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Pharm > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Characteristics of DM

A 
Hyperglycemia
Impaired metabolism
Impaired insulin secretion* 
Insulin resistance*
*or both
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2
Q

% cases that are DM 1

A

5-10%

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3
Q

% cases that are DM2

A

90+

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4
Q

Age of onset DM 1

A

< 30 years

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5
Q

Age of onset DM 2

A

> 30 years

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6
Q

Genetic link DM 1

A

Weak

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7
Q

Genetic link DM 2

A

Strong

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8
Q

Pathogenesis DM 1

A

Absolute deficiency of insulin production

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9
Q

Pathogenesis DM 2

A

Insulin resistance, defective insulin release

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10
Q

Dx of DM

A

Hgb A1C >6.5%
Fasting BG > 126 mg/dL
Classic ssx + random BG > 200 mg/dL
BG > 200 mg/dL 2 hours post OGTT

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11
Q

DM 1

A

Absolute deficiency of insulin production

Autoimmune

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12
Q

Four main features of DM 1

A

1) long pre-clinical period
2) hyperglycemia when 80-90% of beta cells are destroyed
3) Transient remission
4) Established disease

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13
Q

DM 1 Tx

A

Individualized
Goal is to mimic normal physiologic levels
Basal
Bolus
Basal-bolus (long acting for basal coverage; short acting bolus at meal times)

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14
Q

Human Insulin

A 
Regular
Short acting
100 units/mL = standard
500 units/mL (U-500) 
ERROR PRONE
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15
Q

Insulin Analogs

A

Rapid -> ultra short acting

or long acting

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16
Q

NPH insulin

A

Intermediate acting

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17
Q

Insulin mixtures

A

70/30; 50/50

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18
Q

Insulin administsration

A

Oral -> destroys protein
Must be given parenterally
Usually SubQ injection (slow absorption)

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19
Q

How do you give regular insulin

A

IV

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20
Q

Rapid (ultra short) Acting Analogs

A

Rapid absorption due to reduced self-association

Advantage: can dose closer to meal time

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21
Q

Long Acting Insulin Analogs

A

Reduced solubility
Slow absorption
Advantage: continuous coverage w/o more injections

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22
Q

Glargine duration

A 
Long acting (LA)
22-36 hours
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23
Q

Glargine subtypes w/ units

A

Lantus: 100 units/mL
Toujeo: 300 units/mL

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24
Q

Detemir duration

A

LA
12-20 hours
Dose 1-2xs/day

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25
Q

Degludec duration

A

LA

>42 hours

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26
Q

Degludec subtype and units

A

100 units/mL

or 200 units/mL

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27
Q

NPH insulin

A 
Intermediate acting (IA)
Suspension of crystalline zinc insuline and positively charged polypeptide, protamine
Absorbed slower after SubQ injection
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28
Q

NPH duration

A

Longer than regular insulin but shorter than glargine, detemir, or degludec

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29
Q

Early insulin names

A 
Humalin = made by Eli Lilly
Novolin = made by Novo Dordisk
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30
Q

DM 1 inslin total daily dose (TDD)

A

Total daily dose required about 0.4-1 units/kg/day of actual body weight

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31
Q

DM 1 basal insulin dose requirements

A

Should be approximately half total daily dose (TDD)

May use intermediate or long acting (NPH is preferred because it can be mixed)

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32
Q

DM 1 bolus insulin dose requirements

A

Other 50% of TDD
Divided between meals based on type of meal and pt characteristics
Rapid acting or regular

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33
Q

2 injection non-intensive insulin therapy

A

Split-mixed dosing
2 daily injections (2/3 TDD AM; 1/3 TDD PM)
Basal insulin should be 2/3 as morning dose and 1/3 as evening dose (NPH)

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34
Q

3 injection non-intensive insulin therapy

A

3 daily injections -> same dosing as split mixed but moves NPH to bedtime
Decreases nocturnal hypoglycemia
Increased effect at dawn

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35
Q

Intensive insulin therapy

A

multiple BG checks/day

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36
Q

Types of control for sliding scale insulin

A

Tight or regular control

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37
Q

What 2 types of glycemic monitoring are there

A

Blood glucose

HgbA1C

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38
Q

Blood glucose measure

A

Evaluates impact of insulin on meals
Fasting = FBG
Post-Parandial = PPG

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39
Q

HgbA1c

A

Assess glycemic control over 2-3 months

4-6% in non-diabetes

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40
Q

HgbA1c goals

A

AACE guidelines < 6.5%

ADA guidelines < 7%

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41
Q

Interpreting A1C

A

Irreversible process
Lasts life of RBCs (120 days)
Reflects average glucose over 3 months

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42
Q

DM 2 is a disorder of:

A

Insulin secretion
Insulin resistance
Excess glucose production
(can be all of the above)

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43
Q

RF for DM 2

A

Most are modifiable

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44
Q

Tx DM 2

A

Individualize -> based on age and comorbidities

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45
Q

DM 2 lifestyle changes

A 
Start at diagnosis w/ pharmacotherapy
Weight reduction (diet and exercise) 
Tobacco cessation
Minimize alcohol
Nutritional counseling
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46
Q

Initial tx DM 2

A

At diagnosis: lifestyle changes and metformin

Multiple drugs being used earlier

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47
Q

When do you start dual DM 2 tx

A

If not at target A1C after 3 months of monotherapy or baseline A1C > 9%

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48
Q

When do you start triple DM 2 tx

A

If not at target A1C after 3 months of dual therapy

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49
Q

When do you start combo injection therapy for DM 2?

A

Not at target A1C after 3 months of triple therapy
BG > 300-350 mg/dL
A1C > 10-12%

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50
Q

Highly effective hypoglycemia agents

A

Insulin
Biguanides (metformin)
Sulfonylureas (SUs)
Rapid-acting secretagogues (glinides)

51
Q

Insulin for DM2

A

Used earlier now to reduce micro and macrovascular complications

52
Q

When to start insulin in DM 2 pts

A

Not at A1C goal after >2 non-insulin hypoglycemics
If pt has severe fasting BG levels
A1C > 10%
Don’t use as a threat for not reaching A1C goals

53
Q

What kind of insulin do you start w/ in DM 2

A

Basal/long acting
Less hypoglycemia
NPH and LA equally effective
NPH available OTC and cheaper

54
Q

First step in starting insulin for DM 2 pt

A

Start basal (LA) once daily

55
Q

Second step for DM 2 insulin pts

A

Adjust once or twice weekly

56
Q

3rd step DM 2 insulin pts

A

If not at goal begin prandial rapid insulin

57
Q

Step 4 DM 2

A

Begin basal bolus insulin regimen

58
Q

Biguanides DM 2

A

Metformin
Oral
Considered 1st line drug of choice

59
Q

Biguanides and metformin MOA

A

Reduces hepatic glucose production
Reduces intestinal glucose absorption
Increase insulin sensitivity
Improved peripheral glucose uptake and utilization

60
Q

Metformin-glucophage

A

Promotes modest weight loss or weight neutral
Lowers fasting BG 20% and A1C 1-2%
Syndergistic effect w/ sulfonylureas
Generally minimal side-effect profile

61
Q

Metformin-glucophage SE

A

Primarily GI: NV; diarrhea; flatulence

Can lead to lactic acidosis

62
Q

Contraindications to metformin

A

Male: serum creatinine > 1.5 mg/dL
Female: serum creatinine clearance > 1.4 mg/dL
Do not use if CrCl < 30 mL/min (CKD 4/5)
Closely monitor if CrCl is between 30-59 mL/min (CKD 3)

63
Q

First biguanide

A

Phenformin

64
Q

What to monitor for when pt is on metformin

A

Renal issues
Dehydration
Infection/sepsis
overdose

65
Q

Sulfonylureas (SUs)

A 
Dose once daily*
*greater risk for hypoglycemia*
Second line therapy
All equally effective
Overall a moderately effective class
66
Q

Are 1st generation SUs used?

A

Rarely

67
Q

2nd generation SU agents

A

Preferred -> less hypoglycemia

1) Glimepiride
2) Glipizide
3) Glyburide

68
Q

Glimepiride dosing interval

A

q 24 hours

More hypoglycemia than glipizide

69
Q

Glipizide dosing interval

A

q12-24 hours

70
Q

Glyburide dosing interval

A

q12-24 hours

Not preferred -> most hypoglycemia

71
Q

SUs MOA

A

Stimulates release of insulin

Requires presence of insulin (functioning pancreas) -> not good for DM1

72
Q

Rapid acting secretagogues (RAS)

A 
glinides
Oral antidiabetic agents
More frequent dosing than SUs
Nateglinide -> dose ac tid
Repaglinide -> dose ac 2-4xs/day (more effective in A1C reduction)
73
Q

RAS MOA

A

Stimulate insulin release from pancreas
Similar to SUs but shorter half life
Faster onset than SUs (fast acting)

74
Q

RAS SE

A

hypoglycemia (less than SUs)

Weight gain

75
Q

SSx of adrenergic manifestation of hypoglycemia

A 
Shakiness
Nervousness
Anxiety
Palpitations Tachycardia
Sweating (absent or diminished if on beta blockers)
76
Q

SSx of glucagon manifestations of hypoglycemia

A

Hunger
Nausea
Vomiting
Headache

77
Q

SSx of neuroglycopenic manifestations of hypoglycemia

A 
Impaired judgement/mentation
Fatigue
Lethargy
Ataxia (can seem like they are intoxicated)
Stupor
Coma
Seizures
78
Q

Mild (< 50 mg/dL) hypoglycemia tx

A

3 glucose tabs
1/3 c fruit juice
5-6 pieces hard candy (not artificial)
Glucose gel

79
Q

Severe (< 40 mg/dL) hypoglycemia tx

A

Glucagon injection

D50 IV push

80
Q

Moderately effective hypoglycemic agents

A

TZDs
DDP4Is
SGLTsIs

81
Q

Thiazolidinediones TZDs

A

Rosiglitazone -> dose 1-2xs/day
Pioglitazone -> dose 1x/day
Synergistic effect when combined

82
Q

TZD MOA

A

Increase insulin sensitivity by:
Increasing glucose utilization and decreasing hepatic glucose production
“Insulin sensitizer” -> needs insulin present

83
Q

TZD SE

A

weight gain
edema
Increased total cholesterol, LDL, HDL
Hepatic metabolism (avoid if LFTs > 2.5 ULN)

84
Q

What are pts at an increased risk of when on rosiglitazone

A

MI

85
Q

TZD pioglitazone agent, dosing, and cost

A

Actos
Dosed once daily
About $10 a month

86
Q

TZD rosiglitazone agent, dosing, cost

A

Avandia
1-2xs/day
$90/month

87
Q

DPP4Is (gliptins) MOA

A

Inhibits enzyme that degrades incretin homrones which prolongs incretin levels

88
Q

Incretin hormones

A

GLP-1
GIP
*Increase insulin secretion in response to meals

89
Q

What are DPP4Is also known as

A

Incretin enhancers

90
Q

Benefits of prolonged incretin levels

A

Stimulate insulin synthesis and release

Decrease glucagon secretion from pancreatic alpha cells

91
Q

Net result of DPP4Is

A

Prolonged basal insulin secretion

92
Q

Advantages of DPP4Is

A

Oral dosing
Once daily
Minimal hypogylcemia
Weight neutral

93
Q

Disadvantages of DPP4Is

A

Placebo
Costly -> $380/month
Concerns of increased risk of heart failure (no increased risk of hospitalization for HF)

94
Q

Does DPP4I agent Linagliptin require renal adjustment?

A

NO

95
Q

Sodium glucose cotransporter 2 Inhibitors

SGLT2Is

A

Oral anti-diabetics

Moderately effective

96
Q

SGLT2I MOA

A

Inhibits SGLT2 recovery of glucose from the urine (increased urine glucose loss)

97
Q

SGLT2I advantages

A

Lowers BP

Decreases weight

98
Q

SGLT2I adverse effects

A

Genital fungal infections
Dehydration
Risk of ketosis, UTIs, and pyelonephritis

99
Q

Minimally effective hypoglycemic agents

A

alpha glucosiade inhibitors (agi)
Pramlintide
Glucagon-like peptide 1 receptor agonists (GLP-1 RAgs)

100
Q

AGIs

A

Oral dosing
TID
Relatively low cost ($30-$60)

101
Q

AGI MOA

A

Inhbits pancreatic alpha amylase and GI brush border alpha-glucosidases
This delays hydrolysis of carbs and reduces post prandial insulin and glucose peaks

102
Q

AGI advantages

A

Effective for DM1 and DM2
NO hypoglycemia
Efficacy equal between all agents

103
Q

AGI disadvantages

A

Usually need to combine w/ metformin, a sulfonylureas, or insulin
High rate of flatulence and mild rate of diarrhea

104
Q

Pramlintide

A

Synthetic analog of human amylin
Decreases post-prandial glucose leves
No action on beta cells so can be used for DM1 and DM2

105
Q

Advantages of pramlitnide

A

Neutral risk of hypoglycemia

Weight loss

106
Q

Pramlintide dosing

A

SubQ injection before each meal

107
Q

Disadvantages of pramlintide

A

Very $$$ ($1500/month)

Nausea in about half of pts

108
Q

Liraglutide dosing (GLP-1 RAg)

A

once daily

109
Q

How are GLP-1 RAg’s dosed

A

SC injection

110
Q 
Exenatide dosing
(GLP-1 RAg)
A

IR = BID; ER = once weekly

111
Q 
Dulaglutide dosing
(GLP-1 RAg)
A

Once weekly

112
Q 
Albiglutide dosing
(GLP-1 RAg)
A

Once weekly

113
Q

GLP-1 RAg MOA

A

Incretin mimetic
Enhances glucose dependent insulin secretion from beta cells which inhibits the release of glucagon which slows rate of gastric emptying which increases satiety

114
Q

GLP-1 RAg advantage

A

weight loss

115
Q

GLP-1 RAg former disadvangtage

A

Heart failure (was recently discounted)

116
Q

Starting DM2 meds guidelines

A

No single method

Keep other factors into account (pt preference, route, cost, risk of hypoglycemia)

117
Q

Starting DM2 meds steps

A

1) Metformin (mild)
2) add a second drug (mod)
3) add a third drug (severe)
4) Insulin + meds (super severe)
* *Most pts will require multiple meds

118
Q

When do you mainly see DKA?

A

Type 1 diabetics

119
Q

What usually precipitates DKA

A

Not adhering to meds
Infection
Alcohol abuse

120
Q

DKA presentation

A 
Polyuria
Polydypsia
Polyphagia
Weakness
Fruity breath
NV
Sx of dehydration
121
Q

Outpatient tx of DKA

A 
This is mild DKA
Hydrate
Insulin
Potassium
Bicarbonate
Sodium
122
Q

Inpatient DKA tx

A 
Mod-severe DKA
Fluids
Insulin
Potassium
Bicarbonate
Sodium
123
Q

Do you increase or decrease insulin for DM1 pts during the honeymoon period (transient remission)?

A

Decrease

Pharm (32 decks)

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