26 - Diabetes Flashcards
(73 cards)
1
Q
Fasting blood glucose target for adults
A
4-7
2
Q
Fasting blood glucose target for children
A
- 4-8
- Consider target of 6-10 in children who have had severe or excessive hypoglycemia
3
Q
2h post-prandial BG for aduts
A
5-10
4
Q
2h post-prandial BG for children
A
5-10 (same as adults)
5
Q
What can happen from BG levels that are too high?
A
- Diabetic ketoacidosis
- Body can’t take up glucose that is there b/c not enough insulin => high BG levels
- Levels of 13-13.5 mmol/L causes body to start producing ketones, which are then filtered through kidneys and appear in urine
6
Q
Why is it important to keep BG and A1c in recommended levels?
A
- Can become symptomatic on day-to-day basis
- Can cause microvascular complications
7
Q
Describe the possible microvascular complications of diabetes
A
- Nephropathy (kidney damage)
- Retinopathy = leading cause of blindness in Canada
- Neuropathy (lack of sensation in extremities)
8
Q
What are the most common neuropathies of diabetes?
A
- Diabetic gastroparesis = neuropathy in GI tract so normal movement is impaired (feeling of food being stuck when swallowing)
- Erectile dysfunction
9
Q
What is the RRR for glucose control for microvascular complications?
A
- 60% of nephropathy and retinopathy
- 45% of neuropathies
10
Q
___ is a major complication of type 1 diabetes
A
Diabetic ketoacidosis
11
Q
Major causes of diabetic ketoacidosis
A
- Failing to take insulin
- Poor sick day management
12
Q
Do you still need to take insulin on sick days?
A
Cold or flu causes stress that causes hormone release (norepinephrine, cortisol, and glucagon) that causes blood glucose to increase
13
Q
Risk factors for diabetic ketoacidosis in children
A
- Children w/ poor control or previous episodes of DKA
- Peripubertal and adolescent girls (insulin causes weight gain)
- Children on pumps or long-acting insulin
- Children w/ psychiatric disorders
- Those w/ difficult family considerations
14
Q
What is A1C?
A
Glycated hemoglobin
15
Q
What are the various A1C targets?
A
- 6.5% or less in adults w/ T2DM who are at low risk of hypoglycemia to reduce risk of CKD & retinopathy
- 7.0% or less in most adult’s w/ type 1 or 2 DM
- 7.1-8% = functionally dependent
- Goal 7.1-8.5% in px w/ recurrent severe hypoglycemia and/or hypoglycemia unawareness, limited life expectancy, or frail elderly and/or w/ dementia
16
Q
What are the A1C targets for children and why?
A
- A1c targets more relaxed for children b/c being too stringent increases risk of hypoglycemia (has been shown to cause more learning difficulties and cognitive difficulties in children following a tight glucose control)
- < 18 y/o A1c = 7.5% or less
17
Q
Is a 2% change in A1C a big deal?
A
- YES!!
- Going from 7% to 9% is huge and has much greater risk of complications
18
Q
What is the initial dosing range of insulin for type 1 diabetes?
A
0.5-1 U/kg/day
19
Q
When may insulin dosing decrease?
A
- Dose may decrease during a “honeymoon phase” (when insulin causes body to increase insulin production) which can last weeks to months after the initial diagnosis
- 0.2-0.5 U/kg/day
20
Q
When may insulin dosing increase?
A
- Dose may increase for children as they enter puberty
- 0.5-1.5 U/kg/day
21
Q
What should the ratio be for long-acting and rapid-acting insulin?
A
Typically dosing is approx. 50% basal and 50% rapid-acting split between 3 meals
22
Q
of insulin units are adjusted based on ____
A
- BG readings
- Amount of carbs consumed at each meal
- Expected exercise
- Presence of illness
- Changes in age and weight over time
23
Q
Who requires a basal amount of insulin?
A
Everyone
24
Q
What is basal insulin? Give examples
A
- Long-acting (detemir, glargine; should be clear, throw away if cloudy)
- Intermediate-acting (NPH; should be cloudy)
- Both are given 1-2 times/day
25
Onset and duration of long-acting insulin
- Onset 90 min
- Duration 16-24 h (detemir) or 24 h (glargine)
- Gives a small amount of insulin for 24 h, doesn’t have a peak
- Glargine is pH dependent (formulated at pH 4)
26
When should detemir insulin be given and why?
At bed time and in the morning b/c doesn’t last until next bedtime dose if only given at bedtime
27
Onset and duration of intermediate-acting insulin
- Onset 1-3 h
| - Duration < 18 h
28
Which insulin therapy is preferred for adults and type 1 diabetics?
Basal-bolus insulin therapies (multiple daily injections or continuous subcutaneous insulin infusion)
29
When should a continuous subcutaneous insulin infusion be considered?
If glycemic targets not met w/ optimized multiple daily injections
30
What is prandial insulin? Give examples
- Rapid-acting (aspart, glulisine, lispro)
| - Short-acting (Humulin/Toronto)
31
Onset and duration of rapid-acting insulin
- Onset < 20 min
| - Duration 3-5 h
32
Onset and duration of short-acting (Toronto) insulin
- Onset 30 min
| - Duration 6.5 h (about 2x as long as rapid-acting)
33
What is the advantage of rapid-acting insulin over short-acting?
- Better for unpredictable eating schedules (ex: don’t know how much a child will eat, so can give insulin right when they start eating)
- Rapid causes less late morning/afternoon hypoglycemia (short acting lasts longer so will push glucose levels down for more time) **know this**
34
What is important to know about mixing insulin?
- Can’t mix lispro and glargine, will change the PK profile
| - Can mix Humalog w/ NPH
35
Pediatric diabetic ketoacidosis causes increased risk for _____
Cerebral edema
36
Describe proper insulin administration techniques
- Rotate injection spots at the same site (not rotating will affect absorption and leave lumps under skin)
- Inject into abdomen/stomach, outer thigh, or back of arm
- Don’t inject into muscles that are going to be active (will increase absorption)
37
What are some sx of hyperglycemia?
- Polyuria (b/c high blood glucose makes the body want to pee it out, and water follows glucose)
- Polydipsia (excessive thirst)
- Weight loss (losing water weight)
38
What is the proper management of hyperglycemia?
- Monitor for trends in elevated BG and adjust when blood glucose results are consistently elevated; typically, don’t adjust insulin causing a single elevated BG reading
- Adjust only 1 insulin at a time, unless the adjustment will cause low BG readings to occur later in the day
- - In most cases, insulin adjustments should approximate a 10% change to the insulin causing the effect (ex: originally using 4 U at breakfast, increase to 4.5 U)
39
What are some drugs that can increase blood glucose?
- Thiazides (only at higher doses; ex: HCTZ 12.5 mg isn’t concerning, but > 25 mg would require monitoring)
- Prednisone (must monitor in first 1-3 weeks after starting)
- Atypical antipsychotics
- Niacin (doses > 1 g/day)
40
When is a correction factor used?
When pt is very hyperglycemic
41
Describe the correction factor/ insulin sensitivity factor
- For rapid-acting insulin (aspart, glulisine, or lispro) divide 100 by the person’s total daily dose (TDD); result will estimate the reduction in BG for 1 U of insulin (ex: TDD = 33 U, 100 / 33 = 3 mmol/L approx.)
- For short-acting insulin (Humulin R, Novolin ge Toronto) divide 85 by TDD; result will estimate the reduction in BG for 1 U of short-acting insulin (ex: TDD = 33 U, 85 / 33 = 2.6 mmol/L)
42
Describe the insulin to carbohydrate ratio (ICR)
- ICR = total grams of carbs consumed per day / total daily dose of insulin units (ex: 450 g / 33 U = 13.6 g -> 1 U of insulin required for every 13.6 g of carbs consumed)
- Children = 450 g carbs
- Adults = 500 g carbs
- Can find out how many carbs are in different foods directly from “nutrition facts” labels (*don’t include fiber)
43
What is hypoglycemia? What are some sx?
- BG < 4 mmol/L
| - Sx = sweaty and generally feeling unwell
44
What is the tx for hypoglycemia?
- Treat immediately w/ carbs and figure out the cause (ex: exercise, skipped meal, skipped insulin)
- For children < 15 kg = 5 g carbs
- For children 15-30 kg = 10 g carbs
- For anyone > 30 kg = 15 g carbs (ex: 4 glucose tablets, 175 mL of juice or regular soft drink)
45
What is a good option in regards to exercise and T1DM?
Decrease insulin if doing regularly scheduled exercise b/c too much insulin during activity may cause hypoglycemia and can prevent body from burning fat efficiently
46
At what BG level should a person not exercise?
> 14 mmol/L w/ ketones or > 16.7 mmol/L
47
What can cause hyperglycemia following cessation of high intensity exercise?
- Insulin deficiency
| - Stress response
48
When does delayed hypoglycemia following moderate or strenuous activity generally occur?
- 6-15 h following activity
| - Can be responsible for hypoglycemia > 24 h later
49
What are the general recommendations for people w/ diabetes and exercise?
- Good idea to bring sugar tablets and snacks w/ you
- Know sx of hypoglycemia and what to do to treat them
- Monitoring BG before starting exercise and after; if exercise is long, check BG during
- Stay hydrated
50
Describe the recommendations for glycemic management of type 2 diabetes in adults
- In the absence of metabolic decompensation, metformin should be initial agent of choice in people w/ newly diagnosed T2DM, unless contraindicated
- - Metabolic decompensation = marker hyperglycemia, ketosis, or unintentional weight loss
- Contraindications to metformin = class 4 or 5 chronic kidney disease (CrCl < 30 mL/min) and hepatic failure
- Initial use of combinations of submaximal doses of anti-hyperglycemic agents produces more rapid and improved glycemic control and fewer side effects compared to monotherapy at maximal doses
51
What is the recommendation for insulin use in T2DM?
- 3rd line behind metformin and gliclazide??
- May be started on insulin at beginning, used to get them down to normal then started on oral meds to maintain
- Still make insulin, so don’t have to worry about exact insulin injection amounts to account for carbs and stuff like that in type 2 diabetics
52
How often should blood glucose and A1c be measured?
- If using insulin pump, SMBG (self-monitoring of blood glucose) = 4 or more times/day
- If using basal insulin, SMBG = at least as often as insulin is being given (ex: NPH/long-acting given at bedtime, SMBG before breakfast)
- Daily SMBG not usually required if px has prediabetes or has diabetes and is being treated w/ behaviour interventions and is meeting glycemic targets
* *People w/ type 1 diabetes should measure blood glucose about 4 times/day
- Type 2 DM can measure once a day or less (depending on control)
- A1c should be measured every 3 months
53
Metformin -- advantages, max dose, major SE, CI
- One of the best agents to lower A1C
- Also decreases microvascular complications & decrease CV events
- Max dose = around 2500 mg/day; greater than that can cause lactic acidosis, which is 50% fatal
- Major SE = nausea, diarrhea, stomach upset
- Get concerned when CrCl < 40 mL/min b/c absolutely contraindicated in < 30 mL/min
54
Sulfonylureas - CI, MOA, SE
- Can increase weight, so avoid use in obese px
- Glyburide stimulates release of insulin from pancreas (gliclazide very similar)
- Don’t show decrease in CV events
- SE = hypoglycemia & weight gain
55
Acarbose - MOA, dose, efficacy, SE, monitoring
- Blocks alpha-glucosidase (breaks long carbs into smaller carbs) in GI tract & pancreatic alpha-amylase, so delays carb digestion
- Dose – 50 mg once to start, titrate up to 100 mg TID w/ meals; increase dose every 1-2 months
- Takes about 8 weeks for maximal effect
- Efficacy – commonly decreases A1c approx. 0.7-0.8%
- Weight neutral or slight weight loss
- Low risk of hypoglycemia when used alone
* *Associated w/ significant GI effects (flatulence > 40%, diarrhea ~ 30%, abdominal pain)
- Monitor liver function tests (AST, ALT) every 3 months for first year & reassess frequency
56
Thiazolidinediones - example, indication, dose, efficacy, CI, SE, monitoring
- Pioglitazone
- Indicated for type 2 diabetes on high dose insulin (over 2 U/kg) & on maximally tolerated metformin who aren’t achieving optimal control
- Helps increase sensitivity of cells to insulin so they can recognize glucose & uptake it
- Delayed onset of 4 weeks, max effect in 8-16 weeks
- Dose = typically 15-30 mg once daily
- Efficacy – commonly decreases A1c ~ 0.8-0.9%
- Weight gain (approx. 2.5-5 kg) b/c increased glucose uptake in cells
- Minimal risk of hypoglycemia when used alone
- Contraindicated in any amount of heart failure b/c worsens HF
- Not indicated for use w/ insulin due to increased risk of HF
- Edema 5%; rare = mild anemia
- Increased incidence of fractures
- Requires monitoring of liver function (ALT, AST) at baseline
- Monitor for blood in urine & dysuria (rarely associated w/ bladder cancer)
57
DPP-4 inhibitors - example, indication, dose, efficacy, SE
- Sitagliptin
- Indicated in type 2 diabetics who aren’t adequately controlled on or are intolerant to metformin & a sulfonylurea, and for whom insulin isn’t an option
- Dose = typically 100 mg once daily (decrease dose in renal dysfunction)
- Delayed onset < 4 weeks, max effect ~ 18 weeks
- Efficacy = commonly decreases A1c ~ 0.5-0.7%
- Weight neutral or slight weight loss (approx. 1-2 kg)
- Minimal risk of hypoglycemia when used alone
- Doesn’t appear to have beneficial CV outcomes (does have benefit for microvascular complications)
- Caution w/ use in HR (especially saxagliptin)
- Reports of arthralgias, joint pain
58
GLP-1 receptor agonists - example, administration, indication, efficacy, SE, dose, CI, disadvantage
- Liraglutide/ victoza
- Subcut injectable (supplied as 6 mg/mL solution)
- Indicated in combination w/ metformin, or metformin & a sulfonylurea, or metformin & basal insulin
- Efficacy – commonly decreases A1c ~ 1%
- CV benefit – for every 100 px w/ T2DM and high CV risk, tx w/ liraglutide for ~ 4 years will result in 2 less CV events, 2 less cases of nephropathy, but 1 extra case of acute gallbladder disease, and 2 extra cases of discontinuation due to adverse effects (ex: nausea, vomiting, diarrhea)
- - Studied in px that had a CV event and trying to control BG to prevent a second one
- Increased incidence of nausea (39%), headache, diarrhea (21%), hives
- Titrate dose upward; 0.6 mg subcut once daily x 1 week, then 1.2 mg subcut once daily, may increase to 1.8 mg subcut once daily
- Weight neutral or slight weight loss (up to 3 kg)
- Lower risk of hypoglycemia when used alone
- Associated w/ medullary thyroid cancer & multiple endocrine neoplasia syndrome (rare); CI if personal or family hx; can still use in hypothyroidism
- Very expensive!
59
SGLT2 inhibitors - example, indication, efficacy, CV benefits, dose, CI, SE
- Empagliflozin/ jardiance
- Produces increased urinary glucose excretion (blocks re-uptake of glucose in kidneys so it stays in urine)
- CV benefits & adverse effects aren’t consistent in this class of drugs
- Indicated for:
- - Monotherapy (if CI/intolerance to metformin)
- - Combination w/ metformin
- - Combination w/ metformin or sulfonylurea
- - Combination w/ pioglitazone (alone or w/ metformin)
- - Combination w/ insulin (basal or prandial)
- Efficacy = decreases A1c ~ 0.4-0.7%
- CV benefits – reduced risk of composite major CV events and all cause death (why its increasing in popularity for T2DM)
- - Recommended for px w/ previous CV events
- 10 mg daily dose provided virtually same benefit as 25 mg dose
- - Dose typically 10 mg daily w/ 1st meal of the day
- CI in renally impaired px (eGFR < 45 mL/min) b/c drug is less effective
- Weight neutral or weight loss (approx. 4 kg)
- SE = UTI, 3-4-fold increased risk of genital fungal infections, rare DKA; canagliflozin associated w/ increased fractures & greater risk of lower limb amputation
- - Empagliflozin is a good option as long as pt doesn’t have recurrent UTI’s (b/c increases glucose in urine, which induces growth of bacteria)
- - Increased risk of Fourneir’s gangrene (necrotizing fasciitis) around perineum (very rare; inform pt to get checked if experiencing redness, swelling, or pain b/c not a normal UTI; tx = debridement) – not a reason to stop recommending
- Reduced doubling of sCr, initiation of renal replacement therapy, or death due to renal disease
- In adults w/ T2DM w/ clinical CKD in whom glycemic targets aren’t achieved w/ existing anti-hyperglycemic medications and w/ eGFR > 30, SGLT2 inhibitors w/ proven renal benefit may be considered to reduce risk of progression of nephropathy
60
Which meds should be stopped on sick days if pt can't stay hydrated?
SAD MANS = sulfonylureas, ACE inhibitors, diuretics/direct renin inhibitors, metformin, ARBs, NSAIDs, SGLT2 inhibitors
61
What is the objective of sick day management in insulin-managed diabetes?
- Minimize metabolic imbalance
- Avoid severe hypoglycemia
- Prevent hyperglycemia and ketosis leading to DKA
62
What are 2 diabetes emergencies w/ similar qualities?
DKA (diabetic ketoacidosis) and HHS (hyperosmolar hyperglycemic state)
63
Is DKA or HHS more common in T2DM
HHS b/c ketones aren't present
64
Why do BG and ketones increase on sick days?
- Illness and infection allow the body to release counter-regulatory hormones that oppose the action of insulin; this allows circulating levels of glucose to rise quickly along w/ increase in circulating fat cells
- W/ lower insulin levels, higher glucose levels, and increasing fat cells, blood becomes more acidic and ketone bodies increase
65
When is ketone testing recommended?
- All px w/ T1DM during periods of acute illness accompanied by elevated BG
- Measured every 2-4 h around the clock as long as
66
Should insulin be omitted on sick days?
- Never
- Supplemental rapid-acting or short-acting may be needed for hyperglycemia and ketosis
- Can safely be given every 3-4 h w/o discussion w/ physician
67
What is the target for BG and ketones during brief illness?
- BG < 14 mmol/L
| - Ketones negative
68
What should be done if pt is having trouble eating and drinking?
- 10-15 g of carbs should be taken every 1-2 h to prevent hypoglycemia
- 250 mL an hour while awake can be recommended to prevent dehydration
69
When should pharmacotherapy be initiated w/ gestational diabetes?
If pt doesn't achieve BG targets w/in 2 weeks of initiation of nutritional therapy and exercise
70
Which anti-hyperglycemics are safe in pregnancy?
- Use of insulin to achieve glycemic targets has been shown to decrease fetal & maternal morbidity
- Multiple daily injections are most effective
- Metformin shown to be safe in pregnancy
- In women w/ GDM who decline insulin & don't tolerate or are inadequately controlled on metformin, glyburide may be used (glyburide = 3rd line after insulin & metformin)
71
Why should gestational diabetes be diagnosed and treated?
- Macrosomia (large baby)
- Shoulder dystocia & nerve injury (during birth, babies’ shoulder is dislocated b/c is so big)
- Neonatal hypoglycemia
- Preterm delivery
- Hyperbilirubinemia
- C section
- Offspring obesity
- Offspring diabetes
72
What are the targets for GDM?
- Fasting & preprandial BG < 5.3 mmol/L
- 1h postprandial BG < 7.8 mmol/L
- 2h postprandial BG < 6.7 mmol/L
73
Describe the recommendation for ASA use in diabetics?
- ASA not routinely recommended for primary prevention of CVD among diabetics
- Insufficient evidence to support use of ASA for primary prevention (weighing risk of bleeding vs. CVD protection = no benefit)
