Diabetes Flashcards
Type I Diabetes Definition
Caused by autoimmune disorder leading to insuling deficiency
Commonly seen in children/adolescents
Rapid symptom onset
Type II Diabetes Definition
90% of people with diabetes
Caused by progressive loss of insulin or insulin resistance
Commonly seen in adults (>30 y/o)
Insidious onset
T2DM Risk Assessment
Diabetes Lab Values
HbA1c (%)
Fasting plasma glucose (mg/dL)
Oral Glucose Tolerance Test (mg/dL)
HbA1c (%) - ≥ 6.5
Fasting plasma glucose (mg/dL) - ≥ 126
Oral Glucose Tolerance Test (mg/dL) - ≥ 200
Prediabetes Lab Values
HbA1c (%)
Fasting plasma glucose (mg/dL)
Oral Glucose Tolerance Test (mg/dL)
HbA1c (%) - 5.7-6.4
Fasting plasma glucose (mg/dL) - 100-125
Oral Glucose Tolerance Test (mg/dL) - 140-199
Normal Blood Glucose Lab Values
HbA1c (%)
Fasting plasma glucose (mg/dL)
Oral Glucose Tolerance Test (mg/dL)
HbA1c (%) - ~5.7
Fasting plasma glucose (mg/dL) - ≤ 99
Oral Glucose Tolerance Test (mg/dL) - ≤ 139
Metformin Brand Name
Glucophage
Metformin Medication Class
Biguanide
Metformin MOA
Reduces hepatic glucose output
Enhanced insulin sensitivity leading to increased glucose uptake
May have some effects on gut microbiome
Metformin Indication
Type 2 diabetes as an adjunct to diet and exercise
(“1st” line)
Metformin Administration
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.
Metformin Time to Effect/Length of Therapy
Initial response may take a few weeks
Expected glycemic effect: decrease A1c by 1-2%
Length of therapy: chronic/long-term
Metformin Common Side Effects
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.
Metformin Serious Side Effects
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.
Metformin Contraindications
Severe renal impairment (eGFR <30ml/min/1.73 m)
Acute or chronic metabolic acidosis (including ketoacidosis)
Metformin Monitoring Parameters
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)
Insulin glargine Brand Name
Lantus
Long-acting (basal)
Insulin lispro Brand Name
Humalog
Rapid-acting (prandial)
Insulin aspart Brand Name
Novolog
Rapid-acting (prandial)
Insulin MOA
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
Insulin Indications
Mandatory/1st line for type 1 diabetes
Adjunct for type 2 diabetes to help with glucose control
Insulin Administration
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.
Insulin Length of Therapy
Chronic/long-term
Insulin glargine PK parameters
(Time to onset, time to peak, duration of action)
Lantus
Time to onset 2-3 hours
Time to peak - No peak
Duration of action - 22-24 hours
Insulin lispro PK Parameters
(Time to onset, time to peak, duration of action)
Humalog
Time to onset - 15-30 mins
Time to peak - 1-2 hours
Duration of action - 3-4 hours
Insulin aspart PK Parameters
(Time to onset, time to peak, duration of action)
Novolog
Time to onset - 15-30 mins
Time to peak - 1-2 hours
Duration of action - 3-5 hours
Insulin Common Side Effects
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
Insulin Precautions
History of recurrent episodes of hypoglycemia
Insulin Monitoring Parameters
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
General Guide for Insulin Dosing
T1DM
- 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!)
General Guide for Insulin Dosing
T2DM
- 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)
