Diabetes Flashcards
1
Q
What is the central problem in all types of diabetes?
A
The central problem in all types of diabetes is that blood glucose (BG) remains high (hyperglycemia) due to decreased insulin secretion from the pancreas, decrease insulin sensitivity, or both. Chronic hyperglycemia can lead to damage throughout the body, including organ and nerve damage
2
Q
What is insulin and what is it responsible for??
A
Insulin is a hormone produced by beta-cells (also called islet cells) in the pancreas. It is responsible for moving glucose out of the blood and into body cells to be used as energy. The glucose is either moved to muscle cells (primarily) for immediate use, or stored for later us by liver cells (as glycogen) or adipose (fat) cells
3
Q
What is glucagon and what is it responsible for?
A
Glucagon is produced by alpha-cells in the pancreas and works when BG is low. Glucagon pulls glucose back into the circulation by releasing glucose from glycogen. If glycogen is depleted, glucagon will signal fat cells to make ketones as an alternative energy source
4
Q
What is type 1 diabetes?
A
Type 1 diabetes is caused by an autoimmune destruction of beta-cells in the pancreas. Once the beta-cells are destroyed, insulin cannot be produced.
5
Q
What is a possible complication of type I diabetes?
A
Without insulin, glucose cannot enter muscle cells. The body goes into starvation mode, and starts to metabolize fat into ketones to use as an alternative energy source. Ketones are very acidic. Very high ketone levels can cause diabetic ketoacidosis (DKA) which is a medical emergency
6
Q
When is TID typically diagnosed?
A
Most TID is diagnosed in children, but it can develop at any age. Family history is the biggest risk factor
7
Q
What is the C-peptide test and how can it be used to diagnose TID?
A
The C-peptide test is used to determine if the patient is still producing insulin. C-peptide is released by the pancreas only when insulin is released. TID is diagnosed when there is a very low or absent (undetectable) C-peptide level
8
Q
How should patients with TID be treated?
A
Patients with TID must be treated with insulin and should be screened for other autoimmune disorders
9
Q
What is type 2 diabetes?
A
Type 2 diabetes is due to both insulin resistance and insulin deficiency. the pancreatic beta-cells produce less insulin over time as they become damaged
10
Q
What is T2D typically associated with?
A
Obesity, physical inactivity, family history and the presence of other comorbid conditions
11
Q
How is T2D typically treated?
A
T2D is usually diagnosed in older patients and can be managed with lifestyle modification alone (in a small number of patients) or in combination with oral and/or injectable medications
12
Q
What is prediabetes?
A
Prediabetes means there is an increased risk of developing diabetes. In prediabetes the BG is higher than normal, but not high enough for diabetes diagnosis.
13
Q
What can reduce the risk of progression from prediabetes to diabetes?
A
Following dietary and exercise recommendation
14
Q
How can Metformin be helpful in prediabetes?
A
Metformin can be used to help improve BG levels, especially in patients with a BMI > 35, age < 60 years and women with a history of gestation diabetes.
15
Q
What are the two types of diabetes in pregnancy?
A
Diabetes that was present prior to becoming pregnant or diabetes that developed during pregnancy
16
Q
What happens to babies born to mothers with hyperglycemia during pregnancy?
A
Babies are larger than normal (macrosomia) and are at high risk for developing obesity and diabetes later in life
17
Q
When are most pregnant women tested for GDM and what test do they use?
A
Most pregnant women are tested for GDM at 24-28 weeks gestation using the oral glucose tolerance test (OGTT)
18
Q
How should diabetes in pregnancy be treated?
A
Hyperglycemia, if present, should be treated first with lifestyle modifications (diet and exercise). If medication is needed, insulin is preferred. Metformin and glyburide are sometimes used
19
Q
What are some major risk factors of diabetes?
A
Physical inactivity, overweight (BMI > 25 or 23 in Asian-Americans), high risk race or ethnicity (African-American, Asian-American, Latino/Hispanic Americans, Native American or Pacific Islander), History of gestational diabetes, A1C > 5.7, first-degree relative with diabetes. HDL < 35 mg/dL or TG > 250 mg/dL, hypertension, CVD history or smoking history, conditions that cause insulin resistance (acanthosis nigricants, PCOS)
20
Q
What are the classic symptoms of hyperglycemia?
A
Polyuria (excessive urination), polyphagia (excessive hunger or increased appetite), polydipsia (excessive thirst)
21
Q
What are other symptoms of diabetes?
A
Other symptoms include fatigue, blurry vision, erectile dysfunction and vaginal fungal infections
22
Q
When should people be screened for diabetes?
A
Everyone, even those with no other risk factors, should be tested beginning at 45 years old. All asymptomatic children, adolescents and adults who are overweight, with at least one other risk factor should be tested. If the result is normal, repeat testing every 3 years
23
Q
What are the three types of test used to identify if prediabetes or diabetes is present?
A
1) Hemoglobin A1C indicates the average BG over approximately the past 3 months
2) Fasting plasma glucose (FPG) gives the BG at that moment, and is taken after fasting for > 8 hours
3) The OGTT determines how well glucose is tolerated by measuring the BG level 2 hours after drinking a liquid that is high in sugar (glucose)
24
Q
What A1c indicates prediabetes?
A
5.7-6.4
25
What A1c indicates diabetes?
> 6.5
26
What FPG is considered prediabetes?
100-125
27
What FPG is considered diabetes?
> 126
28
What OGTT result is prediabetes?
140-199
29
What OGTT results shows diabetes?
>200
30
What is the A1c goal of someone who has diabetes and is not pregnant?
< 7
*An A1c goal of < 6.5% may be acceptable if it can be reached without significant hypoglycemia. A less-stringent goal of < 8% may be appropriate (e,g, if severe hypoglycemia, or with a limited life-expectancy)
31
How often should A1c be measured?
Quarterly (every 3 months) if not yet at goal or biannually (every 6 months or twice per year) if at goal
32
What is the estimated average glucose (eAG)?
The estimated average glucose (eAG) is an interpretation of the A1C value that makes it appear similar to a glucose meter value. An A1c of 6% is equivalent to an eAG of 126 mg/dL. Each additional 1% increases the eAG by ~28 mg/dL
33
What are some lifestyle modifications recommended for patients with diabetes?
Weight loss, individualized medical nutrition therapy, physical activity, smoking cessation
34
What is the goal waist circumference?
Goal waist circumference is < 25 inches for females and < 40 inches for males
35
How much weight should overweight or obese patients be encouraged to lose?
> 5%
36
What are some recommendations with individualized medical nutrition therapy?
- Consume natural forms of carbohydrates and sugars
- Avoid alcohol or drink in moderation
- Patients with TID should use carbohydrate-counting where the prandial (mealtime) insulin dose is adjusted to the carbohydrate intake
37
What is considered a carbohydrate serving?
A carbohydrate serving is measured as 15 grams, which is approximately one small piece of fruit, 1 slice of bread or 1/3 cup of cooked rice/pasta
38
How much physical activity should patients with diabetes perform?
- Perform at least 150 minutes of moderate-intensity aerobic activity per week spread over at least 3 days
- Reduce sedentary (long hours of sitting) habits by standing every 30 minutes, at a minimum
39
What is recommended in terms of smoking cessation with diabetes patients?
Encourage all patients who smoke to quit
40
What is the goal of treating diabetes?
Treatment is aimed at preventing the long-term complications of diabetes
41
What are the categories of complications of diabetes?
Microvascular or macrovascular
42
What is considered microvascular disease?
Retinopathy, diabetic kidney disease, peripheral neuropathy, increased risk of foot infections and amputations, autonomic neuropathy
43
What is considered macrovascular disease?
Coronary artery disease, cerebrovascular disease, peripheral artery disease
*Macrovascular disease is the same as atherosclerotic cardiovascular disease
44
What does the American Diabetes Association generally recommend for monitoring, preventing and treating complications of uncontrolled diabetes?
Antiplatelet therapy, cholesterol control, diabetic retinopathy monitoring, vaccinations, neuropathy monitoring, blood pressure control, foot care counseling, diabetic kidney disease
45
What is the antiplatelet therapy recommendation for diabetes patients?
- Aspirin 75-162 mg/day (usually given as 81 mg/day) is recommended for ASCVD secondary prevention (if allergy, use clopidogrel 75 mg/day)
- Not recommended for primary prevention (in most); the risk of bleeding is about equal to the benefit. Can consider if high risk
- CAD/PAD: aspirin + low-dose rivaroxaban can be added
- Used in pregnancy to decrease risk of preeclampsia
46
What is the recommendation for monitoring for diabetic retinopathy?
Eye exam with dilation at diagnosis. If retinopathy, repeat annually. If not, repeat every 1-2 years
47
What is the recommendation for cholesterol control in patients with diabetes?
- High intensity statin: diabetes + ASCVD or Age 50-75 years with multiple ASCVD risk factors
- Moderate intensity statin: diabetes + age 40-75 years with no ASCVD or diabetes + age < 40 years + ASCVD risk factors
- Add-on treatment: Ezetimibe if ASCVD 10-yr risk > 20% or Vascepa if LDL is controlled by TGs are 135-499 mg/dL
- Monitoring: lipid panel annually and 4-12 weeks after starting a statin or increasing the dose
48
What are the recommended vaccinations for patients with diabetes?
Required in addition to all childhood vaccines: Hepatitis B virus series, influenza annually, pneumovax 23 (1 dose between ages 2-64, and another dose at age > 65)
49
What is the blood pressure goal of patients with diabetes?
< 130/80 if ASCVD or 10 year risk > 15% or <140/90 acceptable if ASCVD risk < 15%
50
What is the treatment recommendation for blood pressure control of patients with diabetes?
- No albuminuria: thiazide, CCB, ACE inhibitor or ARB
- Albuminuria: ACE inhibitor or ARB
- CAD: ACE inhibitor or ARB
51
What is the recommendation for neuropathy monitoring for patients with diabetes?
- Annually: a 10-g monofilament test and 1 other test to assess sensation (feeling)
- Comprehensive foot exam at least annually. If high-risk, refer to podiatrist
52
What are possible treatment options for neuropathy for patients with diabetes?
Pregabalin, duloxetine or gabapentin
53
What is the recommended foot care counseling for patients with diabetes?
- Every day: wash, dry and examine feet. Moisturize the top and bottom of the feet, but not between the toes
- Each office visit: take off shoes to have feet checked
- Annual foot exam by a podiatrist
- Trim toenails with nail file; do not leave sharp edges from the clipper
- Wear socks and shoes. Elevate feet when sitting
54
How often should diabetic kidney disease be monitored?
Check urine albumin and eGFR annually if normal kidney function or twice yearly if reduced kidney function (eGFR 30-60 mL/min/1.73 m2 or urine albumin > 300)
55
What are some natural products that can decrease BG with low or minimal efficacy?
Products used to decrease BG include cassia cinnamon, alpha lipoic acid, chromium, magnesium and Panax/American ginsengq
56
What are the goals of treatment for type 2 diabetes?
The goals of treatment are to maintain BG levels in the target range (while avoiding hypoglycemia) and to reduce long-term complications of hyperglycemia
57
What is considered first line treatment for type 2 diabetes?
Metformin is the first-line treatment and should be used indefinitely unless contraindications are present or it is not tolerated
58
When is it recommended to start two medications to treat type 2 diabetes?
- Start two drugs at baseline if the A1C is 8.5-10%
- Start two drugs at baseline regardless of A1C if the patient has ASCVD, heart failure or CKD. A drug with proven benefit for these conditions should be used
59
When should you add on a drug after Metformin?
Add on a second drug if the A1C remains above goal on Metformin. In this case, treatment is driven by patient-specific factors (e.g. cost, risk of hypoglycemia and weight). Continue adding medications in this way until the A1C goal is met
60
When should insulin be used initially for the treatment of T2D?
Insulin can be used initially if hyperglycemia is severe (A1C > 10% or BG > 300 mg/dL)
61
What is the recommended second drug added if a patient has ASCVD or high risk?
GLP-1a or SGLT2i with benefit
62
What is the recommended second drug added if a patient has HF?
SGLT2i with benefit
63
What is the recommended second drug added if a patient has CKD?
SGLT2i or GLP1a with benefit
64
What is the recommended second drug added if a patient has no ASCVD, HF or CKD?
Any class. Consider hypoglycemia risk, weight loss/gain potential, cost
- Best for hypoglycemia risk: DPP-4i, GLP1a, SGLT2i, TZD
- Best for weight loss: GLP-1a or SGLT2i
- Best for cost: SU or TZD
65
What are the SGLT2i with benefit?
Empagliflozin, canagliflozin or dapagliflozin
66
What are the GLP-1a with benefit?
Dulaglutide, liraglutide, SC semaglutide
67
What should be added as a third drug if a patient with ASCVD or HF or CKD still has an A1c above goal?
GLP-1a or SGLT-2i (if not started), TZD, basal insulin, SU, DPP-4
68
What should be added as a third drug if a patient with no ASCVD, HF or CKD has an A1c above goal?
Any drug class not yet started
69
What are combination medications that should be avoided?
- DPP-4i + GLP1a
| - SU + insulin
70
What is the MOA of Metformin?
Metformin primarily works by decreasing hepatic glucose production, decrease intestinal absorption of glucose and increasing insulin sensitivity
71
What is a boxed warning of Metformin?
Lactic acidosis: risk increases with renal impairment, radiological studies with contrast, excessive alcohol or certain drugs
72
What is a contraindication of Metformin?
eGFR < 30, acute or chronic metabolic acidosis (includes DKA)
73
What are some warnings associated with Metformin?
- Not recommended to start if eGFR 30-45; reassess if already taking and eGFR falls < 45
- Vitamin B12 deficiency
74
What are some side effects of Metformin?
GI effects: nausea, diarrhea, flatulence, cramping; usually transient (resolve over time)
75
What are some notes about Metformin?
- Decreases A1C by 1-2%, weight neutral, no hypoglycemia
| - ER: swallow whole; can leave a ghost tablet (empty shell) in the stool
76
What are some significant Metformin drug interactions?
- Intravascular iodinate contrast media can increase the risk of lactic acidosis. Discontinue metformin before the imaging procedure. Metformin can be restarted 48 hours after the procedure if eGFR is stable
- Alcohol can increase the risk for lactic acidosis; excessive intake, acute or chronic, should be avoided
- The combination of Metformin and Topiramate can increase the risk of metabolic acidosis
77
What is the sodium glucose co-transporter protein responsible for?
The sodium glucose co-transporter 2 (SGLT2) protein, expressed in the proximal renal tubules, is responsible for the reabsorption of filtered glucose
78
What is the benefit of SGLT2 inhibitors?
By inhibiting SGLT2, these drugs reduce reabsorption of glucose and increase urinary glucose excretion, which decrease BG concentrations
79
How are SGLT2 inhibitors dosed?
SGLT2 inhibitors are dosed based on eGFR
80
What are some examples of SGLT2 inhibitors?
Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance), Ertugliflozin (Steglatro)
81
What is a contraindication of SGLT2 inhibitors?
Dialysis
82
What are some warnings about SGLT2 inhibitors?
- Ketoacidosis (d/c prior to surgery due to risk)
- Genital mycotic infections, urosepsis and pyelonephritis, necrotizing fasciitis of the perineum
- Hypotension, AKI and renal impairment (due to intravascular volume depletion)
83
What is a warning specifically associated with Canagliflozin?
Increased risk of leg and foot amputations, higher risk with history of amputation, PAD, peripheral neuropathy and/or diabetic foot ulcers, hyperkalemia risk when used with other drugs that increase potassium; risk of fractures
84
What are some side effects of SGLT2 inhibitors?
Weight loss, increased urination, increased thirst, hypoglycemia, increased Mg/PO4
85
What are some notes about SGLT2 inhibitors?
- Decreases A1C by 0.7-1%, low hypoglycemia risk (unless used with insulin)
- Canagliflozin, dapagliflozin and empagliflozin have shown reductions in HF and CKD progression. Most renal data is with canagliflozin and dapagliflozin. Most heart failure is with empagliflozin and dapagliflozin
86
What are some significant SGLT2 inhibitor drug interactions?
- Increased risk of intravascular volume depletion (causing hypotension and AKI) if used in combination with diuretics, RAAS inhibitors or NSAIDs
- Uridine diphosphate glucuronosyltransferase (UGT) inducers can decrease levels of canagliflozin; consider using 300 mg dose if used in combination and eGFR > 60 mL/min/1.73 m2
87
What is the MOA of glucagon-like peptide 1 (GLP-1) agonists?
GLP-1 agonists are analogs of the incretin hormone GLP-1, which increases glucose-dependent insulin secretion, decreased glucagon secretion, slows gastric emptying, improves satiety and can result in weight loss
88
Wha are key similarities between all GLP-1 agonists?
They are all SC injections available in either single-dose or multidose pens, except semaglutide also comes as an oral tablet. Some are available in combination with long-acting insulin
89
What are some examples of GLP-1 agonists?
Liraglutide (Victoza), Dulaglutide (Trulicity), Exenatide (Byetta), Exenatide ER (Bydureon), Lixisenatide (Adlyxin), Semaglutide (Ozempic-SC, Rybelsus-PO)
90
What is a boxed warning for al GLP-1 agonists except Byetta and Adlyxin?
Risk of thyroid C-cell carcinomas; do not use if personal or family history of medullary thyroid carcinoma (MTC) or with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2)
91
What are some warnings about GLP-1 agonists?
- Pancreatitis (can be fatal, risk factors: gallstones, alcoholism or increased TGs)
- Not recommended in patients with severe GI disease, including gastroparesis
92
What is a warning specific to Bydureon?
Serious infection-site reactions (e.g. abscess, cellulitis, necrosis) with or without SC nodules
93
What is a warning specific to Ozempic?
Increased complications with diabetic retinopathy
94
What are some side effects of GLP-1 agonists?
Weight loss, nausea, vomiting, diarrhea, hypoglycemia, injection site reactions
95
What are some notes about GLP-1 agonists?
- Decreases A1C by 0.501.5%: decreased postprandial BG, low hypoglycemia risk
- Do not use with DPP-4 inhibitors (overlapping mechanism)
- Liraglutide, dulaglutide and semaglutide have demonstrated ASCVD benefit
- Betta and Adlyxin: give dose within 60 minutes of meals (others anytime)
- Pen needles are not provided with Byetta, Victoza or Adlyxin; provided with all others (which are the weekly injections)
96
What are some GLP-1 agonist drug interactions?
- Therese drug slow gastric emptying and can reduce the absorption of orally administered drugs. Use caution with narrow therapeutic index drugs or drugs that require threshold concentrations for efficacy. Take oral contraceptives at least one hour before exenatide and at least 11 hours after Adlyxin
- Can increase the INR in patients on warfarin
97
What are the two insulin secretagogues?
Sulfonylureas and meglinitides
98
How do insulin secretagogues work?
They work by stimulating insulin secretion from the pancreatic beta-cells to decrease postprandial BG
99
What is the difference between meglitinides and sulfonylureas?
Meglitinides have a faster onset (15-60 minutes) and a shorter duration of action compared to SUs
100
What are some examples of sulfonylureas?
Glipizide, Glimepiride, Glyburide
101
What are some contraindications of sulfonylureas?
Sulfa allergy (not likely to cross-react)
102
What are some warnings about sulfonylureas?
Hypoglycemia
103
What are some side effects of sulfonylureas?
Weight gain, nausea
104
What are some notes about sulfonylureas?
- Decreases A1c by 1-2%: decreased efficacy after long-term use (as pancreatic beta-cell function declines)
- Patients with G6PD deficiency can be at increased risk of hemolytic anemia with sulfonylureas
105
What is a counseling point of Glipizide IR?
Take 30 minutes before a meal; all other products are taken with breakfast or the first meal of the day; may need to hold doses if NPO
106
What is a counseling point of Glucotrol XL?
Glucotrol XL is an OROS formulation and can leave a ghost tablet (empty shell) in the stool
107
What is a counseling point of Glimepiride and Glyburide?
Glimepiride, glyburide not preferred in elderly (on the Beers criteria) due to hypoglycemia risk
108
What are some examples of Meglitinides?
Repaglinide and Nateglinide
109
What are contraindications of Meglitinides?
Type 1 diabetes, DKA
110
What are some warnings of Meglitinides?
Hypoglycemia, caution with severe liver/renal impairment
111
What are some side effects of Meglitinides?
Weight gain, headache, upper respiratory tract infections
112
What are some notes about Meglitinides?
Decreases A1C by 0.5-1.5%
113
What are some sulfonylurea and meglitinide drug interactions?
- Insulin in combination with either SUs or meglitinides increase risk of hypoglycemia and should be avoided. Use caution with other drugs that can decrease BG
- SUs are CYP2C9 substrates; use caution with 2C9 inducers or inhibitors
- Gemfibrozil and clopidogrel can increase repaglinide, leading to decreased BD (contraindicated with gemfibrozil)
- Alcohol can increase the risk for delayed hypoglycemia when taking insulin or insulin secretagogues
114
What is the MOA of dipeptidyl peptidase 4 (DPP-4) inhibitors?
DPP-4 inhibitors prevent the enzyme DPP-4 from breaking down incretin hormones, glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP)
115
What is the function of incretin hormones, GLP-1 and GIP?
These hormones help to regulate BG levels by increasing insulin release from the pancreatic beta cells and decreases glucagon secretion (which decrease hepatic glucose production) from pancreatic alpha-cells
116
What are some examples of DPP-4 inhibitors?
Sitagliptin (Januvia), Linagliptin (Tradjenta), Saxagliptin (Onglyza), Alogliptin (Nesina)
117
What are some warnings about DPP-4 inhibitors?
- Pancreatitis, severe arthralgia (joint pain), acute renal failure, hypersensitivity reactions, bullous pemphigoid (blisers/erosions requiring hospitalization)
- Risk of heart failure seen with saxagliptin and alogliptin but warning added for class
118
What is a specific warning of alogliptin?
Hepatotoxicity
119
What are some side effects of DPP-4 inhibtors?
Generally well tolerated,, can cause nasopharyngitis, URTIs, UTIs, peripheral edema, rash
120
What are some notes about DPP-4 inhibitors?
- Decreases A1c by 0.5-0.8%, weight neutral, low hypoglycemia risk
- Do not use with GLP-1 agonists (overlapping mechanism)
121
What is a major drug interaction of Saxagliptin?
Saxagliptin is a major substrate of CYP450 3A4 and P-gp. Limit the dose to 2.5 mg with strong CYP3A4 inhibitors, including protease inhibitors
122
What is major drug interaction of Linagliptin?
Linagliptin is a major substrate of CYP3A4 and P-gp. Linagliptin levels are decreased by strong CYP3A4 inducers
123
What is the MOA of thiazolidinediones (TZDs)?
TZDs are peroxisome proliferator-activated receptor gamma (PPARy) agonists that increase peripheral insulin sensitivity (increases uptake and utilization of glucose by peripheral tissues)
124
What are some examples of TZDs?
Pioglitazone (Actos) and Rosiglitazone (Avandia)
125
What is a boxed warning of TZDs?
Can cause or exacerbate heart failure, do not use with NYHA Class III/IV heart failure
126
What is a boxed warning specific to Rosiglitazone?
Increased risk of MI
127
What are some warnings about TZDs?
- Hepatic failure, edema (including macular edema), risk of fractures
- Can stimulate ovulation, which can lead to unintended pregnancy; may need contraception
128
What are some warnings of Pioglitazone?
Increases risk of bladder cancer; do not use in patients with a history of bladder cancer
129
What are some side effects of TZDs?
Peripheral edema, weight gain, URTIs, myalgia
130
What are some side effects specific to Rosiglitazone?
Increases LDL, HDL and total cholesterol
131
What are some notes about TZDs?
Decreases A1c by 0.5-1.4%, low risk of hypoglycemia
132
What is a major drug interaction of TZDs?
TZDs are major substrates of CYP2C8; use caution with CYP2C8 inducers or inhibitors
133
What are some other medications that can be used to treat Type 2 diabetes?
Alpha-glucoside inhibitors, bile acid binding resins, dopamine agonist, amylin analog
134
What are some examples of alpha-glucosidase inhibitors?
Acarbose, Meglitol
135
What is the MOA of alpha-glucosidase inhibitors?
Inhibit the metabolism of intestinal sucrose, which delays glucose absorption
136
What are some notes about alpha-glucosidase inhibitors?
- Do not cause hypoglyceia alone, but if hypoglycemia occurs due to another drug, it cannot be treated with sucrose; glucose tablets or or gel need to be purchased to treat hypoglycemia
- Each dose should be taken with the first bite of each meal
- GI side effects are common (flatulence, diarrhea, abdominal pain)
137
What is an example of bile acid binding resins?
Colesevelam (Welchol)
138
What are some notes about bile acid binding resins?
- Constipation is the most common side effect
| - Can bind and decrease absorption of other drugs and fat-soluble vitamins (A, D, E, K)
139
What is an example of dopamine agonist?
Bromocriptine
140
What are some notes about Bromocriptine?
- Contraindicated in patients with syncopal migraines and those who are breastfeeding
- Should not be used with metoclopramide or other dopamine agonists
141
What is an example of Amylin analog?
Pramlinitide (Symlin)
142
What is the MOA of Pramlinitide?
Helps control PPG by slowing gastric emptying, which suppresses glucagon secretion following a mean and increases satiety
143
What are some notes about Pramlinitide?
- Can be used in type 1 or type 2 diabetes, administered SC prior to each major meal. Skip dose if skipping meal
- Contraindicated in gastroparesis
- Significant hypoglycemia risk; must reduce mealtime insulin dose by 50% when starting
- Side effects include nausea, vomiting, anorexia and weight loss
144
What is the typical physiology in patients without diabetes in terms of insulin release?
In an individual without diabetes, the pancreas controls the release of insulin the body. It provides a consistent level (or basal amount) of insulin at all times, then releases more insulin when the BG is elevated postprandially
145
What can be done in a patient with type 1 diabetes?
In a patient with diabetes, insulin can be administered to mimic the normal physiologic process. Insulin cannot be given orally; it is given as a subcutaneous injection (most common), intravenously (less often, usually for acutely high BG) or inhaled
146
What does it mean when a medication is high-alert?
It means it has a high risk of causing patient harm and requires extra care during handling and administration
147
Why is insulin a high-alert medication?
Insulin is high-alert primarily due to human errors, such as misreading measurements, using the wrong insulin, type, strength, dose or frequency and skipping meals
148
Describe basal insulin.
Basal insulin includes glargine, detemir and ultra-long acting degludec. These insulins are "peakless" with an onset of 3-4 hours and duration of > 24 hours. They mainly impact fasting glucose
149
Describe the properties of insulin NPH.
Insulin NPH is intermediate-acting but i can be used as a basal insulin. NPH has an onset of 1-2 hours, and it peaks at 4-12 hours, which can cause hypoglycemia. BG control is further complicated by the variable, unpredictable duration of action (14-24 hours)
150
What does the P in NPH stand for and what is its function?
The P in NPH is for protamine, which helps to delay absorption/extend the duration of effect. Protamine also comes in lispro-protamine and aspart-protamine, which have the same onset, peak and duration as NPH. These come in premixed solutions only and are combined with standard rapid-acting insulin (aspart and lispro)
151
Describe the properties of rapid-acting insulin.
Rapid-acting insulin includes aspart, lispro and glulisine. These provide a bolus dose, similar to the pancreas releasing a burst of insulin in response to food. They have a fast onset (~15 min), peak in 1-2 hours and a duration of 3-5 hours)
152
Describe the properties of regular insulin U-100
Regular insulin U-100 is considered a short-acting insulin; it can be given as a bolus at mealtimes like rapid-acting insulin, but has a slower onset and lasts longer than needed for a meal. Regular insulin has an onset of 30 minutes, peaks at ~2 hours and lasts 6-10 hours
153
Describe the properties of regular U-500
Regular U-500 is a very concentrated insulin. The onset is the same as regular insulin U-200, but the duration is closer to NPH; it can last up to 24 hours. It is often dosed twice daily or TID, before meals
154
Describe the properties of inhaled insulin
Inhaled insulin is not used commonly. It is a mealtime insulin with fast absorption through the lungs
155
What are some contraindications of insulin?
Do not administer during episodes of hypoglycemia
156
What are some warnings of insulin?
Hypoglycemia, hypokalemia (insulin facilitates K+ entry into cells, and is used to treat hyperkalemia)
157
What are some side effects of insulin?
- Weight gain: insulin causes excess glucose to move into adipose cells
- Lipoatrophy: loss of SC fat at the injection site (which disfigures skin) and lipohypertrophy (accumulation of fat lumps under injection site). Avoid both by rotating injection sites and using analog insulins (lower risk than with older insulins)
158
What are the storage and administration requirements of insulin?
- Most vials are 10 mL and most pens are 3 mL. Insulin concentrations are 100 units/mL, unless noted otherwise
- Do not shake; turn suspensions (NPH, protamine mixes) up and down slowly or roll between hands. Do not freeze or expose to extreme heat
- Unopened insulin vials and pens are stored in the refrigerator. Open vials and pens can be kept at room temperature. It is more painful/uncomfortable to inject cold insulin
- Pen devices should never be shared (even if the needle is changed) due to the risk for transmission of blood-borne pathogens
- Any percentage mixture of NPH and regular (for rapid acting) insulins can be made by mixing the two insulins the same syringe; regular insulin (or rapid acting) is clear and is drawn up (into the syringe) first, before the NPH, which is cloudy
159
What are some examples of rapid-acting (bolus) insulin?
Aspart (Novolog, Fiasp), Lispro (Humalog, Admelog, Lyumjev), Lispro U-200 (Humalog U-200), Glulisine (Apidra), Afrezza
160
What are some notes about rapid-acting insulin?
- Inject SC 515 minutes before meals to have insulin available when glucose from the meal is absorbed
- Used as prandial insulin and for correction doses when BG is high
- Preferred insulin type for insulin pumps
- Aspart and lispro insulins come in premixed insulins with intermediate-acting protamine
- Co-formulations with faster absorption: Fiasp is formulated with niacinamide and Lyumjev is a newer form of lispro, formulated wiht treprostinil and citrate
161
What are some notes about Afrezza?
- Contraindicated in any lung disease, including asthma and COPD; do not use Afrezza in smokers
- Can cause acute bronchospasm, cough and throat pain
- Requires lung minotiring with pulmonary function tests (FEV1); replace inhaler every 15 days
162
What is an example of short-acting insulin?
Regular (Humulin R, Novolin R)
163
What are some notes about regular insulin?
- Inject SC 30 minutes before meals to have insulin available when the glucose from the next meal is absorbed
- Used as prandial insulin and for correction doses when BG is high (often by sliding scale)
- Regular insulin is preferred for IV infusions, including in parenteral nutrition; it is less expensive than other insulin and when administered as a continuous IV infusion, the onset is immediate. IV regular insulin should be prepared in a non-PVC container
- Often given with NPH twice daily, 30 min before breakfast and dinner. Lunch is covered by the NPH and possibly some residual regular insulin. This regimen requires jsut 2 injections per day
164
What are some notes specifically about concentrated regular?
- Five times as concentrated as regular insulin, many safety risks. Recommended only when patients require > 200 units of insulin per day
- The predicted dose of Humulin R U-500 should always be expressed in units of insulin
- All patients using the U-500 insulin vial must be prescribe U-500 insulin syringes to avoid dosing errors
- Do not mix with any other insulin; only administer at SC injection (not IV, IM or in an insulin pump)
165
What is an example of an intermediate-acting insulin?
NPH (Humulin N, Novolin N)
166
What are some notes about NPH?
- Given as a basal insulin, typically dosed twice daily as an add-on to oral drugs. Can be a less expensive alternative but has more hypoglycemia
- If nocturnal hypoglycemia occurs with NPH dosed once daily QHS, the dose can be split
167
What are some examples of long-acting insulin?
Detemir (Levemir), Glargine (Lantus, Toujeo, Basaglar, Semglee)
168
What are some notes about long-acting insulin?
- Usually injected once daily; detemir may need to be given twice daily
- Caution required: Lantus is 100 units/mL and Toujeo is a concentrated insulin glargine with 300 units/mL
- Toujeo has max effect by the 5th day; the coverage may not be adequate initially
- Lantus and Toujeo and Apidra are made by the same manufacturer and all of them use the same SoloStar pen
- Do not mic with any other insulins
169
What is an example of an ultra-long acting insulin?
Insulin degludec
170
What are some notes about ultra-long acting insulin?
- Insuilin degludec comes in a vial and Tresiba Flextouch pen. The vial has 100 units/mL. Tresiba FlexTouch pens come in 100 units/mL and 200 units/mL
- Tresiba cna be useful when insulin detemir or glargine causes nocturnal hypoglycemia
171
What are the different types of premixed insulin?
- 70/30 mixes: 70% NPH/30% regular (Humulin 70/30, Novolin 70/30)
- 75/25 mix: 75% lispro protamine/25% lispro
- 50/50 mix: 50% lispro protamine/50% lispro (Humalog mix 50/50)
172
What are some notes about the premixed insulins?
- Given BID (before breakfast and after dinner) or sometimes TID with rapid acting insulin
- In premixed insulins, the percentage of NPH or protamine insulin is listed first and the percentage of short-acting or rapid-acting insulin is listed second
- NPH or protamine makes the mixes cloudy
173
What are some major drug interactions of insulin?
- Rosiglitazone: increases risk of heart failure when taken with insulin; do not use together
- Pramlinitide: must reduce mealtime insulin by 50% when starting pramlinitide to avoid severe hypoglycemia
- Avoid the combination of insulin with sulfonylureas or meglitinides. May need to decrease insulin dose when used with drugs that can cause hypoglycemia
- May need to decrease insulin dose when used with direct acting antivirals for hepatitis c treatment due to risk of hypoglycemia
174
What insulin is available OTC?
Regular, NPH and premixed 70% NPH/30% regular insulins can be sold OTC or can be dispensed with a prescription for insurance coverage
175
What is preferred if an injectable medication is needed to reduce the A1c in T2D?
GLP-1 receptor agonist is preferred and should be considered first. If the patient is already on a GLP-1 agonist, insulin should be started. An exception is when using insulin initially to treat very high BG at diagnosis (A1C > 10 or BG > 300) or if symptoms of catabolism are present
176
What are the steps to initiating insulin therapy in T2D?
1) Add basal insulin: 10 units SC daily or 0.1-0.2 units SC/kg/day and titrate based on fasting amount plasma glucose
2) If FPG not at goal or A1c above goal, add prandial insulin: 4 units or 10% of basal dose SC once daily prior to largest meal and titrate based on prandial blood glucose; add on doses prior to other meals if needed
3) If A1c still not at goal, either do full basal/bolus regimen (basal insulin daily + prandial-insulin before each meal) or mixed insulin regimen (twice daily NPH + short/rapid self-mixed or premixed)
177
What is the recommendation for treatment of T1D?
All people with T1D require insulin. Most are treated with an insulin pump or multiple daily injections of insulin designed to mimic the normal pattern of insulin secretion
178
Why are rapid-acting injectable insulins and long-acting basal insulins preferred over short- and intermediate-acting insulins?
They have less hypoglycemia risk and better mimic the physiologic pattern of insulin made by the body
179
What are the steps to starting a basal-bolus insulin regimen in type 1 diabetes?
- The typical starting dose for T1D is 0.5 units/kg/day. Insulin is dosed using total body weight with 50% of total daily dose administered as a basal insulin and 50% as prandial insulin
1) Calculate TDD (0.5 u/kg/day)
2) Divide the TDD into 50% basal insulin and 50% bolus insulin
3) Divide the bolus insulin evenly among 3 meals (or allocate more insulin for larger meals and less for smaller meals)
180
Why is an NPH and regular insulin regimen not preferred?
Neither insulin has a profile that can mimic the natural insulin release from the pancreas as well as basal and rapid-acting insulin combinations
181
What is the process of starting a regimen with NPH and regular insulin?
The starting TDD of insulin is the same as with basal-bolus regimens but 2/3 of the TDD is given as NPH and 1/3 is given as regular insulin
182
Who can be a candidate for using insulin pumps?
Users must be motivated, willing to test their BG frequently and be able to understand the pump's operation. Prior experience with multiple daily injections is a requirement for sqitching to a pump
183
How are insulin pumps designed?
Pumps hold insulin in a reservoir. The insulin runs out of the pump through tubing to a small infusion set placed on the skin, usually on the abdomen, through a small cannula that inserts under the skin. The cannula tip rests in subcutaneous fatty tissue, where the insulin is released. The insulin reservoir, tubing and infusion set need to be replaced regularly
184
How does an insulin pump work?
- Insulin pumps deliver rapid-acting insulin (preferred) by two complementary methods, continuous and bolus dosing
1) Continuous dose: small amounts of insulin are released every few minutes to provide a basal insulin level
2) Bolus doses: pumps can be programmed to release a number of insulin units to match the carbohydrates in a meal. The bolus dose is calculated by the patient's insulin to carbohydrate ratio. The bolus dose is adjusted based on the current BG level
185
What indicates that an adjustment is needed for the basal insulon?
Fasting BG highs or lows and/or similar trends that last most of the day (except with BG spikes after eating), typically indicate that the basal insulin dose needs to be changed
186
What should be done to basal insulin if there is a low BG trend?
Decrease the basal or NPH insulin dose
187
What should be done to the basal insulin if there is a high BG trend?
Increase the basal or NPH insulin dose
188
When should mealtime insulin be adjusted?
If the postprandial BG is high or low following the same meal on most days, the regular or rapid-acting insulin dose taken prior to that meal should be increased for high BG or decreased for low BG. If the preprandial BG is high or low before the same meal on most days, the regular or rapid-acting insulin dose taken before the previous meal should be increased for high BG, or decreased for low BG
189
What are the different mealtime insulin dosing options?
1) Use the same insulin dose every time
| 2) Calculate an insulin dose at each meal
190
When is using the same insulin dose for mealtime dosing beneficial?
The mealtime insulin can be set at the same dose everyday for a meal. This assumes that about the same grams of carbohydrates are eaten at dinner everyday. This method results in high or low BG when the carbohydrate intake is high or lower, respectively
191
When is calculating an insulin dose at each meal beneficial?
When different amounts of carbohydrates are eaten at each meal, a simple calculation can provide the right amount of rapid-acting or regular insulin needed
192
How is the bolus dose calculated?
The bolus dose is calculated with the insulin-to-carbohydrate ratio
193
What is the insulin to carbohydrate ratio (ICR)?
The ICR indicates the grams of carbohydrates covered by 1 unit of insulin
194
What are the two variations of the ICR formula?
Regular insulin uses the Rule of 450 and rapid-acting insulin uses the Rule of 500. The TDD of insulin used in the formula should account for both long-acting and short or rapid-acting insulins included in this regimen
195
What is the formula for rule of 450?
450/total daily dose of insulin (TDD) = grams of carbohydrates covered by. 1 unit of regular insulin
196
What is the rule of 500?
500/total daily dose of insulin = grams of carbohydrate covered by 1 units of rapid-acting insulin
197
What is a correction dose?
BG that is higher than the targeted range can be corrected with a bolus called a correction dose
198
How do you calculate the correction dose?
1) The first step is to calculate the correction factor, which indicates how much the BG will be lowered (in mg/dL) by 1 unit of insulin. To calculate the correction factor, use the 1500 rule for regular insulin and 1800 rule for rapid-acting insulin
2) Next, calculate the correction dose, which is the total units of insulin needed to return the BG to the target range. The formula for the correction dose is the same for both regular and rapid-acting insulin
199
What is the formula for the 1500 rule?
1500/total daily dose of insulin = correction factor for 1 unit of regular insulin
200
What is the formula for the 1800 rule?
1800/total daly dose of insulin = correction factor for 1 unit of rapid-acting insulin
201
What is the formula to calculate the correction dose?
(BG now- target BF)/correction factor
202
What is the general rule for insulin conversions?
Most insulin conversions are 1:1 but the regimen might need to be split up differently
203
What are the exceptions to the 1:1 insulin conversion rule?
1) NPH dosed BID -> insulin glargine dosed daily: use 80% of NPH dose
2) Toujeo -> insulin glargine or insulin detemir: use 80% of the Toujeo dose
204
What containers does insulin come in?
- Vials (usually 10 mL), ready to be drawn up with an insulin syringe. Humulin R U-500 comes in a 20 mL vial
- Pens, ready to inject once a needle is attached. Pens are dialed to the number of units needed. All pens contain 3 mL of insulin, except Toujeo comes as two sizes: 1.5 mL and 3 mL
- All insulin pens are multi-dose; needles must be dispensed with all insulin pens. Some pens are disposable and other s have replaceable cartridges
205
What are the benefits and risks of concentrated insulin?
Concentrated insulin is useful to reduce the volume of the injection, but can be fatal when used incorrectly. Fortunately, most concentrated insulin comes in pens, which are simply dialed to the correct dose
206
What containers does concentrated insulin come in?
The concentrated insulin that comes in both a pen and a vial is regular insulin U-500, which has higher risk
207
What are some examples of insulin that comes concentrated?
- Rapid acting: Humalog KwikPen, Lyumjev KwikPen (200 units/mL)
- Regular insulin: Humulin R U-500 KwikPen and vial (500 units/mL)
- Long-acting: Tresiba Flextouch (200 units/mL) and Toujeo Solostar, Toujeo Max SoloStart (300 units/mL)
208
When is very concentrated regular U-500 useful?
Humulin R U-500 is five times as concentrated as U-100 insulin. It is useful for patients taking > 200 units/day, but have a high risk for dosing errors
209
What are some methods to avoid dosing errors with U-500 insulin?
- The prescribed dose of Humulin R U-500 should always be expressed in units of insulin. Only dispense with U-500 syringes
- Humulin R U-500 KwikPen provides up to 300 units with one injection and has a lower risk of dosing errors
210
What are some counseling points about insulin stability?
Unused insulin vials, pens and cartridges are stored in the refrigerator. The expiration date of refrigerated insulin is the manufacturer's expiration date on the label. Once the insulin is in use it can be kept at room temperature, but the expiration date no longer applies. The insulin must be used within a specific number of days based on the type of insulin
211
Which insulin has a room temperature stability of 10 days?
Humalog Mix 50/50 and 75/25 pens and Humulin 70/30 pen
212
Which insulin has a room temperature stability of 14 days?
Humulin N pen and Novolog Mix 70/30 pen
213
Which insulin has a room temperature stability of 28 days?
Apridra, Humalog, Novolog, Admelog, Lyumjev, Fiasp, Humalog Mix 50/50 and 75/25 vials, Novolog Mix 70/30 vial, Novolin R U-100, N and 70/30 pens, Humulin R U-500 pen, Lantus, Basaglar, Semglee vials and pens
214
Which insulin has a room temperature stability of 31 days?
Humulin R U-100, N and 70/30 vials
215
Which insulin has a room temperature stability of 40 days?
Humulin R U-500 vial
216
Which insulin has a room temperature stability of 42 days?
Novolin R U-100, N and 70/30 vials, Levemir vial and pen
217
Which insulin has a room temperature stability of 56 days?
Tresiba pen and Toujeo pen
218
What is the rule in selecting an insulin syringe?
Use the smallest syringe that will hold the units of insulin. It is easier to read the unit markings on smaller syringes, which makes them more accurate
- 0.3 mL syringe for up to 30 units
- 0.5 mL syringe for 30-50 units
- 1 mL syringe for 51-100 units
219
How do you select a syringe for Humulin R U-500 insulin vials?
Humulin R U-500 insulin vials can only be dispensed with U-500 syringes. The U-500 syringes have a dark green cap and the U-500 syrignes have dark green needle covers
220
How do you select an insulin pen needle?
Needles are chosen by the length and the gauge (thickness)
221
What is the meaning of gauge?
The higher the gauge, the thinner the needle. The 32G cannula is thinnest and has a width of ~ 2 human hairs. Shorter needles and higher-gauge needles cause less pain
222
What are the shortest needles available?
The shortest needles are 4 mm and 5 mm in length and are preferred for most pens. They do not require the skin to be pinched during administration and are good for thinner patients and children
223
What is a counseling point is a patient is using an 8 mm needle?
8 mm needles are long enough for most patients; pinch up the skin before injecting
224
When is a 12.7 mm needle needed?
12.7 mm (1.2 inch) needles may be needed for obese patients; pinch up the skin before injecting
225
What are the steps for insulin injection?
1) Get supplies. Wash hands
2) Check insulin for discoloration and particles. Discard if present
3) If insulin contains NPH or protamine, it is a suspension and needs to be resuspended (do not shake): vials (roll the bottle gently between the hands), pens (invert 4-5 times)
4) Clean injection site. If using a vial, wipe the top with an alcohol swab
5) Pens: use a new needle for each injection. Prior to each injection, prime the needle by turning the knob to 2 units, face the needle away from you and press the injection button
6) Vials: use a new syringe for each injection. Inject an equal volume of air into the vial before withdrawing the insulin. Limit bubbles in the syringe. If mixing NPH and regular or rapid-acting insulin in the same syringe, the clear insulin should be drawn into the syringe before the cloudy insulin
7) Insulin is best absorbed in the abdomen (preferred). Alternative sites for injection: posterior upper arm, superior buttocks and lateral thigh area
8) With needles > 5 mm, gently pinch a 2 inch portion of skin between your thumb and first finger first
9) Insert the needle all the way in. Pens are injected straight down. Syringes are injected at 90 degrees for most or 45 degrees if the patient is thin
10) Press the injection button (pen) or plunger (syringe) all the way down to inject the insulin. Count 5-10 seconds before removing the needle
11) Rotate injection sites around the abdomen regularly to prevent skin damage
12) Properly dispose of needles or entire syringes
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How can patients properly dispose of needles and syringes?
Used needles, syringes, single-dose pens (with needles attached) and lancets should be placed in a sharps disposal container and taken to a disposal site. Locations are provided by the local public health agency. Alternatively, a heavy plastic milk bottle (not glass) or metal coffee can works well
227
What does self-monitoring blood glucose refer to?
Self-monitoring blood glucose (SMBG) refers to patients tracking their BG using a glucose meter or a continuous glucose monitor (CGM)
228
What is a CGM?
CGMs are taped to the skin and have a probe that passes through the skin and into the fatty tissue. The probe provides measurements of the glucose level in the interstitial fluid between the cells
229
What are the steps to prepare to use a glucose meter?
- If the meter requires calibration, recalibrate each time a new canister of test strips is opened, if the meter was left in extreme cold or heat, if it was dropped or if the BG value does not match what the patient is feeling
- Keep the test strips in the original container, with the cap closed. Light and air damage test strips. Check the expiration date; expired test strips can give false results
- Wash hands vigorously, using warm water
- Dry hands thoroughly; water can dilute the blood sample and give a false result
- Allow arm to hang down for 30 seconds so blood can pool into the fingertips. Do not squeeze the finger
230
What are the steps to test with glucose meter?
- Insert test strip into meter
- Prick side of fingertip (side is less painful) with a lancet
- Apply a drop of blood to the test strip
- Record the result in a log book, or the meter might store the results
- Dispose the used lancet in a sharps container
231
When should alternative site testing be done?
- Some meters are approved to test blood from both the fingertip and alternative sites (forearm, palm or thigh) which can hurt less than the side of a fingertip
- Alternative testing sites are useful only when the BG is steady. The BG level can be ~20 minutes old. Do not use when the BG is changing quickly
- The lancing device might need to have a special cap screwed onto the tip to use on an alternative site
232
How is hypoglycemia defined?
Hypoglycemia is defined as a BG < 70 mg/dL. Low BG can have severe consequences, including falls, motor vehicle accidents and death. Each episode contributes to irreversible cognitive impairment
233
What are symptoms of hypoglycemia?
Symptoms include dizziness, anxiety/irritability, shakiness, headache, diaphoresis (sweating), hunger, confusion, nausea, ataxia, tremors, palpitations/tachycardia and blurred vision
234
What can severe hypoglycemia cause?
Severe hypoglycemia can cause seizures, coma and death
235
What is hypoglycemia treatment if patient is conscious and able to swallow?
Pure glucose, in tablets or gel, is preferred, but any form of carbohydrate that contains glucose will work. Added fat is not recommended; it slows absorption and prolongs the hypoglycemia. To treat follow the rule of 15
236
What is the rule of 15?
1) Take 15-20 grams of glucose or simple carbohydrates
2) Recheck BG after 15 minutes
3) If hypoglycemia continue, repeat steps 1&2
4) Once BG is normal, eat a small meal or snack
237
What are some examples of products that have 15 grams of simple carbs?
4 ounces of juice, 8 oz of milk, 4 oz regular soda, 1 tablespoon sugar, honey or corn syrup, 3-4 glucose tablets or 1 serving glucose gel
238
What is the hypoglycemia treatment for a patient who is unconscious?
When oral treatment is not possible, treat with dextrose (if there is IV access) or with glucagon. Caregivers of someone at high-risk for hypoglycemia should know how to use a glucagon 1 mg SC injection, dasiglucagon injection (Zegalogue) or glucagon nasal spray (Baqsimi). If using glucagon, place the patient in a lateral recumbent position (on side) to protect the airway and prevent choking when consciousness returns
239
What are some drugs that cause hypoglycemia?
- Insulin is the primary cause of drug-induced hypoglycemia
- Sulfonylureas and meglinitides and pramlintide are high-risk (glyburide, glimepiride and first-generation sulfonylureas are not recommended in the elderly due to this risk)
- GLP-1 agonists, DPP-4 inhibitors, TZDs and SGLT2 inhibitors have a low risk for hypoglycemia when used alone. When used in combination wiht insulin or a sulfonylurea, the risk is higher
- Alcohol, especially if taken on an empty stomach, can cause hypoglycemia when used with insulin or sulfonylureas
- Caution: beta-blockers, especially if non-selective, can cause hypoglycemia and mask adrenergic symptoms of hypoglycemia. Sweating and hunger are not masked. Counsel to recognize symptoms and test BG if unsure
240
What are some examples of medications that increase blood glucose?
Beta-blockers, thiazide and loop diuretics, tacrolimus, cyclosporine, protease inhibitors, quinolones, antipsychotics, statins, steroids, cough syrups, niacin
241
What is the target BG range for most non-critical and critical care patients in the hospital?
140-180 mg/dL
242
Why is the used of sliding scale insulin alone to control BG strongly discouraged?
This method of administering insulin in response to elevated BG levels is reactionary and leads to poor outcomes. Most sliding scales are not patient-specific
243
What are the methods to inpatient glucose control?
- Insulin is used for most hospitalized patients; the regimen depends primarily on oral intake
- If oral intake is adequate, a regimen with basal, bolus and correction doses is preferred
- A basal and correction dose strategy is recommended if patient is not eating well (poor intake)
- Correction dose insulin is given when BG is already high. The insulin dose given will correlate with the BG on a scale. The difference is that the correction dose scale is designed for a specific patient. It is based on the patient's insulin sensitivity factor, which indicates how much the BG will drop with each unit of insulin
244
What is diabetic ketoacidosis?
Diabetic ketoacidosis is a life-threatening crisis with high BG, ketoacidosis and ketonuria
245
What is DKA typically caused by?
DKA is commonly the initial presentation in T1D or caused by insulin non-adherence or subtherapeutic insulin dosing
246
Why are ketones present in DKA?
In DKA, ketones are present because triglycerides and amino acids are used for energy, which produces free fatty acids and glucagon converts the FFAs into ketones. Insulin normally prevents this conversion, but in DKA, insulin is absent or severely lack
247
What are the key features to recognizing DKA?
- BG > 250 mg/dL
- Ketones, nausea and vomiting
- Anion gap acidosis (arterial pH < 7.35, anion gap > 12)
248
What is the primary cause of hyperosmolar hyperglycemic state?
The primary cause is illness that leads to less fluid intake. This, along with fluid shifts and osmotic diuresis, leads to severe dehydration with altered consciousness. Ketones are not present because in T2D the patient still makes insulin
249
What are the key characteristics of recognizing HHS?
- Confusion, delirium
- BG > 600 mg/dL with high serum osmolality > 320 mOsm/L
- Extreme dehydration
- pH > 7.3, bicarbonate > 15 mEq/L
250
Describe the DKA and HHS treatment
- The primary treatment is aggressive fluids (first) and insulin to treat the hyperglycemia
- Fluids first for all patients: start with NS and when blood glucose reaches 200 mg/dL, change to D5W1/2NS
- Regular insulin infusion (regular is preferable in IV solutions): 0.1 units/kg bolus, then 0.1 units/kg/hr continuous infusion OR 0.14 units/kg/hr continuous infusion
- Prevent hypokalemia: insulin shifts K+ into the cells so monitor and keep serum level between 4-5 mEq/L
- Treat acidosis if pH < 6.9; acidosis may be corrected by fluids: give sodium bicarbonate if needed
251
What medication should be avoid if a patient has cancer?
Pioglitazone (bladder), GLP-1 agonists (thyroid)
252
What medication should be avoid if a patient has gastroparesis, GI disorders?
GLP-1 agonists, pramlintide
253
What medication should be avoid if a patient has genital infection/UTI?
SGLT2 inhibitors
254
What medication should be avoid if a patient has heart failure?
TZDs, alogliptin, saxagliptin
255
What medication should be avoid if a patient has hepatotoxicity?
TZDs, alogliptin
256
What medication should be avoid if a patient has hypoglycemia?
Insulin, sulfonylureas, meglitinides and pramlintide
257
What medication should be avoid if a patient has hypotension/dehydration?
SGLT2 inhibitors
258
What medication should be avoid if a patient has hypokalemia?
Insulin
259
What medication should be avoid if a patient has ketoacidosis?
SGLT2 inhibitors (can occur when NG < 250 mg/dL); increased risk with acute illness, dehydration, renal impairment. Discontinue SGLT2 inhibitors prior to surgery to reduce risk
260
What medication should be avoid if a patient has lactic acidosis?
Metformin; increased risk with renal impairment, alcoholism, hypoxia
261
What medication should be avoid if a patient has osteopenia/osteoporosis?
Canagliflozin (decreased BMD, fractures), TZDs (fractures)
262
What medication should be avoid if a patient has pancreatitis?
DPP-4 inhibitors, GLP-1 agonists
263
What medication should be avoid if a patient has peripheral neuropathy, PAD, foot ulcers?
Canagliflozin
264
What medication should be avoid if a patient has sulfa allergy?
Consider avoiding sulfonylureas
265
What medication should be avoid if a patient has renal insufficiency?
Metformin, SGLT2 inhibitors, exenatide, glyburide; may need to start insulin at a lower dose
266
What medication should be avoid if a patient has weight gain/obesity?
Sulfonylureas, meglitinides, TZDs, insulin
267
What are some key counseling points of Metformin?
- Can cause lactic acidosis, diarrhea, nausea (usually goes away). Taking with food and using long-acting metformin will help
- With long-term metformin, take a vitamin B12 supplement
- Long acting formulations of metformin can leave a ghost tablet in the stool
268
What are some key counseling points of SGLT2 inhibitors?
Can cause hypotension, ketoacidosis (stop prior to surgery to reduce risk), severe UTIs and genital fungal infections
*Canagliflozin: amputation risk (avoid if foot problems, neuropathy), fractures
269
What are some key counseling points of GLP-1 receptor agonists?
- Byetta, Adlyxin: give within 60 minutes of meals; others can be taken anytime
- Trulicity, Bydureon, Bydureon BCise, Ozempic: inject once a week (the needles are inside the box)
- Byetta, Victoza, Adlyxin: needles need to be purchased
- If injection has been in the refrigerator, leave at room temperature 15 minutes before using
- Bydureon BCise: shake the injection well to mix the medication. Look in the window to check for drug particles; if present, shake given
- Can cause nausea, diarrhea, decrease in appetite, weight loss, pancreatitis and gallbladder disease, kidney damage (especially due to severe vomiting and diarrhea)
- Bydureon: injection-site reactions
- Ozempic: diabetic retinopathy
270
What are some key counseling points of thiazolidinediones?
Can cause heart failure, weight gain, bone fractures, Pioglitazone (bladder cancer)
271
What are some key counseling points about DPP-4 inhibitors?
Can cause pancreatitis, renal impairment, severe arthralgia
*Saxagliptin and alogliptin: heart failure
272
What are some key counseling points of sulfonylureas/meglitinides?
- Take sulfonylureas with breakfast, except glipizide IR: take 30 minutes before breakfast
- Take meglitinides 15-30 minutes before meals. Do not take if skipping the meal
- Can cause hypoglycemia and weight gain
273
What are some key counseling points of insulins?
- Subcutaneous injection (except Afrezza). Rotate injections sites
- Can cause hypoglycemia, hypokalemia, weight gain
- Store unopened insulin pens/vials in the refrigerator. Once opened, store at room temperature and discard after the designated number of days (for that type of insulin)
274
What are some key counseling points of Pramlintide?
- When starting, reduce dose of mealtime insulin by 50%. Inject before meals. Do not mix with insulin
- Can cause nausea
275
What are some key counseling points of alpha glucosidase inhibitors?
- Can cause flatulence and diarrhea
| - Do not cause hypoglycemia. If you get hypoglycemia (from another medication) treat with glucose tablets or gel
