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NAPLEX > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Criteria for Prediabetes

A
  • A1C 5.7-6.4
  • FBG 100-125
  • OGTT 2-hr BG 140-199
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2
Q

Criteria for Diabetes

A
  • A1C >= 6.5
  • FBG >= 126
  • OGTT 2-hr BG >= 200
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3
Q

Non-Preggo Diabetic Targets

A
  • A1C < 7
  • Preprandial BG 80-130
  • 2-hr PPG < 180
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4
Q

Preggo Diabetic Targets

A

-Preprandial BG =<95
-1-hr PPG =< 140
-2-hr PPG =< 120
(A1C inaccurate during pregnancy)

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5
Q

Estimated Average Glucose

A
  • Based on A1C
  • 6% A1C = 126 eAG
  • Each 1% increase ~ 28 increase in eAG
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6
Q

Microvascular Diabetes Complications

A
  • Retinopathy
  • Diabetic Kidney Disease
  • Peripheral neuropathy
  • Autonomic neuropathy (ED, loss of bladder control, etc.)
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7
Q

Macrovascular Diabetes Complications

A

-CAD, including MI
-CVA, including stroke
-PAD
(same as ASCVD)

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8
Q

Best Drug Class for Diabetes + ASCVD

A
  • GLP-1a

- SGLT2i with benefit

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9
Q

Best Drug Class for HF

A

SGLT2i with benefit

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10
Q

Best Drug Class for CKD

A
  • SGLT2i (preferred for albuminuria)

- GLP-1a with benefit

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11
Q

Best Drug Classes for Hypoglycemic Risk

A
  • DPP4i
  • GLP-1a
  • SGLT2i
  • TZD
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12
Q

Best Drug Classes for Weight Loss

A
  • GLP-1a

- SGLT2i

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13
Q

Best Drug Classes for Cost Concerns

A
  • Sulfonylureas

- TZD

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14
Q

Glucophage

A
  • Metfomin (Also Fortamet or Glumetza)
  • Biguanide
  • Start at 500 mg and titrate up weekly to maintenance dose (usually 1000 mg/d)
  • Max dose: 2000-2500 mg/d
  • Give with meal to reduce GI upset
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15
Q

Biguanide Information

A
  • Mechanism: Decreases hepatic glucose production and intestinal glucose absorption, increases insulin sensitivity
  • Warning: Lactic Acidosis; increased risk w/ renal impairment, contrast dye, and excessive alcohol
  • CI: eGFR < 30, metabolic acidosis
  • Warning: Don’t start if eGFR is 30-45, can cause vit. B12 deficiency
  • SE: Diarrhea, nausea
  • Drops A1C 1-2%, weight neutral, no hypoglycemia
  • ER: swallow whole, ghost tablet
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16
Q

Invokana

A
  • Canagliflozin
  • SGLT2i
  • Shown reduction in HF & CKD progression
  • Increases risk of leg/foot amputations, hyperkalemia, and fractures
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17
Q

Farxiga

A
  • Dapagliflozin
  • SGLT2i
  • CI if eGFR < 30
  • Shown reduction in HF & CKD progression
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18
Q

Jardiance

A
  • Empagliflozin
  • SGLT2i
  • CI if eGFR < 30
  • Shown reduction in HF & CKD progression
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19
Q

SGLT2i Information

A
  • Mechanism: Inhibits SGLT2 in proximal tubules to reduce reabsorption of glucose and increase urinary glucose excretion
  • Warning: Ketoacidosis, genital mycotic infections/urosepsis/pyelonephritis/etc., hypotension, AKI (due to volume depletion)
  • SE: Weight loss, increased urination/thirst
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20
Q

Victoza

A
  • Liraglutide
  • GLP-1a
  • Administered daily (must buy pens needles separately)
  • Demonstrated ASCVD benefit
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21
Q

Saxenda

A
  • Liraglutide
  • GLP-1a
  • For weight loss, not diabetes!
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22
Q

Trulicity

A
  • Dulaglutide
  • GLP-1a
  • Administered weekly
  • Demonstrated ASCVD benefit
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23
Q

Byetta

A
  • Exenatide
  • GLP-1a
  • Administered BID (must buy pens needles separately)
  • Not recommended if CrCl < 30
  • Give within 60 mins of meals
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24
Q

Bydureon (+/- BCise)

A
  • Exenatide ER
  • GLP-1a
  • Administered once weekly
  • Not recommended if CrCl < 30
  • Can cause serious injection site rxns with or without nodules
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25
Q

Adlyxin

A
  • Lixisenatide
  • GLP-1a
  • Administered QD (must buy pens needles separately)
  • Give within 60 minutes of meals
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26
Q

Ozempic

A
  • Semaglutide
  • GLP-1a
  • Administered once weekly
  • PO formulation (Rybelsus) given daily
  • Demonstrated ASCVD benefit
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27
Q

GLP-1a Information

A
  • Mechanism: analogs of GLP-1 which increases insulin secretion, decreases glucagon, slows gastric emptying, improves satiety, and can cause weight loss
  • Boxed Warning: risk for thyroid C-cell carcinomas (Byetta and Adlyxin excluded)
  • Warning: Pancreatitis, not recommended with severe GI disease/gastroparesis
  • SE: Weight loss, nausea
  • Don’t use with DPP4i (overlapping mechanism, prevent GLP-1a breakdown)
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28
Q

Glucotrol

A
  • Glipizide
  • Sulfonylurea (insulin secretagogues)
  • IR: take 30 minutes before a meal
  • XR: OROS formulation, ghost tablet
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29
Q

Amaryl

A
  • Glimepiride
  • Sulfonylurea (insulin secretagogues)
  • Beer’s criteria (hypoglycemic risk)
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30
Q

Glynase

A
  • Glyburide
  • Sulfonylurea (insulin secretagogues)
  • Beer’s criteria (hypoglycemic risk)
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31
Q

Sulfonylurea Information

A
  • Mechanism: stimulate insulin secretion for beta-cells to decrease postprandial BG
  • CI: Sulfa allergy
  • Warning: hypoglycemia
  • SE: Weight gain, nausea
  • Unless otherwise specified, take with breakfast/first meal of day
  • May hold doses if NPO
  • Drops A1C 1-2%
32
Q

Meglinides

A
  • Mechanism: stimulate insulin secretion for beta-cells to decrease postprandial BG
  • Repaglinide or Nateglinide (Starlix)
  • Repaglinide: take 15-30 minutes before meals
  • Nateglinide: Take 1-30 minutes before meals
  • Warning: hypoglycemia
  • SE: Weight gain
33
Q

1st Generation Sulfonylureas

A
  • Chlorpropamide
  • Tolazamide
  • Tolbutamide
  • DON’T use due to prolonged hypoglycemia
34
Q

Januvia

A
  • Sitagliptin
  • DPP4i
  • Risk of HF
35
Q

Tradjenta

A
  • Linagliptin
  • DPP4i
  • No renal adjustments necessary
36
Q

DPP4i Information

A
  • Mechanism: Prevents breakdown of incretin hormons like GLP-1 and GIP; increases insulin release and decreases glucagon secretion
  • Warning: Pancreatitis, arthralgia, renal failure, risk of HF
  • DON’T use with GLP-1a
37
Q

Actos

A
  • Pioglitazone
  • TZD
  • Increased risk of bladder cancer (don’t use in patients with bladder cancer hx)
38
Q

Avandia

A
  • Rosiglitazone

- TZD

39
Q

Thiazolidinediones

A
  • Mechanism: PPARy-agonists that increase peripheral insulin sensitivity
  • Box Warning: Can exacerbate HF; don’t use with NYHA III/IV HF
  • Warning: hepatic failure, edema (macular), risk of fractures
  • SE: Peripheral edema, weight gain
40
Q

Alpha-Glucosidase Inhibitors

A
  • Acarbose or Miglitol
  • MUST treat with glucose tablets/gel (not sucrose) if hypoglycemia is occuring
  • Each dose should be taken with first bite of meal
  • SE: flatulence, diarrhea, abdominal pain
41
Q

Bile Acid Binding Resins

A
  • Colesevelam (Welchol)

- Constipation is most common SE

42
Q

Amylin Analog

A
  • Pramlintide (Symlin)
  • SQ injection
  • MOA: helps PPG control by slowing gastric emptying which decreases glucagon
  • Administered prior to each meal
  • CI: gastroparesis
  • Significant hypoglycemic risk, reduce mealtime insulin by 50% when starting
  • SE: Nausea, weight loss
43
Q

Actoplus Met

A

Metformin + Pioglitazone

44
Q

Janumet

A

Metformin + Sitagliptin

45
Q

Invokanamet

A

Metformin + Canagliflozin

46
Q

Rapid-Acting Insulin

A
  • Aspart (Novolog)
  • Lispro (Humalog)
  • Clear and colorless
  • Given SQ 5-15 min before meals
  • Stable 28d room temp
47
Q

Short-Acting Insulin

A
  • Regular (Humulin - normal or concentrated option; 500 u/mL or Novolin R)
  • Clear and colorless
  • OTC or Rx
  • Preferred for IV infusions, non-PVC container
  • Inject SQ 30 minutes before meals
  • Stable 28d room temp EXCEPT U-100 Humulin - stable 31d room temp
48
Q

Intermediate-Acting Insulin

A
  • NPH (Humulin - stable 14d room temp or Novolin N - stable 28d room temp)
  • Cloudy
  • OTC or Rx
  • Basal insulin, given BID
  • More hypoglycemia, more affordable
49
Q

Long-Acting Insulin

A
  • Detemir (Levemir) - stable 42d room temp
  • Glargine (Lantus or Toujeo, concentrated 300 u/mL)
  • Lantus: stable 28d room temp
  • Toujeo: stable 56d room temp
  • Clear and colorless
  • Given once daily
  • Don’t mix with other insulins
50
Q

Ultra-Long Acting Insulin

A
  • Degludec (Tresiba) - stable 56d room temp

- 100 or 200 u/mL options

51
Q

Premixed Insulins

A
  • 70/30: 70% NPH and 30% regular; Humulin (stable 10d room temp) or Novolin 70/30 (stable 14d room temp) - Rx or OTC
  • Also 75/25 and 50/50 mixes made with lispro protamine and lispro (stable 10d room temp)
  • If contain rapid-acting: give 15 minutes before meal
  • If contain regular insulin: give 30 minutes before meal
52
Q

Initiating Basal-Bolus Insulin Regimen

A
  1. Calculate TDD (0.5 u/kg/d, using TBW)
  2. Divide TDD by 50% - 50% basal and other 50% rapid
  3. Divide rapid-bolus units by three for meals (can allocate for larger/smaller meals too)
53
Q

Initiating NPH-Regular Insulin Regimen

A
  • NOT preferred
  • Lower cost and less injections overall though
  • Same TDD calculation but 2/3 is NPH and 1/3 is regular
54
Q

ICR for Regular Insulin

A
  • Rule of 450

- 450/TDD = grams of carbs covered by 1u of regular insulin

55
Q

ICR for Rapid-acting Insulin

A
  • Rule of 500

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

56
Q

CF for Regular Insulin

A
  • 1500 Rule

- 1500/TDD = CF for 1 unit of regular insulin

57
Q

CF for Rapid-Acting Insulin

A
  • 1800 Rule

- 1800/TDD = CF for 1 unit of rapid-acting insulin

58
Q

BID NPH => QD Glargine

A
  • Exception to 1:1 Dosing Conversion

- 80% of NPH TDD => Glargine once daily dose

59
Q

Toujeo => Insulin Glargine or Determir

A
  • Exception to 1:1 Dosing Conversion

- 80% of Toujeo dose for insulin glargine or detemir

60
Q

Drugs that Increase BG

A
  • B-blockers
  • Thiazide and Loop diuretics
  • Tacrolimus and cyclosporine
  • PI
  • Quinolones
  • antipsychotics
  • Statins
  • Steroids (systemic)
  • Cough syrups
  • Niacin
61
Q

Drugs that Decrease BG

A
  • B-blockers
  • Quinolones
  • Tramadol
62
Q

If cancer present, avoid…

A
  • Pioglitazone (bladder)

- GLP-1a (thyroid, medullary thyroid carcinoma)

63
Q

If gastroparesis/GI disorders present, avoid…

A
  • GLP-1a

- Pramlintide

64
Q

If genital infections/UTI present, avoid…

A

-SGLT2i

65
Q

If HF present, avoid…

A
  • TZDs
  • Alogliptin
  • Saxagliptin
66
Q

If hepatotoxicity present, avoid…

A
  • TZDs

- Alogliptin

67
Q

If hypoglycemia present, avoid…

A
  • Sulfonylureas
  • Meglitinides
  • Insulin
  • Pramlintide
68
Q

If hypokalemia present, avoid…

A

-Insulin

69
Q

If Ketoacidosis present, avoid…

A
  • SGLT2i (D/C prior to surgery to reduce risk)

- Increased risk with renal impairment, dehydration, acute illness

70
Q

If lactic acidosis present, avoid…

A
  • Metformin

- Increased risk with renal impairment, alcoholism, hypoxia

71
Q

If osteopenia/osteoporosis present, avoid…

A
  • Canagliflozin (Decreases BMD, fracture risk)

- TZDs (Fracture risk)

72
Q

If pancreatitis present, avoid…

A
  • GLP-1a

- DPP4i

73
Q

If peripheral neuropathy, foot ulcers, or PAD are present, avoid…

A

-Canagliflozin

74
Q

If severe sulfa allergy is present, avoid…

A

-Sulfonylureas (or use cautiously)

75
Q

If renal insufficiency (CrCl/eGFR < 30) is present, avoid…

A
  • Metformin
  • SGLT2i
  • Exenatide
  • Glyburide
  • May need to start insulin at a lower dose
76
Q

If weight gain/obesity is present, avoid…

A
  • Sulfonylureas
  • TZDs
  • Meglitinides
  • Insulin

NAPLEX (59 decks)

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