DM case studies Flashcards
2014 criteria for Dx DM
1) HbA1c >6.5% OR
2) FPG > 126 OR
3) 2 hr PG >200 after 75g OGTT OR
4) random plasma glucose >200 with sx hypergly
5) absence of hyperglycemia sx, first 3 options confirmed with repeat test
ADA targets FPG
70-130
ADA target 2 hr post meal
<180
ADA HbA1c target
<7%
Stages of Tx for T2DM
- lifestyle
- life + oral
- Life + oral in AM +bedtime NPH or glargine insulin
- Life + 2x/d insulin (rapid and intermediate)
- Life + 3-4 daily insulin injections (rapid before meals, 1x/d long acting)
A good first choice oral med for type 2DM?
Metformin 500 mg before largest meal, increase by 500mg weekly in divided doses bw Breakfast and supper (so GI tract adjusts)
- most pt need 1g BID (2g total) for optimal effect
- max recommended dose is 2550 mg/d, but most clinicians stop at 2gm/d
- preferrable to sulfonylurea bc won’t cause weight gain
What are the insulin secretagogues
*stimulate insulin secretion
Sulfonylurea (glucotrol/Glipizidel, Amaryl)
Meglitinides (repaglinide (prandin))
What are the insulin sensitizers and how do they work
increase sensitivity of liver and muscles to insulin (lower both glucose and insulin)
- biguanides (meformin (glucophage))
- TZD (actos (pioglitazone), avandia (rosiglitazone))
What are the a glucosidase inhibitors and how do they work
CHO blockers
Acarbose (precose) and Miglitol (glyset)
Warning on Avandia/rosiglitazone
can cause HF (angina, MI)
What are the Incretin Mimetics and how do they work
GLP-1 agonists; Exendin, the synthetic peptide version of naturally occuring incretin GLP-1
*Exenatide (BYetta)
What are the DPP-IV inhibitors and how do they work
inhibit DPP IV, potentiate action of incretins
Sitagliptin (januvia)
Saxagliptin (onglyza)
What is the synthetic amylin and how does it work?
Pramlintide (symlin)
*use for Type1and2, use with insulin
After Metformin (500mg start), then increase 500mg weekly up to 2 mg/d divided in breakfast and supper doses, what SECOND step would be appropriate in T2DM tx
add second oral agent –> sulfonylurea
- Glucotrol (glipizide) 5 mg qAM
- most pt controlled with sulfonylurea at 5-10 mg qd at reakfast
- max dose = 20mg/d
if DM has infection and worsening DM sx.. what do you do
first treat infection with antibiotic (ie Cipro 250 big for UTI) then see how blood sugars respond and treat accordingly
After no further benefits from oral agents, how to treat Type2DM?
Add insulin
Total recommendation: lifestyle, oral agent, bedtime NPH (humulin N)
BIDS!! Bedtime Insulin, Daytime Sulfonylurea
Or, newer recommendation: once daily peakless long acting insuline glargine (lantus) at bedtime
after adding insulin, what are your goals for tx
the same! want FPG bw 70-130, 2 hr post meal <7%
How do you start bedtime insulin
Humulin N (NPH) or long acting Lantus (glargine) at bedtime *prevent elevated FBS in mornign.. don't give too much though! Somogyi effect
How much is one formula when starting bedtime insulin
- 15 unit/kg (15u max) of NPH or Glargine at bedtime
* OR start with 10-15 units and monitor with SMBG
What should you beware of when starting insulin?
Somogyi, Dawn, Waning effect
Somogyi:
Insulin lispro: onset, peak, duration
15 min
1 hr till peak
2-4 hr duration
Regular Humulin R Insulin: onset, peak, duration
1/2-1hr onset
2-3 hr peak
3-6 hr duration
NPH onset, peak, duration
Onset 2-4 hr
Peak 6-12
Duation 10-16
Glargine (lantus) onset, peak duration
onset 1-2 hr
No peak
Duration 20-24+
