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NR 565 Final Study Guide
1. WEEK 5: ...
2. Thyroid
o Diagnosis & Evaluation
What labs are used to diagnose?: -TSH - used primarily for screening and diag- nosing hypothyroid and for monitoring replacement therapy in hypothyroid patients -T4 - Used to monitor thyroid hormone replacement therapy and to screen for thyroid dysfunction -T3 - Useful in the diagnosis of hyperthyroidism; can also be used to monitor hormone replacement therapy -TSH low -T4 normal -T3 is high = hyperthyroidism
3. Thyroid
o Diagnosis & Evaluation
Timeframe for re-check of labs after starting levothyroxine?: Recheck TSH 6-8 weeks after initiating therapy and after any dosage change; Check TSH at least once a year after serum TSH is stabilized
4. Thyroid
o Diagnosis & Evaluation
Signs and symptoms of hypothyroidism?: Hypothyroidism: Depend on severity.
o Mild: subtle and may go unrecognized
o Moderate to severe:
-Face is pale, puffy, and expressionless. -Skin cold and dry. -Hair is brittle and hair loss occurs. -Slowed Heart rate. -Patient may complain of lethargy, fatigue, and -Temperature is lowered & intolerant to cold. -Thyroid Enlargement may occur if reduced levels of T3 and T Mentation may be impaired.
5. Thyroid
o Diagnosis & Evaluation Signs and symptoms of hyperthyroidism?: o Elevated Heart rate and strong, and dysrhythmias and angina may develop
o The CNS is stimulated, resulting is nervousness, insomnia, rapid thought flow, and rapid
speech, hyperreflexia, tremors
o Skeletal muscles may weaken and atrophy
o Metabolic rate is raised, resulting in health and skin that is warm and moist
o Feeling Hot + Heat intolerance
o Appetit is increased but fails to match metabolic rate resulting in weight loss
o All of these signs are referred to as thyrotoxicosis
o Also usually present with exophthalmos - bulging of the eyes
6. Thyroid
o Treatment Treatment of thyroid storm?: Characterized by profound hyperthermia (105 de- grees F or higher), severe tachycardia, restlessness, agitation, and tremor. Unconsciousness, coma, hypotension, and heart failure may ensure. These symptoms are produced by excessive levels of thyroid hormone Thyroid crisis can be life
9. Thyroid
o Treatment
Drug/Food/Supplement interactions with levothyroxine: Absorption of levothy- roxine is reduced by food - it should be taken on an empty stomach in the morning, at least 30-60 minutes before breakfast Drugs that reduce absorption include: H2 receptor blockers, PPIs, Carafate, Ques- tran, Colestid, Maalox/Mylanta, Tums, iron, Mag salts, Xenical Drugs that accelerate levothyroxine: Phenytoin, Carbamazepine, rifampin, Sertra- line, and phenobarbital Patients taking the following drugs may need to increase their dose of levothyroxine: Warfarin and catecholamines Levothyroxine can also increase requirements for insulin and digoxin
10. Diabetes
o How to confirm a diagnosis prior to beginning treatment: Fasting plasma glucose >/=
125mg/dl OR Random plasma glucose >/= 200mg/dl plus symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) OR Oral glucose tolerance test (OGTT): 2-hour plasma glucose >/= 200mg/dl OR HgbA1C pf 6.5% or greater - (a test that provides an estimate of glycemic control over the previous 2-3 months) is now considered a standard test as well
11. Diabetes
o A1C
General goals: To keep A1C below 7% o <8% is less stringent for those with hx. Of severe hypoglycemia, limited life expectancy, pr advanced microvascular or macrovascular complications
12. Diabetes
o A1C
Older Adult goal: Recommended goal for A1C in the geriatric population is 7.5-8% in older patients with moderate comorbidities and life expectancy less than 10 years o 8-8.5% for older patients with complex medical issues
13. Diabetes o
A1C
When should insulin be considered?: Recommendation: A GLP-1 should be considered before starting insulin Insulin is introduced in Step 3 which includes a 3-drug combination which includes insulin. A1C of 9% of greater would start at Step 2 with dual med therapy A1C of 10% or greater or fasting glucose of 300 or greater and is symptomatic would start on combination injectable therapy immediately (Step 4)
14. Diabetes o
A1C
At what time interval should it be re-checked?: Should be monitored every 3 months until value drops to 7% and at least every 6 months thereafter
15. Diabetes
o Action of Insulin: Metabolic actions of insulin are primarily anabolic - Insulin promotes
conservation of energy and buildup of energy stores, such as glycogen and the hormone also promotes cell growth and division Stimulates cellular transport (uptake) of glucose, amino acids, nucleotides, and potassium Insulin promotes synthesis of complex organic molecules In all: Under the influence of insulin - glucose is converted into glycogen, amino acids are assembled into proteins, and fatty acids are incorporated into triglycerides
16. Diabetes
o Pioglitazone contraindications: Associated with heart failure secondary to renal retention of
fluid. If heart failure is diagnosed, pioglitazone should be discontinued or used in reduced dosage
17. Diabetes
o Be familiar with abbreviations of diabetic drug classifications (GLP-1, TZD, DPP4-I, SGLT2i): ....
o GLP-1 (Exenatide) (AKA mimetics): Lowers blood glucose by slowing gastric acid emptying,
stimulating glucose- dependent insulin release, suppressing post- prandial glucagon release, and reducing appetite
26. Mechanism of Action
-Biguanide (Metformin): -Decreases Glucose production by the liver
27. Mechanism of Action
o TZD (Pioglitazone): Decrease insulin resistance and increase glucose uptake by muscle and
adipose tissue -and decrease glucose production by the liver
28. Mechanism of Action
o DPP-4i (Alogliptin): Enhance the activity of incretins (by inhibiting their break-
down of DPP-4) and thereby increase insulin release, reduce glucagon release -and decrease hepatic glucose production
29. Mechanism of Action
o Sulfonylureas -Glipizide (Glucotrol): Promote insulin secretion by the pancreas- es; may also
increase tissue response to insulin -Educate on risk of Hypoglycemia side effect
30. Mechanism of Action
o SGLT2i (Canagliflozin): Increase glucose excretion via the urine by inhibiting SGLT-2 in the
kidney tubules -decreasing glucose levels, and inducing weight loss by caloric loss through the urine
31. Which diabetic medication(s) come with a concern of hypoglycemia?: o Sulfonylureas
o Meglitinides (Glinides)
o Thiazolidinediones (Glitazones) - only in the presence of excessive insulin
o Glucagon-like Peptide-1 Receptor Agonists (GLP-1) (Incretin Mimetics)
o Amylin Mimetics
32. ADA's DM Treatment Algorithm: Step 1: At diagnosis, initiate lifestyle changes plus metformin.
Step 2: Continue step 1 & add a 2nd drug (TZD, DPP-4, SGLT-2, or GLP-1). A sulfonylurea or basal insulin should be considered if patient doesn't achieve goal with these drugs. Step 3: 3-drug combo, including metformin. Step 4: 3 drug therapy that includes basal insulin fails to reach goals after 3-6 months, proceed to combination injectable insulin.
- WEEK 6: ...
34. Methylxanthines
o Who is at risk for toxicity and why?: At risk: Those with liver disease, smokers, caffeine drinkers,
those taking certain medications Why: Liver disease
- theophylline is metabolized in the liver, and this can cause decreased metabolism which increases drug levels = toxicity Smokers
- smoking can induce theophylline metabolism which increases drug clearance. Therefore, if the patient stops smoking and does not have the dose of theophylline is not decreased, the patient is at risk for developing toxicity Caffeine drinkers
- Caffeine can intensify the adverse effects of theophylline on the CNS and the heart. Caffeine can also complete with theophylline for drug- metabolizing enzymes causing theophylline levels to rise. Those taking theophylline should avoid caffeine products and those containing caffeine Drugs that increase theophylline levels -
awakenings= more than once/week (often nightly for 5 y.o. & up). SABA use= several times a day Effect on activity= severe activity limitation. Risk for exacerbations requiring systemic glucocorticoids= even greater increased frequency & intensity of exacerbations or wheezing. 0-4 y.o (STEP 3), 5-11 y.o. (STEP 3 OR 4), 12 y.o. & up (STEP 4 OR 5)
40. Asthma & COPD
o Symptoms associated with each classification of asthma (mild-persistent, moderate-persistent,
etc.).: - Nighttime wakening from ages 0-4 years old is nor- mal and cannot be used in the data due to asthma nighttime wakening Steps 3-5 are more aggressive as our patients get older Pg. 575 in the book for classifications of asthma severity and recommendation for initial treatment Intermittent: symptoms 2 days a week or less No nighttime wakening SABA use is 2 days a week or less Mild-persistent: symptoms more than 2 days a week but less than daily Nighttime wakening 1-2 times a month SABA use is more than 2 days a week but less than daily Moderate-persistent: Symptoms daily Nighttime wakening 3-4 times a month SABA use is daily Severe-persistent: Symptoms several times a day Nighttime wakening more than once a week SABA use is several times a day 7 Recommended step is step 3-4 for ages 5-11 and step 4-5 for those above 12 years old (Steps on pg. 576-577 in book)
41. Asthma & COPD
o Know examples of drug classes (SABA, LABA, ICS, etc.): SABA, LABA,
Know examples: Examples: Salmeterol, formoterol, oldaterol
46. Asthma & COPD o
LABA
Benefits of use Use in COPD: Benefits of use: LABAs are for patients who experience frequent attacks and dosing is done on a fixed, NOT PRN, schedule. For asthma, they must be combined with a glucocorticoid because they are not a first line therapy in asthma (FDA recommends a LABA and glucocorticoid are both contained in the same inhaler to prevent a LABA asthma-associated death - LABA monotherapy in asthma is contraindicated) Use in COPD: LABAs are preferred over SABAs for patients with stable COPD. LABA can increase the risk for severe asthma attacks and asthma related death; however, this is not a concern for those with COPD
47. Asthma & COPD
o Inhaled Corticosteroid (ICS)
Know examples: Examples: Budesonide, ciclesonide, beclomethasone
48. Asthma & COPD
o Inhaled Corticosteroid (ICS)
Benefits of use: Benefits of use: Most effective drugs available for long-term control of airway inflammation. By reducing inflammation, they reduce bronchial hyper-reactivity and decrease airway mucus production in both asthma and COPD. They do not alter the course of the conditions, but they
provide significant long-term control and management of symptoms
49. Cromolyn: Used as prophylaxis for mild to moderate asthma
50. Monoclonal Antibodies: Used for allergy-related asthma and Eosinophilic asthma
51. Leukotriene Receptor antagonists: Second-line therapy to reduce inflamma- tion and
bronchoconstriction
52. B2RA (Beta 2 Receptor Agonists): Can be used PRN, for EIB, COPD exacer- bations, and
maintenance therapy
53. Methylxanthines: Maintenance therapy for chronic stable asthma
54. Anticholinergics: Approved for bronchospasm related COPD
55. Asthma & COPD
o At what point would an oral steroid be prescribed?: May be required for
patients with moderate to severe persistent asthma or for management of acute exacerbations of asthma of COPD. Because of their 8 potential for toxicity, they are prescribed only when symptoms cannot be controlled with safer medications (inhaled glucocorticoids or inhaled B agonists). Treatment should also be as brief as possible because of the risk for toxicity with duration of use.
56. Asthma & COPD
o When would roflumilast be indicated for a COPD patient?: For patients with severe, chronic
COPD with a primary chronic bronchitis component, the risk for exacerbations may be reduced with this drug.
57. Smoking Cessation
o Nicotine replacement
How it works: How it works: NRT allows smokers to substitute a pharmaceutical source of nicotine for the nicotine in cigarettes - and then gradually withdraw the replacement nicotine.
Gum: Gum: Patients should be advised to chew the gum slowly and intermittently for approximately 30 minutes. Rapid chewing can release too much nicotine at one time which results in effects similar to those of excessive smoking (nausea, throat irritation, and hiccups). Foods and beverages can reduce nicotine absorption, so patients should not eat or drink 15 minutes before chewing the gum.
60. Smoking Cessation
o Nicotine replacement
Patch: Patch: Patches are applied once a day to clean, dry, nonhairy skin of the upper body or upper arm. The site should be changed daily and not reused for at least 1 week. Starting patch is determined based on the number of cigarettes smoked daily. o Adverse effects: short lived erythema, itching, and burning can occur under the patch. Discontinue patch is there is severe erythema, itching, and edema.
61. Smoking Cessation
o Nicotine replacement Nasal spray: Nasal spray: The nasal spray increases blood levels of nicotine rapidly like it does with smoking. Some patients are unable to give the spray up because of the similar effects to smoking that it gives. o Adverse effects my most users include rhinitis, sneezing, coughing, watering eyes, and nasal/throat irritation which usually only last a few days. Nicotine nasal spray should be avoided by patients with sinus problems, allergies, and asthma.
62. Wellbutrin
Contraindications: Seizure disorders, anorexia/bulimia, stroke, alcohol use, CNS depressants, and barbiturates.
63. Bupropion
Recommended length of treatment: 150mg PO daily for 3 days, then 150mg PO twice daily for 7- 12 weeks. Treatment with Bupropion should start 1-2 weeks before smoking cessation and should decrease use after 7-12 weeks. Bupropion was the first non-nicotine drug approved as an aid to smoking cessation. It reduced the urge to smoke and reduces some symptoms of nicotine withdrawal (irritability and anxiety).
64. Tuberculosis (TB)
o What constitutes drug-resistant TB: Occurs when TB bacteria become resistant to the drugs
used to treat the disease and includes multidrug-resistant (MDR TB) and extensively drug- resistant (XDR TB). MDR TB is caused by bacteria that are resistant to both isoniazid and rifampin, two potent TB drugs XDR TB infection is less common and is caused by resistance to isoniazid and rifampin as well as any fluoroquinolone and at least one of three second-line medications. These patients have a greatly decreased number of treatment options and a higher risk of death
65. Tuberculosis (TB)
o Treatment of TB in a pregnant person, what all should be included?: Rifabutin is deemed the
safest during pregnancy. The CDC reports that the benefit justifies the risk for isoniazid, rifampin, and pyrazinamide. The CDC does not recommend rifapentine due to insufficient data on pregnant women. Ethambutol has caused teratogenesis in animal studies and there have been reports of eye abnormalities in children; therefore, should only be given if the benefits are deemed greater than the risks
66. Tuberculosis (TB)
o Isoniazid (INH) is a drug that can be used to prevent TB in people that have been exposed.: Primary
agent for treatment and prophylaxis of TB. This drug has early bactericidal activity and is
o Short-term use increases the risk of what?
Symptoms this may be occurring: Risk of community-acquired pneumonia Long-term can cause C.Diff -Symptoms this may be occurring: -Pneumonia by altering the upper GI flora and impairing WBC function, this risk is only limited to the first few days of use, and then it is the same risk as nonusers
74. GERD
o How to treat moderate to severe GERD: PPIs are the best treatment for long term
maintenance therapy is recommended
75. GERD
o What medication for GERD to avoid in older adults and why?: PPIs due to increased risk for
fractures and dementia
76. GERD
o Treating GERD during pregnancy
Which cytoprotective agents would be used: Do not use Cytotec (Misoprostol): Because prostaglandins stimulation uterine contractions and the use of this medica- tion during pregnancy has caused partial or complete expulsion of the developing fetus
77. GERD
o When to test for h. Pylori
How to treat h. Pylori: Test after the failure of lifestyle modifications and OTC antacids of H blockers have not worked Pg. 593 table 64.2: 2 antibiotics and an antisecretory agent
78. PUD
o Lifestyle modifications to support ulcer healing: Eat 5-6 small meals per day, stop smoking,
avoid NSAIDS in PUD, decrease stress and anxiety, alcohol can exacerbate PUD symptoms
79. Anti-diarrheal
o Which one contradicted in children during or after chickenpox: Bismuth (Pepto bismol):
increased risk for Reye's syndrome
80. Anti-diarrheal
o Patient teaching for ciprofloxacin for traveler's diarrhea: Use drug if symptoms develop and are
severe or do not improve within a few days Don't give cipro for someone who is pregnant, febrile, or has bloody diarrhea Should only be used when symptoms are severe; mild symptoms are treated with loperamide. The med can cause serious side effects, so prophylaxis is not recommended
81. Anti-diarrheal
o Which one is associated with gray/black stools and a black tongue: Bismuth (Pepto bismol)
82. Constipation
o Lifestyle modifications to suggest prior to treatment: Increase fluids, exercise after meals,
improve diet, and increase fiber
83. Constipation
o Risks of laxatives during pregnancy: GI stimulation can cause labor
84. Constipation
