NR 566 Week 1-3 Midterm Exam Study Guide: Diabetes Management and Medications, Exams of Nursing

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NR 566 Week 1 - 3 Midterm Exam

Week 1

Professor question: Why are statins recommended in the evening instead of morning? (pg 561) After starting John on insulin, he calls the office saying he feels bad. He said when he checked his blood sugar before calling it was 52 mg/dl. What instructions should he be given?

Answer from classmate : Statins are recommended to be taken in the evening. Cholesterol synthesis is highest through the night and first thing in the morning. The biosyntheses of cholesterol follows a normal circadian rhythm. Administration at night allows for the medication to be at peak levels in the body during the time of high cholesterol synthesis (Korani et al., 2019). A blood glucose level <70mg/dL is considered to be hypoglycemia. John called the office with a sugar of 52mg/dL. He would be given instructions that follow "the rule of 15". This means that when symptoms occur, he should consume 15 g of a fast-acting carbohydrate. After 15 minutes, he should recheck his blood glucose. John should also be educated on the best options of carbohydrates to consume. Examples would be 4 oz of juice, four-five hard candies, honey, or half a can of regular soft drink. Another education point is that John needs to have a meal within a few hours after the low blood glucose. He may also need to see his doctor for adjustments to be made on insulin dosage as well as meal patterns to help prevent another low blood glucose episode from occurring (Woo & Robinson, 2016).

Professor question : What diabetic medications would be contraindicated in patients with heart failure?

Which diabetic drug(s) may have beneficial effects in heart failure?

(text has info on this but ADA 2020 guidelines has even more up to date info on this topic, so here is the page. See Recommendation 9.9 and 9.10)

https://care.diabetesjournals.org/content/43/Supplement_1/S

answer from classmate : Suppose John was showing signs of heart failure. What diabetic medications would be contraindicated in patients with heart failure?

Metformin is contraindicated in patients with renal insufficiency and unstable heart failure (Woo & Robinson, 2016). According to the American Diabetes Association

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and if his HgbA1C is not sufficiently controlled at the 3 month follow up then, long acting Lantus insulin should be added to the regime. Additionally, John should be placed on an Angiotensin Converting Enzyme inhibitor or Angiotensin Receptor Blocker and likely increase his atorvastatin to 20mg tablet (ADA, 2020).

Which diabetic drug(s) may have beneficial effects in heart failure?

With the scenario presented previously and with the addition of heart failure, John should be placed on either a sodium-glucose cotransporter 2 inhibitor (SGLTi) or a glucagon-like peptide 1 receptor agonist (GLP-1 RA) to improve glycemic management (ADA, 2020a). Both SGLT2i and GLP-1 RA have demonstrated cardiovascular disease benefits by reducing CVD events and HF hospitalizations in association with diabetes mellitus (ADA, 2020b). The differential in which medication to use for John would be based on his Glomerular Filtration Rate (GFR), decreasing GFR rates or worsening chronic kidney disease would indicate stoppage of SGLT2i and use of GLP-1 RA. Per the American Diabetes Association (2020), John with mild HF would be initially placed on a GLP 1- RA Liraglutide (Victoza). Victoza is a once daily injection that aids in treating T2DM by increasing insulin synthesis and release, decreasing amount of glucagon and gastric emptying, and reducing food intake (Woo & Robinson, 2016). Additionally, placing John on a GLP-1 RA would help decrease his obesity with its proven beneficial tendency to increase metabolism and improve weight loss (Woo & Robinson, 2016).

Professor question: What lab do we need to check prior to starting metformin? (hint: which organ function needs to be evaluated?)

What other potential adverse effects are there associated with metformin? (Micromedex in the library is a good source for this info)

Answer : The most important lab is eGFR/renal function since this determines whether we can safely use metformin. See recommendations below.

I also included information on contrast administration. The concern is that if dye impairs renal function, the risk of lactic acidosis is increased.

Another potential adverse effect is B12 deficiency.

"Clinical recommendations based upon the patient’s renal function

• Before initiating therapy, obtain an eGFR
• Initiation of therapy is not recommended in patients with eGFR between 30 – 45 mL/minute/1.73 m²

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• Obtain an eGFR at least annually in all patients receiving therapy
• In patients at increased risk for development of renal impairment (e.g., the elderly), renal function should be assessed more frequently

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concentration of thyroid hormones. It is proposed that carbamazepine increases the extra-thyroidal metabolism of thyroid hormones (Woo & Robinson, 2016). Total T measures the bound and free thyroid hormone and can change when binding proteins

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differ. Free T4 measure what is not bound and able to enter and affect the body tissues. The normal range for Free T4 is 0.7-1,86 ng.dL (9-24 pmol/L) In hypothyroidism, you would expect the Free T4 to be low whereas in hyperthyroidism, you would expect the Free T4 to be high.

Professor question : Can you review in our text the sulfonylurea class? What is the MOA, what are some examples? What are the adverse effects? Thanks!!

Answer from classmate : According to the text, the sulfonylurea class was the first class of oral drugs developed to help manage blood glucose levels in patients with type 2 diabetes mellitus. This class of drug has shown to be similarly effective as metformin and have the ability to reduce HbA1c levels by about 1,5%(Woo & Robinson, 2016). This class of drug’s mechanism of action is the increase the secretion of insulin via the stimulation of beta cells of the pancreas (Costello & Shivkumar, 2020) thus it is important that the patient is still able to produce some endogenous insulin. The drugs improve the binding between the insulin and the insulin receptors thus improve the utilization of the insulin to a certain extent (Woo & Robinson, 2016). These drugs may also enhance the effect of the diuretic hormone and have a slight diuresis effect. Sulfonylureas are recommended as a co-therapy, the drug is not as effective as a monotherapy since it is unable to sustain glycemic targets over time(Woo & Robinson, 2016). Some examples of sulfonylurea drugs are: Chlorpropamide, Tolazamide, Glipizide, and Glimepiride

Professor question : If our patient had HF and Afib, he might be on digoxin. What medication for DM can decrease digoxin levels? (class and examples)

Pg 579

Classmate answer: Acarbose and miglitol decrease digoxin levels when given together. Acarbose and Miglitol are oral antihyperglycemic drugs that treat type II diabetes and are classified as alpha-glucosidase inhibitors. These drugs competitively inhibit the absorption of complex carbohydrate from the small intestines. This result in delayed digestion of carbohydrates causing flatulence. Alpha-glucosidase inhibitors lower blood glucose after meals. Since this class of drugs reduce digoxin concentrations thus reduce effect, it is recommended to choose another antihyperglycemic drug that does not interact with digoxin. These drugs are gives as an adjunct with other therapy for type II diabetes. The most common adverse reactions are GI disturbances but these side effects cab be reduces if the dose is titrated slowly.

Professor question : Jason- glad you recognized that contrast dye can be an issue for patients on metformin.

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Classmate answer : Wow, I am glad you brought that to my attention. I work in the emergency room and have heard radiology give the speech over and over. It usually goes something like "don't take your glucophage for 48 hours because it binds with the dye and makes it harder to pass" and they hand them a piece of paper that tells them when to start taking it again. Now I know this is not the case. In the emergency room we check the patient's kidney function prior to giving the contrast. We have an acceptable range for non diabetic patients and a range for diabetic patients. On occasion we give IV contrast to patients with poor kidney function with the understanding that they will have dialysis afterwards. "There is controversy about the causal relationship between exposure to IV CM and PC-AKI" (Van der Molen et. al, 2018). In the ER setting there is no follow up to check kidney function post IV contrast. It has been mentioned that the patient can start their glucophage after 48 hours as long as kidney function remains acceptable but this seems like a step that is skipped. Making sure the patient is hydrated seems to be emphasized more, either through PO or IV routes. This will help maintain proper kidney function after receiving IV contrast.

Professor question: Can you review for us what the ADA criteria for diagnosis of T2DM are? Classmate answer: The ADA diagnoses T2DM based on several criteria. The patient may have a fasting glucose of 126mg/dL (7.0 mmol/L) or higher. A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher in the midst of a 75-g oral glucose clearance test. Also, a random plasma glucose of 200mg/dL (11.1 mmol/L) or higher with a patient that is also displaying signs of hyperglycemia or that they maybe in a hyperglycemic crisis. And lastly, the patient has a hemoglobin A1c level of 6.5% (48 mmol/dL) or higher (ADA, 2020).

Professor question: If John’s A1C remains elevated and he does not have any indicators or at high-risk for ASCVD, CKD, or HF, a thiazolidinedione (TZD) could be prescribed (American Diabetes Association, 2020). How do thiazolidinediones help control blood sugar? Why is it important that there is little to no risk indicators for cardiovascular involvement when prescribing TZDs? pg 581-

Classmate answer: Pioglitazone (Actos) and rosiglitazone (Avandia) are the two thiazolidinedione (TZD) that are available in the United States. TZD’s help by improving insulin sensitivity. The presence of insulin is needed for TZD’s to work which makes them ideal in the management of Type II Diabetics. TZD’s act on the peroxisome proliferator-activated receptor gamma. This receptor helps regulate gene transcription resulting in expression of proteins that improve insulin action in the cell. This mechanism of action provides an increased utilization of available insulin by the liver and muscle cells as well as that in adipose tissue (Micromedex, 2020).

TZD’s prescription use is contraindicated in patients with NYHA class III or IV heart

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failure. Initiating or increasing dose of TZD’s requires the observation of any possible signs of heart failure. Heart failure signs and symptoms can include, rapid weight gain, dyspnea, and edema (Teri Moser Woo Phd Aprn Cnl Cpnp-pc Faanp et al., 2015, p. 581).

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Professor question: If John is started on insulin and he still struggles to meet A1C goals, a sodium–glucose cotransporter 2 (SGLT2) inhibitor to insulin therapy has shown the ability to improve A1C levels while also aiding in decreasing body weight when

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compared with insulin therapy alone (American Diabetic Association, 2020). How do SFLT2 drugs work and what are some examples of drugs in that class? Pg 589

Classmate answer: Sodium-glucose cotransporter-2 inhibitors also referred to as SGLT- 2 inhibitors or gliflozins work through a mechanism of action that prevents SGLT2 in the kidney from reabsorbing glucose from the glomerular filtrate for its return back to the plasma resulting in increased urinary glucose excretion and lower plasma glucose concentrations (U.S. Food and Drug Administration, 2018). In normoglycemic individuals, renal filtration handles 160 -180 grams of glucose daily of which more than 99% is reabsorbed and returned to the systemic circulation through the proximal tubules (Seufert, 2015). The SGLT2 acting on the proximal convoluted tubules regulate the major pathway for renal glucose reabsorption and its inhibition by medications in this drug category promote therapeutic glucosuria, thereby achieving desired plasma glucose levels (Garber et al., 2020). This mechanism of action is unique to this class of drugs enabling plasma glucose lowering activity that is independent of insulin secretion, pancreatic beta-cell mass, and insulin sensitivity (Seufert, 2015). SGLT2 inhibitors are prescription glucose lowering agents in tablet form and are FDA-approved for use with diet and exercise to decrease blood sugar levels in type 2 adult diabetics (U.S. Food and Drug Administration, 2018). Utilization of these medications demonstrate reductions in plasma glucose, HgbA1c, body weight, and blood pressure (Garber et al., 2020). Studies also show statistically significant results in lowering rates of all-cause cardiovascular death, myocardial infarction, non-fatal stroke, lower risk of associated hospitalizations for heart failure, and reduced progression of renal disease (Garber et al., 2020). The American Diabetes Association (2019) has recommended to consider the use of SGLT2 inhibitors in type 2 diabetes patients with an estimated glomerular filtration rate of greater than or equal to 30 ml / minute / 1.73 m2 and particularly in cases with greater than 300 mg / g albuminuria to reduce the risk of diabetic kidney disease progression, cardiovascular events, or both. Contraindications to this medications include prior hypersensitivity to its components, severe renal impairment, and patients on dialysis (U.S. Food and Drug Administration, 2018). Precautions for SGLT2 inhibitors include risks for volume depletion, ketoacidosis, urosepsis and pyelonephritis, hypoglycemia, necrotizing fasciitis of the perineum (Fournier’s Gangrene), risk of leg and foot amputations, and urogenital mycotic infections (U.S. Food and Drug Administration, 2018). The drug listing in this class include: canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, sotagliflozin, luseogliflozin, tofoglifozin, ipragliflozin, and remogliflozin (Giugliano & Esposito, 2019).

Week 2

Professor FACTS: The current IDSA guidelines (2019) recommend the following 3 options when treating CAP in a previously healthy patient:

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3. Macrolide (if the resistance in the community is not too high).

If a patient has comorbidities (eg DM, COPD) or recent antibiotic use, the recommendation is to use one of the following options:

1. A respiratory fluoroquinolone

Diagnosis and Treatment of Adults with Community-acquired

Pneumonia. An Official Clinical Practice Guideline of the American

Thoracic Society and Infectious Diseases Society of America https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST (Links to an external site.)

2. Beta-lactam plus either doxy or a macrolide

Prednisone should not be prescribed routinely for viral or bacterial pneumonia. Guidelines recommend use in the severely ill ICU patient.

Classmate response: I followed the link to the American Thoracic Society and Infectious Diseases Society of American and reviewed the current official clinical practice guidelines for treating an otherwise healthy adult with community-acquired pneumonia. Previously, when researching, I believe I used articles found within our Chamberlain Library. After reviewing the official clinical practice, I see that the first line of treatment would be high dose Amoxicillin, doxycycline, or like I listed above, a macrolide antibiotic. One of the primary reasons I mentioned prednisone as an additional treatment option is due to reflection of past experience. It is good to see that in the official clinical practice guidelines, that is not routinely prescribed for viral or bacterial pneumonia. I have been prescribed a respiratory fluoroquinolone, levofloxacin, in the past to treat pneumonia. Levofloxacin is generally a safe, well-tolerated, broad-spectrum antibiotic that has a good pharmacodynamic profile and pharmacokinetic profile, and exhibits low potential for resistance against S. pneumoniae (Metlay, et al., 2019). Important patient teaching for levofloxacin includes the risk that the patient will develop tendonitis or a tendon rupture during the course of treatment or for several months after treatment. It is the recommendation of the FDA that at the first sign of tendon pain, swelling, or inflammation, patients should discontinue the levofloxacin, avoid exercise, and use of the affected area, and contact their provider immediately for a tendon evaluation as well as a change to a non-fluoroquinolone antibiotic (2016). While taking this medication it is important for patients to remain aware of their bodies so that they can quickly notice when there has been a change.

Professor response to classmate: So glad you reviewed the guidelines! They just came out the end of last year.

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I was surprised that Amox made it into the guidelines, but it is related to resistance and that the higher dose can overcome that resistance.

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mismanaged. Examples of misuse or mismanagement include: People do not complete a full course of TB treatment, Health care providers prescribe the wrong treatment (the wrong dose or length of time), drugs for proper treatment are not available, drugs are of poor quality (Centers for Disease Control and Prevention, 2020).

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Acquired or secondary resistance occurs in a patient who has been previously treated for TB. Poorly or inadequately treated TB is the leading cause of secondary resistance. Extensively resistant TB (resistant to multiple second-line drugs) is resistant both to isoniazid and rifampin and to any fluoroquinolone drug and at least one of three second- line injectable drugs (amikacin, kanamycin, or capreomycin). Drug resistance can be proved only by susceptibility testing (Woo, & Robinson, 2016).

If INH resistance is documented in a patient on a 9-month regimen (without PZA), then INH should be discontinued. If EMB was included in the initial regimen, then treatment with RIF and EMB should continue for a minimum of 12 months. If the initial treatment did not include EMB, then testing for drug susceptibility should be repeated, and INH needs to be discontinued and two new drugs should be added (Woo, & Robinson, 2016). The regimen may need to be adjusted when drug susceptibility test results are available. Any patient whose TB demonstrates resistance must be seen by an infectious disease specialist who treats patients with TB. Inadequate treatment is one of the leading causes of secondary resistant TB (Woo, & Robinson, 2016).

Professor question: From our text can you tell us the findings of the SMART trial regaring salmeterol use?

Classmate answer: The Salmeterol Multicentre Asthma Research Trial was a large random controlled trial in asthma patients that evaluated the safety of salmeterol use. The findings showed that a non-significant increase in combined respiratory-related deaths and/or life-threatening events found in patients using salmeterol. The SMART trial also had findings of a statistically significant increase of death and life-threatening situations among African American patients. According to Rottenkolber (2015), "a significantly increased risk for “combined respiratory-related death or life-threatening experience and combined asthma-related deaths or life-threatening experience was found for African Americans who had no prescription of inhaled corticosteroids at baseline."

In the conclusion of the SMART trial contrast, at baseline no significant differences between patients receiving salmeterol or placebo were found in the results as well as previous and current published guidelines. Long-acting beta-2-agonist was recommended to be prescribed only to patients receiving inhaled corticosteroids.

After results were given to the public, according to Rottenkolber (2015), "information for health care providers were sent out by the FDA stating that long-acting beta-2-agonist should be prescribed to asthma patients only if other medicines, including low-or- medium dose inhaled corticosteroids do not control asthma." The FDA imposed a Black box’ warning on long-acting beta-2-agonists.