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Nursing 565 Final Exam Study Guide
- The first-line medication for type 2 DM is metformin.
- ADA and other professional guidelines inform prescribing decisions.
- Combination injectable therapy should be considered for immediate implementation in patients with an A1C of 10% or higher.
- TZDs, like Actos, can precipitate CHF and should be avoided in patients with heart failure.
- Older adults should be started on lower doses of levothyroxine.
- Radioactive iodine treatment results in lifelong hypothyroidism.
- When treating hypothyroidism, TSH levels should be monitored every 6-8 weeks until the patient achieves a euthyroid state.
- Signs and symptoms of hypothyroidism and hnursing yperthyroidism (pp. 418-419) Hypothyroidism: The face is pale, puffy, & expressionless. The skin is cold & dry. The hair is brittle, & hair loss occurs. Heart rate & temperature are lowered. The patient may c/o lethargy, fatigue, & cold intolerance. Mentation may be impaired. Thyroid enlargement may occur if reduced levels of T 3 & T 4 promote excessive release of TSH. Hyperthyroidism: Heartbeat is rapid & strong, & dysrhythmias & angina may develop. The CNS is stimulated, resulting in nervousness, insomnia, rapid thought flow, & rapid speech. Skeletal muscles may weaken & atrophy. Metabolic rate is raised, resulting in increased heat production, increased body temperature, intolerance to heat, & skin that is warm & moist. Increased appetite, but weight loss may occur if caloric intake fails to match the increase in metabolic rate. (Exophthalmos w/Graves’ disease).
- What adjunctive therapy is good to prescribe to control symptoms of hyperthyroidism other than thyroid specific medications? Know drug classes and examples of those drug classes. (pp. 419, 423) Beta-blockers & nonradioactive iodine may be used as adjunctive therapy for hyperthyroidism. Beta-blockers: Suppress tachycardia by blocking beta-receptors on the heart. (“-lol”) Nonradioactive iodine: Inhibits synthesis & release of thyroid hormones. (Lugol Solution = mixture containing 5% elemental iodine & 10% potassium iodine).
- Monitoring needs and intervals for thyroid medications. (pp. 421, 423) Hypothyroidism: Levothyroxine (T 4 ) (Brand-name: Levoxyl, Synthroid ) Therapeutic Goal: Resolution of signs & symptoms of hypothyroidism & restoration of normal lab values for serum TSH & free T 4. Baseline Data: Obtain serum levels of TSH & free T 4. Monitoring: Check TSH 6-8 weeks after initiating therapy & after any dosage change. Check TSH at least once a year after serum TSH is stabilized.
Identifying High-Risk Patients: Use w/caution in those patients with cardiovascular disease & start w/lower doses in older adult patients. Evaluating Therapeutic Effects: Look for a reversal of signs of thyroid deficiency & an absence of signs of thyroid excess. In children, normalization of intellectual function, growth, & development should occur. Monthly measurements of height provide a good index of thyroid sufficiency. Lab tests should indicate normal plasma levels of TSH & T 4. Measure TSH levels at least 1x/year. Minimizing Adverse Effects: Overdose may cause thyrotoxicosis. Symptoms include tachycardia, angina, tremor, nervousness, insomnia, sweating, & heat intolerance. Hyperthyroidism: Methimazole (a thionamide) (Brand-name: Tapazole ) Therapeutic Goal: Methimazole has 4 indications—reduction of thyroid hormone production in Graves’ disease, control of hyperthyroidism until the effects of radiation on the thyroid become manifest, suppression of thyroid hormone production before subtotal thyroidectomy, & treatment of thyrotoxic crisis. Baseline Data: Obtain serum levels of TSH, T 3 , & T 4. Check baseline CBC & LFTs prior to initiation. Monitoring: Check CBC w/differential if signs or symptoms of infection. Check LFTs if signs or symptoms of liver dysfunction. Identifying High-Risk Patients: Methimazole should be avoided in the 1 st^ trimester of pregnancy & in women who are breastfeeding. Evaluating Therapeutic Effects: Monitor for weight gain, decreased heart rate, & other indications that levels of thyroid hormone have declined. Lab tests should indicate a decrease in serum free T 3 & free T 4. Minimizing Adverse Effects: Agranulocytosis: Inform patients about early signs of agranulocytosis, including fever or sore throat. If follow-up blood tests reveal leukopenia, methimazole should be stopped. Hypothyroidism: Methimazole may cause excessive reductions in thyroid hormone synthesis. If signs of hypothyroidism develop or if plasma levels of T 3 & T 4 become subnormal, dosage should be reduced.
- Propylthiouracil (PTU) carries a risk for liver toxicity. Although rare, the FDA recommends against using PTU as a first-line treatment due to potential for hepatic toxicity. (p. 422) Also a thionamide, PTU suppresses synthesis of thyroid hormones. Its therapeutic uses include pregnant women in the 1 st^ trimester, thyroid storm, & patients w/intolerance to methimazole. It has caused rare cases of liver injury. Onset is sudden & progression is rapid.
- Effects of maternal hypothyroidism on offspring and appropriate patient teaching related to need for treatment. (p. 418) Maternal hypothyroidism can result in permanent neuropsychological deficits in the child, including decreased IQ. The effect of maternal hypothyroidism is limited largely to the 1st^ trimester, a time
- Hgb A1C goals- what are they generally? (p. 400) Review goal guidelines for different age groups within the ADA DM Guidelines linked in the Endocrine Case Studies and on your Student Lesson Plan. The general goal is to keep the Hgb A1c less than 7%. A less stringent goal of less than 8% may be appropriate for some patients, such as those with a history of severe hypoglycemia, limited life expectancy, or advanced microvascular or macrovascular complications. Hgb A1c should be measured every 3 months until the value drops to 7% & at least every 6 months thereafter. (A value of 6.5% or greater is considered diagnostic of diabetes.) Older Adults: Older adults who are otherwise healthy with few coexisting chronic illnesses & intact cognitive function & functional status should have lower glycemic goals (such as A1c <7.5%), while those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals (such as A1c <8.0-8.5%). Children & Adolescents: A reasonable A1c target for most children & adolescents with type 2 diabetes treated with oral agents alone is <7%. More stringent A1c targets (such as <6.5%) may be appropriate for selected individual patients if they can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes & lesser degrees of beta-cell dysfunction & patients treated with lifestyle or metformin only who achieve significant weight improvement.
- Review diagnostic criteria and process for DM (p. 398) Criteria for the Diagnosis of Diabetes Mellitus Fasting plasma glucose? 126 mg/dL (no caloric intake for at least 8 hours) OR Random plasma glucose? 200 mg/dL plus symptoms of diabetes (polyuria, polydipsia, & unexplained weight loss) OR Oral glucose tolerance test (OGTT): 2-hour plasma glucose? 200 mg/dL (plasma glucose content is measured 2 hours after ingesting the equivalent of 75 grams of anhydrous glucose dissolved in water) OR Hemoglobin A1C 6.5% or higher
- Know examples, mechanism of action, and contraindications for DM drug classes. (pp. 407-
- Biguanides: Metformin ( Glucophage, Fortamet, Glumetza, Riomet ) THE DRUG OF CHOICE FOR INITIAL THERAPY IN MOST PATIENTS W/TYPE 2 DM
MOA: Inhibits glucose production in the liver, slightly reduces glucose absorption in the gut, & sensitizes insulin receptors in target tissues (fat & skeletal muscle) & thereby increases glucose uptake in response to whatever insulin may be available. Inhibits hepatic gluconeogenesis, increases glycolysis, increases peripheral glucose uptake Contraindications: GFR <30 (renal insufficiency), metabolic acidosis, diabetic ketoacidosis, lactic acidosis, hypoxemia, dehydration, sepsis, surgery, hepatic disease, alcoholics. Side effects: Lactic acidosis, B12 deficiency, GI upset BLACK BOX WARNING: Lactic Acidosis—Severe metabolic acidosis can occur with accumulation of metformin. Highest risk occurs in diabetic patients with significant renal impairment. (If a patient is on meVormin and needs to have IV contrast for imaging, meVormin should be held on the day of the procedure and for 48 hours akerward. Serum creatinine should be normal before resuming meVormin.) Second-Generation Sulfonylureas: Glimepiride ( Amaryl ), Glipizide ( Glucotrol ), Glyburide ( DiaBeta ) MOA: Stimulate the release of insulin from pancreatic islets by stimulating the beta cells to secrete insulin. Increases release of insulin (by depolarizing K+ channels->Ca+ channels to open-
increased insulin release Side effects: hypoglycemia, photosensitivity, blood dyscrasia, weight gain Contraindications: Pregnancy & breast-feeding. Use these drugs with caution in patients with renal or hepatic dysfunction_. (Have a long half-life & are not commonly used due to a high risk of severe hypoglycemia. Cause photosensitivity. Can cause blood dyscrasias & weight gain.)_ Meglitinides (Glinides): Nateglinide ( Starlix ), Repaglinide ( Prandin ) MOA: Facilitates calcium influx in pancreatic beta-cells, which leads to increased insulin release. (Same MOA as sulfonylureas but are shorter acting & taken with each meal.) Contraindications: Type 1 DM, diabetic ketoacidosis. Use with caution in patients with liver impairment & those taking gemfibrozil ( Lopid ). (Most significant adverse effect is hypoglycemia— patients should eat no later than 30 minutes aker taking this drug.) Thiazolidinediones (Glitazones) AKA TZDs: Pioglitazone ( Actos ), Rosiglitazone ( Avandia ) MOA: Decrease insulin resistance & thereby increase glucose uptake by muscle & adipose tissue & decrease glucose production by the liver. Bind to the peroxisome proliferator-activated receptor gamma (PPAR-gamma)->increases insulin sensitivity Side effects: heart failure, fractures Contraindications: TZD should be avoided in patients with congestive heart failure (CHF) as it causes water retention &edema, which aggravates CHF. TZDs should also be avoided in patients with or a history of bladder cancer, active liver disease, type 1 DM, or pregnancy. TZDs may cause weight gain; therefore, monitoring weight and BMI is needed. Regular LFTs monitoring is also recommended due to the action of the drug in the liver. BLACK BOX WARNING: Pioglitazone is associated with heart failure (HF) secondary to renal retention of fluid. If HF is diagnosed, pioglitazone should be discontinued or used in reduced dosage.
- Be familiar with treatment algorithm for DM and when to increase or decrease insulin. (pp. 399- 400) ADA’s DM Treatment Algorithm Step 1 : At diagnosis, initiate lifestyle changes plus metformin. Step 2 : Continue step 1 & add a 2 nd^ 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. In most patients, treatment is recommended to begin at Step 1 & progress to Steps 2, 3, & 4 as necessary. For patients who have an A1c of? 9% at the time of diagnosis, dual therapy is recommended (i.e., start at Step 2 ). For patients who have an A1c? 10%, a fasting blood glucose? 300, or are markedly symptomatic, injectable therapy should be considered immediately. Increase insulin: High carb diet, infection, stress, obesity, adolescent growth spurt, & pregnancy after 1st^ trimester. Decrease insulin: Missed meal or low carb diet, exercise, & 1 st^ trimester of pregnancy.
- Be familiar with frequency of Hgb A1C monitoring timeline. (p. 400) *Hgb A1c provides an index of average glucose levels over the prior 2-3 months. A1c should be measured every 3 months until the value drops to 7% & at least every 6 months thereafter.
- Know when to start insulin. *Start on all type 1 DM patients. *Drug of choice for gestational diabetes. The ADA recommends initiation of basal insulin at 10 units/day or 0.1–0.2 units/kg/day, adjusted by 10–15% or 2–4 units once or twice weekly to reach a target fasting plasma glucose (FPG) in patients whose A1c remains uncontrolled after >3 months of triple combination therapy ( Step 3 ) or patients with an A1c >10%. With a fasting glucose level >300 or markedly symptomatic, start insulin therapy right away.
- Know how insulin is mixed (combination and amount) when Total Daily Dose (TDD) is calculated. (p. 404) Mixing should be done only with insulins of proven compatibility. Of the 3 longer-acting insulins in current use, only NPH insulin is appropriate for mixing with short-acting insulins (regular, lispro, aspart, & glulisine insulins). When a mixture is prepared, the short-acting insulin should be drawn into the syringe first to avoid contaminating the stock vial of the short acting insulin with NPH insulin.
- Know what type of insulin and how much is needed according to carbohydrate intake.
Total daily insulin dose (TDD) calculation includes basal insulin replacement & bolus insulin replacement. Basal insulin replacement encompasses approximately 50% of the total daily insulin dose which replaces insulin from fasting (overnight) & between meals. This dose is usually constant. Bolus insulin replacement encompasses approximately 50% of the total daily insulin dose & provides carbohydrate coverage & high blood sugar correction. The bolus dose for carbohydrate or food coverage is prescribed as an insulin to carbohydrate ratio, which represents how many grams of carbohydrate are covered or disposed of by 1 unit of insulin. For example, the total daily dose (TDD) of insulin can be calculated by taking the total weight of the patient's weight in kilograms (kg) multiplied by 0.6 units. This means half of the TDD is the basal insulin dose of glargine (Lantus) (50%) & the other half is the rapid-acting bolus/mealtime insulin (50%).
- Know insulin types with examples. (pp. 402-405) Week 6 Key Points
- GOLD guidelines inform the diagnosis, treatment, and prevention of COPD.
- Ipratropium is a short-acting anticholinergic used in the management of COPD.
- Salmeterol and formoterol are long-acting beta-agonists (LABAs). The FDA has recommended LABAs be used only in conjunction with inhaled steroids in asthma.
- LABAs are not recommended for use as rescue treatments in asthma.
- SABAs (albuterol and levalbuterol) are recommended for rescue use in asthma.
Symptoms= 2 days/week or less. Nighttime awakenings= none (2 times/month or less for 5 y.o. & up). SABA use= 2 days/week or less. Effect on activity= none. Risk for exacerbations requiring systemic glucocorticoids= 0-1 time/year. ( STEP 1 ) Mild persistent : Symptoms= more than 2 days/week but less than daily. Nighttime awakenings= 1-2 times/month (3-4 times/month for 5 y.o. & up). SABA use= more than 2 days/week but less than daily AND no more than 1 time on any day. Effect on activity= minimal activity limitation. Risk for exacerbations requiring systemic glucocorticoids= 2 or more times/6 months OR wheezing lasting more than 1 day 4 or more times/year (2 or more times/year for 5 y.o. & up). ( STEP 2 ) Moderate persistent: Symptoms= daily Nighttime awakenings= 3-4 times/month (more than once/week but less than nightly for 5 y.o. & up). SABA use= daily. Effect on activity= some activity limitation. Risk for exacerbations requiring systemic glucocorticoids= increased frequency & intensity of exacerbations or wheezing. ( STEP 3 ) Severe persistent: Symptoms= several times daily Nighttime 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 )
- Be familiar with examples of drug classes (p.
- Anti-inflammatory Drugs: Glucocorticoids: USED TO CONTROL INFLAMMATION IN BOTH ASTHMA & COPD INHALED: Beclomethasone dipropionate ( QVAR ), Budesonide ( Pulmicort ), Fluticasone propionate ( Flovent HFA & Flovent Diskus )
ORAL: Methylprednisolone ( Medrol & Medrol Dose-Pak ), Prednisolone ( Orapred ), Prednisone ( Deltasone ) MOA: Decrease respiratory symptoms by suppressing inflammation, leading to reduced bronchial hyperreactivity & decreased airway mucus production. Contraindications: Inhaled glucocorticoids are contraindicated for patients w/persistently positive sputum cultures for Candida albicans. Leukotriene Receptor Antagonists (LTRA): Montelukast ( Singulair ), Zafirlukast ( Accolate ), Zileuton ( Zyflo ) USED AS 2 ND^ LINE THERAPY WHEN GLUCOCORTICOID CAN’T BE USED & AS ADD-ON THERAPY WHEN GLUCOCORTICOID ALONE IS INADEQUATE MOA: Decrease bronchoconstriction & inflammatory responses such as edema & mucus secretion through suppressing the effects of leukotrienes (compounds that promote smooth muscle constriction, blood vessel permeability, & inflammatory responses through direct action as well as through recruitment of eosinophils & other inflammatory cells). Contraindications: Montelukast has a BLACK BOX WARNING as this drug is known to cause serious neuropsychiatric effects such as agitation, aggression, insomnia, depression, anxiety, and suicidal ideation. A thorough health history and patient education are necessary before prescribing this medication. These symptoms can occur at any time during treatment. If these symptoms occur, the drug should be stopped immediately. Mast Cell Stabilizer: Cromolyn ( Nasalcrom ) RARELY USED, INDICATED FOR THE TREATMENT OF EXERCISE-INDUCED ASTHMA MOA: Act by stabilizing the cell membranes of mast cells to prevent the release of histamine, an inflammatory mediator. Also inhibits eosinophils, macrophages, & other inflammatory cells. Contraindications: Allergy to cromolyn. Otherwise, considered the safest of all anti-asthma meds. Monoclonal Antibodies: Omalizumab ( Zolair ) ANTI-IgE ANTIBODY, 2 ND^ LINE AGENT INDICTATED ONLY FOR ALLERGY-RELATED ASTHMA MOA: Forms complexes w/free IgE in the body & thereby reduces the amount of IgE available to bind with its receptors on mast cells. Contraindications: BLACK BOX WARNING —Omalizumab carries a risk for anaphylaxis that may occur at any time during the course of treatment. Patients should be notified of signs or symptoms that necessitate seeking medical care. Patients should be routinely monitored after administration in health care settings (drug is given SQ). Bronchodilators: Beta-Adrenergic Agonists: THE MOST EFFECTIVE DRUGS AVAILABLE FOR RELIEVING ACUTE BRONCHOSPASM & PREVENTING EXERCISE-INDUCED BRONCHOSPASM
Beta-Agonist/Cholinergic Antagonist Combinations: Albuterol/ipratropium ( Combivent ), Vilanterol/umeclidinium ( Anoro )
- Know Lifespan considerations for methylxanthines. Approved for child of all ages, including neonates. Pregnant women: associated with adverse effects in some animal studies. Breastfeeding: warns against breastfeeding if mom may have toxic levels. Older adults: high risk for toxicity. Contraindicated in patients with seizures or peptic ulcer disease (PUD).
- Know risk factors for fatal asthma attacks. Per the NIH, several risk factors have been associated with asthma mortality: -history of near-fatal asthma requiring intubation and mechanical ventilation. -hospitalization or emergency care visit for asthma in the past year. -currently using or having recently stopped using oral corticosteroids (a marker of event severity) -not currently using inhaled corticosteroids. -a history of psychiatric disease or psychosocial problems. -poor adherence with asthma medications and/or poor adherence with (or lack of) a written asthma action plan. -food allergy in a patient with asthma.
- Be familiar with benefits of various nicotine replacement options. (p. 269) Nicotine patch: Nonprescription; provides a steady level of nicotine; easy to use; unobtrusive. Nicotine gum: Nonprescription; user controls dose. Nicotine lozenge: Nonprescription; user controls dose; easier to use than nicotine gum. Nicotine spray: User controls dose; fastest nicotine delivery & highest nicotine levels of all nicotine- based products. Nicotine inhaler: User controls dose; mimics hand-to-mouth motion of smoking. Varenicline ( Chantix ): Easy to use (pill); no nicotine; most effective pharmacologic aid to smoking cessation. Bupropion ( Zyban, Buproban ): Easy to use (pill); no nicotine; promotes weight loss, which may limit cessation-related weight gain; 1st^ choice drug for smokers w/depression.
- Know contraindications and length of treatment of smoking cessation medications. (p. 269) Nicotine patch: Length of treatment= 8-10 weeks for NicoDerm CQ , 12 weeks for Nicorette Invisipatch. Contraindicated in patients w/MI in past 2 weeks or w/severe angina. Nicotine gum: Length of treatment= use beyond 6 months not recommended. Contraindicated in patients w/MI in past 2 weeks or w/severe angina.
Nicotine lozenge: Length of treatment= dosing should decrease over a period of 12 weeks & stop after 12 weeks. Contraindicated in patients w/MI in past 2 weeks or w/severe angina. Nicotine spray: Length of treatment= after 3 months, taper use to complete cessation over additional 2-3 months. Contraindicated in patients w/MI in past 2 weeks or w/severe angina; should be avoided by those w/sinus problems, allergies, or asthma. Nicotine inhaler: Length of treatment= decrease use after 4-6 weeks. Contraindicated in patients w/MI in past 2 weeks or w/severe angina; should not be used by those w/asthma. Varenicline ( Chantix ): Length of treatment= initial treatment is 12 weeks; may continue additional 12 weeks if initial treatment is successful. Use caution in patients w/history of renal insufficiency, psychiatric disorder, seizure hx or risk, alcohol use, & cardiovascular disease. *Because of concerns about unpredictable physical & psychiatric adverse effects, the U.S. has banned the use of this drug by truck drivers, bus drivers, airplane pilots, & air traffic controllers. Bupropion ( Zyban, Buproban ): Length of treatment= decrease use after 12 weeks(?). Contraindicated in patients w/MAOI use within 14 days; seizure disorder; bulimia/anorexia; or abrupt alcohol, benzo, sedative, or anti-seizure discontinuation. BLACK BOX WARNING: neuropsychiatric effects, caution in pts w/psych hx.
- Know patient teaching needed for the various types of nicotine replacement options. (pp. 269-
Nicotine patch: Apply patch once daily to clean, dry, non-hairy skin of the upper body or upper arm. The site should be changed daily & not reused for at least 1 week. Nicotine gum: Chew the gum slowly & intermittently for approx. 30 minutes. Avoid rapid chewing which can release too much nicotine at one time. Because foods & beverages can reduce nicotine absorption, patients should not eat or drink while chewing or for 15 minutes before chewing. Nicotine lozenge: Place lozenge in mouth & allow it to dissolve over 20-30 minutes. Do not eat or drink for 15 minutes before dosing & while the lozenge is in the mouth. Patient should not chew or swallow the lozenge. Nicotine spray: Should not use if you have a history of sinus issues, asthma, or allergies. Nicotine inhaler: Inhaler should not be used by patients w/asthma. Because the cartridges contain dangerous amounts of nicotine, they should be kept away from children & pets. Varenicline ( Chantix ): Patients should notify the prescriber if they experience new or worsening cardiovascular symptoms. Bupropion ( Zyban, Buproban ): BLACK BOX WARNING: Postmarketing reports indicate that bupropion can cause serious neuropsychiatric effects , including mood changes, erratic behavior, & suicidality. All patients should be advised to contact their prescriber if they experience a significant change in behavior or mental status. Bupropion should be used with caution in patients with a history of psychiatric disease.
- Know life span considerations of TB drugs including children, pregnancy, and breastfeeding. (p. 701)
- Know patient instructions needed for respiratory drugs. Glucocorticoids: Inform patients these meds are used as preventive therapy--not for aborting an ongoing attack. Instruct to take on a regular schedule, not as needed. Have patients demonstrate proper technique. If prescribed both SABA & glucocorticoid, explain that delivery of glucocorticoid to the airways can be enhanced by inhaling a SABA 5 minutes before inhaling the glucocorticoid. Teach patients with chronic asthma to monitor & record peak expiratory flow (PEF), symptom frequency & symptom intensity, nighttime awakenings, effect on normal activity, & SABA use. Advise patients to rinse mouth & gargle after dosing to minimize dysphonia & oropharyngeal candidiasis. Cromolyn: Instruct patients on proper use & care of nebulizers. For acute prophylaxis, instruct patients to administer cromolyn 15 minutes before exercise & exposure to other precipitating factors (ex: cold, environmental agents). For long-tern use, instruct patients to take cromolyn on a regular schedule. Be sure to inform them that full therapeutic effects may take several weeks to develop. Beta-2-Adrenergic Agonist: For patients who have difficulty with hand-breath coordination, using a spacer with a one-way valve may improve results. Advise patients with asthma to assess peak expiratory flow daily & compare with personal best. Counsel patients to keep a record of these assessments along with symptom frequency & intensity, nighttime awakenings, effect on normal activity, & SABA use. Inform patients who are using MDI or DPI that, when two inhalations are needed, an interval of at least 1 minute should lapse between inhalations. Instruct patients to report chest pain associated with changes in heart rate or rhythm. This could indicate cardiac stress secondary to adrenergic effects. Warn patients against exceeding recommended dosages. If worsening symptoms require more frequent use of SABA, notify provider. Inform patients that inhaled LABAs should be taken on a fixed schedule, & always in combo with an inhaled glucocorticoid. Also instruct patients to take oral beta-2-adrenergic agonists on a fixed schedule, not PRN. Sustained-released preparations should be swallowed intact. No crushing or chewing. Theophylline: Warn patients that if a dose is missed, the following dose should not be doubled. Instruct to swallow enteric coated & sustained-release meds intact. Warn patients against consuming caffeine-containing beverages since it can intensify adverse effects while decreasing med breakdown. Instruct patients to call the clinic if they start to develop symptoms of nausea, vomiting, abdominal discomfort, diarrhea, insomnia, restlessness, or palpitations because this can signify toxicity. Warn patients that smoking tobacco or marijuana can increase theophylline clearance, resulting in ineffective dosing.
- Know when it would be appropriate to prescribe an oral corticosteroid in respiratory patients. (p. 561) Oral glucocorticoids may be required for patients with moderate to severe persistent asthma or for management of acute exacerbations of asthma or COPD. Because of their potential for toxicity, these drugs are prescribed only when symptoms cannot be controlled with safer medications
(inhaled glucocorticoids, inhaled beta-2-adrenergic agonists). Because the risk for toxicity increases with duration of use, treatment should be as brief as possible. -Be familiar with roflumilast. (p. 567 & 579) Roflumilast: A phosphodiesterase-4 (PDE4) inhibitor that is approved for management of COPD. MOA: Selective inhibitor of PDE, an enzyme that inactivates cyclic adenosine monophosphate (cAMP). By raising levels of cAMP in lung cells, the drug reduces inflammation by suppressing cytokine release & by decreasing pulmonary infiltration by neutrophils & other WBCs. Cough & excessive mucus production are reduced & mucociliary clearance is improved. Therapeutic use: Approved only for management of COPD. It is not a 1 st^ line drug, but it is used for exacerbation prophylaxis in patients with severe COPD with a primary chronic bronchitis component & a history of frequent exacerbations. Adverse effects: Diarrhea, reduced appetite, weight loss, nausea, headache, back pain, & insomnia. Caution: Prescribe with caution for patients w/depression. Safety in pregnancy has not been established. Breastfeeding is not recommended when taking this drug. Preparations, dosage, & administration: Available in oral tablets containing 250 mcg & 500 mcg. Recommended dosing is 250 mcg/day x 4 weeks & then 500 mcg/day. It may be administered with or without food. Administering with food will delay the time of absorption but not the extent.
- Know when to use LABA, SABA, Combo drugs in COPD. (p. 579) Initiation of COPD Pharmacologic Management COPD Category Symptom Control 1 st-choice recommendation Management of Persistent Symptom or Further Exacerbation A (Few symptoms, low risk) SABA Consider LAMA or LABA n/a B (Increased symptoms, low risk) SABA LAMA or LABA Combination LAMA/LABA C (Few symptoms, high risk) SABA LAMA Combination LAMA/LABA (preferred) or LABA/IGC D (Increased symptoms, high risk) SABA LAMA or LAMA/LABA or IGC/LABA Combination LAMA/LABA/IGC If exacerbations continue, consider adding: Roflumilast Azithromycin ICG=Inhaled glucocorticoid; LABA=Long-Acting Beta-2 Agonist; LAMA=Long-Acting Muscarinic Antagonist; SABA= Short-Acting Beta-2 Agonist Week 7
Breastfeeding women: Senna is safe for use during breastfeeding. Data are lacking regarding the use of polyethylene glycol and bisacodyl (Dulcolax); caution is advised. Older adults: All laxatives discussed in this chapter can be used in the older-adult population. The older adult should be monitored closely for dehydration. SALINE AGENTS should be used with caution in patients with renal dysfunction, cardiovascular disease, dehydration, and diabetes mellitus (can cause hyperglycemia). These agents are contraindicated in older adults, and patients with heart failure. Avoid lubricants as well. Other Contraindications: Laxatives must be avoided by individuals experiencing abdominal pain, nausea, cramps, or other symptoms of appendicitis, regional enteritis, diverticulitis, and ulcerative colitis. Laxatives are also contraindicated for patients with acute surgical abdomen. In addition, laxatives should not be used in patients with fecal impaction or obstruction of the bowel, because increased peristalsis could cause bowel perforation. Last, laxatives should not be employed habitually to manage constipation. Avoid stimulants in abdominal obstruction, N/V with fever, and abd pain. Diarrhea: Children: Diphenoxylate (plus atropine) AKA Lomotil LIQUID VERSION ONLY. Age 2-5 years, 1mg QID. Age 5-12 years, 1-2mg QID. Loperamide (Immodium). Ages 2-5 years 1mg TID. Ages 5–8 years, 2 mg BID. Ages 8–12 years, 2 mg TID. Paregoric. Children : 0.25–0.5 mL/kg BID-QID. Travelers diarrhea in children: Azithromycin (Zithromax) is preferred for children (10 mg/kg on day 1 and 5 mg/kg on days 2 and 3) Pregnant women: Travelers diarrhea in pregnant women: Azithromycin (Zithromax) is preferred for pregnant women (1000 mg once or 500 mg once daily for 3 days). DO NOT USE Rifaximin in pregnancy to treat traveler’s diarrhea. Adults: Diphenoxylate (plus atropine):^ Adults: 5 mg, QID Difenoxin (plus atropine): Adults: 2 mg initially, then 1 mg after each loose stool Loperamide: Adults (initial dose): 4 mg Older adults: nothing specific listed in the book regarding antidiarrheals and older adults. Mild diarrhea can be managed with nonspecific antidiarrheals. Antibiotics should be administered only when clearly indicated, such as severe infections with Salmonella, Shigella, Campylobacter, or Clostridium species. Ulcers (AKA Peptic Ulcer Disease) Infants: Both PPIs and H 2 receptor antagonists are used safely in infants as young as 1 month to treat GERD and duodenal ulcers.
Children/adolescents: PPIs and H 2 receptor antagonists can be used safely in children, just in smaller doses. Side-effect profiles resemble those of adults. Some PPIs (esomeprazole) and H 2 receptor antagonists (ranitidine) are safe for use in pregnancy. Breastfeeding women: Use of drugs such as omeprazole, esomeprazole, and ranitidine is not predicted to cause any adverse effects in breastfed infants. Older adults: PPIs are associated with increased risk for fractures from osteoporosis. PPIs can also cause medication interactions and vitamin or mineral deficiencies. There should be a clear indication for prescribing these medications in this older population. GERD Weight loss, HOB elevated and sit upright after meals, avoid triggering food (citrus and acidic, caffeine, ETOH, spicy, chocolate). 8-week course of PPI once a day before first meal. If unresponsive, increase BID. Can add H2 receptor antagonist at bedtime with daytime PPI with nighttime reflux. Prokinetic drugs such as metoclopramide can be used in GERD treatment as well. Safe in pregnant patients if indicated. -Know examples of the different types of antidiarrheals and how they work. Types: Opioids are the most effective antidiarrheal agents. By activating opioid receptors in the GI tract, these drugs decrease intestinal motility and thus slow down intestinal transit, which allows more time for absorption of fluid and electrolytes. In addition, activation of opioid receptors decreases secretion of fluid into the small intestine and increases absorption of fluid and salt Several opioid preparations—diphenoxylate, difenoxin, loperamide, paregoric, and opium tincture —are approved for diarrhea. Of these, diphenoxylate (Lomotil, others) and loperamide (Imodium, others) are the most frequently employed. -Be familiar with metoclopramide’s use, MOA, side effects, monitoring and patient teaching. Metoclopramide ( Reglan ): used as anti-emetic by blocking dopamine receptors & increasing motility. Used in diabetic gastroparesis & GERD. Off label – hiccups & N/V in early pregnancy, Post- Op Nausea or Nausea r/t drugs, toxins, radiation therapy. AVOID while breastfeeding & in older adults & GI obstruction/perf/hemorrhage. Side effects: With high-dose therapy, sedation and diarrhea are common. Long-term high-dose therapy can cause irreversible tardive dyskinesia, characterized by repetitive, involuntary movements of the arms, legs, and facial muscles. Older adults are especially vulnerable and can develop involuntary movement disorders after a single dose. To reduce the risk for tardive dyskinesia, treatment should be as brief as possible using the lowest effective dose. Owing to its ability to increase gastric and intestinal motility, metoclopramide is contraindicated in patients with GI obstruction, perforation, or hemorrhage.
