Diabetes: Lecture 2

Question 1

Goal of Diabetes Management?

Answer 1

Reduce morbidity and mortality
Prevent or slow progression of late complications
Keep BG lvl as close to normal as possible
Keep pt free of symptoms of hyper/hypo glycemia
Maximize pt contribution to their health

Question 2

Trialnet.org

Answer 2

ppl with Type 1 diabetes enter this study or have relatives

intent to find how insulin production can be preserved

Question 3

Prediabetes A1c?

Answer 3

Between 5.7% and 6.4%

Question 4

Patients with A1c between 5.5% and 6%…..

Answer 4

increased risk of DM in 5 years between 9-25%

Question 5

Patients with A1c between 6.0% and 6.4%….

Answer 5

Increased risk of DM in 5 years between 25-50%

Question 6

Those with prediabetes should be informed about increased risk for….

Answer 6

DM, CVD and how to reduce risk

Question 7

Treatments for Prediabetes?

Answer 7

Metformin = 31% reduction in risk after 3 years
Diet and Exercise change = 57% reduction risk after 3 years

Method for that group was weight loss of 7% and 30min/day exercise. Low fat/high fiber diet

Question 8

Good points Metformin Pre-DM?

Answer 8

strong evidence

Demonstrated long-term safety

as effective as lifestyle with DMI > 35

Women with History of GDM, metformin + lifestyle reduced risk to 50%

Question 9

Bad points Metformin Pre-DM?

Answer 9

less effective than lifestyle changes

not better than placebo of those 60+

Question 10

Big diabetes study?

Answer 10

DPP

Question 11

Overall, only med considered for pre-DM?

Answer 11

Metformin, shown to be best for variety of reasons

Question 12

ADA pre-DM recommendations

Answer 12

Screen yearly
Treat other CVD risk factors
DPP = lifestyle modification…Weight loss/Physical activity

Metformin considered those at high risk

Question 13

ADA risk factors to be considered high risk?

Answer 13

A1c of pre-DM
DMI >35
60yr old +
Women w/ H/o GDM

Question 14

Foods that don’t raise blood glucose?

Answer 14

Fats and proteins

Carbs = raise BG

Question 15

Lifestyle changes with Type 1?

Answer 15

Carb count to determine insulin dose, meal planning with insulin timing

eat at consistent times, synchronized with insulin

Question 16

Lifestyle changes in Type 2?

Answer 16

Moderate weight loss = 7%
Moderate caloric restriction
Pay attention to carbs
Increase fiber
Reduce salt

Question 17

Carb info

Answer 17

1 serving = 15 grams

Limit to 3(W)-4(M) servings of Carb per meal or 1-2 serving per snack

Question 18

Perfect plate method

Answer 18

1/2 = Veggies
1/4 = carbs
1/4 = protein

If still hungry, go back for veggies/protein

Question 19

Quick Nutrition counseling diabetes?

Answer 19

No sugar sweetened beverages
No juice 
Severly limit deserts
Cheat less often
Plan meals

Question 20

Physical Activity Recommendation

Answer 20

Children w/DM or Pre-DM = 60min/day
Adults = 150min/week

• all adults, esp those with DM, decrease sedentary behavior*

Question 21

Drug Therapy Type 1

Answer 21

Insulin = mandatory

Oral agents and GLP-1 RA injectables no indicated

Question 22

Pramlintide (Symlin) info

Answer 22

indicated for Type 1

Not often used, injected at every meal but not very effective in glucose lowering.
V expensive ~$2500 month

Question 23

Biguanide

Answer 23

Metformin

Question 24

SGLT2 inhibitors

Answer 24

Canagliflozin (Invokana)
Dapagliflozin (Farxiga)
Empagliflozin (Jardiance)

Question 25

GLP-1RA

Answer 25

``` Exenatide* (Byetta and Bydureon) Liraglutide*(Victoza) Dulaglutide* (Trulicity) Lixisenatide (Adlyxin) Semaglutide* (Ozempic (SC) and Rybelsus (PO)) ```

Question 26

Sulfonylureas | insulin secretagogues

Answer 26

Glyburide* (Diabeta, Glynase) | Glipizide* (Glucotrol)

Question 27

Non-SU Secretagogues

Answer 27

Repaglinide* (Prandin)

Question 28

DPP4 inhibitors

Answer 28

Sitagliptin* (Januvia) Saxagliptan* (Onglyza) Linagliptin* (Tradjenta)

Question 29

TZDs *Thiazolidinediones

Answer 29

Pioglitazone (Actos)

Question 30

General 1st line therapy for Type 2 DM?

Answer 30

generally includes metformin and comprehensive lifestyle modifications *Depends on comorbidities, pt centered treatment factors*

Question 31

Type 2 DM w/ ASCVD

Answer 31

GLP and/or SGLT2i

Question 32

Type 2 DM w/ HF

Answer 32

SGLT2i

Question 33

Type 2 DM w/ CKD

Answer 33

Elevated UACR = SGLT2i preferred or GLP | No elevated UACR = GLP and/or SGLT2i

Question 34

Metformin MOA

Answer 34

Inhibits Hepatic Glucose Production *Major efect îs decrease hepatic glucose output, lowering fasting BG levels* Also increases insulin sensitive and better uptake in the muscle

Question 35

Miscellaneous Metformin info

Answer 35

``` Multiple generic Comes in combo w/ a bunch of stuff Pills are big IR and ER formulations *Generally add agents too, not replace with BG uncontrolled* ```

Question 36

Metformin Efficacy

Answer 36

Reduce A1c ~1%, - 1.5% reduced risk of micro/macrovascular complications Decrease weight *Dose not cause hypoglycemia as monotherapy*

Question 37

UKPDS

Answer 37

landmark trial used to establish goals

Question 38

Metformin Adverse Effect

Answer 38

GI = diarrhea,cramping,bloating (start low dose taper up, take w/ food, switch to ER) B12 deficiency Lactic acidosis = V rare

Question 39

When to not use Metformin?

Answer 39

Known Hypersensitivity Alcohol Abuse = LFTs 3x ULN Liver Dysfunction = LFTs 3x ULN Stop for acute serious medical situations that req restrictions, start 2 day after Sig renal disease When undergoing iodinated contrast media

Question 40

Dose adjustment recommendations Metformin

Answer 40

eGFR > 60 = OK eGFR = 45-59 = continue using, reduce dose eGFR = 30-44 = Don't start, can continue reduce 50% eGFR < 30 = Should DC

Question 41

Metformin IR Dosing

Answer 41

BID = due to side effects Usually 1000mg BID Max dose IR = 2550mg/day, stop ~ 2000mg If GI sx not tolerated, go to ER

Question 42

Metformin ER Dosing

Answer 42

can be dosed once daily | max dose is 1500mg/day of the 750mg

Question 43

Metformin Monitoring

Answer 43

Compliance A1c, renal function, B12 check SMBG readings Low blood sugar not expected with monotherapy Don't take on empty stomach, w/ meals GI SE can decrease or go away after few weeks.

Question 44

GLP-1 RA with proven cv benefit

Answer 44

Liraglutide (Victoza) Semaglutide (Ozempic) Dulaglutide (Trulicity)

Question 45

SGLT2i with proven Cv benefit

Answer 45

Empagliflozin (Jardiance) | Canagliflozin (Invokana)