Lecture 26: DM Management Part 2 Flashcards
1
Q
When is insulin indicated?
A
- T1DM
- Longstanding or refractory T2DM
- Hyperglycemic crises
2
Q
What two characteristics are insulin classified by?
A
- Time to onset
- Duration of action
3
Q
What are the common SE of insulin?
A
- HYPOGLYCEMIA
- Wt gain
- Injection-site reactions (lipohypertrophy, lipoatrophy)
4
Q
Why does insulin cause weight gain?
A
Increased intake of excess glucose will be converted to fat.
5
Q
What is the standard STRENGTH of insulin?
A
100 units/1mL
6
Q
What is meant by basal and bolus insulin?
A
- Basal: background/long-acting (50%)
- Bolus: postprandial, short-acting (50%)
7
Q
How much insulin does someone usually need?
A
0.5 Units/kg
8
Q
What is the longest acting insulin?
A
Insulin degludec (Tresiba)
9
Q
What are the concerns with inhaled insulin?
A
- Cough
- Increased risk of lung cancer (periodic PFT’s)
10
Q
What are the concerns with mixed insulin preparations?
A
- Difficult to adjust dosage.
- NPH is often used, which has an unpredictable pattern.
- Expensive for aspart/degludec combo.
NPH has a significant peak and trough.
11
Q
What gauge are insulin pens and needles?
A
Ultrafine, 31g-33g
12
Q
What is the dawn phenomenon?
A
- Low insulin in the morning, resulting in hyperglycemia
- Often a result of nocturnal release of glucagon.
- Treated by taking more insulin at night.
Down insulin
13
Q
What is the somogyi effect?
A
- Hyperglycemia in the morning as a result of excess exogenous insulin at night.
- Often a result of hypoglycemia at night, which is regulated and then converted to rebound hyperglycemia in the morning.
- Treated by decreasing insulin at night.
So much insulin
14
Q
How can you differentiate dawn phenomenon vs somogyi effect?
A
- 3AM checks of BG
- Decreasing bedtime insulin and seeing morning glucose levels.
Always test by decreasing insulin, NOT BY INCREASING
15
Q
What is the physiologic dosing regimen for insulin?
A
- 4 inj/day (3 short, 1 long)
- 3-4 BG checks/day
- 50/50 dosing or carb counting
16
Q
What insulin is preferred for bolus dosing?
A
Rapid-acting > regular/short-acting
17
Q
What is the premixed insulin dosing regimen?
A
- BID
- 2-3 BG checks/day
18
Q
What is the sliding scale insulin?
A
- Regular insulin, primarily IP settings.
- Reactive approach, but causer wider swings.
- May require a basal insulin.
19
Q
What drug class is metformin and its MOA?
A
Metformin is a biguanide.
MOA: Inhibits hepatic gluconeogenesis.
Minor decrease in intestinal absorption of glucose.
Slightly improves insulin sensitivity.
Lowers A1C about 1-2% usually.
20
Q
What is the first-line therapy for T2DM?
A
Metformin!
Unless a specific CI is present.
21
Q
What secondary benefits does metformin have besides lowering BG?
A
- Weight loss
- Improving lipid TGs
22
Q
What are the concerns regarding metformin?
A
- GI SE: especially Diarrhea
- B12 deficiency
- BBW: Lactic acidosis (rare)
23
Q
When is lactic acidosis more likely to occur with metformin use?
A
- CKD
- Liver Failure
- Excess ETOH intake
24
Q
What are the CIs to metformin?
A
- Allergy
- Acidosis
- CKD
- CHF, hospitalization, radiocontrast
25
What are the two thiazolidinediones (TZDs)?
* Rosiglitazone
* Pioglitazone
26
What is the MOA of a TZD?
* Unlock muscle and fat cells to help them utilize glucose.
* Improves insulin sensitivity.
* Decreased gluconeogenesis
* Increased adipogenesis
* Binds to PPAR-gamma to carry out above effects.
27
What are both TZDs and metformin specifically NOT associated with?
Hypoglycemia.
28
What is the secondary beneficial effect of pioglitazone?
Improving HDL and TG
29
What are the concerns with TZDs?
* Wt gain
* Edema
* Bladder cancer (pioglitazone risk)
* lipids (rosiglitazone increases LDL, TG, and minor benefit of HDL.)
* BBW: CHF, rosi also causes MI.
* Fx risk
* Anemia
* Mnemonic: You get a PIzza and calZONE (pioglitazone) at a PPAR-lar, and the word is a mouthful (wtgain)
30
What are the CIs to TZDs?
* Allergy
* CHF (class 3/4)
31
How do both sulfonylureas and meglitinides work?
* Increased production of insulin by the pancreas.
* Bind to ATP-sensitive K+ channel, depolarizing cell and opening Ca channels to release more insulin from beta cells.
* Insulin secretagogue
32
What are the sulfonylureas?
* Glimepiride
* Glipizide
* Glyburide
* Mnemonic: Sulfas smell like Gas
33
What are the concerns with sulfonylureas/meglitinides?
* HYPOGLYCEMIA
* Wt gain
* TID dosing for megs
* Chronic liver or kidney disease makes for a poor candidate.
34
What are the CIs to sulfonylureas/meglitinides?
* Allergy to rx OR sulfa allergy
* DKA
35
What is the MOA of an alpha-glucosidase inhibitor?
* Inhibits the breakdown of starch in the intestine.
* Delayed carbohydrate absorption.
36
What are the two alpha-glucosidase inhibitors?
* Acarbose
* Miglitol
37
What are the main concerns with alpha-glucosidase inhibitors?
* GI: Flatulence
* Increased hypoglycemia risk if given with sulfonylureas or insulin
* TID dosing
38
What are the CIs to alpha-glucosidase inhibitors?
* Allergy
* DKA
* Cirrhosis
* Chronic GI disease (IBD, colon ulcers, obstruction, etc)
39
What is the MOA of a SGLT2 inhibitor?
* Inhibit renal glucose absorption
* Increased renal glucose excretion via inhibition of protein.
* Acts on proximal tubule.
40
What are the 4 SGLT2 inhibitors?
* Canagliflozin
* Dapagliflozin
* Empagliflozin
* Ertugliflozin
* Mnemonic: GLucose FLOwing out
41
Why are SGLT2 inhibitors used?
* Wt loss
* Insulin-independent
* Lowers BP
* Can improve CKD even in non-DM pts)
42
What are the main concerns with SGLT2 inhibitors?
* Incidence of GU infections
* Genital mycotic infections
* Dehydration
* Can worsen GFR if it is low.
| Sugar near the genitals = food for microbes.
43
What are the CIs to SGLT2 inhibitors?
* Allergy
* Moderate-severe CKD (Doesn't work once GFR is low)
44
How do GLP-1 receptor agonists work?
* Mimics incretin GLP-1
* Increased insulin release
* Decreased glucagon release
* Decreased gastric emptying
* Increased satiety
* Increased beta cell proliferation
45
What are the GLP-1 agonists?
* Exenatide
* Liraglutide
* Lixisenatide
* Dulaglutide
* Semaglutide
* Tirzepatide
46
What is the main secondary benefit for a GLP-1 agonist?
Weight loss
47
What are the concerns/disadvantages of GLP-1 agonists?
* SC injection (except rybelsus)
* Hypoglycemia if taking insulin secretagogues
* BBW: Thyroid cancer
48
What are the CIs to GLP-1 receptor agonists?
* Allergy
* PMHx or FMHx of medullary thyroid carcinoma or MEN2
| Caution in someone using decreased GI motility drugs.
49
How do DPP-4 inhibitors work?
* Inhibits the enzyme that degrades GLP-1.
* Exact same effects as GLP-1 receptor agonists.
50
What are the DPP-4 inhibitors?
* Sitagliptin
* Saxagliptin
* Linagliptin
* Alogliptin
51
What is the primary reason GLP-1 receptor agonists are preferred over DPP-4 inhibitors?
Higher efficacy.
52
What is the CI to a DPP-4 inhibitor?
* Allergy
| Less SE than a GLP-1 receptor agonist as well.
53
How do amylin analogs work?
* Mimics amylin.
* Decreases glucagon release
* Decreased gastric emptying
* Increased satiety
54
Why are amylin analogs good?
* Useful in both T1 and T2DM.
* Wt loss.
* Improves FBG and PPBG.
55
What is the BBW of an amylin analog?
Hypoglycemia if used with insulin.
56
What are the CIs to amylin analogs?
* Allergy
* Gastroparesis
* Unawareness of hypoglycemia
57
What is the amylin analog?
Pramlintide
58
What are the two add-on drugs for DM?
* Colesevelam (bile acid sequestrant)
* Bromocriptine (Dopamine receptor antagonist)
59
What medication can be combined with long-acting insulin?
* GLP-1 agonists
* Given as a single daily dose.
60
What is the ideal target A1C for a diabetic?
< 7%
61
What is the primary tx for T1DM? Regimen?
Insulin, ideally basal-bolus or pump.
| Pramlintide can be adjunct.
62
What drugs are not indicated for T1DM?
* Metformin
* GLP-1
* DPP-4
* SGLT2 inhibitor
63
What is the preferred insulin type for T1DM?
Analog insulin (rapid-acting/long-acting) is more preferable than human insulin.
64
How do we treat an unconscious, hypoglycemia patient?
* Inj/Nasal Glucagon kit
* IV Dextrose (D50W)
65
What is the preferred treatment for prediabetes?
* Behavioral interventions.
* Metformin is recommended only if BMI> 35, Age < 60, or hx of gestational diabetes.
66
How should we manage a newly diagnosed T2DM patient?
* Metformin + diet + exercise
67
When should insulin be considered as therapy for a newly diagnosed T2DM patient?
* A1c > 9%
* Significant hyperglycemia S/S
68
How do we manage a T2DM pt not at goal within 3 months?
* Add another agent
* Add 2 more agents
* Add insulin
69
What T2DM meds are associated with hypoglycemia?
* Sulfonylureas
* Meglitinides
* Pramlintide
* Insulin
70
Which T2DM drugs cause weight loss?
* GLP-1 agonist
* SGLT2 inhibitor
* Pramlintide
* Metformin
71
Which T2DM drugs cause weight gain?
* Sulfonylureas/meglitinides
* TZDs
* Insulin
72
Glycemic control drug algorithm
73
What are the rapid acting insulins?
* Lispro
* Aspart
* Glulisine
74
What are the long-acting insulins?
* Determir
* Glargine
* Degludec
