NR566 Midterm review questions with answers (Week 1, 2, 3)

Please give all credit to these responses to my classmates in Professor Halls class!!! Hope this helps in reviewing for our midterm!! Sorry for the late submission! Good luck everyone  Week 1 Professor question: Why are statins recommended in the evening instead of morning? (pg 561) After starting John on insulin, he calls the office saying he feels bad. He said when he checked his blood sugar before calling it was 52 mg/dl. What instructions should he be given? Answer from classmate: Statins are recommended to be taken in the evening. Cholesterol synthesis is highest through the night and first thing in the morning. The biosyntheses of cholesterol follows a normal circadian rhythm. Administration at night allows for the medication to be at peak levels in the body during the time of high cholesterol synthesis (Korani et al., 2019). A blood glucose level <70mg/dL is considered to be hypoglycemia. John called the office with a sugar of 52mg/dL. He would be given instructions that follow "the rule of 15". This means that when symptoms occur, he should consume 15 g of a fast-acting carbohydrate. After 15 minutes, he should recheck his blood glucose. John should also be educated on the best options of carbohydrates to consume. Examples would be 4 oz of juice, four-five hard candies, honey, or half a can of regular soft drink. Another education point is that John needs to have a meal within a few hours after the low blood glucose. He may also need to see his doctor for adjustments to be made on insulin dosage as well as meal patterns to help prevent another low blood glucose episode from occurring (Woo & Robinson, 2016). Professor question: What diabetic medications would be contraindicated in patients with heart failure? Which diabetic drug(s) may have beneficial effects in heart failure? (text has info on this but ADA 2020 guidelines has even more up to date info on this topic, so here is the page. See Recommendation 9.9 and 9.10) answer from classmate: Suppose John was showing signs of heart failure. What diabetic medications would be contraindicated in patients with heart failure? Metformin is contraindicated in patients with renal insufficiency and unstable heart failure (Woo & Robinson, 2016). According to the American Diabetes Association (2020), Metformin can be utilized in patients with stable heart failure, not currently hospitalized, and Glomerular filtration rate should be greater than 30 ml per hour. In this instance, John should be switched to fast acting insulin Humalog, to cover mealtimes and if his HgbA1C is not sufficiently controlled at the 3 month follow up then, long acting Lantus insulin should be added to the regime. Additionally, John should be placed on an Angiotensin Converting Enzyme inhibitor or Angiotensin Receptor Blocker and likely increase his atorvastatin to 20mg tablet (ADA, 2020). Which diabetic drug(s) may have beneficial effects in heart failure? With the scenario presented previously and with the addition of heart failure, John should be placed on either a sodium-glucose cotransporter 2 inhibitor (SGLTi) or a glucagon-like peptide 1 receptor agonist (GLP-1 RA) to improve glycemic management (ADA, 2020a). Both SGLT2i and GLP-1 RA have demonstrated cardiovascular disease benefits by reducing CVD events and HF hospitalizations in association with diabetes mellitus (ADA, 2020b). The differential in which medication to use for John would be based on his Glomerular Filtration Rate (GFR), decreasing GFR rates or worsening chronic kidney disease would indicate stoppage of SGLT2i and use of GLP-1 RA. Per the American Diabetes Association (2020), John with mild HF would be initially placed on a GLP 1- RA Liraglutide (Victoza). Victoza is a once daily injection that aids in treating T2DM by increasing insulin synthesis and release, decreasing amount of glucagon and gastric emptying, and reducing food intake (Woo & Robinson, 2016). Additionally, placing John on a GLP-1 RA would help decrease his obesity with its proven beneficial tendency to increase metabolism and improve weight loss (Woo & Robinson, 2016). Professor question: What lab do we need to check prior to starting metformin? (hint: which organ function needs to be evaluated?) What other potential adverse effects are there associated with metformin? (Micromedex in the library is a good source for this info) Answer: The most important lab is eGFR/renal function since this determines whether we can safely use metformin. See recommendations below. I also included information on contrast administration. The concern is that if dye impairs renal function, the risk of lactic acidosis is increased. Another potential adverse effect is B12 deficiency. "Clinical recommendations based upon the patient’s renal function • Before initiating therapy, obtain an eGFR • Initiation of therapy is not recommended in patients with eGFR between 30 –45 mL/minute/1.73 m² • Obtain an eGFR at least annually in all patients receiving therapy • In patients at increased risk for development of renal impairment (e.g., the elderly), renal function should be assessed more frequently Professor question: According to the text, what labs should be checked in a week after initiating an ACEI? Why? Classmate answer: The labs that need to be checked in a week for patients who take ACE inhibitors are Serum Creatinine, BUN levels and electrolytes, particularly the potassium levels. ACE tends to increase the potassium levels causing hyperkalemia. This is when the levels are above 5.5. This will cause AKI (Acute Kidney Injury). If the levels of all 3 are elevated, then discontinuation of the ACE is needed. The labs need to be checked 1-2 weeks of initiation and after the dose is increased. If levels are stable, then the recheck can occur in 4 weeks. According to Woo & Robinson (2016), ACE inhibitors decrease proteinuria in those with CKD and help with blood pressure control. Adding an ACE inhibitor for patients with known CKD commonly results in increased serum creatinine. The improvement in proteinuria happens despite this effect. It is acceptable to have an 30% increase in SCr with the discontinuation of the ACE inhibitor. Professor question: What anti-arrhythmic medication in the reading this week requires pulmonary and thyroid function monitoring every 6 months? Classmate answer: Amiodarone (Cordarone) is a medication that treats or prevent abnormal rhythms of the heart (Amiodarone, 2020). This medication is an extremely effective anti-arrhythmia medication, but like all medication it comes with the potential of adverse effects. Taking Amiodarone puts you at high risk for pulmonary fibrosis, so a chest x-ray and pulmonary function studies are recommended every 3-6 months (Woo & Robinson, 2016). Amiodarone also requires close monitoring for thyroid dysfunction. It is also recommended to assess thyroid-stimulating hormone (TSH) and free T4 for potential impairment (Woo & Robinson, 2016). Professor question: Can you review the classes of angina from our text? Classmate answer: Woo and Robinson (2016), identifies two forms of angina- chronic stable angina and Low-risk unstable angina. The New York Heart Association and the CCS have developed a classification system that helps providers grade the severity of angina. The classification identifies several classes; Class I, II, III, and IV. Class, I is proven coronary artery disease without symptoms, class II is angina only with usually strenuous physical excretion, class III is angina during routine physical activity while Class IV is angina that occurs during minimal activity or rest. (p. 885) Professor question: From our text, can you review the statin strength from weakest to highest? Classmate answer: no answer from classmate given but from the quiz: correct answer was rosuvastatin, lovastatin, atorvastatin (lowest to highest strength)