Diabetes - Endocrinology Flashcards
1
Q
What is Type I Diabetes?
A
The patient’s own antibodies attack and destroy the beta cells in the pancreas that make insulin
2
Q
When is Type I Diabetes commonly diagnosed?
A
In children - but can develop at any age
3
Q
What happens if there is no insulin in Type I Diabetes?
A
Glucose can’t enter the muscle cells –> body goes into starvation mode –> body starts to metabolize fat into ketones as an alternative energy source
4
Q
Why is it bad if the body metabolizes fat into ketones in Type I Diabetes?
A
ketones are acidic –> high ketone levels can cause diabetic ketoacidosis –> medical emergency
5
Q
What protein can be used to see if an adult has Type I Diabetes compared to Type II Diabetes? Why?
A
C-peptide b/c this protein is released by the pancreas only when insulin is released –> Type I diabetes is diagnosed when there is very low C-peptide level
6
Q
Presentation of Type II Diabetes?
A
- low level of physical activity
2. overweight or obese
7
Q
What happens in Type II Diabetes?
A
pancreas will attempt to overcome insulin resistance by producing more insulin –> beta cells will become dysfunctional –> insulin production decreases –> BG becomes elevated
8
Q
What is prediabetes a risk for?
A
Type II diabetes
9
Q
How are 2 ways that diabetes can be present in pregnancy?
A
- diabetes was present prior to becoming pregnant
2. diabetes developed during pregnancy
10
Q
What risks are babies at born to mothers who had hyperglycemia during the pregnancy and how do they present when born
A
- at risk for developing obesity and diabetes later in life
2. are larger than normal
11
Q
When is the oral glucose tolerance test used?
A
during pregnancy - typically between 24-28 weeks
12
Q
What medications may be needed for pregnant women who develop diabetes during pregnancy?
A
- insulin is preferred
2. metformin and glyburide are sometimes used
13
Q
What microvascular diseases can result from prolonged hyperglycemia?
A
- retinopathy - mild to complete vision loss
- nephropathy - kidney failure
- neuropathy - pain, loss feeling with decrease blood circulation –> resulting in amputation
- autonomic neuropathy
- erectile dysfunction
- gastroparesis
- loss of bladder control –> UTIs
14
Q
What macrovascular diseases can result from prolonged hyperglycemia?
A
- atherosclerosis - ASCVD
- coronary artery disease including MI
- cerebrovascular disease including stroke
- peripheral artery disease with pain and high risk of amputation
15
Q
What are the classic symptoms of high BG?
A
The 3 P’s:
- polyuria - excessive urination
- polyphagia - excessive hunger or increased appetitie
- polydipsia - excessive thirst
16
Q
What are other uncommon symptoms that can be present in Type II diabetes besides the 3 P’s?
A
- fatigue
- blurry vision
- erectile dysfunction
- vaginal fungal infections
17
Q
Risk factors for developing type II diabetes?
A
- physical inactivity
- first-degree relative with diabetes
- high risk face or ethnicity
- african-american
- asian-american
- latinos/hispanics
- native americans
- pacific islanders - baby delivered >9 pounds or diagnosis of gestational diabetes
- HDL <35 or TG >250
- hypertension (140/90 or taking BP meds)
- A1C >5.7%
- conditions that cause insulin resistance (PCOS)
- cardiovascular disease history
18
Q
What does an A1C test represent?
A
the average BG over the past approx. 3 months
19
Q
What does a fasting plasma glucose represent?
A
the BG at the moment after over 8 hours of fasting
20
Q
What is the oral glucose tolerance test?
A
measures how well a person can tolerate a very surgery drink by measuring the post-prandial glucose level
21
Q
How can diabetes be diagnosed?
A
- A1C >/= 6.5% or FBG >/= 126 twice with the same or different blood sample
- different diagnostic test
22
Q
How often should the A1C test be conducted if the patient is NOT at goal?
A
every 3 months
23
Q
How often should the A1C test be conducted if the patient is at goal?
A
EVERY 6 MONTHS
24
Q
What is the goal for A1C?
A
either <6.5% or <7%
25
What is the diabetes diagnostic criteria for A1C?
>/=6.5%
26
What is the diabetes diagnostic criteria for FBG?
>/=126 mg/dL
27
What is the diabetes diagnostic criteria for 2-hours PPG after OGTT or classic symptoms + random BG?
>/=200 mg/dL
28
What is the prediabetes diagnostic criteria for A1C?
5.7-6.4%
29
What is the prediabetes diagnostic criteria for FBG?
100-125 mg/dL
30
What is the prediabetes diagnostic criteria for 2-hours PPG after OGTT or classic symptoms + random BG?
140-199 mg/dL
31
What is the A1C treatment goal for non-pregnant individuals?
<7%
32
What is the preprandial goal for non-pregnant individuals?
80-130 mg/dL
33
What is the 2-hour PPG goal for non-pregnant individuals?
<180 mg/dL
34
What is the average BG of a A1C 6%? Additional A1C 1%?
126 mg/dL
28 mg/dL
35
How much exercise should a diabetic individual get?
at least 150 minutes/week spread over at least 3 days
36
What antiplatelet therapy should a diabetic patient get for ASCVD secondary prevention?
Aspirin 81 mg/day
| *CAN BE USED IN PREGNANCY TO DECREASE THE RISK OF PREECLAMPSIA
37
If a patient has an allergy to aspirin, what is an alternative they can use for ASCVD secondary prevention?
Clopidogrel 75 mg/day
38
How often should diabetic patients get a lipid panel check?
annually
39
What class of drugs should diabetic patients get for cholesterol control and how often should they be reevaluated?
statins
every 4-12 weeks after starting a statin or increasing the dose
40
What kind of statin and what statin should patients with diabetes + ASCVD or 50-75 y/o with multiple ASCVD risk factors get?
high intensity statin
atorvastatin 40-80 mg or rosuvastatin 20-40 mg
41
What kind of statin should patients with diabetes with no ASCVD and older patients (40-75 y/o) get?
moderate intensity statin
42
What kind of statin should patients with diabetes with no ASCVD risk factors and younger people (<40 y/o) get?
no statin
43
What kind of statin should patients with diabetes with ASCVD risk factors and younger people (<40 y/o) get?
moderate intensity statin
44
What drug could be added if the patient is at max tolerated statin and has a ASCVD 10 year risk factor >20%?
ezetimibe
45
What drug should be given for cholesterol control if LDL is controlled but TG 135-499 mg/dL?
Vascepa
46
If you are Type II diabetic, what should you do to prevent diabetic retinopathy?
eye exam with dilation
if retinopathy, repeat annually - if not, repeat every 1-2 years
47
What is the goal BP considered by the ACC/AHA and ADA guidelines?
<130/80 mmHg
48
What goal BP is considered by the ADA guidelines if patient has low ASCVD risk?
<140/90 mmHg
49
What should diabetic patients with hypertension and no albuminuria use?
thiazide diuretic, CCB, ACEI or ARB
50
What should diabetic patients with hypertension and albuminuria use?
ACEI or ARB with thiazide or CCB if needed
51
How often should albumin in the urine be checked if no kidney disease?
yearly
52
How often should albumin in the urine be checked if there is kidney disease?
twice yearly
53
What vaccinations are required for patients with diabetes?
1. hepatitis B virus series
2. influenza annually
3. both pneumococcal vaccines - Prevnar 13 and Pneumovax 23
54
What is the first line drug treatment for Type II diabetes?
metformin
55
what eGFR is contraindicated in metformin?
eGFR <30
56
What class and drugs should patients with ASCVD major issue use as an add on from metformin?
SGLT-2 Inhibitors
- empagliflozin
- canagliflozin
* CI in eGFR <30*
GLP-1 agonists
- dulaglutide
- liraglutide
- semaglutide
57
If patients have HF or CKD as a major issue, and their eGFR >30, what should they use as an add on from metformin?
SGLT-2 Inhibitors
- empagliflozin (Jardiance)
- canagliflozin (Invokana)
58
If patients have HF or CKD as a major issue, and their eGFR <30, what should they use as an add on from metformin?
GLP-1 agonists
- dulaglutide
- liraglutide
- semaglutide
59
What drug class/drugs should be an add on from metformin if patient want to lose weight?
SGLT-2 inhibitors
GLP-1 agonists
- semaglutide
- liraglutide
- dulaglutide
60
What drug treatment options for Type II diabetes should not be used together?
1. GLP-1 agonists and DPP-4 inhibitors
| 2. sulfonylureas and meglitinide
61
What drug classes should be an add on to metformin if the patient is at high risk of hypoglycemia?
1. DPP-4 inhibitors
2. GLP-1 agonists
3. SGLT-2 inhibitors
4. thiazolidinediones
62
If patients are on metformin and GLP-1 agonists, ad the A1C is still above target, what should they use?
basal insulin or bedtime NPH insulin
63
What is the typically starting dose for basal insulin or bedtime NPH insulin?
10 units/day or 0.1-0.2 units/kg/day
64
How do you typically titrate basal insulin or bedtime NPH insulin?
increase by 2 units every 3 days to reach FBG goal
65
What happens if you experience hypoglycemia while titrating basal insulin or bedtime NPH insulin?
decrease dose by 10-20%
66
What should be used before starting insulin in most patients?
GLP-1 agonist
67
If adding a basal insulin or bedtime NPH insulin is not adequate to reach A1C goal, what should be done?
add prandial (meal-time) insulin - start with one daily dose - before meal with the highest carb intake or highest post-prandial BG
additional prandial doses can be added prior to meals
68
What do GLP-1 agonists end in?
-utide
69
What do SGLPT-2 inhibitors end in?
-gliflozin
70
What do DPP-4 inhibitors end in?
-gliptin
71
What class is metformin?
biguanide
72
What is the brand name of metformin?
glucophage
73
What are the MOAs of metformin?
1. decreases hepatic glucose output
2. increases insulin sensitivity
3. decreases intestinal glucose absorption
74
How much of a decrease in A1C% is metformin monotherapy?
1-1.5%
75
Does metformin cause hypoglycemia?
no
76
What kind of weight change does metformin cause?
no change - neutral
77
What is the max dosing of metformin that it should be titrated to?
2000 mg/day or 2550 mg/day with 850 mg TID
78
Common side effects of metformin?
TYPICALLY WELL-TOLERATED:
1. diarrhea
2. nausea
79
When should metformin be taken?
with a meal to decrease nausea
if ER - swallow whole and take with dinner
80
What is the boxed warning with metformin?
lactic acidosis - increased risk with renal disease, alcoholism, or hypoxia
81
Warnings with metformin?
1. don't start metformin if eGFR is 30-45
2. Vitamin B12 deficiency
3. stop prior to iodinated contrast media
82
What drugs fall in the class of thiazolidinediones?
1. pioglitazone
| 2. rosiglitazone
83
What is the ending of thiazolidinediones?
-glitazone
84
What is the MOA of thiazolidinediones?
increases muscle cell-sensitivity to insulin in to increase BG entry into the muscles
85
How much does thiazolidinediones decrease A1C%?
1%
86
Do thiazolidinediones cause hypoglycemia?
not by itself
if used with another drug class, it may - may need to decrease the dose
87
What weight changes does thiazolidinediones cause?
weight increase
88
Renal impairment rules with thiazolidinediones?
1. no dose adjustment necessary with thiazolidinediones
| 2. not commonly used in patients with renal impairment due to fluid retention
89
Common side effects associated with thiazolidinediones?
1. edema
2. weight gain
3. bone fractures
90
Important information on rosiglitazine?
drug increases LDL, HDL, total cholesterol, and BP
91
Boxed warning with thiazolidinediones?
should not be used in patients with NYHA Class III/IV heart failure
92
Warnings associated with thiazolidinediones?
1. hepatic failure
2. edema
3. fractures especially in females
4. can cause or worsen HF
5. can stimulate ovulation - may need contraception
93
Warning associated with pioglitazone?
do not use in patients with a history of bladder cancer
94
What drugs are in the class SGLT-2 inhibitors?
1. canagliflozin*
2. empagliflozin*
3. dapagliflozin
4. ertugliflozin
95
What is the brand name of canagliflozin?
Invokana
96
What is the brand name of empagliflozin?
Jardiance
97
What is the MOA of SGLT-2 inhibitors?
to increase the renal excretion of BG
98
How much do SGLT-2 inhibitors decrease A1C%?
0.7-1%
99
Does SGLT-2 inhibitors cause hypoglycemia?
not by itself
if used with other drugs, it can - may need to decrease the dose
100
What weight change is associated with SGLT-2 inhibitors?
weight loss
101
What benefits are associated with empagliflozin and canagliflozin?
heart failure and renal benefit
102
When should you take SGLT-2 inhibitors?
every morning
103
Should there be dose adjustments with renal failure if taking SGLT-2 inhibitors?
yes - decrease the dose for all drugs
104
Common side effects associated with SGLT-2 inhibitors?
1. UTIs
2. genital fungal infections
3. weight loss
4. increase in urination
5. increase in thirst
105
What are the boxed warnings associated with canagliflozin?
1. amputation risk - avoid if pt has foot problems/peripheral neuropathy
2. bone fractures - avoid drug with fracture risk
106
Warnings associated with SGLT-2 inhibitors?
1. increase in LDL
2. hyperkalemia
3. fluid loss
4. hypotension
5. ketoacidosis
6. severe UTIs
7. genital fungal infections
107
What is the eGFR CI with SGLT-2 inhibitors?
eGFR <30
108
What drugs are associated with DPP-4 inhibitors?
1. sitagliptin*
2. linagliptin*
3. saxagliptin
4. alogliptin
109
What is the brand name of sitagliptin?
Januvia
110
What is the brand name of linagliptin?
Tradjenta
111
What is the MOA of DPP-4 inhibitors?
increase in incretin --> less glucagon --> lowers BG
112
How much does DPP-4 inhibitors decrease A1C%?
<1%
113
Do DPP-4 inhibitors cause hypoglycemia?
not by itself - may cause hypoglycemia if used in combination with other drugs - may need to reduce the dose
114
Do DPP-4 inhibitors cause weight change?
no
115
What should DPP-4 inhibitors never be used in combination with and why?
GLP-1 agonists - similar MOA
116
Are DPP-4 inhibitor dose adjustments necessary with renal impairment?
yes - all except linagliptin
117
Common side effects associated with DPP-4 inhibitors?
GENERALLY WELL-TOLERATED
1. nasopharyngitis (common cold)
2. headache
118
Warnings associated with all DPP-4 inhibitors?
1. pancreatitis
2. severe arthralgia (joint pain)
3. acute renal failure
119
Warnings associated with alogliptin?
1. hepatotoxicity
| 2. do not use with heart failure
120
Warnings associated with saxagliptin?
1. do not use with heart failure
| 2. more common side effects - edema, UTIs, and hypoglycemia when used with insulin or sulfonylureas
121
What do sulfonylureas end in?
-ide
122
What drugs are in the class sulfonylureas?
1. glipizide
2. glimepiride
3. glyburide
123
What is the MOA of sulfonylureas?
to increase insulin secretion
124
How much do sulfonylureas decrease A1C?
0.8%
125
Do sulfonylureas cause hypoglycemia?
yes
126
Do sulfonylureas cause weight change?
yes - weight gain
127
What should sulfonylureas not be used with?
1. insulin
| 2. meglitinides
128
Common side effects associated with sulfonylureas?
GENERALLY WELL-TOLERATED
1. hypoglycemia
2. weight gain
129
Important warnings associated with Glipizide XL
1. made with an OROS formulation - a ghost tablet (empty shell) can present in stool
2. decrease in efficiency after long-term use since beta-cell function declines
130
Contraindications associated with sulfonylureas?
sulfa allergy
131
Warnings associated with sulfonylureas?
1. hypoglycemia
| 2. beers criteria - do not use in elderly patients due to hypoglycemia - especially if patients are using glyburide
132
What do meglitinides end in?
-glinide
133
What drugs are in the class meglitinides?
1. Repaglinide
| 2. Nateglinide
134
What is the MOA of meglitinides?
to increase meal-time insulin section
135
What A1C% do meglitinides decrease?
1%
136
Do meglitinides cause hypoglycemia?
yes - especially if the meal is skipped and the dose is still taken
137
Do meglitinides cause weight change?
yes - weight gain
138
Common side effects associated with meglitinides?
GENERALLY, WELL-TOLERATED
1. hypoglycemia
- if you skip a meal, skip the dose to avoid hypoglycemia
2. weight gain
139
What should meglitinides be used in combination with and why?
insulin and sulfonynureas - same MOA
140
What kind of injections are GLP-1 agonists and what is the exception?
all are SC injections - except for oral semaglutide
141
What drugs are in the class GLP-1 agonists?
1. liraglutide
2. dulaglutide
3. exenatide
4. lixisenatide
5. semaglutide
142
What are the brand names of liraglutide? What is the difference?
Victoza and Saxenda
-Saxenda is used for weight loss
143
What is the brand name of dulaglutide?
Trulicity
144
What is the brand name of Exenatide?
Byetta
145
What is the brand name of semaglutide?
Ozempic-injection
146
What is the MOA of GLP-1 agonists?
"incretin mimetic"
increase in incretin --> less glucagon --> lowers BG and slows gastric emptying --> increase in satiety
147
How much of the A1C do GLP-1 agonists decrease?
1%
148
Do GLP-1 agonists cause hypoglycemia
no - not by itself - maybe if used in combinations with other drugs
149
Do GLP-1 agonists cause weight changes?
yes - weight loss
150
Do any GLP-1 agonists have ASCVD benefit and which ones?
yes-
1. liraglutide
2. dluaglutide
3. semaglutide SC injection
151
What should you not use GLP-1 agonists with and why?
DPP-4 inhibitors - same MOA
152
Should you decrease the dose of GLP-1 agonists with renal impairment?
yes
153
What is the CI CrCl of Exenatide?
CrCl <30 mL/min
154
What is the CI CrCl of Lixisenatide?
CrCl <15 mL/min
155
Common side effects associated with GLP-1 agonists?
1. nausea/vomiting
2. decrease in appetite/weight loss
3. dyspepsia (indigestion)
4. injection site reactions
156
Which GLP-1 agonist injections are dosed weekly?
1. Dulaglutide
2. Exenatide ER
3. Semaglutide
157
How often is Exenatide (Byetta) dosed?
twice daily
158
Boxed warnings for GLP-1 agonists?
1. all except Exenatide (Byetta) and Lixisenatide (Adlyxin) - do not use if personal /family history of medullary thyroid cancer
2. do not use if history of multiple endocrine neoplasia
159
Warnings associated with GLP-1 agonists?
1. pancreatitis - monitor for symptoms of severe abdominal pain/nausea
2. AKI/CKD (kidney damage) due to fluid loss and dehydration
3. hypersensitivity - anaphylaxis and angioedema
4. gallbladder disease
5. GI symptoms - if so, titrate slowly and discontinue if fluid depletion
- do not use if gastroparesis
160
Warning associated with Exenatide ER?
serious injection-site reactions - abscess and skin nodules
161
Warnings associated with Semaglutide?
diabetic retinopathy
162
If a patient has cancer, what should they avoid?
Pioglitazone
163
If a patient has bladder cancer, what should they avoid?
dapagliflozin - SGLT-2 inhibitor
164
If a patient has thyroid issues, including medullatory thyroid cancer, what should they avoid?
GLP-1 agonists
165
What should elderly patients avoid and why?
sulfonylureas - due to hypoglycemia risk - especially with Glyburide
166
What should patients with GI disorders or gastroparesis avoid?
GLP-1 agonists
167
What should patients with genital infections or UTIs avoid?
SGLT-2 inhibitors
168
What should patients with heart failure avoid?
1. Thiazolidinediones
2. alogliptin - DPP-4 inhibitor
3. saxagliptin - DPP-4 inhibitor
169
What should patients with hepatotoxicity avoid?
1. Thiazolidinediones
| 2. alogliptin - DPP-4 inhibitor
170
What should patients avoid if they present with hypoglycemia?
1. insulin - more hypoglycemia with NPH and regular insulin
| 2. drugs that increase insulin such as sulfonyulreas
171
What should patients with hypotension avoid?
SGLT-2 inhibitors
172
What should patients with hyperkalemia avoid?
Canagliflozin - SGLT-2 inhibitor
173
What should patients with hypokalemia avoid?
insulin
174
What should patient who experience hypersensitivity reactions avoid?
DPP-4 inhibitors
175
What should patients with ketoacidosis avoid?
SGLT-2 inhibitors
176
What should patients with lactic acidosis avoid?
metformin
177
What should patients with osteoporosis/osteopenia avoid?
1. canagliflozin - SGLT-2 inhibitor
| 2. Thiazdolinediones
178
What should patients with pancreatitis avoid?
1. GLP-1 agonists
| 2. DPP-4 inhibitors
179
What should patients with peripheral neuropathy and foot ulcers avoid?
canagliflozin - SGLT-2 inhibitor
180
What should patients with retinopathy avoid?
semaglutide SC injection - Ozempic
181
What should patients with sulfa allergy avoid?
sulfonylureas
182
What should patients with renal insufficiency (CrCl <30) avoid?
1. metformin
2. SGLT-2 inhibitors
3. exenatide - GLP-1 agonist
4. Glyburide - sulfonylurea
183
What should patients that have weight gain avoid?
1. sulfonylureas
2. meglitinides
3. thiazolidinediones
4. insulin
184
What drugs are regarded as basal insulin?
1. degludec
2. glargine
3. detemir
185
What drugs are regarded as rapid-acting insulin?
1. aspart
2. lispro
3. glulisine
186
What is NPH insulin?
intermediate-acting insulin
187
What does P in NPH stand for?
protamine
188
What is the onset time of rapid-acting insulin
around 15 minutes
189
When does rapid-acting insulin peak?
in 1-2 hours
190
What is the duration of rapid-acting insulin?
3-5 hours
191
What is the purpose of rapid-acting insulin?
controls meal-time blood glucose
192
What is the purpose of regular-acting insulin?
controls meal-time BG
193
What is the onset for regular-acting insulin?
30 minutes
194
When does regular-acting insulin peak?
2 hours
195
How long does regular-acting insulin last?
6-10 hours
196
What is the onset time of detemir?
3-4 hours
197
How long does determir last for?
one whole day
198
When does detemir peak?
never peaks
199
What is the onset of glargine?
3-4 hours
200
What is the onset time of Toujeo?
6 hours
201
How long does glargine last for?
1 day
202
When does glargine peak?
no peak
203
When is the onset of degludec?
1 hour
204
How long does degludec last for?
over 42 hours
205
When does degludec peak?
no peak
206
What is the DDI between insulin and rosiglitazone?
increase risk of heart failure
207
What is the brand name of Aspart?
Novolog
208
What is the brand name of Lispro?
Humalog
209
What kind of insulin is Humulin R and Novolin R considered?
short-acting insulin; regular
210
What kind of insulin is Humulin N and Novolin N considered?
intermediate-acting
211
What is the brand name of insulin detemir?
Levemir
212
What are the brand names of insulin glargine?
Lantus and Toujeo
213
Can u mix basal/long-acting insulin with other insulin?
no - inject separately
214
When is Glargine (Toujeo) used instead of Glargine (Lantus)?
when more than 20 units/day is needed
215
When is the maxed effect of Toujeo?
on the 5th day
216
What kind of insulin is insulin degludec?
ultra-rapid acting insulin
217
When is insulin degludec used instead of levemir or glargine?
when patients experience nocturnal hypoglycemia
218
How do you convert NPH that is dosed BID to Lantus or Basaglar that is dosed daily
Use 80% of the NPH dose
219
How do you convert Toujeo to Lantus or Basaglar?
Use 80% of the Toujeo dose
220
What does ICR stand for and what is the purpose for the calculation?
Insulin to carbohydrate ratio
calculates how much grams of carbohydrate is covered by 1 unit of insulin
221
How do you calculate the ICR for regular insulin?
Rule of 450
222
How do you calculate the ICR for rapid-acting insulin?
Rule of 500
223
What does the correction factor mean?
how much BG is needed to lower 1 unit of insulin
224
How do you calculate the correction factor for regular insulin?
1,500 Rule
225
How do you calculate the correction factor for rapid-acting insulin
1,800 Rule
226
How to calculate the correction dose?
(current BG - target BG)/(correction factor)
227
Which insulin is most affected by the fasting BG?
the basal insulin
228
Which insulin is most affected by the post-prandial BG?
the rapid acting or short acting insulin
229
Should you alternative injection sites and which sites are optimal?
yes -
1. posterior upper arm
2. superior buttocks
3. lateral thigh area
230
How long is most insulin stable at room temperature for?
28 days
231
Drugs that can increase and decrease BG?
1. beta blockers
2. quinolones
3.
232
Drugs that can increase BG?
1. thiazide and loop diuretics
2. tacrolimus, cyclosporine
3. protease inhibitors
4. antipsychotics
5. statins
6. systemic steroids
7. cough syrups
8. niacin - Vitamin B3
233
Drugs that can decrease BG?
1. Linezolid
2. Lorcaserin
3. Pentamidine
4. Tramadol
234
What is the BG that is defined as hypoglycemia?
<70 mg/dL
235
Hypoglycemia symptoms?
1. dizziness
2. anxiety/irritability
3. shakiness
4. headache
5. diaphoresis (sweating)
6. hunger
7. confusion
8. tremors
9. palpitations/tachycardia
10. blurred vision
236
What can severe hypoglycemia cause?
1. seizures
2. coma
3. death
237
What are common drugs thatinduced hypoglycemia?
1. insulin
2. sulfonylureas
3. meglitinides (considered "insulin secretagogues"
*greater risk if patients are drinking alcohol on an empty stomach with these other drugs
238
Which drugs have the lowest risk of hypoglycemia when used alone?
1. GLP-1 agonists
2. DPP-4 inhibitors
3. Thiazolidinediones
4. SGLT-2 inhibitors
239
How do you treat a patient experiencing hypoglycemia symptoms that is conscious?
rule of 15
240
How do you treat a patient experiencing hypoglycemia that is unconscious?
dextrose (if patient has IV access) or glucagon
*caregivers should know how to administer a 1mg SC glucagon injection or a 3mg glucagon nasal spray
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What is the target range for BG?
140-180 mg/dL
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How do you recognize diabetic ketoacidosis?
1. BG >250 mg/dL
2. ketones - "fruity breath"
3. N/V
4. anion gap acidosis - arterial pH <7.35 and anion gap >12
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What is the emergency state that is common in type 2 diabetes?
hyperosmolar hyperglycemic state
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How do you recognize hyperosmolar hyperglycemic state?
1. confusion/delirium
2. BG >600 with high serum osmolality >320 mOsm/L
3. extreme dehydration
4. pH >7.3 and bicarbonate >15 mEq/L
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DKA and HSA standard treatment?
1. agressive fluids
- start with NS
- when BG reaches 200 mg/dL and change to D5W 1/2NS
2. insulin to treat the hyperglycemia
3. monitor for hypokalemia and keep serum level between 4-5
4. give sodium bicarbonate if pH <6.9
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Important counseling points with metformin?
1. can cause nausea and diarrhea at first which can go away - taking the medication with food or switching to a long-acting formulation to be taken at dinner will help
2. do not chew or break long-acting formulation - can cause a ghost tablet in the stool
3. can cause lactic acidosis
4. stop medication prior to contrast dye - can restart medication when renal function is normal
5. take a Vitamin B12 supplement if taking metformin long-term
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Important counseling points with thiazolidinediones?
1. take once daily in the morning
2. can cause or worsen heart failure
3. can cause weight gain
4. greater risk for bone fractures
5. don't use pioglitazone if patient has history of bladder cancer
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Important counseling points with SGLT-2 inhibitors?
1. take once daily in the morning
2. can cause an increase in LDL cholesterol
3. can cause hypotension
4. can cause ketoacidosis - stop medication prior to surgery to reduce risk
5. can cause severe UTIs or genital fungal infections
6. amputation risk, fractures, and hyperkalemia risks associated with canagliflozin
- avoid if patient has neuropathy or foot problems
7. dapagliflozin - bladder cancer risk
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Important counseling points with DPP-4 inhibitors?
1. take once daily in the morning
2. can cause pancreatitis
3. can cause renal impairment
4. can cause severe arthralgia
5. heart failure risk with saxagliptin and alogliptin
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Important counseling points with meglitinides/sulfonylureas?
1. take sulfonylureas with breakfast, except with glipizide IR - take 30 min before breakfast
2. take meglitinides 15-30 min before meals - do not take if skipping meals
3. can cause hypoglycemia and weight loss
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Important counseling points with GLP-1 agonists?
1. take Adlyxin and Byetta within 60 minutes of a meal - take the others anytime
2. if injection has been in the refrigerator - wait at least 15 min at room temperature before using
3. can cause nausea, diarrhea, decrease in appetite, weight loss
4. increased risk of pancreatitis and gallbladder disease
5. increased risk of kidney damage, especially from dehydration if there is severe vomiting or diarrhea
6. can cause hypersensitivity reaction including anaphylaxis or angioedema
7. Bydureron can cause severe injection-site reactions such as abscess and nodules
8. Ozempic has increased risk of diabetic retinopathy
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Important counseling points for Pramlintide?
1. when starting, reduce the dose of meal-time insulin by 50%
2. inject before meals
3. do not mix with insulin
4. can cause nausea
