DIABETES

Question 1

WHEN IS INSULIN GIVEN IV?

Answer 1

1) Patients with KETOACIDOSIS
2) During the PERIOPERATIVE PERIOD
3) During LABOR + DELIVERY
4) In ICU SITUATIONS

–> Regular human insulin is used for IV therapy

Question 2

WHAT IS BASAL BOLUS INSULIN REGIMEN?

Answer 2

• one DAILY shot of GLARGINE or DETEMIR (long acting) as well as (usually take it at bed time)
• Doses of lispro, aspart, or glulisine to provide coverage for each meal

rules:

• long actin insulin can be given at bedtime or in the morning (bedtime more usual)
• if patient skips a meal, they omit a premeal bolus
• if the meal is larger than normal, they increase the premeal bolus
• similar dose adjustements can be made to accommodate snacks, exercise patterns, and acute illnesses

Question 3

WHAT IS INSULIN PUMP THERAPY?

Answer 3

• is the best way to mimic normal insulin secretion
• consists of a battery-operated pump and a computer that programs the pump to deliver predetermined amounts of insulin

–> only use 1 type of insulin: usually use GLULISINE, LISPRO, or ASPART (rapid acting insulins) into the pump

Question 4

DRUGS INTERACTIONS THAT CAUSE HYPOGLYCEMIA

Answer 4

1) ETHANOL –> decreases gluconeogenesis (messes with NADH/NAD

2) BETA BLOCKERS –> masks symptoms and decreases gluconeogenesis and glycogneolysis

3) SALICYLATES –>

• enhance B cell sensitivity to glucose
• weak peripheral insulin-like action

Question 5

DRUG INTERACTIONS THAT CAUSE HYPERGLYCEMIA WITH INSULIN

Answer 5

1) EPINEPHRINE, GLUCOCORTICOIDS, ATYPICAL ANTIPSYCHOTICS, HIV PROTEASE INHIBS

–> d/t anti insulin action at peripheral tissues

2) PHENYTOIN, CLONIDINE, CA2+ CHANNEL BLOCKERS

–> decrease insulin secretion DIRECTLY

3) DIURETICS

–> deplete K+ which inhibits insulin secretion indirectly

Question 6

HOW TO MANAGE A DIABETIC PATIENT IN HOSPITAL?

Answer 6

• ORAL antibiabetic agents should be DISCONTINUED during acute illness and replaced with INSULIN
• oral agents can be restarted on discharge

Question 7

FIRST AGENT USED IN DM IF LIFESTYLE INTERVENTION DID NOT ACHEIVE HbA1c goals?

Answer 7

METFORMIN

• monotherapy with most non-insulin antidiabetic agents can reduce HbA1c ~1%
• patients with HbA1c >9% are unlikely to achieve HbA1c goals with monotherapy

therefore, therapy may be started with a combination of two non-insulin agents or with insulin itself

Question 8

WHEN TO ADVANCE TO DUAL THERAPY?

Answer 8

IF MONOTHERAPY DOES NOT ACHIEVE HbA1c goal over 3 MONTHS, the next step is to add a second agent:

1) ORAL AGENT
2) EXENATIDE OR
3) INSULIN
- the higher the HbA1c, the more likely insulin will be required
- on average, any second non-insulin agent can be expected to reduce HbA1c by an additional 1%

Question 9

WHEN TO ADVANCE TO TRIPLE COMBO THERAPY?

Answer 9

-if the 2-drug combo fails to achieve the glycemic target a third agent can be added

–> the most robust response will usually be with insulin

-diabets is associated with progressive B-cell loss: many patients will eventually need t obe transitioned to insulin

-the decision to transition to insulin should be favored when the HbA1c > 8.5%

Question 10

WHEN TO TRANSFER TO INSULIN?

WHAT KIND OF INSULIN?

Answer 10

• the decision to transition to insulin should be favored when the HbA1c > 8.5%
• insulin is typically begun at a LOW DOSE, with a SINGLE INJECTION of BASAL INSULIN
• either
  1) NPH (intermediate acting) OR
  2) GLARGINE/DETEMIR (long acting) insulin may be used
• the dose is then uptitrated

Question 11

PATIENT HAS SIGNIF POSTPRANDIAL GLUOCCSE EXCURSIONS… which insulin to use?

Answer 11

• typically rapid acitng insulins are used
  1) LISPRO
  2) ASPART
  3) GLULISINE

Question 12

WHICH DRUG IS MOST EFFECTIVE OF DIABETES MEDICATIONS IN LOWERING GLYCEMIA

Answer 12

INSULIN

• it can decrase any level of elecvated HbA1C to or close to the therapeutic goal
• there is NO MAXIMUM DOSE of insulin beyond which a therapeutic effect will not occur
• large doses of insulin may be necessary to overcome the insulin resistance of type 2 DM

Question 13

WHAT 4 SITUATIONS IS INSULIN WARRANTED TO USE AS THE INITIAL THERAPY:

Answer 13

1) SIGNIF HYPERGLYCEMIC CONDITIONS
2) KETONURIA
3) HbA1c > 10%
4) RANDOM GLUCOSE > 300mg/dL

Question 14

DIABETS AND HTN… WHAT TO GIVE?

Answer 14

GIVE EITHER

1) ACE INHIBITOR OR
2) ARB

Question 15

DIABETES + DYSLIPIDEMIA?

Answer 15

STATINS

statins should be given REGARDLESS of lipid levels to diabetic patients

1) WITH overt CVD
2) WITHOUT CVD but who are

• >40 y/o and have
• 1 or more other CVD risk factors (family history of CVD, hypertension, smoking, dyslipidemia, or albuminuria)

Question 16

INCREASED CV RISK? WHAT ELSE TO GIVE?

Answer 16

ASPIRIN = ANTIPLATELET AGENTS

-aspirin therapy should be considered as a primary prevention strategy in pateints with type 1 or type 2 diabetes at increased CV risk (10 year risk > 10%)

Question 17

DIABETES AND NEUROPATHIC PAIN… WHAT TO GIVE?

Answer 17

DYSTAL SYMMETRIC POLYNEUROPATHY

• drugs used for neuropathic pain include
  1) AMITRIPTYLINE,
  2) PREGABALIN
  3) GABAPENTIN
  4) DULOXETINE
  5) VENLAFAXINE
  6) VALPROATE
  7) OPIOIDS

Question 18

DIABETES + GASTROPARESIS SYMPTOMS?

TREAT WITH?

Answer 18

• gastroparesis symptoms may improve with dietary changes and prokinetic agents such as
  1) METOCLOPRAMIDE
  2) ERYTHROMYCIN

Question 19

4 USES FOR GLUCAGON?

Answer 19

1) SEVERE HYPOGLYCEMIA

–> used to treat severe hypoglycemia in apteints with diabetes treated with insulin

2) RADIOLOGY OF THE BOWEL

–> used because of its ability to relax intestine

3) B-BLOCKER POISONING

–> antidote for B-blocker overdose

4) GLUCAGON C-PEPTIDE TEST

–> test for residual B-cell function in diabetes

Question 20

ANTIDIABETIC DRUGS IN PREGNANCY

Answer 20

1) DOC IN PREGNANCY = REGULAR INSULIN

NON-INSULIN ANTI-DIABETICS

–> metformin, and Sitagliptin = both category B

-rest are category C