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Naplex 2023 > Diabetes > Flashcards

Diabetes Flashcards

1
Q

what 2 things causes hyperglycemia in diabetes

A

decreased insulin secretion and decreased insulin sensitivity

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2
Q

what type of cells produces insulin

A

beta-cells

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3
Q

what organ produces insulin

A

pancreas

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4
Q

where does insulin cause glucose to go

A

into body cells

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5
Q

glycogen

A

quick glucose reserve stored for later use by liver cells

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6
Q

what cells produces glucagon

A

alpha-cells

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7
Q

what does glucagon do

A

turns glycogen into glucose

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8
Q

ketones

A

what glucagon signals fat cells to make for energy source if glycogen in depleted

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9
Q

type 1 diabetes

A

autoimmune destruction of beta-cells
body uses ketones from fat for energy
very low or absent c-peptide level

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10
Q

what age can be first diagnosed with type 1 diabetes

A

children

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11
Q

c-peptide test

A

used to determine if patient is still producing insulin

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12
Q

type 2 diabetes

A

insulin resistance and deficiency
obesity, physical inactivity, family history
can be managed with lifestyle modifications alone or with oral and/or injectable medications

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13
Q

prediabetes

A

increased risk of developing diabetes
BG higher than normal
dietary and exercise recommendations

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14
Q

how often should prediabetes be monitored for DM

A

annually

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15
Q

who can esp. benefit from metformin in prediabetes

A

BMI 35 or more
history of GDM

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16
Q

diabetes in pregnancy

A

prior to becoming pregnant or during pregnancy (GDM)
puts babies at risk for diabetes and obesity to have mother with hyperglycemia during pregnancy

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17
Q

macrosomia

A

babies born to mothers with hyperglycemia in pregnancy are larger than normal

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18
Q

Oral glucose tolerance test (OGTT)

A

used to test pregnant women with GDM

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19
Q

preferred first treatment for GDM

A

lifestyle (diet and exercise)

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20
Q

preferred medication for GDM

A

insulin

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21
Q

DM risk factors

A

physical inactivity
BMI >25 (23 in Asian-Americans)
race/ethnicity: AA, Asian-American, Latino/Hispanic-American, Native American, Pacific Islander
history of GDM
A1C 5.7 or more
first-degree FH
increasing age

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22
Q

Symptoms of hyperglycemia

A

polyuria
polyphagia
polydipsia
fatigue
DKA in T1D

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23
Q

what is the most common initial presentation of T1DM

A

DKA

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24
Q

when should everyone begin being tested for DM

A

35

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25
Q

when should asymptomatic children be tested for DM

A

overweight with at least 1 other risk factor

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26
Q

3 diagnostic tests for DM

A

A1C (shows BG over 3 months)
FPG (fast for 8 hours or longer)
OGTT (measure BG 2 hours after drinking sugary liquid)

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27
Q

what is the A1C criteria for diabetes

A

6.5 or more

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28
Q

what is the A1C criteria for prediabetes

A

5.7-6.4

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29
Q

what is the FPG criteria for diabetes

A

126 or more

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30
Q

what is the FPG criteria for prediabetes

A

100-125

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31
Q

what is the OGTT criteria for diabetes

A

200 or more

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32
Q

what is the OGTT criteria for prediabetes

A

140-199

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33
Q

what is next step after test diagnosis DM

A

confirm with second abnormal test unless there is clear clinical diagnosis (class symptoms plus abnormal test)

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34
Q

what is the A1C goal in non-pregnant DM

A

<7
<6.5 may be acceptable if can be reached without significant hypoglycemia
<8 may be appropriate if severe hypoglycemia, limited life expectancy

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35
Q

what is the preprandial goal for non-pregnant DM

A

80-130

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36
Q

what is the preprandial goal in GDM

A

95 or less

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37
Q

what is the 1-hr PPG in GDM

A

140 or less

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38
Q

what is the 2-hr PPG in non pregnant DM

A

<180

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39
Q

What is the 2-hr PPG in GDM

A

120 or less

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40
Q

how often should glycemic control be tested

A

every 3 months if not at goal
every 6 months if at goal

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41
Q

how to convent A1C to eAG

A

A1C 6% = 126 mg/dL eAG
each addition 1% inc = inc eAG by 28 mg/dL

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42
Q

goal waist circumferance

A

<35 female
<40 male

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43
Q

should T1DM or T2DM use carb counting with prandial insulin matches carb intake

A

T1DM

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44
Q

1 serving of carbs

A

15 g
one small piece of fruit
1 slice of bread
1/3 c cooked rice/pasta

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45
Q

physical activity goals

A

150 minutes/week over 3 or more days
stand every 30 minutes

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46
Q

microvascular disease examples

A

retinopathy
nephropathy
peripheral neuropathy
autonomic neuropathy (gastroparesis, loss of bladder control, ED)

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47
Q

macrovascular disease examples

A

same as ASCVD
CAD (inc. MI)
CVA (inc stroke)
PAD

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48
Q

when should aspirin 81 mg/day be used

A

ASCVD secondary prevention
not primary prevention; can consider if high risk
use in pregnancy to dec risk of preeclampsia

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49
Q

diabetic retinopathy screening

A

eye exam with dilation at DM diagnosis

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50
Q

how often should eye exam be repeated if abnormal (retinopathy)

A

annually

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51
Q

vaccination recommendation

A

Hepatitis B series
yearly Influenza
Pneumococcal per guidelines

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52
Q

neuropathy testing frequency

A

annually

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53
Q

what should be used for neuropathy test

A

10-g monofilament test and 1 other (pinprick, temperature, vibration) to test sensation

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54
Q

what are treatment options for neuropathy

A

pregabalin
duloxetine
gabapentin

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55
Q

what are every day foot care counseling tips

A

moisturize top and bottom of feet
do not moisturize between toes
keep toenails trimmed with nail file to not leave sharp edges
wear socks and shoes
elevate feet when sitting
each office visit take off shoes to have feet checked

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56
Q

how often should comprehensive foot exam be done

A

annually

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57
Q

who should receive high-intensity statin

A

diabetes + ASCVD
50-75 w/ multiple ASCVD risk factors

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58
Q

who should receive moderate-intensity statin

A

diabetes + age 40-75 w/o ASCVD
diabetes + age <40 + ASCVD risk factors

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59
Q

when should ezetimibe be added-on to maximally tolerated statin

A

ASCVD 10-yr risk >20%

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60
Q

how often should lipids be monitored

A

annually

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61
Q

how often should urine albumin and eGFR be monitored for diabetic kidney disease if normal kidney function

A

annually

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62
Q

how often should urine albumin and eGFR be monitored for diabetic kidney disease if abnormal kidney function

A

twice yearly if eGFR 30-60

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63
Q

what should be used to treat diabetic kidney disease with albuminuria

A

ACEI or ARB

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64
Q

what should be used to treat diabetic kidney disease if eGFR 25 or more and urine albumin 300 or more

A

SGLT2i

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65
Q

albuminuria criteria

A

either urine albumin 30 mg/24 hours or UACR 30 mg/g

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66
Q

BP goal

A

<130/80 (esp ASCVD or 10-yr risk 15% or more)
<140/90 if ASCVD risk <15%

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67
Q

what should be used to treat BP if no albuminuria

A

ACEI/ARB
thiazide
DHP CCB

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68
Q

what should be used to treat BP if albuminuria

A

ACEI/ARB

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69
Q

what natural products can decrease BG

A

cinnamon
alpha lipoic acid
chromium

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70
Q

generally first-line treatment

A

Metformin

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71
Q

what should be added to metformin if ASCVD or high risk (55 or older with CAD, carotid or lower extremity artery stenosis >50%, LVH)

A

GLP1 with proven ASCVD benefit: liraglutide, dulaglutide, SC semaglutide

SGLT2i with proven ASCVD benefit: canagliflozin, dapagliflozin, empagliflozin

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72
Q

what should be added to metformin and SGLT2i or GLP1 if still above goal after adding med for ASCVD, HF, CKD

A

GLP-1if not started: liraglutide, dulaglutide, etc.
SGLT2i if not started: canagliflozin, dapagliflozin, empagliflozin, etc.
TZD: pioglitazone, rosiglitazone
basal insulin
sulfonylureas: glipizide, glimepiride, glyburide

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73
Q

what drug should be added to metformin if HF

A

SGLT2i with benefit: canagliflozin, dapagliflozin, empagliflozin

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74
Q

what drug should be added to metformin if CKD

A

SGLT2i with benefit (preferred if albuminuria): canagliflozin, empagliflozin, dapagliflozin
GLP-1 with benefit: liraglutide, dulaglutide, semaglutide

75
Q

best for hypoglycemic risk

A

DPP-4i: sitagliptin, linagliptin
GLP-1: liraglutide, dulaglutide
SGLT2i: canagliflozin, dapagliflozin, empagliflozin
TZD: pioglitazone, rosiglitazone

76
Q

best for weight loss

A

GLP-1: liraglutide, dulaglutide
SGLT2i: canagliflozin, dapagliflozin, empagliflozin

77
Q

best for cost

A

SU: glipizide, glimepiride, glyburide

78
Q

MOA of metformin

A

dec hepatic glucose production
inc insulin sensitivity
dec intestinal absorption of glucose
use is dependent on eGFR

79
Q

metformin dosing

A

IR: 500 mg daily
titrate weekly
usual maintenance: 1000 mg BID
max dose: 2000-2550 mg/day
give with meal to dec GI upset

80
Q

metformin BBW

A

lactic acidosis: inc with renal impairment, contrast, excessive alcohol

81
Q

metformin CI

A

eGFR <30
acute or chronic metabolic acidosis (inc DKA)

82
Q

metformin warnings

A

not recommended to start if eGFR 30-45
vitamin B12 deficiency

83
Q

metformin side effects

A

diarrhea, nausea

84
Q

metformin notes

A

dec A1C 1-2%
weight neutral
no hypoglycemia
ER: can leave ghost tablet in stool
dose titration recommended to reduce GI effects

85
Q

metformin DI

A

contrast: inc risk of lactic acidosis; d/c before procedure; restart after 48 hours if eGFR stable
alcohol: inc risk of lactic acidosis

86
Q

SGLT2i MOA

A

inhibit SGLT2 receptors in proximal renal tubules - dec reabsorption of glucose and inc glucose urinary excretion
based on eGFR
“flozin”

87
Q

Dapagliflozin renal dosing

A

eGFR <25: initiation is not recommended

88
Q

empagliflozin renal dosing

A

eGFR <30: not recommended for glycemic control

89
Q

ertugliflozin renal dosing

A

eGFR <45: not recommended

90
Q

SGLT2i warnings

A

ketoacidosis (can occur with BG <250; d/c prior to surgery)
genital mycotic infections
urosepsis
pyelonephritis
necrotizing fasciitis (perineum)
hypotension and AKI from volume depletion

91
Q

Canagliflozin warnings

A

inc risk of leg and foot amputations
hyperkalemia risk when used with other drugs that inc K
fractures

92
Q

SGLT2i side effects

A

weight loss
inc urination
inc thirst

93
Q

SGLT2i notes

A

reduce HF, CKD progression, and ASCVD

94
Q

SGLT2i DI

A

diuretics, RAAS inhibitors, NSAIDs: inc risk of volume depletion = hypotension and AKI

95
Q

GLP-1 MOA

A

analogs of GLP-1 (agonist)
inc glucose-dependent secretion, dec glucagon secretion, slow gastric emptying, improve satiety, weight loss
SQ injection
some can be in combo with long-acting insulin
“tide”

96
Q

liraglutide dosing

A

daily injection

97
Q

dulaglutide dosing

A

weekly injection

98
Q

exenatide dosing

A

BID injection
CrCl <30: not recommended

99
Q

exenatide ER dosing

A

weekly injection
eGFR <45: not recommended

100
Q

Lixisenatide dosing

A

daily injection

101
Q

semaglutide dosing

A

weekly injection or PO daily

102
Q

GLP-1 BBW

A

all (except Byetta and Adlyxin): thyroid c-cell carcinomas

103
Q

GLP-1 warnings

A

pancreatitis
not recommended with severe GI disease (inc. gastroparesis)
Bydureon: serious injection-site rxns w and w/o nodules

104
Q

GLP-1 side effects

A

weight loss
nausea (reduced with dose titration)

105
Q

GLP-1 notes

A

don’t use with DPP-4 inhibitors
ASCVD benefit: lira, dula, SC sema
Byetta and Adlyxin: take within 60 min of meal
pen needles not provided in Byetta, Victoza, or Adlyxin; provided with the others (weekly injections)
dose titration recommended to reduce nausea

106
Q

GLP-1 agonist injection counseling

A

inject in abdomen
attach new pen needle each injection
press button and count 5-10 seconds before removing needle
rotate injection sites each time
dispose needles in sharps container
do not store pen with needle attached

107
Q

SUs MOA

A

stimulate insulin secretion to dec postprandial BG
start with “g” and end in “ide”

108
Q

meglitinides MOA

A

stimulate insulin secretion to dec postprandial BG
faster onset (15-60 min) compared to SU
end in “glinide”

109
Q

SUs CI

A

sulfa allergy

110
Q

SU warnings

A

hypoglycemia (don’t use older, first gen (chlorpropamide, tolazamide, tolbutamide” bc prolonged hypoglycemia)

111
Q

SU side effects

A

weight gain
nausea

112
Q

SU notes

A

dec A1C 1-2%
Glipizide IR: 30 minutes before meal
others: with breakfast; may hold doses if NPO
Glucotrol XL: ghost tablet in stool
Glimepiride, glyburide: on Beers criteria bc hypoglycemia; not best for elderly

113
Q

meglitinides dosing

A

repaglinide: 15-30 min before meals
nateglinide: 1-30 min before meals

114
Q

meglitinides warnings

A

hypoglycemia

115
Q

meglitinides side effects

A

weight gain

116
Q

sulfonylurea/meglitinide DI

A

in combo with insulin inc risk of hypoglycemia = avoid

117
Q

DPP-4 inhibitors MOA

A

prevent DPP-4 breaking down incretin hormones that inc insulin release and dec glucagon secretion
“gliptin”

118
Q

linagliptin dosing

A

only DPP-4i without renal dose adjustments

119
Q

DPP-4i warnings

A

pancreatitis
severe arthralgia
renal failure
saxagliptin and alogliptin: risk of HF

120
Q

DPP-4i notes

A

do not use with GLP-1 agonists (overlapping mechanism)

121
Q

TZDs MOA

A

PPAR gamma agonist = inc peripheral insulin sensitivity
“glitazone”

122
Q

TZDs BBW

A

cause/exacerbate HF; do not use with Class III/IV HF

123
Q

TZDs warnings

A

edema (inc macular edema)
fractures

124
Q

TZDs side effects

A

peripheral edema
weight gain

125
Q

Alpha-glucosidase inhibitors comments

A

Acarbose/Precose and Miglitol/Glyset
hypoglycemia needs glucose tablets or gel to treat
each dose with first bite of each meal
ADRs: flatulence, diarrhea, abdominal pain

126
Q

bile acid binding resins comments

A

colesevelam/Welchol
constipation is ADR

127
Q

Amylin analog comments

A

pramlintide/Symlin
SC injection
significant hypoglycemia: reduce mealtime insulin by 50% when starting

128
Q

insulin analogs

A

basal/rapid-acting insulin that mimics natural pattern of insulin secretion

129
Q

ultra-long acting insulin

A

degludec
peakless
duration of 24 hr or more
mainly impact fasting glucose
available 100 units/mL and 200 units/mL

130
Q

long-acting insulin

A

glargine, detemir
duration 24 hr or more
mainly impact fasting glucose
once daily
clear and colorless
Toujeo in concentrated 300 units/mL
do not mix with other insulins

131
Q

Intermediate-acting insulin

A

insulin NPH (Humulin N, Novolin N)
onset 1-2 hrs
peaks at 4-12 hours (can cause more hypoglycemia)
variable, unpredictable duration of action (14-24 hours)
P = protamine; delays absorption
usu BID
cloudy
OTC available

132
Q

rapid-acting insulin

A

aspart, lispro, glulisine
give bolus dose
fast onset (15 min)
inject 5-15 min before meals
peak 1-2 hours
duration 3-5 hours
use as prandial and correction (SS)
clear and colorless

133
Q

regular insulin

A

Humulin R, Novolin R
insulin U-100
short-acting insulin
onset 30 min
inject 30 min before meals
use as prandial and correction (SS)
peak 2 hours
lasts 6-10 hrs
clear and colorless
OTC available
preferred for IV (inc parenteral nutrition); prepare in non-PVC container

134
Q

pre-mixed insulins

A

70% NPH/30% regular (humulin/novolin 70/30)
available OTC
if contains rapid-acting: inject 15 minutes before meal
if contains regular: inject 30 minutes before meal

135
Q

other insulins

A

U-500: very concentrated; duration closer to NPH; BID or TID before meals; recommended only if need >200 units/day; must be prescribed U-500 insulin syringes to avoid dosing errors; do not mix with other insulin

inhaled insulin: mealtime insulin with fast absorption through lungs; CI in lung disease; monitor FEV1

136
Q

insulin warnings

A

hypoglycemia
hypokalemia

137
Q

insulin side effects

A

weight gain
lipoatrophy
lipohypertrophy
avoid lipoatrophy and hypertrophy by rotating injection sites

138
Q

insulin storage and administration

A

most vials 10 mL
most pens 3 mL
most conc 100 units/mL
do not shake (turn mixed insulins)
do not freeze or expose to extreme heat
unopened insulin in refrigerator
open insulin at room temp
never share pens (BBP)
can mix NPH and regular (or rapid-acting) insulin in same syringe (regular/rapid-acting insulin is clear and NPH makes it cloudy)

139
Q

ultra-long acting insulin

A

degludec
peakless
duration of 24 hr or more
mainly impact fasting glucose

140
Q

pre-mixed insulins

A

70% NPH/30% regular (humulin/novolin 70/30)
available OTC
if contains rapid-acting: inject 15 minutes before meal
if contains regular: inject 30 minutes before meal

141
Q

insulin DI

A

avoid with SU or meglitinides (hypoglycemia)
do not use with rosiglitazone: inc risk of HF
pramlintide: reduce meal insulin 50% when starting pramlintide (severe hypoglycemia)

142
Q

what is the preferred first injectable medication for T2D?

A

GLIP-1s
except use insulin for initial very high BG at diagnosis (A1c >10% or BG 300 or more)

143
Q

starting insulin in type 2 diabetes

A

10 units daily or 0.1-0.2 units/kg/day - titrate based on FPG

if FPG not at goal or FPG at goal but A1C above goal - add prandial insulin 4 units or 10% of basal dose once daily before largest meal; titrate based on prandial BG and add doses to other meals if needed

not at A1C goal - full basal/bolus (basal daily, bolus with meals) regimen or mixed insulin regimen twice daily

144
Q

which insulins are preferred for T1DM

A

rapid-acting and long-acting bc less hypoglycemia over short/intermediate

145
Q

regimen for T1DM with NPH and regular

A

same TDD as basal/bolus but 2/3 TDD as NPH and 1/3 as regular

146
Q

what is a requirement for insulin pump

A

multiple daily injection experience

147
Q

what insulin is preferred in pump

A

rapid-acting

148
Q

when adjust basal insulin

A

high/low FPG

149
Q

when to adjust mealtime insulin

A

PPG high/low

150
Q

Rule of 450

A

used for regular insulin
450/TDD = g of carbs covered by 1 unit insulin

151
Q

Rule of 500

A

used for rapid-acting insulin
500/TDD = g of carbs covered by 1 unit insulin

152
Q

1500 Rule

A

correction factor for regular insulin
shows how much his BG will drop from 1 unit of insulin
1500/TDD

153
Q

1800 Rule

A

correction factor for rapid-acting insulin
shows how much his BG will drop from 1 unit of insulin
1800/TDD

154
Q

Correction dose equation

A

(BG now - target BG)/correction factor = correction dose = add that many units to normally given insulin

155
Q

exceptions to converting insulins

A

NPH BID to glargine (Lantus, Toujeo) daily - use 80% of NPH dose

Toujeo to insulin glargine (Lantus, Basaglar or insulin detemir (Levemir) - use 80% of Toujeo dose hy

156
Q

insulins stable at room temp for 10 days

A

Humalog Mix 50/50 and 75/25 pens

157
Q

insulins stable at room temp for 2 weeks

A

Humulin N pen
Novolog 70/30 pen

158
Q

insulins stable at room temp for 28 days

A

Apidra, Humalog, Novolog, Amelog, Lyumjev, Fiasp vials/pens
Humalog Mix 50/50 and 75/25 vials
Novolog 70/30 vial
Novolin R U-100, N and 70/30 pens
Humulin R U-500 pen
Lantus, Basaglar, Semglee vials and pens

159
Q

insulins stable at room temp for 31 days

A

Humulin R U-100, N and 70/30 vials

160
Q

insulins stable at room temp for 40 days

A

Humulin R U-500 vial

161
Q

insulins stable at room temp for 42 days

A

Novolin R U-100, N and 70/30 vials
Levemir vial and pen

162
Q

insulins stable at room temp for 8 weeks

A

Tresiba pen
Toujeo pen

163
Q

insulin syringe sizes

A

0.3 mL for up to 30 units
0.5 mL for 30-50 units
1 mL for 51-100 units

164
Q

how to ID u-500 vials and needles

A

dark green cap on vials
green needle covers (U-100 have orange)

165
Q

meaning of needle gauge

A

higher gauge = thinner = less pain
short needles also cause less pain

166
Q

preferred length of needles for most pens

A

4-5 mm (shortest)
no skin pinching needed

167
Q

what needles most patients use

A

8 mm; pinch up 2” skin when using
inject at 45 degrees in thin
count 5-10 seconds before removing needle

168
Q

needles needed by obese patients maybe

A

12.7 mm (1/2 inch); pinch up skin when using

169
Q

how to prime needle

A

each injection, prime needle with 2 units

170
Q

preferred injection site for insulin

A

abdomen

171
Q

what do CGMs measure

A

glucose level in interstitial fluid between cells

172
Q

alternative BG testing sites

A

some meters can test in forearm, palm, or thigh
only when BG is steady
do not use after eating, after exercise, or when hypoglycemia is suspected

173
Q

hypoglycemia

A

BG <70
con contribute to falls
contributes to irreversible cognitive impairment
symptoms: sweating, hunger confusion
severe: causes seizures, come, death
report all episodes to prescriber
Treatment: rule of 15 = 15 g of glucose/simple carb; check BG in 15 min; repeat is still low; eat small meal/snack once normal
unconscious treatment: dextrose IV; glucagon 1 mg SC, nasal spray (put patient in lateral recumbent position - on side) if using glucagon

174
Q

15 g of simple carbs

A

1/2 c juice
1 c milk
4 oz regular soda
1 T honey, sugar, corn syrup
3-4 glucose tablets
1 serving glucose gel

175
Q

drugs that cause hypoglycemia

A

insulin
SU
meglitinides
GLP-1, DPP-4s, SGLT2i, TZDs with insulin/SU
alcohol (esp on empty stomach) with insulin/SU

176
Q

drugs that mask hypoglycemia

A

beta blockers (esp non-selective) mask adrenergic symptoms (shakiness, anxiety) but will not mask sweating and hunger

177
Q

drugs that cause hyperglycemia

A

preferable to avoid
beta blockers*
thiazide/loop diuretics
tacrolimus
cyclosporin
PIs
Quinolones*
antipsychotics
statins
steroids
cough syrups
niacin

178
Q

drugs that lower BG

A

beta blockers*
quinolones*
tramadol

179
Q

impatient glucose control

A

target usu 140-180 BG
discouraged to use SSI alone
preferred: basal, bolus, and correction

180
Q

insulins used for SSI and correction dose

A

rapid-acting (preferred bc quicker)
regular

181
Q

DKA recognition

A

BG >250
ketones - “fruity” breath
abdominal pain, n/v, dehydration
anion gap acidosis (arterial pH <7.35, anion gap >12)

182
Q

HHS

A

usually from illness that leads to less fluid intake
severe dehydration w/ altered consciousness
confusion, delirium
BG >600
osmolality >320
pH >7.3

183
Q

DKA and HHS treatment

A

aggressive fluids first
then regular insulin infusion for hyperglycemia
prevent hypokalemia
treat acidosis if pH <6.9; acidosis may correct by fluids

Naplex 2023 (21 decks)

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