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NAPLEX 21 > Diabetes > Flashcards

Diabetes Flashcards

1
Q

In type I diabetes, what cells do the antibodies attack?

A

the beta cells (islet cells)

these cells make insulin within the pancreas

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2
Q

very high ketone levels can cause what?

A

DKA – medical emergency

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3
Q

What protein is used to test if T1D is present?

A

C-peptide protein – VERY low levels or absent in T1D

-released by the pancreas only when insulin is released.

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4
Q

How are women tested for diabetes in pregnancy?

A

oral glucose tolerance test (OGTT) *preferred

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5
Q

What is the drug of choice in pregnancy for diabetes?

A

insulin

metformin and glyburide are sometimes used

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6
Q

Retinopathy
Nephropathy
Neuropathy
Autonomic neuropathy

are all what type of damage?

A

mircovasular disease

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7
Q

What is macrovascular disease?

A

ASCVD, including MI, CVA, PAD

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8
Q

What are the classic symptoms caused by high BG?

A

polyuria - excessive urination
polyphagia - excessive hunger
polydipsia - excessive thirst

> fatigue, flurry vision, ED, vaginal fungal infections

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9
Q

Risk factor for DM

HDL:
TG:

A

HDL < 35

TG>250

PCOS!!

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10
Q

when should people start being tested for DM? regardless of risk factors

A

45y

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11
Q

alll asx children, adolescents and adults who are overweight (BMI>25 or >23 in asian Americans) with at least one other risk factor (ie physical activity) should be tested. If neg, when should it be repeated?

A

3 years

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12
Q

FPG is taken after how many hour fast?

A

8hr

> 126, must be confirmed again by testing with the same or with a new blood sample

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13
Q

BG measured how often? (goal A1C<6.5/7%
not at goal =
at goal =

A

3 months

6 months

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14
Q

Diagnostic criteria: diabetes
A1C
FPG
2hr PPG after OGTT

A

> 6.5
126
200

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15
Q

Diagnostic criteria: prediabetes
A1C
FPG
2hr PPG after OGTT

A

5.7-6.4
100-125
140-199

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16
Q

Treatment goals: not pregnant
preprandial
2hr PPG

A

80-130

<180

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17
Q

Treatment goals: pregnant
preprandial
1hr PPG
2hr PPG

A

<95
<140
<120

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18
Q

An A1c of 6% is equivalent to an eAG of 126mg/dL

Each addition 1% increases the eAG by how much?

A

28mg/dL

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19
Q

Comprehensive care: anti platelet therapy

A

aspirin 81mg for ASCVD secondary prevention
- aspirin allergy = clopidogrel 75 daily

NOT RECOMMENDED FOR PRIMARY PREVENTION

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20
Q

Comprehensive care: cholesterol control

A

ANNUAL lipid panel ; most need statins (recheck after 4-12 weeks of starting/incing dose)

can add ezetimibe to max tolerated dose of statin if ASCVD risk >20%

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21
Q

What statin level?

Diabetes + ASCVD (post-MI, PAD), or 50-75y with multiple ASCVD risk factors

A

HIGH

atorvastatin 40-80mg

rosuvastatin 20-40mg

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22
Q

What statin level?

diabetes without ASCVD and older (40-75)

A

moderate

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23
Q

What statin level?

diabetes without ASCVD and younger <40

A

no risk factors for ASCVD –> no statin

ASCVD risk factors: moderate-intensity statin

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24
Q

Peripheral neuropathy - how often get checked?

A

annually with a 10g monofilament & 1 other test to asses sensation

tx options: pregabalin, duloxetine, gabapentin

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25
Q

Diabetic retinopathy

how often?

A

when diagnosed –> eye exam with dilation

if retinopathy, annually, if not repeat Q1-2 years

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26
Q

Vaccinations for diabetes

A

HBV

flu

both Prevnar 13, pneumovax 23 [2-64, then another 65+]

shingrix

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27
Q

Blood pressure goal for diabetes

A

<130/80 (ACC/AHA)

<130/80 if ASCVD risk is high, if not >140/90 (ADA)

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28
Q

Diabetes with hypertension no albuminuria

treatment

A

thiazide, CCB, ACE, or ARB

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29
Q

Diabetes with albuminuria +/- HTN

treatment

A

ACE, ARB

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30
Q

how often check albumin if no kidney disease? if they have kidney disease?

A

yearly

twice yearly

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31
Q

What are natural products used to dec BG

A

cinnamon

alpha lipoic acid

chromium

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32
Q

First line treatment for DM

A

metformin + physical activity

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33
Q

patient has HF, CKD, ASCVD RISK/ASCVD, in everyone (regardless of A1c):

ASCVD major issue: treatment

A

GLP-1RA (dulaglutide, liraglutide, semaglutide SC in only)

OR

SGLT2i (empagliflozin, canagliflozin) if eGFR ok; CI if eGFR <30

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34
Q

diabetes treatment if HF or CKD major issue

A

SGLT-2i (empa, canag, dapa). IF eGFR ok (>30)

if cannot use, go with GLP-1RA (dulaglutide, liraglutide, semaglutide)

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35
Q

patient has HF, CKD, ASCVD RISK/ASCVD

> A1c 6.5% treatment options

A

add the other class SGLT2i or GLP-1RA, using the drugs with CVD benefit

if using SGLTi, can add DPP4i

add basal insulin with CVD benefit (glargine U100 or degludec

TZD - NOT WITH HF

SU

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36
Q

Do not use which agents with DPP4i?

A

GLP-1RA (same MOA)

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37
Q

Patient does not have ASCVD, HF or CKD but A1C >6.5%

goal: minimize hypoglycemia

A

DPP4i

GLP-1RA

SGLT-2i

TZD

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38
Q

Patient does not have ASCVD, HF or CKD but A1C >6.5%

goal: minimize hypoglycemia

remains elevated

A

add different class from

DPP4i

GLP-1RA

SGLT-2i

TZD

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39
Q

Patient does not have ASCVD, HF or CKD but A1C >6.5%

goal: weight loss

A

options with best evidence:

GLP-1RA (semaglutide, liraglutide, dulaglutide)

SGLT-2i

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40
Q

Patient does not have ASCVD, HF or CKD but A1C >6.5%

goal: weight loss

remains elevated

A

use other class (GLP-1RA or SGLT-2i)

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41
Q

Patient does not have ASCVD, HF or CKD but A1C >6.5%

goal: minimize hypoglycemia

remains elevated x2

A

if triple therapy is required or SGLT2i and/or GLP-1RA are CI: use DPP4i

if DPP4- not tolerated or CI or already on GLP-1RA, cautiously add either:

TZD
basal insulin
SU

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42
Q

when is metformin started in combo instead of alone?

A

A1c >1,5% goal

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43
Q

if eGFR <30 what treatment?

A

NO metformin

insulin can be used initially if hyperglycemia is severe BG>300/a1c >10%

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44
Q

Consider what agent before insulin if above A1c target goal?

A

GLP-1RA

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45
Q

Consider what options before full basal-bolus dose insulin if above A1c target goal?

remains elevated —

A

add basal insulin or bedtime NPH insulin

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46
Q

Adding on basal insulin or bedtime NPH insulin, what’s the starting dose?

A

0.1-0.2u/kg/day (TDD)

-set FPG target
- choose titration algorithm (inc 2u every 3 days)
if hypoglycemia dec dose by 10-20%

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47
Q

patient on GLP-1RA, NPH bedtime insulin with titrated dose… remains elevated…

A

add meal-time insulin, starting with ONE daily dose, before meal with highest carb intake or highest postprandial BG

additional prandial doses can be added up to 2-3 times daily prior to meals

if insufficient –> full basal-bolus regimen

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48
Q

Top 3 treatments:
metformin
GLP-1RAs
SGLT-2i

side effects

A

weight LOSS

NO hypoglycemia

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49
Q

Brand: Actoplus Met

A

generic: metformin/pioglitazone (TZD)

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50
Q

Brand: Janumet

A

generic: metformin/sitagliptin (DPP4i)

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51
Q

Brand: invokamet

A

generic: metformin/canagliflozin

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52
Q

MOA: dec hepatic glucose output

A

metformin (BIGUANIDE)

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53
Q

Brand: Glucophage, Glucophage XR, Fortamet, Glumetza

A

generic: metformin

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54
Q

Metformin boxed warnings

A

lactic acidosis - increase risk with renal disease!!

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55
Q

Brand: Actos

A

generic: pioglitazone

TZD

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56
Q

Brand: Avandia

A

generic: rosiglitazone

TZD

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57
Q

MOA: increase muscle cell-sensitivity to insulin to inc BG entry

A

TZDs

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58
Q

Which agent causes hypoglycemia when used with insulin so much that the insulin dose may need to be reduced?

& ALSO CAUSE WEIGHT GAIN

A

TZDs

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59
Q

Side effects of TZDs

A

edema, weight gain, bone fractures

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60
Q

Which diabetic agents should not be used in HF? (class III/IV)

A

TZD

BBW

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61
Q 
Warnings:
Hepatic failure
Edema
worsen HF
Fractures
stimulate ovulation
BLADDER CANCER
A

TZD

bladder cancer – pioglitazone

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62
Q

Brand: invokana

A

generic: canagliflozin

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63
Q

Brand: Jardiance

A

generic: empaglyflozin

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64
Q

MOA: increase BG renal excretion via proximal tubule

A

SGLT2i

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65
Q

Which agent causes hypoglycemia when used with insulin so much that the insulin dose may need to be reduced?

& ALSO CAUSE WEIGHT LOSS

A

SGLT2i

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66
Q

Which SGLT2i have a BBW for amputation risk?

A

canagliflozin

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67
Q 
Warnings:
inc LDL
inc K
fluid loss, hypotension
Ketoacidosis, even with BG <250
A

SGLT2i

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68
Q

How many days should you DC SGLT2i prior to surgery

A

3 days, to reduce the risk of ketoacidosis

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69
Q

Brand: januvia

A

generic: sitagliptin

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70
Q

Brand: tradjenta

A

generic: linagliptin

71
Q

Which agent causes hypoglycemia when used with insulin so much that the insulin dose may need to be reduced?

& ALSO no difference in weight change

A

DPP4 inhibitors

72
Q

MOA: inc incretin –> less glucagon –> lowers BG

A

DPP4i

73
Q

What agent of the DPP4i can you use in renal impairment with no dose chagne

A

linagliptin

74
Q

WARNINGS:
pancreatitis
severe joint pain
acute renal failure

A

DPP4i

alogliptin - hepatotoxicity
alogliptin & saxagliptin - avoid in HF

75
Q

Brand: glucotrol, glucotrol XL

A

generic: glipizide

SU

76
Q

Brand: Amaryl

A

generic: glimepiride

SU

77
Q

Brand: glynase

A

generic: glyburide, micronized

SU – highest risk for hypoglycemia (and chlorpropamide)

78
Q

MOA: increase insulin secretion

A

sulfonylureas

79
Q

These agents cause hypoglycemia, weight gain, and cannot use with insulin or with meglitidies

A

SU

80
Q

What drugs are meglitinides?

A

repaglinide (Prandin)

Nateglinide (Starlix)

81
Q

MOA: increase insulin secretion

A

meglitinides

82
Q

These agents have hypoglycemia especially is the meal is skipped and the dose Is still taken, and weight gain. this med also has to be taken 15-30 mins before meals

A

meglitinides

83
Q

Do no use which meds with each other?

A

SU-meglitinides

GLP-1RA-DPP4i

84
Q

Brand: Victoza

A

generic: liraglutide

85
Q

Brand: Trulicity

A

generic: dulaglutide

86
Q

MOA: “incretin mimetic”

A

GLP1RA

87
Q

Which GLP1RA is dosed daily?

weekly?

A

daily - liraglutide

weekly - dulaglutide *needles provided

88
Q

Which GLP1RA are given within 60 mins of meal

A

Byetta (exenatide)

Adlyxin (lixisenatide)

89
Q

WARNING:

pancreatitis

A

GLP-1RAs

90
Q

This agent is a synthetic analog of amylin

A

pramlintide (SymlinPen 60, 120)

91
Q

What agent is used in both 1&2 DM

A

Pramlintide

92
Q

This agent has a CI with gastroparesis

A

Pramlintide

SEVERE HYPOGLYCEMIA – BBW

93
Q

Uncommon use, not in guidelines medications

A

alpha-glucosidase inhibitors: MOA- inhibitors sucrose breakdown in gut
acarbose (Precose), miglitol (Glyset)

Bile-acid binding resin: colesevelam (Welchol)

Dopamine agonist: Bromocriptine (Cycloset) – also used in PD

94
Q

if present - cancer

avoid:

A

pioglitazone, dapa (bladder cancer), GLP1RA (thyroid,)

95
Q

if present - elderly

avoid:

A

SU

96
Q

if present - gastroparesis, GI disorders

avoid:

A

GLP1RAs, pramlintide

97
Q

if present - UTI

avoid:

A

SGLT2i

98
Q

if present - hepatotoxicity

avoid:

A

TZDs, alogliptin

99
Q

if present - hypotension/dehydration

avoid:

A

SGLT2

100
Q

if present - inc K

avoid:

A

canag

101
Q

if present - low K

avoid:

A

insulin

102
Q

if present - hypersensitivity

avoid:

A

DPP4i

103
Q

if present - ketoacidosis

avoid:

A

SGLT2,

104
Q

if present - lactic acidosis

avoid:

A

metformin

105
Q

if present - osteoporosis

avoid:

A

canag, TZDs

106
Q

if present - pancreatitis

avoid:

A

DPP4i, GLP1RA

107
Q

if present - peripheral neuropathy, PAD, foot ulcers

avoid:

A

canag

108
Q

if present - retinopathy

avoid:

A

semaglutide SC inj (ozempic)

109
Q

if present - sulfa allergy

avoid:

A

SU

110
Q

if present -renal insufficiency

avoid:

A

metformin, SGLT2, eventide, glyburide

111
Q

if present - weight gain

avoid:

A

SU, meglitinides, TZD, insulin

112
Q

What do alpha cells produce in the pancreas?

A

glucagon

beta cells – insulin

113
Q

Examples of basal insulin

A

glargine
detemir (binds to albumin!)
degludec

114
Q

Rapid-acting and short-acting insulin examples

A

Fiasp (has niacinamide/vit B3) QUICK AF

Regular insulin

115
Q

intermediate acting

A

NPH

116
Q

Onset of detemir

A

3-4 hours lasts 1 day no peak

117
Q

Onset of glargine

A

3-4 hours (Toujeo 6 hours) lasts 1 day, no peak

118
Q

Onset of degludec

A

onset in 1 hour, lasts 42+ hours no peak

119
Q

NPH onset

A

1-2 hours, peaks 4-12 hours, lasts 14-24 houra

120
Q

Regular onset

A

30 mins, peaks 2 hours, lasts 6-10 hours

121
Q

Rapid acting onset

A

15 min, peaks in 1-2 hours, lasts 3-5 hours

122
Q

Brand: Novolog

A

generic: aspart

RA, preferred bolus, less hypoglycemia

123
Q

Brand: Humalog

A

generic: lispro

RA, preferred bolus, less hypoglycemia

124
Q

Brand: Humulin R, Novolin R

A

generic: regular

SA, can be mixed with NPH (regular drawn up first because its clear)

125
Q

Brand: Humulin N, Novolin N

A

generic: NPH (CLOUDY)

intermediate acting

126
Q

Brand: levemir

A

generic: detemir

do not mix

127
Q

Brand: Lantus, Toujeo

A

generic: glargine

do not mix

128
Q

What is the typical starting dose for T1D?

A

0.5units/kg/day

TBW

50% basal, 50% bolus (3 meals)

129
Q

What is a requirement for switching to a pump?

A

prior experience with multiple daily injections

130
Q

Insulin pumps deliver what type of insulin

A 
rapid acting
(continous and bolus/ICR dosing)

~basal/long-acting

131
Q

Usual conversion between insulins are 1:1 except:

NPH dose BID –> Lantus or Basaglar dosed daily

A

use 80% of NPH dose

example: NPH 30 units AC breakfast and 20 units AC dinner = 50 units NPH daily
50x0. 8= 40 units Lantus or basaglar

132
Q

Usual conversion between insulins are 1:1 except:

Toujeo –> Lantus or Basaglar dosed daily

A

use 80% of the toujeo dose

133
Q

Humulin 70/30

what is the regular insulin?

A

70 - NPH

30 - regular

134
Q

All pens contain 3mL, EXCEPT:

A

Toujeo is concentrated glargine (U300), with two cartridge sizes = 1.5mL and 3mL

135
Q

Which insulin comes concentrated?

Rapid acting:

Humalog Kwikpen (Lispro):

Regular:

Humulin R (PEN & VIAL):

Long-acting –

Tresiba Flextouch pen (degludec):

Toujeo Solostar, Toujeo Max Solostar (Glargine):

A

Rapid acting: Humalog Kwikpen (lsipro): 200U/mL

Regular: Humulin R U500 Kwikpen AND vial: 500U/mL (20mL total)

Long-acting –

Tresiba Flextouch pen (degludec) 200U/mL

Toujeo SoloStar, Toujeo Max Solostar pens (glargine): 300U/mL (1.5mL and 3mL)

136
Q

What color is the cap to U500 insulin?

A

GREEN

U100 is orange

137
Q

Regular ICR … Rule of…

A

450

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

138
Q

Rapid acting ICR… rule of..

A

500

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

139
Q

What is the correction factor?

A

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

140
Q

Correction factor for REGULAR

A

1500 rule

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

141
Q

Correction factor for RAPID ACTING

A

1800 Rule

1800/TDD = correction factor for 1 unit of RA insulin

142
Q

Calculating the correction dose – both types use this forumula

A

BG now - target BG/ correction factor = correction dose

143
Q

Prior to each injection prime the needle by turning the knob how many units

A

2

144
Q

Insulin is best absorbed where

A

abdomen

alt: forarm, palm, thigh

145
Q

Novolog pen (aspart) - lasts at room temp how long

A

14 days

146
Q

What pen and vials last 56 days?

A

Degludec (tresiba) vial and pen)

Lantus vial and pen

147
Q

Humalog mixes vials pens last how long?

A

PENS= 10

VIALS = 28

humulin R vial = 31 days

148
Q

CGMS provide measurements of the glucose where?

A

interstitial fluid between the cells

149
Q

Drugs that inc BG

A 
BB
thiazide, loops
tacrolimus, cyclosporin
protease inhibitors
atiphyschotics (olanzapin, quetiapine)
statins
steroids
cough syrups
niacin
150
Q

Drugs that DEC BG

A 
linezolid
lorcaserin (Belviq)
Pentamidine
BB
quinolognes
tramadol
151
Q

What drugs can cause both inc or dec BG

A

quinolone and BB

152
Q

what is defined as hypoglycemia?

A

<70

153
Q

What sx of hypoglycemia are not masked from BB?

A

sweating and hunger

154
Q

Treatment if conscious

A

pure glucose - 15g then check

155
Q

treatment if unconscious

A

dextrose IV or glucagon 1mg SC, nasal spray

156
Q

BG >250
ketones, fruity breath
anion gap acidosis (arterial pH <7.35, anion gap>12)

what is this?

A

DKA

157
Q

confusion, delirum
BG >600, osmolality >320
extreme dehydration
pH>7.3, bicarb >15

what is this?

A

HHS

158
Q

Treatment for both DKA and HHS

A

fLUIDS!!!
NS then switch to D5W1/2NS when BG 200

watch for potassium

regular insulin infusion 0.1u/kg bolus, then 0.1u/kg/hr

sodium bicarb as needed

159
Q

when are TZDs taken?

A

morning

160
Q

GLP1RA which agents need needles to be purchased

A

Byetta, Victoza, Adlyxein

161
Q

Albuminuria is defined as

A

> 30mg/24 hr

162
Q

Recommended BG while in the hospital?

A

140-180

163
Q

Most insulins have how many units per mL?

A

100u/mL with 100mL (u-100)

164
Q

Toujeo

A

glargine

*comes in 1.5mL and 3mL cartridges

165
Q

Tresiba

A

degludec

166
Q

which insulin comes in U-500 both pen and vial? (higher risk of fatality)

A

regular U-500

167
Q

What insulin is stable at room temp for 28 days?

“LAG”

A

Humalog (lispro) vial, pen cartridge, mixes vials

Glargine (Basaglar) pen

Novolog (aspart) vial, pen, cartridge

Glulisine and lispro vial, pen

168
Q

What insulin is stable at room temp for 10 days?

“L”

A

Humalog (lispro) mixes PEN!!

169
Q

What insulin is stable at room temp for 31 days?

“HR”

A

Humulin R vial

170
Q

What insulin is stable at room temp for 14 days?

“HN”

A

Humulin N (NPH), N/R PENS

171
Q

What insulin is stable at room temp for 40 days?

“HR500”

A

Humulin R U-500 vial

172
Q

What insulin is stable at room temp for 42 days?

“NRND”

A

Novolin R (regular)
Novolin N (NPH)
Novolin N/R
Novolin 70/30 NPH

VIALS!

detemir (levemir) vial and pen

173
Q

What insulin is stable at room temp for 56 days?

“DG”

A

degludec (tresiba) vial and pen

Toujeo (glargine) pen

NAPLEX 21 (60 decks)

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