Black box warnings/Drugs on Step 1

[unsung]

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So what are some important black box warnings, notable drug adverse effects/DDIs, or drug mechs that are likely to be tested on Step 1?

There's like a thousand and one details to know about drugs... but what are the ones you've seen come up time & again?

Post anything that comes to mind or you find significant!

 

[ArcGurren]

Off the top of my head...

Tricyclics = cardiotoxicity, coma, seizures, anticholinergic (BIG one)

SSRIs = sexual dysfunction

Typical antipsychotics = tardive dyskinesia (irreversible), akathesia, hyperprolactinemia or galactorrhea (this should all make sense if you understand the dopaminergic pathways)

Class IC antiarrythmics = never give to a post-MI patient ever or risk fatal v-tach

Amiodarone = everything ever - pulmonary fibrosis, hypo or hyperthyroidism (thyrotoxicosis), liver enzymes increased. Thyroid problems should be obvious because iodine is part of amiodarone (hence amIODarone)

Nitrates = tachyphylaxis and monday symptoms

Nitroprusside = cyanide toxicity (gets metabolized down to 5 CN apiece)

Lithium = a ton of bad stuff; hypothyroidism, Ebstein's anomaly, nephrogenic diabetes insipidus (you would give K sparing diuretics to clear overdose because it gets cleared the same way Na does)

Trazodone = priapism (teeeeeheeeeeee i so mature)

Bupropion = seizures in bulimics

MAOIs = a CLASSIC one - serotonin syndrome (in combo with SSRIs, Rx with cyproheptadine) and HTN crisis with tyramine (causes overproduction of NE, Epi, etc)

Phenytoin = another nasty one; gingival hyperplasia, CYP450 inducer, cleft lip/palate (big time teratogen), hirsutism, coarsening, and SLE-like syndrome. UW also mentioned something called "pseudolymphoma" though I need to read more about it to understand this, something to do with highly generalized lymphadenopathy

Phenobarbital = a BIG one is that you never give it to someone with AIP as it can actually induce heme synthesis which is BAD as it can exacerbate symptoms

Benzos = actually pretty simple; short acting are addictive, long acting are drowsy. Well duh. That's what they do.

Halothane = centrilobular liver necrosis


Holy crap that's a long list...


I'd also make sure to know all the CYP450 inducers/reducers (brain's working a bit slow on those right now but there's good mnemonics for them in FA)

 

[ArcGurren]

Got more!

Thiazides = hyperlipidemia, hyperglycemia, hyperuricemia, hypercalCEMIA, hypokalemia and hypomagnesemia

Loop diuretics = hypocalcemia and hypercalciURIA

Furosemide and thiazdes can induce a sulfa allergy so in that instance you would give another loop, ethacrynic acid, which does not

ACEIs = angioedema (worsens if you have C1 esterase deficiency), cough (bradykinin buildup), hyperkalemia, very teratogenic, CI in bilateral renal artery stenosis

Digoxin = the motherlode! a whole bunch of EKG changes, yellowing of vision, worsened by hypokalemia and quinidine; has a really really narrow therapeutic window

Statins and fibrates = rhabdomyolysis (individually and together), LFTs increase

Metformin = lactic acidosis

That's all I can think of for now

 

[AbbyNormal]

Clozapine has a black box warning for drug-induced agranulocytosis. Can also cause myocarditis/cardiomyopathy.

 

[Encephalectomy]

Got more!

Thiazides = hyperlipidemia, hyperglycemia, hyperuricemia, hypercalCEMIA, hypokalemia and hypomagnesemia

Loop diuretics = hypocalcemia and hypercalciURIA

Furosemide and thiazdes can induce a sulfa allergy so in that instance you would give another loop, ethacrynic acid, which does not

ACEIs = angioedema (worsens if you have C1 esterase deficiency), cough (bradykinin buildup), hyperkalemia, very teratogenic, CI in bilateral renal artery stenosis

Digoxin = the motherlode! a whole bunch of EKG changes, yellowing of vision, worsened by hypokalemia and quinidine; has a really really narrow therapeutic window

Statins and fibrates = rhabdomyolysis (individually and together), LFTs increase

Metformin = lactic acidosis

That's all I can think of for now

Like a boss!

 

[ArcGurren]

Like a boss!

Hahaha thanks, back atcha . I hope this remains in my head on test day lol.

Oh, and I've got more. Can't believe I forgot about the clozapine = agranulocytosis thing, thanks Abby.

Protease Inhibitors = lipodystrophy and hyperglycemia

NNRTIs = Stevens Johnson Syndrome

Lamotrigine = Stevens Johnson Syndrome

Amphotericin B = everything possible awful wrong ever (mostly nephrotoxicity and associated hypokalemia/magnesia causing EKG changes)

Ketoconazole, Cimetidine, Digoxin, Spironolactone = boobs

Etanercept, Infliximab, all the TNFalpha inhibitors = TB reactivation

3rd Gen Cephs, Metronidazole = disulfiram reaction

Methicillin = hypersensitivity interstitial nephritis

Vancomycin = red man syndrome (histamines, give with antihistamine to control)

Tetracyclines = teratogenic, cause deposition and chelate calcium

Fluoroquinolones = tendon rupture in kids, tendonitis in adults

Amantadine = not really an adverse effect per se but it also increases dopamine release, which makes it good for Parkinson's


I'll try and post up some random autonomic ones later

 

[futIDdoc]

Aminoglycosides = OTOtoxic & nephrotoxic
Chloramphenicol = aplastic anemia and grey baby
cyclophosphamide = sterile hemorrhagic cystitis

 

[ArcGurren]

Autonomics:

NE = reflex bradycardia and can decrease renal perfusion; also you can get tissue site necrosis with it because of it's alpha1 effects (so you'd generally give it with an alpha-1 blocker to counteract the local vasoconstriction)

Cocaine = local anesthesia and vasoconstriction (so you NEVER give epinephrine with it if you're using it as a local anesthetic)

Prazosin, terazosin, -osin = first dose orthostatic hypotension (makes sense, think about it - if you block alpha receptors you don't have as good a compensatory increase in vasoconstriction when you stand up)

Clonidine = if you withdraw it too fast you get rebound hypertension (since you've basically prevented NE and EPI release, it'll get released in droves and cause a nasty hypertension - withdraw it SLOWLY)

Beta blockers = mask hypoglycemic symptoms (tachycardia, tremors) so you do not want to give to a diabetic

Metoprolol = associated with hyperlipidemia

Alpha agonists (phenylephrine etc) = associated with tachyphylaxis, i.e. it'll stop working if you give it for too long

 

[MrBigLips]

Can you guys think of anything else? Obviously, as the OP mentioned, there are tons. But what about the ones you definitely have to know? Or is this it?

 

[ThereHeIs]

Aspirin = Reye's 😱

Infliximab = Reactivation of latent TB (Do a PPD before rx)

 

[futIDdoc]

Can you guys think of anything else? Obviously, as the OP mentioned, there are tons. But what about the ones you definitely have to know? Or is this it?

This list is far from complete as far as adverse SE's. My rule if its in FA or UWORLD, know it.

 

[MrBigLips]

This list is far from complete as far as adverse SE's. My rule if its in FA or UWORLD, know it.

Will do, thanks!