Advanced Pharmacology NSG 533
Goal of diarrhea treatment - CORRECT ANSWER-Goal of treatment: Identify and Treat
primary cause, Manage secondary causes, prevent electrolyte & acid/base disturbances
& dehydration , provide symptomatic relief ,
Note the primary goal is NOT ALWAYS to stop diarrhea (see below, Infectious
diarrhea)!
Non-pharmacologicalRehydration , oral preferredAvoid Soda products, Gatorade*,
Chicken broth, TeaDietResume age-appropriate diet once rehydratedSecondary causes
can include medications. An evaluation of medications an possible substitution of
offending medications should be considered (if possible)Magnesium containing
antacids, metformin (1/3 of patients), antibiotics (25% incidence), anti-inflammatory /
anti-gout agents (eg. colchicine), etc.
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 - CORRECT 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 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
A patient with type 1 diabetes reports taking propranolol for hypertension. What concern
does this information present for the provider? - CORRECT ANSWER-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." -
CORRECT ANSWER-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)? - CORRECT ANSWER-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)? - CORRECT
ANSWER-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? -
CORRECT ANSWER-Cimetidine
What lifestyle modifications should be recommended? - CORRECT ANSWER--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? - CORRECT ANSWER--
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? - CORRECT
ANSWER--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? - CORRECT ANSWER--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? - CORRECT ANSWER-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
Goal of diarrhea treatment - CORRECT ANSWER-Goal of treatment: Identify and Treat
primary cause, Manage secondary causes, prevent electrolyte & acid/base disturbances
& dehydration , provide symptomatic relief ,
Note the primary goal is NOT ALWAYS to stop diarrhea (see below, Infectious
diarrhea)!
Non-pharmacologicalRehydration , oral preferredAvoid Soda products, Gatorade*,
Chicken broth, TeaDietResume age-appropriate diet once rehydratedSecondary causes
can include medications. An evaluation of medications an possible substitution of
offending medications should be considered (if possible)Magnesium containing
antacids, metformin (1/3 of patients), antibiotics (25% incidence), anti-inflammatory /
anti-gout agents (eg. colchicine), etc.
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 - CORRECT 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 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
A patient with type 1 diabetes reports taking propranolol for hypertension. What concern
does this information present for the provider? - CORRECT ANSWER-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." -
CORRECT ANSWER-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)? - CORRECT ANSWER-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)? - CORRECT
ANSWER-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? -
CORRECT ANSWER-Cimetidine
What lifestyle modifications should be recommended? - CORRECT ANSWER--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? - CORRECT ANSWER--
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? - CORRECT
ANSWER--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? - CORRECT ANSWER--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? - CORRECT ANSWER-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
