Diabetes Part 1 Flashcards
What are the ultra rapid/rapid acting insulins
- humalog, amelog (insulin lispro)
- lyumjev (insulin lispro- aabc)
- novolog, flasp (insulin aspart)
- apidra (insulin gluilisine)
what is the use of ultra rapid/rapid acting insulins
- bolus dosing (meals) and insulin pumps (administration ranges 5-15 minutes before meals to immediately to 20 minutes after meal)
what is the short acting insulin
humulin R or novolin R ( regular insulin)
what is the short acting insulin use
bolus dosing (meals)
(administration ranges 15-30 minutes before meals - see specific product information)
what is the intermediate acting insulin
humulin N or novolin N- NPH
what is the use of intermediate acting insulin
basal like (administration Q day to BID)
what are the long acting insulins
- lantus, basaglar (insulin glargine) - 100 units/mL
- semglee (insulin glargine- ygfn)
- toujeo ( insulin glargine) 300 units/mL
what is the use of the long acting insulin
basal (administration Q day)
what is the ultra long insulin
tresiba (insulin degludec)
what is the use of the ultra long acting insulin
basal (administration QD, anytime of day)
what are the classes of each medication for type 2 diabetes
- biguanide
- glucagon like peptide receptor agonists (GLP1-RA- “tides”)
- glucose dependent insulinotropic polypeptide (GIP) agonist + glucagon like peptide 1 co-agonist
- sodium glucose cotransporter- 2 inhibitors
- dipeptidyl-peptidase-4 inhibitors
- thiazolidinedione (TZD- glitazones)
- sulfonylureas (SU)
- alpha glucosidase inhibitors
- bile acid sequestrant
- amylin analogue
- dopaminergic
- meglitinides
what is the generic and brand name for biguanide
- metformin
- glucophage/glucophage ER
what is the generic and brand name for - glucagon like peptide receptor agonists (GLP1-RA- “tides”)
-dulaglutide, exenglutide, liraglutide, lixisenatide, semaglutide
-trulicity, byetta,bydureon, victoza/Saxenda, adlyxin, ozempic/rebelsus/Wegovy
what is the generic and brand name for glucose dependent insulinotropic polypeptide (GIP) agonist + glucagon like peptide 1 co-agonist
- tirzepatide
- mounjaro/zepbound
what is the generic and brand name for sodium glucse cotransporter-2 inhibitor
- bexaglifozin, canagliflozin, dapagliflozin, empagliflozin, ertugliflozin
- brenzarvy
- invokana
- farxiga
- jardiance
- steglatro
what is the generic and brand name for dipeptidyl peptidase-4 inhibitors
- alogliptin, linagliptin, saxagliptin, sitagliptin
- nesina, tradjenta, onglyza, januvia
what is the generic and brand name for dipeptidyl peptidase-4 inhibitors
- pioglitazone
- actos
what is the generic and brand name for sulfonylurea
- glipizide, glyburide, glimepiride
- glucotrol, diabeta, glynase, micronase, amaryl
what is the generic and brand name for alpha- glucosidase inhibitors
- acarbose, miglitol, precose, glyset
what is the generic and brand name for bile acid sequestrant
- colesevelam
- welchol
what is the generic and brand name for amylin analogue
-pramlintide
- symlin
what is the generic and brand name for dopaminergic
- bromocriptine QR
- cycloset
what is the generic and brand name for meglitinides
- repaglinide, netaglinide
- prandin, starlix
what is glucose homeostasis
balance between hepatic glucose production and peripheral glucose uptake and utilization
what is the source of energy
glucose
what does insulin do
most important regulator of glucose/metabolic equilibrium
what do the pancreatic islet hormones do
maintain glucose balance
what are the 4 types of peptide secreting cells in the pancreas and what do they do
- beta - secrete insulin
- alpha - secrete glucagon
- delta - secrete somatostatin
- PP - secrete pancreatic polypeptide
_____ is the main factor controlling synthesis and secretion of insulin
glucose
what are the two ways insulin is released
- steady basal release of insulin
- repsonse to increased glucose
about ____ of insulin stored in the pancreas of an adult is secreted daily
1/5
describe glucose stimulated insulin secretion
- glucose transported by glucose transporter into beta cell
- metabolism alters ion channel (Ca2_ activity leading to insulin secretion
- incretin hormones: glucagon like peptide 1 and glucose dependent insulinotropic polypeptide released by cells in the small intestine after food ingestion, stimulate insulin secretion when the blood glucose is above the fasting level
what is DM
a group of complex chronic metabolic disorders characterized by high blood glucose concentration (hyperglycemia
- insulin deficiency
- often combined with insulin resistance
- abnormalities in the metabolism of carbohydrates, proteins, fats and insulin
what is hyperglycemia due to
- uncontrollde hepatic glucose output
- reduced uptake of glucose by skeletal muscle
- reduced glycogen synthesis
describe type 1 DM
- absolute deficiency of insulin resulting from autoimune destruction of pancreatic B cells - insulin deficiency
- generally an auto immune mediated process
- commonly occurs in childhood and adolesence- usually manifests before 40 years old
- requires exogenous insulin
- prone to DKA with hyperglycemia
- without insulin treatment patients will ultimately die of diabetic ketoacidosis
describe type 2 diabetes
- generally a consequence of metabolic disease and most commonly presents in obest patients
- often manifests after 40 years old
- hyperglycemia due to insulin resistance (proceeds overt disease) and progressive loss of insulin secretion
- may have normal, increased or decreased insulin levels due to abnormal beta cell function
- may or may not require exogenous insulin
- managed with diet, oral/subcutaneous antidiabetic agents and insulin SC
- accounts for 95% of individuals with diabetes over 30 years
- alarming increases T2MD in obese children and adults
- can be delayed or prevented with lifestyle modifications- diet, physical activity, and weight control
- less likely to develop DKA with hyperglycemia
what is the clnical presentation of diabetes
- polydispia
- polyphagia
- polyuria
- nocturia
- blurred vision
- type 1 associated with weight loss, ketoacidosis
- majority of type 2 patients are asymptomatic and dx by lab testing
what are the criteria for testing for diabetes or prediabetes in asymptomatic patients
- testing should be considered in adults with overweight or obesity BMI >25 or have one of the following risk factors: first degree relative with diabetes, high risk race, history of CVD, HTN, HDL cholesterol level less than 35mg/dl or triglyceride level >250 mg/dl, people w polycystic ovary syndrome, physical inactivty
- people with pre diabetes (A1C greater than 5.7%) should test yearly
- people who were dx with GDM should have testing 1-3 years
- testing should begin at age 35
- is results are normal repeat every 3 years
- individuals with high risk groups should be closely monitored
what does A1C show
glucose binds hemoglobin and shows the average amount of glucose in persons blood over last 3-4 months
what is the A1C, fasting blood sugar, and glucose tolerance test for normal people
- A1C: below 5.7%
- fasting bood sugar test: 99mg/dl
- glucose tolerance test: 140mg/dl
what is the A1C, fasting blood sugar, and glucose tolerance test for prediabetes people
A1C- 5.7-6.4%
fasting blood sugar: 100-135 mg/dl
- glucose tolerance test: 140-199 mg/dl
what is the A1C, fasting blood sugar, and glucose tolerance test for diabetes people
- A1C: 6.5% or above
- fasting blood sugar test: 126 mg/dl or above
- glucose tolerance test: 200mg/dl or above
what are the macrovascular complications
- brain
- heart
- extremities (peripheral vascular disease)
what are the mcirovascular complications
- eyes
- kidney
- nerves: peripheral and autonomic
- periodontal disease
what are the glycemic goals for adults with diabetes
- A1C: less than 7%
- preprandial capillary plasma glucose: 80-130 mg/dl
- peak post prandial glucose: less than 180mg/dl
what is the non pharmacologic therapy for DM
- medical nutrition therapy
- physical activity
what are the recommendations for medical nutrition therapy
- focus on carbohydrates for glycemic management
- stay between 3-4 carbohydrate choices for 45-60 grams of carbohydrate per meal
- eat 3 meals or 5 smaller meals throughout the day
- if numeracy skills are low, may use plate method
what are the recommendations for physical activity
- helps body regulate glucose and decrease insulin resistance
- lowers BP, cholesterol, stress, weight
- amount: 150 mins of moderate- intensity spread over at least 3 days and no more than 2 consecutive days without
- resistance training 2x per week
where is insulin destroyed
GI tract
what is the MOA, indications and formulations of insulin
- MOA: mimics endogenous insulin
- indications: required in T1DM and sometimes used in type 2
- formulations: injection or inhalation
describe the formulation of insulin today
- recombinant human insulin (made by recombinant DNA- rDNA Technology
- avoid batch variability and allergies from animal sources
- modifed amino acid sequences (insulin analogs) provide rapid/short acting and long acting/basal insulins
- differences in timing to peak effect and duration
- categorized by their onset of action
describe ultra rapid/rapid acting insulins
- rx only
- appearance - clear/colorless
- rDNA - human insulin analogs
- insulin lispro
- insulin aspart
- insulin glulisine
describe short acting (regular) insulin
- non rx: 100 units/ml
- appearance- clear/colorless
- rDNA- human insulin analogs
- humulin R and novolin R
describe inhaled insulin - afrezza and how is it contraindicated in, not recommended for and downfalls
- rapid acting insulin - given with meals
- oral inhalantion
- amount of insulin delivered to lungs depends on individual factors
- dosing conversion from injected insulin
- contraindicated in chronic lung disease (asthma/COPD)
- not recommended in smokers
- risk of bronchospasms and cough
- expensive
describe the intermediate acting (NPH) insulin
- NPH- neutral protamine hagedorn
- non rx
- appearance- cloudy
- rDNA - human isophange insulin suspension
describe long acting insulin
- rx only
- appearance - clear, colorless
- rDNA- human insulin analogs
describe the ultra acting insulin
- rx only
- appearance- clear, colorless
- rDNA - human insulin analogs
describe insulin mixtures
- actions of immediate/short and longer acting insulin combined
- protamine formulations longer acting
- typically given pre breakfast and pre supper or pre breakfast, lunch and supper
- disadvantages in dosing and individualizing therapy - more risk of hypoglycemia
what are the brand names of insulin mixtures
- humalog mix 75/25
- novolog mix 70/30
- humalog mix 50/50
- humulin 70/30
- novolin 70/30
describe the reusable insulin pen
must load with insulin cartridges- sold separately
describe the disposable insulin pens
come filled with insulin and are thrown away when empty
what are the advantages of pens
- overall easier injection, user friendly, saves time
- better for visually impaired
- better for patients with minimal dexterity
- portable; socially friendly
- more accurate dosing; less insulin waste
what are the disadvantages of pens
- more expensive
- only some insurance companies pay for pends or have preferred pens
- cannot mix insulin unless pre mixed insulin pen available
- not all insulin types are available for use in insulin pen cartridges
- should only be used for self injection. pen needle must be removed with no way to prevent accidental needle sticks if administered by another person
what are examples of pens used in DM
- apidra solostar
- humalong kwikpen
- humulin pen
- lantus solostar
- levelmir flexpen,
- novolog mix flex pen
- novopen junior
- autopen
what are the common insulin regimens
- multiple daily injections: basal- bolus regiment (usually 4 injections/day)
- mimics physiologic insulin release
what are the basal insulin regimens
long acting analog
what are the bolus regimens
ultra rapid acting or rapid acting analog
regimens may include:
flexible dose of bolus adjusted to carbohydrates
- fixed doses of bolus
describe the rapid acting/NPH
- 2 injections/day
- rapid or regular insulin mixed with NPH in same syringe
describe continuous insulin infusion pumps
- growing use- primarily in T1DM
- deliver exogenous insulin that more closely approximates the normal biologic function and performance of the pancrease
- devices only use short or rapid acting insulin as basal insulin with continuous delivery with bolus administration as needed
- programmed external pump - worn continuously
- delivers insulin through a cannula inserted beneath the surface of the skin
- one injection site for 72 hours
- many pumps have continuous glucose monitoring system integrated within the pump or they can be used separatelyw
what are the advantages of continuous insulin infusion pumps
- improved glycemic control
- decreased A1c
- decreased risk of hypoglycemia
what are the adverse effects of continuous insulin infusion pumps
- pump failures - hyperglycemia or hypoglycemia
- mechanical failures
- blockages within the infusion set
- infusion site complications
- instability of the insulin stored within the pump
- user errors- usually the most common
- rates declining as technology improves
- importance of patient education
- infections at the injection site- lipomas
- more expensive than multiple daily injections
what are the dental adverse effects
- either hypo or hyperglycemia may occur
- if pt is confused/unresponsive, always push suspend button immediately
- then check disaply to assess last glucose trend
what is the purpose of continuous glucose monitoring
- to monitor blood glucose levels in patients with diabetes
describe blood glucose meters
- finger sticks (plasma- blood glucose) - moment in tiem
- self monitoring of blood glucose
- frequency of monitoring varies depending on type of diabetes and medications
- occasional to morning fasting, before meals,
how does the continuous glucose monitoring work
- measures ISF
- readings generally at 5 minute intervals
- small sensor with a cannula is inserted into arm or abdomen - replaces every 10-14 days
- transmistter sends readings wirelessly usually to phone, computer or other monitoring device
- alerts can be sent to notify of low or high glucose
- used by pts with type 1 or 2
- insurance coverage varies with type 2
- finger stick blood glucose meters should be used for rapidly changing glucose or when patients experience symtpoms that may be due to low or high blood glucose dont match CGM readings
describe the use of insulin in type 1 diabetes
- life long insulin required along with diet management
- multiple daily injections of prandial insulin and basal insulin or continuous subcutanesou insulin infusion
- often require lower doses of insulin than type 2 because less issue with insulin resistance
describe insulin use in type 2 DM
- other tx options usually implemented first unless severe hyperglycemia
- diet management
- oral anti diabetic agents
- about 1/3 patients benefit from insulin
- eventually every pt with type 2 DM requires insulin - beta cell failure
- often require higher doses of type 1 bc of insulin resistance
- often start with basal/long acting insulin and continue certain oral anti diabetic agents
- may add bolus to basal if glycemic goals not met
what is the insulin dosing with type 1 diabetes
- starting dose is based on weight, with doses ranging from 0.4-1.0 units/kg/day of total insulin with higher amounts required during puberty
what is the insulin dosing with type 2 diabetes
- basal insulin alone is the most convenient initial insulin regimen, beginning at 10 untis per day or 0.1-0.2 units/kg/day depending on degree of hyperglycemia
- many individuals with type 2 diabetes may require mealtime bolus insulin dosing in addition to basal insulin
- the recommended starting dose of mealtime insulin is 4 units, 0.1 units/kg or 10% of basal dose
- after titration to goals and advancing disease, patients with type 2 require higher doses than type 1 because of insulin resistance
what are the adverse effects of insulin
- weight gain
- hypoglycemia
- highest risk of any diabetes medication
- higher control = increased risk of hypoglycemia
- manage patient as if hypoglycemia until proven otherwise
what are the symptoms of hypoglycemia
- shaky/tremors
- confusion
- nervous/anxious
- sweating
- clamminess, lightheadedness/dizziness
- fatigue
- sleepiness
- agitation
- anxiety
- hunger
- nausea
- tingling or numbness
- vision changes
- tinnitus
- headache
- anger/stubbornness
- sadness
- tachycardia
what can severe hypoglycemia result in
significant cognitive impairment requiring outside assistance, seizures, or loss of consciousness
what are the definitions for hypoglycemia
- not all patients will experience hypoglycemia
- certain antidiabetic drugs and pt risk factors increase risk
- serious clinically significant: <54 mg/dl
- glucose alert value: < 70mg/dl
patients skipping a meal for a dental procedure or a dental visit should:
not take their short/rapid acting insulin dose
patients who eat normally before dental appt should:
take all their insulin prior to a visit
if patients experience hypoglycemia:
- duration will differ depending on the type of insulin
- hypoglycemia caused by rapid acting insulin will resolve quickly
- an episode caused by insulin degludec (or long acting insulins) could potentially continue to be a problem for many hours
what is the therapy for type 2 DM
- diet management
- oral antidiabetic agents - possess varying amounts of hypoglycemic risk
- insulin therapy
- other injectable therapy (GLP1 inhibitors)
- be able to identify the magnitude of risk for hypoglycemic for various antidiabetic agents
- many classes and lots endings and abbreviations for drug classes to keep up with
what medications act on the liver and what do they do
- glucose production
- biguanides (thiazolidinediones)
what medications act on the intestine and what do they do
- glucose absorption:
- alpha glucosidase inhibitors
- bile acid sequestrants
- slowed gastric emptying: incretin and amylin mimetics
what medications act on the pancreas and what do they do
- insulin secretion:
- sulfonylureas
- meglitinides
- insulin
- DPP-4 inhibitors
- incretin mimetics
- glucagon inhibition:
- incretin mimetics
- DPP-4 inhibitors
-amylin mimetics
what is the medication that work on the kidney
- sodium glucose co transporter 2 inhibitor
what are the medications that work on the muscle and what do they do
- peripheral glucose uptake: thiazolidinediones
- satiety/feeding: incretin mimetics, amylin mimetics, dopaminergics
what medication is a biguanide and whaat is the MOA, formulation and describe its use
- metformin (glucophage)
- MOA: decreases hepatic glucose production (gluconeogenesis- markedly increased in type 2) - primary mechanism. decreases insulin resistance (increases insulin sensitivity- increased glucose utilization in muscle and adipose tissues. inhibits intestinal absorption of glucose
- formulation: oral
- often first line/ initial agent for type 2 because lower cost and effective A1c lowering for oral agent. also used in pre diabetes
describe risks of metformin
- low risk of hypoglycemia with monotherapy
- notable GI adverse drug effects such as diarrhea/loose stools, flatulence, dyspepsia, abdominal distension/pain, nausea/vomitting
- risk of B12 defiency
- rare risk of causing lactic acidosis
what are the risks associated with B12 deficiency and oral manifestations
- megaloblastic anemia/pernicious anemia
- oral manifestations: glossitis, glossogynia, recurrent ulcers, cheilitis, dysgeusia, lingual paresthesia, burning sensation, and pruritis
what are the glucagon like peptide-1 receptor agonists and what is the MOA, formulations and dosing
- albiglutide, dulaglutide, exenatide, liraglutide, lixisenatide, semaglutide
- moa: mimics human GLP-1. destimulates GLP-1 receptors in the pancreas to increases insulin secretion in response to elevated glucose. in addition to stimulation of GLP-1 receptors in the GI tract and CNS decrease glucagon secretion and slow gastric emptying
- formulation: most as SC injections only
- dosing: varies from BID, daily, and weekly depending on medication and formulation
what are the benefits of GLP1-RA
- weight loss
- higher dosages FDA approved for weight loss: semaglutide and liraglutide
- CV benefits: athersclerotic CV disease
- kidney benefits: CKD
what are the ADEs of GLP1-RAs
- GI (nausea and diarrhea)
- injection site reactions
- pancreatitis (rare)
- gallbladder disease
- thyroid C cell tumors
is hypoglycemia a risk with GLP1-RAs
low risk with monotherapy
what is the GIP/GLP-1 receptor co-agonist and what is its MOA and formulation
- tirzepatide
- “twincretin”
- MOA: dual agonist/co-agonist activates both the glucagon like peptide-1 receptor and the glucose dependent insulinotropic polypeptide receptor: increases to insulin secretion in response to elevated glucose, decreases glucagon secretion, slows gastric emptying
- weight managemnt indication
- formulation: injections SC only
what are the ADEs of GIP/GLP-1 receptor co-agonist
- GI
- pancreatitis (rare)
- gallbladder diseases (rare)
- low risk of hypoglycemia when used as monotherapy
- linked to medullary thyroid cancer in rodents
what are the additional considerations with GIP/GLP-1 RAs
- more weight loss than GLP-1 agonists
- more A1c reduction than most GLP-1 agonists
- No CV or kidney outcomes data
- monitor for retinopathy progression
- may delay oral contraceptive absorption
where are the sodium glucose cotransporter-2 inhibitors located and what do they do and what are the names
- located in the S1 segment of the proximal renal tubule
- SGLT2 responsible for 90% of glucose reabsorption
- drug names: bexagliflozin, canagliflozin, dapagliflozin, empagliflozin, ertugliflozin
what is the MOA and formulation of SGLT2 inhibitors
- MOA: blocks glucose reabsorption in the proximal convoluted tubules of the kidney which increases excretion of glucose in the urine. blocks sodium reabsorption
- formulation: oral
what are the ADEs of SGLT2 inhibitors (flozins)
- genital mycostic infections (Fungal, yeast)
- UTIs
- hypoglycemia: low risk as monotherapy, may significantly reduce insulin needs
what are the benefits of SGLT2 inhibitors
- CV benefits: atherosclerotic CVD and heart failure
- renal benefits: CKD
- weight loss
what are the sulfonylureas, MOA and formulation
- glimepiride, glyburide, glipizide (2nd generation)
- MOA: secretagogues, stimulate insulin release from pancreas (primary), helps the pancrease release more insulin which lowers glucose
- stimualte beta cells causing insulin secretion
- lower fasting and post prandial glucose
- formulation is oral
what are the meglitinides, MOA and formultion
- nateglinide, repaglinide
- MOA: secretagogues
- increase insulin resistance from the pancreas in response to food, keeping blood glucose from rising too high after meals
- like sulfonylureas but shorter acting- taken with meals
- hold dose if skipping meals
- lower post prandial glucose
- formulation: oral
what are the ADEs of secretagogeus
- hypoglycemia - especially in older adults
- caution using with other drugs the cause hypoglycemia (usually dc with the use of insulin)
- weight gain
- durability declines over time - relatively short lived efficacy
what are the thia-zolidine-diones, MOA and formulation
- pioglitazone
- MOA: increases peripheral insulin sensitivity
- increase glucose uptake into muscles by enhancing the effectiveness of endogenous insulin. binds to nuclear receptor- peroxisome proliferator activated receptor gamma in adipose , muscle and liver
- reduce glucose output
- formulation: oral
- low risk of hypoglycemia when used as a monotherapy
what are the TZDs adverse effects and additional information
edema/fluid retention
- weight gain
- heart failure (avoid in pt with symptomatic heart failure)
- increased risk of fractures
- additional info:
- glycemic control better sustained over diabetic course
- potential role in treatment of NAFLD
what are the dipeptidyl peptidase 4 inhibitors and MOA and formulation
- alogliptin, linaliptin, saxagliptin sitagliptin
- MOA: inhibits degradation of incretin hormones which decreases glucagon release resulting in insulin secretion, decreased gastric emptying and decreased blood glucose levels
- hypoglycemia with monotherapy- low risk
- formulation: oral
what are the ADEs of DPP-4 inhibitors and additional information
- may be associated with pancreatitis (rare)
- new or worsening heart failure (aloglptin and saxaliptin)
- may cause severe joint pain (rare)
- additional information: dosage modification needed with renal impairment
- CYP3A4 drug interaction
- weight neutral
- generally well tolerated
what are the less commonly used medication
- alpha glucoside inhibitors
- bile acid sequestrant
- dopaminergic agents
- amylin analog
what meds can cause significant hypoglycemia
insulins, sulfonylureas and meglitinides
in severe cases hypoglycemia can result in:
loss of consciousness, coma, or even death
what is DM
a group of chronic metabolic disorders characterized by high blood glucose concentration
- insulin deficiency
- risks for microvascular and macrovascular complications
- uncontrolled diabetes leads to devastating consequences
what is the management for type 1 DM
insulin therapy and diet management
what is the therapy for type 2 DM
diet management with oral and/or insulin/GLP1RA therapy
the mechanisms of action of the drug therapy involved with treating DM involves:
either providing/increase insulin and/or lowering glucose by various means
what is the most dangerous adverse effect of some diabetic medications
hypoglycemia
