Advanced Pharmacology NR 565 Final Exam Questions and Verified Answers

What labs are used to diagnose thyroid problems? Free and total T3 Free and total T4 TSH Anti-TPO Hypothyroidism labs - increased TSH, decreased T3 &T4 hyperthyroidism labs - decreased TSH and increased T3 &T4 When to recheck labs after starting levothyroxine? - 6-8 weeks or after dose change, then 12 months once stabilized S/S hypothyroidism - pale, puffy, and expressionless face, cold and dry skin, brittle hair/hair loss, low heart rate and body temperature, lethargy, fatigue, cold intolerance, mental status changes, thyroid enlargement Think "hypo low and slow" S/S hyperthyroidism - strong and rapid heart rate, dysrhythmias, angina, nervousness, insomnia, rapid thought flow and speech, muscle weakness/atrophy, increased metabolic rate (increased heat production, increased body temperature, heat intolerance), warm/moist skin, increased appetite, weight loss despite increased caloric intake think "hyper as in fast" result of not treating hypothyroidism during pregnancy - permanent neuropsychological deficits in the child. First trimester: fetus unable to produce their own thyroid hormones. Fetal thyroid gland is fully functional in the second trimester. Medication to treat SYMPTOMS of hyperthyroidism - beta blocker (decrease HR) non-radioactive iodine How to take levothyroxine with food? - take on an empty stomach in the morning, 30-60 minutes before breakfast Supplement/drug interactions with levothyroxine - antacids, iron, calcium Confirm diabetes diagnosis prior to treatment - fasting plasma glucose greater than or equal to 126, A random plasma glucose of greater than or equal to 200 plus symptoms of diabetes, an oral glucose tolerance test of two hours, plasma glucose of greater than or equal to 200, or a hemoglobin A1c, a 6.5 or higher (on two occasions) A1c general goal - <7% Older adult A1c goal - <8% When should insulin be considered? - For patients with an A1c >10%, a fasting blood glucose >300 or are markedly symptomatic At what interval should A1c be rechecked? - 2-4 times a year (every 3 months) until A1c drops to 7% and at least every 6 months there after action of insulin - regulation of glucose metabolism. Insulin promotes glucose and amino acid uptake into muscle and adipose tissues, and other tissues except brain and liver. It also has an anabolic role in stimulating glycogen, fatty acid, and protein synthesis First, it stimulates cellular transport (uptake) of glucose, amino acids, nucleotides, and potassium. Second, insulin promotes synthesis of complex organic molecules. Under the influence of insulin and other factors, glucose is converted into glycogen, amino acids are assembled into proteins, and fatty acids are incorporated into triglycerides Pioglitazone (TZD) contraindications - do not give to patients with heart failure or history of bladder cancer GLP-1 - glucagon-like peptide-1 receptor agonist ending in -glutide/tide ex. semaglutide TZD - Thiazolidinedione's end in -ones ex. glitazones DPP4-1 - Dipeptidyl Peptidase-4 inhibitors end in -gliptin ex. gliptins SGLT2i - sodium-glucose contransporter 2 inhibitors end in-flozin Which drug class should be considered for diabetes prior to insulin - metformin Ratio of basal insulin to rapid acting insulin in total daily dose of insulin? - 50% Which diabetic medications come with concern to hypoglycemia? - Amylin Analogues, Insulin, Meglitinides, Sulfonylureas (think these medications AIMS cause hypoglycemia) Treatment of thyroid storm? - K iodine or strong iodine solution to suppress thyroid release and methimazole to suppress thyroid synthesis Preferred treatment is PTU SGLT2i - increase glucose secretion via the urine by inhibiting SLGT in the kidney tubules, decreasing glucose levels and inducing weight loss by caloric loss through the urine higher chance of UTI DPP-4i - Enhance the activity of incretins and thereby increase insulin release, reduce glucagon release, and decrease glucose production by the liver TZD - decreases insulin resistance and increase glucose uptake by muscle and adipose tissue, decrease glucose production by the liver contraindicated in patients with heart failure A newly pregnant mother shows understanding of hypothyroidism in pregnant women by stating - Increase dose up to 50% starting in weeks 4-8 and levels off at week 16 It can cause neurophysiological damage such as IQ, mental development, derangement of growth Biguanide mechanism of action - decreases glucose production by the liver ex. metformin (used for PCOS too) Metformin contraindicated - renal insufficiency d/t risk of lactic acidosis HF A female patient is taking canagliflozin comes in with a UTI and 6 months ago had a fungal infection. What are the next steps? - -flozin (SGlT2i) dc and change medications Methylxanthines- risk for toxicity - Smokers require higher doses. Smoking increases clearance so if you stop smoking levels will rise to toxic levels. Heart disease and liver disease require lower doses. Initial doses are based on weight and age Methylxanthines should be used cautiously in patients that have an untreated seizure disorder or peptic ulcer disease. Overdose/toxicity can cause severe dysrhythmias and convulsions. To manage toxicity, discontinue medication use, and administer activated charcoal plus a cathartic. Have IV lidocaine or amiodarone and IV benzodiazepines on hand if the patient is in the hospital. Older patients are at much higher risk for toxicity when taking methylxanthines. Asthma and COPD - manage with a BLANK as needed - SABA sulfonylureas MOA - Promote insulin secretion by the pancreas stimulate beta cells of the pancreas to secrete more insulin. Stimulates insulin release from pancreatic islet-will only work in DM2. increased risk of hypoglycemic events Do not use it in pregnancy and breastfeeding examples: Glimepiride (Amaryl) Glyburide (DiaBeta; Micronase) Glipizide (Glucotrol) end in -ide GLP-1 MOA - increase in insulin production and inhibit postprandial glucagon release and increase satiety. Suppress appetite/ stimulate weight loss Augment effects of incretin hormone GLP-1 Can also cause pancreatitis so monitor amylase and lipase Use caution if a patient has a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2. 1st line treatment for diabetes - lifestyle changes and metformin Insulin dose calculation - step 1: Calculate TDD by using 0.6 units/kg/day step 2: calculate mealtime carbs by dividing 500 for rapid acting or 450 for regular by TDD step 3: round step 4: ratio step 5: for a 50g carb meal divide 50 by ratio number for insulin coverage number A patient wakes up at night a few times a week, has been using his SABA daily, and has been experiencing symptoms daily, and states he cannot make it up flight of stairs without trouble breathing. What is his severity of his asthma symptoms and what step should be considered? - Moderate persistent asthma Step 3- not well controlled, SABA PRN, low dose IGC and LABA OR medium dose IGC When should roflumilast be indicated for a COPD patient? - reserved for severe cases of COPD with a primary component of chronic bronchitis A patient has been SOB/wheezing 2 days a week with nighttime awakenings two times a month, and has had one exacerbation in the last year. She is currently using a SABA and low dose IGC. What are next steps? Is it well controlled? - Well controlled, re-evaluate 1-6 months. Consider stepping down if well controlled for 3 months. Intermittent asthma For asthma, a LABA has been prescribed, what other medication must a LABA be used with? - combine with glucocorticoid Benefits of using ICS - very effective, safer than systemic, usually minor adverse reactions Examples of SABA drugs - or bronchodilators/short acting Albuterol Levalbuterol isoproterenol terbutaline sulphate Why is it important to know the frequency a patient is using their SABA? - SABA use is a marker of inadequate asthma control Patient instructions/education for SABA - Using a spacer with a one-way valve may improve results Assess peak expiratory flow daily and compare personal best Counsel patients to keep record of these assessments along with symptom frequency and symptom intensity, nighttime awakenings, effect on normal activity, and SABA use Inform patients who are using inhalers that two are needed and an interval of at least 1 minute in between LABA examples - salmeterol formoterol oldaterol LABA use in COPD - preferred over SABA for stable COPD long term control ICS examples - Budesonide Fluticasone Propionate At what point should an oral steroid be prescribed? - moderate to severe persistent asthma or for management of acute exacerbations of asthma or COPD only can be prescribed when symptoms cannot be controlled with safer medications (ICS, inhaled SABA/LABA) risk of toxicity increases with duration of use Bupropion recommended length of treatment - decrease use after 12 weeks Wellbutrin contraindications - can cause neuro psychiatric effects such as mood changes, erratic behavior, and suicidal thoughts. use cautiously in patients with seizures, cocaine abuse, anorexia, and psychiatric disease. drug interactions are MAOI, other bupropion drugs. Nicotine patch patient education - applied once a day to non hairy areas, patch should be changed daily and the site should not be reused for 1 week steady level of nicotine Nicotine gum patient education - chew slowly and intermittently for approximately 30 minutes, rapid chewing can release too much nicotine at one time resulting in nausea, throat irritation, and hiccups. food can decrease nicotine absorption so do not eat while chewing or 15 minutes before bad taste Nicotine nasal spray patient education - fastest delivery and highest nicotine level most irritating, mucous membranes thin How does nicotine replacement work - Decrease nicotine craving and symptoms of withdrawal ex/nicotine patch, gum or nasal spray, lozenges What constitutes drug resistant TB - Multi-drug resistant TB (MDR-TB): resistant to isoniazid and rifampin (2 most effective anti-TB drugs) XDR-TB (most severe form of MDR-TB) is resistant to isoniazid, rifampin, all fluoroquinolones, and at least one of the injectable second line anti-TB drugs (amikacin or capreomycin) Treatment of TB in a pregnant person, what all should be included? - rifabutin is the safest anti-TB drug for use during pregnancy per CDC, benefit justifies risk for isoniazid, rifampin, and pyrazinamide ethambutol is known to cause teratogenesis in animal studies and eye abnormalities in children; benefit must outweigh risk in order to use