Chamberlain College: NR566 weeks 1-3 midterm review questions_ LATEST
Week 1
Professor question: Why are statins recommended in the evening instead of morning? (pg 561)
After starting John on insulin, he calls the office saying he feels bad. He said when he checked his blood sugar before calli...
Professor question: Why are statins recommended in the evening
instead of morning? (pg 561)
After starting John on insulin, he calls the office saying he feels bad. He said
when he checked his blood sugar before calling it was 52 mg/dl. What
instructions should he be given?
Answer from classmate: Statins are recommended to be taken in the
evening. Cholesterol synthesis is highest through the night and first thing in
the morning. The biosyntheses of cholesterol follows a normal circadian
rhythm. Administration at night allows for the medication to be at peak levels
in the body during the time of high cholesterol synthesis (Korani et al.,
2019).
A blood glucose level <70mg/dL is considered to be hypoglycemia. John
called the office with a sugar of 52mg/dL. He would be given instructions
that follow "the rule of 15". This means that when symptoms occur, he
should consume 15 g of a fast-acting carbohydrate. After 15 minutes, he
should recheck his blood glucose. John should also be educated on the
best options of carbohydrates to consume. Examples would be 4 oz of
juice, four-five hard candies, honey, or half a can of regular soft drink.
Another education point is that John needs to have a meal within a few
hours after the low blood glucose. He may also need to see his doctor for
adjustments to be made on insulin dosage as well as meal patterns to help
prevent another low blood glucose episode from occurring (Woo &
Robinson, 2016).
Professor question: What diabetic medications would be contraindicated
in patients with heart failure?
Which diabetic drug(s) may have beneficial effects in heart failure?
(text has info on this but ADA 2020 guidelines has even more up to date
info on this topic, so here is the page. See Recommendation 9.9 and
9.10)
answer from classmate: Suppose John was showing signs of heart failure.
What diabetic medications would be contraindicated in patients with heart
failure?
Metformin is contraindicated in patients with renal insufficiency and
,unstable heart failure (Woo & Robinson, 2016). According to the American
Diabetes Association (2020), Metformin can be utilized in patients with
stable heart failure, not currently hospitalized, and Glomerular filtration rate
should be greater than 30 ml per hour. In this instance, John should be
switched to fast acting insulin Humalog, to cover mealtimes
,and if his HgbA1C is not sufficiently controlled at the 3 month follow up
then, long acting Lantus insulin should be added to the regime.
Additionally, John should be placed on an Angiotensin Converting Enzyme
inhibitor or Angiotensin Receptor Blocker and likely increase his
atorvastatin to 20mg tablet (ADA, 2020).
Which diabetic drug(s) may have beneficial effects in heart failure?
With the scenario presented previously and with the addition of heart
failure, John should be placed on either a sodium-glucose cotransporter 2
inhibitor (SGLTi) or a glucagon-like peptide 1 receptor agonist (GLP-1 RA)
to improve glycemic management (ADA, 2020a). Both SGLT2i and GLP-1
RA have demonstrated cardiovascular disease benefits by reducing CVD
events and HF hospitalizations in association with diabetes mellitus (ADA,
2020b). The differential in which medication to use for John would be
based on his Glomerular Filtration Rate (GFR), decreasing GFR rates or
worsening chronic kidney disease would indicate stoppage of SGLT2i and
use of GLP-1 RA. Per the American Diabetes Association (2020), John
with mild HF would be initially placed on a GLP 1- RA Liraglutide (Victoza).
Victoza is a once daily injection that aids
in treating T2DM by increasing insulin synthesis and release, decreasing
amount of glucagon and gastric emptying, and reducing food intake (Woo
& Robinson, 2016).
Additionally, placing John on a GLP-1 RA would help decrease his
obesity with its proven beneficial tendency to increase metabolism and
improve weight loss (Woo & Robinson, 2016).
Professor question: What lab do we need to check prior to starting
metformin? (hint: which organ function needs to be evaluated?)
What other potential adverse effects are there associated with metformin?
(Micromedex in the library is a good source for this info)
Answer: The most important lab is eGFR/renal function since this
determines whether we can safely use metformin. See recommendations
below.
I also included information on contrast administration. The concern is that
if dye impairs renal function, the risk of lactic acidosis is increased.
Another potential adverse effect is B12 deficiency.
"Clinical recommendations based upon the patient’s renal function
, • Before initiating therapy, obtain an eGFR
• Initiation of therapy is not recommended in patients with eGFR
between 30 –45 mL/minute/1.73 m²
• Obtain an eGFR at least annually in all patients receiving therapy
• In patients at increased risk for development of renal
impairment (e.g., the elderly), renal function should be assessed
more frequently
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