NSG533|NSG 533 Advanced Pharmacology Test 1 Week
4 Questions and 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, BUN - 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 diabet - 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? - 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
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 effects of all his other medications
and plasma levels of those medications elevated. What was most likely the
medication he took? - ANSWER Cimetidine
What lifestyle modifications should be recommended? - ANSWER -losing weight if
overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
What medications / foods can contribute to GERD? - ANSWER -Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, progesterone,
theophylline, nitrates
-Foods: cirus fruits/juices, coffee, tomatoes, spicy food, carbonated drinks
Fried/fatty foods, garlic, onions, chocolate
What is the most effective PPI or H2RA within each of these classes? - ANSWER -
PPI- bismuth quadruple therapy combined with proton pump inhibitors
-H2RA- Famotidine 80mg
Other products such as antacids are also available. What are some of these and
what is their place in therapy? - ANSWER -Reflux symptoms <2 times a week
(infrequent)
-Effective for immediate relief
-Magnesium/Aluminum Hydroxide (Maalox)- can cause constipation
-Alginic Acid
4 Questions and 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, BUN - 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 diabet - 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? - 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
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 effects of all his other medications
and plasma levels of those medications elevated. What was most likely the
medication he took? - ANSWER Cimetidine
What lifestyle modifications should be recommended? - ANSWER -losing weight if
overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
What medications / foods can contribute to GERD? - ANSWER -Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, progesterone,
theophylline, nitrates
-Foods: cirus fruits/juices, coffee, tomatoes, spicy food, carbonated drinks
Fried/fatty foods, garlic, onions, chocolate
What is the most effective PPI or H2RA within each of these classes? - ANSWER -
PPI- bismuth quadruple therapy combined with proton pump inhibitors
-H2RA- Famotidine 80mg
Other products such as antacids are also available. What are some of these and
what is their place in therapy? - ANSWER -Reflux symptoms <2 times a week
(infrequent)
-Effective for immediate relief
-Magnesium/Aluminum Hydroxide (Maalox)- can cause constipation
-Alginic Acid
