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Diabetes, Thyroid, and GI Study Guide

Review combinations insulins (70/30), etc: page 668 Humulin 70/30, Novolin: 70% NPH, 30% regular insulin Humulin 50/50: 50% NPH insulin, 50% regular insulin Novolog Mix 70/30: 70% insulin aspart protamine, 30% insulin aspart Humalog Mix 75/25: 75% insulin lispro protamine, 25% insulin lispro Of the 3 long acting insulins in current use, only NPH insulin is appropriate for mixing with short acting insulins (ie, regular, lispro, aspart, and glulisine insulins). When a mixture is prepared, the short acting insulin should be drawn into the syringe first. Draw clear BEFORE cloudy. NPH is cloudy. Regular insulin Short duration, slower acting, usually mixed with NPH, clear, 15-30 minutes before meal. Humulin R, Novolin R, U-100 or U 500 Management of ketoacidosis: page 682 Severe manifestation of insulin deficiency, characterized by hyperglycemia, production of ketoacids, hemoconcentration, acidosis, and coma. Symptoms evolve quickly, over several hours to a few days. Brought on by derangements of glucose and fat metabolism. Altered glucose causes hyperglycemia, water loss, and hemoconcentration. See page 682 Treatment is directed at correcting hyperglycemia and acidosis, replacing lost water and sodium, and normalizing potassium balance. We begin IV fluids and electrolytes, followed ASAP by IV insulin. Although it might seem reasonable to drive glucose levels down quickly with lots of insulin, doing so is unsafe and should be avoided. Instead, reduce slowly by about 50 mg/dL/hr. (insulin is a hormone. Think of it as the key to let the glucose or sugar in the blood into the cells that need glucose.) -insulin replacement -bicarbonate for acidosis -water and sodium replacement -potassium replacement -normalization of glucose levels

BS checks in a pregnant diabetic patient page 660 Blood glucose levels must be monitored 6-7 times per day. Insulin and food must be adjested accordingly. Management of diabetes during pregnancy is a challenge. -the placenta produces hormones that antagonize insulins actions. -production of cortisol, a hormone that promotes hyperglycemia, increases threefold during pregnancy, increasing the need for insulin. -because glucose can pass freely from the maternal circulation to the fetal circulation, hyperglycemia in the mom will stimulate insulin production in the fetus, possibly resulting in hyperinsulinemia, which can have adverse effects on the fetus.

HgbA1c page 663 Measurement of glycosylated hemoglobin provides an index of average glucose levels over the prior 2-3 months. Measure every 3-6 months to get a long term picture of glycemic control. Mixing insulins Glargine/Lantus page 667 Long duration. Low solubility Releases in small amounts over an extended time. In contrast with other ong acting insulins (NPH or detemir), whose blood levels rise to a distinct peak then fall to a trough, insulin glargine achieves blood levels that are relatively steady over 24 hours. Thus, less risk of hypoglycemia or hyperglycemia. Supplied as a clear solution in 10ml vials containing 100 units/ml and in 3ml cartriges for use in an OptiClick Pen. DO NOT MIX; DO NOT GIVE IV IV insulin page 669 IV infusion is reserved for emergencies that require a rapid reduction in blood glucose. 3 short acting insulins may be used: -insulin aspart (Novolog) -insulin lispro (Humalog) -insulin glulisine (Apidra)

Including regular insulin, all should be diluted to a concentration of 0.05 to 1 unit/ml. Which insulins are cloudy? Clear? NPH is the only cloudy. The rest are clear. Use of beta blocker with diabetic medications page 684 Beta blockers can delay awareness of hypoglycemia by making hypoglycemia-induced signs that are caused by activation of the sympathetic nervous system, such as tachycardia and palpatations. In addition, beta blockers can inhibit the breakdown of glycogen to glucose, and can impede glucose replenishment. Metformin-which labs to monitor page 684 and slides Metformin (a biguanide) decreases glucose production by the liver and increases glucose uptake by thhe muscle. In patients who need to lose weight, metformin can also help by reducing appetite. Major adverse effects are GI disturbances: decreased appetite, nausea, and diarrhea. Does NOT cause hypoglycemia. Rarely, metformin causes lactic acidosis, which can be fatal. This risk is increased by renal impairment, which decreases metformin excretion and thereby causes levels to rise rapidly. Glitizonescontraindications page 677 Most prominent side effect is renal retention of fluid, which results in edema and weight gain. Not a big deal for most patients, BUT For patients with heart failure, fluid retention can make symptoms worse. Use with caution in patients with mild heart failure and DO NOT use in patients with severe heart failure. Can cause liver injury, so watch ALT. Tx for H pylori page 917 Antibiotics. For PUD, use -antibiotics to eradicate H pylori, -use an antisecretory agent (misoprotisol or antacid) to reduce gastric acidity and -enhance mucosal defenses (sucralfate and misoprostol)

Antibiotics: Amoxicillin (Amoxil)

Bismuth (Pepto-Bismol) Clarithromycin (Biaxin) Metronidazole (Flagyl) Tetracycline (Achromycin V) Tinidazole (Tindamax) Metronidazole page 918 Very effective against sensitive strains of H pylori. Over 40% of strains are now resistant. Most common side effects are nausea and headache. Avoid alcohol, do not take if pregnant. SE tagament page 919 Cimetidine reduces volume of gastric juices and its hydrogen ion concentration. It suppresses basal acid secretion and secretion stimulated by gastrin and acetylcholine. Produces selective blockade of H2 receptors, cannot reduce symptoms of allergy. Orally, IV or IM. Therapeutic uses: Gastric/ Duodenal ulcers GERD Zollinger Ellison Syndrome Aspiration Pneumonitis Heartburn/ acid/ sour stomach Adverse effects: Antiandrogenic effects: gynecomastia, reduces libido, impotence CNS effects: likely in elderly patients or those with renal or hepatic impairments. Hallucination, confusion, lethargy, excitation or seizures. Pneumonia, colonization of bacteria in gut because of gastric acidity reduction. Carafate page 923 (Sucralfate) Sticky gel that adheres to the ulcer crater, creating a barrier. Promotes duodenal ulcer healing by creating a protective barrier against acid and pepsin. NO acid neutralizing capacity, does not decrease acid secretion. Can cause constipation.

Enoxaparin (Lovenox) page 601 Low Molecular Weight Heparin Anticoagulant Expensive compared to unfractionated heparin. Therapeutic uses: -Prevention of DVT following abdominal surgery, hip or knee replacement -treatment of established DVT, with or without PE -prevention of ischemic complications in patients with unstable angina or MI

INR values page 605 (see description under table 51-3) Anticoagulant effects are evaluated by monitoring PT, or prothrombin time, a coagulation test that is especially sensitive to alterations in Vitamin K dependent factors. Average pretreatment value for PT is 12 seconds. Use with warfarin, Coumadin Protamine sulfate page 600 Antidote to severe heparin overdose. Protamine is a small protein. Bonds with heparin. Forms a complex devoid of anti-coagulant activity. Lasts for 2 hours, administered slow IV. The objective of anticoagulant therapy is to reduce anti-coagulant activity to a level that is low enough to prevent thrombosis, but not so low as to promote spontaneous bleeding. Do aPTT test, activated partial thromboplastin time. Normal value is 40 seconds. At therapeutic levels, heparin increases the aPTT by a factor of 1.5 to a 2, making the aPTT 60 to 80 seconds. FYI: (page 608 has difference between warfarin and heparin) Sx of DVT Half of all DVT cases cause no symptoms. If you do have any of the DVT symptoms below -especially if they occur suddenly -- call your doctor right away: Swelling in one or both legs Pain or tenderness in one or both legs, which may occur only while standing or walking Warmth in the skin of the affected leg Red or discolored skin in the affected leg Visible surface veins Leg fatigue If a blood clot breaks free and travels to your lungs it's called a pulmonary embolism, and it can be fatal. Pulmonary embolism may not cause symptoms, but if you ever suffer sudden

coughing, which may bring up blood; sharp chest pain; rapid breathing or shortness of breath; or severe lightheadedness, call 911 or go to an emergency room immediately. Low molecular weight heparins page 601 LMW heparins are simply heparin preparations composed of molecules that are shorter than those found in unfractionated heparin. LMW heparins are as effective as unfractionated heparins and easier to use BECAUSE LMW heparins can be given on a fixed dose schedule and dont require aPTT monitoring. They can be used at home; where as unfractionated heparin must be given in a hospital. Thus, LMW heparins are now considered first-line therapy for prevention and treatment of DVT. 3 available: -enoxaparin (Lovanox) -dalteparin (Fragmin) -tinzaparin (Innohep) Side effects of heparin therapy page 602 Bleeding is the major adverse effect. However, the incidence of bleeding complications is less than with unfractionated heparin. Despite this, LMW heparins are considered safe for outpatient use. Like unfractionated heparin, LMW heparins can cause IMMUNE MEDIATED THROMBOCYTOPENIA. Can be treated with protamine sulfate. Like unfravtionated heparin, LMW heparins can cause severe neurologic injury, including permanent paralysis, when given to patients undergoing spinal puncture or spinal or epidural anesthesia. Risk of harm is increased by concurrent use of anti-platelet drugs, such as aspirin or warfarin. Transdermal nitrates Nitroglycerinside effects, how to administer Calcium channel blockers in patients with angina

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