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424 Pharmacology > Endocrine > Flashcards

Endocrine Flashcards

1
Q

How does hyper vs. hypothyroidism affect insulin? What consideration is needed for patients with these conditions?

A
  • Hypothyroidism: delays insulin breakdown; patients will require less insulin units
  • Hyperthyroidism: increased metabolism and renal clearance; requiring more insulin than baseline
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2
Q

What is the goal A1C for nonpregnant adults? How often is the A1C drawn?

A
  • 7%
  • Every 6 months for those who are compliant, every 3 months for those who are not
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3
Q

What are the pharmacodynamics of insulin? (5)

A
  • Stimulates glucose entry into cells
  • Increases storage of glucose as glycogen in muscle and liver cells
  • Inhibits glucose production in liver and muscle cells
  • Promotes protein synthesis by increasing amino acid transport into cells
  • Enhances fat storage and prevents mobilization of fat for energy
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4
Q

There are several different forumulations of insulin, what are the onset, peak and duration of rapid acting & short acting insulins?

When should you instruct your patient to take their dose of short acting insulin?

*NOTE: clarifying this info as different times were presented in lecture vs. asynch. Info included is from asynch

A
  • Rapid acting
    • Onset 15 min
    • Peak 30-90 min
    • Duration 5 hours
  • Short acting
    • Onset 30 min
    • Peak 2 hours
    • Duration 3-7 hours
    • Take 30 minutes before mealtime
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5
Q

There are several different forumulations of insulin, what are the onset, peak and duration of intermediate, long acting and ultra-long acting insulins?

*NOTE: clarifying this info as different times were presented in lecture vs. asynch. Info included is from asynch

A
  • Intermediate: NPH insulin
    • Onset 1-1.5 hours
    • Peak 4-12 hours
    • Duration 10-16 hours
  • Long acting: Detemir, glargine
    • Onset 3-6 hours
    • Peak none
    • Duration 20-24
  • Ultra-long-acting: Degludec
    • Onset 1 hour
    • Peak none
    • Duration 42 hour
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6
Q

What are some items of caution/contraindication related to insulin? (3)

A
  • Careful monitoring of glucose in patients with: hepatic dysfunction, renal impairment, pregnancy, hypo or hyper thyroid
  • Pregnancy/lactation: rapid or short acting approved - first line in pregnancy
  • Peds: approved
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7
Q

What medication can mask symptoms of hypoglycemia and should be used in caution with most medications for diabetic patients?

A

Beta-blockers

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8
Q

Glucagon

Indication & Pharmacodynamics

A

Indication: hypoglycemic episode

Pharmacodynamics: accelerates liver glycogenolysis - results in increased breakdown of glycogen to glucose and inhibition of glycogen synthesis to increase blood glucose levels

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9
Q

Glucagon

Caution/contraindications: contraindication, when to avoid & Adverse fx (3)

A
  • Caution/contraindications
    • Contraindication: hypersensitivity to glucagon or lactose
    • Avoid: insulinoma or pheochromocytoma
  • Adverse fx: nausea, hypertension, hypersensitivity reaction
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10
Q

Biguanides: Metformin (Glucophage)

Indication & Pharmacodynamics

A

Indication: first-line diabetes management in patients older than 10

Pharmacodynamics: increases peripheral glucose uptake and utilization; decreases hepatic glucose production and intestinal absorption of glucose

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11
Q

Which anti-diabetic medications do NOT cause hypoglycemia alone? (4)

A
  • Metformin
  • Thiazolidinediones
  • Alpha-glucosidase inhibitors
  • Selective sodium-glucose cotransporter 2 inhibitors (SGLT-2)
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12
Q

Which anti-diabetic medications are considered insulin secretagogues? (2)

A
  • Sulfonylureas
  • Meglitinides
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13
Q

Biguanides: Metformin (Glucophage)

Effects on blood glucose levels & weight

A
  • lowers postprandial and basal glucose levels
  • Considered weight neutral
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14
Q

Biguanides: Metformin (Glucophage)

Caution/contraindications: avoid, caution, other considerations, pregnnacy, peds, monitoring

A
  • Avoid: eGFR less than 30, liver disease
  • Caution: eGFR 30-45, B12 anemia/deficiency
  • Other considerations: Hold 48 hours before and after radiologic studies with contrast
  • Pregnancy - may be considered; lactation: compatible
  • Peds: 10+
  • Monitoring: renal function, ketones, A1C
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15
Q

Biguanides: Metformin (Glucophage)

Adverse fx (6)

When do the GI ADRs tend to resolve?

A
  1. diarrhea
  2. bloating
  3. nausea
  4. flatulence
  5. HA
  6. vit B12 deficiency

GI issues usually resolved within 2 weeks after starting dose

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16
Q

Biguanides: Metformin (Glucophage)

Black box warning - how can you educate your patient to avoid this issue?

A
  • Black box warning: lactic acidosis - death, hypothermia, hypertension and resistance of bradyarrythmias
  • Education
    • Encourage keeping well hydrated
    • Alcohol potentiates drug’s effect on lactate metabolism
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17
Q

Thiazolidinediones (TZDs)

Pioglitazone (Actos), rosiglitazone (avandia)

Pharmacodynamics

A

Pharmacodynamics: enhances insulin sensitivity by improving insulin action in the cell; increases utilization of insulin by liver and muscle cells; decreases hepatic glucose production

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18
Q

Thiazolidinediones (TZDs)

Pioglitazone (Actos), rosiglitazone (avandia)

Caution/contraindications: avoid, other considerations, pregnancy, peds, interactions, monitoring

A
  • Avoid: NYHA class III & IV HF; ALT levels greater than 2.5 times above NL; active or hx of bladder cancer
  • Other considerations: Increased risk for bone fractures
  • Pregnancy/lactation: avoid
  • Peds: 18+ ok
  • Interactions: drugs metabolized by the CYP450 system; coricidin, corticosteroids, ketoconazole
  • Monitoring: liver enzymes, A1C
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19
Q

Thiazolidinediones (TZDs)

Pioglitazone (Actos), rosiglitazone (avandia)

Adverse fx (6)

A
  1. fluid retention
  2. wt gain
  3. HA
  4. myalgia
  5. HTN
  6. URI
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20
Q

Sulfonylureas

Glipizide, glyburide, glimepiride

Pharmacodynamics

A

Pharmacodynamics: cause an increase in endogenous insulin secretion by the beta cells of the pancreas; reduces glucose release from the liver; potentiate the fx of ADH

21
Q

Sulfonylureas

Glipizide, glyburide, glimepiride

Which of these need to be taken on an empty stomach vs. with food?

A
  • Glipizide needs to be taken on an empty stomach
  • others need to be taken with food
22
Q

Sulfonylureas

Glipizide, glyburide, glimepiride

Caution/contraindications: avoid, caution, pregnancy, peds, interaction, monitoring

A
  • Avoid: elderly, sulfa allergies, G6PD deficiency
  • Caution: renal and hepatic impairment
  • Pregnancy/lactation: avoid; but d/c 2-4 weeks before expected delivery date if using
  • Peds: 18+ ok; 10-18 years - unlabeled recommendation
  • Interaction: sulfonamides, thiazide diuretics; insulin can only be combined with glimepiride
  • Monitoring: A1C, CBC
23
Q

Sulfonylureas

Glipizide, glyburide, glimepiride

Adverse fx (12)

A
  1. hypoglycemia
  2. wt gain
  3. nausea
  4. epigastric fullness
  5. heartburn, rashes
  6. pruritis
  7. urticaria
  8. agranulocytosis
  9. SIADH
  10. hemolytic anemia
  11. leukopenia
  12. thrombocytopenia
24
Q

Meglitinides

repaglinide (prandin), nateglinide (Starlix)

Pharmacodynamics

Which blood glucose levels does this medication effect? When does it need to be taken?

A
  • Pharmacodynamics: block ATP-dependent potassium channels, depolarizing the membrane and facilitating calcium entry through calcium channels; increased calcium stimulates insulin release from pancreatic beta cells
  • Reduce postprandial blood glucose levels
  • Needs to be taken with a meal (30 min before)
25
Q

Meglitinides

repaglinide (prandin), nateglinide (Starlix)

Caution/contraindications: avoid, caution, pregnancy, peds, interactions, monitoring

A
  • Avoid: elderly
  • Caution: renal and hepatic impairment
  • Pregnancy/lactation: avoid
  • Peds: 18+ ok
  • Interactions: CYP450 inducers; antifungals, antimicrobials
  • Monitoring: A1C
26
Q

Meglitinides

repaglinide (prandin), nateglinide (Starlix)

Adverse fx (6)

A
  1. hypoglycemia
  2. wt gain
  3. HA
  4. diarrhea
  5. arthralgias
  6. chest or back pain
27
Q

Alpha-glucosidase inhibitors

Acarbose, miglitol

Pharmacodynamics

Which blood glucose levels are affected? When should it be taken?

How much can this medication lower A1C?

A
  • Pharmacodynamics: competitively inhibits absorption of complex carbohydrates from small bowel; delays carbohydrate digestion
  • Best for post-prandial elevation, should be taken with the first bite of food
  • Lower A1c by 1%, improve high triglycerides
28
Q

Alpha-glucosidase inhibitors

Acarbose, miglitol

Caution/contraindications: avoid, caution, pregnancy, peds

A
  • Avoid: bowel diseases, predisposition to intestinal obstruction
  • Caution: renal and hepatic impairment
  • Pregnancy/lactation: avoid
  • Peds: avoid
29
Q

Alpha-glucosidase inhibitors

Acarbose, miglitol

In a hypoglycemic episode, what should be used for management?

A

Hypoglycemia would be treated with milk as plain sucrose would not be well absorbed

30
Q

Alpha-glucosidase inhibitors

Acarbose, miglitol

Adverse fx (4)

A
  1. flatulence
  2. diarrhea
  3. abdominal pain
  4. elevated serum transaminases
31
Q

Selective sodium-glucose cotransporter 2 inhibitors (SGLT-2)

-flozins (canaglifozin, dapagliflozin)

Indications & Pharmacodynamics

A

Indication: first choice to add if A1C not at goal with metformin

Pharmacodynamics: inhibit renal SGLT-2 in the proximal tubule, blocking reabsorption of glucose in kidneys, increasing urinary glucose excretion and reduction of plasma glucose

32
Q

Selective sodium-glucose cotransporter 2 inhibitors (SGLT-2)

-flozins (canaglifozin, dapagliflozin)

How much do these drugs reduce A1C?

What other diseases can it help reduce the risk for?

A
  • Reduce A1C by 1%
  • Reduce ACSVD risk, HF, and CKD progression
33
Q

Selective sodium-glucose cotransporter 2 inhibitors (SGLT-2)

-flozins (canaglifozin, dapagliflozin)

Caution/contraindications: black box warning, avoid, other considerations, pregnancy, peds, monitoring

A
  • Black box warning: risk of Fournier’s gangrene (from GU infection)
  • Avoid: eGFR less than 30
  • Other considerations: Increased risk for bone fractures; Canagliflozin: increased risk of amputation
  • Pregnancy/lactation: avoid
  • Peds: limited data
  • Monitor: GU infections, sores on the lower limbs, new pain or tenderness
34
Q

Selective sodium-glucose cotransporter 2 inhibitors (SGLT-2)

-flozins (canaglifozin, dapagliflozin)

Adverse fx (7)

A
  1. hyperkalemia
  2. GU fungal infections
  3. UTI
  4. renal insufficiency
  5. urinary frequency
  6. hypotension
  7. urticaria
35
Q

Dipeptidyl Peptidase-4 (DPP-4) inhibitors

-gliptins

Pharmacodynamics

A

Pharmacodynamics: inhibit DPP-4 enzyme that inactivates GLP-1 and GIP hormones (incretin), which are hormones that increase insulin synthesis and release from pancreatic beta cells, decrease glucagon secretion from pancreatic alpha cells

36
Q

Dipeptidyl Peptidase-4 (DPP-4) inhibitors

-gliptins

How much can this medication reduce A1C?

Which blood sugar levels does it impact?

A
  • Lower A1C by 1%
  • Impact pre and postprandial blood glucose levels
37
Q

Dipeptidyl Peptidase-4 (DPP-4) inhibitors

-gliptins

Caution/contraindications: caution, pregnancy, peds, interaction, monitoring

A
  • Caution: renal impairment (except for linagliptin)
  • Pregnancy/lactation: Avoid
  • Peds: limited data
  • Interaction: ACE inhibitors
  • Monitoring: renal function; A1C
38
Q

Dipeptidyl Peptidase-4 (DPP-4) inhibitors

-gliptins

Adverse fx (4)

A
  1. hypersensitivity reactions
  2. acute pancreatitis
  3. arthralgias
  4. hypoglycemia
39
Q

Glucagon-like Peptide 1 (GLP-1) Receptor agonists

-tides (exenatide, liraglutide)

Pharmacodynamics

A

Pharmacodynamics: analog of the incretin hormone GLP-1 (normally increases glucose-dependent insulin secretion, decreases inappropriate glucagon secretion, and slows gastric emptying)

40
Q

Glucagon-like Peptide 1 (GLP-1) Receptor agonists

-tides (exenatide, liraglutide)

How much can this medication lower A1C?

Which blood sugar levels are impacted?

A
  • Lower A1C by 2%
  • Impacts pre and post prandial blood glucose
41
Q

Glucagon-like Peptide 1 (GLP-1) Receptor agonists

-tides (exenatide, liraglutide)

Caution/contraindications: avoid, black box warning, pregnancy, peds, interactions

A
  • Avoid: moderate to end stage renal disease, severe GI disease
  • Black box warning: risk of thyroid c-cell tumors
  • Pregnancy/lactation: limited data
  • Peds: limited data
  • Interactions: increased INR with warfarin, digoxin
42
Q

Glucagon-like Peptide 1 (GLP-1) Receptor agonists

-tides (exenatide, liraglutide)

Adverse fx (6)

A
  1. nausea
  2. vomiting
  3. diarrhea
  4. injection site reaction
  5. HA
  6. pancreatitis
43
Q

Thyroid agents

Levothyroxine (synthroid)

Indication & Pharmacodynamics

When should this medication be administered?

A
  • Indication: Hypothyroidism; TSH greater than 10 or between 5-10 with goiter or positive antithyroid peroxidase antibodies
  • Pharmacodynamics: synthetic form of T4. Normally converted to active metabolite T3, then able to bind to thyroid receptor proteins in the nucleus and exert metabolic fx through control of DNA transcription and protein synthesis
  • Admin on an empty stomach 30 min prior to a meal
44
Q

Thyroid agents

Levothyroxine (synthroid)

Caution/contraindications: monitoring, avoid, caution, pregnancy, peds

A
  • Monitoring: check TSH levels 6-8 weeks after initiating treatment; goal TSH 0.3-3.0
  • Avoid: recent MI
  • Caution: cardiovascular disease, adrenal insufficiency
  • Pregnancy/lactation: OK
  • Peds: OK
45
Q

Thyroid agents

Levothyroxine (synthroid)

Adverse fx (7)

A
  1. decreased bone mineral density with long term therapy
  2. increased HR
  3. increased BP
  4. anxiety
  5. nervousness
  6. insomnia
  7. weight loss
46
Q

Antithyroid agents

Methimazole (Tapazole) & Propylthiouracil (PTU)

Indication & Pharmacodynamics

A

Indication: Hyperthyroidism

Pharmacodynamics: inhibits synthesis of thyroid hormones by blocking oxidation of iodine in the thyroid gland; does not inactivate circulating thyroid hormones

47
Q

Antithyroid agents

Methimazole (Tapazole) & Propylthiouracil (PTU)

Caution/contraindications: peds, drug interactions, monitoring

Which medication can be used during the first vs. 2nd/3rd trimesters of pregnancy?

Note: black box warning related to PTU

A
  • Pregnancy: PTU during first trimester, Methimazole for 2nd and 3rd; lactation: lowest dose
  • Peds: OK
  • Drug interactions: caution with meds that can suppress bone marrow, lithium, warfarin, OTC cold meds
  • Monitoring: thyroid studies, CBC, liver/renal panels
  • PTU specific black box warning: hepatotoxicity
48
Q

Antithyroid agents

Methimazole (Tapazole) & Propylthiouracil (PTU)

Adverse fx (8)

A
  1. drowsiness
  2. HA
  3. arthralgia
  4. skin rash
  5. urticaria
  6. fever
  7. agranulocytosis
  8. hepatitis

424 Pharmacology (12 decks)

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