diabetes Flashcards
glucagon is produced in
alpha cells in the pancrease
insulin is produced in
Beta cells in pancrease
ketones
glucagon signals fat cells to maek ketonees as an alternative energy source
DKA
typically in T1 Diabetes
C peptde level is very low or absent T1D is diagnosed
diabetes in pregnancy
before pregnancy
during pregnancy- gestational
- in anycase BG goals are more stringent
can cause fetus to be larger
oral glucose test OGTT at 24-28 weeks
symptoms
poly uria
polyphagia (hunger)
polydipsia (THIRST)
Diagnosis
HG A1C >6.5 A1C
fasting plasma glucose (8hours or more) >126
OGTT(2 hours after drinking glucose) >200
pregnant diagnosis for Diabetes
pre prandial>95. (80-130)
1 hr PPG 140. (-)
2 hour >120. (normal 180)
what are some microvascular complications of diabetes
retinopathy
diabetic kidney disease
peripheral neuropathy
autonomic neuropathy
what are some macrovascular disease
coronary artery disease (CAD) including MI
Cerebrovascular disease (CVA)
peripheral artery disease (PAD)
*kinda like ASCVD
is aspirin recomended for primary prevention
NOPE only secondary prevention
CAD/PAD aspirin + lowdose rivaroxaban
used in pregancy to reduce risk of preeclampsia
statin therapy
High if diabetes + ASCVD
age 50-75 with multiple ASCVD
moderate if diabetes with no ASCVD
diabetes +ASCVD
what are some natural products used in T2D
cinamon
alpha lipoic acid
chromium
magnesium
ginseng
treatment options
metformin- 1st line
when to use 2 drugs
A1c 8.5-10
when ASCVD risk
when to use insulin
A1C >10 or PPG >300
refer to page 616
for Treatment pathway
what is metformin
GLucophage
Biguanide that decrease hepatic glucose production, absorption of glucose in the intestines
increase insulin sensitivity
can lower 1-2%
can cause GI effects
should not be used in eGFR<30, metabolic acidosis
max 2000-2550
metformin should be stopped before
Dye use
topiramate use can increase risk of metabolic acidosis
what are some SGLT2 inhibitros
Canagliflozin invokana
dapagliflozin farxiga
empagliflozin jardiance
does SGLT2 cause weight gain
no weight losss
does metformin cause weight gain
no weight neutral
does SGLT2 cause hypoglycemia
YES
does metfomin cause hypoglycemia
nope
VITB12 defeciency
which diabetes med can be used in HF
SGLT2
dapagli
canagli
empagli
what are some risks for sglt2
dialysis
can cause hypo
<30 should not be used
urosepsis
hypotension aki ketoacidosis
how much Ac1 is reduced by SGLT2
0.7-1%
SGLT2 MOA
proximal renal tubules inhibits SGLT reducing reabsorption of glucose and increase urinary glucose excretion
GLP 1 agonist MOA
increase insulin secretion
decrease glucagon secretion
slows gastric emptying
improves satiety
weight loss
what are some GLP1
liraglutide or victoza, saxenda
dulaglutide or trulicity
semaglutide or OZempic or rybelsus is oral
how much A1c lowering by GLP
0.5-1.5
what can you not use with GLP and why
DPP4 uses same pathway
GLP can increase INR
true
weight loss is true for GLP
YES
GLP can cause hypoglycemia ?
true
sulfonylurea MOA
stimulate insulin secretion
what are some clinical pearls of sulfonul ureas
can cause weight gain
sulfa allergy
take 30 mins before meal
what are some sulfonulureas
glipizide or glucotrol
glimeperide or amaryl
glyburide or glynase
how much A1c can be reduced by sulfonulureas
1-2%
what is the MOA of meglinitides
same as sulfonylurea
what are some meglinitides
repaglinide
nateglinide
is there weight gain or hypoglycemia risk with meglinitide
YES same as sulfonyl urea
what is the MOA of DPP4
prevents enzyme DPP4 from breaking down incretin hormones, GLP1 and GIP
indirectly these hormones help to regulate GB levels by increasing insulin release and decreasing glucagon secretion
what are some DPP4
sitagliptin januvia
linagliptin trajenta
saxagliptin Onglyza
alogliptin nesina
which Dpp 4 does not require renal dose adjustment
Trajenta
how much A1c can be lowered by DPP4
0.5-0.8%
what are the side effects of DPP4
pancreatitis, severe joint pain, AKI
** do not use with GLP
moa of thiazolidinediones
PPARy agonist- peroxisome proliferator-activated receptor gamma agonist
increases insulin sensitivity
what are some thiazolidinediones
pioglitazone (actos)
rosiglitazone -avandia
what are some side effects of thiazolidinediones
can cause HF
Hepatic failure, edema fractures
can thizolidine cause weight gain or hypo glycemia
YES, low risk of hypoglycemia
what are some drug classess/ drugs used for T2DM
alpha glucosidae inhibitors
bile acid binding resins
dopamine agonist
amylin analog
what are alpha glucosidase and what is the MOA
acarbose, miglitol
inhibits the metabolism of intestinal sucrose which delays glucose absorption
Bile acid binding resins and what is the MOA
Colesevelam, Welchol
can bind and decrease absorption of other drugs
Dopamine agonist
Bromocriptine (Cycloset)
amylin analog and MOA
Pramlintide- Symlin
helps control PPG by slowing gastric emptying which suppresses glucagon secretion and increase satiety
what are basal insulin with examples
for fasting glucose with 3-4 hours onset and lasts 24 hours- peakless
glargine
detemir
degludec
What are NPH with examples
intermediate with 1-2 hours onset peaks 4-12 hours with unpredictable duration of action
Humulin novolin N
what is the work of protamine
delay absorption and duration of effects
what are rapid acting insulins and examples
bolus insulins with fast onset 15 mins ish aand peaks 1-2 hours with a duration of 3-5 hours
regular insulins
onset 30 mins with peak 2 hours and lasts 6-10 hours
what are the most important warnings for insulin
hypoglycemia and hypokalemia
weight gain
lipoatrophy
what time should rapid acting injected
5-15 mins before meals
how long before a meal should short acting be administered
30 mins before meals
which insulin can be found in RX and OTC
short acting regular insulin- humulin R and novolin R
NPH- Humulin N and Novolin N
pre mixed insulin- humulin 70/30 novolin 70/30
what is a long acting insulin
basal- detemir (levemir), glargine (lantus, toujeo, basaglar, senglee)
what are some ulta long acting basal insulin
degludec - tresiba
why should you not combine thiazolidinediones with insulin
Heart failure risk
why should insulin with sulfonylurea or meglinitide be avoided
hypoglycemia also monitor with GLP, DPP4 SGLT2
how to initiate insulin in T2DM
A1C >10% or PPBG>300 sign of DKA
add basal 10 units/ 0.1-0.2 units /kg/ day \
add 4 units or 10% of basal dose
how to initaite insulin in T1DM
rapid and long acting are preferred
0.5units/kg/day use TBW
50% basal 50% PPG (this divided by 3 since with meal
if NPH then 2/3 NPH and 1/3 regular
how to use insulin pumps
continuous dose
bolus dose- insulin to carbohydrate ratio
what is the insulin to carbohydrate ratio
grams of carbohydrate covered by 1 unit of insulin
what rule is used for regular insulin
rule of 450
what rule is used for rapid acting insulin
rule of 500
what is the ICR formula
grams of carbs covered by 1 unit of insulin =450 or 500/ TDD
correction dose
- calculate correction factor to find out how much BG will be lowered by 1 unit of insulin
- total insulin needed to return the BG to target.
BG now - target BG / Correction factor
correction factor for regular
1500/TDD= correction factor for 1 unit of insulin
correction factor for Rapid acting
1800/ TDD = correction factor for 1 unit of Rapid acting insulin
NPH to basal conversion
use 80% of NPH
toujeo to glargine
80% of toujeo
which insulins are good for 10 days
humalog 50/50 and 75/25 pens
humulin 70/30
which insulins are good for 14 days or 2 weeks
humulin N pen
novolog mix 70/30 pen
which insulin is good for 31 days
Humulin R vials
humulin N 70/30 vials
which insulin good for 40 days
Humulin R 500 vial
which humulin good for 42 days
levemir vial and pen
Novolin R and N 70/30 vials
which insulin good for 56 days
Tresiba
Toujeo
the higher the gauge the ___ the needle
thinner
thinnest gauge size
32G 28 is thickest
which size syringe requires pinching
4mm and 5mm do not require pinching
insulin injection counselling
get supplies
wash hands
NPH or protamine suspensions need to swirled or rolled
if pens invert up and down 4-5 times
clean injection site
use new needle for every application
prime the needle 2 units
turn the dosing to the required dosing
use clear insulin first if mixing NPH in a vial
best application site is the abdomen
needles more than 5mm gently pinch a 2 inch
insert needle straight down at 90 degrees or 45 if thin pt
press injection down and count 5-10 seconds
rotate injections ite
properly dispose needles
what is hypoglycemia
<70
symptoms of hypo
dizziness, sweating hunger confusion nausia
severe hypo symptoms
seizure coma death
how to tx hypo
rule of 15
15-20g of glucose
recheck after 15 mins
repeat
4oz of juice
8oz milk
4oz soda
1 tbsp sugar
3-4 glucose tabs
if unconscious how to tx hypo
IV dextrose or glucagon SC
nasal glucagon
what drugs cause Hypo
insulin
sulfonylurea and meglinitide
GLP, DPP4 TZD SGLT2 low risk alone
BB quinolones can cause both
tramadol
what drugs can cause Hyperglycemia
BB Quinolones can cause both
diuretic
tacrolimus, cyclosporine
protease inhibitor
antipsych
statins
steroids
cough syrups
niacin
what is diabetic ketoacidosis
DKA- high BG , ketoacidosis and ketonuria
BG>250
ketones
anion gap acidosis Arterial pH<7.35 anion gap>12
hyperosmolar hyperglycemic state HHS
higher mortality rate than DKA
primary cause is illness that leads to less fluid intake
leads dehydration with altered consciousness
confusion, delirium
BG>600 high osm >320
extreme dehydration
pH>7.3 bicarbonate >15
what is the tx for HHS and DKA
fluids first- start with NS, when blood glucose reaches 200mg/dL change to D5W1/2NS
regular insulin- 0.1/unit/kg bolus and then 0.1 units/kg/hr or 0.14 units/kg/hr
prevent hypokalemia- insulin shifts K into the cells
treat acidosis pH <6.9 - give sodium bicarb
what is Tx for DKA
fluids start with NS, when blood blucose 200 change to D5W1/2 NS
