ADVANCED PHARMACOLOGY NSG 533
QUESTIONS AND ANSWERS WITH
GUARANTEED A+ GRADE
EP is a 38-year-old female patient that comes in for diabetes education and management. She
was diagnosed 12 years ago and states lately she is not able to control her diet although she
continues a 1600 calorie diet with appropriate daily carbohydrate intake (per dietitian
prescription) and walks 40 minutes every day of the week. She states compliance with all
medications. She denies any history of hypoglycemia despite being able to identify signs and
symptoms and describe appropriate treatment strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to thyroid cancer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high school
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopril 20 mg daily, sertraline 100 mg
daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L, BUN - Correct Answers -
Exenatide - Exenatide (Bydureon) once weekly has been able to demonstrate weight loss and
decrease A1C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP due to the
self-reported history of thyroid cancer.
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia
which could be made worse by this drug. The package insert does not indicate a specific
potassium concentration cut off to no longer use this medication; however, there are better
choices in this patient.
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical
trials and currently the patient does not have any cautionary 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 management and is associated
with significant GI side effects. More information would be needed regarding fasting and post-
prandial numbers. In addition, adding acarbose would only lower A1c by 0.8% at best and
therefore would not achieve the desired A1C goal of <7%
,JR is a 68-year-old African American man with a new diagnosis of T2DM. He was classified as
having prediabetes (at risk for developing diabetes) 5 years before the diagnosis and has a
strong family history of type 2 diabetes. JR's blood pressure was 150/92 mm Hg. His laboratory
results revealed an A1C of 8.1%, normal cholesterol panel, and normal renal/hepatic function
were noted with today's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed 2 y ago)
Pancreatitis (idiopathic) (acute hospitalization 3 y ago)
Family history: Type 2 diabetes
Medication: HCTZ 25 mg daily, simvastatin 10 mg daily
Allergies: SMZ/TMP
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist Circumference: 46 in Weight: 267 lb
Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
Despite improvements in the past six weeks due to lifestyle changes and exercise, drug therapy
is to be started for JR's diabet - Correct Answers -Metformin is the drug of choice recommended
for most patients with diabetes in addition to lifestyle modifications assuming no
contraindications or intolerabilities are present upon evaluation. Metformin has also shown to
provide positive weight neutral/loss effects in obese patients. It is crucial to know the renal
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 several potential choices. The
second step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-1)
receptor agonist, it can be a TZD, it can be a sulfonylurea agent, it can be a SGLT2 inhibitor, or it
could be basal insulin. Anything next 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 pancreatitis, so this specific agent should be avoided. $$$
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic control and
may assist with weight loss goals for this patient. New information suggests these agents may
provide benefits in those with ASCVD. JR has a past history of pancreatitis and GLP-1 analogs are
not recommended due to this contraindication
,TZDs have data to support an A1C reduction necessary to gain glycemic 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 associated with weight gain. They
also have the potential to cause hypoglycemia, 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 hypertension. What concern does
this information present for the provider? - Correct Answers -A patient with Type 1 DM is insulin
dependent for glucose control and at high risk for hypoglycemic episodes. Propanolol causes
prolonged hypoglycemic episodes. Needs to switch to ACE or ARB.
A provider teaches a patient who has been diagnosed with hypothyroidism about a new
prescription for levothyroxine. Which statement by the patient indicates a need for further
teaching?
a. "I should not take heartburn medication without consulting my provider first."
b. "I should report insomnia, tremors, and an increased heart rate to my provider."
c. "If I take a multivitamin with iron, I should take it 4 hours after the levothyroxine."
d. "If I take calcium supplements, I may need to decrease my dose of levothyroxine." - Correct
Answers -D. Calcium may reduce levothyroxine absorption. Further education is needed if the
patient feels she can take half of a prescribed medication.
MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal and alcohol
he experiences significant GI distress. He takes an OTC heartburn remedy. Within a minute or
two he develops what he will later describe as "belching, nausea and a bad bloated feeling".
Several of the ulcers began to bleed and he becomes profoundly hypotensive from the blood
loss and is taken to the ED. Endoscopy confirms multiple bleeds; the endoscopist remarks that it
appears as if the lesions had been literally stretched apart causing additional tissue damage.
What did the patient most likely take (i.e. what was the OTC remedy)? - Correct Answers -I
would accept Alka-Selzer. I contains NaHCO3 (as well as ASA). In the presence of HCL it Liberates
CO2, that can cause gastric distention, belching and nausea. The reaction is fairly swift allowing
little time for dissipation. Tums, its primary ingredient calcium carbonate which when taken
, cause a reaction with the stomach acid such as production of carbon dioxide gas which can
cause bloating and the stomach to stretch to tear the ulcers open.
On your way to this examination, you experience the vulnerable feeling that an attack of acute
diarrhea is imminent! If you stop at a drug store, which anti-diarrheal drugs could you buy
without a prescription even though it is chemically related to the strong opioid analgesic
meperidine (but acts only on the peripheral opioid receptor)? - Correct Answers -Loperamide
JA has multiple medical problems and is taking several drugs including theophylline, warfarin
and phenytoin. His conditions were well controlled, but recently he started to experience some
GI distress for which of his "well intentioned friends" gave him some medication. He presents to
you with toxic effects of all his other medications and plasma levels of those medications
elevated. What was most likely the medication he took? - Correct Answers -Cimetidine
What lifestyle modifications should be recommended? - Correct Answers --losing weight if
overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
What medications / foods can contribute to GERD? - Correct Answers --Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, 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 H2RA within each of these classes? - Correct Answers --PPI-
bismuth quadruple therapy combined with proton pump inhibitors
QUESTIONS AND ANSWERS WITH
GUARANTEED A+ GRADE
EP is a 38-year-old female patient that comes in for diabetes education and management. She
was diagnosed 12 years ago and states lately she is not able to control her diet although she
continues a 1600 calorie diet with appropriate daily carbohydrate intake (per dietitian
prescription) and walks 40 minutes every day of the week. She states compliance with all
medications. She denies any history of hypoglycemia despite being able to identify signs and
symptoms and describe appropriate treatment strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to thyroid cancer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high school
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopril 20 mg daily, sertraline 100 mg
daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L, BUN - Correct Answers -
Exenatide - Exenatide (Bydureon) once weekly has been able to demonstrate weight loss and
decrease A1C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP due to the
self-reported history of thyroid cancer.
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia
which could be made worse by this drug. The package insert does not indicate a specific
potassium concentration cut off to no longer use this medication; however, there are better
choices in this patient.
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical
trials and currently the patient does not have any cautionary 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 management and is associated
with significant GI side effects. More information would be needed regarding fasting and post-
prandial numbers. In addition, adding acarbose would only lower A1c by 0.8% at best and
therefore would not achieve the desired A1C goal of <7%
,JR is a 68-year-old African American man with a new diagnosis of T2DM. He was classified as
having prediabetes (at risk for developing diabetes) 5 years before the diagnosis and has a
strong family history of type 2 diabetes. JR's blood pressure was 150/92 mm Hg. His laboratory
results revealed an A1C of 8.1%, normal cholesterol panel, and normal renal/hepatic function
were noted with today's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed 2 y ago)
Pancreatitis (idiopathic) (acute hospitalization 3 y ago)
Family history: Type 2 diabetes
Medication: HCTZ 25 mg daily, simvastatin 10 mg daily
Allergies: SMZ/TMP
Vitals: BP: 150/92 mm Hg P: 78 beats/min RR: 12 rpm Waist Circumference: 46 in Weight: 267 lb
Height: 5 ′ 6 ″ BMI: 43.1 kg/m 2
Despite improvements in the past six weeks due to lifestyle changes and exercise, drug therapy
is to be started for JR's diabet - Correct Answers -Metformin is the drug of choice recommended
for most patients with diabetes in addition to lifestyle modifications assuming no
contraindications or intolerabilities are present upon evaluation. Metformin has also shown to
provide positive weight neutral/loss effects in obese patients. It is crucial to know the renal
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 several potential choices. The
second step can be a dipeptidyl peptidase-4 inhibitor, it can be a glucagon-like peptide-1 (GLP-1)
receptor agonist, it can be a TZD, it can be a sulfonylurea agent, it can be a SGLT2 inhibitor, or it
could be basal insulin. Anything next 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 pancreatitis, so this specific agent should be avoided. $$$
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic control and
may assist with weight loss goals for this patient. New information suggests these agents may
provide benefits in those with ASCVD. JR has a past history of pancreatitis and GLP-1 analogs are
not recommended due to this contraindication
,TZDs have data to support an A1C reduction necessary to gain glycemic 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 associated with weight gain. They
also have the potential to cause hypoglycemia, 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 hypertension. What concern does
this information present for the provider? - Correct Answers -A patient with Type 1 DM is insulin
dependent for glucose control and at high risk for hypoglycemic episodes. Propanolol causes
prolonged hypoglycemic episodes. Needs to switch to ACE or ARB.
A provider teaches a patient who has been diagnosed with hypothyroidism about a new
prescription for levothyroxine. Which statement by the patient indicates a need for further
teaching?
a. "I should not take heartburn medication without consulting my provider first."
b. "I should report insomnia, tremors, and an increased heart rate to my provider."
c. "If I take a multivitamin with iron, I should take it 4 hours after the levothyroxine."
d. "If I take calcium supplements, I may need to decrease my dose of levothyroxine." - Correct
Answers -D. Calcium may reduce levothyroxine absorption. Further education is needed if the
patient feels she can take half of a prescribed medication.
MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal and alcohol
he experiences significant GI distress. He takes an OTC heartburn remedy. Within a minute or
two he develops what he will later describe as "belching, nausea and a bad bloated feeling".
Several of the ulcers began to bleed and he becomes profoundly hypotensive from the blood
loss and is taken to the ED. Endoscopy confirms multiple bleeds; the endoscopist remarks that it
appears as if the lesions had been literally stretched apart causing additional tissue damage.
What did the patient most likely take (i.e. what was the OTC remedy)? - Correct Answers -I
would accept Alka-Selzer. I contains NaHCO3 (as well as ASA). In the presence of HCL it Liberates
CO2, that can cause gastric distention, belching and nausea. The reaction is fairly swift allowing
little time for dissipation. Tums, its primary ingredient calcium carbonate which when taken
, cause a reaction with the stomach acid such as production of carbon dioxide gas which can
cause bloating and the stomach to stretch to tear the ulcers open.
On your way to this examination, you experience the vulnerable feeling that an attack of acute
diarrhea is imminent! If you stop at a drug store, which anti-diarrheal drugs could you buy
without a prescription even though it is chemically related to the strong opioid analgesic
meperidine (but acts only on the peripheral opioid receptor)? - Correct Answers -Loperamide
JA has multiple medical problems and is taking several drugs including theophylline, warfarin
and phenytoin. His conditions were well controlled, but recently he started to experience some
GI distress for which of his "well intentioned friends" gave him some medication. He presents to
you with toxic effects of all his other medications and plasma levels of those medications
elevated. What was most likely the medication he took? - Correct Answers -Cimetidine
What lifestyle modifications should be recommended? - Correct Answers --losing weight if
overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
What medications / foods can contribute to GERD? - Correct Answers --Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, 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 H2RA within each of these classes? - Correct Answers --PPI-
bismuth quadruple therapy combined with proton pump inhibitors
