diabetes Flashcards
Dx of prediabetes
- A1c: 5.7-6.4%
- FPG:100-125
- OGTT: 140-199
Dx of DM
- A1c >6.5
- FPG: >126
- OGTT: > 200
glycemic target in DM: not pregnant
A1c: <7
pre-prandial: 80-130
2-hr PPG: <180
glycemic target in DM: pregnant
pre-prandial: < 95
1-hr PPG: < 140
2-hr PPG: < 120
microvascular disease
retinopathy, DKD, peripheral neuropathy, autonomic neuropathy (gastroparesis, loss of bladder control, ED)
macrovascular disease
CAD, CVA, PAD`
ASA for ppx in DM
recommended for secondary prevention or in pregnancy to prevent preclampsia
Cholesterol control in DM
-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
diabetic retinopathy
eye exam
vaccinations for patients with diabetes
HBV, influenza, pneumococcal
DKD
-monitor urine albumin and eGFR annually
-treat albuminuria with ACEi or ARB
-if eGFR > 25 mL/min and urine albumin > 300: SGLT2
neuropathy
-foot exams
-pregabalin, duloxetine, or gabapentin
blood pressure
- <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
natural products
cinnamon, alpha lipoic acid, chromium
first-line treatment for T2DM
metformin + life style changes
second drug regardless to A1c
-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
DO NOT COMBINE
DPP-4i + GLP-1a
SU + Insulin
second drug if A1c is above goal & no ASCVD, HF, or CKD
-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
Biguanide
-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
SGLT2
-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
Glucagon-like peptide 1 agonists (GLP-1a)
-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
Insulin secretagogues: SU
-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
Insulin secretagogues: meglitinides
-repaglinide and nateglinide
-hypoglycemia
-weight gain
Dipeptidyl Peptidase 4 inhibitors (DPP4-i)
-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
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
Alpha-Glucosidase inhibitors
-Acarbose (Precose)
-inhibit metabolism of intestinal sucrose
-each dose should be taken with first bite of each meal
Metformin/pioglitazone (Actoplus)
metformin + TZD
Metformin/sitagliptin (Janumet)
metformin + DPP-4 inhibitor
Metformin/Canagliflozin (Invokamet)
metformin + SGLT2
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
intermediate-acting insulin
-insulin NPH
-can be used as basal insulin
-onset of 1-2 hrs and peaks at 4-12 hrs
-dosed BID
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
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)
concentrated insulin
for those that require > 200 IU/day
Mixed insulin
-70 NPH/ 30 R (Humulin 70/30, Novolin 70/30)
-75/25 mix (lispro protamine/lispro)
-50/50 (lispro protamine/lispro)
starting insulin in T2DM
- add basal insulin: 10 IU SC QD or 0.1-0.2 SC/kg/day and titrate base on FPG
- 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
starting insulin in T1DM
- 0.5 IU kg/day
- insulin dosed on TBW
- 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
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
adjusting basal insulin
low BG trend: decrease the basal or NPH insulin dose
high BG trend: incr basal or NPH insulin dose
postprandial BG high or low
-if following same meal on most days - regular or rapid-acting insulin dose taken prior should be increased/decreased
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
mealtime dosing
- use the same insulin dose every time
- 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
ICR: Rule of 450 FOR REGULAR
450/TDD of insulin = g of carbohydrates covered by 1 IU of regular insulin
ICR: Rule of 500 FOR RAPID-ACTING
500/TDD of insulin = g of carbohydrates covered by 1 IU of rapid-acting insulin
Correction factor: 1500 Rule FOR REGULAR
1500/TDD of insulin = correction factor for 1 IU of regular insulin
Correction factor: 1800 Rule FOR RAPID-ACTING
1800/TDD of insulin = correction factor of 1 IU of rapid-acting insulin
correction dose
(BG now) - (target blood glucose) / correction factor = correction dose
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
Room temperature stability: 10 days
humalog mix 50/50 and 75/25 pens
humulin 70/30 pen
Room temperature stability: 14 days
humulin N pen
novolog mix 70/30 pen
Room temperature stability: 31 days
Humulin R U-100, N and 70/30 vials
Room temperature stability: 40 days
humulin R U-500 vial
Room temperature stability: 42 days
Novolin R U-100, N, and 70/30 vials, levemir vial and pen
Room temperature stability: 56 days
tresiba, toujeo
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
hypoglycemia
dizziness, anxiety/irritability, shakiness, headache, diaphoresis, hunger, cofnusion
-severe hypoglycemia can cause seziures, coma, and death
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
hypoglycemia tx for those unconcious
dextrose or glucagon
drugs that cause hypoglycemia
insulin, SU, meglitinides, alcohol, beta blockers
drugs that increase BG
BB, thiazide, loop diuretics, tacrolimus, cyclosporine, protease inhibitor, quinolones, antipsychotics, statins, steroids, cough syrups, niacin
drugs that decrease BG
BB, quinolones, tramadol
Diabetic Ketoacidosis
-high BG, ketoacidosis, and ketonuria
-BG > 250, ketones, abdominal pain, nausea, vomiting, dehydration
-anion gap
Hyperosmolar hyperglycemic state
-severe dehydration with altered consciousness
-confusion, delirium
-BG > 600
-extreme dehydration
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
if presents with: cancer
avoid GLP-1a
if presents with: gastroproesis, GI disorder
Avoid GLP-1a and pramlintide
if presents with: genital infection/UTI
avoid SGLT2
if presents with: HF
avoid TZDs, alogliptin, saxagliptin
if presents with: hypoglycemia
avoid insulin, SU, meglitinides, and pramlintide
if presents with: hypotension/dehydration
avoid SGLT2
if presents with: hypokalemia
avoid insulin
if presents with: ketoacidosis
avoid SGLT2
if presents with: lactic acidosis
avoid metformin
if presents with: osteopenia/osteoprosis
avoid canagliflozin and SU
if presents with: pancreatitis
avoid DPP-4 i, GLP-1a
if presents with: peripheral neuropathy, PAD, foot ulcers
avoid canagliflozin
if presents with: sulfa allergy
avoid SU
if presents with: renal insufficiency
avoid metformin, SGLT2 inhibitors, exenatide, glyburide
