Diabetes Flashcards
fasting glucose diabetic diagnosis
126 or greater
2 hour 75 gram glucose tolerance test diabetic diagnosis
200 or greater
hba1c % for diagnosis of diabetes
6.5% or greater
prediabetes diagnosis a1c
5.7-6.4%
random plasma glucose of ____ or greater can also diagnose diabetes
200 or greater
diagnosis for gestational diabetes
two step strategy screening done 1) 50 gram oral glucose (non fasting) in 24th to 28th week of pregnancy, glucose measure after 1 hour -if value 140 or greater proceeds to 2nd step 2) full glucose tolerance test fasting! 100g sugar load test must meet 2 criteria -fasting >95 -1hour >180 -2 hour >155 -3 hour >140
one step GDM diagnosis
75 gram OGTT at 24 - 48 weeks after an overnight FAST of at least 8 hours
diagnosis made if any of the following criteria are made
- fasting 92 or greater
- 1h 180 or greater
- 2h 153 or greater
pre prandial goal
80-130
post prandial goal
<180
goal alc
less than 7
microalbumin in the urine
<30mg/24hr is what you want
eAG =estimated average glucose
6%=126
add 28.5 to get any other percent
ace or arb in diabetics if
microalbuminuria >30 mg/day or eGFR <60 ml/min
aspirin in diabetes in
history of stroke or MI
- 10 year risk score greater than 10 percent
- 50 or older with smoker, dyslipidemia, htn, FMH, albumineria)
statins in diabetes if >40
if >40 yes
- no risk factors: moderate
- risk factors: high
statins in diabetes less than 40
only if ascvd/ risk factors
risk factors for statins in diabetes
LDL 200 or greater HTN, Smoker, albumineria, FMH of ascvd
high int. statins
rosuvastatin (crestor) 20-40
atorvastatin (lipitor) 40-80
diabetic eye exam
annually
urine exam
annually
foot exam
check each visit
check for pulse and infection
diabetic foot infections
mild superficial infections (strep+mssa): cephalexin, dicloxacillin
if mrsa is a concern: doxy or bactrim
deeper infections add gram negative coverage and anaerobic coverage
trim toenails straight
across and check feet everyday
vaccines in DM
flu 6 months or older
pneumococcal 2 or older then again at 65
hep b age 19-59
hep b age
19-59
rapid acting insulins
lispro (humalog)
aspart (novolg)
glulisine (apidra)
rapid acting discard after
humalog
novolog
apidra
28 days
fiasp
insulin aspart works faster than other rapids (5 min quicker) 100u/ml
where to inject insulin
2 inch away from belly buttom
back of the arm
thigh
keep it in place, dont pull it out right away
rapids are used to
cover a meal should be clear onset 5-15 min peak 1-2 hours duration 3-5 hours
how many units of insulin are in a 3 ml pen
300 units
how many units of insulin are in a 10 ml vial
1000 units
who do you not use afreeza in
asthma/copd
afreeza is
rapid
effect of insulin on potassium
hypokalemia, brings potassium into the cell and out of the blood
used as a treatment for hyperkalemia
afreeza room temp for
unopened 10 days
opened strips 3 days
bring cartridge to room temp before using (10 min)
discard inhaler after 15 days
humulin R u-500
RX only!
5x as potent
vial 40 days
pen 28 days
humulin R and Novolin R are
regular insulins they are OTC onset is 30 min duration is 6- 8 hours THey are CLEAR because of the R (R is for regular) 100u/ml
humulin R room temp discard after
31 days
novolin R room temp discard after
42 days
intermediate acting insulins are OTC
NPH
Humulin N
Novolin N
NPH=clear or cloudy
cloudy
humulin N discard after
31 days
novolin N R discard after
42 days (6 weeks)
intermediated acting onset and duration
onset 2 hours
peak 6 to 8 hours, consider a snack after 6 hours after the dose
duration 10-16 hours
in combo insulins the bigger number is the ___ acting
longer acting
glargine cannot be
mixed with any other insulin product
long acting insulins are RX
detemir (levemir)
glargine (lantus, toujeo, basaglar, semglee)
degludec (tresiba)
tresiba room temp for
56 days
detemir (levemir) room temp for
42 days
levemir/ detemir can be QD or __
BID
toujeo is U-
300
when switching from toujeo to basaglar
reduce dose by 20 percent
tresiba is only
once daily
detemir flex touch pen
prime 2 units insert, press, hold in for 6 sec
all insulin glargine are given
qd
lantus room temp
28 days
nph to detemir (levemir)
1:1
nph once daily to lantus or toujeo
1:1
nph twice daily to glargine u-100
decrease dose by 20 percent and give glargine once daily
long acting to nph
1:1 and give BID
toujeo u-300 to lantus, basaglar, or levemir(detemir)
decrease dose by 20 percent and give QD
insulin is given
SC
regular insulin can be given
IV IM or SQ
rotate injection site with insulin to avoid
lipohypertrophy (lump of fat under skin)
use shortest __mm and thinnest __-__gauge for insulin
4mm, 29-32
type 1 starting insulin
0.5 u /kg/day
type 2 starting insulin
0.1-2u/kg/day (start with basal)
check glucose if high can add 1 unit per __ mg/dl above glucose goal
50mg;dl
pramlintide(symlin)
both type 1 and type 2 used as an adjunct to patients who use meal time insulin
pramlintide (symlin) should only be used if the patient is already on
insulin
pramlintide is a ____ line measure due to risk of hypoglycemia and cost
3rd
do not give symlin to patients with
alc >9
hypersensitivity to metacresol preservative
gastroparesis or gi motility meds like reglan
pramlinitide makes you feel ___
full thus causes severe nausea can also cause anorexia and weight loss
MOA of symlin
a synthetic analog of human amylinm, a naturally occuring hormone made by pancreatic beta cells. amylin is secreted with insulin from beta cells and lowers post prandial blood sugars
other things that symlin (pramlinitide) does
1) delays gastric empyting
2) INHIBITS post prandial blood glucose release
3) reduces appetite/weight loss
pramlinitide dosing
t1dm: 15mcg sq tid immediately before meals
t2dm: 60 mcg sq tid immediately before meals
SE of pramlinitide
nausea, anorexia, weight loss, SEVERE hypoglycemia
symlin room temp
discard after 30 days
storage room temp 28 days
humalog novolog apidra lantus bydureon
storage room temp 30 days
symlin
byetta
victoza
storage room temp 31 days
humulin R/N combos
storage room temp 42 days
Novolin R/N combos
Detemir (Levemir)
Room temp 56 days
glargine (toujeo)
10 days room temp pens
humalog mix
humulin mix
14 day pen storage
novolog mix
humulin N prefilled pen
28 day pen storage
novolin N flex pen
Humalog
Novolog
Lantus
42 day pen storage
Detemir (levemir)
hypoglycemia
blood sugar 70 or less
examples of fast sugar for hypoglycemia
5-6 life savers 2 cubes sugar 4 oz orange juice 6 jelly beans 3-4 glucose tablets
hypoglycemia and patient is unconcious
glucagon 1 mg sc/im/iv
or glucose (iv dextrose) if glucagon is unavailable
sick day management
insulin requirements increase with illness and infection
patient must inject insulin and check glucose every 3-4 hours
DKA
usually insulin dependent
caused by illness or noncompliance
ask if insulin has been ski[[ed look for signs of infection
signs and symptoms of DKA
FRUITY BREATH!
N/V, abdominal pain
how to treat DKA
hydrate: w/ 0/9% nacl
give insulin
give dextrose when glucose drops below 200 or 250
DKA tx
DIABETES
D dehydrated- hydrate w NS
I insulin (regular insulin, IV 0.1 u/kg/hr)
A acidosis
B bicarbonate
E electrolytes (monitor k, mg, po4, hco3)
T Time
E Electrolytes
S Sugar (when glucose drops below 200 or 250)
if hypoglycemic at 3am how to fix
symogi effect
decrease bedtime NPH
if hyperglycemic at 3am how to fix
dawn phen.
not decreasing insulin
hypoglycemia causes an increase in
NE and EPI
side effects make sense
sweating tachycardia
biguanide
metoformin
sulfonylureas
glimepiride
glipizide
glyburide
meglinitides
“glinides”
repaglinide (prandin)
nateglinide (starlix)
thiazolidinedones
“glitizones”
rosiglitizone
pioglitizone
GLP1 agonists
"tides" liraglutide lixisenatide exenatide semaglutide
dpp4 inhibitors
"gliptins" sitagliptin alogliptin linagliptin saxagliptin
SGLT2 inhibitors
“gliflozoins”
- canagliflozin
- dapaglifolzin
- empagliflozin
- ertugliflozin
alpha glucosidase inhibitors
acarbose
miglitol
dopamine agonist
bromocriptine (cycloset)
Metformin (biguanide) names
glucophage glucophage XR fortamet glumetza riomet
metformin MOA
decrease hepatic glucose production
decreases intestinal absorption of glucose
improves insulin sensitivity
metformin does not cause
- hypoglycemia
- weight gain
it causes weight loss and favorable lipid effects
glucophage max dose
2550 mg.day
fortamet max
2500 mg.day
glucophage XR max dose
2000 mg/day
glumetza max dose
2000 mg/ day
metformin SE
nausea low appetite---weight loss diarrhea--take w food to decrease upset stomach decrease vit b12 lactic acidosis metallic taste PREG CAT B
metformin CI in eGFR
30, initiation not rec. w eGFR 30-45
D/C metformin before an iodinated contrast imaging procedure in patients with egfr <60 or history of
liver disease
alcoholism
HF
sulfonylureas MOA
increase insulin secretion from pancreatic beta cells
sulfonylureas SE
weight gain due to increase insulin
hypo glycemia due to increase insulin
take with first meal of the day
metformin does not
secrete insulin
metformin/pioglitazone
actoplus met
metformin/sitagliptin
janumet
metformin/canagliflozin
invokanamet
ER formulations of metformin leave a
ghost tablet
lactic acidosis risk increases with
renal disease
1st line in pregnancy
insulin
glimepiride brand
amaryl max 8 mg
glipizide brand
glucotrol/ glucotrol xl use if renal impaired
glyburide brand
glynase (do not use in renal or hepatic impairment)
___ and ___ sulfonylureas are on the beers criteria for patients that are >65
glyburide and glimepiride, use glipizide (glucotrol) for patients greater than 65
Amaryl (glimepiride)
1-2 mg QD max 8 mg
metabolized 100 percent by the liver
safe in renal failure , dose must be reduced- glipizide is first choice
Glucotrol (glipizide)
max dose 20 mg BID (40 mg QD) glipizide ER (glucotrol xl): max 20 mg qd - oros ghost tablet
DOC in RENAL and elderly if using a sulfonylurea
IR- TAKE 30 min before first meal of day
Glynase (glyburide)
high risk with elderly becuase it is sooo long acting avoid in patients 65 or older
do not use in renal or hepatic failure
repaglinide brand
prandin
nateglinide
starlix
meglinide MOA
stimulate insulin secretion from beta cells
mostly affect postprandial glucose
meglinides SE
weight gain
hypoglycemia
dose adjust in renal impairment
most important thing with meglinides (prandin, starlix) (repaglinide, nateglinide)
if a meal is missed or added omit or add a dose accordingly, give before meals :)
pioglitazone
actos ( i p when i act)
rosiglitazone
avandia
tzds MOA
insulin sensitizers
increase skeletal muscle cell sensitivity to insulin
TZDs boxed warning
avoid with heart failure
TZDs warnings
hepatic failure
edema
can cause or worsen heart failure
bone fractures
can stimulate ovulation (may need contraception)
avoid with history of bladder cancer (pioglitazone)
which TZD increases lipids
rosiglitazone (avandia)
which tzd decreases TGs
pioglitazone (actos)
dont give TZDs with
insulin
liraglutide brand
victoza QD
lixisenatide
adlyxin QD
exenatide
byetta BID
exenatide ER
bydureon once weekly
dulaglutide
trulicity once weekly
semaglutide
ozempic once weekly
semaglutide
rybelsus tabs PO QD
GLP1 agonists “tides” MOA
- slows down gi motility
- decrease appetite- weight loss
- decrease glucagon
- increase insulin
GLP 1 agonist SE
G- gi symptoms, gall bladder disease L-weight Loss P-pancreatitis 1- thyroid tumors- boxed warning A- acute renal failure and chronic renal failure exacerbation
do not use GLP1 with
DPP4, so no tides with gliptins
boxed warnings for GLP1s “tides”
do not use if personal family hx of medullary thyroid cancer (MTC)
do not use if hx of multiple endocrine neoplasia (MEN2)
saxenda max
victoza max
saxenda weight loss 3 mg
victoza DM 1.8 mg
must dispense needles with
byetta, victoza, adlyxin
needles are provided with
weekly insulin
dulaglutide is given
once weekly
bydureon, trulicity, ozempic come with or without needles
with
do you give GLP 1s in end stage renal disease
no
exenatide (byetta) is given
BID (6 hours apart) 60 min before meals
exenatide CI in crcl
<30
exenatide ER (bydureon, bydureon BCise) given
weekly must mix either 15 sec or 80 sec
trulicity (dulaglutide) given
once weekly
room temp 14 days
semaglutide (ozempic and rybelsus)
ozempic (SQ once weekly)
rybelsus (tabs) 3mg then up to 7-14 mg after 30 days
rybelsus special things
take on empty stomach
store in original pack
byetta/bydureon CI
GFR <30
victoza avoid in (liraglutide)
ESRD
adlyxin avoid in
crcl <15 ESRD
ozempic (semaglutide) no dosage adj nes. in
renal impairment
trulicity avoid in
ESRD
DPP 4 Inhibitors (gliptins) are usually
add on therapy
dpp 4 Is
SALSa:JNTO Sitagliptin: januvia Alogliptin: Nesina Linagliptin: tradjenta Saxagliptin: onglyza
sitagliptin brand
januvia
alogliptin brand
nesina
linagliptin brand
tradjenta
saxagliptin brand
onglyza
SE with DPP ivs gliptins
joint Pain (arthralgia) Pancreatitis
how to take DPPIVs
with or without food
brands together DPPIVs (4)
januvia
nesina
tradjenta
onglyza
all are oral!
DPP4 MOA
- Pancreas: GLP1 and GIP cause increase insulin release and decrease glucagon release both leading to decrease blood glucose
(inhibit you from metabolizing GLP 1, so you have more of it) - liver: decrease release of glucose
- feeling of fullness: reduce food intake
- slow down the absorption of glucose from the GI
DPP4 on weight
neutral
dose adjust all dpp 4s except
linagliptin (tradjenta)
avoid saxagliptin (onglyza) and alogliptin (nesina) in
HF
linagliptin (tradjenta) can be given in
RENAL
4 drugs to not given in HF
saxagliptin, alogliptin, rosiglitazone, pioglitazone
which two DPP 4s are cyp 3a4 substrates
linagliptin (tradjenta)
saxagliptin (onglyza)
janumet, janumet XR
sitagliptin+metformin
all SGLT2s are
QD in the morning! or will be peeing all night
canagliflozin
invokana
empagliflozin
jardiance
dapaglifozin
farxiga
ertugliflozin
steglatro
sglt2 brands together
invokana
jardiance
farxiga
steglatro
SGLT2 side effects
S
G- genital yeast infections
L-increase Ldl, Lower weight, Lower BP, Labs: increase K, mg, po4
T-bone fracTures
Once daily in the morning
- KETOACIDOSIS (peeing out sugar)
- Necrotizing Fascitits
-diuretic effect (weight, bp)
SGLT2s work on the
proximal renal tubule to increase glucose excretion
benefits of canagliflozin
reduces cv events, ckd progression, HF
(good for kidneys and heart)
black box warning for increase risk of lower limb amputations
flozins are CI if crcl is less than what
30
invokana (canagliflozin) do not use if CRCL less than
30
canagliflozin dose (invokana)
100 mg QD before first meal
can increase to 300 mg qd before first meal
invokamet
canagliflozin/metformin
canagliflozin (invokana) cautions
increase scr genital yeast infections weight loss hypotension increase LDL increase potassium bone fracTures hypoglycemia - not alone but when combined with insulin or secretagoues ketoacidosis necrotizing fascitits increase risk of lower limb amputations
flozins protect the ___ like aces
kidneys
it has renal protection!
watch sglt2s with other meds that increase
potasssium
stop sglt2s 3 days before
surgery, to decrease risk of ketoacidosis
dapagliflozin not recommend in crcl less than
45
xigduo
dapagliflozin/metformin
dapagliflozin is FDA approved for ___ as an adjunctive agent for patient with reduced ejection fraction with or without diabetes
HF
can use this for heart failure they dont have to have diabetes to use it
ertuglaflozin do not use if egfr is less than
60
empagliflozin (jardiance) reduces what
major cv events and progression of HF and CKD
alpha glucosidase inhibitors
1
2
acarbose (precose)
migitol (glyset)
alpha glucosidase inhibitor MOA
inhibit alpha glucosidase enzymes of the proximal SMALL INTESTINE BRUSH BORDERS
prevent the breakdown of polysaccarhides (sucrose) to monosaccharides (glucose and fructose)
do not prevent but delay absorption
- BIND TO SUCROSE*
- if you skip a meal skip this
acarbose brand
precose
migitol brand
glyset
alpha glucosidase inhibitor if hypoglycemic on these take ___ or ___ not ___
fructose or lactose
not sucrose
the sucrose will just bind and not get absorbed
so no table sugar!
orange juice and milk okay
bromocriptine (cycloset) increases what
dopamine, it’s also used in parkinsons
wouldnt give bromocriptine or cycloset in ___
schizoprenia
bromocriptine inhibits the production of
MILK
avoid in lactating mothers
increasing dopamine decreases
prolactin
cinnamon helps with
type 2 diabetes
not for long term only short term 4 months
decrease in b12 gives what type of anemia
macrocytic anemia
2nd line therapies after metformin for diabetes
sulfonylureas: hypoglycemia and weight gain
glitazones: actos and avandia (weight gain, fluid retention, HF, liver failure, decrease bone density)
insulin: recommended for initial therapy when fasting glucose if over 250 or a1c is 9-10 can also be an add on
when to initiate insulin first
fasting glucose over 250
OR
a1c 9-10
For patients who are close to their a1c gaol but have high post prandial glucose:
meglitinides: do not use with sulfonylureas glp 1 agonists: lose weight dpp4 inhibitors: weight neutral sglt2: weight loss alpha glucosidase inhibitors: GI SE
TZDs are through the
LIVER
diabetes in pregnancy gold standard
insulin
collagenase:santyl
topical ointment that uses enyzmes to remove dead skin and necrotic tisse from wounds and does not harm healthy tissue
rayos generic
prednisone
parlodel generic
bromocriptine for parkinsons and diabetes
dexilant generic
dexlansoprazole
can steroids and ppis increase the risk of bone fractures
yes
vials have how many units of insulin
1000 u
pens how many units of insulin
300 u
DM meds with CV benefit
liraglutide
canagliflozin
empagliflozin
DM meds with HF benefit
canagliflozin
empagliflozin
dapagliflozin
niacin (vitamin b3) can cause
hypergylcemia increase blood glucose
which meds can reduce insulin sensitivity in women with pcos
tzds and metformin
do not mix symlin (pramlinitide) with any
insulin
metformin is CI with active ___ disease and __ is checked at baseline
liver disease
LFT
exenatide er can cause severe
skin lesions (nodules) injection site reaction
beta blockers block signs of hypoglycemia (shaking, anxiety, palpitations) but which two can still be present
sweating and hunger
DKA signs
fruit breath, N/V, BG greater than 250, ketones in the urine or blood, anion gap acidosis
what medication is CI in patients with gastroparesis
pramlinitde
type 1 diabetes has __ c peptide levels
low
quinolones can increase
blood glucose
target BG in the hospital
140-180
HHS causes severe
dehydration, most common in type 2, ketones not usually present in urine
hpyoglycemia what to treat
8 oz milk 3-4 glucose tabs 4 oz soda 4 oz oj 1 tbsp honey 1 serving glucose gel
15-20 grams of carbs
insulin available as 200u/ml
insulin lispro and degludec
medications that can cause drug induced diabetes
systemic steroids
protease inhibitors
antipsychotics
fat into ketones is
DKA
what test is used in pregnancy for testing for GDM
oral glucose tolerance testr
hypergylcemia can cuase
Microvascular:
retinopathy-vision loss
nephropathy- kidney impairment/failure
neuropathy- loss of feeling—amputations
autonomic neuropathy- erectile dysfxn, gastroparesis, UTIS
Macrovascular: Atherosclerosis-ASCVD CAD: including MI CVA: including Stroke PAD: amputations
*depression and DKA,HHS
3 Ps for hyperglycemia
other symptoms also
polyuria( increase urination)
polydypsia (increase thirst)
polyphagia (increae hunger)
fatigue, blurry vision, ED, vaginal fungal yeast infections
when to test for diabetes what age
45
also test if one risk factor and bmi 25 or greater (physical inactivity is a risk factor lol)
a1c is measured every __ months if not at goal
3 months
and 6 months if at goal
pre meal pregnant goal
95 or less
1 hour
2 hour
post meal pregnant goal
1 hour 140 or less
2 hour 120 or less
aspirin dose for DM
75-162mg usually 81mg
natural products for DM
cinnamon
alpha lipoic acid
chromium
If CVD major issue use:
dulaglutide, liraglutide, semaglutide
If renal allows can use: empagliflozin, canagliflozin
HF or CKD major issue use:
empagliflozin, canagliflozin, dapagliflozin
if renal doesnt allow for that use
dulaglutide, liraglutide, semaglutide
never use what two together
glp 1 (tide) and dpp 4 (gliptin)
do not use ___ with heart failure
alogliptin (nesina) or saxagliptin (onglza)
how many units a day when starting a type 2 on it
10 units or 0.1 to 0.2 u/kg/dau at bedtime of basal
2 common things with metformin, GLP1s, and SGLt2s
weight loss and no hypoglycemia
byetta and adlyxin give within
60 min of meals other give anytim
symlin (pramlinitide) has a boxed warning for
and its CI in
severe hypoglycemia
gastroparesis
decrease meal time insulin dose by 50%
used with meals
insulin does what to potassium
hypokalemia
hyperkalemia with
canagliflozin
renal insuffiency avoid (CRCL <30)
metformin, SGLT2I, exenatide, glyburide
can you use afrezza in smokers
no
increase risk of heart failure when taking rosiglitazone with ____ do not use together
insulin
inject rapids how many minutes before eating
5-15 min before
regular is injection how soon before meals
30 minutes
iv regular insulin should be given in what type of container
non pvc container
nph is
humulin N, novolin N
do not mix long actings with
any other insulin
toujeo has how many units per ml in the pen and comes in what pen sizes
300 u/ml
comes in 1.5 ml- 450 u/ml
comes in 3 ml- 900 u/ ml
insulin that comes concentrated
humalog kwikpen (lispro)- 200u/ml
humulin r u-500 kwik pen and vial- 500 u/ml
tresiba flex touch pen (degludec) 200 u/ml
toujeo solostar, max star pens (glargine) 300 u/ml
humulin r u-500 comes in a __ ml
20 ml and has 10,00 u of insulin
use 0.3 ml syringe for
up tp 30 units
use 0.5 ml syringe for
30-50 units
use 1ml syringe for
51- 100 units
beta blockers can cause
hypo or hyper glycemia
drugs that can cause hyperglycemia
thiazides and loops tacrolimus, cyclosporine protease inhbitors quinolones antipsychotics statins steroids cough syrups niacin
quinolones can cause
hypo or hyperglycemia
drugs that can cause hypoglycemia
linezolid lorcaserin (belviq) pentamidine beta blockers quinoloines tramadol
tramadol and linezolid can decrease
blood glucose
hypoglycemia symptoms
dizziness anxiety irritability shakiness headache diaphoresis (sweating) hunger confusion nausea ataxia tremors tachycardia palpitations blurred vision
severe hypoglycemia can cause
seizures coma and death
