Diabetes Flashcards
Types of short acting insulin
Lispro (Humalog),Aspart (Novolog), Glulisine (Apidra)
(These are similar analogues of human insulin.)
Regular insulin
Types of long acting insulin
NPH
Glargine (Lantos)
Detemir (levermir)
NPH+Humulin N
Duration of action of NPH insulin
16 to 24 hours
How is NPH insulin usually administered
Two thirds in the a.m. and one third in the p.m.
How is Glargine insulin administered
It is started at 80% of the prior total insulin dose. It is split when the dose becomes greater than 60 units
Describe detemir insulin
It is similar to glargine insulin. It is not supposed to cause weight gain and it’s length of activity increases with its dose
Specifics about NPH combined with Humulin N insulin
It is actually intermediate acting. It’s onset is 1 to 2 hours, it peaks at 4 to 8 hours, and it lasts 10 to 20 hours. It is cheaper than long-acting insulin
What is the onset and duration of action of the short acting human analog insulins?
Their onset is at 15 minutes, they peak at 1 to 3 hours, and their duration is 2 to 5 hours.
How much of the daily dose of insulin in type one diabetics consists of short acting insulin?
One third of the daily insulin dose
Describe regular insulin
It’s onset of action is 30 to 60 minutes, it’s peak is 2 to 4 hours, and it’s duration is 8 to 10 hours.
What is the average dose of insulin according to the weight of the patient? How is it given?
.6 to .8 units per kilogram per day. One half is given for basal needs and one half at meals.
Describe differences in insulin action according to injection site
Availability is faster in the abdomen and slower in the thigh. Exercise increases absorption from the thigh. Injection into the arm decreases exercise – induced hypoglycemia by 60%. Injection into the abdomen decreases exercise – induced hypoglycemia by 90%.
Describe the dosing of glargine insulin.
It is usually started at 10 units per day and increased by 10 units per day until the fasting plasma glucose is less than 100.
What is a positive 50 g glucose tolerance test for gestational diabetes? When is the test administered?
It is positive if it is over 130 to 140. It is administered at 24 to 28 weeks.
How many grams of glucose are given for a three hour glucose tolerance test for gestational diabetes? What is a positive three hour glucose tolerance test?
100 g of glucose are given. A positive test consists of two or more of the following: fasting blood sugar of greater than 95, one hour greater than 180, two hours greater greater than 155, three hours greater than 140.
What kind of ongoing screening for diabetes should a mother with gestational diabetes get postpartum?
She should be screened 6 to 12 weeks postpartum, and then every three years forever.
How many jellybeans equals a 50 g glucose load?
18
What children should be screened for diabetes?
Children who have a high body mass index or whose weight is greater than 85% for their age. Children with at least two of the following risks: family history of diabetes in a first or second degree relative, high-risk ethnicity, signs or symptoms of insulin resistance (acanthosis,hypertension, dyslipidemia or polycystic ovaries).
When should children be screened for diabetes?
Every two years beginning at age 10 if they are at risk for diabetes.
What are the ADA recommendations for screening adults for diabetes?
Adults with a body mass index of greater than or equal to 25+ one additional risk should be screened. Those risks include physical inactivity, a family history of diabetes especially in a first degree relative, a high-risk ethnicity, previous gestational diabetes, a previous baby weighing more than 9 pounds, hypertension, history of vascular disease, an HDL less than 35, triglycerides greater than 250, history of impaired glucose tolerance, acanthosis nigricans or other conditions associated with diabetes.
How often and when should adults who are at risk for diabetes be screened?
They should be screened at age 45 and then every three years.
Per the USPSTF, what is the most important risk factor in screening for diabetes?
HTN
What is the treatment for pre-diabetes?
Lifestyle changes. Metformin if the patient is obese and less than 60 years old.
What A1C level is considered to be pre-diabetes?
5.7 to 6.4
Define metabolic syndrome.
Greater than or equal to three of the following: insulin resistance/glucose intolerance (FBS greater than 100), obesity (waist greater than 40 inches in men or 35 inches in women), HDL less than 50 in women or less than 40 in women, blood pressure greater than 130/85, Microalbuminuria greater than 20 µg per minute.
Metformin dosing
Start at 500 mg extended release, titrate up to 2000 mg per day. Take with meals.
Metformin should be avoided in which patients?
It should be avoided in patients with liver dysfunction, metabolic acidosis, those who are undergoing studies with contrast, and those with a low GFR. A low GFR would mean less than 1.4 in women and less than 1.5 in men.
What ethnic groups are at high risk for diabetes?
Latinos, blacks, Asians, Pacific islanders, and native Americans.
In what ways does diabetes tend to be different and Asians?
It develops at a younger age, it is less likely to be associated with obesity, and there is a higher risk of renal failure than for whites with diabetes.
What lifestyle changes should be recommended to patients with impaired glucose intolerance?
Losing 5 to 10% of body weight and performing at least 30 minutes of moderate exercise such as walking daily
What is the blood glucose level goal for diabetics who are critically ill and in intensive care setting?
140 to 180 mg/dL
What is the blood glucose level goal for inpatients who are not in intensive care?
90 to110 fasting and less than 180 postprandial.
What is the LDL level goal in diabetic patients who are unable to reach target levels with either the maximum tolerated dose of statins or due to complications from statin therapy?
A decrease in LDL to 40% from baseline.
What drugs should a patient who is older than 40, has type two diabetes and another risk factory for coronary artery disease be taking?
A statin, an angiotensin-converting enzyme inhibitor and aspirin
What percent of US people over 20 have diabetes? What will that percentage be in 2030?
10.7% now and 33.9% by 2030.
Definition of impaired fasting glucose
Fasting plasma glucose level between 100 and 125 mg/dL
Definition of impaired glucose tolerance
This is diagnosed when the two hour oral glucose tolerance test measurement is between 140 and 199 mg/dL
When should fasting glucose testing be used as opposed to two hour postprandial testing as a screening test for diabetes? What are the advantages and disadvantages of each test?
Fasting plasma glucose is easier to use in terms of cost, convenience and patient acceptability. the oral glucose tolerance test is more sensitive and somewhat more specific but is used less often because it is not as reproducible and the test is longer and more complicated than the fasting test. FPG tests for abnormalities in basal insulin and the oral glucose tolerance test tests for abnormalities in carbohydrate metabolism. Therefore confirming an abnormal initial screening test result with the other test is a good idea.
Compared with intensive lifestyle efforts alone, metformin is most likely to prevent the progression of prediabetes to diabetes in which of the following patients?
A) a 65-year-old black individual
B) a 51 year old Latina woman with a body mass index of 36 kg/m²
C) a 27-year-old American Indian with gestational diabetes
D) a 49-year-old Asian individual with postprandial hyperglycemia
B
Which one of the following tess should be used to screen for diabetes in an asymptomatic 11-year-old patient with a body mass index greater than the 95th percentile for age and sex? A. Fasting plasma glucose B. Hemoglobin A-1 C C. Two hour oral glucose tolerance D. One hour postprandial blood glucose
A
A patient with type two diabetes asked about continuous subcutaneous insulin infusion. You should counsel him that compared with multiple daily injections of insulin, continuous subcutaneous insulin infusion with lispro is associated with which of the following?
A. more postprandial glucose fluctuations
B. Greater weight loss
C. Increased likelihood of hypoglycemia
D. Greater decrease in hemoglobin
A-1C level
E. Less overall expense
D
A patient with poorly controlled diabetes and a body mass index of 37 consults you about bariatric surgery. Which of the following statements is true?
A. Diabetes control only improves in 25% of patients
B. Weight loss is higher in patients with laparoscopic adjustable gastric banding than gastroplasty
C. After 10 years of follow-up, there is no difference in diabetic control or mortality in patients with bariatric surgery compared with patients who did not have surgery.
D. Lipid levels, hypertension, and obstructive sleep apnea improve in patients who have had surgery.
D
You are transitioning from insulin infusion to subcutaneous insulin in
a 110 kg inpatient with diabetes who now has a normal dietary intake. Which one of the following is a reasonable estimate of her basal insulin needs over 24 hours?
A. Five units per day
B. 10 units per day
C. 22 units per day
D. 62 units per day
E. 80 units per day
C
In managing the nutritional needs of an inpatient the diabetes, which one of the following should you recommend?
A. A specified number of carbohydrate servings
B. Avoidance of any added sugar.
C. Avoidance of concentrated sweets.
D. A liberal diabetic diet.
E. An American diabetes Association diet.
A
A patient with type two diabetes has an allergy to aspirin. Which of the following should be substituted for aspirin for the prevention of coronary artery events? A. Diprydamole B. Sulfapyrazine C. Clopidogrel D. Ticlodipine E. Warfarin
C
True or false: a blood pressure level of 140/90 mm is an appropriate goal for a patient with type two diabetes.
False: the target blood pressure level goal for individuals with type two diabetes should be less than 130/80.
How are African-Americans with type two diabetes different from whites?
They have higher insulin resistance and somewhat lower body mass indexes than whites. They are at risk at 26 versus 30.
How do Latino Americans with type two diabetes differ from whites?
Peripheral vascular disease is 80% more common. Mortality is two times white. 50% of Latino children will develop diabetes. The rate in Latinos will double in the next 10 years.
How do you calculate the average blood sugar from the A-1 C value?
You multiply the (A-1 C value -2)x30
When do you add insulin to a diabetic regimen?
When the fasting blood sugar is consistently over 250 or a random glucose over 300.
What are exenatide and liraglutide and what do they do?
Byetta and Victoza. They are GLP-1 receptor agonists/incretin mimetics. They slow gastric emptying, promote satiety, and enhance weight loss.
Exenatide and liraglutide side effects and problems
They are very expensive. They are pregnancy category C. They may cause nausea, vomiting, diarrhea, dizziness and weight loss. They increase hypoglycemia especially with the sulfonylureas. Liraglutide may cause thyroid tumors.
What are the most effective medications to decrease postprandial glucose?
Incretin mimetics such as exenatide and liraglutide.
What are the differences in dosing between exenatide and liraglutide?
Both are injected. Exenatide is given twice per day. It may be given with insulin but not in the same syringe. Liraglutide is given once per day. it is better in renal failure. It does cause increased thyroid tumors which exenatide does not.
