Nonpharmacologic Management Essay Examples

Know presentation, DX and Management

Diagnoses List

 

1. Acute bronchitis-

DESCRIPTION

Acute cough due to inflammation of the bronchioles, bronchi, and trachea; usually follows an upper respiratory infection or exposure to a chemical irritant.

ETIOLOGY

• Adenovirus
• Rhinovirus
• Influenza A and B
• Parainfluenza

RISK FACTORS

• Upper respiratory infection
• Air pollutants
• Smoking and/or secondary exposure
• Reflux esophagitis
• Allergy
• Chronic obstructive pulmonary disease
• Acute and chronic sinusitis
• Infants
• Older adults
• Immunosuppression

ASSESSMENT FINDINGS

• Cough: dry and nonproductive, then productive; may be purulent
• URI symptoms
• Fatigue
• Fever due to bacterial infection; more common in smokers and patients with COPD
• Fever due to viral cause (unusual after first few days) Nonpharmacologic Management Essay Examples
• Burning sensation in chest
• Crackles, wheezes
• Chest wall pain
• Nonpharmacologic Management Essay Examples

DIFFERENTIAL DIAGNOSIS

• Pneumonia
• Tuberculosis
• Asthma

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DIAGNOSTIC STUDIES

• Decision criteria for chest radiographs: tachypnea, hypoxia, fever, abnormal lung exam
• Only consider chest X-ray if high index of suspicion for pneumonia or superimposed heart failure
• Consider PPD: expect negative results
• PREVENTION

• Smoking cessation
• Avoid known respiratory irritants
• Treat underlying conditions that contribute to risk (asthma, gastroesophageal reflux disease, etc.)
• Influenza immunization for high-risk populations

 

NONPHARMACOLOGIC MANAGEMENT

• Increase fluid intake
• Use humidifier
• Rest
• Smoking cessation
• Consider honey in children older than 1 year
• Patient education about disease, treatment, expected cause of cough, and emergency actions

PHARMACOLOGIC MANAGEMENT

• Cough suppressants for nighttime relief
• Avoid antihistamines
• Antibiotics if organism is bacterial
• Antivirals if influenza diagnosed
• Decongestants and antihistamines are ineffective unless sinusitis or allergy is underlying
• Bronchodilators if wheezing or prior history of asthma

Although antibiotics are commonly prescribed, they are NOT recommended.
ACUTE BRONCHITIS PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Cough Suppressants Suppress cough in the medullary center of the brain	dextromethorphan/guaifenesin	Adult: 10 mL q 4 hr  Max: 4 doses in 24 hours Children 6-12 years: 5 mL q 4-6 hr; Max: 4 doses in 24 hr Children <6 years: not recommended	Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor Contraindicated in Parkinson’s disease Potential drug interaction with some SSRIs Avoid in patients who are having difficulty clearing secretions
	Robitussin DM various generics	Dextromethorphan 10 mg/5 mL  Guaifenesin 100 mg/5 mL
	dextromethorphan	Adult and ≥12 years: 10 mL q 6-8 hr prn for cough  Max: 4 doses in 24 hr Children 6-12 years: 5 mL every 6-8 hr prn for cough Max: 4 doses in 24 hr 4-6 years: 2.5 mL every 6-8 hr prn for cough Max: 4 doses in 24 hr	Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor Contraindicated in Parkinson’s disease Potential drug intervention with some SSRIs Avoid in patients who are having difficulty clearing secretions Do not use if on a sodium restricted diet
	Delsym	Dextromethorphan 15 mg/5 mL (alcohol free/orange or grape flavor)  Adult: 10 mL q 12 hr Children 6-12 years: 5 mL q 12 hr Children 4-6 years: 2.5 mL q 12 hr
	codeine/guaifenesin	Adults and children ≥ 12 years: 10 mL q 4 hr prn cough Max: 6 doses in 24 hrChildren 6-12 years: 5 mL q 4 hr prn cough Max: 6 doses in 24 hr	Do not use if taking an MAO inhibitor or for 2 weeks after stopping an MAO inhibitor Contraindicated in Parkinson’s disease Potential drug interaction with some SSRIs Schedule V medication Avoid in patients who are having difficulty clearing secretions Avoid narcotic cough suppressants in patient with COPD or asthma May be habit forming May aggravate constipation
	Robitussin AC	Each 5 mL contains  100 mg guaifenesin and  10 mg codeine
Antitussives Topical anesthetic effect on the respiratory stretch receptors	benzonatate	Adults and children > 10 years:  100-200 mg TID prn cough Max: 600 mg daily	Do not break or chew capsule – can produce local anesthesia and may reduce patient’s gag reflex Monitor for dizziness, drowsiness and visual changes Begins to act in 15-20 minutes and lasts for 3-8 hours Avoid use in patients sensitive to or taking agents with PABA – possible adverse CNS effects
	Tessalon	Caps: 100 mg, 200 mg
Expectorants	guaifenesin	Adult: 200-400 mg PO q 4 hr prn  Max: 2400 mg/day Children 2-5 years: 50-100 mg. PO q 4 hr prn Max: 600mg/ day Children 6-11 years: 100-200 mg PO q 4 hr prn Max: 1200 mg/day Children ≥12 years: 200-400 mg PO q 4 hr prn; Max: 2400 mg/day.	Caution if nephrolithiasis Caution in patients under 6 years Take with plenty of water; do not cut/crush/chew ER tab
Short-Acting Bronchodilators	albuterol	Inhalation:  Adult Dose: metered-dose inhaler (MDI) or dry powder inhaler (90 mcg/actuation): 2 inhalations q 4 to 6 hr as needed Metered-dose inhaler (100 mcg/actuation): Acute treatment: 1 to 2 inhalations; additional inhalations may be necessary if inadequate relief however patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment.Nonpharmacologic Management Essay Examples Maintenance (in combination with corticosteroid therapy): 1 to 2 inhalations TID-QID Max: 8 inhalations daily Dry powder inhaler (200 mcg/inhalation): Acute treatment: 1 inhalation (200 mcg) as needed; Max: 4 inhalations (800 mcg)/day; patient should be advised to promptly consult health care provider or seek medical attention if prior dose fails to provide adequate relief or if control of symptoms lasts <3 hr Maintenance (in combination with corticosteroid therapy): 1 inhalation (200 mcg) q 4-6 hr; Max: 4 inhalations (800 mcg)/day Nebulization solution: 2.5 mg TID-QID as needed; Quick relief: 1.25 to 5 mg q 4-8 hr as needed (NAEPP 2007) Pediatric: Inhalation: Metered-dose inhaler or dry powder inhaler (90 mcg/actuation) quick relief: refer to adult dosing for all ages Metered-dose inhaler (100 mcg/actuation): Children 6 to 11 years: Acute treatment: 1 inhalation; additional inhalations may be necessary if inadequate relief; however, patients should be advised to promptly consult health care provider or seek medical attention if no relief from acute treatment Maintenance (in combination with corticosteroid therapy): 1 inhalation; may increase to maximum of 1 inhalation QID Children ≥12 years and adolescents: refer to adult dosing	Inhalation: Metered-dose inhalers: Shake well before use; prime prior to first use, and whenever inhaler has not been used for >2 weeks or when it has been dropped, by releasing 3 to 4 test sprays into the air (away from face). HFA inhalers should be cleaned with warm water at least once per week; allow to air dry completely prior to use. A spacer device or valved holding chamber is recommended for use with metered-dose inhalers. Storage Metered-dose inhalers (HFA aerosols): Store at 15°C to 25°C (59°F to 77°F). Do not store at temperature >120°F. Do not puncture. Do not use or store near heat or open flame. Ventolin HFA: Discard when counter reads 000 or 12 months after removal from protective pouch, whichever comes first. Store with mouthpiece down. Use with caution in patients with impaired renal disease, hyperthyroidism, diabetes, glaucoma

 

 

CONSULTATION/REFERRAL

• Refer to pulmonologist if symptoms not improved after 4 weeks

FOLLOW-UP

• 7 days if not improved or if condition worsens
• High-risk groups (i.e., those with co-existing disease) warrant quicker follow-up

EXPECTED COURSE

• Shorter symptom duration if causative agent is rhinovirus or coronavirus
• Symptoms may persist 3-4 weeks

POSSIBLE COMPLICATIONS

• Pneumonia
• Chronic cough

 

2. Acute laryngopharyngitis

DESCRIPTION

An acute inflammation of the pharynx/tonsils. The most common cause of acute pharyngitis is viruses. Accurate diagnosis and treatment of Strep pharyngitis is important to prevent rheumatic fever, poststreptococcal glomerulonephritis, to reduce transmission, and to limit complications, such as peritonsillar abscess, lymphadenitis, and mastoiditis

ETIOLOGY

Causes
Viral*	Bacterial
Rhinovirus Adenovirus Parainfluenza Epstein-Barr virus (mononucleosis) Respiratory syncytial virus	Group A beta-hemolytic Streptococcus** Haemophilus influenzae Mycoplasma pneumonia Chlamydia pneumoniae Neisseria gonorrhoeae No pathogen can be isolated in many cases

* Most common etiology
** Common depending on time of year

INCIDENCE

• Prevalent in school age population, but occurs in all age groups (5-18 years most common)
• Occurs in 5-15% of adults and 20-30% of children
• More common during winter months

RISK FACTORS

• Age
• Exposure during Group A beta-hemolytic Streptococcus (GABHS) infection outbreaks
• Family history of rheumatic fever places higher risk if GABHS is untreated

ASSESSMENT FINDINGS

• Sore throat and pharyngeal edema
• Tonsillar exudate and/or enlarged tonsils
• Malaise
• Clinical findings are not specific for diagnosis of bacterial or viral illness. The signs and symptoms of strep pharyngitis and other etiologies overlap, and an accurate diagnosis based on clinical findings alone is difficult
• Suggestive of Strep:
  • Cervical adenopathy
  • Fever >102° F (38.8° C)
  • Absence of other upper respiratory findings (cough, nasal congestion, etc.)
  • Petechiae on soft palate
  • “Beefy red” tonsils
  • “Sandpaper” rash (bridge of nose, neck, and/or torso)
  • Abdominal pain, headache
  • Streptococcal tonsillitis has a distinct odor
• Suggestive of viral infection:
  • Concurrent conjunctivitis, nasal congestion, hoarseness, cough, diarrhea or viral rash. Nonpharmacologic Management Essay Examples

Modified Centor Clinical Prediction Rule for Group A Strep infection
Tonsillar exudates	+1 point
Tender anterior chain cervical adenopathy	+1 point
Fever by history	+1 point
Age <15 years	+1 point
Age 15-45	0 points
Age >45	-1 point
Cough (almost always excludes Streptococcus)	-1 point
3-4 points: treat empirically for Strep infection 2 points: rapid Strep test, treat if positive 1 point: unlikely Strep 0 or -1 points: do not test or treat

DIFFERENTIAL DIAGNOSIS

• Upper respiratory illness
• Tonsillitis
• Mononucleosis

DIAGNOSTIC STUDIES

• Rapid antigen strep test (95-99% specific).
• The swab should be taken from the tonsils, tonsillar fossa, and the posterior pharyngeal wall. Good specimen is essential
• In children and adolescents, negative rapid antigen test should be confirmed with a throat culture. Confirmation not necessary in adults due to lower risk for the development of acute rheumatic fever

 

 

10% of patients with mononucleosis have concomitant Strep infection

 

Antistreptolysin (ASO) titer should not be ordered to diagnose acute infection (ASO detects past infection)

 

PREVENTION

• Avoid contact with infected people during outbreaks
• Good hand washing, especially during cold weather months
• Teach patients not to share drinking glasses, eating utensils, etc.
• Prompt treatment of patients with family history of rheumatic fever

NONPHARMACOLOGIC MANAGEMENT

• Gargling with warm salt water
• Increased fluid intake
• Patient education about disease, course and treatment
• Change toothbrush after treatment

PHARMACOLOGIC MANAGEMENT

• Antipyretics/analgesics (acetaminophen, ibuprofen) are adjunctive treatment for fever and throat pain
• Empiric treatment of asymptomatic household contacts of strep pharyngitis patients is not routinely recommended
• For Strep pharyngitis, amoxicillin and penicillin V (10 days) are drugs of choice. For penicillin-allergic children, cephalexin/cefadroxil/clindamycin (10 days) or macrolides (5 days) are recommended
• Antibiotics no benefit in treatment of nonstrep pharyngitis infections. Exceptions are Corynebacterium diphtheriae, Neisseria gonorrhoeae, and others

 

Medication (based on patient’s age or weight)	Treatment
Penicillin G	One IM injection
Penicillin V Amoxicillin	Requires 10 days of treatment
First-generation cephalosporins	Requires 10 days of treatment
Second-generation cephalosporins	5 days of treatment
Azithromycin (for PCN allergy); limited efficacy against Streptococcal infection and should only be used for patients with documented history of PCN anaphylaxis or hives	12 mg/kg dose daily x 5 days

• Clindamycin 7 mg/kg TID x 10 days for resistant/chronic recurrent Streptococcal infection
• Mupirocin BID-TID to nasal mucosa for carrier

STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Penicillin Bacterial; Bactericidal: inhibits cell wall mucopeptide synthesis; inhibits beta-lactamaseGeneral commentsIndicated for infections caused by penicillinase-sensitive microorganisms  Generally well tolerated; watch for hypersensitivity reactions Clavulanate broadens spectrum of coverage Consider amoxicillin/clavulanate if failure after 72 hours Give in divided doses Amoxicillin and Penicillin V are considered first-line agents in most cases, unless other antibiotic exposure in the last 90 days The course of treatment is 10 days for all beta-lactam antibiotics, but FDA has approved 5-day course of cefdinir and cefpodoxime	penicillin V potassium	Adult: 500 mg 2-3 times daily for 10 days  Children: 250 mg PO BID-TID  for 10 days Adolescents: 500 mg PO BID for 10 days	Lactation: Safe Give 1 hour before and 2 hours after meals
	Pen V K	Tablet: 250 mg, 500 mg Oral Solution: 125 mg/5 mL, 250 mg/5 mL
	penicillin G benzathine	Adult: 1.2 million units IM for 1 dose <27 kg: 0.6 million units IM for 1 dose ≥27 kg: 1.2 million units IM for 1 dose	Lactation: Safe Do not confuse Bicillin L-A with Bicillin C-R Do not confuse penicillin G benzathine with penicillamine or penicillin G procaine. They are NOT interchangeable Very painful injection if not combined with Penicillin G procaine (Ex. 900,000 units of Penicillin G benzathine + 300,000 units of Penicillin G procaine = 1.2 million units)
	Bicillin L-A	Injection: 600,000 units/mL, 1.2 million units/2 mL NOT FOR IV USE
	amoxicillin	Adult: 500-875 mg PO q 12 hr for 10-14 days (higher dosing for severe infections)  Children:  >40 kg: dose for 10 days 50 mg/kg once daily for 10 days Max: 1 g/day Alternate: 25 mg/kg BID for 10 days Max: 500 mg/dose	GI side effects Amoxicillin is not stable in the presence of beta lactamase producing organisms DO NOT USE IF HISTORY OF HIVES OR ANAPHYLAXIS TO PENICILLIN Decrease dose for renal impairment Children’s dose of amoxicillin should never exceed maximum adult dose. Nonpharmacologic Management Essay Examples
	Amoxil	Caps: 250 mg, 500 mg Tabs: 500 mg, 875 mg Suspension: 250 mg/5 mL; 400 mg/5 mL Pediatric drops: 50 mg/mL
	Moxatag	775 mg ER Tab daily for 10 days

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STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Macrolides Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrestGeneral commentsEffective treatment for S. pyogenes in the presence of penicillin allergy  Associated with higher rates of GI side effects Age, weight and severity of infection determine dose in children Local antibiotic resistant rates should be considered prior to prescribing.	azithromycin	Adult:  Usual: 500 mg daily for 3 days Alternative: 2 g as a single dose or 500 mg on day 1 and 250 mg days 2-5Children >6 months old: Usual: 10 mg/kg once daily for 3 days or 10 mg/kg on day 1 and 5 mg/kg days 2-5 Max: 500 mg daily	Lactation: Safety Unknown First-line for penicillin allergic (Type I allergic reaction) Consider clindamycin, if failure after 48-72 hours Avoid concomitant use of aluminum or magnesium containing antacids Cautious use if renal or hepatic impairment Hypersensitivity reactions may recur after initial successful symptomatic treatment
	Zithromax	Tabs: 500 mg, 250 mg Powder: 2 g/bottle Suspension: 100 mg/5 mL, 200 mg/5 mL
	clarithromycin	Adult: 250 mg PO q 12 hr for 10 days  Children 6 months and older: 15 mg/kg/day PO divided q 12 hr for 10 days Max: 250 mg/dose	Cautious use in patients with either renal or hepatic dysfunction Clarithromycin may be involved in drug reactions involving CYP 450 system; special care when prescribing concurrently with 3A4 substrate medications Common side effect is an abnormal taste in mouth while taking tablet or suspension
	Biaxin	Coated tabs: 250 mg, 500 mg
	Biaxin XL	Coated tabs extended release: 500 mg
Other Antibacterials Bacteriostatic or bactericidal, inhibits protein synthesisGeneral commentsHalf-life is 2.4-3 hours  Carries a black box warning for C. difficile associated diarrhea	clindamycin	Adult: 300 mg PO q 8 hr for 10 days  Children: 7 mg/kg/day PO divided q 8 hr for 10 days Max: 300 mg/dose Adolescents: 150-300 mg PO q 6 hr Max 300 mg per dose	Lactation: Probably Unsafe May cause exfoliative dermatitis Caution in hepatic dysfunction Only use if other antibiotics have been unsuccessful Use in patients with initial bacterial failure who are penicillin/cephalosporin allergic with Type I reaction; consider use in patients who failed therapy with ceftriaxone (used in conjunction with tympanocentesis)

continued

STREPTOCOCCUS A PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
	Cleocin	Injection: 150 mg/mL Tabs: 75 mg, 150 mg, 300 mg Capsule: 150 mg, 300 mg Solution: 75 mg/5 mL Granules for solution: 75 mg/5 mL	Cautious use in patients with hepatic, renal impairments, colitis Side effects include pseudo-membranous colitis, C. difficile diarrhea Take with a full glass of water
First Generation Cephalosporins Arrests bacterial growth by inhibiting bacterial cell wall synthesisGeneral commentsCaution if recent antibiotic associated colitis	cephalexin	Adult: 500 mg PO q 12 hr for 10 days  Children >1 year of age:  25-50 mg/kg/d in 2-4 divided doses for 10 days Max: 500 mg q 12 hr	Cautious use in patients with history of hives or anaphylaxis to penicillin Dosage reduction needed for renal impairment Give without regard to meals PT should be monitored in patients at risk: renal or hepatic impairment, poor nutritional state After mixing suspension, store in refrigerator for up to 14 days
	Keflex	Caps: 250 mg, 500 mg, 750 mg Tablets: 250 mg, 500 mg Suspension: 125 mg/5 mL,  500 mg/5 mL
	cefadroxil	Adult: 1 g PO daily in divided doses q 12 hr for 10 days  Children: 30 mg/kg PO divided q 12 hr for 10 days	Cautious use in patients with history of hives or anaphylaxis to penicillin Dosage reduction needed for renal impairment No dosage reduction needed for geriatric patients
	Duricef	Caps: 500 mg, 1000 mg, Tabs: 1000 mg Suspension: 250 mg/5 mL, 500 mg/5 mL

CONSULTATION/REFERRAL

• Evidence of acute renal failure and reddish, tea-colored urine (2-3 weeks post infection) may indicate acute poststreptococcal glomerulonephritis
• Tonsillar edema and upper airway obstruction
• Peritonsillar abscess

Tonsillectomy is not recommended to reduce the frequency of Strep pharyngitis

 

FOLLOW-UP

• None usually needed
• Patient no longer considered contagious after 24 hours on antibiotic
• Follow-up culture not recommended, may be done to assure compliance

EXPECTED COURSE

• Peak fever and pain on days 2 and 3
• Lasts 4-10 days

POSSIBLE COMPLICATIONS

• Upper airway obstruction
• Acute post-Strep glomerulonephritis after Streptococcal infection
• May develop sloughing of skin on fingertips and toes in weeks following Strep infection

 

3. Acute maxillary sinusitis

DESCRIPTION

Also known as: (Acute Rhinosinusitis, Recurrent Acute Rhinosinusitis, Chronic Rhinosinusitis)

Inflammation of at least one paranasal sinus due to bacterial, viral, or fungal infection; or allergic reaction. Annually, acute bacterial rhinosinusitis costs more than $3 billion and accounts for more outpatient antibiotic prescriptions than any other diagnosis. The terms sinusitis and rhinosinusitis are used interchangeably because inflammation of the sinus cavities and nasal cavities are usually concurrent.

• Classification
  • Acute rhinosinusitis (ARS): symptoms <12 weeks
  • Recurrent ARS (RARS): at least three episodes of acute bacterial rhinosinusitis in a year
  • Chronic rhinosinusitis (CRS): symptoms of varying severity >12 weeks. Further classified with or without nasal polyps; abnormal findings on CT scan or nasal endoscopy. Nonpharmacologic Management Essay Examples

ETIOLOGY

	Bacterial
Acute   sinusitis	Streptococcus pneumoniae species (most common) Haemophilus influenza (common in smokers) Moraxella catarrhalis
	Viral
	Rhinovirus Coronavirus Influenza A and B Parainfluenza virus Respiratory syncytial virus
Chronic  sinusitis	Gram-negative more likely Staphylococcus aureus Pseudomonas aeruginosa Anaerobic organisms

 

Vast majority of rhinosinusitis cases are due to viruses, NOT bacteria. Viral URIs usually precede bacterial infections of the sinuses. It is the persistence of symptoms that suggests sinusitis.

INCIDENCE

• Common in all ages
• Men = Women
• Common in early fall and early spring
• 13% of adults annually
• A majority of patients with rhinosinusitis seek care from their PCPs

RISK FACTORS

• Allergies, asthma
• Tooth abscess (25% of chronic sinusitis is due to tooth abscess)
• Cigarette smoking
• URIs, cystic fibrosis, immune deficiencies
• Swimming in contaminated water
• Any condition that results in swollen nasal mucous membranes, such as common cold and allergic rhinitis
• Anatomical abnormalities that prevent normal mucosal drainage, such as ciliary dyskinesia, nasal polyps and deviated septum
• Asthma, GERD, and otitis media are often comorbid with CRS

ASSESSMENT FINDINGS

• Fever (may or may not be present)
• Persistent symptoms of URI (>10-14 days)
• Nasal congestion and/or discharge (may be purulent and/or bloody)
• Headache
• Sore throat from persistent postnasal discharge
• Pain/pressure over cheeks and upper teeth (suggests maxillary sinus involvement)
• Pain/pressure and tenderness over eyebrows (suggests frontal sinus involvement)
• Pain/pressure and tenderness behind and between eyes (suggests ethmoid sinus involvement)
• Cough
• Anosmia
• Halitosis
• Postnasal discharge, throat clearing
• Periorbital edema

Bacterial infection more likely if: symptoms >10 days, worsening of symptoms after initial improvement, persistent purulent nasal discharge, fever, unilateral face or tooth pain.

DIFFERENTIAL DIAGNOSIS

• Viral URI
• Allergic rhinitis
• Nonallergic rhinitis (triggered by strong odors or change in temperatures)
• Dental abscess
• Headaches
• Nasal foreign body
• Wegener’s granulomatosis

DIAGNOSTIC STUDIES

• CBC: elevated WBC count if bacterial infection
• Sinus X-rays: opaque areas on radiographs; air-fluid levels
• CT scan: most useful tool to evaluate recurrent sinusitis but unable to differentiate viral from bacterial infection. Required before surgery or when complications of sinusitis are suspected
• Imaging recommended with unilateral CRS to exclude tumor, anatomical defect, or foreign body. MRI is superior to CT for soft tissue imaging
• Transillumination: opacification with air-fluid levels if sinus cavity is infected
• Allergen-specific IgE testing for respiratory allergens for RARS or CRS
• Evaluate for immune deficiency if CRS is resistant to treatment: quantitative IgG, IgA, IgM; pneumococcal antibody; complement function and T-cell number and function
• Consider culture and sensitivity for treatment resistant infections
• Consider evaluating for cystic fibrosis in a child with CRS with nasal polyps, especially if Pseudomonas aeruginosa is cultured from the sinuses

PREVENTION

• Promote drainage by avoiding irritants that increase swelling in mucous membranes and cause retention of sinus exudate
• Blowing, rather than “sniffing” nose
• Good hand washing to prevent URIs
• Management of allergic rhinitis

 

NONPHARMACOLOGIC MANAGEMENT

• Avoid environmental irritants (cigarette smoke)
• Manage allergic rhinitis appropriately
• Humidified air can improve mucus clearance
• Look for the presence of otitis media when evaluating a patient with rhinosinusitis (and vice versa)
• Increase fluid intake
• Sleep with head of bed elevated to aid with drainage
• Patient education regarding disease, treatment options, etc.

PHARMACOLOGIC MANAGEMENT

Current data support watchful waiting of acute infections for 10 days; start antibiotic therapy if symptoms extend beyond 10 days.

• Antibiotics: for acute infections and patients with moderate to severe infection
• Amoxicillin-clavulanate is first-line antibiotic
• Doxycycline, levaquin, or moxifloxacin if PCN allergy
• Macrolides no longer recommended due to high rate of resistance
• Amoxicillin not recommended; M. catarrhalis and H. influenzae can produce ß-lactamase and are resistant to amoxicillin
• If no improvement occurs within 3-5 days, consider an alternate antibiotic that broadens coverage or covers resistant bacteria.
• If partial response, consider additional 10-14 days with same or different antibiotic. If no substantial improvement or resolution in 21-28 days, refer to specialist
• Decongestants: oral route preferred over topical, however, may use oxymetazoline q 12 hours for 1-3 days for ARS. Neither oral nor topical are beneficial for CRS
• Analgesics for headache, antipyretics for fever
• Topical intranasal steroids as monotherapy or in conjunction with antibiotics, especially in children and/or adults with underlying allergies. May consider a 3- to 6-week course of topical antibiotics for CRS (mupirocin, gentamicin, tobramycin nebulized or irrigations). Low systemic absorption. Studies demonstrate 82% improvement
• CRS: oral antibiotic plus short course of oral steroids. Antibiotics of greater benefit for patients without nasal polyposis. Antibiotic therapy beyond 10-14 days is recommended. Oral steroids should be prescribed for patients with nasal polyps to decrease polyp size. Nasal steroids should be prescribed for patients with and without polyps; CRS is an inflammatory condition
• Patients with asthma who develop rhinosinusitis should be treated aggressively, since successful treatment will improve asthma
• Saline irrigation may be used as adjunctive therapy, using distilled or boiled tap water only. Patients should be instructed to clean the delivery device to avoid contamination. Squeeze bottles are superior to saline sprays, nebulizers, or devices (Neti pot)
• In children, ARS is self-limiting, and antibiotic treatment facilitates improvement and resolution. Nasal steroids are a useful adjunct, however, nasal irrigation, antihistamines, decongestants, and mucolytics have not been proven beneficial for ARS in children.
• In children with CRS, the mainstay of treatment is medical; surgery less frequently needed
  • Limited data support antibiotic therapy
  • Intranasal steroids should be prescribed, and antibiotics should be used for acute exacerbations
  • Surgery is an infrequent treatment for CRS in children; when needed, adenoidectomy with or without antral maxillary irrigation is used. Nonpharmacologic Management Essay Examples

Risk for resistance should be evaluated prior to determining antibiotic therapy. Risk factors for resistance include: age <2 years or >65 years, recent antibiotic use, hospitalization within the past 5 days, presence of co-morbid conditions, immunocompromised state.

 

ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT Reserve antibiotics for persistent, unimproved symptoms >10 days or severe symptoms for >3-4 days
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Penicillin Inhibits cell wall synthesis of gram-positive bacteria (Staph, Strep) and are most effective against organisms with rapidly dividing cell wallsGeneral commentsIndicated for infections caused by penicillinase-sensitive microorganisms  Generally well tolerated; watch for hypersensitivity reactions May have high rates of resistance depending on geographic region	amoxicillin	Adult: 500 mg-875 mg PO q 12 hr for 5-7 days    Children: >40 kg: dose as adult <3 months: 20-30 mg/kg/day PO divided q 12 hr for 48-72 hr >3 months: 25-45 mg/kg/day PO divided q 12 hr >2 years old: 80-90 mg/kg/day PO divided q 12 hr for 5-7 days; do not exceed max adult dose	DO NOT USE IF HISTORY OF HIVES OR ANAPHYLAXIS TO PENICILLIN Ineffective against beta lactamase-producing organisms Decrease dose for renal impairment Children’s dose of amoxicillin should never exceed maximum adult dose Consider high-dose amoxicillin for severe sinusitis or likelihood of drug-resistant Streptococcus pneumoniae
	Amoxil	Caps: 250 mg, 500 mg Tabs: 500 mg, 875 mg Suspension: 250 mg/5 mL; 400 mg/5 mL Pediatric drops: 50 mg/mL
	Moxatag	Extended-release tabs: 775mg
Extended-Spectrum  Penicillin Inhibits cell wall synthesis of gram-positive bacteria (Staph, Strep) and are most effective against organisms with rapidly dividing cell walls   General comments   Addition of clavulanic acid (as potassium) extends antimicrobial spectrum (covers many gram-negative organisms) and protects PCN molecule if the organism produces beta lactamase   Clavulanic acid is known to cause diarrhea	amoxicillin/clavulanic acid  (as potassium)	Adult: 500/125 mg PO TID or 875/125 mg PO q 12 hr for 5-7 days    Alternative: 2000 mg or 90 mg/kg PO q 12 hr for 10 days for S. pneumoniae or at risk for resistance   Children: >40 kg: dose as adult <3 months: 30 mg/kg/day PO q 12 hr for 7-10 days >3 months and older and <40 kg: 25-45 mg/kg/day PO q 12 hr	DO NOT USE IN PATIENTS WHO HAD HIVES OR ANAPHYLAXIS TO PENICILLIN Children: base dose on amoxicillin component Monitor for PCN hypersensitivity Take with meals to minimize gastrointestinal side effects Contraindicated in severe renal impairment (CrCl <30 mL/min), dialysis, or history of Augmentin-associated cholestatic jaundice, hepatic dysfunction Chew tabs contain phenylalanine
	Augmentin	Tabs: 250/125 mg, 500/125 mg, 875/125 mg  Elixir: 125/31.25/5 mL; 250/62.5/5 mL XR: 1000/62.5 mg
Tetracycline Bacteriostatic, inhibits bacterial protein synthesis by disruption of RNA at ribosomal sites General comments  May alter GI flora	doxycycline	Adult: 100 mg PO q 12 hr or 200 mg PO daily for 5-7 daysChildren: not recommended	Caution in hepatic impairment and recent colitis associated with antibiotic use Associated with diarrhea

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ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT Reserve antibiotics for a) Persistent and not improving symptoms > 10 days or b) Severe symptoms for > 3-4 days
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
May lead to permanent yellowing or graying of the teeth in children <8 years old.	Vibramycin	Tabs: 100 mg Elixir: 25 mg/5 mL, 50 mg/5 mL
Cephalosporins Third generationProvides broader coverageof gram-negative organisms; beta-lactamase-producing organisms  General comments Recommended in combination with clindamycin for children with penicillin allergy. Not indicated as monotherapy for treatment of sinusitis For patients who had skin rash to penicillin, OK to use third-generation cephalosporin Generally well tolerated	cefpodoxime	Adult ≥12 years: Sinusitis:  Usual: 200 mg q 12 hr for 10 days Children (2 months to 12 years):  Usual: 5 mg/kg q 12 hr for 10 days Max: 200 mg/dose	NOT likely to cause an adverse reaction in patients with history of IgE response to penicillins; use caution Decrease dose for renal impairment Children’s dose should not exceed adult dose Cefpodoxime: take tabs with food; suspension may be given without regard to food
	Vantin	Tabs: 100 mg and 200 mg Suspension: 50 mg/5 mL, 100 mg/5 mL
	Various generics
	cefdinir	Adult > 13 years:  Usual: 300 mg q 12 hr (or 600 mg q 24 hr) for 10 days Children 6 months-12 years:  Usual: 7 mg/kg q 12 hr or 14 mg/kg daily for 10 days Max: 300 mg per dose	Separate medication by at least 2 hours when giving with iron supplements (except iron fortified cereals)
	Omnicef	Tabs: 300 mg  Suspension: 125 mg/5 mL, 250 mg/5 mL
	Various generics
	Cefixime	Children 6 months to 11 years: Usual: 8 mg/kg/day for 10 days Max: 400 mg/day
	Suprax
Other Antibacterials Bacteriostatic or bactericidal, inhibits protein synthesisGeneral commentsHalf-life is 2.4-3 hours  Carries a black box warning for C. difficile associated diarrhea	Clindamycin	Adult: 300 mg PO q 8 hr x 10 days  Children: 10-25 mg/kg/day PO q 6-8 hr Max: 1.8 g/day Adolescents: 150-300 mg PO q 6 hr Max: 1.8 g/day PO	May cause exfoliative dermatitis Caution in hepatic dysfunction
	Cleocin	Tabs: 75 mg, 150 mg, 300 mg Elixir: 75 mg/5 mL
Macrolides Inhibit protein synthesis by binding to the 50S ribosomal subunitGeneral commentsMacrolides are not recommended for empiric treatment due to high rates of resistance. May consider as alternative to PCN in pregnancy, if allergic to PCN  Avoid concomitant aluminum- or magnesium-containing antacids	azithromycin	Adults:  Usual: 500 mg daily for 3 days Alternative: 2 g as a single dose or 500 mg on day 1 and 250 mg days 2-5 Children >6 months old:  Usual: 10 mg/kg once daily for 3 days or 10 mg/kg on day 1, and 5 mg/kg days 2-5 Max: 500 mg daily	Azithromycin 2-g single dose MUST be taken on an empty stomach; multiday doses may be taken without regard to food Cautious use in patients with either renal or hepatic dysfunction
	Zithromax	Tabs: 500 mg, 250 mg  Powder: 2 g/bottle Suspension: 100 mg/5 mL, 200 mg/5 mL
	Various generics

 

ontinued

ACUTE SINUSITIS PHARMACOLOGIC MANAGEMENT Reserve antibiotics for a) Persistent and not improving symptoms > 10 days or b) Severe symptoms for > 3-4 days
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Quinolones Inhibit the action of DNA gyrase, which is essential for the organism to replicate itselfGeneral comments  Broad-spectrum antimicrobial agents   Monitor for QT prolongation and photosensitivity   Avoid in ages <18 years, pregnant women, due to potential impairment in bone and cartilage formation   Monitor for hypoglycemic reactions	levofloxacin	Adult >18 years:  Usual: 500 mg once daily for 10-14 days Alternative: 750 mg daily for 5 days Children: not recommended	Reduce dose for impaired renal function Avoid drugs that prolong QT interval Absorption significantly decreased by dairy products, multivitamins, and calcium containing products Possible increased risk of tendinitis or tendon rupture Causes photosensitivity
	Levaquin	Tabs: 250 mg, 500 mg, 750 mgOral solution: 480 mL
	moxifloxacin	Adult: Usual: 1 tablet once daily for 5-7 daysChildren: not indicated
	Avelox	Tabs: 400 mg

PREGNANCY/LACTATION CONSIDERATIONS

• Sinusitis may be aggravated by physiologic nasal congestion due to pregnancy
• Mild decongestant use considered safe for short-term use, but not proven effective
• Avoid antibiotics unless absolutely necessary
• Avoid tetracyclines, quinolones during pregnancy or lactation

CONSULTATION/REFERRAL

• Refer to ENT for recurrent infections or treatment-resistant infections. May require endoscopic surgical intervention
• Consider immediate referral for periorbital cellulitis
• Emergency care if meningitis suspected

FOLLOW-UP

• Indicated until clinically free of infection
• If unresolving/worsening symptoms after 3-5 days of antibiotic therapy

EXPECTED COURSE

• Good prognosis for acute sinusitis
• Chronic sinusitis often recurs unless causative factor is treated (e.g., allergic rhinitis, drainage problems) or eliminated (e.g., mechanical obstruction)

POSSIBLE COMPLICATIONS

• Abscess
• Meningitis
• Periorbital cellulitis

 

4. Allergic rhinitis

DESCRIPTION

Inflammatory IgE-mediated disease of the mucous membranes of the nasal tract with subsequent mucosal edema, clear discharge, sneezing, and nasal stuffiness. It may be seasonal, perennial, or episodic. The diagnosis is made when the patient presents with history and physical consistent with an allergic cause and one or more of the following is present: nasal congestion, rhinorrhea, itchy nose, or sneezing.

ETIOLOGY

• Results from any substance or condition that causes an IgE-mediated response characterized by rupture of mast cells and release of histamines, leukotrienes, prostaglandins and other substances
• Most common seasonal allergens are pollens from grass, trees, weeds
• Most common perennial allergens are mold, animal dander, dust mites, smoke. Nonpharmacologic Management Essay Examples

INCIDENCE

• 10-20% of children
• 20-30% of adolescents
• Usually diminishes with age
• Most common age of onset is 10-20 years

RISK FACTORS

• Family history
• Other atopic diseases (e.g., asthma, atopic dermatitis, allergic conjunctivitis, food allergy)
• Repeated exposure to the allergic substance
• Nonadherence to treatment

ASSESSMENT FINDINGS

• “Allergic shiners:” dark, discolored areas beneath the lower eyelids resulting from impeded lymphatic and venous drainage
• Conjunctival injection, watery eyes
• Pale, boggy nasal mucosa with congestion and clear rhinorrhea
• Transverse crease on tip of nose due to “allergic salute:” long-term wiping of nose in an upward direction due to itch/tickle
• Mouth breathing and dry lips
• Sore throat/dry mouth upon waking
• Palpable lymph nodes
• Enlarged tonsils and adenoids
• Document presence of associated conditions: sleep-disordered breathing, otitis media, rhinosinusitis, conjunctivitis, asthma, atopic dermatitis

DIFFERENTIAL DIAGNOSIS

• Vasomotor rhinitis
• Rhinitis medicamentosa
• Infection
• Tumors
• Nasal foreign body
• Common cold

DIAGNOSTIC STUDIES

• Usually none
• CBC: eosinophilia if acute reaction
• Consider cultures if infection is suspected
• Sinus films are not recommended
• CT scan primary imaging study
• Allergy testing for patients who do not respond to empiric treatment. Note: antihistamines will suppress reaction to skin allergy testing (usually stop antihistamines 1 week prior to testing)
• Diagnostic allergen prick/droplet tests (usually performed by allergist)
• RAST (RadioAllergoSorbent Test): allergen-specific IgE test (ImmunoCAP) used in patients in whom a severe reaction is possible. Blood test to detect specific IgE antibodies. Benefit: venous blood testing; may be done by PCP; no need to stop antihistamines prior to testing

PREVENTION

• Minimize continuous exposure to commonly known allergens
• Remove offending allergens/avoid exposure
• Adherence to pharmacological regimen
• Avoidance of allergen is first line of treatment

NONPHARMACOLOGIC MANAGEMENT

• Avoidance/elimination of allergens. Examples: frequent vacuuming, dusting; removal of feather pillows; frequent air filter changes; removal of house plants; pet control; removal of carpet and stuffed animals; use of hypoallergenic pillow/mattress covers; no smoking in home)
• If pharmacologic therapy does not reduce symptoms, offer immunotherapy or refer
• In cases of nasal airway obstruction and enlarged inferior turbinates that don’t respond to medical therapy, refer to ENT
• Referral for acupuncture for patients interested in nonpharmacologic therapy

PHARMACOLOGIC MANAGEMENT

• Saline nasal spray helps to “wash” offending particles trapped in airways
• Antihistamines (nonsedating and sedating available)
• Nasal steroids (preferred agent for most cases)
• Nasal antihistamine sprays (for seasonal, perennial, or episodic allergic rhinitis)
• Combination therapy when monotherapy doesn’t achieve adequate response
• Systemic steroids (avoid if possible and use only short-term)
• Topical cromolyn (mast cell stabilizer)
• Leukotriene modifier more common if patient has other allergies based on diagnosis (e.g. asthma), but not recommended as primary therapy
• Decongestants, oral or topical

ALLERGIC RHINITIS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name®)	Dosage  How supplied	Comments
	diphenhydramine	Adult: 25-50 mg q 4-6 hr Max: 300 mg/dayChildren:  <6 years: individualize 6–12 years: 12.5-25 mg q 4-6 hr Max: 150 mg/day	Cautious use in patients with glaucoma, difficulty urinating due to an enlarged prostate gland, COPD Avoid alcohol within 6 hours of dose May cause profound drowsiness in some patients
	Benadryl	Chew tabs: 12.5 mg Tabs: 25 mg Liquid: 12.5 mg/5 mL Injection: 50 mg/mL
	hydroxyzine	Adult: 25 mg TID-QID  Children: <6 years: 50 mg daily in divided doses >6 years: 50-100 mg daily in divided doses	Unable to establish safety during pregnancy May produce drowsiness in any dose. Appropriate care advised If used in older patients, should administer a low dose and monitor carefully
	Atarax	Caps: 25 mg, 50 mg
	Vistaril	Suspension: 25 mg/5 mL; available in 4 oz.; 1 pt
Antihistamines Second GenerationGeneral commentsDoes not typically produce drowsiness (except cetirizine) and usually dosed once daily    Recommended for patients with primary complaints of sneezing and itching nose	cetirizine	Adults and children ≥12 years:  5-10 mg dailyChildren: 6–11 years: 5-10 mg based on symptom relief 2–6 years: 2.5 mg daily or BID	Caution with activities requiring mental alertness; produces drowsiness because of its affinity for H1 receptors Dosage adjustment needed for ages 77 and older, renal and hepatic impairment Take without regard to food Consider taking in the evening
	Zyrtec	Tabs: 10 mg Chew tabs: 5 mg; 10 mg Syrup: 1 mg/mL; 4 oz bottle
	levocetirizine	Adults and children ≥12 years: 5 mg once daily in the evening  Children: 6–11 years: 2.5 mg once daily in the evening 6 months–5 years: 1.25 mg once daily in the evening	Adjust dose for renal impairment; contraindicated in children 6 months to 11 years with renal impairment Avoid engaging in activities requiring mental alertness Avoid concurrent alcohol or CNS depressants
	Xyzal	Tabs: 5 mg scored Oral Solution: 0.5 mg/mL
	fexofenadine	Adults and children ≥12 years:180 mg daily or 60 mg BID  Children 2–11 years: 30 mg BID	Shake bottle well before use Reduce dose for renal impairment Allegra ODT contains phenylalanine (other Allegra products do not) Avoid aluminum- and magnesium-containing antacids Less effective if taken with fruit juices; take with water Do not expect sedation
	Allegra	Tabs: 30 mg, 60 mg, 180 mg ODT tab: 30 mg Suspension: 6 mg/mL
	loratadine	Adults and children ≥6 years: 10 mg daily  Children 2-5 years: 5 mg once daily	Children use RediTabs or syrup Adjustment needed for renal or hepatic impairment Do not expect sedation

continued

ALLERGIC RHINITIS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name®)	Dosage  How supplied	Comments
	Claritin	Chew Tabs: 5 mg Redi Tabs: 10 mg Syrup: 1 mg/mL
	desloratadine	Adult: 5 mg daily  Children 6 months-11 months:1 mg (2 mL) daily 1-5 years: 1.25 mg (2.5 mL) daily 6-11 years: 2.5 mg (5 mL) daily >12 years: 5 mg daily	Children use RediTabs or syrup Do not expect sedation
	Clarinex	Tabs: 5 mg RediTabs: 2.5 mg Syrup: 0.5 mg/mL
Topical nasal steroids Exert glucocorticoid activity on the nasal mucosa and thus have local anti-inflammatory effectsGeneral comments Indicated for perennial, seasonal allergic rhinitisSymptoms usually improved after 2 weeks but most benefit after a few days  Discontinue if no improvement in symptoms after 3 weeks   Use lowest dose possible, especially in children due to systemic side effects   Epistaxis may occur if mucous membranes become dried or injured from use Mechanics of use important	budesonide	Adult: Starting dose: 1 spray (32 mcg) per nostril daily Usual: 2-4 sprays per nostril daily Max: 4 sprays per nostril dailyChildren 6-12 years: Initial: 1 spray per nostril daily Usual: 1-2 sprays per nostril daily Max: 2 sprays per nostril daily	Gently shake container prior to use Individualize dosage for symptoms Even with minimal systemic absorption of intranasal steroids, possible vertical growth impairment in pediatric patients Rare risk of glaucoma, increased intraocular pressure, cataracts Avoid exposure to chickenpox or measles
	Rhinocort AQ	8.6 g (120 metered sprays)
	fluticasone	Adult: 2 sprays (50 mcg/spray) each nostril daily or 1 spray per nostril 2 times daily  Children >4 years:  Initial: 1 spray each nostril daily Max: 2 sprays each nostril daily	Individualize dosage for symptoms Even with minimal systemic absorption of intranasal steroids, possible vertical growth impairment in pediatric patients Rare risk of glaucoma, increased intraocular pressure, cataracts Avoid exposure to chickenpox or measles Improvement in symptoms may occur as soon as 12 hours but may not be achieved for several days
	Flonase	16-g container, 120 sprays; dose as above age 4 to adult
	Veramyst	Adult: 2 sprays each nostril daily  Children 2-12 years: Initial: 1 spray each nostril daily Max: 2 sprays each nostril daily
	mometasone	Adults and children ≥12 years: 2 sprays (50 mcg/spray) each nostril daily  Children 2-11 years: 1 spray per nostril daily	Individualize dosage for symptoms Even with minimal systemic absorption of intranasal steroids, possible vertical growth impairment in pediatric patients Rare risk of glaucoma, increased intraocular pressure, cataracts Avoid exposure to chickenpox or measles No change in dosage required for older patient
	Nasonex	17 g, 120 sprays

continued

ALLERGIC RHINITIS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name®)	Dosage  How supplied	Comments
	triamcinolone	Adult: 2 sprays (55 mcg/spray) per nostril daily  Children: 6-12 years: Initial: 1 spray each nostril per day Max: 2 sprays each nostril once daily 2-5 years: 1 puff each nostril daily	Individualize dosage for symptoms Even with minimal systemic absorption of intranasal steroids, possible growth retardation when used in pediatric patients Rare risk of glaucoma, increased intraocular pressure, cataracts Avoid exposure to chickenpox or measles Shake well before each use Improvement in symptoms may occur as soon as 12 hours but may not be achieved for several days
	Nasacort (OTC)	16.5 g, 120 sprays
	ciclesonide (Omnaris)	Adults and children >6 years: 2 puffs each nostril daily
	beclomethasone		HFA delivery, similar to delivery system of asthma inhaler, penetrates deep into nasal cavity
	Beconase AQ	42 mcg/inhalation Children 6-12 years: Initial: 1 spray per nostril daily Usual: 1-2 sprays per nostril daily Max: 2 sprays per nostril daily
	Qnasl	40 and 80 mcg/spray Children 4-11 years: 1 spray 40 mcg/inhalation each nostril daily >12 years: 1 spray 80 mcg/inhalation each nostril daily
Antihistamine/ Corticosteroid combination May be used for patients who do not get relief with corticosteroid spray alone	azelastine/ fluticasone	Adults and children >6 years: 1 spray each nostril daily
	Dymista
Leukotriene Receptor Antagonist Oral agents may be used as adjunct in combination with other oral antihistamines and inhaled corticosteroids Should not be offered for primary therapy    Also beneficial in asthma	montelukast	Children 6-24 months: 4 mg granules daily in evening Children 2-6 years: 4-mg chewable tablet daily Children 6-15 years: 5-mg chewable tablet daily Children >15 years: 10-mg tablet daily	Granules may be sprinkled on any food, such as applesauce or yogurt
	Singulair	Granules: 4 mg Chewable tabs: 4 and 5 mg Tablets: 10 mg

CONSULTATION/REFERRAL

• Allergist for testing beyond allergen-specific IgE (ImmunoCAP) when symptoms persist despite treatment
• Allergist may recommend allergen immunotherapy (injection or sublingual)
• ENT for sinus-related etiologies or nasal polyposis
• Emergency department for severe allergic response to allergens

FOLLOW-UP

• 2-4 weeks after initial evaluation and then every 3-6 months depending on patient and symptom severity

EXPECTED COURSE

• Allergies tend to diminish in severity as people age
• Allergic response is heightened each time allergen is contacted
• Allergic response usually not seen at first exposure
• Risk for developing asthma or atopic dermatitis (“allergic triad”)

POSSIBLE COMPLICATIONS

• Otitis media
• Secondary infections of sinuses, tonsils, pharynx
• Sinusitis
• Epistaxis
• Facial changes (e.g., persistent transverse crease due to allergic salute; allergic shiners; chronic dry lips; chronic nasal flaring)
• Snoring (sleep apnea/obstructed breathing)

 

5. Anxiety

DESCRIPTION

Psychic and physical experience of dread, foreboding, apprehension, or panic in response to emotional or physiologic stimuli; may be acute or chronic. Many anxiety disorders develop in childhood and tend to persist if untreated.

 

Common types of anxiety disorders included in the DSM-5 are: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder (social phobia), panic disorder, panic attack specifier, agoraphobia, generalized anxiety disorder, substance/medication-induced anxiety disorder, anxiety disorder due to another medical condition, other unspecified anxiety disorder, and unspecified anxiety disorder.

ETIOLOGY

• Behavioral theory: anxiety is the conditioned response to specific environmental stimuli
• Genetic component (first-degree relative increases likelihood eightfold)
• Biologic theories
  • Norepinephrine, serotonin, and gamma-aminobutyric acid (GABA) are poorly regulated
  • The autonomic nervous system inappropriately responds to stimuli
  • Functional cerebral pathology causes anxiety disorder symptoms
  • Hypothalamic pituitary adrenal (HPA) axis highly implicated

INCIDENCE

• 7.7% lifetime prevalence in U.S. population
• Women > Men
• Most prevalent in 20- to 45-year-olds
• Average age of onset 11 years old
• Separation anxiety is the most common reason given for school refusal (mean age 9 years)

Anxiety is the most common psychiatric disorder in the United States.

RISK FACTORS

• Organic causes:
  • Organic syndromes: endocrinopathies, cardiorespiratory disorders, anemia
  • Use of or withdrawal from medications and substances
    • Alcohol
    • Antihypertensives
    • Caffeine, including analgesics containing caffeine
    • Cocaine, marijuana, hallucinogens, synthetics
    • Corticosteroids
    • Lidocaine
    • Oral contraceptives
    • Nonsteroidal anti-inflammatories
    • Withdrawal from selective serotonin reuptake inhibitors (SSRIs)
  • Family history
• Psychosocial stressors:
  • Marital discord
  • Medical illness
  • Job and/or school-related stress
  • Financial problems
• Psychiatric disorders:
  • Major depressive disorder (MDD)
  • Post-traumatic stress disorder (PTSD)
  • Personality disorders
  • Schizophrenia and other psychotic disorders

ASSESSMENT FINDINGS

• Children:
  • Excessive anxiety about separation after age 3-4 years
  • Note: DSM-5 states that separation anxiety may be present in adulthood
  • Unrealistic worry about harm to self or family
  • Persistent worry about past behavior, competence, or future events
• Adults:
  • Complaints of apprehension, restlessness, edginess, distractibility
  • Insomnia
  • Somatic complaints:
    • Fatigue, headaches
    • Paresthesia, near syncope, derealization, dizziness, diaphoresis
    • Palpitations, tachycardia, chest pain/tightness
    • Dyspnea, hyperventilation
    • Nausea, vomiting, diarrhea
  • Excessive rumination

DIFFERENTIAL DIAGNOSIS

• Obsessive compulsive disorder
• Oppositional defiant disorder
• Personality disorders
• Depression
• Bipolar disorder
• Attention deficit disorder
• Cognitive disorder such as delirium
• Substance intoxication or withdrawal
• Posttraumatic stress disorder
• Any medical condition that involves stimulation of the sympathetic nervous system
  • Arrhythmias, MI, valvular disease
  • Endocrinopathies: hyperthyroidism, Cushing syndrome, hypoglycemia, electrolyte imbalances, menopause
  • Medication/substance reactions and/or withdrawals
  • Anemia
  • Asthma, COPD, pulmonary embolism, pneumothorax

DIAGNOSTIC STUDIES

• TSH
• CBC, urinalysis
• Urine drug screen
• Focus on medical conditions for which patient is already being treated
• Direct attention toward arrhythmias, hyperthyroidism, drugs
• Evaluate prominent constellation of symptoms
• Psychologic testing
  • Patient-Reported Outcome Measurement Information System (PROMIS) for emotional distress-anxiety: available for adults, adolescents and children
  • Hamilton Anxiety Scale
  • Zung Anxiety Self-Assessment

NONPHARMACOLOGIC MANAGEMENT

• Psychotherapy
  • Education about diagnosis, treatment plan, and prognosis
  • Support and empathic listening
  • First-line treatment for children and adolescents
  • Relaxation techniques
  • Cognitive behavioral therapy
  • Reconditioning: exposure to feared stimuli in controlled setting to develop tolerance and eventually eradicate the anxiety response
• General measures
  • Regular exercise and healthy diet
  • Adequate sleep and limit caffeine intake
  • Serial office visits

Advise patients to avoid alcohol consumption because this increases the risk of drug interactions and is associated with high rates of abuse and rebound anxiety.

PHARMACOLOGIC MANAGEMENT

• Benzodiazepines should be of limited duration, with intent of allowing patient to benefit from behavioral treatments
  • Drugs should play an adjunctive role, except in panic disorder
  • Drugs reduce—not eradicate—symptoms
  • Long-term use of SSRIs or other serotonergic agents may be required

Selective serotonin reuptake inhibitors (SSRIs) may not achieve therapeutic response for 2-4 weeks. Full anti-anxiety response may take 12 weeks or more. Consider starting with lower doses.  Use of benzodiazepines until an SSRI or SNRI becomes effective is a common short-term strategy; expectations of use and duration should be discussed with the patient at the time treatment is initiated.

• Specific phobia
  • Benzodiazepines: short-term use only, up to 1-3 months with planned taper
  • Works well but concerns with addiction in long-term use
• Generalized anxiety disorder
  • First-line treatment
    • Selective serotonin reuptake inhibitors (SSRIs)
    • Selective norepinephrine reuptake inhibitors (SNRIs)
  • Buspirone (BuSpar)
    • Adult: 7.5 mg PO BID-TID; usual range 20-30 mg/day
    • Children <6 years: not recommended
    • 6-17 years: 7.5-30 mg PO BID
  • Tabs: 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg
• Panic disorder
  • First-line treatment: SSRIs and SNRIs
  • Tricyclic antidepressants (TCAs): Perform risk assessment; can be lethal in overdose
  • Benzodiazepines
  • Beta blockers may also be helpful, particularly with panic associated with specific stimuli

Be aware of the boxed warning about risk for increased suicidality in children, adolescents, and young adults who take SSRIs.

 

ANXIETY PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Benzodiazepines (BNZs) binds at stereospecific receptors at several sites in the CNSGeneral comments CNS depressant activity is produced, ranges from mild impairment to hypnosis. Do not engage in activities that require mental alertness while taking  All BNZs have abuse potential Do not mix with other CNS depressants (like alcohol); sedative effect is enhanced Tolerance develops with daily use Lowest effective dose should be used Use for short periods of time (2-4 weeks) All BNZs are Schedule IV Lower dosages in older adults Monitor for seizures during withdrawal Withdrawal symptoms can occur with abrupt withdrawal, especially after 12 weeks Preference is to use BNZs with shorter half-life in older adults, to avoid cumulative toxicity DO NOT MIX WITHketoconazole, itraconazole Caution in patients with renal, hepatic, alcohol use, or pulmonary dysfunction; may cause respiratory depression Contraindicated in acute narrow-angle glaucoma Contraindicated in patients with history of substance misuse	alprazolam	Immediate Release Adult >18 years:  Initial: 0.25-0.5 mg PO TID Max: 4 mg PO daily in divided doses Older or debilitated: 0.25 mg PO BID-TIDExtended Release Adult:  0.5-1 mg PO daily in the AM; increase at intervals of at least 3-4 days Usual: 3-6 mg/day Max: 10 mg/day	May increase dose at intervals of 3-4 days. Do not increase by more than 1 mg daily Most addictive of this class due to short half-life and rapid onset
	Xanax	Tabs: 0.25 mg, 0.5 mg, 1 mg, 2 mg
	Xanax XR	Extended-release tabs: 0.5 mg, 1 mg, 2 mg, 3 mg
	clonazepam	Adult > 18 years: Initial: 0.25-0.5 mg PO BID-TID Max:  4 mg PO daily in divided dosesOlder or debilitated: start at lowest dose and slowly titrate up	Less addictive due to long half-life Boxed Warning: Be aware of prescribing opiates and benzodiazepine together; higher incidence of respiratory failure and death when combined
	Klonopin	Tabs: 0.5 m, 1 mg, 2 mg ODT: 0.125 mg, 0.25 mg, 0.5 mg,1 mg, 2 mg
	diazepam	Adult:  Initial: 2-10 mg PO BID-QID depending on severity of symptomsOlder or debilitated: 2-2.5 mg PO 1 or 2 times initially; increase gradually as tolerated	Less addictive due to long half-life
	Valium	Tabs: 2 mg, 5 mg, 10 mg
	lorazepam	Adult: Initial: 2-3 mg/d PO given BID-TIDOlder or debilitated: 1-2 mg/d PO in divided doses	Preferred BNZ for patients with compromised hepatic functioning due to avoiding the first pass Common BNZ utilized to assist with detox from alcohol; short-term use in monitored environment
	Ativan	Tabs: 0.5 mg, 1 mg, 2 mg scored

continued 

ANXIETY PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Selective Serotonin Reuptake Inhibitors (SSRIs)General commentsMay increase the risk of suicidal thinking and behavior in patients with major depressive disorder, especially in children, adolescents and young adults  Monitor patient closely for clinical worsening, suicidality, unusual changes in behavior, especially during initial months of therapy. Ideally, patient should be seen within 2 weeks of initiating or changing the dose of an antidepressant   Full effect may be delayed 4 weeks or longer   May increase risk of bleeding, especially in combination with aspirin, NSAIDs, warfarin   Do not abruptly stop usage   Monitor for hyponatremia   Drug interactions may occur with many medications given in combination with SSRIs. Check compatibility   **Use of SSRIs in the treatment of anxiety disorders could be indefinite	fluoxetine  *FDA indication for the treatment of panic disorder	Adult: 20 mg PO once daily.  May increase dose after several wk if insufficient clinical response. Doses >20 mg may be administered in single dose or BID   Max: 80 mg daily   Children 8-17 years: Initial: 10-20 mg PO daily. If started on 10 mg/day, increase after 1 wk to 20 mg/day   Lower weight children: start at 10 mg/day PO; may increase after several wk to 20 mg/day	Avoid in patients with uncontrolled narrow-angle glaucoma No dosage adjustment recommended for renal dysfunction or older patients. However, older adults may have greater sensitivity Monitor for weight change during treatment May alter glycemic control (hypoglycemia during use, hyperglycemia after discontinuing) Discontinuation should take place gradually rather than abruptly
	Prozac	Tabs: 10 mg, 20 mg, 40 mg Solution: 20 mg/5 mL
	escitalopram  *FDA indication for treatment of generalized anxiety disorder	Adult: 10 mg PO once daily. May increase in 1 to 2 wk Max Adults: 20 mg PO daily Max Older Adults: 10 mg PO daily Note: requires gradual tapering to discontinueChildren >12: dosing is same as adult dosing except increase should be delayed until after 3 weeksNot approved for patients <12 years old	Avoid in patients with uncontrolled narrow-angle glaucoma No dosage adjustment recommended for renal dysfunction or older adults. However, older adults may have greater sensitivity Prolongs the QT interval Watch for hyponatremia Discontinuation should take place gradually rather than abruptly
	Lexapro	Tabs: 5 mg, 10 mg, 20 mg  Liquid: 5 mg/5 mL
	paroxetine  *FDA indication for the treatment of panic disorder, social anxiety disorder, and generalized anxiety disorder	Adult: Initial: 20 mg PO in morning; may increase dose in 10-mg increments at 1-week intervals Max: 50 mg dailyOlder or debilitated: Initial: 10 mg PO Max: 40 mg PO daily	At least 14 days should elapse between MAO inhibitor and administration of paroxetine Avoid in patients with uncontrolled narrow-angle glaucoma Cautious use in history of seizures Discontinuation should take place gradually rather than abruptly; consider 10 mg/d at wkly intervals before discontinuing Sedation is common complaint; consider dosing at bedtime. Monitor for weight gain; not uncommon
	Paxil	Tabs: 10 mg, 20 mg, 30 mg, 40 mg  Suspension: 10 mg/5 mL
	Paxil CR	Adult:  Initial: 25 mg PO daily; adjust by 12.5 mg/d PO at wkly intervals Max: 62.5 mg/d   Older or debilitated: Initial: 12.5 mg/d PO Max: 50 mg/d PO
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)General commentsAntidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment.  Monitor BP before beginning SNRIs and regularly during treatment; could increase BP.	duloxetine    *FDA indication for treatment of generalized anxiety disorder	Adult: 60 mg PO once daily Alternative: 30 mg PO once daily for 1 wk, then increase to 60 mg once daily Max: 120 mg PO but no evidence doses >60 mg PO confer greater benefit	At least 14 days should elapse between MAO inhibitor and administration of citalopram Avoid in patients with uncontrolled narrow-angle glaucoma
	Cymbalta	Caps: 20 mg, 30 mg, 60 mg caps
	venlafaxine  *FDA indication to treat panic disorder and social anxiety disorder	Adult: 37.5-375 mg PO daily in divided doses with food; should taper over a minimum of 2 wk
	venlafaxine ER	Adult: 75-225 mg PO daily with food; taper dose by no more than 75 mg/wk PO to discharge
	Effexor XR	Caps: 37.5 mg, 75 mg, 150 mg caps

continued 

ANXIETY PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Anxiolytic; Serotonin 1A partial agonist; serotonin stabilizer  General comments Slower onset than benzodiazepines; optimum effect requires 3 to 4 weeks of therapy. Do not use with MAOIs; caution with itraconazole, cimetidine, nefazodone, erythromycin, and other CYP3A4 inhibitors	buspirone	Adult: 7.5 mg PO BID-TID, usual range 20-30 mg/day  Max: 60 mg daily   Children 6-17 years: 7.5-30 mg PO BID   Not approved for use in children <6 years old	Buspar brand discontinued in U.S. Not recommended for severe renal or hepatic impairment Monitor for signs/symptoms of serotonin syndrome, especially in combination with other serotonin modulators Avoid large quantities of grapefruit juice No FDA indication for children aged 6-17 years; use would be off-label
	Buspar	Tabs: 5 mg, 7.5 mg 10 mg, 15 mg, 30 mg

PREGNANCY/LACTATION CONSIDERATIONS

• BNZs contraindicated in pregnancy and lactation
• TCAs contraindicated in pregnancy
• SSRIs contraindicated in first trimester but may be continued by midwife/obstetrician

CONSULTATION/REFERRAL

• Parent/child or family intervention
• Evidence of substance abuse
• Disabling symptoms
• Symptoms that worsen despite treatment

FOLLOW-UP

• Regular follow-up visits are important to reinforce education about nonpharmacologic management and proper use of medications
• Avoid prescribing anxiolytics by telephone
• Remain alert to signs of medication misuse
• Tricyclic antidepressants require periodic serum levels along with baseline and follow-up EKGs

EXPECTED COURSE

• Anxiety in children can be a precursor to agoraphobia or panic disorder in adulthood
• Treatment of medical cause usually, but not always, initiates improvement
• Short-term anxiety disorders usually respond well to treatment
• Obsessive compulsive disorder requires long-term pharmacologic therapy and psychotherapy

Generalized anxiety disorder is a chronic disease with many exacerbations and relapses.   Exacerbations are more common during times of stress.  Relapses more common in the first year if medication is discontinued.

POSSIBLE COMPLICATIONS

• Work- and school-related difficulties
• Self-medication leading to alcohol abuse, benzodiazepine dependence
• Social impairment
• Cardiac arrhythmias related to TCA use
• Falls due to sedating effects of medications, especially in older adults
• Suicide

 

6. Asthma

DESCRIPTION

A chronic inflammatory disorder of the respiratory system that causes airway constriction and hyperresponsiveness of the bronchi. Airway narrowing increases mucus production, reversible airway obstruction, inflammation, and airway hyperresponsiveness. Symptoms range from occasional and mild to severe and debilitating.

A consistent definition of asthma is elusive because symptoms vary among patients. It is helpful to think of asthma as an inflammatory disorder of the airways. The WHO defines asthma as a disease characterized by “recurrent attacks of breathlessness and wheezing that vary in severity and frequency from person to person.”

ETIOLOGY

• Inflammation of the bronchial mucosa and spasm of the bronchial smooth muscle leads to narrowing of the small and, occasionally, the large airways
• Produces characteristic cough and wheezing

INCIDENCE

• In the United States, 18.4 million adults and 7.2 million children are affected by asthma
• 1 in 11 children and 1 in 12 adults have asthma
• Asthma is responsible for almost 500,000 hospitalizations and 1.9 million ED visits per year
• Most common noncommunicable disease of early childhood; half of cases develop during childhood
• Leading cause of missed school days and work, with an estimated annual cost of $56 billion in lost productivity, medical care, and death

RISK FACTORS

• Comorbid conditions:
  • Adults: URI, COPD, GERD, obesity, obstructive sleep apnea, chronic sinusitis
  • Children: URI, viral respiratory infection in susceptible people, cystic fibrosis, obesity
  • Respiratory irritants: tobacco smoke, wood smoke, perfumes, pollution, cockroaches, dust mite exposure
• History of atopy and allergen exposure
• Exercise
• Residing in an urban area
• Family history
• Female sex: women account for nearly 65% of asthma deaths overall
• Black race/ethnicity: black people are three times more likely to die from asthma than people of other races. Black women have the highest asthma mortality rate of all groups, more than 2.5 times higher than white women

A personal or family history of asthma or other atopic diseases is suggestive of asthma in a patient with symptoms of asthma.

ASSESSMENT FINDINGS

• Between attacks, patients with asthma are generally free from symptoms
• Initially, airway constriction causing expiratory wheezing
• Shortness of breath
• Tachypnea
• Tachycardia
• A nonproductive cough
• Chest tightness
• Hyperresonance
• Prolonged expiration
• Accessory muscle use in severe asthma attack
• Sudden nocturnal dyspnea
• Decreased exercise tolerance
• Normal growth and development in children, even with frequent steroid use

Classification of Asthma Severity
Mild intermittent	Symptoms ≤2 days per week or ≤2 nights per month; Exacerbations brief
Mild persistent	Symptoms ≥2 times per week, but <1 time per day or <2 nights per month
Moderate persistent	Daily symptoms or more than 3-4 nights per month
Severe persistent	Continual symptoms or frequent nighttime symptoms >1 night per month

Source: National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

DIFFERENTIAL DIAGNOSIS

• Respiratory infections
• Heart failure
• Gastroesophageal reflux disease
• Habitual or nonasthma-related cough
• COPD
• Tuberculosis
• Foreign body aspiration, especially in children

A diagnosis of asthma requires the presence of respiratory symptoms such as intermittent dyspnea, cough, wheezing, and variable expiratory airflow obstruction.

DIAGNOSTIC STUDIES

• Spirometry
• Pulmonary function tests
• Consider allergy testing
• Peak flow monitoring
• Methacholine challenge test

PREVENTION

• Identify and minimize known asthma triggers by avoiding allergens and irritants
• Take prescribed asthma medications daily
• Learn early signs and symptoms of asthma exacerbation
• Implement an asthma action plan, a preplanned medication plan for asthma exacerbations
• Influenza and pneumococcal pneumonia immunizations
• Monitor peak flow values
• Learn correct use of inhalers, spacers, and other medications: about half of people using inhalers do so incorrectly

An asthma action plan can be based on a patient’s peak expiratory flow rate, but symptom-based plans appear equally effective.

NONPHARMACOLOGIC MANAGEMENT

• Peak flow monitoring
• Avoidance of asthma triggers if possible
• Ongoing patient and family education about disease, treatment, trigger avoidance, asthma management, and emergency actions can minimize asthma severity
• Use of asthma action plan and proper use of peak flow meter can reduce ED visits and hospitalizations

PHARMACOLOGIC MANAGEMENT

• Inhaled corticosteroids (ICSs) are the mainstay of treatment and are indicated for all categories of persistent asthma
• Among ICS molecules, fluticasone has greater systemic side effects than other steroids, and budesonide has a better systemic adverse effect profile
• Newer ICSs, such as ciclesonide, might be more beneficial in reducing systemic effects

All patients with persistent asthma must have a rescue medication (short acting bronchodilator), like albuterol, to use when bronchoconstrictive episode occurs.

 

Mild Intermittent	Short-acting bronchodilator: for exacerbations
Mild persistent	Preferred treatment: low-dose ICS Short-acting bronchodilator for exacerbations Alternative treatment: cromolyn, leukotriene ORsustained-release theophylline (serum concentration 5-15 mcg/mL) Consider leukotriene blocker (Singulair, Accolate)
Moderate persistent	Preferred treatment: low- to medium- dose ICS and long-acting inhaled bronchodilator Short-acting bronchodilator for exacerbations Alternative treatment: low- to medium-dose inhaled corticosteroid and leukotriene blocker OR theophylline
Severe persistent	Preferred treatment: high-dose ICS and long-acting inhaled bronchodilators AND, if needed, oral corticosteroids (2 mg/kg/d not to exceed 60 mg/d) Short-acting bronchodilator for exacerbations Omalizumab is an option when other asthma medications are ineffective. It is an expensive anti-IgE medication given as an injection every 2 to 4 wk to prevent reactions from allergic triggers

Source: National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

For infants and children <5 years of age: Cromolyn (Intal) preferred over steroids if provides adequate symptom management. Nebulized bronchodilator preferred over metered-dose inhaler. Use spacer/holding chamber and face mask
Mild intermittent	Short-acting bronchodilator: for exacerbations
Mild persistent	Preferred treatment: low-dose ICS Short-acting bronchodilator for exacerbations Alternative treatment: cromolyn, leukotriene Consider leukotriene blocker (Singulair)
Moderate persistent	Preferred treatment: low-dose ICS and long-acting inhaled bronchodilator OR medium-dose inhaled corticosteroid Short-acting bronchodilator for exacerbations Alternative treatment: low-dose ICS and leukotriene blocker OR theophylline
Severe persistent	Preferred treatment: high-dose ICS and long-acting inhaled bronchodilators AND, if needed, oral corticosteroids (2 mg/kg/day not to exceed 60 mg/day) Short-acting bronchodilator for exacerbations

Source: National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

ASTHMA PHARMACOLOGIC MANAGEMENT Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Short-Acting Bronchodilators  Stimulate beta 2 receptors in the lungs, causing bronchodilation. Used as rescue inhalersGeneral commentsParadoxical bronchospasm can result from use of bronchodilators; may be life-threatening  Increased use of albuterol can signify deteriorating asthma. Give special consideration to anti-inflammatory treatment (corticosteroids)	albuterol (inhaled or nebulized)	Adult and ≥12 years: Usual: 2 puffs q 4-6 hr prn for bronchospasm Alternative: 1 puff q 4-6 hours Children <4 years: not recommended ≥4 years: 2 puffs q 4-6 hours; 1 puff q 4 hours may sufficePrevention of exercise-induced asthma: ≥4 years: 2 puffs q 15-30 min before exercise Each puff: albuterol 90 mcg	Can increase heart rate and blood pressure, cause QT prolongation and ST segment depression Cautious use in patients with cardiac arrhythmias, convulsive disorders, hyperthyroidism Use extreme caution in patients on MAO inhibitors, beta blockers May cause hypokalemia, especially if in conjunction with potassium-wasting medications. Consider monitoring potassium levels Possible decreases in digoxin levels Shake well before each spray
	Ventolin HFA	17-g canister contains 200 actuations
	albuterol	Adult and ≥12 years: Usual: 2 puffs q 4-6 hr Children ≥4 years: 2 puffs q 4-6 hr; 1 puff q 4 hr may be sufficient for some patients Each puff: albuterol 90 mcg
	ProAir HFA	8.5 g canister/200 actuations
Long-Acting Bronchodilators Stimulate beta 2 receptors in the lung: maintenance meds that do not treat an acute asthma attackGeneral commentsParadoxical bronchospasm can result from use of bronchodilators and may be life-threatening  Long-acting bronchodilators increase the risk of asthma-related death. Do not use in patients with asthma unless accompanied by a long-term asthma control medication, such as an inhaled steroid	salmeterol	Adult: 1 puff q 12 hr	Only for use in conjunction with a long-term asthma control medication, such as an inhaled steroid  Do not use long-acting agents to treat acute symptoms. These agents take 15-20 minutes to produce bronchodilation Tolerance develops with prolonged use Significant drug interactions with ketoconazole, erythromycin, clarithromycin Can increase heart rate, blood pressure, and cause QT prolongation and ST segment depression Cautious use in patients with cardiac arrhythmias, convulsive disorders, hyperthyroidism Use extreme caution in patients on MAO inhibitors, beta blockers May cause hypokalemia, especially if in conjunction with potassium-wasting medications. Consider monitoring potassium levels
	Serevent Diskus	Each puff:30 mcg salmeterol 60 actuations

continued 

ASTHMA PHARMACOLOGIC MANAGEMENT Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Xanthines Cause bronchodilation by relaxing smooth muscle of the bronchi and pulmonary blood vesselsGeneral commentsUsed as an alternative in asthma treatment; not first line  Toxicity is a general concern with theophylline. Activated charcoal used to manage acute and chronic toxicity	theophylline	Adult:  Initial: 300-400 mg daily for 3 days; if tolerated, increase dose to 400-600 mg daily; after 3 more days, if tolerated and needed, increase dose to blood level Max: 400 mg daily for patients with impaired clearance or age >60 years12-15 years: 16 mg/kg Max: 400 mg/day PO	The xanthenes are central respiratory stimulants and reduce fatigability in patients with COPD Must monitor levels (10-20 mcg/mL is desirable). Common symptom of toxicity is repetitive vomiting Elevated levels predispose patient to ventricular arrhythmias, seizures. Use is ill advised in patients with active peptic ulcer disease, seizure disorders, cardiac arrhythmias Monitor for tremors, anxiety, jitteriness Many food-drug interactions involving CYP 450 system No dosage adjustment for renal impairment; need adjustment for hepatic insufficiency, heart failure Smoking increases clearance of theophylline High-fat meal increases absorption of theophylline Do not crush or chew extended-release tablets Aminophylline is converted to theophylline
	Theo-24	Tabs: 100 mg, 200 mg, Extended-Release Caps: 300 mg, 400 mg
Anticholinergics (Short-Acting) Block action of acetylcholine and thus cause mild bronchodilation and prevent bronchoconstrictionGeneral commentsNo used first line in asthma  Monitor for signs of worsening narrow-angle glaucoma, worsening GI/GU obstruction	ipratropium	Adult: 2 puffs QID Max: 12 puffs/24 hr solution for nebulizer Adult: 500 mcg TID-QID	Not indicated for relief of acute bronchospasm Works well in conjunction with a bronchodilator Atrovent HFA canister does not require shaking, but it does need to be primed
	Atrovent HFA	17 mcg/puffs 12.9 g/200 puffs Solution: 2.5 mL/vial (25)
Inhaled Corticosteroids Glucocorticoids decrease activity of inflammatory cells and mediatorsGeneral commentsSteroid activity is local (in the lungs) and is associated with minimal systemic absorption  Decreases in bone density can occur with steroids; monitor May cause immunosuppression; possible increased risk of pneumonia, worsening of existing infections. Cautious use with concurrent 3A4 inhibitors	fluticasone propionate	Adult: Previously on bronchodilators: Initial: 88 mcg inhaled BID Max: 440 mcg inhaled BIDPreviously on inhaled steroids: Initial: 88-220 mcg inhaled BID Max: 440 mcg inhaled BIDPreviously on oral steroids: Initial: 440 mcg inhaled BID Max: 880 mcg inhaled BID	Slowly wean patients on oral steroids to inhaled steroids Abrupt withdrawal of oral steroids can cause symptoms of adrenal insufficiency (fatigue, weakness, hypotension) Inhaled glucocorticoids have fewer and less severe adverse effects than orally administered glucocorticoids. Clinicians should aim for the lowest dose possible to avoid systemic adverse effects on hypothalamo-pituitary-adrenal axis, bone density and growth
	Flovent HFA	44 mcg/actuation (10.6 g) 110 mcg/ actuation (12 g) 220 mcg/actuation (12 g)

continued 

ASTHMA PHARMACOLOGIC MANAGEMENT Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Monitor for increased intraocular pressure, glaucoma and/or cataracts  Rinse mouth well after use to prevent thrush	budesonide	Adult:  Initial: 360 mcg inhaled BID Alternative: Some patients may respond to 180 mcg inhaled BID Max: 720 mcg inhaled BID	Inhaled steroids do not cause systemic effects Monitor for symptoms of fungal infection in the mouth and pharynx
	Pulmicort Flexhaler	Available: 180 mcg/actuation, 120 doses
	mometasone	Previously on bronchodilators alone or inhaled steroids Initial: 220 mcg once in the PM Max: 440 mcg daily as single dose or dividedPreviously on oral corticosteroids (wean gradually) Initial: 440 mcg inhaled BID Max: 880 mcg inhaled daily
	Asmanex Twisthaler	Inhalations-20 g; 240 actuations
Combination Inhaled Corticosteroid/Long-Acting Bronchodilator Glucocorticoids decrease activity of inflammatory cells and mediators Steroid activity is local (in the lungs) and is associated with minimal systemic absorptionGeneral commentsParadoxical bronchospasm can occur with combo medications  Close monitoring for glaucoma and cataracts is warranted Possible metabolic effects: hypokalemia, hyperglycemia Rinse mouth well after use to avoid thrush	fluticasone/salmeterol	Adults and children ≥12 years: Not previously on inhaled steroid: 1 puff 100/50 or 250/50 dailyAlready on inhaled steroid:  see literatureIf insufficient response after 2 wk use next highest strength Max: 1 puff 500/50 BID Children 4-11 years: 1 puff 100/50 BID	Monitor for symptoms of fungal infection in the mouth and pharynx NOT indicated for the relief of acute bronchospasm Increased risk of pneumonia Risks associated with inhaled steroids and long-acting bronchodilators are identical in these combination products, as in individual products Base initial dose on asthma severity
	Advair Diskus	100/50, 250/50, 500/50 Diskus (60 blisters)
	budesonide/formoterol	Adults and children ≥12 years:  2 puffs 80/4.5 or 160/4.5 BID (AM and PM) If inadequate response after 1-2 wk of 80/4.5, increase to 2 puffs 160/4.5 Max: 2 puffs 160/4.5	Monitor for symptoms of fungal infection in the mouth and pharynx NOT indicated for the relief of acute bronchospasm Increased risk of pneumonia in patients Risks associated with inhaled steroids and long-acting bronchodilators are identical in these combinations products, as in individual products
	Symbicort	Available: 80/4.5, 160/4.5 60, 120 actuations

continued 

ASTHMA PHARMACOLOGIC MANAGEMENT Inhaled steroids are used for the maintenance of asthma control in patients with persistent asthma. Long-acting beta agonists (LABAs) may increase the risk of asthma-related death and should NEVER be used alone in the management of asthma. LABAs should only be used with a concurrent long-acting steroid.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Leukotriene antagonists Block the action of leukotrienes which are released from mast cells and eosinophils and are associated with airway edema, increased inflammatory activity and smooth muscle contractionGeneral commentsThese agents are NOT substitutes for bronchodilators or inhaled steroids  Take daily Monitor for drug interactions with zafirlukast	montelukast	Adults and children >15 years:  10 mg Children 6-14 years: 5 mg chew tab PO daily; Children 2-5 years: 1 4-mg chew tab PO daily; Children 12-23 months: 1 4-mg granule packet PO dailyFor prevention of exercise-induced asthma: take at least 2 hr before exercise	Cautious use in hepatic dysfunction Not for use as lone product in severe asthma Chew tab contains phenylalamine Leukotriene antagonists are helpful in managing allergic component
	Singulair	Tabs: 10 mg Chew tabs: 4 mg, 5 mg  Oral granules: 4 mg
	omalizumab	Adult and children ≥12 years: Initiate dosing according to Table 1 or 2 (next section)  Table 1: Subcutaneous Xolair doses q 4 wk for patients ≥12 years: Pretreatment serum IgE ≥30-100 IU/mL: 30-60 kg, >60-70 kg, >70-90 kg, dose 150 mg; >90-150 kg, dose 300 mg   Pretreatment serum IgE >100-200 IU/mL: 30-60 kg, >60-70 kg, >70-90 kg, dose 300 mg   Pretreatment serum IgE >200-300 IU/mL: 30-60 kg, dose 300 mg   Higher body wt and serum IgE levels, move to biwkly dosing (below)	May be appropriate when other asthma meds are ineffective; anti-IgE medication given IM every 2-4 weeks to prevent reactions from allergic triggers FDA indication for moderate to severe persistent allergic asthma First monoclonal antibody with FDA indication to treat chronic idiopathic urticaria in adults and adolescents who remain symptomatic despite H1 antihistamine treatment Xolair is a subcutaneous injection administered in office by a healthcare provider Provider must be prepared to manage anaphylaxis that can be life-threatening Indication is for moderate to severe persistent asthma in patients ≥6 years who have a positive skin test or in whom symptoms are inadequately controlled with inhaled corticosteroids Limitations of use: not indicated for treatment of urticarial or other allergies and does not treat acute bronchospasm or status asthmaticus
	Xolair
		Table 2: Subcutaneous Xolair doses q 2 wk for patients ≥12 years:  Pretreatment serum IgE >100-200 IU/mL: >90-150 kg, dose 225 mg   Pretreatment serum IgE >200-300 IU/mL: >60-70 kg, >70-90 kg, dose 225 mg; >90-150 kg, dose 300 mg   Pretreatment serum IgE >300-400 IU/mL: 30-60 kg, >60-70 kg, dose 225 mg; >70-90 kg, dose 300 mg   Pretreatment serum IgE >400-500 IU/mL: 30-60 kg, >60-70 kg, dose 300 mg; >70-90 kg, dose 375 mg; higher wt, do not dose   Pretreatment serum IgE >500-600 IU/mL: 30-60 kg, dose 300 mg; >60-70 kg, dose 375 mg; higher wt, do not dose   Pretreatment serum IgE >600-700 IU/mL: 30-60 kg, dose 375 mg; higher wt, do not dose
		Patients 6 to <12 year:  Subcutaneous Xolair doses 2 q 2  or 4 weeks for pediatric patients with asthma who begin Xolair between ages 6 and <12 years:https://www.gene.com/downlo ad/pdf/xolair_prescribing.pdf

PREGNANCY/LACTATION CONSIDERATIONS

• Stress importance of prevention
• Poor control can result in low birth weight infants, premature labor/delivery, increased risk of fetal mortality
• Aggressive treatment of symptoms with steroids, bronchodilators, and theophylline if needed

CONSULTATION/REFERRAL

• Allergist/pulmonologist for patients with severe persistent asthma, a life-threatening exacerbation, or hospitalization for asthma, and patients who required more than two rounds of oral steroids in a year or who are candidates for immunotherapy

FOLLOW-UP

• As needed to educate patient, parent, caregiver about disease and management
• Every 3-6 months for stable disease

EXPECTED COURSE

• Excellent with adherence to asthma action plan
• Small percentage of patients have poor control, even with proper medication use
• Risk of mortality increased by nocturnal symptoms, history of intubation for asthma, history of hospitalization/ICU admission for asthma, more than three ED visits annually for asthma, and oral steroid dependence
• Adult women, black people, and older adults have the highest death rates

POSSIBLE COMPLICATIONS

• Respiratory failure/death from unrelieved bronchospasms
• Steroid dependence

 

7. Back pain-

DESCRIPTION

Activity intolerance due to lumbar pain that involves an intervertebral disc. Referral of pain to the buttocks, posterior thighs, and/or down one or both legs (radiculopathy) is common.

 

Low back pain is generally mechanical in nature and attributed to degenerative changes.

 

Radiculopathy is a disorder of the spinal nerve roots due to compression, inflammation, or tearing of nerve roots at the site of entry into the vertebral canal.

Back pain can be further classified into three categories  Acute: less than 6 weeks’ duration Subacute: 6 weeks to 3 months’ duration Chronic: symptoms for more than 3 months or on more than half of days in the prior 6 months

ETIOLOGY

• Often unclear; stretching or tearing of nerves, muscles, tendons, ligaments, or fascia of back secondary to trauma or chronic mechanical stress
• Compression or irritation of a nerve root is a common cause. Nonpharmacologic Management Essay Examples

The vertebral discs most commonly affected in low back pain are L4-L5 and L5-S1.

INCIDENCE

• >85% of U.S. population affected at some point
• Most common musculoskeletal problem worldwide
• Second most common reason to seek healthcare
• Common cause of hospitalizations and subsequent surgeries
• Overall prevalence is 38% of the U.S. population
• Prevalence of chronic low back pain is about 15%
• Men = Women

RISK FACTORS

• Obesity
• Sedentary lifestyle, inadequate conditioning
• Cigarette smoking
• Preexisting psychological conditions
• Chronic occupational strain, improper lifting techniques
• Exaggerated lumbar lordosis, chronic poor posture
• Leg length discrepancy
• Age >65 years

ASSESSMENT FINDINGS

• Pain in back, buttocks and/or one or both thighs that is aggravated by movement, rising from seated position, standing, and flexion; may be relieved by rest, repositioning, or reclining
• Muscle spasm may be present over lumbosacral area due to soft tissue involvement (ligaments, muscles)
• Pain may radiate down leg and below the knee
• Assess rectal tone in patients describing cauda equina syndrome
• Motor, sensory, and reflex examinations are imperative
• Observe gait, assess lower extremity strength and bulk of muscles, pulses
• Deep tendon reflexes (DTR)
  • Patellar: tests nerves at roots L2-L4
  • Achilles: tests nerves at roots S1-S2
• DTR responses are graded as follows:
  • 0: no response
  • +1: diminished response
  • +2: normal response
  • +3: increased response
  • +4: hyperactive response

Diminished DTR responses may imply myopathies, decreased muscle mass, and nerve root impairment. DTR responses greater than normal are characteristic of pyramidal tract disease, electrolyte imbalance, hyperthyroidism, or other endocrine abnormalities.
New-onset radicular pain in older patients is often a sign of spinal stenosis.

 

Straight leg raise test; elevation of affected leg in supine position will elicit pain at 20-30° for severe disease, 30-60° for moderate disease. Crossed leg raise test: elevating unaffected leg produces pain in affected leg.

 

DIFFERENTIAL DIAGNOSIS

• Low back strain
• Herniated intervertebral disc
• Prostatitis, pyelonephritis
• Vascular occlusion at level of bifurcation; abdominal aneurysm
• Carcinoma if bony metastasis occurs
• Endometriosis, fibromyoma
• Depression, hysteria
• Malingering
• Compression fracture, osteoporosis
• Osteoarthritis
• Ankylosing spondylitis
• Cauda equina syndrome
• Hip or pelvic pathology

DIAGNOSTIC STUDIES

• Routine imaging is not recommended for patients with acute or nonspecific back pain. Red flag symptoms (below) or lack of clinical improvement in 4-6 weeks warrants consideration of plain film imaging
  • Neurologic deficits
  • History of cancer
  • Accompanying unexplained weight loss
  • Substance abuse: steroids, alcohol, drugs
  • History of significant trauma
  • Patient involved in litigation, desiring compensation
• Consider additional studies only for patients who have severe or progressive neurologic deficits or symptoms of underlying conditions
  • MRI
  • CBC, ESR, serum calcium, alkaline phosphatase, serum immunoelectrophoresis
  • Urinalysis

Many patients have bulging discs but do not experience symptoms.

PREVENTION

• Education about proper lifting techniques, body mechanics
• Conditioning exercises
• Maintenance of appropriate weight for height
• Avoid cigarette smoking

NONPHARMACOLOGIC MANAGEMENT

• Patient education and reassurance (80-90% recover by 6 weeks), NSAIDs, acetaminophen and muscle relaxers for nonspecific acute low back pain (AAFP evidence rating A)
• Avoid bed rest or restrict to no more than 1-2 days
• Physical therapy (McKenzie method), core strengthening exercises after acute injury to decrease recurrence (Evidence rating B)
• Chiropractor/spinal manipulation not more effective than medical treatment (Evidence rating B)
• No substantial benefit with steroids, acupuncture, massage, traction, lumbar supports or exercise program (Evidence rating A)
• Gradually resume activities as tolerated and include gradually increasing low-stress aerobic exercises
• Physical modalities
  • Cryotherapy for 20-30 minutes several times up to 48 hours after onset
  • Apply heat for 20-30 minutes several times a day after the first 48 hours
  • Exercise: isometric tightening of abdominal and gluteal muscles after acute pain subsides; lumbar hyperextension exercises
• Education about preventive measures
• Shoe insoles, shoe lifts recommended for leg length discrepancies >2 cm

Conservative measures are usually recommended for the first 6 weeks, unless neurological deficits or severe pain is present.

PHARMACOLOGIC MANAGEMENT

• NSAIDs reduce pain and inflammation and promote healing
• Acetaminophen reduces pain but is more effective in combination with a narcotic analgesic or NSAID
• Muscle relaxants have NOT been proven more effective than NSAIDs either alone or concomitantly, but they are helpful for spastic conditions
• Short-term use of opioid analgesics for pain relief has NOT been proven more effective than NSAIDs; opioids are associated with potential for physical dependence
• Consider epidural steroid injections to reduce inflammation and pain if conservative treatments fail

CONSULTATION/REFERRAL

• Findings that indicate neurological involvement
• Recurrent or chronic pain unresponsive to therapy
• Physical therapy initially if pain is moderate and conservative treatment has not provided relief

FOLLOW-UP

• Return for repeat evaluation in 24-48 hours if pain is severe, and in 7-10 days if pain is moderate; follow every 2-4 weeks until able to resume lifestyle
• Ongoing education and support about lifestyle changes
• If unable to tolerate activities despite no serious underlying pathology, explore psychosocial factors. Nonpharmacologic Management Essay Examples

EXPECTED COURSE

• In 80% of cases, symptoms resolve in 4-6 weeks

POSSIBLE COMPLICATIONS

• Prolonged disability associated with physical, psychological, social, and economic factors

 

8. BPH

DESCRIPTION

Benign enlargement of the prostate gland that narrows the urethral lumen and leads to increased prostatic smooth muscle tone. Pathophysiology associated with various lower urinary tract symptoms.

ETIOLOGY

• Exact cause unknown, but strong evidence supports age-related hormonal changes and an androgen/estrogen imbalance
• Epithelial ratio changes secondary to aging increase the number of prostatic stem cells and decrease cell death
• The presence of androgens is necessary for the development of benign prostatic hyperplasia (BPH)

INCIDENCE

• Uncommon age younger than 40
• 42% of men aged 51-60 years
• 82% of men by age 70-80 years
• Responsible for $1.1 billion in healthcare costs annually and 4.4 million office visits annually

RISK FACTORS

• Elevated PSA levels, increased physical activity
• Increasing age
• Family genetics
• Black men more likely to be affected than other patient populations
• Asian men less likely than any other patient population to be diagnosed with BPH
• Cigarette smoking, male-pattern baldness, and metabolic syndrome are now considered weak risk factors for BPH

ASSESSMENT FINDINGS

• Weak urinary stream
• Hesitancy and postvoid dribbling
• Incomplete emptying of bladder
• Frequency and urgency
• Nocturia
• Urinary incontinence
• Urinary retention
• Hematuria: gross or microscopic
• Firm, smooth, symmetrically enlarged prostate

The size of the prostate in a man with benign prostatic hyperplasia (BPH) does not always correlate with symptoms.

 

DIFFERENTIAL DIAGNOSIS

• Prostatitis
• Prostate cancer
• Urethral stricture
• Neurogenic bladder
• Effect of medications (e.g., sympathomimetics, opiates, antihistamines, anticholinergics)
• Urinary tract infection
• Malignancy (bladder or prostate)

DIAGNOSTIC STUDIES

• Initial evaluation with American Urological Association Symptom Index, a self-administered tool that asks seven questions about symptoms of prostatism: incomplete emptying, frequency, intermittency, urgency, a weak stream, hesitancy, and nocturia. The index is scored from 0-35 depending on symptoms:
  • Mild symptoms: score of 0-7
  • Moderate symptoms: score of 8-19
  • Severe symptoms: score of 20-35
• May also use International Prostate Symptoms Score (IPSS)
• Urinalysis: pyuria if residual urine present
• Creatinine for assessment of renal function
• Postvoid residual urine measurement (>100 mL)
• Prostate-specific antigen (PSA): may be elevated, but <10 ng/mL
• Ultrasound of prostate (not necessary for routine evaluation of the gland)
• Needle biopsy
• IVP, CT or MRI of the prostate
• Optional testing: maximal urinary flow rate, postvoid residual urine volume, urine cytology

NONPHARMACOLOGIC MANAGEMENT

• Lifestyle modifications may provide relief of mild symptoms (AUA score 0-7)
  • Limit fluids before bedtime
  • Frequent voiding
  • Avoid sympathomimetic or anticholinergic medications (e.g., decongestants) due to increased risk of urinary retention
  • Avoid caffeine, alcohol, and other beverages that produce diuresis
  • Sitting to urinate vs. standing may reduce symptoms
• Surgical options for patients with moderate to severe symptoms:
  • Transurethral resection of the prostate (TURP): gold standard for relief of symptoms related to urinary retention in men with low surgical risk, or those desiring long-term benefit
  • Transurethral incision of the prostate (TUIP), radiofrequency ablation and microwave therapy are all viable options for younger men who cannot tolerate TURP or photoselective vaporization (PVP) surgeries
  • Photoselective vaporization (PVP) is an ablative procedure generally performed on an outpatient basis. PVP removes less prostate tissue and produces less blood than TURP. HoLEP and ThuLep are variations of photolaser surgery that are synonymous with open prostatectomy
  • Open prostatectomy may be necessary for very large prostates (>100 g)

A normal prostate gland in a young man weighs about 20 grams.

• Indications for surgery: severe symptoms, refractory urinary retention, recurrent urinary tract infections, recurrent hematuria, bladder stones, renal insufficiency due to BPH

PHARMACOLOGIC MANAGEMENT

• Pharmacologic therapy is indicated in mild to moderate disease (AUA score >8)
• Mild to moderate symptoms warrant treatment with an alpha-1 adrenergic antagonist as monotherapy; provides immediate therapeutic benefits
• 5-alpha reductase inhibitors should be used long term for maximum efficacy: 6-12 months of treatment may be required for symptom improvement
• In men with severe symptoms, it is acceptable to initiate therapy with a combination of alpha-1 adrenergic antagonists and a 5-alpha reductase inhibitor

BENIGN PROSTATIC HYPERPLASIA PHARMACOLOGIC MANAGEMENT Prior to initiating therapy, appropriate evaluation is necessary to identify conditions such as infection, prostate cancer, stricture disease, hypotonic bladder or other neurogenic disorders that might mimic BPH
Class	Drug Generic name (Trade Name)	Dosage How supplied	Comments
Alpha 1 adrenergic antagonists  Blockade of the alpha adrenergic receptors causes relaxation of smooth muscle in the prostate and neck of the bladder   General comments May cause orthostatic hypotension   Use with caution in patients taking erectile dysfunction medications   Seek medical attention for priapism	doxazosin	Adult:  Initial: 1 mg PO daily Usual: titrate for effect Max: 8 mg PO daily Extended Release Adult: Initial: 4 mg PO daily Usual: titrate for effect Max: 8 mg PO daily	Drug therapy must be individualized Increase immediate-release dose at 7- to 14-day intervals; increase extended-release dose at 3- to 4-week intervals Extended-release form contraindicated in patients with hepatic dysfunction Extended-release form should be taken daily with breakfast Do not crush or chew extended-release form
	Cardura	Tabs: 1 mg, 2 mg, 4 mg, 8 mg scored
	Cardura XL	Extended-release tabs: 4 mg, 8 mg
	tamsulosin	Adult:  Initial: 0.4 mg PO daily Max: 0.8 mg PO daily	Dose daily at consistent time May increase dose after 2-4 weeks If higher doses are held for extended periods, resume at lower dose and titrate down
	Flomax	Caps: 0.4 mg caps
	terazosin	Adult:  Initial: 1 mg PO/day at HS Usual: titrate for effect Max: 20 mg PO/day	Syncope most likely timed with dosage administration If higher doses are held for extended periods, resume at lower dose and titrate down
	Hytrin	Tabs: 1 mg, 2 mg, 5 mg, 10 mg Caps: 1 mg, 2 mg, 5 mg, 10 mg
	Alfuzosin	Adult:  Initial/Max: 10 mg PO daily
	Uroxatral	Tabs: 10 mg
	silodosin	Adult:  Initial: 8 mg PO daily CrCl of 30-50: 4 mg PO daily CrCl <30: contraindicated Max: 8 mg PO daily
	Rapaflo	Tabs: 4 mg, 8 mg

 

BENIGN PROSTATIC HYPERPLASIA PHARMACOLOGIC MANAGEMENT Prior to initiating therapy, appropriate evaluation is necessary to identify conditions such as infection, prostate cancer, stricture disease, hypotonic bladder or other neurogenic disorders that might mimic BPH
Class	Drug Generic name (Trade Name)	Dosage How supplied	Comments
5-Alpha Reductase Inhibitors  Inhibit conversion of testosterone to DHT Enlargement of the prostate gland is caused by DHT General comments Pregnant women should not handle product May take 6-12 months to assess benefit of therapy PSA levels will decrease while on this therapy	dutasteride	As Monotherapy: Adult:  Initial: 0.5 mg PO daily Max: 0.5 mg PO dailyAs Combination Therapy Initial: 0.5 mg PO daily Max: 0.5 mg PO daily in combination with tamsulosin (0.4 mg) daily	Do not crush or chew If higher doses are held for extended periods, resume at monotherapy dose and titrate back
	Avodart	Caps: 0.5 mg
	finasteride	As Monotherapy: Adult:  Initial: 5 mg PO daily Max: 5 mg PO dailyAs Combination Therapy: Adult: Initial: 5 mg PO daily Max: 5 mg PO daily in combination with doxazosin daily	Do not crush or chew May be taken without regard to meals May decrease amount of ejaculation
	Proscar	Tabs: 5 mg
Phosphodiesterase-5 (PDE-5) Inhibitors  Inhibit phosphodiesterase type 5 (PDE-5), enhance effects of nitric oxide, and increase cGMP, resulting in relaxation of smooth muscle. Nonpharmacologic Management Essay Examples   General comments   Use cautiously in patients with BP of 90/50 mm Hg, CAD with MI and CABG or revascularization in the last 6 months, retinal disorders, or bleeding risks   Not safe to be administered with nitrates or long-acting nitrates   Transient hypotension may occur   Obtain baseline creatinine level   Patients should be urged to report sudden changes in vision   Priapism lasting greater than 4 hours should be evaluated	tadalafil	Adult:  Initial: 2.5 mg PO daily Max: 5 mg PO daily CrCl <30: contraindicated	Avoid concomitant use of nitrates Use caution if patient on alpha blocker May be taken without regard to meals Use with caution in patients with recent MI, CVA May use lower starting dose in older adults or patients with diminished renal or hepatic function
	Cialis	Tabs: 2.5 mg, 5 mg, 10 mg, 20 mg
5-alpha reductase inhibitors decrease PSA. For purposes of screening for prostate cancer, PSA value must be doubled in order to compare with premedication result.

CONSULTATION/REFERRAL

• Refer for urological evaluation if refractory to treatment, evidence of renal complications, or if surgery indicated

FOLLOW-UP

• Annual digital rectal exam
• PSA annually
• Review possible side effects of medications and screen for erectile dysfunction
• Patient should be encouraged to keep a log of symptoms and voiding patterns, including volume of urination, for review at follow-up

EXPECTED COURSE

• Symptoms improve or stabilize in 70-80% of patients
• 20-30% of patients require treatment due to worsening of symptoms

POSSIBLE COMPLICATIONS

• Acute urinary retention
• Urinary incontinence (nocturnal is common)
• Nocturia
• Urinary tract infection
• Prostatitis
• Hydronephrosis
• Erectile dysfunction from pharmacologic or surgical treatment

 

9. Depressive disorder

DESCRIPTION

Depression is a constellation of signs and symptoms that have multifactorial causes including life circumstances, biological predisposition, and epigenetic influences. Disturbances in cognitive, emotional, behavioral, and somatic regulations are involved. Depressed mood and anhedonia are the major symptoms.

Anhedonia is a loss of pleasure or interest in things that previously provided joy or pleasure. To be diagnosed with depressive disorders, the patient must exhibit depression and/or anhedonia along with other specifiers.

ETIOLOGY

• Still not well understood
• Impaired synthesis and/or metabolism of norepinephrine, serotonin, dopamine and/or other neurotransmitters

Gamma-aminobutyric acid (GABA)/glutamate, N-methyl-D-aspartate (NMDA) and other neurotransmitters affecting the structural integrity of the brain are thought to be possible factors or contributing factors in depression.

• Evidence indicates genetic predisposition (30-40%)
•  60-70% of cases are related to specific environmental factors including adverse events in childhood and ongoing or recent stress due to interpersonal adversities. Examples include: childhood sexual abuse, other lifetime trauma, decreased or absent social support, and marital issues

Serotonin produces calmness and relaxed state Norepinephrine and dopamine enhance productivity, ambition, concentration and ability to feel pleasure GABA exerts effects on feelings of calmness NMDA is an excitatory neurotransmitter

INCIDENCE

• Major depressive disorder affects 16 million adults annually in the United States
• Will affect 5-20% of the U.S. population at some time
• 1.5-3 times more common among people with an affected first-degree relative
• Affects 2% of preadolescents and 5% of adolescents in the U.S.
• The World Health Organization expects depression to be the leading cause of disability worldwide by 2020

RISK FACTORS

• Female sex
• Psychosocial stressors
• Postpartum period
• Physical or chronic illness, especially migraines and back pain
• Prior episodes of depression and suicide attempts
• Family history of suicide
• Alcohol or substance abuse
• Children with a history of being bullied or experiencing other forms of abuse
• Retirement, aging, significant losses (death of a spouse, loss of job, divorce, etc.)

ASSESSMENT FINDINGS

• Children:
  • Anorexia
  • Sleep disturbance
  • Apathy and sluggishness
  • Developmental delay
  • Anxiety, irritability, cries easily, restlessness
  • Aggression, hyperactivity
  • School problems
  • GI or other somatic complaints
  • Poor self-esteem
  • Cognitive dulling
  • Suicidal thoughts or self-injury
  • Withdrawal or increased clinging behaviors
• Adolescents:
  • Similar to adults
  • Impulsivity
  • Fatigue
  • Hopelessness
  • Substance abuse
• Adults:
  • Depressed mood for 2 weeks or longer and/or anhedonia; at least one of these MUST be present
  • Decreased or increased appetite
  • Weight loss or gain
  • Sleep disorder
  • Psychomotor agitation or retardation
  • Fatigue, loss of energy
  • Feelings of worthlessness, inappropriate guilt
  • Recurrent thoughts of death
  • Difficulty thinking/concentrating or indecisiveness

In adults, depression is likely if the patient experiences anhedonia or depression and any four or more of the following: change in appetite, sleep pattern, fatigue, psychomotor retardation or agitation, poor self-image, concentration difficulty, or suicidal ideation.

DIFFERENTIAL DIAGNOSIS

• Children:
  • Bipolar disorder
  • Attention deficit disorder
  • Separation anxiety
  • Chronic physical illness
  • Conduct disorder
  • Physical or sexual abuse
  • PTSD
  • Substance misuse
  • Organic causes
• Adults:
  • Bipolar disorder
  • Substance misuse
  • Physical illness: organic brain diseases, diabetes, liver, or renal failure
  • Grief reaction; important to distinguish
  • Other psychiatric disorders
  • Medication abuse/use
  • Medication withdrawal
  • Hypothyroidism, B12 deficiency
  • Dementia

DIAGNOSTIC STUDIES

• Structured interviews/questionnaires:
  • The Children’s Depression Inventory
  • Children’s Depression Scale
  • Depression Self-Rating Scale
  • Hamilton Depression Scale
  • DSM-5 cross cutting tools for depression (PROMIS) in children (ages 6-17), adolescents (ages 11-17) and adults
  • Patient Health Questionnaire 9 (PHQ-9; available in a modified form for adolescents)
  • Beck’s Depression Inventory
  • Child Behavior Checklist for ages 4-18 years
  • Pediatric symptom checklist
  • Zung self-rating depression scale
  • Geriatric depression scale

Laboratory studies do not diagnose depression but are used to rule out other conditions.

• Laboratory studies:
  • TSH to rule out hypothyroidism
  • Urine drug screen for substance use disorders
  • ECG as baseline to rule out arrhythmias or heart block before instituting tricyclic antidepressants
  • Consider fasting blood sugar, vitamin D, vitamin B12 and folate levels
  • Some genetic testing is available to help with selection of specific psychotropic medications that are metabolized via the CYP 450 system. This is especially important in patients who have not responded adequately to multiple trials of antidepressants

TCA may provoke arrhythmias in patients with subclinical sinus node dysfunction.

PREVENTION

• Maintain a high index of suspicion in adolescents and adults with family or personal history of depression, suicide attempts (especially within the previous 5 years), chronic illness and/or recent loss
• Ask patients suspected of suicide intent about plan, lethality and availability of method
• Routine questioning about use of alcohol and drugs starting during adolescence and extending into the lifespan. Consider including any school-aged child in questioning about alcohol and drugs as well

NONPHARMACOLOGIC MANAGEMENT

• Identify suicidal risk, plan, lethality, availability and intent
• Establish safe environment: ensure patient safety in least restrictive environment
  • When suicidal urges are present, obtain a “commitment to treatment” statement with a crisis response plan directed at planned responses to addressing behaviors
• Provide community resources, suicide hotline
• Suicide threats should be interpreted as a communication of desperation and are to be taken seriously; know your state’s involuntary commitment laws and APRN scope of practice
• Psychoeducation
  • Ongoing information about illness, symptoms, prognosis, and therapy
  • Include interpersonal relationships, work, other health-related needs
  • Discourage major life changes while in a depressive state
  • Help set realistic, attainable, concrete goals
  • Educate about importance of avoiding alcohol
• Psychotherapy
  • The treatment of choice with or without pharmacological interventions in mild to moderate depression
  • Pharmacological treatment works best when accompanied by psychotherapy
  • Establish and maintain a supportive therapeutic relationship
  • Remain available during times of crisis
  • Maintain vigilance for signs of destructive impulses
  • Strengthen expectations of help and hope for the future
  • Enlist support of others in patient’s social network
• Electroconvulsive therapy (ECT)
  • Indicated for depression in which a rapid antidepressant response is imperative: depression coupled with psychotic features, catatonic stupor, mania, severe suicidality, suicidality in pregnancy, or severe nutritional compromise
  • Indicated for patients who prefer this method of treatment, or who have responded unsatisfactorily to antidepressant medication in the past
  • High rate of therapeutic success
  • Chief side effects are transient postictal confusional state and memory impairment that resolve in a few days
• Light therapy
  • Particularly effective for seasonal affective disorder
  • Exposure to bright white artificial light for 30 minutes or more in morning and/or evening
  • May be used along with pharmacotherapy
• Transcranial magnetic stimulation (TMS)
  • Used in resistant depression
  • Side effects are significantly reduced
  • Treatment is 4-5 times a week for 4-6 weeks
• Vagus nerve stimulation (VNS)
  • Approved for adult patients with long-term or recurrent major depression
  • Requires surgical implantation of a stimulator that runs from the collarbone to the vagus nerve in the neck
    

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In moderate to severe depression, psychotherapeutic interventions in conjunction with pharmacologic therapy are superior to either approach used alone.

PHARMACOLOGIC MANAGEMENT

• Determine coexisting substance use disorders and general medical conditions
• Selective serotonin reuptake inhibitors (SSRIs)
• Serotonin norepinephrine reuptake inhibitors (SNRIs)
• Novel antidepressants
• Tricyclic antidepressants (TCAs)
• Monoamine oxidase inhibitors are not used first or second line because of numerous food and drug interactions. These drugs are usually prescribed by psychiatric specialists
• Atypical antipsychotics may be used to augment poor response to antidepressants alone. These are powerful medications and should be monitored for side effects common to all antipsychotics

TCAs and SSRIs/SNRIs are equally efficacious, but SSRIs have a better side effect profile and would not be fatal if a month’s supply were taken at once. All antidepressants carry a boxed warning about suicidal thoughts and urges in children, adolescents and young adults.
ANTIDEPRESSANT PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
Selective Serotonin Reuptake Inhibitors (SSRIs)    General comments   Considered first-line treatment for depression   May increase the risk of suicidal thinking and behavior in patients with major depressive disorder, especially in children, adolescents and young adults   Monitor patient closely for clinical worsening, suicidality, or unusual changes in behavior, especially during the initial months of therapy. Ideally patient should be seen within 2 weeks of initiating or changing the dose of an antidepressant   Write prescription for smallest practical amount   Full effect may be delayed for 4 weeks or longer   May increase risk of bleeding, especially in combination with aspirin, NSAIDs, warfarin   Do not abruptly stop usage   Monitor for hyponatremia   Drug interactions may occur with many medications given in combination with SSRIs; check compatibility   Treatment should be sustained for 6-18 months with the first episode of major depression   Avoid alcohol when taking SSRIs   May cause decrease in libido   Do not administer to patients within 5 weeks of taking MAO inhibitors; high risk of serotonin syndrome when coadministered. Monitor for other serotonergic agents and educate about increased risk for serotonin syndrome	fluoxetine	Adult: 20 mg PO once daily. Increase dose after several weeks if insufficient clinical response. Doses >20 mg may be administered once daily or BID  Max: 80 mg daily   Children 8-17 years: Initial: 10-20 mg PO daily. If started on 10 mg/day, increase after 1 wk to 20 mg/day Lower weight children: start at 10 mg/day PO; may increase after several wks to 20 mg/day	Avoid in patients with uncontrolled narrow-angle glaucoma No dosage adjustment recommended for renal dysfunction or older adults. However, older adults may have greater sensitivity Monitor for weight change during treatment May alter glycemic control (hypoglycemia during use, hyperglycemia after discontinuing) Discontinuation should take place gradually rather than abruptly
	Prozac	Tabs: 10 mg, 20 mg, 40 mg  Solution: 20 mg/5 mL
	Prozac weekly	Caps: 90 mg e-c delayed release pellets	Used in maintenance phase Start 7 days after last dose of fluoxetine 20 mg when switching from daily dose See fluoxetine for precautions
	citalopram	Adult: 20 mg PO once daily. May increase to 40 mg PO daily after at least 1 wk in between dose increases    Older adult and hepatic impairment: 20 mg PO daily; 40 mg/day PO only for non-responding patients Max: 60 mg daily	At least 14 days should elapse between MAO inhibitor and administration of citalopram Avoid in patients with uncontrolled narrow angle glaucoma No dosage adjustment necessary for renal impairment Discontinuation should take place gradually rather than abruptly Keep dose at lowest effective dose secondary to QT prolongation
	Celexa	Tabs: 10 mg, 20 mg, 40 mg
	escitalopram	Adult: 10 mg PO once daily. May increase in 1 to 2 wk  Max Adults: 20 mg PO daily Max Older adults: 10 mg PO daily Note: Requires gradual tapering to discontinue   Children >12 years: dosing is same as adult dosing, except increase should be delayed until after 3 wk Not approved in patients younger than 12 years	Avoid in patients with uncontrolled narrow-angle glaucoma No dosage adjustment recommended for renal dysfunction or older adults. However, older adults may have greater sensitivity Prolongs the QT interval Watch for hyponatremia Discontinuation should take place gradually rather than abruptly
	Lexapro	Tabs: 5 mg, 10 mg, 20 mg  Liquid: 5 mg/5 mL
	paroxetine	Adult:  Initial: 20 mg PO in morning; may increase dose in 10-mg increments at 1-wk intervals Max: 50 mg daily   Older adults, debilitated: Initial: 10 mg PO Max: 40 mg PO daily	At least 14 days should elapse between MAO inhibitor and administration of paroxetine Avoid in patients with uncontrolled narrow-angle glaucoma Cautious use in history of seizures Discontinuation should take place gradually rather than abruptly; consider 10 mg/day at weekly intervals before discontinuing
	Paxil	Tabs: 10 mg, 20 mg, 30 mg, 40 mg  Suspension: 10 mg/5 mL
	Paxil CR	Adult:  Initial: 25 mg PO daily; adjust by 12.5 mg/day PO at wkly intervals Max: 62.5 mg/day   Older adults, debilitated: Initial: 12.5 mg/day PO Max: 50 mg/day PO
	sertraline	Adult: 50 mg PO daily in AM or PM; may increase at 1-wk intervals  Max: 200 mg/day PO	At least 14 days should elapse between MAO inhibitor and administration of citalopram Avoid in patients with uncontrolled narrow-angle glaucoma No dosage adjustment necessary for renal impairment Need dosage adjustment for hepatic dysfunction Dilute oral concentrate in 4 oz water, ginger ale, lemon/lime soda, or orange juice before administering
	Zoloft	Tabs: 25 mg, 50 mg, 100 mg  Oral concentrate: 20 mg/mL
	Vilazodone	Adult: 40 mg PO once daily	Advise patient to take with food for adequate absorption Not approved for children No dosage adjustment necessary for patients with renal impairment
	Viibryd	Tabs: 10 mg, 20 mg, and 40 mg
Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs)    General comments   Antidepressants increase risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment	duloxetine	Adult: 60 mg PO once daily  Alternative: 30 mg PO once daily for 1 wk, then increase to 60 mg once daily Max: 120 mg PO but no evidence doses >60 mg PO confer greater benefit	May increase the risk of suicidal thinking and behavior in patients with major depressive disorder Do not administer to patients taking MAO inhibitors Avoid in patients with uncontrolled narrow-angle glaucoma May be given without regard to meals Increased risk of bleeding with NSAIDs, aspirin, warfarin Do not prescribe for patients with substantial alcohol use Monitor for orthostatic hypotension and syncope within first week of therapy
	Cymbalta	Caps: 20 mg, 30 mg, 60 mg
	venlafaxine	Adult: 37.5-375 mg PO daily in divided doses with food; should taper this medication over at least 2 wk
	venlafaxine ER	Adult: 75-225 mg PO daily with food; taper dose by no more than 75 mg PO per wk to discharge
	Effexor XR	Caps: 37.5 mg, 75 mg, 150 mg
	desvenlafaxine	Adult:  Initial: 50 mg PO daily; Max: 100 mg daily
	Pristiq	Extended-release tabs: 50 mg, 100 mg
Tricyclic Antidepressants    General comments   Antidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment   TCAs should never be prescribed to children due to risk of sudden death   According to Halter (2018), patients must take therapeutic doses of TCAs for 10-14 days or longer before they begin to work. Full effects may not be seen for 4 to 8 weeks	amitriptyline	Adult: 75 mg PO in divided doses in late afternoon or HS  Alternate: 50-100 mg HS. May increase by 25-50 mg Max: 150 mg/day   Older adults and adolescents: 10 mg PO TID Alternate: 20 mg PO HS	Prescribe smallest amount feasible. Deaths may occur from overdosage with this class of medications May cause sedation; give HS Do not administer to patients taking MAO inhibitors Cautious use in patients with cardiovascular disorders. May cause sinus tachycardia, prolonged QT interval, or arrhythmias Close supervision if given to patients with hyperthyroidism When possible, discontinue prior to elective surgery Fluctuations in blood sugar are possible Cautious use in patients with hepatic dysfunction Periodically monitor drug level
	Elavil	Tabs: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
Norepinephrine and Dopamine Reuptake Inhibitors    General comments   Antidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment	bupropion	Adult: 150 mg PO initially, with target of 300 mg daily given in the AM. If tolerated, can increase to 300 mg as soon as 4 days after starting dose	Full antidepressant effect may not be seen for 4 weeks Dosage adjustment in patients with renal or hepatic dysfunction Contraindicated in seizure disorder, current or prior diagnosis of bulimia Contraindicated in patients undergoing abrupt cessation of alcohol or benzodiazepines Known to assist with sexual side effects of other antidepressants At least 14 days should elapse between MAO inhibitors and bupropion When switching patients from Wellbutrin tablets or from Wellbutrin SR tablets, give the same total daily dose as a single dose of Wellbutrin XR
	Wellbutrin XL	Tabs: 150 mg, 300 mg
	Wellbutrin SR	Adult: 150 mg PO given in AM initially. Target of 300 mg PO daily given in divided doses. Must separate BID doses by 8 or more hr. If tolerated, can increase to 300 mg in divided doses as soon as 4 days after starting 150-mg dose  Max: 200 mg BID
Serotonin Antagonists and Reuptake Inhibitors  (SARIs)   General comments   Trazodone should be used with caution in patients with hepatic impairment   Can be used as adjunct to the treatment of residual anxiety and insomnia with other antidepressants   Useful for patients concerned about sexual side effects and weight gain from other antidepressants	trazodone	Adult: Depression as monotherapy:  Initial: 150 mg/daily in divided doses; can increase every 3-4 days by 50 mg/day as needed for a maximum of 400 mg/day
	Desyrel	Scored Tabs: 50 mg, 100 mg, 150 mg, 300 mg
Noradrenaline and Specific Serotonergic agents (NaSSAs)    General comments   Sedation and weight gain are common with mirtazapine   Breaking a 15-mg tablet in half and administering 7.5 mg dose may increase sedation   Adding mirtazapine to venlafaxine or SSRIs may reverse drug-induced anxiety, insomnia, and GI complaints	mirtazapine	Adult: 15 mg-45 mg HS  Initial: 15 mg q HS; increase 1-2 wk until desired efficacy is reached; max is generally 45 mg/day
	Remeron	Tabs (scored):15 mg, 30 mg, 45 mg  SolTab disintegrating tabs: 15 mg, 30 mg, 45 mg
Other    General comments   Known as a multimodal antidepressant that works on multiple neurotransmitters, including serotonin, glutamate, acetycholine, dopamine, norepinephrine, and histamine   Formerly named Brintellix   Tablet should not be crushed, divided, or dissolved   Shown effective in older adult population   Early results suggest more robust pro-cognitive actions than other antidepressants	vortioxetine	Adult: 5 mg-20 mg daily  Initial: 10 mg once daily; can decrease to 5 mg daily or increase to 20 mg daily depending on patient response Max: 20 mg daily
	Trintellix	Tabs: 5 mg, 10 mg, 15 mg, 20 mg

CONSULTATION/REFERRAL

• Psychiatrist or psychiatric APRN if patient has suicide plan, or for ECT if severe major depression is coupled with psychosis, nutritional compromise, or suicidality. Make appointment and referral at time of visit
• Indications for inpatient psychiatric treatment:
  • Unable to adequately care for self or cooperate with outpatient treatment
  • Has suicidal or homicidal ideation and plan, particularly if method is violent
  • Lack of psychosocial support
  • Complicating psychiatric or medical conditions that make outpatient treatment unsafe
  • Coexistence of substance use disorder

In older adults, depression often coexists with dementia or can even be misdiagnosed as dementia.

FOLLOW-UP

• Within 2 weeks after initiating medication or sooner if patient’s condition dictates
• For a first episode of depression, antidepressant medications should be continued for at least 4-6 months after complete remission of symptoms. Second episodes of depression should be treated for 2 years; three or more episodes may warrant lifetime treatment
• Antidepressant medications should be tapered rather than abruptly discontinued
• Patients with multiple prior episodes of depression may require long-term pharmacologic management
• After recovery from a suicide attempt, explore frame of mind to determine whether suicidal thoughts persist
• Educate about constructive methods of seeking help for future problems
• Further explore sudden, noticeable recovery from major depressive disorder; could be a warning sign of upcoming suicide

EXPECTED COURSE

• 60-70% response rates to antidepressants of all classes
• 4-6 weeks required to fully respond to medication management
• The most common reason for antidepressant failure in primary care is an inadequate dosage, inadequate trial or inadequate length of time on the medication. If some symptom relief is achieved within the first few weeks, continue to push the medication dosage up slowly until the maximum dosage is reached before adding anything else. If no response by 3-4 weeks, switching agents is suggested. After three or more attempts at finding an antidepressant that is efficacious, specialist referral should be considered
• Depression should be treated to remission, not some degree of symptom relief
• High relapse rate during the first 8 weeks after resolution of symptoms

POSSIBLE COMPLICATIONS

• Suicide: overdose of tricyclics is potentially lethal
• Bizarre behavior may endanger social relationships and reputation
• Increased risk of suicide at start of antidepressant therapy; weekly follow-up appointments needed; closely monitor for suicidal ideations
• Complicating psychiatric or medical conditions
• Serotonin syndrome when combining several medications
• Substance abuse resulting from attempts to self-medicate

Most patients with bipolar disorder present with depressive symptoms, not with mania. Careful screening is critical, since antidepressants can cause mania.

 

10. Diabetes Type II-

DESCRIPTION

Complex chronic metabolic illness characterized by abnormal insulin secretion, resistance to insulin in target tissues, and/or a decrease in insulin receptors.

ETIOLOGY

• Influenced by genetics as well as environmental factors
• High body mass with central obesity is strongest environmental factor
• Inactivity
• Drug- or chemical-induced: glucocorticoids, highly active antiretroviral therapy

INCIDENCE

• 30 million (9.4%) of U.S. population
• Incidence rising in all age groups; especially among those born later than 2000
• Increased rates in people with black, American Indian, Hispanic, or Pacific Islander ethnicity
• Men and women affected equally

RISK FACTORS

• BMI >25 kg/m2
• History of gestational diabetes
• History of delivery of macrosomic infant
• Family history of Type 2 diabetes (T2DM)
• Conditions associated with insulin resistance (polycystic ovarian syndrome, acanthosis nigricans)
• HDL-C <35 mg/dL to/- TG >250 mg/dL
• Hypertension or treatment for hypertension
• History of cardiovascular disease
• Hemochromatosis
• Impaired fasting glucose
• Sedentary lifestyle

BMI cut point for screening overweight/obese Asian patients for prediabetes and T2DM is 23 kg/m2.

ASSESSMENT FINDINGS

• Usually discovered on routine examination
• Chemistry panel and urinalysis: glucosuria, proteinuria, hyperglycemia
• Obesity
• Polydipsia, polyuria, polyphagia
• Fatigue
• Blurred vision
• Chronic skin infections
• Balanitis sometimes seen in men older than 65 years
• Chronic candidal vulvovaginitis in women
• May present with hyperosmolar state or coma

Long Term Effects of Hyperglycemia
Hypertension Diabetic kidney disease Coronary artery disease, myocardial infarction Peripheral neuropathy Cerebrovascular accident Severe peripheral vascular insufficiency

DIFFERENTIAL DIAGNOSIS

• Diabetes mellitus Type 1 (T1DM)
• Prediabetes
• Gestational diabetes
• Cushing’s syndrome
• Pheochromocytoma
• Acromegaly
• Corticosteroid use

DIAGNOSTIC STUDIES

American Diabetes Association  Diagnostic Criteria
Fasting Plasma Glucose	≥126 mg/dL, confirmed on different day
Random Plasma Glucose	≥200 mg/dL with symptoms OR 2-hour plasma glucose ≥200 mg/dL on OGTT with 75-g glucose load OR ≥200 mg/dL, confirmed on different day
Prediabetes (impaired fasting glucose)	Fasting glucose between 100 mg/dL and 125 mg/dL, confirmed on different day OR A1C 5.7-6.4% OR OGTT 140-199 mg/dL
Hgb A1C	≥6.5%

*OGTT, oral glucose tolerance test

• Screening: ADA recommends adults ≥45 years be screened every 3 years, and more often if fasting plasma glucose close to 126 mg/dL
• ADA recommends screening patients with history of gestational diabetes at 6-12 weeks’ gestation with OGTT and every 3 years after that for life
• Type 1 distinguished from Type 2: C peptide levels are below normal in T1DM and normal or above normal in T2DM

A patient with A1C range of 5.7-6.4% has a diabetes risk similar to someone who has T2DM. These patients should be counseled on ways to aggressively reduce their risk for development of T2DM.

PREVENTION

• Weight loss to reach and maintain normal BMI
• Exercise 150 minutes or more/week (no more than 2 consecutive days without activity); resistance training 2-3 times/week on nonconsecutive days
• Reduce length of sedentary intervals by interrupting prolonged sitting every 30 minutes
• Focus on education about obesity, low-fat, low-calorie diet, exercise, sequelae, treatments
• Increase awareness; screen for social determinants of health:
  • Financial ability to afford medication
  • Access to healthy foods
  • Food insecurity
  • Community support

NONPHARMACOLOGIC MANAGEMENT

• Weight loss: primary goal for all obese patients with T2DM; even modest weight loss of 5-10 lbs can help increase insulin sensitivity
• Nutrition plan:
  • Three visits with registered dietitian at diagnosis, plus ongoing follow-up visits semiannually to annually
  • An individualized medical nutrition program, preferably one developed by a registered dietitian
• Avoid alcohol
• Avoid smoking, including e-cigarettes
• Exercise
  • Increases insulin secretion, glucose utilization and HDL levels
  • Endurance exercise is optimal (e.g., walking)
  • Perform stress test first if older than 35 years and diagnosed with diabetes
• Periodic physical examinations:
  • Blood pressure and cardiac assessment
  • Funduscopic and vision examination at time of diagnosis, then every 2 years, or if vision problems occur
  • Oral examination
  • Thyroid palpation
  • Skin examination
  • Neurological examination
  • Abdominal examination
  • Examine feet for pulses, cleanliness, odor, swelling, mobility, nail thickness, bruises, pressure points; include sensory evaluation at every visit
  • Psychosocial screening and follow-up for symptoms of distress, depression, anxiety, eating disorders, cognitive capacity

PHARMACOLOGIC MANAGEMENT

• Initiate metformin at diagnosis unless contraindicated
• First-line drug classes: biguanides (metformin), sulfonylureas, thiazolidinediones, GLP-1, dipeptidyl peptidase-4 (DDP-4)
• Second-line drug classes: insulin, meglitinides, diphenylalanine derivatives, bile sequestrants, SGLT2 inhibitors, alpha-glucosidase inhibitors

TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name)	Dosage  How supplied	Comments
Biguanides  Decrease production of glucose in the liver; decrease absorption of glucose in the intestine, and improve insulin sensitivity by increasing peripheral glucose uptake and utilization   General comments   Lactic acidosis is rare but serious metabolic complication   Does not produce hypoglycemia unless caloric intake is deficient, strenuous exercise without caloric compensation occurs, or, in older adults, debilitation or malnourishment   May produce weight loss, improved lipid profiles   May be used as monotherapy or in combination with TZD, insulin, sulfonylureas   Metformin should be temporarily discontinued in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials because use of such products may result in acute alteration of renal function	metformin	Immediate Release  Adult: Metformin 500 mg BID; increase in increments of 500 mg wkly Max: 2000 mg daily in 2 divided doses   Alternate: 850 mg once daily with meals. Increase in increments of 850 mg every 2 wk   Max: 2550 mg/ day in divided doses except Glumetza 2000 mg/day   Children 10-16 years: 500 mg BID, given with meals. Increase in increments of 500 mg wkly Max: 2000 mg daily in divided doses DO NOT USE XR in children	Pregnancy: no evidence of risk Dose with food Avoid in binge drinkers Careful use in patients with heart failure, renal or hepatic dysfunction Diarrhea, flatulence are common initial side effects; usually resolves by 2 weeks Goal is to decrease fasting plasma glucose and Hgb A1C levels to norm or near norm Monitor blood glucose to determine lowest effective dose
		Extended Release  Adult: 500 mg once daily with evening meal. Increase in 500-mg increments, not sooner than once wkly Max: XR 2000 mg/day	Give once daily with evening meal Swallow whole, never crush or chew Do not use in children
	Glucophage, various generics	Tabs: 500 mg, 850 mg, 1000 mg
	Glucophage XL, various generics	Extended-release tabs: 500 mg, 750 mg, 1000 mg

continued

 

TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name)	Dosage  How supplied	Comments
Thiazolidinediones (TZDs)  Inhibit gluconeogenesis in the liver, improve insulin liver sensitivity in the skeletal muscle and adipose tissue, and consequently reduce circulating insulin levels in hyperinsulinemic patients   General comments   Can exacerbate or precipitate heart failure   Not recommended in patients with symptomatic heart failure   Contraindicated in patients with Class III or IV heart failure   Depends on the presence of insulin for its action   May be used as monotherapy or in combination with metformin, insulin, sulfonylureas	pioglitazone	Adult >18 years:  Initial: 15 mg or 30 mg once daily Usual: individualized Max: 45 mg/day   Children: not established	Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks Monitor ALT prior to initiation, then periodically per clinical judgment Do not initiate in patients with hepatic dysfunction If ALT increases >3 times the upper limits of normal and remains elevated, discontinue pioglitazone Monitor for fluid retention; may exacerbate heart failure No adjustment necessary for renal dysfunction May increase risk of fractures in menopausal women Can be taken without regard to meals
	Actos	Tabs: 15 mg, 30 mg, 45 mg
Meglitinides  Potentiate insulin secretion from pancreas (short-acting secretagogue)   General comments   Do not use with insulin   May be used as monotherapy or with metformin	repaglinide	Adult: 0.5 mg within 30 min of meal or at mealtime BID to QID for patients not previously treated or with Hgb A1C <8%  Titrate by doubling dose at intervals of at least 1 wk Max: 16 mg/day   Alternate: in patients previously treated with antidiabetic agents and Hgb A1C >8%, initially 1-2 mg with 2-4 meals daily. Titrate by doubling dose at intervals of at least 1 wk Max: 16 mg/day	Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks Preprandial dosing only If a meal is skipped (or added), skip (or add) a repaglinide dose Should not be used with sulfonylureas Use with caution in hepatic failure, age >65, or debilitated patients; may be sensitive to hypoglycemic effects of repaglinide Dose adjustment recommended for renal dysfunction Do not take with gemfibrozil
	Prandin	Tabs: 0.5 mg, 1 mg, 2 mg
Alpha glucosidase inhibitors  Delay absorption of carbohydrates following a meal, resulting in a smaller rise in glucose elevation   General comments   Contraindicated in patients with inflammatory bowel disorders   May be used as monotherapy, with a sulfonylurea, or with insulin	miglitol	Adult: give one tablet 30 min before meals  Initial: 25 mg TID; may start at 25 mg daily and gradually increase to TID. Increase to 50 mg TID after 4-8 wk Usual: 50 mg TID Max: 100 mg TID   Children: not recommended	Pregnancy: animal studies have failed to demonstrate a risk to fetus; no adequate studies in pregnant women These agents do NOT enhance action of insulin Dosage adjustment needed for renal dysfunction; no adjustment needed for hepatic dysfunction If hypoglycemia results, do NOT administer sucrose (absorption will be delayed); instead, administer dextrose Flatulence and diarrhea are common side effects
	Glyset	Tabs: 25 mg, 50 mg, 100 mg

continued

TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name)	Dosage  How supplied	Comments
	acarbose	Adult:  25 mg TID; take with first bite of main meal; increase at 4- to 8-wk intervals Max: 100 mg TID Max <60 kg: 50 mg TID Max >60 kg: 100 mg TID	Pregnancy: animal studies have failed to demonstrate a risk to fetus; no adequate studies in pregnant women Patients with low body weight may be at increased risk for elevated serum transaminases Contraindicated in inflammatory bowel disease Cautious use in renal dysfunction Initially monitor blood glucose 1 hour postprandially during titration, then glycosylated hemoglobin Monitor serum transaminases every 3 months during first year and periodically thereafter
	Precose	Tabs: 25 mg, 50 mg, 100 mg
DDP IV Inhibitors  Dipeptidyl-peptidase-4 (DDP-IV) inhibitors enhance biologically active GLP-1 to increase insulin secretion and suppress glucagon secretion. Preserve beta cell potentia; weight neutral   General comments   Boxed Warning May cause or exacerbate CHF. Watch closely after initiation or dose increase. Contraindicated in patients with NYHA Class III-IV CHF and not recommended in patient with symptomatic CHF   May be used in combination with metformin, TZD, sulfonylurea, insulin	sitagliptin	Adult:  Initial: 100 mg daily Usual: 100 mg once daily Max: 100 mg daily   Children <18 years: not recommended	Pregnancy: animal studies have failed to demonstrate risk to fetus; no adequate studies in pregnant women Dosage adjustment needed for moderate or severe renal dysfunction Take with or without food Monitor renal function prior to initiation and periodically May need to initially lower dose of sulfonylurea Caution with digoxin; monitor pulse rate Monitor for pancreatitis
	Januvia	Tabs: 25 mg 50 mg, 100 mg
	saxagliptin	Adult: may use 2.5-5 mg once  daily Initial: 2.5 mg or 5 mg once daily taken without regard to meals Usual: 5 mg Max: 5 mg daily	Pregnancy: animal studies have failed to demonstrate risk to fetus; no adequate studies in pregnant women May need to initially lower dose of sulfonylurea Dosage adjustment needed for moderate or severe renal dysfunction; no adjustment needed for hepatic dysfunction Take with or without food Monitor for drug interactions with 3A4/5 inhibitors. Nonpharmacologic Management Essay Examples
	Onglyza	Tabs: 2.5 mg, 5 mg
SGLT2 Inhibitors  Boxed Warning Lower limb amputation: twofold increased risk of leg and foot amputations with use of canagliflozin. Prior history of PVD, neuropathy, or diabetic foot ulcers may increase risk. Monitor for infection, new pain or tenderness, sores or ulcers involving the lower limb	canagliflozin	Adult: 100 mg PO daily; give with first meal of day  Max: 300 mg daily   Renal Dosing: eGFR 45-59: 100 mg daily eGFR 30-44: avoid use eGFR <30: contraindicated D/C if eGFR is persistently <45   Peds dosing: not applicable	Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks eGFR at baseline Lipid panel Potassium level if renal impairment or hypokalemia risk Caution in older patients Caution in T1DM Caution hypotension
	Invokana	Tabs: 100 mg, 300 mg
	dapagliflozin	Adult: 5 mg PO q am	Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks Caution in older adults Caution with hyperlipidemia Active bladder cancer eGFR <60 Contraindicated in T1DM
	Farxiga	Tabs: 5 mg, 10 mg

continued

TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name)	Dosage  How supplied	Comments
	empagliflozin	Peds dosing: not applicable	Pregnancy: NO adequate studies to show safety Caution with insulin or sulfonylurea Caution with renal impairment; discontinue if GFR falls below 45 mL/min Caution with hyperlipidemia Increased risk for UTI Caution with diuretics; may cause volume depletion Increased risk for genital mycotic infections Caution with older adults and with renal impairment Contraindicated in T1DM
	Jardiance	Tabs: 10 mg, 25 mg
Glucagon-Like Peptide (GLP-1)  Promotes release of insulin from pancreatic beta cells in the presence of elevated glucose concentrations   General comments   Boxed Warning Thyroid C-cell Tumor Risk: contraindicated in patients with medullary thyroid carcinoma history or patients with family history   May be used with metformin, sulfonylurea, or a TZD   Weight loss is desired side effect	exenatide	Adult:  Initial: 5 mcg BID subcutaneously within 60 min before morning and evening meals (at least 6 hr apart). After 1 month, may increase to 10 mcg Usual: 10 mcg BID Max: 10 mcg BID	Pregnancy: no well-controlled studies in humans, but potential benefits may warrant use Cautious use in patients with end-stage renal disease No dosage adjustment needed for hepatic dysfunction Must be refrigerated prior to first dose, then kept at room temperature Administer SC injection in thigh, abdomen, or upper arm within 60-minute period before morning and evening meals. Do not administer after a meal If dose missed, resume as prescribed with the next dose Common side effect is nausea and anorexia May decrease effectiveness of oral contraceptives
	Byetta	Forms: 5 mcg /1.2 mL prefilled pen (60 doses); 10 mcg/2.4 mL prefilled pen (60 doses)
	dulaglutide	T2DM  Start 0.75 mg SC q wk: max 1.5 mg/wk   Pedi: no dosage available	Boxed Warning:thyroid C-cell tumor risk Contraindicated in patients with medullary thyroid carcinoma history or with family history Caution T1DM Diabetic ketoacidosis Pancreatitis history Gastroparesis Renal impairment Reactions Angioedema Decreased appetite Abdominal pain Tachycardia PR prolongation Amylase & lipase increase Pregnancy & lactation: inadequate information at this time
	Trulicity	INJ Pen: 0.75 mg/0.5 mL per injection, 1.5 mg/0.5 mL per injection
Sulfonylurea Agents  Stimulate release of insulin fromfunctioning pancreatic beta cells   Secondary failure may occur withextended therapy   General comments   Sulfonylureas may be potentiated by many drugs: NSAIDs, quinolones, highly protein-bound drugs, beta-blocking agents, thiazides, others	glimepiride	Adult:  Initial: 1-2 mg once daily with breakfast or first main meal. After reaching dose of 2 mg, increase by up to 2 mg at 1- to 2-mg intervals if needed Usual: 1-4 mg once daily Max: 8 mg/day	Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks Cautious use with renal or hepatic dysfunction, age >65 or debilitated Once 8 mg has been reached and fasting glucose is >150 mg/dL, insulin may be recommended Monitor blood glucose for 1-2 weeks when transferring patient from a longer-acting sulfonylurea to glimepiride
	Amaryl	Tabs: 1 mg, 2 mg, 4 mg

continued

TYPE 2 DIABETES MELLITUS PHARMACOLOGIC MANAGEMENT
Class	Drug  Generic name (Trade name)	Dosage  How supplied	Comments
	glipizide	Adult:  Initial: 5 mg before breakfast. Increase by 2.5-5 mg every few days Max: 15 mg once daily dose Max: 40 mg daily in divided doses 30 min before mealsOlder adults, debilitated, hepatic impairment Initial: 2.5 mg daily Adult:  Initial: 5 mg with breakfast Usual: 5-10 mg once daily Max: 20 mg once daily	Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks Cautious use in renal or hepatic dysfunction
	Glucotrol	Tabs: 5 mg, 10 mg	Pregnancy: no well-controlled studies in humans; evaluate benefits vs. risks Do not crush, chew or divide
	Glucotrol XL	Extended-release tabs: 5 mg,  10 mg

 

EXAMPLES OF COMBINATION DRUGS
Combination Type	Fixed-Dose Combination, mg	Trade Name
DPP IV and biguanide	Sitagliptin-metformin (50/500, 50/1000)	Janumet
Meglitinide and biguanide	Repaglinide and metformin (1/500, 2/500)	PrandiMet
Sulfonylurea and biguanide	Glipizide and metformin (2.5/250, 2.5/500, 5/500)	Metaglip
	Glyburide and metformin (1.25/250, 2.5/500, 5/500)	Glucovance
TZD and biguanide	Pioglitazone and metformin (15/500, 15/850)	Actoplus Met
	Rosiglitazone and metformin (2/500, 4/500, 2/1000, 4/1000)	Avandamet
TZD and sulfonylurea	Rosiglitazone and glimepiride (4/1, 4/2, 4/4)	Avandaryl

DPP IV, Dipeptidyl peptidase-4 inhibitor; TZD, thiazolidinediones

Some drug combinations are available in multiple fixed doses. Each drug is reported in milligrams

 

INSULINS
Insulin Preparation	Onset in hours	Peak in hours	Duration hours
Novolog	< 0.25	1-3	3-5
Levemir	1	0	24
Lantus	1.1	0	> 24
Apidra	0.25	1	2-4
Humalog	< 0.25	1	3.5-4.5
Humalog mix 75/25	< 0.25	0.5-1.5	24
Humalog mix 50/50	< 0.25	1	16
Novolin R	0.5	2.5-5	8
Humulin 70/30	0.5	2-2	24
Humulin 50/50	0.5	3-5	24
Novolin 70/30	0.5	2-12	24
Humulin N	1-2	6-12	18-24
Novolin N	1-5	4-12	24
Toujeo	Develops more than 6 hours after administration	0	24

• Insulin
  • Recommended early in course of oral therapy, but often used when oral agents have been exhausted
  • 0.1-0.2 units/kg/day or 10 units daily of peakless insulin recommended as initial insulin therapy
  • If unable to achieve glycemic goals, administer mealtime insulin
• Other Pharmacologic Therapy
  • Antihypertensive treatment for blood pressure >140/90 mm Hg (130/80 mm Hg considered); no deference to ACE inhibitor or ARB as first-line agent
  •  HMG-CoA reductase inhibitors (statins)
    • Moderate LDL-lowering capacity for hyperlipidemia in T2DM patients ages 40-75; LDL 70-189 mg/dL without additional CV risk factors (primary prevention)
    • High LDL-lowering capacity for hyperlipidemia in any patient who has cardiovascular event or LDL >190 mg/dL (secondary prevention)
  • Focus on education about self-care, low-fat/carb/calorie diet, regular exercise, sequelae, treatments. Nonpharmacologic Management Essay Examples

PREGNANCY/LACTATION CONSIDERATIONS

• Oral agents are generally avoided; however, metformin has been used to treat pregnant women with pregestational diabetes (T1DM or T2DM that existed prior to conception)
• Sulfonylureas are avoided because they cross the placenta and can cause fetal hyperinsulinemia
• Universal screening at 24 to 28 weeks’ gestation for detection of gestational diabetes. If glucose >140 mg/dL 1 hr after 50 g oral glucose load, 3-hr GTT is recommended
• Refer to registered dietitian and diabetes educator
• Addition of insulin if glucose >90 mg/dL fasting or ≥120 mg/dL on two or more occasions in a 2-week period
• Self-monitoring of glucose four times a day or more
• Women with gestational diabetes have increased risk for later development of T2DM, thus follow-up is warranted
• Increased risk of maternal and fetal complications:
  • Pregnancy accelerates development of retinopathy and pregnancy-induced hypertension
  • Increased risk of spontaneous abortion, stillbirth, and congenital anomalies
  • Increased risk of macrosomia resulting in shoulder dystocia

Screen women with gestational diabetes 6-12 weeks  postpartum and continue surveillance throughout lifetime.

CONSULTATION/REFERRAL

• Endocrinologist
• Registered dietitian
• Certified diabetes educator
• Ophthalmologist
• Early referral to foot specialist when needed

FOLLOW-UP

Guidance for follow-up is detailed in Standards of Medical Care in Diabetes 2018, Comprehensive Medical Evaluation and Assessment of Comorbidities (Chapter 3, Table 3.1): https://doi.org/10.2337/dc18-S003

EXPECTED COURSE

• Dependent on glucose control; poor control results in increased risk for vascular complications
• Complications typically develop 10-15 years after onset but can present earlier if DM undetected for years before diagnosis

POSSIBLE COMPLICATIONS

• Diabetic kidney disease, renal failure
• Peripheral neuropathy
• Retinopathy
• Cardiovascular and peripheral vascular disease
• Glaucoma, cataracts, blindness
• Skin ulcerations, gangrene of lower extremities; limb amputations
• Charcot foot
• Diabetic ketoacidosis
• Gastroparesis

 

11. Eczema

DESCRIPTION

Chronic pruritic skin eruption presenting as a patchy plaque-like rash with inflammation. Acute exacerbations appear in characteristic sites. “Eczema” is often used interchangeably with “atopic dermatitis,” but the term eczema describes acute symptoms associated with atopic dermatitis. Eczema occurs most frequently in children, but it affects many adults.

Commonly seen in patients with other atopic illnesses (e.g., asthma, allergic rhinitis).

ETIOLOGY

• Multifactorial: genetic, physiological, immunologic and environmental factors
• Elevated serum IgE levels
• Personal family history of allergies, asthma, allergic rhinitis

INCIDENCE

• Affects almost 10% of children
• 60% first experience symptoms between infancy & age 12 years
• Begins after age 2 months, resolves by age 3 years
• 90% have remission by puberty
• Affects both sexes equally
• More common in black and Asian patients

RISK FACTORS

• Family history of atopic diseases
• Skin infections
• Stress
• Temperature extremes
• Contact with irritating substances (wearing new clothing prior to washing, harsh soaps, skin products with perfumes)

ASSESSMENT FINDINGS

• General: pruritus, erythema, dry skin, facial erythema, infraorbital folds (Dennie-Morgan folds); antecubital fossa, posterior patella areas; scalp area
• Infants:
  • Lesions on flexural surfaces of arms, legs, on trunk, face (especially cheeks)
  • Lesions are erythematous and papular
  • Vesicles may ooze, form crusts
• Children:
  • Lesions common on wrists, ankles and flexural surfaces
  • Presence of scales and plaques; lichenification occurs as a result of scratching
• Adults:
  • Flexural surfaces are common sites (dorsa of the hands and feet)
  • Often reappears in adulthood after absence since childhood
  • Lichenification and scaling are typical

DIFFERENTIAL DIAGNOSIS

• Contact dermatitis
• Seborrheic dermatitis
• Scabies
• Psoriasis

DIAGNOSTIC STUDIES

• Usually none needed
• Skin biopsy to rule out other skin disorders
• 80% of patients may have eosinophilia during episodes of disease activity
• Serum allergy testing is available

PREVENTION

• Liberal use of emollients to prevent dry skin
• Avoid known precipitating factors (stress, wool clothing, detergents with fragrance, etc.)
• Wash clothing with fragrance-free detergents, fabric softeners and dryer sheets
• Keep environments as free of dust as possible
• Use of air purifiers and humidifiers
• Eliminate carpets; clean bedding weekly; use mattress protectors to reduce dust mites
• Wash bedding in water that is 120 to 130 degrees F
• Humidity in home should be no more than 50%

 

Serum allergy testing reveals that dust mites in the environment pose a high threat for skin allergies.  Dermatophagoides farinae: American dust mite Dermatophagoides pteronyssinus: foreign dust mites

NONPHARMACOLOGIC MANAGEMENT

• Bathing is recommended; moisturizer should be applied 1 to 3 minutes after patting skin dry, while skin is slightly moist (pores are open only 1 to 3 minutes)
• Superfatted soaps are best; nonsoap cleansers should have a neutral or low pH
• Prevent skin trauma (sunburns, etc.)
• When possible, soak in warm water for 20 minutes before applying emollient
• Apply cool wet compresses (Burow’s solution) if lesions are weeping or oozing
• Wet wrap therapy for moderate to severe atopic conditions
• Avoid ointments for oozing atopic dermatitis, to allow lesions to dry. Promotes healing
• Sunshine or UVB treatments
• Bleach baths: 3 times weekly (1/4 cup of household bleach in a full tub of water; soak 2-3 minutes). Atopic patients are predisposed to skin infections
• Patient education about disease process, self-care, and precipitating factors, as well as importance of hydrating the skin with moisturizers 1-2 times daily, or as often as needed to keep skin moist. Nonpharmacologic Management Essay Examples

PHARMACOLOGIC MANAGEMENT

• Topical corticosteroids (creams are preferred) are the mainstay of therapy (use lowest potency that controls symptoms)
• Antihistamines (oral and topical) for itching
• Emollients 2-3 times per day or as needed to correct dry skin (Eucerin, Lubriderm, Cetaphil, Vaseline). Steroid-sparing emollients recommended
• Oral corticosteroids may be used for severe cases. Due to the chronic nature of this disease, use only in short bursts
• Intralesional steroid injections
• Topical calcineurin inhibitors: Elidel cream 1% or Tacrolimus ointment 0.03% and 0.1%; maintenance dosing twice weekly for 12 months, use moisturizers on other days. This proactive approach may reduce or delay exacerbations
• Dry skin treated with corticosteroid therapy will exhibit minimal response; however, use for 7 days or less may ease symptoms of erythema and pruritus.

ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients due to larger ratio of skin surface area to body weight. Limit use to lowest effective potency and time.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Low-Potency Steroids exert their anti-inflammatory effect through mechanical, chemical, microbiological and immunological means General comments    Use lowest potency that produces desired effect   Skin atrophy and changes in skin color are possible with long term use   Areas with greatest absorption are the face, groin, and axillae. Consider lowest potency steroids in these areas or avoid prolonged use Systemic absorption is usually minimal, but broken skin absorbs significantly more steroid Topical steroids will worsen skin infections	alclometasone  dipropionate 0.05%	Adults and children >1 years: apply thin film, massage in BID to TID	For external use only Do not use longer than 3 weeks No dosage adjustment needed for geriatric patients Do not occlude or use under diaper
	Aclovate	Cream, oint: 15 g, 45 g,60 g
	fluocinolone acetonide 0.01%	Adults and children: apply thin film BID to QID 0.01% solution 0.025% cream 15 g, 60 g	For external use only Do not use longer than 3 weeks No adjustment in dosage needed for geriatric patients
	Synalar solution	Cream/ointment: 15 g, 60 g Solution: 60 mL, 90 mL
	hydrocortisone butyrate 0.1%	Adult and Children > 2 years: apply thin film BID to QID	For external use only Do not use longer than 3 weeks
	Locoid	Cream/Ointment: 15 g, 30 g, 45 g

continued

ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients because of larger skin surface area to body weight ratio. Limit use to lowest effect potency and time.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Medium-Potency Steroids exert their anti-inflammatory effect through mechanical, chemical, microbiological, and immunological means General comments    Use lowest potency that produces desired effect   Skin atrophy and changes in skin color are possible with long term use   Areas with greatest absorption are the face, groin, and axillae. Consider lowest potency steroids in these areas or avoid prolonged use   Topical steroids will worsen skin infections	triamcinolone  acetonide 0.025% or 0.1%	Adults and children: apply thin film BID to QID	Intended for external use only Caution with use longer than 2 weeks; may change skin pigmentation Caution in pediatric patients
	Aristocort cream Kenalog cream, lotion, ointment	Ointment: 0.1% (medium), 0.025% (medium/low) 15 g, 80 g Cream: 0.1%, 0.025%, 15 g, 80 g Lotion: 0.1% 60 mL Spray: 0.0147%
	desoximetasone 0.05%	Adults and children >10 years: apply thin film BID	Intended for topical use only Caution with use longer than 2 weeks; may change skin pigmentation
	Topicort LP cream	Cream: 15 g, 60 g
	flurandrenolide 0.025%	Adults and children: apply BID to TID	Intended for topical use only Caution with use longer than 2 weeks; may change skin pigmentation
	Cordran	Cream/ointment: 30 g, 60 g
	fluticasone propionate 0.05%	Adult: apply thin film BID    Children >3 months: apply a thin film once daily or BID	Intended for topical use only Safety of use in pediatric patients for more than 4 weeks has not been established No dosage adjustment recommended for geriatric patients
	Cutivate	Cream: 15 g, 30 g Lotion: 60 mL, 120 mL
	hydrocortisone valerate 0.2%	Adult: apply thin film BID to TID  Children: Pediatric dosing not available	Intended for topical use only Caution with use longer than 2 weeks; may change skin pigmentation
	Westcort	Cream/ointment: 15 g, 45 g, 60 g

continued 

ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients due to larger ratio of skin surface area to body weight. Limit use to lowest effective potency and time.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	mometasone furoate 0.1%	Adults and children >2 years: apply thin film once daily	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation DO NOT USE WITH AN OCCLUSIVE DRESSING
	Elocon	Cream/ointment: 15 g, 45 g Lotion: 30 mL, 60 mL
	desoximetasone 0.05% *Cream = medium potency	Adults and children >10 years: apply thin film BID	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation
	Topicort *Ointment = medium potency	Cream/ointment: 15 g, 60 g, 100 g
High-Potency  Corticosteroids Exert anti-inflammatory effect through mechanical, chemical, microbiological, and immunological means   General comments   Use lowest potency that produces desired effect   Skin atrophy and changes in skin color are possible with long term use   Areas with greatest absorption of steroid are the face, groin, and axillae. Consider lowest potency steroids in these areas   Topical steroids will worsen skin infections   Do not use more than 50 g/week	amcinonide 0.1%	Adult: thin film BID to TID  Children: Pediatric dosing not available	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation
	Cyclocort	Cream/ointment: 15 g, 30 g, 60 g Lotion: 30 mL, 60 mL
	betamethasone  dipropionate 0.05%	Adult and children > 13 years: apply thin film once daily to BID Max: 2 consecutive wk	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation Studies demonstrate HPA axis suppression in some children No dosage adjustment recommended for geriatric patients
	Diprolene AF	Ointment/cream: 15 g, 50 g
	desoximetasone 0.05% gel, 0.25% cream/ointment	Adults and children >10 years: apply thin film BID	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation Research shows HPA axis suppression in some children
	Topicort gel	Cream/gel: 15 g, 60 g Ointment: 30 mL, 60 mL

continued 

ATOPIC DERMATITIS PHARMACOLOGIC MANAGEMENT Pediatric patients may be more susceptible to topical corticosteroid-induced HPA axis suppression than older patients due to larger ratio of skin surface area to body weight. Limit use to lowest effective potency and time.
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Super High Potency Exert anti-inflammatory effect through mechanical, chemical, microbiological, and immunological means General comments    Use lowest potency that produces desired effect   Skin atrophy and changes in skin color are possible with long term use   Areas with greatest absorption of steroid are the face, groin, and axillae. Consider lowest potency steroids in these areas or avoid prolonged use   Topical steroids will worsen skin infections   Do not use more than 50 g/week	betamethasone dipropionate augmented 0.05%	Adults and children >13 years: apply thin film once daily to BID  Max: 2 consecutive wk	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation Research shows HPA axis suppression in some children No dosage adjustment recommended for older adults
	Diprolene	Ointment: 15 g, 45 g, 60 g  Lotion: 30 mL, 60 mL Gel: 15 g
	clobetasol propionate 0.05%	Adults and children ≥12 years: apply thin film BID  Max: 50 g/wk	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation Research shows HPA axis suppression in some children No dosage adjustment recommended for older adults
	Temovate cream, gel, ointment, scalp, emollient Clobex, Cormax	Cream/Ointment: 15 g, 30 g, 45 g, 60 g Solution: 50 mL Foam: 100 g Scalp emollient: 50 mL
	flurandrenolide 4 mcg/ sq cream	Adult:  Cream: apply a thin film BID to TID Tape: Apply tape to clean, dry skin; replace every 12 to 24 hr	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation Change tape every 12 hours
	Cordran	Cream: 60g, 120g  Tape: 3” x 24” and 3” x 80”
	halobetasol propionate 0.05%	Adults and children >12 years: apply thin layer BID  Max: 50 g/wk	Topical use only Caution with use longer than 2 weeks; may change skin pigmentation Do not use with occlusive dressings No dosage adjustment recommended for geriatric patients
	Ultravate	Cream/Ointment: 15 g, 45 g

CONSULTATION/REFERRAL

• Dermatology specialist
• Allergy specialist

FOLLOW UP

• Initial treatment and at 2 weeks, then 6 to 8 weeks
• Follow-up is important to assure that patient is improving and steroid medication is not being overused for prolonged periods. Education is important for parents/patients. If flare is severe, prescribe a stronger steroid for 2 weeks and then decrease potency, or change to topical calcineurin inhibitors such as Elidel or Protopic. Daily moisturization is important

EXPECTED COURSE

• Waxes and wanes; expect flaring

POSSIBLE COMPLICATIONS

• Secondary infection: (excoriations in child likely need treatment for skin infection; eczema slow to improve if infection is not treated)
• Steroid atrophy

 

12. Fibromyalgia / myositis

ASSESSMENT FINDINGS

• Burning, stiffness or aching pain at multiple sites (radiating low back, neck and upper posterior shoulder tightness)
• Stiffness on arising
• Fatigue
• Poor sleep, frequent awakenings with inability to fall asleep again
• Sensation of swollen joints and paresthesias
• Memory problems, headaches, light-headedness, dizziness
• Anxiety and/or depression
• Symptoms are triggered or aggravated by temperature changes, lack of sleep, and physical and/or mental stress
• Widespread pain for at least 3 months
• Bilateral pain above and below the waist. Nonpharmacologic Management Essay Examples

Symptoms are common and nonspecific. Therefore, the physical examination may be unremarkable.

 

CONSULTATION/REFERRAL

• Pain management
• Rheumatology
• Psychiatry

Refer nonresponders to a pain specialist or rheumatologist.

 

DESCRIPTION

Fibromyalgia is a complex, idiopathic, chronic neurologic condition characterized by widespread heightened pain sensitivity, sleep disturbance, fatigue, headache, cognitive difficulties, digestive problems, paresthesias and psychological distress.

DIAGNOSTIC STUDIES

• Structured interviews/questionnaires:
  • American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia: 3-month history of pain and symptoms of fatigue, awakening fatigued, cognitive problems; no other health problem explains pain/symptoms
• Laboratory studies:
  • Complete blood count
  • Complete metabolic panel with renal function and liver function
  • Urinalysis
  • Erythrocyte sedimentation rate
  • Rheumatoid factor, if patient has suggestive symptoms
  • Antinuclear antibody, if patient has suggestive symptoms
  • Thyroid-stimulating hormone, T3, T4
  • Creatinine phosphokinase
  • Vitamin D, (25-hydroxy)
  • Vitamin B12
  • Iron studies: TIBC, ferritin, iron
  • Magnesium
  • CRP
  • Additional tests are not recommended for diagnosis unless clinically indicated
  • X-rays, scans and muscle biopsy are normal

Laboratory studies are not diagnostic but are necessary to rule out other disorders.

 

DIFFERENTIAL DIAGNOSIS

• Chronic fatigue syndrome
• Hypothyroidism
• Metabolic and inflammatory myopathies (especially in patients taking statins)
• Polymyalgia rheumatica
• Myofascial pain syndrome
• Osteoarthritis
• Rheumatoid arthritis
• Systemic lupus erythematosus (SLE)

ETIOLOGY

• Unknown, but likely involves nervous system

EXPECTED COURSE

• Fluctuating, chronic course

FOLLOW-UP

• Variable and depends on symptom severity, coping abilities, and patient resources
• Within 2 weeks after initiating medication

INCIDENCE

• Fibromyalgia affects approximately 5 million U.S. adults
• Women > Men
• Can affect children and adolescents

NONPHARMACOLOGIC MANAGEMENT

• The goal of treatment is to improve function and reduce pain
• Complementary and Alternative Therapy
  • Stress Management: cognitive behavioral therapy, relaxation training, group therapy, biofeedback, mindfulness, meditation
  • Exercise: low-impact cardiovascular exercise (walking, swimming, bicycling), strength and aerobic conditioning, flexibility and balance; research shows exercise is most effective treatment
  • Alternative Therapies: Chinese herbal tea, acupuncture, tai chi, yoga, hypnosis, chiropractic therapy, massage therapy, magnetic therapy, trigger point injections
  • Patient Education:
    • Avoid changes in diet
    • Avoid highly processed foods
    • Avoid tobacco smoke exposure
    • Exercise as prescribed: don’t increase without consulting provider
    • Avoid unnecessary life changes
    • Pace activities
  • Provide community resources
• Helpful websites:
  • The Arthritis Foundation
    • http://www.arthritis.org
  • The Fibromyalgia Network Web
    • http://www.fmnetnews.com
  • American College of Rheumatology
    • http://www.rheumatology.org
  • National Fibromyalgia Awareness Campaign
    • http://www.fmaware.org
  • National Fibromyalgia Partnership, Inc.
    • http://www.fmpartnership.org
  • American Chronic Pain Association
    • http://theacpa.org
• Establish and maintain a supportive therapeutic relationship

Psychotherapeutic interventions in conjunction with pharmacologic therapy are superior to either used alone.

 

PHARMACOLOGIC MANAGEMENT

•  Determine coexisting substance use disorders and general medical conditions
• Strongly recommended to avoid opioid narcotic medication, which may worsen the pain. If patient is already on opioids, recommended gradual withdrawal over 2-3 weeks
• Tramadol may be used short term if needed
• Acetaminophen and NSAIDs are not effective, except to treat other pain triggers (arthritis)
• Benzodiazepines and nonbenzodiazepine sleep agents (zolpidem) are not recommended for sleep. Nonpharmacologic Management Essay Examples

FIBROMYALGIA PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)		Dosage How Supplied	Comments
Selective Serotonin Reuptake Inhibitors (SSRIs)    General comments   May increase the risk of suicidal thinking and behavior in patients with major depressive disorder   Monitor patient closely for clinical worsening, suicidality, unusual changes in behavior, especially during initial months of therapy   Write Rx for smallest practical amount   Full effect may be delayed for 4 weeks or longer   May increase risk of bleeding, especially in combination with aspirin, NSAIDs, warfarin   Do not abruptly stop usage   Monitor for hyponatremia   Drug interactions may occur with many medications given in combination with SSRIs. Check compatibility   Treatment should be sustained for several months   Avoid alcohol when taking SSRIs   May cause decrease in libido		fluoxetine	Adult: 20 mg once daily.  Increase dose after several weeks if insufficient clinical response. Doses >20 mg may be administered once or twice daily Max: 80 mg daily   Children 8-17 years: Initial: 10-20 mg daily. If started on 10 mg/day, increase after 1 week to 20 mg/day. Lower weight children, start at 10 mg/day; may increase after several weeks to 20 mg/day	No adequate human fetal studies; evaluate benefits vs. risks Do not administer to patients within 5 weeks of taking MAO inhibitors Avoid in patients with uncontrolled narrow-angle glaucoma No dosage adjustment recommended for renal dysfunction or age >65; older adults may have greater sensitivity Monitor for weight change during treatment May alter glycemic control (hypoglycemia during use, hyperglycemia after discontinuing) Discontinuation should take place gradually, not abruptly
		Prozac	Tabs: 10 mg, 20 mg, 40 mg  Solution: 20 mg/5 mL
		Prozac weekly	Caps: 90 mg e-c delayed-release pellets	No adequate human fetal studies; evaluate benefits vs. risks Used in maintenance phase Start 7 days after last dose of fluoxetine 20 mg when switching from daily dose See fluoxetine for precautions
		paroxetine	Adults:  Initial: 20 mg in morning; may increase dose in 10-mg increments at 1-week intervals Max: 50 mg daily Older adults, debilitated: Initial: 10 mg Max: 40 mg daily	Evidence of human fetal risk At least 14 days should elapse between MAO inhibitor and administration of paroxetine Avoid in patients with uncontrolled narrow-angle glaucoma Cautious use with history of seizures Discontinuation should take place gradually rather than abruptly; consider 10 mg/day at weekly intervals before discontinuing
		Paxil	Tabs: 10 mg, 20 mg, 30 mg, 40 mg  Susp: 10 mg/5 mL
		Paxil CR	Adults:  Initial: 25 mg daily; adjust by 12.5 mg/day at weekly intervals Max: 62.5 mg/day   Older adults, debilitated: Initial: 12.5 mg/day Max: 50 mg/day	See paroxetine
Alpha-2 Delta Ligand    General comments   Potentiates CNS depression with alcohol, other CNS depressants   Additive edema, weight gain with thiazolidinediones		pregabalin	Adults:  Initial: 75 mg BID; may increase to 150 mg BID within 1 wk as tolerated; max 450 mg/day Renal impairment (CrCl <60 mL/min): reduce dose	No adequate human fetal studies; Nursing not recommended Avoid abrupt cessation; taper over 1 wk Discontinue if angioedema, hypersensitivity reactions, myopathy or markedly elevated creatine kinase levels HF: ocular conditions Diabetes: monitor skin integrity Monitor suicidal tendencies
		Lyrica	Capsule: 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, 300 mg  Solution: 20 mg/mL
Alpha-2 Delta Ligand    General comments   Off-label use   Potentiates CNS depression with alcohol, other CNS depressants   Give 2 hours after antacids   May antagonize hydrocodone   May interfere with some urine protein tests		gabapentin	Adults:  Initial: 300 mg daily x 1 day, then 300 mg BID x 1 day, then 300 mg TID, then titrate to effect. Max 2400 mg/day	No adequate human fetal studies. Nursing not recommended Avoid abrupt cessation; taper over 1 wk Monitor for DRESS/multiorgan hypersensitivity, anaphylaxis, angioedema; discontinue if occurs
		Neurontin	Capsules: 100 mg, 300 mg, 400 mg  Tablets: 600 mg, 800 mg Oral Solution: 250/5mL
Serotonin and Norepinephrine Reuptake  Inhibitors (SNRIs)   General comments   Antidepressants increase risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment May increase risk of suicidal thinking and behavior in patients with major depressive disorder Monitor patient closely for clinical worsening, suicidality, unusual changes in behavior, especially during initial months of therapy May increase risk of bleeding, especially in combination with aspirin, NSAIDs, warfarin Do not abruptly stop usage Avoid alcohol when taking SNRIs		duloxetine	Adults: 60 mg once daily  Alternative: 30 mg once daily for 1 wk, then increase to 60 mg once daily Max: 120 mg but no evidence doses >60 mg confer greater benefit	No adequate human fetal studies; evaluate benefits vs. risks May increase risk of suicidal thinking and behavior in patients with major depressive disorder Do not administer to patients taking MAO inhibitors Avoid in patients with uncontrolled narrow-angle glaucoma May be given without regard to meals Increased risk of bleeding with NSAIDs, aspirin, warfarin Do not prescribe for patients with substantial alcohol use Monitor for orthostatic hypotension and syncope within first week of therapy No adequate human fetal studies; evaluate benefits vs. risks May increase risk of suicidal thinking and behavior in patients with major depressive disorder Do not administer to patients taking MAO inhibitors Avoid in patients with uncontrolled narrow-angle glaucoma May be given without regard to meals Increased risk of bleeding with NSAIDs, aspirin, warfarin Do not prescribe for patients with substantial alcohol use Monitor for orthostatic hypotension and syncope within first week of therapy
		Cymbalta	Caps: 20 mg, 30 mg, 60 mg caps
		milnacipran	Adults:  Day 1: 12.5 mg once Days 2-3: 12.5 mg BID Days 4-7: 25 mg BID After day 7: 50 mg BID Max: 100 mg BID Severe renal impairment (CrCl 5-29 mL/min: maintenance 25 mg BID; Max 50 mg BID Older adults and adolescents: 20 mg HS
		Savella	Tabs: 12.5 mg, 25 mg, 50 mg, 100 mg
Muscle Relaxants    General comments   Increased risk of serotonin syndrome with other serotonergic drugs   Potentiates anticholinergics, alcohol, and other CNS depressants   May antagonize clonidine   Tramadol increases seizure risk		cyclobenzaprine	Adults: Start 10 mg at bedtime. May increase to 40 mg/day divided daily to TID  Max dose: 40 mg daily	Potential benefits may warrant use; no risk shown in animal studies May cause drowsiness Moderate to severe hepatic impairment Note with glaucoma: increased intraocular pressure Contraindicated in acute post MI, arrhythmias, heart block, HF, hyperthyroidism Avoid MAOIs within 14 days
		Flexeril	Tabs: 5 mg, 7.5 mg, 10 mg
Tricyclic Antidepressants    General comments   Antidepressants increase the risk of suicide in adolescents and young adults <24 years. Close monitoring by family members and caregivers is advised, especially during the first few months of treatment		amitriptyline	Adults:  25-50 mg HS Max: 150 mg/day Older adults and adolescents: 20 mg HS Nonpharmacologic Management Essay Examples	No adequate fetal studies in humans; evaluate benefits vs. risks Prescribe smallest amount feasible; deaths may occur from overdosage with this class of medications May cause sedation; administer at bedtime if feasible Do not administer to patients taking MAO inhibitors Cautious use in patients with cardiovascular disorders. May cause sinus tachycardia, prolonged QT interval, or arrhythmias Close supervision if given to patients with hyperthyroidism or being treated for hyperthyroidism When possible, discontinue prior to elective surgery Fluctuations in blood sugar are possible Cautious use in patients with hepatic dysfunction
		Elavil	Tabs: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg

POSSIBLE COMPLICATIONS

• Chronic pain
• Chronic work loss
• Marked functional impairment
• Severe depression and anxiety

PREVENTION

• No specific prevention known

RISK FACTORS

• Female sex
• Age 20 to 50 years
• Genetics
• Infections
• Physical or emotional trauma
• Rheumatic disease (osteoarthritis, lupus, rheumatoid arthritis, ankylosing spondylitis)
• Nonpharmacologic Management Essay Examples

 

13. Hyperlipidemia

DESCRIPTION

Elevated levels of blood lipids: cholesterol, cholesterol esters, phospholipids, and/or triglycerides.

ETIOLOGY

• Inherited disorder of lipid metabolism
• High intake of dietary lipids
• Obesity, sedentary lifestyle
• Diabetes mellitus
• Hypothyroidism
• Anabolic steroid use
• Hepatic disorders: hepatitis, cirrhosis
• Renal disorders: uremia, nephrotic syndrome
• Stress
• Drug-induced: thiazide diuretics, β-blockers, cyclosporine
• Alcohol and caffeine
• Metabolic syndrome: characterized by hypertension, glucose intolerance, obesity, dyslipidemia, and/or coagulation abnormalities

INCIDENCE

• Hypercholesterolemia >200 mg/dL: 100 million people in U.S.
• Hypercholesterolemia >240 mg/dL: 35 million people in U.S.
• Men = Women, but onset is 10-15 years later in women
• Incidence increases as age increases
• Familial Hypercholesterolemia (FH)
  • 2% or 1:200 with LDL >190 have mutation in one or more genes
  • Need early preventive therapy to reduce cumulative and chronic LDL exposure that leads to early heart disease

RISK FACTORS

• Family history of CHD [type 2 familial hypercholesterolemia (FH)]
• Physical inactivity
• Smoking
• Age: men > 45 years, women > 55 years or premature menopause without estrogen replacement
• Obesity
• Diet high in saturated fat
• Diabetes mellitus

ASSESSMENT FINDINGS

• Few physical findings
• Xanthomata
• Xanthelasma
• Corneal arcus prior to age 50
• Bruits
• Angina pectoris
• Myocardial infarction
• Stroke

DIFFERENTIAL DIAGNOSIS

• Consider secondary causes: hypothyroidism, pregnancy, diabetes, nonfasting state

DIAGNOSTIC STUDIES

• Fasting lipid profile (9-12 hours of fasting)
• Nonfasting sample: total cholesterol, LDL and
• HDL values minimally affected by eating; triglycerides elevated by eating
• Glucose
• Urinalysis, creatinine (for detection of nephrotic syndrome, which can induce dyslipidemia)
• TSH (for detection of hypothyroidism, which may secondarily cause hypercholesterolemia)

PREVENTION

• 1% decrease in cholesterol decreases CHD risk by 2%
• Adults and children >2 years: reduce dietary intake of fats to <30% of total calories; <7% should be from saturated fat (10% reduction in LDL with this diet)
• Total cholesterol intake <200 mg/day
• Minimize use of trans fatty acids
• Increase intake of fiber, vegetables, fruits, and other whole grains
• Decreased intake of fat is not recommended for children <1 year old
• Identify and eliminate risk factors in children and adults
• Encourage active lifestyle in children to reduce obesity risk
• Adults should exercise at least 2.5 hours per week (sustained aerobic activity increases HDL, decreases TC)
• Weight control and avoidance of tobacco products
• Appropriate management of systemic diseases (e.g., diabetes mellitus, hypothyroidism, hypertension)

NONPHARMACOLOGICAL MANAGEMENT

• Therapeutic lifestyle changes (TLC): nutrition, weight reduction, increased physical activity (See Prevention)
• Patient education about risk factors, lifestyle modifications, diet, exercise, etc.

INDICATIONS FOR PHARMACOLOGICAL MANAGEMENT

• Three risk categories (demographics, labs, personal history) delineate treatment options based on ASCVD 10-year risk calculation and/or presence of major risk factors. See tool at http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/
• Primary lipid target is LDL
• Nonpharmacologic Management Essay Examples

STATIN INTOLERANCE

 

If statin intolerance suspected, temporarily discontinue statin therapy, decrease dosage, and re-challenge with 2-3 statins of differing metabolic pathways and intermittent (1-3x weekly) dosing of long half-life statins

 

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults

Groups Who Benefit From Statin Use  History of CHD or stroke Patients with LDL ≥190 mg/dL DM (no evidence of ASCVD), 40-75 years old with LDL 70-189 mg/dL No evidence of ASCVD or DM; LDL 70-189 mg/dL PLUS estimated 10-year ASCVD risk ≥7.5%

 

Lipid Screening Recommendation

When increased risk for CHD is present, screen men at ages 20-30 and women after age 20 Screen men without risk factors beginning at age 35 Optimal screening interval and age to stop screening are unknown

Source: U.S. Preventive Services Task Force Guide to Clinical Preventive Services, 2014.

Pediatric patients
Total Cholesterol <170 mg/dL	Desirable
LDL Cholesterol <110 mg/dL	Desirable

 

Major Risk Factors

Age (men ≥45 years, women ≥55 years) Family history of premature CHD (first-degree relatives, CHD in men <55 years, in women <65 years) Cigarette smoking Hypertension (BP ≥140/90 mm Hg or on antihypertensive therapy) HDL <40 mg/dL, triglycerides >200 mg/dL Metabolic syndrome Established CHD (history of MI, stable/unstable angina, previous CAD interventions) CHD risk equivalents (peripheral artery disease, abdominal aortic aneurysm, carotid disease, diabetes mellitus)

Source: Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) by the National Cholesterol Education Program (NCEP), 2004.

Summary of 2013 ACC/AHA Updated Guidelines
Risk	Demographics	Lipid Goals/Pharmacologic Intervention
High	Secondary prevention in adults >75 years old Primary prevention in adults with LDL ≥190 mg/dL Primary prevention in adults 40-75 years old with LDL 70-189 mg/dL PLUS estimated ASCVD risk of ≥7.5% Primary prevention in DM aged 40-75 years with LDL 70-189 mg/dL PLUS estimated ASCVD risk ≥7.5%	Goal: 50% reduction in LDL with statin (atorvastatin 40 mg or 80 mg daily; rosuvastatin 20 mg or 40 mg daily)
Moderate	Secondary prevention in adults >75 years old Primary prevention in adults 40-75 years old with LDL 70-189 mg/dL PLUS estimated ASCVD risk ≥7.5% Primary prevention in DM 40-75 years old PLUS estimated ASCVD risk of ≥7.5%	Goal: 30-49% reduction in LDL with statin (atorvastatin 10 mg or 20 mg daily; fluvastatin 40 mg BID, 80 mg daily; lovastatin 40 mg daily; pitavastatin 2 mg or 4 mg daily; pravastatin 40 mg or 80 mg daily; rosuvastatin 5 mg or 10 mg daily; simvastatin 20 mg or 40 mg daily)

 

PHARMACOLOGIC MANAGEMENT

SUMMARY OF LIPID LOWERING AGENTS

DRUG CLASS	↓ LDL	↑ HDL	↓ TRIGS
Statins	19-54%	5-15%	7-30%
Bile Acid Sequestrants	15-30%	3-5%	Insignificant
Nicotinic Acid	5-25%	15-35%	20-50%
Fibric Acids	5-7%	10-20%	20-50%
Cholesterol Absorption Inhibitor	15-18%	3-3.5%	Insignificant
PCSK9 inhibitors	52.8%	–	–

 

LIPID LOWERING AGENTS
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
HMG-CoA Reductase  Inhibitors (Statins) Inhibit HMG-CoA, the enzyme that is partly responsible for cholesterol synthesis; decrease total cholesterol, LDL; minimal increase in HDL General comments: Considered first line therapy Perform liver function tests before initiating therapy, at 4-6 and 12 weeks, and after each dose increase, then periodically (or per manufacturer’s recommendations) To be used in conjunction with diet, exercise, & weight reduction in overweight patients Watch for myopathy, rhabdomyolysis Watch for drug interactions, especially with grapefruit juice and lovastatin, simvastatin, atorvastatin   Not safe during pregnancy	atorvastatin	LDL-C reduction < 45%  Adult: Initial: 10 or 20 mg/day Usual: 10-80 mg/day Max: 80 mg/day LDL-C reduction > 45% Initial: 40 mg/day Usual: 40-80 mg/day Max: 80 mg/day Heterozygous Familial Hypercholesterolemia Children: < 10 years:not recommended 10-17 years: Initial: 10 mg/day Usual: 10 mg/day Max: 20 mg/day	If concomitant use with gemfibrozil, maximum dose should not exceed 10 mg/day If concomitant use with clarithromycin, itraconazole, or protease inhibitors, maximum dose should not exceed 20 mg/day
	Lipitor	Tabs: 10 mg, 20 mg, 40 mg, 80 mg
	fluvastatin	LDL-C reduction < 25%  Adult: Initial: 20 mg in evening Usual: 20-80 mg/day Max: 80 mg/day LDL-C reduction > 25% Adult: Initial: Lescol XL 80 mg in PM OR 40 mg Lescol daily or BID daily or twice daily Usual: 80 mg/day Max: 80 mg/day Children: not recommended	Avoid in patients with substantial alcohol consumption Avoid concomitant fibrates, cyclosporine May be taken without regard to meals
	Lescol	Tabs: 20 mg, 40 mg
	Lescol XL	Extended-release tabs: 80 mg

continued

LIPID LOWERING AGENTS
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
	lovastatin	CrCl > 30 mL/min  Adult: Initial: 10-20 mg (evening) Usual: 10-80 mg/day in single or divided doses Max: 80 mg day (single or divided dose) CrCl >30 mL/min  Adult: Initial: 10-20 mg/day Usual: 10-20 mg/day Max: 20 mg day Heterozygous Familial Hypercholesterolemia Children: < 10 years: not recommended 10-17 yrs: Initial: 10-20 mg/day Usual: 10-40 mg/day Max: 40 mg/day	Take with evening meal Patients on amiodarone or verapamil should not exceed 40 mg/day Start with lower doses if patient on cyclosporine or danazol; do not exceed 20 mg/day For patients on fibrates or high-dose niacin, do not exceed 20 mg/day Nonpharmacologic Management Essay Examples
	Mevacor Altocor	Tabs: 10 mg, 20 mg, 40 mg
	pravastatin	Normal Renal/Hepatic Function  Adult: Initial: 10 mg/day Usual: 20-40 mg/day Max: 80 mg/day Children: < 8 years: not recommended 8-13 years: 20 mg/daily 14-18 years: 40 mg/daily Impaired Renal/Hepatic Function Adult: Initial: 10 mg/day Usual: 20 mg/day Max: 20 mg/day	May adjust dose after 4 weeks Take at bedtime
	Pravachol	Tabs: 10 mg, 20 mg, 40 mg, 80 mg

continued

LIPID LOWERING AGENTS
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
	rosuvastatin	CrCl > 30mL/min  Adult: Initial: 10 mg/day Usual: 5-20 mg/day Max: 40 mg/day CrCl < 30mL/min Adult: Initial: 5 mg/day Max: 10 mg/day Heterozygous Familial Hypercholesterolemia Children: < 10 years: not recommended 10-17 yrs: Initial: 5-10 mg/day Usual: 5-20 mg/day Max: 20 mg/day	May be taken without regard to meals Maximum dose reserved only for patients who do not achieve LDL-C goal In Asian patients, initiate therapy at 5 mg/day In patients taking cyclosporine, maximum dose is 5 mg/day In patients taking antiviral agents, maximum dose is 10 mg/day
	Crestor	Tabs: 5 mg, 10 mg, 20 mg, 40 mg
	simvastatin	Normal risk of CHD event  Adult: Initial: 20-40 mg HS Usual: 40 mg HS Max: 40 mg HS   High risk of CHD event Adult: Initial: 40 mg HS Usual: 40-80 mg HS Max: 80 mg HS   Heterozygous Familial Hypercholesterolemia Children: <10 years: not recommended 10-17 years: Initial: 10 mg HS Usual: 10-40 mg HS Max: 40 mg HS	Dosage adjustments at intervals of 4 weeks or more If concomitant use with gemfibrozil, simvastatin maximum dose should not exceed 10 mg/day Start with lower doses if patient on cyclosporin or danazol; do not exceed 10 mg/day Patients on amiodarone or verapamil should not exceed 20 mg/day Patients on diltiazem should not exceed 40 mg/day
	Zocor	Tabs: 5 mg, 10 mg, 20 mg, 40 mg, 80mg

continued

LIPID LOWERING AGENTS
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Bile Acid Sequestrants  Bind bile acids in the intestine which prevents their absorption. These insoluble bile acid complexes are excreted in the feces General comments In conjunction with diet, used to decrease total cholesterol, LDL May prevent absorption of fat soluble vitamins A, D, E & K Watch for constipation, flatulence May reduce absorption of many oral medications	cholestyramine	Adult: Initial: one packet with food or fluids 1-2 times a day Usual: 2-4 packets divided in 2 doses daily Max: 6 doses/day	Do not administer with other medications Mix only with noncarbonated liquids
	Questran	Carton: 60 pkts Can: 378 g
	Questran Light	Carton: 60 pkts Can: 268 g
	colesevelam	Adult: Initial: 3 tabs BID OR 1 packet 3.75 g/day OR 1 packet 1.875 g BID Usual: same as initial Max: same as initial Children:< 10 years:not recommended10-17 years: same as adult, but use powder form	Use with caution in pregnancy due to binding of other nutrients If powder, mix in 4-8 oz water Take with meals Contraindicated in patients with history of bowel obstruction Contraindicated in patients with serum triglycerides >500 mg/dL Caution in patients with history of pancreatitis
	Welchol	Tabs: 625 mg  Pkt: 1.875 g, 3.75 g
	colestipol	Adult: Initial: 1 packet OR 1 scoop/day OR 2-4 g/dayUsual: 1-6 packets OR 1-6 scoops OR 2-16 g (per day or divided doses)Max: 6 packets OR 6 scoops OR  16 g (per day or divided doses) Children: not recommended	Use with caution in pregnancy due to binding of other nutrients Do not crush tablet formulation Titrate dose upward weekly to achieve max Chronic use can lead to increased bleeding tendency (vitamin K depletion) Nonpharmacologic Management Essay Examples
	Colestid	Carton: 30 packet, 90 packet  Powder: 300 g, 500 g
	Colestipol	Tab: 1 g

continued

LIPID LOWERING AGENTS
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Fibric Acids  Increase lipolysis and elimination of triglyceride-rich particles from plasma. Results in lowering of triglycerides, LDL   General comments   Concomitant use of gemfibrozil and statins can produce rhabdomyolysis and acute renal failure   Increases gallstone formation risk   Monitor liver function studies and glucose during therapy; both may be elevated	gemfibrozil	Adult: Initial: 1.2 g daily in 2 divided doses, 30 min AC Usual: same as initial Max: same as initialChildren: not recommended	Concomitant therapy with cerivastatin increases risk of myopathy and rhabdomyolysis Avoid in patients with pre-existing gallbladder disease Discontinue after 3 months if lipid response is inadequate Avoid concomitant therapy with HMG-CoA reductase inhibitors
	Lopid	Tabs: 600 mg
	fenofibrate	Normal Triglycerides  Adult: Initial: 145 mg/day Usual: same as initial Max: same as initial Elevated Triglycerides Initial: 48 mg/day Usual: 48-145 mg/day Max: 145 mg/day Children: not recommended	Contraindicated in patients with severe renal or hepatic dysfunction Avoid in patients with pre-existing gallbladder disease Caution in patients with warfarin-type anticoagulants Adjust at 4-8 week intervals; discontinue after 2 months of max dose if not favorable lipid response
	TriCor	Tabs: 48 mg, 145 mg
	fenofibric acid	Mixed Hyperlipidemia  Adult: Initial: 135 mg/day Usual: same as initial Max: same as initial Hypertriglyceridemia Adult: Initial: 45 mg/day Usual: 45-135 mg/day Max: 135 mg/day Renal Impairment Adult: Initial: 45 mg/day Usual: 45 mg/day Max: 45 mg/day Children: not recommended	As mono therapy, targets severe hypertriglyceridemia As combination therapy (with HMG-CoA reductase inhibitors, targets mixed hyperlipidemia Contraindicated in patients on dialysis
	Trilipix	Caps: 45 mg, 135 mg

continued

LIPID LOWERING AGENTS
Class	Drug Generic name (Trade name®)	Dosage How supplied	Comments
Niacin Not well understood but thought to decrease hepatic VLDL production. VLDL is converted to LDL. Also, may decrease lipoprotein production in the liver; increases HDLGeneral commentsMonitor liver function studies before initiation of treatment, at 6 and 12 weeks after treatment, with each dosage increase, and periodically  Poorly tolerated. Causes flushing and hypotension. Take at bedtime with an aspirin to improve tolerability Monitor for myalgias and rhabdomyolysis	niacin (nicotinic acid)	Adult: Initial: 250 mg with evening meal; increase every 4-7 days until 1.5-2 g/day Usual: 1.5-3 g/day (may be in 3 divided doses) Max: 6 g/dayChildren: not recommended	Upward titration of dose required Avoid taking on empty stomach Do not interchange immediate release dosage form with extended release dosage form
	Niacor	Tabs: 500 mg
	niacin (nicotinic acid),  extended release	Adult:  Initial: 500 mg/HS, wk 1-4; then 1000 mg/HS wk 5-8; then 1500 mg/HS wk 9-12; then 2000 mg/HS wk 13-16 Usual: 1000-2000 mg/HS Max: 2000 mg/HSChildren: not recommended	Upward titration should not exceed 500 mg in a 4-week period If therapy interrupted, resume on titration schedule Women may require lower doses than men Use with caution in patients with renal or hepatic dysfunction Do not interchange immediate-release dosage form with extended-release dosage form
	Niaspan	Tabs: 500 mg, 750 mg, 1000 mg
Cholesterol Absorption Inhibitor  Inhibits absorption of cholesterol by the small intestine. Does not inhibit cholesterol synthesis (statins) or increase bile acid excretion	ezetimibe	Adult: Initial: 10 mg/day Usual: same as initial Max: same as initialChildren:> 10 years: Initial: 10 mg/day Usual: same as initial Max: same as initial	Alone or in combination with statin No evidence of myopathy when used alone Not necessary to monitor hepatic function unless patient on other therapy that requires monitoring GI complaints are most common Nonpharmacologic Management Essay Examples
	Zetia	Tabs: 10 mg
PCSK9 inhibitors  Mechanism of action is attaching to the PCSK9 proteins, which are responsible for destruction and recycling of LDL-C receptors located on the liver	alirocumab	Subcutaneously every 2 wk; if LDL-C response is inadequate, increase dosing to 150 mg every 2 wk    Evolocumab dose based on type of FH being treated   For heterozygous FH, evolocumab 140 mg subcutaneously every 2 wk or 420 mg once per month	Considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher-risk patients with clinical ASCVD or familial hypercholesterolemia Not recommended for use in primary prevention patients in the absence of familial hypercholesterolemia Measure LDL-C every 2-6 weeks after initiation or adjustment of therapy
	Praluent	Injection: 75 mg/mL

PREGNANCY/LACTATION CONSIDERATIONS

• Cholesterol levels are usually elevated during pregnancy
• Measurement is not recommended
• Treatment contraindicated

CONSIDERATIONS FOR SPECIAL POPULATIONS

• Older adults: benefits with total cholesterol and LDL reduction
• Statins typically well tolerated by older adults
• Diabetes: aggressive management of hyperlipidemia needed

The ACC/AHA writing committee supports consideration of adding ezetimibe 10 mg daily as the first non-statin agent for many higher-risk patient groups. However, the committee does not recommend niacin as an additional non-statin therapy for the situations discussed in the document. Consistent with the 2013 guideline, the panel recommends looking first at lifestyle issues, including diet, exercise and smoking, followed by statin therapy.

 

CONSULTATION/REFERRAL

• Dietitian
• Refer children with hyperlipidemia that does not respond to dietary and conservative measures; specialist intervention needed

FOLLOW-UP

• Evaluate lipid values every 5 years starting at age 20 if normal values obtained
• After initiation of lipid lowering therapy, monitor lipids every 6-8 weeks until goal attained; then every 6-12 months to evaluate compliance

EXPECTED COURSE

• Depends on etiology and severity of disease
• 1% decrease in LDL value decreases CHD risk by 2%

POSSIBLE COMPLICATIONS

• Coronary artery disease
• Cerebrovascular disease
• Peripheral vascular disease
• Arteriosclerosis

 

14. Hypertension-

Systolic and/or diastolic blood pressure that is higher

than expected for age or pregnancy status. A presumptive diagnosis can be made if the average of two measurements is abnormal on two separate visits. Hypertension (HTN) is classified as primary (essential) or secondary. Isolated systolic hypertension is common in older adults. Nonpharmacologic Management Essay Examples

ACC/AHA guidelines emphasize link between hypertension and cardiovascular disease. The ASCVD Risk Calculator should be used to make treatment decisions: http://tools.acc.org/ASCVD-Risk-Estimator-Plus/#!/calculate/estimate/. Available as a mobile app: ASCVD Risk Estimator Plus

 

ACC/AHA Classification of HTN

BP Category	Systolic BP		Diastolic BP
Normal	<120 mm Hg	and	<80 mm Hg
Elevated	120-129 mm Hg	and	<80 mm Hg
HTN stage 1	130-139 mm Hg	or	80-89 mm Hg
HTN stage 2	≥140 mm Hg	or	≥90 mm Hg

 

ACC/AHA Target BP Goal

Classification of patients	Goal
For adults with confirmed HTN and known CVD or 10-year ASCVD event risk of 10% or higher	<130/80 mm Hg
For adults with confirmed HTN, without additional markers of increased CVD risk	<130/80 mm Hg may be reasonable

Source: 2017 ACC/AHA guidelines

ETIOLOGY

ADULT

Causes of Primary Hypertension
No known cause in 90% of cases
Causes of Secondary Hypertension
Renal	Acute glomerulonephritis Chronic renal failure Polycystic kidney disease Pyelonephritis
Vascular	Coarctation of the aorta Renal artery stenosis
Endocrine	Primary hyperaldosteronism Pheochromocytoma Cushing’s syndrome Neuroblastoma Hyperthyroidism
Neurologic	Increased intracranial pressure Sleep apnea
Pharmacological	Oral contraceptives Corticosteroids Cocaine NSAIDs Decongestants Sympathomimetics

PEDIATRIC

Causes of Primary Hypertension
In children >10 years, HTN is usually primary. However, secondary causes must be ruled out.
Causes of Secondary Hypertension  Approximately 10% of cases of HTN
Renal	Most common cause (80%)
Vascular	Coarctation of the aorta (5-10% due to this)
Endocrine	Adrenal dysfunction Hyperaldosteronism Hyperthyroidism
Neurologic	Increased intracranial pressure Sleep apnea Nonpharmacologic Management Essay Examples
Pharmacological	Oral contraceptives Corticosteroids Cocaine NSAIDs Decongestants Sympathomimetics

INCIDENCE

• 85 million U.S. residents have HTN; in 45.9% of them, HTN is uncontrolled
• Reported rates of HTN in children vary from 2-13% (highest in black and Asian children)
• Black adults have higher incidence than general population
• Men > Women
• Initially appears between 30-55 years
• Increased prevalence in older adults
• 5-10% of all pregnancies

RISK FACTORS

• Modifiable risk factors:
  • Cigarette smoking (including secondhand)
  • Diabetes mellitus
  • Dyslipidemia/hypercholesteremia
  • Overweight/obesity (obesity is single most important factor in children; important in adults as well)
  • Physical inactivity/low fitness
  • Unhealthy diet
  • Excessive dietary intake of sodium
  • Excessive alcohol consumption
• Relative fixed risk factors:
  • CDK
  • Family history
  • Increased age (>55 years male; >65 years female)
  • Low socioeconomic
  • Low educational status
  • Male sex
  • Obstructive sleep apnea (OSA)
  • Psychosocial stress
  • Pregnancy

ASSESSMENT FINDINGS

• Most patients are asymptomatic
• Occipital headaches
• Headache on awakening in morning
• Blurry vision
• Exam of optic fundi: look for AV nicking, arteriolar narrowing, hemorrhages, exudates, and papilledema
• Left ventricular hypertrophy (after longstanding hypertension)
• Pregnancy with hypertension and proteinuria, edema, and excessive weight gain
• Perform exam of symmetrical pulses, auscultate for carotid and abdominal bruits, auscultate over kidneys for bruits
• Nonpharmacologic Management Essay Examples

 

Pediatric Classification of HTN

Age 1-13 Years	Age ≥13 Years
Normal BP: <90th percentile	Normal BP: <120/80 mm Hg
Elevated BP: ≥90th-95th percentile or 120/80 mm Hg to <95th percentile (whichever is lower)	Elevated BP: 120/<80 to 129/<80 mm Hg
Stage 1 HTN: ≥95th percentile to <95th percentile +12 mm Hg or 130/80 to 139/89 mm Hg (whichever is lower)	Stage 2 HTN: ≥130/80 mm Hg
Stage 2 HTN: ≥95th percentile + 12 mm Hg or ≥140/90 mm Hg (whichever is lower)	Stage 2 HTN: ≥140/90 mm Hg

DIFFERENTIAL DIAGNOSIS

• Secondary hypertension
• White coat hypertension (artificially elevated BP due to anxiety in medical environment)

DIAGNOSTIC STUDIES

• Urinalysis: may reveal proteinuria
• Electrolytes, creatinine, calcium
• Fasting lipid profile
• Fasting blood glucose
• Electrocardiogram (ECG)
• Other studies depending on history and physical exam
• Measure BP twice, 5 minutes apart
• Patient should be seated and proper cuff size and application used (ALWAYS assess contralateral arm to confirm elevated reading)
• Consider using ambulatory BP monitoring and home BP monitoring to aid in diagnosis and management

 

Goal of diagnostic studies is to identify target organ damage, any underlying cause, and/or additional risk factors.

 

PREVENTION

• Maintenance of healthy weight and BMI
• Smoking cessation
• Regular aerobic exercise
• Alcohol in moderation (<1 oz/day)
• Stress management
• Adherence to medication regimen

NONPHARMACOLOGIC MANAGEMENT

• If Stage 1, no hx of CVD, and risk score <10%, initiate lifestyle changes first
• Stage 2, lifestyle + medication
• Lifestyle changes can reduce systolic BP by 4-11 mm Hg
• Implement DASH (Dietary Approaches to Stopping Hypertension) eating plan
• Reduce dietary sodium and increase potassium (except with CKD and certain medications)
• Nonpharmacologic Management Essay Examples
• Increase fruits, vegetables, whole grains
• Reduce saturated fat intake
• Obtain ideal body weight; 1 mm Hg BP reduction for every 1 kg reduction in body weight
• 90-150 mins of aerobic exercise and/or three sessions of isometric resistance exercise per week
• Reduce alcohol intake: 2 or < drinks per day for men and 1 or < drinks per day for women
• Identification and management of stressors
• Counseling about elimination of other cardiovascular risks (e.g., smoking cessation)
• Treatment of underlying disease, if applicable
• Twice-weekly BP checks during pregnancy, if elevated
• Do not restrict salt intake during pregnancy
• Patient education about disease, treatment, prevention of complications, long-term implications, diet changes, and lifestyle modifications
• Self-monitoring patients should:
  • Use valid instruments for accurate measurements
  • Position themselves correctly with the bottom of the cuff above the bend of the elbow
  • Take two readings 1 minute apart each morning before medication and each evening before dinner
  • Weekly readings for 2 weeks after treatment changes and the week before the clinic visit
  • Average home readings on two or more occasions

PHARMACOLOGIC MANAGEMENT

• Start Medication:
  • Primary prevention of CVD is recommended for adults without history of CVD AND a 10-year ASCVD risk of ≥10% or higher and Stage 1 HTN OR a 10-year ASCVD risk <10% with SBP 140 mm Hg or higher or a DBP 90 mm Hg or higher
  • Secondary prevention of CVD with history of clinical CVD AND Stage 1 HTN
  • If Stage 2, start TWO BP-lowering medications
  • In black patients, two or more medications recommended: thiazide and calcium channel blockers are the most effective
  • A variety of agents may be used in adult, pediatric, and nonpregnant patients:
    • Diuretics: may decrease renal function in patients with chronic renal failure and in patients with renal insufficiency
    • Angiotensin-converting enzyme inhibitors (ACE inhibitors)
    • Angiotensin II receptor blockers (ARBs)
    • Do NOT use ACE and ARB together
    • Beta blockers (NOT first line)
    • Calcium channel blockers
    • Vasodilators
    • Combination of above
  • In pregnant patients:
    • Vasodilators
    • Beta blockers
    • Methyldopa (Aldomet)
    • Calcium channel blockers
    • Avoid ARBs and ACE inhibitors

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Thiazide Diuretics  Increase excretion of sodium and chloride and thus water; decrease circulating plasma volume   General comments   Monitor for hypokalemia (check potassium level about 2 weeks after initiation and with increase in dose)   Maintain potassium 4-5 mmol/L   May worsen gout and elevate blood glucose and lipids	hydrochlorothiazide (HCTZ)	Adult:  Initial: 25 mg/day Usual: 12.5-50 mg/day Max: 50 mg/day   Children: Initial: 1-2 mg/kg/day in 1-2 divided doses <6 months: max 3 mg/kg/day 6 months-2 years: max 37.5 mg/day 2-12 years: max 100 mg/day	Relatively inexpensive Careful use in sulfonamide allergy Contraindicated in patients with anuria
	Various generics (Esidrix, HCTZ, HydroDIURIL, Microzide, Oretic, thiazide)	Caps: 12.5 mg Tabs: 25 mg, 50 mg, 100 mg
	chlorthalidone	Adult:  Initial: 12.5-25 mg/day Usual: 12.5-50 mg/day Max: 50 mg/dayChildren: not recommended	Preferred thiazide Chlorthalidone provides more consistent 24-hour BP control than HCTZ
	Hygroton	Tabs: 25 mg, 50 mg
	chlorthalidone	Adult:  Initial: 15 mg/day Usual: 30-45 mg/day Max: 50 mg/dayChildren: not recommended	Do not interchange between trade and generic due to bioavailability differences Higher doses predispose patients to hypokalemia
	Thalitone	Tabs: 15 mg (trade) Tabs: 30 mg, 50 mg (generic)
Loop Diuretics Inhibit absorption of sodium and chloride in proximal/distal tubules and loop of HenleGeneral commentsMore potent diuretic action than thiazides  Monitor for dehydration, electrolyte imbalances and hypotension May be used for patients who develop fluid overload Increases calcium excretion Nonpharmacologic Management Essay Examples	furosemide	Adult:  Initial: 20-40 mg BID Usual: Individualized for effect Max: 320 mg (split in 2-3 doses); do not exceed maximum adult dose   Children: Initial: 2 mg/kg Max: 6 mg/kg	Second-line therapy after thiazides Use lower doses in older adults Diuretic of choice in reduced Cr Cl patients Risk of ototoxicity
	Lasix	Tabs: 20 mg, 40 mg, 80 mg Solution: 10 mg/mL, 40 mg/mL
	torsemide	Adult:  Initial: 5 mg daily Usual: 5-10 mg/day Max: 10 mg (either daily or split between doses) Children: not recommended	Second-line therapy after thiazides Contraindicated in patients with sulfonylurea allergy May take without regard to meals Risk of ototoxicity
	Demadex	Tabs: 5 mg, 10 mg
Potassium-Sparing Diuretics Enhance the action of thiazide and loop diuretics and counteract potassium loss by these agents	spironolactone	Adult:  Initial: 12.5 mg/day (single or split dose) Usual: 25-50 mg daily Max: 200 mg/day (single or split dose) Children: not recommended	Usually not first-line agent Requires at least 2 weeks of therapy to determine effectiveness Contraindicated in patients with anuria, acute renal insufficiency, hyperkalemia
	Aldactone	Tabs: 25 mg, 50 mg, 100 mg

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	triamterene	Adult:  Initial: 100 mg BID after meal Usual: 100 mg BID Max: 300 mg/day Children: not recommended	If taking another diuretic or anti-HTN agent, must lower starting dose Patients should not be receiving potassium supplementation
	Dyrenium	Caps: 50 mg, 100 mg
Angiotensin-Converting  Enzyme (ACE) Inhibitors Inhibit the action of angiotensin-converting enzyme (ACE), which is responsible for conversion of angiotensin I to angiotensin II; angiotensin II causes vasoconstriction and sodium retention. Prevents breakdown of bradykinin   General comments   First-line agent   End in “pril”   Dry cough is common side effect; monitor for first-dose hypotension, hyperkalemia, acute renal failure   Angioedema is rare but more common in black patients   Monitor for renal failure and worsening chronic heart failure   Preferred in patients with diabetes and heart failure   Avoid use in patients with bilateral renal artery stenosis	benazepril	Patients NOT on Diuretics Adult: Initial: 10 mg/day Usual: 20-40 mg/day Max: 80 mg/dayChildren: >6 years: Initial: 0.2 mg/kg/day Max: 0.6 mg/kg/day (or 40 mg)Patients On diuretics Adult: Initial: 5 mg/day Usual: 20-40 mg/day Max: 80 mg/day  Patients with renal  impairment (glomerular filtration < 30mL) Initial: 5 mg/day Usual: 20-40 mg/day Max: 40 mg/day	Little additional effect noted at doses >40 mg Considered MONOTHERAPY in children Avoid in children with glomerular filtration rates <30 mL/min
	Lotensin	Tabs: 5 mg, 10 mg, 20 mg, 40 mg
	captopril	Patients NOT on diuretics  Adult: Initial: 25 mg BID or TID Usual: 25-50 mg/day Max: 450 mg/day   Children: not recommended   Patients on diuretics Adult: Initial: 6.25-12.5 mg BID or TID Usual: 25-150 mg BID or TID Max: 450 mg/day   Patients with renal impairment (glomerular filtration <30 mL) Initial: 6.25-12.5 mg BID or TID Usual: 12.5-75 mg/day
	Capoten	Tabs: 12.5 mg, 25 mg, 50 mg, 100 mg

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	enalapril maleate	Patients NOT on diuretics  Adult: Initial: 5 mg/day Usual: 10-40 mg/day (single or split doses) Max: 40 mg/day   Patients ON diuretics Adult: Initial: 2.5 mg/day Usual: 10-40 mg/day (single or split doses) Max: 40 mg/day   Patients with renal impairment (glomerular filtration <30 mL) Initial: 2.5 mg/day Usual: 10-40 mg/day (single or split doses) Max: 40 mg/day   Children: not recommended	Avoid potassium supplements Use with caution in patients on lithium Recommend holding diuretics 3 days prior to starting, if appropriate for patient If patient on diuretic, must monitor for 2 hours after initial dose If patient on dialysis, give only 2.5 mg on days of dialysis
	Vasotec	Tabs: 2.5 mg, 5 mg, 10 mg, 20 mg
	lisinopril	Patients NOT on Diuretics Adult: Initial: 10 mg/day Usual: 20-40 mg/day Max: 80 mg/dayChildren ≥6 years: Initial: 0.07 mg/kg Usual: Individualize Max: 0.61 mg/kg – do not exceed maximum adult dosePatients on diuretics OR with renal  impairment (glomerular  filtration < 30mL) Adult: Initial: 2.5 mg/day Usual: 2.5-5 mg/day Max: 5 mg/day	Recommend holding diuretics 3 days prior to starting, if appropriate for patient Doses at 80 mg may not produce significantly greater effect compared to 40 mg
	Prinivil	Tabs: 2.5 mg, 5 mg, 10 mg, 20 mg, 40 mg
	Zestril
	ramipril	Patients NOT on diuretics  Adult: Initial: 2.5 mg/day for 7 days; 5 mg/day for 21 days; then 10 mg/day Usual: 2.5-20 mg/day (single or split dose) Max: 20 mg/day   Children: Not recommended   Patients on diuretics OR with renal impairment (Cr Cl <40 mL/min) Initial: 1.25 mg/day for 7 days; 2.5 mg/day for 21 days; then 5 mg/day Usual: 2.5-5 mg/day (single or split dose) Max: 5 mg/day	Requires initial titration of dosage schedule May increase lithium levels

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	Altace	Caps 1.25 mg, 2.5 mg, 5 mg, 10 mg Tabs 1.25 mg, 2.5 mg, 5 mg, 10 mg
Angiotensin II Receptor Blockers (ARBs)  Block vasoconstriction and sodium retention effects of AT II (angiotensin II) found in many tissues   General comments   End in “sartan”   Does not affect bradykinin; therefore, no cough as with ACE inhibitors. Good renoprotective action; therefore, good alternative in patients with diabetes who cannot tolerate ACE inhibitors   Monitor for hypotension and possible renal failure	candesartan cilexetil	Patients NOT on diuretics, not volume depleted  Adult: Initial: 16 mg/day Usual: 8-32 mg/day (single or split dose) Max: 32 mg/day   Children: <1 year: not recommended 1-6 years: Initial: 0.2 mg/kg/day Usual: 0.05-0.4 mg/kg/day Max: do not exceed max adult dose   6-17 years: Weight <50 kg; Initial: 4-8 mg/day Usual: 2-16 mg/day Max: 16 mg/day   Weight >50 kg; Initial: 4-8 mg/day Usual: 2-16 mg/day Max: 4-32 mg/day	Dose is individualized for effect Nonpharmacologic Management Essay Examples Initial response seen in ~2 weeks, full response in 4-6 weeks If patient has volume depletion or impaired renal function, consider lower dose and provide close supervision
	Atacand	Tabs: 4 mg, 8 mg, 16 mg, 32 mg
	eprosartan mesylate	Patients NOT on diuretics, not volume depleted  Adult: Initial: 600 mg/day Usual: 400-800 mg/day (single or split dose) Max: 800 mg/day   Children: not recommended	In severe renal impairment, do not exceed 600 mg/day Volume or salt-depleted patients must be closely monitored when initiating treatment
	Teveten	Tabs: 400 mg, 600 mg
	losartan	Patients NOT on diuretics, not volume depleted  Adult: Initial: 50 mg/day Usual: 25-100 mg/day (single or split dose) Max: 100 mg/day   Children: <6 years: not recommended >6 years: Initial: 0.7 mg/kg/day Usual: 0.7-1.4 mg/kg/day Max: 1.4 mg/kg/day; do not exceed maximum adult dose   Patients on diuretics or volume depleted Adult: Initial: 25 mg/day Usual: 25-100 mg/day (single or split dose) Max: 100 mg/day   Children: not recommended	Initial effect within 1 week, may take 3-6 weeks for maximum effect
	Cozaar	Tabs: 25 mg, 50 mg, 100 mg

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	olmesartan medoxomil	Patients NOT on diuretics, not volume depleted  Adult: Initial: 20 mg/day Usual: 20-40 mg/day Max: 40 mg/day   Children: Weight >20 and <35 kg: Initial: 10 mg/day Usual: Individualize Max: 20 mg/day Weight >35 kg: Initial: 20 mg/day Usual: Individualize Max: 40 mg/day	Taken without regard to food Doses must be individualized Clinical effect within 2 weeks Caution when initiating in patients with hepatic or severe renal impairment At doses >40 mg, addition of diuretic recommended
	Benicar	Tabs: 5 mg, 20 mg, 40 mg
	valsartan	Patients NOT on diuretics, not volume depleted  Adult: Initial: 80 mg/day Usual: 80-320 mg/day Max: 320 mg/day   Children: <6 years: not recommended; 6-16 years: Initial: 1.3 mg/kg/day Usual: Individualize Max: 160 mg/day	Taken without regard to food Clinical effect within 2 weeks; maximum effect in 4 weeks Caution when initiating in patients with hepatic or severe renal impairment At doses >80 mg, addition of diuretic recommended
	Diovan	Caps: 80 mg, 160 mg  Tabs: 40 mg, 80 mg, 160 mg, 320 mg
Cardioselective  Beta Blockers Decrease sympathetic stimulation by beta blockade in the heart   General comments   Consider post-MI, in heart failure, ischemic heart disease   Should be avoided (or used cautiously) in patients with airway disease, heart block   Should be used with caution in patients with diabetes (may mask symptoms of hypoglycemia) and in patients with peripheral vascular disease   May cause exercise intolerance	acebutolol	Adult:  Initial: 400 mg/day (single or split dose) Usual: 200-800 mg/day Max: 1200 mg/day   Children: not recommended	DO NOT ABRUPTLY STOP DRUG BID dosing more effective than single dose Has intrinsic sympathomimetic activity
	Sectral	Caps: 200 mg, 400 mg

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	atenolol	Adult:  Initial 50 mg/day Usual: 50-100 mg/day Max: 100 mg/day   Children: not recommended   >65 years or patients with renal impairment CrCl 15-35 mL/min Initial: 25 mg/day Max: 50 mg/day   CrCl <15 mL/min Initial: 25 mg/day Max: 25 mg/day	DO NOT ABRUPTLY STOP DRUG May titrate dose upward after 1 week Patients on dialysis should be monitored under hospital supervision for dosages given post-treatment
	Tenormin	Tabs: 25 mg, 50 mg, 100 mg
	bisoprolol fumarate	Adult:  Initial: 5 mg/day Usual: individualize Max: 20 mg/day   Patients with renal or hepatic dysfunction Initial: 2.5 mg/day Usual: individualize Max: 20 mg/day   Children: not recommended	DO NOT ABRUPTLY STOP DRUG Individualize for patient effect Advance from 5 mg to 10 mg to 20 mg as needed
	Zebeta	Tabs: 5 mg, 10 mg
	metoprolol succinate, extended release	Adult:  Initial: 25-100 mg/day Usual: 100-400 mg/day Max: 400 mg/dayChildren: not recommended	DO NOT ABRUPTLY STOP DRUG; must be tapered over 2 weeks NOTE DIFFERENT DOSAGE FORMS; extended release form preferred for HTN control Individualize for patient effect Advance dosage at weekly intervals
	Lopressor	Extended-release tabs: 25 mg, 50 mg, 100 mg, 200 mg
	Toprol-XL	Extended-release tabs: 25 mg, 50 mg, 100 mg, 200 mg
	metoprolol tartrate	Adult:  Initial: 100 mg/day (single or divided dose) Usual: 100-400 mg/day (single or divided dose) Max: 450 mg/day (single or divided dose)Children: not recommended	DO NOT ABRUPTLY STOP DRUG; must be tapered over 2 weeks NOTE DIFFERENT DOSAGE FORMS; extended-release form preferred for HTN control; Single immediate doses may not offer 24-hour coverage Individualize for patient effect Titrate dosage at weekly intervals Should be given with meals
	Lopressor	Tabs: 25 mg, 50 mg, 100 mg, 200 mg
	Toprol-XL	Tabs: 25 mg, 50 mg, 100 mg, 200 mg

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Non-Cardioselective  Beta Blockers Block stimulation of both beta1 (heart) and beta 2 (lungs) receptors, causing decreased heart rate, blood pressure, and cardiac output (beta1), as well as decreased central motor activity, inhibition of renin release from the kidneys, reduction of norepinephrine from neurons, and mild bronchoconstriction (beta 2)   General comments   End in “lol”   Contraindicated in patients with bronchoconstrictive disease (i.e., asthma, COPD, etc.)   Cautious use in patients with diabetes due to masking signs and symptoms of hypoglycemia (tachycardia, blood pressure changes)   Nonspecific beta blockade helpful in patients with tremors, anxiety and migraine headaches	nadolol	Adult:  Initial: 20-40 mg/day Usual: 40-80 mg/day Max: 320 mg/day   Children: not recommended   Special dosing schedule in renal impairment Initial: 20 mg CrCl >50: 24 hr CrCl 31- 50: 24-36 hr CrCl 10- 30: 24-48 hr CrCl <10: 40-60 hr	DO NOT ABRUPTLY STOP DRUG; may take 2 weeks to withdraw drug while patient is closely monitored Individualize therapy Taken without regard to meals Note dosing schedule for renal dysfunction
	Corgard	Tabs: 20 mg, 40 mg, 80 mg, 120 mg, 160 mg
	penbutolol	Adult:  Initial: 20 mg/day Usual: 20-40 mg/day Max: 80 mg/dayChildren: not recommended	DO NOT ABRUPTLY STOP DRUG; may take 2 weeks to withdraw drug while patient is closely monitored Full effect within 2 weeks
	Levatol	Tabs: 20 mg
	pindolol	Adult:  Initial: 5 mg BID Usual: 10-30 mg/day Max: 60 mg/dayChildren: not recommended	DO NOT ABRUPTLY STOP DRUG Individualize therapy; adjust dose every 1-2 weeks Has intrinsic sympathomimetic activity Contraindicated with thioridazine
	Visken	Tabs: 5 mg, 10 mg
	propranolol	IMMEDIATE RELEASE Adult:  Initial: 40 mg BID Usual: 120-240 mg/day Max: 640 mg/dayChildren:  Initial: 1 mg/kg/day (in two divided doses) Usual: 2-4 mg/kg/day (in two divided doses) Max: 16 mg/day (in two divided doses) or 640 mg/dayEXTENDED RELEASE Adult:  Initial: 80 mg/day Usual: 120-160 mg/day Max: 640 mg/day	DO NOT ABRUPTLY STOP DRUG Extended-release form has different kinetics; CANNOT switch between dosage forms on a 1:1 mg basis Titrate for effective BP; titration may vary from a few days to several weeks Do not crush or chew tablets Contraindicated with thioridazine
	Inderal	Tabs: 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
	Inderal LA	Extended-release caps: 60 mg,  80 mg, 120 mg, 160 mg

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Calcium Channel Blockers  Dihydropyridine (DHP) Inhibit movement of calcium ions across the cell membrane and vascular smooth muscle, which depresses myocardial contractility and increases cardiac blood flow   General comments   End in suffix “pine”   Does not cause bradycardia   Monitor for hypotension and worsening of heart failure, ankle edema   Good choice in patients with isolated systolic hypertension, for migraine prophylaxis, and in patients with stable angina   Serious drug interactions with grapefruit juice   Long-acting DHP calcium channel blockers preferred for isolated systolic hypertension	amlodipine besylate	Adult:  Initial: 5 mg/day Usual: 5-10 mg/day Max: 10 mg/day   >65 years, renal or hepatic patients: Initial: 2.5 mg/day   Children: > 6 years: Initial: 2.5 mg/day Usual: 2.5-5 mg/day Max: 5 mg/day	Titrate for effect; increase doses at 7- to 14-day intervals; must reassess patient after each titration Nonpharmacologic Management Essay Examples
	Norvasc	Tabs: 2.5 mg, 5 mg, 10 mg
	felodipine	Adult:  Initial: 2.5-5 mg/day Usual: 2.5-10 mg/day Max: 10 mg/day   >65 years or hepatic patients: Initial: 2.5 mg/day   Children: not recommended	Titrate for effect; increase dose after minimum 2-week interval Do not crush or chew tablets Bioavailability affected by meals; take on empty stomach
	Plendil	Extended-release tabs: 2.5 mg,  5 mg, 10 mg
	nicardipine HCL	Immediate-Release Formulation  Adult: Initial: 20 mg TID Usual: 20-40 mg TID Max: 120 mg/day   Children: not recommended   Sustained-Release Formulation Adult: Initial: 30 mg BID Usual: 30-60 mg BID Max: 60 mg BID   Children: not recommended	Individualize treatment Lower doses required if impaired hepatic function Effective response requires peak and trough BP measurements Titrate dose after 3 days Additional monitoring required if changing between dose formulations
	Cardene	Caps: 20 mg, 30 mg
	Cardene SR	Sustained-release caps: 30 mg, 45 mg, 60 mg
	nifedipine	Adult:  Initial: 30-60 mg/day Usual: 30-60 mg/day Max: 120 mg/dayChildren: not recommended	Individualize treatment; advance doses at 1- or 2-week intervals Use extended-release formulations for HTN control Take on empty stomach Do not crush or chew extended-release formulations Must be withdrawn slowly if discontinued
	Procardia XL	Extended-release tabs: 30 mg,  60 mg, 90 mg
	Adalat CC	Extended-release tabs: 30 mg,  60 mg, 90 mg
	nisoldipine	Adult:  Initial: 17 mg/day Usual: 8.5-34 mg/day Max: 34 mg/day   >65 years OR with hepatic dysfunction Initial: 8.5 mg/day   Children: not recommended	Individualize treatment; advance doses at 1- to 2-week intervals Take on empty stomach Do not crush or chew

continued

HYPERTENSION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	Sular	Extended-release tabs: 8.5 mg,  17 mg, 25.5 mg, 34 mg
Calcium Channel Blockers: Non-Dihydropyridine  (Non-DHP) Inhibit movement of calcium ions across cell membrane and vascular smooth muscle, which depresses myocardial contractility and increases cardiac blood flow   General comments   Watch for conduction defects   Decreases heart rate   Use cautiously or avoid with β-blockers   Monitor for worsening of heart failure, hypotension, bradycardia, constipation   Consider in patients with atrial fibrillation with rapid ventricular   Grapefruit juice may increase serum concentration of CCB	diltiazem	Adult:  Initial: 120-240 mg/day Usual: 240-360 mg/day Max: 480-540 mg/day*   >60 years: Initial: 120 mg/day   Children: not recommended *See prescribing information for maximum dose limits	Use extended-release formulations for HTN control Available in multiple formulations (tablets and capsules) and strengths Individualize therapy; titrate biweekly Start with lowest dose possible, especially patients >65 years Do not crush or chew Incidence of side effects increases as dose increases
	Cardizem LA	Extended-release tabs: 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
	Cardizem CD	Extended-release caps: 120 mg,  180 mg, 240 mg, 300 mg, 360 mg
	Dilacor XR	Extended-release caps: 120 mg  180 mg, 240 mg (administer on empty stomach)
	Tiazac	Extended-release caps: 120 mg  180 mg, 240 mg, 300 mg, 360 mg, 420 mg
	verapamil	Adult:  Initial: 180 mg/day Usual: 180-240 mg/day Max: 360 mg/day (must be in divided doses)*   Children: not recommended *Refer to prescribing information for additional guidelines	Use extended-release formulations for HTN control Available in multiple formulations (tablets and capsules) and strengths; refer to specific product for additional guidelines Individualize therapy; titrate at biweekly intervals Older adults or small stature people may require lower starting dose
	Calan SR	Caps: 120 mg, 180 mg, 240 mg
	Covera HS (give at bedtime)	Extended-release tabs: 120 mg,  240 mg
	Isoptin SR	Sustained-release tabs: 120 mg, 180 mg, 240 mg
	Verelan PM (give at bedtime)	Extended-release caps: 100 mg, 200 mg, 300 mg
Direct Renin  Inhibitor Decreases plasma renin activity (PRA) and inhibits conversion of angiotensinogen to Angiotensin I   General comments   Monitor K+ levels in patients with diabetes   Caution with maximum doses of ACE inhibitors   May be potentiated by statins and ketoconazole	aliskiren hemifumarate	Adult: Initial: 150 mg/day Usual: 150-300 mg/day Max: 300 mg/dayChildren: not recommended	Individualize therapy; adjust dose after 2 weeks Take on empty stomach Use with caution in patients with renal impairment Use with caution in patients with volume and/or salt depletion
	Tekturna	Tabs: 150 mg, 300 mg

 

COMBINATION DRUGS FOR HYPERTENSION
Combination Type*	Fixed-Dose Combination, mg†	Trade Name
ACEIs and CCBs	Amlodipine-benazepril hydrochloride (2.5/10, 5/10, 5/20, 10/20)	Lotrel
	Enalapril-felodipine (5/5)	Lexxel
	Trandolapril-verapamil (2/180, 1/240, 2/240, 4/240)	Tarka
ACE inhibitors and diuretics	Benazepril-hydrochlorothiazide (5/6.25, 10/12.5, 20/12.5, 20/25)	Lotensin HCT
	Captopril-hydrochlorothiazide (25/15, 25/25, 50/15, 50/25)	Capozide
	Enalapril-hydrochlorothiazide (5/12.5, 10/25)	Vaseretic
	Fosinopril-hydrochlorothiazide (10/12.5, 20/12.5)	Monopril/HCT
	Lisinopril-hydrochlorothiazide (10/12.5, 20/12.5, 20/25)	Prinzide, Zestoretic
	Moexipril-hydrochlorothiazide (7.5/12.5, 15/25)	Uniretic
	Quinapril-hydrochlorothiazide (10/12.5, 20/12.5, 20/25)	Accuretic
ARBs and diuretics	Candesartan-hydrochlorothiazide (16/12.5, 32/12.5)	Atacand HCT
	Eprosartan-hydrochlorothiazide (600/12.5, 600/25)	Teveten-HCT
	Irbesartan-hydrochlorothiazide (150/12.5, 300/12.5)	Avalide
	Losartan-hydrochlorothiazide (50/12.5, 100/25)	Hyzaar
	Olmesartan medoxomil-hydrochlorothiazide (20/12.5,40/12.5,40/25)	Benicar HCT
	Telmisartan-hydrochlorothiazide (40/12.5, 80/12.5)	Micardis-HCT
	Valsartan-hydrochlorothiazide (80/12.5, 160/12.5, 160/25)	Diovan-HCT
BBs and diuretics	Atenolol-chlorthalidone (50/25, 100/25)	Tenoretic
	Bisoprolol-hydrochlorothiazide (2.5/6.25, 5/6.25, 10/6.25)	Ziac
	Metoprolol-hydrochlorothiazide (50/25, 100/25)	Lopressor HCT
	Nadolol-bendroflumethiazide (40/5, 80/5)	Corzide
	Propranolol LA-hydrochlorothiazide (40/25, 80/25)	Inderide LA
	Timolol-hydrochlorothiazide (10/25)	Timolide
Centrally acting drug and diuretic	Methyldopa-hydrochlorothiazide (250/15, 250/25, 500/30, 500/50)	Aldoril
	Reserpine-chlorthalidone (0.125/25, 0.25/50)	Demi-Regroton, Regroton
	Reserpine-chlorothiazide (0.125/250, 0.25/500)	Diupres
	Reserpine-hydrochlorothiazide (0.125/25, 0.125/50)	Hydropres
Diuretic and diuretic	Amiloride-hydrochlorothiazide (5/50)	Moduretic
	Spironolactone-hydrochlorothiazide (25/25, 50/50)	Aldactazide
	Triamterene-hydrochlorothiazide (37.5/25, 75/50)	Dyazide, Maxzide

*Drug abbreviations: BB, beta-blocker; ACE inhibitor, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker.

†Some drug combinations are available in multiple fixed doses. Each drug dose is reported in milligrams.

PRESCRIBING STRATEGIES

• Thiazide diuretics: chlorthalidone is preferred over HCTZ; stop if eGFR <30
• Initial selection of agent depends on underlying disease
• Consider ACE inhibitors or ARBs in patients with diabetes, proteinuria, heart failure; avoid during pregnancy
• Beta blockers no longer recommended first line for uncomplicated hypertension, but consider in patients with heart failure, first 2-3 years post MI (to prevent remodeling), ischemic heart disease, and migraine headaches
• Calcium channel blockers (dihydropyridine; DHP) encouraged in isolated systolic hypertension, asthma, migraines, ischemic disease; consider for stroke prevention
• If Stage 2, initiate therapy with two drugs
• Selection of antihypertensives in children is similar to adults

CONSULTATION/REFERRAL

• Refer to cardiologist: children with significant or severe hypertension
• Refer as needed for secondary causes of hypertension

FOLLOW-UP

• Inquire about compliance, medication side effects
• Monthly, until patient reaches goal; then every 3-6 months as appropriate

EXPECTED COURSE

• Only 25% of patients who are treated for hypertension are actually at goal; expect complications if inadequately managed
• Most patients require more than one medication to reach goal

POSSIBLE COMPLICATIONS

• Stroke
• Coronary artery disease
• Myocardial infarction
• Renal failure
• Heart failure
• Eclampsia (seizures)
• Pulmonary edema
• Hypertensive crisis

 

15. Hypothyroidism

DESCRIPTION

Clinical state that results from a reduction in circulating free thyroid hormone or from resistance to the action of thyroid hormone.

ETIOLOGY

• Majority of cases are due to primary thyroid gland failure resulting from autoimmune destruction (Hashimoto’s thyroiditis)
• Ablative therapy for hyperthyroidism
• Other causes are congenital, secondary or tertiary, due to pituitary or hypothalamic disease

INCIDENCE

• Predominant age is >40 years
• Women > Men
• Common in adults >65 years

RISK FACTORS

• Increasing age
• Family history
• Postpartum
• Pituitary disease
• Hypothalamic disease
• Autoimmune diseases
• History of head or neck irradiation
• Treatment of hyperthyroidism
• Treatment with lithium or iodine-containing amiodarone

ASSESSMENT FINDINGS

• Clinical symptoms range from asymptomatic to myxedema coma
• Lethargy, delayed deep tendon reflexes
• Mild weight gain, swelling of hands and feet, macroglossia, periorbital edema
• Nonpharmacologic Management Essay Examples
• Intolerance to cold
• Constipation
• Menstrual irregularities, decreased libido, infertility
• Memory loss, dull facial expression, depression
• Muscle cramps, arthralgias, paresthesias
• Coarse dry skin, hair loss from body and scalp, brittle nails
• Bradycardia, enlarged heart
• Reduced systolic BP and increased diastolic BP
• Anemia
• Hyponatremia
• Atrophic or enlarged thyroid
• Decreased sweating
• Depression
• Hoarseness
• Pubertal delay

Expect lipid levels to be elevated in patients who have hypothyroidism. Treat lipids if still elevated after TSH <10 mIU/L.

DIFFERENTIAL DIAGNOSIS

• Depression
• Dementia
• Congestive heart failure
• Kidney failure
• Many others; presenting symptoms are usually vague

DIAGNOSTIC STUDIES

• Serum TSH is increased in thymoprivic (rare) and goitrous hypothyroidism (often >20 mIU/mL); normal or undetectable in pituitary or hypothalamic hypothyroidism
• T₄ decreased most commonly; occasionally T₃ decreased
• Free T₄ index ↓ = T₃ resin uptake x total serum T₄

Subclinical hypothyroidism: slightly elevated TSH and nonspecific symptoms; monitor TSH every 3 months. Treatment increases risk of osteopenia/osteoporosis.

PREVENTION

• Periodic monitoring of thyroid hormone levels for patients treated for hyperthyroidism
• Identification of risk factors
• Newborn thyroid screening at 2-6 days of age

Congenital hypothyroidism: educate parents about etiology, treatment with L-thyroxine to prevent intellectual disabilities, and need for follow-up care.

NONPHARMACOLOGIC MANAGEMENT

• Educate parents that children may manifest behavioral problems at the beginning of treatment
• Assess growth and development in children
• High-fiber diet to prevent constipation
• If obese, diet for weight loss/body fat reduction
• Educate about need for lifelong adherence to thyroid replacement medication and need to report signs of toxicity, infection, or cardiac symptoms
• Annual lipid level assessment

PHARMACOLOGIC MANAGEMENT

• L-thyroxine daily; begin at lower dose in older adults or in presence of cardiac disease (consider 25 mcg daily)
• In young, healthy patients, 1.6 mcg/kg/day is anticipated replacement dose
• Older patients should be started at 25-50 mcg/day and increased to 1.0 mcg/kg/daily as symptoms and side effects are monitored
• Adult: maintenance: 50-200 mcg/day
• Infants: 6-15 mcg/kg/day based on age
• Children: 4-6 mcg/kg/day based on age
  • >12 years: 2-3 mcg/kg/day incomplete puberty
  • >12 years: 1.6 mcg/kg/day complete puberty

Goal of treatment in infants and children is rapid achievement of T4 concentration >10 mIU/L or a serum T4 in the upper half of the normal range for age. Rapid replacement results in attainment of normal IQ.

• Tabs: 25 mcg; 50 mcg; 88 mcg; 100 mcg; 112 mcg; 137 mcg; 150 mcg; 175 mcg; 200 mcg; 300 mcg

In older patients, start low and go slow when initiating replacement.
L-thyroxine should be given on an empty stomach. In children, may crush tabs and mix in 5-10 mL of water, breast milk or formula. Do not mix with soy formula or formula containing iron or calcium. Antacids or simethicone can decrease absorption.

PREGNANCY/LACTATION CONSIDERATIONS

• Starting at 8 weeks’ gestation, L-thyroxine dose requirements rise by 25-50%
• TSH should be assessed every 4 weeks during first half of pregnancy, then less frequently in second half of pregnancy
• If TSH reference range is 0.1-2.5 mIU/L, then:
  • TSH goal during first trimester is 0.1-2.5 mIU/L
  • TSH goal during second trimester is 0.2-3 mIU/L
  • TSH goal during third trimester is 0.3-3 mIU/L
• Reduce L-thyroxine to prepregnancy dose immediately after delivery
• Breastfeeding is not a contraindication to L-thyroxine therapy

CONSULTATION/REFERRAL

• Refer to pediatric endocrinologist for congenital hypothyroidism
• Refer to ER and endocrinologist for myxedema coma
• Refer to endocrinologist for secondary or tertiary hypothyroidism

FOLLOW-UP

• Measure TSH after patient has been on L-thyroxine for 6 weeks, and every 6-8 weeks until at goal, then annually unless symptomatic
• Examine periodically for signs of thyrotoxicity (e.g., tremor or tachycardia)
• Congenital hypothyroidism: periodically monitor T4 and TSH
• Acquired hypothyroidism: monitor initial response to medication at 4 to 6 weeks (using TSH and symptoms), then monitor TSH annually

EXPECTED COURSE

• Improvement is expected 2 weeks after initiation of medication
• Signs and symptoms should resolve in 3 to 6 months
• Lifelong therapy is needed

POSSIBLE COMPLICATIONS

• Myxedema coma: life-threatening, severe hypothyroidism; may require intravenous L-thyroxine and cardiorespiratory assistance
• Thyrotoxicity
• Treatment-induced CHF in older adults or patients with coronary artery disease
• Bone demineralization due to overtreatment over a long period
• Without treatment, congenital hypothyroidism may lead to mental retardation
• Growth and development delays
• Increased susceptibility to infection
• Sexual dysfunction
• Infertility

16. Nail fungus- Tinea Unguium- Tinea Corporis

DESCRIPTION

A group of fungal infections affecting various parts of the body. The specific type is identified by characteristic appearance, etiologic agent and site.

ETIOLOGY

 

• Trichophyton, Microsporum, Epidermophyton
• Pityrosporum species: tinea versicolor causative agent
• T. rubrum and Trichophyton interdigitale: tinea unguium, causative agents

 

INCIDENCE

• Common
• More prevalent in summer months, warm climates

RISK FACTORS

• Tinea capitis
  • Daycare attendance
  • Contact with infected items (e.g., combs, brushes, hats)
  • Poor hygiene
  • Diabetes
• Tinea corporis
  • Close contact with animals
  • Warm climates
  • Obesity
  • Prolonged use of topical steroids
  • Immunocompromised state
• Tinea cruris
  • Wearing wet clothing
  • Excessive sweating
  • Obesity
  • Prolonged use of topical steroids
  • Immunocompromised state
• Tinea pedis
  • Occlusive footwear
  • Damp footwear
  • Prolonged use of topical steroids
  • Immunocompromised state
  • Poor foot hygiene
• Pityriasis versicolor (previously tinea versicolor)
  • Hot, humid climates
  • Wearing wet clothing
  • Prolonged use of topical steroids
  • Immunocompromised state

ASSESSMENT FINDINGS

• Tinea capitis
  • Round patchy scales on scalp
  • Occasionally, alopecia develops
  • Most common in pediatric patients
• Tinea corporis
  • Rash
  • Pruritus
  • Well-circumscribed, red, scaly, plaque usually on the trunk
  • May occur in groups of three or more
• Tinea cruris
  • Pruritus
  • Well marginated half-moon plaques in the groin and/or upper thighs
  • May take on eczematous appearance from chronic scratching
  • Does not affect the scrotum or penis
  • May appear as vesicles
  • Rare in pediatric patients before puberty
• Tinea pedis
  • Itching, malodor, and burning of feet
  • Maceration in toe webs
  • Scaling or blistering on soles of feet
  • Bacterial superinfections possible
  • Runners, older adults, and patients with diabetes more susceptible
  • Spreads easily to groin area and hands
• Tinea versicolor
  • Well-marginated lesions of varying colors (white, red, brown); hence the name “versicolor”
  • Rare itching
  • Common in axilla, shoulders, chest, back (sebum rich areas)

DIFFERENTIAL DIAGNOSIS

• Tinea capitis: alopecia areata, psoriasis, seborrhea, trichotillomania
• Tinea corporis: pityriasis rosea, psoriasis, atopic dermatitis
• Tinea cruris: candidiasis, intertrigo, psoriasis
• Tinea pedis: intertrigo, dyshidrosis, psoriasis
• Tinea versicolor: pityriasis alba, vitiligo

DIAGNOSTIC STUDIES

• KOH scraping
• Wood’s lamp exam (some tinea will not fluoresce, most forms of tinea capitis will not fluoresce)

PREVENTION

• Good personal hygiene
• Identification and treatment of infected humans and pets (tinea capitis and corporis)
• Remove wet clothes as soon as possible
• Dry between toes after showering and bathing
• Avoid direct contact with surfaces in public bathing facilities
• Put socks on before undergarments
• Avoid sharing clothing, sports equipment or towels with other people

NONPHARMACOLOGIC MANAGEMENT

• Tinea capitis
  • Good hygiene
  • Consider monitoring liver function if treated with griseofulvin or another oral antifungal
  • Teach patients to wear sunscreen and minimize sun exposure because of increased photosensitivity when taking griseofulvin
  • Treat family members and infected pets
  • Shaving of head not necessary for treatment
• Tinea corporis
  • Good hygiene
  • Avoid contact with lesions
• Tinea cruris
  • Keep area as dry as possible
  • Do not scratch
• Tinea pedis
  • Dry between toes
  • Trim dead skin
• Tinea versicolor
  • Keep area as dry as possible

PHARMACOLOGIC MANAGEMENT

TINEA INFECTIONS PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Tinea Capitis	griseofulvin	Adult: 500 mg daily Max: 1 g daily Children:30-50 pounds: 125-250 mg/day>50 pounds: 250-500 mg/day	Usually requires 4-6 weeks treatment Take with a high-fat meal to improve absorption Contraindicated in patients with porphyria, hepatic dysfunction Derived from penicillin; theoretically possible for reaction in penicillin-sensitive patients (no reports) Avoid exposure to sunlight May reduce efficacy of oral contraceptives
	Grifulvin V	Tabs: 100 mg, 500 mg Suspension: 125 mg/5 mL
	Various generics
Tinea Corporis/Cruris/Pedis  General comments To prevent relapse, use 1 week after apparent resolution Keep skin clean, dry; expose to air and light when possible to speed resolution Many antifungals available, all have specific indications for fungal infections	econazole	Adult: apply to cover area once daily	Treat for at least 2 weeks; if no improvement, reassess diagnosis Tinea pedis: TREAT 4 WEEKS Information on pediatric dosing not available Do not use vaginally
	Spectazole	Cream: 15 g, 30 g, 85 g
	Various generics
	ketoconazole 2%	Adult: Apply once daily to cover affected and immediate surrounding area  Nonpharmacologic Management Essay Examples	Treat at least 2 weeks; if no improvement, reassess diagnosis Tinea pedis: TREAT 6 WEEKS Safety and efficacy in children have not been established Do not use vaginally
	Various generics	Cream: 15 g, 30 g, 60 g
	terbinafine	Adults and children >12 years: wash affected skin with soap and water and dry completely before applying	Treat for at least 2 weeks; if no improvement, reassess diagnosis Do not use vaginally
	Lamisil	Cream: various sizes

continued

TINEA INFECTIONS PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Tinea Versicolor	ketoconazole 2% shampoo	Adult: apply shampoo to damp skin of affected area and a wide margin surrounding affected area. Leave in place for 5 minutes, rinse off with water. One application should be sufficient	Treatment of infection may not result in immediate normalization of pigment. May take several months Keep away from eyes and mucous membranes
	Nizoral shampoo	4 oz plastic bottle
	Selenium sulfide 2.25% shampoo	Adult: apply to affected areas and lather with a small amount of water. Leave on skin for 10 minutes, then rinse thoroughly. Repeat daily for 7 days	May cause skin irritation, increase in normal hair loss Keep away from eyes and mucous membranes
	Various generics	180 mL bottle
	itraconazole	Adult: 200 mg PO BID for 1 week per month; 2 pulses for fingernails, 3 pulses for toenails    Children: Pulse therapy 5 mg/kg/day for 1 week per month; 2 pulses for fingernails, 3 pulses for toenails	Test hepatic function initially and monthly Monitor for 3A4 drug interactions that can produce hepatotoxicity Take with food
	Sporanox; Onmel
	terbinafine	Adult: 250 mg PO daily for 6 weeks for fingernail, 12-16 wk for toenail    PULSE dosing: 250 mg PO daily for 7-10 days monthly or 7 days q 3 months; skin monthly for 3 months; fingernails monthly for 6 months; toenails monthly for 9 months; topical antifungal also used   Children: Weight <20 kg: 65.5 mg/day Weight 20-40 kg: 125 mg/day Weight >40 kg: 250 mg /day 6 wk for fingernails, 12 wk for toenails Pulse dosing 7-10 days monthly for 3-6 months for fingernails, 6-9 months for toenails	Test hepatic function initially and 1 month after first month if dosing daily If pulse dosing, hepatic function initially for baseline Can interfere with other medications; instruct patient NOT to take with other medications May stop statin drugs when pulse dosing Adults: follow up every 3 months Children: follow up monthly Children: hepatic function panel and CBC at baseline
	Lamisil
	fluconazole (second line therapy)	Adult: 150 mg – 450 mg wkly for 3 months in fingernail and 6 months in toenails  Tinea Versicolor: 150 mg daily for 7 days (monthly) older than 12 years   Children: 3-6 mg/kg wkly for 12-16 wk for fingernail and 18-26 wk for toenail	Liver functions can interfere with other medications; Do not take along with other medications GI upset; take with food
	Diflucan
	griseofulvin (lower efficacy and chance of relapse)	Adult: 500-1000 mg/day for 6-9 months in fingernails and 12-18 months for toenails; take with fatty food    Children: 10 mg/kg per day for ages 1 month and older (maximum 500 mg) Tinea Capitis: dose daily for 1 month; recheck child and dose for a second month	GI upset and headache
	Gris Peg

continued 

TINEA INFECTIONS PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
TOPICALS	ciclopirox	Tinea unguium: topically daily for 48 wk	Contact dermatitis as well as irritation Nonpharmacologic Management Essay Examples
	Penlac
	naftifine 1% / 2% cream or gel	Tinea corporis, pedis, cruris: nightly for 2-4 wk
	Naftin
	sertaconazole	Tinea pedis, corporis, cruris: use daily for 4 wk
	Ertaczo 2% cream
	luliconazole	Tinea corporis and cruris:use daily for 1 week  Tinea pedis: daily for 2 wk
	Luzu 1% cream
	efinaconazole	Onychomycosis: apply to nails nightly for 48 – 52 wk
	Jublia 10% cream
	tavaborole	Onychomycosis: apply to nails nightly for 48 – 52 wk
	Kerydin

PREGNANCY/LACTATION CONSIDERATIONS

• Oral antifungals contraindicated in pregnancy

CONSULTATION/REFERRAL

• Dermatologist for cases that do not respond to treatment

FOLLOW-UP

• Monthly

EXPECTED COURSE

• Tinea capitis
  • Usually resolves after 2 months of daily treatment with griseofulvin and ketoconazole shampoo 2%
• All tinea has a high reinfection rate, especially in:
  • Patients with diabetes
  • Immunocompromised patients
  • Patients living in moist climates
• Treatment with pulse dosing of oral medication plus a topical will treat the infection effectively
• Secondary infections are possible; treat accordingly

COMPLICATIONS

• Tinea capitis
  • Alopecia or scarring can occur if left untreated
• Tinea pedis and tinea unguium
  • Can spread to the groin and hands

 

17. Obesity

Complex chronic disease of excess and dysfunctional adipose tissue that contributes to systemic disease. A 5-10% weight loss may improve obesity-related complications.

ETIOLOGY

• Multifactorial: physiologic, genetic, environmental, psychological, cultural
  • Physiologic: imbalance between food intake and energy expenditure; dysregulation of hunger and satiety hormones (e.g., ghrelin, leptin, GLP-1, PPY, CCK)
  • Genetic: several single genes cause rare forms of obesity; dozens of genes influence common forms of obesity
  • Environmental: decreased activity, energy-dense foods
  • Obesogenic medications (e.g., antihistamines, steroids, beta blockers, secretagogues, SSRIs) may cause or contribute to weight gain
• Weight regain has basis in physiologic counterresponse to weight loss: decreased energy expenditure, increased appetite resulting altered physiology

INCIDENCE

• Increasing in the U.S.
• Prevalence of obesity in the U.S.
  • 35% of adults
    • Greater incidence in women (especially black and Hispanic women)
  • 17% of children
    • Greatest in adolescents

RISK FACTORS

• Parental obesity
• Decreased socioeconomic status
• Intake of calorically dense, nutrient-deficient highly palatable foods
• Sedentary lifestyle/inactivity
• Increased screen use, especially among children

ASSESSMENT FINDINGS

• Staging of disease is based on complication-specific criteria per AACE Guideline 2016
  • Stage 0: BMI 25-29.9 (overweight) and ≥30 (obesity) with no complications
  • Stage 1: BMI ≥25 with mild to moderate complications
  • Stage 2: BMI ≥25 with mild to moderate complications or requiring aggressive weight loss treatment
  • BMI ≥25 with at least one severe complication
  • ≥23 for some ethnicities
• Waist circumference (added cardiometabolic risk assessment)
  • Women >35 inches
  • Men >40 inches
• Review weight history and weight loss attempts, current eating strategies, current activity level, complete past medical and family history, and review of systems with an emphasis on obesity-related comorbidities/complications

DIAGNOSTIC STUDIES

• None needed for diagnosis, but can assist with identification of obesity-related comorbidities and complications, development of treatment plan, and medication management
• Thyroid function studies
• Lipid profile
• Fasting glucose, HgbA1C
• Liver function tests
• CBC
• Chemistry panel
• Lipase, amylase
• EKG
• Screening questionnaire for depression, anxiety and/or binge eating
• Screening questionnaire for sleep apnea

PREVENTION

• Well-balanced diet following USDA MyPlate: www.choosemyplate.gov
• Reduce sedentary behavior, increase regular physical activity: goal 150 minutes/week, including resistance exercise
• Sufficient sleep: inadequate sleep causes ghrelin to increase and leptin to decrease, producing greater hunger than when rested

NONPHARMACOLOGIC MANAGEMENT

• Counseling about lifelong strategies
• Behavior interventions
  • Realistic goal setting
  • Education
  • Health outcomes
  • Focus on progress
• Determine caloric requirement for body weight and institute 500-750 kcal/day dietary deficit during weight loss
• Track food and activity electronically or on paper
• Increase activity level to at least 150 minutes/week
• Regular follow-up for health outcomes, weight loss tracking, motivation, and improvement in obesity-related complications

Healthy Home Ideas
Plan, purchase and prepare healthy foods Use shopping lists Stock pantry with healthy foods Keep fruits and vegetables accessible Avoid bringing unhealthy foods into home Try to eat family meals 5 times/week Decrease screen time Enlist a weight loss and/or exercise partner

PHARMACOLOGIC MANAGEMENT

• Short-term medication
  • Phentermine
    • Sympathomimetic/increases satiety
    • Adult:
      • 15-37.5 mg PO Q AM
      • 13 weeks only as per label
      • Not safe during pregnancy
    • Adverse effects: palpitations, tachycardia, increased BP, overstimulation, tremor, dizziness, insomnia, dysphoria, HA, dry mouth, diarrhea, constipation
    • Contraindications: cardiovascular disease, uncontrolled hypertension, hyperthyroidism, glaucoma, drug abuse history, MAO inhibitor use in past 14 days
    • Note: Endocrine Society provides guidance on reasonable long-term use of phentermine 7.5-15 mg PO once daily with several qualifiers
      • State professional board regulations and laws must be followed; if long-term use is not precluded, other issues to consider include informing patient about off-label use, contraindications, and need for close follow-up
• Chronic medications
  • Orlistat (Xenical)
    • Blocks the digestion and absorption of fat in the stomach and intestines
    • Adult:
      • Prescription: 120 mg PO TID
      • OTC: 60 mg PO daily
    • Adverse effects: oily and frequent bowel movements; bowel urgency; fecal incontinence; flatus; increased risk for cholelithiasis and urinary oxalate (rare); postmarketing reports of liver injury; may decrease absorption of fat-soluble vitamins; approved for long-term use
    • Contraindications: chronic malabsorption syndromes, pregnancy, bulimia, organ transplant
  • Lorcaserin (Belviq)
    • Exact mechanism unknown; activates 5-HT2C receptors (selective serotonin agonist), thus promoting satiety
    • Adult:
      • 10 mg PO BID
      • 20 mg PO once daily (XR formulation)
      • DEA Schedule IV
      • Not safe during pregnancy
      • REMS program related to pregnancy testing before and during therapy
    • Drug interactions: safety unknown, SSRIs, SNRIs, MAO inhibitors, triptans, bupropion, dextromethorphan, St. John’s wort
    • Adverse effects: headache, dizziness, fatigue, nausea/vomiting, dry mouth, constipation, cough, bradycardia, hyperprolactinemia, hypoglycemia (patients with diabetes), musculoskeletal pain, depression, valvular heart disease, serotonin syndrome, neuroleptic malignant syndrome
    • Contraindications: CrCl <30, CHF, valvular heart disease, pregnancy, depression, diabetes, bradycardia
    • Miscellaneous: D/C if weight loss <5% after 12 weeks, renal dosing CrCl 30-50 (caution advised)
  • Phentermine-topiramate (Qsymia)
    • Sympathomimetic and neurostabilizer; promotes satiety
    • Adult:
      • 3.75 mg/23 mg PO starting dose; titrate to 7.5 mg/46 mg, 11.25 mg/69 mg; maximum dose 15 mg/92 mg
      • DEA Schedule IV
      • Not safe during pregnancy
    • Monitoring: depression, hypokalemia, CV evaluation at baseline; consider ECHO
    • Drug interactions: may potentiate CNS depressants and hypokalemia of non-potassium-sparing diuretics
    • Adverse effects: paresthesias, constipation, dysgeusia, insomnia, dizziness, HA, nausea, back pain, fatigue, diarrhea, blurred vision, anxiety, alopecia, hypesthesia, irritability, attention disturbance, GERD, tachycardia, metabolic acidosis, nephrolithiasis, osteoporosis, hyperthermia, pulmonary HTN, Steven-Johnson syndrome
    • Contraindications: MAO inhibitors within 14 days, pregnancy, breastfeeding, CV disease, hyperthyroidism, glaucoma, history of drug abuse
    • Miscellaneous: D/C if weight loss <5% after 12 weeks on maximum dose (taper off if discontinuing at maximum dose)
  • Naltrexone-bupropion (Contrave)
    • Opioid antagonist and antidepressant; promotes satiety and suppresses cravings
    • Adult:
      • 8 mg/90 mg, 1 tab PO q AM; titrating to max of 2 tabs PO q AM and 1 tab PO q PM
      • Not safe during pregnancy
      • Boxed Warning: suicidal thoughts and behaviors, neuropsychiatric reactions
    • Monitoring: Cr at baseline, BP, HR, depression/suicide risk
    • Drug interactions: opioid analgesics, interaction with CYP2D6 metabolized medications; beware drugs that lower seizure threshold
    • Adverse effects: nausea, constipation, headache, vomiting, dizziness, insomnia, dry mouth and diarrhea
    • Nonpharmacologic Management Essay Examples
    • Contraindications: within 14 days of MAO inhibitor dose, uncontrolled hypertension, seizure disorders, eating disorders, chronic opioid use, pregnancy
    • Caution: should not be taken with a high-fat meal because of resulting significant increase in bupropion and systemic exposure to naltrexone; alcohol intolerance reported so alcohol intake should be limited/avoided
    • Miscellaneous: D/C if weight loss <5% after 12 weeks at maximum dose (taper off if discontinuing at maximum dose)
  • Liraglutide (Saxenda)
    • Glucagon-like peptide-1 receptor agonist; promotes satiety
    • Adult:
      • Initiate at 0.6 mg/day SQ for 1 week; increase in weekly intervals until 3-mg dose is reached
      • Not safe during pregnancy
      • REMS program related to potential risk for medullary thyroid carcinoma and risk for acute pancreatitis
    • Drug interactions: delays gastric emptying so may impact concurrent oral medications
    • Adverse effects: nausea, hypoglycemia, diarrhea, constipation, vomiting, headache, decreased appetite, dyspepsia, fatigue, dizziness, abdominal pain, increased lipase
    • Contraindications: Personal or family history of medullary thyroid carcinoma, multiple endocrine neoplasia syndrome type 2 (MENS 2), pregnancy, gastroparesis
    • Miscellaneous: D/C if weight loss <4% after 12 weeks at maximum dose (taper off if discontinuing max dose); if patient misses medication or it is interrupted for more than 3 days, restart at 0.6 mg and taper back to max dose

SURGICAL MANAGEMENT

• Bariatric procedures may be options for patients with BMI >35 with significant comorbidities, or BMI >40
• Impact is on metabolic and hormonal role in obesity as well as restrictive food intake
  • Common surgical procedures
    • Adjustable gastric banding
    • Sleeve gastrectomy
    • Roux-en-Y gastric bypass

PREGNANCY/LACTATION CONSIDERATIONS

• Well-balanced diet should be maintained in pregnancy
• Restrictive caloric intake is not recommended in pregnancy
• Common time of onset or worsening of obesity
• Anti-obesity medications not recommended in pregnancy

CONSULTATION/REFERRAL

• Obesity specialists
• Bariatric surgery center
• Dietitian specializing in obesity care (nutritional counseling)
• Personal trainer (specializing in differently abled exercises and accommodations)
• Psychotherapist for compulsive eating disorders
• Support programs (e.g., Weight Watchers, Taking Off Pounds Sensibly, Overeaters Anonymous)

FOLLOW-UP

• Long-term, frequent follow-up as for most chronic conditions. This disease has a relapsing nature based on physiology, so patients require close monitoring
• Surgical patients need long-term follow-up with surgeon and primary care to monitor weight loss and nutrition
• Annual labs as indicated by medication administration, comorbidities, and annual needs

EXPECTED COURSE

• Chronic condition that is rarely cured but can be controlled
• Long-term maintenance of weight loss difficult
• Dependent on sustained patient motivation and circumstances

OBESITY-RELATED COMPLICATIONS

• Prediabetes
• Metabolic syndrome
• Type 2 diabetes mellitus
• Dyslipidemia
• Cancer (multiple types)
• Hypertension
• Cardiovascular disease
• Nonalcoholic fatty liver disease, nonalcoholic steatohepatitis
• Polycystic ovary syndrome, infertility (women)
• Male hypogonadism
• Obstructive sleep apnea
• Respiratory disease (including asthma)
• Osteoarthritis
• Urinary stress incontinence
• Gastroesophageal reflux disease (GERD)
• Psychiatric disorders (depression, anxiety, binge eating disorder, stigmatization)

POSSIBLE COMPLICATIONS

• Increased mortality
• Cholelithiasis, especially with rapid weight loss
• Thromboembolism
• Decreased mobility
• Decreased exercise tolerance

 

18. Osteoarthritis

DESCRIPTION

Progressive destruction of the articular cartilage and subchondral bone accompanied by osteophyte formation and sclerosis. Osteoarthritis (OA) is confined to the joints. Constitutional symptoms are absent.

Osteoarthritis is the most common joint disease in the United States.

 

ETIOLOGY

• Primary OA can be a localized or generalized disease with no known cause
• Secondary OA is associated with trauma, infection, or metabolic disorders

INCIDENCE

• Women > Men especially after age 50
• Predominantly > age 40
• Common: affects more than 30 million U.S. adults

RISK FACTORS

• Obesity
• Age
• Trauma
• Prolonged use or overuse of joints related to occupation or activity
• Family history
• History of developmental dysplasia of the hip or slipped femoral epiphysis
• Hemophilia
• Paget’s disease

ASSESSMENT FINDINGS

• Joint pain, usually asymmetrical, develops insidiously and accompanies or follows physical activity
• Morning stiffness lasting < 1 hour. Stiffness resumes towards the day’s end or after periods of activity
• Joints are cool with possible crepitus and limited range of motion
• Overgrowth of osteophytes results in bony enlargement, especially bunions (MTP joint), Heberden’s nodes (DIP joints), and Bouchard’s nodes (PIP joints)

Commonly involved joints:  Distal interphalangeal (DIP) Proximal interphalangeal (PIP)  First carpometacarpal (CMC)  First metatarsophalangeal (MTP) Hips, knees, cervical and lumbar spine

DIFFERENTIAL DIAGNOSIS

• Gout, pseudogout
• Infective arthritis
• Inflammatory arthritis: rheumatoid, psoriatic, ankylosing spondylitis, juvenile idiopathic, systemic lupus, erythematosus (SLE)
• Joint injury
• Soft tissue injury
• Peripheral vascular disease
• Giant cell arteritis
• Bursitis
• Tendinitis
• Osteopenia, osteoarthritis
• Neuropathy

DIAGNOSTIC STUDIES

• No diagnostic laboratory tests are available for osteoarthritis; diagnosis is based on history, physical, and X-ray findings
• X-rays: osteophytes, joint space narrowing, and subchondral sclerosis
• Inflammation markers: negative
  • Erythrocyte sedimentation rate (ESR)
  • Rheumatoid factor (RF)
  • Antinuclear antibodies (ANA)
• In younger patients, consider iron saturation or ferritin levels to rule out hemochromatosis

PREVENTION

• Weight control
• Management of underlying causes of secondary disease

NONPHARMACOLOGIC MANAGEMENT

• Emphasis must be given to nonpharmacologic management to delay or minimize use of medications that have adverse effects
• Weight loss, if indicated: loss of 10% of body weight can lead to improvement in reported symptoms
• Education: OA is a chronic disorder requiring patient participation in muscle strengthening to provide joint support
• Patient education: focused on discussion of the etiology of OA, risk factors and expected prognosis to optimize management
• Organized program of supervised exercise
• Rest
• Knee or elbow braces to stabilize joints during exercise
• Orthotic shoes, cane, collar, sling, corset, wedged insoles
• Apply heat and/or cold to affected joints
• Wedge osteotomy, arthroplasty
• Acupuncture may be beneficial
• Topical creams or liniments for counterirritant effect
• Tai chi, acupuncture and yoga are alternative therapies that may be considered for management of OA symptoms

PHARMACOLOGIC MANAGEMENT

• Pharmacologic therapy should only be used when symptoms are present; routine use has not been shown to modify the disease
• Medication therapy is usually needed long term; use is associated with many possible side effects
• Careful consideration should be given to existing comorbid conditions when selecting therapy (e.g., diabetes, poorly controlled hypertension, cardiovascular disease, peptic ulcer disease, chronic kidney disease, advanced age)
• The use of acetaminophen as a first-line agent for OA is no longer recommended due to safety concerns and lack of efficacy for musculoskeletal pain
• Short-acting NSAIDs are associated with fewer side effects than long-acting forms
• Concomitant use of misoprostol (Cytotec) to prevent gastric ulcer development caused by NSAIDs
• Consider COX-2 inhibitors for GI protection (risk of GI bleeds decreased but still present)
• Topical NSAIDs may be an excellent alternative for older adults and patients who tolerate NSAIDs poorly
• Duloxetine (Cymbalta) can be used for patients with OA in multiple joints and those with comorbid conditions in which NSAIDs are contraindicated
• Topical capsaicin can be used if one or a few joints are involved
• Tramadol (Ultram) is recommended by the American College of Rheumatology as add-on therapy for patients with OA involving the hands, knees and/or hips who have not responded to other treatment modalities. Narcotic analgesics indicated only briefly for severe exacerbation
• Intra-articular corticosteroid injections, limited to four times a year, are recommended for knee, shoulder and hip
• Hyaluronic acid use for knee arthritis is also an accepted modality

The risk for vascular events such as myocardial infarction or stroke is increased with use of NSAIDs.
OSTEOARTHRITIS PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
NSAIDs  Inhibit cyclooxygenase (COX-1 and COX-2) activity and prostaglandin synthesis General comments:   May cause serious gastrointestinal events including bleeding, ulceration, perforation; may occur without warning   Use with caution in patients who have known or suspected cardiovascular risk factors   May lead to or worsen hypertension   May lead to fluid retention or worsening heart failure   Avoid concomitant use with salicylates   Use with caution in patients who have asthma   Avoid use in patients who have renal disease   Patients must receive accompanying medication guide when product dispensed   Consider comorbid conditions: will need close monitoring if used	celecoxib	Adult: 200 mg PO once daily OR 100 mg PO BID	Mostly COX-2 selective Avoid in patients who have sulfonamide hypersensitivity Reduce dose by 50% if hepatic impairment
	Celebrex	Caps: 50 mg, 100 mg, 200 mg
	diclofenac	Adult: total daily dose of 100-150 mg PO in two or three divided doses	Avoid in late pregnancy due to inhibition of uterine contractions
	Voltaren	Tabs: 25 mg, 50 mg, 75 mg
	diclofenac topical	Adult: Gel: apply 4 g QID; Max: 16 g/joint/day up to 32 g/day total Solution: apply 2 sprays 2% solution per knee BID OR Apply 40 gtt 1.5% solution per knee QID	Avoid if history of asthma or aspirin allergy Creatinine at baseline CBC and chemistries if used long term Do not use prior to or after heart bypass surgery
	Voltaren Gel	Gel: 1%
	Pennsaid	Solution: 1.5%, 2%
	etodolac	Adult:  Initial: titrate for effect 300 mg PO BID or TID 400 mg PO BID 500 mg PO TID Usual: 300 mg PO BID Max: 1000 mg/day PO	Avoid late in pregnancy due to premature closure of the ductus arteriosus May diminish effect of ACE inhibitors
	Lodine	Caps: 200 mg, 300 mg Tabs: 400 mg, 500 mg
	ibuprofen	Adult:  Initial: titrate for effect 400 mg TID or QID 600 mg TID or QID 800 mg TID Usual: 2,400-3,200 mg daily PO Max: 3200 mg/day PO	Avoid late in pregnancy due to premature closure of the ductus arteriosus May diminish effect of ACE inhibitors Available by prescription or as various OTC products Nonpharmacologic Management Essay Examples
	Motrin	Tabs: 400 mg, 600 mg, 800 mg
	indomethacin	Adult:  Initial: 25 mg BID-TID; may increase by 25-50 mg daily Usual: 25-50 mg TID Max: 200 mg daily	Avoid in recent MI and severe heart failure Caution in hepatic or renal impairment
	Indocin
	ketoprofen	Immediate Release Adult: Initial: 50 mg PO QID OR 75 mg PO TID Max: 300 mg PO dailySustained Release Adult: Initial: 200 mg PO daily Max: 200 mg PO daily	Avoid use late in pregnancy Do not mix dose forms Reduce dose in patients > 75 years
	Orudis	Caps: 50 mg, 75 mg Extended-release caps: 200 mg
	meloxicam	Adult: Initial: 7.5 mg PO daily Usual: 7.5 mg PO daily Max: 15 mg PO daily	May be taken without regard to meals
	Mobic	Tabs: 7.5 mg, 15 mg Suspension: 7.5 mg/5 mL

continued 

OSTEOARTHRITIS PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
	nabumetone	Adult:  Initial: 1 g daily Max: 2 g daily in 1-2 divided doses.	Must be renal dosed May affect ACE inhibitors
	Relafen
		Tabs: 500 mg, 750 mg
	naproxen	Adult: use lowest effective dose and shortest effective treatment duration  Initial: 250-500 mg PO every 12 hr Max: 1500 mg/day PO x 6 months	Hemoglobin at baseline Long-term use: may increase risk of heart attack or stroke May cause GI bleeding and ulceration Not recommended for children <2 years
	Naprosyn
	sulindac	Adult:  Initial: 200 mg daily Max: 400 mg daily, usually given in divided doses	May affect ACE inhibitors Contraindicated in aspirin allergy Coronary artery bypass graft surgery
	Clinoril	Tabs: 200 mg

CONSULTATION/REFERRAL

• Orthopedist
• Physical therapist
• Supervised exercise program
• Nutritionist for weight loss
• Self-management classes
• Tai Chi classes
• Acupuncturist

FOLLOW-UP

• Regularly scheduled return visits for evaluation, support and education
• NSAID therapy requirements (includes COX-2): periodic CBC, renal function studies, and stool for occult blood

EXPECTED COURSE

• Usually progressive with more pain at rest, joint effusions, and bony enlargement
• Goals of therapy are to minimize pain and optimize functioning while targeting modifiable risk factors; achievement of a plan of care that is tailored to the patient’s needs and goals

POSSIBLE COMPLICATIONS

• Adverse effects from NSAIDs
• Adverse effects from corticosteroids
• Depression associated with chronic illness

 

19. Pain in hip, shoulder and knee

DESCRIPTION

Pain in orthopedic conditions is mostly centered in and around the joints. Pain sources include:

• The bones of the joint
  • Articulating surfaces of the joints
• Soft tissue within the joints
  • Ligaments, cartilage
• Supportive soft tissue structures external to the joint
  • Ligaments, tendons, muscles, fascia
• Nerves
  • Resulting from impinged or damaged nerves

 

ETIOLOGY

• Inflammation
  • Synovial neovascularization
  • Lymphocytes, plasma cells, and macrophages infiltrate the synovial capsule with release of pro-inflammatory cytokines
  • Hyperplasia of the cells of the synovial lining
  • Newer data indicates possible involvement of proinflammatory cytokines, such as adipokines, in the development of OA
• Effusion
  • Increased production of synovial fluid with or without blood within a joint
  • Increased synovial fluid and/or blood within the capsule of a bursa near a joint, such as the prepatellar bursa of the knee
• Direct damage
  • Trauma to the joint

PREVALENCE

Osteoarthritis (OA) is a common presentation of orthopedic pain. Pain in OA is nearly universal. However, the severity of pain is variable and does not always correspond with the severity of joint damage

 

• More than 30 million adults in the U.S. have OA
• 13.9% of adults 25 and older have OA in at least one joint
• 33.6% of adults 65 and older are affected by OA

RISK FACTORS

• Joint overuse or injury
• Age: OA is more common in people older than 50, and the risk increases with age
• Sex: women are more likely to develop OA than men, especially after age 50 and especially knee arthritis
• Obesity: extra weight puts more stress on joints, particularly weight-bearing joints like the hips and knees
  • Cofactor in the development of OA in non-weightbearing joints (e.g., fingers, wrists)
  • Increased presence of proinflammatory cytokines
  • Increased weight load on knee, worsened by varus malalignment
  • A 10% initial decrease in body weight may result in 28% improvement in pain in the average obese patient
• Genetics: having a family member with OA increases the risk of developing OA. Having hand OA is associated with having knee OA
• Race: differences among races in terms of access to OA care, management, and outcomes. Some Asian groups may have a lower risk for developing OA

ASSESSMENT FINDINGS

• Adult
  • Osteoarthritis
    • Limited joint movement
    • Pain with movement
    • Stiffness that worsens with use
    • Joint crepitus with movement
    • Joint deformity (related to development of osteophytes and loss of articular cartilage)
    • Swelling is rare
  • Soft tissue injuries
    • Pain
    • Swelling
    • Deformity
    • Stiffness, decreased joint mobility
  • Inflammatory arthropathy
    • Swelling with increased warmth (synovitis)
    • Pain with movement and at rest
    • Stiffness that lasts an hour or more after resting
    • Deformity associated with joint swelling and possible joint erosion (erosion increases as disease progresses)
  • Infections
    • Joint swelling with erythema and increased warmth
    • Pain that increases with movement of the joint
    • Potential fever
    • Possible associated cellulitis
    • Patient holds joint in position of comfort (for example: flexion of the knee or hip)
• Children:
  • Symptoms are similar to those noted above
  • Children with septic arthritis tend to appear toxic, with irritability, high fever, and severe pain associated with joint movement
  • Specific orthopedic diseases in children have defined symptoms beyond the scope of this review

DIFFERENTIAL DIAGNOSIS

• Children: osteoarthritis does not occur in children. Common differentials for joint pain in children include:
  • Orthopedic
    • Slipped capital femoral epiphysis
    • Legg-Calvé-Perthes disease
    • Overuse syndromes
    • Trauma
  • Infection:
    • Septic arthritis, pyogenic arthritis
    • Gram-positive organisms
    • Gonococcal arthritis
    • Toxic/transient synovitis
    • Osteomyelitis adjacent to joint
    • Reactive arthritis
    • Lyme arthritis, Lyme disease (Borrelia burgdorferi)
    • Acute rheumatic fever
  • Autoimmune:
    • Juvenile idiopathic arthritis
    • Systemic lupus erythematosus
  • Hematological:
    • Hemarthrosis
  • Neoplastic:
    • Osteoid osteoma adjacent to joint
    • Osteosarcoma adjacent to joint
    • Ewing’s sarcoma adjacent to joint
    • Leukemia
• Adults:
  • Osteoarthritis
  • Inflammatory (autoimmune) arthropathies
    • Examples: rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis
  • Infection
    • Joint infection (septic arthritis, pyogenic arthritis)
      • Bacterial: gonococcal or nongonococcal
      • Viral
      • Fungal
    • Lyme disease (Borrelia burgdorferi)
  • Bone infection
    • Osteomyelitis
    • Osteitis
  • Trauma and over use syndromes
    • Fractures, sprained ligaments, tendinitis, fasciitis

DIAGNOSTIC STUDIES

• Radiographs
• MRI
• CT
• Ultrasound

Laboratory studies:  No laboratory studies for osteoarthritis To evaluate for autoimmune/inflammatory differentials: CRP ESR Rheumatologic studies

 

PREVENTION

• Maintain a healthy weight
• Avoid inactivity
• Regular participation in low-impact exercises
  • Aquatics
  • Aerobic (cardiovascular) exercise weekly in at least 10-minute increments, with sessions distributed throughout the week
    • 150 minutes of moderate intensity OR
    • 75 minutes of vigorous intensity
    • To increase health benefits, increase exercise to 300 minutes weekly of vigorous-intensity aerobic exercise
  • Moderate to high-intensity muscle strengthening exercises 2 or more days each week; exercises should involve all muscle groups
  • Patients with chronic health issues should be under the care of a health professional to help guide safe levels of exercise
  • For more specific information and exercise intensity examples see Office of Disease Prevention and Health Promotion guidance at: https://health.gov/paguidelines/guidelines/chapter4.aspx
• Treat joint injuries promptly

NONPHARMACOLOGIC MANAGEMENT

• Physical therapy
• Occupational therapy
• Exercise
  • Tai Chi
  • Yoga
  • Exercise regimens (see Prevention)
• Chiropractic
• Massage
• RICE protocol (rest, ice, compression, elevation)
• MEAT Protocol (movement, exercise, analgesia, treatment)
• Heat applied to joint

PHARMACOLOGIC MANAGEMENT

• Joint injection of steroids with/without analgesics
• Non-narcotic pain relievers and NSAIDs

For all medications, use the lowest effective dose for the shortest period of time needed.

 

ORTHOPEDIC PAIN PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
Non-narcotic Analgesic	acetaminophen	Adults:  650-1000 mg every 4-8 hr; max 4 g/day   Children: <6 years: use pediatric dosage forms 6-11 years: 325 mg q 4-6 hr; max 1.625 g/day Max daily dose: 3,000 mg (4,000 mg/day per some sources) Nonpharmacologic Management Essay Examples   Infants: Dosage forms: be sure the parent/guardian understands which strength of liquid formulation to use Usual pain dose: 10-15 mg/kg PO q 4-6 hr prn; Max daily dose: 75 mg/kg/day up to 1 g/4 hr and 4 g/day from all sources   Dosage chart: https://www.healthychildren.org/English/safety-prevention/at-home/medication-safety/Pages/Acetaminophen-for-Fever-and-Pain.aspx   Neonates: Max: 60 mg/kg/day	Side effects: headache, decreased appetite Allergy: rash, itching, angioedema, severe dizziness, or shortness of breath Rare but severe: liver toxicity, Stevens-Johnson syndrome, thrombocytopenia, lymphopenia Caution: hepatic impairment, chronic alcohol use
	Tylenol	Tabs: 325 mg, 500 mg, 650 mg adult liquid 500 mg/15 mL (7% alcohol)
	aspirin	Adults:  Dosage (pain): 650 mg q 4 hr Max adult dose: 4,000 mg/24 hr   Children: do not give to children <12 yr	Side effects: bruising, GI bleeding, dizziness, nausea, vomiting, heartburn, tinnitus Allergic reactions: shortness of breath, skin rash, angioedema Reye’s syndrome association: do not give to children or adolescents with influenza or varicella zoster virus Caution: patients drinking ≥3 alcoholic drinks/day
	Bayer aspirin, Bayer Children’s Aspirin, Ecotrin (and many others)	Pill /capsule strengths: 800 mg, 500 mg, 325 mg, 81 mg, 975 mg, 650 mg, 125 mg, 600 mg, 60 mg, 300 mg, 162 mg, 1 g, 227.5 mg, 1200 mg, 162.5 mg; buffered/enteric-coated 500 mg, 325 mg, 81 mg
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)    General comments:   Hypersensitivity to drug/class/components   Aspirin-exacerbated respiratory disease (AERD), ASA or NSAID-induced asthma or urticaria   Risk of heart attack or stroke: longer use or higher dose increases risk   Risk of ulceration, bleeding, perforation. (patients may not exhibit GI symptoms)   Increases heart failure risk   Avoid in moderate to severe renal insufficiency (CrCl <30 mL/min)   Avoid with low-dose aspirin, antiplatelet use or concomitant anticoagulant use   Avoid if peptic ulcer, age >65, debilitated or moderate hepatic impairment	ibuprofen	Adults: 1200-3200 mg/day divided into 3-4 doses.  Reduced dose in older adults; begin with a low dose   Children: 30-40 mg/kg/day, divided into 3-4 doses.   Infants: younger than 6 months: use with caution; base on weight as above. Safety has not been established	Side effects: tinnitus, hearing loss, nervousness Contraindicated: Within 14 days of CABG ASA or NSAID-induced asthma or urticaria pregnancy starting at 30 weeks’ gestation Perioperative use in CABG surgery Caution Women trying to conceive Asthma Fluid retention Dehydration Smoker Alcohol use May interfere with effectiveness of loop and thiazide diuretics
	Advil, Motrin/Medipren, Nuprin	Adults:  OTC tabs: 200 mg OTC suspension: 100 mg/5 mL Rx tabs: 400 mg, 600 mg, 800 mg   Children/Infants: Infant drops 50 mg/1.25 mL, Liquid 100 mg/5 mL Liquid 100 mg/1 tsp, Chewable 50-mg tablets, Junior-strength 100-mg tablets Caution parents to use correct strength
	naproxen	Adults: 250 mg BID but may be taken q 6-8 hr (1000 mg/day max) OR 375 mg BID OR 500 mg BID  Max: 1250 on first day; 1000 mg thereafter   Reduced dose in older adults; begin with a low dose   Children: 13-24 kg: 62.5 mg BID 25-37 kg: 125 mg BID >38 kg: 187.5 mg BID	Side effects: nausea, constipation, ALT/AST elevation, tinnitus, dyspnea Contraindicated: Within 14 days of CABG ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation Perioperative use in CABG surgery Caution: Women trying to conceive Asthma Fluid retention Dehydration Smoker Alcohol use May interfere with the effectiveness of loop and thiazide diuretics
	Aleve, Anaprox, Naprelan, Naprosyn	Dose depends on brand, caution patients to carefully read the label
	celecoxib	Adults: 200 mg PO once daily    Children: indicated for idiopathic RA   2 years and older with weight 10-25 kg: 50 mg PO q 12 hr   2 years and older with weight >25 kg: 100 mg PO q 12 hr   Safety not established in <2 years	Side effects: diarrhea, heartburn, nausea, abdominal pain, back pain, dizziness, headache, stuffy nose, sore throat Contraindicated: ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation Perioperative use in CABG surgery Hypersensitivity to sulfonamides Caution: Asthma Allergy to aspirin Poor CYP2C9 metabolizers (consider decreasing starting dose by 50% or use alternative therapy) Passes into breast milk
	Celebrex	Caps: 50 mg, 100 mg, 200 mg, 400 mg
	diclofenac	Adults: 50 mg BID-TID, or 75 mg BID PO    Children: safety and efficacy in children have not been established; use in children is not recommended	Side effects:constipation, diarrhea, loss of appetite, heartburn, bloating, increased bleeding time, edema, headache, rash/itchy skin, tinnitus Contraindicated: ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation Perioperative use in CABG surgery Caution: Fluid retention May exacerbate anemia Not recommended for use during pregnancy or when breastfeeding
	Cambia, Cataflam, Voltaren, Voltaren-XR, Zipsor, Zorvolex	Topical gel: Solaraze 3% Gel, Voltaren 1% Gel, Inflamma-K kit (diclofenac 1.5% topical solution with Salonpas patch), Flector (180 mg diclofenac epolamine and 13 mg diclofenac epolamine per gram of adhesive)
	diflunisal	Adults: 500 mg PO q 12 hr; Start: 1000 mg PO x 1; Max: 1500 mg/day    Do not cut/crush/chew CrCl <50: decrease dose 50%; HD/PD: no supplement   Children: safety and efficacy in children not established; use in children not recommended	Side effects: diarrhea, headache, constipation, flatulence, dizziness, fatigue Contraindicated: ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation Perioperative use in CABG surgery Caution: Fluid retention Renal impairment Hepatic impairment
	Dolobid	Tabs: 250 mg, 500 mg
	etodolac	Adults: 200-500 mg  Max dose 1000 mg/24 hr   Children: give with food if GI upset occurs   ≥6 years, 20-30 kg 400 mg PO once daily   ≥6 years, 31-45 kg 600 mg PO once daily   ≥6 yearsr, 46-60 kg 800 mg PO once daily   ≥6 yr, >60 kg 1000 mg PO once daily	Side effects:somnolence, tinnitus, ecchymosis, abnormal stools, fatigue, arthralgia, photosensitivity, delayed ovulation, constipation, headache, dizziness, ALT/AST elevation Contraindicated: ASA- or NSAID-induced asthma or urticaria, pregnancy starting at 30 weeks’ gestation Perioperative use in CABG surgery Caution: Women trying to conceive Asthma Fluid retention Dehydration Smoker Alcohol use Renal papillary necrosis May interfere with the effectiveness of loop and thiazide diuretics
	Lodine	Caps: 200 mg, 300 mg  Tabs: 400 mg, 500 mg Extended-release tabs: 400 mg, 500 mg 600 mg
	ketoprofen	Adults: give with food if GI upset occurs  50 mg or 75 mg PO TID 200 mg; ER PO once daily Max: 300 mg/day; 200 mg/day ER   Renal dosing: Mild impairment: max 150 mg/day; CrCl <25: max 100 mg/day   Hepatic dosing: hepatic impairment: max 100 mg/day   Children: safety and efficacy in children not established; use in children not recommended	Side effects: constipation, headache, GI upset, tinnitus, photosensitivity Contraindicated: ASA- or NSAID-induced asthma or urticaria Pregnancy starting at 30 weeks’ gestation CABG surgery perioperative use Caution: Women trying to conceive Asthma Dehydration Smoker Alcohol use
		Caps: 50 mg, 75 mg  Extended-release caps: 200 mg
	ketorolac	Adults:  Parenteral single-dose treatment: 60 mg IM x 1 Alternative: 30 mg IV x 1 ≥65 years or if weight <50 kg: give 30 mg IM x 1 or 15 mg IV x 1   Parenteral multiple dose treatment: 30 mg IM/IV q 6 hr; Max: 120 mg/day ≥65 years or if weight <50 kg: give 15 mg IM/IV q 6 hr up to 60 mg/day   Combined duration of PO/IM/IV not to exceed 5 days   PO route: 10 mg PO q 4-6 hr; Start: 20 mg PO x 1 Max: 40 mg/day   Patients who received parenteral treatment: start 10 mg PO x 1 ≥65 years or if weight <50 kg: duration of combined PO/IM/IV treatment not to exceed 5 days   Renal dosing: Single-dose treatment renal impairment: 30 mg IM x 1 or 15 mg IV x 1 Advanced impairment: contraindicated   Multiple dose treatment renal impairment: 15 mg IM/IV q 6 hr, max 60 mg/day or may switch to 10 mg PO q 4-6 hr, max 40 mg/day Advanced impairment: contraindicated   Hepatic dosing: Caution advised   Children: ≥6 months 0.5 mg/kg IM/IV q 6 hr up to 72 hr Alternative: 1 mg/kg IM/IV q 6 hr up to 24-48 hr Max: 30 mg/dose IM or 15 mg/dose IV   Renal dosing: Renal impairment: decrease dose by 50% Advanced impairment: contraindicated	Side effects:photosensitivity, blood dyscrasias, headache, dizziness Contraindicated: Pregnancy starting at 30 weeks’ gestation CABG surgery perioperative use Caution: Women trying to conceive Cerebrovascular hemorrhage Active bleeding Major surgery preop use Epidural or intrathecal use Labor and delivery Severe Volume depletion Asthma Inflammatory bowel disease Smoker Alcohol use
	Toradol	Adult:  INJ (prefilled syringe, IM): 60 mg/2 mL INJ (prefilled syringe, IM/IV): 15 mg/mL, 30 mg/mL INJ (vial): 15 mg/mL, 30 mg/mL   Children: Tabs: 10 mg INJ (prefilled syringe, IM): 60 mg/2 mL; INJ (prefilled syringe, IM/IV): 15 mg/mL, 30 mg/mL INJ (vial): 15 mg/mL, 30 mg/mL
	indomethacin	Adults: 25-50 mg PO BID-TID-QID  Max: 200 mg/day; ER 150 mg/day Alternative: 75 mg; ER PO once daily Titrate to 25-50 mg q 7 days   Children (indicated for rheumatoid arthritis): 1-2 mg/kg/day PO divided BID-QID Max: 4 mg/kg/day up to 150-200 mg/day; ER 4 mg/kg/day up to 150 mg/day Alternative: 1-2 mg/kg/day; ER PO divided once or twice daily   Renal impairment: dose adjustment may be required but specific pediatric dosing adjustments not defined   Hepatic dosing: not defined Hepatic impairment: caution advised	Side effects: dyspepsia, GI upset, somnolence, dizziness, headache Contraindicated: ASA- or NSAID-induced asthma or urticaria Pregnancy starting at 30 weeks’ gestation CABG surgery perioperative use Neonates with untreated infection, active bleeding, necrotizing enterocolitis, pulmonary atresia Active bleeding Severe tetralogy of Fallot Severe aortic coarctation Significant renal impairment thrombocytopenia Pulmonary atresia Suppository form in proctitis history, recent rectal bleeding Caution: Women trying to conceive Fluid retention Alcohol use Smoker Concurrent nephrotoxic agent use Dehydration Sepsis Asthma Psychiatric disorder Neurologic disease
	Indocin, Tivorbex	Caps: 25 mg, 50 mg  Extended-release caps: 75 mg Suppository: 50 mg INJ: various
	nabumetone	Adults:  1000-2000 mg/day PO divided once to twice daily Start: 1000 mg PO once daily Max: 2000 mg/day x 7-14 days   Renal dosing: CrCl 30-49: Start: 750 mg once daily Max: 1500 mg/day CrCl <30: Start: 500 mg once daily Max: 1000 mg/day   HD/PD: no supplement Hepatic dosing: not defined   Severe impairment: caution advised   Pediatric dosing is unavailable or not applicable for this drug	Side effects: dyspepsia, GI upset, somnolence, dizziness, headache Contraindicated: ASA- or NSAID-induced asthma or urticaria Pregnancy starting at 30 weeks’ gestation Nonpharmacologic Management Essay Examples CABG surgery perioperative use Caution: Women trying to conceive Asthma Fluid retention Dehydration Smoker Alcohol use
	Relafen	Tabs: 500 mg, 750 mg
	meloxicam	Adults:  7.5-15 mg PO once daily Start: 7.5 mg PO once daily Max: 15 mg/day   Mild-moderate renal impairment: no adjustment CrCl <15: avoid use HD: max 7.5 mg/day   Hepatic dosing: Child-Pugh Class A or B: no adjustment Child-Pugh Class C: not defined   Children >60 kg: 7.5 mg PO once daily Max: 7.5 mg/day   Renal and hepatic impairment: dose adjustment may be required but specific pediatric dosing adjustments not defined; see adult renal dosing for guidance	Side effects: diarrhea, nausea, dizziness, somnolence Contraindicated: ASA- or NSAID-induced asthma or urticaria Pregnancy starting at 30 weeks’ gestation CABG surgery perioperative use Caution: Women trying to conceive Asthma Fluid retention Dehydration Smoker Alcohol use Hypovolemia
	Mobic	Tabs: 7.5 mg, 15 mg
	piroxicam	Adults:  20 mg PO once daily Max: 20 mg/day   Renal dosing: no adjustment HD/PD: no supplement   Hepatic dosing: not defined Hepatic impairment: consider decreased dose   Pediatric dosing is unavailable or not applicable for this drug	Side effects: dyspepsia, nausea, abdominal pain constipation, headache, dizziness, somnolence Contraindicated: ASA- or NSAID-induced asthma or urticaria Pregnancy starting at 30 weeks’ gestation CABG surgery perioperative use Caution: Women trying to conceive Poor CYP2C9 metabolizers Asthma Fluid retention Dehydration Alcohol use Smoker Prolonged use
	Feldene	Caps: 10 mg, 20 mg
	salsalate	Adults: 1500 mg PO BID  Alternative: 1000 mg PO TID   Renal dosing: not defined, caution advised   Hepatic dosing: not defined Hepatic impairment: caution advised   Pediatric dosing is unavailable or not applicable for this drug	Side effects: tinnitus, nausea, impaired hearing, rash, vertigo Contraindicated: ASA- or NSAID-induced asthma or urticaria CABG surgery perioperative use Influenza, varicella, or febrile viral infection (patients <20 years old) Caution: Asthma Fluid retention Dehydration Smoker Alcohol use
	Disalcid	Tabs: 500 mg, 750 mg
	sulindac	Adults: 150-200 mg PO BID  Start: 150 mg PO BID Max: 400 mg/day   Renal dosing: adjust dose amount Significant impairment: decrease dose HD/PD: no supplement   Hepatic dosing: not defined Hepatic impairment: consider decrease   Pediatric dosing is unavailable or not applicable for this drug	Side effects:nausea/vomiting, diarrhea, abdominal pain, constipation, dizziness, headache, rash, ALT, AST elevated, somnolence, tinnitus Contraindicated: ASA- or NSAID-induced asthma or urticaria Pregnancy starting at 30 weeks’ gestation CABG surgery perioperative use Caution: Women trying to conceive Asthma Dehydration SLE Mixed connective tissue disease Renal lithiasis history Smoker Alcohol use
	Clinoril	Tabs: 150 mg, 200 mg
	tolmetin	Adults: 200-600 mg PO TID  Start: 400 mg PO TID Max: 1800 mg   Renal dosing: no adjustment HD/PD: no supplement   Hepatic dosing: not defined Hepatic impairment: caution advised   Children: ≤2 years: 15-30 mg/kg/day PO divided TID-QID Start: 20 mg/kg/day PO divided TID-QID Max: 30 mg/kg/day Renal dosing: see adult dosing Renal impairment: dose adjustment may be required but specific pediatric dosing adjustments not defined; see adult renal dosing for guidance   Hepatic dosing: not defined Hepatic impairment: caution advised	Side effects: nausea, abdominal pain, constipation, dizziness, headache, rash, ALT, AST elevated, urticaria, somnolence Contraindicated: ASA- or NSAID-induced asthma or urticaria Pregnancy starting at 30 weeks’ gestation CABG surgery perioperative use Caution: Women trying to conceive Corticosteroid use Alcohol use Smoker Dehydration Concurrent diuretics ACE inhibitor use ARB use Asthma

CONSULTATION/REFERRAL

• For pain that is poorly responsive to standard treatment
• For evaluation for potential joint replacement or other surgical interventions
• For interventional radiologic procedures
  • Fluoroscopy-guided joint injections
  • Fluoroscopy-guided joint aspirations

FOLLOW-UP

• Within 2-4 weeks after initiating medication
• For increased pain or disability
• Swelling, increased warmth, or erythema in the affected joint(s)

EXPECTED COURSE

• Dependent on the cause of orthopedic pain
• Maintaining a healthy weight and appropriate exercise regimen may help prevent or delay associated joint damage and improve symptoms

 

POSSIBLE COMPLICATIONS

• Disability
• Need for joint replacement
• Falls due to joint damage and pain that may lead to changes in gait and balance

 

20. Pain in knee
21. Pain in shoulder

 

22. Reflux esophagitis- GERD

DESCRIPTION

Gastroesophageal reflux is the movement of gastrointestinal contents into the esophagus or beyond, facilitated by decreased lower esophageal sphincter (LES) tone. Some reflux is physiologic. Gastroesophageal reflux disease (GERD) is present when gastric contents flow upward into the esophagus or oropharynx, producing symptoms.

INCIDENCE

• Affects one-third of Americans at some point
• Affects 81% of patients 60 years and older
• Affects 50-60% of women during pregnancy
• Little is known about prevalence in children and adolescents
• Small number of infants develop GERD, but recurrent vomiting common:
  • 50% of infants in first 3 months
  • 67% of 4-month-old infants
  • 5% of 10- to 12-month-old infants
  • Resolves spontaneously in nearly all infants

RISK FACTORS

• Factors that may reduce LES tone:
  • Alcohol ingestion
  • Anticholinergic medications
  • Calcium channel blockers
  • Caffeine
  • Chocolate, peppermint
  • Fatty, spicy, citrus foods
  • Hormones: estrogen, progesterone, glucagon, secretin
  • Meperidine
  • Nicotine
  • Obesity
  • Pregnancy
  • Theophylline
• Aging
• Diabetes mellitus, diabetic gastroparesis
• Delay in gastric emptying
• Increased gastric acid secretion
• Irritation of esophageal mucosa by:
  • NSAIDs
  • Tetracycline
  • Quinidine
  • Caffeine
• Zenker’s diverticulum
• Zollinger-Ellison syndrome
• Childhood GERD predisposes to GERD in adolescence and adulthood
• Risk factors for GERD during childhood:
  • Neurologic disorder (cerebral palsy)
  • Congenital malformation (esophageal atresia or trachea-esophageal fistula)
  • Severe chronic pulmonary disease (cystic fibrosis)

ASSESSMENT FINDINGS

• Chest pain: (requires a cardiac workup)
• Postnasal drip, throat clearing
• Chronic sore throat, hoarseness
• Dysphagia
• Erosion of teeth by acid
• Esophageal pain referred to neck, mid-back, upper abdomen
• Extraesophageal presentation: asthma, chronic cough, laryngitis
• Sensation of lump in throat
• Pyrosis (heartburn) is cardinal symptom: burning beneath sternum, typically postprandial and nocturnal
• Regurgitation
• Ulceration: hematemesis, fatigue, anemia
• Infants:
  • Apnea
  • Apparent life-threatening event (ALTE)
  • Arching of back during feeding
  • Disturbed sleep
  • Dysphagia or refusal to eat
  • Irritability or excessive crying
  • Weight loss or poor weight gain
  • Recurring vomiting
  • Respiratory problems/stridor
• Child or adolescent:
  • Recurrent vomiting or regurgitation
  • Heartburn or chest pain
  • Hoarseness

Bilious vomiting and hematemesis are RED flags in children.

DIFFERENTIAL DIAGNOSIS

• Asthma
• Cardiac disease
• Cholelithiasis
• Esophageal spasm or infection
• Lower respiratory infection: bronchitis, pneumonia
• Peptic ulcer disease
• Pulmonary edema
• In infants and children, consider:
  • Gastrointestinal obstructions
  • Gastrointestinal disorders
  • Neurologic disorders
  • Infectious disease
  • Metabolic or endocrine disorders
  • Renal conditions
  • Toxic conditions
  • Cardiac problems: chronic heart failure

DIAGNOSTIC STUDIES

• Presumptive diagnosis of GERD can be made based on symptoms of heartburn and regurgitation. Diagnostic testing is not needed in this setting; empiric PPI therapy for 8 weeks should be initiated
• If cerebral palsy is present, cardiac evaluation is recommended before starting empiric PPI therapy
• Endoscopy is recommended for patients with GERD symptoms that do not respond to empirical trial of PPI therapy or who experience dysphagia
• Nonpharmacologic Management Essay Examples
• Ambulatory esophageal pH testing is indicated when considering endoscopy
• Infants and children:
  • History and physical sufficient to reliably diagnose reflux, recognize complications, and initiate management in most infants with vomiting, and in older children with regurgitation and heartburn
  • Upper GI study to evaluate presence of anatomic abnormalities
  • Esophageal pH monitoring: acid reflux
  • Endoscopy and biopsy assess presence and severity of esophagitis, strictures, and Barrett’s esophagus; exclude other disorders
  • Empiric medical therapy for a trial period to determine if reflux is causing specific symptoms

NONPHARMACOLOGIC MANAGEMENT

• Education: physical causes of GERD, common aggravating and ameliorating factors, and lifestyle changes to control GERD:
  • Avoid recumbence for 2 hours after meals
  • Elevate head of bed, including entire chest
  • Weight loss if indicated
  • Reduce size of meals and amount of fat, acid, spices, caffeine, and sweets
  • Smoking cessation
  • Reduce alcohol consumption
  • Avoid stooping, bending after meals
  • Do not wear tight-fitting garments
• Selective elimination of caffeine, chocolate, alcohol, and acidic foods is recommended since they decrease the lower esophageal sphincter and cause symptoms in some patients
• Surgical interventions, crural tightening or fundoplication reserved for patients with stricture, hemorrhage, Barrett’s esophagitis, chronic aspiration or intractable symptoms
• Infants:
  • Milk thickening: reduces episodes of vomiting
  • Supine position for sleep to reduce risk of sudden infant death syndrome (SIDS)
  • Diet changes: hypoallergenic formula
• Child or adolescent:
  • Position left side with head of bed elevated
  • Lifestyle changes:
    • Avoid caffeine, chocolate, spicy foods
    • Avoid cigarette smoke and alcohol use
    • Weight control

PHARMACOLOGIC MANAGEMENT

• 8-week course of PPI therapy is treatment of choice
• PPI therapy should be dosed once a day and before the first meal of the day
• If partial response to daily PPI, increase to BID dosing
• If symptoms persist after 8 weeks of PPI therapy, consider low-dose PPIs or H2 blockers for maintenance therapy

GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Antacids  Neutralize hydrochloric acid in the stomach to rapidly cause pH to rise General comments Blocks absorption of many drugs: digoxin, tetracyclines, benzodiazepines, iron and others	calcium carbonate	Adults: chew 2-4 tabs as symptoms occur Max: 15 tablets in 24 hoursChildren: not recommended	Pregnancy: may use Do not use maximum dosage for more than 2 weeks FDA has not evaluated and approved this OTC product for reflux Produces rapid relief of heartburn symptoms Use with caution in patients with heart failure, renal failure, edema, cirrhosis, gout, age >60
	Tums various generics	Tabs: 200 mg packs of 12, 36, 75, 150 tablets
H2 antagonists  Inhibit gastric acid secretion by inhibiting H2 receptors of the gastric parietal cells   General comments Symptomatic response to therapy does not preclude gastric malignancy   Onset of antisecretory action is about 1 hour with inhibition of secretion for 10-12 hr	cimetidine	Adults and children >16 years:  Initial: 800 mg BID for 12 wk Alternative: 400 mg 4 times daily for 12 wk Max: 12 wk Adult Max: 1600 mg/day Children:  Neonates: 5-10 mg/kg/day q 8-12 hr Infants: 10-20 mg/kg/day q 6-12 hr Children: 20-40 mg/kg/day q 6 hr	Pregnancy: may use Cimetidine associated with many 3A4 drug interactions Long-term therapy may be associated with B12 deficiency May take several days to achieve relief Allow 1 hr between H2 blocker and antacid consumption Dose adjustment needed for renal and hepatic impairment Give with food
	Tagamet	Solution: 300 mg/5mL  Tabs:200, 300, 400, 800 mg
	ranitidine	Adult: 150-300 mg BID  Max: 6 g in hypersecretory conditions   Children ≥1 month-16 years: 5-10 mg/kg/day in two divided doses BID or TID	Pregnancy: may use Efferdose is 25 mg. Dissolve in (no less than) 5 mL water. Do not chew, swallow whole or dissolve on tongue Contains phenylalanine Potential drug interactions with procainamide, warfarin, glipizide, others Dose adjustment needed for renal and hepatic impairment No dosage adjustment needed for older adults
	Zantac	Tabs: 75 mg, 150 mg, 300 mg  Efferdose: 25 mg effervescent tabs Syrup: 15 mg/mL

continued

GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	famotidine	Adult:  With symptoms of GERD: 20 mg BID for up to 6 wk   Treatment of esophagitis due to GERD: 20 or 40 mg BID for up to 12 wk   Children <3 months: 0.5 mg/kg/day divided once daily 3-12 months: 1 mg/kg/day divided BID 1-6 years: 1-2 mg/kg/day divided BID	Pregnancy: may use 20 mg BID was superior to 40 mg at bedtime for improvement of symptoms No drug interactions have been identified No dosage adjustment needed for older adults Dose adjustment needed for renal and hepatic impairment
	Pepcid	Tabs: 20 mg, 40 mg  Susp: 40 mg/5 mL
	nizatidine	Adults: 150 mg BID or 300 mg HS  Children: 6 months-12 years: 5-10 mg/kg/day BID >12 years: 150 mg BID Peds Max: 300 mg/day	Pregnancy: may use Lactation: probably safe Renal insufficiency: decrease dose
	Axid	Tabs: 150 mg, 300 mg  Solution: 15 mg/mL

continued

GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
Proton Pump Inhibitors  Potently suppress gastric acid secretion by inhibiting the hydrogen/potassium pump in gastric parietal cells   General comments Therapy > 3 years may lead to B12 malabsorption   Take at same time each day Take before meal, when hydrogen/potassium pumps are most active Symptomatic response does not preclude the presence of gastric malignancy   May interfere with medications whose bioavailability is affected by gastric pH   PPI may be associated with an increased risk of osteoporosis-related fractures of the hip, wrist or spine. Use lowest dose and shortest duration of PPI appropriate for the patient’s condition   Daily treatment longer than 3 years may lead to malabsorption of vitamin B12   Consider this diagnosis if clinical symptoms occur	dexlansoprazole	Adult ≥18 years: 30 mg daily for 4 wk	Pregnancy: caution advised Take without regard to food NO dosage adjustment necessary for older adults or renal impairment Dosage adjustment needed for hepatic impairment
	Dexilant	Tabs: 30 mg, 60 mg
	esomeprazole	Adult: 20-40 mg once daily for 4-8 weeks    Children: 1-11 months: 0.5 mg/kg once daily for 10 days 1-17 years and <55 kg: 10 mg once daily for 10 days 1-17 years and >55 kg: 20 mg once daily for 10 days	Pregnancy: caution advised Lactation: safety unknown Take without regard to food May affect plasma levels of antiretroviral drugs No dosage adjustment needed for renal or hepatic insufficiency Take with full glass of water Take 1 hr before meals
	Nexium	Caps: 20 mg, 40 mg e-c delayed releaseSuspension: 20 mg, 40 mg per packet
	lansoprazole	Short term treatment of symptomatic GERD:  >30 kg: 30 mg once daily for up to 12 wk   Children: 1-11 years and <30 kg: 15 mg daily for 12 wk 1-11 years and >30 kg: 30 mg daily for 12 wk 12-17 years: 15 mg daily for 12 wk Peds Max: 30 mg day	Pregnancy: caution advised Possible drug interactions with antiretroviral therapy, diazepam, warfarin, phenytoin and others No dosage adjustment necessary in older adults or with renal impairment Dosage adjustment needed for hepatic impairment
	Prevacid	Caps: 15 mg, 30 mg  Solu tabs: 15 mg, 30 mg Oral Suspension packets: 15 mg, 30 mg

continued

GASTROESOPHAGEAL REFLUX DISEASE PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name®)	Dosage How Supplied	Comments
	omeprazole	Adults: 20 mg up to 4 wk If esophagitis accompanies GERD: 20 mg daily for 4-8  wk Children:  1-16 years: >20 kg: 20 mg once daily 10-20 kg: 10 mg once daily 5-10 kg: 5 mg once daily	Pregnancy: caution advised Lactation: probably safe Possible drug interactions with antiretroviral therapy, diazepam, warfarin, phenytoin and others No dosage adjustment necessary in older adults or with renal impairment Dosage adjustment needed for hepatic impairment
	Prilosec	Caps: 10 mg, 20 mg, 40 mg  Oral suspension packets: 2.5 mg, 10 mg
	pantoprazole	For short-term treatment of erosive esophagitis associated with GERD:  Adult: 40 mg once daily for up to 8 wk Non-erosive esophagitis: 20 mg once daily for 4-8 wk   Children 5 years and older: 15 to <40 kg: 20 mg once daily for up to 8 wk 5 years and older: >40 kg: 40 mg once daily for up to 8 wk	Pregnancy: caution advised Lactation: probably safe Possible drug interactions with antiretroviral therapy, diazepam, warfarin, phenytoin and others Nonpharmacologic Management Essay Examples No dosage adjustment necessary in older adults
	Protonix	Delayed-Release Tabs: 20 mg,  40 mg Suspension: 40 mg/packet

CONSULTATION/REFERRAL

• Cardiologist: severe chest pain, radiating pain
• Gastroenterologist:
  • Dysphagia
  • Unexplained weight loss
  • Vomiting
  • GI bleeding
  • Anemia
  • Palpable abdominal mass
  • Recurrent or refractory symptoms
  • Long history of alcohol and/or nicotine abuse
  • Regular NSAID use
• Infants/children: pediatric gastroenterologist
  • Uncomplicated reflux: If symptoms worsen or do not improve by 18-24 months
  • Recurrent vomiting and poor weight may require medical therapy, hospital observation, and/or endoscopy with biopsy
  • Infant who refuses feeding
  • Child >2 years with recurrent vomiting or regurgitation
  • Child with dysphagia
  • Unresolved chronic heartburn or chest pain in older child or adolescent

FOLLOW-UP

• CBC
• Screen for B12 deficiency and increased risk of osteopenia after long-term PPI use

EXPECTED COURSE

• Most patients respond well to combined nonpharmacologic therapies, but symptoms may return once medication is withdrawn

POSSIBLE COMPLICATIONS

• Erosion and ulceration
• Stricture
• Barrett’s esophagitis
• High-grade dysplasia
• Esophageal adenocarcinoma
• Aspiration pneumonia
• Co-existing conditions in children with GERD:
  • Esophagitis
  • Dysphagia (difficulty swallowing)
  • Odynophagia (painful swallowing)
  • Asthma
  • Recurrent pneumonia
  • Upper airway syndrome
  • Anemia
  • Hematemesis

 

23. Tinea corporis
24. URI- COMMON COLD

ASSESSMENT FINDINGS

• Obtain a thorough history to aid in diagnosis; assessment findings are similar to that of other diagnoses (e.g., Strep pharyngitis, sinusitis, bronchitis, and allergic rhinitis)
• Most common symptoms: nasal stuffiness, sneezing, scratchy, irritated throat/hoarseness
• Red/irritated nasal mucosa
• Nasal secretions are initially clear; may progress to be cloudy, yellow, or green
• Malaise, headache
• Halitosis
• Cough
• Occasionally, low-grade fever; may be higher in pediatric rhinovirus infections

DESCRIPTION

An infection of the upper respiratory tract (nares, pharynx, hypopharynx, uvula, and tonsils) caused by a virus. The symptoms may last for 3-10 days and are usually self-limiting.

DIAGNOSTIC STUDIES

• Usually none indicated, but tests may be helpful to rule out other diseases that require specific targeted treatment (ex.: Strep, influenza, mononucleosis, pertussis)
• CBC if symptoms persist: elevated WBC indicates bacterial infection
• Culture of nasal washings (usually not helpful)

If CBC indicates bacterial infection, consider differential diagnoses.

DIFFERENTIAL DIAGNOSIS

• Allergic rhinitis
• Influenza
• Sinusitis
• Pertussis
• Mononucleosis
• Epiglottitis
• Group A Strep
• Mumps
• Rubeola
• Varicella

ETIOLOGY

• Rhinoviruses are the most common cause (30-50%)
• Parainfluenza and influenza viruses
• Adenoviruses
• Coronaviruses (20%)
• Enteroviruses, including Coxsackievirus
• Moraxella catarrhalis causes illness in children more than adults
• Respiratory syncytial virus (RSV)

EXPECTED COURSE

• Complete resolution within 10-14 days. Fever, sneezing, and pharyngitis symptoms resolve early in the course. Cough and nasal discharge symptoms last longer

FOLLOW-UP

• None usually needed

INCIDENCE

• Adolescents and adults: 2-4 annually
• School-aged children: 7 annually
• Kindergarten: 12 annually
• Most occur in late fall and winter, peaking late winter/early spring
• The most common infectious disease and most frequent acute outpatient diagnosis; leading cause of missed days of work/school

NONPHARMACOLOGIC MANAGEMENT

• Increased rest
• Increased fluids
• Humidify inspired air
• Hard candy or lozenges for scratchy throat
• Saline nose drops and bulb syringe for infants
• Avoid secondhand smoke and alcohol, discontinue tobacco
• Teach patients that hand washing is the single most effective preventive measure

PHARMACOLOGIC MANAGEMENT

All products are used for symptom relief. Antihistamines are used to dry nasal secretions.

 

Topical decongestants (sympathomimetics) reduce edema in nasal passages, promote drainage, and are available over the counter for temporary relief. However, there are numerous contraindications with topical decongestants and so they are not usually recommended. Examples: Oxymetazoline (Afrin, Duration) and Phenylephrine (Neo-Synephrine)

 

COMMON COLD PHARMACOLOGIC MANAGEMENT Many over the counter products are available as single agents and combinations of antihistamines and decongestants. None speed resolution of infection but may help alleviate symptoms.
Class	Drug Generic name (Trade name)	Dosage How supplied	Comments
Antihistamines  First GenerationGeneral commentsAvoid simultaneous use of CNS depressants Care when driving or engaging in activities that require attention Most available over the counter	diphenhydramine	Adult: 25-50 mg q 4-6 hr; Max: 300 mg/dayChildren: < 6 years: individualize 6-12 years: 12.5-25 mg q 4-6 hr Max: 150 mg/day	Cautious use in patients with glaucoma, difficulty urinating due to an enlarged prostate gland, COPD Avoid alcohol within 6 hours of taking May cause profound drowsiness in some patients
	Benadryl	Chew tabs: 12.5 mg Tabs: 25 mg Liquid: 12.5 mg/5 mL Injection: 50 mg/mL
	Various generics
Oral decongestants Act on adrenergic receptors affecting sympathetic tone of the blood vessels and causing vasoconstriction This results in mucous membrane shrinkage and improved ventilationPseudoephedrine is now a DEA scheduled substance.	pseudoephedrine tabs	Adults and children > 12 years:  Usual: two 30 mg tablets q 4-6 hr Max: 8 tabs in 24 hr Alternative: one 120 mg tablet q 12 hr Alternative: one 240 mg extended- release tab once/24 hr Children 6-12 years: Usual: one 30 mg tab q 4-6 hr Max: 4 tabs in 24 hr Children 6-11 years: Alternative: two teaspoons q 4-6 hr Max: 8 teaspoons in 24 hr Children 4-5 years: Usual: One teaspoon q 4-6 hr Max: 4 teaspoons in 24 hr	Do not use in patients with hypertension Cautious use in patients with thyroid disease, CAD, PAD, arrhythmias, prostate disease, or glaucoma Watch for tachycardia and palpitations Do not crush, divide, or dissolve tablets
	Sudafed	Tabs: 240 mg, 120 mg, 60 mg,  30 mg Liquid: 15 mg/5 mL
	Various generics
	phenylephrine	Tabs: 10 mg Liquid: 2.5 mg/5 mL
	Sudafed PE brand. Nonpharmacologic Management Essay Examples
Antihistamines  Second GenerationGeneral commentsDo not typically produce drowsiness (except cetirizine) and usually dosed once daily	fexofenadine	Adults and children ≥ 12 years: 180 mg daily or 60 mg BID  Children 2-11 years: 30 mg BID	Shake bottle well before use Reduce dose for renal impairment Allegra ODT contains phenylalanine (other Allegra products do not) Avoid aluminum- and magnesium-containing antacids Less effective if taken with fruit juices; take with water Do not expect sedation
	Allegra	Tabs: 30 mg, 60 mg, 180 mg  ODT tab: 30 mg Suspension: 6 mg/mL

continued

COMMON COLD PHARMACOLOGIC MANAGEMENT Many over the counter products are available as single agents and combinations of antihistamines and decongestants. None speed resolution of infection but may help alleviate symptoms. Nonpharmacologic Management Essay Examples.
Class	Drug Generic name (Trade name)	Dosage How supplied	Comments
	loratadine	Adults and children ≥ 6 years: 10 mg daily  Children 2-5 years: 3 mg once daily	Children use chew tabs or syrup Adjustment needed for renal or hepatic impairment Do not expect sedation
	Claritin	Chew Tabs: 5 mg,  Redi Tabs: 10 mg Syrup: 1 mg/mL
	cetirizine	Adults and children ≥12 years:  5-10 mg daily   Children: 6-11 years: 5-10 mg based on symptom relief 2-6 years: 2.5 mg daily or BID
	Zyrtec	Tabs: 10 mg  Chew tabs: 5 mg; 10 mg Syrup: 1 mg/mL; 4 oz bottle
	desloratadine	Children: 6-11 months: 1 mg (2 mL) daily 1-5 years: 1.25 mg (2.5 mL) daily 6-11 years: 2.5 mg (5 mL) daily > 11 years: 5 mg daily	Children use RediTabs or syrup Do not expect sedation Nonpharmacologic Management Essay Examples
	Clarinex	Tabs: 5 mg Redi Tabs: 2.5 mg Syrup: 0.5 mg/mL

 

Antihistamines have NOT been shown to alleviate cold symptoms; however, OTC versions are widely used.

 

The FDA discourages the use of OTC combination cough/cold products in children ≤2 years old.

 

POSSIBLE COMPLICATIONS

• Sinusitis
• Bronchitis, bronchiolitis
• Pneumonia
• Otitis media
• Asthma in patients whose asthma symptoms are triggered by viral infections
• Nonpharmacologic Management Essay Examples

Avoid aspirin in children to reduce the risk of Reye’s Syndrome.

PREGNANCY/LACTATION CONSIDERATIONS

• Medications usually avoided if possible
• Most oral decongestants considered safe for short-term use, but no adequate studies have been performed in humans

PREVENTION

• Good hand washing
• Avoid exposure to infected people
• Adequate rest
• Stress management
• Use of vitamin C or zinc to prevent the common cold lacks evidentiary support

Use of intranasal zinc products may produce transient or permanent loss of smell.

RISK FACTORS

• Exposure to infected people (inhaling viral droplets due to coughing/sneezing)
• Psychological stress
• Touching of contaminated surfaces and subsequent touching of nose or conjunctiva (portal of entry)
• Infants and children are most susceptible due to lack of immunity to offending viruses
• Inflammation and obstruction due to allergic rhinitis and asthma
• Smoking and exposure to secondhand smoke
• Travel, other situations in which a person is exposed to large numbers of people in close proximity

 

25. Urinary tract infection

DESCRIPTION

Infection and inflammation of the kidney, bladder or urethra. Bacterial infection of the bladder mucosa is the most common type of urinary tract infection (UTI).

ETIOLOGY

• Bacteria (e.g., E. coli [75-95% of cases], Proteus mirabilis, Klebsiella pneumoniae, Enterobacter, or Staphylococcus saprophyticus)
• More commonly caused by gram-negative bacteria of colonic origin
• Most UTIs in adult women are due to ascending infections from the urethra
• Hematogenous spread is rarely the cause

INCIDENCE

• Responsible for 7 million office visits and 1 million hospital admissions annually
• 43% of women aged 14-61 have had at least one UTI
• Women > Men
• Uncommon in men <50 years old
• 4-7% prevalence in pregnant women
• Most common of all bacterial infections in women
• Girls: most common ages 7-11 years
• In children, UTI is highest in boys <1 year and girls <4 years

Women are more likely than men to have urinary tract infections because women have short urethras compared to men.

RISK FACTORS

• Previous urinary tract infection
• Diabetes mellitus (women)
• Pregnancy
• Increase in frequency of sexual activity
• Use of spermicides and/or diaphragm, oral contraceptives
• Urinary tract abnormalities (e.g., tumors, calculi, strictures, anomalies, neuropathic bladder, vesicoureteral reflux or polycystic kidneys)
• Benign prostatic hyperplasia
• Fecal/urinary incontinence
• Cognitive impairment
• Immunocompromised host
• Infrequent voiding
• Indwelling urinary catheter
• Postmenopausal state

Always assess UTI risk factors in pediatric patients with suspected UTI.

ASSESSMENT FINDINGS

• Burning, frequency, and/or urgency during urination
• Pain during or after urination
• Sensation of incomplete bladder emptying
• Fever, chills
• Hematuria: gross or microscopic
• Lower abdominal and/or back pain
• Costovertebral angle tenderness
• Dribbling of urine in men
• Small volume and/or frequent voiding
• Foul-smelling urine

The most common symptom of upper urinary tract infection in young children is fever.

DIFFERENTIAL DIAGNOSIS

• Vaginitis
• Sexually transmitted disease
• Hematuria from another cause
• Pregnancy
• Pelvic inflammatory disease
• Prostatitis, epididymitis
• Enuresis
• Overactive bladder

DIAGNOSTIC STUDIES

• Urinalysis: WBCs present, positive leukocyte esterase, positive nitrites
• Bacterial count >100,000 CFU/mL of urine (midstream catch)
• Urine culture with sensitivity
• Blood pressure and temperature
• Routine imaging recommended for:
  • Girls <3 years with first UTI
  • Boys with a first UTI (any age)
  • Children with febrile UTI or recurrent UTI
  • Child with a UTI and family history of renal disease
  • Abnormal pattern of voiding
  • Poor growth
  • Hypertension
• Imaging in children: renal ultrasound to detect obstruction; voiding cystourethrogram to establish vesicoureteral reflux

The preferred method of collecting a urine specimen in children who are not toilet-trained is catheterization.
Urine culture results will be altered if patient has taken an antibiotic prior to collection of urine for culture.

PREVENTION

• Good hydration
• Emptying bladder immediately after sexual intercourse
• Estrogen therapy in postmenopausal women
• Avoidance of spermicidal products
• Good perineal hygiene
• Removal and avoidance of urinary catheters as soon as reasonably possible
• Frequent voiding
• Antibiotic prophylaxis
• Clinical trials suggest circumcision in boys; no clear recommendation in adult men

NONPHARMACOLOGIC MANAGEMENT

• Good hydration
• Voiding after intercourse (if infection associated with sexual intercourse)
• Good perineal hygiene

PHARMACOLOGIC MANAGEMENT

• Consider:
  • TMP-SMX (Bactrim)
  • Nitrofurantoin (Macrobid)
  • Fosfomycin (Monurol)
• Alternative Regimens:
  • Ciprofloxacin
  • Levofloxacin (Levaquin)
  • Beta-lactams

URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
Sulfa Agents  Block synthesis of folic acid by bacteria, thus inhibiting bacterial replication	sulfamethoxazole (SMX) –  trimethoprim (TMP)	Adult: one DS or 2 regular-strength tabs BID PO for 10-14 days    Children >2 months: give 8 mg/kg PO daily of trimethoprim and 40 mg/kg PO daily of sulfamethoxazole in 2 divided doses	Pregnancy: TMP – avoid use during pregnancy secondary to possible risk of teratogenicity. SMX – caution in third trimester Avoid use during pregnancy Nonpharmacologic Management Essay Examples Stevens-Johnson syndrome, toxic epidermal necrolysis, and blood dyscrasias have been associated with sulfa use Photosensitivity may occur
	Bactrim Septra	Tabs: 400 mg SMX- 80 mg TMP  Suspension: 200 mg SMX- 40 mg TMP/5 mL
	Bactrim DS	Tabs: 800 mg SMX-160 mg TMP
Fluoroquinolones  Inhibit the action of DNA gyrase, which is essential for organism replication   General comments   Fluoroquinolones are associated with an increased risk of tendinitis and tendon rupture in all ages. This risk is further increased in patients older than 60, in patients taking corticosteroid drugs, and in patients with kidney, heart or lung transplants   May exacerbate myasthenia gravis; use with caution in this population   Patients may experience moderate to severe photosensitivity while on medication   Monitor for prolongation of QT interval   May alter blood glucose levels in patients on antidiabetic agents	ciprofloxacin	Adult:  Acute uncomplicated 250 mg PO BID for 3 days   Mild/moderate 250 mg PO BID for 7-14 days   Severe/complicated 500 mg PO BID for 7-14 days   Children: NOT first drug of choice 10-20 mg/kg PO BID Max: 400 mg PO/dose	Pregnancy: No known risk of teratogenicity Lactation: Avoid breastfeeding for 4 hours after dose; possible risk of infantile C. difficile infection Avoid with theophylline, antacids, iron, zinc or NSAIDs at higher doses Caution with drugs that lower seizure threshold Hypersensitivity reactions like Stevens-Johnson syndrome may occur CNS disturbances such as seizure, dizziness, insomnia, nervousness may occur
	Cipro	Tabs:  250 mg, 500 mg Suspension: 250/5 mL, 500/5 mL
	levofloxacin	Adult:  Acute uncomplicated 250 mg PO daily for 3 days   Complicated 250 mg PO daily for 10 days OR 750 mg PO daily for 5 days   Children: not recommended	Pregnancy: Risk of bone and cartilage damage, embryo-fetal toxicity (based on animal studies) Lactation: Avoid breastfeeding for 4-6 hours after dose Concomitant use with NSAIDs may increase risk of CNS stimulation and seizures Maintain adequate hydration
	Levaquin	Tabs: 250 mg, 500 mg, 750 mg
	ofloxacin	Adult:  Acute uncomplicated 200 mg PO BID for 3 days   Complicated 200 mg PO BID for 10 days   Children: not recommended	Pregnancy: Risk of bone and cartilage damage, embryo-fetal toxicity (based on animal studies) Lactation: Avoiding breastfeeding for 4-6 hours after dose Concomitant use with NSAIDs may increase risk of CNS stimulation and seizures Maintain adequate hydration
	Floxin	Tabs: 200 mg, 400 mg

continued 

 

 

 

URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
Penicillins  Inhibit cell wall synthesisIn species that produce beta-lactamase, amoxicillin, and ampicillin are ineffectiveAmoxicillin/potassium clavulanate is effective against organisms that produce beta-lactamase	amoxicillin and potassium clavulanate	Adult:  Mild/Moderate 500/125 mg PO BID for 3 days   Severe 875/125 mg PO BID for 5-7 days   Children: Mild/Moderate < 30 kg: 30 mg/kg PO daily in divided doses q 12 hr (dose is based on amoxicillin component) Use 125 mg/31.25 mg/5 mL suspension ONLY > 3 months, < 40 kg: 25 mg/kg PO daily in divided doses q 12 hr OR 20 mg/kg PO daily in divided doses q 8 hr Max single dose: 500 mg PO amoxicillin > 3 months, > 40 kg: adult dosing	Pregnancy: May use during pregnancy, but possible risk of teratogenicity identified in human studies. Animal studies do not support risk Lactation: May use; no known risk of infant harm. Limited human studies support possible risk for infantile diarrhea, rash, urticaria, thrush, or somnolence Adjust dose if renal insufficiency Avoid if history of hypersensitivity to penicillin TWO 250 mg tablets SHOULD NOT be substituted for a 500-mg dose due to the clavulanic acid component
	Augmentin
		Tabs: 250/125 mg, 500/125 mg,  875/125 mg Susp: 125/31.25 mg/5 mL, 250/62.5 mg/5 mL, 400/57 mg/5 mL, 600/42.9 mg/5 mL
Cephalosporins -Second Generation  Inhibits cell wall synthesis of bacteria   General comments   ~ 2-10% cross sensitivity with penicillin; contraindicated if patient has history of anaphylactic response or hives   Recommended as first-line treatment in children	cefaclor	Adult: 250-500 mg PO TID    Children: 20-40 mg/kg PO daily in three divided doses Max: 2 g/day	Pregnancy: Risk of fetal harm low per human data; no known fetal risk based on animal studies Lactation: No known risk of infantile harm; possible risk of infantile diarrhea based on human studies Nonpharmacologic Management Essay Examples
	Ceclor	Tabs: 250 mg, 500 mg  Suspension: 125 mg/5 mL, 187 mg/5 mL, 250 mg/5 mL, 375 mg/5mL
	cefuroxime	Adult: Uncomplicated  250-500 mg PO BID for 5-10 days   Children: 20-30 mg/kg PO daily in divided doses BID Max: 1000 mg PO daily	Pregnancy: conflicting human data show possible risk of induced abortion. No known fetal risk based on animal studies Lactation: No known risk of infantile harm May be taken without regard to meals Ceftin tablets and Ceftin suspension are NOT bioequivalent Renal dysfunction prolongs half-life of product
	Ceftin	Tabs: 250 mg  Suspension: 125 mg/5 mL, 250 mg/5 mL

ontinued 

URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
Cephalosporins – Third Generation  Inhibits cell wall synthesis of bacteria   General comments   2-10% cross sensitivity with penicillin; contraindicated if patient has history of anaphylactic response or hives	cefixime	Adult: 400 mg PO once daily OR 200 mg PO BID for 3-7 days    Children: not approved	Pregnancy: risk of fetal harm low per human data; no known fetal risk based on animal studies Lactation: No known risk of infantile harm Reduce dose by 25% if renal dysfunction
	Suprax	Tabs: 400 mg Suspension: 100 mg/5 mL, 200 mg/5 mL
	cefpodoxime	Adult: 100 mg PO BID for 7 days	Pregnancy: Risk of fetal harm low per human data; no known fetal risk based on animal studies Lactation: No known risk of infantile harm Avoid antacids 2 hours before and after dose
	Vantin	Tabs: 100 mg Suspension: 50 mg/5 mL, 100 mg/5 mL
Miscellaneous	nitrofurantoin	Adult: 100 mg PO BID for 5-7 days (with food)  Children: <12 years: not recommended >12 years: see adult dosing	Pregnancy: Risk teratogenicity and hemolytic anemia. Contraindicated at 38-42 weeks’ gestation Lactation: Conditional safety dependent on dose and patient population Contraindicated if patient has anuria, oliguria, or impaired renal function Should be taken with food Avoid concurrent use of antacids
	Macrobid	Caps: 100 mg
	fosfomycin	Adult: 3 g PO x 1  Children: > 12 years: see adult dosing	Pregnancy: May be used during pregnancy; no known risk of teratogenicity Lactation: Safety unknown Mechanism of Action: bactericidal; inactivates enolpyruvyl transferase and inhibits cell wall synthesis
	Monurol	Packets: 3 g pkts

continued 

URINARY TRACT INFECTION PHARMACOLOGIC MANAGEMENT
Class	Drug Generic name (Trade name)	Dosage How Supplied	Comments
Anti-spasmodic  Inhibits smooth muscle spasm of the bladder and urinary tract	flavoxate	Adult: 100-200 mg PO TID or QID  Children: not recommended	Pregnancy: Caution advised due to lack of data. No known risk in animal studies Lactation: Safety unknown Do not use in patients with glaucoma, intestinal obstruction Nonpharmacologic Management Essay Examples
	Urispas	Tabs: 100 mg
	phenazopyridine	Adult: 100-200 mg PO TID daily after meals; maximum 2 days of therapy  Children: not recommended	Pregnancy: contraindicated in pyelonephritis; caution advised due to lack of data. No known risk in human studies Lactation: Safety is unknown The dye exerts an analgesic effect on the bladder and urinary tract mucosa via unknown means Must be used in conjunction with an antibiotic to treat UTI Discolors urine orange and can stain undergarments Use with caution in patients with hepatic or renal dysfunction Maximum of 6 doses per UTI because drug can accumulate and toxicity can result May discolor soft contact lens
	Pyridium	Tabs: 100 mg, 200 mg
E. coli has high rates of resistance to beta lactams (penicillins and cephalosporins). These medications are not preferred agents to treat UTIs.

• Women: 3 days of treatment usually adequate for uncomplicated UTI; consider 7-14 days if complicated
• Men: treat for 7-10 days
• Children: 7-10 days
• Antibiotic often used for children is a second- or third- generation cephalosporin due to gram-negative coverage and palatability

PREGNANCY/LACTATION CONSIDERATIONS

• Urine culture recommended
• Penicillin, cephalosporin, and nitrofurantoin are good first choices, but consider regional resistance rates to E. coli
• Treat for 10-14 days
• May need prophylactic antibiotics for duration of pregnancy
• Avoid quinolones and sulfa drugs

CONSULTATION/REFERRAL

• Consultation with urologist for recurring infections, infection in child younger than 4 months, pyelonephritis in children, and in presence of acute illness
• Referral to urologist if anatomic abnormality is suspected or diagnosed
• Hospitalization may be required for patients with severe symptoms

FOLLOW-UP

• Post-treatment culture if patient has frequent or recurrent UTIs
• Evaluate children 1 week after therapy begins
• Education about alteration of sexual practices may be needed in men who acquire UTI through anal intercourse; safe sexual practices such as condom use should be reinforced
• Children’s voiding patterns should be evaluated for regular bladder emptying, voiding dysfunction, urine withholding and possible constipation. Constipation can contribute to voiding dysfunction and should be treated if suspected

EXPECTED COURSE

• Complete resolution without complications within 2-3 days after starting treatment; patients should finish entire antibiotic regimen
• Nonpharmacologic Management Essay Examples

POSSIBLE COMPLICATIONS

• Pyelonephritis
• Renal abscess
• Sepsis