endocrine Flashcards
A 56-year-old man was recently diagnosed with type 2 diabetes mellitus and is currently taking metformin (Glucophage) 500 mg daily. His initial HbA1C was 8.0%, which decreased to 7.5% at his 3-month follow-up. What is the best course of action for this patient?
increase dose to 500 mg twice a day
In patients with normal kidney function, the starting dose of metformin is 500 mg daily, which can be titrated up to a maximum dose of 2,250 mg daily. Most glycemic benefits are seen with doses between 1,000 and 2,000 mg a day. This patient is on a low dose of metformin and only had a small reduction in A1C, so the best course of action in this situation would be to increase the metformin dose to 500 mg twice daily and obtain a follow-up HbA1C in 3 months (B).
When initiating antihyperglycemic therapy, an HbA1C (otherwise known as a glycosylated hemoglobin) should be monitored every 3 months, with a goal HbA1C of ≤ 6.5% for most patients. Along with lifestyle modifications, metformin is the preferred first-line agent for type 2 diabetes. Metformin offers glycemic efficacy, promotes weight loss, and is low risk for hypoglycemia. It can be started at lower doses and steadily titrated up as the patient tolerates it. HbA1C reduction at appropriate doses is expected to be 1.0–2.0%. Metformin is generally well tolerated with minimal adverse effects. Lower doses are required for patients with underlying kidney disease, and kidney function testing should be performed annually. If persistent or rebound hyperglycemia develops while on metformin, a second agent should be added to the patient’s drug regimen.
A 35-year-old woman presents to the clinic today with increasing bilateral leg heaviness bilaterally and a small amount of blood in her urine. Her medical history includes generalized anxiety disorder and systemic lupus erythematosus. At her last visit 3 months ago, all of her lab results were within normal limits. Which of the following is the most appropriate plan of care for this patient?
Lupus nephritis is a frequent complication of systemic lupus erythematosus (SLE). The patient presented with new bilateral edema and hematuria. More information is needed to see if her kidneys are the root cause of her symptoms and to treat this patient further. Therefore, ordering a kidney function panel (B) for further investigation would be most appropriate for this patient.
SLE is an autoimmune disorder with multiple system involvement. The loss of immunity to self-antigens leads to pathogenic antibody production and tissue damage. Treatment is focused on mitigation of tissue damage and achieving remission through focused medication and lifestyle and risk profile alteration.
A 68-year-old woman presents to the clinic for a follow-up on her type 2 diabetes mellitus. She also has a medical history of hypertension and atrial fibrillation. She is currently taking metformin, and her HbA1C is 8.3% at the present visit. The nurse practitioner decides to order an additional diabetes medication. Which of the following medications offer cardioprotection and could be prescribed to this patient?
Canagliflozin (A) is a sodium-glucose cotransporter 2 (SGLT2) inhibitor that is used in the treatment of diabetes mellitus. It has cardioprotective features and is recommended for patients with type 2 diabetes mellitus and atherosclerotic heart disease or heart failure because they hinder progressive cardiovascular and kidney disease.
A woman who is in menopause would like to stop her hormone replacement therapy due to concerns about the increased risk of breast cancer. Her predominant menopausal symptoms are hot flashes and night sweats. Which medication would be the most appropriate option for this patient?
Paroxetine (Paxil) (C), a selective serotonin reuptake inhibitor (SSRI), has been shown to improve vasomotor menopausal symptoms. Vasomotor symptoms, commonly known as hot flashes, are the most common symptom among those with menopausal symptoms, affecting up to 80% of patients. Symptoms can last longer than 7 years. Other symptoms can include vulvovaginal atrophy, increased risk of urinary tract infections, and other genitourinary symptoms. Short-term forgetfulness, mood changes, and sleep disturbance can also be present.
A 40-year-old woman with type 2 diabetes presents to the clinic with concerns of spiking blood sugar between lunch and dinner. She states she is on a rapid-acting insulin sliding scale and long-acting insulin. Which change should be implemented to help prevent or curb this glycemic spike?
Insulin aspart (Novolog) (A) is a rapid acting insulin that is commonly dosed with meals and as a sliding scale regimen based on a patient’s glucose prior to eating (preprandial). It is the appropriate insulin to add as a mealtime dose when patients experience blood glucose spikes between meals because of its short-acting properties. Peak time action of insulin aspart is 2 hours with initial effect within the first 30 minutes, making it an ideal choice to control expected postprandial glycemic spikes.
The nurse practitioner is discussing the importance of glycemic control with a patient with an HbA1C of 9.2%. Which microvascular complication is this patient at an increased risk of?
Patients with uncontrolled diabetes are at greater risk of microvascular complications like retinopathy, nephropathy, and neuropathy. Diabetic neuropathy results from nerve damage and is characterized by the loss of sensation in the hands and feet (C). Other conditions like heart disease, infections, or stroke can occur as a result of microvascular complications. Improved glycemic control lowers the level of risk for microvascular complications in patients with type 2 diabetes mellitus. Most patients with diabetes mellitus should aim for an HbA1C of < 7%.
Diabetic nephropathy results from damage to the blood vessels in the kidneys. Diabetic retinopathy occurs as a result of damage to the blood vessels in the eyes and can lead to vision impairments.
what gland regulates calcium
parathyroid
The nurse practitioner is prescribing empagliflozin (Jardiance) for the treatment of type 2 diabetes mellitus. Which of the following is the mechanism of action for this medication?
Blocks glucose reabsorption by the kidneys which increases glucosuria
Empagliflozin, canagliflozin, and dapagliflozin are in a class of diabetes medications called sodium-glucose cotransporter 2 inhibitors. These are once-daily oral medications that block glucose reabsorption by the kidneys, which increases glucosuria (A). The increase in glucose excretion in the urine causes a reduction of plasma glucose concentration and may also contribute to weight loss. The chief side effects of this medication are an increased risk of urinary tract infections (UTIs), genital infections in women, and hypotension. This medication is typically not a good option for patients with a history of frequent UTIs or incontinence due to the glucosuria.
For which of the following patients with type 2 diabetes would it be most appropriate to initiate a sodium-glucose cotransporter 2 inhibitor for glycemic control?
patient with cardiac disease
Sodium-glucose cotransporter 2 (SGLT2s) inhibitors are used in patients with type 2 diabetes mellitus who have comorbid kidney or cardiovascular disease (C), as it may improve outcomes in both of these areas. SGLT2
The most commonly used SGLT2 inhibitors are empagliflozin, canagliflozin, and dapagliflozin.
A 29-year-old woman presents to the clinic for a follow-up on her hyperthyroidism. She is scheduled for radioactive iodine treatment in 2 weeks. Which of the following medications would be the most appropriate for symptom relief during this time?
Atenolol (tenormin)
Hyperthyroidism can be managed with radioactive iodine therapy, but a beta-blocker, such as atenolol (A), is a relatively safe option for symptom relief in the meantime. Beta-blockers decrease heart rate and blood pressure, which will alleviate common symptoms associated with hyperthyroidism.
A 62-year-old man presents to the clinic for a follow-up on his hyperthyroidism. He has a medical history of diabetes mellitus and atrial fibrillation. The nurse practitioner discusses discontinuing one of the medications with the patient’s cardiologist. Which of the following medications is inappropriate and may need to be discontinued for this patient?
amiodarone
Amiodarone should not be used long term due to the high incidence of adverse effects. Amiodarone can also cause thyroid toxicity and should be avoided in patients with thyroid disease (i.e., both hypothyroidism and hyperthyroidism). Thyroid disorders are a common complication of amiodarone therapy. Every patient started on amiodarone should undergo thyroid function testing before initiation. Patients on amiodarone should be monitored for signs and symptoms of thyroid dysfunction. Fatigue, constipation, cold intolerance, and coarse hair are clinical manifestations of hypothyroidism. Low-grade fever, tachycardia, hypertension, weight loss, and restlessness are clinical manifestations of hyperthyroidism.
An adrenocorticotropic hormone (ACTH) stimulation test (B) is typically used in diagnosing adrenal insufficiency, which presents in
Addison disease
primary cause of hyperparathyroidism is
parathyroid adenoma
Thiazolidinediones (TZD) are oral antidiabetic medications that are widely available and used as monotherapy or in combination with other diabetic medications. However, they are contraindicated in individuals with
New York Heart Association class III and IV cardiac status. A patient with a recent ejection fraction of 31% (C) would not be a good candidate for TZDs given the diagnosis of heart failure with a reduced ejection fraction (HFrEF).
The diagnostic criteria for metabolic syndrome include
waist circumference > 35 inches in women and > 40 inches in men, triglyceride levels > 150 mg/dL, HDL levels < 50 mg/dL in women and < 40 mg/dL in men, a blood pressure ≥ 130/85 mm Hg, and a fasting blood glucose > 100 mg/dL (B). A patient must meet three or more of the criteria to be diagnosed with metabolic syndrome.
