Module 8: Unit A Diabetes

Question 1

Short Duration, Rapid Acting Insulin examples

Answer 1

lispro (Humalog)
aspart (Novolog)
glulisine (Apidra)

Rapid-acting inhaled insulin
(Afrezza)

Question 2

Indication short duration, rapid acting insulins

Answer 2

Used for postprandial glycemic control
Preferred insulin for pumps for bolus and basal glycemic control

Prandial glycemic control

Question 3

BBW affrezza

Answer 3

Risk of acute bronchospasm in patients with chronic lung disease

Question 4

Onset, peak and duration of rapid acting insulin (Humalog, Novalog, etc.)

Answer 4

O: 5-15 minutes
P: 0.75-3 hours
D: 3-5 hours

Question 5

Risks with insulin

Answer 5

Hypoglycemia

Question 6

D2D with insulins

Answer 6

Enhance hypoglycemia: anti-diabetic medications, beta-blockers, MAOIs, SSRIs, salicylates, quinolones, androgens, alcohol.

Raise glucose: Thiazide diuretics, glucocorticoids, and sympathomimetics. requiring an adjustment of insulin dosage.

Beta-blockers can delay and/or mask symptoms of hypoglycemia AND potentiate hypoglycemia by ↓ glycogenolysis.

Question 7

Short Duration, Short-Acting Insulin examples

Answer 7

regular insulin (Humulin R, Novolin R)

Question 8

regular insulin (Humulin R, Novolin R) uses

Answer 8

Given 30 m before meals to control postprandial hyperglycemia

Also used in insulin pumps for basal glycemic control (less expensive than rapid-acting, but slower onset)

Question 9

Safety with regular insulin

Answer 9

Higher risk of hypersensitivity due to the presence of protamine (foreign particle can trigger an allergic reaction)

Question 10

Onset Peak Duration: Regular insulin

Answer 10

15-30 minutes
2-4 hours
5-8 hours

Question 11

Intermediate-Acting Insulin

Answer 11

NPH- neutral protamine (Humulin-N)

Hagedorn (Novolin N)

Question 12

NPH neutral protamine (Humulin-N) and Hagedorn (Novolin N) uses

Answer 12

Glycemic control between meals and overnight.

Question 13

Intermediate insulin (NPH (Humulin-N and Novolin N) onset, peak, duration

Answer 13

O: 1-2 hr
P: 4-12 hr
D: 18-24hr

Question 14

Considerations with intermediate insulin

Answer 14

Much less expensive than long-acting/basal insulin but requires dosing 2-3 times/day along with short-acting insulin for postprandial glycemic control

Question 15

Long and ultra-long

-acting (basal)

Answer 15

Long duration
glargine U-100 (Lantus)
detemir (Levemir)

Ultra-long duration
glargine U-300 (Toujeo)
degludec (Tresiba)

Question 16

Use for long and ultra-long duration insulin

Answer 16

Basal coverage

Question 17

glargine U-100 (Lantus) OPD

Answer 17

O: 1-2
P: none
D: 24 h

Question 18

detemir (Levemir) OPD

Answer 18

detemir (Levemir)
O: 1-2 h
P: 4-8
D: 24 hr (varies by dose)

Question 19

glargine U-300 (Toujeo) OPD

Answer 19

O: 3 h
P: none
D: up to 48 hours

Question 20

degludec (Tresiba) OPD

Answer 20

degludec (Tresiba)
O: 30-90 m
P: none
D: >24 h

Question 21

Intermediate-Acting/Combination Preparations

Answer 21

70% NPH/30% regular (Humulin 70/30, Novolin 70/30)
50% NPH/50% regular (Humulin 50/50)
70% aspart protamine/30%aspart (Novolog Mix 70/30)
75% lisproprotamine / 25% lispro (Humalog Mix 75/25)
50% lisproprotamine 50% lispro (Humalog Mix 50/50)

Question 22

Mixed insulin OPD

Answer 22

Onset: 30 minutes,
Peak: 0.5-12 hours,
Duration: up to 24 hours

Question 23

Basal bolus strategy:

Answer 23

Combination of a long or ultra-long acting insulin for basal coverage and short insulin for meal coverage

Question 24

Insulin Pump:

Answer 24

Rapid-acting insulin (preferred) provides a steady (hourly) SQ infusion (units/hr) along with preprogrammed boluses for meal and snack coverage

Question 25

Sulfonylureas examples

Answer 25

glyburide (DiaBeta) glimeperide (Amaryl) glipizide (Glucotrol)

Question 26

Indication sulfonylureas

Answer 26

DM2

Question 27

MOA Sulfonylureas (glyburide, etc.)

Answer 27

Promotes insulin secretion by the pancreas and may ↓ insulin resistance/ ↑ tissue response to insulin

Question 28

Safety sulfonylureas

Answer 28

hypoglycemia- dose-dependent weight gain ↑ effects of alcohol

Question 29

Pregnancy safety with sulfonylureas

Answer 29

contraindicated during pregnancy

Question 30

Biguanides:

Answer 30

metformin (Glucophage, Fortamet)

Question 31

metformin (Glucophage, Fortamet) indication

Answer 31

T2DM glycemic control Prevention of T2DM Off label: Gestational DM PCOS

Question 32

MOA metformin

Answer 32

↓ hepatic gluconeogenesis, ↑ tissue response to insulin, ↓ absorption of glucose in the gut (small effect)

Question 33

Safety, D2D with metformin

Answer 33

GI s/s, nausea, cramping, diarrhea, ↓ appetite. lactic acidosis D2D: cimetidine (Tagamet), resulting in an increase in metformin blood levels Excessive Alcohol can cause lacitic acidosis

Question 34

BBW metformin

Answer 34

Lactic acidosis. ↑ accumulation of metformin. Highest risk with renal impairment

Question 35

Monitoring metformin

Answer 35

↓ absorption of vitamin B12 and folic acid | Renal funciton

Question 36

Thiazolidinediones (-Glitazones) examples

Answer 36

pioglitazone (Actos) | rosiglitazone (Avandia)

Question 37

indication pioglitazone (Actos) and rosiglitazone (Avandia)

Answer 37

T2DM | Often added to metformin

Question 38

Pioglitazone (Actos) and rosiglitazone (Avandia) MOA

Answer 38

↓ insulin resistance, ↑ glucose uptake by cells, ↓ hepatic gluconeogenesis

Question 39

Safety Pioglitazone (Actos) and Rosiglitazone (Avandia)

Answer 39

Contraindicated with HF and hypersensitivity hypoglycemia (ONLY in the presence of insulin) edema HF, bladder CA, fracture (↑ women), promotes ovulation Some reports of hepatic injury (rare)

Question 40

BBW Thiazolidinediones (GLITAZONES)

Answer 40

cause or exacerbate congestive heart failure (CHF

Question 41

Monitoring Thiazolidinedines (-GLIZAZONES)

Answer 41

LFTs

Question 42

Alpha-glucosidase inhibitors example

Answer 42

acarbose (Precose)

Question 43

acarbose (Precose) use

Answer 43

T2DM adjunctive therapy

Question 44

acarbose (Precose) MOA

Answer 44

Delays CHO digestion and absorption which slows postprandial glucose elevations

Question 45

acarbose (Precose) side effects

Answer 45

GI s/s flatulence, cramps, abd. distention, and borborygmus (technical term for rumbling and gurgling sounds in belly)

Question 46

Tx for hypoglycmeia with Precose

Answer 46

If hypoglycemia develops (acarbose PLUS a hypoglycemic agent), sucrose metabolism is ↓ by acarbose, so GLUCOSE must be used to treat.

Question 47

SGLT2 Inhibitors | “-Gliflozins”

Answer 47

canagliflozin (Inovkana) | dapaglifozin (Farxiga)

Question 48

MOA SGLT2 INhibitors (-Gliflozins)

Answer 48

↑ glucose excretion in urine by inhibiting SGLT-2 (↓ glucose reabsorption in tubules) which lowers circulating glucose and weight loss 2° less calories (glucose excreted in urine)

Question 49

Safety and D2D SGLT2 (-Gliflozins)

Answer 49

Genital mycotic infections (female >male), UTI, ↑ urination orthostatic hypotension rifampin, phenytoin, phenobarbital and similar inducers can ↓ efficacy

Question 50

Additional benefit of SGLT2 (-Gliflozins)

Answer 50

Cardioprotective

Question 51

DPP-4 inhibitors

Answer 51

-GLIPTINs sitagliptin (Januvia) linagliptin (Tradjenta)

Question 52

Indication DPP-4 inhibitors (-GLIPTINs)

Answer 52

T2DM

Question 53

Safety DPP-4 Inhibitors (-GLIPTINs)

Answer 53

pancreatitis, hypersensitivity URI, HA, inflammation of the throat and nasal passages hypersensitivity hypoglycemia (with other agents)

Question 54

GLP-1 Receptor Agonist | incretin mimetics

Answer 54

``` -TIDEs exenatide (Byetta) exenatide ER (Bydureon) semaglutide (Ozempic) liraglutide (Victoza) dulaglutide (Trulicity) ```

Question 55

Indications GLP-1 receptor agonsit (-TIDES)

Answer 55

T2DM | weight loss

Question 56

GLP-1 (-TIDE) Receptor Agonist safety

Answer 56

pregnancy: risk of fetal harm Hypersensitivity hypoglycemia (dose-dependent), GI s/s nausea, vomiting, diarrhea, constipation, pancreatitis, renal insufficiency, increased risk for CA: medullary thyroid and theoretical risk with multiple endocrine neoplasms (MENs)

Question 57

BBW GLP-1 Receptor Agonist

Answer 57

Risk of thyroid C-cell tumors. Semaglutide is contraindicated in patients with a personal or family history of MTC or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2).

Question 58

other use for semaglutide

Answer 58

Semaglutide is gaining popularity as an anti-obesity medication