Diabetes Flashcards
What is the initial daily dosing for Type 1 diabetes?
0.5-1 unit/kg/day
How is the daily dose divided for type 1 diabetes?
50% basal
50% rapid acting
The number of units needed are adjusted based on ??
- blood glucose readings
- the amount of carbs consumed at each meal
- expected exercise
- presence of illness
- changes in age
- changes in weight
What is the A1C goal for <6 years old?
<8%
What is the A1C goal for 6-12 years old?
<7.5%
What is the A1C goal for anyone over 12 years old?
<7%
What is the FPG goal for <6 years old?
6-10 mmol/L
What is the FPG goal for 6-12 year olds?
4-10 mmol/L
What is the FPG goal for those over 12?
4-7 mmol/L
What is the 2hr post prandial PG (plasma glucose) goal for those over 12?
5-10 (or 5-8 if A1C target not met)
Why are the targets higher for those <6 ?
Caution is required to minimize hypoglycaemia bc that can cause cognitive impairment.
In most cases, insulin adjustments should approximate a ___% change to the insulin causing the effect.
10%
What is the “Correction Factor” or “Insulin Sensitivity Factor” for rapid acting insulin?
100/TDD = how much one unit of rapid acting insulin should reduce their BG by.
What is the “Correction Factor” or “Insulin Sensitivity Factor” for short acting insulin?
85/TDD = how much one unit of short acting insulin should reduce their BG by.
How do you adjust for if Pt wants extra slice of cake for dinner?
Use insulin to carbohydrate ratio (ICR)
500/TDD (or # carbs in a day/TDD)
This will give you the grams of carbs that uses 1 unit of insulin.
Ex.
500/33 units = 13.6 grams of carbs
1 unit is required for 13.6 grams of carbs
Say cake = 27.2 grams of carbs (no fibre),
Then tell Pt to inject 2 extra units of insulin.
Subtract _____ from # of carbs.
fibre
Do you increase or decrease insulin for exercise?
decrease
When should a diabetic not exercise?
- If they have hypoglycaemia (<4 mmol/L)
- If their BG is > 14 mmol/L with ketones
- If their BG is > 16.7 mmol/L
Delayed hypoglycaemia can occur up to ___ hrs after exercise.
36
Which medications should someone not take if they are ill and are diabetic and why?
SADMANS
- Sulfonylureas
- ACEi
- Diuretics, direct renin inhibitors
- Metformin
- ARBs
- NSAIDs
- SGLT2 inhibitors
ARB, ACEi, Direct renin inhibitors, NSAIDs, diuretics, and SGLT2 inhibitors increase risk for a decline in kidney function
Metformin and sulfonylureas have reduced clearance and increase risk for adverse effects.
List examples of sulfonylureas
Gliclazide
Glimepiride
Glyburide
If you become sick and are unable to drink enough fluid (risk of dehydration), which meds should you stop?
- BP pills
- Water pills (diuretic)
- Metformin
- Diabetes pills
- Pain meds
- NSAIDs
**important to tell patients who are buying OTC combo products that they should buy the one with tylenol and not advil !!
How does illness affect insulin?
Illness and infection allow the body to release counter regulatory hormones that oppose the action of insulin, and therefore can increase BG.
What is the objective of sick day management in diabetic patients?
to minimize metabolic imbalance, avoid severe hypoglycaemia and prevent hyperglycaemia and ketosis leading to the developing of DKA
Hyperglycemia is a risk factor for ______
DKA
What is DKA?
And what is the treatment for DKA?
- HYPERglycemia puts patients at risk for DKA.
- This condition develops when your body can’t produce enough insulin.
- Without insulin, your body starts to break down fat as a fuel bc it can’t break down sugar.
- When fat breaks down, ketones can be present in urine and blood.
- Treatment: Insulin
Should you stop insulin on sick days?
NO
NEVER
NO WAY
Symptoms of DKA?
nausea, vomiting, ab pain
When should a diabetic patient test their ketones?
When they are sick and BG levels remain elevated > 14 mmol/L
Illness:
Which insulins do you adjust?
Usually keep the long acting or intermediate acting dose the same.
Start by adjusting the rapid or short acting insulin.
Supplemental rapid or short acting insulin can be safely given every 3-4 hours without discussion with a physician
What do you tell a diabetic patient for monitoring during illness?
Monitor BG and ketones every 2-4 hours around the clock as long as significant hyperglycaemia and/or ketonuria/ketonemia persist
What is the target ranges for BG for illness?
- BG < 14 mmol/L
- urinary ketones should be negative
- blood ketones of 0.6 or less
What if a patient can’t eat?
10-15 grams of carbs should be taken every 1-2 hours (to prevent starvation ketosis and hypoglycaemia)
Why do they need extra fluids in a time of illness?
How much fluids do they need?
To prevent dehydration and facilitate excretion of ketones in the urine.
2200 mL/day (9 cups)
Rule of thumb = 1 cup/hr while awake
When would you need to communicate with the CDE or physician?
If patient:
- Is unable to tolerate fluids
- Has recurrent vomiting (more than once in 4 hours)
- Has recurrent diarrhea (more than 5 times in a day)
- Has taken extra insulin (2 additional doses) as recommended, but hyperglycaemia and ketones do not improve
- Has an illness that is very severe, worsens, or lasts longer than 12-24 hours
- Is unable to keep BG > 6
- Shows sings or symptoms of DKA, dehydration or any other serious problem
- Has any questions/concerns about sick day management
How much do you change insulin by if:
- BG > 14
- Blood ketones 1.5-3
- Urinary ketones are positive/moderate
10% increase of TDD. If this doesn’t work within 2-3 hours, try 10-15% of TDD
*If on an insulin pump, use 1.5 times usual correction
How much do you change insulin by if:
- BG > 20
- Blood ketones < 1.5
- Urinary ketones are negative/small
10% increase of TDD. If this doesn’t work within 2-3 hours, try 10-15% of TDD
*If on an insulin pump, use 1.5 times usual correction
How much do you change insulin by if:
- BG > 20
- Blood ketones > 3
- Urinary ketones are large
15% increase of TDD in additional to usual dose and/or consult with your HCT. If not improving, seek medical help
How much do you change insulin by if:
-BG < 6
reduce usual dose by 5-10%
How much do you change insulin by if:
- BG 6-20
- Blood ketones < 1.5
- Urinary ketones are negative/small
usual dose at usual times with corrections
Are ketones detected earlier in blood or urine?
blood
What is the acronym SICK stand for?
S = blood sugar testing I = insulin C = Carb and fluid K = ketone testing
MOA of Acarbose
Blocks alpha-glucosidases in GI tract - delays carb digestion
Example of Acarbose
Glucobay
Dose of Acarbose
- 50mg once daily to start
- Titrate up to 100mg TID with meals
- Increase dose every 1-2 months
Acarbose:
Takes approximately _______ for max effect
8 weeks
Acarbose:
What change in A1C would you predict?
a decrease in A1C of 0.5-0.8%
Acarbose:
How does it affect weight?
Weight neutral or slight weight loss
Acarbose:
Risk of hypoglycaemia?
low risk of hypoglycaemia when used alone
Acarbose:
SE ?
Associated with significant GI side effects:
- flatulence > 40%
- diarrhea approx 30%
Acarbose:
What do you need to monitor while on this medication?
Liver function tests (AST, ALT)
Acarbose:
Cost
$1/day
Acarbose:
Pharmacare coverage?
part 1
Acarbose:
Why does this medication cause problems for TREATING hypoglycaemia?
This medication works by delaying carb digestion, so you cannot tell them to have a snack or juice.
THEY MUST HAVE FAST-ACTING GLUCOSE
-food won’t be absorbed and broken down fast enough
Example of Pioglitazone
Actos
Pioglitazone:
When will you see effects?
Delayed onset of 4 weeks, max effect in 8-16 weeks
Pioglitazone:
How will it change A1C?
decrease A1C by 0.8-1%
Pioglitazone:
How does it affect weight?
weight gain (approx 4 kg)
Pioglitazone:
Hypoglycemia?
no hypoglycaemia when used alone
Pioglitazone:
Contraindicated in ?
any amount of HF
Pioglitazone:
Not indicated for use with _____
insulin (due to increased risk of HF)
Pioglitazone:
SE
- edema (5%)
- mild anemia (rare)
- increased incidence of fractures
Pioglitazone:
Must monitor ?
liver function (ALT, AST)
Pioglitazone:
Associated rarely with ____ ______: monitor for blood in urine and dysuria
bladder cancer
Pioglitazone:
Cost
$0.59-1.22/day
Pioglitazone:
Pharmacare coverage?
Part 3 EDS
- For use in patients who are not optimally controlled on MAX doses of metformin and either a sulfonylurea or repaglinide or with CI to the agents
- Type 2 DM on high doses of insulin (over 2U/kg) and on MAX tolerated metformin who are not achieving optimal control
DPP-4 inhibitors are known as ?
incretin enhancers
List examples of DPP-4 inhibitors
The "Liptins" sitagliptin saxagliptin linagliptin alogliptin
DPP-4 inhibitors:
When do you expect results
delayed onset < 4 weeks, max effect approximately 18 weeks
DPP-4 inhibitors:
What decrease in A1C would you expect?
decrease A1C by 0.7%
DPP-4 inhibitors:
Hypoglycemia ?
not when used alone
DPP-4 inhibitors:
Long term efficacy and safety ______
unknown
DPP-4 inhibitors:
May want to avoid in ____ _____
heart failure (may not be as problematic as we once thought)
DPP-4 inhibitors:
SE
- urticaria
- angioedema
- arthralgias
- joint pain
- pancreatitis (rare)
- increased incidence of sore throat/infection, headache, nausea (<10%), diarrhea (<10%)
DPP-4 inhibitors:
cost
$3/day
DPP-4 inhibitors:
Pharmacare coverage?
Part 3 EDS
-For the treatment of patients with T2DM who have previously been treated with metformin and a sulfonylurea. Should be used in patients with diabetes who are not adequately controlled on or are intolerant to metformin and a sulfonylurea, and for whom insulin is not an option.
List examples of glucagon-like peptide-1 receptor agonists
The “tides”
- Exenatide
- Liraglutide (victoza - SC injectable)
- Dulaglutide
- Albiglutide
Glucagon-like peptide-1 receptor agonists:
Indicated for?
in combination with metformin, or merformin and a sulfonylurea, or metformin and a basal insulin
Glucagon-like peptide-1 receptor agonists:
What drop in A1C do you expecT?
0.8-1.4%
Glucagon-like peptide-1 receptor agonists:
Treatment with liraglutide (victoza) showed benefit in what type of patients?
decreased risk of CV events in those that were at high risk of having a CV event
Glucagon-like peptide-1 receptor agonists:
Liraglutide dose?
Titrate the dose upward: 0.6 mg SC once daily x 1 week, then 1.2mg SC once daily, may increase to 1.8mg SC once dialy
Glucagon-like peptide-1 receptor agonists:
How does it affect weight?
weight neutral or slight weight loss (approx 3 kg)
Glucagon-like peptide-1 receptor agonists:
Risk of hypoglycaemia?
lower risk of hypoglycaemia when used alone
Glucagon-like peptide-1 receptor agonists:
Long term efficacy and safety _____
unknown
Glucagon-like peptide-1 receptor agonists:
Associated with _____ cancer (contraindicated if person or family history)
thyroid
Glucagon-like peptide-1 receptor agonists:
SE?
- reports of pancreatitis (rare)
- increased incidence of nausea (39%), headache, diarrhea (21%), hives
Glucagon-like peptide-1 receptor agonists:
Cost?
$2.98-8.95/day
very $$$$
Glucagon-like peptide-1 receptor agonists:
Pharmacare coverage?
No pharmacare coverage
List examples of SGLT-2 inhibitors
The “Flozins”
- canagliflozin
- dapagliflozin
- empagliflozin
SGLT-2 inhibitors:
MOA
causes increased urinary glucose excretion
SGLT-2 inhibitors:
A1C decrease?
0.7-1%
SGLT-2 inhibitors:
Reduces risk of ?
composite CV events and all cause death
SGLT-2 inhibitors:
Dose of empagliflozin?
typically 10 mg daily with 1st meal of the day up to a maximum dose of 25 mg daily.
SGLT-2 inhibitors:
Who is empagliflozin CI in?
renally impaired patients with eGFR less than 45 mL/min and ESRD patients or patients on dialysis
SGLT-2 inhibitors:
Weight?
Weight neutral or weight loss (approx 4kg)
SGLT-2 inhibitors:
SE ?
- UTI (18% in females)
- genital fungal infections (4%)
- nausea
- constipation
- urinary frequency
- light-headedness
- increased K, Mg, P04
- decreased BP
- decreased intravascular volume
- rare DKA
Which 2 groups do we need to know well for the exam?
Glucagon-like peptide-1 receptor agonist
SGLT-2 inhibitors
Patients with a prior history of genital infections are more likely to experience a genital infection event while on ________
jardiance
Jardiance - cost?
$3/day
Jardiance - pharmacare?
Part 3 EDS
-For the treatment of patients with T2DM who have previously been treated with metformin and a sulfonylurea. Should be used in patients with DM who are not adequately controlled on or are intolerant to metformin and a sulfonylurea, and for whom insulin is not an option.
Exercise:
When should you monitor BG?
before, during and after exercise
Exercise:
Adjust insulin or food?
preferred to adjust insulin
food - for unplanned activity
Exercise:
How can hypoglycaemia be prevented?
- adding food
- decreasing insulin
Exercise:
Always carry ?
a source of fast acting glucose
Exercise:
Vigorous activity, day-long activity or those with a history of delayed hypoglycaemia may need to adjust intermediate or long-acting insulin by ____5
30-50%
Exercise:
An insulin pump may be disconnected during exercise for _____ hours
1-2 hours
*BG should be checked before disconnecting the pump and upon reconnecting.
Exercise:
How do you determine the insulin adjustment?
ask pt the intensity and duration and adjust according to the chart
