Term
|
Definition
hypothalamic pituitary axis |
|
|
Term
what does it mean when said HPA is dinural |
|
Definition
higher activity in morning |
|
|
Term
what can increase the HPA axis activity the best |
|
Definition
stress, which can over ride normal feedback controls |
|
|
Term
what does ACTH stand for, what is its job |
|
Definition
adrenocorticotrophic hormones
stimylates adrenal cortex to secrete glucocorticoids, mineralcoricoids, weak androgens |
|
|
Term
what are two weak androgens |
|
Definition
andeostendione dehydropiandrosteone |
|
|
Term
what are the three zones of the adrenal cortex |
|
Definition
zona glomerulosa - outer zona fasculata - inner zona reticularis - inner |
|
|
Term
what enzymes does cortex outer zone have, what does it secrete |
|
Definition
secretes aldosterone (mineralcorticoids) via aldosterone synthase |
|
|
Term
how is mineralcorticoid production stimulated |
|
Definition
ACTH acutely stimulates
angiotensin II receptors with Gs protein initiate it |
|
|
Term
what happens to the cortex if it does not get enough stimulation |
|
Definition
does not atrophy without pituitary stimulation |
|
|
Term
what enzymes does the cortex inner zones have, what do they secrete |
|
Definition
12-a-hydroxylase, 11-B0hydroxylase
secretes glyucocorticoids |
|
|
Term
what stimulates inner cortex, what if there is too much stimulation |
|
Definition
increases in ACTH cause hyperplasia, hypertrophy, increased cortisol and androgens |
|
|
Term
|
Definition
ACTH increases due to impaired cortisol synthesis |
|
|
Term
what happens if the inner cortex does not get stimulation |
|
Definition
|
|
Term
what occurs in the acute phase of steroid production |
|
Definition
within seconds increased supply of cholesterol to substrate (depends on amount of cholesterol) |
|
|
Term
what occurs in the chronic phase of steroid production |
|
Definition
within hours steridogenic enzyme transcription is increased |
|
|
Term
where are most of the enzymes for steroid production |
|
Definition
|
|
Term
explain the process of steroid hormone production (3 steps) |
|
Definition
1. cholesterol is turned into pregnilone via CHOLESTEROL SIDE CHAIN CLEVAGE ENZYME (P450 SCC) **RATE LIMIT
2. pregnilone is turned into cortisol, aldosterone, and adrenal androgens
3. products go to receptors and cause transcription. their structures are similar and they can activate e/o receptors |
|
|
Term
how is production of cortisol stimulated |
|
Definition
hypothalamus releases CRF and AVP which activate pituitary which releases ACTH which acrivates adrenal gland which releases cortisol |
|
|
Term
what controls rate of cortisol production |
|
Definition
ACTH release from pituitary corticotropes which are regulated by corticotropin releasing hormone (CRH) |
|
|
Term
how is cortisol production/stimulation regulated (2) |
|
Definition
ACTH can stimulate production but will burn out so it stops activity in hypothalamus
cortisol (glucocorticoids) stop activity in pituitary and hypothalamus |
|
|
Term
cortisol and aldosterone bind same receptors for same affinity, how does the body discriminate |
|
Definition
in mineralcorticoid (ALD) receptors it has enzyme barrier with 11-B-hydroxy DH that metabolizes cortisol to cortisone which cannot bind ALD receptor |
|
|
Term
what are the 7 areas / systems that corticosteroids effects |
|
Definition
carb and protein metabolism lipid metabolism cardiovascular skeletal muscle CNS blood immune supression/anti-inflammatory |
|
|
Term
what do corticosteroids do to carb and protein metabolism |
|
Definition
protect glucose dependent tissues from starvation (brain and heart)
glucogenolysis glyconeogenesis diminish glucose utilization in tissue
cause protein break down |
|
|
Term
what do corticosteroids to to lipid metabolism |
|
Definition
stimulate lipolysos increase fat in neck (buffalo hump) and face (moon faces) loss of fat in extremities |
|
|
Term
what do corticosteroids to do skeletal muscle |
|
Definition
needed for normal function decreased muscle work due to adrenocorticol insufficiency (addison's disease) hypercorticism: causes muscle wasting |
|
|
Term
what effects do corticosteroids have on CNS (5) |
|
Definition
mood, behavior, brain excitability
in cushings and addisons: neuroses, psychoses |
|
|
Term
what does corticosteroids do to the immune system (7) |
|
Definition
decreases cytokine production, lymphocyte response, histamines, leukotrienes, arachadonic acid release via phospholipase A2 inhibition supress inflammation decrease WBC circulation |
|
|
Term
what are the HPA axis drugs (2) |
|
Definition
|
|
Term
what are the short acting glyucocorticoids (2) |
|
Definition
|
|
Term
what are the intermediate acting glucocorticoids (3) |
|
Definition
prednisone methylprednisolone triamcinolone |
|
|
Term
what are the long acting glucocorticoids (2) |
|
Definition
betamethazone dexamethazone |
|
|
Term
what are the corticosteroid inhibitors (3) |
|
Definition
aminoglytethimide ketoconazole spironolactone |
|
|
Term
what are the mineral corticoids |
|
Definition
|
|
Term
|
Definition
high concentrations affect hypothalamus, stimulate corticoid and androgen receptors testing HPA axis |
|
|
Term
|
Definition
tests HPA axis ysing synthetic ACTH residues 1-24 |
|
|
Term
|
Definition
antigenic: comes from animals
vasopressin par causes hyponatremia |
|
|
Term
short acting glucocorticoid MOA |
|
Definition
metabolized via reduction in liver to 11-8-hydeoxyderivative to be active |
|
|
Term
side effects of short acting glucocirticoids (4) |
|
Definition
antiinflammatory salt retension minteral corticoid effects less potent |
|
|
Term
side effects of intermediate acting glucocorticoids (3) |
|
Definition
more potent low salt retension low mineralcorticoid effect |
|
|
Term
side effects of long acting glucocorticoids (3) |
|
Definition
most potent no salt retension no mineralcorticoid effect |
|
|
Term
shared side effects of all glucocirticoids (12) |
|
Definition
withdrawl: flare of of disease acute adrenal insufficiency HPA supression fluid and electrolyte imbalance hypertension hyperglycemia fat redistribution osteoperosis myopathy behavorial changes cataracts increased infection |
|
|
Term
why do glucocirticoids cause acute adrenal insufficiency |
|
Definition
due to rapid withdrawl after prolonged use |
|
|
Term
who do glucocirticoids cause HPA supression |
|
Definition
occurs with supraphysiologocal doses for 2wk + |
|
|
Term
how do glucocirticoids cause osteoperosis |
|
Definition
inhibit ostroblasts and decrease bone formation |
|
|
Term
how are glucocirticoids administered (9) |
|
Definition
oral, injected, inhaled, topical, optic, opthalamic, enema, rectal, retro rocket |
|
|
Term
where are glucocirticoids metabolized and eliminated |
|
Definition
metabolized in liver excreted in kidney |
|
|
Term
what affects the distribution of glucocirticoids |
|
Definition
90% bound to proteins (corticosteroid binding globulin, transcortin, albumin) |
|
|
Term
what are the clinical uses of glucocirticoids (15) |
|
Definition
adrenal insufficiency chronic primary adrenal insufficiency congenital adrenal hypoplasia RA SLE degrnerative joint regional pain syndrome (injection) allergies asthma PJP influenza virus ocular disease: supresses inflammation but increases IOP cerebral edema stroke spinal cord injuty |
|
|
Term
what are 2 diseases that cause chronic primary adrenal insufficiency |
|
Definition
adrenal surgery
cortex lesion (addisons) |
|
|
Term
|
Definition
|
|
Term
aminoglytethimide clinical use |
|
Definition
|
|
Term
|
Definition
|
|
Term
ketoconazole clinical use |
|
Definition
|
|
Term
|
Definition
competes for mineralcorticoid receptor and stops Na reabsorption |
|
|
Term
spironolactone clinical use |
|
Definition
|
|
Term
|
Definition
act on DCT to increase reabsorption of Na into plasma and excretion of K and H |
|
|
Term
fludorcortisone clinical use (4) |
|
Definition
addisons severe salt loss adrenogenital syndrome orthostatic hypotension |
|
|
Term
3 functions of FSH, which are the main ones |
|
Definition
main: spermatogenesis in seminiferous tubules regulate testicular growth steroidogenesis |
|
|
Term
what are the 4 functions of LH, which is the main one |
|
Definition
main: regulate testosterone release from leydig cells regulate resticular growth steroidogenesis spermatogenesis |
|
|
Term
how is the release of testosterone regulated |
|
Definition
it feeds back to hypothalamus and pituitary |
|
|
Term
what is the process of testosterone production |
|
Definition
cholesterol > progesterone > andostenedione or androstendione . testosterone |
|
|
Term
what enzyme produces testosterone |
|
Definition
12B-hydrosteroid dehydrogenase |
|
|
Term
how is testosterone transported in the body |
|
Definition
sex hormone binding globulin (can enter cell too may have role in action)
some on albumin
1-2% unbound |
|
|
Term
what enzyme turns testosterone into DHT, where is it located |
|
Definition
steroid 2a-reductase in non-genital skin and liver
steroid 5a-reductase in urogenital tract |
|
|
Term
what is the difference between testosterone and DHT |
|
Definition
DHT has a higher binding affinity |
|
|
Term
what are the 6 general functions of testosterone |
|
Definition
embryo: virilize urigenital tract of male
growth of testes, scrotum, penis
thicken and make skin more oily
increase height and muscle
axillary hair
larynd development |
|
|
Term
what are the testosterone drugs (5) |
|
Definition
testosterone aq testosterone cypionate fluxymesterone testosterone gel (androgel) danzol |
|
|
Term
what are the anti-androgens (5) |
|
Definition
spironolactone flutamide ketoconazole cimetidine finasteride |
|
|
Term
what is used to treat impotence (3) |
|
Definition
sildenafil vardenaful tadalafil |
|
|
Term
|
Definition
stop androgen binding to receptor
stop synthesis of androgens
decrease p450enz 12a-hydroxylase C12-20 lyase complex which decreases testosterone |
|
|
Term
|
Definition
non-steroid competitive inhibitor of DHT |
|
|
Term
|
Definition
H2 receptor antagonist that competes for receptor |
|
|
Term
|
Definition
5a-reductase competitive inhibitor of conversion enzyme of DHT to testosterone |
|
|
Term
|
Definition
normally NO activates gyanulyl cyclase which causes smooth m. relaxation of corpus callosum letting blood in then phosphodiesterase (PDE) closes it off
drug inhibits PDE |
|
|
Term
11 uses of all testosterone drugs |
|
Definition
androgenic: hypogonadism, failure of hypo-pit-axis
anabolic: osteroperosis, burns, surgery recovery
counteract cortical hormone effects
growth: skeletal muscle growth in pre-pubescent boys and dwarfism
unapproved: increase lean body mass, muscle strength, agression |
|
|
Term
clinical use of fluoxymesterone |
|
Definition
more focused on anabolic effects of androgens (little androgenic effects)
osteoperosis, burns, surgurical recovery |
|
|
Term
clinical use of danzol (3) |
|
Definition
not very androgenic
endometrosis, fibrocystic breast disease, hereditary angioedema |
|
|
Term
clinical use of spironolactone (2) |
|
Definition
women: hirsutism men: causes impotence |
|
|
Term
clinical use of flutamide (1) |
|
Definition
prostate cancer (with GnRH blocker or an estrogen) |
|
|
Term
clinical use of ketoconazole (1) |
|
Definition
prostate cancer (high dose) |
|
|
Term
clinical use of cimetidine |
|
Definition
|
|
Term
clinical use of finasteride (3) |
|
Definition
prostatic hyperplasia
male pattern baldness (low dose) |
|
|
Term
side effects flutamide (2) |
|
Definition
|
|
Term
side effects ketoconazole |
|
Definition
|
|
Term
|
Definition
males with zollinger ellison get cynecomastia |
|
|
Term
|
Definition
|
|
Term
side effects impotence treatment (6) |
|
Definition
no effect in absence of stimulation
headache flushing dyspenia change in color vision decreased BP |
|
|
Term
what is a major contraindication to impotence drugs |
|
Definition
|
|
Term
what is the longest lasting impotence drug, how long |
|
Definition
|
|
Term
side effects of all testosterone drugs in females only (8) |
|
Definition
masculinization acne facial hair deeper voices male pattern baldness muscle development menstural irregularities virilization of fetus |
|
|
Term
side effects of all testosterone drugs in males only (5) |
|
Definition
priapism impotence decreased spermatogenesis gynecomastia |
|
|
Term
side effects of all testosterone drugs in any sex or age (6) |
|
Definition
increased LDL decreased HDL coronary artery disease fluid retention edema PANCREATITIS |
|
|
Term
side effects of all testosterone drugs in kids only (4) |
|
Definition
abnormal sexual maturity premature closure of epiphysis hepatic abnormalities psychosis |
|
|
Term
side effect of testosterone gel |
|
Definition
absorbed to skin, transfered to others on hands |
|
|
Term
|
Definition
interacts with progesterone and androgen receptors and supresses pituitary-ovarian axis decreasing FSH and LH |
|
|
Term
how are the 5 testosterone drugs administered |
|
Definition
testosterone aq- IM testosterone cypionate- IM fluxymesterone- oral testosterone gel- topical danzol- oral |
|
|
Term
where is testosterone gel metabolized and excreted |
|
Definition
metabolized in liver excreted in urine |
|
|
Term
which testosterone has the shortest and longest half life, how long |
|
Definition
testosterone aq: short 10-100 min testosterone cypopnate: long 8d |
|
|
Term
|
Definition
leuprolide grosereline nafarelin histerlin triptorelin |
|
|
Term
|
Definition
ganirelix cetorelix abarelix degarelix |
|
|
Term
|
Definition
|
|
Term
2 GH antagonists / somatistatin agalons |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
Lutropin / recombinant hCG |
|
|
Term
|
Definition
|
|
Term
2 prolactin antagonist, 1 AKA |
|
Definition
aka: dopamine agonist
bromocriptine cabergoline |
|
|
Term
2 vasopressin agonist and their receptors |
|
Definition
8-L-arginine vasopressin (V1)
desmopressin (V2) (tetracycline antibiotic) |
|
|
Term
3 vasopressin antagonists and their receptors |
|
Definition
conivaptin (V1+V2)
tolvaptin (V2)
lithium (V2) |
|
|
Term
|
Definition
control FSH and LH release
pulsatile (replacement) therapy: increases release
continous (supression) therapy: inhibits release |
|
|
Term
|
Definition
stops release of FSH and LH |
|
|
Term
|
Definition
longitudinal growth via ILGF-1 and some ILGF-2 |
|
|
Term
|
Definition
complex of ILGF-1 and ILGF binding protein 3 that causes growth |
|
|
Term
|
Definition
somatostatin agonist stop GH, glucagon, insulin, and gastrin release |
|
|
Term
|
Definition
|
|
Term
where do menotropins come from |
|
Definition
|
|
Term
where does urofollitropin come from |
|
Definition
|
|
Term
where does lutropin come from |
|
Definition
recombinant LH (identical to hCG so it can be used) |
|
|
Term
|
Definition
|
|
Term
how does a prolactin antagonist work |
|
Definition
dopamine agonist decreases prolactin release |
|
|
Term
why would some have increased prolactin (2) |
|
Definition
anti-psychotic drugs (dopamine receptor blockers) prolactinoma |
|
|
Term
what happens when prolactin is increased (4) |
|
Definition
amenorrhea no ovulation galactorhea breast tenderness |
|
|
Term
|
Definition
induces myometrial contraction by changing ion concentrations |
|
|
Term
what does ADH to do V receptors (8), what type of receptor |
|
Definition
Gq receptors
V1a: vasoconstriction, glycogenolysis, platelet aggregation, ACTH release
V1b: ant pituitary, pancrease, brain, adrenal medulla |
|
|
Term
what tissues have V2 ADH receptors on them, what type of receptor is it |
|
Definition
Gs receptor on aquaporin 2 on collecting duct cells |
|
|
Term
GnRH agonist side effects |
|
Definition
continous therapy gives flare in condition prior to supression (desensitization) |
|
|
Term
GH antagonist side effects (5) |
|
Definition
flatulence steratorrhea biliary sludge gall stones sinus bradycardia |
|
|
Term
|
Definition
simillar to ADH water retension or intoxication (if on IV) |
|
|
Term
|
Definition
mimics nephrogenic diabetes insupidus |
|
|
Term
how can GnRH be administered |
|
Definition
pulastile: every 1-4 hours continous |
|
|
Term
why is administering GnRH different than just giving the hormone (gonadorelin) |
|
Definition
the half life of the drug will be longer than administering the hormone |
|
|
Term
what is the benifit of using a GnRH antagonist over agonist (2) |
|
Definition
no flare in hormone levels before supression more rapid onset |
|
|
Term
|
Definition
B blockers Mg sulfate inhaled anasthetics |
|
|
Term
what is pulsatile GnRH used for (3) |
|
Definition
infertility delayed puberty hypogonadism |
|
|
Term
what is continous GnRH used for (4) |
|
Definition
endometrosis uterine fibroids prostate cancer central precoious puberity |
|
|
Term
when do you decide to treat central precoious puberty |
|
Definition
before 8 in girls and before 9 in boys |
|
|
Term
how is prostate cancer treated (2) |
|
Definition
GnRH agonist with androgen receptor blocker to inhibit flare OR GnRH antagonist |
|
|
Term
what do GnRH antagonists treat |
|
Definition
prostate cancer ovarian hyperstimulation prep for in vitro fertilization |
|
|
Term
why is GnRH antagonist used for prep for in vitro fertilization |
|
Definition
prevents premature LH surge |
|
|
Term
what is somatropin used for (3) |
|
Definition
GH deficiency (<4cm/y)
Growth failure: prader willi, turner syndrome, AIDS wasting
idiopathic short stature |
|
|
Term
what is mecasermin used for |
|
Definition
patient is deficient in ILGF-1 and exogenous GH isnt working |
|
|
Term
|
Definition
DOC for acromeagly and gigantism
hormone secreting tumors
bleeding esophageal varices |
|
|
Term
what causes acromeagly and gigantism |
|
Definition
|
|
Term
what are 4 GH secreting tumors |
|
Definition
gastrinoma glucagonoma carcinoid secreting tumors carcinoid syndrome |
|
|
Term
what is carcinoid syndrome |
|
Definition
carcinoid tumor with liver metastasis and serotonin secretion |
|
|
Term
what is the use for pegvisomant |
|
Definition
acromeagly third alternative |
|
|
Term
|
Definition
induce spermatogenesis or ovulation in infertility |
|
|
Term
use of prolactin antagonist (2) |
|
Definition
hyperprolactinemia
bromocriptime: acromeagly 2nd alternative |
|
|
Term
|
Definition
lactation in natural doses
pharmacological doses: control post partum hemorrhage, induce labor but causing uterine contraction |
|
|
Term
|
Definition
vasoconstriction stops bleeding esophageal varicies, post-op ileus, abdominal distension |
|
|
Term
|
Definition
central diabetes insipidus SIADH |
|
|
Term
use of V1/V2 antagonist (2) |
|
Definition
euvolumeic or hypervolemic hyponatremia SIADH |
|
|
Term
what is diabetes insipidus |
|
Definition
increased ADH due to pituitary or hypothalamus trauma or tumor |
|
|
Term
what is nephrogenic diabetes insiputis |
|
Definition
broken V2 receptors on nephron |
|
|
Term
what categories of drugs are hypothalamic hormone drugs (2) |
|
Definition
GnRH/gonadorelin agonist
GnRH antagonist |
|
|
Term
what categories of drugs are anterior pituitary hormone drugs (8) |
|
Definition
GH agonist GH antagonist GH blocker FSH + LH FSH LH prolactin agonist prolactin antagonist |
|
|
Term
what categories of drugs are the posterior pituitary hormone drugs (4) |
|
Definition
oxytocin vasopressin agonist vasopressing antagonist lithium |
|
|
Term
explain thyroid hormones from ingestion of iodine to T3/4 production and storage (7 steps) |
|
Definition
1. ingest iodine 2. TSH stimulates iodine uptake and hormone production 3. iodine active transport into thyroid 4. activated with THYROID PEROXIDAZE (using Hb and H2O2) 5. monotyrostol and diiodotyrosyl are produced 6. THYROID PEROXIDASE links AA making T3 and T4 in a 1:4 ratio 7. T3 and T4 are stored in thyroglobulin |
|
|
Term
explain thyroid hormone release from thyroglobulin to arrival at the tissues (7 steps) |
|
Definition
1. thyroglobulin fuses with lysoosme
2. proteolytic enzymes break it into... - monotyrosyl and dioxotyrosyl which stay in thyroid - T3/T4 which go into blood - excess iodine which stays in thyroid
3. T3/4travel in blood on thyroxine binding globulin and albumin
4. T3/4 are released at tissues |
|
|
Term
what motifications occur to T3/4 at the tissues (2) |
|
Definition
diodinase enzymes remove 5' outer ring...
- 5-DI and 5-DII turn T4 to T3 (41% of T3)
- 5-DIII turns T4 into reverse T3 |
|
|
Term
where are T3 and T4 degraded |
|
Definition
|
|
Term
what are the differences in T3 and T4 elimination |
|
Definition
T3 is eliminated in 2 d due to increased protein binding increasing hald life
T4 is eliminated in 6-7d |
|
|
Term
how does iodine regulate thyroid hormone production |
|
Definition
decreased iodine decrease thyroid hormones which stimulate TSH causing thyroid hypertrophy (gioter) and selective T3 formation |
|
|
Term
how does the production of thyroid hormone reulate itself |
|
Definition
it doesnt
it stops TSH production but increases thyrotropin releasing hormone (TRH) production which cancel |
|
|
Term
what is the difference in tissue binding and activity of T3 and T4 |
|
Definition
T3 binds with 5x higher affinity
T4 binds with lower affinity |
|
|
Term
what are the 6 areas in general thyroid hormones affect |
|
Definition
growth and development basal metabolic rate released when cold to regulate body temp heart CNS cholesterol metabolism |
|
|
Term
how does the thyroid effect growth and development (5) |
|
Definition
differentiation and myelination of cnS
potentiation of GH, PTH, and calcitonin |
|
|
Term
in what organs does the thyroid hormone effect on basal metabolic rate have the most effect (4) |
|
Definition
heart, muscle, liver, kidney |
|
|
Term
what changes do thyroid hormones cause in the heart (4) |
|
Definition
sensitize it (synergistic) increase CO, HR, contractility |
|
|
Term
what effects do thyroid hormones have on the CNS |
|
Definition
sensitize catecholamine receptors (synergistic) |
|
|
Term
what does thyroid hormone do to cholesterol metabolism |
|
Definition
stimulates metabolism of cholesterol to bile acids
important! lack can cause hypercholesterolemia |
|
|
Term
what is the name for adult hypothyroidism |
|
Definition
|
|
Term
what is the name for child hypothyroidism |
|
Definition
|
|
Term
what are the 9 signs of child hypothyroidism |
|
Definition
impaired growth mental retardation pot belly dwarfism lethargy hypothermia slow HT poor appetite death if untreated |
|
|
Term
what are the 8 signs of adult hypothyroiodism |
|
Definition
pallid expression blank expression dry skin brittle nails weakness reduced CO fatigue cold intolerence |
|
|
Term
what are two diseases of hyperthyroidism |
|
Definition
graves and plummers disease |
|
|
Term
what are 7 characteristics of graves disease |
|
Definition
diffuse toxic goiter exophthalmos: big eyes hot moist skin forced rapid heart beat angina arrhythmia heart failure |
|
|
Term
what are 4 causes of graves disease |
|
Definition
autoimmune: IgG bind to TSH receptor
chorionic: placental secretion of TSG stimulates receptors in pregnancy |
|
|
Term
what are 6 signs of plummer's disease |
|
Definition
toxic nodular goiter hot moist skin forced rapid heart beat angina arrhythmia heart failure |
|
|
Term
what are 5 general signs of hyperthyroidism |
|
Definition
hot moist skin forced rapid heart beat angina arrhythmia heart failure |
|
|
Term
what are the 3 treatments for hyperthyroidism |
|
Definition
surgical removal of thyroid local radiation with radioactive iodine anti thyroid agents |
|
|
Term
what causes a thyroid storm (7) |
|
Definition
complication of hyperthyroidism triggered by stress, thyroid surgery, trauma, diabetic ketoacidosis, labor, heart disease, radioactive iodine |
|
|
Term
what are the 7 treatments of a thyroid storm |
|
Definition
fluids anti-pyretics cooling blankets propylithiouracil in large doses iodates B blockers and Ca can control tachyarrhytima dexamethasone |
|
|
Term
what are the three thyroid hormone drugs, what hormone is each |
|
Definition
desiccated thyroid - T3 and T4 levothyroxine - T4 liothyroxine - T3 |
|
|
Term
what are the advantages of using liothyronlne over levothyroxine (4) |
|
Definition
liothyroline does not have to be converted for full potential, fast onset, good absorption, good when someone has problem with T4 to T3 conversion enzyme |
|
|
Term
what is the clinical use for thyroid hormones (3) |
|
Definition
hypothyroidism non-toxic goiter replacement therapy |
|
|
Term
what are the contraindications to thyroid hormones (3) |
|
Definition
acute MI
increase anticoagulant effects
reduce digitalis effects |
|
|
Term
what are the 3 side effects or problems with desiccated thyroid |
|
Definition
antigenic because it comes from pork
highly variable biological activity
religous objections to treatment |
|
|
Term
what are the two anti-thyroid or thiroureylenes |
|
Definition
propylthiouracil and methimazole |
|
|
Term
|
Definition
stop iodiniation of throsyl in thyroglobulin
block thyroid peroxidae inhibiting coupling reaction
prophylthiouracil- blocks conversion of T3 to T4 |
|
|
Term
what are the three side effects of anti-thyroids |
|
Definition
agranulocytosis
marrow aplasic (improves on DC)
secreted into breast milk |
|
|
Term
what can anti-thyroids be used to treat (7) |
|
Definition
graves disease small goiters mild hyperthyroidism
deplete thyroid hormone before radiation hyperthyroidism in elderly
after radiation
prethyrodectomy- prevent surge in surgery
thyroid storm - prophylthiouracil due to T3 to T4 ability |
|
|
Term
|
Definition
saturated potassium iodide prevents thyroid hormone release
inhibits hormone synthesis by decreasing TSG and blcking its action (wolff chickoff effect) |
|
|
Term
|
Definition
rebound hyperthyroidism
angioedema
hypersensitivity
iodism |
|
|
Term
what is iodism, what are 7 signs |
|
Definition
chronic intoxication of iodine
burning bouth, throat, eyes, headache, productive cough, gastric irritation, skin lesions |
|
|
Term
what are the three uses of iodine |
|
Definition
reduce vascularity and increase gland firmness
thyroid storm prevention
pre surgery |
|
|
Term
|
Definition
gets trapped in thyroid and B-rays destory parenchyma B-rays only destory bad tissue |
|
|
Term
what are three side effects of radioactive iodine |
|
Definition
cannot use in pregnancy
delayed hypothyroidism
chromosomal abberations (cannot use in kids and pregnancy) |
|
|
Term
what is the half life of radioactive iodine |
|
Definition
|
|
Term
what is the use of radioactive iodine |
|
Definition
|
|
Term
what is another name for radioactive iodine |
|
Definition
|
|
Term
|
Definition
growth and development of endochondral bone |
|
|
Term
define remodeling, when does it occur |
|
Definition
continoous process of breakdown and renewal final option after linear growth in finished |
|
|
Term
what are the three steps in remodeling |
|
Definition
IL-1 and IL-6 released from osteoblast stimulate osteoclast to reabsorb tunnels in corticoid bone or scallops in trabecular bone
osteoclasts replaces bone areas with collagen, osteocalcin, and protein
mineralization occurs after osteoblasts achieve 20 microns of thickness |
|
|
Term
what are three problems with bone remodeling |
|
Definition
deficits occur after each cycle
deficits increase with age
can never get back to origional bone mass after remodel |
|
|
Term
what three things can alter remodeling |
|
Definition
|
|
Term
what hormones alter remodeling (5) |
|
Definition
thyroid PTH vitamin D glucocorticoids estrogen |
|
|
Term
|
Definition
neuron excitability neurotransmitter release muscle contraction membrane integrity blood coagulation secondary messenger for hormones |
|
|
Term
|
Definition
skeleton in a pool exchangable with interstitial fluid |
|
|
Term
what is stored in bone (5) |
|
Definition
|
|
Term
|
Definition
75% is from dairy intake adults 45-50 yo should have supplement with vitamin D |
|
|
Term
how does Ca get into the body |
|
Definition
facilitated diffusion through SI |
|
|
Term
|
Definition
inversly proportional to intake (not as good as we age) |
|
|
Term
where and how much Ca is excreted |
|
Definition
150mg is loss via billiary and intestinal sloughing 9mg is secreted in kidney but 98% is reabsorbed |
|
|
Term
what do loop diruetics do to Ca excretion |
|
Definition
act on ascending limg to cause increased Ca loss (but its a better diruetic) |
|
|
Term
what do thiazida diruetics do to Ca excretion |
|
Definition
uncouple Na and Ca excretion causing reduced Ca loss |
|
|
Term
where is phosphate located in the body |
|
Definition
80% in bone 15% in soft tissue |
|
|
Term
what are 5 functions of phosphate |
|
Definition
membrane phospholipids modifies Ca role in renal H excretion secondary messenger energy metabolism |
|
|
Term
where, how, and how much phosphate is absorbed in the gut |
|
Definition
active transport and vit D stimulate absorption 2/3 is absorbed |
|
|
Term
where is phosphate is excreted, how much |
|
Definition
excreted in urine 80% is reabsorbed |
|
|
Term
|
Definition
prehormone is cleaved in ER and in golgi it makes PTH which lives in secretory granules until secreted. if not secreted soon enough they undergo proteolysis and the gland gets hypertrophy and hyperplasia |
|
|
Term
what is the half life of PTH |
|
Definition
|
|
Term
how does PTH act on target cells |
|
Definition
|
|
Term
what are the functions of PTH (4) |
|
Definition
increase Ca and P absorption in intestines by activating vitamin D
increase bone reabsorption bia osteoblast action on osteoclast
increase Ca reabsorption in kidney
inhibit kidney phosphate reabsorption |
|
|
Term
|
Definition
parafollicular C cells in thyroid release it when plasma Ca is high |
|
|
Term
what are the two actions of calcitonin |
|
Definition
inhibition of osteoclast bone reabsorption
increased urinary Ca and P excretion |
|
|
Term
what are the two types of viramin D and where are they made |
|
Definition
D2: yeast D3: animals and higher plants |
|
|
Term
|
Definition
in the bodycholesterol is reduced and is converted by UV into D3 hich is procesed in liver to calcifediol and then to calcitrol in kidney |
|
|
Term
what are 4 pieces of evidence suggesting vitamin D is a hormone |
|
Definition
made in body in skin not needed in diet (in theory) transported in blood to distant sites specific receptors in target tissues on DNA |
|
|
Term
how does vitamin D affect the body |
|
Definition
increases absorption of P and Ca in SI
increases mobalization of P and Ca from bone with PTH help
decreases P and Ca excretion in kidney |
|
|
Term
|
Definition
prehormone is cleaved in ER and in golgi it makes PTH which lives in secretory granules until secreted. if not secreted soon enough they undergo proteolysis and the gland gets hypertrophy and hyperplasia |
|
|
Term
what is the half life of PTH |
|
Definition
|
|
Term
how does PTH act on target cells |
|
Definition
|
|
Term
what are the functions of PTH (4) |
|
Definition
increase Ca and P absorption in intestines by activating vitamin D
increase bone reabsorption bia osteoblast action on osteoclast
increase Ca reabsorption in kidney
inhibit kidney phosphate reabsorption |
|
|
Term
|
Definition
parafollicular C cells in thyroid release it when plasma Ca is high |
|
|
Term
what are the two actions of calcitonin |
|
Definition
inhibition of osteoclast bone reabsorption
increased urinary Ca and P excretion |
|
|
Term
what are the two types of viramin D and where are they made |
|
Definition
D2: yeast D3: animals and higher plants |
|
|
Term
|
Definition
in the bodycholesterol is reduced and is converted by UV into D3 hich is procesed in liver to calcifediol and then to calcitrol in kidney |
|
|
Term
what are 4 pieces of evidence suggesting vitamin D is a hormone |
|
Definition
made in body in skin not needed in diet (in theory) transported in blood to distant sites specific receptors on DNA |
|
|
Term
what are three things vitamin D does in the body |
|
Definition
absorption of Ca and P in SI
increase mobalization of Ca and P from bone with PTH help
decrease P and Ca excretion in kidney |
|
|
Term
5 symptoms of hypocalcemia |
|
Definition
parasthesia increased neuromuscular excitability laryngospasm muscle cramps tonic clonic convulsions |
|
|
Term
2 symptoms of hypercalcemia |
|
Definition
diverse clinical conditions dehydration due to compormised renal concentration |
|
|
Term
4 symptoms of hypophosphatemia |
|
Definition
malaise muscle weakness osteomalacia decreases RBC ATP and 2,3-BPG causing hemolytic anemia and impaired oxygenation - rare |
|
|
Term
what are 4 causes of hypercalcemia |
|
Definition
increased intake of Ca in hypothyroid pt
familial benign hypercalcemia
vitamin D toxicity
milk alkali syndrome |
|
|
Term
what is used to treat hypercalcemia |
|
Definition
calcitonin IV bisphosphate corticosteroids - vitamin D toxicity |
|
|
Term
what is wrong in familial benign hypercalcemia |
|
Definition
parathyroid cannot sense Ca so it increases PTH |
|
|
Term
how can you get vitamin D toxicity |
|
Definition
overuse of hyperparathyroid drugs |
|
|
Term
what is used to treat vitamin D toxicity |
|
Definition
calcitonin IV bisphosphate corticosteroids |
|
|
Term
what causes milk alkali syndrome |
|
Definition
milk alkali powder increases Ca reabsption |
|
|
Term
what are two conditions that cause hypercalcemia and hypophosphatemia |
|
Definition
hyperparathyroidism PTH secreting tumor |
|
|
Term
what is used to treat hypercalcemia and hypophosphatemia |
|
Definition
calcitonin IV bisphosphate IV/oral phosphate - hyperparathyroid corticosteroids - PTH tumor |
|
|
Term
how does hyperparathyroid cause problems, what are two complications |
|
Definition
increases PTH secretion renal stones, peptic ulcers |
|
|
Term
what type of cancer is a PTH secreting tumor |
|
Definition
squamous or epithelial cell |
|
|
Term
what is used to treat PTH secreting tumor |
|
Definition
calcitonin IV bisphosphate corticosteroids |
|
|
Term
what is used to treat hyperparathyroidism |
|
Definition
calcitonin IV bisphosphate IV/oral phosphate |
|
|
Term
what causes paget's disease, 6 symptoms |
|
Definition
excessive remodeling weak, mishape, painful bones deafness cord compression cardiac failure |
|
|
Term
what is used to treat paget's disease |
|
Definition
calcitonin IV bisphosphate |
|
|
Term
what are two conditions that cause hypophosphatemia |
|
Definition
aluminum antacid toxicity normal children: mild childhood anemia due to decreased affinity of Hb to O2 |
|
|
Term
what is used to treat hypophosphatemia |
|
Definition
|
|
Term
what three conditions can cause hypocalcemia and hypophosphatemia |
|
Definition
familial benign hypophosphatemia rickets/osteomalacia hypophosphatemia |
|
|
Term
what is used to treat hypocalcemia and hypophosphatemia |
|
Definition
IV/oral phosphate vitamin D - rickets/osteomalacia |
|
|
Term
what is wrong in familial benign hypophosphatemia, what is a complication |
|
Definition
impaired vitamin D production causes increased PTH which depletes bone of Ca and P
causes dwarfism |
|
|
Term
|
Definition
impaired vitamin D production causes increased PTH which deplates bone of Ca and P |
|
|
Term
what are signs of rickets in kids (2) |
|
Definition
|
|
Term
what are signs of rickets in adults |
|
Definition
painful bones weak muscles |
|
|
Term
what are three conditions that cause hypocalcemia and hyperphosphatemia |
|
Definition
hypoparathyroidism pseudohypoparathyroidism renal disease |
|
|
Term
what is wrong in hypoparathyroidism , what is the cause |
|
Definition
decreased release o f PTH due to thyroid or neck surgery, autoimmune or genetic disease |
|
|
Term
how is hypoparathyroidism treated |
|
Definition
|
|
Term
what is wrong in pseudohypoparathyroidism, what other symptoms are there |
|
Definition
body does not respond to PTH short stature, metacarpals, metatarsals |
|
|
Term
what is the treatment for pseudohypoparathyroidism |
|
Definition
|
|
Term
what does renal disease do to Ca and P |
|
Definition
|
|
Term
how do we treat the Ca and P effects of renal disease |
|
Definition
aluminum antacids calcitriol |
|
|
Term
|
Definition
acts on osteoclast to inhibit bone reabsorption rapid Ca reduction |
|
|
Term
|
Definition
in hypercalcemia body will become sensitized in a few days |
|
|
Term
what are 4 uses of calcitonin |
|
Definition
hypercalcemia hypercalcemia + hyperphosphatemia paget's disease osteoperosis |
|
|
Term
what are the 2 IV bisphosphates |
|
Definition
|
|
Term
what is the MOA of IV bisphosphate |
|
Definition
inhibit osteoclast bone reabsorption reduction of Ca over several days |
|
|
Term
what 4 things for IV bisphosphates treat |
|
Definition
hypercalcemia hypercalcemia + hyperphosphatemia paget's disease osteoperosis |
|
|
Term
|
Definition
takes 1-2 days to reduce Ca |
|
|
Term
what two things do corticosteroids treat |
|
Definition
lymphoma (PTH secreting tumor) vitamin D toxicity caused hypercalcemmia |
|
|
Term
|
Definition
increases plasma phosphate levels |
|
|
Term
what are 3 side effects of IV/oral phosphate |
|
Definition
mild laxative if not needed is rapidly excreted (no storage) excess can reduce Ca via percipitation in soft tissue and be toxic |
|
|
Term
4 uses of IV/oral phosphate |
|
Definition
hypophosphatemia hypocalcemia + hypophosphatemia hyperparathyroidism mild laxative |
|
|
Term
|
Definition
supression of PTH decreases bone turn over |
|
|
Term
side effects of vitamin D analogs |
|
Definition
possible vitamin D toxicity |
|
|
Term
4 uses of vitamin D analogs |
|
Definition
rickets / osteomalacia osteoperosis treat hypoparathyroidism due to thyroid or parathyroid operation renal failure 0 calcitrol |
|
|
Term
what are the three types of vitamin D analogs and their administration |
|
Definition
ergocalciferol: oral, iv, im dihydrotachysterol: oral calcitrol: oral, iv |
|
|
Term
what molecule is ergocalciferol |
|
Definition
|
|
Term
what molecule is dihydrotachysterol |
|
Definition
|
|
Term
what are the three types of Ca analogs and their administeration and why |
|
Definition
Ca chlorida: IV (IM causes vasodilation and burning)
Ca glyconate IV (IM causes abscess)
CA gluceptate IV or IM (IM causes some irritation) |
|
|
Term
what are two uses of calcium analogs |
|
Definition
hypocalcemia + hyperphosphatemia malabsorption or malnutrition of Ca |
|
|
Term
|
Definition
decrease plasma phosphate by decreasing phosphate absorption |
|
|
Term
aluminum antacids side effects |
|
Definition
|
|
Term
aluminum antacids clinical use |
|
Definition
clearance of phosphate in kidney failure |
|
|
Term
define osteoperosis, who is it normally seen in |
|
Definition
low bone mass and microfractures with minimal trauma in older women |
|
|
Term
what are the types of osteoperosis |
|
Definition
primary type 1 primary type 2 secondary |
|
|
Term
what is the cause of osteoperosis primary type 1 |
|
Definition
loss of trabecular bone due to estrogen lack at menopause |
|
|
Term
what is the cause of osteoperosis primary type 2 |
|
Definition
loss of cortical and trabecular bone in men and women due to remodeling inefficiency, diet, activation of parathyroid axis with age |
|
|
Term
what is the cause ot secondary osteoperosis |
|
Definition
systemic illness medication: glucocorticoids, phenytoin |
|
|
Term
what are the three regulators of bone density |
|
Definition
physical activity endocrine status Ca intake |
|
|
Term
what is the trend in bone density over time |
|
Definition
stable until 50 then progressivel decline |
|
|
Term
what are 8 drugs that treat osteoperosis, state if they are for a specific kind or patient |
|
Definition
calcitonin IV bisphosphate vitamin D analogs Ca carbonate estrogen - post menopause osteoperosis raloxifene thiazide diruetuc testosterone - hypogonadal males |
|
|
Term
what is a side effect of Ca carbonate |
|
Definition
constipation when >2000 mg/d |
|
|
Term
what estrogen is used for osteperosis |
|
Definition
conjugated equine estrogen without progesterone |
|
|
Term
side effect of raloxifene |
|
Definition
anti-estrogen in breast tissue |
|
|
Term
|
Definition
selective estradiol receptor modulator
agonist in liver and bone |
|
|
Term
how do thiazidie diruetics help osteoperosis |
|
Definition
|
|
Term
what is the main way to distinguish between diabetes mellitus and insipidus |
|
Definition
melllitus has glucose in the urine |
|
|
Term
why is the glucose in the urine in diabetes |
|
Definition
glucose in the blood exceeds capacity for reahsption so it is excreted in the urine |
|
|
Term
what is the cause of type I diabetes (3) |
|
Definition
B cells cant make enough insulin, destoried B cells dont respond to glucose, B cell lesions and necrosis |
|
|
Term
what are 5 signs of type I diabetes |
|
Definition
polydipsia polyphagia polyuria ketoacidosis hyperglycemia |
|
|
Term
describe the typical type I diabetes patient |
|
Definition
onset in childhood looks undernourished |
|
|
Term
does diabetes have a genetic predisposition |
|
Definition
type II more than type I. but yes |
|
|
Term
what is the treatment for type I diabetes |
|
Definition
|
|
Term
describe the typical type II diabetes patient |
|
Definition
|
|
Term
what is the cause of type II diabetes |
|
Definition
insulin resistant and inabilit to make enough insulin can progress to be like type I |
|
|
Term
what is the treatment for type II diabetes |
|
Definition
weight reduction, exercise, dietary modification oral hypoglycemics last resort: exogenous insulin |
|
|
Term
what are 6 complications of diabetes |
|
Definition
hyperglycemia increased BP neuropathy proteinuria cardiovascular disease (more type II) diabetic retinopathy diabetic neuropathy |
|
|
Term
what is the treatment for neuropathy and proteinuria |
|
Definition
|
|
Term
what is the treatment for diabetic cardiovascular disease |
|
Definition
statins lower lipid and cholesterol, stop smoking |
|
|
Term
what is the treatment for diabetic neuropathy |
|
Definition
foot care, ulcer care, erythromycin for vagus neuropathy causing GI immotility |
|
|
Term
what are the two types of diabetes insipidus, what causes each |
|
Definition
central: deficiency in ADH nephrogenic: lack of response to ADH |
|
|
Term
how can you distinguish between central and nephrogenic diabetes insipidus |
|
Definition
demopressin replaces ADH so if urine production decreases they have central |
|
|
Term
how does diabetes insipidus cause disease (no matter which type) |
|
Definition
causes lack of reabsorption of water in the CD |
|
|
Term
|
Definition
B cells of islets of langerhans |
|
|
Term
what are normal fasting insulin levels |
|
Definition
|
|
Term
what occurs in fasting metabolism |
|
Definition
adipose releases FA which is processed in liver to glucose pancreas releases glucagon which signals to the liver to make glucose glucose is first used in the brain then other major organs |
|
|
Term
what are normal prandial insulin levels |
|
Definition
|
|
Term
what occurs in prandial metabolism |
|
Definition
carbs are ingested and turned into glucose which is ingested and distributed to the organs pancreas releases insulin which tells the liver, muscle, and adipose to store glucose |
|
|
Term
how does glucose get into the cell |
|
Definition
insulin turns on GLUT facilitated diffusion transporters which activate TK which intrinsically phosphorlyates various substrates
insulin stimulates translocation of GLUT4 transporters to the membrane allowing for glucose to get into the cell |
|
|
Term
how are B cells activated to release insuln |
|
Definition
glucose comes through GLUT2 receptors and glucokinase phosphorlyates it so it can stay in the cell.
G6P is shuttled to ATP production which increases ATP in relation to ADP
ratio switches on K channel and cell moves from basal state (hyperpolarized and inhibited) to depolarized
this causes Ca cannels to open and Ca moves in stimulating release of insulin |
|
|
Term
|
Definition
single chain precursor called preproinsuln (A and B chains connected by C peptide) is cleaved in ER to proinsulin, processed in golgi to insulin, and released with C peptide |
|
|
Term
what is the clinical significance of C peptide |
|
Definition
helps determine if insulin levels are due to edogenous (no C) or endogenous (has C) insulin |
|
|
Term
what is the best determinant of insulin levels, why |
|
Definition
HBA1C because it shows BG over several months |
|
|
Term
what is the cycle of insulin |
|
Definition
increases after a meal and is at low basal levels between meals |
|
|
Term
|
Definition
B cells of islets of langerhans |
|
|
Term
what are normal fasting insulin levels |
|
Definition
|
|
Term
what occurs in fasting metabolism |
|
Definition
adipose releases FA which is processed in liver to glucose pancreas releases glucagon which signals to the liver to make glucose glucose is first used in the brain then other major organs |
|
|
Term
what are normal prandial insulin levels |
|
Definition
|
|
Term
what occurs in prandial metabolism |
|
Definition
carbs are ingested and turned into glucose which is ingested and distributed to the organs pancreas releases insulin which tells the liver, muscle, and adipose to store glucose |
|
|
Term
how does glucose get into the cell |
|
Definition
insulin turns on GLUT facilitated diffusion transporters which activate TK which intrinsically phosphorlyates various substrates
insulin stimulates translocation of GLUT4 transporters to the membrane allowing for glucose to get into the cell |
|
|
Term
how are B cells activated to release insuln |
|
Definition
glucose comes through GLUT2 receptors and glucokinase phosphorlyates it so it can stay in the cell.
G6P is shuttled to ATP production which increases ATP in relation to ADP
ratio switches on K channel and cell moves from basal state (hyperpolarized and inhibited) to depolarized
this causes Ca cannels to open and Ca moves in stimulating release of insulin |
|
|
Term
|
Definition
single chain precursor called preproinsuln (A and B chains connected by C peptide) is cleaved in ER to proinsulin, processed in golgi to insulin, and released with C peptide |
|
|
Term
what is the clinical significance of C peptide |
|
Definition
helps determine if insulin levels are due to edogenous (no C) or endogenous (has C) insulin |
|
|
Term
what is the best determinant of insulin levels, why |
|
Definition
HBA1C because it shows BG over several months |
|
|
Term
what is the cycle of insulin |
|
Definition
increases after a meal and is at low basal levels between meals |
|
|
Term
what are the short acting insulins (4) |
|
Definition
insulin lispro insulin aspart insulin glulisine insulin regular |
|
|
Term
what are the long acting insulins (2) |
|
Definition
insulin glargine insulin detemir |
|
|
Term
what are the insulin AA combinations (3) |
|
Definition
lispro + protamine asprt + protamine NPH + R |
|
|
Term
what insulins have the best HBA1C control |
|
Definition
|
|
Term
what are the side effects of all insulin medications (2) |
|
Definition
hypooglycemia lipodystrophy |
|
|
Term
what are the ratings of the hypoglycemic effects of the different types of insulin |
|
Definition
short acting has most long acting is second no peak insulin has no effect |
|
|
Term
what are three sources of insulin, which is used today |
|
Definition
beef - outdated pork - outdated E. coli produces human insulin |
|
|
Term
how is insulin administered (2) |
|
Definition
subcutaneous IV (emergency) |
|
|
Term
which type of insulin is the most rapidly absorbed |
|
Definition
|
|
Term
how well is insulin absorbed |
|
Definition
depends on prep human is absorbed the best and most quickly |
|
|
Term
where is insulin metabolized and by what |
|
Definition
metabolized to be inactive in liver and kidney by insulinase |
|
|
Term
how long does it take for short acting insulin to kick in, how long does it last |
|
Definition
onset <15 min duration 3-6 hours |
|
|
Term
why is long acting insulin long acting, what is the duration |
|
Definition
NPH (insulin isophane suspension complexed with zinc) allows slow release 12-18h |
|
|
Term
which insulin has slow release and rapid onset, how does it work |
|
Definition
insulin combined with AA
onset <10min because insulin dosent stick together due to AA substitution and is more free for use |
|
|
Term
how long does no peak insulin last |
|
Definition
24 hours of consistant plasma levels |
|
|
Term
how is a pregnant woman with diabetes treated |
|
Definition
|
|
Term
how do insulin pumps work |
|
Definition
uses short acting insulin on continous infusion to provide steady basal insulin level and bolus injections depending on size and time of meal |
|
|
Term
|
Definition
emergency, when someone needs insulin fast ketoacidosis |
|
|
Term
what is a non-intensive diabetes treatment |
|
Definition
NPH with lispro at breakfast and dinner |
|
|
Term
what are the two most populat insulin redigmen, which is bettwe |
|
Definition
glargine x2 and lispro x4 or insulin pump
best one depends on pt |
|
|
Term
what is the general pathway in diabetes treatment |
|
Definition
diet and exercise (if type II)
check liver function - if abnormal use insulin
check kidney function (Cr)- if not abnormal use metformin
if still hyperglycemic- try sulfonylurea
if still hypoglycemic- try combo meal time + basal medication)
if still hyperglycemic- use insulin |
|
|
Term
what drug is contraindicated with oral hypoglycemics |
|
Definition
|
|
Term
what drugs antagonize insulin or oral hypoglycemics (4) |
|
Definition
corticosteroids, estrogen, thyroid hormones thiazides |
|
|
Term
what are the 4 sulfonylureases |
|
Definition
gen 1: chlorpropamide
gen 2: glipizide, glyburide, glomepiride |
|
|
Term
what are the two thiazolidiendiones |
|
Definition
pioglitazone rosiglitazone |
|
|
Term
what are the two aa derivatives |
|
Definition
|
|
Term
what are the two a-glycosidase inhibitors |
|
Definition
|
|
Term
|
Definition
|
|
Term
what drugs mimic incretin (2) |
|
Definition
|
|
Term
what drugs inhibit DPP-4 (3) |
|
Definition
stilagliptin saxagliptin linagliptin |
|
|
Term
what drug is synthetic amylin hormone |
|
Definition
|
|
Term
what drig is a SGLT2 inhibitor |
|
Definition
|
|
Term
what is used as a anti-hypoglycemic (2) |
|
Definition
glucagon glucose tablets glucose source - grape juice |
|
|
Term
what are the 5 categories of oral hypoglycemics |
|
Definition
sulfonylureases thiazolidiendiones AA derivatives a-glucosidase inhibitors biguanides |
|
|
Term
|
Definition
bind and block K channel on B cells depolarizing, opening Ca channel letting it in and causing insulin release
reduce glucagon (indurect due to insulin decrease)
increase insulin blocking (maybe increasing receptors) |
|
|
Term
MOA thiazolidiendiones (3) |
|
Definition
increase sensitivity to insulin in tissues
decrease hepatic glucose output
use PPARy in adipose to increase insulin receptors |
|
|
Term
|
Definition
|
|
Term
a-glucosidase inhibitor MOA |
|
Definition
inhibit enzyme in SI brush border decreasing sugar absorption prevents post-prandial rise in glucose |
|
|
Term
|
Definition
inhibits gluconeogenesis stimulates glucolysis increases glucose uptake in tissues |
|
|
Term
exenatide and liraglutide MOA |
|
Definition
mimics incretins
incretins are released from intestines in response to food and increase insulin secretion |
|
|
Term
sitagliptin, saxagliptin, linagliptin MOA |
|
Definition
inhibit dipeptitdyl peptidase 4 (DPP-4) so incretin cannot be degradedand insulin increases |
|
|
Term
|
Definition
synthetic amylin hormone
normally made in pancreas after meal to slow rate of food absorption in intestines and reduce appetite |
|
|
Term
|
Definition
blocks Na/glucose cotransporter 2 in PCT preventing reabsorption |
|
|
Term
|
Definition
stops active hypoglycemia |
|
|
Term
side effects sulfonylureases (4) |
|
Definition
all cause hypoglycemia
mostly 1st gen causes: hyponatremia, disulfram, hypotension (so basically don't use in old people) |
|
|
Term
thiazolidiendione side effects (2) |
|
Definition
hypoglycemia
MI and other cardio events - dont use with CHF pt (especially rosiglitazone) |
|
|
Term
AA derivative side effects |
|
Definition
|
|
Term
a-glucosidase inhibitor side effects (3) |
|
Definition
flatulence diarrhea abdominal cramps NO hypoglycemia |
|
|
Term
|
Definition
lactic acidosis in pt with renal or heart failure
NO hypoglycemia |
|
|
Term
exenatide, liraglutide side effects (5) |
|
Definition
liragltide; weight loss
hyoiglycemia: low risk
nausea, vomiting, diarrhea |
|
|
Term
sitagliptin, saxagliptin, linagliptin side effects (2) |
|
Definition
|
|
Term
pramlintide side effects (3) |
|
Definition
weight loss nausea hypoglycemia |
|
|
Term
SGLT2 inhibitor side effects (3) |
|
Definition
increased K female GU infections |
|
|
Term
how is glucagon administered |
|
Definition
|
|
Term
how is canaglifolozin administered |
|
Definition
oral once a day before first meal |
|
|
Term
how is pramlintide administered |
|
Definition
|
|
Term
how is sitagliptin, saxagliptin, linagliptin administered |
|
Definition
|
|
Term
how is exenatide, liraglutide administered |
|
Definition
|
|
Term
what is sitagliptin, saxagliptin, linagliptin used for |
|
Definition
type II diabetes - need functioning B cells |
|
|
Term
what is exenatide, liraglutide used for |
|
Definition
type II diabetes - need functioning B cells |
|
|
Term
what is pramlintide used for |
|
Definition
adjunct to insulin in type I or II diabetes (lower insulin though) |
|
|
Term
where is metformin metabolized and excreted |
|
Definition
not metabolized excreted in urine |
|
|
Term
what plasma protein is metformin bound to |
|
Definition
|
|
Term
which oral hypoglycemic has the shortest half life |
|
Definition
|
|
Term
how are thiazolidiendiones used |
|
Definition
with insulin or in another combo (not enough alone) |
|
|
Term
where are sulgonylureases metabolized and excreted |
|
Definition
|
|
Term
which drug should you never use in pregnant diabetic patients, why |
|
Definition
thiazolidiendiones can cross placenta and deplete fetal pancreas of insuln |
|
|
Term
what are the 4 main uses for estrogen or progesterone drugs |
|
Definition
hormone replacement therapy / post-menopause
contraception
health benifits of contraception
receptor antagonist: breast cancer, infertility |
|
|
Term
what is another name for the follicular phase, how long is it |
|
Definition
proliferative phase, length varies |
|
|
Term
what are the two phases of the menstural cycle |
|
Definition
|
|
Term
what is another name for the lutela phase, how long is it |
|
Definition
|
|
Term
explain the process of hormone production in the follicular phase |
|
Definition
pulses of GnRH cause release of LH and FSH estrogen increases reduce LH and FSH release inhibin is mad ein ovary and causes feedback decreasing FSH mid cycle estrogen reaches peak for 36 hours and stops inhibiting gonadotropins and causes surge instead |
|
|
Term
what happens in the luteal phase |
|
Definition
corpus luteum secretes progesterone (estrgen levels stay elevated) if pregnancy does not occur corpus luteum regresses due to lack of LH and progesterone and falls so endometrium sheds causing menstural discharge |
|
|
Term
what does progesterone do for the baby/uterus |
|
Definition
stops endometrium proliferation helps with implantation and growth of blastocyst causes growth of endometrial vessels |
|
|
Term
what is the general structure of estrogen |
|
Definition
18C with an aromatic phenolic acid ring (required for selective high affinity binding) |
|
|
Term
what is the natural form of estrogen, where is it made in men and women |
|
Definition
17B estradiol
women: ovarian granulosa cells men and post-menopause; adipose tissue viea DHEA from adrenal cortex |
|
|
Term
what stimulates for estrogen release |
|
Definition
gonadotropins stimulate aromatase |
|
|
Term
what are precursors for estrogen |
|
Definition
androstendione testosterone |
|
|
Term
estrogen needs aromatic ring to work, how does it get it |
|
Definition
aromatase using NADPH and O |
|
|
Term
where are estrogen receptors located |
|
Definition
ovarian granulosa, sertoli and leydig cells, stroma of adipose, placenta, blastocyte, brain |
|
|
Term
how is estrogen converted between its different forms |
|
Definition
estradiol oxidized to esterone via 12-hydroxysteroid DH
estradiol and esterone converted to estriol |
|
|
Term
what is the down side of using natural progesterone |
|
Definition
|
|
Term
what are the two types of synthetic progesterone |
|
Definition
21C progesterone skeletons 19-nortestosterone |
|
|
Term
what is 19-nortestosterone |
|
Definition
progesterone without C19, 20, 21 resembles testosterone more so has effects of both |
|
|
Term
where is progesterone made, when |
|
Definition
made in testis, adrenal cortex, placenta, and ovary corpus luteum
begins being made in follicular phase and increases in luteal phase later in pregnancy |
|
|
Term
what is the relationship between progesterone and the cns |
|
Definition
increases body temp 1 deg midcycle until onset of menstural flow (ovulation) |
|
|
Term
what is the down side to using estrogen alone in hormone replacement |
|
Definition
risk of endometrial carcinoma due to hyperplasia of the endometrium |
|
|
Term
what is the benifit of combined estrogen progesterone therapy in hormone replacement |
|
Definition
estrogen receptors dont get out of hand because it has to make some progesterone receptors too |
|
|
Term
how is a post-menopausal women with a uterus treated forr hormone replacement |
|
Definition
progesterone/estrogen combination |
|
|
Term
what are contraindications to progesterone/estrogen hormon replacement |
|
Definition
unable to tolerate progestins risk of cardiovascular disease poorlipoproteins use estrogen alone |
|
|
Term
how is a post-menopausal women with a hysterctomy treated for homeone replacement |
|
Definition
estrogen alone, no where for it to cause carcinoma |
|
|
Term
what are 4 ways to administer hormone replacement therapy |
|
Definition
cyclic continous transdermal patch vaginal ring |
|
|
Term
what is the redigmen for cyclic hormone replacement |
|
Definition
estrogen 15d estrogen and progesterone 10d repeat |
|
|
Term
what is the redigmen for continous hormone replacement |
|
Definition
estrogen and progesterone daily OR estrogen and progesterone 10d esteogrn 15d repeat |
|
|
Term
what are the contents of combination oral contraceptives |
|
Definition
estrogen: ethinyl estradiol or mestraol progesterone: norethindrone or norgestrel |
|
|
Term
what are the three types of oral contraceptives |
|
Definition
monophasic biphasic triphasic |
|
|
Term
how are monophasic oral contraceptives administered |
|
Definition
same amount of estrogen and progesterone in each tablet for 21d |
|
|
Term
how are biphasic oral contraceptives administred |
|
Definition
two tablets with different amounts for 21 days |
|
|
Term
what is the benifit of biphasic oral contraceptives |
|
Definition
reduce steroids administred because it approximates estrogen to progesterin ratio of menstural cycle |
|
|
Term
how are triphasic oral contraceptives administered |
|
Definition
three tablets with different amounts for 21 days |
|
|
Term
what is the general MOA of contraceptives |
|
Definition
estrogen supresses FSH and stops follicular development proteitiating action of progestrin which stops LH surfe progesterin stops ovulation, thickens cervical mucous, and causes endometrial atrophy estrogen stabilizes endometrial lining (bleeding control) |
|
|
Term
what are 4 contraindications to oral contraceptives |
|
Definition
thrombotic disease over 35 and smoking hormone sensitive tumor (breast canceR) pregnancy |
|
|
Term
what are the 4 forms of estrogen, talk about the bioavailability and blood distribution of each |
|
Definition
natural: 12B estradiol, esterone, estriol: poor oral bioavailability high first pass effect
17B estradiol estrace: microcrystaline form, reduced first pass |
|
|
Term
what are the benifits of a transdermal estrogen patch |
|
Definition
slow release increased bioavailability constant blood levels |
|
|
Term
what are the 4 types of synthetic estrogens |
|
Definition
conjugated ethinyl estradiol menastrol estradiol cruptionate |
|
|
Term
what is conjugated estrogen made of where does it come from |
|
Definition
many conjugated estrogen metabolites pregnant mares |
|
|
Term
what is the structure of ethinyl estradiol |
|
Definition
ethinyl group on C17 of estrace nucleus |
|
|
Term
how is mestranol metabolized |
|
Definition
prodrug converted to ethinyl estradiol |
|
|
Term
what is a non-steroidal estrogen agonist |
|
Definition
|
|
Term
what is the MOA of oestrogen contraceptives |
|
Definition
passivly diffuse into cell
bind nuclear receptors in genital, breast, HPA, bone, and liver
interact with estrogen response elements (ERE) which alter transcription
supress FSH stopping follicle development and stabilizing endometrial lining (bleeding control) |
|
|
Term
what are the 12 negative side effects of estrogen contraceptives |
|
Definition
elevated TG decrease bile acid (due to cholesterol secretion) removal: hot flashes, chills, sweating, parasthesia
nausea cramping fluid retention dizzy headache breast tenderness Mi or thrombosis in women >35 who smoke |
|
|
Term
what are the good side effects of estrogen contraceptives (and natural functions) (14) |
|
Definition
decrease cholesterol increase HDL decrease LDL
growth of uterus, vagina, fallopian tubes, breast, ducts, sexual development
fat distribution, growth spurt, fusion of epiphysis
increase plasma binding proteins
prevent bone loss: block reabsorption
decrease endometrial and ovarian cancer
decrease fibroadenomas, fibrocysts, PID
decrease blood loss and cause cycle regularity |
|
|
Term
why are esgtrogen contraceptives used (7) |
|
Definition
contraception replacement fibroadenomas fibrocysts PID cycle regularity failure of ovarian development |
|
|
Term
what are three diseases that include failure of ovarian development |
|
Definition
dwarfism turner syndrome hypopituitarism |
|
|
Term
what is the administration of the 4 estrogen contraceptives |
|
Definition
conjugated: oral active ethinyl estradiol: oral active mestranol: not for replacement estradiol crypionate: long acting given IM |
|
|
Term
how are estrogen drugs excreted |
|
Definition
in urine with glucourindes and sulfate conjugates |
|
|
Term
what are the side effects of diethylstilbesterol |
|
Definition
congenital abnormalities in fetus |
|
|
Term
why would you use diethylstilbesterol |
|
Definition
|
|
Term
what are the three antiestrogen drugs |
|
Definition
chlomiphene tamoxifen raloxifene |
|
|
Term
|
Definition
competitive agonist of estrogen binding
stimulates ovulation in women with normal HPA and estrogen levels by opposing negative feedback increasing gonadotropin pulse amplitude (not frequency) |
|
|
Term
|
Definition
competitive antagonist of estrogen binding antagonizes receptor |
|
|
Term
|
Definition
partial agonist effect on bone reabsorption and plasma lipoproteins NO effect on reproductive tissues selective estrogen receptor modulator |
|
|
Term
what is the structure of clomiphene |
|
Definition
mixed isomeres cis has estrogenic activity trans has anti-estrogenic activity |
|
|
Term
what is the structure of tamoxifen |
|
Definition
pure trans isomere (only the useful part of clomiphene) |
|
|
Term
why would you use clomiphene |
|
Definition
|
|
Term
why would you use tamoxifen |
|
Definition
block hormone induced breast tumors
adjunct with surgery or chemo |
|
|
Term
why would you use raloxifene |
|
Definition
osteoperosis post-menopause |
|
|
Term
what are the side effects of clomiphene (6 |
|
Definition
ovarian hyperstimulation increased multiple births ovarian cysts anti-estrogenic: follicle, endometrium, cervical mucous (counter active) |
|
|
Term
what are the side effects of tamoxifen (3) |
|
Definition
decrease tumor development in other breast endometrial carcinoma hormone independent breast tumors |
|
|
Term
how is clomiphene administered, half life, where metabolized, where excreted |
|
Definition
oral t.5 = 5-7d hepatic metabolism GI excretion |
|
|
Term
tamoxifen: aministration, metabolism, excretion |
|
Definition
oral hepatic metabolism Gi excretion |
|
|
Term
explain how tamoxifen is eliminated |
|
Definition
phase 1: 4-11d phase 2: 4d (hydroxytamoxifen) |
|
|
Term
what are the two aromatase modifying drugs |
|
Definition
|
|
Term
|
Definition
selective aromatase inhibitor stops conversion of androgens to estrogens reversible |
|
|
Term
|
Definition
aromatase inactivastor acts as false substrate for enzyme and intermediate irreversibly binding to acrive site (suicide inhibition) stopping conversion of androgens to estrogens
irreversible |
|
|
Term
what is the clinical use of amastrazole |
|
Definition
post-menopausal hormone dependent breast cancer |
|
|
Term
what is the use of exemestane |
|
Definition
post-menopausal hormone dependent breast cancer |
|
|
Term
what is an anti-progesterin drug, what progesterin structure family is it from |
|
Definition
mifepristone
19-nortestosterone derivative |
|
|
Term
|
Definition
potent competitive inhibitor of progesterone and glucocorticoids
decrease in progesterone cause abortion by detaching blastocyst
myometrial contraction and cervical softening allow for expulsion |
|
|
Term
|
Definition
administer up until 49 days after pregnancy abortion pill |
|
|
Term
what are the 4 progesterone contraceptives and their progesterone structure family |
|
Definition
norethindrone: 19-nortestosterone norgestrel: 19-nortestosterone mexroxyprogesterone acetate: 21C progesterone progestasert |
|
|
Term
what is the admnistration of the 4 progesterone contraceptives |
|
Definition
norethindrone: oral norgestrel: oral, subdermal (5y) mexroxyprogesterone acetate: IM (3mo) progestasert: intrauterine |
|
|
Term
MOA progesterone contraceptives |
|
Definition
supresses LH surge thickens cervical mucous decreases endometrial proliferation stops ovulation |
|
|
Term
where are progesterone receptors |
|
Definition
genital, mammary, CNS (hypothalamus) |
|
|
Term
what is the role of progesterone in pregnancy |
|
Definition
maintains it supresses mensturation and uterine contraction proliferation of mammary acini |
|
|
Term
why not use a progesterone contraceptive all alone |
|
Definition
|
|
Term
what are the uses of progesterone contraceptives |
|
Definition
ovarian supression: dysmenorrhea, endometrosis, histurism, uterine bleeding
hormone replacement: combined with estrogen
fibroadenomas fibrocysts PID
cycle regulation |
|
|
Term
in general why is progesterone added to estrogen contraceptives, why aernt progesterone side effects a big deal |
|
Definition
avoid side effects of estrogen
progesterone side effects usually go away after 1 year |
|
|
Term
what are the side effects of progesterone contraceptives (11) |
|
Definition
spotting amenorrhea decreased HDL increased LDL edema weight gain: fat deposition bloating acne histuism
impaired glucose tolerance: longer term, short term increases basal insulin
MI and thrombosis in women >35 who smoke |
|
|
Term
MOA of the morning after pill |
|
Definition
combination oral contraceptive in a high dose |
|
|
Term
administration of the morning after pill |
|
Definition
taken within 72 hours of intercourse ineffective after 7 days (cannot un-implant) |
|
|
Term
what is the 21 patch made of |
|
Definition
ethinyl estradiol norelgestromin |
|
|
Term
administration of 21 patch |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
drug that binds to the same site as the ligand and makes the same signal |
|
|
Term
define allosteric agonist |
|
Definition
drug that binds to different site than drug making no signal but causing drug to be more effective |
|
|
Term
|
Definition
drug produces lesser response than the ligand and competes for ligand site |
|
|
Term
define competitive agonist |
|
Definition
drug binds reversibly to receptor but increase in ligand can overcome it |
|
|
Term
define non-competitive agonist, what are the two types |
|
Definition
binds to receptor and prevents agonist from producing max effect
irreversible: more common, same receptor allosteric: different receptor |
|
|
Term
how can you tell if something on a graph is more potent or effective |
|
Definition
moving left on the X axis is more potent moving up on the Y axis is more effective |
|
|
Term
what does a partial agonist graph look like compared to agonist |
|
Definition
less effective shorter, less high on the Y axis |
|
|
Term
what does a allosteric agonist graph look like compared to agonist |
|
Definition
same effectiveness (height on Y axis) increased potency (more left on X axis) |
|
|
Term
what does a non-competitive agonist graph look like compared to agonist |
|
Definition
very short, sinking less effective (height on Y axis) less potent (more right on X axis) |
|
|
Term
what does a antagonist graph look like compared to agonist |
|
Definition
same effectiveness (height on Y axis) less potency (more right on X axis) |
|
|
Term
how does a Gs protein work |
|
Definition
activates cAMP which increases PKA |
|
|
Term
how does a Gi protein work |
|
Definition
decreases cAMP which decreases PKA |
|
|
Term
how does a Gq protein work |
|
Definition
releases IP3 and DAG IP3 releases Ca DAG and Ca activate PKC |
|
|
Term
what is the point of equal ionization |
|
Definition
|
|
Term
what happens to an acid and base if you put it in stuff that is lower (more basic) than the pKa |
|
Definition
acid will ionize base will not ionize |
|
|
Term
what happens to an acid and base if you put it in stuff that is higher (more acidic) than the pKa |
|
Definition
acid will not ionize base will ionize |
|
|
Term
what form of a drug is best excreted |
|
Definition
WA will be excreted beter in a basic enivornment
WB will be excreted better in an acidic enivornment |
|
|
Term
what form of a drug is best distributed in the body |
|
Definition
the same form
WA likes acid WB likes base |
|
|
Term
what is used to fix and WB or WB drug OD |
|
Definition
NaHCO3 is used to alkalize urine and fix WA OD
NH3CL is used to acidify urine and fix WB OD |
|
|
Term
|
Definition
increases gene expression of P450 metabolizing enzymes which decreases the plasma level of the drug making it less effective and decreasing presence of symptoms |
|
|
Term
what are 5 examples of inducers |
|
Definition
rifampin, bensopyrine, chronic ethanol, phenytoin, barbituates |
|
|
Term
|
Definition
decrease gene expression for metabolizing P450 enzymes increasing plasma concentration of the drug which increases symptoms |
|
|
Term
what are 4 examples of inhibitors |
|
Definition
cimetidine, erythromycin, ketonazole, grapefruit |
|
|
Term
define first order metabolism |
|
Definition
rate of drug metabolism is proportional to concentration of the free drug constant fraction of drug is metabolized per unit time |
|
|
Term
define zero order metabolism |
|
Definition
drugs with large doses saturate metabolizing enzymes constant amount of drug is metabolized per unit time |
|
|
Term
what are 3 examples of drugs with zero order kinetics |
|
Definition
aspirin, ethanol, phenytoin |
|
|
Term
what is a maintience dose for, how is it calculated |
|
Definition
adjust rate so input equals rate of loss to keep a steady plasma level
(Cs)(Cl)/(F) |
|
|
Term
what is loading dose for, how is it calculated |
|
Definition
load initial volume of drug needed
(Cp)(Vd)/(F) |
|
|
Term
how long does it take to get to steady state, what is it dependent on(2) |
|
Definition
4-5 half lives depends on half life and steady state is determined by first order kinetics |
|
|
Term
|
Definition
zidovudine lamivudine entricitabine |
|
|
Term
|
Definition
host adds 3P then drug terminates DNA elongation |
|
|
Term
|
Definition
peripherial neuropathy lactic acidosis marrow supression - zidovudine |
|
|
Term
|
Definition
|
|
Term
|
Definition
host adds 2P, drug terminates DNA elongation |
|
|
Term
|
Definition
|
|
Term
|
Definition
maculopapular rash CNS effects - enfavirenz |
|
|
Term
|
Definition
binds reverse transcriptase causing inactivation |
|
|
Term
name a protease inhibitor, what is the MOA |
|
Definition
ritonavir inhibits protease stopping viral replication |
|
|
Term
protease inhibitor side effects (5) |
|
Definition
central fat deposition insulin release hyperglycemia P450 inhibitor - increased in infants |
|
|
Term
|
Definition
in combination with out PI because it is an extra good P450 inhibitor |
|
|
Term
name an integrase inhibitor |
|
Definition
|
|
Term
|
Definition
inhibits viral genetic integration into host chromosomes |
|
|
Term
name three anti-herpes drugs |
|
Definition
acyclovir gencyclovir foscarnet |
|
|
Term
|
Definition
TK adds 1P, host adds 2P, DNA chain termination |
|
|
Term
acyclovir side effects (4) |
|
Definition
delerium tremor seizure nephrotoxicity (crystal urea, drink water) |
|
|
Term
|
Definition
TK adds 1P, host adds 2P, DNA chain termination |
|
|
Term
|
Definition
|
|
Term
|
Definition
stops reverse transcriptase and DNA polumerase |
|
|
Term
fascarnet side effects (2) |
|
Definition
nephrotoxicity altered Ca and P balance |
|
|
Term
what two herpes drugs treat CMV |
|
Definition
|
|
Term
name and influenza a and b drug |
|
Definition
|
|
Term
|
Definition
neuroaminidase inhibitor that stopps viral budding |
|
|
Term
|
Definition
|
|
Term
|
Definition
stops mycolic acid assembly |
|
|
Term
|
Definition
peripherial neuritis (take B6 to fix) |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
rifampin side effects (5) |
|
Definition
P450 inhibitor pseudomembrane colitis renal failure anemia red/orange urine |
|
|
Term
|
Definition
|
|