SPRING Top 200

• 23.6 Million
• 25%

• Type 1
• Type 2
• Gestational
• Type 1.5

• Results from beta cell destruction
• Autoimmune disorder
• Failure to produce insulin
• 5-10% of Americans
• Diagnosed in children or young adults

• Thin
• Excessive Urination
• Hunger
• Thirst
• Fruity Breath

• Results from a progressive insulin secretory defect on the background of insulin resistance
• Most common form
• Does not make enough or makes too much insulin

• Obese
• May be asymptomatic
• Polydipsia
• Polyphagia
• Polyuria

• Diabetes diagnosed during pregnancy
• 4% of all pregnant women
• Often goes away after baby is born

• Type 1 in someone older
• Same presentation as Type 1 Diabetes

100-125 mg/dL

70-110 mg / dL

Glycosylated hemoglobin--average amount of glucose in the blood over the last 2 to 3 months

< 6.5%

Insulin

Pancreas beta cells

Low blood sugar--> pancreas releases glucagon from alpha cells--> liver releases glucose into blood--> normal blood levels

High blood glucose--> pancreas releases insulin from beta cells--> fat cells take in glucose from blood--> normal blood levels

• Genetic defects in beta cell function or insulin action
• Diseases of the exocrine pancreas (i.e. cystic fibrosis)
• Drug or chemical induced

• A1c > 6.5% OR
• Fasting Blood Glucose > 126 mg/dL OR
• 2 hour plasma glucose > 200 mg/dL OR
• A random plasma glucose > 200 mg/dL

• Increased thirst
• Headaches
• Difficulty concentrating
• Blurred vision
• Frequent urination
• Fatigue
• Weight Loss

• Hot
• Sweaty
• Shaky
• Dizzy
• Headache
• Pale skin
• Stimulates stress in the body

• Use a glucagon kit
• Glucose Tablets
• Candy

Hypoglycemia

• Increases the risk of low blood sugar.
• Liver will not produce any glucose until it has rid the body of all alcohol

Both

Binds to cells to allow glucose from the body to be absorbed--> reduces blood glucose

Excess of insulin stimulates your fat cells to store more fat causing weight gain.

• Increase insulin secretion
• Reduce rate of glucose production

• Hypoglycemia
• Weight gain

• Decreases glucose production
• Increase sensitivity to insulin

• Diarrhea
• Abdominal Discomfort
• Lactic Acidosis

• Increases sensitivity to insulin
• Decrease glucose production

6 weeks

Improves HDL and TG

• Weight gain
• Edema
• Hypoglycemia

• Patients with abnormal liver functions
• Patients with CHF

Delays uptake of glucose by blocking enzymes that digest glucose in the small intestine

WITH food

Flatulence or abdominal discomfort

• Acarbose (Precose)
• Miglitol (Glyset)

• Increase insulin secretion
• Decrease glucose production

• FPG: Decrease by 10-15 mg/dL
• A1c: Decrease by 0.5-0.6%
• Post-Prandial Glucose: Decrease by 50 mg/dL

GI side effects

Increase insulin production

Rapid for a short duration

• Hypoglycemia
• Weight gain

• Hormones in the gut which act on the pancreas to increase insulin production.
• Increase B-cell growth/replication

Type 2

• TZD
• Biguanides

• Sulfonylureas
• Meglitinides
• DPP-IV inhibitors
• Incretin mimetics

Alpha-glucosidase inhibitors

• DPP-IV Inhibitors
• TZD
• Biguanides
• Sulfonylureas (rate)

Pork and Beef

Regular

• Onset: 10-30 minutes
• Peak: 30 minutes-3 hours
• Duration: 3 to 5 hours

• Onset: 30-60 minutes
• Peak: 2-5 hours
• Duration: Up to 8 hours

• Onset: 1-2 hours
• Peak: 4 to 12 hours
• Duration: 16-24 hours

• Onset: 1-5 hours
• Peak: No clear peak
• Duration: Up to 24 hours

• Insulin aspart (NovoLog)
• Insulin glulisine (Apidra)
• Insulin lispro (Humalog)

Insulin Regular (Humulin R, Novolin R)

Insulin NPH human (Humulin N, Novolin N)

• Insulin glargine (Lantus)
• Insulin detemir (Levemir)

• Inflammation
• Mild to moderate pain
• Fever
• May affect platelets

• Decrease inflammation
• Decrease pain
• Treat fever

Cox-1 and Cox-2 enzymes

• The enzyme "cycloxgenase"
• It catalyzes the conversion of free essential fatty acids to prostaglandins.

Prostaglandins are mediators in inflammatory reactions. Can be good or bad.

Provides relief from symptoms of inflammation and pain

Good

• Kidneys
• Gastric Mucosa
• Platelets

Speeds up the production of prostaglandalins.

COX 1

Platelet aggregation

Bad

COX 2

Leads to prostaglandin synthesis involved in pain and inflammation.

• Ibuprofen
• Naproxen

No

• Peptic ulceration
• Dyspepsia

NSAIDs irritate the gastric mucosa due to the acidity of the medicine as well as inhibiting COX 1.

• Renal insufficiency
• Hyperkalkemia

• Arthritis
• Back pain
• heavy periods
• Sprains/ strains
• Migraine

• Anti-inflammatory effects
• Analgesic effects
• Antipyretic effects
• Gastric side effects (less in COX-2 selective)
• Can cause renal toxicity

• 6 months or older:
• Temp < 102.5: 5 mg/kg/DOSE
• Temp > 102.5: 10 mg/kg/DOSE
• Dosed every 6-8 hours

40 mg/kg/DAY

• Hypothalamus receives info about the body temp from thermosensitive neurons in the CNS and skin.
• Temperature levels increase and trigger physiologic and behavioral mechanisms to return temperature to normal such as: sweating, vasodilation, increased peripheral blood flow, hyperventilation

Bacterial or viral infections.

• Fever
• 1 out of 5 ER visits
• 20-30% of MD calls

Aid patient in discomfort and parent anxiety.

100-102

103-105

• > 106
• rare but serious complications can occur

CALL MD

3 days

Reye's Syndrome

Pregnant: promote premature closure of the ductus arteriosus in the fetus

81 mg to 325 mg

• Bextra, Vioxx
• Increased risk of cardiovascular disorders

• 10-15 mg/kg/dose every 4 hours as needed
• DO NOT EXCEED 5 DOSES IN 24 HOURS

• 235-650 mg every 4 hours
• 1000 mg tid/qid
• MAXIMUM DOSE: 4 g/ day

• Highly prevalent allergen-induced upper airway inflammatory disease
• Can be seasonal or year round

Allergic Rhinitis

• Age
• Early food exposure
• Maternal smoking
• Indoor allergen exposure
• Parental allergic disorder

NO

• Reduce symptoms
• Increase patient's QOL

• Lifestyle changes
• Pharmacologic treatment

• Bind to and stabilize the H-1 receptor
• Inhibit mast cell and basophil mediator release
• Reduces sneezing, itching, ocular irritation

• Histamine
• H-1 antagonists reduce or eliminate the effects of histamine

• Stops cramping of smooth muscle
• Sedation
• Dry Mouth
• Trouble concentrating
• Raises Temperature

More

Yes

• Dry Mouth
• Dry Eyes
• Constipation
• Urinary Retention

Short (dosed every 4-6 hours)

• Brompheniramine
• Chlorpheniramine
• Diphenhydramine
• Meclizine
• Hydroxyzine
• Promethazine

Second generation

No, poor penetration. Therefore, less CNS effects

• Fexofenadine
• Loratadine
• Desloratadine

• Allergic rhinitis
• Allergic conjunctivitis
• Allergic dermatological conditions
• Urticaria
• Angioedema
• Pruritus (insect bites)
• Anaphylactic or anaphylactoic reactions
• Nausea and vomiting
• Sedation (1st generation)

Symptom

• Allergies and asthma
• Lung infections
• COPD
• Sinusitis leading to postnatal drip
• Lung disease
• GERD
• Cigarette smoking
• Exposure to secondhand smoke
• Exposure to air pollutants
• ACE Inhibitors
• Croup

• Mucolytics
• Expectorants
• Suppressants
• Decongestants
• Antihistamines
• Pain relievers

Not for children < 4 y.o.a. UNLESS under guidance of healthcare professionals

• Expectorant-- loosens phlegm
• Increases the lubrication of your lungs allowing for a productive cough and decreased chest congestion
• Many dosage forms
• DRINK WATER

Binds to opiate receptors in the CNS, causes cough suppression by direct central action in the medulla and produces a generalized CNS depression

• Relax striated muscles (pain management)
• Skeletal muscles (relief of spasticity in neuromuscular disease or minor strain injuries)

• Flexeril
• Soma
• Skelaxin
• Zanaflex
• Robaxin

• Progressive brain disorder
• Most common form of dementia-- destroys brain cells
• Advances at different rates: 3-20 years

• Memory
• Ability to learn
• Reason
• Judgement
• Communication Skills
• Ability to carry out daily activities

MEMORY LOSS

• Cholinesterase Inhibitors
• Uncompetitive NMDA receptor antagonist
• Vitamin E

• Increase levels of Acetylcholine
• Aricept
• Exelon
• Razadyne

Because our bodies eventually stop producing acetylcholine

• Namenda
• MOA unknown--> regulates glutamate which is responsible for cell death

• Eye strain
• Sinusitis
• Tension/stress induced
• Brain tumors
• Idiopathic
• Head injury
• Medication induced
• Dehydration
• Caffeine withdrawal
• Food triggers
• Environmental triggers

Migraines

• Cluster
• Migraine

Tension

Neck disorder

Eye strain

Sinusitis

• Lower your body temperature
• Chiropractic Care
• Preventative Therapy
• Medications

• NSAIDs
• Triptans
• BP meds
• Antidepressants
• Muscle Relaxers

Serotonin

Vascular (migraine/cluster)

• Bind to serotonin receptors in the brain
• Inhibit pro-inflammatory neuropeptide release

• Imitrex
• Maxalt
• Amerge
• Zomig
• Axert

• GERD
• Ulcers
• Esophagitis
• Gastroparesis
• Nausea/Vomiting

symptoms or mucosal damage produced by the abnormal relux of gastric contents into the esophagus

Regurgitated liquid usually contains acid and pepsin that are produced by the stomach.

• Increased hormone production
• Growing fetus can cause pressure

• Erosive esophagitis
• Non-erosive reflux disease
• Barrett's esophagus

• Alleviate Symptoms
• Decrease the frequency of recurrent disease
• Promote healing of mucosal injury
• Prevent complications

• Lifestyle changes
• Pharmacologic intervention
• Surgery
• Endoscopic therapies

• It is a specialized ring of muscle that surrounds the lower most end of the esophagus and it's function is to prevent reflux.
• Laxity of LES: easier opening of the LES allows for a greater backward flow of acid

• Heartburn (painful) HALLMARK
• Belching
• Regurgitation

• Cough
• Asthma
• Hoarseness
• Chest pain
• Pharyngitis
• Dental erosions
• Metallic taste in mouth
• Nausea

• Upper body elevation while sleeping
• Smaller and less fatty meals
• Lose weight
• Smoking cessation
• Avoid alcohol
• Earlier evening meals
• Avoiding injurious foods

Neutralize acid in the stomach by mixing with HCL to form water and salt. Reduces gastric pH

Protective barrier that floats on the surface of gastric contents

• Mg= diarrhea
• Aluminum= constipation
• Calcium= stimulates gastrin release

Treatment of mild to moderate GERD (mainly heart burn)

Bind H2 receptors on parietal cells preventing histamine-induced activation

30 minutes before a meal

No

• 12 weeks of therapy
• improvement in 60% of patients

Zantac

Pepcid, Tagamet, Axid

Tagamet

Moderate to severe GERD, May strengthen LES

Blocks the secretion of acid into the stomach by acid-secreting parietal cells

Yes-- protects the esophagus so it can heal

1 hour before meals

Alcohol

Prilosec, Nexium, Prevacid

• Dexilant
• Protonix
• Aciphex
• Zegerid

Zegerid

Dexilant

A break in the lining of the esophagus that occurs in an area of inflammation.

Acid reflux damages the cells that line the esophagus causing inflammation. IF damage is severe, ulcers form. May erode into the esophageal blood vessels and give rise to bleeding.

• It is a bacteria that infects the mucus lining of the stomach and upper intestines that can cause ulcers and gastritis.
• 2/3 of the world are infected but asymptomatic

• Clarithromycin Triple Therapy x 14 days:
• Clarithromycin
• PPI
• Amoxicillin OR metronidazole

• Bismuth Quadruple Therapy x 10-14 days
• Bismuth
• PPIF or H2 Antagonist
• Metronidazole
• Tetracycline

• Emetogenic stimuli to chemoreceptor trigger zone (CTZ) through blood or CSF
• Vestibular stimuli--> motion sickness
• Direct irritation of GI tract sending stimuli to vomiting center in brain and CTZ
• CNS associated--> psychiatric disorders, stress, anticipation

• Phenergan
• Zofran

• Promethazine (generic)
• H1 antagonist, anticholinergic
• Administration: PO, IM, PR

• Ondansetron (generic)
• 5-HT3 antagonist
• Administration: PO, IV
• Commonly used for chemotherapy induced nausea and vomiting

Increase the pressure in the lower esophageal sphincter and strengthen the contracts of the esophagus--> Speeds up emptying of the stomach

No

30 minutes before meals and at bedtime

• Pro-motility
• GERD, nausea/vomiting, gastroparesis
• AE: weakness, somnolence, tardive dyskinesia, neuroleptic malignant syndrome

Osteoporosis

Women

Hips and spine

• Low bone mineral density
• Advanced age
• History of adult fracture

• Chronic Pain
• Deformity
• Disability
• Deconditioning
• Depression
• NH placement
• Death

• Primary (unknown cause)
• Secondary ( disease related, medication induced)

• Age
• Gender
• Ethnicity

• Too much caffeine
• White or Asian ethnicity
• Family History

• Balanced Diet
• Adequate calcium and Vit D intake
• Avoid smoking
• Limit alcohol and caffeine
• Weight-bearing exercise
• Bone density test and medication

• 700, 600
• 1000, 600
• 1300, 600
• 1000, 600
• 1200, 800-1000

• Prevent fractures by improving bone strength and reducing the risk of falling and injury
• Relieve symptoms of fractures and skeletal deformity
• Maximize physical function

• Biphosphonates (first line)
• SERM (post menopausal women only)
• Monoclonal antibody

• Inhibit osteoclast activity and reduce bone resorption and turnover.
• Heartburn, indigestion, jaw bone pain

• First thing in the morning
• With a full glass of water
• Wait at least 30 minutes after to eat
• Remain sitting or standing for at least 30 minutes

• Boniva
• Reclast

• Fosamax
• Actonel
• Reclast

Those with renal insufficiency

Fosamax

Boniva

• SERM
• Osteoporosis, Breast Cancer, Hormone Replacement Therapy
• Hot flashes, night sweats, leg cramps, blood clots

• Calcitonin (miacalcin)
• Denosumab (prolia)

• Permanent cessation of menses due to dysfunction of the ovaries.
• Between the ages of 47-53

Hot flashes, night sweats, abnormal uterine bleeding, vaginal dryness, incontinence, sleep disturbances, mood changes, depression, sexual changes, problems with concentration and memory

• Premarin (Conjugates Estrogens; pregnant mare urine)
• Estrace (Estradiol)

Relief of moderate to severe vasomotor symptoms

• vaginal bleeding
• venous thromboembolism
• stroke

WITH

Those with a history of breast cancer.

• Prevent pregnancy
• Regulate menstrual cycle
• Treat acne

• Progestin and estrogens
• Prevents ovulation and alters endometrium lining

• Women with pre-existing CV disease or risk: DVT, pulmonary embolism, stroke, MI
• Higher estrogen containing pills may increase risk of breast cancer

• PCOS treatment
• Endometriosis treatment
• Dysmenorrhea treatment
• Reduce ovarian cancer risk by 40%
• Reduce endometrial cancer risk by 50%

• A hormone imbalance leading to overproduction of follicles each month by the ovaries with producing an egg.
• Irregular/no periods, depression, excessive weight gain, acne, abnormal hair growth, infertility
• Goes hand in hand with insulin resistance
• Body begins to make more androgens

• When endometrial tissue develops outside of the uterus. Tissue implants -> proliferates-> thickens-> sheds with each menstrual cycle-> tissue becomes trapped-> scar tissue formation
• Symptoms: pelvic pain, infertility

Ethinyl estradiol

• Norgestimate
• Drospirenone
• Norelgestromin
• Norethindrone

Those with a uterus.

Too much estrogen

Early or mid-cycle breakthrough bleeding, increased spotting, hypomennorhea

Breast tenderness, headache, fatigue, changes in mood

Too much androgen

• Involuntary loss of urine
• Increased: Females, Obesity (BMI > 30), Advanced Age (> 50), Poor function status

• UTI
• Medications
• Constipation
• Tumor

• Muscle/tissue weakness
• Urinary tract abnormality
• Increased during menstrual cycle
• Nerve damage
• Idiopathic

• Urge (Overactive Bladder): urinary urgency with increased frequency and nocturia, with or without UI-- Increase bladder muscle contraction or nerve problems
• Stress: loss of urine or exertion, sneezing, or coughing; bladder pressure > urethral pressure
• Mixed
• Overflow
• Functional

• Lifestyle modifications
• Kegel exercise
• Bladder training
• Intravaginal Devices
• Medications
• Nerve Stimulation
• Surgery

• They tone the pelvic muscles that stop the flow of urine when you urinate (pubococcygeus muscles).
• Squeeze and hold up to10 seconds x 20 reps tid
• Contract ONLY pelvic muscles

• Ditropan/Oxytrol/Gelnique
• Detrol/Detrol LA
• Toviaz
• Vesicare
• Sanctura/Sanctura XR
• Enablex

• Ditropan/Oxytrol/Gelnique
• Detrol/Detrol LA
• Toviaz

• Detrol/ Detrol LA (high affinity for bladder receptors)
• Vesicare (M3>M2)
• Enablex (highly selective M3>M2)

• Urge Incontinence/Overactive Bladder: competitive muscarinic receptor antagonist that decreases bladder contractions, detrusor pressure, and incomplete voiding
• Administer once (ER) or twice (IR) daily (adjust in hepatic/renal insufficiency)
• AE: dry mouth, headache, constipation, blurred vission, dizziness
• May take weeks or months for full efficacy

• Benign Prostatic Hyperplasia
• Enlarged prostate that presses on the urethra leading to urination and bladder problems

• Dribbling at the end of urination
• Urinary retention
• Incomplete bladder emptying
• Incontinence
• Nocturia
• Slowed/delayed/strained urination

• urinate with initial urge
• avoid alcohol and caffeine
• avoid drinking close to bedtime
• avoid OTC decongestants/antihistamines
• regular exercise
• kegel exercises
• reduce stress

• Alpha 1 Blockers
• 5 alpha reductase Inhibitors
• Muscarinic Blockers

• Doxazosin
• Prazosin
• Tamsulosin
• Terazosin
• Alfuzosin
• Silodosin

• Finasteride
• Dutasteride

• Treatment of symptomatic BPH alone or in combination with 5 alpha reductase inhibitor
• Side effects: orthostatic hypotension, dizziness, weakness, decreased libido, insomnia, rhinitis, abnormal ejaculations, ejaculatory problems, intraoperative floppy iris syndrome
• Administer 30 minutes after the same meal each day

• Treatment of symptomatic BPH alone or in combination with an alpha adrenergic blocker (increase symptom relief and increase urine flow rate)
• SE: erectile dysfunction, decreased libido, increase breast size/tenderness, rash
• PCX: pregnant females should not handle crushed or broken tablets

• Inability to achieve or maintain an erection
• Affects 65% of men between 40-70 years of age

arousal -> Ach released from pelvic nerve-> NO released from cavernosal nerves-> smooth muscle relaxation-> areterial inflow/decreased venous outflow-> penile rigidity

Endothelial damage--> decreaseNO production

• Medications
• CV disease
• Diabetes
• Depression
• Alcoholism
• Smoking
• Penile trauma
• Neurologic disease
• Obesity
• Renal disease

• Increased sexual function
• Improve quality and quantity of erections suitable for intercourse
• Maintain adequate erection for patient and partner satisfaction

• Lifestyle modifications: increase physical activity, dietary changes, disease state management
• Medications: phosphodiesterase type 5 (PDE5) inhibitors, Yohimbine
• Surgical: Vasoactive injection therapy, vaccum pump devices, penile prosthesis

Inhibit cGMP --> build up of cGMP--> smooth muscle relaxation--> increased inflow of blood

SE: headache, flushing, dyspepsia, rhinitis, impaired color discrimination, dizziness, hypotension, CV effects, sudden hearing loss

Nitrates

Grapefruit juice

• Viagra
• Levitra
• Cialis

24-36 hours

• Without
• 30 minutes prior to intercourse; once daily

• Nope--efficacy not proven
• SE: dizziness, anxiety, flushing, headache, hypertension, tachycardia, tremor