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Therapeutics > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What does A1c measure?

A

average blood sugar over the past 3 months;

percentage of hemoglobin molecule covered by glucose

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2
Q

How often is A1c checked?

A

every 3-6 months

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3
Q

What can falsely elevate A1c?

A

iron deficiency anemia
blood transfusion
(anything that lengthens RBC lifespan)

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4
Q

What can falsely decrease A1c?

A

blood loss
hemolytic anemia
(anything that shortens RBC lifespan)

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5
Q

What are the glycemic targets in adults?

A

A1c: <7%
FPG: 80-130mg/dL
PPG: <180mg/dL

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6
Q

What are glycemic targets for healthy older adults?

A

A1c: <7.5%
FPG: 90-130
Bedtime: 90-150

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7
Q

What are glycemic targets for complex older adults

A

A1c: <8%
FPG: 90-150
Bedtime: 100-180

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8
Q

What are glycemic targets for very complex/poor health older adults?

A

A1c: <8.5%
FPG: 100-180
Bedtime: 110-200

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9
Q

What are the glycemic targets for children & adolescents?

A

A1c: <7.5%
FPG: 90-130
Bedtime: 90-150

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10
Q

What are the glycemic targets for pregnant women?

A

A1c: <6-6.5%
FPG: <95
1 hr PPG: <140
2 hr PPG: <120

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11
Q

How long after a patient is started on metformin can you intensify their therapy to a 2 drug therapy?

A

3 months (only intensify therapy if they are not at their glycemic targets at this time)

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12
Q

What is the A1c lowering ability of insulins?

A

1.5-3.5%

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13
Q

Afrezza is what kind of insulin?

A

inhaled; acts like a rapid acting insulin

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14
Q

What routine testing do you need to do if someone is on Afrezza?

A

pulmonary function tests @ baseline, 6 months, annually

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15
Q

Who is Afrezza contraindicated for and who is it recommended not to use for?

A

C/I: COPD and asthma

recommended not to use: smokers

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16
Q

How is Afrezza dosed?

A

Initial dose: 4 units/meal

Available in 4, 8, and 12 unit cartridges

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17
Q

How is glargine U-300 different from glargine U-100?

A
  • U-300 same units per dose as U-100 but more concentrated
  • U-300 lasts longer (duration: 36hrs)
  • U-300 less likely to cause hypoglycemia
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18
Q

glargine U-300 dosing

A

insulin naive: 0.2units/kg (type 2) 0.2-0.4 units/kg (type 1)
once daily basal insulin: 1:1 conversion
twice daily NPH: 80% of total NPH dose

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19
Q

How is degludec different from glargine U-100?

A
  • degludec lasts longer (8-40 hrs)

- degludec has less risk of hypoglycemia

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20
Q

Degludec dosing

A

starting dose:
- insulin naive: 10 units/day
- from other insulin: 1:1 conversion given once daily
doses must be given at least 8 hours apart

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21
Q

How long does it take degludec to reach steady state?

A

2-3 days

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22
Q

Which patients is degludec good for?

A

pt who needs flexible dosing
pt on >80units/day of insulin
pt at high risk for hypoglycemia

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23
Q

glargine U-100 (basaglar)

A

follow-on biologic;

not bioequivalent to Lantus, but works just as well

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24
Q

lispro U-200

A

bioequivalent to lispro U-100;

1:1 conversation from lispro U-100 to lispro U-200

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25
Q

When should you consider using lispro U-200 over lispro U-100?

A

if a pt is on high mealtime doses

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26
Q

Humulin R U-500

A

regular insulin that behaves like NPH

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27
Q

Who should be considered to switch to Humulin R U-500

A

patient on >200 units/day

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28
Q

Humulin R U-500 dosing

A

A1c >8%: 100% of U-100 TDD
A1c <8%: 80% of U-100 TDD
Will be given BID or TID
Will be the only insulin used (when switching a pt to U-500 d/c all other insulins they are on)

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29
Q

Initiating insulin in type 1 diabetes

A

TDD: 0.4-1 unit/kg/day (usually just use 0.5 units/kg/day)
1/2 to 2/3: basal
1/3 to 1/2: bolus

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30
Q

initiating insulin in type 2 diabetes

A

10 units/day OR 0.1-0.2 units/kg/day

adjust: 10-15% OR 1-2 units, 1-2 times/week until at goal

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31
Q

Adding rapid acting insulin in type 2 diabetes

A

4 units, OR 0.1 unit/kg OR 10% of basal dose given once before largest meal
adjust: 10-15% OR 1-2 units, 1-2 times/week until at goal

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32
Q

Which Insulin to adjust:
FPG dysfunction?
PPG dysfunction?
hyperglycemic all day?

A

FPG: adjust basal
PPG: adjust bolus
all day: fix the fasting first

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33
Q

Bolus insulin adjustments

A

10-15% OR 1-2 units

1-2 times/week until at goal

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34
Q

Basal insulin adjustments

A

10-15% OR 2-4 units

1-2 times/week until at goal

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35
Q

switching from NPH to detemir

A

1:1 conversion given once daily

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36
Q

switching from NPH to glargine U-100, U-300, degludec

A

once daily NPH: 1:1 conversion given once dialy

twice daily NPH: 80% of TDD given once daily

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37
Q

switching from glargine to detemir

A

1:1 conversion

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38
Q

FROM glargine U-100 or detemir TO glargine U-300, degludec U-100, degludec U-200

A

1:1 conversion

39
Q

FROM glargine U-100 or detemir TO NPH

A

1: 1 conversion, give NPH twice daily

* can consider 20% dose reduction

40
Q

FROM Rapid or short acting insulin TO short or rapid acting insulin

A

1: 1 conversion

* watch for meal timing

41
Q

Major side effects of insulin?

A

hypoglycemia

lipohypertrophy

42
Q

What blood sugar is considered hypoglycemic?

A

<70mg/dL

43
Q

How to manage hypoglycecmia

A

15:15 rule
give 15g of carbs, check sugar 15 min later
repeat if necessary

glucagon kit

44
Q

What tends to cause lipohypertrophy?

A

repeated injections at the same site

reuse of needles

45
Q

What are 2 non-diabetes drugs that can be beneficial in diabetes?

A

colesevalem

bromocriptine

46
Q

What are the 2 classes of drugs that are non-insulin injectables?

A

GLP-1 agonists

Amylin analog

47
Q

Which 2 drugs should be CONSIDERED for a type 2 diabetic with atherosclerotic cardiovascular disease

A

empagliflozin

liraglutide

48
Q

How long can it take to see the maximum effects of metformin?

A

2 weeks

49
Q

does metformin primarily effect FPG or PPG?

A

FPG

50
Q

Long term use of metformin can cause what deficiency?

A

vitamin B12 deficiency

51
Q

metformin dosing

A

titrate over 4 weeks
start at 500mg daily for 1 week
up the dose by 500mg each week up to 2000mg (1000mg BID)

52
Q

Why do you titrate metformin slowly?

A

minimize GI effects (diarrhea)

53
Q

At what dose do sulfonylureas have their maximum therapeutic effects?

A

50% of max daily dose

54
Q

Which sulfonylurea should you avoid using and is not recommended for use by the ADA?

A

Glyburide

55
Q

What is the durability of use of sulfonylureas?

A

They work really well for the first 6 months, then don’t work as well anymore

56
Q

Sulfonylurea dosing

A

glyburide: max daily dose 10mg BID
glipizide: 20mg BID max daily dose
glimeperide: max daily dose 8mg daily
* you should only use 50% of max daily dose to reach maximum therapeutic dose

57
Q

Do sulfonylureas mostly effect FPG or PPG?

A

FPG

58
Q

Do glinides mostly effect FPG or PPG?

A

PPG

59
Q

Why do glinides have a lower risk of hypoglycemia than sulfonylureas?

A

glinides have a rapid onset and short duration of action

60
Q

How often do you need to dose glinides?

A

3 times a day

given before each meal

61
Q

do thiazolininediones primarily effect FPG or PPG?

A

FPG

62
Q

How long does it take to get maximum therapeutic effects of TZD’s?

A

8-12 weeks

63
Q

What is the durability of TZD’s?

A

good durability;

lowers A1c initially and will continue to do so with chronic use

64
Q

Why has the safety of TZD’s been questioned?

A

rosiglitazone study: increased risk of MI and death from CV disease

pioglitazone: edema, weight gain, bone fractures, bladder cancer, macula edema

65
Q

Do alpha glucosidase inhibitors effect FPG or PPG?

A

PPG

66
Q

how often do you dose alpha glucosidase inhibitors?

A

multiple times a day;

mealtime dosing

67
Q

what should you counsel a patient on when starting them on an alpha glucosidase inhibitor?

A

most effective if diet contains a large amount of carbs

can cause lots of flatulence (not usually tolerable)

68
Q

Do DPP-4 inhibitors effect FPG or PPG?

A

PPG

69
Q

How long does it take to see the max effects of a DPP-4 inhibitor?

A

2 weeks

70
Q

If you give a DPP-4 inhibitor with a sulfonylurea what changes do you need to make with dosing?

A

reduce dose of sulfonylurea

71
Q

Why are SGLT-2 inhibitors good for all durations of diabetes?

A

not dependent on beta cell function

72
Q

Do SGLT-2 inhibitors effect FPG or PPG?

A

FPG

73
Q

What organ are you most worried about damaging with use of SGLT-2 inhibitors?

A

kidneys

SGLT-2 push excess blood sugar out through the kidneys

74
Q

do GLP-1 receptor agonists effect FPG or PPG?

A

both
daily GLP-1: PPG
weekly GLP-1: FPG

75
Q

GLP-1 receptor agonists are most approved for use with what other diabetes drug?

A

prandial insulin

76
Q

What must you give an amylin analogue in combination with?

A

intensive insulin regimen (basal and bolus)

77
Q

When selecting what drug to use to intensify treatment what should you consider?

A

the patient’s co-morbid conditions

goal is to optimize treatment without worsening other conditions

78
Q

What drug combinations should you avoid?

A

sulfonylurea + glinide

GLP-1 + DPP-4 inhibitor

79
Q

Which drugs should you consider using in co-morbid CV disease?

A

liraglutide
empagliflozin
canagliflozin
metformin

80
Q

which drugs should you avoid in co-morbin CV disease?

A

saxagliptin/alogliptin
TZD’s
sulfonylurea

81
Q

What drugs should you avoid or dose reduce in renal disease?

A 
metformin
sulfonylureas
DPP-4 inhibitors
exenatide, exenatide ER
SGLT-2 inhibitors
82
Q

Metformin and renal disease (CrCl cutoffs)

A 
C/I: CrCl <30
don't initiate metformin: CrCl 30-35
if pt already on metformin:
- CrCl 45-60: continue use
- CrCl 30-45: weight the risks/benefits
83
Q

Canagliflozin (SGLT-2) renal dosing

A

normal dose: 100 or 300 mg/day
renal:
- CrCl 45-59: 100mg daily
- CrCl <45: avoid use

84
Q

Empagliflozin (SGLT-2) renal dosing

A

normal dose: 10 or 25mg/day
renal:
- CrCl <45: avoid use

85
Q

Dapagliflozin (SGLT-2) renal dosing

A

normal dose: 5 or 10 mg/day
renal:
- CrCl <60: avoid use

86
Q

How to minimize risk of hypoglycemia with insulin use

A

use rapid acting and long or ultra-long acting

87
Q

how to minimize risk of hypoglycemia with sulfonylureas

A

take with food

88
Q

how to minimize risk of hypoglycemia with glinides

A

take with food

89
Q

how to minimize risk of hypoglycemia with amylin analogue

A

reduce dose of bolus insulin by 50%

90
Q

Which diabetes drugs are approved for use in children?

A

insulin

metformin

91
Q

which classes of drugs cause weight loss?

A

GLP-1 agonists
amylin analogue
SGLT-2 inhibitors

92
Q

Which classes of drugs are weight neutral?

A

metformin
DPP-4 inhibitors
alpha glucosidase inhibitors (AGI)

93
Q

Which classes of drugs cause weight gain?

A

TZD’s
sulfonylureas
glinides
insulin

94
Q

Which classes of drugs are generic (cheaper)?

A 
metformin
sulfonylureas
glinides
TZD's
AGI
insulin glargine U-100

Therapeutics (3 decks)

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