The betes Flashcards
Type 1 diabetes vs Type 2 diabetes
1:
-5-10% of adutls (peak age 13/14)
-AI destruction of pancreatic beta cells leading to insulin deficiency
-DKA can be initial presentation
–fast breathing (Kussmaul)
–fruity breath
–HA, NV, tired, dry skin and mouth
2:
-MC, >90% adults
-hyperglycemia due to progressive loss of insulin secretion from beta cell superimposed with insulin resistance
-polyuria, polydipsia, nocturia, blurred vision, weight loss
C peptides to see if type 1 or 2
<0.3-0.6 is type 1
>0.3-0.6 Type 2
American diabetes association criteria for diag
- A1C >= 6.5%
- Fasting BG>= 126 mg/dl
- 2 hour plasma glucose >= 200 mg/dl during an OGTT
Non pharm therapy
- Medical nutrition therapy- carb counting
- Weight loss or maintenance
- Physical activity
- Diabetes self management education and support
Pharm therapy overview of DM
- Sulfonylureas
- Glucosidase inhibitor
- Biguanide
- Thiazolidenedione
- Incretin mimetics- DPP- inhibitors, GLP-1 agonist
- SGLT2 inhibitors
- Alpha-glucosidase inhibitors
Goals of therapy
- Achieve OPTIMAL GLYCEMIC CONTROL- base on age, comorb, pt preference
- Reduce the onset & progression of DIABETES RELATED COMPLICATIONS
- Minimize microvascular complications= NEUROPATHY, RETINOPATHY, NEPHROPATHY
- Aggressively address CV RISK FACTORS= LEAD TO CERTAIN PROTECTIVE MEDS
- improve QUALITY OF LIFE
Biguanides
Metformin- 1ST LINE IN T2DM- reduces A1C by 1.5-2.0%
MOA: Activates AMP kinase -> decreases hepatic glucose production-> partial enhances insulin sensitivity in peripheral tissues= NO DIRECT ACTION ON BETA CELLS
TAKE WITH FOOD
SE: GI- n/v/d
RARE: LACTIC ACIDOSIS IN SEVERE ILLNESS
DONT USE IN GFR <30 OR VITAMIN B12 DEFICIENCY
Sulfonylureas
2nd mc prescribed- 1.5-2.0% decrease
NOT FOOD DEPENDENT
1st gen: low potency, high ae
-chlorpropamide, tolazamide, tolbutamide
2nd gen: GLYBURIDE, GLIPIZIDE, GLIMEPIRIDE
MOA: enhances insulin secretion by binding to specific sulfonylurea receptor (SURI) ON BETA CELLS + NOT FOOD DEPENDENT= membrane voltage channel-> insulin release= IMMED RELEASE OF INSULIN REGARDLESS OF GLUCOSE
SE: HYPOGLYCEMIA and weight gain
Thiazolidinediones
2/3rd line: Pioglitazone and Rosiglitazone - 1-1.5%
MOA: bind to peroxisome proliferator activator receptor gamma (PPAR-gamma)= enhances insulin sens @ muscle, live, and fat tissues= glucose and lipid metabolism
MAY TAKE 3-4 MONTHS TO SEE EFFECT
AE: edema, NEW OR WORSENING HEART FAILURE, weight gain, bone fractures, and bladder cancer- BC WORKS IN PERIPHERY
Glucagon-Like Peptide-1 Receptor Agonists
Ozempic, Trulicity, Wegouy, Mounjaro= SQ
3-6 hours= Short acting around food
10-12 hours= long acting without food
MOA: mimics action of GLP-1 stimulate insulin secretion from the Beta cells in glucose dependent manner works on
1. Pancreas- increase insulin release and decrease glucagon
2. Hypothalamus- decrease appetite (CROSSES BBB)
3. Stomach- slow gastric emptying
not 1st line=Combo or monotherapy-> EXCEPT W/ DPP-4 bc work in same sense
AE: NVD, injxn sit rxn
RARE: ACUTE PANCREATITIS, HIGER RISK CARCINOMA AND MEN TYPE 2
PE: injection instructions- thigh/abdomen, rotate sites
Dipeptidyl Peptidase-4 inhibitors
2nd/3rd line: Sitagliptin, saxagliptin, linagliptin, alogliptin- 0.5-1.0%
MOA: inhibit DPP-4 enzyme responsible for degradation of GLP-1 and GIP (gastric inhibitory polypeptide)
AE: stuffy, runny nose, HA, URI -> less n/v than GLP1 bc not interact w/ stomach lining as much
Rare: HEART FAILURE, PANCREATITIS, SJS, joint pain
Sodium-Glucose Cotransporter-2 Inhibitors
2nd line/combo: Jardiance; canagliflozin, dapagliflozin, empagliflozin, ertugliflozin- 0.5-1%
MOA: reduce plasma glucose by preventing kidnyes from reabsorbing glucose back in bloodstream leading to glucose excretion in the urine
CONTRAIN FOR GFR<45
benefit: weightloss bc water loss
SE: hypotn, genitalia fungal infxn/UTI bc of loose glucose out, Euglycemic DKA= normal bs but DKA, DEHYDRATION AND YEAST INFXN
Rare: Amputations, fractures, Fournier gangrene
alpha- glucosidase inhibitors
Acarbose and Miglitol
MOA: competitively inhibit maltase, isomaltase, sucrase, and glucoamylase in the SI, delaying breakdown of sucrose and complex carbs
SE: flatulence, abdominal pain, diarrhea
Alt option= not in ADA tx algorithm
Overview
Insulin
DOC FOR GESTATIONAL DIABETES
Insulin-prep for insulin peptide and manufactured through recombinant DNA
Advantage: achieve wide range of glucose targets and dose can be individualized based on glycemic levels
Disadvantages: risk of hypoglycemia, wt gain, injxn burden
Abdomen most consistent absorption
Type 1= Insulin
Type 2= w/ time will need
Basal Insulin
BACKGROUND INSULIN- long acting
Most convenient- Initial insulin formulation in T2DM
options: NPH, detemir, glargine U-100, glargine U-300, degludec U-100, degludec U-200
se:
-Hypoglycemic-> nocturnal hypoglycemia
-less glucose availability
-cost
Bolus insulin
MEAL TIME INSULIN- Short or rapid acting insulins
Rapid: aspart, lispro, glulisine
Ultra rapid: inhaled human insulin or fast acting insulin aspart (Fiasp)
MIMIC PRANDIAL ENDOGENOUS INSULIN RELEASE
PRIOR TO MEAL TIME BUT ONSET MATTERS
Other insulins
- U-500
-for extreme insulin resistance - Pre-mixed insulin products= basal and prandial component
-fewer injxns but hard to tailor to pt - Inhaled insulin
-se: cough and URI
Type 1 DM
- Lifestyle mod and Metformin
- Max out metformin and A1C above target
-add to metformin = GLP-1, SGLT-2 INHIBITORS, dpp-4 inhibitors, sulfonylureas, thiazolidinediones, basal insulin - Add injectables
-1st line: GLP-1 not if A1C>10 or symptom hyperglycemia= insulin
-2nd: Basal Insulin 10 units per day or 0.1-0.2 units/kg/day-> 3-0-3 method (check fasting sugars for 3 days- average them= if above 130 = increase by 3 units till within goal
-3rd: prandial insulin- 4 units or 10% basal dose w/ largest meal of day
-4th: oral meds after adding insulin
- CONTINUE GLP-1, METFORMIN, SFLT2 INHIB
-STOP TZDS, SULFONYLUREAS - organization guidelines
-AACE <6.5 A!C or dual therapy for A1C>7.5, insuline A1C >9
-ADA <7%, insulin A1C >10%
T1DM management
INSULIN IS REQUIRED
high cost-> long acting insulin to provide basal componenet and 2 rapid acting insulin
low cost-> two intermed acting insulin and two injecitons of short acting insulin
Dosing insulin
Adjunctive therapy in t1dm
Pramlintide- amylin agonist
MOA: mimics action amylin (neurohormone co-secreted from beta cells w/ insulin) reduces glucagon secretion, slows gastric emptying, increases satiety
FIRST NON INSULIN APPROVED FOR T1DM
lowers a1c by 0.6%
AE: GI
in conjunction w/ insulin can cause hypoglycemia
Diabetic Ketoacidosis
precipitating factor: PNA, UTI, COVID
Presentation: stupor, coma, abdominal pain
Labs:
-serum glucose
-electrolytes
-plasma creatinine
-CBC
-Urinalysis
-serum ketones
-ABG
Dx: HYPERGLYCEMIA + ANION GAP METABOLIC ACIDOSIS + KETONEMIA
Tx:
1. Correction of fluids and electrolytes= Lactated ringers
2. Administer insulin
3. Frequent monitoring - hourly glucose
Tx of DKA
