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
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
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
