Diabetes Flashcards
Symptoms of hyperglycemia
polyuria (excessive urination) polydipsia (excessive thirst) weight loss polyphagia (increased hunger) headache blurred vision
diuretics in DM
can cause worsening of glucose control
dosing of sulfonylureas
start at lowest dose and titrate up as needed
Patient criteria for tx with sulfonylurea
disease duration <5 years
no hx of insulin or good glycemic control on <40u/d
close to normal body weight
FPG <180
most important adverse effect of sulfonylureas
hypoglycemia
in younger patients hypoglycemia can be associated with alcohol abuse and overexertion
Sulfonylureas and nursing
all but glyburide (B) are pregnancy category C
do not take while nursing
contraindications for sulfonylureas
sulfa allergy
Metformin mechanism of action
does not stimulate insulin secretion and is therefore not a hypoglycemic
inhibits hepatic glucose production and intestinal glucose absorption and improves peripheral sensitivity to insulin
Dosing metformin
initially 500-850 1-2 times daily
can increase every 1-2 weeks to a max dose of 2550mg/d
do not increase any more frequently than weekly
contraindications to metformin
severe renal insufficiency
alcoholics
children
dehydration
metformin and iodine
dc prior to receiving and until at least 48h after d/t impairment of renal
adverse reactions to metformin
GI side effects should subside with continued therapy
lactic acidosis
signs of lactic acidosis
late-onset vomiting/diarrhea
unusual drowsiness, extreme fatigue, muscle aches, or unexplained hyperventilation
metformin and cimetidine
increases hypoglycemia risk
metformin and glucocorticoids or alcohol
increases risk for lactic acidosis
thiazolidinediones (TZDs) mech of action
reduces resistance at sites of insulin action without directly stimulating in sulin secretion from pancreatic beta cells
Administration of metformin
Take with meals
administration of TZDs
take with the main meal of the day
TZD drugs
rosiglitazone (Avandia)
pioglitazone (Actos)
unique to rosiglitazone
may see small increases of HDL and LDL
concern specific to pioglitazone
increased risk of bladder cancer
may reduce concentration of birth control
TZD and ovulation
may restore menses in previously anovulatory premenopausal women
contraindications for TZDs
HF
active liver disease
symptoms of liver failure to assess for with TZDs
abdominal pain fatigue n/v jaundice dark urine
drugs to use with caution with TZDs
digoxin warfarin fexofenadine midazolam nifedipine
a-Glucosidase inhibitors mech of action
slows absorption of carbs from the intestines minimizing the post-prandial rise in BG
why are a-glucosidase inhibitors not often used as monotherapy
limited ability to lower A1C and side effect profile
administration of a-glucosidase inhibitors
should be taken with the first bite of each meal
contraindications to a-glucosidase inhibitors
IBD, colonic ulceration, obstructive bowel disorders, chronic intestinal disorders of digestion/absorption, nursing, liver cirrhosis (Acarbose in particular)
a-glucosidase drug interactions
may decrease levels of propranolol and ranitidine
meglitinide analogs mech of action
rapid-acting
stimulate release of insulin from the pancreas in response to a meal
meglitinide analog drugs
repaglinide (Prandin)
nateglinide (Starlix)
Administration of meglitinide analogs
15-30 min prior to meals
contraindications for meglitinide analogs
DM1 DKA severe infection, surgery, trauma, or other severe stressors pregnant/nursing children
dipeptidyl peptidase-4 inhibitors (DPP4-i) drugs
sitagliptin (Januvia) saxagliptin (Onglyza) linagliptin (Tradjenta) vildagliptin (Galvus) alogliptin (Nesina)
contraindications for DPP4-i drugs
Type1 DM
pancreatitis hx (sitagliptin)
caution with renal impairment
most common adverse effects of DPP4-i drugs
URI, UTI, HA
mech of action of incretins
stimulate glucose-dependent secretion of insulin from pancreatic beta cells while supressing the inappropriate release of glucagon from alpha cells. Slows gastric emptying and increases satiety
Increntins (GLP-1R) drugs
exenatide (Byetta, Bydureon)
liraglutide (Victoza)
albiglutide (Tanzeum)
dulaglutide (Trulicity)
exentaide (Byetta) missed dose
restart treatment at next scheduled dose time
injection administered 60 minutes prior to morning and evening meal and spaced more than 6 hours apart
Liraglutide (Victoza) dosing
initial dose 0.6mg not effective for glycmic control but must be administered for 1 week to lessen GI symptoms. Once tolerated, increase dose to 1.2mg. Max is 1.8mg
Administration of Exenatide ER (Bydureon)
dosed once weekly with no adjustment for renal impairment
contraindications to Incretins (GLP-1R)
Type1 DM, DKA, allergy, severe GI disorders including gastroparesis, pregnancy/nursing
Liraglutide should not be taken if there is a personal/family hx of medullary thyroid cancer or mutliple endocrine neoplasia syndrome type 2
exenatide is associated with pancreatitis (fatal and nonfatal)
Incretins drug interactions
do not administer close to drugs with narrow therapeutic window due to decrease in gastric emptying
close monitoring of INR when on warfarin
exenatide can reduce effectiveness of birth control if administered within 1 hour of each other.
dopamine receptor agonist drug
bromocriptine mesylate (Cycloset)
What should you notify your provider about in relation to bromocriptine mesylate (Cycloset)
symptoms of orthostatic hypotension
contraindications of bromocriptine mesylate (Cycloset)
nursing women
bromocriptine mesylate (Cycloset) interactions
can exacerbate psychotic disorders or decrease effectiveness of meds
not recommended for use with other dopamine receptor agonists fo tx of:
Parkinson’s, restless leg, acromegaly, etc.
amylin analog
Pramlintide (Symlin)
synthetic of pancreatic hormone amylin that is cosecreted with insulin in response to food
injectable medication
mech of action of Pramlintide (Symlin)
- delays gastric emptying wich delays rise in postprandial glucose release
- then alters the release of additional inappropriate glucagon by pancreatic alpha cells
- increases satiety wich decreases overall caloric intake and promotes weight loss
Pramlintide (Symlin) can treat type1 or type 2 DM
dosage of Pramlintide (Symlin) in Type1 DM
15mcg prior to any major meal
titrated up in 15mcg increments to a max dosee of 30-60mcg
dosage of Pramlintide (Symlin) in Type2 DM
60mcg just prior to any major meal
dose is increased to 120mcg in 3-7 days if there is no nausea
Pramlintide (Symlin) and insulin
Insulin has to be reduced by 50% in both Type1 and Type2
contraindications to Pramlintide (Symlin)
poor compliance to diabetic regimens
HgbA1C>9%
taking meds that increase gastric motility
pediatrics
Pramlintide (Symlin) interactions
cannot mix with insulin
other interactions on p.797
SGLT2 inhibitors drugs
empagliflozin (Jatdiance)
canagliflozin (Invokana)
dapagliflozin (Farxiga)
SGLT2 inhibitors mech of action
causes more glucose to be secreted into urine rather than be reabsorbed in the kidney
SGLT2 inhibitor contraindications
Type1 DM
DKA
severe kidney disease
hemodialysis
adverse event of SGLT2 inhibitors
hyperkalemia mycotic infections UTI renal insufficiency can cause increased urinary frequency
hypotension with SGLT2 inhibitors
may be increased with low volume status (diuretics, ACEIs, ARBs)
very rapid-acting insulin
Humalog (lispro)
Novolog (aspart)
Glulisine
short-acting insulins
Humulin R
Novolin R
intermediate-acting insulin
NPH
long-acting insulin
lantus (glargine)
Levemir (detemir)
Toujeo
Humulin U
basal insulins
NPH
glargine
detemir
bolus insulin
regular
lispr
aspart
general calculation for starting insulin therapy
0.55 x Total weight in kg = total units of insulin per day
two ways to start insulin
may be supplemental or in addition to oral agents (typically singel daily injections started between 10-20u)
may be sole therapy in at least 2 injections daily usually before breakfast and dinner or bedtime
dosing insulins mixed with long-acting, intermediate-acting, or premixed formulations
dosed twice daily prior to breakfast and dinner
combination insulins
70/30 (NPH/regular)
50/50 (NPH/regular)
75/25 (NPL/lispro)
70/30 (NPA/aspart)
guidelines for insulin daily doses in lieu of empiric estimations
children/adults: 0.5-0.6u/kg/day
adults during illness or adolescents: 0.5-0.75u/kg/day
adolescents during growth spurt: 1.25-1.5u/kg/day
pregnancy: 0.7u/kg/day
Recommendations for dosing twice daily insulin
2/3 in am with a 2:1 ratio of intermediate- to short-acting insulin
1/3 with dinner with a 1:1 ratio of short acting and intermediate acting insulin
adjusting insulin doses based on clinical response
table 46.5 on p. 801
insulin sensitivity factor calculation
ISF = 1500/TDD
if you take 50u insulin in 24 then: 1500/50=30
Each unit of insulin lowers BG by 30mg/dL
what is the insulin sensitivity factor used for
To help you decide how many units of insulin to adjust
dawn phenonmenom
worsening hyperglycemia in the early morning hours caused by growth hormone surges while sleeping
somogyi effect
rebound hyperglycemia that occurs after an early morning episode of insulin-induced hypoglycemia
symptoms of hypoglycemia while sleeping
night sweats, nightmares, sleep disturbances, early morning headaches
most common drugs that potentiate insulin effects
salicylates beta-blockers MAOIs alcohol sulfa drugs
most common drugs that antagonize insulin
corticosteroids isoniazid niacin estrogens thyroid hormones thiazides phenothiazines sympathomimetics
indications for continuous glucose monitoring (CGM)
frequent hypoglycemia
hypoglycemia unawareness
elevated HgbA1C despite multiple treatment plan adjustments
red flag for Type2 DM in adolenscents
acanthosis nigricans (dark pigmentation in skin creases and flexural area) this is a sign of insulin resistance
presentation of children with Type1 DM
inapropriate polyuria, dehydration, poor wight gain, ketonuria
insulin therapy dosages for children
- 7mg/kg before puberty
- 0mg/kg midpuberty
- 2mg/kg after puberty
only DM drugs approved for children
insulin
metformin
potential neonatal complications of gestational DM
shoulder dystocia, hypoglycemia, polycythemia, respiratory distress
first-line insulin therapy for Type1 DM
basal at night with rapid prior to meals
1st line insulin dosing for type1 DM
0.5-0.6u/kg/d
25-50% given as basal insulin once daily
prandial insulin distribution: 40% before brakfast, 30% prior to lunch, 30% prior to dinner
1st line therapy for DM 2 with HgbA1C <7.5
monotherapy with an oral agent
Biguanide, GLP1, DPP4i or AGi
when are biguanides the agent of choice for monotherapy
Type2DM with HgbA1C<7.5
patients with metabolic syndrome
BG levels are <250
When are AGi (a-glucosidase inhibitor) used as monotherapy
Type2 DM with HgbA1C<7.5
postprandial hyperglycemia but only mild fasting glucose elevations
combo therapy recommended for HgbA1C >8
sulfonylurea and biguanide
what must be monitored in combo treatment with a biguanide and TZD
liver and renal function
Look at tables 46.6-46.10 on pages 803-805
and
figure 46.2 on p. 804
