ic13 and ic14 DM Flashcards
Effect of Insulin on Hba1c
2.5%
Where is exogenous insulin metabolised?
Kidney
Why should we rotate injection sites?
Prevent lipohypertrophy, bulging of adipose tissue
List 3 rapid acting insulin
When should it be taken?
LAG
Lispro
Aspart
Glulisine
5 mins before meal
What is an intermediate acting insulin?
What is the duration of action? How frequent should it be taken?
NPH
10-16hrs
2 injections a day
List 2 long acting insulins
Detemir
Glargine (U-100)
List a short acting insulin
Regular Actrapid
List 2 ultra-long insulins
Degludec
Glargine U-300 (Toujeo)
Which insulin is used for corticosteroid induced hyperglycemia?
NPH
Which insulin is suitable to be mixed?
NPH + Rapid acting or Short acting
Long acting (Glargine, Detemir) cannot
How many doses to take for pre-mix insulin?
When should pre-mixed insulin be administered? What is the exception?
2 doses
15 mins before meal, cos use rapid acting insulin
Except Mixtard, which uses regular insulin. Administer 30 mins before meal
What to do with oral therapy if starting on insulin?
Metformin, SGLT2i
Continue
TZD - discontinue or reduce dose
Sulfonylurea
If patient is on basal insulin eg. glargine
Reduce SU dose by 50%
If patient is on PPG insulin or Premix insulin
Discontinue
DPP4i (eg. Sitagliptin, Linagliptin)
Discontinue if on GLP-1 agonist
What are exceptions for insulin dose conversion?
When converting to detemir/glargine U-100, need to decrease glargine dose by 20%
Either when converting 2x NPH to U-100 or converting U-300 glargine to U-100 glargine
What is the definition of Hypoglycemia? (blood glucose level)
Symptoms?
Hypoglycemia < 4
Blur vision
Sweating
Hunger
Confusion
Anxiety
Shaking
Rapid heartbeat
Dizziness
Headache
Weakness, fatigue
Irritability
What to do when feeling symptoms of hypoglycemia?
Examples of 15g of carbs?
15-15-15
15g of carbs → Wait 15 mins → Check BG → Below 4 then another 15g of carbs
15g of fast acting carbohydrates
0.5 cup of fruit juice
5 pieces of hard candy
0.5 cup of soft drinks
What are the adverse effects of Insulin? (2 points)
1) Hypoglycemia
2) Weight gain
Stability of insulin if not refrigerated or opened
If not refrigerated or opened, 28 days
What insulin dose to start for patients?
How to titrate insulin?
What is the limit of basal/total insulin?
0.2units/kg of NPH
If the patient is obese, start on 10 units at bedtime
If FPG not at goal, increase by 2 units every 3 days
If FPG > 10 consistently, increase by 4 units every 3 days
Limit: 0.5 units/kg
What if Hba1c is not at goal but basal dose at limit OR FBG at goal?
Add prandial coverage for the biggest meal
4 units or 10% of basal insulin
(if patient hba1c <8%, can reward patient) Reduce basal insulin dose by 4 units or 10%
OR
If patient is on bedtime NPH 10 units, can split 2/3 in morning and 1/3 in evening
Why shouldnt we increase total insulin to more than 0.5units/kg?
Overbasalisation, insulin will lose its effectiveness, can result in weight gain and hypoglycemia
What is the first line treatment for T2DM?
If Hba1c still > 7 after Meformin, what drug to add on? Add on therapy considerations (best glucose lowering efficacy, elderly, promote weight loss)
Metformin
Best glucose lowering efficacy:
Insulin, GLP-1 agonist
For elderly (want to reduce hypo):
Avoid Insulin, SU
If want weight loss also:
GLP-1 agonist, SGLT2i
If patient needs more glucose lowering effect than oral medications can give, which 2 injectables can be given?
Which is preferred, under what circumstance (4 points)
GLP-1 over Insulin
Insulin is considered if
1) Ongoing catabolism (weight loss)
2) Symptoms of hyperglycemia
3) A1c > 10%
4) BG > 16.7
What to do when patient has high BG when waking up?
Check if its Dawn phenomenon (normal) or Somogyi effect
Check blood glucose at 2am, if its very low then its Somogyi, as body responds by releasing glucagon
How does Diabetic Ketoacidosis (DKA) occur?
Signs of DKA? (4 points)
When body does not have enough insulin, body breaks down fat and produce ketones
Alert
BG>14 mmol/L
Ketones found in blood, urine
Patient has fruity breath
Signs of Hyperglycemic Hyperosmolar State (HHS) (3 points)
Patient usually dehydrated, confused
BG > 33 mmol/L
Measure patient’s serum osmolality AKA solute within plasma eg. glucose, urea, sodium
Very high (> 320)
BP target for DM patients
What is the first line antihypertensive for patients with DM
130/80
ACE/ARBs
Who is elligible for primary prevention of ASCVD
Primary prevention for ASCVD
Target LDL
For 40-75yo
Use moderate statins eg. Atorva 10-20mg
1.8mmol/L
What to use for secondary prevention for ASCVD
Target LDL
Use high intensity statin eg. Atorva 40-80mg
Can add Ezetimibe or PCSK9i
1.4mmol/L
What 2 symptoms will patients with Diabetic kidney disease have?
T1DM
Albuminuria
Retinopathy
T2DM
only Albuminuria
When not to use Finerenone?
When patient eGFR < 25 (same as Dapagliflozin)
What are ASCVD risk factors?
LDL > 2.6
High blood pressure
Smoking
CKD
Albuminuria
Family history of premature ASCVD
When should Aspirin be used for prevention of ASCVD
Secondary prevention (ASCVD already happened)
Primary prevention
50-70 yo with at least 1 ASCVD risk factor
When should SGLT2i not be used?
when eGFR <20ml/min
