Advanced Pharmacology NSG 533 with questions and well stated 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, BU - 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 di - 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 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.
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, BU - 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 di - 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 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.
