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PR3152 > IC12 Diabetes I > Flashcards

IC12 Diabetes I Flashcards

1
Q

Pre-DM is diagnosed through _____________.

A

Screening

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2
Q

What are the recommended investigation for screening of DM?

A

1) Fasting plasma glucose
2) HbA1c

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3
Q

How is diagnosis for DM confirmed?

A

2 different tests above threshold

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4
Q

Those between 18 to 39 can consider doing a ________ for DM.

A

risk assessment tool

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5
Q

What are some the 2 ways to delay or prevent progression of DM?

A
  1. Lifestyle intervention
  2. Metformin
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6
Q

Lifestyle intervention for pre-DM consist of __________.

A

Healthy diet and physical activity (minimum 150 mins moderate OR 75 mins vigorous to intense)

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7
Q

Metformin is considered for people with pre-diabetes if _________ or _______________.

A
  1. Glycemic status does not improve after lifestyle intervention
  2. unable to adopt lifestyle intervention
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8
Q

Which special populations with pre-DM should be considered for metformin?

A
  1. BMI ≥ 23kg/m2
  2. <60yo
  3. women with history of gestational diabetes
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9
Q

How is DM classified?

A

Type 1 - insufficient insulin secretion
Type 2 - insulin resistance

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10
Q

Are type 1 and type 2 diabetes mutually exclusive?

A

No

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11
Q

What is T1DM?

A

Absolute deficiency of pancreatic β cell functions

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12
Q

Patients with T1DM present with ______ antibodies.

A

Positive

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13
Q

What are the 3 stages in T1DM?

A

Stage 1: Autoimmunity, Normoglycemic, Pre-symptomatic

Stage 2: Autoimmunity, Dysglycemia, Pre-symptomatic

Stage 3: Autoimmunity, New-onset hyperglycemia, symptomatic

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14
Q

________ is measured to see if there is insulin present.

A

C-peptide

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15
Q

What complications does HbA1c correlates with?

A

Microvascular

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16
Q

What is T2DM?

A

Progressive loss of adequate β cell insulin secretion on the background of insulin resistance

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17
Q

Insulin is resistant in T2DM when in presence of insulin, _________ is impaired and __________ increases.

A
  1. glucose utilization
  2. hepatic glucose
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18
Q

Patients with T2DM presents with _______ antibodies.

A

negative

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19
Q

C peptide levels in T1DM is _______, while level in T2DM is _________ or ________

A

absent, normal, abnormal

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20
Q

Clinical presentation in T1DM is _________ and ______ in T2DM.

A

abrupt, gradual

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21
Q

Patients with T1DM is often ______ while patients with T1DM is often _________ in physical appearance.

A

thin, overweight

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22
Q

Patients with T1DM is _________ prone to ketosis while ketosis in patients with T2DM is _______.

A

frequent, not common

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23
Q

Diabetic patients often presents with _______, ______, ________ as symptoms.

A

polydipsia, polyuria, polyphagia

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24
Q

List at least 3 signs and symptoms in hypoglycemic patients.

A
  1. shaking
  2. fast heartbeat
  3. sweating
  4. dizzy
  5. weak/ fatigue
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25
Q

Name the 4 parameters used to measure DM.

A
  1. Fasting blood glucose (no caloric intake for ≥ 8 hours)
  2. Random/ causal plasma glucose (anytime regardless of meals)
  3. Postprandial plasma glucose (2 hours, after meals)
  4. HbA1c (amount of glucose in blood over past 3 months)
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26
Q

________ hyperglycemia is more important than postprandial hyperglycemia in contributing to increasing HbA1c.

A

Basal

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27
Q

Postprandial blood glucose can be measured using a ___________.

A

standardized 75g oral glucose tolerance test (OGTT)

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28
Q

Who should be checked for DM?

A

≥ 40 years old or those with high risk factors

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29
Q

People with HbA1c ≤ 6.0% have ______ probability of DM. _____ further test needed unless got symptoms. Further tests with ______ or _______ can be administer if suspected to have DM.

A
  1. Low
  2. No
  3. Fasting blood glucose
  4. 2 hour oral glucose tolerance test
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30
Q

What are the recommendations for people with HbA1c ≤ 6.0%.

A
  1. Healthy lifestyle
  2. Weight management
  3. Repeat the test 3 years later
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31
Q

People with HbA1c of 6.1 - 6.9% require a second test with ______ and _____ . Those with a 2nd HbA1c ≤ _____ for FPG or < _____ mmol/L OGTT is considered non-diabetic.
Those with a 2nd HbA1c between _____ for FPG or between _____ mmol/L OGTT is considered pre-diabetic. Those with a 2nd HbA1c ≥ _____ for FPG or ≥ _____ mmol/L OGTT is considered diabetic.

A
  1. Fasting plasma glucose
  2. oral glucose tolerance test
  3. 6
  4. 7.8
  5. 6.1 to 6.9
  6. 7.8 to 11.0
  7. 7
  8. 11.1
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32
Q

People with HbA1c of ≥ _____% has high probability of diabetes.

A

7

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33
Q

If FPG or OGTT is used instead of HbA1c, diagnosis requires _____ test results.

A

2

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34
Q

What are some macrovascular complications of DM?

A

CVS diseases, stroke

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35
Q

What are some microvascular complication of DM?

A

Retinopathy, nephropathy, neuropathy

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36
Q

Life expectancy of DM with complications is reduced by ________.

A

5 to 10 years

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37
Q

DM patients presenting with macrovascular complications should be check for __________ every _______ if not controlled and ________ if controlled. Additionally, _____ should be checked during every visit.

A
  1. lipids level
  2. 3 to 6 months
  3. 1 year
  4. blood pressure
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38
Q

DM patients with retinopathy are checked every _____ if unstable and every ______ if stable.

A
  1. 6 months
  2. 1 year
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39
Q

DM patients with nephropathy are checked _______ or ______ depending if they present with protein/ albumin in urine.

A
  1. 6 months
  2. annually
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40
Q

What are the 3 screening test for DM patients?

A
  1. Diabetic Retinal Photography
  2. Diabetic foot screening
  3. Diabetic Nephropathy test
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41
Q

T1DM patients should be screened for retinopathy within ____ after onset and those with T2DM should be screened at _________.

A
  1. 5 years
  2. time of diagnosis
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42
Q

Patients with no evidence of retinopathy ≥ 1 exams and is well controlled should be checked again in _______. Otherwise, check _______.

A
  1. 1 to 2 years
  2. Annually
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43
Q

Women with diabetes should be screened before or during _____ trimester and after giving birth for ______

A
  1. first
  2. 1 year
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44
Q

Diabetic foot screening should be done ___________ or ______ frequently if at higher risk.

A
  1. annually
  2. more
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45
Q

What are the three prevention advice that should be given to patients to prevent them from getting diabetic foot?

A
  1. Maintain optimal glycemic control
  2. Quit smoking
  3. Good foot care and appropriate footwear
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46
Q

Diabetic nephropathy test should be done for T1DM _____ after diagnosis and T2DM at __________.

A
  1. 5 years
  2. Time of diagnosis
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47
Q

What are the components to check for in a nephropathy test?

A
  1. (Serum Cr and/or eGFR) AND (urine albumin/creatinine ratio or protein creatinine ratio)
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48
Q

What is the HbA1c goal for DM patients?

A

<7%

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49
Q

What is the FBG goal for DM patients?

A

4 to 7 mmol/L

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50
Q

What is the PPG goal for DM patients?

A

< 10 mmol/L

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51
Q

HBA1c can be more stringent (6 to 6.5%) in patients with _________ disease duration, _________ life expectancy, no significant ________ diseases.

A
  1. short
  2. long
  3. CVS
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52
Q

HBA1c is less stringent (7.5 to 8%) in patients with history of _________ hypoglycemia, _________ life expectancy, ________, and those that cannot attain good glucose level despite intensive ________, repeated _______, effective _______.

A
  1. severe
  2. limited
  3. comorbidities
  4. self monitoring blood glucose
  5. counselling
  6. pharmacotherapy
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53
Q

How does metformin works?

A

decrease hepatic glucose production and increase peripheral/ muscle glucose uptake and utilization

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54
Q

Is metformin safe in pregnancy?

A

Yes

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55
Q

When do metformin exerts its maximum effect?

A

2 weeks

56
Q

How is immediate formulated metformin usually given?

A

500 to 800 mg OD

57
Q

How is immediate formulated metformin titrated?

A

Increase by 500 to 850mg OD every 1 to 2 weeks

58
Q

What is the maximum dose for immediate formulated metformin?

A

2250 mg/day

59
Q

Only ________ formulated metformin can be given to children ≥ 10.

A

immediate

60
Q

How is extended-release metformin usually given?

A

500mg OD

61
Q

How is extended-release metformin usually titrated?

A

Add 500mg weekly

62
Q

What is the max dose of extended-release metformin that can be given a day?

A

2000mg

63
Q

Which population(s) is/ are metformin contraindicated in?

A

GFR ≤ 30mL/min
HF
Sepsis
Respiratory failure
Liver impairment
≥ 80 year old
Alcoholism

64
Q

What are the side effects of metformin?

A

loss of appetite, metallic taste, hypoglycemia, possible weight loss (or none)

65
Q

What are the 3 drug drug interactions of metformin?

A
  1. EtOH (increase lactic acidosis risk)
  2. Iodinated contrast material (affect kidney, withhold for ≥ 48 hours and restart only when stable)
  3. inhibitors or inducers of organic cationic transporters (cimetidine, dolutegravir, ranolazine)
66
Q

Metformin can decrease HbA1C by _____ to _____.

A

1.5%, 2%

67
Q

How do thiazolidinediones work?

A

They are PPAR gamma agonists, which promotes glucose uptake into target cells such as skeletal muscles and adipose tissues by increasing insulin sensitivity and decreasing insulin resistance.

68
Q

Do thiazolidinediones have effect on insulin secretion?

A

No

69
Q

How long does thiazolidinediones take to exert maximum effect?

A

up to 1 month

70
Q

Thiazolidinediones undergo _____ clearance.

A

hepatic

71
Q

List one example of thiazolidinediones.

A

Pioglitazone

72
Q

How is Pioglitazone given?

A

15 mg or 30 mg tablet

73
Q

How is Pioglitazone titrated?

A

increase by 15 mg to maximum of 45mg OD

74
Q

Thiazolidinediones are given to patients who cannot take _______ or used in _______ with other drugs.

A
  1. metformin
  2. combination
75
Q

Thiazolidinediones have DDI with _______ and ______ inhibitors and inducers.

A

CYP3A4
CYP2C8

76
Q

What are the adverse effects of thiazolidinediones?

A
  1. Hepatotoxicity
  2. Fluid retention
  3. fracture (more likely in women)
  4. weight gain (dose related)
  5. bladder cancer risk
  6. increased risk of hypoglycemia if on insulin therapy
77
Q

Which population is thiazolidinediones contraindicated in?

A
  1. active liver disease
  2. symptomatic/ history of HF (class 3 and 4)
  3. active or history of bladder cancer
78
Q

How do one stop or start thiazolidinediones if hepatotoxicity arises?

A
  1. monitor liver functions
  2. If ALT> 3x ULN, stop/ do not start
  3. If ALT> 1.5x ULN, repeat LFTs till normal.
  4. If signs and symptoms of liver dysfunction, stop.
79
Q

Thiazolidinediones decrease HbA1c by _____ to ____ %

A

0.5, 1.4

80
Q

Sulfonylureas are given to patients if T2DM cannot be managed by _____ and ____ alone.

A

diet
exercise

81
Q

How do sulfonylureas work?

A

It mainly stimulates insulin secretion by blocking K+ channel or β cells. This then helps decrease hepatic glucose output and increase insulin sensitivity.

82
Q

Name one sulfonylurea in the 2rd generation.

A

Glipizide

83
Q

Glipizide cannot be given to people who are _____ to sulfonylurea.

A

hypersensitive

84
Q

What are the DDIs with glipizide?

A
  1. β blockers (slow heart beat, masks signs and symptoms of hypoglycemia)
  2. Disulfiram-like reaction with EtOH (1st gen > 2nd/3rd gen)
  3. CYP2C9 inhibitors like amiodarone, 5-FU, fluoxetine (increase potency)
85
Q

Sulfonylureas lower HbA1c by ______%.

A

1.5

86
Q

Sulfonylurea is given ____ meals and used in caution if patients have _____ meal schedules.

A

before
irregular

87
Q

What is the adverse effect of sulfonylureas?

A

weight gain

88
Q

Can sulfonylureas be used in T1DM?

A

No. They require working β cells

89
Q

How do DPP4i works?

A

It decreases gastric emptying, increase glucose dependent insulin biosynthesis and secretion and decrease glucagon and increase β cell function.

90
Q

Name three examples of DPP4i.

A

Sitagliptin
Vildagliptin
Linagliptin

91
Q

How is sitagliptin given?

A

100mg OD

92
Q

How do one dose adjust sitagliptin?

A

eGFR ≥ 30 to < 45: 50mg OD (reduce half)
eGFR < 30: 25mg OD (reduce to 1/4)

93
Q

What is DDI associated with sitagliptin?

A

increases digoxin when co-administered

94
Q

How is vildagliptin given?

A

50mg BD if with metformin
50mg OD if with sulfonylurea

95
Q

How do one dose-adjust vildagliptin?

A

CrCl ≥ 50mL/min: 50mg BD
CrCl < 50ml/min: 50mg daily

96
Q

How is linagliptin given?

A

5mg OD

97
Q

What DDI is associated with linagliptin?

A

CYP3A4 inducer (decreases linagliptin)

98
Q

What are the adverse effects associated with DPP4i?

A

severe joint pain, headaches, hypersensitivity, acute pancreatitis, skin rash, bullous pemphigoid

99
Q

DPP4i reduces HbA1c by _____ to _____% in monotherapy.

A

0.5, 0.8

100
Q

DPP4i is usually the ____ or _____ line agent and given in ______.

A
  1. 2nd
  2. 3rd
  3. combination as dual or triple therapy
101
Q

Which group of patient should DPP4i not be given to?

A

Those with history of acute pancreatitis.

102
Q

What are the advantages of DPP4i over GLP-1?

A

Cheaper
Decrease GI side effects

103
Q

What are the disadvantages of DPP4i over GLP-1?

A

weight neutral, small HbA1c reduction, no BIG 3 benefits (ASCVD, HF, CKD)

104
Q

How does SGLT-2 inhibitors work?

A

increase renal glucose excretion and hence decrease blood glucose

105
Q

What the glycemic considerations for patients with renal issues?

A

Do not start if eGFR < 45.
Discontinue if eGFR is persistently below 45.

106
Q

What the cardiorenal considerations for patients with renal issues?

A

Do not start if eGFR < 25 for dapagliflozin and if < 20 for empagliflozin.
Discontinue at start of dialysis.

107
Q

Name the three SGLT-2i.

A

Canagliflozin, Empagliflozin, Dapagliflozin

108
Q

How is canagliflozin given?

A

100mg OD before first meal

109
Q

How is canagliflozin titrated?

A

increase to 300mg OD if eGFR > 60ml/min

110
Q

Canagliflozin should not be started/ should be stopped if eGFR is lesser than ____ ml/min.

A

30

111
Q

How is canagliflozin dose adjusted in renal patients?

A

eGFR 30 to 60 = 100mg OM
If albuminuria > 300mg/d, continue 100mg OM

112
Q

How is empagliflozin given?

A

10mg OD, morning with or without food

113
Q

How is empagliflozin titrated?

A

Increase to 25mg OD

114
Q

Empagliflozin and Dapagliflozin should not be started/ should be discontinued when eGFR is lesser than _____ ml/min.

A

45

115
Q

Is dose adjustment for Empagliflozin or Dapagliflozin if eGFR > 45ml/min?

A

No

116
Q

How is dapagliflozin given?

A

5mg OD, morning with or without food

117
Q

How is dapagliflozin titrated?

A

Increase to 10mg OD

118
Q

What are some of the side effects of SGLT2i?

A

Hypotension
Hypoglycemia
Genital mycotic infection/ UTI
Increase risk of diabetic ketodosis

119
Q

What are some side effects specific to Canagliflozin?

A

Lower limb imputation
Hyperkalemia
Fractures

120
Q

Which groups of patients is SGLT2i contraindicated in?

A

ESRD/ Dialysis

121
Q

SGLT2i reduces HbA1c by ___ to ____%.

A

0.8; 1

122
Q

What are some benefits of SGLT2i?

A

Slight weight loss
ASCVD benefits (Cana, Empa)
HF benefits (Dapa, Empa)
CKD (Dapa)

123
Q

How does α-glucosidase inhibitors work?

A

Delay glucose absorption and decrease PPG by competitively inhibiting brush border α-glucosidases enzymes required for breakdown of complex carbohydrates locally acting

124
Q

Who is α-glucosidase inhibitors indicated for?

A

T2DM patients whose hyperglycemia cannot be managed by diet and exercise.

125
Q

Name an example of α-glucosidase inhibitors

A

Acarbose

126
Q

Acarbose is dosed based on ________.

A

Weight

127
Q

How is acarbose given?

A

25mg BD/TDS with each meal (rapid onset with meals)

128
Q

How is acarbose titrated?

A

increase by 25mg/day every 2 to 4 weeks to maximum dose of 150mg/day for ≤60kg or 300mg/day for >60kg

129
Q

Acarbose decreases __________ glucose and is dose-dependent.

A

post-prandial glucose

130
Q

What are the adverse effects of acarbose?

A

GI - flatuence (no 1 reason for discontinuation)
Increase LFT (especially when dose is more than 100mg TDS)

131
Q

Is acarbose recommended in patients with CrCl < 25?

A

No

132
Q

Who cannot use acarbose?

A

GI diseases such as obstruction or IBD
Liver cirrhosis

133
Q

What are some DDI associated with acarbose?

A

Intestinal adsorbents and digestive enzyme preparations decreases effect of drug

134
Q

Acarbose reduce HbA1c by ____ to ____%.

A

0.5 to 0.8

135
Q

Acarbose can be considered to be taken with _______ meal of the day since it is often used in carbohydrate rich diet.

A

Largest

PR3152 (2 decks)

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