Diabetes

Question 1

Type I Diabetes Definition

Answer 1

Caused by autoimmune disorder leading to insuling deficiency

Commonly seen in children/adolescents

Rapid symptom onset

Question 2

Type II Diabetes Definition

Answer 2

90% of people with diabetes

Caused by progressive loss of insulin or insulin resistance

Commonly seen in adults (>30 y/o)

Insidious onset

Question 3

T2DM Risk Assessment

Answer 3

Question 4

Diabetes Lab Values

HbA1c (%)

Fasting plasma glucose (mg/dL)

Oral Glucose Tolerance Test (mg/dL)

Answer 4

HbA1c (%) - ≥ 6.5

Fasting plasma glucose (mg/dL) - ≥ 126

Oral Glucose Tolerance Test (mg/dL) - ≥ 200

Question 5

Prediabetes Lab Values

HbA1c (%)

Fasting plasma glucose (mg/dL)

Oral Glucose Tolerance Test (mg/dL)

Answer 5

HbA1c (%) - 5.7-6.4

Fasting plasma glucose (mg/dL) - 100-125

Oral Glucose Tolerance Test (mg/dL) - 140-199

Question 6

Normal Blood Glucose Lab Values

HbA1c (%)

Fasting plasma glucose (mg/dL)

Oral Glucose Tolerance Test (mg/dL)

Answer 6

HbA1c (%) - ~5.7

Fasting plasma glucose (mg/dL) - ≤ 99

Oral Glucose Tolerance Test (mg/dL) - ≤ 139

Question 7

Metformin Brand Name

Answer 7

Glucophage

Question 8

Metformin Medication Class

Answer 8

Biguanide

Question 9

Metformin MOA

Answer 9

Reduces hepatic glucose output

Enhanced insulin sensitivity leading to increased glucose uptake

May have some effects on gut microbiome

Question 10

Metformin Indication

Answer 10

Type 2 diabetes as an adjunct to diet and exercise

(“1st” line)

Question 11

Metformin Administration

Answer 11

XR: administer once daily with a meal (supper). Do not crush, cut or chew.

IR: administer with largest meal of the day. If split dosing, take with food to minimize upset.

Question 12

Metformin Time to Effect/Length of Therapy

Answer 12

Initial response may take a few weeks

Expected glycemic effect: decrease A1c by 1-2%

Length of therapy: chronic/long-term

Question 13

Metformin Common Side Effects

Answer 13

GI upset - N/V/D, gas

Administer with largest meal of the day (while eating or immediately after) or use XR formulation (delivers to the site of absorption in intestine vs delivery directly to the stomach as with IR formulation)

Vitamin B12 deficiency

Monitor hematologic profile annually and check B12 levels every 2-3 years or as indicated by hematologic parameters.

Question 14

Metformin Serious Side Effects

Answer 14

Lactic acidosis (RARE)

Risk factors for lactic acidosis to be aware of: renal dysfunction, alcoholism, hypoxia, and hepatic dysfunction. Some symptoms to note: confusion, slurred speech, weakness, cramps, and nausea.

If a patient is at risk for lactic acidosis, monitor renal/hepatic function. Lactate levels may be monitored if patient is symptomatic.

Question 15

Metformin Contraindications

Answer 15

Severe renal impairment (eGFR <30ml/min/1.73 m)

Acute or chronic metabolic acidosis (including ketoacidosis)

Question 16

Metformin Monitoring Parameters

Answer 16

Effectiveness:

• A1c (anticipate 1-2% reduction)
• Impact primarily on fasting glucose

Safety:

• Renal function (SCr, BUN, UOP)
• Blood sugar (in patients with diabetes using insulin)
• Hepatic function (monitored to help assess risk of lactic acidosis)

Question 17

Insulin glargine Brand Name

Answer 17

Lantus

Long-acting (basal)

Question 18

Insulin lispro Brand Name

Answer 18

Humalog

Rapid-acting (prandial)

Question 19

Insulin aspart Brand Name

Answer 19

Novolog

Rapid-acting (prandial)

Question 20

Insulin MOA

Answer 20

Builds: ↑ uptake of glucose by muscle/fat

↑ syntesis of fatty acids

Stores: ↑ liver glycogen stores

↓ glycogen breakdonw by liver

Preserves: ↓ breakdown fatty acids into ketone bodies

Question 21

Insulin Indications

Answer 21

Mandatory/1st line for type 1 diabetes

Adjunct for type 2 diabetes to help with glucose control

Question 22

Insulin Administration

Answer 22

Aspart, lispro: Inject subcutaneously 15-20 minutes before meals. Rotate injection sites.

Glargine: Inject subcutaneously at a convenient time of day (can be morning or bedtime). May occasionally see twice daily dosing. Rotate injection sites.

Question 23

Insulin Length of Therapy

Answer 23

Chronic/long-term

Question 24

Insulin glargine PK parameters

(Time to onset, time to peak, duration of action)

Answer 24

Lantus

Time to onset 2-3 hours

Time to peak - No peak

Duration of action - 22-24 hours

Question 25

Insulin lispro PK Parameters

(Time to onset, time to peak, duration of action)

Answer 25

Humalog

Time to onset - 15-30 mins

Time to peak - 1-2 hours

Duration of action - 3-4 hours

Question 26

Insulin aspart PK Parameters

(Time to onset, time to peak, duration of action)

Answer 26

Novolog

Time to onset - 15-30 mins

Time to peak - 1-2 hours

Duration of action - 3-5 hours

Question 27

Insulin Common Side Effects

Answer 27

Hypoglycemia

Rule of 15:

• 15 gram fast-acting carbs (8 oz OJ, 1 apple, 1 slice of bread)
• Wait for 15 minutes
• Repeat with 15 grams of carbohydrates if needed
• Seek help if severe or not responding to carbs
• Follow with a carb/protein snack if meal not for 1-2 hrs

Weight gain

Meal planning/physical activity should help mitigate weight gain

Question 28

Insulin Precautions

Answer 28

History of recurrent episodes of hypoglycemia

Question 29

Insulin Monitoring Parameters

Answer 29

Effectiveness:

• A1c (can titrate insulin dose to effect)
• Impact on glucose depends on type of insulin (e.g. rapid-acting insulin has direct effects on post-prandial glucose)

Safety:

• Blood sugar regularly (typically 1 fasting and 3 post-prandial checks)
• Weight

Question 30

General Guide for Insulin Dosing

T1DM

Answer 30

• Recall goal is to mimic normalglucose pattern because patient is no longer making insulin
• Start with estimated total daily dose (TDD) of 0.4-0.6 units/kg/ABW
  
  • Give 50% as basal insulin and 50% as prandial/pre-meal bolus insulin (split between 3 meals)
• Titrate insulin as needed to achieve glucose targets (remember safety!)

Question 31

General Guide for Insulin Dosing

T2DM

Answer 31

• Recall patient is still making some insulin so goal is to supplement other medications in reaching A1c and glucose goals.
• Start with estimated basal insulin dose of 0.1-0.2 units/kg once daily
• Titrate basal insulin to fasting glucose target by increasing dose 2 units SC every 3 days
• Check in with patient (assess efficacy and safety)