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FINAL EXAM
class notes
252
Nursing
Graduate
11/26/2011

Additional Nursing Flashcards

 


 

Cards

Term
What are risk factors for Type II DM?
Definition

 

a. Increased body weight (>20% above ideal weight), increased triglycerides (≥250mg/dl), decreased

 

HDL (<35 mg/dl), and fasting blood glucose ≥100mg/dl, HTN st

  1. Previous history of gestational diabetes or family history of type 2 diabetes (1

  2. Race: African Americans, Alaska Native, Asian American, Hispanic/Latino Americans, American

    Indians, and Pacific Islanders.

  3. GDM

2. GDM
a. Obesity

b. glucose in the urine
c. family history of DM
d. age >35 y
e. previous delivery of babies >9 lbs f. ethnicity

Term
How do you diagnose type II DM?
Definition

 

  1. 1. Fasting Blood Glucose (FBG) ≥126 mg/dl (fasting 8 hours)
    2. Casual blood sugar
    ≥200 mg/dl with symptoms of diabetes (not for routine use)
    3. Two hour post glucose challenge of 200 mg/dl (oral glucose tolerance test - OGTT)

Term
Treatment for Type II DM with decrease the complications for:
Definition

 

  1. Infections

  2. Microvascular complications a. Retinopathy

    b. Neuropathy c. Nephropathy

  3. Macrovascular complications (#1 Killer) a. Myocardial Infarction
    1. Stroke 2. Peripheral vascular disease - Ischemic heart disease

Term
What are the goals for therapy with DM?
Definition

1. Post Prandial glucose <140 mg/dl (PPG taken 2 hours after meal is begun)

2. Maintain glycated hemoglobin (HbA1c <7% - ADA; AACE goal in <6.5

3. Blood pressure < 130/80

4. Total cholesterol <200mg/ml

5. Lose weight if overweight

Term
What are symptoms of hypoglycemia?
Definition

 

  1. Hunger, nausea, lethargy, tachycardia, sweating, nervousness, confusion, tremor, convulsions, stupor, coma, vomiting.

  2. Symptoms of hypoglycemia caused by sympathetic excess (e.g., sweating, palpitations, and trembling) are prominent during the first few years after onset of diabetes. Many patients with long-term diabetes (>10yr) have a depressed adrenaline response to hypoglycemia.

  3. Nocturnal hypoglycemia - nightmares, poor sleep quality, morning headaches, and sweating.

  4. d. Alcohol can cause unawareness of hypoglycemia because in some patients, symptoms of hypoglycemia are similar to alcohol intoxication.

Term
What are symptoms of hyperglycemia?
Definition
Polyuria, polydipsia, polyphagia, and fatigue.
Term
What are non drug managment methods for DM?
Definition

 

1. Diet

2. Exercise
3. Address Insulin Problem

a. Replace insulin – insulin (Only acceptable method for Type 1)
b. Increase insulin release by pancreas – sulfonylureas, meglitinides, exenatide, sitagliptin
c. Decrease glucose absorption – alpha-glycosidase inhibitors
d. Decrease liver glucose production and increase peripheral insulin sensitivity – biguanides,

thiazolidinedioes
e. Prolong activity of incretins which stimulate insulin release and inhibit glucagon release -

Sitagliptin
4. Daily aspirin, treatment of hypertension and dyslipidemia will help to reduce macrovascular

complications
5. Good personal hygiene will help to prevent infections 6. Stop smoking

Term
What does insulin do in the body?
Definition

 

A. Pharmacology (Insulin stores energy)

1. Promotes the transport of glucose into muscle, liver, and adipose tissue.
2. Suppresses the release of fatty acids from adipose tissue preventing the formation of ketone bodies (little insulin is needed for this effect so that ketosis is only seen with severe insulin deficiency).

3. Accelerates potassium uptake into muscle cells

4. Promotes incorporation of amino acids into proteins.

5.Normal patterns of insulin release from the pancreas

Term
When is it clinically appropriate to use insulin?
Definition

1. Type I

2. Type II with: 1. Symptoms uncontrolled by diet and exercise. 2. Symptoms not controlled by oral hypoglycemics. 3 Major stress or surgery.

3. Gestational Diabetes with sub-optimal control with diet or oral agents

4. Hyperalimentation (before you increase the dose of insulin- check the serum potassium)

5. Emergency situations: Ketoacidosis and hyperosmolar hyperglycemic states (HHS)

6. Used in ICU's to maintain BG control. Doing so has been shown to decrease mortality. Down side is inadvertantly causing hypoglycemia.

Term

Insulin Preparations

Lispro (humalog) and Aspart

Definition

 

  1. have the fastest onset of action and should be given within 5-10 minutes of a meal.

Term

Insulin Preparaitons

Regular Insulin

Definition
a rapid onset and duration of action
Term

Insulin Preparations

Glargine (lantus)

Definition

 

  1. provides a very slow and even release of insulin from a subcutaneous injection site for a 24 hour period – administered at bedtime. Lantus may be used once daily in patients previously needing twice-daily injections of NPH. If switching to Lantus from NPH, reduce the total daily insulin dose by 20%.

 

Term

Insulin Preparations

Detemir (Levemir)

Definition

 

  1. long acting insulin can be given once or twice daily. If given once, dose should be in the evening. If given twice, one dose in morning and second dose approximately 12 hours later.

Term

Insulin Preparations

Where can you administer them? And where has the fastest absorption?

Definition

-Speed of absorption: Abdomen > Arm > Thigh > Buttocks (does not apply to glargine or detemir)

- Massage and local heat will increase speed of absorption

Term

What is the standard concentration for insulin?

What is given to patients with marked insulin resistance?

Definition

1. U-100 hass 100 units of insulin per ml. This concentraton is used most frequently.

2. U-500 (500 units per ml) is still mainly used in patients wih marked insulin resistance.

Always use a syringe compatible with the concentration.

Term
What are the only insulin preparations that may be given IV?
Definition

REGULAR and RAPID-ACTING INSULINS

(all insulins can be given subcutaneous)

Term
What should you always check when administering insulin?
Definition

 

 concentration on vial (U-100 or U-500) as well as type Regular, NPH, etc

Term
Can two different insulins be mixed in the same syringe?
Definition
YES, example NPH +Regular for SQ administration
Term
How long may mixtures in syringes be stored for?
Definition
3 weeks
Term
What is sequence for administration of NPH and regular insulin?
Definition

 

  1. Important Notes:
    a. Mixture in syringes may be stored in refrigerator for 3 weeks. b. NPH/Regular insulin mixing sequence

    Inject air into NPH
    Inject air into regular insulin Withdraw regular insulin
    Withdraw NPH.

Term
Clear before cloudy?
Definition
YES
Term
What should you do to a cloudy insulin vial before administering?
Definition

 

  1. Always roll the vial of cloudy insulin preparation between palms of hand prior to use to ensure adequate mixing of the suspension. Do not shake vigorously. Doing so will cause bubbles to form in the liquid and decreasing the accuracy of the dose.

Term
What abbreviation should not be used with units?
Definition
U it looks like a "0"
Term
How should insulin be stored?
Definition

 

  1. a. Do not freeze; clumping of the suspension may result.

  2. b. Stable at room temperature for 30 days.
    c. Always observe expiration date on vial.
    d. A good rule of thumb is to keep in refrigerator

Term
When switching a patient from animal insulin to human insulin what should they be warned?
Definition

 

When switching from animal insulin to human insulin, the patient should be warned that their insulin requirement may be reduced and the nature of their hypoglycemic warning symptoms may change. For these reasons, increase monitoring is necessary after the transition to human insulin.

Term
What drug can alter the signs and symptoms of hypoglycemia?
Definition
Beta blockers
Term
What should you administer when a patient is hypoglycemic?
Definition

 

  1. b. Administer 4oz of sweetened juice, 2 teaspoons sugar, honey or corn syrup, cake mate, or several

    candies. Check blood sugar after 15 minutes, if still below 70, give another dose of sugar. Once above 70, give a snack. If food is given initially with the sugar, the food will decrease the speed of absorption of the sugar.

    c. If patient is unresponsive, use intravenous glucose or parenteral glucagon (onset of action SQ=IM; IV faster then SQ or IM).

Term
What can cause lipohypertrophy?
Definition

 

  1. Lipohypertropy can be caused if one injection site is used too often. Injecting into this area can cause less pain but will also slow absorption of insulin.

Term
Do patients have local or systemic insulin injection reactions?
Definition
BOTH
Term
What is the Somogyi effect?
Definition

 

  1. hypoglycemia during early morning hours causes a rebound hyperglycemia that is observed as a high morning glucose

Term
What is the Dawn Effect?
Definition

 

  1. occurs in everyone, cortisol is highest in morning antagonizing insulin effect and causing an increase in serum glucose.

Term
What are patient related variables when it comes to administering?
Definition

 

  1. Decreased visual acuity, as with retinopathy, may make it difficult to measure insulin dose accurately.

  2. Renal dysfunction may change the accuracy of the urine glucose tests.

  3. Activity level

  4. Timing of meals

  5. Infection: Increased stress may increase insulin need.

  6. Pregnacy
  7. Other drugs: alcohol, thiazides, corticosteroids
Term

SULFONYLUREAS

Glyburide(Diabeta)

Glipizide (Glucotrol)

Glimepiride (Amaryl)

PHARMACOLOGY

Definition

 

  1. Stimulate the release of insulin from the pancreatic beta cells and can cause hypoglycemia.

  2. Extra pancreatic mechanism include enhancement of insulin sensitivity in peripheral tissue.
Term

SULFONYLUREAS

Glyburide(Diabeta)

Glipizide (Glucotrol)

Glimepiride (Amaryl)

Are they used for Type I or II DM?

Definition
ONLY type II
Term

SULFONYLUREAS

Glyburide(Diabeta)

Glipizide (Glucotrol)

Glimepiride (Amaryl)

What are some toxicities?

Definition

 

  1. 1. Hypoglycemia. Predisposing factors: old age decreased renal function, excessive dose.

    1. Gastrointestinal disturbances are fairly common and are dose related.

    2. Skin reactions: pruritus, rash. Switching to another agent may help although cross sensitivity among sulfonylureas has been reported.

    3. Antabuse reaction: facial flushing and nausea may be experienced when alcohol is consumed. This reaction is most common with chlorpropamide.

    4. SIADH: Chlorpropamide and to a lesser extent tolbutamide, may enhance the effect and release of ADH leading to fluid retention or water overload. In contrast, tolazamide, acetohexamide and glyburide may even have a diuretic effect.

    5. Can cause weight gain.
Term

SULFONYLUREAS

Glyburide(Diabeta)

Glipizide (Glucotrol)

Glimepiride (Amaryl)

 What are patient related varialble?

Definition

1. Renal Dysfunction

2. Drug interactions: Oral anticoagulants, sulfonamides and chloramphenicol may enhance sulfonylurea effects while alcohol and rifampin may decrease the effect.

3. Chronic Liver Disease.

Term

MEGLINITIDES

Repaglinide (Prandin)

Nateglinide (Starlix)

PHARMACOLOGY

Definition

 

  1. Both are insulin secretagogues stimulating the release of insulin from the pancreas and both can cause hypoglycemia.

  2. Repaglinide –has a fast onset and short duration of action making it useful for PRN therapy in patients who each at erratic times.

  3. Decreased risk of hypoglycemia compared to sulfonylureas due to shorter duration of action

 

Term

MEGLINITIDES

Repaglinide (Prandin)

Nateglinide (Starlix)

CLINICAL USE

Definition

 

  1. a. Not effective in Type 1 diabetes
    b. Use in the treatment of Type II diabetics with diet
    c. Particularly useful in a patient who eats at erratic times because of its fast onset d. Can be used alone or in combination with metformin

Term

MEGLINITIDES

Repaglinide (Prandin)

Nateglinide (Starlix)

ADMINISTRATION

Definition

 

a. Repaglinide - Administer 0-30min before each meal. Start with a dose of 0.5mg.

May increase dose based on response; allow one week before dose adjustment. (max dose is 16mg/day)

b. Nateglinide – Administer 60-120 mg 1-30min before each meal TID.

Term

ALPHA-GLUCOSIDASE INHIBITORS (AGI)

Acarbose (Precose)

Militol (Glyset)

PHARMACOLOGY

Definition

 

  1. AGIs delay the digestion and absorption of complex carbohydrates and thereby reduce postprandial increase in blood glucose concentration. Their mechanism of action is to reversibly inhibit intestinal alpha glucosidase, which hydrolyse oligosaccharides, tri & disaccharides to glucose and other monosaccharides in the brush border of the small intestine.

  2. AGIs do not inhibit lactase and does not block absorption of glucose. Unlike the sulfonylureas and meglitinides, AGIs do not cause hypoglycemia.

  3. Reduce postprandial hyperglycemia and hyperinsulinemia.
Term

ALPHA-GLUCOSIDASE INHIBITORS (AGI)

Acarbose (Precose)

Militol (Glyset)

CLINICAL USES

Definition

 

  1. Are indicated in Type 2 to decrease postprandial hyperglycemia.

  2. AGIs can be used as monotherapy, or combined with metformin and/or a sulfonylurea to provide better glucose control.
Term

ALPHA-GLUCOSIDASE INHIBITORS (AGI)

Acarbose (Precose)

Militol (Glyset)

ADMINISTRATION

Definition

1. Acarbose - Take 25 mg at the start of meals (with first bite). Increase by 25mg/dose at interval of 4-8 weeks (max daily dose 150mg if <60kg and 300mg if >60kg).

2.Miglitol – Take 25 mg with each meal, may increase to 50mg with each meal after 4-8 weeks. Max dose is 100mg tid.

3. Hypoglycemia – While AGIs will not directly cause hypoglycemia, hypoglycemia might still occur because of other therapy (i.e., sulfonylurea). Teach the patient to use a glucose or fructose based product to treat hypoglycemia. NOTE - If a patient become hypoglycemic, and the only thing around is sucrose – Try it anyway.

 

 

 

 

 

 

 

Term

ALPHA-GLUCOSIDASE INHIBITORS (AGI)

Acarbose (Precose)

Militol (Glyset)

What is the most common GI toxicity?

Definition

 

Most common is GI: diarrhea, abdominal pain, and flatulence. These effects develop within the first weeks of therapy and are related to undigested carbohydrates in the lower GI tract. These toxicities tend to decrease with time.

Term

BIGUANIDE

Metformin (Glucophage)

Pharmacology

Definition

 

  1. Metformin increases glucose uptake by muscles and decreases hepatic glucose production. Unlike sulfonylureas, metformin does not stimulate insulin release from the pancreas and therefore does not cause hypoglycemia when used alone.

  2. Not metabolized, excreted unchanged by the kidneys
Term

BIGUANIDE

Metformin (Glucophage)

Clinical Uses

Definition

 

  1. Is indicated as adjunct therapy to diet in Type 2 diabetes where diet alone is inadequate.

  2. Therapy with metformin does not cause weight gain.

  3. Because of differing mechanisms of action, metformin and a sulfonylurea can be combined to provide better glucose control.

  4. Consider as mono therapy in obese or dyslipidemia patients with no cardiovascular impairment, good renal and hepatic function, and no ethanol abuse.

  5. PCOS: Caused by decreased peripheral insulin sensitivity leading to increased serum insulin levels. Increased serum insulin stimulates the ovaries causing arrest of follicular development (chronic an ovulation), polycystic ovaries, and increased release of androgens (hirsutism).

    Polycystic Ovarian Syndrome (PCOS)
Term

BIGUANIDE

Metformin (Glucophage)

Administration

Definition

 

  1. Decrease GI symptoms by giving with food, and starting at a low dose then gradually titrate (START SLOW)

    upward.

  2. Monitor baseline (and yearly) liver and renal function

  3. Monotherapy

  4. Combination with sulfonylurea

  5. Combination with thiazolidinedioes

  6. Combination with insulin
Term

BIGUANIDE

Metformin (Glucophage)

DRUG INTERACTIONS

Definition

 

  1. a. Cimetidine will increase the blood level of metformin by 50%.
    b. Iodinated contrast dyes – discontinue metformin on day of study and restart 48 hours following
    study (do not restart with metformin if renal function is not normal)

Term

BIGUANIDE

Metformin (Glucophage)

PATIENT RELATED VARIABLES

Definition

 

a. Renal disease – Discontinue if serum creatinine is >1.5 mg/dl in males or >1.4 mg/dl in females.

b. Avoid in patients prone to lactic acidosis: CHF requiring treatment, renal dysfunction, liver dysfunction, or excessive alcohol ingestion.

Term

BIGUANIDE

Metformin (Glucophage)

TOXICITY

Definition

 

  1. Most common is GI: nausea, vomiting, diarrhea, abdominal bloating, and flatulence. Can be treated by decreasing the dose of metformin for 2 weeks and then increase back to target dose.

  2. Lactic acidosis is rare (1 in 33,000) but may be life threatening if it occurs. Avoid in patients with decreased hepatic or renal function, or in patients with excessive alcohol ingestion.
Term

THIAXOLIDINEDIOES

Pioglitazone (Actos)

Rosiglitazone (Avandia)

PHARMACOLOGY

Definition

 

  1. Work primarily by increasing target cell sensitivity to insulin thus allowing muscle uptake of glucose.

  2. Reduce insulin levels.

  3. Reduce hepatic production of glucose
Term

THIAXOLIDINEDIOES

Pioglitazone (Actos)

Rosiglitazone (Avandia)

CLINICAL USES

 

Definition

 

  1. a. Use in the treatment of Type 2 diabetes. Not effective in Type 1 diabetes
    b. Can be used as monotherapy or in combination with metformin or a sulfonylurea or insulin. c. Requires 4-12 weeks for maximum clinical effect.

Term

THIAXOLIDINEDIOES

Pioglitazone (Actos)

Rosiglitazone (Avandia)

PATIENT RELATED VARIABLEs

Definition

 

  1. Heart Failure – Can increase plasma volume and should be avoided in patients with heart failure (especially for NYHA class 3 or 4).(INCREASE PERIPHERAL EDEMA)

Term

THIAXOLIDINEDIOES

Pioglitazone (Actos)

Rosiglitazone (Avandia)

TOXICITIES

Definition

 

  1. Liver damage - monitor liver enzymes at baseline then every 2 months for first year then periodically thereafter.
    Pioglitazone – has least problem with increasing lipid levels.
    Avandia – FDA alert stemming from contradictory information suggesting an association with an increased risk of myocardial infarction.

Term

Amylinomimetics

(amylin like Drug)

PHARMACOLOGY

 

 

Definition

 

Amylin is a hormone co-secreted with insulin from beta cells that suppresses postprandial glucagon

secretion thereby decreasing hepatic glucose production. Also, decreases appetite and GI motility.

Term

Amylinomimetics

(amylin like Drug)

PRAMLINTIDE (Symlin)

Has actibivity of amylin

Definition

 

  1. Used in Type 2 diabetes as an adjunct treatment in patients who use mealtime insulin therapy and have failed to achieve desired glucose control with or without a concurrent sulfonylurea agent and/or metformin.

  2. Used in Type 1 diabetes as an adjunct treatment in patients who use mealtime insulin therapy and who have failed to achieve desired glucose control despite optimal insulin therapy.

  3. Administered by SC injection (comes in a vial) – do not mix with insulin – inject before each meal

  4. Do not administer with other drugs that slow GI motility (e.g., anticholinergics)

  5. Side effects: Hypoglycemia, N/V diarrhea

  6. Keep vials refrigerated.
Term

Incretin Analogs

Pharmacology

Definition

 

  1. Glucagon-Like Peptide-1(GLP-1): An important incretin hormone that facilitates glucose dependent insulin secretion.

  2. Incretin is a hormone that is secreted from L cells of the intestine that enhances insulin secretion inresponse to food.
Term

Incretin Analogs

Exentide (Byetta)

Has incretin like activity

Definition

 

1. Comes as either a 5mcg or 10mcg injection “pen” each containing 60 doses (one month’s supply)

2. Administered BID before morning and evening meals.
3. Refrigerate injection pens between injections
4. Do not use in patient’s with Type 1 diabetes
5. Side effects: most common are N/V diarrhea

Term

Dipeptidyl Peptidase IV (DPP-IV) inhibitor

Sitagliptin (Januvia)

PHARMACOLOGY

Definition

 

1. GLP-1 facilitates glucose-dependent insulin secretion

2. DPP-IV is the major enzyme that degrades GLP-1

Term

Dipeptidyl Peptidase IV (DPP-IV) inhibitor

Sitagliptin (Januvia)

Definition

 

1. Orally active: dose is 100mg daily
2. Toxicity: N/V/D
3. Only used in Type 2 diabetes

Term
What drugs used in DM are renoprotective and decrease on the onset of macro albuminemia?
Definition

ACE inhibitors and angiotensin II blockers

also CCB

-Thiazide diuretics can cause insulin resistance but still can be used.

- Should be on beta-blockers if have CAD unless contrainsicated.

Term
What drug do you want to avoid in DM?
Definition
Niacin – Avoid in diabetics because it increases insulin resistance.
Term

CHOLESTEROL MANAGEMENT

terms

Cholesterol

 

Definition

 

  1. A lipid which is an essential component of bile acid and cell membranes; precursor of steroid hormones.
Term

CHOLESTEROL MANAGEMENT

terms

TRIGLYCERIDE

Definition

 

  1. A lipid made from fatty acids and glycerol;

  2. provides fatty acids for energy storage and production.

Term

CHOLESTEROL MANAGEMENT

terms

LIPIDS

Definition
are not charged and therefore not soluble in water or blood.
Term

CHOLESTEROL MANAGEMENT

terms

Lipoprotein

Definition

 

  1. Carrier protein - combination of cholesterol, triglycerides and apolipoproteins which allows for transportation of cholesterol and triglycerides in the blood. Apolipoproteins are on the surface of lipoproteins and help bind the lipoprotein to cell surfaces and is a cofactor for breakdown of TGs.

Term

CHOLESTEROL MANAGMENT

Terms

Chylomicron

Definition

 

  1. Form in which cholesterol & triglycerides are transported from the intestine to the liver or general circulation.

Term

CHOLESTEROL MANAGMENT

Terms

LDL

Definition

 

  1. (low density lipoprotein) - main carrier of blood cholesterol from the liver to peripheral tissues. Results from loss of TG in VLDL particles. These particles are small and can deposit in arterial walls.

Term

CHOLESTEROL MANAGEMENT

Terms

VLDL

Definition

 

  1. (very low density lipoprotein) - main carrier of blood triglycerides (TG) from liver to peripheral tissues.

Term

CHOLESTEROL MANAGEMENT

Terms

HDL

Definition

 

  1. (high density lipoprotein), helps to remove cholesterol from peripheral tissues (extrahepatic tissue) and returns it to the liver. High levels are protective.

Term

CHOLESTEROL MANAGEMENT

Total Cholesterol =

Definition
LDL+HDL+VLDL
Term

CHOLESTEROL MANAGEMENT

HMG-CoA Reductase

Definition

 

  1. he rate limiting enzyme in cholesterol synthesis in the liver.

Term
What are high risk factors other than elevated LDL?
Definition

 

Cigarette smoking (w/i past month)
Hypertension (BP
140/90 mmHg or on antihypertensive medications) Low HDL cholesterol (<40mg/dl)

Family history of premature CHD (CHD in male first degree relative <55 yo; CHD in female first degree relative <65yo.)
Age (men
≥45yo; women ≥55yo)

Term
What are the 5 characteristics that qualify you for metabolic syndrome?
Definition

 

1. Abdominal Obesity

2. Triglycerides

3. HDL cholesterol

4. Blood Pressure Fasting glucose

5. Fasting Glucose
Term
After you treat LDL, what do you want to get under control?
Definition
VLDL
Term

Which medications will decrease LDL? which medication may not?

*******

Definition

1. Bile Acid Sequestrants

2. Ezetimibe

3. Fibric Acids (may reduce by 30% or increase by 45%, may increase LDL if TG is high)

4. HMG-CoA Reductase

5. Nicotinic Acid

Term

What cholesterol medication increases HDL?

*****

Definition

1. Bile Acid Sequestrants

2. Ezetimibe

3. Fibric Acids

4. HMG-CoA Reductase

5. Nicotinic Acid

Term

What cholesterol medication decreases Triglycerides and which medication decreases Triglycerides?

*****

Definition

Bile Acid Sequestrants increase TG

Ezetimibe, Fibric acids, HMG-CoA Reductase Inhibitor and nicotinic acid all decreases TG

Term

HMG-CoA Reductase Inhibitors

STATINS

What are the long acting statins?

Definition

 

  1. Atorvastatin (Lipitor)*

  2. Rosuvastatin (Crestor)*

Term

STATINs

Atorvastatin and Rosuvastatin

What can they cause

Definition

they have the longest half life and they can cause evevated liver enzyme blood levels (AST an ALT)

Term

STATINS

What are the two most liophylic?

Definition

Simvastatin and Lovastatin

 (most likely to cause elevated CK)

Term

Except for Pravastatin and Rosuvastatin, the metabolism of all statins is decreasd by CYP3A4 inhibitors which increase risk of myopathy. CYP3A4 is inhibited by:

***

Definition

1. Erythromyocin which inhibits the metabolism of statins and increases the blood level.

2. and Grapefruit Juice which also increased the blood level of statin.

Term

Other drugs that increase risk of myopathy when coadministered with statins are?

****

Definition

Gemifibrozil and Nicotinic Acid (potential muscle breakdown)

Term

HMG-CoA Reductase Inhibitors

Pharmacology

Definition

 

is the rate limiting enzyme in the synthesis of cholesterol. Its inhibition reduces formation of cholesterol in the liver which in turn stimulates activity of LDL receptors in the liver. Increased activity of LDL receptors increases removal of LDL from circulating blood.

Term

HMG-CoA Reductase

Administration

What is the most effective time to administer?

**

Definition

when given in the evening * except the long acting ones

-to allow maximum effect make adjustment only ever 4-6 weeks

Term

STATINS

Patient Related Variables

What pregancy category is it?

Definition
X
Term

STATINS

Toxicity

***

Definition

 

GI: diarrhea, constipation, abdominal pain, nausea.

Elevation of liver enzymes. Monitor AST and ALT (baseline, 12 wks, and annually thereafter or after dose increase). Elevations are reversed when dose is decreased.

Myopathy - diffuse muscle pain or weakness, with increased creatine phosphokinase (>10x normal). See drug interactions. Monitor CK

Rhabdomyolysis – Most patients with rhabdomyolysis had muscle pain, unrelated to exercise, within 3 weeks.(make sure patients know to report to you if they have muscle pain unrelated to exercise, STOP medication quickly)

 

Term

Bile Acid Sequestrants

Cholestyramine (Questran)

Colestipol (Colestid)

Colesevelam (WelChol)

DRUG INTERACTIONS

*****

Definition

Binds with many drugs; take other medications 1 hour before or 4 hours after bile acid sequestrants

Term
Ezetimibe (Zetia)
Definition

1. Selectively inhibits absorption of cholesterol from small intestines

2. Can be used a lone or in combination with a statin

3. Dose: 10mg qd

4. Adverse effects- well tolerated.

Term

FIBRATES

Gemfibrozil (Lopid)

Fenofibrate (Tricor)

Clofibrate (Atromid-S)

What cholesterol do these primarily decrease?

Definition
VLDL
Term

FIBRATES

Gemfibrozil (Lopid)

Fenofibrate (Tricor)

Clofibrate (Atromid-S)

What do they have a drug interaction with?

Definition
Warfarin increased effect
Term

FIBRATES

Gemfibrozil (Lopid)

Fenofibrate (Tricor)

Clofibrate (Atromid-S)

ADVERSE EFFECTS

*****

Definition

LIVER AND MUSCLE (same as statins)

a. increase in CK and LFTs

b. Cholethiasis, cholecystitis

c. contraindicated in GB disease, liver dysfunction, severe kidney dysfunction.

Term

NIACIN

(Nicotinic Acid, Vitamin, Vitamin B3)

PHARMACOLOGY

 

Definition

 

  1. Decreases formation of VLDL and LDL; increased formation of HDL

  2. Nicotinamide is not the same thing as niacin and will not decrease cholesterol.

Term

NIACIN

(Nicotinic Acid, Vitamin, Vitamin B3)

ADMINISTRATION TECHNIQUES

What do you want to try and minimize?

****

Definition

 

  1. Dose 1.5-3gm/day; start with low dose (100-250mg qd) increase dose slowly at 4-7 day intervals to limit flushing.
  2. Aspirin, 30-60 minutes prior to the dose of niacin is helpful in decreasing the flushing.

  3. Slow release formulations reduce cholesterol less effectively than fast release formulations and have increased risk of hepatotoxicity

Term

NIACIN

(Nicotinic Acid, Vitamin, Vitamin B3)

What are patient related variables?

*****

Definition

1. Diabetes: May worsen glucose control (increased insulin resistance)

2. Gout: may elevate uric acid(compete for clearance at renal tubule)

3. Ischemic Heart Disease: vasodilation can cause reflex tachycardia which can worsen ischemia.

4. Peptic Ulcer Disease: Niacin increases acid formation and may aggravate PUD

5. Drug interaction: Coadministration with HMG-CoA Reductase inhibitors may increase incidence of myositis.

Term

NIACIN

Adverse effects

Definition

1. Elevated LFTs. may be more common with slow release preparations. Monitor AST and ALT

2. Dose related flushing of the face and neck, with or without puritis, is a dose limiting toxicity.

3. GI: heartburn, nausea, diarrhea, abdominal discomfort.

Term

Omega-3- fatty acids

What do they decrease?

What adverse effects do they have

Definition

1. they decrease TG by effects on apoproteins

2. May cause diarrhea, excess bleeding and fishy taste.

Term

What are positive symptoms of schizophrenia?

****

Definition

Caused by dopamine over activity in the mesoblimbic area of the brain (functional arousal, memory, stimulus processing and motivational behavior)-typical and atypical antipyschotics are effective because block dopamine in this are of the brain.

Paranoia

Aggression

Sleep disturbances

Disorganized thinking/speech

Hallucinations (generally voices)

Distorted perceptions

Delusions (generally paranoid of external forces)

decreased appetite

Term

What are the negative symptoms of schizoprenia?

***8

Definition

caused by dopamine inactivity in mesocorital area of the brain (functional cognition, communication, social function and response to stress). Typical antipsychotics are non specific dopamine blockers and also block in this part of the brain causing further dopamine inactivity and worsening of negative symptoms. Atypicals (because they are selective for mesolimbic are) don't make negative symptoms worse and may have modest effect to improve

Disorientation

Poor memory

lack of insight

confusion

poor judgemet

anhedonia.

Term
What are drugs that can cause psychosis?
Definition

 

Cocaine, amphetamine

LSD
Phencyclidine
Anticholinergics (excessive dose) – atropine

Term

Antipsychotics

PHARMACOLOGY

***

Definition

 

1. Blocks dopamine receptors
2. Blocks acetylcholine receptors (except for Risperidone and Ziprasidone)

3. Blocks histamine-1 receptors (Risperidone and Ziprasidone very low)

4. Blocks alpha-1 adrenergic receptors.

 

 

Term

Antipsychotic agents

What is the goal of therapy?

****

Definition

 

1. To reduce the symptoms of psychosis and improve the manageability and social functioning of the patient.

Response to Therapy:

FIrst week: Decreased agitaion (ACTION IS SLOW)

2-4 weeks: Improved socialization

4-6 weeks: Involvement in thought disorder, decreased hallucinations/delusions, conversation becomes more appropriate

Maintenance therapy may be necessary to prevent relapse.

 

 

Term
What have comparitive studies shown for antipsychotics?
Definition

 

  1. Comparative studies have demonstrated equivalent efficacy of antipsychotic drugs when used in comparable doses. Exception: the atypical antipsychotics are more effective for negative symptoms.

Term
What drug is reserved for difficult to treat patients?
Definition

Clozapine is generally effective for schizoprenia unresponsive to other therapies.

Term

Antipsychotics

What can you assume with relationship between Extraparemetal effects and Anticholinergic?

Definition

If there is a lot of EPS side effects then there is less anticholinergic. And if there are more anticholinergic side effects there is les EPS side effects.

Term

Antipsychotics

Extrapyramidal Symtoms (EPS)

Definition

 

EPS are thought to be the result of reduced dopamine activity in the basal ganglia, resulting in a relative cholinergic hyperactivity. Classification of EPS and treatment strategies for EPS are noted below.

Term

Antipsychotics

Dystonia

Definition

 

  1. sudden, often dramatic contractions of skeletal muscle groups; often involves head, neck, back or laryngeal muscles; generally occurs within 24 - 96 hours of therapy initiation or dosage increase.

Term
If someone has dystonia you should....?
Definition

 

Treatment: Treat as a medical emergency with anticholinergic agents such as diphenhydramine (IV or IM) or benztropine (Cogentin) (IM).

Term

Pseudo-Parkinsonism

 

Definition

 

  1. Stiffness, shuffling gait, pill rolling, mask-like facies, cog-wheeling at elbow.

  2. Treatment: often responds to a decrease in antipsychotic dose or use of oral anticholinergics.

Term

Antpsychotic Side effects

Akathisia

Definition

-Inability to sit still, urge to move about; easily mistaken for increased anxiety and agitation

-Treatment: Less responsive to anticholinergics; may respond to decrease in antipsychotic dose or switching to a low potency antipsychotic, or administration of beta blocker (propranolol is the drug of choice because of its lipid solubility allowing it to cross the blood brain barrier very well) or a benzodiazepine such as diazepam.

Term

antipsychotic Side effects

Sedation

Definition

 

  1. related to antihistaminic properties; more prominent with low potency antipsychotics. Tolerance develops.

Term

antipsychotic side effects

orthostatic hypotension

Definition

 

  1. related to alpha-1 adrenergic blockade; more common with low potency antipsychotics. Tolerance develops.

Term

antipsychotics side effects

Anticholinergic

Definition

 

Dry mouth, Urinary retention, Dry skin

Blurry vision, Cognitive impairment, Constipation
Tachycardia

Term

antipsychotics side effects

Skin reactions

Definition

 

  1. photosensitivity with the low potency phenothiazines. Patients should protect themselves from the sun.

Term

antipsychotic side efects

TARDIVE DYSKINESIA

 

Definition

CAN BE PERMANENT

 

  1. Tardive dyskinesia resolves slowly and is potentially irreversible. Associated with long periods of antipsychotic drug use. Symptoms include rhythmic involuntary movementsof tongue, lips or jaws, and in later stages will include jerky or purposeless movements of extremities and can occur after as little as 6 months of therapy. Rating scales for involuntary movements are available (Abnormal Involuntary Movement Scale) and should be used so that early detection is possible. There are no consistently effective treatments for tardive dyskinesia, so prevention is the best approach. All antipsychotics have been associated with tardive dyskinesia. Not yet with ziprasidone. Long term dopamine blockade causes an up regulation and super- sensitivity. When the antidopamine is withdrawn, the super sensitivity is unmasked and TD occurs. Clozapine (best) and quetiapine (next best) can actually improve TD Sx without masking – secondary to their ability to decrease up-regulation (loose dopamine receptor binding
Term

antipsychotics side effects

Agranulocytosis

Definition

 

  1. Can occur with any antipsychotic but is most common with clozapine. Occurs in about 1% of patients during the first 18 months of therapy. Greatest risk is during the first 6 months. Monitoring WBC count is mandatory – prior to initiation, every week for first 6 months then every other week for months 6-12, then every 4 weeks. Clozapine is discontinued if WBC count drops below 2000/mm3 or ANC drops below 1000/mm3.

Term

antipsychotic side effects

Neuroleptic Malignant Syndrome

****

What is used to treat?

Definition

 

  1. Can occur with any antipsychotic agent. (1-2% usually early in therapy or after the dose has been increased). Clinical S & Sx evolve over 24-72 hrs and include body temperature >38°C; autonomic dysfunction (↑HR, ↑↓BP, sweating, ↑RR), rigidity, and altered level of consciousness. Dantrolene (36 vials) and bromocriptine are used for supportive therapy.

Term

What are side effects of all antipsychotics?

 

Definition

 

  1. (except for clozapine and quetiapine – loose dopamine blockade) can increase prolactin because they block dopamine. Hyperprolactinemia develops in 1-5% (galactorrhea, menstrual cycle changes).

Term
What can antisychotics due to seizure threshold?
Definition
Seizure threshold is decreased especially with the atypicals and with clozaril (esp. with high doses)
Term

antipyschotics side effects

Erectile dysfunction

Definition

 

  1. Erectile dysfunction in males and loss of libido in males and females occurs in 25-50% (treat with decrease in dose – if possible)

Term

antipsychotic side effects

Cardiac

Definition

 

QTc prolongation – especially with mellaril, droperidol and ziprasidone. Most significant with droperidol which has a BLACK BOX WARNING regarding this effect

Term

antipsychotics

Administration issues

***

Definition

*slow onset of action

*when combined with TCA, antiarrythmic, floroquinolones or erythromyocin it can cause QT prolongation. SEVERAL DRUGS be aware.

-SSRI esp Prozac and Paxil – increase blood levels of phenothiazines, haldol and risperidone
Fluvoxamine - increase metabolism of clozapine and quetiapine.
Smoking increases metabolism of clozapine and quetiapine (stop smoking can increase levels of clozapine and quetiapine and cause seizures)

Term

antipsycotics

MONITORING PARAMETERS

Definition
  1. EPS - observe patient for tremor, drooling, muscle spasm, restlessness, repetitive involuntary movement, stiffness, cog-wheeling.

  2. Detection of Tardive Dyskinesia - Use a non-voluntary movement scale in patient on long term therapy.

  1. Cardiovascular - pulse and orthostatic hypotension

  2. Anticholinergic effects - dry mouth, constipation, urinary hesitancy, tachycardia, blurred vision

  3. Sedation

  4. White blood cell counts (esp. with clozapine)

  5. Weight gain (except with molindone and ziprasidone) especially with clozapine and olanzapine.

  6. Sexual dysfunction

  7. Liver enzymes (LFTs)

 

Term
Who is depression more frequently seen in?
Definition
female
Term
To make a dx. of depression you must have...?
Definition

-5 or more od the following symptoms during the same 2 week period and not attributable to drugs or a general medical condition. S.I.G.E.C.A.P.S. (Suicidal ideation, interest, guilt, energy, concentrating, appetitie, psychomotor agitation, sleep disturbances)

Term
When a patient is on antidepressant when sould response to medication be assessed?
Definition

4-6 weeks. geriatrics patients can take up to 12 weeks.

Term
What do all antidepressants have an effect on?
Definition
5-HT, NE, and DA
Term

Non-tricyclic antidepressants

Have what?

Definition

(5-HT, DA, & NE reuptake inhibitors) 75-375 mg ( large range)

 

Term

SSRI's (antidepressants)

Have what?

Definition
5-HT short range between dosages
Term
What doses for antidepresseants are used in elderly patients?
Definition

- Lower doses and is what is used initial in all patients

Term
MAO (A&B) Inhibitors do what?
Definition
inhibit breakdown of NE, serotonin, and dopamine
Term
Tricyclic antidepressants also share what following properties?
Definition

1. Blocks cholinergic

2. Blocks alpha-1 adrenergic receptors

3. Blocks histamine 1-receptors

Term
During the first week of a tricylclic antidepressant what will it cause?
Definition
Decreased agitation and anxiety
Term
During the first week of a SSRI, What will it cause?
Definition

May increase agitation (FDA warning, primarily with children, slight increase in the # of suicides)

Term
How many weeks for the acute phase in antidepressants take to occur? (may take this long to see the full effect)
Definition
6-12 weeks
Term
How long should an antidepressant be continued once full effects are felt and the patient feels better?
Definition

4-9 months: acute phase

1 or more years: Maintenance phase ( necessary in some patients to avoid relapse)

 

May consider discontinuation of therapy following a single episode of depression where the patient is fully remitted for at least 6 months (on therapy) and has no family history. If patient relapses within 5 years, therapy should be continued indefinitely. Patients with 3 or more episodes of depression should be on life long therapy (relapse off of therapy is >90%).

Term

Can plasma level monitoring be used for some patients?

***

Definition

YES

 

-TCA have a curvilinear relationship between plasma levels and antidepressant effect (poor response is seen with plasma levels that are either too low or too high). SWEET SPOT

-Dose response for SSRIs are relatively flat (max dose is not much higher then minimum dose.)

-Dose response for Venlafaxine is steep, maximum dose is considerably higher than minimum dose.

 

Term

Tricyclic Antidepressants

Adverse Effects

***

Definition

* Patients with suicidal tendancies are being treated with a potentially lethal drugs that take up to 3-6 weeks to work (may want to give them a small amount and follow up on progress frequently)

  1. Anticholinergic effects - dry mouth, tachycardia, urinary retention, constipation, blurred vision

  2. Postural hypotension (alpha-1 blockade)

  3. Sedation, weight gain (antihistaminic effect)

  4. Arrhythmias - can be lethal in overdose (obtain baseline EKG)

 

Term

SSRI's

Adverse Effects

(Only need to know class effect, not each individual drug)

Definition

 

  1. Insomnia – Last dose should not be after 5pm. Exception: Paxil can be given at bedtime because of the sedation caused by its anticholinergic effect.

    Anticholinergic effects – only with Paroxetine (Paxil)
    Weight gain – most problematic with Paroxetine (Paxil)
    Bradycardia in elderly – Citalopram (Celexa) and Fluoxetine (Prozac)

    Decreased libido / anorgazmia – Most problematic - Paroxetine (Paxil) Fluoxetine (Prozac)Celexa / Zoloft, Least problematic- Fluvoxamine (Luvox)

    SIADH (especially >70yo) Monitor serum sodium esp. in first several months

    Most common toxicities are short lived nausea, vomiting, HA, diarrhea (esp. Luvox)

Term

Bupropion (wellbutrin)

Adverse effects

Definition

low incidence of weight gain, low incidence of sedation, no clinically relevant anticholinergic or antihistaminic effects. Most common side effects are insomnia and agitation. May increase risk of seizures in patients at risk of seizure activity.

 

Term

Venlafaxine

adverse effects

Definition
MONITOR BP regularly. associated with an increase in SBP.
Term

Amoxapine

***

What symptoms can it cause?

adverse effects

Definition

 

  1. Extrapyramidal symptoms secondary to DA receptor blockade, seizures, sedation, anticholinergic effects.

Term
How long do MAO inhibitors last after they are discontinued?
Definition

14 days after D/C'd

 

HYPERTENSIVE CRISIS can occur with concomitant sympathomimetic use or foods high in tyramine. Hypertension can be treated with phentolamine.

Term
What is the major administration issue with Tricyclics?
Definition
is generally given as one daily dose at bedtime.
Term
What is an administeration issue with SSRI?
Definition
Last dose not after 5 pm to avoid insomnia
Term

When you discontinue an antidepressant you should...?

***

Definition

*-taper the drug over 1-2 weeks to avoid withdrawal symptoms.

  1. watch for inadvertent discontinuation during transition for outpatient to inpatient care.
    1. Venlafaxine and SSRI (Especially Luvox and Paxil) i. Flu like symptoms

      ii. Agitation
      iii. Insomnia
      iv. Worseningofdepression

      v. Electric shock feeling

    2. TCA and MAO Inhibitor

      i. Delirium ii. Insomnia

 

Term
SSRI's interact....
Definition
with many things ALWAYS look it up
Term
What can be given concurrently with antidepressants to augment them?
Definition

 

  1. a. Low dose lithium (0.4 – 0.6 mEq/L)
    b. Levothyroxine in a patient with borderline hypothyroidism
    c. Atypical antipsychotics
    d. Stimulants (Ritalin / Dexadrine) in patients who are apathetic, amotivational or lack energy

Term

St. John's Wart

Antidepressant

Definition

-may be effective for mild to moderate depression

-It is a food supplement so there is no regulation/no control

Term
Bipolar I Disorder
Definition
One or more manic or mixed episodes, usually accompanied by major depressive episodes
Term
Bipolar II Disorder
Definition
One or more depressive episodes accompanied by atleast one hypomanic episode
Term
How long will and average manic episode last?
Definition
on average 2-4 months
Term
What are the treatments for bipolar?
Definition

 

Mood stabilizers Lithium (MOST COMMon

Carbamazepine (Tegretol) Oxcarbazepine (Trileptal) Lamotrigine (Lamictal) Valproic Acid (Divalproex) Olanzapine (Zyprexa) Resperidone (Risperdal) Clozapine (Clozaril) Gabapentin (Neurontin) Topiramate (Topamax)

Antidepressants
Bupropion (Wellbutrin)

Venlafaxine (Effexor)

Anti-anxiety meds (generally avoided because of drug dependence risk) Lorazepam (Ativan)

Clonazepam (Klonopin)
Calcium Channel Blockers (poor evidence of efficacy) Cognitive behavioral therapy
Family therapy
Electroconvulsive Therapy (ECT)

Term

What is the acute treatment for Manic or mixed episodes of Bipolar?

****

Definition

1. Lithium + antipsychotic (olanzapine or risperidone) OR

2. Valproate (preferred over lithium for mixed episode) + antipsychotic (olanzapine or risperidone) PREFERRED OVER LITHIUM FOR MIXED EPISODES.

Term

What is the preffered treatment for Depressive Episodes?

***

Definition

1. Antidepressant monotherpay is NOT recommended ( can throw the patient into a manic episode) manic phase will be unmasked.

FIRST Line : lithium or lamotrogine

ADD on therapy if necessary: second line buprion

third line venlafaxine or MAO inhibitor

Term
When is ECT treatment be used?
Definition

treatment for refractory and depression with psychosis or catatonia.

Term
what is the best treatment for rapid cycling bipolar?
Definition

 

Antidepressant can contribute to rapid cycling and should be tapered if possible

Lithium or valproate or lamotrigine; combination therapy may be necessary

Term

What is the best maintenance therapy for bipolar?

***

Definition

 

Best (evidenced based)

Lithium

Valproate
Lamotrigine (depression relapse prevention)


Alternatives:

Lamotrigine

Carbamazepine or oxcarbazepine

ECT

Term

Lithium

Place in therapy

***

Definition

-First line in all patients diagnoses with bipolar disorder except for mixed episodes

-Clinical response onset is a week to 10 days

Term

How should lithium be dosed?

***

Definition

 

  1. Start low and titrate up based on blood levels. Typical starting dose 300mg BID-

    TID or 600mg sustained release QD. In elderly, start with 150mg BID.

Term

When should lithium blood levels be measured?

***

Definition

 

Blood concentration levels of lithium should be measured no sooner than 12 hours after last dose

 

Term

How is lithium secreted out of the bosy and what will affect elimination?

***

Definition

-Lithium is elminated by the kidneys; Renal dysfunction will decrease elimination and increase risk for toxicity.

-Dramatic changes in Na and fluid intake can change lithium levels

-Maintain good fluid intake.

-Hyponatremia and/or hypovolemia will decrease elimnation of lithium: thiazide diuretics, NSAIDS (including COX-2 inhibitors), ACeI, salt restricted diets

Term
Are the adverse reactions to lithium dose related?
Definition
yes
Term

Adverse toxicities of lithium include?

***

Definition

- Polyuria, polydipsia, weight gain, cognitive problems (dulling, mental slowness, poor concentration, confusion), fine hand tremor, sedation, impaired coordination.

-

 

 

Term

Adverse effects

Lithium

Hypothyroidism

Definition

 

  • (occurs in 5-35% of patients) o

  • Most frequent in women

    o Most typically occurs after 6-18 months of therapy o

  •  Not a reason to discontinue therapy with lithium
    o If present, treat with levothyroxine

Term
How can you minimize the adverse symptom of a tremor that is seen with the administration of lithium?
Definition

-minimize by titrating the dose slowly and by using divided doses or sustained release formulations

-treat by using a single daily dose (sustained release) at bedtime

-Use beta blockers if necessary

Term

What can happen with an overdose level of lithium?

***

Definition

N/V/D

Course tremor, ataxia, dysarthria

marked confusion

seizure, coma

Term

Lamotrogine

Bipolar

What does have a black box warning for?

Definition

increased risk with rash with combination therapy.

Term

Osteoporosis

Who does it affect?

What are the causes of primary and secondary?

Definition

-Most common skeletal disorder.

-Affects over 10 million Americans (80% women)

-Primary cause unknown

-Secondary cause (drugs and other diseases)

- Primary mostly in postmenopausal women.

-Secondary mostly in me and premenoponopausal women.

Term
What are general risk factors for Osteoporosis?
Definition

-Low bone density

-Current cigarette smoking

-Low body weight

-Advanced Age

-ETOH consumption >2 drinks per day

-Glucocorticoid Steroid therapy

-Female

-Osteoporotic fractures in first degree relative

-Caucasian ethnicity

-low physical activity

Term

What are drugs associated with causing Osteoporosis?

What is the main one?

******

Definition

-Anticonvulsants (Dilantin, Phenobarbital)

-Aromatose inhibitors

-Methotrexate

-Glucocorticoids (>5 mg prednisone per day for 3 months) decrease GI calcium absorption and increase calcium excretion. Systemic steroids, NOT inhaled

-Immunosuppresents

-Lithium

Term
Cortical bone
Definition
dense compact bone that gives bone strength (80% of skeleton)
Term
Trabecular Bone
Definition
sponge like, found on inner surface of long bones, vertbrae, ribs, pelvis
Term

bone remodeling

OSTEOCLASTS

Definition
BREAKDOWN BONE (breaks apart)
Term

bone remodeling

OSTEOBLASTS

Definition

FORM NEW BONE IN CAVITIES CREATED BY OSTEOCLASTS (puts down new bone)

Term
When is peak bone mass occur?
Definition
at 25-35 years old
Term
What is osteoporosis?
Definition
The imbalance between osteoblast and osteoclast activity.
Term
What occurs during menopause that causes increased osteoporosis?
Definition

decrease in estrogen level leading to increased bone remodeling (15% of bone loss in first 5 years and 1 % per year afterwards) Increased risk for fractures due to bone loss.

Term
When should screening start for osteoporosis?
Definition

-Women over 65 y/o

-Men over 70 y/o

-Individuals > 50 y/o with history of fracture, or secondary cause of OP

-FRAX- evaluates 10 year risk for hip or major osteoporosis fracture.

Term

What are the goals of therapy in osteoporosis?

 

Definition

-Preventing fractures

-Maintaining or increasing Bone Mineral Density (BMD)

-Preventing Bone Loss from secondary causes.

-Decreasing morbitdity and mortality

Term
What are modifable risk factors for osteoporosis?
Definition
Smoking, low calcium intake, poor nutrition, alcohol intake, physical inactivity.
Term
What are non-pharmalogical treatments for osteoporosis?
Definition

-Nutrition: dietary Ca and Vitamin D

-Exercise: weight bearing exercise

-Preventing of falls: avoiding medicaitons that affect change in mental status if possible (an tipsychotics, benzo, TCAs, sedative/hypnotics, anticholinergic and DIURETICS)

Term
How does calcium replacement help osteoporosis?
Definition
Decreases bone turnover, slows bone loss
Term
How does Vitamin D help osteoporosis?
Definition
Increases Calcium absorption
Term

What calcium supplement has the most calcium in it?

What is the lowest?

Definition

-Calcium Carbonate (40%) Os-Cal, Caltrate, Tums

Body can only absorb 500 mg at a time so never dose more that that. Need 1500 mg per day so dose TID.

-Calcium gluconate (9%)

Term

What is the only calcium preparation that should not be taken with food?

*****

 

Definition

Calcium Citrate: preferred salt for patient on agent that reduce stomach acid. Prefferred with a patient that is on a PPI (acid is reduced)

Term
What is an adverse side effect of Calcium replacement?
Definition
constipation, flatulence, bloating
Term

What are drug interactions with calcium replacement?

****

Definition

PPI, H2 blockers, iron, tetracycline, fluoroquinolones

JUST SEPERATE FROM CALCIUM, DON'T COADMINISTER

Term

BISPHOSPHONATES

Alendronate, ibandronate

What line of therapy are they and how do they work?

Definition
First line therapy; Binds to bone matrix and prevent osteoclast activity; increase bone mineral density 5-8% in lumbar spine and 3-6% in hip; decrease mortality related to hip fractures
Term

BISPHOSPHONATES

Alendronate, ibandronate

What are the adverse effects of Biophosphonates?

*****

Definition

-N/V/D (why injection is given once a week to reduce toxicity effects) esophageal irritation, dyspepsia, esophogeal reflux

-Influenza like symptoms with IV formulation

-Osteonecrosis of the Jaw: RARE Risk factors include chemo, corticosteroids, infection, pre-excisting dental disease

Term

BISPHOSPHONATES

Alendronate, ibandronate

What lab values do you want to get a baseline of as well as continue to monitor?

Definition

-Serum Cr

-alk phos

-phosphate

-Mg

-Ca, prior to IV administration

Term

BISPHOSPHONATES

Alendronate, ibandronate

What is a big administration factor you want to be sure you teach your patient before you administer this medication?

Definition

-Food and calcium supplements decrease PO absorption take 30-60 mins before first meal of the day with 6-8 oz of water. (very poorly absorbed)

-Sit upright for 30-60 min after PO administration (Large pills stuck in the esophagus can burn through wall).

-Swallow tablets whole

- Renally eliminated

Term

Selective Estrogen Receptor Modulators

(SERMs)

Raloxifene

How do they work?

Definition

-decrease bone resorption and turnover

-increase BMD and decreases fractures

Term

Selective Estrogen Receptor Modulators

(SERMs)

Raloxifene

What are the major adverse reactions?

*****

Definition

hot flashes, leg cramps, increase risk of VTE (Venous Thrombus Embolism)

Hx of VTE is contraindicated to use

Term

Is hormone therapy recommended for Osteoporosis?

*****

Definition

NO, not recommended for OP treatment alone

-HERS study found increase in VTE and Breast CA even though it does decrease fractures in postmenopausal women.

Term

osteoporosis

Calcitonin

how does it work?

Who may it help?

Definition

-Hormone that regulates calcium levels (Salmon is more potent and longer acting than mammalian)

-Binds to osteoclast receptors and inhibits bone resporption

-Decreases vertebral fractures

-May be helpful for patients with pain for vertebral fractures.

Term

osteoporosis

Calcitonin

How can it be administered?

What other benifit does it have other than helping with OP?

****

Definition

-Intranasal or SQ/IM: Intranasal preferred because of less toxicity

-Benefits from parenteral administration decrease over time (antibodies decrease form a decrease effectiveness overtime)

Term

osteoporosis

Teriprartide

How does it work?

how do you administer?

Definition

-recombinant human parathyroid hormone

-stimulates osteoblast activity.

- Increase BMD and decreases fractures

-Administer SQ daily

 

Term

osteoporosis

Teriparatide

What are the adverse effects?

*****

What is seen in aninimals but not yet in humans?

Definition

Nausea, headache, leg cramps, dizziness, injection site pain, hypercalcemia, orthostatic hypotension

-Osteosarcoma reported in animal studies, Report not seen in humans *Maxiumum durations recomended 2 years because No studies over that time period

Term

osteoporosis

What is the first line treatment for men?

Definition

Alendoronate and teriparatide approved for treatment of OP in men

Term
What is menopause?
Definition

the permanent cesation of menses; no menses dor at least 12 months to make a diagnosis; occurs between ages 40 and 58 naturally; perimenopause occurs 2-8 years before menopause; irregular mentrual cycles, longer cycle intervals, decreased length of menses, vasomotor symtoms.

Term
 What is the pathophsyiology on menopause?
Definition

-With age, ovarian follicles decrease.

-High levels of FSH, needed for follicles to mature and ovulation to occur

-During perimenopause, FSH concentrations can be higher during some cycles and low during others, leading to irregular menses.

-During menopause, estradiol, decreases 90% leading to an increase in FSH and LH secretion

-Symptoms associated with decreased estradiol concentrations. (hot flashes, night sweats, vaginal dryness, atrophy, mood swings, and insomnia)

Term
What is the goal of treatment for menopause?
Definition

-Goal of therapy is to decrease symptoms, improve quality of life, and minimize adverse effects.

- Most effective treatment for vasomotor symptoms and vulvovaginal atrophy is hormone therapy (estrogen therapy).

 

Term
In menopause what can reduce vasomotor symptoms?
Definition

Quit smoking

Limit alcohol and caffein intake

Limit hot beverage/spicy foods

Keep cool, dress in layers

Reduce stress

Increase exercise.

Urinary incontinence: kegel exercises

Term

Estrogen

how does it work in the treatment of menopause?

Definition

-Treats vasomotor symptoms and vulvovaginal atrophy

-use appropriate route, lowest dose, shortest duration

-can be used alone in patients with hysterectomy

Term

Estrogen

What are the different way to administer?

Definition

-topical route for vaginal symptoms

-Oral or tansdermal for vasomotr symptoms.

-Transdermal: lowerrisk of VTE, increasing TG, or liver functional abnormalities.

Term

What should be given with estrogen in women with an intact uterus to decrease the risk of endometrial hyperlasia/cancer?

*******

Definition

Progesterones

At lease 12-14 days of the month

Term
What are adverse effects of estrogens?
Definition

Nausea, headache, bloating, breast tenderness, bleeding,

Serious: CHD, stroke, VTE, breast cancer, gallbladder disease

Term
What are side effects of progesterones?
Definition

-Nausea, weight gain, headache, bleeding, irritability, depression

-Serious: VTE, decreased bone mineral denisity

Term

What are the contraindications for Estrogen and Progesterone Therapy?

*****

Definition

-CHD, or significant CHD risk farctors, Breast cancer, History or active VTE, pregnancy, liver disease, undiagnosed vaginal bleeding.

Term

Hormone Replacement Therapy

What was discovered in the HERS trial 1998?

Definition

-Study in women with established CHD

-Increased risk of CHD in 1st year of estrogen therapy

-Increased gallbladder disease

-Increased risk for VTE

Term

Hormone Replacement Therapy

Women's Health Initiative

(WHI) Study

What was discovered in this study?

Definition

-In women without CHD; ages 50-79 y/o with intact uterus; HRT vs. placebo for 8.5 years

-Stopped after 5.2 years (increased risk for breast cancer in HRT group)

-Nonsignificant increase in rish in CHD, stroke, VTE

-Decreased in fractures. (helps osteo)

(use short term 5 years or less)

Term

How should Hormone Replacement therapy be discontinued?

****

Definition

-Should be taperd to prevent recurrence of hot flashes

-May take 3-6 months to taper.

-Dose taper or day taper methods

-Should try to taper after 1 year.

-May need to reintiate if symptoms continue.

Term

Nonhormonal/ Alternative Therapy

What does SSRI's/venlafaxine help treat in menopause?

Definition

-Depression, anxiety, hot flashes.

Term

Nonhormonal/ Alternative Therapy

Phytoestrogens

Should these be used as first line treatment for menopause?

Definition

POOR DATA

-Similar to human estrogens

-Source is soy protein

- Measured by amount of isoflavone

-Should not be used in women with estrogen-dependent cancers.

Term

Nonhormonal/Alternative Therapy

Black Cohosh

Is there good data for treatment of menopause?

Definition

Just from reported improvement/no data

-Unknown mechanism

-Mild-moderate hot flashes

-Lack of good data, not recommended for use

Term

Nonhormonal/ Alternative Therapy

Gabapentin

How is this used for menopause?

Definition

-decrease severtiy and frequency of hot flashes

Term

Nonhormonal/Alternative Therapy

Clonidine

Is this a good treatment for menopause?

Definition

Decreased hot flashes

Good evidence, careful with hypotension

Term
What do you need to monitor in Nonhormonal/Alternative treatment in the treatment of menopause?
Definition

-Symptoms/QOL

-Hormonal therapy (Bleeding/spotting)

-Adverse effects

-Blood Pressure

-Breast Exams/mammograms

-BMD every 5 years

-TSH

Term
What does the thyroid hormone do in the body?
Definition

-regulates energy metabolism and functions in the development of fetal growth.

-T3 and T4 are produced by binding of iodine to tyrosine molecules on thyroglobulin (organification)

-Monoiodotyrosine (MIT) and diiodotyrosine (DIT) bind to form T3 and T4 (T3 has the activity)

Term

thyroid hormone production

What is the acting hormone?

Definition

-80% of thyroid hormone is T4

-majority of physiologic activity is from T3

-T4 is converted to T3 in peripheral tissues

-Hypothalamic-pituitary-thyroid-axis controls production and release of thyroid hormone

Term
Where is the problem ususally in thyroid problems?
Definition

the thyroid

Term
What diagnostic tests are done for thyroid?
Definition

TSH levels

Free T3 and T4 (thyroid hormone are highly protein bound)

Different antibodies can be measured in patients with autoimmune thyroid disorders.

Term
What are causes of primary hypothyroidism?
Definition

-Autoimmune thyroiditid (Hashimoto's disease)

-Drugs (amiodarone, iodides, sulfonlureas,lithium)

-Lithium inhibits release of thyroid hormones from the gland, may cause thyrotoxicosis if withdrawn in patients with hyperthyroidism

-Sulfonylureas inhibit thyroid organification

-Iodine deficiency

Term
What are the causes of Secondary Hypothyroidism?
Definition

-Pituitary Disease

-Hypothalmic Disease

Term
What are s/s of hypothyroidism?
Definition

-fatigue, depression, cold intolerance, dry skin, weight gain, bradycardia, nonpitting edema, hyporeflexia, constipation LOW ENERGY

Term

What is the treatment goal for hypothyroidism?

What is the hormone of choice?

****

Definition

-Goal: achieve euthroid state and alleviate symptoms.

-Synthetic-L-thyroxine (T4) is the drug of choise

-Preparations come in: T4 (L-thyroxine), T3 (liothyronine), T3/T4 combination (liotrix, Armor Thyroid)

Term
What is the main
Definition
Term
When the TSH is not in target range, how much do you increase the dose?
Definition
by 10-20%
Term

What is the half life of T4?

(thyroid replacement)

****

Definition
7-10 days; so it may take a month or so to get to steady state
Term

How should thyroid medication be dosed?

If a dose is missed again can they take the missed dose the next day?

Definition
Daily; yes, and can do this for a few days
Term

 When should you check TSH levels after initiation of thyroid therapy?

*****

Definition

6-8 weeks

Term

Thyroid Replacement therapy

When you swich administration methods, do you need to adjust the dose? (from Oral to parental)

****

Definition

decrease the dose by 50% or hold in short term discontinuation. Injection needs to prepared just before administration

*****

Term
What are adverse effects of thyroid replacement therapy?
Definition

hyperthyrodism

exacerbation of ischemic heart disease

transient hair loss

GI hypotility

Arrythmias

Term
What are patient related variables with thyroid replacement?
Definition

-Phenytoi and phenobarbital may increase clearance of T4

-Clearance of T4 decreases with age

-Cardiac disease and hyptertension.

Term
In hypothyroidism, what effect can it have on a pregnancy?
Definition
increases the risk for miscarriage and decreased learning ability of the child
Term
How should children be treated who have hypothyroidism?
Definition

-If identified as hypo, full replacement doses of thyroid hormone should be prescribed (dose replacement is based on age)

-Free T4 levels should be monitored and used for dose titration in INFANTS

Term
What is Myxedema Coma?
Definition

-Life threatening condition (60-70% mortality)

-severe, longstanding hypothyroidism

-300-500 mcg IV levothyroxine

-convert to full replacement dose of oral T4

 

Term

Hyperthyroidism

What are the causes?

 

Definition

Graves Disease (most common)

-Thyroid nodules or multinodular goiter [more common in elderly]

-thyroid cancer

-iodine excess

-excess thyroid hormone intake

-Drug induced (amiodarone, iodine, interfieron)

Term
What are signs and symptoms for hyperthyroidism?
Definition

Heat intolerance, weight loss, increased sweating, palpitaitons, tachycardia, diarrhea, warm moist skin, expothalamous, hyper-reflexia

Term
What is the goal of treatment in hyperthyroidism?
Definition

Goal: acieve and maintain clinical euthyroid state, control symptoms.

Therapy: Decrease hormone production (Pr opylythiouracil (PTU), methimazole, iodides

-Block hormone activity (beta adrenergic blockers)

-Chemical Destruction of gland: I (radiaoactive iodine)

Term

PTU and Methimazole

(Tx. of hyperthyroidism)

Which is first line treatment unless the patient is pregnant?

Definition

PTU: pregnant

Methimazole: everyone else

Term

PTU and Methimazole

(Tx. of hyperthyroidism)

What are some administration considerations that need to be made?

Definition

-Onset of action is slow since the gland may contain large amounts of stored hormone. Time to achieve a euthyroid state is 3-12 weeks.

-Initial doses are higher than maintenance doses.

-Initial doses have to be decreased after 4-6 weeks.

-Monitor T4 Serum Concentrations.

-May be tapered and stopped after 12-24 months

Term

PTU and Methimazole

(tx. in hyperthyroidism)

 What are adverse effects?

******

Definition

-Rarely agranulocytosis: may be present initially as a sore throat and a fever (reversible)

-hypothyroidism

-hypersensitivity: usually self limiting

Term

PTU and Methimazole

(tx. in hyperthyroidism)

What are patient related variables?

Pregnancy

******

Definition

-Pregnancy: although both drugs cross the placenta, PTU is preferred because it crosses to a lesser extent than MMI.

Term

tx. of hyperthyroidism

Iodides

How do they work?

Definition

-A daily thyroidal iodine uptake of 100 mcg is required for normal thyroid function.

-High amounts of iodine (>30 mg/day):

     -reduce iodine trapping by the gland

     -inhibit iodine organification

     -inhibit release of T3 and T4 from the gland

-Effects of high doses of iodine are short term

-Long term therapy leads to "escape" of these effects and hormone levels increase to higher than baseline.

Term

tx. of hyperthyroidism

What are some administration consideraitons?

What is important to be aware of?

*****

Definition

-Short term for sever hyperthyroidism.

-Preoperative preperation for Grave's patient.

-Onset of action is faster than PTU or MMI

-IMPORTANT NOTE: difference in concentrations. Lugol's solution. 6.3 mg/drop. SSKI's mg iodine/drop

Term

tx. for hyperthyroidism

How should iodine solution be administerd?

****

Definition

-Through a straw into the back of the mouth to avoid staining teeth

-Give flavored because it tastes terrible

-Discontinue 2-3 weeks prior to radioactive iodide. Decrease uptake of radioactive iodine into the thyroid gland.

Term

tx. of hyperthyroidism

Iodine

What are the adverse effects?

Definition

-Bitter taste, dental staining, and gastritis

-Fever, rash

-Iodine induced hyperthyroidism, severe headache

Term
What does "Radioactive Iodine" do to the thyroid?
Definition

-Concentration in the thyroid gland and leads to destruction of the gland

-Administration: Do not use in pregnancy;Do not administer other iodide 2-3 weeks prior.

-Adverse Effect: Hypothyroidism

Term
How do "beta adrenergic blockers" treat hyperthyroidism?
Definition

-Propranolol" inhibits concersion of T4 to T3.

-Blocks the adrenergic manifestations of hyperthyroidism.

E.g tremors, palpitations, excessive sweating.

- Mainly control symptoms and do not alter the disease.

Term
Before thyroid surgery for hyperthyroidism, what must the patient be?
Definition

euthyroid

Subtotal thyroidectomy for patients with goiters or thyroid cancers and those who do not respond to other therapy.

Term
What happens to pregnant women with Graves Disease?
Definition

Pregnancy may worsen hyperthyroidism

-B-hCg is a TSH agonist.

 

Neonates and perdiatric hyperthyroidism: neonates of mothers with Graves Disease may be hyperthyroid at birth.

PTU, methimazole, SSKI may be used to treat

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