Diabetes Mellitus 1 and 2 Flashcards
Type 1 diabetes means; type 2 diabetes means; another common form of diabetes:
beta-cell destruction (autoimmune usually); progressive insulin secretory defect;
gestational diabetes mellitus (during pregnancy you have increased insulin resistance)
A couple techniques allowing for health providers and patients to assess effectiveness of management plan on glycemic control:
- patient self-monitoring of blood glucose (SMBG)
2. continuous glucose monitoring systems (CGMS)
After a meal, what happens with insulin and glucagon in diabetics?
Insulin is lower than usual, glucagon is higher
Incretin hormones:
- synthesized in the L cells, primarily the ileum and colon
- produced in response to incoming nutrients (orally more so than IV)
- stimulate insulin secretion
Most important is GLP-1!!!!
GLP-1 actions:
- enhances glucose-dependent insulin secretion
- slows gastric emptying
- suppresses glucagon secretion
- promotes satiety
- receptors in the islet cells, CNS, elsewhere
- metabolized rapidly by DPP-4
(DR SIGG)
GLP-1 release is
reduced in type 2 diabetes
At the time of type 2 diabetes diagnosis, initiate
metformin therapy along with lifestyle interventions, unless metformin is contraindicated; if type 2 diabetes has symptomatic and/or elevated blood glucose levels or A1C, consider insulin therapy, with or without additional agents
If noninsulin monotherapy at max tolerated dose not achieving or maintaining A1c target over 3 months
add second oral agent, GLP-1 receptor agonist, or insulin
Metformin (Glucophage)
Class: Biguanide
Mech: Activates hepatic AMP-kinase and inhibits mito isoform of glycerophosphate dehydrogenase; decreases hepatic glucose production
Thera: First-line therapy in diabetes due to no weight gain or hypoglycemia, reduction in cardiovascular events and mortality; maybe less cancer
Important SE’s: Lactic acidosis (rare)
Other SE’s: GI (diarrhea, abdominal discomfort, N & V), B12 deficiency
Misc: Contraindicated in renal impairment; cheap
Glipizide (Glucotrol)
Glyburide (Micronase)
Glimepiride (Amaryl)
Gliclazide (Diamicron)
Class: Sulfonylurea
Mech: Closure of ATP-sensitive K+ channels on β-cell plasma membrane –> stimulation of insulin release
Thera: Reduction in cardiovascular events and mortality
Important SE’s: Weight gain; hypoglycemia; could blunt myocardial ischemic preconditioning
Misc: Cheap
Repaglinide (Prandin); Nateglinide (Starlix)
Class: Meglitinide
Mech: Closure of ATP-sensitive K+ channels on β-cell plasma membrane –> stimulation of insulin release
Thera: Used with meals (short-acting)
Important SE’s: Weight gain; hypoglycemia (less than sulfonylureas); could blunt myo ischemic preconditioning, dosing frequency
Misc: Short acting;
Pioglitazone (Actos)
Class: Thiazolidinedione
Mech: Binds PPAR-γ, a nuclear transcription factor; increases peripheral insulin sensitivity
Thera: No hypoglycemia; increase HDL cholesterol while decreasing triglycerides; maybe reduction in MI’s
Important SE’s: Weight gain; edema; heart failure; bone fractures;
Other SE’s: Increased risk of bladder cancer
Misc: generics available
Rosiglitazone (Avandia)
Class: Thiazolidinedione
Mech: Binds PPAR-γ, a nuclear transcription factor; increases peripheral insulin sensitivity
Thera: No hypoglycemia
Important SE’s: Weight gain; edema; heart failure; bone fractures; increased cardiovascular events, LDL cholesterol goes up
Misc: Expensive; contraindicated in heart disease
Acarbose (Precose); Miglitol (Glyset)
Class: α-glucosidase inhibitor
Mech: Competitively inhibit enzymes that break down carbohydrates into simple sugars, delaying GI carbohydrate absorption & reduces postprandial glucose levels
Thera: Nonsystemic medication that decreases postprandial glucose; weight neutral and no hypoglycemia
Important SE’s: GI (gas, flatulence, diarrhea), dosing frequency, modest reduction in A1c
Misc: Taken with each carbohydrate containing meal
Exenatide (Byetta); Liraglutide (Victoza); Albiglutide, dulaglutide
Class: GLP-1 receptor agonist
Mech: Activates GLP-1 receptor in β-cells, endocrine pancreas, and brain; increases insulin secretion and decreases glucagon secretion in a glucose-dependent fashion; slows gastric emptying, increases satiety
Thera: Leads to weight reduction; may improve β-cell mass
Important SE’s: Acute pancreatitis; GI (nausea, vomiting, diarrhea)
SE’s: hypoglycemia (less than sulfonylureas; caution with renal insufficiency
Misc: Injection only; expensive
Sitagliptin (Januvia); Vildagliptin (Galvus); Saxagliptin (Onglyza); Linagliptin (Tradjenta)
Class: DPP-4 inhibitor
Mech: Inhibition of GLP-1 metabolism, increasing GIP and GLP-1 concentration; increases insulin and glucagon secretion
Thera: No hypoglycemia, weight neutrality
Important SE’s: Urticaria/angioedema; pancreatitis
Misc: Expensive
Canagliflozin (Invokana)
Class: SGLT2 inhibitor
Mech: Redfuces glucose resorption in the kidney; increases urinary glucose excretion
Thera: No hypoglycemia; weight loss possible
Important SE’s: UTIs; genital mycotic infections; volume depletion; hyperkalemia; hypersensitivity; increased LDL chol
Misc: Expensive
Colesevelam (Welchol)
Class: Bile acid sequestrant
Mech: Binds bile acids/cholesterol, and decreses hepatic glucose production
Thera: No hypoglycemia; decreased LDL cholesterol
Important SE’s: Increase in triglycerides
Other SE’s: Constipation; may interfere with absorption of other medications, modest A1c reduction
Most common consequence with sulfonylurea and insulin traetment; who will it more likely happen to? What increases risk?
Hypoglycemia;
type 1 more than type 2;
think over 60, impaired renal function, poor nutrition, liver disease, increased physical activity, longer duration of diabetes
Symptoms of hypoglycemia:
- confusion, slurred speech, dizzy
- shaking, nervousness, sweating, palpitations
- extreme hunger
- tingling of hands, tongue, lips
- vision change, poor coordination
- unresponsiveness, unconsciousness or seizures
Glucagon emergency kit given only when
pt unconscious or unable to swallow; type 1 should always have a prescription, while the type 2 had previously severe low blood sugar
Severe hypoglycemia in the hospital requires
use of IV DEXTROSE!!!
Many patients with diabetes will need
multiple therapies to attain glycemic target levels long term (oral agent monotherapy won’t get to A1c goal)
Therapeutic inadequacy is
failure to reach targeted treatment goals, with dietary noncompliance and physical inactivity being contributing factors; maybe stress, insulin resistance
