Natsumi Pharm - Endo

Question 1

Mineralocorticoid & Glucocorticoid

Answer 1

PREGNENOLONE

precursor of progestogens, mineralocorticoids, glucocorticoids, androgens, and estrogens

Question 2

Fludrocortisone

Answer 2

Mineralocorticoid

Question 3

Prednisone
Dexamethasone
Hydrocortisone
Fluticasone
Methylprednisolone
Mometasone
Triamcinolone
Clobetasol propionate
Prednisolone
Beclomethasone
Budesonide
Fluocinonide

Answer 3

Glucocorticoid

Question 4

Pills, Oral/nasal, or topica?

Dexamethasone
Prednisone
Methylprednisolone
Prednisolone 
Fluticasone
Mometasone
Beclomethasone
Budesonide 
Clobetasol propionate
Fluocinonide
Mometasone
Fluticasone
Triamcinolone
Hydrocortisone

Answer 4

Pills
Dexamethasone
Prednisone
Methylprednisolone
Prednisolone 

Oral/Nasal sprays
Fluticasone
Mometasone
Beclomethasone
Budesonide 

Topicals
Clobetasol propionate
Fluocinonide
Mometasone
Fluticasone
Triamcinolone
Hydrocortisone

Question 5

Estrone (E1)

Answer 5

marker post-menopause (stored in adipose) and for cancer (ovary, testes, adrenals)

Question 6

Estradiol (E2)

Answer 6

most prevalent outside of pregnancy

Estriol (E3), considered “protective”—highest in pregnancy

Question 7

Estriol (E3)

Answer 7

considered “protective”—highest in pregnancy

Question 8

Ethinyl estradiol

Answer 8

The only estrogen used in oral contraceptive pills

Lowest effective dose of ethinyl estradiol preferred to reduce risk of DVT

Question 9

Conjugated estrogens

Answer 9

Vaginal cream is Estrace

Pregnancy category X—no reason to use in a pregnant woman

Question 10

Medroxyprogesterone acetate

Answer 10

Progesterone

Uses: prevention of endometrial hyperplasia in nonhysterectomized postmenopausal women who are receiving conjugated estrogens tablets; secondary amenorrhea; abnormal uterine bleeding (fibroids)
Bloating symptoms, migraine, weight change

Contraindicated in women with undiagnosed abnormal genital bleeding; known, suspected, or history of breast cancer; known or suspected estrogen- or progesterone-dependent neoplasia; active DVT, PE, or a history of these conditions; active arterial thromboembolic disease (for example, stroke and MI), or a history of these conditions; known liver impairment or disease; known or suspected pregnancy.

WARNINGS: cardiovascular disorders, breast cancer, probably dementia

Pregnancy category X (natural progesterone suppositories are sometimes used in the first trimester to help hold a pregnancy in a woman who has miscarried previously)

Question 11

Levonorgestrel

Answer 11

Progestin

Mirena/Skyla/Kyleena (IUD); Plan B/My Way/Next Choice (“morning after” pill, 1.5mg); Norgeston (“mini”-pill 0.03mg/progestin-only birth control pill)

Question 12

Norethindrone

Answer 12

Used alone or in combination with ethinyl estradiol for combination (progestin + estrogen) oral contraceptive and menopausal agent (norethindrone + EE)
Pregnancy category X

Question 13

Drospirenone

Answer 13

Used in combination with ethinyl estradiol for combination oral contraception

Contraindicated in smokers, particularly over age 35 years; associated with increase in gall bladder disease

Pregnancy category X

Question 14

Norgestimate

Answer 14

Used in combination with ethinyl estradiol for combination oral contraception

Contraindicated in smokers, particularly over age 35 years; associated with increase in gall bladder disease

Pregnancy category X

Question 15

Norelgestromin

Answer 15

Used in combination with ethinyl estradiol for combination oral contraception

Contraindicated in smokers, particularly over age 35 years; associated with increase in gall bladder disease

Pregnancy category X

5 letter = pathch NOR EL GE STRO MIN (5 syllable)

Question 16

OCP’s nutrient depletion

Answer 16

Folic acid
B1, B2, B3 (variable), B6, B12
Vitamin C
Calcium
Magnesium
Selenium
Zinc
Tyrosine

Question 17

Drospirenone/ethinyl estradiol
Norethindrone/ethinyl estradiol
Norgestimate/ethinyl estradiol

Answer 17

OCP

Black box warning: stroke, MI, PE, DVT, breast cancer, dementia

Question 18

Clomiphene

Answer 18

Ovulatory stimulant

Uses: treatment of ovulatory dysfunction in women desiring pregnancy after impediments to achieving pregnancy have been excluded or adequately treated

Best outcomes seen in women with polycystic ovary syndrome, amenorrhea-galactorrhea syndrome, psychogenic amenorrhea, post-oral-contraceptive amenorrhea, and certain cases of secondary amenorrhea of undetermined etiology.

Warnings: potential for ovarian hyper-stimulation syndrome and hepatic dysfunction.

Pregnancy category X

Question 19

Dehydroepiandrosterone (DHEA)

Testosterone

Answer 19

Androgen

(DHEA is a prescriptive agent—as is Melatonin—elsewhere in the world; here in the US, both are available over-the-counter.)

Question 20

Testosterone

Answer 20

Used for: primary hypogonadism (congenital or acquired)-testicular failure due to cryptorchidism, bilateral torsion, orchitis, vanishing testis syndrome; or orchidectomy; hypogonadotropic hypogonadism (congenital or acquired)-gonadotropin or LHRH deficiency, or pituitary-hypothalamic injury from tumors, trauma, or radiation.

Routes: IM, patch, nasal gel, orally, topical cream
Should be given to men with consistent symptoms/signs of hypogonadism & low plasma testosterone levels (<3ng/ml). Safety and efficacy of Testosterone in men with “age-related hypogonadism” (also referred to as “late-onset hypogonadism”) have not been established!

SE: acne, gynecomastia, irritation at site of administration, headache, transfer to female partner; cholestatic jaundice syndrome, liver carcinoma, BPH, prostate cancer, DVT. [Women: clitoral hypertrophy, hirsutism, acne, amenorrhea]

• Liver cell tumors
• Peliosis hepatitis

Pregnancy category X; C-III

Question 21

Spironolactone

Answer 21

Aldosterone antagonist

Question 22

Regular
Lispro
Glargine

Which is fast acting?

Answer 22

Classic anabolic hormone: promotes carbohydrate metabolism; facilitates glucose, amino acid, triglyceride uptake & storage in liver, cardiac & skeletal muscle, adipose tissue

Insulin, regular, Actrapid/Humulin R/Novolin R—fast acting
Insulin, lispro, HumaLOG—very fast acting
Insulin, glargine, Lantus/Basaglar—basal level of insulin

Structurally similar to endogenous insulin; zinc ions provide stability; recombinant DNA technology
For use in insulin dependent diabetes mellitus

SE: injection site reaction, lipodystrophy; hypoglycemia
Nutrient considerations: alpha lipoic acid, vitamins C & E, n-acetyl cysteine protect insulin under oxidative stress; chromium improves insulin sensitivity (numerous ways); magnesium improves insulin sensitivity

Pregnancy category B

Question 23

Glucagon

Answer 23

For rescue of hypoglycemia
Recombinant DNA technology; IV, IM, or SQ administration
CI in pheochromocytoma

Question 24

Desmopressin

Answer 24

Modified arginine vasopressin: Desmopressin, DDAVP

Synthetic analogue of the natural pituitary hormone 8-arginine vasopressin (ADH), an antidiuretic hormone affecting renal water conservation

Limits amount of water eliminated in urine
Used for diabetes insipidus, coagulation disorders (hemophilia A, von Willebrand’s disease type I)

SE: headaches, facial flushing, nausea, seizures, hyponatremia
Available po, sl, nasal spray, IV

Pregnancy category B

Question 25

Oxytocin

Answer 25

Oxytocin, Pitocin/Syntocinon The “love” hormone produced by posterior pituitary gland Released during/after childbirth, with breastfeeding, at orgasm—creates bonding, evokes feelings of contentment, decreases anxiety; protects against stress Used for medical (rather than elective) induction of labor, to control postpartum bleeding or hemorrhage Available IV, nasal spray Pregnancy category X

Question 26

Bromocriptine,

Answer 26

Ergot alkaloid: Prolactin blocker Dopamine receptor agonist Uses: hyper-prolactinemia associated dysfunctions (amenorrhea with or without galactorrhea, infertility or hypogonadism); prolactin-secreting adenomas; acromegaly; Parkinson’s disease SE: hypotension Pregnancy category B

Question 27

Somatropin

Answer 27

Growth hormone Recombinant DNA growth hormone; assists growth of linear bone, skeletal muscle, and organs by stimulating chondrocyte proliferation and differentiation, lipolysis, protein synthesis, and hepatic glucose output; stimulates erythropoietin which increases red blood cell mass; exerts both insulin-like and diabetogenic effects; enhances the transmucosal transport of water, electrolytes, and nutrients across the gut Labeled indications: growth failure in pediatrics; growth hormone deficiency in adults; cachexia of HIV; short bowel syndrome in patients receiving specialized nutritional support (Zorbtive). SE: upper respiratory tract infection, arthralgia, arthropathy, headache, hypoesthesia, increased serum glucose, limb pain, myalgia, paresthesia, and peripheral edema; fatigue, fluid retention, gynecomastia, hyperglycemia, insomnia, joint stiffness, joint swelling, nausea, and anasarca (extreme generalized edema) Pregnancy category C

Question 28

Metformin reduction %?

Answer 28

Uses: adjunct to diet and exercise to improve glycemic control in adults and children with type 2 diabetes mellitus Decreases glucose production in the liver, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization Activates energy-regulating enzyme AMPK, which inhibits gluconeogenesis, fatty acid synthesis, and cholesterol synthesis Increases insulin signaling Reduction in HbA1C: 1.5-2% Common side effects: lactic acidosis, diarrhea, nausea, nausea and vomiting, flatulence, asthenia Uncommon but serious: Lactic acidosis Nutrient depletions: vitamin B-12, folate Contraindicated in patients with renal disease/dysfunction; patients with acute or chronic metabolic acidosis Pregnancy category B

Question 29

Metformin Considerations

Answer 29

Chromium enhances insulin activity and glucose control Magnesium co-administered with sulfonylureas and/or metformin may improve insulin sensitivity and secretion—less drug warranted (850mg MgOH) Vitamin E (natural, mixed tocopherols/tocotrienols) may enhance glycemic control

Question 30

Glyburide Reduction %

Answer 30

Sulfonylurea - Stimulate insulin release from pancreatic β-cells to overcome insulin resistance Orally available; metabolized by liver Adverse reactions: hypoglycemia, weight gain Generally considered effective, reasonably safe, inexpensive Typical reduction in HbA1C: 1-2% Adverse reactions: 1. hypoglycemia 2. weight gain 3. GI upset Contraindicated in diabetic ketoacidosis

Question 31

Nutrient Depletions, Sulfonylureas

Answer 31

CoQ10 Magnesium (diabetics tend to be deficient before drug therapy)

Question 32

Pioglitazone

Answer 32

Thiazolidinedione - insulin sensitizer Typical reduction in HbA1C: 1.5-2% SE: heart failure & bladder cancer *BLACK BOX WARNING: may cause or worsen heart failure* ``` Not to be used in DMI/with exogenous insulin or in patients with class III or class IV heart failure Caution in patients with edema Drug interactions: CYP2C8 Inhibitors and Inducers; no known nutrient wasting ``` Pregnancy category C

Question 33

Liraglutide

Answer 33

GLP-1 agonist - Increases glucose-dependent insulin secretion INJECTION Typical reduction in HbA1c: 1%

Question 34

Canaglifozin

Answer 34

SGLT-2 antagonist - reduces reabsorption of filtered glucose from the tubular lumen and lowers the renal threshold for glucose. Improvement of macrovascular vessels Use in DMII with diet and exercise SE: SUPER URINARY FREQUENCY (pollakiuria), necrotizing fasciitis, loss of genitalia, limb amputation Pregnancy category C **DIURETIC ON STEROID!! THIS SHIT IS DANGEROUS

Question 35

Stigliptin

Answer 35

DPP-4 inhibitor - Prolongs active incretin levels for glucose regulation SE: Anxiety, blurred vision, chills, cold sweats, confusion, cool, pale skin, depression, dizziness, fast heartbeat, headache, increased hunger, loss of consciousness, nausea, nightmares, seizures, shakiness, slurred speech, unusual tiredness or weakness Pregnancy category B 1% reduction They do not perform as well Another injectable

Question 36

Liothyronine, Levothyroxine, Lugol's solution

Answer 36

Liothyronine, Cytomel (T3) Levothyroxine, Synthroid/Levoxyl (T4) Thyroid USP, (Armour) is a blend of T3 & T4 from dessicated pig thyroid Lugol’s solution (LOW dose), elemental iodine and potassium iodide Used in hypothyroidism & TSH pituitary suppression Side effects are typically signs/symptoms of hyperthyroidism Contraindicated in patients with untreated subclinical (suppressed serum TSH level with normal T3 and T4 levels) or overt thyrotoxicosis of any etiology and in patients with acute myocardial infarction. Levothyroxine is contraindicated in patients with uncorrected adrenal insufficiency. Pregnancy category A

Question 37

Hormones T4 and T4 work better with which nutrients?

Answer 37

No known depletions, but the hormones (T3, T4) work better with associated nutrients: ``` Selenium Zinc Iodine Copper Tyrosine (Adrenal support) ```

Question 38

Propylthiouracil, Methimazole, Lugol’s solution

Answer 38

Lugol’s solution (HIGH dose) Methimazole - Inhibits synthesis of thyroid hormone Propylthiouracil (PTU) - Preferred agent in thyroid storm Inhibits thyroid peroxidase, Inhibits conversion of T4 to T3 in the periphery Labeled uses: hyperthyroidism (Grave’s disease or toxic multinodular goiter) for whom surgery or radioactive iodine therapy is not an appropriate treatment option; symptom control in preparation for thyroidectomy or radioactive iodine therapy SE: rash, arthralgia; **life-threatening hepatotoxicity**, agranulocytosis, vasculitis, hypoprothrombinemia Pregnancy category D (Generally, methimazole is considered the safer of the two; not in pregnancy.)

Question 39

If the pregnant woman is in thyroid storm, which hyperthyroid agent should you use? If not pregnant, which one is safer?

Answer 39

pregnant = PTU Not pregnant = Methimazole

Question 40

Melatonin

Answer 40

Hormone produced by pineal gland Release is inhibited by light; promoted by dark Useful for circadian rhythm entrainment; powerful free-radical scavenger & antioxidant—cancer, CVD, autoimmune diseases, depression, SAD Useful in learning and memory—ADD/ADHD, ASD, Alzheimer’s Over-the-counter status in the US; prescription elsewhere Pregnancy category not assigned

Question 41

hCG

Answer 41

Human chorionic gonadotropin (hCG) Used to cause ovulation and treat infertility in women, increase sperm count in men, assist in testicular dropping into scrotum in young boys SE: ovarian hyper-stimulation syndrome Pregnancy category X