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AGPCNP Board Prep > Ch11: Diabetes > Flashcards

Ch11: Diabetes Flashcards

1
Q

who should you consider screening for diabetes

A

all adults who are OVERWEIGHT (BMI >25) and have one or more additional risk factors:

  • physically inactive
  • first-degree relative with T2DM
  • member of high risk community (African American, Latinx, Native American, Asian American, Pacific Islander)
  • given birth to a baby >9lbs (4kg) or h/o GDM
  • HTN
  • low HDL<35 and/or elevated triglycerides >250
  • PCOS
  • A1c >5.7%, impaired glucose tolerance, or impaired fasting glucose on prior testing
  • other signs associated with insulin resistance such as obesity, acanthosis nigricans
  • CVD
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2
Q

in the absence of clinical risk factors, when should T2DM screening begin and how often?

A

age 45yo

Q3 year intervals (more frequent depending on risk factors)

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3
Q

(3) different lab tests that can be used to diagnose diabetes

A
  • plasma glucose (fasting or random - cheapest test)
  • OGTT (most expensive, least convenient)
  • A1c (looks at average glycemic control over 3 months, convenient, cheap)
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4
Q

how to diagnose T2DM on plasma glucose labs

A
  • fasting > or = 126

- random > or = 200 with symptoms of polyphagia, polyuria, polydipsia, unexplained weight loss, o hyperglycemic crisis

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5
Q

how to diagnose T2DM on OGTT

A

2-hr plasma glucose > or = 200 after a 75-g glucose load

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6
Q

how to diagnose T2DM on A1c

A

> or = 6.5%

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7
Q

how to diagnose pre-diabetes on A1c

A

5.7% - 6.4%

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8
Q

normal range for A1c

A

<5.6%

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9
Q

American Diabetes Association goal A1c for someone with DM

A

<7.0% for most

individualize based on factors such as duration of diabetes, age, life expectancy, comorbidities, hypogylcemia unawareness

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10
Q

normal range for fasting (preprandial) plasma glucose

A

<100 mg/dL

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11
Q

American Diabetes Association goal for fasting (preprandial) glucose in someone with DM

A

80-130 mg/dL

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12
Q

how often should you test A1c in patient with T2DM who has stable glycemic control and is meeting treatment goals

A

2x yearly (Q6 months)

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13
Q

How often should you test A1c in patient with T2DM whose therapy recently changed and/or they are not meeting target glycemic goals

A

4x yearly (Q3 months)

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14
Q

Appropriate goal A1c for a 25yo F with T1DM who is highly engaged in her care, low risk for hypoglycemic unawareness, high likelihood of being able to manage hypogylcemia

A

<6.5%

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15
Q

Appropriate goal A1c for an 80yo frail older adult with CVD, OA, and limited mobility who is high risk for hypoglycemic unawareness and resulting cognitive dysfunction, falls, CVD events

A

<8%

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16
Q

American Diabetes Association goal for peak post-prandial (1-2 hours after a meal) glucose in someone with DM

A

<180 mg/dL

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17
Q

normal range for peak post-prandial (1-2 hours after a meal) glucose

A

<140 mg/dL

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18
Q

basic MOA: metformin

A

insulin sensitizer

sensitizes the body’s cell to insulin, reducing insulin resistance

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19
Q

FIRST LINE TREATMENT FOR DIABETES OR PRE-DIABETES, per all guidelines

A

metformin

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20
Q

efficacy on A1c reduction: Metformin

A

1-2%

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21
Q

hypoglycemia risk: Metformin

A

low

this is why safe/ok for someone with only pre-dm

makes you utilize the insulin in your body better, doesn’t make you release more insulin

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22
Q

weight impact: metformin

A

neutral or modest loss

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23
Q

adverse effects: metformin

A

GI upset, lactic acidosis (generally only those >80yo and have impaired renal function)

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24
Q

cost consideration: Metformin

A

cheap

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25
Q

compelling indication: Metformin

A

first-line medication for all folks with diabetes, as long as no contraindication

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26
Q

medication class: Metformin

A

biguanide

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27
Q

medication class: pioglitazone (Actos)

A

TZD (thiazolidinediones)

“glitazones”

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28
Q

MOA: pioglitazone (Actos)

A

insulin sensitizer

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29
Q

efficacy on A1c reduction: pioglitazone (Actos)

A

1-2%

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30
Q

hypoglycemia risk: pioglitazone (Actos)

A

low

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31
Q

weight impact: pioglitazone (Actos)

A

gain (because increases circulating volume, e.g., edema)

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32
Q

adverse effects: pioglitazone

A

edema, heart failure, fractures

aka, older adult with hypertensive heart disease is not a good candidate

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33
Q

cost consideration: pioglitazone (Actos)

A

low cost

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34
Q

compelling indication: pioglitazone (Actos)

A

minimal hypoglycemia risk, low cost, and efficacious for someone without high ASCVD risk

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35
Q

medication class: glipizide

A

sulfonylurea

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36
Q

MOA: sulfonylureas (e.g., glipizide, glyburide)

A

increases insulin release (constantly)

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37
Q

efficacy on A1c reduction: sulfonylureas (e.g., glipizide, glyburide)

A

1-2%

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38
Q

hypoglycemia risk: sulfonylureas (e.g., glipizide, glyburide)

A

moderate to high

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39
Q

weight impact: sulfonylureas (e.g., glipizide, glyburide)

A

gain

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40
Q

adverse effects: sulfonylureas (e.g., glipizide, glyburide)

A

hypoglycemia, otherwise pretty well-tolerated

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41
Q

cost consideration: sulfonylureas (e.g., glipizide, glyburide)

A

low cost

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42
Q

compelling indication: sulfonylureas (e.g., glipizide, glyburide)

A

cheap (otherwise, doesn’t work that well on A1c, causes weight gain, and comes with high risk for hypoglycemia….)

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43
Q

medication class: glyburide

A

sulfonylurea

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44
Q

medication class: sitagliptin (Januvia)

A

DPP4 inhibitor

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45
Q

medication class: linagliptin (Tradjenta)

A

DPP4 inhibitor

46
Q

MOA: DPP4 inhibitors (e.g., sitagliptin, linagliptin)

A

increases insulin release AFTER a rise in glucose (e.g., after a meal, as opposed to constantly by the sulfonylureas)

47
Q

efficacy on A1c reduction: DPP4 inhibitors

A

~0.75%

48
Q

hypoglycemia risk: DPP4 inhibitors

A

low

49
Q

weight impact: DPP4 inhibitors

A

neutral

50
Q

adverse effects: DPP4 inhibitors

A

almost none, extremely well-tolerated

51
Q

cost consideration: DPP4 inhibitors

A

expensive

52
Q

compelling indication: DPP4 inhibitors

A

minimal risk of hypoglycemia and don’t cause weight gain (but otherwise, expensive and doesn’t work that well on A1c)

53
Q

medication class: exenatide (Byetta, Bydurion)

A

GLP1 receptor agonist

54
Q

medication class: semaglutide (Ozempic, Rybelsus)

A

GLP1 receptor agonist

55
Q

medication class: dulaglutide (Trulicity)

A

GLP1 receptor agonist

56
Q

MOA: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)

A

increases insulin release AFTER a meal or rise in glucose

57
Q

efficacy on A1c: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)

A

1-2%

58
Q

hypoglycemia risk: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)

A

low (because only increases insulin release after sensing a rise in blood glucose like after a meal)

59
Q

weight impact: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)

A

loss (s/t slows gastric emptying)

60
Q

adverse effects: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)

A

GI upset (nausea, vomiting) –> avoid in someone with gastroparesis (neuropathy of the gut)

usually this side effects gets better with continued use

61
Q

cost consideration: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)

A

expensive

62
Q

compelling indication: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)

A

recommended for those with CVD

minimal hypoglycemia risk

helpful in losing weight!

great drug, but expensive and GI side effects

63
Q

medication class: liraglutide (Victoza)

A

GLP1 receptor agonist

64
Q

medication class: canagliflozin (Invokana)

A

SGLT2 inhibitor

65
Q

medication class: empagliflozin (Jardiance)

A

SGLT2 inhibitor

66
Q

medication class: dapagliflozin (Farxiga)

A

SLGT2 inhibitor

67
Q

MOA: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)

A

increases renal excretion of glucose after sensing a rise in serum glucose

68
Q

efficacy on A1c reduction: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)

A

~0.75%

69
Q

hypoglycemia risk: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)

A

low

70
Q

weight impact: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)

A

loss

71
Q

adverse effects: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)

A

GU infections (candida, UTI), dehydration

this is because you are peeing out sugar

the sugar is leaving the body attached to water, so it can cause dehydration –> be wary with older adults who don’t drink water

72
Q

cost consideration: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)

A

expensive

73
Q

compelling indication: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)

A

recommended for use with CVD or CKD (may protect against progression)

minimal hypoglycemia risk

can help with weight loss

moderately effective against A1c but very high cost

74
Q

MOA: insulin

A

insulin replacement or supplementation

75
Q

medication class: insulin glargine

A

basal insulin (long acting)

76
Q

medication class: insulin aspart

A

bolus insulin (short acting)

77
Q

medication class: insulin lispro

A

bolus insulin (rapid acting)

78
Q

efficacy on A1c reduction: insulin

A

highest!

79
Q

of all medication classes in diabetes, which will always give you the best A1c reduction?

A

insulin

and you can titrate up as much as you need

80
Q

hypoglycemia risk: insulin

A

high

81
Q

weight impact: insulin

A

gain

82
Q

adverse effect: insulin

A

hypoglycemia

83
Q

cost consideration: insulin

A

expensive (NPH and regular insulin are less expensive, but not used as commonly anymore)

84
Q

compelling indication: insulin

A

when 2 or more drugs (including insulin releasers) are no longer adequate to maintain glycemic control, this is a marker of beta cell failure and must supplement with exogenous insulin

85
Q

when to consider starting your T2DM patient on insulin?

A

once they are no longer meeting therapeutic goals on 2 or more antidiabetic medications (including an insulin releaser), this is an indication of possible beta cell failure and requires supplementation with exogenous insulin

86
Q

who needs insulin in T1DM?

A

EVERYONE!

they would die without exogenous insulin

87
Q

general rule of insulins: % bolus vs. % basal

A

50% basal

50% bolus

88
Q

with whom should you consider starting insulin right off the bat with new T2DM diagnosis?

A

if A1c >9% and/or with symptoms (polys, visual changes, etc.)

short course of insulin for 2-3 weeks (also concurrent metformin) can help achieve normoglycemia, and then see if they can come off

89
Q

(3) medication classes that increase endogenous release of insulin from the pancreas in T2DM

A
  • sulfonylureas
  • DPP4 inhibitors
  • GLP1 RAs
90
Q

onset of action: rapid-acting insulins

A

~ 5 min

91
Q

onset of action: short-acting insulins

A

~30 minutes

92
Q

onset of action: long-acting insulins

A

1-2 hours

93
Q

onset of action: intermediate-acting insulin

A

1-2 hours

94
Q

in critically ill patients with diabetes, blood glucose levels should generally be kept at ……

A

140-180 mg/dL

95
Q

peak action: rapid acting insulins

A

~1 hr

96
Q

contraindications to insulin

A

none!

bioidentical hormone

97
Q

peak action: short-acting insulins

A

~2-3 hrs

98
Q

peak action: long-acting insulins

A

none

99
Q

peak action: intermediate-acting insulins

A

6-14 hrs

100
Q

duration of action: rapid-acting insulins

A

~4 hrs

101
Q

duration of action: short-acting insulins

A

3-6 hours

102
Q

duration of action: long-acting insulin

A

24 hrs

103
Q

duration of action: intermediate-acting insulin

A

16-24 hrs

104
Q

medication class: insulin detemir (Levemir)

A

long-acting insulin

105
Q

with peak action of insulin, most likely time to have….

A

hypoglycemia

106
Q

medication class: insulin Lantus

A

long-acting insulin

107
Q

medication class: regular insulin

A

short-acting

108
Q

medication class: NPH insulin

A

intermediate-acting

109
Q

ABCDEFG to T2DM treatments

A

A = aspirin 75-162 mg/day (clopidogrel [Plavix] if allergic)

B = blood pressure control using 2 or more agents if have HTN including a thiazide diuretic and ACE or ARB

C = cholesterol control, statin therapy is usually indicated
Also, creatinine, GFR, and urine microalbumin should be checked yearly

D = diet (limit trans and saturated fats,, refer to dietician), and dental care

E = exercise (>150min/week of moderate activity) and eye exam (dilated) annually

F = foot exam visually with every visit, teach protective foot behaviors, comprehensive lower sensory exam using monofilament test

G = goals, review goals of therapy including glycemic and lipid targets, physical activities, etc.1

110
Q

(5) components of metabolic syndrome

A
  • increased waist circumference
  • hypercholesterolemia
  • low HDL cholesterol
  • high blood pressure
  • high blood sugar

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