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Amb Care > Week 2 Lectures > Flashcards

Week 2 Lectures Flashcards

1
Q

Name the 3 hard ASVCD endpoints

A

The 3 classic ASVCD endpoints: cardiovascular death, myocardial infarction, stroke

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2
Q

Straight leg test

(a) Classic finding of what

A

Pt lies supine- reproduction of sciatica pt when leg elevated 30-60 degrees is associated w/

(a) lumbar disk herniation of lower lumbar nerve roots (L5 and S1)

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3
Q

Janumet

A

Janumet = combo diabetes drug of Metformin and Sitagliptin (DPP4 inhibitor)

-aka for diabetes

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4
Q

Exenatide

A

Exenatide = GLP-1 analog => works to increase insulin and decrease glucagon release

-decreases gastric emptying (promoting early satiety and weight loss) but often => nausea (in 50% of pts)

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5
Q

44 yo F w/ DM2 and BMI 36
BP 124/78
ASCVD risk 4%

What do you recommend for her lipids?

A

Even tho ASCVD risk isn’t over 7.5%, she meets 1 of the 4 groups that benefits from moderate dose statin therapy = diabetics age 40-70 w/ LDL 70-189

(if ASVCD risk > 7.5% she’d qualify for high intensity dosage)

Recommend moderate-intensity statin:
Simvastatin 20-40 mg at bedtime
Rosuvastatin 5-10 mg qAM

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6
Q

Exenatide

(a) Disadvantage
(b) Most common side effect

A

Exenatide (GLP-1 analog)

(a) It’s an injectable- subcutaneous BID
(b) Most common side effect is nausea in 50% of pts due to the delayed gastric emptying

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7
Q

26 yo w/ LDL of 240 since her teens
BP 120/75
On OCP but wants to go off b/c just got married

What do you recommend for her lipids?

A

Meets 1 of the 4 groups that benefit from high intensity statin therapy since LDL > 190
=> Rosuvastatin 40 mg + test family

Stay on OCPs b/c can’t get pregnant on a statin (pregnancy category X)

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8
Q

3 most common cancers that met to the spine

A

Breast, lung, prostate

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9
Q

What is the one group of pts that DON’T benefit from statins?

A

Pts on hemodialysis- shown not to benefit from statin therapy

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10
Q

2 side effects of metformin

A

GI

lactic acidosis

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11
Q

Which end goals benefit most from tight glucose control?

A

Microvascular end points (retinopathy etc) benefit most (and faster) than macrovascular end points from tight glucose control

-no clear macrovascular benefits from tight control have yet been proven (but they’re probs there just take a long time to study)

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12
Q

What are the most common neurologic impairments seen in a pt w/ disk herniation

A

Most common neurologic impairments correlate w/ the motor and sensory territories of L5 and S1 nerve roots (b/c most common place of disk herniation) =>

weakness of ankle and great toe dorsiflexors (L5)
-‘point your toe towards your head’

diminished ankle reflexes (S1)

sensory loss in feet (L5 and S1)

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13
Q

Sulfonylureas

(a) Advantage
(b) Mechanism
(c) Disadvantage

A

Sulfonylureas = Glimepiride

(a) Advantage- very cheap and efficacious
(b) Works by stimulating insulin release from pancreas regardless of the serum glucose
(c) Disadvantage is weight gain and hypoglycemia

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14
Q

What is high intensity statin therapy?

A

High-intensity statin therapy is 1 of the following 4:

Atorvastatin 40 or 80 mg
Rosuvastatin 20 or 40 mg

-4 specific target groups that get this high-intensity statin therapy

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15
Q

What ages are considered premature MI?

A

Premature MI for family risk:

-Before 55 in father/brother or before 65 in mother or sister

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16
Q

ACCORD trial: clinical take away from mortality difference btwn A1C 6.4% vs. 7.5%

A

ACCORD trial: the lower A1C had higher mortality, but probably from death from hypoglycemic arrhythmias => take away = back off from the very sick and elderly in terms of tight glucose control

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17
Q

Adverse effects of pioglitazone

A
  • weight gain
  • edema
  • CHF (rare but can cause irreversible loss of EF)
  • osteoporotic fractures

Doesn’t cause hypoglycemia

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18
Q

Go to drug for lowering TG

A

Fibric acids = fenofibrate

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19
Q

Dipeptidyl peptidase-4 inhibitor

(a) Name of drug
(b) Mechanism

A

DPP4 inhibitor

(a) Sitagliptin
- on Bellevue formulary as Janumet = combo drug of Sitagliptin and Metformin
(b) Mechanism- DPPP 4 inactivates incretin hormones => Sitagliptin slows the inactivation of incretins => increases insulin release, inhibits glucagon secretion

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20
Q

Danger of TG above 1,000 mg/dL

A

TG over 1,000 is associated w/ acute pancreatitis => keep pt under 500 to prevent pancreatitis

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21
Q

Name some secondary causes of hyperlipidemia

A
  • Diabetes
  • Hypothyroidism (always check TSH before startin statin therapy)
  • Chronic renal failure
  • Nephrotic syndrome
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22
Q

Requirement for bariatric surgery

A

BMI 35+ qualify + one comorbidity
-comorbidity can practically be anything: diabetes, back pain, HTN etc (and duh these ppl have these)…so basically anyone w/ BMI > 35

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23
Q

Diabetes drugs that cause weight loss

A

Weight loss:

  • Metformin: neutral/loss
  • wt loss: SGLT2 inhibitors (you’re peeing away your glucose)
  • GLP-1 receptor agonist
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24
Q

Why must simvastatin be taken at night?

A

Short half-life and most cholesterol biosynthesis (what you’re inhibiting w/ a statin) occurs at night when you’re sleeping and not eating

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25
Q

When is the Friedewald equation no longer of use?

A

LDL calculation via Friedewald eqn is unreliable when TG are over 400

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26
Q

Friedewald equation

A

Friedewald equation = calculation of LDL

LDL = total cholesterol - HDL - (TG/5)

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27
Q

What is UACR? What does it correlate with?

(a) Value for CKD

A

UACR = urine albumin: creatinine ratio- estimation of albumin excretion in urine

(a) UACR > 30 mg/g (mg/day) indicates chronic kidney disease
- so follow UACR in diabetes as a marker of diabetic nephropathy

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28
Q

2 lowest costing oral diabetes meds besides metformin

A

Sulfonylureas (glimepiride) and thiazolidinedione (pioglitazone) are both low cost

29
Q

Differentiate specificity and sensitivity w/ mneumonics

A

SpPin vs. SnNout

SpPin: specific tests: positive result rules the diagnosis in

SnNout: for sensitive tests: negative results rules the dx out

30
Q

Describe the algorithm used to titrate glargine dose

A

Glargine (Lantus) = Detamir
‘3-0-3’ titration algorithm

Start at 0.2 units/kg at bedtime. Then every 3 days take average of fasting AM fingersticks from the past 3 days

  • if average is over 110, increase glargine dose by 3 units
  • if average is btwn 80-110, continue same glargine dose (target)
  • if average under 80, decrease glargine by 3 units
31
Q

Repaglinide

A

Repaglinide = Meglitinide, stimulates prandial insulin release

32
Q

Glimepiride

(a) Max dose

A

Glimepiride = sulfonylurea
-stimulates insulin release from pancreas regardless of serum glucose

(a) Max dose: Glimepiride 8 mg daily
- 1,2,4 mg tabs

33
Q

Urinary retention and saddle anesthesia

A

= Cauda equina syndrome

(can be caused by a massive mdiline disk herniation)

-surgical emergency

34
Q

Describe sciatica pain

A

Sciatica is pain associated w/ nerve root irritation

Sharp/burning pain that radiates from the lower back down the posterior or lateral aspect of the leg (usually to the foot or ankle)

Often associated w/ numbness or paresthesia

35
Q

Which diabetes pts get insulin?

A

Insulin started when pt cannot maintain A1C under 8% on maximal oral therapy

36
Q

3 prescriptions every diabetic on insulin needs

A
  1. Alcohol swabs
  2. lancets
  3. test strips for the glucometer
37
Q

When to you glimepiride and repaglinide together

A

Never, don’t use repaglinide (meglitinide) w/ glimepiride (sulfonylurea) since meglitinides can’t increase beta cell insulin secretion in pts on max glimepiride
-they do the same thing (just w/ dif timelines) so useless to do both

38
Q

Ezetimibe

A

Ezetimibe = Zetia

  • cholesterol absorption inhibitor
  • add-on to statins (works synergistically) and for pts who don’t tolerate statins
39
Q

Neurologic claudication

(a) Classic finding of what

A

Neurologic claudication = pain (or sometimes neurologic signs) in legs produced by walking

(a) Classic finding in spinal stenosis

40
Q

Dx: Pt w/ back pain on long-term corticosteroid therapy

A

Pt w/ back pain who is receiving long-term corticosteroid therapy is considered to have a compression fracture until proven otherwise

41
Q

When do you start pioglitazone in a diabetic pt?

A

Part of pioglitazone’s mechanism is altering gene transcription involved in glucose and fat metabolism (which takes time) => may take 3 mo to reach full expression => not an acute medication

-start in outpatient when have 3 mo to see effect

42
Q

Metformin contraindications

A

Metformin- contraindicated in pts at risk for lactic acidosis: creatinine over 1.4 in F, over 1.5 in M

-also contraindicated in pts w/ liver disease

43
Q

Statin contraindications

A
  • pregnancy

- progressive liver disease (bc high dose statins can cause elevated AST/ALT)

44
Q

What determines statin dose in diabetics?

A

ASVCD risk

Diabetic over 40:
Moderate dose statin if ASCVD risk under 7.5%
High intensity statin if ASVCD risk over 7.5%

45
Q

What labs should be checked before starting a statin

A

Before starting statin check:

  • LFTs (b/c high dose statins can cause AST/ALT elevation
  • CK (b/c of myopathy side effect)
  • TSH (b/c hypothyroidism can be a cause of secondary hyperlipidemia)
46
Q

Glimepiride vs. Repaglinide

A

Glimepiride (sulfonylurea) is more gradual but lasts longer, higher risk of hypoglycemia

Repaglinide- faster but shorter acting than Glimepiride, stimulates prandial insulin release
-less hypoglycemia

Similar mechanism- both stimulate insulin release by closing beta-cell K channels

47
Q

A1C cutoffs for

(a) Prediabetes
(b) Diabetes
(c) Diabetes w/ good control
(d) Criteria for dx w/ diabetes

A

A1C cut offs:

under 5.7 is normal

(a) 5.7-6.4 is prediabetes
(b) Diabetes is over 6.5%
(c) Diabetes target is A1C under 7%

(d) To officially be diagnosed w/ DM- need to have 2 separate readings over 6.5%

48
Q

What do you recommend for his lipids?

70 yo M w/ HTN and HLD, drug stent placed 6 mo ago, BP currently 137/79

A

Meets 1 of the 4 groups that benefit from high intensity statins since he has a stent = proven ASCVD
=> Rosuvastatin 20 (or 40) mg or atorvastatin 40 mg (or 80)

49
Q

Contraindications of pioglitazone

A

Pioglitazone contraindicated in class 3 and 4 CHF pts- b/c rare but can cause irreversble loss of ejection fraction

50
Q

Questions on the PHQ 9 form

A

SIGECAPS + depressed mood

Depressed, down, or sad?
Sleep- insomnia or hypersomnia
Interest- anhedonia
Guilt or feelings of worthlessness or that you’re a disappointment
Energy- decreased, excess fatigue
Concentration- decreased, can’t concentrate on reading a book or watching tv
Appetite- increased or decreased
Psychomotor retardation (have ppl noticed you moving or talking slower) or agitation (fidgety, jittery)
Suicidality- thoughts that you may be better off dead or thoughts of harming yourself

PHQ9 uses scale how many times in the past 2 weeks
0 = not at all
1 = several days
2 = more than 1/2 the days
3 = nearly every day
51
Q

Name a case in which an ACEi would be indicated w/o HTN in a diabetic pt

A

When UACR (urine albumin:creatinine ratio) is over 30 mg/g

-UACR > 30 mg/g indicates CKD (which in diabetic pt you assume to be diabetic nephropathy

52
Q

2 meds that make a diabetic pt ‘maximally sensitized’

A

Diabetic pt is thought to be maximally sensitized if on Metformin 1,000 BID and Pioglitazone 30 mg QD

53
Q

Function of Incretin hormones

A

Incretin hormones (ex: GLP-1 and GIP) work to increase insulin release and decrease glucagon release

54
Q

Dosing of Sitagliptin

A

Sitagliptin (DPP-4 inhibitor)

-standard dose is 100 mg daily

Need to renally dose

  • 50 mg daily for GFR 30-50
  • 25 mg daily for GFR under 30
55
Q

2 key risk factors in the ASCVD risk calculator

A

Age and sex really run the show

56
Q

Max dose of simvastatin

(a) for all pts
(b) for pts also on almodipine
(c) For pts also on CCB

A

Simvastatin max dose

(a) 40 mg, 80 mg is associated w/ rhabdomyolsysis
(b) Pts on amlodipine- max dose of simvastatin is 20 mg (b/c of myopathy risk)
(c) Pts on CCB- max dose of simvastatin is 10 mg

57
Q

Pioglitazone

(a) Mechanism
(b) Preferred dose

A

Pioglitazone = sensitizing agent

(a) PPAR-gamma agonist = decreases insulin resistance
Alters gene transcription involved in fat and glucose metabolism
(b) Preferred dose = PIoglitazone 30 mg PO w/ breakfast

58
Q

Which diabetes meds don’t cause hypoglycemia and wt gain?

A
  • Metformin
  • Pioglitazone (PPAR-gamma agonist): doesn’t cause hypoglycemia but causes weight gain
  • Sitagliptin (DPP4 inhibitor) is weight neutral and doesn’t cause hypoglycemia
59
Q

Which diabetics get a statin?

A

Basically any diabetic over 40 gets a statin, unless their LDL is under 70 (super rare)

60
Q

Which statin doesn’t require dose adjustment in severe renal insufficiency

A

Atorvastatin

61
Q

Best indication for hyperlipidemia medication that isn’t a statin

A

Basically the best indication for something else besides a statin is someone w/ TG over 500
(to prevent pancreatitis)

62
Q 
49 yo M w/ DM2
BP 164/102
BMI 40
Acanthosis nigricans, A1C 9.4%
TC 214, TG 164, ASCVD risk 9.2%
UACR 65.7

Current meds
Metformin 500 PO BID
Lisinopril 20 mg
Simvastatin 40 mg

(a) What do you recommend for his lipids?
(b) What would you do for his HTN
(c) What would you do for his DM2?

A

(a) Lipids
ASCVD risk above 7.5% and DM2 btwn 40-70 yoa => high intensity statin => Switch simvastatin to Atorvastatin 20 mg
-if used Rosuvastatin you’d have to adjust for kidney disease
-don’t need to give aspirin unless ASCVD is over 10% (but at 9.2% this guy could be borderline)

(b) HTN: not at goal of

63
Q

TG lowering drugs

A
  • Fenofibrate
  • Fish oils: omega-3 polyunsaturated fatty acids
  • Niacin

+weight loss

64
Q

Biguanides

(a) Mechanism
(b) Main side effects
(c) Max dose

A

Biguanides = Metformin

(a) suppresses gluconeogenesis by inhibiting mitochondrial glycerophosphate
- when liver becomes insulin resistant it pumps out glucose regardless of serum glucose => exacerbates hyperglycemia

(b) GI sid effects
(c) Max dose = 850 mg TID, max effective dose 1000 mg BID

65
Q

Name the 4 groups who benefit from statin therapy

aka statin indications

A

Statin indications:

(1) ASVCD (atherosclerotic cardiovascular disease): coronary artery disease, TIA or stroke, peripheral argery disease
- if under 75 yoa: high-potency statin
- if over 75 yoa: moderate-potency statin

(2) LDL-cholesterol over 190 mg/dl
- also check here for familial hypercholesterolemia

(3) Diabetes, age 40-75 w/ LDL 70-189 mg/dl
ASCVD risk over 7.5%- high intensity dose
ASVCD risk under 7.5%- moderate intensity

(3) Anyone aged 40-75 w/ over 7.5% ASCVD risk

66
Q

Why fish oils aren’t as good as fenofibrate

A

Fish oils are approved for lowering TG (same as fenofibrate), but may raise LDL by up to 50%

67
Q 
51 yo M w/ DM2 currently on 
Amlodipine 10 mg
Metformin 1000 mg BID
HCTZ 25 mg 
Aspirin 81 mg
ASCVD risk 15.8%

TC 194, HDL 32, TG 1245

What do you recommend for his lipids?

A

For his lipids:

  1. High dose statin = Rosuvastatin 40 mg
    - diabetic age 40-70 w/ LDL btwn 70-189
    - also has ASCVD risk > 7.5%

Be careful here not to use simvastatin, can’t use simvastatin w/ amlodipine on board

  1. Fish oil
    - or could use fenofibrate, but would then need to reduce the statin dose to reduce rhabdo risk
68
Q

Best measure to control to reduce complications of diabetes

A

BP control was proven more effective than glucose control in reducing complications

69
Q

Which diabetes drug needs to be renally dosed?

A

Sitagliptin (DPP-4 inhibitor) needs to be renally dosed

Standard dose is 100 mg daily

Need to renally dose

  • 50 mg daily for GFR 30-50
  • 25 mg daily for GFR under 30

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