Endocrine: DM, Thyroid, Steroids, Autoimmune Flashcards
Repaglinide
(Prandin)
secretagogue, can cause hypoglycemia and weight gain
Hypoglycemia
< 70
Glucagon secreted by
alpha cells
Insulin secreted by
beta cells
TZDs
Thiazolidinediones are PPAR gamma agonists that improve peripheral insulin sensitivity (increase uptake and utilization of glucose); improve insulin sensitivity in muscle cells
Glucagon injection kit
Glucagon is used when a patient is unconscious. Glucagon is available as a SC injection kit, reconstituted solution for injection and nasal spray. The kit includes a vial and a syringe that contains the reconstitution liquid.
DM + albuminuria
According to the ADA, any patient with diabetes and albuminuria [defined as a urinary albumin excretion of 30 mg/24 hours or greater or a urine albumin-to-creatinine ratio (UACR) of 30 mg/g or greater] should receive an ACE inhibitor or ARB, but not both together. This is true whether the patient has hypertension or not.
DM drugs w/ cancer risk
Actos (pioglitazone), dapagliflozin - bladder cancer. GLP1-RAs (thyroid, medullary thyroid CA)
Insulin adjustment when pramlintide started- protocol
Mealtime insulins need to be reduced by 50% when starting pramlintide
Miglitol
Glycet- Miglitol is an alpha-glucosidase inhibitor. Another agent in the class is acarbose. These drugs should be taken with the first bite of each meal. Hypoglycemia cannot be treated with sucrose.
Pramlintide slows gastric emptying and is contraindicated
in patients with gastroparesis. MOA- an injectable, under GLPRA1s, amylin analog, slowing gastric emptying and increasing satiety
Glucose at home testing instructions
Hands should be washed first to clean the testing site. The hands should be dry, as water will dilute the blood sample. The finger pads should not be used as a testing site. A new test strip should be used for each test. Alternate testing sites are not recommended when blood glucose is changing or when hypoglycemia is suspected because alternate sites can give a test result that is 20 - 30 minutes old.
Insulin use in the hospital
Sliding scale insulins alone are no longer recommended to manage hyperglycemia in hospitalized patients. Per the ADA guidelines, in patients with poor oral intake (this patient is not eating a regular diet until later in the day after her CT scan), a basal insulin regimen with bolus correction doses (aka sliding scale insulin) is recommended. Short- or rapid-acting insulins and agents that cause hypoglycemia (such as sulfonylureas) should not be scheduled in a patient that is not eating regular meals.
Hospitalized patients should have their BG maintained between
140-180 mg/dL
The ADA treatment goals for patients with type 2 diabetes are preprandial blood glucose ____ and peak postprandial blood glucose _____
80-130 mg/dL; < 180 mg/dL
Insulin should be considered initially in patients with severe hyperglycemia, defined as an _____
A1C > 10%
Diabetes diagnostic criteria: A1c, FPG, PPG
A1c >/= 6.5, FBG >/= 126, PPG >/= 200
Pre-diabetes diagnostic criteria: A1c, FPG, PPG
A1c >/= 5.7, FBG 100-125, PPG 140-199
Diabetes treatment goals, not pregnant: A1c, preprandial, PPG
<7, FBG 80-130, PPG < 180
Diabetes treatment goals, pregnant: A1c, preprandial, PPG
FBG = 95, 1 hr PPG = 140, 2hr PPG = 120 (stricter)
Actos
pioglitazone, TZD
Janumet
metformin + januvia (sitagliptin, a DPP4i)
Invokanamet
invokana (canagliflozin, SGLT2i) + metformin
Avandia
rosiglitazone, TZD
Jardiance
empagliflozin, SGLT2
Weight loss
metformin, GLP1, SGLT2
Little/no hypoglycemia risk
metformin, DPP4, SGLT2, TZD, GLP1
Weight gain
insulin, TZD, SUs, meglitinides
Januvia
sitagliptin
Tradjenta
linagliptin
DPP4s CI with what class DM meds?
GLP1s (-glutides), similar moa
Do NOT use ___ in NYHF class 3-4
TZDs; can cause or worsen HF
Glucotrol, Glucotrol XL
glipizide
Glumetza
metformin
Fortamet
Metformin
Glucophage
metformin
Do not start metformin with eGFR __-__
30-45
Beers criteria- dont use ___ in elderly. Highest risk med is ____.
SUs; glyburide (Glynase)
Glynase
glyburide
Amaryl
glimepiride
Take ____ 30 mins PO ac
Glucotrol (glipizide)
meglitinides
repaglinide, nateglinide; can cause weight gain, hypoglycemia - if you skip a meal, skip dose d/t risk of hypoglycemia. Do NOT use with insulin or SU, same MOA (increase insulin secretion)
Starlix
nateglinide (meglitinide)
Victoza
liraglutide
Trulicity
dulaglutide
GLP1 RA that also comes in PO form
semaglutide PO = Rybelsus , SC = ozempic
GLP RA
incretin mimetics; decrease dose with renal impairment
Byetta
exenatide, GLP1 RA
Bydureon
exenatide ER, GLP1 RA
1-2/day GLP-RAs - need to give needles
Byetta, Victoza [once a day], Adlyxin (exenatide, liraglutide, lixisenatide)
Adlyxin
lixisenatide, GLP1 RA
GLP RAs - give without regard to meals EXCEPT ____ and ___. Give those ___ mins ___ meals.
Byetta and Adlyxin (exenatide and lixisenatide); give 60 mins prior to meals.
Bydureon serious reaction injection site reaction risk of ____.
Skin nodules. Bydureon = exenatide ER
GLPs have risk of _____
pancreatitis
Synthetic analog of amylin
Pramlintide
SymlinPen 60, 120
Pramlintide; synthetic amylin analog, can be used in both type 1 and 2 DM. CI is gastroparesis as its MOA is already slowing gastric emptying and increasing satiety.
BOXED warning: severe hypogylcemia when used with insulin
DM drugs with hypoglycemia risk
insulin, pramlintide (when used with insulin), SUs, meglitinides (when dose is given but meal is skipped)
gastroparesis, GI disorders
GLP RAs, pramlintide
Genital infection/UTI
SGLT2 (-flozins)
HF
TZDs, alogliptin, saxagliptin
hepatotoxicity
TZDs, alogliptin
hyperkalemia
invokana (canag)
hypokalemia
insulin
ketoacidosis
SGLT2
lactic acidosis
metformin, do not use if GFR < 30
osteopenia, osteporosis
TZDs (fractures), invokana (canag, decreases BMD and risk of fractures)
RA insulin
aspart, lispro (Novo, Huma)
SA insulin
= regular insulin. Humulin R, Novolin R
Intermediate acting insulin
NPH (N), cloudy, RX and OTC
____ insulin preferred in IV
regular (N)
LA insulin
det, lev (Lantus, Toujeo, Basaglar)
Converting BID NPH to Lantus or Basaglar; use __% of NPH dose
80%
Converting Toujeo to Lantus or Basaglar; use __% of Toujeo dose
80%
Starting a basal-bolus insulin dose
1/2 of TBW is the TDD needed. divide that in 1.2 and that is your basal TDD units. the other half, divide by 3 and that is your units per meal. To check your work: add all total units, that should be half of the patient’s TBW.
Insulin stability at room temp: 28 days
Humalog vial, pen, cartridges, humalog mixes: vials only. Glargine, glulisine (Apidra). Novolog vial, pen, cartridge. Lantus vial pen
Insulin stability at room temp: 10 days
Humalog MIXES pens (vials are 28 days)
Drugs that cause hyperglycemia** +++ (12)
Beta blockers, quinolones, thiazide and loops, tacrolimus, cyclosporine, PIs, antipsychotics (ex: olanzapine, quetiapine), statins, niacin, systemic steroids, cough syrups
Insulin stability at room temp: 28 days
Humalog vial, pen, cartridges, humalog mixes: vials only. Glargine, glulisine (Apidra). Novolog vial, pen and cartridge. Lantus (vial and pen)
Drugs that cause hypoglycemia*** - - - (6)
beta blockers, quinolones, linezolid, lorcaserin (Belviq), pentamidine, tramadol
HHS
HHS is predominantly a complication of type 2 diabetes (rarely type 1) in which high BG can cause severe dehydration and increases in osmolarity. The condition is a medical emergency
How are DPP4s and GLP1s similar?
Januvia is sitagliptin, a DPP-4 inhibitor. Medications in this class prevent the breakdown of incretin hormones [like glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP)] thereby increasing insulin release and decreasing glucagon secretion. This ultimately decreases glucose production.
treating hypoglycemia
15-20 grams of carbohydrates are recommended for treating hypoglycemia which includes 8 oz of milk, 3-4 glucose tabs, non-diet soda (4 oz), 1 tablespoon of honey and other items. Be sure to retest in 15 minutes and have the patient eat a small amount of food to prevent recurrence
Meds that interact with levothyroxine
Some medications can bind levothyroxine and decrease its absorption, such as antacids (containing aluminum, magnesium or calcium), bile acid sequestrants (e.g., cholestyramine), potassium binding resins (e.g., sodium polystyrene sulfonate), phosphate binders (e.g., sevelamer), iron, orlistat and sucralfate. The administration of these drugs should be separated from levothyroxine.
PTU has a boxed warning for ?
PTU has a boxed warning for severe liver injury, which can come on suddenly, even after long-term use. Both methimazole and PTU can cause rash and agranulocytosis (a form of bone marrow suppression).
___ is used in the first trimester of pregnancy because of the fetal risk associated with ___. ___ can be used in the 2nd and 3rd trimesters.
PTU is used in the first trimester of pregnancy because of the fetal risk associated with methimazole. Methimazole can be used in the 2nd and 3rd trimesters.
T3 vs T4 ; __ is more potent that __.
T3 is much more potent than T4.
Patients with known ___ should be started at __-__ mcg/day of levothyroxine.
Patients with known CAD should be started at 12.5-25 mcg/day of levothyroxine.
Levothyroxine pill colors
12 strengths
Orangutans will vomit on you right before they become large proud giants
orange white violet olive yellow red brown turquoise blue lilac pink green
25 50 75 88 100 112 125 137 150 175 200 300
PTU and methimazole can cause ____, which presents as a syndrome with symptoms such as ____ (6)
Both PTU and methimazole can cause drug-induced lupus erythematosus (DILE), which presents as a syndrome with symptoms such as muscle/joint pain, malar (butterfly) rash, weight loss, photosensitivity, fatigue and depression.
Drugs that can cause hyPOthyroidism
I A T L C (i always think long & confused; hypo)
Interferons, * (both hypo and hyper) Amiodarone, * (both hypo and hyper) Tyrosine kinase inhibitors (sunitinib, etc), Lithium, Carbamazepine
Treating thyroid storm
In addition to PTU, patients with thyroid storm should be treated with SSKI or Lugol’s solution, a beta-blocker, a corticosteroid and acetaminophen.
Treating thyroid storm
In addition to PTU, patients with thyroid storm should be treated with SSKI or Lugol’s solution, a beta-blocker, a corticosteroid and acetaminophen.
Drugs that can cause hyPERthyroidism
Interferons, * (both hypo and hyper)
Amiodarone, * (both hypo and hyper)
Iodine
Drugs that can cause hyPERthyroidism
Interferons, * (both hypo and hyper)
Amiodarone, * (both hypo and hyper)
Iodine
RA sx
all over, bilateral, morning stiffness, bone deformity
RA meds
MTX, HCQ, Leflunomide (Arava)
Arava, toxicities, MOA
leflunomide, hepatotoxic.
CI in pregnancy, need a negative pregnancy test and 2 forms of BC. If pregnancy desired, patient must wait 2 years of being off this med OR accelerated drug elimination option
MOA: inhibits pyrimidine synthesis, reducing proliferation (why its CI in preg) and inflammation
MTX boxed warnings are
pregnancy (inhibits folate synthesis), hepatotoxic, myelosuppression, mucositis/stomatitis
MTX is dosage forms and dosing
PO, IM, SC. PO = TREXall, SC = oTREXup, Rasuvo.
Dosed once weekly, never given daily (reports of adverse events like GI bleed, liver issues, mouth sores). 7.5-20 mg / week.
