ADVANCED PHARMACOLOGY NSG 533
QUESTIONS WITH CORRECT ANSWERS
EP is a 38-year-
old female patient that comes in for diabetes education and management. She was diagnosed
12 years ago and states lately she is not able to control her diet although she continues a 1600
calorie diet with appropriate daily carbohydrate intake (per dietitian prescription) and walks 4
0 minutes every day of the week. She states compliance with all medications. She denies any h
istory of hypoglycemia despite being able to identify signs and symptoms and describe approp
riate treatment strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to thyroid cancer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high school
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopril 20 mg daily, sertraline 100 m
g daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L, BUN - CORRECT ANSWER -
Exenatide -
Exenatide (Bydureon) once weekly has been able to demonstrate weight loss and decrease A1
C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP due to the self-
reported history of thyroid cancer.
Dapagliflozin -
Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia which could be m
ade worse by this drug. The package insert does not indicate a specific potassium concentratio
n cut off to no longer use this medication; however, there are better choices in this patient.
Sitagliptin -
Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical trials and c
urrently the patient does not have any cautionary objective measures to not use this medicati
on. DPP-IV inhibitors are weight neutral. DPP-
IV inhibitors can be used in patients taking sulfonylureas; however, it may be recommended to
reduce or stop the sulfonylurea dose.
,Acarbose -
Acarbose (Precose) is not recommended for initial management and is associated with signific
ant GI side effects. More information would be needed regarding fasting and post-
prandial numbers. In addition, adding acarbose would only lower A1c by 0.8% at best and ther
efore would not achieve the desired A1C goal of <7%
JR is a 68-year-
old African American man with a new diagnosis of T2DM. He was classified as having prediabe
tes (at risk for developing diabetes) 5 years before the diagnosis and has a strong family histor
y of type 2 diabetes. JR's blood pressure was 150/92 mm Hg. His laboratory results revealed a
n A1C of 8.1%, normal cholesterol panel, and normal renal/hepatic function were noted with t
oday's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed 2 y ago) Pan
creatitis (idiopathic) (acute hospitalization 3 y ago)
Family history: Type 2 diabetes
Medication: HCTZ 25 mg daily, simvastatin 10 mg daily
Allergies: SMZ/TMP
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist Circumference: 46 in Weight: 267
lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
Despite improvements in the past six weeks due to lifestyle changes and exercise, drug therap
y is to be started for JR's diabet - CORRECT ANSWER -
Metformin is the drug of choice recommended for most patients with diabetes in addition to li
festyle modifications assuming no contraindications or intolerabilities are present upon evaluat
ion. Metformin has also shown to provide positive weight neutral/loss effects in obese patients
. It is crucial to know the renal status of patients commencing metformin therapy to limit the r
isk of lactic acidosis (JR is without contraindication).
Since his entry A1C is >7.5%, dual therapy is indicated. There are several potential choices. The
second step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-
1) receptor agonist, it can be a TZD, it can be a sulfonylurea agent, it can be a SGLT2 inhibitor,
or it could be basal insulin. Anything next can be tried depending on what suits the circumstan
ce
,DPP4 inhibitors are weight neutral bet relatively benign side effect profile. Sitagliptin has been
associated with case reports of pancreatitis, so this specific agent should be avoided. $$$
GLP-
1 analog and has data to support an A1C reduction necessary to gain glycemic control and may
assist with weight loss goals for this patient. New information suggests these agents may prov
ide benefits in those with ASCVD. JR has a past history of pancreatitis and GLP-
1 analogs are not recommended due to this contraindication
TZDs have data to support an A1C reduction necessary to gain glycemic control, but are associ
ated with weight gain, negative effects on lipids and increased risk of fracture. Until recently, T
ZDs have also been linked to increased CV events and use has fallen out of favor
Sulfonylureas provide excellent A1C lowering, but are also associated with weight gain. They al
so have the potential to cause hypoglycemia, so patient education is crucial. Because of his all
ergies to "sulfa", use would be contr
A patient with type 1 diabetes reports taking propranolol for hypertension. What concern does
this information present for the provider? - CORRECT ANSWER -
A patient with Type 1 DM is insulin dependent for glucose control and at high risk for hypoglyc
emic episodes. Propanolol causes prolonged hypoglycemic episodes. Needs to switch to ACE or
ARB.
A provider teaches a patient who has been diagnosed with hypothyroidism about a new prescr
iption for levothyroxine. Which statement by the patient indicates a need for further teaching?
a. "I should not take heartburn medication without consulting my provider first."
b. "I should report insomnia, tremors, and an increased heart rate to my provider."
c. "If I take a multivitamin with iron, I should take it 4 hours after the levothyroxine."
d. "If I take calcium supplements, I may need to decrease my dose of levothyroxine." -
CORRECT ANSWER -
D. Calcium may reduce levothyroxine absorption. Further education is needed if the patient fe
els she can take half of a prescribed medication.
MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal and alcohol
he experiences significant GI distress. He takes an OTC heartburn remedy. Within a minute or t
, wo he develops what he will later describe as "belching, nausea and a bad bloated feeling". Se
veral of the ulcers began to bleed and he becomes profoundly hypotensive from the blood loss
and is taken to the ED. Endoscopy confirms multiple bleeds; the endoscopist remarks that it a
ppears as if the lesions had been literally stretched apart causing additional tissue damage. W
hat did the patient most likely take (i.e. what was the OTC remedy)? - CORRECT ANSWER -
I would accept Alka-
Selzer. I contains NaHCO3 (as well as ASA). In the presence of HCL it Liberates CO2, that can ca
use gastric distention, belching and nausea. The reaction is fairly swift allowing little time for di
ssipation. Tums, its primary ingredient calcium carbonate which when taken cause a reaction
with the stomach acid such as production of carbon dioxide gas which can cause bloating and
the stomach to stretch to tear the ulcers open.
On your way to this examination, you experience the vulnerable feeling that an attack of acute
diarrhea is imminent! If you stop at a drug store, which anti-
diarrheal drugs could you buy without a prescription even though it is chemically related to th
e strong opioid analgesic meperidine (but acts only on the peripheral opioid receptor)? -
CORRECT ANSWER -Loperamide
JA has multiple medical problems and is taking several drugs including theophylline, warfarin a
nd phenytoin. His conditions were well controlled, but recently he started to experience some
GI distress for which of his "well intentioned friends" gave him some medication. He presents t
o you with toxic effects of all his other medications and plasma levels of those medications ele
vated. What was most likely the medication he took? - CORRECT ANSWER -Cimetidine
What lifestyle modifications should be recommended? - CORRECT ANSWER --
losing weight if overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
QUESTIONS WITH CORRECT ANSWERS
EP is a 38-year-
old female patient that comes in for diabetes education and management. She was diagnosed
12 years ago and states lately she is not able to control her diet although she continues a 1600
calorie diet with appropriate daily carbohydrate intake (per dietitian prescription) and walks 4
0 minutes every day of the week. She states compliance with all medications. She denies any h
istory of hypoglycemia despite being able to identify signs and symptoms and describe approp
riate treatment strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to thyroid cancer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high school
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopril 20 mg daily, sertraline 100 m
g daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L, BUN - CORRECT ANSWER -
Exenatide -
Exenatide (Bydureon) once weekly has been able to demonstrate weight loss and decrease A1
C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP due to the self-
reported history of thyroid cancer.
Dapagliflozin -
Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia which could be m
ade worse by this drug. The package insert does not indicate a specific potassium concentratio
n cut off to no longer use this medication; however, there are better choices in this patient.
Sitagliptin -
Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical trials and c
urrently the patient does not have any cautionary objective measures to not use this medicati
on. DPP-IV inhibitors are weight neutral. DPP-
IV inhibitors can be used in patients taking sulfonylureas; however, it may be recommended to
reduce or stop the sulfonylurea dose.
,Acarbose -
Acarbose (Precose) is not recommended for initial management and is associated with signific
ant GI side effects. More information would be needed regarding fasting and post-
prandial numbers. In addition, adding acarbose would only lower A1c by 0.8% at best and ther
efore would not achieve the desired A1C goal of <7%
JR is a 68-year-
old African American man with a new diagnosis of T2DM. He was classified as having prediabe
tes (at risk for developing diabetes) 5 years before the diagnosis and has a strong family histor
y of type 2 diabetes. JR's blood pressure was 150/92 mm Hg. His laboratory results revealed a
n A1C of 8.1%, normal cholesterol panel, and normal renal/hepatic function were noted with t
oday's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed 2 y ago) Pan
creatitis (idiopathic) (acute hospitalization 3 y ago)
Family history: Type 2 diabetes
Medication: HCTZ 25 mg daily, simvastatin 10 mg daily
Allergies: SMZ/TMP
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist Circumference: 46 in Weight: 267
lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
Despite improvements in the past six weeks due to lifestyle changes and exercise, drug therap
y is to be started for JR's diabet - CORRECT ANSWER -
Metformin is the drug of choice recommended for most patients with diabetes in addition to li
festyle modifications assuming no contraindications or intolerabilities are present upon evaluat
ion. Metformin has also shown to provide positive weight neutral/loss effects in obese patients
. It is crucial to know the renal status of patients commencing metformin therapy to limit the r
isk of lactic acidosis (JR is without contraindication).
Since his entry A1C is >7.5%, dual therapy is indicated. There are several potential choices. The
second step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-
1) receptor agonist, it can be a TZD, it can be a sulfonylurea agent, it can be a SGLT2 inhibitor,
or it could be basal insulin. Anything next can be tried depending on what suits the circumstan
ce
,DPP4 inhibitors are weight neutral bet relatively benign side effect profile. Sitagliptin has been
associated with case reports of pancreatitis, so this specific agent should be avoided. $$$
GLP-
1 analog and has data to support an A1C reduction necessary to gain glycemic control and may
assist with weight loss goals for this patient. New information suggests these agents may prov
ide benefits in those with ASCVD. JR has a past history of pancreatitis and GLP-
1 analogs are not recommended due to this contraindication
TZDs have data to support an A1C reduction necessary to gain glycemic control, but are associ
ated with weight gain, negative effects on lipids and increased risk of fracture. Until recently, T
ZDs have also been linked to increased CV events and use has fallen out of favor
Sulfonylureas provide excellent A1C lowering, but are also associated with weight gain. They al
so have the potential to cause hypoglycemia, so patient education is crucial. Because of his all
ergies to "sulfa", use would be contr
A patient with type 1 diabetes reports taking propranolol for hypertension. What concern does
this information present for the provider? - CORRECT ANSWER -
A patient with Type 1 DM is insulin dependent for glucose control and at high risk for hypoglyc
emic episodes. Propanolol causes prolonged hypoglycemic episodes. Needs to switch to ACE or
ARB.
A provider teaches a patient who has been diagnosed with hypothyroidism about a new prescr
iption for levothyroxine. Which statement by the patient indicates a need for further teaching?
a. "I should not take heartburn medication without consulting my provider first."
b. "I should report insomnia, tremors, and an increased heart rate to my provider."
c. "If I take a multivitamin with iron, I should take it 4 hours after the levothyroxine."
d. "If I take calcium supplements, I may need to decrease my dose of levothyroxine." -
CORRECT ANSWER -
D. Calcium may reduce levothyroxine absorption. Further education is needed if the patient fe
els she can take half of a prescribed medication.
MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal and alcohol
he experiences significant GI distress. He takes an OTC heartburn remedy. Within a minute or t
, wo he develops what he will later describe as "belching, nausea and a bad bloated feeling". Se
veral of the ulcers began to bleed and he becomes profoundly hypotensive from the blood loss
and is taken to the ED. Endoscopy confirms multiple bleeds; the endoscopist remarks that it a
ppears as if the lesions had been literally stretched apart causing additional tissue damage. W
hat did the patient most likely take (i.e. what was the OTC remedy)? - CORRECT ANSWER -
I would accept Alka-
Selzer. I contains NaHCO3 (as well as ASA). In the presence of HCL it Liberates CO2, that can ca
use gastric distention, belching and nausea. The reaction is fairly swift allowing little time for di
ssipation. Tums, its primary ingredient calcium carbonate which when taken cause a reaction
with the stomach acid such as production of carbon dioxide gas which can cause bloating and
the stomach to stretch to tear the ulcers open.
On your way to this examination, you experience the vulnerable feeling that an attack of acute
diarrhea is imminent! If you stop at a drug store, which anti-
diarrheal drugs could you buy without a prescription even though it is chemically related to th
e strong opioid analgesic meperidine (but acts only on the peripheral opioid receptor)? -
CORRECT ANSWER -Loperamide
JA has multiple medical problems and is taking several drugs including theophylline, warfarin a
nd phenytoin. His conditions were well controlled, but recently he started to experience some
GI distress for which of his "well intentioned friends" gave him some medication. He presents t
o you with toxic effects of all his other medications and plasma levels of those medications ele
vated. What was most likely the medication he took? - CORRECT ANSWER -Cimetidine
What lifestyle modifications should be recommended? - CORRECT ANSWER --
losing weight if overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
