Page 1 of 45
ADVANCED PHARMACOLOGY NSG 533 EXAM 2 2025
Can be used as monotherapy or as add-on therapy for T2DM ..
Presenting A1C of 9 + symptoms or failure to achieve goal A1C on
adequate trial of 2-3 agents at maximally tolerated doses -
answer-Often starting with a long acting insulin
When glycemic goals aren't reached despite basal insulin (Good
FBG and pre-prandial BG, but elevated HbA1C), Consider prandial
therapy with fast-acting insulin. Begin fast-acting insulin before
largest meal.Variation exists between ADA and ACCE in their
recommendations
If HbA1C still elevated, add fast-acting to another
mealSulfonylurea can continue up until the point where prandial
(rapid) insulin is addedMetformin can / should continue !!
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
, Page 2 of 45
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 - 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 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%
, Page 3 of 45
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 - 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 renal status of patients commencing
, Page 4 of 45
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
ADVANCED PHARMACOLOGY NSG 533 EXAM 2 2025
Can be used as monotherapy or as add-on therapy for T2DM ..
Presenting A1C of 9 + symptoms or failure to achieve goal A1C on
adequate trial of 2-3 agents at maximally tolerated doses -
answer-Often starting with a long acting insulin
When glycemic goals aren't reached despite basal insulin (Good
FBG and pre-prandial BG, but elevated HbA1C), Consider prandial
therapy with fast-acting insulin. Begin fast-acting insulin before
largest meal.Variation exists between ADA and ACCE in their
recommendations
If HbA1C still elevated, add fast-acting to another
mealSulfonylurea can continue up until the point where prandial
(rapid) insulin is addedMetformin can / should continue !!
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
, Page 2 of 45
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 - 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 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%
, Page 3 of 45
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 - 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 renal status of patients commencing
, Page 4 of 45
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
