Diabetes Flashcards by vanessa Prusia

Type I DM described

autoimmune process involving beta cell destruction resulting in insulin deficiency

short hx of symptoms
weight loss
ketonuria
polydipsia
polyphagia
polyuria
child or young adult

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Type 2 DM described

insulin resistance with insulin def eventually
few if any symptoms
dx during routine screening

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What age should testing for DM start if no symptoms

screen every 3 years

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Other criteria to suggest DM testing

BMI >25
physical inactivity
1st degree relative with type 2
women who have had baby > 9lbs or GM
HTN
women with PCOS
HDL < and triglycerides >250
acanthosis nigricans

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High risk ethnicity for DM

African American
Latino
Native American
Asian American
Pacific Islander

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Tests for dx of DM

plasma glucose
glucose tolerance test
A1C

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plasma glucose for DM dx

Fasting > 126

Random draw >200 with symptoms of polyphagia, polyuria, polydipsia

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glucose tolerance test for DM dx

2 h glucose of >200 after 75g loading glucose dose

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A1C for DM dx

> 6.5%

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Pre DM according to tests

Fasting 100-125
Glucose tolerance test 140-199
A1C 5.7-6.4

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Target A1C in those dx with DM

<7%

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Target fasting BS in those dx with DM

70-130

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Post prandial BS in those dx with DM

<180

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Target bedtime BS for those dx with DM

90-150

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How often to draw A1C in pts with DM

2 x a year who are meeting goals and are stable

4 x a year for those how tx is changing or not well controlled

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Target A1C for older adults

<8%

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Sulfonylurea meds for DM tx

glipizide
glyburide
glimepride

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Sulfonylurea mechanism of action

insulin secretague

reduce A1C by 1-2%

Facts about sulfonylureas

adjust for renal impairment
potosensitizing
less effective with > 5 years use

Biguanide meds for DM tx

metformin

Buguanide mechanism of action

reduces hepatic glucose production and intestinal glucose absorption and insulin sensitizer via increased glucose intake
A1C reduction of 1-2%

Facts about Buganide

monitor creatinine
avoid in heart failure
with contrast or surgery d/c for day before and 2 days following until you know renal fx at baeline
risk of B12 deficiency

Thiazolidinedione meds for DM tx

Pioglitazone (actos)

Thiazolidinedione mechanism of action

insulin sensitizer at PPAR receptors of muscle and adipose tissue
A1C reduction 1-2%

Facts about Thiazolidinedione

``` risk of hepatic toxicity: monitor ALT edema risk no in heart failure not to be used with insulin or nitrates can be associated with risk of bladder cancer ```

Glucagon like peptide 1 agonists meds (GLP-1) for DM tx

exenatide (byetta) Liraglutide (vitoza) injections

Glucagon like peptide 1 agonists mechanism of action

stimulates insulin production in response to increase in plasma glucose, inhibits PP glucagon release slows gastric empyting A1C reduction 1-2%

Facts about Glucagon like peptide 1 agonists

``` can cause n/v no in gastroparesis no in hx of pancreatic issues caution in renal impairment: if Cr CL <30 no can use with insulin ```

Dipeptidly peptidase 4 inhibitor (DPP-4) meds for DM tx

sitagliptin (januvia) saxagliptin (onglyza) linagliptin (tradjenta)

Dipeptidly peptidase 4 inhibitor (DPP-4) mechanism of action

increase levels of incretin | increasing synthesis and release of insulin from pancreatic beta cells and decreasing release of glucagon

Facts about Dipeptidly peptidase 4 inhibitor (DPP-4)

adjust for renal impairment well tolerated with little hypoglycemic risk combine with metformin or TZD monitor for pancreatitis

Alpha-glucosidase inhibitor meds for DM tx

acarbose | migitol

Alpha-glucosidase inhibitor mechanism of action

delays intestinal carb absorption by reducing postprandial digestion of startches and disaccharides

Facts about Alpha-glucosidase inhibitor

taken with 1st bite of meal helpful for postpradial hyperglycemia gas producing avoid with inflammatory bowel disease and impaired renal fx

When to use insulin in type 2 DM

At time of Dx to achieve control when glucose >250 When acutely ill: try to keep BS 140-180 When 2 oral agents don't maintain control

Lispro insulin (Humalog) onset/peak/duration

Onset: 15-30 min, give 15 min of eating Peak: 30 min - 2.5 hr Duration: 3-6.5 hr

Aspart insulin (Novolog) onset/peak/duration

Onset: 10-20 min, give 5-10 min before meals Peak: 1-3 hr Duration: 3-5 hr

Glulisine insulin (Apidra) onset/peak/duration

Onset 10-15 min, give right after meals Peak: 1-1.5 hr Duration: 3-5 hours

Regular insulin (Humulin R, Novolin R) onset/peak/duration

Onset: 30min-1 hour Peak: 2-3 hr Duration 4-6 hr

Intermediate acting insulin (NPH, Novolin N, Humulin N)

Onset: 1-2 hr Peak: 6-14 hr Duration 16-24 hr

Long acting insulin (Lantus) onset/peak/duration

Onset: 1 hr Peak: None Duration: >24 hr

Long acting insuline detemir solution (Levemir) onset/peak/duration

Onset: 1-2 hr Peak: 6-8 hr Duration: Albumin bound, 12 hr for .2 units/kg and 24 r for .4 nits/kg

Steps for drug therapy in Type 2 DM

counsel pt's regarding lifestyle modifications add metformin draw A1C in 3 months and if not in target then add a medication If A1C not met in with 2 agents then consider a 3rd

Additional care considerations for Type 2 DM

aspirin 75mg or and ACE or ARB beta blocker if at risk for MI check creatinine, GFR and urine microalbumin annually limit trans and saturated fats physical activity >150min/wk eye exam annually foot exam each visit with 10g monofilamient