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UTA test 3 NURS 5334 UTA Advanced Pharmacology Questions With Complete Solutions 1.Which of the following medication can be used to Tx gestational diabetes? Metformin Glucotrol Pioglitazone Sitagliptin Insulin 2.What is the 4-step approach in the Tx, if DM type 2? the 4-step approach Step 1: lifestyle + metformin Step 2: continue step 1 and add drug Step 3: step up to 3 drug combination including metformin Step 4: more complex insulin regimen
- John comes in with random glucose of 250? Does any further testing for DM need to be done? NO You get more AlC reduction with insulin than with oral meds but it causes weight gain. Hold off as long as possible before using insulin
- Jane has type I diabetes and is taking a beta blocker. What does she need to be aware of?
b. Beta blockers impair glycogenolysis and glycogenolysis a means which the body can respond to and counteract a fall in blood sugar
- Gina is taking Canagliflozin for her diabetes. The NP tells her this may increase her risk for: c. UTI and yeast infections *NTK diagnostic criteria for DM Fasting glucose >/ 126 Random glucose >-200 AlC 6.5 No other test necessary especially with other symptoms of hyperglycemia All diabetics should be on ACE or ARB for renal protection Diabetic blood pressure goal <130/ Type 2 DM stepwise approach (ALWAYS encourage lifestyle changes in all steps) o )metformin and lifestyle changes upon diagnosis o 2) at follow-up, if not controlled add another medication second medication is individualized- side effects cost, etc. (no right/wrong second approach) o 3) progress to a 3 dug combo therapy o 4) if 3 drug combo with basal insulin fails after 3- more months proceed to more complex insulin regimen
MOA: decrease insulin resistance, decrease glucose production SE: can cause liver cancer (monitor liver enzymes), weight gain, renal retention of fluid (caution with HF) alpha-glucosidase inhibitors: acarbose, miglitol o MOA: delay absorption of glucose in intestine o SE: explosive diarrhea, no effect on weight DPP-4 inhibitors (-gliptins): sitagliptin o SE: UTI, weight loss SGLT-2 inhibitors (-flozins): canagliflozin, dapagliflozin, empagliflozin, ertugliflozin MOA: block reabsorption of glucose à glucosuria glucosuria causes increased risk for UTI and yeast infection Do not work well with GFR <45 Do not initiate with <45; if already on - flozin may continue until GFR <30 o Work very well for weight loss Injectable antihyperglycemics GLP-1 receptor agonists: exenatide, liraglutide, lixisentatide, semaglutide, dulaglutide GLP-1 receptor agonists: exenatide, liraglutide, lixisentatide, semaglutide, dulaglutide MOA: slow gastric emptying, stimulate glucose dependent release of insulin, inhibit postprandial release of glucagon, and
suppress appetite (weight oss) o SE: increased risk of medullary thyroid cancer hypoglycemia, GI effects, pancreatitis Amylin mimetics: pramlintide *NTK for antihyperglycemics-drug class main SE & which drugs impact weight Drugs that cause weight gain: sulfonureas, meglitinides, TZDS Drugs that cause weight loss: DPP-4 inhibitors, SGLT- inhibitors, GLP-1 receptor agonists Weight neutral: alpha-glucosidase inhibitors Thyroid (4 questions Review pathophysiology oHypothalamus release thyrotropin-releasing hormoneà stimulates pituitary to release thyroid stimulating hormone (TSH) à stimulates thyroid gland to produce T4 à T4 converts to T3 (active metabolite) Primary hypothyroidism (thyroid issue); secondary (pituitary issue); tertiary (hypothalamus issues). 2/3" are managed by endo Diagnostics: (always check TSH to determine if further testing or dosage adjustment oHypothyroid: high TSH, low free T4 o Hyperthyroid: low TSH, high free T
Use weight to dose initial levothyroxine dose à use TSH for further adjustments o Use ideal body weight for overweight patients levothyroxine (most common) o T4 preparation (T4 converts to T3) o Long half-life; check every 6-8 weeks for dose adjustments o Administer on empty stomach (either at night or 30- 60 minutes before breakfast) Other thyroid meds o liothyronine liothyronine synthetic T o liotrix liotrix mixture of T3 & T4 in 4:1 fixed ratio levothyroxine alone produces this ratio *NTK: same effect as levothyroxine with extra benefit and VERY expensive o armour thyroid from desiccated animal thyroid glands works well, but more difficult to manage 15mg300 mg tablets Thyroid medications are highly protein bound; keep this in mind when patient is on other highly bound drugs (warfarin); dose may need to be adjust Drugs that decrease absorption of TH: (GI drugs) H2 receptor blockers, PPIS, cholestyramine, colestipol
Hyperthyroidism Management (hyperthyroid usually autoimmune-Grave's) Hyperthyroidism Management (hyperthyroid usually autoimmune-Grave's) Drugs that decrease absorption of TH: (GI drugs) H2 receptor blockers, PPIS, cholestyramine, colestipol Drugs that receptor Hyperthyroidism Management (hyperthyroid usually autoimmune-Grave's) Side note- very difficult to regulate; Dr Jarrell would refer to endo & only treat cardiac symptoms until endo appt available Ablation of thyroid with radioactive iodine if necessary Usually start with antithyroid medications: 2 options o methimazole o propylthiouracil methimazole: drug of choice for hyperthyroidism treatment exception-pregnancy In pregnant female, start propylthiouracil because methimazole causes esophageal atresia in the fetus during 1" trimester à after trimester switch to methimazole propylthiouracil propylthiouracil o Black Box-severe liver damage Estrogen Effects primary and secondary Metabolic effects
Tamoxifen has been used to prevent breast cancer in those who are at high risk for estrogen receptor type breast cancer; can increase risk for uterine cancer by activation of uterine receptors Raloxifine is similar to tamoxifen but does not activate receptors in the uterus à no increased risk for uterine cancer o Benefits protection protection against development of osteoporosis, maintenance of urogenital tract, reduction of LDLS o Disadvantages: some promote breast/uterine cancer can cause thromboembolism, do not help manage hot flashes Duavee (estrogen/bazedoxifene): combines estrogen with estrogen antagonist o o Use: vasomotor symptoms/osteoporosis in post menopausal women o Bazedoxifene reduces risk of excessive growth of uterine lining r/t estrogen o Still has risks of estrogen use (use in lowest dose, for shortest time possible) 3 approve indications for HRT ) moderate to severe vasomotor symptoms associated with menopause (SSRI/SNRI can also help with vasomotor symptoms) 2.) moderate to severe symptoms of vulvar/vaginal atrophy associated with menopause (topical/tablets are good for
this) 3.) prevention of postmenopausal osteoporosis & related fracture (only high-risk patients) .Other benefits of HRT Cardio protection, prevention of colorectal cancer, positive effect on wound healing, tooth retention, and glycemic control Older studies have shown HRT was too high risk/low benefit; however, these studies are being discredited due to tested population (63+) Takeaway- it is ok to use estrogen early in menopause, give at lowest dose possible for no longer than 5 years at a time Birth control Read about different types of estrogen and progestins in contraceptives Estrogen Routes Routes of estrogen: tablets, patches, topical creams, gels, spray (cream/gel/spray good for atrophy s/t menopause), insertable rings Tabs & creams little systemic absorption; a little more with rings o Progesterins- produced by ovaries & placenta AE: teratogenic effects, can cause breast cancer, depression, bloating, breakthrough bleeding Use: thins lining of uterus; postmenopausal combination HRT for those with uterus, dysfunctional uterine bleeding, amenorrhea, fertility
True Do not initiate it if the GFR is already less than 45, but if they are already taking the med, then it can be given until the GFR gets to less than 35. This is because if the kidneys are not functioning well then, the drugs don't work that well. These drugs stimulate the kidney's to remove glucose.
- Optimally at what interval should the TSH be reassessed after d. 6-8wks
- Which of the following can induce thyroid dysfunction? Amiodarone (and lithium)
- Irma is an 80yr old with CAD she has an elevated TSH with a low free T4 she weighs 80kg. What dosage of levothyroxine are you going to initiate? a. 12.5-25mcg (anyone 65 or over you will start them with no more than 25 and she has concurrent CAD she needs to start even lower so 12.5-25mcg)
- Stacy is a 30yr old that has elevated TSH and low Free T4. 75meg (calculate using 1.6meg/kg/day)
- Jane is in her first trimester of pregnancy and has symptomatic hyperthyroidism, what is the endocrinologist going to prescribe? Propylthiouracil
- Mary is postmenopausal is having severe vasomotor symptoms. She has a uterus., She would like to start hormones. NP b. will start her on estrogen and progesterone
- Julie is wanting to start OCPS but would like to discontinue in 1 year to try for pregnancy. The NP will prescribe: Beyaz (due to having added folic acid
- A patient just call you and she missed a pill she is on a 28day cycle. you tell her Take the pill as soon as possible and continue the pack. Use another form of contraception for 7days b. Nothing
- Lisa has migraines with aura. you are discussion contraception you recommend Mirena IUD (Migraines with aura cannot take combination oral contraceptives)
- One of the main reason's women stop progestin only pills c. break through bleeding (Progesterone only pills can also cause weight gain, depo-provera is a big one for wt gain up to 10 lbs in first year. If the pt waits long enough the bleeding will eventually stop but some pts are just not patient) 17.Sally is post-menopausal. and has been having frequent UTI, NP
- The meglitinides are particularly helpful adjuncts in Type 2 diabetes to minimize risk of postprandial hyperglycemia
- You are prescribing Levothyroxine to an elderly 82yr old Which of the following should you keep in mind c. The levothyroxine dose needed by the clderly is 75% less of what is needed by a voung adult
- What is the most common adverse effect noted with alpha glucosidase inhibitors use? GI upset 25.Which of the following should be monitored with a TZD c. ALT (Because they can cause liver cancer)
- The meglitinides are particularly helpful adjuncts in Type 2 diabetes to minimize risk of hyperglycemia postprandial hyperglycemia
- You are prescribing Levothyroxine to an elderly 82yr old Which of the following should you keep in mind The levothyroxine dose needed by the elderly is 75 % less of what is needed by a young adult Methimazole is primarily excreted via d. Urine
Patients taking anti-thyroid drug should avoid which of the following Seafood (because of the iodine)
