NR 566 Week 1 to 3 Midterm Exam Review (Q
& A)
Please give all credit to these responses to my classmates in Professor Halls
class!!! Hope this helps in reviewing for our midterm!! Sorry for the late
submission! Good luck everyone
Week 1
Professor question: Why are statins recommended in the evening instead
of morning? (pg 561)
After starting John on insulin, he calls the office saying he feels bad. He said
when he checked his blood sugar before calling it was 52 mg/dl. What
instructions should he be given?
Answer from classmate: Statins are recommended to be taken in the evening.
Cholesterol synthesis is highest through the night and first thing in the
morning. The biosyntheses of cholesterol follows a normal circadian rhythm.
Administration at night allows for the medication to be at peak levels in the
body during the time of high cholesterol synthesis (Korani et al., 2019).
A blood glucose level <70mg/dL is considered to be hypoglycemia. John
called the office with a sugar of 52mg/dL. He would be given instructions
that follow "the rule of 15". This means that when symptoms occur, he
should consume 15 g of a fast-acting carbohydrate. After 15 minutes, he
should recheck his blood glucose. John should also be educated on the best
options of carbohydrates to consume. Examples would be 4 oz of juice,
four-five hard candies, honey, or half a can of regular soft drink. Another
education point is that John needs to have a meal within a few hours after
the low blood glucose. He may also need to see his doctor for adjustments
to be made on insulin dosage as well as meal patterns to help prevent
another low blood glucose episode from occurring (Woo & Robinson, 2016).
Professor question: What diabetic medications would be contraindicated in
patients with heart failure?
Which diabetic drug(s) may have beneficial effects in heart failure?
(text has info on this but ADA 2020 guidelines has even more up to date
info on this topic, so here is the page. See Recommendation 9.9 and
9.10)
https://care.diabetesjournals.org/content/43/Supplement_1/S98
answer from classmate: Suppose John was showing signs of heart failure. What
diabetic medications would be contraindicated in patients with heart failure?
Metformin is contraindicated in patients with renal insufficiency and
,unstable heart failure (Woo & Robinson, 2016). According to the American
Diabetes Association (2020), Metformin can be utilized in patients with
stable heart failure, not currently hospitalized, and Glomerular filtration rate
should be greater than 30 ml per hour. In this instance, John should be
switched to fast acting insulin Humalog, to cover mealtimes
, and if his HgbA1C is not sufficiently controlled at the 3 month follow up then,
long acting Lantus insulin should be added to the regime. Additionally, John
should be placed on an Angiotensin Converting Enzyme inhibitor or
Angiotensin Receptor Blocker and likely increase his atorvastatin to 20mg
tablet (ADA, 2020).
Which diabetic drug(s) may have beneficial effects in heart failure?
With the scenario presented previously and with the addition of heart
failure, John should be placed on either a sodium-glucose cotransporter 2
inhibitor (SGLTi) or a glucagon-like peptide 1 receptor agonist (GLP-1 RA) to
improve glycemic management (ADA, 2020a). Both SGLT2i and GLP-1 RA
have demonstrated cardiovascular disease benefits by reducing CVD events
and HF hospitalizations in association with diabetes mellitus (ADA, 2020b).
The differential in which medication to use for John would be based on his
Glomerular Filtration Rate (GFR), decreasing GFR rates or worsening chronic
kidney disease would indicate stoppage of SGLT2i and use of GLP-1 RA. Per
the American Diabetes Association (2020), John with mild HF would be
initially placed on a GLP 1- RA Liraglutide (Victoza). Victoza is a once
daily injection that aids in treating T2DM by increasing insulin synthesis and
release, decreasing amount of glucagon and gastric emptying, and reducing
food intake (Woo & Robinson, 2016).
Additionally, placing John on a GLP-1 RA would help decrease his obesity
with its proven beneficial tendency to increase metabolism and improve
weight loss (Woo & Robinson, 2016).
Professor question: What lab do we need to check prior to starting metformin?
(hint: which organ function needs to be evaluated?)
What other potential adverse effects are there associated with metformin?
(Micromedex in the library is a good source for this info)
Answer: The most important lab is eGFR/renal function since this determines
whether we can safely use metformin. See recommendations below.
I also included information on contrast administration. The concern is that if
dye impairs renal function, the risk of lactic acidosis is increased.
Another potential adverse effect is B12 deficiency.
"Clinical recommendations based upon the patient’s renal function
• Before initiating therapy, obtain an eGFR
• Initiation of therapy is not recommended in patients with eGFR
between 30 –45 mL/minute/1.73 m²
• Obtain an eGFR at least annually in all patients receiving therapy
• In patients at increased risk for development of renal
impairment (e.g., the elderly), renal function should be assessed
more frequently
& A)
Please give all credit to these responses to my classmates in Professor Halls
class!!! Hope this helps in reviewing for our midterm!! Sorry for the late
submission! Good luck everyone
Week 1
Professor question: Why are statins recommended in the evening instead
of morning? (pg 561)
After starting John on insulin, he calls the office saying he feels bad. He said
when he checked his blood sugar before calling it was 52 mg/dl. What
instructions should he be given?
Answer from classmate: Statins are recommended to be taken in the evening.
Cholesterol synthesis is highest through the night and first thing in the
morning. The biosyntheses of cholesterol follows a normal circadian rhythm.
Administration at night allows for the medication to be at peak levels in the
body during the time of high cholesterol synthesis (Korani et al., 2019).
A blood glucose level <70mg/dL is considered to be hypoglycemia. John
called the office with a sugar of 52mg/dL. He would be given instructions
that follow "the rule of 15". This means that when symptoms occur, he
should consume 15 g of a fast-acting carbohydrate. After 15 minutes, he
should recheck his blood glucose. John should also be educated on the best
options of carbohydrates to consume. Examples would be 4 oz of juice,
four-five hard candies, honey, or half a can of regular soft drink. Another
education point is that John needs to have a meal within a few hours after
the low blood glucose. He may also need to see his doctor for adjustments
to be made on insulin dosage as well as meal patterns to help prevent
another low blood glucose episode from occurring (Woo & Robinson, 2016).
Professor question: What diabetic medications would be contraindicated in
patients with heart failure?
Which diabetic drug(s) may have beneficial effects in heart failure?
(text has info on this but ADA 2020 guidelines has even more up to date
info on this topic, so here is the page. See Recommendation 9.9 and
9.10)
https://care.diabetesjournals.org/content/43/Supplement_1/S98
answer from classmate: Suppose John was showing signs of heart failure. What
diabetic medications would be contraindicated in patients with heart failure?
Metformin is contraindicated in patients with renal insufficiency and
,unstable heart failure (Woo & Robinson, 2016). According to the American
Diabetes Association (2020), Metformin can be utilized in patients with
stable heart failure, not currently hospitalized, and Glomerular filtration rate
should be greater than 30 ml per hour. In this instance, John should be
switched to fast acting insulin Humalog, to cover mealtimes
, and if his HgbA1C is not sufficiently controlled at the 3 month follow up then,
long acting Lantus insulin should be added to the regime. Additionally, John
should be placed on an Angiotensin Converting Enzyme inhibitor or
Angiotensin Receptor Blocker and likely increase his atorvastatin to 20mg
tablet (ADA, 2020).
Which diabetic drug(s) may have beneficial effects in heart failure?
With the scenario presented previously and with the addition of heart
failure, John should be placed on either a sodium-glucose cotransporter 2
inhibitor (SGLTi) or a glucagon-like peptide 1 receptor agonist (GLP-1 RA) to
improve glycemic management (ADA, 2020a). Both SGLT2i and GLP-1 RA
have demonstrated cardiovascular disease benefits by reducing CVD events
and HF hospitalizations in association with diabetes mellitus (ADA, 2020b).
The differential in which medication to use for John would be based on his
Glomerular Filtration Rate (GFR), decreasing GFR rates or worsening chronic
kidney disease would indicate stoppage of SGLT2i and use of GLP-1 RA. Per
the American Diabetes Association (2020), John with mild HF would be
initially placed on a GLP 1- RA Liraglutide (Victoza). Victoza is a once
daily injection that aids in treating T2DM by increasing insulin synthesis and
release, decreasing amount of glucagon and gastric emptying, and reducing
food intake (Woo & Robinson, 2016).
Additionally, placing John on a GLP-1 RA would help decrease his obesity
with its proven beneficial tendency to increase metabolism and improve
weight loss (Woo & Robinson, 2016).
Professor question: What lab do we need to check prior to starting metformin?
(hint: which organ function needs to be evaluated?)
What other potential adverse effects are there associated with metformin?
(Micromedex in the library is a good source for this info)
Answer: The most important lab is eGFR/renal function since this determines
whether we can safely use metformin. See recommendations below.
I also included information on contrast administration. The concern is that if
dye impairs renal function, the risk of lactic acidosis is increased.
Another potential adverse effect is B12 deficiency.
"Clinical recommendations based upon the patient’s renal function
• Before initiating therapy, obtain an eGFR
• Initiation of therapy is not recommended in patients with eGFR
between 30 –45 mL/minute/1.73 m²
• Obtain an eGFR at least annually in all patients receiving therapy
• In patients at increased risk for development of renal
impairment (e.g., the elderly), renal function should be assessed
more frequently
