Final Exam Material Flashcards
ideal body weight equation (males)
IBW = 50 kg + 2.3 (inches over 60”)
ideal body weight equation (females)
IBW = 45.5 kg + 2.3 (inches over 60”)
When do you use ideal body weight for fluids/electrolytes calculations?
If actual body weight >130% of IBW; use actual body weight otherwise
Where does most fluid loss occur in the body?
Skin, lungs, and kidneys
isotonic range
275-290 mOsm/L
What is the administration rate of maintenance fluids?
30-40 mL/kg/day
What tonicity can crystalloids be?
Isotonic, hypotonic, and hypertonic
Which fluids are crystalloids?
Normal saline (NS), 1/2 NS, D5W, lactated ringers (LR)
Which fluids are for resuscitation?
NS and LR
Which fluid is a maintenance fluid?
1/2 NS
Which fluid is for free water replacement and NOT a maintenance fluid by itself?
D5W
What is the most common maintenance fluid?
D5W + 1/2 NS + 20 mEq KCl/L
What tonicity can colloids be?
Hypertonic
Which fluids are colloids?
Albumin (5% or 25%), hetastarch, tetrastarch, blood, Plasmanate
What is albumin 5% used for?
Hypovolemia
What is albumin 25% used for?
Hypoproteinemia
What are signs and symptoms of dehydration?
Tachycardia, hypotension, <0.5 mL/kg/hr urine output, BUN/SCr ratio >20
normal sodium concentration range
135-145 mEq/L
What tonicity can hyponatremia be associated with?
Hypertonic, isotonic, hypotonic
How do you treat symptomatic hypovolemic hypotonic hyponatremia?
NaCl 3%
How do you treat asymptomatic hypovolemic hypotonic hyponatremia?
NaCl 0.9%
What drugs can cause SIADH, which causes isovolemic hypotonic hyponatremia?
Antipsychotics, carbamazepine, SSRIs
How do you treat symptomatic isovolemic hypotonic hyponatremia?
Furosemide and NaCl 3%
How do you treat asymptomatic isovolemic hypotonic hyponatremia?
NaCl 0.9% and water restriction
How do you treat symptomatic hypervolemic hypotonic hyponatremia?
Furosemide and judicious NaCl 3%
How do you treat asymptomatic hypervolemic hypotonic hyponatremia?
Furosemide
What is the maximum increase for serum sodium when treating hyponatremia?
0.5 mEq/L/hr OR 8-12 mEq/L/day
What is the rate of increase for serum sodium in acute hyponatremia?
1-2 mEq/L/hr until symptoms resolve
What is the goal serum sodium for acute hyponatremia?
120 mEq/L
What is the maximum increase for serum sodium when treating acute hyponatremia?
8-12 mEq/L in first 24 hours
How do you treat acute hyponatremia?
NaCl 0.9% (asymptomatic) OR NaCl 3% (symptomatic)
rule of eights
Replace half of sodium deficit in 8 hours, the remaining deficit in 8-16 hours
monitoring for acute hyponatremia
Measure serum sodium concentration Q2-4H until asymptomatic, then Q6-8H until WNL
What tonicity is hypernatremia associated with?
Hypertonic
How do you treat hypovolemic hypernatremia?
-Restore hemodynamic status first (if necessary), then calculate free water deficit
-Treat with D5W and/or enteral free water via feeding tube
hypovolemic hypernatremia monitoring
Check serum sodium concentration Q3-6H for first 24 hours, then check Q6-12H after symptoms resolve and serum sodium concentration <145 mEq/L
How do you treat isovolemic hypernatremia?
Desmopressin or vasopressin
How do you treat hypervolemic hypernatremia?
Stop hypertonic fluids/cause(s) and use a diuretic if needed
normal potassium concentration range
3.5-5 mEq/L
How do you treat hypokalemia at a range of 3-3.4 mEq/L?
Oral potassium for patient with cardiac conditions
How do you treat hypokalemia at a range of <3 mEq/L?
-PO for asymptomatic patients
-IV for symptomatic patients and those who cannot tolerate PO
What are the appropriate rates of administration for potassium correction treatment?
-10 mEq/hr without cardiac monitoring
-20 mEq/hr with cardiac monitoring
-40-60 mEq/hr if emergency with severe hyperkalemia
How do you treat hyperkalemia?
-Calcium
-Albuterol, Bicarb, Insulin and Glucose
-Kayexalate/Lokelma, Diuretics (furosemide), Renal unit for dialysis Of Patient
normal magnesium concentration range
1.5-2.5 mg/dL
In hypomagnesemia, what should you treat before giving the patient magnesium medications?
Associated electrolyte disturbances (especially potassium)
What are the treatment options for asymptomatic patients with >1 mg/dL of magnesium presenting with hypomagnesemia?
-Milk of magnesia 5-10 mL PO QID
-Magnesium oxide 800 mg PO QD or 400 mg PO TID with meals
What are the treatment dosages for symptomatic patients or patients who cannot tolerate oral route presenting with hypomagnesemia?
-1-2 mg/dL –> 0.5 mEq/kg
-<1 mg/dL –> 1 mEq/kg
normal calcium concentration range
8.5-10.5 mg/dL
How do you treat acute hypocalcemia?
-100-300 mg elemental calcium IV over 5-10 minutes
-administer 1 gm/hr
-correct hypomagnesemia
How do you treat chronic hypocalcemia?
-1-3 g/day of elemental calcium (i.e., CaCO3 650 mg PO QID = 1 g elemental calcium/day)
-calcitriol 0.25 mcg PO QD/QOD (may need to increase by 0.25 mcg Q4-8W to 1 mcg PO QD)
normal phosphorus concentration range
2.5-4.5 mg/dL
How do you treat mild to moderate (1-2 mg/dL) hypophosphatemia?
-30-60 mMol/day of Phos-NaK BID/TID
-5 mL diluted Fleets Phospho-Soda BID/TID
How do you treat severe (<1 mg/dL) hypophosphatemia?
-if potassium <4 mEq/L –> KPhos
-if potassium ≥4 mEq/L –> NaPhos
What is the maximum rate of infusion for IV phosphorus?
7 mMol/hr
What part of the kidney is the major reabsorption site?
Proximal tubule
How do NSAIDs affect the afferent and efferent arterioles?
-constricts afferent arteriole (decreased vasodilatory prostaglandins)
-constricts efferent arteriole (increased angiotensin II)
How do ACEi/ARBs affect the afferent and efferent arterioles?
-slightly dilates afferent arteriole (slightly increased vasodilatory prostaglandins)
-dilates efferent arteriole (decreased angiotensin II)
nephritic syndrome
inflammation disrupting glomerular basement membrane
nephrotic syndrome
podocyte damage leading to glomerular charge-barrier disruption
signs and symptoms of nephritic syndrome
-increased hematuria
-red blood cell casts present
signs and symptoms of nephrotic syndrome
-increased edema
-increased proteinuria
-low serum albumin
What diuretic drug classes are potassium-wasting?
Carbonic anhydrase inhibitors, osmotic diuretics, sodium-potassium-chloride symport inhibitors (loop diuretics), sodium-chloride symport inhibitors (thiazides)
carbonic anhydrase inhibitors suffix
-amide
osmotic diuretic drugs
-mannitol
-isosorbide
-glucose
-glycerine
loop diuretic drugs
-bumetanide
-torsemide
-ethacrynic acid
What diuretic drug classes are potassium-sparing?
Renal epithelial sodium channel inhibitors, mineralocorticoid receptor antagonists, vasopressin antagonists
renal epithelial sodium channel inhibitor drugs
-amiloride
-triamterene
mineralocorticoid receptor antagonists suffix
-one
normal SCr (men)
0.74-1.35 mg/dL
normal SCr (women)
0.59-1.04 mg/dL
normal BUN
6-24 mg/dL
normal CrCl (men)
110-150 mL/min
normal CrCl (women)
100-130 mL/min
normal eGFR
≥60
normal vitamin D concentration
≥50 ng/mL
normal PTH concentration
10-55 pg/mL
normal hemoglobin (men)
14-18 g/dL
normal hemoglobin (women)
12-16 g/dL
normal transferrin saturation (TSAT) (men)
20-50%
normal transferrin saturation (TSAT) (women)
15-50%
normal ferritin (men)
24-336 mcg/L
normal ferritin (women)
11-307 mcg/L
normal mean corpuscular volume (MCV)
80-100 fl
normal red cell distribution width (RDW) (men)
11.8-14.5%
normal red cell distribution width (RDW) (women)
12.2-16.1%
When can you not use the Cockroft and Gault formula to estimate CrCl?
acute kidney injury (AKI)
Cockroft and Gault equation (men)
CrCl = ((140-age) x IBW)/(SCr x 72)
Cockroft and Gault equation (women)
CrCl = CrCl for men x 0.85
adjusted body weight equation
AjBW = IBW + 0.4(ABW - IBW)
calcium-containing phosphate binders
Calcium carbonate (Tums) and calcium acetate (PhosLo)
What percentage elemental calcium does calcium carbonate have?
40%
calcium carbonate dosing
500 mg PO TID with meals
calcium carbonate maximum dose
1500 mg/day
What percentage elemental calcium does calcium acetate have?
25%
calcium acetate dosing
2-3 tablets PO TID with meals
non-calcium-containing phosphate binders
Sevelamer carbonate (Renvela), lanthanum carbonate (Fosrenol), sucroferric oxyhydroxide (Velphoro), Auryxia (ferric citrate), aluminum hydroxide (Amphojel), magnesium carbonate (Mag-Carb), nicotinic acid, nicotinamide
Which non-calcium-containing phosphate binder should you NOT use?
aluminum hydroxide (Amphojel)
unactivated vitamin D medications
ergocalciferol (calciferol), cholecalciferol
activated vitamin D medications
calcitriol (Rocaltrol and Calcijex), paricalcitol (Zemplar), doxercalciferol (Hectorol)
Which vitamin D medication requires activation by the liver (prodrug)?
doxercalciferol (Hectorol)
Should hemoglobin or hematocrit be used to assess anemia?
hemoglobin
What are the KDIGO guidelines for initiation of iron supplementation?
TSAT <30% and ferritin <500 ng/mL
What is the preferred agent for intravenous iron?
iron sucrose (Venofer)
When should erythropoiesis stimulating agents (ESAs) be used in CKD patients?
-hemoglobin <10 g/dL and falling at rapid rate (stage 3-5 without dialysis)
-hemoglobin 9-10 g/dL (stage 5 with dialysis)
What are the indications for renal replacement therapy (RRT)?
Acid/base balance
Electrolyte balance
Intoxication
Overload of fluids
Uremia
What substances are not removed during hemodialysis?
High volume of distribution, high lipophilicity, large molecular weight, highly protein bound
What are the different types of peritoneal dialysis?
CAPD
CCPD
NIPD
TPD
Which type of peritoneal dialysis does not require a machine?
CAPD
What are the common manifestations of diabetes?
polydipsia
polyuria
polyphagia
ketoacidosis
What is the role of the alpha-subunit of the insulin receptor?
repress catalytic activity of the beta-subunit
How does somatostatin affect glucose secretion?
inhibits glucose secretion
What is the role of the beta-subunit of the insulin receptor?
cause autophosphorylation of the other beta-subunit
What is the molecular target of thiazolidinediones?
peroxisome proliferator-activated receptor gamma (PPARgamma)
thiazolidinedione adverse effects
-cardiovascular toxicities
-risk of bladder cancer (pioglitazone)
-hepatotoxicity
What is the molecular target of sulfonylureas?
potassium channels
sulfonylurea adverse effects
-hypoglycemia
-risk of cardiovascular events
-GI side effects
-weight gain
What drugs cause hypoglycemia?
-alcohol
-high dose salicylates
-beta adrenergic blockers
-ACE inhibitors
-fluoxetine
-somatostatin
-anabolic steroids
-MAO inhibitors
What drugs cause hyperglycemia?
-oral contraceptives
-corticosteroids
-epinephrine
-thiazide diuretics
-catecholamines
-glucocorticoids
-thyroid hormone
-calcitonin
-somatropin
-isoniazid
-phenothiazines
-morphine
What is the molecular target of glinides?
potassium channels
What is the molecular target of metformin?
mitochondrial complex I
How does metformin decrease blood glucose levels?
-inhibits gluconeogenesis
-increases translocation of GLUT4 to cell surface –> increased glucose uptake into cells
What is the effect of alpha-glucosidase inhibitors?
decreased absorption of carbohydrates from the intestine
What is the effect of SGLT2 inhibitors?
decreased reabsorption of glucose into blood –> increased excretion of glucose in urine
What are resistin levels in patients with type 2 diabetes?
elevated
What are the effects of resistin?
Stimulates glucose excretion by the liver and increases insulin resistance
What are adiponectin levels in patients with type 2 diabetes?
lowered
What are the effects of adiponectin?
Reduces blood glucose and insulin resistance
What are TNFalpha levels in patients with type 2 diabetes?
elevated
What are the effects of TNFalpha?
Stimulates lipolysis in white adipose tissue (WAT) and increases insulin resistance in skeletal muscle
What is the effect of GLP-1 analogs?
decreased glucagon release
What are the effects of amylin?
-suppresses appetite
-slows gastric emptying
-inhibits glucagon release
What chemical change causes insulin resistance in obesity?
phosphorylation with serine instead of tyrosine
What hormones cause insulin resistance in pregnancy?
-CRH
-cortisol
-progesterone
-placental GH
-placental lactogens
diagnostic criteria for diabetes mellitus (need at least two)
-fasting blood glucose (FBG) ≥126 mg/dL OR
-A1c ≥6.5% OR
-random glucose ≥200 mg/dL with symptoms of diabetes OR
-2 hour postprandial glucose ≥200 mg/dL during oral glucose tolerance test (OGTT)
What are the microvascular diseases resulting from diabetes?
-diabetic kidney disease
-ocular complications
-neuropathy
normal urine albumin-creatinine ratio (UACR)
<30 mg/g
microalbuminuria screening
-patients with type 1 diabetes for ≥5 years or patients with type 2 diabetes –> annually
-UACR >300 mg/g and/or eGFR <60 –> biannually
-non-pregnant patients with UACR ≥300 mg/g or eGFR <60 –> prescribe ACEi/ARB
diabetic kidney disease treatment
-SGLT2 inhibitor (first-line; with type 2 diabetes with/without kidney disease)
-GLP-1RA (second-line)
-mineralocorticoid receptor antagonist (with CKD and albuminuria and at risk for cardiovascular events)
eye exam frequency for diabetic patients
-initial eye exam within 5 years of diagnosis (type 1 diabetes)
-initial eye exam at diagnosis (type 2 diabetes)
-if no evidence of retinopathy for ≥1 annual exam and glycemia controlled –> assess Q1-2Y
-if retinopathy present –> assess annually (at least)
peripheral neuropathy testing
-assess within 5 years of diagnosis (type 1 diabetes)
-assess at diagnosis (type 2 diabetes)
-annual monofilament testing
neuropathy treatment
-pregabalin, duloxetine, or gabapentin (first-line)
-tricyclic antidepressants, venlafaxine, carbamazepine, tramadol, capsaicin, or tapentadol (second-line)
What are the macrovascular diseases resulting from diabetes?
-cardiovascular disease
-stroke
-peripheral vascular disease
-periodontal disease
treatment for patients with diabetes and atherosclerotic cardiovascular disease (ASCVD) and/or heart failure
-SGLT2 inhibitor OR
-GLP-1RA
What is the blood pressure goal for pregnant patients with diabetes?
110-135/85 mm Hg
statin dosing for diabetic patients
-none to moderate intensity statin based on risk factors (for patients ages 20-39 with no ASCVD)
-moderate intensity statin (for patients ages 40-75 with no ASCVD)
-high intensity statin (for patients ages 40-75 with ≥1 risk factor)
-high intensity statin and lifestyle modifications (for patients with ASCVD)
secondary prevention of CVD in patients with diabetes and history of CVD
-aspirin (first-line; 75-162 mg/day)
-clopidogrel (if aspirin allergy)
Who can be considered for use of aspirin with primary prevention of CVD?
patients ≥50 years old with one major risk factor who are not at increased risk of bleeding
fasting blood glucose goal for diabetic patients
80-130 mg/dL
A1c goal for diabetic patients
-7% (ADA guidelines; consider 6% for some patients and pregnant women)
-≤6.5% (AACE guidelines)
A1c monitoring
-biannually (if at treatment goal)
-quarterly (if therapy changed or not at treatment goal)
What insulin is preferred for intravenous administration?
regular insulin
How long are insulin vials stable at room temperature for?
28 days (42 days for detemir)
How long are prefilled insulin syringes stable with refrigeration for?
28 days
How long are prefilled insulin syringes stable at room temperature for?
10-28 days
How long is regular/NPH mixture stable for?
7 days with refrigeration
How long is ultra short-acting/NPH mixture stable for?
need to give ASAP
rule of 15s
-start with 15 gm of fast-acting carbohydrates unless blood glucose <50 mg/dL (use 30 gm instead)
-wait 15 minutes –> check blood glucose –> if blood glucose <80 mg/dL, then repeat with another 15 gm of fast-acting carbohydrates
What are examples of 15 gm of fast-acting carbohydrates?
-4 oz orange juice
-6 oz Coke
-5-6 lifesavers
-2 tsp sugar
-1 tbsp honey
-4 glucose tablets
What should you do after treating a hypoglycemic event?
-if meal ≤1 hour away, eat meal
-if meal >1 hour away, eat 30 gm carbohydrate snack
At what blood glucose level should you use glucagon?
<54 mg/dL
How do you change doses from QD NPH to a(n) (ultra) long-acting insulin?
1:1
How do you change doses from BID NPH to a(n) (ultra) long-acting insulin?
decrease dose by 20%
How do you change doses from U-100 insulin to a concentrated insulin?
1:1
How do you change doses from BID NPH to glargine U-300?
decrease dose by 20%
How do you change doses from QD glargine or detemir to QD concentrated glargine?
may need to increase dose of QD concentrated glargine
How do you change doses from U-100 basal-bolus regimen to U-500 regimen?
-if A1c ≥8% –> 1:1
-if A1c ≤8% –> decrease dose by 20%
What is the average daily dose of insulin for type 1 diabetes?
0.5-0.6 units/kg/day
What is the “honeymoon phase” dose of insulin for type 1 diabetes?
0.1-0.4 units/kg/day
What is the distribution for basal-bolus regimen for type 1 diabetes?
-50-70% basal insulin
-30-50% bolus insulin
What is the distribution for BID regular/NPH mixture for type 1 diabetes?
-40% NPH and 15% regular (morning)
-30% NPH and 15% regular (night)
What is the starting dose of insulin for type 2 diabetes?
-0.1-0.2 units/kg/day OR 10 units/day (ADA guidelines)
-0.1-0.2 units/kg/day (AACE guidelines; if A1c <8%)
-0.2-0.3 units/kg/day (AACE guidelines; if A1c >8%)
How do you adjust basal insulin dose for type 2 diabetes?
increase dose by 2 units Q3 days to reach fasting blood glucose goal
bolus insulin for type 2 diabetes
-consider for patients taking ≥0.5 units/kg/day of basal insulin
-start with 10% of basal dose OR 4-5 units of (ultra) short-acting insulin with largest meal
-adjust dose 10-15% Q3-4 days
rule of 500
500/total daily dose of insulin = gm of carbohydrates
rule of 1800 (only for ultra short-acting insulin)
1800/total daily dose of insulin = # of mg/dL blood glucose will drop for every 1 unit of insulin
rule of 1500 (only for regular insulin)
1500/total daily dose of insulin = # of mg/dL blood glucose will drop for every 1 unit of insulin
Somogyi effect
nocturnal hypoglycemia with rebound hyperglycemia
metformin cautions for use/contraindications
-renal dysfunction (use eGFR for dosing)
-acute decompensated hospitalized, unstable, or severe renal/hepatic disease heart failure patients
-alcoholics
-post myocardial infarction
-hepatic failure
-surgery/radiologic procedure with contrast dye (hold 1-2 days before and ~2 days after depending on patient status)
-COPD
-shock
metformin dosing
-start with 500 mg PO BID or 850 mg QD with meals
-titrate Q1-2W by 250-500 mg/day
-maximum dose: 2 gm/day
How often should you monitor serum creatinine if a patient’s eGFR is ≥60?
annually
How often should you monitor serum creatinine if a patient’s eGFR is 45 ≤ x < 60?
every 3-6 months
Can you start metformin if a patient’s eGFR is 30 ≤ x < 45?
No
How do you adjust the dose of metformin if a patient’s eGFR is 30 ≤ x < 45?
decrease dose by 50%
How often should you monitor serum creatinine if a patient’s eGFR is 30 ≤ x < 45?
every 3 months
Can you take metformin if a patient’s eGFR <30?
No
SGLT2 inhibitor adverse effects
-urinary tract infections
-genital fungal infections
-increased urination
-hypotension
-increased cholesterol
-diabetic ketoacidosis
-bone fractures and decreased bone mineral density (canagliflozin)
-acute kidney injury (canagliflozin and dapagliflozin)
-increased risk of foot and leg amputations (canagliflozin)
What patients cannot take SGLT2 inhibitors?
patients with end-stage renal disease (ESRD) on hemodialysis
How should SGLT2 inhibitors be managed if a patient is undergoing surgery?
-hold 3 days before surgery (4 days for ertugliflozin)
-restart once oral intake is back to baseline and other factors have resolved
GLP-1 agonist contraindications
-chronic pancreatitis
-personal/family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2
-pre-existing gallbladder disease
-gastroparesis
-proliferative diabetic retinopathy
Rybelsus dosing
3 mg PO QD for 30 days, then 7 mg PO QD
maximum dose of Rybelsus
14 mg/day (7 mg/day if on Ozempic 0.5 mg SQ QW)
DPP-4 inhibitor adverse effects
-nasopharyngitis
-upper respiratory tract infections
-headache
-acute pancreatitis
-joint pain
-heart failure (except for sitagliptin)
When should you start dual therapy for diabetes?
A1c >9%
What is the insulin dosing for pregnancy patients with gestational diabetes?
0.7-1.0 units/kg/day
What is the second-line treatment for pregnancy patients with gestational diabetes?
metformin
What diabetes medication should be avoided for pregnancy patients with gestational diabetes?
sulfonylureas
A1c goal for elderly patients
<8.0%
fasting blood glucose goal for elderly patients
90-150 mg/dL
bedtime glucose goal for elderly patients
100-180 mg/dL
How should basal insulin be adjusted before a patient’s surgery?
-decrease dinnertime basal insulin dose by ~25%
-give 75-80% of dose the morning of surgery
How should metformin be adjusted before a patient’s surgery?
hold day of surgery
How should oral glucose lowering medications be adjusted before a patient’s surgery?
hold the morning of surgery
How should NPH insulin be adjusted before a patient’s surgery?
give 50% of dose the morning of surgery
Who does diabetic ketoacidosis usually occur in?
type 1 diabetes patients
What commonly causes diabetic ketoacidosis?
-poor adherence to treatment regimen
-infection (most commonly UTIs)
diabetic ketoacidosis symptoms
-nausea/vomiting
-abdominal pain
-changes in mental status
-fruity breath
-Kussmaul respirations
-coma
What is the diabetic ketoacidosis triad?
hyperglycemia
hyperketonemia
metabolic acidosis
What are the goals of treatment for diabetic ketoacidosis?
-restore circulatory volume
-inhibit ketogenesis and return of normal glucose metabolism
-correct electrolyte imbalances
How should you administer fluids to a patient with diabetic ketoacidosis?
-administer NS at 500-1000 mL/hr for first 1-4 hours
-evaluate corrected sodium at 2-4 hours
-if corrected sodium is normal/high –> change to 1/2 NS and decrease rate by 50%
-if corrected sodium is low –> continue NS and decrease rate by 50%
-when blood glucose approaches 200 mg/dL, change to D5W and 1/2 NS at 150-200 mL/hr until ketoacidosis resolved
How should you administer insulin to a patient with diabetic ketoacidosis?
-start 0.1 units/kg/hour with/without bolus of 0.1 units/kg
-if glucose does not fall by ≥10% in the first hour, give, repeat, or increase bolus dose
When can you switch a patient from IV to SQ insulin in diabetic ketoacidosis?
-blood glucose <200 mg/dL AND (at least two of the following criteria)
-anion gap closes ≤12 mEq/L
-bicarbonate level ≥15 mEq/L
-venous pH >7.3
How do you dose a patient on SQ insulin for diabetic ketoacidosis?
-0.5-0.8 units/kg/day (50/50 basal/bolus; insulin naïve patients)
-total amount of IV insulin and convert to daily requirement using basal/bolus OR Q6H NPH insulin
How long should IV and SQ insulin be overlapped in patients with diabetic ketoacidosis to prevent rebound ketoacidosis or hyperglycemia?
2-4 hours
anion gap equation
anion gap = sodium - (chloride + bicarbonate)
At what potassium level should insulin NOT be started for patients with diabetic ketoacidosis?
<3.3 mmol/L
When should bicarbonate be repleted in patients with diabetic ketoacidosis?
pH <6.9
What are the goals of treatment for HHS?
-restore circulatory volume
-restore urine output to ≥50 mL/hour
-return blood glucose to normal
How should you administer fluids to a patient with HHS?
-administer 1/2 NS OR NS at 500-1000 mL/hr for first 1-4 hours
-evaluate corrected sodium at 2-4 hours
-if corrected sodium is normal/high –> reduce rate
-if corrected sodium is low –> consider NS
-when blood glucose is 300 mg/dL, change to D5W and 1/2 NS at 150-200 mL/hr until resolution of HHS
What type of insulin is available in insulin cartridges?
rapid-acting insulin
What does a higher gauge needle indicate?
thinner needle
How many units should you prime an insulin pen with?
2 units
How many units should you prime Humulin R U-500 KiwkPen with?
5 units
How many units should you prime Toujeo Max SoloStar U-300 with?
4 units
How many units should you prime Toujeo SoloStar U-300 with?
3 units
What devices are available for patients with a fear of needles?
-TickleFLEX
-NovoFine Autocover pen needles
-Autoshield Duo pen needles
What are adverse reactions of Afrezza?
-hypoglycemia
-cough
-throat pain or irritation
What are contraindications for Afrezza?
asthma and/or COPD
What GLP-1 agonists are dosed QD/BID?
-Byetta (BID; exenatide IR)
-Victoza (QD; liraglutide)
Which non-insulin injectables are auto-injectors?
-Trulicity
-Bydureon BCise
-Mounjaro
Which non-insulin injectable has pen needles included?
Ozempic
Is reconstitution required for glucagon injections?
Yes
Is inhalation required for Baqsimi?
No
What medications may result in more adverse events than benefits in older adults?
-sedative/hypnotics
-neuroleptics/antipsychotics
-antidepressants
-opioids (especially long-acting)
-loop diuretics
-alpha blockers
What is the most common type of urinary incontinence in both men and women?
urge
Is stress urinary incontinence more common in men or women?
women
What causes urge urinary incontinence?
hyperactivity of detrusor muscle
What causes stress urinary incontinence?
outlet incompetence with abdominal pressure
What causes overflow urinary incontinence?
outlet obstruction, inability to urinate, or uncoordinated detrusor constriction
Is aging a barrier to medication nonadherence?
No
What are physiologic changes in elderly patients?
-decreased total body water
-decreased lean body mass
-increased body fat
-decreased baroreceptor response/activity
-reduced heart rate variability
-decreased hepatic blood flow
-decreased renal blood flow
-decreased neurotransmitter volume
How does aging affect the volume of distribution of water-soluble drugs?
decreases
How does aging affect the concentration of water-soluble drugs?
increases
How does aging affect the volume of distribution of lipid-soluble drugs?
increases
How does aging affect the half-life of lipid-soluble drugs?
increases
How does aging affect the clearance of hepatically cleared drugs?
decreases
How does aging affect the half-life of hepatically cleared drugs?
increases
How does aging affect the clearance of renally cleared drugs?
decreases
How does aging affect the half-life of renally cleared drugs?
increases
Who is involved in the decision-making process of the BEERS criteria?
Interprofessional panel of 12 experts in geriatric care and pharmacotherapy
How does the committee describe the quality of evidence for the BEERS criteria?
GRADE-based approach
What are the three phases of platelet activation?
platelet adhesion
platelet secretion
platelet aggregation
What chemical inhibits thrombogenesis?
PGI2 (prostacyclin)
What chemicals are released from platelet granules to bind to ADP receptors?
ADP
TXA2
5-HT (serotonin)
What chemical are platelets cross-linked by?
fibrinogen
What is the molecular target of clopidogrel, prasugrel, and ticagrelor?
P2Y12 receptor
What drugs bind irreversibly to the P2Y12 receptor?
clopidogrel and prasugrel
What drug binds reversibly to the P2Y12 receptor?
ticagrelor
What is the molecular target of abciximab and eptifibatide?
GP IIb/IIIa receptor
What is the molecular target of dipyridamole and cilostazol?
cAMP phosphodiesterase
What converts prothrombin to thrombin?
factor Xa (prothrombin activator)
What does prothrombin time measure?
How long it takes for clot to form in blood sample
What does bleeding time evaluate?
Platelet function
What does activated thromboplastin time measure?
How long it takes for blood to form clot
What is the normal INR value for patients not taking anticoagulants?
1.0
What is the INR therapeutic range for patients taking anticoagulants?
2.5-3.5
What is the difference between the mechanism of actions of heparin and low molecular weight heparins?
Low molecular weight heparins can only bind factor Xa, whereas heparin can bind thrombin and factor Xa
What is the molecular target of warfarin?
vitamin K epoxide reductase (VKORC1)
What is plasminogen?
Anticoagulant protein that circulates in inactive form
What is plasmin?
Proteolytic enzyme that digests fibrin and fibrinogen
Which drug lacks the fibrin binding domain?
reteplase
Is alteplase or tenecteplase more selective?
tenecteplase
What is the molecular target of tranexamic acid and lysine?
lysine binding sites on plasminogen molecules
What is the molecular target of aminocaproic acid?
Kringle domain of plasminogen
Does all deep vein thrombosis lead to pulmonary embolisms?
No
Do all pulmonary embolisms lead to deep vein thrombosis?
Yes
indirect thrombin inhibitor drugs
-heparin
-low molecular weight heparin (enoxaparin)
heparin dosing
80 units/kg (IV bolus) followed by 18 units/kg/hr (infusion)
heparin monitoring
activated partial thromboplastin time (aPTT)
characteristics of heparin associated thrombocytopenia (HAT)
-HIT type I
-non-immune mediated
-mild decrease in platelets
-occurs around 48-72 hours after administration of heparin
-transient
-do not need to discontinue heparin
characteristics of heparin induced thrombocytopenia (HIT)
-immune mediated
-thrombotic complications
-occurs between 7-14 days after administration of heparin
-platelets drop >50% from baseline or <100,000/mm
-need to discontinue heparin
Is monitoring required for low molecular weight heparins?
No
What is the enoxaparin dosing for prophylaxis?
-30 mg SQ Q12H (surgery)
-40 mg SQ QD (medical)
What is the enoxaparin dosing for treatment?
-1 mg/kg SQ Q12H
-1.5 mg/kg SQ QD
indirect factor Xa inhibitor drug
fondaparinux
direct factor Xa inhibitor drugs
-lepirudin
-bivalirudin
-argatroban
