ADVANCED PHARMACOLOGY NSG 533
QUESTIONS WITH CORRECT ANSWERS
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 4
0 minutes every day of the week. She states compliance with all medications. She denies any h
istory of hypoglycemia despite being able to identify signs and symptoms and describe approp
riate 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 m
g 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 ANSWER -
Exenatide -
Exenatide (Bydureon) once weekly has been able to demonstrate weight loss and decrease A1
C% 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 m
ade worse by this drug. The package insert does not indicate a specific potassium concentratio
n 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 c
urrently the patient does not have any cautionary objective measures to not use this medicati
on. 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 signific
ant 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 ther
efore 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 prediabe
tes (at risk for developing diabetes) 5 years before the diagnosis and has a strong family histor
y of type 2 diabetes. JR's blood pressure was 150/92 mm Hg. His laboratory results revealed a
n A1C of 8.1%, normal cholesterol panel, and normal renal/hepatic function were noted with t
oday's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed 2 y ago) Pan
creatitis (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 therap
y 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 li
festyle modifications assuming no contraindications or intolerabilities are present upon evaluat
ion. 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 r
isk 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 circumstan
ce
,DPP4 Linhibitors Lare Lweight Lneutral Lbet Lrelatively Lbenign Lside Leffect Lprofile. LSitagliptin Lhas
Lbeen Lassociated Lwith Lcase Lreports Lof Lpancreatitis, Lso Lthis Lspecific Lagent Lshould Lbe
Lavoided. L$$$
GLP-
1 Lanalog Land Lhas Ldata Lto Lsupport Lan LA1C Lreduction Lnecessary Lto Lgain Lglycemic Lcontrol
Land Lmay Lassist Lwith Lweight Lloss Lgoals Lfor Lthis Lpatient. LNew Linformation Lsuggests Lthese
Lagents Lmay Lprov Lide Lbenefits Lin Lthose Lwith LASCVD. LJR Lhas La Lpast Lhistory Lof Lpancreatitis
Land LGLP-
1 Lanalogs Lare Lnot Lrecommended Ldue Lto Lthis Lcontraindication
TZDs Lhave Ldata Lto Lsupport Lan LA1C Lreduction Lnecessary Lto Lgain Lglycemic Lcontrol, Lbut Lare
Lassoci Lated Lwith Lweight Lgain, Lnegative Leffects Lon Llipids Land Lincreased Lrisk Lof Lfracture.
LUntil Lrecently, LT LZDs Lhave Lalso Lbeen Llinked Lto Lincreased LCV Levents Land Luse Lhas Lfallen
Lout Lof Lfavor
Sulfonylureas Lprovide Lexcellent LA1C Llowering, Lbut Lare Lalso Lassociated Lwith Lweight Lgain.
LThey Lal Lso Lhave Lthe Lpotential Lto Lcause Lhypoglycemia, Lso Lpatient Leducation Lis Lcrucial.
LBecause Lof Lhis Lall Lergies Lto L"sulfa", Luse Lwould Lbe Lcontr
A Lpatient Lwith Ltype L1 Ldiabetes Lreports Ltaking Lpropranolol Lfor Lhypertension. LWhat Lconcern
Ldoes Lthis Linformation Lpresent Lfor Lthe Lprovider? L- LCORRECT LANSWER L-
A Lpatient Lwith LType L1 LDM Lis Linsulin Ldependent Lfor Lglucose Lcontrol Land Lat Lhigh Lrisk Lfor
Lhypoglyc Lemic Lepisodes. LPropanolol Lcauses Lprolonged Lhypoglycemic Lepisodes. LNeeds Lto
Lswitch Lto LACE Lor LARB.
A Lprovider Lteaches La Lpatient Lwho Lhas Lbeen Ldiagnosed Lwith Lhypothyroidism Labout La Lnew
Lprescr Liption Lfor Llevothyroxine. LWhich Lstatement Lby Lthe Lpatient Lindicates La Lneed Lfor Lfurther
Lteaching?
a. "I Lshould Lnot Ltake Lheartburn Lmedication Lwithout Lconsulting Lmy Lprovider Lfirst."
b. "I Lshould Lreport Linsomnia, Ltremors, Land Lan Lincreased Lheart Lrate Lto Lmy Lprovider."
c. "If LI Ltake La Lmultivitamin Lwith Liron, LI Lshould Ltake Lit L4 Lhours Lafter Lthe Llevothyroxine."
d. "If LI Ltake Lcalcium Lsupplements, LI Lmay Lneed Lto Ldecrease Lmy Ldose Lof
Llevothyroxine." L- LCORRECT LANSWER L-
D. LCalcium Lmay Lreduce Llevothyroxine Labsorption. LFurther Leducation Lis Lneeded Lif Lthe
Lpatient Lfe Lels Lshe Lcan Ltake Lhalf Lof La Lprescribed Lmedication.
MC Lhas Lundiagnosed Lmultiple Lgastric Lulcers. LShortly Lafter Lconsuming La Llarge Lmeal Land
, Lalcohol Lhe Lexperiences Lsignificant LGI Ldistress. LHe Ltakes Lan LOTC Lheartburn Lremedy.
LWithin La Lminute Lor Lt
QUESTIONS WITH CORRECT ANSWERS
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 4
0 minutes every day of the week. She states compliance with all medications. She denies any h
istory of hypoglycemia despite being able to identify signs and symptoms and describe approp
riate 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 m
g 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 ANSWER -
Exenatide -
Exenatide (Bydureon) once weekly has been able to demonstrate weight loss and decrease A1
C% 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 m
ade worse by this drug. The package insert does not indicate a specific potassium concentratio
n 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 c
urrently the patient does not have any cautionary objective measures to not use this medicati
on. 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 signific
ant 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 ther
efore 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 prediabe
tes (at risk for developing diabetes) 5 years before the diagnosis and has a strong family histor
y of type 2 diabetes. JR's blood pressure was 150/92 mm Hg. His laboratory results revealed a
n A1C of 8.1%, normal cholesterol panel, and normal renal/hepatic function were noted with t
oday's laboratory test results.
Past medical history: Hypertension (diagnosed 4 y ago) Hyperlipidemia (diagnosed 2 y ago) Pan
creatitis (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 therap
y 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 li
festyle modifications assuming no contraindications or intolerabilities are present upon evaluat
ion. 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 r
isk 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 circumstan
ce
,DPP4 Linhibitors Lare Lweight Lneutral Lbet Lrelatively Lbenign Lside Leffect Lprofile. LSitagliptin Lhas
Lbeen Lassociated Lwith Lcase Lreports Lof Lpancreatitis, Lso Lthis Lspecific Lagent Lshould Lbe
Lavoided. L$$$
GLP-
1 Lanalog Land Lhas Ldata Lto Lsupport Lan LA1C Lreduction Lnecessary Lto Lgain Lglycemic Lcontrol
Land Lmay Lassist Lwith Lweight Lloss Lgoals Lfor Lthis Lpatient. LNew Linformation Lsuggests Lthese
Lagents Lmay Lprov Lide Lbenefits Lin Lthose Lwith LASCVD. LJR Lhas La Lpast Lhistory Lof Lpancreatitis
Land LGLP-
1 Lanalogs Lare Lnot Lrecommended Ldue Lto Lthis Lcontraindication
TZDs Lhave Ldata Lto Lsupport Lan LA1C Lreduction Lnecessary Lto Lgain Lglycemic Lcontrol, Lbut Lare
Lassoci Lated Lwith Lweight Lgain, Lnegative Leffects Lon Llipids Land Lincreased Lrisk Lof Lfracture.
LUntil Lrecently, LT LZDs Lhave Lalso Lbeen Llinked Lto Lincreased LCV Levents Land Luse Lhas Lfallen
Lout Lof Lfavor
Sulfonylureas Lprovide Lexcellent LA1C Llowering, Lbut Lare Lalso Lassociated Lwith Lweight Lgain.
LThey Lal Lso Lhave Lthe Lpotential Lto Lcause Lhypoglycemia, Lso Lpatient Leducation Lis Lcrucial.
LBecause Lof Lhis Lall Lergies Lto L"sulfa", Luse Lwould Lbe Lcontr
A Lpatient Lwith Ltype L1 Ldiabetes Lreports Ltaking Lpropranolol Lfor Lhypertension. LWhat Lconcern
Ldoes Lthis Linformation Lpresent Lfor Lthe Lprovider? L- LCORRECT LANSWER L-
A Lpatient Lwith LType L1 LDM Lis Linsulin Ldependent Lfor Lglucose Lcontrol Land Lat Lhigh Lrisk Lfor
Lhypoglyc Lemic Lepisodes. LPropanolol Lcauses Lprolonged Lhypoglycemic Lepisodes. LNeeds Lto
Lswitch Lto LACE Lor LARB.
A Lprovider Lteaches La Lpatient Lwho Lhas Lbeen Ldiagnosed Lwith Lhypothyroidism Labout La Lnew
Lprescr Liption Lfor Llevothyroxine. LWhich Lstatement Lby Lthe Lpatient Lindicates La Lneed Lfor Lfurther
Lteaching?
a. "I Lshould Lnot Ltake Lheartburn Lmedication Lwithout Lconsulting Lmy Lprovider Lfirst."
b. "I Lshould Lreport Linsomnia, Ltremors, Land Lan Lincreased Lheart Lrate Lto Lmy Lprovider."
c. "If LI Ltake La Lmultivitamin Lwith Liron, LI Lshould Ltake Lit L4 Lhours Lafter Lthe Llevothyroxine."
d. "If LI Ltake Lcalcium Lsupplements, LI Lmay Lneed Lto Ldecrease Lmy Ldose Lof
Llevothyroxine." L- LCORRECT LANSWER L-
D. LCalcium Lmay Lreduce Llevothyroxine Labsorption. LFurther Leducation Lis Lneeded Lif Lthe
Lpatient Lfe Lels Lshe Lcan Ltake Lhalf Lof La Lprescribed Lmedication.
MC Lhas Lundiagnosed Lmultiple Lgastric Lulcers. LShortly Lafter Lconsuming La Llarge Lmeal Land
, Lalcohol Lhe Lexperiences Lsignificant LGI Ldistress. LHe Ltakes Lan LOTC Lheartburn Lremedy.
LWithin La Lminute Lor Lt
