11a - DM Part 1 Flashcards
(127 cards)
1
Q
How many people in US have DM?
A
- 1 million
1. 25million w DM1
2
Q
How much does DM cost?
A
$1 out of every $5 spent on health care
3
Q
What type of syndrome is DM?
A
A syndrome of disordered metabolism and inappropriate hyperglycemia
4
Q
DM age at onset?
A
DM1: <30, peaks at 12-14
DM2: <40 (traditionally)
5
Q
DM pancreatic function
A
DM1: none
DM2: insulin present in low, normal, or high amounts
Its a sensitivity issue
6
Q
DM pathogenesis
A
DM1: autoimmune beta cell destruction
DM2:
- defect in insulin secretion,
- tissue resistance to insulin,
- increased hepatic glucose output
7
Q
DM fam hx?
A
DM1: none
DM2: strong
8
Q
DM obesity?
A
DM1: uncommon (unless using insulin wrong)
DM2: common (60-90%)
9
Q
DM ketoacidosis hx
A
DM1: common
DM2: rare
10
Q
Dm clinical presentation
A
DM1: moderate to sever 3p’s
DM2: mild polyuria, fatigue, often diagnosed incidentally
11
Q
DM insulin required?
A
DM1: yes
DM2: no/yes/merica!
12
Q
DM fasting C peptide
A
DM1: very low
DM2: normal to high
13
Q
What is DM1?
A
“DM of childhood”
Autoimmune destruction of beta cells of pancreas islets of lagerhans
A catabolic disorder
14
Q
What is DM2?
A
Insulin resistance + beta cell loss and dysfunction
15
Q
What is the greatest risk factor for DM2?
A
Obesity
Especially visceral obesity
16
Q
What is MODY?
A
Maturity onset diabetes of the young
Doesnt fit type 1 or 2
17
Q
Characteristics of MODY
A
Non-insulin dependent DM Age <25 Non obese Impaired glucose-induced secretion of insulin Autosomal dominant inheritance
18
Q
What are the secondary causes of MODY?
A
Insensitivity to insulin from tumors, drugs, liver disease
Reduced insulin secretion from pheo, pancreatitis, or drugs
19
Q
Other names for metabolic syndrome?
A
Syndrome X
Dysmetabolic syndrome
20
Q
Metabolic syndrome and the heart?
A
Metabolic syndrome is an independent risk factor for cardiovascular disease
Increased risk of coronary artery disease and stroke
21
Q
Clinical abnormalities associated with metabolic syndrome
A
Insulin resistance Dyslipidemia HTN Hypercoagulability Proinflammatory state Hyperuricemia Hyperinsulinemia Abdominal obesity
22
Q
Dyslipidemia in metabolic syndrome?
A
H: TG
L: HDL
H: LDL
23
Q
Why does metabolic syndrome cause hypercoagulability?
A
Elevated plasminogen activator inhibitor-1
Hyperfibrinogenemia
Increased PLT aggregation
24
Q
Metabolic proinflammatory state indications?
A
Elevated CRP
Endothelial dysfunction
25
Define abdominal obesity in reference to metabolic syndrome?
Males: waist > 40”
Females: waist > 35”
26
How is metabolic syndrome diagnosed?
```
Must have 3 of 5
Obesity: 40,35
Insulin resistance
Hyperlipidemia (TG >150)
Hypercholesterolemia (HDL <40)
Hypertension (>130/85)
```
27
SS of DM1?
Polyuria
Polydipsia
Polyphagia
```
Blurred vision
Wt loss
Lpostural HOTN
Paresthesias
Ketoacidosis
LOC
```
28
What causes the polyuria in DM1?
Osmotic diuresis from hyperglycemia
Leads to glucose, free water and electrolytes into the urine
29
What is often the 1st sign of DM2?
Candidiasis
30
S/S of DM2?
Asymptomatic (often)
Skin infections
Obesity
Acanthosis nigricans
31
What are rare symptoms of DM2?
Hyperglycemic hyperosmolar coma
32
What types of skin infections are common with DM2?
Candidiasis
Generalized pruitis
Vaginitis
33
What labs are good for DM?
UA
- glucose
- ketonuria
Blood
- glucose
- oral glucose tolerance test
- HbA1C
- Fructosamine
34
What is nondiabetic glycosuria?
Benign condition often seen during pregnancy and other times, where glucose spills into urine while blood glucose is normal
35
What level of ketonuria leads to hostpitalization?
>3.0mmol/L
36
What is the lifespan for glycohemoglobins?
They live for the 120d lifespan of RBCs
37
What does HbA1C show?
Glycemia of previous 8-12 weeks.
38
What is used to screen for DM, what is not?
HbA1C can be a screening tool
UA cannot
39
What will cause false high/low HbA1C?
High: low red cell turnover
- iron deficiency
- b12 deficiency
- folate deficiency
- kidney/liver failure
Low: rapid red cell turnover
- hemolysis
- recent transfusion
- anemia
- heavy bleeding
- kidney/liver failure
40
What should serum glucose levels be?
Fasting >126 mg/dL: diabetes
Fasting 100-125 mg/dL: impaired
Random: >200mg/dL w symptoms: diabetes
41
What is pre-diabetes?
A gray zone between normal and diabetic
42
What if pt has normal HbA1C levels but abnormal fasting glucose?
It may be pre-diabetes
43
What do pre-diabetics need to do?
Make some changes
Decreasing body wt 5-10%, diet, exercise, and drugs can prevent/delay DM2
44
How is the oral glucose tolerance test performed?
Pt eats 150-200g carbs/day x 3 days
NPO after midnight
75g glucose in H2O
Blood is collected at 0 and 120 min post ingestion
45
What are the normal, impaired and diabetic ranges for oral glucose tolerance test?
Normal: <100 fasted and <140 at 2 hr
Impaired 140-199 at 2 hr
Diabetes >126 fasting and or >200 at 2 hr
46
HbA1C levels, normal, impaired, DM
Normal: <5.7
Impaired: 5.7-6.4
Diabetes: >6.5
47
Of the diabetic complications what is most sensitive to raises in HbA1C?
Retinopathy followed closely by neuropathy
48
What does an HbA1C of 5 represent in glucose?
97
49
What does an HbA1C of 7 equate to in glucose
154
50
Why do we look at fructosamine?
It is similar to HbA1C but the 1/2 life is shorter than hemoglobin so we can see changes in glucose after 1-2 weeks
51
What is serum fructosamine/
Formed by non enzymatic glycosylation of serum proteins
Predominantly albumin
52
What labs will help diferentiate between DM1 and DM2?
Insulin
C-peptide
Autoantibodies
53
What are c-peptides?
Fragment of proinsulin
| They are markers for insulin secretion
54
Is c-peptide a reliable test for DM1 and DM2?
Not really it cant always distinguish between them
55
What autoantbodies are seen with DM1?
Islet-cell (IA2)
Anti-glutamic acid decarboxylase (antiGAD65)
Anti-insulin
56
How are DM labs confirmed?
Any abnormal labs must be confirmed on a different day to make a diagnosis
57
What are the symptoms seen with glucose >200mg/dL?
Thirsty
Dry
Tired
58
What are the symptoms seen with glucose <60mg/dL?
Shaky
Sweaty
Weak
59
What is the margin of error for finger sticks <60mg/dL?
Up to 20% different than lab testing
60
Are urine tests reliable for DM monitoring?
Not at all
61
Does tight monitoring affect 5 yr mortality?
No change in 5 yr mortality
| There is a slight increase in CV event risk
62
What diet is recommended for DM by the ADA?
45-65% carbs
25-35% fats
10-35% protein
63
What are some other dietary recommendations for DM patients?
High soluble fiber content
High insoluble fiber
High insoluble fiber
Low Glycemic index foods
64
Why are DM pts advised to eat fiber?
Soluble fiber
1. The favorable effect on lipids
2. Slows glucose absorption
Insoluble fiber
1. Helps you poo
65
What is the glycemic index?
Carbohydrate foods are rated based on their speed of transformation into glucose.
Lower glycemic foods are 55 or less
-fruits, veggies, whole grains, legumes
Higher glycemic foods are >70
-potato, white bread, rice
66
What are the alcohol recommendations for ETHO?
Moderation (LOL)
Men 2 drinks/day
Women 1 drink/day
67
What does ETOH do to DM pts?
Causes hypoglycemia
68
What effect does wt loss have on DM?
5-10% loss of weight decreases insulin resistance
69
What medications do DM pts need to be on?
Glycemic control drugs
ASA
Lipid lowering
BP lowering (ace/arb preferred)
70
What are the available types of glycemic control agents?
Oral
| Insulin
71
Broad strokes; how do the oral agents work?
- Stimulate insulin secretion
- Stimulate liver, muscle, adipose to lower glucose
- Affect absorption of glucose
72
What classes of oral glycemic control agents are available?
```
Binguinides
GLP-1 RA
SGLT-2i
DPP-4i
TZD
AGI
SU/GLN
```
73
What is the go to oral agent?
Biguinides - metforman
1st line for new DM-2
74
How do biguanides work?
Suppress hepatic gluconeogenesis and increase hepatic insulin sensitivity
75
What are the advantages to metformin (glucophage)
It improves lipids
NO hypoglycemia risk
Cheap
Weight neutral
76
What are the disadvantages of metformin?
GI effects
| Lactic acidosis risk (renal insufficiency pts)
77
Contraindications for metformin?
CKD
Alcoholics
CHF
78
What are SGLT2?
Selective sodium dependent glucose Co Transporter - 2 Inhibitors
Empagliflozin (jardiance)
Canagliflozin (invokana)
79
How do SGLT2s work?
Reduce reabsorption of filtered glucose and lowers the renal threshold for glucose resulting in increased urinary glucose excretion
80
What SGLT2 is FDA approved for reducing CV risk?
Empagliflozin (jardiance)
81
Advantages for SGLT2s?
Potential CV benefit “class effect”
82
Disadvantages of SGLT2?
```
Wt loss
Increased urination
BP reduction (slight)
Genital fungal infections
UTI
```
83
CI for SGLT2?
Renal dysfunction
84
What are GLP1 drugs?
Glucagon-like peptide 1 receptor agonist
Exanatide (byetta)
Liraglutide (victoza)
85
How are GLP1 drugs prescribed?
Add on therapy only w metformin or sulfonylurea
86
Advantages of GLP1s?
Wt loss
| Address post prandial glucose
87
What are the disadvantages for GLP1s?
Injection
GI effects
Pancreatitis
Medullary thyroid cancer(?)
88
CI for GLP1s?
MEN2
Medullary thyroid cancer
Gastroparesis
89
What are DPP4 inhibitors?
Dipeptidyl peptidase-4
Sitagliptin (januvia)
Saxagliptin (onglyza)
90
What do DPP4 inhibitors do?
Stabilize insulin secretion
| Decrease glucagon release
91
Advantages of DPP4?
Wt neutral
Non-injection
Low hypoglycemia risk
92
Disadvantages of DPP4Is?
Serious reactions
Pancreatitis
URI symptoms
93
CI for DPP4Is?
Renal impairment (adjust dose)
94
What are TZDs?
Thiazoladinediones
Rosiglitazone (avandia)
Pioglitazone (actos)
95
What do TZDs do?
Sensitizes peripheral tissue to insulin
96
Advantages to TZDs?
Improved lipids
| Slows DM progression
97
Disadvantages to TZDs?
Increased risk of angina/MI
Edema (3-4% of pax)
Anemia
Wt gain
98
What are AGIs?
A-glucosidase inhibitors
Acarbose (precose)
Miglitol (glyset)
99
How to AGIs work?
Affect glucose absorption by delaying carb absorption (what a concept)
100
Advantages of AGIs?
Wt neutral
| Addresses post-prandial glucose
101
Disadvantages of AGIs?
Gi effects
102
Contraindications for AGIs?
Chronic intestinal disorders
Cirrhosis
Renal impairment
103
How do secretagogues work?
They stimulate insulin release from pancreatic B cells
104
Examples of secretagouges?
Sulfonylureas
1st gen: tolbutamide (orinase)
2nd gen: glipizide (glucotrol)
Meglitinide analogs
- repaglinide (prandin)
D-phenylalanine derivitive
- nateglinide (starlix)
105
Advantages of secretagouges?
Longevity
| Cheap
106
Disadvantages of secretagogues?
Hypoglycemia
| Wt gain
107
CI for secretagogues?
Sever liver or renal disease
108
Normal glucose indices?
Average FPG or preprandial: <100
Average 2hr postprandial: <140
Average bedtime glucose: <120
HbA1C: <6%
109
Goal (for DM) glucose indices?
Average FPG or preprandial: 90-130
Average 2hr postprandial: <150
Average bedtime glucose: 110-150
HbA1C: <7%
110
What glucose indices require action?
Average FPG or preprandial: <80 or >140
Average 2hr postprandial: >180
Average bedtime glucose: <110 or >160
HbA1C: >/= 7%
111
How to use oral agents if HbA1C is <9?
```
Titrate agent over 3 months
Reinforce med, diet and exercise
Recheck HbA1C and after 6 months
Still not good? Add agent (triple therapy)
Recheck at 9 mo, still bad- insulin
```
112
What if HbA1C is >9 with symptoms?
Start with insulin + metformin
113
HbA1C therapy levels?
A1C <7.5: monotherapy
A1C >7.5: dual therapy, triple therapy
A1C >9: insulin + metformin
114
What type of insulin do we use? Why?
Highly purified human insulin
It has fewer reactions than Pig insulin
115
Formulations of insulin?
Rapid acting
Intermediate acting
Long acting
116
Rapid acting insulin ultra short acting?
Humalog (lispro)
Novolog (aspart)
Apidra (glulisine)
117
Rapid acting insulin short acting?
Humulin R (regular)
Not oft used
118
Intermediate acting insulin?
```
Humulin N (NPH)
Lente
```
Onset 2-4 hrs, peak at 9
119
Long acting insulin?
glargine (Lantus)
Detemir (levemir)
Bedtime dose
120
What is the preferred DKA insulin tx?
Humulin R (regular)
121
How to add insulin to oral glucose agents?
Continue oral agents at same dose
Add single bedtime insulin dose
If still not fixed:
Add daytime
Adjust doses weekly
122
What oral agent is not administered with insulin?
Sulfonylureas
123
What is pre-breakfast hyperglycemia?
Dawn phenomenon
Somogyi effect
Both are high morning levels
Check glucose at 0200-0300
124
What is the dawn phenomenon?
Elevated glucose at 0200-0300
Leads to nocturnal GH secretion
Morning hyperglycemia
Tx is increase bedtime insulin
125
What is the somogy phenomenon?
Low glucose at 0200-0300 glucose
Stimulates epinephrine -> high glucose levels by 0700
Increases the glucose release from the liver)
Tx: reduce bedtime insulin
126
How common is the dawn phenomenon?
As many as 75% of DM1 pts experience this
127
How many apples grow on a tree?
All of them
