NSG 533 Module 2 Diabetes Flashcards
Diet regarding gestational diabetes:
An individualized meal plan consisting of at least 175 g of carbohydrate, 71 g of protein, and 28 g of fiber per day is recommended
in all pregnant women.
Goals regarding gestational diabetes:
Preventing ketosis, promoting adequate growth of the fetus, maintaining satisfactory BG levels, and preventing nausea and other undesired GI side effects are desired goals in
these patients.
The
ADA currently advocates for ______ as the primary pharmacotherapeutic choice for GDM.
insulin
Neither ______ nor ______ is
considered first line owing to the fact that they cross the placenta as
well as concerns over inconsistent efficacy data in this population.
metformin
glyburide
The
primary focus of ______ for T1DM patients and T2DM patients
taking mealtime insulin is matching optimal insulin dosing to
carbohydrate consumption while maintaining a healthy balance.
MNT
Medical Nutrition Therapy
There is ______ evidence of efficacy for improved BG control
for any individual herb or supplement.
insufficient
Metabolic surgeries, such as __________, are recommended for patients with T2DM and
BMI that is or exceeds 40 kg/m2
regardless of glycemic control.
Roux-en-Y gastric bypass
Yearly influenza vaccinations are recommended for all patients
with DM ______ of age or older.
6 months
PER ADA TREATMENT ALGORITHM:
FIRST-LINE Therapy is ______ and ______ (including weight management and physical activity)
Metformin
Comprehensive Lifestyle
ASCVD
atherosclerotic cardiovascular disease
PER ADA TREATMENT ALGORITHM:
If there are indicators of high risk or established ASCVD, CKD, or HF:
Consider therapies independently of baseline A1C, individualized A1C target, or metformin use.
PER ADA TREATMENT ALGORITHM:
Regarding +ASCVD/Indicators of high risk.
- established ASCVD
- indicators of high ASCVD risk (age >55 years with coronary, carotid or lower-extremity artery stenosis >50%, or LVH.)
Use either a GLP-1 RA with proven CVD benefit
OR
an SGLT2i with proven CVD benefit
Regarding ADA tx algorithm related to +ASCVD/Indicators, if A1C remains above target after receiving either GLP-1 or SGLT2i, then:
If further intensification
is required or patient is
unable to tolerate GLP-1
RA and/or SGLT2i, choose
agents demonstrating
CV benefit and/or safety:
- For patients on a
GLP-1 RA, consider
adding SGLT2i with
proven CVD benefit
and vice versa. - TZD
- DPP-4i if not on
GLP-1 RA - basal insulin
- SU
If further intensification
is required or patient is
unable to tolerate GLP-1
RA and/or SGLT2i, choose
agents demonstrating
CV benefit and/or safety:
-For patients on a
GLP-1 RA, consider
adding SGLT2i with
proven CVD benefit
and vice versa.
- TZD
- DPP-4i if not on
GLP-1 RA - basal insulin
- SU
ADA tx algo, +HF:
(Particularly HFrEF (LVEF <45%)
SGLT2i with proven
benefit in this
population
ADA tx algo, +CKD
(with NO DKD and albuminuria)
For patients with T2D
and CKD8 (e.g., eGFR
<60 mL/min/1.73 m2) and
thus at increased risk of
cardiovascular events
Either/or:
GLP-1
RA or SGLT2i with
proven
CVD
benefit.
ADA tx algo.
If NO indicators of high risk or established ASCVD, CKD, or HF.
If AIC above individualized target proceed as below.
Compelling need to minimize hypoglycemia.
See picture.
DPP-4i
If AIC above target —>
SGLT2i OR TZD
GLP-1 RA
If AIC above target —>
SGLT2i OR TZD
SGLT2i
If AIC above target —>
GLP-1 RA
OR
DPP-4i
OR
TZD
TZD
If AIC above target —>
SGLT2i
OR
DPP-4i
OR
GLP-1 RA
If AIC still above target even after replacing those meds, consider:
The addition of SU OR basal insulin
The ADA recommends dual therapy when the A1c is greater
than or equal to _____.
8.5%
ADA guidelines state ___________ alone is the first-line therapy
option for T2DM.
metformin
Because T2DM generally tends to be a progressive disease, BG
levels will eventually increase, making ________ therapy the eventual required therapy in many patients, and therefore, _________ should not be used rhetorically as a prophylactic deterrent as this
may result in patient trust issues and/or feelings of failure.
insulin
Oral and injectable agents are available to treat
patients with T2DM who are unable to achieve glycemic control
through meal planning and physical activity.
-
-
DPP-4i meds:
Dipeptidyl
peptidase-4
inhibitors
Gliptins:
GLP-1 RA:
Rybelsus
SGLT2i
Selective sodium-dependent
glucose
cotransporter-2
inhibitor
TZD
Thiazolidinediones
Biguanides
Second-generation sulfonlyureas
AGIs
Meglitinides
Biguanides
Glucophage (Metformin)
Do not start or, if
already taking,
continue
cautiously if eGFR
30–45 mL/min/
1.73 m2. Consider
50% of maximum
doses and
monitoring of renal
function every
3 months.
Biguanides
Glucophage (Metformin)
if <30 gfr
Contraindicated in <30 GFR
Biguanides
Glucophage (Metformin)
hepatic impairment?
Avoid or use
cautiously in
patients at
risk for lactic
acidosis (renal
impairment or
alcohol abuse)
Biguanides
Glucophage (Metformin)
SE?
GI (diarrhea,
abdominal
pain)
DPP-4i meds:
Dipeptidyl
peptidase-4
inhibitors
Sitagliptin
Saxagliptin
Linagliptin
Alogliptin
-
Su___________ (DM drug class) enhance insulin secretion by blocking ATP-sensitive potassium channels in the cell membranes of pancreatic
β-cells.
Sulfonylureas
First-generation sulfonylureas are more likely to cause drug
____________.
interactions
All s____________ (DM drug class), except tolbutamide, require dosage adjustment or are not recommended in renal impairment.
sulfonylureas
One limitation of sulfonylurea therapy is the inability of these
products to stimulate insulin release from β-cells at extremely high
glucose levels, a phenomenon called __________________.
glucose toxicity
Common
adverse effects of SUs include ______________________________.
hypoglycemia and weight gain
In SUs there may
be some cross-sensitivity in patients with ________________.
sulfa allergy
Although producing the same effect as sulfonylureas, nonsulfonylurea secretagogues, meglitinides, have a much shorter __________________________________________.
onset
and duration of action
_____________ produce a pharmacologic
effect by interacting with ATP-sensitive potassium channels
on the β-cells; however, this binding is to a receptor adjacent
to those to which sulfonylureas bind.
Meglitinides
The primary benefit of nonsulfonylurea secretagogues is in reducing postmeal ____________________.
glucose
levels
This agent is thought to lower BG by
decreasing hepatic glucose production and increasing insulin sensitivity in both hepatic and peripheral muscle tissues; however, the
exact mechanism of action remains unknown
Biguanides
Unlike sulfonylureas, m__________________ (DM med) retains the ability
to reduce FBG levels when they are over 300 mg/dL (16.7 mmol/L).
metformin
me______________ does not affect insulin release from β-cells of the pancreas, so hypoglycemia is not a common side effect.
Metformin
me_______ significantly reduced all-cause mortality and risk
of stroke in overweight patients with T2DM compared with
intensive therapy with sulfonylurea or insulin in the UKPDS.
Metformin
It also reduced diabetes-related death and myocardial infarction
compared with a conventional therapy arm.
Metformin
____________ is recommended for prevention of T2DM in patients with prediabetes,
especially when the patient has a BMI greater than or equal to
35 kg/m2
, is less than 60 years old, or is a woman with a history
of GDM.34
Metformin
____________ is considered foundational therapy along
with lifestyle modification for T2DM and often used in combination with other antihyperglycemics for synergistic effects.28
Metformin
Per US labeling, __________ is contraindicated in patients with
estimated glomerular filtration rates (eGFR) less than 30 mL/
min/1.73 m2.
metformin
It is not recommended for new start in patients
whose eGFR is 30 to 45 mL/min/1.73 m2
.
Metformin
Therapy with me____________ (DM med) should be withheld in patients
undergoing radiographic procedures in which nephrotoxic dye is
used if their eGFR is between 30 and 60 mL/min/1.73 m2
. Therapy
should be withheld the day of the radiographic procedure, and
renal function should be assessed 48 hours after the procedure.
If renal function is normal, therapy may be resumed.
metformin
me_____________ (DM med)
should be held 24 hours before surgery and restarted after
oral intake is resumed and renal function is evaluated as normal.
Metformin
Primary side effects associated with ____ include
decreased appetite, nausea, and diarrhea. Side effects can be minimized through use of extended-release products and slow titration of the dose and often subside within 2 weeks.42
metformin
Interference with vitamin B12 absorption has also been reported and periodic
B12 testing is recommended especially in those patients with macrocytic anemia or peripheral neuropathy.
Metformin
Me___________ (DM med) is thought to inhibit mitochondrial oxidation of lactic acid, thereby increasing the chance of lactic acidosis, a condition which rarely occurs. Patients at risk for lactic acidosis include those with renal impairment and those who are of advanced age.
Metformin
M_________ (DM med) should
be withheld promptly in cases of hypoxemia, sepsis, or dehydration.
Metformin
Patients should avoid consumption of excessive amounts of
alcohol while taking m_______________ (DM med), and use of the drug should be
avoided in patients with liver disease.
metformin
T__s are known to increase insulin sensitivity by stimulating
peroxisome proliferator-activated receptor gamma (PPAR-γ)
which increases insulin sensitivity and decreases plasma fatty
acids.
TZDs
_____(drug class) may produce fluid retention and edema and are, thus, contraindicated in New York Heart Association Class III and IV heart
failure.
TZDs
Fluid retention appears to be dose related and increases
when combined with insulin therapy.
T___ (DM drug class)
TZDs
While rare, ____ (psych drug class) can worsen
macular edema.
TZDs
Weight gain of 4 kg (8.8 lb) is common with T__s (DM drug class) and results from both fluid retention and fat accumulation.
TZDs
Increased rates of upper and lower limb fractures are known
to occur with T_____ (DM drug class) therapy.
TZD
Premenopausal anovulatory women
may begin to ovulate on T__s (DM drug class) therapy, and therefore, counseling
regarding this should be provided to all women capable of becoming pregnant.
TZD
Safety of ___ (DM drug class) therapy in patients with cardiovascular disease seems to differ between specific drugs. A meta-analysis
reported a significantly greater risk of myocardial infarction with
rosiglitazone compared with other oral agents. A subsequent
study found rosiglitazone use associated with a nonsignificant
increase in myocardial infarction risk and nonsignificant reduction in stroke, but a trend toward increased cardiovascular risk
in patients with a history of ischemic heart disease.
TZD
A meta-analysis of __________ in patients with established cardiovascular disease demonstrated significant reduction in major adverse
cardiovascular events (MACE), myocardial infarction, and stroke
but did not reduce risk of all-cause mortality.
pioglitazone
pioglitazone (Actos) is a:
Thiazolidinedione (TZD)
Acarbose and miglitol are ________ that compete
with enzymes of the small intestines that break down complex
carbohydrates.
α-glucosidase inhibitors (AGIs)
These drugs delay absorption of carbohydrates
and reduce postprandial BG concentrations as much as 40 to
50 mg/dL (2.2–2.8 mmol/L); however, A1c reductions range only
from 0.3% to 1% (0.003–0.01; 3–11 mmol/mol Hgb).
α-______________________ (DM drug class)
α-glucosidase inhibitors (AGIs)
High incidences of GI side effects have limited their use.
α-glucosidase inhibitors (AGIs)
_________ (drug class): (or gliptins; sitagliptin, saxagliptin, linagliptin,
and alogliptin) are approved as adjunct to diet and exercise to
improve glycemic control in adults with T2DM.
DPP-4 inhibitors
Common adverse effects include
headache and nasopharyngitis. Hypoglycemia is not a common
adverse effect with these agents because insulin secretion results
from GLP-1 activation caused by meal-related glucose detection
and not from direct pancreatic β-cell stimulation.
DP______ (DM drug class)
DPP-4 inhibitors
They lower BG
concentrations by inhibiting DPP-4, the enzyme that degrades
endogenous GLP-1, thereby increasing the amount of endogenous GLP-1.
DPP-4 inhibitors
Acute pancreatitis, including hemorrhagic and necrotizing pancreatitis, has
been reported in patients taking DP________ (DM drug class).
DPP-4 inhibitors
gliptins
These agents should
not be given to patients with a history of pancreatitis.
DP_________ (DM drug class, -gliptins)
gliptins
DPP-4 inhibitors
SG_________ (DM drug class) (canagliflozin, dapagliflozin, empagliflozin,
and ertugliflozin) are approved as adjunct to diet and exercise
to improve glycemic control in adults with T2DM and may be
used as monotherapy or add-on.
SGLT2 inhibitors
Inhibition of SGLT2
in the proximal tubules reduces reabsorption of filtered glucose
and lowers the renal threshold for glucose which together cause
increased urinary excretion of glucose and decreased plasma
glucose concentrations.
SGLT2 inhibitors
_________________ (DM med, -flozin), added to standard of care in patients with established ASCVD, was shown to reduce the composite of cardiovascular death, all-cause mortality, and death from cardiovascular
causes.4
Empagliflozin
SGLT2 inhibitors
__________ (med, -flozin) was evaluated in two trials which enrolled
patients with T2DM at high cardiovascular risk. ____________
reduced the risk of primary outcome of death from cardiovascular causes, nonfatal myocardial infarction, or nonfatal stroke. An
increased risk for lower-limb amputation was detected, primarily
involving the toe or metatarsal in patients with a history of previous amputation or peripheral vascular disease
Canagliflozin
____
part of the SGLT2 inhibitors
SG_______ ( DM drug class, -flozin) did
not show a difference in the risk of cardiovascular death, nonfatal myocardial infarction, and stroke in patients with ASCVD or
ASCVD risk factors but did lower risk of cardiovascular death
or hospitalization for heart failure
Dapagliflozin
SGLT2 inhibitors
All three medications have
shown a significant reduction in hospitalizations for heart failure,
leading to development of ongoing clinical trials in patients with
heart failure with and without diabetes. Additionally, CVOTs for
________________________________________________________________________________________
evaluated the
effects of these agents on renal outcomes. All were found to have
a positive effect on renal outcomes in patients with T2DM at high
cardiovascular risk.
empagliflozin, canagliflozin, and dapagliflozin
SGLT2 inhibitors
Possible adverse reactions with S_________________ (DM drug class) include an
increased incidence of urinary tract infections (UTIs) and genital
mycotic infections due to increased glucose excretion. Osmotic
diuresis occurs which may result in symptomatic hypotension.
SGLT2 inhibitors
Renal function should be monitored at baseline to guide initial dosing and periodically during treatment to assess suitability of continuation
which DM drug class? The flozins.
SGLT2 inhibitors
Volume status including BP, hematocrit, serum potassium,
serum magnesium, serum phosphate, and low-density lipoprotein
(LDL) cholesterol are also recommended monitoring parameters
for this drug class:
S__________ (DM drug class)
SGLT2 inhibitors
Cases of euglycemic ketoacidosis have been
reported with S________________ (DM drug class). Before initiation, patients should
have risk for ketoacidosis assessed (including insulin deficiency,
dose decreases of insulin, caloric restriction, surgery, and infection).
SGLT2 inhibitors
S___________ (DM drug class) should be held at least 3 days prior to surgery then restarted once the patient is stable to minimize risk of
DKA.
SGLT2 inhibitors
Increased risk for bone fracture has been
associated with ____________ use as well as newly diagnosed
bladder cancer with ______________.
SLGT2 inhibitor
dapagliflozin
Although rare, patients may
develop necrotizing fasciitis of the perineum (Fournier gangrene)
SG___s (DM drug class)
SLGT2 inhibitor
Should ketoacidosis occur, the ____________ (DM drug class) should be
held or discontinued.
SGLT2 inhibitor
Exenatide, liraglutide, dulaglutide, semaglutide, and lixisenatide
are indicated for treatment of T2DM to improve glycemic control.
These agents are part of the group of drugs known as incretins.
Glucagon-Like Peptide 1 Receptor Agonists
GLP-1 RAs
______________ (drug class) lower BG levels by:
(a) producing glucose-dependent insulin secretion;
(b) reducing postmeal glucagonsecretion, which decreases postmeal glucose output;
(c) increasing satiety which decreases food intake; and
(d) regulating gastric emptying, which allows nutrients to be absorbed into the
circulation more smoothly
GLP-1 RAs
_____________ is not recommended in patients with creatinine clearance (CrCl) of less than
30 mL/min (0.50 mL/s), and ___________ is not recommended in
patients with CrCl less than 15 mL/min (0.25 mL/s).
Exenatide
lixisenatide
The main side effects of
G_____________ (DM drug class) therapy include nausea, vomiting, and diarrhea. These
GI adverse effects tend to lessen over time.
GLP-1 RA
G_______________ (DM drug class) have
been associated with cases of acute pancreatitis and should not
be started in patients with a history of pancreatitis.
GLP-1 RAs
Any patient
with symptoms of acute pancreatitis, including abdominal pain,
nausea, and vomiting, should have GL______ (DM drug class) therapy discontinued until pancreatitis can be ruled out.
GLP-1 RA
All _______ (DM drug class) except
for lixisenatide contain a black-box warning about thyroid C-cell
tumors.38 These agents are contraindicated in patients with a personal or family history of medullary thyroid cancer and in those
with a history of multiple endocrine tumors.
GLP-1 RAs
A quick release formulation of the central-acting ______________, _______________ is approved for treatment of T2DM but
should be considered a last line option due to the modest impact
on BG levels and A1c.
The mechanism of action for how bromocriptine regulates glycemic control is unknown, but data indicate that bromocriptine administered in the morning improvesinsulin sensitivity, likely a result of its effect on dopamine
oscillations. Main side effects include rhinitis, dizziness, asthenia, headache, sinusitis, constipation, and nausea. Contraindica tions include syncopal migraine and women who are nursing.
dopamine
agonist, bromocriptine,
_______ is the one agent that can be used in all types of DM, has
no specific maximum dose, and can be titrated to suit each individual patient’s needs.
Insulin
All patients
with a history of cardiovascular disease should be prescribed _________ 75 to 162 mg/day as a secondary prevention strategy.
aspirin
______________ is an option for patients with atherosclerosis who are allergic
to aspirin.
(For pts with DM.)
Clopidogrel
The ADA currently recommends _________________ be
considered for patients with DM and no history of heart disease
if patient is 50 years of age or older and has at least one additional
cardiovascular risk factor including family history of premature
ASCVD, hypertension, dyslipidemia, smoking, or albuminuria.
antiplatelet therapy
Patients with diabetes and known ASCVD are recommended
to receive a high-intensity ______ drug.
statin
Uncontrolled BP plays a major role in development of
macrovascular events and microvascular complications, including retinopathy, nephropathy, and erectile dysfunction, in
patients with DM.
-
(Key concept)
__________________ (BP drug class) are recommended in DM patients to reduce BP, and ARBs are next recommended as the second option.
ACEi
_____________ - Compelling indication with elevated BLOOD PRESSURE
ACEI (or ARBs)
USE in: high CV risk patients (10-yr CV risk > 10%) - Typically: male > 50 yo or female >60 yo with 1 additional major risk factor (FH of CVD, HTN, smoker, dyslipidemia or albuminuria)
________ (med)
ASA (or Clopidogrel if allergic)
NOT recommended: low CV risk patients - men <50 yo or women <60 yo without major CV risk factors or 10-yr CV risk < 5%
ASA (or Clopidogrel)
For All patients 40-75 with diabetes (see above)
Moderate intensity ________ is indicated regardless of baseline LDL
High intensity ______ should be considered in those with a 10 year risk > 7.5%
Statin
Please note when transitioning from oral therapy for type II DM to insulin, ________ is retained! Secretagogues are discontinued possibly when basal insulin is initiated, but definitely when prandial (fast/rapid) insulin is to be added.
metformin
_______________________ provides the greatest flexibility and control of all regimens.
Sliding Scale Should NOT be used
Basal-bolus (long acting basal + rapid/fast acting bolus)
- Difficult to do in home setting, requires education and understanding of patient and caregiver
- Allows patient to become hyperglycemic, better to schedule dosing and prevent rises in BG
- Requires frequent blood glucose monitoring, $$$ and compliance issues
Why sliding scale shouldn’t be used.
Regarding insulin therapy, you often want to start with __________________
a long-acting insulin
s_________________ (DM drug class) can continue up until the point where prandial (rapid) insulin is added
Sulfonylurea
