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Therapeutics 2 Kappa Epsilon > Diabetes - Kania > Flashcards

Diabetes - Kania Flashcards

1
Q

Normal Glucose Homeostasis:

Glucose uptake by ______ is insulin independent

A

brain

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2
Q

Overall Effects of Insulin:

  • Glucose ______
  • Glycogen _____
  • Fatty acid _____
  • Protein ______
A

removal; storage; storage; synthesis

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3
Q

Overall Effects of Glucagon:

theres 3 of them

A

increase glycogenolysis & gluconeogenesis

inhibit insulin release

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4
Q

what “counterregulatory hormones” are released in fasting metabolism

A
  • Glucagon
  • epinephrine
  • cortisol
  • growth homrone
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5
Q

what do the “counterregulatory hormones” do in the body

A

overall increase glucose levels - done by increasing glycogenolysis and gluceneogenesis

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6
Q

Diabetics will have decreased insulin
or insulin resistance can cause:

_______ hepatic glucose output
(anabolism or catabolism)
Lipo (genesis or lysis)

A
  • INCREASED glucose output
  • causes catabolism
  • lipoLYSIS
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7
Q

Diabetics will have decreased insulin

or insulin resistance –> increased glucose output –> leads to what S/Sx

A
  • the POLYs (polydipsia, polyuria, polyphagia)
  • lack of energy
  • infections
  • blurred vision
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8
Q

Diabetics will have decreased insulin

or insulin resistance –> catabolism –> what 2 things?

A

wt LOSS and stunted growth

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9
Q

Diabetics will have decreased insulin

or insulin resistance –> lipolysis –> what 3 things?

A
  • more FFA (causes decreased glucose uptake/ will increase hepatic glucose output)
  • ketoacidosis
  • acidosis
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10
Q

what is the resorptive capacity of the kidney for glucose

A

~180 mg/dL

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11
Q

Minimum concentration of glucose is ______ which is need for CNS to function

A

40 - 60 mg/dL

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12
Q

why does weight loss happen when diabetes is uncontrolled?

A

the glucose calories are lost in the urine; protein and fat stores are broken down

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13
Q

why does fatigue occur with uncontrolled diabetes?

A

think of the “food coma/post thanksgiving meal tiredness” - diabetics have hyperglycemia postprandial

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14
Q

why increased infections (UTI and RTIs)?

A

more glucose = more food for bacteria!

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15
Q

What are risk factors for DM

A
  • 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
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16
Q

how to be categorized as obese?

A

20% over IBW

BMI >/= 25 kg/m2

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17
Q

Drug Induced Diabetes:

what drugs increase hepatic glucose output

A

Glucocorticoids & Sympathomimetics

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18
Q

Drug Induced Diabetes:

what drugs decrease insulin secretion

A

phenytoin; beta-blockers; Ca2+ channel blockers

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19
Q

Biggest caution with beta-blockers and diabetics

A

beta blockers can blunt signs of acute hypoglycemia (they cover up tachycardia and BP changes)

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20
Q

Drug Induced Diabetes:

what drugs increase insulin resistance

A

thiazide diuretics; Niacin (@ high doses); Glucocorticoids

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21
Q

Drug Induced Diabetes:

what drugs are toxic to beta cells

A

pentamidine

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22
Q

Drug Induced Diabetes:

what drugs stimulate appetite

A

phenothiazines; marijuana; androgens

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23
Q

Drug Induced Diabetes:

what are some “other” drugs

A

protease inhibitors (-avir) drugs -HIV drugs
&
antipsychotic drugs

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24
Q

what are some endocrine related disorders that can cause DM

A
  • cushings (more cortisol = more glucose)
  • hyperthyroidism
  • acromegaly

Dx have increased GH, cortisol, glucagon, epinephrine which all lead to more glucose!

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25
Q

What kind of infections can lead to DM

A

CMV and Rubella

viruses will destroy beta cells –> less insulin secretion

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26
Q

Genetic Syndromes that can lead to DM

A
  • Down’s syndrome
  • Turner’s syndrome
  • Huntingtons chorea
  • porphyria (build up of RBC chemical..)
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27
Q

what is a NORMAL fasting blood glucose

A

< 100 mg/dL

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28
Q

what is a NORMAL 2 hr OGTT

A

< 140 mg/dL

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29
Q

what is a NORMAL A1c?

A

< 5.7%

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30
Q

what is a NORMAL random glucose

A

< 200 mg/dL

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31
Q

should not look at A1c for which patients?

A

pregnant and anemic pts - bc Hgb already messed up…

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32
Q

ADA criteria for Screening for T2DM in asymptomatic/ undiagnosed individuals:

  • ALL adults starting at age _____
A

45 years

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33
Q

ADA criteria for Screening for T2DM in asymptomatic/ undiagnosed individuals:
Test asymptomatic adult of any age if they are ______ and _____

A

obese/overweight; have 1+ risk factor

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34
Q 
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

A

overweight; 2; insulin resistance; 10 years

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35
Q

what are signs of insulin resistance

A

HTN, Dyslipidemia, PCOS

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36
Q

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?

A

7%; 150;
Criteria: BMI over 35; less than 60 y.o; women w/ prior GDM
Monitor annually

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37
Q

what are the main components of therapy

A

the 4 “M”s

Meals, movement, monitoring, medications

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38
Q

General Approach to treating Diabetes:

A

1- educate pt and family
2 - set realistic goals
3 - make plan
4 - have pt help pick/and come to agreement

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39
Q

Main 3 things of Non-Pharm treatment

A

Nutrition, Exercise, General health

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40
Q

Nutritional Therapy for Diabetes

A
  • 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
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41
Q

Long Term Complications of Diabetes:

Microvascular Disease - what can happen

A

Ocular complications; Diabetic kidney disease; Neuropathy

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42
Q

Long Term Complications of Diabetes:

Macrovascular Disease - what can happen

A

ASCV, Stroke, Peripheral Vascular Disease (aka numbing)

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43
Q

What are the high intensity statins? (mg strengths too)

A

Atorvastatin 40 - 80 mg/day

Rosuvastatin 20 - 40 mg/day

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44
Q

What are the moderate intensity statins? (mg strengths too)

A 
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
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45
Q

______ readings impact the A1C more when A1C is lower

A

post parandial glucose

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46
Q

the UKPDS study reported that every 1% inA1c = a ___% reduction in risk of CVD events

A

18%

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47
Q

Types of neuropathy and issues seen with long term diabetic complications

A 
Peripheral neuropathy
GI neuropathies
Urinary Retention
Postural Hypotension
Erectile Dysfunction
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48
Q

What are GI neuropathies?

A
  • gastroparesis (delayed emptying)
  • Diarrhea/constipation
  • Fecal incontience
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49
Q

How to help with GI neuropathies

A

smaller meals more times per day

50
Q

FDA approved meds for Peripheral Neuropathy

A

Pregabalin, Duloxetine, Tapentadol

51
Q

Other (aka off label) med options for peripheral neuropathy

A

gabapentin, TCAs, venlafaxine, carbamazepine, tramadol, capsaicin

52
Q

what 2 BP meds should NEVER be taken together

A

ACEI and ARB

53
Q

what are the preferred BP agents for diabetics?

A

ACEI and ARBs (because help preserve kidney function)

54
Q

Other meds for BP control in diabetics

A

HCTZ, amlodipine, chlorthalidone

55
Q 
Peripheral Vascular Disease in Diabetics:
Common Symptoms:
\_\_\_\_\_\_\_ pain
\_\_\_\_\_\_\_ feet
\_\_\_\_\_\_ pulses
A

Leg, Cold, Absent

56
Q

Criteria to use aspirin in diabetes as PRIMARY PREVENTION

A
  • if pt is at increased CV risk (aka 10 year > 10%)

- Men or Women over 50 and with a major risk factor

57
Q

Criteria to use aspirin in diabetes as SECONDARY PREVENTION

A

if pt has CVD/has hx of CVD use it!!! (even if under 50 years old)

58
Q

when to NOT use aspirin for diabetics

A

if under 50 and NO major risk factor

59
Q

if A1C is high, ________ is the majority of the issue, thus should be controlled first

A

FBG (fasting blood glucose)

60
Q

Patients are seen as at risk for Diabetes if….

Fasting glucose levels are ________

A

b/w 100 and 126 mg/dL

61
Q

Patients are seen as at risk for Diabetes if….

Glucose tolerance test is ________

A

between 140 and 200

62
Q

Patients are seen as at risk for Diabetes if….

A1C is _______

A

between 5.7% and 6.5%

63
Q

________ is recommended for all T2DM if not contraindicated and if it is tolerated

A

Metformin!

64
Q

Metformin’s Efficacy (aka what values will it affect?)

A

A1C and FBG (very well too!)

65
Q

Metformin dosing involves ______ adjustment

A

renal

66
Q

T or F: Metformin has an increased risk of hypoglycemia

A

FALSE (its just letting the insulin you already have work better…)

67
Q

T or F: Metformin can benefit lipids

A

True!

68
Q

Metformin: is there an effect on weight?

A

No weight gain! sometimes loss of weight seen

69
Q

how does metformin have CV protection

A

it can increase fibrinolysis (related to blood clotting)

70
Q

Disadvantages of Metformin:

it may cause ________

A

lactic acidosis

71
Q

Metformin Contraindication

A

Heart failure patients (class 3 and 4)

72
Q

Alcoholics have an overall increased risk for ______ and thus should avoid what be under caution/monitored when on this drug….

A

lactic acidosis; metformin

73
Q

what vitamin deficiency/malabsorption is seen with metformin

A

Vit. B12

74
Q

Main side effects and how to help them for Metformin

A

GI side effects (N/V, diarrhea, flatulence)

titrate dose/take with largest meal

75
Q

The Vit. B12 deficiency risk from metformin is worrisome in what 2 pt populations

A
  • anemics

- peripheral neuropathy pts

76
Q

Max dose of metformin

A

2 g/day

77
Q

Initial dose of metformin

A

500 mg PO BID OR 850 mg QD (take w/ meals)

78
Q

How often/how much to increase metformin

A

250-500 mg/day once a week

79
Q

when to use XL metformin

A

if GI side effects of regular metformin is too wild for the patient

80
Q

GFR Level and Metformin Recommendation:

GFR is > 60

A

do metformin like normal and monitor SCr annually

81
Q

GFR Level and Metformin Recommendation:

GFR b/w 60 and 45

A

still use metformin! just check SCr q3 -6 mos

82
Q

GFR Level and Metformin Recommendation:

GFR b/w 45 and 30

A

do not INITIATE metformin;
if already on metformin - reduce dose by 50%
monitor Scr q3 mos

83
Q

GFR Level and Metformin Recommendation:

if GFR less than 30

A

do NOT take metformin (do not start it, must stop if already on it)

84
Q

What drugs are DPP4 Inhibitors?

A

the “gliptins”

Januvia, onglyza, tradjenta, Nesina

85
Q

brand for sitagliptin

A

januvia

86
Q

brand for saxagliptin

A

onglyza

87
Q

brand for linagliptin

A

tradjenta

88
Q

brand for alogliptin

A

Nesina

89
Q

T or F: DPP4 inhibitors have a hypoglycemia risk

A

FALSE! (wont happen because DPP4 inhibitors promote GLP1 which is glucose dependent)

90
Q

T or F: Metformin will affect PPG

A

false! (only A1c and FBG)

91
Q

DPP4 inhibitors Efficacy (aka what values does it affect)

A

decrease PPG!!!

92
Q

T or F: all DPP4 inhibitors need renal adjusting

A

false! 3/4 of them do need renal adjusting! (Linagliptin aka Tradjenta does NOT need adjusting)

93
Q

ADE’s of DPP4 inhibitors

A
  • Nasopharyngitis
  • Upper RTIs
  • HA
  • Reports of Acute Pancreatitis!
    (FDA warnings of HF risk and joint pain)
94
Q

Metformin renal dosing adjusting we learned is based off GFR or CrCl

A

GFR

95
Q

DPP4 inhibitor renal dosing adjusting we learned is based off GFR or CrCl

A

CrCl

96
Q

Dosing of Linagliptin

include renal adjustment if needed

A

5 mg QD

no renal adjusting!! only DPP4 inhibitor that doesn’t need it

97
Q

Dosing of Sitagliptin

include renal adjustment if needed

A

CrCl > 50 mL/min = 100 mg QD
CrCl 30 - 50 = 50 mg QD
CrCl < 30 OR ESRD on dialysis = 25 mg QD

98
Q

Dosing of Saxagliptin

include renal adjustment if needed

A

2.5 - 5 mg QD

CrCl < 50 = 2.5 mg QD

99
Q

which DPP4 inhibitor has no increased risk for CV events or HF hospitalizations

A

sitagliptin

100
Q

what drugs are SGLT2 inhibitors

A

the “gliflozins” (remember flo and peeing out glucose…)

  • Invokana (canagliflozin)
  • Farxiga (Dapagliflozin)
  • Jardience (Empagliflozin)

alphabetical — C,D,E…?

101
Q

Efficacy of SGLT2 inhibitors (aka what values does they affect)

A

weight loss and PPG!!

102
Q

T or F: SGLT2 inhibitors do not need renal adjustment

A

false (super false…. because it works on the kidneys)

103
Q

Dosing of Canagliflozin

include renal adjustment if needed

A

CrCl: above 60 : 100 mg QD (300 mg MAX)

CrCl: 45 - 60: 100 mg QD (MAX)

CrCl: < 45: DONT USE Canagliflozin

104
Q

Dosing of Dapagliflozin

include renal adjustment if needed

A

CrCl above 60: 5 mg QD (MAX of 10 mg daily)

CrCl below 60: DO NOT USE DRUG

105
Q

Dosing of Empagliflozin

include renal adjustment if needed

A

CrCl > 45 mL/min: 10 mg Daily (Max of 25 QD)

If CrCl < 45 mL/min: DO NOT USE DRUG

106
Q

Sulfonylureas Efficacy (aka what values does it influence)

A

A1c and FBG (very well - close to metformin)

107
Q

Glyburidde and Glipizide should be taken before or with meals?

A

BEFORE! 30 mins before is best - lets pancreas to start working

but make sure to not take med and then not eat!!!

108
Q

ADE’s of SGLT2 inhibitors

A

UTIs/gential infections/increased urination

Hypoglycemia, Hypotension, hyperkalemia, increased cholesterol

FDA warnings

109
Q 
SGLT2 inhibitors can cause:
\_\_\_\_\_\_glycemia
\_\_\_\_\_\_tension
\_\_\_\_\_\_kalemia
\_\_\_\_\_\_\_cholesteremia

(hypo or hyper)

A

HYPOgly; HYPOten, HYPERkal, HYPERchol

110
Q

FDA warnings that came out for SGLT2 inhibitors

A

DKA risk!!
Bone fractures/decreased BMD
Acue kidney injury

111
Q

Hematologic ADE’s seen in which antidiabetic drug

A

Sulfonylureas (apparently this is common in sulfas…..)

112
Q

Hematologic ADE’s seen in sulfonylureas

A

leukopenia, thrombocytopenia, aplastic anemia

113
Q

Sulfonylureas — Increased Risk for Hypoglycemia Seen in what kind of patients?

A

elderly or pts w/ renal/hepatic disease
pts w/ irregular dietary intake
alcoholics
pts taking other hypoglycemic agents

114
Q

which drug class is now under investigation to see if the max doses are really necessary/efficacious at higher doses

A

Sulfonylureas!

115
Q

T or F: Sulfonylureas are for both Type 1 and Type 2 diabetics

A

FALSE!!! Type 1 does not have active beta cells - so drug ain’t gonna work for type 1 pts

116
Q

Max Dose for Glimeperide

A

8 mg

117
Q

Max Dose for Glipizide

A

40 mg

118
Q

Max Dose for Glipizide XL

A

20 mg

119
Q

Max Dose for Glyburide

A

20 mg

120
Q

Max Dose for Glyburide Micronized

A

12 mg

121
Q

What type of patients are best for Sulfonylureas

A
  • no type 1 patients
  • Short duration of diabetes (bc pancrease probably still working)
  • FBS < 250 mg/dL
  • has high fasting C-peptide level
122
Q

should a pt use insulin and a sulfonylurea?

A

No! sulfonylureas help make insulin… if needing insulin - sulfonylureas won’t help when youre not making insulin

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