Advanced Pharmacology NSG 533 With Solution.
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.
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.
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?
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."
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)?
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)?
Loperamide
JA has multiple medical problems and is taking several drugs including theophylline, warfarin and
phenytoin. His conditions were well controlled, but recently he started to experience some GI distress
for which of his "well intentioned friends" gave him some medication. He presents to you with toxic
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.
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.
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?
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."
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)?
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)?
Loperamide
JA has multiple medical problems and is taking several drugs including theophylline, warfarin and
phenytoin. His conditions were well controlled, but recently he started to experience some GI distress
for which of his "well intentioned friends" gave him some medication. He presents to you with toxic
