Diabetes Flashcards
risk factors for diabetes
family history and ethnicity overweight BMI > 25kg/m2 prediabetes history of gestational diabetes poor diet and low physical inactivity HTN Hx cardiovascular disease
which two drug classes are most commonly cause hyperglycemia?
protease inhibitors and corticosteroids
which atypical antipsychotic is most likley to cause hyperglycemia?
olanzapine (zyprexa)
which two anti rejection meds cause hyperglycemia?
cyclosporine and tacrolimus
symptoms of hyperglycemia
polyphagia polyuria polydypsia blurred vision fatigue
macrovascular complications of diabetes
CAD (HTN, MI, HF)
CVD (TIA/stroke)
PAD
microvascular complications of diabetes
retinopathy
nephropathy
peripheral neuropathy
autonomic neuropathy
why do patients with diabetes get erectile dysfunction and gastroparesis?
they are suffering from autonomic neuropathy,which is damaget to autonomic nerves that control digestion, HR, prespiration, blood pressure
three best ways to lose weight
reduce calorie intake
choose nutrient dense foods
exercise
goal of weight loss?
lose 10% over 6 months which is about half to 2 pouonds per weeks
waist circumference less than 35 woemn and <40 males
what are some nutrient dense foods to eat?
vegetables fruits whole grains fat free or low fat milk seafood lean meats eggs beans and legumes nuts and seeds
what is one serving of carbohydrates?
15grams
how many carb servings for diabetics to eat
3-4 servings per meal and 1-2 per snack
why should diabetics avoid alcohol?
it exacerbates hypoglycemia and can calso cause hyperglycemia depending on the alcohol
max intake for alcohol in diabetics
1 drink for women
2 drinks for men (per day for both)
what are the recommended exercise for diabetics?
aerobic exercise: 30 minutes x 5 days per week
Resistance : 2 times per week
what does the A1c measure
it measures the average blood glucose of the past 2-3 months
how often should the a1c be measured?
if they are not controlled: quarterly (every 3 months)
If they are controlled (at a1c goal) then twice per year
what does the ADA says are the goal for A1c for diabetics?
7.0%
ADA goal for blood glucose before and after eating
before eating 70-130 mg/dl
1-2 hours after the start of the meal <180mg/dL
AACE a1c goals
<= to 6.5
AACE blood glucose goal before and after meals
before <140mgdl
when should the a1c goal be more stringent ? when should you aim toward the lower end?
when the patients are younger adults and not experiencing hypoglycemia
when should your a1c goal be less stringent?
people with severe hypoglycemia limited life expectancy extensive comorbid conditions advanced complications longstanding diabetes hard to reach goal
what is the estimated average glucose for patients? eAG goal?
goal is less than 154 mg/dl
correlation of a1c with blood sugars (average)
a1c 6 to 126 7 to 154 8 to 183 9 to 212 >10 to 200+
first line bp meds for diabetics? why?
ACE inhibitors
ARBs
because they decrease progression to diabetic nephropathy
LDL goal for diabetics
< 100mg/dL in patient without overt CVD. if patients have overt CVD goal 40 in men goal and >50 in women
TGs should be less than 150
what is the usual ASA dose for dm patients to take daily?
75- 162 mg daily (usually ASA 81mg EC) .
what is an alternative to ASA if allergy?
clopidogrel 75mg po qd
which diabetes patietns should receive ASA tx?
if 10 year risk is >10% which includes men > 50, women > 60 with at least one major risk factor: fan history of CVD, htn, smoking, syslpidemia, or albuminuria
how often should patients receive a urine test for albumin?
once every year starting at the time of diagnosis for ppl with dm 2. for ppl with DM1 starting with 5 years after diagnosis
define microalbuminuria?
if protein found in urine is 30-299 mg/day
what defines macroalbuniuria?
urnie protein level > 300mg/day
how often should a comprehensive eye esame be performed?
once a year. Longer intervals of 2-3 years ok if if patin has had normal eye exams and is well contorlled
how often should diabetics get a foot exam?
once a year
how often should diabetics inspect their feet?
once daily
foot care for diabetics
look for any new changes
clean feet and dry, apply lotion sparingly, not between the toes, trim nails carefully
don’t walk barefoot
wear proper fitting comfortable shoes
which vaccines should diabetics receive? and how often
influenza every year
pneumococcal: every patient > 2yo one time. Repeat the vaccination if patient is 65 or older and their first vaccination was more than 5 years ago.
hepatitis B in patients 19-59 years of age
for how long do you try each agent in order to try adding another one?
3 motnhs.
MOA of metformin
decreasing hepatic glucose production primarily
also knone to decrease intestnal absorption of glucose and improve insulin sensitivity
brand metformin
Glucophage, fortamet, glumetza
available metformin strengths
500, 850, 1000
ER: 500, 750, 1000
max daily dose of metformin allowed?
2550mg (850 TID)
Combo brand with met + glyburide?
Glucovance
combo brand with sitagliptin?
janumet
what dose start for metformin
IR : 500mg po daily to BID or 850 mg daily
ER: 500 - 1000mg with dinner
what is the black box warning for metformin?
can cause lactic acidosis
what is lactic acidosis? symptoms?
having an acidic ph in the blood with a buildup of lactate Sx: muscle soreness hyperventilation abdominal pain lethargy slow heart rate
when is metformin contraindicated?
in males Scr > 1.5mg/dl or >1.4 females
if Clcr < 60ml/min
if metabolic acidosis
stop if patient in a state of hypoxia, such as resp failure, sepsis, decompsated heart failure
metformin side effects
NVD
flatulence
long term vit b12 deficiency
advantages of metformin
weight neutral
no hypoglycemia!
labs to monitor for metformin
A1c
SCR
BUN
FBG
what category for pregnancy for metformin
B
what should you do if a patient is going to get IV contrast dye and is on metformin?
hold the met prior to dose, and wait 48hrs after procedure to take the next dose
what two agents taken with metformin have drug interacitions?what is the interaction
alcohol and iodinated contrast dyes increase the risk of lactic acidosis
patient counseling for metformin
take with meals (morning and evening). for once daily take with evening meal
GI sx: N/V/D abd discomfort
MOA of Sulfonylureas?
stimulate insulin secretion from beta cells
chlorpropamide brand name
diabinese
glipizide brand name
glucotrol
glimepiride brand
amaryl
glyburide brand
DiaBeta
max glipizide per day
20 mg
normal dose of glipizide
IR 5-10mg bid
XL 2.5-10 po daily
normal dose of glyburide
1.25-5mg daily
max glyfuride dose
20mg/day
side effects of sulfonylureas
hypoglycemia
weight gain
monoitoring for SUs
FBG, A1C
what not used the first generation SUs?
they cause long-lasting hypoglycemia
what is the pregnancy category for SUs
C
how does renal funciton affect glyburide?
it has an active metabolite that is renally cleared. IT accumlates if dysfunciton so doent use in pateints with CrCl < 50ml/min
should glyburide be used in the elderly population?
no because it has an increased risk of hypoglycemia
what time of the day to take sulfonyl ureas?
if once daily: with BF
if twice daily: with
which bile acid binding resing can lower blood glucose ?
welchol
dosing for welchol
6 tabs po daily with meal and liquid
3 tabs po bid with meal and liquid
3.75 g packed daily
1.875g bid dissolved in water
how much does the welchol lower A1C?
0.5%
common side effects of welchol?
constipation
dyspepsia
nausea
abdominal pain
pregnancy category of welchol?
B
which medications should be taken 4 hours before welchol?
levothyroxine glyburide cyclosporine oral contraceptives take welchold 4-6 hours before niaspan
what is the MOA of bromocriptine to lower BG?
dopamine agaonist and works in the CNS to decrease insulin resistance
can a pregnant women use bromocriptine?
yes preg category B but contrainidicated if she is nursing
which is the only insulin that does not have a concentration of 100Units/ml?
Humulin R has U-500 or 500Units/ml
name the three rapid acting insulins?
Aspart (Novolog)
Lispro (Humalog)
glulisine (Apidra)
when should someone inject themselves with rapid acting insulins?
inject up to 15 min prior to eating or may inject immediately after a meal
what are the names of the regular insulin?
humulin R
Novolin R
when should you inject the regular insulin?
30 minutes before a meal but not after a meal due to risk of hypoglycemia
duration of action of reuglar insulin?
4-6 hours
Name of NPH insulins?
Humulin N
Novolin N
what is the onset of action of NPH?
1-2 hours
what is the duration of action of NPH?
8-12 hours Up to 24 hours
what are the names of hte long-acting or basal insulins?
insulin detemir (Levemir) insulin glargine (lantus)
how often per day to dose NPH?
once or twice daily
how often to dose long acting insulins?
once or twice daily
how long is the onset of detemir vs glargine?
detemir is 4 hours
glargine is 2 hour
duration of rapid acting insulins?
3-5 hours
what is the starting dose for a patient with type 1 diabetes?
0.6 units/ kg/day which is the TDD
if using basal-bolus insulin combination ofr type 1 diabetes, how do you divide up the insulin?
50% of the TDD is the basal
50% is the bolus insulin (which again is divided TID for each meal)
if using NPH-Regular insulin combination ofr type 1 diabetes, how do you divide up the insulin?
2/3 of TDD is NPH
1/3 is the regular insulin (which is usually dosed BID
what is the rule of 500 and how do you use it?
is the rule that allows patients to calculate how many grams of carbs are covered by 1 unit of insulin
Equation– 500/TDD = grams of carbs covered by one unit of insulin
correction factor 1800 rule
1800/TDD = correction factor
Corrrection dose:
(Blood glucose now- Target blood glucose) / correction factor = correction dose
what is the starting dose of insulin for long acting or NPH insulin for type 2 diabetes?
10 units QHS
or 0.2 U /kg
what do you if a patient is getting hypoglyecemic episodes wit htheir isnulin or is getting a FPG of < 70?
reduce bedtime dose by 4 units or 10% whichever is greater
what is the target range for blood glucose for patients?
70-130 mg/dl
what is the target A1C?
< or = to 7%
by how much do u increase the insulin when not at BG?
can increase by 2 units about ~ 3 days utlnil FPG are at target range.
when do you check again if the A1C is at goal?
in 2-3 months
insulin administration teaching
- wash hands and lay out supplies
- check insulin for any discoloration, crystals or lumps
- clean skin site of injection and wipe top of insulin vila with alcohol swab
- Inject equal volume of air into vial that is going to be taken out to avoid negative pressure. Avoid bubbles in syringe
- Inject in abdomen at least 1 inch away from navel. Rotate injection site.
why rotate injection site of insulin administration?
avoid inflammation and atrophy
what other areas can you inject the insulin?
the lateral thighs and the posterior upper arm
whats the goal A1C in gestational diabetes?
<6%
what are the goal BG for gestational dm
pre prandial < 140
2 hours after eating <120
what constitutes 15 g of rapidly absorbed carbs?
1/2 cup of juice or soda 1 cup of milk 1 tablespoon of sugar or honey 2 tables spoons of raisns 4-5 saltine crachkers 3-4 glucose tabs
what is the dose for an unconscious patient with hypoglycemia?
glucagon 1mg SC, IM or IV
symptoms of DKA
hyperglycemia, polyuria, polyphagia, polydypsia, blurred vision
metabolic acidosis (fruity breath, dyspnea) and dehydration
DKA lab abnormaltiels
Glucose >300 ketones in urine and lbood pH, 7.2, HCO3 <15meq/l WBC 15-40 cells /mm3
what is the treatment for DKA?
IV fluids and insulin and electroltes
Usually given Normal Saline, then 1/2 NS then correcting potassium
what does insulin do to potassium levels?
drives the potassium into the cell
MOA of meglitinites?
stimulate insulin secretion
side effects of meglitinites?
hypoglycemia
weight gain
URTI
which is more effective prandin or starlix?
prandin is slightly more effective than starlix
pregancy category for meglitindes
C
what medications can be used in pregnant women for BG control?
insulin (NPH and regular are FDA approved but others are used too)
Metformin :)
GLyburide (but not in the first trimester)
what tow atnibitoic types can cause hypoglycemia?
FQs
SMX/TMP
how do you take meglintinides
15-30 min before meals. If you skip a meal, skip your dose
symptoms of hypoglycemia
hunger shakinees irritability headache sweaty confusion fast heartbeat
MOA of TZDs
increase insulin sensitivity
by how much does each drug class lower A1C?
metformin 1-2% SU- 1-2% Meglitinides 0.5-1.5% TZDs 0.5-1.4% Alphaglucosidase 0.5-0.8% DPP4= 0.5-0.8% GLP-1= 0.5-1%
pioglitazone strengths
15, 30, 45 mg (max ) once daily
bbw for actos?
Can excacerbate HF NYHA class 3/4
SE of pioglitazone
peripheral edema WT gain CHF increase fracture risk increase risk of bladder cancer if used for longer than 1 year
preganancy category pioglitazone?
C
how long does ti take to lower blood glucose with TZDs
several weekas
MOA of Alpha glucosidase inhibitors
inhibits alpha glucosidase inhibitorswhic leads to delayed absorpiton of glucose
how do you take the alpha glucosidase inihbitors (carbose dosing)
start at 25mg wti first bite of each meal. Increase by 25 mg every 1-2 months (max 300mg/day ) divided dose
must take with food and wit hfull glass of water
side effects of acarbose?
flatulence
diearrhea
abdominal pain
contraindicated in IBD , colonic ulceration or complete bowerl obstruction
advantages of acarbose?
increase HDL, dec TG, dec TC
weight neutral
Pregnancy category B
how often do you check LFTs with acarbose?
q 3 montht in the first year
does flatulence stay with acarbose?
goes away with time
MOA of DPP 4 inhibitors
inhibits dPP4 enzymes which mormall break down increntin hormones. As a result, there are more incretin hormones and this leads to increase insulin secretion, decreases glucagon secretion, decrease hepatic glucose production
advantages of sitagliptin
pregnancy category B
weight neutral
januvia dose
100mg po qd if clcr <30ml/min use 25mg po qd
Side effects of januvia?
p
symptoms of pancreatitis
severe stomach pain that does not go away +/- vomiting
when should you take januvia?
in the morning plus or minus food
MOA GLP-1 Agonists
analogs of GLP-1 increase insulin secretion decrease gluacong secreation slow gastric emptying increase satiety can have weight loss!
brand name exenatide?
byetta or bydureon
what is the brand name for liraglutide?
victoza
where do you inject exenatide?
abdomin, SC, count to five
how long is exenatide stable at room temperature?
30 days
which patients are at risk for pancreatitis with exenatide?
history of pancreatitis
alcoholism
high triglycerides
gallstones
when should you avoid exenatide?
clCr<30 ml/min
pancreatitis risk
exenatide pregnancy category
C
SE exenatide?
*Nausea
V/D
hypoglycemia
weight loss
when to take byetta?
twice daily QAM and QPM, 30-60 min before meals
stroage of exenatide?
room temperature after fisrt use at 25 degrees C but not more
dont freeze and protect from light
remove needles when storing to avoid air bubbles in pen`
what to do about the nausea caused by byetta?
consume adequate liquids if vomiting
decreases with time
MOA of pramlintide?
synthetic analog of amylin. Amylin slows gastric emptying prevents glucagon increase after a meal, increases satiety
BBW of pramlintide?
if co administered with insulin , can lead to severe hypoglycemia
when how to take pramlintide?
inject in the abdomen prior to meals
main SEs of pramlintide?
hypoglycemia*
Nausea
anorexia
if you are taking pramlintide and insulin, how do you adjust the dose?
decrease the insulin dose by 50% of the rapid acting, short acting and mixed insulins
what is the ADA definition of PRE diabetes?
FPG between 100 but < 126 or A1C from 5.7 to 6.4 %
how can pre-diabetics prevent or delay diabetes?
> 150minutes exercise per week with healthy eating
if above IBW , goal is to lose 5% weight
adding metformin is optional
what does the ADA define as impaired glucsoe tolerance?
level of 140-199 mg /dl from 1-2 hours post 75g OGTT
if a person has gestational diabetes, when should they be screened for diabetes?
6 weeks after delivery and then at least annually after that
what screening tests are good for diabetes and prediabetes?
FPG after 8 hour fasting
A1C is acceptable as an alternative
who should receive aspirin therapy?
type 2 diabetics with > 20% 10 year risk for CVD and may prescribe if 10-20% 10 year risk
where do you calculate the 10 year risk?
2009 ADA guideline criteria
how does the ADA define Pre-diabetes?
FBG between 100 and 126 or A1c between 5.7 and 6.4%
what does the ADA define as Diabetes?
FBG > 126 or a1c >= 6.5%
which diabetics should receive ASA therapy?
if > 20% 10 year risk for CVD
maybe if risk is 10-20%
not if risk <10
how do you prevent or delay the onset of diabetes?
- physical activty > 150minutes / week and healthy eating storgnly recomommended
- if you are above your ideal body weight, aim for sutstained body weight loss of 5%
- Adding metformin is OPTIONAL
how often should a women with gestational diabetes be screened for diabetes?
6 weeks after delivery and then annually after that.
which population of individuals should be screened annually for diabetes?
patients with HLD > 130 LDL
HTN
Pre diabetes
history of gestational diabetes or a baby >9lbs
who should be screened every 5 years?
- if you are 45 years or older
- if you are < 45 and BMI > 25 with addional risk factors: physical inactivity, first-degree relative with diabetes, high risk ethnic population, HDK < 35 or tG> 250, PCOS,
which diabetics should receive ASA therapy?
if > 20% 10 year risk for CVD
maybe if risk is 10-20%
not if risk <10
when mixing insulins which goes first?
clear before cloudy (alphabetical)
whats the typical starting dose for type 1 diabetes patietns
0.6 U/kg/day (total daily dose)= TDD
50% basal dose, 50% mealtime (divided each by 3)
rule of 500 for Insulin to Carb Ration
500/ TDD = grams of carbohydrate covered by 1 Unit of insulin
1800 rule to find correction factor
1800/tdd = correction factor
correction dose w/ 1800 rule
(BG now- target BG )/correction factor = correction dose
