Diabetes Therapeutics Flashcards
according to the ADA, what are the recommendations for tailoring diabetes treatment to reduce disparities?
-providers should assess social context, including potential food insecurity, housing stability, and financial barriers
-patients should be referred to local community resources when available
-patients should be provided with self-management support
according to the ADA, what are the criteria for testing in asymptomatic adults?
1. all adults ___ years or older, if normal, repeat every __ years
2. patients with prediabetes should be tested _____
3. women with history of GDM should be tested every __ years
4. testing every _____ years should be considered if BMI is over ____ (or BMI over _____ in asian americans) and at least one of the following risk factors???
35, 3
yearly
3
1-3, 25, 23,
-first-degree relative with diabetes
-women with PCOS
-hypertension
-HDL under 35 and/or TG over 250
-history of CVD
-physical inactivity
-BMI over 40
blood glucose levels used to diagnose diabetes based on fasting plasma glucose and 2-hour plasma glucose (after 75-g OGTT)?
**diagnosis of Diabetes requires what in regards to testing?
Fasting plasma glucose:
diabetes: over 126
2-hour plasma glucose (after 75-g OGTT):
diabetes: over 200
**2 Abnormal test results
define latent autoimmune diabetes (LADA)
autoimmune diabetes associated with older age (30-50 y/o), presence of islet autoantibodies, and a slower progression to insulin requirement
what are examples of disease-induced diabetes?
hyperglycemia caused by systemic infections, hyperthyroidism, pancreatitis, cushing syndrome, cystic fibrosis, and organ transplant
what are examples of drug-induced diabetes?
transplant meds and corticosteroids
define monogenic diabetes
genetic defects resulting in Beta-cell dysfunction
when do we screen for gest. diabetes in pts w/ risk factors for DM?
if no risk factors?
at first prenatal visit
24-28 weeks of gestation (third trimester)
how do we test for gest. diabetes?
what lab values confirm gest. diabetes?
1-step 75g OGTT or 2-step with 50g followed by a 3 hour 100g OGTT for those who screen positive
1-step:
Fasting over 92
1 hr over 180
2 hour over 153
2-step:
Fasting over 95
1 hr over 180
2 hr over 155
3 hr over 140
what is the C-peptide level at diagnosis for T2DM, T1DM, and LADA?
T2DM: normal to increased , can be low if late
T1DM: very low or undetectable
LADA: decreased but still detectable
Guidelines to diagnosing diabetes: Adult with suspected type 1 diabetes—
Test islet autoantibodies. if positive?
if negative, check C-peptide. what does C-peptide level tell us?
type 1 diabetes
if over 200 perform genetic testing for monogenic diabetes. if under 200 diagnose with T1 diabetes.
what did the Diabetes Prevention Program show?
lifestyle changes with intensive diet and exercise is significantly better at preventing diabetes than prescribing metformin
patients with prediabetes should be referred to?
what are the goals?
an on-going support program modeled on the diabetes prevention program
7% weight loss and at least 150 min/week of moderate activity
T/F no drug therapies are approved for diabetes prevention, but metformin may be considered
true
for starting a statin:
initiate if LDL is over?
if age 40-75 with diabetes?
190
start moderate-intensity statin and determine use of high-intensity
in a pt with ASCVD risk 5-7.5%, what risk enhancers would make you consider a moderate-intensity statin?
-family history
-LDL chronically over 160
-TG chronically over 175
-CKD
-metabolic syndrome
-preeclampsia, premature menopause
-inflammatory diseases
-ethnicity (south asian)
For diabetes care, how often should the following be assessed?
height/weight, blood pressure, lifestyle management, depression
every visit
how often should a diabetic foot exam, dilated retinal exam, and urinary albumin be performed?
at least annually
when do we prescribe aspirin for diabetics?
what about clopidogrel?
secondary prevention with a history of ASCVD, potentially primary prevention depending on pt bleeding risk
use clopidogrel 75mg for pts with ASCVD and documented aspirin allergy
what did the ASCEND trial show?
aspirin was not much more effective at preventing adverse bleeding outcomes compared to placebo
what is diabetic ketoacidosis (DKA)?
uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketones
what is hyperosmolar hyperglycemic state (HHS)?
severe hyperglycemia, hyperosmolality, and dehydration w/o ketoacidosis
what are the characteristics of DKA?
-glucose over 250
-ketosis (beta-hydroxybutyrate over 3)
-acidosis (pH less than 7.3)
-bicarb/CO2 less than 18 (bodies response to decreasing pH)
-anion gap over 10-12
-positive urine or blood acetoacetate
what are the signs/symptoms of DKA?
-excessive urination
-severe thirst
-blurred vision
-signs of dehydration
-warm dry skin
-kussmaul respiration (deep breathing due to high CO2 compensation
-fruity odor breath
-progressive mental status changes
what are common causes of DKA?
what meds increase the chance of DKA?
-missed insulin doses
-infection
-new-onset DM
-clozapine, olanzapine, steroids, SGLT2-is (for T1DM)
what is the primary cause of HHS? other causes?
infection
missed med doses, MI, stroke, and trauma
signs/symptoms of HHS?
-hyperglycemia, but little acidosis
-symptom progression over days
-severe dehydration
what are characteristics of HHS? (distinguishes it from DKA)
-glucose over 600
-pH over 7.3
-bicarb/CO2 over 15
-urine or blood beta-hydroxybutyrate less than 3
-serum osmolality over 320
-anion gap under 12
-urine or blood acetoacetate negative or low positive
how do we treat hyperglycemic crises?
give fluids, potassium repletion to correct acidosis, and give insulin to correct hyperglycemia (causes decrease in potassium)
IV fluid administration protocol during hyperglycemic crisis:
administer 0.9% NaCl at 500-1000 ml/h during first 1-2h. if still low give 25-500 ml/h
when glucose reaches 200-250 change to 5% dextrose with 0.45% NaCl until resolution of ketoacidosis
insulin administration protocol during hyperglycemic crisis:
IV/SC
IV: 0.1 U/kg IV bolus then IV infusion
SC: 0.2 U/kg SC bolus then every 2h
check serum or capillary glucose every 1-2h. when it reaches 200-250, reduce insulin to 0.1 u/kg SC every 2h until resolution of ketoacidosis
potassium administration protocol during hyperglycemic crisis:
if serum K+ less than 3.3, hold insulin and give KCl until over 3.3. Target is 4-5
what about protocol for pH less than 6.9 during hyperglycemic crisis?
mix of NaHCO3 (sodium bicarb) ,H2O and KCl and infuse over 2 h until pH over 7 and monitor K+
DKA or HHS is considered resolved when?
patient alert and osmolality below 315
patient able to eat
hypoglycemia is classified as any decrease in plasma glucose less than?
what population group is more vulnerable?
70
young children and elderly
a 1% change in A1C increases the risk of hypoglycemia by ___
reducing A1C from 7% to 6% results in an increase from 60 to ___ episodes of hypoglycemia
42%
85
which medications contribute to hypoglycemia?
insulin, sulfonylureas (glipizide, glyburide), meglitinides (glinides), and quinolones (both high and low blood sugar)
1st signs of hypoglycemia?
other signs?
hunger, irritability
shaking, sweating, fast heardbeat, fatigue, HA, impaired vision
why would people with frequent hypoglycemia be at an increased risk of not being able to recognize hypoglycemic symptoms?
-reduced epinephrine response to low glucose
-increased expression of GLUT 1-3 (GLUT-4 has decreased function) causing more efficient glucose uptake which prevent sx of low glucose
how do we treat mild hypoglycemia?
severe?
“rule of 15”: eat 15g carb and re-check in 15 min
glucagon kit
what are we measuring when we measure a pts fructosamine?
measures the amount of glycated albumin reflecting average glucose over 2-3 wks
how can we average a pts estimated glucose given their A1C?
(A1C - 2) x 30
every 10% increase in time in range corresponds to _______ A1C reduction… so 70% TIR is approximately what A1C?
0.5-0.8%
7%
what factors may impact A1C due to changing red blood cell turnover?
sickle cell disease, pregnancy/postpartum, hemodialysis, recent blood loss/transfusion, or erythropoietin therapy
according to the ADA, what are the glycemic goals for diabetics? (A1C, pre-prandial, 1-2h peak post-prandial)
what about the AACE?
A1C: <7
pre-p: 80-130
post-p: <180
A1C: <6.5
pre-p: <110
post-p: <140
according to the ADA what are the glycemic goals in pregnancy? (A1C, pre-prandial, 1/2h peak post-prandial)
A1C: <6%
pre-p: under 95
1h post-p: under 140
2h post-p: under 120
time in range goal in pregnancy (based off CGM) should be?
70% of the time below 140
what is the glycemic target in hospitalized pts?
140-180
what are considerations for individual glycemic targets for patients?
-risk of hypoglycemia and adverse drug effects— low risk = more stringent A1C goals, high risk= less stringent A1C goals
-patient preference– assess based on pts motivation and self-care
patients who are hypoglycemic are at an increased risk of?
CVD leading to CV death
AACE guidelines: diabetes + ASCVD or high risk for ASCVD– best drug classes?
GLP-1 or SGLT2-i
AACE guidelines: diabetes + HF – best drug classes?
SGLT2-i
AACE guidelines: diabetes + stroke – best drug classes?
GLP-1 or pioglitazone
AACE guidelines: diabetes + CKD – best drug classes?
SGLT2-i or GLP-1
when should insulin be considered for T2DM?
CBGS > 300 or A1C >10%
which SGLT2-is have benefits for ASCVD?
empagliglozin and canagliflozin
which SGLT2-is have benefits for HF?
empagliflozin and dapagliflozin
which SGLT2-is have benefits for CKD?
empagliflozin, canagliflozin, and dapagliflozin
which GLP-1 or GLP-1/GIPs have benefits for ASCVD?
liraglutide, semaglutide, and dulaglutide
which GLP-1 or GLP-1/GIPs have benefits for HF?
all neutral
which GLP-1 or GLP-1/GIPs have benefits for CKD?
liraglutide, semaglutide, and dulaglutide
which TZD may have benefits for ASCVD?
pioglitazone
which drug classes can cause weight gain in diabetes?
TZDs, sulfonylureas, and insulin
what eGFR rate is considered kidney impairment?
under 60
what is first-line therapy in a pt with no co-morbidities with newly diagnosed DM?
lifestyle modifications and metformin ER (less SEs than IR, and only if eGFR is over 30)
what is a reasonable A1C goal for a healthy older adult?
what about older adult with complex impairments?
<7-7.5%
<8%
if a patient’s primary goal is to minimize risk of hypoglycemia, what drug classes should be avoided for treating DM?
sulfonylureas (especially glyburide) and insulins
first-line treating diabetes in a pt with compromised kidney function is an SGLT-2 inhibitor, what is an important counseling point?
can cause UTIs: wear cotton underwear and rinse area with water after urinating to prevent them
first-line treating diabetes in a pt with ASCVD, our best evidence is the use of? other patients included would be pts without CVD, but are over 55 and have 2 risk factors, which are?
GLP-1 RAs
obesity, HTN, smoking, HLD, and albuminuria
first-line treating diabetes in a pt with HF are?
SGLT2-is
first-line treating diabetes in a pt with liver dysfunction are?
pioglitazone and GLP-1s, semaglutide has the best evidence
which drug classes would be best considered if the pts primary goal is to minimize costs?
metformin, TZDs, sulfonylureas, and insulin N,R
what is acarbose? how does it work?
alpha-glucosidase inhibitor: slows the action of certain enzymes that break food down into sugars. This slows down digestion of carbohydrates to keep your blood sugar from rising very high after you eat.
which DPP-4 is contraindicated in pts with HF?
saxagliptin
