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NAPLEX > Chapter 44: Diabetes > Flashcards

Chapter 44: Diabetes Flashcards

1
Q

Without insulin, glucose cannot enter muscle cells and the body goes into starvation mode & starts to metabolize ___ into ___ to use an an alternative energy source

A

fat
ketones
(very high ketone levels can cause DKA)

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2
Q

Which protein is used to test if T1D is present

A

C-peptide

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3
Q

T1D is diagnosed when there is a ____ C-peptide level

A

very low or absent

C-peptide is released by the pancreas only when insulin is present

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4
Q

Which factors can increase the likelihood of insulin resistance, and eventually T2D

A

lifestyle, genetics, other RF (low level of physical activity, being overweight or obese)

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5
Q

Which drug is used to delay T2D if younger (< 60 years) but higher-risk, with moderate obesity (BMI > 35) and/or a history of gestational diabetes

A

Metformin

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6
Q

T/F: prediabetes can be reversed

A

true - with a healthier lifestyle. BG should be checked annually to see if the condition has progressed to T2D

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7
Q

Babies born to mothers who had hyperglycemia during the pregnancy are larger than normal, which is called

A

fetal macrosomia

These babies are at higher risk for developing obesity and diabetes later in life

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8
Q

Which test is preferred for pregnant women to test for GDM

A

OGTT

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9
Q

Which medication is preferred in pregnant women to reduce hyperglycemia

A

Insulin

Lifestyle with diet an exercise should be tried first

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10
Q

What are the macrovascular diseases caused by diabetes

A

Atherosclerosis –> ASCVD (CAD, CVA, PAD)

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11
Q

What are the microvascular diseases caused by diabetes

A

Retinopathy
Nephropathy
Neuropathy
Autonomic neuropathy (ED, gastroparesis, loss of bladder control, UTIs)

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12
Q

What are the classic symptoms caused by high BG

A

Polyuria
Polyphagia
Polydipsia
(other sx which may be the only sx present in T2D include fatigue, blurry vision, ED, and vaginal fungal infections)

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13
Q

Who should be tested for diabetes and at which age

A

EVERYONE, even those with no other RF should be tested beginning at 45 years old

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14
Q

All asymptomatic children, adolescents and adults who are overweight (BMI >/= __ or >/= __ in Asian Americans) with at least one other RF (e.g., physical inactivity) should be tested for diabetes

A

25

23

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15
Q

Diagnostic tests:

  • Hgb A1c indicates the average BG over the past __ months
  • FBG gives the BG at that moment, and is taken after an >/= __-hour fast
  • OGTT measures how well a very sugary drink is tolerated by measuring ___ levels
A

3
8
PPG

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16
Q

A positive result from diagnostic tests is an A1C >/= __% or FBG >/= __ mg/dL must be confirmed by testing again with the same or with a new blood sample or with another diagnostic test

A

6.5%

126 mg/dL

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17
Q

The A1c should be measured every __ months if not yet at goal
If at goal, the test should be repeated every __ months

A 
3 months (quarterly)
6 months
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18
Q

Diagnosis for diabetes:
A1C:
FPG:
2-hour PPG after OGTT or classic sx + random BG:

A

> / = 6.5%
/ = 126 mg/dL
/ = 200

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19
Q

Diagnosis for prediabetes:
A1C:
FPG:
2-hour PPG after OGTT or classic sx + random BG:

A

5.7-6.4%
100-125
140-199

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20
Q

Treatment goals for non-pregnant patients with diabetes:
A1C:
Preprandial:
2-hr PPG:

A

< 7%
80-130
< 180

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21
Q

Treatment goals for pregnant patients with diabetes:
Preprandial:
1-hr PPG:
2-hr PPG:

A

< / = 95
< / = 140
< / = 120

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22
Q

The estimated eAG is an interpretation of the A1C value. An A1C of 6% is equivalent to an eAG of ___ mg/dL. Each additional 1% increases the eAG by ~___ mg/dL

A

126

28

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23
Q

Everyone with any risk of diabetes, including simply getting older, should quit smoking and get moving, with at least __ min of physical activity weekly, spread over at least __ days, with aerobics and resistance exercise (e.g., with weights)

A

150 min

3 days

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24
Q

Antiplatelet therapy:
Aspirin __ mg/day is recommended for ASCVD secondary prevention (e.g., post-MI), but not recommended for primary prevention.
It is used in pregnancy to ↓ risk of ___

A

81 mg/day
preeclampsia
**new update: ASA + low dose rivaroxaban can be added to pts wth CAD and/or PAD

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25
Cholesterol control: __ lipid pannel. -Diabetes + ASCVD with multiple ASCVD RF should get which statins -Diabetes without ASCVD and older should get which intensity statin -Diabetes without ASCVD and younger (<40)
- High-intensity: atorvastatin 40-80 mg or rosuvastatin 20-40 mg - moderate-intensity - no ASCVD RF = no statin; ASCVD RF = moderate
26
Neuropathy: - Annually, which tests should be performed - What are treatment options
10-g monofilament test and 1 other test to assess sensation Pregabalin, duloxetine, and gabapentin
27
Foot care counseling
- Every day: examine feet, wash and dry - Annual foot exam - Moisturize top and bottom of feet but not in between toes - Trim toenails with nail file - Wear socks and shoes. Elevate feet when sitting
28
Weight control: | A healthy weight circumference is key to reducing insulin resistance (< __" females, < __" males)
35 | 40
29
Diabetic retinopathy: - Type 2, when diagnosed, get eye exam with ___. If retinopathy, repeat ___. - To ↓ risk/slow progression:
dilation annually stop smoking, control BG, BP and cholesterol
30
BP control & kidney disease: - ACC/AHA goal BP - ADA goal BP - Diabetes with HTN, no albuminuria tx - Diabetes with albuminuria +/- HTN tx - Diabetes with CAD tx - No kidney disease: check urine for albumin ___ - Kidney disease: check urine for albumin ___
- < 130/80 - < 130/80 if higher ASCVD risk (>/= 15%); if not, use < 140/90 - no albuminuria: Thiazide, CCB, ACEi, or ARB - with albuminuria: ACEi or ARB - CAD: ACEi or ARB (new update)*** - no kidney disease: yearly - kidney disease: twice yearly
31
Albuminuria is either a urine albumin >/= __ mg/24 hours or a UACR >/= __ mg/g
30 | 30
32
Vaccinations for diabetes
- Hep B series - Influenza annually - PPSV23: one dose before age 65, another dose at age 65+ if it has been 5 years since the first dose
33
Natural products that can be used in diabetes
Cassia cinnamon alpha lipoic acid chromium
34
treatment for T2D: If patient has HF, CKD, ASCVD/high ASCVD risk, everyone regardless of A1C should get which therapies if: - ASCVD major issue - HF or CKD major issue:
- ASCVD major issue: use GLP-1 with CVD benefit (dulaglutide, liraglutide, semaglutide SC inj only) OR SGLT2 (empagliflozin, canagliflozin) if eGFR adequate (CI if < 30) - HF or CKD major issue: SGLT2 first that reduces HF and/or CKD progression (empa, cana, dapa) if eGFR adequate. If cannot use SGLT2, use dulaglutide, liraglutide, semaglutide SC inj only
35
Which drugs have little to no risk of hypoglycemia
DPP4i GLP1 SGLT2 TZD
36
Which two diabetes meds have a similar MOA and should NOT be used together
DPP4 and GLP
37
Best options for T2D if need weight loss
GLP1 (sema, lira, dula) or SGLT2
38
First line treatment for T2D
Metformin
39
Metformin is CI in eGFR < ___
30
40
Insulin can be used initially if hyperglycemia is severe (A1C > ___ or BG > ___)
10% | 300 mg/dL
41
How to add basal insulin in T2D
Start 10 units a day or 0.1-0.2 units/kg/day | If hypoglycemia, ↓ dose by 10-20%
42
If patient is on bedtime NPH and you want to convert to BID NPH regimen, how would you convert it
Total dose = 80% of current bedtime NPH dose 2/3 given in AM 1/3 given at bedtime
43
How to add prandial insulin in T2D
Start 4 units a day or 10% of basal insulin dose If A1C < 8%, consider ↓ basal dose by 4 units a day or 10% of basal dose Titrate: ↑ dose by 1-2 units or 10-15% twice weekly if hypoglycemia, ↓ dose by 10-20%
44
In T2D, which medication class should be started prior to insulin in most pts
GLP (exception is if A1C > 10% or BG > 300 mg/dL)
45
What are the 2 big similarities with the top 3 treatments for T2D
Weight loss and no hypoglycemia (Metformin, GLP and SGLT2)
46
Metformin MOA
↓ hepatic glucose output
47
Starting dose for metformin IR & ER
IR: 500 mg PO daily or BID ER: 500 mg PO daily with dinner
48
ER formulation of metformin counseling point
Leaves a ghost tablet in the stool
49
Metformin BW
Lactic acidosis - ↑ risk with renal disease
50
Metformin warnings
Do not START with eGFR 30-45 B12 deficiency Stop prior to iodinated contrast media
51
Metformin CI
eGFR < 30
52
Which drugs are TZDs
Pioglitazone (Actos) | Rosiglitazone (Avandia)
53
TZD BW
Do not use with NYHA Class III/IV HF | TZDs are rosiglitazone and pioglitazone
54
TZD warnings/SE
Hepatic failure Edema Can cause or worsen HF (esp rosiglitazone when used w insulin) Fractures Can stimulate ovulation Pioglitazone: avoid with bladder CA history
55
SGLT2 inhibitors MOA
↑ BG renal excretion
56
All SGLT2s must have a dose decrease with
renal impairment
57
SGLT2 SE and warnings
UTIs, genital fungal infection, weight loss D/c 3 days prior to surgery to ↓ risk of ketoacidosis ↑ LDL, hyperkalemia Fluid loss, hypotension Ketoacidosis, even when BG < 250 mg/dL Remember with SGLT2i, you are peeing the glucose out, so thats why you get UTIs, fluid loss
58
SGLT2 is CI with eGFR < ___
30
59
Canagliflozin BW
Amputation risk
60
Which drugs are SGLT2 inhibitors
Canagliflozin (Invokana) | Empagliflozin (Jardiance)
61
Which drugs are DPP4 inhibitors
Sitgliptin (Januvia) | Linagliptin (Tradjenta)
62
All DPP4 inhibitors should have a dose decrease with renal impairment, EXCEPT
Linagliptin
63
DPP4 warnings
``` Pancreatitis Arthralgia Renal failure Alogliptin: hepatotoxicity Alogliptin, saxagliptin: do not use with HF ```
64
SU should not be used with which medication class
insulin or meglitinides
65
Glipizide IR dosing
30 min PO before meals; others with breakfast
66
Glucotrol XL (glipizide) counseling point
OROS formulation; ghost tablet in stool | ↓ efficacy after long-term use
67
SU contraindication
Sulfa allergy
68
SU should be avoided in which patient population
Elderly (BEERS criteria) due to hypoglycemia risk (esp glyburide and chlorpropamide)
69
Important counseling point if skipping a meal with meglitinides
skip meal = skip dose to avoid hypoglycemia
70
Which drugs are GLP1
Liraglutide (Victoza) | Dulaglutide (Trulicity)
71
Liraglutide is dosed how many times per day | Dulaglutide?
Lira - daily | dula - weekly
72
Byetta and Adlyxin should be given within __ min of meals
60
73
Pen needles are provided with which GLPs
Weekly injections only (Trulicity, Byduron, Byduron BCise, Ozempic)
74
Bydureon warning
Serious injection-site reactions (skin nodules)
75
GLP1s can cause
pancreatitis
76
Pramlintide is used in which type(s) of diabetes & what is the MOA
Type 1 & 2 | Synthetic analog of amylin, slows gastric emptying & ↑ satiety
77
Pramlintide CI
gastroparesis
78
Pramlintide SE
N/V Anorexia HA
79
Pramlintide BW
severe hypoglycemia
80
Alpha-glucosidase inhibitors (acarbose and miglitol) should be taken 3 times daily with
the first bite of each meal
81
Alpha-glucosidase inhibitors (acarbose and miglitol) SE
Flatulence, diarrhea
82
Alpha-glucosidase inhibitors (acarbose and miglitol) important counseling point about hypoglycemia
If hypoglycemia occurs due to another drug, the low BG CANNOT be treated with sucrose; need to treat it with glucose tabs or gel only
83
Bile-acid binding resin, colesevelam, decreases absorption of
vitamins ADEK
84
Bile-acid binding resin, colesevelam, CI
TG > 500 | pancreatitis
85
Glucagon is produced by which cells in the pancreas
alpha cells
86
Basal insulin includes
glargine, detemir, and ultra-long acting degludec
87
the P in NPH stands for
protamine
88
Rapid acting insulin: - Onset - Peak - Duration
onset: ~15 min Peak: 1-2 hrs Duration: 3-5 hours
89
Regular insulin: - Onset - Peak - Duration
onset: 30 min Peak: 2 hrs Duration: 6-10 hours
90
NPH insulin: - Onset - Peak - Duration
Onset: 1-2 hrs Peak: 4-12 hrs Duration: 14-24 hrs
91
``` Basal insulin: All have no peak Detemir: onset and duration Glargine: onset and duration Degludec: onset and duration ```
Detemir: - Onset: 3-4 hrs - Duration: 1 day Glargine: - onset: 3-4 hrs (Tujeo 6 hrs) - Duration: 1 day Degludec: - onset: 1 hr - duration: 42+ hrs
92
Insulin can cause hypoglycemia and
hypokalemia weight gain lipoatrophy
93
Must reduce meal-time insulin by __% when starting pramlintide to avoid severe hypoglycemia
50%
94
Which insulins are rapid-acting
Aspart (Novolog) | Lispro (Humalog) - remember humans have a lisp
95
When should rapid-acting insulins be injected
5-15 min before eating
96
Which insulins are short-acting
Regular (Humulin R, Novolin R)
97
Regular insulin is injected __ min before meals
30 min
98
When is regular insulin preferred over rapid-acting insulin
For IV infusions, including parenteral nutrition
99
When regular (or rapid-acting) insulin and NPH are mixed in the same syringe, which should be drawn up into the syringe first?
Regular (or rapid-acting) first - clear solution then NPH - cloudy solution (clear before cloudy)
100
Which insulins are NPH
Humulin N, Novolin N
101
Which insulins are available OTC
NPH and Regular
102
Which insulins are long-acting (basal)
Detemir (Levemir) Glargine (Lantus, Tujeo, Basaglar) (remember the brand names start with L for long-acting)
103
How to convert NPH given BID to Lantus, Basaglar, or Tujeo
Use 80% of NPH dose
104
How to convert Tujeo to Lantus or Basaglar
Use 80% of the Tujeo dose
105
Insulin Glargine as Lantus is ____ units/mL | Glargine as Tujeo is ___ units/mL
100 units/mL | 300 units/mL
106
What are the 2 sizes of Tujeo
SoloStar 1.5 mL | Max SoloStar 3 mL pen
107
Ultra-long acting basal insulin, degludec (Tresiba), comes in which 2 sizes for the pen
100 units/mL and 200 units/mL
108
Insulin mixes come in which concentrations
70/30 75/25 50/50 (the NPH or protamine insulin is first, the short or rapid-acting insulin is second)
109
Typical insulin starting dose for T1D
0.5 units/kg/day (TBW) Divide 50% basal and 50% bolus Divide bolus evenly among 3 meals
110
What is a requirement for switching a patient to an insulin pump
Prior experience with multiple daily injections
111
Usually, dose of the new insulin is a 1:1 conversion. What are the exceptions
-NPH dosed BID --> Lantus, Basaglar or Tujeo dosed daily Use 80% of the NPH dose -Tujeo --> Lantus or Basaglar Use 80% of the Tujeo dose
112
Which insulins come in concentrated formulations
Rapid acting: Humalog KwikPen (lispro) 200 units/mL Regular: Humulin R U-500 KwikPen & vial 500 units/mL Long-acting: Tresiba Flextouch (degludec) 200 units/mL & Tujeo Solostar (glargine) 300 units/mL
113
The U-500 Humulin vials have which color cap and the syringes have which color needle cover
green cap and green needle cover
114
The higher the gauge, the ___ the needle
thinner
115
The ICR indicates:
number of grams of carbs covered by 1 unit of insulin
116
ICR formula for regular insulin
450/ TDD of insulin = grams of carbs covered by 1 unit of regular insulin
117
ICR formula for rapid-acting insulin
500/ TDD of insulin = grams of carbs covered by 1 unit of rapid-acting insulin
118
What does the correction factor indicate
how much the BG will be lowered by 1 unit of insulin
119
What is the correction factor for regular insulin
1500/TDD = correction factor for 1 unit of regular insulin
120
What is the correction factor for rapid-acting insulin
1800/TDD = correction factor for 1 unit of rapid-acting insulin
121
Correction dose formula
(BG now) - (Target BG) / correction factor
122
With which needle sizes does the skin need to be pinched up
> 5 mm
123
All insulins are stable at RT for 28 days except:
``` Humalog mixes, pens - 10 Humulin R vial - 31 Humulin N, N/R pen - 14 Humulin R U-500 vial - 40 Novolin R, Novolin N, Novolin N/R 70/30 vials - 42 Novolog mixes in pens - 14 Detemir (Levemir) - 42 Degludec (Tresiba) - 56 Glargine (Tujeo) - 56 ``` (notice the vials have a longer stability than the pens)
124
What is the rule of 15 for hypoglycemia
Take 15 grams of glucose or simple carbs Recheck BG after 15 min Once BG is normal, eat a small meal or snack
125
If patient is unconscious and is hypoglycemic, what can be used
dextrose if IV access or glucagon
126
Causes of DKA
Insulin was not taken Insulin was taken but the dose was inadequate d/t a stressor Initial presentation in type 1, when the B cells are gone
127
How to recognize DKA
BG > 250 mg/dl Ketones ("fruity breath") Anion gap acidosis (arterial pH < 7.35, anion gap > 12)
128
How to recognize HHS
Confusion, delirium BG > 600 mg/dL with high serum osmolality Extreme dehydration pH > 7.3
129
DKA and HHS treatment
- Fluids first (NS); when BG reaches 200, change to D5W1/2NS - Regular insulin infusion - Replace K as needed - Treat acidosis if pH < 6.9 with sodium bicarbonate

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