Diabetes Type 1 Therapeutics Flashcards
1
Q
approximately __% of cases of diabetes are type 1
A
10
2
Q
what are the 2 principle fuel of the body?
A
glucose and free fatty acids (stored as glycogen & triglycerides)
3
Q
the brain can only use what form of fuel?
A
glucose
4
Q
glucogenesis occurs in what organs?
A
liver and kidneys
5
Q
insulin is secreted by the ___ cells of the pancreas
A
beta
6
Q
insulin is secreted in high concentrations of ____ and suppressed in low concentrations
A
glucose
7
Q
meals cause what type of release of insulin?
A
biphasic relase (a large burst in the first 30 min and the the rest over 1-2 hrs post meal)
8
Q
how does insulin decrease blood glucose?
A
allows glucose to enter the cells to be used
9
Q
what is the effect of insulin of FFA?
A
helps them be stored as triglycerides
10
Q
what is the effect of insulin on glycogen?
A
helps the liver and muscles store glycogen for future use
11
Q
what causes GLP-1 to be released?
A
food (glucose)
12
Q
GLP-1 is secreted from ___
A
the intesting
13
Q
GLP-1 stimulates the release of ___
A
insulin from beta cells
14
Q
GLP-1 suppresses the release of ____
A
glucagon
15
Q
what is the effect of GLP-1 on food intake?
A
reduces it (why patients have significant weight loss)
16
Q
what is the effect of GLP-1 on gastric emptying?
A
slows
17
Q
what enzyme causes the degradation of GLP-1?
A
DPP-4
18
Q
what is glucagon?
A
hormone that increases the amount of glucose/fuel in the blood
19
Q
how does glucagon increase the amount of glucagon in the blood?
A
causes breakdown/release of stored glycogen in the muscle/liver (glucogenesis)
20
Q
glucagon converts FFAs into the ____ after prolonged starvation
A
ketone bodies
21
Q
type 1DM involves the autoimmune destruction of ____, which lead to insulin deficiency
A
beta cells
22
Q
t/f T1DM can be idiopathic, or there can be detectable antibodies to diagnose
A
t
23
Q
what are 3 classic symptoms of T1DM?
A
polydipsia, polyuria, polyphagia
24
Q
t/f the onset of T1DM is typically acute/severe
A
t, most patients are diagnosed by a DKA episode
25
what is the typical body type of T1DM?
usually lean, may have significant weight loss before diagnosis
26
t/f the malfunction of beta cells is progressive in T2DM
t
27
the rate of beta cell dysfunction in T2DM may be affected by the level of ___ control
glucose
28
in T2DM, impaired glucose may be present for ____ years before diagnosis
5-8
29
ketosis is rare in T2DM, but ____ is more common in poorly controlled T2 patients
hyperosmolar hyperglycemic state (HHS)
30
what is Latent Autoimmune Diabetes in Adults (LADA)?
when antibodies attack the pancreatic beta cells
31
LADA shares ___ aspects of both Type 1 and Type 2 diabetes
genetic
32
what is the therapy for LADA?
patients may not require insulin at diagnosis, but may progress to insulin over months to years
33
what do the BMI and antibody titers of LADA patients look like?
variable
34
what FPG is diagnostic of diabetes?
7.0 mmol/L or greater
35
what A1C is diagnostic of diabetes?
6.5% or more
36
what 2 hour PG in a 75g load OGTT is diagnostic of diabetes?
11.1 mmol/L or greater
37
what random PG is diagnostic of diabetes?
11.1 mmol/L or more
38
what are 2 acute complications of diabetes?
hypoglycemia and DKA
39
what are some microvascular complications of diabetes?
retinopathy, neuropathy, nephropathy
40
what are macrovascular complications of diabetes?
CVD, cerebrovascular dx, peripheral arterial dx, amputation
41
what are the ABCDESSS of diabetes?
```
A1C targets
BP targets
Cholesterol targets
Drugs for CVD risk reduction
Exercise & diet
Screening complications
Smoking cessation
Self-management, stress
```
42
hypoglycemia typically occurs when the BG is ___mmol/L
less than 4.0
43
what are the symptoms of mild hypoglycemia?
tremors, palpitations, sweating, anxiety, tingling, nausea, exercessive hunger
44
what are the symptoms of moderate hypoglycemia?
headache, mood changes, irritability, visual disturbances, dizziness
45
what are the symptoms of severe hypoglycemia?
unresponsive, unconscious, seizures, coma
46
hypoglycemia should be treated with ___
15g of carbs
47
give examples of 15g of carbs to treat hypoglycemia
1. glucose tabs
2. 3/4 cup of juice or reg soft drink
3. 6 lifesavers
4. 15ml honey
5. 15ml or 3 packs table sugar in water
48
if treating hypoglycemia, how long do you wait after taking the 15g of carbs to test BG?
15 minutes
49
if BG is above 4 15min after treating a low and the next meal is within an hour away, what do you do next?
you are good, can wait until next meal to eat, just be mindful of Sx
50
if BG is above 4 15min after treating a low and the next meal is more than 1hr away, what should be done?
eat a starch and protein snack
51
give 2 examples of starch/protein snacks that can be eaten between meals to prevent lows
7 crackers and 1 piece of cheese; 1 piece of bread and 2 tabs of peanut butter (can also mix and match the carb/protein)
52
what is the A1C target for most patients with type 1 or 2 diabetics?
7.0 or below
53
what is the typical A1C target for type 2 patients to reduce risk of CKD and retinopathy if patients are at low risk for hypoglycemia?
6.5 or less
54
what is the A1C target for patients who are functionally dependent?
7.1-8.0
55
what is the A1C target for patients with recurrent severe hypoglycemia and or hypoglycemia unawareness?
7.1-8.5%
56
what is the A1C target for patients with limited life expectancy?
7.1-8.5%
57
what is the A1C target for patients who are frail elderly w/wo dementia?
7.1-8.5%
58
you should not target an A1C higher than ___% to minimize hyperglycemia and acute/chronic complications
8.5%
59
what is the target FPG?
4.0-7.0
60
what is the target 2hr PPG?
5.0-10.0
61
what is the target 2hr PPG if the A1C targets are not being met?
5.0-8.0
62
what is the target LDL in diabetic patients?
2.0 mmol/L or less
63
what is the target BP for diabetic patients?
<130/80 mmHg
64
what bloodwork tests can be used to diagnose diabetes?
c-peptide, fasting insulin & antibody tests, urinalysis, electrolytes, TSH, CBC, ACR, SCr, eGFR
65
how often should A1C be monitored?
every 3 months; can be every 6 months if normal
66
how often should SCr and eGFR be tested?
periodically unless indicated
67
what are the benefits of exercise in diabetes?
1. improve comorbidities/complications
2. decrease insulin resistance
3. decrease development of peripheral neuropathy
4. weight management
68
t/f both aerobic and resistance exercise can be beneficial in diabetes
t
69
the recommended exercise regimen is ___minutes of aerobic exercise per week and ___ sessions of resistance training
150; 2
70
t/f all patients with diabetes should see a dietitian
t
71
t/f diabetic patients should eat 3 regular meals a day
t
72
what foods should be reduced in diabetic patients?
1. sugar-containing drinks
2. cream/sugar in coffee
3. fried foods
4. desserts and "unhealthy" snacks
73
what dietary elements should be increased in diabetic patients?
water, fruits and veg
74
what does the glycemic index of food mean?
refers to the amount of increase in BG the consumption of carbs when compared to glucose or white bread
75
foods with ____(lower or higher) glycemic index may help with BG control
lower
76
what is the effect of alcohol on BG?
can cause hypoglycemia
77
if a patient is on insulin or secretagogues, the hypoglycemia caused by alcohol can occur up to ___hrs after consumption
24
78
what are acceptable alcohol intakes for diabetic patients (once their BG levels are controlled) for women and men?
2 standard drinks/day or 10/week for women and 3/day or 15/week in men
79
t/f adequate food/carb intake is important before, during and after alcohol
t
80
what are some safety recommendations for alcohol consumption in diabetic patients?
1. monitor for lows through the night & early morning (set an alarm)
2. tell someone to look out for you
3. GLUCAGON MAY NOT WORK, call 911
4. wear medic alert bracelet
81
insulin reduces A1c by ___%
1.5-2.5%
82
is there a max insulin dose?
no
83
what are the side effects of insulin?
hypoglycemia, weight gain, hypokalemia
84
where can insulin be injected?
abdomen, upper arms, anterior.lateral thigh, butt
85
you should not inject insulin (or anything else) within __ cm of the belly button
5cm
86
is it recommended to wipe skin with alcohol before injecting insulin?
no (evidence does not suggest benefit and may cause stinging, but you can use alcohol on the catridge before placing the needle)
87
basal insulins are also called ____ insulin
background
88
basal insulins include ___ and ___ acting insulins
intermediate and long
89
what is an example of intermediate acting insulin?
NPH
90
what is the brand name of NPH insulin?
Humulin-N and Novolin ge NPH
91
what is the onset time for NPH (intermediate acting insulin)?
1-3hrs
92
what is the peak time for NPH (intermediate-acting) insulin?
5-8hrs
93
what is the duration for NPH (intermediate acting) insulin?
up to 18hrs
94
what are the types of long-acting insulin?
detemir (Levemir), Glargine U-100 (Lantus), Glargine U-300 (Tuojeo), Glargine biosimilar (Basaglar), Degludec U-100, U-200 (Tresiba)
95
what is the brand name of detemir?
levemir
96
what is the brand name of glargine U-100?
lantus
97
what is the brand name of glargine U-300?
tuojeo
98
what is the brand name of the glargine biosimilar?
basaglar
99
what is the brand name for degludec U-200?
tresiba
100
what is the onset time of long-acting insulins?
1.5hrs
101
what is the peak time of long acting insulins?
they have no peak
102
what is the duration of detemir?
16-24hrs
103
what is the duration of Lantus?
24hrs
104
what is the duration of tuojeo?
>30hrs
105
what is the duration of degludec?
42hrs
106
bolus insulin is also called ____ insulin
prandial/mealtime; short-acting, rapid-acting
107
regular insulin, aspart, faster-acting insulin aspart, lisipro, and glulisine fall under what category of insulin?
bolus
108
what are the 2 categories of bolus insulin?
Rapid-acting and short-acting
109
which insulins are rapid acting?
Aspart (Nove-Rapid), Gluisine (Apidra), Lispro U-100, U-200 (Humalog), faster-acting insulin aspart (Fiasp)
110
what is the brand name for Aspart?
Novo-rapid
111
what is the brand name for Glulisine?
Apidra
112
what is the brand name for Lispro U-200?
Humalog
113
what is the brand name for Faster acting insulin aspart?
Fiasp
114
what is the onset time of Aspart (Novo-Rapid)?
9-20min
115
what is the peak time for Apsart (Novo-Rapid)?
1-1.5hrs
116
what is the duration of Aspasrt (Novo-Rapid)?
3-5hrs
117
what is the onset time for Glulisine (Apidra)?
10-15min
118
what is the peak time of Glulisine (Apidra)?
1-1.5hrs
119
what is the duration of Glulisine (Apidra)?
3.5-5hrs
120
what is the onset time of Lispro U-100, U-200 (Humalog)?
10-15min
121
what is the peak time of lispro U-100, U-200 (humalog)?
1-2 hrs
122
what is the duration of lispro U-100, U-200?
3-4.75hrs
123
what is the onset time of FIASP?
4 min
124
what is the peak time of FIASP?
0.5-1.5hr
125
what is the duration of FIASP?
3-5hrs
126
insulin regular (Humulin R, Novolin ge Toronto) and Insulin regular (Entuzity U-500) are examples of what type of bolus insulin?
short-acting
127
what is the onset time of insulin regular (Humulin R, Novolin ge Toronto)?
30
128
what is the peak time of Insulin regular (Humulin R, Novolin ge Toronto)?
2-3hrs
129
what is the duration of Insulin regular (Humulin R, Novolin ge Toronto)?
6.5hrs
130
what is the onset time of Insulin regular (entuzity U-500)?
15min
131
what is the peak time of insulin regular entuzity U-500?
4-8hrs
132
what is the duration of Insulin regular entuzity U-500?
17-24hrs
133
what is premixed insulin?
short or rapid acting insulin mixed with intermediate acting insulin in various percentages (30/70, 40/60, 50/50)
134
when can pre-mixed insulin be useful?
in patients with less stringent A1C targets and those who dont want to (or cant) give more than 2 injections per day
135
how long does it take for Insulin glargine U-300 (Tuojeo) to reach steady state?
3-4 days
136
a ____% higher dose of insulin glargine U-300 (tuojeo) is required compared to insulin glargine
10-15%
137
when changing from U-300 glargine to U-100 glargine, how do you adjust the dose?
reduce the dose by 20%
138
how long does it take insulin degludec (tresiba) to reach steady state?
3-4 days
139
in insulin naive type 2 patients, what is the starting dose of insulin degludec (tresiba)?
10 units
140
in type 1 diabetes, how should the dose of tresiba be adjusted comapred to the dose of T2?
reduce by 20%
141
how often is tresiba titrated?
once weekly or every 4 days
142
insulin regular humulin R U-500 (Entuzity) provides both ___ and ____ coverage
basal & bolus
143
the insulin regular Humulin R U-500 (Entuzity) has pen increments of __Units
5
144
when dosing Insulin regular humulin R U-500 (Entuzity) BID, ___% is given before breakfast and ___% is given before dinner
60; 40
145
when insulin regular humulin R U-500 (Entuzity) is dosed TID, __% is given before breakfast, ___% before lunch and ___% before dinner
40%, 30%, 30%
146
insulin regular humulin R U-500 (Entuzity) should be given how soon before a meal?
30 min
147
when starting insulin in type 1 patients, what is the starting dose?
0.3--1.0 U/kg/day in divided doses (basal and bolus) --> usually 0.5u/kg/day
148
what doses of insulin may be appropriate in Type 1 patients in their honeymoon phase?
0.2--06 u/kg/day
149
___% of the daily insulin should be given as basal
40-60%
150
carb counting is usually started prior to starting what type of device?
insulin pump
151
how is an insulin carb ratio calculated?
total daily carbs / total daily bolus insulin
152
insulin carb ratios are adjusted based on what glucose reading?
2hr post-meal
153
what is the role of an insulin pump?
provides continuous infusion and allows for flexible timing of meals, exercise etc.
154
when a patient has an insulin pump, do they still need to give themselves a bolus at meals and/or snacks?
yes
155
what type of insulin do insulin pumps use?
rapid acting insulin
156
Using an insulin pump requires one injection every ___ days
3
157
t/f insulin pumps may have reduced frequency of severity of hypoglycemia
t
158
on sick days, how often should patients check their BG?
every 2-3 hours
159
should patients omit insulin on sick days?
NO! They may even need more insulin (monitor)
160
how often should patients check their ketones on sick days?
every 2-3 hours or when using the washroom
161
how should patients adjust their food intake on sick days?
try to keep carb intake as normal as possible using small meals and liquids containing carbs
162
when should patients call 811 or a healthcare provider during sick days?
if moderate to large ketones, cant keep BG above 4, vommiting/diarrhea for more than 24hors, signs of DKA, unable to manage insulin or take care of self
163
what happens in DKA?
a lack of insulin stimulates an accelerated starvation process with lipolysis and the formation of ketone bodies
164
when does DKA typically happen?
when patient is undiagnosed or newly diagnosed or if insulin has been omitted
165
what are the effects of DKA?
volume depletion, dehydration, decreased GFR, electrolyte depletion, and acidosis
166
what is the treatment regimen for DKA?
1. IV fluids (watch osmolarity --> rapid decrease can cause cerebral edema)
2. IV insulin (0.1u/kg/hr)
3. K to avoid hypokalemia
167
in DKA, what type of insulin needs to be given?
short acting (regular)
168
in DKA, insulin shoul be held until the K is greater than ___mmol/L
3.3
169
when managing glucose issues based on trends in a patient, you treat lows first and then you target what reading to fix next?
the first high glucose reading of the day
170
t/f sometimes you may need to adjust more than one insulin dose at a time, but try to only change one at a time
t
171
what is the Dawn phenomenon?
release of hormones in the early morning hours that cause rise in BG (cortisol is the hromone that causes this)
172
what is the Symogi effect?
rebound hyperglycemia caused by an episode of hypoglycemia, usually between 1 and 3 am
173
how can Dawn and symogi effect be diagnosed?
testing BG at bedtime and through the night and early moring
174
how often should BG be tested in type 1 diabetics?
at least as often as insulin is injected (before each meal and before bed)
175
in continuous glucose monitoring, how long can a sensor be worn?
6-7 days
176
Can continuous glucose monitoring completely eliminate finger-prick testing?
no
177
continuous glucose monitoring takes readings from what fluid?
interstitial fluid
178
how long can the freestyle libre sensor be worn?
14 days
179
can the freestyle libre give readings if you scan through clothing
yes
180
flash glucose monitoring (freestyle libre) provides glucose readings from what fluid?
interstitial fluid
181
what is the MOA of SGLT2 in diabetes?
decrease renal glucose resorption and decrease renal threshold for glucose
182
SGLT2 can decrease A1C in what timeframe?
3-6 months
183
what are the side effects of SGLT2 inhibitors?
increased yeast infections and UTI, increased BUN and SCR, decreased BP and hypovolemia
184
what is the effect of SGLT2 on weight?
weight loss
185
how much do SGLT2 decrease A1C?
0.5-0.8%
186
what are risk factors for DKA with SGLT2?
low carb intake/fasting, acute serious illness, elderly, surgery, decreased insulin dose, excessive alcohol intake
187
you should not drive if your BG is less than
4
188
when on long car trips, you should check you BG every __hrs
4
189
after a low, it may take ___minutes for your brain to recover
40
190
once you have treated a low, dont drive until your BG is above ____mmol/L
5.0
191
what type of insulin is "cloudy"
NPH
192
what needs to be done to NPH insulin before using?
inverted 10 times until it is uniform
193
if BG reaches ___mmol/L, you need to start checking your ketones
14
194
the optimal response of SGLT2 on A1C may take how long?
up to 6 months
195
what is the chemical rxn that occurs in a glucometer?
glucose in blood reacts with glucose oxidase to form glucuronic acid which then reacts with ferricyanide to form ferrocyanide which gets oxidized by an electrode that generates a current directly proportional to the glucose concentration
196
endogenous insulin is mostly broken down by the ___, exogenous insulin is mostly broken down by the ___
liver; kidenys
197
what are some situations when a patient needs to test their BG more?
1. pregnancy
2. sickness
3. exercise
4. hospitalization
5. when starting out on new dose
198
how is insulin stored?
fridge until opened, once opened keep at room temp for 1 month (will help prevent stinging)
199
how long can levemir and tuojeo be kept at room temp?
42 days
200
what affect does massaging a muscle have on insulin absorption?
increases it
201
order the injection sites of insulin in order of most to least well absorbed
1. abdomen
2. back or arms
3. thighs
4. butt
202
what is the effect of heat on insulin absorption?
increases
203
what is the effect of dehydration on insulin absorption?
slows
204
what is the effect of lipohypertrophy on insulin absorption?
decreases
205
what is the effect of insulin concentration on its absorption?
more dilute are absorbed faster than highly concentrated
206
what is the effect of renal impairment on insulin PK?
lowers insulin clearance and may prolong and intensify the action of endogenous and exogenous insulin
207
what is the effect of insulin antibodies on insulin PK?
IgG antibodies bind insulin as it is absorbed and release it slowly which delays or prolongs its effect
208
what is the effect of hyperthyroidism on insulin PK?
increases the clearance of insulin and increases the action of insulin making control difficult
209
what is the effect of hepatic impairment on insulin PK?
hepatic impairment puts patients at higher risk for hypoglycemia
210
when do you need to do a finger prick to test BG and CANNOT do it from alternate sites?
in hypoglycemia, sickness, not stable glucose levels
211
what is the effect of echinacea in diabetes?
some sources say it can lower BG by having an effect on insulin-induced adipocyte differentiation
212
what is the effect of pseudoephedrine on diabetes?
can raise BG, do not recommend taking it
213
what type of respirations in DKA cause CO2 levels to be low and O2 to be high?
Kussmaul's breathing
214
why is bicarb not frequently given to DKA patients?
there is not enough evidence to suggest using it and it can cause ADRs like increased hospitalization duration, worsening ketoenemia etc. and likely has no benefit over traditional therapy
215
why does hypokalemia occur in DKA?
hyperglycemia causes osmotic loss of fluid and electrolytes
216
why does the treatment of DKA cause hypokalemia?
insulin causes glucose to move into cells, which draws up more fluid, which also causes K to leave the blood and move into cells
217
why is D5W given to DKA patients?
too much glucose moving into the cells of the brain bringing water with it can cause cerebral edema, so they give D5W which cant cross membranes so it will keep some water in the blood
218
what is the screening test for diabetic retinopathy?
dilated eye exam
219
what is the screening test for diabetic neuropathy?
filament testing
220
what are the lon-term effects of diabetic retinopathy?
vision impairment, blurred vision, floaters, blindness, glaucoma
221
what are the possible treatments for diabetic retinopathy?
1. retinal photocoagulation (laser therapy_
2. vitrectomy
3. anti-vascular endothelial factor (VEGF) like ranibizumab
4. steroids
5. aldose reductase inhibitors
222
what are the 2 types of diabetic retinopathy?
proliferative and non-proliferative
223
how often should screening for complications occur in Type 1 and Type 2?
Type 1: within 5 years of diagnosis and then annually
| Type 2: on diagnosis and then yearly
224
what are the two classes of diabetic Neuropathy?
1. peripheral
| 2. autonomic
225
what are some treatments for diabetic neuropathy?
1. anticonvulsants (gabapentin, preganalin, valproate)
2. Antidepressants (amitriptyline, duoloxetine and venlafaxine)
3. dopamine agonists to promote gastric motility: metaclopramide & azithromycin
4. topicals (capsaicin and nitrates)
226
what are treatment options for diabetic nephroptahy?
1. SGLT2 inhibitors
2. RAAS blockers for BP
3. neurologic botanicals and anticholinergic to prevent retention
227
what are the screening tests for diabetic nephropathy?
ACR and eGFR
228
what ACR may indicate kidney damage?
2.0 or higher
