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3152 finals > dosing > Flashcards

dosing Flashcards

1
Q

DM goals in sg

A

HbA1cL <7 (7-8.5% for vulnerable)

FBG 5-7mmol/dL

PPG <10 mmol/dL

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2
Q

stringent goal

A

6-6.5%

□ Shorter disease duration

□ Long life expectancy

□ No significant CVS disease

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3
Q

Less stringent goal

A

7.5-8%

□ History of severe hypoglycemia

□ Limited life expectancy

□ Advanced complications

□ Extensive comorbid conditions

□ Unable to attain target even when:
-Intensive SMBG
- Repeated counselling
-Effective pharmacotherapy

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4
Q

diagnose DM in SG

A

2 abnormal test results from same blood sample may be used to diagnose T2DM

HbA1c >7
HbA1c 6.1-6.9%
+
FPG>7mmol/L
2hOGTT >11.1mmol/L

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5
Q

metformin

A

A1c: 1.5 - 2%
regular: 850mg TDS
extended: 1g BD

max 2550mg

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6
Q

metformin dose adj

A

GFR 30-45 = 50% dose reduction
GFR <30 = discontinue

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7
Q

SU A1c

A

A1c: 1.5-2%

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8
Q

TZD A1c

A

A1c: 0.5-1.4%

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9
Q

GLP1 RA ADV

A

ASCVD (benefits
CKD (minimal)
HF (neutral)

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10
Q

GLP1 A1c

A

0.7-1.5%

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11
Q

SGLT2i adv

A

Ascvd (CE)
CKD (D)
HF (DE)

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12
Q

SGLT2i dose

A

0.8 - 1%

dapaglifozin 5mg OD (max 10mg)

empagliflozin 10mg OD (25mg max)

canaglifozin 100mg OD (max 300mg)

CONTINUE EVEN IF <30mL/min unless not tolerated/ kidney repalcement therapy

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13
Q

a-glucosidase inhibitor A1c

A

acarbose
0.5-0.8%

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14
Q

DPP-4 agonist

A

0.5 - 0.9%

sitagliptin crcl 30-50
ESRD, severe renal impairment

linagliptin
- no renal adj

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15
Q

when to start insulin

A

Catabolism (weight loss)
symp of Hypergly
A1c > 10%
BGL > 16.7 mmol/L

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16
Q

start basal insulin

A

10 IU NPH ON

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17
Q

titrate basal insulin

A

incr 2 unit every 3 days

incr 4 units every 3 days (if FPG > 10mmol/l)

decr 10-20% if hypoglycemia

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18
Q

when to start prandial insulin

A

1) FBG at goal (5-7) but HbA1c above goal

2) basal dose maxed (0.5IU/kg)

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19
Q

initiate prandial insulin

A

1) 10% of basal insulin dose / 4U
2) split bedtime NPH (2/3 AM, 1/3 PM)

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20
Q

titrate basal when added prandial

A

if (A1c <8%)

reduce basal by 4IU/ or by 10%

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21
Q

dose conversion of insulin

A

decr 10-20% if pt hypoglycemic

decr 20% for
1) BD NPH –> OD glargine/ detemir

2) glargine-300 –> basal insulin

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22
Q

changes in regimen after adding insulin

A

SGLT2i (continue)
metformin (continue)

TZD (decr/ stop – hypogly)

SU (decr/ stop when basal added – if pt hypogly) (or can wait until prandial added)

DPP4i (stop if GLP1 added)

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23
Q

range for TH and TSH

A

T4: 0.8-2.7 ng/dL

TSH: 0.4-4.2 MIU/L

  • goal for hypoTH (0.4-4mIU/L)
  • goal for elderly TSH 6.9
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24
Q

screening of thyroid in which pop

A

ROUTINE TEST FOR: (risk developmental risk)
- Preg
- Pediatric pt

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25
compelling indications for screening
1) Presence of autoimmune disease (T1DM, cystic fibrosis) 2) 1st degree relative w/ autoimmune thyroid disease (genetics) 3) Psychiatric disorders - TH abnormality affects psychiatric 4) Take amiodarone/ lithium 5) History of head/ neck radiation for malignancies - Radiation predisposes 6) Symptoms of hypo/ hyperthyroidism
26
diagnosis of hyperthyroidism labs
1* hypothyroidism - HIGH TSH, LOW T4 - +ve Ab (TPO, ATgA) Central hypothyroidism - LOW TSH, LOW T4
27
diagnosis for hyperthyroidism labs
* HIGH FREE T4 * LOW TSH (except in TSH-secreting adenomas) * RAIU (radioactive iodine uptake) * Presence of TRAb, ATgA, TPO Biopsy
28
RAIU meaning
Used to better see if the gland is ACTIVELY secreting TH INCR UPTAKE: ○ Graves, TSH-secreting adenomas, toxic adenoma, multinodular goiter DECR UPTAKE: ○ Thyroiditis, cancer
29
levothyroxine initiate dose
young, healthy: 1.5-1.6 mcg/kg/day 50-60 yo, no CVD: 50mg/day 50-60 yo, CVD: 12.5-25mcg/day
30
titrate levothyroxine doses
incr/decr 12.5-25 mcg/day 10-20% of weekly dose
31
admin for levothyroxine
30-60mins before meal 4hr after dinner 2hrs apart from Ca, Milk, Fe, Antacid, Biphosphonate
32
monitor for hypoTH levothyroxine tx
2-3mnths for TSH to respond 2-3wk for sx relief central hypo: monitor FT4
33
start tx for hypoTH
TSH > 10mIU/L (decr risk of CHD) TSH 4.5 - 10 AND (sx of hypoTH/ TPO ab/ CVS risk) inititate at 25-75 mcg of levothyroxine
34
monitor for hypoth euthyroid state
thyroid function test recommended semiannually to annually in nonpreg adults pt
35
HYPOTH and preg
incr dose by 30-50% to counter for rise in TBG 1st trimester TSH: <2.5 MIU/L 2nd trimester TSH: <3 MIU/L 3rd trimester TSH: <3.5 MIU/L
36
monitor and titrate carbimazole, propylthiouracil by
monitor: 4-6mnth for max sx effect. thyroid size, TSH levels monthly dose titrate as needed based on FT4, Sx
37
why not monitor TSH in hyperthyroidism
TSH remains suppressed for many mnths (1-2yrs)
38
why slow onset in reducing sx
max effect takes 4-6mnths - needs to deplete stored T4 lvls
39
remission in hyperTH means
decr size, normal TSH and T4 for 1yr after discontinuation of antithyroid therapy
40
iodides for hyperTH
1) Before surgery (7-10 days) = shrink 2) After ablation (3-7days) = inhibit thyroiditis mediated release of stored TH (BURST) 3) Thyroid storm (too much TH)
41
PRE-ECLAMPSIA End organ damage
LFT > 2x UNL SCr 2x PLT <100 Pul oedema Neurological complications
42
PRE-ECLAMPSIA proteinuria
24h urinary portein > 300mg Dipstick > 2+ Urine Cr > 0.3 mg/dl
43
estrogen dosing
High dose: 50ug Mod, standard 30-35 Favour lower (20-25mcg) Low dose: 15-20ug
44
prevent pre-eclampsia
Low dose aspirin 100mg PO 12-16wks, until delivery * High risk pt * HTn previous preg * Multifestation preg * Autoimmune disease * CKD, DM
45
Favour lower (20-25mcg)
○ Adolescene ○ Underweight <50kg ○ Age > 35yrs ○ Peri-menopause ○ Fewer ADR
46
High dose: 50ug
○ Obese, >70.5kg ○ Early-mid cycle breakthrough bleed, spot ○ Non adherence ○ ADR: vascular embolic events, Cancers
47
menopause PO (uterus intact)
1) Continuous cyclic □ Prog added on either 1st/ 15th of mnth for 10-14days only -Only if perimenopausal stage 2) Continuous-combined □ Estrogen & progestin daily - Amenorrhea take place after several mnths
48
initiate HRT must monitor for
* Annual mammography * Endometrial surveillance ○ Unopposed estrogen: any vag bleeding ○ Continuous cyclic (E/P off) § If bleed occur when P on ○ Continuous-combine (E/P) § If bleed prolonged § heavier than normal § freq § persists after treatment for > 10mnths
49
Assessment of BPH (7)
Digital rectal exam Ultrasonography Max urinary flow rate (Qmax) Prostate size (<25g) Prostate specific antigen (PSA) > 1.5ng/mL post void residual >200mL AUA-SSI
50
Tadalafil
(5mg PO daily) 36hr before intercourse Can be taken DAILY * Onset: 15min-2hr * Duration of action: 36h * Consideration ○ Regardless of food Hep, renal adj
51
meds that affect BPH
* Anticholinergics * Decr bladder musc contractibility ○ Antihist, tricyclic antidepressants (TCAs) * A1 adrenergic AGONIST * Contract prostate smooth muscles * Decongestants (Pseudoepinephrine) * Opioid analgesic * Incr urinary retention * Diuretic * Incr urinary frew * Testosterone *Stimulate prostate growth
52
Medication induced ED
BP -- clonidine, methyldopa, BB (Xnevibolol), thiazide diuretic anticholinergic -- TCA, 1st gen antihist, phenothiazines dopamine -- metoclopramide serotonin selective reuptake inhibitors 5a reductase inhibitors -- finasteride, dutasteride CNS depressants -- benzodiazepines, anticonvulsants
53
Testosterone replacement
Restore serum testosterone lvl to normal range (300-1100 ng/dL; 10.4-38.2 nmol/L)
54
monitor for testosterone replacement
* 1-3mnths * 6/12mn interval Discontinue if no improvement after 3mn (high risk for SE)
55
when to take PDE5i
S - 1hr before, empty stomach V - 1hr before, empty stomach T - 36hr before, regardless of food A - 30mins before, regardless of food
56
PDE5i ADR
hypotension, priapism, hearing loss S - PDE6 V - PDE6, QTc T - PDE11 muscle ache A -
57
when can take nitrates + PDE5i
Avoided for 12hrs after avanafil 24hrs after sildenafil, vardenafil 48hrs after tadalafil
58
why is nitrite CI for PDE5i
NO acts as vasodilator, worsens hypotension with the use of PDE5i, which also inhibits degradation of cGMP, leads to smooth muscle relaxation, causing vasodilation
59
initiate low dose PDE5i
Low dose esp for: ○ Pt > 65yo ○ Alpha blockers ○ Renal failure pt ○ CYP3A4 inhibitors Incr serum conc of PDE5i
60
monitoring for PDE5i
Efficacy ○ Failure reported: § Admin w/ food § Time, freq of dosing § Sexual stimulation § Titration to max dose Safety (BP, ADR, DDI -- GTN, hypertensives, alcohol, CYP3A4i) Change in cardiac health status
61
ADR of PDE5i
* Headache * Rhinitis * Flushing * Muscle and back pain (PDE11) * Dizziness * Hypotension * Prolonged erections, priapism ○ Blood trapped inside) ○ Seek ED if >4hrs * Sudden hearing loss *Tinnitus and dizziness * S,V = Nonarteritic anterior ischemic optic neuropathy (NAION) PDE6
62
considerations of alprostadil
* (unlike PDE5i): no need sexual stimulation to work * Fast onset: 5-10mins * DDI: not used with PDE5i * DF: 1) Intraurethral 2) Intracavernosal
63
tx considerations for ED
1. PDE5i as 1st line agent a. All have similar efficacy profile b. Diff onset, duration of action, SE profile 2. Alprostadil a. Avoided due to priapism & pain 3. Testosterone 1st line if a. ED + symptomatic hypogonadism b.Consider SE
64
meds that affect BPH
TOAAD * testosterone * opioid analgesic * anticholinergics * a1 adrenergic agonist * diuretic
65
Anticholinergics
* Decr bladder musc contractibility ○ Antihist, tricyclic antidepressants (TCAs)
66
A1 adrenergic AGONIST
* Contract prostate smooth muscles * Decongestants (Pseudoepinephrine)
67
* Opioid analgesic
* Incr urinary retention
68
Diuretic
* Incr urinary freq
69
Testosterone
*Stimulate prostate growth
70
Medication induced ED (organic)
anticholinergic bp CNS depressant dopamine serotonin selective reuptake inhibitor 5a reductase inhibitors
71
Anticholinergics
TCA, 1st gen antihist, phenothiazines ○ MOA: decr Ach activity ○ Alt: bupropion, trazodone, 2nd gen antihistamine, atypical antipsychotics 2nd gen
72
BP
clonidine, methyldopa, BB (Xnevibolol), thiazide diuretic ○ MOA: Decr penile blood flow ○ Alt: nebivolol, ACEi, ARB, loop diuretic
73
CNS depressants
(benzodiazepines, anticonvulsants) ○ MOA: suppress perception of psychic stimulus ○ Alt: anticonvulsant - valproic acid, gabapentin
74
dopamine
(metoclopramide) ○ MOA: decr ACh activity ○ Alt: PPI, erythromycin
75
SSRI
○ MOA: incr serotonin in brain, decr testosterone ○Alt: bupropion, trazodone
76
5a RI
(finasteride, dutasteride) ○ MOA: decr testosterone ○ Alt: (a-blockers) terazosin, alfuzosin

3152 finals (9 decks)

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