DM

Question 1

High risk ethnic groups

Answer 1

African-American, Latino, Native American, Asian American, Pacific Islander.

Question 2

Criteria for diabetes testing in asymptomatic adults

Answer 2

Patients that are overweight and have additional risk factors including:

Physical inactivity
first-degree relative with type two diabetes
members of High risk ethnic groups
history of gestational diabetes
hypertension
hyperlipidemia
polycystic ovarian syndrome
pre-diabetic lab results on previous testing
history of cardiovascular disease

Otherwise a screening for diabetes should begin at age 45 years. If results are normal, testing should repeat in at least three year intervals with consideration of more frequent testing depending on risk status

Question 3

Contraindication for TZD

Answer 3

High risk for edema, avoid with congestive heart failure patients

Question 4

Recommended for the use of cardiovascular disease in diabetics

Answer 4

GLP-1 agonist and SLGT2 inhibitor

Question 5

Indication for insulin

Answer 5

Type 1 diabetic

Type 2 diabetic when two or more drugs including insulin releasers no longer are adequate to maintain glycemic control, marker of beta cell failure

Highest risk of hypoglycemic affect but highest of efficiency on A-1 C reduction

Question 6

Contraindicator for GLP-1 agonists

Answer 6

FTA black box warning: risk of thyroid tumors. Avoid in patients with personal or family history of thyroid cancer

Question 7

Type 1 DM insulin plan

Answer 7

Basal or long acting = about 50% of total daily insulin

Bolus is rapid acting = about 50% of total daily insulin

Insulin pump

Question 8

Indication for insulin and type 2 diabetes

Answer 8

At time of diagnoses A-1 C is greater than 9% with classic poly symptoms.

One more than two oral or injectable agents are in adequate to maintain glycemic control. This indicates beta cell dysfunction

Critically ill - tight control 140-180 important

Question 9

rapid acting insulin

Answer 9

Onset of action is 5 minutes
peak is 1 hour
duration is 4 hours

Question 10

Short acting insulin

Answer 10

Humulin R, Novolin R

Onset 30 min
Peak 2-3 hours
Duration 3-6 hours

Question 11

Long-acting insulin

Answer 11

Perferred basal insulin

Insulin detemir (levemir) and insulin glargine (basaglar kwikpen, lantus, lantus pen, toujeo pen)

Onset 1-2 hours
NO PEAK
Duration 24 hours

Question 12

Intermediate acting NPH insulin

Answer 12

Used BID as alternative to basal insulin

Novolin N, Humulin N also known as 70/30 NPH/regular insulin

Inexpensive

Onset 1-2 hours
Peak 6-14 hours
Duration 16-24 hours

Question 13

Additional type two diabetes treatment considerations ABCDEFG

Answer 13

Aspirin
blood pressure control
cholesterol: Staten therapy usually indicated
creatinine or renal function
diet
dental care
exercise
Eye exams
annually foot examination with every visit
goals of therapy glycemic lipid physical activity and

Question 14

Microvascular damage

Answer 14

Retinopathy, nephropathy and neuropathy

Question 15

Macrovascular damage

Answer 15

Atherosclerosis, heart disease (coronary artery disease, MI)

Question 16

Target organs of diabetes mellitus

Answer 16

Eyes, kidneys, heart or vascular system, peripheral nerves esp feet.

DM is the most common reason for chronic renal failure requiring dialysis and lower limb amputation in the United States

Question 17

Ketones

Answer 17

Abrupt cessation of insulin production causes body fat to be used as fuel which then breaks down into ketones. Ketones, the metabolic product of fat breakdown.

Question 18

Prediabetes

Answer 18

A1c between 5.7% and 6.4%

Fasting blood sugar of 100 to 125

Question 19

Diagnostic criteria for DM

Answer 19

A-1 C greater than 6.5%
fasting blood sugar greater than 126
symptoms of hyperglycemia plus random blood sugar 200 or two hour plasma glucose >200

Question 20

Goals of DM treatment: lab value normals

Answer 20

Fasting blood sugar of 70 to 100
post prandial plasma glucose less than 180
hemoglobin A1c <6

Less stringent alc (<8%) if elderly or frail patient. Increased risk of unawareness hypoglycemia

Question 21

Labs for management of diabetes

Answer 21

Newly diagnosed diabetic - a1c check every three months. Then once blood glucose is controlled check twice a year.

Lipids Should be checked once a year

Random urine for microalbuminuria at least once a year. Albumin to creatinine ratio is preferred.
If positive order a 24 hour urine for protein and creatinine.

Question 22

Recommendations for preventative care for DM patients

Answer 22

ShinGrix in two doses 2 to 6 months apart
Annual flu
pneumonia vaccinations
prescribe aspirin 81 mg if high-risk for MI or stroke annual eye exam is by ophthalmologist
podiatrist for older diabetics
blood pressure goal less than 130/80
biannual dental appointments

Question 23

Hypoglycemic response

Answer 23

Sweaty palms, tiredness, dizziness, rapid pulse, strange behavior, confusion, and weakness. If patient on BB -Hypoglycemic response can be blunted or blocked.

Question 24

Diabetic retinopathy on eye exam

Answer 24

Cotton wool spots or soft exudates, Neovascularization (tiny/fragile new blood vessels arterioles in retina) microaneurysms with dot and blot hemorrhages

Question 25

Biguanides

Answer 25

Metformin

Insulin sensitizer

decreases glucose production in liver and glucose absorption in gut, increases glucose uptake from cells.

side effects: GI diarrhea

FIRST LINE MEDICATION

Question 26

TZD

Answer 26

pioglitazone. “-glitazone”

insulin sensitizer - increases insulin sensitivity in adipose tissue, skeletal muscles and in liver.

side effects: weight gain & peripheral edema and liver dysfunction

* do no use in CHF patients*

Question 27

sulfonaurea

Answer 27

glipizide “-zide or -ride”

Stimulates insulin release, constant

side effects: hypoglycemia, weight gain and many drug interactions

Question 28

DPP-4 inhibitors

Answer 28

sitagliptin “-gliptin”

stimulates insulin release, post prandial glucose rise
delays gastric emptying and increases satiety

low in hypoglycemic risk but high in cost

Question 29

GLP-1

Answer 29

exenatide or Ozempic or Victoza

Stimulates insulin release, post glucose rise
slows gastric emptying and increases satiety

side effects: GI upset - do not use in gastroparesis

Recommonded in CVD patients and low hypoglycemic risk but high in cost.

Question 30

SGLT-2 inhibitor

Answer 30

Canagliflozin “-gliflozin”

think flo = urine. “serum glucose lost in toilet”

renal glucose excretion post glucose rise.

side effects: GU infections and dehydration

Recommended in CVD patient and renal disease. minimal hypoglycemic risk and helpful in weight loss.