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NAPLEX Review > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What type of diabetes is an autoimmune disease?

A

Type 1

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2
Q

What cells in the pancreas make insulin?

A

Beta

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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

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4
Q

What test is preferred in pregnant women to test for gestational diabetes?

A

oral glucose tolerance test (OGTT)

Highly sensitive

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5
Q

What medications are used for diabetes in pregnancy?

A

Insulin is preferred for tight control

Metformin and glyburide can also be used

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6
Q

What mental health issue is associated with high blood glucose?

A

Depression

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7
Q

What are the 3 classic symptoms that are caused by high BG?

A

Polyuria
Polyphagia
Polydipsia

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8
Q

What lab value is a risk factor for diabetes?

A

HDL < 35
TG >250
A1C > 5.7%

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9
Q

What diagnostic tests are available for diabetes?

A

Hgb A1c
Fasting plasma glucose (FPG)
Oral glucose tolerance test (OGTT)

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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

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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

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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

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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

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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

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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

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16
Q

What natural products are used to lower BG?

A

Cinnamon
Alpha lipoic acid
Chromium
Not proven to be effective

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17
Q

What is first line therapy for T2DM?

A

Metformin + lifestyle changes

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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

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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

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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

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21
Q

What anti-diabetic should not be used with GLP-1 RA?

A

DPP-4i

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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

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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

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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
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25
Q

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?

A

decrease to 80%
Give 2/3 in morning
Give 1/3 at bedtime
Titrate based on patient needs

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26
Q

How do you initiate prandial insulin?

A

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

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27
Q

If patient is on basal/NPH insulin and prandial insulin, what should be initiated if A1c above target?

A

Stepwise additional injections of prandial insulin
Consider self-mixed/split insulin regimen
Consider twice daily premixed insulin regimen

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28
Q

When should insulin be initiated at the beginning of T2DM treatment?

A

If A1c >10% or BG >300q

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29
Q

What are the first 3 medications in the T2DM algorithm?

A

Metformin first (unless insulin)
Then add GLP-1 RA or SGLT2i
Then add the other

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30
Q

What generic medications are in the brand name medication Actoplus Met

A

Metformin + pioglitazone

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31
Q

What generic medications are in the brand name medication Janumet

A

Metformin + sitagliptin

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32
Q

What generic medications are in the brand name medication Invokamet

A

Metformin + canagliflozin

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33
Q

Metformin MOA

A

decrease hepatic glucose output, increase insulin sensitivity, and decreased intestinal glucose absorption

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34
Q

Metformin A1c decrease?

A

1-1.5%

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35
Q

Metformin BBW, Warnings, CI

A

BBW: lactic acidosis
Warnings: do not start with eGFR 30-45, vitamin B12 deficiency, stop prior to iodinated contrast
CI: eGFR <30

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36
Q

What medications are thiazolidinediones?

A

Pioglitazone

Rosiglitazone

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37
Q

Thiazolidinediones MOA

A

increased muscle sensitivity to insulin to increase BG entry

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38
Q

Thiazolidinediones A1c decrease?

A

~1%

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39
Q

What anti-diabetics cause weight gain?

A

TZD
SU
Meglitinides

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40
Q

What anti-diabetics cause weight loss?

A

SGLT2i

GLP-1 receptor agonists

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41
Q

How can TZD and SGLT2i cause hypoglycemia?

A

Pioglitazone
Rosiglitazone
Doesn’t cause hypo by itself but can enhance effects of insulin

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42
Q

TZD SE, BBW, warnings

A

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

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43
Q

What medications are SGLT2i?

A

Canagliflozin (invokana)

Empagliflozin (Jardiance)

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44
Q

SGLT2i A1c decrease?

A

0.7-1%

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45
Q

SGLT2i SE, BBW, warning, CI

A

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

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46
Q

What medications are DPP-4i?

A

Sitagliptin (Januvia) and linagliptin (Tradjenta)

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47
Q

DPP-4 inhibitor MOA

A

Increase incretin causing less glucagon which lowers BG

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48
Q

DPP-4i A1c decrease

A

~1%

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49
Q

DPP-4i warnings

A

Pancreatitis, severe arthralgia, acute renal failure, alogilptin hepatotoxicity,
Do not use alo and saxa with HF

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50
Q

SU medications

A

Glipizide, glimepiride, glyburide

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51
Q

SU MOA

A

increase insulin secretion

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52
Q

SU A1c decrease

A

~0.8%

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53
Q

SU SE, CI, warnings

A

SE: hypoglycemia, weight gain
CI: sulfa allergy - cross-reaction rare
Warnings: hypoglycemia, beers criteria

54
Q

Meglitinides SE and warnings

A

SE: Hypoglycemia and weight gain; skip meal = skip dose
Warnings: do not use with insulin or sulfonylureas (same MOA)

55
Q

What medications should NOT be used with meglitinides?

A

SU and insulin

56
Q

What medications are Sulfonylureas?

A

Glipizide, Glimepiride, glyburide

57
Q

What medications are meglitinides

A

Repaglinide

Nateglinide

58
Q

What medications are GLP-1 receptor agonists

A 
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Exenatide (Byetta)
Lixisenatide (Adlyxin)
Semaglutide (Ozempic)
59
Q

Indications and brand names for liraglutide

A

Liraglutide (Victoza) - diabetes

Liraglutide (saxenda) - weight loss

60
Q

Meglitinides MOA

A

Increased insulin secretion

61
Q

GLP-1 receptor agonists MOA

A

increases incretin causing less glucagon which lowers BG nad slows gastric emptying, increasing satiety

62
Q

GLP-1 RA BBW and warnings

A

BBW: Family hx of medullary thyroid CA
Warnings: Pancreaitis

63
Q

Pramlintide CI, SE, BBW

A

CI: gastroparesis
SE: N/V, anorexia, HA
BBW: severe hypoglycemia when used with insulin

64
Q

What medications are alpha-glucosidase inhibitors

A

Acarbose

Miglitol

65
Q

Alpha-glucosidase inhibitors MOA

A

Inhibits sucrose breakdown in gut; decrease glucose absorption

66
Q

Alpha-glucosidase inhibitor dosing, SE

A

Dosign: start TID with first bit eof each meal
SE: flatulence, diarrhea

67
Q

What diabetes medications should be avoided in patients with
Cancer

A

Pioglitazone
Dapagliflozin (bladder CA)
GLP-1 RA (thyroid)

68
Q

What diabetes medications should be avoided in patients with
Elderly

A

SU

69
Q

What diabetes medications should be avoided in patients with
Gastroparesis/GI disorders

A

GLP1 RAs, pramlintide

70
Q

What diabetes medications should be avoided in patients with
Genital infections/UTI

A

SGLT2i

71
Q

What diabetes medications should be avoided in patients with
HF

A

TZD
Alogliptin
Saxagliptin

72
Q

What diabetes medications should be avoided in patients with
Hepatotoxicity

A

TZDs

Alogliptin

73
Q

What diabetes medications should be avoided in patients with
Hypotension/Dehydration

A

SGLT2i

74
Q

What diabetes medications should be avoided in patients with
Hyperkalemia

A

Canagliflozin

75
Q

What diabetes medications should be avoided in patients with
Hypokalemia

A

Insulin

76
Q

What diabetes medications should be avoided in patients with
Hypersensitivity

A

DPP-4i

77
Q

What diabetes medications should be avoided in patients with
Ketoacidosis

A

SGLT2i

78
Q

What diabetes medications should be avoided in patients with
Lactic acidosis

A

Metformin

Do not use if eGFR < 30

79
Q

What diabetes medications should be avoided in patients with
Osteopenia/Osteoporosis

A

Canagliflozin

TZD

80
Q

What diabetes medications should be avoided in patients with
Pancreatitis

A

DPP-4i

GLP-1 RA

81
Q

What diabetes medications should be avoided in patients with
Peripheral neuropathy

A

Canagliflozin

82
Q

What diabetes medications should be avoided in patients with
Retinopathy

A

Semaglutide SC injection (Ozempic)

83
Q

What diabetes medications should be avoided in patients with
Sulfa allergy, severe

A

Consider avoiding SU

84
Q 
What diabetes medications should be avoided in patients with 
Renal insuffieicney (eGFR or CrCl < 30)
A

Metformin
SGLT2i
Exenatide
Glyburide

85
Q

Where is glucagon produced? Insulin?

A

Glucagon: Alpha-cells in the pancreas
Insulin: beta-cells in the pancreas

86
Q

Insulin MOA

A

Moves BG into muscle cells to be used as energy, into fat cells, or to be stored as glycogen

87
Q

Glucagon MOA

A

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
Q

Aspart, lispro, glulisine insulin onset, peak, and duration

A

Onset: 15 min
Peak: 1-2 horus
Duration: 3-5 hours

89
Q

Insulin regular onset, peak, and duration

A

Onset: 30 min
Peak: 2 hr
Duration: 6-10 hr

90
Q

NPH insulin onset, peak, and duration

A

Onset: 1-2 hours
Peak: 4-12 hours
Duration: 14-24 hours

91
Q

Degludec insulin onset, peak, and duration

A

Onset: 1 hour
Peak: none
Duration: 42+ hours

92
Q

Glargine insulin onset, peak, and duration

A

Onset: 3-4 hourws
Peak: none
Duration: 24 hours

93
Q

Detemir insulin onset, peak, and duration

A

Onset: 3-4 hours
Peak: none
Duration: 24 hours

94
Q

Afrezza inhaled insulin CI

A

ANY lung disease at all (especially COPD and asthma); smoking

95
Q

What are examples of rapid acting insulins?

A

Aspart (Novolog)

Lispro (Humalog)

96
Q

What are examples of short acting insulin?

A

Regular (Humulin R, Novolin R)

97
Q

What type of insulin is preferred in parenteral nutrition?

A

Regular

98
Q

What 2 insulins can be mixed in the same syringe?

A

NPH and regular (or rapid acting)

Do regular or rapid acting first THEN NPH

99
Q

What are examples of intermediate-acting insulin?

A

NPH

100
Q

What insulins should appear cloudy? Clear?

A

Cloudy: NPH
Clear: all others

101
Q

What are examples of long-acting insulin?

A

Detemir (Levemir)

Glargine (Lantus, Toujeo, Basaglar)

102
Q

What are examples of ultra-long acting insulin?

A

Degludec

103
Q

What are examples of 70/30 insulin mix?

A

Humulin 70/30

Novolin 70/30

104
Q

What insulins can be dispensed OTC?

A

Regular, NPH, and pre-mixed 70/30

105
Q

How is insulin dosed in type 1 diabetic patients?

A

0.5 units/kg/day (TBW)
50% basal
50% bolus divided among 3 meals

106
Q

Why are NPH and regular not preferred in type 1 diabetics? How is it dosed in T1DM?

A

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
Q

How to convert between insulins

A

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
Q

What is the volume of all insulin pens?

A

3mL
EXCEPT
Toujeo (glargine) - 1.5mL and 3mL

109
Q

What are the concentrated insulins and what are their strengthes?

A

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
Q

What syringe volume should be dispensed for someone receiving
up to 30 units
30-50 units
51-100 units?

A

30: 0.3 mL
30-50: 0.5 mL
51-100: 1 mL

111
Q

What length of pen needle do you not need to pinch the skin?

A

4mm and 5mm

112
Q

What does the insulin-carb-ratio (ICR) indicate?

A

The number of grams of carbs covered by 1 unit of insulin

113
Q

How to calculate the insulin-carb-ratio (ICR)?

A

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
Q

How to calculate the correction factor for bringing down high blood sugar?

A

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
Q

How to calculate the correction dose for bringing down high blood sugar?

A

(BG now - target BG)/correction factor = correction dose

116
Q

How do you prime a pen needle?

A

Turn the knob to 2 units and press the injection button

117
Q

What is the preferred injection site for insulin? Why?

A

Abdomen

Best absorbed here

118
Q

How long is insulin stable at room temperature?

A 
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
Q

What are approved sites of BG testing?

A

Some are fingertip only

Some are fingertip, forearm, palm, or thigh - only good if BG is stable and not rapidly changing

120
Q

What drugs increase BG?

A 
Beta blockers
Thiazide and loop diuretics
Tacrolimus
Cyclosporine
Protease inhibitors
Quinolones
Antipsychotics
Statins
Steroids (systemic)
Cough syrups
Niacin
121
Q

What drugs decrease BG?

A 
Linezolid
Lorcaserin (Belviq)
Pentamidine
Beta blockers
Quinolones
Tramadol
122
Q

What is considered hypoglycemia?

A

BG < 70

123
Q

What diabetes medications can cause hypoglycemia?

A

Insulin
SU
Meglitinides

124
Q

How to treat someone who is unconscious from hypoglycemia

A

Glucagon 1mg SQ, IV, IM

If IV access can give 10-25g of glucose

125
Q

Why is sliding scale not recommended as the sole method of control for BG?

A

It doesn’t “control” anything it is just reactive to high blood sugar

126
Q

What is the target range for most non-critical and critical care patients with diabetes?

A

140-180 mg/dL

127
Q

Characteristics of diabetic ketoacidosis (DKA)

A

BG>250
Ketones in urine and blood
Anion gap acidosis (arterial gas < 7.35, anion gap > 12)

128
Q

Characteristics of hyperosmolar hyperglycemic state (HHS)

A

Confusion, delirium
BG > 600 with high osmolality >320 mOsm/L
Extreme dehydration
pH . 7.3, bicarbonate > 15

129
Q

Which is most common in type 1 DM - DKA or HHS?

A

DKA

130
Q

Which is most common in type 2 DM - DKA or HHS?

A

HHS

131
Q

How to treat DKA and HHS

A

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)

NAPLEX Review (79 decks)

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