DIABETES Flashcards
criteria for diagnosis of metabolic syndrome
- Waist circumference men >40in, women >35in (abd obesity)
- Triglycerides >150
- BP >130/85
- FBS >100
- HDL men less 40, women less than 50
criteria for diagnosis of pre-diabetes
FBS->100
A1C 5.7 – 6.4
criteria for diagnosis of T2DM
FBS->126
A1C >6.5
Expected effect of insulin resistance on lipids and blood pressure.
(1) high levels of plasma triglycerides
(2) low levels of HDL
(3) the appearance of small dense low-density lipoproteins (sdLDL), as well as an excessive postprandial lipemia
What is the primary action of biguanides?
Decreases liver glucose production
What is the primary action of glitinides?
Ex: prandin, starlix
Increases insulin release in pancreas
“Mini - sulfonylureas”
hypoglycemia less of a problem
What is the primary action of sulfonylureas?
Ex: glyburide, glipizide, glimepiride
Increases insulin release in pancreas
What is the primary action of TZDs?
Ex: Actos, Avandia (glitazones)
Increases insulin sensitivity
Decrease glucose production by liver
What is the primary action of DPP-4-I?
Ex: Januvia, Tradjenta (gliptins)
Increases insulin secretion
Decreases glucagon secretion
Reduce both fasting and postprandial (after food) blood glucose levels, without causing weight gain.
What is the primary action of SGLT2-I?
Ex: Invokana, Jardiance
Blocks glucose reabsorption by the kidney – increases glucosuria
What is the primary action of GLP-1?
Ex: Trulicity, Victoza (glutides)
Increases insulin secretion
Decreases glucagon secretion
Slows gastric emptying
Increases satiety
What is the primary action of insulin?
Increases glucose disposal
Decreases liver glucose production
What is the role of basal insulin?
The amount of insulin the patient needs to maintain a normal metabolic state when fasting.
Insulin needed even when patient is not eating (to control gluconeogenesis).
How do you know when the basal dose is correct?
if the blood sugar does not change when the patient is NPO [it is about ½ of the daily total; on average about 1 unit/hour in a person weighing 70 kg]
How is basal insulin dosed?
Weight based
0.1-1.5 u/kg/day—on average 0.6 units per kg/day is a good starting point
50% of this is basal
50% is meal time [15%/15%/20% split might work is patient eats smaller breakfast and lunch]
What are the ADA and AACE recommendations for starting a patient on basal insulin?
10 units of basal and increase 2 units every 3-4 days until fasting glucose is 100 mg/dL—that is the basal dose [may be at our calculated dose of 30 units or a bit more or less]
THEN you start the mealtime dosages—start with the largest meal
What is the starting basal insulin dose for an adult?
0.5-1 u/kg/d of body weight
What is the starting basal insulin dose for an older adult?
0.6 u/kg/d of body weight
What should the starting dose be if a patient is frail or small?
consider 0.2 u/kg/d to start—all as an evening dose
What is the role of correctional insulin?
insulin given to bring a high blood glucose level down to target range (with target usually below 150 mg/dL pre-meal, and below 200mg/dL at bedtime or 2am). Use rapid-acting insulin (aspart, lispro, or glulisine) or short-acting insulin (regular).
What is the role of nutritional insulin?
Insulin to cover carbohydrate intake from food, dextrose in IV fluid, tube feeds, TPN. Use rapid-acting insulin (aspart, lispro, or glulisine) or short-acting insulin (regular).
What is the role of bolus insulin?
Rapid acting insulin given either by syringe or pump
Correction bolus is given to lower a high BS—this is similar to old time “sliding scale” routines
Current moniker is mealtime bolus given to cover the amount of calories and CHO that patient is going to eat at the meal or at snack time [happy hour, birthday party, etc.].
How much on average does 1 unit of insulin lower BS by?
20 mg/dL
What should before meal glucoses [lunch and dinner] be?
140 mg or less
What should 2 hour postprandial glucoses be around?
160 mg or less
What is the ADA recommendation for starting mealtime/correction insulin?
starting 4 units with meals [start with largest meal], then increase by 2 units every 3-4 days until at target
On average, 1 unit of insulin covers how many grams of CHO?
10 grams of CHO
Which patients are not appropriate for intensified insulin therapy?
Those with glycemic control of 70-120 mg/dl and no complications
Those with hypoglycemic unawareness
Those who are poorly motivated and unwilling to check blood sugars several times a day
Those who have had DM <6-12 months
What is the peak and duration for long acting (basal) insulin?
Ex: Detemir, glargine, degludec
Peak: Minimal hr
Duration: 20-36 hr
What is the peak and duration for intermediate acting insulin?
Ex: NPH
Peak: 8-12 hr
Duration: 12-20 hr
What is the peak and duration for short acting (regular) insulin?
Peak: 2-4 hr
Duration: 6-8 hr
What is the peak and duration for rapid acting insulin?
Ex: aspart, glulisine, lispro
Peak: 1-2 hr
Duration: 3-5 hr
Intensive Glycemic Control Does Not Reduce Macrovascular Risk in which patients?
Older Patients With Longer Duration of Disease
What are the components of Macrovascular Risk Reduction?
- Individualized glucose control
- Hypertension control
- Dyslipidemia control
- Smoking cessation
- Aspirin therapy
- Diagnosis and management of:
- – Autonomic cardiac neuropathy
- – Kidney disease
How do you manage diabetic nephropathy?
Optimal control of BP, lipids and BS
smoking cessation
ACE, ARB or renin inhibitor
Monitor K+
Nephrologist referral for Stg 4 CKD
What is neuropathy?
loss of sensation, pain, burning
What will improve the risk of neuropathy?
Decrease in A1C
Diabetic Neuropathy Evaluation and tests
Foot inspection
- ulcers
- venous stasis disease
Neurologic testing
- loss of sensation
- ankle reflexes
Painful neuropathy
Cardiovascular autonomic neuropathy
- HR variability with deep inspiration
- valsalva manuever
- change in position from prone to standing
Dietary Recommendations for Diabetes
Low glycemic foods <55 out of 100 on index
healthy fats such as fish, nuts, avocado
CHO from fruits and vegetables (7-10 servings per day)
What is the A1C reduction for AGIs?
0.7-1%
What is the A1C reduction for Biguanides?
Ex: Metformin
1.5-2%
What is the A1C reduction for GLP-1?
.78-1.9%
What is the A1C reduction for SGLT2-I?
0.6-1%
What is the A1C reduction for DPP-4-I?
0.56-0.59%
What is the A1C reduction for TZDs?
0.5-1.5%
What is the A1C reduction for sulfonylureas?
1-2%
What factors should guide choice of oral anti-diabetic?
hypoglycemic risk
efficacy
impact on weight
potential side effects
cost
patient preference
What is long term use of metformin associated with?
Vitamin B12 deficiency
Current guidelines now state to consider initiating insulin therapy in
symptomatic newly diagnosed T2DM
A1C >10
FBS >300
What organ does metformin (biguanide) target?
liver
Metformin dosing and titrating
500mg BID with meals
Increase by 500 mg every 1-3 weeks
Max dose 2000mg
Metformin side effects
GI upset
lactic acidosis
do not use in GFR <30 or in contrast media
age >80
SGL2-I targets which organ?
Kidney
SGLP2-I
yeast infections (due to glucosuria)
hyperkalemia
hypoglycemia
hypotension (due to volume depletion)
lower limb amputation risk, bone fx (Invokana)
recommended in this class if Jardiance due to decrease in CV risk
What is the target organ(s) for TZDs?
Ex: Actos, Avandia
muscle, fat and liver
How long until you see improvement with TZDs?
6-8 weeks
Side effects of sulfonylureas
HYPOGLYCEMIA
weight gain
Contraindications: Advanced CKD, sulfa allergy
Side effects of TZDs
swelling of legs
fluid retention
weight gain
Do not prescribe for CHF patients
When should patients with type 2 diabetes have an
initial dilated and comprehensive eye examination
by an ophthalmologist or optometrist?
at the time
of the diabetes diagnosis and annually
When targeting blood glucose targets, which glucose should you treat first?
FIX the FAST ( FBG) FIRST, then
go for postprandial
