Seizures, Eye, Diabetes Flashcards
which two agents have most benefits in CV outcomes for diabetes
empagliflozin and liraglutide
name DPP4 inhibitors- which do you use with caution in HF
saxagliptan (caution HF), sitagliptan, alogliptan
which diabetic agents cause hypoglycemia most
SUs, meglitinide (insulin secretagogue) insulin
name short acting insulins
aspart, glulisine, lispro
what renal fx is metformin CI? cautioned?
caution 60, CI less than 30
who are thiazoledinediones CI in?
heart failure
what is type 1 diabetes
deficiency of insulin due to autoimmune beta cell destruction
what is type 2 diabetes
insulin resistance with some degree of deficiency
what to start with diagnosis of type 2 diabetes
-A1C less than 8.5- lifestyle, metformin if not controlled in 2-3 months. If greater, start metformin right away and often need combination therapy
how many SMBG should be done per day for those on basal-bolus insulin (insulin more than once per day)
minimum 3x- mix of both pre and post prandial
SMBG in patients on oral therapy- with or without insulin
individualize based on risk of hypo, dosage changes or evaluation of new agents, concurrent illness. Infrequent is okay if achieving targets and not on agents that induce hypo. When not meeting targets, do some pre and post, individualized. If on oral and once daily insulin- test at least once daily at different times
how much activity is recommended in diabetes
greater than or equal to 150 minutes per week- exercise increases insulin sensitivity so adjust insulin accordingly (moderate exercise will likely decrease, but a stress response with intense exercise may increase blood glucose)
monitoring for people with diabetes
BP at all appropriate visits, foot exams yearly, A1C q3m, SCr and urine ACR yearly, eye exam q1-2 years,
which insulin regimen is inappropriate in type 1 diabetes
conventional
when around a meal do you give regular and rapid acting insulins
regular- 20-30 minutes before meal. rapid- shortly before or within 20 minutes of starting a meal
symptoms of mild-mod hypoglycemia- how to treat
sweating, tremors, tachycardia, hunger, N, weakness. Give 15g glucose- will raise BG about 2mmol within 20 minutes. Retest in 15, and if still below 4mmol/L, give another 15
symptoms of severe hypoglycemia- how to treat
neuroglycopenic sx like confusion, difficulty speaking, uncounsious, etc. Give 20g carbs/glucose, retest in 15 minutes, if still below 4 mmol/L give another 20
what is localized fat hypertrophy
result of frequent use of same injection site resulting in low or unpredictable absorption of insulin from that site
when should you aim to reach target a1c in newly diagnosed diabetes patients
3-6 months
MOA of SU and meglitinides
insulin secretagogues- squeeze pancreas to release more insulin
MOA of metformin and thiazolidinediones
decrease hepatic glucose production (shut off leaky liver) and increase tissue sensitivity to insulin
MOA of DPP4 inhibitors and GLP1 agonists
mimic or enhance incretin hormones. DPP4 augments the action on GLP1 by preventing its breakdown, while glp1 agonists increase insulin, suppress glucagon, and increase satiety by slowing gastric emptying
MOA acarbose
delay or prevents digestion of complex carbs
which antidiabetics are associated with weight gain?
SUs/insulin secretagogues, insulin, TZDs
which antidiabetics are associated with weight loss?
glp1 agonists, and modest with SGLT2 inhbitors. -almost all are weight neutral. Weight gain ones are SU/insulin secretagogues, insulin, TZDs
strongest evidence for antidiabetic agent with reducing mortality and macrovascular endpoints
metformin
SU with most risk of hypoglycemia
glyburide -also associated with most weight gain
which diabetic medications should be skipped if you skip a meal
meglitinides- repaglinide, etc- take them just prior to meal
TZD MOA in diabetes
PPAR gamma agonists- influence gene expression in cell leading ot enhaned insulin sensitivity and lower levels of blood glucose and circulating insulin
which antidiabetic meds are CI in bladder cancer (current or past)
pioglitazone, dapigliflozin
which groups of antidiabetic meds are associated with rare risk of pancreatitis
GLP1agonists and DPP4 inhibitors
diabetes meds CI in those with hx or fam hx of medullary thyroid cancer or multiple endocrine neoplasia syndrome
GLP1agonists
which antidiabetic agents have potential for hypotension
sglt2 inhibitors
which antidiabetic meds have rare SE of diabetic ketoacidosis-what are sx?
sglt2 inhibitors -N/V, abdominal pain, fruity acetone breath, decreased LOC, seizure, stroke
appropriate empiric dose of basal insulin HS for type 2 needing to start insulin
5-10 units HS. Or 0.1-0.2Ukg
target A1C is ___; this is based on benefit seen in
less than or equal to 7. reduced microvascular and neuropathic complications. less than or equal to 6.5 may be suggested if benefits thought to outweigh risks of hypogly (prevent nephro and retinopathy). A1C target up to 8.5% may be suggested in frail elderly, limited life expectancy or recurrent hypogly
target for FPG or preprandial
4-7 mmol/L
target for 2 hour PPG
5-10, or 5-8 if a1c goal not met
when might fibrates be useful in cholesterol treatment
TG remain a problem
BP target in diabetes
less than 130/80
folic acid during pregnancy in diabetic patients:
5mg daily at least 3 months prior to conception, continued until 3 months gestation, then reduced to 0.4-1mg daily and continue through preg and a min of 6 months post partum or until breastfeeding is complete
diabetes in pregnancy- drugs
d/c teratogens like ace, arb, statin, and start insulin. Of can’t take insulin, start glyburide or metformin
What is diabetic ketoacidosis
from severe insulin def
SE with metformin
metallic taste, N (take with food), diarrhea
SE with DPP4 inh
nasopharyngitis
SE GLP 1 inh
N, V, D
SE insulin secretagogues
weight gain, hypoglycemia more common,
SE SGLT2 inh
GU infections, hypotension, hyperkalemia (caution with loop diuretics and volume depletion),
when should ketone testing be performed
BG 14 or more, presence of sx of ketoacidosis or when acutely ill and have high BG
major risk factor for AMD
smoking- advise patients to quit and maintain balanced diet
treatment for wet AMD
VEG-F inhibitors- effective for decreasing vision loss. Injected directly into eye.
beta carotene in AREDs formulas
no longer recommended due to increased risk of lung cancer therefore no forms contain it anymore
how long should you wait between different eye drop medications
five minutes
side effects of all eye drops
local irritation, blurred vision temp
prostaglandin eyedrops examples, what they do and common SE
“prosts” lower pressure of eye- brown pigmentation of iris, elongation of eyelashes
only modifiable risk factor for glaucoma
elevated intraocular pressure
drug that can commonly worsen glaucoma
corticosteroids
drugs used to treat open angle glaucoma initially, and then after
beta blocker or prostaglandin analogue first,then add or substitute carbonic anhydrase inhibitor, adrenergic agonist, or whatever hasn’t been used in first line
how do beta blockers work in glaucoma
decrease formation of aqueous humour and therfore pressure. CI in certain pulmonary and cardiac diseases
examples of carbonic anhydrase inibitors and how they work in glaucoma- what line are they and why
dorzolamide, brinzolamide, decrease aqueous humor. Not first line because not as effective to lower IOP, but can be used as adjunct or in patients CI to BB. Bitter or unusual taste on instillation normal
how do prostaglandins work in glaucoma
lower IOP by increasing outflow
cholinergic agonists in glaucoma
pilocarpine- directly stimulate muscarinic receptors to contract muscle and increase outflow. SE= miosis (reduced night vision), spasm, brow ache
combination products in glaucoma
all more effective than either agent on their own, all contain timolol
what products OTC are cautioned in angle closure glaucoma
antihistamines/decongestants- rarely a problem in open angle glaucoma (most common), but can provoke angle closure glaucoma in those predisposed
what is there cross reactivity with for carbonic anhydrase inhibitors
sulfonamides
what happens when vasoconstricting or decongestant eye drops are used too often
rebound hyperemia
first line choice for absense seizures
ethosuximide- not first line or even second for anything else
first line anti seizure for generalized tonic clonic and focal/partial
both: carbamaz, lamotrigine, pheny. Tonic also had valproic/divalproex. Partial also has levitiracetam
avoid these seizure meds in absense
gaba for sure, carba (may worsen absense seizures) and pheny use with caution
avoid these seizure meds in myoclonic
carb (caution), pheny
avoid these seizure meds in pregnancy, and give what
valproic acid/divalproex, in child bearing age females give folic acid at least 1mg daily some say 5mg
general principles in AED therapy
single AED started at fraction of target dose to minimize AE (expect phenytoin and phenobarb), add second if max tolerated dose isn’t satisfactory and gradually withdraw first agent after maintenance dose of 2nd drug has been achieved. Polytherapy reserved for when 2-3 drugs have failed
what suggests impending status epilepticus, and what is SE
SE= over 30 minutes and associated with high morbidity and mortality ie brain injury, if over 5 treat as impending
name enzyme inducing AEDs that are a problem with COC and may lower efficacy. What else may they be a problem with?
carbamazepine, phenobarb, phenytoin, topiramate, primidone. Use barrier method as well in these patients or other methods (IUD, depot etc) but still use barrier. Also problem with other DI- reduce levels of other drugs
AEDS in pregnancy- general principles of choosing therapy
use montherapy if possible, don’t change AEDs as risk of malformation is highest during first tri anyway when may not know preg yet and switching puts at risk of seiures, AED levels may drop due to increased clearance so watch, vitamin K given to all newborns at delivery to prevent hemorrhagic diseases. Breastfeeding? ensure watch levels as they may now increase! all appear okay, but barbituates may sedate baby
name the epilepsy barbituates
primidone and phenobarb
common SE with valproic /divalproex
N, weight gain, tremor, hair loss, blood dyscrasias, hepatotox; cognitive effects less than older AEDs
common carbamaz SE
rash (rarely very serious-steen johnson- skin peels off), transient neutropenia, N, dizzy/drowsy (not as much as others)
lamotrigine AE and DI
rash (can be serious), insomnia. Must have very slow titration. Valproic acid inhibits metabolism, increased met with enzyme inducing AEDs, hormonal contraceptives reduce serum levels of it up to 50%
levetiracetam SE
sleepy, decreased energy, HA, irritable, depression
