Diabetes Flashcards
how often should BG be checked in prediabetics
annually
The preferred treatment for gestational diabetes
insulin*
metformin and glyburide are sometimes used
Classic symptoms of high BG
polyruia
polydipsia
polyphagia
diagnostic criteria (A1c, FPG, 2-hr PPG)
a1c: >6.5 (pre: 5.7-6.4)
FPG: >126 (pre: 100-125)
2-hr PPG: >200 (pre: 140-199)
Treatment goals: not pregnant
A1c <7 or 6.5
preprandial: 80-130
2hr PPG: <180
Treatment goals: pregnant
preprandial: <95
1hr PPG: <140
2hr PPG: <120
what is the eAG for an A1c of 6%
126
what does 1% ^ in A1c roughly equal in eAG
1% increase in A1c is about 28mg/dl increase in eAG
statin instensity needed in diabetics
high if ASCVD (post-MI, PAD) or >50 with multiple risk factors
mod: no ASCVD and 40-75yo
Patients <40yo w/ ASCVD: mod
Patients <40yo w/o ASCVD: no statin
blood pressure goal in diabetes
<130/80 mmHg
when is an ACEi or ARB needed in diabetic patients
Albuminuria or HTN present
drugs with little/no risk of hypoglycemia
GLP-1
DPP4 inhibitors
SGLT2s
TZD
1st line in T2DM with HF
SGLT2: empag, canag, dapagliflozin
CI for SGLT2
eGFR <30
T2DM with ASCVD first line
GLP1: dulagluride, liraglutide, semaglutide
SGLT2: empagliflozin, canagliflozin
first line in diabetes
METFORMIN
cut off for metformin initiaion
eGFR<30
when can insulin be initiated initially
A1c>10% or BG > 300mg/dL
which drug classes bascially do the same thing and shouldn’t be initiated together
DPP4 and GLP-1s
What is the starting dose of basal or bedtime NPH insulin?
10 units daily or TDD of 0.1-0.2 units/kg/day
How/when to initiate prandial insulin
initiate if BG is not controled with basal insulin at goal. Start with once daily dose before meal with highest carb intake or highest post-prandial BG
What percentage of basal do we start prandial insulin at?
10%
When to pick SGLT2 over GLP-1
heart failure or CKD patients
Warnings with metformin
lactic acidosis with renal disease or alcohol disease
B12 deficiency
stop prior to contact media
What eGFR indicates to not initiate metformin
30-45
Side effects of thiazolidinediones
“-glitazones”
edema
weight gain
bone fractures
Because of certain side effects, which patients would we not want to start a thiazolidinedione on?
Heart failure (edema)
What is a unique warning with thiazolidinediones?
“glitazones”
can stimulate ovulation!
Which sglt2s provide renal benefit
canagliflozoin (invokanna)
empagliflozin (jardiance)
which sglt2s provide hf benefit
canagliflozoin (invokanna)
empagliflozin (jardiance)
dapagliflozin (Farxiga)
when do sglt2s need to be d/c acutely
3 days prior to surgery to decrease risk of ketoacidosis
Boxed warning of amputation with _____
canagliflozin (invokanna)
do not use in neuropathy
eGFR of ____ = SGLT2s CI
eGFR <30
Which DPP4 does not need adjusted for renal impairment
linagliptin (Tradjenta)
which DPP4 can cause hepatotoxicity?
Alogliptin (Nesina)
which DPP4s should not be used in HF
aloglpitin (Nesina)
saxagliptin (Onglyza)
Which drug class should not be used with insulin
sulfonyureas (-ide) glipizide, glimepiride, glyburide AND meglitinides (glinide) repaglinide, nateglinide
What is a unique thing about sulfonyureas having to do with prolonged use
efficacy will decrease due to decreased beta cell function
MOA of sulfonyureas
increase insulin secretion by beta cells
Which drug class has a Beers Criteria warning against use
sulfonyureas
MOA of DPP4 inhibitors
increases incretin causing less glucagon production therefore lowering blood glucose
thiazolidinediones MOA
(actos/avandia)
increase muscle uptake of blood glucose due to increased sensitivity
Meglitinides MOA
-glinide
incease mealtime insulin secreation
risk of hypoglycemia with meglitinides?
YES! Especially if patient skips meals`
Which drug class can cause weight gain?
meglitinides, insulin, sulfonylureas, tzds
GLP1 that can be used in type 1 DM
pramlintide (symlin)
Which GLP1s come with pen needles?
weekly injections: Trulicity, Bydureon, Ozempic
which diabetic drug should be avoided in hyperkalemia?
canagliflozin
____ cells produce glucagon
alpha
____ cells produce insulin
beta
What is the glucose reverse in the liver/muscle stored stored as?
glycogen
MOA glucagon
pulls glucose into blood stream from glycogen stores
When are ketones made?
When glycogen stores in liver are low, glucagon signals fat cells to create ketones
List of basal insulins
glargine
detemir
degludec
which basal insulin is ultra-long acting
degludec
what is Regular insulin’s role
bolus, but is slower acting than a rapid acting insulin
NPH facts
intermediate acting
p = protamine
hypoglycemia risk due to peaks that don’t coincide with food intake
variable, duration of action (14-24 hours)
onset and duration: rapid acting
15 min onset
3-5 hour duration
onset and duration: regular insulin
30 min onset
6-10 hours duration
onset and duration- NPH
1-2 hour onset
14-24 hour duration
onset and duration- detemir
3-4 hour
1 day
pros of basal insulin
NO PEAKS!
onset and duration - glargine
3-4 hour
1 day
onset and duration - degludec
1 hour onset
42+ hour duration
which diabetic drug should not be used with insulin due to risk of heart failure
rosiglitazone
which is rapid acting, humalog or humulin?
humalog and novolog!
think, diabetics need to LOG their meals and these are used at meal time
How is NPH given? `
twice daily before breakfaast and supper
how to start basal/bolus regime
if doing TID, start with 0.5u/kg/day then split 50:50 among basal and bolus dosing. bolus dosing should be spread out tid
how to convert between insulins
typically 1:1 except NPH ->lantus or Toujeo ->lantus - use 80% of current dosing
what is the ICR
insulin to carb ratio - how many grams of carbs are covered by 1 unit insulin
how to calculate icr
regular: rule of 450 = 450/TDD insulin
Rapid: rule of 500 = 500/TDD = g of carbs covered by 1 unit insulin
what is the correction factor?
indicates how much the BG will be lowered by 1 unit of insulin
How to calculate the correction factor
regular: 1500 rule
1500/TDD
rapid: 1800 rule
1800/tdd
how to calculate correction dose
(BG now - target BG)/correction factor
how to use correction dose
add it to the normal number of units of insulin before meals
If a patients BG readings before dinner are consistently high and they are on basal/bolus regime, what dose needs changed?
increase lunch time bolus
which insulins have a room temp stability other than 28 days?
10: humalog mix pen
14: humulin N and N/R pens
31: humulin R vial
40: Humulin R U-500 vial
41: Novolin N, R, N/R, 70/30 vials, levemir
56: Tresiba, Toujeo pen
goal BG in hospitalized patients
140-180
Lab values of DKA
bg >250
ketones in urine and serum
anion gap acidosis (pH<7.35, gap >12)
Treating DKA and HHS
aggressive fluid resuscitation with NS, once BG 200 switch to D5W 1/2 NS
Watch K+ and replace as needed
insulin infusion 0.1 u/kg/hr
give sodium bicarb with pH is <6.9
what is HHS
hyperosmolar hyperglycemic state: confusion/delirium BG>600 with osmolarlity of >320 dehydration pH>7.3
