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BCPS > Diabetes > Flashcards

Diabetes Flashcards

1
Q

How often to screen diabetes

A

T1DM: When symptomatic
T2DM: Every 3 years after age 35 (unless risk factors)
Prediabetes: Annually to see if T2DM
Gestational: first prenatal visit if risk factors, then at 24-28 weeks, then 4-12 weeks after delivery, then every 3 years for T2DM

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2
Q

T1 & T2DM Diagnosis Criteria

A

FPG >=126
Random glucose >=200
75 g OGTT >=200
A1C >=6.5%

Requires 2 abnormal tests from same sample OR 2 separate test samples of same test

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3
Q

Gestational Diabetes diagnosis

A

Use OGTT at 24-28 weeks
If 75 g test:
Fasting >=92
1 hr post >= 180
2 hr post >=153

If 50g test:
1hr post >=140
requires additional 100g test

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4
Q

Prediabetes diagnosis

A

FPG 100-125
OGTT 75g 2 hour post 140-199
A1C 5.7-6.4%

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5
Q

T1 & T2DM Glycemic Goals

A

A1C <7.0%
FPG 80-130
Postprandial <180
If CGM: Time in range >=70%, time below range <4%

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6
Q

Gestational DM Glycemic Goals

A

FPG <= 95
1 hour postprandial <140
2 hour postprandial <120

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7
Q

BP goal in DM

A

<130/80

Reduces microvascular AND macrovascular sequelae

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8
Q

Lipid goals DM

A

-ASCVD Risk Factor: High intensity w/ goal <70
-Established ASCVD: High intensity w/ goal <55
-40-75 w/ DM: Moderate intensity
-50-75 with risks: High intensity

If not at goal, add ezetimibe or PSK9i

Reduces macrovascular sequelae

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9
Q

Insulin affecting prandial glucose

A

Rapid acting & Short acting

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10
Q

Insulin affecting fasting glucose

A

Intermediate & Long acting

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11
Q

Initial total insulin dose for naive

A

0.3-0.6 unit/kg/day

Basal is usually 50% TDI

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12
Q

Insulin to Carbohydrate Ratio (ICR)

A

TDI/500 = amount of carbs (in g) that 1 unit of rapid acting insulin will cover

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13
Q

Insulin Sensitivity Factor (ISF)

A

1800/TDI = how much 1 unit of rapid-acting insulin will lower blood glucose

Human insulin = 1500

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14
Q

Pramlintide MOA, administration, BBW, A1c reduction

A

MOA: Amylin analog (cosecreted with insulin, similar to GLP1)

Administered SC before meals with insulin

**Must reduce rapid/short/combination insulin by 50%

BBW: Severe hypoglycemia

0.5-1% A1C reduction

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15
Q

Initial DOC for T2DM

A

Metformin

Consider combination therapy is initial A1C>= 1.5% personal goal

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16
Q

When to consider insulin therapy

A

AIc >- 10%
A1C > 2% above goal

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17
Q

Initial dosing basal insulin & how to adjust

A

0.1-0.3 units/kg/day

Adjust by 10-15% or 2-4 units 1-2x weekly until target FPG reached

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18
Q

When to add bolus insulin

A

If basal insulin dose >= 0.5 units/kg/day or if significant postprandial glucose excursions

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19
Q

Metformin MOA, renal adjustment, A1C effect

A

MOA: reduces hepatic gluconeogensis, increases insulin sensitivity, increases intestinal absorption of glucose

Renal adj:
CrCl <45: do not initiate. reduce dose by 50%
CrCl <30: do not initiate. discontinue.

1-2% A1C reduction

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20
Q

Sulfonylureas MOA, AE, A1C, glycemic effect

A

MOA: bind to receptors on pancreatic B cells to stimulate insulin secretion

AE: Hypoglycemia, weight gain

Glipizide > glyburide or glimepiride for older adults or renal impairment

Reduce or d/c when starting bolus insulin d/t hypoglycemia

1-2% A1C reduction

Fasting & prancial glucose

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21
Q

Meglitinides MOA, AE, A1C reduction, glycemic effect

A

Nateglinide, repaglinide
MOA: increase insulin secretion from pancreas

AE: hypoglycemia, weight gain
Caution repaglinide + gemfibrozil

0.5-1.5% A1C reduction

Prandial glucose

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22
Q

Pioglitazone MOA, AE, BBW, A1C reduction, glycemic effect

A

MOA: improves insulin sensitivity

AE: weight gain (by fluid retention), proximal bone fracture, bladder cancer

BBW: Use in heart failure

Reduce dose or d/c when starting insulin due to edema

0.5-1.4% A1C reduction

Fasting & prandial

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23
Q

DPP-4 inhibitors MOA, AE, CI, A1C reduction, glycemic effect

A

Sitagliptin, saxagliptin, linagliptin, alogliptin
MOA: Inhibit enzyme responsible for breakdown of GLP-1 – although weight neutral

AE: HA, arthralgia,
Sitagliptin only: pancreatitis, angeioedema, SJS, anaphylaxis

CI: heart faliure (saxagliptin, alogliptin)

0.5-0.8% A1C reduction

Prandial

24
Q

Sitagliptin renal adjustment

A

Usual: 100mg daily
GFR 30-45: 50mg daily
GFR <30: 25mg daily

25
Q

Saxagliptin renal adjustment

A

Usual: 5mg daily
GFR <45: 2.5mg daily
Strong 3A4 inhibitor: 2.5mg daily

26
Q

Alogliptin renal adjustment

A

Usual: 25mg daily
CrCl 30-59: 12.5mg
CrCl < 30: 6.25mg

27
Q

SGLT2i MOA, A1C reduction, glycemic effect

A

Canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, bexagliflozin
MOA: Increase urinary glucose excretion by blocking normal reabsorption in proximal convoluted tubule

AE: rare euglycemic DKA & fournier’s gangrene

D/C 3-4 days before surgery

0.5-0.8% A1C reduction

Fasting & prandial

28
Q

SGLT2i with CV benefit

A

Empagliflozin
Dapagliflozin
Canagliflozin

29
Q

SGLT2i with renal benefit

A

Empagliflozin
Dapagliflozin
Canagliflozin

Initiate if GFR >20 and Urinary albumin:creatinine >=200; target 30% albuminuria reduction

30
Q

SGLT2i with HF benefit

A

Empagliflozin
Dapagliflozin
Canagliflozin
Ertugliflozin

31
Q

Canagliflozin renal dosing

A

Usual: 100mg - 300mg max (before first meal)
GFR 30-59: 100mg daily
GFR <30: do not initiate. May continue if already on if albuminuria >300

32
Q

Dapagliflozin renal dosing

A

Usual: 5-10mg qAM
GFR <25: not recommended. May continue if already on until dialysis

33
Q

Empagliflozin renal dosing

A

Usual: 10-25mg qAM
GFR <20: do not initiate, but may continue until dialysis

34
Q

Ertugliflozin renal dosing

A

Usual 5-15mg qAM
GFR <45: do not initiate; discontinue

35
Q

Bexagliflozin renal dosing

A

Usual: 20mg qAM
GFR <30: do not initiate; discontinue

36
Q

GLP-1 agonists for DM (AE, A1C reduction, glycemic effect)

A

Exenatide, Liraglutide, Lixisenatide, Dulaglutide, Semaglutide

Hypoglycemia may occur with sulfonylurea

Caution: hx of pancreatitis, gastroparesis, Personal/family hx medullary thyroid cancer (lira, sema, dula, exena)

0.8-1.6% A1C reduction

Daily dosing: prandial
Weekly dosing: Fasting

37
Q

Tirzepatide A1C reduction, glycemic effect

A

2-2.3%

Fasting & prandial

38
Q

Alpha-glucosidase inhibitors MOA, CI, A1C reduction, glycemic effect

A

Acarbose, miglitol

MOA: slow absorption of glucose by slowing breakdown of large carbs into smaller sugars

CI: IBD, intestinal obstruction

0.5-0.8% A1C reduction

Prandial

Weight loss

39
Q

Colesevelam CI, A1C reduction, glycemic effect

A

Bile acid sequesterant that reduces hepatic gluconeogenesis

CI: TG > 500

0.3-0.5% A1C reduction

Prandial

40
Q

Bromocriptine MOA, AE, A1C reduction, glycemic effect

A

MOA: Dopamine agonist; may reset circadian rhythm to reduce caloric intake - not well understood

AE: N/V/HA, syncope

Caution with other dopamine antagonists

0.1-0.6% reduction in A1C

Fasting & prandial
Possible CV benefit

41
Q

Inpatient glycemic goal

A

140-180

Start insulin if >180

42
Q

Inpatient glycemic management

A

Basal insulin
+/- bolus insulin if eating

Do not only use sliding scale

43
Q

Level 1 hypoglycemia

A

<70 but >=54 with or without symptoms

Give 15-20g glucose, check BG 15min, give another dose until normalized then eat meal/snack

44
Q

Level 2 hypoglycemia

A

<54 - clinically significant

Give 15-20 g glucose, recheck BG after 15 min, then give another 15-20g if needed, once normal give meal/snack

45
Q

Level 3 hypoglycemia

A

Altered mental and/or physical status

Glucagon 1mg SC or IM or 3mg nasally

46
Q

DKA fluid replacement

A

0.45-0.9% NS

Change to D5W1/2NS when BG <200

47
Q

DKA insulin therapy

A

0.1 unit/kg regular insulin
Then 0.1 unit/kg/hr drip
Recheck BG at first hour. If <10% decrease, give 0.14 unit/kg IV bolus

Reduce to 0.02-0.05 unit/kg/hr when BG <200

Pause if K<3.3

48
Q

DKA Potassium therapy

A

Hold if >5.3
<5.3 but >3.3: Fluids containing 20-30mEq/L K
<3.3: potassium 20-30 mEq/hr

49
Q

DKA Bicarbonate therapy

A

May use if serum pH <6.9

50
Q

DKA Goals of Therapy (considered resolved when..)

A

Venous pH >7.3
Serum bicarbonate >= 15
Anion gap <= 12

51
Q

Albuminuria

A

Need 2/3 specimens with urinary albumin excretion >30mg/g over 3-6 months for diagnosis

Use ACE/ARB

52
Q

When to screen microvascular complications

A

Initially at T2DM Diagnosis
After 5 years of T1DM Diagnosis

Then Annually

53
Q

Neuropathy Treatment

A

TOC: glycemic control to minimize progression

TCAs (amitriptyline, desipramine)
Gabapentin, pregabalin, lamotrigine
Duloxetine, paroxetine, citalopram, venlafaxine
Tramadol, APAP
Tapentadol ER
Topical capsaicin

54
Q

FDA approved neuropathy agents

A

TCAs
Pregabalin
Duloxetine
Tapentadol ER

55
Q

Diabetes Insipidus, central & nephrogenic tx

A

Decreased antidiuretic hormone (vasopressin)

Central: desompressin with or without chlorpropamide, carbamazepine

Nephrogenic: thiazide, indomethacin, Na restriction

BCPS (34 decks)

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