USMLE Pharmacology and Treatment Flashcards: The 200 Ques’ ns You're Most Likely to See on the Exam: For Steps 1, 2 & 3 How to Use These Cards “USMLE Flashcards" is a series of works designed to answer the most common questions on the USMILE. In the "Pharmacology and Treatment" set, we attempted to answer the basic question tested on USMLE: Step 1—"When is a particular drug the onswer?"—and on Steps 2 and 3—"What is the most accurate and best treatment for a given diagnosis” The index provided will help you organize your deck in a way that best suits your study style. Flashcards are cate- gorized by category and given a number within that category. We recommend reviewing through the deck by category and then testing yourself by reviewing them in random order to get the most out of this deck. We wish you good luck in your studies and great success in your future medical career! Kaplan Medical : ly eArtaw)This publication is designed to provide accurate and authoritative information in regard tothe subject matter covered, Its sold with the understand- ing that the publisher is not engaged in rendering legal, accounting, of other professional service If legal advice or other expert assistance is required, the services of a competent professional should be sought. Vice President and Publisher: Maureen McMahon Exitorial Director: Jennifer Farthing Acquisitions Eitor Allyson Rogers Development Editor Sheryl Gordon Production Editor: Dominique Polfict Production Designer: TC Cover Designer: Carly Schnur (© 2008 by Conrad Fischer, MO Published by Keplan Publishing, a division of Kaplan, Inc. 1 Liberty Plaza, 24th Floor New York, NY 10006 All ights reserved. The text of this publication, or any part thereof, may net be reproduced in any manner whatscever without written permission fom the publisher Printed in Chine April 2008 10987654321 1ISBN-13: 978-1-4277-97063 kaplan Publishing books are available at special quantity discounts to use for sales promotions, employee premiums, or educational purposes. Please email our Special Sales Department to crder or for more information at kaplanpublishing@kaplancom, or waite to Kaplan Publishing, 1 Liberty Plaza, 24th Floor, New York, NY 10006.USMLE Pharmacology and Treatment Flashcards: The 200 Questions You're Most Likely to See on the Exam: For Steps 1, 2 & 3 Conrad Fischer, M.D. is the Associate Chief of Medicine for Educational and Academic Enlightenment at SUNY Downstate School of Medicine in Brooklyn. Dr. Fischer serves as an Attending Physician at King’s County Hospital, the largest municipal hospital in New York City. Dr. Fischer has been a Residency Program Director at Maimonides Medical Center and Flushing Hospital in the past. He has been Chaitman of Medicine for Kaplan Medical since 1999 and is the only person to teach in Step 1, Step 2, Step 3, Internal Medicine Boards and for the Re-Certification examination in Internal Medicine. Other works by Conrad Fischer: USMLE Flashcards: The 200 Diagnostic Tests You Need to Know for the Exar USMLE Physical Findings Flashcords: The 200 Questions Youre Most Likely to See on the Exarn USMLE Medical Ethics: The 50 Cses You Are Most Likely to See on the Test Internal Medicine Question Book Disclosure ‘The material presented here is objectively based on evidence. | have no relationship with any phar- maceutical manufacturers to disclose. ! do not solicit, nor receive grants, honoraria or speakers fees from any drug company or their representatives, APLANPreface ‘These cards are designed to answer the questions: “What is the best therapy for this patient?” “What is the mechanism of action of this medication?” “What is the most common adverse effect of this medication?” They represent an encapsulation of my years of teaching experience and knowledge of the exam. The pharmacology and treatment cards will also put you on the cutting edge of your ability to treat patients Mercy is an attribute of divinity. You, as the student, are blessed by the unique ability to relieve the suffering of many, cure some, and be compassionate to all. | wish you the rapture and the unparalleled joy of the deep study of medicine. We have never been able to do more, heal more and cute more than right now. It is @ miracle that you can prevent harm and make the lives of others better. IF you see the treatments as miracles, energy will flow into you and you will develop a breathless excitement to leatn more, We are very lucky to have the chance to learn more. feel your anxiety about the exam. | challenge you to feel lucky that you have the chance to learn miraculous and beautiful things to do for patients. Congratulations! You are blessed, indeed, to be studying medicine at the best time to learn it in the history of the world, Never be put off by those who tell you medicine wes better in the past This isthe best it has ever been! And you are only starting. Dedication ‘This work is dedicated to my mother Dorothy Jiskra and to my father Fred Fischer for the wild and livelong pursuit of being alive, the hunger for knowledge, and the yearning to receive and express love that I strive to embody. Acknowledgment Dr. Fischer wishes to acknowledge the gracious support of his Fearless Leader, Dr. Edmund Bourke. . in ooUSMLE Pharmacology and Treatment Flashcards: The 200 Questions You're Most Likely to See on the Exam: For Steps 1, 2 & 3 Cardiology 1 ACE Inhibitors ‘Atrial Fibilation Calcium Channel Blockers Spironolactone and eplerenone Propranolol ‘Aderosine/SVT Aspirin Dipytiderole Clopidogrel and Tidopidine liostazol [ACE Inhibitors, adverse effects Glycopictein tibia inhibitors Thrombolyties Digoxin Digoxin Toxicity 16 "7 18 19 20 2 2 23 24 ‘Amiodarone Congestive Failure Mitral Stenosis Lipid Management, Statins Lipid management, Cholestyramine, fibric acid derivatives, Niacin Implantable Defibrillator ‘Anticoagulation Magnesium Sulfate Wolff-Parkinson-White, Proceinamide, Catheter ablation Dermatology 1 2 3 4 Minocycline Acne Atopic Dermatitis, Psoriasis Endocrinology 1 Propylthiouracil TU) and Methimazole Hyperthyroidism Bisphosphonates Cake Sitagiiptin, Exenatide Pramlintide Orlistat Fludrocortisone ‘Alpha Glucosidase Inhibitors Metformin Sulfonylureas Diabetic Nephropathy Glargine insulinGastroenterology 3 Finasteridine and dutasteride 5 Polymyxin B and Colistin 1 Interferon 4 Ezetimibe 6 Bites 2 ibavirin 5 Uigeincontinence 7 Molatia prophylaxis, Mefloquine 3 Chronic Hepatts 8 6 Varenicline and atovequone/progueril 4 Helicobacter pylori 7 Bupropion 8 lyme Disease 5 Girthosis and varices 9 Influenza 6 Lactulose, hepatic Hematology 10 CMV retinitis encephalopathy 1 Thrombin inhibitors 11 Drotrecogin 7 Pericilamine 2. Hydreayutea 12. HIV postexposure prophylaxis 8 TIPS, esophageal varices 3 Anagrelide 13 Hepatitis B and C post exposure 9. GERD, Nissen fundoplication 41 prophylaxis 10 Achalasia 5 Plasmapheresis 14° Rabies Prophylaxis 11 Food poisoning, invasive 6 Von Willebrand's Disease, 15. Tetanus Prophylaxis diarthea, Campylobacter DDAVP 16 Influenza Vaccine 12. Diabetic gastroparesis, 7 Anticoagulation, Factor V 17 Preumococcal Vaccination 13. Inflammatory Bowel Disease Mutation, Atrial Fibrillation 18 Clindamycin 14 Pls 8 “Lone” Atrial Fibrillation 19 Metronidazole 15 Zollinger-fllison Syndrome 9 Anticoagulation in pregnancy 20. Aspergillus 16. Primary biliary cirrhosis 10 Sickle-Cell Fever 21. Echinecandins 17. Hemochromatosis 22 Posaconazole 18 Inrteble Bowel Syndrome Infectious Diseases 23 PPD 1 Acyclovir 24 TB General Medicine 2 Rifexinin 25 TB Medication Adverse Effects 1 Sildenafil 3 Daptomycin and Linezolc 26 Preumocystis pneumonia 2 Benign Prostatic Hypertiophy 4 Tigecycline 27. Urethuis Cervictis — © 2008 KaplanEro erect ty ‘pe onan begeese vewseuy seepere I oo — ermeenn.optiainogy ea Petey 1 Oiene 1 Seoncatenaee Seas tertlonyQ.. Dermatology ewe Minocycline 1. Whats the most common question for which minocycline is the answer? 2. How daes minocycline work? 3, What are the most common adverse effects of minocycline?Dermatology cara Minceyetine is the best orl antibiotic for severe aene that snot con tolled by topical antibiotics or topical vitamin A deehatives, such as tectinoin. Other inccations fr minocycline include te followin Nocardia Aatinorycoss Rosacea 2. inocytine sa teraeyline antibiotic that Inhibits protein produc tion in bacteria 3. linocytine con cause Blulsh discoloration of the skin but doesnot use a photosensitivity rash as deaycyclne can cause. Minocytine can bring on wertiga by causing vestibular dysfunction.Q. Dermatology card2 Case 1:Awernan comesin 1, What isthe treatment for each of these vith mild acne she hasafew cases? ‘comedanes with an accasonal inflamed papule or pustule Case 2:/ man hasfaledintel 3. What are the adverse effects of these therapy fr acne and has na treatments? ‘merous papules and pustules with mie seating. 2. How does each treatment work? (Case 3: Your patients very istessed and depressec be- ‘cause of numerous large cysts ‘nthe face, neck, and tuk, eis severely scamedDermatology ea Case ssid omen are Mid iss seated ith toplelbe- zoyl peroxide tpi ntact oot amyen Beery! peroide bth ascent Tosca Souls wl heat the osave cals Pople fem tre cavecones (Case 2: is moderate to severe acne resulting in scarring. In action to benzoyl peroxide the patient shoul be tested with a topical vitamin A derivative (ercin) An oral antibiotic such 95 minocycline shoul! be used & severe cystic ane An oral antibiotic 2rd oral vitamin A in) ae needed kotetnoin will decrease sebum production but 's extremely teratogenic anc can cause severe depression, dry skin, anchypertipidemiaQ. Dermatology core 3 Case:An adolescent boy 1 |. What is the best therapy to treat the comes to see you fr teat Remeron ign meetlalora tardy: > hari the best long em therpy? hhands, and feet in the flexural 3, hat are the other indications for this cores” % What fomscthg Heabehas seasonal hints and occasional unica,Dermatology cara ‘nopiedermatsisteatedwith antihistamines suchasfexofenadine, ‘etirizine c loratadine, ) 200 md/dl despite the use of maximal doses of several oral hypoglycemic agents. His hemoglobin Alc is > 9 percent. In addition, his glucose levels fluctuate during the day. Card 11 1. What is the best therapy for this patient? 2. What is the duration of these therapies? \ KAPLANA. Endocrinology aa 1. Insulin glargine should be given as a once-a-day injection combined with one of the rapidly acting insulins (glulisine, aspart, or lispro) with meals. 2. Insulin glargine rapidly reaches a peak level and maintains a constant level for 24 hours. Glargine is similar in effect to an insulin infusion pump. The short-acting insulins (glulisine, aspart, and lispro) reach a peak effect in 50-60 minutes and last for about 4 hours. They seem to be equal in efficacy.Q. Gastroenterology Card1 Interferon 1, When are interferons used? 2. What is their mechanism of action? 3. What are the most common adverse effects of interferons? he KAPLANGastroenterology Card 1 1. Interferon alpha is used to treat the following conditions: + Chronic hepatitis C in combination with ribavirin + Chronic hepatitis B + Melanoma + Cryoglobulinemia in combination with ribavirin Interferon beta is used to treat the following condition - Multiple sclerosis 2. The mechanism of interferons are not clear. They are a cytokine that assists the immune response by inhibiting viral replication within the cells. They are immune modulatory and benefit multiple sclerosis. 3. Interferons cause flulike symptoms, such as myalgia, arthralgia, depression, thrombocytopenia, and leukopenia.Q. Gastroenterology Ribavirin PWN = Card 2 « What is ribavirin? . How does ribavirin work? . When is ribavirin the answer? . What are the most common adverse effects associated with ribavirin?Gastroenterology Card2 1. Ribavirin is a purine nucleoside that is used as an antiviral. 2. Ribavirin inhibits viral messenger RNA synthesis. It competitively inhibits cellular inosine-5'-phosphate dehydrogenase and interferes with the synthesis of guanosine triphosphate (GTP) and thus nucleic acid synthesis in general. It inhibits both RNA and DNA viruses. 3. Ribavirin is the answer when the question describes a case of chronic hepatitis C. The hepatitis C antibody should be positive with an ele- vated polymerase chain reaction (PCR) RNA viral load and possibly liver inflammation. It is used in combination with interferon. Ribavirin is also the answer for respiratory syncytial virus. 4. Ribavirin can cause anemia.Q. Gastroenterology Card 3 Case: A 42-year-old woman 1. What is the best therapy for this with chronic hepatitis B is in patient? the clinic to be evaluated for treatment. Her surface antigen 2+ How does this treatment work? has remained positive formore 3, than six months. Her hepatitis Hbe antigen is positive as well. What are the most common adverse effects of this treatment?Gastroenterology Card 3 1. Chronic hepatitis B is defined as the persistence of surface antigen for longer than six months. Entecavir, lamivudine, telbivudine, adefo- vir, and interferon are all approved for use. Therapy is most effective for those who are positive for the hepatitis B e antigen (HbeAg) or hepa- titis B DNA polymerase. 2. Entecavir, lamivudine, adefovir, and telbivudine all inhibit viral reverse transcriptase (DNA polymerase). They cause DNA chain termination. 3. Entecavir, lamivudine, adefovir, and telbivudine all cause lactic acidosis and can cause an acute exacerbation of hepatitis when therapy is discontinued. Adefovir is nephrotoxic. Interferon causes flulike symp- toms, such as myalgias, arthralgia, and headache.Q. Gastroenterology Case: A 40-year-old woman with persistent epigastric pain is found to have a large gastric ulcer. On biopsy, there is no malignancy. The pathological specimen is positive for Helicobacter pylori. Card 4 1. What is the best therapy for this patient? 2. What alternate treatment should be offered if the initial treatment fails?A. Gastroenterology Card 4 1, The best initial therapy for Helicobacter pylori is a proton pump inhibi- tor (PPI), such lansoprazole, omeprazole, pantoprazole, rabeprazole, or esomeprazole, combined with two antibiotics. The two preferred anti- biotics are clarithromycin and amoxicillin. 2. If the initial therapy fails, treatment is with a PPI combined with bis- muth subsalicylate and two different antibiotics, tetracycline and metronidazole.Q. Gastroenterology Case: A 56-year-old man with de acute variceal hemorrhage from alcoholic cirrhosis comes to the emergency department. He has been started on intra- venous fluids and has received a blood transfusion and fresh frozen plasma. 4. Card 5 What medication is most likely to benefit the patient at this time? 2. How does it work? 3. What are the most common adverse effects of this medication? What procedure will you perform if the medication fails? What are the other indications for this medication? Ne KAPLAN)Gastroenterology 1. iv Card 5 Octreotide (somatostatin) is used in acute variceal bleeding to decrease the severity of the hemorrhage. Octreotide is synthetic somatostatin. It decreases portal pressure and splanchnic blood flow, because there are numerous somatostatin receptors throughout the portal circulation. It is superior to vasopressin or sclerotherapy. Propranolol would decrease the frequency of recurrent bleeding but has no effect on acute bleeding. There are no significant adverse effects of octreotide. 4. |foctreotide does not control the bleeding, endoscopic band ligation y is the next best step in therapy. Transfuse as needed however remem- ber that massive transfusions can cause coagulopathy. Somatostatin is used to control growth hormone release in patients with acromegaly who are not candidates for surgery. It is also used to control diarrhea in carcinoid syndrome. |t helps treat glucagonoma.Q. Gastroenterology Card 6 Case: A 48-year-old man 1. What is the most effective therapy for presents with altered mental this man? status secondary to hepatic insufficiency. . How does it work? 3. What are its most common adverse effects?Gastroenterology a 1, Lactulose is the most effective therapy for hepatic encephalopa- thy. It can also be used to treat constipation. It is superior to neomycin as the best initial therapy of hepatic encephalopathy. 2. Lactulose is a nonabsorbed disaccharide. Bacteria in the colon con- sume the lactulose and lower the pH of the bowel. [his acidification changes ammonia (NH,) to ammonium (NH,+). Ammonium is not as easily absorbed and is more readily excreted. 3. Lactulose causes bloating, diarrhea, and flatulance. It can result in hypernatremia and hypokalemia.Q. Gastroenterology Card 7 Penicillamine 1. What is penicillamine? 2. How does it work? 3. What are penicillamine’s most common adverse effects? 4. When is penicillamine the answer? \ eauGastroenterology Card 7 1, Penicillamine is a peni -derived chelating agent used in a num ber of toxicities. 2. Penicillamine chelates copper, mercury, zinc, and lead. It also decreases T cell activity and rheumatoid factor. It can cause nephrotic syndrome and is bone marrow suppressive. - Penicillamine is the drug of choice for Wilson’s disease. It is sometimes used for lead poisoning and severe rheumatoidarthritis not fespon- ding to other therapies. It is used to treat eystinuria. It can be used to treat arsenic and mercury poisoning as wellQ. Gastroenterology Card 8 Case: A 54-year-old alcoholic 1. What can you do now to treat this man is admitted for an episode episode of bleeding? of vomiting blood from esophageal varices. He has had 2+ What are the most common several such episodes before complications of this therapy? and has been twice treated with esophageal band ligation. He is already being transfused and hydrated and has a normal prothrombin time. 3. What medication will prevent subsequent bleeding episodes?Gastroenterology 1. Card 8 Acute esophageal bleeding can be treated with endoscopic band ligation. If this has been done, then a transvenous (or transjugu- lar) intrahepatic portosystemic shunt (TIPS) is useful. A catheter is placed into the hepatic vein, and a shunt is created through the liver to the portal vein. It results in an immediate decrease in portal hyperten- sion. The most common wrong answer is sclerotherapy. Sclerotherapy is inferior to band ligation. 2. The most common adverse effect of TIPS is hepatic encephalopathy. 3. Propranolol is used to prevent recurrent variceal bleedingQ. Gastroenterology Card9 Case: Your patient is very 1. Which will benefit this patient? distressed by persistent symp- toms of epigastric and chest tater ee Dee pain from gastroesophageal + Cisapride reflux disease (GERD). She still + Helicobacter pylori treatment has symptoms despite high + Nissen fundoplication doses of proton pump inhibi- + Resection of the distal esophagus 2. When is each of the above choices the correct answer? tors (PPIs). hy KAPLAN.e Gastroenterology ap 1. Nissen fundoplication is the treatment most likely to benefit a patient with persistent reflux (GERD) symptoms despite PPIs. This is a surgically placed narrowing of the distal esophagus in which the stomach is sewn around the esophagus. H2, or histamine, blockers are never as effective as PPIs; they are never the answer if someone has failed PPI therapy for anything. Cisapride is a promotility agent that has been removed from the market for causing arrhythmias. Cisapride is never the right answer, unless the question asks, “Which of the following is most likely to cause torsade de pointes (TDP).” Helicobacter pylori does not cause GERD. Treating it won't help. Distal esophagectomy is the treatment for high-grade dysplasia from Barrett's esophagus.Q. Gastroenterology Card 10 Case: A 38-year-old woman 1. What is the best therapy? comes to you with dysphagia occurring with the ingestion of both solids and liquids. She wakes up with regurgitated food particles on her pillow. Barium studies show narrow- ing of the gastroesophageal sphincter. Manometry reveals a failure of the sphincter to relax. 2. What is the answer if this therapy fails? h KAPLAN)A. Gastroenterology Coie 1. Achalasia is treated with esophageal dilation. Pneumatic dilation is performed. In those refusing pneumatic dilation, botulinum toxin injection can be performed. The problem with botulinum toxin injec- tion is that it is not a permanent procedure and the symptoms can recur after 6-12 months, requiring additional injections or therapy, 2. If pneumatic dilation or botulinum toxin injection repeatedly fail, sur- gical intervention is performed, The Heller myotomy is the surgical cutting of the lower esophageal sphincter.Q. Gastroenterology Card 11 Case: A 27-year-old healthy 1. Should he receive antibiotics? gastroenterology fellow has developed severe, bloody diarrhea and abdominal pain over the last day. He is having 10 bowel movements a day. His pulse is 125, temperature 103°F. He is orthostatic and has abdominal tenderness. He is vigorously hydrating himself. 2. If so, what is the best antibiotic treatment for this patient? h KAPLAN16 Gastroenterology ee 1. Severe bloody diarrhea from food poisoning is treated with antibiotics, if the patient shows signs of sepsis. The question will describe hypotension, bloody diarrhea, and abdominal pain. 2. The best empiric therapy for severe infectious diarrhea is a fluoroqui- nolone, such as ciprofloxacin. Ciprofloxacin has the greatest range of coverage for invasive pathogens, such as Campylobacter and Salmonella.Q. Gastroenterology Card 12 Case: A 53-year-old diabetic 1. What is the best therapy for this woman is evaluated for chronic patient? abdominal bloating and a sense of fullness. She also 2. How does this therapy work? has nausea with occasional vorniting. She sometimes has constipation and sometimes diarrhea. Upper endoscopy is normal. \ KAPLAN)A Gastroenterology C1 1. Diabetic gastroparesis is characterized by abdominal bloating, fullness, early satiety, and nausea. The best therapy for diabetic gastroparesis is with erythromycin or metoclopromide. 2. Erythromycin increases the release of motilin in the gastrointes- tinal tract. This increases the force and frequency of contractions in the stomach and intestines. In a normal patient, this results in vorniting and diarrhea. In a patient with diabetic gastroparesis, this increases the forward flow of the gastric contents. Metoclopromide increases the force of gastric contractions as well.Q. Gastroenterology Card 13 Case: A young woman 1. What is the best initial therapy? resents with multiple bowel ae : ee ca ae and 2. What would you give if her disease is abdominal pain. Some bowel not controlled with this therapy? movements have blood. She has recently been diagnosed with Crohn's disease. Ny asuse)e Gastroenterology Se 1, Mesalamine derivatives are the best initial therapy for both Crohn's disease and ulcerative colitis. Mesalamine is the most effective way of delivering 5-aminosalicylic acid (5-ASA). Several formulations exist. Asacol delivers the 5-ASA to the distal bowel. Pentasa delivers therapy to the entire bowel. Sulfasalazine gives 5-ASA but has many more adverse effects, such as rash, hemolysis, and renal toxicity, because of the sulfa component. N Acute episodes of worsening inflammatory bowel disease that are not controlled with 5-ASA derivatives are treated with the oral steroid budesonide. Budesonide has enormous first-pass effect in the liver, so it has limited systemic toxicity. Azathioprine can be used to keep disease under control without the use of steroids.Q. Gastroenterology Card 14 Case: A 44-year-old woman 1. What is the best initial therapy? comes to you for follow-up of reflux symptoms that she has had for five years. Endoscopy 3. How often should the patient be reveals 3 cm of columnar endoscoped? epithelium of the distal esophagus. 2. How does this therapy work? EeeGastroenterology Cia 1. Barrett's esophagus is columnar epithelium extending up out of the stomach into the distal esophagus. Barrett's esophagus should be trea ted with proton pump inhibitors (PPIs), such as omeprazole, panto- prazole, lansoprazole, esomeprazole, or rabeprazole. 2. PPls work by inhibiting the release of acid from the parietal cells of the stomach. They inhibit the K+/H+ ATPase. PPIs have no major adverse effects. 3. Surveillance endoscopy for Barrett's esophagus should be performed every 2-3 years. If lowgrade dysplasia is present, repeat endoscopy should be performed in six months.Q. Gastroenterology Card 15 Case: Aman develops multiple 1, What is the treatment for localized ulcers in several parts of his disease? duodenum. They recur after . . treatment for Helicobacter pylor, 2+ What is the treatment for metastatic His gastrin level is elevated. disease? He undergoes endoscopic ultrasound and an octreotide scan to determine therapy. N, KAPLAN)A. Gastroenterology Cae 1. An endoscopic ultrasound and octreotide scan are performed to deter- mine the presence of metastases. Localized Zollinger-Ellison syndrome (ZES) or gastrinoma is treated with surgical resection. 2. Metastatic ZES is treated with lifelong proton pump inhibitors (PPls).Q. Gastroenterology Card 16 Case: A 55-year-old woman is 1, What is the best initial therapy for this in the office because of patient? pruritus. Her alkaline phospha- tase is elevated. The aspartate 2. How does this therapy work? aminotransferase (AST) and 3. What are the adverse effects of therapy? alanine aminotransferase (ALT) are minimally elevated. Anti-mitochondrial antibodies are present in increased amounts. \ (a)Gastroenterology 1. Card 16 Primary biliary cirrhosis is treated with ursodeoxycholic acid. Chole- styramine may decrease itching but should not be given at the same time as the ursodeoxycholic acid, because it may decrease its absorption. The mechanism of ursodeoxycholic acid is poorly understood. It decrea- ses plasma and endogenous bile acid concentrations. This reduces hepatotoxicity, because the endogenous bile acids are more toxic to the liver. Ursodeoxycholic acid also decreases eosinophil activation and may decrease the immune destruction of hepatocytes. . Ursodeoxycholic acid is generally devoid of adverse effects.Q. Gastroenterology Card 17 Case 1: A 43-year-old man 1. What is the best initial therapy in comes to the office for fatigue, each case? joint pain, darkened skin, : and erectile dysfunction. His 2. How do these therapies work? serum iron and ferritin levels are markedly elevated. The MRI shows an abnormal liver. Case 2: A patient with sickle cell disease comes in for treat- ment. She has been transfused for severe sickle cell crises 5 times a year for 10 years.Gastroenterology ae Case 1: The first case is hereditary hemochromatosis from the overabsorp- tion of iron in the duodenum. This patient should undergo periodic phlebotomy to decrease the iron load. Case 2: 1. The second patient has developed hemochromatosis from repeated blood transfusions leading to iron overload. Phlebotomy is the fastest way to remove iron from the body. You cannot use phlebotomy, how- ever, to manage iron overload in a patient who needs repeated transfu- sions, such as with beta thalassemia major, myelodysplastic syndrome, or sickle cell disease. When iron overloadis from overtransfusion, chelation therapy is used. Deferasirox is an oral iron chelator. Deferoxamine has to be given by injection and is much harder to use. 2. Chelating agents bind iron and allow it to be excreted.Q. Gastroenterology Card 18 Case: A 25-year-old woman 1. What is the best initial therapy for this comes to see you for the fifth patient? time in two months because : ae of abdominal pain. She has 2. What is the initial therapy for the pain? periods of diarrhea alternating 3, What is the therapy if the first treatment ith ‘ with constipation. The does not work? symptoms are less severe at night. Her abdominal CT scan and colonoscopy are normal. Ny KAPLAN)Gastroenterology Card 18 1. Irritable bowel syndrome (IBS) is initially treated with dietary modifica- tions, such as increasing fiber content. The best sources of fiber are bran, psyllium husks, and methylcellulose. . Antispasmodic medications, such as dicyclomine or hyoscyamine, may decrease pain. They have a modest anticholinergic effect. Diarrhea can be treated with diphenoxylate or loperamide, which inhibit gas- trointestinal motility. . If fiber and antispasmodic agents are not effective, tricyclic antide- pressants may work. Tricyclics are anticholinergic and have a beneficial effect on neuropathic pain.Q. General Medicine Sildenafil, Tadalafil, and Vardenafil Card1 « For which question are these medications the most likely answer? 2. How do they work? 3. What are their most common adverse effects?General Medicine ca 1. Sildenafil, tadalafil, and vardenafil are the best initial therapies for eree- tile dysfunction. Sildenafil has also been approved for the treatment of pulmonary hypertension. 2. These medications are phosphodiesterase inhibitors. [hey decrease vascular tone and increase flow into the penis by increasing local concentrations of nitric oxide. 3. Phosphodiesterase inhibitors can cause hypotension, headache, and facial flushing. They should not be used in combination with nitrates for patients who have coronary artery disease. Grapefruit juice can increase the levels of these medications because of its effect on inhibiting cyto- chrome P450.Q. General Medicine Case: A 72-year-old man 1 comes to the office because of a delay in his ability to urinate. He has a decreased urinary stream, increased urinary frequency, and hesi- tancy. There is no burning pain when he urinates. 4. Urinalysis is normal. Card 2 . What is the best initial therapy for this patient? 2. How does this therapy work? 3. What are the most common adverse effects of therapy? What procedure would you try if the first therapy does not work?A. General Medicine cas 1. The best therapy for benign prostatic hypertrophy (BPH) is a combi- nation of 5a-reductase inhibitors, such as finasteride, and peripheral alpha blockers, such as doxazosin, terazosin, prazosin, or tamsulosin. N Finasteride blocks the production of dihydrotestosterone, which stimulates growth of the prostate. Peripheral alpha blockers relax the internal urinary sphincter, opening the bladder neck, prostate capsule, and prostatic urethra. Prozosin, terazosin, doxazosin, and tam: sulosin increase the volume of the urinary stream 3. Peripheral alpha blockers can cause dizziness and orthostatic hypo- tension. Tamsulosin has the same therapeutic benefit with less incidence of hypotenstion. 4, fmedical therapyfails, the treatmentof BPHisatransurethralresection of the prostate (TURP).Q. General Medicine Card 3 Finasteride and Dutasteride 1. When are finasteride and dutasteride the most likely answers? 2. How do these medications work? 3. What are the most common adverse effects of finasteride and dutasteride? _h KAPLAN)