Ch11: Diabetes Flashcards
who should you consider screening for diabetes
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
in the absence of clinical risk factors, when should T2DM screening begin and how often?
age 45yo
Q3 year intervals (more frequent depending on risk factors)
(3) different lab tests that can be used to diagnose diabetes
- plasma glucose (fasting or random - cheapest test)
- OGTT (most expensive, least convenient)
- A1c (looks at average glycemic control over 3 months, convenient, cheap)
how to diagnose T2DM on plasma glucose labs
- fasting > or = 126
- random > or = 200 with symptoms of polyphagia, polyuria, polydipsia, unexplained weight loss, o hyperglycemic crisis
how to diagnose T2DM on OGTT
2-hr plasma glucose > or = 200 after a 75-g glucose load
how to diagnose T2DM on A1c
> or = 6.5%
how to diagnose pre-diabetes on A1c
5.7% - 6.4%
normal range for A1c
<5.6%
American Diabetes Association goal A1c for someone with DM
<7.0% for most
individualize based on factors such as duration of diabetes, age, life expectancy, comorbidities, hypogylcemia unawareness
normal range for fasting (preprandial) plasma glucose
<100 mg/dL
American Diabetes Association goal for fasting (preprandial) glucose in someone with DM
80-130 mg/dL
how often should you test A1c in patient with T2DM who has stable glycemic control and is meeting treatment goals
2x yearly (Q6 months)
How often should you test A1c in patient with T2DM whose therapy recently changed and/or they are not meeting target glycemic goals
4x yearly (Q3 months)
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
<6.5%
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
<8%
American Diabetes Association goal for peak post-prandial (1-2 hours after a meal) glucose in someone with DM
<180 mg/dL
normal range for peak post-prandial (1-2 hours after a meal) glucose
<140 mg/dL
basic MOA: metformin
insulin sensitizer
sensitizes the body’s cell to insulin, reducing insulin resistance
FIRST LINE TREATMENT FOR DIABETES OR PRE-DIABETES, per all guidelines
metformin
efficacy on A1c reduction: Metformin
1-2%
hypoglycemia risk: Metformin
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
weight impact: metformin
neutral or modest loss
adverse effects: metformin
GI upset, lactic acidosis (generally only those >80yo and have impaired renal function)
cost consideration: Metformin
cheap
compelling indication: Metformin
first-line medication for all folks with diabetes, as long as no contraindication
medication class: Metformin
biguanide
medication class: pioglitazone (Actos)
TZD (thiazolidinediones)
“glitazones”
MOA: pioglitazone (Actos)
insulin sensitizer
efficacy on A1c reduction: pioglitazone (Actos)
1-2%
hypoglycemia risk: pioglitazone (Actos)
low
weight impact: pioglitazone (Actos)
gain (because increases circulating volume, e.g., edema)
adverse effects: pioglitazone
edema, heart failure, fractures
aka, older adult with hypertensive heart disease is not a good candidate
cost consideration: pioglitazone (Actos)
low cost
compelling indication: pioglitazone (Actos)
minimal hypoglycemia risk, low cost, and efficacious for someone without high ASCVD risk
medication class: glipizide
sulfonylurea
MOA: sulfonylureas (e.g., glipizide, glyburide)
increases insulin release (constantly)
efficacy on A1c reduction: sulfonylureas (e.g., glipizide, glyburide)
1-2%
hypoglycemia risk: sulfonylureas (e.g., glipizide, glyburide)
moderate to high
weight impact: sulfonylureas (e.g., glipizide, glyburide)
gain
adverse effects: sulfonylureas (e.g., glipizide, glyburide)
hypoglycemia, otherwise pretty well-tolerated
cost consideration: sulfonylureas (e.g., glipizide, glyburide)
low cost
compelling indication: sulfonylureas (e.g., glipizide, glyburide)
cheap (otherwise, doesn’t work that well on A1c, causes weight gain, and comes with high risk for hypoglycemia….)
medication class: glyburide
sulfonylurea
medication class: sitagliptin (Januvia)
DPP4 inhibitor
medication class: linagliptin (Tradjenta)
DPP4 inhibitor
MOA: DPP4 inhibitors (e.g., sitagliptin, linagliptin)
increases insulin release AFTER a rise in glucose (e.g., after a meal, as opposed to constantly by the sulfonylureas)
efficacy on A1c reduction: DPP4 inhibitors
~0.75%
hypoglycemia risk: DPP4 inhibitors
low
weight impact: DPP4 inhibitors
neutral
adverse effects: DPP4 inhibitors
almost none, extremely well-tolerated
cost consideration: DPP4 inhibitors
expensive
compelling indication: DPP4 inhibitors
minimal risk of hypoglycemia and don’t cause weight gain (but otherwise, expensive and doesn’t work that well on A1c)
medication class: exenatide (Byetta, Bydurion)
GLP1 receptor agonist
medication class: semaglutide (Ozempic, Rybelsus)
GLP1 receptor agonist
medication class: dulaglutide (Trulicity)
GLP1 receptor agonist
MOA: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)
increases insulin release AFTER a meal or rise in glucose
efficacy on A1c: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)
1-2%
hypoglycemia risk: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)
low (because only increases insulin release after sensing a rise in blood glucose like after a meal)
weight impact: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)
loss (s/t slows gastric emptying)
adverse effects: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)
GI upset (nausea, vomiting) –> avoid in someone with gastroparesis (neuropathy of the gut)
usually this side effects gets better with continued use
cost consideration: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)
expensive
compelling indication: GLP1 RAs (e.g., liraglutide, semaglutide, dulaglutide, exenatide)
recommended for those with CVD
minimal hypoglycemia risk
helpful in losing weight!
great drug, but expensive and GI side effects
medication class: liraglutide (Victoza)
GLP1 receptor agonist
medication class: canagliflozin (Invokana)
SGLT2 inhibitor
medication class: empagliflozin (Jardiance)
SGLT2 inhibitor
medication class: dapagliflozin (Farxiga)
SLGT2 inhibitor
MOA: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
increases renal excretion of glucose after sensing a rise in serum glucose
efficacy on A1c reduction: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
~0.75%
hypoglycemia risk: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
low
weight impact: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
loss
adverse effects: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
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
cost consideration: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
expensive
compelling indication: SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin)
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
MOA: insulin
insulin replacement or supplementation
medication class: insulin glargine
basal insulin (long acting)
medication class: insulin aspart
bolus insulin (short acting)
medication class: insulin lispro
bolus insulin (rapid acting)
efficacy on A1c reduction: insulin
highest!
of all medication classes in diabetes, which will always give you the best A1c reduction?
insulin
and you can titrate up as much as you need
hypoglycemia risk: insulin
high
weight impact: insulin
gain
adverse effect: insulin
hypoglycemia
cost consideration: insulin
expensive (NPH and regular insulin are less expensive, but not used as commonly anymore)
compelling indication: insulin
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
when to consider starting your T2DM patient on insulin?
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
who needs insulin in T1DM?
EVERYONE!
they would die without exogenous insulin
general rule of insulins: % bolus vs. % basal
50% basal
50% bolus
with whom should you consider starting insulin right off the bat with new T2DM diagnosis?
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
(3) medication classes that increase endogenous release of insulin from the pancreas in T2DM
- sulfonylureas
- DPP4 inhibitors
- GLP1 RAs
onset of action: rapid-acting insulins
~ 5 min
onset of action: short-acting insulins
~30 minutes
onset of action: long-acting insulins
1-2 hours
onset of action: intermediate-acting insulin
1-2 hours
in critically ill patients with diabetes, blood glucose levels should generally be kept at ……
140-180 mg/dL
peak action: rapid acting insulins
~1 hr
contraindications to insulin
none!
bioidentical hormone
peak action: short-acting insulins
~2-3 hrs
peak action: long-acting insulins
none
peak action: intermediate-acting insulins
6-14 hrs
duration of action: rapid-acting insulins
~4 hrs
duration of action: short-acting insulins
3-6 hours
duration of action: long-acting insulin
24 hrs
duration of action: intermediate-acting insulin
16-24 hrs
medication class: insulin detemir (Levemir)
long-acting insulin
with peak action of insulin, most likely time to have….
hypoglycemia
medication class: insulin Lantus
long-acting insulin
medication class: regular insulin
short-acting
medication class: NPH insulin
intermediate-acting
ABCDEFG to T2DM treatments
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
(5) components of metabolic syndrome
- increased waist circumference
- hypercholesterolemia
- low HDL cholesterol
- high blood pressure
- high blood sugar
