Chapter 44: Diabetes Flashcards
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
fat
ketones
(very high ketone levels can cause DKA)
Which protein is used to test if T1D is present
C-peptide
T1D is diagnosed when there is a ____ C-peptide level
very low or absent
C-peptide is released by the pancreas only when insulin is present
Which factors can increase the likelihood of insulin resistance, and eventually T2D
lifestyle, genetics, other RF (low level of physical activity, being overweight or obese)
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
Metformin
T/F: prediabetes can be reversed
true - with a healthier lifestyle. BG should be checked annually to see if the condition has progressed to T2D
Babies born to mothers who had hyperglycemia during the pregnancy are larger than normal, which is called
fetal macrosomia
These babies are at higher risk for developing obesity and diabetes later in life
Which test is preferred for pregnant women to test for GDM
OGTT
Which medication is preferred in pregnant women to reduce hyperglycemia
Insulin
Lifestyle with diet an exercise should be tried first
What are the macrovascular diseases caused by diabetes
Atherosclerosis –> ASCVD (CAD, CVA, PAD)
What are the microvascular diseases caused by diabetes
Retinopathy
Nephropathy
Neuropathy
Autonomic neuropathy (ED, gastroparesis, loss of bladder control, UTIs)
What are the classic symptoms caused by high BG
Polyuria
Polyphagia
Polydipsia
(other sx which may be the only sx present in T2D include fatigue, blurry vision, ED, and vaginal fungal infections)
Who should be tested for diabetes and at which age
Everyone starting at 35 with no RF, test everyone with at least 1 RF
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
25
23
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
3
8
PPG
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
6.5%
126 mg/dL
The A1c should be measured every __ months if not yet at goal
If at goal, the test should be repeated every __ months
3 months (quarterly) 6 months
Diagnosis for diabetes:
A1C:
FPG:
2-hour PPG after OGTT or classic sx + random BG:
> / = 6.5%
/ = 126 mg/dL
/ = 200
Diagnosis for prediabetes:
A1C:
FPG:
2-hour PPG after OGTT or classic sx + random BG:
5.7-6.4%
100-125
140-199
Treatment goals for non-pregnant patients with diabetes:
A1C:
Preprandial:
2-hr PPG:
< 7%
80-130
< 180
Treatment goals for pregnant patients with diabetes:
Preprandial:
1-hr PPG:
2-hr PPG:
< / = 95
< / = 140
< / = 120
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
126
28
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)
150 min
3 days
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 ___
81 mg/day
preeclampsia
**new update: ASA + low dose rivaroxaban can be added to pts wth CAD and/or PAD
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
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
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
Weight control:
A healthy weight circumference is key to reducing insulin resistance (< __” females, < __” males)
35
40
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
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
Albuminuria is either a urine albumin >/= __ mg/24 hours or a UACR >/= __ mg/g
30
30
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
Natural products that can be used in diabetes
Cassia cinnamon
alpha lipoic acid
chromium
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
Which drugs have little to no risk of hypoglycemia
DPP4i
GLP1
SGLT2
TZD
Which two diabetes meds have a similar MOA and should NOT be used together
DPP4 and GLP
Best options for T2D if need weight loss
GLP1 (sema, lira, dula) or SGLT2
First line treatment for T2D
Metformin
Metformin is CI in eGFR < ___
30
Insulin can be used initially if hyperglycemia is severe (A1C > ___ or BG > ___)
10%
300 mg/dL
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%
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
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%
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)
What are the 2 big similarities with the top 3 treatments for T2D
Weight loss and no hypoglycemia (Metformin, GLP and SGLT2)
Metformin MOA
↓ hepatic glucose output
Starting dose for metformin IR & ER
IR: 500 mg PO daily or BID
ER: 500 mg PO daily with dinner
ER formulation of metformin counseling point
Leaves a ghost tablet in the stool
Metformin BW
Lactic acidosis - ↑ risk with renal disease
Metformin warnings
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
Metformin CI
eGFR < 30
acute or chronic metabolic acidosis
Which drugs are TZDs
Pioglitazone (Actos)
Rosiglitazone (Avandia)
TZD BW
Do not use with NYHA Class III/IV HF
Rosi: incr risk of MI
TZDs are rosiglitazone and pioglitazone
TZD warnings/SE
Edema (macular, peripheral)
Weight gain
Can cause or worsen HF
Risk of fractures
[Can stimulate ovulation
Pioglitazone: avoid with bladder CA history]
SGLT2 inhibitors MOA
↑ BG renal excretion
by inhibiting SGLT2 in proximal tubule
All SGLT2s must have a dose decrease with
renal impairment
based on eGFR not CrCl
SGLT2 SE and warnings
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
SGLT2i eGFR cutoffs
Jardiance - <30 not for glycemic control
Dapagliflozin - 25-45 (not for glycemic control), < 25 don’t initiate
Canagliflozin BW
Incr risk of leg and foot amputations
Which drugs are SGLT2 inhibitors
Canagliflozin (Invokana)
Empagliflozin (Jardiance)
Dapagliflozin (Farxiga)
Which drugs are DPP4 inhibitors
Linagliptin (Tradjenta)
Sitgliptin (Januvia)
All DPP4 inhibitors should have a dose decrease with renal impairment, EXCEPT
Linagliptin
DPP4 warnings
Pancreatitis Arthralgia Renal failure Alogliptin: hepatotoxicity Alogliptin, saxagliptin: risk of HF
SU should not be used with which medication class
insulin or meglitinides
Glipizide IR dosing
30 min PO before meals; all other products take with breakfast
Glucotrol XL (glipizide) counseling point
OROS formulation; ghost tablet in stool
↓ efficacy after long-term use
SU contraindication
Sulfa allergy
SU A1c decrease
1-2%
SU should be avoided in which patient population
Elderly (BEERS criteria) due to hypoglycemia risk (esp glyburide and chlorpropamide)
Important counseling point if skipping a meal with meglitinides
skip meal = skip dose to avoid hypoglycemia
Which drugs are GLP1
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Liraglutide is dosed how many times per day
Dulaglutide?
Lira - daily
dula - weekly
Byetta and Adlyxin should be given within __ min of meals
60
Pen needles are provided with which GLPs
Weekly injections only (Trulicity, Byduron, Byduron BCise, Ozempic)
Not with Byetta, Victoza, Adlyxin
GLP1s can cause
pancreatitis
Pramlintide is used in which type(s) of diabetes & what is the MOA & administration
Type 1 & 2
Synthetic analog of amylin, slows gastric emptying & ↑ satiety, Subcut
Pramlintide CI
gastroparesis
Pramlintide SE
N/V
Anorexia
HA
Pramlintide BW
severe hypoglycemia
Alpha-glucosidase inhibitors (acarbose and miglitol) should be taken 3 times daily with
the first bite of each meal
Alpha-glucosidase inhibitors (acarbose and miglitol) SE
Flatulence, diarrhea
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
Bile-acid binding resin, colesevelam, decreases absorption of
vitamins ADEK
metformin/pioglitazone brand
Actoplus Met
Metformin/sitagliptin brand
Janumet
metformin/canagliflozin brand
Invokamet
Bile-acid binding resin, colesevelam, CI
TG > 500
pancreatitis
Glucagon is produced by which cells in the pancreas
alpha cells
Basal insulin includes
glargine, detemir, and ultra-long acting degludec
the P in NPH stands for
protamine
Rapid acting insulin:
- Onset
- Peak
- Duration
onset: ~15 min
Peak: 1-2 hrs
Duration: 3-5 hours
Regular insulin:
- Onset
- Peak
- Duration
onset: 30 min
Peak: ~2 hrs
Duration: 6-10 hours
NPH insulin:
- Onset
- Peak
- Duration
Onset: 1-2 hrs
Peak: 4-12 hrs
Duration: 14-24 hrs
Inhaled insulin time of use
mealtime
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
Insulin can cause hypoglycemia and
hypokalemia
weight gain
lipoatrophy/hypertrophy
Must reduce meal-time insulin by __% when starting pramlintide to avoid severe hypoglycemia
50%
Which insulins are rapid-acting
Aspart (Novolog)
Lispro (Humalog) - remember humans have a lisp
When should rapid-acting insulins be injected
5-15 min before eating
Which insulins are short-acting
Regular (Humulin R, Novolin R)
Regular insulin is injected __ min before meals
30 min
When is regular insulin preferred over rapid-acting insulin
For IV infusions, including parenteral nutrition
regular insulin specific container
non-PVC
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)
Which insulins are NPH
Humulin N, Novolin N
Which insulins are available OTC
NPH, Regular, and 70/30 premixes of NPH and Regular
when is Humulin R U-500 recommended
When > 200 units/day required
Do NOT mix with other insulins
Which insulins are long-acting (basal)
Detemir (Levemir)
Glargine (Lantus, Tujeo, Basaglar)
(remember the brand names start with L for long-acting)
How to convert NPH given BID to Lantus, Basaglar, or Tujeo
Use 80% of NPH dose
How to convert Toujeo to Lantus or Basaglar
Use 80% of the Toujeo dose
Insulin Glargine as Lantus is ____ units/mL
Glargine as Toujeo is ___ units/mL
100 units/mL
300 units/mL
What are the 2 sizes of Toujeo
SoloStar 1.5 mL
Max SoloStar 3 mL pen
Ultra-long acting basal insulin, degludec (Tresiba), comes in which 2 sizes for the pen
100 units/mL and 200 units/mL
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)
Typical insulin starting dose for T1D
0.5 units/kg/day (TBW)
Divide 50% basal and 50% bolus
Divide bolus evenly among 3 meals
What is a requirement for switching a patient to an insulin pump
Prior experience with multiple daily injections
Usually, dose of the new insulin is a 1:1 conversion. What are the exceptions
-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
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
The correct insulin syringe size to number units
0.3 mL - up to 30 units
0.5 mL - 30-50 units
1 mL - 51-100 units
The U-500 Humulin vials have which color cap and the syringes have which color needle cover
green cap and green needle cover
The higher the gauge, the ___ the needle
thinner
The ICR indicates:
number of grams of carbs covered by 1 unit of insulin
How to start NPH and Regular insulin regimen
2/3 TDD as NPH and 1/3 as Regular
not preferred regimen
ICR formula for regular insulin
450/ TDD of insulin = grams of carbs covered by 1 unit of regular insulin
ICR formula for rapid-acting insulin
500/ TDD of insulin = grams of carbs covered by 1 unit of rapid-acting insulin
What does the correction factor indicate
how much the BG will be lowered by 1 unit of insulin
What is the correction factor for regular insulin
1500/TDD = correction factor for 1 unit of regular insulin
What is the correction factor for rapid-acting insulin
1800/TDD = correction factor for 1 unit of rapid-acting insulin
Correction dose formula
(BG now) - (Target BG) / correction factor
With which needle sizes does the skin need to be pinched up
> 5 mm
All insulins are stable at RT for 28 days except:
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
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
If patient is unconscious and is hypoglycemic, what can be used
dextrose if IV access or glucagon
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
How to recognize DKA
BG > 250 mg/dl
Ketones (“fruity breath”)
Anion gap acidosis (arterial pH < 7.35, anion gap > 12)
How to recognize HHS
Confusion, delirium
BG > 600 mg/dL
Serum osmolality >320 mOsm/L
Extreme dehydration
pH > 7.3
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
