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3152 finals > dosing > Flashcards

dosing Flashcards

1
Q

DM goals in sg

A

HbA1cL <7 (7-8.5% for vulnerable)

FBG 5-7mmol/dL

PPG <10 mmol/dL

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2
Q

stringent goal

A

6-6.5%

□ Shorter disease duration

□ Long life expectancy

□ No significant CVS disease

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3
Q

Less stringent goal

A

7.5-8%

□ History of severe hypoglycemia

□ Limited life expectancy

□ Advanced complications

□ Extensive comorbid conditions

□ Unable to attain target even when:
-Intensive SMBG
- Repeated counselling
-Effective pharmacotherapy

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4
Q

diagnose DM in SG

A

2 abnormal test results from same blood sample may be used to diagnose T2DM

HbA1c >7
HbA1c 6.1-6.9%
+
FPG>7mmol/L
2hOGTT >11.1mmol/L

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5
Q

metformin

A

A1c: 1.5 - 2%
regular: 850mg TDS
extended: 1g BD

max 2550mg

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6
Q

metformin dose adj

A

GFR 30-45 = 50% dose reduction
GFR <30 = discontinue

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7
Q

SU A1c

A

A1c: 1.5-2%

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8
Q

TZD A1c

A

A1c: 0.5-1.4%

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9
Q

GLP1 RA ADV

A

ASCVD (benefits
CKD (minimal)
HF (neutral)

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10
Q

GLP1 A1c

A

0.7-1.5%

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11
Q

SGLT2i adv

A

Ascvd (CE)
CKD (D)
HF (DE)

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12
Q

SGLT2i dose

A

0.8 - 1%

dapaglifozin 5mg OD (max 10mg)

empagliflozin 10mg OD (25mg max)

canaglifozin 100mg OD (max 300mg)

CONTINUE EVEN IF <30mL/min unless not tolerated/ kidney repalcement therapy

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13
Q

a-glucosidase inhibitor A1c

A

acarbose
0.5-0.8%

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14
Q

DPP-4 agonist

A

0.5 - 0.9%

sitagliptin crcl 30-50
ESRD, severe renal impairment

linagliptin
- no renal adj

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15
Q

when to start insulin

A

Catabolism (weight loss)
symp of Hypergly
A1c > 10%
BGL > 16.7 mmol/L

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16
Q

start basal insulin

A

10 IU NPH ON

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17
Q

titrate basal insulin

A

incr 2 unit every 3 days

incr 4 units every 3 days (if FPG > 10mmol/l)

decr 10-20% if hypoglycemia

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18
Q

when to start prandial insulin

A

1) FBG at goal (5-7) but HbA1c above goal

2) basal dose maxed (0.5IU/kg)

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19
Q

initiate prandial insulin

A

1) 10% of basal insulin dose / 4U
2) split bedtime NPH (2/3 AM, 1/3 PM)

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20
Q

titrate basal when added prandial

A

if (A1c <8%)

reduce basal by 4IU/ or by 10%

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21
Q

dose conversion of insulin

A

decr 10-20% if pt hypoglycemic

decr 20% for
1) BD NPH –> OD glargine/ detemir

2) glargine-300 –> basal insulin

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22
Q

changes in regimen after adding insulin

A

SGLT2i (continue)
metformin (continue)

TZD (decr/ stop – hypogly)

SU (decr/ stop when basal added – if pt hypogly) (or can wait until prandial added)

DPP4i (stop if GLP1 added)

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23
Q

range for TH and TSH

A

T4: 0.8-2.7 ng/dL

TSH: 0.4-4.2 MIU/L

  • goal for hypoTH (0.4-4mIU/L)
  • goal for elderly TSH 6.9
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24
Q

screening of thyroid in which pop

A

ROUTINE TEST FOR: (risk developmental risk)
- Preg
- Pediatric pt

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25
Q

compelling indications for screening

A

1) Presence of autoimmune disease (T1DM, cystic fibrosis)

2) 1st degree relative w/ autoimmune thyroid disease (genetics)

3) Psychiatric disorders
- TH abnormality affects psychiatric

4) Take amiodarone/ lithium

5) History of head/ neck radiation for malignancies
- Radiation predisposes

6) Symptoms of hypo/ hyperthyroidism

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26
Q

diagnosis of hyperthyroidism labs

A

1* hypothyroidism
- HIGH TSH, LOW T4
- +ve Ab (TPO, ATgA)

Central hypothyroidism
- LOW TSH, LOW T4

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27
Q

diagnosis for hyperthyroidism labs

A
  • HIGH FREE T4
  • LOW TSH (except in TSH-secreting adenomas)
  • RAIU (radioactive iodine uptake)
  • Presence of TRAb, ATgA, TPO
    Biopsy
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28
Q

RAIU meaning

A

Used to better see if the gland is ACTIVELY secreting TH

INCR UPTAKE:
○ Graves, TSH-secreting adenomas, toxic adenoma, multinodular goiter

DECR UPTAKE:
○ Thyroiditis, cancer

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29
Q

levothyroxine initiate dose

A

young, healthy: 1.5-1.6 mcg/kg/day
50-60 yo, no CVD: 50mg/day
50-60 yo, CVD: 12.5-25mcg/day

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30
Q

titrate levothyroxine doses

A

incr/decr 12.5-25 mcg/day
10-20% of weekly dose

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31
Q

admin for levothyroxine

A

30-60mins before meal
4hr after dinner
2hrs apart from Ca, Milk, Fe, Antacid, Biphosphonate

32
Q

monitor for hypoTH levothyroxine tx

A

2-3mnths for TSH to respond
2-3wk for sx relief

central hypo: monitor FT4

33
Q

start tx for hypoTH

A

TSH > 10mIU/L (decr risk of CHD)
TSH 4.5 - 10 AND (sx of hypoTH/ TPO ab/ CVS risk)

inititate at 25-75 mcg of levothyroxine

34
Q

monitor for hypoth euthyroid state

A

thyroid function test recommended semiannually to annually

in nonpreg adults pt

35
Q

HYPOTH and preg

A

incr dose by 30-50% to counter for rise in TBG

1st trimester TSH: <2.5 MIU/L
2nd trimester TSH: <3 MIU/L
3rd trimester TSH: <3.5 MIU/L

36
Q

monitor and titrate carbimazole, propylthiouracil by

A

monitor: 4-6mnth for max sx effect.
thyroid size, TSH levels

monthly dose titrate as needed based on FT4, Sx

37
Q

why not monitor TSH in hyperthyroidism

A

TSH remains suppressed for many mnths (1-2yrs)

38
Q

why slow onset in reducing sx

A

max effect takes 4-6mnths
- needs to deplete stored T4 lvls

39
Q

remission in hyperTH means

A

decr size, normal TSH and T4 for 1yr after discontinuation of antithyroid therapy

40
Q

iodides for hyperTH

A

1) Before surgery (7-10 days) = shrink

2) After ablation (3-7days) = inhibit thyroiditis mediated release of stored TH (BURST)

3) Thyroid storm (too much TH)

41
Q

PRE-ECLAMPSIA End organ damage

A

LFT > 2x UNL
SCr 2x
PLT <100
Pul oedema
Neurological complications

42
Q

PRE-ECLAMPSIA proteinuria

A

24h urinary portein > 300mg
Dipstick > 2+
Urine Cr > 0.3 mg/dl

43
Q

estrogen dosing

A

High dose: 50ug
Mod, standard 30-35
Favour lower (20-25mcg)
Low dose: 15-20ug

44
Q

prevent pre-eclampsia

A

Low dose aspirin 100mg PO
12-16wks, until delivery

  • High risk pt
  • HTn previous preg
  • Multifestation preg
  • Autoimmune disease
  • CKD, DM
45
Q

Favour lower (20-25mcg)

A

○ Adolescene
○ Underweight <50kg
○ Age > 35yrs
○ Peri-menopause
○ Fewer ADR

46
Q

High dose: 50ug

A

○ Obese, >70.5kg
○ Early-mid cycle breakthrough bleed, spot
○ Non adherence
○ ADR: vascular embolic events, Cancers

47
Q

menopause PO (uterus intact)

A

1) Continuous cyclic
□ Prog added on either 1st/ 15th of mnth for 10-14days only

-Only if perimenopausal stage

2) Continuous-combined
□ Estrogen & progestin daily
- Amenorrhea take place after several mnths

48
Q

initiate HRT must monitor for

A
  • Annual mammography
  • Endometrial surveillance
    ○ Unopposed estrogen: any vag bleeding
    ○ Continuous cyclic (E/P off)
    § If bleed occur when P on
      ○ Continuous-combine (E/P)
      § If bleed prolonged
      §  heavier than normal
      §  freq
      §  persists after treatment for > 10mnths
49
Q

Assessment of BPH (7)

A

Digital rectal exam
Ultrasonography
Max urinary flow rate (Qmax)
Prostate size (<25g)
Prostate specific antigen (PSA) > 1.5ng/mL
post void residual >200mL
AUA-SSI

50
Q

Tadalafil

A

(5mg PO daily)

36hr before intercourse

Can be taken DAILY
* Onset: 15min-2hr
* Duration of action: 36h
* Consideration
○ Regardless of food
Hep, renal adj

51
Q

meds that affect BPH

A
  • Anticholinergics
    • Decr bladder musc contractibility
      ○ Antihist, tricyclic antidepressants (TCAs)
  • A1 adrenergic AGONIST
    • Contract prostate smooth muscles
    • Decongestants (Pseudoepinephrine)
  • Opioid analgesic
    • Incr urinary retention
  • Diuretic
    • Incr urinary frew
  • Testosterone
    *Stimulate prostate growth
52
Q

Medication induced ED

A

BP – clonidine, methyldopa, BB (Xnevibolol), thiazide diuretic
anticholinergic – TCA, 1st gen antihist, phenothiazines
dopamine – metoclopramide
serotonin selective reuptake inhibitors
5a reductase inhibitors – finasteride, dutasteride
CNS depressants – benzodiazepines, anticonvulsants

53
Q

Testosterone replacement

A

Restore serum testosterone lvl to normal range (300-1100 ng/dL; 10.4-38.2 nmol/L)

54
Q

monitor for testosterone replacement

A
  • 1-3mnths
  • 6/12mn interval

Discontinue if no improvement after 3mn (high risk for SE)

55
Q

when to take PDE5i

A

S - 1hr before, empty stomach
V - 1hr before, empty stomach
T - 36hr before, regardless of food
A - 30mins before, regardless of food

56
Q

PDE5i ADR

A

hypotension, priapism, hearing loss
S - PDE6
V - PDE6, QTc
T - PDE11 muscle ache
A -

57
Q

when can take nitrates + PDE5i

A

Avoided for 12hrs after avanafil

24hrs after sildenafil, vardenafil

48hrs after tadalafil

58
Q

why is nitrite CI for PDE5i

A

NO acts as vasodilator, worsens hypotension with the use of PDE5i, which also inhibits degradation of cGMP, leads to smooth muscle relaxation, causing vasodilation

59
Q

initiate low dose PDE5i

A

Low dose esp for:
○ Pt > 65yo
○ Alpha blockers
○ Renal failure pt
○ CYP3A4 inhibitors Incr serum conc of PDE5i

60
Q

monitoring for PDE5i

A

Efficacy
○ Failure reported:
§ Admin w/ food
§ Time, freq of dosing
§ Sexual stimulation
§ Titration to max dose

Safety (BP, ADR, DDI – GTN, hypertensives, alcohol, CYP3A4i)

Change in cardiac health status

61
Q

ADR of PDE5i

A
  • Headache
  • Rhinitis
  • Flushing
  • Muscle and back pain (PDE11)
  • Dizziness
  • Hypotension
  • Prolonged erections, priapism
    ○ Blood trapped inside)
    ○ Seek ED if >4hrs
  • Sudden hearing loss
    *Tinnitus and dizziness
  • S,V = Nonarteritic anterior ischemic optic neuropathy (NAION) PDE6
62
Q

considerations of alprostadil

A
  • (unlike PDE5i): no need sexual stimulation to work
    • Fast onset: 5-10mins
    • DDI: not used with PDE5i
  • DF:
    1) Intraurethral
    2) Intracavernosal
63
Q

tx considerations for ED

A
  1. PDE5i as 1st line agent
    a. All have similar efficacy profile
    b. Diff onset, duration of action, SE profile
  2. Alprostadil
    a. Avoided due to priapism & pain
  3. Testosterone 1st line if
    a. ED + symptomatic hypogonadism
    b.Consider SE
64
Q

meds that affect BPH

A

TOAAD

  • testosterone
  • opioid analgesic
  • anticholinergics
  • a1 adrenergic agonist
  • diuretic
65
Q

Anticholinergics

A
  • Decr bladder musc contractibility
    ○ Antihist, tricyclic antidepressants (TCAs)
66
Q

A1 adrenergic AGONIST

A
  • Contract prostate smooth muscles
    • Decongestants (Pseudoepinephrine)
67
Q
  • Opioid analgesic
A
  • Incr urinary retention
68
Q

Diuretic

A
  • Incr urinary freq
69
Q

Testosterone

A

*Stimulate prostate growth

70
Q

Medication induced ED (organic)

A

anticholinergic
bp
CNS depressant
dopamine

serotonin selective reuptake inhibitor
5a reductase inhibitors

71
Q

Anticholinergics

A

TCA, 1st gen antihist, phenothiazines
○ MOA: decr Ach activity
○ Alt: bupropion, trazodone, 2nd gen antihistamine, atypical antipsychotics 2nd gen

72
Q

BP

A

clonidine, methyldopa, BB (Xnevibolol), thiazide diuretic
○ MOA: Decr penile blood flow
○ Alt: nebivolol, ACEi, ARB, loop diuretic

73
Q

CNS depressants

A

(benzodiazepines, anticonvulsants)
○ MOA: suppress perception of psychic stimulus
○ Alt: anticonvulsant - valproic acid, gabapentin

74
Q

dopamine

A

(metoclopramide)
○ MOA: decr ACh activity
○ Alt: PPI, erythromycin

75
Q

SSRI

A

○ MOA: incr serotonin in brain, decr testosterone
○Alt: bupropion, trazodone

76
Q

5a RI

A

(finasteride, dutasteride)
○ MOA: decr testosterone
○ Alt: (a-blockers) terazosin, alfuzosin

3152 finals (9 decks)

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