Term
| 5 reasons for required monitoring of Lithium |
|
Definition
1. Narrow Therapeutic Window
2. Wide Inter-individual variables (large differences in Vd and wide ranges of CL)
3. Intra-individual variables (Age, Duration of therapy)
4. Renal Function
5. Thyroid Function |
|
|
Term
| Lithium is a ______valent ___ion |
|
Definition
|
|
Term
| Salt forms of lithium: carbonate= |
|
Definition
|
|
Term
| Salt forms of Lithium: citrate= |
|
Definition
|
|
Term
| Bioavailability of Regular Release Lithium |
|
Definition
|
|
Term
| Bioavailability of SR Lithium |
|
Definition
|
|
Term
| Regular Release Lithium is available in what strengths? |
|
Definition
|
|
Term
| SR Lithium is available in what strengths? |
|
Definition
|
|
Term
| 4 characteristics of SR Lithium |
|
Definition
1. Decreased adverse effects assoc. with peak concentrations and rising serum levels such as N&V
2. Increased compliance
3. Increased ability of kidneys to concentrate urine
4. Increase Diarrhea on an empty stomach |
|
|
Term
| Lithium is absorbed for the _______ and _______ by ________ __________. |
|
Definition
| jejunum, illeum, passive diffusion |
|
|
Term
| Tmax for lithium citrate (liquid) |
|
Definition
|
|
Term
| Tmax for Lithium Carbonate Regular Release |
|
Definition
|
|
Term
| Tmax for Lithium Carbonate SR |
|
Definition
|
|
Term
| Distribution of Lithium is best represented by what model? |
|
Definition
|
|
Term
|
Definition
|
|
Term
| What would be the result seen in the half life in a geriatric patient on Lithium? |
|
Definition
| Increased hald life due to decreased Vd |
|
|
Term
| What would be the result on half life of Lithium in a pregnant women? |
|
Definition
| Decreased half life due to increased Vd |
|
|
Term
| T/F Lithium crosses the placenta |
|
Definition
|
|
Term
| T/F Lithium is not excreted in breast milk |
|
Definition
|
|
Term
| When should a pregnant women avoid Lithium? |
|
Definition
| during the first trimester of pregnancy and 1 week before delivery. |
|
|
Term
| What could result from a pregnant women taking Lithium at inoptimal times during her pregnany? |
|
Definition
| cardiac anomalies (~7-8% of infants) |
|
|
Term
| Elimination of Lithium mimics what ion? |
|
Definition
|
|
Term
| Lithium is excreted renally as a _____ ion |
|
Definition
|
|
Term
| Is lithium bound by plasma proteins? |
|
Definition
|
|
Term
| What percent of lithium is filtered? |
|
Definition
|
|
Term
| What percent of lithium is reabsorbed? |
|
Definition
|
|
Term
| Where does the majority of lithium reabsoprtion occur? |
|
Definition
|
|
Term
| What is the half life of lithium at a maintenance dose? |
|
Definition
| 18-27 hours (normal=24 h) |
|
|
Term
| half life of lithium during acute mania |
|
Definition
|
|
Term
| Half life of Lithium in geriatric pts |
|
Definition
|
|
Term
| How does sodium intake effecr SLi? |
|
Definition
| decrease Na (either by decrease intake or icreased excretion) is going to cause an increase in SLi |
|
|
Term
| Profuse Sweating results in what effect on SLi? |
|
Definition
|
|
Term
| Acute protracted diarrhea has what result of SLi |
|
Definition
|
|
Term
| percentage of renal function lost per year for adults |
|
Definition
|
|
Term
| Percentage of renal function lost to pts on Lithium |
|
Definition
|
|
Term
| What effect do Thiazide Diuretics have on SLi? |
|
Definition
|
|
Term
| What effect do NSAIDS have on SLi? |
|
Definition
|
|
Term
| What effects do ACE inhibitors have on SLi? |
|
Definition
| Increase SLi by an undefined amount |
|
|
Term
| What effect do methylxanthines have on SLi? |
|
Definition
| Decrease it by causing an alteration in Sodium disposition in the kidneys |
|
|
Term
|
Definition
| caffeine and theophylline |
|
|
Term
| Lithium Therapeutic levels during acute mania |
|
Definition
|
|
Term
| Lithium therapeutic levels during chronic phase |
|
Definition
|
|
Term
| Lithium therapeutic levels in geriatric patients |
|
Definition
|
|
Term
| When should SLi samples be taken |
|
Definition
| approx 12 hours after dose (best time is in morning, 12 hours after PM dose) |
|
|
Term
| When should SLi samples be taken |
|
Definition
| approx 12 hours after dose (best time is in morning, 12 hours after PM dose) |
|
|
Term
| What lithium level would cause muscle weakness, nausea, and irritability |
|
Definition
|
|
Term
| What lithium level would mimic alcoholic intoxication |
|
Definition
|
|
Term
| What lithium level would result in ataxia, impaired consciousness, marked apathy, or parkinsonian movements |
|
Definition
|
|
Term
| What level of Lithium would require dialysis for Lithium |
|
Definition
|
|
Term
| What is meant by distributional rebound? |
|
Definition
| monitor patient to make sure SLi levels dont rebound to greated than 1mEq/L due to the fact that distribution between phases is not equal. |
|
|
Term
| How often should SLi levels be drawn during a patient experiencing acute mania |
|
Definition
| every 2-3 days due to high levels of Lithium dose |
|
|
Term
| How often should SLi be drawn when starting a new therapy? |
|
Definition
| every 1-2 weeks for the first 4 to 8 weeks of therapy or until patient has stabilized |
|
|
Term
| How soon after a dosage change should SLi be drawn? |
|
Definition
|
|
Term
| How often should SLi levels be drawn on a stablilized patient? |
|
Definition
|
|
Term
| For Lithium Dosing, If CrCL is 10-50ml/min how should Lithium be dosed? |
|
Definition
| 50-75% of the recommmended daily dose |
|
|
Term
| If CrCL is <10ml/min how should Lithium be dosed |
|
Definition
| 25-50% of recommended daily dosing |
|
|
Term
| What is the dosing schedule on the Fixed Dosing method |
|
Definition
|
|
Term
| What is an advantage of the fixed dosing method? |
|
Definition
|
|
Term
| What is a disadvantage of the Fixed point method? |
|
Definition
| Patients may be at subtherapeutic levels for the first 5-7 days required to reach steady state |
|
|
Term
| When using the Two point method (Perry method) when is the best time to evaluate SLi levels |
|
Definition
|
|
Term
| What is a disadvantage of the Two point method? |
|
Definition
| Delays initiation of therapy longer than other methods because it requires 36 hours after the test dose |
|
|
Term
| What is an advantage of the Repeated one point method? |
|
Definition
| Allows for rapid initiation of therapy if doses q 12 hours apart |
|
|
Term
| in the repeated one point method, the change in time of sampling between C1 and C2 should be equal to |
|
Definition
|
|
Term
| Which SSRI takes the longest amount of time to reach maximum concentrations? |
|
Definition
| Fluoxetine and Sertraline both take 6-8h |
|
|
Term
| Which SSRI takes the shortest amount of time to reach maximum concentration? |
|
Definition
|
|
Term
| Which SSRI(s) has the great Bioavailability (F%) |
|
Definition
| Celexa (citalopram) and Lexapro (escitalopram) are both 80% bioavailable |
|
|
Term
| Which SSRI has the lowest bioavailability (F%) |
|
Definition
| Zoloft (Sertraline) is >44% bioavailable |
|
|
Term
| Which SSRI has the largest Vd> |
|
Definition
| Prozac (Fluoxetine) of 20-42L/kg |
|
|
Term
| Which SSRI has the smallest Vd? |
|
Definition
| Luvox (Fluvoxamine) >5L/Kg |
|
|
Term
| Which SSRI has the longest parent compound half life? |
|
Definition
|
|
Term
| Which SSRI has the shortest half life of the parent compound? |
|
Definition
|
|
Term
| Which SSRI's do NOT have active metabolites? |
|
Definition
| Luvox (fluvoxamine), Paxil (paroxetine), Lexapro (escitalopram) |
|
|
Term
| Whic SSRI is the smallest percentage of Serotonin Reuptake inhibition at the minimum effective dose? |
|
Definition
| Celexa (citalopram) @ 60% |
|
|
Term
| Where are SSRI's absorbed from? |
|
Definition
|
|
Term
| what is the approximate absorption time of an SSRI |
|
Definition
|
|
Term
| T/F, Distribution of SSRI's is highly variable |
|
Definition
|
|
Term
| What three SSRI's are highly protein bound? |
|
Definition
| fluoxetine, paroxetine, and sertraline |
|
|
Term
| T/F The fact that some SSRI's are highly bound greatly influences their distribution |
|
Definition
| False, protein binding displacement interactions are not clinically significant |
|
|
Term
| Where are SSRI's metabolized for the majority? |
|
Definition
|
|
Term
| How are SSRI's metabolized? |
|
Definition
|
|
Term
| Norfluoxetine and fluoxetine have ________ activity. |
|
Definition
|
|
Term
| Desmethylsertraline is _____times less potent than sertraline. |
|
Definition
|
|
Term
| which two SSRI's inhibit their own metabolism? |
|
Definition
| fluoxetine and paroxetine |
|
|
Term
| What would be the result of therapy with an SSRI and an MAOI? |
|
Definition
|
|
Term
| T/F: SSRI's and MAOIs can be given together as long as each drug is monitored for therapeutic levels |
|
Definition
| FALSE-absolute contraindication with use of MAOI's and SSRIs |
|
|
Term
| What would be the result of administration of Fluoxetine with an anticonvulsant? |
|
Definition
| plasma levels of the anticonvulsant would be INCREASED by up to 50% due to oxidative metabolism inhibition by fluoxetine |
|
|
Term
| Why should SSRI's be used with caution in patients with epilepsy or a history of epilepsy? |
|
Definition
| because SSRI's have an epileptogenic effect |
|
|
Term
| How would hepatic disease effects SSRI plasma concentration? |
|
Definition
| extend half life and decrease CL |
|
|
Term
| ______% of Caucasians lack CYPIID6 |
|
Definition
|
|
Term
| ______% of ASIANS lack CYPIIC19 |
|
Definition
|
|
Term
| Why should geriatric patients be started on a dose of 10mg/day of paroxetine vs the normal 20mg/day? |
|
Definition
| because they experience a magnified effect of auto-inhibition by paroxetine. |
|
|
Term
| Which SSRI and its active metabolite plasma level concentrations may be DOUBLE in elderly patients? |
|
Definition
| fluoxetine and norfluoxetine |
|
|
Term
| T/F: Obesity plays no role in plasma concentration of SSRI's |
|
Definition
|
|
Term
| The plasma concentration of paroxetine in milk is_____ |
|
Definition
|
|
Term
| Smoking while taking FLUOVOXAMINE will decrease plasma concentrations by _____% compared to non smokers |
|
Definition
|
|
Term
| What is meant by a "Flat relationship" of SSRI's |
|
Definition
| the antidepressant effect is not increased as dose is increased. the relationship is not clear between dose and antidepressant effect. |
|
|
Term
| Normal Dose of Fluoxetine |
|
Definition
|
|
Term
| Normal dose of Paroxetine |
|
Definition
|
|
Term
| Normal dose of Sertraline |
|
Definition
|
|
Term
| Withdrawal symptoms of what three SSRI's include FATIGUE, SEVERE ABDOMINAL CRAMPS, DISTENSION, INSOMNIA, INFLUENZE LIKE SYMPTOMS, HA, NAUSEA, IRRITABILITY, SHOCK LIKE SYMPTOMS |
|
Definition
| fluvoxamine, paraxotine, and sertraline |
|
|
Term
| What SSRI's does not typically produce withdrawal symptoms when discontinued? and why? |
|
Definition
| fluoxetine because of its long half life |
|
|
Term
| What CYP450 isoenzyme(s) interacts with Fluoxetine? |
|
Definition
|
|
Term
| What CYP450 isoenzyme(s) interact with Flovaxime |
|
Definition
|
|
Term
| What CYP450 isoenzyme interacts with Paroxetine? |
|
Definition
|
|
Term
| What CYP450 isoenzyme interacts with Paroxetine? |
|
Definition
|
|
Term
| What CYP450 isoenzyme ineracts with Sertraline |
|
Definition
|
|
Term
| What is the first line option for euphoric mania? |
|
Definition
|
|
Term
| Where is Lithium metabolized? |
|
Definition
|
|
Term
| Where is lithium metabolized? |
|
Definition
| It is NOT metabolized, it is 100% filtered as a free ion |
|
|
Term
Sample question: Which of the following classes of medications may decrease serum lithium concentrations
A. Thiazide diuretics
B. Methylxanthines
C. NSAIDS
D. ACEIs |
|
Definition
|
|
Term
| What is Benzodiazepine absorption based on? |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| The two prodrugs PREZEPAM and CLORAZEPATE are metabolized to what active metabolite? |
|
Definition
|
|
Term
| When given IM ___________ (Benzo) and _________ (Benzo) are absorbed slowly and erratically |
|
Definition
| Chlordiazepoxide; Diazepam |
|
|
Term
| When given IM, _______(Benzo) and ________ (Benzo) are absorbed rapidly and completely |
|
Definition
|
|
Term
| Example of a rapidly absorbed and thus abused Benzo. |
|
Definition
|
|
Term
| Distribution of a benzo into the adipose tissue is dependent upon what? |
|
Definition
| Lipophilicity (faster for more lipophilic drugs) |
|
|
Term
| T/F Benzos are highly protein bound |
|
Definition
|
|
Term
| Benzos have (small/large) Vd |
|
Definition
|
|
Term
| Where does Benzodiazepine metabolism occur? |
|
Definition
|
|
Term
| Phase 1 metabolism of Benzos consists of? |
|
Definition
| Oxidation, Reduction, and hydrolysis to active metabolites |
|
|
Term
| What do Phase II reactions of Benzos consist of? |
|
Definition
| Conjugation to inactive metabolites |
|
|
Term
| 2 Benzo's that do not have active metabolites: |
|
Definition
|
|
Term
| How are Benzo's eliminated? |
|
Definition
|
|
Term
| What is the best choice for a benzo in a pt with Liver Disease? |
|
Definition
| short acting, no accumulation |
|
|
Term
| In a pt with Liver Disease, no dosing adjustment is needed for benzos metabolized primarily through what phase? |
|
Definition
| Phase II (glucoronide conjugation) |
|
|
Term
| three benzos that are metabolized primarily through glucoronide conjugation |
|
Definition
| oxazepam, lorazepam, temazepam |
|
|
Term
| Two benzos with multiple biotransformations |
|
Definition
| chlordiazepoxide and diazepam |
|
|
Term
| The elderly have increased sensitivity to Benzo's due to three main reasons |
|
Definition
1. Decreased oxidative metabolism
2. Decreased albumin (thus increased free drug)
3. Decreased GFR, renal blood flow, and tubular excretory capacity |
|
|
Term
| List two Benzos that would be appropriate for an elderly patient. |
|
Definition
|
|
Term
| What are the characteristics of a benzo that is appropriate for use in an elderly patient |
|
Definition
1. Short Half life
2. few hepatic biotransformations
3. No active metabolites |
|
|
Term
| Benzodiazepine indications (5 listed) |
|
Definition
| anxiety, alcohol withdrawal syndromes, sleep disorder, epilepsy, status epilepticus |
|
|
Term
| Benzodiazepine Dosing (general) |
|
Definition
| start at the lowest end of the dosage range, increase by small increments every 3 to 5 days |
|
|
Term
| Side effects of Benzodiazepines (3 listed) |
|
Definition
1. Sedation
2. Motor Impairment
2. Memory Impairment |
|
|
Term
| What is meant by Tolerance in relation to Benzo's? |
|
Definition
| Down regulation of GABA receptors asscoiated with long term use |
|
|
Term
| How should you address Abstinence Syndrome? |
|
Definition
| taper dosage by 25% per week until 1-2mg equivalents of alprazolam, then decrease by 25% of the remaining dosage every week. |
|
|
Term
| How could you treat the resurgence of sypmtoms during withdrawal of a benzodiazepine? |
|
Definition
| Increase the dose and taper more slowly. OR switch to a benzo with a longer half life and taper off more slowly. |
|
|
Term
| How can you avoid confusion of resurgence of symptoms vs. withdrawal symptoms when D/C a Benzo? |
|
Definition
|
|
Term
| Monitoring parameters for change in Vd (of aminoglycosides) (5 listed) |
|
Definition
1. Patient weight
2. Fluid status (intake and output)
3. Change in hematocirt or serum albumin
4. Cardiovascular hemodynamics
5. Serum aminoglycoside at peak and trough concentrations. |
|
|
Term
| Serum protein binding for aminoglycosides |
|
Definition
|
|
Term
| aminoglycosides are bacteriocidal against what type of organism? |
|
Definition
|
|
Term
| Administration via this route is not typically recommended for Aminoglycosides due to variability in absorption and thus variability in time needed to read Cmax |
|
Definition
|
|
Term
| Preferred method of aminoglycoside administration |
|
Definition
|
|
Term
| Standard infusion time of an intermittent IV infusion |
|
Definition
|
|
Term
| Route of administration not recommended for Aminoglycoside administration due to post antibiotic effect. |
|
Definition
|
|
Term
| Oral administration of Aminoglycosides can lead to _________ in patients with renal failure |
|
Definition
|
|
Term
| Aminoglycoside absoprtion can be substantial and can result in significant toxicity and is considered malpractice |
|
Definition
|
|
Term
| Where are aminoglycosides well distributed? |
|
Definition
| synovial, peritoneal, ascitic, and pleural fluids |
|
|
Term
| Where are aminoglycosides slowly distributed? |
|
Definition
| Bile, Feces, Prostate, and amniotic fluids |
|
|
Term
| Where are aminoglycosides poorly distributed? |
|
Definition
|
|
Term
| Fetal concentrations are _____% to _____% of maternal serum concentrations |
|
Definition
|
|
Term
| Vd of aminoglycosides approximates _______________ body water. |
|
Definition
|
|
Term
| What is Vd of aminoglycosides based on dosing weight? |
|
Definition
|
|
Term
| What is the Vd of aminoglycosides for neonates? |
|
Definition
|
|
Term
| Explain why pediatric pts typically have a larger Vd of aminoglycosides |
|
Definition
| Because pediatric pts have a higher body water content than adults. |
|
|
Term
| Pts with a low serum albumin are likely to have a (larger/smaller) Vd of aminoglycosides? |
|
Definition
|
|
Term
| Aminoglycoside elimination is primarily via ___________ _____________. |
|
Definition
| Glomerular Filtraton (~99%) |
|
|
Term
| Aminoglycosides may be reabsorbed in the ________ tubule by _________. |
|
Definition
|
|
Term
| Urino AMG concentration is usually ______ to ______ times greater than peak serum concentrations following a dose |
|
Definition
|
|
Term
| Factors affecting AMG disposition (6 listed) |
|
Definition
1. Renal Function (~50%)
2. Age
3. Distribution (body wt and fluid status)
4. Fever
5. Hematocrit
6. Gender |
|
|
Term
| T/F elimination of AMG is highly predictable based ClCr |
|
Definition
|
|
Term
| Aminoglycoside elimination __________ with increasing age. |
|
Definition
|
|
Term
| Serum concentrations of aminoglycosides are typically ______ to ______% lower in febrile patients |
|
Definition
|
|
Term
| What is the effect on half life of aminoglycosides in pregnant women? |
|
Definition
| decreased half life due to increased GFR, renal blood flow, CO, and total body water |
|
|
Term
| AMG's should not be used in pts greater than ______ y/o |
|
Definition
|
|
Term
| What is the effect of Aminoglycoside half life in burn patients? |
|
Definition
| decreased half life (eliminated more rapidly due to hypermetabolic state) |
|
|
Term
| What is the effect of AMG clearance in patients with Cystic Fibrosis? |
|
Definition
| an increased clearance is observed |
|
|
Term
| T/F: Elimination of AMG's is rapid in patients with Gynecologic infections |
|
Definition
|
|
Term
| Aminoglycosides should be used with extreme caution in patients with ________ or _________ due to the development of hepatorenal syndrome and subsequent death. |
|
Definition
|
|
Term
|
Definition
| aerobic and facultative gram negative bacteria and Staph aeurus |
|
|
Term
| Optimal peak to MIC ratio is _______ |
|
Definition
|
|
Term
| __________ is used in synergism with beta lactams for treatment of staph or enterococcus |
|
Definition
|
|
Term
| What AMG is used in combo with other drugs for the treatment of Tuberculosis? |
|
Definition
|
|
Term
| _________ bacteria are routinely resistant to AMGs |
|
Definition
|
|
Term
|
Definition
| inhibits protein synthesis by binding to ribosomal mRNA |
|
|
Term
| suppression of bacterial effect beyong the time of direct exposure to the antibiotic. |
|
Definition
|
|
Term
| peak to MIC ratio necessary for response |
|
Definition
|
|
Term
| two most common toxicities seen with AMG abx's |
|
Definition
| ototoxicity and nephrotoxicity |
|
|
Term
| Ototoxicity occurs in ______ to ______% of patients on AMGs |
|
Definition
|
|
Term
| Ototoxicity is associated with trough AMG leves > than ______mg/L |
|
Definition
|
|
Term
| Risk factors for ototoxicity |
|
Definition
| fever, bacteremia, concurrent use of ethacrynic acid, liver dysfunction, and the ratio of BUN to Scr as a measure of dehydration |
|
|
Term
| Tubular necrosis due to cell death of the proximal distal renal tubular cells |
|
Definition
|
|
Term
| Neuromuscular paralysis is assoc with the concurrect of |
|
Definition
1. Magnesium
2. curare like drugs
3. Botulism txin |
|
|
Term
| AMG once daily dosing, give ____ to ____mg/kg as a single daily dose in patients with Clcr >70ml/min |
|
Definition
|
|
Term
| Once daily dosing of AMG: if sample drawn 16-18 hours after dose is <2mg/L what should you do? |
|
Definition
| Continue with 24 hour dosing |
|
|
Term
| In once daily dosing, if AMG conc is above 2mg/L after the 16-18 hour sample, what should you do? |
|
Definition
| implement a 48-72 hour dosing interval |
|
|
