NSG 533 Exam 1 Advanced
Pharmacology Questions and Answers
1. EP is a 38-year-old female patient that comes in for diabetes
education and management. She was diagnosed 12 years ago and
states lately she is not able to control her diet although she
continues a 1600 calorie diet with appropriate daily carbohydrate
intake (per dietitian prescription) and walks 40 minutes every day of
the week. She states compliance with all medications. She denies
any history of hypoglycemia despite being able to identify signs and
symptoms and describe appropriate treatment strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to
thyroid can- cer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high
school Medications: Metformin 850 mg tid, glipizide 20 mg bid,
lisinopril 20 mg daily, sertraline 100 mg daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L,
BUN 16 mg/dL, SCr 0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to
obtain an A1C goal of less than 7% and would be appropriate in the
patient? Please provide an explanation of appropriateness or lack
,thereof.: Exenatide - Exenatide (Bydureon) once weekly has been able to demonstrate
weight loss and decrease A1C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP
due to the self-reported history of thyroid cancer.
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia which could
be made worse by this drug. The package insert does not indicate a specific potassium concentration
cut ott to no longer use this medication; however, there are better choices in this patient.
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical trials
and currently the patient does not have any cautionary objective measures to not use this medication.
DPP-IV inhibitors are weight
neutral. DPP-IV inhibitors can be used in patients taking sulfonylureas; however, it may be recommended
to reduce or stop the sulfonylurea dose.
Acarbose - Acarbose (Precose) is not recommended for initial management and is associated with
significant GI side effects. More information would be needed regarding fasting and post-prandial numbers.
In addition, adding acarbose would only lower A1c by 0.8% at best and therefore would not achieve the
desired A1C goal of <7%
2. 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 (diag- nosed 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 diabetes. Which
drug therapy would be the best for JR to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management.: Metformin is the
drug of choice recommended for most patients with diabetes in addition to lifestyle modifications
assuming no contraindica- tions 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. $$$
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic control and may
assist with weight loss goals for this patient. New information suggests these agents may provide
, benefits in those with ASCVD. JR has a
past history of pancreatitis and GLP-1 analogs are not recommended due to this contraindication
TZDs have data to support an A1C reduction necessary to gain glycemic control, but are associated
with weight gain, negative effects on lipids and increased risk of fracture. Until recently, TZDs have also been
linked to increased CV events and use has fallen out of favor
Sulfonylureas provide excellent A1C lowering, but are also associated with weight gain. They also have
the potential to cause hypoglycemia, so patient education is crucial. Because of his allergies to "sulfa",
use would be contraindicated SGLT2 inhibitors have data to support an A1C reduction necessary to
gain glycemic control. In addition, they are associated with weight loss and blood pressure lowering.
New information demonstrates these agents may be beneficial in those with ASCVD, heart failure and /
or CKD. They are also associated with dyslipidemias as well. Prior to starting therapy, renal function and
electrolytes would have to be assessed. $$$
Based on the ASCVD recommendations (which are now paralleled by the 2015 ADA recommendations),
all patients with type I or II DM ages 40-75 should be on a moderate intensity statin. If the patients 10
years ASCVD risk is greater than 7.5%, a high intensity statin can be considered. Since all information
needed to perform the estimate is not present, we can assume JR need at least moderate intensity
statin. ACCE/ACE guidelines still resemble those of ATPIII. Even so, the recommendation is for a statin
regardless of LDL-C in diabetics over 40 with at least 1 risk factor of ASCVD. Options: atorvastatin 10mg,
rosuvastatin 10, simvastatin 20-40, pravastatin 40, lovastatin 40, fluvastatin 40.
An angiotensin-converting enzyme inhibitor and considered to be a drug of choice for renal protection in
patients with diabetes. ACEi and ARBs have demonstrated a reduction in renal progression to overt
proteinuria. African Americans may not see the maximum effect of blood pressure lowering with ACEi due to
a decreased amount of renin. Combination therapy with a thiazide would be a reasonable add on
Pharmacology Questions and Answers
1. EP is a 38-year-old female patient that comes in for diabetes
education and management. She was diagnosed 12 years ago and
states lately she is not able to control her diet although she
continues a 1600 calorie diet with appropriate daily carbohydrate
intake (per dietitian prescription) and walks 40 minutes every day of
the week. She states compliance with all medications. She denies
any history of hypoglycemia despite being able to identify signs and
symptoms and describe appropriate treatment strategies.
PMH: T2DM, HTN, obesity, depression, s/p thyroidectomy due to
thyroid can- cer
FmHx: Noncontributory
SHx: (−) Smoking, alcohol use, past marijuana use while in high
school Medications: Metformin 850 mg tid, glipizide 20 mg bid,
lisinopril 20 mg daily, sertraline 100 mg daily, multivitamin daily
Vitals: BP 128/82 mg Hg; P 72 beats/min; BMI 31 m/kg2
Laboratory test results: Na 134 mEq/L, K 5.4 mEq/L, Cl 106 mEq/L,
BUN 16 mg/dL, SCr 0.89 mg/dL, glucose 128 mg/dL; A1C 7.8%
Based on EP's profile above, which of the agents would be able to
obtain an A1C goal of less than 7% and would be appropriate in the
patient? Please provide an explanation of appropriateness or lack
,thereof.: Exenatide - Exenatide (Bydureon) once weekly has been able to demonstrate
weight loss and decrease A1C% by 0.7% to 1.2% in clinical trials; however it is contraindicated for EP
due to the self-reported history of thyroid cancer.
Dapagliflozin - Dapagliflozin (Farxiga) is contraindicated in this patient due to hyperkalemia which could
be made worse by this drug. The package insert does not indicate a specific potassium concentration
cut ott to no longer use this medication; however, there are better choices in this patient.
Sitagliptin - Sitagliptin (Januvia) is able to obtain an A1C goal of less than 7% based on clinical trials
and currently the patient does not have any cautionary objective measures to not use this medication.
DPP-IV inhibitors are weight
neutral. DPP-IV inhibitors can be used in patients taking sulfonylureas; however, it may be recommended
to reduce or stop the sulfonylurea dose.
Acarbose - Acarbose (Precose) is not recommended for initial management and is associated with
significant GI side effects. More information would be needed regarding fasting and post-prandial numbers.
In addition, adding acarbose would only lower A1c by 0.8% at best and therefore would not achieve the
desired A1C goal of <7%
2. 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 (diag- nosed 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 diabetes. Which
drug therapy would be the best for JR to trial?
Discuss your opinion of JR's lipid management.
Discuss your opinion of JR's blood pressure management.: Metformin is the
drug of choice recommended for most patients with diabetes in addition to lifestyle modifications
assuming no contraindica- tions 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. $$$
GLP-1 analog and has data to support an A1C reduction necessary to gain glycemic control and may
assist with weight loss goals for this patient. New information suggests these agents may provide
, benefits in those with ASCVD. JR has a
past history of pancreatitis and GLP-1 analogs are not recommended due to this contraindication
TZDs have data to support an A1C reduction necessary to gain glycemic control, but are associated
with weight gain, negative effects on lipids and increased risk of fracture. Until recently, TZDs have also been
linked to increased CV events and use has fallen out of favor
Sulfonylureas provide excellent A1C lowering, but are also associated with weight gain. They also have
the potential to cause hypoglycemia, so patient education is crucial. Because of his allergies to "sulfa",
use would be contraindicated SGLT2 inhibitors have data to support an A1C reduction necessary to
gain glycemic control. In addition, they are associated with weight loss and blood pressure lowering.
New information demonstrates these agents may be beneficial in those with ASCVD, heart failure and /
or CKD. They are also associated with dyslipidemias as well. Prior to starting therapy, renal function and
electrolytes would have to be assessed. $$$
Based on the ASCVD recommendations (which are now paralleled by the 2015 ADA recommendations),
all patients with type I or II DM ages 40-75 should be on a moderate intensity statin. If the patients 10
years ASCVD risk is greater than 7.5%, a high intensity statin can be considered. Since all information
needed to perform the estimate is not present, we can assume JR need at least moderate intensity
statin. ACCE/ACE guidelines still resemble those of ATPIII. Even so, the recommendation is for a statin
regardless of LDL-C in diabetics over 40 with at least 1 risk factor of ASCVD. Options: atorvastatin 10mg,
rosuvastatin 10, simvastatin 20-40, pravastatin 40, lovastatin 40, fluvastatin 40.
An angiotensin-converting enzyme inhibitor and considered to be a drug of choice for renal protection in
patients with diabetes. ACEi and ARBs have demonstrated a reduction in renal progression to overt
proteinuria. African Americans may not see the maximum effect of blood pressure lowering with ACEi due to
a decreased amount of renin. Combination therapy with a thiazide would be a reasonable add on
