Diabetic medications Flashcards
GLPs go up to the brain and tell your body to release _________. Also tell your brain to stop _________.
insulin / eating
Eating stops or slows down _________ in the liver and begins ________storage
gluconeogenesis / glyocgen
Characterisitics of Type I DM
before age 30, abrupt onset, requires exogenous insulin to treat, ketoacidosis prone, wide fluctuations in BG concentration, THIN body habitus
Genetically predisposed Type I DM
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.
S/S at time of dx for DM I
hyperglycemia, ketoacidosis, 3Ps
Type II DM characteristics
not ketoacidosis prone, may require exogenous insulin, obese body habitus, relatively stable BG concentration
DM diagnosis for fasting and random BS
Fasting BS 126 mg/dl or greater, Random BS >200 mg/dl
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.
15 mg/dl / 20%
Measure of the percent of Hgb that has been non-enzymatically glycosylated by glucose on the beta chain
HgA1C
Normal A1C
4-6%
ADA recommends HgbA1C range of_____ depending on the age of the diabetic patient
<7-8.5%
T/F Trying to hit A1C targets or reducing blood sugars fast are not showing any better outcomes and actually the outcomes are worse.
TRUE
The insulin storage molecule is a ___________
pro-insulin
Proinsulin, which is converted to insulin by proteolytic cleavage of amino acids ________ and the connecting peptide.
31, 32, 64, and 65
review slides 16 and 17 regarding
insulin and receptors
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 _______ ____________
receptor / phosphorylated / plasma membranes
Glucose transporters facts
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.
Massive rush of insulin secretion results in cellular uptake of ___________ which results in RE-FEEDING syndrome that can be ______.
Phos, potassium, mag / fatal
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
insulin resistance
With insulin resistance, compensatory ___________ occurs to overcome this resistance
hyperinsulinemia
This occurs with low circulating concentrations of insulin
insulin receptor saturation
Insulin receptor number is ______ related to the plasma concentration of insulin. Insulin can regulate the population of __________
receptors
With insulin, the effect is longer than the ______
half-life
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.
5 to 10 minutes / 50%
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.
kidney
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
30 to 90 / tissue
Insulin administered ____ is released slowly into the ciruclation to produce a sustained biological effect
SQ
Basal rate of insulin secretion by the pancreas is ___ units/hr
1
Food prompts a __ to __ fold increase in insulin secretion. Total daily secretion of insulin is approximately ___ units/day
5 to 10 / 40 unit
ANS effects on insulin secretion
beta 2 receptors alpha 1 receptors
Insulin response to glucose is greater for _____ ingestion than for IV infusion
oral
_______ is good for those that are not very good at remembering to take their insulin
tresiba
Tresiba duration
up to 42 hours
review slides 22 and 23 regarding
insulin types and duration
Older insulin agents are made from ____ and ______.
beef and pork
_____ is one of the top 5 drugs that send people to the ER. Most severe effect from insulin is __________
insulin / hypoglycemia
New agents are produced by ______ _________. So allergy or immunoresistance that could accompany admin of animal insulins is no longer a significant problem
recombinant technology
Only _____ ______ insulin can be given IV, via a pump
short-acting
Side effects of insulin
hypoglycemia, hypokalemia, allergic reactions, lipodystrophy, insulin resistance, drug interactions
Hypoglycemia symptoms reflect the compensatory effects of increased epinephrine which are
diaphoresis, tachycardia, HTN
Rebound hyperglycemia caused by SNS activity in response to hypoglycemia may mask the correct diagnosis. This is referred to as the _____ ____
Somogyi Effect
CNS symptoms of hypoglycemia include mental confusion progressing to _____ and ______
seizures and coma
T/F hypoglycemia diagnosis is difficult under GA based on symptoms
TRUE
Local allergic reactions present as what and are due to what
red hardened areas at the site of injection due to noninsulin materials in the preparation
Chronic ____ admin may lead to the development of antibodies to protamine
NPH
Insulin resistance is when patients require greater than _____ units/day
100 units/day
Acute insulin resistance is associated with _____, _____ and _______. This leads to a _______ of receptors
trauma, surgery, infection / down-regulation
Hypoglycemic effects of insulin is countered by
ACTH or glucocorticoids, estrogren, glucagon
Epinephrine effects on insulin
inhibits the secretions of insulin, stimulates glycogenolysis
Typical dose of long-acting or intermediate insulin is ___% while the additional rapid-acting doses are _____%
70% / 30%
External pump sites are changed every __ to ___ days
2 to 4
Inhaled insulin is called
Afreeza
Afreeza is a ______ acting insulin with an onset of about __ to ___ minutes and duration of ____ hrs
rapid / 10-15 min / 3 hrs
Insulin sliding scales should not be used alone without basal coverage unless someone is on a steroid and not ___________
diabetic
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
short / long and short
Glucose molecules are ______ and cause what kind of complications
large / atherosclerosis, neuropathy, nephropathy, retinopathy
The number one cause of dialysis, retinopathy, and non-traumatic amputation is _________
diabetes
Risks of hyperglycemia
microanigiopathy, impaired leukocyte function, cerebral edema, impaired wound healing, postop sepsis, hyponatremia
Glucose overpowers _________. End up holding onto more fluid because the body is trying to match the _________ due to the large glucose molecules
Na / osmolarity
Higher rather than low BG is desired under GA because GA can ______ the signs of low BG. Optimal BG is ___ to _____, <150 for __________
mask / 80-180 / total joints
When should an IDDM patient be operated on
first case in the morning
Ideally, with an IDDM patient you should start an infusion of ____ prior to giving insulin and continue throughout the perioperative period
D5W
Non-tight glucose control regimen for the patient using SQ insulin
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
Tight control for longer or serious procedures
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
Patients with insulin pumps
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
Sulfonylureas MOA
act at pancreatic beta cells to stimulate release of insulin
With sulfonylureas, they are typically dosed at _______, but newer ones are dosed _____ daily
mealtimes / once
Sulfonylureas have high rates of ______ and ______. Avoid in patients with allergies to sulfa drugs; however, cross-reactivity of _____ is low.
hypoglycemia and failure / ABX
Sulfonylureas are primarily metabolized by the ____ and excreted by the ________. Carries a higher risk of _______ in renal failure.
liver/ kidneys / renal failure
Most common severe complication of sulfonylureas is _______. DOA is up to ____ days.
hypoglycemia / 7 days
T/F Sulfonylureas can cause hypoglycemia requiring prolonged infusions of glucose-containing solutions. They can also cross the placenta causing fetal hypoglycemia.
TRUE
Side effects of sulfonylureas
weight gain, GI disturbances, AVOID in liver dz (acetohexamide is safe)
Contradindications to sulfonylureas
hypersensitivity to sulfonamides, patients with hypoglycemic unawareness, poor renal function
Glipizide is the most common one that has no active metabolite and safe for Crcl less than ___
10
Glyburide you should consider _____ function prior to administration
kidney
With glyburide if kidney function shifts even a little bit, or require ______ supplementation, they are at highest risk for __________
insulin / hypoglycemia
(Sulf 2nd gen)Glyburide is a ______ daily dose with effects for ____ hrs and plasma clearance in ____ hrs
single / 24 / 36
(Sulf 2nd gen) Glipizide stimulates insulin _______ over a 12 hr period. Effects persist for prolonged periods (at least 3 years without evidence of ______.
secretion / tolerance
(Sulf 2nd gen) Glimepiride works by _________
stimulating insulin secretion
Sulfonylureas 1st Generation
Tolbutamide, acetohexamide, chlorpropamide
Tolbutamide is the ______ acting and _____ potent 1st gen sulf, associated with FEWEST side effects
shortest / least
Acetohexamide is a 1st gen sulf where most of its hypoglycemic action is due to its principle _______.
metabolite
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
longest / hyponatremia / renal
Alpha-Glucosidase Inhibitors
Acarbose, miglitol
MOA for alpha-glucosidase Inhibitors
Decrease intestinal hydrolysis of complex carb
Side Effects of Alpha-Glucosidase Inhibitors
GI upset, Increase LFTs, avoid in IBS and obstructions
Meglitinides
Repaglinide , Nateglinide
MOA for Meglitinides
Increase insulin secretion from islet cells like sulfonuylureas
With Meglitinides, The have a faster onset of about ___ hr and shorter DOA of around ___ hrs. Should administer __ to ___ min AC and NEVER while ________.
1 / 4 / 15 to 30 minutes / Fasting
Meglitinides are only active in the presence of __________ which decreases the risk of prolonged ________ episodes
glucose / hypoglycemic
Meglitinides adverse effects
hypoglycemia (but less than Sus), WT gain, URI
Biguanides AKA
Metformin / Glucophage
Glucophage (biguanides) work by decreasing ________ glucose prodcution, reducing glucose absoprtion from the ______, and increases _________ sensitivity.
hepatic / intestine / insulin
Advantages of metformin
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
Summary for metformin
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
Metformin gut microbiota changes include reduced bacteriodes ________. High rats of this is linked to obesity, glucose intolerance and reduced insulin sensitivity.
fragilis
Metformin causes increased glycoursodeoxycholic acid (GUDCA). It acts as an FXR __________ by inhibiting signaling of intestinal FXR
antagonist
Metformin side effects
Most common: anorexia, nausea, diarrhea, and rarely lactic acidosis | Others include N/V, increasee RR and HR, abdominal pain, shock
If metformin is started too soon or at full dose post op it can worsen what?
PONV
Metformin perioperative considerations: risk of lactic acidosis in the intraoperative period. Discontinue ____ hrs prior to elective surgery. Avoid dehydration, hypoxemia and hypovolemia.
48
IV contrast in the presence of metformin increases the risk of _________. Should hold metormin ____ hrs prior to and after dye and check ____ levels
nephrotoxicity / 48 hrs / Creatinine
Perioperative / IV contrast with metformin considerations per package insert
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.
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.
30 to 60 / 48
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
1.5 /1.4 / 30 /45
Do you want to give metformin for someone over the age of 80, with hepatic impairment or CHF
not really
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.
lactate / hydrated
Thiazolidinediones (TZDs)
Rosiglitazone, Pioglitazaone
TZDs MOA
decrease insulin resistance, decrease hepatic glucose output, and require the presence of insulin and are especially effective in obese patients
TZDs side effects
WT gain, hepatotoxicity, peripheral edema, CHF exacerbations, risk of bone fractures
Controversial increase in MI and CV death with ______________
Avandia (Rosiglitazone)
DPP-4 Inhibitors (dipeptidal peptidase inhibitors)
Sitaglipitin, Saxaglipitin, Linagliptin, Alogliptin
DPP-4 MOA: increases pancreatic insulin _______. Limits _______ secretion. Slows _____ _______. Promotes ___________.
secretion / glucagon / gastric emptying / satiety
DPP-4 Inhibitors side effects
URIs and UTIs, headache, weight NEUTRAL, lower risk of hypoglycemia, post-marketing pancreatitis, angioedema, Stevens Johnson, anaphylaxis
DPP-4 inhitors there are no ____ recommendations and fairly low risk of ______.
hold / hypoglycemia
GLP-1 analogs are _______ mimetics. They work by ______ gastric emptying and reduce postprandial _______ secretion.
incretin / prolonging / glucagon
GLP-1 analogs (Incretin Mimetics)
Exanatide, Liraglutide, Albiglutide, Dulaglutide
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.
beta / spit
Spit from Gila monster
Pramlinide (symlin)
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.
diarrhea / pancreatitis / weight loss
Side effects of GLP-1 Analogs
N/V/D, weight loss and PANCREATITIS
GLP-1 precautions. Want to avoid(Exanatide) Byetta in ____ failure. Avoid Liraglutide (Victoza) with ______ carcinoma.
renal / thyroid
Post op issues with GLp-1 analogs include slowing down the gut in combination with inuslin therapy greatly increases the risk of __________
hypoglycemia
Amalyin analogs adverse effects
black box for hypoglycemia especially with Type I DM, N/V, anorexia, headache, gastroparesis
SLGT2 Inhibitors
Canaglifozin, Dapaglifozin, Empagliflozin
SLGT2 inhibitors work in the ____ of the kidney by causing the diabetic patient taking the medication to just pee out the glucose and sodium
PT
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 ______.
excretion / 30 / toes
If someone already has bad circulation would you want to use a SLGT2 inhibitor?
NO, think toe amputations
With SLGT2 inhibitors there is an increased risk of perioperative __________ _________________
euglycemic ketoacidosis
Clinical presentation of Hypothyroid (HASHIMOTO DZ)
cold intolerance, dry skin, fatigue, lethargy, weak, weight gain, bradycardia, slow reflexes, corase skin and hair, periorbital swelling, painful/heavy menstruation, MYXEDEMA COMA
Clinical presentation of HYPERthyroidsim (GRAVES DZ)
weight loss/incr appetite, heat intolerance, goiter, fine hair, tachycardia, nervous, anxiety, insomnia, lighter periods, amenorrhea, sweating, warm and moist skin, exopthalmus, thyroid storm
Armour thyroid is made from ______ animal thyroid.
dessicated
Armour thyroid manufacturer no longer produces this and has to be specially _______. T4 to T3 ratio is what
compounded / 4:1
How would the effectiveness of armour thyroid be demonstrated?
return of TSH to normal and decrease in size of goiter
How does armour thyroid work?
suppresses the responsiveness and cause regression of TSH sensitive malignant tumors
Levothyroxine is ____. It is the most frequently administered frug for the treatment of diseases requiring thyroid hormone replacement.
T4
Euthyroid state is usually maintained with what dose of synthroid?
100 to 200 mcg daily
Due to synthroid’s long elimination half life (7 days), patients unable to take oral meds do not require immediate ___________ to IV form.
replacement
Synthroid is DEIODINATED and converted to ____, the thyroid hormone wither greater biological acitivity.
T3 (T3 has more biologic activity)
Liothyronine (T3) (Cytomel) is a _____________ isomer of T3. It is ___ to ____ times as potent as levothyroxine (synthroid).
levorotatory / 2.5-3 times
What preculdes Cytomel from use for long-term thyroid replacment
rapid onset and short DOA
Cytomel also has a higher incidence of _______ side effects
cardio
Hypothyroidsim anesthetic implications
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
Anithyroid drugs include ____ and _____
PTU and Methimazole
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).
iodine
PTU MOA: Blocks the peripheral _______ of T4 to T3.
deiodination
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 _______.
thyroidectomy / orally / depleted
Adverse effects of anithyroid medications
transient leucopenia, rash, arthralgias, lupus-like symptoms, fever, granulocytosis early in therpay, hepatotoxic
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.
iodines / TH
Uses for iodines
combined with the propranolol for the treatment of hyperthyroidism before thyroidectomy, chronic treatment is associated with recurrence of previously suppressed excessive thyroid gland activity
Thyroid storm (thyroxicosis) is a severe exacerbation of ______ due to sudden excessive release of thyroid hormone.
hyperthyroidism
What does Thyroid storm look like.
Abrupt onset, hyperthermia, tachycardia, CHF, dehydration, and shock, resembles MH, more likely to occur in the first 6-19 hrs postop than intraop.
When would you see thyroid storm perioperatively?
6-19 hrs post op
Treatment for thyroid storm
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.
Sodium Iodide IV in thryorid stom works by reducing the release of active hormones from the ______ _____
thyroid gland
Cortisol role in thryoid storm works to treat acute primary ______ _______ from increased metabolism and use of corticosteroids
adrenal insufficiency
Propranolol role in thyroid storm works to alleviate the ________ effects of thyroid hormones. It also reduces the peripheral conversion of T4 to T3.
cardiovascular
PTU MOA reduces the synthesis of new _____ ______
thyroid hormones
