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Therapeutics 1 > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

What are the signs and symptoms of type 1 diabetes?

A

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

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2
Q

What are the signs and symptoms of type 2 diabetes?

A

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

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3
Q

What is the criteria for diagnosis for diabetes mellitus?

A

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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4
Q

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

A

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

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5
Q

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

A

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

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6
Q

A1C reflects the average blood sugar levels of the previous…

A

60-90 days

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7
Q

How often should stable patient’s A1C be monitored?

A

2 times/year (6 months)

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8
Q

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

A

every 3 months

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9
Q

What drugs are strongly recommended for type 2 diabetes?

A

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

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9
Q

MOA: biguanides (Metformin)

A

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

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10
Q

What is the first line therapy in type 2 diabetes?

A

biguanides (Metformin)

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11
Q

How is metformin eliminated?

A

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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12
Q

What are the common adverse effects of metformin?

A

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

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13
Q

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

A

metformin

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14
Q

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

A

-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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15
Q

What are the contraindications of metformin?

A

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

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16
Q

What are the advantages of metformin?

A

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

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17
Q

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

A

exenatide, LIRAGLUTIDE, DULAGLUTIDE, lixisenatide, SEMAGLUTIDE

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18
Q

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

A

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

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19
Q

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

A

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

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20
Q

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

A

GLP-1 agonists and SGLT2 (canagliflozin and empagliflozin)

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21
Q

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

A

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

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22
Q

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

A

dulaglutide and liraglutide (GLP-1)

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23
Q

Which two drug classes should not be combined?

A

GLP-1 and DPP-4

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24
Q

What are the adverse effects of GLP-1 agonists?

A

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

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25
Q

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

A

tirzepatide

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26
Q

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

A

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

27
Q

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

A

history of medullary thyroid cancer

28
Q

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

A

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

29
Q

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

A

CANAGLIFLOZIN, dapagliflozin, EMPAGLIFLOZIN, ertugliflozin, bexagliflozin

30
Q

What is the mechanism of action of SGLT2 inhibitors?

A

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

31
Q

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

A

SGLT2 inhibitors

32
Q

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

A

SGLT2 inhibitors

33
Q

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

A

reduce chronic kidney disease progression and cardiovascular events

34
Q

What are the contraindications of SGLT2 inhibitors?

A

end-stage renal disease (dialysis)

35
Q

What are the adverse effects associated with SGLT2 inhibitors?

A

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

36
Q

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

A

sitagliptin, saxagliptin, linagliptin, alogliptin

37
Q

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

A

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

38
Q

What are the adverse effects of DDP-4 Inhibitors?

A

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

39
Q

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

A

heart failure

40
Q

What is the mechanism of action of sulfonylureas?

A

stimulate the release of insulin from functioning pancreatic beta cells

41
Q

What are the contraindications of sulfonylureas?

A

diabetic ketoacidosis and use caution in patients with sulfa allergy

42
Q

What are the adverse effects of sulfonylureas?

A

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

43
Q

What drugs are sulfonylureas?

A

glipizide, glyburide, glimepiride

44
Q

What drugs are thiazolidinediones (TZD)?

A

rosiglitazone, pioglitazone

45
Q

What is the mechanism of action of thiazolidinediones?

A

decrease insulin resistance, decrease hepatic glucose output

46
Q

What are the contraindications of TZD?

A

patients with class 3 or 4 heart failure

47
Q

What are the BLACK BOX warnings for TZD?

A

edema, coronary disease (rosiglitazone)

48
Q

What are the adverse effects of TZD?

A

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

49
Q

What monitoring parameters are unique with TZD?

A

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

50
Q

Which insulin preparations are rapid acting analogs?

A

aspart, lispro, glulisine, inhaled

51
Q

Which insulin preparations are short acting?

A

regular (Humulin R)

52
Q

Which insulin preparations are intermediate acting?

A

NPH (Humulin N)

53
Q

Which insulin preparations are long-acting analogs?

A

glargine, detemir

54
Q

Which insulin preparations are ultra-long acting?

A

degludec

55
Q

What is the rate of absorption based on injection site?

A

abdomen > arm > buttocks > thigh

56
Q

Describe the Somogyi Effect

A

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

57
Q

What is the treatment for the somogyi effect?

A

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

58
Q

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

A

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

59
Q

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

A

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

60
Q

What is once daily dosing insulin injections also known as?

A

basal augmentation

61
Q

What type of patients is basal augmented used in?

A

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

62
Q

Describe: Basal/Bolus Concept in Insulin Administration

A

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

63
Q

Describe: Split-mixed

A

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)

64
Q

Describe: Long-acting + short acting Boluses

A

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

65
Q

What are the adverse effects of insulin?

A

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

66
Q

What are the long-term complications of diabetes?

A

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

Therapeutics 1 (16 decks)

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