IC11, 12, 13 Diabetes Management Flashcards

Question

When do you start metformin to prevent pre-diabetes?

Answer 1

Pre-diabetes: FPG 6.1-6.9 mmol/L PPG 7.8-11mmol/L Start metformin for pre-diabetes (look at FPG/PPG): 1. BMI > 35kg/m2 2. Women with prior gestational DM 3. <60y/o

Answer 2

1. Diarrhea 2. Nausea and vomiting 3. Anorexia 4. Metallic taste (take with food) 5. ↓ Vit B12 absorption (anaemia, peripheral neuropathy) 6. Lactic acidosis (mental confusion, shortness of breath, nausea, abdominal pain)

Answer 3

Renal Impairment: CrCl >=60: continue, monitor every 1yr CrCL 45-59: continue, monitor every 3-6 months CrCl 30-44: halve dose, monitor every 3 months OR do NOT start CrCl <30: Stop metformin

Answer 4

1. Renal Impairment: CrCl >=60: continue, monitor every 1yr CrCL 45-59: continue, monitor every 3-6 months CrCl 30-44: halve dose, monitor every 3 months OR do NOT start CrCl <30: Stop metformin 2. Lactic Acidosis: Avoid when in hypoxic state e.g. Heart failure, sepsis, alcohol abuse, hepatic impairment, >80y/o 3. Avoid in acute HF

Answer 5

DDI: 1. Alcohol --> lactic acidosis 2. Iodinated contrast medium (hold for >=48hrs after screen) --> renal impairment 3. Cationic drugs e.g. cimetidine, digoxin, dofetilide --> compete for renal tubular transport

Answer 6

MOA: - ↑ functioning B-cell to secrete insulin by blocking K+ channel - ↓ hepatic glucose output + ↑ insulin sensitivity Hba1c↓: by 1.5% [1st] Monotherapy + diet + exercise Combi w others

Answer 7

1. Hypoglycemia 2. Weight gain 3. Blood dyscrasias (rare)

Answer 8

CI: 1. Hypersensitivity to any SUs Hepatically cleared (glipizide) DDI: 1. B-blockers --> mask hypoglycemia S&S e.g. tremors, fast HR 2. Disulfiram-like reaction w alcohol e.g. drunk, N&V etc. with a small amt of SU esp. with tolbutamide 3. CYP2C9 inhibitors e.g. amiodarone, 5-FU, fluoxetine (since it undergoes hydroxylation)

Answer 9

PPG (taken with or 15-30 mins before meals) - Skip dose if miss dose

Answer 10

MOA: - ↑ cell sensitivity to insulin - ↓ insulin resistance Benefits: - Fatty liver disease (NASH / NAFLD) Hba1c↓: by 0.5-1.4% [2nd] Monotherapy + diet + exercise Combi w others (only pioglitazone can be combined with insulin)

Answer 11

A lot of SE: 1. Hepatotoxic - If >3xUNL, do NOT start OR DISCONTINUE - If symptoms, discontinue 2. Edema 3. Fracture (esp women during long term use) 4. Weight gain 5. Bladder cancer (pioglitazone) 6. ↑ LDL (rosiglitazone) A lot of ADRs

Answer 12

CI: 1. Class III & IV HF 2. Active Liver Disease

Answer 13

Acarbose MOA: - Competitively inhibits brush border a-glucosidase from breaking down complex carbohydrates --> delay glucose absorption in gut Adjunct therapy in T2DM Used with insulin in T1DM Hba1c↓: by 0.5-0.8% [3rd]

Answer 14

PPG (eat with meals esp. carbo-rich meal, skip dose if skip meal)

Answer 15

ADR: 1. Flatulence 2. Abdominal pain 3. Diarrhea (osmotic diarrhea) 4. ↑ LFT CI: 1. Breastfeeding 2. GI diseases (obstruction, irritable bowel disease) DDI: 1. Intestinal Absorbents e.g. charcoal 2. digestive enzyme preparations e.g. Yakult

Answer 16

MOA: - ↑ insulin secretion - ↓ glucagon secretion - Delay gastric emptying Benefits: - Weight loss (↓ food intake, ↓ gastric emptying, N&V) - *ASCVD - HF - CKD --> preferred over insulin if need more glucose lowering Hba1c↓: by 0.7-1.5% [2nd] SC 0.6mg OD --> increase to 1.2mg OD after 1 week Max 1.8mg OD When need more glucose lowering after trying most of the oral agents

Answer 17

A lot of SE: 1. LESS N&V 2. MORE Diarrhea 3. Acute Pancreatitis 4. Dyspepsia (indigestion for exenatide) CI: 1. Avoid in patients with history of thyroid cancer

Answer 18

MOA: - Inhibits DPP-4 which ↓ degradation of GLP-1 - ↑ insulin secretion - ↓ glucagon secretion - Delay gastric emptying Adjunct therapy, dual or triple combi Hba1c↓: by 0.5-0.9% [3rd]

Answer 19

Pros over GLP-1 RA: 1. PO 2. Less GI ADR Cons over GLP-1RA: 1. Weight neutral 2. No big 3s 3. Less Hba1c ↓

Answer 20

Sitagliptin: 1. Acute pancreatitis 2. Abdominal pain 3. Nausea & vomiting 4. fever Linagliptin: (milder SE) 1. Nasopharyngitis 2. Runny nose 3. sore throat Severe joint pain

Answer 21

Sitagliptin: renally cleared Linagliptin: NOT renally cleared

Answer 22

MOA: - ↑ urine glucose excretion - ↓ glucose reabsorption Benefits: - Weight loss (pee a lot) - ASCVD (empa, cana) - HF - CKD Hba1c↓: by 0.8-1% [3rd] Usually in combi

Answer 23

1. Hypotension 2. Hypoglycemia 3. Renal impairment 4. ↑ LDL 5. ↑ urinary urgency 6. Female mycotic genital infection 7. Fournier’s gangrene 8. Euglycemic diabetic ketoacidosis 9. (Cana) amputation, hyperkalemia, fractures

Answer 24

1. If patient has DM, CKD and GFR > 30, give SGLT2i 2. Do NOT give if GFR < 30mL/min - Since it has to be filtered to inhibit the SGLT2 receptors in the proximal tubules 3. But once on SGLT2i and GFR falls below 30, it’s ok to continue (unless not tolerated or renal replacement therapy)

Answer 25

- SQ usually at the abdominal area - Fastest to slowest distribution --> abdominal area (highly perfused), upper arms, thighs, buttocks - Exogenous insulin eliminated by kidneys (take renal impairment into account) - Want to use shortest needle, 4mm for pen and 6mm for syringes --> max 8mm - 100units = 1mL

Answer 26

Factors affecting absorption of insulin: o Hot Temperature ↑ o Massage ↑ o Exercise ↑ o Jet injectors ↑ o Lipohypertrophy ↓ (thick and hard tissues)

Answer 27

Storage: o Unopened and refrigerated: until expiry date o Unopened and NOT refrigerated: 28 days o Opened: 28 days

Answer 28

ADR: 1. Hypoglycemia --> use 15-15-15 rule (give 15g of carbo, wait 15 mins, if BG still < 4 mmol/L then give another 15g of carbo) 2. Weight gain (worse than SU, need to diet, exercise and lose weight) 3. Lipohypertrophy (need to rotate sites)

Answer 29

1. Ultra-short acting insulin Aspart Lispro-aabc 2. Rapid Acting Aspart Lispro Glulisine 3. Short Acting Regular 4. Intermediate Acting NPH 5. Long Acting Detemir Glargine U-100 6. Ultra-long Acting Degludec Glargine U-300

Answer 30

Ultra-short acting insulin 1. Aspart 2. Lispro-aabc Start of a meal or within 20 mins after starting a meal PPG (Aspart: Vit B3 increases speed of initial absorption L-arginine stabilizes formulation) (Lispro-aabc: Treprostinil enhance absorption via vasodilation Citrate enhances vascular permeability)

Answer 31

Rapid Acting Aspart Lispro Glulisine 15 mins before meal PPG 3-5 hours

Answer 32

Short Acting Regular 30 mins before meal PPG 6-8 hours

Answer 33

Intermediate Acting NPH Twice daily FBG 12 hours

Answer 34

Long Acting Detemir Glargine U-100 Once daily at the same time FBG 24 hours

Answer 35

Ultra-long Acting Degludec Glargine U-300 Once daily anytime (degludec) Once daily at the same time (glargine U-300) FBG 42 hours 36 hours Lower risk of hypoglycemia than long acting since they are peakless

Answer 36

Combination: - 70 NPH + 30 aspart - 75 NPH + 25 lispro - 50 NPH + 50 regular - 70 NPH + 30 regular - Aspart + Degludec *NPH component tells us the dosing frequency --> 2x / day *The non-NPH component tells us the timing to administer e.g. Aspart --> 15 mins before meal - Glargine/detemir CANNOT mix due to excipients present that makes that long acting - Glulisine can only mix with NPH - Combi must change both FPG and PPG coverage together

Answer 37

1. Metformin - Continue 2. SU e.g. glipizide - Discontinue or halve dose when adding basal insulin - Discontinue if add mealtime/premixed insulin due to risk of hypoglycemia But might not use SU then since starting insulin might imply that it is late-stage diabetes 3. TZDs Discontinue or reduce dose when starting insulin due to risk of hypoglycemia OR change to pioglitazone 4. SGLT2i Continue 5. DPP-4i Continue But discontinue if start on GLP-1 RA

Answer 38

Conversion of units from 1 type of insulin to the other: All 1:1 conversion and reduce dose by 10-20% if high risk of hypoglycemia, except: 1. Twice daily NPH (alone) to once daily glargine / detemir --> 20% reduction (e.g. 20units of NPH BD --> 32units of glargine OD) 2. Glargine U-300 to glargine / detemir --> 20% reduction Need to break down the combi insulin into 2 separate drugs before converting

Answer 39

Metformin + exercise + diet

Answer 40

1st line: Metformin + diet + exercise - Consider combi therapy if Hba1c very high - If have history of ASCVD / HF/ CKD (regardless of Hba1c), though expensive can add: o ASCVD --> SGLT2i / GLP-1 RA o HF --> SGLT2i o CKD --> SGLT2i > GLP-1RA - If Hba1c not at goal (need more Hba1c lowering), add: o Need to avoid hypoglycemia --> avoid SU and insulin o Need weight loss --> GLP-1 RA / SGLT2i (avoid SU and insulin) o Need cheap options --> SU > TZD > DPP-4i

Answer 41

Add GLP-1 RA first before insulin

Answer 42

Add insulin when: 1. Ongoing Catabolism (weight loss, maybe be a sign of delayed T1DM) 2. Symptoms of hyperglycemia 3. A1c > 10% (large contribution from FBG) 4. Random BG > 16.7 mmol/L

Answer 43

basal insulin

Answer 44

Start basal insulin: - 10 units or 0.1-0.2 units/kg a day, NOT >10 units AND must always round off to even numbers e.g. if calculate and get 6.8 then can round off to 6 units - e.g. bedtime NPH (once daily) or bedtime glargine/detemir/Degludec ($$$) If Hba1c uncontrolled, change dose of basal insulin (and look at *FBG to titrate) - increase by 2 units every 3 days until FBG at goal - Increase by 4 units every 3 days if FBG consistently > 10mmol/L - decrease by 10-20%, when have unexplained hypoglycemia

Answer 45

If Hba1c still above goal, despite basal dose > 0.5units/kg OR FPG at goal (problem is PPG): 1. Add prandial coverage (rapid or short acting) o 1 dose with largest meal o add 4 units or 10% of basal insulin o If Hba1c 0.5units/kg o since there will be minimal effect on FBG over a certain point o ADR: weight gain, hypoglycemia, postprandial hyperglycemia

Answer 46

Somogyi effect: (consider reducing basal insulin dose) Hypoglycemic (sharp drop in BG) at night (due to high dose insulin or lack of snack) - Body compensates for it by releasing more glucagon and thus glucose Dawn Phenomenon: Body releases cortisol in the waking hours - increase glucose secretions sharply Both leads to high BG levels in the morning

Answer 47

1. Aspirin / clopidogrel a. Secondary prevention of ASCVD events --> for those with diabetes and have ASCVD events b. Primary prevention of ASCVD events --> for those with diabetes and high risk for ASCVD - ASCVD risk factors: **o LDL-C > 2.6mmol/L o High BP o Smoking o CKD o Albuminuria o Family history of premature ASCVD** - Low risk: young (<50y/o) AND NO other major ASCVD risk factors o **NOT** recommended for low risk of ASCVD - Use clinical judgement for those grey areas o E.g. young but have 1 or more ASCVD risk factors o E.g. elderly but no risk factors - Do NOT start aspirin for elderly > 70y/o, risk > benefits 2. Smoking cessation 3. BP 4. lipid profile 5. metabolic syndrome 6. Influenza and Pneumonia vaccines

Answer 48

Diabetic Ketoacidosis: Common in T1DM 1. Complete lack of insulin  lipolysis, metabolism of free fatty acid 2. Stress  stimulates glucagon, increase gluconeogenesis and reduce peripheral ketone utilization Alert Stupor / coma (severe) 1. High Ketone + acidosis 2. High acetone 3. Low pH (acidic) 4. Variable blood conc. 5. Large anion gap 6. High BG (>14mmol/L) Ketones in urine and blood, fruity breath odour Hyperglycemic Hyperosmolar State: Common in T2DM 1. Extreme Dehydration Stupor (drunk/irritable) 1. No Ketone + acidosis 2. Low acetone 3. Normal pH 4. Concentrated blood 5. Small anion gap 6. Very High BG (>33mmol/L)