Diabetes

Question 1

Goals of diabetes mellitus therapy

Answer 1

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

Question 2

Immunizations for diabetes patients

Answer 2

Influenza, pneumococcal, hep B

Question 3

Numeric goals for DM patients

Answer 3

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

Question 4

Immunizations for diabetes patients

Answer 4

Influenza, pneumococcal, hep B

Question 5

Diagnostic numbers for DM

Answer 5

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

Question 6

Metformin drug class and MOA

Answer 6

Biguandes: (insulin sensitizer)

• Reduces hepatic glucose production
• Improves peripheral glucose utilization

Question 7

Actions of metformin

Answer 7

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

Question 8

Contraindications of metformin

Answer 8

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

Question 9

Adverse effects of metformin

Answer 9

Largely gastrointestinal

CI in renal dysfunction due to risk of lactic acidosis

Question 10

Adverse effects of insulin

Answer 10

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

Question 11

Short acting insulin prepartations

Answer 11

Insulin lispro
Insulin aspart
Insulin glulisine
Regular insulin

Question 12

Time of injection for short acting insulin preparations

Answer 12

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

Question 13

Most commonly used insulin when IV route is needed?

Answer 13

Regular insulin

Question 14

Intermediate-acting insulin

Answer 14

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

Question 15

Long-acting insulin preparations

Answer 15

Determir
Glargine
Used as basal formulations

Question 16

Microvascular complications of DM

Answer 16

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

Question 17

Macrovascular complications of DM

Answer 17

Coronary artery disease
Peripheral vascular disease
Cerebrovascular disease

Question 18

How to test for nephropathy in DM

Answer 18

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

Question 19

Macrovascular preventive measures for DM?

Answer 19

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

Question 20

Microvascular preventive measures for DM?

Answer 20

Glucose control
Aggressive HTN treatment
ACE inhibitor or ARB therapy

Question 21

First line treatment for HTN in DM?

Answer 21

ACE or ARB

Question 22

Lipid management with DM

Answer 22

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

Question 23

Symptoms of hyperglycemia (9)

Answer 23

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

Question 24

Initial dosing of metformin for DM

Answer 24

Start with 500 mg once daily

Build up to 1000 mg twice daily if tolerated

Question 25

Results of DKA

Answer 25

``` 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 ```

Question 26

Clinical signs of DKA

Answer 26

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

Question 27

Treatment of DKA

Answer 27

IV fluids and insulin

Question 28

MOA of GLP-1

Answer 28

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

Question 29

Sulfonylureas: drugs

Answer 29

Glimepiride glipizide glyburide (causes more hypoG, avoid use)

Question 30

Benefits of sulfonylureas

Answer 30

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

Question 31

Disadvantages of sulfonylureas

Answer 31

Risk of hypoglycemia Modest weight gain May lose effect earlier

Question 32

Sulfonylureas MOA

Answer 32

Causes stimulation of insulin production regardless of glucose levels

Question 33

Short acting insulin secretagogues drugs | Meglitinides

Answer 33

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

Question 34

Alpha glucosidase inhibitors

Answer 34

``` 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 ```

Question 35

``` Thiazolidinediones: Drugs MOA Metabolism Benefits SE CI ```

Answer 35

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

Question 36

GLP-1 drugs

Answer 36

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

Question 37

``` GLP-1: MOA Benefits SE CI ```

Answer 37

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

Question 38

DPP-4 inhibitors Drugs MOA AE

Answer 38

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

Question 39

``` SGLT-2 inhibitors MOA Adv CI Disadvantanges ```

Answer 39

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