Please enable JavaScript.

Coggle requires JavaScript to display documents.

Contraception And Headache - Coggle Diagram

- - - - PK/PD/PGX: rapidly abs orally, undergoes 1st pass met, excreted urin & feces; progestin has longer half life in pill, high PB, ~40% F
      - MOA: progestin thickens cervical mucus, delays sperm transport, induce endometrial atrophy, blocks LH surge to inhibit ovulation; estrogens suppress FSH release (blocking LH surge), stability endometrial lining, provide cycle control
      - ADEs: Serious (loss of vision, unilateral numbness/tingling, hemoptysis, slurring speech) potentially serious (absence of menses, spotting, breast mass, RUQ pain, migraine, jaundice, depression
      - Regimen: take 28 days followed by 7d of placebo, 84 active days, 7d placebo, can take continuously
      - Monitoring: BP, immobility (due to increased VTE risk)
      - Duration: indefinite
      - CIs: >35yo w/migraine, uncontrolled HTN, smoking, DM w/vascular disease; predisposed to VTE; migraine w/aura; pregnancy
      - Warnings/Precautions: not to be used with uncontrolled HTN (especially systolic 160, diastolic 100)
      - DDIs: any drug that alters GI abs, lower dose of estrogen = more likely DDI will compromise effectiveness, abx especially rifampin, anticonvulsants (induce met = phenobarb carba, pheny) (OCs decrease lamotrigine effectiveness)
      - Special Pops: progestin only OC may be more effective in obese pts (>90kg, especially if bariatric surgery)
      - Education & Counseling: doesn't protect against STIs, encourage condom use
      - Monitoring: pt sx (N/V, breast tenderness), weight, visual inspection of skin, depression screening, menstrual sx (breakthrough bleeding) --> improves usually after 2-3 cycles, may need lower androgenic
      - different doses: 50mcg estrogen, sub 50 monophasic, sub 50 monophasic extended cycle (>21d), sub 50 multiphasic
    - - Ella (ulipristal)
        
        Monitoring: Evaluate for pregnancy if menses delayed 1 week following contraception
        
        ADEs: Headache, nausea, and upper abdominal pain
        
        PK/PD/PGX: Rapid absorption, metabolized by CYP3A4, 94% protein binding, half-life 32 to 38 hrs
        
        MOA: Selective progesterone receptor modulator that delays follicular rupture, thereby preventing ovulation
        
        Regimen: 30 mg PO ASAP within 120 hrs of unprotected sex or suspected contraceptive failure
        
        Duration: Taken once with suspected contraceptive failure or unprotected sex. Not recommended to repeat dose within same menstrual cycle
        
        CIs: Known or suspected pregnancy
        
        Warnings/Precautions: Consider possibility of ectopic pregnancy if pregnancy occurs with contraception use
        
        DDIs: CYP3A4 inducers and inhibitors
        
        Special Pops: Not recommended for use in breast feeding individuals. Ideal for patients between 155 and 195 lbs. Prescription is needed for this medication.
        
        Education & Counseling: Administer with or without food. If vomiting occurs within 3 hrs, consider another dose. This medication is not intended for frequent use to prevent pregnancy.
      - Plan B (levonorgestrel)
        
        PK/PD/PGX: Rapid and complete oral absorption, about a 30 hour half life, Hepatic metabolism via 3A4
        
        MOA: Thickening of the cervical mucus, which inhibits sperm passage and survival. Inhibition of ovulation through a negative feedback loop
        
        ADEs: Nausea, vomiting, and irregular bleeding
        
        Regimen: 1.5 mg tablet for 1 dose
        
        Monitoring: Evaluate for pregnancy, period is delayed for 1 or more week, irregular bleeding or abdominal
        
        Duration: 1 dose to be given with 72 hours of unprotected intercourse
        
        CIs: Do not use for regular birth control. Do not use if you are already pregnant.
        
        Special Pops: Not for use in patients confirmed to be pregnant. Levonorgestrel is present in breast milk in small amounts, patients who are breastfeeding may use levonorgestrel for EC. Less effective in obese patients.
        
        DDIs: Strong CYP3A4 inducers may create subtherapeutic levels,
        
        Warnings/Precautions: Does not protect against STIs/STDs, irregular bleeding may occur, not intended for routine contraception
        
        Education & Counseling: Oral EC will not disrupt the embryo if a pregnancy already exists. Counsel on the timing of the dose, common ADEs, and use of a regular contraceptive method
    - - PK/PD/PGX: rapidly orally absorbed,
      - MOA: for contraception- suppresses ovulation, thickens cervical mucus (which inhibits sperm penetration), alters follicle-stimulating hormone (FSH) and luteinizing hormone (LH) concentrations, slows the movement of ovum through the fallopian tubes, and alters the endometrium. For EC (emergency contraception) - inhibiting or delaying ovulation
      - ADEs: Liver problems - look out for dark urine N/V. stroke - look out for weakness on one side of body, drooping eye, blurred eyesight. Blood clots - pain, redness, swelling on one side of the body.
      - Regimen (dose, freq, route): Oral - In addition to oral pills, progestin-only contraception is available as an implant, intrauterine device (IUD), and injection. The norethindrone POP (progestin-only pill) formulation is taken continuously (ie, no pill-free or nonhormonal pill week). The drospirenone formulation consists of 24 hormonally active tablets followed by 4 inert tablets.
      - Monitoring (what, why, how often): monitor for side effects, abnormal bleeding. Assessment of pregnancy, weight.
      - CIs: patients with acute liver disease, pregnant, breast cancer, abnormal uterine bleeding, tumors
      - Warnings/Precautions: Less effective than combination OCs. Risk of ectopic pregnancy higher since minipills may not block ovulation
      - DDIs: Substrate of CYP3A4.
      - Special Pops: Better option for those who smoke over 15 cigs a day, those with migraines with aura, those at increased risk of VTE, patients who are obese, first 21 days postpartum
      - Education & Counseling: If you are 3 hours late taking a pill, patients should use a backup method of contraception for 48 hours. Associated with irregular and unpredictable menstrual bleeding. If GI upset occurs, administer with food.
- - - - PK/PD/PGX: Long half-life around 30 days, degraded by proteolytic enzymes
      - MOA: Humanized monoclonal antibody that binds to the Calcitonin Gene-Related Peptide ligand, thereby preventing from interacting with the CGRP receptor.
      - ADEs: Antibody development, nasopharyngitis, nausea, injection site reaction
      - Regimen: Administered subcutaneously or intravenously every 1-3 months.
      - Monitoring: Record number of monthly migraines
      - Duration: Indefinitely
      - CIs: Severe hypersensitivity
      - Warnings/Precautions: Many formulations contain Polysorbate 80, which could lead to hypersensitivity reaction. Patients with ECG abnormalities and recent hx of cardiovascular events were excluded from many of these studies.
      - DDIs: None
      - Special Pops: Current preventative therapies are only approved for use in adults. Hepatic and renal impairment not expected to impact dosing. Long term studies for special populations (geriatric, pediatric, prenancy) have not been completed. Cost is a major limiting factor to the regular use. In addition, patient will need a clinic visit to complete IV infusion.
      - Education & Counseling: If SQ route, patient should be instructed how to administer an injection. Counsel and signs of an allergic reaction.
  - - - PK/PD/PGX: Absorption (complete), Distribution (Vd: Females: 110 L; Males 140 L), Metabolism (Via monoamine oxidase-A; forms metabolites; significant 1st-pass metabolism), Excretion (Urine [82%, 14% as unchanged drug]; feces [12%]), Onset (Most pts have response to tx within 2 hrs), Time to Peak (Maxalt: 1 to 1.5 hrs; Maxalt-MLT: 1.6 to 2.5 hrs), Half-Life (2-3 hrs), Protein Binding (14%), Bioavailability (~45%).
      - MOA: Selective agonist for serotonin (5-HT1B and 5-HT1D receptors) in cranial arteries; causes vasoconstriction and reduces sterile inflammation associated with antidromic neuronal transmission correlating with relief of migraine.
      - ADEs: N/V, dizziness, and fatigue.
      - Regimen: 1 PO PRN for migraine.
      - Monitoring: HA severity, S/Sx of angina, CV eval on pts with multiple CV conditions.
      - Duration: Indefinitely unless otherwise told by MD.
      - CIs: Hypersensitivity, IHD/CVD, IBD, Uncontrolled HTN.
      - Warnings/Precautions: CAD, Serotonin Syndrome, Arrhythmias.
      - DDIs: SSRIs, SNRIs, TCAs, and MAOIs.
      - Special Pops: No dose adjustments for impaired kidney/hepatic function. However, AUC and plasma concentrations are increased in pts on hemodialysis. Infant fetal risk cannot be ruled out due to limited data in pregnant women.
      - Education & Counseling: Do not take more than 2 tabs in 24 hrs. If ODT, then allow to disintegrate on tongue then swallow w/ saliva not water. Can take w/ or w/o food. Do not take as prophylaxis as overuse can increase severity and frequency of HA.
    - - PK/PD/PGX:
      - MOA: Acetaminophen (Although not fully elucidated, the analgesic effects are believed to be due to activation of descending serotonergic inhibitory pathways in the CNS. Interactions with other nociceptive systems may be involved as well. Antipyresis is produced from inhibition of the hypothalamic heat-regulating center) Caffeine (Blocks adenosine receptors [mainly A1 and A2A subtypes], induces calcium mobilization from the sarcoplasmic reticulum and inhibits calcium reuptake, increases levels of cyclic AMP by inhibiting phosphodiesterase)
      - ADEs: Abdominal Pain, Nausea, Heartburn
      - Regimen: 2 tablets Q6H PRN
      - Monitoring:
      - Duration: Indefinitely unless otherwise specified by MD
      - CIs: Other acetaminophen-containing drugs, or if allergic to any component (i.e., acetaminophen, aspirin, caffeine)
      - Warnings/Precautions: Skin Reactions (i.e., Reye's Syndrome in children and teenagers), Allergic Reactions, Hepatotoxicity, and Stomach Bleeding
      - DDIs:
      - Special Pops: No dose adjustments for pts with renal/hepatic impairment. May increase stomach bleeding in pts > 60 yrs old. Children recovering from chicken pox or flu-like symptoms should use with caution due to Reye's syndrome. Also, caution use in peds due to risk of hepatotoxicity from acetaminophen. Beer's list for >325 mg aspirin-use per day in elderly patients.
      - Education & Counseling: frequent consumption of aspirin or acetaminophen alone can result in medication-overuse headache, combination analgesics appear to pose a greater risk
  - - - Education & Counseling: used in combo w/ASA or APAP + caffeine for tension HA
      - DDIs: lots
      - CIs: hypersensitivity to any component, porphyria (Hgb abnormally met)
      - Monitoring: physical sx for therapeutic (pain, muscle contraction) toxic (excessive drowsiness, dizziness, lethargy, CNS stimulation)
      - ADEs: intoxicated feeling, fatigue, dizziness, hypotension, abd pain, N/V; CNS depression
      - PK/PD/PGX: excreted unchanged in urine, T.5=61h, 45% PB, 30h of analgesia,
      - MOA of butalbital: short to intermediate acting barbiturate, depresses sensory cortex, decreases motor activity, alters cerebellar fx, produces drowsiness, sedation, hypnosis, dose dep resp depression
      - Regimen: 50-100mg q4h, don't exceed 300mg/day (reduce dose in renal failure & geriatric pts) take as soon as HA begins
      - Duration: prn
      - Warnings/Precautions: should limit use due to concerns of overuse, med overuse HA, w/drawal; hepatotoxic
      - Special Pops: barbiturates are in breast milk, crosses placenta; use w/ caution in geriatric pts
    - - Monitoring: Kidney and liver function
      - ADEs: Upset stomach, constipation, feeling sleepy, feeling tired/weak, Injection site reactions and constipation are the most common adverse effects (erenumab)
      - CIs: Severe hepatic impairment (Not recommended), some medications (ubrogepant) contraindicated with strong CYP3A4 inhibitors
      - PK/PD/PGX: Primarily metabolized via CYP3A4, highly protein bound 98%, around 50% excreted unchanged in urine and feces.
      - DDIs: CYP3A4 inducers may cause sub therapeutic levels, CYP3A4 inhibitors may cause supratherapuetic levels, Rifampin may cause decreased levels
      - MOA: CGRP Receptor antagonist
      - Education & Counseling:
      - Duration: Indefinately
      - Regimen: Daily administration, indefinitely until told otherwise by HCP
      - Warnings/Precautions: Dose reduction required with renal impairment (atopgepant), not recommended in severe hepatic impairment (atopgepant)
      - Special Populations: little evidence to guide the use of the CGRP antagonists in specific populations (eg, children, older adults, and pregnant or lactating patients)