IC11-13 Flashcards
Macrovascular vs microvascular examples
Microvascular:
Retinopathy, nephropathy & neuropathy
Macrovascular: CVS
Does a drop in HbA1c correlate with drop in CV outcomes?
No; CV outcomes improve as A1c decreases but eventually worsens as A1c continues to drop
A 1% decrease in absolute HbA1c correlates to around ____ reduction in the risk for microvascular complications.
35%
Treatment goals for:
- HbA1c, FBG, PPG
HbA1c: ≤ 7%
More stringent: 6.0 - 6.5%
Less stringent: 7.5 – 8.0% +
(7.0% to 8.5%) if vulnerable patients
FBG: 4-7 mmol/L (in practice, 5-7)
PPG: < 10 mmol/L
To change from mmol/L to mg/dL: multiply by 18
Max dose for metformin
3g/ day
Adverse effects of metformin
▪ Common: GI, anorexia, metallic taste (usually transient; take with food to alleviate)
▪ Long-term use may ↓serum B12 concentrations
▪ Rare but fatal: lactic acidosis
Risk factors for hypoxemia
Heart failure, sepsis, liver impairment, alcoholism, ≥ 80 yo
How long should metformin be held after Iodinated contrast material/radiologic procedure?
Hold for ≥48 hrs after contrast administration; restart
when renal function returns to normal post-procedure
Charge for metformin
Positively charged
Use of metformin in eGFR 30-44
Half dose
At what range of eGFR is metformin contraindicated?
< 30
Benefits of metformin apart from blood glucose lowering
Positive effects on lipid, possible reduction in CV events (T2DM)
Can sulfonylurea be used in patients with no functional ß- cells?
No
When should sulfonylurea be taken?
15-30 mins before meal
Which sulfonylurea are hepatically eliminated only?
Tolbutamide & glipizide
Can sulfonylurea be taken without food?
No; insulin is secreted by SU hence if there is no food, this leads to hypoglycemia
Adverse effects of sulfonylurea
➢ Hypoglycemia (especially in elderly)
➢ Weight gain (~2-5 kg)
➢ Blood dyscrasias (rare)
MOA for thiazolidinediones
Peroxisome proliferator activated receptors agonist to promote glucose uptake into target cells (skeletal muscle/adipose)
▪ ↓insulin resistance; ↑ increase insulin sensitivity
Onset and Route of elimination for thiazolidinediones
Takes up to 1 month to work; eliminated by liver
Adverse effects of thiazolidinediones
➢ Hepatotoxicity
➢ Edema (caution in NYHA Class I or II HF)
➢ Fracture (increased risk; more likely in women)
➢ Weight gain
➢ Bladder cancer (Pioglitazone)
➢ Elevated LDL (Rosiglitazone)
Contraindication of thiazolidinediones
Active liver disease; NYHA Class III or IV HF
Benefits of thiazolidinediones apart from blood glucose lowering
Appears to be beneficial in patients with Fatty Liver Disease
Only drug approved for α-Glucosidase Inhibitors
Acarbose
Onset of metformin
Onset: within days; max effects take up to 2 weeks
Onset and Route of elimination for α-Glucosidase Inhibitors
Onset is rapid with each meal; Elimination: 50% via feces
MOA for α-glucosidase inhibitor
➢ Delay glucose absorption and ↓PPG by competitively inhibit brush border α-
glucosidases enzyme required for breakdown of complex carbohydrates
➢ Acts locally
Adverse effects for α-glucosidase inhibitor
➢ GI: flatulence, abdominal pain, diarrhea (most common cause of drug discontinuation)
➢ ↑ LFT (specific for acarbose; ↑risk at dose >100 mg TDS)
Contraindications for α-glucosidase inhibitor
➢ Breast-feeding
➢ GI diseases (obstruction, irritable bowel disease)
_______ is the #1 reason for α-glucosidase inhibitor discontinuation
Flatulence
When could α-glucosidase inhibitor ideally be taken?
May consider taking with the largest meal of the day or with the meal that
consists the most carbs; as it is mainly used to control postprandial blood glucose
What does GLP-1 stand for?
Glucagon-like peptide 1
What does DPP-4 stand for?
Dipeptidyl-peptidase 4
Dosing for liraglutide & Max dose
Initiate at 0.6mg then titrate to 1.2mg after 1 week. Can increase to 1.8mg
Long acting agents of GLP-1 are a/w lesser ____ but more ____
N/V; diarrhoea
Which drug is recommended over insulin as first-line injectable? (for greater glucose lowering)
GLP-1 receptor agonist
2 Examples of DPP-4 i
Sitagliptin/ Linagliptin
Which DPP-4i does not need dose adj?
Linagliptin
Dose adj for sitagliptin
CrCl (30-49): 50mg OD
CrCl < 30: 35mg OD
Original dose: 100mg OD
Signs and symptoms of pancreatitis
N/V, abdominal pain, fever
Advantages of DPP-4 i over GLP-1 agonists
Lower incidences of GI adverse events
Disadvantages of DPP-4 i over GLP-1 agonists
weight neutral, smaller HbA1c reduction, no “big 3” benefits (ASCVD, HF, CKD)
3 examples of SGLT2i
Canagliflozin, Dapagliflozin, Empagliflozin
Mode of elimination for endogenous vs exogenous insulin
Endogenous: Liver;
Exogenous: Kidney
More muscular region results in ____ insulin absorption
Faster
Higher gauge, ____ needle -> ___ pain but ____ needle weakness & ____ speed of injection
finer; decr; incr; decr
– Unopened insulin vials: good until _____ only if stored in
refrigerator
* if not refrigerated, good for _____
– Opened insulin vials: good for ____ regardless of refrigeration
– Other insulin containing devices (e.g. pen, refill cartridges): vary, see package insert.
expiration date; 28 days; 28 days
Which length of needles do not need pinch?
4 or 5 mm (only for pens) EXCEPT patient with lesser SC fat using arms or thighs for injection
Which ppl inject at 45 degrees?
frail elderly or cachexic adults or children
Which insulins are usually not mixed?
Long-acting -> detemir & glargine
Significance of anion gap
Represents acidosis
beta- hydroxybutyrate, acetoacetic acid, and acetone are examples of ____
ketones
Dawn phenomenon
release of cortisol in the waking hours causes BG levels to rise sharply
Somogyi effect
BG levels drop sharping at night (miss bedtime snack/ too much insulin, etc), body responds by releasing glucagon, BG level incr
How to differentiate btw dawn phenomenon and somogyi effect?
Wake up at 2-3am to test BG
How does insulin cause lipoatrophy?
due to immune response due to pork and beef insulin
How does insulin cause lipohypertrophy?
due to not rotating injection sites
Adverse effects of insulin
- Weight gain
- Lipodystrophy
- Local allergic rxn (redness, swelling & itch at injection site -> more for beef and pork insulin)
When is insulin considered?
➢Ongoing catabolism (weight loss)
➢Symptoms of hyperglycemia
➢A1c > 10%
➢BG > 16.7 mmol/L
In which age group should you NOT start aspirin?
> 70 y/o
ASCVD risk factors
- LDL ≥ 2.6 mmol/L,
- high blood pressure,
- smoking,
- chronic kidney disease,
- albuminuria,
- family history of premature ASCVD.
