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Clin Lab Med > DM case studies > Flashcards

DM case studies Flashcards

1
Q

2014 criteria for Dx DM

A

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

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2
Q

ADA targets FPG

A

70-130

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3
Q

ADA target 2 hr post meal

A

<180

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4
Q

ADA HbA1c target

A

<7%

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5
Q

Stages of Tx for T2DM

A
  1. lifestyle
  2. life + oral
  3. Life + oral in AM +bedtime NPH or glargine insulin
  4. Life + 2x/d insulin (rapid and intermediate)
  5. Life + 3-4 daily insulin injections (rapid before meals, 1x/d long acting)
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6
Q

A good first choice oral med for type 2DM?

A

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
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7
Q

What are the insulin secretagogues

A

*stimulate insulin secretion
Sulfonylurea (glucotrol/Glipizidel, Amaryl)
Meglitinides (repaglinide (prandin))

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8
Q

What are the insulin sensitizers and how do they work

A

increase sensitivity of liver and muscles to insulin (lower both glucose and insulin)

  • biguanides (meformin (glucophage))
  • TZD (actos (pioglitazone), avandia (rosiglitazone))
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9
Q

What are the a glucosidase inhibitors and how do they work

A

CHO blockers

Acarbose (precose) and Miglitol (glyset)

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10
Q

Warning on Avandia/rosiglitazone

A

can cause HF (angina, MI)

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11
Q

What are the Incretin Mimetics and how do they work

A

GLP-1 agonists; Exendin, the synthetic peptide version of naturally occuring incretin GLP-1
*Exenatide (BYetta)

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12
Q

What are the DPP-IV inhibitors and how do they work

A

inhibit DPP IV, potentiate action of incretins
Sitagliptin (januvia)
Saxagliptin (onglyza)

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13
Q

What is the synthetic amylin and how does it work?

A

Pramlintide (symlin)

*use for Type1and2, use with insulin

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14
Q

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

A

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
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15
Q

if DM has infection and worsening DM sx.. what do you do

A

first treat infection with antibiotic (ie Cipro 250 big for UTI) then see how blood sugars respond and treat accordingly

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16
Q

After no further benefits from oral agents, how to treat Type2DM?

A

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

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17
Q

after adding insulin, what are your goals for tx

A

the same! want FPG bw 70-130, 2 hr post meal <7%

18
Q

How do you start bedtime insulin

A 
Humulin N (NPH) or long acting Lantus (glargine) at bedtime
*prevent elevated FBS in mornign.. don't give too much though! Somogyi effect
19
Q

How much is one formula when starting bedtime insulin

A
  1. 15 unit/kg (15u max) of NPH or Glargine at bedtime

* OR start with 10-15 units and monitor with SMBG

20
Q

What should you beware of when starting insulin?

A

Somogyi, Dawn, Waning effect

Somogyi:

21
Q

Insulin lispro: onset, peak, duration

A

15 min
1 hr till peak
2-4 hr duration

22
Q

Regular Humulin R Insulin: onset, peak, duration

A

1/2-1hr onset
2-3 hr peak
3-6 hr duration

23
Q

NPH onset, peak, duration

A

Onset 2-4 hr
Peak 6-12
Duation 10-16

24
Q

Glargine (lantus) onset, peak duration

A

onset 1-2 hr
No peak
Duration 20-24+

25
Q

In addition to achieving normal FPG, PPG and avoiding hypoglycemia, intensive insulin tx should..

A

improve lipid profile

Reduce risks/costs of tx complications

26
Q

Nomenclature: NPH? NPL?

A

NPH: neutral protamine Hagedorn
NPL: neutral protamine lispro

27
Q

Pre-mixed combo?

A

70/30 = 70 NPH (neutral protamine hagedorn), 30 regular
75/25 = 75 NPL (neutral protamine lispro), 25 Lispro
*NPL glargine??

28
Q

Insulin replacement Nonphysiologic is

A

NPH (8 am, 6pm)

29
Q

Conventional Physiologic Insulin replacement is

A

NPH and Regular??? slide 32 diabetes case studies

30
Q

calculating dose insulin.. obese and non obese

A

1-1.2 u/kg/d for obese
.5-.7 u/kg/d for non obese
Give 2/3 at breakfast and 1/3 at dinner… start with 50% total daily dose. Monitor SMBG

31
Q

What about if need better control after morning and evening meal

A

add 4units Humalog (lispro) before breakfast and dinner

observe glucose response

32
Q

What does physiologic vs nonphysiolic insulin regimen mean

A

PHysio = mimic B cell secretion
replace Basal and Prandial separately normally

  • NPH used to be basal and Regular was prandial but each have basal and prandial effects
  • beware insulin stacking –> hypoglycemia
33
Q

what is a better physiological approach

A

Lipspro (prandial) and NPL (glargine??)

give 75% NPL and 25% lispro aka HUMALOG 75/25 (8am and 6pm)

34
Q

What is the purpose of basal insulin

A

suppress glucose production bw meals and overnight
*nearly constant levels
50% daily needs

35
Q

What is the pupose of bolus/prandial insulin

A

limit hyperglycemia after meals
immediate rise and sharp peak at 12 hr after meal
10-20% total insulin

36
Q

What is a sliding scale’s purpose

A

allow DM pt or clinician to make controlled alterations in insulin dose when diet, exercise, etc affect readings** used for shorter acting insulin
*attempt to correct blood glucose that is already too high (reactive rather than Proactive)

alter based on patients reponse
150-180.. take 2 more units
181-210 take 4 more units
211-250 take 6…

37
Q

what is replacing sliding scale and how does this method work

A

CHO counting - more proactive

  • pt determines # g of CHO in food they plan to eat, assess their current blood sugar and planned exercise to ultimately calculate insulin needs
  • RD consult needed!!
  • note sliding scale still used in hospital settings bc flexibility needed
38
Q

Explanations for Morning Hyperglycemia

A
  1. Waning of insulin action: (increase insulin or change timing)
  2. Dawn Phenomenon: (increase GH bw 3-7am, increases glucose) *increase insulin or change timing
  3. Somogyi: REBOUND hypergly due to nocturnal HYPOglycemia and counter-regulation by cortisol, glucagon and GH…. tx: reduce supper or bedtime insulin dose, and/or take bedtime snack
39
Q

what is the newer regimen of insulin tx

A 
3-4 inj/d
peakless glargine (lantus) for basal + rapid acting lispro or aspart before each meal
(more injections but more flexibility, avoids stacking and hypoglycemia)
40
Q

what other condition is hypoglycemia associated with

A

increased risk dementia (increased risk with each additional hypoglycemic episode)
**too tight glycemic control may increase risk for hypoglycemia thus increase risk for dementia

41
Q

for T2DM ,what is a proper HbA1C

A

between 7-7.5% seems reasonable bc too tight control increases risk for hypoglycemia

Clin Lab Med (6 decks)

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