Diabetes Flashcards
Sulfonylureas (secretagogues)
Increase insulin production by pancreas. Bind to Katp channel, Inhibit K efflux, depolarize, increase Ca, increase insulin release
glipizide (take on empty stomach), glimepiride, glyburide (not recommended cardio MI)
Contraindicated in liver/renal impairment
Weight gain, hypoglycemia
Alpha glucosidase (amylase) inhibitors
Slow starch and disaccharide absorption in the gut
Lower post-prandial peak
Acarbose, Glyset
If hypoglycemic give simple sugar (glucose/galactose)
Adverse: flatulence
Meglitinides
Bind to SUR1.More potent release of insulin from pancreas. Insulin suppresses hepatic glucose production
Nateglinide, repaglinide
May cause weight gain, hypoglycemia
Flexible, skip dose if skipped meal
Biguanide
Decrease all cause mortality, MI
Decrease glucose production in liver
Increase peripheral glucose uptake (Glut4) and activate AMPK (inhibit PEPCK glucose formation) decrease conversion of lactate to pyruvate
Increase fatty acid oxidation, less fatty liver, increase hepatic insulin sensitivity
Decrease intestinal glucose absorption
Metformin, take with largest meal
Weight loss, improves lipid profile
Adverse: diarrhea, VitB12 deficiency, lactic acidosis avoid: SCr >1.5
Cleared renally
Thiazolidinediones (TZD)
Increase uptake of sugar by muscle and fat cells (adipocytes)
PPARy ligands, increase adiponectin (good for insulin sensitivity)
Pioglitazone, rosiglitazone (more toxic on lipid profile)
Cause weight gain (adipose PPARy triglyceride synthesis from glucose)
And fluid retention (kidney PPARy), edema CHF, bone fracture
Proinsulin
Endogenous
Has C-peptide
T1DM lacks proinsulin
Type 1 DM
No insulin to bind to receptor and stimulate glucose uptake or conversion into fatty acids
Goal preprandial 110
2 hour post prandial 140
Requires multiple insulin injections and
Type 2 DM
Risk >45 African Latino Asian
Skeletal muscle and adipose tissue become insulin resistant
Decreased signaling capacity for the insulin receptor. Glut transporter 4 levels decrease
Not a CHD risk equivalent
Can have single insulin injection w/oral
Insulin
Benefit of early addition
Inhibit PEPCK (rate limiting enzyme)
Bind to insulin receptor, glut4 transporter, glucose into glycogen, pyruvate, fatty acid
Humalog
Reverses Lys and Pro (lispro)
Rapid acting
15 min before or at meal
Use rapid acting in insulin pump
Novolog
Insulin aspart
Proline to aspartic acid
Rapid acting
Apidra
insulin glulisine
Glutamic acid to lysine
Rapid acting
Short acting insulin
Novolin R, Humulin R
IV insulin Recombinant direct hexamer to monomer (no dimer) faster absorption
Effect appears in 30 min
More weight gain, more glycemic highs and lows
Intermediate acting
NPH Novolin N
NPH Humulin N
Effect appears in 2 hours
Less doses BID
Long acting
Insulin glargine (lantus) - precipitates at neutral pH. Glycine to asparagine
Insulin detemir (Levemir)
Long duration, designed to be peakless
Less weight gain
Incretins/GLP-1
Pen formulations
Stimulate release of insulin during a meal before glucose levels rise
Exanatide (Byetta)
Potentiate glucose-mediated insulin secretion
Suppress postprandial glucagon release
Slow gastric emptying
Cause weight loss
Avoid if CrCl <30
DPP4 inhibitor
DPP4 enzyme inactivates GLP-1
Inhibit DPP4
Sitagliptan (Januvia)
No weight gain
May increase heart failure
Do not combo w/ GLP
HgbA1C < 9%
Metformin & lifestyle
Metformin lowers 2% A1C at best
Caution alcohol lowers blood sugar
HgbA1C 9-10%
Metformin + 2nd agent
Sulphonylurea, TZD, DPP4inhibitor, GLP-1
HgbA1C >10%
Metformin & insulin
Scr > 1.5 give insulin
Sodium glucose transporter 2 inhibitor
Inhibit glucose reabsorption in proximal tubule and let glucose be released in the urine
Canigliflozin, dapagliflozin
Weight loss, lowers BP
Need GFR>60
Chronic urinary glucose excretion is benign
Statin
Proves beneficial, regardless of LDL goal target, 30% change is ideal
High Beneficial if prior stroke (ASCVD)
40-75 w/diabetes
LDL >190
40-75 w/ASCVD risk >7.5%
High intensity: ator 80, rosu 20 for overt CVD
Caution myopathy in elderly >75
Can supplement VitD
Blood pressure
Target is < 140/80
Target 120/80 long term renal disease
Persistent albuminuria >30mg/day
Protein spills in urine
Initiate thiazides, ACE, ARB, or CCB
Thiazides, CCBs first line in blacks
Don’t combine ACE and ARB
Beta blockers are not first line anti hypertensive therapy
Weight loss
Decrease adipocytes, increase adiponectin, increase insulin sensitivity
Brain function
Blood glucose >40mg/dL
Blood glucose monitoring
Check glucose 2 hours after injecting
Insulin injections
Use within 28 days
Syringe requires dexterity
Pens are easier, more expensive
Rotate injection site
Inject to fat vs. muscle (faster uptake)
Abdomen>arm>thigh>
0.5 U/kg/day
1/2 basal (glargine)
1/2 / 3 at each meal (lispro)
A1C to mg/dL
130mg/dL=6%
30mg/dL=1%
Goal <8% if vascular complications
General 7%, recently diagnosed
Reduce microvascular, MI
Every 1% increase increases CVD 18%
Mixed insulin
Higher % is NPH
Lower % is short-acting
Clear before cloudy (NPH)
Never mix long acting
SMBG
Rapid: 2hours post prandial
Short: before next meal or bed snack
NPH: 12 hours after
Long acting: before breakfast
Insulin pump
Good for those with dawn rise BG
Recurrent hypoglycemia
Lifestyle, busy
Needs to monitor BG QID
Hypoglycemia
BG <70mg/dL
Shaky, sweating, hunger
15g carb, 15 min check
Glucagon if patient uncooperative or unconscious
Diabetic Keto Acidosis
T1 and T2DM
INSULIN constant infusion
Potassium supplement
IV fluids
Hyperosmolar hyperglycemic state
HHS or HONK no ketones
Mostly older T2DM
Hypotonic fluids and low-dose insulin
Somogyi
Rebound hyperglycemia at night
Decrease NPH dose at bedtime
ISensitivityF ICarbRatio
ISF = 1700/ total daily insulin doses
1 unit / mg/dL
ICR= ISFx0.33
