Week 9 Fun Times

Anything Goes!

100

Your patient with Hashimoto’s is seeing you for a new OB visit. You know to increase her levothyroxine by this much:

25%

200

A nurse calls to tell you that your patient is experiencing flushing and chest tightness a few minutes into their IV iron infusion. You run into the room and stab your patient with an epi pen because THIS IS AN ANAPHYLACTIC REACTION AND THEY CAN NEVER GET IV IRON AGAIN!!!!! (T or F)

F >> infusion reactions are uncommon but can be managed without abandoning treatment. 

• Management = stop infusion; if symptoms resolve, treat as a reaction not anaphylaxis: premedicate (hydrocortisone, Benadryl, Pepcid) and run infusion slowly

400

Both RhoGAM and MMR vaccine are indicated for your patient who has just given birth and has reliable follow-up. When is the best time to administer these?

• RhoGAM prior to discharge (within 72h of birth)
• MMR vaccine in 3 months (RhoGAM can interfere with efficacy of MMR vaccine)

Other option is to give MMR but check antibody titer in 3 months

Pharmacowhats?

100

You give your patient a choice between oral and IM promethazine for therapeutic rest, but tell them that IM promethazine will be more effective. Why?

Bypasses first-pass metabolism (greater absorption/bioavailability)

200

Your patient on MgSO4 has a mag level of 10 and a creatinine of 1.2; you recognize that her kidneys are not clearing the magnesium. Is this a pharmacokinetic issue, or a pharmacodynamic issue?

Pharmacokinetic (drug excretion)

300

Your postpartum patient with a history of DVT is worried about breastfeeding while on Lovenox prophylaxis. You tell her it is totally safe for her baby, for 2 reasons--what are they?

• Heparin/LMW heparin is a large molecule that does not transfer easily into breastmilk
• Any amount that does transfer cannot be absorbed via oral route

400

Your patient is a huge pharm nerd and wants to know why the interval for titrating pitocin is 30 minutes. Because you know that the half-life of pitocin is up to 6 minutes and you understand the relationship between half-life and steady state, you tell her that:

Drugs reach a steady state in the body after about 5 half-lives (about 30 minutes for pitocin)

500

Which of acyclovir's following properties make it SAFE to use while breastfeeding?

• Low molecular weight
• Lipophilic
• pH neutral
• Low bioavailability
• Short half-life (3h)
• Low protein-binding
• Used for treatment in infants
• RID 2–4%

PROTECTIVE properties: low bioavailability, short half-life, used for treatment in infants, RID <10%, pH neutral (alkalinity = sequestration in breastmilk)

• Properties that are NOT protective: low molecular weight, lipophilic, low protein-binding

Pharma Karma

100

Your patient in triage has a repeat severe-range blood pressure 15 minutes after receiving 20mg IV Labetalol. What will you (nicely) ask the nurse to do next?

Give 40mg IV Labetalol please

200

Your pregnant patient has a Hgb of 10.3 and a ferritin of 9. What counseling is APPROPRIATE:

• Make sure you are taking a prenatal vitamin that also has iron
• You will absorb just as much iron if you take it every OTHER day
• Supplemental iron will be most effective if you take it EVERY day
• Take your iron with orange juice
• You do not need to continue taking iron after you receive an IV iron infusion

• You will absorb just as much iron if you take it every OTHER day
• Take your iron with orange juice
• You do not need to continue taking iron after you receive an IV iron infusion

300

This well-studied antidepressant has a lower risk of maternal withdrawal symptoms, but a greater risk of poor neonatal adaptation.

fluoxetine

400

Your patient has a UTI with culture sensitivity to cephalexin (Keflex). She had hives in childhood after getting penicillin and was told she should also avoid cephalosporins, as they are also beta-lactam antibiotics. How do you counsel her?

Cephalexin is a 3rd-generation cephalosporin with virtually zero chance of cross-reactivity with penicillin 

• 1st and 2nd-gen have a very small chance, but 3rd and 4th-gen side chains are too different for cross-reactivity

500

Your patient is in preterm labor at 30 weeks’ gestation and they need 48h tocolysis to get through their betamethasone window. You remember that at this gestational age, indomethacin is contraindicated because it may prematurely close the ductus. (T or F)

F >> both nifedipine and indomethacin are options at 30w; indomethacin is contraindication after 32w