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Endo/Repro: Week 2 > Christian: Clinical Overview of Diabetes > Flashcards

Christian: Clinical Overview of Diabetes Flashcards

1
Q

How can you prove a pt injected herself?

A

C peptide level

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2
Q

What is the difference between type 1 and type 2?

A

Type 1 is autoimmune B cell destruction, while type 2 is influenced by environmental factors and is a PROGRESSIVE insulin secretory defect (nearly 50-80% of B cell fxn is lost by the time of dx)

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3
Q

Type 1 (rapid onset, severe def)

A

loss of insulin-producing beta cells of the islets of Langerhans
autoimmune destruction (antibodies to glutamic acid decarboxylase (GAD)-65 are frequently present)
honeymoon period often present
concordance is seen in 50% of monozygotic twins

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4
Q

Type 2 (insidious onset)

A

abnormal insulin action and secretion in target tissues such as the liver, muscle, adipose; further glucose cannot stimulate uptake or suppress its own release
impaired suppression of glucagon secretion after the ingestion of a meal
environmental factors that contribute to obesity

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5
Q

What causes drug induced hyperlycemia?

A

Glucocorticoids!

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6
Q

What is gestational diabetes?

A

diagnosed during pregnancy and clearly not overt diabetes

usually diagnosed by glucose tolerance tests (first a one hour challenge – if >140 mg/dL, another 3 hour test will be performed, checking sugar every hour and if 2 reads are high => gestational DM)

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7
Q

Who do we screen for diabetes?

A

All overweight adults (BMI >25) with > 1 RF:

  • physical inactivity
  • first degree relative w/ diabetes
  • high risk race/ethnicity
  • woman with baby > 9 lb or hx of GDM
  • HTN
  • HDL
  • women w/ PCOS
  • A1C > 5.7
  • obesity, acanthosis nigricans
  • hx of CVD
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8
Q

When do you begin screening for DM for normal individuals?

A

at 45, rescreen every 3 yrs

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9
Q

How do you dx diabetes?

A

fasting plasma glucose of 126 mg/dL on 2 separate occasions

random plasma glucose of 200 mg/dL with symptoms (polyuria, polydipsia, weight loss)

plasma glucose >200 mg/dL 2 hours after a 75-g oral glucose load (pregnancy)

glycosylated hemoglobin >6.4% (A1c)
*6.5 and above = diabetic

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10
Q

What does an A1C correlate to?

A

6% correlates to 135

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11
Q

What is seen on physical exam in a pt with diabetes?

A 
Waist circumference
BP
Thyroid
Heart and lung exam
Pulses in arms and legs
carotid artery bruis
Skin (acanthosis nigricans)
Feet for sores, injuries and decreased sensation
Reflexes/sensation
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12
Q

What microvascular complications can occur in DM?

A
  • retinopathy (eye exam)
  • neuroapthy (monofilament)
  • nephropathy (microalbumin screen)–> may be candidate for ACE inhibitors to prevent acceleration
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13
Q

What macrovascular complications can occur w/ DM?

A

CAD

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14
Q

What type of labs do you do on a diabetic?

A 
glucose (fasting or random)
A1c
Lipids
renal panel 
microalbumin
TSH
hepatic panel
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15
Q

Why do we test A1C every 3 mos?

A

test for amt of glucose adhered to RBC

need to allow for turnover of RBC

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16
Q

Why do we do a hepatic panel for DM?

A

high correlation w/ steatohepatitis

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17
Q

What are goals/screening standards for a diabetic pt?

A

measure hemoglobin A1c every 6 months
maintain hemoglobin A12c at individual targets of less than 7%/less than 8%
measure LDL annually
maintain LDL cholesterol to less than 100 mg/dL or at level achieved by high dose statin
BP < 140/80 mm Hg
annual proteinuria screen
annual flu shot, pneumococcal vaccine UTD
avoid tobacco (RF for atherosclerotic disease)

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18
Q

What tx do we use for T1D?

A

Intensive therapty mimics the pancreas

-short (regular, lispro, aspart, glulisine) + long (glargine, detemir)

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19
Q

Who do you do an IGT for?

A

pregnant women

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20
Q

How do you tx a pt w/ metabollic syndrome?

A

IFG, begin diet and exercise therapy

21
Q

What does Metformin do?

A

Lowers A1C by 1-2%

*first line tx

22
Q

What are the ADA tx guideline for diabetes?

A
  1. Initial drug monotherapy (Metformin)
  2. Two drug combination (Sulfonylurea-motivated to check blood sugar)
  3. Three drug combinations

If failing it’s time for insulin

23
Q

DM was diagnosed with diabetes after an A1c of 8.6%, confirmed after repeat testing. He was started on metformin, however, his A1c has maintained for the past 6 months at 7.5% after titration of metformin. In discussing other agents, DM is concerned about cost. He is also concerned about weight gain, as his weight has not decreased much with lifestyle changes. He has not had hypoglycemic episodes, however, he is worried about it. What should our next medication be?

A 
Glipizide 5mg twice daily
Sitagliptan 100mg daily
Pioglitazone 15mg daily
Insulin glargine 10 units at bedtime
**Utilize shared decision making to determine next option
24
Q

What is the best treatment for T2D?

A

Metformin

25
Q

What does Metformin do?

A

decrease hepatic glucose production

no hypoglycemia, weight neutral (maybe loss), lipid lowering, decreases macrovascular complications

26
Q

What are the SE of Metformin?

A

diarrhea, abd bloating

Some pts can’t tolerate it

27
Q

Who do you NOT give Metformin to?

A

renal impairment (Cr >1.5 men, >1.4 women)
cardiac, resp insuf, sepsis leading to hypoxia or reduced tissue perfusion
LACTIC ACIDOSIS
liver disease, alcohol abuse
radiographic contrast agents (Hold metformin for 48-72 hrs**)

28
Q

How do you monitor Metformin?

A

A1c every 3-6 mos

SCr and Hgb/Hcdt/RBC (baseline and annually)

Vit B 12 every 2-3 yrs

29
Q

What are hte DDIs with Metformin?

A

EtOH
cimetidine
IV contrast

30
Q

***PD returns a few years later; she is currently taking metformin 1000mg BID. Her A1c today is 7.8%. She is having trouble adhering to TLC due to varied work schedule. She is adamant about not wanting to use injectable medications and also is concerned about cost. You want to add a medication. You choose:

A
  • *a. glipizide XL 5 mg daily (sulfonyureal)
    b. pioglitazone 15 mg daily (expensive)
    c. sitagliptan 25 mg daily (GLP, expensive, new, not as effective)
    d. exenatide 5 mcg BID (GLP, injection)
31
Q

Glyburide (rarely used), glipizide and glimepirirde are all examples of …

A

sulfonylureas

32
Q

What is the MOA of sulfonylureas?

A

bind to sulfonylurea receptor on beta cells, stimulate insulin release

33
Q

What are SE of sulfonylureas?

A

hypoglycemia, weight gain, potential impairment of cardiac ischemic preconditioning

34
Q

What should NEVER be used w/ insulin?

A

sulfonylureas

35
Q

What do THiazolidinediones do?

A

Increases the amount of glucose taken up by muscle cells and keeps the liver from overproducing glucose

36
Q

WHat are TDZs used fo?

A

addresses primary defect of T2D, no hypoglycemia, lipid lowering, decreased macrovascular complications

37
Q

What are the SE of TDZs?

A

edema
can precipitate CHF
increase fx risk in women
increase MI w/ rosiglitazone

EXPENSIVE

38
Q

How do GLP-1 agonists and DPP-IV inhibitors work?

A

activate GLP-1 receptors, increase glucose-dependent insulin secretion, decrease glucagon secretion, delay gastric emptying

DPP-IV inhibits degradation of GLP-1 and GIP (gastric inhibitory peptide)

39
Q

What ist he down side of GLP-1 agonists and DPP-IV inhibitors?

A

not as effective, expensive

SE= nausea, vomiting, pancreatitis

40
Q

What is the MOA of GLP-1 R agonist?

A

incretin (GLP-1) analog  increased insulin synthesis and release (β cells), decreased glucagon secretion (α cells), and decreased hepatic glucose production

May promote early satiety

41
Q

What are SE of GLP-1?

A

N/V, diarrhea

Can slow gastric emptying> can alter absorption of oral meds

42
Q

What is the MOA of DPP-IV inhibitors first line?

A

blocks the degradation of incretin by inhibiting the DPP-IV enzyme > increased insulin synthesis and release (β cells), decreased glucagon secretion (α cells), and decreased hepatic glucose production

43
Q

What drugs can affect the pancreas?

A

DPP-IV inhibitors and GLP-1 agonists

44
Q

PD is now 67 years old and has been treated for T2DM with metformin 1000mg BID and glipizide XL 10 mg daily. She is compliant with medication use but admits cost is a concern because she no longer can afford to pay for her meds out of pocket. Her A1c is now 9.4% – what is the most effective next step?

A

a. add exenetide 5mcg BID
b. Increase metformin to 1500 mg BID
* *c. add lantus 10 units at HS (long acting)
d. add NPH insulin 10 units at HS (intermediate)

45
Q

What is the goal of insulin therapy?

A

Mimic natural insulin release

46
Q

What are the ADA’s glycemic targets for most pts?

A

HbA1c <180

47
Q

When should you consider more stringet HbA1c targets?

A

short disease duration
long life expectancy
no sig CVD

48
Q

When you should you consider less stringent HbA1c targets?

A

h/o severe hypoglycemia
limited life expectancy
advanced complications

49
Q

What are metabolic abnormalities associated w/ DM?

A

steatohepatitis
elevated triglycerides/low HDL
hyperuricemia
acanthosis nigricans

Endo/Repro: Week 2 (11 decks)

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