Diabetes Flashcards
what is the A1c?
% of hemoglobin molecule glycosylated with glucose
how often is the A1c ordered?
ordered at least 2x/year (if pt very well controlled)
-more commonly every 3 months
what info does the A1c provide?
“long term” marker of glycemic control
what do you use to help to explain A1c (%) to patients?
eAG - estimated average glucose
rule of A1c?
A1c of 7% = eAG of 150
-every 1% increase of A1c add 30 to the 150
what is normal blood sugar if fasting?
120
what is normal blood sugar post-prandial?
140
the higher the A1c means what?
the more contribution of fasting glucose
the lower the A1c means what?
the more contribution of postprandial glucose
what factors falsely decrease A1c?
any condition that shortens the life cycle of the RBC
- blood loss w/in 3 months - e.g., donated blood, had trauma
- hemolytic anemia
what factors falsely increase A1c?
- iron deficiency anemia (that’s not treated)
- blood transfusion w/in 3 months
what is the ADA recommendation for glycemic targets in adults for A1c?
< 7%
what is the ADA recommendation for glycemic targets in adults for pre-prandial/fasting plasma glucose (FPG)?
80-130 mg/dL
what is the ADA recommendation for glycemic targets in adults for 1-2 hr. post-prandial glucose (PPG)?
< 180 mg/dL
what are the ADA recommendations for glycemic targets in adults older than 65 that are healthy?
(A1c, fasting/pre-prandial glucose, bedtime glucose)
A1c- < 7.5% (7-7.5%)
FPG- 90-130 mg/dL
Bedtime glucose- 90-150
what are the ADA recommendations for glycemic targets in adults older than 65 that have complex/intermediate health?
(A1c, fasting/pre-prandial glucose, bedtime glucose)
A1c- < 8% (7.5-8%)
FPG- 90-150
Bedtime glucose- 100-180
what are the ADA recommendations for glycemic targets in adults older than 65 that have very complex/poor health?
(A1c, fasting/pre-prandial glucose, bedtime glucose)
A1c- < 8.5% (8-9%)
FPG- 100-180
Bedtime glucose- 110-200
what are the ADA recommendations for glycemic targets in children & adolescents < 18?
(A1c, pre-prandial/fasting plasma glucose, bedtime glucose)
A1c- <7.5%
FPG- 90-130 mg/dL
Bedtime- 90-150 mg/dL
why are glycemic goals relaxed for children and adolescents <18?
glycemic goals are relaxed for children and adolescent to prevent cognitive impairment/worsening of brain development
-hypoglycemia can interfere with brain development and cognitive development
what is the ADA recommendation for glycemic targets in pregnancy?
(A1c, FPG, 1hr post-prandial glucose, 2hr post-prandial glucose)
A1c- ≤ 6-6.5%
FPG- ≤ 95 mg/dL
1hr post-prandial glucose- ≤140 mg/dL
2hr post-prandial glucose- ≤120mg/dL
what may gestational diabetes present with more?
postprandial hyperglycemia due to carbohydrate intolerance
what is postprandial monitoring associated with when pregnant?
less preeclampsia
who does hyperglycemia effect when pregnant?
mom and baby
what is the FIRST LINE txt for someone with diabetes?
Metformin
why would a pt with diabetes not be on metformin?
if C/I due to can’t stand GI effects or they have bad kidney function
what is the regimen for someone that didn’t achieve goals in 3 months with just metformin?
dual therapy (metformin PLUS another medication)
what is the regimen for someone that didn’t achieve goals in another 3 months with dual therapy?
triple therapy (metformin PLUS 2 more medications)
what is the regimen for someone that didn’t achieve goals in another 3 months with triple therapy?
combination injectable therapy
pharmacotherapy selection considerations (2 types of factors)
patient factors and medication factors
pharmacotherapy selection considerations (patient factors)
- preference (e.g., do they want pill, injection, etc)
- co-morbid conditions
- insurance coverage
- duration of diabetes
- current weight
- hypoglycemia risk
- age
- aptitude for self-care
why is the duration of diabetes a factor when selecting pharmacotherapy?
medications that are reliant on beta cell function for use may not be applicable for someone that has had diabetes for years
pharmacotherapy selection (medication factors)
- safety (side effects)
- efficacy (A1c lowering effects/durability)
- targeted blood glucose effects
- ease of use/administration
- cost/generic availability
- dosage form availability
what do diabetics have an increased risk of in terms of infection?
have increased risk of developing infection and hard time clearing the infection
what is the number one cause of death in diabetic patients?
CVD: heart attacks and strokes
what is the blood pressure goal for someone with diabetes with comorbid HTN?
≤ 140/90
what are the recommendations for CVD risk management?
- BP ≤ 140/90 with co-morbid HTN
- low-dose aspirin therapy for those with increased CV risk
- statin therapy for those with ASCVD and those >40 years with increased CV risk (smokers, older, obese)
when do you screen for diabetic nephropathy?
yearly
ACEi or ARB for those with urinary albumin excretion
how often do you screen for retinopathy?
year or every 2 years
how often do you screen for neuropathy?
yearly
what 2 types of insulin does pancreas secrete?
basal and bolus
what is basal insulin?
constant, low level release of insulin
-role is to maintain glucose homeostasis in the fasting state
what is bolus insulin?
meal stimulated insulin
-role is to cover meal stimulated bursts of glucose
what is A1c lowering ability?
approx. 1.5-3.5%
who needs insulin?
- type 1 diabetes
- gestational diabetes
- hyperglycemic crisis (DKA)
- type 2 diabetes
type 2 diabetes criteria that requires insulin?
- A1c ≥ 9%
- Glucose ≥ 300 mg/dL
- Marked hyperglycemia (classic six’s)
- A1c above goal despite 3, non-insulin anti diabetic agents
what insulin can be used as a second line agent, after metformin?
basal insulin
what percent of beta cell function has been lost at time of diagnosis?
about 50% and decreases as the disease progresses
what route do you take afrezza insulin?
inhalation (pulmonary administration)
-good for people that don’t like injections
what type of insulin is afrezza?
dry powder of human (recombinant DNA) insulin
what is the onset, peak, and duration of afrezza?
onset- 12-15 min
peak- 30 min
duration- 3 hrs
what are the ads for afrezza?
remember it is inhaled
- cough
- throat/mouth irritation
- hypoglycemia
- acute bronchospasm (pts w/restricted airway diseases)
- hypersensitivity rxns
what routine test is required when someone takes afrezza?
routine pulmonary fxn tests (PFTs) @ baseline, 6 months and annually
agrezza insulin is C/I in who?
- if pt has COPD and/or asthma
- causes increased bronchoconstriction in asthma
what patients can you NOT use afrezza in?
smokers due to it having less efficacy in them
what dosages is inhaled insulin available in?
4 unit- blue
8 unit- green
12 unit- yellow
why do you need multiple cartridges for doses > 12 units of inhaled insulin?
b/c inhaled insulin only comes in 4, 8, and 12 units
-if pt needs 17 units then need more cartridges
what is the dosage for a insulin naive patient taking inhaled insulin?
inhale 4 units with each meal
titrate every 7 days by 4 units per meal until PPG within goal range
what is the conversion for injected mealtime insulin dose of up to 4 units to afrezza dose?
4 units (1 blue)
what is the conversion for injected mealtime insulin dose of 5-8 units to afrezza dose?
8 units (1 green)