32 - Diabetes Flashcards
What is the most common cause of death in patients with diabetes?
heart disease
Type ___ can cause ketoacidosis
1
What are some drugs that can cause dysglycemia?
-beta blockers
-corticosteroids
-SGAs
-thiazide or loop diuretics
-immunosuppressive agents
-protease inhibitors
-niacin
-isoniazid
etc.
What is criteria for diagnosis?
Any one of the following:
- RPG > 11.1 mmol/L
- FPG > 7 mmol/L
- plasma glucose 2 hrs after 75 g oral glucose load > 11.1 mmol/L
- HbA1c > 6.5% (in non-pregnant patients)
*should confirm result on a different day to confirm diagnosis
How often should ppl get tested for T2DM?
every 3 years in individuals over 40 years of age by using either FPG or HbA1C
What A1C at diagnosis means they should probably start insulin?
> 8.5%
In newly diagnosed T2DM with A1C < ____ can do lifestyle mods alone
8.5%
How long do you try lifestyle mods for before adding pharmacological therapy?
2-3 months
Non-pharms?
- self management education
- nutritional management
- self monitoring of blood glucose
- physical activity
- ongoing monitoring
- immunizations
What immunizations should ppl with diabetes get?
- annual influenza vaccine
- one time pneumococcal vaccine
*a 2nd pneumococcal vaccine is recommended for patients over 65 years old who received their original immunization > 5 years earlier at < 65 years of age
List some rapid insulins
aspart, glulisine, lispro
List some short-acting insulins
regular
List some intermediate-acting insulins
NPH
List some ultra long actinginsulins
degludec
Most lean patients with T1DM require how much insulin ?
0.5 units of insulin / kg
s/e of insulin
- hypoglycemia
- localized fat hypertrophy (need to rotate injection sites)
- allergic reactions (switch to different insulin manufacturer)
- immune-mediated insulin resistance
For T2DM, what is usually 1st line when they need pharmacological therapy?
monotherapy with metformin
aim to reach desired HbA1c in how long?
3-6 months
List the biguanide
metformin
How does metformin work?
decreases hepatic glucose production and may lower glucose absorption and enhance insulin-mediated glucose uptake
Does metformin cause weight gain?
no
Does metformin cause hypoglycemia?
risk is low when used as monotherapy
How much is A1C decreased by with metformin?
1%
Metformin has strongest evidence for ?
reducing macrovascular endpoints and mortality in overweight patients
List an alpha glucosidase inhibitor
acarbose
How does acarbose work?
inhibits intestinal alpha-glucosidases, delays digestion of starches and disaccharides, and reduces postprandial glucose levels
major s/e of acarbose?
GI
How much does acarbose lower A1c by?
less than or equal to 1%
How do you treat hypoglycemia in those on acarbose?
must use glucose!
b/c the digestion of sucrose is impaired by acarbose
List some DPP-4 inhibitors
- saxagliptin
- sitagliptin
- linagliptin
How do DPP-4 inhibitors work?
GLP-1 is degraded by DPP-4 so we inhibit that to increase GLP-1 which is glucagon-like peptide
this inhibits glucagon release and lowers blood sugar
How much do DPP-4 inhibitors lower A1C by ?
less than or equal to 1%
Which DPP-4 inhibitor is only approved for use in combo with other antihyperglycemics?
saxagliptin
How do GLP-1 agonists work?
- mimic GLP-1, an endogeous incretin hormone
- incretins are released after you eat and stimulate insulin release to decrease blood sugar
- also suppresses glucagon secretion during the postprandial period, slows gastric emptying and increases satiety
most common s/e of GLP-1 agonists?
nausea
How are dulaglutide and semaglutide given?
SC once weekly
How is liraglutide given?
SC once daily
How is lixisenatide given?
SC once daily within 1 hour of a meal
How is Exenatide solution given?
SC BID prior to meals
How is Exenatide suspension given?
SC once weekly
Which GLP-1 agonists decrease CV death in those with high CV risk?
Liraglutide and semaglutide
List the insulin secretagogues (sulfonylureas)
1st gen: chlorpropamide, tolbutamide
2nd gen: gliclazide, glimepiride, glyburide
How do SUs work?
stimulate basal and meal-stimulated insulin release
How much can SUs decrease A1c ?
by 1-1.5%
____ has highest risk of hypoglycemia in it’s class, esp in those who are elderly or with decreased renal function
glyburide
Although more common with glyburide, ____ and ___ ___ can occur with any of the SUs
hypoglycemia and weight gain
Glyburide is on _____ list
BEERS
T or F: has glyburide been shown to reduce efficacy over time?
true
What is the place in therapy for SUs?
- add on therapy
- or monotherapy when metformin is CI
List the agent from the class insulin secretagogue: meglitinide that’s available in canada
repaglinide
Compare repaglinide’s action to SUs
much shorter
How does Repaglinide need to be taken
need to be taken just prior to meals and should be omitted if meal is missed
How much will Repaglinide lower A1c by?
1-1.5%
List some SGLT2 inhibitors
canagliflozin, dapagliflozin, empagliflozin
How do the SGLT2 inhibitors work?
prevent glucose reabsorption in the kidneys which increases excretion of urinary glucose.
benefits of SGLT2 inhibitors?
may cause weight loss and reduce BP
s/e of SGLT2 inhibitors
- mycotic genital infections
- UTIs
- decreased bone mineral density
- some reports of DKA
Who should you avoid SGLT2 inhibitors in?
avoid in those with poor kidney function or those at risk of volume depletion
List examples of thiazolidenediones (TZDs)
pioglitazone
rosiglitazone
How do TZDs work?
agonists at PPARG receptors which influences gene expression leading to enhanced insulin sensitivity and lower levels of BG and circulating insulin
TZD have high or low hypoglycemia risk
risk is low when used as monotherapy
How much can TZDs decrease A1c by?
1-1.5%
s/e of TZD
weight gain, may lead to increased risk of heart failure
can also worsen macular edema and increase risk of fractures
are TZD CV safe?
CV safety still in question
What cancer is pioglitazone CI in patients with active or previous cancer?
bladder cancer
how do you initiate insulin?
40% of TDD as basal insulin
20% of TDD given TID before meals 3 times daily
TDD = total daily dose = 0.5 units/kg of body weight
how do you give premixed insulin?
2/3 TDD given in the morning
1/3 TDD given before the evening meal
how can we help achieve vascular protection in addition to lowering BG?
- achieve BP goal
- achieve serum lipid goal
- promote weight loss to normal BMI
- encourage smoking cessation
- give anti-platelet therapy to those with established CV disease
What is the LDL goal?
LDL less than or equal to 2 mmol/L or a 50% reduction from baseline
Why do we choose statins over fibrates or niacin?
- Statins are cardioprotective
- Fibrates have limited evidence to reduce further ischemic attacks
- Niacin can actually increase BG levels and has not been shown to improve CV outcomes
What is the BP goal for diabetics?
< 130/80 mmHg
What agents are first choice for HTN in diabetes?
ACEi or ARB
Pregnancy:
How much folic acid do they need and for how long?
5mg folic acid at least 3 months prior to conception, continue until 3 months gestation then just need 0.4-1 mg folic acid daily until 6 months post partum or when they stop breastfeeding
List important parts in the pre-pregnancy planning
- folic acid
- eye exam
- get HbA1c < 7% (<6% if safely achievable)
- screen for CV disease
- stop teratogenic meds (ACEi, ARB, statins)
Pregnancy:
After how long should they start insulin after trying nonpharms?
2 weeks
Pregnancy:
What is first line after nonpharms?
insulin
Pregnancy:
What oral meds can you use?
glyburide or metformin (off-label use tho)
Pregnancy:
What is FPG target?
< 5.3 mmol/L
Pregnancy:
What is 1 hr PPG target?
< 7.8 mmol/L
Pregnancy:
What is 2 hr PPG target?
< 6.7 mmol/L
Breastfeeding:
Is insulin transferred through breast milk? Is it safe?
Yes but the baby will degrade the insulin in GI tract before it reaches systemic so it’s ok
When should patients with GDM get re-assessed for hyperglycemia? with what test?
75 g OGTT between 6 weeks and 6 months following delivery
Breastfeeding:
Oral options if insulin can’t be used?
glyburide and metformin have been used but have limited data on long term effects
Which meds can decrease the incidence of T2DM in those at risk patients?
metformin
acarbose
TZDs
orlistat
_________ may prevent DM but in the study it also increased risk of heart failure
rosiglitazone
What are DKA symptoms?
- variable hyperglycemia
- volume depletion
- acidosis
- depressed levels of consciousness
- detectable ketones in urine or blood
Briefly describe management of DKA
- fluids
- potassium chloride - only give if urine is being produced
- insulin - only give if K+ > 3.3 mmol/L
- bicarbonate
- lab tests
- supportive care
- pitfalls
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