Diabetes I and II Flashcards
Metformin
Decreases hepatic synthesis of glucose; no effect on circulating insulin levels
Benefits: Weight neutral, no risk of hypoglycemia when used as monotherapy
Adverse effects: GI upset (nausea, vomiting, bloating); contraindicated in patients with renal disease, metabolic acidosis, IV iodinated contrast, congestive heart failure
Sulfonylureas
Increase endogenous insulin release by blocking the ATP-sensitive K+ channel on pancreatic beta cells
Adverse effects: Hypoglycemia, weight gain, GI upset
Contraindicated in: Sulfa allergies, G6PD deficiency, hepatic/renal disease
Thiazolidinediones (TZDs)
Bind to the PPAR-y / RXR receptor on adipocytes; binding activates adiponectin, which increases expression of genes that control insulin sensitivity in adipose and skeletal muscle tissue
Adverse effects: Fluid retention / edema, hepatotoxicity
Contraindicated in patients with CHF, liver disease, or high CVD risk
GLP-1 agonists
Potentiate glucose-stimulated (post prandial) insulin release and decrease post prandial glucagon
Benefits: Lowers A1c, increases satiety, induces weight loss
Adverse effects: Nausea, hypoglycemia when administered in combination with sulfonylureas; must be administered as SC injection
DPP-4 Inhibitors
Block the action of DPP-4 leading to 2-3x increased circulating levels of endogenous GIP and GLP-1; main effect is to potentiate endogenous insulin secretion and decrease glucagon secretion
Benefits: Orally administered
Adverse effects: Nasopharyngitis, headache, ?Stevens-Johnson Syndrome, ?Acute pancreatitis
Amylin analog
Normally, amylin is co-secreted with insulin from pancreatic B cells and functions to reduce food intake and induce weight loss; amylin levels are elevated in TIIDM suggesting amylin insensitivity
Amylin analog is administered before meals to patients on prandial insulin therapy
Benefits: Reduces food intake and induces weight loss
Drawbacks: SC injection and cannot be mixed with insulin, insulin-induced hypoglycemia, nausea/vomiting
SGLT-2 Inhibitors
Blocks glucose reabsorption in the kidney leading to increased glucose excretion
Benefits: Weight loss, decreased BP
Adverse effects: GU infection, hypovolemia, hyperkalemia, impaired bone metabolism; contraindicated in patients with severe renal disease / dialysis
Fasting glucose values
Normal: < 100
Pre-Diabetes: 101-125
Diabetes: > 126
Impaired fasting glucose values
101-125
2hour OGTT values
Normal: < 140
Pre-Diabetes: 141-199
Diabetes: > 200
Impaired glucose tolerance values
141-199
A1c values
Normal: < 5.7%
Pre-Diabetes: 5.8-6.4%
Diabetes > 6.5%
Glycemic goals in diabetes management
A1c < 7%
Fasting glucose: 70-130
2hr post-prandial glucose: < 180
Glargine (Lantus)
Long acting insulin used for basal therapy; lasts 24 hours with no prolonged peak, administered 1x/daily
*Cannot be mixed with other insulins due to acidity
Detemir (Levemir)
Long acting insulin used for basal therapy; lasts 12-18 hours, administered 2x/day for basal coverage
NPH Insulin
Intermediate-acting insulin used 2x/daily for basal therapy; lasts 12-16 hours, can be used to treat mid-day hyperglycemia associated with lunch, and can be mixed with other insulins
*Comes as a cloudy solution
Regular insulin
Short acting, human recombinant insulin; effect lasts 6-8 hours
Not used in outpatient management of diabetes; given as IV infusion to treat DKA inpatient
Rapid-acting insulin analogs
Humalog, Novolog, Glulisine
Absorbed rapidly by SC injection; effect peaks at 1-1.5 hours and lasts 3-5 hours; administered immediately before meals for control of post-prandial hyperglycemia
Can be administered in the same syringe as NPH insulin for combination basal/bolus therapy; can be used with insulin infusion devices
Mixed insulin
Rapid acting insulin analog + NPH; can be used as combination basal-bolus therapy, often injected 2x/day before breakfast and dinner; comes in several preparations:
75% NPH / 25% Humalog
70% NPH / 30% Humalog
50% NPH / 50% Humalog
What formula estimates a starting dose for basal insulin?
0.2 units / kg / day
How is the correction factor calculated?
1600 / total daily dose of insulin
This gives the amount (g/dL) that blood glucose should decrease in response to 1 unit of insulin; individuals with greater insulin insensitivity will have a lower correction factor
What is the Dawn phenomenon?
Early morning hyperglycemia in response to surging growth hormone and/or cortisol
Indications for insulin therapy in type 2 DM
Signs of severe insulin deficiency: fasting glucose > 250, random glucose > 300, A1c > 10%, weight loss
Hospitalization for hyperglycemic hyperosmolar state, or diabetic ketoacidosis
Patients should be maintained on insulin for several months outpatient; may be tapered and switched to non-insulin therapy eventually
