DM Flashcards
Dx of DM
A1c >6.5%
fasting plasma glucose >126mg/dL
oral glucose tolerance test >200 mg/DL
prediabetes
fasting plasma glucose between 100 and 125 mg/dL
glycemic targets for non-pregnant w/ dm
A1C <7.0%
premeal plasma glucose 80-130mg/dL
peak post meal glucose >180mg/dL
Tight glycemic control benefits
decrease in:
kidney disease
neuropathy
opthalmic complications
MI, angina
more hypoglycemic episodes
Short duration: rapid acting
Lispro - injectable (SQ)
onset: 10-30 min
peak: 30 min - 2.5 hours
duration: 3-6 hours
immediately before eating, or after eating in some patients
can be mixed with NPH in same syringe
Afrezza - inhaled
education for rapid acting
rotate sites
s/s hypoglycemia (tachy, sweaty,
hygiene (at site and hands)
storage - fridge 3mo
1 mo not in fridge
avoid direct sunlight
prefilled syringes - 1-2 weeks in fridge
short duration: short acting
regular insulin
humulin R, novolin R
Clear
SQ, IM, IV
can be mixed with NPH
onset: 30-60 minutes
peak: 1-5 hours
duration: 6-10 hours
U100 and U500
U500 only for pts with insulin resistance, never given IV
Intermediate acting
NPH
Humulin N, Novolin N
Cloudy
2x daily SQ
only mix with short-acting and rapid-acting in the syringe (clear before cloudy)
onset: 1-2 hours
peak: 6-14 hours
duration: 16-24 hours
long duration
insulin glargine (lantus)
insulin detemir (levemir)
1xdaily
incidence of hypoglycemia not as common
clear, SQ only
onset: 1-2 hours
peak: none
duration: 24 hours
ultra long duration
Insulin Glargine (U-300) (same as lantus but 3x more concentrated)
Insulin Degludec (U100, U200)
1x/day
prefilled pens only, SQ only
onset: 6 hrs
peak: none
duration: >24 hrs
Somogye Effect
aka “rebound hyperglycemia”
treated with bedtime snack
morning blood sugar is elevated
dawn phenomenon
occurs in sleep for all people
hormone release to maintain and restore cells that cause glucose to rise
persons with DM have hyperglycemia upon wakening
treated with increasing night-time insulin
Biguanides (metformin)
can be used in pregnancy
MOA: decreases production glucose in liver, increases binding of insulin to receptors, reduces slightly the glucose absorption in gut, DOES not promote insulin release (does not promote hypoglycemia - safe to skip meals or eat irregularly)
ADRs: n/d, rare but srs - lactic acidosis
renal insufficiency - accumulates to toxicity - avoid in renal pts
HOLD for 48 hrs prior to contrast media
roles of insulin
- Moves glucose from blood –> muscle, liver, fat cells
- Stimulates storage of glucose in liver and muscle
- Enhances storage of dietary fats in adipose tissues
- Transports amino acids into the cell
s/s hypoglycemia
shaky, decreased LOC, confusion, diaphoretic, early-tachy (can look like stroke or drunk)
sulfonylureas
stimulates the release of insulin, some also inc sensitivity
glipizide, glyburide, glimepiride
ADRs: hypoglycemia, weight gain,
disulfiram-like rxn with alcohol
d-d - bblkrs diminish benefit (suppress insulin release, suppress s/s hypoglycemia)
avoid in pregnancy
meglitinides
MOA: stimulates pancreatic release of insulin, equal in efficacy to sulfonylureas
quick onset, short duration - pt should eat w/in 30 minutes, skip if don’t eat
ADR: hypoglycemia
Thiazolidinediones (glitazones)
MOA: decreases insulin resistance/increases insulin sensitivity
ADRs:
contraindicated in HF patients (fluid retention) peripheral edema
Weight gain
low risk for hypoglycemia
Low risk- hepatic dysfxn
Alpha-glucosidase
Acarbose
MOA: delays absorption of carbs - blocks enzyme in small intestine. Decreases postprandial glucose spike
T2dm not otherwise controlled with other agents
ADRs:
will NOT produce hypoglycemia
GI side effects common- gas
can decrease absorption of iron
Dipeptidyl Peptidase-4 inhibitors (DPP-4 inhibitors) (gliptins)
Sitagliptin
MOA: enhances action of Incretin hormones
incretin hormones: released after eating, stimulate pancreas to release insulin, inhibits glucagon secretion, slows gastric emptying, suppresses appetite
ADRs: pancreatitis (rare) - should be taught s/s (severe abd pain)
hypersensitivity rxns (rare)
Sodium-Glucose Co-transporter 2 inhibitors (SGLT2)
Canagliflozin, Dapagliflozin, Empagliflozin
MOA: block reabsorption of glucose - more exreted in urine
T2dm failing to reach glycemic goals
ADRs: infections - genital fungal, UTI, increased urination
Hypotension
Avoid in renal insufficiency
non insulin injectables
GLP-1 receptor agonist - incretin mimetics (t2dm only)
Amylin Mimetic (both t1 and t2) - preamlintide
GLP-1 receptor agonists - incretin mimetics
ty2dm only
endogenous incretins slow gastric emptying, stimulate insulin release, suppress appetite - improve glucose control and assist weight loss
exenatide, liraglutide, dulaglutide
exenatide - SQ, used in combo w/ metformin or sulfonylurea
ADRs: pancreatitis (severe abd pain), care with PO drugs since slows gastric motility
Amylin Mimetic
pramlintide
type 1 and type 2
Injectable- administered b4 meals - different site than mealtime insulin
MOA: analog of amylin - supplements effect of mealtime insulin - delay gastric emptying and suppress glucagon release
- reduces post-prandial glucose levels and fluctuations
ADR:
hypoglycemia - insulin doses may need to be reduced
N/v/d
other medications helpful in DM
ace inhibitor/ARB - reduces nephropathy progression, rxed if albuminuria is present or HTN w/o albuminuria
Statins - reduce cholesterol, shown to reduce CV events (even in non HL pts)
moderate to severe hypoglycemia
IV dextrose
parenteral glucagon (by rx)
-prefilled syringes admin IM, SQ, IV
-releases stored glucose from liver - 10 minutes to start elevating BGL
-pt may vomit after admin
if FSBG - 50-70 and can swallow, admin 1 juice, recheck. >50 2 juices
