Diabetes Flashcards
Microvascular complications
Retinopathy, Nephropathy , peripheral neuropathy, autonomic neuropathy (erectile dysfunction, gastroparesis, loss of bladder control, UTIs)
Rest factors for type two diabetes
- First degree relative with diabetes
- Race:Native American, African-American, Asian American, Hispanic, Pacific Islander
- Overweight with a BMI >/=25 kg/m²
- Physical inactivity
- Hypertension or taking hypertension medication
- HDL less than 35 and/or triglycerides >250
- History of cardiovascular disease
- A1C >/= 5.7%
- Women who delivered a baby weighing more than 9 pounds or who had gestational diabetes
- Women with polycystic ovary syndrome
- Other conditions associated with insulin resistance examples are severe obesity, acanthosis nigricans
Macrovascular complications
Coronary artery disease, cerebrovascular disease, peripheral artery disease
Diagnostic criteria for diabetes
- Classics symptoms such as polyuria, polydipsia, and unexplained weight loss
- Fasting plasma glucose >/= 126
- Two hour plasma glucose of greater than 200
- A1C >= 6.5%
Goals of treatment
A1C < 140/80 mmHg (ACE/ARB 1st line)
Cholesterol: LDL less than 100 (all diabetics with an LDL of 70 or higher and who are age 40–75 should be taking a moderate or high-intensity statin)
Lifestyle modifications
- Weight loss: shoot for a 7% decrease and a waist circumference less than 35 inches for females and less than 40 inches for men
- Diet: low-carb, low fat
- Exercise: at least 150 minutes per week
- All patients who smoke should receive cessation counseling
Comprehensive Care
- Primary prevention of CV disease: 81 mg aspirin if major risk factors such as family history of CVD, HTN, smoking, dyslipidemia, or albuminuria
- Nephropathy screening: annual urine test for albumin (looking for micro albumin 30-299 mg/day) ACE/ARB should be used for HTN to protect kidneys
- Retinopathy screening: annual dilated comprehensive eye exam is recommended in patients with diabetes
- Foot care: annual foot exam performed by a podiatrist and daily by patient
Vaccinations for adults with diabetes
- HepB if 19-59yo and never completed series
- Influenza: annually
- PPSV23 (pneumovax): at 2-64 yo and again at >65 if >5 years since previous vaccination
- TdaP: once afterward Td every 10 years
ADA treatment algorithm for type two diabetes
- Lifestyle modification
- Metformin monotherapy unless contraindicated
- If A1C not at goal within 3 months consider adding a second agent (sulfonylurea, TZD, DPP-4, GLP-1, insulin)
- still not at goal w/in 3 months: add 3rd agent
Biguanide
Metformin (glucophage)
PREGNANCY CATEGORY B
MOA: decrease hepatic glucose production; can also decrease intestinal absorption of glucose and improve insulin sensitivity
A1C: 1-2% decrease
Blackbox warning: lactic acidosis (more risk when used with alcohol or in the case of renal/ hepatic impairment)
Symptoms of lactic acidosis: weakness, sleepiness, decreased HR, cold, muscle pain, SOB, stomach pain, lightheaded
Contraindications: Scr >= 1.5 men or 1.4 women; CrCl < 60, metabolic acidosis, DC if patient receiving iodinated contrast media do not start until 48 hours after procedure
Warning: should be stopped in any case of hypoxia such as decompensated heart failure, respiratory failure, acute MI or sepsis; avoid in anyone with hepatic impairment
Side effects: diarrhea, nausea, vomiting, flatulence, weight neutral, Little to no risk of hypoglycemia
Metformin combo drugs
\+ Glipizide (Metaglip) \+ glyburide (Glucovance) \+ Poglitazone (Actosplus met) \+ rosiglitazone (avandamet) \+ sitagliptan (JANUMET) \+ saxagliptan (kombiglyze XR) \+ linagliptan (jentadueto) \+ alogliptan (kazano)
Sulfonylurea
Chlorpropamide (diabinese): 1st gen agent
Glipizide (glucotrol)
Glimeperide (amaryl)
Glyburide (diabeta): only one that is renally adj.
MOA: stimulate insulin secretion from the pancreatic beta cells
Warning: sulfa allergy, do not use with Meglitinides (prandin and starlix) due to similar MOA
SIDE EFFECTS: HYPOGLYCEMIA (most associated with chlorpropamide and glyburide) and weight gain
Drug interactions: do not use with insulin due to hypoglycemic
Counseling: keep away from children, do not take or not eating, recognize the signs and symptoms of low blood sugar
Meglitinides
Repaglinide (prandin)
Nateglinide (starlix)
MOA: stimulate excellent secretion from the pancreatic beta cells; do not use with sulfonylureas due to similar MOA
Dosing: take approximately 30 minutes before meals as used for postprandial glucose
Side effects: hypoglycemia, mild weight gain, upper respiratory tract infection
Drug interactions: gemfibrozil increases Prandin concentrations and can decrease blood glucose recommend Fenofibrate instead
Counseling: take 30 minutes prior to meals if you forget to take those before eating skip that does take it your next meal; do not take if not eating, keep away from children
TZD
Pioglitazone (actos)
Risoglitazone (avandia)
MOA: PPARy agonists that increase peripheral insulin sensitivity (insulin sensitizers)
Blackbox warning: make exacerbate or cause heart failure in some patients; do not initiate therapy in patients with NYHA class 3/4 heart failure
Warning: do not use Poglitazone in patients with active bladder cancer
Side effects: peripheral edema, weight gain, URTIs, CHF, increase fracture risk, increased LFTs, Poglitazone has increased risk of bladder cancer beyond one year, (increase HDL, decrease triglycerides and total cholesterol for Actos)
Counseling: may take several weeks for the drug to lower blood sugar, take once daily with or without food, contact your doctor right away if you’re passing dark colored urine, have pale stools, feel more tired than usual with your skin and/or whites of your eyes become yellow, this drug can cause water retention
Alpha glucosidase inhibitors
Acarbose (precose)
Miglitol (glyset)
Pregnancy category B
MOA: inhibit alpha glucosidases resulting in delayed glucose absorption and lowering of postprandial hyperglycemia (also causes increased satiety)
Dosing: take with the first bite of each meal (needs to be in the stomach with your food); do not use If CrCL less than 25
Contraindications: IBD, colonic ulceration, partial or complete intestinal obstruction
Side effects: G.I. effects (flatulence, diarrhea, abdominal pain), weight neutral
Counseling: this drug does not cause hypoglycemia but if hypoglycemia is present you cannot treat with sucrose, things present in fruit juices, or with table sugar/candy, you must purchase glucose tablets of gel to have on hand to treat any hypoglycemic episode as sucrose will not be absorbed normally
DPP-4 inhibitors
Sitagliptan (januvia)
Saxagliptan (onglyza)
Linagliptan (tradjenta)
Alogliptan (nesina)
Pregnancy category B
MOA: prevents DPP-4 from breaking down GLP-1 which helps to regulate blood glucose levels by increasing insulin release from the pancreatic beta cells and decreasing glucagon secretion from pancreatic alpha cells these are known as INCRETIN ENHANCERS
DOSING: ALL MUST BE RENALLY ADJUSTED EXCEPT Linagliptan
Side effects: nasopharyngitis, upper respiratory tract infections, UTIs, peripheral edema, weight neutral
Drug interactions: saxagliptan is a major 3A4 a substrate use lower doses with strong 3A4 inhibitors such as ketoconazole, clarithromycin, itraconazole, nefazodone, telithromycin; linagliptan is a major 3A4 substrate and levels are decreased by strong inducers such as carbamazepine, efavirenz, phenytoin, Rifampin, St. John’s wort
SGLT2
Canagliflozin (invokana)
Pregnancy category C
MOA: reduces reabsorption of filtered glucose and lowers the renal threshold for glucose which increases urinary glucose excretion
contraindications: severe renal impairment, end stage renal disease or on dialysis
Side effects: female genital mycotic infections, UTIs, hyperkalemia, increased urination, renal insufficiency, hypovolemia, hypotension, increased thirst, hypoglycemia (avoid high doses of insulin or insulin secretagogues initially)
drug interactions: monitor digoxin levels of taking to digoxin concurrently due to increased AUC
GLP-1
Exenatide (Byetta)
Exenatide extended release (bydureon)
Liraglutide (victoza)
Pregnancy category C
MOA: increased insulin secretion and decrease glucagon secretion, slows gastric emptying and increases satiety and may result in weight loss (INCRETIN mimetics)
Counseling: due to risk of pancreatitis seek medical help if you develop stomach pain that does not go away with it without vomiting, inject into the abdomen which is preferred, upper leg, or the back of the upper arm and count to five before withdrawing
Byetta
Should be given within 60 minutes usually 30 before the morning and evening meal
Warnings: pancreatitis can occur but occurs most commonly with risk factors such as history of pancreatitis, gallstones, alcoholism, high triglycerides; avoid in severe renal impairment and severe G.I. disease
Side effects: nausea is the primary side effect, vomiting, diarrhea, constipation, hypoglycemia in most patients, weight loss, pancreatitis
Must dispense a med guide
Drug interactions: oral contraceptive levels may be decreased and therefore should be taken one hour before Byetta injection; may enhance the anticoagulant effects of warfarin
Counseling: inject two times each day within 60 minutes of the morning and evening meal but never inject after a meal due to the risk of hypoglycemia
Only stable for 30 days outside of the refrigerator therefore discard if not used within 30 days
Bydureon
Inject SC once every seven days may inject without regard to meals but it’s MISSED within three days of next dose SKIP
Blackbox warning: thyroid C cell carcinoma contraindicated in the medullary thyroid carcinoma with those with family history or patients with multiple endocrine neoplasia syndrome type 2
Warnings: pancreatitis, avoidance of your impairment and severe G.I. disease
Effects: nausea is the primary side effect, weight loss, nodule at injection site, pancreatitis
Counseling: watch for signs of thyroid cancer including a lump or swelling in your neck, hoarseness, trouble swallowing, shortness of breath
Liraglutide (victoza)
Given without regards to meals, can be stored at room temperature for up to 30 days (once daily dosing)
Blackbox warning: thyroid c cell carcinoma
Warnings: pancreatitis use caution in moderate renal impairment use is not recommended in severe renal impairment
Side effects: nausea and 28%, diarrhea, vomiting no weight loss, less hypoglycemia than with Exenatide, pancreatitis
Drug interactions: slows gastric emptying and can reduce the extent and rate of absorption of orally administered drugs
Pramlintide (symlin)
Pregnancy category C
USED IN BOTH TYPE ONE AND TYPE TWO DIABETES
MOA: acts like amylin produced by the pancreatic beta cells to assist in postprandial glucose control. Amylin helps slow gastric emptying, prevent an increase in serum glucagon following a meal, and increases satiety
Dosing: administered by injection in the abdomen or thigh prior to each meal; skip the dose is not consuming more than 250 cal or not eating
Blackbox warning: coadministration with insulin may induce severe hypoglycemia
Contraindications: hypoglycemia unawareness
Side effects: hypoglycemia (must reduce mealtime insulin by 50%), nausea, anorexia, weight loss
Note can affect the absorption of orally administered drugs
Bile acid binding resins
Colesevelam (welchol)
It’s a category B
MOA: glycemic control mechanism is unknown but does reduce cholesterol levels
Contraindications: Bal instruction, triglycerides over 500, history of hypertriglyceridemia induced pancreatitis
Side effects: constipation, dyspepsia, nausea, bloating, can increase triglycerides by 5%
Drug interactions: separate the following medications by four hours: cyclosporine, glimepiride, glipizide, glyburide, levothyroxin, olmesartan, phenytoin and oral contraceptives
Monitor INR is given with warfarin
Rapid Acting Insulin
Aspart (novolog, novolog flex pen)
Glulisine (apidra, apidra solostar)
Lispro (humalog, humalog kwikpen)
Injected 15 minutes prior to a meal, these are gone in 3 to 5 hours
Regular or short acting insulin
Regular insulin (humulin R, novolin R)
Injected 30 minutes before a meal and the onset is at least 30 minutes and last for 6 to 10 hours
Basal insulin
NPH “intermediate” (humulin N, novolin N): given wants or twice daily and Onset of action is 1 to 2 hours with a peak of 4 to 8 hours and a duration of up 24 hours
Long-acting insulin: insulin detemir (lev emir, levemir flex pen), insulin glargine (lantus, lantus solostar): just wants or twice daily and the onset and variation is patient specific and for both the onset is around 1 to 2 hours and both last approximately 24 hours
Premixed insulins
Insulin aspart protamine suspension and insulin aspart (novolog 70/30, novolog 70/30 flex pen)
Insulin lispro protamine and insulin lispro ( humalog 50/50, humalog 50/50 kwikpen, humalog 75/25 mix and kwikpen)
Onset: 10 to 30 minutes
Peak: varies
Duration: 14 to 24 hours
The first number is the long-acting intermediate insulin and the second number is the short acting insulin
Order of onset and duration
Rapid, short acting (regular), intermediate or NPH (N or mixes), long-acting
Mixing insulins
NPH can be mixed with regular or rapid acting insulin
Clear before cloudy
Cloudy insulin
NPH
Vial size and pen size
Most are 10 ML but U-500 insulin comes in a 20 ML vial
All pens are three ML a piece
Insulin stability and other injectables at room temperature
14days: humulin N and Novolin N pens, novolog 70/30 pen
28 days: apidra, humalog, novolog, humulin N (vial), lantus, bydureon, (humalog 50/50 & 75/25, humulin 70/30, novolog 70/30—-vials)
30 days: Byetta, victoza, symlin
31 days: humulin R
42 days: novolin R, novolin N, novolin 70/30 (vial), levemir
Insulin injection sites
Preferred: abdomen (quickest absorption and most predictable)
Others: posterior upper arm, superior buttocks, lateral thigh
Alternate injection sites in the same region
Hypoglycemia
Glucose<70
Drug causes: (number one drug is insulin followed by sulfonylureas and Meglitinides)
Symptoms: dizziness, headache, anxiety, shakiness, sweating, excessive hunger, confusion, clumsy, tremors, palpitations, fast heart rate, and blurred vision
Note some non-cardioselective beta blockers such as carvedilol and propranolol can mask the symptoms
Treatment: 15-20g of glucose (1/2 cup of juice, 1cup of milk, 1tbs of sugar, 3 or 4 glucose tabs, 1 serving of glucose gel; retest glucose in 15 minutes and repeat if not above goal (note glucagon is only used if the patient is unconscious or not conscious enough to Soaptree the hypoglycemia)
Diabetic ketoacidosis (DKA)
Not enough insulin and the body breaks down fat to make energy that’s breakdown calls the concentration of Keatons in the blood to increase this can lead to coma and death
Symptoms: hyperglycemia, polyuria, polyphagia, polydipsia, blurred vision, metabolic acidosis and dehydration
Labs: glucose over 300, ketones in the urine, pH less than 7.2, bicarb less than 15, WBC 15-40
Treatment: IV fluids and insulin and correcting electrolytes (particularly sodium and potassium potassium should be greater than 3.5 as potassium will drop further once insulin is administered)
Order insulin shortest to the longest
Rapid acting>regular (R)>intermediate (NPH)> long
Onset rapid: 30 min Onset short (regular): 30-1hr Onset intermediate: 1-4 hr Onset long: 1.5 hr
Duration: 3-4hr, 3-6hr, 10-16hr, 12-24hr (levemir is 12 with some pts and should be dosed bid in those patients)
