Endocrine #1 (Diabetes) Flashcards
Insulin is produced in the _______ by cells called ________.
What does insulin do (the main job)?
Pancreas
Islet cells
-Increases cellular uptake of glucose
-Major anabolic hormone
What is the pathophysiology of Diabetes Type I?
Insulin deficiency due to Beta cell destruction in the islets of Langerhan’s in the pancreas (Autoimmune condition)
The pancreas is producing no or little insulin
True or False: Diabetes is the leading cause of blindness in the US?
True
What are some symptoms of Diabetes Type I?
What is unique about the age of onset with Type I?
Polyuria, Polydipsia, Polyphagia
-blurry vision
-poor wound healing
-hypotension
Bimodal: 4-6 years old and 10-14 years old
In diabetic ketoacidosis (DKA), what happens?
Insulin deficiency and increased regularly hormones (cortisol, glucagon, growth hormone, and catecholamines)
What are some symptoms of DKA?
-Diabetic symptoms
-AMS, stupor
-Abdominal pain
-Decreased skin turgor
-Tachypnea, tachycardia
-Fruity (acetone) breath
-Kussmaul Respirations (deep)
What are some eye symptoms of diabetes?
-Increased floaters
-Blurriness
-Poor night vision
-Colors faded
-Cotton wool spots, flame hemorrhages, dot & blot hemorrhages (on fundus exam)
What is seen on diagnostics for DKA?
-Glucose > 250
-Ketones in urine
-Bicarb < 22
-pH < 7.3
What is the treatment for DKA? (Remember SIPS)
-Saline IVF
–Isotonic (normal saline) until hypotension resolves, then 0.45% normal saline
-Regular Insulin
-Potassium Repletion (check serum K+ hourly)
-Search for underlying cause
What is the pathophysiology of Diabetes Type II?
Insulin resistance, decreased insulin secretion, inappropriate glucagon secretion
-Free fatty acids and cytokines impair glucose uptake
-Pancreatic alpha cells release glucagon to increase blood sugar
-Beta cells secrete inadequate levels of insulin
Risk Factors for DM Type II
-Age > 45
-Obesity
-Sedentary
-Family History of DM
-Hypertension
-Dyslipidemia
-CVD, PCOS
Symptoms of DM II
-Most asymptomatic and diagnosed on screening
-Polyuria, Polydipsia, Polyphagia
-Nocturia
-Weight loss
-Blurry vision
-Yeast infections (balanitis in men)
-Paresthesias
Diagnostics for Diabetes (list all of them)
-HbA1c 6.5 or greater
-Fasting glucose > 126 on more than 1 occasion (GOLD)
-Random (non-fasting glucose) > 200 with symptoms
-2 hour glucose tolerance test > 200
-3 hour glucose tolerance test in pregnancy (GOLD)
Who do you screen for DM?
-BMI > 25 with any of the following
–Baby > 9 lbs
–Inactivity, FH, PCOS, HTN
–HDL < 35, TG > 250
What lab is done to differentiate between Type I DM and Type II?
C-peptide
-If there is none, it is Type I
Explain what Type 1.5 DM is and what lab you can get to aid in this diagnosis
AKA Latent Autoimmune Diabetes in Adults
-Diagnosed during adulthood, sets in gradually (like Type II), but has an autoimmune factor and isn’t reversible with diet and lifestyle changes (like Type I)
-Glutamic acid decarboxylase GAD-65
What is the best initial treatment for Diabetes Type II?
Lifestyle changes: diet, exercise, dietary counseling, frequent follow ups initially
What is the best first-line medication for Diabetes Type II and what is the MOA?
What are some side effects? Who should NOT use this?
Metformin (Biguanide)
-Decreases gluconeogenesis in the liver and increase peripheral tissue uptake of insulin (in muscles)
-Adverse Effects: GI complaints, B12 deficiency
-Hold before contrast, do not give if hepatic/renal impairment
-Thiazolidinediones (TZD’s)
–What is the ending of these medications?
–MOA?
–What is a concern with Pioglitazone?
–What is a concern with Rosglitazone?
Glitazone
Increases insulin sensitivity at peripheral receptor sites
Bladder cancer with Pioglitazone
MI with Rosiglitazone
-Sulfonylureas (G’s)
–Name some of these medications
–MOA
–When should you NOT use these?
–Side effects?
-Glipizide, Glyburide, Glimepiride
-Stimulates B-cell insulin release
-Do not use if pregnant
-Adverse: Hypoglycemia, weight gain
-GLP-1 Agonists (-tides)
-MOA
-Name some examples
-Side Effects
MOA: –Mimics incretin –> increased insulin secretion, decreased glucagon, decreased gastric emptying
Liraglutide
S/E: Weight loss, acute pancreatitis, GI
DDP4 Inhibitors (-gliptins)
–MOA
-Side Effects
-Increases GLP –> increased insulin
–S/E: gastric motility slowing, acute pancreatitis
SGLT2 Inhibitors (-flozin)
–MOA
-What is one POSITIVE
-Adverse Effects
-MOA: increased urinary glucose excretion
-Improves cardio outcomes (lowers BP and HF)
-UTI and yeast infections (due to sugary urine)
What does glucagon do and what does insulin do?
Glucagon increases blood sugar levels whereas insulin decreases blood sugar levels
What is the treatment order for diabetes that you should follow?
-Exercise & Metformin
-Add TZD
-Add Exenatide (GLP1)
What medication should you start with in Asians?
TZD’s
What is the Somogyi Phenomenon?
Nocturnal hypoglycemia followed by rebound hyperglycemia (increase in growth hormone!)
What is the treatment for the Somogyi Phenomenon?
Prevent hypoglycemia
-decrease nighttime NPH dose
-Move evening NPH earlier
-Give bedtime snack
What is the Dawn Phenomenon?
Normal glucose until rise at 2-8AM from a nightly surge of hormones
What is the treatment for the Dawn Phenomenon?
Decrease early morning hyperglycemia
-Bedtime injection of NPH
-Increase NPH dose
-Avoid carbs at night
There are many different insulin types. Explain
-Rapid Acting
–Names
–Onset
–Last
–Give when?
Lispro, Aspart
-Onset: 5-15 min
-Lasts: 2-4 hours
-Give at same time as meal
-Short Acting Insulin
–Name
–Onset
–Lasts
-Give when?
Regular Insulin
Onset 30 minutes
Lasts 5-8 hours
Give 30-60 min prior to meal
Intermediate Insulin
-Names
-Onset
-Lasts
-NPH, Lente
-Covers half a day, overnight
Long Acting Insulin
-Names
-Lasts
-Determir, Glargine
Lasts 1 full day
What is hypoglycemia defined as?
What’s the treatment if severe?
70mg or less
If severe (<40), give IV bolus of D50 or IV glucagon
What is hyperosmolar hyperglycemic state? What is the MCC?
Insulin deficiency and counterregulatory hormone excess
Infection (UTI, PNA)
Symptoms of HHS?
What is this the equivalent to?
Profound dehydration
-Polyuria, polydipsia, nocturne, fatigue, weakness
The Type II equivalent of Type I DKA
What diagnostics are shown for HHS?
Treatment?
Increased osmolarity (>320)
Increased serum glucose (>600)
SIPS
Hypertension is a complication of DM. What is the treatment goal and what medications should you use if comorbid with DM?
<140/90
Ace or ARB
What type of diabetic neuropathy is the MC type? Explain this.
What is the treatment?
Symmetric: Stocking glove distribution (distal LE)
Pregabalin, Duloxetine, Amitriptyline
Gastroparesis is another complication of DM. What are some treatment options?
Metoclopramide or Erythromycin
True or False: DM is the MCC of end-stage renal disease.
What is seen on histology after urine dipstick in this condition?
True
Kimmelsteil-Wilson Lesion: pink hyaline material around capillaries
