Prescribing in Pregnancy
What factors determine a molecules affect on the fetus?
Bonus: Give an example for each factor (if applicable).
What is, lipid solubility (thiopental is very lipid soluble versus succinylcholine), size (heparin bigger than warfarin so less likely to diffuse), pH, transportors (specific fetal transporter for sulfonamide glyburide), albumin binding, and placental drug metabolism (prednisolone >> prednisone)
See slide 2 of tutoring PPT for review.
Which of the following is NOT necessary to write a prescription?
A. A specific diagnosis and/or indication
B. Availability of generic versions
C. Physician name, address, and license
D. Dose, route, frequency, and duration
Bonus: Of the three correct answers above, which is most likely to affect compliance?
What is, B (does not need to address generics)
Bonus: Dose, route, and frequency. Have to consider patient schedule, eating habits, ability to administer own medications.
Slides 2-4 of the tutoring PPT
List the four drug groups most commonly associated with anxiety.
Bonus: Give at least TWO medications for each group.
What is: anticholinergic (benztropine, benadryl, meperidine, obybutynin), stimulants (caffeine, nicotine), OTC medications (phenylephrine, phenylpropanolamine, pseudoephedrine [allergy medications]), and recreational drugs (cocaine, amphetamines, cannabis, MDMA, and withdrawal from sedatives)
See slide 4 of tutoring PPT
What are some non-psychiatric uses of antipsychotics?
Bonus:What are the main differences between typical and atypical antipsychotics?
What is, pruritis, emesis, neuroleptic anesthesia, and preoperative sedatives
Bonus: Both are equally effective for positive symptoms, but atypicals have a safer ADR profile and have a greater effect on negative symptoms.
See slide 4, 7 of Antipsychotics tutoring PPT
What should be considered when giving IM injections in preterm infants?
Bonus: What medications have increases uptake in the stomach and which medications have decreased uptake in the stomach?
What is, there is little muscle mass with poor perfusion (may stay in muscle without distributing) and rapid improvement in perfusion can lead to toxicity
Bonus: penicillin, ampicillin are increased. Phenytoin, acetaminophen, and phenobarbital are decreased
See slides 2-3 of tutoring PPT
Describe the FDA categories for drug safety in pregnancy.
Bonus: What is the recommended regimen of folic acid for women of reproductive age with and without history of NTD-affected pregnancy?
What is, A: studies in women fail demonstrate risk, B: animal studies show no risk but no studies in humans OR animal studies showed risk that wasn't replicated in humans, C: animal studies showed harm and no human studies to confirm OR studies in women and animals are unavailable, D: known harm, but can be used if benefit outweighs risk, X: proven harm, contraindicated
Bonus: 400 mcg daily for women w/o folate deficiency. 400 mcg + 4000 mcg for women w/ h/o NTD-pregnancy.
See slides 7-11, 23 of the tutoring PPT
Which of the following medical abbreviations correctly corresponds to their term?
A. hs >> hourly
B. gtt >> glucose titration
C. PR >> as needed
D. qhs >> every night
Bonus: What are the medical abbreviations for medications administered in the eyes?
What is, D
Bonus: OD (right eye), OS (left eye), OU (both eyes)
Slides 6-7 of the tutoring PPT
Name THREE positive reasons for using BZD's and THREE negative reasons for use.
Bonus: What BZD is preferred for acute panic attacks but is deadliest in OD?
What is, positives: fast acting, good for acute anxiety, high therapeutic index, antidote available, minimal CV affects (hypotension, bradycardia); negatives: dependence, hangover, amnestic effects, CNS depression that is additive with EtOH or opiates (OD), psychomotor dysfunction (ability to drive, operate machines)
Bonus: alprazolam (Xanax)
See slides 5-6, 16 of tutoring PPT
What medication is useful in combination with ECT to restore sensitivity?
Bonus: What values must be monitored regularly in the drug alluded to above?
What is, clozapine
Bonus: monitoring of CBC with differential weekly for the first 3-6 months then monthly after that to monitor for agranulocytosis.
See slides 12, 17
What must be kept in mind when giving neonate sulfonamide antibiotics?
Bonus: What is the effect of perinatal use of phenobarbital on the neonate?
What is, can compete with bilirubin for albumin binding and increase risk for kernicterus
Bonus: early maturation of p450 enzymes may occur which can increase drug metabolism
See slides 5, 7 of tutoring PPT
Warfarin is a category D drug in pregnancy. List its complications and what trimester they correspond to.
Bonus: Describe the affects of cigarette smoke on the fetus.
What is, 1st trimester use: hypoplastic nasal bridge (saddle nose deformity) and chondrodysplasia punctata; 2nd trimester: CNS malformations; 3rd trimester: bleeding risk
Bonus: IUGR, premature delivery, SIDS, perinatal complications
Slides 22, 21 of the tutoring PPT
What are the main causes of non-compliance in patients?
Bonus: What are some factor that encourage compliance?
What is, failure to obtain medication (access), failure to take medication, premature discontinuation (antibiotics), and medication taken incorrectly.
Bonus: Good communication, living with others, having a symptomatic illness, designing a frequency and route compatible with routine, arthritis-friendly packaging, and transportion.
Slides 14-16 of the tutoring PPT
Which SSRI's are known for increasing risk of Torsade de Pointe?
Which SSRI's cause the least amount of sexual dysfunction?
What is, escitalopram, citalopram
Bonus: bupropion (less tolerated in anxiety), mirtazapine, and nefadazone
See slide 8 of anxiolytics and 6 of antidepressants tutoring PPT
What antipsychotics are most implicated in weight gain, dyslipidemia, and diabetes?
Bonus: What antipsychotics are implicated in ocular ADR's (give both).
What is, olanzapine, clozapine (monitor weight, fasting glucose, lipids, and A1C as needed)
Bonus: chlropromazine (corneal/lens deposits), thioridazine (retinal deposits, browning of vision)
See slide 16-17 of antipyschotics tutoring PPT
What age dependent changes in GFR and metabolism are observed as neonates grow into toddlers?
Bonus: What enzyme causes neonate CNS sensitivity to opiates?
What is, GFR matches adult values by 6-12 months. At toddler age, GFR and metabolism can exceed adults.
Bonus: p-glycoprotein (pumps morphine from BBB to rest of body but is low in infants so can accumulate there)
See slides 7-9 of tutoring PPT
What medication is known to cause an syndrome consisting of cleft palate, small head, hypoplastic face, nails, and toes, and neurologic defects?
Bonus: What medication can cause facial paralysis, limb anomalies (club feet, missing digits), strabismus, and corneal erosion from blinking?
What is, phenytoin (hydantoin syndrome)
Bonus: misoprostol (mobius sequence)
See slides 19-20 of the tutoring PPT
Describe the classification of controlled substances
Bonus: What category can not be refilled without a prescription?
What is, I (high potential): no accepted medical use; II (high potential): accepted medical use, misuse may lead to dependence; III (intermediate risk): accepted medical use, mod-low risk for physical dependence, high risk for psychological dependence; IV (mild risk): accepted medical use, limited potential for dependence; V (low risk): accepted medical use, low possible dependence.
Bonus: Cat II (also can't be refilled over the phone)
Slide 17-18 of tutoring PPT
What is the mechanism of action of Suvorexant?
What is are some advantages of ZZE's over BZD's for sleep problems?
What is, orexin antagonism that enables sleep
Bonus: Less hangover effect, less risk of dependence, less changes to sleep architecture, less amnesia
See slides 12-13 of anxiety tutoring PPTName FOUR ADR's caused by lithium use.
Bonus: What medications, when used with lithium, increases risk of toxicity? [there are two mentioned]
What is, tremors, nephrogenic DI, teratogenic effects (Epsteins), sick-sinus syndrome, thyroid disorder
Bonus: NSAID's and diuretics (both reduce clearance)
Name THREE drugs that cause significant effects in infants being breastfed and THREE drugs that cause moderate effects.
Bonus: What substance causes effects in breastfed infants if their mother is an ultra-rapid metabolizer?
What is, Moderate: tetracycline, EtOH (large amounts), phenobarbital, phenytoin, prednisone, theophylline; Significant: amiodarone (thyroid), chloral hydrate, chloramphenicol (grey baby, BM suppression), heroin, methadone (dependence), radioactive iodine (thyroid)
Bonus: codeine (rapidly metabolized to morphine which accumulates in CNS)
See slides 13-17 of tutoring PPT
What medication causes a congenital heart defect consisting of PDA, a hypoplastic left ventricle, hypoplastic aorta, and an ASD?
Bonus: What medication causes a heart defect consisting of an ASD and displaced tricuspid valve?
What is, isotretinoin (hypoplastic left heart syndrome, also craniofacial anomalies)
Bonus: lithium (epstein's anomaly)
See slides 17-18 of the tutoring PPT
Also remember to review highlighted points on these slides: 13-15 and 21
What program is FDA sponsored and compiles data based on mandatory pharmaceutical reporting and voluntary physician reporting?
Bonus: What is the program that monitors vaccine safety?
What is, Med Watch
Bonus: VAERS (vaccine adverse event reporting system)
Slide 20 of tutoring PPT.
May also want to review slide 22 and familiarize yourselves with medical abbreviations listed in slides 6-7.
Name THREE other uses of anxiolytics and FIVE other substances that may cause additive CNS depression.
Bonus: What medication class is contraindicated in porphyria conditions?
What is, insomnia, sedation/amnesia before surgical procedures, seizures, balanced anesthesia, ethanol withdrawal, muscle relaxation, and psychiatric aids, AND EtOH, opiates, anticonvulsants, phenothiazine, antihistamines, antihypertensives, TCA's
See slides 14, 20 of tutoring PPT.
Also review slides 15-19 on anxiety tutoring PPT
A dry, hyperthermic patient presents to the ED with muscle rigidity, autonomic dysfunction, and marked elevations in leukocyte and creatine kinase. What is this condition and what is the treatment for it?
Bonus: Another patient presents with abnormal choreoathetoid movements (spasms, tongue protrusion, etc.). What is this condition and how is it treated?
What is, neuromalignant syndrome, treated with antiparkinsonism drugs, diazepam, dantrolene, and bromocriptine. Also need active cooling and a later switch to an atypical antipsychotic.
Bonus: Tardive dyskinesia, treated early by switching to quetiapine or clozapine, can consider dose reduction, and then removal of all central anticholinergic drugs (TCA's, antiparkinsonism). May need diazepam if previous treatments fail.
See slides 19, 14 of the tutoring PPT
Also review: 6, 10, 13, 18, and 20
A 30 lbs (13.6 kg) 3-year-old is being prescribed amoxicillin for an ear infection. The adult dose is 500 mg. Calculate the dosage using Young's and Clarks equations.
Bonus: Of the three estimation methods, which is most accurate?
What is, Young's: 100 mg, Clark's: 100 mg (lbs), 97 mg (kg)
Bonus: BSA is most accurate. Both weight and age estimates can underestimate. Weight can overestimate in obesity.
See slides 18-19 of tutoring PPT