NSG 533 - Advanced Pharmacology
Exam 1
Question:
What are the goals set by ACE /ACCE and are they written in stone for all patients?
Answer:
Primary target for glycemic control is HbA1C Individualize HbA1C goal - based on...Duration of DM Age/life expectancy Comorbid conditions Known CVD or advanced comorbid conditions Hypoglycemic unawareness Individual patient considerations
Question:
Please note when transitioning from oral therapy for type II DM to insulin, metformin is retained! Secretagogues are discontinued possibly when basal insulin is initiated, but definitely when prandial (fast/rapid) insulin is to be added
Answer:
Options to add to basal insulin for prandial coverage...Fast-acting insulin 1 / 4
DPP-4 inhibitors Incretin mimetics Glinides Alpha-glucosidase inhibitors Colesevelam
Question:
What are the various types of oral and non-insulin medications and what represents a rational combination of medications?
Answer:
Combinations should have different mechanism of action Combinations should avoid overlapping ADRs Combinations should ideally be selected based on need for better basal vs post-prandial control Selection should account for patient specific concerns (eg. weight, CVD risk, etc)
Question:
What antidiabetic medications have compelling indications:
Answer:
for those with underlying ASCVD or at high risk for CVD for those with CKD for those with a compelling need to avoid hypoglycemia 2 / 4
for those where weight is an important consideration (ie which are associated with weight loss, gain or are weight neutral)
Question:
What are the various insulins and describe the pharmacokinetics (onset, peak, duration) and how are they used (eg basal, basal-bolus, split-mixed, sliding scale (Ask if you don't understand)).
Answer:
Basal-bolus (long acting basal + rapid/fast acting bolus) provides the greatest flexibility and control of all regimens Sliding Scale Should NOT be used Difficult to do in home setting, requires education and understanding of patient and caregiver Allows patient to become hyperglycemic, better to schedule dosing and prevent rises in BG Requires frequent blood glucose monitoring, $$$ and compliance issues
Question:
Can be used as monotherapy or as add-on therapy for T2DM .. Presenting A1C of 9 + symptoms or failure to achieve goal A1C on adequate trial of 2-3 agents at maximally tolerated doses
Answer:
Often starting with a long acting insulin When glycemic goals aren't reached despite basal insulin (Good FBG and pre-prandial BG, but elevated HbA1C), Consider prandial therapy with fast- 3 / 4
acting insulin. Begin fast-acting insulin before largest meal. Variation exists between ADA and ACCE in their recommendations If HbA1C still elevated, add fast-acting to another meal Sulfonylurea can continue up until the point where prandial (rapid) insulin is added Metformin can / should continue!!
Question:
What agents are used to treat hypothyroid disease? What makes the medications different and what do the guidelines recommend for use
Answer:
Recommendation 22.1: Patients with hypothyroidism should be treated with
Levothyroxine monotherapy. Grade A other forms of thyroid replacement may be associated with necessary cost, lack of therapeutic rationale, increase adverse effects and allergenicity (animal based products)
Starting therapy Normal adult dose: 1.6 mcg/kg/day (~100-125 mcg/day)
based on IBW (LBW)Titration by 25-50 mcg every 4-6 weeks until TSH normalizes EXCEPTIONS include elderly, chronically ill patients or history of cardiovascular disease. Initially 12.5-25 mcg/day, then titrate to maintenance dose until TSH normalizes Expect higher requirements during pregnancy Thyroid hormone demand Increases in TBG Destruction of T4 by placental deiodinases
Question:
How is treatment monitored and how should results be interpreted as far as therapy changes (the relationship between TSH and T3-4)
Answer:
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