Advanced Pharmacology for Nurse
Practitioners (The University of Texas
at Arlington)
, Exam 3 Study Questions
• What drugs are used to treat gestational diabetes?
o Metformin and Insulin
• What A1C value indicates diabetes mellitus? Pre-DM?
o 6.5% or greater is considered diabetes
o 5.7-6.4% pre-diabetes
• What fasting and random values indicate DM?
o Fasting plasma glucose—126 or greater is diabetes
o Random (casual) plasma glucose—anything greater than 200 is diabetes
• What are complications of insulin therapy?
o Hypoglycemia
o Can develop lipohypertrophy
▪ Accumulation of subcutaneous fat that occurs when it is injected too
frequently at the same site
o Allergic reactions
▪ Characterized by red and intensely itchy welts, breathing becomes difficult
▪ If severe allergy develops:
• Desensitization procedure (small doses to larger doses)
o Hypokalemia
▪ Promotes the uptake of potassium cells and insulin activates a membrane-
bound enzyme with sodium potassium and ATPase that pumps potassium into
the cells and sodium out
• Drug interactions?
o Hypoglycemic agents
▪ Can intensify the hypoglycemia included by insulin
▪ Examples: sulfonylureas, glinides, alcohol
o Use with caution with hyperglycemic agents
▪ Examples: thiazide and glucocorticoids and sympathomimetics
• What effect do beta blockers have on insulin?
o delay awareness of and response to hypoglycemia by masking the signs that
are associated with stimulation of sympathetic nervous system
o Impair glycogenolysis
o Prevent the bodies counter-regulatory response
• What are other therapeutic uses besides DM?
o Hyperkalemia
o Aids in diagnosis of GH deficiency
o Diabetic ketoacidosis
• Insulin dosage must be coordinated with what?
o Carbohydrate intake
• What is B/P goal in diabetic?
o To be controlled, within normal 120/80
• What medication can be given to decrease risk of diabetic nephropathy?
o ACE inhibitor or ARB
1
,• What role does exercise play in treatment of both type 1 and type 2 DM?
o Exercise increases cellular responsiveness to insulin and increases glucose tolerance
o 150 minute per week of moderate intensity exercise is recommended
• What are the 4 steps in the 4-step approach?
o Step 1—diagnosis
▪ Lifestyle changes plus metformin
o Step 2
▪ Lifestyle changes plus metformin and a second drug (sulfonylurea, TZD or a
DPP4 inhibitor, a sodium glucose cotransporter or SGLT-2 inhibitor, a glucagon-
like peptide 1, or a GLP-1 receptor agonist or basal insulin
▪ Second drug choice made considering efficacy, the hypoglycemia risk of the
patient, the patient tolerability, and weight-related considerations (some
help
weight loss, some cause weight gain), cost
o Step 3
▪ Three drug combination
• Metformin
• Plus 2 other drugs from step 2
o Decided based on a drug and patient specific considerations
o Step 4
▪ If 3 drug combination that includes basal insulin fails after 3-6 months,
more complex insulin regimen
▪ Usually in combination with one or more non-insulin medications
• When a patient is on insulin therapy what are the blood glucose goals before meals?
At bedtime?
o Before meals—70-130
o Bedtime—100-140
• What is the A1C goal? When is goal below 7 not appropriate?
o 7% or below
o Those with severe hypoglycemia risk, limited life expectancy, advanced microvascular
or macrovascular complications—not below 7
• What are the short acting insulins? Intermediate? Long acting?
o Short duration: Rapid acting
▪ Insulin lispro [Humalog]
▪ Insulin aspart [NovoLog]
▪ Insulin glulisine [Apidra]
o Short duration: Slower acting
▪ Regular insulin [Humulin R, Novolin R]
o Intermediate duration
▪ Neutral protamine Hagedorn (NPH) insulin
▪ Insulin detemir [Levemir]
o Long duration
▪ Insulin glargine
• When are short duration insulins used?
2
, o Administered in association with meals to control the post-prandial rise in blood
glucose between meals and at night
• When are intermediate insulins needed?
o Administer 2-3 times daily to provide glycemic control between meals and during
the night
• How long is duration of glargine? Levemir? Degludec?
o Glargine—up to 24 hours
o Levemir
▪ Low dose (0.2 units/kg)—12 hours
▪ High doses (0.4 units/kg)—20-24 hours
o Degludec—up to 42 hours
• What are routes of administration? Which can be inhaled?
o SQ injection
o IV infusion
o Inhalation—Afrezza, mealtime insulin
• What is typical dosing for type 1? Type 2?
o Total doses may range from 0.1 unit/kg body weight to more than 2.5 units/kg
o Type 1
▪ Initial doses typically range from 0.5-0.6 units/kg per day
o Type 2
▪ Initial doses range from 0.2-0.6 units/kg per day
▪ Dosage increased or decreased according to carb intake, activity
• What are the 3 dosing schedules?
o Twice daily dosing
o Intensive basal/bolus strategy
o Continued subcutaneous insulin
• How does metformin work?
o Inhibits glucose production in the liver
o Reduces glucose absorption in the gut
o Sensitizes insulin receptors in target tissues (fat and skeletal muscle) thus
increase glucose uptake and response to whatever insulin is available
• What are side effects? BB warning?
o GI effects—diarrhea
o Lactic acidosis
• How does alcohol effect?
o Inhibits the breakdown of lactic acid
• What are the therapeutic uses other than DM?
o Gestational diabetes
o PCOS
• Sulfonylureas
o First generation
▪ Chlorpropamide [Diabinese]
▪ Tolazamide [Tolinase]
3
Practitioners (The University of Texas
at Arlington)
, Exam 3 Study Questions
• What drugs are used to treat gestational diabetes?
o Metformin and Insulin
• What A1C value indicates diabetes mellitus? Pre-DM?
o 6.5% or greater is considered diabetes
o 5.7-6.4% pre-diabetes
• What fasting and random values indicate DM?
o Fasting plasma glucose—126 or greater is diabetes
o Random (casual) plasma glucose—anything greater than 200 is diabetes
• What are complications of insulin therapy?
o Hypoglycemia
o Can develop lipohypertrophy
▪ Accumulation of subcutaneous fat that occurs when it is injected too
frequently at the same site
o Allergic reactions
▪ Characterized by red and intensely itchy welts, breathing becomes difficult
▪ If severe allergy develops:
• Desensitization procedure (small doses to larger doses)
o Hypokalemia
▪ Promotes the uptake of potassium cells and insulin activates a membrane-
bound enzyme with sodium potassium and ATPase that pumps potassium into
the cells and sodium out
• Drug interactions?
o Hypoglycemic agents
▪ Can intensify the hypoglycemia included by insulin
▪ Examples: sulfonylureas, glinides, alcohol
o Use with caution with hyperglycemic agents
▪ Examples: thiazide and glucocorticoids and sympathomimetics
• What effect do beta blockers have on insulin?
o delay awareness of and response to hypoglycemia by masking the signs that
are associated with stimulation of sympathetic nervous system
o Impair glycogenolysis
o Prevent the bodies counter-regulatory response
• What are other therapeutic uses besides DM?
o Hyperkalemia
o Aids in diagnosis of GH deficiency
o Diabetic ketoacidosis
• Insulin dosage must be coordinated with what?
o Carbohydrate intake
• What is B/P goal in diabetic?
o To be controlled, within normal 120/80
• What medication can be given to decrease risk of diabetic nephropathy?
o ACE inhibitor or ARB
1
,• What role does exercise play in treatment of both type 1 and type 2 DM?
o Exercise increases cellular responsiveness to insulin and increases glucose tolerance
o 150 minute per week of moderate intensity exercise is recommended
• What are the 4 steps in the 4-step approach?
o Step 1—diagnosis
▪ Lifestyle changes plus metformin
o Step 2
▪ Lifestyle changes plus metformin and a second drug (sulfonylurea, TZD or a
DPP4 inhibitor, a sodium glucose cotransporter or SGLT-2 inhibitor, a glucagon-
like peptide 1, or a GLP-1 receptor agonist or basal insulin
▪ Second drug choice made considering efficacy, the hypoglycemia risk of the
patient, the patient tolerability, and weight-related considerations (some
help
weight loss, some cause weight gain), cost
o Step 3
▪ Three drug combination
• Metformin
• Plus 2 other drugs from step 2
o Decided based on a drug and patient specific considerations
o Step 4
▪ If 3 drug combination that includes basal insulin fails after 3-6 months,
more complex insulin regimen
▪ Usually in combination with one or more non-insulin medications
• When a patient is on insulin therapy what are the blood glucose goals before meals?
At bedtime?
o Before meals—70-130
o Bedtime—100-140
• What is the A1C goal? When is goal below 7 not appropriate?
o 7% or below
o Those with severe hypoglycemia risk, limited life expectancy, advanced microvascular
or macrovascular complications—not below 7
• What are the short acting insulins? Intermediate? Long acting?
o Short duration: Rapid acting
▪ Insulin lispro [Humalog]
▪ Insulin aspart [NovoLog]
▪ Insulin glulisine [Apidra]
o Short duration: Slower acting
▪ Regular insulin [Humulin R, Novolin R]
o Intermediate duration
▪ Neutral protamine Hagedorn (NPH) insulin
▪ Insulin detemir [Levemir]
o Long duration
▪ Insulin glargine
• When are short duration insulins used?
2
, o Administered in association with meals to control the post-prandial rise in blood
glucose between meals and at night
• When are intermediate insulins needed?
o Administer 2-3 times daily to provide glycemic control between meals and during
the night
• How long is duration of glargine? Levemir? Degludec?
o Glargine—up to 24 hours
o Levemir
▪ Low dose (0.2 units/kg)—12 hours
▪ High doses (0.4 units/kg)—20-24 hours
o Degludec—up to 42 hours
• What are routes of administration? Which can be inhaled?
o SQ injection
o IV infusion
o Inhalation—Afrezza, mealtime insulin
• What is typical dosing for type 1? Type 2?
o Total doses may range from 0.1 unit/kg body weight to more than 2.5 units/kg
o Type 1
▪ Initial doses typically range from 0.5-0.6 units/kg per day
o Type 2
▪ Initial doses range from 0.2-0.6 units/kg per day
▪ Dosage increased or decreased according to carb intake, activity
• What are the 3 dosing schedules?
o Twice daily dosing
o Intensive basal/bolus strategy
o Continued subcutaneous insulin
• How does metformin work?
o Inhibits glucose production in the liver
o Reduces glucose absorption in the gut
o Sensitizes insulin receptors in target tissues (fat and skeletal muscle) thus
increase glucose uptake and response to whatever insulin is available
• What are side effects? BB warning?
o GI effects—diarrhea
o Lactic acidosis
• How does alcohol effect?
o Inhibits the breakdown of lactic acid
• What are the therapeutic uses other than DM?
o Gestational diabetes
o PCOS
• Sulfonylureas
o First generation
▪ Chlorpropamide [Diabinese]
▪ Tolazamide [Tolinase]
3
