ADVANCED PHARMACOLOGY NSG 533 FINAL PAPER
QUESTIONS AND ANSWERS RATED A+
✔✔A patient with type 1 diabetes reports taking propranolol for hypertension. What
concern does this information present for the provider? - ✔✔A patient with Type 1 DM is
insulin dependent for glucose control and at high risk for hypoglycemic episodes.
Propanolol causes prolonged hypoglycemic episodes. Needs to switch to ACE or ARB.
✔✔A provider teaches a patient who has been diagnosed with hypothyroidism about a
new prescription for levothyroxine. Which statement by the patient indicates a need for
further teaching?
a. "I should not take heartburn medication without consulting my provider first."
b. "I should report insomnia, tremors, and an increased heart rate to my provider."
c. "If I take a multivitamin with iron, I should take it 4 hours after the levothyroxine."
d. "If I take calcium supplements, I may need to decrease my dose of levothyroxine." -
✔✔D. Calcium may reduce levothyroxine absorption. Further education is needed if the
patient feels she can take half of a prescribed medication.
✔✔MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal
and alcohol he experiences significant GI distress. He takes an OTC heartburn remedy.
Within a minute or two he develops what he will later describe as "belching, nausea and
a bad bloated feeling". Several of the ulcers began to bleed and he becomes profoundly
hypotensive from the blood loss and is taken to the ED. Endoscopy confirms multiple
bleeds; the endoscopist remarks that it appears as if the lesions had been literally
stretched apart causing additional tissue damage. What did the patient most likely take
(i.e. what was the OTC remedy)? - ✔✔I would accept Alka-Selzer. I contains NaHCO3
(as well as ASA). In the presence of HCL it Liberates CO2, that can cause gastric
distention, belching and nausea. The reaction is fairly swift allowing little time for
dissipation. Tums, its primary ingredient calcium carbonate which when taken cause a
reaction with the stomach acid such as production of carbon dioxide gas which can
cause bloating and the stomach to stretch to tear the ulcers open.
✔✔On your way to this examination, you experience the vulnerable feeling that an
attack of acute diarrhea is imminent! If you stop at a drug store, which anti-diarrheal
drugs could you buy without a prescription even though it is chemically related to the
strong opioid analgesic meperidine (but acts only on the peripheral opioid receptor)? -
✔✔Loperamide
✔✔JA has multiple medical problems and is taking several drugs including theophylline,
warfarin and phenytoin. His conditions were well controlled, but recently he started to
experience some GI distress for which of his "well intentioned friends" gave him some
medication. He presents to you with toxic effects of all his other medications and plasma
levels of those medications elevated. What was most likely the medication he took? -
✔✔Cimetidine
,✔✔What lifestyle modifications should be recommended? - ✔✔-losing weight if
overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
✔✔What medications / foods can contribute to GERD? - ✔✔-Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, progesterone, theophylline,
nitrates
-Foods: cirus fruits/juices, coffee, tomatoes, spicy food, carbonated drinks
Fried/fatty foods, garlic, onions, chocolate
✔✔What is the most effective PPI or H2RA within each of these classes? - ✔✔-PPI-
bismuth quadruple therapy combined with proton pump inhibitors
-H2RA- Famotidine 80mg
✔✔Other products such as antacids are also available. What are some of these and
what is their place in therapy? - ✔✔-Reflux symptoms <2 times a week (infrequent)
-Effective for immediate relief
-Magnesium/Aluminum Hydroxide (Maalox)- can cause constipation
-Alginic Acid
✔✔Why would antibiotics be used for PUD caused by H Pylori? What is a typical
regimen and duration of therapy? What patient specific factors should be considered
and how should treatment be monitored? - ✔✔Considerations before regimen choice:
-penicillin allergy
-previous exposure to macroglide antibiotics
Strongest Reccomendation:
-Bismuth Quadruple Therapy 10-14 days
*do not drink alcohol w/ metronidazole*
-Salvage regimen should be different than first regimen
✔✔Who would be a candidate for prophylaxis of NSAID induced ulcer and what agents
are appropriate? What if the patient is on cardio-protective (low dose) aspirin? What if
an NSAID induced ulcer does develop. How should it be treated? - ✔✔Candidate:
-Candidates: Chronic Nsaid Use, Hx ulcers, Zollinger-Ellison
Prevention Treatment- PPI, standard doses (most effective & best tolerated),
Misoprostol (better than H2RA's, No Pregnancy)
✔✔What if an NSAID induced ulcer does develop. How should it be treated? - ✔✔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)? - ✔✔-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 - ✔✔
✔✔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 - ✔✔
✔✔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 - ✔✔
QUESTIONS AND ANSWERS RATED A+
✔✔A patient with type 1 diabetes reports taking propranolol for hypertension. What
concern does this information present for the provider? - ✔✔A patient with Type 1 DM is
insulin dependent for glucose control and at high risk for hypoglycemic episodes.
Propanolol causes prolonged hypoglycemic episodes. Needs to switch to ACE or ARB.
✔✔A provider teaches a patient who has been diagnosed with hypothyroidism about a
new prescription for levothyroxine. Which statement by the patient indicates a need for
further teaching?
a. "I should not take heartburn medication without consulting my provider first."
b. "I should report insomnia, tremors, and an increased heart rate to my provider."
c. "If I take a multivitamin with iron, I should take it 4 hours after the levothyroxine."
d. "If I take calcium supplements, I may need to decrease my dose of levothyroxine." -
✔✔D. Calcium may reduce levothyroxine absorption. Further education is needed if the
patient feels she can take half of a prescribed medication.
✔✔MC has undiagnosed multiple gastric ulcers. Shortly after consuming a large meal
and alcohol he experiences significant GI distress. He takes an OTC heartburn remedy.
Within a minute or two he develops what he will later describe as "belching, nausea and
a bad bloated feeling". Several of the ulcers began to bleed and he becomes profoundly
hypotensive from the blood loss and is taken to the ED. Endoscopy confirms multiple
bleeds; the endoscopist remarks that it appears as if the lesions had been literally
stretched apart causing additional tissue damage. What did the patient most likely take
(i.e. what was the OTC remedy)? - ✔✔I would accept Alka-Selzer. I contains NaHCO3
(as well as ASA). In the presence of HCL it Liberates CO2, that can cause gastric
distention, belching and nausea. The reaction is fairly swift allowing little time for
dissipation. Tums, its primary ingredient calcium carbonate which when taken cause a
reaction with the stomach acid such as production of carbon dioxide gas which can
cause bloating and the stomach to stretch to tear the ulcers open.
✔✔On your way to this examination, you experience the vulnerable feeling that an
attack of acute diarrhea is imminent! If you stop at a drug store, which anti-diarrheal
drugs could you buy without a prescription even though it is chemically related to the
strong opioid analgesic meperidine (but acts only on the peripheral opioid receptor)? -
✔✔Loperamide
✔✔JA has multiple medical problems and is taking several drugs including theophylline,
warfarin and phenytoin. His conditions were well controlled, but recently he started to
experience some GI distress for which of his "well intentioned friends" gave him some
medication. He presents to you with toxic effects of all his other medications and plasma
levels of those medications elevated. What was most likely the medication he took? -
✔✔Cimetidine
,✔✔What lifestyle modifications should be recommended? - ✔✔-losing weight if
overweight
-elevating head of bed while asleep
-eating smaller meals
-avoid foods/meds that exacerbate gerd
-stop smoking
-stop drinking alcohol
✔✔What medications / foods can contribute to GERD? - ✔✔-Medications:
anticholinergics, barbituates, dopamine, estrogen, opioids, progesterone, theophylline,
nitrates
-Foods: cirus fruits/juices, coffee, tomatoes, spicy food, carbonated drinks
Fried/fatty foods, garlic, onions, chocolate
✔✔What is the most effective PPI or H2RA within each of these classes? - ✔✔-PPI-
bismuth quadruple therapy combined with proton pump inhibitors
-H2RA- Famotidine 80mg
✔✔Other products such as antacids are also available. What are some of these and
what is their place in therapy? - ✔✔-Reflux symptoms <2 times a week (infrequent)
-Effective for immediate relief
-Magnesium/Aluminum Hydroxide (Maalox)- can cause constipation
-Alginic Acid
✔✔Why would antibiotics be used for PUD caused by H Pylori? What is a typical
regimen and duration of therapy? What patient specific factors should be considered
and how should treatment be monitored? - ✔✔Considerations before regimen choice:
-penicillin allergy
-previous exposure to macroglide antibiotics
Strongest Reccomendation:
-Bismuth Quadruple Therapy 10-14 days
*do not drink alcohol w/ metronidazole*
-Salvage regimen should be different than first regimen
✔✔Who would be a candidate for prophylaxis of NSAID induced ulcer and what agents
are appropriate? What if the patient is on cardio-protective (low dose) aspirin? What if
an NSAID induced ulcer does develop. How should it be treated? - ✔✔Candidate:
-Candidates: Chronic Nsaid Use, Hx ulcers, Zollinger-Ellison
Prevention Treatment- PPI, standard doses (most effective & best tolerated),
Misoprostol (better than H2RA's, No Pregnancy)
✔✔What if an NSAID induced ulcer does develop. How should it be treated? - ✔✔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)? - ✔✔-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 - ✔✔
✔✔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 - ✔✔
✔✔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 - ✔✔
