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Simmons NURP 423 Exam 2 > Heme/Endocrine > Flashcards

Heme/Endocrine Flashcards

1
Q

What lab parameters are you looking out for iron deficiency anemia?

A

NORMAL - Hemoglobin: women >12g/dL, pregnant>11 g/dL, men >13g/dL - Reticulocyte Count: Women: 0.8-2 RBC Men: 0.8-2.3 RBC ABNORMAL - TIBC elevated >400mcg/dL - Ferritin <120ng/L (goal >500ng/L)

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2
Q

What would microcytic or macrocytic mean corpuscular volume (MCV) indicate?

A

Microcytic <79fL: thalssemia low ferritin iron deficiency Macrocytic >96fL: folate deficiency Vit B12 deficiency

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3
Q

What labs are you monitoring for folate deficiency?

A
  • goal for serum folate level>4ng/mL - elevated homocystein level means low folic acid
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4
Q

What labs are you monitoring for Vit D levels? When would you have f/u labs?

A

25 (OH)D goal 30-32ng/dL deficient <20ng/dL severe deficiency < 12 ng/dL toxicity > 150 ng/dL - 3 months of therapy

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5
Q

What labs are you monitoring for Vit B-12 deficiency?

A

Serum B-12 assay, normal 150-200 pg/mL ABNORMAL: high methylmalonic acid (MMA)

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6
Q

What would you give for iron deficiency anemia? What are some common SE of this med?

A

Ferrous Sulfate 325mg (65mg elemental iron) 3x/day - n/v/d/constipation - may stain teeth

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7
Q

What are monitoring parameters for Ferrous Sulfate?

A

Ferritin goal >500 ng/L & H/H in range - up to 6-8 weeks for Hb to improve, even as long as 6 months - retuculocytosis in 7- 10 days

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8
Q

When is Ferrous Sulfate contraindicated?

A

hemochromatosis hemolytic anemia

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9
Q

What medications affect absorption of Ferrous Sulfate?

A
  • Chelation: levodopa, penicillin, fluorquinolones. - Decreased absorption: Calcium (antacids, milk), aluminum and magnesium, cimetidine, methyldopa & tetracyclines.
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10
Q

When is Vit B-12 supplement indicated?

A
  • pernicious anemia - Crohn’s - Gastric bypass
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11
Q

What are some causes of Vit B-12 deficiency?

A

Poor diet Lack of intrinsic factor ETOH Wt loss sx H pylori Crohns dx Fish tapeworm

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12
Q

What are monitoring parameters for B-12 replacement?

A

Serum B-12 assay (N 150-200pg/mL) Less than 200 is deficient 7-10 days for reticulocytosis Hct rise in 2 weeks & normal in 2mo

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13
Q

When is ORAL B-12 not recommended?

A

Oral vitamin B12 is not recommended for pernicious anemia, due to insufficient absorption due to lack of intrinsic factor.

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14
Q

Why is early diagnosis of B-12 deficiency important?

A

-early dx is important bc neuro deficits can occur: i.e. unsteady gait, paresthesia, slow thinking (first in extremities then moves up) if left untreated can be irreversible

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15
Q

Who should receive folic acid replacement indefinitely?

A

Patients w/hemolytic anemia, malabsorption or chronic malnutrition should receive oral folic acid indefinitely.

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16
Q

Why is folic acid important prenatal & during pregnancy?

A

prevent birth defects of brain and spinal cord

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17
Q

What medications would you need to increase your folic acid intake with?

A

methotrexate dilantin

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18
Q

What is the MOA of unfractionated heparin?

A

Bind to antithrombin III, inactivate Factor 2A and 10A, clotting cascade pathway Inactivate thrombin and prevent conversion of fibrinogen to fibrin

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19
Q

When would is Heparin indicated?

A

Undergo surgery or hemodialysis

Tx of thrombosis

Prophylaxis of VTE

Given inpatient

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20
Q

What are side effects of Heparin?

A

Bleeding

Heparin induced thrombocytopenia

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21
Q

What are monitoring parameters for Heparin? What is the antidote?

A

Bleeding

Heparin induced thrombocytopenia

aPTT

Subsequent tx of warfarin

Antidote: IV protamine sulfate

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22
Q

What meds are low molecular weight heparin? What’s the MOA?

A

enoxaparin

dalterparin

tinzaparin

Anticoagulant effect via binding to antithrombin which irreversibly inactivates clotting factor Xa

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23
Q

When would is low molecular weight heparin indicate?

A

Treatment & secondary prevention of VTE

Treatment of ACS

Prevent clot formation

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24
Q

What are monitoring parameters and antidote of low molecular weight heparin?

A

May need Subsequent tx of warfarin

Can monitor by anti-Za activity but shown to be linearly related so no need to monitor

Antidote: IV protamine sulfate

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25
Q

What are patient education for LMWH?

A

Ensure someone reliably & accurately administer sq injection

on or arrange HH

Monitor for heparin-induced thrombocytopenia

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26
Q

What is the MOA of warfarin/Coumadin?

A

Vitamin K Antagonist

Inhibit activation of clotting factors that depend on Vit K (factors 2,7,9,10)

Completely inhibits VKORC1 that activates Vt K in body, depletes reserves & reduce synthesis of clotting factors

27
Q

Who is warfarin best indicated for?

A

Prevention of valve thrombosis w mechanical heart valves, prevention of VTE in ortho sx, & tx & secondary prevention of VTE

Preferred for those w renal disease

Best for those who can’t take novel anticoag:

ESRD

Mechanical valves

28
Q

What are monitoring parameters for warfarin?

A

Check INR, long onset of effect

Goal: INR 2-3

(2.5 -3.5 for prosthetic heart valves or hypercoagulable conditions)

Labs:

Daily for 2 consecutive days, Dose change q3 days then 2x/weeks for few weeks then monthly

(usually pair w UFH or LMWH for acute DVT/PE)

Start at 5mg/day or lower based on co-morbidities: elevated liver enzymes, >75yo, thyroid status

29
Q

What population is warfarin contraindicated or cautioned with? What is the antidote?

A

Pregnancy X

Caution w fall risk, dementia, HTN

Antidote Vitamin K

30
Q

What drugs affect warfarin?

A

These drugs decrease effect:

(risk for thrombus)

OCPs

Carbamazepine

Barbiturates

Antifungals

These drugs increase effect:

(risk for bleeding)

SSRI’s

Fluoroquinolones, Bactrim (reduce by 50% then check lab in 3d)

NSAIDS

31
Q

What drugs are Direct Thrombin Inhibitor Anticoagulants? What is their MOA?

A

Prevent fibrinogen to fibrin by thrombin

dabigatran etexilate

(Pradaxa)

Only oral

32
Q

When are Direct Thrombin Inhibitor Oral Anticoagulants indicated?

A

CVA & thromboembolism prevention

Prophylaxis, reduce risk, & tx DVT & PE

33
Q

Do any of the Direct Thrombin Inhibitor Oral Anticoagulants have an antidote? What labs are you checking before starting medication?

A

Pradaxa only med in class w antidote (Praxbind)

However, to reverse bleeding for those without antidote only can d/c med, RBC transfusion, & explore source of bleeding

Before initiation check:

PT, PTT, platelet, Cr <15

34
Q

What are some drug/drug interactions with Direct Thrombin Inhibitor Oral Anticoagulants

A

P-glycoprotein inhibitors

(risk for bleeding)

ketoconazole

verapamil

P-glycoprotein inducers

(risk for clots)

phenytoin

rifampin

35
Q

What meds are Factor Xa Inhibitors? What’s the MOA?

A

Bind directly to factor Xa [-xaban]

rivaroxaban (Xarelto)

apixaban

(Eliquis)

edoxaban

(Savaysa)

36
Q

What are some drug/drug interactions with Factor Xa inhibitors?

A

Contraindicated w dual inhibitors of CYP-3A4 & P-glycoprotein

(risk for bleeding)

Antifungals

ritonavir

Contraindicated w dual inducers of CYP-3A4 & P-glycoprotein

(risk for clot)

phenytoin

rifampin

37
Q

What are potential causes of hypothyroidism?

A

Failure of thyroid gland itself (Primary hypothyroidism)

Pituitary or hypothalamic disease (secondary or tertiary hypothyroidism)

Drugs: Amiodarone, Lithium

Radiation

Iodine deficiency

Chronic autoimmune thyroiditis (Hashimoto’s)

Primary hypothyroidism

Elevated TSH

Low T4

Secondary hypothyroidism

Pituitary dysfunction

Low T4

Low TSH

Tertiary hypothyroidism

Due to hypothalamus

Low T4

Low TSH

38
Q

What are TSH goals?

A

TSH goal is 0.5-4.0mIU/mL. Some resources say high normal of 2.5 (p811)

39
Q

When do you check labs for TSH?

A

In reading:

<65yo dose levothyroxine 1.6mcg/kg (round to nearest 25mcg)

> 65yo OR cardiac disease, start at 12.5-25mcg per day

Check TSH every 3 months (textbook) until normal then once a year, check T4 only if they still have symptoms

Check labs for children more often

40
Q

What is the MOA of levothyroxine?

A

Synthetic form of T4 (inactive form)

prodrug

41
Q

What are monitoring parameters for levothyroxine?

A

More monitoring: phenytoin (Dilantin), chemo & carbamazepine (Tegretol)

Amiodarone increases TSH

42
Q

What is time frame response for levothyroxine?

A

6-8 weeks to reach steady state, lab of serum TSH (also T4)

(focus on sx)

Check every 6 months, at least once per year

43
Q

What are contraindications for levothyroxine?

A

Uncorrected renal cortical insufficiency

Adrenal insufficiency

Thyroid toxicosis

44
Q

What are special considerations for special populations?

A

Pediatrics:

Require 4-10mcg/kg/d bc rapid metabolism

Need higher dose

Geriatric

Start at lower dose

Symptoms:

Ataxia

Paresthesia

Carpal tunnel

depression

At risk for bone density issues (may need Dexa scan)

Pregnancy:

Check every trimester

More T4 bound in circulation will need to increase dosing

45
Q

What is patient education for levothyroxine?

A

take on empty stomach 30-60min before meal, DO NOT take within several hours before or after

cholestyramine (Questran)

sucralfate (Carafate)

aluminum-containing antacids

calcium carbonate

46
Q

What are some dose adjustments with levothyroxine?

A

Oral contraceptives or estrogen replacement therapy: need to increase T4 dose

niacin & androgen: need to decrease T4 dose

Salicylates & high dose Lasix: decrease affinity of T4 & T3 to TBG (thyroid-binding globulin) displace hormones & increase free T4 & T3

Monitor anticoag studies more with Coumadin (increase bleeding time)

Limit non-Rx decongestants

47
Q

What are potential causes of hyperthyroidism?

A

Graves disease, autoimmune disease (most common)

Toxic nodular goiter (Plummer disease)

Thyrotoxicosis factitia- intentionally take high T4 doses (p.814)

Toxic adenoma

48
Q

When are follow up lab checks for hyperthyroidism?

A

Evaluate every 1-3 months after start of therapy (T4 level)

Euthyroid within 6-12 weeks of beginning antithyroid

Can decrease dose & reevaluate in 3-4mo

49
Q

What is 1st line for treating hyperthyroidism?

A

Radioactive Iodine

50
Q

What are monitoring parameters and contraindications for radioactive iodine?

A

After treatment hypothyroidism, check TSH & T4

Pregnancy, lactation

Cannot get pregnant for 6mo post tx

51
Q

What is the drug of choice for treatment of hyperthyroidism? What’s the MOA?

A

methimazole

tapazole

Block production of thyroid hormone T3 & T4 in thyroid gland

Blocks oxidation of iodine (prevent T4 to T3)

52
Q

What are side effects for methimazole and PTU?

A

Urticaria

Arthralgia

Transient granulocytopenia

Hepatic abnormalities

GI upset

Fever

Rash, itching

agranulocytosis

53
Q

What is the effect of Iodine on methimazole?

A

Iodine intake caution can enhance med

54
Q

Can you take methimazole in pregnancy?

A

1st trimester of pregnancy PTU okay, methimazole okay 2-3 trimester

55
Q

What are some drug/drug interactions with methimazole?

A

Enhances effects of digoxin, clozapine, theophylline

56
Q

What are some drug/drug interactions w PTU?

A

Enhances effects of warfarin, digoxin

57
Q

What is the MOA of PTU?

A

Interferes

Peripheral conversion of T4 to T3

Inhibit iodine & peroxidase that help to form T4 & T3

58
Q

What is the time response and monitoring parameters of PTU?

A

Routine CBC monitoring 1st 3 months

(agranulocytosis)

Report sx of sore throat & fever immediately!

Takes several weeks to work

Iodine intake caution can enhance med

59
Q

What are considerations for geriatrics and women w hyperthyroidism?

A

Encourage women of childbearing age to consider definitive treatment (radioiodine or surgery) before conception

PTU in 1st Trimester then Methimazole in 2nd or 3rd Trimester

May need higher dosing

Geriatric:

Do not overtreat due to natural rise in TSH

60
Q

What is the MOA of Beta blockers? Which ones are used for hyperthyroidism?

A

propranolol

atenolol

Decrease sx of adrenergic stimulation

Block sympathetic NS activation

61
Q

What are the indications of use of beta blockers in hyperthyroidism?

A

Adjunct agents, treat symptoms

Suppress tachycardia

Given during thyroid storm

Prevent hyperthyroid-induced AFib or control ventricular rate

62
Q

What are signs and symptoms of hypothyroidism?

A
63
Q

What are signs and symptoms of hyperthyroidism?

A

Simmons NURP 423 Exam 2 (4 decks)

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