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PEBC > 32 - Diabetes > Flashcards

32 - Diabetes Flashcards

1
Q

What is the most common cause of death in patients with diabetes?

A

heart disease

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2
Q

Type ___ can cause ketoacidosis

A

1

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3
Q

What are some drugs that can cause dysglycemia?

A

-beta blockers
-corticosteroids
-SGAs
-thiazide or loop diuretics
-immunosuppressive agents
-protease inhibitors
-niacin
-isoniazid
etc.

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4
Q

What is criteria for diagnosis?

A

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

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5
Q

How often should ppl get tested for T2DM?

A

every 3 years in individuals over 40 years of age by using either FPG or HbA1C

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6
Q

What A1C at diagnosis means they should probably start insulin?

A

> 8.5%

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7
Q

In newly diagnosed T2DM with A1C < ____ can do lifestyle mods alone

A

8.5%

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8
Q

How long do you try lifestyle mods for before adding pharmacological therapy?

A

2-3 months

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9
Q

Non-pharms?

A
  • self management education
  • nutritional management
  • self monitoring of blood glucose
  • physical activity
  • ongoing monitoring
  • immunizations
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10
Q

What immunizations should ppl with diabetes get?

A
  • 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

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11
Q

List some rapid insulins

A

aspart, glulisine, lispro

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12
Q

List some short-acting insulins

A

regular

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13
Q

List some intermediate-acting insulins

A

NPH

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14
Q

List some ultra long actinginsulins

A

degludec

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15
Q

Most lean patients with T1DM require how much insulin ?

A

0.5 units of insulin / kg

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16
Q

s/e of insulin

A
  • hypoglycemia
  • localized fat hypertrophy (need to rotate injection sites)
  • allergic reactions (switch to different insulin manufacturer)
  • immune-mediated insulin resistance
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17
Q

For T2DM, what is usually 1st line when they need pharmacological therapy?

A

monotherapy with metformin

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18
Q

aim to reach desired HbA1c in how long?

A

3-6 months

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19
Q

List the biguanide

A

metformin

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20
Q

How does metformin work?

A

decreases hepatic glucose production and may lower glucose absorption and enhance insulin-mediated glucose uptake

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21
Q

Does metformin cause weight gain?

A

no

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22
Q

Does metformin cause hypoglycemia?

A

risk is low when used as monotherapy

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23
Q

How much is A1C decreased by with metformin?

A

1%

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24
Q

Metformin has strongest evidence for ?

A

reducing macrovascular endpoints and mortality in overweight patients

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25
Q

List an alpha glucosidase inhibitor

A

acarbose

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26
Q

How does acarbose work?

A

inhibits intestinal alpha-glucosidases, delays digestion of starches and disaccharides, and reduces postprandial glucose levels

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27
Q

major s/e of acarbose?

A

GI

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28
Q

How much does acarbose lower A1c by?

A

less than or equal to 1%

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29
Q

How do you treat hypoglycemia in those on acarbose?

A

must use glucose!

b/c the digestion of sucrose is impaired by acarbose

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30
Q

List some DPP-4 inhibitors

A
  • saxagliptin
  • sitagliptin
  • linagliptin
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31
Q

How do DPP-4 inhibitors work?

A

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

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32
Q

How much do DPP-4 inhibitors lower A1C by ?

A

less than or equal to 1%

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33
Q

Which DPP-4 inhibitor is only approved for use in combo with other antihyperglycemics?

A

saxagliptin

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34
Q

How do GLP-1 agonists work?

A
  • 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
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35
Q

most common s/e of GLP-1 agonists?

A

nausea

36
Q

How are dulaglutide and semaglutide given?

A

SC once weekly

37
Q

How is liraglutide given?

A

SC once daily

38
Q

How is lixisenatide given?

A

SC once daily within 1 hour of a meal

39
Q

How is Exenatide solution given?

A

SC BID prior to meals

40
Q

How is Exenatide suspension given?

A

SC once weekly

41
Q

Which GLP-1 agonists decrease CV death in those with high CV risk?

A

Liraglutide and semaglutide

42
Q

List the insulin secretagogues (sulfonylureas)

A

1st gen: chlorpropamide, tolbutamide

2nd gen: gliclazide, glimepiride, glyburide

43
Q

How do SUs work?

A

stimulate basal and meal-stimulated insulin release

44
Q

How much can SUs decrease A1c ?

A

by 1-1.5%

45
Q

____ has highest risk of hypoglycemia in it’s class, esp in those who are elderly or with decreased renal function

A

glyburide

46
Q

Although more common with glyburide, ____ and ___ ___ can occur with any of the SUs

A

hypoglycemia and weight gain

47
Q

Glyburide is on _____ list

A

BEERS

48
Q

T or F: has glyburide been shown to reduce efficacy over time?

A

true

49
Q

What is the place in therapy for SUs?

A
  • add on therapy

- or monotherapy when metformin is CI

50
Q

List the agent from the class insulin secretagogue: meglitinide that’s available in canada

A

repaglinide

51
Q

Compare repaglinide’s action to SUs

A

much shorter

52
Q

How does Repaglinide need to be taken

A

need to be taken just prior to meals and should be omitted if meal is missed

53
Q

How much will Repaglinide lower A1c by?

A

1-1.5%

54
Q

List some SGLT2 inhibitors

A

canagliflozin, dapagliflozin, empagliflozin

55
Q

How do the SGLT2 inhibitors work?

A

prevent glucose reabsorption in the kidneys which increases excretion of urinary glucose.

56
Q

benefits of SGLT2 inhibitors?

A

may cause weight loss and reduce BP

57
Q

s/e of SGLT2 inhibitors

A
  • mycotic genital infections
  • UTIs
  • decreased bone mineral density
  • some reports of DKA
58
Q

Who should you avoid SGLT2 inhibitors in?

A

avoid in those with poor kidney function or those at risk of volume depletion

59
Q

List examples of thiazolidenediones (TZDs)

A

pioglitazone

rosiglitazone

60
Q

How do TZDs work?

A

agonists at PPARG receptors which influences gene expression leading to enhanced insulin sensitivity and lower levels of BG and circulating insulin

61
Q

TZD have high or low hypoglycemia risk

A

risk is low when used as monotherapy

62
Q

How much can TZDs decrease A1c by?

A

1-1.5%

63
Q

s/e of TZD

A

weight gain, may lead to increased risk of heart failure

can also worsen macular edema and increase risk of fractures

64
Q

are TZD CV safe?

A

CV safety still in question

65
Q

What cancer is pioglitazone CI in patients with active or previous cancer?

A

bladder cancer

66
Q

how do you initiate insulin?

A

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

67
Q

how do you give premixed insulin?

A

2/3 TDD given in the morning

1/3 TDD given before the evening meal

68
Q

how can we help achieve vascular protection in addition to lowering BG?

A
  • 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
69
Q

What is the LDL goal?

A

LDL less than or equal to 2 mmol/L or a 50% reduction from baseline

70
Q

Why do we choose statins over fibrates or niacin?

A
  • 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
71
Q

What is the BP goal for diabetics?

A

< 130/80 mmHg

72
Q

What agents are first choice for HTN in diabetes?

A

ACEi or ARB

73
Q

Pregnancy:

How much folic acid do they need and for how long?

A

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

74
Q

List important parts in the pre-pregnancy planning

A
  • folic acid
  • eye exam
  • get HbA1c < 7% (<6% if safely achievable)
  • screen for CV disease
  • stop teratogenic meds (ACEi, ARB, statins)
75
Q

Pregnancy:

After how long should they start insulin after trying nonpharms?

A

2 weeks

76
Q

Pregnancy:

What is first line after nonpharms?

A

insulin

77
Q

Pregnancy:

What oral meds can you use?

A

glyburide or metformin (off-label use tho)

78
Q

Pregnancy:

What is FPG target?

A

< 5.3 mmol/L

79
Q

Pregnancy:

What is 1 hr PPG target?

A

< 7.8 mmol/L

80
Q

Pregnancy:

What is 2 hr PPG target?

A

< 6.7 mmol/L

81
Q

Breastfeeding:

Is insulin transferred through breast milk? Is it safe?

A

Yes but the baby will degrade the insulin in GI tract before it reaches systemic so it’s ok

82
Q

When should patients with GDM get re-assessed for hyperglycemia? with what test?

A

75 g OGTT between 6 weeks and 6 months following delivery

83
Q

Breastfeeding:

Oral options if insulin can’t be used?

A

glyburide and metformin have been used but have limited data on long term effects

84
Q

Which meds can decrease the incidence of T2DM in those at risk patients?

A

metformin
acarbose
TZDs
orlistat

85
Q

_________ may prevent DM but in the study it also increased risk of heart failure

A

rosiglitazone

86
Q

What are DKA symptoms?

A
  • variable hyperglycemia
  • volume depletion
  • acidosis
  • depressed levels of consciousness
  • detectable ketones in urine or blood
87
Q

Briefly describe management of DKA

A
  • 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

**page 492

PEBC (130 decks)

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