exam 3 patho

HHS

type 1 DM

autoimmune destruction of b-cells leading to insulin deficiency

type 2 DM

progressive insulin resistance and impaired insulin secretion

DKA

acute metabolic complication of hyperglycemia, ketosis (fruity breath), and metabolic acidosis (low pH)

missed insulin dose, can lead to coma or death

hypoglycemia

<70 mg/dL, dizziness, sweating, confusion, and potential unconsciousness (give glucagon IM)

priority in pediatric diabetes

HbA1C

measures long-term blood glucose control over 2-3 months (long term control)

normal: below 5.7% pre diabetes: 5.7-6.4% diabetic: above 6.5%

diagnostic criteria for diabetes

fasting glucose >126 mg/dL, HbA1C >6.5%, 2-hour OGTT >200mg/dL, random glucose >200 mg/dL + symptoms (3p’s)

oral hypoglycemia

metformin: decreases glucose absorption, contraindicated with contrast dye, causes metallic taste

sulfonylureas (glipizide): stimulate insulin release but risk hypoglycemia

alpha-glucosidase inhibitors (acarbose): delays carbohydrate absorption

insulin

aspart (rapid): taken before meals; risk for hypoglycemia

regular: only IV insulin for DKA

GLP-1 agonists (semaglutide)

enhance insulin secretion, reduce glucagon, slow gastric emptying, increase satiety

chronic complications

peripheral neuropathy, cardiovascular disease, renal failure, infections

DKA v Hyperosmolar Hyperglycemic State (HHS)

DKA: fruity breath, acidosis, ketonuria (breaks down ketones)

HHS: severe hyperglycemia without ketosis, normal pH

hyperthyroidism

graves’ disease; excess thyroid hormones; increased HR, heat intolerance

antithyroid drugs watch for low platelets

hypothyroidism

low thyroid hormones requiring replacement therapy; fatigue, drowsiness, constipation

goiter

thyroid enlargement d/t iodine deficiency or hormone imbalance

avoid iodine with thyroid cancer

elevated TSH levels

TSH and Free T4 Levels

directly monitors thyroid function and therapy

levothyroxine

treat hypothyroidism, take on empty stomach in morning, adjust dosage if s/s persist

emergency IV- 0.1 mg = 100 mcg

overdose s/s: palpitations, angina

methimazole

treats hyperthyroidism, effective if symptoms improve

overdose s/s: palpitations, angina

cushing’s syndrome

excess cortisol, leading to moon face, truncal obesity, and hypokalemia

s/s: high cortisol, hypokalemia, hypernatremia

osliodostat- synthesis inhibitor

addison’s disease

adrenal insufficiency requiring steroid replacement

s/s: hypotension, fatigue, hyperpigmentation

fludrocortisone + prednisone for treatment

corticosteroids

prednisone take in morning to reduce adrenal suppression, monitor for hyperglycemia and sodium retention, IV stress-dosed steroids

long term slows wound healing

SIADH

excessive ADH leading to concentrated urine and hypertension

DI treatment

decreased thirst

desmopressin effectiveness

increased urine concentration, decreased thirst

DDAVP: synthetic ADH used for DI

post-op respiratory risk

morphine induced apnea may lead to hypercapnia (excessive Co2 in blood)

pancreatitis and ARDS risk

severe hypoxemia, tachypnea

neuroendocrine system

CNS/hypothalamus controls pituitary gland

posterior: ADH, oxytocin

anterior: ACTH, FSH, GH, LH, PH, TSH

pituitary hormones visual

anterior drugs

cosyntropin- used in diagnosis of adrenocortical insufficiency

somatropin

octreotide

octreotide

alleviate s/s w/ carcinoid tumors from VIP secretion (diarrhea, flushing, hypotension), treats esophageal varices, may affect glucose reg. (severe hypoglycemia with type 1, hyperglycemia with type 2 or pt w/o diabetes), may enhance toxic effects of drugs that prolong QT interval

given IV/IM/SQ

may order EEG (AE of conduction abnormalities), baseline glucose levels, liver and kidney tests monitoring

somatropin

human GH produced by recombinant technology (hypopituitary dwarfism, wasting/weight loss with HIV)

important to not shake product, SQ or IM

monitor growth, motor skills, height, weight of pediatric pt

AE: headache, muscle pain, hyperglycemia, hypothyroidism, hypercalciuria, fluidlike syndrome

posterior drugs

vasopressin, desmopressin

both control polyuria, polydipsia, and dehydration in DI pt (deficiency of ADH), both can be given nasally

AE: high BP, fever, headache, abd cramps, nausea

desmopressin

can treat bleeding (gastrointestinal hemorrhage), hemophilia A, & type I von willebrand disease (d/t clotting factors), + nocturnal enuresis, clotting factors

available as DDVAP rhinal tube, can be given IV (mix, may change nasal mucosa)

assess VS, hx of asthma, seizure, or cardiovascular disease, neuro status, breath sounds, heart sounds

AE:

vasopressin

controls pulsess arrest and vasodilatory shock (more for blood pressure), watch for s/s of infiltration

caution with seizure disorders, asthma, cardiovascular disease, renal disease

applies topically to nasal membranes (not inhaled), IM, IV (check clarity)

EEG monitoring, VS, invasive monitering (arterial lines, central venous pressure lines, ABGs)

AE: high BP, fever, nausea, abdominal cramping

pituitary drug assessment

weight, height, VS, pregnancy status, medication hx, allergies to prescriptions, OTC, supplements, and herbals

GH: baseline thyroid, glucose, calcium levels (potential hyperglycemia, hypothyroidism, hypercalcemia)

adrenal system

sits on top kidney, cortex (hormone driven; corticosteroids), adrenal medulla (hormone and peripheral autonomic nerve impulse driven; catecholamines)

corticosteroids

not stored by body, synthesized as needed, reg. by HPA axis, negative feedback

cushings- fat in face, shoulders, trunk, and abd (moon face, humpback), hirsutism, ecchymoses, HTN, hypokalemia, abnormal glucose tolerance, muscle atrophy

addisons- decreased blood sodium and glucose, increase K, dehydration, weight loss

adrenal drugs

steroids, synthesizes specific proteins, most modify enzyme activity

glucocorticoids- inhibit inflam. response, lowers fever, stimulates WBC, increase glucose, protein break down, lipolysis, demineralization, mast cell stabilization

indications of adrenal drugs

nasal- rhinitis, prevents polyps

topical- inflam. management on skin

oral- most common prednisone, followed by dexamethasone

methylprednisolone- injectable glucocorticoid followed by hydrocortisone and dexamethasone

bethmethasone- accelerate fetal lung maturation (premature)

contraindications of adrenal drugs

glaucoma, peptic ulcer disease, mental health

caution with diabetes, infection, gastritis or reflux (gastric perforation risk), cardiac, renal, and/or liver disfunct. (alteration in elimination)

AE of adrenal drugs

interactions of adrenal drugs

non-K sparing diuretics (thiazides, loop), aspirin + NSAIDs, anticholinesterase

adrenal drugs ADPIE

asses nutrition, hydration, immune status, baseline weight and labs, I/O, VS, skin

implement early (6-9a), avoid infection, monitor assessments ^, call HCP for edema, SOB, joint paint, fever, mood swings, prednisone + fludrocortisone orally w. snack, avoid abrupt withdrawal, inhaled risk of fungal infection

AE: weight gain, HTN, Na increase, K loss, MS changes, abd distention, ulcer s/s, vision changes

thyroid

T4, T3 (needs iodine from diet, released by TSH), calcitonin

parathyroid

maintain calcium in ECF

hypothyroidism

s/s: cold intolerance, weight gain, depression, dry brittle hair and nails, fatigue

primary most common, hyposecretion can lead to cretinism (youth) or myxedema (adult)

amiodarone can cause

thyroid replacement drugs

levothyroxine (T4; most preffered), lipothyronine (T3), liotrix (T4 + T3; 4:1 ratio)

monitor serum TSH and free thyroid hormone levels for dosing

increase O2 consumption, body temp. blood vol, cell growth/differentiation, stimulate cardiovascular, increase renal blood flood

thyroid contraindications and AE

recent MI, adrenal insufficiency, hyperthyroidism

interacts with warfarin (increases activity)

take on empty stomach in morning

levothyroxine

stick to same brand, dosed in micrograms (question doses >200mcg), IV

baseline VS, medication hx, allergies

avoid iodized salt

antithyroid drugs

treat hyperthyroidism, inhibit precursors to make T3 and T4, prevent surges in hormone after surgery or radioactive treatment, graves’ disease, and thyroidectomy

methimazole, propylthiouracil (PTU), or radioactive iodine, sometimes potassium iodide

antithyroid contraindications

allergies, use in pregnancy (PTU in first trimester)

effects liver and bone marrow, additive leukopenic effects w/ bone marrow suppressants, increase oral anticoagulant

asses VS, thyroid crises s/s

take w/ meals, monitor liver test and CBC, avoid iodized salt, monitor for hypoparathyroidism

pancreas

exocrine- secretes from duct, endocrine- secretes into bloodstream, insulin + glucagon

hyperglycemia complications

macrovascular: plaque effecting central and peripheral circulation

microvascular: damages eyes and kidneys, nerve damage

rapid acting

lispro, aspart, glulisine (LAG, NAH)

15 min

short acting

regular insulin, used in DKA or coma w/ type 1

30-60 min

intermediate acting

NPH

1-2hr

long acting

glargline, detemir, degludec (DDG, LLT)

glargine (lantus): blood levels do not rise or fall, clear, dosed 1-2 daily, sometimes referred as basal insulin

1-2hr

basal bolus

preferred tx for hospitalized pt, basal given to mimic pancreas then bolus mimics response to increase in blood glucose levels, NPO pt not good candidates (risk of hypoglycemia)

non insulin drugs

biguanides

first line drug for type 2, decreases glucose production, metformin initially, can cause weight loss

contraindicated with renal disease/function (creatine clearance of >30 mL/min), can accumulate and cause lactic acidosis

AE: lactic acidosis (hyperventilation, clammy skin, muscle pain, abd pain, dizziness, irregular heart beat)

sulfonylureas

bind to beta cells to release insulin, glipizide, glyburide, glimepiride, must have some functioning beta cells in pancreas, should not be used in advanced diabetes dependent on insulin

contraindicated in hypoglycemia, NPO, or advanced age

can cross-allergy with atbs, AE- hypoglycemia, weight gain

glinides

repaglinide, nateglinide, similar function as sulfonylureas (increase insulin; but not combined), shorter action + given with meal, treats type 2

thiazolidinediones (glitazones)

insulin-sensitizing drugs (decrease insulin resistance by enhancing insulin receptor sensitivity), pioglitazone, can be combined with metformin and sulfonylurea

contraindicated with NY heart association class 3-4 heart failure

BB: can exacerbate HF, not recommended w. symptomatic HF

alpha-glucosidase inhbitor

acarbose, miglitol, reversely inhibit in small intestine, timing important + take with food, lowers glucose spike from food

contraindicated with inflam. bowel disease, malabsorption, or obstruction

AE: flatulence, diarrhea, abd pain

DPP-IV inhibitor

-gliptin, combination drugs, delay breakdown of incretin, reduce glucose concentrations, used w/ diet and exercise to control glycemic levels, sitagliptin may increase digoxin levels

GLP-1 agonist

acts on endogenous hormone incretin (secretes insulin, reduce glucagon production, slow emptying, increase satiety), -tide, semaglutide (ozempic), only for type 2 that are unable to control glucose w/ metformin, sulfonylurea, or glitazone

BB: thyroid C-cell tumor

amylin agonist

secreted with insulin, SQ injections during mealtime if insulin not optimal, pramlintide, take 1hr before other drugs

Sglt2 inhbitors

oral drug, inhibit glucose reabsorption in proximal renal tubules

glucose elvating drugs

below 70mg/dL, D50W, oral tablets, glucagon for unconscious pt