Exam (elaborations) Advanced pharmacology

NR565 Final Exam Study Guide This study guide covers content for the question bank for this course. There are 100 questions on the exam and more content in the exam study bank than will be seen on any given exam. Therefore, you may note more than 100 topic items noted in this study guide. However, there may also be more than one question for a topic listed so you should know each one well. Some items listed are more specific than others. If the item listed seems vague, if it’s a more general question and to be more specific would be to risk the integrity of the question itself. Number of Questions on Exam: 100 Point Value of Each Question: 2 Styles of Questions of Exam: Multiple Choice Only Knowledge Levels: Various (remember, understand, apply) Time Limit: 120 minutes Number of Attempts: 1 Use of Support Materials: Not Allowed Platform Used for Exam: ExamSoft/Examplify Exam Expectations: Review Exam Expectations in Course Announcements Tips on Using this Study Guide 1. Review the topics each week to take notes as you move through the course and focus your reading and content review in the course. 2. You can make notes directly on each tab for the respective week or print out and hand write your notes. 3. If you choose to print, you will want to adjust the size of columns so the table width will fit on a printed page. 4. Re-write your notes if you type them to connect the content to your memory more readily as the activity of writing and saying it again as you write it creates repetition that helps commit the content to memory. 5. Create your own practice questions that are clinical scenario based to move the content from a memorization (Remember) level of learning to an application type of learning. Much of your exam will be at the application level so it's not enough to memorize your notes. 6. Review your study guide and notes as often as you can. Read them out loud so you hear the words externally as well as internally. The more senses you can engage while studying, the more likely you are to remember it.   Week 5 Chapter 48 • Glycemic Goals in Type 2 Diabetes • Diabetic Nephropathy Prevention: • 1st generation vs 2nd generation Sulfonylurea: The second-generation agents are much more potent than the first-generation agents, and hence dosages are much lower (as much as 1000 times lower in some cases). More important, with the second-generation agents, significant drug–drug interactions are less common, and the outcomes tend to be milder. Because of these differences, the second-generation agents have nearly completely replaced the first-generation agents in clinical practice. • DDP4I: Adverse Effects: patients have developed pancreatitis, including fatal hemorrhagic or necrotizing pancreatitis according to postmarketing reports. Patients should be informed about signs and symptoms of pancreatitis (e.g., severe and persistent abdominal pain, with or without vomiting) and instructed to stop sitagliptin immediately • DDP4I: MOA: Sitagliptin (Januvia) enhances the actions of incretin hormones • GLP-1 receptor agonists: MOA it slows gastric emptying, stimulates glucose-dependent release of insulin, inhibits postprandial release of glucagon, and suppresses appetite. Adverse rxn: Exenatide poses a risk for pancreatitis. Severe cases have led to pancreatic necrosis, pancreatic hemorrhage, and even death. Patients should be informed about signs and symptoms of pancreatitis—typically severe and persistent abdominal pain, with or without vomiting—and instructed to stop exenatide immediately • GLP-1 receptor agonists: Monitoring • Glycemic Control Targets: Hypoglycemia is the biggest concern. Pramlintide does not cause hypoglycemia when used alone but poses a risk for severe hypoglycemia when combined with insulin, especially in patients with type 1 diabetes. • Incretin Mimetics: mimics the effects of amylin, reduce postprandial levels of glucose, mainly by delaying gastric emptying and suppressing glucagon secretion. • Incretin Mimetics in Pregnancy: • Meglitinides vs sulfonylureas • Metformin: MOA: First, it inhibits glucose production in the liver. Second, it reduces (slightly) glucose absorption in the gut. And third, it sensitizes insulin receptors in target tissues (fat and skeletal muscle) and thereby increases glucose uptake in response to whatever insulin may be available. • Metformin: Pregnancy: metformin was essentially the same as those with insulin, the traditional agent for managing gestational diabetes—suggesting that metformin may become an acceptable alternative for many women. • Metformin: Side Effects: The most common side effects are decreased appetite, nausea, and diarrhea. These generally subside over time. However, in 3% to 5% of patients, GI side effects lead to discontinuation of treatment. Therefore, the dose of metformin must be titrated up to the target dose to minimize the severity of GI side effects. Metformin decreases absorption of vitamin B12 and folic acid and can thereby cause deficiencies of both. Deficiency of B12, in turn, can contribute to peripheral neuropathy, a common long-term consequence of diabetes. • pioglitazone (TZD): Adverse Effects: pioglitazones can cause ovulation in anovulatory premenopausal women, thereby posing a risk for unintended pregnancy. • pioglitazone (TZD): MOA: Pioglitazone (Actos) reduces insulin resistance and may also decrease glucose production. • Repaglinide (Meglitinide): pt education: the risk for hypoglycemia may be increased. Because of possible hypoglycemia, patients must eat no later than 30 minutes after taking the drug. • SGLT-2 inhibitors: Adverse Effects: female genital fungal infections, urinary tract infections, and increased urination. Because SGLT-2 inhibitors increase the amount of sugar present in the urine, the increased risk for such infections is not much of a surprise. In addition, particularly in older adults, use of canagliflozin can lead to postural hypotension and dizziness, particularly if used in combination with diuretics. • SGLT-2 inhibitors: MOA reduces the reabsorption of glucose, thereby increasing urinary glucose excretion. • SGLT-2 inhibitors: Therapeutic Goal: Management of blood glucose in patients with type 2 diabetes. • Sitagliptin: Side Effects: Importantly, regardless of what the glucose level is—high, normal, or low—sulfonylureas will make it go lower. If the level is high, reducing it will be therapeutic. • Sulfonylurea: Contraindications: Sulfonylureas are contraindicated during pregnancy and breast-feeding. Use these drugs with caution in patients with renal or hepatic dysfunction. • Sulfonylurea: MOA: Sulfonylureas act primarily by stimulating the release of insulin from pancreatic islets. If the pancreas is incapable of insulin synthesis, sulfonylureas will be ineffective—which is why they do not work in patients with type 1 diabetes. • Sulfonylurea: Pregnancy: Sulfonylureas are contraindicated during pregnancy and breast-feeding. • Sulfonylurea: Side Effect: The major side effects with these drugs are hypoglycemia and weight gain. • Thiazolidinediones (TZD) MOA: like glitazones or simply TZDs, reduce glucose levels primarily by decreasing insulin resistance. • Adverse Effects: Pioglitazone can cause ovulation in anovulatory premenopausal women, thereby posing a risk for unintended pregnancy. This effect has not been studied in clinical trials, and hence the incidence is unknown. Women should be informed about the potential for ovulation and educated about contraceptive options. Chapter 49 • Hypothyroidism o Treatment in Infants Dose decreases with age. Doses adjusted to normalize TSH and free T4. o Levothyroxine Administration Levothyroxine is almost always administered by mouth. Oral doses should be taken once daily on an empty stomach (to enhance absorption). Dosing is usually done in the morning, at least 30 to 60 minutes before eating. o Levothyroxine: Drug interactions Among these are phenytoin (Dilantin), carbamazepine (Tegretol, Carbatrol), rifampin (Rifadin), sertraline (Zoloft), and phenobarbital. Accordingly, to maintain adequate levothyroxine levels, patients taking these drugs may need to increase their levothyroxine dosage. o Levothyroxine: Adverse Effects With an acute overdose, thyrotoxicosis may result. Signs and symptoms include tachycardia, angina, tremor, nervousness, insomnia, hyperthermia, heat intolerance, and sweating o Levothyroxine Monitoring Measurement of serum TSH is an important means of evaluation. Successful replacement therapy causes elevated TSH levels to fall. However, TSH will not normalize quickly and often lags behind normalization of serum T3 and T4. • Hyperthyroidism o Methimazole: MOA- First, methimazole prevents the oxidation of iodide, thereby inhibiting incorporation of iodine into tyrosine. Second, methimazole prevents iodinated tyrosines from coupling. Both effects result from inhibiting peroxidase, the enzyme that catalyzes both reactions. Adverse effects: should be avoided by women who are pregnant or breastfeeding. Agranulocytosis is the most dangerous toxicity. The reaction is rare (approximately 3 cases per 10,000 patients) and usually develops during the first 2 months of therapy. Sore throat and fever may be the earliest indications, and patients should be instructed to report these immediately. Treatment During Pregnancy- the drug should be avoided during the first trimester. Use in the second and third trimesters is considered safe. Compared with methimazole, PTU crosses the placenta poorly, and hence risk to the fetus is low. Accordingly, if a thionamide is needed during the first trimester of pregnancy, PTU is the preferred drug. • Thyroid Storm o Symptoms Signs and symptoms include tachycardia, angina, tremor, nervousness, insomnia, hyperthermia, heat intolerance, and sweating.