Diabetes Type 1 & 2/Hypoglycemia

Question 1

Oral Hypoglycemic:

Metformin:
Biguanide, AKA Glucophage. First line medication recommended by ADA and AACE for DM2

1. Suppresses excessive hepatic production of glucose
2. Enhances glucose utilization in peripheral tissues.
3. Reduces fasting and PP hyperglycemia
4. May reduce intestinal absorption of glucose
5. Does not stimulate endogenous insulin production.
6. Can provide cardiovascular protection and contribute to weight loss.

Can be used as monotherapy unless contraindications or intolerance.

Answer 1

Contraindications:

Black Box Warning:
Lactic acidosis= At risk are liver impaired, ETOH abuse, cardiopulmonary insufficiency.

Should be discontinued 24-48 hrs before diagnostic and surgical procedures due to risk of decreased kidney function. Do not resume for at least 6 hrs or adequately hydrated.

Start 500 mg once q.d. With breakfast or dinner x 1 week. Then titrations to b.i.d. to max 2000 mg.

Common SEs:
N/V, diarrhea, abdominal discomfort.

May cause Vitamin B12 deficiency, so periodically test B 12 levels (especially if peripheral neuropathies).

Question 2

Oral Hypoglycemic:

Sulfonylureas require functioning beta cells to be effective, T or F?

Answer 2

True; sulfonylureas stimulate pancreatic insulin secretion; thus, beta cells must still be producing insulin for sulfonylureas to work.

They do not decrease insulin resistance.

Second generation sulfonylureas provide better effect on A1C, approximate 1.5% decrease.

However, carry higher risk of weight gain and hypoglycemia.

Start at lowest possible dose once daily before breakfast; can be increase every two weeks.

Mild GI upset, diarrhea, weight gain are adverse side effects. Serious side effects are hypoglycemia and anemia.

Not for those with liver impairment (metabolized in liver) or in third trimester pregnancy or planning pregnancy.

Number of meds can potentials sulfonylureas effects, resulting in hypoglycemia.

Question 3

Acarbose and Miglitol:
Alpha-glucosidase inhibitors which slow the breakdown of complex CHOs into monosaccharides. Occurs on borders of brush villi, thereby decreasing postprandial blood sugars.

Answer 3

Adverse effects:

Flatulence and diarrhea

Question 4

Two classes of Incretin Mimetics:

Incretins suppress glucagon secretion and modestly reduce A1C by 0.5%-0.8%.

Answer 4

DPP4-Is and GLP1 analogues

Can be used as monotherapy, but are more likely to be used as add on therapy to Metformin.

Can cause severe joint pain and Stens-Johnson’s Syndrome.

Question 5

Patients with severe insulin resistance will likely respond better to which two of the following three medication:

1. Sulfonylureas
2. Metformin
3. Thiazolidenidiones.

Answer 5

Metformin and Thiazolidenidiones

Question 6

GLP1 Analogues

Answer 6

Enhance insulin secretion in a glucose-dependent manner in response to food intake.

Also increase insulin sensitivity, increase beta cell mass, and decrease glucagon secretion. Decrease food’s appeal and prolongs its time in the stomach.

Injectables-daily or weekly must be slowly increased over time from initial dosing.

Contraindicated I’m thyroid carcinomas.

Question 7

Metformin and Thiazolidinediones are good options with insulin if needed. T or F?

Answer 7

True

They increase peripheral tissue sensitivity to insulin, so less insulin is needed.

Question 8

True or False:

Sulfonylureas are likely to contribute to hypoglycemia when given in conjunction with insulin?

Answer 8

True

Sulfonylureas increase endogenous insulin production, so would contribute to hypoglycemia when given as dual therapy with insulin.

Question 9

Which classes of antihypertensives are recommended for diabetic patients?

Answer 9

ACEI and ARBS

They help protect the kidneys from disease and damage.

Question 10

Hypoglycemia:

Answer 10

Blood glucose level <55 in the adult, OR, clinical hypoglycemia occurs when the blood glucose level is low enough to cause signs or symptoms.

Question 11

Where in the CNS are hypoglycemic sensors located?

Answer 11

Hypothalamus

Question 12

Fast Acting Insulin:

Three types

Answer 12

Insulin Glulisine (Apidra): Onset <5 min. Peak 1-2; Duration 2-3

Insulin Aspart (Novolog): Onset <10 min.

Insulin Lispro (Humalog): Onset <15 min.

Question 13

Somogyi Effect:

Answer 13

A unique combination in which a diabetic develops hypoglycemia during the night with rebound hyperglycemia in the morning. Most commonly observed in children with Type 1 DM