Diabetes Flashcards
what 2 things causes hyperglycemia in diabetes
decreased insulin secretion and decreased insulin sensitivity
what type of cells produces insulin
beta-cells
what organ produces insulin
pancreas
where does insulin cause glucose to go
into body cells
glycogen
quick glucose reserve stored for later use by liver cells
what cells produces glucagon
alpha-cells
what does glucagon do
turns glycogen into glucose
ketones
what glucagon signals fat cells to make for energy source if glycogen in depleted
type 1 diabetes
autoimmune destruction of beta-cells
body uses ketones from fat for energy
very low or absent c-peptide level
what age can be first diagnosed with type 1 diabetes
children
c-peptide test
used to determine if patient is still producing insulin
type 2 diabetes
insulin resistance and deficiency
obesity, physical inactivity, family history
can be managed with lifestyle modifications alone or with oral and/or injectable medications
prediabetes
increased risk of developing diabetes
BG higher than normal
dietary and exercise recommendations
how often should prediabetes be monitored for DM
annually
who can esp. benefit from metformin in prediabetes
BMI 35 or more
history of GDM
diabetes in pregnancy
prior to becoming pregnant or during pregnancy (GDM)
puts babies at risk for diabetes and obesity to have mother with hyperglycemia during pregnancy
macrosomia
babies born to mothers with hyperglycemia in pregnancy are larger than normal
Oral glucose tolerance test (OGTT)
used to test pregnant women with GDM
preferred first treatment for GDM
lifestyle (diet and exercise)
preferred medication for GDM
insulin
DM risk factors
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
Symptoms of hyperglycemia
polyuria
polyphagia
polydipsia
fatigue
DKA in T1D
what is the most common initial presentation of T1DM
DKA
when should everyone begin being tested for DM
35
when should asymptomatic children be tested for DM
overweight with at least 1 other risk factor
3 diagnostic tests for DM
A1C (shows BG over 3 months)
FPG (fast for 8 hours or longer)
OGTT (measure BG 2 hours after drinking sugary liquid)
what is the A1C criteria for diabetes
6.5 or more
what is the A1C criteria for prediabetes
5.7-6.4
what is the FPG criteria for diabetes
126 or more
what is the FPG criteria for prediabetes
100-125
what is the OGTT criteria for diabetes
200 or more
what is the OGTT criteria for prediabetes
140-199
what is next step after test diagnosis DM
confirm with second abnormal test unless there is clear clinical diagnosis (class symptoms plus abnormal test)
what is the A1C goal in non-pregnant DM
<7
<6.5 may be acceptable if can be reached without significant hypoglycemia
<8 may be appropriate if severe hypoglycemia, limited life expectancy
what is the preprandial goal for non-pregnant DM
80-130
what is the preprandial goal in GDM
95 or less
what is the 1-hr PPG in GDM
140 or less
what is the 2-hr PPG in non pregnant DM
<180
What is the 2-hr PPG in GDM
120 or less
how often should glycemic control be tested
every 3 months if not at goal
every 6 months if at goal
how to convent A1C to eAG
A1C 6% = 126 mg/dL eAG
each addition 1% inc = inc eAG by 28 mg/dL
goal waist circumferance
<35 female
<40 male
should T1DM or T2DM use carb counting with prandial insulin matches carb intake
T1DM
1 serving of carbs
15 g
one small piece of fruit
1 slice of bread
1/3 c cooked rice/pasta
physical activity goals
150 minutes/week over 3 or more days
stand every 30 minutes
microvascular disease examples
retinopathy
nephropathy
peripheral neuropathy
autonomic neuropathy (gastroparesis, loss of bladder control, ED)
macrovascular disease examples
same as ASCVD
CAD (inc. MI)
CVA (inc stroke)
PAD
when should aspirin 81 mg/day be used
ASCVD secondary prevention
not primary prevention; can consider if high risk
use in pregnancy to dec risk of preeclampsia
diabetic retinopathy screening
eye exam with dilation at DM diagnosis
how often should eye exam be repeated if abnormal (retinopathy)
annually
vaccination recommendation
Hepatitis B series
yearly Influenza
Pneumococcal per guidelines
neuropathy testing frequency
annually
what should be used for neuropathy test
10-g monofilament test and 1 other (pinprick, temperature, vibration) to test sensation
what are treatment options for neuropathy
pregabalin
duloxetine
gabapentin
what are every day foot care counseling tips
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
how often should comprehensive foot exam be done
annually
who should receive high-intensity statin
diabetes + ASCVD
50-75 w/ multiple ASCVD risk factors
who should receive moderate-intensity statin
diabetes + age 40-75 w/o ASCVD
diabetes + age <40 + ASCVD risk factors
when should ezetimibe be added-on to maximally tolerated statin
ASCVD 10-yr risk >20%
how often should lipids be monitored
annually
how often should urine albumin and eGFR be monitored for diabetic kidney disease if normal kidney function
annually
how often should urine albumin and eGFR be monitored for diabetic kidney disease if abnormal kidney function
twice yearly if eGFR 30-60
what should be used to treat diabetic kidney disease with albuminuria
ACEI or ARB
what should be used to treat diabetic kidney disease if eGFR 25 or more and urine albumin 300 or more
SGLT2i
albuminuria criteria
either urine albumin 30 mg/24 hours or UACR 30 mg/g
BP goal
<130/80 (esp ASCVD or 10-yr risk 15% or more)
<140/90 if ASCVD risk <15%
what should be used to treat BP if no albuminuria
ACEI/ARB
thiazide
DHP CCB
what should be used to treat BP if albuminuria
ACEI/ARB
what natural products can decrease BG
cinnamon
alpha lipoic acid
chromium
generally first-line treatment
Metformin
what should be added to metformin if ASCVD or high risk (55 or older with CAD, carotid or lower extremity artery stenosis >50%, LVH)
GLP1 with proven ASCVD benefit: liraglutide, dulaglutide, SC semaglutide
SGLT2i with proven ASCVD benefit: canagliflozin, dapagliflozin, empagliflozin
what should be added to metformin and SGLT2i or GLP1 if still above goal after adding med for ASCVD, HF, CKD
GLP-1if not started: liraglutide, dulaglutide, etc.
SGLT2i if not started: canagliflozin, dapagliflozin, empagliflozin, etc.
TZD: pioglitazone, rosiglitazone
basal insulin
sulfonylureas: glipizide, glimepiride, glyburide
what drug should be added to metformin if HF
SGLT2i with benefit: canagliflozin, dapagliflozin, empagliflozin
what drug should be added to metformin if CKD
SGLT2i with benefit (preferred if albuminuria): canagliflozin, empagliflozin, dapagliflozin
GLP-1 with benefit: liraglutide, dulaglutide, semaglutide
best for hypoglycemic risk
DPP-4i: sitagliptin, linagliptin
GLP-1: liraglutide, dulaglutide
SGLT2i: canagliflozin, dapagliflozin, empagliflozin
TZD: pioglitazone, rosiglitazone
best for weight loss
GLP-1: liraglutide, dulaglutide
SGLT2i: canagliflozin, dapagliflozin, empagliflozin
best for cost
SU: glipizide, glimepiride, glyburide
MOA of metformin
dec hepatic glucose production
inc insulin sensitivity
dec intestinal absorption of glucose
use is dependent on eGFR
metformin dosing
IR: 500 mg daily
titrate weekly
usual maintenance: 1000 mg BID
max dose: 2000-2550 mg/day
give with meal to dec GI upset
metformin BBW
lactic acidosis: inc with renal impairment, contrast, excessive alcohol
metformin CI
eGFR <30
acute or chronic metabolic acidosis (inc DKA)
metformin warnings
not recommended to start if eGFR 30-45
vitamin B12 deficiency
metformin side effects
diarrhea, nausea
metformin notes
dec A1C 1-2%
weight neutral
no hypoglycemia
ER: can leave ghost tablet in stool
dose titration recommended to reduce GI effects
metformin DI
contrast: inc risk of lactic acidosis; d/c before procedure; restart after 48 hours if eGFR stable
alcohol: inc risk of lactic acidosis
SGLT2i MOA
inhibit SGLT2 receptors in proximal renal tubules - dec reabsorption of glucose and inc glucose urinary excretion
based on eGFR
“flozin”
Dapagliflozin renal dosing
eGFR <25: initiation is not recommended
empagliflozin renal dosing
eGFR <30: not recommended for glycemic control
ertugliflozin renal dosing
eGFR <45: not recommended
SGLT2i warnings
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
Canagliflozin warnings
inc risk of leg and foot amputations
hyperkalemia risk when used with other drugs that inc K
fractures
SGLT2i side effects
weight loss
inc urination
inc thirst
SGLT2i notes
reduce HF, CKD progression, and ASCVD
SGLT2i DI
diuretics, RAAS inhibitors, NSAIDs: inc risk of volume depletion = hypotension and AKI
GLP-1 MOA
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”
liraglutide dosing
daily injection
dulaglutide dosing
weekly injection
exenatide dosing
BID injection
CrCl <30: not recommended
exenatide ER dosing
weekly injection
eGFR <45: not recommended
Lixisenatide dosing
daily injection
semaglutide dosing
weekly injection or PO daily
GLP-1 BBW
all (except Byetta and Adlyxin): thyroid c-cell carcinomas
GLP-1 warnings
pancreatitis
not recommended with severe GI disease (inc. gastroparesis)
Bydureon: serious injection-site rxns w and w/o nodules
GLP-1 side effects
weight loss
nausea (reduced with dose titration)
GLP-1 notes
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
GLP-1 agonist injection counseling
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
SUs MOA
stimulate insulin secretion to dec postprandial BG
start with “g” and end in “ide”
meglitinides MOA
stimulate insulin secretion to dec postprandial BG
faster onset (15-60 min) compared to SU
end in “glinide”
SUs CI
sulfa allergy
SU warnings
hypoglycemia (don’t use older, first gen (chlorpropamide, tolazamide, tolbutamide” bc prolonged hypoglycemia)
SU side effects
weight gain
nausea
SU notes
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
meglitinides dosing
repaglinide: 15-30 min before meals
nateglinide: 1-30 min before meals
meglitinides warnings
hypoglycemia
meglitinides side effects
weight gain
sulfonylurea/meglitinide DI
in combo with insulin inc risk of hypoglycemia = avoid
DPP-4 inhibitors MOA
prevent DPP-4 breaking down incretin hormones that inc insulin release and dec glucagon secretion
“gliptin”
linagliptin dosing
only DPP-4i without renal dose adjustments
DPP-4i warnings
pancreatitis
severe arthralgia
renal failure
saxagliptin and alogliptin: risk of HF
DPP-4i notes
do not use with GLP-1 agonists (overlapping mechanism)
TZDs MOA
PPAR gamma agonist = inc peripheral insulin sensitivity
“glitazone”
TZDs BBW
cause/exacerbate HF; do not use with Class III/IV HF
TZDs warnings
edema (inc macular edema)
fractures
TZDs side effects
peripheral edema
weight gain
Alpha-glucosidase inhibitors comments
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
bile acid binding resins comments
colesevelam/Welchol
constipation is ADR
Amylin analog comments
pramlintide/Symlin
SC injection
significant hypoglycemia: reduce mealtime insulin by 50% when starting
insulin analogs
basal/rapid-acting insulin that mimics natural pattern of insulin secretion
ultra-long acting insulin
degludec
peakless
duration of 24 hr or more
mainly impact fasting glucose
available 100 units/mL and 200 units/mL
long-acting insulin
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
Intermediate-acting insulin
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
rapid-acting insulin
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
regular insulin
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
pre-mixed insulins
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
other insulins
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
insulin warnings
hypoglycemia
hypokalemia
insulin side effects
weight gain
lipoatrophy
lipohypertrophy
avoid lipoatrophy and hypertrophy by rotating injection sites
insulin storage and administration
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)
ultra-long acting insulin
degludec
peakless
duration of 24 hr or more
mainly impact fasting glucose
pre-mixed insulins
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
insulin DI
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)
what is the preferred first injectable medication for T2D?
GLIP-1s
except use insulin for initial very high BG at diagnosis (A1c >10% or BG 300 or more)
starting insulin in type 2 diabetes
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
which insulins are preferred for T1DM
rapid-acting and long-acting bc less hypoglycemia over short/intermediate
regimen for T1DM with NPH and regular
same TDD as basal/bolus but 2/3 TDD as NPH and 1/3 as regular
what is a requirement for insulin pump
multiple daily injection experience
what insulin is preferred in pump
rapid-acting
when adjust basal insulin
high/low FPG
when to adjust mealtime insulin
PPG high/low
Rule of 450
used for regular insulin
450/TDD = g of carbs covered by 1 unit insulin
Rule of 500
used for rapid-acting insulin
500/TDD = g of carbs covered by 1 unit insulin
1500 Rule
correction factor for regular insulin
shows how much his BG will drop from 1 unit of insulin
1500/TDD
1800 Rule
correction factor for rapid-acting insulin
shows how much his BG will drop from 1 unit of insulin
1800/TDD
Correction dose equation
(BG now - target BG)/correction factor = correction dose = add that many units to normally given insulin
exceptions to converting insulins
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
insulins stable at room temp for 10 days
Humalog Mix 50/50 and 75/25 pens
insulins stable at room temp for 2 weeks
Humulin N pen
Novolog 70/30 pen
insulins stable at room temp for 28 days
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
insulins stable at room temp for 31 days
Humulin R U-100, N and 70/30 vials
insulins stable at room temp for 40 days
Humulin R U-500 vial
insulins stable at room temp for 42 days
Novolin R U-100, N and 70/30 vials
Levemir vial and pen
insulins stable at room temp for 8 weeks
Tresiba pen
Toujeo pen
insulin syringe sizes
0.3 mL for up to 30 units
0.5 mL for 30-50 units
1 mL for 51-100 units
how to ID u-500 vials and needles
dark green cap on vials
green needle covers (U-100 have orange)
meaning of needle gauge
higher gauge = thinner = less pain
short needles also cause less pain
preferred length of needles for most pens
4-5 mm (shortest)
no skin pinching needed
what needles most patients use
8 mm; pinch up 2” skin when using
inject at 45 degrees in thin
count 5-10 seconds before removing needle
needles needed by obese patients maybe
12.7 mm (1/2 inch); pinch up skin when using
how to prime needle
each injection, prime needle with 2 units
preferred injection site for insulin
abdomen
what do CGMs measure
glucose level in interstitial fluid between cells
alternative BG testing sites
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
hypoglycemia
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
15 g of simple carbs
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
drugs that cause hypoglycemia
insulin
SU
meglitinides
GLP-1, DPP-4s, SGLT2i, TZDs with insulin/SU
alcohol (esp on empty stomach) with insulin/SU
drugs that mask hypoglycemia
beta blockers (esp non-selective) mask adrenergic symptoms (shakiness, anxiety) but will not mask sweating and hunger
drugs that cause hyperglycemia
preferable to avoid
beta blockers*
thiazide/loop diuretics
tacrolimus
cyclosporin
PIs
Quinolones*
antipsychotics
statins
steroids
cough syrups
niacin
drugs that lower BG
beta blockers*
quinolones*
tramadol
impatient glucose control
target usu 140-180 BG
discouraged to use SSI alone
preferred: basal, bolus, and correction
insulins used for SSI and correction dose
rapid-acting (preferred bc quicker)
regular
DKA recognition
BG >250
ketones - “fruity” breath
abdominal pain, n/v, dehydration
anion gap acidosis (arterial pH <7.35, anion gap >12)
HHS
usually from illness that leads to less fluid intake
severe dehydration w/ altered consciousness
confusion, delirium
BG >600
osmolality >320
pH >7.3
DKA and HHS treatment
aggressive fluids first
then regular insulin infusion for hyperglycemia
prevent hypokalemia
treat acidosis if pH <6.9; acidosis may correct by fluids
