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IPT: Endocrine > Block 3 > Flashcards

Block 3 Flashcards

1
Q

What drugs or hormones increase insulin secretion?

A

Sulfonylureas

Meglitinides

Incretins

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2
Q

What drugs or hormones decrease glucagon secretion?

A

Incretins

Amylin

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3
Q

What drugs or hormones decrease glucose reabsorption?

A

SGLT2 inhibitors

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4
Q

What drugs or hormones increase glucose uptake and utilization?

A

Thiazolidinediones

Metformin

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5
Q

What drugs or hormones are correlated w/ lipotoxicity?

A

Thiazolidinediones

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6
Q

What drugs or hormones decrease hepatic glucose output?

A

Thiazolidinediones

Metformin

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7
Q

What are the pharmaceutical targets in regulating insulin secretion?

A

GI hormones

Pancreatic hormones

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8
Q

Liver cells and carbohydrate metabolism, what is the metabolic action via insulin?

A

Gluconeogenesis goes down

Glycogenolysis goes down

Glycolysis goes up

Glycogenesis goes up

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9
Q

Liver cells and fat metabolism, what is the metabolic action via insulin?

A

Lipogenesis goes up

Lipolysis goes down

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10
Q

Liver cells and protein metabolism, what is the metabolic action via insulin?

A

Protein breakdown goes down

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11
Q

Fat cells and carbohydrate metabolism, what is the metabolic action via insulin?

A

Glucose uptake increases

Glycerol synthesis increases

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12
Q

Fat cells and fat metabolism, what is the metabolic action via insulin?

A

Synthesis of TG

Synthesis of FA

Lipolysis goes down

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13
Q

Fat cells and protein metabolism, what is the metabolic action via insulin?

A

Nothing happens

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14
Q

Muscles and carbohydrate metabolism, what is the metabolic action via insulin?

A

Glucose uptake increases

Glycolysis goes up

Glycogenesis goes up

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15
Q

Muscles and fat metabolism, what is the metabolic action via insulin?

A

Nothing happens

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16
Q

Muscles and protein metabolism, what is the metabolic action via insulin?

A

AA uptake increases

Protein synthesis increases

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17
Q

What are the ultra-short acting insulins or rapid acting?

A

Lispro (Humalog)

Aspart (Novolog)

Glulisine (Apidra)

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18
Q

What are the short acting insulins?

A

Regular insulin (Novolin)

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19
Q

When Regular insulin (Novolin) in administered subcutaneously, what form does it inject as?

A

Hexamer then dimer then a monomer

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20
Q

When should regular insulin (Novolin) be given?

A

30 to 45 min before meals

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21
Q

What are the intermediate-acting insulins?

A

NPH (Humulin)

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22
Q

NPH (Humulin) is a complex made up of…

A

Insulin + Protamine**

**Requires proteolytic degradation for absorption of insulin

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23
Q

What are the long-acting insulins?

A

Insulin glargine (Lantus, Toujeo)

Insulin detemir (Levemir)

Insulin Degludec (Tresiba)

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24
Q

MOA of Metformin?

A

Unknown but linked to decreased ATP and increased cAMP

Decreases hepatic glucose production

Decreases intestinal absorption of glucose

Enhances insulin sensitivity

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25
Q

What are some advantages of Metformin?

A
  1. No Wt gain
  2. No hypoglycemia
  3. Significant lipid lowering effect
  4. Works on those who are insulin resistant
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26
Q

AE of Metformin?

A
  1. Vit. B12 deficiency
  2. Lactic acidosis
  3. Heptatitis
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27
Q

Contraindications of Metformin?

A
  1. Metabolic acidosis or diabetic ketoacidosis
  2. Renal insufficiency
  3. Cardiac collapse / acute MI
  4. Use w/ iodinated contrast
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28
Q

MOA of sulfonylureas?

A

Blocks ATP-sensitive K+ channels which leads to depolarization and influx of calcium

Results in insulin secretion which lowers blood glucose

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29
Q

Which Rx has extrapancreatic effect and what is it?

A

Sulfonylureas

Suppresses hepatic glucose output

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30
Q

Sulfonylurea AE?

A
  1. Hypoglycemia
  2. Tremors and nervousness
  3. GI hemorrhage
  4. Hemolytic + G6PD deficiency anemia
  5. Cholestatic jaundice
  6. Weight gain
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31
Q

Which sulfonylurea has active metabolites?

A

Glyburide

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32
Q

What are some Rx interactions w/ sulfonylureas?

A

Dulaglutide and acarbose

Causes hypoglycemia

**non-sulfonylurea insulin releasing agents also interact with these Rx^

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33
Q

What are the non-sulfonylurea insulin releasing agents?

A

Nateglinide (Starlix)

Repaglinide (Prandin)

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34
Q

Compare the sulfonylureas with the non-sulfonylurea insulin releasing agents

A

Non-sulfonylurea agents have shorter half life and has rapid action (just take 30min before meals)

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35
Q

Non-sulfonylurea insulin releasing agent AE?

A

Hypoglycemia

Respiratory infection

Headaches

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36
Q

What drug is an alpha-glucosidase inhibitor?

A

Acarbose (Precose)

Miglitol (Glyset)

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37
Q

Acarbose MOA?

A

Inhibits digestion of complex sugars (take w/ meals)

Decreases carb uptake after a meal

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38
Q

Acarbose AE?

A

Causes flatulence, GI problems which leads to poor acceptance and compliance

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39
Q

Contraindications of Acarbose?

A
  1. Major GI issues (ulcers, inflammatory, etc)

2. Liver cirrhosis

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40
Q

What are some drug interactions of Acarbose?

A

Dont take w/ another anti-diabetic (risk of hypoglycemia)

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41
Q

Pioglitazone MOA?

A

Stimulates PPAR gamma receptors in adipose tissue and other cells

Leads to activation of transcription factors

Decrease insulin resistance (increases sensitivity of insulin)

Increases glucose uptake and increases hepatic glucose output

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42
Q

Which diabetic Rx requires liver enzyme tests?

A

Pioglitazone

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43
Q

Pioglitazone AE?

A
  1. Water retention and Wt gain
  2. Anemia
  3. Limb fractures
  4. Respiratory infection
  5. Heart, liver failure **can worsen congestive heart failure
  6. Bladder cancer
  7. Macular edema
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44
Q

What are some drug interactions with pioglitazone?

A

Decreased lvls of nifedipine

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45
Q

What diabetic Rx has a black box warning and what is the warning?

A

Exenatide - Causes medullary thyroid carcinoma

GLP-1 agonists = thyroid C-cell tumors

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46
Q

AE of Exenatide?

A
  1. Hypoglycemia if combined w/ other antidiabetic Rx
  2. Pancreatitis and pancreatic cancer
  3. Acute renal failure
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47
Q

What are some contraindications of Exenatide (or just GLP-1 agonists)

A

Multiple endocrine neoplasia syndrome type 2

Family history of medullary thyroid carcinoma

***except with lixisenatide (Adlyxin)

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48
Q

Which Rx is the GLP-1 analog?

A

Exenatide, Liraglutide

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49
Q

Which Rx is the synthetic amylin analog?

A

Pramlinitide (Symlim)

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50
Q

Pramlinitide AE?

A

Weight loss

Decreased gastric emptying

Hypoglycemia

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51
Q

When is Pramlinitide used?

A

Adjunct to insulin

Injected before meals, just DONT mix with insulin

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52
Q

What are the DPP-4 inhibitors?

A

Sitagliptin

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53
Q

Sitagliptin MOA?

A

DPP-4 inhibitor

Degrades GLP-1 and GIP

Stimulates “glucose DEPENDENT” insulin secretion (just like GLP-1 agonists)

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54
Q

Sitagliptin AE?

A

Nasopharyngitis

Pancreatic cancer

Acute renal failure

SJS

Rhabdomyolisis

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55
Q

Which diabetic Rx can cause acute renal failure?

A

Exenatide

DPP-4 inhibitors

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56
Q

Which diabetic Rx can cause pancreatic cancer?

A

Exenatide

DPP-4 inhibitors

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57
Q

What kind of Rx is Canagliflozin?

A

SGLT-2 inhibitors

Reduces blood glucose

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58
Q

Which Rx works independently of insulin?

A

SGLT-2 inhibitors

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59
Q

SGLT-2 inhibitor AE?

A

Urinary infections

Hypovolemia

Diabetic ketoacidosis

Pancreatitis

Bone fractures

Renal impairment

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60
Q

SGLT-2 inhibitor contraindications

A

Severe renal impairment

Possibility of hypotension

Hyperkalemia

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61
Q

What are some drug interactions with SGLT-2 inhibitor?

A

Digoxin, increased levels

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62
Q

What are some clinical pearls of metformin?

A

Hold metformin during periods following stress due to increased %% of lactic acidosis

D/c metformin 48hrs prior to contrast dye due to acute renal damage

Second line therapy for GDM

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63
Q

What is the starting dose for metformin? Titrated? Max dose?

A

Start: 500mg BID or 850mg QD (IR)

500mg daily w/ evening meal (ER)

Titrated: 500mg weekly or 850mg every 2 wks (IR only)

Max: 2550mg (IR) + 2000mg (ER)

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64
Q

Does metformin need to be renally/hepatically adjusted? If so, how is it adjusted?

A

eGFR from 30 to 45 = do not start or adjust for 50% for existing therapy

Liver = caution due to %% of lactic acidosis

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65
Q

What diabetic Rx is concerned w/ Vit. B12 deficiency?

A

Metformin

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66
Q

What is the starting dose of pioglitazone? Titrated? Max?

A

Start: 15 or 30mg QD

Titrate: 15mg q4-6 wks

Max: 45mg

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67
Q

Does pioglitazone need to be renally/hepatically adjusted? If so, how is it adjusted?

A

No renal adjustments

Caution in liver impairment

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68
Q

When is pioglitazone contraindicated?

A

Initiation in pt w/ NYHA Class III/IV heart failure

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69
Q

What are some considerations you must think about when prescribing pioglitazone?

A

It has a delayed onset

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70
Q

What are the brand names for glyburide, glimepiride, and glipizide?

A

Glyburide - Diabeta

Glimepiride - Amaryl

Glipizide - Glucotrol

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71
Q

What are the generic names for Diabeta, Glucotrol, and Amaryl

A

Glyburide - Diabeta

Glimepiride - Amaryl

Glipizide - Glucotrol

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72
Q

What are some contraindications for sulfonylureas?

A
  1. Used in T1DM or DKA

2. Sulfur allergy

73
Q

Do sulfonylureas need to be renally/hepatically adjusted? If so, how is it adjusted?

A

Only Glimepiride needs to be renally adjusted. Start at 1mg in CKD

74
Q

What is the starting dose of glyburide? Titrated? Max?

A

Start: 2.5 to 5mg daily w/ first meal (can start at 1.25 if sensitive to hypoglycemia)

Titrate: 2.5mg q1-2wks

Max: 20mg/day

Micronized formulation=

Start: 1.5 to 3mg daily with first meal (can start at 0.75mg)

Titrate: 1.5mg q1-2wks

Max 12mg/day

75
Q

What is the starting dose of glimepiride? Titrated? Max?

A

Start: 1 to 2mg/day w/ first meal (can start at 1.25mg)

Titrate: 1 to 2mg q1-2wks

Max: 8mg

76
Q

What is the starting dose of glipizide? Titrated? Max?

A

IR = Start: 2.5mg daily BEFORE first meal

Titrate: 2.5 to 5mg q1-2wks. Can be given BID 30min before meals

Max 20mg

ER = Start: 2.5 to 5mg daily BEFORE first meal

Titrate 5mg q1-2wks

Max 20mg

77
Q

Which diabetic Rx is contraindicated with bosentan?

A

Glyburide

78
Q

Which sulfonylurea is not the preferred agent in CKD or elderly patients?

A

Glyburide

79
Q

Which sulfonylurea is preferred in renal dysfunction?

A

Glipizide

80
Q

Brand names of Repaglinide and Nateglinide?

A

Repaglinide - Prandin

Nateglinide - Starlix

81
Q

What is the starting dose of repaglinide? Titrated? Max?

A

Start: 0.5mg before meals (A1c<8) or 1 to 2mg (A1c>8)

Titrate: double dose q1-2wks

Max: 16mg/day

CrCl from 20-40 = initial is 0.5mg/day

W/ cyclosporine = max is 6mg/day

82
Q

What is the starting dose of nateglinide? Titrated? Max?

A

Start: 120mg TID before meals. Can start at 60mg TID if close to A1c goal

Max: 360mg/day

If eGFR <30= initial is 60mg TID

83
Q

What are some considerations to take with repaglinide?

A

Take w/ food (30min before)

Avoid use w/ clopidogrel or gemfibrozil

84
Q

What are some considerations to take with nateglinide?

A

Take w/ food (30min before)

85
Q

Which classes of diabetic Rx are “glucose-independent” insulin secretagogues?

A

Meglitinides (Repaglinide and Nateglinide) and sulfonylureas

86
Q

What dosage form does Repaglinide and Nateglinide come in?

A

PO only

87
Q

Clinical pearls of GLP-1 agonists?

A

GLP-1 agonists and DPP-4 inhibitors are usually not given together

Takes 6-7 wks to reach steady state

Not preferred in ppl w/ gastroparesis

Need to be hydrated

AB development

CV benefits in liraglutide, dulaglutide and semaglutide

88
Q

Which GLP-1 agonists must be renally adjusted?

A

Lixisenatide and Exenatide

Lixisenatide = not recommended <15
Exenatide = not recommended for CrCl <30 (IR) and eGFR <45 (ER)
89
Q

What is the starting dose of Lixisenatide? Titrated? Max?

A

Start: 10mcg daily for 14 days

Titrate: 20mcg daily

Max: 20mcg daily

90
Q

What is the starting dose of Exenatide? Titrated? Max?

A

(IR) Start: 5mcg BID within 60min of meals (6 hrs apart)

Titrate: 10mcg BID after 1 month

(ER) Start 2mcg once weekly (no regard of meals)

91
Q

What is the starting dose of liraglutide? Titrated? Max?

A

Start: 0.6mg SQ daily for 1 wk

Titrate: Then 1.2mg daily

Max: 1.8mg/day

92
Q

Which diabetic Rx is approved for weight loss?

A

Liraglutide (3mg dose) + CV benefits

93
Q

What is the starting dose of dulaglutide? Titrated? Max?

A

Start: 0.75mg once weekly

Titrate: May increase to 1.5mg once weekly

Max: 1.5mg/week

94
Q

What is the starting dose of semaglutide? Titrated? Max?

A

SQ Start: 0.25mg weekly for 4 wks

Titrate: 0.5mg weekly for at least 4 wks (can increase to 1mg/week)

Oral Start: 3mg once daily for 30 days

Titrate: 7mg daily for 30 days (can increase to 14mg daily)

95
Q

Which DPP-4 inhibitor must be renally adjusted?

A

Sitagliptin

Saxagliptin

Aloglipitin

(Linagliptin is the only one that isnt adjusted)

96
Q

Brand names of the DPP-4 inhibitors?

A

Sitaglipin - Januvia

Saxagliptin - Onglyza

Linagliptin - Tradjenta

Alogliptin - Nesina

97
Q

What is the starting dose of sitagliptin? Titrated? Max?

A

Start: 100mg daily

Max: 100mg daily

Renal dose eGFR 30-44 = 50mg daily

If <30 = 25mg daily

98
Q

What is the starting dose of Saxagliptin? Titrated? Max?

A

Start: 2.5 to 5mg daily

Max: 5mg daily

Renal dose eGFR <45 = 2.5mg daily

99
Q

What are some considerations when using DPP-4 inhibitors?

A

Only with Saxagliptin and Alogliptin, increased %% of hospitalization due to heart failure within first 12 months of therapy

100
Q

What is the starting dose of linagliptin? Titrated? Max?

A

Start: 5mg daily

Max: 5mg daily

101
Q

What is the starting dose of alogliptin? Titrated? Max?

A

Start: 25mg daily

Max: 25mg daily

Renal dose eGFR 30-59 = 12.5mg daily

<30 = 6.25mg daily

102
Q

What is the starting dose of pramlinitide? Titrated? Max?

A

(SQ + T1DM) Start: 15mcg prior to major meals

Titrate: 15mcg q3days till 30 to 60 mcg before meals

(SQ + T2DM) Start 60mcg prior to meals

Titrate: 120mcg before meals

103
Q

What is the starting dose of acarbose? Titrated? Max?

A

(PO) Start 25mg TID w/ first bite of meal

Titrate: 50 to 100mg TID (every 4 to 8 wks)

Max: 50mg TID (≤60kg) or 100mg TID (>60kg)

Renal dose not recommended if SCr >2 or CrCl <25

104
Q

What is the starting dose of miglitol? Titrated? Max?

A

(PO) Start: 25mg TID w/ first bite of meal

Titrate: 50 to 100mg TID (every 4 to 8 wks)

Max: 100mg TID

Renal dose not recommended if SCr >2 or CrCl <25

105
Q

SGLT-2 inhibitor MOA?

A

Inhibits SGLT2 cotransporter in proximal renal tubules and prevents reabsorption of glucose

106
Q

What are the SGLT-2 inhibitors?

A

Canagliflozin - Invokana

Empagliflozin - Jardiance

Dapagliflozin - Farxiga

Ertugliflozin - Steaglatro

107
Q

Which diabetic Rx are associated w/ weight loss?

A

Pramlinitide + SGLT-2 inhibitors

108
Q

Which diabetic Rx class is associated w/ euglycemic ketoacidosis?

A

SGLT-2 inhibitors

109
Q

What is the starting dose of canagliflozin? Titrated? Max?

A

Initial: 100mg daily

Max 300mg daily

Renal dose 30-59 eGFR = 100mg daily

<30 is contraindicated

Severe hepatic dysfunction, also not recommended

110
Q

What is the starting dose of empagliflozin? Titrated? Max?

A

Initial: 10mg daily. May increase to 25mg

Max: 25mg daily

Renal dose 30-44 = do not initiate therapy

<30 = contraindicated

111
Q

What are some additional monitoring parameters for canagliflozin?

A

Increased %% of limb amputations and hyperkalemia

but…increased CV benefits

112
Q

What is the starting dose of dapagliflozin? Titrated? Max?

A

Initial 5mg daily

Max: 10mg daily

Renal dosing eGFR 30-44 - do not initiate

113
Q

What is the starting dose of ertugliflozin? Titrated? Max?

A

Initial 5mg daily

Max 15mg daily

Renal dosing eGFR 30-59 - do not initiate

Severe hepatic dysfunction, also not recommended

114
Q

Which SGLT-2 inhibitors should not be recommended with hepatic dysfunction?

A

Canagliflozin and ertugliflozin

115
Q

What are some considerations when prescribing dapagliflozin?

A

Indicated for reduction of heart failure in pt w/ diabetes

116
Q

When evaluating a patient with diabetes and they have ASCVD issues, what can you prescribe them?

A

GLP-1 agonists or SGLT-2 inhibitors

If A1c is above target, add another class

117
Q

When evaluating a patient with diabetes and they have heart failure or CKD issues, what can you prescribe them?

A

SGLT-2 inhibitors first, if that doesnt work then add GLP-1 agonists

If A1c is above target, add another class except TZD

118
Q

When evaluating a patient with diabetes and they do not have any ASCVD, heart failure, or CKD issues and A1c is above target + you want to minimize hypoglycemia, what can you prescribe them?

A
  1. DPP-4 inhibitor
  2. GLP-1 agonist
  3. SGLT-2 inhibitors
  4. TZD
119
Q

When evaluating a patient with diabetes and they do not have any ASCVD, heart failure, or CKD issues and A1c is above target + you want to minimize wt gain or loss some weight, what can you prescribe them?

A
  1. GLP-1 agonists

2. SGLT-2 inhibitors

120
Q

When evaluating a patient with diabetes and they do not have any ASCVD, heart failure, or CKD issues and A1c is above target + cost is an issue, what can you prescribe them?

A
  1. Sulfonylureas

2. TZD

121
Q

What kind of concentrations exist for bolus insulin?

A

Typically U-100

+U-500 (Humulin R)
+U-200 (Humalog)

122
Q

What kind of concentrations exist for basal insulin?

A

Typically U-100

+U-200 (Insulin degludec)
+U-300 (only concentration for insulin glargine)

123
Q

Which basal insulin last the longest?

A

Insulin degludec (>42hrs)

124
Q

When injectable therapy is needed to reduce A1c, what should you do?

A

Start with GLP-1 agonists prior to insulin

If that doesnt work or they were already on a GLP-1 agonist, add basal insulin or bedtime NPH

Initiation: 10IU/day or 0.1-0.2IU/kg/day

If that doesnt work, add prandial insulin or convert to twice daily NPH

Prandial insulin Initiation 4IU or 10% of basal dose

Titrate: Increase dose by 1-2IU or 10-15% twice weekly

125
Q

When should you give regular insulin and rapid-acting insulins with regards to meals?

A

Regular = 30 min prior

Rapid-acting = 10-15 min prior

126
Q

Where are the recommended injection sites for insulin?

A
  1. Abs
  2. Outer thigh
  3. Back of arm
  4. Upper butt
127
Q

What is the rule of 1800 and 1500?

A

Rapid acting = 1800

Insulin sensitivity factor = 1800/TDD

Regular insulin = 1500

Insulin sensitivity factor = 1500/TDD

128
Q

When treating hypoglycemia, what are some examples of 15-20g of simple carbs?

A

Glucose tabs

4oz juice or regular soda

1 tbl spoon of honey

8oz or nonfat or 1% milk

Hard candies

129
Q

How would you treat hypoglycemia with the rule of 15?

A

Consume 15-20g of simple carbs

Check BG after 15min

Repeat process if BG <70

Once normal, eat small snack

Seek medical attention if BG is still <70 x 2 treatments

130
Q

When should you check your BG when using basal or bolus insulin?

A

Basal = Fasting BG

Bolus = 2 hour postprandial glucose or before meals

131
Q

What is the insulin sensitivity factor?

A

How much one unit of BOLUS insulin will degreat pt’s BG

132
Q

List the diabetic drugs in order of efficacy

A

Highest - insulins

Intermediates - SGLT2 + DPP4 + alpha-glucosidase inhibitors and amylin mimetics (pramlinitide)

Everything else is high

133
Q

Which diabetic drugs are associated with weight gain?

A

TZD

Sulfonylureas

Insulins

Meglitinides

134
Q

Which diabetic drugs provide CV benefits?

A

Metformin - benefits ASCVD only

Empagliflozin + Canagliflozin - benefit ASCVD and HF

Dulaglutide, semaglutide, and liraglutide - benefits CVD events

Pioglitazone

135
Q

Which diabetic drugs increase risk of CV effects?

A

Saxagliptin + alogliptin

TZD

136
Q

What are the high and medium cost diabetic Rx?

A

High - SGLT-2i, GLP1-a, DPP-4i, insulin, + Pramlintide

Medium - alpha glucosidase inhibitors + Meglitinides

137
Q

Which diabetic Rx are given SQ?

A

GLP-1 agonist

Pramlintide

Insulin

138
Q

Which diabetic Rx have a risk of hypoglycemia?

A

Insulin

Sulfonylureas

Pramlintide

Meglitinides

139
Q

What is the inpatient definition of hypoglycemia?

A

Level 1 = BG from 54 to 69

Level 2 = BG<54

Level 3 = Severe event regardless of BG

140
Q

What is the target BG in an inpatient setting?

A

BG from 140 to 180

**Cardiac surgery = 110 to 140

141
Q

What is the inpatient definition of hyperglycemia?

A

BG >180

142
Q

Which medications can cause hyperglycemia?

A

Corticosteroids

IV dextrose

Catecholamines

Immunosuppressants

Thiazides + Loop diuretics

Fluoroquinolones (can cause hypo as well)

143
Q

What medications can cause hypoglycemia?

A

Insulins or secretagogues

Alcohol

ACEi/ARBs

Fluoroquinolones (can cause hyper as well)

144
Q

What are some factors for DKA and HHS?

A

Infections

Rx noncompliance or dose inadequacy

Rx such as steroids, thiazides, cocaine, sympathomimetics, atypical antipsychotics

145
Q

Mild, Moderate, and Severe DKA + HHS, what is the glucose range?

A

DKA > 250

HHS > 600

146
Q

Mild, Moderate, and Severe DKA + HHS, which one has ketones?

A

All, sometimes HHS doesnt have it

147
Q

Mild, Moderate, and Severe DKA + HHS, what is the arterial pH range?

A

Mild = 7.25 to 7.3

Moderate = 7 to 7.24

Severe = <7

HHS = >7.3

148
Q

Mild, Moderate, and Severe DKA + HHS, what is the bicarb range?

A

Mild = 15 to 18

Moderate = 10 to 14.9

Severe = <10

HHS = >15

149
Q

Mild, Moderate, and Severe DKA + HHS, what is the serum mOsm/kg?

A

DKA = variable

HHS = >320

150
Q

Mild, Moderate, and Severe DKA + HHS, what is the anion gap?

A

Mild = >10

Moderate = >12

Severe = >12

HHS = variable

151
Q

How do you calculate corrected Na?

A

Na + 1.6 for every 100 BG >100

152
Q

How do you calculate anion gap?

A

Na - (Cl + Bicarb)

Normal <10

Gap >10

153
Q

How do you calculate osmolality?

A

Na x 2 + Glucose/18

Normal 290

Hyperosmol >320

154
Q

DKA diagnosis?

A

MUDPILES

Methanol
Uremia
DKA
Propylene glycol/paraldehyde
Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
155
Q

How do you treat DKA or HHS with insulin?

A

Either give 0.1U/kg as bolus and 0.1U/kg/hr as continuous infusion

or

0.14U/kg/hr as continuous infusion

BG must drop at least 10% in the first hour, if not then give 0.14U/kg as bolus in addition

DKA = goal is under 200

HHS = goal is under 300

For both, reduce infusion to 0.02 to .05U/kg/hr

For DKA only, you could just do 0.1U/kg every 2 hrs instead of infusion

156
Q

Potassium + DKA/HHS, how do you manage it?

A

<3.3 = hold insulin and give 20 to 30 mEq potassium/hr

> 5.2 = do not give potassium + check potassium every 2hrs

3.3 to 5.2 = give 20 to 30 mEq of potassium in IV fluids

157
Q

How often should you monitor A1C on someone who has stable control?

A

Twice yearly

158
Q

How often should you monitor A1C on someone who has therapy changes or is not meeting goals?

A

3 months

159
Q

What should the A1C goal be on someone that has T1DM?

A

≤6.5

160
Q

A1C goal of ≤6.5 should be set or someone with T2DM if and only they….

A

are treated with lifestyle modifications or metformin alone

161
Q

What is the A1C goal for DM in pregnancy?

A

<6

162
Q

What is the A1C goal for GDM?

A

Not commonly done due to inaccuracies w/ pregnancy (increased RBC)

163
Q

What is the fasting plasma glucose levels in DM in pregnancy + GDM?

A

<95

164
Q

What is the post-prandial glucose levels in DM in pregnancy + GDM?

A

<140 (1hr)

<180 (2hr)

165
Q

When should an individual monitor their blood glucose once?

A

Usually when fasting

Well-controlled diabetes w/ rare hypoglycemic episodes

On agents that are not likely to cause hypoglycemia

166
Q

When should an individual monitor their blood glucose multiple times daily?

A

Recent change in regimen

On agents that are likely to cause hypoglycemia

T1DM

Acute illness

167
Q

Symptoms of hypoglycemia can be masked by what?

A

Rx like beta blockers

168
Q

When should an eye exam be performed once diagnosed w/ DM?

A

T1DM = 5 yrs after onset

T2DM = time of diagnosis

Screening time is the same for neuropathy

Screening 1-2 yrs may be considered if there is no evidence of retinopathy and if glycemia is controlled

If retinopathy is present, exam should be performed annually

169
Q

How would you Tx retinopathy?

A

Optimize glycemic control, BP, and lipids

Refer pt if they have macular edema, nonproliferative diabetic retinopathy

**Presence of retinopathy is not a contraindication to aspirin therapy for CV protection

170
Q

Which Rx are given to initially treat neuropathy?

A

Pregabalin

Duloxetine

Gabapentin

171
Q

How often should someone with nephropathy be screened?

A

Once a year for:

T1DM for ≥5 yrs

Anyone w/ T2DM

Twice a year for:

Urinary albumin >30

eGFR <60

172
Q

With someone that has nephropathy, what could you give them to slow the progression?

A

SGLT2 inhibitors (if eGFR≥30+albumin>30)

In pt with CKD and increased % of CV events, use a GLP-1 agonist

Do not d/c RAAS Rx in the absence of volume depletion

Dietary protein should be 0.8g/kg/day (higher in dialysis)

Nonpregnant pt = give ACE or ARB

ACE/ARB not recommended if they have normal BP, normal albumin to creatine (<30) and normal eGFR

173
Q

What are some HTN goals for someone w/ diabetes?

A

If they have a ASCVD risk ≥15 = BP goal of <130/80

ASCVD risk of <15 = BP goal of <140/90

Pregnant = ≤135/85

If they have ≥160/100, give 2 Rx or 1 combination Rx

If BP is not met with 3 classes of HTN Rx, consider mineralocorticoid receptor antagonists

174
Q

When should lipids be screened with diabetes?

A

When not on a statin:

At time of diagnosis of DM

At initial medical evaluation

Every 5 yrs if under 40 years

Obtain lipid prolife at initiation of lipid lowering Rx + at 4-12 wks after or change in dose + annually

175
Q

How should you primarily manage lipids in diabetic pt?

A

Moderate intensity statin = aged 40 - 75

High intensity = 50 - 75

ASCVD risk of 20%+ = add ezetimibe to maximally tolerated statin to reduce LDL by 50%

176
Q

What are the secondary prevention methods in lipid management for diabetic pt?

A

Any pt w/ ASCVD risk and at any age = high intensity statins

Statins are contraindicated in pregnancy

In pt with ASCVD and controlled LDL with elevated TG (135 to 499), add icosapent ethyl

177
Q

Antiplatelet therapy and diabetic pt?

A

Aspirin 75-162mg/day as secondary prevention for ASCVD, may use as primary if you discussed benefits vs bleed risk

If allergic to aspirin, use clopidogrel 75mg/day

Dual low dose aspirin and P2Y12 inhibitor may be used for a year

178
Q

How do you treat a diabetic pt w/ CV disease?

A

Just ASCVD = ACE or ARB with SGLT2i or GLP1 agonist

If they had prior MI = Beta blocker for at least 2 yrs

T2DM, stable HF = Metformin if eGFR >30

IPT: Endocrine (4 decks)

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