NSG533 FINAL PAPER 2026 QUESTIONS
AND VERIFIED SOLUTIONS FULL STUDY
GUIDE RESOURCE
◉ What are the various types of oral and non-insulin medications
and what represents a rational combination of medications?.
Answer: Combinations should have different mechanism of action
Combinations should avoid overlapping ADRs
Combinations should ideally be selected based on need for better
basal vs post-prandial control
Selection should account for patient specific concerns (eg. weight,
CVD risk, etc)
◉ What antidiabetic medications have compelling indications:.
Answer: for those with underlying ASCVD or at high risk for CVD
for those with CKD
for those with a compelling need to avoid hypoglycemia
for those where weight is an important consideration (ie which are
associated with weight loss, gain or are weight neutral)
,◉ What are the various insulins and describe the pharmacokinetics
(onset, peak, duration)and how are they used (eg basal, basal-bolus,
split-mixed, sliding scale (..Ask if you don't understand))..
Answer: Basal-bolus (long acting basal + rapid/fast acting bolus)
provides the greatest flexibility and control of all regimens
Sliding Scale Should NOT be used
Difficult to do in home setting, requires education and
understanding of patient and caregiver
Allows patient to become hyperglycemic, better to schedule dosing
and prevent rises in BG
Requires frequent blood glucose monitoring, $$$ and compliance
issues
◉ Can be used as monotherapy or as add-on therapy for T2DM ..
Presenting A1C of 9 + symptoms or failure to achieve goal A1C on
adequate trial of 2-3 agents at maximally tolerated doses.
Answer: Often starting with a long acting insulin
When glycemic goals aren't reached despite basal insulin (Good FBG
and pre-prandial BG, but elevated HbA1C), Consider prandial
therapy with fast-acting insulin. Begin fast-acting insulin before
largest meal.Variation exists between ADA and ACCE in their
recommendations
If HbA1C still elevated, add fast-acting to another mealSulfonylurea
can continue up until the point where prandial (rapid) insulin is
addedMetformin can / should continue !!
,◉ What agents are used to treat hypothyroid disease? What makes
the medications different and what do the guidelines recommend for
use.
Answer: Recommendation 22.1: Patients with hypothyroidism
should be treated with Levothyroxine monotherapy. Grade Aother
forms of thyroid replacement may be associated with necessary cost,
lack of therapeutic rationale, increase adverse effects and
allergenicity (animal based products)
Starting therapyNormal adult dose: 1.6 mcg/kg/day (~100-125
mcg/day) based on IBW (LBW)Titration by 25-50 mcg every 4-6
weeks until TSH normalizesEXCEPTIONS include elderly, chronically
ill patients or history of cardiovascular disease . Initially 12.5-25
mcg/day, then titrate to maintenance dose until TSH
normalizesExpect higher requirements during pregnancyThyroid
hormone demandIncreases in TBGDestruction of T4 by placental
deiodinases
◉ How is treatment monitored and how should results be
interpreted as far as therapy changes (the relationship between TSH
and T3-4).
Answer: Monitoring should be every 6-8 weeks after starting or
dose/product change. If TSH is not in target range (0.5-2.5 mIU/L)
alter dose in 10% to 20% increments. ..
levothyroxine has a T 1/2 of 6-10 days (and NTI .. see below). How
does this relate to the fact that after initiating or changing a does or
, changing a product (IE brand to generic, generic to brand or one
generic brand to another), TSH should be checked in about 6 weeks?
◉ Why are thyroid replacement drugs considered to have a narrow
therapeutic index ( NTI )and what does that mean clinically?.
Answer: The therapeutic index (TI) is the range of doses at which a
medication is effective without unacceptable adverse events. Drugs
with a narrow TI (NTIs) have a narrow window between their
effective doses and those at which they produce adverse toxic
effects. Oral Bioavailability: (erratic) 40-80%brand vs generic Highly
protein bound (99%)Half-lifeEuthyroid = 6-7 daysHypothyroid = 9-
10 daysSteady State: @ 6 weeks or 4-5 t1/2 's ... this is the bases for
monitoring @ six weeks from start or changes!
Consider changes such as brand to generic, different generics
manufactures, different pharmacies, etcAny such change will require
repeat lab monitoring @ ~ 6 weeks to confirm the same clinical
response
◉ What are some drug-drug, drug-food interactions associated with
thyroid replacement.
Answer: drug binding interactions, di-valent cations, amiodarone,
certain antibiotics
◉ RECOMMENDATION 13 Methimazole should be used in virtually
every patient who chooses antithyroid drug therapy for GD, except
during the first trimester of pregnancy when propylthiouracil is
AND VERIFIED SOLUTIONS FULL STUDY
GUIDE RESOURCE
◉ What are the various types of oral and non-insulin medications
and what represents a rational combination of medications?.
Answer: Combinations should have different mechanism of action
Combinations should avoid overlapping ADRs
Combinations should ideally be selected based on need for better
basal vs post-prandial control
Selection should account for patient specific concerns (eg. weight,
CVD risk, etc)
◉ What antidiabetic medications have compelling indications:.
Answer: for those with underlying ASCVD or at high risk for CVD
for those with CKD
for those with a compelling need to avoid hypoglycemia
for those where weight is an important consideration (ie which are
associated with weight loss, gain or are weight neutral)
,◉ What are the various insulins and describe the pharmacokinetics
(onset, peak, duration)and how are they used (eg basal, basal-bolus,
split-mixed, sliding scale (..Ask if you don't understand))..
Answer: Basal-bolus (long acting basal + rapid/fast acting bolus)
provides the greatest flexibility and control of all regimens
Sliding Scale Should NOT be used
Difficult to do in home setting, requires education and
understanding of patient and caregiver
Allows patient to become hyperglycemic, better to schedule dosing
and prevent rises in BG
Requires frequent blood glucose monitoring, $$$ and compliance
issues
◉ Can be used as monotherapy or as add-on therapy for T2DM ..
Presenting A1C of 9 + symptoms or failure to achieve goal A1C on
adequate trial of 2-3 agents at maximally tolerated doses.
Answer: Often starting with a long acting insulin
When glycemic goals aren't reached despite basal insulin (Good FBG
and pre-prandial BG, but elevated HbA1C), Consider prandial
therapy with fast-acting insulin. Begin fast-acting insulin before
largest meal.Variation exists between ADA and ACCE in their
recommendations
If HbA1C still elevated, add fast-acting to another mealSulfonylurea
can continue up until the point where prandial (rapid) insulin is
addedMetformin can / should continue !!
,◉ What agents are used to treat hypothyroid disease? What makes
the medications different and what do the guidelines recommend for
use.
Answer: Recommendation 22.1: Patients with hypothyroidism
should be treated with Levothyroxine monotherapy. Grade Aother
forms of thyroid replacement may be associated with necessary cost,
lack of therapeutic rationale, increase adverse effects and
allergenicity (animal based products)
Starting therapyNormal adult dose: 1.6 mcg/kg/day (~100-125
mcg/day) based on IBW (LBW)Titration by 25-50 mcg every 4-6
weeks until TSH normalizesEXCEPTIONS include elderly, chronically
ill patients or history of cardiovascular disease . Initially 12.5-25
mcg/day, then titrate to maintenance dose until TSH
normalizesExpect higher requirements during pregnancyThyroid
hormone demandIncreases in TBGDestruction of T4 by placental
deiodinases
◉ How is treatment monitored and how should results be
interpreted as far as therapy changes (the relationship between TSH
and T3-4).
Answer: Monitoring should be every 6-8 weeks after starting or
dose/product change. If TSH is not in target range (0.5-2.5 mIU/L)
alter dose in 10% to 20% increments. ..
levothyroxine has a T 1/2 of 6-10 days (and NTI .. see below). How
does this relate to the fact that after initiating or changing a does or
, changing a product (IE brand to generic, generic to brand or one
generic brand to another), TSH should be checked in about 6 weeks?
◉ Why are thyroid replacement drugs considered to have a narrow
therapeutic index ( NTI )and what does that mean clinically?.
Answer: The therapeutic index (TI) is the range of doses at which a
medication is effective without unacceptable adverse events. Drugs
with a narrow TI (NTIs) have a narrow window between their
effective doses and those at which they produce adverse toxic
effects. Oral Bioavailability: (erratic) 40-80%brand vs generic Highly
protein bound (99%)Half-lifeEuthyroid = 6-7 daysHypothyroid = 9-
10 daysSteady State: @ 6 weeks or 4-5 t1/2 's ... this is the bases for
monitoring @ six weeks from start or changes!
Consider changes such as brand to generic, different generics
manufactures, different pharmacies, etcAny such change will require
repeat lab monitoring @ ~ 6 weeks to confirm the same clinical
response
◉ What are some drug-drug, drug-food interactions associated with
thyroid replacement.
Answer: drug binding interactions, di-valent cations, amiodarone,
certain antibiotics
◉ RECOMMENDATION 13 Methimazole should be used in virtually
every patient who chooses antithyroid drug therapy for GD, except
during the first trimester of pregnancy when propylthiouracil is
