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NAPLEX BABY > Endocrine Conditions* > Flashcards

Endocrine Conditions* Flashcards

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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
Intermediate Acting Insulin
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
25
Long-acting insulins
-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
26
Pre - mixed insulins
-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
27
Insulin dosing in DM1
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
28
Insulin Conversions
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
29
Selecting an Insulin Syringe
-0.3 mL up to 30 units -0.5 mL for 30-50 units -1 mL for 51-100 units
30
Meal time insulin dosing
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)
31
Calculating correction factor: regular insulin
-rule of 1500 1500/ total daily dose of insulin = correction factor for 1 unit of regular insulin
32
Calculating the correction factor: Rapid-acting
-rule of 1800 1800/total daily dose of insulin = correction factor for 1 unit of rapid-acting insulin
33
Calculating the correction dose (for both types of insulin)
(BG now) - (target BG) / correction factor = correction dose
34
Room temp stability of insulin: 1-2 weeks
-Humalog Mix 50/50 and 75/25 pens -Humulin 70/30 pen ~10 days
35
Room temp stability of insulin: 2 weeks
Humulin N pens Novolog Mix 70/30 pens -14 days
36
Room temp stability of insulin: ~4 weeks
-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
Room temp stability of insulin: ~6 weeks
-Humulin R U-500 vial (40 days) -Novolin R U-100,N and 70/30 vials -Levemir vial and pen --> both 42 days
38
Room temp stability of insulin: 8 weeks
-Tresiba pen -Toujeo pen 56 days
39
Hypoglycemia
-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
Causes of hypoglycemia
-insulin, sulfonylureas, meglitinidis -Linezolid, lorcaserin (Belviq), Pentamidine, BBs, quinolines, tramadol -Low risk when used alone: GLP-1, DDP-4, TZD, SGLT2s
41
Drugs that cause hyperglycemia
-BBS, tzds, diuretics, tacrolimus, cyclosporine, protease inhibitors, quinolones, antispychotics, statins, steriods, cough syrups, niacin
42
Hyperglycemia: DKA
-BG > 250 -ketones, abdominal pain, N/V, dehydration -anion gap (pH < 7.35, anion gap > 12)
43
Hyperglycemia: HHS
-confusion, delirium -BG > 600 mg/dL with high serum osmolarity > 320 mosm/mL -extreme dehydration -pH > 7.3, bicarb > 15
44
Treatment of HHS and DKA
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
DM drug safety issues and what drugs to avoid with each condition
-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
Hypothyroidism: signs and symptoms
-cold intolerance -dry skin -fatigue -constipation -weight gain -voice changes -weakness -depression -menorrhagia (heavy period)
47
Hypothyroidism
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
Select drugs that can cause hypothyroidism
-Interferons -Tyrosine Kinase Inhibitors (Suntinib) -Amiodarone -Lithium -Carbamazepine ( I TALC)
49
TX of hypothyroidism: Levothyroxine, T4 (Synthroid, Levoxyl, Clnithroid)
-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
Levothyroxine tablet colors*
(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
Hyperthyroidism
Presentation: increased metabolism Causes: Graves disease (autoimmune- antibodies stimulate the thyroid to increase T4), thyroid nodule, certain drugs, excess thyroid hormone replacement
52
Signs and Symptoms of Hyperthyroidism*
-heat intolerance/sweating -agitation -palpitations/tachycardia -light/absent menstrual periods -diarrhea -weight loss -tremor -thinning hair -exophthalmos
53
Treatment of Hyperthyroidism
-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
Potassium Iodine use after exposure to radiation
-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
Thyroid Strom
-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
Pregnancy and hypothyroidism
-levothyroxine -will require a 30-50% increase in the dose
57
Pregnancy and Hyperthyroidism
-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
Cushings Syndrome
-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
Ways to reduce systemic steroid risks
-use EOD dosing -for joints- inject into the joint -use lowest dose for the shortest period of time -inhaled steroids for asthma
60
Systemic steroids Dose Equivalent*
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
Immunosuppression and glucocorticoids
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
Glucocorticoids short term SEs
-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
Rheumatoid arthritis (RA)
-chronic, bilateral and symmetrical joint swelling, pain, stiffness, deformity Lab test: -RF (non specific) -Anti-citrullinated peptide antibody (ACPA) - more specific
64
TX for RA: Non-Biologic DMARDs: Methotrexate (Otrexup, Rasuvo, Trexall, Xatmep)
-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
TX for RA: Non-Biologic DMARDs: Hydroxychloroquine (Plaquenil)
-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
TX for RA: Non-Biologic DMARDs: Sulfasalazine (Azulfidine)
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
TX for RA: Non-Biologic DMARDs: Leflunomide (Arava)
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
TX for RA Non-Biologic DMARDs: Janis Kinase Inhibitors
-Tofacitinib (Xeljanz) -Baricitinib (Olumiant) --> inhibits JK enzymes -do not use with biologic DMARSs or potent immunosuppressants BBW: serious infections, malignancy, thrombosis
69
RA tx: Anti-TNF biologic DMARDs
-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
TX for RA: Non-TNF biologic DMARDs
--> 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
Systemic Lupus Erythematosus (SLE) presentations
-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
Drugs that can cause DILE*
-methimazole -procainamide * -propylthiouracil -methyldopa -minocycline -quinidine -isoniazid * -anti-TNF agents -terbinafine -hydralazine * *top drugs
73
Systemic Lupus Erythematosus (SLE) drug treatment
--> 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
Multiple Sclerosis
-chronic disease which attacks the myelin sheath Presentation: more common in women age 20-40 yrs Diagnosis: MRI Goals: prevent progression of disease
75
Multiple Sclerosis Treatment
-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
Multiple Sclerosis treatment: oral immunomodulators and monoclonal antibodies
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
Raynaud's Phenomenon
-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
Sjogren's Syndrome; dry eye tx
Cyclosporine emulsion
79
Sjohern's syndrome; dry mouth tx
-sugar free chewing gum or lozenges -antimicorbial mouthwash rinses -salivia subs -oral muscarinic agonists: --> pilocarpine (salagen) --> Cevimeline (Evoxac)
80
Psoriasis: drug treatment
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

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