Module 7 quiz Flashcards
Medications that reduce the incidence of diabetic nephropathy
Insulin + ACEI or ARBs (prevention of nephropathy and HTN)
BP goal
<140/90
Action of Insulin
Stimulates uptake of glucose, amino acids, nucleotides & K promotes synthesis of complex organic molecules
Rapid acting insulin
Lispro/Humalog
Onset: 15 mins
Duration: 3-6 hours
Admin: must give with meals
Goal: Post-prandial BG control, between meals and at night
Note: Must be used with intermediate or long acting agent in DM I
Short Acting Insulin
Regular/Humalin R
Onset: 30-60 min
Duration: 6-10 hours
Admin: Must be given immediately before or after eating or via infusion pump
Goal: Post-prandial BG control when given before meals, basal control via pump
Notes: Slower onset than rapid acting, and faster onset than longer acting. Most on pumps use rapid not regular
Intermediate insulin
NPH (Humalin N/ Novolin N)
Onset: 60-120 mins
Duration: 16-24 hours
Admin: Can NOT be given at meal times to control post prandial BG. Instead BID or TID dosing.
Goal: Control b/w meals and night
Notes: Only longer acting insulin suitable for mixing with short acting (Regular, Lispro, Aspart, Gluisine)
Mixing tips: Draw short acting first to not contaminate NPH vial (clear then cloudy)
Long duration- Glargine
Onset:70min
Duration:18-24 hours
Admin: QD or BID in some to achieve full basal coverage
Goal: Prolonged control up to 24 hours
Notes:Dosing at anytime of day, must be consistent though. achieves steady state BG control throughout day
Ultralong duration
Glargine 300
Onset: 360 min
Duration: >24 hours
Admin: only insulin analog that lasts up to 42 hours
Goal: basal glycemic control
Notes: similar to glargine 100, does not have a peak
Long duration-Detemir
Onset: 60-120min
Duration: varies
Goal: basal glycemic control
Notes: slow onset, dose dependent duration of action, low doses up to 12 hours. Higher doses up to 20-24 hours
Biguanides action and SE
Metformin
-Drug of choice for initial therapy, can be used alone or in combination
-Action: does not drive blood glucose down. Inhibits glucose production in liver, reduces absorption in the gut and sensitizes insulin receptors=increased uptake
SEs: diarrhea, nausea, lactic acidosis
Sulfonylureas
Glipizide
First oral anti-diabetic drug, can be used alone or in combo
-Action: promote insulin release by stimulation of beta cells. Only used in DM II. May also increase target cell sensitivity to Insulin.
SEs: Can cause weight gain, and dose dependent hypoglycemia (may be persistent=D5 infusion)
Notes: 1st generation=less potent, more dug-drug interactions. 2nd gen=more potent, fewer interactions, used more often
Alpha Glucosidase Inhibitors
Acarbose
Monotherapy or combination therapy
Action: Act in intestines delaying absorption of carbs=reduces rise in BG after meals
SEs: R/t bacterial fermentation of carbs: flatulence, cramps, boborygmus, diarrhea, No hypoglycemia w/ monotherapy
Notes: Can decrease iron absorption. Liver dysfunction can occur-Monitor LFTs
Androgens (produced, actions, uses, adverse effects)
Produces by testes, adrenal cortex, and ovaries
Actions: promote male secondary sex characteristics
uses: management of androgen deficiency in males
Adverse effects: virilization & hepatotoxicity
Testosterone and testosterone esters
Approved for those with documented testosterone deficiency d/t hypogonadism
Indications: delayed puberty, therapy in menopausal women, cachexia, refractory anemias, drug therapy for transgender men
Adverse effects: virilization in women, girls and boys, hepatotoxicity, negative effects on blood lipids, abuse potential, thromboembolism
5 Alpha Reductase inhibitors
Finasteride
Action: Reduced DHT in blood by 70%. Does NOT reduce testosterone=promotes regression of prostate epithelial tissue and relieves mechanical obstruction
Considerations: most effective in men w/ very enlarged prostates, decrease in ejaculate and libido in 5-10%, risk for gynocomastia
Alpha receptor blockers
Flomax
Action: Blockade of alpha 1 receptors-relaxation of bladder neck (trigone/sphincter), prostate capsule, and prostatic urethra decreasing dynamic obstruction
Considerations: Therapy must be continued life long, bloackade of alpha 1 results in systemic vasodilation and may cause hypotension, overall tolerated well, may interact w/ beta blockers
Estrogen type: steroidal hormone
Actions: supports maturation of female secondary sex characteristics, increases bone mass, reduces CVD, promotes and supresses coagulation, neuroprotective
Uses: contraceptive & non contraceptive, HRT (w/ progestin), hypogonadism, acne, cancer palliation (prostate and metastatic breast ca), GAT (off label)
Adverse effects: endometrial hyperplasia, breast ca, thromboembolic events
Side effects: nausea, headache including migraine
Contraindications: liver disease, hx of breast ca
Drug-Drug interactions: estrogens are major substrates of CYP system
Progestins
Naturally produced
help prevent endometrial CA, used in IVF
SEs: breast tenderness
DONT GIVE TO PATIENTS W/ UNDIAGNOSED VAGINAL BLEEDING
Levothyroxine
synthroid: identical to natural hormone T4
-Indications: All forms of hypothyroidism
SEs: Rare but many drug-drug interactions=reduced absorption (PPIs, sucralfate, antacids, Ca+, and iron supplements)
-Reduced absorption w/ food/take on empty stomach 30-60 mins before breakfast
-Highly protein bound w/ prolonged half life (7 days)
-Levels remain steady even w/ QD dosing
-Takes 1 month for levels to reach steady state
-Narrow therapeutic range- DON’T CHANGE BRANDS
Recommendations for prescribing oral hypoglycemic agents
Hypoglycemia-BS <70
Fast acting oral sugar to be given PO for patients not NPO
-glucose tabs, orange juice, sugar carbs, honey corn syrup/soda
-15 grams of fast acting carbohydrate
Comorbid illnesses that may impact the dose of insulin required (7)
-surgery
-acute illness
-enteral/parental nutrition
-steroids
-epi infusion
-inflammatory response
-critical illness
Discuss dual agent therapy in the treatment of DM
4 step approach ( 2019 ADA standards)
1. Lifestyle changes + metformin (diagnosis)
2. Add second agent (efficacy, tolerability, hypoglycemia risk, weight considerations, cost). If A1C>9%/fasting BS>300, or BIG symptoms-start at step 2 (include injectable-basal insulin)
3. Progress to three drug combo (includes metformin)
4. After 3-6 months of #3 (including basal insulin)-combo injectable regimen (insulin +GLP-1receptor agonist)
Describe risks for hypoglycemic episodes (9)
-use of insulin or oral anti-diabetics
-impaired kidney or hepatic function
-longer duration of DM
-Frailty or old age
-Cognitive impirement
-impaired counterregulatory repsonse/hypoglycemia unawareness
-physical or intellectual disability that can impair behavioral response to hypoglycemia
-alcohol use
-polypharmacy (w/ ACE/ARBS, nonselective BB)
Treatment of hypoglycemia
Considerations: NPO status, LOC, Absorptive capacity of gut (edema/ileus), IV access, potential for prolonged hypoglycemia
Options: 15 grams of fast acting carb
-glucagon
-glucose tabs
-Dextrose IV or Continuous infusion
Pt education for self administering insulin
Mixing of insulin should only be done with those proven compatible
-only intermediate acting insulin (NPH) is approved to mix with short acting insulin
-when mixing short acting should be drawn first to avoid contamination
-Pt should monitor glucose levels 4x daily
-Insulin dosage must be closely matched w/ insulin needs
E.g. when a meal is missed or low in carbs, decrease insulin dose
-stress, obesity, infection requires increased dose
Primary and adjunct treatment for Grave’s disease
-Surgical thyroidectomy
-destruction w/ radioactive iodine
-Supression of hormone synthesis w/ an antithyroid drug
Radiation is preferred treatment for adults, antithyroid drugs are preferred for younger patients
-BB and nonradioactive iodine may be used as adjunct therapy
-BB suppress tachycardia + non radioactive iodine inhibits synthesis and release of thyroid hormones
Grave’s Disease
hyperthyroidism ( most common in women 20-40)
Thionamides
Methimazole & Propylthiouracil (PTU)
Actions: suppress synthesis of thyroid hormones
Indication: long term treatment for hyperthyroidism, or short term prep for thyroidectomy or treatment w/ radioactive iodine
Methimazole
First line drug.
Does not destroy exisiting thyroid hormone so effects may be delayed
-Uses: monotherapy for Graves Dz, adjunct to radiation therapy/surpresson prior to thyroidectomy/thyrotoxic crisis
Containdications: pregnancy/breast feeding
SEs: agranulocytosis-rare symptom of toxicity
Radioactive Iodine
Action: destruction of thyroid tissue, results in clinical remission w/out destroying the entire thyroid (ideally but not always)
-Adverse effects: delayed hypothyroidism (frequent complication)
Benefits: low cost, lacks the risks associated with thyroidectomy, death is extremly rare, no tissue other than thyroid is injured
Contraindications: pregnancy and breast feeding
Pt w/ thyrotoxic crisis
thyroid storm=excessive thyroid hormone
Triggers: major surgery or severe illness
S/S: profound tachycardia, severe hyperthermia, restlessness, tremor, agitation, coma, hypotension, HF
Life threatening response to excessive thyroid hormone
Treatment: high dose potassium iodide, methimazole, BB
More supportive measures: sedation, cooling, glucocortioids, IV fluids
-Fever, tachycardia can look like sepsis, be aware
Implications of pregnancy as it r/t thyroid treatment
Avoid methimazole in first trimester
Methimazole can cause neonatal hypothyroidism, goiter, and congenital hypothyroidism
PTU is preferred drug during first trimester
Emergency contraceptive options currently available in the US
Emergency contraceptive-taken immediately following intercourse
-Progestin only pills-Plan B one-step-levonorgestrel alone
-next choice one dose
-Ulpristal acetate emergency contraceptive (ella)-supresses ovulation
Estrogen/progestin (Yupze regimen)
Copper IUD-expensive
what is ED most commonly treated with
PDE-5 inhibitors (Sidenafil)
Sidenafil adverse effects
hypotension, priapism aka painful erection lasting more than 4 hours, nonarteritic optic neuropathy, hearing loss, headache, flushing, diarrhea, rash, dizziness
Sidenafil drug interaction
-avoid nitrates for at least 12 hours after sidenafil as they cause hypotension, life threatening hypotension can be caused if drugs are combined
-Alpha-adrenergic antagonists (Cadura) used for prostate hyperplasia-can dilate arterioles and lower BP leading to postural hypotension
-Inhibitors of CYP34A can suppress the metabolism, increasing its level
-grapefruit juice can elevate its level
Premature Ejaculation treatment
no drugs are FDA approved, off label uses include:
SSRIs
Topical anesthetics
trycyclic antidepressants (Clomiprmine) used as 2nd line when SSRI can not be taken
Radiofrequency ablation
Selective estrogen receptor modifiers (SERMS)
Activate estrogen in selected tissue
-prototype: tamoxifen-inhibits cell growth in breast (cancer treatment)
-SEs: hot flashes, thromboembolism
What oral antidiabetic is similar to sulfonyuras?
Meglitinides/Glinides
Meglitinidies/Glinides
actions similar to sulfonyureas. Shorter acting, must be taken with meals (w/in 30 min)
non responders to sulfonyureas will not respond to glinides
