DM Flashcards
High risk ethnic groups
African-American, Latino, Native American, Asian American, Pacific Islander.
Criteria for diabetes testing in asymptomatic adults
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
Contraindication for TZD
High risk for edema, avoid with congestive heart failure patients
Recommended for the use of cardiovascular disease in diabetics
GLP-1 agonist and SLGT2 inhibitor
Indication for insulin
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
Contraindicator for GLP-1 agonists
FTA black box warning: risk of thyroid tumors. Avoid in patients with personal or family history of thyroid cancer
Type 1 DM insulin plan
Basal or long acting = about 50% of total daily insulin
Bolus is rapid acting = about 50% of total daily insulin
Insulin pump
Indication for insulin and type 2 diabetes
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
rapid acting insulin
Onset of action is 5 minutes
peak is 1 hour
duration is 4 hours
Short acting insulin
Humulin R, Novolin R
Onset 30 min
Peak 2-3 hours
Duration 3-6 hours
Long-acting insulin
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
Intermediate acting NPH insulin
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
Additional type two diabetes treatment considerations ABCDEFG
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
Microvascular damage
Retinopathy, nephropathy and neuropathy
Macrovascular damage
Atherosclerosis, heart disease (coronary artery disease, MI)
Target organs of diabetes mellitus
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
Ketones
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.
Prediabetes
A1c between 5.7% and 6.4%
Fasting blood sugar of 100 to 125
Diagnostic criteria for DM
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
Goals of DM treatment: lab value normals
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
Labs for management of diabetes
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.
Recommendations for preventative care for DM patients
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
Hypoglycemic response
Sweaty palms, tiredness, dizziness, rapid pulse, strange behavior, confusion, and weakness. If patient on BB -Hypoglycemic response can be blunted or blocked.
Diabetic retinopathy on eye exam
Cotton wool spots or soft exudates, Neovascularization (tiny/fragile new blood vessels arterioles in retina) microaneurysms with dot and blot hemorrhages
Biguanides
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
TZD
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*
sulfonaurea
glipizide “-zide or -ride”
Stimulates insulin release, constant
side effects: hypoglycemia, weight gain and many drug interactions
DPP-4 inhibitors
sitagliptin “-gliptin”
stimulates insulin release, post prandial glucose rise
delays gastric emptying and increases satiety
low in hypoglycemic risk but high in cost
GLP-1
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.
SGLT-2 inhibitor
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.
