Pharm Exam 3 Study Guide Revised .docx

**NURS 615: Advanced Pharmacology Summer 2024** **Exam 3 Personal Study Guide** **Corticosteroids** - **MOA** - **Inhibits gene transcription for COX-2 cytokines, cell adhesion molecules, and inducible nitric oxide synthase** - **Creates multi-level suppression of inflammation** - Inhibit arachidonic acid metabolism - Strengthen biologic membranes - Inhibit production of interleukin-1, tumor necrosis factor and other cytokines - Impairs phagocytosis and lymphocytes - Inhibits tissue repair - **Scheduling** - Short-term: divided doses for 48-72 hours, then taper till discontinued - Replacement therapy: daily admin between 0600-0900 - Alternate-day therapy: double dose taken QOD in the morning (maintenance therapy) - **Side effects** - HTN, weight gain, muscle weakness, insomnia, systemic immunosuppressant, potential for decreased wound healing and increased infections, hyperglycemia, increased intra-ocular pressure, mood changes, peripheral edema, easy bruising, adrenal suppression (Malaise, myalgia, hypotension, fever) - **Monitor/ teaching** - Monitor blood sugars for hyperglycemia - Patient may need vitamin D and calcium phosphate to prevent osteoporosis (long term use) - Report black/tarry stools and abdominal pain - Adrenal suppression with long term therapy -- DO NOT STOP ABRUPTLY - Taper to decrease withdraw symptoms - Malaise, myalgia, nausea, headache, low grade fever, relapse of symptoms, hypotension - Need to prescribe PPI with long term use or if corticosteroid is \>1GM to protect stomach - Do not take with active infections: may worsen fungal infections - **Hydrocortisone**---exogenous equivalent of endogenous cortisol; duration of action varies - [Use]: Anti-inflammatory - [Route]: varies - [MOA]: bind to glucocorticoid receptors in target tissues - **Prednisone** - [Use:] replacement tx. for adrenal cortical insufficiency, asthma, allergic/anaphylactic reactions, collagen disease, COPD, RA, hematologic disorders, ulcerative colitis & crohn's, neoplastic disease, dermatology - [Administration Guidelines]: 1 dose daily or QOD in the morning; taper down when discontinuing - [Patient Teaching:] never stop abruptly, Zantac or Prilosec to prevent GI irritation, assess for wound healing and s/sx of infections, diabetics may need to take more insulin - [SE:] suppression of normal response to infection, ↑risk for infections (TB, herpes, varicella), GI (n/v, ulcers), skin (acne, delayed wound healing), Ca+ loss and ↑risk for fractures, sodium/fluid retention, anxiety, insomnia, ↑blood glucose - **Methylprednisolone (Medrol):** poison ivy - **Methylprednisolone sodium succinate (Solumedrol):** short-term IV for acute problems - **Dexamethasone:** short-term maximum anti-inflammatory activity - **Topical** - **Joint injection:** pain control; tissue damage if given too often **[GOUT]** Form of arthritis caused by hyperuricemia with deposition of urate crystals in various tissues - Four Phases 1. [Asymptomatic hyperuricemia]---no treatment required; diet and lifestyle changes to lower urate levels 2. [Acute gouty arthritis]---sudden onset of pain, erythema, limited ROM, swelling in involved joint 3. [Inter-critical gout] 4. [Chronic tophaceous gout] - Management of acute pain---most often with NSAIDS and corticosteroids - Xanthine oxidase---enzyme responsible for the conversion of hypoxanthine and xanthine to uric acid **[Antigout Drugs]** - **Xanthine Oxidase Inhibitors**---reduce the inflammatory process or prevent synthesis or uric acid - **Allopurinol (Zyloprim)** - [Use:] chronic management of hyperuricemia - [MOA:] competitive inhibitor of XO enzyme; decreases total purine production; inhibits synthesis of uric acid by inhibiting xanthine oxidase conversion of hypoxanthine and xanthine to uric acid - [Side effects:] rare occurrence of severe allopurinol hypersensitivity syndrome, skin rash, flu symptoms, painful or little urination, drowsiness/ dizziness - [**STOP**:] **if maculopapular rash is seen** - [Monitor/ Teaching:] interactions with various antibiotics, anti-epilepsy drugs, immunosuppressants, warfarin and diuretics; renal dysfunction = dose modification, may rarely causes decrease blood counts, monitor liver and kidney function - [AVOID:] AZATHIOPRINE AND MERCAPTOPURINE AND ACE INHIBITORS - **Febuxostat** - [Use:] chronic management of hyperuricemia - [MOA:] same as allopurinol - [Side effects:] gout flares, nausea, mild rash, liver problems, heart attack symptoms - [Monitor /Teaching:] Symptoms may worsen initially, treat concurrently with NSAID or colchicine for up to 6 months, monitor liver (contraindicated with liver disease) and renal fx - [AVOID:] AZATHIOPRINE AND MERCAPTOPURINE - **Colchicine** - [Use:] *acute* gout flare-ups and flare-up prophylaxis; also Behcets syndrome - [MOA:] Binds to microtubular proteins; interferes w/ function of mitotic spindles & inhibit migration of granulocytes to inflamed area; reduces lactic acid production by granulocytes → decreases deposition of uric acid - [**Low Dose:**] 1.2mg initial dose and 0.6mg one hour later. Symptoms usually abate within 12 hours and gone within 24-48 hours \*Both cause diarrhea and low dose is as effective as high, so low dose is the go to\* - **[High Dose:]** used for recalcitrant cases; 0.6 to 1.2mg every 1 to 2 hours until relief is obtained or adverse reactions develop (total of 4 to 8mg maximum administration dosage) - [Side Effects:] GI distress/diarrhea (take with food to help) - [Monitor/ teaching:] check renal function prior to and during treatment, increase fluid intake, impaired renal or hepatic function requires dose reduction, AVOID NSAIDS & grapefruit juice - [Report IMMEDIATELY:] proximal muscle weakness, myalgia, and neuropathy (usually resolve in 3-4 weeks after stopping medication - **Uricosuric Drugs** - **Lesinurad**---used in combination with XO inhibitors; never used as monotherapy - **Probenecid** -- uric acid reducer; blocks transport of acidic media across transporters in the kidneys; NOT used in acute attacks, frequent urination, N/V, HA, skin rash - Not an anti-inflammatory, used for CHRONIC gout management - Monitor CBC for blood dyscrasias - Encourage fluids r/t risk of stone development & possible nephrolithiasis - Avoid: ASA and salicylates - Take medication with food or milk to reduce GI upset +-------------+-------------+-------------+-------------+-------------+ | **Drug** | **MOA** | **Side | **Monitorin | **Patient | | | | Effects** | g** | Teaching** | +=============+=============+=============+=============+=============+ | Allopurinol | Inhibit | Maculopapul | Uric Acid | DC at first | | | xanthine | ar | Levels | sign of | | | oxidase | skin rash, | | skin | | | | fever, | Liver/renal | reaction | | | | chills, | function, | | | | | arthralgia, | BUN, Cr, | Continue | | | | jaundice, | CrCl | w/colchicin | | | | eosinophili | | e | | | | a, | | if acute | | | | leukocytosi | | attack | | | | s, | | | | | | leukopenia | | | +-------------+-------------+-------------+-------------+-------------+ | Febuxostat | Inhibit | Nausea, | Uric Acid | Continue | | | xanthine | arthralgia, | Levels | w/colchicin | | | oxidase | hepatic | | e | | | | dysfunction | Liver | if acute | | | | | function | attack | +-------------+-------------+-------------+-------------+-------------+ | Colchicine | Binds to | N/V, | Uric Acid | Diarrhea | | | microtubula | [diarrhea]{ | Levels, | mgt during | | | r |.underline} | | acute | | | proteins; | , | B12, | attack | | | interferes | abdominal | renal/liver | | | | w/ function | pain | function | | | | of mitotic | | | | | | spindles & | | | | | | inhibit | | | | | | migration | | | | | | of | | | | | | granulocyte | | | | | | s | | | | | | to inflamed | | | | | | area; | | | | | | reduces | | | | | | lactic acid | | | | | | production | | | | | | by | | | | | | granulocyte | | | | | | s | | | | | | → decreases | | | | | | deposition | | | | | | of uric | | | | | | acid | | | | +-------------+-------------+-------------+-------------+-------------+ | Lesinurad | Changes | Cardiovascu | Uric Acid | Take with | | | uric acid | lar | Levels | food, ↑ | | | into inert | events | | fluids | | | chemicals | | | | | | to be | | | Take at | | | renally | | | same time | | | excreted | | | w/XO | | | | | | | | | | | | Avoid | | | | | | Aspirin | +-------------+-------------+-------------+-------------+-------------+ | Probenecid | Inhibit | N/V, | Uric Acid | Avoid | | | renal | diarrhea, | Levels | Aspirin; | | | tubular | abdominal | | ↑water | | | reabsorptio | pain, | Caution w/ | intake | | | n | anaphylaxis | sulfa | (risk | | | of urate; | , | allergy | kidney | | | ↑secretion | nephrolithi | | stones) | | | of uric | asis | CBC | | | | acid | | | | +-------------+-------------+-------------+-------------+-------------+ - **Non-Antigout Medications** - Goal for rapid reduction of pain and inflammation - NSAIDS---can replace use of colchicine within first 24hr Steroids **[OSTEOARTHRITIS & RHEUMATOID ARTHRITIS PAIN]** - **Osteoarthriti**s---pain to weight-bearing joints and repetitive use joints---chronic - Old age, trauma, repetitive use - Heberden's nodes, Bouchard's nodes - **Rheumatoid arthritis**---systemic autoimmune disease---inflammatory changes in joints (small joints of hands and feet) - Swan-neck deformity of fingers ![](media/image2.png) **Nonprescription---Osteoarthritis** - **Acetaminophen**---Highly selective cox-2 inhibitor, inhibit central and peripheral prostaglandin synthesis - [Use:] analgesic and antipyretic - [MOA:] not completely known; inhibits COX-2 - [Side Effects:] hypersensitivity, renal damage, anemia, thrombocytopenia, angioedema, SJS, and liver damage - [Dosage Guidelines:] (adult) Max dose is now *2gm every 24 hours* ([was] 4gm in 24 hours) - **Acute Overdose**: potential for fatal liver damage---gastric lavage and oral n-acetylcysteine - [Monitor/ Teaching:] do not give to patients with liver dx/ alcoholics - **[Black Box Warning]**: hepatic toxicity/hepatocellular necrosis - **[Antidote]**: Gastric lavage w/in 4 hours and oral n-acetylcysteine - **NSAIDs- (ibuprofen, naproxen, celecoxib, ketorolac, ASA)** - First line treatment of mild to moderate pain, inflammation - [MOA:] Inhibition of COX-1 & COX-2 pathways which decrease prostaglandin formation that causes pain response and inflammation. - **[Black Box Warning]**: increased risk for CV thrombosis, MI, and CVA; increased risk for GI bleeding, ulceration, and perforation of the stomach/intestines. Elderly at greater risk of GI events. - Drug interactions with warfarin (increased bleeding) - DO NOT GIVE IN PREGNANCY - **Ibuprofen** - [Use:] OTC management of mild to moderate pain, inflammation, and fever - [MOA:] Nonselective Cox 2 inhibitor, decreases prostaglandins, antipyretic - [Side Effects:] renal/liver impairment, N/V, rash - **[Black Box Warning]**: GI bleeding, thrombotic events - **Celecoxib (Celebrex):** less GI side effects - **Indomethacin**--- Tx acute gouty arthritis; can cause depression and psychosis; can help close patent ductus arteriosis - **Sulindac**-Tx acute gouty arthritis - **Aspirin**---monitor CBC and salicylate levels on long term therapy; tinnitus=toxicity; avoid 1 weeks prior to surgery; prescribe H2 blocker (ranitidine) if heartburn, decrease platelet aggregation - **Monitor for salicylism** - **Corticosteroids**---see page 1; utilized frequently for treatment of arthritis - **Analgesic: pregabalin** - [Tx] neuropathy, RLS, fibromyalgia, seizures - [MOA]: binds to calcium channels in CNS which decreases release of excitatory neurotransmitters - [SE]: drowsiness, dizziness, dry mouth, edema - [Monitor/ teaching:] no alcohol, taper down slowly **[PAIN]** **Opioid Analgesics** (regulated bye the DEA Controlled Substances Act) - Full agonists, partial agonists, and antagonists - Work on 3 types of opioid receptors - Mu---morphine---major analgesic receptor - Delta---spinal analgesia - Kappa-morphine and other high potency analgesics - Most opioids work on the Mu receptor in brain and spinal cord; metabolized in liver, excreted in urine - [MOA:] Enhance activity in descending aminergic pathways that exert inhibitory effects on the processing of nociceptive information in the spinal cord - CNS Effects: analgesia, euphoria, sedation, respiratory depression - Cough suppression (codeine) - Nausea and Vomiting - Cardiovascular Effects: bradycardia, vasodilation - GI Effects: constipation, decreased motility, increased stomach/intestinal tone, biliary constriction - GU Effects: decreased renal function - Hypothalamus: alters heat regulations - [Side Effects:] dysphoria, respiratory depression, N/V, constipation, urinary retention, hypotension, tolerance/dependence, psychological dependence - [Complications:] opioid toxicity → **Naloxone (Narcan) for reversal** - **Agonists** - **Morphine** - **Codeine (Tylenol \#3)** - **Hydrocodone (Vicodin, Lortab)** - **Oxycodone (Percocet, Oxycontin)** - **Mixed Agonist-Antagonist**---activate one receptor and block another - **Butorphanol (Stadol)** - **Nalbuphine (Nubain)** - **Non-Opioid Analgesic** - **Tramadol (Ultram)** - [Use:] mild to moderately severe pain - [MOA:] binds to Mu receptor; CYP metabolism - [Side Effects:] GI upset/obstruction/ileus, respiratory depression (with overdose & alcohol), tolerance & dependency - [Monitoring & Teaching:] monitor renal/hepatic function with long term use; taper off to avoid withdrawal symptoms **Legal/Ethical Considerations & Federal Regulations of Prescribing Controlled Substances** - Controlled Substances Act---1970---regulate the manufacture, importation, possession, use, and distribution of certain substances → DEA is responsible - Controlled Substance Scheduling - Providers must comply with federal and state regulations when prescribing **Drug Scheduling** ![](media/image4.png) **Schedule** **Description** **Examples** -------------- ------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- 1 Most potential for abuse and dependence heroin, LSD, marijuana, ecstasy, peyote 2 High potential for abuse and dependence---some medicinal qualities---no refills vicodin, cocaine, meth, oxycontin, Adderall 3 Moderate potential for abuse or dependence---acceptable medicinal qualities---prescription required tylenol w/codeine, ketamine, steroids, testosterone 4 Low potential for abuse or dependence---acceptable medicinal qualities---prescription required w/refills xanax, darvon, valium, Ativan, ambien, tramadol 5 Lowest potential for abuse or dependence---acceptable medicinal qualities---prescription required w/fewest refill regulations robitussin AC, Lomotil, motofen, lyrica A nursing student asks the nurse to explain the role of cyclooxygenase-2 (COX-2) and its role in inflammation. The nurse will explain that COX-2 converts arachidonic acid into a chemical mediator for inflammation. A nursing student asks how nonsteroidal antiinflammatory drugs (NSAIDs) work to suppress inflammation and reduce pain. The nurse will explain that NSAIDs inhibit cyclooxygenase that is necessary for prostaglandin synthesis. A patient is taking ibuprofen 400 mg every 4 hours to treat moderate arthritis pain and reports that it is less effective than before. What action will the nurse take? Counsel the patient to discuss a prescription NSAID with the provider. A patient who is taking aspirin for arthritis pain asks the nurse why it also causes gastrointestinal upset. The nurse understands that this is because aspirin inhibits both COX-1 and COX-2. A patient is taking aspirin to help prevent myocardial infarction and is experiencing moderate gastrointestinal upset. The nurse will contact the patients provider to discuss changing from aspirin to which drug? Enteric-coated aspirin A patient who is 7 months pregnant and who has arthritis asks the nurse if she can take aspirin for pain. The nurse will tell her not to take aspirin for which reason? It can result in adverse effects on her fetus. The nurse is performing a health history on a patient who has arthritis. The patient reports tinnitus. Suspecting a drug adverse effect, the nurse will ask the patient about which medication? Aspirin (Bayer) The nurse is teaching a patient about using high-dose aspirin to treat arthritis. What information will the nurse include when teaching this patient? You may need to stop taking this drug a week prior to surgery. A patient who takes high-dose aspirin to treat rheumatoid arthritis has a serum salicylate level of 35 mg/dL. The nurse will perform which action? Assess the patient for tinnitus. The nurse provides teaching for a patient who will begin taking indomethacin (Inderal) to treat rheumatoid arthritis. Which statement by the patient indicates a need for further teaching? I should take indomethacin on an empty stomach. The nurse is caring for a postpartum woman who is refusing opioid analgesics but is rating her pain as a 7 or 8 on a 10-point pain scale. The nurse will contact the provider to request an order for which analgesic medication? Ketorolac (Toradol) A patient who has osteoarthritis with mild to moderate pain asks the nurse about taking over-the-counter ibuprofen (Motrin). What will the nurse tell this patient? It may take several weeks to achieve therapeutic effects. The nurse is caring for a patient who has been taking an NSAID for 4 weeks for osteoarthritis. The patient reports decreased pain, but the nurse notes continued swelling of the affected joints. The nurse will perform which action? Notify the provider that the drug is not effective. The nurse is discussing celecoxib (Celebrex) with a patient who will use the drug to treat dysmenorrhea. What information will the nurse include in teaching? The initial dose will be twice the amount of subsequent doses. The nurse is caring for a patient who has rheumatoid arthritis and who is receiving infliximab (Remicade) IV every 8 weeks. Which laboratory test will the nurse anticipate that this patient will need? Complete blood count The nurse is teaching a patient about taking colchicine to treat gout. What information will the nurse include when teaching this patient about this drug? Increase fluid intake. Which antigout medication is used to treat chronic tophaceous gout? Allopurinol (Zyloprim) The nurse is assessing a patient who has gout who will begin taking allopurinol (Zyloprim). The nurse reviews the patients medical record and will be concerned about which laboratory result? Elevated BUN and creatinine The nurse provides teaching for a patient who will begin taking allopurinol. Which statement by the patient indicates understanding of the teaching? I will get yearly eye exams. Which are characteristic signs of inflammation? (Select all that apply.) A. Edema B. Erythema C. Heat Henry is 82 years old and takes two aspirin every morning to treat the arthritis pain in his back. He states the aspirin helps him to "get going" each day. Lately he has had some heartburn from the aspirin. After ruling out an acute GI bleed, what would be an appropriate course of treatment for Henry? Add an H2 blocker such as ranitidine to his therapy. The trial period to determine effective anti-inflammatory activity when starting a patient on aspirin for rheumatoid arthritis is: 4 to 6 days All nonsteroidal anti-inflammatory drugs (NSAIDS) have an FDA Black Box Warning regarding: Potential for causing life-threatening GI bleeds Jamie has fractured his ankle and has received a prescription for acetaminophen and hydrocodone (Vicodin). Education when prescribing Vicodin includes: He should not take any other acetaminophen-containing medications. Henry presents to clinic with a significantly swollen, painful great toe and is diagnosed with gout. Of the following, which would be the best treatment for Henry? Low-dose colchicine Patient education when prescribing colchicine includes: Colchicine always causes some degree of diarrhea. Larry is taking allopurinol to prevent gout. Monitoring of a patient who is taking allopurinol includes: BUN, creatinine, and creatinine clearance Phil is starting treatment with febuxostat (Uloric). Education of patients starting febuxostat includes: Febuxostat may cause severe diarrhea. Sallie has been taking 10 mg per day of prednisone for the past 6 months. She should be assessed for: Osteoporosis Patients whose total dose of prednisone will exceed 1 gram will most likely need a second prescription for: Omeprazole, a proton pump inhibitor to prevent peptic ulcer disease Daniel has been on 60 mg of prednisone for 10 days to treat a severe asthma exacerbation. It is time to discontinue the prednisone. How is prednisone discontinued? Develop a tapering schedule to slowly wean Daniel off the prednisone. Patients with rheumatoid arthritis who are on chronic low-dose prednisone will need co-treatment with which medications to prevent further adverse effects? A. A bisphosphonate B. Calcium supplementation C. Vitamin D D. All of the above Patients who are on or who will be starting chronic corticosteroid therapy need monitoring of Serum glucose Patients who are on chronic long-term corticosteroid therapy need education regarding: Reporting black tarry stools or abdominal pain When prescribing NSAIDS, a complete drug history should be conducted as NSAIDs interact with these drugs: Warfarin, an anticoagulant Josefina is a 2-year-old child with acute otitis media and an upper respiratory infection. Along with an antibiotic she receives a recommendation to treat the ear pain with ibuprofen. What education would her parent need regarding ibuprofen? Josefina needs to be well-hydrated while taking ibuprofen. **[DIABETES]** - **DM Type 1**---insulin dependent; body does not make enough insulin - polyuria, polydipsia, polyphagia - weight loss, fatigue, ↑infections, rapid onset, familial, peak incident 10-15 y.o.a. - **DM Type 2**---body does not utilize insulin appropriately or efficiently - Sedentary lifestyle, familial, avg. 50 y.o.a., ↑BP, fatigue, ↓energy, recurrent infection, polyuria, polydipsia - **Hypoglycemia**---dizziness, confusion, diaphoresis, tachycardia - **Hyperglycemia**---polyuria, polydipsia, weight loss - **DKA**---fruity/acetone breath, tachypnea (Kussmauls), lethargy, focal sign, obtundation, coma **Insulin-**used for DM I and II, start with daily dose of 0.2-0.4u/kg for DM type I - MOA: acts by increasing peripheral glucose by skeletal muscle and fat +---------+---------+---------+---------+---------+---------+---------+ | **Insul | **Onset | **Peak* | **Durat | **MOA** | **Side | **Pt. | | in** | ** | * | ion** | | Effects | Teachin | | | | | | | ** | g** | +=========+=========+=========+=========+=========+=========+=========+ | **Rapid | 0.2-0.5 | 1-2 | 3-5 | Binds | ↓glucos | | | ** | hours | hours | hours | to | e | | | | | | | glycopr | | | | Humalog | About | | | otein | ↓potass | | | /Lispro | 15 | | | recepto | ium | | | | minutes | | | r | | | | Novolog | | | | on | | | | /Aspart | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **Short | 30-60 | 3-4 | 3-7 | cell | ↓glucos | Take | | /Regula | minutes | hours | hours | surface | e | 30-45 | | r** | | | |. | | minutes | | | | | | | ↓potass | before | | Regular | | | | Increas | ium | eating | | /Humuli | | | | e | | | | n | | | | periphe | | | | R/Noval | | | | ral | | | | in | | | | | | | | R | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ | **Inter | 2-4 | 4-12 | 10-18ho | glucose | ↓glucos | Mix | | mediate | hours | hours | urs | uptake | e | before | | ** | | | | by | | injecti | | | | | | | ↓potass | on | | NPH | | | | | ium | | +---------+---------+---------+---------+---------+---------+---------+ | **Long* | 3-4 | None | Up to | skeleta | ↓glucos | | | * | hours | | 24 | l | e | | | | | | hours | muscle | | | | Lantus/ | | | | and | ↓potass | | | Glargin | | | | fat. | ium | | | e | | | | | | | | | | | | | | | | Levemir | | | | | | | | /Detemi | | | | | | | | r | | | | | | | +---------+---------+---------+---------+---------+---------+---------+ - When changing from NPH to Glargine, initial dose should be decreased by 20% to avoid hypoglycemia **How long is insulin stable at room temperature once opened? ** A. 3 months B. 7 days C. 30 days D. 14 days **A 48-year-old new patient admission has been added to the APN's schedule. She has a history of latent autoimmune diabetes in adults (LADA). She is currently utilizing a mixed insulin twice a day and a rapid-acting insulin (RAI) with meals according to her sliding scale. Her fasting blood glucose is 95 mg/L and the HbA1C is 6.5%. Which action taken by the APN today would be most appropriate? ** A. The APN would indicate that no adjustments are needed. B. The APN would change to basal bolus method. C. The APN would request additional information before making changes at this appointment. D. The APN would instruct the patient to include RAI before meals. **To be considered for insulin pump therapy, the patient should at least be able to do which of these? ** A. Monitor blood sugar once a day to verify continuing glucose monitor B. Monitor blood sugar eight times a day C. Monitor blood sugar when fasting D. Monitor blood sugar three times a day and when necessary **A 48-year-old patient with a history of type 2 diabetes mellitus (DM) has questions about the initiation of insulin. The patient is told that exogenous insulin lowers blood glucose by which mechanism? ** A. Inhibiting the storage of glucose as glycogen B. Stimulating glucose production in the liver C. Decreasing fat storage D. Stimulating glucose entry into the cell **Which insulin injectable has the shortest onset of action? ** A. Regular insulin B. Lispro C. Insulin glargine D. Inhaled human insulin **A 32-year-old male patient with type 2 diabetes mellitus (DM) reports a recent episode of hypoglycemia in the morning. The APN is reviewing the medications and decides that adjustment of which medication would be most appropriate? ** A. Insulin detemir B. Sitagliptin C. Glyburide D. Insulin lispro **Patients who require exogenous insulin should be cautioned to drink alcohol in moderation, because alcohol can have which effect? ** A. Increase the risk of cardiovascular disease B. Result in 25% weight increase C. Mask the symptoms of diabetes D. Increase blood glucose levels **A patient with a history of latent autoimmune diabetes in adults (LADA), coronary artery disease (CAD), and peripheral arterial disease (PAD) presents to the office with uncontrolled glucose levels. The APN considers switching the patient from a premixed insulin preparation to a basal-bolus insulin combination for which reason? ** A. This combination lowers exogenous insulin requirements. B. This combination increases the number of insulin receptors. C. This combination mimics endogenous insulin production. D. This combination decreases cardiovascular risk. **Which medication is preferred for the treatment of gestational diabetes? ** A. Regular insulin B. Insulin glargine C. Human inhaled insulin D. Metformin **The patient is scheduled for a cardiac catheter this morning and has been NPO since midnight. He has a 10-year history of latent autoimmune diabetes in adults (LADA) and is currently on a basal/bolus regimen with good control. The blood glucose this morning is 170 mg/dL. The APN is writing orders for the procedure when the RN asks about the insulin dose this morning. Which action is most appropriate for the APN to instruct the RN to take? ** A. Hold the morning dose of insulin because the patient administered insulin detemir the previous night. B. Administer the usual dose of 15 units of Humulin Lispro. C. Give an oral antidiabetic medication with a sip of water. D. Reduce the Humulin Lispro insulin dose to 5 units. **Intensive insulin regimens have proven their effectiveness with the greatest impact on lowering blood glucose. Which of these is an intensive insulin regimen? ** A. Humalog 70/30 subcutaneously twice a day B. Metformin bid and Novolin 75/25 daily at bedtime C. Insulin glargine 10 daily at bedtime and insulin lispro 5 units before each meal D. Neutral protamine Hagedorn (NPH) subcutaneously every evening **A 78-year-old patient with a history of uncontrolled type 2 diabetes mellitus (DM), diabetic retinopathy, and peripheral neuropathy has an HbA1c of 10%. She is taking the maximum dose of three oral agents and should begin insulin therapy as the next step. Which medication would be most appropriate for this patient? ** A. Rapid-acting insulin (RAI) before each meal B. Basal insulin pen to be injected at bedtime C. Sulfonylurea D. Sodium-glucose cotransporter 2 (SGLT-2) inhibitor **For the diabetic patient with hypothyroidism, the APN should expect to take which action? ** A. Add a 3 a.m. blood glucose B. Increase insulin doses C. Decrease basal insulin D. Increase doses of thyroid hormone Which groups is routine screening of asymptomatic adults for diabetes appropriate? (Select all that apply) A. Native Americans B. African Americans C. Hispanics D. Asians **[Classes of Anti-Diabetic Medications]** **For which type of diabetes is treatment with oral agents often sufficient? ** A. Type 1 diabetes mellitus (DM) B. Type 2 diabetes mellitus (DM) C. Latent autoimmune diabetes in adults (LADA) D. Maturity-onset diabetes of the young (MODY) **Biguanides** - [Use:] DM2; first line treatment for adults and children \>10; also lowers cholesterol, triglycerides, and can aid in weight loss - [MOA:] decrease hepatic glucose production, decrease intestinal absorption of glucose, improve insulin sensitivity by increasing peripheral glucose uptake and utilization - [Side Effects:] N/V, **diarrhea** - [Contraindicated in:] renal disease or dysfunction, metabolic acidosis \*can cause lactic acidosis (diarrhea, dizziness, bradycardia, hypotension) - [Monitoring & Teaching:] check renal function (serum creatinine) prior to start and throughout therapy; take with food to decrease GI upset, can cause lactic acidosis, can reduce B12 and TSH - Hold for 48 hours after contrast studies - **Metformin** **A 17-year-old patient diagnosed with type 2 diabetes mellitus (DM) should be started on which oral medication? ** A. Repaglinide (Prandin) B. Metformin (Glucophage) C. Insulin glargine (Lantus) D. Sitagliptin (Januvia) **Which adverse effect of metformin is most common? ** A. Weight loss B. Lactic acidosis C. Flatulence D. Reduction of low-density lipoprotein (LDL) levels **Which measure provides the most accurate information on the effectiveness of metformin? ** A. An annual HbA1c B. The percentage of weight loss C. Fasting blood glucose (FBG) D. Postprandial blood glucose **A 29-year-old male patient with a history of type 2 diabetes mellitus presents to the office for a routine health maintenance visit. His HbA1C has increased by 2% within the past 4 months. The APN discusses the option of adding an additional medication. The patient informs the APN that he is concerned about his weight but is unable to start a weight loss program at this time due to the complexity of his schedule. Which medication change should be considered?** A. Decrease linagliptin B. Increase glipizide C. Decrease canagliflozin D. Increase metformin **There is some debate about the use of metformin in patients with type 1 diabetes mellitus (DM) because metformin is more effective in patients with which characteristics? ** A. Complete loss of beta cell function B. Tissue insensitivity to insulin C. Excessive liver glucose production D. Increase of glucagon-like peptide-1 (GLP-1) levels **A patient is diagnosed in the clinic with type 2 diabetes mellitus (DM). Which of these is the initial medication of choice for type 2 DM? ** A. Amylin agonists B. Dipeptidyl peptidase-4 (DPP-4) inhibitors C. Thiazolidinediones (TZDs) D. Biguanides **Metformin should be discontinued and switched to a different medication for which reason? ** A. Glomerular filtration rate (GFR) below 30 mL/min B. Diarrhea C. Abdominal pain D. Radiological study with contrast **A 50-year-old male patient with acanthosis nigricans is concerned about the risk of diabetes. The APN would inform the patient that he can decrease his risk of diabetes through which strategy? ** A. Starting metformin B. Maintaining a body mass index (BMI) of 30 C. Exercising for 60 minutes per week D. Measuring his HbA1c every 3 years **A patient with type 2 diabetes mellitus (DM) is exercising for 30 minutes three times a week. Her HbA1c is not at goal and will require an additional medication. The addition of which medication is most appropriate? ** A. Low-dose basal insulin B. Sulfonylureas C. Biguanide D. Dipeptidyl peptidase-4 (DPP-4) inhibitor **Type 2 diabetes mellitus (DM) has four primary alterations in glucose metabolism. One of the alterations includes tissue insensitivity to insulin. Which medications have the greatest effect on tissue insensitivity to insulin? ** A. Biguanides B. Sulfonylureas C. Meglitinides D. Sodium-glucose cotransporter 2 (SGLT-2) inhibitors **Sulfonylureas "rides"** - [Use:] DM2 (recommended for older adults); usually given in conjunction with metformin; considered step 2 therapy d/t risk of hypoglycemia - [MOA:] stimulates insulin release from pancreatic beta cells to decrease blood glucose - [Side Effects:] hypoglycemia, weigh gain, GI upset, hemolytic anemia, agranulocytosis, leukopenia, thrombocytopenia - [Monitoring & Teaching:] CBC, monitor for fever/sore throat - [Contraindicated in:] sulfa allergy patients (hypersensitivity type 1), infection/trauma - **Glimepiride** - **Chlorpropamide** - **Glipizide**---do not take with food - **Glyburide** - **Which oral medication has the most potential for hypoglycemia? ** A. Selective sodium-glucose cotransporter 2 (SGLT-2) inhibitor B. Dipeptidyl peptidase-4 (DPP-4) inhibitor C. Short-acting rapid insulin D. Sulfonylurea **A 40-year-old female patient presents to your office accompanied by her caregiver with complaints of increased nocturia. She has a history of type 2 diabetes mellitus and rheumatoid arthritis since childhood. She ambulates with a walker due to severe limitation in her lower extremities. Her blood glucose log reveals fasting blood glucose levels ranging from 50 to 65 and postprandial blood glucose levels 200 to 290. Which medication adjustment would be priority to initiate first? ** A. Start linagliptin. B. Stop glimepiride. C. Decrease dapagliflozin. D. Start NovoLog 5 units subcutaneously before each meal. **Alpha-Glucosidase Inhibitors** - [Use:] DM2; used as an adjuvant medication - [MOA:] inhibits absorption of carbohydrates thus decreasing amount of glucose available for absorption - [Side Effects:] flatulence, diarrhea, abdominal discomfort (SEs can resolve if dosage is lowered) - [Monitoring & Teaching:] serum creatinine and electrolytes; contraindicated with inflammatory or irritable bowel syndrome - Must be taken with first bite of each meal: 50-100mg PO TID - **Acarbose** - **Miglitol** **A 32-year-old patient with ulcerative colitis and type 2 diabetes mellitus (DM) should avoid which medication? ** A. Biguanide B. Meglitinide C. Sulfonylurea D. Alpha-glucosidase inhibitor **A 27-year-old patient is diagnosed with maturity-onset diabetes of the young (MODY) and was prescribed an alpha-glucosidase inhibitor. The APN instructs the patient that which glucose time is most appropriate for evaluating the effectiveness of the medication? ** A. Fasting B. Postprandial C. Bedtime D. Preprandial **Which medication has been shown to be beneficial to the diabetic patient with hypertriglyceridemia?** A. Saxagliptin B. Metformin C. Acarbose D. Amylin **Acarbose (Precose) has which feature? ** A. Expedited carbohydrate absorption B. Reduced postprandial peaks of plasma glucose C. Short-term induction process D. Enhanced pancreatic beta cell secretion **A patient with type 2 diabetes mellitus (DM) is taking a rapid-acting insulin before meals and an alpha-glucosidase inhibitor three times a day. Her blood glucose log reveals a fasting glucose of 50 on several occasions. The APN instructs the patient that which of these will increase glucose levels when the patient is experiencing hypoglycemia? ** A. Glucagon B. ½ can of soda C. 4 grapes D. 1 cup of fruit juice **Alpha-glucosidase inhibitors function by which primary mechanism of action? ** A. Increasing endogenous insulin secretion B. Suppressing glucogenesis C. Delaying the absorption of complex carbohydrates (CHO) D. Inhibiting the reabsorption of glucose in the kidney **Thiazolidinediones (TZDs) "glitazones"** - [Use:] DM2 (off label PCOS) - [MOA:] decrease insulin resistance and improve insulin sensitivity - [Side Effects:] water retention, edema, heart failure, weight gain, hypoglycemia, increased risk for bone fx - **Black Box Warning**: ischemic cardiovascular risk and heart failure , bladder cancer and bone fractures - [Monitoring & Teaching:] monitor weight and cardiac function, use backup birth control - **Rosiglitazone (Avandia)** - **Pioglitazone (Actos)---**increased risk for bladder cancer; backup birth control recommended **Premenopausal anovulatory women should consider a birth control method when taking which medication? ** A. Sulfonylurea B. Thiazolidinediones (TZD) C. Biguanide D. Meglitinide **Rosiglitazone should not be used in patients with which condition? ** A. Class III heart failure B. Peripheral arterial disease C. Obesity D. Angina **Meglitinides "glinides"** - [Use:] DM2 - [MOA:] Close ATP-dependent potassium channels in beta cell membrane, depolarizes beta cell and opens calcium channels, increasing the secretion of insulin \*\*Stimulates pancreas to produce more insulin\*\* - [Side Effects:] hypoglycemia (less likely b/c shorter ½ life), weight gain - [Monitoring & Teaching:] take at the start of the meal; do not take if meal is not eaten; do not take at bedtime - **Repaglinide** - **Nateglinide** **A truck driver with a history of maturity-onset diabetes of the young (MODY) and obesity complains of increased dysuria and polydipsia. After review of his home glucose readings, the APN notes a trend of elevated postprandial glucose levels. The addition of which oral medication is most appropriate? ** A. Sulfonylurea B. Insulin glargine C. Insulin lispro before meals D. Meglitinide **Dipeptidyl Peptidase-4 Inhibitors (DPPD-4)---\"[Gliptins]"** - [Use:] DM2 (combined with metformin is best for patients with high cholesterol) - [MOA:] block DPPD-4 by increasing incretin levels; extends action of GLP-1 and GIP to inhibit glucagon release which increases insulin secretion; decreases gastric emptying and blood glucose - [Side Effects:] very minimal; low risk for hypoglycemia; no weight gain - [Caution & Monitoring:] concurrent ACE inhibitors ↑risk for angioedema; ↑concentration of digoxin w/gliptin; monitor renal function and caution use with renal disease - **Sitagliptin** - **Saxagliptin** - **Linagliptin** - **Alogliptin** **The APN would avoid use of saxagliptin (Onglyza) in which patient? ** A. 63-year-old patient with body mass index (BMI) of 40 who is currently using insulin glargine B. 52-year-old patient with history of pancreatitis C. 50-year-old patient with creatinine of 1.6 and glomerular filtration rate of 75 mL/min D. 38-year-old patient who was newly diagnosed with type 2 diabetes mellitus with occasional mild nausea **A patient with type 2 diabetes mellitus (DM) has concerns about starting insulin because of his current occupation. He states that his food intake has increased in the past 2 months, which has resulted in elevated home blood sugars. After a review of the home blood glucose readings, the APN decides on a medication to improve pre- and postprandial blood glucose levels. The addition of which medication is most appropriate? ** A. Dulaglutide B. Sitagliptin C. Pramlintide D. Nateglinide **Glucagon-like Peptide Agonists (GLP-1) "tides"** - [Uses:] DM2 (adjunct therapy with metformin or sulfonylureas; reduces BP, reduces triglycerides) - [MOA:] acts on GLP-1 receptors to slow gastric emptying and stimulate insulin release; increase insulin secretion from beta cells and suppress glucagon release from the alpha cells and slows gastic emptying - [Side Effects:] GI distress, weight loss - [Monitoring & Teaching:] avoid concurrent use with digoxin, lovastatin, & warfarin; monitor digoxin levels; monitor renal function/thyroid/pancreas - [Contraindicated in:] GI disease - \*\*Low risk of hypoglycemia\*\* - **Exenatide (Byetta)---**administer 1 hour before meal BID atleast 6 hours apart - **Liraglutide (Victoza)** - **Trulicity** **A patient with a history of pancreatitis should avoid which medication? ** A. Thiazolidinedione B. Biguanide C. Meglitinide D. Glucagon-like peptide-1 (GLP-1) receptor agonist **Glucagon-like peptide-1 (GLP-1) inhibitors are used most effectively in patients with which condition? ** A. Latent autoimmune diabetes in adults (LADA) B. Type 2 diabetes mellitus (DM) C. Type 1 diabetes mellitus (DM) D. Maturity-onset diabetes of the young (MODY) **Selective Sodium Glucose Co-transporter Inhibitors (SGLT-2) "flozins"** - [Use:] DM2 (used alone or in combination with metformin or others) - [MOA:] Inhibit SGLT-2 to prevent reabsorption of glucose in renal tubules and facilitate glucose excretion in the urine. - [Side Effects:] yeast infection, UTI, increased urination, renal insufficiency, hypoglycemia, hyperkalemia, GI upset, fatigue, weight loss, increases LDL - [Monitoring & Teaching:] monitor renal function and potassium frequently, monitor patients on digoxin - **Black Box Warning: [ ]**necrotizing fasciitis of the perineum - **Canagliflozin (Invokana)** - **Dapagliflozin (Farxiga)** - **Emagliflozin (Jardiance)** - Contraindicated in patients with kidney disease or dialysis - Do not take canagliflozin w/ primizide; Canagliflozin increase effects of ACEs and ARBs **The APN should avoid prescribing which medication for a patient diagnosed with gestational diabetes? ** - Metformin - Insulin - Glyburide - Canagliflozin **A 72-year-old male patient is taking a sodium-glucose cotransporter 2 (SGLT-2) inhibitor for type 2 diabetes mellitus. The APN should be concerned if the patient reports which symptom? ** A. Falls B. Glycosuria C. Increased hemoglobin D. Weight loss **Canagliflozin should not be initiated in patients with which condition? ** A. End-stage renal disease B. Anemia C. Obesity D. Glycosuria **Amyline Agonist** - [Use:] DM1 & DM2 - [MOA:] Synthetic analogue of human amylin; Acts on glucagon secretion, slowing emptying and suppression of appetite; decreases BG after meals - [Side Effects:] increased risk of hypoglycemia with insulin - [Contraindicated in:] hypoglycemia unawareness and gastroparesis - [BBW:] increased risk of hypoglycemia with insulin - [Monitoring & Teaching:] give immediately before each meal - **Pramlintide (Symlin)** **Pramlintide can be utilized in which patient? ** A. Type 1 diabetic patient with a history of gastroparesis B. Type 1 diabetic patient with history of multiple hypoglycemic episodes C. Type 2 diabetes mellitus patient who self-monitors blood glucose once a day D. Type 2 diabetes mellitus patient with history of renal insufficiency **One of the major differences between type 1 diabetes mellitus (DM) and type 2 DM is that type 2 DM has which feature? ** A. Insulin is not necessary for survival. B. Insulin resistance C. Loss of beta cell function D. Initial noninsulin endogenous requirements **According to the American Diabetic Association (ADA) standards of medical care in diabetes, which of these is a diagnostic criterion for diabetes? ** A. HbA1c 6.5% B. Random glucose less than 200 mg/dL C. Fasting glucose of 100 mg/dL D. Fasting glucose less than 92 mg /dL **Which of these can increase HbA1c? ** A. Chronic renal failure B. Blood loss C. Alcohol use D. Pregnancy **Which of these is a microvascular complication of uncontrolled diabetes? ** A. Proliferative retinopathy B. Cardiovascular disease C. Stroke D. Peripheral vascular disease **Patients that are diagnosed with type 1 diabetes mellitus (DM) should also be screened for which condition? ** A. Thyroid dysfunction B. Cardiovascular disease C. Intermittent claudication D. Elevated creatinine **Hypoglycemia should be avoided in children with diabetes for which reason? ** A. Growth delay B. Increased cardiovascular risk C. Vision impairment D. Impaired brain development **A 28-year-old obese female patient who is 6 weeks pregnant has an elevated fasting blood sugar level of 200. The APN would most suspect which condition in the patient? ** A. Gestational diabetes B. Type 1diabetes mellitus (DM) C. Type 2 diabetes mellitus (DM) D. Prediabetes **The mother of an adolescent patient with a history of acanthosis nigricans is concerned about the risk of developing diabetes because this condition is linked to insulin resistance. The APN instructs the patient's mother that the patient should be tested for diabetes if the patient also meets which criterion? ** A. HbA1c greater than 6.5% B. Family history of type 1 diabetes C. European American ethnicity D. Body mass index (BMI) greater than 85th percentile for age and sex **The APN is testing for gestational diabetes and instructs the patient who is 24 weeks pregnant how the oral glucose tolerance test is conducted. The patient states that her mother has diabetes and has a blood test called an HbA1c, which is tested three times a year. The APN informs the patient that the HbA1c would not be an adequate measurement for diagnosis of gestational diabetes for which reason? ** A. HbA1c is unreliable in early pregnancy. B. HbA1c test is more expensive. C. Oral glucose tolerance test (OGTT) is more effective. D. HbA1c is unreliable in disorders with hepatic gluconeogenesis. **The mother of a 12-year-old male patient with history of type 1 diabetes mellitus (DM) is concerned about end organ complication from diabetes. The APN states that one of the potential complications is nephropathy and provides the mother with which information regarding testing for the development of nephropathy? ** A. It will take place at every medical visit. B. It will take place at the time of diagnosis. C. It will take place after the duration of DM has been at least 5 years. D. It will begin in 5 years. **A patient with type 2 diabetes mellitus and a history of cardiomyopathy has an ejection fraction (EF)% of 35%. The patient is currently taking metformin and canagliflozin (Invokana). Which laboratory finding would indicate immediate treatment? ** A. Glycosuria on dipstick B. Positive nitrates on dipstick C. HbA1c of 7.9% D. Serum potassium of 3.5 mEq/L **The APN prescribed exenatide for a 56-year-old female patient with a history of type 2 diabetes mellitus (DM) on her last visit. The APN should be concerned if the patient reports which symptom? ** A. Abdominal pain and nausea B. Nausea C. Diarrhea D. Reduced appetite **A more stringent HbA1c goal of 6.5% may be indicated for which patient? ** A. 22-year-old type 1 diabetic patient who is concerned about family planning B. 68-year-old type 2 diabetic patient with a history of hypoglycemia C. 78-year-old type 2 diabetic patient with a history of dementia in an assisted living facility D. 45-year-old type 1 diabetic patient who is unable to get dressed without assistance **Which laboratory test can be utilized when HbA1c is considered unreliable, such as in the case of hemolytic anemia? ** A. C-peptide B. Insulin level C. Fructosamine D. Glucose tolerance test **A patient presents with a history of obesity and a *Candida* infection on last visit. Today the patient complains of polyuria and mild polydipsia. The HbA1c is 6.0%. The APN most suspects which condition in the patient? ** A. Type 1 diabetes mellitus (DM) B. Prediabetes C. Type 2 diabetes mellitus (DM) D. Latent autoimmune diabetes in adults (LADA) **HbA1c can be unreliable in which medical condition?** A. Sickle cell disease B. Cystic fibrosis C. Cardiovascular disease D. Peripheral artery disease **A patient with type 1 diabetes mellitus (DM) is concerned about long-term complications as the result of a history of diabetes for the past 10 years. The APN assures the patient that complications from diabetes can be minimized through which strategy? ** A. Maintaining an HbA1c low enough that does not result in hypoglycemia B. Keeping fasting blood glucose at goal C. Undergoing an annual ophthalmic examination D. Implementing lifestyle changes **A new patient presents to the clinic with a 10-year history of type 2 diabetes mellitus (DM) and hypertension. Today, she complains of blurred vision, elevated blood pressure, and bilateral lower extremity swelling. The APN begins to interview the patient and discovers that the last healthcare visit was approximately 2 years ago. Her recent visit to the ophthalmologist revealed moderate nonproliferative diabetic retinopathy. She also has a history of consuming six cans of beer daily for the past 5 years. The APN's next step in diabetes management most appropriately includes which action? ** A. Referral to an alcohol cessation program B. Conducting a fundoscopic examination C. Starting a thiazide diuretic D. Obtaining an HbA1c **Which of these varies in the United States by ethnic group? ** A. Rate of prediabetes progressing to diabetes B. Incidence of type 1 diabetes mellitus (DM) C. Prevalence of type 2 diabetes mellitus (DM) D. Cost-effectiveness of lifestyle interventions **The APN is concerned about a patient who has developed a complication from diabetes when the patient presents which symptom? ** A. Impaired vision B. Urticaria C. Elevated thyroid levels D. Edema **The patient is an older adult who has a diagnosis of Type II diabetes mellitus and hypertension. The APN is prescribing her a beta blocker today. The APN should teach her that which symptom is an indication of hypoglycemia that is not masked by beta blockers? ** A. Dizziness B. Diaphoresis C. Fatigue D. Syncope **Diabetes mellitus (DM) can result from which condition? ** A. Hyperlipidemia B. Hypertension C. Cystic fibrosis D. Coronary heart disease **Which peptide hormone is cosecreted with insulin in response to food? ** A. Amylin B. Glucagon-like peptide-1 (GLP-1) C. C-peptide D. Glucagon **When do the symptoms of type 1 diabetes begin? ** A. After 80% to 90% of beta cell loss B. After 40% to 50% of beta cell loss C. After 20% to 30% of beta cell loss D. After 60% to 70% of beta cell loss **[THYROID]** **Hypothyroidism**---thyroid does no produce enough thyroid hormone **Hyperthyroidism (Grave's Disease)**---thyroid produces too much thyroid hormone **Thyroid Replacement hormones** - [Use:] to replace thyroid hormone in hypothyroidism - [MOA:] synthetic T4 hormone, also to prevent recurrent thyroid cancer - [Side Effects:] very little on stable doses - **[Too Much TH replacement]**: hyperthyroid s/s, tachycardia, increased O2 demands, arrythmia-afib/aflutter, nervousness, N/V/D, chest pain, hypertension, unexplained weight loss, extreme fatigue, irritability, heat intolerance, menstrual irregularity - [Contraindicated in:]recent MI - [Monitoring & Teaching:] take first thing in the morning on an empty stomach 30 minutes before other food or other medications or at least 30 minutes after administration; long term use and high dose associated with bone mineral [loss ] - Monitor TSH and free T4 check initially at 4-8 weeks; once thyroid levels have returned to WNL recheck at 6 months and then every 12 months there on after - Elderly at highest risk for side effects (watch for tachycardia and angina) - Pregnancy requires dose increases and monitoring - Patient should hold if HR \>100bpm - Do not change brands; this would require dose adjustments and lab monitoring - **Levothyroxine (Synthroid, Levoxyl, T4)**---drug of choice for replacement of hormone T4 - **Liothyronine (Cytomel T3)** **The lowest dose possible of levothyroxine (Synthroid) should be given to the patient with which condition? ** A. Pregnancy B. Diabetes C. Osteoporosis D. Simple nontoxic goiter **The APN is teaching the mother of a 6-month-old infant with a diagnosis of congenital hypothyroidism. Which information would the APN include regarding levothyroxine (Synthroid)? ** A. It should not be crushed. B. It is given as a suspension from the pharmacy. C. It should be crushed and added to infant formula. D. It will not begin until the child is 1 year old. **A patient being treated for hypothyroidism returns for a follow-up office visit. The APN is concerned that the patient is taking an excessive amount of the thyroid hormone replacement when the patient reports which symptom? ** A. Weight gain B. Fatigue C. Chest pain D. Bradycardia **The APN is teaching the mother of a 6-month-old infant with a diagnosis of congenital hypothyroidism. Which information would the APN include regarding levothyroxine (Synthroid)? ** A. It should not be crushed. B. It is given as a suspension from the pharmacy. C. It should be crushed and added to infant formula. D. It will not begin until the child is 1 year old. **The APN is consulting with the patient about the thyroid panel from the previous visit. The APN instructs the patient to stop the 25-mcg tablet and continue with the 100-mcg tablet. The patient has a low health literacy and does not have the medication available for the "teach back" method. How can the APN assist with the identification of the medication to ensure the correct dosing on this visit? ** A. Give instructions to a family member during a phone call during office hours on the following day. B. Give instructions using the colors of the tablets \*\*\*Thyroid hormone tabs are color coded\*\*\* C. Have the patient return with the medication bottles. D. Call the pharmacy for assistance. **The goal of thyroid replacement in congenital hypothyroidism is to achieve normal IQ and neurological function. Close monitoring is needed when the infant diet consists of which of these? ** A. Breast milk B. Cooked cereal C. Milk-based formula D. Soy-based formula **Testing of which levels best monitors the effectiveness of thyroid replacement? ** A. Thyroid-stimulating hormone (TSH) B. Serum triiodothyronine (T~3~) C. Levothyroxine D. Serum thyroxine (T~4~) **Levothyroxine (Synthroid) is contraindicated in the patient with which comorbidity? ** A. Diabetes B. Osteoporosis C. Myocardial infarction (MI) D. Peripheral vascular disease **The APN is seeing a patient with a history of diabetes and hypothyroidism. The patient recently discovered that she was 8 weeks pregnant. The APN should expect to take which action? ** A. Increase thyroid replacement by 25% B. Decrease thyroid replacement by 25% C. Decrease beta blocker by 50% D. Increase beta blocker by 50% **It is important that thyroid levels are normal in congenital hypothyroidism to prevent which complication? ** A. Depression B. Mental retardation C. Obesity D. Hyperreflexia **Antithyroid Drugs** - [Use:] First line drugs in the treatment of hyperthyroidism or thyrotoxicosis - [Drug Interactions:] multiple - **Propylthiouracil (PTU)** - [MOA:] inhibits action of iodine (& thyroperoxidase enzyme) preventing formation of T3T4 - [SE]: [agranulocytosis] (fever & sore throat is 1^st^ sign, chills, rash, bruising), vasculitis, temporary [alopecia], rash, aplastic anemia, acute renal failure, hepatotoxicity, pancreatitis (rare) - [Monitoring:] monitor CBC w/ diff, thyroid levels, LFTs prior to treatment and throughout, monitor lithium and warfarin levels closely - [**BBW**:] liver failure -- report headache, malaise, weakness, jaundice of skin or eyes - Drug of Choice for pregnant women with hyperthyroidism - **Methimazole (Tapazole)** - [MOA:] thyroid hormone synthesis inhibitor - Used for toxic goiter and hyperthyroidism, Preferred in all patients with Graves disease except in 1^st^ trimester of pregnancy - [Side Effects:] agranulocytosis (Stop immediately), vasculitis, hepatotoxicity, pancreatitis, jaundice, pruritis, dark urine, acholic stools, abdominal pain, fatigue, fever - Can cause fetal aplasia cutis (absence of skin on the scalp) -- DO NOT GIVE IN PREGNANCY - May take 6-12 months before euthyroid levels; Start at higher dose to restore euthyroid and followed by maintenance - [Monitoring:] CBC w/ diff (fever/sore throat/rash), monitor T3 and T4 after 4 wks of treatment then every 4-8 weeks until euthyroid state then every 3-4 months - Beta Blockers can also be given for hyperthyroidism to slow down rate and workload of heart **Which symptom should be reported to the healthcare provider and may be a reason to discontinue an antithyroid medication? ** A. Weight gain B. Agranulocytosis C. Weakness D. Headache **The purpose of an antithyroid agent is to have which action?** A. Decreasing triiodothyronine (T~3~) production B. Increasing thyroid-stimulating hormone (TSH) levels C. Decreasing the conversion from T~3~ to TSH Inhibiting the synthesis of thyroid hormone **[CARDIAC & HYPERTENSION]** - Systolic HTN: treat with diuretic and Calcium Channel - MI: treat with BB (Ace systolic) - Angina: treat with BB - Tachycardia: treat with BB - DM2 with or without proteinuria (ACE) - ACE and ARBs along with protein restriction help in the tx/slowing progression of diabetic neuropathy **ACE Inhibitors: 1^st^ choice for HTN control in patients with DM "prils" -- decrease blood volume & decrease peripheral resistance** - [**Drugs:**] **Lisinopril (Prinivil)**, **Enalapril (Vasotec), Captopril (Capoten), Ramipril (Altace)** - [Use:] HTN, vasodilation, improved glucose disposal, reduction in LV changes, slow diabetic nephropathy in patients with microalbuminuria and DM 1, symptomatic patients with chronic stable angina to prevent MI - [MOA:] prevent the conversion of angiotensin 1 to angiotensin 2, thus disrupting the RAAS. Also decreases aldosterone and increases bradykinin - [Side Effects:] *dry hacking cough*, hypotension, angioedema- increased risk when administered with "gliptins" - [BBW:] fetal toxicity [ ] - [Monitoring & Teaching:] Monitor renal function, LFTs, electrolytes (specifically K+ before start and 1 week after), WBC and proteinuria, lithium (may cause increased levels and risk toxicity) - [AVOID NSAIDS] -- reduced effect of ACE inhibitors - Alcohol increases hypotension - Take 1 hour apart from antacid (prevents absorption) - Decrease ACE dose with Cr \>2.5 - Contraindicated: Bilateral renal artery stenosis, pregnancy, and angioedema - If dry, hacking cough develops, switch to ARB - Discontinue diuretics 2-3 days before starting an ACEI if potassium depleting r/t risk of hyperkalemia **Which drug is considered to be a first-line therapy for the treatment of heart failure? ** A. Non-dihydropyridine calcium channel blockers (CCBs) B. Coenzyme Q~10~ C. Clopidogrel (Plavix) D. Angiotensin-converting enzyme inhibitors (ACEIs) **Which adverse reaction is uncommon with use of angiotensin-converting enzyme inhibitors (ACEIs)? ** A. Dizziness B. Fatigue C. Neutropenia D. Cough **Which angiotensin-converting enzyme inhibitor (ACEI) requires frequent dosing, which can subsequently negatively impact patient adherence in therapy? ** A. Captopril B. Benazepril C. Ramipril D. Lisinopril **Angiotensin-converting enzyme inhibitors (ACEIs) have a higher risk of angioedema and cough in which race? ** A. Native American B. Hispanic C. White D. Asian **Angiotensin Receptor Blockers (ARBs): 1^st^ choice for HTN control in patients with DM "sartans" -- decrease blood volume & decrease peripheral resistance** - **[Drugs:] Candesartan (Atacand), Losartan (Cozaar), Valsartan (Diovan)** - [Use:] HTN - [MOA:] block the binding of angiotensin 2 receptor to angiotensin 1 receptor on cell membrane; reduce vascular tone and enhance sodium and water clearance - [Side Effects:] Similar to ACEIs but NO dry-hacking cough as it does not increase bradykinin, hypotension - [BBW: fetal toxicity ] - [Monitoring & Teaching:] - C/I: bilateral renal artery stenosis, pregnancy, angioedema, hyperkalemia - Monitor renal/ hepatic function and electrolytes (specifically K+ before start and 1 week after) - AVOID NSAIDS - Give antacids 1 hour prior **The initial dose for an angiotensin II receptor blocker (ARB) may need to be lower in which of these? ** A. Impaired hepatic function B. Congestive heart failure C. Diabetes D. Male gender **A patient presents to the clinic today for follow up on hypertension. He states that he has noticed a dry "hacking" cough since he started lisinopril 4 weeks ago. He denies other respiratory or cardiovascular symptoms. Which action taken by the APN is most appropriate? ** A. Increase the dose of lisinopril and evaluate the patient in 2 weeks. B. Treat the patient with an antibiotic and prednisone. C. Stop the lisinopril and start losartan. D. Add aliskiren to the current medication regime. **A patient presents for a follow-up appointment of her hypertension and is taking telmisartan. The APN notes that her blood pressure is elevated today and reviews her medication profile. Which medications could decrease the antihypertensive response and result in an elevated blood pressure reading? ** A. Nitrates B. Phenothiazines C. Other antihypertensives D. NSAIDs **The action of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), and direct renin inhibitors on the renin-angiotensin-aldosterone (RAA) system lowers blood pressure and reduces the adverse effects of which disease on the kidney? ** A. Peripheral artery disease B. Diabetes C. Glycosuria D. Multiple sclerosis **Which action should be considered when planning the management of angiotensin II receptor blockers (ARBs)? ** A. Stop diuretics for 2 to 3 days to allow hydration before starting an ARB. B. Start at the highest dose and titrate as needed. C. Increase the dose at 1- to 2-day intervals. D. Increase the dose of diuretics before initiation of an ARB. **Calcium Channel Blockers: "pines" -- decrease peripheral resistance** - [Use:] **1^st^ line treatment for African Americans**, HTN, angina, HF -amlodipine, migraines-verapamil - [MOA:] prevent the opening of calcium channels, reducing the effect of calcium on excitation, contraction, coupling of skeletal smooth and cardiac muscle, and regulating aldosterone, and pacemaker signal conduction; reduces afterload with no effect on preload and reduces the force of contraction(block calcium channels in the heart and blood vessels resulting in vasodilation and decreased HR) - [Side Effects:] hypotension (dizziness, headache, syncope), heart failure (congestion, SOB, cough, palpitations), GI (dry mouth, N/V, reflux, constipation), sexual dysfunction, hyperglycemia, photosensitivity, hyperpigmentation, peripheral edema - [Contraindicated*:* ] in patients with EF \2 mg/mL - Take at the same time each day - Do NOT take with verapamil, amiodarone, erythromycin, epinephrine - Hypokalemia leads to dig toxicity; Eat a high potassium diet-milk 1 hour later; high fiber may decrease absorption - **Digoxin** **Which of these represents a rare adverse reaction associated with cardiac glycosides (CGs)?** A. Nausea B. Gynecomastia C. Vomiting D. Anorexia **A patient presents with a new complaint of nausea, vomiting, palpitations, and yellow-green halos around lights since he completed an antibiotic for a sinus infection. He has been taking brand name Lanoxin (digoxin) for several years with normal laboratory ranges. He recently had a basic chemistry profile, thyroid stimulating hormone, and a renal profile, all of which were within normal ranges. Which action taken by the APN is most appropriate? ** A. Change his Lanoxin to generic digoxin. B. Start sodium supplements and order laboratory tests to assess for renal impairment. C. Order a digoxin level due to the recent use of an antibiotic. D. Increase Lanoxin (digoxin) and order laboratory tests to assess potassium and sodium levels. **A patient will be starting on a medication regime of digoxin. Which information should the APN include in his education? ** A. Missing or doubling doses is acceptable due to the drug's long half-life. B. Patients should eat a diet low in potassium. C. Tablets cannot be crushed and administered with food. D. Milk may have some effect on absorption, so doses should be separated by 1 hour of consumption. **Class I : Sodium Channel Blockers** - [Use:] SVT and ventricular arrythmias - **[Class IA MOA]**: lengthens duration of action potential - [IA Drugs]: disopyramide, quinidine, procainamide - IA S/E: N/V, increased HR, widened QRS, prolonged QT and PR, lupus like syndrome, low BP, bradycardia - Monitor for CHF if administered post MI/ACS (difficulty breathing, JVD, or peripheral edema - **[Class IB MOA:]** shortens duration of action potential - [IB Drugs:] lidocaine - [IB S/E:] drowsiness, confusion, CV depression - **[Class IC MOA]**: minimally increases action potential - [IC Drugs]: flecainide and propafenone - IC S/E: may exacerbate arrythmias, malignant arrythmias, dizziness, fatigue - With procainamide there is a chance of systemic lupus erythematosus development and may also lead to drug induce fever - Monitor CBC and ANA - Procainamide has a short ½ life and needs to be dosed every 2-4 hours **Class II: Beta Receptor Blockers "olol"** - [Use:] HTN, rate control - [MOA:] Block beta receptors in the heart causing decreased HR, force of contractility, and rate of AV conduction - [Side Effects:] bradycardia, lethargy, GI disturbances, CHF, hypotension, depression - BBW: MI if stopped abruptly - [Contraindicated:] Asthma patients [ ] - **metoprolol** - **propranolol** **Class III: Potassium Channel Blockers** - [Use:] ventricular dysrhythmia - [MOA:] Not well understood; Delay repolarization and lengthen refractory period and duration of action potential - [SE:] N/V, altered taste, corneal microdeposits, ↓↑thyroid (blocks conversion of T3T4; iodine), pulmonary fibrosis, hepatitis, epididymitis, bradycardia, heart blocks, dysrhythmias, prolonged QT, light sensitivity, blue skin discoloration, interstitial lung disease, optic neuropathy - [BBW:] amiodarone has potential pulmonary toxicity, hepatoxicity, proarrhythmic effects [ ] - [Monitoring/Teaching:] Monitor chest x-ray, pulmonary function every 3-6 months; Monitor TSH q6 months - Do not take missed doses and avoid grapefruit juice - **Amiodarone** - **Sotalol (nonselective beta adrenergic blocker but has Class III properties)** **Which drug inhibits the enzyme that converts T~4~ to T~3,~ has iodine as a major component, and has a risk for patients with underlying predisposition to thyroid disease to develop thyrotoxicosis or hypothyroidism? ** A. Enalapril B. Amiodarone C. Digoxin D. Hydralazine **Class IV antiarrhythmic: Calcium Channel Blockers** - [Use:] Supraventricular arrythmias, A-fib and A-flutter with rapid ventricular response - [MOA:] inhibit calcium ions movement across cardiac and smooth muscle thus decreasing myocardial contractility and oxygen demand - [SE:] peripheral edema, facial flushing, constipation, bradycardia, heart block, HA, dizziness, orthostatic hypotension, syncope, vfib, pulmonary edema - [Monitor:] lithium levels as verapamil may decrease, digoxin levels as diltiazem may increase - [Do NOT:] drink grapefruit juice - **Diltiazem** - **Verapamil** - **Nifedipine** **Class V antiarrhythmic** - [Use:] SVT - [MOA:] depresses the pacemaker activity of the SA node, decreasing heart rate and the ability of the AV node to conduct impulses from the atria to the ventricles - [SE:] arrythmias, SOB, hypotension - Monitor EKG and change positions slowly - **Adenosine** **Anticholinergic** - [Use:] sinus bradycardia and heart block, decreases secretions - [MOA:] inhibit acetylcholine sites in smooth muscles as well as secretory glands and CNS; causes decreased vagal stimulation of heart which allows for an increase in HR - [SE:] can't pee, can't see, can't spit, can't shit - Monitor for urinary retention - **Atropine** +-----------------+-----------------+-----------------+-----------------+ | **Classificatio | **Drug** | **MOA / Use** | **Side | | n** | | | Effects** | +=================+=================+=================+=================+ | **1A Na+ | Quinidine, | Slow action | N/V, ↑HR, | | channel | Procainamide | potential | widened QRS, | | blocker** | (can cause | depolarization, | prolonged PR | | | positive ANA) | increase | and QT | | | | conduction rate | | | | | to AV node | | +-----------------+-----------------+-----------------+-----------------+ | **1B Na+ | Lidocaine, | Block active & | Drowsiness, | | channel | Mexiletine | inactive Na+ | confusion, CV | | blocker** | | chan. | depression | | | | | | | | | Ventricular | | | | | arryth d/t MI, | | | | | CV sx/cath., | | | | | cardioversion, | | | | | digoxin | | | | | toxicity | | +-----------------+-----------------+-----------------+-----------------+ | **1C Na+ | Flecainide, | Block Na+ fast | Malignant | | channel | Propafenone | channel during | arrhythmias, | | blocker** | | phase 0 or | dizziness, | | | | action | fatigue, can | | | | potential | mask signs of | | | | | hypoglycemia | | | | A-fib | | +-----------------+-----------------+-----------------+-----------------+ | **2 Beta | Propranolol, | Cause | - Bradycardia | | receptor | Metoprolol, | significant | , | | Blocker** | Acebutolol, | ↑refractory | dizziness, | | | Esmolol | period of AV | fatigue, | | | | node; neg. | non-selecti | | | | inotropic | ve | | | | effects | cannot be | | | | | used with | | | | - A-fib, | asthma | | | | A-flutter & | "please | | | | ventricular | listen | | | | dysrhythmia | carefully" | | | | s | | | | | | - BBW: MI if | | | | | stopped | | | | | abruptly | +-----------------+-----------------+-----------------+-----------------+ | **3 K+ channel | Amiodarone, | **A:** Na+/Ca+ | - Pulmonary | | blocker** | Sotalol | channel | fibrosis, | | | | blockade | thyroid | | | | | issues | | | | **S:** prolong | | | | | action | - No | | | | potential, ERP, | grapefruit | | | | & QT interval | juice | | | | | | | | | - V-fib and | - BBW: | | | | SVT | cardiotoxic | | | | | ity | +-----------------+-----------------+-----------------+-----------------+ | **4 Ca+ channel | Verapamil, | Inhibit Ca+ | Peripheral | | blocker** | Diltiazem, | mvt.; slow | edema, facial | | | Nifedipine | conduction b/t | flushing, | | | | atria and | dizziness, | | | | ventricles | constipation | | | | | | | | | - A-fib, | -Change | | | | A-flutter, | positions | | | | SVTs | slowly | +-----------------+-----------------+-----------------+-----------------+ [ **\ **] **[ANTI-LIPID DRUGS]** - Atherosclerosis is major cause of CVD - Four major classes of lipoproteins - LDL (low-density lipoproteins) - HDL (high-density lipoproteins) - VLDL (very low-density lipoproteins) - Triglycerides - Patient Teaching: take as prescribed and do not skip doses or double up on missed doses; encourage healthy lifestyle, cardiac diet, exercise, and smoking cessation. **Which class of antianginal drugs negatively affects hypercholesterolemia by increasing triglycerides and low-density lipoprotein (LDL) cholesterol and reducing the level of high-density lipoprotein (HDL)? ** 1. Angiotensin-converting enzyme inhibitors (ACEIs) 2. Nonselective beta blockers 3. Cardioselective beta blockers 4. Calcium channel blockers **HMG-CoA Reductase Inhibitors---Statins** - [Use:] lower total cholesterol, LDL, and apo B lipoprotein levels - [MOA:] Block HMG-CoA reductase---an enzyme required in the initial step in cholesterol synthesis - [Side Effects:] headache, GI upset; liver damage, possible increase in intracerebral hemorrhage, myoglobinuria (rhabdomyolysis), myalgias, DM, neuropathy, sexual dysfunction - [Monitoring & Teaching:] Get baseline LFT and creatinine prior to start of statin; take in the evening as a single dose; report muscle cramps/weakness, dark urine → check CPK to rule out rhabdo; avoid grapefruit juice and alcohol - Do not give to patients with 1^st^ or 2^nd^ degree relatives that have history of muscle issues with statins - Ezetimibe is an adjunct to diet and statins to reduce total cholesterol/LDL/triglycerides - **Atorvastatin (Lipitor)** - **lovastatin** - **Rosuvastatin (Crestor)** - **Simvastatin (Zocor)** - **Pitavastatin (Livalo)** **Which information should be included in the education for a patient taking an antilipidemic? ** A. Other drugs should be taken 1 hour before or 4 hours after the bile-acid sequestrant. B. Lovastatin should be taken first thing in the morning. C. Bile-acid sequestrants should be taken after meals. D. A high-fiber diet may reduce the chance for muscle pain associated with reductase inhibitors. **Which condition has shown limited to no benefit with the initiation of HMG-CoA reductase inhibitors (statins)? ** A. Advanced heart failure B. Type II diabetes C. Low-density lipoprotein (LDL) cholesterol levels above 150 mg/dL D. Moderate atherosclerosis **The APN is initiating an HMG-CoA reductase inhibitor. Which statement by the patient demonstrates understanding of the education of the drug? ** A. "I will return in 6 to 8 weeks to repeat my lipid panel bloodwork." B. "I will require standard serial monitoring of liver laboratory tests every 4 weeks." C. "I will expect to experience some muscle pain 1 to 2 years after starting the medication." D. "If my dose is increased at my next appointment, I will return in one year to repeat my laboratory tests." **A patient who the APN has been treating with simvastatin presents today with complaints of diffuse myalgias and muscle tenderness and weakness. The APN notes that his creatine kinase (CK) value is more than 10 times the upper limit of normal. Which condition would the APN most likely suspect?** A. Hepatic injury B. Renal insufficiency C. Myopathy D. Impaction **Which drug blocks synthesis of cholesterol in the liver by competitively inhibiting HMG-CoA reductase activity and induces an increase in high-affinity low-density lipoprotein (LDL) receptors, resulting in an increased catabolism of LDL, and an increase in the liver's extraction of LDL precursors? ** A. Ezetimibe (Zetia) B. Colestipol (Colestid) C. Fluvastatin (Lescol) D. Gemfibrozil (Lopid) **Bile Acid Sequestrants/Resins** - [Use:] decrease cholesterol especially LDL; best for patients with low CV risk - [MOA:] exchange chloride ions for bile acids promoting an increase in bile acid secretion (helps excrete cholesterol) - [Side Effects:] GI---constipation/impaction, flatulence, N/V/D, abdominal pain; headache, reduced folate, burnt odor in urine, heartburn, weight loss - [Monitoring & Teaching:] laxatives or stool softeners may be helpful; monitor folate levels, increase fiber and fluid intake, take with food, can interfere with fat soluble vitamin absorption - **Cholestyramine (Questran)** - **Colesevelam** **Which drug can be used to treat hyperlipidemia in a patient with active liver disease? ** A. Cholestyramine (Questran) B. Simvastatin (Zocor) C. Rosuvastatin (Crestor) D. Fluvastatin (Lescol) **Fibric Acid Derivatives/Fibrates** - [Use:] ***hypertriglyceridemia*** with a hx./family hx. of atherosclerosis; - [MOA:] increases lipolysis of triglycerides by lipoprotein lipase (decrease triglyceride production & transport) - [Side Effects:] GI---dyspepsia, abdominal pain, n/v/d; cholelithiasis (excreted in bile), decrease H/H & WBC, hepatotoxicity - [Monitoring & Teaching:] CBC, lipid panel; do not mix with other anti-cholesterols (esp. statins) due to increased risk of rhabdo - [Contraindicated: gemfibrozil- do not give to pt with gallbladder dx] - **Fenofibrate (Tricor)-lowers LDL** - **Gemfibrozil (Lopid)-raises HDL, minimal effect on LDL** **Nicotinic Acid/Niacin** - [Use:] reduce triglycerides/total cholesterol/LDL while increasing HDL - [MOA:] inhibit VLDL secretion thus decreasing production of LDL - [Side Effects:] GI, flushing, pruritis d/t vasodilation, N/V, diarrhea, hepatotoxicity, hyperglycemia - [Monitoring & Teaching:] can take Aspirin 300mg 30 min prior to administration to avoid flushing reaction; take with food and avoid alcohol; monitor creatinine - **Niacin (B3)** **Omega 3 & Omega 6 Fatty Acids** - [Use:] reduce triglycerides - [MOA:] inhibit VLDL and apo-B-100 synthesis - [Side Effects:] GI upset, increased risk for hemorrhage - [Monitoring & Teaching:] TGs & LDL, liver function and s/sx of bleeding - **Lovaza** - **Vascepa** - **Fish Oil** **Which drug is approved for cases of high triglycerides that do not respond to primary interventions? ** - Omega-3 carboxylic acid drug group - Fluvastatin - Atorvastatin - Rosuvastatin **Cholesterol Absorption Inhibitor** - [Use:] decrease cholesterol; LDL & triglycerides - [MOA:] acts at brush border of the small intestine to inhibit the absorption of cholesterol leading to reduction in the delivery of intestinal cholesterol to the liver - [Side Effects:] fatigue, diarrhea, arthralgia, respiratory infection, hepatotoxicity - [Monitoring & Teaching:] monitor lipids and liver function - **Ezetimibe** **[HEART FAILURE]** **Heart Failure** - **HFpEF**---heart failure with Preserved ejection fraction - **HFrEF**---heart failure with Reduced ejection fraction - **1^st^ line therapy:** treat with ACE or ARB - And diuretic (coreg and losartan); - Add BB especially those w/o A-fib - OR use hydralazine/nitrates in African American and those intolerant of ACE/ARBs - **2^nd^ line therapy:** digoxin - High degree of toxicity - Improves contractility and cardiac output - Only used in a small \# of people with poor refractory symptoms, are in a-fib, or have chronic low BP - **3^rd^ line therapy:** diuretics (loop, thiaizide, potassium sparing) **Heart Failure Therapy Guidelines** - **ACE inhibitors**---inhibit RAAS--- "pril" - Potassium sparing; typically mixed with K+ losing diuretics; good choice for diabetics (kidney sparing) - Prevent breakdown of bradykinin (cough & angioedema) - **Lisinopril, Enalapril, Ramipril** - SE: hypotension, renal dysfunction, cough, angioedema - Avoid NSAIDs, avoid alcohol (can increase hypotension) **Angiotensin-converting enzyme inhibitors (ACEIs) can be prescribed in which condition? ** A. Bilateral renal artery stenosis B. Congestive heart failure C. Pregnancy D. Renal impairment - **ARBs**---inhibit RAAS---"sartan" - Potassium sparing; do not block bradykinin (no cough) - **Losartan, Valsartan, Irbesartan** - Avoid NSAIDs, give antacids 1 hour apart - **Beta Adrenergic blockers**---block sympathetic response to low EF---"olol" - Nonselective: Affect beta 1 (heart) and beta 2 (lungs, blood vessels, and uterus) - **carvedilol, labetalol (both also block alpha1)** - **nadolol, propranolol, sotalol** - Selective: Affect only beta 1 - **metoprolol, bisoprolol, esmolol, atenolol, acebutolol** - [MOA:] Occupy beta-receptor sites and blocking catecholamines (norepinephrine and epinephrine) from stimulating effects at these sites causing increased PVR, decreased HR and BP, decreased oxygen consumption, decreased contractility, decreased cardiac output - [Uses:] Post MI prevention, angina, HTN, cardiomyopathy, supraventricular arrythmias, migraines, essential tremors, OA glaucoma, pheochromocytoma - [SE:] hypotension, bradycardia, fatigue, HF, N/V/D/C, AV block, bronchospasm, depression, erectile dysfunction **A patient with left ventricular dysfunction is taking a calcium channel blocker (CCB) and a beta blocker (BB). This combination may induce which condition? ** A. Heart failure or bradycardia B. Tachycardia and hypotension C. Angina and tachycardia D. Hypoglycemia **A 33-year-old female with a medical history of diabetes mellitus, hypertension, and new onset of hyperthyroidism complains of palpitations and recent 5-pound weight loss. Which medication adjustments would be priority for this patient? ** A. Start propranolol B. Increase levothyroxine C. Decrease methimazole D. Start digoxin **Beta blockers (BBs) are generally contraindicated in which patient?** A. The patient who has unstable asthma B. The patient who has had a myocardial infarction (MI) C. The patient who has hypertension D. The patient who has stable Type II diabetes **Diuretics** **Thiazide Diuretics -- decrease blood volume** - [Use:] Edema in heart failure/liver cirrhosis/kidney disorders, HTN - [MOA:] act on distal renal tubule to inhibit sodium reabsorption; deplete body sodium and reduce fluid volume - [Side Effects:] glucose intolerance (K+), hyperlipidemia, hypotension & risk of falls, tinnitus - [Monitoring & Teaching:] can decrease excretion of many drugs; monitor electrolytes, renal/hepatic function, use caution in patients with history of gout or renal calculi, use caution in diabetic patients - **HCTZ** - **Chlorthalidone** **Loop diuretics** - MOA: inhibit sodium and calcium reabsorption in ascending Loop of Henle, thus increasing renal excretion of sodium, chloride and water - [Use:] Edema in heart failure/liver cirrhosis/kidney disorders - Most potent diuretic available resulting in the largest volume of diuresis. - SE: ↑ urination, headache, dizziness, thirst, muscle cramps, stomach cramps, N/V/D, electrolyte abnormalities which can lead to arrythmia, ototoxicity when given alongside aminoglycosides and cisplatin, hyperglycemia r/t reducing the effects of oral antidiabetic drugs, lithium or digoxin toxicity - most safe in pregnancy - **Furosemide, Toresemide, Metolazone** - Most commonly prescribed for HF (Lasix & Toresemide) **Potassium -Sparing diuretic** - MOA: block mineralocorticoid receptors which inhibits effects of aldosterone on collecting ducts and distal tubule resulting in excretion of sodium, water, bicarbonate, and calcium - 1^st^ line treatment for HTN - [Use:] severe heart failure, post-MI failures with resistant HTN, edema, diuretic induced hypokalemia, cirrhosis, and kidney disease - SE: hyperkalemia (if used in conjunction with potassium supplement or ACE), headache, dizziness, thirst, muscle cramps, N/V/D , gynecomastia, erectile dysfunction, and abnormal menstrual bleeding - NSAIDs can decrease effect - **Spironolactone (Aldactone)** **Which precaution or contraindication is noted with the use of diuretics? ** A. Hepatic dysfunction is an absolute contraindication to the use of a diuretic. B. The use of diuretics can improve hyperuricemia in patients with a history of gout or renal calculi. C. Potassium-sparing diuretics have an absolute contraindication for patients with severely impaired renal function. D. Older adults are at increased risk for hypertension. **Which patient is at risk for cardiac glycoside (CG) toxicity? ** A. A 65-year-old healthy older adult B. A 45-year-old who is on loop diuretics C. A 25-year-old Type II diabetic D. A 56-year-old who is on albuterol **Which laboratory abnormality can commonly occur with treatment of loop diuretics? ** A. Elevated thyroid-stimulating hormone levels B. Low potassium levels C. Elevated hepatic enzymes D. Hematuria **A patient presents today for the initiation of medication for his hypertension. He has a history of gout and takes antigout medication. Which medication can cause hyperuricemia in this patient? ** A. Calcium channel blockers B. Angiotensin-converting enzyme inhibitors C. Thiazide diuretics D. Nitrates **Nitrates** - [Use:] increase O2 supply to the coronary arteries - [MOA:] Cause vasodilation, decrease preload and decrease myocardial oxygen demand - [SE:] headache, orthostatic hypotension, reflex tachycardia, dizziness - [Monitoring/Teaching:] Do not take concurrently with alcohol or within 24 hours of erectile dysfunction medications i.e. sildenafil (Viagra) d/t risk of hypotension - **[Nitroglycerin: 3 Q5 min if no relief call 911 ]** - **[Isosorbide mononitrate ]** - **[Isosorbide dinitrate ]** **Which drug classification contains drugs that are well absorbed by oral, buccal, sublingual, and transdermal routes? ** A. Angiotensin II receptor blockers (ARBs) B. Nitrates C. Peripheral vasodilators D. Diuretics **Nitrates can be used in which patient? ** A. A 60-year-old patient with a recent cerebral hemorrhage B. A 32-year-old patient with closed-angle glaucoma C. A 55-year-old patient with bronchospastic asthma D. A 40-year-old patient who has a hypersensitivity response to nitrates **The APN is prescribing sublingual nitroglycerin (NTG) to a patient. Which statement by the patient indicates that he understands the education regarding the drug? ** A. "Once I open the nitroglycerin bottle, it is generally effective for 2 years." B. "I can store the unopened bottle on my car dash in case I need it." C. "If my chest pain is not relieved by the second dose of the nitroglycerin, I should take a third dose and call 911." D. "This medication takes a long time to start working." **Anticoagulants** - **Warfarin (Coumadin)** - [Use:] prevention of thrombosis & thromboembolism; DVT, PE, A-fib with thrombus, MI - [MOA:] inhibit vitamin K epoxide reductase enzyme (prevents formation of several clotting factors) - [SE:] bleeding, red/brown urine, black/bloody stool, headache, stomach pain, joint pain, hepatitis - [Monitoring/Teaching:] vitamin K restricted diet (kale, spinach), reversal is Vitamin K; monitor INR (2-3), 3-5 days to reach therapeutic INR, liver function; Do NOT give in pregnancy (crosses placental barrier)---give heparin - **Dabigatran (Pradaxa)** - [Use:] A-fib not caused by heart valve dysfunction; 150mg BID, DVT, PE, prevent CVA - [MOA:] IIa inhibitor -- block thrombin receptors to prevent activation of clotting factors - [SE:] bleeding, hypotension, GI upset, angioedema - [Monitoring/Teaching:] no INR required; reversal is Idarucizumab (Praxabind) - **Rivaroxaban (Xarelto), Apixaban (Eliquis**) - [Use:] nonvalvular A-fib, prevent DVT & PE - [MOA]: Factor Xa inhibitor - [SE:] bleeding, increased LFTs - [BBW:] do not stop abruptly = increased risk of thromboembolic events - [Monitoring/Teaching:] **Heparin** - [Use:] DVT, PE, CVA, thromboembolis - [MOA:] activates antithrombic which inhibits thrombus formation; prevents new clots and prevents current clots from growing but does not break up clots - [SE:] bleeding, HIT (microclots that cause ischemia to appendages), hypersensitivity - [Monitor/ teaching:] monitor APTT levels, therapeutic level should be 45-80 if \>80= problem! - [Antidote:] **protamine sulfate** **Antiplatelet** - **Clopidogrel (Plavix)** - [Use:] prevention of platelet aggregation, prevent MI and CVA in patients with CAD - [MOA:] ADP receptor antagonist - [SE:] bleeding, hypotension, dysrhythmias, GI upset, rash

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