pharm cases Flashcards
(153 cards)
1
Q
case 1: 55 y/o woman with new onset T2DM. She is on no medication yet for her T2DM. HTN, obesity, T2DM. Lisinopril 10 mg daily. 61 inches 210 BMI 40. A1c 8.5, eAG 197.
2 DOC options? 3 options
A
DOC 1 options:
- metformin
- sulfonylurias
- insulin
DOC2: Atorvastatin since on ACE
2
Q
what should you make sure to do when starting someone on metformin? why?
A
titrate up gradually to avoid MASSIVE DIARREAH
3
Q
what is a SE of metformin?
A
extreme diarreah
4
Q
what will most people with diabetes be on? 3
A
statin
ACE/ARB
metformin
5
Q
what should you add if someone has cardiovascular disease?
A
ASA 81 mg
some people argue that HTN is enough for a cardiac issue that this is warrented but there is controversy around this
6
Q
what is the inital DOC for T2DM?
A
metformin
7
Q
what is the drug class for metformin?
A
biguanides
8
Q
what is the MOA of metformin? 6 things
A
- decrease hepatic glucose production
- decrease renal gluconeogensisi
- slow intestinal absorption of glucose
- increase tissue glycolysis
- increase glucose removal from blood
- decrease serum glucagon levels
9
Q
what is something that metformin can cause?
A
blockade of hepatic gluconeogenesis impairs renal clearance of lactic acid
leads to lactic acidosis in renal insufficiency
10
Q
what do you need to do if someone is taking metformin and needs CT contrast?
A
hold the metformin for 48 hours
11
Q
a person with T2DM at the time of dx has had this for how long?
A
10 years….thats how long it has been unknown for
12
Q
what are the two sulfonylureas?
A
- glipizide
2. repaglinide
13
Q
what is the drug class for glipizide?
A
2nd generation sulfonylureas
14
Q
what is the MOA of glipizide?
A
stimulates pancreatic Beta cells release of insulin
15
Q
what drug when txing diabetes do you need to be careful in sulfa allergy?
A
glipizide
16
Q
what is the drug class for repaglinide?
A
meglitinides
Non-sulfonulurea secretagogue
17
Q
what is the MOA of repaglinide?
A
binds to the sulfonylurea receptor on the Beta cell sto stimuate insulin release
18
Q
which of the sulfonylureas would you want to use in someone that has a sulfa allergy?
A
repaglinide
19
Q
what is the name of the rapid acting insulin?
A
Lispro
20
Q
what is the name of the short acting insulin?
A
regular
21
Q
how long does it take for the rapid acting insulin to work?
A
5-15 minutes
22
Q
what is the name of the intermediate-acting insulin?
A
neutral protamine
23
Q
what are the names of the long acting insulin?
A
insulin glargine
24
Q
what are the two concentrations that insulin glargine comes in?
A
300 and 100
25
how long does the short acting insulin work? whats the name?
regular
| 5-8 hours
26
what is the name of the intermediate acting insulin and how long does it work?
neutral protamine
| 10-24 hours
27
what are the names of the long acting insulin and how long does it work?
insulin glargine
| 20-24 hours
28
what is the name of the oral inhalation rapid acting insulin?
human rDNA insulin
29
what is the name of the insulin that is inhaled?
human rDNA insulin
30
Case 2: 55 y/o lady with follow up for her recent DEXA scan. BMD >2.5 SD below threshold. She hasn’t had any fractures to date. Alcoholism, tobacco, HTN, SH 6 cups of coffee a day. sedentary. Amlodipine 5 mg daily. BMI 33. A&Ox3.
what are the 3 DOC?
she has progressed to osteoporosis
DOC1: alendronate
DOC2: exercise program
DOC3: calcium and vitamin D
31
what type of exercising do you need to do if you have osteoporosis?
weight bearing exercise to build the bone
**aka exercise on a bike doesn't work**
32
what is the drug class for alendronate?
oral biphosphenate
33
what is the MOA of alendronate?
decrease rate of bone resorption
34
what do you need to monitor when giving someone alendronate?
Ca and vit D
**think about it, you need to have adequate levels of this if you are going to build bone back up***
35
what must you remember to do when taking alendronate?
take in the AM with 8 oz water and remain upright for 30 minutes!
36
Case 3: 35 y/o sedentary obese female with a A1C of 7.8 eAG=196 on retest. you dx T2DM. HTN. T2DM, obesity. chorithiadone 12.5 mg. BMI 34. initial A1C 7.5, retest 7.8. (eAG=187-196), LDL 190, TC 300. CrCL 90cc/min
3 DOC?
DOC1: metformin
DOC2: atorvastatin
DOC3: take off chlorthiadone and switch to ACE since dieuretics are contraindicated with metformin and need to protect the kidneys
37
what drug shouldn't you take metformin with?
dieruretics
38
case 4: 70 y/o lade with newly dxed T2DM. she is in clinic to get her second A1C result and start tx if needed. HTN obesity CKD3. Anemia of chronic disease. T2DM. HCTZ 12.5 mg daily. BMI 32. acanthosis nigrans on posterior neck. A1c=8.5, 8.7 eGFR 35 ml/min. UA, glucose pos, ketone neg, protein neg.
2 DOC?
DOC1: reduced dose metformin since low eGFR (msut reduce dose)
DOC2: linsinopril (since HTN and T2DM)
**order lipid panel to determine if statin nessacary**
39
what are the goal A1c for elderly and young people?
young=7
elderly=8
40
what does pushing the A1c below 7 do?
NOT MUCH
this is why the goal for younger people is 7 because its has been found that below this doesn't do much better
41
why is the goal A1c for elderly patient 8?
elderly are at sever risk for hypoglycemia so if 75 and older we don’t want to get TOO LOW fall and break hip with 25% mortality rate….so we try to get to 8
42
Case 5: 17 was on hiking trip and lost insulin and is now in the ED because he was without it for 36 hours. you now need to give him tx to go home with but he hates shots and would like to minimize this a much as possible. T1DM. BMI 25. FBS=110. UA ketones=none
DOC1 (2 options)
long acting insulin (since would decrease the frequency need to be given) +/- short acting insulin with meals
DOC1: insulin glargine U100 or U300
43
do T1DM or T2DM use higher insulin doses?
T2DM since you have to overcome their insulin resistance!
***they have decreased production AND insulin resistance....so must tx both!!***
44
what is the first indiation of a Tye II diabetic?
an increase in insulin to deal with higher sugar which burns out the beta cells
45
what should you monitor prost prandial with using a short acting insulin?
eAG or the persons BS!!
46
case 6: 50 y/o female with T2DM has instituded TLS changes and lost 15 of her body weight and has been titrated up to 1 gm of metformin ever 12 hours but her A1c is now 7.8. she is allergic to sulfa meds. HTN. Hyperlipidemia. T2DM. analphylaxsis to sulfa. Linsinopril 10 mg daily, atorvastatin 10 mg daily, metformin 1000 mg BID. A&Ox3. A1c=9 (eAG=211), current A1c=7.8 (eAG 177). LDL 165. BP 150/90.
4 DOC? 1 consideration?
DOC: repaglinide; sulfonylurea
DOC2: linsinopril dose increase 20 mg
DOC3: atorvastatin increase 40 mg since increase risk for CVD
DOC4: ASA 81
**don't want to use glipizide because has sulfasensitivtiy and could kill her**
47
repaglinide is a ______
secretagogue which means it makes the beta cells work harder
48
what should you keep in mind when giving someone a sulfonylureas?
it pushes the beta cells to release more insulin, causing them to burn our more quickly....
metformin and insulin don't do this, just a heads up!!
49
what can the sulfonylureas cause?
eventual burn out of the beta cells
50
Case 7: 75 y/o with new T2DM with A1c of 12 (eAG=298). He is here to start tx. HTN, hyperlipidemia, COPD, T2DM. chlorathiodone 12.5 mg. Amlodipine 10 mg daily. atorvastatin 20 mg daily. BMI 35. TC=150. Tri=100, HDL=45 LDL=90 A1c=12 eAG=298. eGFR=40 ml/min
4 DOC options?
DOC1: Glargine insulin starting at 0.2 units and up titrate
DOC2: rapid acting insulin pre-meals
DOC3: Add lisinopril for kidney protection, decrease amlodpiine down to 5 mg
DOC4: increase atorvastatin 40 mg
**oral meds aren't enough for this guy...thats why giving the insulin**
51
Case 8: 75 y/o patient on tx for T2DM and has 3 episodes of episodic hypoglycemia in the last 3 months. She fell during two of them. metformin 1000 mg BID, glipizide 10 mg BID, acarbose 25 mg AC TID. A&Ox3. BMI 30. A1c 7.2 eAG=160
2 DOC options?
her A1c is ok for her age
DOC1: think the episodes are from too high of dose of glipizide so decrease the dose!!
DOC2: start lisinopril
***take away: someone 75 and older can have a A1c that is between 7.5 and 8 and be ok!!***
52
case 9: 50 y/o pt with osteoporosis who is scared to do stuff cause she is scared to break something. 1 ppd tobbacco use. seizure disorder, HTN, tobacco. BMI 24, A&Ox3. DEXA=BMD T score over 2.5 SD below threshold
DOC3?
DOC1: alendronate
DOC2: stop smoking!!! has negative impact on bone
DOC3: vitamin D and calcium (insure you have enough material to regrow bones)
53
what is important to advise a patient to do if they have osteoporosis and are a smoker?
stop smoking because it has a negative impact on bone
54
what is the indication for alendronate?
prevention and treatment of osteoporosis
55
what should you not take with alendronate?
NSAIDS
| antacids
56
when should you repeat the DEXA scan after starting alendronate for osteoporosis?
1-2 years
57
what do you need to monitor when taking alendronate?
Ca and vit D levels
if these are low replace them because these materials are needed to build back the bone
58
case 10: 50 y/o female with daytime sleepiness and fatigue, cold intolerance and weight gain of 15 in the past 6 weeks and new depression. G3P3A0. BMI 28. Thinning hair, palpable thyroid without nodularity. decreased DTRs. TSH=20, H&H 12/35. CBC normal.
dx? DOC? 1 consideration?
hypothyroidism
DOC1: levothyroxine (T4)
**repeat the TSH in 6 weeks!!**
59
what is the drug class of levothyroxine?
thyroid agent
synthetic T4 replacement
60
what is the MOA of levothyorxine? 3
replace T4 that is converted to T3 in the periphreal tissues
binds to nuclear receptors
initiates protein synthesis, metabolic rate, and promotes gluconeogensisi
61
what is the indication for levothyroxine?
hypothyroidism
62
when would you expect the TSH to normalize after giving pt levothyroxine?
6-8 weeks
63
Case 11: 55 y/o male with TSH of 18 and cold intolerance, weight gain, fatigue, course and dry skin. BMI 27, A&Ox3. decreased DTRs. skin coarse, dry, thin hair. TSH 18, H&H 12/36. CBC wnl.
DOC1?
if it TSH remained low after 3 months of tx what 3 labs would you want to check?
DOC1: levothyroxine
if after 3 months, the TSH only decreased a little you should check:
check lipids, FT3 and FT4
64
if a patient with hypothyroidism had normal T4 but deficient T3 what drug would you want to use?
liothyronine (T3)
65
what is the drug class for liothyronine?
thyroid agent
synthetic T3 replacement
66
what is the MOA of liothyronine?
T3 in periphreal tissues binds with nuclear receptors
prompts protein synthesis , metabolic rate increase, and promotes gluconeogensisi
67
what is the indication for liothyronine?
hypothyroidism not responsive to T4 replacement
68
what treating thyroid hormone levels with replacement, what do you monitor?
TSH levels
69
if a person has a A1c of 10-12, what is it likely they will need?
insulin since the percent of the other medications isn't enough to lower it down to 7 (reccomended)
70
what should you know about the halflife of levothyroxine or T4?
it has a long halflife so only need to take once a day
71
Case 12: 80 y/o male with three recent falls when getting up rapidly from seated position. T2DM. glipizide XL 10 mg daily. 160/90 deated. 155/85 reclining, 130/70 standing. BMI 23. A1c= 7.3. Na 130 (135-145), K=5.2 (3.5-5), BUN=12 (8-20), eGFR=45.
3 DOC?
DOC: fludrocortisone since low Na and high K....not absorbing enough
DOC2: ACE (diabetes)
DOC3: statin (diabets)
***elderly people can have lower Na levels naturally, but the issue is that he is sxs and having orthostatic hypotension so want to tx!****
72
what are two drugs commonly used in diabetics that are on the $4 list?
metformin and lisinopril
73
what is the eGFR cut of to use metformin?
30 ml/min
74
what should you keep in mind about elderly patients and when do you use fludrocortisone?
if OVER 75 elderly patients can naturally sodium waste and have lower sodium which is ok so long as they aren't symptomatic, once they start getting symptomatic is when you need to treat them with fludrocortisone...
...symptomatic would include dizziness and orthostatic hypotension
EXCEPTION: if the sodium is less than 120 then you would go ahead and tx regardless of sxs
75
what is the drug class for fludrocortisone?
mineralcorticoid
76
what is the MOA of fludrocortisone?
promotes increase distal renal tubule absorption of Na and loss of K
77
what is the two indications of fludrocortisone?
addisons disease (adrenocotical insufficiency)
resistant orthostatic hypotension
78
if someone has T2DM and is taking metformin...what is the next line drug you would typically turn to?
if this same patient had an allergy to sulfa what would you give them?
sulfonyureas
if allergic to sulfa use the sulfonyurea repaglinide (this isn't contraindicated for someone with sulfa allergy)
79
what can happen in a patient if they are drinking too much water?
they can hemodilute themselves and make the urine electrolytes look less than they are
80
Case 13: 60 y/o lady who is not obese and active. A1c of 8 with repeat testing. She has no health insurance. BMI 27. A1c=7.9, 8. eAG 183. eGFR=50 ml/min. LDL=140.
3 DOC?
DOC1: metformin
DOC2: ACE
DOC3: statin
81
what are two diabetes drugs that are on the $4 list?
metformin
| glypizide
82
what should do when initiating metformin?
titrate up to prevent diarreah
83
what do you need to avoid when taking metformin?
avoid alcohol because it increases the risk of lacti acidosis
84
Case 14: 55 y/o woman with hypothyroidism txed with levothyroxine 112 micrograms for the past 3 months. her TSH was 11 and is now 9. hypoparathyroidism. chronic Fe deficiency. osteopenia. chronic constapation. GERD. levothyroxine 125 micrograms daily in AM. FESO4 325 mg twice daily. CaCO3 1,200 mg daily. Omeprazole 20 mg daily in AM. BMI 28. TSH 11 three months ago, retest today 9 (stil high).
Question to ask? then DOC?
***want to check T3 and T4 levels because some people can't convert T4 to T3 ~15% of the population***
DOC1: ask patient if they have been taking this with the calcium or the iron because this decreases the efficacy of the levothyroxin
DOC2: increase the levothyroixine dose
85
what are three medications you want to avoid taking with levothyroixine because it decreases the efficacy? how far apart to they need to be taken?
corticosteroids
calcium
FeSO4
must be taking FOUR HOURS APART
86
when should you take levothyroixine?
in the morning 30 minutes before breakfast
87
what is the initial and most common dosing of levothyroixine?
12.5-25 mcg initial/MC dose
88
what can depression occur with?
either hyper or hypothyroidism
89
what must you remember when treating a patient for hypothyroidism and they aren't responding with T4 tx?
15% of people have a hard time converting T4 to T3 so these folks may need to take T3 supplelemtnation as well as T4
KNOW IT!!!
90
case 15: 35 y/o with tachycardia, heat intolerance, anxiety, weight losee of 10 lbs in past month, and a palpable but nontender thyroid gland. BMI 22. ext: fine resting finger tremor and anxious. TSH 0.2 (0.5-2.5). FT4=2.3 ng/dL (0.7-1.86), PG=eng.
primary care DOC? 2 drugs that would likely be started by endocrinologist
Graves disease:
primary care DOC: propranalol for SYMPTOM CONTROL
2 DOC from endocrinologist: methimazole or propthiouracil
91
what do you use to treat the sxs of hyperthyroidism like in graves? what do these patients typically come in with?
PALPABLE THYROID
propanolol
92
what are the sxs of hyperthryroidism that propanalol is used to tx? 3
tachycardiac, anxiety, hypertension
93
what is the drug class of methimazole?
antithyroid agent
94
what is the MOA of methimazole?
blocks oxidation of iodine in the hyroid gland preventing iodine combining with tyrosine to for T3 and T4
95
what is the indication for methimazole?
hyperthyroidism
96
what is the drug class for propy;thiouracil?
antithyroid agents thiamine
97
what is the MOA of propylthiouracil?
interfere with thyroid hormone synthesis and inhibits the conversion of T4 to T3
98
what do you need to keep in mind about propythiouracil?
it has immunosupressive effects of the bone
99
what two drugs should you think of when you think of hyperthyroidism?
methimazole
| propylthiouracil
100
case 16: 70 y/o female with new T2DM who are starting on tx today. she has seen the TV ads for canagliflozin and would like to try it. HTN, CKD, T2DM. Chlorthiadone 12.5 mg daily. BMI 28. A1c=9.5. eGFR=25 ml/min.
what can you use? 3 DOC?
can't use metformin here because the eGFR is less than 30
DOC1: glargine insulin
DOC2: linsinopril
DOC3: statin
101
what is the dosing for insulin for T2DM?
0.2 units per kilo
102
who typically requires more insulin, T1DM or T2DM?
typically type 2 needs more insulin because of the insulin resistance (replace and combat) than type 1 (just replace)
103
what is the cut off eGFR for metformin? when must it be dose adjusted?
eGFR cut off for metformin is 30 ml/min***this just changed so should know it*** give reduced dose between 30-45***
104
typically, how much do oral agents lower the A1c?
0.5 to 1% (sometimes 1.5% but majority 1%)
105
what is the risk SULFONYLUREA IS THE # 1 CASE OF DEATH RISK FOR ELDERLY!
HYPOGLYCEMIA
this stimualte the pancreatic cells to release insulin
106
case 17: 60 year old female who has osteoporosis which has not responded to biphosphonate therapy. she has a hx of prior fall with hip fracture and also two previous vertebral fractures. Left hip ORIF. HTN. Osteoporosis. chlorthalidone 12.5 mg daily. BMI 18. Thin, alert, active 60 years old. BMD T-scoreless than-2.5.
DOC:
DOC1: denosumab because of high fracture risk every 6 months injection
107
what is the drug class for denosumab?
RANK ligand inhibitor
108
what is the MOA of denosumab?
human antibody that attaches to the RANK receptor on the surface of the osteoclast and inhibits it and causes apoptosis
109
what is the indication for denosumab?
high fracture risk and osteoporosis
110
what and how is denosumab dosed?
60 mg subcutaneously every 6 months
111
what must you make sure to do before starting denosumab?
make sure the Ca and vitamin D levels are adequate before starting
112
what for of caclium would you want to give to a patient who is starting denosumab and is also taking a PPI like omprazole or prapantizole?
CITRATE
this can be absorbed without an acidic environment so this is the best option if someone is taking a PPI
113
what are the two phases of osteoclast and osteoblast activity?
2 weeks of osteoclast activity
| 12 weeks of osteoblast activity
114
parafollicular cells are responsible for.....
calcitonin
115
case 18: 80 y/o woman with osteoporosis txd for past 5 years with alendronate. She has a LOW FRACTURE RISK. she wants to know if she needs to continue to take the biphosphonate because she finds it difficult to take. osteoporosis HTN CKD. linsinopril 10 mg daily. fosamax 10 mg daily. BMI 22. eGFR 45 ml/min.
can she come of it?
she can go off of it because studies show that the drug stays in the system for the next 5 years and check DEXA
116
how long does biphosphonate stay in your system after stopping it?
5 years
117
who can you stop biphosphonate in?
those with low fracture risk...but if they have a drop in their T score or have a fracture need to restart
118
what is the T score that you would initiate biphosphonate?
over 2.5 SD=osteoporosis
119
what is the SD for osteopenia?
1.0-2.5
120
what do you want the SD to be in a normal person?
below 1
121
Case 19: 80 y/o woman with osteoporosis txed with aldendronate the last 5 years. She has HIGH fracture risk with previous vertebral fracture and hip. she wants to know if she needs to keep taking the bisphosphonate because she thinks its hard to take. osteoporosis HTN CKD ORIF right hip vertebral fracture. Lisinopril 10 mg daily. fosamax 10 mg. very thin. eGFR 45 ml/min.
DOC option?
DOC: can change from a daily prescription to a weekly prescription so she doesn't have to take it as much but still gets the benfit!!! since high risk don't want to stop it
since high risk continue anothe 5 years and go from there
122
what what point do you consider stoping biphosphonates in all elderly?
85 because they will be covered till 90
123
why do we take patients off of biphosphonates?
Uncontrolled fractures – these folks have bone formation but not normally like a healthy person would – outer layer is fine, but do not form trabecular part of bone as well as a healthy individual – this causes...
DISTAL FEMOR SHAFT FRACTURE
124
what are the two biphosphonates?
alendronate
| zoledronic acid
125
if the two biphoshonates which protects against hip and vertebral fractures?
alendronate
126
why do we tell patients to sit upright 30 minutes after taking biphosphates alendronate and zoledronic acid?
because it can cause esophagitits and erosion
127
what patient population wouldn't you want to use biphosphates in?
someone who can't sit up at half hour after taking it like a paraplegic?!
128
of the biphosphonates which is oral which is IV?
oral=alendondrate
IV=zoledronic acid
129
what is a strange sxs that you want to watch out for when taking a biphosphonate?
osteonecrosis of the jaw so get dental eval prior to use
130
case 20: 18 y/o man admitted to hospital after MVA from binge drinking. he has hx of T1DM and was initially txed with sliding scale insulin coverage in hospital. now being discharged and doesn’t know what type of insulin he was taking. T1DM. alcoholism. concussion. A1c 9/9 (eAG=240).
DOC?
DOC: 75/25 insulin glarine/regular short-acting insulin
complicating factor: BS would be much better with long acting and short acting but problem is binge drinker so in akward position until alcoholism under control….couple ways to do this. some protocals call for 50/50 basal and short acting, and 75/25 basal insulin and short acting so want to use the 75/25 option because it gives him less change to mess up with the short term acting better control chance of sugar
131
what are the two ratios of long and short acting insulin that are typically used in patients that require both?
75/25 long/short
and
50/50
******calculate the total dose and then divide by the the ratio of how much should be given when****
132
what can make BS really wonky?
uncontrolled alcoholism
133
in T1DM, what is the units of insulin per Kg you use?
0.2-0.6 there is a range that is accetable
134
in T2DM, what is the units of insulin per kg you use?
0.2, not a range
135
what should you ALWAYS worry about in patients who are taking insulin?
HYPOGLYCEMIA
136
what is the drug heiarchy for T2DM?
1. metformin
2. sulfonylureas
3. insulin
137
what type of medications do you use for T1DM?
long and short acting insulin
138
how can long acting insulin be dosed?
once in the morning or BID
139
what is the SOMOGYI effect?
hypoglycemia begets hyperglycemia"
HYPOGLYCEMIA increases counter regulatory hormones and insulin resistance leading to HYPERGLYCEMIA which increases the insulin dose and leads to HYPOGLYCEMIA
**nocturnal episodes are difficult to discern**
140
DAWN effect
increase in blood glucose between 5-9 without preceeding low glucose
alone it leads to only mild hyperglycemia
141
what happens if the DAWN and SOMOGYI effect occur at the same time
CAN CAUSE VERY HIGH BLOOD GLUCOSE LEVELS WITHOUT INGESTING ANY FOOD
142
of the insulins, which one get be given IV?
regular short acting insulin
143
Case 21: 70 y/o with T2DM who A1c is 9.0 despite fulld dose metformin and glipizide therapy. he would like to start insulin therapy. HTN T2DM COPD tobacco use CKD. lisinopril 20 mg daily. albuterol MDI PRN. symbicort. Metformin 1000 mg BID. flipizide 10 mg BID. BMI 20. A1c 9.0. eGFR 50 ml.min. BUN 15.
DOC?
DOC: stop glipizide and start insulin glargine w/ or w/o metformin
144
what is the only difference between the 100 and 300 insulin glargine?
the 300 is more concentrated so the patient can inject less fluid
145
What is the A1C goal for elderly with comorbid conditions?
7.5-8 (can be on the higher side since you don't want to risk them becoming hypoglycemic)
146
case 22: 45 y/o pt with new onset T2DM. A1c is 9.0 he is obese sedentary and is a cross country truck driver. he is quiet anxious about being able to keep his job. HTN. obesity. hyperlipidemia. HCTZ 25 mg daily. BMI 34. HbgA1c=9.0%.
3 DOC?
big deal is that you don’t want him to become hypoglycemic
DOC1: METFORMIN (less likely to cause hypoglycemia)
DOC2: ACE
DOC3: statin
147
Case 23: 65 y/o self employed pt who has T2DM for the past 10 years. he wants to keep working for another 10 years. he is having progressively more difficult time controlling his BS with oral medications of the past year. HTN, T2DM, COPD, tobacco. Lisinopril 20 mg daily. metformin 1000 mg twice daily. glipizide 10 mg daily. umecladinium DPI daily COPD. albuterol MDI PRN. BMI 29. A1c ranges from 7.4-7.8 over the past year.
DOC? 2
HIS GOALS: **want to avoid insulin as long as possible so he can work another 10 years** (unrealistic BUT)...
DOC: increase metformin and add long acting insulin....this would mean that he would have to take less of it!
148
how can meformin be dosed?
once daily or BID
149
case 24: 85 y/o female with multiple problems with episodes of hypoglycemia over the past year. T2DM. HTN. angina. COPD. Tobacco. CKD4. diabetic neuropathy. HF. glargine insulin U100 30 units SQ, lispro insulin 15 min pre-prandial twice daily at 3-5 units. lisinopril 20 mg daily, amlodipine 5 mg daily, atrovent MDI, spiriva DPI, duloxetine 60 mg daily (neuropathy), furosemide 40 mg for over 5 lbs. BMI 33. prolonged expiratory phase with scarred wheezing but without rales. A1c=6.7-7 pover past year but 4 episodes of symptomatic hypoglycemia (glu=40-50 mg during episode), eGFR=25 ml/min
her probelm is reccuring hypoglycemia
a1c is 6.7-7 so she is under titer control than she should be, decrease glargine 5 units and then decrease lispro so she is taking 3-4 units POST PRANDIAL
if she is taking it before a meal you don’t know how much she is going ot eat because of her age so it might be easier to give it after eating
150
what can you do with lispro insulin to prevent hypoglycemic episodes?
dose postprandially in elderly so that way you don't have to worry about how much they are going to eat and overshooting it with a preprandial dose
151
what are three common side effects of insulin?
HYPOGLYCEMIA
WEIGHT GAIN
SUBQ FAT ATROPHY
152
hypoglycemia leaves a person at increased risk for 2
syncope and hip fracture
153
what are two things that insulin interacts with?
alcohol increases hypoglycemia risk
beta blockers
