Endocrine: pancreas Flashcards
1
Q
List the rapid acting insulins
- what is their:
1. onset
2. peak
3. Duration
4. coverage–when to give and used with what other insulins
A
Lispro (humalog)
Aspart (novolog)
Glulisine (Aprida)
- **rapid absoprtion
- *quicker onset
- **shorter DOA
- 5-15 mins onset
- 45-75 minPEAK
- duration is 2-4 hours
- give this at the same time as a meal… can beused with intermediate or long acting insulin
2
Q
list the short acting insulin
- onset
- peak
- Duration
- coverage–when to give and used with what other insulins
A
Regular Insulin
- 30 min onset
- 2-4 hour peak
- duartion 5-8 hrs
- give 30-60 min PIROR to meal… can be used with intermediate or long acting insulin
3
Q
list the intermediate acting insulin
- onset
- peak
- Duration
- coverage–when to give and used with what other insulins
A
NPH
- 2 hour onset
- 4-12hour peak
- 8-18 hour duration
- covers insulin for about 1/2 day…. OR over night.
Can be given in combo with rapid or short acting
4
Q
list the long acting insulin
- onset
- peak
- Duration
- coverage–when to give and used with what other insulins
A
Detemir and Glargine
- 2 hours
- 3-9 hours (Detemir) and NO PEAK for Glargine
- 6-24 hours..dose dependent (Detemir) and 20-24hours for Glargine
- Detemir covers insulin for 24 hours—BASAL insulin
Glargine has fewer hypoglycemic episodes than NPH
do not mix long acting with other insulins*
5
Q
DOA for Repaglinide
A
2 hours
6
Q
DOA for Acarbose
A
6 hours
7
Q
DOA for metformin
A
6 hours
8
Q
DOA for Glyburide
A
18 hours
9
Q
DOA for GLipizide
A
20 hrs
10
Q
DOA for canalilflozin
A
24 hours
11
Q
DOA for Glimepiride
A
24 hours
12
Q
DOA for Sitagliptin
A
24 hours
13
Q
insulin
- type of hormone
- pre cursor?
A
polypeptide hormone
pro-insulin—->insulin + c-peptide
14
Q
how is insulin produced
A
recombinant DNA technology
- get it from an animal source
- used to use bovine or equine
15
Q
factors that affect the duration of various insulins
A
- dose
- timing of dose
- inj site
- blood supply
- temperature of PT
- patients physical activity
16
Q
why is insulin always SC or IV injection and not PO?
A
polypeptide hormone=degrades in GI tract Rapidly
17
Q
when is IV insulin indicated?
A
more so for emergent situations
18
Q
routes of admin for insulin
A
SC–daily basis
IV–emergent settings
inhalation—not as effective tho
19
Q
adverse effects of insulin
A
- hypoglycemia
- weight gain
- local injection site rxns
- lipodystrophy
- bronchosapsms (with inhaled use)
20
Q
s/s of hypoglycemia begin at what serum level?
A
70 or below
21
Q
do we want patients to adminsiter Insulin in the same site or various ones? why?
A
VARIOUS
so lipodystrophy and site irritation does not occur
22
Q
what is the general progression of DM2 treatments
A
- diet–life style mods
- 1+ metformin
- combo therapy
- multiple injections of insulin—— after 15+ years of DM2… a lot of patients are not producing insulin bc their bodies are sooooooo resistant and need exogenous insulin
23
Q
Aspart
Onset
Peak action
DOA
- when do administer
- combo tx with?
A
Rapid acting
onset: 5-15 mins
peak: 0.5-1.5 hours
DOA: 2-4 hrrs
- Give this at the same time as a meal… 15 mins B4
- can be used with NPH or long acting
24
Q
Glulisine
Onset
Peak action
DOA
A
Rapid acting
onset: 5-15 mins
peak: 0.5-1.5 hrs
DOA: 2-4 hrs
25
```
Lispro
Onset
Peak action
DOA
*when do administer
*combo tx with?
```
Rapid acting
onset: 5-15 mins
peak: 0.5-1.5 hours
DOA: 2-4 hrrs
- Give this at the same time as a meal... 15 mins B4
- can be used with NPH or long acting
26
Regular Insulin
onset
peak hrs
DOA
* when to give
* comb tx with?
Short acting
onset: 0.5-1.0 hours
peak: 2-3 hours
DOA: 3-6 hours
Give 30-60 mins B4 meals
-used with NPH or long acting insulin
27
when do you administer regular insulin
| -what happens if you wait longer or dont eat the meal?
30 mins before meal
| *hypoglycemia
28
when do you administer rapid acting insulin?
| -what happens if you wait longer or dont eat the meal?
15 mins before meal
| *hypoglycemia
29
Neutral Protamine Hagedorn (NPH)
- onset
- peak
- DOA
how long does this cover insulin for?
-combo tx with?
Intermediate acting
onset: 2-4 hours
peak: 4-12 hours
DOA: 8-18 hours
- covers insuliin for half the day or over night
- can be given in combo with rapid (lispro or aspart) or short acting (reg insulin)
30
what makes regular insulin become NPH
+zinc
| +protamine--allows for delay in the onset and peak and longer DOA
31
which insulin preparation do we use in PTs to create "basal rate" of insulin
NPH
| *prevents those peaks and valleys of glucose levels throughout the day*
32
which insulin is indicated for a PT who we want to keep an effective basal rate throughout the day
NPH
33
longer acting insulin preps are meant to control glucseo for greater than _______ hours
12
34
contraindication for long acting insulin preps
in treatment of acute "spikes" in glucose
35
Detemir
- onset
- peak
- DOA
covers insulin for how long
-mix with others?
LONG acting
onset: 2 hrs
peak: 3-9hrs
DOA: 6-24 hours
* cover insulin for 1 full day-->providing basal insulin
* DO NOT give with other insulins at the same time*
36
Glargine
- onset
- peak
- DOA
-mix with others?
LONG acting
onset: 2-4 hours
Peak: no real peak
DOA: 20-24 hours
* FEWER hypoglycemic episodes vs NPH**
* DO NOT give with other insulins at the same time*
37
which long acting insulin is used for replacement of basal rate insulin>
glargine
| DOA=20-24 hrs
38
which insulin prep is similar to NPH
Detemir
39
who is indicated for the combo-preps of insulin
WELL controled DM patients
| *had DM for a long time, know their diet, know their own peaks and valleys naturally
40
storage of ALL insulin preps?
in the fridge
41
what is added to insulin preps to make them longer acting?
protamine
42
frequency of the combo preps??
usually twice/day BEFORE meals
43
List the Dual Combo Preps
75/25 Proatmine Lispro(75%) and Lispro (25%)
70/30 Protamine aspart (70%) and Aspart (30%)
50/50 Priatmine lispro and lispro
70/30 NPH (70) and Regular insulin (30)
44
```
For all combo preps
onset
peak
DOA
*which is MC used?
```
combo prep
Onset: 5-20 mins
Peak: DUAL peaks.. so first is after two hours and then second peak another 2-3 hours
DOA: 10-16 hours
70% NPH and 30% reg insulin MC used
45
which has fewer hypoglycemic episodes--NPH or Glargine
Glargine
46
should PTs mix diff insulins in the same bottle?
NO
47
when do we generally give the long acting preps?
am
or
pm
48
amylin
hormone that is co-secreted by B cells of the pancreas in a NORMAL state
-delays gastric emptying,
delays post-prandial glucagon
improves satiety
49
```
Pramlinitide
drug lass
MOA
INDs
when to take
Kinetics
SE
Contra
```
Synthetic Amylin Analogs
MOA/ind: used as meal-time adjunct to insulin therapy for both DM 1 and DM 2
kinetics: SQ pre-prandial PRIOR to insulin dose. can be given if patient is making their own insulin OR taking exogenous
timing: dose must be RIGHT before meal and before insulin
SE:
- MUST decrease insulin dose by 50% for meal-time dosing to ensure no hypoglycemia
- nausea
- anorexia
contra:
- pre-existing delayed gastric emptying
- do not mix this drug in same syringe as insulin
50
factors that influence the effects of insulin (5)
- stress
- infection
- nutrition in the last 12 hours
- exercise
- hydration
51
when will insulin work at its best?
when glycemic control is monitored closely
52
in general: how much insulin will drop BGL by 50 mg/dl?
1 unit
53
in general: 1 unit of insulin drops the BGL by?
50 mg/dl
54
PT A is 400 pounds and PT B is 100 pounds, one unit of insulin is adminsterd to each--which PT will experience a greater drop in BGL?
PT B--100 lb pt
BC fatter patient has more body surface area---more systemic inflammation-- more adipose tissue--
55
when treating a PT.. what is the MOST IMP first thing to do before starting tx
get their baseline BGL via finger stick
*diaries over the course of 1 or 2 wks*
knowing peaks and valleys
am, pm, nightime and before bed
56
normal BGL range
70-120
57
basal rate is generally calculated how?
body wt
58
standard insulin injection involves?
two daily injections
59
intensive outPT treatment involves?
3+ injections daily
60
ADA recc a target gluclose of______ and a HbA1C below
BGL 154 or < which translates to a HbA1c or <7%
61
HbA1c define
measurement by which hemoglobin also has glycosylated “sugar” hemoglobin attached to it.
62
The higher above 6.5% for HbA1c means?
the poorer control the patient has.
63
standard hospital in-PT treatment has a BGL targget of?
<120
64
whcih drug is mainly used inpatient?
humalog or Lispro bc its cheap
65
inPT fingerstick scheduling?
what is tighter control scheduling?
am and before meals and pm
* AC
* HS
tigher control:
q2
q4
q6
66
indications for insulin drips inpatient
- where is this done?
- what is the scheudling for finger sticks
post-op
HHS
DKA
monitored ward where fingersticks done q1 hr
67
what is an incretin hormone
GLP-1 or glucagon like peptide 1
and
Glucose-dependent insulinotropic polypeptide (GIP)
is release in gut
resp for 60-70% of post prandial insulin secretion
68
what is incretin effect
-when we take glucose ORALLY, a higher response to it occurs to the body where we secrete MORE insulin than if we were to administer glucose IV
why?
BECAUSE of the incretin hormones released---GLP-1 and GIP
69
when are incretin hormones secreted
post-prandially
70
which insulin is adminsited during emergent?
REGULAR IV insulin
71
which patients may require decrease in insulin dose?
renal insufficicnecy DM
72
what does "basal" insulin levels mean
basal=fasting
73
insulins used to acheive basal control
NPH
| any of the long acting--gargline or detemir
74
variable degrees of insulin resistance, impaired insulin secretion, and excessive hepatic glucose production explains?
DM 2
75
when do we start pharmaco-managing DM 2 patietns?
| what do we stsrt with
not controlled with diet alone
| *start with PO
76
PTs who are older than ____ YO are less/more likely to respond well to oral glucose lowering agents and may require____ adjunct
40 yo
respond LESS
insulin adjunct
77
list the sulfonylureas.. also called?
- MOA (3)
- administered how
- which generation are these three
- is there a risk for hypoglycemia with these drugs ?
- SE?
- what kind of PT education would you give
- kinetics
```
SECOND GEN:
**insulin secretagogues**
Glybruide
Glipizide
Glimepiride
```
YES risk of hypoglycemia
*PO
MOA
-promotes insulin release from B cells of pancreas
-additionally reduce hepatic glucose production by liver
-increase peripheral insulin sensitivity
SE:
- hypoglycemia**
- hyPERinsulinemia
- Wt gain
PT Education:
- side effects
- balance this accordingly with meals
- need to see nutritionists
Kinetics:
- heavily met by liver
- excreted by kidneys in urine/feces
78
hypoglycemia is MC with which class of anti-hyperglycemics used in DM 2
sulfonylureas
79
Glyburide
- class
- route
- contraindications
Sulfonylureas
PO
contra: patients with CRF
80
list the drugs that reduce effect of sulfonylureas--leading to??? (6)
leads to hyperglycemia/loss of glucose control
1. atypical antipsychotics
2. corticosteroids
3. diuretics
4. Niacin
5. Phenotihaizdes
6. Sympathomimetics
81
list the drugs that increase/potentiate effect of sulfonylureas--leading to??? (7)
leads to HYPOglycemia
1. azoles
2. BBs
3. Chloramphenicol
4. Clarithromycin
5. MOAIs
6. Salicylates
7. Sulfonamides
82
Metaglitinides--list the drugs
- MOA
- administered how
- when to use?
- is there a risk for hypoglycemia with these drugs ?
- SE?
- what kind of PT education would you give
- kinetics
Repaglinide and Nateglinide
MOA: similar to the sulfonlyureas except these drugs are FASTER onset of action and SHORTER DOA
****insulin secregogues***
Admin: PO
IND: monotherapy in PTs with contraindications to metformin or in combo with metformin
SE:
- some hypoglycemia,
- LOTS of drug-drug interactions since heavily hepatically metabolized
- wt. gain
education: HAS to be given with food
83
Repaglinide contraindicated ?? Who can get it
hepatic impairment--contra
CAN give to renal failure PTs and sulfa allergies
84
Biguanides
| list the drugs
metformin
| *insulin sensitizer*
85
Metformin
- MOA
- Kinetics/dynamics
- SE
- Indications
- contraindications
MOA: increases glucose uptake and use by the target tissues---decreasing insulin resistance (drives glucose INTO cells essentially).
**reduces hepatic gluconeogenesis*
kinetics/dynamics
- PO
- very well absorbed
- NOT bound to proteins
- excreted urine
SE
- little effects with hypoglycemia
- N/V/D
- Wt loss (which is good for DM2)
- renal dysfunction
- macrocytic anemia--B12 deficiency
- sometimes severe N/V/D
- metabolic acidosis (esp in PTs who are renal failure)
CONTR:
- Acute MI
- sepsis
- CHF
- acute or chronic renal failure
Indicactions:
- first line PO agent for DM 2
- can be used alone or in adjunct with insulin or insulin secretagogues (incrs risk of hypoglycemia)
86
does metformin promote insulin secretion?
NO!!
| it is an insulin senitizer--- it increases glucose uptake
87
long term use of metformin is assoc with what diseases
B12 deficiency and lactic acidosis prodcution
| *why we always get CBC and CMP on PTs for check-ups to make sure no anion-gap acidosis
88
what is the BBW for Metformin XR?
traces of NDMA in the make up of the pill. N-nitrosodiumethylamine--carcinogenic
89
Thiazolidinediones
- drug class
- MOA
- list the drugs
- indications
- SE
- Contras
Pioglitazone and Rosiglitazone
Insulin Sensitizers
MOA: increases insulin sensitivity at the peripheral receptor sites at skel muslces, adipose tissue and liver. *****Does not promote B islet cell insulin release*****
*****no risk of hypoglycemia or hyperinsulinemia*****
basically, increases insuin receptor sensitivity at the adipose skel muscles and liver rec sites--increased utilization of glucose and decrease glucose production
- indications:
- adjunct therapy ONLY ( not monotherapy)
- second line drug for DM 2
SE
- hepatoxicity
- periph edema
- chf exacerbations
- incr rates of fx in females
90
SE for Pioglitazone
peripheral edema
CHF exacerbations
liver toxicity (ETOH, hepatitis, etc)
91
SE for Rosiglitazone
Cardiovascular events
92
DM 2 treatments PO
1st line
2nd line
```
1st Metformin
2nd Pioglitazone (only if PT does not have HF)
```
93
what needs to be done before putitng a PT on Rosiglitazone or Pioglitazone
get LFTs
94
which drugs are effective in highly insulin-resistant patients?
Thiazolindiinediones----- Pioglitazone and Rosiglitazone
95
```
Alpha-GLucosidase Inhibitors
-what is alpha-glucosidase?
name the drug
-MOA
-when to administer
-what is the effect on insulin secretion
-kinetics
-indications (what is impotant for the PT to have)
-Contras
-SE
-complications
```
Acarbose and Miglitol
alpha-glucosidase-->enzyme found in brush border of intestinal mucosa--resp for b/d of CHOs into glucose
MOA: delays intestinal glucose absoprtion by inhibitng pancreatic alpha amylase--esentially delays digestion of CHOs
Administration: after FIRST bite of EACH meal
NO effect on insulin secretion: NOT a sensitizer or stimulator
kinetics:
- poor absorbed
INDS:
- pt needs to be able to make their own insulin (see above for reasoning)
- good to use in PTs with renal insufff
SE
- GI cramping
- diarrhea
compications:
- -non-infectious hepatitis
Contras:
-IBS/IBD, bowel obstrucion, colonic dz or ischemic bowel
96
DPP-4
| functin?
Dipeptidyl peptidase-4
| -resp for inactivation of incretin hormones--such as GLP-1
97
GIP
glucose dependent insulinotropic peptide
| *incretin hormone
98
GLP-1
glucagon like peptide 1
| *incretin homrone
99
1. -Glinides
2. -Liptin
3. -azone
4. -liflozin
5. -tide
1. Metaglitinides
2. DDP-4 inhibitors
3 Thiazolidinediones
4. Sodium-glucose cotranspoter 2 inhibitors
5. GLP-1 receptor agonists (SCs)
100
DPP-4 inhibitors
- drug names
- MOA
- kinetics
- SE
- indications
- administration
-liptin
Alogliptin, Linagliptin, Saxagliptin, Sitagliptin (januvia)
MOA: block DDP-4-->prolonging the acitivty of incretin homrones to increase release of insulin in response to meals---also reduced inapp secretion of glucagon.
Kinetics: PO, well abosrbed, can be combined with any other of the DM2 PO drugs and insulin
SE:
- HA
- Nasopharyngitits
- Acute pancreatitis
- severe joint point
- skin changes
INDS:
-monotherapy or adjunctive
ADMIN:
- take w. or w.o food
- once/day
101
```
Sodium-glucose cotransporter 2 inhibitors
drug names
MOA
SE
Indications
contras
```
-liflozin
Canagliflozin, Dapagliflozin, Ertugliflozin, Empaglifozin
MOA: increases urinary glucose excretion by lowering renal glucose threshold-----reabsorbtion of filtered glucose in the tubular lumen of kidney
SE:
- decrease the sodium reasborption causing---OSMOTIC DIURESIS----- causing HYPOTENSION
- genitourinary infections-frequent UTIs and yeast infections
- transient n/v
Indications:
-can be given with metformin
contra:
- renal impairment
102
which drug is approved to reduce cardiovascular events in PTS with DM 2
Empagliflozin----- NA-glucose cotransporter 2 inhibitor
103
whats the advantage to first line PO agents?
better overall HgA1C reduction over time
104
List the SQ injectables for DM 2
what is their drug class
MOA
general BBW for all
-tide
GLP-1 rec agonists
Dulaglutide (truicity)
Liraglutide
Semaglutide
Exenatide
MOA: long acting GLP-1 receptor agonists--they increase glucose dependent insulin release, decreases secretion of glucagon, slows gastric empty and increases satiety
BBW: can cause medulary thyroid CA
CONTRA IN MEN 2 PT
105
Dulaglutide (truicity)
drug class
scheduling for dosing
SE
GLP-1 rec agonists
Kinetics: SC
WEEKLY dosing
```
SE:
BBW: for medullary thyroid CA
hypersensitivty GI
gallbladder dz
actue pancreatitis
```
106
```
Liraglutide
drug class
MOA
Kinetics
Admin scheduling
SE
```
GLP-1 agonist
kintetics: can be in combo with metformin or other POs or with basal insulin
Dosing: 1x/day
SE: injection site rxn, NV/D
BBW: medullary thyroid CA
107
Semaglutide
- kinetics
- SE
- dosing scheudle
GLP-1 agonist
kinetics: yes in combo with other oral agents.. not for DM1 PT tho
Dose: once weekly
SE:
injection site rxn, NV/D
BBW: medullary thyroid CA
108
```
Exenatide
kinetics
dosing schedyle
SE
INds
how much can this reduce HbA1C
```
GLP-1 agonist
kintics:
SC
-can work in combo with basal insulin.
Inds
-for PT who failed metformin
SE:
injection site rxn, NV/D
BBW: medullary thyroid CA
Can reduce HbA1c by 1.5-2 points
109
Other non-hyperglycemic agents to give
Indications?
MOA
Bromocriptine--dopamine agonist
Colvestram--bile sequestrant
* not really used due to high SE profile
* would be given to pre-DM
MOA: somehow lowr HbA1C
