Week 5 - Final Review Flashcards
What lab tests are used to diagnose hypothyroidism?
- Serum TSH used to screen and diagnose hypothyroidism (Even with small T3 and T4 changes there will be an abnormally high level of TSH)
What are normal/hypo/hyper levels of TSH?
- Hyperthyroid – under 0.3
- Normal – 0.3-6
- Hypothyroid – over 6
How long after initiation of treatment for hypothyroidism would you recheck labs?
Check TSH 6-8 weeks after initiating therapy and after any dosage change
What are the signs and symptoms of hypothyroidism?
- face is pale, puffy, and expressionless
- skin is cold and dry
- hair is brittle, and hair loss occurs.
- Heart rate and temperature are lowered.
- lethargy, fatigue, and intolerance to cold.
- Mentation may be impaired
- Thyroid enlargement
What are the signs and symptoms of and hyperthyroidism?
- Nervousness
- Insomnia
- rapid thought flow
- rapid speech
- Skeletal muscles may weaken and atrophy.
- Metabolic rate is raised, resulting in increased heat production, increased body temperature, intolerance to heat, and skin that is warm and moist.
- Appetite is increased, weight loss
How is a thyroid storm treated?
Using a combination of:
- antithyroid drugs
- corticosteroids
- beta-blockers
- iodine solution
- supportive measures are needed
Can be a result of not treating hypothyroidism during pregnancy.
What medication is used to treat symptoms of hyperthyroidism?
- Methimazole or propylthiouracil
These are antithyroid drugs which treat the symptoms but not the condition itself.
What medications reduce absorption of levothyroxine?
- Histamine 2 (H2) receptor blockers (cimetidine)
- Proton pump inhibitors (lansoprazole)
- Sucralfate (Carafate)
- Cholestyramine, Colestipol
- Aluminum-containing antacids (-Maalox, Mylanta),
- Calcium supplements (-Tums, Os-Cal)
- Iron supplements (ferrous sulfate),
- Magnesium salts
- Orlistat (Xenical)
What drugs accelerate metabolism of levothyroxine?
- phenytoin (Dilantin),
- carbamazepine (Tegretol, Carbatrol),
- rifampin (Rifadin),
- sertraline (Zoloft), and
- phenobarbital.
How do you confirm a diagnosis of diabetes?
- Fasting glucose ≥ 126
- Random glucose ≥200
- Oral glucose tolerance test ≥200
- HbA1c 6.5% or higher
What are the general goals for a1c when treating diabetics?
General goal: < 7%
Older Adult goal: < 8%
In what situations should insulin be used for treatment?
- For all T1D
- Gestational diabetes
- Newly diagnosed diabetics with an A1C greater than 10% and a fasting glucose over 300
How often should an A1C be checked after beginning treatment for diabetes?
Every three months until it is less or equal to 7%
Then every 6 months thereafter
Name three actions of insulin
- Promotes conservation of energy and buildup of energy stores (glycogen)
- Stimulates cellular uptake of glucose, amino acids, neucleotides and potassium.
- Promotes synthesis of complex organic molecules –> assembly of amino acids into proteins and fatty acids incorporated into triglycerides
What are contraindications for pioglitazone?
- Patients with severe HF
- Patient with bladder cancer or history of bladder cancer
GLP-1
Glucagon-like peptide-1 receptor agonists
TZD
Thiazolidinediones
DPP4-I
Dipeptidyl peptidase 4 Inhibitors
SGLT2i
Sodium-glucose Cotransporter 2 Inhibitors
Which drug class should be considered for diabetes prior to insulin?
Biguanides
Mechanism of action for GLP-1
Glucogon like peptide (non insulin injectable)
Augments the effects of the incretin hormone GLP-1 by:
- activating receptors for GLP-1 to slow gastric emptying
- stimulate release of insulin
- inhibit postprandial release of glucagon
- suppress appetite.
Thereby reducing glucose levels and inducing weight loss.
Mechanism of Action for TZD
Thiazolidinediones
Reduce glucose levels by decreasing insulin resistance
Activation of a PPAR receptor which turns on insulin-responsive genes resulting in:
- increased cellular uptake of glucose by the skeletal muscle and adipose cells
(Enhances response to insulin, therefore insulin needs to be present for the drug to work)
MOA for DPP-4i
Dipeptidyl peptidase 4 Inhibitors
Enhances the action of incretin hormones to:
- stimulate release of insulin
- suppress release of glucagon
- keep blood glucose levels from climbing too high
Sulfonylureas
Stimulating the release of insulin from pancreatic islets (not for DM1) by binding with and blocking ATP sensitive potassium channels int eh cell membrane. The membrane then depolarizes permitting a Ca influx causing a release of insulin.
SGLT2i
Sodium-glucose Cotransporter 2 Inhibitors
Reduces the reabsorption of glucose thereby increasing urinary glucose excretion to improve glycemic control and weight loss
Which diabetic medication(s) come with a concern of hypoglycemia?
- GLP-1 receptor agonists
- Glinides
- Thiazolidinediones
- Sodium glucose cotransporter 2 inhibitors
- Sulfonylureas
Ratio of basal insulin to rapid-acting insulin in total daily dose (TDD) of insulin
50:50
50% insulin for rapid acting
50% for basal
Insulin to carbohydrate ratio when calculating basal insulin
1:10
1 unit of insulin to 10 grams of carbs
What is wrong with this sentence?
A patients states that she will take her Insulin lispro 30-60 minutes before a meal.
A short duration: short acting insulin should be taken before a meal 15-30 min before a regular acting is 30-60 such as regular insulin that is not commonly used for meals.
What is wrong with this sentence?
“As long as the short-acting insulin is drawn up first I can mix my insulin glargine with it.”
Of the long-acting medications, ONLY NPH the intermediate duration is suitable for mixing with the short action insulins.
What is wrong with this sentence?
A patient states, “My sugars have been around 65-68 at times but I feel the medication is working.”
Patient can have hypoglycemia unawareness. Usually occurs with someone who is practicing tight glycemic control. Loosen tight control for a few weeks to regain hypoglycemic awareness.
What is wrong with this sentence?
A women who is taking Pioglitazone states, “I’m glad that this medication promotes weight loss.”
First this medication promotes increase in LDL levels, which increases cardiovascular risk.
Also, she’s a female so speak about exercise and weight bearing exercise d/t possible increased risk for fractures.
A female patient taking Canagliflozin comes in with a UTI and 6 months ago had a fungal infection. What are your next steps?
Discontinue and change medications
A patient taking Sitagliptin reports abdominal pain with vomiting. What are your next steps?
Discontinue, meds he has pancreatitis.
Who should not take metformin?
- renal insufficiency due to risk of lactic acidosis
- hx of lactic acidosis
- HF
Sulfonylureas should not be used during __________ or with _______ or _______ impairment.
Pregnancy
Hepatic
Renal
Biggest concern with sulfonylureas is hypoglycemia
When is it appropriate to increase insulin need?
When using Pioglitazone
What is the total daily dose of insulin for a person that weighs 70kg?
Total daily dose = weight in kg x 0.6.
50% should be short acting, 50% should be long acting.
In this example 21 basal, 21 bolus
If a person is eating a 50 carb meal, how much short acting insulin will be needed based on the total daily dose of 42?
450 rule for regular insulin
500 rule for rapid acting
500/ total daily dose’
- Example: 500/42 = 11.9 (rounded up to 12) gives you the carb to insulin ratio
- Ratio equals 1:12
- Meal is 50g carbs, 50/12= 4.1 units of insulin for rapid carbohydrate coverage
A patient receives his first lab results showing an AIC of 7.2%. What is the diagnosis?
Recheck again for confirmation of diabetes over 6.5%
An A1C of _________ is considered prediabetic?
5.7-6.4%
A random glucose of ________ is considered diabetic
> 200
A person with diabetes has recurrent severe hypoglycemia events. What should his A1C goal be?
Less stringent A1C goals (such as <8%) may be appropriate for patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite DS
When is it okay for a patient to have an A1C goal of 6.5%?
When there are no hypoglycemic events and the patient can handle it.
How often should an A1C be monitored when stable or when unstable?
Stable - every 6 months
Unstable - every 3 months
A person comes in with an A1C of 10% and a fasting glucose of >300, what are the next steps for the provider?
Combination injectable therapy immediately. If over 9% can start at step 2 with dual therapy.
Function of SLGT-2
Increase glucose excretion via the urine by inhibiting SLGT in the kidney tubules
MOA of Biguanides
- inhibits glucose production in the liver
- reduces glucose reabsorption in the gut
- sensitizes insulin receptors in target tissues to increase glucose uptake
Function of TZD
Decreases insulin resistance and increase glucose uptake by muscle and adipose tissue
Function of DPP-4
Enhance the activity of incretins and thereby increase insulin release, reduce glucagon release
What are some food/supplement interactions that can occur with levothyroxine?
Antacids
Calcium
Iron
how to take it: (morning 30-60 min before eating on an empty stomach
What labs would you order to help diagnosis thyroid conditions?
TSH, T3 free T4, anti TPO
What is the role of Radioactive Iodine and what is a possible adverse effect?
To destroy thyroid tissue with those with hyperthyroidism and/or have not responded to therapy.
Possible hypothyroidism
What adjunctive medication can be used for hyperthyroidism?
Beta blockers and non radioactive iodine
Once a patient reaches a euthyroid state, how often should they be tested?
a. every 6 months
b. once a year
c. every 3 months
d. in 4-8 weeks
B - once a year
A patient has a TSH of .28, a free T4 of 3, and a free T3 over 650. What medication should she be started on?
Methimazole, PTU, radioactive iodine. These labs indicate hyperthyroidism.
Treatment for thyroid storm:
K iodide or strong iodine solution to suppress thyroid release. Methimazole to suppress thyroid synthesis.
A patient is has just been prescribed levothyroxine. The NP put in a lab order to check TSH levels in:
a. 4-6 weeks
b. one week
c. 6-8 weeks
d. once a year
C - 6-8 weeks after initiating therapy
A patient comes into the clinic complaining of sore throat and fever. She has recently started Methimazole in the last 4 weeks. What does this suggest?
Agranulocytosis. Must check CBC and LFTS for infection. Labs may not always catch in time since it progresses rapidly.
Examples of biguanides
- metformin
- glucophage
- fortamet
Examples of sulfonylureas
- glipizide
- gliperamide
- glyburide
Examples of GLP-1
- exanatide
- liraglutide
- dulaglutide
Examples of TZD
- pioglitazone
- rosiglitazone
Examples of DPP-4i
- sitagliptin
- saxagliptin
- linagliptin
- alogliptin
Examaples of SGT2-i
- canagliflozin
- dapagliflozin
- epaglifozin
