NGR6172 Unit 4 Endocrine

□ What are the adverse effects of methotrexate (a DMARD) used to treat RA?

- Hepatotoxicity - bone marrow suppression - GI ulceration - teratogenesis (fetal harm) - pneumonitis

METFORMIN □ What are the clinical signs of lactic acidosis?

- Hyperventilation - myalgia - malaise - unusual somnolence

□ What are the clinical manifestations of an acute adrenal crisis?

- Hypotension - dehydration - weakness - lethargy - GI symptoms

DRUGS FOR DIABETES □ What does hyperinsulinemia do to the body?

- Increases smooth muscle proliferation - increases angiotensin II - enhances sympathetic activation

INSULIN THERAPY □ Which insulins are considered long acting or basal insulins?

- Insulin glargine (Lantus) - insulin detemir (Levemir) ---> at higher doses

HYPOGLYCEMIA & HYPERGLYCEMIA □ What effect does hyperglycemia have on WBCs?

- It inactivates WBCs leading to increased risk of infection. ** Patients with DM are considered to be immune compromised

DRUGS FOR DIABETES □ What is the goal LDL level for a patient with DM according to the newest cholesterol guidelines?

- LDL levels should be reduced by 50% - use moderately intense statins per the ACC/AHA - keep LDL < 70 mg/dL according to the National Lipid Association

□ Name the vaccines that are considered "live virus vaccines" and should not be given to pregnant women or individuals with immune compromise:

- MMR - Varicella - FluMist - Zostavax - Yellow Fever - rotavirus vaccine

INSULIN THERAPY □ Should you discontinue the metformin when insulin is initiated?

- Many providers consider the metformin helpful to decrease the amount of insulin needed by decreasing insulin resistance and continue using the metformin. - Metformin is also used in patients with type 1 DM if they are overweight and likely have insulin resistance

METFORMIN □ Which medications target post prandial glucose elevations?

- Metformin - meglitinides - alpha-glucosidase inhibitors - incretin enhancers

□ Name the 3 classes of drugs used to treat RA?

- NSAIDs - glucocorticoids - DMARDs

□ What are the adverse effects of colchicine?

- Nausea - vomiting - severe diarrhea - abdominal pain

□ What are the uses for selective estrogen receptor modulators (SERMs) such as raloxifene (Evista)?

- Postmenopausal osteoporosis - breast CA

□ When should live virus vaccines be avoided?

- Pregnancy - immunocompromised state - previous anaphylaxis - illness

□ What are the characteristics of the hypersensitivity reaction seen with allopurinol?

- Rash - fever - eosinophilia - liver dysfunction - kidney dysfunction

METFORMIN □ What conditions may make a person on metformin more prone to lactic acidosis?

- Renal insufficiency - liver disease - severe infection - hypoxemia

□ What are the adverse effects of the biologic DMARD, entanercept (Enbrel)?

- Risk of infection - reactivation of TB - severe allergic reactions - heart failure - cancer - hematologic disorders liver injury - demyelinating disorders

□ What are the skin manifestations seen with acetaminophen?

- Steven Johnson Syndrome (SJS) - Acute Generalized Exanthematous Pustulosis (AGEP) - Toxin Epidermal Necrolysis (TEN)

HYPOGLYCEMIA & HYPERGLYCEMIA □ What are the clinical signs of hypoglycemia?

- Tachycardia - palpitations - diaphoresis - nervousness - fatigue - headache

□ What is the mean population normal level of TSH?

1.2 mIU/L

□ What dosage of thyroid replacement is recommended for a healthy adult?

1.6 micrograms/kg/day

□ What is the recommended dose of acetaminophen in children?

10-15 mg/kg/dose every 4-6 hours, Note that this is "per dose" not mg/kg/day. - When calculating the dose in ePocrates, in the interval box, select every 24 hours

INSULIN THERAPY □ What is the onset of action of insulin aspart (Novo Log)

10-20 minutes

□ A patient with the influenza virus can be given oseltamivir (Tamiflu) to reduce symptoms. It is most effective if given within ________hours after onset of symptoms?

12 hours

□ What is the recommended age to receive the varicella vaccine?

12-18 months of age and at age 4. Younger infants will not be able to mount an immune response less than 12 months

□ How should thyroid replacement be titrated?

12.5-25 microgram adjustments

INSULIN THERAPY □ If a patient with Type 2 diabetes plans on consuming 105 grams of carbohydrates, they will need to inject____________units of rapid acting insulin.

14

□ NSAIDs should not beused before CABG surgery of for ________days after surgery.

14

□ The LAIV should be delayed by________days if patients have received antivirals such as amantadine, rimantadine, zanamivir, or oseltamivir 48 hours before vaccination.

14 days

DRUGS FOR DIABETES □ What is the goal BP for a patient with DM according to JNC- 8?

140/90 mm Hg Some organizations prefer 135/80 mm/Hg

INSULIN THERAPY □ A simple method of calculating insulin needed to cover carbohydrate ingestion is that 2 units of rapid acting insulin is needed for every__________grams of carbohydrates.

15

□ Gardasil is a quadrivalent vaccine indicated for females and males 9-26 years. What are the 4 target types of HPV prevented?

16 & 18 cause cancer, 6 & 11 cause genital warts

INSULIN THERAPY □ If a patient with Type 2 diabetes plans on consuming 15 grams of carbohydrates, they will need to inject____________units of rapid acting insulin.

2

□ If the patient drinks 3 drinks/day of alcohol, acetaminophen should be limited to:

2 grams

METFORMIN □ What is the maximum dose of metformin?

2,000 mg/day. - Drug sources will list the maximum dose at 2500 mg/day however, there is no additional benefit at doses more than 200 mg/day and increased risk of adverse effects.

□ Vitamin D deficiency is noted when 25 OH is less than?

20 ng/mL. - Many sources and labs use 30 ng/mL as the cutoff for deficiency

INSULIN THERAPY □ How long does of insulin Aspart (Novo Log) last?

3-5 hours

□ Which drugs have been associated with osteonecrosis of the jaw and atypical long bone fractures?

Bisphosphonates: - alendronate (Fosamax) - risedronate (Actonel) - ibanfronate (Boniva) - zoledronate (ReClast) - etidronate (Didronel)

□ Pioglitazone has been associated with__________?

Bladder cancer

□ Can acetaminophen and warfarin be used together?

Bleeding can occur because acetaminophen inhibits the metabolism of warfarin

□ Why are nonselective beta blockers used in hyperthyroidism?

Blockage of beta receptors in the periphery are helpful to relieve tremors

□ How is osteoporosis defined?

Bone marrow density (BMD) value 2.5 SD below the mean

□ The following instructions apply to____________? Take in the morning before breakfast on an empty stomach, no food including orange juice or coffee for at least 30 minutes after administration. Take with a full glass of water. Remain upright (sitting or standing) for at least 30 minutes.

Bisphosphonates such as alendronate (Fosamax).

□ Rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, allergic conditions, asthma, dermatological disorders, and neoplasms are often treated with___________?

Glucocorticoids

□ Which class of drugs are anti-inflammatory agents used to relieve symptoms of severe RA and may also retard disease progression?

Glucocorticoids - suppress immune response, slowing disease process - inhibits prostaglandin, leukotrienes and histamines to relieve symptoms

□ Which agents inhibit inflammation process by stopping the synthesis of chemical mediators (prostaglandins, leukotrienes, histamine) and thereby reduces swelling, warmth, redness and pain, suppress infiltration of phagocytes and proliferation of lymphocytes to reduce the immune component of inflammation?

Glucocorticoids examples are: Short: - cortisone - hydrocortisone Intermediate acting: - prednisone - prednisolone - methylprednisolone - trimcinolone Long acting: - betamethasone - dexamethasone

□ Which agents suppress bone formation, accelerate bone reabsorption by osteoclasts, and reduce intestinal absorption of calcium that can lead to osteoporosis?

Glucocorticoids can cause bone loss

□ Why does blood pressure increase when patients are taking glucocorticoids?

Glucocorticoids cause sodium and water retention.

INSULIN THERAPY □ A patient presents to the clinic with a blood sugar of 240 mg/dL because they ran out of their oral agents. Why is it important to prescribe a 2-3 week course of insulin therapy?

Glucose toxicity occurs and oral medications are not absorbed as well in the hyperglycemic state

□ What happens when alcohol and acetaminophen are used together?

Glutathione stores are depleted and the toxic metabolite of acetaminophen is not broken down leading to liver toxicity

DRUGS FOR DIABETES □ Glucose interacts spontaneously with Hbg in RBCs to form glycated derivatives that can be measured in the blood. What is the name of this test that serves as an index of average glucose levels over the prior 2-3 months?

Glycosylated hemoglobin (HbA1C)

□ Rapid bounding pulse, dysrhythmias, angina, nervousness, insomnia, rapid thought flow and speech, increased metabolism, increased temperature, skeletal muscle atrophy, intolerance to heat, warm moist skin, weight loss despite appetite and exophthalmus are clinical signs of_____________?

Graves' disease or hyperthyroidism.

□ Which human papilloma virus (HPV) types are known to cause cancer?

HPV types 16 and 18

□ Name a condition associated with hypothyroidism.

Hashimoto's thyroiditis.

□ TZDs are contraindicated in patients with_____________?

Heart failure

□ To reduce the risk of _____________, blood pressure should be controlled to at least 150/90 mm HG before starting aspirin therapy (preferably lower).

Hemorrhagic stroke

□ Activation of the varicella virus that had been dormant within the sensory nerve roots can cause a linear distribution of vesicles called________________?

Herpes zoster or shingles.

□ Patients with hypothyroidism can have (higher or lower) LDLs?

Higher

□ Patients with adrenal insufficiency should be given (higher or lower) doses of glucocorticoids during times of stress such as trauma or surgery?

Higher doses are needed to avoid cardiovascular collapse

□ A patient on an inducing agent such as phenytoin will need (higher or lower) dosages of thyroid replacement?

Higher. - The levothyroxine may be metabolized before it is able to be effective

□ What is the treatment of Addison's disease?

Hydrocortisone (which is both mineral and glucocorticoid).

□ Treatment with GH can lead to (hyperglycemia or hypoglycemia)?

Hyperglycemia

HYPOGLYCEMIA & HYPERGLYCEMIA □ What is the Somogyi phenomenon (rebound hyperglycemia)?

Hyperglycemia following an episode of nocturnal hypoglycemia

□ NSAIDs increase sodium reabsorption, and decrease renal blood flow. The end result leads to (hypertension or hypotension)?

Hypertension

□ Excess secretion of aldosterone can lead to (hypotension or hypertension)

Hypertension. - This can be treated with aldosterone blockers.

□ Propylthiouracil (PTU), methimazole (Tapazole) and radioactive iodine-131 are used to treat_________________________?

Hyperthyroidism

□ Excessive levels of thyroid hormone, low TSH and high T4 are associated with_____________?

Hyperthyroidism and or Grave's disease **low TSH + high T4 = Hyper

□ What is the boxed warning on pramlintide (Symlin)?

Hypoglycemia *mimics the effects of amylin, suppresses glucagon secretion

HYPOGLYCEMIA & HYPERGLYCEMIA □ What is the cause of the rebound hyperglycemia with the Somogyi phenomenon?

Hypoglycemia episode leads to release of counter-regulatory hormones (epinephrine, cortisol, & growth hormone) and stored glucose in the liver

HYPOGLYCEMIA & HYPERGLYCEMIA □ Which condition is more threatening, hypoglycemia or hyperglycemia?

Hypoglycemia is especially problematic-caution with older individuals and those with ASCVD

SULFONYLUREAS □ What are the major adverse effects from the oral hypoglycemics for Type 2 diabetics called sulfonylureas?

Hypoglycemia, GI upset, fetal harm, Wt gain, sun sensitivity, incr cardiovascular mortality, hepato-renal insult

□ Primary hyperaldosteronism can be caused by an adrenal adenoma. The excess secretion of aldosterone can cause (hypokalemia or hyperkalemia)

Hypokalemia

□ Why are pregnant women screened for thyroid disease?

Hypothyroidism in the fetus is catastrophic

□ Which polio virus vaccine is used in this country?

IPV

HYPOGLYCEMIA & HYPERGLYCEMIA □ What is the treatment for insulin overdose?

IV dextrose or glucagon

□ NSAIDs vary in their onset of action and duration. Naproxen (Aleve) can be given every 12 hours and meloxicam (Mobic) every 24 hours. Which NSAID has a very rapid onset, and has to be given more frequently?

Ibuprofen (Advil, Motrin, others)

□ A patient received MMR and 2 weeks later presents for varicella vaccination. When can the second live virus vaccine be given and why?

If the live virus vaccines are not given on the same day, you will need to wait 28 days because the immune response will be blunted.

□ When are cardio selective beta blockers used to treat symptoms of hyperthyroidism?

If the patient has bronchoconstrictive lung disease, cardio selective agents can be used

□ Where can you get copies of the VIS?

Immunize.org has them available in many languages and it is REQUIRED that you give this to the patient

□ Giving immunoglobulin for exposure to hepatitis is considered (active or passive) immunity and provides immediate protection?

Immunoglobulin administration = passive immunity.

□ When would bisphosphonates be contraindicated?

In individuals that cannot sit up for 30 minutes or have esophageal disorders.

□ The influenza vaccine formally called TIV is now called__________

Inactivated influenza vaccine or IIV.

□ Glucocorticoids either endogenous or exogenous can (increase or decrease) serum glucose levels?

Increase - Glucocorticoids can cause hyperglycemia. Caution when prescribing to patients with diabetes

□ By suppressing host defenses (immune responses and phagocytic activity of neutrophils and macrophages), glucocorticoids can (increase or decrease) susceptibility to infection?

Increase. - Glucocorticoid use can increase the risk of infection, masking early symptoms.

DRUGS FOR DIABETES □ In patients with insulin resistance, the insulin levels are (increased or decreased)?

Increased

□ Why was a Black Box Warning issued for rosiglitazone (Avandia)?

Increased cardiovascular events

SGLT2 INHIBITORS □ What are the adverse effects of the SGLT2 inhibitors?

Increased urination, may cause dehydration and hypotension, hyperkalemia, slightly increase LDL 4.5-8%, urinary tract infections and genital yeast infections

□ The American Heart Association recommends that nondrug measures, acetaminophen and if that is not effective ibuprofen or naproxen be used. COX-2 inhibitors should only be uses as a__________resort?

Last

□ What is the maximum recommended dose of acetaminophen?

Less than 4 grams per day is now the recommended amount. Some sources advise no more than 3 grams.

DRUGS FOR DIABETES □ What is the target value HbA1C for patients with diabetes?

Less than 7% (ADA)--- Ideal is 6.5% (AACE). I - Important new research indicates that tight glucose control in some individuals can be detrimental. Patients should be treated as individuals.

Oral Hypoglycemics and Other Agents SULFONYLUREAS Glipizide (Glucotrol) Glyburide Glimepiride (Amaryl) BIGUANIDES Metformin (Glucophage) THIAZOLIDINEDIONES (TZDs) Rosiglitazone (Avandia) Pioglitazone (Actos) ALPHA-GLUCOSIDASE INHIBITORS Acarbose (Precose) Miglitol (Glyset) MEGLITINIDES Repaglinide (Prandin) Nateglinide (Starlix) INCRETIN MIMETICS Sitagliptin (Januvia) Saxagliptin (Onglyza) SGLT2 INHIBITORS Canagliflozin (Invokana) Dapagliflozin (Farxiga) GLP1 AGONISTS Exenatide (Byetta) Liraglutide (Victoza) Pramlintide (Symlin)

List Mechanism of Action and Adverse Effects:

□ Should immunocompromised children receive live virus vaccines?

Live vaccines are generally avoided in children with symptomatic HIV or lymphoma.

□ MMR, varicella, Flumist (LAIV-influenza vaccine), RotaTeq (Rotavirus), OPV (no longer used in this country), the new shingles vaccine (Zostavax), smallpox, and yellow fever vaccines are examples of______________?

Live virus vaccines.

□ Which organ can be damaged by excessive doses of acetaminophen (Tylenol)?

Liver

INSULIN THERAPY □ Is insulin detemir (Levemir) considered a long acting or intermediate acting insulin?

Long Acting Insulin - at higher doses (0.4 units/kg) it has a duration of 20-24 hours

INSULIN THERAPY □ What type of insulin is recommended as the initial choice in patients with DM

Long-acting basal insulin should be the initial choice in most cases

METFORMIN □ Why should metformin be discontinued in patients with CHF?

Low flow states can increase the risk of lactic acidosis

□ How is pertussis treated?

Macrolide antibiotics are effective

METFORMIN □ Why is it important to check a CBC is patients taking metformin?

Megaloblastic anemia (elevated MCV) is a possible result if B12 levels are diminished

□ A patient with sulfa allergy and elevated post prandial glucose may benefit from:

Meglitinides such as: - repaglinide (Prandin) - nateglinide (Starlix) common ending: "-linides"

□ Which class of anti-diabetic drugs stimulate the release of insulin from the pancreas, can lead to hypoglycemia, and must be given before meals?

Meglitinides such as: - repaglinide (Prandin) - nateglinide (Starlix)

METFORMIN □ Most patients with Type 2 diabetes and normal renal function can be started on___________?

Metformin

METFORMIN □ Which anti diabetic drug suppresses gluconeogenesis, enhances glucose uptake and utilization by muscle and does not promote insulin secretion or cause hypoglycemia?

Metformin

□ Which antithyroid drugs can cause agranulocytosis?

PTU and methimazole

INSULIN THERAPY □ What types of insulin are given IV?

Mostly regular insulin. - The insulin analogs are approved for IV use

INSULIN THERAPY □ Which types of insulin are always cloudy?

NPH and any type of pre-mix (70/30 or 75/25) that contains NPH.

□ Name the anti-inflammatory drugs used to treat an acute attack of gout.

NSAIDs, glucocorticoids and colchicine are used to treat an acute attack of gout.

HYPOGLYCEMIA & HYPERGLYCEMIA □ Why is it important to place an individual on their side after the administration of glucagon for hypoglycemia?

Nausea and vomiting can occur after receiving glucagon

INSULIN THERAPY □ Can you mix insulin glargine (Lantus) with rapid acting insulins?

No

INSULIN THERAPY □ Is NPH considered a basal insulin?

No

□ Do NSAIDs protect against MI?

No

□ Does acetaminophen (Tylenol) have anti-inflammatory actions?

No

□ Should patients with a history of pancreatitis take exenatide (Byetta)?

No

□ Would a patient with inflammatory bowel disease be a good candidate for therapy with a meglitinide?

No

□ Should you order a Total T4?

No, free T4 is recommended. Current "Choose Wisely" recommendations call for only the serum TSH

□ Is a goiter present in thyroid disease?

No, not always

□ Should patients with a history of gastroparesis take exenatide (Byetta), a GLP-1 receptor agonist?

No, risks for pancreatitis and N/V/D can occur

SULFONYLUREAS □ A patient has a known severe allergy to sulfa. Can a sulfonylurea be used?

No, sulfonylureas are not recommended. - This was more of a problem with the earlier sulfonylureas.

INSULIN THERAPY □ Can you give 70/30 combinations at HS?

No, they need to be given with a meal

HYPOGLYCEMIA & HYPERGLYCEMIA □ Should HbA1c goal be the same for patients with heart disease?

No. -hypoglycemia can cause cardiovascular death

□ Do COX-2 inhibitors prolong bleeding time?

No. - A new study shows that they can increase coagulation leading to MI.

□ True or False? Allergy to egg is a contraindication to receiving the MMR immunization.

No. It is no longer a contraindication.

□ Are sulfonylureas started initially in patients with DM?

No.....it's a 2nd line treatment as well as insulin. Start with metformin.

SULFONYLUREAS □ Which oral hypoglycemic can be used during pregnancy?

None are approved at the moment and all cross the placental barrier. - Metformin is often used during pregnancy

□ What is the purpose of measuring C-peptide levels in patients with diabetes?

Normal C-peptide levels indicate that the pancreas is producing insulin.

□ Do sulfonylureas target insulin resistance in their mechanism of action (MOA)?

Not really...reducing glucose levels does improve insulin resistance

METFORMIN □ Does metformin typically cause hypoglycemia?

Not typically

□ What is the difference between the no longer used OPV and the IPV vaccine for polio virus?

OPV is a live attenuated vaccine. IPV is composed of inactivated poliovirus.

□ Why is it important to correct hypothyroidism before treating hyperlipidemia?

Often, treating the hypothyroid state can normalize the lipids

□ How is oral levothyroxine (T4) administered?

On an empty stomach to enhance absorption (30-60 minutes prior to breakfast). - Taking the levothyroxine at night before bed is also a good option.

INSULIN THERAPY □ Once the insulin vial is opened, it can be stored at room temperature for________?

One month. - Be aware that in Florida, it is best to keep opened and unopened vials in the refrigerator. Insulin is very easily broken down in higher ambient temperatures. - Warm the pen or syringe by rolling with the hands to bring it to room temperature for administration. Insulin injected cold, is not absorbed as well.

□ What is the length of time to discontinue ASA and NSAIDs prior to surgery?

One week or 7-10 days.

□ Which anti-thyroid drug might be better in pregnancy because it does not cross the placental barrier as easily?

PTU. - Both cross the placental barrier and can inhibit fetal thyroid function

□ A patient on the GPL-1, exenatide (Byetta) presents with abdominal and pain and vomiting. This may be a sign of:

Pancreatitis

□ Intravenous immune globulin (IVIG), rabies, and tetanus immune globulin are used to provide immediate protection against a recent infection and are considered examples of (active or passive) immunity?

Passive. - The effects are immediate but lasts only as long at the antibodies remain in the body

DRUGS FOR DIABETES □ Why is the term "prediabetes" preferred rather than impaired fasting glucose or impaired glucose tolerance or borderline diabetes?

Patients are more inclined to initiate self-care when their condition is called "pre-diabetes" and are at risk for developing DM

INSULIN THERAPY □ When does insulin aspart (Novo Log) peak?

Peaks --> 1-3 hrs - with an onset and duration of: Onset--> 10-20min Duration--> 3-5hrs

□ An individual has a cough lasting greater than 3 weeks in duration and the presence of post tussive vomiting. This could be a sign of_______________?

Pertussis

WARNING: CONGESTIVE HEART FAILURE Thiazolidinediones, cause or exacerbate congestive heart failure in some patients. After initiation of pioglitazone, and after dose increases, monitor patients carefully for signs and symptoms of heart failure (e.g., excessive, rapid weight gain, dyspnea, and/or edema). If heart failure develops, it should be managed according to current standards of care and discontinuation or dose reduction of must be considered. Pioglitazone is not recommended in patients with symptomatic heart failure. Initiation of pioglitazone in patients with established New York Heart Association (NYHA) Class III or IV heart failure is contraindicated.

Pioglitazone (Actos)

□ What are some causes of Cushing's disease?

Pituitary or adrenal adenomas & over treatment with glucocorticoids

□ Why is the risk of MI and stroke increased with celecoxib?

Platelet aggregation is not suppressed and blocking COX-2 in blood vessels causes vasoconstriction

□ What complication from varicella disease in adults can occur?

Pneumonia

□ Zostavax is recommended for individuals age 60 and above to decrease the risk of herpes zoster. The greatest concern with herpes zoster also called "shingles" is____________?

Post herpetic neuralgia-it can be excruciatingly painful for months following the outbreak. Even though it is approved for age 50 and up, the ACIP recommends age 60 for increased efficacy and duration of protection

DRUGS FOR DIABETES □ Which measure of glycemic control becomes elevated first in most patients with DM -the fasting or post prandial glucose?

Post prandial

□ DPP-4 inhibitors have an effect mostly on (fasting or post prandial) glucose elevations?

Post prandial

□ Meglitinides are helpful for (fasting or post-prandial) glucose elevations?

Post prandial

DRUGS FOR DIABETES □ Patients with normal fasting blood sugar may have elevated bA1c levels because of elevations of___________________?

Post prandial glucose

□ The vaccination of a significant portion of a population provides a measure of protection for individuals who have not developed immunity. This is called_________?

"Herd" immunity

INSULIN THERAPY □ How is mealtime dosage of insulin adjusted?

Postprandial blood sugar (2 hours after the start of the meal) should be about 140 mg/dL

□ What are the contraindications to receiving the varicella vaccine?

Pregnancy and immune related disorders.

METFORMIN □ Metformin should be discontinued when the serum creatinine is greater than_________?

Previously recommendations based on Creat: --> 1.3 in men --> 1.4 in woman Recent recommendations based on GFR: --> lowering the dose to 1000 mg if eGFR is 45 --> discontinuing metformin with a eGFR of 30 - As you know the creatinine is not a good measure of renal function in older adults.

□ Do sulfonylureas contribute to beta cell decline?

Probably -other agents may prolong beta cell function - sulfonylureas incr endogenous insulin secretion by the beta cells, only useful if beta cell function is present.. - lower A1C 1-2%

□ Which of the NSAIDs has the safest cardiovascular profile?

Probably ibuprofen. This information is evolving.....

INSULIN THERAPY □ What is the most important complication from insulin treatment?

Profound hypoglycemia

□ Which drug is commonly used to suppress tachycardia in patients with hyperthyroidism?

Propranolol (Inderal), a non-cardio selective BB

□ The enzyme cyclooxygenase (COX) is responsible for the synthesis of _____________?

Prostaglandins

□ Why is it prudent to use caution when prescribing glucocorticoids to individuals with existing psychologic disorders?

Psychosis can occur with the use of glucocorticoids

□ What are the adverse effects of the DMARD hydroxychloroquine (Plaquenil)?

Retinal damage

□ The following are goals in treating__________? (1) relieve symptoms (pain, inflammation, and stiffness) (2) maintain joint function and range of motion) (3) minimize systemic involvement (4) delay disease progression.

Rheumatoid Arthritis (RA)

□ What disorders are associated with deficits in Vitamin D?

Rickets and osteomalacia.

□ Which TZD has restricted use in the US due to possible increased cardiovascular (CV) risk?

Rosiglitazone (Avandia)

DRUGS FOR DIABETES □ What is SMBG?

S_elf M_onitoring B_lood G_lucose

□ The T4 that is released from the thyroid gland is converted in the periphery to _______?

T3

□ Why is it important to test for TB and treat it if present prior to the initiation of a biological agent for treatment of RA?

TB, if not treated can be extrapulmonary and disseminated when TNF inhibitors are used

□ What is the recommended treatment for patients with prediabetes?

TLC. - Pharmacotherapy can be initiated in patients with high risk of developing DM

□ Which lab is used to screen for thyroid disease?

TSH

□ TZDs can cause weight (loss or gain)?

TZDs can cause major weight gain, and fluid retention

□ What is the MOA of thiazolidinediones (TZDs) such as rosiglitazone (Avandia)?

TZDs reduce blood sugar by increasing insulin sensitivity.

□ When prolonged glucocorticoid therapy is discontinued, there is a period during which the adrenals are unable to produce endogenous glucocorticoids due to adrenal suppression. - The withdrawal syndrome can produce hypotension, hypoglycemia, myalgias, arthralgias, and fatigue. How can adrenal suppression be avoided?

Tapering the doses of glucocorticoids or giving every other day

□ If someone has received Td, do you need to wait to give Tdap?

Tdap should be given regardless of interval since previous Td

□ Painful spasm of skeletal muscle, stiffness of the jaw (lockjaw), difficulty swallowing, restlessness, irritability, headache, fever, chills, and convulsions are all clinical signs of_____________?

Tetanus

INSULIN THERAPY □ Why is it important to draw regular insulin up first when combinations of insulin are used?

The NPH will inactivate or contaminate the rapid acting insulin.

□ It some patients it is a good idea to lower the dose of antihypertensive medications when starting a SGLT2 inhibitor because___________?

The SGLT2 inhibitors can cause hypotension. - Be especially cautious in older individuals and start at the lowest dose to see how the patient responds. - Be sure to discuss the symptoms of hypotension.

METFORMIN □ What is the advantage of using extended release metformin?

The entire dose can be taken with the evening meal with less gastrointestinal adverse effects

HYPOGLYCEMIA & HYPERGLYCEMIA □ A patient on insulin becomes groggy and you suspect that they are experiencing hypoglycemia. What should you check before giving 4 ounces of orange juice?

The gag reflex

□ Why are the 500 mg tablets of metformin preferred over the 1,000 mg tabs?

The larger tablets are very hard to swallow (as if made for a horse...)

□ Which of the influenza vaccines is contraindicated in patients that are pregnant, under age 2 or over age 49, or are immunocompromised and is administered nasally?

The live attenuated influenza vaccine (LAIV) nasal FluMist which is no longer recommended (2017)

□ Liraglutide (Victoza) in an incretin mimetic similar to exenatide that has been associated with___________?

Thyroid cancer

□ Why are patients on glucocorticoids advised to have eye exams every 6 months?

To assess for: - Cataracts - open-angle glaucoma

METFORMIN □ Why is it necessary to hold metformin prior to diagnostic tests using dyes and prior to surgery?

To decrease the risk of lactic acidosis

INSULIN THERAPY □ Why is it important to gently agitate NPH insulin prior to administration?

To disperse the particles in suspension

□ Why do patients with adrenal insufficiency need increased doses of glucocorticoids during times of stress.

To prevent adrenal crisis (hypotension and shock). - Use the "3 by 3 rule" by taking 3 times the usual dosage for 3 days and carry an emergency supply of glucocorticoids. Wearing an ID bracelet is also important.

□ Why are glucocorticoids gradually withdrawn?

To prevent adrenal suppression

□ What is the purpose of the National Vaccine Injury Compensation Program?

To provide compensation for injury or death caused by a vaccination.

□ Why is it important to spell out micrograms when writing a prescription for thyroid replacement?

To reduce errors

METFORMIN □ True or False, Metformin improves insulin resistance?

True

□ Patients with DM in general have an increased risk of pancreatitis, True/False?

True

□ Serum levels of growth hormone in children who are candidates for GH replacement should be below normal levels. True or False.

True

□ True or False? If GI symptoms occur, colchicine should be stopped immediately regardless of the status of the joint pain.

True

□ A prednisone burst of 7-10 days does not need a taper. True or false?

True, however it does not hurt to taper.

□ Allopurinol, febuxostat, probenecid and sulfinpyrazone are used to reduce uric acid levels. These drugs are not used in acute gouty attacks. True or false?

True.

□ Patients taking glucocorticoids can often have problems sleeping. True or false?

True. = Dosing in the AM may be beneficial.

□ In a child with no prior vaccination for varicella, how many doses would need to be administered?

Two doses of varicella vaccine administered at least four weeks apart.

DRUGS FOR DIABETES □ Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) results in dehydration and hemoconcentration and is more common in patients with (Type 1 or Type 2 diabetes)?

Type 2-Acidosis and ketosis does not occur

□ Practitioners are required to report certain adverse events to this system. The information is used to help determine whether a particular event that occurs after vaccination is actually caused by the vaccine and what the risk factors might be. It is called the_______________?

Vaccine Adverse Event Reporting System (VAERS).

□ Name a pharmacologic treatment for diabetes insipidus.

Vasopressin

□ What are the severe adverse effects of the DTaP vaccine?

Very rarely, DTaP vaccine can cause encephalopathy, shock or seizures.

METFORMIN □ Which vitamin may be lowered in patients on metformin?

Vitamin B12

□ Why is it recommended to give a one-time Tdap to individuals instead of the usual Td that is given every 10 years for tetanus?

Waning immunity to pertussis has been noted with increased incidence

□ When should screening for thyroid disease be done?

When symptoms are present, although some guidelines call for routine screening with a TSH in older adults

INSULIN THERAPY □ When do you discontinue the oral agents when insulin is initiated?

When they are no longer effective, usually when mealtime insulin is needed

A patient with a history of esophagitis would not be a candidate for treatment with: a) Alendronate (Fosamax) b) Calcium and Vitamin D c) Raloxifene (Evista) d) Pepcid

a) Alendronate (Fosamax) quiz 5

Which class of drugs used to treat diabetes can cause excessive GI symptoms such as flatulence? a) Alpha-Glucosidase Inhibitors (Precose and Glyset) b) TZDs (Pioglitazone) c) Sulfonlyureas (Glipizide, Glyburide) d) Meglinides (Prandin and Starlix)

a) Alpha-Glucosidase Inhibitors (Precose and Glyset) Quiz 1

A patient with Grave's disease is started on methimazole (Tapazole). In addition to thyroid function tests, what other labs will be needed? a) CBC & CMP b) HbA1c c) Fecal occult blood test d) Uric acid

a) CBC & CMP - this med has a risk for agranulocytosis** Quiz 2

Which drug would be used for a patient with a bone density scan revealing a T-score of -1.2? a) Calcium and vitamin D b) Alendronate (Fosamax) c) Raloxifene (Evista) d) Calcitonin-Salmon

a) Calcium and vitamin D quiz 6

Which disorder is characterized by an excess of circulating corticosteriods and causes obesity, hyperglycemia, hypertension and electrolyte imbalances? a) Cushing's disease b) Addison's disease c) Acromegaly d) diabetes insipidis

a) Cushing's disease Quiz 3

Vasopressin is a preparation of antidiuretic hormone (ADH) and is given to individuals with: a) Diabetes insipidus b) Diabetes mellitus c) Cushing's disease d) Addison's disease

a) Diabetes insipidus Quiz 3

The NP manages care for a patient with diabetes who takes metformin. Which laboratory result would cause the greatest concern? a) Elevated creatinine b) Microcytosis c) Thrombocytopenia d) Hypercalcemia

a) Elevated creatinine Quiz 1

A patient at the clinic is having symptoms of throat swelling after the administrating of a vaccination. The most important treatment is: a) IM epinepherine b) Oral antihistamine c) Beta 2 agonist d) Oxygen

a) IM epinepherine Quiz 4

There are a number of NSAIDs on the market and one individual will respond better to one than the other. Which NSAID requires multiple daily dosing, has a short half life, and would be effective for someone needing immediate pain relief? a) Ibuprofen (Advil) b) Naproxen (Aleve) c) Meloxicam (Mobic) d) Oxaprozin (Daypro

a) Ibuprofen (Advil) quiz 6

A patient is about to begin treatment for rheumatoid arthritis with a biologic agent. Which of the following blood tests are needed: a) PPD b) Uric acid levels c) Blood glucose d) Urine for microalbumin

a) PPD quiz 6

A patient presents with Grave's disease complaining of tremor, anxiety, and tachycardia. Which of the following drugs will provide the most rapid and best symptom control? a) Propranolol b) Metoprolol c) Levothyroxine d) Methimazole

a) Propranolol Quiz 2

Henry, age 72, has a fasting blood sugar (FBS) level of 176 mg/dL. He has never been given a diagnosis of diabetes before. Your next would be to: a) Repeat the FBS and do a HBA1c b) Order an oral glucose tolerance test. c) Start him on a sulfonylurea agent. d) Order a fructosamine measurement.

a) Repeat the FBS and do a HBA1c Quiz 1

Which statement is true regarding the use of acetaminophen? a) The new recommended highest dose per day is 3000 mg/day b) Acetaminophen has anti-inflammatory properties c) Acetaminophen should not be taken by individual with renal impairment d) Acetaminophen can be taken with alcohol without problems

a) The new recommended highest dose per day is 3000 mg/day quiz 5

A patient with a history of pancreatitis should not be started on: a) Exenatide (Byetta) or oral incretins b) TZDs c) Insulin d) Sulfonlyureas

a)Exenatide (Byetta) or oral incretins Quiz 1

Which of the following medications are given because they alter or modify the course of rheumatoid arthritis? (Choose all that apply) a) Methotrexate b) Hyproxychloroquine (Plaquenil) c) Adalimumab (Humira) d) NSAIDs

a, b & c a) Methotrexate b) Hyproxychloroquine (Plaquenil) c) Adalimumab (Humira) quiz 6

□ Electrolyte imbalances such as (hyperkalemia or hypokalemia) can occur with glucocorticoid use?

hypokalemia

□ The first GLP-1 to be approved as a weight loss drug was:

liraglutide (Saxenda)

□ Which antithyroid drug has been associated with liver failure?

propylthiouracil (PTU) MOA: - inhibitis thyroid hormone sysnthesis - inhibits conversion of T4-->T3

What area of the pituitary secretes GH, ACTH, TSH, FSH/LH and MSH?

the anterior pituitary

□ How is hypothyroidism treated?

thyroid hormone replacement, which then converts to T3 in the body. Examples: levothyroxine (Synthroid) lithyronine (Cytomel) liotrix (Thyrolar) armour thyroid

□ TSH can be elevated in times of illness. It is best to confirm abnormal results and include a free T4 to assess for subclinical disease before treating, true/ false?

true

INSULIN THERAPY □ How do you calculate basal insulin needs?

½ of the TDD

INSULIN THERAPY □ How do you calculate mealtime dosage or bolus insulin?

½ of the TDD split among the 3 meals

INSULIN THERAPY □ How are mixed insulins such as 70/30 combinations given?

- 2/3 of the TDD in the am before breakfast - 1/3 before dinner

□ Name the two drugs that lower blood sugar by inhibiting digestion and absorption of dietary carbohydrates thereby reducing the rise in blood sugar that occurs after meals.

- Acarbose (Precose) - Miglitol (Glyset) [alpha- glucosidase inhibitors]

DRUGS FOR DIABETES □ Insulin resistance occurs in type 2 diabetes. Which ethnic groups are at higher risk for developing insulin resistance?r

- African Americans - Asian Americans - Mexican Americans

□ What are the components of the Fracture Risk Assessment Tool (FRAX)?

- Age - sex - weight - previous fracture - parent with a hip fracture - smoking - use of glucocorticoids - RA - secondary osteoporosis - more than 3 drinks/day - femoral neck bone mineral density

□ Pneumococcal vaccination is recommended for people age 65 and older. It is recommended in younger individuals if they have risk factors such as:

- Asplenia - sickle cell disease - HIV - malignancy - immunosuppressive therapy - CSF leaks - organ transplant - cochlear implantation

□ Name lifestyle measures aimed to promote bone health.

- Avoid smoking - Avoid ETOH - regular weight-bearing exercise prevents bone loss

□ What other drugs can interfere with levothyroxine absorption?

- Bile acid resins - sucralfate - acid reducers

□ In addition to thyroid function tests, what other labs are necessary in patients treated with antithyroid drugs?

- CBC - liver transaminases

□ What is the recommended amount of vitamin D?

- Children < 1 yr = 400 IU/day - Age 1-7 yrs = 600 IU day - Age > 71 yr = 800 IU day * This information is evolving

DRUGS FOR DIABETES □ How is DM diagnosed?

- Fasting blood sugar > or equal to 126 mg/dL or random check > 200 mg/dL. - HbA1c > 6.5

SULFONYLUREAS □ What is the mechanism of action of sulfonylureas?

- They stimulate release of insulin from the pancreas - "incr indogenous insulin" secretion - incr tissue response to insulin examples: - glipizide (Glucotrol) - glyburide (Diabeta) - glimeparide (Amaryl) ** only helpful if beta cell function is present**

□ Is it acceptable to use generic thyroid replacement?

- Use the same manufacturer for generic versions. - If the patient had thyroid cancer, use a branded product. - Most endocrinologist prefer the branded products for better control. - There is variation in absorption among brand and generic formulation

□ What is the problem with using ASA and NSAIDs during pregnancy?

- Uterine contraction suppression - premature closure of the ductus arteriosus occurs - uterine bleeding can be intensified.

□ Give examples of medications that can alter thyroid function.

- amiodarone - lithium - interferon

DRUGS FOR DIABETES □ Name some medications that can elevate blood glucose levels and increase the risk of DM: (5)

- antipsychotics - glucocorticoids - statins - sympathomimmetics - thiazide diuretics

□ What are the major complications of NSAID use?

- bleeding - gastric erosion - renal impairment - sodium retention.

SGLT2 INHIBITORS □ Dapagliflozin (Farxiga) and Canagliflozin (Invokana) are SGTLT2 inhibitors. What is the MOA?

- increase glucose excretion in the urine by inhibiting sodium-glucose co-transporter 2 (SGLT2) in the kidney

□ Which NSAIDs have the greatest potential for increasing cardiovascular risk?

- indomethacin (Indocin) --> (71%) - sulindac (Clinoril) --> (41%) - meloxicam (Mobic) --> (37%)

INSULIN THERAPY □ Name the newer rapid acting insulins that have an earlier onset of action than regular insulin and need to be injected 10-30 minutes prior to eating.

- insulin lispro (Humalog) - insulin aspart (Novo Log) - insulin glulisine (Apidra)

DRUGS FOR DIABETES □ Which medications target post prandial glucose elevations?

- metformin - meglitinides - alpha glucosidase inhibitors - incretin enhancers

HYPOGLYCEMIA & HYPERGLYCEMIA □ Which special groups of patients might not need extensive lowering of HbA1c?

- older adults - children - adolescents - those with ASCVD disease

DRUGS FOR DIABETES □ What are some of the risk factors for DM?

- overweight (BMI > 25 kg/m2) - inactive - have a first-degree relative with DM - in a high-risk race/ethnic groups - have had gestational DM

DRUGS FOR DIABETES □ Name some situations in which the goal HbA1c may be as high as 8%.

- patients with a history of severe hypoglycemia - limited life expectancy - advanced renal or macrovascular complications - extensive comorbid conditions - long-standing DM in which the A1C goal have been difficult to attain.

DRUGS FOR DIABETES □ What kinds of conditions interfere with the HbA1c assay?

- sickle cell trait - anemia - alterations in red cell function - acute blood loss - chronic renal failure - Ethnic groups from Africa, Mediterranean, and Southeast Asia may have alterations in red cell function that alter HbA1c assay

□ What are the clinical manifestations of thyrotoxicosis?

- tachycardia - angina - tremor - nervousness - insomnia - hyperthermia - heat intolerances and sweating

HYPOGLYCEMIA & HYPERGLYCEMIA □ Name drug classes that can increase blood sugar levels.

- thiazide diuretics - sympathomimetics - glucocorticoids - antipsychotics - possibly statins

□ What are the clinical manifestations of salicylism?

- tinnitus - sweating - headache - dizziness Note: commonly seen with ASA treatment

□ What are the adverse effects of Selective Estrogen Receptor Modulators (SERM's)?

- venous embolism (DVT) - PE - fetal harm - hot flashes *binds to estrogen receptors to mimic the effects of estrogen, bone lipid metab and blood clotting

INSULIN THERAPY □ How do you calculate the total daily dose (TDD) of insulin?

0.5 units/kg/day is a good start for many patients. - The range is 0.3-0.8 mg/kg/day

DRUGS FOR DIABETES □ What are the components of the metabolic syndrome?

1) Abdominal obesity-waist > 40 inches for men and 35 inches for women 2) High TG greater than 150 mg/dL 3) Low HDL below 40 mg/dL in men and 50 mg/dL in women 4) Hyperglycemia FBS greater than 100 mg/dL 5) High blood pressure 130/85 or undergoing drug therapy for HTN

Name 2 hormones secreted by the posterior pituitary gland?

1) oxytocin 2) Antidiuretic Hormone (ADH)

□ What is the recommended daily intake of calcium for adults 19-50 years old?

1,000 mg/day or more. 1,200 mg/day if > age 50 and female.

METFORMIN □ What is the expected HbA1c reduction with the use of metformin?

1-2%

□ How many mg of calcium are in an 8-ounce glass of milk?

300 mg.

INSULIN THERAPY □ How many grams of carbohydrates in 16 ounces of Coca Cola?

40 grams!

DRUGS FOR DIABETES □ Patients without risk factors for DM should be screened starting at age_____?

45

□ What level of HbA1c is considered "prediabetes" or impaired fasting glucose (IFG?)

5.7-6.4% (According to the 2015 AACE/ACE Guideline HbA1c of 5.5% is considered prediabetes)

INSULIN THERAPY □ What portion of the total daily dose is the basal requirement?

50%

INSULIN THERAPY □ If a patient with Type 2 diabetes plans on consuming 45 grams of carbohydrates, they will need to inject____________units of rapid acting insulin.

6

□ How long does it take to get the full benefit of methimazole?

6-12 months

□ How long should you wait to check TSH after initiation of treatment?

6-8 weeks

□ Uric acid levels greater than_______________often require treatment?

6.5

□ What level of blood glucose is considered hypoglycemia?

70 mg/dL or if the patient is symptomatic

INSULIN THERAPY □ A patients will most likely require insulin at the initial presentation when the HbA1c is >______%

9%

DRUGS FOR DIABETES □ What is the target post prandial glucose (2 hours after the start of a meal) in patients with DM?

< 140 mg/dL (AACE) < 180 mg/dL (ADA)

□ What is the FRAX score?

A Fracture Risk Assessment tool that can identify individuals with risk fracture from the WHO

DRUGS FOR DIABETES □ A patient with diabetes has microalbuminuria (albumin in the urine). Which antihypertensive agent should be started to decrease kidney damage?

ACE inhibitor or ARB

□ In order to minimize adrenal insufficiency, glucocorticoids are often given in the (AM or PM). This mimics the burst of glucocorticoids rereleased naturally by the adrenal glands

AM

□ What is the problem with metformin and alcohol?

Alcohol can inhibit the breakdown of lactic acid and contribute to lactic acidosis

□ Radioactive iodine (131) is often employed to suppress thyroid production in patients with hyperthyroidism. How long does it take for the response to fully develop?

About 3 months - Patients will need to be monitored and most likely will receive thyroid replacement (levothyroxine) long term

□ How long does it take for levothyroxine to reach plateau?

About 4-5 weeks

□ Why should you avoid taking levothyroxine with calcium, iron, or antacids?

Absorption of the levothyroxine will be diminished.

DRUGS FOR DIABETES □ What is the skin manifestation that may be present with DM?

Acanthosis nigricans

□ How is acetaminophen overdose treated?

Acetylcysteine

□ Which type of immunity (passive or active) takes weeks to develops and lasts for years?

Active

□ The immunity produced by vaccinations is considered (active or passive)?

Active immunity is conferred with vaccination.

□ Where are glucocorticoids produced?

Adrenal cortex

□ At what age do women experience accelerated bone loss?

After menopause with continued loss for several years (2%-3% per year).

□ When would a patient need a second dose of the pneumococcal vaccine?

Age 65 and older if the first dose was given prior to age 65 and 5 years have elapsed since dose # 1 or they are at high risk

□ When should adults be screened for osteoporosis?

Age 65 or if risk factors are present

□ The following contraindications apply to which vaccine: Pregnancy, history of thrombocytopenia or purpura, anaphylactic reactions to gelatin, or neomycin?

All are contraindications to receiving the MMR vaccine.

□ Who should receive influenza vaccination?

All individuals age 6 months or greater that might get the flu

□ COX-2 inhibitor celecoxib (Celebrex) contains sulfa and should not be taken by patients with sulfonamide_____________?

Allergies

□ What are the contraindications to DTaP immunization?

Anaphylactic reaction or encephalopathy within 7 days of vaccination.

□ Severe adverse effects of the MMR vaccine include_________________?

Anaphylaxis and transient thrombocytopenia.

□ Why is it important to use lower doses of thyroid replacement in those individuals with heart disease?

Atrial fibrillation is a risk

□ In 1998, Andrew Wakefield published a paper that was found to be fraudulent concerning the association of MMR and_______________?

Autism

□ Food to avoid in patients with hyperuricemia include:

Avoid foods high in Purine: - organ meat (liver, kidneys, sweetbreads, brains) - meat (bacon, beef, pork and lamb) - anchovies, sardines, herring, mackeral and scallops - gravy - beer

METFORMIN □ Why is it important to recommend B12 supplementation in patients taking metformin?

B12 levels are often found to be lowered in patients taking metformin

□ Reye's syndrome and encephalitis are rare complications of varicella disease in children. Common complications of varicella disease in children include_____________?

Bacterial supra infection and acute cerebellar ataxia.

DRUGS FOR DIABETES □ How should lipids be managed in patients with prediabetes?

Because macrovascular disease may be evident prior to the diagnosis of DM. - lipid levels of patients with prediabetes should be managed in the same manner as those of patients with DM

INSULIN THERAPY □ If a patient injects Regular insulin and then eats breakfast, when would you be worried about hypoglycemia?

Before lunch when the insulin is at its peak Onset: 30-60min Peak: 1-5hrs Duration: 6-10hrs

HYPOGLYCEMIA & HYPERGLYCEMIA □ Which class of drugs masks the hypoglycemic events by suppressing tachycardia and palpitations?

Beta blockers

HYPOGLYCEMIA & HYPERGLYCEMIA □ In what ways can beta blockers be helpful in patients with DM?

Beta blockers decrease the SNS stimulation that goes along with DM. - They are sometimes used in spite of their adverse effects of decreasing the s/s of hypoglycemia

□ What is the potential problem when patients are taking NSAIDs, ASA, and glucocorticoids?

Concurrent use increases the risk of peptic ulcer disease.

□ Name a drug used to inhibit excessive production of prolactin (hyperprolactinemia).

Cabergoline (Dostinex)

□ Why is it important to separate some drugs when taking calcium supplementation?

Calcium can interfere with the absorption of some drugs such as levothyroxine

□ Valdecoxib (Bextra) and Rofecoxib (Vioxx) were removed from the market due to an increase risk of myocardial events. The only Cox 2 inhibitor on the market is____________?

Celecoxib (Celebrex), a COX-2 inhibitor.

HYPOGLYCEMIA & HYPERGLYCEMIA □ Morning hyperglycemia may be due to Somogyi or Dawn phenomenon. How can the two problems be distinguished?

Check the 3:00 AM glucose (BgL < 60 at 03:00). Somogyi Phenomenon - hyperglycemia following an episode of nocturnal hypoglycemia. - rebound hyperglycemia - release of counter-regulatory hormones (epinepherine, cortisol, growth hormones) - S/S's: headache, nightmares, restless sleep, fasting hyperglycemia, normally seen in Pt's with well controlled levels - Bgl < 60 at 3am Dawn Phenomenon - increase in counter-regulatory hormones that leads to incr glucose production, a decr in glucose utilization and an incr in morning bgl - normal bgl at bedtime - fasting hyperglycemia - S/S's: normal Bgl at 3am

□ Flat affect, puffy pale face, dry skin, brittle hair and hair loss, decreased heart rate and temperature, lethargy, fatigue, intolerance to cold, elevated TSH and depressed T4 are clinical signs of (hypothyroidism or hyperthyroidism)?

Clinical signs and symptoms of hypothyroidism.

□ The FDA recently revisited the old dosing of a drug that was directed to be given 0.6 mg 2 tabs then one tab every hour until pain subsides or GI toxicity occurs to treat gout. Over a hundred deaths have occurred and the new dosing as advised by the FDA is 2 tabs followed by 1 tab an hour later. The drug is_______________?

Colchicine

DRUGS FOR DIABETES □ Name a lipid lowering drug that is approved for diabetes and lowers HbA1c

Colesevelam (Welchol) - which is a bile acid sequestrant

□ Obesity, hyperglycemia, glucosuria, hypertension, fluid and electrolyte disturbances, osteoporosis, muscle weakness, myopathy, hirsutism, menstrual irregularities, and decreased resistance to infection are all clinical signs of______________?

Cushing's syndrome

□ What is the name of the disorder characterized by excessive levels of glucocorticoids?

Cushing's syndrome

DRUGS FOR DIABETES □Women with polycystic ovarian syndrome are at risk of developing____?

DM

□ Which agents used to treat RA are the most toxic?

DMARDs

□ Name the oral drug class that slows the breakdown of naturally occurring incretins to improve glucose:

DPP-4 inhibitors: - sitagliptin (Januvia) - saxagliptin (Onglyza) - linagliptin (Tradjenta)

□ What class of drugs used to treat RA slows progression and delays joint injury?

D_isease M_odifying A-ntirheumatic D_rugs (DMARDs) Examples: Non-biologics: blocks Folic acid from becoming active - methotrexate - sulfasalazine (Azulfidime) - hydroxychloroquine (Plaquenil) - azathioprine (Imuran) - gold salts Biologics: neutralizes TNF, suppresses inflammation - entanercept (Enbrel) - infliximab (Remicade) - adalimumab (Humira) - rituximab (Rituxan) - abatacept (Orencia)

□ Why are lower levels of thyroid replacement used in older adults?

Decrease in renal clearance increases thyroid hormone levels in the body

□ Patients with diabetes insipidus have (increased or decreased) levels of antidiuretic hormone (ADH)?

Decreased

Why do patients on glucocorticoids delay immunizations?

Decreased antibody response and risk of developing viral disease.

□ Addison's disease is a (deficiency or excess) in glucocorticoids and mineralcorticoids?

Deficiency

HYPOGLYCEMIA & HYPERGLYCEMIA □ What can happen when a patient taking insulin or a secretagogue drinks alcohol?

Delayed hypoglycemia

□ TSH level in a patient with Graves' Disease are (elevated or depressed)?

Depressed

□ Which of the glucocorticoids are the longest acting?

Dexamethasone and betamethasone are the longest acting

DRUGS FOR DIABETES □ Sustained hyperglycemia, polyuria, polydipsia, ketonuria, and weight loss are clinical signs of____________?

Diabetes mellitus (DM)

METFORMIN □ What are the gastrointestinal adverse effects associated with metformin?

Diarrhea

DRUGS FOR DIABETES □ Which agent for depression can also be beneficial for patients with diabetic peripheral neuropathy?

Duloxetine (Cymbalta) has indications for diabetic peripheral neuropathy. - Inhibition of norepinephrine (NE) reuptake allows for more NE at nerve terminals and is thought to have a role in reducing the neuropathic pain of diabetic peripheral neuropathy

INSULIN THERAPY □ How many units of insulin are in one ml of U100 insulin?

Each ml contains 100 units of insulin

□ Why is it important to initiate therapy with DMARDs within 3 months of diagnosis?

Early treatment can retard the disease progression "time is joint"

□ Influenza vaccination is contraindicated in individuals with hypersensitivity to__________?

Eggs

□ TSH levels in a patient with hypothyroidism are (elevated or depressed)?

Elevated

□ What is a goiter?

Enlargement of the thyroid gland

□ Give an example of a biologic DMARD used to treat RA?

Entanercept (Enbrel) - suppresses inflammation by neutralizing TNF

□ What is the adverse effect of greatest concern when using bisphosphonates for the treatment of osteoporosis?

Esophagitis is the greatest concern.

METFORMIN □ What is the best time of day to take metformin?

Evening meal - If on 2,000 mg, take 2 tabs every 12 hours with food. - The extended release can be taken all at once with dinner or split BID

INSULIN THERAPY □ How often is NPH injected?

Every 12 hours

□ Why is it important to start with low doses of thyroid replacement in the elderly?

Excess doses can cause: - tachycardia - angina - dysrhythmias

□ Very young children, pregnant or nursing mothers are candidates for radioactive treatment. True or False.

False

METFORMIN □ True/False, 10% percentage of patients are intolerant of metformin?

False, - Actually, about 20% are intolerant

SULFONYLUREAS □ Sulfonylureas are most effective on (fasting blood sugar or post prandial blood sugar)?

Fasting

HYPOGLYCEMIA & HYPERGLYCEMIA □ What is the Dawn phenomenon?

Fasting hyperglycemia due to increases in growth hormone in the dawn hours

DRUGS FOR DIABETES □ Why are the triglycerides often elevated in patients with uncontrolled DM?

Fatty acids are broken down when the body is unable to metabolize glucose properly, because of insulin deficiency or insulin resistance

□ Which NSAID can cause liver injury?

First generation NSAID, diclofenac (Arthrotec)

DRUGS FOR DIABETES □ What is the treatment of diabetic ketoacidosis (DKA)?

Fluid and electrolyte replacement and regular insulin given IV.

□ A pituitary tumor can cause excessive levels of prolactin that stimulate production of breast milk. This condition is called____________?

Galactorrhea

□ Alpha-glucosidase inhibitors such as acarbose (Precose), promote fermentation of carbohydrates in the gut and can cause intolerable GI effects such as___________?

Gas

□ Prostaglandins in the stomach and the kidney are protective. Inhibiting the enzyme that is responsible for making prostaglandins (COX) can lead to_______________?

Gastric erosion and renal impairment.

□ Pramlintide (Symlin) is an injectable amylin analog used with insulin that prolongs gastric emptying time to decrease postprandial glucose. It should not be used in patients with________?

Gastroparesis

□ Which disorder is associated with excessive levels of growth hormone (GH)?

Gigantism

□ How can the risk of gastric ulcers be diminished when using ASA of NSAIDs?

Give with a PPI and eradicate H. Pylori prior to starting therapy. Always take with food

□ Which of the sulfonylureas is considered to be the most potent?

Glimepiride (Amaryl)

□ Date of vaccination, route and site of administration, vaccine type, manufacturer, lot #, expiration date, name, address and title of person administering the vaccine, and the date of the VIS are required______________?

Information recorded in the patient record for each vaccination. - You are statutorily required to provide a copy of the VIS to patients receiving vaccines

INSULIN THERAPY □ What type of therapy lowers the HbA1c the most in patients with DM?

Insulin

INSULIN THERAPY □ Which of the basal insulins has the longest duration?

Insulin glargine (Lantus) was once the longest acting. - Currently there are 3 "super-long acting" basal insulins on the market.

INSULIN THERAPY □ Why should insulin be administered at room temperature?

Insulin injected is better absorbed at room temperature rather than given cold

□ Rotarix carries a small risk of_________________?

Intussusception

□ Why is PTU preferred in thyroid storm?

It blocks conversion of T4 to T3 and may be more effective

INSULIN THERAPY □ Why is basal insulin given at night?

It can be given every 24 hours and night time seems to be convenient because there is no mealtime insulin injection before bed. - It can be given at other times and it can be given BID. -After dinner is convenient because sometimes patients fall asleep and forget to inject at HS.

□ What does levothyroxine do to warfarin levels?

It can intensify warfarin levels

□ Why is the Vaccine Information Sheet (VIS) given to patients receiving immunizations?

It is a Federal mandate

□ Why is vasopressin avoided in patients with coronary artery disease or hypertension?

It is a powerful vasoconstrictor and can cause angina or MI.

□ How long does treatment for hypothyroidism last?

It is lifelong

□ Can GH be used once epiphyseal closure has occurred.

It is not recommended.

□ Can live virus vaccines be given to patients taking glucocorticoids?

It is not recommended. The antibody response to the vaccine will be diminished

INSULIN THERAPY □ What is the problem with insulin sliding scales?

It treats hyperglycemia after it has already occurred

SGLT2 INHIBITORS □ What is the rare serious adverse effect from SGLT2 inhibitors that was noted in the post-market phase?

Ketoacidosis

□ In diabetic ketoacidosis (DKA), the body breaks down fat to produce___________?

Ketoacids

Lactic acidosis can occur due to metformin accumulation. The risk increases with conditions such as sepsis, dehydration, excess alcohol intake, hepatic insufficiency, renal impairment, and acute congestive heart failure. Symptoms include malaise, myalgias, respiratory distress, increasing somnolence, and nonspecific abdominal distress. Laboratory abnormalities include low pH, increased anion gap and elevated blood lactate. If acidosis is suspected, discontinue metformin hydrochloride extended-release tablets and hospitalize the patient

Metformin Hydrochloride Extended-Release Tablets

METFORMIN □ What is the most important rare side effect associated with the use of metformin?

Metformin inhibits lactic acid oxidation leading to lactic acidosis

□ Which antithyroid drug is preferred?

Methimazole is preferred

□ Give an example of a DMARD that is contraindicated in pregnancy causing fetal death and congenital abnormalities.

Methotrexate

□ Can a child with a cough or mild fever receive immunizations?

Mild illness in not a contraindication to receiving immunizations.

□ Gastric ulceration, bleeding tendencies and renal impairment are (increased or decreased) with the COX-2 selective drug called celecoxib (Celebrex)?

Slightly decreased. New evidence disputes the initial safety profile of COX 2 inhibitors

METFORMIN □ How should metformin be initiated?

Slowly, 500 mg/day with gentle titration to avoid gastrointestinal adverse effects. - The 500 mg tablets are more tolerable and easier to swallow.

METFORMIN □ Which drugs for DM are on the $4 list at retailers such as Target and Wal-Mart?

Sulfonylureas and metformin

□ Are preparations of thyroid replacement bioequivalent?

Supposedly-endocrinologist prefer the brand Synthroid

□ What is the purpose of low-dose aspirin following an MI.

Suppression of platelet aggregation (to reduce the risk of vascular mortality).

□ What is treatment for Cushing's syndrome?

Surgical removal of the gland if there is a tumor

□ What is Armour Thyroid and Thyrolar?

Synthetic T4 and T3 combinations

□ How long is the onset of benefits with DMARDs in the treatment of rheumatoid arthritis (RA)?

The onset of disease-modifying anti-rheumatic drugs (DMARDs) is 3-5 months.

□ Which gland regulates calcium balance in the body?

The parathyroid gland.

INSULIN THERAPY □ Why are basal insulins preferred over NPH?

The risk of hypoglycemia is higher with NPH

METFORMIN □ Why is metformin contraindicated in patients with renal impairment?

The risk of lactic acidosis is increased when the serum creatinine is elevated

INSULIN THERAPY □ What is the definition of 'basal" insulin?

The small amount of insulin that the pancreas produces to keep the blood sugar normal in between meals

□ Why does hepatic necrosis occur with acetaminophen?

The toxic metabolite can build up and harm the liver

□ Why is it important to ask a patient about their dental condition prior to the initiation of bisphosphonates?

There is an association between osteonecrosis of the jaw and the use of bisphosphonates. It recommended that major dental procedures be done before starting these drugs

□ Why should ASA be avoided in children with influenza or varicella?

There is an increased risk of Reye's syndrome

□ Why should ibuprofen and acetaminophen be avoided as prophylaxis for fever or pain before vaccination?

These agents my reduce the immune response to vaccines

INSULIN THERAPY □ Why are basal insulins preferred over 70/30 combinations?

They have reduced flexibility and higher risk of hypoglycemia

□ What effect do NSAIDs have on blood pressure?

They increase blood pressure

□ How is Grave's disease treated?

With antithyroid drugs until radioactive iodine can be given.

INSULIN THERAPY □ How can lipohypertrophy (accumulation of subcutaneous fat at sites of frequent insulin injection) be avoided?

With systematic rotation of injection sites. - Absorption of insulin is diminished in areas of lipohypertrophy. Check patients for this complication

DRUGS FOR DIABETES □ Are patients with gestational diabetes at higher risk for diabetes later in life?

Yes

METFORMIN □ Is metformin considered "disease altering?"

Yes

METFORMIN □ Is metformin free at Publix?

Yes

□ A patient is allergic to aspirin. Should they avoid NSAIDs?

Yes

□ A patient presents with an estimated GFR of <60. Would the use of NSAIDs be problematic?

Yes

□ Can the oral incretin like drugs such as sitagliptin cause pancreatitis like injectable exenatide?

Yes

□ Can you give live virus vaccines on the same day?

Yes

□ Do NSAIDs need to be discontinued prior to surgery?

Yes

□ Is it recommended to immunize children born prematurely?

Yes

□ Is weight loss a possibility with the use of exenatide?

Yes

□ Do children require higher doses of thyroid replacement?

Yes -typically 4.0 micrograms/kg/day due to increased metabolic rates

DRUGS FOR DIABETES □ Do oral agents for diabetes cross the placenta?

Yes and the effect on the fetus is not certain. Metformin is often used

□ Are topical NSAIDs effective?

Yes and they are a good option to avoid the systemic effects of NSAIDs

□ Should women who are pregnant receive Tdap?

Yes with each pregnancy around 27-36 weeks

INSULIN THERAPY □ Do patients feel better after starting insulin?

Yes! - They often don't realize how poorly they felt when the blood sugar was elevated.

HYPOGLYCEMIA & HYPERGLYCEMIA □ Can milk be used to reverse hypoglycemic s/s?

Yes, 8 ounces of milk is effective and will not cause the blood sugar to rise as high as orange juice and is preferred

□ Can metformin cause weight loss?

Yes, because of the GI effects

□ Can NSAIDs increase cardiovascular risk?

Yes, by about 12%

□ Are liver enzymes monitored in patients on TZDs?

Yes, it is recommended due to rare cases of hepatic toxicity

HYPOGLYCEMIA & HYPERGLYCEMIA □ A patient presents to the clinic with a blood sugar of 300 mg/dL and insulin is initiated. The patient calls to c/o symptoms of hypoglycemia with a blood sugar of 150 mg/dL. Is this possible?

Yes, listen to the patient

DRUGS FOR DIABETES □ Are patients with diabetes more susceptible to depression?

Yes, make sure you screen and treat to enhance diabetes self-management

□ Can over replacement of thyroid hormone harm the bones?

Yes, osteopenia and osteoporosis can develop

□ Can NSAIDS influence the efficacy of antihypertensive medications

Yes, rendering them less effective

□ Can the Glucagon-like Peptide Receptor Agonist (GLP-1), exenatide (Byetta) cause renal problems?

Yes, there are post-marketing reports of altered kidney function, including renal failure other S/E's include: - N/V/D - Wt loss - fetal harm - hypersensitivity - thyroid CA - Pancreatitis - hypoglycemia

□ Is there a problem with taking ibuprofen or other NSAIDs with ASA?

Yes, they can inhibit the antiplatelet action of ASA. - Take The ASA first and separate the dose of the NSAID by 4 hours

□ If someone does not respond to one NSAID, are they likely to respond to another in the class?

Yes, trials of more than one NSAID may be needed.

□ Can you have a goiter and have normal thyroid function?

Yes-check thyroid function tests (TFTs)

□ Is Addison's disease seen more frequently in patients with type 1 diabetes?

Yes. - these patients have increased risk of all autoimmune disease such as Hashimoto's thyroiditis, pernicious anemia, and celiac disease. - Routine screening is done for these patients at regular intervals.

□ Can a child recovering from an illness that is finishing antibiotic therapy receive immunizations?

Yes. - Try not to miss the opportunity to immunize children.

A patient weighing 96 kg is started on basal bolus insulin. Calculate what his estimated basal and mealtime dosage would be: a) 24 units of Lantus at bedtime and 8 units of NovoLog with meals b) 48 units of Lantus at bedtime and 16 units of NovoLog with meals c) 24 units of NovoLog at bedtime and 8 units of Lantus with meals d) 8 units of Lantus at bedtime and 3 units of NovoLog with meals

a) 24 units of Lantus at bedtime and 8 units of NovoLog with meals Basal dose Regular -> 50% at breakfast, 25% lunch then 25% dinner Lantus is 50% of TDD at HS only (not with meals)

Which of the following statements are true regarding precautions with the use of NSAIDs and other analgesics? (Choose all that apply) a) Because of the risk of Reye's syndrome, aspirin should be avoided by children with influenza or chickenpox b) COX Inhibitors and NSAIDs can increase the risk of cardiovascular events c) NSAIDs can antagonize the antiplatelet actions of aspirin d) Patients on warfarin should take acetaminophen

a, b & c a) Because of the risk of Reye's syndrome, aspirin should be avoided by children with influenza or chickenpox b) COX Inhibitors and NSAIDs can increase the risk of cardiovascular events c) NSAIDs can antagonize the antiplatelet actions of aspirin Quiz 5

A patient with an acute attack of gout can be treated with: (Choose all that apply) a) NSAIDs b) Glucocorticoids c) Colchicine d) Allopurinol

a, b & c a) NSAIDs b) Glucocorticoids c) Colchicin quiz 6

Which of the following statements are true regarding vaccinations? (Choose all that apply). a) Acetaminophen, NSAIDs, and glucocorticoids can reduce the immune response to vaccines b) Some vaccines still contain a small amount of thimerisol c) Passive immunity is better than active immunity d) School children can opt out of receiving vaccinations

a, b, & d a) Acetaminophen, NSAIDs, and glucocorticoids can reduce the immune response to vaccines b) Some vaccines still contain a small amount of thimerisol d) School children can opt out of receiving vaccinations Quiz 4

A patient on thyroid replacement has a TSH of 24 mIU/L. Which of the following may be interfering with the absorption or metabolism of the levothyroxine? a) Phenytoin b) Lansoprazole c) Multivitamin d) Atorvastatin e) Cholestyramine f) Ferrous sulfate

a, b, c, e, & f Med's that interact with metabolism of levothyroxine: *avoid giving with antacids, Ca+, Fe+ and anticholesterol agents - Phenytoin - Lansoprazole - Multivitamin - Cholestyramine - Ferrous sulfate Others: - warfarin ---> incr levels warfarin (inc INR) - Rifampin ---> decr effect levothyroxine - AED's ---> decr effect levothyroxine - sertraline ---> decr effect levothyroxine Quiz 2

A pregnant woman seeks advice on the influenza vaccination. Because she is pregnant which of the vaccines if needed would NOT be provided because of the pregnancy? (Choose all that apply). a) FluMist nasal influenza vaccine b) Fluzone (inactivated influenza vaccine-does not contain mercury) c) MMR d) Varicella e) Gardisil

a, c, d, & e Avoid during pregnancy a) FluMist nasal influenza vaccine c) MMR d) Varicella e) Gardisil Quiz 4

A patent is seen by the orthopedist and prescribed high doses of an NSAID for tendinitis. Which of the following conditions may be worsened by the use of the NSAIDs? (Choose all that apply) a) Peptic ulcer disease b) HTN c) Renal insufficiency d) Hyperlipidemia

a,b & c a) Peptic ulcer disease b) HTN c) Renal insufficiency Quiz 5

Which of the following findings are consistent with hypothyroidism: (Choose all that apply) a) Elevated TSH b) Elevated free T4 c) Suppressed free T4 d) Frequent low volume stools e) Constipation f) Bradycardia

a,c, e, & f a) Elevated TSH c) Suppressed free T4 e) Constipation f) Bradycardia Quiz 2

Which insulin has the most rapid onset of action? a) NPH b) aspart (Novolog) or lispro (Humalog) or glulisine (Apidra) c) glargine (Lantus) d) regular (Humulin R), (Novolin R)

b) aspart (Novolog): Onset: 10-20min Peak: 1-3hr Duration: 3-5hr lispro (Humalog): Onset: 15-30min Peak: 0.5-2.5hrDuration: Duration: 3-6hrs insulin glulisine (Apidra): Onset: 10-15min Peak: 1-1.5hr Duration: 3-5hr Quiz 1

Calculate insulin dosage using a premix of Novolin 70/30 for a 66 kg female. Use 0.5 units/kg/day. a) 21 units 15 minutes before the am meal and and 12 units 15 minutes before the pm meal b) 21 units 30 minutes before the am meal and 12 units 30 minutes before the pm meal c) 43 units 30 minutes before the am meal and 23 units 30 minutes before the pm meal d) 43 units 13 minutes before the am meal and 23 units 15 minutes before the pm meal

b) 21 units 30 minutes before the am meal and 12 units 30 minutes before the pm meal *Her weight in kg is 66. Multiply 66 x 0.5=33. Her TDD is 33 units. Give her 2/3 for breakfast and 1/3 before dinner.Since this is NOT rapid acting insulin, give it 30 minutes before the meal. 33 x .66 = 21 units. in the am 33 x .33 =12 units before dinner Quiz 1

Somatostatin analogs are given to patients with acromegaly to suppress: a) ADH b) GH c) Prolactin d) FSH

b) GH Quiz 3

Harriet, age 62, has type 1 diabetes that is well controlled by insulin. Recently, she has been having marital difficulties that have left her emotionally upset. As a result of this stress, it is possible that she will: a) Have an insulin reaction more readily than usual. b) Have an increased blood sugar level. c) Need less daily insulin. d) Need more carbohydrates.

b) Have an increased blood sugar level. Quiz 1

Marie, age 50, has diabetes and checks her blood glucose level several times every day. Her blood glucose level ranges from 250-280 mg/dL in the morning and is usually about 100 at bedtime. In the morning she takes 30 units of neutral protamine Hagedorn (NPH) insulin and 4 units of regular insulin, and before dinner takes 18 units of NPH insulin and 4 units of regular insulin. Although she has had her insulin dosage adjusted several times in the past month, it has had no effect on her high morning blood glucose level. What is your next course of action? a) Increase the evening NPH insulin dosage by 2 more units. b) Have her check her blood glucose level between 2 a.m. and 4 a.m. for the next several days. c) Increase the morning regular insulin dosage by 2 units. d) Order a fasting blood glucose test.

b) Have her check her blood glucose level between 2 a.m. and 4 a.m. for the next several days. Quiz 1

Glucagon is used to treat: a) Hyperglycemia b) Hypoglycemia c) Diabetic ketoacidosis d) Insulin resistance

b) Hypoglycemia Quiz 1

A patient presents to the clinic with a history of hypothyroidism. A pregnancy test is found to be positive. How will the dosage of 100 micrograms of levothyroxine daily be adjusted? a) The levothyroxine is Pregnancy Category D and will be discontinued b) Increased to 137 micrograms per day c) Doubled (200 micrograms per day) d) Decreased to 75 micrograms per day

b) Increased to 137 micrograms per day Quiz 2

Morris has had type 1 diabetes for 10 years. Several recent urinalysis reports have shown microalbuminuria. Your next next step would be to: a) Order a 24-hour urine for protein. b) Start him on an angiotensin-converting enzyme (ACE) inhibitor. c) Stress the importance of strict blood sugar control. d) Send him to a dietitian because he obviously has not been following his diet.

b) Start him on an angiotensin-converting enzyme (ACE) inhibitor. Quiz 1

A patient weighing 210 lbs is in need of insulin. The total daily dose (TDD) for this patient is: (use 0.5 units/kg/day) a) 16 units b) 30 c) 47 d) 105

c) 47 Did you remember to change lbs into kg? 210 lbs is 95.45 kg x 0,5 units/kg/day = 47.7. I rounded to 47 units for the TDD. Quiz 1

Which class of antihypertensive agents may be problematic for clients with diabetes? a) Ace inhibitors b) Calcium channel blockers c) Beta blockers d) Alpha blockers

c) Beta blockers Quiz 1

The American Diabetes Association recommends which of the following quarterly blood tests to be performed on all clients with diabetes? a) Urine b) Liver function c) Glycohemoglobin d) Serum glucose

c) Glycohemoglobin Quiz 1

Your patient with diabetes asks you about insulin glargine (Lantus). You would tell her that: a) It may be administered SC at home, or IV in the hospital if need be. b) The duration of action is 6-8 hours. c) Lantus stays in your system for 24 hours. d) It can be mixed with any other insulin.

c) Lantus stays in your system for 24 hours. Quiz 1

Ace inhibitors are given to clients with diabetes who have: a) An elevated glycohemoglobin level. b) Insulin sensitivity. c) Urine microalbuminuria d) an elevated serum creatinine level.

c) Urine microalbuminuria Quiz 1

The ADA algorithm for type 2 diabetes suggests lifestyle changes and the initiation of which drug? a) glimepiride (Amaryl) b) rosiglitazone (Avandia) c) metformin (Glucophage) d) glipizide (Glucotrol)

c) metformin (Glucophage) Quiz 1

Growth hormone (GH) is indicated for pediatric and adult hormone deficiency. Which of the following is an adverse effect of GH? a) Hyperkalemia b) Hypokalemia c) Hyperglycemia d) Hypoglycemia

c)Hyperglycemia (but why? - (look this up**) Quiz 3

Which of the following questions should be asked prior to administering the influenza vaccine? a) Do you have allergies to Neomycin? b) Do you have allergies to shellfish? c) Do you have allergies to peanuts? d) Do you have allergies to eggs?

d) Do you have allergies to eggs? Quiz 4

Mary, age 72, has been taking insulin for several years. She just called you because she realized that yesterday she put her short-acting insulin in the long-acting insulin box and vice versa. She just took 22 units of regular insulin when she was supposed to take only 5 units. She says that she tried to do a fingerstick to test her glucose level but was unable to obtain any blood. She states that she feels fine. What do you tell her to do first? a) "Keep trying to get a fingerstick and call me back with results." b) "Call 911 before you collapse." c) "Drive immediately to the ER." d) "Drink 4 oz of fruit juice.

d) "Drink 4 oz of fruit juice. QUIZ 1

Dan, age 45, is obese and has type 2 diabetes and has been having trouble getting his glycohemoglobin under control. He's heard that Exenatide (Byetta) causes weight loss and wants to try it. What do you tell him? a) "Lets just adjust your oral antidiabetic agents instead." b) "That's a myth. People usually change their eating habits when taking this and that's what causes the weight loss." c) "With type 2 diabetes, you never want to be on injectable insulin." d) "Let's try it. You're glycohemoglobin will be lowered and you may lose weight."

d) "Let's try it. You're glycohemoglobin will be lowered and you may lose weight." Quiz 1

The late president J.F. Kennedy was treated with corticosteroids and fludrocortisone because he suffered from: a) Diabetes mellitus b) Acromegaly c) Diabetes insipidus d) Addison's disease

d) Addison's disease Quiz 3

A patient on 125 micrograms of levothyroxine presents with a TSH of 0.001 mIU/L and complains of insomnia, nervousness and hyper-defecation. The DTRs are exaggerated and the patient has a fine tremor. The next step is to: a) Discontinue the levothyroxine b) Increase the levothyroxine c) Send the patient to the ED d) Decrease the dose to 100 micrograms per day

d) Decrease the dose to 100 micrograms per day Quiz 2

A patient is scheduled for major surgery. The nurse knows that ASA and any products containing NSAIDs should be discontinued: a) One day prior to surgery b) Two days prior to surgery c) Five days prior to surgery d) One week prior to surgery

d) One week prior to surgery quiz 5

Which of the following are examples of "active" immunity? a) Rabies immunglobulin b) IVIG c) Hepatitis B immune globulin d) TdaP

d) TdaP Quiz 4

Early-morning increases in blood glucose concentration that occur with no corresponding hypoglycemia during the night are referred to as: a) The Somogyi phenomenon. b) Insulin shock. c) Diabetic ketoacidosis. d) The Dawn phenomenon.

d) The Dawn Phenomenon. Quiz 1

Which drug class used to treat diabetes causes fluid retention and should not be used in patients with heart failure? a) sulfonylureas b) biguanides c) DPP-4I ("gliptins") d) thiazolidinediones

d) thiazolidinediones Quiz 1

□ Incretins are hormones that are released from the GI tract after a meal. They slow gastric emptying, stimulate insulin release for the pancreas, inhibit postprandial release of glucagon, and suppress appetite. An injectable drug that mimics this effect is called__________?

exenatide (Byetta) - a Glucagon-like Peptide_1 Receptor Agonist (GLP-1): 1) reduces gastric emptying 2) stimulates glucose dependant release of insulin 3) suppresses appetite 4) helps reduce post prandial Bgl. S/E's: -PANCREATITIS - N/V/D - Wt loss - fetal harm - hypersensitivity - thyroid CA