1|Pag e 2|Pag e
ADVANCED PHARMACOLOGY NSG 533 EXAM|| neutral. DPP-IV inhibitors can be used in patients taking sulfonylureas; however, it
may be recommended to reduce or stop the sulfonylurea dose.
ALL QUESTIONS AND CORRECT ANSWERS||
Acarbose - Acarbose (Precose) is not recommended for initial management and is
LATEST AND CO0MPLET VERSION ALREADY associated with significant GI side effects. More information would be needed
GRADED A+|| ANSWERS WELL ELLABORATED|| regarding fasting and post-prandial numbers. In addition, adding acarbose would
only lower A1c by 0.8% at best and therefore would not achieve the desired A1C
ASSURED PASS!!! goal of <7%
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 JR is a 68-year-old African American man with a new diagnosis of T2DM. He was
carbohydrate intake (per dietitian prescription) and walks 40 minutes every day of classified as having prediabetes (at risk for developing diabetes) 5 years before the
the week. She states compliance with all medications. She denies any history of diagnosis and has a strong family history of type 2 diabetes. JR's blood pressure
hypoglycemia despite being able to identify signs and symptoms and describe was 150/92 mm Hg. His laboratory results revealed an A1C of 8.1%, normal
appropriate treatment strategies. cholesterol panel, and normal renal/hepatic function were noted with today's
laboratory test results.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to thyroid cancer
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed
FmHx: Noncontributory 2 y ago) Pancreatitis (idiopathic) (acute hospitalization 3 y ago)
SHx: (−) Smoking, alcohol use, past marijuana use while in high school Family history: Type 2 diabetes
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopril 20 mg daily, Medication: HCTZ 25 mg daily, simvastatin 10 mg daily
sertraline 100 mg daily, multivitamin daily
Allergies: SMZ/TMP
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist Circumference: 46
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L, BUN - in Weight: 267 lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
ANSWER: Exenatide - Exenatide (Bydureon) once weekly has been able to
demonstrate weight loss and decrease A1C% by 0.7% to 1.2% in clinical trials;
however it is contraindicated for EP due to the self-reported history of thyroid
cancer.
Despite improvements in the past six weeks due to lifestyle changes and exercise,
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to drug therapy is to be started for JR's diabet - ANSWER: Metformin is the drug of
hyperkalemia which could be made worse by this drug. The package insert does choice recommended for most patients with diabetes in addition to lifestyle
not indicate a specific potassium concentration cut off to no longer use this modifications assuming no contraindications or intolerabilities are present upon
medication; however, there are better choices in this patient. evaluation. Metformin has also shown to provide positive weight neutral/loss
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% effects in obese patients. It is crucial to know the renal status of patients
based on clinical trials and currently the patient does not have any cautionary commencing metformin therapy to limit the risk of lactic acidosis (JR is without
objective measures to not use this medication. DPP-IV inhibitors are weight contraindication).
,3|Pag e 4|Pag e
Since his entry A1C is >7.5%, dual therapy is indicated. There are several potential c. "If I take a multivitamin with iron, I should take it 4 hours after the
choices. The second step can be a dipeptidyl peptidase-4 inhibitor, it can be a levothyroxine."
glucagon-like peptide-1 (GLP-1) receptor agonist, it can be a TZD, it can be a
d. "If I take calcium supplements, I may need to decrease my dose of
sulfonylurea agent, it can be a SGLT2 inhibitor, or it could be basal insulin.
levothyroxine." - ANSWER: D. Calcium may reduce levothyroxine absorption.
Anything next can be tried depending on what suits the circumstance
Further education is needed if the patient feels she can take half of a prescribed
DPP4 inhibitors are weight neutral bet relatively benign side effect profile. medication.
Sitagliptin has been associated with case reports of pancreatitis, so this specific
agent should be avoided. $$$
MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal
GLP-1 analog and has data to support an A1C reduction necessary to gain
and alcohol he experiences significant GI distress. He takes an OTC heartburn
glycemic control and may assist with weight loss goals for this patient. New
remedy. Within a minute or two he develops what he will later describe as
information suggests these agents may provide benefits in those with ASCVD. JR
"belching, nausea and a bad bloated feeling". Several of the ulcers began to bleed
has a past history of pancreatitis and GLP-1 analogs are not recommended due to
and he becomes profoundly hypotensive from the blood loss and is taken to the
this contraindication
ED. Endoscopy confirms multiple bleeds; the endoscopist remarks that it appears
TZDs have data to support an A1C reduction necessary to gain glycemic control, as if the lesions had been literally stretched apart causing additional tissue damage.
but are associated with weight gain, negative effects on lipids and increased risk of What did the patient most likely take (i.e. what was the OTC remedy)? -
fracture. Until recently, TZDs have also been linked to increased CV events and ANSWER: I would accept Alka-Selzer. I contains NaHCO3 (as well as ASA). In
use has fallen out of favor the presence of HCL it Liberates CO2, that can cause gastric distention, belching
and nausea. The reaction is fairly swift allowing little time for dissipation. Tums,
Sulfonylureas provide excellent A1C lowering, but are also associated with weight
its primary ingredient calcium carbonate which when taken cause a reaction with
gain. They also have the potential to cause hypoglycemia, so patient education is
the stomach acid such as production of carbon dioxide gas which can cause
crucial. Because of his allergies to "sulfa", use would be contr
bloating and the stomach to stretch to tear the ulcers open.
A patient with type 1 diabetes reports taking propranolol for hypertension. What
On your way to this examination, you experience the vulnerable feeling that an
concern does this information present for the provider? - ANSWER: A patient
attack of acute diarrhea is imminent! If you stop at a drug store, which anti-
with Type 1 DM is insulin dependent for glucose control and at high risk for
diarrheal drugs could you buy without a prescription even though it is chemically
hypoglycemic episodes. Propanolol causes prolonged hypoglycemic episodes.
related to the strong opioid analgesic meperidine (but acts only on the peripheral
Needs to switch to ACE or ARB.
opioid receptor)? - ANSWER: Loperamide
A provider teaches a patient who has been diagnosed with hypothyroidism about a
JA has multiple medical problems and is taking several drugs including
new prescription for levothyroxine. Which statement by the patient indicates a
theophylline, warfarin and phenytoin. His conditions were well controlled, but
need for further teaching?
recently he started to experience some GI distress for which of his "well
a. "I should not take heartburn medication without consulting my provider first." intentioned friends" gave him some medication. He presents to you with toxic
b. "I should report insomnia, tremors, and an increased heart rate to my provider." effects of all his other medications and plasma levels of those medications
elevated. What was most likely the medication he took? - ANSWER: Cimetidine
, 5|Pag e 6|Pag e
Why would antibiotics be used for PUD caused by H Pylori? What is a typical
regimen and duration of therapy? What patient specific factors should be
What lifestyle modifications should be recommended? - ANSWER: -losing
considered and how should treatment be monitored? - ANSWER: Considerations
weight if overweight
before regimen choice:
-elevating head of bed while asleep
-penicillin allergy
-eating smaller meals
-previous exposure to macroglide antibiotics
-avoid foods/meds that exacerbate gerd
Strongest Reccomendation:
-stop smoking
-Bismuth Quadruple Therapy 10-14 days
-stop drinking alcohol
*do not drink alcohol w/ metronidazole*
-Salvage regimen should be different than first regimen
What medications / foods can contribute to GERD? - ANSWER: -Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, progesterone,
theophylline, nitrates Who would be a candidate for prophylaxis of NSAID induced ulcer and what
agents are appropriate? What if the patient is on cardio-protective (low dose)
-Foods: cirus fruits/juices, coffee, tomatoes, spicy food, carbonated drinks
aspirin? What if an NSAID induced ulcer does develop. How should it be treated?
Fried/fatty foods, garlic, onions, chocolate - ANSWER: Candidate:
-Candidates: Chronic Nsaid Use, Hx ulcers, Zollinger-Ellison
What is the most effective PPI or H2RA within each of these classes? - Prevention Treatment- PPI, standard doses (most effective & best tolerated),
ANSWER: -PPI- bismuth quadruple therapy combined with proton pump Misoprostol (better than H2RA's, No Pregnancy)
inhibitors
-H2RA- Famotidine 80mg
What if an NSAID induced ulcer does develop. How should it be treated? -
ANSWER: Ulcer Treatment-
Other products such as antacids are also available. What are some of these and -PPI (most effective)
what is their place in therapy? - ANSWER: -Reflux symptoms <2 times a week
-H2RA (Famotidone 40mg daily)
(infrequent)
-Sucralfate (binding paste, requires multiple doses, adverse med reactions,
-Effective for immediate relief
abdominal side effects)
-Magnesium/Aluminum Hydroxide (Maalox)- can cause constipation
-Alginic Acid
Who is a candidate for stress ulcer prophylaxis (SUP)? - ANSWER: -ICU patients
-Trauma, including spinal cord injuries
ADVANCED PHARMACOLOGY NSG 533 EXAM|| neutral. DPP-IV inhibitors can be used in patients taking sulfonylureas; however, it
may be recommended to reduce or stop the sulfonylurea dose.
ALL QUESTIONS AND CORRECT ANSWERS||
Acarbose - Acarbose (Precose) is not recommended for initial management and is
LATEST AND CO0MPLET VERSION ALREADY associated with significant GI side effects. More information would be needed
GRADED A+|| ANSWERS WELL ELLABORATED|| regarding fasting and post-prandial numbers. In addition, adding acarbose would
only lower A1c by 0.8% at best and therefore would not achieve the desired A1C
ASSURED PASS!!! goal of <7%
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 JR is a 68-year-old African American man with a new diagnosis of T2DM. He was
carbohydrate intake (per dietitian prescription) and walks 40 minutes every day of classified as having prediabetes (at risk for developing diabetes) 5 years before the
the week. She states compliance with all medications. She denies any history of diagnosis and has a strong family history of type 2 diabetes. JR's blood pressure
hypoglycemia despite being able to identify signs and symptoms and describe was 150/92 mm Hg. His laboratory results revealed an A1C of 8.1%, normal
appropriate treatment strategies. cholesterol panel, and normal renal/hepatic function were noted with today's
laboratory test results.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to thyroid cancer
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed
FmHx: Noncontributory 2 y ago) Pancreatitis (idiopathic) (acute hospitalization 3 y ago)
SHx: (−) Smoking, alcohol use, past marijuana use while in high school Family history: Type 2 diabetes
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopril 20 mg daily, Medication: HCTZ 25 mg daily, simvastatin 10 mg daily
sertraline 100 mg daily, multivitamin daily
Allergies: SMZ/TMP
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist Circumference: 46
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L, BUN - in Weight: 267 lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
ANSWER: Exenatide - Exenatide (Bydureon) once weekly has been able to
demonstrate weight loss and decrease A1C% by 0.7% to 1.2% in clinical trials;
however it is contraindicated for EP due to the self-reported history of thyroid
cancer.
Despite improvements in the past six weeks due to lifestyle changes and exercise,
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to drug therapy is to be started for JR's diabet - ANSWER: Metformin is the drug of
hyperkalemia which could be made worse by this drug. The package insert does choice recommended for most patients with diabetes in addition to lifestyle
not indicate a specific potassium concentration cut off to no longer use this modifications assuming no contraindications or intolerabilities are present upon
medication; however, there are better choices in this patient. evaluation. Metformin has also shown to provide positive weight neutral/loss
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% effects in obese patients. It is crucial to know the renal status of patients
based on clinical trials and currently the patient does not have any cautionary commencing metformin therapy to limit the risk of lactic acidosis (JR is without
objective measures to not use this medication. DPP-IV inhibitors are weight contraindication).
,3|Pag e 4|Pag e
Since his entry A1C is >7.5%, dual therapy is indicated. There are several potential c. "If I take a multivitamin with iron, I should take it 4 hours after the
choices. The second step can be a dipeptidyl peptidase-4 inhibitor, it can be a levothyroxine."
glucagon-like peptide-1 (GLP-1) receptor agonist, it can be a TZD, it can be a
d. "If I take calcium supplements, I may need to decrease my dose of
sulfonylurea agent, it can be a SGLT2 inhibitor, or it could be basal insulin.
levothyroxine." - ANSWER: D. Calcium may reduce levothyroxine absorption.
Anything next can be tried depending on what suits the circumstance
Further education is needed if the patient feels she can take half of a prescribed
DPP4 inhibitors are weight neutral bet relatively benign side effect profile. medication.
Sitagliptin has been associated with case reports of pancreatitis, so this specific
agent should be avoided. $$$
MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal
GLP-1 analog and has data to support an A1C reduction necessary to gain
and alcohol he experiences significant GI distress. He takes an OTC heartburn
glycemic control and may assist with weight loss goals for this patient. New
remedy. Within a minute or two he develops what he will later describe as
information suggests these agents may provide benefits in those with ASCVD. JR
"belching, nausea and a bad bloated feeling". Several of the ulcers began to bleed
has a past history of pancreatitis and GLP-1 analogs are not recommended due to
and he becomes profoundly hypotensive from the blood loss and is taken to the
this contraindication
ED. Endoscopy confirms multiple bleeds; the endoscopist remarks that it appears
TZDs have data to support an A1C reduction necessary to gain glycemic control, as if the lesions had been literally stretched apart causing additional tissue damage.
but are associated with weight gain, negative effects on lipids and increased risk of What did the patient most likely take (i.e. what was the OTC remedy)? -
fracture. Until recently, TZDs have also been linked to increased CV events and ANSWER: I would accept Alka-Selzer. I contains NaHCO3 (as well as ASA). In
use has fallen out of favor the presence of HCL it Liberates CO2, that can cause gastric distention, belching
and nausea. The reaction is fairly swift allowing little time for dissipation. Tums,
Sulfonylureas provide excellent A1C lowering, but are also associated with weight
its primary ingredient calcium carbonate which when taken cause a reaction with
gain. They also have the potential to cause hypoglycemia, so patient education is
the stomach acid such as production of carbon dioxide gas which can cause
crucial. Because of his allergies to "sulfa", use would be contr
bloating and the stomach to stretch to tear the ulcers open.
A patient with type 1 diabetes reports taking propranolol for hypertension. What
On your way to this examination, you experience the vulnerable feeling that an
concern does this information present for the provider? - ANSWER: A patient
attack of acute diarrhea is imminent! If you stop at a drug store, which anti-
with Type 1 DM is insulin dependent for glucose control and at high risk for
diarrheal drugs could you buy without a prescription even though it is chemically
hypoglycemic episodes. Propanolol causes prolonged hypoglycemic episodes.
related to the strong opioid analgesic meperidine (but acts only on the peripheral
Needs to switch to ACE or ARB.
opioid receptor)? - ANSWER: Loperamide
A provider teaches a patient who has been diagnosed with hypothyroidism about a
JA has multiple medical problems and is taking several drugs including
new prescription for levothyroxine. Which statement by the patient indicates a
theophylline, warfarin and phenytoin. His conditions were well controlled, but
need for further teaching?
recently he started to experience some GI distress for which of his "well
a. "I should not take heartburn medication without consulting my provider first." intentioned friends" gave him some medication. He presents to you with toxic
b. "I should report insomnia, tremors, and an increased heart rate to my provider." effects of all his other medications and plasma levels of those medications
elevated. What was most likely the medication he took? - ANSWER: Cimetidine
, 5|Pag e 6|Pag e
Why would antibiotics be used for PUD caused by H Pylori? What is a typical
regimen and duration of therapy? What patient specific factors should be
What lifestyle modifications should be recommended? - ANSWER: -losing
considered and how should treatment be monitored? - ANSWER: Considerations
weight if overweight
before regimen choice:
-elevating head of bed while asleep
-penicillin allergy
-eating smaller meals
-previous exposure to macroglide antibiotics
-avoid foods/meds that exacerbate gerd
Strongest Reccomendation:
-stop smoking
-Bismuth Quadruple Therapy 10-14 days
-stop drinking alcohol
*do not drink alcohol w/ metronidazole*
-Salvage regimen should be different than first regimen
What medications / foods can contribute to GERD? - ANSWER: -Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, progesterone,
theophylline, nitrates Who would be a candidate for prophylaxis of NSAID induced ulcer and what
agents are appropriate? What if the patient is on cardio-protective (low dose)
-Foods: cirus fruits/juices, coffee, tomatoes, spicy food, carbonated drinks
aspirin? What if an NSAID induced ulcer does develop. How should it be treated?
Fried/fatty foods, garlic, onions, chocolate - ANSWER: Candidate:
-Candidates: Chronic Nsaid Use, Hx ulcers, Zollinger-Ellison
What is the most effective PPI or H2RA within each of these classes? - Prevention Treatment- PPI, standard doses (most effective & best tolerated),
ANSWER: -PPI- bismuth quadruple therapy combined with proton pump Misoprostol (better than H2RA's, No Pregnancy)
inhibitors
-H2RA- Famotidine 80mg
What if an NSAID induced ulcer does develop. How should it be treated? -
ANSWER: Ulcer Treatment-
Other products such as antacids are also available. What are some of these and -PPI (most effective)
what is their place in therapy? - ANSWER: -Reflux symptoms <2 times a week
-H2RA (Famotidone 40mg daily)
(infrequent)
-Sucralfate (binding paste, requires multiple doses, adverse med reactions,
-Effective for immediate relief
abdominal side effects)
-Magnesium/Aluminum Hydroxide (Maalox)- can cause constipation
-Alginic Acid
Who is a candidate for stress ulcer prophylaxis (SUP)? - ANSWER: -ICU patients
-Trauma, including spinal cord injuries
