pharm cases Flashcards
case 1: 55 y/o woman with new onset T2DM. She is on no medication yet for her T2DM. HTN, obesity, T2DM. Lisinopril 10 mg daily. 61 inches 210 BMI 40. A1c 8.5, eAG 197.
2 DOC options? 3 options
DOC 1 options:
- metformin
- sulfonylurias
- insulin
DOC2: Atorvastatin since on ACE
what should you make sure to do when starting someone on metformin? why?
titrate up gradually to avoid MASSIVE DIARREAH
what is a SE of metformin?
extreme diarreah
what will most people with diabetes be on? 3
statin
ACE/ARB
metformin
what should you add if someone has cardiovascular disease?
ASA 81 mg
some people argue that HTN is enough for a cardiac issue that this is warrented but there is controversy around this
what is the inital DOC for T2DM?
metformin
what is the drug class for metformin?
biguanides
what is the MOA of metformin? 6 things
- decrease hepatic glucose production
- decrease renal gluconeogensisi
- slow intestinal absorption of glucose
- increase tissue glycolysis
- increase glucose removal from blood
- decrease serum glucagon levels
what is something that metformin can cause?
blockade of hepatic gluconeogenesis impairs renal clearance of lactic acid
leads to lactic acidosis in renal insufficiency
what do you need to do if someone is taking metformin and needs CT contrast?
hold the metformin for 48 hours
a person with T2DM at the time of dx has had this for how long?
10 years….thats how long it has been unknown for
what are the two sulfonylureas?
- glipizide
2. repaglinide
what is the drug class for glipizide?
2nd generation sulfonylureas
what is the MOA of glipizide?
stimulates pancreatic Beta cells release of insulin
what drug when txing diabetes do you need to be careful in sulfa allergy?
glipizide
what is the drug class for repaglinide?
meglitinides
Non-sulfonulurea secretagogue
what is the MOA of repaglinide?
binds to the sulfonylurea receptor on the Beta cell sto stimuate insulin release
which of the sulfonylureas would you want to use in someone that has a sulfa allergy?
repaglinide
what is the name of the rapid acting insulin?
Lispro
what is the name of the short acting insulin?
regular
how long does it take for the rapid acting insulin to work?
5-15 minutes
what is the name of the intermediate-acting insulin?
neutral protamine
what are the names of the long acting insulin?
insulin glargine
what are the two concentrations that insulin glargine comes in?
300 and 100
how long does the short acting insulin work? whats the name?
regular
5-8 hours
what is the name of the intermediate acting insulin and how long does it work?
neutral protamine
10-24 hours
what are the names of the long acting insulin and how long does it work?
insulin glargine
20-24 hours
what is the name of the oral inhalation rapid acting insulin?
human rDNA insulin
what is the name of the insulin that is inhaled?
human rDNA insulin
Case 2: 55 y/o lady with follow up for her recent DEXA scan. BMD >2.5 SD below threshold. She hasn’t had any fractures to date. Alcoholism, tobacco, HTN, SH 6 cups of coffee a day. sedentary. Amlodipine 5 mg daily. BMI 33. A&Ox3.
what are the 3 DOC?
she has progressed to osteoporosis
DOC1: alendronate
DOC2: exercise program
DOC3: calcium and vitamin D
what type of exercising do you need to do if you have osteoporosis?
weight bearing exercise to build the bone
aka exercise on a bike doesn’t work
what is the drug class for alendronate?
oral biphosphenate
what is the MOA of alendronate?
decrease rate of bone resorption
what do you need to monitor when giving someone alendronate?
Ca and vit D
think about it, you need to have adequate levels of this if you are going to build bone back up*
what must you remember to do when taking alendronate?
take in the AM with 8 oz water and remain upright for 30 minutes!
Case 3: 35 y/o sedentary obese female with a A1C of 7.8 eAG=196 on retest. you dx T2DM. HTN. T2DM, obesity. chorithiadone 12.5 mg. BMI 34. initial A1C 7.5, retest 7.8. (eAG=187-196), LDL 190, TC 300. CrCL 90cc/min
3 DOC?
DOC1: metformin
DOC2: atorvastatin
DOC3: take off chlorthiadone and switch to ACE since dieuretics are contraindicated with metformin and need to protect the kidneys
what drug shouldn’t you take metformin with?
dieruretics
case 4: 70 y/o lade with newly dxed T2DM. she is in clinic to get her second A1C result and start tx if needed. HTN obesity CKD3. Anemia of chronic disease. T2DM. HCTZ 12.5 mg daily. BMI 32. acanthosis nigrans on posterior neck. A1c=8.5, 8.7 eGFR 35 ml/min. UA, glucose pos, ketone neg, protein neg.
2 DOC?
DOC1: reduced dose metformin since low eGFR (msut reduce dose)
DOC2: linsinopril (since HTN and T2DM)
order lipid panel to determine if statin nessacary
what are the goal A1c for elderly and young people?
young=7
elderly=8
what does pushing the A1c below 7 do?
NOT MUCH
this is why the goal for younger people is 7 because its has been found that below this doesn’t do much better
why is the goal A1c for elderly patient 8?
elderly are at sever risk for hypoglycemia so if 75 and older we don’t want to get TOO LOW fall and break hip with 25% mortality rate….so we try to get to 8
Case 5: 17 was on hiking trip and lost insulin and is now in the ED because he was without it for 36 hours. you now need to give him tx to go home with but he hates shots and would like to minimize this a much as possible. T1DM. BMI 25. FBS=110. UA ketones=none
DOC1 (2 options)
long acting insulin (since would decrease the frequency need to be given) +/- short acting insulin with meals
DOC1: insulin glargine U100 or U300
do T1DM or T2DM use higher insulin doses?
T2DM since you have to overcome their insulin resistance!
they have decreased production AND insulin resistance….so must tx both!!
what is the first indiation of a Tye II diabetic?
an increase in insulin to deal with higher sugar which burns out the beta cells
what should you monitor prost prandial with using a short acting insulin?
eAG or the persons BS!!
case 6: 50 y/o female with T2DM has instituded TLS changes and lost 15 of her body weight and has been titrated up to 1 gm of metformin ever 12 hours but her A1c is now 7.8. she is allergic to sulfa meds. HTN. Hyperlipidemia. T2DM. analphylaxsis to sulfa. Linsinopril 10 mg daily, atorvastatin 10 mg daily, metformin 1000 mg BID. A&Ox3. A1c=9 (eAG=211), current A1c=7.8 (eAG 177). LDL 165. BP 150/90.
4 DOC? 1 consideration?
DOC: repaglinide; sulfonylurea
DOC2: linsinopril dose increase 20 mg
DOC3: atorvastatin increase 40 mg since increase risk for CVD
DOC4: ASA 81
don’t want to use glipizide because has sulfasensitivtiy and could kill her
repaglinide is a ______
secretagogue which means it makes the beta cells work harder
what should you keep in mind when giving someone a sulfonylureas?
it pushes the beta cells to release more insulin, causing them to burn our more quickly….
metformin and insulin don’t do this, just a heads up!!
what can the sulfonylureas cause?
eventual burn out of the beta cells
Case 7: 75 y/o with new T2DM with A1c of 12 (eAG=298). He is here to start tx. HTN, hyperlipidemia, COPD, T2DM. chlorathiodone 12.5 mg. Amlodipine 10 mg daily. atorvastatin 20 mg daily. BMI 35. TC=150. Tri=100, HDL=45 LDL=90 A1c=12 eAG=298. eGFR=40 ml/min
4 DOC options?
DOC1: Glargine insulin starting at 0.2 units and up titrate
DOC2: rapid acting insulin pre-meals
DOC3: Add lisinopril for kidney protection, decrease amlodpiine down to 5 mg
DOC4: increase atorvastatin 40 mg
oral meds aren’t enough for this guy…thats why giving the insulin
Case 8: 75 y/o patient on tx for T2DM and has 3 episodes of episodic hypoglycemia in the last 3 months. She fell during two of them. metformin 1000 mg BID, glipizide 10 mg BID, acarbose 25 mg AC TID. A&Ox3. BMI 30. A1c 7.2 eAG=160
2 DOC options?
her A1c is ok for her age
DOC1: think the episodes are from too high of dose of glipizide so decrease the dose!!
DOC2: start lisinopril
take away: someone 75 and older can have a A1c that is between 7.5 and 8 and be ok!!
case 9: 50 y/o pt with osteoporosis who is scared to do stuff cause she is scared to break something. 1 ppd tobbacco use. seizure disorder, HTN, tobacco. BMI 24, A&Ox3. DEXA=BMD T score over 2.5 SD below threshold
DOC3?
DOC1: alendronate
DOC2: stop smoking!!! has negative impact on bone
DOC3: vitamin D and calcium (insure you have enough material to regrow bones)
what is important to advise a patient to do if they have osteoporosis and are a smoker?
stop smoking because it has a negative impact on bone
what is the indication for alendronate?
prevention and treatment of osteoporosis
what should you not take with alendronate?
NSAIDS
antacids
when should you repeat the DEXA scan after starting alendronate for osteoporosis?
1-2 years
what do you need to monitor when taking alendronate?
Ca and vit D levels
if these are low replace them because these materials are needed to build back the bone
case 10: 50 y/o female with daytime sleepiness and fatigue, cold intolerance and weight gain of 15 in the past 6 weeks and new depression. G3P3A0. BMI 28. Thinning hair, palpable thyroid without nodularity. decreased DTRs. TSH=20, H&H 12/35. CBC normal.
dx? DOC? 1 consideration?
hypothyroidism
DOC1: levothyroxine (T4)
repeat the TSH in 6 weeks!!
what is the drug class of levothyroxine?
thyroid agent
synthetic T4 replacement
what is the MOA of levothyorxine? 3
replace T4 that is converted to T3 in the periphreal tissues
binds to nuclear receptors
initiates protein synthesis, metabolic rate, and promotes gluconeogensisi
what is the indication for levothyroxine?
hypothyroidism