Townsend "Questions to Consider..." Flashcards
What are the criteria that constitute CKD?
- 3 months of kidney damage
OR - eGFR <60
What are the stages of CKD? (eGFR)
- Stage 1: eGFR 90%+
- Stage 2: eGFR 60-89%
- Stage 3: eGFR 30-59%
- Stage 4: eGFR 15-29%
- Stage 5: eGFR <15%
At what stage does CKD start to affect the patient’s life?
- Stage 3, most complications start
What are problems/conditions in CKD that affect patient’s life?
- Anemia
- Bone/Mineral issues
- CV disease
What are the primary causes of CKD and how best to prevent it?
- T2DM 42%
- HTN 28%
- Glomerular Disease 7%
What can be done to slow CKD progression?
- Manage HTN (B/P target < 130/80)
- ACE-I/ARB for albuminuria and HTN (use in CKD + DM patients)
- Statin use - reduce vascular events in CKD
- If DM, A1C <7%
What medications (categories) need to be avoided with CKD (especially = or <30 eGFR)
- NSAIDS
- Bisphosphonates
- Metformin
- Iodine contrast
When do you need to refer patients with CKD to a nephrologist?
- At or before Stage 4
What needs to be part of your treatment monitoring plan with CKD? (Labs specifically)
- Albuminuria: Normal is <30mg/g, Severs > or = 300mg/g
- Lipids
- Check UA for low pH, elevated specific gravity, or protein, RBC, WBCs in urine (early signs of complications)
Labs with CKD
Starting by Stage 3
- Serum albumin
- Phosphorus
- Calcium
- Intact Parathyroid Hormone (PTH)
Dietary considerations with CKD
- Less salt
- Smaller amounts/right kind of protein
- Lean meats, skinless chicken, fish, fruits/veggies, beans (heart healthy)
- Read nutrition labels: watch for high sodium content
A 50-year old male is diagnosed with CKD. The patient’s recent eGFR was 25 mL/min. What stage of CKD is this known as?
- Stage 4
A 62-year old male has an eGFR of 55 mL/min. Patient has a hx of uncontrolled HTN and CAD. You know what medication might be most helpful in treating both HTN and CKD?
A. Lisinopril
B. Metoprolol
C. Amlodipine
D. Verapamil
A. Lisinopril
What constitutes precocious puberty?
- < 8 years old in girls
- <9 years old in boys
What constitutes delayed puberty?
- Girls: no signs by 13 yo or menarche by 16 yo
- Boys: no signs by 14yo or >5 years since 1st sign of puberty w/o additional signs
How would you work-up precocious puberty? (labs, x-rays)
- X-ray L hand to determine bone age
- Labs: LH, FSH, Estradiol/Testosterone
- If labs show Central PP, order MRI of brain to r/o central lesion of brain
What conditions are the most common forms of hypogonadism?
- Girls: Turner syndrome (missing second X chromosome, XO)
- Boys: Klinefelter syndrome (Extra X, XXY)
Which of the following diagnostic tests is not likely included as part of the initial evaluation of AUB?
A. Transvaginal US B. Pregnancy Test C. TSH D. CBC E. MRI
E. MRI
What are the causes of AUB?
- PALM COEIN Polyp Adenomyosis Leiomyoma Malignancy and Hyperplasia
Coagulopathy Ovulatory dysfunction Endometrial Iatrogenic Not yet classified
Causes of AUB
Polyp
- Intermenstrual bleeding
- Asymptomatic
- Dx with sonogram
- RF = Obesity, HTN, DM, Older age, Tamoxifen use
Causes of AUB
Adenomyosis
- Boggy, symmetrical enlarged uterus
- Chronic pain
Causes of AUB
Leiomyoma
- AKA Fibroids
- Benign
- 80% AA/70% Caucasian
- Tx: Ulipristol (SPRM), Laproscopic Sx
Causes of AUB
Malignancy and Hyperplasia
- Self-explanatory
Causes of AUB
Coagulopathy
- 20% of patients
- Von Willebrand (low levels of clotting factor in blood)
- Platelet dysfunction
- Hx of heavy bleeding since menarche
Causes of AUB
Ovulatory dysfunction
- MOST COMMON
- Irregular, short cycle
- Periods of amenorrhea
- In Adolescents occurs d/t immature HPO axis -> Anovulation -> Normal physiology that should resolve in 2 years
- If still persists after 2 years, classify as AUB-E, AUB-I, or AUB-NYC
In general, what labs are checked as part of your plan of care for AUB?
- Coag studies (PT/PTT, Fibrinogen, Iron Studies)
- UPT
- HcG
- CBC (check for anemia)
What constitutes mild AUB? What is the treatment?
- Duration of HMB < 3 months, Hgb WNL
Treatment:
- Observe patient
- Keep menstrual calendar
- Encourage NSAIDS to reduce menorrhagia
What constitutes moderate AUB? What is the treatment?
- Heavy, frequent bleeding q1-3 weeks, Mild anemia
Treatment: Taper monophasic OCP (ethinyl estradiol/norgestrel) + antiemetic – Cycle every 3-6 months
What constitutes severe AUB? What is the treatment?
- Heavy, prolonged bleeding, Hgb <9
Treatment:
- Taper OCP (ethinyl estradiol/norgestrel) q4h til bleeding stops, then use cyclic OCP;
- Iron Supplement
- Nausea meds
Precocious puberty s/s begin before age __ in girls and before age __ in boys?
A. 8,9
B. 5,6
C. 9,10
D. 8,11
A. 8,9
What are the recommendations regarding who needs cholesterol medications?
- Clinical ASCVD patients
- High-risk ASCVD with LDL-C >70mg/dL
- LDL-C >190mg/dL
- 40-75 yo + DM + LDL-C > or = 70mg/dL
- 40-75 yo evaluated for primary ASCVD prevention
- 40-75 yo w/o DM + LDL-C > or = 70mg/dL + 10 yr ASCVD risk of > or = 7.5%
- 40-75 yo w/o DM + 10 yr ASCVD risk of 5%-19.9%
- 40-75 yo w/o DM + LDL-C > or = 70-189mg/dL + 10 yr ASCVD risk of 7.5%-19.9%
- > 75 yo with LDL-C 70-189mg/dL
When should elevated triglycerides be treated with medications?
- Triglycerides > or = 175mg/dL
What are non-statin medications and when should they be used?
- Ezetimibe, Bile acid sequestrants, PCSK9 Inhibitors, Niacin, Fibrates
- In combination with statin or when statins are not tolerated
What are the major medication side effects for cholesterol-lowering medications?
- Bilateral myalgia (muscle pain), involving proximal muscles, usually starts w/in weeks to months after starting statin, resolves after d/c of statin
- HA
- Dyspepsia
- Nausea
- Alopecia
- ED
- Myopathy (muscle weakness)
- Myositis (muscle inflammation)
- Myonecrosis (muscle wasting)
What intensity of statin therapy is required based on risk? What are the medications? Doseages? % of LDL-C reduction?
- High-Intensity
- Medication: Ator 40-80mg/Rosu 20-40mg
- % of LDL-C reduction: > or = 50%
- Mod-Intensity
- Medication: Ator 10-20mg/Rosu 5-10mg/Sim 20-40mg/Pra 40-80mg/Lov 40mg
- % of LDL-C reduction: 30-49%
- Low-Intensity
- Medication: Sim 10mg/Prav 10-20mg/Lov 20mg/Flu 20-40mg
- % of LDL-C reduction: <30%
What patient risk groups are high and very high risk for ASCVD?
- Smokers
- HTN
- Abnormal cholesterol
- DM
- Age
What statins are high intensity?
- Ator 40-80mg
- Rosu 20-40mg
What statins are moderate intensity?
- Ator 10-20mg
- Rosu 5-10mg
- Sim 20-40mg
- Pra 40-80mg
- Lov 40mg
T/F
Most people can lower high cholesterol if they lose weight, eat better, and exercise more.
True
Who might be a candidate for Ezetimibe?
- Statin Intolerant
- Add to statin if LDL-C stays >70mg/dL
Who might be a candidate for PCSK9 inhibitors?
- Statin Intolerant
- CV risk patients
- EXPENSIVE!
What diet and lifestyle recommendations are encouraged in children/adults with dyslipidemia?
- Veggies/Fruits/Whole Grains
- Legumes/Nuts
- Low-fat dairy/poultry
- Fish/Seafood
- Non-tropical vegetable oils
Are there preferred dosing times for statins?
- Evening
Ms. Jones is a 58-year old diabetic patient with hyperlipidemia. Based on this information you would start her out on what statin listed below?
A. No statin, not needed at this time
B. Atorvastatin 40mg
C. Rosuvastatin 40mg
D. Atorvastatin 20mg
D. Atorvastatin 20mg
