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Which of the following is TRUE about using testosterone in older men?<> A.Testosterone might improve energy, strength, and libido.<> B.There are concerns about a possible increased risk of prostate cancer.<> C.Oral methyltestosterone should be tried first.<> D.Both A and B
Answer • D.Both A and B
Before starting testosterone you should check what blood tests? • A. PSA • B. Hemoglobin • C. Liver Function • D. Hemoglobin A1C • E. A, B, C • F. All of the above
Answer • E. A, B, C
What level of testosterone is low and what level is therapeutic in mg/dl? • A. 200/400 • B. 300/500 • C. 300/600 • D. 400/ 700
Answer • C. 300/600
Which of the following is TRUE about chronic use of proton pump inhibitors?<> A.PPIs lower the risk of fractures.<> B.PPIs lower the risk of pneumonia.<> C.Tapering the PPI when stopping may help reduce acid rebound symptoms.<> D.PPIs increase calcium absorption.
Answer • C.Tapering the PPI when stopping may help reduce acid rebound symptoms.<>
Which of the following is TRUE about the interaction between clarithromycin and inhaled salmeterol (Advair, Serevent)?<> A.Clarithromycin can lower salmeterol levels and make it less effective.<> B.Clarithromycin can boost salmeterol levels and cause adverse cardiac effects.<> C.A similar interaction is seen with azithromycin and salmeterol.<> D.A similar interaction is seen with clarithromycin and formoterol (Foradil).
Answer • B.Clarithromycin can boost salmeterol levels and cause adverse cardiac effects.<>
Which of the following is TRUE about using beta-blockers in patients with chronic obstructive pulmonary disease?<> A.Beta-blockers are usually avoided due to fears of bronchoconstriction.<> B.New evidence suggests that beta-blockers might decrease COPD exacerbations.<>C.Cardioselective beta-blocker (metoprolol, etc) are preferred for COPD patients.<> D.All of the above
Answer • D.All of the above
Most states now have Prescription Drug Monitoring Programs for controlled drugs. Which of the following is TRUE?<> A.These programs are proven to reduce diversion.<> B.Information can't be shared with other states.<> C.Prescribers can find out if patients are getting controlled drugs from other prescribers or pharmacies.<> D.The information is only available by phone.
Answer • C.Prescribers can find out if patients are getting controlled drugs from other prescribers or pharmacies.<>
Which of the following is TRUE about drug allergies?<> A.Hydrocodone can be used in a patient with a true allergy to codeine.<> B.Cross-sensitivity usually isn't a problem between sulfa antibiotics and other sulfonamides.<> C.About 10% of patients allergic to penicillin are allergic to cephalosporins.<> D.People allergic to sulfa drugs also need to avoid drugs or foods with sulfur, sulfites, or sulfates.
Answer • B.Cross-sensitivity usually isn't a problem between sulfa antibiotics and other sulfonamides
Opioids. • Most reactions are side effects or "pseudoallergies"...and AREN'T immune mediated. Pseudoallergies are due to histamine release and can lead to hives, itching, etc. In this case, try a lower dose...a different opioid...or pretreat with an antihistamine. For a true opioid allergy, use one from a different class. Patients allergic to codeine CAN usually take fentanyl, meperidine, or methadone...but NOT morphine, hydrocodone, or oxycodone. Avoid tramadol or tapentadol if opioid reactions were severe
Sulfas. • Cross-sensitivity usually is NOT a problem between sulfa antibiotics and other sulfonamides...thiazides, loops, sulfonylureas, etc. If patients need a diuretic and must avoid sulfas, use amiloride, triamterene, spironolactone, or ethacrynic acid. And yes, ethacrynic acid IS available again...after being gone a few years ago. Tell patients allergic to sulfas that they CAN have foods or drugs with sulfur, sulfites, or sulfates. Explain these DON'T cross-react.
Penicillin. • Experts used to think about 10% of patients allergic to penicillin were allergic to cephalosporins...and 47% to imipenem. But actually the risk is only about 1%. Consider using another beta-lactam if the penicillin allergy is mild...but avoid beta-lactams if the reaction to penicillin is severe. If in doubt about a reaction and the drug is critical, consider drug allergy testing...and desensitization if necessary.
What works for Leg Cramps? • A. Quinine • B. Magnessium • C. Calcium • D. Requip • E. Gateraid • F. Nothing works well
Answer • F. Nothing works well
Leg Cramps • Patients are still looking for something that works for nocturnal leg cramps. Almost half of elderly patients have frequent leg cramps with no obvious cause. The problem is there are no proven treatments. First look for possible causes such as diuretics or beta-agonists. Also check serum potassium, magnesium, and calcium. Advise patients to try simple measures...calf stretches, hot or cold packs, hydration with electrolytes (Gatorade, etc). Recommend acetaminophen or ibuprofen for pain relief...but explain they won't prevent cramps. Some experts suggest B-complex vitamins, low-dose diltiazem, or magnesium...but there's only weak evidence of a possible benefit. Don't use vitamin E and gabapentin...evidence suggests that they DON'T work for muscle cramps. Other anticonvulsants and baclofen are sometimes tried for severe cramps, but they aren't proven to help. Don't use them routinely. Don't rely on clonazepam or ropinirole for leg cramps, either. These can be helpful for restless legs syndrome...but there's no evidence that they prevent leg cramps. Of course the 800-pound gorilla is quinine. Don't recommend Hyland's Leg Cramps with Quinine or similar homeopathics. Their quinine content is miniscule and not proven to work. Tonic water has only 20 mg quinine/cup...not enough to help. Rx quinine is still used a lot. But FDA questions its efficacy and says the risks are too high for leg cramps.Qualaquin is the only approved quinine. But its labeling warns not to use it for leg cramps...and it costs about $5 per cap. It's okay to prescribe Qualaquin off-label for leg cramps, but consider the risk of thrombocytopenia, arrhythmias, etc. Consider using our quinine consent form if you're concerned about legal exposure.
Qualaquin 324 mg • Do not use this medication if you have ever had an allergic reaction to quinine or similar medicines such as mefloquine (Lariam) or quinidine (Cardioquin, Quinidex, Quinaglute) • Do not use if you have a history of "Long QT syndrome"; • glucose-6-phosphate dehydrogenase (G-6-PD) deficiency; • myasthenia gravis; or • optic neuritis (inflammation of the optic nerve). • If you have any of these other conditions, you may need a dose adjustment or special tests to safely take quinine: • heart disease or a heart rhythm disorder; • low potassium levels in your blood (hypokalemia); or • kidney or liver disease.
How long patients should take aspirin PLUS clopidogrel (Plavix) OR prasugrel (Effient) after a coronary stent. • A. One month • B. One year • C. Depends on the stent
Answer • C. Depends on the stent
Which of the following is TRUE about antiplatelet therapy after a coronary stent?<> A.Dual antiplatelet therapy is usually given for at least one year after placement of a drug-eluting stent.<> B.Aspirin should be stopped at the same time as clopidogrel.<> C.Drug-eluting stents have a lower risk of thrombosis than bare-metal stents.<> D.Patients who miss one dose of clopidogrel should get another loading dose.
Answer • A.Dual antiplatelet therapy is usually given for at least one year after placement of a drug-eluting stent.
Preventing Thrombosis • Patients should get aspirin indefinitely after a stent. But how long patients should take clopidogrel or prasugrel depends on the type of stent and the indication for the stent.Bare-metal stents are quickly coated with endothelial cells which help prevent stent THROMBOSIS. But cell overgrowth can block the stent and cause RESTENOSIS. For bare-metal stents, use dual therapy with aspirin plus clopidogrel or prasugrel for at least one month for stable patients...and 12 to 15 months for patients with acute coronary syndrome.Drug-eluting stents are coated with meds to help prevent cell overgrowth and restenosis. But the stent metal is exposed longer which can increase the risk for stent thrombosis. Therefore patients with drug-eluting stents usually need dual antiplatelet therapy longer to prevent clots than patients with bare-metal stents. Some evidence suggests one year of dual antiplatelets is enough for drug-eluting stents...but thrombosis risk may persist for years
Which of the following patients are good candidates for carrying TWO doses of injectable epinephrine (EpiPen, etc) for allergic reactions?<> A.Children under age 6 years old<> B.People who will be in remote areas<> C.Patients who have had a prior severe or hard to treat allergic reaction<> D.Both B and C
Answer • D.Both B and C
Epinephrine • Many people get two pens...to keep at different locations. Now some experts recommend carrying two doses at a time. Up to 20% of patients get a second dose to treat anaphylaxis. A second dose is more likely to be needed in patients over age 10...and those with a previous severe reaction. Tell patients to carry two doses if they will be in a remote area...or they have had a more severe or hard to treat reaction. Prescribe two auto-injectors (EpiPen, Adrenaclick)...or one Twinject. Twinjectcosts less than two auto-injectors...but the second dose is given manually so it can be more difficult to use. Advise patients to head to the emergency room after the first dose...and use the second dose 10 minutes after the first one if symptoms persist or return.
Which of the following is TRUE about drug interactions with oxycodone (OxyContin, etc)?<> A.Oxycodone levels can be increased by clarithromycin, ketoconazole, or ritonavir.<> B.Oxycodone levels can be decreased by carbamazepine, phenytoin, or rifampin.<> C.Similar interactions are not seen with codeine, hydromorphone, or morphine.<> D.All of the above
Answer • D.All of the above
Answer • A new black box warning for OxyContin (oxycodone) about interactions with CYP3A4 drugs. CYP3A4 is a major pathway for metabolizing oxycodone, therefore 3A4 inhibitors or inducers can affect oxycodone levels.INCREASED oxycodone levels can be seen when it's combined with 3A4 INHIBITORS...macrolides (clarithromycin, etc), azole antifungals (ketoconazole, etc), or protease inhibitors (ritonavir, etc). For example, voriconazole (Vfend) can almost double oxycodone peak levels and prolong its effects.DECREASED oxycodone levels can be seen if it's combined with 3A4 INDUCERS...carbamazepine, phenytoin, rifampin, St. John's wort, etc. Rifampin decreases oxycodone peak levels by more than 50%. Monitor patients if they need to combine oxycodone with a 3A4 inhibitor or inducer...and adjust doses if needed. Observe the same precautions with other oxycodone products...Percodan,Percocet, etc. Keep in mind that 3A4 inducers or inhibitors are likely to interact with fentanyl...and possibly with hydrocodone, tramadol, and propoxyphene. Methadone can interact with some 3A4 inhibitors or inducers...but probably through a different pathway. To avoid 3A4 interactions, prescribe morphine, codeine, hydromorphone, or tapentadol (Nucynta).
What can be added to Lactulose to prevent Hepatic Encephalopathy?
Answer • Xifaxan (rifaximin) now comes in a 550 mg tablet to prevent hepatic encephalopathy due to chronic liver disease
Rifaximin • Rifaximin is a nonabsorbable antibiotic that originally came on the market for treating traveler's diarrhea. Rifaximin helps prevent hepatic encephalopathy by killing bacteria in the gut that produce ammonia and other toxins. Adding rifaximin to lactulose reduces the risk of recurrent hepatic encephalopathy and hospitalization by 50%. One additional episode is prevented for every 4 patients treated for 6 months. The downside is that rifaximin costs $1200 per month. Some clinicians use metronidazole, neomycin, or vancomycin to TREAT hepatic encephalopathy. But there's not enough evidence to recommend these antibiotics for prevention...and there are concerns about long-term toxicity. Consider using rifaximin when lactulose alone is not enough to prevent recurrent hepatic encephalopathy.
CoQ10 may help with which of the following • A. Statin myalgia. B. Heart failure. C. Hypertension. D. Type 2 diabetes. E. Migraines. F. All of the above
Answer • F. All of the above
CoQ10 Statin myalgia. There's conflicting evidence about CoQ10's effectiveness for statin-induced myopathy...but it's safe, well tolerated, and many people swear by it. Don't use it for myalgia unless there is a strong reason...for example, if providing it helps keep your patient on a statin. In that instance, try 100 mg/day.Heart failure. Some evidence suggests that 60 to 300 mg/day improves quality of life and decreases symptoms and hospitalization. Consider it only as an add-on for patients not well controlled on traditional heart failure meds...and explain it might not help.Hypertension. Some small studies suggest using 100 to 120 mg daily to lower blood pressure...but tell people not to rely on it.Type 2 diabetes. Some evidence suggests that 100 to 200 mg/day can slightly lower A1C...but other studies show no benefit. Tell patients not to rely on it.Migraines. Preliminary evidence suggests that CoQ10 might reduce migraine frequency. If patients want to try this, suggest 100 mg TID...and advise them it can take up to 3 months to see if it helps. CoQ10 doses up to 3000 mg/day are quite safe...but might cause nausea or diarrhea. If needed, suggest dividing doses over 100 mg
Propylthiouracil (PTU) for hyperthyroidism now has a black box warning because of? • A. Renal Failure • B. Hepatic Failure • C. Severe Nausea and Vomiting • D. Severe Headaches • E. Severe Myalgias
Answer • B. Hepatic Failure
Propylthiouracil • The risk of acute liver failure with propylthiouracil (PTU) is about 1 case per 10,000 in adults...and 1 case per 2,000 for children. Liver toxicity is not dose-related and can happen anytime after starting therapy. Liver function tests don't help detect it earlier...because it comes on suddenly and progresses rapidly. Use methimazole (Tapazole) instead for most patients who need a drug to reduce thyroid hormone synthesis. Save propylthiouracil for patients who can't tolerate other options...methimazole, radioactive iodine, or surgery. Also use propylthiouracil for women trying to get pregnant and during the first trimester...because methimazole is associated with birth defects. But use methimazole after the first trimester. And use propylthiouracil for thyroid storm because propylthiouracil inhibits conversion of T4 to T3...methimazole doesn't. Advise patients taking propylthiouracil to stop the drug and alert you if they get symptoms of liver toxicity. Keep in mind that both methimazole and propylthiouracil can cause RARE cases of agranulocytosis within a few months of starting therapy. Tell patients to report symptoms of infection. If this occurs, check a differential white blood cell count.
Hormone Therapy in women is associated with which of the folowing? A. Lung cancerB. Breast cancerC. Endometrial cancerD. Colorectal cancerE. Ovarian cancer F. A, B, C.
Answer • F. A, B, C.
“Hormone therapy" (HT) and Cancer Women still ask if hormone therapy increases cancer risk. Note the politically correct term "hormone therapy" (HT) instead of "hormone replacement therapy" (HRT). Authorities don't want people to think these doses "replace" hormones to their premenopause level. Hormone therapy helps menopausal symptoms and decreases the risk of osteoporosis and fractures...but it's associated with some cancers.Lung cancer is the newest cancer linked with hormone therapy. Estrogen and progestin MIGHT increase the risk of developing lung cancer...especially when used for 10 or more years. It might also promote the growth of existing lung cancer...especially in older women who smoke...possibly because some lung cancer tumors have hormone receptors.Breast cancer risk may increase after about 3 years on estrogen plus progestin...instead of 5 years like experts used to think. But explain that the risk is very small... 8 more cases of breast cancer per 10,000 women using combo therapy for 5 years or longer. And the risk starts to decline 2 to 3 years after stopping hormone therapy.Endometrial cancer risk is 5 times higher for women taking estrogen ALONE for more than 3 years. Continue to add a progestin to an estrogen for a woman with an intact uterus.Colorectal cancer risk was thought to go down based on the initial Women's Health Initiative report. But longer follow-up now suggests that hormone therapy doesn't prevent colorectal cancer.Ovarian cancer risk due to hormone therapy is very small...if any at all. Tell women that using hormone therapy for less than 5 years is NOT associated with a higher risk for ovarian cancer. Continue to recommend caution with hormone therapy...and use small doses for the shortest time and only when needed
Which of the following is TRUE about the new statin, pitavastatin (Livalo)?<> A.Pitavastatin lowers LDL more than higher doses of atorvastatin (Lipitor) or rosuvastatin (Crestor).<> B.Pitavastatin lowers LDL more than 60%.<> C.Pitavastatin doses over 4 mg/day are associated with more rhabdomyolysis.<> D.Pitavastatin has a high risk for CYP450 drug interactions.
Answer • C.Pitavastatin doses over 4 mg/day are associated with more rhabdomyolysis
