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Therapeutics II > DM > Flashcards

DM Flashcards

1
Q

what is the #1 killer in pts with DM

A
  • CVD
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2
Q

what is HbA1C

A
  • % of hb molecules glycosylated with glucose
  • measured q3 mo
  • provides long term glycemic control info
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3
Q

what is eAG

A
  • estimated average glucose

- used to explain BS levels to pts in comparison to A1C

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4
Q

target A1C

A
  • < 7%
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5
Q

target FPG

A
  • 80-130
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6
Q

target PPG 1-2 hours post

A
  • < 180
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7
Q

pts that qualify for A1C goal < 8

A
  • severe hypoglycemia
  • limited life expectancy
  • advanced complications. extensive comorbid conditions
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8
Q

pts that qualify for A1C goal < 6.5

A
  • young
  • no comorbid diseases
  • “pts that can handle it without hypoglycemia or other ADRs”
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9
Q

goal A1C in pts < 18

A
  • < 7.5%
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10
Q

goal FPG in pts < 18

A
  • 90-130
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11
Q

bedtime goal in pts < 18

A
  • 90- 150
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12
Q

why are goals different in children

A
  • prevent cognitive impairment/ worsening of brain dev
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13
Q

target A1C in pregnancy

A
  • < 6%
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14
Q

target FPG in pregnancy

A
  • < 95
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15
Q

target PPG in pregnancy

A
  • 1 hour pp: < 140

- 2 hours pp: < 120

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16
Q

interpreting A1C

A
  • higher= more contribution of FPG

- lower= more contribution of PPG

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17
Q

factors that falsely decrease A1C

A
  • anything that shortens lifespan of RBC
  • blood loss
  • heavy bleeding
  • hemolytic anemia
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18
Q

factors that falsely increase A1C

A
  • iron def anemia

- blood transfusion

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19
Q

vaccines recommended in DM

A
  • flu
  • pneumococcal
  • hep B
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20
Q

lifestyle management of DM

A
  • self mgmt education
  • individualized meal planning
  • weight mgmt
  • physical activity
  • tobacco cessation
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21
Q

physical activity recommendations for DM

A
  • 150 min/wk
  • 2-3 d/wk resistance
  • 2-3 d/wk flexibility
  • interrupt prolonged sitting every 30 min
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22
Q

BP goals in DM

A
  • <130/80 if HTN and ASCVD or ASCVD risk > 15%

- < 140/90 if ASCVD risk < 15%

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23
Q

what is basal insulin

A
  • constant low level

- maintains homeostasis in fasting state

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24
Q

what is bolus insulin

A
  • covers meal stimulated bursts of glucose
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25
when is insulin indicated (not in DM2)
- DM1 - GDM - hyperglycemic crisis
26
when is insulin indicated in DM2
- A1C > 10% - glucose > 300 - marked hyperglycemia +/- wt loss - A1C above goal despite 3 non-insulin meds
27
beta cell function considerations with DM
- at time of dx have already lost 50% of function | - beta cell function will continue to decline
28
advantages of early insulin
- reduced glucose toxicity - facilitates beta cell rest -> preserved function - prevent/ minimize diabetes complications - protect against endothelial damage - overcome pt/ clinician barriers
29
disadvantages of early use of insulin
- most studies that show benefit used multi daily inj or pumps - complex instructions - more health care utilization? - expensive
30
initiating insulin in DM1
- reqires basal bolus coverage - TDD 0.4- 1 u/kg/d - typical starting TDD of 0.5 u/kg/day - half of TDD is basal insulin, other half is divided among meals
31
how do you determine insulin: CHO ratio?
- rule of 500 | - 500/ TDD insulin
32
initial insulin dosing in DM2
- basal insulin: 10 u/d OR 0.2 u/kg/d | - bolus insulin: 4 units/d with largest meal or 10% of basal dose
33
which insulin should be adjusted with FPG dysfunction
- basal
34
which insulin should be adjusted with pre/ post prandial dysfunction
- bolus
35
how do you adjust basal insulin
- takes 3-5 days for basal to reach steady state - titrate 2-4 units 1-2X a week - if hypglycemia reduce dose by 10-20 %
36
how do you adjust bolus insulin
- increase meal time dose by 1-2 units twice weekly OR 10-15% twice weekly - every 3 mo add addition mealtime insulin if not at goal
37
when should regular insulin be injected
- 30-60 min before meal
38
when should rapid acting insulin be injected
- 5-15 min before meal
39
switching between insulin preparations
- generally 1:1 - consider when insulin needs to be taken - exception: NHP -> glarginine or degludec is 80% of NHP TDD
40
what is premixed insulin
- combines NHP or NHP-like insulin with rapid or short acting - 2-3 injections/ day needed
41
benefits of premixed insulin
- simplifies mgmt - less costly? - less injections - good if predictable heating habits and low risk hypoglycemia - comparable A1C lowering ability
42
cons of premixed insulin
- must eat regular meals to avoid hypoglycemia - hard to dose adj - hard to customize regimen - should not be used in T1D
43
definition of hypoglycemia
- serum glucose < 70
44
treatment of hypoglycemia
- use 15:15 rule - check glucose - consume 15-20 g CHO - recheck glucose 15 min later - repeat until glucose normalizes
45
severe hypoglycemia
- < 54 OR requires assistance from another person - cant be treated with PO CHO d/t unconsciousness - use glucagon kit
46
lipohypertrophy
- accum of subcuatenous fat - can reduce insulin - +/- pain - d/t repeated injections at same site
47
how do you prevent lipohypertrophy
- rotate injection site | - use new needles with each injection
48
treatment for DM in hospitalized pts
- insulin preferred - initiate when persistent hyperglycemia > 180 - target glucose range of 140-180
49
treatment for NPO pts
- bolus insulin + bolus correction of needed
50
treatment for pts with good nutritional intake
- basal insulin + bolus insulin at meals
51
treatment for critically ill pts
- cont IV
52
add on treatment in DM2 with ASCVD
- GLP1 | - SGLT2
53
add on treatment in DM2 with HF or CKD
- SGLT2
54
add on treatment in DM2 with need to minimize hypoglycemia
- DPP4 - GLP1 - SGLT2 - TZD
55
add on treatment in DM2 with need to minimize wt gain/ promote wt loss
- GLP1 | - SGLT2
56
add on treatment in DM2 with need to minimize cost
- SU | - TZD
57
how do you titrate metformin?
- week 1: 500 mg - week 2: increase to 500 mg BID - week 3: increase to 500 mg in AM and 1000 mg in PM - week 4: 1000 mg BID
58
which SU is safest in CKD
- glipizide
59
which SGLT2 have best CV benefit
- empagliflozin | - canagliflozin
60
which SGLT2 are best for renal disease
- empagliflozin | - canagliflozin
61
which GLP1 agonists have best CV data
- in order of efficacy: - liraglutide - semaglutide - exenatide
62
which GLP1 agonists ares daily drugs
- exenatide - lizisenatide - liraglutide
63
which GLP1 agonists are weekly long acting drugs
- exenatide ER - dulaglutide - semaglutide - all impact FPG> PPG
64
when should you intensify treatment?
- every 3-6 mo until goal is met - start low and titrate to max dose or max tolerated dose before intensifying - triple combo may be needed
65
injectable regimens for DM2-
- basal insulin - basal + GLP1 - basal + bolus - premixed insulin - usu keep metformin on board to mitigate wt gain and assist in insulin sensitivity
66
combo meds to avoid
- SU + glinide | - GLP1 + DPP4
67
drugs to avoid in CVD
- saxagliptin and alogliptin: increased hospitalizations or HF - TZDs- increased risk HF - SU?- conflicting data
68
meds that delay renal disease progression
-TZDs empa and cana
69
common meds to avoid or need reduction in renal disease
- metformin - SU - DPP4 except linagliptin - exenatide - caution initiating SGLT2 in renal disease
70
metformin considerations for renal disease
- C/I in GFR < 30 - do NOT initiate if GFR 30-45 - if GFR 45-60 and already on metformin, can continue use, monitor renal fn - if GFR 30-45 and already on metformin weigh pros and cons, consider dose reduction by 50%
71
drugs that cause weight loss
- GLP1 - amylin analog - SGLT2
72
drugs that are weight neutral
- metformin - DPP4 - AGI
73
drugs that cause weight gain
- TZDs - SU - glinides - insulin

Therapeutics II (8 decks)

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