ASSIGNMENT OF INEGRATED

THERAPIUTICS-II
DM CASE STUDY

RIFT VALLEY UNIVERSITY

HARAR CAMPUS

FACULTY OF HEALTH SCIENCE:

DEPARTMENT OF PHARMACY 3rd YEAR 2nd SEMISTER

PROGRAM: DEGREE REGULAR

INDIVIDUAL ASSIGNMENT THERAPIUTICS-II

SUBMISSION DATE: September, 30, 2015 EC.

By: GELETA MUKTAR KASIM

ID No: 134/12

SUBMITTED TO: ZENEBE K.

ANSWER THE FOLLOWING QUESTIONS ACCORDINGLY

1. A 48-year-old woman returns to the clinic for a routine follow-up visit about her diabetes. She has a
past medical history of Type 2 diabetes, hypertension, and dyslipidemia. She was diagnosed with
new-onset Type 2 diabetes about two years ago and her elevated glucose levels have been treated
solely with insulin since then. Upon diagnosis, she also received formal education about diabetes
from the clinic's clinical pharmacist and dietitian, both of whom are certified diabetes educators.
The education sessions enlightened and motivated the patient to adopt new and healthy lifestyle
changes. She significantly reduced the amount of carbohydrates in her meals to recommended
quantities and implemented a consistent daily exercise routine. Her glucose levels and Ale have
been at goal for several months and her PCP has been reducing her insulin doses to avoid
hypoglycemia.
Today, she presents hoping to stop her insulin and switch to oral medications to maintain control of
her diabetes. The PCP feels this is possible due to her new and appropriate lifestyle habits and
current level of control.
Allergies; NKDA
Medications: Insulin glargine 16 units every evening; insulin as part four units with breakfast, four
units with lunch, and six units with dinner; lisinopril 10 mg tablet 1 po daily, simvastatin 20 mg tablet
po every evening
Physical Exam/Other Studies: Wt 160 lb Ht 70 in T 98.6°F BP 116776 HR 72 RR 12 O, sat 99%
Physical exam reveals no pertinent findings.
Ale 6.3% fasting glucose 97 LDL 84 TG 144 HDL 55 SCr 1.0 K 3.9 As the clinical pharmacist and
certified diabetes educator in this facility, the PCP asks what oral diabetes medication would be
most appropriate as a first step to replace this patient's insulin regimen. What do you recommend?

2. A 52-year-old man presents to his PCP's office for a routine follow-up visit on diabetes. His past
medical history is significant for Type 2 diabetes, heart failure, hypertension, and dyslipidemia. His
diabetes was diagnosed one year ago and he has only been prescribed metformin for treatment. His
metformin dose was optimized last month, but his blood glucose levels are still not at goal.
However, he did notice an improvement with the dose increase and with recent diet and exercise
improvements. His heart failure has not been very stable lately and his PCP has been adjusting his
diuretic dose to reduce pedal edema.
Allergies: Penicillin (rash)
Medications: Metformin 850 mg tablet 1 po three times daily with meals; lisinopril 40 mg tablet I po
daily. metoprolol succinate 100 mg tablet I po daily: furosemide 40 mg tablet I po twice daily;
atorvastatin 40 mg tablet 1 po every evening; aspirin 81 mg tablet (OTC) I po daily
Physical Exam/Other Studies: Wt 220 lb Ht 72 in T 98.4°F BP 112/66 HR 62 RR 15 O. sat 99%
Physical exam reveals 2 + pitting edema bilaterally at lower legs. Ale 8.5% fasting glucose 213 LDL 66
TG 256 HDL 39 SCr L K 4.3 The PCP adjusts the furosemide to address the pedal edema and calls you,
the clinic pharmacist, for advice on starting a new medication to treat the patient's diabetes. The
patient refuses to start insulin at this time.
You need to add an oral agent that is safe, given the patient's PMH, and effective enough to
potentially attain a goal Alc of <7 percent. What drug class do you recommend?
3. A 44-year-old woman returns to your pharmacotherapy service for diabetes management. Her past
medical history includes Type 2 diabetes (diagnosed about six years ago), hypertension,
dyslipidemia, und obesity. She has been a patient in your outpatient service for nine months now
and her glucose control has been improving. She has been working to adjust her diet and become
consistent with an exercise routine, but further improvements are still needed. She is taking three
oral medications for her diabetes and checks her blood glucose twice daily alternating between
breakfast and dinner one day, and then lunch and bedtime the next day, all finger sticks are done
before meals or at bedtime. Her glucose readings have improved over the past several months after
various medication titrations and these pre-meal values are mostly at goal of 70-130 mg/dl. These
values have been consistently within goal range for the past three months.
Allergies: NKDA
Medications: Metformin 1.000 mg tablet 1 po twice daily; glipizide 10 mg tablet two po twice daily;
pioglitazone 45 mg tablet I po once daily; lisinopril 20 mg tablet 1 po once daily; hydrochlorothiazide
12.5 mg tablet I po daily: pravastatin 40 mg tablet I po every evening; aspirin 81 mg tablet 1 po daily
Physical Exam/Other Studies: Wt 254 lb Ht 75 in T 98.6°F BP 122/78 HR 82 RR 12 O, sat 98%
Physical exam reveals an obese female in no acute distress
Ale 7.9% LDL 104 TG 184 HDL 42 SC 1.1 K4.0
You assess that while her finger stick glucose values have been within goal range for three months,
her Ale is still not improving to goal. You have her assess blood glucose levels two hours after eating
and discover elevations well above the goal of <180 mg/dl. You decide that her glipizide is not
adequately addressing her post prandial needs
If you stop her glipizide, with what oral agent can you replace it to address post prandial
elevations?

4. You are a pharmacist practicing in a community pharmacy chain store. A 34-year-old male patient
that you know well, and have helped many times before, presents for a refill of his routine
medications. He has a past medical history of Type 2 diabetes and hypertension. You have taught
him to use his glucometer at previous visits and regularly check his blood pressure. Last month, he
was started on hasal insulin along with his oral medications and you instructed him on proper
insulin-injection technique. Today, you notice as he approaches the counter, that his shoes are
untied and loose. You ask him about his untied shoes. The patient replies that he is wearing his
shoes that way on purpose, due to profound swelling he has been experiencing in his feet and lower
legs for the past two weeks. He denies SOB, CP, or dizziness
Allergies: NKDA
Medications: Metformin 850 mg tablet I po three times daily, glyburide 5 mg tablet two po twice
daily; pioglitazone 45 mg tablet 1 po once daily; insulin glargine inject 20 units subcutaneously every
evening: lisinopril 10 mg tablet 1 po once daily
Physical Exams/Other Studies: W: 220 lb Ht 80 in BP 112/68 HR 84 RR 12
Physical exam reveals a male in no acute distress with 2+ pitting edema bilaterally, Pertinent lab
values obtained from calling the physician office include:
Ale 8.1% SCr 0.9 K 4.2
 The patient reports compliance with all medications including his new insulin. After assessing the
patient and his recent history, you decide to call the PCP to recommend stopping one of his diabetes
medications due to the lower extremity
Which diabetes medication is most likely responsible for his new edema?

5. A 53-year-old man returns to his doctor's office for a diabetes visit. He has a past medical history
pertinent for Type 2 diabetes (12 years), hypertension, dyslipidemia, and asthma. At his last visit
three months ago, his doses of metformin and glyburide were optimized. The patient reports that a
month later, he experienced an asthma exacerbation and went to the emergency department at a
local hospital. His asthma medications were adjusted and he was given oral steroids to control the
exacerbation. The oral steroids then caused a significant elevation of his blood glucose levels. When
the patient refused to start insulin, providers at the hospital added pioglitazone and acarbose to his
outpatient medication regimen to help control his blood glucose. He saw a training resident
physician for a hospital follow up visit a week later and was given refills and started on sitagliptin as
well. Today, be complains of gastrointestinal guin and bloating with excessive flatulence. This has
been bothering him for weeks now, but he is not sure exactly when it began. His asthma is
controlled.
Allergies: NKDA
Medications: Metformin 1.000 mg tablet 1 po twice daily with food, glyburide 5 mg tablet two
tablets po twice daily with meals; pioglitazone 15 mg tablet 1 po daily, acarbose 25 mg tablet 1 po
three times daily with the first bite of each meal; sitagliptin 100 mg tablet I po daily: lisinopril 40 mg
tablet I po daily; atorvastatin 20 mg tablet po every evening fluticasone/salmeterol 500/50 mcg DPI
inhale I puff twice daily; albuterol 90 mcg MDI inhale 2 puffs as needed every four to six hours with
spacer: prednisone 40 mg tablet po daily
Physical Exam/Other Studies:
Wt 208 lb. Ht 67 in T 98.6°F BP 132/82 HR 90 RR 14 O, sat 99%
Physical exam reveals no wheezes, crackles, rales; no peripheral edema, a bloated abdomen.
Alc 9.7% fasting glucose 348 LDL 76 TG 288 HDL 40 SCL K 3.6 The PCP rules out other causes of the
Gl complaints and suspects a pharmacologic etiology.
Which of the patient's diabetes medications is most likely causing the GI complaints?

6. A 40-year-old man presents to the pharmacy to pick up refills and new prescriptions called in by his
PCP. He has a history of Type 2 diabetes, hypertension, and dyslipidemia. His diabetes is not
controlled as evidenced by his fasting glucose levels ranging from 112-150 mg/dL. And pre-dinner
values ranging from 120-148 mg/dl. However, his two-hour post prandial values are typically <180
mg/dL, and his blood glucose values did improve significantly after recently optimizing his metformin
and glyburide doses. The PCP has called in a new prescription for exenatide 5 meg injected
subcutaneously twice daily before meals. The patient explains that he is willing to pick up his
metformin refill today, but does not want to start the exenatide because he has an extreme fear of
needles and has refused insulin in the past. Two months ago, he had to stop acarbose after a two-
week trial, due to Gl upset and flatulence with bloating. In the distant past, he also had to stop
rosiglitazone due to peripheral edema.
Allergies: NKDA
 Medications: Metformin 1,000 mg tablet 1 po twice daily with meals; glyburide 5 mg tablet two
tablets po twice daily with meals, pravastatin 20 mg tablet I po every evening: lisinopril 40 mg tablet
po once daily; hydrochlorothiazide 25 mg tablet 1 po once daily Physical exam/other studies
(reported verbally by the patient):
Wt 202 lb Ht 70 in
Physical exam not performed.
Ale 7.4%
You spend some time discussing diabetes goals with the patient. You also determine that he has
already made significant improvements to his diet and is exercising. He is very interested in gaining
complete control, but is simply terrified of needles. He would like to try another medication. You
decide to call his PCP to recommend another option.
What drug class might you recommend to attain his goal Ale?

7. A 42-year-old woman presents to the clinic for a diabetes follow-up visit and is interested in losing
weight. She has a past medical history of Type 2 diabetes, heart failure, obesity, and hypertension.
Her heart failure is at NYHA Class III based on her recent symptom patterns and is at times unstable.
She has been consistently improving her lifestyle and is eating more appropriately in regard to
carbohydrates as well as fats, but is not able to tolerate regular exercise. She has seen a significant
improvement in her blood glucose levels. At a recent visit, her metformin was stopped due to risks
associated with unstable heart failure. Since then, her blood glucose levels have only mildly
elevated, but she is not at pre-meal goal values of 70-130 mg/dL.. Most of her pre-meal values range
from 130-155. She has recently heard of a drug that may help lower her blood glucose levels and
also help with weight loss.
Allergies: NKDA
Medications: Glipizide 10 mg tablet 2 po twice daily with meals; lisinopril 40 mg tablet I po once
daily; metoprolol succinate 100 mg tablet 1 po daily: furosemide 40 mg tablet 1 po twice daily;
spironolactone 25 mg tablet 1 po daily
Physical Exam/Other Studies:
Wt 330 lb Ht 65 in BP 118/70 HR 64 RR 15
Physical exam reveals an obese female with trace peripheral edema Ale 7.2% fasting glucose 146
LDL 72 K 4.8 SCr 1.0
You are asked what drug may be appropriate to add to her current regimen to further gain control
of her blood glucose levels with a possible benefit of weight loss. What type of drug do you
recommend?

8. A 36-year-old woman presents to the pharmacy at 7:30 PM for a refill of her insulins. She has a past
medical history of Type 2 diabetes and hypertension. The pharmacy technician that has been
working with the patient comes to get you, the pharmacist, because the patient is "acting funny."
You immediately notice the patient's hands are shaking and her forehead appears sweaty. As you
approach her, she seems to realize that she is experiencing hypoglycemia and retrieves a container
of glucose tablets from her purse. Upon checking her blood glucose, she finds a value of 58 mg/dl.
About 20 minutes after taking the glucose tablets and resting in a chair, she is feeling better and her
glucose has risen to 116 mg/dL. She tells you that two weeks ago, she and her PCP discussed
 reducing carbohydrate portions from her large dinner-time meal. Ever since then, she has been
having low blood glucose levels in the evenings a couple hours after dinner.
Allergies: NKDA
Medications: NPH insulin 36 units subcutaneously before breakfast and 42 units before dinner;
regular insulin 22 units subcutaneously 30 minutes before breakfast, and 30 units 30 minutes before
dinner, enalapril 10 mg tablet 1 po twice daily
Physical Exam/Other Studies: W 192 lb Ht 66 in BP 148/92 HR 86 RR 16
Physical exam reveals an anxious female with resolving diaphoresis. After discussing her new diet
routine, you determine that her new carbohydrate intake is actually appropriate. To avoid the
hypoglycemic episodes, her insulin regimen must be adjusted. You call her PCP's office to make a
recommendation. Which of her four insulin doses would you recommend adjusting?

9. A 32-year-old woman presents to her family medicine clinic for a hospital follow-up visit six weeks
after an admission to a local hospital where she was diagnosed with Type 2 diabetes. She had only
occasionally visited her PCP in the past and this new diagnosis of diabetes is her only outstanding
past medical history. She complains of blurry vision, increased thirst, and increased urinary
frequency. Her pre-meal blood glucose readings (breakfast, lunch, and dinner) from her home
glucometer are all in the 300-400s (mg/dL). She is compliant with her insulin regimen that was
started in the hospital, but is very concerned that she is not getting better.
Allergies: NKDA
Medications: Insulin glargine 40 units subcutaneously every evening, insulin lispro subcutaneously
per sliding scale (200-249 = 2 units; 250-299-3 units: 300-349-4 units: 350-399 = 5 units; 2 400 = 6
units)
Physical Exam/Other Studies: Wt 248 lb Ht 65 in BP 128/32 HR 78 RR 14
Urine ketone negative
Physical exam reveals an obese female distressed over uncontrolled diabetes. The PCP requests a
pharmacotherapy consult with the clinical pharmacist. You determine that the patient has
appropriate insulin injection technique and has started improving her diet. Her blood glucose levels.
have not improved since her hospital discharge. What would be the most appropriate insulin to
adjust at this time?

10. A 35-year-old woman presents to your pharmacy wanting to transfer all of her prescriptions to your
store. She explains that she recently moved to this area from across town. After calling the other
pharmacy and successfully transferring the prescriptions, you spend time gathering some history
from the patient. The patient reports that she has had Type I diabetes for 30 years and has even
developed some diabetes complications that you correctly interpret as neuropathy and
gastroparesis. She also has hypertension and dyslipidemia.
Allergies: Aspirin (rash)
Medications: Insulin glargine 30 units subcutaneously every evening: insulin glulisine 8 units
subcutaneously immediately before each main meal three times daily: pramlintide 30 mcg
subcutaneously before each main meal three times daily; metoclopramide 10 mg tablet 1 po four
times daily with meals and at bedtime; lisinopril 40 mg tablet 1 po daily; hydrochlorothiazide 25 mg
tablet 1 po daily; lovastatin 40 mg tablet I po every evening
Physical Exam/Other Studies: Wt 148 lb Ht 64 in BP 108/72 HR 72
 No labs are available at this time. The patient complains of frequent nausea. She can't eat very much
food because she "gets full" so easily and just doesn't feel like eating. As a result, she often skips
meals. Her blood glucose levels have been very erratic with many high readings mixed with low
readings. She said this all started a few months ago when some new medications were added to her
regimen.
After assessing her medications and her recent history, you realize that there is a contraindication
against the use of one of her medications. You tell her that you are going to call her PCP to discuss
stopping one of her drugs. Which drug should you recommend stopping at this time?

11. A 46-year-old woman presents to her physician complaining of feeling tired, lethargic, and not being
able to think straight for the past four months. She also mentions that she is always turning the heat
up at home while her husband is sitting around in a t-shirt. She wonders if maybe she is starting to
go through menopause and would like a medication to help her have more energy. She has no other
medical conditions that she is aware of at this time.
Allergies: Penicillin (rash)
Medications: None
Physical Exam/Other Studies: Wt 165 lb Ht 65 in T 97.1°F BP 141/78 HR 63 RR 16 O, sat 98%
Physical exam reveals dry skin, periorbital edema, and a normal thyroid gland. TSH 10.1 FT, 0.65
She is given a diagnosis of hypothyroidism What is the best treatment for her hypothyroidism?

12. A 30-year-old woman presents to her physician complaining of palpitations, anxiety, diarrhea, and
weight loss that has been progressively getting worse over the past several months. She also
mentions that she has not been getting her menstrual periods for about the same time period. Her
past medical history is unremarkable.
Allergies: Sulfa (rash)
Medications: None
Physical Exam/Other Studies:
Wt 135 lb Ht 65 in T 99.1°F BP 138/80 HR 140 RR 20 O, sat 98%
Physical exam reveals fine hair, positive lid lag, mild proptosis, enlarged thyroid with a positive bruit,
tachycardia, and a fine tremor when her hands are outstretched. TSH <0.01 FT, 7.3 TT, 15
She is given a diagnosis of hyperthyroidism-likely Graves disease.
In addition to propranolol to control her heart rate, and until she decides whether she wants
surgery or radioactive iodine treatment, what medication could be prescribed to possibility help
her achieve remission of her hyperthyroidism?

13. A 48-year-old woman presents to her physician complaining of palpitations, diarrhea, and weight
loss that has been progressively getting worse over the past several months. She is diagnosed with
hyperthyroidism and scheduled to undergo radioactive iodine treatment. Her past medical history is
unremarkable.
Allergies: NKDA
Medications: None
Physical Exam/Other Studies: Wt 145 lb Ht 67 in T 96.1°F BP 128/78 HR 125 RR 18 O, sat 98%
 Physical exam reveals fine hair, mild proptosis, enlarged thyroid with a positive bruit, and
tachycardia. TSH < 0.01 What medication could be prescribed temporarily to help inhibit thyroid
hormone release following her radioactive iodine treatment?

14. A 19-year-old woman presents to her primary care provider with concerns about her acne. She has a
history of facial acne since age 15. Initially, benzoyl peroxide plus erythromycin gel was beneficial. |
but it caused excessive drying. Adapalene was used next and it controlled her acne for about six
months, but the acne worsened and oral antibiotics were added. Most recently, she has completed
two, three-month courses of minocycline over the past six months that have failed to control her
acne outbreaks. She has also noted some scarring from her acne and cyst formation the past few
months. Allergies: NKDA Medications: Adapalene topical gel applied daily after washing face;
combined oral contraceptive tablet 1 po daily Physical Exam/Other Studies: Wt 125 lb Ht 64 in T
98.5°F BP 110/70 HR 77 RR 16 Physical exam reveals multiple acne lesions on her face and chest
areas. Some cystic lesions and scar ring are also present. SCr 1.0 Fasting glucose 80
Which of the following medications would be the best option to improve her acne and reduce the
number of acne lesions?
a. doxycycline
b. azelaic acid
c. isotretinoin
d. benzoyl peroxide

15. A 14-year-old boy is seen at his dermatologist's office for acne. One month ago, he was started on
tazarotene. His acne was cleared by the medication, however he has experienced skin dryness. He
would like to try another agent.
Allergies: Tetracyclines (rash, hives, facial swelling)
Medications: Tazarotene 0.1% gel applied to affected areas daily
Physical Exam/Other Studies: Wt 155 lb Ht 70 in T 98.5°F BP 110/70 HR 75 RR 18
Physical exam reveals multiple acne lesions on face and chest and back.
Which of the following agents would be appropriate to start at this point?
a. tretinoin
b. oral minocycline
c. isotretinoin
d. topical erythromycin

16. A 14-year-old boy is seen at his dermatologist's office with complaints of acne. He has been
experiencing multiple breakouts of acne lesions on his face, chest and back. He has been trying over-
the-counter medications containing salicylic acid, but they are not working very well to clear the
lesions. He has no medical conditions.
Allergies: NKDA
Medications: Salicylic acid 2% acne wash (OTC) twice daily
Physical Exam/Other Studies: Wt 155 lb Ht 70 in T 98.5°F BP 110/70 HR 75 RR 18
Physical exam reveals multiple acne lesions on face and chest and back.
Which of the following agents would be appropriate to start at this point?
a. isotretinoin
 b. oral minocycline
c. corticosteroids
d. tazarotene

17. An 8-year-old girl is seen at her pediatrician's office for a routine visit. She has a history of allergic
rhinitis, food allergies and atopic dermatitis. As-needed topical corticosteroids control her symptoms
normally but she has experienced some exacerbations recently that are not completely controlled
with steroids. Her mother has brought her to the clinic today to see if there is anything else to help
with the symptoms. She is concerned about using topical corticosteroids for such long periods of
time.
Allergies: NKDA
Medications: Cetirizine 10 mg tab (OTC) I po daily at bedtime; mometasone nasal spray I spray in
each nostril daily: triamcinolone acetonide lotion 0.1% applied to affected areas daily
Physical Exam/Other Studies: Wt 65 lb Ht 51.6 in T 98.5°F BP 110/70 HR 86 RR 18
Physical exam reveals multiple areas of eczematous skin lesions on the torso, extremities and face.
Several of the lesions are excoriated and appear inflamed. What would be an appropriate topical
therapy to begin that may improve the patient's symptoms?

18. A 55-year-old woman with a 30+ year history of plaque type psoriasis presented to the outpatient
dermatology clinic two days ago with another flare-up of her psoriasis. She was diagnosed at age 23
and initially responded to topical therapy with coal tar products and corticosteroids. She
subsequently required photochemotherapy using psoralens with UVA phototherapy. Five years ago,
she started on oral methotrexate. This had kept her condition under control until recently. Now she
is having worsening and more frequent exacerbations of her psoriasis.
Allergies: Topical psoralens (rash, severe skin reactions)
Medications: Methotrexate 5 mg tablet 1 po three times per week; lisinopril 10 mg tablet I po every
morning
Physical Exam/Other Studies:
Wt 140 lb Ht 63 in T 99.0°F BP 128/88 HR 80 RR 20
Physical exam reveals multiple plaques on arms, legs, back and scalp
Which of the following pharmacotherapies would be the best therapeutic option for this
patient to reduce her psoriasis symptoms?
a. cyclosporine
b. topical coal tar
c. methoxsalen
d. infliximab

19. A 26-year-old woman with type 1 diabetes mellitus presents with complaints of suprapubic pain,
dysuria, vomiting, weakness, and dizziness. Physical examination and laboratory evaluation reveal
the presence of diabetic ketoacidosis (DKA) probably precipitated by UTI and stress. The primary
goals of therapy are to appropriately rehydrate the patient, correct the acidosis, replete the
electrolyte deficiencies, and gradually correct the hyperglycemia. Intravenous insulin should be used
initially, as subcutaneous or intramuscular absorption may be impaired in DKA patients who are
 dehydrated. As the DKA resolves, students are asked to reestablish a subcutaneous insulin regimen
that will ultimately lead to normoglycemia.
1. :_______
a. What signs, symptoms, and laboratory findings indicate the presence and severity of diabetic
ketoacidosis in this patient?
b. What are the diagnostic criteria for DKA?
c. What problems beyond hyperglycemia are encountered in DKA that may require
intervention?
2. 2. What are the goals of therapy for this patient?
3. What therapies are available to correct the metabolic derangements of DKA?
4. Outline your specific plan for providing the IV fluids and medications that should be admin
istered to this patient.
5. :_______
a. What monitoring is necessary for the therapeutic plan that you developed for the patient?
b. What changes in the therapeutic regimen should be considered when the blood glucose
drops below 250 mg/dL or the potassium drops into the range of 3.3 to 5.0 mEq/L? Provide
the rationale for your answer.
c. When is the DKA considered to be resolved, and when can IV insulin therapy be converted to
subcutaneous therapy?
d. Outline a plan for converting the patient from IV to subcutaneous insulin after resolution of
the DKA.
6. How should patients be informed about self-management on a "sick day" (ie., when they are
anorectic, nauseated, or vomiting)?
7. Are there any other medications that should be added to her regimen based on her presenting
laboratory values and/or HPI? What, if any, lifestyle recommendations would you make?
8. Describe the non-pharmacologic approaches that should be taken to prevent further
complications associated with diabetes, including the prevention of future episodes of UTI.

 Answers:
1. first line is Metformin ,2nd line sulfonylureas
2. Sulfonylureas
3. Thiazolidinedione(Pioglitazone and rosiglitazone)
4. Thiazolidinedione(Pioglitazone and rosiglitazone)
5. Metformin
6. Dipeptidyl Peptidase-4 Inhibitors(: sitagliptin, saxagliptin, linagliptin, and alogliptin, )
7. Glucagon Like peptide-1 Receptor Agonist, such as semaglutide, Liraglutide.
8. Basal insulin
9. Long acting Basal insulin
10. Hydrochlorothiazide
11. Levothyroxine (L-thyroxine, T4) is considered to be drug of choice for treatment of
hypothyroidism
 12. _
13. Blocker such as propranolol and atenolol.
14. C. isotretinoin
15. D. topical erythromycin
16. A. isotretinoin
17. _
18. A. cyclosporine

19.__________

1) a. Pain, Dysuria, Vomiting, Weakness, Anddizziness.

b. Criteria:
 Diabetic ketoacidosis is distinguished from other diabetic emergencies by the presence of
large amounts of ketones in blood and urine, and marked metabolic acidosis.
Hyperosmolar hyperglycemic state (HHS, sometimes labeled "hyperosmolar non-ketotic
state" or HONK) is much more common in type 2 diabetes and features increased plasma
osmolarity (above 320 mosm/kg) due to profound dehydration and concentration of the
blood; mild acidosis and ketonemia may occur in this state, but not to the extent observed
in DKA. There is a degree of overlap between DKA and HHS, as in DKA the osmolarity may
also be increased.[1]
 Ketoacidosis is not always the result of diabetes. It may also result from alcohol excess
and from starvation; in both states the glucose level is normal or low. Metabolic acidosis
may occur in people with diabetes for other reasons, such as poisoning with ethylene
glycol or paraldehyde.[1]
 The American Diabetes Association categorizes DKA in adults into one of three stages of
severity:
 Mild: Blood pH mildly decreased to between 7.25 and 7.30 (normal 7.35–7.45); serum
bicarbonate decreased to 15–18 mmol/l (normal above 20); the person is alert
 Moderate: pH 7.00–7.25, bicarbonate 10–15, mild drowsiness may be present
 Severe: pH below 7.00, bicarbonate below 10, stupor or coma may occur
c. DKA is a medical emergency, and without treatment it can lead to death. DKA was first
described in 1886; until the introduction of insulin therapy in the 1920s, it was almost universally
fatal. It now carries a mortality of less than 1% with adequate and timely treatment
2) The primary goals of therapy are to appropriately rehydrate the patient, correct the acidosis,
replete the electrolyte deficiencies, and gradually correct the hyperglycemia.
The therapeutic goals of DKA management include:
 optimizationof volumestatus;
 hyperglycemia and ketoacidosis;
 electrolyte abnormalities; and
 potential precipitating factors
3) Bicarbonate supplement
Rehydrate with normal saline, then follow with.45%NaClthenD5.45NS (orother)
Restore electrolytes, ECGs, Hourly blood sugars, IV insulin, Avoid bicarbonate as can affect serum
K+.
4) The amount of fluid replaced depends on the estimated degree of dehydration. If dehydration is
so severe as to cause shock (severely decreased blood pressure with insufficient blood supply to
the body's organs), or a depressed level of consciousness, rapid infusion of saline (1
literforadults,10 ml/kg is recommended to restore circulating volume. Slower rehydration based
on calculated water and sodium shortage may be possible if the dehydration is moderate, and
again saline is the recommended fluid
5)
a. Bloodglucose Electrolytes, volume of fluid should be monitored during treatment

b. Constant in fusion of a fixed dose of insulin and the administration of IV glucose when the
BG level decreases to less than 250 mg/dL (13.9 mmol/L)is prefer able to titration of the
insulin infusion based on the glucose level.
Continuous IV infusion of regular insulin is preferred.
Use IM route only if infusion is not available.
Bolusdose: 0.1 units/kg IV, Maintenance dose: 0.1units/kg/h IV
If blood glucose level has not decreased by50–75mg/dL after 1 hour, double infusion rate.
Once blood glucose reaches 200mg/dL, reduce infusion rateto 0.05–0.1units/kg/h and
change fluid to 5% dextrose with 0.45% NaCl (do not stop insulin infusion). When SC
insulin can be initiated, administer dose 1–2 hours before discontinuing IV infusion.
For uncomplicated DKA, SC rapid-acting insulin can be considered. A bolus dose of
0.2units/kg followed by 0.1units/kg every hour or an initial dose of 0.3units/kg followed
by 0.2units/kg every 2 hours until the blood glucose reaches 3.3mEq/L.
IfKis>5.5mEq/L, do not give K and check serum K every 2hours.
If K is >3.3 but <5.3 mEq/L, give20–30mEq in each liter of IV fluid to maintain K between 4
and 5

c. Insulin therapy to be initiated only if potassium levelsareabove3.3 mEq/L. 17 17 The latter

strategy may delay clearance of the ketosis and prolong treatment. The insulin infusion
should be continued until the urine ketones clear and the anion gap closes. Long-acting
insulin should be given 1-3 hours prior to discontinuing the insulin infusion.
Intramuscular regular insulin or subcutaneous insulin lispro or as part given every 1-2
hours can be used rather than an insulin infusion in patients without hypo perfusion.
Patients can develop hyperchloremic metabolic acidosis with treatment if they have been
given large volumes of normal saline in the course of their treatment.

d. Resolution of DKA is defined as general improvement in the symptoms, such as the ability
to tolerate oral nutrition and fluids, normalization of blood acidity (pH>7.3), and absence
of ketones in blood (<1 mmol/1) or urine.
Once this has been achieved, insulin may be switched to the usual subcutaneously
administrered regimen, one hour after which the intravenous administration can be
discontinued.
6) Attacks of DKA can be prevented in those known to have diabetes to an extent by adherence to
"sick day rules"; these are clear-cut instructions to person on how to treat themselves when
unwell.
Instructions include advice on how much extra insulin to take when sugar levels appear
uncontrolled, an easily digestible diet rich in salt and carbohydrates, means to suppress fever and
treat infection, and recommend ations when to call for medical help.
7) No
8) Diet: awareness of the types of nutrients entering the digestive system, and hence allows
indirectly, significant control over changes in blood glucose levels.
Blood glucose monitoring allows verification of these and closer control, especially important
since some symptoms of diabetes are not easy for the patient to notice without actual
measurement.