Diabetes Part 1 Flashcards by Shanna Radloff

What is A1c?

Percentage of hemoglobin molecule glycosylated with glucose (% of sugar irreversibly bound to Hgb)

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The lower the A1c, the more likely it is that they’re having ____ glucose dysfunction; the higher the A1c, the more likely it is they’re having ____ glucose dysfunction.

The lower the A1c, the more likely it is that they’re having postprandial glucose dysfunction; the higher the A1c, the more likely it is they’re having fasting glucose dysfunction.

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What can falsely decrease A1c levels?

Any condition that shortens the life cycle of RBCs (ex: blood loss w/in 3 months, hemolytic anemia)

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What 2 things can falsely increase A1c levels?

1) iron deficiency anemia (untreated)

2) blood transfusion w/in 3 months

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What are the ADA recommendations on glycemic targets in adults for HbA1c levels?

<7%

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What are the ADA recommendations on glycemic targets in adults for preprandial/fasting plasma glucose?

80-130 mg/dL

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What are the ADA recommendations on glycemic targets in adults for 1-2 hr postprandial glucose?

<180 mg/dL

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What is the A1c goal, fasting or preprandial glucose level, and bedtime glucose level for a healthy older adult?

A1c: <7.5%
Fasting/preprandial: 90-130 mg/dL
Bedtime glucose: 90-150 mg/dL

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What is the A1c goal, fasting or preprandial glucose level, and bedtime glucose level for a complex/intermediate (multiple coexisting conditions) older adult?

A1c: <8%
Fasting/preprandial: 90-150 mg/dL
Bedtime glucose: 100-180 mg/dL

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What is the A1c goal, fasting or preprandial glucose level, and bedtime glucose level for a very complex/poor health older adult?

A1c: <8.5%
Fasting/preprandial: 100-180 mg/dL
Bedtime glucose: 110-200 mg/dL

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What are the ADA recommendations on glycemic targets in children and adolescents for HbA1c levels?

<7.5%

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What are the ADA recommendations on glycemic targets in children and adolescents for preprandial/fasting plasma glucose levels?

90-130 mg/dL

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What are the ADA recommendations on glycemic targets in children and adolescents for bedtime glucose levels?

90-150 mg/dL

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What are the ADA recommendations on glycemic targets in pregnant females for HbA1c levels?

=6-6.5%

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What are the ADA recommendations on glycemic targets in pregnant females for fasting plasma glucose levels?

=95 mg/dL

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What are the ADA recommendations on glycemic targets in pregnant females for 1 hr postprandial glucose levels?

=140 mg/dL

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What are the ADA recommendations on glycemic targets in pregnant females for 2 hr postprandial glucose levels?

=120 mg/dL

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What are the 3 key components to management of type 2 diabetes?

1) lifestyle management for all pts
2) Metformin is tx of choice unless C/I (severe renal dysfunction, someone who cannot tolerate it)
3) pt individuality needs to be considered b/c no 1 size fits all→ need to consider pt specific factors (A1c lowering, how affecting weight, etc.)

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You start with monotherapy for T2DM, except when? (2 conditions) And what do you start with instead?

A1c >9% → start dual therapy

A1c >10%, blood glucose >300 mg/dL, or pt markedly sx → consider combination injection therapy

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What 3 vaccines are important for diabetes pts to receive?

1) influenza
2) pneumococcal
3) Hep B

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What 3 things do you screen for yearly in diabetic pts?

1) nephropathy
2) neuropathy
3) retinopathy

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Which type of insulin is meal stimulated?

bolus

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What is the role of normal physiologic basal insulin?

Constant low levels are released to maintain glucose homeostasis in the fasting state

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What is the role of normal physiologic bolus insulin?

Covers meal stimulated bursts of glucose

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In what 4 instances do you use insulin in type 2 diabetics?

1) A1c > 9% 2) glucose > 300 mg/dL 3) marked hyperglycemia 4) A1c above goal despite 3 non-insulin antidiabetic agents

What is the name of inhaled insulin?

Afrezza

What is the MOA of Afrezza?

Insulin particles encapsulated into microspheres→ particles dissolve in neutral pH of the lung→ absorbed and distributed into circulation

What is the onset, peak, and duration of Afrezza?

Onset in 12-15 mins, peaks at 30 mins, duration= 3 hrs

What are 5 adverse effects of Afrezza?

1) cough 2) throat/mouth irritation 3) hypoglycemia 4) acute bronchospasm 5) hypersensitivity reactions

What test is required at baseline, 6 months, and annually for Afrezza?

Pulmonary function tests (PFTs)

What pt population is Afrezza C/I in?

COPD pts

What are 2 examples of long acting basal insulin?

1) insulin glargine U-100 | 2) insulin detemir

What are 2 examples of ultra-long acting basal insulin?

1) insulin glargine U-300 | 2) insulin degludec U-100, U-200

What is the benefit of ultra-long acting basal insulin?

Has a longer duration of action to mimic pancreatic secretion

What is the MOA of insulin glargine U-300?

Acidic solution→ after injection, solution neutralizes→ formation of microprecipitates→ release small amounts of glargine slowly

What are 4 benefits to insulin glargine U-300 compared to insulin glargine U-100?

1) provides the same # of units as insulin glargine U-100 at ⅓ of the volume 2) released more slowly from subcutaneous tissue to prolong its duration of action (~36 hrs) 3) more predictable absorption→ less interpatient variability 4) less hypoglycemic risk

What are 4 benefits to insulin degludec compared to insulin glargine U-100?

1) 42 hr duration of action 2) comparable efficacy 3) less nocturnal hypoglycemia 4) more flexible dosing

Who needs ultra long acting insulin? (8 pt examples)

1) Anyone requiring basal insulin 2) Pts at high risk of hypoglycemia 3) Pts experiencing hypoglycemia on NPH 4) Pts on twice daily insulin glargine U-100 and detemir 5) Pts who need flexible dosing schedules 6) Pts requiring high doses (>80 units/day0 7) Pts who are not getting 24 hrs of coverage 8) Obese + insulin resistant pts

Which insulin is bioequivalent to Lantus (insulin glargine U-100): Basaglar (insulin glargine U-100) or Humalog kwikpen U-200 (insulin lispro U-200)?

Humalog kwikpen U-200 (insulin lispro U-200) is bioequivalent to Lantus

What pt population would you use Humulin R U-500 in?

Pts on >200 units of insulin/day

T/F: Humulin R U-500 is a basal insulin.

false

What are 5 advantages of early use of insulin?

1) reduce glucose toxicity 2) facilitates beta-cell “rest”-preserving function 3) prevent or minimize diabetes related complications 4) may protect against endothelial damage 5) overcome pt and clinician barriers

What are 7 pt factor barriers to initiation of insulin for T2DM?

1) Feelings of failure 2) Negative impact on social life 3) Injection phobia 4) Myths/misconceptions about insulin 5) Limited training on use 6) Inadequate provider education on pros/cons of use 7) Concern over weight gain and hypoglycemia

What is clinical inertia?

Failure to intensify tx when there is an indication for tx intensification

What is the typical starting dose of insulin in type 1 diabetics if the pt is metabolically stable? How much is the basal requirement? Bolus requirement?

Starting dose: 0.5 units/kg/day ½ - ⅔ = basal requirement ⅓ - ½ = bolus requirement-divided b/w meals

How do you initiate therapy in T2DM?

Initiate basal insulin + metformin; start 10 units/day or 0.1-0.2 units/kg/day

If A1c is not controlled in T2DM started on insulin therapy + metformin, what are 2 options to help reach goal FPG?

1) add 1 rapid acting insulin injection before the largest meal 2) change to premixed insulin 2x/day before breakfast and dinner

How do you adjust basal insulin therapy in T2DM?

Adjust 10-15% or 2-4 units 1-2x/week to reach FPG goal

How do you adjust bolus insulin therapy in T2DM?

Adjust 10-15% or 1-2 units 1-2x/week to reach FPG goal

Why do you titrate bolus insulin less than basal insulin?

b/c higher risk of hyperglycemia, so you want to be more conservative in adjustments

If FPG dysfunction, what do you adjust?

Adjust basal insulin

If pre or postprandial dysfunction, what do you adjust?

Adjust bolus insulin

If hyperglycemia all day, what do you adjust?

Fix the fasting first, then prandial

If the dysfunctional glucose is post-breakfast or before lunch, which insulin needs adjustment?

Pre-breakfast rapid or short acting insulin

If the dysfunctional glucose is post-lunch or pre-dinner, which insulin needs adjustment?

Pre-lunch rapid or short acting insulin

If the dysfunctional glucose is post-dinner or at bedtime, which insulin needs adjustment?

Pre-dinner rapid or short acting insulin

If the dysfunctional glucose is early morning, which insulin needs adjustment?

Basal insulin or PM dose of NPH

What are 9 si/sx of HYPOglycemia?

- Shaking - Hunger - Rapid HR - Sweating - Impaired vision - Anxious - Irritable - Weakness - Dizziness

What are your 3 rapid acting insulins?

1) Humalog (lispro) 2) Novolog (aspart) 3) Apidra (glulisine)

What are your 2 short acting insulins?

1) Humulin R | 2) Novolin R

What are your 3 intermediate acting insulins?

1) Humulin N (NPH) 2) Novolin N (NPH) 3) Humulin R-500

What are your 4 long acting insulins?

1) Lantus, Basaglar (U-100 glargine) 2) Levemir (detemir) 3) Toujeo (U-300 glargine) 4) Tresiba (U-100, U-200 degludec)