Download 1 - RCRMC Family Medicine Residency

Psychiatry, Infections, drugs
Which of the following is TRUE about
the oral anticoagulants used to prevent
stroke due to atrial
fibrillation? A.Pradaxa (dabigatran) 150
mg BID prevents more strokes than
warfarin. B.Xarelto (rivaroxaban) 20 mg
once a day works about as well as
warfarin. C.Both Pradaxa and Xarelto ca
use fewer intracranial bleeds than
warfarin...but more GI bleeds. D.All of
the above
Answer
• D.All of the above
Which of the following is TRUE about
treating ADHD? A.Methylphenidate is
appropriate for some children as young
as 4 years old. B.Methylphenidate 1 mg
is equivalent to 2 mg of amphetamine
salts. C.Stimulants significantly increase
cardiovascular risk in otherwise healthy
kids. D.Stimulants are metabolized faster
in preschoolers than older children.
Answer
• A.Methylphenidate is appropriate for some
children as young as 4 years old.
•
New guidelines and drug shortages will raise new questions about treating ADHD in children.
The new guidelines now recommend treating kids as young as 4...IF they have severe symptoms
that impair function AND behavioral therapy isn't enough. Until now the cutoff was 6-year-olds.
If you need to treat a 4- or 5-year-old, use low-dose methylphenidate. Stimulants are metabolized
slower at this age.
Reassure parents any increased cardiovascular risk from stimulants is likely very small...if it exists
at all...in otherwise healthy kids. Continue to monitor BP and pulse. Avoid stimulants in children
with serious heart problems, such as arrhythmias, cardiomyopathy, etc.
The Adderall (amphetamine salts) and methylphenidate shortages are causing lots of problems.
These will continue at least through the rest of 2011. Two culprits...manufacturing problems...plus
delays caused by cumbersome regulations that limit quantities of controlled substance raw materials.
If needed switch patients to an available med. A rule of thumb: Use about 1 mg methylphenidate
for 0.5 mg of amphetamine salts, dextroamphetamine, or dexmethylphenidate (Focalin)...but
responses vary.
To switch from Adderall to dextroamphetamine or methylphenidate, start with the same total daily
dose and titrate as needed.
To switch from methylphenidate to Adderall, cut the daily dose in half and monitor for response
and side effects.
To switch to a different oral methylphenidate product, use the same daily dose...divided
appropriately. An exception is Concerta...use 18 mg/day of Concertafor 15 mg/day of
methylphenidate.
When in doubt, start with the new product's starting dose.
To HEAR our experts enlighten you on the controversy of when to treat ADHD in kids, see our PL
Detail-Document and listen to PL Voices.
You can also get our PL Chart, Comparison of Drugs for ADHD, for treatment options, dosing,
duration, and cost.
• You'll hear that vitamin E INCREASES the risk of prostate cancer.
This is a surprise...but based on reliable evidence.
Vitamin E was often recommended to PREVENT prostate
cancer...based on several older studies.
The latest big randomized trial suggests the opposite. It shows one
more case of prostate cancer for every 625 men taking 400 units per
day of vitamin E for one year.
There are also cardiovascular concerns. Vitamin E may increase the
risk of hemorrhagic strokes...and taking 400 units/day may increase the
risk of heart failure in patients with diabetes or heart disease.
Vitamin E proponents will point out that the new findings are for
SYNTHETIC vitamin E. They're right. Keep in mind this is the form
most users get.
And there's no solid proof that NATURAL vitamin E is safer or
more effective than the synthetic versions.
Discourage using vitamin E to prevent cancer or heart disease.
Don't go out of your way to discourage using regular multivits... as
long as they do not contain large amounts of synthetic vitamin E
•
TESTOSTERONE If you prescribe AndroGel or Androderm (testosterone),
you'll likely get a call about the strength.
AndroGel now comes in a higher concentration so patients can use less gel.
Using 2 pumps of the new AndroGel 1.62% is similar to using 4 pumps
ofAndroGel 1%.
The new strength will be priced a little LOWER to entice patients to switch.
But they both still cost over $300 a month...and a generic is 2 or more years
away.
If you write for AndroGel, be sure to specify 1% or 1.62%.
Tell men to apply the new AndroGel 1.62% only to their upper arms and
shoulders for better absorption...instead of to their abdomen, too,
like AndroGel1%.
Also tell them to avoid bathing for 2 hours
after applying AndroGel 1.62%...or 5 hours for AndroGel 1% due to the larger
amount.
Androderm now comes in smaller, lower-strength patches...the original
patches will be discontinued at the end of this year.
Use the new 2 mg patch instead of the older 2.5 mg patch...and the new 4 mg
patch instead of the 5 mg patch. Check serum testosterone 2 weeks after the
switch to make sure the new dose is appropriate.
Get our latest PL Chart, Comparison of Testosterone Products, with all
dosage forms including injectable, buccal, and others.
Which of the following is TRUE about
vaccinations for pregnant
women? A.Tdap can now be given to
pregnant women after 20 weeks
gestation. B.Two doses of Tdap should
be given during pregnancy. C.Flu
vaccine with thimerosal is proven to be
harmful during pregnancy. D.FluMist is
appropriate for pregnant women.
Answer
• A.Tdap can now be given to pregnant
women after 20 weeks gestation
•
You'll see a new emphasis on giving Tdap and flu vaccines to pregnant
women...to protect moms AND their newborns.
Tdap (Adacel, Boostrix) used to be given to the mom right AFTER delivery
if needed. But that leaves newborns unprotected until they start getting
pertussis vaccinations at 2 months.
Vaccinate pregnant women after 20 weeks gestation if they haven't
previously gotten Tdap and only need a booster.
When a pregnant woman's vaccine history is unknown or incomplete, give a
3-shot series: one dose right away...another at 4 weeks...and the last at 6 to 12
months. Use Tdap for the first vaccine after 20 weeks gestation...and Td for
the other two injections.
Injectable influenza vaccine (Fluzone, etc) can be given during ANY
trimester. Don't use FluMist...it's not recommended during pregnancy because
it's a live vaccine.
Some states require using a thimerosal-free vaccine for pregnant women and
children...even though there's no proof thimerosal is harmful.
If you need to avoid thimerosal, use one of the prefilled
syringes...EXCEPTFluvirin which has trace amounts of thimerosal.
Consider reporting immunizations to your state's Immunization Information
System...even if it's not required. Providers are being encouraged to use these
vaccine registries...and using them counts as one of the "meaningful use"
criteria for electronic health records
•
GERIATRICS Most current electronic systems don't alert you about too
many anticholinergics in an elderly patient...but they should.
Even a single anticholinergic med can increase the risk of cognitive
impairment by up to 50%...even more in patients who've had a stroke or have a
family history of dementia.
Anticholinergics are also linked to higher hospitalization rates.
Think about each patient's anticholinergic burden...and whether meds can be
stopped, switched, or given in a lower dose.
Antihistamines. Avoid first-generation antihistamines (diphenhydramine,
etc)...including "PM" OTCs, such as Tylenol PM.
Instead, use a second-generation antihistamine (loratadine, etc) or nasal
steroid for allergies...or low-dose trazodone for insomnia.
Antidepressants. Try to avoid tricyclics (amitriptyline, etc) or paroxetine.
Instead, use one of the other SSRIs (sertraline, etc) for depression...and
consider using gabapentin for neuropathic pain.
Overactive bladder agents. Their minimal benefits usually don't outweigh
their significant anticholinergic effects. And there's no proof the newer ones
have less effect on cognition.
Try to avoid bladder control drugs in patients who already have poor
cognition...or those whose quality of life isn't likely to benefit.
Keep in mind that these anticholinergics are sometimes added for
incontinence that's caused or exacerbated by a cholinesterase inhibitor
(Aricept, etc). A great example of using one drug to treat the effects of another.
Re-evaluate whether either one is really needed.
•
The new generic olanzapine (Zyprexa) means you'll see even more patients on atypical
antipsychotics.
In some situations this is appropriate...in others it's not. About 60% of atypical usage
is off-label.
Evidence of effectiveness varies by drug and indication:
Insomnia. Low doses of quetiapine (Seroquel, etc) and others are often used because
they can be sedating. But there's no evidence they're effective for insomnia and they
have serious side effects.
Try zolpidem, trazodone, and others first.
Generalized anxiety disorder. Consider trying quetiapine if patients don't respond to an
SSRI (sertraline, etc) or SNRI (venlafaxine, etc). There's no evidence that any of the
other atypicals are effective for anxiety.
Depression. Olanzapine, Abilify (aripiprazole), and Seroquel XR are approved to use
with an antidepressant for depression...and there's good evidence for risperidone.
But they have only a modest benefit and serious side effects. Try an adequate trial of
antidepressants first.
Dementia. Antipsychotics increase strokes and mortality in elderly dementia patients.
Save them for patients who are a risk to themselves and others due to aggression,
hallucinations, or delusions.
Consider using one-quarter to one-half the usual starting dose of risperidone,
olanzapine, or Abilify...they have the most evidence. Use quetiapine for patients with
Lewy body dementia or Parkinson's.
Monitor blood glucose and lipids at baseline, 12 weeks, and then periodically for
patients on an atypical. Also check weight every month for 3 months, then every 3
months. Keep in mind that olanzapine is one of the worst offenders for causing
metabolic problems
• Dosing and drug interactions with colchicine (Colcrys) for acute gout
are still causing confusion.
We're all used to the old way of dosing colchicine for acute
gout...two tabs initially then one tab every hour until either diarrhea
starts or the pain stops.
But this causes too much toxicity...and even some deaths.
When FDA approved Colcrys, they also approved safer dosing.
The new dosing for a gout flare is to give two 0.6
mg tablets followed by just ONE tab one hour later.
Give even lower and less frequent doses if colchicine is used with
other drugs that inhibit its metabolism.
For example, give just one tab per attack with cyclosporine...one tab
followed by a half tab with strong 3A4 inhibitors (clarithromycin,
etc)...and two tabs with moderate 3A4 inhibitors (verapamil, etc). Tell
patients not to repeat these colchicine doses for at least 3 days.
For severe renal or hepatic impairment, give a 3-tablet course...and
wait at least 2 weeks before repeating the course.
Don't give colchicine plus cyclosporine or a strong 3A4 inhibitor to a
patient with renal or hepatic impairment. This can be fatal.
Continue to use NSAIDs or corticosteroids first-line for acute gout.
They're usually better tolerated and cost less...at least until generic
colchicine is available again
• Reps will promote using Byetta WITH Lantus for type 2 diabetes.
Adding Byetta (exenatide) to Lantus (insulin glargine) lowers A1C
by 1.7%...compared to 1% for Lantus alone.
Think of it as an alternative to adding a short-acting prandial insulin
(Humalog, etc)...when a basal insulin isn't enough.
Byetta doesn't increase hypoglycemia risk...and it can help reduce
the weight gain associated with insulin.
In fact, patients on the combo for 30 weeks LOSE about 4
pounds...compared to GAINING 2 pounds with just Lantus.
But about one in 12 patients will stop Byetta due to nausea,
vomiting, diarrhea, or other side effects.
And Byetta costs about $340/month...compared to up to $190/month
for prandial insulin plus extra for glucose monitoring.
Add either Byetta or a prandial insulin when basal insulin and oral
meds aren't enough for type 2 diabetes.
Lean towards Byetta to reduce weight gain or hypoglycemia.
When starting Byetta, consider lowering the basal insulin dose by
20% if the patient's A1C is 8 or less. Keep in mind that Byetta isn't
appropriate for patients already using prandial insulin
Which of the following is TRUE about
treating UTIs in the
elderly? A.Nitrofurantoin is a good
option for uncomplicated UTIs if renal
function is okay. B.TMP/SMX can cause
hyperkalemia when combined with an
ACE inhibitor or ARB. C.Quinolones are
preferred for complicated UTIs. D.All of
the above
Answer
• D.All of the above
•
URINARY TRACT INFECTIONS Which antibiotics should you use for urinary tract infections
in elderly patients?
It depends on whether it's a complicated UTI or not.
We know all UTIs in older MEN are considered complicated due to possible prostate involvement.
UTIs in women can also be complicated due to a catheter, obstruction, immunosuppression, etc.
Antibiotic selection also depends on kidney function, side effects, and possible drug interactions.
TMP/SMX is first-line for uncomplicated infections...if local resistance is <20%.
Use TMP/SMX DS twice daily for 3 days...and half the dose if kidney function is impaired (CrCl
15 to 30 mL/min).
Watch for possible hyperkalemia if TMP/SMX is combined with an ACEI, ARB, or potassium...or
increased INR with warfarin.
Nitrofurantoin 100 mg BID for 5 days is a good option for uncomplicated UTIs...IF renal function
is okay. Avoid nitrofurantoin in women with a CrCl <60 mL/min...or for a complicated UTI.
Quinolones are the best choice for complicated UTIs and kidney infections...or if patients can't take
TMP/SMX or nitrofurantoin. Avoid moxifloxacin or gemifloxacin...they don't get into the urine.
Avoid quinolones if local resistance is over 10%...and adjust the dose for impaired renal function.
Keep in mind possible adverse CNS effects...tendon rupture...hyper- or hypoglycemia...or increased
INR in warfarin patients.
Beta-lactams (amoxicillin, etc) are usually less effective for UTIs. Use them only if other
antibiotics aren't an option.
Give antibiotics for 3 to 5 days for uncomplicated UTIs... 7 to 14 days for complicated UTIs...and 6
to 12 weeks for men with prostate involvement.
Don't screen for or treat asymptomatic bacteriuria in most cases. There's no benefit...and it
increases resistance
Which of the following is TRUE about
using NSAIDs in patients with
uncomplicated hypertension? A.Even
occasional use of NSAIDs should be
avoided. B.Combining an NSAID with
an ACE inhibitor or ARB can worsen BP
and renal function. C.Some NSAIDs are
more likely to increase BP than
others. D.Naproxen is the most likely to
increase cardiovascular risk.
Answer
• B.Combining an NSAID with an ACE
inhibitor or ARB can worsen BP and renal
function.
•
NSAIDS Is it okay for patients with uncomplicated hypertension to take
NSAIDs...ibuprofen, celecoxib, etc?
Many can...but you need to be careful.
On average, NSAIDs increase BP by around 5 mmHg in patients with
hypertension...but some patients are more susceptible than others.
Elevations are more likely in the elderly...obese men...and patients
with diabetes, heart failure, or kidney or liver disease.
Tell patients with uncomplicated hypertension that occasional use of
NSAIDs is usually okay...but daily use for just one week can reduce BP
control.
Monitor BP if a hypertensive patient starts a chronic NSAID. Explain that
NSAIDs can also make BP meds less effective.
Be careful about combining an NSAID with an ACE inhibitor or ARB...the
combo can worsen BP and renal function.
And watch for the "triple whammy"...an NSAID plus an ACEI or ARB plus
a diuretic. This combo can push a patient into acute renal failure.
Consider using a calcium channel blocker if a patient needs an
antihypertensive that is less affected by NSAIDs.
Don't expect one NSAID to increase BP more or less than the others.
Suggest naproxen if a chronic NSAID is needed for a patient with
cardiovascular disease...not just hypertension. Naproxen seems to be the least
likely to increase cardiovascular risk
Which of the following is TRUE
about the new generic
atorvastatin (Lipitor)? A.It lowers
LDL more than simvastatin. B.It
has fewer interactions than
simvastatin. C.Atorvastatin 80
mg lowers LDL about as much
as Crestor 20 mg. D.All of the
above
Answer
• D.All of the above
•
Atorvastatin will unseat simvastatin as the most popular generic statin...especially with
simvastatin's new dosing restrictions.
Simvastatin now needs to be limited to 40 mg/day due to the increased risk of
myopathy with higher doses.
Use an even lower simvastatin dose if you give it with amlodipine, diltiazem,
verapamil, amiodarone, or ranolazine. And try not to use it at all with gemfibrozil or
strong 3A4 inhibitors (clarithromycin, etc).
Consider switching to atorvastatin as your statin of choice... it lowers LDL more than
simvastatin and has fewer interactions.
Atorvastatin can even replace Crestor (rosuvastatin) in many cases. Atorvastatin 80
mg and Crestor 20 mg both lower LDL about 55%.
When switching, use atorvastatin 20 mg for simvastatin 40 mg or Crestor 5 mg.
You may hear reps talking up Livalo's (pitavastatin) lack of drug interactions. There's
some truth to this. But when interactions are a concern, use Crestor or pravastatin. They
have a longer track record...and Crestor lowers LDL more thanLivalo.
Keep in mind that LDL-lowering is just treating a lab number. It's patient
OUTCOMES that matter. For secondary prevention, statins prevent one death for every
48 patients treated for 3 to 5 years. For primary prevention, statins prevent one nonfatal
CV event for every 60 patients treated for 4 years.
The price of generic atorvastatin won't drop much until more generics come out in 6
months. But tell Lipitor patients who pay a co-pay for Rxs that they'll likely pay less by
getting the GENERIC.
Until the generic price drops, suggest that patients who pay more than $50/month
keep using their Lipitor co-pay card...the program runs through 2012.
To get the scoop on how atorvastatin really stacks up to Crestor and fact vs fiction on
simvastatin interactions, see our PL Detail-Document and click to listen to PL Voices.
You'll hear an interesting audio snippet of our experts' lively discussion.
Which of the following is TRUE about
using bisphosphonates for
osteoporosis? A.Bisphosphonates can be
stopped after 3 to 5 years for most
patients. B.Bisphosphonates should be
continued in patients at high risk for
fractures. C.Bisphosphonates only stay
in the bone for a few days. D.Both A and
B
Answer
• D.Both A and B
•
You'll hear more controversy about how long patients should take
bisphosphonates (Fosamax, etc) for osteoporosis.
Many patients get put on a bisphosphonate to prevent fractures and are left
on it indefinitely. But long-term use may be associated with problems...jaw
osteonecrosis and atypical femur fractures.
Keep in mind that bisphosphonates persist in the bone for years and may
continue to prevent fractures even after they're stopped.
For example, women who stop alendronate after 5 years have a similar risk
of nonvertebral fractures as those who continue it for 10 years.
And stopping zoledronic acid (Reclast) after 3 years prevents fractures
almost as well as taking it for 6 years.
Consider stopping the bisphosphonate after 3 to 5 years for most patients.
But continue it or switch to another osteoporosis med for patients at high
fracture risk, such as those with a recent fracture... on chronic
corticosteroids...or if bone density continues to drop.
Consider checking bone density or bone turnover markers 2 to 3 years after
stopping a bisphosphonate. If these indicate bone loss, restart the
bisphosphonate...or start raloxifene, calcitonin, Forteo, or Prolia.
Continue to encourage patients to get about 1200 mg/day of
elementalcalcium...and 800 to 2000 units/day of vitamin D.
Which of the following is TRUE about
using tadalafil (Cialis) for benign
prostatic hyperplasia (BPH)? A.It
improves urine flow. B.It works better
than an alpha-blocker (tamsulosin, etc)
for BPH. C.It may be appropriate for
men with erectile dysfunction and mild
BPH symptoms. D.It should never be
combined with an alpha-blocker.
Answer
• C.It may be appropriate for men with
erectile dysfunction and mild BPH
symptoms.
•
Reps will promote daily Cialis (tadalafil) for benign
prostatic hyperplasia (BPH)...not just erectile dysfunction.
Cialis and other phosphodiesterase-5 inhibitors seem to enhance
smooth muscle relaxation in the prostate, bladder, and urethra.
But don't expect a large improvement in BPH symptoms.
Cialis modestly improves urinary frequency, urgency, and
straining...but not urine flow rate. And you have to treat 6 men for one
to benefit.
Continue to start with alpha-blockers (tamsulosin, etc) for
BPH...they're likely to be more effective and they cost less.
Consider using daily Cialis for men with both erectile dysfunction
and mild BPH symptoms.
Or consider adding daily Cialis if a man with both erectile
dysfunction and BPH isn't getting adequate relief from an alphablocker. The combo might work better than either drug alone for BPH.
When adding Cialis to an alpha-blocker, start with just 2.5 mg a
day to reduce hypotension...and titrate to 5 mg.
Cialis 5 mg/day costs about $150 a month. Expect insurers to
require a prior authorization to verify that it's for BPH.
•
MEN'S HEALTH Saw palmetto will fall out of favor for treating
BPH symptoms.
You'll still hear staunch believers claim it works and cite lots of
older studies...but it's not standing up to close scrutiny.
Two NIH-sponsored trials now suggest that saw palmetto is NOT
better than placebo for BPH symptoms...even at high doses.
In fact, our Natural Medicines Comprehensive Database is
downgrading its rating of saw palmetto to "Possibly INeffective."
Evaluating supplements is tricky...results apply mainly to the
specific formulation tested. Amazingly, the recent NIH study used a
saw palmetto product that is NOT available in the U.S.
Tell men not to rely on saw palmetto for BPH. Explain that benefits
are modest at best. But don't be overly concerned if they want to try
it...there's no evidence of serious adverse effects.
Listen to our audio clip, PL Voices, to hear our experts explain why
there's been a shift in thinking about saw palmetto... and tips on how to
pick high-quality supplements in general.
•
DIABETES You'll hear claims that gliptins (Januvia, etc) decrease
cardiovascular risk in diabetes patients.
This is based on a new meta-analysis that suggests gliptins don't
increase cardiovascular risk...and MIGHT even decrease it.
Don't buy it. It hasn't been peer-reviewed and published.
So far, NONE of the diabetes meds are proven to lower CV risk.
Metformin seems to have the most favorable cardiovascular
profile...but there's not enough evidence to say it's cardioprotective.
Pioglitazone (Actos, etc) and rosiglitazone (Avandia) increase heart
failure risk...rosiglitazone likely increases MI risk.
Gliptins lower A1C by about 0.7% and cost about $8/tab. Save
them as a second- or third-line option for patients close to their A1C
goal.
Juvisync (sitagliptin/simvastatin) will be the first gliptin and statin
combo...and will cost the same as Januvia alone.
Consider Juvisync for patients on Januvia who also need a
statin...and for whom simvastatin is an appropriate choice.
Which of the following is TRUE
about adding a GI protectant to an
NSAID? A.Famotidine 80 mg/day
can help prevent NSAID-induced
ulcers. B.PPIs are more effective
than H2-blockers for preventing
NSAID-induced ulcers and
bleeding. C.Misoprostol is an
alternative to using a PPI. D.All of
the above
Answer
• D.All of the above
•
You'll hear reps claim the new Duexis is safer than plain NSAIDs.
But it's usually not the best choice.
Duexis is a combo of ibuprofen 800 mg and famotidine 26.6 mg for TID dosing. This provides
about 80 mg/day of famotidine...the dose that has been shown to reduce NSAID-induced ulcers.
One ulcer is prevented for every 10 patients taking Duexis compared to ibuprofen alone...but it's
not proven to prevent GI bleeds.
PPIs are more effective than H2-blockers for preventing NSAID-induced ulcers...AND they're
proven to prevent GI bleeds.
But PPIs aren't benign. Chronic PPIs are associated with a higher risk of pneumonia, C.
diff diarrhea, hypomagnesemia, and fractures.
Choose a strategy for NSAID users based on their risks.
Use a PPI or misoprostol for those at moderate GI risk due to one or two risk factors...age over 65,
high-dose NSAIDs, prior uncomplicated ulcer, or use of aspirin or another antiplatelet drug.
Vimovo (naproxen/esomeprazole) is the only NSAID/PPI combo... but it costs more than giving a
generic NSAID and PPI separately.
Consider using an H2-blocker for patients at moderate GI risk who can't take a PPI or
misoprostol.
Give famotidine 40 mg BID plus a generic NSAID instead of Duexis. Duexiscontains more
ibuprofen than most patients need...and it costs about $150 per month.
Consider using celecoxib alone instead of a traditional NSAID plus GI protectant for patients at
moderate GI risk...and low CV risk.
Use naproxen if an NSAID is needed for patients at high CV risk... and add a GI protectant for
those at moderate GI risk.
Use celecoxib plus a PPI or misoprostol for patients at high GI risk due to 3 or more risk
factors...concomitant warfarin or corticosteroids...or a prior complicated ulcer. This combo has the
safest GI profile...but avoid NSAIDs altogether if possible.
•
NEUROPATHIC PAIN You'll soon see Gralise (gra-LEEZ), a
new extended-release gabapentin for postherpetic neuralgia (PHN).
Gralise is the second ONCE-daily gabapentin...after the approval
of Horizant for restless legs syndrome earlier this year.
Gralise tabs are similar to Glumetza (metformin ER). These swell
to stay in the stomach longer and gradually release the drug.
Continue to use a tricyclic first-line for post-shingles pain.
If tricyclics aren't enough or aren't tolerated, go to gabapentin,
pregabalin (Lyrica), duloxetine (Cymbalta), opioids, a lidocaine patch,
or capsaicin. Combining a tricyclic and gabapentin can work better
than either one alone.
Gabapentin and pregabalin are only modestly effective for
postherpetic neuralgia. Choose one based on cost or convenience.
Gralise costs about $180/month...compared to $240 for Lyrica and
$40 for gabapentin immediate-release capsules.
But keep in mind that Gralise is given once a day...compared to 2
to 3 times a day for Lyrica or 3 times a day for regular gabapentin.
If you start a patient on Gralise, prescribe the 30-day starter pack to
slowly titrate the patient from 300 mg to 1800 mg/day. Tell patients to
take Gralise in the evening with dinner.
Which of the following is TRUE about drugs
to avoid in patients with
glaucoma? A.Anticholinergic drugs can
worsen glaucoma by constricting the
pupil. B.Anticholinergics are only a problem
for patients with narrow-angle
glaucoma. C.Corticosteroids can worsen
narrow-angle glaucoma. D.It's not necessary
to monitor intraocular pressure in patients
using ophthalmic steroids long-term.
Answer
• B.Anticholinergics are only a problem for
patients with narrow-angle glaucoma.
• OPHTHALMOLOGY Glaucoma patients often ask which drugs to
avoid...and if they don't ask, they should.
Many drugs have warnings not to use them in glaucoma patients.
But these warnings are usually for patients with NARROW-angle
glaucoma...which is much less common than OPEN-angle glaucoma.
Anticholinergic drugs can dilate the pupil and worsen the
obstruction in patients with narrow-angle glaucoma...increasing the
risk of acute angle closure.
Try to avoid anticholinergics or use the lowest effective dose. This
includes many antihistamines, tricyclics, antipsychotics,
antispasmodics, overactive bladder drugs, etc.
Also warn patients to get immediate treatment if they develop eye
pain plus redness, blurred vision, halos around lights, etc.
Reassure patients with OPEN-angle glaucoma that anticholinergic
drugs will not make it worse.
Corticosteroids are another story...these can increase intraocular
pressure and cause or worsen open-angle glaucoma.
Check intraocular pressure when ophthalmic steroids are used for
10 days or longer, especially in high-risk patients.
• EDEMA Questions come up about how to handle drug-induced
edema.
Peripheral edema often prompts clinicians to jump straight to a
workup for thromboembolism or heart, renal, or hepatic failure.
But first look for meds that can cause it.
Dihydropyridine calcium channel blockers (amlodipine, etc) cause
dose-dependent edema. But it's not caused by fluid overload, so
diuretics usually don't help.
Try to lower the dose...or ADD an ACE inhibitor or ARB.
If that doesn't work, switch to a different antihypertensive... even
verapamil or diltiazem cause less edema.
Pioglitazone (Actos, etc) can cause edema...especially with higher
doses. Avoid it in patients with class 3 or 4 heart failure.
In other patients, try a lower dose...or switch meds.
Consider trying spironolactone or hydrochlorothiazide if needed.
They might help...but keep in mind they can sometimes worsen
edema.
Gabapentin, pregabalin, or dopamine agonists (pramipexole, etc)
can cause dose-dependent peripheral edema.
Try to lower the dose or switch meds. Diuretics might help some
patients...but don't count on them.
•
MAGNESIUM Concerns about PPIs and hypomagnesemia are raising questions
about when and how to use magnesium supplements.
PPIs may lower mag levels...possibly due to reduced absorption.
Consider checking serum magnesium in patients on long-term PPIs... especially if
they have muscle cramps, tremors, palpitations, etc.
Also check serum magnesium in patients taking PPIs with drugs that can lower mag,
such as diuretics or cisplatin...or in those on digoxin, because hypomag can lead to dig
toxicity. But keep in mind that serum levels don't always correlate well with total body
stores.
Some insurers require an ICD-9 code on the lab slip. Use 275.2 for
hypomagnesemia...or 995.20 for a drug adverse effect.
Consider checking potassium and calcium at the same time. Hypokalemia and
hypocalcemia can be hard to correct if magnesium is low.
If a supplement is needed, lean toward one that's better absorbed, such as mag lactate
(Mag-Tab SR, etc), mag chloride (Slow-Mag, etc), or mag aspartate (Maginex, etc). Mag
oxide (Mag-Ox, etc) has more elemental magnesium than the others...but has poorer
absorption. Explain that better absorption may mean less diarrhea.
Use 200 to 400 mg/day of elemental magnesium for hypomagnesemia. For 200
mg/day, this works out to about 3 tabs of Mag-Tab SR or Slow-Mag or 4 tabs
ofMaginex. Suggest dividing the dose to improve tolerability.
Use IV magnesium sulfate for severe deficiencies.
If low magnesium doesn't resolve with a supplement in a patient on a PPI, stop the
PPI and switch to an H2-blocker if needed.
Be careful using magnesium supplements in patients with renal insufficiency...to
avoid HYPERmagnesemia.
•
INFECTIOUS DISEASES New guidelines will help improve the treatment
of community-acquired pneumonia in children.
Select an antimicrobial for outpatients based on their age, immunization
status, and suspected pathogen.
Typical bacterial pathogens are common...especially in school-age kids and
adolescents.
Use amoxicillin 90 mg/kg/day for 10 days...up to 4 g/day to cover Strep
pneumoniae.
Use amoxicillin/clavulanate (Augmentin, etc) to add H. influenzae coverage
when kids aren't fully vaccinated for Hib.
Atypical bacterial pathogens such as M. pneumoniae tend to be more
common in school-age kids and adults. Suspect Mycoplasma in kids with
slowly progressing symptoms...malaise, muscle aches, sore throat, and lowgrade fever with a nonproductive cough.
Use azithromycin 10 mg/kg the first day then 5 mg/kg for 4 days... up to
500 mg the first day and 250 mg/day for 4 days.
Viruses are usually the culprit in infants and preschoolers... especially if
they have gotten their pneumococcal and Hib vaccines.
For flu pneumonia, use oseltamivir (Tamiflu)...or zanamivir (Relenza) for
kids 7 years and older if an alternative is needed.
Which of the following is TRUE about using
the new oral anticoagulants for atrial
fibrillation? A.They're an alternative to
warfarin if INR control is poor or monitoring
isn't feasible. B.Dabigatran (Pradaxa) causes
less bleeding than warfarin. C.Rivaroxaban
(Xarelto) is more effective than
warfarin. D.The new anticoagulants are all
given once a day.
Answer
• A.They're an alternative to warfarin if INR
control is poor or monitoring isn't feasible.
•
ANTICOAGULANTS You'll hear controversy over which ORAL anticoagulant to use to prevent
strokes in patients with atrial fibrillation.
Warfarin was our only option for over 50 years...but you'll get more questions about how the new
ones stack up.
Warfarin is obviously the gold standard. You know its limitations...INR monitoring, dose
adjustments, and many interactions.
But advocates call it "the devil we know" because we're familiar with its long-term safety...and it's
the only one with an antidote. It's also the cheapest...about $80/month including INR monitoring once
a month.
Dabigatran (Pradaxa) is a direct thrombin inhibitor...and the first of the new oral anticoagulants
that don't need INR monitoring.
It prevents more strokes than warfarin...about 5 more strokes per 1000 patients per year...with a
similar overall bleeding risk.
But it needs to be given twice daily...and costs about $240/month.
Rivaroxaban (Xarelto) is the first oral factor Xa inhibitor...and will likely be approved for atrial fib
soon.
Reps will tout that it only needs to be given once a day.
But rivaroxaban doesn't work any better than warfarin...and it costs about the same as dabigatran.
Apixaban (Eliquis, ELL-eh-kwiss) will be the next oral factor Xa inhibitor...likely out late next
year. It's the one many are waiting for...it seems more effective AND causes less bleeding than
warfarin.
Continue to feel comfortable using warfarin for atrial fib...especially in longtime users with good
INR control.
Use a newer agent if INR control is poor...or monitoring isn't feasible. For now, lean towards
dabigatran. To switch, wait until the INR is below 2 before starting dabigatran.
Be careful about using dabigatran in the elderly due to bleeding concerns...especially if
underweight or renal function is poor.
Which of the following is TRUE about
the new dosing limits for citalopram
(Celexa, etc)? A.Doses should not
exceed 40 mg/day for anyone. B.Doses
should not exceed 20 mg/day for most
patients over age 60. C.Higher doses
increase the risk of QT prolongation and
torsades. D.All of the above
Answer
• D.All of the above
•
ANTIDEPRESSANTS FDA now says citalopram doses should not
exceed 40 mg/day for anyone...or 20 mg/day for most patients over age
60.
Higher doses of citalopram (Celexa, etc) increase the risk of QT
prolongation and torsades.
Be careful about using citalopram in patients at risk due to
underlying cardiac disease or low serum potassium or magnesium.
Avoid citalopram or monitor ECG if citalopram is used in patients
with heart failure...bradyarrhythmias...or on other meds that can
prolong the QT interval.
Don't exceed citalopram 20 mg in most patients over age 60...or
those with liver impairment. Also avoid going over 20 mg when
combined with CYP2C19 inhibitors...omeprazole, cimetidine, etc.
If these lower doses aren't adequate, switch to another antidepressant.
Sertraline, paroxetine, and fluoxetine seem less likely to cause QT
prolongation.
Don't exceed 20 mg/day of escitalopram (Lexapro). Usual doses
aren't associated with significant QT prolongation...but the risk
increases with higher doses.
•
ANTIDEPRESSANTS Reps are filling up sample closets,
hoping prescribers will use Deplin to improve the efficacy of antidepressants.
Deplin contains L-methylfolate...the active form of folic acid.
The manufacturer can make medical claims for Deplin because it's marketed
as a medical food. Medical foods are a commonly misunderstood category of
products. They're not Rx drugs, not OTCs, not dietary supplements, and not
homeopathics.
Medical foods often have a package insert and say "Rx only" on their
label...but they are NOT approved by FDA like traditional Rx drugs.
There's a link between folate deficiency and depression...possibly because
folates are needed to make serotonin, norepinephrine, and dopamine.
Some preliminary evidence also suggests that adding folate can increase
antidepressant efficacy.
Deplin claims to be more effective than folic acid because it's already in the
active form. But there's no proof that Deplin is more effective...and it costs
more.
Generic folic acid might be worth a try before going to other augmenting
agents...antipsychotics, buspirone, thyroid, lithium, etc.
Use at least 500 mcg/day of folic acid for augmentation. Keep doses under
800 mcg/day in the elderly due to concerns about cancer with higher folate
doses in the elderly.
Which of the following is TRUE about
using azithromycin to prevent COPD
exacerbations? A.Azithromycin 250
mg/day seems to reduce the risk of acute
exacerbations. B.This dose does not
increase bacterial
resistance. C.Azithromycin can worsen
eyesight. D.Thirty-day mortality is
higher after a heart attack than a COPD
exacerbation.
Answer
• A.Azithromycin 250 mg/day seems to
reduce the risk of acute exacerbations.
•
RESPIRATORY / ALLERGY You'll hear debate about whether to
use chronic azithromycin to PREVENT recurrent COPD exacerbations.
Preventing acute COPD exacerbations is a BIG deal.
Each exacerbation worsens lung function and quality of life...plus the 30-day
mortality rate is higher after a severe COPD exacerbation than an MI.
Adding azithromycin 250 mg/day to standard COPD therapy reduces the risk
of acute exacerbations...but may worsen hearing.
There will be one less exacerbation for every 3 COPD patients on oxygen or
with prior exacerbations that take azithromycin for one year...but one in 20
patients will experience slight hearing loss.
The theory is that this benefit is mostly due to azithromycin's antiinflammatory and immunomodulatory effects.
But the big concern is bacterial resistance.
Patients on chronic azithromycin are less likely to be colonized with
respiratory pathogens...but if they are, it's more likely to be with macrolideresistant strains.
Consider azithromycin for patients with severe COPD and frequent
hospitalizations for acute exacerbations.
Don't use a macrolide for an acute exacerbation if the patient is on chronic
azithromycin. Instead, use a quinolone, cephalosporin, or
amoxicillin/clavulanate.
Which of the following is TRUE about
managing hypothyroidism during
pregnancy? A.Levothyroxine doses should be
decreased by 50% during
pregnancy. B.Levothyroxine doses should be
increased by 25% to 30% as soon as
pregnancy occurs. C.TSH should be
monitored every 8 weeks. D.Women should
wait one year after delivery to resume their
pre-pregnancy dose.
Answer
• B.Levothyroxine doses should be increased
by 25% to 30% as soon as pregnancy
occurs.
•
New guidelines will call for tighter and more aggressive control of
hypothyroidism before and during pregnancy.
Levothyroxine needs rapidly increase when a woman becomes
pregnant...leaving many women undertreated in early pregnancy.
Hypothyroidism during pregnancy increases the risk of miscarriage, preterm
birth, low birth weight, and cognitive deficits.
Treatment should begin BEFORE a woman becomes pregnant.
Titrate levothyroxine doses to achieve a TSH less than 2.5 mIU/L when a
woman is planning to become pregnant.
As soon as pregnancy is confirmed, increase the levothyroxine dose by 25%
to 30%. One way to do this is to have the woman take an extra dose of
levothyroxine two days per week as soon as she misses a period or has a
positive home pregnancy test.
Monitor TSH every 4 weeks during the first half of pregnancy...and then at
least once between 26 and 32 weeks of gestation.
Aim for a TSH of 2.5 mIU/L or less in the first trimester...and 3.0 mIU/L or
less during the second and third trimesters.
After delivery, have women resume their pre-pregnancy levothyroxine
dose...and check TSH in 6 weeks. Tell women they may need extra
levothyroxine for several months after delivery.
Remind women not to take levothyroxine and prenatal vitamins at the same
time due to decreased levothyroxine absorption. Recommend
taking levothyroxine first thing in the morning on an empty stomach...and the
prenatal vitamin at least 4 hours later with lunch or dinner.
•
You'll hear about two new opioid formulations, Oxecta and Lazanda.
Oxecta (OX-ec-tah) is a new tamper-resistant, immediate-release oxycodone
tab. It's formulated to discourage potential abusers from crushing, chewing,
snorting, or injecting the opioid.
The tab breaks into chunks instead of a powder if crushed...and turns into a
gel if mixed with liquid. It also contains sodium laurel sulfate, which irritates
the nose if it's snorted.
But this won't stop people from taking large doses orally.
Caution NOT to use Oxecta in feeding tubes...it can clog them.
Lazanda (la-ZAHN-duh) is the first fentanyl nasal spray.
It's for breakthrough pain in opioid-tolerant cancer patients...those on at least
60 mg/day of oral morphine or a 25 mcg/hr fentanyl patch for at least one
week.
Lazanda is absorbed a little faster than Actiq (fentanyl lozenge)...but has a
similar onset for pain relief.
Start all new Lazanda patients with ONE 100 mcg spray and titrate up for
pain control.
Emphasize proper storage and disposal. Advise patients to keep
the Lazandabottle in the child-resistant container between uses...and to empty
any unused solution into the carbon-lined pouch to bind the drug before
disposal.
You'll need to take an FDA-required training program and complete an
enrollment form before you can prescribe Lazanda. You can link to these from
ourPL Detail-Document...or go to LazandaREMS.com.
•
CARDIOLOGY There are MORE safety concerns with dronedarone (Multaq).
This time it has to do with the TYPE of atrial fibrillation.
Multaq improves CV outcomes in some patients with PAROXYSMAL or
PERSISTENT atrial fib. These resolve spontaneously or with cardioversion.
So researchers hoped that Multaq would also benefit patients with PERMANENT
atrial fib. This type continues long-term despite attempts at cardioversion...or it's
decided not to try cardioversion.
But new evidence suggests that patients on Multaq for permanent atrial fib actually
have a higher risk of death and cardiovascular events.
Don't use Multaq or other antiarrhythmics for permanent atrial fib. None of them
improve outcomes.
Instead, use anticoagulation to help prevent strokes...and rate control with a betablocker, verapamil, diltiazem, or digoxin.
Tell patients that it's often okay to stay in atrial fib...especially if they don't have
symptoms.
Don't be too quick to start Multaq for paroxysmal or persistent atrial fib either. It's not
as effective as amiodarone...and may not be much safer.
Multaq may lead to heart, liver, or kidney failure...and possibly increase INR in
patients taking warfarin. Multaq doubles mortality in patients with severe heart failure.
Lean toward amiodarone over dronedarone for patients with paroxysmal or persistent
atrial fib who need rhythm control...especially if they have heart failure or severe left
ventricular hypertrophy.
Which of the following is TRUE about
managing behavior problems in elderly
patients who have dementia? A.Mood
stabilizers (valproate, etc) are proven to be
beneficial. B.Benzodiazepines are a good
choice for agitation. C.Antipsychotics
increase stroke risk and
mortality. D.Psychotropic med regimens
should be re-evaluated once a year.
Answer
• C.Antipsychotics increase stroke risk and
mortality.
•
GERIATRICS It's challenging to manage elderly dementia patients who have behavior
issues...agitation, aggression, delusions, etc.
About 20% of elderly dementia patients experience delusions or hallucinations at some point...and
many become agitated or aggressive.
First rule out some common causes...pain, infection, constipation, incontinence, dehydration, or
adverse med effects.
Nonpharmacologic options can help manage agitation or aggression...and they're safer than meds.
Suggest a calm environment...soothing rituals...reducing noise or sudden changes in surroundings
or caregivers...etc.
Reserve meds for behavior problems that affect safety.
Start LOW...one-quarter to one-half the usual starting dose...and increase SLOWLY if needed.
Antidepressants might be worth a try. Consider an SSRI (citalopram, etc) for agitation...or
trazodone for agitation with insomnia.
Mood stabilizers (valproate, etc) are controversial because of conflicting evidence on whether
they're effective.
If you try them, watch for side effects...nausea and sedation with valproic acid...and rash, dizziness,
and sedation with lamotrigine.
Antipsychotics are very controversial...they increase stroke risk and mortality. There's one more
death for every 52 frail nursing home dementia patients treated with an antipsychotic for 10 weeks.
Save them for patients with disabling delusions, hallucinations, or paranoia...and aggressive
behavior that's harmful to themselves or others. But discuss the risks first.
Try to avoid antipsychotics in patients with Lewy body dementia. These patients often have
fluctuating cognition, parkinsonism, hallucinations, and severe sensitivity to antipsychotics. Use a
very low dose of Seroquel (quetiapine) if necessary.
Benzodiazepines should usually be avoided. Explain that they can actually INCREASE agitation by
worsening cognition.
Re-evaluate psychotropic meds at least quarterly...and attempt to wean patients off therapy as their
condition permits.
•
DRUG INTERACTIONS Computers often give an "interaction alert" when
potassium chloride tabs or caps are combined with an anticholinergic drug.
These alerts are common for potassium chloride (Micro-K, etc) and ORAL
anticholinergics...oxybutynin, amitriptyline, etc.
But now alerts are popping up with INHALED anticholinergics...ipratropium
(Atrovent, etc) and tiotropium (Spiriva).
Plus they're showing up as a severe interaction...because anticholinergics are
listed as a contraindication in the KCl labeling. That's why you may also be
getting calls from pharmacies.
But this is based more on theory than actual evidence.
It's true that potassium chloride can cause GI irritation. The concern is that
anticholinergics might increase this risk by slowing GI motility...but there's no
convincing evidence this happens.
Don't worry about this interaction alert with INHALED agents...they're not
likely to affect GI motility.
But, before you give the okay to use potassium with ORAL anticholinergics, think twice about whether the patient is at risk for GI problems
due to older age...prior GI bleeding...gastroparesis...etc.
Consider switching high-risk patients to a non-anticholinergic med...or
switching to a potassium chloride liquid or powder.
Tell patients to take KCl tabs or caps with a full glass of water and stay
upright for at least 10 minutes...to avoid esophagitis.
•
CORTICOSTEROIDS We're getting questions about whether
hyperglycemia can occur with non-oral corticosteroids...topical, inhaled, or
local injections.
Hyperglycemia is less likely when corticosteroids are given by these routes
instead of systemically...but can still occur in susceptible patients.
Topical steroids can cause hyperglycemia when used in chronic or high
doses...especially for diffuse conditions such as psoriasis.
Monitor blood glucose in patients using high-potency steroids...large steroid
doses...or when treatment exceeds 6 months. Be especially vigilant if patients
are at risk for diabetes.
Inhaled steroids can increase the risk of hyperglycemia when used in high
doses, such as fluticasone 1000 mcg/day or more.
If hyperglycemia occurs, try to lower the steroid dose and add a
bronchodilator or other agent if needed.
Steroid injections into joints can cause hyperglycemia for about 2 to 5 days
in patients with diabetes...and longer for long-acting steroid formulations.
Epidural injections can increase blood glucose up to 2 weeks.
But DON'T proactively adjust diabetes meds for most patients. Instead,
advise those monitoring their blood glucose to call if it gets too high, such as a
fasting glucose above 200 mg/dL for type 2...and above 150 mg/dL for type 1
diabetes.
If you'd like to hear our team discuss how to treat these cases of
Which of the following is TRUE about
stopping antiplatelet drugs? A.Clopidogrel
(Plavix) should be stopped 6 months after
placement of a drug-eluting
stent. B.Antiplatelet drugs usually don't need
to be stopped for procedures with a low
bleeding risk. C.Clopidogrel should be
stopped at least 10 days before
surgery. D.Patients should take 325 mg/day of
aspirin with ticagrelor (Brilinta).
Answer
• B.Antiplatelet drugs usually don't need to be
stopped for procedures with a low bleeding
risk.
•
CARDIOLOGY Patients often don't realize the risk of stopping aspirin, clopidogrel, or other
antiplatelet drugs too soon.
Patients on aspirin for secondary prevention...or on aspirin plus clopidogrel for acute coronary
syndrome or after a stent...sometimes stop these drugs on their own with dire consequences.
For example, stopping aspirin in patients with a prior MI leads to 4 extra MIs per 1000 patients per
year.
Stopping clopidogrel within 30 days after a drug-eluting stent results in 25% of patients having a
stent thrombosis instead of just 1%.
Talk with patients to help them understand the importance of continuing with their antiplatelets.
For stents, continue aspirin plus clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta) for
AT LEAST one MONTH after a bare-metal stent...or at least one YEAR after a drug-eluting stent.
Cardiologists often continue dual antiplatelets longer...especially for higher-risk patients. If you
have questions about when to stop, discuss the pros and cons with the cardiologist.
But...and this is very important...continue aspirin INDEFINITELY. Use just 81 mg/day of aspirin
for most patients...especially those on ticagrelor. Higher aspirin doses make ticagrelor LESS
effective.
Keep in mind that antiplatelet drugs usually DON'T need to be stopped for procedures with a low
bleeding risk...minor surgery, dental extraction, cataract surgery, endoscopy, etc.
For stent patients, try to postpone procedures with a high bleeding risk until clopidogrel, prasugrel,
or ticagrelor is stopped.
If they can't wait, consider continuing the drug through the procedure, if possible...or stopping the
drug for a brief time. Continue aspirin for all but the riskiest surgery.
If the drug must be stopped, stop clopidogrel, ticagrelor, or aspirin 5 days prior...and prasugrel 7
days before surgery
Which of the following is TRUE about
combining simvastatin (Zocor, etc) and
amlodipine (Norvasc, etc)? A.The
combo can increase the risk of
myopathy. B.Patients on amlodipine
should not take more than simvastatin 20
mg/day. C.Amlodipine also significantly
increases levels of atorvastatin
(Lipitor). D.Both A and B
Answer
• D.Both A and B
• STATINS New alerts will raise new questions about the
interaction between simvastatin (Zocor, etc) and
amlodipine (Norvasc, etc).
Some prescribers are surprised...because amlodipine is
only a weak inhibitor of simvastatin metabolism by
CYP3A4 enzymes.
But the combo IS associated with a higher risk of
myopathy.
There's possibly another mechanism at work...such as
inhibiting transport proteins that carry simvastatin into
liver cells for metabolism.
Follow the new FDA guidelines and don't prescribe more
than simvastatin 20 mg/day in patients taking amlodipine.
Switch patients who need simvastatin 40 mg to
pravastatin 80 mg...atorvastatin (Lipitor) 20 mg...or
rosuvastatin (Crestor) 5 mg. Amlodipine isn't likely to
significantly increase levels of these statins
Which of the following is TRUE
about using spinosad (Natroba)
for head lice? A.It can be used
for infants. B.A second treatment
is always required. C.It seems to
work better than OTC permethrin
(Nix, etc). D.It's not well
tolerated.
Answer
• C.It seems to work better than OTC
permethrin (Nix, etc).
•
HEAD LICE Reps will promote Natroba (nah-TRO-buh), a new Rx topical
suspension for head lice.
They'll point out that Natroba (spinosad) seems to work better than OTC
permethrin (Nix, etc)...and it's well tolerated.
It's true that Natroba kills lice AND nits...and it's not absorbed.
But this comes at a cost.
Natroba costs $220...compared to about $10 to $20 for Nix, $160 for
malathion, and $160 for Ulesfia, depending on hair length.
Continue to use OTC permethrin or pyrethrins first-line. They're inexpensive
and usually effective...and permethrin can be used in children as young as 2
months.
If these don't work or resistance is a problem in your area,
prescribe Natroba, malathion (Ovide, etc), or Ulesfia (benzyl alcohol).
Keep in mind that Ulesfia is for ages 6 MONTHS and older...Natroba is for
4 YEARS and up...and malathion is for 6 YEARS and up.
Tell parents that only one treatment is usually needed with Natroba or
malathion. Recommend retreatment in 7 days with Ulesfia...or 7 to 9 days with
permethrin or pyrethrins.
If these options fail, consider Rx oral ivermectin (Stromectol) if the child
weighs at least 15 kg. It kills lice within 24 hours
•
You'll start hearing lots more about the comparisons between warfarin, dabigatran (Pradaxa), and
rivaroxaban (Xarelto).
Now that both Pradaxa and Xarelto will be marketed for atrial fib, people will ask if these are
better than warfarin.
Keep these drugs' pros and cons in perspective.
Efficacy. Pradaxa may have a slight advantage. Pradaxa 150 mg BID prevents about 5 more
strokes per 1000 patients/year than warfarin.
Xarelto 20 mg once a day works about as well as warfarin...but this is in higher-risk patients than
those in the Pradaxa trial.
Side effects. Pradaxa, Xarelto, and warfarin have about the same overall risk of bleeding.
But Pradaxa and Xarelto seem to cause FEWER intracranial bleeds...and MORE GI bleeds...than
warfarin.
Dyspepsia is a problem with Pradaxa.
Cost. Pradaxa and Xarelto each cost about $260/month. Warfarin costs about $80/month even
when you add in INR monitoring once a month.
Continue to use warfarin for many atrial fib patients.
Go to one of the newer anticoagulants if INR control is poor...or warfarin interactions are a
concern...or monitoring isn't feasible.
For now, lean towards Pradaxa before Xarelto. Pradaxa is more effective than warfarin in some
patients.
Use Xarelto for patients who can't tolerate Pradaxa due to dyspepsia...or have trouble
with Pradaxa's BID dosing.
Monitor renal function with the new anticoagulants...and lower the dose if needed. Use Pradaxa 75
mg BID for a CrCl between 15 and 30 mL/min. UseXarelto 15 mg/day for a CrCl between 15 and 50
mL/min.
Don't ROUTINELY use aspirin for atrial fib. New evidence suggests that it's not much better than
placebo...but it still increases bleeding.
Consider aspirin for younger patients without any additional stroke risk factors...or patients who
won't take an anticoagulant.
If you want to be the smartest person in your area about the new anticoags for atrial fib, go to
our PL Detail-Document...and listen to our experts talking on PL Voices. Also see our PL
Chart, Comparison of Oral Antithrombotics, for their indications, dosing, interactions, etc.
•
Many of the antipsychotics can prolong the QT interval...but not all of them
are associated with torsades or sudden death.
Torsades with Seroquel is very rare...and usually linked to an overdose. But
the problem is that you can't predict who will get it.
Patients who develop torsades usually have multiple risks...a long QT
interval,heart disease, older age, female gender, low serum potassium or
magnesium, or slow heart rate.
Watch for patients on multiple meds that can prolong the QT interval...and
meds that interact to boost levels of these QT drugs.
For example, don't combine Seroquel (quetiapine) with other QT
prolongers...macrolides (clarithromycin, etc), quinolones (moxifloxacin, etc),
tricyclics, Geodon (ziprasidone), methadone, or amiodarone.
And proceed carefully if patients are on meds that can lower potassium or
magnesium, such as diuretics or laxatives...or meds that can slow heart rate,
such as beta-blockers.
In risky patients, consider using an alternate antipsychotic that's not linked to
torsades, such
as Zyprexa (olanzapine)...Abilify (aripiprazole)...Latuda(lurasidone)...or Saphri
s (asenapine).
Avoid haloperidol, pimozide, thioridazine, or chlorpromazine in high-risk
patients. These are an even bigger torsades risk than Seroquel
•
GERIATRICS You'll hear about using "START" and "STOPP" instead of Beers to
evaluate appropriate med use in the elderly.
The Beers list is often used to identify drugs to avoid in the elderly. The START and
STOPP criteria take it a step further.
They provide more context by listing situations where specific drugs should be
USED...and when specific drugs should be AVOIDED.
START (Screening Tool to Alert doctors to Right Treatment) lists 22 situations where
meds are indicated. It focuses on common quality- of-care indicators...warfarin for atrial
fibrillation, ACE inhibitors for heart failure or post-MI, metformin for diabetes, etc.
STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) lists
65 risky drug interactions with diseases or other drugs...plus therapeutic duplications.
For example, it advises not to use benzodiazepines in a patient who has fallen in the
past 3 months...or NSAIDs without a PPI or H2-blocker in a patient with a history of
ulcers or GI bleeding.
The Beers list is controversial because prescribers are sometimes dinged for using a
Beers drug in an elderly patient...even when it IS appropriate...such as amitriptyline for
neuropathic pain...amiodarone for atrial fibrillation...or naproxen forarthritis.
STOPP includes some of the same drugs, but provides more guidance.
For example, it suggests avoiding tricyclics for patients with glaucoma, cardiac
conduction problems, dementia, constipation, or benign prostatic hyperplasia...but NOT
neuropathic pain.
Don't fall into the trap of using these tools as the final word. None of them are
appropriate for blanket prescribing protocols or blanket formulary decisions.
Use them to help identify POTENTIAL problems...and then look at the whole picture.
Consider the patient's medication history, chronic diseases, functional status, and
prognosis
•
INFECTIOUS DISEASES Experts are concerned about a new strain of
ceftriaxone-resistant gonorrhea.
Once gonorrhea is resistant to ceftriaxone, we will have run out of simple
andreliable antibiotic options.
The ceftriaxone-resistant strain is already in Japan.
U.S. strains are becoming less susceptible to cephalosporins and
azithromycin...but they still work for now.
Use dual antibiotic therapy for gonorrhea to help reduce resistance...not just
because it also treats chlamydia.
Use ceftriaxone 250 mg IM...PLUS azithromycin 1 g PO instead of
doxycycline. Strains that are more resistant to cephalosporins are usually
resistant to doxycycline.
Don't be tempted to use higher ceftriaxone doses to prevent or overcome
resistance...there's no evidence that this is helpful.
Give cefixime instead of ceftriaxone if an oral option is absolutely
necessary...but watch for treatment failures.
If cefixime doesn't work, use ceftriaxone 250 mg plus azithromycin 2 g...and
retest in one week to make sure it works.
For patients with severe penicillin allergies, use a single 2 g dose of
azithromycin...and retest in a week.
•
ACETAMINOPHEN You'll see changes to OTC Tylenol and other
acetaminophen products to increase safety...starting this fall.
Tylenol products for adults will have a lower maximum dose.
Extra-strength Tylenol labels will say not to take more than six 500 mg tabs
or 3000 mg/day...instead of 8 tabs or 4000 mg/day.
Regular-strength Tylenol products will recommend no more than ten 325 mg
tabs or 3250 mg/day...starting next year.
Extended-release Tylenol dosing won't change. It will still recommend up to
six 650 mg caps or 3900 mg/day.
This is part of the trend to limit acetaminophen doses to reduce the risk of
acute liver failure. Advise patients not to exceed 3000 to 4000 mg/day of
acetaminophen...from all sources.
CONCENTRATED infant drops (80 mg/0.8 mL) will be phased out.
The new infant drops will be the same concentration as the children's liquid
(160 mg/5 mL).
Always give acetaminophen doses in mgs to avoid confusion. Some of the
older infant drops will remain on store shelves until next year...and in
home medicine cabinets even longer.
Important: Keep in mind that telling a parent to give a half teaspoonful
of Tylenoldoes NOT assure that they'll use the 160 mg/5 mL product. Caution
them that if they use the concentrated drops they may have at home, their baby
could get triple the proper dose.
Dosing for kids as young as 6 months will appear on children's
products...and will be based on age AND weight. For ages 4 to 23 months,
recommend 10 to 15 mg/kg every 4 to 6 hours...up to 5 doses per day.
•
ANTICOAGULANTS The new oral anticoagulants are bringing up questions
about how to reverse bleeding due to Pradaxa or Xarelto.
There are currently no antidotes for Pradaxa (dabigatran)
or Xarelto(rivaroxaban)...like vitamin K for warfarin.
But there are things you can do.
Stopping the anticoagulant and waiting 1 to 2 days in patients with healthy renal
function is enough prior to most surgeries. But this may not be fast enough for bleeding
or emergency surgery.
So far there are no specific guidelines...so for now, follow these common-sense best
practices to control bleeding.
Start with activated charcoal to absorb any residual drug if a dose was taken within 2
hours.
Maintain adequate diuresis...especially for Pradaxa since it's primarily renally
excreted.
Consider hemodialysis if feasible for Pradaxa...about 60% of the drug is removed in 2
to 3 hours. Xarelto is NOT dialyzable.
Give red blood cells and fresh frozen plasma as appropriate.
Consider activated prothrombin complex concentrates (aPCC) or recombinant factor
VIIa as a last resort for life-threatening bleeding.
There's not much evidence to support their use...and they increase thrombosis risk.
Plus, factor VIIa costs $5000 to $25,000 per treatment.
Keep in mind that clotting factors (fresh frozen plasma, aPCC, etc) aren't likely to be
wholly effective. That's because these newer anticoagulants INHIBIT clotting
factors...not DEPLETE them.
Be especially careful using Pradaxa or Xarelto in elderly patients with poor renal
function...due to the higher risk of bleeding.
Which of the following is TRUE
about treating migraine headaches in
children? A.Migraines are rare in
children. B.Ibuprofen is often
effective if given in adequate
doses. C.Sumatriptan tablets work
better than the nasal spray for
kids. D.Almotriptan (Axert) is
approved for ages 6 and up.
Answer
• B.Ibuprofen is often effective if given in
adequate doses.
•
MIGRAINES We're getting questions about whether it's okay to use triptans
(sumatriptan, etc) for migraines in CHILDREN.
Yes. Migraines are common in kids...especially teens.
Acetaminophen sometimes helps...ibuprofen is usually better. Use ibuprofen 7.5 to 10
mg/kg/dose...up to 800 mg/dose in older teens.
When OTC analgesics aren't enough, use a triptan...except in the rare case that a child
is at risk for heart disease.
For adolescents, start with almotriptan (Axert) 6.25 mg...rizatriptan (Maxalt) 5
mg...sumatriptan (Imitrex) nasal 5 mg...or zolmitriptan (Zomig) nasal 5 mg. These have
the most evidence in adolescents...and almotriptan is actually approved for ages 12 and
up.
In kids age 6 to 11, lean towards Maxalt 5 mg or Imitrex nasal 5 mg...because these
have the most evidence in younger kids.
Sumatriptan TABLETS are less expensive than the nasal spray...but they may not
work as well, possibly due to slower absorption. The important point is to try another
triptan if one doesn't work. Explain that some patients respond to one triptan but not
another.
Advise patients to take the triptan at the first sign of a headache...and repeat in two
hours if needed.
Advise parents to contact their child's school for the policy on med
administration...these vary between schools.
To help prevent migraines, recommend avoiding common culprits...not enough sleep,
skipped meals, too much caffeine or stress, etc.
Consider PROPHYLAXIS if headaches are frequent or severe enough to interfere with
daily activities. For most kids, start with amitriptyline, nortriptyline, cyproheptadine,
divalproex (Depakote, etc), topiramate (Topamax, etc), or propranolol.
Which of the following is TRUE about
treating more advanced Parkinson's
disease? A.Decreasing the levodopa
dosing interval may help reduce off
time. B.Switching to sustained-release
carbidopa/levodopa will reduce off
time. C.Increasing the levodopa dose
will help dyskinesias. D.Selegiline is
proven to work better than rasagiline
(Azilect) for reducing off time.
Answer
• A.Decreasing the levodopa dosing interval
may help reduce off time
•
You'll see more approaches to treating Parkinson's disease AFTER the "honeymoon" is
over.
It's relatively easy to control symptoms in the early years with low doses of
carbidopa/levodopa...or a dopamine agonist, such as pramipexole (Mirapex, etc) or
ropinirole (Requip, etc).
But when drug efficacy decreases, consider these approaches to control movement
problems in more advanced Parkinson's.
"Wearing off" often occurs after about 5 years of levodopa...where its effects start to
"wear off" sooner after the last dose.
To reduce "off" time, decrease the levodopa dosing INTERVAL by 30 to 60 minutes.
Don't count on switching to sustained-release levodopa (Sinemet CR, etc) to reduce off
time...it doesn't help.
Next try adding a dopamine agonist. This extends "on" time and prevents "deep" offs.
Or add a COMT inhibitor or MAO-B inhibitor.
For a COMT inhibitor, use Comtan (entacapone) or the combo
product Stalevo(carbidopa/levodopa/entacapone). Explain that the combo usually costs
less than the separate tabs. Try to avoid Tasmar (tolcapone)...it's linked to liver failure.
For an MAO-B inhibitor, use either selegiline or rasagiline (Azilect). Rasagiline has
better evidence for reducing off time...but selegiline costs less.
Dyskinesias occur when patients get too much dopamine.
Decreasing the levodopa dose may help...but may mean more Parkinson's symptoms,
such as tremor, stiffness, and rigidity.
Instead, try decreasing the levodopa dose...and adding a dopamine agonist. Dopamine
agonists cause fewer dyskinesias than levodopa...and also help decrease Parkinson's
symptoms.
Or add amantadine...but watch for CNS side effects.
Keep in mind that COMT inhibitors can contribute to dyskinesias by boosting
levodopa's effects. Reduce the dose or stop the COMT inhibitor if necessary.
•
DIABETES Patients are asking about a new "bloodless" glucose
meter.
This comes from misleading TV ads for diabetes supplies.
These ads are actually referring to "alternate site" meters. It's true
that patients don't need to stick their fingers...but they do need to get
blood from their arm or another site.
Tell patients that there aren't any bloodless glucose meters on the
market...but many of the newer ones need only a tiny drop of blood.
Explain that alternate site testing isn't reliable when blood glucose is
changing...after eating, after exercise, or when they're hypoglycemic.
Recommend fingertip testing at these times.
GlucoWatch WAS a bloodless meter...but it's no longer available. It
measured glucose through the skin...but it was plagued by problems.
Tell patients that researchers are trying to invent a bloodless meter to
measure glucose in tears, breath, or through the skin.
•
EDEMA Questions often come up about how to handle peripheral
edema due to dihydropyridine calcium channel blockers (amlodipine,
etc).
These often cause edema...especially at higher doses. It's not due to
fluid overload, so diuretics usually don't help.
Try lowering the dose. Most of the antihypertensive effect is at lower
doses, so cutting the dose in half doesn't also cut the BP benefit in
half.
Or try ADDING an ACE inhibitor or ARB to counteract the edema
and augment the antihypertensive effect.
Switch to a different antihypertensive, if needed. Verapamil or
diltiazem is less likely to cause edema than a dihydropyridine.
Watch for drugs that can increase dihydropyridine levels and,
therefore, the risk of edema. For example, amlodipine levels can be
increased by strong 3A4 inhibitors (clarithromycin, etc).
Multi-axial system
• The DSM-IV organizes each psychiatric diagnosis into
five dimensions (axes) relating to different aspects of
disorder or disability:
• Axis I: Clinical disorders, including major mental
disorders, and learning disorders, Substance Use Disorders
• Axis II: Personality disorders and intellectual disabilities
(although developmental disorders, such as Autism, were
coded on Axis II in the previous edition, these disorders
are now included on Axis I)
• Axis III: Acute medical conditions and physical disorders
• Axis IV: Psychosocial and environmental factors
contributing to the disorder
• Axis V: Global Assessment of Functioning or Children's
Global Assessment Scale for children and teens under the
age of 18
The condition of a patient with depressed
mood on most days for ≥2 yr plus ≥2 of the
following: changes in appetite, sleep, or
energy, lowered self esteem, poor
concentration, or hopelessness should be
diagnosed as:
A) Major depression
B) Dysthymic disorder
C) Bipolar disorder
D) Cyclothymic disorder
Answer
• B) Dysthymic disorder
Major depression
• 2 wk of depressed mood plus 4 SIG E CAPS (mnemonic
for
• increased or decreased Sleep
• Decreased Interest
• Guilt
• decreased Energy
• Decreased Concentration
• increased or decreased Appetite
• Psychomotor agitation or retardation
• thoughts of or attempts at Suicide)
• and without history of mania or hypomania;
• dysthymic disorder—depressed mood on most days for 2
yr plus 2 of changes in appetite, sleep, energy, lowered
self-esteem, poor concentration, or hopelessness
The definition of mania includes which of the
following?
More than 1 wk of persistently elevated,
expansive, or irritable mood
Increased activity and decreased need for
sleep
Grandiosity
Disorganized speech
Indiscretion
A) 2,3,4,5
B) 1,2,4,5
C) 1,2,3,5
D) 1,3,4,5
Answer
• C) 1,2,3,5
Bipolar disorders (BPDs)
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BPD I requires 1 episode of mania
BPD II requires 1 episode of hypomania
Cyclothymic disorder —rapid fluctuation between depression and hypomania
mania—1 wk of persistently elevated, expansive, or irritable mood with 3 (or 4 if mood irritable
only) of DIGFAST (mnemonic for
Distractibility
Indiscretion
Grandiosity
Flight of ideas
increased Activity
decreased need for Sleep
increased Talkativeness or pressured speech)
and must cause marked impairment in occupational or social functioning or necessitate
hospitalization
hypomania—4 days of elevated, expansive, or irritable mood plus 3 (or 4 if mood irritable only) of
DIGFAST
marked impairment in occupational or social functioning not required
cyclothymic disorder —2 yr of numerous episodes of depressive symptoms and hypomanic
symptoms without full-blown major depressive or manic episodes
mood disorder due to general medical condition — medical illness physiologically causes depression,
eg, depression due to hypothyroidism or pancreatic cancer; substanceinduced mood disorders — eg,
mania due to steroids or methamphetamine
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Schizophrenia
2 of delusions (fixed false believes), hallucinations, disorganized speech,
disorganized or catatonic behavior, and negative symptoms
plus 6 mo of continuous disturbance with 1 mo of active symptoms and
significant impairment in self-care and occupational and social functioning
brief psychotic disorder — psychotic symptoms lasting 0 to 30 days
schizophreniform disorder —symptoms lasting 1 to 6 mo
Subtypes:
Paranoid
disorganized (disorganized speech or behavior)
Catatonic
undifferentiated (mainly positive symptoms), or residual (negative symptoms
predominate)
catatonia— treat first-line with trial of intravenous (IV) lorazepam (2 mg); if
benzodiazepines not effective, switch quickly to electroconvulsive therapy
(ECT)
differentiated from neuroleptic malignant syndrome (NMS) by FEVER
mnemonic for Febrile, Elevated creatine phosphokinase (CPK), Vital sign
instability, Elevated white blood count, and Rigidity (catatonic patients have
only rigidity)
Schizoaffective disorder
• both psychotic and mood symptoms that may occur
separately
• 2 types, bipolar or depressive
• symptoms present regardless of mood (unlike major
depression or bipolar disorder with psychotic features, in
which psychosis occurs only during mood disturbance)
• Delusional disorders:
• 1 mo of nonbizarre delusion with no impairment of
function or odd behavior; subtypes—erotomanic,
grandiose, jealous, persecutory, somatic, mixed, and
unspecified
• do not respond well to medication or psychotherapy
A panic attack is defined as a
discrete period of fear peaking in:
A) 10 min
B) 30 min
C) 60 min
D) 90 min
Answer
• A) 10 min
Panic disorder
• recurrent panic attacks with 1 mo of concern about having another
attack or consequences of attack and significant change in behavior
• panic attack—discrete period of fear peaking in 10 min with
• 4 of palpitations, diaphoresis, trembling, dyspnea, sense of choking,
chest pain, nausea, dizziness, derealization or depersonalization, fear
of losing control or dying, paresthesias, chills, and hot flushes
• classified as with or without agoraphobia
• Generalized anxiety disorder (GAD):
• 6 mo of excessive anxiety on most days (not due to features of another
axis 1 disorder)
• 3 of WORRY WART
• (for Wound up or irritable
• Worn out or easily fatigued
• Absent minded or poor concentration,
• Restless
• Tense, or Sleepless)
Which of the following statements about
obsessive compulsive disorder is correct?
A) The obsessions and compulsions are
recognized by patients as excessive and egodystonic
B) The obsessions and compulsions arise
from the patient's desire for rules and
orderliness and are ego-syntonic
C) Patients believe that the obsessive
thoughts are inserted into their minds by
others
D) None of the above
Answer
• A) The obsessions and compulsions are
recognized by patients as excessive and
ego-dystonic
Obsessive compulsive disorder (OCD)
• obsessions, compulsions, or both, recognized by
patient as excessive and ego-dystonic, and that
cause marked distress and interfere with function
• not restricted to another axis 1 diagnosis, eg,
trichotillomania (compulsion of pulling hair),
hypochondriasis (obsession about serious illness),
or paraphilia (compulsions around sexual acting
out)
• obsessions —recurrent, persistent, intrusive,
inappropriate thoughts that cause distress
• Patient recognizes thoughts as products of own
mind
• compulsions— repetitive behaviors that patient
must perform in response to obsession or rigid rule
Posttraumatic stress disorder (PTSD)
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patient experienced, witnessed, or confronted with event that involved actual
or threatened death or serious injury
response involves fear, helplessness, or horror; >1 mo of symptoms in 3 areas
(re-experience, hyperarousal, and avoidance)
re-experience—1 symptom required
Recurrent recollections, nightmares, flashbacks (waking re-experience), or
intense distress after exposure to cues
hyperarousal—2 symptoms required
insomnia, irritability, poor concentration,
hypervigilance, or exaggerated startle response
avoidance—3 symptoms required; avoidance of thoughts, feelings,
conversations, people, or places or activities associated with event
difficulty remembering aspects of event
loss of interest in usual activities
detachment or estrangement
restricted affect
sense of foreshortened future
if symptoms present for <1 mo, diagnosis acute stress disorder
The diagnosis of somatization
disorder requires 4 sexual
symptoms, 2 gastrointestinal
symptoms, 1 pain symptom, and
1 pseudoneurologic symptom.
A) True
B) False
Answer
• B) False
Somatoform disorders
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somatization disorder—multiple physical complaints beginning before 30 yr of
age with treatment sought and impaired functioning
diagnosis requires 4 pain symptoms, 2 gastrointestinal symptoms, 1 sexual
symptom, and 1 pseudoneurologic symptom
conversion disorder—1 symptom affecting motor or sensory function;
hypochondriasis—preoccupation with belief in presence of serious illness
belief persists 6 mo after evaluation and reassurance
body dysmorphic disorder—preoccupation with imagined or minor defect in
appearance
factitious disorder— intentional feigning of signs and symptoms of illness
motivated by desire to have illness and receive care or sympathy
more common in women
Munchausen variant more common in men
malingering—intentional feigning of signs and symptoms of illness motivated
by desire to avoid something (eg, work, military service) or obtain
medications, shelter, or financial compensation
Pain disorder—unexplained pain
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Eating
disorders
anorexia nervosa—refusal to maintain normal body
weight
intense fear of gaining weight
disturbed perception of body weight or shape
often presents with amenorrhea
Bulimia nervosa—recurrent episodes of binge eating and
purging
2 times per week for 3 mo
patients usually depressed, but do not treat with bupropion
(Wellbutrin, Aplenzin, or Zyban) because of risk for
seizures
Paraphilias: 6 mo of recurrent, intense sexual fantasies,
urges, or behaviors focused on specific act or subject
include exhibitionism, fetishism, frotteurism, pedophilia,
sexual masochism or sadism, transvestic fetishism,
voyeurism, and not otherwise specifie
Choose the correct statement(s) about patients with
borderline personality disorder.They may show
suicidal behavior
They typically have a history of stable but abusive
relationships
They have an intense fear of abandonment
Dialectical behavioral therapy is the treatment of
choice
They often show emotional lability
A) 1,2,3,4
B) 2,3,4,5
C) 1,3,4,5
D) 1,2,4,5
Answer
• C) 1,3,4,5
Personality disorders
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pervasive behavior
not time limited
How patient’s world outlook framed
Cluster A: paranoid (4 symptoms required)
schizoid (lack of interest in human relationships)
schizotypal (unusual beliefs with eccentric behavior)
Cluster B: borderline—5 symptoms required, typified by history of unstable
relationships
emotional lability, or suicidal or parasuicidal behavior
intense fear of abandonment (often associated with difficult childhood)
treat with dialectical behavioral therapy (DBT)
histrionic—patient shows superficial emotional lability and desire for attention
narcissistic—patient believes in own specialness, needs attention, arrogant, entitled,
exploits others, and needs power
antisocial—patient lacks concern for anyone’s safety, rules, or social constructs
conduct disorder in child
Cluster C: avoidant—patient desires relationship but cannot participate in one because
of fear of rejection
dependent—unable to live without someone’s care
obsessive compulsive— patient desires rules and orderliness
ego-syntonic rather than egodystonic
Choose the correct statement(s) about
differences among selective serotonin
reuptake inhibitor (SSRI)
antidepressants.
A) Fluoxetine has the longest half-life
B) Paroxetine is the most sedating
C) Fluvoxamine has the most significant
interactions with cytochrome P450
D) A, B, and C
Answer
• D) A, B, and C
Antidepresents
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Selective serotonin reuptake inhibitor (SSRI) antidepressants: fluoxetine (Prozac, Sarafem, Selfemra), citalopram (Celexa), escitalopram (Lexapro),
paroxetine (Paxil, Pexeva), sertraline (Zoloft), and fluvoxamine (Luvox)
3 to 6 wk needed for response
relatively safe in overdose
side effects common but not severe and diminish with time
Sexual dysfunction most long lasting
Differences among SSRIs: half-life— longest for fluoxetine (84 hr); shortest for fluvoxamine
level of activation — sertraline and fluoxetine most activating
citalopram and escitalopram intermediate
paroxetine most sedating
Interactions with cytochrome P450—fluvoxamine has most; citalopram and escitalopram have none
Duration of treatment: administer antidepressants 6 mo (ideally1 yr) after resolution of symptoms to prevent relapse
Serotonin-norepinephrine reuptake inhibitor (SNRI) antidepressants: venlafaxine (Effexor) has greater affinity for serotonin, and duloxetine (Cymbalta)
inhibits both equally
Tricyclic antidepressants (TCAs): imipramine first available antidepressant; highly efficacious but side effects (anticholinergic effects and orthostatic
hypotension) limit patient adherence
easily fatal in overdose
desipramine and nortriptyline have least anticholinergic potential
doxepin, protriptyline, and amitriptyline have most
nortriptyline has lowest risk for orthostasis
clomipramine most serotonergic (often used in OCD)
doxepin most sedative
on overdose, TCAs block fast sodium channel, causing cardiac toxicity and fatal arrhythmias (treat with IV sodium bicarbonate)
Monoamine oxidase inhibitor (MAOI) antidepressants: more efficacious but more side effects
phenelzine (Nardil) and tranylcypromine (Parnate) irreversibly inhibit MAOA and MAOB increasing synaptic monoamines; risks include hypertensive crisis
and serotonin syndrome
patient must adhere to tyramine-free diet
drug interactions —with serotonergic (serotonin syndrome) or sympathomimetic drugs (hypertensive crisis)
2-wk washout period required before reintroducing any serotonergic drug
antibiotic linezolid weakly inhibits MAOA and can cause hypertensive crisis and serotonin syndrome
Other antidepressants: mirtazapine (Remeron)— antagonist of
inhibitory 2 receptors; increases release of serotonin and norepinephrine; strong antihistamine
adverse effects include somnolence and weight gain
bupropion—increases dopamine and norepinephrine
rarely associated with sexual dysfunction; increases risk for seizures (especially in patients with eating disorders)
adjunct treatment for sexual dysfunction induced by SSRIs
Anxiolytics: SSRIs and SNRIs used first-line
Some antiepileptic and
neuroleptic medications are
commonly used as mood
stabilizers for patients with
bipolar disorder.
A) True
B) False
Answer
• A) True
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Mood
stabilizers:
for patients with BPD, do not start unopposed antidepressant (may
push patient into mania)
start mood stabilizer first
antiepileptics commonly used include valproate, carbamazepine, and
oxcarbazepine
lithium — start at 300 mg twice daily, monitor, and titrate to
therapeutic level (0.7 to 1.2 mEq/L)
adverse effects—renal injury with diabetes insipidus, thyroid injury,
hyperparathyroidism, tremor, dry mouth, nausea, and benign
leukocytosis
toxicity characterized by confusion, nausea and vomiting, tremor,
ataxic gait, blurred vision, orthostasis, hyperreflexia, and fasciculations
treat with aggressive IV fluids if blood level <2.5 mEq/L or
hemodialysis if blood level >2.5 mEq/L; monitor levels closely, even
after dialysis;
drug interactions— nonsteroidal antiinflammatory drugs (NSAIDs),
thiazide diuretics, and angiotensin-converting enzyme (ACE)
inhibitors
activated charcoal does not affect lithium overdose but useful if patient
A patient who shows elevated creatine
phosphokinase, vital sign instability,
elevated white blood count, and rigidity
is likely to have which of the following
disorders.
A) Catatonia
B) Serotonin syndrome
C) Neuroleptic malignant syndrome
D) None of the above
Answer
• C) Neuroleptic malignant syndrome
Neuroleptics
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typical (eg, haloperidol, chlorpromazine, fluphenazine) atypical (eg, risperidone, quetiapine,
olanzapine,
ziprasidone) block dopamine; atypicals less specific and act
on serotonin, acetylcholine, and histamine as well as dopamine; first-line treatment for psychotic
disorders but indicated in others; some atypicals approved as mood stabilizers
in BPD (ie, ziprasidone, olanzapine, quetiapine, aripiprazole, and risperidone)
Intramuscular injection (ensures compliance): long-acting—
decanoate preparations of haloperidol and fluphenazine,
risperidone (Risperdal Consta), and paliperidone (Invega
Sustenna); short-acting — haloperidol, chlorpromazine,
olanzapine (Zyprexa), ziprasidone (Geodon)
Intravenous:— none approved for IV injection, but IV haloperidol standard of care for delirium
Adverse effects: typicals — extrapyramidal (ie, dystonia and parkinsonism), akathisia, tardive
dyskinesia
Prolongation of QTc interval, and NMS
atypicals — weight gain, metabolic syndrome, and diabetes mellitus, prolongation of QTc interval,
and NMS
clozapine—most efficacious but increases risk for life-threatening agranulocytosis
requires federal permission for prescribing; must document failure of other treatments and use
federal national registry
regular monitoring of white blood cell count and absolute neutrophil count required
NMS—differentiated from serotonin syndrome by presence ofrigidity in NMS and clonus in
serotonin syndrome
discontinue agent and provide supportive car
Electroconvulsive therapy is
indicated for which of the
following conditions?
A) Major depression
B) Bipolar disorder
C) Catatonia
D) A, B, and C
Answer
• D) A, B, and C
Electroconvulsive therapy
• indicated for major depression (especially if patient
cachectic or psychotic), BPD, acute exacerbation of
schizophrenia, or catatonia
• paralyzes patient and induces seizure lasting 25 sec
• very efficacious with no absolute contraindications;
relative contraindications include coronary artery disease,
hypertension, arrhythmias, space-occupying intracranial
lesions, cerebral aneurysms, history of recent stroke, or
pregnancy
• adverse effects—postictal confusion (typically clears in
days to weeks)
• anterograde and retrograde amnesia (lasting 6 mo)
Psychodynamic psychotherapy
• psychoanalysis to achieve understanding of previously
unconscious conflicts
• Cognitive behavioral therapy: assumes thoughts and
feelings influence each other; very effective for depression,
anxiety, and
• treatment of choice for OCD
• Dialectical behavioral therapy: specifically intended for
borderline personality disorder
• focuses on mindfulness
• regulation of emotion,
• and radical acceptance
• Important stages: behavior change—precontemplation,
contemplation, preparation, action, maintenance, and
relapse; grief—
• denial, anger, bargaining, depression (not in linear
progression), and acceptanc
For most uncomplicated
abscesses or boils, antibiotics
(ABX) are recommended as the
first line of
treatment.
(A) True (B) False
Answer
• (B) False
• Case 1: 32 yr-old man with 3 days of enlarging painful lesion on left
thigh attributed to spider bite
• afebrile; remainder of vital signs (VS) normal
• area of induration with surrounding erythema and some purulent
drainage noted
• Management of skin abscesses: for most uncomplicated abscesses or
boils, incision and drainage (I&D) alone likely adequate
• controversial whether antibiotics (ABX) provide additional benefit
(multiple observational studies plus 3 recent randomized controlled
trials [RCTs] of uncomplicated skin abscesses report high clinical cure
rates with and without ABX
• however, data from 2 RCTs suggest ABX may also help prevent
recurrent infections)
• ABX therapy recommended for abscesses associated with — severe or
extensive disease (rapidly progressive or with associated septic
phlebitis)
• signs and symptoms of systemic illness; associated comorbidities or
immmunosuppression; extremes of age; area difficult-to-drain; failure
of previous I&D
• Microbiology of purulent skin and soft tissue infections
(SSTIs): in study of patients presenting to 11 emergency
departments (EDs) throughout United States, methicillinresistant Staphylococcus aureus (MRSA) accounted for
59% of SSTIs, while Beta-hemolytic Streptococcus (BHS)
accounted for only 3%
• Treatment of purulent cellulitis: empiric therapy for
community acquired (CA)-MRSA recommended
• therapy for BHS unlikely to be necessary
• recommended duration of therapy 5 to 10 days
• Empiric oral ABX therapy for uncomplicated purulent
SSTIs: options trimethoprim-sulfamethoxazole (TMPSMX), doxycycline or minocycline, clindamycin, and
linezolid
• rifampin not recommended for routine treatment of SSTI
Case 2
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28-yr-old woman with erythema of left foot for last 48 hr
no purulent drainage, exudates, or abscess
afebrile; other VS also normal
Treatment of nonpurulent cellulitis
empiric therapy for BHS recommended
therapy for CA-MRSA recommended if patient fails to respond to Beta-lactam
ABX, and should be considered in patients with systemic toxicity;
options for empiric treatment — cephalexin (eg, Keflex, Panixine, Biocef),
dicloxacillin, clindamycin, and linezolid
if no response to cephalexin or dicloxacillin, add ABX effective against
MRSA
Treatment of complicated SSTIs: mainstay of therapy surgical debridement;
empiric therapy for MRSA recommended pending data from cultures
options for ABX therapy—vancomycin, linezolid, daptomycin, telavancin,
ceftaroline, and clindamycin
tigecycline associated with increased risk for mortality (not recommended;
consider alternative agent); recommended duration of therapy 7 to 14 day
The recommended duration
of ABX therapy for
purulent cellulitis is
_______ days.
(A) 5 to 10 (C) 14 to 21
(B) 7 to 14 (D) 3
Answer
• (A) 5 to 10
Which of the following options
for ABX treatment of
complicated skin and soft tissue
infections (SSTIs) is
associated with an increased risk
for mortality?
(A) Vancomycin (C) Linezolid
(B) Daptomycin (D) Tigecycline
Answer
• (D) Tigecycline
Current guidelines suggest firstline treatment of recurrent SSTIs
is:
(A) Focus on personal hygiene
and wound care
(B) Decolonization with topical
ABX
(C) Decolonization with oral
ABX
(D) B or C
Answer
• (A) Focus on personal hygiene and wound
care
Case 3
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case 1 patient returns 4 wk later with another abscess on opposite thigh
notes that after I&D of first abscess, did not keep wound covered, and occasionally touched site to
make sure healing properly
site of old abscess clean with well-healed scar
patient undergoes I&D and receives 1 wk of TMP-SMX
Management of recurrent SSTIs: pathogenesis of recurrent SSTIs unclear
however, likely complex interplay between host, environment, and pathogen
current guidelines recommend focusing first on personal hygiene, wound care, and environmental
hygiene
if these measures fail or with evidence of ongoing household transmission, consider decolonization
with topical ABX
caveat —mupirocin appears to decrease S aureus colonization among nasal carriers in short term, but
no studies show impact on prevention of recurrent SSTIs
Decolonization: regimens to consider—intranasal mupirocin twice daily for 5 to 10 days
mupirocin for 5 to 10 days plus topical skin antiseptic (eg, chlorhexidine) for 5 to 14 days
mupirocin for 5 to 10 days plus dilute bleach baths (one-quarter cup to one-quarter tub of water) for
15 min twice weekly for 3 mo
oral ABX for decolonization —Cochrane review found oral ABX provide no benefit in eradicating
MRSA among patients in health care settings
systematic review found rifampin plus antistaphylococcal antibiotic superior to antistaphylococcal
agent alone in reducing S aureus colonization
however, no studies have evaluated impact of therapy on rates of infection
guidelines suggest using oral ABX for decolonization only as last resort (watch for drug interactions,
potential side effects, and development of resistance
Imaging with _______ has low
sensitivity for diagnosing
necrotizing SSTIs, but may be
helpful if gas is
present.
(A) Computed tomography (C)
Plain films
(B) Ultrasonography (D)
Magnetic resonance imaging
Answer
• (C) Plain film
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Case 4
39-yr-old man with 1-day history of leg pain and erythema (worsening pain/swelling
over 24 hr)
development of bulla formation
febrile, tachycardic, and slightly hypotensive
has white blood cell count with left shift
Necrotizing SSTIs: can be monomicrobial (most common pathogen group A
Streptococcus) or polymicrobial
risk factors include intravenous (IV) drug use, diabetes, obesity, and chronic
immunosuppression (but often have no precipitating factor)
Clinical presentation—patient often presents with nonspecific complaints
on physical examination (PE), can be difficult to distinguish from cellulitis (sometimes
only mild local erythema found
pain out of proportion clue to deeper necrotizing infection);
diagnosis— can be challenging
many characteristic findings (eg, bullae, induration, fluctuance, crepitus, necrosis) occur
later in presentation
most common findings (tenderness, warmth, erythema, fever, and tachycardia) often
seen with “run of the mill” SSTIs
plain films have low sensitivity, but may be helpful if gas present
computed tomography and ultrasonography may identify other diagnoses; magnetic
resonance imaging fairly sensitive but has low specificity
management—if necrotizing SSTI suspected, consider early surgical consultation and
treat empirically (antimicrobial therapy with piperacillin-tazobactam or carbapenem,
plus clindamycin and vancomycin
Bites from _______ are
associated with the highest risk
for infection.
(A) Dogs (B) Cats (C) Humans
(D) Rabbit
Answer
• (B) Cats
Case 5
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21-yr-old man bitten by dog
receives several deep puncture wounds on hand
Animal bites: risk factors for infection —biting species (cats associated with highest risk, followed
by humans; dogs associated with relatively low risk)
location (hand, foot, joint, or other vulnerable areas [eg, face])
wound type (deep puncture wounds, crush injuries)
interval to medical care (treatment delay >12 hr)
host factors (eg, advanced age, underlying comorbidities or immunosuppression, steroid use)
microbiology—infections typically polymicrobial
most common pathogen in dog and cat bites Pasturella
recommended empiric treatment regimen—amoxicillin-clavulanate (Augmentin) (plus anti-MRSA
agent, if indicated)
with penicillin allergy, consider ciprofloxacin plus clindamycin or Moxifloxacin
consider prophylaxis if—bites moderate to severe, or on face or hands
patient immunocompromised
bitten by cat
risk for rabies—in assessing risk after bite, consider local epidemiology
if bite from dog, cat, or ferret, prophylaxis recommended if rabies suspected
if bite from skunk, raccoon, fox, or bat, consider animal rabid unless proven negative by laboratory
test (immediate prophylaxis recommended)
bites from rabbits and small rodents typically do not require prophylaxis;
recommended postexposure prophylaxis regimen —clean wound with virucidal agent
Rabies immunoglobulin (administer full dose around wound and remaining volume intramuscularly
at site distant from vaccine
Vaccinate for 4 days
Case 6
• 53-yr-old ED physician with 9-day history of progressive
cellulitis of left forearm
• initially noted pustule and performed I&D on himself
• despite taking cephalexin and clindamycin for 4 days,
developed progressive erythema and drainage
• started IV vancomycin and ceftriaxone, with no
improvement after 3 days
• Nocardia brasiliensis—found in soil and environment
worldwide
• incubation period 1 to 6 wk; infection often associated with
mild systemic symptoms
• diagnosis made by biopsy and culture
• treatment TMP-SMX for 4 to 6 mo
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Case
7
26-yr-old man with 6-wk history of papule on right hand that
progressed to ulcer
patient presented to ED and urgent care multiple times and received
several courses of ABX with no improvement
diagnosed with Leishmania panamensis infection
Management of nodular lymphangitis: biopsy critical for diagnosis
(pathology for fungi and mycobacteria; cultures for bacterial, fungal,
and mycobacterial disease)
consider empiric therapy if index of suspicion high based on etiology
and patient history
organisms to consider include Francisella tularensis, N brasiliensis,
Mycobacterium marinum, Sporothrix schenkii, and L panamensis
“Masqueraders” of infectious cellulitis
contact dermatitis
Drug reactions
deep venous thrombosis
Sweet syndrome
Underlying malignancy
The population-adjusted
incidence of sepsis has been
_______ in the United States.
(A) Decreasing (B) Stable (C)
Increasing
Answer
• (C) Increasing
Sepsis
• occurs when systemic inflammatory response
syndrome (SIRS) overlaps with infection (defined
by visual inspection or culture)
• most commonly caused by bacteremia
• Impact of sepsis in United States: retrospective
study of patients hospitalized for sepsis between
1979 and 2000 found mortality rate declined from
28% during first 6 yr of study to 6% during last 6
yr (mortality still quite high; 20% of severely
affected patients die; tenth-leading cause of death
in United States)
• population-adjusted incidence of sepsis increasing
Multiplex polymerase chain
reaction is easier to use for
detecting pathogens in _______
infections than in
_______ infections.
(A) Bacterial; fungal (B) Fungal;
bacterial
Answer
• (A) Bacterial; fungal
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Diagnosis of sepsis
establish source—look for epidemiologic clues
obtain gram stains (from urine, sputum, and superficial sites) and cultures (from all
sites)
targeted imaging;
Source control— critical step in early management (diagnostic and therapeutic)
data from cultures always delayed
potential additional diagnostic aids —procalcitonin (may have role in monitoring
therapy and/or limiting duration of ABX)
multiplex polymerase chain reaction (PCR; can potentially decrease time to pathogen
diagnosis
easier to use in detecting bacterial [vs fungal] pathogens)
Importance of appropriate initial ABX therapy: several studies have demonstrated
significant increase in mortality when inadequate ABX used at start of treatment for
sepsis
Infection-specific considerations in choosing ABX therapy:
consider source, susceptibility of pathogen (know local antibiogram and trends in
hospital epidemiology), host factors (eg, asplenia, neutropenia, history of solid organ
transplantation), and recent antibiotic exposure
Comments: between 1979 and 2001, rise in gram-positive and gram-negative bacterial
infections mirrored that in sepsis
however, from late 1990s to 2001, incidence of fungal infections rose substantiall
All the following are risk factors
for nosocomial infections,
except:
(A) Increasing age (C) Male sex
(B) Immunosuppression (D)
Recent antibiotic exposur
Answer
• (C) Male sex
Risk factors for nosocomial
infections
• (vancomycin-resistant enterococci [VRE],
MRSA, gram-negative rods, or Candida):
health care exposure
• increasing age
• Immunosuppression
• exposure to invasive devices
• recent antibiotic exposure
Combination vs monotherapy
• area of some controversy; 2004 and 2005 meta-analyses found no
overall benefit with combination therapy vs monotherapy for treatment
of gram-negative bacteremia
• however, in recent study of gram-negative sepsis, results showed no
survival advantage overall, but subgroup analysis found combination
therapy beneficial in patients with septic shock or neutropenia
• in another recent study of patients with culture-proven, bacterial septic
shock, propensity-matched analysis found combination therapy
associated with lower 28-day mortality and greater number of
ventilator- and vasopressor- or inotrope-free days;
• Hypothesized mechanisms of benefit—1 agent increases likelihood of
pathogen susceptibility
• prevention of emergence of resistant organisms
• potential immunomodulatory effects of second agent
• synergistic antimicrobial effect of combination (leading to more rapid
killing of pathogen)
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Drug-dosing considerations in critically ill patients:
pharmacokinetics —penetration into various body fluids
activity of drug in anaerobic environment (eg, abscess)
Presence of foreign material
organ dysfunction that may necessitate dose adjustment
pharmacodynamics —degree of serum protein binding
pattern of killing
degree of persistent effect
patients with sepsis typically have increased volume of distribution and variations in clearance
Beta-lactams: pattern of activity time above minimal inhibitory concentration (MIC; ideally, should
to be 4 to 5 times above MIC 40% to 70% of time)
achieved by increasing frequency of dosing or changing to continuous or extended infusions
retrospective cohort study of patients with Pseudomonas infection found extended (vs regular) dosing
resulted in much lower mortality rate in patients with Acute Physiology and Chronic Health
Evaluation (APACHE) score 17
at speaker’s institution, piperacillin-tazobactam infusions extended to 4 hr and carbapenem infusions
to 3 hr
Aminoglycosides: peak-to-MIC ratio most important factor in proper dosing
once-daily dosing most effective
small study from late 1990s showed >90% probability of response (fever and leukocytosis) by day 7
if ratio of maximum concentration (Cmax ) to MIC >10
lower incidence of nephrotoxicity at day 5 with once-daily dosing
drug monitoring necessary in critically ill patients due to clearance variation
Which of the following interventions is
included in the acute-care (first 6 hr) bundle
for sepsis care?
(A) Administer low-dose corticosteroids
(B) Achieve glucose control between >70
mg/dL and <150 mg/dL
(C) Measure serum lactate
(D) Consider administering activated protein
C
Answer
• (C) Measure serum lactate
Timing of administration of ABX and patient survival
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Study found administration of ABX within first hour of documented hypotension associated with 20% mortality rate
each 1-hr delay in ABX administration associated with 7% increase in mortality
Early goal-directed therapy (EGDT) for sepsis-induced hypoperfusion
goal of EGDT to complete series of interventions in first 6 hr after presentation in order to maximize oxygen delivery
and minimize organ dysfunction
interventions include aggressive fluid resuscitation, transfusion to hemoglobin >12 g/dL, use of pulmonary artery
catheter for hemodynamic monitoring, sedation, and ventilation paralysis, as needed
in one study, EGDT shown to reduce mortality rate from 46% to 30%
criticisms of study —with bundled approach, difficult to separate relative value of each intervention
single-center trial
controls “overly sick”
ongoing concern and reluctance to place pulmonary artery catheter and transfuse per protocol because of potential
complications
Currently 3 large ongoing multicenter trials looking at each intervention and their incremental benefit (data not yet
published)
Bundled approach to sepsis care: currently divided into 2 components
acute-care bundle — to be completed within first 6 hr
measure serum lactate
obtain blood cultures and administer ABX
treat hypotension and/or elevated lactate (IV fluids; vasopressors)
if persistent hypotension or lactate >4 mmol/L, implement transfusion and pulmonary artery monitoring for
hemodynamics
longer-term-care bundle —to be completed within first 24 hr
administer low-dose corticosteroids
glucose control between >70 mg/dL and <150 mg/dL (controversial)
maintain low tidal volume (6 mL/kg) with ventilation
consider activated protein C
caveat —much of this subject to change
new sepsis guidelines due in 2012 (should incorporate data from ongoing studies)
Which of the following is(are) a
symptom(s) of depression?
A) Social withdrawal
B) Pessimism
C) Fearful affect
D) All the above
Answer
• D) All the above
Late-life depression
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frequently underdiagnosed and undertreated due to misconception that depression part of normal
aging
definition — pervasive sadness, depressed mood, loss of interest in normal activities, feeling that life
no longer worth living
suicide— most adverse consequence of untreated depression
duration — months or years
Presentation: often coincides with medical illness and general deterioration of health
often underdiagnosed due to attribution of depression to natural consequences of concomitant illness
(eg, cardiovascular disease [CVD])
consequences — prolonged suffering for patient and family
reduced quality of life
poorer prognosis for general medical illness
increased costs
increased risk for suicide and mortality
Diagnosis: difficult in context of other illnesses (ie, symptoms may overlap)
observer-rated scales used more often in elderly than in younger patients
appearance — fearful or sad affect
behavior — social withdrawal, deterioration in self-care, or decreased conversation
irritability or sadness considered first primary symptom of depression on some scales
thought content — brooding, self-pity, pessimism, increased sense of failure and/or punishment,
feeling helpless, low self-esteem, wish to die
practice tips— do not allow empathy to interfere with diagnosis
major depressive disorder not consequence of illness
Medications for patients with
depression and physical illness
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Cochrane Review (2010) — over 51 published placebo-controlled trials of
elderly patients with concomitant illnesses (eg, cancer, diabetes); medications
more effective than placebo
longer studies — better response seen with 12 to 14 wk vs 6 to 8 wk duration
safety and efficacy of tricyclics— comparable to selective serotonin reuptake
inhibitors (SSRIs)
Medications associated with development of depression:
Reserpine
Steroids
certain drugs used for cancer treatment (eg, interferon)
polypharmacy—medications not typically
associated with depression when used alone may cause depression when used
in combination
eliminate medications as appropriate (first line of treatment)
cognitive deficits and depression often resolve without addition of
antidepressant medication
Depression can be an early
indicator of Alzheimer disease in
elderly patients.
A) True
B) False
Answer
• A) True
Cognitive disorders
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depression often early sign of deteriorating cognitive disorder, eg, Alzheimer
disease (AD)
Similar rates of depression seen in subcortical dementias, eg, Parkinson
disease, vascular dementias
vascular depression— first onset generally at >60 yr of age consider hidden
neurologic disorder or vascular risk factors (eg, hypertension, CVD,
cerebrovascular disease)
often associated with reduced depressive ideation and increased somatic
symptoms, psychomotor retardation, and cognitive dysfunction
does not respond as well to medication as nonvascular depression
depression with executive dysfunction —considered to have frontostriatal
origin
characterized by psychomotor retardation, reduced interest in activities,
anhedonia rather than sadness, impaired instrumental activities of daily living,
limited insight, and impaired executive functioning (eg, setting goals, planning
activities, initiating and sustaining effort, monitoring performance
Treatment for depression with
cognitive impairment in elderly
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antidepressants— studies show marginal efficacy (possibly attributable to high
response rates in groups receiving placebo
speaker postulates that this effect due to frequent follow-up visits with caring
clinician)
problemsolving therapy— shown to be highly effective in studies by Arean et
al and Alexopoulos et al
aimed at relieving stress by teaching patients how to cope with everyday
difficulties
after 6 wk, problem-solving therapy more effective than supportive therapy
prolonged effects observed in patients followed beyond 12 wk
donepezil— cholinesterase inhibitor used to improve cognition in patients with
cognitive dysfunction
when given to patients with minimal cognitive impairment who had responded
to antidepressant medication (in study by Reynolds), cognition improved (less
progression to dementia), but likelihood of recurrence of depression increased
Which of the following
symptoms is not associated with
vascular depression?
A) Increased depressive ideation
B) Increased somatic symptoms
C) Psychomotor retardation
D) Cognitive dysfunction
Answer
• A) Increased depressive ideation
Which of the following
treatments has been shown to be
highly effective in improving
depression in elderly patients
with comorbid cognitive
impairment?
A) Antidepressant medications
B) Problem-solving therapy
C) Memory enhancers
D) None of the above
Answer
• B) Problem-solving therapy
Multiple losses and bereavement
• elderly lose jobs, money, homes, abilities, health, and
loved ones;
• bereavement — relationship with depression controversial
• Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM IV) — cautions against treating
depression within 2 mo of loss of loved one and
diagnosing major depression after bereavement
• however, depression after bereavement common and as
persistent as any other type of depression with similar
outcomes, treatment responses, and recurrence rates
• “fallacy of misplaced empathy” — inappropriate to dismiss
signs of major depressive episode as “normal” in patients
despondent because of loss (treat accordingly
Which of the following is a
characteristic of normal grief
rather than depression?
A) Dysphoria that occurs in
waves
B) Guilt focused on deserving to
be depressed
C) Feeling that nothing is
enjoyable
D) Being inconsolable
Answer
• A) Dysphoria that occurs in waves
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Distinguishing between normal grief and major
depressive disorder
normal grief — dysphoria in waves, often precipitated by reminders of deceased, but mixed with
happy pleasant memories
not inconsolable
wants to be with others and talk
major depression — pervasive feeling that nothing enjoyable
guilt focused on deserving to be depressed (rather than letting down person who died)
suicidal ideation or feeling undeserving of life (rather than wishing to be reunited with deceased)
diagnostic tip — consider severity of depression and history
not determined by time since loss of loved one
Treatment for bereavement-related depression: no randomized controlled trials (RCTs) of
psychotherapy
literature suggests positive effects; several studies demonstrate efficacy and safety of medication
study by Zisook et al — patients who met criteria for major depression given bupropion within 8 wk
of losing spouse
depression and symptoms of grief diminished over time
Psychotherapy: historically considered ineffective
in past 10 to 15 yr, controlled trials have proven otherwise
indications — acute treatment of major depression
after remission to prevent further episodes
prophylactic treatment with problem-solving therapy or SSRIs after stroke associated with lower
rates of depression, compared to placebo
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Antidepressants
tricyclics — mainstay in 1960s and 1970s
desipramine least anticholinergic and nortriptyline least likely to cause orthostatic hypotension (OH)
effective in elderly, but anticholinergic side effects can adversely affect cognition
also associated with potentially detrimental antihistaminic and cardiovascular effects
SSRIs — introduced in late 1980s
safer and more tolerable than tricyclics; serotonin-norepinephrine reuptake inhibitors (SNRIs) — also effective
mirtazapine may be beneficial in frail underweight elderly due to potential side effect of weight gain
efficacy — study by Nelson showed that response to antidepressants shows greater divergence from response to
placebo with longer (10-14 wk) duration of treatment; patients with early onset of depression, more severe depression,
and/or more recurrent depression attain better response
weigh modest benefits of antidepressants against potential safety issues (eg, increased risk for bleeding,
hyponatremia, decreased bone density)
treatment tip — “start low, go slow,” but increase dose until patient responds or fails to tolerate
Other effective modalities: exercise — for minor and major depression
not as strongly recommended for major depressive disorder, but some data suggest benefit
bright light — for major and minor depression
electroconvulsive therapy (ECT) — for more resistant depression
transcranial magnetic stimulation (TMS) — approved by Food and Drug Administration, but effects not as robust as
ECT
Collaborative care: depression in primary care settings often undertreated or not treated effectively
outcomes of collaborative care models, eg, Improving Mood Promoting Access to Collaborative Treatment
(IMPACT) consistently superior to those of traditional approaches
findings— higher patient satisfaction
sustained effects
crosses cultural boundaries
associated with fewer thoughts of suicide
cost — $522 per patient
savings tremendously outweigh alternative
should be standard of care
Results of randomized controlled trials do not
always apply to elderly patients with dementia
because:
A) Patients with dementia are commonly
excluded from the trials
B) Patients >80 yr of age are commonly
excluded in the trials
C) Patients with multiple comorbidities are
commonly excluded from the trials
D) All the above
Answer
• D) All the above
All the following are conditions
commonly comorbid with
dementia, except:
A) Diabetes
B) Hypertension
C) Ulcerative colitis
D) Congestive heart failure
Answer
• C) Ulcerative colitis
Which of the following is not a
complication of late-stage
dementia?
A) Behavioral disturbances
B) Gait disorders and falls
C) Weight loss
D) Hair loss
Answer
• D) Hair loss
A noisy chaotic environment can
trigger agitation in patients with
dementia.
A) True
B) False
Answer
• A) True
Which of the following statements about
management of agitation in advanced dementia
is incorrect?
A) Undiagnosed pain may be the underlying cause
B) Medication is the first line of treatment
C) Focus treatment on symptoms that place patient
or others at risk
D) Do not treat trivial or annoying behaviors
Answer
• B) Medication is the first line of treatment
Menopause can produce symptoms as a result of declining
hormone levels. Which one of the following sentences is
TRUE concerning the use of testosterone in postmenopausal
women?
Testosterone production declines approximately 90% with
the onset of menopause.
Testosterone improves sexual functioning and reduces the
vasomotor symptoms associated with menopause.
The Nurses’ Health Study showed no link between combined
estrogen/testosterone therapy and increased risk of breast
cancer.
Dehydroepiandrosterone (DHEA) and DHEA sulfate
(DHEAS) are not reasonable alternatives for testosterone
when considering androgen therapy in postmenopausal
women.
Because of its effect on the lipid profile, testosterone has
been determined to be safe in postmenopausal women with
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Menopause can produce severe and disabling symptoms in some women, and many studies have sought to evaluate the effectiveness of
therapies in alleviating these symptoms. Those most commonly described are vasomotor symptoms, loss of libido, vaginal
dryness/atrophy, depressed mood, poor sleep, cognitive disturbances and an overall decrease in quality of life. Not only do estrogen
levels decline with menopause, but so do androgen levels. There is approximately a 50% reduction in androstenedione and subsequent
testosterone production. A few studies have found that reduced levels of testosterone result in a decrease in sexual desire and
functioning that improves with the addition of androgen therapy. Low circulating levels of testosterone have also been correlated with
hip fracture and reduced bone density. Because of such results women have been started on testosterone therapy since the 1970s,
despite lack of approval by the Food and Drug Administration (FDA).
Doses of testosterone at higher-than-physiologic levels do appear to improve sexual functioning, libido and sexual arousal while also
improving bone composition, muscle strength and quality of life. A review (Alexander, et al.) of randomized controlled trials
determined that testosterone with estrogen replacement improved overall sexual functioning, but the number of women responding was
variable, as were the dosing and regimen used in the trials reviewed. The addition of testosterone does improve bone density. However,
there is little evidence that use of testosterone is useful in managing vasomotor symptoms except when combined with estrogen.
Dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS) decline with age along with testosterone. While replacing these
substances increases testosterone levels, vasomotor symptoms, mood and sleep disturbances do not improve.
The use of testosterone and androgens has potential risks. Adverse side effects with high doses of androgens include acne, hirsutism
and a reduction in HDL levels. Long-term cardiac effects resulting from lowered HDL levels are unknown and pose a theoretical
concern, although no long-term studies have explored the cardiovascular risks or safety. Virilization is rare but can occur in women
taking doses that are higher than exist physiologically. Women receiving estrogen and testosterone hormone replacement therapy in the
Nurses’ Health Study from 1978-2002 were found to have a greater risk of breast cancer with each year of use (17.2% increased; 95%
confidence interval [CI] 6.7-28.7%).
The evidence regarding the use of testosterone in menopause is conflicting and its safety uncertain; therefore, a thorough review of
individual risks and potential benefits should be undertaken before initiating testosterone therapy. The North American Menopause
Society recommends that testosterone therapy only be considered and started in women who suffer from decreased sexual
functioning that causes personal distress with no identifiable cause (SOR C; Ref. 5). DHEA and DHEAS are not recommended,
since little evidence supports their use and the FDA does not regulate these over-the-counter formulations for content or purity.
Continued monitoring is recommended once a woman chooses to begin therapy and should focus primarily on monitoring for potential
side effects such as virilization, breast cancer and altered lipid levels. Baseline liver function tests and lipid levels are recommended and
should be obtained again at 3 months and annually if stable. Contraindications to testosterone therapy are similar to those for estrogen.
These include breast or uterine cancer or women with cardiovascular or liver disease.
A 45-year-old male patient comes to the office for a routine
physical. During the history taking, the patient states his wife
has said he has bad breath. He has tried mouthwashes and
increasing his fluid intake, but his wife says they have not
helped. Breath mints seem to cover his bad breath but do not
eliminate it. Which one of the following would be the BEST
recommendation regarding the patient’s halitosis?
Obtain a H. pylori antibody test.
Prescribe empiric therapy with oral antibiotics.
Recommend aggressive oral hygiene with frequent flossing
and tongue brushing.
Schedule an esophagogastroduodenoscopy (EGD) to evaluate
the patient for gastrointestinal reflux disease.
Schedule a computed tomography (CT) of the sinuses and
upper airway.