NR566 Midterm study guide with complete solutions

Bioavailability of bisphosphonate drugs and appropriate patient education Histamine2 blocking agents double alendronate bioavailability, but the impact is unknown. Aspirin may decrease the bioavailability of tiludronate by up to 50% when taken 2 hours after the tiludronate. Although indomethacin increases the bioavailability of tiludronate by 2- to 4-fold, the bioavailability is not significantly altered by diclofenac; therefore, each NSAID must be considered individually. Adverse effects associated with long-term use of bisphonates Etidronate has also been associated with fractures in patients with Paget's disease when they are given high doses or when therapy lasted longer than 6 months. These patients must be carefully monitored with x-rays and laboratory work to assess for these lesions. The development of a rare form of subtrochanteric femur fracture in non-Paget's patients using bisphosphonates is under close scrutiny and has contributed to movement away from osteopenia prevention care to only osteoporosis therapy (FDA, 2010a). 00:03 01:40 Specifics about administration and education regarding pancreatic enzymes All doses are taken immediately before or with meals or snacks with a fatty component. Fruit, hard candy, fruit juice like drinks, tea or coffee, or popsicles do not require enzymes (CFF, 2009). Capsules may be opened and sprinkled on food. Capsules with enteric-coated beads should not be chewed. They may be sprinkled on soft acidic food that is not hot and that can be swallowed without chewing, such as applesauce or gelatin. Swallow immediately because the proteolytic enzymes may irritate the mucosa. Following with a glass of water or juice or eating immediately after taking the drug helps to ensure that the medication is swallowed and does not remain in contact with the mouth and esophagus for long periods. Pancrelipase is destroyed by acid. Proton pump inhibitors, sodium bicarbonate, or aluminum-based antacids may be used with preparations without enteric coating to neutralize gastric pH. Calcium- and magnesium-based antacids should not be used for this purpose because they interfere with drug action. Enteric-coated beads are designed to withstand the acid pH of the stomach. Enteric-coated formulations should not be mixed with alkaline food or the coating will be destroyed. Common adverse effects with aromatase inhibitors Adverse effects for the drug class include various pain syndromes, vertigo, insomnia resulting in daytime sleepiness and confusion, increased risk of blood clots, and hair loss. A key concern is the loss of bone mass. Bone loss can be significant when considering the concurrent osteoporotic risks of postmenopause. Closer monitoring is required. All patients should be on calcium and vitamin D supplementation. A relative leukopenia can occur, but the incidence of viral and bacteria infections is not considered greater than matched groups (about 10%). Hypertension occurs in 10% of patients. A life-threatening increase in blood clotting can result in MI, stroke, or pulmonary embolus. Hot flashes can be intense. Drugs associated risk for bone loss which should be monitored Aromatase inhibitors Thyroid hormones Glucocorticoids PPIs SSRIs Clinical signs and symptoms DM Increased thirst Frequent urination Extreme hunger Unexplained weight loss Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin) Fatigue Irritability Blurred vision Slow-healing sores Frequent infections, such as gums or skin infections and vaginal infections Risk factors & associated complications of DM Complications: stroke, heart attack, peripheral artery disease, diabetic retinopathy, cataracts, glaucoma, diabetic nephropathy, peripheral neuropathy, diabetic foot. Risk factors: 45 years old, physical inactivity, 1st degree relative relative with DM, high risk ethic group (african american, hispanic, native american, asian american, and pacific islander), hx of gest DM, htn, HDL 35, triglycerides 250, polycystic ovarian syndrome, acanthosis nigricans, hx of cardiovascular disease. Diagnostic criteria of DM Acute symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dL. *Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes are polyuria, polydipsia, and unexplained weight loss. Fasting plasma glucose ≥126 mg/dL. * Fasting is defined as no caloric intake for at least 8 h. 2-h postload plasma glucose in an oral glucose tolerance test ≥200 mg/dL. The test uses a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. Hb A1c ≥6.5%. PRE-DIABETES: Fasting plasma glucose 100-125 mg/dL (IFG) or plasma glucose 140-199 mg/dL (IGT) 2 hr post-ingestion of standard glucose load (75 g) or Hb A1c 5.7%-6.4% Criteria for screening asymptomatic adults Individuals ≥45 yr and who have a BMI ≥25 kg/m2 should be tested. If normal, the test should be repeated at 3 yr intervals. Individuals 45 yr and who have a BMI ≥25 kg/m2 and have additional risk factors should have more frequent testing. Additional risk factors are the following: • Physically inactive • First-degree relative with diabetes • Members of high-risk ethnic group (African American, Hispanic, Native American, Asian American, Pacific Islander) • Delivered a baby weighing 9 lb or previously diagnosed with GDM • Hypertensive (B/P ≥140/90 mm Hg) • HDL cholesterol ≤35 mg/dL and/or triglyceride level ≥250 mg/dL • Have polycystic ovary syndrome (PCOS) • IGT or IFG on previous testing • Have other clinical conditions associated with insulin resistance (PCOS or acanthosis nigricans) • History of CVD Rapid Acting Insulin Humalog, Novolog, Apidra Short Acting Insulin Regular (Humulin R, Novolin R) Intermediate Acting Insulin Isophane (NPH, Humulin N) Long Acting Insulin Lantus, Levimir Fixed Combo Insulin 70/30 (NPH/regular ratio) 50/50 (NPH/regular ratio) 75/25 (NPH/lispro) 70/30 (NPH/aspart) A1C Treatment Goal Less than 7% Daily dose of insulin for initiation 0.1/kg or 10 units Insulin Treatment Algorithm for Type 1 DM Total daily insulin requirement is 0.3 to 0.5 units/kg body weight/d with titration to glycemic targets. Higher doses for acute illness. Adjustments made after reviewing patterns over 3 days. Hypoglycemia addressed first, then hyperglycemia. Adjustments up or down done in increments of 1 unit. A1C monitoring during oral or insulin diabetes management Because Hb A1c reflects mean glycemia over the preceding 2 to 3 months, it should be measured at least twice a year if patients are meeting treatment goals or have stable glycemic control; it should be measured every 3 months if therapy has changed or if patients are not meeting treatment goals Correlate mean plasma glucose level according to A1C Hemoglobin A1c Levels Mean Plasma Glucose (mg/dL) 6= 126 7= 154 8= 183 9= 212 10= 240 11= 269 12= 290 Clinical manifestations of diabetic autonomic neuropathy Resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sweat gland dysfunction, impaired neurovascular function, and the potential for autonomic failure in response to hypoglycemia. Hypoglycemia treatment (amount of carbohydrates and examples) They should take 15 gm of carbohydrate and recheck their sugars in 15 minutes. Drug monitoring with metformin Monitor B12 levels Antidiabetic medications associated with photosensitivity Sulfonylureas Antidiabetics to avoid in the elderly & why Sulfonylureas produces severe hypoglycemia. Glimepiride produces hypoglycemia. Glyburide is the most likely to cause hypoglycemia. Metformin due to older adults often have renal insufficiency or heart failure. Alpha-glucosidase inhibitors are not well tolerated. All meds should be started at the lowest possible dose. Improving patient compliance with diabetes treatment Nonadherence to the treatment regimen may result in increased risk for complications and reduced life expectancy. Healthcare providers should be aware of potential problems with nonadherence, discuss the importance of adherence at each follow-up visit, and assist patients in removing barriers to adherence such as lack of social support and cost of the treatment regimen. A team approach with the patient as an active partner should be maximized. Ways to deal with nonadherence are discussed in Chapter 6. Patient education booklets are available from the ADA, which can be accessed on the Internet at . Diabetic medications to avoid when taking digoxin Metformin - dig may increase the effect of metformin leading to lactic acidosis. Diabetic medications with need for renal dose adjustment Metformin Diabetic medications associated with increased risk for genital mycotic infections Selective Sodium Glucose Co-transporter 2 (SGLT-2) Time anticipated for total reversal of hyperthyroid symptoms with methimazole A treatment typically requires 6 to 12 months for total reversal of hyperthyroid symptoms. Routine testing with drug therapy TSH and free T4 levels Every 4 to 8 weeks until euthyroid During pregnancy evaluate at 8 weeks' and 6 months' gestation Recommend dietary iodine intake 100-150 mcg/day for normal thyroid function Drugs that increase metabolism of T4 Carbamazepine, Phenytoin Symptoms of Hyperthyroidism increased CO, decreased peripheral vascular resistance, tachycardia at rest, arrhythmias, dyspnea and reduced vital capacity, increased appetite with weight loss, diarrhea, nausea, vomiting, abdominal pain, sweating, flushing warm skin, hair loss, nails grow away from nail beds, oligo/amenorrhea, impotence/decreased libido in men, restlessness, short attention span, fatigue, insomnia, emotional lability, enlarged gland. Symptoms of Hypothyroidism reduced stroke volume and HR, increased peripheral resistance to maintain B