pharmacology 2 section 2 review questions
pharmacology 2 section 2 review questions NURS 406 001
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This 10 page Class Notes was uploaded by Heather Notetaker on Sunday September 25, 2016. The Class Notes belongs to NURS 406 001 at University of Tennessee - Knoxville taught by Glen E Farr (P) in Fall 2016. Since its upload, it has received 6 views.
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Date Created: 09/25/16
Review Questions 1. What are the major sideeffects of more than a onetime dose of glucocorticoids? 2. Why is it usually necessary to taper a course of oral corticosteroids? To prevent HPA axis suppression and adrenal shutdown 3. What is the difference between a physiologic dose and pharmacological dose of a “steroid”? Which is higher? Physiologic doses of corticosteroids are used for replacement therapy in adrenocortical insufficiency (Addison's Disease). Pharmacological doses are used for their antiinflammatory effects in: Osteoarthritis and other rheumatic and pain disorders (usually shortterm and 34 injections/year due to cartilage and tendon damage) Collagen diseases (e.g., Systemic Lupus Erythematosus) Allergic disorders Ophthalmic and otic disease Respiratory diseases (asthma, COPD, croup) Inflammatory bowel disease, e.g., ulcerative colitis Dermatitis, eczema, psoriasis Transplant clients and those with autoimmune disorders may use corticosteroids for their immunosuppressive effects. 4. You have an order for methylprednisolone 4 mg tablets twice daily and the pharmacy sends dexamethasone 4 mg tablets to be given twice daily. You administer without question since they are both corticosteroids. Is this appropriate? 5. What are the primary indications or uses of desmopressin (DDAVP®, Stimate®)? Desmopressin (DDAVP®), an analog of vasopressin, is synthetic antidiuretic hormone (ADH) that may be administered orally, intranasally, or parenterally. o It has a longer duration of action than vasopressin and a more favorable adverse effect profile, and has replaced vasopressin as the drug of choice for central diabetes insipidus. It causes less stimulation of smooth muscle than does vasopressin. o It is used to treat: Central diabetes insipidus (controls the polyuria, polydipsia and dehydration) Pituitary surgery or trauma (controls the polyuria and polydipsia) Nocturnal enuresis (bedwetting) Hemophilia A or Type I von Willebrand’s disease (controls bleeding —mechanism not clear) 6. Describe the recent FDA warning for desmopressin and the approval status of desmopressin products. Risk of overhydration (water intoxication) from either form of ADH is high. The FDA has issued a “Safety Alert” warning that some patients taking desmopressin, including children who take desmopressin for enuresis, may be at risk of seizures due to hyponatremia and death. 7. A parent asks about the best way to treat her 5 yearold son to help prevent “wetting the bed.” What would you recommend? o Anticholinergic treatment, particularly with tricyclic antidepressants like imipramine, are sometimes useful in children who have urinary urgency, restricted bladder capacity from detrusor hyperactivity at night, and combined daytime wetting and nocturnal incontinence as well as in children who do not respond to desmopressin (level of evidence, B). o Desmopressin (DDAVP®) is most effective for children with monosymptomatic enuresis, nocturnal polyuria, and normal bladder capacity (level of evidence, A). DDAVP® is a synthetic form of antidiuretic hormone which causes the kidneys to reabsorb fluid and reduce urine output. Remind parents not to give their child too much drug or too much fluid at night while using DDAVP®. The drug causes water retention, which could lead to seizures. 8. What effect does pregnancy have on the need for thyroid hormone therapy? Even a slightly underactive thyroid—too mild for symptoms—during pregnancy might trigger premature birth and babies born with lower IQs. Most experts suggest increasing levothyroxine doses by 1/3 as soon as pregnancy is confirmed. o The current consensus is to check TSH every 6 weeks during pregnancy. o Most pregnant women will eventually need a 50% higher levothyroxine dose. 9. Differentiate between levothyroxine (LT4) and the other agents used in the treatment of hypothyroidism. 10. What is the association between levothyroxine sodium (Synthroid®, etc.) and: a. osteoporosis? b. fatigued and/or obese euthyroid clients? c. concurrent calcium or soy ingestion? d. treating obesity? 11. Explain the optimum way to take levothyroxine sodium (Synthroid®, etc.) as to when to take, with what, etc. Long acting, providing for once daily dosing, but takes about 6 weeks to reach steady state concentrations Available in tablets in increasing increments of 12.5 µg or 25 µg ranging in dose from 25 µg to 300 µg. o Use about 1.7 µg/kg/day or 100125 µg/day for most younger clients as a replacement dose, but start at a lower dose and titrate up. As one ages, the requirement usually decreases and the dose can be as low as 0.5 µg/kg/day. This will reduce the risk of fracture and atrial fibrillation. o So, older clients and those with heart disease should start with less, normally 25 to 50 µg. Higher doses can lead to A. fib and other arrhythmias. Interesting note is that canines require ~15 µg/kg/day—almost 10 times the human dose. 12. A client is concerned about taking radioactive iodine and how much limitation she will have in contact with others. Outline your “patient education” information you would provide. Patients should allow only 10 minutes of “hug time” with children and should keep about 3 feet away most of the time. 13. Describe the purpose of giving someone potassium iodide following a nuclear accident? These agents block accumulation of radioactive iodine in the thyroid, which helps prevent thyroid cancer, but does not protect other parts of the body or protect against other forms of radiation. 14. Thioamides, such as propylthiouracil (PTU) and methimazole (Tapazole®) are used to treat what condition? How do they work? Hyperthyroidism (Graves disease) 15. What is the recent boxed warning on propylthiouracil? 2010 boxed warning regarding reports of severe liver injury and acute liver failure, in some cases fatal, that have been reported in both adult and pediatric patients who used this drug. 16. List three drugs (other than “sugars”) that may increase blood glucose. 17. What is the current thinking on the use of insulin in clients with type 2 diabetes? 18. Describe inhaled insulin powder (Afrezza®) from the following standpoints: a. Is it absorbed more or less quickly than subcutaneous injection? More quickly because it’s inhaled b. What does the FDA require that all patients be prescreened with prior to prescribing? All patients are prescreened with spirometry testing. c. Does it cause more or less weight gain and hypoglycemia than injected insulin? This seems to result in less weight gain and hypoglycemia than injected insulin d. Is the cost of Afrezza® more, less or about the same as other rapidacting insulins? Cost is about twice the cost of other rapidacting insulins: $280 v. $160 19. In what ways do insulin lispro (Humalog®), aspart (NovoLog ) and glulisine (Apidra®) differ from Regular (R) human insulin, e.g., Humulin®? Generally given subcutaneously, but can give Regular (R) (Humulin®, Novolin®) insulin I.V. in emergencies. Note that insulin analogs, e.g., lispro (Humalog®), aspart (NovoLog®), glulisine (Apidra®), glargine (Lantus®), and detemir (Levemir®) should not be administered I.V. 20. Describe the pharmacokinetic differences in the basal insulins glargine (Lantus®) and detemir (Levemir®) Unlike the other available basal formulations, NPH insulin and Lantus® (insulin glargine), Levemir® is soluble at a neutral pH. 21. What is Toujeo® and how does it differ from Lantus®? Like Lantus®, it is a oncedaily, longacting basal insulin to treat adults with both type 1 and type 2 diabetes but lasts a few hours longer than Lantus®. It has a more gradual and prolonged release of insulin from subcutaneous depot than Lantus®, thus might cause less hypoglycemia. 22. What is the primary use for repaglinide (Prandin®) and nateglinide (Starlix ) and when should these agents be taken in relation to a meal? Repaglinide (Prandin®) and nateglinide (Starlix®), which works in a manner similar to sulfonylureas, is used by type 2 patients to manage mealrelated glucose foods and in type 2 clients on glargine insulin (Lantus®) as a bolus. It is taken before or with meals. 23. What were the primary findings of: a. The Diabetes Control and Complications Trial (DCCT) The report of the Diabetes Control and Complications Trial (DCCT) in NEJM 1993; 329:977986, provides a rationale for more intensive glucose control, which can reduce nephropathy, neuropathy and retinopathy. b. The Kumamoto Trial The Kumamoto study examined whether intensive glycemic control could decrease the frequency or severity of diabetic microvascular complications in 110 patients with type 2 diabetes. c. The UKPDS The landmark United Kingdom Prospective Diabetes Study (UKPDS) is a 20year, prospective randomized clinical trial of 4209 patients which compared the effects of intensive therapy to achieve tight blood glucose control to conventional therapy on the microvascular and macrovascular complications of type 2 diabetes. 24. What is the approximate reduction in1c levels generally achieved by optimum doses of antidiabetic agents? Intensive therapy significantly the mean A1c, 9.4% to 7.1%, compared to conventional therapy and produced reductions in the risk of progression of: Retinopathy 65% Nephropathy 70% DCCT UKPDS Kumamoto A1c reduction 9 to 7% 8 to 7% 9.4 to 7.1% 25. Describe the 2016 changes with metformin regarding dosing and renal function. In a response to mounting evidence, in 2016, the FDA ruled that metformin can be used safely in patients with mild and, in some cases, moderate kidney impairment after decades of warning against it. Metformin previously had been contraindicated for patients with renal disease or dysfunction, as suggested by serum creatinine levels at or above 1.5 mg/dL for men and 1.4 mg/dL for women, or abnormal creatinine clearance. There was a concern for lactic acidosis. 26. A client on your floor is going for a CT with contrast. She is currently taking metformin. Why did the physician issue the order to hold the metformin 48 hours after the CT? However, even with data to suggest that metformin does not cause lactic acidosis, most facilities have the policy that metformin should be withheld 48 hours after procedures in patients undergoing radiologic studies involving intravascular administration of iodinated contrast media, e.g., diatrizoate (Hypaque®), iothalamate (Conray®), iodixanol (Visipaque®), ioversol (Optiray®), because use of such products may result in acute alteration of renal function. Some clinicians recommend holding metformin prior to any surgical procedure or in patients receiving anesthesia since restricted fluid intake may adversely affect renal function. 27. Among the sulfonylureas, which one is now considered the “best” choice for treating type 2 diabetes? And why? Metformin? 28. What is the primary adverse effect of the alpha glucosidase inhibitors (e.g., acarbose—Precose® and miglitol—Glyset )? Flatulence (gas), abdominal discomfort, diarrhea. Adverse GI effects diminish in frequency and intensity over time. 29. What oral agent is generally considered the “firstline” drug for obese or dyslipidemic clients with type 2 diabetes? 30. Outline the recommended drug treatment of a 12 yearold child with type 2 diabetes. Begin with diet modification and an exercise program. Patients should be encouraged to do at least 30 minutes of physical activity a day. The ADA recommends metformin (Glucophage ) for firstline drug 31. What are the reasons that the “glitazones” rosiglitazone (Avandia ) and pioglitazone (Actos ) have basically disappeared in the U.S.? Several toxicities? 32. What are the advantages of the Bydureon® pen over the previous formulation of Bydureon®? Available as twice a day injection (Byetta®) and as Bydureon®, a onceaweek injection of exenatide. 33. What were the findings of the Diabetes Prevention Program? Results show that medication or a combination of “prescribed” diet and exercise can prevent type 2 diabetes or delay type 2 diabetes in patients with impaired glucose tolerance (IGT). 34. Explain the source, indication and mechanism of action of exenatide (Byetta®). What is its role as a “diet drug”? 35. Why would a client with type 2 diabetes and hypertension be treated with an ACE inhibitor (e.g., Capoten®) or an ARB (e.g., Avapro®)? Current diabetes guidelines still recommend starting an ACEI or ARB for this MICROalbuminuria, even in patients without hypertension. That's because MICROalbuminuria was thought to be an early marker for kidney disease, but it turns out this isn't true. Now we know that adding an ACEI or ARB at this early stage does NOT reduce the risk of progression to endstage renal disease. It's a different story for diabetes patients who spill more protein, enough to be called MACROalbuminuria. 36. What are the current guidelines on insulin storage? Bottom line: Unopened insulin vials kept under refrigeration are stable until their labeled expiration dates. For opened vials, ADA suggests that patients be instructed to store vials at room temperature for about one month and to avoid temperature extremes. 37. Bromocriptine has long been used for conditions other than diabetes. What are those? What is the mechanism of action of this drug under the name Cycloset®? Bromocriptine is a synthetic dopamine agonist that is also indicated for pituitary tumors and a variety of hyperprolactinemia syndromes. It is also commonly recognized as a treatment for Parkinson's disease, and was the first dopamine agonist marketed for this purpose. The mechanism of action in treating diabetes is not completely understood. It is thought to involve increased dopaminergic activity in the hypothalamus. It is a synthetic dopamine agonist that is also indicated for Parkinson’s disease and many hyperprolactinemia syndromes. 38. Why is insulin a restricted substance by the International Olympic Committee? 39. What is the role of becaplermin (Regranex®) in the treatment of a client with diabetes? Becaplermin (Regranex®)—a topical gel of recombinant human plateletderived growth factor (rhPDGF) that increases proliferation of cells that repair wounds and form granulation tissue. Used for diabetic leg and foot ulcers. Boxed warning to address the increased risk of cancer mortality in patients who use 3 or more tubes of the product. 40. A type2 diabetes client you’re for caring tells you he is taking “Welchol®, which I looked up and it said it was for cholesterol. What’s going on?” Your response? It is the first and only medication approved to reduce both A1C and LDL cholesterol. However, it may increase triglycerides, which are usually present in clients with diabetes. 41. Compare and contrast the following incretins based on their mechanism of action, route of administration, efficacy and effect on weight: a. Sitagliptin (Januvia®) b. Saxagliptin (Onglyza®) c. Liraglutide (Victoza®) d. Exenatide (Byetta®, Bydureon®) e. Linagliptin (Tradjenta®) f. Albiglutide (Tanzeum®) g. Dulaglutide (Trulicity®) h. Lixisenatide (Adlyxin®) 42. Why would a client with diabetes taking Glynase Prestabs® (glyburide) also be taking Cymbalta® or Lyrica®? 43. What is the mechanism of action of canagliflozin (Invokana®) for the treatment of adults with type 2 diabetes? However, later in 2016, The Medical Letter, July 18, 2016, reported on a study (NEJM, June 14, 2016) that found that use of empagliflozin (Jardiance®) has been shown to slow progression of renal disease in patients with type 2 diabetes and established cardiovascular disease. Whether the other two SGLT2 inhibitors, canagliflozin (Invokana®) and dapagliflozin (Farxiga®), have cardiovascular or renal benefits is unknown. All three of these drugs could increase serum creatinine and decrease eGFR, particularly in elderly patients with hypovolemia and other risk factors. 44. What adverse effect with SGLT2 inhibitors such as empagliflozin (Jardiance®) was reported in 2015? Canagliflozin (Invokana®), dapagliflozin (Farxiga®) and empagliflozin (Jardiance®) are in a new class of drugs: oral inhibitors of sodium glucose cotransporter 2 (SGLT2). Inhibition of SGLT2 reduces resorption of glucose in the kidney, resulting in increased urinary glucose excretion, with a consequent lowering of plasma glucose levels as well as weight loss. They increase the risk of severe UTI and ketoacidosis. 45. In April 2016, the FDA issued a new alert about the potential for increased risk for heart failure in patients taking saxagliptin (Onglyza®) and alogliptin (Nesina®). 46. A female client you are caring for is taking dapagliflozin (Farxiga®). What is the most like side or adverse effects she will have? However, later in 2016, The Medical Letter, July 18, 2016, reported on a study (NEJM, June 14, 2016) that found that use of empagliflozin (Jardiance®) has been shown to slow progression of renal disease in patients with type 2 diabetes and established cardiovascular disease. Whether the other two SGLT2 inhibitors, canagliflozin (Invokana®) and dapagliflozin (Farxiga®), have cardiovascular or renal benefits is unknown. All three of these drugs could increase serum creatinine and decrease eGFR, particularly in elderly patients with hypovolemia and other risk factors. Because a numeric increase in bladder cancer was seen with dapagliflozin in one of these trials, dapagliflozin is not recommended for patients with active bladder cancer or moderate to severe renal impairment.
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