection, or cardiac symptoms
Annual lipid level assessment
PHARMACOLOGIC MANAGEMENT
L-thyroxine daily; begin at lower dose in older adults or in presence of cardiac disease (consider 25 mcg daily)
In young, healthy patients, 1.6 mcg/kg/day is anticipated replacement dose
Older patients should be started at 25-50 mcg/day and increased to 1.0 mcg/kg/daily as symptoms and side effects are monitored
Adult
: maintenance: 50-200 mcg/day
Infants
: 6-15 mcg/kg/day based on age
Children
: 4-6 mcg/kg/day based on age
>12 years: 2-3 mcg/kg/day incomplete puberty
>12 years: 1.6 mcg/kg/day complete puberty
Goal of treatment in infants and children is rapid achievement of T4 concentration >10 mIU/L or a serum T4 in the upper half of the normal range for age. Rapid replacement results in attainment of normal IQ.
Tabs
: 25 mcg; 50 mcg; 88 mcg; 100 mcg; 112 mcg; 137 mcg; 150 mcg; 175 mcg; 200 mcg; 300 mcg
In older patients, start low and go slow when initiating replacement.
L-thyroxine should be given on an empty stomach. In children, may crush tabs and mix in 5-10 mL of water, breast milk or formula. Do not mix with soy formula or formula containing iron or calcium. Antacids or simethicone can decrease absorption.
PREGNANCY/LACTATION CONSIDERATIONS
Starting at 8 weeks’ gestation, L-thyroxine dose requirements rise by 25-50%
TSH should be assessed every 4 weeks during first half of pregnancy, then less frequently in second half of pregnancy
If TSH reference range is 0.1-2.5 mIU/L, then:
TSH goal during first trimester is 0.1-2.5 mIU/L
TSH goal during second trimester is 0.2-3 mIU/L
TSH goal during third trimester is 0.3-3 mIU/L
Reduce L-thyroxine to prepregnancy dose immediately after delivery
Breastfeeding is not a contraindication to L-thyroxine therapy
CONSULTATION/REFERRAL
Refer to pediatric endocrinologist for congenital hypothyroidism
Refer to ER and endocrinologist for myxedema coma
Refer to endocrinologist for secondary or tertiary hypothyroidism
FOLLOW-UP
Measure TSH after patient has been on L-thyroxine for 6 weeks, and every 6-8 weeks until at goal, then annually unless symptomatic
Examine periodically for signs of thyrotoxicity (e.g., tremor or tachycardia)
Congenital hypothyroidism: periodically monitor T4 and TSH
Acquired hypothyroidism: monitor initial response to medication at 4 to 6 weeks (using TSH and symptoms), then monitor TSH annually
EXPECTED COURSE
Improvement is expected 2 weeks after initiation of medication
Signs and symptoms should resolve in 3 to 6 months
Lifelong therapy is needed
POSSIBLE COMPLICATIONS
Myxedema coma: life-threatening, severe hypothyroidism; may require intravenous L-thyroxine and cardiorespiratory assistance
Thyrotoxicity
Treatment-induced CHF in older adults or patients with coronary artery disease
Bone demineralization due to overtreatment over a long period
Without treatment, congenital hypothyroidism may lead to mental retardation
Growth and development delays
Increased susceptibility to infection
Sexual dysfunction
Infertility
Nail fungus- Tinea Unguium- Tinea Corporis
DESCRIPTION
A group of fungal infections affecting various parts of the body. The specific type is identified by characteristic appearance, etiologic agent and site.
ETIOLOGY
Trichophyton, Microsporum, Epidermophyton
Pityrosporum
species: tinea versicolor causative agent
T. rubrum
and
Trichophyton interdigitale
: tinea unguium, causative agents
INCIDENCE
Common
More prevalent in summer months, warm climates
RISK FACTORS
Tinea capitis
Daycare attendance
Contact with infected items (e.g., combs, brushes, hats)
Poor hygiene
Diabetes
Tinea corporis
Close contact with animals
Warm climates
Obesity
Prolonged use of topical steroids
Immunocompromised state
Tinea cruris
Wearing wet clothing
Excessive sweating
Obesity
Prolonged use of topical steroids
Immunocompromised state
Tinea pedis
Occlusive footwear
Damp footwear
Prolonged use of topical steroids
Immunocompromised state
Poor foot hygiene
Pityriasis versicolor (previously tinea versicolor)
Hot, humid climates
Wearing wet clothing
Prolonged use of topical steroids
Immunocompromised state
ASSESSMENT FINDINGS
Tinea capitis
Round patchy scales on scalp
Occasionally, alopecia develops
Most common in pediatric patients
Tinea corporis
Rash
Pruritus
Well-circumscribed, red, scaly, plaque usually on the trunk
May occur in groups of three or more
Tinea cruris
Pruritus
Well marginated half-moon plaques in the groin and/or upper thighs
May take on eczematous appearance from chronic scratching
Does not affect the scrotum or penis
May appear as vesicles
Rare in pediatric patients before puberty
Tinea pedis
Itching, malodor, and burning of feet
Maceration in toe webs
Scaling or blistering on soles of feet
Bacterial superinfections possible
Runners, older adults, and patients with diabetes more susceptible
Spreads easily to groin area and hands
Tinea versicolor
Well-marginated lesions of varying colors (white, red, brown); hence the name “versicolor”
Rare itching
Common in axilla, shoulders, chest, back (sebum rich areas)
DIFFERENTIAL DIAGNOSIS
Tinea capitis:
alopecia areata, psoriasis, seborrhea, trichotillomania
Tinea corporis:
pityriasis rosea, psoriasis, atopic dermatitis
Tinea cruris:
candidiasis, intertrigo, psoriasis
Tinea pedis:
intertrigo, dyshidrosis, psoriasis
Tinea versicolor:
pityriasis alba, vitiligo
DIAGNOSTIC STUDIES
KOH scraping
Wood’s lamp exam (some tinea will not fluoresce,
most
forms of tinea capitis will not fluoresce)
PREVENTION
Good personal hygiene
Identification and treatment of infected humans and pets (tinea capitis and corporis)
Remove wet clothes as soon as possible
Dry between toes after showering and bathing
Avoid direct contact with surfaces in public bathing facilities
Put socks on before undergarments
Avoid sharing clothing, sports equipment or towels with other people
NONPHARMACOLOGIC MANAGEMENT
Tinea capitis
Good hygiene
Consider monitoring liver function if treated with griseofulvin or another oral antifungal
Teach patients to wear sunscreen and minimize sun exposure because of increased photosensitivity when taking griseofulvin
Treat family members and infected pets
Shaving of head not necessary for treatment
Tinea corporis
Good hygiene
Avoid contact with lesions
Tinea cruris
Keep area as dry as possible
Do not scratch
Tinea pedis
Dry between toes
Trim dead skin
Tinea versicolor
Keep area as dry as possible
PHARMACOLOGIC MANAGEMENT
TINEA INFECTIONS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Tinea Capitis
griseofulvin
Adult:
500 mg daily
Max
: 1 g daily
Children:
30-50 pounds:
125-250 mg/day
>50 pounds:
250-500 mg/day
Usually requires 4-6 weeks treatment
Take with a high-fat meal to improve absorption
Contraindicated in patients with porphyria, hepatic dysfunction
Derived from penicillin; theoretically possible for reaction in penicillin-sensitive patients (no reports)
Avoid exposure to sunlight
May reduce efficacy of oral contraceptives
Grifulvin V
Tabs: 100 mg, 500 mg
Suspension: 125 mg/5 mL
Various generics
Tinea Corporis/Cruris/Pedis
General comments
To prevent relapse, use 1 week after apparent resolution
Keep skin clean, dry; expose to air and light when possible to speed resolution
Many antifungals available, all have specific indications for fungal infections
econazole
Adult
: apply to cover area once daily
Treat for at least 2 weeks; if no improvement, reassess diagnosis
Tinea pedis: TREAT 4 WEEKS
Information on pediatric dosing not available
Do not use vaginally
Spectazole
Cream: 15 g, 30 g, 85 g
Various generics
ketoconazole 2%
Adult
: Apply once daily to cover affected and immediate surrounding area
Nonpharmacologic Management Essay Examples
Treat at least 2 weeks; if no improvement, reassess diagnosis
Tinea pedis: TREAT 6 WEEKS
Safety and efficacy in children have not been established
Do not use vaginally
Various generics
Cream: 15 g, 30 g, 60 g
terbinafine
Adults and children >12 years:
wash affected skin with soap and water and dry completely before applying
Treat for at least 2 weeks; if no improvement, reassess diagnosis
Do not use vaginally
Lamisil
Cream: various sizes
continued
TINEA INFECTIONS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Tinea Versicolor
ketoconazole 2% shampoo
Adult:
apply shampoo to damp skin of affected area and a wide margin surrounding affected area. Leave in place for 5 minutes, rinse off with water. One application should be sufficient
Treatment of infection may not result in immediate normalization of pigment. May take several months
Keep away from eyes and mucous membranes
Nizoral shampoo
4 oz plastic bottle
Selenium sulfide 2.25% shampoo
Adult:
apply to affected areas and lather with a small amount of water. Leave on skin for 10 minutes, then rinse thoroughly. Repeat daily for 7 days
May cause skin irritation, increase in normal hair loss
Keep away from eyes and mucous membranes
Various generics
180 mL bottle
itraconazole
Adult:
200 mg PO BID for 1 week per month; 2 pulses for fingernails, 3 pulses for toenails
Children:
Pulse therapy 5 mg/kg/day for 1 week per month; 2 pulses for fingernails, 3 pulses for toenails
Test hepatic function initially and monthly
Monitor for 3A4 drug interactions that can produce hepatotoxicity
Take with food
Sporanox; Onmel
terbinafine
Adult:
250 mg PO daily for 6 weeks for fingernail, 12-16 wk for toenail
PULSE dosing:
250 mg PO daily for 7-10 days monthly or 7 days q 3 months; skin monthly for 3 months; fingernails monthly for 6 months; toenails monthly for 9 months; topical antifungal also used
Children:
Weight <20 kg:
65.5 mg/day
Weight 20-40 kg:
125 mg/day
Weight >40 kg:
250 mg /day
6 wk for fingernails, 12 wk for toenails
Pulse dosing 7-10 days monthly for 3-6 months for fingernails, 6-9 months for toenails
Test hepatic function initially and 1 month after first month if dosing daily
If pulse dosing, hepatic function initially for baseline
Can interfere with other medications; instruct patient NOT to take with other medications
May stop statin drugs when pulse dosing
Adults: follow up every 3 months
Children: follow up monthly
Children: hepatic function panel and CBC at baseline
Lamisil
fluconazole (second line therapy)
Adult
: 150 mg – 450 mg wkly for 3 months in fingernail and 6 months in toenails
Tinea Versicolor:
150 mg daily for 7 days (monthly) older than 12 years
Children:
3-6 mg/kg wkly for 12-16 wk for fingernail and 18-26 wk for toenail
Liver functions can interfere with other medications;
Do not take along with other medications
GI upset; take with food
Diflucan
griseofulvin (lower efficacy and chance of relapse)
Adult:
500-1000 mg/day for 6-9 months in fingernails and 12-18 months for toenails; take with fatty food
Children:
10 mg/kg per day for ages 1 month and older (maximum 500 mg)
Tinea Capitis
: dose daily for 1 month; recheck child and dose for a second month
GI upset and headache
Gris Peg
continued
TINEA INFECTIONS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
TOPICALS
ciclopirox
Tinea unguium
: topically daily for 48 wk
Contact dermatitis as well as irritation
Nonpharmacologic Management Essay Examples
Penlac
naftifine 1% / 2% cream or gel
Tinea corporis, pedis, cruris:
nightly for 2-4 wk
Naftin
sertaconazole
Tinea pedis, corporis, cruris
: use daily for 4 wk
Ertaczo 2% cream
luliconazole
Tinea corporis and cruris:
use daily for 1 week
Tinea pedis:
daily for 2 wk
Luzu 1% cream
efinaconazole
Onychomycosis
: apply to nails nightly for 48 – 52 wk
Jublia 10% cream
tavaborole
Onychomycosis
: apply to nails nightly for 48 – 52 wk
Kerydin
PREGNANCY/LACTATION CONSIDERATIONS
Oral antifungals contraindicated in pregnancy
CONSULTATION/REFERRAL
Dermatologist for cases that do not respond to treatment
FOLLOW-UP
Monthly
EXPECTED COURSE
Tinea capitis
Usually resolves after 2 months of daily treatment with griseofulvin and ketoconazole shampoo 2%
All tinea has a high reinfection rate, especially in:
Patients with diabetes
Immunocompromised patients
Patients living in moist climates
Treatment with pulse dosing of oral medication plus a topical will treat the infection effectively
Secondary infections are possible; treat accordingly
COMPLICATIONS
Tinea capitis
Alopecia or scarring can occur if left untreated
Tinea pedis and tinea unguium
Can spread to the groin and hands
Obesity
Complex chronic disease of excess and dysfunctional adipose tissue that contributes to systemic disease. A 5-10% weight loss may improve obesity-related complications.
ETIOLOGY
Multifactorial: physiologic, genetic, environmental, psychological, cultural
Physiologic: imbalance between food intake and energy expenditure; dysregulation of hunger and satiety hormones (e.g., ghrelin, leptin, GLP-1, PPY, CCK)
Genetic: several single genes cause rare forms of obesity; dozens of genes influence common forms of obesity
Environmental: decreased activity, energy-dense foods
Obesogenic medications (e.g., antihistamines, steroids, beta blockers, secretagogues, SSRIs) may cause or contribute to weight gain
Weight regain has basis in physiologic counterresponse to weight loss: decreased energy expenditure, increased appetite resulting altered physiology
INCIDENCE
Increasing in the U.S.
Prevalence of obesity in the U.S.
35% of adults
Greater incidence in women (especially black and Hispanic women)
17% of children
Greatest in adolescents
RISK FACTORS
Parental obesity
Decreased socioeconomic status
Intake of calorically dense, nutrient-deficient highly palatable foods
Sedentary lifestyle/inactivity
Increased screen use, especially among children
ASSESSMENT FINDINGS
Staging of disease is based on complication-specific criteria per AACE Guideline 2016
Stage 0: BMI 25-29.9 (overweight) and ≥30 (obesity) with no complications
Stage 1: BMI ≥25 with mild to moderate complications
Stage 2: BMI ≥25 with mild to moderate complications or requiring aggressive weight loss treatment
BMI ≥25 with at least one severe complication
≥23 for some ethnicities
Waist circumference (added cardiometabolic risk assessment)
Women >35 inches
Men >40 inches
Review weight history and weight loss attempts, current eating strategies, current activity level, complete past medical and family history, and review of systems with an emphasis on obesity-related comorbidities/complications
DIAGNOSTIC STUDIES
None needed for diagnosis, but can assist with identification of obesity-related comorbidities and complications, development of treatment plan, and medication management
Thyroid function studies
Lipid profile
Fasting glucose, HgbA1C
Liver function tests
CBC
Chemistry panel
Lipase, amylase
EKG
Screening questionnaire for depression, anxiety and/or binge eating
Screening questionnaire for sleep apnea
PREVENTION
Well-balanced diet following USDA MyPlate: www.choosemyplate.gov
Reduce sedentary behavior, increase regular physical activity: goal 150 minutes/week, including resistance exercise
Sufficient sleep: inadequate sleep causes ghrelin to increase and leptin to decrease, producing greater hunger than when rested
NONPHARMACOLOGIC MANAGEMENT
Counseling about lifelong strategies
Behavior interventions
Realistic goal setting
Education
Health outcomes
Focus on progress
Determine caloric requirement for body weight and institute 500-750 kcal/day dietary deficit during weight loss
Track food and activity electronically or on paper
Increase activity level to at least 150 minutes/week
Regular follow-up for health outcomes, weight loss tracking, motivation, and improvement in obesity-related complications
Healthy Home Ideas
Plan, purchase and prepare healthy foods
Use shopping lists
Stock pantry with healthy foods
Keep fruits and vegetables accessible
Avoid bringing unhealthy foods into home
Try to eat family meals 5 times/week
Decrease screen time
Enlist a weight loss and/or exercise partner
PHARMACOLOGIC MANAGEMENT
Short-term medication
Phentermine
Sympathomimetic/increases satiety
Adult:
15-37.5 mg PO Q AM
13 weeks only as per label
Not safe during pregnancy
Adverse effects:
palpitations, tachycardia, increased BP, overstimulation, tremor, dizziness, insomnia, dysphoria, HA, dry mouth, diarrhea, constipation
Contraindications:
cardiovascular disease, uncontrolled hypertension, hyperthyroidism, glaucoma, drug abuse history, MAO inhibitor use in past 14 days
Note:
Endocrine Society provides guidance on reasonable long-term use of phentermine 7.5-15 mg PO once daily with several qualifiers
State professional board regulations and laws must be followed; if long-term use is not precluded, other issues to consider include informing patient about off-label use, contraindications, and need for close follow-up
Chronic medications
Orlistat (Xenical)
Blocks the digestion and absorption of fat in the stomach and intestines
Adult:
Prescription: 120 mg PO TID
OTC: 60 mg PO daily
Adverse effects:
oily and frequent bowel movements; bowel urgency; fecal incontinence; flatus; increased risk for cholelithiasis and urinary oxalate (rare); postmarketing reports of liver injury; may decrease absorption of fat-soluble vitamins; approved for long-term use
Contraindications:
chronic malabsorption syndromes, pregnancy, bulimia, organ transplant
Lorcaserin (Belviq)
Exact mechanism unknown; activates 5-HT2C receptors (selective serotonin agonist), thus promoting satiety
Adult:
10 mg PO BID
20 mg PO once daily (XR formulation)
DEA Schedule IV
Not safe during pregnancy
REMS program related to pregnancy testing before and during therapy
Drug interactions:
safety unknown, SSRIs, SNRIs, MAO inhibitors, triptans, bupropion, dextromethorphan, St. John’s wort
Adverse effects:
headache, dizziness, fatigue, nausea/vomiting, dry mouth, constipation, cough, bradycardia, hyperprolactinemia, hypoglycemia (patients with diabetes), musculoskeletal pain, depression, valvular heart disease, serotonin syndrome, neuroleptic malignant syndrome
Contraindications:
CrCl <30, CHF, valvular heart disease, pregnancy, depression, diabetes, bradycardia
Miscellaneous:
D/C if weight loss <5% after 12 weeks, renal dosing CrCl 30-50 (caution advised)
Phentermine-topiramate (Qsymia)
Sympathomimetic and neurostabilizer; promotes satiety
Adult:
3.75 mg/23 mg PO starting dose; titrate to 7.5 mg/46 mg, 11.25 mg/69 mg; maximum dose 15 mg/92 mg
DEA Schedule IV
Not safe during pregnancy
Monitoring:
depression, hypokalemia, CV evaluation at baseline; consider ECHO
Drug interactions:
may potentiate CNS depressants and hypokalemia of non-potassium-sparing diuretics
Adverse effects:
paresthesias, constipation, dysgeusia, insomnia, dizziness, HA, nausea, back pain, fatigue, diarrhea, blurred vision, anxiety, alopecia, hypesthesia, irritability, attention disturbance, GERD, tachycardia, metabolic acidosis, nephrolithiasis, osteoporosis, hyperthermia, pulmonary HTN, Steven-Johnson syndrome
Contraindications:
MAO inhibitors within 14 days, pregnancy, breastfeeding, CV disease, hyperthyroidism, glaucoma, history of drug abuse
Miscellaneous:
D/C if weight loss <5% after 12 weeks on maximum dose (taper off if discontinuing at maximum dose)
Naltrexone-bupropion (Contrave)
Opioid antagonist and antidepressant; promotes satiety and suppresses cravings
Adult:
8 mg/90 mg, 1 tab PO q AM; titrating to max of 2 tabs PO q AM and 1 tab PO q PM
Not safe during pregnancy
Boxed Warning:
suicidal thoughts and behaviors, neuropsychiatric reactions
Monitoring:
Cr at baseline, BP, HR, depression/suicide risk
Drug interactions:
opioid analgesics, interaction with CYP2D6 metabolized medications; beware drugs that lower seizure threshold
Adverse effects:
nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth and diarrhea
Nonpharmacologic Management Essay Examples
Contraindications:
within 14 days of MAO inhibitor dose, uncontrolled hypertension, seizure disorders, eating disorders, chronic opioid use, pregnancy
Caution:
should not be taken with a high-fat meal because of resulting significant increase in bupropion and systemic exposure to naltrexone; alcohol intolerance reported so alcohol intake should be limited/avoided
Miscellaneous:
D/C if weight loss <5% after 12 weeks at maximum dose (taper off if discontinuing at maximum dose)
Liraglutide (Saxenda)
Glucagon-like peptide-1 receptor agonist; promotes satiety
Adult:
Initiate at 0.6 mg/day SQ for 1 week; increase in weekly intervals until 3-mg dose is reached
Not safe during pregnancy
REMS program related to potential risk for medullary thyroid carcinoma and risk for acute pancreatitis
Drug interactions:
delays gastric emptying so may impact concurrent oral medications
Adverse effects:
nausea, hypoglycemia, diarrhea, constipation, vomiting, headache, decreased appetite, dyspepsia, fatigue, dizziness, abdominal pain, increased lipase
Contraindications:
Personal or family history of medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2 (MENS 2), pregnancy, gastroparesis
Miscellaneous:
D/C if weight loss <4% after 12 weeks at maximum dose (taper off if discontinuing max dose); if patient misses medication or it is interrupted for more than 3 days, restart at 0.6 mg and taper back to max dose
SURGICAL MANAGEMENT
Bariatric procedures may be options for patients with BMI >35 with significant comorbidities, or BMI >40
Impact is on metabolic and hormonal role in obesity as well as restrictive food intake
Common surgical procedures
Adjustable gastric banding
Sleeve gastrectomy
Roux-en-Y gastric bypass
PREGNANCY/LACTATION CONSIDERATIONS
Well-balanced diet should be maintained in pregnancy
Restrictive caloric intake is not recommended in pregnancy
Common time of onset or worsening of obesity
Anti-obesity medications not recommended in pregnancy
CONSULTATION/REFERRAL
Obesity specialists
Bariatric surgery center
Dietitian specializing in obesity care (nutritional counseling)
Personal trainer (specializing in differently abled exercises and accommodations)
Psychotherapist for compulsive eating disorders
Support programs (e.g., Weight Watchers, Taking Off Pounds Sensibly, Overeaters Anonymous)
FOLLOW-UP
Long-term, frequent follow-up as for most chronic conditions. This disease has a relapsing nature based on physiology, so patients require close monitoring
Surgical patients need long-term follow-up with surgeon and primary care to monitor weight loss and nutrition
Annual labs as indicated by medication administration, comorbidities, and annual needs
EXPECTED COURSE
Chronic condition that is rarely cured but can be controlled
Long-term maintenance of weight loss difficult
Dependent on sustained patient motivation and circumstances
OBESITY-RELATED COMPLICATIONS
Prediabetes
Metabolic syndrome
Type 2 diabetes mellitus
Dyslipidemia
Cancer (multiple types)
Hypertension
Cardiovascular disease
Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis
Polycystic ovary syndrome, infertility (women)
Male hypogonadism
Obstructive sleep apnea
Respiratory disease (including asthma)
Osteoarthritis
Urinary stress incontinence
Gastroesophageal reflux disease (GERD)
Psychiatric disorders (depression, anxiety, binge eating disorder, stigmatization)
POSSIBLE COMPLICATIONS
Increased mortality
Cholelithiasis, especially with rapid weight loss
Thromboembolism
Decreased mobility
Decreased exercise tolerance
Osteoarthritis
DESCRIPTION
Progressive destruction of the articular cartilage and subchondral bone accompanied by osteophyte formation and sclerosis. Osteoarthritis (OA) is confined to the joints. Constitutional symptoms are absent.
Osteoarthritis is the most common joint disease in the United States.
ETIOLOGY
Primary OA can be a localized or generalized disease with no known cause
Secondary OA is associated with trauma, infection, or metabolic disorders
INCIDENCE
Women > Men especially after age 50
Predominantly > age 40
Common: affects more than 30 million U.S. adults
RISK FACTORS
Obesity
Age
Trauma
Prolonged use or overuse of joints related to occupation or activity
Family history
History of developmental dysplasia of the hip or slipped femoral epiphysis
Hemophilia
Paget’s disease
ASSESSMENT FINDINGS
Joint pain, usually asymmetrical, develops insidiously and accompanies or follows physical activity
Morning stiffness lasting < 1 hour. Stiffness resumes towards the day’s end or after periods of activity
Joints are cool with possible crepitus and limited range of motion
Overgrowth of osteophytes results in bony enlargement, especially bunions (MTP joint), Heberden’s nodes (DIP joints), and Bouchard’s nodes (PIP joints)
Commonly involved joints:
Distal interphalangeal (DIP)
Proximal interphalangeal (PIP)
First carpometacarpal (CMC)
First metatarsophalangeal (MTP)
Hips, knees, cervical and lumbar spine
DIFFERENTIAL DIAGNOSIS
Gout, pseudogout
Infective arthritis
Inflammatory arthritis: rheumatoid, psoriatic, ankylosing spondylitis, juvenile idiopathic, systemic lupus, erythematosus (SLE)
Joint injury
Soft tissue injury
Peripheral vascular disease
Giant cell arteritis
Bursitis
Tendinitis
Osteopenia, osteoarthritis
Neuropathy
DIAGNOSTIC STUDIES
No diagnostic laboratory tests are available for osteoarthritis; diagnosis is based on history, physical, and X-ray findings
X-rays: osteophytes, joint space narrowing, and subchondral sclerosis
Inflammation markers: negative
Erythrocyte sedimentation rate (ESR)
Rheumatoid factor (RF)
Antinuclear antibodies (ANA)
In younger patients, consider iron saturation or ferritin levels to rule out hemochromatosis
PREVENTION
Weight control
Management of underlying causes of secondary disease
NONPHARMACOLOGIC MANAGEMENT
Emphasis must be given to nonpharmacologic management to delay or minimize use of medications that have adverse effects
Weight loss, if indicated: loss of 10% of body weight can lead to improvement in reported symptoms
Education: OA is a chronic disorder requiring patient participation in muscle strengthening to provide joint support
Patient education: focused on discussion of the etiology of OA, risk factors and expected prognosis to optimize management
Organized program of supervised exercise
Rest
Knee or elbow braces to stabilize joints during exercise
Orthotic shoes, cane, collar, sling, corset, wedged insoles
Apply heat and/or cold to affected joints
Wedge osteotomy, arthroplasty
Acupuncture may be beneficial
Topical creams or liniments for counterirritant effect
Tai chi, acupuncture and yoga are alternative therapies that may be considered for management of OA symptoms
PHARMACOLOGIC MANAGEMENT
Pharmacologic therapy should only be used when symptoms are present; routine use has not been shown to modify the disease
Medication therapy is usually needed long term; use is associated with many possible side effects
Careful consideration should be given to existing comorbid conditions when selecting therapy (e.g., diabetes, poorly controlled hypertension, cardiovascular disease, peptic ulcer disease, chronic kidney disease, advanced age)
The use of acetaminophen as a first-line agent for OA is no longer recommended due to safety concerns and lack of efficacy for musculoskeletal pain
Short-acting NSAIDs are associated with fewer side effects than long-acting forms
Concomitant use of misoprostol (Cytotec) to prevent gastric ulcer development caused by NSAIDs
Consider COX-2 inhibitors for GI protection (risk of GI bleeds decreased but still present)
Topical NSAIDs may be an excellent alternative for older adults and patients who tolerate NSAIDs poorly
Duloxetine (Cymbalta) can be used for patients with OA in multiple joints and those with comorbid conditions in which NSAIDs are contraindicated
Topical capsaicin can be used if one or a few joints are involved
Tramadol (Ultram) is recommended by the American College of Rheumatology as add-on therapy for patients with OA involving the hands, knees and/or hips who have not responded to other treatment modalities. Narcotic analgesics indicated only briefly for severe exacerbation
Intra-articular corticosteroid injections, limited to four times a year, are recommended for knee, shoulder and hip
Hyaluronic acid use for knee arthritis is also an accepted modality
The risk for vascular events such as myocardial infarction or stroke is increased with use of NSAIDs.
OSTEOARTHRITIS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
NSAIDs
Inhibit cyclooxygenase (COX-1 and
COX-2) activity and prostaglandin
synthesis
General comments:
May cause serious gastrointestinal events including bleeding, ulceration,
perforation; may occur without warning
Use with caution in patients who
have known or suspected cardiovascular risk factors
May lead to or worsen hypertension
May lead to fluid retention or worsening heart failure
Avoid concomitant use with salicylates
Use with caution in patients who
have asthma
Avoid use in patients who have renal disease
Patients must receive accompanying medication guide when product dispensed
Consider comorbid conditions: will need close monitoring if used
celecoxib
Adult:
200 mg PO once daily
OR
100 mg PO BID
Mostly COX-2 selective
Avoid in patients who have sulfonamide hypersensitivity
Reduce dose by 50% if hepatic impairment
Celebrex
Caps: 50 mg, 100 mg, 200 mg
diclofenac
Adult:
total daily dose of 100-150 mg PO in two or three divided doses
Avoid in late pregnancy due to inhibition of uterine contractions
Voltaren
Tabs: 25 mg, 50 mg, 75 mg
diclofenac topical
Adult:
Gel:
apply 4 g QID;
Max: 16 g/joint/day up to 32 g/day total
Solution:
apply 2 sprays 2% solution per knee BID
OR
Apply 40 gtt 1.5% solution per knee QID
Avoid if history of asthma or aspirin allergy
Creatinine at baseline
CBC and chemistries if used long term
Do not use prior to or after heart bypass surgery
Voltaren Gel
Gel: 1%
Pennsaid
Solution: 1.5%, 2%
etodolac
Adult:
Initial:
titrate for effect
300 mg PO BID or TID
400 mg PO BID
500 mg PO TID
Usual:
300 mg PO BID
Max:
1000 mg/day PO
Avoid late in pregnancy due to premature closure of the ductus arteriosus
May diminish effect of ACE inhibitors
Lodine
Caps: 200 mg, 300 mg
Tabs: 400 mg, 500 mg
ibuprofen
Adult:
Initial:
titrate for effect
400 mg TID or QID
600 mg TID or QID
800 mg TID
Usual:
2,400-3,200 mg daily PO
Max:
3200 mg/day PO
Avoid late in pregnancy due to premature closure of the ductus arteriosus
May diminish effect of ACE inhibitors
Available by prescription or as various OTC products
Nonpharmacologic Management Essay Examples
Motrin
Tabs: 400 mg, 600 mg, 800 mg
indomethacin
Adult:
Initial:
25 mg BID-TID; may increase by 25-50 mg daily
Usual:
25-50 mg TID
Max:
200 mg daily
Avoid in recent MI and severe heart failure
Caution in hepatic or renal impairment
Indocin
ketoprofen
Immediate Release
Adult:
Initial:
50 mg PO QID
OR
75 mg PO TID
Max
: 300 mg PO daily
Sustained Release
Adult:
Initial
: 200 mg PO daily
Max
: 200 mg PO daily
Avoid use late in pregnancy
Do not mix dose forms
Reduce dose in patients > 75 years
Orudis
Caps: 50 mg, 75 mg
Extended-release caps: 200 mg
meloxicam
Adult:
Initial:
7.5 mg PO daily
Usual:
7.5 mg PO daily
Max:
15 mg PO daily
May be taken without regard to meals
Mobic
Tabs: 7.5 mg, 15 mg
Suspension: 7.5 mg/5 mL
continued
OSTEOARTHRITIS PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
nabumetone
Adult:
Initial:
1 g daily
Max:
2 g daily in 1-2 divided doses.
Must be renal dosed
May affect ACE inhibitors
Relafen
Tabs: 500 mg, 750 mg
naproxen
Adult:
use lowest effective dose and shortest effective treatment duration
Initial:
250-500 mg PO every 12 hr
Max:
1500 mg/day PO x 6 months
Hemoglobin at baseline
Long-term use: may increase risk of heart attack or stroke
May cause GI bleeding and ulceration
Not recommended for children <2 years
Naprosyn
sulindac
Adult:
Initial:
200 mg daily
Max:
400 mg daily, usually given in divided doses
May affect ACE inhibitors
Contraindicated in aspirin allergy
Coronary artery bypass graft surgery
Clinoril
Tabs: 200 mg
CONSULTATION/REFERRAL
Orthopedist
Physical therapist
Supervised exercise program
Nutritionist for weight loss
Self-management classes
Tai Chi classes
Acupuncturist
FOLLOW-UP
Regularly scheduled return visits for evaluation, support and education
NSAID therapy requirements (includes COX-2): periodic CBC, renal function studies, and stool for occult blood
EXPECTED COURSE
Usually progressive with more pain at rest, joint effusions, and bony enlargement
Goals of therapy are to minimize pain and optimize functioning while targeting modifiable risk factors; achievement of a plan of care that is tailored to the patient’s needs and goals
POSSIBLE COMPLICATIONS
Adverse effects from NSAIDs
Adverse effects from corticosteroids
Depression associated with chronic illness
Pain in hip, shoulder and knee
DESCRIPTION
Pain in orthopedic conditions is mostly centered in and around the joints. Pain sources include:
The bones of the joint
Articulating surfaces of the joints
Soft tissue within the joints
Ligaments, cartilage
Supportive soft tissue structures external to the joint
Ligaments, tendons, muscles, fascia
Nerves
Resulting from impinged or damaged nerves
ETIOLOGY
Inflammation
Synovial neovascularization
Lymphocytes, plasma cells, and macrophages infiltrate the synovial capsule with release of pro-inflammatory cytokines
Hyperplasia of the cells of the synovial lining
Newer data indicates possible involvement of proinflammatory cytokines, such as adipokines, in the development of OA
Effusion
Increased production of synovial fluid with or without blood within a joint
Increased synovial fluid and/or blood within the capsule of a bursa near a joint, such as the prepatellar bursa of the knee
Direct damage
Trauma to the joint
PREVALENCE
Osteoarthritis (OA) is a common presentation of orthopedic pain. Pain in OA is nearly universal. However, the severity of pain is variable and does not always correspond with the severity of joint damage
More than 30 million adults in the U.S. have OA
13.9% of adults 25 and older have OA in at least one joint
33.6% of adults 65 and older are affected by OA
RISK FACTORS
Joint overuse or injury
Age: OA is more common in people older than 50, and the risk increases with age
Sex: women are more likely to develop OA than men, especially after age 50 and especially knee arthritis
Obesity: extra weight puts more stress on joints, particularly weight-bearing joints like the hips and knees
Cofactor in the development of OA in non-weightbearing joints (e.g., fingers, wrists)
Increased presence of proinflammatory cytokines
Increased weight load on knee, worsened by varus malalignment
A 10% initial decrease in body weight may result in 28% improvement in pain in the average obese patient
Genetics: having a family member with OA increases the risk of developing OA. Having hand OA is associated with having knee OA
Race: differences among races in terms of access to OA care, management, and outcomes. Some Asian groups may have a lower risk for developing OA
ASSESSMENT FINDINGS
Adult
Osteoarthritis
Limited joint movement
Pain with movement
Stiffness that worsens with use
Joint crepitus with movement
Joint deformity (related to development of osteophytes and loss of articular cartilage)
Swelling is rare
Soft tissue injuries
Pain
Swelling
Deformity
Stiffness, decreased joint mobility
Inflammatory arthropathy
Swelling with increased warmth (synovitis)
Pain with movement and at rest
Stiffness that lasts an hour or more after resting
Deformity associated with joint swelling and possible joint erosion (erosion increases as disease progresses)
Infections
Joint swelling with erythema and increased warmth
Pain that increases with movement of the joint
Potential fever
Possible associated cellulitis
Patient holds joint in position of comfort (for example: flexion of the knee or hip)
Children
:
Symptoms are similar to those noted above
Children with septic arthritis tend to appear toxic, with irritability, high fever, and severe pain associated with joint movement
Specific orthopedic diseases in children have defined symptoms beyond the scope of this review
DIFFERENTIAL DIAGNOSIS
Children:
osteoarthritis does not occur in children. Common differentials for joint pain in children include:
Orthopedic
Slipped capital femoral epiphysis
Legg-Calvé-Perthes disease
Overuse syndromes
Trauma
Infection:
Septic arthritis, pyogenic arthritis
Gram-positive organisms
Gonococcal arthritis
Toxic/transient synovitis
Osteomyelitis adjacent to joint
Reactive arthritis
Lyme arthritis, Lyme disease (
Borrelia burgdorferi
)
Acute rheumatic fever
Autoimmune:
Juvenile idiopathic arthritis
Systemic lupus erythematosus
Hematological:
Hemarthrosis
Neoplastic:
Osteoid osteoma adjacent to joint
Osteosarcoma adjacent to joint
Ewing’s sarcoma adjacent to joint
Leukemia
Adults:
Osteoarthritis
Inflammatory (autoimmune) arthropathies
Examples: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis
Infection
Joint infection (septic arthritis, pyogenic arthritis)
Bacterial: gonococcal or nongonococcal
Viral
Fungal
Lyme disease (
Borrelia burgdorferi
)
Bone infection
Osteomyelitis
Osteitis
Trauma and over use syndromes
Fractures, sprained ligaments, tendinitis, fasciitis
DIAGNOSTIC STUDIES
Radiographs
MRI
CT
Ultrasound
Laboratory studies:
No laboratory studies for osteoarthritis
To evaluate for autoimmune/inflammatory differentials:
CRP
ESR
Rheumatologic studies
PREVENTION
Maintain a healthy weight
Avoid inactivity
Regular participation in low-impact exercises
Aquatics
Aerobic (cardiovascular) exercise weekly in at least 10-minute increments, with sessions distributed throughout the week
150 minutes of moderate intensity OR
75 minutes of vigorous intensity
To increase health benefits, increase exercise to 300 minutes weekly of vigorous-intensity aerobic exercise
Moderate to high-intensity muscle strengthening exercises 2 or more days each week; exercises should involve all muscle groups
Patients with chronic health issues should be under the care of a health professional to help guide safe levels of exercise
For more specific information and exercise intensity examples see Office of Disease Prevention and Health Promotion guidance at: https://health.gov/paguidelines/guidelines/chapter4.aspx
Treat joint injuries promptly
NONPHARMACOLOGIC MANAGEMENT
Physical therapy
Occupational therapy
Exercise
Tai Chi
Yoga
Exercise regimens (see
Prevention
)
Chiropractic
Massage
RICE protocol (rest, ice, compression, elevation)
MEAT Protocol (movement, exercise, analgesia, treatment)
Heat applied to joint
PHARMACOLOGIC MANAGEMENT
Joint injection of steroids with/without analgesics
Non-narcotic pain relievers and NSAIDs
For all medications, use the lowest effective dose for the shortest period of time needed.
ORTHOPEDIC PAIN PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
Non-narcotic Analgesic
acetaminophen
Adults:
650-1000 mg every 4-8 hr; max 4 g/day
Children:
<6 years:
use pediatric dosage forms
6-11 years:
325 mg q 4-6 hr; max 1.625 g/day
Max daily dose:
3,000 mg (4,000 mg/day per some sources)
Nonpharmacologic Management Essay Examples
Infants:
Dosage forms: be sure the parent/guardian understands which strength of liquid formulation to use
Usual pain dose:
10-15 mg/kg PO q 4-6 hr prn;
Max daily dose:
75 mg/kg/day up to 1 g/4 hr and 4 g/day from all sources
Dosage chart:
https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Acetaminophen-for-Fever-and-Pain.aspx
Neonates:
Max:
60 mg/kg/day
Side effects:
headache, decreased appetite
Allergy:
rash, itching, angioedema, severe dizziness, or shortness of breath
Rare but severe:
liver toxicity, Stevens-Johnson syndrome, thrombocytopenia, lymphopenia
Caution:
hepatic impairment, chronic alcohol use
Tylenol
Tabs: 325 mg, 500 mg, 650 mg adult liquid 500 mg/15 mL (7% alcohol)
aspirin
Adults:
Dosage (pain): 650 mg q 4 hr
Max adult dose:
4,000 mg/24 hr
Children:
do not give to children <12 yr
Side effects:
bruising, GI bleeding, dizziness, nausea, vomiting, heartburn, tinnitus
Allergic reactions:
shortness of breath, skin rash, angioedema
Reye’s syndrome association:
do not give to children or adolescents with influenza or varicella zoster virus
Caution:
patients drinking ≥3 alcoholic drinks/day
Bayer aspirin, Bayer Children’s Aspirin, Ecotrin (and many others)
Pill /capsule strengths: 800 mg, 500 mg, 325 mg, 81 mg, 975 mg, 650 mg, 125 mg, 600 mg, 60 mg, 300 mg, 162 mg, 1 g, 227.5 mg, 1200 mg, 162.5 mg; buffered/enteric-coated 500 mg, 325 mg, 81 mg
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
General comments:
Hypersensitivity to drug/class/components
Aspirin-exacerbated respiratory disease (AERD), ASA or NSAID-induced asthma or urticaria
Risk of heart attack or stroke: longer use or higher dose increases risk
Risk of ulceration, bleeding, perforation. (patients may not exhibit GI symptoms)
Increases heart failure risk
Avoid in moderate to severe renal insufficiency (CrCl <30 mL/min)
Avoid with low-dose aspirin, antiplatelet use or concomitant anticoagulant use
Avoid if peptic ulcer, age >65, debilitated or moderate hepatic impairment
ibuprofen
Adults:
1200-3200 mg/day divided into 3-4 doses.
Reduced dose in older adults; begin with a low dose
Children:
30-40 mg/kg/day, divided into 3-4 doses.
Infants:
younger than 6 months: use with caution; base on weight as above. Safety has not been established
Side effects:
tinnitus, hearing loss, nervousness
Contraindicated:
Within 14 days of CABG
ASA or NSAID-induced asthma or urticaria pregnancy starting at 30 weeks’ gestation
Perioperative use in CABG surgery
Caution
Women trying to conceive
Asthma
Fluid retention
Dehydration
Smoker
Alcohol use
May interfere with effectiveness of loop and thiazide diuretics
Advil, Motrin/Medipren, Nuprin
Adults:
OTC tabs: 200 mg
OTC suspension: 100 mg/5 mL
Rx tabs: 400 mg, 600 mg, 800 mg
Children/Infants:
Infant drops 50 mg/1.25 mL, Liquid 100 mg/5 mL
Liquid 100 mg/1 tsp,
Chewable 50-mg tablets,
Junior-strength 100-mg tablets
Caution parents to use correct strength
naproxen
Adults:
250 mg BID but may be taken q 6-8 hr (1000 mg/day max)
OR
375 mg BID
OR
500 mg BID
Max:
1250 on first day; 1000 mg thereafter
Reduced dose in older adults; begin with a low dose
Children:
13-24 kg: 62.5 mg BID
25-37 kg: 125 mg BID
>38 kg: 187.5 mg BID
Side effects:
nausea, constipation, ALT/AST elevation, tinnitus, dyspnea
Contraindicated:
Within 14 days of CABG
ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation
Perioperative use in CABG surgery
Caution:
Women trying to conceive
Asthma
Fluid retention
Dehydration
Smoker
Alcohol use
May interfere with the effectiveness of loop and thiazide diuretics
Aleve, Anaprox, Naprelan, Naprosyn
Dose depends on brand, caution patients to carefully read the label
celecoxib
Adults:
200 mg PO once daily
Children:
indicated for idiopathic RA
2 years and older with weight 10-25 kg:
50 mg PO q 12 hr
2 years and older with weight >25 kg:
100 mg PO q 12 hr
Safety not established in <2 years
Side effects:
diarrhea, heartburn, nausea, abdominal pain, back pain, dizziness, headache, stuffy nose, sore throat
Contraindicated:
ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation
Perioperative use in CABG surgery
Hypersensitivity to sulfonamides
Caution:
Asthma
Allergy to aspirin
Poor CYP2C9 metabolizers (consider decreasing starting dose by 50% or use alternative therapy)
Passes into breast milk
Celebrex
Caps: 50 mg, 100 mg, 200 mg, 400 mg
diclofenac
Adults:
50 mg BID-TID, or 75 mg BID PO
Children
: safety and efficacy in children have not been established; use in children is not recommended
Side effects:
constipation, diarrhea, loss of appetite, heartburn, bloating, increased bleeding time, edema, headache, rash/itchy skin, tinnitus
Contraindicated:
ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation
Perioperative use in CABG surgery
Caution:
Fluid retention
May exacerbate anemia
Not recommended for use during pregnancy or when breastfeeding
Cambia, Cataflam, Voltaren, Voltaren-XR, Zipsor, Zorvolex
Topical gel: Solaraze 3% Gel, Voltaren 1% Gel, Inflamma-K kit (diclofenac 1.5% topical solution with Salonpas patch), Flector (180 mg diclofenac epolamine and 13 mg diclofenac epolamine per gram of adhesive)
diflunisal
Adults:
500 mg PO q 12 hr; Start: 1000 mg PO x 1;
Max:
1500 mg/day
Do not cut/crush/chew
CrCl <50: decrease dose 50%; HD/PD: no supplement
Children:
safety and efficacy in children not established; use in children not recommended
Side effects:
diarrhea, headache, constipation, flatulence, dizziness, fatigue
Contraindicated:
ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation
Perioperative use in CABG surgery
Caution:
Fluid retention
Renal impairment
Hepatic impairment
Dolobid
Tabs: 250 mg, 500 mg
etodolac
Adults: 200-500 mg
Max dose
1000 mg/24 hr
Children:
give with food if GI upset occurs
≥
6 years, 20-30 kg
400 mg PO once daily
≥
6 years, 31-45 kg
600 mg PO once daily
≥
6 yearsr, 46-60 kg
800 mg PO once daily
≥
6 yr, >60 kg
1000 mg PO once daily
Side effects:
somnolence, tinnitus, ecchymosis, abnormal stools, fatigue, arthralgia, photosensitivity, delayed ovulation, constipation, headache, dizziness, ALT/AST elevation
Contraindicated:
ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation
Perioperative use in CABG surgery
Caution:
Women trying to conceive
Asthma
Fluid retention
Dehydration
Smoker
Alcohol use
Renal papillary necrosis
May interfere with the effectiveness of loop and thiazide diuretics
Lodine
Caps: 200 mg, 300 mg
Tabs: 400 mg, 500 mg
Extended-release tabs: 400 mg, 500 mg 600 mg
ketoprofen
Adults:
give with food if GI upset occurs
50 mg or 75 mg PO TID
200 mg; ER PO once daily
Max:
300 mg/day; 200 mg/day ER
Renal dosing:
Mild impairment: max 150 mg/day;
CrCl <25: max 100 mg/day
Hepatic dosing:
hepatic impairment: max 100 mg/day
Children:
safety and efficacy in children not established; use in children not recommended
Side effects:
constipation, headache, GI upset, tinnitus, photosensitivity
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
Pregnancy starting at 30 weeks’ gestation
CABG surgery perioperative use
Caution:
Women trying to conceive
Asthma
Dehydration
Smoker
Alcohol use
Caps: 50 mg, 75 mg
Extended-release caps: 200 mg
ketorolac
Adults:
Parenteral single-dose treatment: 60 mg IM x 1
Alternative
:
30 mg IV x 1
≥
65 years or if weight <50 kg:
give 30 mg IM x 1 or 15 mg IV x 1
Parenteral multiple dose treatment:
30 mg IM/IV q 6 hr;
Max:
120 mg/day
≥
65 years or if weight <50 kg:
give 15 mg IM/IV q 6 hr up to 60 mg/day
Combined duration of PO/IM/IV not to exceed 5 days
PO route:
10 mg PO q 4-6 hr;
Start:
20 mg PO x 1
Max:
40 mg/day
Patients who received parenteral treatment:
start 10 mg PO x 1
≥65 years or if weight <50 kg:
duration of combined PO/IM/IV treatment not to exceed 5 days
Renal dosing:
Single-dose treatment renal impairment:
30 mg IM x 1 or 15 mg IV x 1
Advanced impairment:
contraindicated
Multiple dose treatment renal impairment:
15 mg IM/IV q 6 hr, max 60 mg/day or may switch to 10 mg PO q 4-6 hr, max 40 mg/day
Advanced impairment:
contraindicated
Hepatic dosing:
Caution advised
Children:
≥6 months
0.5 mg/kg IM/IV q 6 hr up to 72 hr
Alternative:
1 mg/kg IM/IV q 6 hr up to 24-48 hr
Max:
30 mg/dose IM or 15 mg/dose IV
Renal dosing:
Renal impairment:
decrease dose by 50%
Advanced impairment:
contraindicated
Side effects:
photosensitivity, blood dyscrasias, headache, dizziness
Contraindicated:
Pregnancy starting at 30 weeks’ gestation
CABG surgery perioperative use
Caution:
Women trying to conceive
Cerebrovascular hemorrhage
Active bleeding
Major surgery preop use
Epidural or intrathecal use
Labor and delivery
Severe
Volume depletion
Asthma
Inflammatory bowel disease
Smoker
Alcohol use
Toradol
Adult:
INJ (prefilled syringe, IM): 60 mg/2 mL
INJ (prefilled syringe, IM/IV): 15 mg/mL, 30 mg/mL
INJ (vial): 15 mg/mL, 30 mg/mL
Children:
Tabs: 10 mg
INJ (prefilled syringe, IM): 60 mg/2 mL; INJ (prefilled syringe, IM/IV): 15 mg/mL, 30 mg/mL
INJ (vial): 15 mg/mL, 30 mg/mL
indomethacin
Adults:
25-50 mg PO BID-TID-QID
Max:
200 mg/day; ER 150 mg/day
Alternative:
75 mg; ER PO once daily
Titrate to 25-50 mg q 7 days
Children (indicated for rheumatoid arthritis):
1-2 mg/kg/day PO divided BID-QID
Max
: 4 mg/kg/day up to 150-200 mg/day; ER 4 mg/kg/day up to 150 mg/day
Alternative:
1-2 mg/kg/day; ER PO divided once or twice daily
Renal impairment:
dose adjustment may be required but specific pediatric dosing adjustments not defined
Hepatic dosing:
not defined
Hepatic impairment:
caution advised
Side effects:
dyspepsia, GI upset, somnolence, dizziness, headache
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
Pregnancy starting at 30 weeks’ gestation
CABG surgery perioperative use
Neonates with untreated infection, active bleeding, necrotizing enterocolitis, pulmonary atresia
Active bleeding
Severe tetralogy of Fallot
Severe aortic coarctation
Significant renal impairment thrombocytopenia
Pulmonary atresia
Suppository form in proctitis history, recent rectal bleeding
Caution:
Women trying to conceive
Fluid retention
Alcohol use
Smoker
Concurrent nephrotoxic agent use
Dehydration
Sepsis
Asthma
Psychiatric disorder
Neurologic disease
Indocin, Tivorbex
Caps: 25 mg, 50 mg
Extended-release caps: 75 mg
Suppository: 50 mg
INJ: various
nabumetone
Adults:
1000-2000 mg/day PO divided once to twice daily
Start:
1000 mg PO once daily
Max:
2000 mg/day x 7-14 days
Renal dosing:
CrCl 30-49:
Start:
750 mg once daily
Max:
1500 mg/day
CrCl <30:
Start:
500 mg once daily
Max:
1000 mg/day
HD/PD:
no supplement
Hepatic dosing
: not defined
Severe impairment:
caution advised
Pediatric dosing is unavailable or not applicable for this drug
Side effects:
dyspepsia, GI upset, somnolence, dizziness, headache
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
Pregnancy starting at 30 weeks’ gestation
Nonpharmacologic Management Essay Examples
CABG surgery perioperative use
Caution:
Women trying to conceive
Asthma
Fluid retention
Dehydration
Smoker
Alcohol use
Relafen
Tabs: 500 mg, 750 mg
meloxicam
Adults:
7.5-15 mg PO once daily
Start:
7.5 mg PO once daily
Max:
15 mg/day
Mild-moderate renal impairment:
no adjustment
CrCl <15:
avoid use
HD:
max 7.5 mg/day
Hepatic dosing:
Child-Pugh Class A or B:
no adjustment
Child-Pugh Class C:
not defined
Children >60 kg:
7.5 mg PO once daily
Max:
7.5 mg/day
Renal and hepatic impairment:
dose adjustment may be required but specific pediatric dosing adjustments not defined; see adult renal dosing for guidance
Side effects:
diarrhea, nausea, dizziness, somnolence
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
Pregnancy starting at 30 weeks’ gestation
CABG surgery perioperative use
Caution:
Women trying to conceive
Asthma
Fluid retention
Dehydration
Smoker
Alcohol use
Hypovolemia
Mobic
Tabs: 7.5 mg, 15 mg
piroxicam
Adults:
20 mg PO once daily
Max:
20 mg/day
Renal dosing:
no adjustment
HD/PD:
no supplement
Hepatic dosing:
not defined
Hepatic impairment:
consider decreased dose
Pediatric dosing is unavailable or not applicable for this drug
Side effects:
dyspepsia, nausea, abdominal pain constipation, headache, dizziness, somnolence
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
Pregnancy starting at 30 weeks’ gestation
CABG surgery perioperative use
Caution:
Women trying to conceive
Poor CYP2C9 metabolizers
Asthma
Fluid retention
Dehydration
Alcohol use
Smoker
Prolonged use
Feldene
Caps: 10 mg, 20 mg
salsalate
Adults:
1500 mg PO BID
Alternative:
1000 mg PO TID
Renal dosing:
not defined, caution advised
Hepatic dosing:
not defined
Hepatic impairment:
caution advised
Pediatric dosing is unavailable or not applicable for this drug
Side effects:
tinnitus, nausea, impaired hearing, rash, vertigo
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
CABG surgery perioperative use
Influenza, varicella, or febrile viral infection (patients <20 years old)
Caution:
Asthma
Fluid retention
Dehydration
Smoker
Alcohol use
Disalcid
Tabs: 500 mg, 750 mg
sulindac
Adults:
150-200 mg PO BID
Start:
150 mg PO BID
Max:
400 mg/day
Renal dosing:
adjust dose amount
Significant impairment:
decrease dose
HD/PD:
no supplement
Hepatic dosing:
not defined
Hepatic impairment
: consider decrease
Pediatric dosing is unavailable or not applicable for this drug
Side effects:
nausea/vomiting, diarrhea, abdominal pain, constipation, dizziness, headache, rash, ALT, AST elevated, somnolence, tinnitus
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
Pregnancy starting at 30 weeks’ gestation
CABG surgery perioperative use
Caution:
Women trying to conceive
Asthma
Dehydration
SLE
Mixed connective tissue disease
Renal lithiasis history
Smoker
Alcohol use
Clinoril
Tabs: 150 mg, 200 mg
tolmetin
Adults:
200-600 mg PO TID
Start:
400 mg PO TID
Max:
1800 mg
Renal dosing:
no adjustment
HD/PD:
no supplement
Hepatic dosing:
not defined
Hepatic impairment:
caution advised
Children:
≤
2 years:
15-30 mg/kg/day PO divided TID-QID
Start:
20 mg/kg/day PO divided TID-QID
Max:
30 mg/kg/day
Renal dosing:
see adult dosing
Renal impairment:
dose adjustment may be required but specific pediatric dosing adjustments not defined; see adult renal dosing for guidance
Hepatic dosing:
not defined
Hepatic impairment:
caution advised
Side effects:
nausea, abdominal pain, constipation, dizziness, headache, rash, ALT, AST elevated, urticaria, somnolence
Contraindicated:
ASA- or NSAID-induced asthma or urticaria
Pregnancy starting at 30 weeks’ gestation
CABG surgery perioperative use
Caution:
Women trying to conceive
Corticosteroid use
Alcohol use
Smoker
Dehydration
Concurrent diuretics
ACE inhibitor use
ARB use
Asthma
CONSULTATION/REFERRAL
For pain that is poorly responsive to standard treatment
For evaluation for potential joint replacement or other surgical interventions
For interventional radiologic procedures
Fluoroscopy-guided joint injections
Fluoroscopy-guided joint aspirations
FOLLOW-UP
Within 2-4 weeks after initiating medication
For increased pain or disability
Swelling, increased warmth, or erythema in the affected joint(s)
EXPECTED COURSE
Dependent on the cause of orthopedic pain
Maintaining a healthy weight and appropriate exercise regimen may help prevent or delay associated joint damage and improve symptoms
POSSIBLE COMPLICATIONS
Disability
Need for joint replacement
Falls due to joint damage and pain that may lead to changes in gait and balance
Pain in knee
Pain in shoulder
Reflux esophagitis- GERD
DESCRIPTION
Gastroesophageal reflux is the movement of gastrointestinal contents into the esophagus or beyond, facilitated by decreased lower esophageal sphincter (LES) tone. Some reflux is physiologic. Gastroesophageal reflux disease (GERD) is present when gastric contents flow upward into the esophagus or oropharynx, producing symptoms.
INCIDENCE
Affects one-third of Americans at some point
Affects 81% of patients 60 years and older
Affects 50-60% of women during pregnancy
Little is known about prevalence in children and adolescents
Small number of infants develop GERD, but recurrent vomiting common:
50% of infants in first 3 months
67% of 4-month-old infants
5% of 10- to 12-month-old infants
Resolves spontaneously in nearly all infants
RISK FACTORS
Factors that may reduce LES tone:
Alcohol ingestion
Anticholinergic medications
Calcium channel blockers
Caffeine
Chocolate, peppermint
Fatty, spicy, citrus foods
Hormones: estrogen, progesterone, glucagon, secretin
Meperidine
Nicotine
Obesity
Pregnancy
Theophylline
Aging
Diabetes mellitus, diabetic gastroparesis
Delay in gastric emptying
Increased gastric acid secretion
Irritation of esophageal mucosa by:
NSAIDs
Tetracycline
Quinidine
Caffeine
Zenker’s diverticulum
Zollinger-Ellison syndrome
Childhood GERD predisposes to GERD in adolescence and adulthood
Risk factors for GERD during childhood:
Neurologic disorder (cerebral palsy)
Congenital malformation (esophageal atresia or trachea-esophageal fistula)
Severe chronic pulmonary disease (cystic fibrosis)
ASSESSMENT FINDINGS
Chest pain: (requires a cardiac workup)
Postnasal drip, throat clearing
Chronic sore throat, hoarseness
Dysphagia
Erosion of teeth by acid
Esophageal pain referred to neck, mid-back, upper abdomen
Extraesophageal presentation: asthma, chronic cough, laryngitis
Sensation of lump in throat
Pyrosis (heartburn) is cardinal symptom: burning beneath sternum, typically postprandial and nocturnal
Regurgitation
Ulceration: hematemesis, fatigue, anemia
Infants:
Apnea
Apparent life-threatening event (ALTE)
Arching of back during feeding
Disturbed sleep
Dysphagia or refusal to eat
Irritability or excessive crying
Weight loss or poor weight gain
Recurring vomiting
Respiratory problems/stridor
Child or adolescent:
Recurrent vomiting or regurgitation
Heartburn or chest pain
Hoarseness
Bilious vomiting and hematemesis are RED flags in children.
DIFFERENTIAL DIAGNOSIS
Asthma
Cardiac disease
Cholelithiasis
Esophageal spasm or infection
Lower respiratory infection: bronchitis, pneumonia
Peptic ulcer disease
Pulmonary edema
In infants and children, consider:
Gastrointestinal obstructions
Gastrointestinal disorders
Neurologic disorders
Infectious disease
Metabolic or endocrine disorders
Renal conditions
Toxic conditions
Cardiac problems: chronic heart failure
DIAGNOSTIC STUDIES
Presumptive diagnosis of GERD can be made based on symptoms of heartburn and regurgitation. Diagnostic testing is not needed in this setting; empiric PPI therapy for 8 weeks should be initiated
If cerebral palsy is present, cardiac evaluation is recommended before starting empiric PPI therapy
Endoscopy is recommended for patients with GERD symptoms that do not respond to empirical trial of PPI therapy or who experience dysphagia
Nonpharmacologic Management Essay Examples
Ambulatory esophageal pH testing is indicated when considering endoscopy
Infants and children:
History and physical sufficient to reliably diagnose reflux, recognize complications, and initiate management in most infants with vomiting, and in older children with regurgitation and heartburn
Upper GI study to evaluate presence of anatomic abnormalities
Esophageal pH monitoring: acid reflux
Endoscopy and biopsy assess presence and severity of esophagitis, strictures, and Barrett’s esophagus; exclude other disorders
Empiric medical therapy for a trial period to determine if reflux is causing specific symptoms
NONPHARMACOLOGIC MANAGEMENT
Education: physical causes of GERD, common aggravating and ameliorating factors, and lifestyle changes to control GERD:
Avoid recumbence for 2 hours after meals
Elevate head of bed, including entire chest
Weight loss if indicated
Reduce size of meals and amount of fat, acid, spices, caffeine, and sweets
Smoking cessation
Reduce alcohol consumption
Avoid stooping, bending after meals
Do not wear tight-fitting garments
Selective elimination of caffeine, chocolate, alcohol, and acidic foods is recommended since they decrease the lower esophageal sphincter and cause symptoms in some patients
Surgical interventions, crural tightening or fundoplication reserved for patients with stricture, hemorrhage, Barrett’s esophagitis, chronic aspiration or intractable symptoms
Infants:
Milk thickening: reduces episodes of vomiting
Supine position for sleep to reduce risk of sudden infant death syndrome (SIDS)
Diet changes: hypoallergenic formula
Child or adolescent:
Position left side with head of bed elevated
Lifestyle changes:
Avoid caffeine, chocolate, spicy foods
Avoid cigarette smoke and alcohol use
Weight control
PHARMACOLOGIC MANAGEMENT
8-week course of PPI therapy is treatment of choice
PPI therapy should be dosed once a day and before the first meal of the day
If partial response to daily PPI, increase to BID dosing
If symptoms persist after 8 weeks of PPI therapy, consider low-dose PPIs or H2 blockers for maintenance therapy
GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Antacids
Neutralize hydrochloric acid in the stomach to rapidly cause pH to rise
General comments
Blocks absorption of many drugs: digoxin, tetracyclines, benzodiazepines, iron and others
calcium carbonate
Adults
: chew 2-4 tabs as symptoms occur
Max
: 15 tablets in 24 hours
Children
: not recommended
Pregnancy: may use
Do not use maximum dosage for more than 2 weeks
FDA has not evaluated and approved this OTC product for reflux
Produces rapid relief of heartburn symptoms
Use with caution in patients with heart failure, renal failure, edema, cirrhosis, gout, age >60
Tums
various generics
Tabs: 200 mg packs of 12, 36, 75, 150 tablets
H2 antagonists
Inhibit gastric acid secretion by inhibiting H2 receptors of the gastric parietal cells
General comments
Symptomatic response to therapy does not preclude gastric malignancy
Onset of antisecretory action is about 1 hour with inhibition of secretion for 10-12 hr
cimetidine
Adults and children >16 years:
Initial:
800 mg BID for 12 wk
Alternative:
400 mg 4 times daily for 12 wk
Max:
12 wk
Adult Max:
1600 mg/day
Children:
Neonates:
5-10 mg/kg/day q 8-12 hr
Infants:
10-20 mg/kg/day q 6-12 hr
Children:
20-40 mg/kg/day q 6 hr
Pregnancy: may use
Cimetidine associated with many 3A4 drug interactions
Long-term therapy may be associated with B12 deficiency
May take several days to achieve relief
Allow 1 hr between H2 blocker and antacid consumption
Dose adjustment needed for renal and hepatic impairment
Give with food
Tagamet
Solution: 300 mg/5mL
Tabs:200, 300, 400, 800 mg
ranitidine
Adult:
150-300 mg BID
Max
: 6 g in hypersecretory conditions
Children ≥1 month-16 years:
5-10 mg/kg/day in two divided doses BID or TID
Pregnancy: may use
Efferdose is 25 mg. Dissolve in (no less than) 5 mL water. Do not chew, swallow whole or dissolve on tongue
Contains phenylalanine
Potential drug interactions with procainamide, warfarin, glipizide, others
Dose adjustment needed for renal and hepatic impairment
No dosage adjustment needed for older adults
Zantac
Tabs: 75 mg, 150 mg, 300 mg
Efferdose: 25 mg
effervescent tabs
Syrup: 15 mg/mL
continued
GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
famotidine
Adult:
With symptoms of GERD:
20 mg BID for up to 6 wk
Treatment of esophagitis due to GERD:
20 or 40 mg BID for up to 12 wk
Children
<3 months:
0.5 mg/kg/day divided once daily
3-12 months:
1 mg/kg/day divided BID
1-6 years:
1-2 mg/kg/day divided BID
Pregnancy: may use
20 mg BID was superior to 40 mg at bedtime for improvement of symptoms
No drug interactions have been identified
No dosage adjustment needed for older adults
Dose adjustment needed for renal and hepatic impairment
Pepcid
Tabs: 20 mg, 40 mg
Susp: 40 mg/5 mL
nizatidine
Adults:
150 mg BID or 300 mg HS
Children:
6 months-12 years:
5-10 mg/kg/day BID
>12 years:
150 mg BID
Peds Max:
300 mg/day
Pregnancy: may use
Lactation: probably safe
Renal insufficiency: decrease dose
Axid
Tabs: 150 mg, 300 mg
Solution: 15 mg/mL
continued
GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
Proton Pump Inhibitors
Potently suppress gastric acid secretion by inhibiting the hydrogen/potassium pump in gastric parietal cells
General comments
Therapy > 3 years may lead to B12 malabsorption
Take at same time each day
Take before meal, when hydrogen/potassium pumps are most active
Symptomatic response does not preclude the presence of gastric malignancy
May interfere with medications whose bioavailability is affected by gastric pH
PPI may be associated with an increased risk of osteoporosis-related fractures of the hip, wrist or spine.
Use lowest dose and shortest duration of PPI appropriate for the patient’s condition
Daily treatment longer than 3 years may lead to malabsorption of vitamin B12
Consider this diagnosis if clinical symptoms occur
dexlansoprazole
Adult ≥18 years:
30 mg daily for 4 wk
Pregnancy: caution advised
Take without regard to food
NO dosage adjustment necessary for older adults or renal impairment
Dosage adjustment needed for hepatic impairment
Dexilant
Tabs: 30 mg, 60 mg
esomeprazole
Adult
: 20-40 mg once daily for 4-8 weeks
Children:
1-11 months:
0.5 mg/kg once daily for 10 days
1-17 years and <55 kg:
10 mg once daily for 10 days
1-17 years and >55 kg:
20 mg once daily for 10 days
Pregnancy: caution advised
Lactation: safety unknown
Take without regard to food
May affect plasma levels of antiretroviral drugs
No dosage adjustment needed for renal or hepatic insufficiency
Take with full glass of water
Take 1 hr before meals
Nexium
Caps: 20 mg, 40 mg
e-c delayed release
Suspension: 20 mg, 40 mg per packet
lansoprazole
Short term treatment of symptomatic GERD:
>30 kg:
30 mg once daily for up to 12 wk
Children:
1-11 years and <30 kg:
15 mg
daily for 12 wk
1-11 years and >30 kg:
30 mg
daily for 12 wk
12-17 years:
15 mg daily for 12 wk
Peds Max:
30 mg day
Pregnancy: caution advised
Possible drug interactions with antiretroviral therapy, diazepam, warfarin, phenytoin and others
No dosage adjustment necessary in older adults or with renal impairment
Dosage adjustment needed for hepatic impairment
Prevacid
Caps: 15 mg, 30 mg
Solu tabs: 15 mg, 30 mg
Oral Suspension packets: 15 mg, 30 mg
continued
GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name®)
Dosage
How Supplied
Comments
omeprazole
Adults
: 20 mg up to 4 wk
If esophagitis accompanies GERD:
20 mg daily for 4-8 wk
Children:
1-16 years:
>20 kg:
20 mg once daily
10-20 kg:
10 mg once daily
5-10 kg:
5 mg once daily
Pregnancy: caution advised
Lactation: probably safe
Possible drug interactions with antiretroviral therapy, diazepam, warfarin, phenytoin and others
No dosage adjustment necessary in older adults or with renal impairment
Dosage adjustment needed for hepatic impairment
Prilosec
Caps: 10 mg, 20 mg, 40 mg
Oral suspension packets: 2.5 mg, 10 mg
pantoprazole
For short-term treatment of erosive esophagitis associated with GERD:
Adult:
40 mg once daily for up to 8 wk
Non-erosive esophagitis:
20 mg once daily for 4-8 wk
Children 5 years and older:
15 to <40 kg:
20 mg once daily for up to 8 wk
5 years and older:
>40 kg:
40 mg once daily for up to 8 wk
Pregnancy: caution advised
Lactation: probably safe
Possible drug interactions with antiretroviral therapy, diazepam, warfarin, phenytoin and others
Nonpharmacologic Management Essay Examples
No dosage adjustment necessary in older adults
Protonix
Delayed-Release Tabs: 20 mg,
40 mg
Suspension: 40 mg/packet
CONSULTATION/REFERRAL
Cardiologist: severe chest pain, radiating pain
Gastroenterologist:
Dysphagia
Unexplained weight loss
Vomiting
GI bleeding
Anemia
Palpable abdominal mass
Recurrent or refractory symptoms
Long history of alcohol and/or nicotine abuse
Regular NSAID use
Infants/children: pediatric gastroenterologist
Uncomplicated reflux: If symptoms worsen or do not improve by 18-24 months
Recurrent vomiting and poor weight may require medical therapy, hospital observation, and/or endoscopy with biopsy
Infant who refuses feeding
Child >2 years with recurrent vomiting or regurgitation
Child with dysphagia
Unresolved chronic heartburn or chest pain in older child or adolescent
FOLLOW-UP
CBC
Screen for B12 deficiency and increased risk of osteopenia after long-term PPI use
EXPECTED COURSE
Most patients respond well to combined nonpharmacologic therapies, but symptoms may return once medication is withdrawn
POSSIBLE COMPLICATIONS
Erosion and ulceration
Stricture
Barrett’s esophagitis
High-grade dysplasia
Esophageal adenocarcinoma
Aspiration pneumonia
Co-existing conditions in children with GERD:
Esophagitis
Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
Asthma
Recurrent pneumonia
Upper airway syndrome
Anemia
Hematemesis
Tinea corporis
URI- COMMON COLD
ASSESSMENT FINDINGS
Obtain a thorough history to aid in diagnosis; assessment findings are similar to that of other diagnoses (e.g., Strep pharyngitis, sinusitis, bronchitis, and allergic rhinitis)
Most common symptoms: nasal stuffiness, sneezing, scratchy, irritated throat/hoarseness
Red/irritated nasal mucosa
Nasal secretions are initially clear; may progress to be cloudy, yellow, or green
Malaise, headache
Halitosis
Cough
Occasionally, low-grade fever; may be higher in pediatric rhinovirus infections
DESCRIPTION
An infection of the upper respiratory tract (nares, pharynx, hypopharynx, uvula, and tonsils) caused by a virus. The symptoms may last for 3-10 days and are usually self-limiting.
DIAGNOSTIC STUDIES
Usually none indicated, but tests may be helpful to rule out other diseases that require specific targeted treatment (ex.: Strep, influenza, mononucleosis, pertussis)
CBC if symptoms persist: elevated WBC indicates bacterial infection
Culture of nasal washings (usually not helpful)
If CBC indicates bacterial infection, consider differential diagnoses.
DIFFERENTIAL DIAGNOSIS
Allergic rhinitis
Influenza
Sinusitis
Pertussis
Mononucleosis
Epiglottitis
Group A Strep
Mumps
Rubeola
Varicella
ETIOLOGY
Rhinoviruses are the most common cause (30-50%)
Parainfluenza and influenza viruses
Adenoviruses
Coronaviruses (20%)
Enteroviruses, including Coxsackievirus
Moraxella catarrhalis
causes illness in children more than adults
Respiratory syncytial virus (RSV)
EXPECTED COURSE
Complete resolution within 10-14 days. Fever, sneezing, and pharyngitis symptoms resolve early in the course. Cough and nasal discharge symptoms last longer
FOLLOW-UP
None usually needed
INCIDENCE
Adolescents and adults: 2-4 annually
School-aged children: 7 annually
Kindergarten: 12 annually
Most occur in late fall and winter, peaking late winter/early spring
The most common infectious disease and most frequent acute outpatient diagnosis; leading cause of missed days of work/school
NONPHARMACOLOGIC MANAGEMENT
Increased rest
Increased fluids
Humidify inspired air
Hard candy or lozenges for scratchy throat
Saline nose drops and bulb syringe for infants
Avoid secondhand smoke and alcohol, discontinue tobacco
Teach patients that hand washing is the single most effective preventive measure
PHARMACOLOGIC MANAGEMENT
All products are used for symptom relief. Antihistamines are used to dry nasal secretions.
Topical decongestants (sympathomimetics) reduce edema in nasal passages, promote drainage, and are available over the counter for temporary relief. However, there are numerous contraindications with topical decongestants and so they are not usually recommended. Examples: Oxymetazoline (Afrin, Duration) and Phenylephrine (Neo-Synephrine)
COMMON COLD PHARMACOLOGIC MANAGEMENT
Many over the counter products are available as single agents and combinations of antihistamines and decongestants. None speed resolution of infection but may help alleviate symptoms.
Class
Drug
Generic name
(Trade name)
Dosage
How supplied
Comments
Antihistamines
First Generation
General comments
Avoid simultaneous use of CNS depressants
Care when driving or engaging in activities that require attention
Most available over the counter
diphenhydramine
Adult:
25-50 mg q 4-6 hr;
Max:
300 mg/day
Children:
< 6 years:
individualize
6-12 years:
12.5-25 mg q 4-6 hr
Max:
150 mg/day
Cautious use in patients with glaucoma, difficulty urinating due to an enlarged prostate gland, COPD
Avoid alcohol within 6 hours of taking
May cause profound drowsiness in some patients
Benadryl
Chew tabs: 12.5 mg
Tabs: 25 mg
Liquid: 12.5 mg/5 mL
Injection: 50 mg/mL
Various generics
Oral decongestants
Act on adrenergic receptors affecting sympathetic tone of the blood vessels and causing vasoconstriction
This results in mucous membrane shrinkage and improved ventilation
Pseudoephedrine is now a DEA scheduled substance.
pseudoephedrine tabs
Adults and children > 12 years:
Usual
: two 30 mg tablets q 4-6 hr
Max
: 8 tabs in 24 hr
Alternative
: one 120 mg tablet q 12 hr
Alternative
: one 240 mg extended- release tab once/24 hr
Children 6-12 years:
Usual
: one 30 mg tab q 4-6 hr
Max:
4 tabs in 24 hr
Children 6-11 years:
Alternative:
two teaspoons q
4-6 hr
Max:
8 teaspoons in 24 hr
Children 4-5 years:
Usual:
One teaspoon q 4-6 hr
Max:
4 teaspoons in 24 hr
Do not use in patients with hypertension
Cautious use in patients with thyroid disease, CAD, PAD, arrhythmias, prostate disease, or glaucoma
Watch for tachycardia and palpitations
Do not crush, divide, or dissolve tablets
Sudafed
Tabs: 240 mg, 120 mg, 60 mg,
30 mg
Liquid: 15 mg/5 mL
Various generics
phenylephrine
Tabs: 10 mg
Liquid: 2.5 mg/5 mL
Sudafed PE brand
Antihistamines
Second Generation
General comments
Do not typically produce drowsiness (except cetirizine) and usually dosed once daily
fexofenadine
Adults and children ≥ 12 years:
180 mg daily or 60 mg BID
Children 2-11 years:
30 mg
BID
Shake bottle well before use
Reduce dose for renal impairment
Allegra ODT contains phenylalanine (other Allegra products do not)
Avoid aluminum- and magnesium-containing antacids
Less effective if taken with fruit juices; take with water
Do not expect sedation
Allegra
Tabs: 30 mg, 60 mg, 180 mg
ODT tab: 30 mg
Suspension: 6 mg/mL
continued
COMMON COLD PHARMACOLOGIC MANAGEMENT
Many over the counter products are available as single agents and combinations of antihistamines and decongestants. None speed resolution of infection but may help alleviate symptoms. Nonpharmacologic Management Essay Examples.
Class
Drug
Generic name
(Trade name)
Dosage
How supplied
Comments
loratadine
Adults and children ≥ 6 years:
10 mg daily
Children 2-5 years:
3 mg once daily
Children use chew tabs or syrup
Adjustment needed for renal or hepatic impairment
Do not expect sedation
Claritin
Chew Tabs: 5 mg,
Redi Tabs: 10 mg
Syrup: 1 mg/mL
cetirizine
Adults and children ≥12 years:
5-10 mg daily
Children:
6-11 years
: 5-10 mg based on symptom relief
2-6 years:
2.5 mg daily or BID
Zyrtec
Tabs: 10 mg
Chew tabs: 5 mg; 10 mg
Syrup: 1 mg/mL; 4 oz bottle
desloratadine
Children:
6-11 months:
1 mg (2 mL) daily
1-5 years:
1.25 mg (2.5 mL) daily
6-11 years:
2.5 mg (5 mL) daily
> 11 years:
5 mg daily
Children use RediTabs or syrup
Do not expect sedation
Nonpharmacologic Management Essay Examples
Clarinex
Tabs: 5 mg
Redi Tabs: 2.5 mg
Syrup: 0.5 mg/mL
Antihistamines have NOT been shown to alleviate cold symptoms; however, OTC versions are widely used.
The FDA discourages the use of OTC combination cough/cold products in children ≤2 years old.
POSSIBLE COMPLICATIONS
Sinusitis
Bronchitis, bronchiolitis
Pneumonia
Otitis media
Asthma in patients whose asthma symptoms are triggered by viral infections
Nonpharmacologic Management Essay Examples
Avoid aspirin in children to reduce the risk of Reye’s Syndrome.
PREGNANCY/LACTATION CONSIDERATIONS
Medications usually avoided if possible
Most oral decongestants considered safe for short-term use, but no adequate studies have been performed in humans
PREVENTION
Good hand washing
Avoid exposure to infected people
Adequate rest
Stress management
Use of vitamin C or zinc to prevent the common cold lacks evidentiary support
Use of intranasal zinc products may produce transient or permanent loss of smell.
RISK FACTORS
Exposure to infected people (inhaling viral droplets due to coughing/sneezing)
Psychological stress
Touching of contaminated surfaces and subsequent touching of nose or conjunctiva (portal of entry)
Infants and children are most susceptible due to lack of immunity to offending viruses
Inflammation and obstruction due to allergic rhinitis and asthma
Smoking and exposure to secondhand smoke
Travel, other situations in which a person is exposed to large numbers of people in close proximity
Urinary tract infection
DESCRIPTION
Infection and inflammation of the kidney, bladder or urethra. Bacterial infection of the bladder mucosa is the most common type of urinary tract infection (UTI).
ETIOLOGY
Bacteria (e.g.,
E. coli
[75-95% of cases],
Proteus mirabilis
,
Klebsiella pneumoniae
,
Enterobacter
, or
Staphylococcus saprophyticus
)
More commonly caused by gram-negative bacteria of colonic origin
Most UTIs in adult women are due to ascending infections from the urethra
Hematogenous spread is rarely the cause
INCIDENCE
Responsible for 7 million office visits and 1 million hospital admissions annually
43% of women aged 14-61 have had at least one UTI
Women > Men
Uncommon in men <50 years old
4-7% prevalence in pregnant women
Most common of all bacterial infections in women
Girls: most common ages 7-11 years
In children, UTI is highest in boys <1 year and girls <4 years
Women are more likely than men to have urinary tract infections because women have short urethras compared to men.
RISK FACTORS
Previous urinary tract infection
Diabetes mellitus (women)
Pregnancy
Increase in frequency of sexual activity
Use of spermicides and/or diaphragm, oral contraceptives
Urinary tract abnormalities (e.g., tumors, calculi, strictures, anomalies, neuropathic bladder, vesicoureteral reflux or polycystic kidneys)
Benign prostatic hyperplasia
Fecal/urinary incontinence
Cognitive impairment
Immunocompromised host
Infrequent voiding
Indwelling urinary catheter
Postmenopausal state
Always assess UTI risk factors in pediatric patients with suspected UTI.
ASSESSMENT FINDINGS
Burning, frequency, and/or urgency during urination
Pain during or after urination
Sensation of incomplete bladder emptying
Fever, chills
Hematuria: gross or microscopic
Lower abdominal and/or back pain
Costovertebral angle tenderness
Dribbling of urine in men
Small volume and/or frequent voiding
Foul-smelling urine
The most common symptom of upper urinary tract infection in young children is fever.
DIFFERENTIAL DIAGNOSIS
Vaginitis
Sexually transmitted disease
Hematuria from another cause
Pregnancy
Pelvic inflammatory disease
Prostatitis, epididymitis
Enuresis
Overactive bladder
DIAGNOSTIC STUDIES
Urinalysis: WBCs present, positive leukocyte esterase, positive nitrites
Bacterial count >100,000 CFU/mL of urine (midstream catch)
Urine culture with sensitivity
Blood pressure and temperature
Routine imaging recommended for:
Girls <3 years with first UTI
Boys with a first UTI (any age)
Children with febrile UTI or recurrent UTI
Child with a UTI and family history of renal disease
Abnormal pattern of voiding
Poor growth
Hypertension
Imaging in children: renal ultrasound to detect obstruction; voiding cystourethrogram to establish vesicoureteral reflux
The preferred method of collecting a urine specimen in children who are not toilet-trained is catheterization.
Urine culture results will be altered if patient has taken an antibiotic prior to collection of urine for culture.
PREVENTION
Good hydration
Emptying bladder immediately after sexual intercourse
Estrogen therapy in postmenopausal women
Avoidance of spermicidal products
Good perineal hygiene
Removal and avoidance of urinary catheters as soon as reasonably possible
Frequent voiding
Antibiotic prophylaxis
Clinical trials suggest circumcision in boys; no clear recommendation in adult men
NONPHARMACOLOGIC MANAGEMENT
Good hydration
Voiding after intercourse (if infection associated with sexual intercourse)
Good perineal hygiene
PHARMACOLOGIC MANAGEMENT
Consider:
TMP-SMX (Bactrim)
Nitrofurantoin (Macrobid)
Fosfomycin (Monurol)
Alternative Regimens:
Ciprofloxacin
Levofloxacin (Levaquin)
Beta-lactams
URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
Sulfa Agents
Block synthesis of folic acid by bacteria, thus inhibiting bacterial replication
sulfamethoxazole (SMX) –
trimethoprim (TMP)
Adult:
one DS or 2 regular-strength tabs BID PO for 10-14 days
Children >2 months:
give 8 mg/kg PO daily of trimethoprim and 40 mg/kg PO daily of sulfamethoxazole in 2 divided doses
Pregnancy: TMP – avoid use during pregnancy secondary to possible risk of teratogenicity. SMX – caution in third trimester
Avoid use during pregnancy
Nonpharmacologic Management Essay Examples
Stevens-Johnson syndrome, toxic epidermal necrolysis, and blood dyscrasias have been associated with sulfa use
Photosensitivity may occur
Bactrim
Septra
Tabs: 400 mg SMX- 80 mg TMP
Suspension: 200 mg SMX- 40 mg TMP/5 mL
Bactrim DS
Tabs: 800 mg SMX-160 mg TMP
Fluoroquinolones
Inhibit the action of DNA gyrase, which is essential for organism replication
General comments
Fluoroquinolones are associated with an increased risk of tendinitis and tendon rupture in all ages. This risk is further increased in patients older than 60, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants
May exacerbate myasthenia gravis; use with caution in this population
Patients may experience moderate to severe photosensitivity while on medication
Monitor for prolongation of QT interval
May alter blood glucose levels in patients on antidiabetic agents
ciprofloxacin
Adult:
Acute uncomplicated
250 mg PO BID for 3 days
Mild/moderate
250 mg PO BID for 7-14 days
Severe/complicated
500 mg PO BID for 7-14 days
Children:
NOT first drug of choice
10-20 mg/kg PO BID
Max: 400 mg PO/dose
Pregnancy: No known risk of teratogenicity
Lactation: Avoid breastfeeding for 4 hours after dose; possible risk of infantile
C. difficile
infection
Avoid with theophylline, antacids, iron, zinc or NSAIDs at higher doses
Caution with drugs that lower seizure threshold
Hypersensitivity reactions like Stevens-Johnson syndrome may occur
CNS disturbances such as seizure, dizziness, insomnia, nervousness may occur
Cipro
Tabs: 250 mg, 500 mg
Suspension: 250/5 mL, 500/5 mL
levofloxacin
Adult:
Acute uncomplicated
250 mg PO daily for 3 days
Complicated
250 mg PO daily for 10 days
OR
750 mg PO daily for 5 days
Children:
not recommended
Pregnancy: Risk of bone and cartilage damage, embryo-fetal toxicity (based on animal studies)
Lactation: Avoid breastfeeding for 4-6 hours after dose
Concomitant use with NSAIDs may increase risk of CNS stimulation and seizures
Maintain adequate hydration
Levaquin
Tabs: 250 mg, 500 mg, 750 mg
ofloxacin
Adult:
Acute uncomplicated
200 mg PO BID for 3 days
Complicated
200 mg PO BID for 10 days
Children:
not recommended
Pregnancy: Risk of bone and cartilage damage, embryo-fetal toxicity (based on animal studies)
Lactation: Avoiding breastfeeding for 4-6 hours after dose
Concomitant use with NSAIDs may increase risk of CNS stimulation and seizures
Maintain adequate hydration
Floxin
Tabs: 200 mg, 400 mg
continued
URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
Penicillins
Inhibit cell wall synthesis
In species that produce beta-lactamase, amoxicillin, and ampicillin are ineffective
Amoxicillin/potassium clavulanate is effective against organisms that produce beta-lactamase
amoxicillin and potassium clavulanate
Adult:
Mild/Moderate
500/125 mg PO BID for 3 days
Severe
875/125 mg PO BID for 5-7 days
Children:
Mild/Moderate
< 30 kg:
30 mg/kg PO daily in divided doses q 12 hr (dose is based on amoxicillin component)
Use 125 mg/31.25 mg/5 mL suspension ONLY
> 3 months, < 40 kg:
25 mg/kg PO daily in divided doses q 12 hr
OR
20 mg/kg PO daily in divided doses q 8 hr
Max single dose:
500 mg PO amoxicillin
> 3 months, > 40 kg:
adult dosing
Pregnancy: May use during pregnancy, but possible risk of teratogenicity identified in human studies. Animal studies do not support risk
Lactation: May use; no known risk of infant harm. Limited human studies support possible risk for infantile diarrhea, rash, urticaria, thrush, or somnolence
Adjust dose if renal insufficiency
Avoid if history of hypersensitivity to penicillin
TWO 250 mg tablets SHOULD NOT be substituted for a 500-mg dose due to the clavulanic acid component
Augmentin
Tabs: 250/125 mg, 500/125 mg,
875/125 mg
Susp: 125/31.25 mg/5 mL, 250/62.5 mg/5 mL, 400/57 mg/5 mL, 600/42.9 mg/5 mL
Cephalosporins -Second Generation
Inhibits cell wall synthesis of bacteria
General comments
~ 2-10% cross sensitivity with penicillin; contraindicated if patient has history of anaphylactic response or hives
Recommended as first-line treatment in children
cefaclor
Adult:
250-500 mg PO TID
Children:
20-40 mg/kg PO daily in three divided doses
Max:
2 g/day
Pregnancy: Risk of fetal harm low per human data; no known fetal risk based on animal studies
Lactation: No known risk of infantile harm; possible risk of infantile diarrhea based on human studies
Nonpharmacologic Management Essay Examples
Ceclor
Tabs: 250 mg, 500 mg
Suspension: 125 mg/5 mL,
187 mg/5 mL, 250 mg/5 mL,
375 mg/5mL
cefuroxime
Adult: Uncomplicated
250-500 mg PO BID for 5-10 days
Children:
20-30 mg/kg PO daily in divided doses BID
Max:
1000 mg PO daily
Pregnancy: conflicting human data show possible risk of induced abortion. No known fetal risk based on animal studies
Lactation: No known risk of infantile harm
May be taken without regard to meals
Ceftin tablets and Ceftin suspension are NOT bioequivalent
Renal dysfunction prolongs half-life of product
Ceftin
Tabs: 250 mg
Suspension: 125 mg/5 mL,
250 mg/5 mL
ontinued
URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
Cephalosporins – Third Generation
Inhibits cell wall synthesis of bacteria
General comments
2-10% cross sensitivity with penicillin; contraindicated if patient has history of anaphylactic response or hives
cefixime
Adult:
400 mg PO once daily
OR
200 mg PO BID for 3-7 days
Children:
not approved
Pregnancy: risk of fetal harm low per human data; no known fetal risk based on animal studies
Lactation: No known risk of infantile harm
Reduce dose by 25% if renal dysfunction
Suprax
Tabs: 400 mg
Suspension: 100 mg/5 mL, 200 mg/5 mL
cefpodoxime
Adult:
100 mg PO BID for 7 days
Pregnancy: Risk of fetal harm low per human data; no known fetal risk based on animal studies
Lactation: No known risk of infantile harm
Avoid antacids 2 hours before and after dose
Vantin
Tabs: 100 mg
Suspension: 50 mg/5 mL, 100 mg/5 mL
Miscellaneous
nitrofurantoin
Adult:
100 mg PO BID for 5-7 days (with food)
Children:
<12 years:
not recommended
>12 years:
see adult dosing
Pregnancy: Risk teratogenicity and hemolytic anemia. Contraindicated at 38-42 weeks’ gestation
Lactation: Conditional safety dependent on dose and patient population
Contraindicated if patient has anuria, oliguria, or impaired renal function
Should be taken with food
Avoid concurrent use of antacids
Macrobid
Caps: 100 mg
fosfomycin
Adult:
3 g PO x 1
Children:
> 12 years:
see adult dosing
Pregnancy: May be used during pregnancy; no known risk of teratogenicity
Lactation: Safety unknown
Mechanism of Action: bactericidal; inactivates enolpyruvyl transferase and inhibits cell wall synthesis
Monurol
Packets: 3 g pkts
continued
URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class
Drug
Generic name
(Trade name)
Dosage
How Supplied
Comments
Anti-spasmodic
Inhibits smooth muscle spasm of the bladder and urinary tract
flavoxate
Adult:
100-200 mg PO TID or QID
Children:
not recommended
Pregnancy: Caution advised due to lack of data. No known risk in animal studies
Lactation: Safety unknown
Do not use in patients with glaucoma, intestinal obstruction
Nonpharmacologic Management Essay Examples
Urispas
Tabs: 100 mg
phenazopyridine
Adult:
100-200 mg PO TID daily after meals; maximum 2 days of therapy
Children:
not recommended
Pregnancy: contraindicated in pyelonephritis; caution advised due to lack of data. No known risk in human studies
Lactation: Safety is unknown
The dye exerts an analgesic effect on the bladder and urinary tract mucosa via unknown means
Must be used in conjunction with an antibiotic to treat UTI
Discolors urine orange and can stain undergarments
Use with caution in patients with hepatic or renal dysfunction
Maximum of 6 doses per UTI because drug can accumulate and toxicity can result
May discolor soft contact lens
Pyridium
Tabs: 100 mg, 200 mg
E. coli
has high rates of resistance to beta lactams (penicillins and cephalosporins). These medications are not preferred agents to treat UTIs.
Women: 3 days of treatment usually adequate for uncomplicated UTI; consider 7-14 days if complicated
Men: treat for 7-10 days
Children: 7-10 days
Antibiotic often used for children is a second- or third- generation cephalosporin due to gram-negative coverage and palatability
PREGNANCY/LACTATION CONSIDERATIONS
Urine culture recommended
Penicillin, cephalosporin, and nitrofurantoin are good first choices, but consider regional resistance rates to
E. coli
Treat for 10-14 days
May need prophylactic antibiotics for duration of pregnancy
Avoid quinolones and sulfa drugs
CONSULTATION/REFERRAL
Consultation with urologist for recurring infections, infection in child younger than 4 months, pyelonephritis in children, and in presence of acute illness
Referral to urologist if anatomic abnormality is suspected or diagnosed
Hospitalization may be required for patients with severe symptoms
FOLLOW-UP
Post-treatment culture if patient has frequent or recurrent UTIs
Evaluate children 1 week after therapy begins
Education about alteration of sexual practices may be needed in men who acquire UTI through anal intercourse; safe sexual practices such as condom use should be reinforced
Children’s voiding patterns should be evaluated for regular bladder emptying, voiding dysfunction, urine withholding and possible constipation. Constipation can contribute to voiding dysfunction and should be treated if suspected
EXPECTED COURSE
Complete resolution without complications within 2-3 days after starting treatment; patients should finish entire antibiotic regimen
Nonpharmacologic Management Essay Examples
POSSIBLE COMPLICATIONS
Pyelonephritis
Renal abscess
Sepsis