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Pharmacology Test #5 > Insulin and Diabetes > Flashcards

Insulin and Diabetes Flashcards

1
Q

Criteria for the Diagnosis of Diabetes

A
  1. A1C greater than or equal to 6.5%
  2. Fasting plasma glucose greater than or equal to 126 mg/dL
  3. 2-h plasma glucose greater than 200 mg/dL during an OGTT
  4. A random plasma glucose greater than 200 mg/dL
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2
Q

Glucose intolerance in type 1 diabetes characterized by

A

no functioning insulin-secreting pancreatic beta cells, dependency on exogenous insulin and a tendency towards ketoacidosis

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3
Q

Type 1 diabetes is thought to be caused by

A

antibodies that destroy pancreatic beta cells that may be triggered by viruses, chemicals etc. in genetically predisposed individuals

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4
Q

Role of glucagon

A

increased glucagon levels in the presence of increased blood glucose levels

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5
Q

Hyperlipidemia in diabetes

A

increased fatty acid mobilization from fat cells; increased fatty acid oxidation - ketoacidosis

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6
Q

What happens in hyperglucemia (due to lack of insulin)

A
  1. decreased glucose uptake in cells where glucose uptake is insulin-dependent
  2. decreased glycogen synthesis
  3. increased conversion of amino acids to glucose
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7
Q

Cardiovascular complications from diabetes

A

micro and macro angiopathies

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8
Q

Neuropathy complications from diabetes

A

increased blood glucose levels lead to increased utilization of the polyol pathway (Aldose Reductase); increased cytosolic water in neural cells

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9
Q

Nephropathy complications from diabetes

A

renal vascular changes and changes in the glomerular basement membrane

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10
Q

Ocular complications from diabetes

A

cataracts, retinal microaneurysms and hemorrhage

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11
Q

Increased susceptibility to what? with diabetes

A

increased susceptibility to infections

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12
Q

Conventional therapy goals of insulin therapy and monitoring

A

reduce acute symptoms - polyuria, dehydration and ketoacidosis

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13
Q

Intensive therapy goals of insulin therapy and monitoring

A

keep blood glucose levels below 150 mg/dL; prevent/delay onset of complications; increased risk of hypoglycemia

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14
Q

Oxidation products of glucose react irreversibly with proteins to form

A

Advanced glycation end-products (AGE)

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15
Q

Advanced glycation end-products (AGE) results in

A

loss of normal protein function; acceleration of aging process; theorized to account for many long-term complications of diabetes

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16
Q

AGE precursor, methylglyoxal, inhibits

A

vasorelaxation stimulated by acetylcholine/NO

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17
Q

Role of the alpha subunits in the insulin receptor

A

regulatory unit of the receptor; represses the catalytic activity of the beta subunit; repression is relieved by insulin binding

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18
Q

Role of the beta subunits in the insulin receptor

A

contain the tyrosine kinase catalytic domains (autophosphorylation)

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19
Q

Insulin effects on the liver

A

inhibits: glycogenolysis; ketogenesis; and gluconeogenesis
stimulates: glycogen synthesis and triglyceride synthesis

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20
Q

Insulin effects on the skeletal muscle

A

glucose transport; amino acid transport

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21
Q

Insulin effects of the adipose tissue

A

triglyceride storage and glucose transport

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22
Q

Glucose disposal in a fasting state

A

75% is non-insulin dependent (Liver, GI, brain)

25% is insulin-dependent (skeletal muscle)

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23
Q

Glucagon is secreted in a fasting state to prevent

A

hypoglycemia

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24
Q

Glucose disposal in a fed state

A

80-85% is insulin-dependent (skeletal muscle)
4-5% is insulin-dependent in adipose tissue
Glucagon secretion is inhibited

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25
In a fed state, insulin inhibits the release of what?
inhibits release of FFA from adipose tissue
26
What does decreased serum FFA regulate?
enhances insulin action of skeletal muscle; reduces hepatic glucose production
27
GLUT1
constitutive; widely expressed
28
GLUT2
constitutive; beta-cells and liver
29
GLUT3
constitutive; neurons
30
GLUT4
insulin-induced; skeletal muscle and adipocytes
31
Pancreatic polypeptide hormones
glucagon; somatostatin; insulin; amylin
32
Actions of glucagon
Stimulates glycogen breakdown; increases blood glucose
33
Actions of somatostatin
general inhibitor of secretion
34
Actions of insulin
stimulates uptake and utilization of glucose
35
Actions of amylin
co-secreted with insulin; slows gastric emptying; decreases food intake; inhibits glucagon secretion
36
Where is insulin synthesized?
synthesized as a single peptide and deposited in secretory granules in the beta cells
37
What happens to insulin in the beta cell secretory granules?
insulin is cleaved to A and B chains, and C (connecting) peptide by proconvertases
38
Human insulin cDNA in plasmid expressed in E. coli
Humulin
39
Human insulin cDNA in plasmid expressed in transformed yeast
Novolin
40
Units/concentration of insulin
100 units/ml | 28 units/mg insulin
41
Lispro
Humalog
42
Aspart
Novolog
43
Glulisine
Apidra
44
Glargine
Lantus
45
Detemir
Levemir
46
Degludec
Tresiba
47
Ultra rapid onset/very short action insulins
Lispro (Humalog); Aspart (Novolog); Glulisine (Apidra)
48
Rapid onset/short action insulin
Regular
49
Intermediate onset/action insulin
NPH
50
Slow onset/long action insulin
Glargine (Lantus); Detemir (Levemir); Degludec (Tresiba)
51
What happens when you delay the absorption of insulins
prolong the onset and duration
52
What happens when you increase the absorption of insulins
decrease time to onset and duration
53
Absorption and duration of action of NPH
slow absorption, long duration of action
54
What decreases the self-association of Lispro (Humalong)?
reversing positions of P28 and K29 on insulin B chain
55
Onset of Humalog (Lispro) compared to regular insulin
regular: 30-60 minutes Lispro: 5-15 minutes
56
Difference between human insulin and Aspart (Novolog)
Proline 29 in B chain is switched to Aspartate
57
Onset of Aspart (Novolog)
rapid onset: 5-15 min, short duration
58
Difference between human insulin and Glulisine (Apidra)
Asn 3 and Lys 29 in B chain are switched to Lys and Glu
59
Difference between human insulin and Glargine (Lantus)
Asn 21 of alpha-chain is changed to Gly | 2 Arg residues added to the end of the beta-chain
60
Difference between human insulin and Detemir (Levemir)
Thr 30 of beta-chain is deleted, and Lys 29 is myristylated | Binds serum albumin extensively
61
Difference between human insulin and Degludec (Tresiba)
Thr 30 of beta-chain is replaced by gamma-Glu/C16 fatty acid | Binds serum albumin extensively
62
Routes of administration for insulins
1. subcutaneous - all preparations 2. insulin infusion pump - rapidly acting 3. IV - regular 4. Inhalation - Afrezza
63
Afrezza (Regular Human Insulin) is contraindicated in which patients?
contraindicated in patients with asthma and COPD; may reduce lung function (decrease FEV)
64
Inhaled insulin
Afrezza
65
Types of patients using insulin
1. Type 1 diabetics 2. Patients with ketosis and hyperosmolar coma 3. Some Type II diabetics
66
Mode of action of insulin in a diabetic patient
1. decreased liver glucose output 2. increase fat storage 3. increase glucose uptake
67
Hypoglycemia treated with
glucose or glucagon
68
Adverse reactions to insulin
Lipodystrophy; lipoatrophy; insulin resistance
69
lipodystrophy
lump of fat at overused injection site
70
lipoatrophy
concavities in subcutaneous tissue
71
insulin resistance
immune response to insulin
72
Agents that increase blood glucose in diabetics
catecholamines; glucocorticoids; oral contraceptives; thyroid hormone; calcitonin; somatropin; isoniazid; phenothiazines; morphine
73
Agents that increase the risk of insulin hypoglycemia
ethanol; beta blockers; ACE inhibitors; fluoxetine; somatostatin; anabolic steroids; MAO inhibitors; exercise
74
Overview of treatment of type II diabetes
1. Diet + exercise 2. Diet + exercise + oral antidiabetic drugs/GLP-1 analogs 3. Diet + exercise + insulin
75
Effects of sulfonylurea receptors
1. binds to sulfonylurea receptors 2. inactivates K+ channel 3. decreased cell polarization 4. activates voltage sensitive Ca2+ channels 5. increase Ca2+ and activity of microfilaments 6. increased exocytosis of insulin containing granules
76
1st generation sulfonylureas
1. Tolbutamide 2. Tolazamide 3. Chlorpropamide
77
2nd generation sulfonylureas
1. Glipizide 2. Glyburide/Glibenclamide 3. Glimepiride
78
Repaglinide
a non-sulfonylurea hypoglucemic agent
79
Sulfonylureas vs. "Glinides"
1. mechanism of action is the same 2. glinides have a quick onset and a short duration of action 3. glinides are taken before each meal
80
Starlix (Nateglinide)
non-sulfonylurea Katp channel blocker
81
Starlix (Nateglinide) is synergistic with
metformin
82
Adverse effects of sulfonylureas
lasting and prolonged hypoglycemia (due to long half life); G.I. problems; weight gain and increased numbers of secondary failures
83
Lasting and prolonged hypoglycemia with sulfonylureas has been mistaken for what in the elderly?
has been misdiagnosed as stroke and has lead to permanent neurological damage and death with elderly patients
84
Drugs which may enhance the action of sulfonylureas and increase the risk of hypoglycemia
salicylates; phenylbutazone; sulfonamides; clofibrate
85
Drugs having their own hypoglycemic effects which may be additive to the sulfonylureas
alcohol (associated with severe sulfonylurea hypoglycemic reactions); and high dise salicylates
86
Drugs which cause hyperglycemia which in turn oppose the action of sulfonylureas and insulin therapy
oral contraceptives; epinephrine; thiazide diuretics; corticosteroids; thyroid
87
The incretin effect
oral glucose stimulates a larger insulin response than IV glucose in humans
88
Why does the incretin effect happen?
GLP-1 (from the L-cells in the intestine) potentiates excitation-secretion and excitation-transcription coupling in the beta-cell
89
The incretin effect is diminished in which patients
Type II diabetic patients
90
Benefits of GLP-1 analog treatment in type II diabetics
reduce hyperglycemia with low risk of hypoglycemia; weight loss; increase beta cell mass(?)
91
GLP-1 analogs
Exenatide; Victoza (Liraglutide); Tanzeum (Albiglutide); Dulaglutide (Trulicity)
92
Exenatide co-administered with
metformin, TzDs, or sulfonylureas
93
Adverse effects of Exenatide
nausea and vomiting; risk of pancreatitis
94
Victoza (Liraglutide) co-adminstered with
metformin, TzDs, and sulfonylureas
95
Adverse effects of Victoza (Liraglutide)
nausea and vomiting, pancreatitis, risk of thyroid tumors - monitor calcitonin levels
96
Adverse effects of Dulaglutide (Trulicity)
risk of thyroid C-cell tumors, contraindicated in patients with a family history of medullary thyroid cancer
97
Inhibitors of Dipeptidyl Peptidase 4 (DPP-4) - the enzyme that degrades GLP-1
Januvia (Sitagliptin); Onglyza (Saxagliptin); Tradjenta (Linagliptin); Nesina (Alogliptin)
98
Side effects of DPP IV inhibitors
nausea, vomiting, constipation, headache, severe skin reactions; reduced WBC counts (infections); potential increased risk of cancers
99
Symlin (Pramlintide) is what kind of analog
amylin analog
100
MOA of alpha-glucosidase inhibitors
decrease the absorption of carbohydrate from the intestine via inhibition of gut alpha-glucosidases on the brush border (sucrase, maltase, glucoamylase)
101
Strategy for inhibition of sodium glucose transporter 2 (SGLT2)
decrease the threshold for glucose excretion in urine; reduce blood glucose levels
102
SGLT2 inhibitors
Dapagliflozin; Empagliflozin; Canagliflozin
103
Adverse effects of Canagliflozin
increase risk of genital/UT infections; increased urine flow/volume depletion; increased risk of hypoglycemia with SU and insulin; contraindicated in patients with renal impairement
104
Do not use Dapagliflozin in patients with
bladder cancer
105
Causes of insulin resistance
1. Polymorphisms in insulin signaling pathway proteins (rare) 2. Obesity - especially accumulation of fat in the abdominal cavity 3. inactivity
106
Role of fatty acids in obesity-induced insulin resistance
FFA levels are increased in obese people; acutely raising FFA levels causes insulin resistance; acute lowering of plasma FFA levels reduces chronic IR
107
Oral antidiabetic drugs - non-hypoglycemic agents
Metformin
108
Advantages of biguanides over sulfonylureas
rarely causes hypoglycemia; rarely causes weight gain
109
MOA of metformin
activator of AMP-activated kinase (AMPK); increase the efficiency of sensitivity to insulin in liver, fat and muscle cells
110
Metformin contraindications
contraindicated in those disorders which increase the tendency toward lactic acidosis
111
metformin effects on blood lipid profile
decreased serum triglycerides; decreased serum LDL
112
Thiazolidinediones
Rosiglitazone (Avandia); Pioglitazone (Actos)
113
MOA of Thiazolidinediones
decrease insulin resistance or improve target cell response to insulin (activators of PPARy)
114
Main target of Thiazolidinediones
adipocytes - enhances adipocyte differentiation; enhances FFA uptake into subQ fat; reduces serum FFA; shifts lipids into fat cells from non-fat cells
115
Why is thiazolidinedione prescribing restricted?
due to cardiovascular toxicities; both are contraindicated in CHF
116
Factors regulated by activation of PPARy
Resistin; Adiponectin; TNFalpha; Leptin; Angiotensinogen; Plasminogen Activator Inhibitor 1

Pharmacology Test #5 (11 decks)

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