Diabetes Type 2 Flashcards
released from distal ileum and colon in response to food containing carbs and fats
GLP-1 (glucagon-like peptide)
T2DM Patients have a loss of what?
first phase insulin response
loss of amylin
a fasting plasma glucose of greater than what is considered a diagnosis of DM?
FPG>126
what is an impaired fasting glucose (IFG) “pre diabetes”
100-125
what is an impaired glucose tolerance test (2 hour post-load glucose)
140-199
who should be screened for DM?
any patient BMI >25
age >45 (no risk factors) and repeat every 3 years
what children should be screened for T2DM?
BMI>85th percentile Plus 2 of the following Family hx ethnicity associated w/ risk signs of insulin resistance maternal hx or gestational DM
what is involved w/ Polycystic ovarian syndrome
Hyperandrogenism Hirsutism Menstrual irregularities Obesity infertility
condition w/ excess growth hormone
acromegaly
condition w/ excessive corticosteroids
cushing’s syndrome
what are microvascular complications of DM?
Retinopathy
Nephropathy
Neuropathy
what are macrovascular complications of DM?
Atherosclerotic Cardiovascular diagnosis
Dyslipidemia
what is the A1C goal for people w/ T2DM?
<7.0%
what can patients who have IGT or IFG do you prevent progression of DM?
weight loss <7%) and increase physical activity
14 grams dietary fiber/ 1000 kcals
what are complications w/ gestational DM?
maternal morbidity
fetal macrosomia
higher rate of pre-eclampsia
mother at risk for developing T2DM later
risk factors for GDM?
severely obese previous GDM or large infant presence of glycosuria diagnosis of PCOS strong family hx
when are women screened for GDM?
at 24-26 weeks gestation
do an OGTT
women with GDM should be screened for DMT2 when?
6-12 weeks postpartum
what is the cornerstone of management of T2DM?
diet (>7% weight loss) and exercise (150 min/wk minimum)
what other changes changes can help someone w/ T2DM lower CV risk
Smoking cessation
Lipid management
Blood Pressure control
Antiplatelet therapy
patient on oral meds for glucose control use SMBG to do what?
help them achieve their glycemia goals
when should A1C be taken for someone at goal?
twice a yaer
when should A1C be checking for someone not at goal?
every 3 months
what drugs class has the MOA of “Direct stimulation of insulin release from viable pancreatic beta-cells thus reducing blood glucose levels (↑ insulin secretion)”
sulfonylureas
at high doses what do sulfonylureas do?
decrease hepatic glucose production (decrease levels of glucagon)
how much do sulonylureas decrease A1C by?
1.5%
why are 1st generation sulfonylureas not used?
resulted in hypoglycemia
what are the names of the 2nd generation sulfonylureas
Glyburide
Glipizide
Glimepride
what type DM can’t you use sulfonylureas in?
GDM
T1DM
ADRs of sulfonylureas?
Hypoglycemia (elderly, hepatic or renal impairment)
weight gain
when should glyburide be administered?
Administer with breakfast or first main meal
what sulfonylureas has the greatest risk of hypoglycemia due to longer 1/2 life and no recommended with CrCl<50
not a first line agent
Glyburide
sulfonylurea that is administered 30 minutes before first main meal and not recommended with CrCl<10
glipizide
sulfonylureas that you Administer with first main meal
Not recommended if CrCl < 22 ml/min
glimepiride
when is there reduced GI absorption w/ sulonylureas
Reduced GI absorption if blood glucose > 250 mg/dL
when do you monitor FPG w/ sulfonylureas
in 2 weeks
A1C in 3 months
contraindications w/ sulfonylureas
sulfa allergy
avoid with ETOH
pregnant
drug interactions w/ sulfonylureas
Sulfonamide antibacterials Propranolol Salicylates Phenylbutazone ETOH
oral diabetic med that Stimulate insulin release from pancreatic beta-cells
Shorter half life than sulfonylureas
Rapid release of insulin that only lasts 1-2 hours
meglitinides
when do you take meglitinides?
with meals
targetes postprandial glucose levels
what are the 2 meglitinides?
repaglinide
nateglinide
meglitinide that is Approved for monotherapy or in combination w/metformin.
Taken before meals 3 X/day
Allergy to sulfas not an issue
ADR hypoglycemia
repaglinide
meglitinide that is Phenylalanine derivative
Faster onset of action and shorter duration of action than repaglinide; less A1C reduction than repaglinide
Approved for monotherapy an combination w/metformin.
Taken 3X/d before meals
nateglinide
adrs w/ meglitinides?
hypoglycemia
weight gain
monitoring w/ meglitinides
FPG at 2 weeks
Postprandial glucose at initiation
A1C at 3 months
DOC for treatment of T2DM
Metformin
MOA of metformin
Does not affect insulin secretion but requires the presence of insulin to be effective.
decreases production of hepatic glucose production.
decreases intestinal glucose absorption.
increases peripheral glucose uptake.
increases insulin sensitivity
what type patient does metformin work best in?
patients w/ significant hyperglycemia
ADRs w/ metformin
GI symptoms (decrease if taken w/ food) lactic acidosis (increase w/ renal failure, CHF, hypoxemia, ETOH)
monitoring for metformin
SCr at baseline
FPG at 2 weeks
A1C at 3 months
worst side effect w/ metformin
lactic acidosis
contraindications w/ metformin
SCr >1.5 in men and 1.4 in women
acute or chronic metabolic acidosis
precautions to use w/ metformin
radiocontrast studies Age >80 (unless normal GFR) hypoxic states liver dysfunction alcoholism heart failure requiring pharmacologic tx
benefits of metformin
No weight gain
No hypoglycemia as monotherapy
Inexpensive
Approved for use as monotherapy and in combination with other therapy
what are 2 thiazolidinediones (TZDs) (Insulin sensitizers)
rosiglitazone and pioglitazone
how much do TZDs decrease A1C?
0.5%-1.4% (May take 4 weeks for effect)
what is required for TZD action?
endogenous insulin
beneficial CV effects w/ pioglitazone
increased HDL
decreased triglycerides
with rosiglitazone what CV benefits are there?
increase LDL (not beneficial) but increase HDL
ADRs w/ TZDs
fluid retention
weight gain
redistribution of adipose tissue
new onset heart failure (higher when combined w/ insulin)
Contraindications w/ TZDs
alcohol abuse
elevated liver enzymes (D/C if LFTs elevated 2-3 times ULN)
Hf NYHA class III or IV
BBW and TZDs
increased risk of CHF and MI risk
what drugs Delays intestinal carbohydrate absorption
Inhibits alpha-glucosidase found in the small intestinal brush border
Prevent glucose absorption and post-prandial glucose levels
alpha-glucosidase inhibitors
what are 2 alpha-glucosidase inhibitors
acarbose
miglitol
how much do alpha-glucosidase inhibitors decrease A1C by?
A1C 0.5-0.8%
ADRs of alpha-glucosidase inhibitors
loose stools
flatulence
monitoring w/ alpha-glucosidase inhibitors
Post prandial glucose at initiation
A1C in 3 months
contraindications w/ Alpha-Glucosidase Inhibitors
Chronic intestinal disease
Cirrhosis
what drug class Prevent degradation of endogenous glucagon-like peptide-1 (GLP-1) and insulinotropic polypeptide (GIP)
Incretin hormones released in response to meal
Increase insulin synthesis and release from beta cells
Intracellular signaling
GLP-1 also lowers glucagon secretion from pancreatic alpha cells
Dipeptidyl peptidase-4 (DPP-4) inhibitor
what drugs are Dipeptidyl peptidase-4 (DPP-4) inhibitors
Sitagliptin (Januvia®)
Saxagliptin (Onglyza)
how much do Dipeptidyl peptidase-4 (DPP-4) inhibitors decrase A1C
A1C 0.5-0.7%
benefits for DPP-4 inhibitors
weight neutral
approved for monotherapy or combo
weight neutral
Bile acid sequestrant: received FDA indication in January 2008 for Type 2 diabetes as an adjunct to diet and exercise
previously approved for LDL reduction
Colesevelam (WelChol)
efficacy of Colesevelam (WelChol)
0.4-0.8% A1C decrease
has Colesevelam (WelChol) been studied as monotherapy
no
ADRs of Colesevelam (WelChol)
constipation/ nausea/ indigestion
increase triglycerides
Contraindications w/ Colesevelam (WelChol)
Bowel obstruction
History of hypertriglyceridemia-induced pancreatitis
Triglycerides >500 mg/dL
what is a glucagon-like peptide peptide 1 (GLP-1) agonist?
exenatide (byetta)
what is the efficacy of exenatide?
decrease A1c by 0.5-1%
what is exenatide FDA approved for?
T2DM in patients on metformin, sulfonylurea, TZD or a combo who aren’t at goal
is exenatide approved with use for basal insulin?
No
ADRs w/ exenatide
N/V/D
modest weight loss
anti-exenatide antibodies
what ADR can exenatide cause w/ espeically sulonylureas
hypoglycemia
what monitoring needs to be done w/ exenatide?
renal function
A1C in 3 months
contraindications w/ exenatide?
T1DM
precautions w/ exenatide
ClCr <30 (changes dose)
gastroparesis
hypoglycemia
SubQ injection that is FDA approved for Type 1 or 2 diabetes in patients on optimal insulin therapy who are still not at goal
With or without metformin and/or sulfonylurea therapy
pramlintide
what is pramlintide administered in conjuction w/?
mealtime insulin
additional med for people with CHD and DM?
81 mg aspirin
what are the first lines for HTN for people w/ DM?
ACEI or ARB in combo w/ thiazide diuretic
what is the goal BP for a diabetic patient?
<130/80
if a DM patients is over the age of 40 w/ a risk factor or overt CVD what should be added?
statin
if a statin isn’t tolerated what should a DM be placed on as well?
BAR (bile acid resin)
niacin
fibrate
is a life threatening condition similar to DKA
Extreme hyperglycemia and fluid deficits
Arises from inadequate insulin but occurs primarily in older type II patients
hyperosmolar hyperglycemic state (HHS)
what is the different between hyperosmolar hyperglycemic states (HHS) and DKA?
HHS lacks lipolysis, ketonemia, and acidosis
Diagnostic criteria for hyperosmolar hyperglycemic states (HHS)
Plasma glucose > 600mg/dL
Serum osmolality of > 320 mOsm/kg
Tx for hyperosmolar hyperglycemic states (HHS)
Rehydration
Correction of electrolyte imbalances
Continuous insulin infusion
Reduce blood glucose levels gradually to avoid cerebral edema
