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NR566 Midterm complete exam
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Bioavailability of bisphosphonate drugs and appropriate patient education - answer Histamine blocking agents double alendronate bioavailability, but the impact is unknown. Aspirin may decrease the bioavailability of tiludronate by up to 50% when taken 2 hours after the tiludronate. Although indomethacin increases the bioavailability of tiludronate by 2- to 4-fold, the bioavailability is not significantly altered by diclofenac; therefore, each NSAID must be considered individually. Adverse effects associated with long-term use of bisphonates - answer Etidronate has also been associated with fractures in patients with Paget's disease when they are given high doses or when therapy lasted longer than 6 months. These patients must be carefully monitored with x-rays and laboratory work to assess for these lesions. The development of a rare form of subtrochanteric femur fracture in non-Paget's patients using bisphosphonates is under close scrutiny and has contributed to movement away from osteopenia prevention care to only osteoporosis therapy (FDA, 2010a). Specifics about administration and education regarding pancreatic enzymes - answer All doses are taken immediately before or with meals or snacks with a fatty component. Fruit, hard candy, fruit juice like drinks, tea or coffee, or popsicles do not require enzymes (CFF, 2009). Capsules may be opened and sprinkled on food. Capsules with enteric-coated beads should not be chewed. They may be sprinkled on soft acidic food that is not hot and that can be swallowed without chewing, such as applesauce or gelatin. Swallow immediately because the proteolytic enzymes may irritate the mucosa. Following with a glass of water or juice or eating immediately after taking the drug helps to ensure that the medication is swallowed and does not remain in contact with the mouth and esophagus for long periods. Pancrelipase is destroyed by acid. Proton pump inhibitors, sodium bicarbonate, or aluminum-based antacids may be used with preparations without enteric coating to neutralize gastric pH. Calcium- and magnesium-based antacids should not be used for this purpose because they interfere with drug action. Enteric-coated beads are designed to withstand the acid pH of the stomach. Enteric-coated formulations should not be mixed with alkaline food or the coating will be destroyed. Common adverse effects with aromatase inhibitors - answer Adverse effects for the drug class include various pain syndromes, vertigo, insomnia resulting in daytime sleepiness and confusion, increased risk of blood clots, and hair loss. A key concern is the loss of bone mass. Bone loss can be significant when considering the concurrent osteoporotic risks of postmenopause. Closer monitoring is required. All patients should be on calcium and vitamin D supplementation. A relative leukopenia can occur, but
the incidence of viral and bacteria infections is not considered greater than matched groups (about 10%). Hypertension occurs in 10% of patients. A life-threatening increase in blood clotting can result in MI, stroke, or pulmonary embolus. Hot flashes can be intense. Drugs associated risk for bone loss which should be monitored - answer Aromatase inhibitors Thyroid hormones Glucocorticoids PPIs SSRIs Clinical signs and symptoms DM - answer Increased thirst Frequent urination Extreme hunger Unexplained weight loss Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin) Fatigue Irritability Blurred vision Slow-healing sores Frequent infections, such as gums or skin infections and vaginal infections Risk factors & associated complications of DM - answer Complications: stroke, heart attack, peripheral artery disease, diabetic retinopathy, cataracts, glaucoma, diabetic nephropathy, peripheral neuropathy, diabetic foot. Risk factors: >45 years old, physical inactivity, 1st degree relative relative with DM, high risk ethic group (african american, hispanic, native american, asian american, and pacific islander), hx of gest DM, htn, HDL < 35, triglycerides >250, polycystic ovarian syndrome, acanthosis nigricans, hx of cardiovascular disease. Diagnostic criteria of DM - answer Acute symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dL.
Short Acting Insulin - answer Regular (Humulin R, Novolin R) Intermediate Acting Insulin - answer Isophane (NPH, Humulin N) Long Acting Insulin - answer Lantus, Levimir Fixed Combo Insulin - answer 70/30 (NPH/regular ratio) 50/50 (NPH/regular ratio) 75/25 (NPH/lispro) 70/30 (NPH/aspart) A1C Treatment Goal - answer Less than 7% Daily dose of insulin for initiation - answer 0.1/kg or 10 units Insulin Treatment Algorithm for Type 1 DM - answer Total daily insulin requirement is 0.3 to 0. units/kg body weight/d with titration to glycemic targets. Higher doses for acute illness. Adjustments made after reviewing patterns over 3 days. Hypoglycemia addressed first, then hyperglycemia. Adjustments up or down done in increments of 1 unit. A1C monitoring during oral or insulin diabetes management - answer Because Hb A1c reflects mean glycemia over the preceding 2 to 3 months, it should be measured at least twice a year if patients are meeting treatment goals or have stable glycemic control; it should be measured every 3 months if therapy has changed or if patients are not meeting treatment goals Correlate mean plasma glucose level according to A1C - answer Hemoglobin A1c Levels Mean Plasma Glucose (mg/dL) 6= 126 7= 154
Clinical manifestations of diabetic autonomic neuropathy - answer Resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sweat gland dysfunction, impaired neurovascular function, and the potential for autonomic failure in response to hypoglycemia. Hypoglycemia treatment (amount of carbohydrates and examples) - answer They should take 15 gm of carbohydrate and recheck their sugars in 15 minutes. Drug monitoring with metformin - answer Monitor B12 levels Antidiabetic medications associated with photosensitivity - answer Sulfonylureas Antidiabetics to avoid in the elderly & why - answer Sulfonylureas produces severe hypoglycemia. Glimepiride produces hypoglycemia. Glyburide is the most likely to cause hypoglycemia. Metformin due to older adults often have renal insufficiency or heart failure. Alpha-glucosidase inhibitors are not well tolerated. All meds should be started at the lowest possible dose.
Symptoms of Hypothyroidism - answer reduced stroke volume and HR, increased peripheral resistance to maintain BP, bradycardia, macrocytic anemia assoc. With B12 deficiency, dyspnea, hypoventilation, CO2 retention, decreased appetite, constipation, weight gain, fluid retention, dry flaky skin, dry hair, slow wound healing, cool skin, decreased libido, confusion, slow speech, memory loss, clumsy movements. Hyperthyroid drugs with risk for hepatic toxicity - answer propylthiouracil Bile acid sequestrants absorption and administration - answer affect LDL-C with a modest increase in HDL-C. They are not commonly prescribed to treat dyslipidemias in patients with diabetes. Not only do they increase TGs but they may pose problems for patients with diabetic gastroparesis. The increase in TG is especially of concern in diabetics because the pancreas is already under stress. Levothyroxine administration instructions - answer Take first thing in the morning at least 30, preferably one hour before eating. On an empty stomach with only water. Achieve consistency in taking the med to avoid fluctuating thyroid levels. Differentiate between primary and secondary hypothyroidism - answer Primary disorders include the following:
- Defective hormone synthesis resulting from autoimmune thyroiditis, endemic iodine deficiency, or antithyroid drugs that were used to treat hyperthyroidism
- Congenital defects or loss of tissue after treatment for hyperthyroidism Secondary causes of hypothyroidism, which are less common, include conditions that cause either pituitary or hypothalamic failure. In secondary disorders, the TSH response is inadequate so that the gland is normal or reduced in size, with both T3 and T4 synthesis equally reduced. Differentiate between primary and secondary hyperthyroidism - answer Primary is the term used when the pathology is within the thyroid gland. Secondary hyperthyroidism is the term used when the thyroid gland is stimulated by excessive TSH in circulation. Precautions and testing for xanthine derivatives - answer Monitored closely for signs of toxicity When therapy is initiated, theophylline levels should be drawn frequently as the dosage is titrated. Signs of toxicity- serum theophylline level should be drawn Once stabilized, monitoring should be done every 6 to 12 months
Mild intermittent asthma - answer Symptoms occur less often than twice a week and the patient is asymptomatic between exacerbations; nighttime symptoms occur less than twice a month; and peak expiratory flow (PEF) is greater than 80% predicted. The use of short-acting beta2 agonists (SABA) should be less than twice a week, unless used for exercise-induced bronchospasm (EIB). Mild persistent asthma - answer Symptoms occur more often than twice a week but less often than once a day and exacerbations may affect activity; nighttime symptoms occur 3 to 4 times a month; and PEF is greater than 80% predicted. Patients with mild persistent asthma may use their short- acting beta2 agonists more than twice a week but not daily, and not more than once daily. Moderate persistent asthma - answer The patient is having daily symptoms; requires daily use of a beta2 agonist; exacerbations affect normal activity; nighttime symptoms occur more often than once a week; and PEF is greater than 60% to less than 80%. Severe persistent asthma - answer The patient has some degree of symptoms all the time; extremely limited physical activity and frequent exacerbations; frequent nighttime symptoms, often 7 days a week; and decreased lung function (PEF less than 60% predicted). Table 30-1 outlines the classifications of asthma severity in patients aged 12 years or older. Risk factors for fatal asthma attacks - answer Previous severe exacerbations requiring intubation or ICU. Two or more hospitalizations. More than 3 ED visits in the past year. Use of more than 2 SABA canisters per month. Difficulty perceiving airway obstruction or worsening asthma. Low socioeconomic status or inner-city residence. Asthma step therapy - answer The Expert Panel Report 3: Guidelines (NAEPP, 2007) recommends a stepwise approach to the pharmacological management of asthma. Management can begin at a higher level and gradually step down or start low and move up, depending on the patient's status when beginning treatment. Step 1: SABA PRN
- inhaled corticosteroids do not modify the long-term decline in FEV1 seen in COPD, but as both monotherapy and in combination with inhaled bronchodilators they decrease exacerbations and improve health status in patients with symptomatic COPD Therefore, the current ACP and GOLD guidelines recommend starting a patient on moderate- to high- dose inhaled corticosteroids Combination therapy of ICS and a long-acting beta agonist, such as Advair (salmeterol/fluticasone), is more effective in decreasing exacerbations than either agent alone combination therapy should be considered in any patient with moderate to severe COPD defined by FEV1 less than 60% of predicted. Oral corticosteroids are useful in the short-term treatment of acute COPD exacerbation Use of oral corticosteroids in the treatment of asthma - answer Inhaled corticosteroids are the preferred long-term control medications for managing the inflammatory process associated with asthma. Dosages for the inhaled corticosteroids vary with the specific product and the delivery method. The patient with persistent asthma is started on inhaled corticosteroids according to the All patients with mild persistent asthma are started on a low dose of inhaled corticosteroids. Children older than age 12 and adults may be treated with cromolyn, nedocromil, leukotriene modifiers, or theophylline as alternative therapy. Pneumonia goals of treatment - answer Return to baseline respiratory status Fever resolves in 2 to 4 days Leukocytosis resolves by day 4 of treatment Chest x-ray may take 4 weeks or more to return Common bacterial pathogens of Adult pneumonia - answer S. pneumoniae Patients with underlying lung disease Nontypeable Haemophilus influenza and Moraxella catarrhalis Staph aureus: co-pathogen with influenza Mycoplasma pneumoniae Viral pneumonia
Common bacterial pathogens of Adult Community-Acquired Pneumonia - answer Consult current treatment guidelines for the most recent treatment guidelines for community acquired pneumonia (CAP) Common bacterial pathogens of CAP in pregnant women - answer Main pathogens are S. pneumoniae H. influenzae, M. pneumoniae, and viruses Macrolides Pregnancy category B: erythromycin, azithromycin Pregnancy category category C: clarithromycin Comorbid conditions or recent antibiotics: Beta-lactam plus a macrolide Common pediatric pneumonia pathogens - answer S. pneumoniae is the most common cause of bacterial pneumonia in patients of all ages Increase in viral pneumonia with PCV7 vaccine Infants 4 to 16 weeks Consider chlamydia Over 5 years through adolescence Consider mycoplasma Community-acquired methicillin-resistant staphylococcus aureus Virus Clinical practice guidelines for treatment of CAP - answer Children under age 5 years Bacterial pneumonia (S. pneumoniae) Amoxicillin: 80 to 90 mg/kg/day Ceftriaxone: 50 mg/kg/day until able to take oral antibiotics Penicillin allergy: clindamycin or a macrolide Infant with suspected chlamydial pneumonia Azithromycin 20 mg/kg/day for 3 days OR erythromycin (EryPed) 50 mg/kg for 14 days Children 5 Years or Older
Myocardial infarction. Life-threatening arrhythmias. Severe or worsening angina pectoris. Bupropion is contraindicated in patients with seizure disorders, bulimia, and anorexia nervosa and within 14 days of MAOIs. Tuberculosis Etiology - answer Infectious disease caused by M. tuberculosis· Inhaled into the alveolus and spreads from lungs· M. tuberculosis grows slowly· Infection is spread almost exclusively by aerosolization of contaminated lung secretions Rational drug selection for pregnancy for tuberculosis - answer INH and RIF. EMB should be included unless INH resistance is unlikely. 6 month therapy. Pyridoxine (vit b6) 25 mg/d should be added to the regimen to decrease incidence of peripheral neuropathy assoc with INH. Rational drug selection for children for tuberculosis - answer INH and RIF are used for asymptomatic infection for 6-9 months. Multidrug regimens (INH RIF PZA EMB) are used for progressive disease. EMB may be used if risk of drug-resistant organisms is present. DOT should be used for all children. Criteria for resistant TB diagnosis - answer Primary resistance risk factors: exposure to a patient with drug-resistant TB, immigration from a country with a high prevalence of d-r TB, and greater than 4% incidence of d-r RB in the community. Acquired/Secondary risk factors: poorly or inadequately treated TB. DRUG RESISTANCE CAN ONLY BE PROVEN BY SUSCEPTIBILITY TESTING. Second-line treatment usually requires injectable medications, which complicates the treatment regimen. Fluoroquinolones such as levofloxacin, moxifloxacin, and gatifloxacin are all active against M. tuberculosis. Based on the evidence so far, levofloxacin is the preferred oral fluoroquinolone for treating drug-resistant TB or when first-line agents cannot be used because of intolerance Risk factors for fatal hepatitis with INH use - answer Pregnant and postpartum patients. Patients 50- 64 years of age. Daily alcohol use, chronic liver disease, IV drug use. Black and hispanic women.INH has a black-box warning regarding the development of severe/fatal hepatitis, even after months of treatment.
Prophylactic TB treatment for high risk patients - answer INH or via DOT with weekly INH/RPT. Standard anti-TB drugs ING and RIF used for asymptomatic infection for 6-9 months. ACEIS and ARBS benefits in other conditions - answer CAD, Post MI, heart failure. Clinical pearl: If you hear an abdominal bruit in a patient known to have vascular disease, give captopril, a short-acting ACEI, and measure serum creatinine prior to the dose and within 1 or 2 days after the dose. A rapid rise in the creatinine level suggests renal artery stenosis. A slower rise probably indicates a problem with poor hydration that can be corrected by rehydrating the patient and discontinuing or lowering the dose of any diuretics the patient is taking. Management of ACEI side effects - answer Education concerning hypotensive reactions. For ACEI-related cough, no effective treatment - may change to another ACEI or ARB. Change in taste resolves on its own within 8-12 weeks. Amiodarone monitoring - answer Cxray, PFT every 3-6 mo. TSH, free T4 every 6 mo. Opthalmic exam (slit lamp and fundoscopy) every 6 mo. Flecainide monitoring - answer ECG, liver function studies, serum drug levels. Watch for sinus node problems and AV block. Keep trough <1 mcg/mL. Mexiletine monitoring - answer Liver function studies, Aspartate aminotransferase (AST) elevations > times upper limit of normal have been observed. Procainamide monitoring - answer CBC and Antinuclear antibody (ANA) titer. At intiation of therapy for blood dyscrasias; at initiation for indication of lupus-like symptoms. Propafenone monitoring - answer Liver function studies, CBC, renal and liver function studies Sotalol monitoring - answer Fasting blood glucose
assist in decreasing heart rate resulting from conditions such as hyperthyroidism and from negative feedback patterns secondary to decreased cardiac output.
- Conditions that heighten the myocardium's contractile response. Beta blockers and CCBs both have negative inotropic effects. Angina - answer Pain in the heart region caused by lack of oxygen. Ischemia caused by the imbalance between myocardial oxygen supply (MOS) and myocardial oxygen demand (MOD) produces pain referred to as. Angina risk factors - answer smoking, hypertension, hypercholesterolemia, low high-density lipoprotein (HDL) cholesterol, diabetes mellitus. Class I Angina - answer Proven coronary artery disease without symptoms Ordinary physical activity, such as walking or climbing stairs, does not cause angina. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation. Class II Angina - answer Angina only with unusually strenuous physical exertion Slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly; walking uphill; walking or stair climbing after meals; in cold wind; under emotional stress; or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of ordinary stairs at a normal pace and in normal conditions does not cause angina. Class III Angina - answer Angina during routine physical activity Marked limitations of ordinary activity. Angina occurs on walking one to two blocks on the level and climbing one flight of stairs in normal conditions and at a normal pace. Class IV Angina - answer Angina during minimal activity or rest Inability to carry on any physical activity without discomfort. Angina may occur at rest. Short-acting Nitrates - answer can be used in patients with mild, stable CAD for immediate relief on an as needed basis
Short-acting forms are also less expensive but must be taken several times each day. Long-acting nitrates - answer can be used for treatment of angina in patients when beta blockers and ACE inhibitors are ineffective or contraindicated For patients who respond well to sublingual or translingual nitroglycerin and who experience angina episodes more than "rarely," and who are intolerant of beta blockers, these oral or transdermal nitrates are generally indicated. Angina Treatment - answer All appropriate patients with angina should be on aspirin 81 to 162 mg/d If aspirin is contraindicated, clopidogrel (Plavix) 75 mg daily may be an effective substitute Patients with angina only on exertion, a normal resting ECG, and symptoms that can be controlled by rest and intermittent nitroglycerin ACE inhibitors and beta-adrenergic blockers are the mainstays of initial drug therapy for patients with angina The second-generation dihydropyridine CCBs (amlodipine and felodipine) and long-acting nitrates can be used for treatment of angina in patients when beta blockers and ACE inhibitors are ineffective or contraindicated Short-acting, sublingual nitrates can be used in patients with mild, stable CAD for immediate relief on an as needed basis Drugs which increase myocardial oxygen supply - answer One mechanism available to increase oxygen supply is to dilate the coronary arteries and bring more blood flow to the myocardium. Nitrates can do this in patients with normal hearts. ACE inhibitors also affect both the MOS and the MOD sides of the equation. statins should be included in the treatment regimen for angina. Their role is on the MOS side of the equation; reduction in LDL cholesterol levels plays a significant role in decreasing the formation of atherosclerotic plaque. This plaque is central to the narrowing of the arterial lumen. Long-acting nitrate effects - answer They widen your blood vessels to increase blood flow to the heart. Nitroglycerine rationale for route of administration chosen - answer For patients who respond well to sublingual or translingual nitroglycerin and who experience angina episodes more than "rarely," and who are intolerant of beta blockers, long-acting oral or transdermal nitrates are generally indicated
Drugs contraindicated in patients with angina - answer Beta blockers are contraindicated for patients with severe, uncontrolled reactive airway diseases and vasospastic angina Patho of heart failure - answer -Heart tries to compensate for not pumping an adequate amt of blood -Increased heart rate -Blood vessels dilate -Heart hypertrophy -Right side triggered by MI or lung dx -Vascular resistance -Greater O2 demand -Cells become hypoxic HF Stage A - answer High risk for development of HF; no underlying structural cardiac disease (HTN, DM, hyperlipidemia, etc) ACE inhibitors Treat HTN + lipids Lifestyle changes HF Stage B - answer Structural heart disease but asymptomatic. ACE inhibitors Beta-blockers HF Stage C - answer Structural heart disease with past or current symptoms of HF ACE inhibitors and beta-blockers Diuretics Digitalis
Dietary salt restriction HF Stage D - answer End-stage disease. Requires specialized treatment strategies such as mechanical circ support, continuous inotropic infusions, cardiac transplantation, or hospice care. Systolic Dysfunction - answer Left ventricular dysfunction (systolic heart failure) begins with injury to the myocardium and is usually a progressive process, even in the absence of additional myocardial insults. The principal mechanism relates to remodeling, which occurs as a homeostatic mechanism to decrease wall stress through increases in wall thickness. Diastolic Dysfunction - answer Diastolic dysfunction, also known as heart failure with preserved ejection fraction (HF-pEF), results from inadequate relaxation and loss of muscle fiber elasticity, resulting in a slower filling rate and elevated diastolic pressures. Although cardiac output is reduced, ejection fractions remain within normal limits Diastolic Dysfunction Causes - answer Valvular dysfunction, hypertrophic and ischemic cardiomyopathy, uncontrolled HTN, hypothyroidism. Systolic Dysfunction Causes - answer Injury to the myocardium Diagnostic testing for HF - answer 2D ECG with Doppler flow studies - most useful! Chest xray, CBC, urinalysis, serum electrolytes, BUN, creatinine, HbA2c, liver fxn studies, fasting lipid profiles, and thyroid-stim hormone. Brain natriuretic peptide (BNP) to id patient with elevated left-ventricular filling pressures. Limited role of digoxin in treatment of HF - answer Although digoxin increases the force of contraction and modulates the RAAS, thereby improving functioning and symptoms and reducing hospitalizations, it has little if any effect on mortality. Published data suggest that digoxin does not improve quality of life, symptoms, or mortality rates The development of ACE inhibitors, combined with the risks of toxicity and multiple drug interactions associated with the cardiac glycosides (CGs), has moved digoxin to a third-line drug except for selected cases.
