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Other Topics EXAM 2
Other Topics EXAM 2 - Wilhelm
61
Pharmacology
Graduate
04/07/2012

Additional Pharmacology Flashcards

 


 

Cards

Term
the 4 mechanisms involved in the pathogenesis of acne lesions
Definition
INCREASED FOLLICULAR KERATINIZATION

keratinization within the hair follicle is a normal process

acne involves keratinocyte clumping and plugging in the hair follicle pore

increased sloughing of keratinocytes leads to microcomedo formation

INCREASED SEBUM PRODUCTION

sebum production influenced by androgen stimulation at puberty

acne affected pilosebaceous units have a hyperresponsiveness to circulating androgens

BACTERIAL GROWTH

Propionibacterium acnes resides in the follicle as normal flora

trapped keratinocytes and sebum leads to growth of P. acnes

P. acens causes lipolysis of sebum TGs to free fatty acids

INFLAMMATION

inflammation is due to P. acnes mediated T cells reponse, cytokine release, and production of free fatty acids
Term
acne lesions
Definition
PRIMARY LESIONS

microcomedo - underneath the skin and CANNOT BE SEEN

NONINFLAMMATORY LESIONS

closed comedo (AKA white head) - a plug of sebum, keratinocytes, and microorganisms blocking a closed hair follicle opening (says beneath the skin surface); 1-2 mm diameter)

closed comedo (AKA blackhead) - a plug of sebum, keratinocytes, and microorganisms blocking a dilated hair follicle opening (reaches the skin surface); 2-5 mm diameter

INFLAMMATORY LESIONS

papule - a well defined, elevated, palpable, distinct area of skin (<5 mm diameter) involving the epidermis/dermis

pustule - a papule filled with purulent fluid (<5 mm diameter)

nodule - an elevated, firm, distinct, palpable, round or oval lesion (> 5 mm diameter) that occurs in the dermis/hypodermis

cyst - a docule filled with purulent fluid (>5 mm diameter)
Term
classification and severity of acne by type of lesion
Definition
TYPE 1

comedonal acne

comedones only, fewer than 10 lesions on face, no lesions on trunk, no scaring

only classification that can be treated with OTC products

TYPE II

papular acne

10-25 papule lesions on face/trunk, mild scarring, inflammatory lesions < 5 mm

TYPE III

pustular acne

> 25 pustule lesions, moderate scarring, inflammatory lesions < 5 mm with visible purulent core

TYPE IV

severe/persistent pustulocystic acne

nodules/cycsts, extensive scarring, inflammatory lesions > 5 mm

RECALCITRANT SEVERE CYSTIC ACNE

extensive nodules/cysts
Term
classification and severity of inflammatory acne
Definition
MILD

few to numerous closed comedones
few to numerous open comedones
possible papules/pustules
no nodules
no scarring

MODERATE

few to numerous closed comedones
few to numerous open comedones
NUMEROUS papules/pustules
few nodules
possible scarring

SEVERE

few to numerous closed comedones
few to numerous open comedones
NUMEROUS papules/pustules
EXTENSIVE nodules
EXTENSIVE scarring
Term
non pharm treatment of acne
Definition
cleanse the skin:
clean gently BID
use mild soap, soapless cleanser and water
use hands or soft wash cloth, pat dry

minimize exacerbating factors:
avoid frequent touching of skin
avoid friction producing clothing/devices
choose noncomedogenic cosmetics (oil free)
do not pick of sqeeze lesions
minimize stress
avoid medications (PIMPLES): phenytoin, isoniazid, moisturizers, phenobarbital, lithium, ethionamide, steroids
Term
topical acne treatments
Definition
retinoids

antimicrobials
Term
topical retinoids
Definition
tretinoin (Retin-A, Retin-A Micro, Stalin, Renoza [wrinkles])

adapalene (Differin)

tazarotene (Tazorac, Avage [wrinkles])
Term
topical tretinoin indication
Definition
1ST LINE THERAPY (DOC) for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy
Term
topical tretinoin MOA
Definition
increase turnover (keratolytic) and decrease cohesiveness (comedolytic) of follicular epithelial cells

anti-inflammatory

inhibits formation of new and leads to extrusion of existing comedones
Term
topical tretinoin ADRs
Definition
skin irritation, erythema, peeling, sensitivity to sun, wind, and cold
Term
topical tretinoin administration
Definition
AAA thin layer after washing/drying face at HS; wait 30 minutes after washing face to apply

start every other day then qHS

0.025% cream for mild acne with sensitive, non oily skin

0.01% gel for moderate acne with sensitive, oily skin

0.025% gel for moderate acne with non sensitive, oily skin

combination with benzoyl peroxide qAM and tretinoin
Term
topical adapalene indication
Definition
alternative 1st line therapy for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy
Term
topical adapalene MOA
Definition
3rd generation retinoid with selective affinity for retinoic acid receptors (RARs) in the epidermis
Term
topical adapalene ADRs
Definition
similar to tretinoin, skin irritation, erythema, peeling, sensitivity to sun, wind, and cold
Term
topical adapalene administration
Definition
AAA thin layer after washing/drying face at HS
Term
topical tazarotene indications
Definition
alternative 1st line therapy for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy
Term
topical tazarotene MOA
Definition
new generation retinoid, prodrug, selectively binds to RARs

comedolytic, keratolytic, and antiinflammatory
Term
topical tazarotene ADRs
Definition
dose related erythema, pruritis, stinging, burning

more severe ADRs than the other, but works better

pregnancy category X
Term
topical tazarotene administration
Definition
AAA thin layer after washing/drying face at HS
Term
topical antimicrobials
Definition
benzoyl peroxide (Benzac AC, Brevosyl, Lavclen, Triaz)

erythromycin (Eryderm, Ery Pads)

clindamycin (Cleocin T, Clindagel, ClindaMax, Evoclin)

azelaic acid (Azelax, Finacea [rosacea])
Term
topical benzoyl peroxide indication
Definition
alternative 1st line therapy for treatment of comedonal acne, mild to moderate inflammatory acne, and maintenance therapy

adjunctive therpy with retinoids, topical and systemic antibiotics (to prevent resistance)
Term
topical benzoyl peroxide MOA
Definition
bactericidal against P. acnes

liberates free oxygen radicals that oxidize bacterial proteins

P. acnes resistance is not known to develop

some comedolytic, keratolytic, and indirect anti-inflammatory activity
Term
topical benzoyl peroxide ADRs
Definition
dryness, irritation, may bleach or discolor fabric, sun sensitivity
Term
topical benzoyl peroxide administration
Definition
10% strength not significantly more efficacious but can be more irritating

AAA thin layer 30 minutes after washing/drying face at HS

start with 15 minute titration to 2 hours then BID if needed

can also increase concentration 2.5% then 5%

combination with benzoyl peroxide qAM and tretinoin qHS

combination product Epiduo = benzoyl peroxide (2.5%) + adapalene (0.1%) gel AAA pea size amount daily (forehead, each cheek, chin)
Term
topical erythromycin and clindamyin indication
Definition
alternative 1st line therapy (short to intermediate term) for treatment of mild to moderate inflammatory acne

adjunctive therapy with retinoids, benzoyl peroxide

combination has increased efficacy and reduced bacterial resistance
Term
topical erythromycin and clindamycin MOA
Definition
antibacterial against P. acnes with indirect suppression of inflammation
Term
topical erythromycin and clindamycin ADRs
Definition
erythema, peeling, dryness, burning
Term
combination products
Definition
Benzamycin = benzoyl peroxide (5%) + erythromycin (3%) apply BID; stored in refrigerator; expires 3 months after dispensing

Benzaclin = benzoyl peroxide (5%) + clindamycin (1%) apply BID; store at room temperature; expires 3 months after dispensing

Duac = benzoyl peroxide (5%) + clindamycin (1%) apply qHS; store in refrigerator and after it is dispensed store at room temperature; good for 2 months after dispensing

Ziana = tretinoin (0.025%) + clindamycin (1.2%) apply qHS
Term
topical erythromycin and clindamycin administration
Definition
AAA thin layer after washing/drying face BID
Term
topical azelaic acid indication
Definition
alternative therapy for mild to moderate acne for patients that cannot tolerate benzoyl peroxide

post inflammatory hyperpigmentation, as it has skin lightening properties
Term
topical azelaic acid MOA
Definition
antibacterial against P. acnes with indirect suppression of inflammation, comedolytic activity

P. acnes resistance is not known to develop
Term
topical azelaic acid ADRs
Definition
mild - burning, pruritus, stinging, tingling

erythema, dryness, rash, peeling, irritation, dermatitis < 1%

no systemic ADRs or photosensitivity
Term
topical azelaic acid administration
Definition
AAA thin layer after washing/drying face BID
Term
systemic acne treatments
Definition
ANTIMICROBIALS:

tetracyclines - minocycline (Minocin, Dynacin, Solodyn, Myrac), doxycycline (Vibramycin), tetracycline (Sumycin)

macrolides - erythromycin (Ery-Tab), azithromycin (Zithromax)

ORAL RETINOID:

isotretinoin (Accutane, Amnesteem, Claravis, Sotret)

HORMONAL ACNE TREATMENTS:

norgestimate/ethinyl estradiol (Ortho-Tri-Cyclen)
noresthindrone acetate/ethinyl estradiol (Estrostep)
dropsrienone/ethinyl estradiol (Yasmin, Yaz)
spironolactone
Term
tetracyclines (minocycline, doxycyline, tetracycline) indications
Definition
MINOCYCLINE = 1ST LINE ORAL THERAPY for moderate to severe inflammatory acne used in combination with topical

doxycyline = alternative oral therapy to minocycline used in combination with topical

tetracycline = 2nd line alternative oral therapy to minocycline/doxycyline used in combination with topical
Term
tetracycline (minocycline, doxycyline, tetracycline) MOA
Definition
antibacterial against P. acnes with indirect suppression of inflammation
Term
tetracyclines (minocycline, doxycyline, tetracycline) ADRs
Definition
GI upset, hepatotoxicity, predisposition to superinfections (vaginal candidiasis)

photosensitivity, chelation (dairy/antacid interaction)

cannot use in children < 10 years old or pregnant women
tooth discoloration
inhibition of skeletal growth in developing fetus

cannot use with systemic retinoids due to risk of intracranial HTN

minocycline - dose related dizziness, urticaria, autoimmune hepatitis, systemic lupus erythematosus like syndrome, serum sickness like reaction

MUST take with a full glass of water

minocycline hyperpigmentation 4 distinct types:
1) blue-black pigmentation confined to sites of scarring or inflammation on the face
2) blue-gray circumscribed pigmentation of normal skin on the lower legs and forearms
3) diffuse muddy brown pigmentation of normal skin accentuated in sun exposed areas
4) circumscribed blue-gray pigmentation within acne scars confined to the back
Term
tetracyclines (minocycline, doxycycline, tetracycline) administration
Definition
minocycline - 50 mg BID or 100 mg daily as initial and maintenance doses
more effective than tetracycline
high lipid solubility leads to enhanced penetration into tissue and sebaceous follicles

doxycycline - 100-200 mg daily, 30 minutes before meals
when improvement seen, decrease dose to 50 mg daily

tetracycline - 500 mg BID 1 hour before meals
after 1-2 months, when improvement is seen, decrease dose to 500 mg daily for another 1-2 months
Term
macrolides (erythromycin and azithromycin) indication
Definition
erythromycin - alternative oral therapy to tetracyclines for moderate to severe inflammatory acne used in combination with topical
used in patients who cannot tolerate or develop resistance to tetracycline

azithromycin - alternative oral therapy to erythromycin for moderate to severe inflammatory acne used in combination with topical

clindamycin is NOT used for acne due to risk of pseudomembranous colitis
Term
macrolides (erythromycin and azithromycin) MOA
Definition
antibacterial against P. acnes with indirect suppression of inflammation
Term
macrolides (erythromycin and azithromycin) ADRs
Definition
GI upset (N/V, abdominal pain, diarrhea) - more common with erythromycin
Term
macrolides (erythromycin and azithromycin) administration
Definition
erythromycin - 250 mg QID with food

azithromycin - 500 mg three times weekly
Term
oral isotretinoin indication
Definition
1ST LINE ORAL THERAPY (DOC) for the treatment of severe, recalcitrant, nodular acne

conventional treatment failure, scarring acne, chronic relapsing acne and acne with severe psychological distress
Term
oral isotretinoin MOA
Definition
induction of atrophy of sebaceous gland with decreased sebum production and change in sebum composition

inhibition of P. acnes growth

inhibition of inflammation

altered patterns of keratinization
Term
oral isotretinoin ADRs
Definition
MAIN ADRS:

depression - monitor and counsel on risk

dryness - mouth (sugar free candy, lozenges, gum), eyes (eye drops, avoid contact lenses), nose (lubricant), skin (nondrying moisturizers), lips (lip moisturizers with sunscreen)

muscles and joint pain - NSAIDs

alopecia - reversible when treatment DC

hypertriglyceridemia - reversible when treatment DC

acne flare - continue treatment

photosensitivity - sue moisturizing sunscreen, protective clothing

SERIOUS ADRS:

increased CPK, hyperglycemia, photosensitivity, hepatomegaly, abnormal LFTs, arthralgia, muscle stiffness

pregnancy category X

RELATIVE CONTRAINDICATIONS:

hyperlipidemia, DM, severe osteoporosis

MONITORING:

FLP, LFT, CBC
Term
oral isotretinoin administration
Definition
0.5-2 mg/kg/day in 2 divided doses with food for 20 weeks

cumulative dose of 120-150 mg/kg/treatment course

lower dose (<0.5 mg/kg) may be used but is associated with higher relapse rate

50% reduction in pustules after 2-4 weeks
Term
isotretinoin and teratogenicity
Definition
isotretinoin causes severe birth defects

pregnancy prevention and management program (iPLEDGE)

FDA/manufacturer run risk management program

MD, patient, RPh, wholesalers, and manufacturers must register

program to prevent female patient starting therapy if pregnant and female patient on therapy becoming pregnant

contraception required

begin OC 1 month prior to treatment, continue during treatment, and for 1 month (usually 4 months) after completion

female must commit to use 2 forms of effective contraception

approved forms of contraception:
primary forms - tubal sterilization, partner's vasectomy, IUD, hormonal (OC, patches, injection, implants, ring)
secondary forms: diaphragm, cervical cap, male latex condom, vaginal sponge (all must be used with spermicide)

not approved: OC w/o estrogen, IUD progesterone T, female condoms, natural family planning, breastfeeding, fertility awareness, withdrawal, cervical shield

must have 2 negative urine or blood pregnancy tests before receiving initial Rx

each month of treatment, patient must have a negative pregnancy test

MD enters patient's pregnancy results and 2 forms of contraception use into iPLEDGE system

iPLEDGE system verifies that all criteria have been met prior to allowing pharmacy authorization to fill and dispense Rx
Term
oral contraceptives (norgestimate/ethinyl estradiol, norethindrone acetate/ethinyl estradiol, drospirenone/ethinyl estradiol) indication
Definition
effects on acne of patches and vaginal rings has not been studied

alternative treatment for women with moderate acne

first line treatment of moderate to severe acne in women with laboratory evidence of hyperadrogenism
Term
oral contraceptives (norgestimate/ethinyl estradiol, norethindrone acetate/ethinyl estradiol, drospirenone/ethinyl estradiol) MOA
Definition
antiandrogen effect leading to decreased sebum production

decreases free trestosterone levels

inhibit ovarian production of androgens by suppressing ovulation
Term
oral contraceptives (norgestimate/ethinyl estradiol, norethindrone/ethinyl estradiol, drospirenone/ethinyl estradiol) ADRs
Definition
N/V, breast tenderness, spotting and breakthrough bleeding, weight gain, acne flare

thromboembolism
Term
spironolactone indication
Definition
alternative, off label treatment for moderate to severe acne in women with laboratory evidence of hyperandrogenism
Term
spironolactone MOA
Definition
antiandrogen and inhibitor of 5alpha-reductase decreases sebum production
Term
spironolactone ADRs
Definition
dose dependent, hyperkalemia, irregular menses, breast tenderness
Term
spironolactone administration
Definition
50-200 mg daily in 1-2 divided doses

higher doses than those used for BP lowering
Term
which topical formulation do you recommend?
Definition
solutions, gels, creams, lotions, washes, disposable wipes:

gels have better stability, more potent, contain alcohol, propylene glycol, or water

alcohol based products cause more drying/irritation

cleansing washes - good for larger reas such as back and chest but not enough contact time to make an impact on the acne

skin type:

oily to normal skin = gels, solutions, otions

normal skin = gels, solutions, lotions, creams

normal to dry skin = lotions, creams (help moisturize dry skin)

apply product to entire affected area not individual lesions
Term
recommend appropriate treatment options based on severity of disease: mild comedonal
Definition
1st choice -> topical retinoid

alternatives -> alternate topical retionid OR salicylic acid OR azelaic acid

alternatives for females -> topical retinoid

maintenance -> topical retinoid
Term
recommend appropriate treatment options based on severity of disease: mild papular pustular
Definition
1st choice -> topical retinoid PLUS topical antibiotic

alternatives -> alternate topical retinoid PLUS alternate topical anticiotic OR azelaic acid

alternatives for females -> topical retinoid PLUS topical antibiotic

maintenance -> topical retinoid
Term
recommend appropriate treatment options based on severity of disease: moderate papular pustular
Definition
1st choice -> oral antibiotic PLUS topical retinoid +/- benzoyl peroxide

alternatives -> alternate oral antibiotic PLUS alternate topical retinoid +/- benzoyl peroxide

alternatives for females -> oral antiandrogen PLUS topical retinoid/azelaic acid +/- topical antibiotic

maintenance -> topical retinoid +/- benzoyl peroxide
Term
recommend appropriate treatment options based on severity of disease: moderate nodular
Definition
1st choice -> oral antibiotic PLUS topical retinoid +/- benzoyl peroxide

alternatives -> oral isotretinoin OR alternate oral antibiotic PLUS alternate topical retinoid +/- benzoyl peroxide/azelaic acid

alternatives for females -> oral antiandrogen PLUS topical retinoid +/- oral antibiotic +/- alternate topical antibiotic

maintenance -> topical retinoid +/- benzoyl peroxide
Term
recommend appropriate treatment options based on severity of disease: severe nodular/conglobate
Definition
1st choice -> oral isotretinoin

alternatives -> oral antibiotic PLUS topical retinoid PLUS benzoyl peroxide

alternatives for females -> oral antiandrogens PLUS topical retinoid +/- alternate topical antibiotic

maintenance -> topical retinoids +/- benzoyl peroxide
Term
realistic goals
Definition
topical products may take 4-8 weeks (up to 12 weeks) to see improvement

adverse effects usually resolve with continued use

acne may get worse before better

oral antibiotic may take 3-6 months to see improvement

dangers of overtreatment
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