Exam 3 Flashcards

Question

What are the appropriate recommended uses and contraindications/precautions for insulin, metformin, SGLT2 inhibitors?

Answer 1

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)

Answer 2

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.

Answer 3

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

Answer 4

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

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

- 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.

Answer 10

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.

Answer 11

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.

Answer 12

DKA: - Hyperglycemia - Hyperketonemia - Metabolic acidosis HHS: no/few ketones, normal pH, extremely high glucose, high serum osm - Severe hyperglycemia - Hyperosmolality!! - Severe fluid depletion

Answer 13

Corrected sodium: Measured Na + 1.6[(glucose - 100)/100] Anion gap: Na - (Cl + Bicarb) Osmolality: (Na x 2) + BUN/2.8 + Glucose/18

Answer 14

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

Answer 15

1. 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. 2. 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. 3. 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.

Answer 16

1. 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 2. Restore urine output to 50mL/hour or more (fluids) 3. 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

Answer 17

- 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.

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

Inhaled - chronic lung disease (asthma/COPD) Non-insulin injectables - - GLP-1s: Type 1 diabetes, history of throid tumors, history of pancreatitis - Amylinomimetic:

Answer 22

- Discomfort or fear of finger sticks - Elevated readings - Reminder of disease - Cost - Inconvenience - Social stigma - Lack of understanding

Answer 23

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

Answer 24

Humulin U500 -> 5 units Toujeo Max SoloStar U300 -> 4 units Toujeo Solostar U300 -> 3 units

Answer 25

Daily: - Byetta (exenatide IR is BID) - Victoza (liraglutide) - Adlyxin (lixisenatide) Weekly: - Trulicity (dulagluide) - Ozempic (semaglutide) - Bydureon BCise (exenatide ER) - Mounjaro (tirzepatide)

Answer 26

Require pen needles: - Victoza, adlyxin - SymlinPen - Soliqua - Xultophy Pen needles included: - Ozempic Auto-injector: - Trulicity - Bydureon BCise - Mounjaro