NR565 Final Exam - Chamberlain

What labs are used to diagnose hypo/hyper thyroid? - TSH, T3 and T4. Timeframe for re-check of labs after starting levothyroxine - 6-8 weeks (long halflife). Yearly after stable. Signs and symptoms of hypothyroidism - Dry hair, puffy face, goiter in the neck, slow heartbeat, weight gain, constipation, infertility, increased risk of miscarriages, irregular menstrual cycle, cold intolerance. Drug of choice for hypothyroidism - Levothyroxine (Synthroid) § Signs and symptoms of hyperthyroidism - Hair loss, bulging eyes, goiter, rapid heartbeat, weight loss, diarrhea, menstrual periods loss often or longer. Drug of choice for hyperthyroidism - Methimazole (Tapazole) Treatment of thyroid storm - Combination of antithyroid drugs, corticosteroids, beta-blockers, iodine solution, and supportive measures. PTU is preferred treatment. Result of not treating hypothyroidism during pregnancy: - Permanent neuropsychological deficits in the child. Decrease IQ/neuropsychological function. First trimester. Medication to treat symptoms of hyperthyroidism (notice this is treating symptoms and not the hyperthyroidism itself): - Beta blockers (tachycardia) - propranolol/atenolol most popular.Non-radioactive iodine. Drug/Food/Supplement interactions with levothyroxine: - -Histamine receptor blockers, PPIs, sucralfate, aluminum containing antacids, calcium supplements, iron, magnesium salts. -Separate administration of these drugs by 4 hours. -Food reduces absorption. -Accelerate the metabolism: Phenytoin, carbamazepine, rifampin, sertraline, and phenobarbital. -Effects of warfarin are enhanced. -Increase cardiac responsiveness to catecholamines. -May need to increase requirements for insulin/digoxin. How to confirm a diagnosis of DM prior to beginning treatment: - Fasting plasma glucose above 126. A random plasma glucose of over 200 plus symptoms of diabetes, an oral glucose tolerance test of two hours, plasma glucose of over 200, or a A1C higher than 6.5. A1c general goals - 7, patients that experience severe hypoglycemia/have a limited life expectancy may have an A1C goal of 8. A1c older adults - 8, those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals such as 8.0-8.5. When should insulin be considered? - For patients who have an A1c 10%, a fasting blood glucose 300, or markedly symptomatic. At what time interval should A1c be re-checked? - Every 2-3 months and max of 4 times a year. If 7, every 6 months. Action of Insulin - Anabolic, energy conservation, promotes cellular growth and division. Pioglitazone contraindications: - Heart failure (severe = no, mild = caution) and bladder cancer. Causes fluid retention. GLP-1 (abbreviation and examples) - Glucagonlike Peptide - Subcutaneous injections - Dulaglutide (Trulicity), Semaglutide (Ozempic), Liraglutide (Victoza). SGLT2i (abbreviation and examples) - Sodium Glucose Cotransporter 2 Inhibitors - Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance). DPP4-I (abbreviation and examples) - Dipeptidyl Peptidase-4 Inhibitors - Sitagliptin, Saxagliptin, Linagliptin, Alogliptin. TZD (abbreviation and examples) - Thiazolidinediones - Rosiglitazone & Pioglitazone Which drug class should be considered for diabetes prior to insulin? - It is recommended that a GLP-1 be considered before starting insulin. Metformin? Ratio of basal insulin to rapid-acting insulin in total daily dose (TDD) of insulin - Basal and bolus insulin replacement encompasses approximately 50% of the total daily insulin dose (TDD) Example: TDD = patient's weight in kg (80kg) x 0.6 units = 48 units. That means 24 units of the TDD is the basal insulin dose and the other 24 units is rapid-acting. How is total daily dose (TDD) of insulin calculated - TDD is calculated by taking the total weight in kg and multiply by 0.6 units. Know the carbohydrate-to insulin ratio when calculating basal insulin - Mealtime dose is calculated using the 450 rule for regular insulin and 500 rule for rapid acting insulin then divide by TDD. The answer (rounded) = the ratio of 1:the # answer. That means that if the meal is 60g of carbs, 60 divided by the # in answer = # of units of rapid-acting insulin. GLP-1 MOA - Augment effects of incretin hormone GLP-1. Cause an increase in insulin production and inhibit postprandial glucagon release and increase satiety. TZD MOA - Decrease insulin resistance. Enhance insulin sensitivity in muscle tissue and reduce glucagon production in the liver. DPP-4i MOA - Enhance actions of incretin hormones. Inhibit DPP-4 activity and increase active incretin concentrations which result in increased insulin secretion and decreased glucagon. Sulfonylureas MOA - Stimulate insulin release from pancreatic islet. SGLT2i MOA - Limits reabsorption of glucose in the renal tubules. Block glucose reabsorption by the kidneys in the proximal nephron and increase the release of glucose in urine. Which diabetic medication(s) come with a concern of hypoglycemia? - Insulin, meglitinides, sulfonylureas, amylin analogues Acute symptoms of diabetes plus casual plasma glucose concentration greater than or equal to 200 mg/dL. *Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes are polyuria, polydipsia, and unexplained weight loss. · Diabetes mellitus · Pre-diabetes - · Diabetes mellitus Fasting plasma glucose greater than or equal to 126 mg/dL. *Fasting is defined as no caloric intake for at least 8 hours. · Pre-diabetes · Diabetes mellitus - · Diabetes mellitus 2 hour post-load plasma glucose in an oral glucose tolerance test greater than or equal to 200 mg/dL. The test uses a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. · Pre-diabetes · Diabetes mellitus - · Diabetes mellitus HgbA1c greater than or equal to 6.5% · Pre-diabetes · Diabetes mellitus - · Diabetes mellitus Fasting plasma glucose 100 to 125 mg/dL (IFG) or · Diabetes mellitus · Pre-diabetes - · Pre-diabetes Plasma glucose 140 to 199 mg/dL (IGT) 2 hours post-ingestion of standard glucose load (75 g) or · Diabetes mellitus · Pre-diabetes - · Pre-diabetes HgbA1c 5.7% to 6.4% · Diabetes mellitus · Pre-diabetes - · Pre-diabetes Methylxanthines (Theophylline) Who is at risk for toxicity and why? - Smokers require higher doses. Heart and liver disease require lower doses. Older patients are at much higher risk. Toxicity can cause severe dysrhythmias and convulsions. Step 1 therapy for asthma and COPD - Manage with a SABA (albuterol) as needed.