Medical Student Quick Topics

Breast Cancer
Chemotherapy
- General
  - Increased risk of MDS, Mixed MDS/MPN, and AML (10-20% of all cases of these cancers are chemotherapy related)
    - Therapy-Related Myeloid Leukemia
    - Etiology and management of therapy-related myeloid leukemia
- Common Regimens
  - ABVD
    - Adriamycin, Bleomycin, Vinblastine, Dacarbazine
    - Hodgkin Lymphoma
  - BEACOPP
    - Bleomycin, Etoposide, Adriamycin/doxorubicin, Cyclophosphamide, Oncovorin/vincristine, Procarbazine, Prednisone
    - Hodgkin Lymphoma
  - FOLFIRI
    - Leucovorin, 5-Fluorouracil, Irinotecan
    - Advanced-stage and Metastatic Colorectal Cancer
  - FOLFOX
    - Leucovorin, 5-Fluorouracil, Oxaliplatin
  - R-CHOP
    - Rituximab, Cyclophosphamide, Hydroxy-doxorubicin, Oncovorin/Vincristine, Prednisone

Pulmonology

Acute Respiratory Failure
- [Noninvasive Ventilation for ARF](https://www.thoracic.org/statements/resources/cc/niv-guidelines.pdf
ARDS
Asthma
- Novel START: Prn Budesonide+formoterol reduced risk of exacerbations vs. Albuterol
- AMAZES: Azithromycin reduced rate of asthma exacerbations, improved QOL in severe
COPD
- Treatment
ICU
Interstitial Lung Disease (ILD)
- IPF
- Sarcoidosis
Lung Cancer
- National Lung Cancer Screening Trial
- Early Palliative care in metastatic NSCLC improves QOL and improved survival
Pleural Effusion
- Lights Criteria for Pleural Effusions
- Management
  - Management of infectious processes of the pleural space: a review
  - Malignant Pleural Effusions
Sleep Apnea
- Evaluation and Management of Obesity Hypoventilation Syndrome

Rheumatology

ANCA-Associated Vasculitis
- RAVE: Rituximab is non-inferior to Cyclophosphamide in inducing remission
Ankylosing Spondylitis
Gout
OA
- Management
Polymyalgia Rheumatica
- Overview
*Pseudogout
- RF
RA
- TICORA: Intensive > standard therapy in improving disease control at 18 months
Septic Arthritis
- Sensitivity of ESR and CRP in ruling out Septic Arthritis

Medications

Antibiotics
- 50S Inhibitors
  - Linezolid
    - No more than 28 days recommended, weekly CBC for possible bone marrow suppression
    - SE: Thrombocytopenia (30%), Pure Red Cell Aplasia, Neutropenia, Pancytopenia (>2 weeks), Peripheral neuropathy, Lactic Acidosis
      - Optic Neuropathy
        
        Optic disc edema, hyperemia, reduced color perception
        
        Typically after long-term use (>4 weeks)
        
        May be irreversible, periodic eye and neurological exams for long courses
      - Serotonin Syndrome, Lactic Acidosis
Anti-Thrombotics
- Antiplatelet Drugs
  - Clopidogrel (Plavix)
    - Efficacy decreased with omeprazole
      - Consider switching to different PPI (except esomeprazole) or H2RA (except cimetidine)
        
        Clopidogrel with or without omeprazole in coronary artery disease
        
        ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines
        
        Expert position paper on the use of proton pump inhibitors in patients with cardiovascular disease and antithrombotic therapy
    - Pantoprazole (weak CYP2C19, favored)
      - Decrease GIB in DAPT in high risk patients
        
        Prior GIB, Age >65, PUD, H. Pylori
- Anticoagulants
  - A. Vitamin K Antagonists
    - Warfarin (Coumadin)
      - MOA: Vitamin K epoxide reductase inhibitor
        
        Inhibits Prothrombin (II), VII, IX, X, C, S
      - CI: Pregnancy (crosses placenta)
        
        Vit k, nasal hypoplasia, stippled epiphyses in first trimester
      - Warfarin Metabolism
        
        CYP450 Inhibitors (Increased Warfarin effect)
        
        Risk of Hemorrhage
        
        Acetaminophen, NSAIDs, Metronidazole, Amiodarone, Cimetidine, Cranberry Juice, Ginkgo biloba, VitE, omeprazole, Thyroid hormone, SSRIs
        
        CYP450 Inducers (Decreased Warfarin effect)
        
        Risk of Thrombosis
        
        Carbamazepine, Phenytoin, Ginseng, St. John Wort, OCPs, Phenobarbital, Rifampin, Spinach/Sprouts (Vitamin K)
  - B. Factor Xa Inhibitors
    - I. Heparins/Glycosaminoglycans/Binds Antithrombin
      - A. Unfractionated Heparin (UFH) (Parenteral)
        
        Must monitor using aPTT
        
        Dose dependent, saturable, weaker binding to endothelial, macrophage, hbpps
        
        Activates Antithrombin (III) ≥ binds fibrin
        
        Accelerates Antithrombin clot inhibition
        
        Inhibiting Thrombin and Factor Xa
        
        Forms thrombin-antithrombin complex
        
        Neutralized by PF4 (platelet rich thrombi)
        
        Heparin Inducted Thrombocytopenia (HIT)
        
        Protamine sulfate (1mg to 100U) to reverse
        
        SE: Osteoporosis, increase bilirubin
      - B. Low-Molecular-Weight Heparin (LMWH) (Parenteral)
        
        Enoxaparin (Lovenox)
        
        Made from Unfractionated Heparin
        
        Greater capacity to potentiate factor Xa inhibition than thrombin due to being a short chain (2:1 – 4:1 Xa to iia)
        
        VTE + Cancer
        
        Dose independent, renal clearance, rare resistance, no monitoring
        
        Little aPTT affect, measure anti-Xa to monitor (Heparin-Xa)
        
        Every 4 hours
        
        Obesity, renal insufficiency, pregnant, valves
      - C. Antithrombin III Inhibitors (Indirect Factor Xa inhibitors) (Parenteral)
        
        Fondaparinux (Arixtra)
        
        (smallest heparin chains) AT3
        
        Can be used in surgical, ortho, VTE patients, only binds AT3, no thrombin rate inhibition, Xa only
        
        Renal cleared, can use in HIT, no antidote, no need to monitor
    - II. Direct Factor Xa Inhibitors
      - Factor Xa for monitoring
        
        Stroke prevent, long term anticoagulation in nonvalvular afib
        
        VTE treatment w/o cancer
        
        Reversal: 4F-PCC or Andexanet Alfa
        
        Modified factor Xa that competes with factor Xa Inhibitors for factor X
      - Apixaban (Eliquis)
        
        10mg BID for 7 days
        
        2.5-5mg PO BID
      - Rivaroxaban (Xarelto)
        
        15mg BID for 21 days for VTE
        
        20mg PO daily with dinner
        
        Renal Excretion
      - Edoxaban (Lixiana, Savaysa)
        
        60mg PO daily
    - III. Direct Thrombin Inhibitors (DTIs) (Parenteral)
      - Inhibit Thrombin (IIa)
      - Univalent
        
        Argatroban
        
        Liver metabolism, not renal
        
        Used if HIT suspected
        
        aPTT, prolongs INR
        
        Measure Factor X instead to monitor warfarin
        
        Dabigatran (Pradaxa, Oral)
        
        150mg PO BID or 75mg PO BID if Crcl = 15-30
        
        Direct Thrombin Inhibitor, Renally excreted, aPTT to monitor
        
        PPIs decrease absorption
        
        Reversal:
        
        <6 hours: Consider activated charcoal
        
        Idarucizumab
        
        Humanized monoclonal antibody fragment
        
        Reverses within 1 hour
        
        Hemodialysis (68% can be removed in 4 hours)
Beta-Blockers
- Metoprolol (Lopressor, Toprol XL)
  - Substrate of CYP2D6
    - 2-to-3-fold increase with Escitalopram, Citalopram, Duloxetine
    - 4-to-6-fold increase with Paroxetine, Fluoxetine, Bupropion
    - Sertraline, Venlafaxine, Mianserine, and Mirtazapine safer
    - Discontinuation and dose adjustment of metoprolol after metoprolol-paroxetine/fluoxetine co-prescription in Dutch elderly
      - Link
      - Link
  - CI: Sinus bradycardia, 1st degree AV block (PR >0.24), cardiogenic shock, SSS, WPW
Calcium-Channel Blockers
- Amlodipine
  - 30–50-hour half-life (longest)
    - No renal adjustment needed
  - New CAD without HF to decrease hospitalizations for unstable angina and revascularization (PREVENT)
  - Non-FDA
    - Diabetic Nephropathy
      - Combined therapy with ACEI/ARB exerts a greater antiproteinuric effect in T2DM
  - Side Effects
    - No use dependence or prolongation of QT
    - 10mg: Edema (10.8%), Headaches (7.3%), Palpitations/Fatigue (4.5%), Dizziness (3.4%), Nausea (2.9%), Flushing (2.6%), Abdominal Pain (1.6%)
      - Link
    - Mixed hepatocellular-cholestatic pattern of DILI, usually complete recovery within 4-8 weeks when stopped
    - Amlodipine + Erythromycin/Clarithromycin increase risk of hypotension and AKI 2/2 decreased CYP3A4 metabolism
    - Increased risk of myopathy/Rhabdomyolysis with high-dose statins
Diuretics
- Thiazides
  - General
  - MOA: Inhibit the reabsorption of Na+ and Cl- from the distal convoluted tubule, blocks Na-Cl symporter • Intravascular volume depletion via diuresis reduces peripheral vascular resistance • Indirectly increases the basolateral Na+/Ca2+ antiporter • Better than ACEI in preventing strokes (reduced risk of CV events)
  - Use: Essential hypertension, edema, CHF, Nephrogenic DI, osteoporosis
  - SE: hyperGLUC (glucose, lipids, uric acid, calcium), Allergy, Gout
    - Dose-dependent hypokalemia
    - Metabolic Alkalosis, Azotemia
    - Hyponatremia (typically within 1-2 weeks)
    - Euvolemic w/dizzy spells, lethargy, malaise, vomiting
      - May alternatively present as Orthostatic Hypotension/Volume depletion/increased risk of falls
      - Worse than loops
      - More common in older women with low BMI
      - 36% <130, age >70 had 3.9x higher risk
    - Give oral potassium supplements or potassium sparing diuretic (spironolactone)
    - Increased risk of T2DM, not first-line in T2DM
    - Falls
      - Discontinue in elderly with falls
      - Increased Risk
      - Volume Depletion leading to orthostasis
- SGLT-2s

Medical Student Quick Topics

Student/Intern Readings

Cardiology

Dermatology

Endocrinology

Gastroenterology (GI)

General

Geriatrics

Hematology

Infectious Disease

Neurology

Nephrology

Oncology

Pulmonology

Rheumatology

Medications

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