EXAM 6 Flashcards
Which cells are affected in the pancreas, leading to cessation of insulin production?
Beta cells.
What would a fasting glucose of 124 mg/dL tell you?
Prediabetic.
Range is 100-125. Over 125 is diabetic.
Normal is 60-100.
This is fasting for 8 hours.
If a patient has a HbA1C of 5.6%, what would this indicate?
Normal rating.
Anything over 6.5% is considered diabetic.
What do we treat gestational diabetes with?
Insulin therapy.
This incretin enhancer can increase digoxin levels:
sitaglipin (Januvia)
CONTRAINDICATED in DKA and Type I
This alpha-glucosidase inhibitor can increase the risk of hypoglycemia when paired with a sulfonylureas:
acarbose (Precose)
This thiazolidinedione (TZD) can worsen HF d/t the increased fluid retention:
rosiglitazone (Avandia)
CONTRAINDICATED in DKA and Type I
What do we call the time at which the max effect of a drug happens?
Peak
What do we call the time at which a physiologic response happens after receiving a drug?
Onset
What do we call the total length of time for the physiologic response of a drug?
Duration
Which duration of insulin therapy do insulin glargine (Lantus) and insulin determir (Levemir) belong in?
Long duration
Which duration of insulin therapy do insulin aspart (Novolog) and lispro (Humalog) belong in?
Rapid duration
Which duration of insulin therapy does human regular insulin belong in?
Short duration
Which duration of insulin therapy does isophane insuline (NPH, Humulin N) belong in?
Intermediate duration
What is the Somogyi phenomenon?
The tendency of the body to react to extremely low blood sugar (hypoglycemia) by overcompensating, resulting in high blood sugar.
When blood glucose levels drop too low, the body sometimes reacts by releasing counterregulatory hormones such as glucagon and epinephrine. These hormones spur the liver to convert its stores of glycogen into glucose, raising blood glucose levels. This can cause a period of high blood sugar following an episode of hypoglycemia.
The Somogyi effect, also known as the “rebound” effect, was named after Michael Somogyi, the researcher who first described it.
When is the Somogyi effect most likely to occur?
The Somogyi effect is most likely to occur following an episode of untreated nighttime hypoglycemia, resulting in high blood sugar levels in the morning.
People who wake up with high blood sugar may need to check their blood glucose levels in the middle of the night (for example, around 3 AM). If their blood sugar level is falling or low at that time, they should speak with their health-care team about increasing their food intake or lowering their insulin dose in the evening.
The only way to prevent the Somogyi effect is to avoid developing hypoglycemia in the first place.
Which drug is used for emergency treatment of hypoglycemia?
glucagon (GlucaGen)
** For the patient who is unconscious OR
unable to eat/drink
- Given IV, IM, SQ
- Stimulates the breakdown of stored glycogen (glyconeogenesis).
- Increases gluconeogenesis.
What are the adverse effects of glucagon?
N/V
HYPERglycemia
Which anti-diabetic medication is contraindicated with people who have a sulfa allergy and alcohol use?
glyburide (DiaBeta)
Thiazide diuretics have a similar chemical make-up to sulfa so are also contraindicated.
Alcohol increases the hypoglycemic affects of glyburide.
This anti-diabetic drug stimulates the release of insulin from the beta cells AND improves the insulin-binding to receptors (decreasing resistance):
glyburide (DiaBeta). A sulfonylureas.
CI: sulfa allergy (also thiazide diurectics if they have a sulfa allergy), and alcohol use
Which anti-diabetic drug has the adverse effects of hypoglycemia and hepatoxicity?
glyburide (DiaBeta)
This antiemetic drug is the most effective for motion sickness:
Scopolamine
Route: PO, Transdermal patch behind the ear
Anticholinergic.
What are the adverse effects of scopolamine?
- Drowsiness
- Disorientation
- Blurred vision
- Dry mouth
- Urinary retention
- Constipation
What is the mechanism of action of anticholinergic antiemetics?
Suppresses nerve traffic in the neuronal pathway that connects the inner ear to the vomiting center.
What is the mechanism of action of antihistamine antiemetics?
They BLOCK the neuronal pathway that connects the inner ear to the vomiting center… by blocking the H1 receptors.
What are the 3 antihistamine medications that are used as antiemetics?
- Dimenhydinate (Dramamine)
- Meclizine (Antivert)
- Cyclizine (Marezine)
Routes: PO, IM
What are the adverse effects of the antihistamine antiemetic medications?
- Blurred vision
- Sedation
- Dry mouth
- Urinary retention
- Constipation
What is the mechanism of action for the phenothiazines and dopamine antagonists?
- Inhibit dopaminergic receptors in the chemoreceptor trigger zone.
Which phenothiazine/dopamine antagonist is used to treat N/V due to chemotherapy?
What are its adverse effects?
Promethazine (Phenergan)
Adverse effects:
- Extrapyramidal symptoms (EPS)
- Anticholinergic effects
- Hypotension
- Sedation
Which antiemetic has the risk of extrapyramidal symptoms?
Promethazine (Phenergan)
Which class of antiemetic works by blocking 3 types of 5-HT receptors in CTZ and on afferent vagal neurons of upper GI?
Serotonin (5-HT) receptor antagonists.
Which serotonin 5-HT receptor antagonist is used to treat N/V due to chemotherapy?
What are its adverse effects?
Ondansetron (Zofran) - NO extrapyramidal effects
– HA
– D
– Dizziness
** Use with caution with cardiac disease bc it can cause dysrhythmias ! **
Which antiemetic needs to be used with caution with cardiac disease?
Ondansetron (Zofran)
This is the most effective drug available for N/V due to chemotherapy.
– Prevents acute emesis but not delayed emesis.
ROUTE: PO, IV
If Ondansetron is taken with this other medication then it is even more effective than when taken by itself:
Dexamethason (Decadron)
Which class of antiemetics works by potentiating the action of GABA (an inhibitory neurotransmitter) in the CNS?
What would be common adverse effects due to this action?
Benzodiazepines.
These antiemetics fall under the “miscellaneous” category of antiemetics.
Ex: Ativan (Lorazepam)
Adverse effects:
- Sedation, memory problems
Which Benzo works by suppression of anticipatory emesis?
Ativan (Lorazepam).
Which Benzo is used to help treat EP symptoms that may be experienced when taking promethazine (Phenergan)?
Ativan (Lorazepam).
Which antiemetic is the only cannabinoid available for medical use?
Dronabinol (Marinol).
Which antiemetic is commonly used to treat N/V associated with chemotherapy and appetite stimulation in AIDS patients?
Dronabinol (Marinol)
The only cannabinoid available for medical use.
MA is unknown.
It’s the principal psychoactive agent in marijuana.
ROUTE: PO
What are the adverse effects of dronabinol (Marinol)?
- Paranoia
- Euphoria
- Confusion
- Increased sensory awareness
- Drowsiness
- Decreased motor coordination
- Hypotension
Which antiemetic is contraindicated with psychiatric disorders?
Dronabinol (Marinol)
Due to the psychoactive agent
Which antiemetics (that fall under “misc”) are used to treat N/V due to chemo OR acute post surgical N/V?
Glucocorticoid Antiemetics:
- Methylprednisolone (Solu-Medrol)
- Dexamethasone (Decadron)
They are effective alone or in combination with other antiemetics (like dexamethasone combined with ondansetron).
What do we call the autoimmune disorder of hypothyroidism?
Hashimoto’s thyroiditis
What do we call the autoimmune disorder of hyperthyroidism?
Grave’s disease
This excessive secretion of thyroid hormone leads to a goiter and exopthalamos (bulging eyes).
Which hyperthyroid treatment has many drug interactions and a black box warning?
Propylthioracil (PTU)
Black box: May cause liver injury and hepatic failure
Drug Interactions:
* Increases the actions of anticoagulants
- Decreases the effectiveness of iodine-containing drugs
- Can alter the levels of metoprolol, propranolol, and digoxin.
Which hyperthyroid treatment works by suppressing the conversion of T4 to T3?
Propylthiouracil (PTU)
This is the first step in the synthesis of thyroid hormone.
Which hyperthyroid treatment has the following adverse effects:
Agranulocytosis
Hypothyroidism
Paresthesias
Thrombocytopenia
Propylthiouracil (PTU)
Also has a black box warning of potential liver injury and hepatic failure as well as many drug interactions:
- Increases potency of anticoagulants
- Decreases potency of iodine-containing drugs
- Can alter levels of metoprolol, propranolol, and digoxin.
What is agranulocytosis?
What are paresthesias?
What is thrombocytopenia?
Agranulocytosis: an acute condition involving a severe and dangerous leukopenia (lowered white blood cell count)
Paresthesias: an abnormal sensation, typically tingling or pricking (“pins and needles”), caused chiefly by pressure on or damage to peripheral nerves.
Thrombocytopenia: deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury.
What is the name of the medication used to treat hypothyroidism?
Levothyroxine (Levothroid, Synthroid)
This replaces the T4 hormone, it is identical to endogenous thyroid hormone.
NO adverse effects if therapeutic dose is reached.
If toxic dose:
- Tachycardia
- Palpitations
- Nervousness
- Tremors
- Insomnia
Which thyroid disorder causes a major problem to most organ systems bc it decreases their metabolic state?
Hypothyroidism. Caused by Hashimoto’s thyroiditis [an autoimmune], insufficient dietary iodine, destruction with radioactive iodine, or surgical removal.
- Cold intolerance
- Lower BP
- Bradycardia
- Weight gain
- Fatigue
Which hyperthyroid treatment is on the DEA list bc it is also used to manufacture crystal meth?
Logul’s Solution
This consists of 5% iodine and 10% potassium iodide. Seems counterproductive to treat HYPERthyroidism with more iodine, but high levels of iodine inhibit synthesis of thyroid hormone.
What does toxicity look like with Logul’s solution?
This is called iodism and manifests as a metallic taste, burning, sore teeth and gums.
Why would someone elect to destroy their thyroid gland by ingesting radioactive iodide (131I)?
For those who want to avoid surgery and who cannot take hyperthyroid medication.
May cause hypothyroidism
Given PO
Taken up by the thyroid gland tissue and nothing else.
How far in advance is Logul’s Solution given prior to thyroid surgery?
10-14 days.
Given PO
Treats thyrotoxicosis (hyperthyroidism)
What affect on the body does the thyroid have?
Metabolism
GI function
Cardiac function
Growth and development
Which 3 anti-diabetic drugs are contraindicated in DKA and Type I diabetes?
- Sitaglipin (Januvia)
- Rosiglitazone (Amanda)
- Repaglinide (Prandin)
This insulin is identical to endogenous insulin and works by decreasing BG levels by transporting glucose into the cell (gatekeeper) and by storing glucose as glycogen:
Human Regular Insulin (Humulin R)
Also works by inhibiting the release of glucagon.
Given SQ or IV… via syringe, Opticlick pen, insulin pump, or continuous infusion.
Treatment of hyperkalemia and stimulation of growth hormone secretion are two off label uses of which insulin therapy?
Human Regular Insulin (Humulin R)
Hyperkalemia: by helping shift K+ into the cells
When mixing insulin pull clear-before-cloudy. What are some storage considerations?
- Out of direct sunlight
- Out of direct heat
- Keep in cool dry place
- If opened, toss after 30 days
NPH and regular are often mixed.
Signs and symptoms of hypoglycemia:
Heart palpitations Fatigue Pallor Shakiness Anxiety Sweating Hunger Irritability Tingling sensation around the mouth Crying out during sleep
LATE:
- Confusion, abnormal behavior or both, such as the inability to complete routine tasks
- Visual disturbances, such as blurred vision
- Seizures
- Loss of consciousness
Signs and symptoms of hyperglycemia:
EARLY signs: Frequent urination Increased thirst Blurred vision Fatigue Headache
LATE: Fruity-smelling breath N/V Shortness of breath Dry mouth Weakness Confusion Coma Abdominal pain
This anti-diabetic med (biguanide) reduces gluconeogenesis and decreases reabsorption of glucose in the GI tract:
Metformin (Glucophage)
Rarely causes hypoglycemia
Adverse effects:
- Decreased appetite
- Decreased absorption of vit B12 and folic acid
Which anti diabetic medication is contraindicated in patients with renal impairment and with caution when using IV contrast dye?
Metformin (Glucophage)
Dye: Contraindicated 2 days prior and 2 days AFTER dye administration.
Which biguanide (anti-diabetic) has a rare adverse effect of lactic acidosis?
Metformin (Glucophage)
Could be from liver or kidney disease as well.
Which meglitinide anti-diabetic medication needs some of the pancreas to be functioning in order for the drug to work?
Repaglinide (Prandin)
Needs pancreatic functioning because its mechanism of action is stimulating the release of insulin from the beta cells.
Adverse effects: Hypoglycemia
Contraindicated in DKA and Type I
This thiazolidinedione (TZD) anti-diabetic medication works by increasing cellular sensitivity to insulin (decreasing insulin resistance):
Rosiglitazone (Avandia)
This also decreases gluconeogenesis
Adverse effects:
- Edema
- Macular edema
- Increased lipid levels (which would lead to increased edema due to their polarity?)
Which TZD anti-diabetic medication can worsen HF d/t the increased fluid retention secondary to the increased lipid levels?
Rosiglitazone (Avandia)
Adverse effects:
Edema, macular edema and increased lipid levels
Contraindicated in DKA and Type I
Which anti-diabetic medication is a newer class and works by inhibiting the enzyme DPP-4?
Sitaglipin (Januvia), an Incretin Enhancer…
It inhibits DPP-4 from breaking down incretins which are hormones that are released by the small intestine in response to meals… incretins increase insulin secretion, decrease glucagon secretion, delay gastric emptying and increasing satiety.
Adverse effects: None serious
Drug interactions: may increase digoxin levels.
Contraindicated in DKA and Type I
Which anti-diabetic drug may potentially produce hypoglycemia if paired with glyburide or regular insulin?
Sitaglipin (Januvia)
This drug may also increase digoxin levels… could that be because it delays gastric emptying?
Which anti-diabetic works by delaying absorption of dietary carbohydrates in the GI tract and inhibiting an enzyme responsible for carbohydrate breakdown?
Acarbose (Precose)
Adverse effects:
Diarrhea
Flatulence
Abdominal distention
**Increased risk of hypoglycemia if paired with glyburide (sulfonylureas).
Etiology of PUD: Peptic Ulcer Disease develops with imbalance between mucosal defensive factors (such as mucus, bicarbonate, blood flow, and prostaglandins) and aggressive factors (such as H.pylori, NSAIDs, Acid, Pepsin, and Smoking). Contributing factors are on the back…
- H. pylori
- Family Hx of PUD
- NSAIDs
- Increased caffeine
- Smoking tobacco
- Increased stress
- Zollinger-Ellison syndrom (ZES)
This bacterium is a gram negative bacillus. It colonizes the stomach and the duodenum, between the mucus layer and the epithelium. H. pylori has colonized what percentage of the world’s population and how is it thought to cause injury?
50% of the world’s population has been colonized.
H. pylori are thought to promote enzymatic degradation to the mucosal layer, causing injury to mucosal cells
60-80% of patients with duodenal ulcers have H. pylori.
This is most common in unsanitary, crowded, conditions.
