EXAMS 4 (FINALS) Flashcards
advantages of inhalation route for asthma and COPD drugs
- enhanced therapeutic effect
- minimal systemic effects
- rapid relief for acute attacks
metered dose inhalers
- requires hand breath coordination
- spacers
inhaled corticosteroids / glucocorticoids
- beclomethaSONE
- fluticaSONE
- mometaSONE
- BudeSONIDE
- cicleSONIDE
ADVERSE EFFECTS ARE MINIMAL
oral glucocorticoids
prednisone
prednisolone
methylprednisolone
adverse effect of inhaled glucocorticoids
oropharyngeal candidiasis
dysphonia
slow growth ( DOES NOT AFFECT OVERALL HEIGHT)
adverse effect of oral glucocorticoids
osteoporosis
adrenal suppression
hyperglycemia
peptic ulcers
counseling point for inhaled glucocorticoids (BUDESONIDE)
solution for nebulizer
- rinse mouth and gargle with water after use
- use daily as directed for preventing of exacerbations
- chronic inhaled steroids can decrease the rate of growth in children does not limit overall height
leukotriene modifiers drugs
- ziLEUton
- zafirLUKAST
- monteLUKAST (2nd line therapy for asthma. can be used for allergic riginits and exercise induced bronchospasm)
cromolyn mechanism of action
- mast cell stabilizer
- prevents relapse of histamine and other mediators
- reduce inflammation
CONSDERATION: less effective than glucocorticoids
beta 2 agonists (first line drugs for asthma and copd)
SHORT ACTING (PRN for ongoing attacks)
- albuterol
- levalbuterol
LONG ACTING BETA 2 AGONISTS
- arformoterol
- formorerol
- salmeterol
adverse effect of short acting beta 2 agonist
tachycardia
angina
tremor
adverse effects of long acting beta 2 agonist
- increase risk of severe asthma and asthma related death
- only use in combination with another long term control medication
- NEVER USE ALONE
Long acting Beta 2 agonist role
ASTHMA
- 2nd line therapy
- use with glucocorticoids
COPD
- 1st line therapy
- given on schedule not PRN
methylxanthines (theoPHYLLINE and aminoPHYLLINE) physiologic effects
INDICATIONS: last line therapy in asthma and COPD
bronchodilation
anticholinergic drugs for asthma/COPD
ipraTROPIUM ( can be used with ALBUTEROL)
tioTROPIUM
aCLIDINIUM
umeCLIDINIUM
ADVERSE EFFECTS: dry mouth
besides ipraTROPIUM, DO NOT USE FOR IMMEDIATE RELIEF
treatment goals for asthma
REDUCING IMPAIRMENT
- prevent chronic symptoms
- reduce SABA use to less than 3 days per week
- maintain normal pulmonary function
- maintain normal activity levels
- meet patient and family expectations for care
REDUCING RISK
- prevent recurrent exacerbations
- minimize need for ED visits
- prevent loss of lung function
- maximal benefits with minimal ADEs
severe exacerbations of asthma and COPD
- given oxygen
- systemic glucocorticoid (PO/IM/IV)
- high dose of nebulized SABA
- nebulized ipratropium
- consider magnesium IV
COPD treatment goals (CONSIDER ANTIBIOTIC)
REDUCE IMPAIRMENT
- reduce symptoms
- improve patients health status
- increase exercise tolerance
REDUCING RISK
- reduce mortality
- prevent progression
- prevent exacerbations
role of glucocorticoids (steroids) in metabolism
CARBOHYDRATES
- stimulates gluconeogenesis
- decrease peripheral glucose utilization and glucose update by muscles and adipose cells
- promotes glucose storage
PROTEIN
- break down protein allow amino acids for production of glucose
FAT
- breakdown fat
role of glucocorticoids (steroids) CNS
affect mood
CNS excitation
euphoria
role of glucocorticoids (steroids) Cardiovascular system
- maintain functional integrity of the vascular system
- increase RBC and hemoglobin levels
- increase neutrophil counts
role of glucocorticoids (steroids) STRESS RESPONSE
increase level of glucocorticoids released in order to maintain blood pressure and glucose levels
role of glucocorticoids (steroids) respiratory system in neonates
necessary for lung maturation in preterm infants
drug of choice for mineralocorticoid replacement
fludrocortisone
drug of choice for glucocorticoids
hydrocortisone
prednisone
dexamethasone
what changes should be made to dose in event of stress or illness (GOUCOCORTICOID REPLACEMENT)
dose should be increased according to the 3 by 3 rule
3 by 3 rule = take 3 times the patients normal dosage for 3 days
glucocorticoids replacement
it’s a lifelong therapy
- replacement therapy should mimic normal patterns of glucocorticoids secretion
- take entire daily dose upon waking up
- take 2/3 of the dose in morning and 1/3 in afternoon
drug interactions of glucocorticoids
NSAIDS - increase risk of peptic ulcer disease
INSULIN and oral anti diabetic agents - increase glucose release (may require higher doses of anti diabetic agents)
VACCINES - may decrease efficacy of vaccines
CONTRAINDICATIONS
- systemic fungal infections
- lice virus vaccines due to risk of developing infection
adverse effects of glucocorticoids
- adrenal suppression
- osteoporosis
- glucocorticoids intolerance
- infection
- psychological disturbances (CAN ALSO BE MINIMIZED) (insomnia agitation anxiety = can also be minimized by administering glucocorticoids in the morning
- peptic ulcer disease
- myopathy
what is cosyntropin test
synthetic analog of ACTH used to test adrenal function and diagnose adrenal insufficiency
what test is preferred to diagnose hypothyroidism
serum THS
- diagnose hypothyroid
- monitor treatment of hypothyroid
- differentiate primary and secondary hypothyroid
- serum T4 (but TSH IS PREFERRED)
what tree at is preferred for hyperthyroidism
serum t3
- measures total t3 bound and unbound
USED TO DIAGNOSE HYPERTHYROIDISM
why is management of hypothyroidism in infants and pregnant women especially important
PREGNANCY
- can be difficult to identify due to non specific symptoms, decreases IQ Oof fetus, impairment of other neurological functions MOST DETRIMENTAL IN 1st TRISEMESTER
INFANTS
- fetus cannot produced their own thyroid hormone yet
MEDICATIONS USED TO TREAT HYPOTHYROIDISM
levothyroxine (keep by bed, take when wake up on empty stomach)
liothronine
liotrix
armour thyroid
counseling points for levothyroxine
- take on empty stomach 30 to 6 mins before eating
- monitor TSH 6 to 8 weeks after initiation or dose change
- IV dose is ~ 50% less than PO dose (ORAL IS BETTER)
50 mcg IV = 100 PO
30 PO = 15 IV
IV is half of PO
drug classes for hyperthyroidism
- thionamides
- radioactive iodine
- beta blockers
- non radioactive iodine ( lugol’s solution )
thionamides ( methimazole, porpylthiouracil (PTU) ) mechanism of action
- inhibits the peroxidase enzyme
- prevents oxidation of iodine to iodine
- prevents copping of iodinated tyrosines
PTU has extra mechanism= blocks conversion of t4 or t3 in the periphery (in acute crisis, this is not gonna work alone)
THIONAMIDES DO NOT DESTROY THYROID HORMONE that has already been produced
thionamides adverse effects
- well tolerated
- symptoms of hypothyroid
- agranulocytosis = severe dangerously low WBC count
- hepatotoxicity (PTU)
METHIMAZOLE= considered hazardous agents wear gloves
THIONAMIDES COMPARISON
methimazole = generally 1st line therapy but PRU preferred in pregnancy
- hazardous agent
- long highlife
- use once daily
- cause
PolyThioUracil (PTU) = patient experiencing thyroid storm
- preferred in pregnancy
- short half life so require frequent dosing
- blocks coversion of T4 to t3
RADIOACTIVE IODINE MECHANISM OF ACTION
- isotope 131-I is concentrated in the thyroid gland
- beta particles destroy thyroid tissue but do not leave thyroid gland
- MAXIMAL EFFECTS SEEN IN 2 to 3 MONTHS
ADVANTAGES OF RADIOACTIVE IODINE
- low cost
- avoidance of thyroid surgery
- rare adverse effects
- no damage to non thyroid tissues
NON RADIOACTIVE IODINE ( LUGOL SOLUTION)
- DOES NOT DESTROY TISSUE LIKE RADIOACTIVE IODINE
- iodine is converted to IODIDE in the GI tract before absorption
- IODIDE decreases uptake of iodine into the thyroid gland
- IODIDE suppresses iodination of tyrosine coupling of tyrosine residues
HIGH CONCENTRATIONS INHIBITS RELEASE OF THYROID HORMONE
beta blockers for hyperthyroidism
MOA: used for symptomatic management. dosing is individualized (titration to effect)
PREFERRED BETA BLOCKER FOR HYPERTHYROIDISM
- also prevent conversion t4 to t3 in the periphery
IV - give slowly to avoid hypotension
how are insulins differentiated from one another
tight glycemic control ~ HIGH RATES OF HYPOGLYCEMIA (avoid in patients at high risk for hypoglycemia)
- INTENSIVE THERAPY= glucose levels are maintained in a specific range around the clock
loose glycemic control
- less intensive monitoring
MONITORING TREATMENT of DIABETES MELLITUS
self monitoring blood glucose
- recommended for all patients with DM receiving insulin
- finger stick
HEMOGLOBIN A1c (HgbA1c) - long term management of DM
ONSET AND DURATION OF EACH TYPE OF INSULIN
- short duration ( aspart, lispro )= peak 15-30 mins, short duration of few hours
intermediate duration
long duration = do not display a significant peak and last up to 24 hours
short duration insulin
FAST ACTING
- insulin aspart
- insulin lispro
GIVEN WITH MEALS TO CONTROL POST-
PRANDINAL RISE IN GLUCOSE
GIVE WITH MEALS OR SNACKS
SLOWER ACTING
- insulin regular
- before meals to control post-prandial rise in blood glucose
- IV infusion for management of diabetic ketoacidosis
- duration 6-10 hours
intermediate duration insulin
NPH ( neutral protamine hagedorn) insulin
- cloudy in color can be mixed with short acting
- glucose between meals and overnight
- cannot be used to control mealtime increases in blood glucose
- CONTROL OF BG BETWEEN MEALS AND OVERNIGHT
LONG DURATION INSULIN ( glargine U-100 and U-300, detemir, degludec )
- insulin glargine ( U-100 )
- insulin detemir
between meals and overnight
some time each day
DO NOT EXHIBIT PEAK like NPH does
DECREASES RISK OF HYPOGLYCEMIA
ULTRA LONG (glargine U 300 and degludec)
U-300 is 3 times more concentrated than U-100 formation.
be careful when dealing with these preparations as it can be easy to make an error when dosing
MIXING INSULIN
- short acting should be drawn into the vial first
- draw NPH insulin unit the vial second
INSULIN STORAGE
unopened vials should be kept refrigerated
- vials should never be frozen, IF FROZEN, DISCARD
- opened vials can be kept at a room temperature for 28 days
- avoid shaking insulin vial as this destroys the insulin molecules
INSULIN THERAPY
required for all with TYPE 1
- optional for type 2 diabetes
- drug of choice for gestational DM
more carbs= higher doses
adverse effects of insulin
hypoglycemia
weight gain
hypokalemia
allergic reaction
COUNSELING POINTS INSULIN
- signs and symptoms of hypoglycemia
- use of GLUCAGON if necessary for hypoglycemia
BIGUANIDES DRUG
metformin = drug of choice for initial management of type 2 diabetes
metformin mechanism of action
- inhibits glucose production in the liver
- sensitizes insulin receptors in skeletal and adipose tissue
- reduces glucose absorption in the gut
DOES NOT STIMULATE INSULIN RELASE = LOW RISK OF HYPOGLYCEMIA
METFORMIN adverse effects
- diarrhea
- nausea
- decreased appetite vitamin B12 and folic acid deficiency
- lactic acidosis ( avoid use in patients with significant renal impairment )
monitoring of metformin
- hemoglobin A1c
- GI adverse effects
- Renal functions
COUNSELING POINTS METFORMIN
- do not crush ER tablets
- take with food
- start low doses and titrate up
- GI adverse effects are common but will resolve with continued use
Thiazolidinediones (TZDs) drugs
MOA= cells become more responsive to insulin and therefore blood glucose levels will decrease. insulin must be present for these drugs to work
pioGLITAZONE = preferred in clinical experience rosaGLITAZONE = biggest concern
evaluated by FDA for possible increase in CV including myocardial infarction
Thiazolidinediones adverse effect
do not typically cause hypoglycemia on their own
- monitor liver function tests
ADVERSE EFFECT:
- upper respiratory tract infection
- exacerbation of existing heart failure (DO NOT USE IN PATIENTS WITH SEVERE HF
- hepatotoxicity
Alpha glucose inhibitors (acarbose, miglitol) ADVERSE EFFECT
GI ADVERSE EFFECTS
flatulence
cramps
abdominal distention and bloating
diarrhea
DO NOT CAUSE HYPOGLYCEMIA WHEN USED ALONE
DIPEPTIDYL PEPTIDASE-4 (DPP-4) inhibitors (-GLIPTIN)
- inhinits dipstidyl peptidase (DPP-4) enzyme
- DPP 4 enzymes normally inactivates incretin hormones, by doing such, incretin hormones have a longer duration of action
INCRETIN: stimulates release of insulin and suppresses glucagon secretion. these actions prevent blood glucose levels from rising too high
ADVERSE EFFECT: pancreatitis
COUNSELING
- monitor blood glucose when used with sylfonylurea
- sign and symptoms of pancreatitis
