diabetes Flashcards
prediabetes
metformin
can be used to help improve BG levels especially if pt w/ a BMI of >=35, <60 years, and women with a history of gestational mellitus
c-peptide test
used to determine if the patient is still producing insulin
this is released by the pancreas only when insulin is released
type 1 diabetes is indicated by very low or absent C-peptide level
risk factors
- physical inactivity
- overweight >25 or >23 in Asian
- gestational diabetes
- > A5.7%
- first-degree relative w/ diabetes
- HDL <35, TG> 250
- CVD, hypertension
diagnosis
- hemoglobin A1C: indicates average BG over approximately the past 3 months
- fasting blood glucose (FPG): gives BG at the moment and is taken after fasting for >=8 hrs
- OGTT determines how well glucose is tolerated by measuring BG level 2 hrs after drinking liquid that is high in glucose
diabetes diagnosis
A1C >= 6.5%
EPG>= 126
OGTT >= 200
prediabetes diagnosis
A1C >= 5.7-6.4%
EPG>= 100-125
OGTT >= 140-199
glycemic targets in diabetes
not prego
prego
not prego: A1C <7, preprandial 80-130, after meals 2 hours <180
prego: preprandial <=95, after meals 1 hour <=140 and after 2 hours <= 120
testing frequency
quarterly if not yet at goal
and biannually every 6 months if at goal
physical activity
150 min moderate-intensity per week over at least 3 days
reduce sedentary- stand every 30ming
diabetes complications
microvascular
retinopathy, kidney disease, peripheral neuropathy, autonomic neuropathy (gastroparesis, loss of bladder control, and erectile dysfunction)
diabetes complications
macrovascular
CAD, CVA, PAD, ASCVD
Natural products
cinnamon
alpha lipoic acid
chromium
pt w/ ASCVD, HF or chronic kidney disease
regardless of A1C, w/ or w/out metformin
start a GLP-1 or SGLT 2 inhibitors
if baseline A1C is 8.5%-10%
start patient on two drugs, metformin + non-insulin drug
insulin can be started if
A1C >10% or BG>= 300mg/dL
if injectable medication is preferred
GLP1 agonist over insulin is preferred
metformin
glucophage, fortamet, glumetza
boxed warning: lactic acidosis- increased renal impairment
contra: GFR <30 and chronic metabolic acidoses don’t start if GFR <45
can cause vitamin b12 deficiency
decrease A1C by 1-2%
- biguanide
metformin and topiramate
increase risk of metabolic acidosis
canagliflozin
Inovkana
don’t start if GFR <30 unless albuminuria
increased risk of leg and foot amputations, higher history of PAD, peripheral neuropathy,
risk of fractures and hyper K risk!!
-SGLT2
dapagliflozin
farxiga
do not start if GFR < 25, or even 24-45 rang…
-SGLT2
empagliflozin
jardiance
do not start if GFR <30
-SGLT2
-SGLT2 general info
safety/SE/monitoring
contra in dialysis
warning:
- ketoacidosis can occur so D/C prior to surgery
- genital mycotic infection, urosepsis, pyelonephritis, necrotizing fasciitis
- hypotension and AKI (due to volume depletion)
shown reduction in HF, CKD, and ASCVD
liraglutide
victoza
saxenda- for weight loss
daily dosing
- shown ASCVD benefit
- GLP-1 agonist
dulaglutide
trulicity
weekly dosing
- shown ASCVD benefit
- GLP-1 agonist
Exenatide
Byetta
BID dosing (give 60 min of meals)
do not start CrCl <30
- GLP-1 agonist
Exenatide ER
bydureon
weekly dosing
do not start eGFR <45
- serious injection-site reactions (abscess, cellulitis, necrosis)!
- GLP-1 agonist
lixisenatide
adlyxin
daily dosing
not recommended if eGFR< 15
- GLP-1 agonist
semaglutide
ozempic- sc - weekly
rybelsus- oral - daily
wegovy- for weight loss
- increased complications w/ diabetic retinopathy
- shown ASCVD benefit
- GLP-1 agonist
- GLP-1 agonist
general info
Safety/ SE/ monitoring
- all (except Byetta and Adlyxin): risk of thyroid C-cell carcinomas
- warning: pancreatitis, not recommended in pt w/ severe GI disease
- SE: weight loss, nausea
Notes - DO NOT use w/ DPP-4 inhibitors
- byetta and adlyxin within 60 min of meal
- pen needles are not provided with byetta, victoza, or adlyxin- provided with all other which are the weekly dose
Glipizide
Glucotrol
Glucotrol XL- OROS formulation can leave ghost tablets
glipizide IR: take 30 min before meals
- SU and meglitinides
glimepiride
Amaryl
not preferred in elderly on beer’s criteria
- SU and meglitinides
glyburide
micronized
Glynase
not preferred in elderly on beer’s criteria
- SU and meglitinides
- SU
Safety/ SE/ monitoring
contra: sulfa allergy
warning: hypoglycemia
SE: weight gain, nausea
decrease A1C by 1-2%
pt w/ G6PD deficiency can be increased risk of hemolytic anemia
repaglinide
contra w/ gemfibrozil
contra: type 1 diabetes, DKA
SE: hypo and weight gain, and upper respiratory tract infections
- SU and meglitinides
nateglinide
contra: type 1 diabetes, DKA
SE: hypo and weight gain, and upper respiratory tract infections
- SU and meglitinides
sitagliptin
Januvia
warning: pancreatitis, severe arthralgia (join pain), acute renal failure
do not use w/ glp-1 agonsts
- DPP4-inhibitor
linagliptin
Tradjenta
warning: pancreatitis, severe arthralgia (join pain), acute renal failure
do not use w/ glp-1 agonsts
- DPP4-inhibitor
pioglitazone
actos
boxed warning: can exacerbate HF, do not use w/ NYHA class III/IV HF
warning: edema, risk of fractures hepatic failure, can stimulate ovulation so unpregnant prego
SE- weight gain
- thiazolidinedione
Rosiglitazone
Avandia
boxed warning: can exacerbate HF, do not use w/ NYHA class III/IV HF
INCREASED RISK OF MI w/ this med!!
warning: edema, risk of fractures hepatic failure, can stimulate ovulation so unpregnant prego
SE- weight gain
- thiazolidinedione
- thiazolidinediones
- DPP4-Inhibitors
- sulfonylureas and meglitinides
- GLP1- agonist
- SGLT-2 inhibitors
- biguanide
MOA
- peroxisome proliferator-activated receptor gamma agonists that increase peripheral insulting sensitivity
- prevent the enzyme DDP-4 from breaking down incretin hormones
- stimulating insulin secretion for pancreatic beta-cells to decrease postprandial BG (meglitinides have faster onset and shorter duration)
- analogs of incretin hormone GLP-1, which increase glucose-dependent insulin secretion, decrease glucagon secretion, slows gastric emptying
- proximal renal tubules, prevents reabsorption of glucose
- decrease hepatic glucose production, increase insulin sensitivity, and decrease intestinal absorption of glucose
alpha-glucosidase inhibitors
acarbose
miglitol
acarbose (precose)
miglitol (Glyset)
- MOA: inhibit the metabolism of intestinal sucrose, which delays glucose absorption
does not cause hypo alone but if it does, sucrose food won’t work, use glucose tablets or gel
- each dose w/ first bite of meal
bile acid binding resin
colesevelam
Welchol
also indicated for dyslipidemia
constipation most common SE
dopamine agonist
bromocriptine
cycloset
contra in pt w/ syncopal migraines
should not be used w/ metoclopramide or other dopamine agonists
amylin analog
pramlintide
Symlin (SC injection)
MOA: control post-prandial glucose by slowing gastric emptying
admin SC before each big meal
contra: in gastroparesis
unopen insulin
refrigerate
rapid-acting (bolus) insulin
injection
aspart (Novolog)
lispro (Humalog) lispro U-200 (Humalog U-200)
glulisine (Apidra)
clear and colorless
rapid-acting (bolus) insulin
inhaled
afrezza!
clear colorless
contra in lung disease and smokers
replace inhaler ever 15 days
requires FEV1 monitoring
short-acting (bolus) insulin
regular (Humulin R, Novolin R)
prefered for IV infusion
concentrated regular (Humulin R U-500)
fives times as concentrated- recommend in pt w/ required >200 units per day
need to be prescribed U-500 syringes
admin SC!!!! not IV, IM or insulin pump!!!
intermediate-acting (basal) insulin
NPH (Humulin N, Novolin N)
cloudy!
given BID generally,
if Hypo at night, do 2/3 am and 1/3 pm
long-acting (basal) insulin
detemir (Levemir)
glargine (Lantus, Toujeo)
lantus is 100units/ml toujeo is 300 units/ml
semglee is a biosimilar interchanged w/ glargine without separate prescription but biosimilar Rezoglar to glargine can not! NEED NEW prescription
ultra-long acting (basal) insulin
degludec (Tresiba)
vial is 100units/ml but pen comes 100units/ml and 200units/ml
starting basal in type 1 and type 2
0.5 units/kg/day type 1 then divided by 2 to get basal and other is bolus
type 2 is 0.1 to 0.2 units/kg/day
insulin room temp stability
1-2 weeks
Humalog Mix 50/50 and 75/25 pens
Humlin 70/30 pen
insulin room temp stability
2 weeks
Humulin N pen
Novolog Mix 70/30 pen
insulin room temp stability
about 4 weeks
Apidra, Humalog, Novolog- vial and pen= 28 days
Humalog Mix 50/50 and 75/25 vials = 28 days
Novolog Mix 70/30 vials = 28 days
Novolin R U-100, N and 70/30 pen = 28days
Humulin R U-500 pen= 28 days
Lantus, Basaglar, Semglee vials and pen= 28 days
Humulin R U-100, N and 70/30 vials= 31 days
insulin room temp stability
about 6 weeks
Humulin R U-500 vial= 40 days
Novolin R U-100, N, and 70/30 vials= 42 days
Levemir vial and pen= 42 days
insulin room temp stability
about 8 weeks
tresiba pen = 56 days
toujeo pen = 56 days
insulin best absorbed
abdomen!
alternative sites: posterior upper arm, superior buttocks, and lateral thigh area
drugs that increase BG
beta-blockers (they can lower too)
thiazide & loop diuretics
tacrolimus
cyclosporines
PI
quinolones (can lower too)
antipsych
statins
steroids
cough syrups
niacin
drugs that lower BG hypoglycemia risk
beta blockers
quinolones
tramadol
DKA
BG >250
Ketones in urine etc.
anion gap (arterial pH <7.35, anion gap >12)
hyperosmolar hyperglycemic state (HHS)
confusion, delirium
BG >600mg/dL
extreme dehydration
pH > 7.3, bicarb 15 mEq/L
DKA and HHS tx
- fluids first for all pts (start NS, and when BG 200mg/dl switch to dex/NS)
- regular insulin infusion
- prevent hypokalemia
- tx acidosis of pH <6.9
cancer
avoid GLP-1 agonists
GI disorders, gastroparesis
avoid GLP-1 agonists, pramlintide
genital infection/UTI
avoid SGLT2
HF
avoid TZDs, alogliptin, saxagliptin
Hypoglycemia risk
avoid insulin, sulfonylureas, meglitinides and pramlintide
hypotension/dehydration
avoid SGLT2
ketoacidosis
avoid SGLT2 and remember D/C SGLT2 prior to surgery to avoid ketoacidosis
lactic acidosis
avoid metformin w/ renal impairment, alcoholism
osteopenia/osteoporosis
avoid canagloflozin, TZDs
pancreatitis
avoid DPP-4 inhibitors, GLP-1 agonists
peripheral neuropathy, PAD, foot ulcers
avoid canagliflozin
sulfa allergy, severe
avoid sulfonylureas
renal insufficiency
avoid metformin, SGLT2, exenatide, glyburide
weight gain/ obesity
avoid sulfonylureas, meglitinides, TZDs, insulin
