Treatment DM Pt 1

Question 1

DM txt goals

Answer 1

• reduce microvascular, microvascular and neuropathic complications
• prevent complications from high blood glucose levels
• minimize hypoglycemic episodes
• maintain overall quality of life
• educate

Question 2

DM glycemic goals of therapy

Answer 2

A1C < 7
preprandial glucose 80 - 130 mg/dL
postprandial glucose < 180 mg/dL

Question 3

DM Patient education

Answer 3

diabetes disease process
txt options
nutritional management
physical activity
medication use
monitor blood glucose
self-management of disease
prevent and txt acute and chronic complications

Question 4

What lifestyle changes for DM

Answer 4

nutrition
self monitoring
physical activity
adherence meds

Question 5

Pathophysiology of DM

Answer 5

Decrease Insulin Secretion (pancreas)
- sulfonyureas
- meglitinides
Decrease glucose use (peripheral tissue)
- thiazolidinedione
Increase glucose made (liver)
- biguanide
Sugar absorption (gut)
- alpha-glucosidase inhibitor

Question 6

treatment algorithm for DM2

Answer 6

Non-pharm
Metformin –> 3 months
add additional DM2 drug or insulin –> 3 months
add additional DM2 drug or insulin –> 3 months
metformin + basal insulin + bolus insulin + GLP-1-RA (start here if BG >= 300 and/or A1C >= 10-12

Question 7

What is somogyi effect in DM

Answer 7

rebound hyperglycemia after hypoglycemia

Question 8

Titration of Metformin

Answer 8

begin with low dose metformin (500mg) taken qday or bid with meals
after 5-7 days if GI side effects have not occurred advance to 850 or two 500 mg tablets bid
if GI side effects appear as doses advanced, decrease to previous lower dose, and try to advance the dose at a later time
the maximum effective dose can be up to 1000mg bid but is often 850mg bid

Question 9

Dosing for insulin

Answer 9

DM1: starting dose- 0.5-0.6 units/kg/day
-usual dose: 0.5-1 unit/kg/day divided into 50% basal and 50% prandial insulin (20% pre-breakfast and 15% for other 2)
DM2: starting dose- 0.1-0.2 units/kg/day

Follow up weekly while adjusting the dose

Question 10

What is the honeymoon phase

Answer 10

temporary remission of hyperglycemia that occurs in some pts newly dgx with type 1 DM when some insulin secretion resumes for a short time before stopping again

Question 11

What is the dawn phenomenon

Answer 11

relative resistance to insulin during early morning hours

Question 12

Medications that can increase glucose

Answer 12

interferon alfa, diazoxide, diuretics, glucocorticoids, nicotinic acid, OCs, phenytoin, beta blockers, sympathomimetics, clozapine and olanzapine

Question 13

OTC medications and how they affect blood glucose

Answer 13

Decongestants
-usually contain pseudoephedrine which can raise blood sugar and BP
Analgesics
-aspirin is ok in low doses, acetaminophen and ibuprofen do not affect glucose control or DM
cough preperations
-watch for combination products that contain decongestants
-syrups also contain sugar
Cough drops
-many contain sugar and may raise blood sugar if taken in large quantities

Question 14

Metformin (Glucophage) (MOA, Adv, Dis, A1C, and dose)

Answer 14

MOA: activates AMP kinase which decreases hepatic glucose production
Ad: extensive experience, no hypoglycemia, decrease CVD events
Dis: GI side effects, lactic acidosis risk, vitamin B12, multiple CI, CKD acidosis, hypoxia, dehydration
A1C 1-1.5%
Dose: 1000mg bid

Question 15

Glipizide (Glucotrol)

Answer 15

MOA: closes KATP channels on beta cells plasma membrane which increase insulin secretion (may be helpful for some but in insulin resistant pts it won’t be helpful)
Ad: extensive experience, decrease microvascular risk
Dis: hypoglycemia, increase weight, possibly blunts myocardial ischemic preconditioning, low durability
A1C 1-1.5%
Dose: 5-20 mg qd

Question 16

Pioglitazone (Actos)

*it’s a “glitz zone” when you’re acting

Answer 16

MOA: activates PPAR-y which increase insulin sensitivity
Ad: no hypoglycemia, durability, increase HDL, decrease TGs, possible decrease in CVD events
Dis: increase weight, edema and heart failure, bone fractures, increase LDL, possible increase in MI
A1C: 1-1.5%
Dose 15-45mg qd

Question 17

Sitagliptin (Januvia)

Answer 17

MOA: inhibits DDP-4 which increases post prandial active incretin which increases insulin secretion and decreases glucagon
Ad: no hypoglycemia (becuz it only increases insulin secretion if BG is too high)
Dis: angioedema/urticarial, other immune mediated derm effects, possible acute pancreatitis, possible increase in HF hospitalization
A1C: 0.5-1%
Dose: 100mg daily

Question 18

Exenatide (Byetta)

*say Bye to Etta when she Exits

Answer 18

MOA: activates GLP-1 receptors which increases insulin secretion and decreases glucagon secretion which slows gastric emptying and increases satiety
Ad: no hypoglycemia, decrease weight, decrease postprandial glucose excursions, decrease some CV risk factors
Dis: GI side effects, increase HR, possible acute pancreatitis, C cell hyperplasia/medullary thryoid tumors in animals, injectable, training requirements
A1C: 1-1.5%
Dose: 10 mcg sq bid (increase after 1 month)