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30 Cards in this Set

  • Front
  • Back
HbA1c
1. How is it created?
2. What is the target?
3. Name 4 ways to control glucose.
4. Name 8 negative side effects seen when HbA1c is above 7%.
1. Excess glucose leads to a shift of glucose from the glycolytic pathway to the minor Sorbitol, Hexosamine and glycation pathways, leading to the production of Oxidative end-products and the oxidation of HbA.

2. 7%

3. Weight control, exercise, oral antihypoglycemics and insulin.

4. Pancreatic B-cell dysfuntion, atherosclerosis, retinopathy, nephropathy, neuropathy, CAD, CHF and MI.
Gabapentin
1. Mech of Action
2. Uses
3. Doses
4. SE
1. GABA analog - inhibits pain signals

2. Excellent in chronic pain, post-herpetic neuralgia, diabetic neuropathy. Very good when combined with an opiate in chronic pain.

3. 900-3600mg divided bid or tid. Start with 100mg bid and titrate up.

4. Dizziness, somnolescence, confusion
Lyrica (Pregabalin)
1. Mech of Action
2. Uses
3. Doses
4. Side effects
4. Doses
1. Analog of GABA - inhibits pain signals

2. Chronic pain, fibromyalgia, post-herpetic pain, diabetic neuropathy, epilepsy

3. 150mg/day divided bid-tid. max of 300mg for pain, 600mg for epilepsy.

4. Dizziness, somnolescence, blurred vision, euphoria
Codeine
1. Mech of Action
2. Uses
3. Doses
See OCM Pain Management
Nortriptyline
1. MOA
2. Uses
3. Doses
4. SE
5. Contraindications
1. TCA - inhibits re-uptake of serotonin and norepinephrine

2. Depression, anxiety, migraines, fibromyalgia, chronic pain and neuropathic pain.

3. 10-25mg po qhs

4. Dry mouth, sedation, orthostatic hypotension, prolonged QTc, constipation.

5. Prolonged QT syndrome, SSRIs.
Describe your approach to the management of pain considering the WHO step-ladder approach.
Step 1 - Acetominophen, ASA, Ibuprofen, NSAIDs, TCAs (Nortriptylene), Gabapentin, Pregablin

Step 2 - Codeine, Tramadol

Step 3 - Morphine and it's Derivatives plus Step 1.
Tramadol
1. Classification
2. MOA (2)
3. Uses (2)
4. Advantages (2)
5. SE (6)
6. Doses
1. synthetic analog of codeine.

2. possesses agonist actions at the μ-opioid receptor and effects reuptake at the noradrenergic and serotonergic systems.

3. Moderate to severe pain
- neuropathic and nociceptive

4. Less respiratory depression, decreased addictive potential

5. nausea, vomiting, sweating and constipation. Drowsiness and decreases the seizure threshold. Dependence and withdrawal with prolonged use. Increased risk of Serotonin Syndrome when combined with SSRI.
6. 75-200mg/d divided bid-tid
Give 5 common triggers of DKA.
DKA can be triggered by infection, ischemia, infarction, intoxication, medication non-compliance
Give 2 risk factors for Type 1 Diabetes and 5 for Type 2 Diabetes.
Type 1 DM:
personal history of autoimmune disease, family history

Type 2 DM:
first degree relative with DM
age >40 years
obesity (especially abdominal), hypertension, hyperlipidemia, coronary artery disease, vascular disease, prior GDM, macrosomic baby (>4 kg)
PCOS
history of IGT or IFG
presence of complications associated with diabetes

both:
member of a high risk population (e.g. Aboriginal, Hispanic, Asian or African descent)
Criteria for Diabetes - give 4.
One of the following on 2 occasions:

1. Random BG >11.1 mmol/L (200 mg/dL) with symptoms of DM (fatigue, polyuria, polydipsia, unexplained weight loss) OR

2. Fasting BG >7.0 mmol/L (126 mg/dL) OR

3. BG 2 hours post 75 g OGTT >11.1 mmol/L (200 mg/dL) OR

4. HbA1c >7% or 0.07
Who should be screened for diabetes?
1. Mass screening for Type 2 DM is not recommended

2. test FBG in everyone >40 q3 yrs

3. more frequent and/or earlier testing if: presence of >1 risk factor (as previously listed) and all pregnant women
How should pregnant women be tested for diabetes?
all pregnant women between 24-28 weeks gestation

1. non-fasting 1 hr 50 g OGCT >10.3 mmol/L (186 mg/dL) is diagnostic

2. if between 7.8-10.2 mmol/L (141-184 mg/dL) do confirmatory fasting 2 hr 75 g OGTT
What is the risk of diabetes in a woman who has had GDM?
if develop GDM, have a 50% chance of developing Type 2 DM over 20 years
Describe a sliding scale for an insulin the following types of diabetics:

1. Insulin Naive (Low Resistance)
2. High levels of insulin resistance
What are the goals of diabestes management with respoect to:

1. fasting or preprandial glucose
2. 2 hours postprandial glucose
3. HbA1c
4. blood pressure
5. lipids
1. fasting or preprandial glucose
a. ideal: 4-6 mmol/L (72-108 mg/dL)
b. recommended: 4-7 mmol/L (72-126 mg/dL)

2. 2 hours postprandial glucose
ideal: 5-8 mmol/L (90-144 mg/dL)
recommended: 5-10 mmol/L (90-180 mg/dL)

3. HbA1c
ideal: <0.06
recommended: <0.07
suboptimal: 0.07-0.084
inadequate: >0.084

4. blood pressure:
adults: <130/80 (DM and HTN guidelines)

5. lipids
LDL cholesterol <2.0 mmol/L
triglyceride <1.5 mmol/L
total cholesterol/HDL ratio <4.0
1. Describe how you would use HbA1c to tailor your treatment plan in newly diagnosed diabetes.

2. Describe the 6 Step treatment plan.
Starting Treatment with Oral Hypoglycemics:

HbA1c 7-9% --> encourage dietary, exercise changes and follow closely for several weeks, broach topic of metformin

HbA1c >9% --> start treatment immediately

HbA1c >11% --> start insulin immediately


STEP-WISE Approach to Diabetes Management

Step 1 - If HbA1c <9% encourage dietary, exercise changes and follow closely for several weeks, broach topic of metformin

Step 2 - If HbA1c >7% despite Step 1 or HbA1c >9% --> Metformin 250mg od --> bid --> 500mg bid --> 2500mg bid

Step 3 - Add rosiglitazone (Avandia 2-8mg od) OR d/c Metformin and switch to insulin secreteagogue - sulfonylureas:
glyburide (2.5-5mg od) or gliclazide (40-160mg divided bid)

Step 4 - Add Alpha-glucosidase inhibitor - acarbose (Glucobay 25 mg OD titrated
to 100 mg tid)

Step 5 - Add NPH Insulin 5U qhs with Metformin, d/c other meds. Titrate up Metformin qhs until HbA1c <7%

Step 6 - Add Insulin after each meal and d/c Metformin
Metformin
1. Class of Medication
2. Mechanism of Action
3. Doses
4. Contraindications
5. SE
6. Effectiveness
1. Biguanid
2. • sensitizes peripheral tissues to insulin ––> increases glucose uptake
• decreases hepatic glucose production

3. Start 250 od --> bid --> 500mg bid. Max dose 2500mg.

4. ABSOLUTE:
• moderate to severe liver . dysfunction
• mild renal dysfunction
• cardiac dysfunction

5. SE
• GI upset (abdo discomfort bloating, diarrhea)
• lactic acidosis
• anorexia

6. decreased HbA1C 1.0-1.5%
How does Warfarin work?

2. How long does it take to work?

3. How do you manage the delay in warfarin effect?
1. nhibition of the vitamin K-dependent gamma-carboxylation of coagulation factors II, VII, IX, and X, is delayed until the normal clotting factors are cleared from the circulation;

2. the peak effect does not occur until 36 to 72 hours after drug administration. During the first few days of warfarin therapy, prolongation of the prothrombin time (INR) mainly reflects the depression of factor VII, which has a half-life of five to seven hours (show figure 1). This does not represent adequate anticoagulation because the intrinsic clotting pathway remains intact until factors II, IX and X are sufficiently reduced, which takes about five days with adequate dosing.

3. heparin and warfarin treatment should overlap by four to five days when warfarin is initiated in patients with thrombotic disease
1. How does heparin work?

2. How about LMW Heparin? ie. enoxaparin, tinzaparin.
Heparin is an indirect thrombin inhibitor which complexes with antithrombin (AT, formerly known as AT III), converting this circulating cofactor from a slow to a rapid inactivator of thrombin, factor Xa, and to a lesser extent, factors XIIa, XIa, and IXa [1,3]. The binding of heparin to the heparin binding site on AT produces a conformational change in AT, accelerating the inactivating function of AT 1000- to 4000-fold [4,6].
Give 5 advantages of LMW Heparin over unfractionated heparin.
* They have greater bioavailability when given by subcutaneous injection.

* The duration of the anticoagulant effect is greater because of reduced binding to macrophages and endothelial cells, permitting administration only once or twice daily.

* The anticoagulant response (anti-Xa activity) to LMW heparin is highly correlated with body weight, permitting administration of a fixed dose. However, the dose may have to be adjusted for patients who are extremely obese or have renal failure (see "Special patient groups" below) [1].

* Laboratory monitoring is not necessary in nonpregnant patients; in fact, there is little correlation between anti-Xa activity and either bleeding or recurrent thrombosis.

* They are much less likely to induce immune-mediated thrombocytopenia than unfractionated heparin: 0 versus 2.7 percent in one study [64].

* They do not increase osteoclast number and activity as much as unfractionated heparin, and may therefore produce less bone loss [65,66].

* LMW heparin can be safely administered in the outpatient setting
How can you reverse heparin overdosing?
Protamine sulfate should be titrated up until bleeding stops and aPTT returns to therapeutic levels.

Protamine is less effective with LMWH.
How do you monitor therapeutic heparin levels?
1. Only in the hospital setting and much poorer effect than LMWH.

2. Monitor aPTT - take aPTT 4-6 hours prior to a dose, and 4-6 hours after a dose.
Give 7 risk factors for VTE (DVT & PE).
1. pregnant patients
2. deficiency of antithrombin,
3. protein C,
4. or protein S;
5. the lupus anticoagulant;
6. cancer
7. OCP
8. Surgery
9. Prolonged sitting/bedrest
1. How should you treat a first episode of IDIOPATHIC VTE (DVT or PE

2. How long?
1. LMW Heparin as soon as you have a strong clinical suspicion and promptly start Warfarin (coumadin) with a minimum of 5 days overlap until INR is 2-3.

2. For a patient with a first episode of idiopathic VTE, we recommend anticoagulation for a minimum of three months (Grade 1A). Following this time, and periodically thereafter, all patients should be evaluated for the risk/benefit ratio of long-term anticoagulation.

* For patients with a first unprovoked proximal VTE, we suggest indefinite treatment (eg, >12 months) over treatment for a lesser period of time (Grade 2A).

Patient values and preferences, bleeding risks, and the ability to achieve good anticoagulation monitoring factor heavily into this decision. Thus, for patients with a first unprovoked proximal VTE, no risk factors for bleeding, for whom good anticoagulant monitoring is achievable, and who place a higher value on prevention of recurrent VTE and a lower value on the burdens and risks of long-term anticoagulation, the 2008 ACCP Guidelines have given a strong recommendation for indefinite treatment (Grade 1A) [128].

However, many patients will not fit this pattern, and the appropriate length of treatment for them is unclear. (See "Length of treatment" above and see "Therapeutic use of warfarin", section on Bleeding for additional guidance on this issue).
How do Heparin and LMWH work?
Essential Thrombocytothemia
1. Cause (2)
2. Dx (3)
3. Symptoms
4. Tx of Chronic disease (2)
5. Tx of Acute Thrombosis (3)
1. JAK2 mutation (50%) or may be early PCV or prefibrotic myeloproliferative disorder

2. Platelet count >450, +JAK2 mutation, no other cancer or PCV.

3. Symptoms
a. Thrombosis - DVT, PE
b. Hemorrhage - dysfunctional platelets
c. Budd-Chiari syndrome

4. Tx
a. Asymptomatic - Tx if platelets >1000
b. Symptomatic - Hydroxyurea 1st line (anagrelide, aspirin, dipyridamole all 2nd line).
c. Heparin, Warfarin - then Hydroxyurea
Give 6 causes of Thrombocytosis.
Causes
1. Infection
2. Exercise & Dehydration
3. MI
4. Cancer
5. Autoimmune disease
6. Essential Thrombocythemia (50% due to JAK2 mutation) - seen with PCV.
Who should receive the first wave of the H1N1 influenza vaccine?
1. 5 target groups (approximately 159 million persons nationally):

* Pregnant women
* Household and caregiver contacts of children younger than 6 months of age (e.g. parents, siblings, and daycare providers)
* Health care and emergency medical services personnel
* Persons from 6 months through 24 years of age
* Persons aged 25 through 64 years who have medical conditions associated with a higher risk of influenza complications

Then the second round will be to all those between 25-64
How many H1N1 shots does a person need?
For 2009 H1N1 monovalent vaccines, that means that clinicians should administer two doses of 2009 H1N1 monovalent vaccine to children 6 months through 9 years of age. Persons 10 years and older should receive one dose.
Give 5 symptoms of influenza (H1N1).
Fever or feverishness
Cough or sore throat
chills, body aches/muscle pain, headache, fatigue, runny nose, and occasionally diarrhea and vomiting