Diabetes Flashcards
What does A1c measure?
average blood sugar over the past 3 months;
percentage of hemoglobin molecule covered by glucose
How often is A1c checked?
every 3-6 months
What can falsely elevate A1c?
iron deficiency anemia
blood transfusion
(anything that lengthens RBC lifespan)
What can falsely decrease A1c?
blood loss
hemolytic anemia
(anything that shortens RBC lifespan)
What are the glycemic targets in adults?
A1c: <7%
FPG: 80-130mg/dL
PPG: <180mg/dL
What are glycemic targets for healthy older adults?
A1c: <7.5%
FPG: 90-130
Bedtime: 90-150
What are glycemic targets for complex older adults
A1c: <8%
FPG: 90-150
Bedtime: 100-180
What are glycemic targets for very complex/poor health older adults?
A1c: <8.5%
FPG: 100-180
Bedtime: 110-200
What are the glycemic targets for children & adolescents?
A1c: <7.5%
FPG: 90-130
Bedtime: 90-150
What are the glycemic targets for pregnant women?
A1c: <6-6.5%
FPG: <95
1 hr PPG: <140
2 hr PPG: <120
How long after a patient is started on metformin can you intensify their therapy to a 2 drug therapy?
3 months (only intensify therapy if they are not at their glycemic targets at this time)
What is the A1c lowering ability of insulins?
1.5-3.5%
Afrezza is what kind of insulin?
inhaled; acts like a rapid acting insulin
What routine testing do you need to do if someone is on Afrezza?
pulmonary function tests @ baseline, 6 months, annually
Who is Afrezza contraindicated for and who is it recommended not to use for?
C/I: COPD and asthma
recommended not to use: smokers
How is Afrezza dosed?
Initial dose: 4 units/meal
Available in 4, 8, and 12 unit cartridges
How is glargine U-300 different from glargine U-100?
- 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
glargine U-300 dosing
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
How is degludec different from glargine U-100?
- degludec lasts longer (8-40 hrs)
- degludec has less risk of hypoglycemia
Degludec dosing
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
How long does it take degludec to reach steady state?
2-3 days
Which patients is degludec good for?
pt who needs flexible dosing
pt on >80units/day of insulin
pt at high risk for hypoglycemia
glargine U-100 (basaglar)
follow-on biologic;
not bioequivalent to Lantus, but works just as well
lispro U-200
bioequivalent to lispro U-100;
1:1 conversation from lispro U-100 to lispro U-200
When should you consider using lispro U-200 over lispro U-100?
if a pt is on high mealtime doses
Humulin R U-500
regular insulin that behaves like NPH
Who should be considered to switch to Humulin R U-500
patient on >200 units/day
Humulin R U-500 dosing
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)
Initiating insulin in type 1 diabetes
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
initiating insulin in type 2 diabetes
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
Adding rapid acting insulin in type 2 diabetes
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
Which Insulin to adjust:
FPG dysfunction?
PPG dysfunction?
hyperglycemic all day?
FPG: adjust basal
PPG: adjust bolus
all day: fix the fasting first
Bolus insulin adjustments
10-15% OR 1-2 units
1-2 times/week until at goal
Basal insulin adjustments
10-15% OR 2-4 units
1-2 times/week until at goal
switching from NPH to detemir
1:1 conversion given once daily
switching from NPH to glargine U-100, U-300, degludec
once daily NPH: 1:1 conversion given once dialy
twice daily NPH: 80% of TDD given once daily
switching from glargine to detemir
1:1 conversion
FROM glargine U-100 or detemir TO glargine U-300, degludec U-100, degludec U-200
1:1 conversion
FROM glargine U-100 or detemir TO NPH
1: 1 conversion, give NPH twice daily
* can consider 20% dose reduction
FROM Rapid or short acting insulin TO short or rapid acting insulin
1: 1 conversion
* watch for meal timing
Major side effects of insulin?
hypoglycemia
lipohypertrophy
What blood sugar is considered hypoglycemic?
<70mg/dL
How to manage hypoglycecmia
15:15 rule
give 15g of carbs, check sugar 15 min later
repeat if necessary
glucagon kit
What tends to cause lipohypertrophy?
repeated injections at the same site
reuse of needles
What are 2 non-diabetes drugs that can be beneficial in diabetes?
colesevalem
bromocriptine
What are the 2 classes of drugs that are non-insulin injectables?
GLP-1 agonists
Amylin analog
Which 2 drugs should be CONSIDERED for a type 2 diabetic with atherosclerotic cardiovascular disease
empagliflozin
liraglutide
How long can it take to see the maximum effects of metformin?
2 weeks
does metformin primarily effect FPG or PPG?
FPG
Long term use of metformin can cause what deficiency?
vitamin B12 deficiency
metformin dosing
titrate over 4 weeks
start at 500mg daily for 1 week
up the dose by 500mg each week up to 2000mg (1000mg BID)
Why do you titrate metformin slowly?
minimize GI effects (diarrhea)
At what dose do sulfonylureas have their maximum therapeutic effects?
50% of max daily dose
Which sulfonylurea should you avoid using and is not recommended for use by the ADA?
Glyburide
What is the durability of use of sulfonylureas?
They work really well for the first 6 months, then don’t work as well anymore
Sulfonylurea dosing
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
Do sulfonylureas mostly effect FPG or PPG?
FPG
Do glinides mostly effect FPG or PPG?
PPG
Why do glinides have a lower risk of hypoglycemia than sulfonylureas?
glinides have a rapid onset and short duration of action
How often do you need to dose glinides?
3 times a day
given before each meal
do thiazolininediones primarily effect FPG or PPG?
FPG
How long does it take to get maximum therapeutic effects of TZD’s?
8-12 weeks
What is the durability of TZD’s?
good durability;
lowers A1c initially and will continue to do so with chronic use
Why has the safety of TZD’s been questioned?
rosiglitazone study: increased risk of MI and death from CV disease
pioglitazone: edema, weight gain, bone fractures, bladder cancer, macula edema
Do alpha glucosidase inhibitors effect FPG or PPG?
PPG
how often do you dose alpha glucosidase inhibitors?
multiple times a day;
mealtime dosing
what should you counsel a patient on when starting them on an alpha glucosidase inhibitor?
most effective if diet contains a large amount of carbs
can cause lots of flatulence (not usually tolerable)
Do DPP-4 inhibitors effect FPG or PPG?
PPG
How long does it take to see the max effects of a DPP-4 inhibitor?
2 weeks
If you give a DPP-4 inhibitor with a sulfonylurea what changes do you need to make with dosing?
reduce dose of sulfonylurea
Why are SGLT-2 inhibitors good for all durations of diabetes?
not dependent on beta cell function
Do SGLT-2 inhibitors effect FPG or PPG?
FPG
What organ are you most worried about damaging with use of SGLT-2 inhibitors?
kidneys
SGLT-2 push excess blood sugar out through the kidneys
do GLP-1 receptor agonists effect FPG or PPG?
both
daily GLP-1: PPG
weekly GLP-1: FPG
GLP-1 receptor agonists are most approved for use with what other diabetes drug?
prandial insulin
What must you give an amylin analogue in combination with?
intensive insulin regimen (basal and bolus)
When selecting what drug to use to intensify treatment what should you consider?
the patient’s co-morbid conditions
goal is to optimize treatment without worsening other conditions
What drug combinations should you avoid?
sulfonylurea + glinide
GLP-1 + DPP-4 inhibitor
Which drugs should you consider using in co-morbid CV disease?
liraglutide
empagliflozin
canagliflozin
metformin
which drugs should you avoid in co-morbin CV disease?
saxagliptin/alogliptin
TZD’s
sulfonylurea
What drugs should you avoid or dose reduce in renal disease?
metformin sulfonylureas DPP-4 inhibitors exenatide, exenatide ER SGLT-2 inhibitors
Metformin and renal disease (CrCl cutoffs)
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
Canagliflozin (SGLT-2) renal dosing
normal dose: 100 or 300 mg/day
renal:
- CrCl 45-59: 100mg daily
- CrCl <45: avoid use
Empagliflozin (SGLT-2) renal dosing
normal dose: 10 or 25mg/day
renal:
- CrCl <45: avoid use
Dapagliflozin (SGLT-2) renal dosing
normal dose: 5 or 10 mg/day
renal:
- CrCl <60: avoid use
How to minimize risk of hypoglycemia with insulin use
use rapid acting and long or ultra-long acting
how to minimize risk of hypoglycemia with sulfonylureas
take with food
how to minimize risk of hypoglycemia with glinides
take with food
how to minimize risk of hypoglycemia with amylin analogue
reduce dose of bolus insulin by 50%
Which diabetes drugs are approved for use in children?
insulin
metformin
which classes of drugs cause weight loss?
GLP-1 agonists
amylin analogue
SGLT-2 inhibitors
Which classes of drugs are weight neutral?
metformin
DPP-4 inhibitors
alpha glucosidase inhibitors (AGI)
Which classes of drugs cause weight gain?
TZD’s
sulfonylureas
glinides
insulin
Which classes of drugs are generic (cheaper)?
metformin sulfonylureas glinides TZD's AGI insulin glargine U-100
