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Foundations of Pharmacy Care > Exam II: RAAS, Diabetes drugs > Flashcards

Exam II: RAAS, Diabetes drugs Flashcards

1
Q

Dipines like amlodipine are ?

A

Calcium channel blockers

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2
Q

Two types of calcium channel blockers based on chemical structure? (Give an example of each)

A
  1. Dihydropyridines (DHPs) - amlodipine etc.

2. Non-Dihydropyridines (non-DHPs) - diltiazem, verapamil

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3
Q

Name three differences between DHPs and non-DHPs as far as their effects on the body.

A
  1. Dihydropyridine (DHP) CCBs tend to be more potent vasodilators
  2. Non-dihydropyridine (non-DHP) agents have more marked negative inotropic effects (lower heart rate)
  3. Non-DHPs more advantageous for patients with chronic kidney disease and diabetic nephropathy.
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4
Q

How do Calcium Channel Blockers (CCBs) control blood pressure?

A

CCBs regulate Ca2+ influx into cells. This hinders heart contractility, relaxes smooth muscle in the arterial wall and lowers blood pressure.

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5
Q

In addition to vasodilation, what effects do non-DHPs have on the heart?

A

Decrease the heart rate by depressing atrioventricular (AV) node conduction

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6
Q

What is Raynaud’s Prevention? What medication drug class can treat this disorder?

A

Raynaud’s Prevention - an idiopathic condition affecting the hands and fingertips, causing them to become cold, spastic, numb and ulcerated.

Dipines can treat this disorder.

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7
Q

This drug class can treat angina (chest pain), afib, tachycardia can migraines.

A

CCBs

Dipines

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8
Q

Adverse Drug Reactions: Peripheral edema, Orthostasis, Heart block. Name the drug class. (Hint: Treats hypertension)

A

Non-DHP CCBs

Diltiazem and verapamil

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9
Q

What type of drugs should be used with caution when a patient a taking a CCB? (2)

A
  1. Drugs metabolized by Cytochrome P450 3A4

2. Non-DHPs taken with beta blockers

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10
Q

Cautions to take when giving CCBs with these two type of patient populations. (Hint: think age and heart failure)

A
  1. Do not use non-DHPs for patients with a a left ventricular ejection fraction of <40%
  2. Initiate at lower doses in older patients
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11
Q

“RAAS” drugs stands for?

A

Renin Angiotensin Aldosterone System Antihypertensives

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12
Q

Types of RAAS inhibitors (3)? Give brief description for each.

A
  1. ACE inhibitors - Prevents Angiotensin I from being converted to angiotensin II which prevents vasoconstriction and activation of aldosterone
  2. Angiotensin II receptor blockers (ARBs) - Angiotensin II cannot bind to its receptor
  3. Direct Renin Inhibitors – Target renin coming directly from the kidneys (prevents the RAAS pathway from occurring to increase BP)
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13
Q

Briefly describe the RAAS pathway.

A

Lower blood pressure sensed in the kidneys

  1. Renin released from the kidneys to the blood
  2. Renin cleaves angiotensin in to angiotensin I (inactive) in the liver
  3. Angiotensin converting enzyme (ACE) converts Ang I to Ang II (active)
    4a. Ang II acts on adrenal cortex - stimulates aldosterone release - Water and sodium retention
    5a. Ang II acts on various AT receptors throughout the body to cause cause vasoconstriction, decrease urine output and fluid retention.

Blood pressure increased

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14
Q

Difference between “pril” and “prilat”? ie. Enalapril vs Enalaprilat

A

Enalaprilat - active metabolite, poorly absorbed, must be admin IV

Enalapril - prodrug (inactive), can be given PO

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15
Q

What type of RAAS drug are “pril” drugs like Benazepril? Also describe mechanism of action.

A

ACE inhibitors

Prevents conversion of angiotensin I to angiotensin II (potent) by competitive inhibition of ACE

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16
Q

ACE inhibitors AND ARBs are first line therapies for hypertension in what cases? (Name the common factors between the two) –> 6

A
  1. Non-African American patients
  2. Patients with albuminuria
  3. HF or LVEF less than or equal to 40%
  4. Coronary Artery Disease
  5. Post Myocardial Infarction
  6. Recurrent stroke prevention
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17
Q

Contraindications for ACE inhibitors AND ARBs.

A
  1. Bilateral renal artery stenosis (narrowing of renal arteries)
  2. Pregnancy
  3. Angioedema (swelling between skin and mucosa typically in the lips) –> most common in African American patients
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18
Q

Adverse reactions for ACE inhibitors AND ARBs. (4)

A
  1. Increases in serum creatinine (limited increase as much as 30% okay)
  2. Hyperkalemia
  3. Angioedema (occurs 2-4x more in African Americans)
  4. Dry cough
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19
Q

Angioedema and cough is much less common in ACE inhibitors or ARBs?

A

Less common in ARBs

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20
Q

What must be monitored when a patient is taking an ACE I or ARB?

A

Reassess SCr (serum creatine) and potassium K in 1-2 weeks after initiation or dose titration

Much more frequently in patients with renal impairment

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21
Q

Potassium Supplements and other medications that can increase potassium

Cause drug interactions with what type of RAAS drugs?

A

All three types

ACE I (pril)

ARB (sartan)

DRI (kiren)

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22
Q

Four drug-drug interactions present for ACE inhibitors. (Besides potassium increasing meds)

A
  1. Lithium carbonate (ACE I drugs increase lithium levels)
  2. K+ sparing diuretics like Triamterene + HCTZ - increased risk of hyperkalemia
  3. NSAID - both drugs affect the kidneys
  4. Food
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23
Q

What type of RAAS drug are “sartan” drugs like Olmesartan? Also describe mechanism of action.

A

Angiotensin II Receptor Blockers (ARB)

Inhibits the binding of Angiotensin II to receptors, making the Angiotensin II ineffective as a vasoconstrictor

Also no Na+ retention effect.

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24
Q

What type of RAAS drug are “kiren” drugs like Aliskiren Hemifumarate (Tekturna®)? Also describe mechanism of action.

A

Direct Renin Inhibitor

Directly inhibits the RAAS at its point of activation; reduces the production of Angiotensin I and Angiotensin II

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25
Q

Therapeutic indication (1) for Aliskiren Hemifumarate (Tekturna®) –> Direct Renin Inhibitor.

A

Hypertension

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26
Q

Contraindications for Aliskiren Hemifumarate (Tekturna®) –> Direct Renin Inhibitor. (4)

A
  1. Pregnancy
  2. Concomitant use of ACE I and ARBs in diabetic patients - risk of hypotension, renal impairment and hyperkalemia.
  3. Concomitant use of ACEI or ARBS in patients with a Creatinine Clearance (CrCl) of <60 mL/min/1.73m2 - tests kidney function
  4. Concomitant use of cyclosporine or itraconazole
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27
Q

High fat meals increase absorption of Aliskiren Hemifumarate (Tekturna®) –> Direct Renin Inhibitor.

True/False

A

False

High-fat meals decrease absorption substantially

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28
Q

Patients with renal insufficiency should avoid this RAAS drug?

A

Aliskiren Hemifumarate (Tekturna®) –> Direct Renin Inhibitor.

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29
Q

All hypoglycemic drugs do what? Other names to describe these drugs (2)

A

Reduce blood glucose

Antidiabetic drugs = antihyperglycemic drugs = hypoglycemic drugs

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30
Q

Where is insulin produced and secreted? What stimulates its release?

A

Islets of Langerhans β cells in pancreas

Stimulated by increased blood glucose

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31
Q

Two goals of therapy in diabetes mellitus?

A
  1. Regulate levels of blood glucose/maintain normal glucose levels
  2. Avoid ketoacidosis and hypoglycemia
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32
Q

Percentage of patients with DM in the US. Are most diagnosed? More males or females?

A

14.3% with DM in US

Most undiagnosed in this percentage

Slightly higher percentage of males

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33
Q

Symptoms/signs of DM?

A
  1. Polydipsia (Great thirst)
  2. Polyuria (Frequent dilute urination)
  3. Polyphagia (Great hunger)
  4. Weight Loss (Typically Type I)
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34
Q

What sign gives a definitive diagnosis of DM?

A

HbA1c above 6.5%

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35
Q

Five comorbidities associated with DM.

A
  1. Cardiovascular
  2. Diabetic peripheral neuropathy
  3. Amputation of Limbs
  4. Renal [nephropathies]
  5. Ocular damage [retinopathy]
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36
Q

What is diabetes insipidus?

A

Caused by a deficiency of the pituitary hormone vasopressin

Failure of renal absorption that leads to larger amounts of dilute urine

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37
Q

What are the levels of blood glucose for pre-diabetic patients (fasting mg/dL and HbA1c)?

A

Fasting blood glucose 100-125 mg/dL

HbA1c 5.7-6.4%

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38
Q

IDDM (insulin dependent diabetes mellitus)
JODM (juvenile onset diabetes mellitus - insulin deficiency)

Type I or Type II DM?

A

Type I DM

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39
Q

Insulin desensitization or insulin resistance

Type I or Type II DM?

A

Type II DM

40
Q

List risk factors for Type II DM. (7)

A
  1. Genetic predisposition
  2. Age
  3. Obesity
  4. Hypertension
  5. Hypercholesterolemia
  6. History of gestational diabetes
  7. Lack of anaerobic exercise
41
Q

What is gestational diabetes and how common is it?

A

Pregnant patients with hyperglycemia who were not previously diagnosed (14% of pregnancies usually between the 5-6 month)

42
Q

Exogenously administered insulin is mandatory in what type of diabetes? Optional in what type?

A

Mandatory - Type I

Optional - Type II

43
Q

Diet and exercise is recommended in which type of DM?

A

Type I and Type II no matter how controlled blood glucose levels are.

Diet and exercise is crucial for all patients.

44
Q

Routes of administration for exogenous insulin.

A

SubQ, IM, IV

45
Q

Normal levels for blood glucose (mg/dL) - fasting, random and oral glucose tolerance test.

A

Fasting - less than 100 mg/dL

Random - less than 200 mg/dL

Oral glucose tolerance - less than 140 mg/dL

46
Q

When is an oral glucose tolerance test taken?

A

2 hours post ingestion of glucose drink

47
Q

blood glucose vs. HbA1c?

A

HbA1c reflects your average blood glucose level over the last 10-12 weeks

48
Q

Each % reduction in HbA1c is equivalent to BG level of how many mg/dL?

A

% point reduction in HbA1c = 40 mg/dL

49
Q

At that HbA1c level must exogenous insulin be added to a Type 2 diabetic therapy?

A

HbA1c > 9%

50
Q

Nomenclature for sulfonylureas (diabetes) - 5

A

AMIDE, RIDE, ZIDE, GLI, GLY

51
Q

First line therapy for Type 2 diabetes

A

Metformin

52
Q

How do sulfonylurea lower blood sugar?

A

Interact with ATP sensitive K channels in the beta cells, thus increase the secretion of insulin

53
Q

Indications for sulfonylureas. (include off label)

A

Type II diabetes - not as first line

Off label - diabetes insipidus

54
Q

Advantages and disadvantages of sulfonylurea therapy.

A

Advantages – low cost

Disadvantages – weight gain, risk for hypoglycemia

55
Q

Sulfonylurea drugs cannot be discontinued even if goal HbA1c levels are reached.

True/False

A

False

These drugs are not intended for continuous use.

A holiday can be attempted if HbA1c goal is reached.

56
Q

Allergic skin reactions, somnolence, GI upset, pharyngitis.

Adverse reactions seen with this type of hypoglycemic drug?

A

Sulfonylureas

AMIDE, RIDE, ZIDE, GLI, GLY

57
Q

Hypoglycemia is a risk of taking hypoglycemic drugs. What are the symptoms?

A

Usually seen with blood glucose < 70 mg/dL

  1. Weakness, dizziness, tremors, sweating
  2. Confusion
  3. Tachycardia
58
Q

Pregnancy category for sulfonylureas except for Glyburide.

A

Category C, except GLYBURIDE (category B)

59
Q

Glipizide, glyburide and glimepiride are what generation of sulfonylureas?

A

2nd generation

60
Q

Chlorpropamide. drug class? generation?

A

First generation Sulfonylurea

61
Q

Formin drug class and pharmacological effect on the body?

A

Biguanides

  1. Decrease hepatic glucose production
  2. Increase secretion of GLP-1
  3. Decrease GI absorption of glucose
62
Q

How much are Formin drugs supposed to lower HbA1c?

A

Expected to lower HbA1c 1-1.5%

63
Q

What is the box warning for Formin drugs?

A

Lactic acidosis

64
Q

Symptoms of lactic acidosis? (5)

A
  1. Bradycardia, arrhythmias
  2. Malaise
  3. Somnolence
  4. Respiratory dysfunction
  5. Abdominal pain
65
Q

Cautions (2) and adverse drug effects (1) when taking Formin drugs?

A
  1. May cause GI issues (diarrhea, nausea)
  2. Renal impairment - not recommended
  3. Acute liver injury - not recommended
66
Q

Advantages and disadvantages of taking Formin drugs?

A

Advantages

  1. HbA1c reduction by 1-1.5%
  2. Weight neutral
  3. Low (no) risk for hypoglycemia

Disadvantages

  1. GI side effects
  2. Risk of lactic acidosis
67
Q

Hypoglycemic drugs with low/no risk hypoglycemia?

A
  1. Formin - ie. Metformin
  2. Glitazone - ie. Pioglitazone
  3. Gliptin - ie. Sitagliptin (Januvia®)
  4. Tide/Glutide - ie. Dulaglutide (Trulicity®)
  5. Gliflozin - ie. Empagliflozin (Jardiance®)
68
Q

Glinide drugs like Repaglinide are in what chemical drug class? What pharmacological effects do these drugs have?

A

Meglitinide non-sulfonylureas

  1. Stimulate insulin release
  2. Faster onset but shorter duration (rapid release of insulin)
  3. Reduce hepatic glucose production
69
Q

Why should a Glinide drug like Repaglinide be taken 15 minutes before a meal?

A

Lessens risk of hypoglycemia

70
Q

Advantages of Glinide drugs (meglitinide non-sulfonylureas) over Formin drugs (sulfonylureas). (3)

A
  1. More dosing flexibility
  2. Better glucose control after meals - Rapid onset, shorter duration
  3. Shown to have better outcome
71
Q

Disadvantages of Glinide drugs (meglitinide non-sulfonylureas) over Formin drugs (sulfonylureas). (2)

A
  1. Marginal HbA1c reduction (0.5-1%)

2. Risk of hypoglycemia

72
Q

What is the chemical class of Glitazone drugs like Pioglitazone? What pharmacologic effects does it have on the body?

A

Thiazolidinediones

“Insulin Sensitizers”
1. Reduce insulin resistance

  1. Increase insulin sensitivity in adipose tissue, skeletal muscle and liver
  2. Reduce hepatic glucose production
73
Q

Rosiglitazone maleate (Avandia®) has been formally approved to be taken with insulin.

True/False

A

False

Pioglitazone is the only Thiazolidinedione drug formally approved to be taken with insulin.

74
Q

Weight gain, heart failure, anemia, increased fracture risk.

Side effects of what hypoglycemic medication class?

A

Thiazolidinediones

Rosiglitazone maleate (Avandia®)

Pioglitazone

75
Q

Rosiglitazone - increased risk of MI
Pioglitazone - increased risk of bladder cancer

True/False

A

True

76
Q

How long does it take Glitazone (Thiazolidinediones) drugs to affect blood glucose?

A

about 2 weeks

77
Q

A patient fasting for a long period of time can discontinue a Glitazone (Thiazolidinediones) drug.

True/False

A

True

78
Q

Warning and precautions for patients taking Glitazone (Thiazolidinediones) drugs?

A
  1. Liver impairment (use with caution) - test liver function
  2. Weight gain
  3. Peripheral edema (usually in ankles and feet)
79
Q

Symptoms of abnormal liver function. Especially for patients taking a Glitazone (Thiazolidinediones) drug.

A
  1. Jaundice
  2. Fatigue
  3. Abdominal pain
80
Q

Advantages and disadvantages of taking Glitazone (Thiazolidinedione) drugs.

A

Advantages

  1. HbA1c reduction 1-1.5%
  2. Low risk of hypoglycemia

Disadvantages

  1. Weight gain
  2. Edema
81
Q

Gliptin drugs like Saxagliptin (Onglyza®) pharmacological effects on the body? (2)

A

Dipeptidyl peptidase-4 inhibitors (DPP-4 Inhibitors)

  1. Suppress glucagon secretion
  2. Incretin-Mimetic agents - potentiate insulin release and decrease glucagon release
82
Q

Gliptin drugs like Saxagliptin (Onglyza®) can be used with insulin.

True/False

A

False

Not to be used in combination with insulin

83
Q

What hypoglycemic drugs are weight neutral? (2)

A
  1. Gliptin - ie. Sitagliptin (Januvia®)

2. Formin - ie. Metformin

84
Q

Advantages and disadvantages of Gliptin (DPP-4 inhibitors) drugs.

A

-Advantages

  1. Weight neutral
  2. Well tolerated
  3. Low/no risk of hypoglycemia

Disadvantages

  1. Marginal reduction of HbA1c (0.5-1%)
  2. Hypersensitivity reactions (rare) –> Steven-Johnson Syndrome, Anaphylaxis
85
Q

What are Glucagen® Hypokit, Gvoke HypoPen® used for?

A

rDNA origin - SubQ injection for hypoglycemic crisis –> treats low blood sugar

86
Q

What is the chemical class of Tide/Glutide hypoglycemic drugs? What pharmacological effects do they have on the body?

A

Synthetic peptide

Glucagon-like peptide-1 receptor agonists [GLP-1 Receptor Agonists]

Incretin-mimetic agents

  1. Suppress glucagon secretion
  2. Increase glucose dependent insulin secretion
  3. Slow gastric emptying
  4. Promote satiety
87
Q

Tide/Glutide drugs like Dulaglutide (Trulicity®) are weight neutral.

True/False

A

False

Tide/Glutide drugs have been associated with weight loss

88
Q

Tide/Glutide drugs like Dulaglutide (Trulicity®) is injected insulin.

True/False

A

False

These drugs are administered SubQ. However, it is not insulin.

89
Q

Therapeutic indications for Tide/Glutide drugs like Dulaglutide (Trulicity®)?

A

Mono or combo therapy for Type 2 diabetes in conjunction with diet and exercise.

90
Q

What combination therapies exist with Tide/Glutide drugs like Dulaglutide (Trulicity®)?

A

Can be given in combination with metformin or glimepiride or thiazolidinediones.

Most GLP-1-RA products can also be administered with insulin

91
Q

Advantages and disadvantages of GLP-1 RA

drugs (Tide/Glutide)?

A

Advantages

  1. HbA1c reduction 1-1.5%
  2. Weight loss
  3. Low/no hypoglycemia risks
  4. Reduction in the risk of cardiovascular morbidity/mortality

Disadvantages

  1. No oral option
  2. Pancreatitis
  3. GI side effects
92
Q

What pharmacological effect do Gliflozin (ie. Empagliflozin (Jardiance®)) drugs have on the body?

A

Sodium-glucose co-transporter 2 inhibitor (SGLT-2 inhibitor)

  1. Reduce the reabsorption of glucose
  2. Increase urinary glucose excretion
  3. Reduce both fasting and post-prandial blood glucose and HbA1c
93
Q

Advantages and disadvantages of SGLT-2 Inhibitors (Gliflozin)?

A

Advantages

  1. No risk of hypoglycemia
  2. Weight loss
  3. Reduction in blood pressure

Disadvantages

  1. Marginal effect on HbA1c (0.5-1% reduction)
  2. Pancreatitis
  3. Hepatic failure
  4. Urinary tract infection
94
Q

Name the two Alpha-glucosidase Inhibitors.

A

Acarbose (Precose®)

Miglitol (Glyset®)

95
Q

Alpha-glucosidase Inhibitors pharmacological effect on the body?

A

Inhibit the alpha-glucosidase intestinal enzyme that hydrolyze carbohydrates to monosaccharides in the small intestine

  1. Delays the absorption of carbs (including glucose) from the GI tract
96
Q

Alpha-glucosidase Inhibitors can be taken on an empty stomach.

True/False

A

False

Must be taken with each meal (usually TID)

GI side effects: Flatulence, diarrhea, abdominal pain

Foundations of Pharmacy Care (12 decks)

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