Psychiatry, Infections, drugs

1. Psychiatry, Infections, drugs

2. Which of the following is TRUE about the oral anticoagulants used to prevent stroke due to atrial fibrillation? A.Pradaxa (dabigatran) 150 mg BID prevents more strokes than warfarin. B.Xarelto (rivaroxaban) 20 mg once a day works about as well as warfarin. C.Both Pradaxa and Xarelto cause fewer intracranial bleeds than warfarin...but more GI bleeds. D.All of the above

3. Answer • D.All of the above

4. Which of the following is TRUE about treating ADHD? A.Methylphenidate is appropriate for some children as young as 4 years old. B.Methylphenidate 1 mg is equivalent to 2 mg of amphetamine salts. C.Stimulants significantly increase cardiovascular risk in otherwise healthy kids. D.Stimulants are metabolized faster in preschoolers than older children.

5. Answer • A.Methylphenidate is appropriate for some children as young as 4 years old.

6. New guidelines and drug shortages will raise new questions about treating ADHD in children.    The new guidelines now recommend treating kids as young as 4...IF they have severe symptoms that impair function AND behavioral therapy isn't enough. Until now the cutoff was 6-year-olds.    If you need to treat a 4- or 5-year-old, use low-dose methylphenidate. Stimulants are metabolized slower at this age.    Reassure parents any increased cardiovascular risk from stimulants is likely very small...if it exists at all...in otherwise healthy kids. Continue to monitor BP and pulse. Avoid stimulants in children with serious heart problems, such as arrhythmias, cardiomyopathy, etc. The Adderall (amphetamine salts) and methylphenidate shortages are causing lots of problems.    These will continue at least through the rest of 2011. Two culprits...manufacturing problems...plus delays caused by cumbersome regulations that limit quantities of controlled substance raw materials.    If needed switch patients to an available med. A rule of thumb: Use about 1 mg methylphenidate for 0.5 mg of amphetamine salts, dextroamphetamine, or dexmethylphenidate (Focalin)...but responses vary. To switch from Adderall to dextroamphetamine or methylphenidate, start with the same total daily dose and titrate as needed. To switch from methylphenidate to Adderall, cut the daily dose in half and monitor for response and side effects. To switch to a different oral methylphenidate product, use the same daily dose...divided appropriately. An exception is Concerta...use 18 mg/day of Concertafor 15 mg/day of methylphenidate.    When in doubt, start with the new product's starting dose.    To HEAR our experts enlighten you on the controversy of when to treat ADHD in kids, see our PL Detail-Document and listen to PL Voices.    You can also get our PL Chart, Comparison of Drugs for ADHD, for treatment options, dosing, duration, and cost.

7. You'll hear that vitamin E INCREASES the risk of prostate cancer.   This is a surprise...but based on reliable evidence.   Vitamin E was often recommended to PREVENT prostate cancer...based on several older studies.   The latest big randomized trial suggests the opposite. It shows one more case of prostate cancer for every 625 men taking 400 units per day of vitamin E for one year.   There are also cardiovascular concerns. Vitamin E may increase the risk of hemorrhagic strokes...and taking 400 units/day may increase the risk of heart failure in patients with diabetes or heart disease.   Vitamin E proponents will point out that the new findings are for SYNTHETIC vitamin E. They're right. Keep in mind this is the form most users get.   And there's no solid proof that NATURAL vitamin E is safer or more effective than the synthetic versions.   Discourage using vitamin E to prevent cancer or heart disease.   Don't go out of your way to discourage using regular multivits... as long as they do not contain large amounts of synthetic vitamin E

8. TESTOSTERONEIf you prescribe AndroGel or Androderm (testosterone), you'll likely get a call about the strength. AndroGel now comes in a higher concentration so patients can use less gel. Using 2 pumps of the new AndroGel 1.62% is similar to using 4 pumps ofAndroGel 1%.    The new strength will be priced a little LOWER to entice patients to switch. But they both still cost over $300 a month...and a generic is 2 or more years away.    If you write for AndroGel, be sure to specify 1% or 1.62%.    Tell men to apply the new AndroGel 1.62% only to their upper arms and shoulders for better absorption...instead of to their abdomen, too, like AndroGel1%.    Also tell them to avoid bathing for 2 hours after applyingAndroGel 1.62%...or 5 hours for AndroGel 1% due to the larger amount. Androderm now comes in smaller, lower-strength patches...the original patches will be discontinued at the end of this year.    Use the new 2 mg patch instead of the older 2.5 mg patch...and the new 4 mg patch instead of the 5 mg patch. Check serum testosterone 2 weeks after the switch to make sure the new dose is appropriate.    Get our latest PL Chart, Comparison of Testosterone Products, with all dosage forms including injectable, buccal, and others.

9. Which of the following is TRUE about vaccinations for pregnant women? A.Tdap can now be given to pregnant women after 20 weeks gestation. B.Two doses of Tdap should be given during pregnancy. C.Flu vaccine with thimerosal is proven to be harmful during pregnancy. D.FluMist is appropriate for pregnant women.

10. Answer • A.Tdap can now be given to pregnant women after 20 weeks gestation

11. You'll see a new emphasis on giving Tdap and flu vaccines to pregnant women...to protect moms AND their newborns. Tdap (Adacel, Boostrix) used to be given to the mom right AFTER delivery if needed. But that leaves newborns unprotected until they start getting pertussis vaccinations at 2 months.    Vaccinate pregnant women after 20 weeks gestation if they haven't previously gotten Tdap and only need a booster.    When a pregnant woman's vaccine history is unknown or incomplete, give a 3-shot series: one dose right away...another at 4 weeks...and the last at 6 to 12 months. Use Tdap for the first vaccine after 20 weeks gestation...and Td for the other two injections. Injectable influenza vaccine (Fluzone, etc) can be given during ANY trimester. Don't use FluMist...it's not recommended during pregnancy because it's a live vaccine.    Some states require using a thimerosal-free vaccine for pregnant women and children...even though there's no proof thimerosal is harmful.    If you need to avoid thimerosal, use one of the prefilled syringes...EXCEPTFluvirin which has trace amounts of thimerosal.    Consider reporting immunizations to your state's Immunization Information System...even if it's not required. Providers are being encouraged to use these vaccine registries...and using them counts as one of the "meaningful use" criteria for electronic health records

12. GERIATRICS   Most current electronic systems don't alert you about too many anticholinergics in an elderly patient...but they should.    Even a single anticholinergic med can increase the risk of cognitive impairment by up to 50%...even more in patients who've had a stroke or have a family history of dementia.    Anticholinergics are also linked to higher hospitalization rates.    Think about each patient's anticholinergic burden...and whether meds can be stopped, switched, or given in a lower dose. Antihistamines. Avoid first-generation antihistamines (diphenhydramine, etc)...including "PM" OTCs, such as Tylenol PM.    Instead, use a second-generation antihistamine (loratadine, etc) or nasal steroid for allergies...or low-dose trazodone for insomnia. Antidepressants. Try to avoid tricyclics (amitriptyline, etc) or paroxetine. Instead, use one of the other SSRIs (sertraline, etc) for depression...and consider using gabapentin for neuropathic pain. Overactive bladder agents. Their minimal benefits usually don't outweigh their significant anticholinergic effects. And there's no proof the newer ones have less effect on cognition.    Try to avoid bladder control drugs in patients who already have poor cognition...or those whose quality of life isn't likely to benefit.    Keep in mind that these anticholinergics are sometimes added for incontinence that's caused or exacerbated by a cholinesterase inhibitor (Aricept, etc). A great example of using one drug to treat the effects of another. Re-evaluate whether either one is really needed. 

13. The new generic olanzapine (Zyprexa) means you'll see even more patients on atypical antipsychotics.    In some situations this is appropriate...in others it's not. About 60% of atypical usage is off-label.    Evidence of effectiveness varies by drug and indication: Insomnia. Low doses of quetiapine (Seroquel, etc) and others are often used because they can be sedating. But there's no evidence they're effective for insomnia and they have serious side effects.    Try zolpidem, trazodone, and others first. Generalized anxiety disorder. Consider trying quetiapine if patients don't respond to an SSRI (sertraline, etc) or SNRI (venlafaxine, etc). There's no evidence that any of the other atypicals are effective for anxiety. Depression. Olanzapine, Abilify (aripiprazole), and Seroquel XR are approved to use with an antidepressant for depression...and there's good evidence for risperidone.    But they have only a modest benefit and serious side effects. Try an adequate trial of antidepressants first. Dementia. Antipsychotics increase strokes and mortality in elderly dementia patients. Save them for patients who are a risk to themselves and others due to aggression, hallucinations, or delusions.    Consider using one-quarter to one-half the usual starting dose of risperidone, olanzapine, or Abilify...they have the most evidence. Use quetiapine for patients with Lewy body dementia or Parkinson's.    Monitor blood glucose and lipids at baseline, 12 weeks, and then periodically for patients on an atypical. Also check weight every month for 3 months, then every 3 months. Keep in mind that olanzapine is one of the worst offenders for causing metabolic problems

14. Dosing and drug interactions with colchicine (Colcrys) for acute gout are still causing confusion.    We're all used to the old way of dosing colchicine for acute gout...two tabs initially then one tab every hour until either diarrhea starts or the pain stops.    But this causes too much toxicity...and even some deaths.    When FDA approved Colcrys, they also approved safer dosing.    The new dosing for a gout flare is to give two 0.6 mg tablets followed by just ONE tab one hour later.    Give even lower and less frequent doses if colchicine is used with other drugs that inhibit its metabolism.    For example, give just one tab per attack with cyclosporine...one tab followed by a half tab with strong 3A4 inhibitors (clarithromycin, etc)...and two tabs with moderate 3A4 inhibitors (verapamil, etc). Tell patients not to repeat these colchicine doses for at least 3 days.    For severe renal or hepatic impairment, give a 3-tablet course...and wait at least 2 weeks before repeating the course.    Don't give colchicine plus cyclosporine or a strong 3A4 inhibitor to a patient with renal or hepatic impairment. This can be fatal.    Continue to use NSAIDs or corticosteroids first-line for acute gout. They're usually better tolerated and cost less...at least until generic colchicine is available again

15. Reps will promote using Byetta WITH Lantus for type 2 diabetes.    Adding Byetta (exenatide) to Lantus (insulin glargine) lowers A1C by 1.7%...compared to 1% for Lantus alone.    Think of it as an alternative to adding a short-acting prandial insulin (Humalog, etc)...when a basal insulin isn't enough. Byetta doesn't increase hypoglycemia risk...and it can help reduce the weight gain associated with insulin.    In fact, patients on the combo for 30 weeks LOSE about 4 pounds...compared to GAINING 2 pounds with just Lantus.    But about one in 12 patients will stop Byetta due to nausea, vomiting, diarrhea, or other side effects.    And Byetta costs about $340/month...compared to up to $190/month for prandial insulin plus extra for glucose monitoring.    Add either Byetta or a prandial insulin when basal insulin and oral meds aren't enough for type 2 diabetes.    Lean towards Byetta to reduce weight gain or hypoglycemia.    When starting Byetta, consider lowering the basal insulin dose by 20% if the patient's A1C is 8 or less. Keep in mind that Byetta isn't appropriate for patients already using prandial insulin

16. Which of the following is TRUE about treating UTIs in the elderly? A.Nitrofurantoin is a good option for uncomplicated UTIs if renal function is okay. B.TMP/SMX can cause hyperkalemia when combined with an ACE inhibitor or ARB. C.Quinolones are preferred for complicated UTIs. D.All of the above

17. Answer • D.All of the above

18.  URINARY TRACT INFECTIONSWhich antibiotics should you use for urinary tract infections in elderly patients?    It depends on whether it's a complicated UTI or not.    We know all UTIs in older MEN are considered complicated due to possible prostate involvement. UTIs in women can also be complicated due to a catheter, obstruction, immunosuppression, etc.    Antibiotic selection also depends on kidney function, side effects, and possible drug interactions. TMP/SMX is first-line for uncomplicated infections...if local resistance is <20%.    Use TMP/SMX DS twice daily for 3 days...and half the dose if kidney function is impaired (CrCl 15 to 30 mL/min).    Watch for possible hyperkalemia if TMP/SMX is combined with an ACEI, ARB, or potassium...or increased INR with warfarin. Nitrofurantoin 100 mg BID for 5 days is a good option for uncomplicated UTIs...IF renal function is okay. Avoid nitrofurantoin in women with a CrCl <60 mL/min...or for a complicated UTI. Quinolones are the best choice for complicated UTIs and kidney infections...or if patients can't take TMP/SMX or nitrofurantoin. Avoid moxifloxacin or gemifloxacin...they don't get into the urine.    Avoid quinolones if local resistance is over 10%...and adjust the dose for impaired renal function.    Keep in mind possible adverse CNS effects...tendon rupture...hyper- or hypoglycemia...or increased INR in warfarin patients. Beta-lactams (amoxicillin, etc) are usually less effective for UTIs. Use them only if other antibiotics aren't an option.    Give antibiotics for 3 to 5 days for uncomplicated UTIs... 7 to 14 days for complicated UTIs...and 6 to 12 weeks for men with prostate involvement.    Don't screen for or treat asymptomatic bacteriuria in most cases. There's no benefit...and it increases resistance

19. Which of the following is TRUE about using NSAIDs in patients with uncomplicated hypertension? A.Even occasional use of NSAIDs should be avoided. B.Combining an NSAID with an ACE inhibitor or ARB can worsen BP and renal function. C.Some NSAIDs are more likely to increase BP than others. D.Naproxen is the most likely to increase cardiovascular risk.

20. Answer • B.Combining an NSAID with an ACE inhibitor or ARB can worsen BP and renal function.

21. NSAIDSIs it okay for patients with uncomplicated hypertension to take NSAIDs...ibuprofen, celecoxib, etc?    Many can...but you need to be careful.    On average, NSAIDs increase BP by around 5 mmHg in patients with hypertension...but some patients are more susceptible than others.    Elevations are more likely in the elderly...obese men...and patients with diabetes, heart failure, or kidney or liver disease.    Tell patients with uncomplicated hypertension that occasional use of NSAIDs is usually okay...but daily use for just one week can reduce BP control.    Monitor BP if a hypertensive patient starts a chronic NSAID. Explain that NSAIDs can also make BP meds less effective.    Be careful about combining an NSAID with an ACE inhibitor or ARB...the combo can worsen BP and renal function.    And watch for the "triple whammy"...an NSAID plus an ACEI or ARB plus a diuretic. This combo can push a patient into acute renal failure.    Consider using a calcium channel blocker if a patient needs an antihypertensive that is less affected by NSAIDs.    Don't expect one NSAID to increase BP more or less than the others.    Suggest naproxen if a chronic NSAID is needed for a patient with cardiovascular disease...not just hypertension. Naproxen seems to be the least likely to increase cardiovascular risk

22. Which of the following is TRUE about the new generic atorvastatin (Lipitor)? A.It lowers LDL more than simvastatin. B.It has fewer interactions than simvastatin. C.Atorvastatin 80 mg lowers LDL about as much as Crestor 20 mg. D.All of the above

23. Answer • D.All of the above

24. Atorvastatin will unseat simvastatin as the most popular generic statin...especially with simvastatin's new dosing restrictions.      Simvastatin now needs to be limited to 40 mg/day due to the increased risk of myopathy with higher doses.      Use an even lower simvastatin dose if you give it with amlodipine, diltiazem, verapamil, amiodarone, or ranolazine. And try not to use it at all with gemfibrozil or strong 3A4 inhibitors (clarithromycin, etc).     Consider switching to atorvastatin as your statin of choice... it lowers LDL more than simvastatin and has fewer interactions.     Atorvastatin can even replace Crestor (rosuvastatin) in many cases. Atorvastatin 80 mg and Crestor 20 mg both lower LDL about 55%.     When switching, use atorvastatin 20 mg for simvastatin 40 mg or Crestor 5 mg.      You may hear reps talking up Livalo's(pitavastatin)lack of drug interactions. There's some truth to this. But when interactions are a concern, use Crestor or pravastatin. They have a longer track record...and Crestor lowers LDL more thanLivalo.     Keep in mind that LDL-lowering is just treating a lab number. It's patient OUTCOMES that matter. For secondary prevention, statins prevent one death for every 48 patients treated for 3 to 5 years. For primary prevention, statins prevent one nonfatal CV event for every 60 patients treated for 4 years.     The price of generic atorvastatin won't drop much until more generics come out in 6 months. But tell Lipitor patients who pay a co-pay for Rxs that they'll likely pay less by getting the GENERIC.      Until the generic price drops, suggest that patients who pay more than $50/month keep using their Lipitor co-pay card...the program runs through 2012.      To get the scoop on how atorvastatin really stacks up to Crestor and fact vs fiction on simvastatin interactions, see our PL Detail-Document and click to listen to PL Voices. You'll hear an interesting audio snippet of our experts' lively discussion. 

25. Which of the following is TRUE about using bisphosphonates for osteoporosis? A.Bisphosphonates can be stopped after 3 to 5 years for most patients. B.Bisphosphonates should be continued in patients at high risk for fractures. C.Bisphosphonates only stay in the bone for a few days. D.Both A and B

26. Answer • D.Both A and B

27. You'll hear more controversy about how long patients should take bisphosphonates (Fosamax, etc) for osteoporosis.     Many patients get put on a bisphosphonate to prevent fractures and are left on it indefinitely. But long-term use may be associated with problems...jaw osteonecrosis and atypical femur fractures.     Keep in mind that bisphosphonates persist in the bone for years and may continue to prevent fractures even after they're stopped.      For example, women who stop alendronate after 5 years have a similar risk of nonvertebral fractures as those who continue it for 10 years.      And stopping zoledronic acid (Reclast) after 3 years prevents fractures almost as well as taking it for 6 years.     Consider stopping the bisphosphonate after 3 to 5 years for most patients. But continue it or switch to another osteoporosis med for patients at high fracture risk, such as those with a recent fracture... on chronic corticosteroids...or if bone density continues to drop.      Consider checking bone density or bone turnover markers 2 to 3 years after stopping a bisphosphonate. If these indicate bone loss, restart the bisphosphonate...or start raloxifene, calcitonin, Forteo, orProlia.     Continue to encourage patients to get about 1200 mg/day of elementalcalcium...and 800 to 2000 units/day of vitamin D.

28. Which of the following is TRUE about using tadalafil (Cialis) for benign prostatic hyperplasia (BPH)? A.It improves urine flow. B.It works better than an alpha-blocker (tamsulosin, etc) for BPH. C.It may be appropriate for men with erectile dysfunction and mild BPH symptoms. D.It should never be combined with an alpha-blocker.

29. Answer • C.It may be appropriate for men with erectile dysfunction and mild BPH symptoms.

30.  Reps will promote daily Cialis (tadalafil) for benign prostatic hyperplasia (BPH)...not just erectile dysfunction.Cialis and other phosphodiesterase-5 inhibitors seem to enhance smooth muscle relaxation in the prostate, bladder, and urethra.     But don't expect a large improvement in BPH symptoms.Cialis modestly improves urinary frequency, urgency, and straining...but not urine flow rate. And you have to treat 6 men for one to benefit.     Continue to start with alpha-blockers (tamsulosin, etc) for BPH...they're likely to be more effective and they cost less.     Consider using daily Cialis for men with both erectile dysfunction and mild BPH symptoms.      Or consider adding daily Cialis if a man with both erectile dysfunction and BPH isn't getting adequate relief from an alpha-blocker. The combo might work better than either drug alone for BPH.     When adding Cialis to an alpha-blocker, start with just 2.5 mg a day to reduce hypotension...and titrate to 5 mg.Cialis 5 mg/day costs about $150 a month. Expect insurers to require a prior authorization to verify that it's for BPH.

31.  MEN'S HEALTHSaw palmetto will fall out of favor for treating BPH symptoms.     You'll still hear staunch believers claim it works and cite lots of older studies...but it's not standing up to close scrutiny.     Two NIH-sponsored trials now suggest that saw palmetto is NOT better than placebo for BPH symptoms...even at high doses.     In fact, our Natural Medicines Comprehensive Database is downgrading its rating of saw palmetto to "Possibly INeffective."     Evaluating supplements is tricky...results apply mainly to the specific formulation tested. Amazingly, the recent NIH study used a saw palmetto product that is NOT available in the U.S.      Tell men not to rely on saw palmetto for BPH. Explain that benefits are modest at best. But don't be overly concerned if they want to try it...there's no evidence of serious adverse effects.      Listen to our audio clip, PL Voices, to hear our experts explain why there's been a shift in thinking about saw palmetto... and tips on how to pick high-quality supplements in general.

32.  DIABETESYou'll hear claims that gliptins (Januvia, etc) decrease cardiovascular risk in diabetes patients.     This is based on a new meta-analysis that suggests gliptins don't increase cardiovascular risk...and MIGHT even decrease it.     Don't buy it. It hasn't been peer-reviewed and published.      So far, NONE of the diabetes meds are proven to lower CV risk.     Metformin seems to have the most favorable cardiovascular profile...but there's not enough evidence to say it's cardioprotective.      Pioglitazone (Actos, etc) and rosiglitazone (Avandia) increase heart failure risk...rosiglitazone likely increases MI risk.     Gliptins lower A1C by about 0.7% and cost about $8/tab. Save them as a second- or third-line option for patients close to their A1C goal. Juvisync (sitagliptin/simvastatin) will be the first gliptin and statin combo...and will cost the same as Januvia alone.      Consider Juvisync for patients on Januvia who also need a statin...and for whom simvastatin is an appropriate choice.

33. Which of the following is TRUE about adding a GI protectant to an NSAID? A.Famotidine 80 mg/day can help prevent NSAID-induced ulcers. B.PPIs are more effective than H2-blockers for preventing NSAID-induced ulcers and bleeding. C.Misoprostol is an alternative to using a PPI. D.All of the above

34. Answer • D.All of the above

35. You'll hear reps claim the new Duexis is safer than plain NSAIDs.      But it's usually not the best choice.Duexis is a combo of ibuprofen 800 mg and famotidine 26.6 mg for TID dosing. This provides about 80 mg/day of famotidine...the dose that has been shown to reduce NSAID-induced ulcers.      One ulcer is prevented for every 10 patients taking Duexis compared to ibuprofen alone...but it's not proven to prevent GI bleeds.      PPIs are more effective than H2-blockers for preventing NSAID-induced ulcers...AND they're proven to prevent GI bleeds.     But PPIs aren't benign. Chronic PPIs are associated with a higher risk of pneumonia, C. diff diarrhea, hypomagnesemia, and fractures.     Choose a strategy for NSAID users based on their risks.Use a PPI or misoprostol for those at moderate GI risk due to one or two risk factors...age over 65, high-dose NSAIDs, prior uncomplicated ulcer, or use of aspirin or another antiplatelet drug. Vimovo (naproxen/esomeprazole) is the only NSAID/PPI combo... but it costs more than giving a generic NSAID and PPI separately.Consider using an H2-blocker for patients at moderate GI risk who can't take a PPI or misoprostol.      Give famotidine 40 mg BID plus a generic NSAID instead of Duexis. Duexiscontains more ibuprofen than most patients need...and it costs about $150 per month.Consider using celecoxib alone instead of a traditional NSAID plus GI protectant for patients at moderate GI risk...and low CV risk.Use naproxen if an NSAID is needed for patients at high CV risk... and add a GI protectant for those at moderate GI risk.Use celecoxib plus a PPI or misoprostol for patients at high GI risk due to 3 or more risk factors...concomitant warfarin or corticosteroids...or a prior complicated ulcer. This combo has the safest GI profile...but avoid NSAIDs altogether if possible.

36.  NEUROPATHIC PAIN     You'll soon see Gralise (gra-LEEZ), a new extended-release gabapentin for postherpetic neuralgia (PHN).Gralise is the second ONCE-daily gabapentin...after the approval of Horizant for restless legs syndrome earlier this year.Gralise tabs are similar to Glumetza (metformin ER). These swell to stay in the stomach longer and gradually release the drug.     Continue to use a tricyclic first-line for post-shingles pain.     If tricyclics aren't enough or aren't tolerated, go to gabapentin, pregabalin (Lyrica), duloxetine (Cymbalta), opioids, a lidocaine patch, or capsaicin. Combining a tricyclic and gabapentin can work better than either one alone.      Gabapentin and pregabalin are only modestly effective for postherpetic neuralgia. Choose one based on cost or convenience.Gralise costs about $180/month...compared to $240 for Lyrica and $40 for gabapentin immediate-release capsules.      But keep in mind that Gralise is given once a day...compared to 2 to 3 times a day for Lyrica or 3 times a day for regular gabapentin.      If you start a patient on Gralise, prescribe the 30-day starter pack to slowly titrate the patient from 300 mg to 1800 mg/day. Tell patients to take Gralise in the evening with dinner.

37. Which of the following is TRUE about drugs to avoid in patients with glaucoma? A.Anticholinergic drugs can worsen glaucoma by constricting the pupil. B.Anticholinergics are only a problem for patients with narrow-angle glaucoma. C.Corticosteroids can worsen narrow-angle glaucoma. D.It's not necessary to monitor intraocular pressure in patients using ophthalmic steroids long-term.

38. Answer • B.Anticholinergics are only a problem for patients with narrow-angle glaucoma.

39. OPHTHALMOLOGYGlaucoma patients often ask which drugs to avoid...and if they don't ask, they should.      Many drugs have warnings not to use them in glaucoma patients.      But these warnings are usually for patients with NARROW-angle glaucoma...which is much less common than OPEN-angle glaucoma.     Anticholinergic drugs can dilate the pupil and worsen the obstruction in patients with narrow-angle glaucoma...increasing the risk of acute angle closure.     Try to avoid anticholinergics or use the lowest effective dose. This includes many antihistamines, tricyclics, antipsychotics, antispasmodics, overactive bladder drugs, etc.      Also warn patients to get immediate treatment if they develop eye pain plus redness, blurred vision, halos around lights, etc.      Reassure patients with OPEN-angle glaucoma that anticholinergic drugs will not make it worse.     Corticosteroids are another story...these can increase intraocular pressure and cause or worsen open-angle glaucoma.      Check intraocular pressure when ophthalmic steroids are used for 10 days or longer, especially in high-risk patients.

40. EDEMA     Questions come up about how to handle drug-induced edema.     Peripheral edema often prompts clinicians to jump straight to a workup for thromboembolism or heart, renal, or hepatic failure.      But first look for meds that can cause it.Dihydropyridine calcium channel blockers (amlodipine, etc) cause dose-dependent edema. But it's not caused by fluid overload, so diuretics usually don't help.      Try to lower the dose...or ADD an ACE inhibitor or ARB.     If that doesn't work, switch to a different antihypertensive... even verapamil or diltiazem cause less edema. Pioglitazone (Actos, etc) can cause edema...especially with higher doses. Avoid it in patients with class 3 or 4 heart failure.      In other patients, try a lower dose...or switch meds.     Consider trying spironolactone or hydrochlorothiazide if needed. They might help...but keep in mind they can sometimes worsen edema. Gabapentin, pregabalin, or dopamine agonists (pramipexole, etc) can cause dose-dependent peripheral edema.      Try to lower the dose or switch meds. Diuretics might help some patients...but don't count on them.

41.  MAGNESIUM     Concerns about PPIs and hypomagnesemia are raising questions about when and how to use magnesium supplements.     PPIs may lower mag levels...possibly due to reduced absorption.     Consider checking serum magnesium in patients on long-term PPIs... especially if they have muscle cramps, tremors, palpitations, etc.      Also check serum magnesium in patients taking PPIs with drugs that can lower mag, such as diuretics or cisplatin...or in those on digoxin, because hypomag can lead to dig toxicity. But keep in mind that serum levels don't always correlate well with total body stores.     Some insurers require an ICD-9 code on the lab slip. Use 275.2 for hypomagnesemia...or 995.20 for a drug adverse effect.      Consider checking potassium and calcium at the same time. Hypokalemia and hypocalcemia can be hard to correct if magnesium is low.     If a supplement is needed, lean toward one that's better absorbed, such as mag lactate (Mag-Tab SR, etc), mag chloride (Slow-Mag, etc), or mag aspartate (Maginex, etc). Mag oxide (Mag-Ox, etc) has more elemental magnesium than the others...but has poorer absorption. Explain that better absorption may mean less diarrhea.     Use 200 to 400 mg/day of elemental magnesium for hypomagnesemia. For 200 mg/day, this works out to about 3 tabs of Mag-Tab SR or Slow-Mag or 4 tabs ofMaginex. Suggest dividing the dose to improve tolerability.     Use IV magnesium sulfate for severe deficiencies.      If low magnesium doesn't resolve with a supplement in a patient on a PPI, stop the PPI and switch to an H2-blocker if needed.      Be careful using magnesium supplements in patients with renal insufficiency...to avoid HYPERmagnesemia.

42. INFECTIOUS DISEASES     New guidelines will help improve the treatment of community-acquired pneumonia in children.      Select an antimicrobial for outpatients based on their age, immunization status, and suspected pathogen.Typical bacterial pathogens are common...especially in school-age kids and adolescents.     Use amoxicillin 90 mg/kg/day for 10 days...up to 4 g/day to cover Strep pneumoniae.      Use amoxicillin/clavulanate (Augmentin, etc) to add H. influenzae coverage when kids aren't fully vaccinated for Hib.Atypical bacterial pathogens such as M. pneumoniae tend to be more common in school-age kids and adults. Suspect Mycoplasma in kids with slowly progressing symptoms...malaise, muscle aches, sore throat, and low-grade fever with a nonproductive cough.     Use azithromycin 10 mg/kg the first day then 5 mg/kg for 4 days... up to 500 mg the first day and 250 mg/day for 4 days.Viruses are usually the culprit in infants and preschoolers... especially if they have gotten their pneumococcal and Hib vaccines.      For flu pneumonia, use oseltamivir (Tamiflu)...or zanamivir (Relenza) for kids 7 years and older if an alternative is needed.

43. Which of the following is TRUE about using the new oral anticoagulants for atrial fibrillation? A.They're an alternative to warfarin if INR control is poor or monitoring isn't feasible. B.Dabigatran (Pradaxa) causes less bleeding than warfarin. C.Rivaroxaban (Xarelto) is more effective than warfarin. D.The new anticoagulants are all given once a day.

44. Answer • A.They're an alternative to warfarin if INR control is poor or monitoring isn't feasible.

45. ANTICOAGULANTS   You'll hear controversy over which ORAL anticoagulant to use to prevent strokes in patients with atrial fibrillation.    Warfarin was our only option for over 50 years...but you'll get more questions about how the new ones stack up. Warfarin is obviously the gold standard. You know its limitations...INR monitoring, dose adjustments, and many interactions.    But advocates call it "the devil we know" because we're familiar with its long-term safety...and it's the only one with an antidote. It's also the cheapest...about $80/month including INR monitoring once a month. Dabigatran (Pradaxa) is a direct thrombin inhibitor...and the first of the new oral anticoagulants that don't need INR monitoring.    It prevents more strokes than warfarin...about 5 more strokes per 1000 patients per year...with a similar overall bleeding risk.    But it needs to be given twice daily...and costs about $240/month. Rivaroxaban (Xarelto) is the first oral factor Xa inhibitor...and will likely be approved for atrial fib soon.    Reps will tout that it only needs to be given once a day.    But rivaroxaban doesn't work any better than warfarin...and it costs about the same as dabigatran. Apixaban  (Eliquis, ELL-eh-kwiss)  will be the next oral factor Xa inhibitor...likely out late next year. It's the one many are waiting for...it seems more effective AND causes less bleeding than warfarin.    Continue to feel comfortable using warfarin for atrial fib...especially in longtime users with good INR control.    Use a newer agent if INR control is poor...or monitoring isn't feasible. For now, lean towards dabigatran. To switch, wait until the INR is below 2 before starting dabigatran.    Be careful about using dabigatran in the elderly due to bleeding concerns...especially if underweight or renal function is poor. 

46. Which of the following is TRUE about the new dosing limits for citalopram (Celexa, etc)? A.Doses should not exceed 40 mg/day for anyone. B.Doses should not exceed 20 mg/day for most patients over age 60. C.Higher doses increase the risk of QT prolongation and torsades. D.All of the above

47. Answer • D.All of the above

48.  ANTIDEPRESSANTS   FDA now says citalopram doses should not exceed 40 mg/day for anyone...or 20 mg/day for most patients over age 60.    Higher doses of citalopram (Celexa, etc) increase the risk of QT prolongation and torsades.    Be careful about using citalopram in patients at risk due to underlying cardiac disease or low serum potassium or magnesium.    Avoid citalopram or monitor ECG if citalopram is used in patients with heart failure...bradyarrhythmias...or on other meds that can prolong the QT interval.    Don't exceed citalopram 20 mg in most patients over age 60...or those with liver impairment. Also avoid going over 20 mg when combined with CYP2C19 inhibitors...omeprazole, cimetidine, etc.    If these lower doses aren't adequate, switch to another antidepressant. Sertraline, paroxetine, and fluoxetine seem less likely to cause QT prolongation.    Don't exceed 20 mg/day of escitalopram (Lexapro). Usual doses aren't associated with significant QT prolongation...but the risk increases with higher doses.

49. ANTIDEPRESSANTS   Reps are filling up sample closets, hoping prescribers will use Deplin to improve the efficacy of antidepressants. Deplin contains L-methylfolate...the active form of folic acid.    The manufacturer can make medical claims for Deplin because it's marketed as a medical food. Medical foods are a commonly misunderstood category of products. They're not Rx drugs, not OTCs, not dietary supplements, and not homeopathics.    Medical foods often have a package insert and say "Rx only" on their label...but they are NOT approved by FDA like traditional Rx drugs.    There's a link between folate deficiency and depression...possibly because folates are needed to make serotonin, norepinephrine, and dopamine.    Some preliminary evidence also suggests that adding folate can increase antidepressant efficacy. Deplin claims to be more effective than folic acid because it's already in the active form. But there's no proof that Deplin is more effective...and it costs more.    Generic folic acid might be worth a try before going to other augmenting agents...antipsychotics, buspirone, thyroid, lithium, etc.    Use at least 500 mcg/day of folic acid for augmentation. Keep doses under 800 mcg/day in the elderly due to concerns about cancer with higher folate doses in the elderly.

50. Which of the following is TRUE about using azithromycin to prevent COPD exacerbations? A.Azithromycin 250 mg/day seems to reduce the risk of acute exacerbations. B.This dose does not increase bacterial resistance. C.Azithromycin can worsen eyesight. D.Thirty-day mortality is higher after a heart attack than a COPD exacerbation.