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CLIN MED II- ENDOCRINOLOGY > PANCREAS- INSULIN/GLUCOSE RELATED DISORDERS > Flashcards

PANCREAS- INSULIN/GLUCOSE RELATED DISORDERS Flashcards

GLC METABOLISM, DM 1 & 2

1
Q

islets of langerhans cells

A

alpha- glucagon
beta- insulin
D- somatostatin
PP- pancreatic polypeptide

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2
Q

glucose metabolism
- insulin and glucagon function

A

insulin and gluc work antagonistically to keep plasma gluc conc in acceptable range

  • insulin: when FED, moves ingested gluc into cells for energy production
  • glucagon: when FASTING, gluc promotes glucose production from bodily stores
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3
Q

glucose metabolism

insulin
- storage/use where
- stored in
- excess glucose stored where
- what stim insulin release

A
  • gluc driven intracellularly for storage/use in adipose tissue and skeletal muscle
  • promotes storage as glycogen in liver and skeletal muscles
  • excess glucose stored as glycogen or fat
  • insulin release stim by plasma GLC >100
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4
Q

glucose metabolism

glucagon
- stim when

A

triggers liver and skeletal muscle to use glycogen and non glucose intermediates to synth glucsoe for release into bloodstream
- release stimulated by plasma GLC <100

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5
Q

glucose metabolism

glucose obtained from 3 sources

A
  • intestinal absorp of food
  • glycogenolysis (breakdown glycogen/ glucose store in storage form)
  • gluconeogenesis (create gluc from precursors derived from carb, protein, fat metab)
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6
Q

gluc range high or low effects

A

low- sensitive tissue (ex: brain) will not function
high- cause lasting damage to cellular proteins

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7
Q

INSULIN

lipid v. protein metabolism

A

LIPID
- promotes fat storage within adipose tissue and liver
- controls storage and formation of TG
- inc cholesterol synth

PROTEIN
- stim uptake of AA into cells, promote protein synth
- inhibit protein breakdown

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8
Q

diabetes mellitus (DM)
- definition
- pathophys

A

PERSISTENT hyperglycemia
- defects in insulin secretion and/or insulin action
- results in exces of glucose in BLOODSTREAM, not enough in CELLS (starvation state)

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9
Q

DM1 v. DM2

A

DM1
- impaired insulin secretion 2/2 autoimmune destruction of pancreatic islet B cells
- dec/NO insulin production

DM2
- tissue resistance to insulin action
eventual impaired insulin production (if untreated)

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10
Q

DM1
- onset
- risk inc?

A

typical onset is ages <30
- rapid onset (weeks to months)
- 2-8x premature mortality risk compared to general population

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11
Q

DM1
- pathogenesis phases

A

1- B cell autoimmunity: islet related antibodies appear
2- asymptomatic loss of B cell secretory capacity due to inflamm
3- loss of B cell secretory function w/development of DM symptoms

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12
Q

DM1
- risk factors

A
  • genetic predisposition (fam hx or autoimmune ds)
  • viral trigger or pancreatic injury/trauma
  • age <30
  • linked to autoimmune ds and specific assoc genes (HLA DR3 and DR4)
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13
Q

DM2
- onset
- assoc in what pts
- patho

A

tissue resistance to insulin
- onset >30 yo
- strong assoc w obesity
- may be present prior to dx

patho: body can create insulin, but cells dont transport glucose through membrane into cells
- obesity assoc w elevated free fatty acid levels in plasma–>contributes to insulin resistance within skeletal muscles

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14
Q

DM2
pathogenesis steps

A

1- dec tissue sensitivity to insulin, stim B cells to produce MORE insulin
2- inc in insulin can make up for resistance temporarily
3- overworked B cells die off over time/fail to be stim by excess glucose–> lead to circ glucose and sx appear

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15
Q

DM2
- risk factors

A
  • genetic predisposition (fam hx)
  • age >45
  • overweight
  • sedentary lifestyle
  • hx of gestational DM (or deliv baby >9lbs)
  • african american, latino, american indian, alsak native descent
  • non alc fatty liver ds
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16
Q

DM
- common symptoms

A
  • polyuria/nocturia
  • polydipsia
  • polyphagia
  • wt loss
  • fatigue, blurry vision
  • freq candidal infx
  • numbness/tingling of extremities

3 P’s!!!!

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17
Q

DM
- common signs (skin, vasc)

A

skin changes
- acanthosis nigricans (DM2): thick velvety hyperpigmented skin in folds
- necrobiosis lipoidica diabeticorum: demarctated yellow-brown atrophic plaques (can be telangiectatic)

vascular
- eyes: cotton wool spots, flam hemorrhages, neovasc
- PV: lower ext dec pulse, ulcers
- neuro: dec vibratory/sensation, dec monifilament testing

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18
Q

DM SYMPTOMS

polyuria/nocturia

A
  • serum glucose conc >180
  • exceeds renal threshold for gluc reabsorption–> inc urinary glucose excretion
  • prompts kidneys to make more urine (osmotic diuresis)—urinate more freq at night
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19
Q

DM SYMPTOMS

polydipsia

A
  • glycosuria causes osmotic diuresis (polyuria)—> hypovolemia
  • leads to polydipsia as body attempts to make up fluid losses

sugar juice exacerbates issue

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20
Q

DM SYMPTOMS

blurry vision

A

inc serum glucose levels cause fluid to move in and out of parts of eye (osmotic pressure)
- leads to lens changing shape, ability to refract light, and see clearly

diabetic retinopathy complication

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21
Q

DM SYMPTOMS

polyphagia + wt loss

A
  • wt loss CAN be a presenting symptom
  • glucose stays in bloodstream, rather than moving into cells—-> body thinks its starving–>prompts you to eat more and break down fat and muscle to compensate
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22
Q

DM SYMPTOMS

frequent candidal infections

A

inc blood sugar glucose levels also means inc gluc in sweat, saliva, and urine

  • fungus loves sugar–> encouraged to grow under these conditions
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23
Q

DM SYMPTOMS

numbness/tingling extremities

A

secondary to neuropathy likely due to microscopic vasculitis
- causes ischemia to capillaries supply nerves (cause nerve damage)

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24
Q

DM SIGNS

DM2- acanthosis nigricans

A

assoc w significant insulin resistance
- causes cells to reproduce at more rapid rate
- hyperpigmented/thick velvety skin axilla, groin, back of neck

25
# DM SIGNS necrobiosis lipoidica diabeticorum - progression - MC location found - tx
- blood vessel inflamm damages skin collagen - begins as red brown or violaceous papules//plaques----> progress to sharp demarcated, yellow brown, atrophic, telangiectatic plaques - may be painful/ulcerate - MC pretibial area tx- topical or intralesional corticosteroids
26
diagnose symptomatic pt
confirm w 1 pos test - random blood glucose >=200 + symptoms - symptoms: polyuria/nocturia, polydipsia, blurred vision, polyphagia, wt loss, freq yeast infx, DKA or HHS
27
diagnose asymptomatic pt
need 2 of following to be pos - fasting plasma glucsoe (FPG) >=126 - HgB A1C >=6.5 - oral glucose tolerance test (OGTT) >= 200 ## Footnote can be 2 diff tests on same day or the same test on 2 diff days
28
A1C - how is it taken - normal range - equiv to what mg/dL
estimate of blood glucose over past 3 months - normal range <5.7 - 6% determines an avg of BG of 130 - each 1% over is about 30 more (ex: 7% approx = 160)
29
A1C unreliable for which pts
unreliable in pts w abnorm RBC morph - due to shortened lifespan of RBC ex: sickle cell ds, sherocytosis, thalassemias
30
screening for DM - who and when
- most pts: age 35, then Q3 years - hx of GDM (gestational), test Q3y after dx - special considerations- test earlier Q1Y anyone with symptoms, pre DM, overweight w other RF) ## Footnote ex: dx in 1st degree relative, HTN, HLD, CVD, high risk ethnicity
31
screening for pre diabetes (impaired glucose tolerance) - what tests - management
pre diabetes- dx to identify asymp pts at high risk for developing DM - use asymp DM testing (FPG, OGTT, HbA1C) - management: first lifestyle mod, if no improvement use metformin
32
other helpful labs - pos/high/or low in which DM?
- insulin auto antibodies (GAD65, islet cell, IA2): pos in DM1 - C peptide: byproduct of pancreatic insulin production, HIGH in DM2, low/absent in DM1 - fasting insulin: high in DM2 - serum fructosamine: glycemic control over 1-2 weeks (use in pts w abnorm HgB states which cause less accurate A1C)
33
management- general goals, glycemic goal, and cardiac management
goal: dec risk micro & macro vasc complications from hyperglycemia while minimizing hypoglycemia and med ADRs - glycemic control: target A1C <=7% - cardiac risk management: smoking cessation, diet/exercise/wt loss, BP control, HLD management
34
# MANAGEMENT glycemic control - testing - goal levels post and pre prandial
check FSG 4x a day - before meals and before sleep, log values target FSG levels (DM1 and 2) - fasting/pre prandial 80-130 - post prandial: 140-180 - avoid <70 and >180
35
DM med tx overview - all, DM1, DM2 - DM2 specifics
ALL- diet/lifestyle mod DM1- insulin, combo of rapid acting (prandial) and long acting (basal) insulin DM2- oral and/or SQ agents - metformin usually first PO agent, choose next according to comorbid - add insulin if A1C >9 or remains elevated on 2+ oral agents (long acting/basal added)
36
DM1 tx - injx sites - emergency DKA route?
INSULIN - maintenance tx inject SC (abd, arm, leg, buttocks) - emergency DKA give IV diet and lifestyle mod
37
# DM1 prandial v. basal insulin - names
prandial- short acting - lispro, aspart basal- long acting - insulin glargine, insulin detimir, insulin DEGLUDEC (longest/ultra long acting)
38
# DM1 MANAGEMENT insulin regimen - types of insulin used - regimen frequency - dose
basal bolus therapy - INTENSIVE insulin regimen - long acting 1-2x a day + rapid acting 3x a day (bolus/prandial) starting dose: -.2-0.5 units/kg/day split 50-50% between basal and prandial doses
39
# DM1 MANAGEMENT insulin regimens - insulin pump - consists of? - freq
- continuous SC infusion of rapid acting insulin acts as "basal insulin" - + pre prandial SC rapid acting boluses (prevent spikes before eating)
40
# DM1 MANAGEMENT insulin regimens - twice/day "mixed insulin" - consists of? - freq - for what pts
- short acting "regular" + intermed acting "NPH" mixed tog before breakfast and dinner (BID) - option for pts who are not willing or able to commit to intensive insulin therapy or pump ## Footnote NPH is just reg insulin mixed with protamine and zinc which slows down absorp---> becomes intermed
41
# DM1 MANAGEMENT additional considerations- carb counting - insulin to carb ratio - rx
- adjust mealtime insulin based on carb count - 1 unit insulin per 15g carb ingested dec hypoglycemia risk compared to fixed dose rx glucagon, glucose tabs for all pts taking insulin rx glucometer, educate on FSG checks, logging values
42
insulin mods inpatient - surgery
switch mealtime insulin to sliding scale, but continue basal surgery- NPO pre op - reduce long acting by 20-30% - hold prandial until eating again
43
inpatient insulin - sliding scale
prandial insulin dose according to premeal FSG - pts STILL NEED LONG ACTING BASAL INSULIN
44
special condition requiring insulin adjustment - testing
dawn phenomenon and somogyi effect - 2 indep conditions that cause morning HYPERglycemia and req adjust to evening insulin - check overnight 3 am gluc to determine cause
45
dawn v. somogyi effect
Dawn - cause: nocturnal GH secretion - 3 am gluc is HIGH - tx: inc evening insulin Somogyi - cause: hypOglycemia overnight causes rebound hyperglycemia - 3 am gluc is LOW - tx: dec evening insulin ## Footnote 3 AM - high, dawn, inc (HDI) - low, somo, dec (LSD)
46
# DM2 MANAGEMENT DM2 diet and lifestyle mod
- wt loss and healthy diet - mediterranean style diet - low glycemic index foods---> lowers FSG after meals - 150 min/week mod intensity aerobic exercise
47
# DM2 MANAGEMENT lifestyle mods for what A1C level can be attempted in DM2 - what kind of pt
lifestyle mods for 3-6 months in pts w/A1C <7.5 IF pt is highly motivated AND Asx (asymp)
48
# DM2 MANAGEMENT oral or SC medication - first chosen - second - progression
METFORMIN first chosen - next is chosen according to comorbid ex) GLP-1 ag in CVD, SGLT2i in kidney ds progression - monotherapy-->dual--->triple - +/- insulin if still not at goal ## Footnote 2 kidneys (SGLT2i), 1 heart (GLP-1)
49
DM2 common meds names
- biguanides: metformin - GLP1 agonists: exena**tide**, semaglu**tide** - SGLT2i: canagliflozin - DPP-4i: sitagliptin - Sulfonylureas: glyburide, glipizide, glimepiride - thiazolidinediones: pioglitazone - Alpha-glucosidase inhib: acarbose, miglitol
50
biguanides: metformin - ADRs - special considerations - CI - hold when?
ADRs: lactic acidosis, GI effects special considerations - MC 1st line PO med in DM2 and preDM - initiation CI with eGFR <30 - hold for IV contrast/inpatient admission due to risk lactic acidosis
51
GLP1 agonists - ADRs - benefits - BBW for which conditions - caution for?
ADRs: pancreatitis, n/v/d/gi Special considerations - benefit: wt loss, reduced CV mortality - black box warning medullary thyroid ca/multiple endocrine neoplasia 2A caution gastroparesis
52
SGLT2i - ADRs - benefits
ADRs: DKA, **UTI, GU candidasis, dec bone density ** benefits: reduce progression of DKD/nephropathy in pts w declining GFR, helpful in CHF (mild diuretic effect)
53
sulfonylureas - MOA - ADRs
MOA: stim pancreatic beta cell insulin release ADRs: hypoglycemia cheap, works fast, but not used anymore
54
thiazolidinediones - ADRs and CI
ADRs: CI with CHF, causes edema, wt gain
55
alpha glucosidase inhibitors - best for what pts - CI
- pts w/very high carb diet and or inc postprandial glc - CI in chronic bowel ds
56
DM2 choosing oral agents (cardiac/CKD rf)
most pts: strt lifestyle mods + metformin - consider GLP1 or SGLT2 in cardiac/renal - can add as 2nd agent if A1C >1% over goal, or recheck A1C at 3 months hasn't reached goal
57
2nd agent for CKD/ASCVD v. no comorbid
ASCVD: GLP1 or SGLT2 - liraglutide> semaglutide> exenatide - empagliflozin >canagliflozin CHF or CKD: SGLT2 - empagliflozin >canagliflozin no ASCVD, CHF, or CKD - obesity: GLP 1 or SGLT2---> semaglutide>liraglutide - low cost: SU or TZD
58
DM2 adding insulin - when - what kind of insulin
- start/add if A1C >9% at diagnosis OR - A1C remains >7% despite being on 2+ meds after A1C recheck at 3 months usually BASAL INSULIN/long acting (detemir, glarganine, degludec) - prandial can be added if long acting fails to control A1C

CLIN MED II- ENDOCRINOLOGY (11 decks)

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