PHARM III All Lectures Flashcards
(268 cards)
1
Q
What are the two direct/ peripherally acring antispastic agents
A
Dantrolene and Botulium toxin A
They both alter function of nicotinic-muscle receptors or skeletal muscle fibers
2
Q
What is the durantion of use and Clin/Ind for cyclobezaprine
A
Short term in combination with physcial therapy
Do not use for cerebral palsy or spinal cord injury
Has the potentail to lower the SZR threshold, DO NOT USE with tramadol
3
Q
Can you use cyclobenzaprine and tramadol together
A
No! Both lower the SZR threshold
4
Q
Since Cyclobenzaprine is like a TCA, what are its ADE and C/I
A
DROWSINESS , dry mouth, urinary retention, increadsed occular pressure
SERTONIN SYNDROME
C/I: Recent MI, any heart problems, DO NOT USE w/in 14 days of a MAOI
Hyperthyroidism
Caution in preg.
5
Q
Orphenadrine is an analog of what other drug and is indicated for what condition
A
Diphenhydramine
Clinical Use: Treatment of muscle spasm associated with acute painful musculoskeletal conditions
Used short term (2-3 weeks)
6
Q
Since orphanadrine is an anticholinergic what are its ADE and C/I
A
Anticholinergic effects: dry mouth (1st to appear); tachycardia, urinary hesitancy or retention, blurred vision, nausea/vomiting, etc.
High risk for confusion in elderly
Contraindications: glaucoma, pyloric or duodenal obstruction, stenosing peptic ulcers, prostatic hypertrophy or obstruction of the bladder neck, and myasthenia gravis
7
Q
Carisoprodol is metabalized to what.. which is what gives it its anziolytic and sedative effects
A
Meprobamate
8
Q
What is the clinical indication of carisoprodol
A
Relief of discomfort associated with acute, painful musculoskeletal conditions in adults
Used short term (2-3 weeks)
9
Q
What are the ADE and C/I of carisoprodol
A
Withdrawl, sedation, dizzyness, HA, SZR,
Caution with ETOH and depressants
High risk of confusion in elderly
DO NOT USE IN PREGNANCY
10
Q
Can Carisoproldol be used in pregnancy
A
NO , adverse events have been observed in animal reproduction studies
11
Q
What is the clinical use and ADE of metaxalone
A
Clinical Use:
Relief of discomforts associated with acute, painful musculoskeletal conditions
Appears to cause less drowsiness than others
Adverse Effects:
Nausea, gastrointestinal upset, sedation, dizziness, headache, anxiety, or irritability
Serotonin Syndrome
Caution combining with alcohol and other CNS depressants
High risk for confusion in elderly
12
Q
What is the Clin/use and ADE of methocarbamol
A
Adjunctive treatment of muscle spasm associated with acute painful musculoskeletal conditions
Treat muscle spasticity associated with tetanus (toxin) poisoning
ADE: BLACK BROWN OR GREEN URINE!
Caution in use wtih ETOH or depressants
C/I iv formulations in pts with renal impairment and hepatic impairment
13
Q
A pt presents with tetanus poisoning, what Antispasmodic can you use to Tx
A
Methocarbamol
14
Q
What is the clin use and ADE of tizanidine
A
Clinical Use:
Muscle spasticity
Short acting agent
Adverse Effects:
Drowsiness is the most prominent adverse effect
Start low and titrate the dose up (2mg TID)
15
Q
What is the most prominent ADE of tizanidine
A
Drowsiness
Can also cause drymouth, HOTN, asthenia, and hepatotoxic (A2 agonist)
16
Q
Baclofen inhibits the release of what substance in the spinal cord
A
Substance P
17
Q
Which is better, baclofen or diazapem
A
Baclofen casues as much antispamodic activity as diazapem with out the same amount of sedation which can be a good thing
18
Q
Can you use baclofen in SZR pts
A
Increased seizure activity reported in epileptic patients, therefore withdraw slowly
19
Q
Can you use Diazapam in preg. Pts
A
Cat D, no
20
Q
A pt presetns with post herpatic neuralgia, what medication can help
A
Gabapentin and Gabapentin enacarbil (prodrug)
21
Q
Can Gabapentin Enacarbil be used for epilespy
A
prodrug for gabapentin and is indicated for post herpetic neuralgia and restless leg syndrome, NOT epilepsy
22
Q
How are gabapentin and pregabalin eliminated
A
eliminated renally; adjustments may be necessary for renal dysfunction and hemodialysis
23
Q
What are the ADE of Gabapentin and pregabalin
A
Dizziness, and wt gain
Gaba: drowsiness and fatigue
Pre: Sex Dyf., angioedema,
24
Q
What is the antidote to Botulinum Toxin
A
Equine Botulinum Antitoxin
25
Do NMBA effect the CNS
NO! Only act periphearlly
26
A female pt presents with a unilateral severe HA, desribes it as pulsating that is aggrevated by physical activity
Complains of Nauseas, photophobia, and phonophobia, tyopically lasting up from 4-72 hours
What kind of HA is this
Migraine
27
A female ptr presents with cc of HA x 1 day
States pain is Bilateral and has a pressing/ tighting sensation, is not effected by physical activity, denies nausea, but sometimes has photo/phono phobia
Think what kind of HA
Tension
28
A male pt present with cc of HA x 45 minutes
Describes it as unilateral severe piercing sensation
States he has ipsilateral nasal congestion, miosis, and ptosis, and frequently the HA occur at night
What kind of HA
Cluster
29
What does the acronym snooping refer to with HA
S: systemic symptoms or signs (e.g., fever, weight loss), or systemic disease (e.g., cancer)
N: neurologic symptoms or signs
O: onset sudden (e.g., thunderclap headache)
O: onset late in life (> 40 years)
P: pattern change (progressive with loss of headache-free periods; change in type)
Go SNOOP for an alt cause
30
What does the Acronym POUNDing mean when it comes to HA
```
Pulsatile
One day duration or less
Unilateral
N/V
Disabling intensity
```
POUNDING=migraine
31
What is the criteria to Dx a Migraine without aura
```
Al least 5 attacks that last 4-72 hours with at least 2 of the follwoing:
Unilateral
Pulsating
Mod-severe pain
Aggrivated by phycical activity
```
During the HA at least 1 of the follwing s/s:
N/V, photo or phonophobia
32
WHat is the Dx criteria for Migrain with aura
A least TWO HA with at least 1 S/s of aura ( Visual, sensory, speach, language, motor, brainstem, or retinal)
With at least two of the following:
- One aura symptom spreads gradually over ≥5 min, and/or two or more symptoms occur in succession
- Each aura symptom lasts 5-60 min
- At least one aura symptom is unilateral
- The aura is accompanied, or followed within 60 min, by headache
33
What is the gene that is associated with genetic predisposition of migraines
50% of cases of familial hemiplegic migraine (FHM) are caused by mutations within the CACNL1A4 gene on chromosome 19
34
What is the important mediator in Migraines
Seretonin (5-HT)
35
What is the neuronal theroy of Migraines
Migraine aura may be explained by the neuronal theory in that the positive (e.g., light around the edges of the field of vision) and negative (e.g., blind spots or tunnel vision) symptoms of the migraine aura are caused by neuronal dysfunction, not ischemia
36
Activation of what system is the reason for pain in a migraine
Pain results from activity within the trigeminovascular system
Activation of trigeminal sensory nerves triggers the release of vasoactive neuropeptides:
- Calcitonin gene-related peptide [CGRP]
- substance P
- neurokinan A
These Produce vasodilation and dural plasma extravasation leading to neurogenic inflammation
37
What are the 4 phases of a Migraine
1. Premonitory S/s
(phono/photophobia, hyperosmia, anxiety, depression , euphoria, polyuria, diarrhea, stiff neck, tawning, food cravings, ect)
2. Aura
(Positive or negative visual (most often), sensory, or motor symptoms that develop over 5-20 minutes and last for usually 60 minutes, with the headache usually following within 60 minutes)
3. HA
( Generally begins with a dull ache that intensifies over a period of minutes to hours to a throbbing headache, which worsens with each arterial pulse)
4. Resolution
(Fatigue, irritable, impaired concentration, scalp tenderness, mood changes (e.g., refreshed and euphoric or malaise and depression))
38
What are the short term goals of Migraine Tx
Treat attacks rapidly and consistently without recurrence
Restore the subject’s ability to function
Minimize the use of backup and rescue medications
Optimize self-care and reduce subsequent use of resources
Cause minimal/no adverse effects
Be cost-effective
39
What are the long term goals of Migraine Tx
Reduce migraine frequency, severity, and disability
Improve quality of life
Prevent headache
Avoid escalation of headache medication use
Educate and enable patients to manage their disease
40
What is the primary end point of Migraine Tx
Headache response (pain-relief or pain-free within 2 hours) (Primary endpoint)
41
What is the MIDAS
Migraine disabilty assesment
42
What is a MIDAS grade I
MIDAS score of 0-5
Means little or no disability
43
What is a MIDAS grade II
Score of 6-10
Means mild disability
44
What is a MIDAS grade III
Score from 11-20
ind. moderate disabilty
45
What is a MIDAS grade IV
Score greater than 21+
Ind. severe disability
46
A score of less than 2 on the Monitoring Headache Response Migraine-ACT Questionnaire means what
Score of ≤ 2 may indicate a need to change the patient’s acute medication therapy
Score of ≤ 1 may indicate that the change is mandated
47
What is the Sterp care across migraine Tx
HA 1 = treat with NSAID
HA 2= Tx w/ NSAID
HA 3= Tx with NSAID
If unsuccessful response in more than 2 HA Tx with NSAID then treat HA 4 with triptan
48
What is the Step Care within Migriane Tx
HA treated with an NSAID yet unsuccesful after 2 hrs
Then treat with a triptan
49
What is the stratified Care approach to Migraine Tx
PTs with MIDAS grade II= NSAID
| MIDAS grade III-IV= triptan
50
What are the two specific therapies for migraines
Ergotamines and Triptans
51
Is acetaminophen better or worse at treating HA than NSAIDs
Pain-free response at 2hrs found inferior to other commonly used NSAIDs and aspirin
52
Are there any studies supporting the use of Butabital for HA
NOPE
53
Can pts taking MAOI take Midric C-IV
NO!
54
Can pts with HTN take Midrin C-IV
No, isometheptane causes vasocon
55
What should pts who take Excedrin be cautioned of with daily use
Caution of caffeine withdrawal headaches if taking daily
56
How long can NSAIDs be used in HA tx
Limit use to < 15 days per month to prevent drug overuse headache
57
How do NSAIDS help Tx migraines
magraines: prevents neurogenically mediated inflammation in the trigeminovascular system
58
Should NSAIDS be used in pts with PUD, Renal insuf, bleeding D/o
No can cause bleeding and remember renal trifecta
59
What is the most effective route for ergotamines
Rectal !
60
What is ergotism
Ergotism: intense vasoconstriction resulting in peripheral vascular ischemia and possible gangrene, as well as possibly tonic-clonic convulsions accompanied by mania and hallucinations
From taking ergotamine
61
Can preg pts take ergotamine
NO! Cat X
62
Ca Triptans and ergotamine be used together
Do not use within 24 hours of a triptan
63
Can ergotamines be used in pts with CVDz, Hepatic or Renal Dz
No!
64
Long term use with ergotamines can cause what valvular heart problems
Fibrotic valve thickening (e.g., aortic, mitral, tricuspid) with long-term use
65
Can you give ergotamine alone
No, cuases N/V so need to premedicate
66
What medication is used to treat status migraniosus
Dihydroergotamine IV (45)
67
What is the advantage of using Dihydroergotamine vs ergotamine
Dihydroergotamine has less ADE
68
Can you use dihydroergotamine and Triptans together
Do not use within 24 hours of a triptan
69
What are the highest likely hood of success triptans when treating migraines
The highest likelihood of consistent success was found with rizatriptan, eletriptan, and almotriptan
ERA!
70
How many times per month can a pt use triptans
Limit use to ≤ 9 days per month
71
What pts can Triptans NOT be used in
Patients with a history of ischemic heart disease (e.g., angina, previous MI, etc.), uncontrolled hypertension, and cerebrovascular disease (e.g., stroke)
Do not use in patients with hemiplegic and basilar migraines
72
How should the 1st does of triptans be administered
Patients at risk of coronary artery disease should have 1st triptan dose in the clinic with vitals ± ECG
Consider administering the 1st triptan dose in the clinic with vitals ± ECG in patients with a likelihood of unrecognized coronary disease (i.e., significant hypertension, hypercholesterolemia, obese patients, diabetics, smokers, etc.)
73
If a pt is taking a triptan for HA, can you also give then an ergotaine
Do not use within 24 hrs of ergotamines
74
Can triptans and SSRIs be used together
Caution with other serotonin active medications serotonin syndrome
75
What is seretonin syndrome
A potentially life-threatening drug reaction resulting from excess serotonin
Presents as a clinical triad of abnormalities:
-Cognitive effects
-Neuromuscular dysfunction
-Autonomic dysfunction
76
A pt presents to the ED with AMS, myoclonus/ hyperreflexia, and hyperthermia
What triad of S/s if this reflecting
Seretonin syndrome
77
What is the Tx approach to seretonin syndrome
Withdrwal offending agent
| Supportive care
Cyporheptadine
78
Which Triptan contains a sulfa group and can not be given to pts with sulfa ALLRGY
Almotriptan
79
If a pt is taking propranolol, what adjustmnet must be made to Rizatriptan Rx
Decreased the dose to 5 mg in pts taking propranolol
80
If a pt is taking clarithromycin ( a CYP3A4 Inh.) how must they take eletriptan
Can not be used with in 72 hours
81
Can preg. Pts used butophanol
When used in pregnancy, abnormal fetal heart rate was noted
82
Butorphanol as a partial Mu agonist has what ADE
HOTN, N/V, blurred vision, sedation
83
What is the best way to prevent Medication over use headaches
Prevention is best: limit use of migraine therapies to 2 days/week
Treat by discontinuing the offending agent
- Takes 3 to 8 weeks following medication withdrawal to evaluate efficacy
- May bridge with prophylactic HA medications
84
What are the thresholds to start a pt on migraine prophylaxis
Frequency and duration (generally accepted thresholds):
> 4 HA/month or
Last >12 hours
85
What is an adequate trial time frame for a migraine prophylaxis tx
1-2 months
86
How is Treatment generally administered for migraine prophylaxasis
Treatment is generally continued for 3-6 months after the frequency and severity of headaches decrease, and then is tapered gradually (over 2-4 weeks) and discontinued
87
A pt presents with recurring headaches that are in a predicatble pattern (menstral migraines)
What is an approaprite prophylaxis
NSAID at the time of the HA
88
When can BB be used in Migraine Tx
In healthy or comorbid HTN, angina, or anxiety
89
A pt with comorbid depression or insomina, with migraines should get what meds
TCAs
90
A pt with SZR and Migraines should get what Dx
Anticonvulsants
91
Topiramate causes a 2-4 fold increase in what condition
Kidney stones
Can also cause Met Acidosis
92
If a pt has astham or raynouds can they take BB
NO!
93
What is the NSAID used for Mentrual migraines
Naproxen
94
What electrolyte is a useful prophylaxis of migraines in pregnancy
Magnesium
95
What expensive medication can be considered for pts with 15 or more HA a month
Botulism toxin A
96
Is a pt is pregnant, what is the best Tx of their migraines
Acetaminophen for active attacks
Mag for prophylaxis
97
What is the most common type of primary HA
Tension HA
98
What seperates a tension HA from a migriane
Differences:
Lacks premonitory symptoms and aura
Pain usually mild to moderate in intensity, bilateral, and described as dull, non-pulsatile tightness or pressure that occurs in a hatband distribution around the head
Disability minor in comparison to a migraine
Routine physical activity does not affect headache severity
99
What is the criteria for Dx of a Acute Tension HA
At least TEN episodes occuring more than 1 day a momth lasting form 30minutes to 7 days
```
With at least 2 of the followingL
Bilateral
Pressing/tightning
Mild to mod pain
Not aggrevated by physical activity
```
Can not have N/V or either photo/phonophobia
100
What is the critera for chronic tension HA
HA more than 15 days per month for more than 3 months
Lasting hours or continous
```
Meeting at least 2:
Bilateral
Pressing/ tightning
Mil-mod pain
Not aggrevated by phys. Activity
```
Can not have N/V or photophobia+phonophobia
101
When should prophylaxis be considered for tension HA
Consider if headache frequency (> 2/week), duration (> 3-4 hours), or severity results in medication use or significant disability
102
What are the ADE of using a TCA (amitryptyline) for tension HA
: anticholinergic side effects, weight gain, orthostatic hypotension, and arrhythmia concerns
Should be taken at night
103
1st degree relatives of people with cluster HA have what risk of having it as well
1st degree relatives have a 14-fold increased risk for also having cluster headaches
104
A pt presents to the exam room , pacing back and forth holding his head, states that the pain is only one one side of his head, and is severe ..
what kind of HA could this be
Cluster HA
105
What is the criterea to Dx a cluster HA
A least FIVE attacks that are severe with unilateral eye pain lasting 15-180 minutes if untreated
HA is accompanied by at least 1 ipsilateral S/s
106
What is the Tx appraoch to Cluster HA
O2 is the 1st line Tx
Sumatriptan is the most effective Rx
107
What is T1DM
results from β-cell destruction, usually leading to an absolute insulin deficiency
108
What is T2DM
results from a progressive insulin secretory defect often in the presence if insulin resistance (i.e., a relative insulin deficiency exists)
109
What fasting glucose indicated Diabetes
126 mg/dL
110
What Oral Glucose Tolerance Test value indicated DM
Greater than 200mg/dL
111
What A1C value indicated DM
Greater than 6.5
112
What is the 7th leading cause of deaith in the US
DM
113
Reducing Hypertension in DM pts has what profoudn effect
In general, for every 10 mmHg reduction in SBP, the risk for any complication related to diabetes is reduced by 12%
Reducing DBP from 90 to 80 mmHg reduces the risk of major cardiovascular events by 50%!!!
114
What is the leading cause of new cases of blindness among adults
DM
115
What week of pregnancy are pts screened for DM
24th-28th week
116
What are the BG goals for a pt with GDM
Goal:
Preprandial: ≤95 mg/dl
1 hr postprandial: ≤140 mg/dl
2 hr postprandial: ≤120 mg/dl
117
A preg pt presents to the clinc, she has no Hx of DM or GDM, when should she be screened for GDM
At 24-28 weeks
118
A pt has risk factors for DM and GDM and is pregnant, when should she be screened for GDM
At the 1st prental visit
119
Women with GDM should be screened for DM how many weeks post partum
6-12 weeks
120
Which two DM Rx are preg cat C
Glargine and glulisine
All other DM medications are labeled B
121
What is the threshold that defines hypoglycemia
Less than 70
122
A pt presents with tachyHR, tremors, sweating, anxiety and complains of hunger
What should you check
BG
123
What is level 1 hypoglycemia and what is the Tx appraoch
BG of 60-70 mg/dL
15-15-15 rule
124
What is level 2 hypoglycemia and what is the Tx approach
BG 41-59 mg/dL
30-15-30 rule
125
What is level 3 hypoglycemia and what is the Tx approach
BG less than 40 mg/dL
Glucagon 1mg subQ
Or 50mls of D50W IV
126
How do most T1DM pts present initially
DKA
127
What are the hallmark Dx labs for DKA
Hyperglycemia
Acidosis
Anion Gap
Ketonemia or Ketouria
128
What is the inital approach to Hyperglycemic emergencies
Check BG, serume/urine ketones, CMP, start IV fluids of 1 L per hr
129
If the potassium level is below 3.3
| How should you admin inulin
DONT!
Hold insulin and give K+ until K is greater than 3.3
Than give K+ in each L of IV fluid to maintain a level between 4-5 mEq/L
130
What are the two Insulin approaches to hyprglycemic emergencies
Either
0.1 U/kg as IV bolus follwoed ob a o.1 U/Kg/Hr of IV infusion
Or 0.14U/kg pr Hr as Iv continuous infusion
In both approaches, If serum gl doesnt fall by 10% in the first hour give 0.14 bolus.
131
When should Tx approach be amended in DKA
When serum gl reaches 200 reduce Insulin to 0.02-0.05 U
Keep serum gl between 150-200 until resolution of S/s
132
WHen should Tx appraoch to HHS be ammended
When serum gl reaches 300 reduce Insulin to 0.02-0.05
Keep gl between 200-300 until resolution of S/s
133
On sick days how often should T1DM check BG
Every 2-4 hours if increased
134
On sick days how often shoudl T2DM pts check thier BG
2-4 times a day if elevated
135
What is the age of onset difrences of T1 vs T2 DM
T1 usually before the age of 30
T2 is usually after 40
136
Is there a strong familail link for T1DM
No, however T2 there is
137
If a pt has a fasting plasma glucose of 100-125
What would we call this
Pre diabetic
138
If a pt had a Glucose Tolerance test from 140-199
| What would we call this
Pre DM
139
An A1C of 5.7-6.4 is what
PreDM
140
in general, every 1% drop in HbA1c reduces the risk of microvascular complications by what percent
40%
141
What are the Common ADE of Insulin use
Hypoglycemia ( can be life threatening)
Wt gain (4kg)
Lipohypertrophy: fat mass occurring at the injection site
Lipoatrophy: dimpling in the skin at the injection site due to fat breakdown
142
Where can Insulin not be injected
Into the umbilicus
143
What is the site of most rapid absoprtionfor Insulin, what is the least
Fastest in the abdominal fat
Slowest in the superior buttocks
144
How does renal failure and hepatic failure effect insulin clearnace
Decreased clearance
145
What is the role of Bolus insulin
Controls post pradinal hyperglycemia
146
What is the role of basal insulin
Controls fasting hyperglycemia
147
When must rapid acting insuling be administered
Either 5-15 minutes before
Or withing 20 minutes after a meal
Lispro: Give SQ within 15 mins before or immediately after meals
Aspart: Give SQ 5 to 10 mins before meals
Glulisine : Give SQ injection within 15 mins before or within 20 mins after a meal
148
How is afrenza administered
Inhaled , at the beginning of a meal
| Useful for pts that dont want to stick themselves
149
If switchingn to afrenza from subQ insulin what is the conversion
SQ mealtime insulin: round up to the nearest 4 units and converting unit-per unit
Example: 6 units of Novolog to 8 units of Afrezza
150
What pts is U500 insulin used for
U500 (high concentration regular insulin) used for patients requiring > 200 units/day
151
What kind of insulin is U500
Short acting (refular) insulin
152
How is short acting insulins administered
Can be IV or SubQ
30 min beofre meals
153
How is intermediate acting insulin administered
Not in relation to meals, can be used a basal insulin
154
What does NPH insulin stand for
Neutral protamine hagedorn
155
Of the long acting insulings, Glargine and detemir, which one is bound to albumin
Detemir
156
Can long acting insulins be mixed with other insulins
Do not micx with other insulins or dilute!
157
Using Regular short acting insulin after a meal increases the risk of …
HOglycemeia
158
WHat is the major risk of U500 insulin
Inadvertent OD
159
For basal insulin , which has the lower risk of noctural HOglycemia, NPH or Long acting?
Long acting, like determir and glargine have the lower risk
160
What is the ave. Daily req Insulin for a T1 DM
O.5 units per kg
161
What is the insulin to carb ration when using regular insulin
450/TDD
162
What is the insulin to CHO ration when using rapid acting insulin
500/TDD
163
1 unit of insulin is estimated to cover how many gm of CHO
15gm
164
What is the rule of 1500 and 1800
Regular Insulin: Correction factor = 1500/TDD
Rapid-Acting Insulin: Correction factor = 1800/TDD
Correction dose= (current BG-desired blood BG)/ corretion factor
Example
Current Bg 234, desired BG is 120
Pts wt is 100kg
Assume 0.5u/kg
(234-120)/ (1500/50)= 3.8 (4)units of regular insulin
Or 114/( 1800/50)= 3.16 (3) units of rapid acting insulin
165
If pre breakfast BG is high/ low what insulin adjustment
adjust evening basal insulin dose
166
If pre-lunch blood glucose is high/low adjust?
adjust morning bolus insulin dose the next morning
167
If pre-supper blood glucose is high/low
| Adjust
adjust morning basal insulin and/or pre-lunch bolus dose the next day
168
If pre-bedtime blood glucose is high/low
| Adjust?
adjust supper rapid/reg insulin dose the next day
169
If 2-hour post-prandial glucose is high/low
Adjust?
adjust pre-meal rapid/reg insulin dose the next day
170
If 0300 BG is high/. Low
Adjust ?
adjust evening basal insulin dose the next day
171
What is the difference between somogu effect and dawn phenomenon
Dawn: Insufficient evening basal insulin leads to AM hyperglycemia secondary to normal waking process
—0200 to 0300 SMBG results reveal a normal or elevated blood sugar
Solution: increase the evening basal insulin
Somogyi: Too much evening basal insulin leads to hypoglycemia in the middle of the night
—0200 to 0300 SMBG results reveal a decreased blood sugar
In response to the hypoglycemia, the body responds by increasing glycogenolysis and gluconeogenesis leading to AM hyperglycemia
Solution: decrease the evening basal insulin
172
What are the Rsk fxs for T2DM
```
Physical Inactivity
Family Hx
High Rsk Ethnicity
Delivering a baby >9lbs
GDM Dx
Polycyctis ovarian syndrome
HTN
Hx of CVD
Dislipidemia (HDL < 35 or TriGs>250)
A1C > 5.7
```
173
Define Metabolic syndrome
40in (men) 35in (women) waist
HDL less than 40 (men) or 50 (women)
Or Statin
TriGs > 150 or Rx
HTN or Rx
Fasting gl > 100 or Rx
174
What are the 4 markers for T2 DM Dx
A1c greater than 6.5
Fasting gl > 126
2-hr gl > 200
Random gl> 200
175
What are the goal of therapy for Type 2 Dm pts
A1c below 7.0
Or beolw 8.0 in eledery
(Tight control is below 6.5)
Post pradnianl bg less than 180
176
What is a proper excercise regime for a pt with T2 DM
150 min/wk mod intensity aerobic activity
Spread over 3 days a week
With resistance training 2 times a week
177
What is the primary and secondary prevention of CVD for pts with DM
Aspring
Or clopiogrel ( if allergy)
178
What is the bp goal for a pt with DM
Less than 130/80
179
A T2DM pt presents with an A1c of 8.8
What is the treatement approach
1. Above goal? Yes= metfromin
2. Follow up in 3 months
3. Above goal? Add an option 1 med
(GLP-1, SGLT2, DPP4, TZD, SU)
180
If a pt is started on a GLP-1, what med can not be part of thier treaptmetn
DDP-4 (liptins)
181
Are Sulfonyrueas usually added on to pts regiments
No, SU are usually started first if the pt can afford other options, but rarely added on later
182
What are the 4 option 1 DM rx
GLP-1, SGLT-2, DPP-4, TZD
If the pt is poor then you can consider SU
183
If a pt is started on a GLP 1, and is not at goal, what is the next step
SGLT2
184
If a pt is started on an SGLT-2, and is not a goal what is the next step
GLP-1
185
If a pt is started on a DPP-4 and is not at goal what is the next step
SGLT-2
186
If a pt is started in a TZD, and is not at goal what is the next step
SGLT-2
187
Can you combine DPP4s with GLP1
No!
188
If a pt has ASCVD
| What is the appraoch to Tx thier T2DM
Must start with either a GLP-1 or a SGLT2,
If not at goal add on which ever of the above was not started first
If still not at goal then d/c to GLP-1 and add on a DPP-4 ,
And if still not at goal start pt on basal insulin
189
What is the threshold to place a pt on metfrom plus an option 1 med
If A1c is above 1.5% goal
190
If a pt has an AIc above 10% what is the approach
Can start insulin right away
Using a Dual injectable therapy approach
GLP-1 + Basal insulin
If not at goal then add mealtime insulings starting at largest meal of day and adding until Goal is met
191
SGLT-2i (flozins) have what major ADE
Can cause CHF and CKD
192
GLP-1 (tides) have what major ADE
ASCVD risk
193
What is the only labeled oral agent DM Rx for use in children
Metformin
194
How should metformin be used in the elderely
Should not be titrated to max doses
195
What are the ADE of metfomin
Gi upset , Lactic Acidosis
| METfromnin acidosis
196
A pt presents to the ED with signs of hyperglycemia, they have a Scr level greater than 1.5, can they be given metfromin
NO, Contraindicated if Scr > 1.4 in females or 1.5 in males
197
A pt comes in to the ED and is a T2DM pt who takes metformin, they may need contrast later as part of thier w/u, what should be done with thier metformin
Hold metformin if radiographic iodinated contrast media is given and resume 2-3 days later after normal renal function documented
198
Can Metformin and cimetidine be used together
Cimetidine (Tagamet) competes for rental tubular secretion with metformin and can increase metformin levels
199
Sulfonuryeas (SU) all end in…
IDE
Ide take my sulfonyureas!
200
What is the most common ADE of SUs
HOglycemia and wt gain
Can also cause allergic reactions
201
Which of the SUs have the highest HOglycemic potential
Chlorpropamide
202
What are the ADE of chlopropamide
HOgl
SIADH, HONa+
Avoid in pts with renal dysfun. Or the eledrly
203
Which of the 2nd gen SUs has the highest HOgl rsk
Glyburide
204
What is the safest SUs for renal dysfun pts
Glimepiride
205
Meglitidines all end in
GlinIDE
Ide take your Melitinides and SUs
206
If repaglinide and gemfibrozil are taken together
What is the effect
Doubles the effectiveness
207
What are the ADE of meglitinides
HOgl
NOT associated with Wt gain
URI and Flu like syndromes
208
What is the role of meglitinides
To be added on to metformin in place of sulfonylureas in patients with irregular eating schedules or in those who develop late hypoglycemia with sulfonylureas
209
Should meglitinides be used a mono tx
One of the last choices as monotherapy for patients with an A1C less than 7.5% Use with caution
210
What is the receptor that TZDs work on
Binds the peroxisome proliferator activator receptor-γ (PPAR-γ) enhancing insulin sensitivity at skeletal muscle, liver, and fat cell
211
Can TZDs be used in CHF pts
NO! Avoid in patients with symptomatic CHF
May result in a dilutional anemia; edema frequency increases when the TZD is combined with insulin (15%)
212
What is the cancer that is associated with TZD use
Increased risk of bladder cancer (Pioglitazone)
213
What is the saying for TZDs
I like to bring TXDs to the PPAR-ty ZONE
| both drugs end in zone and work on the PPAR receptor
214
What is the diffence between GLP-1 and GIP
GLP-1
Secreted from the L-cells in the distal intestine in response to meals
The insulinotropic action of GLP-1 is glucose dependent; glucose concentrations must be greater than 90 mg/dL
Low risk for hypoglycemia
Also suppresses glucagon secretion, slows gastric emptying, and reduces food intake by increasing satiety
GIP
Secreted by K-cells in the intestine
Augments insulin secretion
Has little effect on insulin secretions at glucose concentrations > 140 mg/dL
Does not affect gastric motility, or satiety
215
What is the major differences of GLP-1 Agonists and DPP-4 Inhibitors
```
GLP-1 Agonists:
Slightly greater efficacy
positive weight loss
Administered subcutaneously
Slightly more ADR (e.g., N/V/D)
```
```
DPP-4 Inhibitors:
have slightly worse efficacy
weight neutral
administered PO
Less ADR
```
216
What effect do DPP-4s have on the pancreas
Can cause pancreatitis
217
What are the ADE of DPP-4
Increased Rsk of URI, UTI,
May worsen HF
Pancreatitis
218
Which DDP-4 does not require a renal dose adjustmetn
Linagliptin
219
What are the ADE of GLP-1 agonists
HOgl, HA, N/V/D
Pancreatitis
THYROID CELL CANCER
Renal insuff.
220
If a GLP-1 and a Su are used together, what must you do
consider decreasing the Sulfonylurea dose by 50 % to decrease the risk of hypoglycemia
221
Taking GLP-1 (tide pods) can cause what effect to your wt
Wt loss
Especially semaglutide
222
What are the ADE of using Amylin Analogues
Severe HOgl
Do not use in pts talking GI motility agents
223
CAn you mix pramlintide with insulin
No
224
What is a good drug to use in pts nearç target HbA1c levels with near normal FPG levels, but high postprandial levels
Alpha Glucosidase inhibitors
225
What is the SrCr level that must be present to use Acarbose or Meglitol
ust be above 2mg/dl
226
Which of the SGLT-2 inhibitors are approved for CVD
Empagliflozing and Canagliflozin
227
What are the ADE of SGLT-2 (flozins)
genital fungal infections, UTIs
```
Increased urination
Wt loss ( may be benificaial )
```
228
How does canagliflozin effect stroke risk
Increases stroke risk
229
Which SGLT-2 i
Is assocaited with bladder cancer
Dapagliflozin
230
What effect do dieuretics have on gl
Impaire insulin secrtion and reduce sensitivity and may cause Hyper gl
231
What will the admin of CRH do to a pt with cushings
Administration of CRH in a patient with Cushing’s Dz will result in additional ACTH and cortisol secretion as the normal negative feedback is impaired
Patient’s with ectopic production of ACTH will not respond with additional ACTH and cortisol secretion
232
What is the diffenrence between sustained and pulsatile GnRH
Pulsatile GnRH secretion is required to stimulate the gonadotroph cell to produce and release Luteinizing Hormone (LH) and Follicle Stimulating Hormone (FSH) during the fetal and neonatal period and from the age of 2yrs until the onset of puberty
Sustained non-pulsatile GnRH or GnRH analogs inhibits the release of FSH and LH via down regulation by the pituitary in both women and men resulting in hypogonadism
233
What is the most common ADE of GnRH/ LHRH analogs
Flare ups in the 1st week of tx
Hot flashed, ED< Decreased libido
234
What is the role of LHRH in prostate cancer
LHRH is released to the ant pit which releases LH, LH stimulate leydigs cells to make testosterone whcih increases the prostate growth of cancer cells
235
GnRH/ LHRH anaolgues all end in..
-relin
| Exception leoprolide
236
What is the approariate tx for Prostate cancer
GnRH (relins)
237
A pt presents with endometriosis
What is the approatie hormone tx
GnRH/LHRH (relins)
238
A pt presents at a 7 with puberty onset
| What is the approatire hormone tx
GnRH/LHRH (relins)
239
What two things inhibtit FSH
Inhibin and Estrogens
240
A pt presents with excessive diaphoresis, OA, arthralgias, parasethisias, coarse facial features, with increasing hand/ finger size,
+HTN, HDz, Cardiomegaly
+/- OSA, T2DM
Think
ACROMEGALY
GH secreting adenoma
241
What are the three agents that can be used if surgry is no indicated to treat acromegaly
Somatostatin Analogs
Growth Hormone Receptor Antagonist (GHRA)
Dopamine Agonists
242
What is the ADE of Pegvisomant
Its a growth receptor antagonist
That can cuase N/V, flu like S/s
REVERISBLE elevation in hepatic transaminase
243
What is the role of somatotropin in puberty
Stimulates longitudinal bone growth until the epiphyses close near the end of puberty
244
A pt presents with turners syndrome
Or prader willi syndrome
What agent can help them grown
Somatatropin
245
What hormone when in excess causes amenorrhea, anovulation, infertility, hirsutism, and acne in women, and erectile dysfunction, decreased libido, gynecomastia, and reduced muscle mass in men
Prolacitn
246
What are the ADE of dopamine agonist
Nausea, headache, diarrhea, abdominal pain, light-headedness, orthostatic hypotension, and fatigue
247
What is the ADE of desmopressin/ DDVAP
Hyponatremia and SZR (dilutional)
248
What agent can be used to conttrol bleeding in a pt with hemophilia A or Von Willebrands Dz
Desmopressin
It will control bleeding by stimulating the body to release more von Willebrand factor already stored in the lining of your blood vessels, thereby enhancing factor VIII levels
249
What is the Tx approach to Acute SIADH
The goal is to correct hyponatremia at a rate that does not cause neurologic complications (locked in syndrome/ inducing central pontine myelinolysis (CPM)) , as follows:
—Raise serum sodium by 0.5-1 mEq/hr, and not more than 10-12 mEq in the first 24 hours
Aim at maximum serum sodium of 125-130 mEq/L
Treatment Options:
- 3% hypertonic saline (513 mEq/L)
- Loop diuretics with saline
- Vasopressin-2 receptor antagonists
- Water restriction
250
What is the tx appraoch to chroninc AS/s SIADH
Fluid restriction and Vassopressin receptro antagonists
251
What is the Black Box warning for Conivaptan and Tolvaptan
(Used for in pt SIADH)
Black Boxed Warning: must be initiated and re-initiated in a hospital and monitor serum sodium
Too rapid correction of hyponatremia (>12mEqL/24hrs) can cause osmotic demyelination (Spastic quadriparesis, seizures, coma, and DEATH)
252
If a pt has HF and SIADH, which medication can be used, tolvaptan or conivaptan
TOLVAPTAN!
Coni can notti be used
253
What is the reflex that stimulates Oxcytocin
Neuroendocrine reflex
Breafeading or hearing babies cry
254
What is the off label use of metoclopramide in women
Stimualte lactation
255
What is the most common form of hypothyroidism
Hassimotos (autoimmune hypothyroidism)
256
What 2 drugs can cause hypothyroidism
Amioderone and lithium
257
A pt presenst with CC of wkness, and dry skin , letharrgy and slow speech
Think
hypothyroid ( may also have cold sensation)
258
What is congenital hypothyroidism
Cretenism
259
How often is levothyroxine treatement checked/ adjusted
every 6 weeks
260
What is the treatment appoarch to myxedma coma
Levothyroxine + hydrocortisone
261
A pt presents with progressive weakness, stupor, hypothermia, hypoglycemia, and hypoRR
Think of what thyroid problem
Myxedema coma
262
A pt presents with high fever, tachyHR, tachyRR, dehydration, delirium , N/V/D, and AMS
Think of what thyroid condition
Thyroid storm
263
What are the advantages of methimazole vs. PTU
Methimazole: Pregnancy Category D
PTU is associated with a higher incidence of liver failure
264
What are the black box warnings of methimazole and PTU
```
Severe liver injury
Jaundice
Agranulocytosis
Leukopenia
Arthralgias
And rash
```
265
When a pt is going to get iodine 131, when must iodides be stoped
3-4 days prior
266
What can be used to prophylax for rad exposure in nuclear incidnets
Potassium iodide
267
What is the step by step appraoch to Tx thyroid storm
1. PTU or methimazole
2. Iodide solution Tx (K+ iodide)
3. BB tx (propranolol)
4. Acetaminoiphen
5. Corticosteroids (hyrdocortisone)
5. Bile acid sequestrants (cholestyramine)
268
If a pt is taking a statin, what herbal food should they avoid
Red yeast rice
