Pharmacology/Drug Interaction Pearls · • Amiodarone • Telithromycin, erythromycin, clarithromycin • -Azoles ... Allergic Facies Wright, 2012 ABRS Treatment Guidelines Adult:

Wright, 2012 1

Pharmacology Pearls: What I Wish I Knew Years Ago

Wendy L. Wright, MS, RN, ARNP, FNP, FAANPFamily Nurse Practitioner

Owner - Wright & Associates Family Healthcare

Amherst, New Hampshire

Partner – Partners in Healthcare Education, LLC

Objectives

• Upon completion of this lecture, the participant

will be able to:

– Discuss 10 -20 “pharmacology” pearls of practice

related to various disease states

– Identify techniques to incorporate these

pharmacology pearls into practice

Wright, 2012

Pharmacology/Drug

Interaction Pearls

Wright, 2012

Malpractice Suits

• Drug interactions

–Drug interactions: Now the 4th leading

cause of death in the United States

–Now: 6th leading cause of malpractice

suits against nurse practitioners,

physician assistants, and physicians

Wright, 2012

Many Common Complaints Can Occur From a

Drug/Drug Interaction

• Fatigue

• Constipation or diarrhea

• Confusion

• Incontinence

• Falls

• Depression

• Weakness or tremors

• Excess drowsiness or dizziness

• Agitation or anxiety

• Decreased sexual behavior

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3 Mechanisms For Drug Interactions

• Drug Interactions

– 1. Drug interactions occur when medications

utilize the same enzyme in the liver for

metabolism

– 2. Can also occur if one medication interferes

with another medication’s excretion through

the kidneys

– 3. Can occur if multiple “highly protein bound

drugs” are given to a patient

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Wright, 2012 2

Let’s Start With

Drug Interactions

Which Occur

Through CYP 450

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Cytochrome P450

• History of CYP450

– Not much was known about this drug

metabolism system until Seldane and

erythromycin began to producing Torsade de

Pointe

• CYP450: Enzymes, found within the liver,

which metabolize various medications

• Many medications utilize these pathways

for metabolismWright, 2012

CYP450

• Purpose of this enzyme system is to

metabolize a substance so that it

may be broken down and excreted or

so that it may be delivered to the

tissues on which it will act

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Pathways

• There are > 100 enzymes or pathways

– 1A2

– 2C9

– 2C19

– 3A4

– 2D6

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Terminology

• Substrates

–Metabolized by the isoenzyme

• Inhibitors

–Block the activity of the isoenzyme

• Inducers

–Accelerate the activity of the isoenzyme

Wright, 2012

Examples of Common Drug Interactions

CY P450 Isoenzyme

Drug Substrate Drug Inhibitor Drug

Inducer

1A2 Caffeine

Theophylline

Cimetidine

Fluvoxamine (Luvox)

Ticlopidine (Ticlid)

Fluoroquinolones

Tobacco

Nicotine

Wright, 2012Adapted from: Abramowicz, M. (1999). Drug Interactions. The Medical Letter on Drugs and Therapeutics. 41(1056) 61-62.

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Let Us Look At An Example!

• Patient drinks 4 cups of coffee per day

– Caffeine is a substrate

• You prescribe ciprofloxacin

– Ciprofloxacin is an inhibitor

• What happens to the caffeine levels?

• About what will the patient complain?

Wright, 2012

Another Example

• Patient is on theophylline for COPD

– Substrate

• Smoking (Nicotine)

– Nicotine is an inducer

• What have you had to do with the theophylline

to get this patient to a therapeutic goal?

• Patient develops AECB and quits smoking

• What happens to theophylline levels?

Wright, 2012

CY P450 3A4

• This is the location of most drug-drug

interactions

• 50% of medications are metabolized

through this pathway

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CY P450 Isoenzyme

Drug Substrate

Drug Inhibitor

Drug Inducer

3A4 Amiodarone

Diltiazem

Felodipine

Nifedipine

Verapamil

Lovastatin

Simvastatin

Amiodarone

Clarithromycin

Erythromycin

Fluconazole

Itraconazole

Ketoconazole

Barbiturates

Carbamazepine

Phenytoin

Rifampin

Phenobarbital

St. John’s Wort



CY P450 Isoenzyme

Drug Substrate

Drug Inhibitor

Drug Inducer

3A4 Atorvastatin

Quinidine

Alprazolam

Diazepam

Methadone

Sildenafil

Grapefruit juice

Ritonavir

Fluoxetine

Nefazodone

Barbiturates

Carbamazepine

Phenytoin

Rifampin

Phenobarbital

St. John’s Wort


Also Important

• Drugs that are substrates of the same

CYP 450 substrate can inhibit each

other’s metabolism, possibly resulting in

drug toxicity

Wright, 2012

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Let Us Look At Another Patient• 78 year-old woman with asthma, hypertension,

hyperlipidemia, obesity, osteoarthritis

– Currently on numerous medications including Zocor (simvastatin) 80 mg qhs

• Develops chest pain, rules-in for an MI and undergoes a 6-vessel CABG

– Started on Amiodarone

• 4 weeks later: Creatinine 3.0; LFTs-2x upper limits of normal (had all been normal in patient and before surgery)

– Cardiology consulted – recommend gastroenterology evaluation; Gastro said it was a reaction to the Zocor

• 1 week later – Creatinine 3.2

• What really is going on?Wright, 2012

Drugs Frequently Involved in Interactions

• Statins

– Lova, simva, atorva

• Amiodarone

• Telithromycin, erythromycin, clarithromycin

• -Azoles

• -Antivirals

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Ideally, a Medication Would Use Multiple

Pathways for Metabolism

Wright, 2012

• Some medications use multiple

pathways

• This is ideal

–If one pathway is being utilized by

multiple medications, the medication

can be metabolized by the other

pathway

Another Example

Wright, 2012

CW

• CW is a 52-year-old woman who presents to discuss her recent cholesterol profile

– Lab results are as follows:

• Total cholesterol: 286

• HDL: 46

• LDL: 199

• Triglycerides: 154

• Risk ratio: 6.22

• LFT’s: normal

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Treatment

• CW has been on a diet and exercise plan for the last 3 months attempting to lower her cholesterol without pharmacotherapy

• At today’s visit, atorvastatin therapy initiated

• Dosage: 20 mg qhs

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HMG Co-A Reductase Inhibitors• Metabolized through the liver

– Liver is the primary site of elimination for the majority of medications on the market

– Statins are no exception

– The liver contains numerous enzymes that oxidize or conjugate drugs

• CYP450 is involved in the metabolism of most statins

– In fact, most statins use the 3A4 pathway

– Pravastatin is one exception; it is not metabolized through the CY P450 system; Crestor (rosuvastatin –2C9)

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Caution: CY P450 3A4

• Caution: Medications using CY P450 3A4

– Avoid azole medications (rhabdomyolysis)

– Avoid concomitant gemfibrozil

(rhabdomyolysis)

– Avoid erythromycin and clarithromycin

(increases statin AUC by 50%)

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6 Months Later

• CW calls complaining of cramping in her feet only at night

• It is occurring every night

• This is new; she has never had anything like this before and because of our discussion regarding potential side effects of the statin class, she decided to call

• She was advised to stop atorvastatin and come into the office for an evaluation and a few additional laboratory tests

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Rhabdomyolysis

• Concern regarding rhabdomyolysis

– Fatigue

– Myalgias

– Cramping

– If these occur:

• Discontinue the drug

• CK (Done to exclude muscle involvement)

• LFTs (full liver panel is recommended because we are now potentially dealing with a significant problem)

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CW’s Labs

• Physical examination: normal; no evidence of tender or edematous muscles

• CK: 3305 (normal level: 20-170)

• Chemistry panel: normal

• Urinalysis: normal

• CBC with differential: normal

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Rhabdomyolysis

• Laboratory Features:

– Elevated CK-MM** Most sensitive test

• With rhabdo, range is often: 500 ->100,000 units/L

• Degree of elevation roughly correlates with the risk of renal failure

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What Changed?

• Why did this happen?

• CW went to a walk-in center

• Diagnosed with “walking pneumonia”

• Given a prescription for clarithromycin

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Remember CY P450 3A4

• Atorvastatin is a substrate

• Clarithromycin is an inhibitor

• Blocks 3A4 enzyme causing atorvastatin levels

to increase significantly (50%)

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What Psychiatric Medications Can Do

The Same Thing?

• Nefazodone

• Alprazolam

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Interactions

Involving Renal

System

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Lithium

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CF

• CF is a 62-year-old female with bipolar disorder

• Currently maintained on Lithium 300 mg 2 tablets po bid

• Has been on this dosage x years and doing relatively well; moods are stabilized

• Employed in a steady job; marriage going well

• Presented to family physician for bilateral knee pain

• Diagnosed with osteoarthritis; started on naproxen

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CF Presents 3 Weeks Later

• Husband is concerned

• Seems more confused

• Complaining of dizziness, nausea, and tremor

• Began approximately 1 week ago and seems to be worsening

• CBC with diff, CMP, UA, Lytes, Lithium level, TSH and CT scan obtained

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Laboratory Values

• CBC with diff: normal

• CMP: normal

• Lytes: normal

• UA: normal

• Lithium level: 2.2 mEQ/L (normal: 0.8 mEq/L – 1.2 mEq/L)

• CT scan: normal

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What Changed???

• What caused a

sudden change in

this woman?

– Is this delirium?

– Medication

– TIA?

– CVA?

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Lithium

• Lithium is cleared completely through the renal

system

• Drugs and conditions that influence renal

excretion stand the potential for increasing

serum lithium concentrations

• Such drugs include: thiazide diuretics, NSAIDs,

ACE inhibitors, Calcium channel blockers

(diltiazem and verapamil), Caffeine

Wright, 2012

Let’s Talk About NSAIDs and

Lithium

• NSAIDs

– Have been associated with increasing lithium plasma levels to toxic levels

– OTC medications can produce the same effect yet it is not seen as much as anticipated when they went OTC

– ? Lower dosage

– If you need to use an NSAID in a patient with lithium: consider aspirin and sulindac

– Less likely to cause toxicityWright, 2012

Thiazides and Lithium

• In fact, concomitant use of diuretics has long been

associated with the development of lithium

toxicity

– Thiazide diuretics are thought to be the worst

because they act distally on the renal tubule

(same location as lithium is cleared) causing an

increase in the re-absorption of lithium

Wright, 2012

Wright, 2012 8

Think of All the Antihypertensives

• Most antihypertensives now have

HCTZ in them

• Easy for a drug interaction to

occur

Wright, 2012

Other Drugs Can Lower Lithium Levels

• Osmotic diuretics enhance lithium excretion and are often used for lithium toxicity

• Caffeine and theophylline also decrease lithium levels and therefore need to be monitored if used concomitantly

Wright, 2012

Other Labs to Monitor in Patients

Taking Lithium

• TSH (lithium decreases thyroxine production by interfering with iodine absorption)

• Calcium (increased levels)

• Glucose (increased levels)

• Potassium (increased levels)

• If patient is on a stable dosage, can monitor these every year

Wright, 2012

Other Medications Which Can Alter

The TSH

• Amiodarone

• Lithium

• Interferon

• Why??

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CYP450 Isoenzyme Inhibition by the SSRIs (in vitro*)(in vitro*)

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0 = minimal or weak inhibition; +, ++, +++ = mild, moderate, or strong inhibition

* Clinical significance of in vitro data is unknown

There are limited in vivo data suggesting a modest CYP 2D6 inhibitory effect for escitalopram 20 mg/day.

1A2 2C9 2C19 2D6 3A4Sertraline + + + to ++ + +

Escitalopram 0 0 0 0 0

Citalopram + 0 0 + 0

Fluoxetine + ++ + to ++ +++ ++

Paroxetine + + + +++ +

CYP IsoenzymesCYP Isoenzymes

von Moltke et al., 2001; Greenblatt et al., 2002; Greenblatt et al., 1998

Additional Concerns

• Trimethoprim/sulfamethoxazole with glyburide

– hypoglycemia

• Clarithromycin with digoxin

– digoxin toxicity

• Potassium sparing diuretics with ACE inhibitors

– hyperkalemia

Wright, 2012

Wright, 2012 9

Other Areas of Risk

• Case in NH

• NP wrote RX for Elocon for eczema; large tube

with 5 refills

• Refilled 6 months later

• Patient sued; had been using the steroid cream as

a moisturizer

• Developed striae over lower extremities

• What could have been done differently?

Wright, 2012

Techniques to Avoid Errors

• Clear writing and documentation

• EHR, if available

• Double check dosages

• Avoid writing RX’s when patient is talking to

you or sitting in front of you

• Have a list of high risk drugs; when you see

this list – bells should go off in your head

• Double check interactions

Wright, 2012

HEENT Pearls

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Internal Hordeola

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Blepharitis

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• Mycoplasma

• Intensely painful

• Treatment is with a

macrolide

Bullous Myringitis

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Allergic Facies

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ABRS Treatment Guidelines

Adult: Mild ABRS

No antibiotic use in 4 – 6 weeks

Adult: Mild ABRS


No improvement or worsening at 72

hours

Amoxicillin (1.5 – 4.0 g)/day

Amox/clav (1.75 – 4.0g/250mg)/day

Cefpodoxime (Vantin)

Cefuroxime (Ceftin)

Cefdinir (Omnicef)

Amox/clavulantate (4g/day)

Levofloxacin (Levaquin)

Moxifloxacin (Avelox)

Wright, 2012Sinus and Allergy Health Partnership Guidelines

Otolaryngol Head Neck Surg. 2004;130:1-


Adult: Mild ABRS


Beta-Lactam Allergy

Adult: Mild ABRS


Beta-Lactam Allergy


hours

TMP/SMX (Bactrim)

Doxycycline

Azithromycin (Zithromax)

Clarithromycin (Biaxin)

Erythromycin



Clindamycin (Cleocin) with rifampin




Adult: Mild ABRS and recent antibiotic

usage or moderate ABRS

+/- antibiotic use in 4 – 6 weeks



+/-antibiotic use in 4 – 6 weeks


hours



Amox/clavulanate (4g/day)

Ceftriaxone (Rocephin)

Clindamycin with rifampin

Re-evaluate

Consider complication







Beta-Lactam Allergy

Adult: : Mild ABRS and recent antibiotic



Beta-Lactam Allergy


hours



Clindamycin (Cleocin) with rifampin

Re-evaluate patient

Consider complication



Wright, 2012

Fluoroquinolone Side Effects

• Associated with tendonitis and spontaneous

tendon rupture

– Rupture may occur during or after use

– Discontinue with any tendon pain

**Clinical Pearl: Biggest risk factor is concomitant oral

steroid use

– Give magnesium 325 mg (Magnesium oxide) 6 hours

before fluoroquinolone dose

Lecture Lecture –– Paul Iannini, MD; Worcester, MA, 2006Paul Iannini, MD; Worcester, MA, 2006

Wright, 2012 11

Pulmonary Pearls

Wright, 2012 Wright, 2012

IDSA/ATS 2007 Guidelines

for CAP in Adults

• Practice Guidelines for the Management of

Community-Acquired Pneumonia in Adults

– Revised and published in Clinical Infectious Diseases

2007;44:S27 – S72

http://www.medscape.com/viewarticle/546317 accessed 01-28-2010

Wright, 2012

IDSA/ATS CAP

Outpatient Treatment

• Classification

– Previously healthy, no recent (within past 3

months) antibiotic use

• Likely causative pathogens

– S. pneumoniae (Gm pos) with low DRSP risk

– Atypical pathogens (M. pneumoniae, C.

pneumoniae)

– Respiratory virus including influenza A/B, RSV,

adenovirus, parainfluenza

IDSA/ATS CAP

Outpatient treatment

• Strong recommendation

– Macrolide such as azithromycin, clarithromycin, or

erythromycin

Or

• Weak recommendation

– Doxycycline

Wright, 2012

IDSA/ATS CAP

Outpatient treatment

• Classification

– Comorbidities including: COPD, diabetes,

renal or heart failure, asplenia, alcoholism,

immunosuppressing conditions or use of

immunosuppressing medications,

malignancy or use of an antibiotic in past 3

months

Wright, 2012

IDSA/ATS CAP

Outpatient treatment• Likely causative organism

– S. pneumoniae (Gm pos) with DRSP risk

– H. influenzae (Gm neg)

– Atypical pathogens (M. pneumoniae, C.

pneumoniae, Legionella)

– Respiratory virus as mentioned above

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Wright, 2012

IDSA/ATS CAP classification for

outpatient treatment• Respiratory fluoroquinolone

OrOr

• Advanced macrolide (azithro- or

clarithromycin) plus b-lactam such as HD

amoxicillin (3- 4 g/d), HD amoxicillin-

clavulanate (4 g/d), ceftriaxone (Rocephin),

cefpodoxime (Vantin), cefuroxime (Ceftin)

• Alternative to macrolide: doxycycline

Wright, 2012

Treated With...

• Macrolide x 5 days

• Clinical improvement within 48 hours

• Chest x-ray repeated in 12 weeks to confirm

resolution

– R/O any underlying pathology

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Length of Therapy

• Shortened to 5 days

• Provided that the patient is afebrile by 48 – 72

hours

Neurological Pearls

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Treatments for Migraines

Look How Far We Have Come

• BC: trephination

• 1850: bromide

• 1883: ergotamine

• 1897: aspirin

• 1963: methysergide

• 1975: DHE

• 1993: sumatriptan

• 1998-2003: other triptansTrephination

Wright, 2012

Acute Migraine Management

Evidence-Based Guidelines

• Adopted by AAFP, ACP-ASIM, AAN

– NSAIDs as first-line therapy

– Triptans (or dihydroergotamine) indicated for those who fail to

tolerate or respond to NSAIDs

– No evidence to support the use of butalbital compounds in

acute migraine

– Little evidence to support the use of isometheptene compounds

in migraine

– Opioids “reserved for use when other medications cannot be

used”Snow V, et al. Ann Intern Med 2002;137:840-849.Wright, 2012

Wright, 2012 13

Abortive Medications

The Triptans

Cady R, Dodick DW. Mayo Clin Proc. 2002;77:255-261.

Selective 5-HT1 agonists (the

triptans) have emerged as the gold

standard

for acute migraine therapy.

Hargreaves RJ. Cephalalgia. 2000;20(suppl 1):2-9.

Migraine-Specific Therapy:

The Mechanism of Action

Wright, 2012

Headache Experts Agree That the Optimal Headache Experts Agree That the Optimal

Treatment Strategy Is to Treat Early, Treatment Strategy Is to Treat Early, Before Central Sensitization OccursBefore Central Sensitization Occurs

Adapted from Cady RK. Clin Cornerstone. 1999;1(6):21-32.

Phases of a Migraine Attack

Premonitory/Prodrome

Aura MildModerate to Severe HA Postdrome

Pre-HA Post-HAHeadache

Time

Intensity

TREAT EARLY!

Wright, 2012

Stratified Care vs Step Care

28*†

53*†

69*

20

37

74

0

20

40

60

80

100

1 Hour 2 Hours 4 Hours

Stratified Care

Step Care Within Attacks (All 6 Attacks)

*P < .001 for stratified care vs step care across attacks.†P < .001 for stratified care vs step care within attacks.

Adapted from Lipton RB et al. JAMA. 2000;284:2599-2605.

Attacks (%)

Time Postdose

Step Care Across Attacks (All Attacks)

20

41

55

Headache Response

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Too Much of a Good Thing….

• Use of any product more than 3 times per week

will result in rebound headaches

• Medication Overuse Headache

– Worsening of head pain caused by frequent and

excessive use of immediate relief medications

– Bilateral, diffuse headache

– Waxes and wanes

– Associated with fatigue, n/v, restlessness

– Will never get better on any medications until

rebounding is eliminatedWright, 2012

Wright, 2012 14

Controller Pharmacologic Therapies

• Beta Adrenergic Receptor Antagonists

– Propranolol 40-240mg qd

– Nadalol 20-80mg qd

– Atenolol 50-150mg qd

– Metoprolol 50-300mg qd

Up to 70% - 80% reduction in severity and frequency of migraine headaches

Wright, 2012


• Calcium Channel Blockers

– Verapamil 120-480 mg qd

– Diltiazem 90 - 180 mg qd

– Nifedipine 30 - 120 mg qd

• Mechanism of Action

– Blocks vasoconstriction and increases cerebral blood

flow

Wright, 2012


• Tricyclic Antidepressants

– Amitriptyline 10-120mg qhs

– Nortriptyline 10-150mg qhs

– Doxepin 10-200mg qhs

– Imipramine 10-200mg qhs

• Mechanism of Action

– Believed to inhibit 5–HT receptors, thus interfering with the

impulse of pain

• Efficacy

– Approximately 40 – 60% of patients experience improvement

within 1-2 monthsWright, 2012


• SSRI’s

– Fluoxetine 10-30mg qd

• Other Agents

– Neurontin 600- 2400 qd

– Phenytoin 300-800 mg qd (macrocytosis)

– Depakote 750-1500 mg qd (pancreatitis, hepatic issues)

– Carbamazepine 200-800 mg qd (macrocytosis, thrombocytopenia)

– Topiramate 50 mg bid (sedation/fatigue/metabolic acidosis)

– Pregabalin 100 -150 mg daily

Wright, 2012

Difficulty With Medications

• Managing side effects

– Paresthesias and memory loss: topiramate

• Dose once daily

– Fatigue and dizziness: pregabalin, gabapentin

• Dose at night

Wright, 2012

Alternative or Other Therapies

• ACE Inhibitor– Lisinopril (Prinivil)

• Alpha-2 Agonist Group– Tizanidine (Zanaflex)

• Riboflavin (B2) 400 mg qd

• Magnesium 600 mg qd

• Coenzyme Q-10 150 mg – 300 mg qd

• Feverfew

• Butterbur Extract

Not evaluated by the US Headache Consortium

Wright, 2012

Wright, 2012 15

What Other Therapies

Are Being Done?

• Botulism injections

• Trigger point injections

• Massage

• Chiropractic manipulation

• Consider “headache clinic” for drug

detoxification

Wright, 2012

Cluster Headaches

• Abortive treatment

– Injectable triptans

– 7L O2 via mask

• Preventative Options

– Lithium

Wright, 2012

My Medication Doesn’t Work...

• Prednisone

– 60, 40, 20 mg/day

• Analgesic

– Ketorolac in office or pain medication

• Antiemetic

– Suppository

– Orally dissolving tablet

Wright, 2012

Another Option

• Ketorolac 15 mg, 30 mg or 60 mg

• Monitor blood pressure

• Consider IV fluids

• Consider antiemetic

Wright, 2012

Case Study: June 2009

• SG is 17 year-old female; referred by school nurse

• Presents with mom who is concerned:

– Daily headaches; requiring medication daily (5 – 6 days per week);

using NSAIDs primarily

– Headaches wax and wane; some days worse than others

• Bilateral, pressure. Hard to concentrate. No neuro symptoms

• Has not had a day in 6+ months without headache

– Occasional (1x per week), horrible headaches requiring nurse visit

and frequently, discharge from school

• These are associated with n/photo/phono; occasional vomiting

– Headaches present x 2 – 3 years but worsening

Wright, 2012

Case Study

• Meds: as above

• Allergies: NKDA or NKFA

• PE – completely normal

• Assessment: What is your diagnosis

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Chronic Migraine: Diagnostic Criteria

Not Not

attributable attributable to another to another

disorderdisorder

Meets the Meets the

IHS criteria IHS criteria for migraine for migraine

without aurawithout aura

Occurs Occurs ≥≥ 15 days per month for 15 days per month for ≥≥ 3 months3 months

Usually begins as migraine without aura and Usually begins as migraine without aura and progressesprogresses

As chronicity develops, headache tends to lose its As chronicity develops, headache tends to lose its attackattack--like presentationlike presentation

When medication overuse is present, it is the When medication overuse is present, it is the likely cause of the chronic symptoms likely cause of the chronic symptoms

(Medication overuse headache (Medication overuse headache –– MOH)MOH)

Migraine Fulfilling the Criteria BelowMigraine Fulfilling the Criteria Below

Olesen J et al. Cephalalgia. 2004;24(suppl 1):1-151.Wright, 2012

Common Pitfalls in Migraine Diagnosis:

Importance of Medication Overuse

• MOH is common, but

widely unrecognized

• MOH is almost always

transformed migraine

• Ask patients about all pain

medication use!Patients With CDHPatients With CDH

Patients With HAPatients With HA

General General

PopulationPopulation1%1%11

5%5%--10%10%11

>60%>60%22

1. Diener HC and Katsarava Z. Curr Med Res Opin 2001;17(suppl 1):S17-S21.2. Bigal ME, et al. Neurology 2004;63(5):843-847.Wright, 2012

MOH Diagnosis

• Patients typically overuse multiple

medications simultaneously

– Mean tablets/day = 5.2

– Most commonly overused drugs are

• Butalbital combinations (48%)

• Acetaminophen (46%)

• Opioids (33%)

• ASA (32%)

• Triptans (18%)

Bigal ME, et al. Cephalalgia 2004;24:483-490.Wright, 2012

MOH Diagnosis (cont’d)

• Both diagnosis and treatment require time

– Diagnosis is confirmed in retrospect

– Offending medications must be stopped and

prophylactic medications started

Smith TR and Stoneman J. Drugs 2004;64:2503-2514.Wright, 2012

How Do You Break This Cycle?

• Depends upon what the drug of overuse is

• Prednisone: 20 mg two times daily x 10 days

• Introduce preventative drug

• Absolutely no pain medication

• Consider long-acting NSAID for prophylaxis

• Phenobarbital may be used if overusing butalbital

• Headache diary

Wright, 2012

What Will Happen?

• Abortive meds begin to work better

• Fewer and fewer headaches

• Migraine will return to its acute nature

• Sooner you can treat, more likely to have

success

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SG

• March 2010 visit: Review of headache diary

– Migraine: 1x in past three months; lasted < 1 hour with

medication management. Triggered by too little sleep

– Riboflavin 400 mg once daily; tolerating well

– Triptan available for acute migraine treatment

– No use of NSAIDs in 3 months

– Daily headaches gone

– Working with massage therapist re: tension in neck

– Eating three meals daily rather than skipping meals

– Working on biofeedback

Wright, 2012

Genitourinary Pearls

Wright, 2012

Gorbach et al, 1999 Guidelines for Infections in Primary Care.

Complicated UTIE coli

Proteus

Klebsiella

Enterococci

Pseudomonas

Mixed

Other

S epidermidis

E coli 32%

Enterococci 22%Pseudomonas 20%

S epidermidis 15%

Complicated UTI: Pathogens

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Pathogens: A Discussion

• E. Coli:

– Most common cause of both uncomplicated and

complicated UTI’s

• Enterococci:

– Most common gram positive cause of UTI

– Often associated with recent antibiotic therapy

– Consider recent urologic procedure

– Often cause in the patient with an obstructive

pathologyWright, 2012

http://emediciine.medscape.com/article/245559-overview accessed 03-11

Pathogens: A Discussion

• Staphylococcus saphrophyticus

– Gram positive organism

– Second most common cause in sexually active

woman

• Pseudomonas

– Often seen in the individual with an obstructive

pathology

Wright, 2012

http://emediciine.medscape.com/article/245559-overview accessed 03-11

cUTI Pathogens

• Proteus and Klebsiella

– Predispose the patient to stone formation and are

more often than not seen in patients with calculi

• Tend to be polymicrobial in the setting of an

indwelling catheter or stent placement

Kasper, D.L. (2005). Harrison’s Manual of Medicine (16th ed.). New York, NY.:

McGraw-Hill Companies, Inc. Wright, 2012

Wright, 2012 18

Complicated UTI:

Antimicrobial Choices

• Trimethoprim-sulfamethoxazole (TMP-SMX)

• Fluoroquinolones (ciprofloxacin, ofloxacin,

levofloxacin)

• Aminoglycosides (gentamicin, tobramycin,

amikacin)

• Third-generation cephalosporins (ceftriaxone)

Wright, 2012

Mild – Moderate cUTI

• Guidelines pertain if patient is not residing in

long-term care facility or recently received

fluoroquinolones

– Levofloxacin 250 mg - 500 mg orally once daily

– Ciprofloxacin 250 mg - 500 mg two times daily or

1000 mg XR once daily

http://prod.hopkins-abxguide.org/diagnosis/genitourinary/urinary_tract_infection_complicated accessed 04/12/2009

Wright, 2012

Dosage Adjustment

• Must make sure to account for CrCl in older

population

• May need to reduce dosage based upon level of

kidney disease

Wright, 2012

Culture and Sensitivity

• Once C&S has returned, may narrow spectrum

of antibiotic

• Consider blood cultures

• Consider CBC

• Consider hospitalization, based upon

presentation


Wright, 2012

Guidelines for Treatment

• Severely ill, recent FQ or long-term care facility

resident

– Imipenem

– Piperacillin-tazobactam

– Tobramycin or Gentamycin


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Abdominal Pearls

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Wright, 2012 19

Differentiating Signs and Symptoms of

Chronic Constipation (CC) and IBS-C

*3 BMs/day to 3 BMs/week is considered range of normal stool frequency1. Brandt LJ, et al. Am J Gastroenterol. 2005;100(suppl 1):S5-S21. 2. Delvaux M. Best Pract Res Clin Gastroenterol.

Chronic constipationChronic constipation

IBS with constipation

++-- Abdominal Pain/Discomfort1

++-- Visceral Hypersensitivity2

<3 BMs/Week Normal Stool Frequency*1,3

• Most products will not work until:

– You have cleaned out the patient’s bowel with

colonic cleansing

Chronic Constipation

Wright, 2012

Traditionally Used IBS TreatmentsTreatment

Bulking Agents (eg, wheat bran, corn fiber, psyllium)

Water

Antispasmodics (eg, hyoscyamine, dicyclomine)

Antidepressants (eg, TCAs, SSRIs*)

• Most traditionally used

treatments have little

evidence to support

benefit

TCA, tricyclic antidepressant; SSRI, selective serotonin reuptake inhibitorSpiller R, et al. Gut 2007;56;1770-1798.

Thank You

I Would Be Happy To Entertain Any Questions

Wright, 2012

Wendy L. Wright, MS, RN, ARNP, FNP, FAANP

Wright & Associates Family Healthcare

[email protected]

Wright, 2012

Documents

Pharmacology/Drug Interaction Pearls · • Amiodarone • Telithromycin, erythromycin, clarithromycin • -Azoles ... Allergic Facies Wright, 2012 ABRS Treatment Guidelines Adult: