Exam 3 Flashcards
What are the signs and symptoms of diabetes and how are they related to the pathophysiology of diabetes? (polys, weight loss, fatigue, UTIs/infections, ketoacidosis, blurred vision)
Polyuria - Increased urination due to osmotic diuresis from glucose in urine
Polydipsia - Thirst due to the polyuria
Polyphagia - Increased hunger because the body tissues are “starving” without getting the glucose-dependent uptake
Weight loss - Due to excretion of glucose in urine, body fat and protein stores broken down for fuel
Fatigue - Due to hyperglycemia after a meal
UTIs, respiratory infections, etc - Glucose is great for bacteria growth
Ketoacidosis - Due to body making ketones for fuel because it doesn’t absorb enough glucose
Blurred vision - Osmotic-induced changes in the lens of the eye
What are the long-term complications of diabetes on the kidneys, eyes, peripheral nervous system, and cardiovascular system?
Diabetic kidney disease - There’s persistent proteinuria, a decreased eGPR, and increased arterial BP. This is a major cause of death in Type 1 patients. Do annual urinalysis tests (for microalbuminuria). Limit protein intake to 0.8mg/kg/day, conisder ACE-i or ARB if UACR is high (300)/GFR is low (60)
Retinopathy - Most common complication and most common cause of blindness.
- Glaucoma also common
- Optimize glycemic control, have eye exam every 1-2 years if no evidence of retinopathy
Peripheral neuropathy - Best treatment is to get blood sugars down. Do annual monofilament testing. Pregabalin, duloxetine, or gabapentin for treatment.
GI neuropathies - Gastroparesis, diarrhea/constipation, fecal incontinence
Atherosclerotic cardiovascular disease (ASCVD) - leading cause of morbidity and mortality. SGLT-2Is, and GLP-1RAs are preferred in these patients. Assess CV risk factors annually.
- Also heart failure, stroke, peripheral vascular disease
Diabetic kidney disease - Microalbuminuria tests annually
Retinopathy/glaucoma - Eye exam annually
Peripheral neuropathy - Monofilament testing annually
ASCVD & others - Asses CV risk annually,
- BP goal for T2DM + ASCVD ≥ 15% = <130/80
- BP goal for T2DM + ASCVD < 15% = <140/80
What are the goals of therapy in the treatment of type 1 and type 2 diabetes? How should the patient be monitored to establish whether these goals have been met or not?
Goals of therapy - Keep patient asymptomatic, prevent long-term complications, maintain euglycemia (no low/high values), achieve/maintain appropriate body weight, maintain normal growth in children, enhance patient education/self-reliance, minimize cardiovascular risk factors
- Blood glucose tests: Fasting target is 80-130, random/PPD is <180, HS goal is 90-150.
- A1c: Goal is <7% (maybe <6% in individual patients + pregnant women); A1c of 7% ~150; PPG impacts A1c more at lower A1c ranges, fastings impact A1c more at higher A1c ranges
What is the onset, peak, duration of action, and adverse effects of aspart, lispro, and glulisine?
All have onset of 10-20 mins, peak at 30-90 minutes, and have a duration of 3-5 hours. Compatible when mixed with NPH.
Aspart - Fiasp may have <10min onset and duration up to 7 hours, but that’s the only exception.
What is the onset, peak, duration of action of insulin regular and NPH?
Regular - Onset of 30-60 minutes, peak at 2-4 hours, duration of 5-8 hours. Compatible with NPH
NPH - Onset of 2-4 hours, peak at 4-10 hours, duration of 8-12 hours. Compatible with regular, lispro, aspart, and glulisine.
What is the duration of action of Humulin-R U500, Degludec U300, Glargine U300, and Lispro U200?
Humulin-R U500 - 6-10 hours; Has best A1c reduction, but most weight gain
Degludec U200 - 42 hours
Glargine U300 - >30 hours
Lispro U200 - 3-5 hours
- Change to concentrated when TDD is 200-300units/day
What is the onset, peak, duration of action of glargine, detemir, and degludec?
Glargine - Onset of 2-4 hours, no peak, lasts 20-24 hours.
Detemir - Onset of 1.5-4 hours, peak is 6-14 hours, lasts 16-20 hours.
Degludec - Onset of 1 hour, no peak, lasts ~42 hours.
What are key points we need to think about when designing an initial insulin regimen? What are the recommended starting ranges for Type 1 and 2 patients?
Type 1 patients: More sensitive than Type 2 patients.
- Avg. daily dose is 0.5-0.6u/kg/day
- Honeymoon phase for new diagnosed patients 0.1-0.4u/kg/day
- Should test BG 4x/day
- Basal-bolus dosing: 50-70% of insulin as basal, the last 30-50% as bolus.
- NPH + short-acting: 2/3 of dose in the morning injection, 1/3 in the PM; R/N-0-R/N-0
- Also R/N-0-R-N and using insulin pre-mixes
- Pumps are the goal to get best flexibility. Here we use rapid acting to cover the basal and prandial needs.
Type 2 patients:
- Starting dose is 0.1-0.2u/kg/day or 10 u/day
- Start with basal
- Increase dose every 2-4 days until goals are met, target FBS first
How do we adjust doses of insulin for diabetes patients (type 1 or 2) based on their blood glucose readings?
Type 1: Doses are adjusted based on patient response. Prandial doses can be adjusted based on carb content (ex. 1 unit per 15g carbs). Remember type 1 pts are usually much more sensitive.
- Empiric: increase by 2u decreases by ~50
Type 2: Increase dose by 2 units every 3 days to reach FBS goal.
- For patients on more then 0.5u/kg/day of basal, consider adding bolus to avoid over basalization. Start with 0.1u/kg or 10% basal dose or 4-5 units of bolus.
- Empiric: increase by 4u decreases by ~50
Insulin-to-carb ratio: Average is 1 unit per 10-15g carbs (adult and 20-30g carbs (kids). Assess the carbs eaten over a 3 day period and divide that number per meal by the amount of bolus given.
- Rule of 500: 500/ daily dose of insulin (TDD) = number of grams of carbs per 1 unit of insulin. Ex. 500/40u = 12.5g carb per 1 unit.
Correction Factor: 2:50 > 150
- Rule of 1800: 1800/TDD = # of mg/dL change of BG per 1 unit. Ex. 1800/90 = 20mg/dL drop per 1 unit.
- Rule of 1500: Use if pt is on regular insulin.
What are the typical signs and symptoms of hypoglycemia? What are some predisposing factors for hypoglycemia (including drugs)? What are the available treatment options for hypoglycemia?
Hypoglycemia: Level 1: BG < 70; Level 2: BG < 54
Causes: Increased insulin doses, decreased caloric intake, increased muscle utilization, excessive alcohol
Signs and symptoms: tremors, diaphoresis, anxiety, dizziness, hunger, tachycardia, blurred vision, weakness/drowsiness, headache, irritability, confusion, slurred speech
Treatment: Rule of 15s. 15g of fast-acting carbohydrates unless BS is <50, then use 30g. Then, wait 15 mins and check again. If BG is not > 79, then repeat 15g carbs.
- 4oz OJ, 6 oz cola, 5-6 life savers, 2 tsp sugar, 1tsp honey, 3-4 glucose tabs
What are the advantages and disadvantages of these drug classes for treatment of diabetes: insulin, metformin, SGLT-2s
Ultra rapid insulins:
- Pros: Decreases PPD hypoglycemia and PPD lowering of BS, less nocturnal hypoglycemia, greater flexibility
- Cons: Risk of hypoglycemia is no meal within 15 mins of dose, will need to combine with longer acting for best BS control
Long acting insulins:
- Pros: 24+ hour coverage with constant absorption pattern, no pronounced peak, good for pts with nocturnal hypoglycemic episodes
- Cons: Can’t be mixed with other insulin
Metformin:
- Pros: Decreases hepatic production of glucose, increases glucose utilization, increases GLP-1 secretion; Reduces risk of mortality and CV death, decreases risk of stroke and other heart problems, minimal hypoglycemia, positive/neutral effects on weight, cheap
- Cons: May cause lactic acidosis
SGLT2Is:
- Pros: Improved CV benefits from decreasing weight, decreasing BO, and osmotic diuresis, renoprotective (reduce worsening in renal function)
- Cons: Canagliflozin in particular has warnings for bone fractures, AKIs, leg/foot amputations, and serious genital infections
What are the advantages and disadvantages of these drug classes for treatment of diabetes: GLP-1s, GLP + GIPs, DPP-4s, TZDs, sulfonylureas
GLP-1s -
- Pros: also inhibits glucagon secretion, delays gastric emptying, decreases appetite, decreases weight, CV and renal benefits
- Cons: Expensive, mostly injections
GLP + GIPs -
- Pros: weight loss, really good decrease of A1c
- Cons: Expensive, injection
DPP-4s -
- Pros: Increases glucose-dependent insulin secretion, weight neutral
- Cons: need to adjust doses for renal functions (except linagliptin)
TZDs -
- Pros: Decreases triglycerides, increases HDLs
- Cons: hepatotoxicity, exacerbates HF
Sulfonylureas -
- Pros: Cheap, effective
- Cons: Hypoglycemia, secondary failure pretty common esp. after 5 years
Metformin: Adverse events, monitoring parameters to follow, generic names, usual doses (1, + dosing in renal insufficiency)
Adverse events - GI effects like diarrhea, flatulence, nausea/vomiting, vitamin B12 malabsorption or deficiency
Monitoring - SCr at least annually, Vit B12 annually
Generic - Metformin
Doses - initial is 500mg BID or 850 daily, max dose is 1000mg BID.
- If eGFR is above 60, then normal initial dose. Monitor SCr annually.
- eGRF between 45 and 60, then normal initial dose, but monitor SCr every 3-6 months.
- eGFR between 30 and 45, then don’t start metformin, and reduce by 50% if already taking, monitor SCr every 3 months.
-eGFR less than 30, stop taking metformin and don’t start.
SGLT2 inibitors: Adverse events, monitoring parameters to follow, generic names, usual doses (4, + when they should stop with renal insufficiency)
Adverse events - UTIs, female/male genital fungal infections, increased urination, hypotension, hyperkalemia, increased cholesterol (also FDA risk of leg/foot amputations, bone fracture, AKIs)
Monitoring parameters - Renal function (eGFR)
Generic names - Canagliflozin, empagliflozin, dapagliflozin, ertugliflozin
Usual doses -
Canagliflozin: 100mg (max 300mg daily); Don’t start in eGFR less than 30, but may stay on 100mg if they are already taking it and albuminuria is > 300mg/d
Dapagliflozin: 5mg daily (max 10mg daily); don’t start is eGFR less than 25, if already taking just monitor
Empagliflozin: 10mg daily (max 25mg daily); don’t use in eGFR less than 30
Ertugliflozin: 5mg daily (max 15mg daily); don’t start if eGFR less than 60 (monitor if already on)
GLP-1 agonists: Adverse events, monitoring parameters to follow, generic names, usual doses (7)
Adverse events - Nausea, vomiting, diarrhea, acute pancreatitis, gallbladder disease
Monitoring parameters - retinopathy
Generic names - Liraglutide, dulaglutide, semaglutide, exenatide, lixisenatide
Usual doses -
Dulaglutide/Trulicity: 0.75mg -> 4mg once weekly (caution ESRD)
Semaglutide/Ozempic: 0.25mg x4 weeks -> 0.5mg-2mg once weekly
Liraglutide/Victoza: 0.6mg x7 days, then 1.2mg -> 1.8mg daily
Exenatide/Byetta: 5mcg x1 month, then 10 mcg BID (avoid CrCL < 30)
Exenatide/Bydureon: 2mg once weekly (avoid CrCL < 30)
Lixisenatide/Adylyxin: 10mcg x10 days, then 20mcg daily (avoid eGFR <15)
Oral semaglutide (Rybelsus): 3mg PO daily x30 days, then 7mg daily -> 14mg
GLP-1 + GIP agonists: Adverse events, monitoring parameters to follow, generic names, usual doses (1)
Adverse events - Nausea, vomiting, diarrhea, warnings for pancreatic thyroid tumors and gallbladder disease, tachycardia
Monitoring - Retinopathy
Generics - Tirzepatide
Doses - 2.5mg SQ weekly, increase by 2.5mg/week -> 15mg
DPP4 inhibitors: Adverse events, monitoring parameters to follow, generic names, usual doses (4)
Adverse events - Nasopharyngitis, URIs, headache, some pancreatitis, joint pain, heart failure risk
Monitoring - Renal function
Generic - sitagliptin, saxagliptin, linagliptin, alogliptin
Doses -
Sitagliptin: 100mg daily, CrCL 30-50 decrease to 50mg, CrCL less than 30 decrease to 25mg (same if ESRD with dialysis)
Saxaglipin: 2.5-5mg daily, CrCL < 50 then 2.5mg daily
Linagliptin: 5mg once daily
Alogliptin: 25mg daily, CrCL 30-60 decrease to 12.5mg, CrCL <30 then 6.25mg (same if ESRD and dialysis)
Sulfonylureas (2nd gen): Adverse events, monitoring parameters to follow, generic names, usual doses (5)
Adverse events - Hypoglycemia (d/c if starting insulin), weight gain, hematologic, allergy
Monitoring -
Generic - Glyburide, Glipizide, Glimepiride
Doses - Start low and increase dose every 1-2 weeks until max dosage.
Glimeperide - 1-2mg daily -> 8mg
Glipizide - 2.5-5mg daily -> 40mg
Glipizide XL - 2.5-5mg daily -> 20mg
Glyburide - 1.25-5 daily -> 20mg
Glyburide micronized - 1.5-3mg daily -> 12mg
Thiazolidinediones: Adverse events, monitoring parameters to follow, generic names, usual doses (2)
Adverse events - Hepatotoxicity, resumption of ovulation, exacerbations of HF, edema, fracture risk
Monitoring - LFTs (don’t start if 2.5x normal), n/v, abdominal pain, anorexia, dark urine, fatigue
Generic - Pioglitazone, Rosiglitazone
Dosing -
Pioglitazone: 15, 30mg -> 30-45mg daily max
Rosiglitazone: 4mg -> 8mg daily max
- Titrate up every 12 weeks
Pramlintide: Adverse events, monitoring parameters to follow, generic names, usual doses
Adverse effects - Severe hypoglycemia with concomitant insulin admin, N/V, anorexia
Monitoring -
Generics - pramlintide (symlin)
Dosing -
- Type 1 patients: 15mcg and titrate up by 15mcg to 30-60mcg (may also decrease insulin needs)
- Type 2 patients: 60mcg and titrate up to 120mcg (may also decrease insulin needs)
Meglitinides: Adverse events, monitoring parameters to follow, generic names, usual doses
Adverse events - Hypoglycemia (less than sulfonylureas), weight gain
Monitoring - watch closely for hypoglycemia
Generics - Repaglinide (Prandin), nateglinide (starlix)
Doses -
A1c < 8%, then start 0.5mg repaglinide or 60mg nateglinide w/ meals
A1c > 8%, then start 1-2mg or 120mg nateglinide w/ meals
- repaglinide max is 16mg/day
- nateglinide max is 360mg/day
Adjust doses weekly, skip dose if skip meal, add dose if add meal
α-glucosidase inhibitors: Adverse events, monitoring parameters to follow, generic names, usual doses
Adverse events - GI issues like flatulence, diarrhea, abdominal pain/cramping, rashes, LFTs
Monitoring -
Generic - acarbose, miglitol
Dosing -
- start at 25mg daily with meals fro 7-14 days, then 25mg BID, for 14days, then 25mg TID for 6 weeks, then 50 TID (max if <50kg), then 100mg TID (max if >50mg) if tolerated
What were the key clinical outcomes for these trials about anti-hyperglycemic agents: EMPAG-Reg, DAPA-HG, CANVAS, LEADER, SUSTAIN-6
EMPAG-Reg: Empagliflozin improves CV risk and shows renoprotective characteristics.
DAPA-HG: Dapagliflozin improves CV risk.
CANVAS-R: Canagliflozin improves CV risk.
LEADER: Less CV death in liraglutide group than placebo. Liraglutide shows renal benefits.
SUSTAIN-6: Semaglutide has less CV death than placebo. Same with nonfatal MI and stroke. Semaglutide also has renal benefits
What were the key clinical outcomes for these trials about anti-hyperglycemic agents: REWIND, SAVOR-TIMI, EXAMINE, TECOS
REWIND - showed that dulaglutide has renal benefits
SAVOR-TIMI - Saxagliptin causes more HF hospitilizations than placebo, but no difference in CV death, MI or stroke
EXAMINE - Alogliptin caused more HF hospitalizations than placebo
TECOS - No increased risk for CV events or HF hospitalizations with sitagliptin
What are the appropriate recommended uses and contraindications/precautions for insulin, metformin, SGLT2 inhibitors?
Insulin - Start if A1c is > 10% or if blood glucose readings are above 300
Metformin - Used as an adjunct to diet in uncontrolled type 2 patients, in combo with insulin and other non-insulin products. Use for all type 2 patients (if tolerated and not contraindicated).
- Contraindications: Renal dysfunction, unstable HF patients, heavy alcoholics, pts at risk for lactic acidosis (post MI, shock, COPD, hepatic failure, surgery/radiologic procedure)
SGLT2 inhibitors - Adjunct to diet and exercise, use with or without metformin as initial treatment for type 2 pts or if they are at high risk for atherosclerotic cardiovascular disease, HR, or CKD
- Hold SGLT2 for 3 days before surgery due to risk of DKA
- Risk of bone fractures, AKI, leg/food amputations, serious genital infections (these mostly with canagliflozin)
What are the appropriate recommended uses and contraindications/precautions for GLP-1 agonists, GIP+GLP-1 agonists, DPP-4 inihibitors?
GLP-1 agonists - Use with or without metformin as an appropriate initial therapy or if they are at high risk for ASCVD, HF, or CKD. For T2, GLP-1 is preferred to insulin when possible (if they can afford it and tolerate it). If insulin is used, combo therapy with GLP-1 is recommended
- Contraindications: severe renal disease, pts with chronic pancreatitis, history of medullary thyroid carcinoma, gallbladder disease, gastroparesis,
GLP-1 + GIP - Being marketed especially for weight loss
DPP-4 inhibitors - Monotherapy and add-on therapy with metformin or TZDs in T2 pts, also combo therapy with SUs.
- Contraindicated with GLP-1 agonist, increases digoxin concentrations, durgs like ketoconazole, clarithromycin, rifampin, etc. decrease saxagliptin AUC.
What are the appropriate recommended uses and contraindications/precautions for 2nd gen sulfonylureas, thiazolidinediones, pramlintide, meglitinides, and α-glucosidase inhibitors?
Sulfonylureas - Adjunct to diet and exercise for type 2 patients, used in combo with insulin and other agents. Best for type 2, short duration of diabetes so far, FBS of less than 250, high fasting C-peptide levels.
- Contraindicated with drugs that increase or decrease hypoglycemic effect; Caution if elderly, irregular dietary intake, alcoholics, taking other hypoglycemic agents.
Thiazolidinediones - Use pioglitazone first. Use as adjunct to diet and exercise, and can be in combo with SUs, DPP-4, metformin, or insulin
- Contraindications: Causes with NYHA class III and IV.
Pramlintide - Use in type 1 and 2 patients, also used for weight loss. Use when they are already on insulin but not achieving adequate control.
Meglitinides - Use adjunct to diet and exercise for uncontrolled T2DM or in combo with metformin
- Contraindications: Don’t use with SUs. Caution in elderly and patientst with hypatic/renal dysfunction
α-glucosidase inhibitors - Adjunct to diet and exercise and in combo with other agents
- Contraindications: DKA, inflammatory bowel disease, colonic ulceration, intestinal obstruction, hypersensitivity
What are the contraindicated drugs for diabetes patients with kidney disease, cardiovascular disease, and obesity?
Kidney disease -
- all are neutral (except SGLT-2s and GLP-1s have benefit)
- at eGFR <30, no metformin
Cardiovascular disease -
- ASCVD: SUs may have risk
- HF: TZDs have risk, saxagliptin and alogliptin are potential risk
Obesity -
- TZDs, SUs cause weight gain
What is the optimal treatment for diabetes patients with concomitant hypertension, kidney disease, hyperlipidemia, obesity?
Kidney disease - SGLT2i or if that’s not tolerated, then GLP1RA (liraglutide)
Cardiovascular disease - SGLT2 for heart failure, GLP-1 (dulaglutide) or SGLT2 for ASCVD, maybe TZD later down the road
Obesity - SGLT2s, GLP1s, and metformin cause weight loss
How do we treat diabetes patients who is pregnant? (type 1, type 2, gestational)
Pregnant - Our goals during pregnancy is FBS of 70-95, 1h PPD 110-140, 2h PPD 100-120, A1c <6%.
- Type 1: Increased risk of hypoglycemia in first trimester, increased DKA risk, so prescribe ketone strips, insulin requirements drop after birth
- Type 2: Risk for co-morbidities is higher, control weight, insulin requirements drop after birth
- Gestational: Insulin preferred starting at 0.7-1u/kg/day divided in basal and bolus doses, use metformin if can’t take insulin
Avoid glyburide/glipizide, minimal data on the other agents. Usually we just go with insulin
How do we treat pediatric diabetes patients?
Pediatrics - Determine if type 1 or 2. Goal is A1c <7%
- Type 1: Insulin (pump is preferred), important to think of psychosocial aspects/school system
- Type 2: Focus on weight reduction. If <8.5% do metformin only, if >8.5% do basal insulin + metformin; if those don’t work, at GLP-1 (liraglutide or exenatide); then add bolus insulin/pump
How do we treat diabetes patients who are older adults?
Healthy: goal A1c 7-7.5%, fasting 80-130, HS 80-180, <140/90
Complex/intermediate health: goal A1c <8%, fasting 90-150, HS 100-180, <140/90
Poor health/end-stage: no goal A1c, fasting 100-180, HS 110-200, <150/90
How do we treat diabetes patients who are hospitalized?
- Hyperglycemic patients have much higher risk of infection
- Perform A1c test if none taken within 3 months
If glucose > 180, then start insulin with target of 140-180, maybe 110-140 if no increased hypoglycemia.
- Terminally ill pts use insulin if glucose >250
Monitoring: Check pre-prandial if patient is eating, check q4-6 hours if not eating, if IV insulin check q30min-2h. Beware of hypoglycemia
Treatment: Basal-bolus is preferred if not critically ill, use IV if critical
**short-acting glucocorticoids raise BG throughout the day, longer-acting may cause for insulin adjustment.
Metformin and SGLT2s should be held 3-4 days before surgery, all other oral glucose lowering meds held day of surgery. Give 1/2 of NPH or 75% long-acting morning of surgery.
How do we change between U-100 therapies? How do we change U100 to concentrated insulin (5 types of conversions)?
Between U100 therapies: If NPH -> long-acting, then keep dose the same; If BID NPH -> long-acting, then decrease the dose by 20%.
Changing U100 to concentrated:
- BID NPH -> U300 glargine, then decrease the dose by 20%
- If daily glargine/detemir -> daily concentrated glargine, then it’s a 1:1 conversion
- Basal insulin -> U-200 degludec is a 1:1
- Lispro U100 -> Lispro U200 is a 1:1
- U100 basal-bolus regimen -> U500 regimen may need 20% dose reduction from total insulin. U500 replaces basal and bolus. If A1c > 8%, then 1:1; if A1c < 8%, then 20% reduction.
What is the basic pathophysiology of DKA and HHS?
DKA - A precipitating factor (like non-adherence, infection, or new diagnosis) causes an increased stress response that increases catecholamines/cortisol/GH that oppose insulin. This causes an increase of hepatic glucose production and decreased peripheral insulin sensitivity, all leading to a lack of peripheral glucose uptake and an increase in adipose tissue. Triglycerides are then broken down to glycerol and FFAs. These FFAs are broken down into ketones that are used for fuel.
HHS - Insulin deficiency or resistance leads to reduced glucose utilization that leads to increased hepatic glucose output due to excess glucagon secretion. There’s lot of glucose in urine which leads to increased water loss and dehydration which can cause acute kidney injury, leading to decreased ability to clear excess blood glucose. This leads to hyperosmolality, potentially leading to mental confusion, coma, and seizures.
What is the DKA triad and how is it different from the laboratory presentation of HHS?
DKA:
- Hyperglycemia
- Hyperketonemia
- Metabolic acidosis
HHS: no/few ketones, normal pH, extremely high glucose, high serum osm
- Severe hyperglycemia
- Hyperosmolality!!
- Severe fluid depletion
What is the formula for corrected sodium, anion gap, and osmolality?
Corrected sodium: Measured Na + 1.6[(glucose - 100)/100]
Anion gap: Na - (Cl + Bicarb)
Osmolality: (Na x 2) + BUN/2.8 + Glucose/18
What are the common laboratory abnormalities that happen in patients with DKA or HHS?
DKA: Low blood pH (<7), low bicarb (<10), more than 3 β-HB, more than 12 anion gap
HHS: no ketones, HIGH blood sugar, normal pH, BUN > 100mg/dL, serum osm > 320
What treatment options are there for DKA?
- Restore circulatory volume (fluids)
- Give 0.9% NaCl (NS) at 500-1000mL/hr for the first 1-4 hours
- at 2-4 hours, evaluate the corrected Na
- If Na is corrected, change to 1/2 NS and decrease the rate by 50%; If Na is low, continue NS but still decrease the rate by 50%.
- Once BS is 200, change to D5W with 1/2 NS until ketoacidosis resolves. - Inhibit ketogenesis and return of normal glucose metabolism (insulin)
- After fluids have been initialed, start IV insulin and monitor BG every hour.
- Start 0.1u/kg/hour (+/- bolus of 0.1u/kg); check every hour and adjust dose to maintain glucose of 200-250
- Once anion gap closes, we can change to SubQ and maintain glucose of 150-200
- When transitioning, overlap IV and SubQ by 2-4 hours to prevent rebound ketoacidosis or hyperglycemia. Start at 0.1u/kg q2h and adjust prn; Also could add up rate from drip and divide it into q2h
- When initiating SubQ (for moderate DKA), start 0.2u/kg q2h to maintain BG of 200-250. Once anion gap closes, maintain glucose at 150-200. - Correct electrolyte imbalances (supplement electrolytes)
- Potassium: Want to maintain K of 4-5 mmol/L
- Because we are already starting insulin, want to add KCl supplementation. If K 4-5, add 20mEq/L KCl. If K 3-4, add 40mEq/L KCl. If K < 3, at 10-20 mEq/hr until K > 3, then add 40mEq/L
- Sodium: Keep monitoring corrected sodium, but we are managing this through the fluids we are giving.
- Phosphate: If phos is less than 1mg/dL and there are comorbidities, then we may supplement phos
- Bicarb: Only if pH is less than 6.9 do we give bicarb. In that case, give 50-100 mmol bicarb q1-2h until pH is above 7.
What treatment options are there for HHS?
- Restore circulatory volume (fluids)
- Start with 1/2 NS (or NS) at 500-1000mL/hr for the first 1-4 hours
- Evaluate corrected Na at 2-4 hours
- If Na normal/high, reduce the fluid rate; If Na is low, consider NS
- When blood sugar is 300, change to D5W w/ 1/2 NS until HHS is resolved - Restore urine output to 50mL/hour or more (fluids)
- Return blood glucose to normal (fluids + insulin)
- Start IV insulin at 0.1u/kg/hr (+/1 bolus)
- Check glucose every hour with goal of 300
- Once at 300, decrease infusion to 0.02-0.05u/kg/hour to maintain glucose of 200-300 until pt is mentally alert
- Once mentally alert, can change to SubQ (with 2-4h overlap)
**hypo-K is not as big of an issue here, but maybe supplement 10mEq/L while on insulin if needed.
*Only supplement phos if <1mg/dL
What are the minor differences in the treatment of DKA and HHS?
- The blood sugar goals are different. DKA goal is 150-200, but HHS goal is 300.
- More emphasis on potassium with DKA
- DKA starts with NS, HHS starts with 1/2 NS. DKA reduces NS to 1/2 NS and reduces rate by 50% once Na is corrected, but HHS only reduces rate.
How do we read needle/syringe markings, and what is the difference between needle length and gauge?
Needle/syringe markings - labeled with units; U500 syringes go by 5s. You’ll chose the length and gauge depending on the thickness of the SQ tissue.
Gauge - diameter of the needle, the larger number means smaller needle
Needle length - from 12.7mm to 4mm
What are the general storage guidelines for insulin?
Unused insulin should be stored in refrigerator and it’s good until the expiration date on the bottle.
Used insulin should be stored at room temperature and is good for about 1 month. Same with insulin cartridges.
- Most of the mixes are only good for 10-14 days after being opened (except Novolin 70/30 and ReliOn)
- Ultra long acting Tresiba is good for 56 days
- Other exceptions too
What are good counseling points for patients using insulin, insulin pens, needles/syringes, and injection devices?
Insulin pens:
- Remove the needles and replace the pen cap before storing
- Never store electronic pens in the fridge
Needle/Syringe:
- Use one syringe with one type of insulin
- Don’t wipe the needle with alcohol and don’t let it touch anything but clean skin and insulin bottle topper
- Make sure to recap syringe
- Dispose into sharps bin after use
What are contraindications for inhaled insulin and non-insulin injectables?
Inhaled - chronic lung disease (asthma/COPD)
Non-insulin injectables -
- GLP-1s: Type 1 diabetes, history of throid tumors, history of pancreatitis
- Amylinomimetic:
What are barriers that could prevent a patient from using proper glucose monitoring?
- Discomfort or fear of finger sticks
- Elevated readings
- Reminder of disease
- Cost
- Inconvenience
- Social stigma
- Lack of understanding
What are the components of insulin pumps?
Insulin - the fuel, rapid acting only
Reservoir - the gas tank, inserts into the pump for use
Insulin Pump - the engine, controls how much insulin is used
Infusion set - the tires, delivers the insulin to the body
All insulin pens are primed with 2 units before every administration except for what 3 pens?
Humulin U500 -> 5 units
Toujeo Max SoloStar U300 -> 4 units
Toujeo Solostar U300 -> 3 units
Out of Trulicity, Victoza, Adlyxin, Bydureon BCuse, Byetta, Ozempic, and Mounjaro, which are dosed daily vs. weekly?
Daily:
- Byetta (exenatide IR is BID)
- Victoza (liraglutide)
- Adlyxin (lixisenatide)
Weekly:
- Trulicity (dulagluide)
- Ozempic (semaglutide)
- Bydureon BCise (exenatide ER)
- Mounjaro (tirzepatide)
What non-insulin injectables require pen needles, have pen needles included, or are auto-injectors? (ozempic, bydureon BCise, victoza, adlyxin, symlinPen, trulicity, mounjaro, soliqua, xultophy)
Require pen needles:
- Victoza, adlyxin
- SymlinPen
- Soliqua
- Xultophy
Pen needles included:
- Ozempic
Auto-injector:
- Trulicity
- Bydureon BCise
- Mounjaro
