Diabetes Flashcards
1
Q
What type of diabetes is an autoimmune disease?
A
Type 1
2
Q
What cells in the pancreas make insulin?
A
Beta
3
Q
What can be tested to determine type 1 vs type 2 diabetes in adults? Will this value be high or low?
A
In type 1 diabetes C-peptide protein is very low or absent
4
Q
What test is preferred in pregnant women to test for gestational diabetes?
A
oral glucose tolerance test (OGTT)
Highly sensitive
5
Q
What medications are used for diabetes in pregnancy?
A
Insulin is preferred for tight control
Metformin and glyburide can also be used
6
Q
What mental health issue is associated with high blood glucose?
A
Depression
7
Q
What are the 3 classic symptoms that are caused by high BG?
A
Polyuria
Polyphagia
Polydipsia
8
Q
What lab value is a risk factor for diabetes?
A
HDL < 35
TG >250
A1C > 5.7%
9
Q
What diagnostic tests are available for diabetes?
A
Hgb A1c
Fasting plasma glucose (FPG)
Oral glucose tolerance test (OGTT)
10
Q
What A1c, FPG, 2-hr PPG after OGTT indicates diabetes?
A
A1c: 6.5% or higher
FPG: 126 or higher
PPG: 200 or higher
11
Q
What A1c, FPG, 2-hr PPG after OGTT indicates pre-diabetes?
A
A1c: 5.7-6.4
FPG: 100-125
PPG: 140-199
12
Q
For non-pregnant patients, what is the A1c, preprandial, and 2-hr PPG goal?
A
A1c: <7%
Preprandial: 80-130
2-hr PPG: <180
13
Q
For pregnant patients, what is the preprandial, 1-hr PPG, and 2-hr PPG goal?
A
Preprandial: 95 or less
1-hr PPG: 140 or less
2-hr PPG: 120 or less
14
Q
How do you estimate average glucose from A1c?
A
A1c of 6% = BG of 126
Each 1% increase increases the glucose by ~28
15
Q
What diabetic patients should receive lipid controlling medication?
A
Diabetes + ASCVD or 50-75 with multiple ASCVD risk factors - high intensity
Diabetes and 40-75 - moderate intensity
16
Q
What natural products are used to lower BG?
A
Cinnamon
Alpha lipoic acid
Chromium
Not proven to be effective
17
Q
What is first line therapy for T2DM?
A
Metformin + lifestyle changes
18
Q
What medications should be added on to metformin if patient has HF, CKD, ASCVD or high ASCVD risk, regardless of A1c
A
ASCVD: GLP-1 RA (dulaglutide, liraglutide, semaglutide) or SGLT2i (empag or canagliflozin)
HF or CKD: SGLT2i (empag, canag, dapagliflozin) or GLP-1 RA
19
Q
What medications should be added on to metformin if patient has A1c >6.5% and primary concern is hypoglycemia (low BG) prevention
A
DPP-4
GLP-1 RA
SGLT2i
TZD
20
Q
What medications should be added on to metformin if patient has A1c >6.5% and primary concern is losing weight
A
GLP-1 RA (semaglutide, liraglutide, dulaglutide) or SGLT2i
Can add DPP-4i (if not on GLP-1 RA)
Can add TZD, Basal insulin, or SU
21
Q
What anti-diabetic should not be used with GLP-1 RA?
A
DPP-4i
22
Q
When should basal insulin be initiated in patients with T2DM?
A
After behavioral changes and GLP-1 RA if still above A1c goal
23
Q
What dose should basal insulin or bedtime NPH insulin start at? How should you titrate?
A
10 units/d OR 0.1-0.2 u/kg/d (TBW)
Increase 2 units every 3 days to reach FPG target without hypoglycemia
24
Q
When should prandial insulin be added to basal insulin?
A
If above a1c target despite
- Adequately titrated basal insulin/bedtime NPH
- Basal dose >0.5 units/kg
- FPG at target
25
If a patient is on bedtime NPH and their A1c is above target you can consider switching to BID NPH - how do you do this?
decrease to 80%
Give 2/3 in morning
Give 1/3 at bedtime
Titrate based on patient needs
26
How do you initiate prandial insulin?
Once daily with largest meal or meal with greatest PPG
Start at 4 units/d or 10% of basal dose
Increase by 1-2 units or 10-15% twice weekly
27
If patient is on basal/NPH insulin and prandial insulin, what should be initiated if A1c above target?
Stepwise additional injections of prandial insulin
Consider self-mixed/split insulin regimen
Consider twice daily premixed insulin regimen
28
When should insulin be initiated at the beginning of T2DM treatment?
If A1c >10% or BG >300q
29
What are the first 3 medications in the T2DM algorithm?
Metformin first (unless insulin)
Then add GLP-1 RA or SGLT2i
Then add the other
30
What generic medications are in the brand name medication Actoplus Met
Metformin + pioglitazone
31
What generic medications are in the brand name medication Janumet
Metformin + sitagliptin
32
What generic medications are in the brand name medication Invokamet
Metformin + canagliflozin
33
Metformin MOA
decrease hepatic glucose output, increase insulin sensitivity, and decreased intestinal glucose absorption
34
Metformin A1c decrease?
1-1.5%
35
Metformin BBW, Warnings, CI
BBW: lactic acidosis
Warnings: do not start with eGFR 30-45, vitamin B12 deficiency, stop prior to iodinated contrast
CI: eGFR <30
36
What medications are thiazolidinediones?
Pioglitazone
| Rosiglitazone
37
Thiazolidinediones MOA
increased muscle sensitivity to insulin to increase BG entry
38
Thiazolidinediones A1c decrease?
~1%
39
What anti-diabetics cause weight gain?
TZD
SU
Meglitinides
40
What anti-diabetics cause weight loss?
SGLT2i
| GLP-1 receptor agonists
41
How can TZD and SGLT2i cause hypoglycemia?
Pioglitazone
Rosiglitazone
Doesn't cause hypo by itself but can enhance effects of insulin
42
TZD SE, BBW, warnings
SE: edema, weight gain, bone fractures
BBW: do not use with Class III/IV HF
Warnings, hepatic failure, edema, can cause or worsen HF, fractures, can stimulate ovulation
43
What medications are SGLT2i?
Canagliflozin (invokana)
| Empagliflozin (Jardiance)
44
SGLT2i A1c decrease?
0.7-1%
45
SGLT2i SE, BBW, warning, CI
SE: UTIs, genital fungal infection, weight loss
BBW: canagliflozin amputation risk
Warnings: Increased LDL and K, fluid loss, ketoacidosis with BG <250
CI: eGFR <30
46
What medications are DPP-4i?
Sitagliptin (Januvia) and linagliptin (Tradjenta)
47
DPP-4 inhibitor MOA
Increase incretin causing less glucagon which lowers BG
48
DPP-4i A1c decrease
~1%
49
DPP-4i warnings
Pancreatitis, severe arthralgia, acute renal failure, alogilptin hepatotoxicity,
Do not use alo and saxa with HF
50
SU medications
Glipizide, glimepiride, glyburide
51
SU MOA
increase insulin secretion
52
SU A1c decrease
~0.8%
53
SU SE, CI, warnings
SE: hypoglycemia, weight gain
CI: sulfa allergy - cross-reaction rare
Warnings: hypoglycemia, beers criteria
54
Meglitinides SE and warnings
SE: Hypoglycemia and weight gain; skip meal = skip dose
Warnings: do not use with insulin or sulfonylureas (same MOA)
55
What medications should NOT be used with meglitinides?
SU and insulin
56
What medications are Sulfonylureas?
Glipizide, Glimepiride, glyburide
57
What medications are meglitinides
Repaglinide
| Nateglinide
58
What medications are GLP-1 receptor agonists
```
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Exenatide (Byetta)
Lixisenatide (Adlyxin)
Semaglutide (Ozempic)
```
59
Indications and brand names for liraglutide
Liraglutide (Victoza) - diabetes
| Liraglutide (saxenda) - weight loss
60
Meglitinides MOA
Increased insulin secretion
61
GLP-1 receptor agonists MOA
increases incretin causing less glucagon which lowers BG nad slows gastric emptying, increasing satiety
62
GLP-1 RA BBW and warnings
BBW: Family hx of medullary thyroid CA
Warnings: Pancreaitis
63
Pramlintide CI, SE, BBW
CI: gastroparesis
SE: N/V, anorexia, HA
BBW: severe hypoglycemia when used with insulin
64
What medications are alpha-glucosidase inhibitors
Acarbose
| Miglitol
65
Alpha-glucosidase inhibitors MOA
Inhibits sucrose breakdown in gut; decrease glucose absorption
66
Alpha-glucosidase inhibitor dosing, SE
Dosign: start TID with first bit eof each meal
SE: flatulence, diarrhea
67
What diabetes medications should be avoided in patients with
Cancer
Pioglitazone
Dapagliflozin (bladder CA)
GLP-1 RA (thyroid)
68
What diabetes medications should be avoided in patients with
Elderly
SU
69
What diabetes medications should be avoided in patients with
Gastroparesis/GI disorders
GLP1 RAs, pramlintide
70
What diabetes medications should be avoided in patients with
Genital infections/UTI
SGLT2i
71
What diabetes medications should be avoided in patients with
HF
TZD
Alogliptin
Saxagliptin
72
What diabetes medications should be avoided in patients with
Hepatotoxicity
TZDs
| Alogliptin
73
What diabetes medications should be avoided in patients with
Hypotension/Dehydration
SGLT2i
74
What diabetes medications should be avoided in patients with
Hyperkalemia
Canagliflozin
75
What diabetes medications should be avoided in patients with
Hypokalemia
Insulin
76
What diabetes medications should be avoided in patients with
Hypersensitivity
DPP-4i
77
What diabetes medications should be avoided in patients with
Ketoacidosis
SGLT2i
78
What diabetes medications should be avoided in patients with
Lactic acidosis
Metformin
| Do not use if eGFR < 30
79
What diabetes medications should be avoided in patients with
Osteopenia/Osteoporosis
Canagliflozin
| TZD
80
What diabetes medications should be avoided in patients with
Pancreatitis
DPP-4i
| GLP-1 RA
81
What diabetes medications should be avoided in patients with
Peripheral neuropathy
Canagliflozin
82
What diabetes medications should be avoided in patients with
Retinopathy
Semaglutide SC injection (Ozempic)
83
What diabetes medications should be avoided in patients with
Sulfa allergy, severe
Consider avoiding SU
84
```
What diabetes medications should be avoided in patients with
Renal insuffieicney (eGFR or CrCl < 30)
```
Metformin
SGLT2i
Exenatide
Glyburide
85
Where is glucagon produced? Insulin?
Glucagon: Alpha-cells in the pancreas
Insulin: beta-cells in the pancreas
86
Insulin MOA
Moves BG into muscle cells to be used as energy, into fat cells, or to be stored as glycogen
87
Glucagon MOA
Pulls glucose back into circulation when BG is low by releasing glucose from glycogen
If glycogen is depleted, glucagon with signal fat cells to make ketones as an alternative energy source
88
Aspart, lispro, glulisine insulin onset, peak, and duration
Onset: 15 min
Peak: 1-2 horus
Duration: 3-5 hours
89
Insulin regular onset, peak, and duration
Onset: 30 min
Peak: 2 hr
Duration: 6-10 hr
90
NPH insulin onset, peak, and duration
Onset: 1-2 hours
Peak: 4-12 hours
Duration: 14-24 hours
91
Degludec insulin onset, peak, and duration
Onset: 1 hour
Peak: none
Duration: 42+ hours
92
Glargine insulin onset, peak, and duration
Onset: 3-4 hourws
Peak: none
Duration: 24 hours
93
Detemir insulin onset, peak, and duration
Onset: 3-4 hours
Peak: none
Duration: 24 hours
94
Afrezza inhaled insulin CI
ANY lung disease at all (especially COPD and asthma); smoking
95
What are examples of rapid acting insulins?
Aspart (Novolog)
| Lispro (Humalog)
96
What are examples of short acting insulin?
Regular (Humulin R, Novolin R)
97
What type of insulin is preferred in parenteral nutrition?
Regular
98
What 2 insulins can be mixed in the same syringe?
NPH and regular (or rapid acting)
| Do regular or rapid acting first THEN NPH
99
What are examples of intermediate-acting insulin?
NPH
100
What insulins should appear cloudy? Clear?
Cloudy: NPH
Clear: all others
101
What are examples of long-acting insulin?
Detemir (Levemir)
| Glargine (Lantus, Toujeo, Basaglar)
102
What are examples of ultra-long acting insulin?
Degludec
103
What are examples of 70/30 insulin mix?
Humulin 70/30
| Novolin 70/30
104
What insulins can be dispensed OTC?
Regular, NPH, and pre-mixed 70/30
105
How is insulin dosed in type 1 diabetic patients?
0.5 units/kg/day (TBW)
50% basal
50% bolus divided among 3 meals
106
Why are NPH and regular not preferred in type 1 diabetics? How is it dosed in T1DM?
Higher risk for hypoglycemia, do not mimic natural insulin release b/c they peak
0.5 units/kg/d (TBW)
2/3 given as NPH and 1/3 given as regular
107
How to convert between insulins
1:1 usually
If BID NPH --> Lantus or Basaglar, use 80% of NPH dose
If Toujeo --> Lantus or Basaglar, use 80% of NPH dose
108
What is the volume of all insulin pens?
3mL
EXCEPT
Toujeo (glargine) - 1.5mL and 3mL
109
What are the concentrated insulins and what are their strengthes?
Humalog KwikPen (lispro): 200 units/mL
Humulin R U-500 (regular) KwikPen AND vial: 500 units/mL
Treiba FlexTouch pen (degludec): 200 units/mL
Toujeo SoloStar (glargine): 300 units/mL
110
What syringe volume should be dispensed for someone receiving
up to 30 units
30-50 units
51-100 units?
30: 0.3 mL
30-50: 0.5 mL
51-100: 1 mL
111
What length of pen needle do you not need to pinch the skin?
4mm and 5mm
112
What does the insulin-carb-ratio (ICR) indicate?
The number of grams of carbs covered by 1 unit of insulin
113
How to calculate the insulin-carb-ratio (ICR)?
For regular: rule of 450
450/TDD = grams of carbs covered by 1 unit of regular insulin
For rapid-acting: rule of 500
500/TDD = grams of carbs covered by 1 unit of regular insulin
114
How to calculate the correction factor for bringing down high blood sugar?
Regular: rule of 1500
1500/TDD = correction factor for 1 unit of insulin
Rapid-acting: rule of 1800
1800/TDD = correction factor for 1 unit of insulin
115
How to calculate the correction dose for bringing down high blood sugar?
(BG now - target BG)/correction factor = correction dose
116
How do you prime a pen needle?
Turn the knob to 2 units and press the injection button
117
What is the preferred injection site for insulin? Why?
Abdomen
| Best absorbed here
118
How long is insulin stable at room temperature?
```
Humalog pens: 10 days
Humulin R vials: 31 days
Humulin N N/R pens: 14 days
Humulin R U-500 vial: 40 daysDetemir (Levemir): 42 days
Degludec (Tresiba): 56 days
Glargine (Toujeo): 56 days
All others: 28 days
```
119
What are approved sites of BG testing?
Some are fingertip only
| Some are fingertip, forearm, palm, or thigh - only good if BG is stable and not rapidly changing
120
What drugs increase BG?
```
Beta blockers
Thiazide and loop diuretics
Tacrolimus
Cyclosporine
Protease inhibitors
Quinolones
Antipsychotics
Statins
Steroids (systemic)
Cough syrups
Niacin
```
121
What drugs decrease BG?
```
Linezolid
Lorcaserin (Belviq)
Pentamidine
Beta blockers
Quinolones
Tramadol
```
122
What is considered hypoglycemia?
BG < 70
123
What diabetes medications can cause hypoglycemia?
Insulin
SU
Meglitinides
124
How to treat someone who is unconscious from hypoglycemia
Glucagon 1mg SQ, IV, IM
| If IV access can give 10-25g of glucose
125
Why is sliding scale not recommended as the sole method of control for BG?
It doesn't "control" anything it is just reactive to high blood sugar
126
What is the target range for most non-critical and critical care patients with diabetes?
140-180 mg/dL
127
Characteristics of diabetic ketoacidosis (DKA)
BG>250
Ketones in urine and blood
Anion gap acidosis (arterial gas < 7.35, anion gap > 12)
128
Characteristics of hyperosmolar hyperglycemic state (HHS)
Confusion, delirium
BG > 600 with high osmolality >320 mOsm/L
Extreme dehydration
pH . 7.3, bicarbonate > 15
129
Which is most common in type 1 DM - DKA or HHS?
DKA
130
Which is most common in type 2 DM - DKA or HHS?
HHS
131
How to treat DKA and HHS
Aggressive fluids
Insulin to treat high BG at 0.1 unit/kg bolus then 0.1 units/kg/hr
When BG reaches 200 mg/dL, change to D5W1/2NS
Maintain K of 4-5
Give sodium bicarb if acidosis (pH< 6.9)
