Drugs and AAFP

1. Drugs and AAFP

2. DYSLIPIDEMIA • Lots of patients are asking if they should stop taking niacin (Niaspan, etc) for dyslipidemia.    It's all due to the new study showing that adding niacin to a statin does NOT improve cardiovascular outcomes...and might increase strokes.    This is a surprise.    We're accustomed to adding niacin to a statin to raise HDL...and further lower LDL and triglycerides.    But this might not be helping as much as we thought.    Adding niacin doesn't seem to improve OUTCOMES...in patients with heart disease and an LDL already treated to 70 mg/dL.    Some experts say this study shows that LDL trumps HDL.    Others say this is further evidence of the possible benefit of statins' non-lipid-lowering effects.    But...and it's a big but...this doesn't tell us whether niacin is beneficial for the many patients who are NOT at their LDL goal.    Stick with the current guidelines and focus on lowering LDL.    Emphasize a healthy diet and regular physical activity.    Maximize statins first...they have the best evidence for reducing mortality and cardiac risk.    But don't use simvastatin 80 mg/day...myopathy risk is too high. If simvastatin (Zocor, etc) 40 mg isn't enough, go to atorvastatin (Lipitor) 40 mg or rosuvastatin (Crestor) 10 to 20 mg.    If patients can't reach their LDL goal on a statin alone, discuss the pros and cons of adding niacin, ezetimibe (Zetia), or a bile acid sequestrant.    Explain that combo therapy lowers LDL more. But the cons are the extra cost...potential adverse effects...and lack of good evidence that the combos improve outcomes.    Don't jump to conclusions about niacin and strokes. Niacin has been around a long time...and has never been linked to strokes.

3. DIABETES •   Some people are confusing the news about Avandia and Actos. Avandia products will all but disappear...due to cardiac concerns.    After November 18th, prescribers and patients will have to be enrolled in theAvandia-Rosiglitazone Medicines Access Program to prescribe or get rosiglitazone.    Patients will qualify only if they're already on rosiglitazone...or can't use other diabetes meds, including pioglitazone (Actos, etc).    Retail pharmacies will no longer carry rosiglitazone...patients will have to get it by mail from a specialty pharmacy.    Switch any patients still on rosiglitazone to another med. The Actos situation is different. Pioglitazone sales are being suspended in France and Germany...and scrutinized here...due to concerns about bladder cancer.    But it's premature to abandon pioglitazone.    Any risk is very small...possibly 3 extra cases of bladder cancer for every 10,000 patients per year on pioglitazone long-term.    For now, discuss this possible risk with patients...and don't use pioglitazone in patients who have or had bladder cancer.

4. ANTIDEPRESSANTS •   You'll see Viibryd (VI-brid) marketed as a new "dual-acting" serotonergic antidepressant. Viibryd (vilazodone) inhibits serotonin reuptake like SSRIs...plus it's also a partial serotonin agonist.    The company hoped Viibryd would be more effective than SSRIs.    But it's not. Viibryd doesn't work better than fluoxetine or citalopram...and it causes more GI side effects.    You might also hear that Viibryd has a low risk of sexual side effects...but it's too soon to tell if this is true. Viibryd comes in a starter kit to help minimize GI problems. If you start a patient on Viibryd, give 10 mg/day for 7 days...20 mg/day for 7 days...then 40 mg/day thereafter.    Don't exceed 20 mg/day if patients are taking a strong CYP3A4 inhibitor...ketoconazole, clarithromycin, ritonavir, etc.    Tell patients to take Viibryd with food for adequate absorption...and caution about possible nausea, diarrhea, insomnia, and dizziness. Viibryd will cost $150 per month. Continue to use an SSRI or SNRI first for depression.

5. Singular • Patients are hearing that Singulair is "as good as" inhaled corticosteroids or long-acting beta-agonists for asthma.   This comes from a new study that suggests leukotriene antagonists are "essentially equivalent" to using an inhaled steroid first...or to adding a long-acting beta-agonist second in adults.   Now some patients are hoping to replace a twice-daily inhaler with a once-daily pill. Plus, Singulair will be generic next year.   Help patients put the new info in perspective.   A leukotriene antagonist seems to work as well to improve quality of life after two MONTHS...but not necessarily after two YEARS.   Continue to start with an inhaled steroid for persistent asthma in MOST patients. These have the most evidence for improving outcomes.   Emphasize adherence. Advise patients that inhaled steroids need to be used regularly to prevent exacerbations.   If a low-dose inhaled steroid isn't enough, increase the steroid dose...or add a long-acting beta-agonist. In kids, also consider adding Singulair (montelukast)...it has anti-inflammatory effects and symptoms in kids are often due to inflammation.   Save leukotriene antagonists as monotherapy for patients who have trouble using or adhering to inhaled steroids

6. RESPIRATORY / ALLERGY •    You'll hear about Daliresp (DA-li-resp), a new oral tablet for severe COPD in patients with chronic bronchitis. Daliresp (roflumilast) is the first in a new class of oral phosphodiesterase 4 inhibitors. It works by reducing lung inflammation.    It's added to the usual bronchodilator therapy to decrease exacerbations...but only for severe, chronic COPD.    That's because the modest benefit may not outweigh its risks. Daliresp is linked to insomnia, weight loss, depression, and possibly suicide. There's also concern about a possible increased cancer risk...but tell patients this hasn't been proven. Daliresp 500 mcg/day costs about $200 per month.    Maximize bronchodilators before trying Daliresp.    Watch for interactions with CYP3A4 drugs. CYP3A4 inhibitors (erythromycin, etc) increase Daliresp levels and can increase adverse effects. Strong CYP3A4 inducers (phenytoin, etc) can decrease efficacy.    Caution patients about possible GI side effects...diarrhea, nausea, abdominal pain, etc...especially in the first few weeks.    Warn them to report serious mood or behavioral changes.

7. CLOSTRIDIUM DIFFICILE DIARRHEA •    Reps will promote that the new oral drug Dificid (fidaxomicin) for Clostridium difficile diarrhea is superior to oral vancomycin.    That's because Dificid works at least as well as vanco to control C. diff...but seems to have a lower risk of recurrence.    There's one less recurrence within one month for every 10 patients treated with Dificid instead of oral vancomycin.    But recurrence rates are similar if patients have the more virulent strain of C. diff. About one-third of cases in the U.S. are now caused by this BI/NAP1/027 strain. Dificid costs about $2800 for a standard 10-day course.    Vancomycin 125 mg QID for 10 days costs about $1300 for the capsules...and $60 or less if you give the injectable orally.    Continue to use oral metronidazole 500 mg TID for 10 to 14 days for mild to moderate infections...and oral vancomycin 125 mg QID for 10 to 14 days for severe infections.    Consider using Dificid 200 mg twice daily for 10 days to minimize recurrence risk...or if fewer doses will improve adherence.    Emphasize the importance of handwashing with soap and water. Explain that alcohol gels don't kill C. diff spores.

8. RESTLESS LEGS SYNDROME •   You'll hear reps talking about Horizant for restless legs syndrome.    It's an extended-release version of gabapentin enacarbil...which is converted to plain gabapentin in the body. This formulation increases and prolongs its absorption.    But there's no evidence it works better or is better tolerated. And it costs about $120 a month...compared to $6 to $95 for gabapentin.    Consider Rx meds for patients who need them for restless legs. Dopamine agonists (pramipexole, ropinirole) are often tried first for daily symptoms.    Tell patients to take them about 2 hours before bedtime...but caution about nausea, dizziness, sleepiness, and impulse control problems such as compulsive gambling or shopping.    Give half the dose earlier if symptoms worsen or occur earlier. Carbidopa/levodopa can help with intermittent symptoms. Have patients take one-half or one 25/100 mg tab before bedtime...or a 25/100 mg CR tab if the effects wear off before morning. Gabapentin can help patients who don't tolerate dopamine agonists...or whose symptoms include pain or unpleasant sensations.    Start with gabapentin 100 to 300 mg up to two hours before bedtime...titrating up to about 1800 mg/day if needed.    For doses over 600 mg/day, have patients take half the dose in the late afternoon and the rest up to 2 hours before bedtime. Horizant dosing is different...give 600 mg at 5 PM with food.    Keep in mind that Horizant and gabapentin dosing is not equivalent. Retitrate doses if you need to switch.

9. Positive-pressure ventilation is not necessary in the first _______ of cardiac arrest. A) 2 to 4 min B) 5 to 7 min C) 10 to 12 min D) 15 to 17 min

10. Answer •  C) 10 to 12 min

11. Which of the following drugs have been proven effective in the management of cardiac arrest? A) Vasopressors B) Antiarrhythmics C) Amiodarone D) None of the above

12. Answer •  D) None of the above

13. The "4 Cs" of modern management of cardiac arrest include which of the following?Cardiac compressionsCardioversionCoolingCardiac catheterizationCalcium A) 1,2,3,4 B) 1,2,4,5 C) 1,3,4,5 D) 1,2,3,5

14. Answer • Cardiac compressions • Cardioversion • Cooling • Cardiac catheterization

15. Most cases of unstable bradycardia are not related to acute myocardial infarction. A) True B) False

16. Answer •  A) True

17. Electrocardiographic findings of hyperkalemia include which of the following? A) Peaked T wave B) Widening of QRS complex C) Flattening and eventual loss of P wave D) All the above

18. Answer • D) All the above

19. Which of the following statements about adenosine is correct? A) All patients with supraventricular tachycardia (SVT) respond to adenosine B) Less than 50% of patients with VT respond to adenosine C) Most patients with adenosine-sensitive VT do not have underlying cardiac disease D) Adenosine is reliable for distinguishing VT from SVT

20. Answer • C) Most patients with adenosine-sensitive VT do not have underlying cardiac disease

21. Accelerated idioventricular rhythm does not generally require treatment. A) True B) False

22. Answer •  A) True

23.  All the following statements about amiodarone are true,except: A) Effective for premature ventricular contractions B) Contraindicated in pregnancy C) Shortens QT interval D) Efficacy for treatment of stable VT approximately equal to that of lidocaine

24. Answer • C) Shortens QT interval

25. Which of the following has been shown to be more sensitive than common sense in predicting which patients with syncope will have serious adverse outcomes? A) Boston Syncope Criteria B) Short-Term Prognosis of Syncope (StePS) study C) San Francisco Syncope Rule D) None of the above

26. Answer •  D) None of the above

27. Patients who have taken clopidogrel within _______ of coronary bypass surgery are at risk for increased bleeding complications, increased need for packed cell transfusions, and increased perioperative mortality. A) 2 wk B) 5 days C) 8 days D) 10 days

28. Answer • B) 5 days

29. MANAGEMENT OF ACUTE ASTHMA EXACERBATIONSWhich one of the following is a characteristic of a mild asthma exacerbation?  (check one) A. Dyspnea at rest.  B. Perspiration.  C. Peak expiratory flow of less than 40 percent of personal best.  D. Dyspnea only with activity. 

30. Answer •  D. Dyspnea only with activity.

31. Which one of the following home-based treatments has been shown to produce modest benefits in children with frequent acute asthma exacerbations?  (check one) A. A short course of oral prednisolone at the onset of worsening symptoms.  B. Increased dosage of a long-acting beta2 agonist.  C. Increased dosage of inhaled corticosteroids.  D. Continuous beta2 agonist treatment. 

32. Answer • A. A short course of oral prednisolone at the onset of worsening symptoms.

33. Which of the following are considered risk factors for repeat emergency department visits for acute asthma symptoms in children?  (check all that apply) A. Age older than 10 years.  B. Age younger than two years.  C. Public health insurance.  D. Hispanic ethnicity. 

34. Answer •  B. Age younger than two years.  C. Public health insurance.  D. Hispanic ethnicity. 

35. Clinical giudlines • Inhaled short-acting beta2 agonists are the cornerstones of treatment for acute asthma. • C • An inhaler with a spacer is equivalent to nebulized short-acting beta2 agonist therapy in children and adults. • A • Continuous beta2 agonist administration reduces hospital admissions in patients with severe acute asthma. • A • Inhaled anticholinergic medication improves lung function and decreases hospitalization in school-age children with severe asthma exacerbations. • A • When multiple doses are used in combination with short-acting beta2agonists • Intravenous magnesium sulfate increases lung function and decreases hospitalizations in children with an acute asthma exacerbation. • A • The administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization. • A • Largest effect noted in patients with severe asthma • Oral and parenteral corticosteroids are equally effective in preventing hospital admission in children. • B

36. Diagnosis • Asthma exacerbations can be classified as mild, moderate, severe, or life threatening • Criteria for severity are based on symptoms and physical examination parameters, as well as lung function and oxygen saturation. • Although no single parameter has been identified to assess exacerbation severity, lung function is a useful method of assessment, with a PEF of 40 percent or less of predicted function indicating a severe attack in patients five years or older. • The most useful signs for determining the severity of an asthma exacerbation in children younger than five years, or any child unable to perform a PEF, include the use of accessory muscles of respiration, chest wall retractions, tachypnea greater than 60 breaths per minute, cyanosis, and the presence of inspiratory and expiratory wheezing. • For all patients, pulse oximetry on room air is a useful initial assessment. An oxygen saturation of less than 92 to 94 percent one hour after beginning standard treatment is a strong predictor of the need for hospitalization

37. Management • HOME TREATMENT • Early treatment is the most effective strategy for managing asthma exacerbations. • It is essential to teach patients how to monitor signs and symptoms, and take appropriate action. • Patients who have a written asthma action plan and appropriate medication can often manage mild exacerbations at home. • Key components of an asthma action plan that have reduced emergency department visits and hospitalization include standard written instructions; criteria based on symptoms or PEF (compared with personal best) to trigger action; two to three action points; and individualized, written instructions on the use of inhaled or oral corticosteroids.  • Patients at risk of asthma-related death may need more intensive treatment in a monitored setting at the first sign of an exacerbation. These patients should have an asthma action plan that emphasizes early communication with their physician.

38. Magnessium • The addition of intravenous magnesium sulfate to standard therapy has been studied in adults and children with divergent results. In adults with severe exacerbations of asthma (PEF of 25 to 30 percent or less of predicted function), intravenous magnesium sulfate therapy resulted in slightly better lung function but no change in rates of hospitalization. • In children one to 18 years of age, intravenous magnesium sulfate (25 to 100 mg per kg) has been demonstrated to significantly increase lung function and to decrease hospitalizations. • Nebulized magnesium sulfate has a weak effect on respiratory function and hospital admission rates in adults, and no effect on either outcome in children

39. Steroids • The administration of systemic corticosteroids (500 mg hydrocortisone sodium succinate injection [Solu-Cortef] or 125 mg methylprednisolone sodium succinate injection [Solu-Medrol] in adults, or 1 to 2 mg per kg of prednisone or prednisolone in children one to 18 years of age) within one hour of emergency department presentation decreases the need for hospitalization.In a Cochrane review, the most pronounced effect occurred in patients with severe exacerbations. • Oral and parenteral corticosteroids are equally effective in preventing hospital admission in children, but only parenteral corticosteroids have been studied in adults. • There is insufficient evidence to recommend the use of inhaled corticosteroids in place of or in conjunction with systemic corticosteroids at the time of discharge from the emergency department. Inhaled corticosteroids do not prevent relapse of symptoms requiring admission or improve quality of life or symptom scores

40. POSTDISCHARGE CARE • Patients sent home from the emergency department with systemic corticosteroids (a five- to 10-day nontapering course of 50- to 100-mg prednisone per day in adults) have decreased relapse of asthma symptoms, future hospitalizations, and use of short-acting beta2 agonists. Although seven to 10 days is the usual treatment duration for oral corticosteroids, three days of therapy (1 mg per kg of prednisone) has been shown to be as effective as five days for the complete resolution of symptoms within one week in children two to 15 years of age. • There are insufficient data to recommend the initiation of montelukast in place of oral corticosteroids or the use of inhaled corticosteroids in combination with oral corticosteroids at the time of discharge to prevent a relapse of asthma symptoms.

41. DIAGNOSIS AND TREATMENT OF LICHEN PLANUSWhich one of the following statements about the treatment of oral lichen planus is correct?   (check one) A. Complete resolution is difficult to achieve.  B. Systemic corticosteroids are first-line treatments.  C. Carbon-dioxide laser evaporation is ineffective.  D. Adrenal suppression is a common complication of topical steroid use. 

42. Answer • A. Complete resolution is difficult to achieve.

43. A patient presents with hypertrophic pruritic lichen planus on the ankles. Which one of the following is the most appropriate treatment?  (check one) A. Intralesional triamcinolone (Kenalog).  B. Acitretin (Soriatane).  C. Topical lidocaine (Xylocaine).  D. Topical pimecrolimus (Elidel). 

44. Answer •  A. Intralesional triamcinolone (Kenalog). 

45. Which of the following are appropriate topical treatments for genital lichen planus?   (check all that apply) A. Triamcinolone (Triderm).  B. Tacrolimus (Protopic).  C. Clobetasol (Temovate).  D. Aloe vera gel. 

46. Lichen planus • Lichen planus is a chronic, inflammatory, autoimmune disease that affects the skin, oral mucosa, genital mucosa, scalp, and nails. • Lichen planus lesions are described using the six P's (planar [flat-topped], purple, polygonal, pruritic, papules, plaques). • Onset is usually acute, affecting the flexor surfaces of the wrists, forearms, and legs. • The lesions are often covered by lacy, reticular, white lines known as Wickham striae. • Classic cases of lichen planus may be diagnosed clinically, but a 4-mm punch biopsy is often helpful and is required for more atypical cases. • High-potency topical corticosteroids are first-line therapy for all forms of lichen planus, including cutaneous, genital, and mucosal erosive lesions. • In addition to clobetasol, topical tacrolimus appears to be an effective treatment for vulvovaginal lichen planus. • Topical corticosteroids are also first-line therapy for mucosal erosive lichen planus. • Systemic corticosteroids should be considered for severe, widespread lichen planus involving oral, cutaneous, or genital sites. • Referral to a dermatologist for systemic therapy with acitretin (an expensive and toxic oral retinoid) or an oral immunosuppressant should be considered for patients with severe lichen planus that does not respond to topical treatment. • Lichen planus may resolve spontaneously within one to two years, although recurrences are common. • However, lichen planus on mucous membranes may be more persistent and resistant to treatment.

47. Clinical Recomendations • High-potency topical corticosteroids should be first-line treatments for all forms of lichen planus. • B • Topical calcineurin inhibitors, such as tacrolimus (Protopic) and pimecrolimus (Elidel), should be used as second-line therapies to treat genital and oral lichen planus. • B • Intralesional triamcinolone acetonide (Kenalog), 5 to 10 mg per mL injection, should be used to treat hypertrophic lichen planus. • B • Three to six weeks of oral prednisone therapy should be used to treat severe, widespread lichen planus (tapered course, 30 to 60 mg per day starting dose). • B

49. Answer •  A. Triamcinolone (Triderm).  B. Tacrolimus (Protopic).  C. Clobetasol (Temovate).  D. Aloe vera gel.