Unit 5 - Treatment of DM Flashcards
what are the glycemic targets for non-pregnant adults?
- HcA1c < 7.0% for II, < 130 mg/dL
- postprandial glucose < 180 mg/dL
- individualization is key
- tighter targets if young and healthy
- looser targets if older, extensive comorbidities, hypoglycemia-prone, longer duration of DM
what is the one thing you want to avoid in DM treatment?
hypoglycemia
what is the legacy effect?
even if control is worse later, an initially aggressive treatment will have overall better result in the future
explain islet cell dysfunction in DM II
- alpha cell dysfunction - secrete inappropriately high levels of glucagon after a meal
- fewer B-cells - secrete insufficient levels of insulin, and mass declines over time
incretin hormones
made in L cells, primarily ileum and colon
- produced in response to incoming nutrients
- stimulate insulin secretion
- discovered when insulin response to oral glucose exceeds response to IV glucose
- most important one in humans is glucagon-like peptide 1
what are glucagon-like peptide/hormone 1 actions?
- enhance glucose-dependent insulin secretion
- slow gastric emptying
- suppress glucagon secretion
- promotes satiety
- receptors in islet cells, CNS, elsewhere
- metabolizes rapidly (t 1/2 2-3 min) by DPP-4 (dipepetidyl peptidase-4)
what are the main pathophysiological defects in DM II?
- decreased incretin (GLP-1) effect
- decreased pancreatic insulin secretion
- increased pancreatic glucagon secretion
- decreased peripheral glucose uptake
- hepatic glucose production
what are the recommendations for therapy of DM II?
- at time of diagnosis, initiate metformin therapy + lifestyle interventions unless metformin contraindicated
- -if newly diagnosed with markedly symptomatic and/or elevated blood glucose levels or A1c, add insulin therapy at onset
- if noninsulin monotherapy at max tolerated dose doesn’t work, add a second oral agent, GLP-1 receptor agonist, or insulin
in what drugs is hypoglycemia most common? in which DM? other risk factors?
- sulfonylurea and insulin
- type I > II
- > 60 yo, impaired renal function, poor nutrition, liver disease, increased PA, longer duration of DM
symptoms of hypoglycemia?
- confusion, slurred speech, dizzy, weakness
- shaking, nervousness, sweating, palpitations
- extreme hunger, headache
- mood/behavior change
- tingling of hands, tongue, lips
- vision change, poor coordination
- unresponsive, unconscious, seizures
what is the preferred treatment of hypoglycemia?
- if conscious: glucose (15-20 g)
- if unconscious: glucgon (emergency kit), given by caregiver
- -prescribed to all at significant risk of severe hypoglycemia
- if in hospital - IV dextrose (no N/V associations)
what is in the glucagon emergency kit? who gets it?
very large dose of insulin given only if unconscious or unable to swallow
- turn on side (so don’t aspirate vomit)
- type I always has prescription
- type II should have if previous severe low blood sugar
what is oral therapy inadequacy?
(“inadequacy” used instead of “failure”) failure to reach targeted treatment goals
- primary: dietary noncompliance and physical inactivity
- secondary: stress, insulin resistance, simultaneous use of diabetogenic drugs, progressive B-cell dysfunction
how is efficacy over time?
decreases
- A1c can rise when on stable therapy or with age
- B-cell function decreases at same rate
what is amylin? amounts in DM? what does it do?
37 AA peptide released with insulin from B-cells in response to eating
- absent in DM I, variable in DM II
- slows gastric emptying
- suppresses postprandial glucagon secretion
- reduces appetite
