Diabetes Quiz Flashcards
What does the A1c measure?
% of hemoglobin molecule glycosolated with glucose
How often should A1c be measured?
Atleast twice a year; more commonly every 3 mos
What does A1c provide us with?
The “long term” indication of glycemic control
What is eAG?
eAG is the value patients get when they check blood sugar at home, can use this to correlate the % of A1c
What does 8% A1c correlate to in eAG?
183
The higher the A1c is, what contributes more to it, fasting or prandial levels?
Most contribution of fasting glucose dysfunction
The lower the A1c, what contributes more to it fasting or prandial levels?
More contribution of post prandial dysfunction
What are some factors that can falsely decrease A1c?
Any condition that shortens the life cycle of RBC, blood loss (within 3 mos), Hemolytic anemia
What are some factors that can falsely increase A1c?
Iron deficiency anemia (thats not treated), blood transfusion (within 3 mos)
What is the target value for HbA1c according to the ADA?
<7% (for most)
What is the target value of pre-prandial/ fasting plasma glucose (FPG) according to the ADA?
80-130 mg/dL
What is the target value for 1-2 hours post-prandial glucose (PPG) according to the ADA?
<180 mg/dL
Who are these ADA recommendations for?
NON-PREGNANT ADULTS
Less stringent ADA goals may be appropriate for individual patients with:
Sever hypogylcemia, limited life expectancy, advanced complications/ extensive co-morbid conditions
ADA recommendation for a healthy older adults A1c?
<7.5% (7-7.5%)
ADA recommendation for a healthy older adults fasting or pre-prandial glucose?
90-130
ADA recommendation for a healthy older adults bedtime glucose?
90-150
ADA recommendation for an older adult with complex/intermediate health A1c?
<8% (7.5-8%)
ADA recommendation for an older adult with complex/intermediate health fasting/pre-prandial glucose?
90-150
ADA recommendation for an older adult with complex/intermediate health bedtime glucose?
100-180
ADA recommendation for an older adult with very complex/poor health A1c?
<8.5% (8.0-9.0%)
ADA recommendation for an older adult with very complex/poor health fasting/pre-prandial glucose?
100-180
ADA recommendation for an older adult with very complex/poor health bedtime glucose?
110-200
HbA1c for children and adolescents
<7.5%
Pre-prandial and fasting plasma glucose for children and adolescents
90-130
Bedtime glucose for children and adolescnets
90-150
Why are glycemic goals more relaxed for children and adolescents?
To prevent cognitive impairment/worsening of brain development
Pregnancy HbA1c
<6-6.5%
Pregnancy Fasting plasma glucose
<95
Pregnancy 1 hour post prandial glucose
<140
Pregnancy 2 hour post prandial glucose
<120
Gestational diabetes may present with more what?
Postprandial hyperglycemia, due to carbohydrate intolerance
Postprandial monitoring in pregnancy is associated with what?
Less preeclampsia
What are some patient factors that contribute to drug selection?
Preference, co-morbidities, insurance, duration of diabetes, current weight, hypoglycemia risk, age, aptitude for self-care
Patients are at risk for infection with diabetes, what are some vaccines to keep UTD?
Influenza, pneumococcal, hepatitis B
What are the guidelines for influenza vaccine?
All patients > 6mos
What are the guidelines for pneumococcal vaccine?
All patients 2-64 years of age and all patients 65 or older
What are the guidelines for hep B vaccine?
All unvaccinated patients 19-59; consider administering if > 60 yo
What are some lifestyle managements for diabetes?
Meal planning, weight management, physical activity: 150 mins/week of mod activity, 2-3 days a week of flexibility and interrupt prolonged sitting every 30 minutes
CVD risk management with diabetes
BP goal of <140/90 with HTN, low-dose aspirin therapy, statin therapy for ASCVD and >40yo for increased risk
Basal insulin is what?
40-50%, constant low level release. It maintains glucose homeostasis in the fasting state
Bolus insulin is what?
50-60%, meal stimulated. Covers meal stimulated bursts of glucose
Who needs insulin?
Type 1 diabetics, gestational diabetics, hyperglycemic crisis
T2D who need insulin
A1c >9%, glucose >300, marked hyperglycemia, A1c above goal despite 3 mo non-insulin antidiabetic agents
Basal insulin can be used as what?
Second line agent, after metformin
What is Afrezza?
Inhaled insulin, dry powder of human (recombinant DNA) insulin
How is Afrezza formulated?
To absorb onto technosphere microparticles for pulmonary administration
How is Afrezza absorbed into the circulation?
Insulin particles encapsulated into microspheres, particles dissolve in neutral pH of the lung, absorbed and distributed into circulation
Adverse effects of Afrezza
Cough, throat/mouth irritation, hypoglycemia, acute bronchospasm, hypersensitivity reactions
What tests are required when your taking Afrezza or inhaled insulin?
Routine pulmonary functions tests @ baseline, 6 mos, and annually.
When should Afrezza not be used?
C/I if pt has COPD, increased bronchoconstriction in asthma, less efficacy in smokers!
What are the unit dosings for inhaled insulin?
4 unit: Blue
8 unit: Green
12 unit: Yellow
What does long acting basal insulin offer?
A flatter, peakless profile with prolonged duration of action
What does ultra long acting insulin offer?
Has improved pk and longer duration of action to mimic pancreatic secretion
What is Insulin Glargine U-300 (Toujeo)
Injection. Provides the same number of units as insulin glargine U-100 at a third of the volume
How is Insulin glargine U-300 (Toujeo) absorbed?
Released more slowly from the subQ tissue to prolong its duration of action (36 hours)
What is the bottom line of glargine U-300 (Toujeo)?
Has comparable efficacy to insulin glargine U-100, less severe and nocturnal hypoglycemia with U-300, similar risk of weight gain
Insulin Degludec efficacy
Comparable to insulin glargine U-100, less nocturnal hypoglycemia with degludec, flexible dosing (8-40 hours between doses didnt impact glycemic control)
Who needs ultra long acting insulin?
Anyone required basal insulin, high risk of hypoglycemia, pts with hypoglycemia on NPH, pts on twice daily insulin glargine U-100 and detemir, pts who need flexible dosing schedules, pts requiring high doses, pts who arent getting 24 hours of coverage, obese/insulin resistant patients
Patients requiring __units a day of insulin needs ultra long acting
80 units
Is Insulin glargine U-100 (Basaglar) bioequivalent to insulin glargine U-100 (Lantus)?
No! But it is THERAPEUTICALLY equivalent, cheaper!
What is Insulin lispro U-200 (Humalog kwikpen U-200)
Contains more insulin per pen, delivers half the volume of lispro U-100
Who can Insulin lispro U-200 (Humalog kwikpen U-200) be considered for?
Those with high mealtime dosing
Humulin R U-500
Regular insulin but behaves like NPH
When can Humulin R U-500 be used?
Dosed 2-3 times per day, consider it for pts on >200 units of insulin per day!
What are some advantages of using insulin early?
Reduce glucose toxicity, facilitates B-cell “rest” and preserves function, prevents of minimizes diabetes related complications, may protect against endothelial damage, overcomes patient and clinician barriers
What are some disadvantages of using insulin early?
Most studies that show benefit used MDI or CSII therapy, complex instructions, expensive
What patient factors can effect the initiation of early insulin for T2DM?
Feelings of failure, - impact on social life, myths/misconceptions about insulin, limited training on use, inadequate provider education on pros/cons, concern over weight gain and hypoglycemia
What provider factors can effect the initiation of early insulin for T2DM?
Therapeutic/clinical inertia, perceived patient reluctance/resistance, lack of knowledge and training
How do you initiate insulin for T1D?
Need both basal and bolus coverage; weight based dosing!!
What is the typical starting dose for T1D?
O.5 units/kg/day
1/2 to 2/3 is the basal requirement
1/3-1/2 is the bolus requirement (divided among meals)
How do you initiate basal insulin for a T2D?
Usually do it with metformin, start at 10 units/day OR o.1-0.2 units/kg/day
If the A1c is not controlled after initiating insulin, what is next?
Add 1 rapid acting insulin injection before the largest meal*
What is the dosing for the insulin injection before largest meal?
4 units, 0.1 unit/kg OR 10% of basal dose
What is the other option if A1c is not controlled after initiating insulin?
Change to premixed insulin twice daily (before breakfast and dinner)
What is the dosing for premixed insulin?
Divide the current basal dose into 2/3 AM 1/3 PM or 1/2 AM and 1/2 PM
Insulin adjustments
Determine which blood sugars arent at goal- FPG or Pre/post prandial dysfunction
What to do if the fasting plasma glucose is causing a problem?
Adjust the basal insulin
What to do if the pre or post-prandial glucose is causing a problem?
Adjust the bolus insulin
What to do if hyperglycemia all day?
“Fix the fasting first”
What is the starting dose for insulin naive Degludec?
10 Units daily
How do you convert from insulin to U-500 insulin if your A1c is >8%?
Start on 100% of the U-100 TDD
How do you convert from insulin to U-500 if the A1c is <8% or mean glucose is <183?
Start on 80% of the U-100 TDD
How do you convert U-100 to U-500 if dosing is BID (twice a day)?
Give 60% with breakfast and 40% with dinner
How do you convert U-100 to U-500 if dosing is TID (three times a day)?
Give 40% with breakfast, 30% with lunch and 30% with dinner
How do you adjust the basal insulin?
Titrate by 10-15% or 2-4 units 1-2 times/week to reach FPG goal
How do you adjust the bolus insulin?
Titrate by 10-15% or 1-2 units 1-2 times/week to reach PPG goal
If the post-breakfast or before lunch is the “dysfunctional glucose” which do you adjust?
Pre-breakfast rapid or short acting insulin
If the post-lunch of pre-dinner is the “dysfunctional glucose” which do you adjust?
Pre-lunch rapid or short acting insulin
If the post-dinner or at bedtime is the “dysfunctional glucose” which do you adjust?
Pre-dinner rapid or short acting insulin
If the early morning is the “dysfunctional glucose” which do you adjust?
Basal insulin or PM dose of NPH
When switching between insulin preparations, what is the majority conversion?
1:1
What is the exception to the 1:1 insulin conversion?
NPH -> Glargine U-100, U-300, insulin Degludec
What is the conversion for NPH -> Glargine U-100, U-300, insulin Degludec?
If once daily NPH its a 1:1 conversion
If BID NPH -> 80% of TDD given once daily
Hypoglycemia is a serum glucose level of what?
<70 mg/dL
What is the 15:15 rule?
If hypoglycemic, check the glucose, consume 15g of carbs, recheck in 15 minutes and repeat until levels normal
What else is important to prescribe with insulin?
Glucagon kit: make sure caregivers and family know how to use
What is lipohypertrophy?
Accumulation of subQ fat deposits
How can lipohypertorphy affect insulin?
Can reduce the absorption of insulin
What can cause lipohypertrophy?
Repeated injections at same site OR reuse of needles
How many units of insulin can the 1mL syringe hold?
Up to 100 units of insulin/syringe
What does each line represent in the 1mL syringe?
2 units
How many units of insulin can the 0.5mL syringe hold?
50 units of insulin/syringe
What does each line represent in the 0.5mL syringe?
Each line represents 2 units
How many units of insulin can the 3/10mL syringe hold?
Up to 30 units of insulin/syringe
What does each line represent in the 3/10mL syringe?
Each line represents 1 unit
