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Clinical review > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Goals of diabetes mellitus therapy

A
  1. eliminate symptoms related to hyperglycemia
  2. reduce or eliminate long-term microvascular and macrovascular complications
  3. allow patient normal life as possible
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2
Q

Immunizations for diabetes patients

A

Influenza, pneumococcal, hep B

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3
Q

Numeric goals for DM patients

A

A1C less than 7%
Preprandial plasma glucose: 80-130 mg/dL
Peak postprandial plasma glucose: less than 180
BP: less than 140/90
Lipids: LDL less than 100
HDL greater than 40 for men and 50 for women
Triglycerides: less than 150

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4
Q

Immunizations for diabetes patients

A

Influenza, pneumococcal, hep B

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5
Q

Diagnostic numbers for DM

A

A1C greater than 6.5%
Fasting glucose greater than or equal to 126 mg/dL
75 gm glucose tolerance test, 2 hours with glucose 300 mg/dL or greater
Random glucose greater than 200 mg/dL with symptoms

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6
Q

Metformin drug class and MOA

A

Biguandes: (insulin sensitizer)

  • Reduces hepatic glucose production
  • Improves peripheral glucose utilization
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7
Q

Actions of metformin

A 
Reduces fasting plasma glucose (FPG)
Reduces insulin levels
Improves lipid profile
promotes modest weight loss
Slows intestinal absorption of sugars
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8
Q

Contraindications of metformin

A

Renal insufficiency, GFR less than 60 mL/min
Any form of acidosis
Unstable CHF
Liver disease
Severe hypoxemia
Discontinue in acute MI, exacerbation of HF, sepsis
Or other conditions that cause acute renal failure

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9
Q

Adverse effects of metformin

A

Largely gastrointestinal

CI in renal dysfunction due to risk of lactic acidosis

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10
Q

Adverse effects of insulin

A

Hypoglycemia is the most serious
Weight gain
local injection site reactions
Lipodystrophy

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11
Q

Short acting insulin prepartations

A

Insulin lispro
Insulin aspart
Insulin glulisine
Regular insulin

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12
Q

Time of injection for short acting insulin preparations

A

Lispro, aspart, glulisine: 15 min before meal or within 15 minutes of starting a meal
Regular insulin: 30 minutes before a meal

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13
Q

Most commonly used insulin when IV route is needed?

A

Regular insulin

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14
Q

Intermediate-acting insulin

A

Neutral protamine Hagedorn (NPH)
Used for basal control, in conjunction with fast-acting
It should never be given IV

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15
Q

Long-acting insulin preparations

A

Determir
Glargine
Used as basal formulations

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16
Q

Microvascular complications of DM

A

Nephropathy: most common cause of ESRD
Neuropathy: most common cause of peripheral neuropathy
Retinopathy: most common cause of blindness ages 20-70

17
Q

Macrovascular complications of DM

A

Coronary artery disease
Peripheral vascular disease
Cerebrovascular disease

18
Q

How to test for nephropathy in DM

A

Assess urine albumin excretion yearly
Spot urine sample
Test urine albumin/creatinine ratio
Ratio of greater than 30 considered albuminuria

19
Q

Macrovascular preventive measures for DM?

A 
Glucose control (more helpful for microV)
BP reduction
LDL reduction
Aspirin therapy
ACE inhibitors
Smoking cessation
20
Q

Microvascular preventive measures for DM?

A

Glucose control
Aggressive HTN treatment
ACE inhibitor or ARB therapy

21
Q

First line treatment for HTN in DM?

A

ACE or ARB

22
Q

Lipid management with DM

A

Statin if known Cardiovascular disease
or greater than 40 with 1 or more other risk factors:
Risk factors: LDL greater than 100, HTN, smoking, overweight or obese

23
Q

Symptoms of hyperglycemia (9)

A 
Polyuria
Polydipsia
Polyphagia
weight loss
fatigue
infections (yeast or skin)
blurred vision
poor healing
growth failure in children
24
Q

Initial dosing of metformin for DM

A

Start with 500 mg once daily

Build up to 1000 mg twice daily if tolerated

25
Q

Results of DKA

A 
Low insulin
increased ketone bodies (measurable)
metabolic anion gap acidosis
usually increased plasma K from cells
increased glucose
dehydration
increased serum Cr from renal failure
osmotic diuresis
Total body K and PO4 depletion
26
Q

Clinical signs of DKA

A

Abdominal pain, nausea, vomiting (caused by irritation from inflammatory cytokines)
dehydration (caused by vomiting and osmotic diuresis)
Altered mental status (dehydration and metabolic acidosis)

27
Q

Treatment of DKA

A

IV fluids and insulin

28
Q

MOA of GLP-1

A 
incretin mimetics
improve insulin dependent secretion
slow gastric emptying time
increase satiety
promote B-cell proliferation
29
Q

Sulfonylureas: drugs

A

Glimepiride
glipizide
glyburide (causes more hypoG, avoid use)

30
Q

Benefits of sulfonylureas

A

50 plus years of experience
Good efficacy
very effective in combination therapy
inexpensive/generic

31
Q

Disadvantages of sulfonylureas

A

Risk of hypoglycemia
Modest weight gain
May lose effect earlier

32
Q

Sulfonylureas MOA

A

Causes stimulation of insulin production regardless of glucose levels

33
Q

Short acting insulin secretagogues drugs

Meglitinides

A 
Repaglinide
nateglinide
Need to be taken before each meal
MOA: similar to sulfonylureas
Short acting and expensive
34
Q

Alpha glucosidase inhibitors

A 
acarbose (precose)
miglitol (Glyset)
voglibose
MOA: slow down the absorption of carbs
Primarily affect post-prandial glucose
A1C reduction: 0.4-0.9
AE: flatulence and diarrhea
Not well tolerated
35
Q 
Thiazolidinediones:
Drugs
MOA
Metabolism
Benefits
SE
CI
A

MOA: insulin sensitizers
pioglitazones; Actos, rosiglitazone (black box Cardiac)
Meta: P450
Bene: good for lipid panel
SE: Risk of CV event, weight gain, density
CI: Heart disease class 3 or 4
Concern for: bladder cancer in rosi, hepatotoxicity, possible bone loss

36
Q

GLP-1 drugs

A

exenatide (Bydureon, Byetta) BID or QW for bydureon
liraglutide (Victoza) QD
dualglutide (Trulicity) QW
albiglutide (Tanzeum) QW

37
Q 
GLP-1:
MOA
Benefits
SE
CI
A

MOA: incretins, increase insulin release, decrease glucagon, decrease appetite
Bene: Low risk of hypoG, decreases weight, weekly formulation
SE: N/V/D
CI: History of pancreatitis, gastroperesis, personal or family history of medullary thyroid cancer or MEN 2A or B,
(exenatide) renal GFR <30

38
Q

DPP-4 inhibitors
Drugs
MOA
AE

A

dipeptidyl peptidase-4 inhibitors
sitagliptin (Juaniva), saxagliptin, linagliptin
MOA: prolong the activity of incretin hormones which increases insulin release in response to meals
AE: HA, pharyngitis, URI, possible connection to pancreatitis, uncertain connection to pancreatic cancer

Not a lot of bang for buck according to lecture

39
Q 
SGLT-2 inhibitors
MOA
Adv
CI
Disadvantanges
A

canagliflozin (Invokana): I dose: 100mg, up to 300mg daily
dapagliflozin (Farxiga): I dose: 5mg, up to 10mg daily
empagliflozin (Jardiance): in dose: 10mg, up to 25mg daily
MOA: promotes excretion of glucose in urine along with Na (can cause hypotension)
Adv: Weight loss, decreased BP, bone fracture with invokana, also slight increase risk in LE amputations with ivokana
CI: GFR <60, Ketosis-prone patients, hypotension
Dis: Expensive, yeast infection, no long term safety data

Clinical review (18 decks)

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