Advanced Pharmacology NSG 533
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 16 mg/dL, SCr
0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to obtain an A1C goal
of less than 7% and would be appropriate in the patient? Please provide an explanation
of appropriateness or lack thereof. - 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 diabetes. Which drug therapy would be the best for JR
to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management. - 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. $$$
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic
control and may assist with weight loss goals for this patient. New information suggests
these agents may provide benefits in those with ASCVD. JR has a past history of
pancreatitis and GLP-1 analogs are not recommended due to this contraindication
TZDs have data to support an A1C reduction necessary to gain glycemic control, but
are associated with weight gain, negative effects on lipids and increased risk of fracture.
Until recently, TZDs have also been linked to increased CV events and use has fallen
out of favor
Sulfonylureas provide excellent A1C lowering, but are also associated with weight gain.
They also have the potential to cause hypoglycemia, so patient education is crucial.
Because of his allergies to "sulfa", use would be contraindicated
SGLT2 inhibitors have data to support an A1C reduction necessary to gain glycemic
control. In addition, they are associated with weight loss and blood pressure lowering.
New information demonstrates these agents may be beneficial in those with ASCVD,
heart failure and / or CKD. They are also associated with dyslipidemias as well. Prior to
starting therapy, renal function and electrolytes would have to be assessed. $$$
Based on the ASCVD recommendations (which are now paralleled by the 2015 ADA
recommendations), all patients with type I or II DM ages 40-75 should be on a moderate
intensity statin. If the patients 10 years ASCVD risk is greater than 7.5%, a high
intensity statin can be considered. Since all information needed to perform the estimate
, is not present, we can assume JR need at least moderate intensity statin. ACCE/ACE
guidelines still resemble those of ATPIII. Even so, the recommendation is for a statin
regardless of LDL-C in diabetics over 40 with at least 1 risk factor of ASCVD.
Options: atorvastatin 10mg, rosuvastatin 10, simvastatin 20-40, pravastatin 40,
lovastatin 40, fluvastatin 40.
An angiotensin-converting enzyme inhibitor and considered to be a drug of choice for
renal protection in patients with diabetes. ACEi and ARBs have demonstrated a
reduction in renal progression to overt proteinuria. African Americans may not see the
maximum effect of blood pressure lowering with ACEi due to a decreased amount of
renin. Combination therapy with a thiazide would be a reasonable add on
A patient with type 1 diabetes reports taking propranolol for hypertension. What concern
does this information present for the provider? - 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." -
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)? - 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 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 the strong opioid
analgesic meperidine (but acts only on the peripheral opioid receptor)? - Answer-
Loperamide
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 16 mg/dL, SCr
0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to obtain an A1C goal
of less than 7% and would be appropriate in the patient? Please provide an explanation
of appropriateness or lack thereof. - 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 diabetes. Which drug therapy would be the best for JR
to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management. - 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. $$$
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic
control and may assist with weight loss goals for this patient. New information suggests
these agents may provide benefits in those with ASCVD. JR has a past history of
pancreatitis and GLP-1 analogs are not recommended due to this contraindication
TZDs have data to support an A1C reduction necessary to gain glycemic control, but
are associated with weight gain, negative effects on lipids and increased risk of fracture.
Until recently, TZDs have also been linked to increased CV events and use has fallen
out of favor
Sulfonylureas provide excellent A1C lowering, but are also associated with weight gain.
They also have the potential to cause hypoglycemia, so patient education is crucial.
Because of his allergies to "sulfa", use would be contraindicated
SGLT2 inhibitors have data to support an A1C reduction necessary to gain glycemic
control. In addition, they are associated with weight loss and blood pressure lowering.
New information demonstrates these agents may be beneficial in those with ASCVD,
heart failure and / or CKD. They are also associated with dyslipidemias as well. Prior to
starting therapy, renal function and electrolytes would have to be assessed. $$$
Based on the ASCVD recommendations (which are now paralleled by the 2015 ADA
recommendations), all patients with type I or II DM ages 40-75 should be on a moderate
intensity statin. If the patients 10 years ASCVD risk is greater than 7.5%, a high
intensity statin can be considered. Since all information needed to perform the estimate
, is not present, we can assume JR need at least moderate intensity statin. ACCE/ACE
guidelines still resemble those of ATPIII. Even so, the recommendation is for a statin
regardless of LDL-C in diabetics over 40 with at least 1 risk factor of ASCVD.
Options: atorvastatin 10mg, rosuvastatin 10, simvastatin 20-40, pravastatin 40,
lovastatin 40, fluvastatin 40.
An angiotensin-converting enzyme inhibitor and considered to be a drug of choice for
renal protection in patients with diabetes. ACEi and ARBs have demonstrated a
reduction in renal progression to overt proteinuria. African Americans may not see the
maximum effect of blood pressure lowering with ACEi due to a decreased amount of
renin. Combination therapy with a thiazide would be a reasonable add on
A patient with type 1 diabetes reports taking propranolol for hypertension. What concern
does this information present for the provider? - 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." -
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)? - 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 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 the strong opioid
analgesic meperidine (but acts only on the peripheral opioid receptor)? - Answer-
Loperamide
