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1. Bone is damaged
2. osteoclasts adhere to damaged surface
3. bone is dissolved leaving resoption pit
4. osteoclasts leave area
5. osteoblasts adhere to resoption pit and build new bone
vit D deficiency
high protein intake
excess phosphorus intake
How do bisphosphonates need to be taken
GI-N/V/D, gas, constipation, acid regurgitation, alter taste
esophageal ulcer, gastritis
osteonecrosis of the jaw
increases risk of a fib
histamine2 blocking agents
rule out common treatable disorders that can cause low bone density.
Serum Ca, albumin, Vit D, TSH, Creatinine
Vit D deficiency
Dual energy x-ray absorptiometry (DEXA)
before and one year after treatment
take first thing in morning on empty stomach
take with 8 oz water only
stay upright position after taking
take Ca or antacids at least one hour after
Prior to prescribing metformin, the provider should:
Draw a serum creatinine to assess renal function
Try the patient on insulin
Tell the patient to increase iodine intake
Have the patient stop taking any sulfonylurea to avoid dangerous drug interactions
Both men and women experience bone loss with aging. The bones most likely to demonstrate significant loss are:
Bisphosphonates treat or prevent osteoporosis by:
Inhibiting osteoclastic activity
Fostering bone resorption
Enhancing calcium uptake in bone
Strengthening the osteoclastic proton pump
Prophylactic use of bisphosphonates is recommended for patients with early osteopenia related to long-term use of which of the following drugs?
Selective estrogen receptor modulators
When given subcutaneously, NPH insulin begins to take effect (onset of action):
15 to 30 minutes after administration
60 to 90 minutes after administration
3 to 4 hours after administration
6 to 8 hours after administration
Hypoglycemia can result from the action of either insulin or an oral hypoglycemic. Signs and symptoms of hypoglycemia include:
“Fruity” breath odor and rapid respiration
Diarrhea, abdominal pain, weight loss, and hypertension
Dizziness, confusion, diaphoresis, and tachycardia
Easy bruising, palpitations, cardiac dysrhythmias, and coma
Nonselective beta blockers and alcohol create serious drug interactions with insulin because they:
Increase blood glucose levels
Produce unexplained diaphoresis
Interfere with the ability of the body to metabolize glucose
Mask the signs and symptoms of altered glucose levels
Lipro is an insulin analogue produced by recombinant DNA technology. Which of the following statements about this form of insulin is NOT true?
Optimal time of preprandial injection is 15 minutes.
Duration of action is increased when the dose is increased.
It is compatible with NPH insulin.
It has no pronounced peak
The decision may be made to switch from BID NPH insulin to insulin glargine to improve glycemia control throughout the day. If this is done:
The initial dose of glargine is reduced by 20% to avoid hypoglycemia
The initial dose of glargine is 2 to 10 Units per day
Patients who have been on high doses of NPH will need tests for insulin antibodies
Obese patients may require more than 100 Units per day
When blood glucose levels are difficult to control in Type 2 diabetes some form of insulin may be added to the treatment regimen to control blood glucose and limit complications risks. Which of the following statements are accurate based on research?
Premixed insulin analogues are better at lowering HbA1C and have less risk for hypoglycemia.
Premixed insulin analogues and the newer premixed insulins are associated with more weight gain than the oral antidiabetic agents.
Newer premixed insulins are better at lowering HbA1C and post-prandial glucose levels than are long-acting insulins.
Patients who are not controlled on oral agents and have post-prandial hyperglycemia can have NPH insulin added at bedtime.
Metformin is a primary choice of drug to treat hyperglycemia in Type 2 diabetes because it:
Substitutes for insulin usually secreted by the pancreas
Decreases glycogenolysis by the liver
Increases the release of insulin from beta cells
Decreases peripheral glucose utilization
The action of “gliptins” is different from other antidiabetic agents because they:
Have a low risk for hypoglycemia
Are not associated with weight gain
Close ATP-dependent potassium channels in the beta cell
Act on the incretin system to indirectly increase insulin production
Sitagliptin has been approved for:
Monotherapy in once daily doses
Combination therapy with metformin
Both A and B
Neither A nor B
Directly bind to a receptor in the pancreatic beta cell
Have been approved for monotherapy
Speed gastric emptying to decrease appetite
Can be given orally once daily
Avoid concurrent administration of exenatide with which of the following drugs?
All of the above
Administration of exenatide is by subcutaneous injection:
30 minutes prior to the morning meal
60 minutes prior to the morning and evening meal
15 minutes after the evening meal
60 minutes before each meal daily
Potentially fatal granulocytopenia has been associated with treatment of hyperthyroidism with propylthiouracil. Patients should be taught to report:
Tinnitus and decreased salivation
Fever and sore throat
Hypocalcemia and osteoporosis
Laryngeal edema and difficulty swallowing
Long-acting beta-agonists (LTBAs) received a Black Box warning from the U.S. Food and Drug Administration due to the:
Risk of life-threatening dermatological reactions
Increased incidence of cardiac events when LTBAs are used
Increased risk of asthma-related deaths when LTBAs are used
Risk for life-threatening alterations in electrolytes
Elderly patients who are started on levothyroxine for thyroid replacement should be monitored for:
Tachycardia and angina
increases storage of glucose as glycogen and resets the liver after food intake by reversing the amount of catabolic activity
same ummunogenicity, same binding method, same half-life,
onset of action is much shorter at 15min rather than 30 min of regular insulin
delayed by combining the insulin with protamine, proteolytic enzymes degrade the protamine in NPH to permit absortion
onset 1-1.5 hours
hepatic function impairment
decreased levels of consciousness
A drug interaction of
one month at room temp
and 3 month in fridge
blood glucose levels between 90-130 preprandial
blood glucose levels less than 180 postprandial
bedtime blood glucose levels at 100-140
HbA1c less than 7
type 2- every 6 mo
peripheral and GI neuropathies
it should be clear
do not use if it is cloudy, discolored, viscous
endogenous insulin secretion
second generation compounds are more nonpolar and lipophilic
first generation have ionic bonds and are more likely to be displaced from their binding sites by other drugs
usually dose related
swelling of LE
shortness of breath
type 2 DM
does not stimulate insulin release
does not produce hypoglycemia or hyperinsulinemia
1. renal ds
2. metabolic acidosis
using metformin with renal dysfunction
may result in altered renal function and have been associated with lactic acidosis
48 hours before and 48 hours after
cationic drugs-amiloride, digoxin, morphine, procainamide, quinidine, rantidine, triamterene, vanc
ActoPlus Met- metformin/pioglitazone
renal functions before treatment, then annually
daily to weekly BG
HbA1c every 3mo
Lactic acidosis is characterized by
inhibit alpha-glucosidase enzymes in the intestine
decrease the amount of glucose available for absorption in the GI tract
no they are used in adjunct to other therapy
because they do not act directly on any of the defects in metabolism seen in type 2
they do not enchance pancreatic beta cell secretion of insulin
they do not produce hypoglycemia
they are not associated with weight gain and diminish the weight gain effects of sulfonyureas
not absorbed systemic
metabolized by intestinal bacteria and digestive enzymes
inflammatory bowel, bowel obstruction, chronic intestinal ds
the usual tx with sucrose, fructose, or starches will not work because alpha-glucosidase inhibitors interferes with the absorption
Milk or lactose tablets cant be used
improve glycemic control by imporving insulin sensitivity.
They reduce hepatic glucose production
type 2 DM
because they rely on insulin for their action
calcium channel blockers
HMG-CoA reductase inhibitors
serum transaminase (ALT), if ALT is over 2.5 TDZ's will not be started
Once started tx ALT check every 12 mo
S&S of hepatocellular injury-N/V, abd pain, fatigue, anorexia, jaundice, dark urine needs to be reported
report immediately chest pain, SOB, peripheral edema
close ATP-dependent potassium channels in the beta cell membrane by binding at specific receptor sites.
leads to opening of calcium channels
leads to influx of calcium increases the secretion of insulin
they act on the incretin hormone system to have an indirect effect to increase insulin production.
inhibits dipeptidyl peptidase-4 (DDP-4)
increase in upper resp inf
Exenatide thigh, abdomen, upper arm 60 min before morning meal and evening meal. At least 6 hours apart
decrease amt of food
gradual weight loss
hypoglycemia only of pt taking with sulfonylurea
used to treat type 1 or 2 patients who are also on insulin
subq in thigh or abdomen, not arm
adm immediately before each major meal
increase absorption on empty stomach
met by liver highly protein bound
same effect as own body's hormones
produces the negative feedback loop to reduce further secretionnof TSH and thyroid hormones
coronary artery ds
concomitant diabetes insipidus
increased heart rate=increase O2 demand and decrease O2 supply
decreased bone density in hip and spine
TSH suppression in cancer
recheck every 4 months
for infant every 1-2 months
children every 3-6 months
teach pt to check pulse-if over 100 hold dose and call provider
notify provider if nervousness, chest pain, HTN, weight loss more than 2lb/1week
occurs when there is a breakdown in the feedback loop and the body's tissues are exposed to excessive levels of thyroid hormones
drug induced hepatitis
any drug that produces bone marrow depression
Acute overdoses of acetaminophen can cause potentially fatal liver damage. maximum recommended dose is 4 grams in 24 hours
reflex tachycardia = increasing myocardial O2 demand.
These CCBs only work on the vasculature and do not work on the heart
*not suitable for patients with low HDL levels
*Hypokalemia can predispose to dig toxicity
Dig = color vision disturbance
agranulocytosis; anca positive vasculitis; hepatotoxicity; and pancreatitis (rare).
Every four to eight weeks after the start of treatment for a change in dose. Once the adequate replacement dose has been established the test can be repeated after six and then 12 months unless there is a change in symptoms
Drug induced fever and other allergic responses are possible. Systemic lupus erythematosus can occur, which at the same time leads to polyarthralgia, myalgia, and pleurisy—most of these side effects may occur due to the aestivation of the drug.
Prevents formation of prostaglandins by binding COX-1
Inhibits platelet formation--causing the blood to thin and clot less
Lessens inflammatory response by binding COX-2
Induced ( normally not present in cells) – Built only in special cells (EX a549 lung cells) – Used for signaling pain and inflammation – Produces prostaglandins for inflammatory response – Stimulated only as part of immune response – Production is stimulated by inflammatory cytokines and growth factors. Attributes of COX 1 or 2?
Class I - patients may have symptoms of heart failure at levels that would produce symptoms in normal patients.
Class II - symptoms are more pronounced with ordinary exertion.
Class III - Patients may have symptoms of heart failure with less than ordinary exertion in
class IV- symptoms at rest.
1st line - ACE inhibitor, BB, w/ or w/o diuretic
2nd line - ACE inhibitor, diuretic, digoxin (which is what we think of in preventing HF
3rd line - ACE inhibitor, BB, diuretic, and digoxin.
first in it's class
start w/ 6.25 mg- 12.5 mg TID. Therapeutic range of 25-100 mg TID
Patients w/ fatigue or mild dyspnea are treated with ACE inhibitors alone or w/ diuretics.
cough, hypotension, diminished taste, leukopenia, angioedema, neutropenia, granular cytosis.
Contraindicated in pregnancy, renal artery stenosis, and unilateral stenosis.
BUN, creatinine, K and Na.
Assess response in 1-2 weeks.
Assess for azotemia, hypernatremia, and patients w/ DM should be monitored closely.
Spironolactone or triamterene.
promotes small diuresis.
lower chance of dig dysrhythmia.
ADR - hyperkalemia
maintains a blockade of the circulating and tissue renin-angiotensin-aldosterone system.
Only used in pt's who can't tolerate ACE inhibitors
ADR - hypotension, hyponatremia, hypokalemia, hypovolemia.
Steady state that is reached in 1 week w/ normal renal function. 2-3 weeks w/ renal impairment.
Assess dig level, lytes, and BUN/creatinine.
0.25 mg in elderly
0.125mg in impaired renal function.
to ensure serum level is 0.9-1.2 ng/ml
Isosorbide mononitrate BID 20 mg in AM and afternoon
XR - 30-60 mg Q AM
What condition most likely occurs ina emphysema patient who is experiencing dyspnea?