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NR566 Midterm Exam With Appropriate Answers

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A1C monitoring during oral or insulin diabetes management - Because Hb A1c reflects mean glycemia over the preceding 2 to 3 months, it should be measured at least twice a year if patients are meeting treatment goals or have stable glycemic control; it should be measured every 3 months if therapy has changed or if patients are not meeting treatment goals A1C Treatment Goal - Less than 7% ACEIS and ARBS benefits in other conditions - CAD, Post MI, heart failure. Clinical pearl: If you hear an abdominal bruit in a patient known to have vascular disease, give captopril, a short-acting ACEI, and measure serum creatinine prior to the dose and within 1 or 2 days after the dose. A rapid rise in the creatinine level suggests renal artery stenosis. A slower rise probably indicates a problem with poor hydration that can be corrected by rehydrating the patient and discontinuing or lowering the dose of any diuretics the patient is taking. Adverse effects associated with long-term use of bisphonates - Etidronate has also been associated with fractures in patients with Paget's disease when they are given high doses or when therapy lasted longer than 6 months. These patients must be carefully monitored with x-rays and laboratory work to assess for these lesions. The development of a rare form of subtrochanteric femur fracture in non-Paget's patients using bisphosphonates is under close scrutiny and has contributed to movement away from osteopenia prevention care to only osteoporosis therapy (FDA, 2010a). Allopurinol adverse effects - poor urate clearance with renal impairment, hepatotoxicity, weight loss, pruritis, rash-- more severe, fever, chills, arthralgia, cholestatic jaundice, eosinophilia, leukocytosis, leukopenia. Allopurinol drug interactions - ACEI - hypersensitivity. Aluminum salts - decreased effects. Ampicillin - rate of amp rash higher. Anticoagulants- enhanced anticoag (use Warfarin) Cyclophosphamide - increased risk for bleeding. Theophylline - toxicity risk. Thiazide diuretics - increased incidence of hypersensitivity reactions. Thiopurines - clinically significant increases in pharm and toxic effect of thio. Uricosuric agents - increase excretion of oxypurinol. Allopurinol monitoring - Check liver and renal function

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NR566MidtermExam
A1Cmonitoringduringoralorinsulindiabetesmanagement -BecauseHbA1c
reflectsmeanglycemiaoverthepreceding2to3months,itshouldbemeasuredatleasttwicea
yearifpatientsaremeetingtreatmentgoalsorhavestableglycemiccontrol;itshouldbe
measuredevery3monthsiftherapyhaschangedorifpatientsarenotmeetingtreatmentgoals
A1CTreatmentGoal -Lessthan7%
ACEISandARBSbenefitsinotherconditions -CAD,PostMI,heartfailure.
Clinicalpearl:Ifyouhearanabdominalbruitinapatientknowntohavevasculardisease,give
captopril,ashort-actingACEI,andmeasureserumcreatininepriortothedoseandwithin1or2
daysafterthedose.Arapidriseinthecreatininelevelsuggestsrenalarterystenosis.Aslower
riseprobablyindicatesaproblemwithpoorhydrationthatcanbecorrectedbyrehydratingthe
patientanddiscontinuingorloweringthedoseofanydiureticsthepatientistaking.
Adverseeffectsassociatedwithlong-termuseofbisphonates -Etidronatehasalso
beenassociatedwithfracturesinpatientswithPaget'sdiseasewhentheyaregivenhighdoses
orwhentherapylastedlongerthan6months.Thesepatientsmustbecarefullymonitoredwith
x-raysandlaboratoryworktoassessfortheselesions.Thedevelopmentofarareformof
subtrochantericfemurfractureinnon-Paget'spatientsusingbisphosphonatesisunderclose
scrutinyandhascontributedtomovementawayfromosteopeniapreventioncaretoonly
osteoporosistherapy(FDA,2010a).
Allopurinoladverseeffects -poorurateclearancewithrenalimpairment,
hepatotoxicity,weightloss,pruritis,rash-->moresevere,fever,chills,arthralgia,cholestatic
jaundice,eosinophilia,leukocytosis,leukopenia.
Allopurinoldruginteractions -ACEI-hypersensitivity.
Aluminumsalts-decreasedeffects.
Ampicillin-rateofamprashhigher. Anticoagulants-enhancedanticoag(useWarfarin)
Cyclophosphamide-increasedriskforbleeding.
Theophylline-toxicityrisk.
Thiazidediuretics-increasedincidenceofhypersensitivityreactions.
Thiopurines-clinicallysignificantincreasesinpharmandtoxiceffectofthio.
Uricosuricagents-increaseexcretionofoxypurinol.
Allopurinolmonitoring -Checkliverandrenalfunction
AlternativeHyperlipidemiaTherapies -Omega3FattyAcids
Omacorisaprescriptionformulationthatisamoreconcentrated(840mg)and
quality-controlledsourceofboththeeicosapentanoicacid(EPA)anddocosahexaenoicacids
(DHA)thanthosefoundinOTCsupplements(avg200to500mg).Omacorhasthesame"fish
burp"sideeffectasitsOTCcounterpartsbutmaybemoretolerabletopatientsbecauseofits
twice-a-daydosingschedule.
Amiodaronemonitoring -Cxray,PFTevery3-6mo.
TSH,freeT4every6mo.
Opthalmicexam(slitlampandfundoscopy)every6mo.
Angina -Painintheheartregioncausedbylackofoxygen.Ischemiacausedbythe
imbalancebetweenmyocardialoxygensupply(MOS)andmyocardialoxygendemand(MOD)
producespainreferredtoas_____.
Anginariskfactors -smoking,hypertension,hypercholesterolemia,lowhigh-density
lipoprotein(HDL)cholesterol,diabetesmellitus.
AnginaTreatment -Allappropriatepatientswithanginashouldbeonaspirin81to
162mg/d Ifaspiriniscontraindicated,clopidogrel(Plavix)75mgdailymaybeaneffectivesubstitute
Patientswithanginaonlyonexertion,anormalrestingECG,andsymptomsthatcanbe
controlledbyrestandintermittentnitroglycerin
ACEinhibitorsandbeta-adrenergicblockersarethemainstaysofinitialdrugtherapyforpatients
withangina
Thesecond-generationdihydropyridineCCBs(amlodipineandfelodipine)andlong-acting
nitratescanbeusedfortreatmentofanginainpatientswhenbetablockersandACEinhibitors
areineffectiveorcontraindicated
Short-acting,sublingualnitratescanbeusedinpatientswithmild,stableCADforimmediate
reliefonanasneededbasis
Antidiabeticmedicationsassociatedwithphotosensitivity -Sulfonylureas
Antidiabeticstoavoidintheelderly&why -Sulfonylureasproducessevere
hypoglycemia.
Glimepirideproduceshypoglycemia.
Glyburideisthemostlikelytocausehypoglycemia.
Metforminduetoolderadultsoftenhaverenalinsufficiencyorheartfailure.
Alpha-glucosidaseinhibitorsarenotwelltolerated.
Allmedsshouldbestartedatthelowestpossibledose.
Antihypertensivesteptherapyrecommendations -Asageneralrule,thefollowing
suggestionscanleadtoprogressinachievingtheBPgoalinaprimarycarepopulation:
1.SetanappropriatetherapeuticBPgoalbasedonindividualpatientsandtheircompelling
indications.
2.BepatientandworkonattainingtheBPgoalovermanyweekstomonths.MovingtolowerBP
quicklyismorelikelytoproducesideeffectstothedrugsthatleadtononadherence.Thereisno
evidencethatfasterisbetterexceptincasesofextremevalues.
3.TitrateBPmedicationsnomoreoftenthanevery4to6weeks.Thebodyneedstimeto
demonstratefullresponsetothedrug.

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