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Pharmacology/Drug Interaction Pearls
Pharmacology Pearls: What I Wish I Knew Years Ago Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Family Nurse Practitioner Owner - Wright & Associates Family Healthcare Amherst, New Hampshire 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 Partner – Partners in Healthcare Education, LLC Wright, 2012 Malpractice Suits • Drug interactions Pharmacology/Drug Interaction Pearls • • • • • • • • • • –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 Wright, 2012 Many Common Complaints Can Occur From a Drug/Drug Interaction 3 Mechanisms For Drug Interactions Fatigue Constipation or diarrhea Confusion Incontinence Falls Depression Weakness or tremors Excess drowsiness or dizziness Agitation or anxiety Decreased sexual behavior Wright, 2012 Wright, 2012 • 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 Wright, 2012 1 Cytochrome P450 Let’s Start With Drug Interactions Which Occur Through CYP 450 • 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 metabolism Wright, 2012 Wright, 2012 CYP450 Pathways • 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 • There are > 100 enzymes or pathways – 1A2 – 2C9 – 2C19 – 3A4 – 2D6 Wright, 2012 Wright, 2012 Terminology • Substrates –Metabolized by the isoenzyme Examples of Common Drug Interactions CY P450 Isoenzyme Drug Substrate Drug Inhibitor Drug Inducer Cimetidine Fluvoxamine (Luvox) Ticlopidine (Ticlid) Fluoroquinolones Tobacco Nicotine • Inhibitors –Block the activity of the isoenzyme Caffeine Theophylline • Inducers –Accelerate the activity of the isoenzyme Wright, 2012 Wright, 2012 1A2 Adapted from: Abramowicz, M. (1999). Wright, Drug Interactions. The Medical Letter on Drugs and 2012 Therapeutics. 41(1056) 61-62. 2 Let Us Look At An Example! • Patient drinks 4 cups of coffee per day – Caffeine is a substrate Another Example • Patient is on theophylline for COPD – Substrate • Smoking (Nicotine) • You prescribe ciprofloxacin – Nicotine is an inducer – Ciprofloxacin is an inhibitor • What happens to the caffeine levels? • About what will the patient complain? • 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 Wright, 2012 CY P450 3A4 Examples of Common Drug Interactions • This is the location of most drug-drug interactions • 50% of medications are metabolized through this pathway Examples of Common Drug Interactions Drug Substrate Atorvastatin Quinidine Alprazolam Diazepam Methadone Sildenafil Drug Inhibitor Grapefruit juice Ritonavir Fluoxetine Nefazodone Drug Inducer Barbiturates Carbamazepine Phenytoin Rifampin Phenobarbital St. John’s Wort Adapted from: Abramowicz, M. (1999). Wright, Drug Interactions. The Medical Letter on Drugs and 2012 Therapeutics. 41(1056) 61-62. Wright, 2012 Drug Substrate Amiodarone Diltiazem Felodipine Nifedipine Verapamil Lovastatin Simvastatin Drug Inhibitor Amiodarone Clarithromycin Erythromycin Fluconazole Itraconazole Ketoconazole Drug Inducer Barbiturates Carbamazepine Phenytoin Rifampin Phenobarbital St. John’s Wort Adapted from: Abramowicz, M. (1999). Wright, Drug Interactions. The Medical Letter on Drugs and 2012 Therapeutics. 41(1056) 61-62. Wright, 2012 CY P450 Isoenzyme 3A4 CY P450 Isoenzyme 3A4 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 3 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 6vessel 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) Drugs Frequently Involved in Interactions • Statins – Lova, simva, atorva • • • • Amiodarone Telithromycin, erythromycin, clarithromycin -Azoles -Antivirals – 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 Ideally, a Medication Would Use Multiple Pathways for Metabolism Wright, 2012 Another Example • 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 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 Wright, 2012 Wright, 2012 Wright, 2012 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 Wright, 2012 4 HMG Co-A Reductase Inhibitors Caution: CY P450 3A4 • 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) • Caution: Medications using CY P450 3A4 – Avoid azole medications (rhabdomyolysis) – Avoid concomitant gemfibrozil (rhabdomyolysis) – Avoid erythromycin and clarithromycin (increases statin AUC by 50%) Wright, 2012 Wright, 2012 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 • 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) Wright, 2012 Wright, 2012 CW’s Labs Rhabdomyolysis • 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 Wright, 2012 Wright, 2012 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 Wright, 2012 5 What Changed? • • • • Why did this happen? CW went to a walk-in center Diagnosed with “walking pneumonia” Given a prescription for clarithromycin Wright, 2012 Remember CY P450 3A4 • Atorvastatin is a substrate • Clarithromycin is an inhibitor • Blocks 3A4 enzyme causing atorvastatin levels to increase significantly (50%) Wright, 2012 What Psychiatric Medications Can Do The Same Thing? Interactions Involving Renal System • Nefazodone • Alprazolam Wright, 2012 Lithium Wright, 2012 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 Wright, 2012 Wright, 2012 Wright, 2012 6 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 Wright, 2012 What Changed??? • What caused a sudden change in this woman? – Is this delirium? – Medication – TIA? – CVA? 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 toxicity Wright, 2012 Wright, 2012 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 Wright, 2012 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 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 7 Think of All the Antihypertensives • Most antihypertensives now have HCTZ in them • Easy for a drug interaction to occur 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 Wright, 2012 Other Labs to Monitor in Patients Taking Lithium Other Medications Which Can Alter The TSH • TSH (lithium decreases thyroxine production by interfering with iodine absorption) • Calcium (increased levels) • Glucose (increased levels) • Potassium (increased levels) • Amiodarone • Lithium • Interferon • Why?? • If patient is on a stable dosage, can monitor these every year Wright, 2012 Wright, 2012 CYP450 Isoenzyme Inhibition by the SSRIs (in vitro*) Additional Concerns CYP Isoenzymes • Trimethoprim/sulfamethoxazole with glyburide 1A2 2C9 2C19 2D6 3A4 Sertraline Escitalopram Citalopram + 0 + + 0 0 + to ++ 0 0 + 0 + + 0 0 • Clarithromycin with digoxin Fluoxetine + ++ + to ++ +++ ++ • Potassium sparing diuretics with ACE inhibitors Paroxetine + + + +++ + – hypoglycemia – digoxin toxicity – hyperkalemia 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. von Moltke et al.,Wright, 2001; 2012 Greenblatt et al., 2002; Greenblatt et al., 1998 Wright, 2012 Wright, 2012 8 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 Internal Hordeola HEENT Pearls Wright, 2012 Blepharitis Wright, 2012 Bullous Myringitis • Mycoplasma • Intensely painful • Treatment is with a macrolide Wright, 2012 Wright, 2012 Wright, 2012 9 ABRS Treatment Guidelines Allergic Facies Adult: Mild ABRS No antibiotic use in 4 – 6 weeks Amoxicillin (1.5 – 4.0 g)/day Amox/clav (1.75 – 4.0g/250mg)/day Cefpodoxime (Vantin) Cefuroxime (Ceftin) Cefdinir (Omnicef) Wright, 2012 ABRS Treatment Guidelines Adult: Mild ABRS No antibiotic use in 4 – 6 weeks Beta-Lactam Allergy TMP/SMX (Bactrim) Doxycycline Azithromycin (Zithromax) Clarithromycin (Biaxin) Erythromycin Adult: Mild ABRS No antibiotic use in 4 – 6 weeks Beta-Lactam Allergy No improvement or worsening at 72 hours Levofloxacin (Levaquin) Moxifloxacin (Avelox) Clindamycin (Cleocin) with rifampin Sinus and Allergy Health Partnership Wright, 2012 Guidelines Otolaryngol Head Neck Surg. 2004;130:1- ABRS Treatment Guidelines Adult: Mild ABRS and recent antibiotic usage or moderate ABRS +/- antibiotic use in 4 – 6 weeks Beta-Lactam Allergy Levofloxacin (Levaquin) Moxifloxacin (Avelox) Clindamycin (Cleocin) with rifampin Adult: : Mild ABRS and recent antibiotic usage or moderate ABRS +/- antibiotic use in 4 – 6 weeks Beta-Lactam Allergy No improvement or worsening at 72 hours Re-evaluate patient Consider complication Adult: Mild ABRS No antibiotic use in 4 – 6 weeks No improvement or worsening at 72 hours Amox/clavulantate (4g/day) Levofloxacin (Levaquin) Moxifloxacin (Avelox) Sinus and Allergy Health Partnership Wright, 2012 Guidelines Otolaryngol Head Neck Surg. 2004;130:1- ABRS Treatment Guidelines Adult: Mild ABRS and recent antibiotic usage or moderate ABRS +/- antibiotic use in 4 – 6 weeks Adult: Mild ABRS and recent antibiotic usage or moderate ABRS +/-antibiotic use in 4 – 6 weeks No improvement or worsening at 72 hours Levofloxacin (Levaquin) Moxifloxacin (Avelox) Amox/clavulanate (4g/day) Ceftriaxone (Rocephin) Clindamycin with rifampin Re-evaluate Consider complication Sinus and Allergy Health Partnership Wright, 2012 Guidelines Otolaryngol Head Neck Surg. 2004;130:1- 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 – Paul Iannini, MD; Worcester, MA, 2006 Sinus and Allergy Health Partnership Wright, 2012 Guidelines Otolaryngol Head Neck Surg. 2004;130:1- Wright, 2012 Wright, 2012 10 IDSA/ATS 2007 Guidelines for CAP in Adults • Practice Guidelines for the Management of Community-Acquired Pneumonia in Adults Pulmonary Pearls – Revised and published in Clinical Infectious Diseases 2007;44:S27 – S72 http://www.medscape.com/viewarticle/546317 accessed 01-28-2010 Wright, 2012 Wright, 2012 IDSA/ATS CAP Outpatient Treatment IDSA/ATS CAP Outpatient treatment • Strong recommendation • 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 – Macrolide such as azithromycin, clarithromycin, or erythromycin Or • Weak recommendation – Doxycycline Wright, 2012 Wright, 2012 IDSA/ATS CAP Outpatient treatment • Likely causative organism • 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 Wright, 2012 IDSA/ATS CAP Outpatient treatment – S. pneumoniae (Gm pos) with DRSP risk – H. influenzae (Gm neg) – Atypical pathogens (M. pneumoniae, C. pneumoniae, Legionella) – Respiratory virus as mentioned above Wright, 2012 11 IDSA/ATS CAP classification for outpatient treatment • Respiratory fluoroquinolone Or • Advanced macrolide (azithro- or clarithromycin) plus b-lactam such as HD amoxicillin (3- 4 g/d), HD amoxicillinclavulanate (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 Wright, 2012 Length of Therapy • Shortened to 5 days • Provided that the patient is afebrile by 48 – 72 hours Wright, 2012 Wright, 2012 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 triptans Wright, 2012 Wright, 2012 Neurological Pearls 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 Trephination – Opioids “reserved for use when other medications cannot be used” Wright, 2012 Snow V, et al. Ann Intern Med 2002;137:840-849. 12 Selective 5-HT1 agonists (the triptans) have emerged as the gold standard for acute migraine therapy. Abortive Medications The Triptans Cady R, Dodick DW. Mayo Clin Proc. 2002;77:255-261. Migraine-Specific Therapy: The Mechanism of Action Headache Experts Agree That the Optimal Treatment Strategy Is to Treat Early, Before Central Sensitization Occurs Intensity Phases of a Migraine Attack Pre-HA Premonitory/ Prodrome Aura Headache Mild Moderate to Severe HA Post-HA Postdrome Time TREAT EARLY! Adapted from Cady RK. Clin Cornerstone. 1999;1(6):21-32. Wright, 2012 Wright, 2012RJ. Cephalalgia. 2000;20(suppl 1):2-9. Hargreaves Too Much of a Good Thing…. Stratified Care vs Step Care Headache Response Attacks (%) 100 80 Stratified Care Step Care Across Attacks (All Attacks) Step Care Within Attacks (All 6 Attacks)69* 60 53*† 55 41 40 74 37 28*† 20 20 20 0 1 Hour 2 Hours Time Postdose 4 Hours *P < .001 for stratified care vs step care across attacks. for stratified care vs step care within attacks. Adapted from Lipton RB et al. JAMA. 2000;284:2599-2605. †P < .001 Wright, 2012 Wright, 2012 • 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 eliminated Wright, 2012 13 Controller Pharmacologic Therapies • Beta Adrenergic Receptor Antagonists – Propranolol 40-240mg qd – Nadalol 20-80mg qd – Atenolol 50-150mg qd – Metoprolol 50-300mg qd Controller Pharmacologic Therapies • 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 Up to 70% - 80% reduction in severity and frequency of migraine headaches Wright, 2012 Wright, 2012 Controller Pharmacologic Therapies • 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 months Wright, 2012 Controller Pharmacologic Therapies • 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 Alternative or Other Therapies • ACE Inhibitor – Lisinopril (Prinivil) • Alpha-2 Agonist Group • Dose once daily – Fatigue and dizziness: pregabalin, gabapentin • Dose at night – 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 Wright, 2012 14 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 Another Option My Medication Doesn’t Work... • Prednisone – 60, 40, 20 mg/day • Analgesic – Ketorolac in office or pain medication • • • • Ketorolac 15 mg, 30 mg or 60 mg Monitor blood pressure Consider IV fluids Consider antiemetic • Antiemetic – Suppository – Orally dissolving tablet Wright, 2012 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 Case Study • • • • Meds: as above Allergies: NKDA or NKFA PE – completely normal Assessment: What is your diagnosis • 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 Wright, 2012 Wright, 2012 15 Chronic Migraine: Diagnostic Criteria Common Pitfalls in Migraine Diagnosis: Importance of Medication Overuse Migraine Fulfilling the Criteria Below Meets the IHS criteria for migraine without aura Occurs ≥ 15 days per month for ≥ 3 months Usually begins as migraine without aura and progresses As chronicity develops, headache tends to lose its attack--like presentation attack Not attributable to another disorder Wright, 2012 When medication overuse is present, it is the likely cause of the chronic symptoms (Medication overuse headache – MOH) Olesen J et al. Cephalalgia. 2004;24(suppl 1):1-151. • MOH is common, but widely unrecognized • MOH is almost always transformed migraine • Ask patients about all pain medication use! Wright, 2012 MOH Diagnosis • Patients typically overuse multiple medications simultaneously Bigal ME, et al. Cephalalgia 2004;24:483-490. 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 Wright, 2012 Patients With HA 5%5%-10%1 Patients With CDH >60%2 1. Diener HC and Katsarava Z. Curr Med Res Opin 2001;17(suppl 1):S17S21. 2. Bigal ME, et al. Neurology 2004;63(5):843-847. • Both diagnosis and treatment require time – Diagnosis is confirmed in retrospect – Offending medications must be stopped and prophylactic medications started Wright, 2012 How Do You Break This Cycle? • • • • • • • 1%1 MOH Diagnosis (cont’d) – Mean tablets/day = 5.2 – Most commonly overused drugs are • Butalbital combinations (48%) • Acetaminophen (46%) • Opioids (33%) • ASA (32%) • Triptans (18%) Wright, 2012 General Population Smith TR and Stoneman J. Drugs 2004;64:2503-2514. 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 Wright, 2012 16 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 Genitourinary Pearls Wright, 2012 Wright, 2012 Complicated UTI: Pathogens • E. Coli: Complicated UTI E coli S epidermidis 15% Proteus E coli 32% Klebsiella Enterococci Pseudomonas Mixed Pseudomonas 20% Other Enterococci 22% Pathogens: A Discussion S epidermidis Gorbach et al, 1999 Guidelines for Infections in Primary Care. – 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 pathology http://emediciine.medscape.com/article/245559-overview accessed 03-11 Wright, 2012 Wright, 2012 Pathogens: A Discussion cUTI Pathogens • Staphylococcus saphrophyticus – Gram positive organism – Second most common cause in sexually active woman • Pseudomonas • 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 – Often seen in the individual with an obstructive pathology http://emediciine.medscape.com/article/245559-overview accessed 03-11 Wright, 2012 Wright, 2012 Kasper, D.L. (2005). Harrison’s Manual of Medicine (16th ed.). New York, NY.: McGraw-Hill Companies, Inc. Wright, 2012 17 Complicated UTI: Antimicrobial Choices • Trimethoprim-sulfamethoxazole (TMP-SMX) • Fluoroquinolones (ciprofloxacin, ofloxacin, levofloxacin) • Aminoglycosides (gentamicin, tobramycin, amikacin) 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 • Third-generation cephalosporins (ceftriaxone) 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 http://prod.hopkins-abxguide.org/diagnosis/genitourinary/urinary_tract_infection_ complicated accessed 04/12/2009 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 http://prod.hopkins-abxguide.org/diagnosis/genitourinary/urinary_tract_infection_ complicated accessed 02/01/2012 Wright, 2012 Guidelines for Treatment • Severely ill, recent FQ or long-term care facility resident – Imipenem – Piperacillin-tazobactam – Tobramycin or Gentamycin http://prod.hopkins-abxguide.org/diagnosis/genitourinary/urinary_tract_infection_ complicated accessed 04/12/2009 Wright, 2012 Wright, 2012 Abdominal Pearls Wright, 2012 18 Differentiating Signs and Symptoms of Chronic Constipation (CC) and IBS-C IBS with constipation Chronic constipation - Abdominal Pain/Discomfort1 + - Visceral Hypersensitivity2 + <3 BMs/Week Chronic Constipation • Most products will not work until: – You have cleaned out the patient’s bowel with colonic cleansing Normal Stool Frequency*1,3 *3 BMs/day to 3 BMs/week is considered range of normal stool frequency Wright, 2012 1. Brandt LJ, et al. Am J Gastroenterol. 2005;100(suppl 1):S5-S21. 2. Delvaux M. Best Pract Res Clin Gastroenterol. Traditionally Used IBS Treatments Treatment Bulking Agents (eg, wheat bran, corn fiber, psyllium) Water Antispasmodics (eg, hyoscyamine, dicyclomine) Antidepressants (eg, TCAs, SSRIs*) Thank You I Would Be Happy To Entertain Any Questions • Most traditionally used treatments have little evidence to support benefit TCA, tricyclic antidepressant; SSRI, selective serotonin reuptake inhibitor Spiller R, et al. Gut 2007;56;1770-1798. Wright, 2012 Wendy L. Wright, MS, RN, ARNP, FNP, FAANP Wright & Associates Family Healthcare [email protected] Wright, 2012 Wright, 2012 19
