Study Guide Exam 4 PDF

**Which insulin regiments can lower HgA1c** a. Basal bolus b. Intensive insulin replacement reduced A1C improved long-term outcomes i. Multiple daily injections of insulin ii. Continuous subcutaneous administration via an insulin pump **What is an adverse effect of not having ins...

**Which insulin regiments can lower HgA1c** a. Basal bolus b. Intensive insulin replacement reduced A1C improved long-term outcomes i. Multiple daily injections of insulin ii. Continuous subcutaneous administration via an insulin pump **What is an adverse effect of not having insulin**? c. Lack of insulin can result in iii. Hyperglycemia iv. Ketoacidosis -- acidic, fruity breath, high bs, losing weight, lipids and triglycerides are high. Nausea vomiting abdominal pain v. Tissue catabolism vi. Hypertriglyceridemia **What does the basal dose of insulin do?** Basal insulin suppresses hepatic glucose production and when used in appropriate doses should maintain near normoglycemia in the fasting state **What is the purpose of bolus insulin in a basal bolus program?** Bolus insulin (prandial/premeal) covers the extra requirements after food is absorbed, thereby decreasing postprandial glucose excursions. **Which insulin are considered "basal" i.e. long-acting?** vii. NPH viii. Long-acting insulin analogs (longer duration of action, flatter, more constant plasma levels 1. Insulin glargine 100U and 300U 2. Insulin detemir 3. Insulin degludec 100 U and 200 U ix. Continuous delivery or rapid-acting insulin via a pump **Which insulins are considered "bolus," i.e., short-acting?** d. Regular e. Rapid-acting analogs (quicker onset and peak, shorter duration of action, less weight gain and lower A1C and less hypoglycemia) x. Lispro (U-100, U-200) xi. Aspart xii. Faster aspart xiii. Glulisine **What is the onset of lispro insulin?** 15 to 30 min **What is the duration of action of insulin glargine?** 20 to more than 24 hours **What is the general percent of basal and bolus insulin needed in a newly diagnosed type 1 diabetic?** 50% basal and 50% prandial **What are factors that need to be considered when dosing insulin?** Carbohydrate intake and higher doses required during pregnancy, puberty, and medical illness. If a patient gets sick we will have to increase their insulin doses. **What is the total daily dose of insulin when starting U/Kg, what is the typical dose once stabilized x-x u/kg?** 0.5 U/kg when starting. 0.4-1 U/kg when stabilized. **What factors should be considered for bolus (prandial) insulin?** f. Controls postprandial glucose g. Well timed xiv. Pharmacokinetics of formulation 4. Regular, rapid-acting, inhaled 5. Pre-meal glucose level 6. Carbohydrate consumption a. If carb counting is effective estimates of fat and protein content should be incorporated 7. Anticipated activity (muscle utilization of glucose) -- are they laying around or going for a jog. If going out for a jog we might decrease the insulin intake **Where should insulin be injected, benefits of rotating sites, and what effects IM insulin injection absorption?** - - - - - - - - - - - - - 14. **What are five factors that are associated with Type II diabetes? (i.e. insulin resistance)** - - - - - - - - 15. **What lifestyle factors are associated with Type II diabetes?** h. Diabetes self-management, education, support, avoidance of clinical inertia, and social determinants of health i. Established/high-risk atherosclerotic CV disease/HF/CKD xv. Include agents that reduce cardiorenal risk j. Pharmacologic approaches xvi. Adequate efficacy xvii. Maintain treatment goals k. Weight management 16. **MOA of metformin** Decreases hepatic glucose production, decreases intestinal absorption of glucose, and improves insulin sensitivity (increases peripheral glucose uptake and utilization) 17. **Metformin severe ADE** xviii. GI NVD, flatulence, dyspepsia, abdominal pain (rapid dose escalation, IR formulation, chronic asymptomatic gastritis) xix. Lactic acidosis (increases with increased serum levels, kidney impairment, hepatic impairment, decreased tissue perfusion, [\>]65 y/o, contrast, excess alcohol, hypoxic states) xx. Vitamin B12 deficiency interferes with absorption of B12 (duration of therapy, higher dosages, inadequate B12 stores, [\>]65 y/o 18. **Metformin contraindications?** Several drug interactions, severe renal impairment (CrCl \ 1. enhancement of glucose-dependent insulin secretion 2. slowed gastric emptying causing a decrease in food intake 3. reduction of postprandial glucagon 22. **Which medications are GLP-1** liraglutide, lixisenatide, semaglutide, dulaglutide, exenatide 23. **Which cancer is associated with GLP-1** Medually thyroid cancer, thyroid C-cell tumors 24. **If glucagon production is decreased what happens to glucose production in the liver?** Decrease glucagon secretion leads to Decreased hepatic glucose production 25. **Do Thiazolidinediones increase insulin production or increase insulin sensitivity in fat, muscle, and liver?** Increased insulin sensitivity in fat, liver, and skeletal muscle 26. **What is a very serious potential ADE associated with Sulfonylureas?** Hypoglycemia 27. **Which drug is preferred as initial therapy in Type II diabetes?** Metformin 28. **GERD which agent works faster, and which works longer?** Antacids work the fastest. PPI work the longest and H2 are good but not better than PPI. 29. **What is a caution/ADE when using IV H2 antagonist in the elderly** Central nervous system effects like Delirum and renal impairments. 30. **PPI Bind to the H/K-ATPase system (proton pump) and Suppress secretion of hydrogen ions in the gastric lumen resulting in what?** Inhibition of gastric acid secretion by parietal cells. Reduced stomach acid secretion 31. **What ADE is associated PPI use in the elderly when used for more than a year?** Osteoporosis 32. **When should antiacids be administered to improve effectiveness?** 1 hour after meals and at bedtime 33. **What side effect is associated with magnesium-based antiacids** Diarrhea 34. **What side effects are associated with aluminum-based antiacids?** Constipation 35. **Mechanism of action of sucralfate** Forms a complex by binding with exudate, forming a paste-like adhesive substance. This paste binds and protects ulcers and gastric lining from peptic acid, pepsin, and bile salts. 36. **ADE associated with sucralfate use in patients with renal failure** Risk of aluminum toxicity in patients with renal impairment 37. **In the treatment of GERD what has a faster onset of action in promoting tissue healing PPI or H2RA?** PPI are better. 38. **When are high potency topical corticosteroids prescribed?** Severe skin issues like Severe dermatitis, eczema, psoriaisis 39. **Side effects of topical corticosteroids?** 40. **Know the potency scale for topical corticosteroids** A screenshot of a computer Description automatically generated Look at 12.1 below 41. **When are topical corticosteroids contraindicated?** Infections of the skin, hypersensitivity, around the eyes if untreated infection 42. **MOA of topical corticosteroids** Immune cells interfere :antigen processing, Suppress the release of cytokines 43. **What medications for skin disorders are prescribed in immunosuppressed patients?** IV antivirals and inpatient observation 44. **Know systemic antifungal medication monitoring** Renal and liver enzymes 45. **Know steroid potency from highest to lowest**  46. **Know what oral medications are prescribed for severe acne and the potential ADE** Oral antibiotics like tetracyline. Potential ADE include GI upset. 47. **Know how to interpret lab values for hypo and hyperthyroidism** Hypothyroidism - Thyroid-Stimulating Hormone (TSH): Elevated. TSH is produced by the pituitary gland and stimulates the thyroid to produce thyroid hormones3. When thyroid hormone levels are low, the pituitary produces more TSH to stimulate the thyroid. - Thyroxine (T4): Low. T4 is one of the main hormones produced by the thyroid3. - Free T4 (FT4): Low. This is the portion of T4 that is not bound to proteins and is available to enter tissues3. - Triiodothyronine (T3): Low. T3 is the active form of thyroid hormone4. Hyperthyroidism - Thyroid-Stimulating Hormone (TSH): Low. When thyroid hormone levels are high, the pituitary produces less TSH3. - Thyroxine (T4): High. T4 levels are elevated in hyperthyroidism4. - Free T4 (FT4): High. This indicates an excess of unbound T43. - Triiodothyronine (T3): High. T3 levels are elevated in hyperthyroidism4. 48. **Know MOA for Levothyroxine** Synthetic form of the T4 produced by the body. Will restore thyroid hormone levels in body. 49. **Differentiate between hypothyroidism, hyperthyroidism, euthyroidism and subclinical hypothyroidism**A table of medical information Description automatically generated with medium confidence Hypothyroidism - Definition: A condition where the thyroid gland is underactive, producing insufficient thyroid hormones. - Symptoms: Fatigue, weight gain, cold intolerance, dry skin, and increased risk of heart problems(Drugda et al., 2023). - Biochemical Markers: Low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH) levels(Drugda et al., 2023). Hyperthyroidism - Definition: A condition characterized by an overactive thyroid gland, producing excessive thyroid hormones. - Symptoms: Weight loss, heat intolerance, increased appetite, and anxiety. It may also present with myxedema, a condition typically associated with hypothyroidism(Sciacchitano et al., 2024). - Biochemical Markers: Elevated levels of thyroid hormones (T3 and T4) and suppressed TSH levels(Hirano et al., 2024). Euthyroidism - Definition: A state of normal thyroid function where the thyroid gland produces adequate amounts of hormones. - Biochemical Markers: Normal levels of thyroid hormones and TSH, indicating balanced thyroid function(Sciacchitano et al., 2024). Subclinical Hypothyroidism - Definition: A mild form of hypothyroidism where TSH levels are elevated, but thyroid hormone levels remain within the normal range(Jassim & Al-Jubory, 2024) (Drugda et al., 2023). - Symptoms: Often asymptomatic, but can be associated with an increased risk of coronary heart disease(Drugda et al., 2023). - Prevalence and Management: Commonly diagnosed in older adults, with spontaneous normalization in many cases. Treatment is debated, especially in the elderly, due to potential overtreatment risks(Ruderich & Feldkamp, 2022). 50. **Monitoring hypothyroidism treatment** Checking TSH every 6-8 weeks 51. **Dosing hypothyroidism medication in special populations such as elderly and pregnancy** Pediatrics l. Screening at birth xxi. Treatment with L4 xxii. Newborn dose 10-17mcg/kg/day xxiii. 6 months 5-7 mcg/kg/day xxiv. 1 -- 10 years 3-6 mcg/kg/day xxv. [\] 12 years adult dosing m. Acquired hypothyroidism often caused by autoimmune thyroiditis xxvi. Increased incidence xxvii. More prone to ADE 8. Start with a low dose and titrated b. Symptom improvement c. TSH --goal is the higher end of normal Pregnancy n. Untreated xxviii. Miscarriage xxix. Preterm delivery xxx. Maternal hypertension xxxi. Preeclampsia xxxii. LBW xxxiii. Still birth xxxiv. Child, impaired intellectual development o. If treated prior to pregnancy, increase the dose by 20-50% to maintain TSH \ 52. **What is autoimmune hypothyroidism** Hashimoto's disease 53. **Know the different medications in the treatment of hypothyroidism and where they are derived from** 1\. \*\*Levothyroxine (Synthetic T4)\*\*: This is the most commonly prescribed medication for hypothyroidism. It is a synthetic form of thyroxine (T4), identical to the hormone produced naturally by the thyroid gland. 2\. \*\*Liothyronine (Synthetic T3)\*\*: This medication contains synthetic triiodothyronine (T3), which is the active form of thyroid hormone - It is sometimes used in combination with levothyroxine or for patients who do not convert T4 to T3 efficiently - 3\. \*\*Desiccated Thyroid (Natural Thyroid)\*\*: This medication is derived from the dried thyroid glands of pigs and contains both T3 and T4 hormones. It is less commonly used today but still prescribed in some cases. 54. **Know therapeutic lab values for thyroid** TSH (mU/L)\*\* \| 0.4 - 4.5 Free T4 (ng/dL)\*\*\| 0.9 - 2.3 Total T4 (µg/dL)\*\*\| 5.0 - 11.0 Free T3 (pg/mL)\*\*\| 2.3 - 4.2 55. **Know the symptoms of hypothyroidism and hyperthyroidism** Hypothyroidism (Underactive Thyroid) - Fatigue - Weight gain despite a normal diet - Cold intolerance - Dry skin and hair loss - Constipation - Depression and mood swings - Muscle weakness and joint pain - Memory problems and difficulty concentrating - Hoarseness of voice - Puffy face Hyperthyroidism (Overactive Thyroid) - Weight loss despite an increased appetite - Heat intolerance - Increased sweating - Nervousness and anxiety - Rapid or irregular heartbeat (palpitations) - Tremors (shaking hands) - Frequent bowel movements or diarrhea - Muscle weakness - Sleep disturbances - Fine, brittle hair and hair loss - Changes in menstrual patterns 56. **What medication do you use to manage hyperthyroidism** Antithyroid drugs methimazole and propylthiouracil Beta-blockers to help with cardiac effects while waiting for ATD to take effect Iodine comppounds 57. **What is a thyroid storm** Thyroid storm is a life-threatening condition that results from severe thyrotoxicosis. Triggers include infection, trauma, thyroidectomy, RAI treatment, and abrupt discontinuation of anti-thyroid medications. The clinical presentation of thyroid storm includes signs and symptoms seen in hyperthyroidism but intensified. Treatment is aggressive and requires admission to the intensive care unit. Rapid symptom resolution is accomplished with IV beta-blockers, large doses of ATD, iodine solution, corticosteroids, acetaminophen, cooling blankets, fluids, nutritional support, and respiratory care. 58. **What medication is used in the treatment of long-term hyperthyroidism** Antithyroid drugs methimazole and propylthiouracil, and RAI therapy 59. **What is the indications for high dose topical steroids?** Acute flare ups of lesions and prevention 60. **What are common ADE associated with long term use of topical corticosteroids?** - - - - - - - - 61. **Which class of steroids are safe to use on face?** Low potency. Others will cause rosacea or atrophy of tissue 62. **What are the contraindications to the use of topical corticosteroids?** Open wounds, infections, 63. **What is the mechanism of action of topical corticosteroids?** Interfere with immune cells and suppress cytokines to ultimately reduce inflammation. 64. **Which topical medication can be used in the ocular region? What about immunosuppressed patients?** Topical Calcineurin Inhibitors: Tacrolimus ointment, Pimecrolimus cream 65. **When using systemic antifungals to treat onychomycosis what labs should you monitor?** Liver, renal, CBC, WBC 66. **Know the categories of the topical corticosteroids and be able to rank them from weakest to strongest.**  67. **Which oral medication is used to treat severe treatment-resistant acne?** isotretinoin 68. **Isotretinoin monitoring parameters** 2 neg preg tests prior to initiation and monthly pregnancy tests. Cholestrol, triglyceride levels, cbc, and liver function all at initiation and at 4 weeks then as needed 69. **Which labs indicate hypothyroidism?** TSH is high T4 is low 70. **Mechanism of action of levothyroxine in treatment of hypothyroidism?** Synthetic T4. You are replacing the thyroid hormone 71. **with low TSH and elevated T4 levels indicate what disease state?** hyperthyroidism 72. **After diagnosing and starting treatment of hypothyroidism, when and what should you monitor?** 73. **How would you treat a patient with a history of cardiac disease and is now diagnosed with hypothyroidism? Why** Side effects of drugs can worsen cardiac disease. Use beta-blockers 74. **What is low T4 levels indicative of?** hypothyroidism 75. **What are the signs/symptoms/characteristics of Hashimoto's disease?** Enlarged thyroid,Fatigue, weight gain, cold intolerance, dry skin, hair loss, constipation, depression, memory problems, and muscle aches It is an autoimmune disease from lack of iodine needed to synthesize thyroid hormone. Treat with levothyroxine. 76. **Which thyroid product is derived from animals?** Desiccated thyroid is derived from cow and pig thyroid 77. **What is the target TSH level when treating hypothyroidism?** 0.4 to 4.0ml 78. **Which group of patients is most like to have ADEs associated with treatment of hypothyroidism?** Elderly 65 and older 79. **Signs symptoms of hyperthyroidism?** Heat intolerance. T4 is elevated and TSH low. 80. **What is a complication of untreated hyperthyroidism?** Thyroid storm! Untreated thyrotoxicosis can result in atrial fibrillation, congestive heart failure, embolic events, and osteoporosis 81. **What is a long term treatment of hyperthyroidism?** antithyroid drugs (ATD) are available in the United States: methimazole (MMI) and propylthiouracil (PTU). Radioactive Iodine therapy (RAI therapy)