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Endocrine 1 > Quiz #2 > Flashcards

Quiz #2 Flashcards

Oral agents Injectibles Tx of T1DM Chronic complications of DM

1
Q

<p>What is the expected clinical effect of the GLP-1 agonists on blood glucose control</p>

A

<p>about 1% (0.9% to be exact)</p>

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2
Q

<p>Contraindications to GLP-1 agonists</p>

A

<p>- Type 1 DM

- Ketoacidosis
- Severe GI dz
- Hx of pancreatitis </p>

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3
Q

<p>Additional contraindication to Byetta (GLP-1)</p>

A

<p>ESRD or severe renal impairment (CrCl <30 ml/min)</p>

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4
Q

<p>Additional contraindication to Victoza (GLP-1)</p>

A

<p>Hx or fam hx of medullary thyroid cancer (MTC) or hx of multiple endocrine neoplasia syndrome type 2 (MEN 2)</p>

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5
Q

<p>GLP-1 Agonist

| - MoA</p>

A

<p>- Incretin analogue

- Activate GLP receptors on the cell surface of beta cells → insulin release in the presense of elevated blood glucose
- Decreases glucagon secretion in a glucose-dependent manner
- Lowers blood glucose by delaying gastric emptying</p>

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6
Q

<p>GLP-1 Agonist

| - ADR (5)</p>

A

<p>1. (MC) mild to moderate dose-dependent nausea
• frequency and severity decrease over time with continued use
2. HA
3. Diarrhea
4. Hemorrhage and necrotizing pancreatitis
• Early in therapy (w/in 4-6 weeks)
• Rare
5. Serious hypoglycemia
• Seen when use in combo with secretagogue (sulfonylurea or meglitinide)</p>

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7
Q

<p>Novolog

- speed of onset
- bolus or basal</p>

A

<p>- rapid acting

| - bolus</p>

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8
Q

<p>Humalog

- speed of onset
- bolus or basal</p>

A

<p>- rapid acting

| - bolus</p>

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9
Q

<p>Apidra

- speed of onset
- bolus or basal</p>

A

<p>- rapid acting

| - bolus</p>

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10
Q

<p>Lantus

- speed of onset
- bolus or basal</p>

A

<p>- long acting

| - basal</p>

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11
Q

<p>Levemir

- speed of onset
- bolus or basal</p>

A

<p>- long acting

| - basal</p>

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12
Q

<p>Regular

- name the two
- speed of onset
- bolus or basal</p>

A

<p>- Humulin R and Novolin R

- short acting
- bolus</p>

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13
Q

NPH

  • name the two
  • speed of onset
  • bolus or basal
A
  • Humulin N and Novolin N
  • intermediate acting
  • basal
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14
Q

<p>Which insulins are used as bolus</p>

A

<p>- Fiasp

- Humalog
- Novolog
- Apidra
- Regular</p>

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15
Q

<p>When should inject rapid acting insulin?</p>

A

<p>15 min before meal</p>

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16
Q

<p>When should inject short acting insulin?</p>

A

<p>30 min before meal</p>

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17
Q

<p>Which insulins are used as basal</p>

A

<p>- NPH

- Lantus
- Levemir
- Toujeo
- Basaglar
- Tresiba</p>

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18
Q

<p>What is the key to successful basal insulin injections?</p>

A

<p>inject at the same time every day without regard to meals</p>

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19
Q

<p>What does U-100, U-200, U-300 mean?</p>

A

<p>- U is the number of units of insulin per milliliter of fluid

- Ex: U-100 means there are 100 units of insulin per mL of fluid
- All vials are 10 mL (1,000 units of insulin per vial)</p>

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20
Q

<p>Choose the appropriate starting dose and monitoring parameters for a patient with T2DM starting insulin</p>

A

<p>- Start with 10 U of bedtime basal insulin (Lantus, Levemir, NPH)
- Monitor fasting am and pre-prandial glucose

Also:

- If A1C goal is not met within 2-3 months add bolus insulin
- Use A1C and pre-meal monitoring to guide
- If hypoglycemia occurs, reduce dose by 10%</p>

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21
Q

How to initiate a bolus insulin dose in a patient who is already using basal insulin

A
  • Add a rapid acting insulin for post-prandial control
  • Start with the time of day blood sugar is highest
  • Start with 4 Units, 0.1 U/kg, or 10% of basal dose (Letassy says 5-10 units is fine)
  • Adjust dose by 1-2 U or 10-15% once or twice weekly until reach target glucose levels
  • Dosing is best based on CHO counting
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22
Q

<p>Given a pt at risk for DM, select the medication to reduce or prevent progression to DM based on the outcomes of the prevention studies</p>

A

<p>metformin</p>

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23
Q

<p>State the outcomes of the DCCT on the development or progression of microvascular diabetes complications</p>

A

<p>-this study proved normalizing blood glucose could prevent or delay progression of diabetic complications

- in the primary prevention group:
- 76% RRR in the development of retinopathy
- 34% reduction in nephropathy
- 60% reduction in neuropathy
- secondary prevention group:
- 54% RRR in retinopathy
- 43% reduction in nephropathy </p>

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24
Q

<p>glycemic goals of therapy for a nonpregnant adult with T2DM

- a1c
- preprandial blood glucose</p>

A

<p>-A1c: <7%

| -BG: 80-130 </p>

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25
Q

<p>What are patient risk factors for the development of prediabetes/diabetes </p>

A
  • impaired fasting glucose
  • impaired glucose tolerance test
  • A1c > 5.7-6.4%
  • BMI > 30
  • < 60 yo
  • women w/ hx of gestational DM
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26
Q

<p>Place in therapy for metformin in the tx of T2D</p>

A

<p>if lifestyle changes fail to achieve glycemic goals and A1c is <7.5% then metformin is the drug of choice </p>

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27
Q

<p>expected clinical effect of metformin on the patient's blood glucose control </p>

A

<p>-lowers fasting plasma glucose concentrations by about 55 mg/dl

- reduces A1c by 1-2%
- no hypoglycemia
- no weight gain </p>

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28
Q

<p>contraindications to metformin</p>

A

<p>-renal function

- unstable CHF
- liver dz
- alcohol abuse
- pregnancy/lactation </p>

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29
Q

<p>renal function guidelines for metformin use</p>

A

<p>-DO NOT use in CKD stages 4 and 5

- do not initiate therapy at stage 3B but may continue use at 1000mg max dose
- avoid initiating therapy at stage 3A if expected to become unstable but may continue use at 2000mg max
- CKD stages 1 and 2: max dose 2550 mg </p>

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30
Q

<p>initial dose of metformin</p>

A

<p>500 mg once or twice daily (Letassy said she starts w/ once daily) </p>

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31
Q

<p>titration dose of metformin</p>

A

<p>-start at 500 mg daily

- dose should be increased at the rate of 1 tab weekly
- up to a max dose of 2500 mg per day

*her example:
500mg daily x 1 week; increase to 500 mg BID x 1 month; then add 500 mg where needed </p>

32
Q

<p>ADRs of metformin</p>

A

<p>GI are MC

- early satiety and anorexia
- nausea w/ or w/o vomiting, anorexia, diarrhea, bloating, and abdominal discomfort</p>

33
Q

<p>what needs to be monitored when taking metformin? </p>

A

<p>-B12 concentrations

| -some pts may beed replacement </p>

34
Q

<p>what is the expected clinical effect of the sulfonylureas and meglitinides on the pts BG control? </p>

A

<p>-fasting BG to drop 60-70 mg/dl
-A1c reduction of 1-2%
</p>

35
Q

<p>what is the expected clinical effect of pioglitozone on the pts BG control? </p>

A

<p>-average decrease in A1c is 1.5% (in pts w/ a baseline of 9%) and is seen after 12-14 weeks
-average decrease in A1c when added to another agent: 0.8-1.3%

(the numbers don't agree with this but the pack says it's more effected when used in combo) </p>

36
Q

<p>what is the expected clinical effect of the DPP-4 inhibitors on the pts BG control? </p>

A

<p>0.6-0.8% drop in A1c</p>

37
Q

<p>what is the expected clinical effect of the SGLT2 inhibitors on the pts BG control? </p>

A

<p>-A1c decrease of about 1%

| -some weight loss d/t increased excretion of glucose </p>

38
Q

<p>risk factors for euglycemia DKA d/t SGLT2 inhibitors</p>

A

<p>-major illness

- reduced fluid and food intake
- reduced insulin dose
- type 2 DM

**the packet doesn't specifically state the risk factors, this is just what I interpreted them as </p>

39
Q

<p>given a child w/ T2D, select the most appropriate therapy</p>

A

<p>1. Insulin therapy indications:

- ketosis or DKA
- unclear if T1 or T2
- unusual cases like a random BG >250 or A1c >9%

* all other cases:
1. lifestyle changes: nutrition interventions and physical activity
2. metformin
- confirm T2
- start low (500mg) d/t GI side effects
- monitor for glycemic deterioration
- add insulin if needed
3. test A1c every 3 months
- target = <7%
- intensify tx if needed </p>

40
Q

<p>consequences of absolute or relative lack of insulin on the liver </p>

A

<p>-glycogenolysis occurs to release glucose into the blood

- amino acids are released from the muscle and taken up by the liver to produce new glucose
- lipolysis occurs and releases free fatty acids into the blood which are taken up by the liver to produce ketones
- glycerol is released from adipose and can be taken up by the liver for gluconeogenesis </p>

41
Q

<p>consequences of absolute or relative lack of insulin on the muscle</p>

A

<p>-protein breakdown occurs as well as decreased amino acid uptake by muscle

- protein breakdown occurs at a higher rate than protein synthesis and therefore there is a net loss of protein
- possible decreased muscle mass </p>

42
Q

<p>consequences of absolute or relative lack of insulin on the adipose tissue</p>

A

<p>-lipoprotein lipase doesn't work well in the absence of insulin

- leads to increased lipolysis and decrease in triglyceride synthesis
- net result: weight loss and decreased fat stores
- liver converts free fatty acids to ketones which can lead to ketoacidosis </p>

43
Q

Which insulin types are insulin analogues?

A
  • Novolog
  • Humalog
  • Apidra
  • Lantus
  • Levemir
44
Q

Given a patient with newly diagnosed type 1 diabetes:

-Explain the concept of intensive insulin therapy

A

Intensive insulin therapy tries to achieve a more physiologic replacement of insulin by giving long acting insulin that provides basal insulin and by giving a rapid acting or short acting insulin before meals to provide a bolus of insulin.

45
Q

Given a patient with newly diagnosed type 1 diabetes:
-Select the best basal/bolus insulin regimen for that person (include the amounts provided by basal and bolus insulin—percent breakdown)

A

50 to 70% of the total daily dose should be a basal insulin
-Basal insulins are glargine (Lantus®), detemir (Levemir®) and NPH

30 to 50% of the total daily dose should be given in divided doses before a meal with rapid-acting or short-acting insulin (bolus)
-Bolus or Preprandial insulins are Novolog®, Humalog®, Apidra®

46
Q

Given a patient with newly diagnosed type 1 diabetes:

-Explain the rule of 500 and how to use it to establish an insulin:carb ratio

A

•Establishing insulin to carbohydrate ratios for each meal

  • Insulin:Carb ratios will vary throughout the day
  • Rule of 500 is the carbohydrate coverage ratio
  • 500 ÷ Total Daily Insulin Dose = 1-unit insulin covers so many grams of carbohydrate
47
Q

Given a patient with newly diagnosed type 1 diabetes:

-Explain how the rule of 1800 is used to determine an insulin sensitivity factor

A
  • use the “1800 rule” to calculate insulin sensitivity factor for people who use the rapid-acting insulin analogs lispro (brand name Humalog), aspart (NovoLog), and glulisine (Apidra)
  • this is done by dividing 1800 by the total daily dose (TDD) of rapid-acting insulin
  • if the total daily insulin dose is 40 units, the insulin sensitivity factor would be 1800 divided by 40 = 45
48
Q

Given a patient with newly diagnosed type 1 diabetes:

-Explain how an insulin correction dose is used

A
  • An insulin sensitivity factor is used to determine an insulin correction factor
  • Insulin Correction factors are used to correct or adjust the premeal bolus insulin dose in order to cover the carbohydrate content in a meal plus “correct” a higher than desired blood preprandial blood glucose
49
Q

Given a patient experiencing a hypoglycemic reaction:

-Identify common reasons for hypoglycemia

A

When the patient..

  • skips a meal
  • delays a meal
  • eats less at a meal than usual and does not adjust insulin
  • increases their activity
  • commits a dosage error
50
Q

Given a patient experiencing a hypoglycemic reaction:

-Identify symptoms commonly associated with hypoglycemia

A
  • Headache
  • Shaking
  • Sweating
  • Feeling tired
  • Weakness
  • Hunger
  • *Rapid onset
51
Q

Determine the severity of the hypoglycemia

-Mild hypoglycemia

A
  • Usually manifested as adrenergic symptoms (mediated by epinephrine).
  • These symptoms are anxiety, sweating, tremulousness, tachycardia, hunger.
  • Clinically significant hypoglycemia is defined as a glucose <54 mg/dL.
52
Q

Determine the severity of the hypoglycemia

-Moderate hypoglycemia

A
  • Includes adrenergic symptoms plus neuroglycopenic symptoms including headache, mood change, irritability, confused thinking, and slurred speech.
  • These reactions are usually longer lasting, and the patients usually require assistance in obtaining a glucose source.
  • A second dose of 10 to 15 grams of a simple sugar is usually required.
53
Q

Determine the severity of the hypoglycemia

-Severe hypoglycemia

A
  • Characterized by unresponsiveness, unconsciousness or convulsions.
  • These reactions require emergency care with an intravenous dextrose or IM glucagon injection.
54
Q

Given a patient experiencing a hypoglycemic reaction:

-Determine the appropriate course of treatment and monitoring to bring blood glucose back to normal.

A
  • For severe hypoglycemic reactions in children and adults - use GlucaGen Hypokit (glucagon injection)
  • Use food sources that provide 10 gm of carbohydrate (apple juice, orange juice, sugar, lifesavers, B/D glucose tablets)
  • Use commercial products (Instant glucose, Dex4, cake frosting gel, monojel)
  • To stabilize blood glucose and decrease risk of hypoglycemia use Extendbar and NiteBite
55
Q

Given a patient experiencing a hypoglycemic reaction:

-Select the most likely cause of their hypoglycemia.

A

Medical causes:

  • Altered kidney or liver function
  • Hormonal deficiencies (e.g., pituitary or adrenal)
  • Rapid gastric emptying
  • Hypoglycemic unawareness: MC
56
Q

Given a patient experiencing a hypoglycemic reaction:

-Explain the rule of 15

A

Check blood sugar –> eat 15 gm of carbs –> wait 15 min –> blood glucose will go up.

57
Q

Identify the glycemic goals for children.

A
  • A1c goal of < 7.5%
  • 90 to 130 mg/dL before meals
  • 90 to 150 mg/dL bedtime and overnight
58
Q

Identify the screening for other autoimmune diseases in people with T1DM.
-Thyroid disease

A

Test for antithyroid peroxidase (ANTI-TPO) and antithyroglobulin (ANTI-TG) antibodies soon after the diagnosis
•Measure TSH soon after diagnosis
•If values are normal, consider rechecking every 1-2 years or sooner if symptoms occur.

59
Q

Identify the screening for other autoimmune diseases in people with T1DM.
-Celiac disease

A

Consider screening for celiac disease by measuring either tissue transglutaminase or deamidated gliadin antibodies with normal total serum IgA levels.
•Consider screening in children who have a first degree relative with celiac disease, growth failure or failure to gain weight, weight loss, signs of malabsorption, unexplained hypoglycemia or a loss of glycemic control.
•Children with biopsy-confirmed celiac disease should be placed on a gluten-free diet and consult with dietician to help manage both diabetes and celiac disease.

60
Q

Identify the screening for other autoimmune diseases in people with T1DM.
-In children

A

**hypothyroidism.
•Screen for thyroid peroxidase (TPO) and thyroglobulin antibodies at diagnosis.
•Monitor TSH after metabolic control is established.

61
Q

Given a patient with diabetes, identify the symptoms consistent with hyperglycemia.

A
  • Increased thirst that is not normal
  • Increased need to urinate especially at night
  • Unintended weight loss
  • Repeated vaginal yeast infections (2-3 or more in a 6-month period) or yeast/fungal infections on other parts of the body (otitis externa or in body folds)
  • Fatigue
  • Repeated urinary tract infections
  • Sores that do not heal
  • Erectile dysfunction in men
  • Blurred vision
62
Q

Given a patient with diabetes, select the diagnostic modality.

A
  • Fasting plasma glucose (FPG) (this one is commonly done) OR
  • 2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT) (this one is not commonly done) OR
  • A1c criteria (this one is commonly done in conjunction with FPG)
63
Q

Select the diagnostic criteria (fasting blood glucose, A1c) for prediabetes.

A
  • IFG (impaired fasting glucose) –fasting blood glucose > 100 mg/dl and <125 mg/dl OR
  • IGT (impaired glucose tolerance) –2-hour plasma glucose 140 to 199 mg/dl OR
  • A1c 5.7% to 6.4%
64
Q

Select the diagnostic criteria (fasting blood glucose, A1c,) for diabetes.

A
  • A1c > 6.5% OR
  • Fasting plasma glucose > 126 mg/dl (fasting—no caloric intake for 8 hrs) OR
  • A random (without regard to last food intake) plasma glucose level of >200 mg/dL plus clinical signs and symptoms of diabetes (polyuria, polyphagia, polydipsia, fatigue, weight loss or blurred vision and persistent hyperglycemia).
65
Q

What is the renal threshold for glucose

A

180 mg/dL of glucose

- after this, glucose spills into urin

66
Q

what’s the normal range for serum sodium?

A

135-145 mEq/L

67
Q

What is the effect of DKA on serum sodium

A
  • Hyponatremic

* Osmotic changes pull water out of cells, reducing plasma Na concentration

68
Q

What is the effect of DKA on serum potassium

A
  • DKA causes a potassium deficit, average 300-600 mEq.
  • Factors that cause hypokalemia:
    • Urinary losses
    • Glucose osmotic diuresis
    • Excretion of potassium ketoacid anion salts
69
Q

Presentations of potassium when in DKA

A
  • Hyperkalemic: shift of K out of cells but hasn’t been peed out yet
  • Eukalemic: shift of K out of the cells but have peed enough out that the serum concentration appears normal. Person has lost sig amts of K
  • Hypokalemic: shift of K out of the cell and have peed it out, this is worst case scenario
70
Q

What is the effect of DKA on serum phosphate

A
  • Hypophosphatemia
  • Causes
    • Decreased intake
    • Acidosis-related shift into ECF
    • Phosphaturia dt osmotic diuresis
  • Same as potassium, might present early with hyperphosphatemia or euphosphatemia
71
Q

What is the effect of DKA on serum creatinine

A
  • Acute elevations in serum Cr (and BUN)

* Reflects reduction in glomerular filtration dt hypovolemia

72
Q

What is the effect of DKA on plasma osmolality

A
  • Increased dt elevations in glucose

* Plasma osmolality = sodium + glucose + BUN (not full equation)

73
Q

What is the effect of DKA on WBC count

A

Generally slightly elevated 12,000-13,000 (4,000-11,000 nl)

74
Q

What is the effect of DKA on lipids

A

elevated TG

75
Q

Given a blood glucose and a serum Na, determine the corrected sodium value

A
  • Serum Na concentration will fall approx. 1.6 mEq/L (2) for every 100 mg/100mL increase in glucose concentration

Ex: If blood sugar is 550 and measured serum Na is 130
• 550-100 = 450, the amount of sugar above normal
• 450/100 = 4.5, conversion based on ratio
• (4.5)(2) = 9, amount serum Na is under reported
• 130 + 9 = actual serum sodium level

Endocrine 1 (18 decks)

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