Pharmacy practice 509

• Type I: 5-10% of cases, early onset (<30yo), insulin deficiency
• Sx: weight loss, Polydypsia, Polyphagia, Polyuria
• Tx: Insulin
• others: hypoglycemic, diabetic ketoacidosis

• Type II: 90% of cases, late onset (>40yo), insulin resistant, impaired glucose tolerance
• Sx: usually asymtomatic (except sweating)
• Tx: TLC, PO meds, eventually insulin
• others: metabolic syndrome, undiagnosed until Sx present

• No previous history of DM before pregnancy
• Sx: hyperglycimic and Sxs of DM during pregnancy
• Prevalence: ~4% of pregnant women in the US annually
• Risk factors:
• Maternal Age >25yo
• Hx of GDM
• Hx of polyhydraminos (excess amniotic fluid)
• Prior infant born >9lbs (macrosomia) or with congenital anomolies
• Family Hx of DM
• Obesity (BMI >30)
• Previous unexplained miscarriage/stillbirth
• ethnicity: Hispanic American, Native American, Asian American, African American, Pacific Islander

Elevated blood glucose levels, but not high enough for DM diagnosis

• Impaired Fasting Glucose (IFG): 100-125 mg/dL
• Impaired Glucose Tolerance (IGT): 2hr post prandial 140-200 mg/dL
• A1C range: 5.7%-6.4%

Lifestyle changes MUST be made

• IFG:
• 1^o test for dx
• fasting >8hrs
• help identify pt's with increased risk for DM
• DM diagnosed with 2 tests of elevated glucose at PCP's office

• IGT:
• 2^o test- conformational tool
• fasting >8hrs, then consume 75g glucose, sample 2hrs later

• Normal pt:
• Fasting Plasma Glucose (FPG): <100 mg/dL
• 2hr post prandial: <140 mg/dL
• Random glucose: <140 mg/dL
• A1C: <5.7%

• Pre-Diabetic:
• FPG: 100-125 mg/dL
• 2hr post prandial: 140-199 mg/dL
• A1C: 5.7-6.4%

• Diabetic:
• FPG: >= 126 mg/dL
• 2hr post prandial: >= 200 mg/dL
• A1C: >= 6.5%

• 3 P's: Polydypsia (drinking), Polyphagia (eating), Polyuria
• Blurred vision
• Drowsiness
• Dry Skin
• Slow healing wounds

• Sx: FPG <70 mg/dL
• Shaking
• Palpitations
• Dizziness
• Sweating
• Polyphagia
• Irritability and Anxiety
• Impaired Vision
• Fatigue

• Tx: caused by skipped meals, excessive insulin/diabetic meds, dangerous condition
• 2-3 glucose tabs
• 1/2 cup juice
• 1/2 cup soda
• 5-6 pieces of candy
• 1-2 tsp sugar/honey

Microvascular: nephropathy (end stage renal disease), retinopathy (blindness)

Neuropathy: autonomic neuropathy (gastroparesis and ED), peripheral neuropathy (amputations)

Macrovascular: coronary heart disease (MI), peripheral vascular disease (amputations), cerebrovascular disease (stroke)

• FPG: 70-130 mg/dL
• Post prandial glucose: <180 mg/dL
• A1C: <7%
• BP: <130/80 mmHg
• LDL <100 mg/dL
• Trigs: <150 mg/dL
• HDL: Male >40, female >50 mg/dL

• age >45 yo
• Family Hx (parent or sibling)
• Ethnic Background: Alaskan Native, African American, Hispanic/Latino, Asian American/Pacific Islander
• History of Gestational DM

• Weight BMI >25 kg/m²
• HTN: >140/90 mmHg
• dyslipidemia: HDL < 35 mg/dL, TG >250 mg/dL
• Inactivity (exercise less than 3x week)
• Cardiovascular disease

• eat regularly scheduled meals and snacks
• monitor portion sizes
• limit foods high in fat, salt, sugar
• exercise >30min of aerobic most days of the week
• smoking cessation

• adults >= 20yo should be tested every 5 years
• pt's with higher risk for CHD should be screened more frequently (ie: smoker, diabetic, obese, fam hx of CHD, >=65yo)

• LDL: <100 mg/dL optimal
• 100-129 near optimal
• 130-159 borderline high
• 160-189 high
• >= 190 very high

• TC: <200 mg/dL optimal
• 200-239 borderline high
• >=240 high

• HDL: >60 mg/dL high
• <40 low

• TG: <150 mg/dL
• 150-199 borderline high
• 200-499 high
• >=500 very high-> @risk for pancreatitis

• genetics
• diet
• sedentary lifestyle
• smoking
• 2ndary causes: drugs, diseases

LDL = TC - HDL - (TG/5)

if TG >400 mg/dL, cannot use calculation for LDL

• Established CHD
• abdominal aortic aneurysm
• peripheral arterial disease
• carotid artery stenosis
• diabetes

• smoking
• HTN ( bp >=140/90 mmHg or on HTN meds)
• low HDL (<40 mg/dL)
• family hx of premature CHD
• -----> male: <55 yo
• -----> female: <65 yo
• age: men >=45; women >=55 yo

• High Risk (CHD or CHD risk equivalent):
• LDL Goal: <100, <70 optional
• Initiate TLC: >=100
• consider drug therapy: >=100

• Moderately High (2+ risk factors, 10-20% 10yr risk):
• LDL Goal: <130, <100 optional
• Initiate TLC: >=130
• consider drug therapy: >=130, 100-129 optional

• Moderate (2+ risk factors, <10% 10yr risk):
• LDL Goal: <130
• Initiate TLC: >=130
• consider drug therapy: >=160

• Lower (0-1 risk factors):
• LDL Goal: <160
• Initiate TLC: >=160
• consider drug therapy: >=190, 160-189 optional

• TLC Diet
• increased fiber
• exercise
• weight management
• smoking cessation

• Waist circumference: >40" (men) >35" (women)
• TG >=150
• HDL <50
• BP >=130/85
• fasting glucose >=100

• TC: <170 acceptable
• 170-199 borderline
• 200 high

• LDL: <110 acceptable
• 110-129 borderline
• 130 high

• TypeII Diabetes
• CHD
• HTN
• dyslipidemia
• stroke
• gallbladder disease
• respiratory problems (sleep apnea)
• risk of cancers (endometrium, breast, prostate)
• gynecological problems (abnormal menses, infertility)

• reduces risk factors for:
• diabetes
• CVD
• osteoarthritis
• gallbladder disease

• decreases BP, LDL, TG, blood glucose, A1C
• increases HDL

• underweight: <18.5 kg/m²
• Normal: 18.5-24.9
• overweight: 25-29.9
• obesity class 1: 30-34.9
• obesity class 2: 35-39.9
• extremely obese: >=40

• essential fat: 2-4%
• athletes: 6-13%
• fitness: 14-17%
• acceptable: 18-25%
• at risk: +25%

• essential fat: 10-12%
• athletes: 14-20%
• fitness: 21-24%
• acceptable: 25-31%
• at risk: +32%

• hydrodensity weighing
• anthropometry
• dual energy x-ray absorptiometry (dexa)
• magnetic resonance imaging (MRI)
• bioelectric impedance device (BIA device)

After waking up, 2hrs or more after a meal, or before going to bed

avoid: drinking large amount of water/meal (1-2hrs), after drinking alcohol, after vigorous exercise, after bath/sauna

• *3500 cal = 1 lbs*
• BMI 27-35:
• decrease caloric intake 300-500/day
• weight decrease of 0.5-1 lb/week

• BMI >35:
• decrease caloric intake 500-1000/day
• weight decrease of 1-2 lb/week

• keep total fat intake 20-35% of calories
• ~35% calories from proteins
• ~45-65% calories from carbohydrates
• choose lean meats, fats from mono/poly unsaturated FA, whole grains, fibers
• 300mg/day of cholesterol, 200mg/day if pt has CVD or DM II
• Avoid trans fats

BMI >= 40 or >=30 with serious co-morbid conditions

still must maintain TLC (diet, physical activity, behavioral changes)

fractures, 10-40% increased risk of mortality after a fracture

weakening of the bones (loss of bone mass and structural loss)

sign of osteoperosis: kyphosis (stooped stature), bone pain, fractures

• Age: no specific age, but bone density decreases past 35 yo
• Gender: females, but males can still get the disease
• Family history
• Slender/low weight (BMI <19)
• caucasian/asian
• post-menopausal/estrogen deficient
• history of fractures

• low diet of vit D or calcium
• excessive caffeine consumption
• >2 alcoholic drinks per day
• inactive lifestyle
• lack of weight bearing exercise
• smoking
• lack of sun exposure (vit D)

disease related: paget's disease, chronic kidney disease, liver disease, etc

medication related: coritosteroids, anticonvulsants, aluminum containing antacids (prevents Ca absorption), furosemide, etc

• all women >=65yo
• younger, post menopausal women w/ risk factors
• women during menopausal transition w/ clinical risk factors
• men >70
• men <70 with clinical risk factors
• anybody w/ disease/medication associated with osteoporosis
• women discontinuing estrogen

Look at bone mineral density (BMD) either through a DEXA or heel bone densitometer

• Z score: comparing patients to other people of the same age, sex, and ethnicity (young compared to young)
• for men <50 and women prior to menopause

• > -2 normal
• < -2 below normal range

T score: comparing patients to 30 year olds of the same sex and ethnicity as the patient (old pt's compared to young people) for men >50 and postmenopausal women

• > -1 normal bone density
• -1 to -2.5 low bone mass (osteopenia)
• < -2.5 presence of osteoporosis

• 19-49 yo:
• Ca2+: 1000 mg/day
• vit D: 400-800 IU/day

• >=50 yo:
• Ca2+: 1200 mg/day
• vit D: 800-1000 IU/day

• Calcium Carbonate:
• greatest amount of elemental Ca2+ (40%)
• take with food, do not exceed 500-600 mg/dose

• Calcium Citrate:
• 21% elemental Ca2+
• best absorbed form, less constipating
• more expensive
• doesn't require food

• start weight bearing exercise (walking, dancing, stair-climbing, jumping, etc)
• fall risk reduction
• smoking cessation
• adequate nutrition

• bisphosphanates
• calcitonin
• intermittent parathyroid hormone
• selective estrogen receptor modulators (SERMs)
• estrogen replacement therapy

> 140 SBP OR > 90 DBP

diagnosed after 3 consecutive high readings over 3 different visits @ PCP's office

• Heart: MI or heart failure
• Brain: stroke, paralysis, or death
• Kidneys: kidney damage requiring dialysis
• Eyes: impared vision and blindness

Urgency: DBP >120mmHg, no signs of target organ damage; not life threatening

Emergency: DBP >120mmHg, signs/sx of target organ damage, life threatening

• Age: >60
• Gender: males and postmenopausal women
• Ethnicity: african americans and hispanics
• Family Hx of CVD (women <65, men <55)

• Obesity (BMI >=30)
• lack of physical activity
• smoking
• excess sodium intake
• excess alcohol intake
• stress
• caffeine
• Metabolic syndrome

guidelines for HTN for reducing risk, classification of BP measurements, diets, and BP technique

written in SBP and DBP

Normal: <120 AND <80 (recheck in 2 yrs)

PreHTN: 120-139 OR 80-89 (recheck in 1 yr)

HTN stage I: 140-159 OR 90-99 (confirm w/in 2mo)

HTN stage II: >=160 OR >=100 (evaluate immediately)

Loop diuretics, thiazide diuretics, beta blockers, ACE inhibitors, angiotensin receptor blockers, Ca2+ channel blockers, alpha blockers, alpha-2 agonists

the "lub" "dub" sounds heard through the stethoscope

1st sound is systolic, last sound is diastolic

70-100 bpm

calculated by counting for 15 seconds and multiplying by 4; if irregular, count for 60seconds

10-14 breaths per minute

• Arm below heart (high reading)
• Arm above heart (low reading)
• Legs dangling (high reading)
• unsupported back (high reading)

inappropriate wrapping also gives inaccurate readings

Physical activity, emotional state, pain, noise, temperature, caffeine, smoking, "white coat"

• weight reduction
• exercise
• dash diet
• sodium restriction
• moderation of alcohol
• caffeine and smoking
• good sleeping habits
• stress reduction

DASH diet (reduces SBP 8-14mmHg): Diet rich in nutrients, fiber, and electrolytes

Sodium restriction (reduces SBP 2-8): reduce to 2.4gm of sodium a day (1/4 tsp of salt is 1.5gm)

Alcohol reduction (reduces SBP 2-4): men 2drinks/day, women 1drink/day