Category: Nursing

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

Capstone Portfolio Part 2

Student Name

Chamberlain College of Nursing

NR 661: Capstone Practicum

Session Month and Year

 

 

 

Table of Contents

Exemplar #1. 4

Exemplar #2. 4

Exemplar #3. 5

Exemplar #4. 5

Exemplar #5. 5

Exemplar #6. 6

Exemplar #7. 6

Exemplar #8. 6

Exemplar #9. 7

Exemplar #10. 7

Conclusion. 7

References. 9

Appendix A: Concept Map. 10

Appendix B: Table of Exemplars and Supporting Program Outcomes, MSN Essentials, and NONPF Core Competencies. 11

 

 

Title of your Paper in Upper and Lower Case (Centered, not Bold)

Type your introduction. Although the first paragraph after the paper title is the introduction, no heading labeled Introduction is used. Refer to your assignment guidelines for the headings to be used for the body of the paper.  See the APA file in Doc Sharing for additional resources.

Exemplar #1

Begin to type the body of your paper here.  Use as many paragraphs as needed to cover the content appropriately.

Identify and Explain

           
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Connect

           
Continue to add support for your purpose.
   

Reflect

           
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Exemplar #2

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #3

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #4

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #5

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #6

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #7

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #8

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #9

Use as many headings as necessary to organize your paper.  Short papers may only have first-level headings.  Longer papers may require more organizational detail.  See your APA manual for instructions on formatting multiple levels of headings.

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Exemplar #10

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Conclusion

Papers should end with a conclusion or summary.  The assignment directions will specify which is required. It should be concise and contain little or no detail.  No matter how much space is left on the page, the references always start on a separate page (insert a page break).

 

References

Type your references in alphabetical order here using hanging indents.  See your APA Manual and the resources in your APA folder in Doc Sharing for reference formatting.

 

 

 

 

Appendix A: Concept Map

 

 

 

 

Appendix B: Table of Exemplars and Supporting Program Outcomes, MSN Essentials, and NONPF Core Competencies

 

Program Outcomes

MSN Essentials

CORE

Exemplar

1

2

3

4

5

1

2

3

4

5

6

7

8

9

APN Capstone Portfolio Part 2

 

Table of Contents

APN Capstone Portfolio Part 2. 1

Background
. 4

Exemplar #1: NR503 Population Health, Epidemiology & Statistical Principles
. 5

Chamberlain Program Outcomes
. 7

AACN MSN Essentials
. 7

NONPF Core Competencies
. 7

Connect
. 8

Reflection
. 8

References
. 8

Exemplar #2: NR505 Advance Research Methods: Evidence-Based Practice)
. 9

(Week 4; Research Literature, Design Approach and Sampling Guidelines)
. 9

Chamberlain Program Outcomes
. 10

MSN Essentials
. 10

NONPF Competencies
. 11

Connection
. 11

Reflection
. 11

References
. 12

Exemplar #3: NR507 Advanced Pathophysiology
. 12

Chamberlain Program Outcomes
. 14

AACN MSN Essentials
. 14

NONPF Core Competencies
. 14

Connect
. 15

Reflection
. 15

References
. 16

Exemplar #4: NR508 Advanced Pharmacology
. 16

Chamberlain Program Outcomes
. 17

AACN MSN Essentials
. 18

NONPF Core Competencies
. 18

Connect
. 18

Reflection
. 18

References
. 19

Exemplar #5: NR509 Advanced Physical Assessments
. 20

Chamberlain Program Outcomes
. 21

AACN MSN Essentials
. 21

NONPF Core Competencies
. 21

Connect
. 22

Reflection
. 22

References
. 22

Exemplar #6: NR510: Leadership and Role of the Advanced Practice Nurse
. 23

Chamberlain Program Outcomes
. 24

AACN MSN Essentials
. 24

NONPF Core Competencies
. 25

Connect
. 25

Reflection
. 25

Reference
. 26

Exemplar #7: NR 511 Differential Diagnoses and Primary Care
. 27

Chamberlain Program Outcomes
. 28

AACN MSN Essentials
. 28

NONPF Core Competencies
. 28

Connect
. 29

Reflection
. 29

References
. 30

Exemplar #8: NR601 Primary Care of the Maturing and Ageing Family
. 30

Chamberlain Program Outcomes
. 31

AACN MSN Essentials
. 32

NONPF Core Competencies
. 32

Connect
. 32

Reflection
. 33

References
. 33

Exemplar #9: NR 602 Primary Care of the Childbearing and Childbearing Family
. 34

Chamberlain Program Outcomes
. 35

AACN MSN Essentials
. 35

NONPF Core Competencies
. 35

Connect
. 36

Reflection
. 36

References
. 37

Exemplar #10: NR 602 Advanced Clinical Care and Practice Across the Lifespan Practinum
.. 37

Chamberlain Program Outcomes
. 38

AACN MSN Essentials
. 39

NONPF Core Competencies
. 39

Connect
. 40

Reflection
. 40

References
. 41

References
. 42

Appendix 1: Tabulation of achieved program 0utcome, MSN Essentials and NONPF Competencies. 45

 

 

 

 

 

 

 

 

 

 

 

 

Background

On account of the intense and comprehensive nursing education program that I have undergone at Chamberlain College of Nursing, resulting into an award of Masters of Science in Nursing, here is a compilation of a reflection through the journey. The reflection entails the Program Outcomes, Master’s Education Essentials and the Core Competencies of the National Organization of Nurse Practitioners Faculties with the abbreviations as PO, MSN Essentials, and NONPF. Further, this documentation also covers ten exemplars with an assessment on views of the right argument that all of the above requirements have been covered.

Exemplar #1: NR503 Population Health, Epidemiology & Statistical Principles

In #Week 6 of this course we conducted an Evaluation of Epidemiological Problem. This assignment enabled the students to meet different course outcomes. The assignment required defining key terms in community health, epidemiology, and population-based research. We also gained the knowledge and skills to compare study designs used for obtaining population health information from observation, surveillance, community, and control trial-based research. The assignment also enabled us to commonly used measures of health risk and identify appropriate outcome measures and study designs applicable to epidemiological subfields, for instance chronic disease, infectious disease, reproductive health, environmental exposures, and genetics. We were able to identify important sources of epidemiological data and evaluate a public health problem as regards to place, person, magnitude, and person.

The task was to discuss HIV/AIDS and give its background information. The assignment was able to realize that HIV/AIDS is both an infectious disease and an epidemic disease. Learning that, since its onset, HIV/AIDS has claimed over 35 million lives was very scaring. HIV is considered infectious because it causes a severe impairment of the immune system, which then leads to AIDS (Moyer, 2015). With a weak immune system, AIDS patients become susceptible to other cancers, diseases and infections – often called opportunistic infections since their causal organisms only take advantage of the weakened immune system (Maartens, Celum & Lewin, 2014).

I was able to learn about the worrying prevalence statistics of AIDS with 23,304 people estimated to be living with HIV in Houston Texas (Maartens, et al., 2014). I also established the current surveillance techniques and strategies of HIV in the US and a clear descriptive epidemiological analysis. Finally, I was able to understand the screening and diagnosis methods of HIV. I was then able to develop and action plan for dealing with the disease or infection when I finished my MSN.

Chamberlain Program Outcomes

This assignment enabled me to meet course outcome PO #1: Provide high quality, safe, patient-centered care grounded in holistic health principles (Holistic Health & Patient-Centered Care). The course was able to realize Program Outcome #1 by calculating HIV prevalence in Houston Texas and breaking it down to address particular interests of the populations. The assignment discussed the surveillance methods for HIV, which is one of the techniques that support community intervention plan. I was able to successfully suggest an intervention plan of increasing health awareness on HIV to help in its prevention.

AACN MSN Essentials

This assignment met the AACN MSN Essential I: Background for Practice from Sciences and Humanities. This MSN Essential captures the importance of obtaining an understanding of a disease and using an informed background for practice to manage its prevalence. As demonstrated in the assignment, in identifying HIV’s prevalence and designing an intervention for Houston Texas, I relied on nursing scientific findings to advocate for quality and improved health outcomes.

NONPF Core Competencies

The NONPF that I was able to demonstrate with this assignment were Practice Inquiry, Scientific Foundation and Technology and Information Literacy Competencies. I was able to think critically while compiling data on HIV and being able to apply evidence-based practice to design the intervention plan. I also included research outcomes for practice improvement and improving patient outcomes. I also had to include knowledge from other disciplines as a way of practice inquiry. Using spreadsheet application demonstrated technology and information competency.

Connect

The concepts that I can connect with from the exemplar are screening and surveillance. In nursing context, screening is used to refer to a test conducted to determine a health condition prior to manifestation of symptoms. Screening helps to detect diseases and conditions in their early periods to improve treatment outcomes. This makes screening an essential part of preventive care (Moyer, 2015).

On the other hand, disease surveillance refers to information-oriented activity encompassing gathering, analyzing and interpreting relevant health data from varied and different sources (Houston Health Department. 2015). This requires the use of informatics and technology to enhance surveillance and enable real time analysis. Surveillance leads to effective disease management and enhances preventive measures (Moyer, 2015).

Reflection

This course was very insightful. It enables accomplishments of Program Outcome #, which is to promote safe and high-quality patient-driven care anchored in holistic health tenets. To produce the document of HIV program, I had gone through several scientific studies on HIV prevalence in Houston to understand the disease’s status in the target population. I also had to compare different studies to conclude on the prevalence and determine the incident rate. Understanding the epidemiological perspective of the disease enabled proper identification of the intervention plan. I was also able to apply evidence-based practice in the work.

References

Houston Health Department. (2015). HIV Surveillance Program. HIV Infection in Houston: An Epidemiologic Profile 2010-2014. Houston, Texas; 2015.

Maartens, G., Celum, C., & Lewin, S. R. (2014). HIV infection: epidemiology, pathogenesis, treatment, and prevention. The Lancet, 384(9939), 258-271.

Moyer, V. A. (2015). Screening for HIV: US preventive services task force recommendation statement. Annals of internal medicine, 159(1), 51-60.

Exemplar #2: NR505 Advance Research Methods: Evidence-Based Practice)

(Week 4; Research Literature, Design Approach and Sampling Guidelines)

In NR505 the assignment was Research methods and evidence-based practice. In week #4 of about Research Literature, Design Approach and Sampling Guidelines. I chose obesity in children and adolescents as the phenomenon of interest in the evidence-based practice project. The selected nursing issue for the project was prevention of adolescent and childhood obesity, with the overall aim being to prevent obesity’s co-morbidities. Child and teenage obesity has become a key problem in our society today. I was able to discuss the literature support research of the research, as well as identify the appropriate theoretical framework, research design and methodology including sampling method procedure.

Literature support generated three key pieces of information. The reviewed CDC (2017) document recommended the need for multi-disciplinary research to help develop proper behavioral interventions to prevent childhood obesity. The CDC document also gave a conclusive perspective of diet and exercise as the proper initiatives for obesity control. In a longitudinal study, Cunningham, Kramer & Narayan (2014) agreed with the CDC recommendation and suggestions. Kliegman, et al (2016) suggested the Nelson Textbook of Pediatrics as the key resource for approaches that can help pediatric care including obesity. Lobstein, et al (2015) study concluded an improved governance of food markets and food supply can help address the challenge of obesity. However, it would be impractical to govern food markets and supply, thus instead education should be improved.

The theoretical framework suggested for the study was Henderson’s Needs Theory. The argument was that although the theory works well with inpatients, it can support the problem of helping obesity patients (Ahtisham & Jacoline, 2015). The suggested research approach and design of the study would be qualitative study with a non-experimental (descriptive) inquiry-based design based on the Grounded Theory (GT). The research, as suggested, use interviews and existing documents as its primary data collection tools.

Chamberlain Program Outcomes

The assignment enabled realization of program outcome (PO) #5: Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice (Extraordinary nursing). This is because, evidence-based practice is one of the ways through which nurses can advocate for desirable health outcomes. The assignment enabled the application of the ability to design an evidence-based research. The process involves selecting an appropriate research article, summarizing and reviewing its relevance and information, research design, methodology, sampling and presentation of research findings.

MSN Essentials

This assignment met MSN Essential VI: Health Policy and Advocacy. I was able to engage in advanced research method, and research critique, to inform health advocacy and policy as to attain MSN Essential VI. It is evident that an MSN prepared nurse can apply research outcomes, become a change agent, resolve a nursing practice issues, and help disseminate research findings. I concluded that being able to translate findings of a nursing research is an important.

NONPF Competencies

To achieve the assignment outcome, I needed such NONPF Competencies as policy, scientific foundation and health delivery systems. Policy and health delivery systems competencies enabled me to use health informatics for determining the best guidelines for managing critical health issues. Through scientific foundation I was able to critique different study findings to generate appropriate information for the research. Through health delivery systems competency I was able to synthesize nursing practice methods that would improve patient outcomes.

Connection

I was able to connect with two concepts from this exemplar – research gap and research limitations. Research gaps are the areas with inadequate information, which constraints the research’s effective conclusion. A research gap often leads to recommendation of a new research to further the information. One can conclude there’s a research gap only after a comprehensive literature review.

Research Limitation are the research aspects that inhibit a researcher from attaining the full potential of the research outcomes. It is assumed that every research has a given limitation level such as resources, scope or knowledge. Limitations are the conditions, which an investigator cannot fully manage and will constraint the research’s conclusions and methodology.

Reflection

I thank this course for giving me insight on conducting scientific research and critique. Through program Outcome #5 I am now able for advocating for the realization of a positive health outcome through engaging evidence-based compassionate and collaborative advanced nursing practices that are evidence-based. Having gone through this course, it is evident that nurses could experience challenges in research critiques and general research conduct. Nurses should therefore exhibit NONPF Core Competencies particularly the scientific foundation competencies.

References

Centers for Disease Control and Prevention. (2017). Childhood Obesity Facts. Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion.

Kliegman, R. M., Schor, N. F., St Geme III, J. M., & Behrman, R. E. (2016). Nelson Textbook of Pediatrics. Philadelphia: Elsevier.

Lobstein, T., Jackson-Leach, R., Moodie, M. L., Hall, K. D., Gortmaker, S. L., Swinburn, B. A., . . . Mc Pherson, K. (2015). Childhood and adolescent obesity: Part of a bigger picture. The Lancet, 2510-2520.

National Collaborative on Childhood Obesity Research. (2012). Childhood Obesity in the United States. NCCOR.

 

 

Exemplar #3: NR507 Advanced Pathophysiology

The NR507 Course of Advance Pathophysiology was key in realizing the Chamberlin trained nurse practitioner’s program outcomes, master’s essentials, and core competencies. Pathophysiology focuses on the symptoms and function of diseased organs, to enable diagnosis and effective patient care. The different between pathophysiology and pathology, is that pathology studies all aspects of a disease, and not just the organic function. The question that NR507 sought to answer is how the study of pathophysiology help nurses in their practice. Nurse practitioners must have the right information coupled with practice knowledge and skills to be able to achieve the best evidence-based, comprehensive quality patient outcomes.

Pathophysiology entails Disease and etiology, signs and symptoms, investigation and diagnosis, treatment and prognosis. Pathophysiology puts together all of these steps. Nurse practitioners are expected to have a clear understanding of the process from the etiology and symptoms, through to medical testing, investigation, diagnosis and finally prognosis. It is clear that pathophysiology works closely with evidence-based practice. Thus, nurse can conduct more effective treatments through pathophysiology especially in such situations where anxious, scared patients don’t really understand their conditions. Nurses can educate the patients and calm them down.

There are cases where, through pathophysiology, nurses can help generate a valuable discovery for a patient’s healthcare team. Acting – in their usual crucial role – as their patients’ advocates, it is possible that nurses could catch some overlooked signs or and make them know to the doctor. The course sheds the light of pathophysiology as a way of facilitating the nurses’ knowledge to enable them to comfortably walk their patients through the process of disease etiology, testing, diagnosing, treating and prognosis. Nurses become effective in their work when they clearly understand the different ways biological processes and human organs behave in the presence of a disease. This experience and practice skills is gained through. effective research.

Chamberlain Program Outcomes

I found this course highly critical since it concerns understanding a disease, correct diagnosis, treatment and its prognosis for effective and quality patient care through proper professional identity. Thus, this course met two program outcomes. It met PO #2: Create a caring environment for achieving quality health outcomes (Care-Focused) and PO #4: Integrate professional values through scholarship and service in health care (Professional identity). Pathophysiology ensures that the patient’s care environment is perfect for achieving quality treatment outcomes.

AACN MSN Essentials

The course managed to achieve MSN Essential IV: Translating and Integrating Scholarship into Practice and MSN Essential VIII: Clinical Prevention and Population Health for Improving Health. These two essentials are connected to PO #4, which this course was also able to meet. An MSN prepared nurse must be able to integrate broad, effective patient-centered, culturally competent and organizational concepts to assess, manage and deliver proper clinical care to the patient. As an MSN prepared nurse, I can use pathophysiology to manage a patient and the disease following through all the necessary steps learned throughout the nursing course with appropriate understanding to achieve quality health outcome for the patient.

NONPF Core Competencies

To effectively achieve this course, it was imperative to have such NONPF competencies as quality, independent practice and health delivery systems Competencies. To be able to apply pathophysiology, an MSN trained nurse must exhibit independent practice competencies. It is only through independent practice that the nurse can bring to the doctor’s attention certain aspects of the disease that were overlooked. This competency is supported by quality-oriented practice and having a clear knowledge of the health delivery systems.

Connect

The Autonomic Nervous System, controls the body’s internal organs functions. It controls body muscles and is also an integral part of the peripheral nervous system (Tappen, 2016). The renal system is comprised of body organs, which filter out excess fluid and other substances from the bloodstream. It is responsible for the production, storage and elimination of urine is done. The kidneys, being key part of the renal system, help to excrete excess fluid waste. Further, the kidney filters waste and extra blood from the blood system (Tappen, 2016).

Reflection

One among the many useful and important courses in MSN, this this NR507 Advanced Pathophysiology course sought to answer the question of how the study of pathophysiology help nurses in their practice. It is now clear to me that through this course the nurse can conduct more effective treatments especially in such situations where anxious, scared patients don’t really understand their conditions. I even learned that there are cases where, through pathophysiology, nurses can help generate a valuable discovery for a patient’s healthcare team. This course was important in realizing two program outcomes: PO #2: Create a caring environment for achieving quality health outcomes (Care-Focused) and PO #4: Integrate professional values through scholarship and service in health care (Professional identity). Understanding pathophysiology is an important aspect of nurse evidence-based treatment.

 

References

American Association of Colleges of Nursing.  The Essentials of Masters Education for Nursing (2011). Retrieved from
http://www.aacn.nche.edu/education-resources/MastersEssentials11.pdf

Robinson, B. K., & Dearmon, V. (2013). Evidence-based nursing education: Effective use of instructional design and simulated learning environments to enhance knowledge transfer in undergraduate nursing students. Journal of Professional Nursing, 29(4), 203-209.  doi: 10.1016/j.profnurs.2012.04.022

Tappen, R. M. (2016).
Advanced nursing research: From theory to practice
. Jones & Bartlett Publishers.

Exemplar #4: NR508 Advanced Pharmacology

The focus of this course is on advanced knowledge base and practice skills of pharmacology across in different clinical settings. It discusses the principles of clinical pharmacology, pharmacokinetics, therapeutics, and drug metabolism. Being a dynamic science, advanced Pharmacology as explained in NR508, built upon the previous knowledge to augment our understanding of treatment complexities with pharmacological interventions. The whole of this course expands knowledge of the principles of pharmacology specific to the APN’s role. As a student I was able to explore, analyze, evaluate, and apply common drugs used for treatment of chronic diseases and some self-limiting acute conditions and apply evidence-based practice for prescriptive intervention.

In reflection, through this course, and as an MSN trained nurse, I can now compile patients’ information to provide appropriate evidence-based diagnosis and treatment. I can boast of better understanding of the integration and application of appropriate and quality care to patients while also focusing on organizational standards, and considering distinct and dynamic individual and family populations. I have learned this important aspect of treatment through pharmacokinetics and giving patients appropriate drug choices it is possible to achieve quality treatment.

Through completion of NR 508, I can discuss the principles and concepts of pharmacokinetics, pharmacotherapeutics and pharmacodynamics. I can also now demonstrate an understanding of the key drug classifications with regards to rationale, risks, indications, and efficacy for the pharmacotherapeutic agents regularly prescribed in acute and primary care settings. I also gained the knowledge to evaluate relevant and current research findings to come up with prudent and quality pharmacological interventions. This course has also enabled me to be able to design suitable pharmacologic interventions. This class was one of those that are both enlightening and challenging. I gained the knowledge necessary to arrive at definitive patient diagnosis and establish an apt a treatment plan.

Chamberlain Program Outcomes

I believe this course me program outcome (PO) #5: Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice (Extraordinary nursing). It is important that nurses communicate effectively to patients on the drugs given and treatment plan offered. It is possible that NR508 MET PO #5 because it is the only outcome that champions for desirable health outcomes through compassionate and evidence-based encompassed with collaboration

AACN MSN Essentials

The course attained AACN MSN Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes. MSN Essential VII addresses interprofessional collaboration that enhances patient outcomes and quality of population health. As an MSN prepared nurse, I now understand that to attain quality care, it is important to collaborate with other healthcare professionals so as manage and coordinate the care.

NONPF Core Competencies

Through this course (NR508) it is evident that one needs to show Health Delivery Systems Competencies and practice competencies. These two competencies impact the operationalization of public health and community programs. Using these competencies, a nurse can engage inquiry to come up with appropriate diagnosis, treatment plan and drug prescription. You also need to eb culturally competent to deliver appropriate healthcare and work with others in the healthcare field for effective patient outcomes.

Connect

Through this course, can connect with two terms – allergy and NSAIDs. In the context of pharmacology an allergy is used to refer to the immune system’s response – unnecessary – to a harmless foreign substance (Lilley, Shelly & Snyder, 2019). NSAIDs, on the other hand are non-steroidal anti-inflammatory drugs, which work by obstructing prostaglandins. prostaglandins are the chemicals that trigger the inflammation and pain signal. NSAIDs then help to relieve the inflammation from pain (Lilley, Shelly & Snyder, 2019).

Reflection

This course has benefitted me a lot. Other than knowing the essentials and specific applications of advanced pharmacology, I managed to attain PO #5, which advocates for desirable health outcomes through compassionate and evidence-based approach to nursing practice while elevating collaboration. It is understandable that you cannot work alone when you are a nurse practitioner and that you have to engage other practitioners in the healthcare field to attain quality healthcare outcomes. The course is also aligned to MSN Essential VII, which addresses interprofessional collaboration for enhanced patient outcomes. Thus, while conducting evidence-based and compassionate care, elevating interprofessional collaboration also leads to enhanced patient outcomes.

References

Chamberlain College of Nursing. (2016). Graduate Program Outcomes. Retrieved from
http://www.chamberlain.edu

Chamberlain College of Nursing. (2017). Pharmacokinetics, Pharmacodynamics, Art of Pharmacotherapeutics, Reproductive System Medications and Drug-OTC-Herbal Interactions. Week 1 lesson. Retrieved from
http://www.chamberlain.edu

Lilley, L. L., Shelly Rainforth Collins, P., & Snyder, J. S. (2019). Pharmacology and the nursing process. Mosby.

 

 

 

 

 

 

Exemplar #5: NR509 Advanced Physical Assessments

The name and expectation of the NR509 course is far much different from time one needs to successfully complete the course. I never expected that this course would involve that much activity and time. There is much study and practical application in this course than any other MSN course. I was even overwhelmed with the amount of documentation and information involved with the patients.

This course is best for those planning to undertaking autonomous practice. An FNP is an example of an autonomous practicing nurse. They have the knowledge for emergency nursing, primary care, night-nurse practitioners, community matrons, critical care, occupational therapists, physiotherapists, and working in different pre-surgical clinics, and day surgery, among other places. The course aims to enable one, as a practitioner, to develop advanced physical assessment skills and apply them in a clinical context, including when working as an autonomous practitioner.

Immersion weekend – the lab component of NR-509: Advanced Physical Assessment – gave me a great experience while also being nerve wracking. Occurring in week 7 of NR-509, the Immersion Weekend offered me an opportunity to demonstrate competence and engage critical thinking in my health assessment skills. The course has designed the Immersion Weekend to teach us appropriate assessment techniques on various general medical complaints, which help prepare us for practicum experiences in NR-511. This means, one has to do well in NR509 so as to understand NR511.

Even after all the preparations, study and documentations, NR509 was still difficult to pass. I still had low scores in the NR509 APEA exams in three areas – Neurology, Gastroenterology, and Respiratory. I had to put a lot of work to ensure that I performed well in these three areas so that I would succeed in NR511. Also, to succeed in NR509, one has to be well versed with the previous MSN courses that come before 509, and take keen consideration of pharmacology and pathophysiology.

Chamberlain Program Outcomes

The content and information of this course meets those of Chamberlain MSN PO #1: Provide high quality, safe, patient-centered care grounded in holistic health principles (Holistic Health & Patient-Centered Care). Through this course I have become keener on screening and diagnostics both of which exemplify Program Outcome #1 for provision of safe, patient-centered and high-quality care. Conducting advanced physical assessments require not only clear and informed background in nursing, but critical thinking and evidence-based practice.

AACN MSN Essentials

The course met the conditions for arriving at Essential IX: Master’s-Level Nursing Practice. Clearly, advanced physical assessments highly impact individuals’ healthcare outcomes. Its achievement requires clear and well-defined background in nursing which provokes the essentials of master’s level nursing practice. It is a clear demonstration of advanced level of understanding and comprehension of advanced nursing and its relevant fields.

NONPF Core Competencies

The course also needs a demonstration of NONPF Independent Practice Core competencies. It gives an opportunity to work autonomously exhibiting independent practice as a competency. It also involved independently analyzing the given case studies with stellar profession and distinguished care to provide accurate diagnosis and establish quality outcome. A competent MSN prepared nurse should distinguish between normal and abnormal health results, which is supported by this course.

Connect

I can connect with two terms in this course – shadow-health and gastroenterology. Gastroenterology, as a field of medicine, is involved with interrogating, diagnosing, and suggesting treatment that also encompasses listing preventive care for gastrointestinal and hepatological tissues and organs (Tappen, 2016). Shadow health, on the other hand, is a software that gives healthcare students a virtual learning opportunity through simulations (Foronda
et al
., 2019). Thus, it enables students to test their nursing knowledge and skills and hence build their confidence.

Reflection

The name and expectation of the NR509 course is far much different from time one needs to successfully complete the course. I never expected that this course would involve that much activity and time. There is much study and practical application in this course than any other MSN course. I was even overwhelmed with the amount of documentation and information involved with the patients. The sensitivity is on its screening and diagnostic processes, which both inform the treatment plan making any mistake – if any – at this stage costly and fatal and costly. I discovered that conducting advanced physical assessments needs stellar background in nursing information and proper develop critical thinking. Students can use Shadow Health and case studies to test their physical assessment’s skills and knowledge.

References

Codina, L. M. T. (2007). Adult nurse practitioner intensive review: Fast facts & practice questions. New York: Springer Pub. Co.

Foronda, C. L., Alfes, C. M., Dev, P., Kleinheksel, A. J., Nelson Jr, D. A., O’donnell, J. M., & Samosky, J. T. (2017). Virtually nursing: Emerging technologies in nursing education.
Nurse educator
,
42
(1), 14-17.

Tappen, R. M. (2016).
Advanced nursing research: From theory to practice
. Jones & Bartlett Publishers.

Exemplar #6: NR510: Leadership and Role of the Advanced Practice Nurse

This course was not only important but also practice assuring. Id defined the leadership and role of an APNs practitioners in a wide range of possible careers and employment opportunities. Holding either MSN or a doctorate in nursing, APNs are considered to be the most highly trained category of all registered nurses. They conduct certain functions previously reserved for medical doctors such as diagnosing condition, requesting and/or interpreting laboratory tests, and prescribing medications among others. They have a wide scope of practice and lots of duties to perform either as practitioners or leaders.

APNs apply technical, cognitive and integrative abilities to carry out their practice in ethical and safe approaches for quality outcome of patients. APN must also have the capability of peer and patient education, research and inquiry, mentorship and accountability in interpreting and utilizing research to advance and improve nursing practice. There are two main themes identified in the role of an ANP – organization and system‐focused leadership and Patient‐focused leadership. These are the main leadership orientations of APNs as they seek to contribute to and improve the clinical care environment for patients and their families, other nurses including other healthcare providers, and the entire healthcare system.

Being an APN requires a one to have an MSN. Other MSN’s proceed to earn a doctoral degree to become Clinical Nurse Specialists. With an MSN one also has to obtain a certification after sitting an exam to become an APN. (“Advanced Practice Nursing Fact Sheet”, 2017). It is also important to consider the federal and state Licensure and Regulatory Requirements to practice as an MSN trained APN. With an additional certification, degree and license, being an MSN prepared APN means having a higher responsibility. Further, a complex job title, higher knowledge, more skills and authority give APN new challenges and equal opportunities. Nevertheless, regardless of having higher roles or authority, an APN must always keep in mind that providing quality and safe healthcare is paramount.

Chamberlain Program Outcomes

This course meets the needs of program outcome (PO) #3: Engage in lifelong personal and professional growth through reflective practice and appreciation of cultural diversity
(Cultural Humility).
Nurses are generally leaders both to patients and to their lower ranking colleagues. By pursuing an APN level nursing career, one is aligning with Program Outcome #3 that urges continuous personal and professional growth through reflective practice and appreciation of cultural diversity.

AACN MSN Essentials

This course realizes AACN MSN Essential II: Organizational and Systems Leadership. APN’s are naturally leaders because of their skill levels and associated responsibility, roles and authority. Thus, they must demonstrate both organizational and systems leadership to promote safe and quality care. They must also engage critical thinking in their decision making and engage systems-wide view.

 

NONPF Core Competencies

The accurate and obvious competency that this course instill is the Leadership Competency. As an MSN APN I have to build on leadership competencies (Hickey & Brosnan, 2012). This is because you will have more responsibilities, key roles and authority, which put you in a leadership position. As a leader you have to act on the best interest of all the stakeholders involved in the care process including patients, junior colleagues and other health sector practitioners. You must also exercise effective communication skills and participate in professional organizations to enhance your leadership competences.

Connect

Systems-wide view: seeks consider the organization’s entire units or departments in a bid to accomplish a practical approach to leadership. The systems-wide concept views an organization from a cause-effect view which supports implementation of corrective measures (Cherry & Jacob, 2016).

Nursing leadership is a dynamic concept of nursing that, simply stated involves mentoring (or coaching) and building of supportive relationships to maximize individual potential and enhance professional growth. Mentorship involves a nurse leader sharing their knowledge, behaviors, skills, and attitudes with other nurses (Cherry & Jacob, 2016).

Reflection

APNs are trained to be leaders and demonstrate leadership competencies. This course not only teaches leadership but also gives leadership opportunities for APNs in care environment. While nursing leaders provide higher level leadership, individual nurses are always engaged in leadership, for instance when assigned students or nursing interns. This course is aligned with Program Outcome #3, which urges nurses and APNs to indulge in continuous personal and professional growth while considering cultural diversity

Reference

Advanced Practice Nursing Fact Sheet | 2017 NurseJournal.org. (2017). Retrieved from http://nursejournal.org/advanced-practice/advanced-practice-nursing-fact-sheet/

About Boards of Nursing | NCSBN. (2017). Retrieved from
https://www.ncsbn.org/about-boards-of-nursing.htm

Cherry, B., & Jacob, S. R. (2016).
Contemporary nursing: Issues, trends, & management
. Elsevier Health Sciences.

Hickey, J. V., & Brosnan, C. A. (2012). Evaluation of health care quality in advanced practice nursing. New York: Springer Pub. Co.

 

 

 

 

 

 

 

 

 

Exemplar #7: NR 511 Differential Diagnoses and Primary Care

Through
Differential Diagnosis and Primary Care
 nurse practitioners systematically approach treatment symptoms and signs with careful approach as they see them practice. NR 511 was the key test of my education and learning as an MSN prepared nurse. Organized into categories different categories such as mass, pain, bloody and non-bloody discharge, abnormal laboratory results, and functional changes, this course offers a clinical reference for diagnosis and taking appropriate steps in ensuring that the patient gets appropriate diagnosis. I had the opportunity to conduct my first FNP program clinical rotation. As an MSN, you are prepared to handle different aspect of care and diagnosis. In rotation, I realized that there is more that I need to learn as far as diagnosis and primary care is concerned. Primary care is intensive unlike ER, with the need for more follow up and abroad treatment for quality outcome. There is even more time needed to obtain lab results, hence diagnosis and treatment plan must be based on advanced physical test and the patient’s history.

There is also a key difference between primary care and ER when it comes to medication and treatments. In primary care, there are many protocols and many treatment options and sometimes patients have numerous comorbidities that that must be considered while choosing a plan of care. This often calls for differential diagnosis to ensure that the treatment plan addresses specific diseases and not comorbidities.

Primary care indulge different areas of clinical health and rotation exposes you to different patients in terms of age, gender, and disease infections. You have to be updated in treatment methods and ensure that you have the correct information going into treatment. As an MSN trained APN, you are a leader and perceived to be more knowledgeable and with more skills. Thus, it is only prudent to ensure that you follow the right procedures and ensure quality outcome.

Chamberlain Program Outcomes

NR 511 met PO #1: Provide high quality, safe, patient-centered care grounded in holistic health principles
(Holistic Health & Patient-Centered Care)
. The differential diagnosis and primary course as it helps the MSN APN nurse determine the final diagnosis of the patient and subsequent treatment plan. Thus, it enables the realization of Program Outcome #1, which advocates for safe, high-quality, patient centered healthcare that is premised on holistic health principles. A critical element of the patient’s safety is ensuring that the patient is given correct of a medical condition or illness is a critical element of patient safety and quality attributes of a healthcare system. The treatment plan should be supported with an evidence-based information.

AACN MSN Essentials

The course helped in the realization of two AACN MSN Essentials – Essential V: Informatics and Healthcare Technologies and Essential IX: Master’s-Level Nursing Practice. The realization of these essentials is demonstrated through the achievement of PO #1. Differential diagnosis and Primary care have a direct impact on patient’s healthcare outcomes as addressed by Essential IX addresses. This is because any nursing aspect that directly impacts healthcare outcomes encompass MSN practice due to their requirement of detailed, keener and more informed with high accountability demands.

NONPF Core Competencies

This course managed to demonstrate the need for Quality CompetenciesThrough this course, MSN-APN trained nurses develop NONPF’s quality competencies to enable them operationalize all the other important competencies. One can achieve this trough applying the current and best research study findings and results to clinical practice. Nurse practitioners should also consider the complex relationships between quality, safety, and cost in healthcare delivery. This competency has many other aspects that an MSN-APN nurse must demonstrate.

Connect

Differential Diagnoses – when a patient has a condition that is difficult to understand, clinicians and nurse practitioners use differential diagnosis to distinguish one condition, disorder or disease from others, especially when these conditions present close or similar clinical features (Gorenstein & Comer, 2015). This makes differential diagnosis a systematic diagnostic method that can identify a particular disease where there is a possibility of multiple alternatives.

Test sensitivity – In medical diagnosis, clinicians use test sensitivity to describe a test’s ability “to correctly identify those with the disease (true positive rate)” (Cummings
et al
., 2015). This is the exact opposite of test specificity which describe the test’s ability to correctly identify those without the disease (true negative rate) (Cummings
et al
., 2015).

Reflection

I can categorically say that this course was very critical in MSN because it directly addresses the healthcare’s sensitive stages. It informs the patient’s final diagnosis and all the subsequent treatment plan that the nurse will give. By meeting the requirements of PO #1 this course also directly advocates for f safe, high-quality and patient-centered healthcare that is premised on key holistic health principles. It emphasizes quality outcome and patient safety, which are salient element of healthcare provision. It also encourages evidence-based practice for better outcome.

 

References

Cummings, J., Soomans, D., O’laughlin, J., Snapp, V., Jodoin, A., Proco, H., … & Rood, D. (2015). Sensitivity and specificity of a nurse dysphagia screen in stroke patients.
MedSurg Nursing
,
24
(4), 219-224.

Gorenstein, E. & Comer, R. (2015). Case studies in abnormal psychology. New York, NY: Worth Publishers, a Macmillan Higher Education Company.

National Organization of Nurse Practitioner Facilities. (2013). Nurse practitioner population focused competencies.
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdf

Exemplar #8: NR601 Primary Care of the Maturing and Ageing Family

Part of nursing is being able to provide primary care from pediatrics to the aged population. This course was an opportunity to learn and practice about providing primary care for the maturing and ageing population. This is a very delicate population and one that needs intensive care. Primary care for this category of this population is more intense during prognosis and managing them after treatment (Boeckxstaens & De Graaf, 2011). As an MSN trained APN practitioner, it is important to not only demonstrate leadership but also advocate for the well-being of the patients after treatment.

During this course, I was able to learn that primary care doesn’t mean a fixed organizational structure or style but a blend of functional and variable characteristics to the needs – present and emerging – of the older persons (Boeckxstaens & De Graaf, 2011). Clearly, multimorbidity, disability, dependence and frailty play out often and differently in the aging persons; making a key challenge for primary care to be able to provide an adaptable response to these individuals’ needs. Indeed, caring for the elderly needs involving them in the care decisions since, contrary to what’s believed, the elderly consider their life quality as high (Boeckxstaens & De Graaf, 2011). Furthermore, providing care for the elderly requires coordination and continuity with other specialist care programs.

The central theme of primary care for the old and ageing is delivering seamless integrated care. I learned that instead of disease management, primary care prefers case management approach. This involves proactive geriatric assessment to know the individual’s functional, medical, and social needs, including isolation, and loneliness. We also need clinical or MSN practice guidelines for multimorbidity to avoid costly uncoordinated and multiple prescriptions. Importantly, primary care is a teamwork, and coordinated healthcare provision, and nurses have a significant role in ensuring quality care and alignment with home (family) care and social services

Chamberlain Program Outcomes

This provisions and lessons in this course meet Chamberlain’s PO #5: Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice (Extraordinary nursing). For example, when I helped an elderly patient get a referral by coordination and liaising her service with the relevant office, I operationalized PO #5, which advocates for positive outcomes through collaborative, evidence-based and compassionate practice. The mere fact that coordination and delivering of seamless integrated care in primary care for the ageing is a fulfilment of the PO #5.

AACN MSN Essentials

This course realized the fulfillment of MSN Essential VII, which advocates for Interprofessional Collaboration for Improving Patient and Population Health Outcomes. This essential is in line with PO #5 on the issue of coordinated and integrated care delivery. As an MSN NP you need to be working with different hospital/care departments to support the patient’s and a referral quality result. It is important that a NP consult and coordinate care with other health professionals as provided in essential VII.

NONPF Core Competencies

This course and the achievement of the practical outcomes that I managed to achieve shoed the need for Ethics Competencies as the NONPF core competencies. Dealing with elderly patients needs not only need compassion but also ethics both in their diagnosis and prognosis. I discovered that the elderly person’s families need to be helped to understand the situation including the patient’s prognosis. This is only possible when you infuse ethical principles in decision making.

Connect

        

Geriatrics: refers to the branch of social science or medicine that deals with the health and care of old people (Zaccagnini & White, 2015). This is basically what this course entailed.

Orthopaedic: is a special branch of medicine that deals with the correction of the body’s deformities of bones and muscles. It addresses the diagnosis, corrections, preventing, and treatment of individuals with their skeletal deformities (Zaccagnini & White, 2015). Most old people need to undergo orthopaedic treatment.

Reflection

In summary, I learned that the central theme of primary care for the old and ageing is delivering seamless integrated care. I learned that instead of disease management, primary care prefers case management approach. This involves proactive geriatric assessment to know the individual’s functional, medical, and social needs, including isolation, and loneliness. Nurses also need clinical or MSN practice guidelines for multimorbidity to avoid costly uncoordinated and multiple prescriptions. Importantly, primary care is a teamwork, and coordinated healthcare provision, and nurses have a significant role in ensuring quality care and alignment with home (family) care and social services

Primary care for the old have complex demands. Fortunately, nurses have adequate training to navigate through these complex demands for positive and quality patient outcome. It also needs ethics as a competency to be able to deal with the old and aging population. Further, dealing with this population needs interprofessional collaboration to enhance population and patient health outcomes.

References

Berry, S., Kiel, D. P., Schmader, K. E., & Sullivan, D. J. (2017). Falls: Prevention in nursing care facilities and the hospital setting.
Uptodate. com
.

Boeckxstaens, P., & De Graaf, P. (2011). Primary care and care for older persons: position paper of the European Forum for Primary Care. Quality in primary care, 19(6), 369.

Zaccagnini, M., & White, K. (2015).
The doctor of nursing practice essentials
. Jones & Bartlett Learning

 

Exemplar #9: NR 602 Primary Care of the Childbearing and Childbearing Family

This course course provides an NP student with the essential knowledge, information and experience to be able to diagnose and manage a childbearing/childrearing family and provide them with primary care as well as manage their common health problems. The course placed emphasis on assisting childrearing families to maintain or reach the highest level of functioning and health, focusing on health maintenance, health promotion. I am glad that this course prepared me to meet the MSN PO #1, MSN Essential VII, and the NP Core Competencies #8.

This course is focused on the primary care for low risk of a childbearing woman and her newborn. It is important for an FNP because it applies developmental theoretical perspective, for achieving primary care for during childbearing in a family practice setting. Also, the given clinical component gives the opportunity fo the MSN-FNP’s to integrate the learned theoretical content from their prior courses and use them in clinical gynecologic and obstetrical family practice. It gives the FNP-student nurse practitioner (SNP) skills needed for a quality holistic, primary care of the woman obstetrical client in ambulatory and family practice care.

This course also offers the practice and principles of care for the childbearing woman and family throughout the ante- and post-partum stages. The course explains this process through different ethnicities, ages, and social circumstances and also involves advanced physical assessment (NR509) and management of both normal pregnancy and different pregnancy complications. On top of the different pregnancy’s physiological changes, the course also helps to examine the psychological issues that are commonly encountered during the pregnancy’s prenatal and post-partum care provision.

Furthermore, the builds on human development and growth to focus on support knowledge of assessment and management of chronic and acute health care problems that practitioners encounter in primary care of family, and sometimes pediatric, settings. It analyzes the medical problems and conditions of expectant women, unborn and born infants, as well as children and adolescents within the context of a FNP framework.

Chamberlain Program Outcomes

Program outcome #1 advocates for providing high quality, safe, patient-centered care grounded in holistic health principles (summarized as holistic health & patient-centered care). The significance of holistic care was first emphasized by Florence Nightingale. Holistic care gives a patient satisfaction in the provided healthcare, which is also their right (Andrus, 2014). Through this course, and by meeting MSN PO #1 I am able to address childbearing patients and families’ social, physical, emotional, and spiritual needs, and support them in dealing with their illnesses, to improve their lives.

AACN MSN Essentials

The course achieved MSN Essential VII
:
Interprofessional Collaboration for Improving Patient and Population Health Outcomes. Achievement of this essential recognizes that an APN MSN-prepared nurse, being a leader and member of interprofessional teams, collaborates, consults, and communicates with other professionals in the healthcare field to coordinate and manage care (Andrus, 2014). As an MSN, you coordinate and lead interdisciplinary care teams across different care environment to improve health outcomes. This professional identity is achieved through MSN Essential VII.

NONPF Core Competencies

This course demonstrates the Nurse Practitioner Core Competency # 8: Ethics Competencies. This is because it ensures integration of ethical principles in care decision making, ensures evaluation of the ethical consequences of care decisions. It also applies ethically sound solutions to complex issues related to individuals, populations and systems of care. As an FNP this course has prepared me to promote patient-centered, comprehensive holistic care (Sohi, Champagne & Shidler, 2015). Thus, I know that, ethically it is the patients’ right to choose the type of care they feel comfortable with and can refuse care when they are not comfortable with a given care. This means that the nurse – an MSN-APN prepared FNP – has a responsibility to provide patients with enough information about the treatment and care so that they can make informed decision.

Connect

Postnatal depression: is the form of depression, which a parent can undergo after childbirth. The major victims are mothers but it can also affect fathers. The signs of postnatal depression include difficulty bonding with the new baby, insomnia or intense irritability. If untreated it can go for a long time and can lead to a major depression (Agrawal, 2015).

Postpartum hemorrhage entails excessive bleeding after childbirth. The hemorrhage often takes place after the delivery of the placenta. Its causes include uterine muscles’ loss of tone, or a bleeding disorder or sometimes when the placenta fails to be delivered completely or when it’s tone (Agrawal, 2015).

Reflection

This is one of the courses that is suitable for an FNP because it offers a lot of ways that help the FNP on addressing the social, emotional, spiritual, and physiological needs of parents after childbirth. In essence it helps to the student to operationalize Program Outcome # 1, which urges nurses and care givers to offer safe, high quality and patient-oriented care while considering holistic healthcare tenets. Also, it provides for collaboration and coordination while handling patients enhance desired quality health outcomes. For example, through Essential VII, this course helps you to learn to appreciate other professionals in your team and appreciate the significance of collaboration.

References

Agrawal, P. (2015). Maternal mortality and morbidity in the United States of America.

Andrus, V. L. (2014). Person-Centered Care: Enhancing Patient (Person) Engagement. 
Beginnings
, 
34
(1), 18-21.

Sohi, J., Champagne, M., & Shidler, S. (2015). Improving health care professionals’ collaboration to facilitate patient participation in decisions regarding life-prolonging care: An action research project. 
Journal of Interprofessional Care
, 
29
(5), 409-414.

Exemplar #10: NR 602 Advanced Clinical Care and Practice Across the Lifespan Practinum

As an MSN-FNP this course is very essential for my practice. This course has helped me achieve MSN-FNP Program Outcome #4: professional identity (Integrate professional values through scholarship and service in health care). This course offered an opportunity for practical experience in nursing scholarship. As described by the American Association of Colleges of Nursing (2011), scholarship includes the activities, which systematically advance the practice, research and teaching of nursing through a rigorous inquiry. The course also supports other MSN qualities such as leadership, advanced practice, coordination, collaboration and authority in advocating and providing quality care.

This enabled attainment of course MSN Essential IV
: 
Translating and Integrating Scholarship into Practice. This essential recognizes that the MSN-prepared nurse must apply research outcomes in the practice to make informed decisions and solve practice problems through evidence-based practice. The MSN-prepared nurse also works as a leader and change agent in healthcare setting. Utilizing the guidelines of clinical practice to recognize, plan, manage and treat diseases satisfies this essential.

This course – being an important APN course – continues to provide expanded the practical and theoretical knowledge of diagnostic and disease management principles specific to the MSN-FNP’s, for healthcare needs of all individuals across all ages. It enables students to further their skills in diagnosis, health promotion, prevention of illness, and general care management of complex chronic and acute conditions, as well as behavioral health. This course leads the student to develop and maintain such care strategies as patient education, follow-up, referral, and protocol development through an experience in clinical practicum in an advanced practice setting.

This course solidifies the FNP’s clinical experience, which involves developing knowledge and skills that supports provision of quality healthcare outcome through best research and evidence-based care. Achievement of the course leads to attainment of numerous Nurse Practitioner Core Competencies, key among them being competency # 7: Health Delivery System Competencies. This cluster of competencies (#7) refer to the design, planning, and implementation of community and public health programs for quality healthcare outcome and encompass such skills as effective communication, leadership, compassion, coordination, research and evidence-based practice in care provision (AACN, 2011).

Chamberlain Program Outcomes

This course has helped me achieve MSN-FNP Program Outcome #4: professional identity (Integrate professional values through scholarship and service in health care). This program outcome is especially important for aspiring FNPs in the clinical practice. For example, I have learned to provide primary care to patients of different ages, class and identities, which is important in FNP practice. As an MSN-FNP prepared nurse you’re expected to become a leader and have more skills in different care settings that will make you stand out among other practitioners. Thus, this course has offered important insights on not only MSN requirements but also cultural diversity and behavioral health concerns.

 
AACN MSN Essentials

The meeting of PO #4 enabled attainment of MSN Essential IV: Translating and Integrating Scholarship into Practice. Also, MSN essential III: quality improvement and safety comes close to this course. Expectedly, conducting advanced primary care to different age groups of patients and conduction differential diagnosis requires reliance on both Essential III and IV. As an FNP, attaining MSN level of practice required covering numerous theories, practical, simulations, laboratory sessions and case studies and being able to apply them in real-world.

 
NONPF Core Competencies

This course solidifies the FNP’s clinical experience, which involves developing knowledge and skills that supports provision of quality healthcare outcome through best research and evidence-based care. Achievement of the course leads to attainment of numerous Nurse Practitioner Core Competencies, key among them being competency # 7: Health Delivery System Competencies. This cluster of competencies (#7) refer to the design, planning, and implementation of community and public health programs for quality healthcare outcome and encompass such skills as effective communication, leadership, compassion, coordination, research and evidence-based practice in care provision (AACN, 2011).

 

Connect

Cryotherapy: is a form of therapy treatment that involves using freezing temperatures. It is also known as cold therapy, and used to cool body temperature and bring it down at the cellular and tissue level for therapeutic benefits (Song
et al
., 2016). It is a relatively new concept.

Immunization: often confused vaccination, and sometimes referred to as inoculation. Vaccination involves administering a vaccine (a mild form an infectious agent) in to your body (usually by injection). Immunization is the result of vaccination. The vaccine helps to stimulate the body’s immune system so that the body can recognize the disease and gradually build defenses against the pathogen to protect the body from future infection (Wilder-Smith
et al
., 2017).

Reflection

This course is an essential course for every MSN-FNP nurse because it forms the core of nursing care. Through this course one gets the opportunity to identify with all MSN Program Outcomes especially PO #4, which requires a nurse practitioner to incorporate scholarship and professional values in healthcare service. This course solidifies the FNP’s clinical experience, which involves developing knowledge and skills that supports provision of quality healthcare outcome through best research and evidence-based care. Achievement of the course leads to attainment of numerous Nurse Practitioner Core Competencies, key among them being competency # 7: Health Delivery System Competencies. This cluster of competencies (#7) refer to the design, planning, and implementation of community and public health programs for quality healthcare outcome and encompass such skills as effective communication, leadership, compassion, coordination, research and evidence-based practice in care provision (AACN, 2011).

 

References

American Association of Colleges of Nursing (AACN). (2011). Defining Scholarship for the Discipline of Nursing. Retrieved from 
http://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Defining-Scholarship.

Curtis, K., Fry, M., Shaban, R. Z., & Considine, J. (2016). Translating research findings to clinical nursing practice. 
Journal of Clinical Nursing
, 
26
(5-6), 862-872.

Goroll, A., & Mulley, A. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). China: Wolters Kluwer Health.

Wilder-Smith, A., Longini, I., Zuber, P. L., Bärnighausen, T., Edmunds, W. J., Dean, N., … & Gessner, B. D. (2017). The public health value of vaccines beyond efficacy: methods, measures and outcomes.
BMC medicine
,
15
(1), 138.

 

 

 

 

 

 

 

 

 

References

American Association of Colleges of Nursing (AACN). (2011). Defining Scholarship for the Discipline of Nursing. Retrieved from
http://www.aacnnursing.org/News-Information/Position-Statements-White-Papers/Defining-Scholarship
.

Advanced Practice Nursing Fact Sheet | 2017 NurseJournal.org. (2017). Retrieved from
http://nursejournal.org/advanced-practice/advanced-practice-nursing-fact-sheet/

About Boards of Nursing | NCSBN. (2017). Retrieved from
https://www.ncsbn.org/about-boards-of-nursing.htm

Agrawal, P. (2015). Maternal mortality and morbidity in the United States of America.

Andrus, V. L. (2014). Person-Centered Care: Enhancing Patient (Person) Engagement. Beginnings, 34(1), 18-21.

Berry, S., Kiel, D. P., Schmader, K. E., & Sullivan, D. J. (2017). Falls: Prevention in nursing care facilities and the hospital setting. Uptodate. com.

Boeckxstaens, P., & De Graaf, P. (2011). Primary care and care for older persons: position paper of the European Forum for Primary Care. Quality in primary care, 19(6), 369.

Centers for Disease Control and Prevention. (2017). Childhood Obesity Facts. Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion.

Chamberlain College of Nursing. (2016). Graduate Program Outcomes. Retrieved from
http://www.chamberlain.edu

Chamberlain College of Nursing. (2017). Pharmacokinetics, Pharmacodynamics, Art of Pharmacotherapeutics, Reproductive System Medications and Drug-OTC-Herbal Interactions. Week 1 lesson. Retrieved from
http://www.chamberlain.edu

Cherry, B., & Jacob, S. R. (2016). Contemporary nursing: Issues, trends, & management. Elsevier Health Sciences.

Codina, L. M. T. (2007). Adult nurse practitioner intensive review: Fast facts & practice questions. New York: Springer Pub. Co.

Cummings, J., Soomans, D., O’laughlin, J., Snapp, V., Jodoin, A., Proco, H., … & Rood, D. (2015). Sensitivity and specificity of a nurse dysphagia screen in stroke patients. MedSurg Nursing, 24(4), 219-224.

Curtis, K., Fry, M., Shaban, R. Z., & Considine, J. (2016). Translating research findings to clinical nursing practice. Journal of Clinical Nursing, 26(5-6), 862-872.

Gorenstein, E. & Comer, R. (2015). Case studies in abnormal psychology. New York, NY: Worth Publishers, a Macmillan Higher Education Company.

Goroll, A., & Mulley, A. (2014). Primary care medicine: Office evaluation and management of the adult patient (7th ed.). China: Wolters Kluwer Health.

Foronda, C. L., Alfes, C. M., Dev, P., Kleinheksel, A. J., Nelson Jr, D. A., O’donnell, J. M., & Samosky, J. T. (2017). Virtually nursing: Emerging technologies in nursing education. Nurse educator, 42(1), 14-17.

Hickey, J. V., & Brosnan, C. A. (2012). Evaluation of health care quality in advanced practice nursing. New York: Springer Pub. Co.American Association of Colleges of Nursing.  The Essentials of Masters Education for Nursing (2011). Retrieved from
http://www.aacn.nche.edu/education-resources/MastersEssentials11.pdf

Houston Health Department. (2015). HIV Surveillance Program. HIV Infection in Houston: An Epidemiologic Profile 2010-2014. Houston, Texas; 2015.

Kliegman, R. M., Schor, N. F., St Geme III, J. M., & Behrman, R. E. (2016). Nelson Textbook of Pediatrics. Philadelphia: Elsevier.

Lilley, L. L., Shelly Rainforth Collins, P., & Snyder, J. S. (2019). Pharmacology and the nursing process. Mosby.

Lobstein, T., Jackson-Leach, R., Moodie, M. L., Hall, K. D., Gortmaker, S. L., Swinburn, B. A., . . . Mc Pherson, K. (2015). Childhood and adolescent obesity: Part of a bigger picture. The Lancet, 2510-2520.

Maartens, G., Celum, C., & Lewin, S. R. (2014). HIV infection: epidemiology, pathogenesis, treatment, and prevention. The Lancet, 384(9939), 258-271.

Moyer, V. A. (2015). Screening for HIV: US preventive services task force recommendation statement. Annals of internal medicine, 159(1), 51-60.

National Collaborative on Childhood Obesity Research. (2012). Childhood Obesity in the United States. NCCOR.

National Organization of Nurse Practitioner Facilities. (2013). Nurse practitioner population focused competencies.
http://c.ymcdn.com/sites/www.nonpf.org/resource/resmgr/Competencies/CompilationPopFocusComps2013.pdf

Robinson, B. K., & Dearmon, V. (2013). Evidence-based nursing education: Effective use of instructional design and simulated learning environments to enhance knowledge transfer in undergraduate nursing students. Journal of Professional Nursing, 29(4), 203-209.  doi: 10.1016/j.profnurs.2012.04.022

Sohi, J., Champagne, M., & Shidler, S. (2015). Improving health care professionals’ collaboration to facilitate patient participation in decisions regarding life-prolonging care: An action research project. Journal of Interprofessional Care, 29(5), 409-414.

Tappen, R. M. (2016).
Advanced nursing research: From theory to practice
. Jones & Bartlett Publishers.

Wilder-Smith, A., Longini, I., Zuber, P. L., Bärnighausen, T., Edmunds, W. J., Dean, N., … & Gessner, B. D. (2017). The public health value of vaccines beyond efficacy: methods, measures and outcomes. BMC medicine, 15(1), 138.

Zaccagnini, M., & White, K. (2015). The doctor of nursing practice essentials. Jones & Bartlett Learning

 

 

 

Appendix 1: Tabulation of achieved program 0utcome, MSN Essentials and NONPF Competencies

Exemplar# Title

Program outcome

MSN Essentials Met

NONPF Core Competencies Met

Exemplar I: NR503 Population Health, Epidemiology & Statistical Principles

PO #1: Provide high quality, safe, patient-centred care grounded in holistic health principles (Holistic Health & Patient-Cantered Care)

Essential I: Background for Practice from Sciences and Humanities

Scientific Foundation Competencies.

Technology and Information Literacy Competencies

Exemplar II: NR 505 Advance Research Methods Week 3

PO #5: Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice (Extraordinary nursing)

Essential VI: Health Policy and Advocacy

Scientific Foundation Competencies

Policy Competencies

Exemplar III: NR 507 Advanced Pathophysiology

PO #2: Create a caring environment for achieving quality health outcomes (Care-Focused)

PO #4: Integrate professional values through scholarship and service in health care (Professional identity)

Essential VIII: Clinical Prevention and Population Health for Improving Health

Independent Practice Competencies.

Policy Competencies
.

Exemplar IV: NR 508 Advanced Pharmacology

PO #5: Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice (Extraordinary nursing)

Essential VII: Interprofessional Collaboration for Improving Patient and

Population Health Outcomes.

Health Delivery Systems Competencies

Exemplar V: NR 509 Advanced Physical Assessments

PO #1: Provide high quality, safe, patient-centered care grounded in holistic health principles (Holistic Health & Patient-Centered Care).

Essential IX: Master’s-Level Nursing Practice

Independent Practice Competencies

Exemplar VI: NR510: Leadership and Role of the Advanced Practice Nurse

PO #3: Engage in lifelong personal and professional growth through reflective practice and appreciation of cultural diversity (Cultural Humility))

Essential IX: Master’s-Level Nursing Practice

Leadership Competencies

Exemplar VII NR 511 Differential Diagnoses and Primary Care

PO #1: Provide high quality, safe, patient-centered care grounded in holistic health principles (Holistic Health & Patient-Centered Care)

Essential V: Informatics and Healthcare Technologies

Essential IX: Master’s-Level Nursing Practice

Quality Competencies

Exemplar VIII: NR 601 Primary Care of the Maturing and Ageing Family

PO #5: Advocates for positive health outcomes through compassionate, evidence-based, collaborative advanced nursing practice (Extraordinary nursing))

Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes

Ethics Competencies

Exemplar IX: NR 602 Primary Care of the Childbearing and Childbearing Family

PO #1: Provide high quality, safe, patient-centered care grounded in holistic health principles (Holistic Health & Patient-Centered Care)

Essential VII: Interprofessional Collaboration for Improving Patient and Population Health Outcomes.

Ethics Competencies

Exemplar X: NR 602 Advanced Clinical Care and Practice Across the Lifespan of Practinum

PO #4: Integrate professional values through scholarship and service in health care (Professional identity)

Essential III: Quality Improvement and Safety

Essential IV: Translating and Integrating Scholarship into Practice

Health Delivery Systems Competencies

SOAP Note Format

Patient Information:

Tina Jones is an obese 28-year-old African American female, who comes in today for evaluation and treatment of asthma exacerbation.

S.

CC
(chief complaint)

“I came in because I’ve been having breathing problems, and my inhaler just isn’t working the way it normally does.”

HPI
:
include all the information regarding the CC using the OLDCART format.

Onset: 2 days ago

Location: Nose and lungs

Duration: 2 days

Characteristics: Chest feels tight and she has noticed some wheezing, with non-productive, dry cough

Aggravating Factors: Worse at night when she is lying down on her back.

Relieving Factors: Albuterol inhaler 3 puffs every four hours (however, does not feel like it is completely under control). Drinking water helps with the cough.

Treatment: Albuterol inhaler 3 puffs every four hours

Current Medications
:

Albuterol 90 mcg/spray 3 puffs every four hours as needed for wheezing when around cats

Allergies:

Penicillin= rash

Cats and dust= runny nose, itchy and swollen eyes and increased asthma symptoms

Ms. Jones denies any food or latex allergies

PMHx
:

Asthma diagnosed at age 2 ½

Last time hospitalized for asthma was when she was a little girl, has never been intubated

Type 2 Diabetes Mellitus diagnosed at age 24

Menarche at age 11

Sexually active with men only, last tested for STIs four years ago, never tested for HIV

Soc Hx
:

Tine is a supervisor at Mid American Copy and Ship she has been working there since she was in high school. She is single and never been pregnant. Tine is a non-smoker and reports drinking alcohol socially with friends once a month. Reports the use of Marijuana from age 18 to 20. Tina is part of a book club and enjoys going to church talks. She currently lives with her mother and sister.

Fam Hx
:

Tina reports her sister also has asthma. Denies any family history of COPD, or any throat or neck surgeries. Her mother is living and has high cholesterol and hypertension. Her father passed away in a car accident a year ago. Father had high cholesterol, hypertension and type 2 diabetes. Her bother is obese and her sister has asthma. Tina denies any family history of eczema or COPD.

ROS
:
cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
Constitutional:

Head
:
EENT
: etc. You may list these in paragraph format or bullet format.
Always document the systems in order from head to toe.
You may focus the ROS to match the chief complaint unless you are doing a complete health history.

CONSTITUTIONAL:  No weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes:  No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat:  No hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  No rash or itching.

CARDIOVASCULAR:  No chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Reports shortness of breath, chest tightening, wheezing and non-productive dry cough

GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain.

GENITOURINARY:  No burning on urination, never been pregnant. Last menstrual period started yesterday.

NEUROLOGICAL:  No headache, No change in bowel or bladder control.

MUSCULOSKELETAL:  No muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: History of asthma, with allergy to cats, dust and penicillin.

O.

Physical exam
: See above ROS.

Diagnostic results
: None

A
.

Differential Diagnoses

Asthma exacerbation

No intervention is self-evident. Provide a rationale and evidence based in-text citation for each intervention

Diagnostics:
 

Order PFTs to be completed after exacerbation to have a baseline

Obtain oxygen saturation

 

 

Rx:

list treatments and medications you will order and “continue previous meds” if pertinent. State dosages, length of treatment and reason for choosing a specific treatment or drug.

Tina would be started on corticosteroids such as Flovent (44mcg per actuation) 2-4 puffs inhaled bid

Continue with Albuterol inhaler as well.

Education:
think about covering yourself legally; also indicate when written instructions are given.

 

Tine would be educated on the importance of seeing her asthma doctor regularly to manage and treat asthma symptoms.

 

Encourage her to keep a log of her asthma symptoms and triggers, and bring to her next visit for review.

Referral/Consults
:

 

Ms. Jones would be referred to an Allergist for evaluation and treatment.

 

Follow up:

indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.

 

Follow up appointment would be in 2-4 weeks to review asthma log and make sure medications are helping.

 

Reference

Prieto Centurion, V., Huang, F., Naureckas, E. T., Camargo, C. J., Charbeneau, J., Joo, M. J., & … Krishnan, J. A. (2012). Confirmatory spirometry for adults hospitalized with a diagnosis of asthma or chronic obstructive pulmonary disease exacerbation.
BMC Pulmonary Medicine
,
12
73. doi:10.1186/1471-2466-12-73. Retrieved from:
http://web.a.ebscohost.com.chamberlainuniversity.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=4&sid=285efade-b569-4623-8faf-d8f0d3ad546f%40sessionmgr4007

Self-Reflection

Explicitly describe the tasks you undertook to complete this exam.

Student Response:
I performed a comprehensive assessment. It is a complete, in-depth assessment that includes a complete health history and physical assessment. I have followed the comprehensive assessment following our school immersion examination steps for gathering an objective physical examination. I feel much more comfortable doing the head-to-toe examination somehow. In addition, the interview I performed to obtain were the personal history of illness, family medical history, current and past treatment, medications, risk factors, surgeries, and lastly interview for mental status.

Explain the clinical reasoning behind your decisions and tasks.

Student Response:
Through a comprehensive assessment, the interview started with finding the reason for the clinic visitation, with any health concerns Tina may have. While interviewing Tina, I obtained the subjective data and an education on the current medical problem or preventive medical issues.

Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional practice.

Student Response:
Overall, I have improved my assessment techniques by not only interviewing but also through a physical examination throughout the last 7 weeks. I’m glad that I have the opportunity to use this simulation before an encounter with my first real patient for clinical practice, and know what I am looking for assessment. Honestly, I have never comfortable to ask personal questions such as a sexual relationship, use of illicit drugs, etc. which I thought of privacy which I have never touched before in my nursing career. I realized these questions are part of the necessary data for assessing and diagnosis patients and I feel much comfortable and thankful for this opportunity.

 

Explicitly describe the tasks you undertook to complete this exam.

Student Response:
I performed a comprehensive assessment. It is a complete, in-depth assessment that includes a complete health history and physical assessment. I have followed the comprehensive assessment following our school immersion examination steps for gathering an objective physical examination. I feel much more comfortable doing the head-to-toe examination somehow. In addition, the interview I performed to obtain were the personal history of illness, family medical history, current and past treatment, medications, risk factors, surgeries, and lastly interview for mental status.

Explain the clinical reasoning behind your decisions and tasks.

Student Response:
Through a comprehensive assessment, the interview started with finding the reason for the clinic visitation, with any health concerns Tina may have. While interviewing Tina, I obtained the subjective data and an education on the current medical problem or preventive medical issues.

Identify how your performance could be improved and how you can apply “lessons learned” within the assignment to your professional practice.

Student Response:
Overall, I have improved my assessment techniques by not only interviewing but also through a physical examination throughout the last 7 weeks. I’m glad that I have the opportunity to use this simulation before an encounter with my first real patient for clinical practice, and know what I am looking for assessment. Honestly, I have never comfortable to ask personal questions such as a sexual relationship, use of illicit drugs, etc. which I thought of privacy which I have never touched before in my nursing career. I realized these questions are part of the necessary data for assessing and diagnosis patients and I feel much comfortable and thankful for this opportunity.

Reflection on Cardiovascular Shadow Health

I learned that a thorough cardiovascular assessment will help to identify significant factors that can influence cardiovascular health such as high blood cholesterol, cigarette use, diabetes, or hypertension. Therefore, a cardiovascular exam should be a part of every abbreviated and complete assessment.    A focused cardiovascular assessment is usually indicated after a comprehensive assessment indicates a potential cardiovascular problem. The focused cardiovascular assessment is also indicated when an interval or abbreviated assessment shows a change in status from your previous assessment or the report you received, when a new symptom emerges, or the patient develops any distress.

I feel there is always room for growth, and I would say growth in documentation and placements regarding murmurs was very much discussed in the Shadow Health module.   I think an advantage of a focused assessment, like when we are doing the module, it helps us understand each body system.  The fact the modules looks at so many ways to assess, subjective, objective, and even empathy, can only improve our charting and communication.

I plan on improving by integrating the cardiovascular health history and physical exam.  It takes a lot of objective and subjective information, and knowing how assess, in order to make the correct diagnosis.  Shadow Health, makes us better NP’s by working with the patient and talking into the computer.  It is very important that as I grow into a NP role, the correct questions are asked and for me to be able to analyze all the health information for a diagnosis.

 

Reflection on Cardiovascular Shadow Health

I learned that a thorough cardiovascular assessment will help to identify significant factors that can influence cardiovascular health such as high blood cholesterol, cigarette use, diabetes, or hypertension. Therefore, a cardiovascular exam should be a part of every abbreviated and complete assessment.    A focused cardiovascular assessment is usually indicated after a comprehensive assessment indicates a potential cardiovascular problem. The focused cardiovascular assessment is also indicated when an interval or abbreviated assessment shows a change in status from your previous assessment or the report you received, when a new symptom emerges, or the patient develops any distress.

I feel there is always room for growth, and I would say growth in documentation and placements regarding murmurs was very much discussed in the Shadow Health module.   I think an advantage of a focused assessment, like when we are doing the module, it helps us understand each body system.  The fact the modules looks at so many ways to assess, subjective, objective, and even empathy, can only improve our charting and communication.

I plan on improving by integrating the cardiovascular health history and physical exam.  It takes a lot of objective and subjective information, and knowing how assess, in order to make the correct diagnosis.  Shadow Health, makes us better NP’s by working with the patient and talking into the computer.  It is very important that as I grow into a NP role, the correct questions are asked and for me to be able to analyze all the health information for a diagnosis.

NAPSRx Final Exam Answers 

 

1. How are drugs sorted into therapeutic groups and classes?

A. first by the conditions that they are used to treat. and then by their mechanisms of action

B. first by their mechanisms of action. and then by their therapeutic effects

C. first by their side effects. and then by their therapeutic effects

D. first by their toxicity. and then by their effectiveness

 

2. Bone marrow transplants…

A. require that the patient first undergo chemotherapy or radiation to kill the diseased stem cells and promote white blood cell production.

B. are a type of stem cell therapy. unless patient’s own cells are reinjected.

C. are always a type of stem cell therapy.

D. can help people with leukemia. a condition in which the body does not produce enough white blood cells.

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3. What does AMA stand for?

A. American Medical Academy

B. American Medical Accreditation

C. American Medical Association

D. Association of Medical Assistants

 

NAPSRx Final Exam 4. What section of a drug’s package insert describes situations in which the drug should not be used because the risks outweigh the therapeutic benefits?

A. adverse reactions

B. contraindications

C. overdosage

D. warning/precautions

 

5 What is tertiary care?

A. adding medications together to achieve a better clinical effect

B. highly specialized medical and surgical care provided by a large medical center for unusual or complex medical problems

C. receiving medical or surgical care that does not require an overnight stay in the treatment facility

D. seeing a physician for routine checkups and general healthcare

 

6. Which of the following is NOT one of the stages in the classic approach to brand development strategy covered in your manual?

A. brand personality

B. brand positoning

C. brand quality

D. brand values

 

7 What are vasodilators used to do?

A. decrease vascular resistance and increase blood flow

B. mimic pathogens to stimulate the immune system

C. narrow the blood vessels

D.stimulate the CNS to make the heart beat faster

 

8. What is the name of the condition that occurs after a specific dose of a drug is given at such regular intervals that absorption and elimination (and therefore drug plasma concentration) have become fairly constant?

A. homeostasis

B. steady state

C. titration

D. tolerance

 

9. Which statement is TRUE about ocular administration?

A. Ocular administration is primarily for drugs that must cross the blood-brain barrier.

B. Ocular administration is used primarily to treat the eye.

C. Ocular administration is used when a drug must enter the bloodstream immediately.

D. Ocular administration is used when a drug must produce immediate effects on the brain or spinal cord.

10. Which entities invest’s the most money in pharmaceutical R&D?

A. Canadian pharmaceutical companies

B. the NIH

C. the U.S. Government

D. U.S. pharmaceutical companies

 

NAPSRx Final Exam 11. How are most drugs excreted?

A. via the bloodstream

B. via the heart

C. via the kidneys

D. via the skin

 

12. Over the last few decades, what has happened to legal limitations on sales’ reps discussions about off label uses?

A. Limitations have decreased.

B. Limitations have increased significantly.

C. Limitations have increased slightly.

D. Limitations have remained about the same.

 

13. Answer: Branding name

 

14. What does it mean if two drugs are at parity?

A. Both drugs are essentially in a neutral position.

B. Both drugs are generics.

C. Both drugs have exclusive preferred status.

D. The two drugs are bioequivalent.

 

15 Who is most likely to benefit from electronic sampling programs?

A. Everyone would benefit equally from electronic sampling programs

B. physicians in hospitals who are too busy to see representatives

C. physicians in rural areas who are not as frequently visited by representatives

D. physicians in urban areas who are too busy to see representatives

 

16. When referring to medication dosage, which abbreviation means “one-half’:

A. MS

B. OH

C. SM

D. SS

 

17 What is an internist?

A. a physician who practices internal medicine

B. a physician’s intern

C. a type of oncologist who specializes in chemotherapy

D. an internal sales representative

 

18. Which of the following is a type of white blood cell?

A. erythrocytes

B. insulin

C. Lymphocytes

D.HCs

 

19. Why are novice sales representatives often placed in charge of negotiating MCO formularies?

A. to become more familiar with the healthcare industry

B. to become more familiar with their territories

C. P&T committees are more receptive to new faces.

D. They are not. This job is usually reserved for more experienced reps.

 

20. What distinguishes pharmacodynamics from pharmacokinetics?

A. Pharmacodynamics studies a drug’s ex vivo effects.

B. Pharmacodynamics studies how drugs affect the body.

C. Pharmacodynamics studies the how the body affects drugs.

D. Pharmacodynamics studies the time required for a drug’s absorption.

21 What proportion of the drugs tested on human subjects are eventually approved by the FDA?

A. about 20%

B. about 60%

C. about 70%

D. about 95%

 

NAPSRx Final Exam 22. According to a study discussed in your manual, how do most physicians prefer to receive their drug samples?

A. by borrowing them from hospitals

B. by ordering them over the Internet

C. by trading them for services

D. directly from sales representatives

 

23. Which of the following is an example of a central value?

A. I buy Advil to show that I’m a modern consumer.

B. I like Advil because we were both born in the 80s.

C. I prefer Advil because I like the flavor.

D. I prefer Advil because it’s easier to swallow.

 

24. Which of the following specialties likely has the MOST emergency calls?

A. cardiology

B. psychiatry

C. urology

D. All specialists have the same number of emergency calls.

 

25. What affects the rate of active transport?

A. the availability of carriers. but not energy

B. the availability of energy. but not carriers

C. the availability of carriers and energy

D. neither the availability of carriers nor the availability of energy

 

26. Over the last few decades, what has happened to the FDA approval time for new drugs?

A. It has been lengthened to ensure safer drug products.

B. It has been lengthened to limit DTC marketing

C. It has been shortened to improve drug quality

D. It has been shortened to reduce the cost of new drug development.

 

27. Which of the following would NOT help improve compliance?

A. patients liking their providers

B. patients using only one pharmacist

C. pharmacists understanding how generics differ from brand name drugs

D.  support groups

 

28. Which entity chooses a drug’s trade name?

A. the drug’s inventor

B. the drug’s manufacturer

C. the FDA

D. the United States Pharmaceutical Council

 

29. What type of stem cells are obtained from embryos and can develop into any cell type?

A. multipotent

B.  pluripotent

C. totipotent

D. All stem cells can develop into any cell type.

 

NAPSRx Final Exam 30. As the price a patient pays for a prescription increases, what happens to the likelihood that the patient will fill it?

A. It decreases.

B. It increases.

C. It remains unaffected because the prescription is needed.

D. It remains unaffected because the prescription’s increased cost is offset by its perceived value.

 

31. Most involuntary movements come from which type of muscle tissue?

A. cardiac and smooth

B. only skeletal

C. skeletal and cardiac

D. skeletal and smooth

 

32. Which of the following is NOT one of the body’s major organ systems?

A. the cardiovascular system

B. the cellular system

C. the gastrointestinal system

D.  the musculoskeletal system

 

33. How do most drugs exert their primary physiological effects?

A.  by activating synapses between different types of tissues

B. by binding to cell receptors that are sensitive to their presence

C. by inhibiting synapses between different types of tissues

D.  through genetic mutation

 

34. What is the most reliable source of information for determining therapeutically equivalent drug products?

A. AMA guide

B. Blue Book

C. FDA drug list

D.  Orange Book

 

35. What does subcutaneous mean?

A. beneath the intervention

B. beneath the muscle tissue

C. beneath the outer skin

D. beneath the suture

 

36. What should a sales representative do if all of the prime spaces in a drug cabinet are coccupied?

A. ask staff for permission to move some of the other products in the cabinet

B. ask staff for permission to throw away expired products in the cabinet

C. ask the doctor if he still needs some of the other products in the cabinet

D. surreptitiously move your largest competitors’ products out of the way

 

37. It is inappropriate for physicians’ prescribing behaviors to be educated by their personal tastes and idiosyncrasies

A. TRUE

B. FALSE

 

38.The FDA defines API as the active__ ingredient in a drug, which produces the desired change in the body.

A. pharmaceutical

B. positive

C. potent

D.  primary

 

39. What are the 2 legal classifications of wholesalers?

A. distributors and supply chains

B. pharmacists and NAMs

C. primary and secondary wholesale distributors

D. retailers and institutions

 

40.What term describes the usage of a medication for purposes other than the FDA-approved indications on the labeling?

A. contraindicative indication

B. off-indication usage

C or D. off-label

 

41. What is the acronym for pharmacokinetics?

A. KN

B. PC

C. PK

D. pT

 

42. The dosage range of a drug that is both safe and beneficial is known as the therapeutic window.

A. TRUE

B. FALSE

 

43. What is typically NOT a characteristic of a pharmaceutical sales rep?

A. Pharmaceutical sales reps are authentic and real.

B. Pharmaceutical sales reps are creative.

C. Pharmaceutical sales reps are focused.

D. Pharmaceutical sales reps are not concerned about competitors.

 

44. What entity grants drug patents?

A. the FDA

B. the FDA if the drug is over-the-counter and the U.S. Patent and Trademark Office if the drug is prescription

C. the FDA if the drug is prescription and the U.S. Patent and Trademark Office if the drug is over-the-counter

D. the U.S. Patent and Trademark Office

 

45. Which of the following refers to all active and inert pharmaceutical ingredients in a drug, including fillers and colors?

A. formulation

B. mycoplasma

C. peptide

D. saccharide

 

NAPSRx Final Exam 46. What is the difference between potency and efficacy?

A. Doctors prefer more potent drugs.

B. Drug manufacturers prefer more potent drugs.

C. Potency refers to the drug’s effectiveness. while efficacy refers to its strength.

D. Potency refers to the drug’s strength, while efficacy refers to its effectiveness.

 

47. What is the minimum level of education required for a nurse practitioner?

A. a certification program

B. an associate’s degree

C. a bachelor’s degree

D. a graduate degree

 

48. How many names must a drug have?

A. at most three

B. at least three

C. at most five

D. at least five

 

49. How has a longer development time increased the cost of bringing a new drug to market?

Answer: Increasing the cost of capital

 

50. Senior citizens consume over times as many pharmaceuticals as people under 65.

A. three

B. five

C. ten

D. fifteen

 

51. What agency regulates the distribution and use of narcotics?

A. DEA

B. FTC

C. OIG

D.TSA

 

52. What is passive diffusion?

A. a type of pinocytosis

B. membrane transport via vesicles

C. the use of energy to help a substance pass from a low concentration gradient to a high one

D. when a substance freely moves through a membrane from a high concentration gradient to a low one

 

53. What are the MAIN categories of drugs under FDA jurisdiction?

A. active drugs and active placebos

B. biopharmaceuticals and nutraceuticals

C. non-prescription and nutraceuticals

D. prescription and non prescription

 

54. Answer: Oxytocin

 

55. What are all metabolites?

A. active substances

B. inactive substances

C. injections

D. products of metabolism

56. When a drug is administered orally, where does first-pass metabolism occur?

A. intestine

B. liver

C. pancreas

D. stomach

 

57. What is the medical term for swelling?

A. assay

B. edema

C. instillation

D. protease

 

58. Which of the following is NOT part of the Seven Step Cascade of Emotion?

A. be a consultant. not a rep

B. identify what your product does

C. reflect

D. visualize the power of 10

 

59. Which part of a clinical research paper is frequently referred to as the road map?

A. abstract

B. findings

C. letter to the editor

D . methods

 

60. Which of the following is a main active ingredient in lung surfactants?

A. animal lung extract

B.  germicides

C.  sympathomimetic drugs

D.  theophylline

 

61. What does parenteral mean?

A. child prescriptions

B. injection

C. oral

D. tablet

 

62. Which term denotes a type of substance that enhances the action of a drug or antigen?

A. adjuvant

B. indicated

C. ligase

D peptide

 

63. If a sales representative’s product is placed on the second tier of a standard three-tier formulary, which of the following is most likely true?

A. It has not been reviewed by the P&T committee.

B. It is in a neutral position unless it is at parity with other drugs.

C. It probably has exclusive preferred status if it is not at parity with any other drugs.

D. It will essentially sell itself if it is granted exclusive preferred status.

64. Which of the following is NOT one of the four basic transport mechanisms?

A. active transport

B. homeostasis

C. passive diffusion

D. pinocytosis

 

65. Which statement accurately describes a relationship between drug agonists and antagonists?

A. Agonists and antagonists can be used together.

B. Agonists and antagonists should not be used together.

C. Antagonist drugs activate receptors. while agonists block access to receptors.

D. Antagonists are endogenous whereas agonists are man-made.

66. What is the study of the effects and movement of drugs in the human body?

A. anatomy

B. antology

C. clinical pharmacology

D. pathology

 

67. According to your manual, what is a common complaint that physicians have about traditional sampling methods?

A. that drug sample supply is too unpredictable

B. that patients are less likely to take free samples because they think they are lower quality

C. that patients do not like seeing drug representatives in their offices

D. that they receive too many drug samples

 

68. Which of these entities is formed by two or more hospitals or other healthcare entities to negotiate reduced rates with its aggregated purchasing power?

A. GPO

B. In-state wholesaler

C. PPO

D. RPO

 

69. What is another name for a drug derived from a biologic compound?

A. large molecule

B. oligonucleotide

C. orgaanism

D. small molecule

 

70. What is the most common policy regarding pharmaceutical reps dispensing drug samples in hospitals?

A. By federal law. drug sampling is permitted in all hospitals.

B. By federal law. it is up to individual physicians. not the hospital.

C. Drug sampling is encouraged. but not required.

D. Drug sampling is often forbidden.

 

71 Which of the following would help you build trust with a physician?

A. asking if he or she is having any problems with the managed care coverage of your products

B. repeating a question you already asked

C. surprising the office staff with a new poster in the break room

D. None of these would help you build trust with a physician.

 

72. What term denotes the difference between the usual effective dose and the dose that induces severe or life-threatening side effects?

A. dose-response relationship

B. margin of safety

C. the placebo effect

D. therapeutic window

 

73. What are excipients?

A. a type of cell receptor to which antagonists bind to decrease the effects of the body’s natural agonists

B. another term for generic equivalents

C. sites of action besides the target sites of action

D. the inert ingredients in a drug formulation

 

74. What is another term for the AWP?

A. dock-to-dock price

B. float price

C. list price

D. non-stock price

75. Which of these is the most likely use for a uterotonic agent?

A. to induce labor

B. to make the urine more alkaline

C. to supplement oral food intake

D. to treat hyperthyroidism

 

76. As of November 2013, which of these countries has legalized DTC advertising of prescription drugs?

A. Canada

B. Japan

C. Spain

D. none of these

 

77. Why are oral drugs often taken on an empty stomach?

A.  to be more wholly absorbed by the stomach

B. to minimize absorption by the intestine

C.  to minimize nausea

D. to pass through the stomach more quickly

NAPSRx Final Exam 78. What is one factor that differentiates community health centers from hospitals?

A.  Community health center formularies are more restrictive.

B. Community health centers have higher reimbursement rates.

C. Newer brand name drugs are easier to access at community health centers.

D. None of these

 

79. How does drug sampling provide a social benefit?

A. Doctors donate their unused drug samples to charities.

B. Doctors often use drug samples to treat patients who otherwise could not afford it.

C. It allows patients to try out different prescription medications before consulting with physicians.

D.  Drug sampling provides a social benefit in all of these ways.

 

80. Which medical term denotes the use of a stethoscope to listen to the heart?

A. auscultation

B. cardioversion

C. catheterization

D. echocardiography

 

81. What do enteric coatings do?

A. facilitate vomiting

B. help drugs dissolve in the stomach

C. help drugs enter the bloodstream more quickly

D. prevent dissolution in the stomach

 

82. What is the duration of exclusivity for orphan drugs?

A.  6 months

B. 1 year

C.  7 years

D.  15 years

 

83. What do National Account Managers do?

A. act as the sales reps’ primary point of contact with the rest of the corporation

B. manage the FDA approval process

C. negotiate contracts with MCOs and PBMs

D.  sell only to pharmacies

84. What does it usually mean if a drug recall is voluntary?

A. Pharmacies may choose whether to return the drug or dispense it.

B. The FDA has determined that the drug is perfectly safe. but ineffective.

C. The manufacturer has recalled the product on its own. but negotiated with the FDA beforehand.

D. The manufacturer has recalled the product without negotiating with the FDA.

85. Which phase of clinical trials is also known as the pivotal phase?

A. Phase I

B. Phase III

C Phase IV

D. Phase IX

 

86. During which phase of clinical trials is the new drug’s safety and effectiveness first tested in the target group?

A. preclinical

B. Phase I

C. Phase II

D. Phase III

 

NAPSRx Final Exam 87. How do antacids work?

A. by increasing blood flow to the stomach

B. by lowering gastric pH

C. by raising gastric pH

D. by suppressing cholesterol formation by the liver

 

88. What is one of the biggest time wasters for a pharmaceutical sales rep?

A. Caterers

B. Pharcists

C. receptionists

D. travel time

 

89. What happens when equilibrium is reached?

A.  equal numbers of molecules cross the membrane in both directions

B.  molecules stop moving

C. the concentration gradient decreases indefinitely

D. the concentration gradient increases indefinitely

 

90. What are the most common vectors used in gene therapy?

A.  autologous antigens

B. liposomes

C. naked DNA

D. viruses

 

91. What is the percentage fee that the dispenser pays the wholesaler for distribution?

A. margin fee

B. recharge

C. standard fee

D. upcharge

 

92. What is the difference between a chronic (or continuing) reaction, and a delayed reaction?

A. Chronic reactions are exaggerated. whereas delayed reactions are idiosyncratic.

B. Chronic reactions occur only during treatment. whereas delayed reactions only occur during withdrawal.

C. Chronic reactions persist for a long time. whereas delayed reactions take some time to develop.

D. Delayed reactions are always idiosyncratic. but chronic reactions are not.

 

93 What is clinical effect?

A. federally funded research condition

B. the effect of maximum dosage

C. the response produced by a medication

D. the use of treatment drugs in chemotherapy

 

94. Which of the following is an example of noncompliance?

A. a patient forgetting to take a drug at a specified time of day

B. a patient taking a drug. but only because it has been court-mandated

C. a pharmacist dispensing a generic equivalent of a drug instead of the brand name

D. a physician refusing to prescribe a drug because he or she does not trust the clinical studies on it

 

95. What is the average circulation time of blood?

A. about a minute

B. about 5 minutes

C. about 5 to 10 minutes depending on the patient’s age and health conditions

D. about 10 minutes

 

96. What is one way in which pharmaceutical selling is different from selling in most other industries?

A. In pharmaceutical sales. the decisions-makers. consumers. and payers are usually the same entity.

B. Pharmaceutical selling takes less time because doctors are so busy.

C. Representatives do NOT sell to the end user of the product.

D. Representatives DO sell to the end user of the product.

 

97. From what types of entities do primary wholesale distributors buy most of their drugs?

A. brokerages

B. buying clubs

C. manufacturers

D. physicians

98.What is the Office of the Inspector General (01G)?

A. a department in pharmaceutical companies

B. an arm of the Department of Health and Human Services

C. an arm of the European Medicines Agency D an arm of the FDA

 

99. What are doctors required to consider when deciding whether or not to prescribe a particular drug?

A. quantity of life over quality of life

B. that no drugs with adverse effects should ever be used

C. the inferiority of OTC drugs

D. the severity of the disorder being treated and the effect it has on the patient’s quality of life

NAPSRx Final Exam 100. Which entity assigns a new drug its generic names?

A. the drug’s inventor

B. the Food and Drug Administration

C. the United States Adopted Name Council

D. the United States Pharmaceutical Council

 

101. Drugs can be used days beyond their expiration date.

A.  2-7 days. depending on the most current monograph.

B.  2-90 days. depending on state laws

C. 7-90 days. depending on the type of drug and its therapeutic class.

D. none of these

 

102. What is necessary for a drug to be excreted extensively via the kidneys?

A. The drug must be water-soluble. and not bind too tightly to proteins in the bloodstream.

B. The drug must have a phospholipid bilayer and be non-water-soluble.

C. The drug must have a phospholipid bilayer and bind well to proteins in the bloodstream.

D. The drug must not be water-soluble.

 

103. Which organization or individual initiates the clinical trial and finances the study?

A. clinical research organization

B. investigator

C. researcher

D. sponsor

 

104. The name describes the atomic or molecular structure of a drug.

A. chemical

B.  generic

C. pharmaceutical

D. proprietary

 

105. Under PhRMA Code, is it acceptable or unacceptable for a pharmaceutical sales rep to take a physician and the physician’s spouse to a fundraising dinner?

A. acceptable if only the physician attends

B. acceptable if only the physician attends. and the total is under $100

C. acceptable if the total is under $100

D. unacceptable

 

106. The Hatch-Waxman Act is considered the most significant drug-related affecting the pharmaceutical industry since 1962.

A. experiment

B. legislation

C. process

D. research

 

107. What term denotes the the extent, quality, or degree to which a substance is poisonous or harmful to the body?

A. caliber

B. chronicity

C. indication

D. toxicity

 

108. What issue has MOST encouraged consumers’ desire to see more OTC medications?

A. a weaker patients’ rights movement

B. lack of insurance coverage

C. less reliance on the Internet

D. proliferation of herbal remedies

 

109. What is the degree to which a medication produces a therapeutic effect?

A. diffusion

B. efficacy

C. protease

D. vector

 

110. What is the most important benefit of electronic prescribing?

A. Choice

B. cost

C. inquiries

D.  safety

 

111. When does the FDA regulate generic drugs?

A. only if they are branded generics

B. only if they have been contested

C.  always

D never

 

NAPSRx Final Exam 112. Which phase of trials largely determines the clinical dose?

A. preclinical trials

B. Phase II trials

C. Phase III trials

D. Phase IV trials

 

113. What is an advantage of inactivated vaccines over attenuated vaccines?

A.  Inactivated vaccines are less expensive to prepare.

B. Inactivated vaccines have a higher probability of eliciting the desired immunological response.

C. Inactivated vaccines have a more stable shelf life.

D.  Inactivated vaccines only require a single dose.

114. Which medical term denotes a low supply of oxygen due to low blood flow?

A. potentiation

B. ischemia

C. TID

D. titration

 

115. What are the two main types of prescription drug marketing?

A. (1) marketing to insurance companies. and (2) marketing to pharmacies

B. (1) PBM marketing. and (2) marketing to governments

C. (1) professional physician promotions. and (2) direct-to-consumer advertising

D. (1) publicly-funded marketing. and (2) physician-funded marketing

 

116. What is the site of delivery for subcutaneous injections?

A. fatty tissue beneath the surface of the skin

B.  lymphatic tissue

C. muscle tissue

D. the stomach, via a special type of needle

 

117. What must be contained in the Description section of a pharmaceutical package insert?

A. adverse effects

B. mechanism of action

C. pharmacokinetics

D. the proprietary name and the established name

 

118. What is the study of a medication’s effects as it travels through the body?

A. pharmacodynamics

B. pharmacogenetics

C. pharmacogenomics

D. pharmacokinetics

 

119. Customers purchase products from people they like, trust, and respect. This is called the  

A. closing of the sale

B. first time advantage

C. likeability factor

D. power of knowledge

 

120. What is penicillin’s primary mechanism of action?

A. It disturbs bacterial cell wall synthesis.

B It inhibits the production of viruses.

C. It prevents proper DNA replication.

D. It sends a messenger to the bone marrow to produce extra white blood cells

 

121. According to your manual, how has the U.S. healthcare marketplace changed in the last few decades?

A. Fewer and fewer prescription drugs have been made available as OTCs.

B. Managed care has been increasingly replaced by more patient-centered approaches.

C. The aging Baby Boomer generation has begun demanding more personalized attention.

D. There has been decreased emphasis on preventive health.

 

122. How does pharmaceutical marketing help narrow the treatment gap?

A. It encourages patients to take more active roles in their healthcare.

B. It makes doctors more skeptical of the pharmaceutical industry.

C. It makes patients more skeptical of their doctors’ opinions.

D. all of these

 

123. What do immunosuppressive agents do?

A. decrease risk of infection

B. increase risk of infection

C. reduce the risk of rejection of foreign bodies

D. treat psoriasis

 

124. What types of drugs are EGFR inhibitors?

A. antineoplastics

B. cardiovascular agents

C. CNS agents

D. mitotic inhibitors

 

125. Which of the following means outside of the living body?

A. en vivo

B. ex vitro

C. ex vivo

D. intra vivo

 

126. The FDA requirements for nutraceuticals and medicinal herbs are just as stringent as for pharmaceuticals.

A. TRUE

B. FALSE

 

127. What is the estimated net gain of private-sector healthcare’s contributions to increased U.S. life expectancy?

A. $5-10 billion

B. $40-50 billion

C. $800-900 billion

D.$ 2-5 trillion

 

128. Which statement is TRUE regarding post-approval drug monitoring?

A. All side effects are determined during clinical trials.

B. Drug manufacturers are only required to report adverse effects if they are severe or life-threatening.

C. Drug manufacturers are only required to report adverse effects if they have been proven in clinical studies.

D. The FDA can choose to withdraw their approval if new evidence arises.

 

NAPSRx Final Exam 129. Which term denotes when tolerance to one medication causes increased tolerance to another medication?

A. cell tolerance

B. cross-tolerance

C. indicated tolerance

D. minimized tolerance

 

130. Patents expire __ years from the date of filing.

A. ten

B. fifteen

C. twenty

D. thirty

 

131. After a trade-name drug’s patent expires, how may generic versions of it be sold?

A. only under the branded generic name

B. only under the generic name

C. only under the original trade name

D. under the original trade name or a generic name

 

132. What is required for a new pharmaceutical to be considered a viable therapy?

A. It causes no serious adverse effects.

B. It causes no side effects.

C. It has an active placebo.

D. It is more effective and/or causes fewer serious adverse effects than other drugs on the market.

 

133. Under the AMA guidelines, who is ultimately responsible for minimizing conflicts of interest?

A.  doctors

B. lawyers and office managers

C. pharmaceutical companies

D. sales representatives

 

134. The act of dispensing a pharmaceutical alternative for the product prescribed is

A. alternative licensure

B. equivalence practice

C.  necessitated substitution

D. pharmaceutical substitution

 

135. What does it mean if a drug is said to have a wide margin of safety?

A. Its safety levels have yet to be adequately verified.

B. Its safety varies widely among different types of patients.

C. There is a greater chance of severe or life-threatening side effects.

D. There is a lower chance of severe or life-threatening side effects.

136. Which of the following is the correct medical acronym for effective dose?

A. DE

B. ED

C. EFD

D. eff D

 

137. Why is one group of subjects given an active drug, while another group only receives a placebo?

A. to assess patients’ expectations

B. to assess the drug’s effectiveness

C. to assess the professionalism of the study staff

D. to assess the subjects’ demographics

 

138. A generic version is likely to have some inactive ingredients that are different from those of the original drug.

A. TRUE

B. FALSE

 

139. Which of the following is an example of a functional value?

A.  I drink Coca-Cola because I am a citizen of the world.

B.  I drink Coca-Cola because I like looking like a traditionalist.

C.  I drink Coca-Cola because I like the taste.

D.  I drink Coca-Cola because it is an international brand.

 

140. Where are most drugs metabolized?

A.  interstitial spaces

B.  liver

C. stomach

D . the bloodstream

 

141. What is essential to the ethical requirement that subjects be selected fairly?

A. Selection criteria should be well-supported by documented evidence.

B. Studies should make every attempt to conduct research on subjects who are underprivileged and in need of medical attention.

C. Subjects should be selected based on scientific objectives.

D. all of these

 

NAPSRx Final Exam 142. Which of the following is the most appropriate salutation for a cover letter if you cannot find a contact name?

A. Dear Personnel Department.

B. Dear Sir or Madam,

C. Dear Sir

D.To Whom It May Concern.

 

143. What is part of becoming an indispensable pharmaceutical sales rep?

A. asking for feedback

B. giving the doctors anything they ask for to prescribe your products

C. keeping your market share goals the same each term

D. not bothering busy doctors in hospitals

 

144. Which of the following is NOT typically included in the indications and usage section of the package insert information?

A. diseases or conditions that the drug is approved to treat

B. the drug’s active metabolites

C. the drug’s recommended usual dosage

D. the drug’s usual dosage range

 

145. Which term denotes the practice of classifying physicians and other potential prescribers by anticipated prescription volume?

A. conditioning

B. deciling

C. detailing

D. private labeling

 

146. What makes a drug eligible for fast track approval from the FDA?

A. It is a generic that has already been approved as a branded drug.

B. It is a new drug.

C. It is less expensive than what is currently on the market.

D. It treats patients with a serious. life-threatening condition.

 

147. In the gastrointestinal tract, help break up tablets to ensure full release of the active pharmaceutical ingredient.

A. binders

B. disintegrants

C. dispersing agents

D. lubricants

 

148. According to your manual, what does the PDRP do?

A. It educates patients on their treatment options.

B. It expands sales representatives’ access to patient information.

C. It improves communication between sales representatives and patients in doctors’ offices.

D. It limits sales representatives’ abilities to see individual physicians’ prescribing data.

 

149. What are the components of the central nervous system?

A. the brain and sense organs

B. the brain and spinal cord

C. the brain. spinal cord. and peripheral nervous system

D. the spinal cord and sense organs

150. Which term denotes the origin or cause of a medical condition?

A. cytology

B. discovery

C. etiology

D. pathology

 

151. Patients diagnosed with Type 1 diabetes…

A.  …do not produce enough insulin because they do not have enough B cells.

B.  …have an autoimmune disease.

C.  …produce enough insulin. but it is not as effective.

D.  …rely on insulin from porcine sources.

 

152. Which DTC pharmaceutical marketing tactic is permitted in European countries?

A. disease state ads

B. branded billboards and disease state ads

C. branded highway billboards

D. branded radio ads

 

153. What is one way in which psychologists DIFFER from psychiatrists?

A. Psychologists are more concerned with subconscious memories than conscious ones.

B. Psychologists deal more with emotional than physical issues.

C. Psychologists deal more with physical issues than emotional ones.

D. Psychologists do not have graduate degrees.

 

154. What are PBMs?

A. governmental organizations that provide healthcare

B. organizations that design marketing campaigns

C. organizations that negotiate between pharmaceutical companies and large drug purchasers

D. organizations that write FDA new drug applications

 

155. How does the Hatch-Waxman Act protect research-based drug manufacturers?

A. by limiting the competition

B. by making it easier to bring generic drugs to market

C. by providing a 30-month cooling off period

D. by requiring the FDA to only look at bioavailability studies when approving an ANDA

 

156. What is the process of adjusting drug doses to achieve the maximum positive therapeutic effects while minimizing adverse or side effects?

A.homeostatic maximization

B.steady state administration

C.Sustained release

D.Titration

 

NAPSRx Final Exam 157. Which of the following is studied more in pharmacodynamics than in pharmacokinetics?

A. absorption. Distribution metabolism and excretion

B. dose-response effects

C. the transportation of the drug to the specific site for drug-receptor interaction

D. the way the human body deals with a drug after it has been administered

 

158. How does the healthy human immune system use MHC markers?

A. Substances with MHC markers are discerned as foreign and targeted for destruction.

B. Substances with MHC markers as discerned as foreign and quarantined in the liver.

C. Substances with MHC markers as discerned as foreign and quarantined in the pancreas.

D. Substances without MHC markers are discerned as foreign and targeted for destruction.

 

159. What is a behind-the-counter drug?

A. an OTC drug that must be closely monitored by the pharmacist

B. another term for a generic prescription drug

C. another term for a prescription drug

D. another term for an OTC drug

 

160. When do MSLs meet with clinicians?

A. at nearly any stage of the product’s life cycle

B. only after the district’s sales representatives

C. only prior to launch

D. MSLs do not meet with physicians.