Diabetes Flashcards
What is metabolic syndrome/syndrome X/insulin resistance syndome?
a collection of abnormalities that significantly increase risk of atherosclerotic disease and diabetes
What abnormalities are associated with metabolic syndrome (insulin resistance syndrome)? (5)
-Elevated plasma triglycerides
-Lower HDLS
-High blood pressure
-Abdominal obesity
-Insulin resistance
What is the criteria to Dx insulin resistance syndrome?
-HDL <40mg/dl in men, <50mg/dl female
-BP >135/85
-Trigs >150
-Fasting BG >100
-Waist 35+ in females, 40+ males
How can prediabetes be treated to prevent DM2?
-Counsel patients on diet and exercise —> weight loss
-Metformin (Glucophage) decreases risk but less dramatically
How can you prevent DM1?
No prevention but diet and exercise can reduce disease progression
Normal fasting plasma glucose and A1c
<100, <5.7
Prediabetes fasting glucose and A1c
100-125, 5.7-6.4
Fasting glucose that meets diabetes criteria and A1c
> 126, >6.5
Expected plasma glucose 2 hours after glucose load normal? prediabetic? diabetic?
<140, 140-199, >200
Criteria for diagnosis of diabetes
- FPG >126
- 2 hr post glucose load plasma glucose >200
- A1C >6.5
- In a patient w/ symptom of hyperglycemia a random BG>200
If two tests confirm diagnosis additional testing not needed, if two tests discordant tests should be repeated to confirm
When can an A1c be repeated
every 3 months
What is C-peptide?
a byproduct of insulin that is measured in type 1 diabetics, insulin is difficult to measure therefore C peptide signifies that someone is making insulin
What tests would help diagnose DM1?
- abnormal glucose
- low c-peptide
- antibody tests
- ketonemia, ketonuria, glucosuria
- Elevated plasma glucagon
- Genetic markers HLA-DR, HLA-DQ present in 90%
What antibodies are strongly associated with DM1?
Iselt autoantibodies and antibodies to glutamic acid decarboxylase (GAD)
What percentage of first degree relatives of those with DM1 also have DM1?
5-15%
What percentage of DM1 have type 1B non immune mediated? How does treatment differ?
less than 10%, treatment is the same
Which autoantibody is found in 80% of patients with type 1 at clinical presentation?
GAD 65
Which autoantibody is usually the first marker in young children?
IAA (insulin autoantibodies) in 70% of young children at time of diagnosis
Patients with absolute insulin deficiency and no evidence of autoimmunity have what type of diabetes
1B DM
What is though to cause DM1
1/3 genetic, 2/3 environmental factors such as viruses, stress, toxins, cow milk exposure, hygiene hypothesis
Physical pathology of DM1
pancreatitis from alcohol abuse, hypertriglyceridemia, or removal of pancreas due to cancer or trauma
Typical age of onset for DM2
over 40
DM2 testing should begin at age __ and be repeated every _ years
35, 3
What race is at risk for DM2
african american, american indian, asian american, pacific islander, hispanic/latino
Overweight children should be screened for DM2 if the have what risk factors?
-maternal history of DM or GDM
-1st or 2nd degree relative with DM
-At risk race/ethnicity
-Signs or conditions associated with insulin resistance
polyphagia with weight loss is seen in type 1 or 2?
Type 1
Recurrent blurred vision is seen in type 1 or 2?
type 2
Raised brown red patches on the anterior surface of the lower legs, may develop into open sores
necrobiosis lipoidica diabeticorum
What can cause hypoglycemia?
taking too much insulin, extrapancreatic tumors/insulinomas, beta cell tumors, Addison’s disease, liver dysfunction, alcoholism, ESRD
GI surgery, especially gastric bypass can cause
postprandial or reactive hypoglycemia
What Sx are associated with hypoglycemia and at what BG do they start?
BG 60-70, sweating, palpitations, anxiety, weakness, headaches, vision changes
BG 50
cognitive impairment
Insulinomas are usually from
benign adenomas of the pancreas
What is the whipple triad
hypoglycemic Sx
fasting BG of 45 or less
immediate recovery on administration of glucose
How do you treat hypoglycemia?
15-20 grams glucose or simple carbohydrates, check BG after 15 min, repeat until normal
can use glucose tablets, tube, 2 tbsp raisins, 4 oz juice or soda, 1 tbsp sugar, honey or corn syrup, 8 oz milk, 6-7 hard candies
How to treat sever hypoglycemia when the patient is severely cognitively impaired
Glucagon injection in the buttock, arm, or thigh, or Baqsimi nasal spray
When is insulin used in DM2?
When BG goals are not met with oral medication
Types of rapid acting insulin you might take before a meal (15min onset)
aspart/NovoLog
lispro/Humalog
glulisine/Apidra
Short acting insulin (also can be taken before a meal 30-60min onset)
regular insulin, Novolin R
Long acting insulin
detemir/Levemir
degludec/Tresiba
glargine/Lantus
Intermediate acting insulin (onset 30-60 min)
Humulin N
Novolin N
Glargine/Lantus onset time and peak
4-6 hours, steady all day
Detemir/Levimir onset time and peak
2-3 hours, peak 6-8 hours
Degludec/tresiba onset and peak
1-4 hours, peak 4-6 hours, duration 42 hours
a stable baseline dose of insulin is achieved through
- intermediate or long acting insulin injection
- rapid acting insulin via continuous subcutaneous insulin infusion (pump)
What type of insulin is used before a meal?
short acting 30 min before or rapid acting 15 min before
Long acting insulin given once a day is usually _____ or you can use _____ twice a day to provide a base
glargine/Lantus once a day
detemir/Levemir twice daily
With an insulin pump ____ acting insulin is given as the basal and premeal bolus of insulin
rapid
How does a sliding scale work
take BG every 4-6 hrs and give insulin based on that, may be used for meal time insulin based on how high premeal blood glucose levels are
What is initial therapy for DM2 unless contraindicated?
Metformin
Treatment for DM2 A1c <9%
lifestyle management and metformin
monitor A1c every 3 months if not at target consider dual therapy
A1c > or = 9%
lifestyle management
Dual therapy metformin + another drug
A1c every 3 months if not at target consider triple therapy
A1c > or = 10%
combination injectible therapy
Biguanide
metformin
Biguanide/metformin MOA, side effects, contraindications
MOA: inhibits gluconeogensis
sulfonylureas
glipizide, glyburide, glimepiride
Sulfonylureas MOA, side effects, contraindications
MOA: stimulates pancreatic insulin secretion
Side effects: weight gain, risk of hypoglycemia
Contraindications: caution in pt with liver or kidney failure
Thiazolidinediones
pioglitazone, rosiglitazone
Thiazolidinediones MOA, SE, Contraindications
MOA: sensitizes peripheral tissue by increasing glucose transporter expression - receptor agonist
SA: weight gain, especially with insulin or sulfonylurea, edema issues with CHF/COPD
Contraindications: active liver disease or cardiac failure
GLP1
exentatide (Byetta), liraglutide (Victoza)
GLP-1 MOA, SE, Contraindications
MOA: mimics incretin hormone that stimulates insulin in response to meals, decreases gastric emptying, suppresses glucagon
SE: nausea, vomiting, diarrhea, pancreatitis
Contraindications: FH of medullary thyroid cancer or MEN
injectable and expensive
DPP4 inhibitors
sitagliptin (Januvia)
linagliptin (tradjenta)
DPP4 inhibitors MOA, SE, contraindications
MOA: DPP breaks down GLP1, so inhibiting it increases GLP1 and GIP increasing insulin secretion
SE: weight neutral, no hypoglycemia, nausea, vomiting, nasopharyngitis
Contraindications: stop taking if pancreatitis
SGLT2 inhibitors
canagliflozin (Invokana)
dapagliflozin (Farxiga)
empagliflozin (Jardiance)
SGLT2 inhibitor MOA, SE, contraindications
MOA: blocks reabsorption of gluose in the kidneys increases excretion in the urine
SE: UTIs/yeast infections, dehydration, acidosis, risk of leg and foot amputation, CV benefit for canagliflozin and empagliflozin
