DM Management Flashcards
What is the typical glycemic target/goal for px with DM?
<7% HbA1C w/o significant hypoglycemia (for non-pregnant
may increase depending on life expectancy, harms of treatment>benefit
What are 3 main considerations when personalising T2DM management?
1) Glycemic control
2) Reduction of cardiorenal risk (eg. comorbidities and contraindications)
3) Medication-related factors influencing adherence
4) Px preferences, needs and values (eg. weight, access to treatment)
What is the definition of hypoglycemia?
Plasma glucose conc. low enough to cause symptoms/signs
- impairment of brain function (eg. seizures, unconsciousness, brain death)
- MI, fatal arrythmias
What is Whipple triad?
Method to clinically diagnose symptomatic hypoglycemia:
1) Symptoms, signs, or both consistent w hypoglycemia
2) low reliably measured plasma glucose conc.
3) resolution of symptoms and signs after plasma glucose conc. is raised
What are 6 symptoms and signs of hypoglycemia?
Neuroglycopenic:
1) Confusion/slowed thinking
2) Incoordination
3) Speech difficulty
4) Vision changes
5) Hemiparesis
6) Seizures
Autonomic:
1) Hunger
2) Palpitations
3) Shaking
4) Sweats
5) Tremors
6) Pallor
Non-specific:
1) Irritability
2) Malaise
3) Headache
4) Nausea
5) Nervousness
What are the physiological responses to hypoglycemia?
1) ↓Insulin from ß-cells
2) ↑Glucagon from α-cells
3) ↑Epinephrine from Adrenal medulla
4) ↑Neurogenic symptoms (eg. hunger) from SNS
What are the implications of hypoglycemia?
ST:
1) Acute symptoms
2) Cognitive impairment
3) Mood change
4) Work, Social life and driving impairment
5) Hypothermia
6) Acute morbidity (eg. accidents, coma, CVS/NeuroCVS events)
LT:
1) Weight gain
2) Employment and driving restriction
3) Worsening of DM/vascular complications
4) Cognitive decline
5) Acquired hypoglycemia-induced syndromes
What are 4 causes of hypoglycemia?
Too much insulin:
1) Insulin/sulphonylurea dose too high/ill-timed
2) Medication error
Too little carb intake:
1) Poor oral intake
2) Px kept NBM/missed meals
Others:
1) Disease factors (↓insulin clearance from liver clearance, renal impairment)
2) ↑insulin sensitivity (eg. weight loss)
3) ↑glucose utilisation (eg. exercise)
What are 5 ways to prevent hypoglycemia in DM px?
1) Px education
2) Dietary intervention
3) Exercise management
4) Glucose monitoring
5) Medication adjustment
6) Clinical surveillance
When is insulin therapy indicated?
1) T1DM
2)T2DM
- w severe hyperglycemia
- glycemic target were not reached w 2 or more hypoglycemic agent (HAs)
What are 3 examples of rapid-acting insulin analogues?
1) Lispro
2) Aspart
3) Glulisine
How do rapid-acting insulin analogues act rapidly?
Substitution/addition of amino acids to weaken propensity for insulin to self-associate → less dimer formation → rapid absorption of monomers from subcut tissue @ time of injection
Rapid-acting insulin such as Lispro, Aspart, Glulisine have a (short/long) duration of action and have a (higher/lower) incidence of hypoglycemia.
Rapid:
- short duration
- lower incidence
Rapid-acting insulin such as Lispro, Aspart, Glulisine attain (higher/similar/lower) concentrations after subcut injection compared to conventional human insulin and reduce post-prandial glucose to a (greater/similar/lower) extent.
Rapid:
- high conc. and greater post-prandial reduction than endogenous insulin
What is an example of short-acting insulin?
Regular human insulin
When is regular human (short-acting) insulin administered?
at least 20-30mins prior to meals
Can regular insulin be administered IV vs subcutaneously?
Yes esp during a hyperglycaemic crisis
Regular (short-acting) insulin is associated with (greater/lower) hypoglycemia risk than rapid-acting insulin.
Regular > risk than rapid
What is an example of intermediate-acting insulin?
Neutral Protamine Hagedorn (NPH)
- cloudy
Why does NPH (intermediate-acting) have a high risk of hypoglycemia?
1) High intra/inter px variability of NPH action
2) Long peak effect (NPH acts as basal and prandial so px HAVE to eat when insulin is peaking)
NPH typically requires ____ a day dosing.
Twice
What are 2 examples of long acting insulin analogues?
1) Glargine
2) Detemir
Insulin glargine and detemir (long-acting) have virtually no plasma peak and act for 18-24 hours. Hence, it can be administered ______ daily.
once daily as background insulin
Why are insulin glargine and detemir long acting?
Glargine: forms aggregates at physiological pH and slowly release insulin
Detemir: self-association and binding to albumin
Long acting insulin such as glargine and detemir have (higher/lower) intra-subject variation and (higher/lower) risk of hypoglycemia than NPH
Long acting: lower variation, lower risk than intermediate (NPH)
Long-acting insulins (can/cannot) be mixed in the same syringe with other insulins.
Cannot
- could change how the insulin works
What are 3 ways to mix insulins?
Just prior to administration:
1) Regular + NPH
2) Rapid + NPH
3) Aspart (Rapid) + Degludec
Which insulins CANNOT be mixed?
1) Glargine w anything (incompatible pH)
2) Glulisine w anything (except NPH)
3) Detemir w anything (not recommended by manufacturer)
What are 3 methods of insulin administration?
1) Subcutaneous (default)
2) IV (emergency)
3) Nasal
(AVOID IM and areas with bruises, scar, joints, groin, navel)
What are 5 factors influencing PK of insulin?
1) Injection site (abdo faster than arm, buttock, thighs)
2) Depth of injection (muscles faster than subcut faster than superficial)
3) Larger volumes delay absorption
4) Exercise (specific muscle group → faster abs)
5) Massage of injection site/Heat (faster)
What is a key cause of drug-induced hyperglycemia?
Steroids (glucocorticoids)
What are 4 risk factors of hypoglycemia?
1) Advanced age
2) Renal impairment
3) Intensive insulin regiment
4) poor oral intake/prolonged fasting w high activity levels
