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diabetes Flashcards

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1
Q

Dx of prediabetes

A
  1. A1c: 5.7-6.4%
  2. FPG:100-125
  3. OGTT: 140-199
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2
Q

Dx of DM

A
  1. A1c >6.5
  2. FPG: >126
  3. OGTT: > 200
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3
Q

glycemic target in DM: not pregnant

A

A1c: <7
pre-prandial: 80-130
2-hr PPG: <180

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4
Q

glycemic target in DM: pregnant

A

pre-prandial: < 95
1-hr PPG: < 140
2-hr PPG: < 120

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5
Q

microvascular disease

A

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

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6
Q

macrovascular disease

A

CAD, CVA, PAD`

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7
Q

ASA for ppx in DM

A

recommended for secondary prevention or in pregnancy to prevent preclampsia

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8
Q

Cholesterol control in DM

A

-high intensity statin: for those with DM + ASCVD or those 50-75 w/ multiple ASCVD risk factors
-moderate intensity statin: DM + 40-75 years (no ASCVD) and DM + <40 + ASCVD risk factors
-if on maximally tolerated statin and still not at goal can add ezetimibe

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9
Q

diabetic retinopathy

A

eye exam

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10
Q

vaccinations for patients with diabetes

A

HBV, influenza, pneumococcal

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11
Q

DKD

A

-monitor urine albumin and eGFR annually
-treat albuminuria with ACEi or ARB
-if eGFR > 25 mL/min and urine albumin > 300: SGLT2

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12
Q

neuropathy

A

-foot exams
-pregabalin, duloxetine, or gabapentin

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13
Q

blood pressure

A
  • <130/80 mmHg (if ASCVD > 15%)
  • <140/80 mmHg (if ASCVD < 15%)
    -no albuminuria: thiazide, DHP CCB, ACEi, or ARB
    -albuminuria: ACEi or ARB
    -CAD: ACEi or ARB
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14
Q

natural products

A

cinnamon, alpha lipoic acid, chromium

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15
Q

first-line treatment for T2DM

A

metformin + life style changes

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16
Q

second drug regardless to A1c

A

-ASCVD or high risk: GLP-1a or SGLT2
-HF: SGLT2
-CKD: SGLT2 or GLP-1a
-if ASCVD or high risk and still above goal: add GLP-1 or SGLT2 (if not added), TZD, basal insulin, SU, DPP-4i

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17
Q

DO NOT COMBINE

A

DPP-4i + GLP-1a
SU + Insulin

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18
Q

second drug if A1c is above goal & no ASCVD, HF, or CKD

A

-any class
-consider hypoglycemic risk, weight loss/gain potential, cost
-best for hypoglycemic risk: DPP-4i, GLP-1a, SGLT2, TZD
-best for weight loss: GLP-1a or SGLT2
-best for cost: SU or TZD

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19
Q

Biguanide

A

-decreasing hepatic glucose production, increasing insulin sensitivity, and decreasing intestinal absorption of glucose
-Metformin (Glucophage, Glucophage XR, Fortamet, Glumetza)
-lactic acidosis (risk increases with renal dysfunction)
-contraindicated in eGFR < 30 and do not start if eGFR 30-45
-diarrhea and nausea
-decrease A1c 1-2%, weight neutral, no hypoglycemia

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20
Q

SGLT2

A

-Canagliflozin (Invokana); Dapagliflozin (Farxiga); Empagloflozin (Jardiance)
-ketoacidosis
-genital mycotic infections, urosepsis, pyelonephritis, nec fasc (perineum)
-hypotension and AKI
-invokana: incr risk of leg and foot amputations - do not use in eGFR <30 unless albuminuria > 300
-farxiga: do not start in eGFR < 25
-Jardiance: do not use for glycemic control in eGFR < 30
-weight loss, incr urination, incr thirst

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21
Q

Glucagon-like peptide 1 agonists (GLP-1a)

A

-incr glucose-dependent insulin secretion, decrease glucagon secretion, slow gastric emptying, improves satiety
-liraglutide (victoza); Dulaglutide (Trulicity)
-increased risk of thyroid C cell carcinoma
-Warnings: pancreatitis, is not recommended in patients with severe GI disease
-Side effects: weight loss, nausea
-do not use with DPP4-i

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22
Q

Insulin secretagogues: SU

A

-Glipizide (Glucotrol, Glucotrol XL); Glimepiride (Amaryl); Glyburide
-do not use in those with sulfa allergy
-highest risk of hypoglycemia
-decreases A1c by 1-2%
-Glucotrol XL produces a ghost tablet

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23
Q

Insulin secretagogues: meglitinides

A

-repaglinide and nateglinide
-hypoglycemia
-weight gain

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24
Q

Dipeptidyl Peptidase 4 inhibitors (DPP4-i)

A

-prevent DPP4 from breaking down incretin hormones
-sitagliptin (Januvia); Linagliptin (Tradjenta)
-sitagliptin requires renal adjustment for eGR 30 and less
-warnings: pancreatitis, arthralgias, renal failure
-DO NOT USE WITH GLP1-a

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25
TZDs
-PPARy agonists that increase peripheral insulin sensitivity -pioglitazone (Actos); Rosiglitazone (Avandia) -exacerbate HF (DO NOT USE WITH NYHA III/IV), edema, risk of fractures
26
Alpha-Glucosidase inhibitors
-Acarbose (Precose) -inhibit metabolism of intestinal sucrose -each dose should be taken with first bite of each meal
27
Metformin/pioglitazone (Actoplus)
metformin + TZD
28
Metformin/sitagliptin (Janumet)
metformin + DPP-4 inhibitor
29
Metformin/Canagliflozin (Invokamet)
metformin + SGLT2
30
Basal insulin
glargine (Lantus, Toujeo), detemir (levemir), degludec (Tresiba - extra long acting) -peakless -onset of 3-4 hrs and duration > 24 hrs -impact fasting glucose -Lantus is 100 IU, toujeo is concentrated at 300 IU/mL
31
intermediate-acting insulin
-insulin NPH -can be used as basal insulin -onset of 1-2 hrs and peaks at 4-12 hrs -dosed BID
32
rapid-acting insulin
-aspart (Novolog), lispro (Humalog), and glulisine -provide bolus dose -fast onset of 15 min, peak 1-2 hrs, and duration of 3-5 hrs
33
short acting insulin
-insulin regular (Humulin R, Novolin R) -onset of 30 min, peaks at 2 hours, and lasts 6-10 hrs -preferred for IV infusions (should be prepared in non-PVC container)
34
concentrated insulin
for those that require > 200 IU/day
35
Mixed insulin
-70 NPH/ 30 R (Humulin 70/30, Novolin 70/30) -75/25 mix (lispro protamine/lispro) -50/50 (lispro protamine/lispro)
36
starting insulin in T2DM
1. add basal insulin: 10 IU SC QD or 0.1-0.2 SC/kg/day and titrate base on FPG 2. if not at goal: add prandial insulin - 4 IU or 10% of basal dose SC once daily prior to largest meal 3a: if not at goal: full basal/bolus reigmen 3b: if not at goal: mixed insulin regimen
37
starting insulin in T1DM
1. 0.5 IU kg/day 2. insulin dosed on TBW 3. 50% of the TDD is administered as basal insulin and 50% a prandial (bolus) insulin -calculate TDD (0.5 IU/kg/day, using TBW) -divide TDD into 50% basal insulin and 50% bolus (rapid-acting) insulin -divide the bolus insulin evenly among 3 meals
38
starting regimen with NPH and Regular insulin
-not preferred as it does not mimic natural insulin -2/3 of the TDD is given as NPH and 1/3 is given as regular insulin
39
adjusting basal insulin
low BG trend: decrease the basal or NPH insulin dose high BG trend: incr basal or NPH insulin dose
40
postprandial BG high or low
-if following same meal on most days - regular or rapid-acting insulin dose taken prior should be increased/decreased
41
preprandial BG high or low
-if high or low before the same meal on most days - regular or rapid-acting insulin dose taken before the previous meal should be increased/decreased
42
mealtime dosing
1. use the same insulin dose every time 2. calculate an insulin dose at each meal -bolus dose calculated with the insulin-to-carbohydrate ratio (ICR) -ICR indicates the grams of carbs covered by 1 IU of insulin
43
ICR: Rule of 450 *FOR REGULAR*
450/TDD of insulin = g of carbohydrates covered by 1 IU of regular insulin
44
ICR: Rule of 500 *FOR RAPID-ACTING*
500/TDD of insulin = g of carbohydrates covered by 1 IU of rapid-acting insulin
45
Correction factor: 1500 Rule *FOR REGULAR*
1500/TDD of insulin = correction factor for 1 IU of regular insulin
46
Correction factor: 1800 Rule *FOR RAPID-ACTING*
1800/TDD of insulin = correction factor of 1 IU of rapid-acting insulin
47
correction dose
(BG now) - (target blood glucose) / correction factor = correction dose
48
converting between insulin
-most insulin conversions are 1:1 -except NPH dosed BID > insulin glargine dosed daily --use 80% of the NPH dose -except toujeo -> insulin glargine or levemir--use 80% of the toujeo
49
Room temperature stability: 10 days
humalog mix 50/50 and 75/25 pens humulin 70/30 pen
50
Room temperature stability: 14 days
humulin N pen novolog mix 70/30 pen
51
Room temperature stability: 31 days
Humulin R U-100, N and 70/30 vials
52
Room temperature stability: 40 days
humulin R U-500 vial
53
Room temperature stability: 42 days
Novolin R U-100, N, and 70/30 vials, levemir vial and pen
54
Room temperature stability: 56 days
tresiba, toujeo
55
needle gauge
-higher the gauge, the thinner the needle -32G thinnest -28G thickest -shorter needles and higher gauge needles cause less pain -shortest needles are 4 mm and 5 mm -8 mm needles are long enough
56
hypoglycemia
dizziness, anxiety/irritability, shakiness, headache, diaphoresis, hunger, cofnusion -severe hypoglycemia can cause seziures, coma, and death
57
hypoglycemia tx: Rule 15
-pure glucose or gel is preferred 1. take 15-20 g of glucose or simple carbs 2. recheck BG after 15 min 3. if hypoglycemia continues repeat steps 1 and 2 4. once BG is normal, eat a small meal or snack
58
hypoglycemia tx for those unconcious
dextrose or glucagon
59
drugs that cause hypoglycemia
insulin, SU, meglitinides, alcohol, beta blockers
60
drugs that increase BG
BB, thiazide, loop diuretics, tacrolimus, cyclosporine, protease inhibitor, quinolones, antipsychotics, statins, steroids, cough syrups, niacin
61
drugs that decrease BG
BB, quinolones, tramadol
62
Diabetic Ketoacidosis
-high BG, ketoacidosis, and ketonuria -BG > 250, ketones, abdominal pain, nausea, vomiting, dehydration -anion gap
63
Hyperosmolar hyperglycemic state
-severe dehydration with altered consciousness -confusion, delirium -BG > 600 -extreme dehydration
64
DKA and HHS tx
-aggressive fluids (first) and insulin 1. fluids: start with NS and when glu reaches 200 mg/dL change to D5W1/2NS 2. R insulin infusion: 0.1IU/kg bolus then 0.1 IU/kg/hr continuous infusion OR 0.14 IU/kg/hr continuous 3.prevent hypokalemia 4. treat acidosis if pH < 6.9; acidosis may be corrected by fluids - give sodium bicarb
65
if presents with: cancer
avoid GLP-1a
66
if presents with: gastroproesis, GI disorder
Avoid GLP-1a and pramlintide
67
if presents with: genital infection/UTI
avoid SGLT2
68
if presents with: HF
avoid TZDs, alogliptin, saxagliptin
69
if presents with: hypoglycemia
avoid insulin, SU, meglitinides, and pramlintide
70
if presents with: hypotension/dehydration
avoid SGLT2
71
if presents with: hypokalemia
avoid insulin
72
if presents with: ketoacidosis
avoid SGLT2
73
if presents with: lactic acidosis
avoid metformin
74
if presents with: osteopenia/osteoprosis
avoid canagliflozin and SU
75
if presents with: pancreatitis
avoid DPP-4 i, GLP-1a
76
if presents with: peripheral neuropathy, PAD, foot ulcers
avoid canagliflozin
77
if presents with: sulfa allergy
avoid SU
78
if presents with: renal insufficiency
avoid metformin, SGLT2 inhibitors, exenatide, glyburide

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