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DM Flashcards

1
Q

What are some diabetes related complications?

A 
Lower – Extremity Amputations
Heart Disease
Stroke 
Neuropathy 
Diabetic eye disease 
End-stage renal disease (ESRD)
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2
Q

Classes of diabetes and what that means

A

Type 1 diabetes
β-cell destruction

Type 2 diabetes
Progressive insulin secretory defect

Gestational diabetes mellitus (GDM)

Other specific types of diabetes
Genetic defects in β-cell function, insulin action
Diseases of the exocrine pancreas
Drug-or chemical-induced

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3
Q

What are criteria for testing asymptomatic adults for DM?

A

Adults of any age who are overweight (BMI ≥25 kg/m2 or ≥ 23 kg/m2 in Asian Americans) and who have one or more additional risk factor for diabetes. (B)
First-degree relative with diabetes
high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
women who were diagnosed with GDM
history of CVD
hypertension (≥140/90 mmHg or on therapy for hypertension)
HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)
women with polycystic ovary syndrome
physical inactivity
Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans).

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4
Q

In the absence of any risk factors, when should adults be screened for DM and how often?

A

For all patients, testing should begin at age 45 yrs. (B)

If tests are normal, repeat testing at minimum of 3 year intervals is reasonable. Those with prediabetes should be tested yearly. (C)

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5
Q

What is a normal FBG, 2-hour PP, and A1c?

A

FPG < 100
2-h PG < 140
A1c < 5.7%

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6
Q

What is a high-risk for diabetes (prediabetes) FBG, 2-hour PP, and A1c?

A

FPG 100-125
2-h PG 140-199
A1c 5.7% - 6.4%

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7
Q

What is a FBG, 2-hour PP, and A1c diagnostic for diabetes?

A

FPG < 126
2-h PG < 200 (random PG >200 +/- symptoms)
A1c < 6.5%

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8
Q

What are components of comprehensive DM exam?

A 
Past Medical and Family History
Diabetes History
Family History
Personal history of complications and common comorbidities (next slide)
Social History
Assess lifestyle and behavior patterns
Medication and Vaccinations
Technology Use
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9
Q

What diabetes-related complications should you ask about?

A

Microvascular: retinopathy, nephropathy, neuropathy
Sensory neuropathy - including history of foot lesions
Autonomic neuropathy – including sexual dysfunction and gastroparesis

Macrovascular: CHD, cerebrovascular disease, and PAD

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10
Q

What are important screenings to include for pt c diabetes?

A 
Psychosocial
Depression, anxiety, and eating disorder
Cognitive impairment
DSMES
Hypoglycemia
Pregnancy planning
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11
Q

What should you include in your physical exam for pt c diabetes?

A 
Height, weight, BMI; growth and pubertal development in adolescents and children
Blood pressure, including orthostatic measurements when indicated
Fundoscopic examination
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection or infusion set insertion sites)
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12
Q

What is Acanthosis nigricans?

A

common condition characterized by velvety, hyperpigmented plaques on the skin.
Intertriginous sites, such as the neck and axillae
can occur in association with a variety of systemic abnormalities, many of which are characterized by insulin resistance. Obesity and diabetes mellitus are among the most frequently associated disorders
Benign, asymptomatic disorder, cosmetic concerns are typically the primary indications for treatment. Treatment of the underlying cause, when feasible, is the preferred method of management.

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13
Q

What is diabetic dermopathy?

A

Most common skin lesion in DM
Trauma + Atrophy + Chronic inflammation + poorly vascularized skin
High correlation with retino-vascular disease and sensory neuropathy.
Asymptomatic
Irregular, round, oval, shallow, depressed, atrophic, hyper-pigmented lesions (very few / many, Present in crops; Resolve slowly over 12-18 months.

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14
Q

what is lipohypertrophy?

A

scar tissue that forms where pt is doing frequent injections, will not absorb insulin well, can contribute to poor response to insulin.

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15
Q

What is included in a comprehensive diabetic foot exam?

A

Inspection
Screen for PAD (pedal pulses)
Determination of temperature, vibration or pinprick sensation, and 10-g monofilament sensation

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16
Q

What are risk factors for foot ulcers?

A 
Previous amputation 
Past foot ulcer history 
Peripheral neuropathy 
Foot deformity 
Peripheral vascular disease 
Visual impairment 
Diabetic nephropathy (especially patients on dialysis) 
Poor glycemic control 
Cigarette smoking
Most common sites are plantar to the met heads and hallux.
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17
Q

What labs should be ordered and why?

A

A1c, if results not available within the past 3 months
If not performed/available within past year
Fasting lipid profile, including total, LDL, & HDL cholesterol and TGs
Liver function tests
Test for urine albumin excretion with spot urine albumin-to-creatinine ratio
Serum creatinine and calculated GFR
TSH in type 1 diabetes, dyslipidemia, or women over the age of 50 years
Vitamin B12 if on metformin (when indicated)
Serum potassium in patients on ACE, ARB or diuretics

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18
Q

What referrals should be made and why?

A

Eye care professional for annual dilated eye exam
Family planning for women of reproductive age
Registered dietitian for MNT
Diabetes self-management education/support
Dentist for comprehensive periodontal examination
Mental health professional, if needed

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19
Q

Describe recommendations for immunizations for adults with DM

A

Provide routinely recommended vaccinations for children and adults with diabetes as for the general population according to age-related recommendations. C

Vaccination against pneumococcal disease, including PNA, with 13-valent pneumococcal conjugate vaccine (PCV13) is recommended for children before age 2 years. People with DM age 2 – 64 yrs should also receive 23-valent pneumococcal polysaccharide vaccine (PPSV23). At ≥ 65yrs administer, regardless of vaccination history, additionally PPSV23 is necessary. C

Administer 3-dose series of hepatitis B vaccine to unvaccinated adults with diabetes who are age 19-59 years. C

Consider administering 3-dose series of hepatitis B vaccine to unvaccinated adults with diabetes who are age ≥60 years. C

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20
Q

Discuss glucose monitoring options and principles

A

Techniques available for health providers and patients to assess effectiveness of management plan on glycemic control
Patient self-monitoring of blood glucose (SMBG)
Continuous Glucose Monitoring (CGM)
A1C

SMBG for most patients using intensive insulin regimens. B

When prescribed as part of a broader educational context, SMBG results may help to guide treatment decisions and/or self-management for patients using less frequent insulin injections B or non-insulin therapies. E

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21
Q

Patients on multiple-dose insulin (MDI) or insulin pump therapy should perform SMBG :

A

Prior to meals and snacks
Occasionally postprandial
At bedtime
Prior to exercise
When they suspect low blood glucose
After treating blood glucose until they are normoglycemic
Prior to critical tasks such as driving. B

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22
Q

Good glycemic control associated with?

A

Delayed progression of disease and associated morbidity/mortality
Decreased rates of microvascular and neuropathic complications
Risk reduction for cardiovascular disease

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23
Q

What are the ABCs of diabetic control?

A

A1C
BP
Cholesterol

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24
Q

What are recommendations for A1c testing?

A

Perform the A1C test at least two times a year in patients meeting treatment goals (and have stable glycemic control). E

Perform the A1C test quarterly in patients whose therapy has changed or who are not meeting glycemic goals. E

Point-of-care testing for A1C provides the opportunity for more timely treatment changes E

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25
Q

Discuss glycemic goals (A1c), who qualifies for which goals, and who would benefit from less stringent management (and why!!)

A

A reasonable A1C goal for many nonpregnant adults is <7%. A

More stringent A1C goals (<6.5%) for selected individuals such as those with short duration of diabetes, type 2 diabetes treated with lifestyle of metformin only, long life expectancy, or no significant CV disease. C

Less stringent A1C goals (such as <8%) may be appropriate for patients with B
History of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, longstanding diabetes in whom goal is difficult to achieve.

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26
Q

An A1c of <7.0% corresponds to which FBG and PP?

A

Fasting 80-130

PP<180

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27
Q

What are recommendations for hypoglycemia management?

A

Individuals at risk for hypoglycemia should be asked about symptomatic and asymptomatic hypoglycemia at each encounter. C

Glucose (15–20 g) preferred treatment for conscious individual with blood glucose < 70 mg/dL. E

Glucagon should be prescribed for those at increased risk of clinically significant hypoglycemia, defined as blood glucose < 54 mg/dL, so it is available if needed. E

Hypoglycemia unawareness or episodes of severe hypoglycemia should trigger treatment re-evaluation.

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28
Q

What are signs/symptoms of hypoglycemia?

A 
Shakiness
Irritability
Confusion
Restlessness
Weakness
Tachycardia
Hunger
Sleepiness
Paleness
Blurry visition
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29
Q

What should you use to treat hypoglycemia?

A 
Fast acting carbohydrate (CHO)
Rule of 15
4 oz. fruit juice 
15 g. glucose tablets (3-4 tablets) 
1 tube of glucose gel
4-6 small hard candies 
1-2 tablespoons of honey 
6 oz. regular (not diet) soda (about half a can) 
3 tsp. table sugar
One-half tube of cake mate

If meal delayed, follow with snack

If person unable to swallow, administer glucagon if available.

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30
Q

What does glucagon do?

A

CLINICAL PHARMACOLOGY
Glucagon increases blood glucose concentration and is used in the treatment of hypoglycemia.
Glucagon acts only on liver glycogen, converting it to glucose

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31
Q

What are the indications and usage of glucagon?

A

INDICATIONS AND USAGE
For the treatment of hypoglycemia:
Glucagon is indicated as a treatment for severe hypoglycemia.
Because patients with type 1 diabetes may have less of an increase in blood glucose levels compared with a stable type 2 patient, supplementary carbohydrate should be given as soon as possible, especially to a pediatric patient.

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32
Q

what are contraindications to admin of glucagon?

A

CONTRAINDICATIONS

Glucagon is contraindicated in patients with known hypersensitivity to it or in patients with known pheochromocytoma.

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33
Q

What are recommendations for BP control in pts with diabetes?

A

BP measured at every routine clinic visit.
Patients with elevated BP (≥140/90) should have BP confirmed using multiple readings. B
Most patients with diabetes and HTN should be treated to a SBP goal of <140mmHg and a diastolic BP goal of <90mmHg. A
Lower systolic and diastolic targets, such as 130/80 mmHg, may be appropriate for individuals as high risk of cardiovascular disease. C

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34
Q

What are treatment goals and medications/titration schedule for pts with diabetes and concurrent HTN?

A

Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals. A

Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce CV events in patients with diabetes. A

Pharmacological therapy for patients with diabetes and hypertension comprise a regimen that includes either an ACE inhibitor, angiotensin II receptor blocker, thiazide-like diuretic, or calcium channel blockers.
An ACE inhibitor or ARB, at the maximum tolerated dose indicated for BP treatment, is the recommended first-line treatment for HTN in patients with diabetes and urinary albumin-to-creatinine ration ≥300 mg/g creatinine. A

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35
Q

How should you screen for and monitor HLD in pts with diabetes?

A

Screening
In adults, a screening lipid profile is reasonable
At first diagnosis
At the initial medical evaluation
And every 5 years if under age of 40, or more frequently if indicated.

Continued Monitoring
4-12 weeks after initiation of statins or other lipid-lowering therapy
4-12 weeks after change of statin dose
Annually thereafter to monitor response to therapy. E

36
Q

Recommendations for treatment and goals in pts with DM and HLD

A

Lifestyle modification focus on weight loss; dietary modifications; reduction of saturated fat, trans fat, and cholesterol intake; increase dietary n-3 fatty acids, viscous fiber, & plant sterols; and increase physical activity. A

Intensify lifestyle therapy and optimize glycemic control for patients with elevated TGs ≥150 mg/dL (1.7 mmol/L) and/or low HDL cholesterol <40 mg/dL (1.0 mmol/L) for men and <50 mg/dL (1.3 mmol/L) for women. C

For all patients with DM and atherosclerotic CV disease, high-intensity statin therapy should be added to lifestyle therapy.

37
Q

Recs for antiplatelet agents

A 
Use aspirin therapy (75–162 mg/day) as a secondary prevention strategy in those with diabetes and a history of atherosclerotic cardiovascular disease. A
For patients with ASCVD and documented ASA allergy, clopidogrel (75mg/day) should be used. B
Dual antiplatelet therapy (with low dose ASA and a P2Y12 inhibitor) is reasonable for a year after ACS A  
ASA therapy (75-162mg/day) as primary prevention in those with T1D or T2D who are at increased risk for CV disease.
38
Q

Who should initiate ASA therapy as primary prevention?

A 
Includes most men &amp; women ≥50 years of age who have at least one additional major risk factor:
Family history of ASCVD
Hypertension
Smoking
Dyslipidemia
Albuminuria
39
Q

Recs of DM with CVD

A

In patients with prior myocardial infarction, β-blockers should be continued for at least 2 years after the event. B

In patients with stable HF, metformin may be used if estimated glomerular filtration remains >30mL/min but should be avoided in unstable or hospitalized patients with HF. B

40
Q

What nephro screening is recommended in pts with DM?

A

At least once a year, assess urinary albumin (e.g., spot (UACR) urinary albumin-to-creatinine ratio) and estimated glomerular filtration rate
In patients with T1D duration of ≥5 years
In all patients with T2D. B

41
Q

What nephro treatments and monitoring are recommended for folks with DM?

A

Optimize glucose and BP control
An ACE inhibitor or ARB is recommended for treatment of nonpregnant patients with DM and modestly elevated urinary albumin excretion (30-299mg/day)B and is strongly recommended for those with ≥ 300mg/day creatinine or GFR < 60mL/min/1.73m2. A
Periodically monitor serum Cr and K levels for the development of increased Cr or changes in K when ACE inhibitors, ARBs or diuretics are used. E
An ACE or ARB is not recommended for primary prevention of kidney disease in patients with normal BP and normal UACR (<30 mg/g creatinine), and normal estimated glomerular filtration rate. B

42
Q

How can you reduce the rate and progression of retinopathy in folks with DM?

A

Optimize glycemic control A

Optimize blood pressure control A

43
Q

How and when should you screen those with DM for retinopathy?

A

Initial dilated and comprehensive eye examination by an ophthalmologist or optometrist
Adults with T1D - Within 5 years after diabetes onset B
Patients with T2D – at time of diagnosis of diabetes B
If there is no evidence of retinopathy for one or more annual eye exams and glycemia is well controlled, then exams every 1-2 years may be considered. If any level of retinopathy is present then should be seen at least annually. B

44
Q

What might be seen on a retinal exam of a pt with DM?

A

Neovascularization
cotton wool spots
microaneurysms, edema, and exudates

45
Q

Who, how, and when should you screen for neuropathy?

A
  • All patients should be screened for diabetic peripheral neuropathy
    At diagnosis of T2D and 5 years after diagnosis of T1D, then annually
    Assessment for distal symmetric polyneuropathy should include a careful history and assessment of either temperature or pinprick(small-fiber function) and vibration sensation using a 128-Hz tuning fork (for large- fiber function). All patients should have annual 10-g monofilament testing to identify feet at risk for ulcers and amputation. B
46
Q

How can you treat/manage/address diabetic neuropathy?

A 
Optimize glycemic control to prevent or delay development of neuropathy. B
Either pregabalin (Lyrica) or duloxetine (Cymbalta) are recommended as initial pharmacological treatments for neuropathic pain in diabetes. A
**also good for concomitant depression (SNRIs)
47
Q

What is the recommendation for foot exam/care?

A

Perform a comprehensive foot examination at least annually to identify risk factors predictive of ulcers and amputations B
Inspection (every visit) C
Neurological assessment – 10g monofilament with and pinprick, temperature, vibration testing
Vascular assessment including pulses in legs and feet. B
Pts with symptoms of claudication or decreased and/or absent pedal pulses should be referred for further vascular assessment as appropriate. C

48
Q

How is diabetes management and recommendations for comorbid management different with older adult patients?

A

OA who are otherwise healthy with few existing chronic illnesses and intact cognitive functioning should have lower glycemic goals (A1C <7.5%) while those with MCC or CI or functional dependence should have less stringent goals <8.0-8.5%. C

OA at increased risk of hypoglycemia, medication classes with low risk of hypoglycemia are preferred. B

When palliative care is needed in OA with diabetes, strict BP control and intense lipid management may not be necessary.

Overall comfort, prevention of distressing symptoms, and preservation of quality of life and dignity are primary goals for diabetes management at end of life. E

49
Q

Physical factors that complicate management of DM in older adults

A

Decreased physical activity
Difficulty in preparing food: arthritis, tremor
Alterations in sense: vision, taste, smell
Difficulty in consuming food: poor digestion, dry mouth
Altered renal and hepatic function
Coexisting diseases: infections
Interaction with multiple medications

50
Q

Psychosocial factors that complicate management of DM in older adults

A

Cognitive impairment
Social isolation
Poverty
Psychiatric problems: depression, anxiety
Lack of access to medical care or community resources

51
Q

What aspects of your verbal communication should you consider when speaking with your patients diagnosed with DM?

A

Language in Diabetes Education
Strength based language
Person-first language

Use language that:
is neutral, nonjudgmental, and based on facts, actions or physiology/biology
is free from stigma
is strengths based, respectful, inclusive, and imparts hope
is person centered.

52
Q

What is the most important Rx you can provide patients with diabetes?

A

Diabetes Self-Management Education/Support

53
Q

What are Self care behaviors included in DSME

A 
Being active
monitoring
Healthy coping
reducing risks
problem solving
healthy eating
taking medication
54
Q

What are specific plant-based foods to be included in diabetic diet?

A 
Plant‐Based Foods
• Whole grains (including corn)
• Vegetables
• Legumes (beans, peas, lentils)
• Fruit
• Water (not cow’s milk)
• Small amounts of nuts and seeds
• Vitamin B12
55
Q

What are important considerations with nutritional therapy?

A

Consider personal preferences (e.g., tradition, culture, religion, health beliefs and goals, economics), comorbidities, and metabolic goals.

For BMI>25: Reduced‐energy, healthful eating plan, with a goal of weight loss, weight maintenance, and/or prevention of weight gain
Significant in A1C of 0.3% to 2.0% in adults with type 2 diabetes, with improvements in medication adjustments and QOL

56
Q

Why Plant‐based Whole Foods Dietary Pattern?

A

Pathology:
Lower Inflammation
Some micronutrients have powerful anti‐cancer effects

Nutrition: caloric density → nutrient density
Higher in variety (spectrum of colors)
Only complete source of micronutrients ‐ vitamins & minerals
High amount of fiber (increased satiety) → improved gut microbiome

Environment:
Significantly reduced carbon emissions (~ 20% estimated by UN and WHO)
Increased ability to feed growing world’s population

57
Q

What are physical activity guidelines?

A

Perform 150 minutes or more of moderate-to-vigorous physical activity per week (with no two consecutive days without activity). Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient if young and physically fit.

Engage in 2-3 sessions/week of resistance exercise on nonconsecutive days.

Reduce the daily time spent in sedentary behavior. Prolonged sitting should be interrupted every 30 minutes.

Flexibility training and balance training are recommended 2-3 times/week for older adults. Yoga and tai chi may be included to increase flexibility, muscular strength, and balance.

58
Q

What about smoking?

A

Advise all patients not to use cigarettes and other tobacco product or e-cigarettes.

Include smoking cessation counseling and other forms of treatment as routine component of diabetes care.

59
Q

Factors to Consider when Choosing Pharmacological Agent for Diabetes

A 
Current A1C
Duration of diabetes
BMI
Age of patient
Co-morbidities
Cost of medication
Convenience
60
Q

What are Recommendations for Pharmacological Therapy for Type 1 Diabetes?

A

Multiple daily injections (3–4 injections per day of basal and prandial insulin) or continuous subcutaneous insulin infusion (CSII) A

Use rapid-acting insulin analogs to reduce hypoglycemia risk. A

Educate individuals in how to match prandial insulin dose to carbohydrate intake, premeal blood glucose, and anticipated activity. E

Individuals who have been successfully using continuous subcutaneous insulin infusion should have continued access to this therapy after they turn 65 years of age. E

61
Q

What are some principles to PO management with DM?

A

Higher baseline A1C levels predict greater drop in A1C.
Shorter duration of diabetes predicts greater drop in A1C with any oral agent.
All oral agents require presence of some endogenous β-cell function, as they work by either increasing insulin sensitivity or augmenting β-cell insulin release.

62
Q

What is Metformin? (Get really detailed)

A

CLASS: Biguanides (Glucophage, Glucophage XR)
**Generally first choice medication
ACTION: Reduces hepatic glucose output
Effective in many studies
ADVANTAGES: extensive experience, NO hypoglycemia, ↓ CVD events (UKPDS), ↓ Weight
DISADVANTAGES: GI side effects, Vit B12 deficiency; contraindications: CKD (eGFR<30mL/min/1.73m2), acidosis, hypoxia, dehydration; Lactic acidosis risk (rare)
COST: Low (30 day supply: Metformin (~$10) Metformin XR (~$120)
Max DOSING: 2,000 to 2,500 mg divided BID to TID; XR QD
Decreases A1C 1-2%

63
Q

What are sulfonylureas

A

Previous first choice medication; 2nd generation safer than 1st generation
Glyburide (Diabeta, Gynase, Micronase), Glipizide(Glucotrol), Glimepiride(Amaryl)
ACTION: ↑ insulin secretion from β-cells (closes KATP channels on β-cell plasma membrane)
ADVANTAGES: extensive experience, ↓microvascular risk (UKPDS),
DISADVANTAGES: *Highest risk of hypoglycemia, ↑Weight, High risk of treatment “failure”, renal metabolism and excretion, Sulfa allergies
COST: Low (30 day supply: All ~less than $10)
Max DOSING: Glyburide 20mg, doses >10mg can be divided BID; Glipizide IR 40mg / XR 20mg; Glimepiride 8mg
Decreases A1C 1-2%

64
Q

What are Meglitinides (glinides)?

A

Repaglinide (Prandin, others) and Nateglinide (Starlix, generics)– before meal dosing
ACTION: Rapid acting, bind to alternate sites of SU receptor - Closes KATP channels on β-cell plasma membranes; ↑insulin secretion
ADVANTAGES: ↓post prandial glucose excursions
DISADVANTAGES: Hypoglycemia, ↑ Weight, frequent dosing schedule
COST: Moderate (30day: Repaglinide ~$75; Nateglinide ~$120)
Max DOSING: Repaglinide 16mg, divided TID; Nateglinide 360mg, divided TID
Decreases A1C 1 – 2%

65
Q

What are Thiazolidinediones (TZDs)?

A

Pioglitazone (Actos) now 1st (only?) choice; Rosiglitazone (Avandia)
ACTION: ↑ insulin sensitivity - mostly acts directly on fat and liver cells, enhances insulin action everywhere (activates the nuclear transcription factor PPAR-γ)
ADVANTAGES: Low risk of hypoglycemia as monotherapy, ↑HDL-C, ↓TGs, ?↓CVD events
DISADVANTAGES: 3-6 weeks for glycemic effects, ↑Weight, edema/heart failure, bone fractures, ?↑MI (meta-analysis, rosiglitazone)
**Monitor ALT at start of treatment, every month for 12 months, then every 3 months
COST: Low/High (30 day supply: Pioglitazone ~$14; Rosiglitazone ~$325)
Max DOSING: Pioglitazone 45mg, Rosiglitazone 8mg
Decreases A1C 0.5 – 1%

66
Q

What are α-Glucosidase Inhibitors?

A

Acarbose (Precose, generics) and Miglitol (Glyset, generics). Take before CHO-rich meals
ACTION: Slows intestinal carbohydrate digestion/absorption by intestinal enzyme inhibition
ADVANTAGES: NO hypoglycemia, ↓post prandial glucose excursions
DISADVANTAGES: GI side effects (flatulence, diarrhea), modest glycemic benefit, frequent dosing schedule
COST: Low to moderate (30day Supply: Acarbose ~$45; Miglitol ~$200)
Max DOSING: 300mg, divided TID
Decreases A1C 0.5 – 1%

67
Q

What are Bile acid sequestrants?

A

Colesevelam (Welchol)
ACTION: Binds bile acids in intestinal tract, increasing hepatic bile acid production; ? ↓hepatic glucose production; ?↑incretin levels
ADVANTAGES: Rare hypoglycemia, ↓LDL-C
DISADVANTAGES: GI side effects (constipation, bloating), modest glycemic benefit, ↑triglycerides, may ↓ absorption of other medications
COST: High (30day Supply: ~$600)
Max DOSING: 3.75gm, give QD or divided BID
Decreases A1C 0.5 (when taken w/other glucose lowering agents)

68
Q

What are dopamine 2 agonists?

A

Bromocriptine (Cycloset)
ACTION: Activates dopaminergic receptors; modulates hypothalamic regulation of metabolism, ↑insulin sensitivity
ADVANTAGES: Rare hypoglycemia, ↓? CVD events
DISADVANTAGES: side effects drowsiness, nausea, vomiting, headache, fatigue, rhinitis, and dizziness; modest glycemic benefit, ↑triglycerides, may ↓ absorption of other medications (CYP3A4 interactions)
COST: High (30day Supply: $650)
Max DOSING: 4.8mg
Decreases A1C 0.5 (when added to metformin and a sulfonylurea)

69
Q

Summarize renal reuptake of glucose

A

In type 2 diabetes, enhanced renal glucose reabsorption contributes to hyperglycemia

The glucose transporter SGLT2 is responsible for 90% of this glucose reabsorption

Inhibition of SGLT2
Decreases glucose reabsorption
Increases urinary glucose excretion

Observe weight loss and reduction in blood pressure

70
Q

What are SGLT2 inhibitors?

A

Canagliflozin (Invokana), Dapagliflozin (Farxiga), Empagliflozin (Jardiance)
ACTION: Blocks glucose reabsorption by the kidney, increasing glucosuria. Inhibits SGLT2 in the proximal nephron
ADVANTAGES: NO hypoglycemia, ↓ Weight, ↓ Blood pressure, Associated with lower CVD event rate and mortality in patients with CVD
DISADVANTAGES: GU infections, angioedema/urticaria & other immune-mediated dermatological effects, ↑LDL-C, ↑creatinine, DKA, ?Acute pancreatitis, ? ↑heart failure hospitalizations
COST: High (30day supply: Cana/Dapa/Empa-gliflozin ~$430)
Max DOSING: Canagliflozin 300mg; Dapagliflozin 10mg; Empagliflozin 25mg
Decreases A1C 1%

71
Q

What is the incretin Effect?

A

In patients with T2DM:
The incretin effect is severely reduced
Insulinotropic effects of GIP are virtually absent
Insulinotropic effects of GLP-1 are at least partially preserved
Endogenous GLP-1–mediated insulin secretion does not compensate for loss of insulinotropic activity of GIP
Defective glucagon suppression produces hyperglucagonemia (fasting and post-nutrient state)
Defective incretin-mediated stimulation contributes to defective insulin secretion

72
Q

What are GLP-1 receptor agonists?

A

Injected - Exenatide (Byetta) twice a day before meals;
Liraglutide (Victoza) daily; Exenatide weekly preparation (Bydureon), Albiglutide (Tanzeum), Lixisenatide (Adlyxin), Dulaglutide (Trulicity)
ACTION: Incretin mimetic GLP-1 analog, not recognized by DPPIV; Activates GLP-1 receptors; ↑insulin secretion, ↓glucagon secretion, slows gastric emptying, ↑satiety
ADVANTAGES: Rare hypoglycemia, ↓Weight, ↓post prandial glucose, ↓some CV risk factors, associated with lower CVD event & mortality
DISADVANTAGES: Injectable, GI side effects (nausea, vomiting, diarrhea), ↑heart rate, ? Acute pancreatitis
COST: High
Decreases A1C 0.5 – 1.6%

73
Q

What are DPPIV inhibitors?

A

Sitagliptin (Januvia), Saxaglipitin (Onglyza), Linagliptin (Tradjenta), Alogliptin (Nesina)
ACTION: ↑insulin secretion & ↓glucagon secretion(glucose dependent), Inhibits DPP-IV activity, increasing postprandial active incretin (GLP-1, GIP) concentrations
ADVANTAGES: Rare hypoglycemia, well tolerated
DISADVANTAGES: Angioedema/urticaria & other immune-mediated dermatological effects, ? Acute pancreatitis, ? ↑heart failure hospitalizations
COST: High (30d: Sitagliptin ~$380; Saxa- ~$385; Lina- ~$380; Alo- ~$195)
Max Dosing: Sitagliptin 100mg; Saxa- 5mg; Lina- 5mg; Alo- 25mg
Decreases A1C 0.6 – 0.9%

74
Q

What are Amylin mimetics?

A

Pramlintide (Symlin)
ACTION: Activates amylin receptors; ↓glucagon secretion, slows gastric emptying, ↑satiety
ADVANTAGES: ↓Postprandial glucose excursions, ↓ weight
DISADVANTAGES: injectable; GI side effects (nausea, vomiting); angioedema/urticaria & other immune-mediated dermatological effects, ? Acute pancreatitis, ? ↑heart failure hospitalizations
COST: High (30day Supply: ~$2,000)
Max DOSING: 120mcg/dose (usually 360mg/day; divided prior to major meals)
Decreases ~0.36% when added to insulin with or without metformin and/or a sulfonylurea

75
Q

What’s the problem with just using NPH?

A 
NPH
The same dose 
by the same person 
in the same site 
at the same time of day
Under the same conditions 	
Can vary up to 50% in absorption!
76
Q

How do newer basal insulins compare to older basal insulins?

A 
Smoother, Flatter and More constant profiles
Lower intra-patient variability
Increased adherence
Less hypoglycemia
Less weight gain
77
Q

What are some drawbacks to older insulins like glargine and detemir?

A 
Still slight peak
Some variability
Hypoglycemia
In some cases twice daily injections
More injections, less adherence
78
Q

Things to keep in mind with NPH

A

More people have to switch to NPH due to cost!
Be prepared if switching from NPH to go down in dose until glycemic control is established
Patient demonstrates how to use vial and syringe
Patient understands mixing (rolling technique)
Help patients be more aware of activity levels, meals/snacks and possibly greater night time hypoglycemia

79
Q

What are the steps for insulin intensification?

A

Basal plus one (prandial insulin after largest meal)

Basal/bolus (2-3 prandial doses)

Switch to insulin pre-mix twice daily (70/30, 50/50)

Add GLP-1 RA once daily

80
Q

Why combine GLP-1 RA with Basal Insulin?

A

Improved A1C (comparable to adding prandial insulin)

Added lowering of FPG

Beneficial effects of PPG

Lowers risk of hypoglycemia compared to increase basal insulin along or adding prandial insulin

Less weight gain

81
Q

The current American Diabetes Association (ADA) 2018 Standards of Care involves individualizing targets of treatment plan on the basis of patient characteristics, which include:

A

A. Life expectancy
B. Disease duration
C. Presence or absence of micro- and macrovascular complications
D. Risk for hypoglycemia

82
Q

What is continuous glucose monitoring?

A

Continuous glucose monitoring (CGM) systems measure glucose in interstitial fluid, rather than capillary blood.

CGM devices consist of three (3) components: a glucose sensor, a transmitter, and a receiver (or type of monitor and/or compatible mobile device)

Covered by Medicare:
Dexcom G5 Mobile Continuous Glucose Monitoring System (and the G5 Mobile CGM Touchscreen Receiver component) (DexCom)
FreeStyle® Libre System (Abbott)

83
Q

What are some rapid-acting analogues?

A 
ASpart
Glulisine
Lispro 
technosphere (inhaled)
Regular Human (short acting)
84
Q

What are some basal insulins?

A 
intermediate (twice-daily dosing) NPH
Basal analogues:
glargine
detemir
glargine 300
degludec
85
Q

Medication Considerations for Older Adults

A

Beers Criteria
Avoid: insulin sliding scale; Sulfonylureas
Cost Considerations

Metformin: Avoid in advanced renal insufficiency or heart failure

Thiazolidinediones: Very cautiously use in CHF or at risk for falls/fractures

Incretin‐Based Therapies (DPP‐IV inhibitors & GLP‐1 agonists)

Insulin Therapy Must have good visual & motor skills and cognitive ability

Keys:
Achieving glycemic control while avoiding hypoglycemia
Start with lowest dose and go slow

AGPCNP (30 decks)

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