PHRM3012Quiz2 by karlwinckel https://padlet.com/karlwinckel/PHRM3012Quiz2 PHRM3012 Online Quiz Questions 2 en-us 2016-07-15 00:14:28 UTC 2018-08-16 12:40:42 UTC hello@padlet.com Jason (55yrs) starting Hep C meds https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707175 Using information from http://hep-druginteractions.org/

potential interactions 

1, ledipasvir + atorvastatin 
ledipasvir may increase atorvastatin concentrations due to inhibition of P-gp and/or BCRP
*dose reduction may be considered*

2, ledipasvir/sofosbuvir  + omeprazole caused decreased ledipasvir Cmax and AUC by 11% and 4%, increased sofosbuvir Cmax by 12% and no effect on sofosbuvir AUC. 
*however, omeprazole 20 mg or lower can be administered simultaneously with ledipasvir/sofosbuvir under fasted conditions. BUT should not be taken before ledipasvir/sofosbuvir.*

3, ledipasvir + digoxin
may increase digoxin concentrations due to inhibition of P-gp by ledipasvir
*therapeutic concentration monitoring of digoxin required

It should not be necessary to change digoxin. The patient is within the therapeutic range (0.5-2 ng/mL) although just barely. Adding ledipasvir/sofosbuvir may push that above into toxicity levels. However, close therapeutic monitoring and dose adjustments should suffice. I would avoid changing the digoxin as the patient is stable (heart rate normal) and changing it to other AF therapy may upset this. We can probably rule out options 3 and 4 from this. (IF you do change it, I would prefer beta blocker over the amiodarone. Might have to monitor and adjust anti-hypertensive dose as well depending on side effects)

The website recommends that omeprazole 20mg can be taken simultaneously with ledipasvir/sofosbuvir under fasted conditions. It also cautions to not take PPIs before ledipasvir/sofosbuvir. 
BUT Jason takes his meds with food at 8am (so not fasted?)
therefore should we recommend take PPI + ledipasvir at 6am 
Is that what option 2 is getting at?

Dose reduction of atorvastatin is probably not necessary.
Atorvastatin is pretty well tolerated, Jason's renal and liver functions are good. The atorvastatin dose is pretty low anyways AND statins have a large therapeutic window AND high-dose statins usually used in ACS AND Jason has not reported any side effects. So I think it should be ok to not reduce his atorvastatin dose (option 1)

Its hard to decide between option 1 or 2 since they both seem not to be the BEST option...
Any ideas?

]]> 2018-08-11 11:44:07 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707175 Gemma w/ Chlamydia https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707253 Definitely want to treat it, as if left untreated can make it difficult to get pregnant + increase risk (ectopic pregnancies, etc.) Gemma wants more babies!

From lecture
treatment options are:
Azithromycin 1g po, single dose
or
Doxycycline 100mg po 12 hrly for 7 days

BUT ** Doxycycline is contraindicated in the second and third trimesters of pregnancy.**
know that Gemma is >6months pregnant (or has she already given birth?)

Anyways use azithromycin 1g single dose (safe in pregnancy)


]]> 2018-08-11 11:47:25 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707253 James (60yrs) w/ malaria https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707442 Pretty easy one

Option 2 and 3 are for prophylaxis 
Option 4 is simply wrong (why would you not treat malaria?)

This leaves option 1
according to eTG
atovaquone+proguanil tablets 250+100 mg 4 tabs daily for 3 days
is a good treatment for uncomplicated malaria

(I spotted a typo in the answers, answer C has 110mg instead of 100mg) don't be fooled!]]> 2018-08-11 11:56:54 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707442 Alan's family w/ Giardia https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707674
Note: Flagyl S Oral Suspension contains metronidazole at 200 mg/5 mL (100 mL)

eTG: Giardia
children dose = 30 mg/kg up to 2 g
for the son (13.3kg)
requires ~400mg (399mg)
= 10mL

Alan's dose = 2g od for 3 days
Son's dose = 10mL od for 3 days

The other set of dosing instructions are for if the treatment doesn't work after the 3 days (its in AMH)
So for initial Tx, go with the 3 day one

The next point of debate is whether Alan's wife should get treated.

From UpToDate search giardiasis:
Among asymptomatic individuals, treatment is reasonable to prevent spread of infection in the following circumstances:
●Individuals in settings with risk for transmission to others (such as a child in a daycare setting)
●Household contacts of immunocompromised individuals (especially hypogammaglobulinemia or cystic fibrosis)
●Household contacts of pregnant women
●Food handlers

In the absence of risk for transmission, it is reasonable to forgo treatment of asymptomatic individuals.

Alan's wife work as website designers for their own company, probably mostly stay indoors, little contact with high risk populations
Reasonable to forgo treatment
-> Option 3



]]> 2018-08-11 12:08:39 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272707674 Gina (76yrs) w/ eye problem https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272708176 The question asks which would be the least helpful

Uhhhh... well we haven't learnt much about this sort of thing yet...

She gets the irritating eyes late in the day. Possibly related to the contact lens? (not cleaned properly -> infection?)
-> option 3 will probably help

Using cellufresh might help, its a lubricant eye drop, may provide some relief

Ceasing xalatan will worsen her glaucoma, an eye disorder. Plus she use the xalatan at night anyways so it is doubtful that it is related to her daytime eye problems. But since its an eye drop, it may be some sort of allergic reaction? Could help maybe...

Ceasing amitriptyline...
usually used for neuropathic pain, has some anticholinergic effects i think (blurred vision and such) don't really think its related to her eye problems but it might help. She is already on gabapentin for neuropathic pain as well. So discontinuing amitriptyline may be an option?

Can't decide between option 2 or 4... ]]> 2018-08-11 12:24:50 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272708176 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272735611 Agree]]> 2018-08-12 01:52:20 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272735611 Amitriptyline https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272779599 She takes this at night but is getting eye symptoms late in the day. So I would assume this would be the least effective change to make as ceasing Xalatan eye drops would make eye symptoms worse?? Not sure ]]> 2018-08-12 23:35:55 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272779599 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272780346 I thought option 2 would be incorrect as the website stated to not take omeprazole before the Harvoni. Amiodarone is contraindicated so that rules that option out. ]]> 2018-08-12 23:44:17 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272780346 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272781417 Although according to AMH, atorvastatin metabolised by 3A4 and not P-gp so the interaction possibility is minimal. Also digoxin is a P-gp substrate so the interaction is more likely. ]]> 2018-08-12 23:54:14 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272781417 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272991442 As the Atorvastatin dose is considered low (20mg), if the dose were to increase marginally with co-administration of Harvoni, I don't think it would be a major issue to the patients health. A dose reduction may be required, but I don't think it is the major change required in this circumstance.

It can be co-administered with omeprazole 20mg, which is Jason's current dose, so that would be fine.

Amiodarone is often rhythm control in A. Fib, and is used in rate control under specialist supervision. These aren't exactly interchangeable in this circumstance. Further, Harvoni interacts with the Amiodarone so this is not ideal.

Although they're stable on digoxin, the possibility of co-administration with Harvoni increases the digoxin concentration. Jason is already at 1.9ng/mL, with therapeutic range of 0.5-2ng/mL. I think it would be best to change to metoprolol on the risk of causing digoxin toxicity, as the patient will require monitoring whether they are changed or not, and digoxin toxicity can be fatal.

my answer: Cease digoxin and swap to metoprolol]]> 2018-08-14 04:17:42 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/272991442 Jason (55yrs) starting Hep C meds https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273223673 If I were to answer this question using the information from the link given, I would choose A) Reduce the atorvastatin to 10mg in the morning. As many of you have pointed, it says that a dose reduction may be required.

On the other hand, regarding digoxin, it says that 
therapeutic concentration monitoring is recommended. It doesn't suggest to change the medicine???]]> 2018-08-15 10:41:01 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273223673 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273235276 She was 6 months pregnant earlier in the year, now it's alr more than halfway through the year so i guess we can safely say that she has given birth and is perhaps breastfeeding

Would go for azithromycin 1g because it's just a single dose. She has to take care of her baby, med adherence might be an issue if she is given doxycycline... Not sure what the state of her mental health is right now though. Would definitely consider adherence for this case.]]> 2018-08-15 12:24:21 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273235276 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273236700 cellufresh is authority required  under PBS, for people with severe dry eye syndrome. Not sure if she is even eligible for that item...? She has watery eyes so why would you give someone cellufresh which is meant for dry eyes....? 




]]> 2018-08-15 12:33:58 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273236700 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273241685 I would go with changing digoxin to metoprolol. Digoxin aint exactly very effective unless patient is not very mobile (not sure about jason but he's only 55? And i dont think his comorbidities will limit his movements..). His current digoxin level is quite near the upper limit of the acceptable range so I wouldn't wanna try something new that has lack of data on the interactions and can potentially cause digoxin toxicity. Metoprolol can have benefits for his STEMI (ACS-BANG). It also has no interactions with his other current meds and Harvoni. So why not change digoxin than change atorvastatin dose??? 



]]> 2018-08-15 13:03:49 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273241685 7 day dose for kid should be 3.325mL, not 2.5mL, dose not high enough, therefore options are wrong. https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273389033 agree with below]]> 2018-08-16 03:00:25 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273389033 agree https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273390986 2018-08-16 03:17:50 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273390986 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273390999 i think cha boi down below'z got it]]> 2018-08-16 03:17:54 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273390999 I think 2 but I'm not sure at all https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273437927 Cellufresh - might help relive irritated eye symptoms???

According to MIMS, amitryptyline is a precaution for people with certain types of glaucoma.  However, decreased lacrimation is a side effect so ceasing this might increase watery eyes and not be helpful???  OTOH, amitryptyline is a precaution for people with glaucoma...?!?!?!?


Avoiding contact lenses - if eyes are irritated, avoiding contacts would be helpful

Ceasing xalatan eye drops and changing to an eye drop with less preservative could help symptoms of irritation. (glaucoma monograph AMH) so this would be helpful]]> 2018-08-16 09:19:01 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273437927 https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273440393 Agree with the azithromycin for the reasons below. ]]> 2018-08-16 09:45:48 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273440393 Question https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273454940 When the question asks about ceasing are we ceasing with the aim of changing to a better alternative or stopping completely?]]> 2018-08-16 12:11:22 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273454940 Jason and HEP https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273458588 The CMI for harvoni provides advice for taking harvoni with PPIs, it says  "If you are taking a proton pump inhibitor, take it at the same time as HARVONI or up to 2 hours after taking HARVONI. Do not take before HARVONI. " 
With this, I think we can rule out the omeprazole 2hrs before. 

I dont like the idea of changing the digoxin since he is stable and it is something we can monitor

but is also feels wrong dropping the dose of atorvastatin for a guy after a STEMI, but it feels like the only one that would be appropriate. ]]> 2018-08-16 12:33:59 UTC https://padlet.com/karlwinckel/PHRM3012Quiz2/wish/273458588