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Diabetes Flashcards

1
Q

Role of insulin?

A

A hormone that moves glucose into muscle and other tissue cells

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2
Q

When’s preventing or delaying T2D the focus?

A

Presence of elevated blood glucose

OR

An A1c of 5.7-6.4%

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3
Q

How can diabetes be delayed or prevented wrt:

Body weight
Physical activity

A

Target weightloss of 7% of body weight

Increasing physical activity to at least 150min/wk of moderate activity such as walking

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4
Q

When may Metformin therapy be considered to prevent/delay diabetes?

A

BMI > 35

Less than 60 yrs of age

Women with a history of GDM

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5
Q

Monitoring of Metformin in pre-diabetes?

A

Monitored at least yearly and assisted with methods to reduce CVD risk factors

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6
Q

What’s T1D?

A

Caused by a cellular-mediated autoimmune destruction of the beta cells in the pancreas

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7
Q

List risk factors for T2D

A

First- degree relative with diabetes
Race/Ethnicity (Native A, Blacks, Asian, Hispanics, Pacific Islanders)
Overweight (BMI >= 25 kg/m2)
Physical inactivity
HTN or taking med for HTN
HDL < 35mg/dL and/or TG > 250mg/dL
Hx of CVD
A1c >= 5.7%, IGT, IFG on previous testing
Women who delivered baby weighing > 9lbs or had GDM
Women with poly cystic ovary syndrome
Other clinical conditions associated with insulin resistance e.g. Severe obesity, Acanthosis nigricans)

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8
Q

List drugs that can cause hyperglycemia

A 
Corticosteroids
Protease inhibitors
Atypical antipsychotics e.g. Olanzapine, Clozapine, Quetiapine 
Niacin
Thiazides and loop diuretics
Statins
Octreotide (in type 2)
Fluoroquinolones
Beta-agonists
Carvedilol and Propranolol and possibly other beta-blockers
Cyclosporine, Tacrolimus
Interferons
Diazoxide (Proglycem-used for low BG due to certain dx)
Cough syrups
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9
Q

List drugs that cause hypoglycemia

A

Q FLOP

Quinine

Fluoroquinolones

Lorcaserin (Belviq)

Octreotide (T1D)

Propranolol

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10
Q

Clinical s/sx of hyperglycemia?

A

Polyuria

Polyphagia

Polydipsia

Blurred vision

Fatigue

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11
Q

What clinical s/sx is unique to T1D?

A

Weightloss

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12
Q

Name the main types of long-term complications of diabetes

A

Microvascular dx

Macrovascular dx

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13
Q

List sx of Microvascular dx (long-term complications)

A

Retinopathy (most common)

Nephropathy (may progress to ESRD)

Peripheral neuropathy (increased risk for foot inf and amputations)

Autonomic neuropathy (erectile dysfunction, gastroparesis, loss of bladder control/UTIs)

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14
Q

List sx of Macrovascular dx (long-term complications)

A

Coronary artery dx e.g. HTN, MI, HF

Cerebrovascular dx e.g. TIA/stroke

Peripheral artery dx (PAD)

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15
Q

What’s the tx goal of diabetes?

A

ABC

A1c

Blood pressure

Cholesterol

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16
Q

What’s ADA tx guidelines?

A1c
Preprandial
Postprandial

A

A1c < 7.0%

Preprandial 70-130mg/dL

Postprandial < 180mg/dL

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17
Q

What’s AACE tx guidelines?

A1c
Preprandial
Postprandial

A

A1c < 6.5%

Preprandial < 110 mg/dL

Postprandial < 140 mg/dL

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18
Q

When did ADA recommend AACE A1c values (more stringent A1c goal)?

A

Younger adults not experiencing hypoglycemia

Those with long life expectancy

No significant CVD

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19
Q

In what circumstances is a less stringent A1c goal (such as < 8%) be appropriate?

A

People with severe hypoglycemia

Limited life expectancy

Extensive comorbid conditions

Advanced complications

Longstanding diabetes where the goal is difficult to attain despite optimal efforts

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20
Q

What’s the BP goal of pts with diabetes?

A

< 140/90 mmHg

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21
Q

What’s the first-line BP med for diabetes pts?

A

ACE-I or ARBs

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22
Q

T/F? One or more of the antihypertensive meds should be given at bedtime to diabetic pts?

A

True

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23
Q

What’s the goal of LDL cholesterol in diabetic pts?

A

< 100mg/dL in pts without overt CVD

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24
Q

What’s the cholesterol goal in diabetic pts with overt CVD?

A

LDL < 70mg/dL

TG < 150mg/dL

HDL > 40mg/dL (men)
> 50mg/dL (women)

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25
Q

When should statin therapy be added to diabetic pts regardless of their baseline lipid levels?

A

Overt CVD

Or

Without CVD + pt is > 40yrs + has 1/more CVD risk factors (FH of CVD, HTN, smoking, dyslipidemia, or albuminuria)

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26
Q

What grp of diabetic pts should be on moderate or high-intensity statin according to ATP IV lipid guidelines?

A

40-75 yrs + LDL >= 70mg/dL

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27
Q

List criteria for diagnosis of diabetes

A

Classic sx of hyperglycemia crisis (polyuria, polydipsia and unexplained weight loss) or hyperglycemic crisis AND a random plasma glucose >= 200mg/dL

Or

FPG >= 126mg/dL (fasting = no caloric intake for at least 8 hrs)

Or

2-hr plasma glucose of >= 200mg/dL during a 75g oral glucose tolerance test (OGTT)

Or

A1c >= 6.5%

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28
Q

List categories of risk for diabetes (pre-diabetes)

A

FPG 100-125mg/dL

Or

2-hr plasma glucose in the 75g oral glucose tolerance test (OGTT) of 140-199mg/dL

Or

A1c 5.7-6.4%

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29
Q

What’s the goal of GDM?

A

Tx should keep BG at levels equal to pregnant women who don’t have GDM (this means tighter BG control)

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30
Q

What’s the BG goal in pregnancy wrt

Preprandial

Postpradial (1 hr post-meal)

Postpradial (2 hr post-meal)

A1c

A

Preprandial < 6%

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31
Q

What’s the standard of care in GDM?

A

Nutritional therapy

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32
Q

Howz lifestyle modification used in DM?

A

In combo with med therapy

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33
Q

What’s the recommended waist circumference for men and women with DM?

A

Males < 40 inches

Females < 35 inches

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34
Q

What types of diet may overweight or obese DM pts consider? Are these for long-term or short-term?

A

Low-carbohydrate

Or

Low-fat calorie-restricted

Or

Mediterranean diets

Short-term (up to 2 yrs)

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35
Q

What should be monitored in pts using low-CHO diet?

A

Lipid profiles

Renal fxn

Protein intake

Adjust hypoglycemic therapy as needed

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36
Q

Whats the ADA recommendation on saturated fat? Is it the same as obesity guideline recommendations?

A

Limit saturated fat intake to < 7% of total calories

No! Diff from obesity guidelines

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37
Q

What’s the exercise recommendation for diabetic pts?

A

Aerobic exercise of moderate intensity for at least 30 mins x 5 days/wk
(or 150min/wk)

Resistance x 2 days/wk

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38
Q

What’s the smoking recommendation for DM pts?

A

All pts should receive smoking cessation + other forms of tx as routine component of diabetes care

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39
Q

What’s the primary prevention of CVD in DM pts?

A

Aspirin 81mg

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40
Q

List factors that may warrant using aspirin as primary prevention in DM pts

A

Increased CVD risk (10-yr risk > 10%)

Men > 50yrs
Women > 60 yrs

+

At least 1 additional risk factor e.g.
FH of CVD, HTN, smoking, dyslipidemia or albuminuria

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41
Q

Req for nephropathy screening/tx

A

DM!

Done using Annual urine test. Any protein in urine indicates renal dx

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42
Q

Name the types of diabetic nephropathy?

A

Microalbuminuria - urine protein level of 30-299mg/day

Macroalbuminuria - urine protein level > 300mg/day

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43
Q

What’s Microalbuminuria (DM nephropathy)?

A

Urine protein level of 30-299 mg/day

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44
Q

What’s Macroalbuminuria (DM nephropathy)?

A

Urine protein level > 300mg/day

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45
Q

List DM nephropathy screening timeline in:

T1D

T2D

A

T1D - Annual testing starting 5 yrs after diagnosis

T2D - Annual testing starting at time of diagnosis

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46
Q

What’s the tx of DM nephropathy?

A

Optimize BG and BP control

ACE-I and ARB are 1st line

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47
Q

How Often should eyes of DM be screened

A

T1D - Annually beginning within 5 yrs of diagnosis in pts >= 10yrs

T2D - Annual beginning soon after diagnosis

(Dilated, comprehensive eye exam)

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48
Q

Foot care req in DM wrt comprehensive foot exam and pt responsibilities?

A

Comprehensive foot exam, performed by podiatrist, at least once/yr

Pt responsibility - ALL pts with DM should inspect their feet daily

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49
Q

List req vaccinations for ADULTS with DM

A

Hepatitis B: if 19-59 yrs of age + have never completed series

Influenza: Annually

PPSV23 (Pneumovax): 2-64 yrs + again at 65yrs if >5 yrs since previous vaccination

Tetanus, diphtheria, pertussis (TdaP): Once
Td: Q 10 yrs after TdaP

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50
Q

How soon should Metformin (as monotherapy) be started after DM diagnosis?

A

At or soon after diagnosis,

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51
Q

What may be done if target A1c is not achieved after about 3 months of Metformin monotherapy?

A

You may consider adding a 2nd agent

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52
Q

List the grp of meds used as 2nd line agents in DM

A

Sulfonylurea (2nd gen)

TZD

DPP-4 inhibitor

GLP-1 agonist

Insulin (usually basal)

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53
Q

List agents under Sulfonylurea, used as 2nd agents in DM tx

A

Glipizide (Glucotrol)

Glimepiride (Amaryl)

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54
Q

Which Sulfonylurea is NOT preferred?

A

Glyburide

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55
Q

List agents under TZD, used as 2nd agents in DM tx

A

Pioglitazone (Actos)

Rosiglitazone (Avandia)

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56
Q

List agents under DPP-4 inhibitor, used as 2nd agents in DM tx

A

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin (Tradjenta)

Alogliptin (Nesina)

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57
Q

List agents under GLP-1 agonist, used as 2nd agents in DM tx

A

Exenatide (Byetta)

Exenatide ext-release (Bydureon)

Liraglutide (Victoza)

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58
Q

What type of Insulin is typically used as a 2nd agent in DM? Effect on A1c?

A

Basal insulin

Reduces A1c 1.5%-3.5%

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59
Q

How often should u check back with the pt after starting them on med?

A

Q 3 months

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60
Q

If target A1c isn’t achieved 3 months after adding the 2nd agent, what course of action can be taken?

A

Consider adding a 3rd agent (from the Grp used as 2nd agent)

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61
Q

What’s the next step if a 3 drug combo that includes basal insulin has failed to achieve A1c target after 3-6 months?

A

Use a more complex insulin strategy (multiple daily doses), usually with 1 or 2 non-insulin agents

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62
Q

What grp of DM meds are gen avoided when a pt req more complex insulin regimens?

A

SU - Glipizide (Glucotrol); Glimepiride (Amaryl)

AND

Meglitinides - Repaglinide (Prandin)

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63
Q

When do u consider starting insulin as first line?

A

In severe hyperglycemia (>= 300 mg/dL or A1c >= 10%)

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64
Q

When do u consider Meglitinides?

A

In pts with irregular meal schedules who develop late postprandial hypoglycemia on SUs

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65
Q

When do u consider beginning at the 2 drug stage in DM pts?

A

Pts with A1c >= 9%

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66
Q

List agents under Biguanide. First line therapy?

A

Metformin

Yes

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67
Q

What’s the brand name of Metformin (Biguanide; 1st line agent)?

A

Glucophage

Glucophage XR

Fortamet

Glumetza

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68
Q

What’s the dose of immediate release (IR) Metformin?

A

500mg BID

850mg DAILY

1,000mg

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69
Q

What’s the dose of extended release (XR) Metformin?

A

500mg

750mg

1,000mg

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70
Q

A1c reduction of Metformin?

A

Reduce by 1-2%

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71
Q

Which formation of Metformin, IR or XR, should be taken with dinner?

A

ER 500-1000mg with dinner

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72
Q

What’s the black box warning of Metformin?

A

Lactic acidosis

T4 avoid in pts with hepatic impairment due to increased risk of lactic acidosis

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73
Q

CI to Metformin use?

A

Renal impairment/failure - SCr >= 1.5mg/dL (males)
1.4mg/dL (females)

Abnormal creatinine clearance (CrCl < 60mL/min)

Metabolic acidosis

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74
Q

When should Metformin be temporarily discontinued in pts?

A

Those receiving Intravascular iodinated contrast media

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75
Q

In what med condition should Metformin be stopped?

A

In any case of hypoxia such as

Decompensated HF
Respiratory failure
Acute MI
Sepsis

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76
Q

SE of Metformin use?

A

Diarrhea

Nausea/ Vomiting

Flatulence

Weight neutral

Little to no risk of hypoglycemia (when used as monotherapy$

Vit B12 deficiency (long term)

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77
Q

How to use Metformin in pt using contrast dye?

A

Temporary d/c Metformin

Wait at least 48hrs after procedure and restart only once renal fxn has been confirmed as normal

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78
Q

Effect of alcohol on risk of lactic acidosis?

A

Alcohol increases risk for lactic acidosis, esp with renal impairment and advanced heart dx

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79
Q

What vitamin supplement may be considered with Metformin use? Why?

A

Vitamin B-12 and possibly Folic acid

Bcuz Metformin reduces B-12 absorption -> neuropathy

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80
Q

How to alleviate GI sx associated with Metformin use?

A

Take with meals

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81
Q

Whats the unique counseling to give a pt using Glumetza, Fortamet or Glucophae XR?

A

Pt may see a shell of the med in the stool (medicine is in body and tablet is empty)

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82
Q

Whats the brand name of the combo of Metformin + Sitagliptin (DPP-4 inh)?

A

Janumet

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83
Q

MOA of Sulfonylurea?

A

Stimulate insulin secretion from the pancreatic beta cells

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84
Q

Which DM meds can’t be used with Sulfonylureas? Why not?

A

Meglitinides

Due to similar MOA

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85
Q

List agents under Sulfonylureas

A

Chlorpropamide (Diabinese) - no longer used

Glipizide (Glucotrol, Glucotrol XL, Glipizide XL)

Glimepiride (Amaryl)

Glyburide (DiaBeta) - no longer recommended

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86
Q

Whats the brand name of Chlorpropamide (Sulfonylureas)?

A

Diabinese

They are not typically used

87
Q

Whats the brand name of Glipizide (Sulfonylureas)?

A

Glucotrol

Glucotrol XL

Glipizide XL

88
Q

Whats the brand name of Glimepiride (Sulfonylureas)?

A

Amaryl

89
Q

Whats the brand name of Glyburide (Sulfonylureas)?

A

DiaBeta

90
Q

In Which Sulfonylurea should renal fxn be checked b4 use?

A

Glyburide (DiaBeta)

Avoid in CrCl < 50mL/min. This is why glyburide isn’t a recommended agent

91
Q

SE of Sulfonylurea

Glipizide (Glucotrol, Glucotrol XL, Glipizide XL);
Glimepiride (Amaryl);

A

Hypoglycemia

Weight GAIN

92
Q

List the Sulfonylurea that are still recommended for use

A

Glipizide (Glucotrol, Glucotrol XL, Glipizide XL)

Glimepiride (Amaryl)

93
Q

Can Sulfonylurea regular tablets be interchanged with Sulfonylurea micro nixed tab formulation?

A

No

94
Q

At the initiation of what meds should Sulfonylurea and Meglitinides be d/c?

A

Insulin

95
Q

When should u consider a dose reduction in Sulfonylurea (Glipizide (Glucotrol, Glucotrol XL, Glipizide XL); Glimepiride (Amaryl) AND Meglitinides (Repaglinide (Prandin))?

A

TZD - Pioglitazone and Rosigliatazone

GLP-1 agonist - Exenatide and Liraglutide

DPP-4 inh - Sitagliptin etc

Canagliflozin

96
Q

How do u use Glipizide XR and Glimepiride (Amaryl)?

A

With 1st meal of the day

97
Q

How do u use Glipizide?

A

30mins BEFORE breakfast and dinner

30 mins BEFORE first meal (if dosed onced daily)

98
Q

How do u use Glimepiride?

A

Once daily with 1st meal

99
Q

MOA of Meglitinides?

A

Stimulates insulin secretion from the pancreatic beta cells

100
Q

Which Grp of DM meds should not be used with Meglitinides?

A

Sulfonylureas

101
Q

List agents under Meglitinides

A

Repaglinide (Prandin)

Nateglinide (Starlix)

102
Q

How do u use Meglitinides (Repaglinide -Prandin; Nateglinide - Starlix)?

A

At most 30mins b4 meals (1-30mins)

103
Q

SEs of Meglitinides (Repaglinide - Prandin; Nateglinide - Starlix)?

A

Hypoglycemia

Mild weight gain

UPPER RESPIRATORY TRACT INFECTION

104
Q

Which of the Meglitinides is more effective?

A

Repaglinide (Prandin) slightly more effective than Nateglinide

105
Q

Effect of Gemfibrozil on Prandin (Repaglinide)? Alternative?

A

Gemfibrozil increases Prandin conc -> low BG

Fenofibrate is preferred

106
Q

List agent under Thiazolidinediones (TZDs)

A

Pioglitazone (Actos)

Rosigliatazone (Avandia)

107
Q

What’s the brand name of Pioglitazone (TZDs)?

A

Actos

108
Q

Black box warning of TZDs (Pioglitazone (Actos) and Rosigliatazone (Avandia))?

A

May cause or exacerbate HF in some pts.

T4 don’t use in pts with NYHA class III/IV HF

109
Q

What’s the warning associated with TZDs (Pioglitazone (Actos) & Rosiglitazone (Avandia))?

A

Don’t use in pts with ACTIVE BLADDR CANCER

110
Q

SEs of TZDs (Pioglitazone (Actos) & Rosiglitazone (Avandia))?

A

Peripheral edema

Weight gain

URTIs (similar to Meglitinides)

111
Q

What’s the good SE of Pioglitazone (Actos)?

A

Increases HDL

Reduces TGs and TC

112
Q

List agents under Alpha-Glucosidase inh

A

Acarbose (Precose)

Miglitol (Glyset)

113
Q

What’s the starting dose of both Acarbos and Miglitol and how are they used?

A

25mg with first bite of each meal

114
Q

CI in alpha-Glucosidase inh (Acarbose; Miglitol)?

A

Inflammatory bowel dx (IBD)

Colonic ulceration,

Partial or complete intestinal obstruction

115
Q

SEs of alpha-Glucosidase inh (Acarbose; Miglitol)?

A

GI effects (flatulence, diarrhea, stomach pain) - titrate slowly

Weight neutral

116
Q

Do alpha-Glucosidase inh (Acarbose; Miglitol) by themselves cause low BG?

A

No

117
Q

How do u treat low BG from alpha-Glucosidase inh (Acarbose; Miglitol)? Same as others?

A

No! U can’t treat with sucrose, table sugar or candy.

Treat with glucose tabs or gel

118
Q

List agents in DPP-4 inhibitors

A

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin (Tradjenta)

Alogliptin (Nesina)

119
Q

What’s the brand name of Sitagliptin (DPP-4 inh)?

A

Januvia

120
Q

Which DPP-4 inhibitor agent has NO renal dose impairment?

A

Linagliptin (Tradjenta)

121
Q

SEs of DPP-4 inhibitors (Sitagliptin (Januvia); Saxagliptin; Linagliptin; Alogliptin)?

A

Nasopharyngitis

URTIs

UTIs

Weight neutral

122
Q

How do u take DPP-4 inhibitor (Sitagliptin etc)?

A

Once daily in the morning, with or without food

123
Q

What agent is listed under Sodium Glucose Co-Transporter-2 inhibitor?

A

Canagliflozin (Invokana)

124
Q

SEs of Sodium Glucose Co-Transporter-2 inhibitor agent (Canagliflozin (Invokana))?

A

Female genital mycotic infections

UTIs

Hyperkalemia

Increased urination

125
Q

How do u reduce risk of hypoglycemia if used Canagliflozin or GLP-1 agonists is used with Insulin or Insulin secretagogue?

A

Consider using a lower dose of insulin or insulin secretagogue

126
Q

List agents under Glucagon-Like Peptide-1 (GLP-1) Agonist

A

Exenatide (Byetta)

Liraglutide (Victoza)

127
Q

What’s the brand name of Exenatide (GLP-1 Agonists)?

A

Byetta

128
Q

What’s the brand name of Exenatide ext-release (GLP-1 Agonists)?

A

Bydureon

129
Q

Sites of Byetta/Bydureon inhection? Preferred site?

A

Abdomen (preferred SC inj site)

Thigh

Upper arm

Count to 5 before withdrawing syringe

130
Q

What’s warnings ass with Exenatide (Byetta) and Exenatide ext-release (Bydureon)?

A

Hx of pancreatitis, gallstones, alcoholism or high TGs

Avoid in severe impairment (CrCl < 30mL/min)

Not for use in severe GI dx

131
Q

SEs of Exenatide (Byetta) and Exenatide ext-release (Bydureon) and Liraglutide (Victoza)?

A

Nausea (primary SE)

Weightloss

Vomiting

Diarrhea/ constipation

Anti-Exenatide antibodies

132
Q

OCPs and Byetta use?

A

OCPs levels may be decreased in pts taking Byetta.

Take OCPs at least 1hr b4 Byetta inj

133
Q

Byetta and warfarin?

A

Byetta may ENHANCE anticoagulant effects of warfarin:monitor INR

134
Q

Pancreatitis or inflammation of pancreas may occur with GLP-1 agonist use. T /F?

A

True.

Rare, but can happen

135
Q

Storage of GLP-1 agonists?

A

Refrigerator (stable at room temp for up to 30days)

Never freeze

136
Q

Time to use Byetta (Exenatide)?

A

Inject 2 times each day, within 60 mins b4 morning and evening meals (or b4 the 2 main meals, but they do need to be 6 hrs or more apart)?

137
Q

Dosing of Bydureon?

A

Once every 7 days (weekly)

138
Q

Dosing of Victoza?

A

Once daily

139
Q

Which DM med can be used in both T1D and T2D?

A

Pramlintide (Symlin)

140
Q

Howz Pramlintide (Symlin) used?

A

SC in abdomen or thigh prior to each meal

141
Q

SE of Pramlintide?

A

Hypoglycemia (when starting therapy, reduce meal-time insulins by 50% to reduce risk of hypoglycemia)

Nausea

Anorexia

Weightloss

142
Q

Pramlintide (Symlin) and gastric emptying?

A

Pramlintide (Symlin) can slow gastric emptying

143
Q

List agents under Bile Acid Binding Resins

A

Colesevelam (Welchol)

144
Q

Sulfonylureas and Colesevelam (Welchol)?

A

Give SU (Glimepiride, Glipizide, Glyburide) 4 hrs before Welchol

145
Q

SEs of Colesevelam (Welchol)?

A

Constipation (give senna, or stool softener Docusate, if appropriate)

Dyspepsia

Nausea

Bloating

Can increase TG

146
Q

MOA of Bromocriptine?

A

DA agonist but it improves glycemic control by working in the CNS to decrease insulin resistance

147
Q

How should Bromocriptine be dosed?

A

Take with food, to reduce nausea

148
Q

What’s insulin?

A

Hormone that muscle and adipose tissue require for glucose uptake.

May also have a role in regulating fat storage and inhibits the breakdown of fat for energy

149
Q

What’s the usual concentration of ALL insulins? Exception?

A

All insulins have a concentration of 100 units/mL

Except Humulin R U-500, which has a conc of 500 units/mL

150
Q

List Rapid-acting insulin

A

LAG

Lispro (Humalog, Humalog KwikPen)

Aspart (Novolog, Novolog FlexPen)

Glulisine (Apidra, Apidra SoloStar)

151
Q

List Regular or short-acting insulin

A

Humulin R (only 1 with 500units conc)

Novolin R

152
Q

How do u use rapid-acting insulin (Novolog, Apidra, Humalog)?

A

Up to 15mins b4 eating, or immediately after a meal

153
Q

How do u use Humulin R, Novolog R?

A

30 mins b4 a meal

154
Q

List Baseline or “Basal” Insulin

A

NPH or “Intermediate” Insulin: NPH (Humulin N, Novolin N)

155
Q

How do u use Humulin N, Novolin N?

A

Once or twice a day

Cloudy insulin

156
Q

List Long-acting Insulin agents

A

Insulin Determir (Levemir, Levemir FlexPen)

Insulin Glargine (Lantus, Lantus SoloStar)

157
Q

How u use Levemir, Lantus?

A

Once or twice daily

They both last ~24hrs and don’t peak

158
Q

What’s the advantage of Levemir and Lantus both not peaking?

A

This is important bcuz when insulin peaks, it can increase the risk of hypoglycemia in some pts

159
Q

Look at insulin charts and tables on pgs 416 and 417

A

Make sure u look

160
Q

SEs of Insulin

A

Hypoglycemia

Weight gain

Local skin rxns (to avoid, rotate the inj site)

Lantus (Insulin Glargine) may sting a little when injecting (minor)

161
Q

In mixing insulins urself, how do u remember the right order, that is, the one to draw up first and second

A

Clear b4 Cloudy (alphabetical)

Rapid- or short-acting insulin drawn B4 NPH (Humulin N, Novolin N)

162
Q

What’s the typical starting dose of insulin for T1D?

A

0.6 units/kg/day

This is the total daily dose (TDD) of insulin

163
Q

If using insulin as basal-bolus for T1D, how do u determine dose for each

A

TDD = 0.6/kg/day

Basal = 50% of TDD
Bolus = 50%/3 (each 1/3 given with each meal)
164
Q

If using NPH and Regular insulin for T1D, how do u determine dose for each?

A

TDD = 0.6/kg/day

NPH = 2/3 of TDD
Regular = 1/3 of TDD (gen dosed BID)
165
Q

What’s the insulin-to-carbohydrate ratio (ICR) for rapid acting insulins for T1D?

A

Rule of 500

500/TDD = gms of CHO covered by 1 unit of rapid-acting insulin

166
Q

What’s the insulin-to-carbohydrate ratio (ICR) for regular insulins for T1D?

A

Rule of 450

450/TDD = gms of CHO covered by 1 unit of regular insulin

167
Q

What’s the correction factor for rapid-acting insulin for T1D?

A

1,800 Rule

1,800/TDD = correction factor for 1 unit of rapid-acting insulin

168
Q

What’s the correction factor for regular insulin for T1D?

A

1,500 Rule

1,500/TDD = correction factor for 1 unit of regular insulin

169
Q

What’s the correction dose formula for T1D?

A

(BG now) - (target BG)
Divided by. = Correction dose
Correction factor

170
Q

How do u initiate insulin?

A

Start with bedtime Intermediate-acting insulin

Or

Bedtime or morning long-acting insulin

171
Q

What’s the usual starting dose of insulin in T2D?

A

Can initiate with 10 units

Or

0.2 units per kg

172
Q

How do u titrate up insulin in T2D?

A

Check BG daily (fingerstick)

Increase dose, typically by 2 units Q 3 days until fasting levels are consistently in target range (70-130mg/dL)

173
Q

What’s the target preprandial (fasting) levels in T2D?

A

70-130 mg/dL

174
Q

When can insulin be titrated in larger increments (4 units, Q 3 days)?

A

If FBG > 180mg/dL

175
Q

At this point, if hypoglycemia occurs or FBG < 70mg/dL, what should be done?

A

Reduce bedtime dose by 4 units or 10% - whichever is greater

176
Q

What’s the next step if A1c is < 7% after 2-3 months?

A

Continue regimen

Check A1c Q3months

177
Q

What’s the next step if A1c >= 7% after 2-3 months?

A

If FBG is in target (70-130mg/dL), check BG b4 lunch, dinner & bed.

Can usually begin with ~ 4 units and adjust by 2 units Q3 days until BG is in range

178
Q

What should be done, If pre-lunch BG is out of range?

A

Add rapid-acting insulin (Novolog, Apidra, Humalog) at breakfast

179
Q

What should be done, If pre-dinner BG is out of range?

A

Add NPH insulin (Humulin N, Novolin N) at breakfast

Or

Add Rapid acting insulin (Novolog, Apidra, Humalog) at lunch

180
Q

What should be done, If pre-bed BG is out of range?

A

Add Rapid acting insulin (Novolog, Apidra, Humalog) at dinner

181
Q

Insulin conversion calculations: once daily NPH to Glargine (Lantus)?

A

1:1 (same dose)

182
Q

Insulin conversion calculations: twice daily NPH to Glargine (Lantus)?

A

Reduce TDD by 20% and give Lantus once daily

183
Q

Insulin conversion calculations: NPH to Detemir (Levemir)?

A

1:1 conversion (same dose)

184
Q

Insulin conversion calculations: Glargine (Lantus) to Detemir (Levemir)? And vice versa?

A

1:1 (same dose)

185
Q

Insulin conversion calculations: Regular or Rapid-acting to another Rapid-acting; or Rapid-acting to regular?

A

1:1

186
Q

Insulin conversion calculations: Premixed to Premixed e.g. 70% NPH/30% regular to intermediate/rapid-acting 75/25 or vice versa?

A

1:1 (same dose)

187
Q

Most insulin are 1:1 conversion (same dose, unless adjustment is warranted) except?

A

Twice daily NPH to Glargine (Lantus)

Reduce TDD by 20%

188
Q

Most insulin are stable to room temp for 28-31 days. What’s the exception for LESS time at room temp?

A

Humulin N and Novolin N (pens) - 14 days
Novolog

Humalog 50/50, 75/25 and Humulin 70/30 - 10 days

189
Q

Most insulin are stable to room temp for 28-31 days. What’s the exception for MORE time at room temp?

A

42 days - Novolin R (U-100 vial)
Novolin N (vial)
Novolin 70/30 (vial)
Levemir (Detemir)

190
Q

Storage of unused insulin?

A

Refrigerator

191
Q

Check insulin administration procedure on pg 422

A

Look!

192
Q

What’s the BG level of hypoglycemia?

A

BG < 70mg/dL

193
Q

Whats the #1 drug that causes hypoglycemia?

A

Insulin

194
Q

List the other classes of DM meds that may cuz hypoglycemia. Why?

A

Sulfonylurea (Glipizide, Glyburide, Glimepiride)

And

Meglitinides (Repaglinide -Prandin)

Bcuz they make body secrete more insulin (secretagogue)

195
Q

List other DM drugs that may cuz hypoglycemia

A

Pioglitazone (Actos)

Canagliflozin (Invokana)

Pramlintide

196
Q

List of hypoglycemic sx

A

Dizziness

Headache

Anxiety

Shakiness

Diaphoresis (sweating)

Excessive hunger

Confusion

Clumsy or jerky movements

Tremor

Palpitations or fast HR

Blurred vision

197
Q

What med can mask hypoglycemia sx? What hypoglycemia sx still exhibits, in spite of this med?

A

Non-cardio selective agents (Carteolol, Carvedilol, Propranolol, others)

Sweating and hunger won’t be masked

198
Q

What’s the recommended tx of hypoglycemia in a conscious individual?

A

15-20g of glucose

Or

Any form of CHO that contains glucose eg 1/2 cup / 4 oz of juice or soda, 1 cup/8oz milk, 1 TSP of sugar or honey

199
Q

How soon should BG be re-tested after hypoglycemia tx?

A

15 mins

If BG < 70mg/dL, re-treat and re-check in another 15 mins

200
Q

What should be prescribed for ALL pts at significant risk of severe hypoglycemia?

A

Glucagon

201
Q

When is glucagon used in DM pts?

A

ONLY if pt is unconscious or not conscious enough to self-treat the hypoglycemia

202
Q

Look at Glucometers on Pg 425

A

Ok

203
Q

List alternate glucose site testing areas

A

Upper arm

Thigh

Calf

Fleshy parts of the hand

Fingertips too

204
Q

Whats diabetic ketoacidosis (DKA)?

A

DKA can occur when there’s not insulin and the body breaks down fat to make energy

Breakdown of fats causes the conc of ketones in the blood to increase.

205
Q

Sx of DKA?

A

Hyperglycemia

Polyuria

Polyphagia

Polydipsia

Blurred vision

Metabolic acidosis (fruity breath, dyspnea)

Dehydration (dry mouth, excessive thirst, poor skin turgor, fatigue)

206
Q

DKA Lab Abnormalities?

A

Glucose > 300mg/dL

Ketones present in urine and blood

PH < 7.2

Bicarbonate < 15mEq/L

WBC 15-40 cells/mm3

207
Q

DKA tx?

A

IV fluids and Indulin

Replace electrolytes (starts with NS, followed by 1/2NS and correcting potassium to bring the level > 3.5mEq/L

208
Q

MOA of Metformin?

A

Decrease hepatic glucose output

209
Q

What size of cartridge goes into insulin pen injection?

A

3ml cartridge

210
Q

Usual vol of insulin vial?

A

10ml

211
Q

Usual size of insulin needle used?

A

25/ 29G (or higher)

212
Q

Usual size of insulin syringe used?

A

1ml (also 0.3ml and 0.5ml)

213
Q

What does High blood glucose indicate?

A

Glucose can’t get into cell or can’t be properly stored

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