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NAPLEX BABY > Endocrine Conditions* > Flashcards

Endocrine Conditions* Flashcards

1
Q

Gestational Diabetes

A

Risks to baby:
-macrosomia (large baby- puts on a lot of fat)
-hypoglycemia at birth
-obesity and type 2

Management:
-lifestyle first
-insulin is drug of choice , use if needed
-Metformin and glyburide (not preferred but may be considered)

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2
Q

Goals for diabetes in pregnancy

A

Fasting: < 95 mg/dL
1 hour post meal: < 140
2 hour post meal: < 120

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3
Q

Complications from hyperglycemia: microvascular disease

A

-retinopathy
-nephropathy
-neuropathy
-ED
-gastroparesis
-loss of bladder control

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4
Q

Complications from hyperglycemia: macro vascular disease

A

-ASCVD: CAD,MI,CVA,PAD

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5
Q

DM: diagnosis and treatment goals

A

A1c: >/ 6.5%
FBG: >/ 126
Random BG: >/200

pregnant:
preprandial: < 95
1 hr PPG: </140
2 hr PPH: </120

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6
Q

Vaccines to get if pt has DM

A

-Hep B
-pneumococcal vaccine age 19-64
–> Prevnar 20 (PCV20) x1 OR
–> Vaxneuvance (PCV15) x1, then Pneumovax 23 (PPSV23) x1, 12 months later
-shingrix

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7
Q

Metformin (Glucophage, Fortamet, Glumetza)

A

MOA: dec glucose from liver, inc insulin sensitivity

BBW: lactic acidosis
CI: eGFR < 30, metabolic acidosis
Warnings: do not initiate if eGFR 30-45, d/c if hypoxia, temp d/c prior to IV iodinated contrast dye, vit B12 deficiency with longterm use
SE: diarrhea, nausea, flatulence, dyspepsia

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8
Q

GLP-1s for DM2

A

-Liraglutide (victoza), Dulaglutide (Trulicity), semaglutide (ozempic)
MOA: “incretin secreting”, slows gastric emptying
BBW: pancreatitis, not rec in severe GI disease
SE: weight loss, nausea, diarrhea

-do not use with DPP4s

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9
Q

SGLT2s

A

-Canagaflozin (Invokana), Dapagliflozin (Farxiga), Empagaflozin (Jardiance)

-benefits in pts with HF, CKD, and/or ASCVD

BBW: cana - foot//leg amputations (dont pick with any foot issues)
CI: eGFR < 30
Warnings: ketoacidosis, genital mycotic infections, pyelonephritis, nec. fes, hypotension, AKI, fractures (cana), bladder cancer (dapa)
SE: weight loss, inc urination, inc thirst

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10
Q

Thiazolidinediones

A

-Pioglitazone (actos), rosiglitazone (Avandia)
MOA: increase sell sensitivity to glucose

BBW: can cause or exacerbate HF
CI:HF class 3/4
Warnings: hepatic failure, bladder cancer (P only), edema, fractures, resumption of ovulation
SE: peripheral edema, weight gain, fractures, URTIs

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11
Q

DPP-4 inhibitors

A

Sitagliptin (Januvia), Linagliptin (Tradjenta) - no renal adjustment

Warnings: pancreatitis, severe arthralgia, acute renal failure, HF (saxa & alo), hepatotoxicity (alo)
SE: nasopharyngitis, headache
-weight neutral

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12
Q

Sulfonylureas

A

-Glipizide (Glucotrol), Glimepiride (Amaryl), Glyburide (Glynase- not preferred) - BEERS LIST

-take with meals (breakfast), glipizide IR: take 30 mins before breaky

-do not use with meglitinides
SE: hypoglycemia, weight gain

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13
Q

Meglitinides

A

-Repaglindine (Prandin), Nateglindine (Starlix)
MOA: stimulates insulin secretion from beta cells
-take 1-30 mins before meals
-do not use with sulfonylureas
SE: hypoglycemia, weight gain

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14
Q

Amylinomimetic (Amylin Analog)

A

Pramlintide (Symlin)
–> used for both type 1 & 2 dam; lowers insulin requirement
MOA: Amylin is produced by the pancreatic beta cells to control glucose: slows gastric emptying

BBW: increased risk of hypoglycemia with insulin (when starting, dec mealtime insulin dose by 50%)
CI: gastroparesis, hypoglycemia unawareness
SE: N/V, anorexia, hypoglycemia, headache, weight loss

-give at meal-times, as separate injections, skip dose if < 30 g carbs

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15
Q

rapid acting insulin facts

A

-aspart, lispro, glulisine
-controls mealtime BG, onset ~ 15 mins, peaks 1-2 hrs and lasts 3-5 hrs

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16
Q

regular insulin facts

A

used for mealtime BG control, onset is 30 mins, peaks ~2 hrs ad lasts 6-10 hrs

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17
Q

Basal insulin: Detemir facts

A

long acting, providing baseline coverage
-onset 3-4 hrs, lasts ~1 day with no peak

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17
Q

Intermediate acting insulin facts

A

-NPH
-onset 1-2 hrs, peaks 4-12 hrs and lasts 14-24 hrs

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18
Q

Basal Insulin: Glargine facts

A

-long acting, onset 3-4 hrs (Tuojeo lasts 6 hrs), lasts ~1 day with no peak

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19
Q

Basal insulin: Deglutide facts

A

starts faster and lasts longer, onset ~ 1 hr and lasts 42+ hours with no peak

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20
Q

All insulin SE/warnings

A

CI: Afrezza inhaled insulin- any lung diease, including asthma and COPD, do not use Afrezza in smokers
Warnings: hypoglycemia, hypokalemia: insulin facilitates K+ entry into cells
SE: weight gain, lipatrophy, lipphypertrophy
Notes:
-do not shake: turn suspensions (NPH, Protamine mixes) up/down slowly or roll between hands
-store unopened insulin vials and pens in the refrigerator

DDI:
-Rosiglitazone: inc risk of HF, do not use with insulin
-Pramlintide: dec meal time insulin by 50%
-Consider dec insulin with SGLT2 inhibitors, GLP-1 RAs, TZDs, DPP-4 inhibitors

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21
Q

Rapid acting insulins

A

-Aspart (Novolog, Novolog FlexPen, Fiasp, Fiasp FlexTouch)
-Glulisine (Apidra, Apidra Solostar)
-Lispro (Humalog, Humalog KwikPen) - 100, 200 units/mL

Dosing: given up to 15 mins before or immediately after meals

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22
Q

Inhaled Insulin

A

-Afrezza: inhale at the beginning of meals
BBW: do not use in pts with chronic lung diseases such as asthma or COPD
Warnings: not recommended in smokers
-monitor FEV1

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23
Q

Short acting insulin

A

-Regular Insulin (Humulin R, Novolin R)
–> insulin of choice for IV infusions
–> used as prandial insulin + for correction doses

-Concentrated Regular insulin (U-500):
–> 5 x as concentrated, recommend only when pts require > 200 units of insulin per day

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24
Q

Intermediate Acting Insulin

A

NPH (Humulin N, Novolin N, ReliOn N)
-cloudy
-can be given as basal insulin, typically dosed BID, as an add on to oral drugs- has more hypoglycemia risk

-can mix with rapid and short acting insulins

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25
Q

Long-acting insulins

A

-Insulin detemir (Levemir)
-Insulin glargine (Lantus, Lantus SoloStar, Basaglar KwikPen, Toujeo SoloStar, Toujeo Max SoloStar)
–> Lantus is 100 units/mL
–> Toujeo is concentrated at 300 units/mL
-Insulin degludec (Tresiba FlexTouch)
–> comes in 100 and 200 units/mL

-all usually injected once daily

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26
Q

Pre - mixed insulins

A

-Humalin 70/30, Novolin 70/30 (70% NPH, 30% regular)
-Novolog mix 70/30 (70% aspart protamine, 30% aspart)
-Humalog mix 70/30 (70% lispro protamine, 30% lispro)
-Humalog mix 50/50 ( 50% lispro protamine, 50% lispro)

-given BID or TID

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27
Q

Insulin dosing in DM1

A

1) calculate TDD (0.5 units/kg/day, using TBW)
2) divide the TDD into 50% basal and 50% bolus
3) divide the bolus insulin evenly among 3 meals

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28
Q

Insulin Conversions

A

most conversions are 1:1

EXCEPTIONS:
1) BID NPH to qd insulin glargine (Lantus, Toujeo, Basaglar)
–> use 80% of total daily NPH dose as initial insulin glargine dose
2) once daily Toujeo to once daily Lantus or Basaglar:
–> use 80% of the total daily Toujeo dose as the inital Lantus or Basaglar dose

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29
Q

Selecting an Insulin Syringe

A

-0.3 mL up to 30 units
-0.5 mL for 30-50 units
-1 mL for 51-100 units

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30
Q

Meal time insulin dosing

A

A: ICR rule of 450 for REGULAR
450/ total daily dose of insulin (TDD)

B: ICR rule of 500 for RAPID- ACTING
500/total daily dose of insulin (TDD)

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31
Q

Calculating correction factor: regular insulin

A

-rule of 1500

1500/ total daily dose of insulin = correction factor for 1 unit of regular insulin

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32
Q

Calculating the correction factor: Rapid-acting

A

-rule of 1800
1800/total daily dose of insulin = correction factor for 1 unit of rapid-acting insulin

33
Q

Calculating the correction dose (for both types of insulin)

A

(BG now) - (target BG) / correction factor = correction dose

34
Q

Room temp stability of insulin: 1-2 weeks

A

-Humalog Mix 50/50 and 75/25 pens
-Humulin 70/30 pen

~10 days

35
Q

Room temp stability of insulin: 2 weeks

A

Humulin N pens
Novolog Mix 70/30 pens
-14 days

36
Q

Room temp stability of insulin: ~4 weeks

A

-Apidra, Humalog, Novolog, Admelog, Lyumjev, Fiasp vials and pens
-Humalog Mix 75/25 vial
-Novolog mix 70/30 vial
-Novolin R U-100, N and 70/3- pens
-Humulin R U-500 pen
-Lantus, Basaglar, Semglee vials and pens
-all 28 days
-Humulin R U-100, N and 70/30 vials (31 days)

37
Q

Room temp stability of insulin: ~6 weeks

A

-Humulin R U-500 vial (40 days)
-Novolin R U-100,N and 70/30 vials
-Levemir vial and pen
–> both 42 days

38
Q

Room temp stability of insulin: 8 weeks

A

-Tresiba pen
-Toujeo pen
56 days

39
Q

Hypoglycemia

A

-BG < 70
Symptoms: dizziness, anxiety, shakiness, HA, sweating, hunger, confusion, tremors, palpitations
–> SEVERE: seizures, coma, death

TX:
-take 15 g of sugar (juice, milk, soda, glucose/glucose tabs)
-IV dextrose or glucagon

40
Q

Causes of hypoglycemia

A

-insulin, sulfonylureas, meglitinidis
-Linezolid, lorcaserin (Belviq), Pentamidine, BBs, quinolines, tramadol

-Low risk when used alone: GLP-1, DDP-4, TZD, SGLT2s

41
Q

Drugs that cause hyperglycemia

A

-BBS, tzds, diuretics, tacrolimus, cyclosporine, protease inhibitors, quinolones, antispychotics, statins, steriods, cough syrups, niacin

42
Q

Hyperglycemia: DKA

A

-BG > 250
-ketones, abdominal pain, N/V, dehydration
-anion gap (pH < 7.35, anion gap > 12)

43
Q

Hyperglycemia: HHS

A

-confusion, delirium
-BG > 600 mg/dL with high serum osmolarity > 320 mosm/mL
-extreme dehydration
-pH > 7.3, bicarb > 15

44
Q

Treatment of HHS and DKA

A

1) fluids: NS (when BG 200 –> D5W with 1/2 NS)
2) regular insulin IV: 0.1 u/kg bolus then 0.1u/kg/hr continuous infusion OR 0.14 u/kg/hr continuous infusion
3) prevent hypokalemia: keep K levels between 4-5 mEq/L
4) tx acidosis if pH < 6.9 - give bicarb

45
Q

DM drug safety issues and what drugs to avoid with each condition

A

-cancer (thyroid): GLP1
-gasteroparesis: GLP-1, pramlintide
-genital infection/UTI: SGLT2
-HF: TZD, alogliptin, saxagliptin
-hypoglycemia: insulin, sulfonylureas, meglitinides, pramlintide
-hypotension/dehydration: SGLT2
-hypokalemia: insulin
-ketoacidosis: SGLT2
-lactic acidosis: metformin
-Osteopenia/osteoporosis: canagliflozin
-peripheral neuropathy: canagliflozin
-severe sulfa allergy: sulfonylureas
-renal issues < 30: metformin
-weight gain/obesity: sulfonylureas, meglitinides, TZD, insulin

46
Q

Hypothyroidism: signs and symptoms

A

-cold intolerance
-dry skin
-fatigue
-constipation
-weight gain
-voice changes
-weakness
-depression
-menorrhagia (heavy period)

47
Q

Hypothyroidism

A

Presentation: decreased metabolism
Causes: Hashimoto’s disease (autoimmune, destroys thyroid gland), Iodine deficiency, drugs etc
Diagnosis:
-T4 low
-TSH high
Monitoring: TSH tested, monitor every 4-6 weeks until normal, then 4-6 months later then yearly

–> Myxedema coma: EMERGENCY –> poor circulation, hypothermia, hypo metabolism
TX: IV levothyroxine

48
Q

Select drugs that can cause hypothyroidism

A

-Interferons
-Tyrosine Kinase Inhibitors (Suntinib)
-Amiodarone
-Lithium
-Carbamazepine
( I TALC)

49
Q

TX of hypothyroidism: Levothyroxine, T4 (Synthroid, Levoxyl, Clnithroid)

A

-full replacement dose = 1.6 mcg/kg/day (IBW)
-take 60 mins before breaky (w/water), can take at bedtime (at least 3 hrs after the last meal)
*IV:PO = 0.75:1
-cardiac/elderly conditions: start at standard 25 mcg dose

50
Q

Levothyroxine tablet colors*

A

(Orangutans Will Vomit On You Right Before They Become Large, Proud Giants)

Orange = 25 mcg
White = 50 mcg
Violet = 75 mcg
Olive = 88 mcg
Yellow = 100 mcg
Rose = 112 mcg
Brown = 125 mcg
Turquoise = 137
Blue = 150 mcg
Lilac = 175 mcg
Pink = 200 mcg
Green = 300 mcg

51
Q

Hyperthyroidism

A

Presentation: increased metabolism
Causes: Graves disease (autoimmune- antibodies stimulate the thyroid to increase T4), thyroid nodule, certain drugs, excess thyroid hormone replacement

52
Q

Signs and Symptoms of Hyperthyroidism*

A

-heat intolerance/sweating
-agitation
-palpitations/tachycardia
-light/absent menstrual periods
-diarrhea
-weight loss
-tremor
-thinning hair
-exophthalmos

53
Q

Treatment of Hyperthyroidism

A

-radioactive iodine - historically the tx of choice in graves disease
-thyroidectomy (partial or complete)
Drugs:
-Propylthiouracil (PTU) - used in thyroid storm and 1st trimester of prego
-Methimazole: drug of choice, used in 2nd and 3rd trimester
-BBS to control symptoms
-temporary effect from potassium iodine (Lugol’s solution) or saturated solution of potassium iodine (SSKI)

54
Q

Potassium Iodine use after exposure to radiation

A

-risk of radiation: thyroid cancer

Potassium Iodine treatment:
-blocks accumulation of radioactive iodine in the thyroid gland
-prevents thyroid cancer
-take as soon as possible after exposure
-dosing available on CDC website

55
Q

Thyroid Strom

A

-life threatening emergency
Signs and symptoms*: fever (> 103), tachycardia, tachypnea, dehydration, profuse sweating, agitation, delirium, psychosis, coma

Treatment:
1- PTU 500-1000 mg LD then 250 mg q 4h +
2- SSKI or Lugols +
3- BB (propranolol 40-80 mg PO Q 4 H) +
4- systemic steroid (Dexamethasone 2-4 mg PO q6H)
and aggressive cooling with APAP and cooling blankets

56
Q

Pregnancy and hypothyroidism

A

-levothyroxine
-will require a 30-50% increase in the dose

57
Q

Pregnancy and Hyperthyroidism

A

-postpone pregnancy until euthyroid (if able)
-mild. disease: tx may be stopped
-if tx is needed:
–> propyithiouracil preferred in 1st trimester
–> methimazole preferred fro remainder of pregnancy

58
Q

Cushings Syndrome

A

-develops when the adrenal gland produces too much cortisol or high dose steroids
Complications of high dose steroids: psychiatric changes, glaucoma, acne, DM/BG, GI bleeding, fat depositis in face/buffalo hump, poor bone health, infection etc

59
Q

Ways to reduce systemic steroid risks

A

-use EOD dosing
-for joints- inject into the joint
-use lowest dose for the shortest period of time
-inhaled steroids for asthma

60
Q

Systemic steroids Dose Equivalent*

A

Least potent to most potent:
Short acting:
–> cortisone 25 mg
–> hydrocortisone 20 mg
Intermediate acting:
–> Prednisone 5 mg
–> Prednisolone 5 mg
–> methylprednisolone 4 mg
–> Triamcinolone 4 mg
Long-acting:
–> Dexamethasone 0.75 mg
–> Betamethasone 0.6 mg

61
Q

Immunosuppression and glucocorticoids

A

if pt is on >/ 2 mg/kg/day or >/ 20 mg/day of prednisone or prednisone equivalent for > 2 weeks:
-should not be given live vaccines
-should do steroid taper

62
Q

Glucocorticoids short term SEs

A

-Dexamethasone (Decadron), Hydrocortisone (Solu-cortef), methylprednisolone (medrol), prednisone (Deltasone), Prednisolone (millipred, Orapred ODT), Triamcinolone (Kenalog)
taking < 1 month
-can worsen DM,l HTN, glaucoma, psychiatric conditions
-inc appetite/weight gain, emotional instability, insomnia

63
Q

Rheumatoid arthritis (RA)

A

-chronic, bilateral and symmetrical joint swelling, pain, stiffness, deformity

Lab test:
-RF (non specific)
-Anti-citrullinated peptide antibody (ACPA) - more specific

64
Q

TX for RA: Non-Biologic DMARDs: Methotrexate (Otrexup, Rasuvo, Trexall, Xatmep)

A

-inhibits dihydrofolate reductase
-low WEEKLY dose (PO, SC, IM)
BBW: hepatotoxicity, myelosuppression, mucositis/stomatitis, pregnancy = fetal for fetus
SE: inc LFTs, stomatitis, alopecia (give folic acid supp on the day after MTX to decrease SEs
Monitor: CBC. LFTs, chest x-ray, hep B and C

65
Q

TX for RA: Non-Biologic DMARDs: Hydroxychloroquine (Plaquenil)

A

-use 2nd line or when worried about liver disease with MTX
Warnings: irreversible retinopathy (eye exam for muscle strength before starting)
SE: N/V/D- take with milk or food

66
Q

TX for RA: Non-Biologic DMARDs: Sulfasalazine (Azulfidine)

A

CI: SULFA & SALICYLATE ALLERGY!
Warnings: blood dyscrosias, SJS/TENS, heaptic failure
SE: HA, anorexia, N/V/D
–> can cause yellow/orange discoloration of skin/urine
-impairs folate absorption

67
Q

TX for RA: Non-Biologic DMARDs: Leflunomide (Arava)

A

BBW: embryo-fetal toxicity (strict pregnancy testing and BC reqs - must wait 2 yrs after d/c to try or eliminate drug with 2 options)
-prodrug = teriflunomide
Accelerated drug elimination options:
–> Cholestyramine 8 g PO TID x 11d
–> Activated charcoal suspension 50 g PO Q12H x 11 d

68
Q

TX for RA Non-Biologic DMARDs: Janis Kinase Inhibitors

A

-Tofacitinib (Xeljanz)
-Baricitinib (Olumiant)
–> inhibits JK enzymes
-do not use with biologic DMARSs or potent immunosuppressants
BBW: serious infections, malignancy, thrombosis

69
Q

RA tx: Anti-TNF biologic DMARDs

A

-Entanercept (Enbrel): SC weekly
-Adalimamab (Humira): SC EOW
-Infliximan (Remicade): 3 mg/kg IV at weeks 0,2,6 then q 8 weeks- requies filter, NS only
-Certolizumab pegol (Cimzia): EOW
-Golimimab (Simponi): 50mg SC monthly

BBW: serious infections and malignancies
Warnings: hep B reactivation, hepatotoxicity, lupus-like syndrome, HF
-do not use with other biologic DMARDS or live vaccines
SE: injection site reactions, antibody induction
Monitoring: TB test, hep B virus, LFTs, s&S of infection, malignancies

70
Q

TX for RA: Non-TNF biologic DMARDs

A

–> Rituximab (Rituxan): IV
-binds to CD 20 on B cells
-Give w/ methotrexare
BBW: serious/fatal infusion reactions, PML, HBV reactivation, SJS/TEN - premedication required
–> Anakinra (Kineret): IL-1 receptor antagonist
–> Abatacept (Orencia): Binds to CD80 and CD 86 inhibiting T cells
–> Tocilizumab (Actemra) and Sarilumab (Kevzara): IL-6 receptor antagonist

71
Q

Systemic Lupus Erythematosus (SLE) presentations

A

-female, age 15-45 yrs, african american and asian descent
-butterfly skin rash, affects kidneys, hematologic, neurologic
Labs tests: ANA, anti-SSDNA, and anti-dsDNA

72
Q

Drugs that can cause DILE*

A

-methimazole
-procainamide *
-propylthiouracil
-methyldopa
-minocycline
-quinidine
-isoniazid *
-anti-TNF agents
-terbinafine
-hydralazine *
*top drugs

73
Q

Systemic Lupus Erythematosus (SLE) drug treatment

A

–> steroids: limit to shortest duration and lowest dose possible
–> Hydroxychloroquine (Plaquenil): FDA indication
–> Cyclophosphamide, azathioprine, mycophenolate mofetil, cyclosporine
–> Belimumab (benlysta) : monoclonal antibody
-BBW: infections, do not give live vaccines

74
Q

Multiple Sclerosis

A

-chronic disease which attacks the myelin sheath
Presentation: more common in women age 20-40 yrs
Diagnosis: MRI
Goals: prevent progression of disease

75
Q

Multiple Sclerosis Treatment

A

-Disease modifying therapies:
–> Glatiramer acetate (Copaxone, Glatopa) - preferred in pregnancy
-Interferon beta formulations:
–> Betaseron, Avonex, Plegridy (pegylated form that allows SC dosing every 14 days)
-Oral options:
–> fingolimod, teriflunomide, dimethyl fumarate
Last line: monoclonal antibodies or chemotherapy drugs

76
Q

Multiple Sclerosis treatment: oral immunomodulators and monoclonal antibodies

A

oral:
-Terflunomide (Aubagio): active metabolite of leflunomide
-Fingolimid (Gilenya): bradycardia- requires ECG monitoring for at least 6 hrs after first dose
-Dimethyl fumarate (Tecfidera): swallow capsule whole

IV monoclonal antibodies:
-Natalizuman (Yysabri)
-Alemtuzumab (Lemtrada)
-Oreclizumab (Ocrevus)

Drugs are used for symptom control

77
Q

Raynaud’s Phenomenon

A

-cold or stress can trigger vasospasm of the small blood vessels
= dec blood flow to fingers causes inc cyanosis and pain

TX: nifedipine ER or another DHP CCB

*drugs that can worsen or cause Raynauds: BBS, bleomycin, cisplatin, sympathomimetics

78
Q

Sjogren’s Syndrome; dry eye tx

A

Cyclosporine emulsion

79
Q

Sjohern’s syndrome; dry mouth tx

A

-sugar free chewing gum or lozenges
-antimicorbial mouthwash rinses
-salivia subs
-oral muscarinic agonists:
–> pilocarpine (salagen)
–> Cevimeline (Evoxac)

80
Q

Psoriasis: drug treatment

A

Topical:
-steroids, retinoids, salicylic acid, coal tar
-vitamin D analogues (calcipotriene)
-calcineurin inhibitors (Protopic, Elidel)

Systemic:
-Methotrexate, cyclosporine
-etanercept, infliximab
-Otezla
-Stelara & other monoclonal antibodies

NAPLEX BABY (23 decks)

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