Diabetes - Kania Flashcards
Normal Glucose Homeostasis:
Glucose uptake by ______ is insulin independent
brain
Overall Effects of Insulin:
- Glucose ______
- Glycogen _____
- Fatty acid _____
- Protein ______
removal; storage; storage; synthesis
Overall Effects of Glucagon:
theres 3 of them
increase glycogenolysis & gluconeogenesis
inhibit insulin release
what “counterregulatory hormones” are released in fasting metabolism
- Glucagon
- epinephrine
- cortisol
- growth homrone
what do the “counterregulatory hormones” do in the body
overall increase glucose levels - done by increasing glycogenolysis and gluceneogenesis
Diabetics will have decreased insulin
or insulin resistance can cause:
_______ hepatic glucose output
(anabolism or catabolism)
Lipo (genesis or lysis)
- INCREASED glucose output
- causes catabolism
- lipoLYSIS
Diabetics will have decreased insulin
or insulin resistance –> increased glucose output –> leads to what S/Sx
- the POLYs (polydipsia, polyuria, polyphagia)
- lack of energy
- infections
- blurred vision
Diabetics will have decreased insulin
or insulin resistance –> catabolism –> what 2 things?
wt LOSS and stunted growth
Diabetics will have decreased insulin
or insulin resistance –> lipolysis –> what 3 things?
- more FFA (causes decreased glucose uptake/ will increase hepatic glucose output)
- ketoacidosis
- acidosis
what is the resorptive capacity of the kidney for glucose
~180 mg/dL
Minimum concentration of glucose is ______ which is need for CNS to function
40 - 60 mg/dL
why does weight loss happen when diabetes is uncontrolled?
the glucose calories are lost in the urine; protein and fat stores are broken down
why does fatigue occur with uncontrolled diabetes?
think of the “food coma/post thanksgiving meal tiredness” - diabetics have hyperglycemia postprandial
why increased infections (UTI and RTIs)?
more glucose = more food for bacteria!
What are risk factors for DM
- FH
- Obesity
- Continuous physical inactivity
- Race/Ethnicity
- Hx of IGT, IFG, or A1c (b/w 5.7-6.4%)
- HDL < 35 or TG > 250
- Hx of vascular dx or PCOS
how to be categorized as obese?
20% over IBW
BMI >/= 25 kg/m2
Drug Induced Diabetes:
what drugs increase hepatic glucose output
Glucocorticoids & Sympathomimetics
Drug Induced Diabetes:
what drugs decrease insulin secretion
phenytoin; beta-blockers; Ca2+ channel blockers
Biggest caution with beta-blockers and diabetics
beta blockers can blunt signs of acute hypoglycemia (they cover up tachycardia and BP changes)
Drug Induced Diabetes:
what drugs increase insulin resistance
thiazide diuretics; Niacin (@ high doses); Glucocorticoids
Drug Induced Diabetes:
what drugs are toxic to beta cells
pentamidine
Drug Induced Diabetes:
what drugs stimulate appetite
phenothiazines; marijuana; androgens
Drug Induced Diabetes:
what are some “other” drugs
protease inhibitors (-avir) drugs -HIV drugs
&
antipsychotic drugs
what are some endocrine related disorders that can cause DM
- cushings (more cortisol = more glucose)
- hyperthyroidism
- acromegaly
Dx have increased GH, cortisol, glucagon, epinephrine which all lead to more glucose!
What kind of infections can lead to DM
CMV and Rubella
viruses will destroy beta cells –> less insulin secretion
Genetic Syndromes that can lead to DM
- Down’s syndrome
- Turner’s syndrome
- Huntingtons chorea
- porphyria (build up of RBC chemical..)
what is a NORMAL fasting blood glucose
< 100 mg/dL
what is a NORMAL 2 hr OGTT
< 140 mg/dL
what is a NORMAL A1c?
< 5.7%
what is a NORMAL random glucose
< 200 mg/dL
should not look at A1c for which patients?
pregnant and anemic pts - bc Hgb already messed up…
ADA criteria for Screening for T2DM in asymptomatic/ undiagnosed individuals:
- ALL adults starting at age _____
45 years
ADA criteria for Screening for T2DM in asymptomatic/ undiagnosed individuals:
Test asymptomatic adult of any age if they are ______ and _____
obese/overweight; have 1+ risk factor
ADA criteria for Screening for T2DM in asymptomatic/ undiagnosed individuals: test CHILDREN when... - they are \_\_\_\_\_\_\_\_ AND have \_\_\_\_\_\_ risk factor(s) OR signs of \_\_\_\_\_\_\_\_\_\_\_
Start testing at age ______ OR onset of puberty
overweight; 2; insulin resistance; 10 years
what are signs of insulin resistance
HTN, Dyslipidemia, PCOS
Preventing T2DM:
Weight loss of _____ of body weight
Increase physical activity at least _____ min/week
Initiate Metformin in patients who have what criteria?
Monitor how often?
7%; 150;
Criteria: BMI over 35; less than 60 y.o; women w/ prior GDM
Monitor annually
what are the main components of therapy
the 4 “M”s
Meals, movement, monitoring, medications
General Approach to treating Diabetes:
1- educate pt and family
2 - set realistic goals
3 - make plan
4 - have pt help pick/and come to agreement
Main 3 things of Non-Pharm treatment
Nutrition, Exercise, General health
Nutritional Therapy for Diabetes
- moderate caloric restriction and modest wt loss
- Monitor CARB INTAKE
- limit sugar beverages
- saturated fat limit and NO trans fat/ increase MONOunsaturated fats
- keep cholesterol <300 mg
- Increase whole grains
- alcohol = 2 drinks/day
Long Term Complications of Diabetes:
Microvascular Disease - what can happen
Ocular complications; Diabetic kidney disease; Neuropathy
Long Term Complications of Diabetes:
Macrovascular Disease - what can happen
ASCV, Stroke, Peripheral Vascular Disease (aka numbing)
What are the high intensity statins? (mg strengths too)
Atorvastatin 40 - 80 mg/day
Rosuvastatin 20 - 40 mg/day
What are the moderate intensity statins? (mg strengths too)
Atorvastatin 10 - 20 mg/day Rosuvastatin 5 - 10 mg/day Simvastatin 20 - 40 mg/day Pravastatin 40 - 80 mg/day Pitavastatin 2 - 4 mg/day
______ readings impact the A1C more when A1C is lower
post parandial glucose
the UKPDS study reported that every 1% inA1c = a ___% reduction in risk of CVD events
18%
Types of neuropathy and issues seen with long term diabetic complications
Peripheral neuropathy GI neuropathies Urinary Retention Postural Hypotension Erectile Dysfunction
What are GI neuropathies?
- gastroparesis (delayed emptying)
- Diarrhea/constipation
- Fecal incontience
How to help with GI neuropathies
smaller meals more times per day
FDA approved meds for Peripheral Neuropathy
Pregabalin, Duloxetine, Tapentadol
Other (aka off label) med options for peripheral neuropathy
gabapentin, TCAs, venlafaxine, carbamazepine, tramadol, capsaicin
what 2 BP meds should NEVER be taken together
ACEI and ARB
what are the preferred BP agents for diabetics?
ACEI and ARBs (because help preserve kidney function)
Other meds for BP control in diabetics
HCTZ, amlodipine, chlorthalidone
Peripheral Vascular Disease in Diabetics: Common Symptoms: \_\_\_\_\_\_\_ pain \_\_\_\_\_\_\_ feet \_\_\_\_\_\_ pulses
Leg, Cold, Absent
Criteria to use aspirin in diabetes as PRIMARY PREVENTION
- if pt is at increased CV risk (aka 10 year > 10%)
- Men or Women over 50 and with a major risk factor
Criteria to use aspirin in diabetes as SECONDARY PREVENTION
if pt has CVD/has hx of CVD use it!!! (even if under 50 years old)
when to NOT use aspirin for diabetics
if under 50 and NO major risk factor
if A1C is high, ________ is the majority of the issue, thus should be controlled first
FBG (fasting blood glucose)
Patients are seen as at risk for Diabetes if….
Fasting glucose levels are ________
b/w 100 and 126 mg/dL
Patients are seen as at risk for Diabetes if….
Glucose tolerance test is ________
between 140 and 200
Patients are seen as at risk for Diabetes if….
A1C is _______
between 5.7% and 6.5%
________ is recommended for all T2DM if not contraindicated and if it is tolerated
Metformin!
Metformin’s Efficacy (aka what values will it affect?)
A1C and FBG (very well too!)
Metformin dosing involves ______ adjustment
renal
T or F: Metformin has an increased risk of hypoglycemia
FALSE (its just letting the insulin you already have work better…)
T or F: Metformin can benefit lipids
True!
Metformin: is there an effect on weight?
No weight gain! sometimes loss of weight seen
how does metformin have CV protection
it can increase fibrinolysis (related to blood clotting)
Disadvantages of Metformin:
it may cause ________
lactic acidosis
Metformin Contraindication
Heart failure patients (class 3 and 4)
Alcoholics have an overall increased risk for ______ and thus should avoid what be under caution/monitored when on this drug….
lactic acidosis; metformin
what vitamin deficiency/malabsorption is seen with metformin
Vit. B12
Main side effects and how to help them for Metformin
GI side effects (N/V, diarrhea, flatulence)
titrate dose/take with largest meal
The Vit. B12 deficiency risk from metformin is worrisome in what 2 pt populations
- anemics
- peripheral neuropathy pts
Max dose of metformin
2 g/day
Initial dose of metformin
500 mg PO BID OR 850 mg QD (take w/ meals)
How often/how much to increase metformin
250-500 mg/day once a week
when to use XL metformin
if GI side effects of regular metformin is too wild for the patient
GFR Level and Metformin Recommendation:
GFR is > 60
do metformin like normal and monitor SCr annually
GFR Level and Metformin Recommendation:
GFR b/w 60 and 45
still use metformin! just check SCr q3 -6 mos
GFR Level and Metformin Recommendation:
GFR b/w 45 and 30
do not INITIATE metformin;
if already on metformin - reduce dose by 50%
monitor Scr q3 mos
GFR Level and Metformin Recommendation:
if GFR less than 30
do NOT take metformin (do not start it, must stop if already on it)
What drugs are DPP4 Inhibitors?
the “gliptins”
Januvia, onglyza, tradjenta, Nesina
brand for sitagliptin
januvia
brand for saxagliptin
onglyza
brand for linagliptin
tradjenta
brand for alogliptin
Nesina
T or F: DPP4 inhibitors have a hypoglycemia risk
FALSE! (wont happen because DPP4 inhibitors promote GLP1 which is glucose dependent)
T or F: Metformin will affect PPG
false! (only A1c and FBG)
DPP4 inhibitors Efficacy (aka what values does it affect)
decrease PPG!!!
T or F: all DPP4 inhibitors need renal adjusting
false! 3/4 of them do need renal adjusting! (Linagliptin aka Tradjenta does NOT need adjusting)
ADE’s of DPP4 inhibitors
- Nasopharyngitis
- Upper RTIs
- HA
- Reports of Acute Pancreatitis!
(FDA warnings of HF risk and joint pain)
Metformin renal dosing adjusting we learned is based off GFR or CrCl
GFR
DPP4 inhibitor renal dosing adjusting we learned is based off GFR or CrCl
CrCl
Dosing of Linagliptin
include renal adjustment if needed
5 mg QD
no renal adjusting!! only DPP4 inhibitor that doesn’t need it
Dosing of Sitagliptin
include renal adjustment if needed
CrCl > 50 mL/min = 100 mg QD
CrCl 30 - 50 = 50 mg QD
CrCl < 30 OR ESRD on dialysis = 25 mg QD
Dosing of Saxagliptin
include renal adjustment if needed
2.5 - 5 mg QD
CrCl < 50 = 2.5 mg QD
which DPP4 inhibitor has no increased risk for CV events or HF hospitalizations
sitagliptin
what drugs are SGLT2 inhibitors
the “gliflozins” (remember flo and peeing out glucose…)
- Invokana (canagliflozin)
- Farxiga (Dapagliflozin)
- Jardience (Empagliflozin)
alphabetical — C,D,E…?
Efficacy of SGLT2 inhibitors (aka what values does they affect)
weight loss and PPG!!
T or F: SGLT2 inhibitors do not need renal adjustment
false (super false…. because it works on the kidneys)
Dosing of Canagliflozin
include renal adjustment if needed
CrCl: above 60 : 100 mg QD (300 mg MAX)
CrCl: 45 - 60: 100 mg QD (MAX)
CrCl: < 45: DONT USE Canagliflozin
Dosing of Dapagliflozin
include renal adjustment if needed
CrCl above 60: 5 mg QD (MAX of 10 mg daily)
CrCl below 60: DO NOT USE DRUG
Dosing of Empagliflozin
include renal adjustment if needed
CrCl > 45 mL/min: 10 mg Daily (Max of 25 QD)
If CrCl < 45 mL/min: DO NOT USE DRUG
Sulfonylureas Efficacy (aka what values does it influence)
A1c and FBG (very well - close to metformin)
Glyburidde and Glipizide should be taken before or with meals?
BEFORE! 30 mins before is best - lets pancreas to start working
but make sure to not take med and then not eat!!!
ADE’s of SGLT2 inhibitors
UTIs/gential infections/increased urination
Hypoglycemia, Hypotension, hyperkalemia, increased cholesterol
FDA warnings
SGLT2 inhibitors can cause: \_\_\_\_\_\_glycemia \_\_\_\_\_\_tension \_\_\_\_\_\_kalemia \_\_\_\_\_\_\_cholesteremia
(hypo or hyper)
HYPOgly; HYPOten, HYPERkal, HYPERchol
FDA warnings that came out for SGLT2 inhibitors
DKA risk!!
Bone fractures/decreased BMD
Acue kidney injury
Hematologic ADE’s seen in which antidiabetic drug
Sulfonylureas (apparently this is common in sulfas…..)
Hematologic ADE’s seen in sulfonylureas
leukopenia, thrombocytopenia, aplastic anemia
Sulfonylureas — Increased Risk for Hypoglycemia Seen in what kind of patients?
elderly or pts w/ renal/hepatic disease
pts w/ irregular dietary intake
alcoholics
pts taking other hypoglycemic agents
which drug class is now under investigation to see if the max doses are really necessary/efficacious at higher doses
Sulfonylureas!
T or F: Sulfonylureas are for both Type 1 and Type 2 diabetics
FALSE!!! Type 1 does not have active beta cells - so drug ain’t gonna work for type 1 pts
Max Dose for Glimeperide
8 mg
Max Dose for Glipizide
40 mg
Max Dose for Glipizide XL
20 mg
Max Dose for Glyburide
20 mg
Max Dose for Glyburide Micronized
12 mg
What type of patients are best for Sulfonylureas
- no type 1 patients
- Short duration of diabetes (bc pancrease probably still working)
- FBS < 250 mg/dL
- has high fasting C-peptide level
should a pt use insulin and a sulfonylurea?
No! sulfonylureas help make insulin… if needing insulin - sulfonylureas won’t help when youre not making insulin
