Diabetes lecture 2 Flashcards
List the ominous octet of pathogenesis of type 2 DM
- decreased insulin secretion
- increased glucagon secretion
- increased hepatic glucose production
- neurotransmitter dysfunction
- decreaed glucose uptake
- increased glucose reabsorption
- increased lipolysis
- decreased incretin effect
List the 4 diagnostic criteria for DM
- A1C > or = 6.5
- FBG > or = 126 mg/dL
- 2 hr post prandial glucose > or = 200 mg/dl
- random post prandial glucose > or = 200 mg/dl in those with s/sx of hyperglycemia or hyperglycemia crisis
Education for Diet changes for prediabetic
- improve food choices
- small, evenly spaced meals
- carbohydrate timing/counting
- caloric intake resistriction
Education for exercise changes for prediabetic
- goal > or = 150 min/week
- > or = 3 days/week
- break up 90 min of sitting
- resistance training > or = 2 days/week
- kids > or = 60 min of physical activity daily
Generalized treatment guidlines for type 2 DM
- start with Metformin
- if A1C target unachieved (> 7%) in 3 months, add 2nd agent
- if A1C target unachieved (> 7%) in 3 months, add 3nd agent
- if A1C target unachieved (> 7%) in 3 months, add insulin
What are the 2 types of insulin sensitizers
- Biguanides
- Thiazolidinediones
What medications fall under the Biguanides
Metformin (Glucophage, Glucophage XR)
function of metformin
- slows liver production of glucose
- increases glucose uptake by cells
does metformin cause hypoglycemia
no
side effects of metformin
- GI: bloating, gas
metformin is contraindicated when
- creatinine is > 1.5 in men and > 1.4 in women
- => lactic acidosis
List the Thiazolidinediones
- Pioglitazone
- Rosiglitazone
function of Thiazolidinediones
- alters cell membranes’ responses to insulin, decreasing insulin resistance
- preserves beta cell function of pancreas
- lowers bodys insulin requirements
how long does it take to notice efficacy when taking Thiazolidinediones
3-8 weeks
side effects of Thiazolidinediones
- liver toxicity: check LFTs
- commonly causes weight gain and fluid retention
Thiazolidinediones are contraindicated in
CHF
Pioglitazone has a black box warning for
bladder cancer
What two classes of medications are insulin secretagogues (release insulin via beta cell stimulation)
- sulfonylureas
- meglitinides
List the three sulfonylureas drugs
- Glyburide
- Glimeperide
- Glipizide
function of sulfonylureas
- stimulates insulin secretion by binding to B-cell receptors
- increases sensitivity to glucose and thus releases insulin
side effects of sulfonylureas
- hypoglycemia: take with food
- weight gain
- CKD concerns: decrease dose with Glimiperide and Glyburide; glipizide is most kidney friendly
List the Meglitinides
- Repaglinide
- Nateglinide
function of Meglitinides
- glucose dependent-stimulates insulin release from pancreatic B cells
when should Meglitinides be taken
30 minutes before a meal
which Meglitinides is best to use with CKD
Repaglinide
side effects of Meglitinides
hypoglycemia: take with food
List the alpha-Glucosidase inhibitors
- Arcabose
- Miglitol
Function of alpha-Glucosidase inhibitors
- “carb/starch blockers”
- DELAYS absorption, does not prevent it
- helps to control post-prandial hyperglycemia
when should alpha-Glucosidase inhibitors be taken
take before meals
side effects of alpha-Glucosidase inhibitors
gas, bloating
contraindications to taking alpha-Glucosidase inhibitors
- avoid if serum creatinine > 2 mg/dL
List the 2 Incretin hormones
- GLP-1: glucagon like peptide
- Glucose-dependent insulinotropic polypeptide
function of GLP-1: glucagon like peptide
- chemically looks like glucagon, acts like insulin
- pancreas: stimulates B cells to secrete insulin
- brain: decreases appetite
- gut: delays gastric emptying
- liver/muscle: decreased glucose production
- heart: increases CO
where are incretin hormones synthesized? when are they synthesized?
in the gut
- with food intake, they are released, bind to B-cell receptors, and promote insulin secretion
List the GLP-1s: glucagon-like peptide receptor agonists (injectables)
- Exenatide
- Liraglutide
- Albiglutide
- Dulaglutide
which GLP-1s: glucagon-like peptide receptor agonists (injectables) are taken as daily doses
- Exenatide
- Liraglutide
List the DPP-4 inhibitors
- Sitagliptin
- Saxagliptin
- Linagliptin
- Alogliptin
- Vidalgliptan
function of GLP-1s: glucagon-like peptide receptor agonists (injectables)
- pancreatic B cells will release insulin ONLY with elevated blood sugars
- suppress glucagon release and hepatic glucose production
- early satiety
- slow gastric emptying
side effects of GLP-1s: glucagon-like peptide receptor agonists (injectables)
- weight loss
- Nausea: taper dose
- pancreatitis
- thyroid medullary cancer
- caution with renal insufficiency (GFR must be > 30ml/min)
function of DPP-4 inhibitors
- DPP-4 enzyme inactivates endogenous GLP-1, so inhibitors prevent degradation
- decrease liver glucose production
- increase glucose uptake in the tissues
List the “Glucoretics:” SGLT2 inhibitors
- Canagliflozin
- Dapagliflozin
- Empagliflozin
function of SGLT2 inhibitors
- inhibit SGLT2 that reduces reabsorption of glucose in the kidney
- increases urinary excretion of glucose
- pee out excess sugar: low hypoglycemia rates
- weight loss
side effects of SGLT2 inhibitors
- yeast infections, UTI
- renal clearance
glycemic targets for nonpregnant adults with DM: want peak postprandial capillary PG to be
- < 180 mg/dL
- post-prandial glucose measurements should be made 1-2 hrs after the beginning of the meal
List the 4 categories of insulin
- basal/long acting insulin
- Intermediate acting insulin
- short acting insulin
- meal time/rapid acting insulin
for the rapid-acting insulin, what is
- time of onset
- peak
- effective duration
- onset: < 15 min
- peak: 30-90 min
- effective duration: 3 hr
for the regular insulin, what is
- time of onset
- peak
- effective duration
- time of onset: 30 min-1 hr
- peak: 2-3 hr
- effective duration: 3-6 hr
for the NPH insulin, what is
- time of onset
- peak
- effective duration
- time of onset: 2-4 hr
- peak: 7-8 hr
- effective duration : 10-12 hr
for the long-acting insulin, what is
- time of onset
- peak
- effective duration
- time of onset: 1-2 hr
- peak: flat/predictable
- effective duration: 24 hr
List the basal: long acting insulin
- Glargine
- Detemir
- Degludec: in the system longer than 24 hrs
how should be basal: long acting insulin be taken? What is the typical starting dose? What is FBS goal?
- 1x daily bolus of insulin
- start with 10-20 units
- goal: FBS 80-130
- adjust night-time dose based on morning sugars
List the rapid-acting insulins
- Aspart
- Glulisine
- Lispro
How should rapid-acting insulins be taken
- take 5-15 minutes prior to meal
- take with food
- take up to 3x daily
- risk of hypoglycemia; adjust based on post-prandial sugars
List the 3 pre-mixed insulins
- Humulin 70/30 (NPH/regular)
- Humulin 50/50 (NPH/regular)
- Humalog mix (75/25) (intermediate and rapid Lispro)
What is the intermediate acting insulin
NPH (Humulin)
when should the mixed regular and NPH insulin be taken
- 2/3 daily dose 15 min pre-breakfast
- 1/3 daily dose 15 min pre-dinner
Treatment for type 1 DM
- total dialy insulin 0.5 unites x weight (kg)
- split total dose between basal and meal-time insulin 50:50
- basal: 50% single dose of long acting OR BID of NPH
- meal time: 50% divided by 3 and given at each meal
- ex: 30 u total: give 15 u at bed time (or 7 u BID) and 5 u before each meal
blood sugar logs should have
- pre and post prandial readings
- start with fasting sugars
- random 2 hr post prandial sugars
How does Diabetic ketoacidosis occur
- body burns fat for fuel without sugar
- lack of insulin keeps sugars in bloodstream
- waste of fat catabolism = keytones
- keytones build in blood stream and spill into urine
signs and symptoms of diabetic ketoacidosis
- N/V
- hyperventilation (kussmaul)
- hypotension, shock, dehydration
- increased anion gap
- polyuria, polydipsia, polyphagia
labs are consistent with
- positie urine keytones
- elevated surgars in urine
- hyperglycemia
- low serum CO2
- positive serum keytones
diabetic ketoacidosis
tx of diabetic ketoacidosis
- isotonic saline
- slowly give potassium and phosphate
- IV bicarbonate (reverse acidosis)
- insulin (control sugars)
What is Nonketotic hyperosmolar syndrome? signs and symptoms
- follows severe stress and decrease renal excretion of sugar
- typically in type 2 DM
- severely high BS (>500mg); dehydration, no serum keytones
tx of Nonketotic hyperosmolar syndrome
- fluid/electrolyte replacement
- IV insulin
Hypoglycemia is life threatening. Symptoms can develop from what two systems
-
neurologic (low CNS glucose)
- dizziness, HA
- clouded vision
- sz, coma
-
Adrenergic (adrenaline release)
- sweating, shaking
- tachycardia
- anxiety
- hunger
tx for unconscious patient with hypoglycemia
-
glucagon 1 mg IM/SQ
- vomiting possible side effect
-
IV dextrose (20-50 ml D50W)
- continue to continuous infusion to keep sugars > 100 mg/dl
morning hyperglycemia can be caused by what 3 things
- waning of insulin action
- dawn phenomenon: GH secretion between 3-7 am increases blood sugars
-
Somogyi phenomenon : rebound hyperglycemia secondary to nocturnal hypglycemia
- tx: reduce dinner or QHS insulin dose or take snack before bed
blood pressure goals in DM
- < or = 140/90
- if higher, start on ACE-I or ARB
Lipid goals with DM
- LDL < 100 mg/dl
- TGs <150
- HDL > 40
labs to check at least every 6 months in a DM patient
- A1C
- UA with microalbumin
- CMP with GFR
- Lipid Panel
