endocrine (pharm) Flashcards
glycemic goals of tx in dM hgbA1c and preprandrial and postprandial plasma glucose
hgbA1c
why is correlation between patient report of SBG and hgb A1c important?
it pts feels like blood sugars good but A1c comes back high, think about glucose monitor needing recalibrating, strips, etc
dm patient ed
Describing the diabetes disease process and treatment options
• Incorporating nutritional management and physical activity into lifestyle
• Using medication(s) safely and for maximum therapeutic effectiveness
• Monitoring blood glucose and other parameters and interpreting and using the results for selfmanagement
decision making
• Preventing, detecting, and treating acute and chronic complications
• Developing personal strategies to address psychosocial issues and concerns, and promote
health and behavior change
lifestyle change for dM
Nutrition Self-monitoring Physical activity o Improves insulin sensitivity o May improve glucose tolerance Adherence to medication regimen (if meds necessary
4 main pathogenetic features DM meds target
decreased insulin secretion, increased glucose made by liver, sugar absorption in gut, decreased glucose use by tissues
effect on A1C with physical activity (decreasing weight) and nutriton
decrease in 1-2%
metformin trade name mechanism of action advantages disadvantages cost A1C effect
metformin trade name glucophage mechanism of action ↓ Hepatic glucose production advantages• Extensive experience • No hypoglycemia • ↓ CVD events (UKPDS) disadvantages • Gastrointestinal side effects (diarrhea, abdominal cramping) • Lactic acidosis risk (rare) • Vitamin B12 deficiency • Multiple contraindications: CKD#, acidosis, hypoxia, dehydration, etc. cost: low A1c 1-1.5%
sulfonylureas: glipizide trade name mechanism of action advantages disadvantages cost A1C effect
glipizide trade name glucotrol mechanism of action • Closes KATP channels on -cell plasma membrane • ↑ Insulin secretion advantages• Extensive experience • ↓ Microvascular risk (UKPDS) disadvantages • Hypoglycemia • ↑ Weight • ? Blunts myocardial ischemic preconditioning* • Low durability cost low A1C effect 1-1.5%
thizolidinediones: pioglitazone trade name mechanism of action advantages disadvantages cost A1C effect
thizolidinediones: pioglitazone trade name acts mechanism of action ↑ Insulin sensitivity advantages• No hypoglycemia • Durability • ↑ HDL-C • ↓ Triglycerides (P) • ? ↓ CVD events (ProACTIVE, P) disadvantages • ↑ Weight • Edema/heart failure • Bone fractures • ↑ LDL-C (R) • ? ↑ MI (meta-analyses, R) cost low A1C effect 1-1.5%
alpha glucosidase inhibitors trade name mechanism of action advantages disadvantages cost A1C effect
alpha glucosidase inhibitors trade name acarbose=precose mechanism of action Inhibits intestinal a-glucosidase • Slows intestinal CHO digestion/ absorption advantages • No hypoglycemia • ↓ Postprandial glucose excursions • ? ↓ CVD events (STOP-NIDDM) • Nonsystemic disadvantages • Generally modest A1C efficacy • GI side effects (flatulence, diarrhea) • Frequent dosing schedule cost moderate A1C effect 0.5-1
DPP-4 inhibitors trade name mechanism of action advantages disadvantages cost A1C effect
DPP-4 inhibitors trade name sitagliptin=januvia mechanism of action • Inhibits DPP-4 • ↑ Postprandial active incretin (GLP-1, GIP) • ↑ Insulin secretion† • ↓ Glucagon† advantages • No hypoglycemia • Well tolerated disadvantages• Angioedema/urticarial, other immunemediated derm effects • ? Acute pancreatitis • ? ↑ HF hospitalizations • ? Severe joint pain (rare) cost high A1C effect not great
GLP-1 receptor agonists trade name mechanism of action advantages disadvantages cost A1C effect
exenatide: byetta trade name mechanism of action • Activates GLP-1 receptors • ↑ Insulin secretion† • ↓ Glucagon secretion† • Slows gastric emptying • ↑ Satiety advantages • No hypoglycemia • ↓ Weight • ↓ Postprandial glucose excursions • ↓ Some CV risk factors disadvantages • GI side effects (N, V, D) • ↑ Heart rate • ? Acute pancreatitis • C-cell hyperplasia/medullary thyroid tumors in animals • Injectable • Training requirements cost high A1C effect 1-1.5%
drug that is often used with insulin in type II DM
amylin mimetics (pramlintide)
drug for DMII that is also used for HLD
bile acid sequestrants: colesevelam
drug for DMII that inhibits reabsorption of glucose in proximal tubule and has added benefits of decreased wt and bp
Sodium-glucose cotransporter 2 (SGLT2) inhibitor • Canagliflozin • Dapagliflozin‡ • Empagliflozin
T or F: if A1c is >9, consider starting at dual therapy
T
where should you consider starting if BG >300-350
combo injectable therapy
what is 1st line DM tx? where to go from there?
metformin, check A1c in 3 months, if not at goal and fully titrated and adherent, move on to dual therapy
initial immediate release dosing of metformin
500 mg bid or 850 mg daily
universal dose of regular insulin100 units/ml OTC
100 units/ml OTC
indication for rapid acting insulin
covers for meals
examples of long acting insulin
glargine, detemrir
name of ultra long acting insulin
degludec
best place to keep insulin
Best place is the refrigerator
Can be kept at room temperature if used within 30 days
Do not expose to extreme temperatures or sunlight; no not allow to freeze
f:
don’t use insulin if
Insulin is discolored
Particles have clumped together or are sticking to side of bottle
Past expiration date on bottle or has been unrefrigerated for > 1 month
insulin starting dose for DM1 AND 2
DM1: 0.5-0.6 units/kg/day
DM2: 0.1-0.2 units/kg/day
Usual DMI1 dose: 0.5-1 unit/kg/day in divided doses
50% Basal insulin (long acting)
50% Prandial insulin (prebreakfast, prelunch, predinner)
treatments of hypoglycemia
Conscious patient
Oral glucose tablets 15-20 gm (chew), MR in 15 min if SMBG shows continued
hypoglycemia
Food (orange juice)
Meal or snack once BG normalizes to prevent hypoglycemia recurrence
Unconscious patient
Glucagon: 1 mg SQ, IM or IV produces a response in 5-20 min, MR x 1 or 2 prn
IV dextrose
what do all diabetic patients on insulin and PO agents with r/o of hypoglycemia need to know?
signs and sx of hypoglycemia and how to tx with oral tablets, etc
is acute illness a problem for T2DM patients?
usually not
how to manage BG in T1DM patients with an acute illness?
Patients need to monitor BG frequently,
check urine ketones, use short-acting
insulin as needed
continue usual insulin regimen
and use supplemental rapid-acting insulin basedon BG results
Give additional insulin if ketonuria develops
how do you manage BG in hospital setting?
Scheduled insulin with additional short-acting insulin as needed is recommended, esp b/c you need to hold metformin b/c of risk of renal failure in hospital and possible need for CT with contrast
BP goal for diabetes according to ADA? pregnancy?
Blood Pressure Goal*
what type of management (lifestyle vs. drugs) is appropriate for BP in DM? for which BP ranges? which drug should be used?
Lifestyle therapy** alone (max 3 months) > 120 > 80
Lifestyle therapy** + pharmacologic therapy > 140 > 90
drug: ACEI 1st line, ARB 2nd line
monitoring of BP drugs (ACE/ARB) in diabetcis
BP, serum creatinine, GFR, serum K
what statin intensity should be taken by those 40-75 with no known ASCVD RFs?
moderate, b/c DM is a CVD risk equivalent
what kind of statin tx by ACS and LDL >50 in patients who can’t tolerate high dose statins?
Moderate statins + ezetimibe
anyone with ASCVD should receive what kind of statin therapy?
high dose statins
who with DM should get aspirin?
YES if >50 and RFs and 10 years risk >10 %, NO if
T or F: everyone with DM should be on aspirin therapy
F: If
how do you decide who should be on aspirin therapy?
need to look at 10 year CV risk
increased urine albumin to creatinine ratio (30-299) is an early indicator of what?
diabetic kidney disease
what’s the best way to prevent diabetic kidney disease?
optimize BG & BP and screen for urinary albumin and GFR
how often should someone on insulin therapy check BG?
1-6 x/day
preprandial BG goal
80-130
post prandial BG goal
hgb A1c goal, how often to check?
how to manage pre diabetes ?
Refer to an intensive behavioral counseling program targeting:
• Weight loss of 7% of body weight
• Regular physical activity (≥ 150 min/week of moderate activity, e.g. walking)
• Follow-up counseling appears to be important for success
in those without DM, who should be considered for metformin?
- BMI > 35
* Age
when should patients monitor their BG?
SMBG prior to meals and snacks, occasionally postprandially, at hs, prior to exercise, when
they suspect low BG, after treating low BG until normoglycemic, and prior to critical tasks, e.g. driving.
For patients using less frequent insulin injections or non-insulin therapies, SMBG may be useful as aguide to management
factors that affect blood glucose patterns
meals, exercise, illness, stressful events
T or F: to change BG patterns, Adjust the insulin dose taken after the time of the pattern
F: adjust the one before hand
what is typical number of carbs 1 unit of insulin covers?
12-15
Total daily insulin dose
weight (Kg) x 0.55 units/Kg
carbohydrate coverage equation
500 ÷ TDI (for rapid acting insulin; 450 for regular insulin) then divide carbs in meal by coverage ratio to cover carbs
gold std for pharm tx of hypothryoidism
levothyroxine
AE of thyroid replacement therapy
HTN, tachycardia, insomnia, diarrhea
Excessive doses may lead to heart failure, angina pectoris, MI (rarely caused by coronary
artery spasm) Reduced bone density with excessive doses
T or F: levothyroxine dose is in mcg
T!
indications for an increased thyroid hormone dose
decreased absorption, certain drugs/diets, pregnancy, increased TBG, incresed clearance, impaired deiodination, other: streamline, lovastatin
decreased dose requirements of thyroid hormone
aging, delivery, withdrawal of interacting substance
what needs to happen with warfarin dose when hypothyroid? euthyroid?
increase warfarin dose when hypothyroid, decrease when euthyroid
dosing of levothyroxine
Average dose: ~1.7 mcg/kg/day (typically 100-125 mcg/day); > 75 yo, 1 mcg/kg/day
Take first thing in the morning on an empty stomach (absorption can be by calcium, iron,
fiber); wait ≥ 30 minutes before eating and 4 hours to take calcium iron, magnesium or
aluminum, sucralfate, cholestyramine, and orlistat
who should be started on decreased doses of levothyroxine?
those >50 and those with cardiac disease (don’t want to tax heart with too much hormone)
tx of myxedema coma
300-500 mcg levothryoxine IV + 50-100 mg hydrocortisone q 6h (in case of simultaneous adrenal insufficiency)
what’s best lab to check after levothryoxine therapy and wheN?
TSH q6-8 weeks until euthyroid and then q 6-12 months forever
antithyriod agents: methimzaole and propylthiouracil
MOA
AE
MOA inhibit the synthesis by blocking the oxidation of iodine, do not inactivate circulating T3 and T4; PTU
inhibits peripheral conversion of T4 to T3
AE: maculpapular rash, arthralgias, fevers, agranulocytosis, GI intolerance, hepatoxicity
1st line drug for hyperhtyroidism
methimazole (mmi)
indications for propylthiouracil (PTU)
patients who can’t tolerate other tx; ♀ trying to conceive or
during 1st trimester, tx of thyroid storm
other drugs that can be used to tx hyperthyroidism
beta blocker (“bridging” just controls sx) and iodides (blocks conversion and release)
CI of radioactive iodine
pregnancy (don’t want to expose fetus to radioactive iodine)
1st line tx of hyperthyroid in graves is what for who?
antithyroid drugs for children, adolescents, and in pregnancy or pre-op
best tx for toxic nodules and toxic multi nodular goiter in hyperthyroidism by graves
radioactive iodine
what needs to happen to patients before they can get thytroid surgery?
need to be euthryoid
tx of thyroid storm
Short acting beta blocker, e.g. IV esmolol
IV or oral iodide
Large doses of PTU (900-1200 mg/day in 3 to 4 divided doses)
Supportive care: APAP for fever, fluid and electrolyte management, antiarrhythmic agents
IV hydrocortisone 100 mg q8h due to the potential presence of adrenal insufficiency
Modest weight reductions of ____ have been shown to improve obesity-related health risks
5-10%
drug that began as “when-fen” (fen had valve problems, which works by increasings NE and DA; mild CNS stimulant, helps people lose about 8 pounds, OLD–developed in 1960s, only approved for ST use causes AE of hyperactivity (palpitations, increased BP, HR), and class 4 controlled substance. what do you need to monitor?
phentermine; monitor BP, HR
drug similar to phentermine
diethylpropion
orlistat indication MOA Short or long term? AE CI
orlistat indication obesity MOA: decreases absorption of fat Short or long term? long term AE GI/malabsorption stuff (steatorhrea..) CI: pregnancy, certain drugs (warfarin)
trade names of orlistat
xenical (rx) and alli (OTC)
drug that targets satiety center in brain. what are a few big adverse effects?
lorcaserin (belviq). CNS stuff (serotonin) and serotonin syndrome, euphoria, priapism, valvular heart disease
weight loss drug that combines phentermine with an AED at low doses to lose weight
phentermine/topiramate
drug that is also used to tx alcohol dependence that can be used in obesity. CI?
naltrexone/bupropion, contraindications of higher risks of seizures (anorexia nervosa, alcohol withdrawal, seizure disorder)
drug for weight loss originally made by DM
liraglutide
tx of any cholinergic overdose symptoms (wet, SLUDGE)
atropine
tx of suspected organophosphate (commercial) pesticides to regenerate acetyl-cholinesterase enzyme and saves it from permanent covalent bond
Pralidoxime (2-PAM)
tx of anti-cholinergic toxidrome (bloated as a boat, mad as a hatter)
benzodiapezines to prevent seizures and agitation
tx of opiates
naloxone (be careful not to fully reverse if going to hate you b/c they’ll be OK with some o2 unless heart is failing) and flumezenil
tx of sympathomimetic agents
diazepam, cooling
tx of serotonin syndrome
diazepam, cooling, antipyetics
GI decontamination that absorbs toxins within 1 hour of ingestion
activated charcoal
whole bowel irrigation when charcoal won’t bind to drug
polyethylene glycol osmotically balance solution
approach to patient with overdose
ABCs, when did it occur? (charcoal?), any other toxins?, acetaminophen level? LFTs? bill? BUN/SCR? coags? CBC?
tx of TCA overdose
bicarb
injury from a medicine or lack of an intended medicine
adverse drug event
stop the medication and look for an improvement
dechallenge
if possible, give again and look for similar reaction
rechallenge
FDA program launched in June of 1993 that reports adverse drug evetns
medwatch
who should reports ADEs?
ALL health care practitioners who suspect an ADE
Manufacturers are required to report ADEs discovered to FDA
what ADEs should be reported?
SERIOUS ADEs defined by the FDA as type A or B reactions where the outcome is:
Death
Life-threatening event
Hospitalization (initial or prolonged)
Disability
Congenital anomaly
Medical or surgical intervention was required to prevent permanent damage
ADEs related to newly released agents are particularly important
prescriber problems related to medication errors
Illegible handwriting Incomplete medication orders Use of improper abbreviations Use of apothecary system (gr = grains, grams) Use of improper drug names (5-FU, 6-MP) Ambiguous drug orders Improper expression of drug strengths Unnecessary verbal orders
high hazard meds
Benzodiazepines Calcium Chemotherapeutics Heparin Insulin Lidocaine Magnesium Sulfate IV Opiate Narcotics Potassium Chloride IV
tips to prevent med errors
stay up to date, use current references, double check calculations, always use a leading zero but never a trailing one, avoid verbal orders, include reason for use, avoid dangerous abbreviations, educate patient and caregiver
places to report medication errors to
individual hospital, USP , FDA, ISMP ((institute for safe medical practice)
components of a fiduciary relationship
expertise, holds trust of others, held to high standards, avoid conflicts of interest, is accountable legally
good questions to ask yourself when considering gifts
What is the purpose of the gift and does it truly benefit your patients in some manner?
• What would my patients and colleagues think about this arrangement?
markers of an “appropriate gift”
primarily benefits patients; not of substantive value; if an educational activity,
unbiased and legitimate, no “strings” or conditions
