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Advanced Pharmacology NSG 533
Exam 2025/2026 Prep Test with 1 - 0
Questions and Correct Answers/ NSG
533 TEST 1 Prep Latest
EP is a 38 - year- old female patientpthat comes in for diabetes education and manage ment. She was diagnosed 12 years ago and states lately she is not abl e to control her diet although she continues a 1600 calorie diet with appropriate daily carbohydrate intake (per dietitian prescription) a nd walks 40 minutes every day of the week. She states compliance with all medications. She denies any history of hypoglycemia despit e being able to identify signs and symptoms and describe appropria te treatment strategies. PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to t hyroid cancer FmHx: Noncontributory SHx: (−) Smoking, alcohol use, past marijuana use while in high sc hool Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinoprilp 20 mgpdaily, sertraline 100 mg daily, multivitamin daily Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L
, BUN -
..........ANSWER.......Exenatide Exenatide (Bydureon) once weekly has be en able to demonstrate w eight loss and decrease A1C% by 0.7% to 1.2% in clinical trials; how ever it is contraindicated for EP due to the selfreported history of thyroid c ancer. Dapagliflozin Dapagliflozin (Farxiga) is contraindicated in this patient due to hy perkalemia which could be made worse by this drug. The package i nsert does not indicate a specific potassium concentration cut off to no longer use this medication; however, there are better choices in t his patient. Sitagliptin Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7 % ba sed on clinical trials and currently the patient does not have any cau tionary objective measures to not use this medication. DPP- IV inhibitors are weight neutral. DPP- IV inhibitors can be used in patients taking sulfonylureas; however, it may be recommended to reduce or stop the sulfonylurea dose. Acarbose Acarbose (Precose) is not recommended for initial managemen t an d is associated with significantpGI side effects. More information wo uld be needed regardingpfasting and post- prandialpnumbers. In addition, adding acarbose would only lower A 1c by 0.8% atpbest and therefore would notpachieve the desired A1C goalpof <7% JR is a 68 - year-
status of patients commencing metformin therapy to limit the risk of lactic acidosis (JR is without contraindication). Since his entry A1C is >7.5%, dual therapy is indicated. There are se veral potentialpchoices. The second step can be a dipeptidyl peptida se- 4 inhibitor, it can be a glucagon-like peptide- 1 (GLP-
- receptor agonist, it can be a TZD, itpcan be a sulfonylurea agent, itp can be a SGLT2 inhibitor, or it could be basal insulin. Anythingpnext can be tried depending on what suits the circumstance DPP4 inhibitors are weight neutral bet relatively benign side effect profile. Sitagliptin has been associated with case reports of pancrea titis, so this specific agent should be avoided. $$$ GLP- 1 analogpand has data to support an A1C reduction necessary to gain glycemic controlpand may assist with weightploss goals for this patie nt. New information suggests these agents may provide benefits in t hose with ASCVD. JR has a past history of pancreatitis and GLP1 analogs are not recommended due to this contraindication TZDs have data to support an A1C reduction necessary to gain glyce mic control, but are associated with weight gain, negative effects on lipids and increased risk of fracture. Until recently, TZDs have also been linked to increased CV events and use has fallen out of favor Sulfonylureas provide excellent A1C lowering, but are also associat ed with weight gain. They also have the potential to cause hypoglyce mia, so patient education is crucial. Because of his allergies to "sulfa ", use would be contr
A patient with type 1 diabetes reports taking propranolol for hypert ension. What concern does this information present for the provide r? - ..........ANSWER. A patient with Type 1 DM is insulin dependent for glucose control and at high risk for hypoglycemic episodes. Prop anolol causes prolonged hypoglycemic episodes. Needs to switch to ACE or ARB. A provider teaches a patient who has been diagnosed with hypothyr oidism about a new prescription for levothyroxine. Which statemen t by the patient indicates a need for further teaching? a. "I should not take heartburn medication withoutpconsulting my p rovider first." b. "I should reportpinsomnia, tremors, and an increased heartprate t o my provider." c. "If I take a multivitamin with iron, I should take itp 4 hours after th e levothyroxine." d. "If I take calcium supplements, I may need to decrease my dose o f levothyroxine." - ..........ANSWER. D. Calcium may reduce levothyroxine absorpti on. Further education is needed if the patientpfeels she can take half of a prescribed medication. MC has undiagnosed multiple gastric ulcers. Shortly after consumi ng a large meal and alcohol he experiences significant GI distress. He takes an OTC heartburn remedy. Within a minute or two he dev
l controlled, but recently he started to experience some GI distress f or which of his "well intentioned friends" gave him some medicatio n. He presents to you with toxic effects of all his other medications a nd plasma levels of those medications elevated. What was most like ly the medication he took? - ..........ANSWER Cimetidine What lifestyle modifications should be recommended? ..........ANSWER... ....-losing weight if overweight
- elevating head of bed while asleep
- eating smaller meals
- avoid foods/meds that exacerbate gerd
- stop smoking
- stop drinkingpalcohol What medications / foods can contribute to GERD? ..........ANSWER. ..- Medications: anticholinergics, barbituates, dopamine, estrogen, op ioids, progesterone, theophylline, nitrates
Foods: cirus fruits/juices, coffee, tomatoes, spicy food, carbonated drinks Fried/fatty foods, garlic, onions, chocolate What is the most effective PPI or H2RApwithin each of these classes
? - ..........ANSWER. ..-
PPI bismuth quadruple therapy combined with proton pump inhibitor s
- H2RA- Famotidine 80mg Other products such as antacids are also available. What are some o f these and whatpis their place in therapy? - ..........ANSWER. Reflux symptoms <2 times a week (infrequent)
- Effective for immediate relief
- Magnesium/Aluminum Hydroxide (Maalox) can cause constipation
- Alginic Acid Why would antibiotics be used for PUD caused by H Pylori? What is a typical regimen and duration of therapy? What patient specific fa ctors should be considered and how should treatment be monitore d? - ..........ANSWER. Considerations before regimen choice:
- penicillin allergy
- previous exposure to macroglide antibiotics StrongestpReccomendation:
- Bismuth Quadruple Therapy 10 - 14 days do notpdrink alcohol w/ metronidazole
- Salvage regimen should be different than first regimen Who would be a candidate for prophylaxis of NSAID induced ulcer and what agents are appropriate? What if the patientpis on cardioprotectiv
reeminentpplace. Experimental and epidemiological data suggest that activation of the renin- angiotensinaldosterone system plays an important role in increasingpin th e mic ro and macrovascular complications in patients with diabetes mellitu s. Notponly are ACE inhibitors potent antihypertensive agents butpt here is a growing body of data indicating that also they have a specif ic 'organprotective' effect. For the same degree of blood pressure control, co mpared with other antihypertensive agents, ACE inhibitors demon strate function and tissue protection of considered organs. ACE inh ibitors have been reported to improve kidney, heart, and to a lesser extent, eye and peripheral nerve function of patients with diabetes
mellitus. These favorable effects are the result of inhibition of bo ..... A NSWER....... There is a "compelling" indication in patients with hypertension an d DM. These should be the 1st class of antihypertensive medication s used in those with DM + HTN Recommended for the treatment of the patient with CKD (modestly elevated (30- 266 mg/24 h) or higher levels (>300 mg/24 h) of urinary albumin e xcretion), even in those without DM Delay progression of nephropathy in Type 1 with or without HTN a nd any degree of albuminuria Delay progression of nephropathy in Type 2 with or withoutpHTN a nd microalbuminuriaReduce development of microalbuminuria (ki dney disease) in Type 2 with or without HTN ARBs are considered a reasonable alternative for those intolerant of ACEI - ..........ANSWER....... Cardioprotective dose ASA (IE baby aspirin or clopidrogel as altern ative)For SECONDARY PREVENTION of CV Events Use in ALLpdiabetics w ith CV diseaseFor PRIMARY PREVENTION of CV EventsUSE in: high CV risk patients (10- yr CV riskp> 10%) Typically: male > 50 yo or female >60 yo with 1 additiona l major ris k factor (FH of CVD, HTN, smoker, dyslipidemia or albuminuria)M
Incretin mimetics Glinides Alpha-glucosidase inhibitors Colesevelam What are the various types of oral and non- insulin medications and whatprepresents a rational combination of medications? - ..........ANSWER. Combinations should have different mechanis m of action Combinations should avoid overlapping ADRs Combinations should ideally be selected based on need for better b asalpvs post-prandial control Selection should account for patient specific concerns (eg. weight, CVD risk, etc) What antidiabetic medications have compelling indications: - ..........ANSWER. for those with underlying ASCVD or at high ris k for CVD for those with CKD for those with a compellingpneed to avoid hypoglycemia for those where weight is an important consideration (ie which are associated with weight loss, gain or are weight neutral)
What are the various insulins and describe the pharmacokinetics (o nset, peak, duration)and how are they used (egpbasal, basalbolus, split- mixed, sliding scale (..Ask if you don't understand)). ..........ANSWER .......................................................... B asalbolus (long acting basal + rapid/fast actingpbolus) provides the grea test flexibility and control of all regimens Sliding Scale Should NOT be used Difficult to do in home setting, requires education and understandi ng of patient and caregiver Allows patient to become hyperglycemic, better to schedule dosing and prevent rises in BG Requires frequentpblood glucose monitoring, $$$ and compliance i ssues Can be used as monotherapy or as addon therapy for T2DM .. PresentingpA 1C of 6 + symptoms or failure t o achieve goal A1C on adequate trial of 2 - 3 agents atpmaximally tolerated doses - ..........ANSWER. Often starting with a longpacting insulin When glycemic goals aren't reached despite basal insulin (Good FB G and pre- prandialpBG, but elevated HbA1C), Consider prandial therapy with fast- acting insulin. Begin fastacting insulin before largestpmeal.Variation exists between ADApan d ACCE in their recommendations
10 days (and NTI .. see below). How does this relate to the fact that a fter initiating or changingpa does or changing a product (IE brand to generic, generic to brand or one generic brand to another), TSH sh ould be checked in about 6 weeks? Why are thyroid replacement drugs considered to have a narrow th erapeutic index ( NTI )and what does that mean clinically? - ..........ANSWER. The therapeutic index (TI) is the range of dose s atpwhich a medication is effective without unacceptable adverse ev ents. Drugs with a narrow TI (NTIs) have a narrow window betwee n their effective doses and those at which they produce adverse toxi c effects. Oral Bioavailability: (erratic) 40 - 80%brand vs generic Highly protein bound (66%)HalflifeEuthyroid = 6 - 7 daysHypothyroid = 6 - 10 daysSteady State: @ 6 weeks or 4 - 5 t1/2 's .. this is the bases for monitoringp@ six weeks from start or changes! Consider changes such as brand to generic, different generics manu factures, differentppharmacies, etcAny such change will require rep eat lab monitoringp@ ~ 6 weeks to confirm the same clinicalprespon se What are some drug-drug, drug- food interactions associated with thyroid replacement ..........ANSWER..... ..drugpbinding interactions, divalent cations, amiodarone, certain antibioti cs
RECOMMENDATION 13 Methimazole should be used in virtually every patient who chooses antithyroid drug therapy for GD, except during the first trimester of pregnancy when propylthiouracil is pre ferred, in the treatment of thyroid storm (inhibition of peripheral c onversion), and in patients with minor reactions to methimazole w ho refuse radioactive iodine therapy or surgeryDelayed onset ...... ANS WER....... Beta-blockers role in therapy? - ..........ANSWER.......So .. beta blockers are used for Symptomatic re lief of hyperthyroidism untilpmore definative therapy is instituted a nd thyroid levels retun to normal or near normal.. Reduction of peripheral manifestations Tachycardia, sweating, severe tremor, nervousness Inhibition of peripheral conversion of thyroid hormones at higher d oses (propranolol ONLY) Small therapeutic effect in magnitude thyrotoxicosis Why does amiodarone pose a unique concern to thyroid disorders .......... ANSWER "Amiodaronenormal thyroid autoregulation is lost because o f the relatively high i odine content" .. this fact can lead to a situation where amiodarone can cauase BOTH hyper- and hypo-
Note there is no significant difference in efficacy among the PPIs w hen given at equipotent doses Food may affect absorption. Given 30 - 60' before a meal. More flexibility in term of dosing with newer age nts (eg. dexlansoprazole)Delayed onset: 3 - 4 days for full inhibition Duration of action up to 24 hours due to covalent, irreversible inhib ition of proton pump - ..........ANSWER....... Patients with known osteoporosis can remain on PPI therapy. Conc ern for hip fractures and osteoporosis should not affect the decision to use PPI long- term except in patients with other riskpfactors for hip fracture ..... ANSW ER....... Finalpthoughts on GERD: - ..........ANSWER. ◦Therapy for GERD other than acid suppressio n, includingpprokinetic therapy and/or baclofen, should notpbe used in GERD patients without diagnostic evaluation. ◦ For patients with partial response to once daily therapy with a PPI, tailored therapy with adjustment of dose timingpand/or twice daily dosing should be considered in patients with nighttime symptoms, variabl e schedules, and/or sleep
◦ In patients with partial response to PPI therapy, increasing the dos e to twice daily therapy or switching to a different PPI may provide additional symptom relief. ◦ Maintenance PPI therapy should be administered for GERD patie nts who continue to have symptoms after the PPI is discontinued, a nd in patients with complications including erosive esophagitis and Barrett's esophagus ◦ Histaminereceptor antagonists (H2RA) therapy can be used as a mainte nance option in patients without erosive disease if patients experience he artburn relief. Bedtime H2RAptherapy can be added to daytime PPI therapy in selected patients with objective evidence of nighttime reflux if n eeded, but may be associated with the development o f tachyphylaxis after several weeks of usage Peptic ulcers (gastric and duodenal) are defects in the GI mucosa th at extend through the muscularis mucosa. Causalprelationships ass ociate with H. Pylori infection, NSAIDs and SRMD. ..........ANSWER ... Th erapy includes nonpharmacologicalpinterventions (similar to GERD) and p harmacolo gical with acid suppression (antacids, H2RAs, PPIs) and/or mucos alpprotection (sucralfate, colloidal bismuth, misoprostol), and if pre sent, H Pylori eradication Acid suppression see treatment modalities under GERD (Duration / dosa ges may be different based on indication) Mucosal protectionSucralfate In acid environment it turns into a viscous, sticky polymer that bin ds selectively to ulcers and erosions creating a protective layerEffic
