Advanced Pharmacology NSG 533 Exam
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 40 minutes every day of
| | | | | | | | | | |
the week. She states compliance with all medications. She denies any history of
| | | | | | | | | | | | | |
hypoglycemia despite being able to identify signs and symptoms and describe
| | | | | | | | | | |
appropriate 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 mg 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 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. |
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to
| | | | | | | | | | |
hyperkalemia which could be made worse by this drug. The package insert does
| | | | | | | | | | | | |
not indicate a specific potassium concentration 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 currently the patient does not have any cautionary
| | | | | | | | | | | | |
objective measures to not use this medication. 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 significant 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 therefore 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 prediabetes (at risk for developing diabetes) 5 years before
| | | | | | | | | | | |
the diagnosis and has a strong family history of type 2 diabetes. JR's blood
| | | | | | | | | | | | | |
pressure was 150/92 mm Hg. His laboratory results revealed an A1C of 8.1%,
| | | | | | | | | | | | |
normal cholesterol panel, and normal renal/hepatic function were noted with
| | | | | | | | | |
today's laboratory test results.
| | |
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia
| | | | | | | | |
(diagnosed 2 y ago) Pancreatitis (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 therapy 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
| | | | | | | | | | | | |
lifestyle modifications assuming no contraindications or intolerabilities are
| | | | | | | |
present upon evaluation. 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 risk 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 circumstance
| | | | | | | | | |
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 provide 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 associated with weight gain, negative effects on lipids and increased risk
| | | | | | | | | | | | |
of fracture. Until recently, TZDs 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 also have the potential to cause hypoglycemia, so patient education is
| | | | | | | | | | | | |
crucial. Because of his allergies 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 hypoglycemic 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 prescription 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 feels 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 two he develops what he will later describe as
| | | | | | | | | | | | |
|"belching, nausea and a bad bloated feeling". Several 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
| | | | | | | | | | | |
appears as if the lesions had been literally stretched apart causing additional
| | | | | | | | | | | |
tissue damage. What 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 cause gastric
| | | | | | | | | | | | | | | |
distention, belching and nausea. The reaction is fairly swift allowing little time for
| | | | | | | | | | | | |
dissipation. Tums, its primary ingredient calcium carbonate which when taken
| | | | | | | | | |
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 40 minutes every day of
| | | | | | | | | | |
the week. She states compliance with all medications. She denies any history of
| | | | | | | | | | | | | |
hypoglycemia despite being able to identify signs and symptoms and describe
| | | | | | | | | | |
appropriate 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 mg 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 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. |
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to
| | | | | | | | | | |
hyperkalemia which could be made worse by this drug. The package insert does
| | | | | | | | | | | | |
not indicate a specific potassium concentration 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 currently the patient does not have any cautionary
| | | | | | | | | | | | |
objective measures to not use this medication. 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 significant 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 therefore 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 prediabetes (at risk for developing diabetes) 5 years before
| | | | | | | | | | | |
the diagnosis and has a strong family history of type 2 diabetes. JR's blood
| | | | | | | | | | | | | |
pressure was 150/92 mm Hg. His laboratory results revealed an A1C of 8.1%,
| | | | | | | | | | | | |
normal cholesterol panel, and normal renal/hepatic function were noted with
| | | | | | | | | |
today's laboratory test results.
| | |
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia
| | | | | | | | |
(diagnosed 2 y ago) Pancreatitis (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 therapy 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
| | | | | | | | | | | | |
lifestyle modifications assuming no contraindications or intolerabilities are
| | | | | | | |
present upon evaluation. 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 risk 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 circumstance
| | | | | | | | | |
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 provide 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 associated with weight gain, negative effects on lipids and increased risk
| | | | | | | | | | | | |
of fracture. Until recently, TZDs 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 also have the potential to cause hypoglycemia, so patient education is
| | | | | | | | | | | | |
crucial. Because of his allergies 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 hypoglycemic 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 prescription 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 feels 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 two he develops what he will later describe as
| | | | | | | | | | | | |
|"belching, nausea and a bad bloated feeling". Several 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
| | | | | | | | | | | |
appears as if the lesions had been literally stretched apart causing additional
| | | | | | | | | | | |
tissue damage. What 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 cause gastric
| | | | | | | | | | | | | | | |
distention, belching and nausea. The reaction is fairly swift allowing little time for
| | | | | | | | | | | | |
dissipation. Tums, its primary ingredient calcium carbonate which when taken
| | | | | | | | | |
