Ch 10 Diabetes Flashcards
Type 1 DM
autoimmune with beta cell destruction, causing insulin deficiency
-unexplained weight loss, ketonuria, polydipsia, polyuria, usually diagnosed in acutely ill child or younger adult
type 2 DM
insulin resistance causing insulin deficiency
-usu diagnosed during routine screening
how to diagnose diabetes?
plasma glucose:
fasting (8hrs +) of 126 or more or random 200 or more, WITH sx’s of polyphagia, polyuria, polydipsia, or unexplained weight loss or hyperglycemic crisis
oral glucose tolerance test:
2 hr plasma glucose 200 or more after 75g glucose load
A1C: 6.5% or more
lab values that are at risk/impaired fasting glucose/prediabetes?
fasting: 100-126
oral glucose:140-199
A1C: 5.7-6.4%
how often to check A1C?
if meeting treatment goals and stable glycemic control, 2 or more/year
if not meeting goals or if therapy has changed, every 3 months (4x/year)
A1C goal
< 7% for most (individual depends)
-ie goal of 8% for 80 yrs with CVD, high-risk for hypoglycemic unawareness, falls etc
ie: goal of less than 6.5% for 25 yr old that’s engaged in care,
fasting blood sugar range
80-130 (normal <100)
post prandrial blood sugar
goal <180
NL: < 140
can reflect in a fasting state, the body production of insulin is sufficient but if add in carbs, no longer sufficient
metformin
MOA:
A1C reduces by:
hypoglycemic risk:
weight impact:
AE:
cost:
indication:
MOA: insulin sensitizer
A1C reduces by: high; 1-2%
hypoglycemic risk: low
weight impact: neutral/loss
AE: GI upset (give extended release so don’t have GI upset), stop if GFR <30, frailty, advanced age (inc lactic acidosis risk)
cost: low
indication: 1st line if no contraindication
criteria for testing for diabetes in asymptomatic individuals if overweight (BMI >25) and risk factors:
-physical inactivity
-1st deg relative with DM
-high risk ethnicity (black, latino, native American, asian, pacific)
-gave birth >9lb or dx with gestational db
-HTN 140+/90
-HDL < 35, trigycides >250
-PCOS
-A1C 5.7 or higher, impaired glucose tolerance, impaired fasting glucose on previous test
-obesity, acanthosis nigricans
-Hx CVD
if have no risk factors, when do you screen for DM? if normal result?
starting 45 yrs old
repeat q 3 years, more freq if more risk factors
Thiazolidinediones (TZD) (pioglitazone)
MOA:
A1C reduces by:
hypoglycemic risk:
weight impact:
AE:
cost:
indication:
MOA: insulin sensitizer
A1C reduces by: high; 1-2%
hypoglycemic risk: low
weight impact: gain
AE: edema, HF in at-risk/established HF pts, fractures, do not use with nitrates, don’t use with insulin
cost: low cost
indication: minimal hypoglycemia risk, low cost
sulfonureas (glipizide)
MOA:
A1C reduces by:
hypoglycemic risk:
weight impact:
AE:
cost:
indication:
MOA: insulin releaser (constant release)
A1C reduces by: high 1-2%
hypoglycemic risk:**moderate-high
weight impact: gain
AE: hypoglycemia
cost: low
indication: low cost
DPP-4 inhibitors (-glipitins/sitagliptin)
MOA:
A1C reduces by:
hypoglycemic risk:
weight impact:
AE:
cost:
indication:
MOA: insulin releaser (post glucose rise only)
A1C reduces by: 0.75%
hypoglycemic risk: low
weight impact: neutral
AE: rare
cost: $$$ expensive
indication: minimal hypoglycemia risk
GLP-1 agonist (exenatide, ozempic)
MOA:
A1C reduces by:
hypoglycemic risk:
weight impact:
AE:
cost:
indication:
MOA: insulin releaser post glucose rise only; slows gastric emptying
A1C reduces by: high 1-2%
hypoglycemic risk: low
weight impact: loss
AE: GI upset (n/v), NO in gastroparesis (neuropathy of gut) or pancreatitis
cost: $$$ expensive
indication: proven benefits with pts with ASCVD, CVD, min hypoglycemia risk, weight loss
SGLT-2 inhibitors (canagliflozin)
MOA:
A1C reduces by:
hypoglycemic risk:
weight impact:
AE:
cost:
indication:
MOA: glucose offloading via kidney, post glucose rise
A1C reduces by: 0.75%
hypoglycemic risk: low
weight impact: loss
AE: GU infection (candida, UTI), dehydration, NO with GFR < 30
cost: expensive $$$
indication: proven benefits with pts with ASCVD, HF, CKD, min hypoglycemia risk, weight loss
when to use insulin in DM1?
-ALL pts using basal and bolus insulin
basal vs bolus insulin?
give basal/bolus insulin with adjustments for meals via multiple injections or via insulin pump
-basal (long acting = ~ 50% total daily insulin)
-bolus (rapid-acting)= ~ 50% total daily intake, given in response to glucose rise post intake, post meals, and with snacks
when to use insulin in DM2?
-when A1C is 9 or greater with sx’s (poly’s, visual changes)
- when 2 or more injectables (SU, DPP4, GLP 1) doesn’t work = beta cell function is failing
what happens during the PEAK of action of insulin?
most likely when hypoglycemia reaction can occur
lispro (Humalog), aspart (Novolog), glulisine (Apidra)
onset:
peak:
duration:
rapid-acting
-used multiple times a day with meals, snacks, or as correction insulin
onset: 5 mins
peak: 1 hr
duration: 4 hrs
Humulin R, Novolin R
onset:
peak:
duration:
short acting
onset: 30 mins
peak: 2-3 hrs
duration: 3-6 hrs
Determir (Levemir), glargine (Basalar KwikPen, Lantus, Lantus SoloSTAR pen
onset:
peak:
duration:
long acting insulin
onset: 1-2 hrs
peak: no peak
duration: 24 hrs
Novolin, Humulin N, NPH/regular insulin
onset:
peak:
duration:
intermediate acting NPH insulin
-used BID as an alternate to basal insulin
onset: 2-3 hrs
peak: 6-14 hrs
duration:16-24 hrs
which anti-diabetic drug is cheap and which are expensive?
cheap: metformin, SU (glipizide) and TZD (-glitazone)
expensive: DPP-4 (-gliptin), GLP-1 agonist (exenatide), SGLT-2 (-flozin)
which anti-diabetic drug has a high hypoglycemia risk?
meaning if someone eats randomly bc no time to eat, then don’t want them to be hypoglycemic
high: SU (glipizide)
low: everything else (metformin, tzd, su, DPP4, GLP-1, SGLT-2)
which anti-diabetic drug has benefits on ASCVD, chronic kidney disease, and weight loss?
GLP-1 and SGLT-2
which anti-diabetic drug creates weight loss/gain?
loss: GLP 1(best), SGLT2
gain: TZD, SU
neutral: metformin, DPP4
additional considerations for DM 2 treatment
ABCDEFG
-Aspirin 75mg-162 mg or plavix if allergic, in ASCVD
-BP control (with DM2 and HTN); 2 or more agents (thiazide, CCB and/or ACE/ARB)
-Cholesterol: med-high potency statin (add ezetimibe with high ASCVD risk)
-Creatinine: check cr, GFR, urine albumin annually
-Diet: limit trans/sat fat, DASH diet
-Dental care
-Exercise: >150 mins/wk
-Eye: dilated exam q 1-2 yrs, inc if retinopathy or eye problems
-Foot: visual exam annually or every visit if have sensory loss or prior ulceration; teach protective footwear, use 10 g monofilament with vibration, pinprick, temperature, vascular assess
-Goals of therapy, glycemic control, BP, weight loss
metabolic syndrome diagnosis
WTHHG
-waistline 35 or more W, 40 or more in men
-triglycerides 150+
-HDL low < 50, <40 women
-HTN >130/>85
-glucose (fasting plasma) 100+
treatment and goals of metabolic syndrome
-lifestyle changes to lose weight via healthy diet and increasing activity, smoking cessation
-reduce LDL with statins
-increase HDL and decrease TG with lifestyle mods
-reduce HTN (diuretics, ACE, ARBS, CCB)
-reduce blood sugar
-aspirin to reduce blood clots and stroke
