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Pharmacology II - Emily Britton > Diabetic medications > Flashcards

Diabetic medications Flashcards

1
Q

GLPs go up to the brain and tell your body to release _________. Also tell your brain to stop _________.

A

insulin / eating

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2
Q

Eating stops or slows down _________ in the liver and begins ________storage

A

gluconeogenesis / glyocgen

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3
Q

Characterisitics of Type I DM

A

before age 30, abrupt onset, requires exogenous insulin to treat, ketoacidosis prone, wide fluctuations in BG concentration, THIN body habitus

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4
Q

Genetically predisposed Type I DM

A

altered human lymphocyte antigen on the short arm of chromosome 6, defects causes “insulinitis”. Autoantibodies may be detected at the time of diagnosis but maybe absent years later.

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5
Q

S/S at time of dx for DM I

A

hyperglycemia, ketoacidosis, 3Ps

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6
Q

Type II DM characteristics

A

not ketoacidosis prone, may require exogenous insulin, obese body habitus, relatively stable BG concentration

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7
Q

DM diagnosis for fasting and random BS

A

Fasting BS 126 mg/dl or greater, Random BS >200 mg/dl

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8
Q

BG monitoring ISO guideline 15197 suggests that for glucose levels <75 mg/dl, a meter should read within ____ mg/dl of the reference sample, and for levels greater than or equal to 75 mg/dl, the reading should be within ___%. A meter should also be able to meet these targets in at least 95% of the samples tested.

A

15 mg/dl / 20%

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9
Q

Measure of the percent of Hgb that has been non-enzymatically glycosylated by glucose on the beta chain

A

HgA1C

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10
Q

Normal A1C

A

4-6%

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11
Q

ADA recommends HgbA1C range of_____ depending on the age of the diabetic patient

A

<7-8.5%

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12
Q

T/F Trying to hit A1C targets or reducing blood sugars fast are not showing any better outcomes and actually the outcomes are worse.

A

TRUE

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13
Q

The insulin storage molecule is a ___________

A

pro-insulin

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14
Q

Proinsulin, which is converted to insulin by proteolytic cleavage of amino acids ________ and the connecting peptide.

A

31, 32, 64, and 65

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15
Q

review slides 16 and 17 regarding

A

insulin and receptors

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16
Q

Insulin MOA: Insulin binds to plasma membrane insulin ________. The _________ receptor substrates then activate or inactive numerous enzymes and other mediating molecules. Translocation of glucose transporters to _______ ____________

A

receptor / phosphorylated / plasma membranes

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17
Q

Glucose transporters facts

A

fascilitate glucose diffusion into cells, shift intracellular glucose metabolism towards storage (glyocenesis), stimulate cellular uptake of amino acids, phosphate, potassium, and magnesium. Stimulate protein synthesis and inhibit proteolysis, regulate gene expression via insulin regulatory elements in target DNA.

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18
Q

Massive rush of insulin secretion results in cellular uptake of ___________ which results in RE-FEEDING syndrome that can be ______.

A

Phos, potassium, mag / fatal

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19
Q

Occurs when there is an impaired intracellular insulin signal that results in decreased rectuitment of glucose transport proteins to the plasma membrane and subsequently decreases glucose uptake

A

insulin resistance

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20
Q

With insulin resistance, compensatory ___________ occurs to overcome this resistance

A

hyperinsulinemia

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21
Q

This occurs with low circulating concentrations of insulin

A

insulin receptor saturation

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22
Q

Insulin receptor number is ______ related to the plasma concentration of insulin. Insulin can regulate the population of __________

A

receptors

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23
Q

With insulin, the effect is longer than the ______

A

half-life

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24
Q

The elimination t1/2 of IV insulin is ___ to ___ minutes. It is metabolized in the kidneys and liver. ___% of the insulin that reaches the liver via the portal circulation is metabolized on a single pass through the liver.

A

5 to 10 minutes / 50%

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25
Q

Although half of insulin that reaches the liver is metabolized by a single pass through the liver, _______ dz prolongs the elimination t1/2 more than liver dz.

A

kidney

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26
Q

Despite rapid clearance from the plasma, there is a sustained pharmacologic effect of insulin for about __ to ___ minutes because insulin is tightly bound to ______ receptors

A

30 to 90 / tissue

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27
Q

Insulin administered ____ is released slowly into the ciruclation to produce a sustained biological effect

A

SQ

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28
Q

Basal rate of insulin secretion by the pancreas is ___ units/hr

A

1

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29
Q

Food prompts a __ to __ fold increase in insulin secretion. Total daily secretion of insulin is approximately ___ units/day

A

5 to 10 / 40 unit

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30
Q

ANS effects on insulin secretion

A

beta 2 receptors alpha 1 receptors

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31
Q

Insulin response to glucose is greater for _____ ingestion than for IV infusion

A

oral

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32
Q

_______ is good for those that are not very good at remembering to take their insulin

A

tresiba

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33
Q

Tresiba duration

A

up to 42 hours

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34
Q

review slides 22 and 23 regarding

A

insulin types and duration

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35
Q

Older insulin agents are made from ____ and ______.

A

beef and pork

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36
Q

_____ is one of the top 5 drugs that send people to the ER. Most severe effect from insulin is __________

A

insulin / hypoglycemia

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37
Q

New agents are produced by ______ _________. So allergy or immunoresistance that could accompany admin of animal insulins is no longer a significant problem

A

recombinant technology

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38
Q

Only _____ ______ insulin can be given IV, via a pump

A

short-acting

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39
Q

Side effects of insulin

A

hypoglycemia, hypokalemia, allergic reactions, lipodystrophy, insulin resistance, drug interactions

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40
Q

Hypoglycemia symptoms reflect the compensatory effects of increased epinephrine which are

A

diaphoresis, tachycardia, HTN

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41
Q

Rebound hyperglycemia caused by SNS activity in response to hypoglycemia may mask the correct diagnosis. This is referred to as the _____ ____

A

Somogyi Effect

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42
Q

CNS symptoms of hypoglycemia include mental confusion progressing to _____ and ______

A

seizures and coma

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43
Q

T/F hypoglycemia diagnosis is difficult under GA based on symptoms

A

TRUE

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44
Q

Local allergic reactions present as what and are due to what

A

red hardened areas at the site of injection due to noninsulin materials in the preparation

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45
Q

Chronic ____ admin may lead to the development of antibodies to protamine

A

NPH

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46
Q

Insulin resistance is when patients require greater than _____ units/day

A

100 units/day

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47
Q

Acute insulin resistance is associated with _____, _____ and _______. This leads to a _______ of receptors

A

trauma, surgery, infection / down-regulation

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48
Q

Hypoglycemic effects of insulin is countered by

A

ACTH or glucocorticoids, estrogren, glucagon

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49
Q

Epinephrine effects on insulin

A

inhibits the secretions of insulin, stimulates glycogenolysis

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50
Q

Typical dose of long-acting or intermediate insulin is ___% while the additional rapid-acting doses are _____%

A

70% / 30%

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51
Q

External pump sites are changed every __ to ___ days

A

2 to 4

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52
Q

Inhaled insulin is called

A

Afreeza

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53
Q

Afreeza is a ______ acting insulin with an onset of about __ to ___ minutes and duration of ____ hrs

A

rapid / 10-15 min / 3 hrs

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54
Q

Insulin sliding scales should not be used alone without basal coverage unless someone is on a steroid and not ___________

A

diabetic

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55
Q

For someone with DM II and less than 24 hrs NPO, can cover with _____ acting insulin but if NPO longer than 24 should really be on a _____ and _____ acting

A

short / long and short

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56
Q

Glucose molecules are ______ and cause what kind of complications

A

large / atherosclerosis, neuropathy, nephropathy, retinopathy

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57
Q

The number one cause of dialysis, retinopathy, and non-traumatic amputation is _________

A

diabetes

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58
Q

Risks of hyperglycemia

A

microanigiopathy, impaired leukocyte function, cerebral edema, impaired wound healing, postop sepsis, hyponatremia

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59
Q

Glucose overpowers _________. End up holding onto more fluid because the body is trying to match the _________ due to the large glucose molecules

A

Na / osmolarity

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60
Q

Higher rather than low BG is desired under GA because GA can ______ the signs of low BG. Optimal BG is ___ to _____, <150 for __________

A

mask / 80-180 / total joints

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61
Q

When should an IDDM patient be operated on

A

first case in the morning

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62
Q

Ideally, with an IDDM patient you should start an infusion of ____ prior to giving insulin and continue throughout the perioperative period

A

D5W

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63
Q

Non-tight glucose control regimen for the patient using SQ insulin

A

1/4 to 1/2 the dose of intermediate or long acting insulin as the last dose prior to procedure. Tresiba can be held all together. Small dose of short or rapid acting insulin as needed. Coverage is usually 1 unit or regular insulin for every 50-60mg/dl of BG

64
Q

Tight control for longer or serious procedures

A

continuous IV infusion @ 0.05 units/kg/hr (0.5-1unit/hr). Plasma glucose/150 (100 if on steroids). Maintenance D5W 50ml/hr for every 70 kg of body weight. Check BS every 1-2 hr and adjust rate as needed

65
Q

Patients with insulin pumps

A

Maintain basal infusion rate, turn off preprandial boluses, measure BG every hour, know the typical bolus dose for the patient to decrease BG by 50mg/dl

66
Q

Sulfonylureas MOA

A

act at pancreatic beta cells to stimulate release of insulin

67
Q

With sulfonylureas, they are typically dosed at _______, but newer ones are dosed _____ daily

A

mealtimes / once

68
Q

Sulfonylureas have high rates of ______ and ______. Avoid in patients with allergies to sulfa drugs; however, cross-reactivity of _____ is low.

A

hypoglycemia and failure / ABX

69
Q

Sulfonylureas are primarily metabolized by the ____ and excreted by the ________. Carries a higher risk of _______ in renal failure.

A

liver/ kidneys / renal failure

70
Q

Most common severe complication of sulfonylureas is _______. DOA is up to ____ days.

A

hypoglycemia / 7 days

71
Q

T/F Sulfonylureas can cause hypoglycemia requiring prolonged infusions of glucose-containing solutions. They can also cross the placenta causing fetal hypoglycemia.

A

TRUE

72
Q

Side effects of sulfonylureas

A

weight gain, GI disturbances, AVOID in liver dz (acetohexamide is safe)

73
Q

Contradindications to sulfonylureas

A

hypersensitivity to sulfonamides, patients with hypoglycemic unawareness, poor renal function

74
Q

Glipizide is the most common one that has no active metabolite and safe for Crcl less than ___

A

10

75
Q

Glyburide you should consider _____ function prior to administration

A

kidney

76
Q

With glyburide if kidney function shifts even a little bit, or require ______ supplementation, they are at highest risk for __________

A

insulin / hypoglycemia

77
Q

(Sulf 2nd gen)Glyburide is a ______ daily dose with effects for ____ hrs and plasma clearance in ____ hrs

A

single / 24 / 36

78
Q

(Sulf 2nd gen) Glipizide stimulates insulin _______ over a 12 hr period. Effects persist for prolonged periods (at least 3 years without evidence of ______.

A

secretion / tolerance

79
Q

(Sulf 2nd gen) Glimepiride works by _________

A

stimulating insulin secretion

80
Q

Sulfonylureas 1st Generation

A

Tolbutamide, acetohexamide, chlorpropamide

81
Q

Tolbutamide is the ______ acting and _____ potent 1st gen sulf, associated with FEWEST side effects

A

shortest / least

82
Q

Acetohexamide is a 1st gen sulf where most of its hypoglycemic action is due to its principle _______.

A

metabolite

83
Q

Chlorpropamide is the _________ acting 1st gen sulf. 20% excreted unchanged by the kidneys, can cause ________, and the effects and risk of hypoglycemia could be prolonged with impaired _______ function. Associated with disulfiram-like reactions

A

longest / hyponatremia / renal

84
Q

Alpha-Glucosidase Inhibitors

A

Acarbose, miglitol

85
Q

MOA for alpha-glucosidase Inhibitors

A

Decrease intestinal hydrolysis of complex carb

86
Q

Side Effects of Alpha-Glucosidase Inhibitors

A

GI upset, Increase LFTs, avoid in IBS and obstructions

87
Q

Meglitinides

A

Repaglinide , Nateglinide

88
Q

MOA for Meglitinides

A

Increase insulin secretion from islet cells like sulfonuylureas

89
Q

With Meglitinides, The have a faster onset of about ___ hr and shorter DOA of around ___ hrs. Should administer __ to ___ min AC and NEVER while ________.

A

1 / 4 / 15 to 30 minutes / Fasting

90
Q

Meglitinides are only active in the presence of __________ which decreases the risk of prolonged ________ episodes

A

glucose / hypoglycemic

91
Q

Meglitinides adverse effects

A

hypoglycemia (but less than Sus), WT gain, URI

92
Q

Biguanides AKA

A

Metformin / Glucophage

93
Q

Glucophage (biguanides) work by decreasing ________ glucose prodcution, reducing glucose absoprtion from the ______, and increases _________ sensitivity.

A

hepatic / intestine / insulin

94
Q

Advantages of metformin

A

decrease BG concentrations with only a VERY low risk of hypoglycemia, Have a positive effect on lipid concentrations, lead to mild weight reduction in obese patients

95
Q

Summary for metformin

A

most widely prescribed , lower risk of hypoglycemia, evidence to suggest to have a positive effect on lipid concentrations and mild weight reduction. Sulfonylureas can cause weight gain so this is one way these two are different. Also, metformin will produce satisfactory results in 50% of the sulfonylurea failures

96
Q

Metformin gut microbiota changes include reduced bacteriodes ________. High rats of this is linked to obesity, glucose intolerance and reduced insulin sensitivity.

A

fragilis

97
Q

Metformin causes increased glycoursodeoxycholic acid (GUDCA). It acts as an FXR __________ by inhibiting signaling of intestinal FXR

A

antagonist

98
Q

Metformin side effects

A

Most common: anorexia, nausea, diarrhea, and rarely lactic acidosis | Others include N/V, increasee RR and HR, abdominal pain, shock

99
Q

If metformin is started too soon or at full dose post op it can worsen what?

A

PONV

100
Q

Metformin perioperative considerations: risk of lactic acidosis in the intraoperative period. Discontinue ____ hrs prior to elective surgery. Avoid dehydration, hypoxemia and hypovolemia.

A

48

101
Q

IV contrast in the presence of metformin increases the risk of _________. Should hold metormin ____ hrs prior to and after dye and check ____ levels

A

nephrotoxicity / 48 hrs / Creatinine

102
Q

Perioperative / IV contrast with metformin considerations per package insert

A

Surgical procedures: Withholding of food and fluids during surgical or other procedures may increase the risk for volume depletion, hypotension, and renal impairment. Glucophage should be temporarily discontinued while patients have restricted food and fluid intake.

103
Q

IV contrast considerations with metfromin per pkg insert: With IV contrast it should be D/C at the time of, or prior to contrast with eGFR ___ to ___ ml/min, hepatic impairment, alcoholism, heart failure, or intra-arterial contrast. Re-evaluation of eGFR ______ hrs after study for re-initiation.

A

30 to 60 / 48

104
Q

Metformin contraindications/precautions: Contraindicated for SCr > ____ in males and > _____ in females (old recs). New Rec it’s contraindicated for eGFR < ____ml/min. Do not initiate or re-eval patients with eGFR< ____ ml/min

A

1.5 /1.4 / 30 /45

105
Q

Do you want to give metformin for someone over the age of 80, with hepatic impairment or CHF

A

not really

106
Q

With metformin, you should be thinking did this medication get held for 48 hrs and if not watch oxygen levels, _____ and keep well _______. If start losing massive fluids or 02 sat dropping their risk is increasing.

A

lactate / hydrated

107
Q

Thiazolidinediones (TZDs)

A

Rosiglitazone, Pioglitazaone

108
Q

TZDs MOA

A

decrease insulin resistance, decrease hepatic glucose output, and require the presence of insulin and are especially effective in obese patients

109
Q

TZDs side effects

A

WT gain, hepatotoxicity, peripheral edema, CHF exacerbations, risk of bone fractures

110
Q

Controversial increase in MI and CV death with ______________

A

Avandia (Rosiglitazone)

111
Q

DPP-4 Inhibitors (dipeptidal peptidase inhibitors)

A

Sitaglipitin, Saxaglipitin, Linagliptin, Alogliptin

112
Q

DPP-4 MOA: increases pancreatic insulin _______. Limits _______ secretion. Slows _____ _______. Promotes ___________.

A

secretion / glucagon / gastric emptying / satiety

113
Q

DPP-4 Inhibitors side effects

A

URIs and UTIs, headache, weight NEUTRAL, lower risk of hypoglycemia, post-marketing pancreatitis, angioedema, Stevens Johnson, anaphylaxis

114
Q

DPP-4 inhitors there are no ____ recommendations and fairly low risk of ______.

A

hold / hypoglycemia

115
Q

GLP-1 analogs are _______ mimetics. They work by ______ gastric emptying and reduce postprandial _______ secretion.

A

incretin / prolonging / glucagon

116
Q

GLP-1 analogs (Incretin Mimetics)

A

Exanatide, Liraglutide, Albiglutide, Dulaglutide

117
Q

Amylin analogs (another incretin mimetic) increase insulin secretion, slows gastric empthying and increases ____ cell growth, and cause central appetite suppression. It comes from the ____ of the Gila monster.

A

beta / spit

118
Q

Spit from Gila monster

A

Pramlinide (symlin)

119
Q

Incretin mimetics like GLP-1 analogs slow down the gut but still get _____. _______ is a common concern with this medication. The have been abused from the ____ _____ promise.

A

diarrhea / pancreatitis / weight loss

120
Q

Side effects of GLP-1 Analogs

A

N/V/D, weight loss and PANCREATITIS

121
Q

GLP-1 precautions. Want to avoid(Exanatide) Byetta in ____ failure. Avoid Liraglutide (Victoza) with ______ carcinoma.

A

renal / thyroid

122
Q

Post op issues with GLp-1 analogs include slowing down the gut in combination with inuslin therapy greatly increases the risk of __________

A

hypoglycemia

123
Q

Amalyin analogs adverse effects

A

black box for hypoglycemia especially with Type I DM, N/V, anorexia, headache, gastroparesis

124
Q

SLGT2 Inhibitors

A

Canaglifozin, Dapaglifozin, Empagliflozin

125
Q

SLGT2 inhibitors work in the ____ of the kidney by causing the diabetic patient taking the medication to just pee out the glucose and sodium

A

PT

126
Q

SLGT2 inhibitors (flozins) increased urinary glucose _______. Contraindications include CrCl < ____ml/hr, ESRD, HD. Warning for hypotension, urinary side effects (UTIs), and increased risk of amputations especially of the ______.

A

excretion / 30 / toes

127
Q

If someone already has bad circulation would you want to use a SLGT2 inhibitor?

A

NO, think toe amputations

128
Q

With SLGT2 inhibitors there is an increased risk of perioperative __________ _________________

A

euglycemic ketoacidosis

129
Q

Clinical presentation of Hypothyroid (HASHIMOTO DZ)

A

cold intolerance, dry skin, fatigue, lethargy, weak, weight gain, bradycardia, slow reflexes, corase skin and hair, periorbital swelling, painful/heavy menstruation, MYXEDEMA COMA

130
Q

Clinical presentation of HYPERthyroidsim (GRAVES DZ)

A

weight loss/incr appetite, heat intolerance, goiter, fine hair, tachycardia, nervous, anxiety, insomnia, lighter periods, amenorrhea, sweating, warm and moist skin, exopthalmus, thyroid storm

131
Q

Armour thyroid is made from ______ animal thyroid.

A

dessicated

132
Q

Armour thyroid manufacturer no longer produces this and has to be specially _______. T4 to T3 ratio is what

A

compounded / 4:1

133
Q

How would the effectiveness of armour thyroid be demonstrated?

A

return of TSH to normal and decrease in size of goiter

134
Q

How does armour thyroid work?

A

suppresses the responsiveness and cause regression of TSH sensitive malignant tumors

135
Q

Levothyroxine is ____. It is the most frequently administered frug for the treatment of diseases requiring thyroid hormone replacement.

A

T4

136
Q

Euthyroid state is usually maintained with what dose of synthroid?

A

100 to 200 mcg daily

137
Q

Due to synthroid’s long elimination half life (7 days), patients unable to take oral meds do not require immediate ___________ to IV form.

A

replacement

138
Q

Synthroid is DEIODINATED and converted to ____, the thyroid hormone wither greater biological acitivity.

A

T3 (T3 has more biologic activity)

139
Q

Liothyronine (T3) (Cytomel) is a _____________ isomer of T3. It is ___ to ____ times as potent as levothyroxine (synthroid).

A

levorotatory / 2.5-3 times

140
Q

What preculdes Cytomel from use for long-term thyroid replacment

A

rapid onset and short DOA

141
Q

Cytomel also has a higher incidence of _______ side effects

A

cardio

142
Q

Hypothyroidsim anesthetic implications

A

increased sensitivity to depressant drugs including inhaled anesthetics, hypodynamic cardiovascular system with decreased CO due to decreased HR and SV, slowed metabolism of drugs (especially opioids), unresponsive to baroreceptor reflexes, decreased intravascular fluid volume, impaired ventilatory response to low Pa02 and/or increased PaC02, delayed gastric emptying, hyponatremic, hypothermic, anemic, hypoglycemic, primary adrenal insufficiency, BASICALLY everything is TURNED DOWN

143
Q

Anithyroid drugs include ____ and _____

A

PTU and Methimazole

144
Q

Methimazole MOA is it inhibits the formation of thryoid hormone by interfering with the incorporation of _____ into tyrosine residues of thryoglobin (esentially blocking the synthesis of TH).

A

iodine

145
Q

PTU MOA: Blocks the peripheral _______ of T4 to T3.

A

deiodination

146
Q

Antithyroid drugs are useful in treating hyperthyroidism including thyroid storm before elective ___________. They’re only available _____. Require several days for full effect because performed hormone must be _______.

A

thyroidectomy / orally / depleted

147
Q

Adverse effects of anithyroid medications

A

transient leucopenia, rash, arthralgias, lupus-like symptoms, fever, granulocytosis early in therpay, hepatotoxic

148
Q

Lugol’s solution and saturated KI solution are ______ that are used for the treatment of hyperthyroidism. They work by inhibiting the release of ______ into the circulation.

A

iodines / TH

149
Q

Uses for iodines

A

combined with the propranolol for the treatment of hyperthyroidism before thyroidectomy, chronic treatment is associated with recurrence of previously suppressed excessive thyroid gland activity

150
Q

Thyroid storm (thyroxicosis) is a severe exacerbation of ______ due to sudden excessive release of thyroid hormone.

A

hyperthyroidism

151
Q

What does Thyroid storm look like.

A

Abrupt onset, hyperthermia, tachycardia, CHF, dehydration, and shock, resembles MH, more likely to occur in the first 6-19 hrs postop than intraop.

152
Q

When would you see thyroid storm perioperatively?

A

6-19 hrs post op

153
Q

Treatment for thyroid storm

A

Cold IV fluids, sodium iodide IV, cortisol IV, propranolol IV, Propythiouracil PO, avoid ASA for elevated temp because it may displace thryoxine from carrier proteins.

154
Q

Sodium Iodide IV in thryorid stom works by reducing the release of active hormones from the ______ _____

A

thyroid gland

155
Q

Cortisol role in thryoid storm works to treat acute primary ______ _______ from increased metabolism and use of corticosteroids

A

adrenal insufficiency

156
Q

Propranolol role in thyroid storm works to alleviate the ________ effects of thyroid hormones. It also reduces the peripheral conversion of T4 to T3.

A

cardiovascular

157
Q

PTU MOA reduces the synthesis of new _____ ______

A

thyroid hormones

Pharmacology II - Emily Britton (5 decks)

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