TOPIC: Megaloblastic Anemia

THERAPEUTIC DIFFICULTY: Level 2 Erica Murrell Chapter 31: Iron Deficiency and Megaloblastic Anemias Scenario Patient and Setting: EC, an 83-year-old female; home visit by nurse to perform dressing change for bedsore Chief Complaint: Pain and tingling in her lower extremities, shortness of breath, fatigue, increased anxiety, difficulty sleeping, and constipation History of Present Illness Recent bedsore due to failure to thrive after a recent hip replacement. Visiting nurse performing dressing changes discovered the patient was nonadherent with her medication regimen and had a 5% loss in weight over the last 30 days. Pharmacy consult for review of patient medications requested. Medical History: Hypertension (20 years), chronic obstructive pulmonary disease (COPD), depression, osteoporosis, gout, GERD Surgical History: Hip replacement s/p fall 1 year ago Family/Social History: Family History: Noncontributory Social History: Patient denies smoking tobacco but admits to drinking two shots of bourbon at bedtime to help with recent sleeping problems; lives alone with no family members in the area; only financial resources are her retirement check and Medicare Medications: HCTZ, 25 mg PO daily Lisinopril, 40 mg PO daily Fosamax, 70 mg PO qweek Colchicine, 0.6 mg PO QOD Pepcid, 20 mg PO BID Klonopin, 0.5 mg PO BID Zoloft, 50 mg PO daily Combivent, 2 puffs QID Ambien, 5 mg PO QHS PRN Allergies: No known drug allergies Physical Examination GEN: Frail and pale, moderate distress VS: 126/80, HR 75, RR 14, T 37.8_C, Wt 50 kg HEENT: Pale conjunctiva, pale and dry mucous membranes COR: RRR CHEST: Bilateral wheezes ABD: Soft, slightly tender, decreased bowel sounds GU: Deferred RECT: Guaiac negative stool EXT: Slow capillary refilling with slightly pale nail beds and palms of hands, dry and flaky skin, level 2 bedsore noted slightly below the lower back area NEURO: Alert, oriented to person, place, and time Results of Pertinent Laboratory Tests, Serum Drug Concentrations, and Diagnostic Tests
Na 147 (147) Hgb 100 (10) Albumin 31 (3.1) K 4.0 (4.0) MCV 110 (110) Uric acid 428 (7.2) Cl 97 (97) MCH 1.8 (29) Glucose 5.8 (105) HCO3 26 (26) RDW 0.16 (16) Serum B12 98.1 (133) BUN 8.9 (25) Ca 2.1 (8.4) Serum Fo- 20 (8.8) late Cr 97.2 (1.1) PO4 0.94 (2.9) Hct 0.30 (30) Mg 1.0 (2.0) Peripheral blood smear: normochromic, macrocytic RBCs

Problem List Identify principal problems from the scenario in priority order (see Answers in back of book for correct list of problems). 1. Dehydration 2. Vitamin B12 deficiency 3. Involuntary weight loss 4. Bedsore 5. Constipation 6. Gout 7. Nonadherence SOAP Note To be completed by the student (see Answers in back of book for correct SOAP Note). S: Complains of pain and tingling in her lower extremities, shortness of breath, fatigue, increased anxiety, difficulty sleeping, and constipation O: BP 126/80, HR 75, RR 14, T 37.8_C, Wt 50 kg, pale conjunctiva, pale and dry mucous membranes; bilateral wheezes; guaiac-negative stool; slow capillary refill with slightly pale nail beds and palms of hands, dry and flaky skin, level 2 bedsore noted slightly below the lower back area Labs: Na 147 (147), Hgb 100 (10), MCV 110 (110), serum B12 97.8 (133), albumin 31 (3.1), uric acid 428 (7.2), Ca 2.1 (8.4), Cr 97.2 (1.1), BUN 8.9 (25) Peripheral blood smear shows normochromic, macrocytic RBCs. P: PROBLEM 1: Dehydration Encourage oral liquids such as water, Pedialyte, and Ensure. Monitor I and O daily. Monitor weight, physical signs, and vital signs weekly. Monitor electrolytes biweekly. Avoid alcohol use. PROBLEM 2: Vitamin B12 Deficiency Start Vitamin B12 therapy (not in priority order). Option 1Oral: Adequate absorption 1 to 10 g daily; malabsorption 1,000 g daily Option 2Parenteral: 500 to 1,000 g daily for 1 week, then weekly for 1 month, then monthly for life OR 1,000 g weekly for 4 weeks, then every month for life OR 100 g daily for 1 week, then every other day for seven doses, then every month for life Option 3Intranasal: 500 g once a week Use the lowest dose possible of medications that could increase risk, such as colchicine and Pepcid. Consider having the patient use Tums instead of Pepcid to control her symptoms. Increase the amount of vitamin B12-rich foods in her diet (fresh liver, eggs, meat, kidney, milk, dairy products, fish, and shellfish). Monitor vitamin B12 and iron levels, response to therapy: signs and symptoms, complications of therapy. Recheck levels in 1 month. PROBLEM 3: Involuntary Weight Loss Assess dentition and swallowing to ensure that this is not the cause. If so, then address the problem as needed. Assess current eating patterns and ways to enrich foods eaten.

May need to connect her to a delivery meal service that will bring her meals at home, such as a Meals-on-Wheels program. Institute nutritional support that includes macro and micronutrients such as Ensure, a multivitamin, and so forth. The amount of servings daily would be based on her current eating patterns. If finances are also a problem, check with community resources for seniors, which may provide vouchers. Consider short-term therapy with an appetite stimulant such as Remeron, Marinol, megestrol acetate, or cyproheptadine. Avoid alcohol.

QUESTIONS (See Answers in back of book for correct responses.) 1. What predisposing factor places EC at a greater risk for developing vitamin B12 deficiency? (E-03) a. GERD b. Bedsore c. Elderly d. Postmenopausal status 2. What lab finding coupled with a decreased vitamin B 12 level would suggest vitamin B12 deficiency? (E0-05) a. Decreased iron level b. Increased folate level c. Decreased homocysteine level d. Increased MCV level 3. List the potential causes of vitamin B12 deficiency to consider in EC. (EO-01) Inadequate dietary intake Malabsorption: consider potential causes including low intrinsic factor, disorders of the terminal ileum, drugs Transcobalamin II deficiency (impairs B12 transport) Drug-induced causes 4. A physical assessment finding of ECs that is consistent with anemia is: (EO-05) a. T 37.8_C b. Wt 50 kg c. Slow capillary refilling d. Pale nail beds 5. List the signs and symptoms of anemia. (EO-02) Fatigue, shortness of breath, tingling of extremities 6. Which of the following medications is the most likely contributor to ECs B12 deficiency? (EO-09) a. Colchicine b. HCTZ c. Zoloft d. Lisinopril 7. Vitamin B12 must be obtained through dietary intake or supplementation because it contains which of the following elements? a. Zinc b. Iron c. Cobalt d. Selenium 8. Vitamin B12 is stored primarily in which of the following organs? a. Kidney b. Spleen c. Gallbladder d. Liver

PROBLEM 4: Bedsore Continue dressing changes per nursing. Institute nutritional support that includes macro and micronutrients such as Ensure and multivitamins. Increase fluid intake. Ensure proper positional rotation to help prevent a lack of blood supply to the area. PROBLEM 5: Constipation Assess current frequency and consistency along with her regular pattern. Recommend Bisacodyl for immediate relief and then Colace 100 mg BID. Increase fluid intake to eight 8-oz glasses of water a day. Increase fiber/grains, fruits, and vegetables. Monitor for frequency, consistency, and symptoms of constipation. PROBLEM 6: Gout Flare For flare, take two tabs, then one tab every 1 to 2 hours until relief or maximum of 8 mg is taken. Discourage alcohol use. Check for adherence; if patient has not taken the medications, encourage her to do so in the future. Encourage adequate fluid intake (eight glasses a day). Monitor uric acid level, response to therapy: signs and symptoms. Consider risk versus benefit of drug therapy in an older patient. PROBLEM 7: Nonadherence Review current medications and assess for any type of pattern regarding which medications she is more adherent with versus not (e.g., taking half the dose, skipping certain days, frequent/recent regimen changes, and so forth). Asses reasons for nonadherence: financial, cannot organize the medications, cannot remember to take the medications, confused as to which medications to take, needs assistance in obtaining the medications from the pharmacy. Assess community resources and insurance limitations and possibly locate a pharmacy that will blister pack her medications and deliver them to her. If not possible, then teach the patient to prefill a pill box to help her remember to take her medications for the day. If delivery is a problem and a pharmacy that delivers cant be found, check community resources for seniors, which may be able to deliver her medications to her. Discourage alcohol use.

9. List pros and cons of oral, parental, and intranasal forms of B12 supplementation. (EO-11) Treatment options (not in priority order): a. Oral vitamin B12 1,000 g daily Advantages: Cost-effective, self-administered Disadvantages: Erratic absorption, poor adherence, due to age would want higher dosing regimen b. Parenteral vitamin B12 Advantages: More predictable levels, increased adherence with home visit Disadvantages: Varied recommended doses, decreased lean muscle mass of elderly, pain on injection, possible allergic reaction, cost of home health visit c. Intranasal vitamin B12 Advantages: Three times a week, self administered, well tolerated Disadvantages: Costly, long-term data lacking 10. Develop an education plan for EC regarding the treatment option you would select for EC and why that is the best option for her. (EO-14) Education plan for vitamin B12 therapy a. Lifestyle changes: improving diet, eating habits b. Medication counseling: therapy is for life, importance of adherence i. Oral: Take daily ii. Parenteral: Pain at injection site, keep area clean iii. Intranasal: Lightly clean the area 11. What psychosocial factors may affect ECs adherence to both pharmacologic and nonpharmacologic therapy? (EO-15) Psychosocial factors that may affect adherence a. Patient-specific factors: Assess how such things as her immobility, lack of socialization, and limited finances are affecting, her quality of life and might affect her adherence. Also consider how her new dietary suggestions could affect her limitations. b. Disease factors i. Depression: Assess how this could be affected by her current state (e.g., immobility, finances) ii. Anxiety: Assess how this could be affected by her current state (e.g., immobility, finances) iii. Sleep disturbances: Assess how this could be affected by her current state (e.g., immobility, finances) c. Others i. Supply EC with an advocate since she has no family in the area. ii. Assist EC in finding financial resources as well as resources with meals, supplements, and so forth. 12. Describe the health care providers role in managing ECs vitamin B12 deficiency. (EO-16) Health care providers role a. Assist in the follow-through and adjustment of her plan (both pharmacologic and nonpharmacologic aspects). b. Maintain close follow-up/contact with the patient; develop a good relationship. c. Educate the patient on her disease states. d. Counsel the patient on medications. e. Encourage the patient and provide positive reinforcement. f. Make referrals as needed.

13. Evaluate the pharmacoeconomic considerations relative to ECs plan of care. (EO-17) Pharmacoeconomic considerations a. Cost of therapeutic options b. Cost of managing the disease at home versus at a hospital or skilled nursing facility i. Institution personnel, overhead, treatment, complications, and so forth ii. ECs decreased productivity and quality of life, pain and suffering 14. Summarize the therapeutic, pathophysiologic, and disease management concepts for megaloblastic anemias utilizing a key points format. (EO-18) Anemias are often indicative of another underlying pathology, so a complete evaluation of the cause is necessary. Symptoms of anemia include fatigue, shortness of breath, and neurologic symptoms. Inadequate intake and decreased absorption are two potential cause of vitamin B12 deficiency; therefore, consider evaluating nutrition and the potential effects of other medications on absorption of vitamin B12. Response to therapy may occur in the first week, but correction of the anemia may take longer. Assessments for potential causes of macrocytic anemia include an evaluation of lean body mass, factors that may decrease GI absorption, and economic constraints, particularly in the elderly population. Adherence to pharmacologic and nonpharmacologic interventions should be encouraged and frequently evaluated

TOPIC: Topic: Diabetes Mellitus

THERAPEUTIC DIFFICULTY: Level 3 Stephen M. Setter and Jason L. Iltz Chapter 40: Diabetes Scenario Patient and Setting: AJ, a 65-year-old African American male; ambulatory clinic Chief Complaint: The patient has been experiencing a tingling sensation in his hands and some numbness in his feet. History of Present Illness The patients abnormal sensations in his extremities began roughly 4 months ago and seem to be progressing. Medical History: Diabetes diagnosed 12 years ago; hypertension (HTN) for 15 years; dyslipidemia; non-ST elevation myocardial infarction (MI) 3 years ago; depression x 3 years; history of angina prior to CABG Surgical History: Four (quadruple) coronary artery bypass grafts (CABG) 3 years ago; renal cyst removed at age 45; appendectomy at age 12. Family/Social History: Family History: Mother died at age 78 with CHF; father died of Alzheimers disease at age 81 Social History: Divorced 7 years ago, lives alone. Cigarette smoker 2 packs/day for 45 years; 24 alcoholic drinks per day Medications: Hydrochlorothiazide (HCTZ), 50 mg BID Propranolol, 40 mg BID Nitroglycerin (NTG), 0.4 mg sublingual PRN for chest pain Metformin, 500 mg bid Niacin immediate release, 1 g TID (OTC, selfmedicating) Allergies: No known medication allergies Physical Examination GEN: Well-developed, well-nourished man in no apparent distress; alert and cooperative, somewhat flat affect VS: BP 148/92, HR 54, RR 16, T 37_C, Wt 118 kg, Ht 183 cm HEENT: WNL COR: No heaves or thrills; regular rate and rhythm, 54/min S1 and S2 heard well without splits; no murmurs or rubs; neck veins nondistended
Pulses R L Carotid 2_ 2_ no bruits (2__normal) Femoral 2_ 2_ no bruits AT 1_ 1_ no bruits PT 1_ 1_ no bruits

Results of Pertinent Laboratory Tests, Serum Concentrations, and Diagnostic Tests

Na 135 [135] HCO3 26 [26] Glu 10.82 mmol/L [195] K 3.9 [3.9] BUN 9.6 [27] A1C 9.5% (_7.0%) Cl 99 [99] Cr 123 [1.4] Hct 0.49 [49] Plts 200 _ 109 T Bili 8.55 [0.5] Alb 40 [4.0] [200 _ 103] TC6.6 mmol/L [255 mg/dL] Alk Phos 90 [90] MCV 79 [79] LDL 4.58 mmol/L [177 mg/dL] Hgb 163 [16.3] AST 65 [65] HDL 0.80 mmol/L [31 mg/dL] Uric Acid 452 [7.6] ALT 40 [40] TG 2.66 mmol/L [235 mg/dL] LDH 200 [200] Ca 2.2 [8.8] Ggt 90 [90] PO4 0.97 [3.0] Lkc differential: WNL Urine dipstick (Uristix): 1_ protein Ankle Brachial Index (ABI): L: 0.65, R: 0.75 Geriatric Depression Scale (GDS): 12 of 30

Problem List Identify principal problems from the scenario in priority order (see Answers in back of book for correct list of problems) 1. Poorly controlled type 2 diabetes mellitus (DM) 2. Hypertension 3. Proteinuria 4. Dyslipidemia 5. Nicotine addiction 6. Diabetic peripheral neuropathy 7. Depression 8. Peripheral arterial disease 9. Coronary artery disease (history of angina prior to CABG) SOAP Note To be completed by the student (see Answers in back of book for correct SOAP Note). S: I am having tingling sensations in both of my hands, and my feet are numb. O: A1C 9.5%, FBG 195, BP 148/92, 1+ankle edema, protein 1+, 118 kg BW, diminished pedal pulses (1 of 2+), nonresponse to 10-g monofilament, Cr 1.4, BUN 27, uric acid 7.6, TC 255, LDL 177, HDL 31, TG 235, ABI 0.65 (L), 0.75 (R), MI x 1, metformin for DM, propranolol and HCTZ for HTN, NTG for angina (PRN), self-treatment with niacin for dyslipidemia A: PROBLEM 1: Poorly controlled type 2 DM due to suboptimal therapies (metformin dose too low, too much HCTZ, monotherapy approach, and advanced diabetes) Titrate metformin carefully to 1,000 mg BID. Consider initiation of a basal insulin (e.g., insulin glargine, NPH) and/or addition of a sulfonylurea. Consider initiation of a thiazolidinedione (third line) if insulin or a sulfonylurea is not started. Change HCTZ to 25 mg BID (doses >50 mg/d are associated with insulin resistance). Initiate low-dose ASA therapy (75325 mg). Monitor serum creatinine (metformin is contraindicated with SCr 1.5 or higher in males). Regular self-monitoring of blood glucose. Repeat A1C in 3 months. Refer for diabetes education, preferably by a certified diabetes educator. Discuss importance of regular physical activity (exercise) with physician oversight. Refer to dietitian who specializes in diabetes. Monitor medication compliance. Ensure dilated ophthalmologic exam once yearly.

CHEST: No chest wall deformities; no vertebral tenderness; lungs resonant to percussion; vesicular breath sounds throughout, without crackles, rhonchi, wheezes, or rubs ABD: Moderately protuberant, soft, nontender, no masses; liver and spleen not enlarged GU: WNL RECT: Deferred EXT: 1_ edema bilateral LE, unable to discern 10 g monofilament on plantar surface of feet or on the distal half of the dorsal surface; capillary refill at 2 seconds NEURO: Alert, cranial nerves II, III, VII, VIII, IX, X, XI, XII intact; deep tendon reflexes of biceps, knees, and ankles are normal; Romberg and Babinski negative; gait: walks easily without ataxia; no tremor or pronator drift noted

PROBLEM 2: HTN Due to suboptimal therapy and presence of Type 2 DM ADA-recommended BP goal is below 130/80 mm Hg. More stringent BP goal of 125/75 if patient has kidney disease with proteinuria (>1 g/24 h). Initiate ACE inhibitor (ACE inhibitor plus HCTZ for BP control; ACE inhibitor is beneficial post-MI). If ACE inhibitor + HCTZ do not control BP, then consider adding non-dihydropyridine calcium channel blocker (ACE inhibitors and ARBs may not be as effective in lowering BP in African Americans, but this lack of efficacy may be negated by the addition of a diuretic). Monitor electrolytes (ACE inhibitor/HCTZ can alter electrolytes, in particular K_, so be cautious about the use of potassium-containing salt substitutes). Monitor for ACE inhibitorinduced cough (switch to ARB if ACE inhibitor intolerable). Decrease HCTZ to 25 mg BID (doses >50 mg/day are associated with hyperglycemia). Discontinue propranolol (associated with depression, adverse lipid effects, making of hypoglycemia, and heart rate <60 bpm). ASA therapy as above PROBLEM 3: Proteinuria Due to Type 2 DM Reassess with timed collection (e.g., 4 hour), 24-hour collection, or albumin to creatinine ratio (spot) (two of three specimens collected within a 3- to 6-month period should be abnormal before being classified as having microalbuminuria/macroalbuminuria). Refer patient to a physician experienced in diabetic kidney disease (e.g., nephrologist). Add ACE inhibitor or ARB (see Problem 2 above). Continued surveillance of parameters of kidney disease (microalbuminuria, serum creatinine) Avoid nephrotoxic medications. PROBLEM 4: Dyslipidemia Screen for and modify, if possible, secondary causes of dyslipidemia [thiazide diuretics can increase LDL, blockers without ISA can increase triglycerides and decrease HDL, smoking decreases HDL, diabetes (uncontrolled hyperglycemia) decreases HDL and increases triglycerides, excessive alcohol intake increases triglycerides, kidney disease can increase triglycerides]. Discontinue -blocker therapy and add ACE inhibitor (see Problem 2 above). Decrease thiazide diuretic dose (see Problem 2 above). Tight glycemic control Medical nutritional therapy and physical activity Lifestyle modification (smoking cessation, decrease alcohol intake, weight loss) Discontinue OTC niacin (associated with hyperglycemia and increased uric acid levels; increases LFTs). Add a high-potency HMG-CoA reductase inhibitor to achieve a standard LDL cholesterol goal of below 100 mg per dL, with an optimal goal of less than 70 mg per dL (continue to monitor LFTs closely). Fasting lipid profile baseline, 6 to 8 weeks after medication and/or dosage change and every 6 to 12 months when stable LFTs baseline, 6 to 8 weeks after medication and/or dosage change and every 6 to 12 months when stable

Educate regarding signs and symptoms of myopathy and rhabdomyolysis.

PROBLEM 5: Nicotine addiction Recommend smoking cessation counseling. Assess level of nicotine dependence. Consider use of nicotine replacement therapy. ASA therapy as above (diabetes, smoking, HTN, and dyslipidemia places patient at increased risk for thrombosis) PROBLEM 6: Peripheral neuropathy due to poorly controlled Type 2 DM Reinforce importance of glycemic control and its relationship to neuropathic symptoms. Consider pharmacologic management such as amitriptyline, venlafaxine, or duloxetine (may also improve depressive symptoms). Stress importance of foot care and self-care behaviors. PROBLEM 7: Depression associated with having chronic disease (Type 2 DM) and MI Recommend pharmacotherapy and/or psychotherapy. Pharmacotherapy may include use of a dual norepinephrine/serotonin reuptake inhibitor such as duloxetine or venlafaxine to assist with neuropathy control. Monitor depression and consider referral to psychiatrist. Assess compliance with medications and other lifestyle practices, as depression is associated with suboptimal self-care attitudes and practices. PROBLEM 8: Peripheral artery disease due to atherosclerosis accelerated by Type 2 DM, smoking, dyslipidemia, and HTN ASA therapy as above Reassess 3 to 6 months after lipid, BP, blood glucose, and smoking cessation approaches have been initiated. PROBLEM 9: Coronary artery disease (Angina) Due to atherosclerosis accelerated by Type 2 DM and HTN Adequately controlled at present Refill nitroglycerin q 6 months once bottle opened or once yearly for unopened bottles. If symptoms return, the addition of a non-dihydropyridine calcium channel blocker can help control angina (see Problem 2 above). QUESTIONS (See Answers in back of book for correct responses.) 1. The probable cause of AJs neuropathy is: (EO-1) a. Peripheral vasoconstriction secondary to smoking b. High-dose thiazide diuretic therapy c. Poorly controlled diabetes d. PAD

2. List signs and symptoms of hypoglycemia and hyperglycemia. (EO-2) Hypoglycemia: Hyperglycemia: Feeling weak or dizzy Hunger Nervousness Increased thirst Tremor Frequent urination Confusion Blurred vision Increased sweating Fatigue Tachycardia/palpitations Weight loss Hunger Poor wound healing Irritability 3. Which of the following Ankle Brachial Index (ABI) values is diagnostic for peripheral arterial disease? (EO-1) a. >1.3 b. <1.3 c. >0.9 d. <0.9 4. Which laboratory parameters can be adversely affected by the use of niacin therapy? (EO-5, 9) LFTs, blood glucose levels, uric acid levels 5. Describe the mechanisms of action of metformin. (EO-7) Decreased gluconeogenesis/glycogenolysis in the liver and increased peripheral uptake and utilization of glucose into skeletal muscles 6. Identify factors (medical conditions or drug therapies) that may predispose AJ to the development of hyperkalemia. (EO-4, 8, 10) Kidney disease, development of rhabdomyolysis, ACE inhibitor therapy 7. AJ is placed on atorvastatin 40 mg as a starting dose to assist in lowering his cholesterol. What are the appropriate counseling points to consider for this new therapy? (EO10, 14) Counseling points: Can be taken without regard to meals or time of day (atorvastatin longer half-life) Headache and GI upset are most common. If GI upset is an issue, take with food. Educate regarding signs/symptoms of myopathy and rhabdomyolysis (e.g., bilateral muscle pain, weakness, and/or tenderness, especially if accompanied by fever or malaise). If you miss a dose, take it as soon as you can. If it is almost time for your next dose, take only that dose. Do not take double or extra doses. Keep out of the reach of children in a container that small children cannot open. Store at controlled room temperature between 20_C and 25_C (68_F to 77_F). Keep container tightly closed. Throw away any unused medicine after the expiration date. 8. Which of the following medications is FDA approved for the treatment of painful diabetic peripheral neuropathy? (EO-8, 11, 12) a. Duloxetine b. Gabapentin c. Amitriptyline d. Capsaicin

9. Which of the following medications can interact with ACEI therapy? (EO-9) a. Simvastatin b. Ibuprofen c. Glyburide d. Warfarin 10. AJ is forced to switch insurers. His current cholesterol treatment includes atorvastatin 40 mg daily. His new insurance company covers simvastatin only. Which of the following doses of simvastatin would be equivalent to atorvastatin 40 mg? (EO-17) a. 10 mg b. 20 mg c. 40 mg d. 80 mg 11. Which of the following ethic groups have the highest incidence of diabetes? (EO-3) a. Pima Indians b. African Americans c. Caucasians d. Pacific Islanders 12. AJ has uncontrolled hyperglycemia. Which of the following medication pairs can be associated with druginduced hyperglycemia? (EO-10, 11) a. Niacin/thiazide diuretic b. ACEI/niacin c. ASA/ACEI d. HMG CoA Reductase Inhibitor/Beta Blocker 13. List absolute contraindications to metformin therapy. (EO-4, 6, 8) Serum creatinine 1.5 or more in males, 1.4 or more in females; sepsis; kidney failure; cardiogenic shock; administration of IV iodinated contrast material 14. Which of the following side effects is most often reported with the use of ACE inhibitors? (EO-10) a. Alopecia b. GI upset c. Nonproductive cough d. Headache 15. What psychosocial factors may affect AJs adherence to both pharmacological and nonpharmacologic therapy? (EO-15) Psychosocial factors include: Depression Chronic diseases Lives alone/limited support system Physical activity may be impaired due to smoking and alcohol consumption.

16. Describe the health care providers role relative to the proposed psychosocial factors identified. (EO-16) Health care providers role includes: Detailed treatment, monitoring, and education plan Referral to appropriate specialists, which may include endocrinologist, nephrologist, ophthalmologist, psychologist/psychiatrist, and podiatrist Referral to certified diabetes educator, dietitian, and smoking cessation program 17. Synthesize etiology, pathophysiology, epidemiology, therapeutic, and disease management concepts for diabetes utilizing a key points format. (EO-18) KEY POINTS Diabetes is for the most part an incurable disease, so the overall goals of treatment include maintaining bloodsugar levels in the normal or near-normal range and preventing the short- and long-term complications associated with this disease. Type 1 diabetes is seen primarily in children and adolescents, whereas type 2 diabetes most commonly affects those over age 45. However, with the increase in adolescent obesity, type 2 diabetes is becoming more common in younger individuals. Measuring glycosylated hemoglobin (A1C) is the gold standard for monitoring patients with diabetes, and all patients with diabetes should have this test performed one to four times yearly. Self-monitoring of blood glucose should be performed by most patients with diabetes, and the results should be reviewed regularly with a health care professional. Uncontrolled diabetes results in kidney, eye, and nerve disease that greatly compromises the quality of life of patients with diabetes, so normalization or near normalization of blood glucose is a primary treatment goal. Educating the patient with diabetes is critical to the successful management of this chronic disease. In addition to insulin, the therapeutic options to control diabetes include an array of agents that have various effects on the pancreas, muscle, and liver. The successful treatment of diabetes requires a team approach that incorporates the expertise of physicians, nurses, pharmacists, and dietitians, among others.

TOPIC: Topic: Thyroid Disorder

THERAPEUTIC DIFFICULTY: Level 2 Trisha Ford and Matthew Machado Scenario Patient and Setting: KZ, a 34-year-old female; primary care clinic Chief Complaint: Complaints of fatigue, weight gain, menstrual irregularities, and cold intolerance History of Present Illness Patient was referred for evaluation of thyroid function tests. Her physical examination had been remarkable for a goiter, dry skin, and delayed relaxation of the deep tendon muscles. Medical History: Hypertension (HTN) x 3 years; ventricular tachycardia (controlled with amiodarone for 1 year) Surgical History: NA Family/Social History: Father died of a stroke at 52; glass of red wine 2 to 3 nights a week Medications: Amiodarone, 200 mg PO QD Lisinopril, 10 mg PO QD TUMS, 1 tablet PO PRN Allergies: No known medication allergies Physical Examination GEN: Well developed, well nourished VS: BP 145/88, HR 65, RR 26, T 37.6_C, Wt 132 lb, Ht 58_ HEENT: WNL COR: RRR CHEST: WNL ABD: WNL GU: Deferred RECT: Deferred NEURO: Alert, 0 x 4 Results of Pertinent Laboratory Tests, Serum Drug Concentrations, and Diagnostic Tests
Na 136 (136) Hct 0.35 (35) AST 0.30 (18) Glu 6.1 (110) K 4.0 (4.0) Hgb 80 (8.0) ALT 0.5 (30) Ca 2.2 (8.8) Cl 100 (100) Lkcs 8.2_109 (8.2_103) LDH 1.7 (101) PO4 0.92 (2.8) HCO3 26 (26) Plts 200_109 (200_103) Alk Phos 1.5 (90) Mg (0.6) 1.2 BUN 2.6 (7.4) MCV 80 (80) Alb 40 (4.0) Uric Acid 90 (1.5) Cr 97 (1.1) T Bili 58 (3.4) TSH: 54 (54) Free T4: 51 (3.9) Total T3: 1.3 (85) Thyroid antibodies Urinalysis: NA Chest x-ray films: NA ECG: NA

SOAP Note To be completed by the student (see Answers in back of book for correct SOAP Note). S: Fatigue, weight gain, menstrual irregularities, cold intolerance O: TSH 54 mU per L (elevated); free T 4 51 pmol per L; total T3 1.3 nmol per L, BP 145/88 P: PROBLEM 1: Hypothyroidism Start thyroid replacement therapy. Per the American Thyroid Association of Clinical Endocrinologists, levothyroxine is the drug of choice. Given KZs age, the most appropriate dose would be 50 g; however, because she has a past medical history of ventricular tachycardia, the most appropriate initial dose would be 25 g. Based on the guidelines, KZ should have her TSH rechecked in 6 weeks. PROBLEM 2: Potential Amiodarone-induced hypothyroidism Confirm amiodarone-induced hypothyroidism. Typical thyroid function tests in euthyroid individuals receiving amiodarone include a reduction in FT 4 and a transient elevated TSH for the first 2 months of therapy. Monitor the FT4 and TSH every 6 months. No intervention needed at this time. PROBLEM 3: Potential interaction between tums and levothyroxine Assess the patients use of antacids and consider a nonantacid regimen. Consider use of an H2 antagonist or a proton pump inhibitor. Counsel patient on the interaction between levothyroxine and calcium carbonate-containing products and the need to space administration times by 4 hours. PROBLEM 4: Hypertension Consider increasing the lisinopril dose to 20 mg QD or adding an additional agent (e.g., hydrochlorothiazide 12.5 mg PO QD). Lifestyle modifications should be reinforced with the patient, and the patients adherence with medications should be assessed. QUESTIONS (See Answers in back of book for correct responses.) 1. KZ is experiencing symptoms consistent with which of the following? (EO-1) a. Myxedema coma b. Menopause c. Hashimotos d. Graves disease 2. A potential cause for KZs hypothyroidism is: (EO-3) a. Her cardiac history b. Amiodarone use c. Her age d. Family history

Problem List Identify principal problems from the scenario in priority order (see Answers in back of book for correct list of problems). 1. Hypothyroidism 2. Rule out amiodarone-induced hypothyroidism 3. Potential drug interaction: calcium carbonate (Tums) and levothyroxine 4. Hypertension

3. Which of the following is the most appropriate starting dose of oral levothyroxine for KZ? (EO-6) a. 25 g b. 50 g c. 75 g d. 100 g 4. When converting a patient from IV to PO levothyroxine, the recommended PO dose is % of the IV dose? (EO-6) a. 25 b. 50 c. 75 d. 100 5. Assuming KZ is to receive oral levothyroxine therapy, she should be counseled to do which of the following? (EO-14) a. Separate the levothyroxine dose from TUMS b. Discontinue the amiodarone c. Take her levothyroxine with food d. Separate the levothyroxine dose from lisinopril 6. KZs primary care provider should follow up on her thyroid levels in: (EO-12) a. 1 week b. 2 weeks c. 4 weeks d. 6 weeks 7. KZ has had several follow-up visits to assess TSH levels and adjust her levothyroxine regimen her current dose is levothyroxine 75 g PO QD. On her most recent follow-up appointment KZs TSH level was undetectable. Which of the following adjustments in her levothyroxine regimen is most appropriate? (EO-5) a. Increase the dose by 25 g b. Keep the dose the same c. Decrease the dose by 25 g d. Change levothryoxine to propylthiouracil 8. KZ has now developed hypothermia and does not recognize members of her family. She passed out at work and was picked up by EMTs who noted she was in respiratory distress. She is diagnosed with myxedema coma. What would be the most appropriate therapy for her myxedema coma at this time? (EO-12) a. Increase her oral levothyroxine dose b. IV levothyroxine c. IV steroids d. Liothryonine 9. List possible pharmacologic and nonpharmacologic treatment regimens that could be incorporated in KZs treatment plan. (EO-11) Hypothyroidism is a life-threatening condition that requires pharmacologic management. Levothyroxine is the drug of choice. Young patients, such as KZ, and patients who do not have any cardiac disease should be started on 50 g. KZ has a history of ventricular tachycardia and therefore should be started on 25 g.

10. List signs and symptoms of hypothyroidism and identify those present in KZ. (EO-2) Signs and symptoms of hypothyroidism include dry skin, cold intolerance, weight gain, constipation, weakness, changes in menstruation, lethargy, fatigue, loss of energy, depression, bradycardia, muscle cramps, and myalgia. KZ presents with fatigue, weight gain, menstrual irregularities, and cold intolerance. 11. Describe amiodarones potential effect on thyroid function. (EO-7) Amiodarones effect on thyroid function: Amiodarone can induce a hypothyroid state (incidence from 1%9.8%). No correlation with cumulative dosage or duration of therapy. Usually develops within first 2 years of therapy. Amiodarone-induced hypothyroidism is confirmed by: Elevated TSH (>10 mIU/L) Reduced FT 4 levels Routine monitoring at initiation of amiodarone and every 6 months is recommended. 12. Summarize the pathophysiology of hypothyroidism and the therapeutic management of this condition using a key points format. (EO-18) The classic symptoms of hypothyroidism include weakness, fatigue, lethargy, cold intolerance, constipation, and weight gain. Marked physical findings of hypothyroidism include a puffy and masklike facies, edematous eyelids, thickened and doughy skin changes, hair loss from the lateral aspects of the eyebrows, a large tongue, cardiomegaly, and a yellowish tint of the skin. The American Thyroid Association of Clinical Endocrinologists has published guidelines for the treatment of hypothyroidism. Practitioners should be alert to drugs that cause thyroid illness, interfere with proper laboratory interpretation, or interact with effective medical management. TSH is the most sensitive test for monitoring thyroid function. L-thyroxine is the preparation of choice for managing hypothyroidism. The dosage of L-thyroxine can be adjusted based on symptoms or TSH and FT4 levels after 6 to 8 weeks. Trough TSH levels should be obtained to minimize transient high peak FT4 levels and suppressed TSH levels, for proper interpretation of laboratory results. Once the dosage has been established, therapy should be evaluated on an annual basis.

TOPIC: Chronic Kidney Disease

THERAPEUTIC DIFFICULTY: Level 2 Susan Krikorian Chapter 43: Chronic Kidney Disease Scenario Patient and Setting: HG, a 55-year-old white female seen at her regularly scheduled PCP office visit Chief Complaint: Increasing fatigue and joint pain for several weeks, 2 lb weight gain and slight swelling of her ankles within the last week. History of Present Illness Patient attributed several weeks of increasing joint pain and fatigue to arthritis and started taking 2 tablets acetaminophen (APAP) 650 mg q 6 hours PRN with no relief; HgA1c 12% (1 week ago). Medical History: Type 1 DM since childhood; HTN for 20 years; diabetic nephropathy (microalbuminuria detected 2 years ago); chronic kidney disease (baseline SCr 1.6, 6 months ago); medication nonadherence; seasonal allergies Surgical History: TAH (10 years ago) Family/Social History: Father age 83 with HTN and CAD; mother age 83 with HTN. Married with two children; occasional alcohol use; smoked 1 pack/day x 20 years; quit tobacco 1 year ago Medications: Regular/NPH 70/30(Humulin) insulin, 30 U sc AM, 20 U sc PM HCTZ, 50 mg PO QD Lisinopril, 20 mg PO QD Calcium carbonate, 1,500 mg PO TID w/meals Calcitriol, 0.25 _g PO QD APAP, 650 mg ii tabs q6h PRN for joint pain Allergies: Amoxicillin (rash); radiocontrast dye (pruritis) Physical Examination GEN: Looks older than her stated age and appears in moderate discomfort VS: BP 154/90, HR 85, RR 18, T 37.8_C, Wt 59 kg, Ht 162 cm HEENT: PERRLA, EOMI COR: RRR, nl S1, S2 no rubs or gallops CHEST: CTA ABD: Soft, NT/ND, (-) HSM GU: Deferred RECT: Deferred EXT: Trace ankle edema bilaterally, good distal pulses, restricted ROM in joints; pain assessment 7/10 NEURO: A and O x 3 Results of Pertinent Laboratory Tests, Serum Drug Concentrations, and Diagnostic Tests
Na 140 (140) Hct 0.28 (28) K 5.2 (5.2) Hgb 90 (9.0) Cl 100 (100) Lkcs 7.5 _ 109 (7.5 _ 103) HCO3 20 (20) Plts 210 _ 103 (210 _ 2103) BUN 10 (28) SCr 167 (1.9) Ferritin: Pending Serum Iron: Pending TSAT: Pending ANA: negative Urinalysis: _ protein, hyaline casts Urine output: 10mL/hour Guaiac stool: negative Chest x-ray: unremarkable ECG: normal tracings Estimated GFR _ 29 mL/min/ 1.73 m2 (using MDRD formula)

Problem List Identify principal problems from the scenario in priority order (see Answers in back of book for correct list of problems). 1. Chronic kidney disease 2. Joint pain and renal osteodystrophy 3. Poorly controlled HTN 4. Poorly controlled diabetes and worsening diabetic nephropathy 5. Anemia SOAP Note To be completed by the student (see Answers in back of book for correct SOAP Note). S: Complains of increasing joint pain for several weeks and fatigue O: BP 154/90, HR 85, RR 18, T 37.8_C, Wt 59 kg, Ht 162 cm Medications: Humulin 70/30 20 units AM and 30 units PM; HCTZ 50 mg PO QD; lisinopril 20 mg PO QD; calcium carbonate 1,500 mg PO TID with meals; calcitriol 0.25 mcg PO QD; APAP 650 mg ii tabs q6h PRN for joint pain Trace ankle edema bilaterally; good distal pulses; restricted ROM in joints; pain assessment 7/10 BUN 10 (28), Cr 167 (1.9), Hct 0.28 (28), Hgb 90 (9.0), Glu 14.4 (260), Ca 2.0 (8.0), PO4 2.1 (6.4), Alb 37 (3.7) Ferritin: Pending Serum Iron: Pending TSAT: Pending Urinalysis: _ protein, hyaline casts Estimated GFR _ 29 mL/min/1.73 m2 P: PROBLEM 1: Chronic Kidney Disease Estimated GFR _ 29 mL/min/1.73 m 2 (steadystate SCr 1.9) Patient has signs and symptoms of progressive chronic kidney disease (e.g., proteinuria, edema, development of secondary complicationsanemia, renal osteodystrophy) Discontinue thiazide diuretic (HCTZ). Initiate loop diuretic (furosemide) and titrate dose to effect. Continue ACE inhibitor (lisinopril). Rule out renal artery stenosis and monitor serum K. Avoid nephrotoxic drugs (e.g., NSAIDs, aminoglycosides). Adjust renally eliminated drugs according to kidney function. Monitor serum K and maintain at below 5 mEq per L. Monitor daily I and O and ankle edema. Monitor serum electrolytes, weight, BP, and kidney function [include assessment of spot urine albumin-SCr ratio (mg/g)]. Assess medication adherence to antihypertensives and insulin. Counsel patient on the importance of strict BP and glucose control to delay progression of chronic kidney disease to end-stage kidney disease. Educate patient about dialysis (patients with stage 4 chronic kidney disease require early education about the future need for dialysis). Counsel patient on home BP and blood glucose monitoring.

Consider risk versus benefit of protein restriction (benefit: potentially delay progression to end-stage disease; risk: malnutrition).

PROBLEM 2: Joint pain associated with renal osteodystrophy Monitor ROM and pain severity (scale 110). Measure iPTH to evaluate degree of secondary hyperparathyroidism (elevated iPTH is likely if patient has developed renal osteodystrophy at this stage of chronic kidney disease). Correct hyperphosphatemia: Restrict dietary phosphorus intake to 800 to 1,000 mg per day. Assess patients adherence with pho sphate binder (calcium carbonate) and vitamin D supplementation. Adjust phosphate binder to achieve normal calcium and phosphorus levels; consider the effect of vitamin D therapy on calcium. Consider measuring vitamin D levels (25-hydroxyvitamin D and 1,25-dihydroxyvitamin D) to determine if supplementation of the precursor (ergocalciferol) or active vitamin D (calcitriol) or a vitamin D analog (doxercalciferol or paricalcitol) is warranted. Adjust vitamin D therapy based on assessment of vitamin D status, iPTH level (goal PTH 70110 pg/mL), calcium, and phosphorus. Perform routine radiographic evaluation of long and short bones. Counsel patient to avoid NSAIDs and use acetaminophen to control pain (do not exceed 4 g/ day). Physical and occupational therapy as necessary Recommend exercise according to physical ability. PROBLEM 3: HTN Assess compliance with antihypertensive medications and diet. Replace thiazide diuretic with loop diuretic. Continue ACE inhibitor and titrate dose according to BP. Add a _-blocker or nondihydropyridine calcium channel blocker if needed to achieve goal BP. JNC-VII guidelines recommend BP below 130/80 in patients with chronic kidney disease and overt proteinuria. Monitor BP, weight, serum K, Na, BUN, and SCr. Dietary consult Inform patient to limit daily intake of sodium to less than 2 g. Assess lipid panel and rule out dyslipidemia. PROBLEM 4: Diabetic Nephropathy Lack of adequate blood glucose control (HgA1c 12%). Rule out all causes of hyperglycemia. Optimize BP and blood glucose control with diet and medication. Assess adherence to insulin and dietary compliance. Instruct patient to monitor fasting blood sugar and preprandial blood glucose daily and keep diary. Adjust insulin doses according to blood glucose level. Increase blood glucose monitoring to seven times daily on sick days.

Quantitative assessment of proteinuria (monitor periodically) [include assessment of spot urine albuminSCr ratio (mg/g)]. Continue ACE inhibitor and adjust dose according to proteinuria and BP.

PROBLEM 5: Anemia Rule out folate and vitamin B12 deficiency. Assess iron body stores (serum iron, TIBC, transferrin saturation, and ferritin). Establish an appropriate iron supplementation or maintenance dose. Options: oral iron to provide 200 mg elemental iron per day (monitor for side effects and drug interaction with calcium); IV as sodium ferric gluconate, iron sucrose, or iron dextran if oral iron does not meet goal iron indices Consider the appropriate initial dose of a erythropoietic agent (SC route of administration preferred): epoetin alfa (80120 units/kg per week SC or 120180 units/kg per week IV administered in 13 divided doses) or darbepoetin alfa (0.45 _g/kg SC or IV administered once weekly). Achieve target goal of Hgb 11 to 12 g per dL (adjust dose of erythropoietic agent accordingly). Monitor Hgb, Hct, iron studies, BP, and weight. Failure to respond to erythropoietic therapy requires evaluation of factors causing resistance, such as iron deficiency (primary cause), infection, inflammation, chronic blood loss, aluminum toxicity, hemoglobinopathies, malnutrition, and hyperparathyroidism. Goal TSAT and ferritin for chronic kidney disease patient on erythropoietic therapy: TSAT 20% to 50%, ferritin 100 to 800 ng per mL QUESTIONS (See Answers in back of book for correct responses.) 1. List the possible causes of CKD in this patient. (EO-1) Longstanding HTN and DM 2. Based on this patients estimated GFR, she is classified into which of the following stages of CKD? (EO-2, 3, 5) a. Stage 2 b. Stage 3 c. Stage 4 d. Stage 5 or end-stage kidney disease (ESKD) 3. Describe why monotherapy with HCTZ is not recommended for this patient. (EO-7, 8, 9, 11,13) Thiazides may be less effective in stage 4 chronic kidney disease (GFR < 30 mL/min). Patients with stage 4 disease may require a loop diuretic. Assessment of urine output and BP is needed to determine response and appropriateness of therapy.

4. Explain how CKD leads to abnormalities in calcium, phosphorus, active vitamin D, and iPTH and identify the therapeutic options to address these abnormalities. (EO12) The decline in kidney function with chronic kidney disease decreases phosphorus excretion and leads to an increase in serum phosphorus levels and a reciprocal decrease in serum calcium concentrations. Hypocalcemia is the primary stimulus for release of PTH. Decreased conversion of vitamin D to its active form (1,25dihydroxyvitamin D3) in the kidney also contributes to hypocalcemia and increased production of PTH. Sustained hyperparathyroidism can lead to renal osteodystrophy if not corrected. Dietary phosphorus restriction and phosphate binding agents are needed to control serum phosphorus. Initially a calcium-containing phosphate binder (e.g., calcium carbonate, calcium acetate) may be used to help lower phosphorus and correct calcium concentrations; however, the risk of hypercalcemia must be considered with long-term therapy. Vitamin D deficiency is treated through supplementation of the vitamin D precursor (ergocalciferol), active vitamin D (calcitriol), or a vitamin D analog (doxercalciferol or paricalcitol), depending on vitamin D levels and the stage of kidney disease. [Refer to the NKF-K/DOQI guidelines for bone metabolism and disease: Am J Kidney Dis. 2003;42(4 Suppl 3):1201]. 5. Describe the role of sevelamer or lanthanum in the management of hyperphosphatemia. (EO-10, 12) Sevelamer and lanthanum are alternates to calciumcontaining phosphate binders in the management of hyperphosphatemia in the chronic kidney disease population. These agents do not contain calcium, aluminum, or magnesium and may be used in patients who become hypercalcemic (serum Ca >10.2 mg/dL) on conventional therapy with calcium-containing phosphate binders. 6. The patient exhibits persistent pain and disability associated with renal osteodystrophy not controlled with APAP. Provide your recommendation for short-term use of an opiate. Why is the opiate meperidine avoided in this setting? (EO-6, 10, 13) In the presence of kidney dysfunction, opiates may be used short term to control pain. Use the lowest effective dose of opiate according to kidney function, and do not exceed recommended doses provided by the manufacturer. Meperidine is not recommended as a firstline analgesic agent in patients with kidney disease because serum levels of its inactive metabolite, normeperidine, may accumulate and increase the risk of seizures. 7. Based on this patients estimated GFR (and stage of CKD) the target range for intact PTH (iPTH) is which of the following? (EO-7, 13) a. 3570 pg/mL b. 70110 pg/mL c. 150300 pg/mL d. 400700 pg/mL

8. In this case, describe the role of ACE inhibitors in the prevention of diabetic nephropathy. (EO-5, 8, 12, 13) ACE inhibitors have been shown to delay the progression of kidney disease even in the absence of HTN in clinical trials. The K/DOQI Clinical Practice Guidelines for patients with stage 1 to 4 chronic kidney disease recommend ACE inhibitors to decrease proteinuria. The ADA recommends that all type I diabetics with microalbuminuria or proteinuria take an ACE inhibitor whether or not they are hypertensive. The goal of therapy is to decrease BP to less than 130/80 mm Hg, decrease proteinuria, slow the progression of kidney disease, and reduce the risk of cardiovascular disease. 9. Which of the following is the target Hgb in a patient with anemia of CKD treated with erythropoietic therapy? (EO-5, 8) a. 910 g/dL b. 1112 g/dL c. 1314 g/dL d. 1516 g/dL 10. List the parameters that should be monitored to determine response to erythropoietic and iron therapy in this patient. (EO-5, 8, 12) Serum ferritin (assessment of storage iron), transferrin saturation (assessment of iron readily available for erythropoiesis), Hgb, Hct 11. What are the options for erythropoietic therapy in this patient and the appropriate starting doses? (EO-5, 12) Available agents in the United States are epoetin alfa and darbepoetin alfa. Starting doses of epoetin alfa are 80 to 120 units/kg per week SC or 120 to 180 units/kg per week IV administered in 1 to 3 divided doses. The starting dose of darbepoetin alfa is 0.45 g per kg SC or IV administered once weekly. 12. Describe the recommended strategy for making dosing adjustments to erythropoietic therapy. (EO-5, 12) Dose adjustments of erythropoietic agents are based on the Hgb/Hct response and should not be made more frequently than every 4 to 6 weeks based on the time required for production of mature RBCs (i.e., the pharmacodynamic response). The dose of erythropoietin or darbepoetin may be increased by 25% if there is an inadequate response (e.g., hemoglobin increase <1 g/dL in a 4-week period) or decreased by 25% if the rise in hemoglobin is excessive (e.g., hemoglobin increases by >1 g/dL in a 2-week period). The goal of therapy is to achieve the target hemoglobin of 11 to 12 g per dL. Failure to respond to erythropoietic therapy requires evaluation of factors causing resistance, such as iron deficiency (primary cause), infection, inflammation, chronic blood loss, aluminum toxicity, hemoglobinopathies, malnutrition, and hyperparathyroidism. 13. List psychosocial factors that may influence this patients deterioration of kidney function. (EO-5, 13, 15) Lack of interest, lack of knowledge about progressive kidney disease, chronic pain and tiredness, failure to comply with dietary restrictions, adverse drug reactions

14. Describe the health care providers role in promoting medication adherence in this case. (EO-14, 15, 16) Educate the patient about chronic kidney disease and how strict blood glucose and BP control can delay progression to endstage kidney disease; also educate the patient about dialysis. Educate the patient about secondary complications of chronic kidney disease, such as anemia and renal osteodystrophy. Provide prefilled syringes of insulin by the pharmacy. Provide pill boxes and instructions on how to administer insulin injections. Provide instructions on how to manage missed doses. Provide instructions on how to monitor blood glucose (include times) and BP. Provide patient with a checklist on dietary intake and medication administration, and have the patient keep a diary. Quiz patient on proper techniques and medication administration times. 15. Summarize etiology, pathophysiology, epidemiology, therapeutic, and disease management concepts for CKD utilizing a key points format. (EO-18) Chronic kidney disease is a progressive disease leading to end-stage kidney disease and the need for dialysis. The two leading causes of chronic kidney disease are DM and HTN. ACE inhibitor or ARB therapy has been shown to delay the progression of chronic kidney disease in patients with type 1 DM or type 2 DM and in patients with proteinuria. Renal osteodystrophy is a complication of progressive kidney disease from longstanding metabolic abnormalities (hypocalcemia, vitamin D deficiency) that lead to secondary hyperparathyroidism. Prevention of ROD includes controlling hyperparathyroidism and the associated metabolic abnormalities of chronic kidney disease (hyperphosphatemia, hypocalcemia, vitamin D deficiency) with phosphate binders and vitamin D supplementation. Sevelamer and lanthanum are noncalcium-containing phosphate binders that may be used in patients who are hypercalcemic on conventional calcium containing phosphate-lowering treatment. These agents may be useful in limiting blood vessel calcification in patients on longstanding calcium supplements. Supplementation of vitamin D with a vitamin D precursor (ergocalciferol) in patients with early-stage chronic kidney disease or with active vitamin D (calcitriol) or a vitamin D analog (doxercalciferol, paricalcitol) is necessary based on the stage of kidney disease and vitamin D status. Anemia is another complication of CKD that occurs due to erythropoietin deficiency (hormone produced by the kidney). Iron deficiency is the main cause of hyporesponsiveness to erythropoietic agents such as erythropoietin alfa or darbepoetin alfa. Before prescribing an erythropoietic agent, iron deficiency anemia must be corrected with an oral or IV iron product. Target goals of Hgb (1112 g/dL) and Hct (33%36%) should be maintained while treating anemia with iron and

erythropoietic agents in patients with chronic kidney disease. Patient education is important to improve adherence with medication and nonpharmacologic therapy and to increase the patients knowledge of chronic kidney disease and the associated secondary complications (and dialysis options for patients in later stages of disease).