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NAPLEX 2023 > 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 starting at 35 with no RF, test everyone with at least 1 RF

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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
Q

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)

A
  • High-intensity: atorvastatin 40-80 mg or rosuvastatin 20-40 mg
  • moderate-intensity
  • no ASCVD RF = no statin; ASCVD RF = moderate
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26
Q

Neuropathy:

  • Annually, which tests should be performed
  • What are treatment options
A

10-g monofilament test and 1 other test to assess sensation

Pregabalin, duloxetine, and gabapentin

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27
Q

Foot care counseling

A
  • 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
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28
Q

Weight control:

A healthy weight circumference is key to reducing insulin resistance (< __” females, < __” males)

A

35

40

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29
Q

Diabetic retinopathy:

  • Type 2, when diagnosed, get eye exam with ___. If retinopathy, repeat ___.
  • To ↓ risk/slow progression:
A

dilation
annually
stop smoking, control BG, BP and cholesterol

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30
Q

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 ___
A
  • < 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
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31
Q

Albuminuria is either a urine albumin >/= __ mg/24 hours or a UACR >/= __ mg/g

A

30

30

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32
Q

Vaccinations for diabetes

A
  • 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
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33
Q

Natural products that can be used in diabetes

A

Cassia cinnamon
alpha lipoic acid
chromium

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34
Q

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:
A
  • 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
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35
Q

Which drugs have little to no risk of hypoglycemia

A

DPP4i
GLP1
SGLT2
TZD

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36
Q

Which two diabetes meds have a similar MOA and should NOT be used together

A

DPP4 and GLP

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37
Q

Best options for T2D if need weight loss

A

GLP1 (sema, lira, dula) or SGLT2

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38
Q

First line treatment for T2D

A

Metformin

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39
Q

Metformin is CI in eGFR < ___

A

30

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40
Q

Insulin can be used initially if hyperglycemia is severe (A1C > ___ or BG > ___)

A

10%

300 mg/dL

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41
Q

How to add basal insulin in T2D

A

Start 10 units a day or 0.1-0.2 units/kg/day

If hypoglycemia, ↓ dose by 10-20%

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42
Q

If patient is on bedtime NPH and you want to convert to BID NPH regimen, how would you convert it

A

Total dose = 80% of current bedtime NPH dose
2/3 given in AM
1/3 given at bedtime

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43
Q

How to add prandial insulin in T2D

A

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%

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44
Q

In T2D, which medication class should be started prior to insulin in most pts

A

GLP (exception is if A1C > 10% or BG > 300 mg/dL)

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45
Q

What are the 2 big similarities with the top 3 treatments for T2D

A

Weight loss and no hypoglycemia (Metformin, GLP and SGLT2)

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46
Q

Metformin MOA

A

↓ hepatic glucose output

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47
Q

Starting dose for metformin IR & ER

A

IR: 500 mg PO daily or BID
ER: 500 mg PO daily with dinner

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48
Q

ER formulation of metformin counseling point

A

Leaves a ghost tablet in the stool

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49
Q

Metformin BW

A

Lactic acidosis - ↑ risk with renal disease

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50
Q

Metformin warnings

A

Do not START with eGFR 30-45
B12 deficiency
Lactic acidosis ~ Stop prior to iodinated contrast media, incr risk with renal impairment, avoid excessive alcohol

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51
Q

Metformin CI

A

eGFR < 30
acute or chronic metabolic acidosis

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52
Q

Which drugs are TZDs

A

Pioglitazone (Actos)

Rosiglitazone (Avandia)

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53
Q

TZD BW

A

Do not use with NYHA Class III/IV HF
Rosi: incr risk of MI

TZDs are rosiglitazone and pioglitazone

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54
Q

TZD warnings/SE

A

Edema (macular, peripheral)
Weight gain
Can cause or worsen HF
Risk of fractures
[Can stimulate ovulation
Pioglitazone: avoid with bladder CA history]

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55
Q

SGLT2 inhibitors MOA

A

↑ BG renal excretion
by inhibiting SGLT2 in proximal tubule

56
Q

All SGLT2s must have a dose decrease with

A

renal impairment
based on eGFR not CrCl

57
Q

SGLT2 SE and warnings

A

Ketoacidosis, even when BG < 250 mg/dL
UTIs, genital fungal infection, weight loss
D/c 3 days prior to surgery to ↓ risk of
Fluid loss, hypotension (d/t combo w/ anti-HTN)
↑ LDL, hyperkalemia
Remember with SGLT2i, you are peeing the glucose out, so thats why you get UTIs, fluid loss

58
Q

SGLT2i eGFR cutoffs

A

Jardiance - <30 not for glycemic control
Dapagliflozin - 25-45 (not for glycemic control), < 25 don’t initiate

59
Q

Canagliflozin BW

A

Incr risk of leg and foot amputations

60
Q

Which drugs are SGLT2 inhibitors

A

Canagliflozin (Invokana)
Empagliflozin (Jardiance)
Dapagliflozin (Farxiga)

61
Q

Which drugs are DPP4 inhibitors

A

Linagliptin (Tradjenta)
Sitgliptin (Januvia)

62
Q

All DPP4 inhibitors should have a dose decrease with renal impairment, EXCEPT

A

Linagliptin

63
Q

DPP4 warnings

A 
Pancreatitis
Arthralgia
Renal failure
Alogliptin: hepatotoxicity
Alogliptin, saxagliptin: risk of HF
64
Q

SU should not be used with which medication class

A

insulin or meglitinides

65
Q

Glipizide IR dosing

A

30 min PO before meals; all other products take with breakfast

66
Q

Glucotrol XL (glipizide) counseling point

A

OROS formulation; ghost tablet in stool

↓ efficacy after long-term use

67
Q

SU contraindication

A

Sulfa allergy

68
Q

SU A1c decrease

A

1-2%

69
Q

SU should be avoided in which patient population

A

Elderly (BEERS criteria) due to hypoglycemia risk (esp glyburide and chlorpropamide)

70
Q

Important counseling point if skipping a meal with meglitinides

A

skip meal = skip dose to avoid hypoglycemia

71
Q

Which drugs are GLP1

A

Liraglutide (Victoza)

Dulaglutide (Trulicity)

72
Q

Liraglutide is dosed how many times per day

Dulaglutide?

A

Lira - daily

dula - weekly

73
Q

Byetta and Adlyxin should be given within __ min of meals

A

60

74
Q

Pen needles are provided with which GLPs

A

Weekly injections only (Trulicity, Byduron, Byduron BCise, Ozempic)

Not with Byetta, Victoza, Adlyxin

75
Q

GLP1s can cause

A

pancreatitis

76
Q

Pramlintide is used in which type(s) of diabetes & what is the MOA & administration

A

Type 1 & 2

Synthetic analog of amylin, slows gastric emptying & ↑ satiety, Subcut

77
Q

Pramlintide CI

A

gastroparesis

78
Q

Pramlintide SE

A

N/V
Anorexia
HA

79
Q

Pramlintide BW

A

severe hypoglycemia

80
Q

Alpha-glucosidase inhibitors (acarbose and miglitol) should be taken 3 times daily with

A

the first bite of each meal

81
Q

Alpha-glucosidase inhibitors (acarbose and miglitol) SE

A

Flatulence, diarrhea

82
Q

Alpha-glucosidase inhibitors (acarbose and miglitol) important counseling point about hypoglycemia

A

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
Q

Bile-acid binding resin, colesevelam, decreases absorption of

A

vitamins ADEK

84
Q

metformin/pioglitazone brand

A

Actoplus Met

85
Q

Metformin/sitagliptin brand

A

Janumet

86
Q

metformin/canagliflozin brand

A

Invokamet

87
Q

Bile-acid binding resin, colesevelam, CI

A

TG > 500

pancreatitis

88
Q

Glucagon is produced by which cells in the pancreas

A

alpha cells

89
Q

Basal insulin includes

A

glargine, detemir, and ultra-long acting degludec

90
Q

the P in NPH stands for

A

protamine

91
Q

Rapid acting insulin:

  • Onset
  • Peak
  • Duration
A

onset: ~15 min
Peak: 1-2 hrs
Duration: 3-5 hours

92
Q

Regular insulin:

  • Onset
  • Peak
  • Duration
A

onset: 30 min
Peak: ~2 hrs
Duration: 6-10 hours

93
Q

NPH insulin:

  • Onset
  • Peak
  • Duration
A

Onset: 1-2 hrs
Peak: 4-12 hrs
Duration: 14-24 hrs

94
Q

Inhaled insulin time of use

A

mealtime

95
Q 
Basal insulin:
All have no peak
Detemir: onset and duration
Glargine: onset and duration
Degludec: onset and duration
A

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
96
Q

Insulin can cause hypoglycemia and

A

hypokalemia
weight gain
lipoatrophy/hypertrophy

97
Q

Must reduce meal-time insulin by __% when starting pramlintide to avoid severe hypoglycemia

A

50%

98
Q

Which insulins are rapid-acting

A

Aspart (Novolog)

Lispro (Humalog) - remember humans have a lisp

99
Q

When should rapid-acting insulins be injected

A

5-15 min before eating

100
Q

Which insulins are short-acting

A

Regular (Humulin R, Novolin R)

101
Q

Regular insulin is injected __ min before meals

A

30 min

102
Q

When is regular insulin preferred over rapid-acting insulin

A

For IV infusions, including parenteral nutrition

103
Q

regular insulin specific container

A

non-PVC

104
Q

When regular (or rapid-acting) insulin and NPH are mixed in the same syringe, which should be drawn up into the syringe first?

A

Regular (or rapid-acting) first - clear solution
then NPH - cloudy solution
(clear before cloudy)

105
Q

Which insulins are NPH

A

Humulin N, Novolin N

106
Q

Which insulins are available OTC

A

NPH, Regular, and 70/30 premixes of NPH and Regular

107
Q

when is Humulin R U-500 recommended

A

When > 200 units/day required

Do NOT mix with other insulins

108
Q

Which insulins are long-acting (basal)

A

Detemir (Levemir)
Glargine (Lantus, Tujeo, Basaglar)
(remember the brand names start with L for long-acting)

109
Q

How to convert NPH given BID to Lantus, Basaglar, or Tujeo

A

Use 80% of NPH dose

110
Q

How to convert Toujeo to Lantus or Basaglar

A

Use 80% of the Toujeo dose

111
Q

Insulin Glargine as Lantus is ____ units/mL

Glargine as Toujeo is ___ units/mL

A

100 units/mL

300 units/mL

112
Q

What are the 2 sizes of Toujeo

A

SoloStar 1.5 mL

Max SoloStar 3 mL pen

113
Q

Ultra-long acting basal insulin, degludec (Tresiba), comes in which 2 sizes for the pen

A

100 units/mL and 200 units/mL

114
Q

Insulin mixes come in which concentrations

A

70/30
75/25
50/50
(the NPH or protamine insulin is first, the short or rapid-acting insulin is second)

115
Q

Typical insulin starting dose for T1D

A

0.5 units/kg/day (TBW)
Divide 50% basal and 50% bolus
Divide bolus evenly among 3 meals

116
Q

What is a requirement for switching a patient to an insulin pump

A

Prior experience with multiple daily injections

117
Q

Usually, dose of the new insulin is a 1:1 conversion. What are the exceptions

A

-NPH dosed BID –> Lantus, Basaglar or Toujeo dosed daily
Use 80% of the NPH dose
-Toujeo –> Lantus or Basaglar
Use 80% of the Toujeo dose

118
Q

Which insulins come in concentrated formulations

A

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

119
Q

The correct insulin syringe size to number units

A

0.3 mL - up to 30 units
0.5 mL - 30-50 units
1 mL - 51-100 units

120
Q

The U-500 Humulin vials have which color cap and the syringes have which color needle cover

A

green cap and green needle cover

121
Q

The higher the gauge, the ___ the needle

A

thinner

122
Q

The ICR indicates:

A

number of grams of carbs covered by 1 unit of insulin

123
Q

How to start NPH and Regular insulin regimen

A

2/3 TDD as NPH and 1/3 as Regular

not preferred regimen

124
Q

ICR formula for regular insulin

A

450/ TDD of insulin = grams of carbs covered by 1 unit of regular insulin

125
Q

ICR formula for rapid-acting insulin

A

500/ TDD of insulin = grams of carbs covered by 1 unit of rapid-acting insulin

126
Q

What does the correction factor indicate

A

how much the BG will be lowered by 1 unit of insulin

127
Q

What is the correction factor for regular insulin

A

1500/TDD = correction factor for 1 unit of regular insulin

128
Q

What is the correction factor for rapid-acting insulin

A

1800/TDD = correction factor for 1 unit of rapid-acting insulin

129
Q

Correction dose formula

A

(BG now) - (Target BG) / correction factor

130
Q

With which needle sizes does the skin need to be pinched up

A

> 5 mm

131
Q

All insulins are stable at RT for 28 days except:

A 
Humalog mixes, pens - 10
Humulin N, N/R pen - 14
Novolog mixes in pens - 14
Humulin R vial - 31
Humulin R U-500 vial - 40
Novolin R, N, and N/R 70/30 vials - 42
Detemir (Levemir) - 42
Degludec (Tresiba) - 56
Glargine (Toujeo) - 56

(notice the vials have a longer stability than the pens)

Most insulins stable for 28 days at room temp

132
Q

What is the rule of 15 for hypoglycemia

A

Take 15 grams of glucose or simple carbs
Recheck BG after 15 min
Once BG is normal, eat a small meal or snack

133
Q

If patient is unconscious and is hypoglycemic, what can be used

A

dextrose if IV access or glucagon

134
Q

Causes of DKA

A

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

135
Q

How to recognize DKA

A

BG > 250 mg/dl
Ketones (“fruity breath”)
Anion gap acidosis (arterial pH < 7.35, anion gap > 12)

136
Q

How to recognize HHS

A

Confusion, delirium
BG > 600 mg/dL
Serum osmolality >320 mOsm/L
Extreme dehydration
pH > 7.3

137
Q

DKA and HHS treatment

A
  • 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

NAPLEX 2023 (88 decks)

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