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Clinical Nutrition 1 > Pharmacology & Exercise in Diabetes > Flashcards

Pharmacology & Exercise in Diabetes Flashcards

1
Q

Key points in PA checklist?

A
  • Minimum of 150 mins of moderate-vigorous aerobic exercise/week
  • Include resistance training > 2 times/week
  • Set PA goals, involve multi-disciplinary team if available
  • Minimize uninterrupted sedentary time
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2
Q

What should be assessed pre-exercise?

A

Conditions that can predispose to injury

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3
Q

What conditions may predispose to injury?

A
  • Neuropathy
  • Coronary artery disease
  • Peripheral artery disease
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4
Q

How could coronary artery disease be assessed pre-exercise?

A

Resting ECG, potential stress test

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5
Q

What are the 3 steps in the PA Interactive decision tool?

A

1) Pre-Activity screening
2) PA level and participation
3) PA Program recommendation

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6
Q

Give recommendations for aerobic exercise

A
  • Walk at comfortable pace for 5-15 mins, then progress over 12 weeks to walk for 50 mins/session.
  • Alternatively, try shorter bouts of exercise - such as 10 mins 3x/day after meals
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7
Q

Give recommendations for resistance exercise

A

-Choose 6-8 exercises targeting arms, chest, back, legs, abdomen and work on increasing resistance.

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8
Q

How should resistance training be increased over time?

A

Increase resistance until you can only perform 3 ets of 8-12 reps, with 1-2 mins between each set

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9
Q

What’s important when beginning resistance exercise?

A

Receive instruction and periodic supervision by a qualifies exercise specialist to maximize benefits and minimize risk of injury.

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10
Q

Give recommendations for interval exercise

A
  • alternate between high and low intensity

- will shorten total exercise duration while increasing fitness gains and variety

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11
Q

What is intensity interval training?

A

Example: Alternating between 30 seconds at very high intensity and 90 seconds at low intensity

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12
Q

Exercise in ___ can have similar benefits as other forms of exercise and will help minimize barriers from conditions such as osteoarthritis

A

water

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13
Q

What are 2 additional pieces of exercise advice?

A

1) Use pedometers/accelerometers

2) Break up sedentary time - try getting up briefly every 20-30 mins

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14
Q

List the ABCDESSS of Diabetes care

A 
A1C - optimal glycemic control
BP control
Cholesterol - reach LDL targets
Drugs to protect heart
Exercise and Healthy eating
Screening for complications
Smoking cessation
Self-management, stress, other barriers
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15
Q

A1C target?

A

= 7%

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16
Q

BP target?

A

<130/80

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17
Q

LDL target?

A

<2.0 mmol/L or >50% reduction

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18
Q

Drugs to protect heart? (4)

A

ACEi or ARV
Statin
ASA
SGLT2/GLP-1 RA

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19
Q

When is SGLT2 or GLP-1 RA recommended?

A

T2DM with CVD and A1C not at target

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20
Q

Intensive insulin therapies T1DM

A
  • basal-bolus injection therapy

- continuous subcutaneous insulin infusion

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21
Q

Discuss basal-bolus injection therapy

A
  • Bolus insulin at meal times + basal insulin 1-2x/day

- covers the insulin required at each meal

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22
Q

What does basal-bolus injection therapy simulate?

A

Normal physiological response to meals, but required multiple injections (~1/meal + basal)

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23
Q

Discuss continuous subcutaneous insulin infusion

A

-“insulin pump therapy” infusion via catheter and will cover the amount of insulin needed throughout the day and into the night

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24
Q

When is conventional Tx used?

A

-Elderly, 2 injections/day

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25
Q

Describe the normal BG curve

A

Low in mornings (~5 mmol/L) where BG will peak at each peak, almost superimposed with insulin secretion

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26
Q

What is the goal of insulin therapy in T1DM?

A

Mimic the physiological secretion of insulin in response to meals

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27
Q

Why do we need basal insulin?

A

Since we never have 0 insulin in our system

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28
Q

What are the two types of insulin?

A

Human insulin and insulin analogs (synthesized from AA)

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29
Q

What takes care of the spikes of blood glucose in response to meals? What takes care of the baseline insulin?

A
  • Bolus insulin

- Basal insulin

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30
Q

Describe the effects of Human basal insulin

A

-Require 1 injection/day and works to cover insulin levels slightly higher than our basal needs, peaking in the middle of the day

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31
Q

Describe the effects of Analogue basal insulin

A

Maintains basal insulin levels closer to normal physiology - avoids peaking in middle of the day

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32
Q

Analogue insulin > ___

A

Human insulin

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33
Q

Describe the effects of human bolus insul

A

-Requires 3 injections/day and results in insulin peaks slightly lower, and delayed, compared to glucose levels

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34
Q

Describe the effects of analogue bolus insulin

A

3 injections/day - and better matching with spikes in blood glucose compared to human bolus

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35
Q

What is conventional insulin Tx? When is it recommended?

A

Premixed insulin which mixes long and short-acting, aims to “average” out the peaks of glucose during the day.
-NOT recommended or preferred, but OK for those who have to limit injections, or low education/independence

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36
Q

Effects of human premixed injection?

A

Will partially cover 3 meals/day

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37
Q

Effects of analogue premixed insulin

A

Will cover quite well breakfast and lunch, and skip entirely the lunch

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38
Q

Disadvantages of conventional/premixed?

A

Does NOT match physiological blood glucose, meaning that there will be repeated times during the day where the patient experiences episodes of hyper and hypoglycemia

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39
Q

Bolus insulin can be both ____

A

short and fast acting

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40
Q

Example of fast acting bolus insulin?

A

Lispro/Humalog

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41
Q

Example of short acting bolus insulin?

A

Regular/Humulin-R

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42
Q

Intermediate acting basal insulin?

A

NPH/Humulin-N

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43
Q

Long-acting basal insulin?

A

Glargine/Lantus

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44
Q

Remixed insulin?

A

30/70 or Humulin (30/70)

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45
Q

Advantage of long-acting basal insulin?

A

Duration is 20-24 hours, which means that the patient will only require 1 injection/day and could inject at night –> more convenient

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46
Q

What is to be considered with insulin tx?

A

Its ability to mimic physiological insulin response, and ease of administration

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47
Q

Humalog onset? Peak ? duration?

A

Onset: 10-15 min
Peak:1-2 hr
Duration: 3-5 hr

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48
Q

Humulin-R onset? peak? duration?

A

Onset: 30 mins
Peak: 2-3 hr
DurationL 6.5 hr

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49
Q

Humulin-N onset? peak? duration?

A

Onset: 1-3 hr
Peak: 5-8 hr
Duration: 10-18 hr

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50
Q

Lantus onset? peak? duration?

A

Onset 90 min
Peak: no peak
Duration: 20-24hr

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51
Q

Humulin 30/70 onset? peak? duration?

A

Onset: 30-60 min
Peak: dual
Duration: 10-16 hr

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52
Q

What does conventional Tx consist of?

A

Premixed or fixed insulin plans

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53
Q

Considerations in conventional Tx?

A
  • insulin injections 1-3/day
  • Strict meal plans, CHO and meals should not be skipped
  • PA may lead to hypoglycemia
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54
Q

When in intensive Tx recommended?

A

For better control, more freedom with food intake

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55
Q

Considerations in intensive Tx?

A

-Multiple daily injections (>/=3/day) or continuous insulin infusion via insulin pumps

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56
Q

What does intensive Tx consist of?

A

Basal insulin combined with bolus injections of rapid insulin before meals will mimic normal physiology

57
Q

Pros of intensive Tx?

A
  • More flexible in timing/content of meals can adjust insulin)
  • Delays onset and slows progression of complications
  • Will improve quality of life
  • Can adjust to execise
58
Q

Cons of intensive Tx?

A
  • Must learn carb counting
  • SMBG frequent
  • Requires more injections/day and calculations
  • Must be educated and functionally independent
59
Q

How will intensive Tx reduce progression and complications of DM over 10 years?

A

Stuies show that A1C will reduce to normal levels (<7%) and stay consistent over 10 years

60
Q

How will intensive Tx reduce progression and complications of DM over 20 years?

A

Reduced the risk of non-fatal MI, stroke or death from CVD (recall that heart disease = +++ risk in diabetics)

61
Q

Name 5 ways insulin could be delivered

A
  • Syringe
  • Pen
  • Insulin pump
  • Continuous glucose sensor
  • Glucose sensor (Wifi_
62
Q

Insulin delivery with syringe?

A

Pt can fill syringe w/ amount of insulin, then perform subcutaneous injection

63
Q

Insulin deliver w/ pen?

A

Can “scroll”to adjust amount of insulin, delivered with quick prick and less pain

64
Q

Insulin delivery w/ insulin pump?

A

Installed w/ needle, into skin and must be changed every 2-3 wks – can control release of bolus and basal insulin with NO injections

65
Q

Insulin delivery w/ continuous glucose sensor?

A

Will read BG and adjust insulin accordingly, where the pt will then self-administer the insulin (not automatic)

66
Q

Why no automatic glucose injections?

A

Liabilities, but do exist

67
Q

Explain the advantage of CONTINOUS glucose monitoring

A

If we only monitor at random times during the days, we could miss major episodes of hypo and/or hyperglycemia, and could have the false impression that our BG is normal

68
Q

What is used in the management of T1DM? T2DM?

A

T1: Intensive/conventional Tx
T2: Antihyperglycemic agents

69
Q

First-line medication T2DM?

A

Metformin (glucophage), a biguanide

70
Q

Mechanism of metformin?

A

Two actions: Liver and periphery

  • Decr. gluconeogenesis and increase haptic glucose uptake
  • Incr. insulin sensitivity and glucose uptake
71
Q

Safety of metformin?

A

Common, no hypoG, help w/ weight control

72
Q

Side effects of metformin?

A

GI, transient.

May limit satiety, could help w/ weight loss of 5% and increase insulin sensitivity, B12 deficiency

73
Q

What should be monitored annually for patients on metformin?

A

B12 and folate levels

74
Q

Contraindications to metformin?

A
  • renal insufficiency

- liver or heart failure

75
Q

Name the 4 classes of anti-hyperG agents (AI-IT)

A

a-glucosidase inhibitors
insulin secretogogues
incretin mimetics
thiazolidinediones

76
Q

a-glucosidase inhibtor examples?

A

Acobase/Glucobay

77
Q

insulin secretogogues examples?

A
  • Meglitinide/Repaglinide/Prandin

- Sulfonylurea/Glyburide/Diabteta

78
Q

Action of a-glucosidase inhibitors?

A

(Pill) operates in the intestine to delay intestinal glucose absorption

79
Q

Recommendation for a-glucosidase?

A

Take with meals to maximize the interaction between acarbose and glucose

80
Q

Action of Insulin Sectretogogues ?

A

Will stimulate the secretion of insulin, short or long-action

81
Q

Recommendations for Insulin Sectretogogues ?

A

May pose risk of hyoglycemia, but not as much as pure insulin injections

82
Q

Action of insulin mimetics?

A

Stimulate insulin release an reduce glucagon secretion, play on GLP-1 and delay gastric emptying

83
Q

Action of TZDs?

A

Increase insulin sensitivity in peripheral tissues and liver (HAM)

84
Q

Examples of incretin mimetics?

A

DPP-4 inhibitors or GLP-1 receptor agonists

85
Q

Action of DPP-4 inhibitor (incretin mimetic)

A

Usually, GLP-1 will be degraded by the DPP-4 enzyme. DPP-4 inhibitor will block these actions, thus promoting the survival of GLP-1

86
Q

Action of GLP-1? (Gut-peptide)

A
  • Stimulate insulin release
  • Inhibit glucagon release
  • Slow gastric emptying
  • Increase satiety
87
Q

Which anti hyperG medications may induce 5% weight loss which can improve insulin sensitivity?

A

Incretin mimetics and metformin

88
Q

Action of GLP-1R agonist? (Incretin mimetic)

A

Enhance actions of GLP-1

89
Q

How does GLP-1 lower blood glucose?

A
  • Stimulate insulin release
  • Inhibit glucagon release
  • Slow gastric emptying
90
Q

How does GLP-1 allow for better weight control?

A

Increasing satiety

91
Q

Mechanism of SGLT-2 inhibitors?

A

Will block glucose transport on the proximal renal tubule, promoting glycosuria which will lower blood pressure

92
Q

How does SGLT2 also act to control HTN?

A

Osmotic action will cause the loss of water, as well as the loss of sodium alongside glucose

93
Q

When ___ is added to metformin, there is better efficacy on lowering A1C

A

SGLT2

94
Q

Advantages of SGLT2?

A

Rare hypoG, lower BP, raise HDL

95
Q

Contraindications of SGLT2?

A

Renal failure, loop diuretics, T1DM

96
Q

Side effects of SGLT2?

A

Risk of UTI, infections, hypotension, diabetic ketoacidosis, elevate LDL transiently

97
Q

SGLT2 and CVD risk?

A

Reduce, HTN

98
Q

What is always the foundation of treatment? What may be added based on A1C?

A

Lifestyle and behaviour interventions, metformin

99
Q

If A1C <1.5% below target?

A

Continue lifestyle, then add metformin if target not reached

100
Q

If A1C >1.5% above target?

A

Immediate metformin, and consider adding 2nd anti-hyperG

101
Q

If symptomatic hyperG and/or metabolic decompensation?

A

Initiate insulin immediately with or without metformin

102
Q

All targets are evaluated every ____ months, where the decision regarding treatment of further unmet glycemic targets will be based on ____

A

3

Clinical CVD

103
Q

Presence of clinical CVD and glycemic targets not met?

A

Recommend starting additional anti hyperG w/ CVD benefits

104
Q

Anti-hyperGs with CVD benefit? (CLE)

A
  • Canagliflozin
  • Liraglutide
  • Empagliflozin
105
Q

NO presence of CVD but glycemic targets not met?

A

Recommend starting additional anti hyperG that considers the individuals clinical considerations

106
Q

Anti hyperG agents recommended for those with no CVD but unmet targets?

A

Incretin mimetics

SGLT2 inhibitors

107
Q

Clinical considerations for those with no CVD but un-met targets?

A
  • Avoidance of hypoglycemia, weight-gain
  • Reduced kidney function
  • CVD risk factors
  • Degree of hyperG
  • Patient preference
108
Q

Essentially, what is the goal of anti hyperG medications?

A

Lower A1c

109
Q

What is the best therapy to reduce hyperG?

A

Insulin, but may cause weight gain

110
Q

Difference between insulin from our own pancreas and insulin secretions? how does this impact weight gain?

A

Insulin from our pancreas will be released directly into portal vein, and we will need less of it to accomplish its function. Injected insulin (from subcutaneous) must pass through periphery and exert it actions, thus we require more exogenous insulin to reach the same effects on BG where we know more insulin leads to more weight gain.

111
Q

Bottom line on endogenous vs. exogenous insulin and weight gain?

A

MORE exogenous insulin must be injected to reach the same response, where this excess amount of insulin may lead to weight gain and pose a risk of hypoglycemia

112
Q

Anti hyperG w/ reduced CVD outcomes?

A

GLP-IR

SGLT2

113
Q

Anti hyperG w/ neutral CVD outcomes?

A

DPP-4 inhibitors
Insulin
TZDs

114
Q

Anti hyperG w/ rare incidence of hypoG? ( GSD-TAW)

A 
GLP-1R
SGLT2
DPP-4 inhibitors
TZDs
a-glucosidase inhibitor
Weight loss agent (orlistat)
115
Q

Anti hyperG w/ risk of hypoG?(II)

A 
Insulin
Insulin secretagogues (meglitinide, sulfonylurea)
116
Q

Anti hyperG w/ moderate decrease in weight?

A

GLP-1R

SGLT2

117
Q

Anti hyperG w/ mild decrease in weight?

A

Weight loss agent (orlistat)

118
Q

Anti hyperG w/ mild increase in weight?

A

Insulin secretagogues (meglitinide, sulfonylurea)

119
Q

Anti hyperG w/ moderate increase in weight?

A

Insulin, TZDs

120
Q

Anti hyper G w/ neutral weight gain?

A

DPP-4 inhibitors

a-glucosidase inhibitors

121
Q

Most effective anti hyperG in lowering A1C when added w/ metformin?

A

Insulin

122
Q

Highly effective anti hyperG in lowering A1C when added w/ metformin?

A

GLP-1R

SGLT2

123
Q

Moderate effective antihyperG in lowering A1C when added w/ metformin?

A

DPP-4 inhibitors
TZDs
Insulin secretagogues

124
Q

Mildly effective antihyperG in lowering A1C when added w/ metformin?

A

a-glucosidase inhibitor

Weight loss agent (orlisat)

125
Q

Drug-nutrient interaction w/ biguanides? Metformin)

A

Reduce folate and B12 absorption, take w/ meals

126
Q

Drug-nutrient interaction w/ a-glucosidase inhibitors?

A

take w/ first bite of meal, limit alcohol

127
Q

Drug-nutrient interaction w/ insulin secretagogues?

A

Avoid alcohol, as alcohol can mask symptoms of hypoG (recall that IS can induce hypoG)

128
Q

Drug-nutrient interaction w/ incretin mimetics?

A

Caution w/ alcohol (side effects - do not cause hypoG) , GI side effects, heartburn

129
Q

Drug-nutrient interaction w/ TZDs?

A

None

130
Q

Pharmacotherapy for HTN in patients w/ diabetes WITH CKD or CVD?

A

ACE inhibitor or ARB

131
Q

Pharmacotherapy for HTN in patients w/ diabetes WITHOUT CKD or CVD?

A

ACE inhibitor or ARB OR
DHP-CCB OR
Thiazide diuretic

132
Q

What should be checked 1-2 weeks after initiation of ACEi or ARB?

A

Serum K+ and creatinine at baseline

133
Q

(T/F) Combinations of agents that block the AAS should be used

A

False

134
Q

How should most people w/ diabetes be treated in initial management? Later on?

A

Standard-dose monotherapy, but more than 3 drugs may be needed to reach target values for those w/ diabetes

135
Q

(T/F) Diabetic pts must present with high LDL to be put on statin

A

False, do not need to present with high LDL as CVD risk already so high

136
Q

Diabetic person with CVD disease and greater than 40 - statin?

A

Yes

137
Q

Diabetic with DM >15 years, and >30 y/o - statin?

A

Yes

138
Q

Contraindications to statin therapy?

A

Women of childbearing potential

Clinical Nutrition 1 (30 decks)

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