Advanced Pharmacology NSG 533 ./ ./ ./
EP is a 38-year-
./ ./ ./
old female patient that comes in for diabetes education and mana
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
gement. She was diagnosed 12 years ago and states lately she is n
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ot able to control her diet although she continues a 1600 calorie di
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
et with appropriate daily carbohydrate intake (per dietitian prescri
./ ./ ./ ./ ./ ./ ./ ./
ption) and walks 40 minutes every day of the week. She states co
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
mpliance with all medications. She denies any history of hypogly
./ ./ ./ ./ ./ ./ ./ ./ ./
cemia despite being able to identify signs and symptoms and desc
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ribe appropriate treatment strategies.
./ ./ ./
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due t
./ ./ ./ ./ ./ ./ ./ ./
o thyroid cancer
./ ./
FmHx: Noncontributory ./
SHx: (−) Smoking, alcohol use, past marijuana use while in high
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
school
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopr ./ ./ ./ ./ ./ ./ ./ ./ ./
il 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 mE
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
q/L, BUN - correct answer 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 h
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
yperkalemia which could be made worse by this drug. The packa ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ge insert does not indicate a specific potassium concentration cut
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
off to no longer use this medication; however, there are better cho
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ices 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 a
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ny cautionary objective measures to not use this medication. DPP
./ ./ ./ ./ ./ ./ ./ ./ ./
-IV inhibitors are weight neutral. DPP-
./ ./ ./ ./ ./
IV inhibitors can be used in patients taking sulfonylureas; howev
./ ./ ./ ./ ./ ./ ./ ./ ./
er, it may be recommended to reduce or stop the sulfonylurea dos
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
e.
Acarbose - ./
Acarbose (Precose) is not recommended for initial management
./ ./ ./ ./ ./ ./ ./ ./ ./
and is associated with significant GI side effects. More informati
./ ./ ./ ./ ./ ./ ./ ./ ./
on 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 w
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
as classified as having prediabetes (at risk for developing diabete
./ ./ ./ ./ ./ ./ ./ ./ ./
s) 5 years before the diagnosis and has a strong family history of t
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ype 2 diabetes. JR's blood pressure was 150/92 mm Hg. His labor
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
atory results revealed an A1C of 8.1%, normal cholesterol panel,
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
and normal renal/hepatic function were noted with today's laborat
./ ./ ./ ./ ./ ./ ./ ./
ory test results.
./ ./
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipi
./ ./ ./ ./ ./ ./ ./ ./
demia (diagnosed 2 y ago) Pancreatitis (idiopathic) (acute hospita
./ ./ ./ ./ ./ ./ ./ ./
lization 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 Cir
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
cumference: 46 in Weight: 267 lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
2
Despite improvements in the past six weeks due to lifestyle chang
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
es and exercise, drug therapy is to be started for JR's diabet -
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
correct answer 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 rena ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
l status of patients commencing metformin therapy to limit the ris
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
k of lactic acidosis (JR is without contraindication).
./ ./ ./ ./ ./ ./ ./
Since his entry A1C is >7.5%, dual therapy is indicated. There ar
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
e several potential choices. The second step can be a dipeptidyl pe
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ptidase-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. Anythin
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
g next can be tried depending on what suits the circumstance
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
DPP4 inhibitors are weight neutral bet relatively benign side effe
./ ./ ./ ./ ./ ./ ./ ./ ./
ct profile. Sitagliptin has been associated with case reports of pan
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
creatitis, so this specific agent should be avoided. $$$
./ ./ ./ ./ ./ ./ ./ ./
GLP-
1 analog and has data to support an A1C reduction necessary to g
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ain glycemic control and may assist with weight loss goals for thi
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
s patient. New information suggests these agents may provide be
./ ./ ./ ./ ./ ./ ./ ./ ./
nefits 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 gl
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ycemic control, but are associated with weight gain, negative effe
./ ./ ./ ./ ./ ./ ./ ./ ./
cts on lipids and increased risk of fracture. Until recently, TZDs h
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
EP is a 38-year-
./ ./ ./
old female patient that comes in for diabetes education and mana
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
gement. She was diagnosed 12 years ago and states lately she is n
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ot able to control her diet although she continues a 1600 calorie di
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
et with appropriate daily carbohydrate intake (per dietitian prescri
./ ./ ./ ./ ./ ./ ./ ./
ption) and walks 40 minutes every day of the week. She states co
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
mpliance with all medications. She denies any history of hypogly
./ ./ ./ ./ ./ ./ ./ ./ ./
cemia despite being able to identify signs and symptoms and desc
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ribe appropriate treatment strategies.
./ ./ ./
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due t
./ ./ ./ ./ ./ ./ ./ ./
o thyroid cancer
./ ./
FmHx: Noncontributory ./
SHx: (−) Smoking, alcohol use, past marijuana use while in high
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
school
Medications: Metformin 850 mg tid, glipizide 20 mg bid, lisinopr ./ ./ ./ ./ ./ ./ ./ ./ ./
il 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 mE
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
q/L, BUN - correct answer 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 h
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
yperkalemia which could be made worse by this drug. The packa ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ge insert does not indicate a specific potassium concentration cut
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
off to no longer use this medication; however, there are better cho
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ices 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 a
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ny cautionary objective measures to not use this medication. DPP
./ ./ ./ ./ ./ ./ ./ ./ ./
-IV inhibitors are weight neutral. DPP-
./ ./ ./ ./ ./
IV inhibitors can be used in patients taking sulfonylureas; howev
./ ./ ./ ./ ./ ./ ./ ./ ./
er, it may be recommended to reduce or stop the sulfonylurea dos
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
e.
Acarbose - ./
Acarbose (Precose) is not recommended for initial management
./ ./ ./ ./ ./ ./ ./ ./ ./
and is associated with significant GI side effects. More informati
./ ./ ./ ./ ./ ./ ./ ./ ./
on 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 w
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
as classified as having prediabetes (at risk for developing diabete
./ ./ ./ ./ ./ ./ ./ ./ ./
s) 5 years before the diagnosis and has a strong family history of t
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ype 2 diabetes. JR's blood pressure was 150/92 mm Hg. His labor
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
atory results revealed an A1C of 8.1%, normal cholesterol panel,
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
and normal renal/hepatic function were noted with today's laborat
./ ./ ./ ./ ./ ./ ./ ./
ory test results.
./ ./
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipi
./ ./ ./ ./ ./ ./ ./ ./
demia (diagnosed 2 y ago) Pancreatitis (idiopathic) (acute hospita
./ ./ ./ ./ ./ ./ ./ ./
lization 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 Cir
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
cumference: 46 in Weight: 267 lb Height: 5 ′ 6 ″ BMI: 43.1 kg/m ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
2
Despite improvements in the past six weeks due to lifestyle chang
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
es and exercise, drug therapy is to be started for JR's diabet -
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
correct answer 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 rena ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
l status of patients commencing metformin therapy to limit the ris
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
k of lactic acidosis (JR is without contraindication).
./ ./ ./ ./ ./ ./ ./
Since his entry A1C is >7.5%, dual therapy is indicated. There ar
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
e several potential choices. The second step can be a dipeptidyl pe
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ptidase-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. Anythin
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
g next can be tried depending on what suits the circumstance
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
DPP4 inhibitors are weight neutral bet relatively benign side effe
./ ./ ./ ./ ./ ./ ./ ./ ./
ct profile. Sitagliptin has been associated with case reports of pan
./ ./ ./ ./ ./ ./ ./ ./ ./ ./
creatitis, so this specific agent should be avoided. $$$
./ ./ ./ ./ ./ ./ ./ ./
GLP-
1 analog and has data to support an A1C reduction necessary to g
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ain glycemic control and may assist with weight loss goals for thi
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
s patient. New information suggests these agents may provide be
./ ./ ./ ./ ./ ./ ./ ./ ./
nefits 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 gl
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
ycemic control, but are associated with weight gain, negative effe
./ ./ ./ ./ ./ ./ ./ ./ ./
cts on lipids and increased risk of fracture. Until recently, TZDs h
./ ./ ./ ./ ./ ./ ./ ./ ./ ./ ./
