Final Exam Material Flashcards
1
Q
ideal body weight equation (males)
A
IBW = 50 kg + 2.3 (inches over 60”)
2
Q
ideal body weight equation (females)
A
IBW = 45.5 kg + 2.3 (inches over 60”)
3
Q
When do you use ideal body weight for fluids/electrolytes calculations?
A
If actual body weight >130% of IBW; use actual body weight otherwise
4
Q
Where does most fluid loss occur in the body?
A
Skin, lungs, and kidneys
5
Q
isotonic range
A
275-290 mOsm/L
6
Q
What is the administration rate of maintenance fluids?
A
30-40 mL/kg/day
7
Q
What tonicity can crystalloids be?
A
Isotonic, hypotonic, and hypertonic
8
Q
Which fluids are crystalloids?
A
Normal saline (NS), 1/2 NS, D5W, lactated ringers (LR)
9
Q
Which fluids are for resuscitation?
A
NS and LR
10
Q
Which fluid is a maintenance fluid?
A
1/2 NS
11
Q
Which fluid is for free water replacement and NOT a maintenance fluid by itself?
A
D5W
12
Q
What is the most common maintenance fluid?
A
D5W + 1/2 NS + 20 mEq KCl/L
13
Q
What tonicity can colloids be?
A
Hypertonic
14
Q
Which fluids are colloids?
A
Albumin (5% or 25%), hetastarch, tetrastarch, blood, Plasmanate
15
Q
What is albumin 5% used for?
A
Hypovolemia
16
Q
What is albumin 25% used for?
A
Hypoproteinemia
17
Q
What are signs and symptoms of dehydration?
A
Tachycardia, hypotension, <0.5 mL/kg/hr urine output, BUN/SCr ratio >20
18
Q
normal sodium concentration range
A
135-145 mEq/L
19
Q
What tonicity can hyponatremia be associated with?
A
Hypertonic, isotonic, hypotonic
20
Q
How do you treat symptomatic hypovolemic hypotonic hyponatremia?
A
NaCl 3%
21
Q
How do you treat asymptomatic hypovolemic hypotonic hyponatremia?
A
NaCl 0.9%
22
Q
What drugs can cause SIADH, which causes isovolemic hypotonic hyponatremia?
A
Antipsychotics, carbamazepine, SSRIs
23
Q
How do you treat symptomatic isovolemic hypotonic hyponatremia?
A
Furosemide and NaCl 3%
24
Q
How do you treat asymptomatic isovolemic hypotonic hyponatremia?
A
NaCl 0.9% and water restriction
25
How do you treat symptomatic hypervolemic hypotonic hyponatremia?
Furosemide and judicious NaCl 3%
26
How do you treat asymptomatic hypervolemic hypotonic hyponatremia?
Furosemide
27
What is the maximum increase for serum sodium when treating hyponatremia?
0.5 mEq/L/hr OR 8-12 mEq/L/day
28
What is the rate of increase for serum sodium in acute hyponatremia?
1-2 mEq/L/hr until symptoms resolve
29
What is the goal serum sodium for acute hyponatremia?
120 mEq/L
30
What is the maximum increase for serum sodium when treating acute hyponatremia?
8-12 mEq/L in first 24 hours
31
How do you treat acute hyponatremia?
NaCl 0.9% (asymptomatic) OR NaCl 3% (symptomatic)
32
rule of eights
Replace half of sodium deficit in 8 hours, the remaining deficit in 8-16 hours
33
monitoring for acute hyponatremia
Measure serum sodium concentration Q2-4H until asymptomatic, then Q6-8H until WNL
34
What tonicity is hypernatremia associated with?
Hypertonic
35
How do you treat hypovolemic hypernatremia?
-Restore hemodynamic status first (if necessary), then calculate free water deficit
-Treat with D5W and/or enteral free water via feeding tube
36
hypovolemic hypernatremia monitoring
Check serum sodium concentration Q3-6H for first 24 hours, then check Q6-12H after symptoms resolve and serum sodium concentration <145 mEq/L
37
How do you treat isovolemic hypernatremia?
Desmopressin or vasopressin
38
How do you treat hypervolemic hypernatremia?
Stop hypertonic fluids/cause(s) and use a diuretic if needed
39
normal potassium concentration range
3.5-5 mEq/L
40
How do you treat hypokalemia at a range of 3-3.4 mEq/L?
Oral potassium for patient with cardiac conditions
41
How do you treat hypokalemia at a range of <3 mEq/L?
-PO for asymptomatic patients
-IV for symptomatic patients and those who cannot tolerate PO
42
What are the appropriate rates of administration for potassium correction treatment?
-10 mEq/hr without cardiac monitoring
-20 mEq/hr with cardiac monitoring
-40-60 mEq/hr if emergency with severe hyperkalemia
43
How do you treat hyperkalemia?
-Calcium
-Albuterol, Bicarb, Insulin and Glucose
-Kayexalate/Lokelma, Diuretics (furosemide), Renal unit for dialysis Of Patient
44
normal magnesium concentration range
1.5-2.5 mg/dL
45
In hypomagnesemia, what should you treat before giving the patient magnesium medications?
Associated electrolyte disturbances (especially potassium)
46
What are the treatment options for asymptomatic patients with >1 mg/dL of magnesium presenting with hypomagnesemia?
-Milk of magnesia 5-10 mL PO QID
-Magnesium oxide 800 mg PO QD or 400 mg PO TID with meals
47
What are the treatment dosages for symptomatic patients or patients who cannot tolerate oral route presenting with hypomagnesemia?
-1-2 mg/dL --> 0.5 mEq/kg
-<1 mg/dL --> 1 mEq/kg
48
normal calcium concentration range
8.5-10.5 mg/dL
49
How do you treat acute hypocalcemia?
-100-300 mg elemental calcium IV over 5-10 minutes
-administer 1 gm/hr
-correct hypomagnesemia
50
How do you treat chronic hypocalcemia?
-1-3 g/day of elemental calcium (i.e., CaCO3 650 mg PO QID = 1 g elemental calcium/day)
-calcitriol 0.25 mcg PO QD/QOD (may need to increase by 0.25 mcg Q4-8W to 1 mcg PO QD)
51
normal phosphorus concentration range
2.5-4.5 mg/dL
52
How do you treat mild to moderate (1-2 mg/dL) hypophosphatemia?
-30-60 mMol/day of Phos-NaK BID/TID
-5 mL diluted Fleets Phospho-Soda BID/TID
53
How do you treat severe (<1 mg/dL) hypophosphatemia?
-if potassium <4 mEq/L --> KPhos
-if potassium ≥4 mEq/L --> NaPhos
54
What is the maximum rate of infusion for IV phosphorus?
7 mMol/hr
55
What part of the kidney is the major reabsorption site?
Proximal tubule
56
How do NSAIDs affect the afferent and efferent arterioles?
-constricts afferent arteriole (decreased vasodilatory prostaglandins)
-constricts efferent arteriole (increased angiotensin II)
57
How do ACEi/ARBs affect the afferent and efferent arterioles?
-slightly dilates afferent arteriole (slightly increased vasodilatory prostaglandins)
-dilates efferent arteriole (decreased angiotensin II)
58
nephritic syndrome
inflammation disrupting glomerular basement membrane
59
nephrotic syndrome
podocyte damage leading to glomerular charge-barrier disruption
60
signs and symptoms of nephritic syndrome
-increased hematuria
-red blood cell casts present
61
signs and symptoms of nephrotic syndrome
-increased edema
-increased proteinuria
-low serum albumin
62
What diuretic drug classes are potassium-wasting?
Carbonic anhydrase inhibitors, osmotic diuretics, sodium-potassium-chloride symport inhibitors (loop diuretics), sodium-chloride symport inhibitors (thiazides)
63
carbonic anhydrase inhibitors suffix
-amide
64
osmotic diuretic drugs
-mannitol
-isosorbide
-glucose
-glycerine
65
loop diuretic drugs
-bumetanide
-torsemide
-ethacrynic acid
66
What diuretic drug classes are potassium-sparing?
Renal epithelial sodium channel inhibitors, mineralocorticoid receptor antagonists, vasopressin antagonists
67
renal epithelial sodium channel inhibitor drugs
-amiloride
-triamterene
68
mineralocorticoid receptor antagonists suffix
-one
69
normal SCr (men)
0.74-1.35 mg/dL
70
normal SCr (women)
0.59-1.04 mg/dL
71
normal BUN
6-24 mg/dL
72
normal CrCl (men)
110-150 mL/min
73
normal CrCl (women)
100-130 mL/min
74
normal eGFR
≥60
75
normal vitamin D concentration
≥50 ng/mL
76
normal PTH concentration
10-55 pg/mL
77
normal hemoglobin (men)
14-18 g/dL
78
normal hemoglobin (women)
12-16 g/dL
79
normal transferrin saturation (TSAT) (men)
20-50%
80
normal transferrin saturation (TSAT) (women)
15-50%
81
normal ferritin (men)
24-336 mcg/L
82
normal ferritin (women)
11-307 mcg/L
83
normal mean corpuscular volume (MCV)
80-100 fl
84
normal red cell distribution width (RDW) (men)
11.8-14.5%
85
normal red cell distribution width (RDW) (women)
12.2-16.1%
86
When can you not use the Cockroft and Gault formula to estimate CrCl?
acute kidney injury (AKI)
87
Cockroft and Gault equation (men)
CrCl = ((140-age) x IBW)/(SCr x 72)
88
Cockroft and Gault equation (women)
CrCl = CrCl for men x 0.85
89
adjusted body weight equation
AjBW = IBW + 0.4(ABW - IBW)
90
calcium-containing phosphate binders
Calcium carbonate (Tums) and calcium acetate (PhosLo)
91
What percentage elemental calcium does calcium carbonate have?
40%
92
calcium carbonate dosing
500 mg PO TID with meals
93
calcium carbonate maximum dose
1500 mg/day
94
What percentage elemental calcium does calcium acetate have?
25%
95
calcium acetate dosing
2-3 tablets PO TID with meals
96
non-calcium-containing phosphate binders
Sevelamer carbonate (Renvela), lanthanum carbonate (Fosrenol), sucroferric oxyhydroxide (Velphoro), Auryxia (ferric citrate), aluminum hydroxide (Amphojel), magnesium carbonate (Mag-Carb), nicotinic acid, nicotinamide
97
Which non-calcium-containing phosphate binder should you NOT use?
aluminum hydroxide (Amphojel)
98
unactivated vitamin D medications
ergocalciferol (calciferol), cholecalciferol
99
activated vitamin D medications
calcitriol (Rocaltrol and Calcijex), paricalcitol (Zemplar), doxercalciferol (Hectorol)
100
Which vitamin D medication requires activation by the liver (prodrug)?
doxercalciferol (Hectorol)
101
Should hemoglobin or hematocrit be used to assess anemia?
hemoglobin
102
What are the KDIGO guidelines for initiation of iron supplementation?
TSAT <30% and ferritin <500 ng/mL
103
What is the preferred agent for intravenous iron?
iron sucrose (Venofer)
104
When should erythropoiesis stimulating agents (ESAs) be used in CKD patients?
-hemoglobin <10 g/dL and falling at rapid rate (stage 3-5 without dialysis)
-hemoglobin 9-10 g/dL (stage 5 with dialysis)
105
What are the indications for renal replacement therapy (RRT)?
Acid/base balance
Electrolyte balance
Intoxication
Overload of fluids
Uremia
106
What substances are not removed during hemodialysis?
High volume of distribution, high lipophilicity, large molecular weight, highly protein bound
107
What are the different types of peritoneal dialysis?
CAPD
CCPD
NIPD
TPD
108
Which type of peritoneal dialysis does not require a machine?
CAPD
109
What are the common manifestations of diabetes?
polydipsia
polyuria
polyphagia
ketoacidosis
110
What is the role of the alpha-subunit of the insulin receptor?
repress catalytic activity of the beta-subunit
111
How does somatostatin affect glucose secretion?
inhibits glucose secretion
112
What is the role of the beta-subunit of the insulin receptor?
cause autophosphorylation of the other beta-subunit
113
What is the molecular target of thiazolidinediones?
peroxisome proliferator-activated receptor gamma (PPARgamma)
114
thiazolidinedione adverse effects
-cardiovascular toxicities
-risk of bladder cancer (pioglitazone)
-hepatotoxicity
115
What is the molecular target of sulfonylureas?
potassium channels
116
sulfonylurea adverse effects
-hypoglycemia
-risk of cardiovascular events
-GI side effects
-weight gain
117
What drugs cause hypoglycemia?
-alcohol
-high dose salicylates
-beta adrenergic blockers
-ACE inhibitors
-fluoxetine
-somatostatin
-anabolic steroids
-MAO inhibitors
118
What drugs cause hyperglycemia?
-oral contraceptives
-corticosteroids
-epinephrine
-thiazide diuretics
-catecholamines
-glucocorticoids
-thyroid hormone
-calcitonin
-somatropin
-isoniazid
-phenothiazines
-morphine
119
What is the molecular target of glinides?
potassium channels
120
What is the molecular target of metformin?
mitochondrial complex I
121
How does metformin decrease blood glucose levels?
-inhibits gluconeogenesis
-increases translocation of GLUT4 to cell surface --> increased glucose uptake into cells
122
What is the effect of alpha-glucosidase inhibitors?
decreased absorption of carbohydrates from the intestine
123
What is the effect of SGLT2 inhibitors?
decreased reabsorption of glucose into blood --> increased excretion of glucose in urine
124
What are resistin levels in patients with type 2 diabetes?
elevated
125
What are the effects of resistin?
Stimulates glucose excretion by the liver and increases insulin resistance
126
What are adiponectin levels in patients with type 2 diabetes?
lowered
127
What are the effects of adiponectin?
Reduces blood glucose and insulin resistance
128
What are TNFalpha levels in patients with type 2 diabetes?
elevated
129
What are the effects of TNFalpha?
Stimulates lipolysis in white adipose tissue (WAT) and increases insulin resistance in skeletal muscle
130
What is the effect of GLP-1 analogs?
decreased glucagon release
131
What are the effects of amylin?
-suppresses appetite
-slows gastric emptying
-inhibits glucagon release
132
What chemical change causes insulin resistance in obesity?
phosphorylation with serine instead of tyrosine
133
What hormones cause insulin resistance in pregnancy?
-CRH
-cortisol
-progesterone
-placental GH
-placental lactogens
134
diagnostic criteria for diabetes mellitus (need at least two)
-fasting blood glucose (FBG) ≥126 mg/dL OR
-A1c ≥6.5% OR
-random glucose ≥200 mg/dL with symptoms of diabetes OR
-2 hour postprandial glucose ≥200 mg/dL during oral glucose tolerance test (OGTT)
135
What are the microvascular diseases resulting from diabetes?
-diabetic kidney disease
-ocular complications
-neuropathy
136
normal urine albumin-creatinine ratio (UACR)
<30 mg/g
137
microalbuminuria screening
-patients with type 1 diabetes for ≥5 years or patients with type 2 diabetes --> annually
-UACR >300 mg/g and/or eGFR <60 --> biannually
-non-pregnant patients with UACR ≥300 mg/g or eGFR <60 --> prescribe ACEi/ARB
138
diabetic kidney disease treatment
-SGLT2 inhibitor (first-line; with type 2 diabetes with/without kidney disease)
-GLP-1RA (second-line)
-mineralocorticoid receptor antagonist (with CKD and albuminuria and at risk for cardiovascular events)
139
eye exam frequency for diabetic patients
-initial eye exam within 5 years of diagnosis (type 1 diabetes)
-initial eye exam at diagnosis (type 2 diabetes)
-if no evidence of retinopathy for ≥1 annual exam and glycemia controlled --> assess Q1-2Y
-if retinopathy present --> assess annually (at least)
140
peripheral neuropathy testing
-assess within 5 years of diagnosis (type 1 diabetes)
-assess at diagnosis (type 2 diabetes)
-annual monofilament testing
141
neuropathy treatment
-pregabalin, duloxetine, or gabapentin (first-line)
-tricyclic antidepressants, venlafaxine, carbamazepine, tramadol, capsaicin, or tapentadol (second-line)
142
What are the macrovascular diseases resulting from diabetes?
-cardiovascular disease
-stroke
-peripheral vascular disease
-periodontal disease
143
treatment for patients with diabetes and atherosclerotic cardiovascular disease (ASCVD) and/or heart failure
-SGLT2 inhibitor OR
-GLP-1RA
144
What is the blood pressure goal for pregnant patients with diabetes?
110-135/85 mm Hg
145
statin dosing for diabetic patients
-none to moderate intensity statin based on risk factors (for patients ages 20-39 with no ASCVD)
-moderate intensity statin (for patients ages 40-75 with no ASCVD)
-high intensity statin (for patients ages 40-75 with ≥1 risk factor)
-high intensity statin and lifestyle modifications (for patients with ASCVD)
146
secondary prevention of CVD in patients with diabetes and history of CVD
-aspirin (first-line; 75-162 mg/day)
-clopidogrel (if aspirin allergy)
147
Who can be considered for use of aspirin with primary prevention of CVD?
patients ≥50 years old with one major risk factor who are not at increased risk of bleeding
148
fasting blood glucose goal for diabetic patients
80-130 mg/dL
149
A1c goal for diabetic patients
-7% (ADA guidelines; consider 6% for some patients and pregnant women)
-≤6.5% (AACE guidelines)
150
A1c monitoring
-biannually (if at treatment goal)
-quarterly (if therapy changed or not at treatment goal)
151
What insulin is preferred for intravenous administration?
regular insulin
152
How long are insulin vials stable at room temperature for?
28 days (42 days for detemir)
153
How long are prefilled insulin syringes stable with refrigeration for?
28 days
154
How long are prefilled insulin syringes stable at room temperature for?
10-28 days
155
How long is regular/NPH mixture stable for?
7 days with refrigeration
156
How long is ultra short-acting/NPH mixture stable for?
need to give ASAP
157
rule of 15s
-start with 15 gm of fast-acting carbohydrates unless blood glucose <50 mg/dL (use 30 gm instead)
-wait 15 minutes --> check blood glucose --> if blood glucose <80 mg/dL, then repeat with another 15 gm of fast-acting carbohydrates
158
What are examples of 15 gm of fast-acting carbohydrates?
-4 oz orange juice
-6 oz Coke
-5-6 lifesavers
-2 tsp sugar
-1 tbsp honey
-4 glucose tablets
159
What should you do after treating a hypoglycemic event?
-if meal ≤1 hour away, eat meal
-if meal >1 hour away, eat 30 gm carbohydrate snack
160
At what blood glucose level should you use glucagon?
<54 mg/dL
161
How do you change doses from QD NPH to a(n) (ultra) long-acting insulin?
1:1
162
How do you change doses from BID NPH to a(n) (ultra) long-acting insulin?
decrease dose by 20%
163
How do you change doses from U-100 insulin to a concentrated insulin?
1:1
164
How do you change doses from BID NPH to glargine U-300?
decrease dose by 20%
165
How do you change doses from QD glargine or detemir to QD concentrated glargine?
may need to increase dose of QD concentrated glargine
166
How do you change doses from U-100 basal-bolus regimen to U-500 regimen?
-if A1c ≥8% --> 1:1
-if A1c ≤8% --> decrease dose by 20%
167
What is the average daily dose of insulin for type 1 diabetes?
0.5-0.6 units/kg/day
168
What is the "honeymoon phase" dose of insulin for type 1 diabetes?
0.1-0.4 units/kg/day
169
What is the distribution for basal-bolus regimen for type 1 diabetes?
-50-70% basal insulin
-30-50% bolus insulin
170
What is the distribution for BID regular/NPH mixture for type 1 diabetes?
-40% NPH and 15% regular (morning)
-30% NPH and 15% regular (night)
171
What is the starting dose of insulin for type 2 diabetes?
-0.1-0.2 units/kg/day OR 10 units/day (ADA guidelines)
-0.1-0.2 units/kg/day (AACE guidelines; if A1c <8%)
-0.2-0.3 units/kg/day (AACE guidelines; if A1c >8%)
172
How do you adjust basal insulin dose for type 2 diabetes?
increase dose by 2 units Q3 days to reach fasting blood glucose goal
173
bolus insulin for type 2 diabetes
-consider for patients taking ≥0.5 units/kg/day of basal insulin
-start with 10% of basal dose OR 4-5 units of (ultra) short-acting insulin with largest meal
-adjust dose 10-15% Q3-4 days
174
rule of 500
500/total daily dose of insulin = gm of carbohydrates
175
rule of 1800 (only for ultra short-acting insulin)
1800/total daily dose of insulin = # of mg/dL blood glucose will drop for every 1 unit of insulin
176
rule of 1500 (only for regular insulin)
1500/total daily dose of insulin = # of mg/dL blood glucose will drop for every 1 unit of insulin
177
Somogyi effect
nocturnal hypoglycemia with rebound hyperglycemia
178
metformin cautions for use/contraindications
-renal dysfunction (use eGFR for dosing)
-acute decompensated hospitalized, unstable, or severe renal/hepatic disease heart failure patients
-alcoholics
-post myocardial infarction
-hepatic failure
-surgery/radiologic procedure with contrast dye (hold 1-2 days before and ~2 days after depending on patient status)
-COPD
-shock
179
metformin dosing
-start with 500 mg PO BID or 850 mg QD with meals
-titrate Q1-2W by 250-500 mg/day
-maximum dose: 2 gm/day
180
How often should you monitor serum creatinine if a patient's eGFR is ≥60?
annually
181
How often should you monitor serum creatinine if a patient's eGFR is 45 ≤ x < 60?
every 3-6 months
182
Can you start metformin if a patient's eGFR is 30 ≤ x < 45?
No
183
How do you adjust the dose of metformin if a patient's eGFR is 30 ≤ x < 45?
decrease dose by 50%
184
How often should you monitor serum creatinine if a patient's eGFR is 30 ≤ x < 45?
every 3 months
185
Can you take metformin if a patient's eGFR <30?
No
186
SGLT2 inhibitor adverse effects
-urinary tract infections
-genital fungal infections
-increased urination
-hypotension
-increased cholesterol
-diabetic ketoacidosis
-bone fractures and decreased bone mineral density (canagliflozin)
-acute kidney injury (canagliflozin and dapagliflozin)
-increased risk of foot and leg amputations (canagliflozin)
187
What patients cannot take SGLT2 inhibitors?
patients with end-stage renal disease (ESRD) on hemodialysis
188
How should SGLT2 inhibitors be managed if a patient is undergoing surgery?
-hold 3 days before surgery (4 days for ertugliflozin)
-restart once oral intake is back to baseline and other factors have resolved
189
GLP-1 agonist contraindications
-chronic pancreatitis
-personal/family history of medullary thyroid carcinoma or multiple endocrine neoplasia syndrome type 2
-pre-existing gallbladder disease
-gastroparesis
-proliferative diabetic retinopathy
190
Rybelsus dosing
3 mg PO QD for 30 days, then 7 mg PO QD
191
maximum dose of Rybelsus
14 mg/day (7 mg/day if on Ozempic 0.5 mg SQ QW)
192
DPP-4 inhibitor adverse effects
-nasopharyngitis
-upper respiratory tract infections
-headache
-acute pancreatitis
-joint pain
-heart failure (except for sitagliptin)
193
When should you start dual therapy for diabetes?
A1c >9%
194
What is the insulin dosing for pregnancy patients with gestational diabetes?
0.7-1.0 units/kg/day
195
What is the second-line treatment for pregnancy patients with gestational diabetes?
metformin
196
What diabetes medication should be avoided for pregnancy patients with gestational diabetes?
sulfonylureas
197
A1c goal for elderly patients
<8.0%
198
fasting blood glucose goal for elderly patients
90-150 mg/dL
199
bedtime glucose goal for elderly patients
100-180 mg/dL
200
How should basal insulin be adjusted before a patient's surgery?
-decrease dinnertime basal insulin dose by ~25%
-give 75-80% of dose the morning of surgery
201
How should metformin be adjusted before a patient's surgery?
hold day of surgery
202
How should oral glucose lowering medications be adjusted before a patient's surgery?
hold the morning of surgery
203
How should NPH insulin be adjusted before a patient's surgery?
give 50% of dose the morning of surgery
204
Who does diabetic ketoacidosis usually occur in?
type 1 diabetes patients
205
What commonly causes diabetic ketoacidosis?
-poor adherence to treatment regimen
-infection (most commonly UTIs)
206
diabetic ketoacidosis symptoms
-nausea/vomiting
-abdominal pain
-changes in mental status
-fruity breath
-Kussmaul respirations
-coma
207
What is the diabetic ketoacidosis triad?
hyperglycemia
hyperketonemia
metabolic acidosis
208
What are the goals of treatment for diabetic ketoacidosis?
-restore circulatory volume
-inhibit ketogenesis and return of normal glucose metabolism
-correct electrolyte imbalances
209
How should you administer fluids to a patient with diabetic ketoacidosis?
-administer NS at 500-1000 mL/hr for first 1-4 hours
-evaluate corrected sodium at 2-4 hours
-if corrected sodium is normal/high --> change to 1/2 NS and decrease rate by 50%
-if corrected sodium is low --> continue NS and decrease rate by 50%
-when blood glucose approaches 200 mg/dL, change to D5W and 1/2 NS at 150-200 mL/hr until ketoacidosis resolved
210
How should you administer insulin to a patient with diabetic ketoacidosis?
-start 0.1 units/kg/hour with/without bolus of 0.1 units/kg
-if glucose does not fall by ≥10% in the first hour, give, repeat, or increase bolus dose
211
When can you switch a patient from IV to SQ insulin in diabetic ketoacidosis?
-blood glucose <200 mg/dL AND (at least two of the following criteria)
-anion gap closes ≤12 mEq/L
-bicarbonate level ≥15 mEq/L
-venous pH >7.3
212
How do you dose a patient on SQ insulin for diabetic ketoacidosis?
-0.5-0.8 units/kg/day (50/50 basal/bolus; insulin naïve patients)
-total amount of IV insulin and convert to daily requirement using basal/bolus OR Q6H NPH insulin
213
How long should IV and SQ insulin be overlapped in patients with diabetic ketoacidosis to prevent rebound ketoacidosis or hyperglycemia?
2-4 hours
214
anion gap equation
anion gap = sodium - (chloride + bicarbonate)
215
At what potassium level should insulin NOT be started for patients with diabetic ketoacidosis?
<3.3 mmol/L
216
When should bicarbonate be repleted in patients with diabetic ketoacidosis?
pH <6.9
217
What are the goals of treatment for HHS?
-restore circulatory volume
-restore urine output to ≥50 mL/hour
-return blood glucose to normal
218
How should you administer fluids to a patient with HHS?
-administer 1/2 NS OR NS at 500-1000 mL/hr for first 1-4 hours
-evaluate corrected sodium at 2-4 hours
-if corrected sodium is normal/high --> reduce rate
-if corrected sodium is low --> consider NS
-when blood glucose is 300 mg/dL, change to D5W and 1/2 NS at 150-200 mL/hr until resolution of HHS
219
What type of insulin is available in insulin cartridges?
rapid-acting insulin
220
What does a higher gauge needle indicate?
thinner needle
221
How many units should you prime an insulin pen with?
2 units
222
How many units should you prime Humulin R U-500 KiwkPen with?
5 units
223
How many units should you prime Toujeo Max SoloStar U-300 with?
4 units
224
How many units should you prime Toujeo SoloStar U-300 with?
3 units
225
What devices are available for patients with a fear of needles?
-TickleFLEX
-NovoFine Autocover pen needles
-Autoshield Duo pen needles
226
What are adverse reactions of Afrezza?
-hypoglycemia
-cough
-throat pain or irritation
227
What are contraindications for Afrezza?
asthma and/or COPD
228
What GLP-1 agonists are dosed QD/BID?
-Byetta (BID; exenatide IR)
-Victoza (QD; liraglutide)
229
Which non-insulin injectables are auto-injectors?
-Trulicity
-Bydureon BCise
-Mounjaro
230
Which non-insulin injectable has pen needles included?
Ozempic
231
Is reconstitution required for glucagon injections?
Yes
232
Is inhalation required for Baqsimi?
No
233
What medications may result in more adverse events than benefits in older adults?
-sedative/hypnotics
-neuroleptics/antipsychotics
-antidepressants
-opioids (especially long-acting)
-loop diuretics
-alpha blockers
234
What is the most common type of urinary incontinence in both men and women?
urge
235
Is stress urinary incontinence more common in men or women?
women
236
What causes urge urinary incontinence?
hyperactivity of detrusor muscle
237
What causes stress urinary incontinence?
outlet incompetence with abdominal pressure
238
What causes overflow urinary incontinence?
outlet obstruction, inability to urinate, or uncoordinated detrusor constriction
239
Is aging a barrier to medication nonadherence?
No
240
What are physiologic changes in elderly patients?
-decreased total body water
-decreased lean body mass
-increased body fat
-decreased baroreceptor response/activity
-reduced heart rate variability
-decreased hepatic blood flow
-decreased renal blood flow
-decreased neurotransmitter volume
241
How does aging affect the volume of distribution of water-soluble drugs?
decreases
242
How does aging affect the concentration of water-soluble drugs?
increases
243
How does aging affect the volume of distribution of lipid-soluble drugs?
increases
244
How does aging affect the half-life of lipid-soluble drugs?
increases
245
How does aging affect the clearance of hepatically cleared drugs?
decreases
246
How does aging affect the half-life of hepatically cleared drugs?
increases
247
How does aging affect the clearance of renally cleared drugs?
decreases
248
How does aging affect the half-life of renally cleared drugs?
increases
249
Who is involved in the decision-making process of the BEERS criteria?
Interprofessional panel of 12 experts in geriatric care and pharmacotherapy
250
How does the committee describe the quality of evidence for the BEERS criteria?
GRADE-based approach
251
What are the three phases of platelet activation?
platelet adhesion
platelet secretion
platelet aggregation
252
What chemical inhibits thrombogenesis?
PGI2 (prostacyclin)
253
What chemicals are released from platelet granules to bind to ADP receptors?
ADP
TXA2
5-HT (serotonin)
254
What chemical are platelets cross-linked by?
fibrinogen
255
What is the molecular target of clopidogrel, prasugrel, and ticagrelor?
P2Y12 receptor
256
What drugs bind irreversibly to the P2Y12 receptor?
clopidogrel and prasugrel
257
What drug binds reversibly to the P2Y12 receptor?
ticagrelor
257
What is the molecular target of abciximab and eptifibatide?
GP IIb/IIIa receptor
258
What is the molecular target of dipyridamole and cilostazol?
cAMP phosphodiesterase
259
What converts prothrombin to thrombin?
factor Xa (prothrombin activator)
260
What does prothrombin time measure?
How long it takes for clot to form in blood sample
261
What does bleeding time evaluate?
Platelet function
262
What does activated thromboplastin time measure?
How long it takes for blood to form clot
263
What is the normal INR value for patients not taking anticoagulants?
1.0
264
What is the INR therapeutic range for patients taking anticoagulants?
2.5-3.5
265
What is the difference between the mechanism of actions of heparin and low molecular weight heparins?
Low molecular weight heparins can only bind factor Xa, whereas heparin can bind thrombin and factor Xa
266
What is the molecular target of warfarin?
vitamin K epoxide reductase (VKORC1)
267
What is plasminogen?
Anticoagulant protein that circulates in inactive form
268
What is plasmin?
Proteolytic enzyme that digests fibrin and fibrinogen
269
Which drug lacks the fibrin binding domain?
reteplase
270
Is alteplase or tenecteplase more selective?
tenecteplase
271
What is the molecular target of tranexamic acid and lysine?
lysine binding sites on plasminogen molecules
272
What is the molecular target of aminocaproic acid?
Kringle domain of plasminogen
273
Does all deep vein thrombosis lead to pulmonary embolisms?
No
274
Do all pulmonary embolisms lead to deep vein thrombosis?
Yes
275
indirect thrombin inhibitor drugs
-heparin
-low molecular weight heparin (enoxaparin)
276
heparin dosing
80 units/kg (IV bolus) followed by 18 units/kg/hr (infusion)
277
heparin monitoring
activated partial thromboplastin time (aPTT)
278
characteristics of heparin associated thrombocytopenia (HAT)
-HIT type I
-non-immune mediated
-mild decrease in platelets
-occurs around 48-72 hours after administration of heparin
-transient
-do not need to discontinue heparin
279
characteristics of heparin induced thrombocytopenia (HIT)
-immune mediated
-thrombotic complications
-occurs between 7-14 days after administration of heparin
-platelets drop >50% from baseline or <100,000/mm
-need to discontinue heparin
280
Is monitoring required for low molecular weight heparins?
No
281
What is the enoxaparin dosing for prophylaxis?
-30 mg SQ Q12H (surgery)
-40 mg SQ QD (medical)
282
What is the enoxaparin dosing for treatment?
-1 mg/kg SQ Q12H
-1.5 mg/kg SQ QD
283
indirect factor Xa inhibitor drug
fondaparinux
284
direct factor Xa inhibitor drugs
-lepirudin
-bivalirudin
-argatroban
285
