endocrine (pharm) Flashcards
glycemic goals of tx in dM hgbA1c and preprandrial and postprandial plasma glucose
hgbA1c
why is correlation between patient report of SBG and hgb A1c important?
it pts feels like blood sugars good but A1c comes back high, think about glucose monitor needing recalibrating, strips, etc
dm patient ed
Describing the diabetes disease process and treatment options
• Incorporating nutritional management and physical activity into lifestyle
• Using medication(s) safely and for maximum therapeutic effectiveness
• Monitoring blood glucose and other parameters and interpreting and using the results for selfmanagement
decision making
• Preventing, detecting, and treating acute and chronic complications
• Developing personal strategies to address psychosocial issues and concerns, and promote
health and behavior change
lifestyle change for dM
Nutrition Self-monitoring Physical activity o Improves insulin sensitivity o May improve glucose tolerance Adherence to medication regimen (if meds necessary
4 main pathogenetic features DM meds target
decreased insulin secretion, increased glucose made by liver, sugar absorption in gut, decreased glucose use by tissues
effect on A1C with physical activity (decreasing weight) and nutriton
decrease in 1-2%
metformin trade name mechanism of action advantages disadvantages cost A1C effect
metformin trade name glucophage mechanism of action ↓ Hepatic glucose production advantages• Extensive experience • No hypoglycemia • ↓ CVD events (UKPDS) disadvantages • Gastrointestinal side effects (diarrhea, abdominal cramping) • Lactic acidosis risk (rare) • Vitamin B12 deficiency • Multiple contraindications: CKD#, acidosis, hypoxia, dehydration, etc. cost: low A1c 1-1.5%
sulfonylureas: glipizide trade name mechanism of action advantages disadvantages cost A1C effect
glipizide trade name glucotrol mechanism of action • Closes KATP channels on -cell plasma membrane • ↑ Insulin secretion advantages• Extensive experience • ↓ Microvascular risk (UKPDS) disadvantages • Hypoglycemia • ↑ Weight • ? Blunts myocardial ischemic preconditioning* • Low durability cost low A1C effect 1-1.5%
thizolidinediones: pioglitazone trade name mechanism of action advantages disadvantages cost A1C effect
thizolidinediones: pioglitazone trade name acts mechanism of action ↑ Insulin sensitivity advantages• No hypoglycemia • Durability • ↑ HDL-C • ↓ Triglycerides (P) • ? ↓ CVD events (ProACTIVE, P) disadvantages • ↑ Weight • Edema/heart failure • Bone fractures • ↑ LDL-C (R) • ? ↑ MI (meta-analyses, R) cost low A1C effect 1-1.5%
alpha glucosidase inhibitors trade name mechanism of action advantages disadvantages cost A1C effect
alpha glucosidase inhibitors trade name acarbose=precose mechanism of action Inhibits intestinal a-glucosidase • Slows intestinal CHO digestion/ absorption advantages • No hypoglycemia • ↓ Postprandial glucose excursions • ? ↓ CVD events (STOP-NIDDM) • Nonsystemic disadvantages • Generally modest A1C efficacy • GI side effects (flatulence, diarrhea) • Frequent dosing schedule cost moderate A1C effect 0.5-1
DPP-4 inhibitors trade name mechanism of action advantages disadvantages cost A1C effect
DPP-4 inhibitors trade name sitagliptin=januvia mechanism of action • Inhibits DPP-4 • ↑ Postprandial active incretin (GLP-1, GIP) • ↑ Insulin secretion† • ↓ Glucagon† advantages • No hypoglycemia • Well tolerated disadvantages• Angioedema/urticarial, other immunemediated derm effects • ? Acute pancreatitis • ? ↑ HF hospitalizations • ? Severe joint pain (rare) cost high A1C effect not great
GLP-1 receptor agonists trade name mechanism of action advantages disadvantages cost A1C effect
exenatide: byetta trade name mechanism of action • Activates GLP-1 receptors • ↑ Insulin secretion† • ↓ Glucagon secretion† • Slows gastric emptying • ↑ Satiety advantages • No hypoglycemia • ↓ Weight • ↓ Postprandial glucose excursions • ↓ Some CV risk factors disadvantages • GI side effects (N, V, D) • ↑ Heart rate • ? Acute pancreatitis • C-cell hyperplasia/medullary thyroid tumors in animals • Injectable • Training requirements cost high A1C effect 1-1.5%
drug that is often used with insulin in type II DM
amylin mimetics (pramlintide)
drug for DMII that is also used for HLD
bile acid sequestrants: colesevelam
drug for DMII that inhibits reabsorption of glucose in proximal tubule and has added benefits of decreased wt and bp
Sodium-glucose cotransporter 2 (SGLT2) inhibitor • Canagliflozin • Dapagliflozin‡ • Empagliflozin
T or F: if A1c is >9, consider starting at dual therapy
T
where should you consider starting if BG >300-350
combo injectable therapy
what is 1st line DM tx? where to go from there?
metformin, check A1c in 3 months, if not at goal and fully titrated and adherent, move on to dual therapy
initial immediate release dosing of metformin
500 mg bid or 850 mg daily
universal dose of regular insulin100 units/ml OTC
100 units/ml OTC
indication for rapid acting insulin
covers for meals
examples of long acting insulin
glargine, detemrir
name of ultra long acting insulin
degludec
best place to keep insulin
Best place is the refrigerator
Can be kept at room temperature if used within 30 days
Do not expose to extreme temperatures or sunlight; no not allow to freeze
f:
don’t use insulin if
Insulin is discolored
Particles have clumped together or are sticking to side of bottle
Past expiration date on bottle or has been unrefrigerated for > 1 month
insulin starting dose for DM1 AND 2
DM1: 0.5-0.6 units/kg/day
DM2: 0.1-0.2 units/kg/day
Usual DMI1 dose: 0.5-1 unit/kg/day in divided doses
50% Basal insulin (long acting)
50% Prandial insulin (prebreakfast, prelunch, predinner)
treatments of hypoglycemia
Conscious patient
Oral glucose tablets 15-20 gm (chew), MR in 15 min if SMBG shows continued
hypoglycemia
Food (orange juice)
Meal or snack once BG normalizes to prevent hypoglycemia recurrence
Unconscious patient
Glucagon: 1 mg SQ, IM or IV produces a response in 5-20 min, MR x 1 or 2 prn
IV dextrose
what do all diabetic patients on insulin and PO agents with r/o of hypoglycemia need to know?
signs and sx of hypoglycemia and how to tx with oral tablets, etc
is acute illness a problem for T2DM patients?
usually not
how to manage BG in T1DM patients with an acute illness?
Patients need to monitor BG frequently,
check urine ketones, use short-acting
insulin as needed
continue usual insulin regimen
and use supplemental rapid-acting insulin basedon BG results
Give additional insulin if ketonuria develops
how do you manage BG in hospital setting?
Scheduled insulin with additional short-acting insulin as needed is recommended, esp b/c you need to hold metformin b/c of risk of renal failure in hospital and possible need for CT with contrast
BP goal for diabetes according to ADA? pregnancy?
Blood Pressure Goal*
what type of management (lifestyle vs. drugs) is appropriate for BP in DM? for which BP ranges? which drug should be used?
Lifestyle therapy** alone (max 3 months) > 120 > 80
Lifestyle therapy** + pharmacologic therapy > 140 > 90
drug: ACEI 1st line, ARB 2nd line
monitoring of BP drugs (ACE/ARB) in diabetcis
BP, serum creatinine, GFR, serum K
what statin intensity should be taken by those 40-75 with no known ASCVD RFs?
moderate, b/c DM is a CVD risk equivalent
what kind of statin tx by ACS and LDL >50 in patients who can’t tolerate high dose statins?
Moderate statins + ezetimibe
anyone with ASCVD should receive what kind of statin therapy?
high dose statins
who with DM should get aspirin?
YES if >50 and RFs and 10 years risk >10 %, NO if
T or F: everyone with DM should be on aspirin therapy
F: If
how do you decide who should be on aspirin therapy?
need to look at 10 year CV risk
increased urine albumin to creatinine ratio (30-299) is an early indicator of what?
diabetic kidney disease
what’s the best way to prevent diabetic kidney disease?
optimize BG & BP and screen for urinary albumin and GFR
