Endocrine Conditions: Diabetes Flashcards
Diabetes background info
BG high while dec insulin secretion/sensitivity
Insulin produced by beta-cells, moves glucose out of blood into cells
Glucagon produced by alpha-cells, pulls glucose back into circulation (glycogen -> glucose) when BG is low.
If glycogen low, fat cells make ketones
Type 1 Diabetes
auto-immune destruction of beta-cells
no insulin = glucose cant enter cells = fat turned to ketones = can lead to DKA = med emergency
Type 2 Diabetes
95% of all cases
beta cells produce less insulin as they become damaged
Strongly associated with obesity, physical inactivity, family history, and other comorbid conditions
Prediabetes
increased risk of developing diabetes
BG higher than normal but not high enough to be diabetes
Metformin use in prediabetes useful if patients…
BMI > 35kg/m2
age < 60 yrs old
women history of gestational diabetes mellitus
Two types of diabetes in pregnancy
- develop before pregnancy
- develop during pregnancy
Babies born to moms with hyperglycemia are….
larger than normal
at high risk for developing obesity ad diabetes later in life
When are pregnant women tested for GDM?
24-28 wks
Oral glucose tolerance test (OGTT)
Which med is preferred for diabetes in pregnant patients?
Insulin
Diabets risk factors
physical inactivity
BMI > 25kg/m and 23kg/m in asians
high risk race or ethnicity = AA, Asian, Latino, native, Pacific Islander
Hx of gestational diabetes
A1C > 5.7%
1st deg relative with diabetes
HTN
CVD hx or smoking hx
Classical symptoms of hyperglycemia
Polyuria - excessive urination
Polyphasic = excessive hunger or inc appetie
Polydipsia = excessive thirst
Fatigue, blurry vision, ED = other symptoms
diabetes screening
no risk factors = begin testing at 35yrs old
children, adolescents and adults who are BMI > 25 or > 23 (asian) + 1 risk factor tested
test every 3 years
Diabetes A1C diagnosis
> 6.5
5.7-6.4 = pre diabetes
Diabetes Fasting plasma glucose
> 126
100-125 = pre diabetes
Usual A1c goal for diabetes?
< 7%
8% maybe appropriate if have to be less stringent
How often to test a1c
Quarterly if not at goal
Q6 months if at goal
Diabetse lifestyle modifications
Goal waste circumference < 35in female, < 40 in males
stop drinking
stop smoking
at least 150min exercise per week
weight loss >5% if obese/overweight
Antiplatelet therapy in diabetes
baby aspirin for secondary prevention, dont use for risk
clopidogrel 75 if allergic to aspirin
use in pregnancy to decrease preeclampsia
Diabetic retinopathy info
eye exam every 1-2yrs, early if diagnosed with retinopathy
High dose statin therapy if diabetes with….
Comorbid ASCVD
Age 40 - 75yrs old with > 1 ASCVD risk factor
Moderate intensity statin therapy if diabetes with….
age 40-75, no ASCVD
< 40 yrs old, w/ ASCVD risk factors
Goal LDL lvls for diabetes patients
< 55 if ASCVD
< 70 all others
Neuropathy diabetes info
annual: 10-g monofilament test + 1 other to assess sensation
annual comprehensive foot exam
txm options: gabapentin, pregabalin, duloxetine, TCA
Diabetic Kidney Disease defined as
eGFR < 60
and/or
urine albumin > 30/24hrs or UACR > 30
Diabetic Kidney disease txm
ACEi or ARB
SGLT2i if eGFR > 20
Finerenone if on max dose ACEi/ARB
Diabetes foot care info
daily wash, moisturize top/bottom of feet not between toes
Feet checked each visit
Annual foot exam
elevate feet when sitting
BP control diabetes goal
Goal < 130/80
BP control diabetes if no albuminuria
Thiazide
DHP CCB
ACEi
ARB
BP control diabetes if albuminuria or CAD
ACEi
ARB
IF patient has ASCVD, HF or CKD then start what at baseline for diabetes?
GLP-1 agonist or SGLT2
If patient A1c is 8.5%-10% then start what at baseline for diabetes?
2 drugs (GLP1-agonist + SGLT20
GLP1-agonist MOA
analogs of incretin hormone GLP-1, inc glucose-dependent insulin secretion, decrease glucagon secretion, slow gastric emptying and improve satiety
GLP1-agonists
Liraglutide = Victoza or Saxenda
Dulaglutide = Trulicity
Semaglutide = Ozempic or Wegovy
GLP1 and GIP agonist
Tirzepatide = Mounjaro
Boxed warnings for GLP1-a
except Byetta**
risk of thyroid C-cell carcinomas
GLP1 agonist warnings
pancreatitis
not rec in severe GI disease, including gastroparesis
Ozempic/Mounjaro = inc complications with diabetic retinopathy
GLP1-a and GLP1-a/GIP shouldn’t be used with…
DPP-4 inhibitors
Side effects of GLP1-a
weight loss
nausea = reduced with titration
Byetta and Victoza dont come with..
needles
SGLT2-i mechanism of action
drugs inhibit SGLT2, reducing reabsorption of glucose and inc urinary glucose excretion which reduces BG concentrations
works at proximal renal tubules
SGLT2-is
Canagliflozin = invokana
Dapagliflozin = Farxiga
Empagliflozin = Jardiance
SGLT2-i contraindications
Dialysis
Warnings for SGLT2-i
Ketoacidosis
Genital mycotic infection, urosepsis, pelo, necrotizing fasciitis
Hypotension, AKIO
Canagliflozin = inc risk of leg/foot amputations
SGLT2i Side effects
weight loss
inc urination and thirst
inc Mg/PO4
Inc risk of volume depletion and AKI if SGLT2i used with…..
diuretics
RAAS inhibitors
NSAIDs
Metformin mechanism of action
dec hepatic glucose production, inc insulin sensitivity and dec intestinal absorption of glucose
1st line for T2D and prediabetes
Metformin boxed warning
Lactic Acidosis, risk inc with renal impairment, contrast dye and alc use
Metformin CI
eGFR < 30
acute or chronic metabolic acidosis
Metformin warnings
dont start if eGFR 30-45
monitor B12 lvls
Metformin Side effects
GI side effects: D/N/Farting/cramping
Metformin notes
can dec A1C 1-2%, no hypoglycemia, weight neutral
How to reduce metformin GI side effects?
dose titration
How long after imaging procedure can Metformin be restarted?
48hrs
Insulin secretagogues
Sulfonylureas
Meglitinides
Insulin secretagogues mechanism of action
stimulate insulin secretion from beta cells to decrease postprandial BG
Meglitinides fast onset and shorter duration
Meglitinide ends in glinide
SU start with G- end in -ide
Sulfonylurea contraindications
Sulfa allergy
Sulfonylurea warnings
Hypoglycemia
Sulfonylurea side effects
Weight gain
nausea
Glimepiride and Glyburide not preferred in elderly due to….
hypoglycemia risk
Meglitinides Contraindications
T1D
DKA
Meglitinides warnings
hypoglycemia
Meglitinide side effects
weight gain
Meglitinides should be taken…..
1-30min before meals
DPP-4 inhibitor Mechanism of action
prevent enzyme DPP-4 from breaking down incretin hormones, GLP-1 and GIP
DPP-4 meds
Sitagliptin = Januvia
Linagliptin = tradjenta
DPP-4 inhibitor warnings
pancreatitis
severe joint pain
renal failure
risk of heart failure
DPP-4 inhibitors should,d not be used with….
GLP-1 agonists
Thiazolidinediones (TZD) med
Pioglitazone
TZD (pioglitazone) boxed warnings
can cause or exacerbate heart failure
dont use with NYHA Class III/IV HF
Pioglitazone warnings
edema
risk of fractures
Pioglitazone side effects
peripheral edema
weight gain
UTIs
Basal insulins
glargine
detemir
deluded = ultra long acting
onset 3-4hrs, last 24hrs, mostly for fasting glucose
Intermediate acting insulin
insulin NPH
onset 1-2hrs, peaks 4-12hrs, lasts 14-24hrs
can cause hypoglycemia due to unpredictable duration
P = protamine = extend duration
Rapid acting insulin
aspart
lispro
glulisine
onset 15min, peak 1-2hrs, duration 3-5hrs
Short acting insulin
regular insulin
onset 30min, peak 2hrs, lasts 6-10hrs
General insulin warnings
hypoglycemia
hypokalemia
General insulin side effects
Weight gain
Lipoatrophy = loss of fat at injection side and fat lumps under injection side = rotate sites
Rapid acting insulin info
give 5-15min before meals
dosed often with sliding scale if need BG correction
preferred insulin for pumps
aspart (Novolog) lispro (Humalog)
Short acting insulin info
inject 30min before meals
dosed often with sliding scale if need BG correction
Preferred for IV infusions
regular insulin (Humulin R/ Novolog R)
Intermediate action insulin info
given typically twice daily as add on to oral drugs
NPH (Humilin N/Novolog N)
Long acting insulin info
usually given once daily
detemir = levemir
glargine = Lantus/Toujeo
Lantus = 100u/ml, Toupee = 300u/ml***
Insulin should not be used with….
Sulfonylureas or meglitinides
Which insulins can be sold OTC
Regular
NPH
premixed 70% NPH/ 30% regular
Starting insulin in T2D
10units SC or 0.1-0.2 units/kg/day of basal insulin
titrate based on FPG, if not at goal then at 4 units prandial insulin to largest meal
if A1c not at goal then can do basal insulin daily + prandial with meals or twice daily mixed insulin
Patients with Type 1 Diabetes are mostly treated with….
insulin pump
rapid acting injectable insulins and long-acting basal insulins are preferred
How to convert to mixed insulin from regular insulin
2/3 of TDD is given as NPH
1/3 of TDD is given as regular insulin
If low fasting BG trend then…
dec basal or NPH insulin
If high fasting BG trend then….
increase basal or NPH insulin
Adjusting mealtime insulin
if postprandial BG is high/low following same meal on most days, regular or fast acting insulin dose prior to meal should be increase if high BG or decreased if low BG
if preprandial BG is high/low following same meal on most days, regular or fast acting insulin dose from previous meal should be increase for high BG or decreased for Low BG
Rule of 450
for regular insulin
450/ TDD of insulin = grams of carbs covered by 1 unit of regular insulin
Rule of 500
for rapid acting insulin
500/TDD of insulin = grams of carbs covered by 1 unit of rapid acting insulin
Correction factor
used to calculate bolus if BG higher than target
1,500 rule
for regular insulin
1,500/TDD of insulin = correction factor for 1 unit of insulin
1,800 rule
for rapid acting insulin
1,800/TDD of insulin = correction factor for 1 unit of insulin
How to calculate correction dose
(BG now - BG target)/ correction factor = correction dose
What to do with correction dose?
add units to amount of units normally takes before next meal/dose
NPH to insulin glargine conversion
use 80% of NPH dose to convert
When converting Toujeo to Lantus then….
use 80% of Toujeo dose
Insulin room temp stability
most insulin stable at room temp atleast 28 days. Toujeo/Tresiba = 56 days
Humalog Mix pen & Novolog mix pens 10-14 days
Hypoglycemia is when BG is…
below 70
Hypoglycemia symptoms
dizziness
anxiety/irritability
shakiness
sweating
hunger
confusion
tremors
palpitations
Severe hyperglycemia symptoms
seizures
coma
death
Hypoglycemia treatment if can swallow
pure glucose tab/gel preferred
rule of 15
15-20 gram glucose
recheck Bg after 15min
repeat if still Hypoglycemia
once BG normal, eat small meal/snack
Hypoglycemia treatment if unconscious
Dextrose if IV access
Glucagon 1mg SC injection or spray
Drugs that cause Hypoglycemia
insulin
Sulfonylureas/meglitinides = high risk
other diabetes drugs low risk unless used in combo with insulin
15 grams of simple carbs examples
4oz juice
8oz milk
4oz regular soda
1 tb spoon sugar/honey/corn syrup
3-4 glucose tabs
beta blockers can mask hypoglycemia except for which symptoms
sweating and hunger
Target BG range for non critical and critical care patients in hospital is usually
140-180
DKA can be recognized by…..
BG > 250mg/dL
Ketones (urine, fruity breath), ab pain, Nausea, vomiting and dehydration
Anion gap (arterial pH < 7.35, anion gap > 12)
Hyperosmolar hyperlhycemic state
higher mortality than DKA
mostly in T2D
primary cause is illness that leads to less fluid intake
HHS recognized by…
Confusion, delirium
BG < 600 and serum osmolality > 320
Extreme dehydration
pH > 7.3, bicarb > 15
DKA and HHS treatment
fluids for all patients, once BG hits 200 then change to D5W1/2NS
Regular insulin Infusion
Prevent hypokalemia, keep K+ at 4-5mEq
treat acidosis if pH < 6.9 by giving sodium bicarb
