ADVANCED PHARMACOLOGY NSG 533
COMPREHENSIVE SCRIPT WITH SOLUTIONS
◉ What if an NSAID induced ulcer does develop. How should it be
treated.
Answer: Ulcer Treatment-
-PPI (most effective)
-H2RA (Famotidone 40mg daily)
-Sucralfate (binding paste, requires multiple doses, adverse med
reactions, abdominal side effects)
◉ Who is a candidate for stress ulcer prophylaxis (SUP)?.
Answer: -ICU patients
-Trauma, including spinal cord injuries
-Mechanical ventilation
-Thermal injuries >35% (almost half the body)
◉ Of the agents available to control the complications of diabetes
mellitus, cardiovascular drugs, and particularly ACE inhibitors, have
a pre-eminent place. Experimental and epidemiological data suggest
that activation of the renin-angiotensin-aldosterone system plays an
important role in increasing in the micro- and macrovascular
complications in patients with diabetes mellitus. Not only are ACE
,inhibitors potent antihypertensive agents but there is a growing
body of data indicating that also they have a specific 'organ-
protective' effect. For the same degree of blood pressure control,
compared with other antihypertensive agents, ACE inhibitors
demonstrate function and tissue protection of considered organs.
ACE inhibitors have been reported to improve kidney, heart, and to a
lesser extent, eye and peripheral nerve function of patients with
diabetes mellitus. These favorable effects are the result of inhibition
of bo.
Answer:
◉ There is a "compelling" indication in patients with hypertension
and DM. These should be the 1st class of antihypertensive
medications used in those with DM + HTN
Recommended for the treatment of the patient with CKD (modestly
elevated (30-299 mg/24 h) or higher levels (>300 mg/24 h) of
urinary albumin excretion), even in those without DM
Delay progression of nephropathy in Type 1 with or without HTN
and any degree of albuminuria
Delay progression of nephropathy in Type 2 with or without HTN
and microalbuminuriaReduce development of microalbuminuria
(kidney disease) in Type 2 with or without HTN
ARBs are considered a reasonable alternative for those intolerant of
ACEI.
Answer:
,◉ Cardioprotective dose ASA (IE baby aspirin or clopidrogel as
alternative)For SECONDARY PREVENTION of CV Events- Use in ALL
diabetics with CV diseaseFor PRIMARY PREVENTION of CV
EventsUSE in: high CV risk patients (10-yr CV risk > 10%) -
Typically: male > 50 yo or female >60 yo with 1 additional major risk
factor (FH of CVD, HTN, smoker, dyslipidemia or albuminuria)MAY
consider: intermediate CV risk patrients 10-yr CV risk of 5-10%) -
younger patients with 1 or more risk factors, older patients with no
risk factorsNOT recommended: low CV risk patients - men <50 yo or
women <60 yo without major CV risk factors or 10-yr CV risk <
5%Note - Many authorities consider DM to be an ASCVD risk
equivalentThis is basically everyone with DM.
Answer:
◉ What are the goals set by ACE /ACCE and are they written in stone
for all patients?.
Answer: Primary target for glycemic control is HbA1C
Individualize HbA1C goal - based on...Duration of DMAge/life
expectancyComorbid conditions
Known CVD or advanced comorbid conditionsHypoglycemic
unawareness
Individual patient considerations
◉ Please note when transitioning from oral therapy for type II DM to
insulin, metformin is retained! Secretagogues are discontinued
, possibly when basal insulin is initiated, but definitely when prandial
(fast/rapid) insulin is to be added.
Answer: Options to add to basal insulin for prandial coverage...
Fast-acting insulin
DPP-4 inhibitors
Incretin mimetics
Glinides
Alpha-glucosidase inhibitors
Colesevelam
◉ What are the various types of oral and non-insulin medications
and what represents a rational combination of medications?.
Answer: Combinations should have different mechanism of action
Combinations should avoid overlapping ADRs
Combinations should ideally be selected based on need for better
basal vs post-prandial control
Selection should account for patient specific concerns (eg. weight,
CVD risk, etc)
◉ What antidiabetic medications have compelling indications:.
Answer: for those with underlying ASCVD or at high risk for CVD
for those with CKD
for those with a compelling need to avoid hypoglycemia
COMPREHENSIVE SCRIPT WITH SOLUTIONS
◉ What if an NSAID induced ulcer does develop. How should it be
treated.
Answer: Ulcer Treatment-
-PPI (most effective)
-H2RA (Famotidone 40mg daily)
-Sucralfate (binding paste, requires multiple doses, adverse med
reactions, abdominal side effects)
◉ Who is a candidate for stress ulcer prophylaxis (SUP)?.
Answer: -ICU patients
-Trauma, including spinal cord injuries
-Mechanical ventilation
-Thermal injuries >35% (almost half the body)
◉ Of the agents available to control the complications of diabetes
mellitus, cardiovascular drugs, and particularly ACE inhibitors, have
a pre-eminent place. Experimental and epidemiological data suggest
that activation of the renin-angiotensin-aldosterone system plays an
important role in increasing in the micro- and macrovascular
complications in patients with diabetes mellitus. Not only are ACE
,inhibitors potent antihypertensive agents but there is a growing
body of data indicating that also they have a specific 'organ-
protective' effect. For the same degree of blood pressure control,
compared with other antihypertensive agents, ACE inhibitors
demonstrate function and tissue protection of considered organs.
ACE inhibitors have been reported to improve kidney, heart, and to a
lesser extent, eye and peripheral nerve function of patients with
diabetes mellitus. These favorable effects are the result of inhibition
of bo.
Answer:
◉ There is a "compelling" indication in patients with hypertension
and DM. These should be the 1st class of antihypertensive
medications used in those with DM + HTN
Recommended for the treatment of the patient with CKD (modestly
elevated (30-299 mg/24 h) or higher levels (>300 mg/24 h) of
urinary albumin excretion), even in those without DM
Delay progression of nephropathy in Type 1 with or without HTN
and any degree of albuminuria
Delay progression of nephropathy in Type 2 with or without HTN
and microalbuminuriaReduce development of microalbuminuria
(kidney disease) in Type 2 with or without HTN
ARBs are considered a reasonable alternative for those intolerant of
ACEI.
Answer:
,◉ Cardioprotective dose ASA (IE baby aspirin or clopidrogel as
alternative)For SECONDARY PREVENTION of CV Events- Use in ALL
diabetics with CV diseaseFor PRIMARY PREVENTION of CV
EventsUSE in: high CV risk patients (10-yr CV risk > 10%) -
Typically: male > 50 yo or female >60 yo with 1 additional major risk
factor (FH of CVD, HTN, smoker, dyslipidemia or albuminuria)MAY
consider: intermediate CV risk patrients 10-yr CV risk of 5-10%) -
younger patients with 1 or more risk factors, older patients with no
risk factorsNOT recommended: low CV risk patients - men <50 yo or
women <60 yo without major CV risk factors or 10-yr CV risk <
5%Note - Many authorities consider DM to be an ASCVD risk
equivalentThis is basically everyone with DM.
Answer:
◉ What are the goals set by ACE /ACCE and are they written in stone
for all patients?.
Answer: Primary target for glycemic control is HbA1C
Individualize HbA1C goal - based on...Duration of DMAge/life
expectancyComorbid conditions
Known CVD or advanced comorbid conditionsHypoglycemic
unawareness
Individual patient considerations
◉ Please note when transitioning from oral therapy for type II DM to
insulin, metformin is retained! Secretagogues are discontinued
, possibly when basal insulin is initiated, but definitely when prandial
(fast/rapid) insulin is to be added.
Answer: Options to add to basal insulin for prandial coverage...
Fast-acting insulin
DPP-4 inhibitors
Incretin mimetics
Glinides
Alpha-glucosidase inhibitors
Colesevelam
◉ What are the various types of oral and non-insulin medications
and what represents a rational combination of medications?.
Answer: Combinations should have different mechanism of action
Combinations should avoid overlapping ADRs
Combinations should ideally be selected based on need for better
basal vs post-prandial control
Selection should account for patient specific concerns (eg. weight,
CVD risk, etc)
◉ What antidiabetic medications have compelling indications:.
Answer: for those with underlying ASCVD or at high risk for CVD
for those with CKD
for those with a compelling need to avoid hypoglycemia
