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Study Guide Exam 4 NU 578 ENDOCRINE AND STEROIDS Ch. 48-49, 57- DIABETES Uses and SE for drugs for diabetes including: Insulins, metformin, sulfonylureas, DPP-4 inhibitors (sitagliptin), SGLT-2 inhibitors (canagliflozin, empagliflozin), GLP-1 receptor agonists (exenatide, but… semaglutide, tirzepatide, etc.), acarbose, nateglinide Difference between rapid (lispro and aspart) and longer acting (glargine) and NPH and regular Sulfonylureas : old, but still used o Enhance insulin secretion and sensitivity o Only useful in T2DM, profile similar to insulins except we do not really have rapid acting sulfonylureas DPP4 Inhibitors (Sitagliptan): can cause marked hypoglycemia o Can cause fluid imbalance o Avoid in HF SGL2 Inhibitors (glyflozins): good for HF and DM and renal compromise o Cause patient to excrete more glucose o Good for managing fluid overload in HF, decreased BG for vessel health o SE: genital yeast, gangrene (at the worst) GLP-1 agonists (the tides): o Very useful as incretin mimetics—mimics protein hormone called incretinsslows gastric emptying o Terzepatide esp. induces weight lossup to 14% o Concerns: Associated with alopecia Causes protein and muscle loss Can link to mental health concerns (depression) Insulin use, duration; understanding of basal vs bolus insulin; when is each type used? Insulin Aspart (short): may last 3-5 hours Insulin Glargine (long): may last up to 24 hours Longer acting insulins are basal insulin Bolus are often more rapid acting Metformin uses, SE, monitoring, contraindications, max dose in peds, 2000, adults, 2500mg First choice drug for T2 DM Elevate HDL Risks like lactic acidosis in alcoholics/contrast o Do not use in liver/kidney disease and alcoholics o GI issues-N/V/D, flatulence o D/C drug prior to a procedure and 48 hours after Glucagon use
Frees stored glucose in hypoglycemic patients o Excessive insulin use o Will work in those are well nourished—keep that in mind o Which antidiabetic agents cause marked hypoglycemia? Insulins DPP4 inhibitors Which antidiabetic agents are safe to use in pregnancy? Insulins Metformin Which antidiabetic agents are used to also treat heart/CV disease? Which ones should be avoided? SGLT2 inhibitors (esp. Empagliflozin) GLP1 agonists Avoid ones that cause fluid overload: DPP-4 inhibitors
STEROIDS
Steroid use: topical, taper, PO, IM, IV Short term steroid: taper pack—useful for acute flareup (asthma, sinusitis) o Day one: overwhelm system with steroids (anti inflammatory) and shut down adrenals Topical: o Rash, itching o Careful with applying to face—need lower dosage for face/head/neck IM: o As useful as a taper pack and better tolerated Drug-Drug Interactions (DDIs) with steroids Consider in diabetes o Steroids naturally elevate BG and if diabetic/extremely stressed or has high cortisol secretion, or is dosed with exogenous steroids, expect to make an adjustment to DM meds Side effects: o Increased fluid retention (increased BP) o If taking thyroid hormone therapy, may elevate HR May need to make a dosage adjustment if patient needs short course of steroids while taking thyroid meds or BP gets too high
NSAIDS
Meloxicam uses, SE NSAID uses, allergy, SE, effects on clotting, cross-allergy with? OTC or prescription Work on a family of enzymes called Cyclooxygenases, which control prostaglandin production, thromboxane production, etc. Uses: o Anti-inflammatory o Fever o Antiplatelet to varying degrees (low dose ASA in cardiovascular)—needs to be some indication (cardiac hx, chest pain, risk of stroke) due to risk of bleeds o Pain (HA) SE: o Bleeding Allergy: o Often have a sulfur group so if patient is allergic to sulfa, might have an aspirin allergy. Also Sulfonylureas can cause allergy Knowledge of COX-1 vs COX-2 inhibitors; use of celecoxib Celocoxib (Celebrex): good to treat inflammation secondary to musculoskeletal pain like arthritis o Easier on GI/causes less bleeds o It DOES still have an antiplatelet effect Which NSAIDs should be avoided in a cardiac patient? How to treat moderate pain in a patient with renal disease, liver disease What should be avoided in a cardiac patient? o Diclofenac and Ibuprofen are riskier to use in a cardiac patient because they also have an antiplatelet effect, but only while the patient is taking the drug. Ex: taking some ibuprofen on a Monday for HA. On Tuesday, there are some studies that show in the offset of that drug, platelets get enhanced stickiness o There are some that are not as safe, and it is all tied into anti-clotting antiplatelet activity. Aspirin is often used in cardiac patients because we know it affects platelets for the life of the platelet (7-10 days) How to treat moderate pain in a patient with renal disease o NSAIDS are not kidney friendly, so usually try to avoid in older patients and go for a non- anti inflammatory (Tylenol) o If you are going to use an NSAID, make sure it is the lowest dose/shortest course—no more than 10 days of NSAID in a patient with any renal disease How to treat moderate pain in a patient with liver disease o A bit different than above. When it comes to Tylenol, it is off the table because it could exacerbate liver disease, or if the patient drinks alcohol & uses Tylenol, that could exacerbate liver disease as well.
Vaccines in pediatric patients—reasons for withholding; schedules Reasons for withholding: o Allergies to gelatin or eggs o Live vaccines—hold in immunocompromise (do not have an immune system to recognize/form antibodies) Vaccine SE, age, contraindications; varicella, HPV, MMR, hep B, hep A o Side Effects: allergy, anaphylaxis (rare), pain at injection site, mild fever o Questions will be in regard to SE/CI to Varicella, HPV, MMR, Hep B, and Hep A. Again, we always weight benefits, so SE of thigh pain or mild fever is not a reason to withhold o Question on low grade fever and runny nose—not a reason to withhold o If a child has a runny nose and a fever of 99.9, should immunizations be given or held? Given
MEN’S/WOMEN’S Health Drugs; MUSCULOSKELETAL Ch 50-53, 59- SE and contraindications of estrogens, progestins; assessment of a patient for an IUD, medroxyprogesterone acetate, Tx of vaginal atrophy o Estrogen: o Clot Promoter, especially if patient is over 35 and is a smoker Risk factors: cardiac hx, obesity May want to avoid estrogen for contraception and use a progestin then o Treatment of Vaginal Atrophy o Usually with conjugated estrogens or things that can be applied topically (safest route) Use of testosterone replacement and SE; testosterone use in females (SE) o Testosterone replacement in males: o Typically post orchiectomy o Used in males that produce low testosterone o Synthetic Testosterone: Finasteride o Can promote hair growth o Used for prostate CA depending on dose o Formulation is “testosterone like” o Side Effects: increased lipids Developmental problems in male offspring*** BBW: after d/c use of finasteride, do not donate blood for up to 1 month (risk for pregnant female) Uses of raloxifene, Selective Estrogen Receptor Modulators: SERMs (tamoxifen, Raloxifene) o Used for vaginal dryness, vaginal atrophy, cancers. The line between replacement/cancer is dose o Higher doses tend to slow down hormone dependent CA (prostate, uterine) o Low dose for replacement SE and use of bisphosphonates (OSTEOPOROSIS) o Bisphosphonates: o May be IV, PO. Timing/dosing may be monthly or every day depending on the agent o Side Effects (esp in PO) GERD—taken on an empty stomach and stay upright for 30 mins to an hour Upset balance between osteoclasts (hollowing out bone for new bone growth) and osteoblasts(builder cells)—freeze osteoclasts so they cannot work as hard as they did. JAW: used for talking and chewing. If bite down on hard candy, may cause injury to osteoclasts—they are needed to dig out the injured bone cells and the osteoblast to refill Hard to repair injury to jaw (dental work) while on Bisphosphonates Have a long half life (up to a year) cation women for osteoporosis use that needs dental work
o Some are more potent A1 and lower BP Finasteride use, SE, ADRs Vitamin D use, recommendations for replacement therapy; calcium preparations: can diet be a source of vitamin D? o First step: replacement therapy=encourage patients to change their diets with mild calcium/vitamin D deficiency o Second step: OTC replacement o Then: prescription strength Cinacalcet use; etanercept (and other biologic) use (infliximab, rituximab, adalimumab) o Used for bone and joint afflictions, particularly arthritis o Biologics do not have the SE like methotrexate, but come with heir own. Always targeting something in the immune system that is causing the disease process. We worry about things like infection and CA, even though they are rare, they can happen. Also have to worry about allergy, dosing, can my patients self-administer (most biologics are injectables) o MAB=monoclonal antibodyspecific for inflammatory mediators. Have revolutionized treatment of diseases like asthma, however they are expensive. Patient will need an authorization for these SE and use of methotrexate; contraindications o Methotrexate: for RA and works in ~80% of people that use it, but comes with horrible risks o Works to freeze cell growthfreeze immune cells that cause inflammationteratogenic do NOT use in pregnancy o Can cause liver/kidney issuesmonitor Treatment of gout; febuxostat, anti-inflammatory drugs, allopurinol, treatment of acute vs chronic gout o Know drugs for gout o Anti-inflammatory drugs are great for gout because gout is an inflammatory reactionuric acid is crystalizing in a joint. When it crystalizes, that activates immune cells because they see a foreign body in joint fluidrelease more inflammatory mediatorslowers pH of the joint fluid and causes more precipitation of uric acid o HINT: Question on test: Which of the following would be a 1st choice for gout? Anti- inflammatory o Also a uricosurics drug (makes you urinate out more to reduce gout flare)
GI, VITAMINS, etc. Ch 64- Treatment of PUD o Antibiotics because we want to get rid of our bystander bug. In that case, H. pylori, which is making ulcer disease persist in a patient promoting inflammation o PPIs (Omeprazole) Use and monitoring of PPIs; SE of PPIs; Discontinuing PPIs (taper), H2 blockers o Proton Pump Inhibitors: stop acid secretion in cells that line the stomachcause permanent effect on cells lining stomach and their acid production, but those cells usually have a turnover of 2-3 days. SO, if you take PPI today, by tomorrow, some cells will still be feeling that effect. In the meantime, other cells are replacing the ones that were 3 days old todaygradual turn back on of acid productionpatients really feel that o If you D/C a PPI abruptly after taking them for more than a day/couple weeks or longer especially, they will notice GERD & stomach pain w/ a sour taste in mouth. o PPIs have SE: decreased bone density, increase fractures, horrible GERD w/ abrupt d/c, renal effects (because they affect the hydrogen ion potassium ion exchanger) o Make sure to taper PPI when coming off it. Maybe an alternate day taper and then every week, add another day of not taking it. On the days not taking PPI, especially at first, substitute in an antihistamine (cimetidine, Pepcid, Tagamet) review H2 blockers Treatment of Crohn’s and other GI inflammatory conditions (ulcerative colitis) o With chronic inflammatory conditions, we typically use biologics because they have the best track record (ex. Adalimumab) and make sure to monitor patient for things like enhanced risk of infection/certain cancers o Again, these drugs are expensive, so may have to other drugs that help reduce inflammation in the gut (sulfasalazine) o Injectable drugs MOA of ondansetron o MOA: serotonin antagonist Use/monitoring of the patient using biologics for musculoskeletal or GI conditions Use/monitoring of weight loss drugs including phentermine/topiramate o Book was made before the semiglutides o Topiramate is a drug for seizures but found to lose weight. Sometimes combined with phentermine or Wellbutrin. Produces modest weight loss (2-4%) o Can be combined with Naltrexone as well o Topiramate BBW for birth defects, esp. cleft lip and palate so do not prescribe to someone who is trying/or is pregnant Antiemetics in the cancer patient receiving chemo
