Diabetes

Question 0

Microvascular complications

Answer 0

Retinopathy, Nephropathy , peripheral neuropathy, autonomic neuropathy (erectile dysfunction, gastroparesis, loss of bladder control, UTIs)

Question 1

Rest factors for type two diabetes

Answer 1

1. First degree relative with diabetes
2. Race:Native American, African-American, Asian American, Hispanic, Pacific Islander
3. Overweight with a BMI >/=25 kg/m²
4. Physical inactivity
5. Hypertension or taking hypertension medication
6. HDL less than 35 and/or triglycerides >250
7. History of cardiovascular disease
8. A1C >/= 5.7%
9. Women who delivered a baby weighing more than 9 pounds or who had gestational diabetes
10. Women with polycystic ovary syndrome
11. Other conditions associated with insulin resistance examples are severe obesity, acanthosis nigricans

Question 2

Macrovascular complications

Answer 2

Coronary artery disease, cerebrovascular disease, peripheral artery disease

Question 3

Diagnostic criteria for diabetes

Answer 3

1. Classics symptoms such as polyuria, polydipsia, and unexplained weight loss
2. Fasting plasma glucose >/= 126
3. Two hour plasma glucose of greater than 200
4. A1C >= 6.5%

Question 4

Goals of treatment

Answer 4

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)

Question 5

Lifestyle modifications

Answer 5

1. Weight loss: shoot for a 7% decrease and a waist circumference less than 35 inches for females and less than 40 inches for men
2. Diet: low-carb, low fat
3. Exercise: at least 150 minutes per week
4. All patients who smoke should receive cessation counseling

Question 6

Comprehensive Care

Answer 6

1. Primary prevention of CV disease: 81 mg aspirin if major risk factors such as family history of CVD, HTN, smoking, dyslipidemia, or albuminuria
2. 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
3. Retinopathy screening: annual dilated comprehensive eye exam is recommended in patients with diabetes
4. Foot care: annual foot exam performed by a podiatrist and daily by patient

Question 7

Vaccinations for adults with diabetes

Answer 7

1. HepB if 19-59yo and never completed series
2. Influenza: annually
3. PPSV23 (pneumovax): at 2-64 yo and again at >65 if >5 years since previous vaccination
4. TdaP: once afterward Td every 10 years

Question 8

ADA treatment algorithm for type two diabetes

Answer 8

1. Lifestyle modification
2. Metformin monotherapy unless contraindicated
3. If A1C not at goal within 3 months consider adding a second agent (sulfonylurea, TZD, DPP-4, GLP-1, insulin)
4. still not at goal w/in 3 months: add 3rd agent

Question 9

Biguanide

Metformin (glucophage)

PREGNANCY CATEGORY B

Answer 9

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

Question 10

Metformin combo drugs

Answer 10

\+ Glipizide (Metaglip)
\+ glyburide (Glucovance)
\+ Poglitazone (Actosplus met)
\+ rosiglitazone (avandamet)
\+ sitagliptan (JANUMET)
\+ saxagliptan (kombiglyze XR)
\+ linagliptan (jentadueto)
\+ alogliptan (kazano)

Question 11

Sulfonylurea

Chlorpropamide (diabinese): 1st gen agent
Glipizide (glucotrol)
Glimeperide (amaryl)
Glyburide (diabeta): only one that is renally adj.

Answer 11

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

Question 12

Meglitinides

Repaglinide (prandin)
Nateglinide (starlix)

Answer 12

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

Question 13

TZD

Pioglitazone (actos)
Risoglitazone (avandia)

Answer 13

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

Question 14

Alpha glucosidase inhibitors

Acarbose (precose)
Miglitol (glyset)

Pregnancy category B

Answer 14

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

Question 15

DPP-4 inhibitors

Sitagliptan (januvia)
Saxagliptan (onglyza)
Linagliptan (tradjenta)
Alogliptan (nesina)

Pregnancy category B

Answer 15

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

Question 16

SGLT2

Canagliflozin (invokana)

Pregnancy category C

Answer 16

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

Question 17

GLP-1

Exenatide (Byetta)
Exenatide extended release (bydureon)
Liraglutide (victoza)

Pregnancy category C

Answer 17

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

Question 18

Byetta

Answer 18

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

Question 19

Bydureon

Answer 19

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

Question 20

Liraglutide (victoza)

Answer 20

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

Question 21

Pramlintide (symlin)

Pregnancy category C

USED IN BOTH TYPE ONE AND TYPE TWO DIABETES

Answer 21

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

Question 22

Bile acid binding resins

Colesevelam (welchol)

It’s a category B

Answer 22

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

Question 23

Rapid Acting Insulin

Answer 23

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

Question 24

Regular or short acting insulin

Answer 24

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

Question 25

Basal insulin

Answer 25

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

Question 26

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)

Answer 26

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

Question 27

Order of onset and duration

Answer 27

Rapid, short acting (regular), intermediate or NPH (N or mixes), long-acting

Question 28

Mixing insulins

Answer 28

NPH can be mixed with regular or rapid acting insulin Clear before cloudy

Question 29

Cloudy insulin

Answer 29

NPH

Question 30

Vial size and pen size

Answer 30

Most are 10 ML but U-500 insulin comes in a 20 ML vial All pens are three ML a piece

Question 31

Insulin stability and other injectables at room temperature

Answer 31

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

Question 32

Insulin injection sites

Answer 32

Preferred: abdomen (quickest absorption and most predictable) Others: posterior upper arm, superior buttocks, lateral thigh Alternate injection sites in the same region

Question 33

Hypoglycemia

Answer 33

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)

Question 34

Diabetic ketoacidosis (DKA)

Answer 34

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)

Question 35

Order insulin shortest to the longest

Answer 35

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)