Diabetes Mellitus Flashcards by Kathryn Cannaday

What are the signs and symptoms of type 1 diabetes?

commonly presents with ketoacidosis after several days of polyuria, polydipsia, polyphagia, and weight loss (blurred vision also seen)

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What are the signs and symptoms of type 2 diabetes?

lethargy, polyuria, nocturia (night time urination), polydipsia, and blurred vision

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What is the criteria for diagnosis for diabetes mellitus?

A1C 6.5% + OR symptoms of diabetes + a casual plasma glucose concentration 200 mg/dL+ OR fasting (no caloric intake 8+ hours) 126 mg/dL+ OR 2 hour postload glucose 200mg/dL+ during an oral glucose tolerance test (OGTT)

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What are the glycemic goals of therapy according to the ADA?

-pre-prandial glucose (before meal): 80-130 mg/dL
-postprandial glucose (after meal): <180 mg/dL
-A1C: < 7%

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What management of cardiovascular risk factors are implemented with diabetes control?

-intensive BP control
-treatment of dyslipidemia (LDL, triglycerides)
-smoking cessation
-anti-platelet therapy

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A1C reflects the average blood sugar levels of the previous…

60-90 days

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How often should stable patient’s A1C be monitored?

2 times/year (6 months)

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How often should patient’s not meeting treatment goals be monitored?

every 3 months

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What drugs are strongly recommended for type 2 diabetes?

-biguanides
-glucagon like peptide-1 (GLP-1)
-glucose-dependent insulinotropic polypeptide (GIP)/GLP-1
-sodium-glucose cotransporter 2 (SGLT2)

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MOA: biguanides (Metformin)

-decrease hepatic glucose production
-decrease intestinal absorption of glucose
-decreases insulin resistance

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What is the first line therapy in type 2 diabetes?

biguanides (Metformin)

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How is metformin eliminated?

renally, patients with eGFR 30-45 mL/min/1.73m2 therapy initiation is not recommended but if currently on therapy decrease dose by ~50% and monitor renal function every 3 months

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What are the common adverse effects of metformin?

GASTROINTESTINAL= should be taken with food
-abdominal discomfort
-stomach upset
-diarrhea
-anorexia

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What diabetes drug has a BLACK BOX WARNING that it may cause lactic acidosis (rare)?

metformin

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In what patient population or scenarios should metformin be used with CAUTION?

-tissue hypoperfusion (COPD/asthma/heart failure)
-severe hepatic disease/alcohol abuse
-recent surgery
-decreased renal function- renally cleared, discontinue therapy prior to use of contrast dyes

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What are the contraindications of metformin?

-eGRF < 30 mL/min/1.73m2
-shock, acute MI, sepsis
-chronic or acute metabolic acidosis

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What are the advantages of metformin?

-no hypoglycemia
-no weight gain
-long acting formulation avaliable

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What drugs are glucagon like peptide-1 (GLP-1) agonists?

exenatide, LIRAGLUTIDE, DULAGLUTIDE, lixisenatide, SEMAGLUTIDE

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What GLP-1 agonists can reduce major adverse cardiovascular disease (MACE)?

liraglutide(GLP-1), dulaglutide(GLP-1), semaglutide(GLP-1), canagliflozin(SGLT2), empagliflozin(SGLT2)

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What is the mechanism of action of GLP-1 agonists?

-enhanced insulin release from pancreatic beta cells
-suppresses inappropriately elevated glucagon secretion
-prolongs gastric emptying time

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What drug class would be a good recommendation for patients with established ASCVD or are high risk for ASCVD?

GLP-1 agonists and SGLT2 (canagliflozin and empagliflozin)

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What drugs received a “very high” recommendation for weight loss?

semaglutide (GLP-1) and tirzepatide (GIP/GLP-1)

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What drugs received a “high” recommendation for weight loss?

dulaglutide and liraglutide (GLP-1)

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Which two drug classes should not be combined?

GLP-1 and DPP-4

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What are the adverse effects of GLP-1 agonists?

gastrointestinal effects (N/V, diarrhea and dehydration, dyspepsia), acute pancreatitis

What drugs are glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 agonist?

tirzepatide

What is the mechanism of action of GIP/GLP-1 agonists?

GLP-1 MOA + -enhanced insulin release from pancreatic beta cells (enhanced effect) -decreased insulin resistance

What are the contraindications of GIP/GLP-1 agonists?

history of medullary thyroid cancer

What are the adverse effects of GIP/GLP-1 agonists?

gastrointestinal effects (N/V, diarrhea), acute pancreatitis, possible increase in gallbladder disease

What drugs are sodium-glucose cotransporter 2 (SGLT2) Inhibitors?

CANAGLIFLOZIN, dapagliflozin, EMPAGLIFLOZIN, ertugliflozin, bexagliflozin

What is the mechanism of action of SGLT2 inhibitors?

reduces reabsorption of filtered glucose from the tubular lumen and lowers renal threshold for glucose, increasing the urinary excretion of glucose

What is the preferred drug class in patients that have heart failure?

SGLT2 inhibitors

What is the preferred drug class in patients that have kidney disease?

SGLT2 inhibitors

What other disease have SGLT2 inhibitors be shown to be beneficial in?

reduce chronic kidney disease progression and cardiovascular events

What are the contraindications of SGLT2 inhibitors?

end-stage renal disease (dialysis)

What are the adverse effects associated with SGLT2 inhibitors?

-hyperkalemia -genital fungal infections -necrotizing fasciitis of the perineum (Fournier's gangrene) -renal insufficiency -ketoacidosis -increased risk of leg and foot amputations

What drugs are dipeptidyl peptidase- 4 (DPP-4) inhibitors?

sitagliptin, saxagliptin, linagliptin, alogliptin

What is the mechanism of action of DPP-4 inhibitors?

prevents the DPP-4 mediated breakdown of incretins which results in: enhanced insulin release from pancreatic beta cells, suppresses inappropriately elevated glucagon secretion, prolong gastric emptying

What are the adverse effects of DDP-4 Inhibitors?

gastrointestinal effects (N/V, abdominal pain), joint pain, acute pancreatitis

What conditions should saxagliptan (DPP-4 inhibitor) be avoided in?

heart failure

What is the mechanism of action of sulfonylureas?

stimulate the release of insulin from functioning pancreatic beta cells

What are the contraindications of sulfonylureas?

diabetic ketoacidosis and use caution in patients with sulfa allergy

What are the adverse effects of sulfonylureas?

hypoglycemia (especially in pt who skip meals, exercise, or lose weight are most at risk), weight loss

What drugs are sulfonylureas?

glipizide, glyburide, glimepiride

What drugs are thiazolidinediones (TZD)?

rosiglitazone, pioglitazone

What is the mechanism of action of thiazolidinediones?

decrease insulin resistance, decrease hepatic glucose output

What are the contraindications of TZD?

patients with class 3 or 4 heart failure

What are the BLACK BOX warnings for TZD?

edema, coronary disease (rosiglitazone)

What are the adverse effects of TZD?

edema, weight gain, coronary disease, bladder cancer, increased risk of fractures

What monitoring parameters are unique with TZD?

hepatic transaminases prior to initiation of therapy- discontinue if ALT >2.5

Which insulin preparations are rapid acting analogs?

aspart, lispro, glulisine, inhaled

Which insulin preparations are short acting?

regular (Humulin R)

Which insulin preparations are intermediate acting?

NPH (Humulin N)

Which insulin preparations are long-acting analogs?

glargine, detemir

Which insulin preparations are ultra-long acting?

degludec

What is the rate of absorption based on injection site?

abdomen > arm > buttocks > thigh

Describe the Somogyi Effect

*FASTING HYPERGLYCEMIA* secondary to hypoglycemic event in the middle of the night (confirmed with a glucose reading)

What is the treatment for the somogyi effect?

-decrease long acting insulin dose, decrease evening NPH dose, eat a bedtime meal or snack

What is the initial dosing of insulin for a type 1 patient?

0.5-1 units/kg/day in divided doses but conservative doses may be considered (0.2-0.4 units/kg/day in divided doses) to avoid hypoglycemia

What is the initial dosing of insulin for type 2 patients?

0.5-1 units/kg/day typically paired with an oral agent because they are more resistant to insulin

What is once daily dosing insulin injections also known as?

basal augmentation

What type of patients is basal augmented used in?

type 2, not suitable for type 1 (and usually taken with oral agents)

Describe: Basal/Bolus Concept in Insulin Administration

insulin administration that mimics normal physiologic insulin release obtained by a combination therapy with long and short/rapid insulin

Describe: Split-mixed

*2 injections/day, most common for type 2 patients, but not usually effective at reaching A1C goals for type 1 pt* -AM Injection (2/3 of daily dose): rapid acting or reg insulin + intermediate (NPH) -PM Injection (1/3 of daily dose): rapid acting or reg insulin + intermediate (NPH)

Describe: Long-acting + short acting Boluses

*4 injections/day, excellent choice for type 1 patients* short acting injects at meal times and basal (long-acting) injection once daily- NPH can be used but must be dosed 2x/day

What are the adverse effects of insulin?

allergic reaction, hypoglycemia (blood glucose < 70 mg/dL, level2= <54 mg/dL, level3= severe event associated with altered mental status), lipohypertrophy (fatty accumulation at injection site), weight gain

What are the long-term complications of diabetes?

MIcrovascular disease (vision problems), diabetic kidney disease, neuropathy, foot ulcers