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naplex 2024 > 44. Diabetes (need to complete) > Flashcards

44. Diabetes (need to complete) Flashcards

1
Q

Diabetes is due to decreased___ , ____, or both

A

insulin secretion, insulin sensitivity

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2
Q

Define T1DM

A

Autoimmune destruction of beta-cells (no beta-cells = no insulin production)

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3
Q

Define T2DM

A

insulin resistance and insulin deficiency due to beta-cell damage

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4
Q

Metformin can be used in prediabetes pts with BMI ___, age ___, and women with hx of ____

A

BMI ≥35, age <60 yo, and women with hx of GDM

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5
Q

Pregnant women are tested for GMD at ___ using ____

A

24-28 weeks using oral glucose tolerance test (OGTT)

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6
Q

Risk factors of DM

A

Physical inactivity
Overweight (BMI ≥25 or 23 in asian-americans)
Race (AA, asian-american, latino/hisptanic-american, native american, pacific islander)
Hx of GDM
A1C ≥ 5.7%
First-degree relative with DM (sibling/parent)
HLD, HTN, CVD, smoking
Other conditions that cause insulin resistance (e.g. acanthosis, nigricans, PCOS)

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7
Q

Symptoms of DM

A

Polyuria, polyphagia, polydipsia, fatigue, blurry vision, erectile dysfunction, vaginal fungal infections
T1DM - initial presentation is often DKA

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8
Q

Screening start age

A

35 yo

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9
Q

All asymptomatic children, adolescents, and adults who are ____ and have at least 1 other risk factor should be tested and repeat every ____ years if normal

A

overweight (BMI ≥25 or 23 for asian-americans), repeat every 3 years

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10
Q

There are 3 types of DM tests: ___, ___, and ___. ___ is preferred.

A

Hg A1C, fasting plasma glucose (FPG), and OGTT. No single test is preferred.

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11
Q

T/F: Positive DM test does not require another test to confirm

A

Positive test should be confirmed with a second abnormal test result unless clear clinical diagnosis (e.g classic symptoms + random BG ≥ 200)

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12
Q

Diagnosis Criteria for DM A1C

A

A1C ≥ 6.5%

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13
Q

Diagnosis Criteria for Pre-diabetes A1C

A

5.7-6.4

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14
Q

Diagnosis Criteria for DM FPG (mg/dL)

A

≥126

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15
Q

Diagnosis Criteria for Pre-diabetes FPG (mg/dL)

A

100-125

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16
Q

Diagnosis Criteria for DM OGTT (2hr BG, mg/dL)

A

≥ 200

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17
Q

Diagnosis Criteria for Pre-diabetes OGTT (2hr BG, mg/dL)

A

140-199

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18
Q

Treatment goals for A1C for non-pregnant

A

<7

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19
Q

Treatment goals for Pre-prandial for non-pregnant

A

80-130

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20
Q

Treatment goals for Pre-prandial for pregnant

A

≤95

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21
Q

Treatment goals for 2hr PPG for non-pregnant

A

<180

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22
Q

Treatment goals for 1hr PPG for pregnant

A

≤140

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23
Q

Treatment goals for 2hr PPG for pregnant

A

≤120

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24
Q

A1C testing frequency if not at goal

A

every 3 months

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25
Q

A1C testing frequency if at goal

A

every 6 months

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26
Q

A1C to estimated average glucose (eAG) math

A

A1C 6% = 126 mg/dL + additional 1% = 28 mg/dL

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27
Q

Waist circumference goal for females

A

<35 inches

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28
Q

Waist circumference goal for females

A

<40 inches

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29
Q

1 serving = ___ grams of carbs (list examples)

A

15 g of carbs = 1 small piece of fruit, 1 slice of bread, OR ⅓ cup of cooked rice/pasta

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30
Q

Physical Activity recommendation

A

At least 150 min/week of moderate intensity activity
Reduce sedentary habits, stand every 30 min at minimum

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31
Q

Micro or macrovascular disease: Retinopathy

A

Microvascular

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32
Q

Micro or macrovascular disease: Diabetic kidney disease (i.e. neuropathy)

A

Microvascular

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33
Q

Micro or macrovascular disease: Peripheral neuropathy (i.e. loss of sensation, often in feet, increased risk of foot infections and amputations)

A

Microvascular

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34
Q

Micro or macrovascular disease: Autonomic neuropathy (gastroparesis, loss of bladder control, erectile dysfunction)

A

Microvascular

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35
Q

Micro or macrovascular disease: Coronary artery disease (CAD), including MI

A

Macrovascular

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36
Q

Micro or macrovascular disease: Cerebrovascular disease (CVA), including stroke

A

Macrovascular

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37
Q

Micro or macrovascular disease: Peripheral artery disease (PAD)

A

Macrovascular

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38
Q

T/F: ASA 81mg is recommended for primary prevention in all patients

A

False - ASA 81mg daily is recommended for ASCVD secondary prevention (e.g. post-MI)

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39
Q

Alternative for secondary ASCVD prevention in DM patients if aspirin allergy

A

clopidogrel 75mg daily

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40
Q

High or moderate intensity statin: DM patient with ASCVD

A

High intensity

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41
Q

High or moderate intensity statin: DM patient age 40-75yo with ≥ 1 ASCVD risk factor

A

High intensity

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42
Q

High or moderate intensity statin: DM patient age 40-75yo (no ASCVD)

A

Moderate intensity

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43
Q

High or moderate intensity statin: DM patient age <40 yo with ASCVD risk factors

A

Moderate intensity

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44
Q

Icosapent ethyl (Vascepa) can be added on for cholesterol control if LDL ___ and TG ____

A

LDL is controlled but TG is 135-299 mg/dL

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45
Q

DM patient lipid panel monitoring frequency

A

Annually, 4-12 weeks after starting statin or increasing dose

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46
Q

DM patient eye exam monitoring frequency

A

eye exam at dx, annually if retinopathy, can defer to every 1-2 years otherwise

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47
Q

Required vaccinations for DM patients (in addition to all childhood vaccines)

A

Hep B, influenza (annually), pneumococcal vaccines

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48
Q

Diabetic kidney disease definition

A

eGFR < 60 and/or albuminuria (urine albumin ≥ 30mg/24hrs or UACR≥30 mg/g)

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49
Q

Treatment options for diabetic kidney disease

A

ACEi/ARB, SGLT2i (if eGFR ≥20) or finerenone (once on max tolerated dose of ACEi/ARB)

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50
Q

DM neuropathy monitoring frequency

A

Sensation - annually with 10g monofilament test and 1 other test (pinprick, temp, vibration)
Comprehensive foot exam - at least annually

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51
Q

DM Foot care counseling points

A

Daily: wash, dry, and examine feet, moisturize top and bottom of feet but NOT between toes
Each office visit: check feet
Annually: foot exam by podiatrist
Trim toenails with nail file
Wear socks and shoes, elevate feet when sitting

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52
Q

BP goal for DM patient

A

<130/80

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53
Q

BP treatment options for DM with no albuminuria or CAD

A

thiazide, DHP CCB, ACEi/ARB

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54
Q

BP treatment options for DM with albuminuria or CAD

A

ACEi/ARB

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55
Q

Natural products used for DM

A

cinnamon, alpha lipoic acid, chromium

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56
Q

LDL goal for DM patients

A

LDL <55 if ASCVD, <70 for all others

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57
Q

Insulin can be used initially in T2DM patients if ___ or ____

A

severe hyperglycemia: A1C > 10% or BG ≥ 300

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58
Q

Recommended to start 2 drugs at baseline in T2DM patients if A1C ____

A

8.5-10%

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59
Q

Start ___ or ___ if T2DM patients has ASCVD, HF, or CKD

A

GLP1RA or SGLT2i

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60
Q

T2DM medication combinations to avoid

A

DPP-4i + GLP1RA
SU + insulin

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61
Q

GLP-1 RA MOA

A

Analogs of GLP-1 hormone which increases glucose-dependent insulin secretion, decreases glucagon secretion, slows gastric emptying/improves satiety (=weight loss)

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62
Q

GLP1RA dose frequency:
Liraglutide (Victoza)
Dulaglutide (Trulicity)
Semaglutide (Ozempic)
Exenatide (Byetta)
Exenatide ER (Byetta BCise)

A

Liraglutide (Victoza) - SC daily
Dulaglutide (Trulicity) - SC once weekly
Semaglutide (Ozempic) - SC once weekly, PO once daily
Exenatide (Byetta) - SC BID
Exenatide ER (Byetta BCise) - SC once weekly

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63
Q

Dual GLP-1 and GIP agonist dose frequency: Tirzepatide (Mounjaro)

A

SC weekly

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64
Q

Which GLP1RAs are recommended in patients with ASCVD (or high risk) and as an alternative in CKD because of CV benefits?

A

Liraglutide (Victoza)
Dulaglutide (Trulicity)
SC semaglutide (Ozempic)

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65
Q

Which GLP1RA also comes in an oral tablet formulation?

A

Semaglutide (Rybelsus)

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66
Q

GLP1 RA names end in “-___”

A

“-tide”

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67
Q

GLP1 RA (except Byetta) Boxed warning

A

increased risk of thyroid C-cell carcinoma
Do NOT use if personal or family hx of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2)

68
Q

GLP1 RA Warnings

A

Pancreatitis (can be fatal, RF: gallstones, alcoholism, or increased TGs)
NOT recommended in pts with severe GI disease, including gastroparesis

69
Q

Bydureon BCise warnings

A

Serious injection-site reactions (e.g. abscess, cellulitis, necrosis) with or w/o SC nodules

70
Q

Ozempic and Mounjaro warnings

A

increased complications with diabetic retinopathy

71
Q

Which GLP1RAs have increased complications with diabetic retinopathy

A

Ozempic and Mounjaro

72
Q

Side effects of GLP1RAs and GIP agonists

A

Weight loss, N/V/D (reduced with dose titration), hypoglycemia, injection site reactions, AKI, gallbladder disease
Tirzepatide: increased HR

73
Q

GLP1 RA and GIP agonist A1C decrease %

A

0.5-1.5%

74
Q

GLP1 RA and GIP agonist effect on BG

A

decreases postprandial BG

75
Q

GLP1 RA and GIP agonist hypoglycemic risk

A

Low

76
Q

Do NOT use GLP1 RA and GIP agonists with ___ (overlapping mechanism)

A

DPP-4 inhibitors

77
Q

Exenatide (Byetta) dose timing with meals

A

within 60min of meals

78
Q

Semaglutide (Rybelsus) dose timing with meals

A

Take does ≥30 min before first food/drink/meds of the day

79
Q

Pen needles are not provided with ___ or ____ but provided with all other GLP1RAs

A

Byetta or Victoza

80
Q

T/F: Glucose-lowering effects are often seen immediately with initial doses of GLP1 RAs

A

False - often not seen with initial doses (titrated to reduce GI ADEs)

81
Q

GLP1RAs can (increase/decrease) INR in patients on warfarin

A

Increase

82
Q

SGLT2 inhibitor MOA

A

Inhibits SGLT2 (expressed in proximal renal tubules, responsible for reabsorption of filtered glucose), reduces reabsorption of glucose and increases glucose in urine excretion (decrease BG)

83
Q

Which SGLT2is have shown benefits in patients with HF, CKD, and/or ASCVD?

A

Canagliflozin, dapagliflozin, and empagliflozin

84
Q

SGLT2i names end in “-____”

A

“-gliflozin”

85
Q

SGLT2i dosing frequency and timing

A

once daily in the morning

86
Q

SGLT2i contraindications

A

Dialysis

87
Q

SGLT2i warnings

A

Ketoacidosis (can occur with BG <250, D/C prior to surgery d/t risk)
Genital mycotic infections, urosepsis, pyelonephritis, necrotizing fasciitis (perineum)
Hypotension, AKI, and renal impairment (d/t intravascular volume depletion)

88
Q

Canagliflozin (Invokana) warnings

A

Increase risk of leg and foot amputations, higher risk with hx of amputation, PAD, peripheral neuropathy and/or diabetic foot ulcers
Hyperkalemia risk when used with other drugs that increase potassium
Risk of fractures

89
Q

SGLT2i side effects

A

weight loss, increase urination, increase thirst, hypoglycemia, increase Mg/PO4

90
Q

SGLT2i A1C lowering %

A

0.7-1%

91
Q

SLGT2i hypoglycemia risk

A

low (unless used with insulin)

92
Q

SGLT2i have increased risk of intravascular volume depletion (causing ___ and ___) if used in combination with ____, ___, and ____

A

causing hypotension and AKI if used in combination with diuretics, RAAS inhibitors, or NSAIDs

93
Q

Uridine diphosphate glucuronosyltransferase (UGT) inducers (e.g. ___, __, ____) can (increase/decrease) canagliflozin levels

A

rifampin, phenytoin, phenobarbital can decrease canagliflozin levels
Consider using 300mg dose if used in combo and eGFR≥60

94
Q

Metformin MOA

A

decrease hepatic glucose production
increase insulin sensitivity
decrease intestinal absorption of glucose

95
Q

Metformin boxed warning

A

Lactic acidosis - increased risk with renal impairment, contrast dye, and excessive alcohol/drugs

96
Q

Metformin contraindications

A

eGFR <30, acute or chronic metabolic acidosis (includes DKA)

97
Q

Metformin warnings

A

NOT recommended to start if eGFR 30-45 (reassess if already taking and eGFR falls <45)
VitB12 deficiency: s/sx can include peripheral neuropathy and cognitive impairment; monitor B12 levels periodically (e.g. every 1-2 years)

98
Q

Metformin ADEs

A

GI effects (diarrhea, nausea, flatulence, cramping)
Typically transient

99
Q

Metformin A1C lowering %

A

1-2%

100
Q

Metformin weight effect

A

Neutral

101
Q

Metformin hypoglycemia risk

A

No hypoglycemia

102
Q

Metformin ER can leave ____ in stool

A

ghose tablet

103
Q

Intra-arterial ____ (used for imaging studies) can increase risk of lactic acidosis. Discontinue metformin before imaging procedure. Restart metformin ___ after procedure if eGFR is stable.

A

Iodinated contrast media, 48hrs

104
Q

Alcohol can ____ risk of lactic acidosis

A

increase
excessive intake, acute or chronic, should be avoided

105
Q

Which can increase risk of lactic acidosis with metformin?

A

Iodinated contrast media
alcohol
topiramate + metformin

106
Q

SUs and meglitinides MOA

A

stimulate insulin secretion from pancreatic beta-cells to decrease postprandial BG

107
Q

Meglitinides have (faster/slower) onset and (shorter/longer) duration of action compared to SUs

A

faster onset (15-60min) and shorter duration of action

108
Q

Name 3 older, first generation SUs (should NOT be used)

A

chlorpropamide, tolazamide, and tolbutamide

109
Q

Meglitinide names end in “-____”

A

“-glinide”

110
Q

SUs names start with “__” and end in “-___”

A

Start with G and end with “-ide”

111
Q

SUs contraindications

A

Sulfa allergy ( not likely to cross-react)

112
Q

SUs warnings

A

hypoglycemia

113
Q

SUs ADEs

A

Weight gain, nausea

114
Q

SUs A1C lowering %

A

1-2%

115
Q

T/F: Efficacy of SUs increase the longer you use it

A

False - decreased efficacy after long-term use (as pancreatic beta-cell function declines)

116
Q

Glipizide IR dose timing with meals

A

Take 30 min before meals
All other products taken with breakfast or first meal of the day
May need to hold doses if NPO

117
Q

Glucotorol XL is an OROS formulation and can leave a ___ in stool

A

ghost tablet

118
Q

Which SUs are not preferred in elderly (Beers criteria) d/t hypoglycemia risk

A

Glimepiride, glyburide

119
Q

Patients with ___ deficiency can be increased risk of hemolytic anemia with SUs

A

G6PD

120
Q

Repaglinide dose timing with meals

A

Take 15-30 min before meals

121
Q

Nateglinide dose timing with meals

A

1-30 min before meals

122
Q

Meglitinides contraindications

A

T1DM, DKA

123
Q

Meglitinides warnings

A

Hypoglycemia, caution with severe liver/renal impairment

124
Q

Meglitinides ADEs

A

weight gain, HA, URTIs

125
Q

Meglitinides A1C lowering %

A

0.5-1.5%

126
Q

SUs are CYP___ substrates, use caution with inducers or inhibitors

A

CYP2C9

127
Q

___ and ___ can increase repaglinide, leading to decrease BG

A

Gemfibrozil and clopidogrel

128
Q

Repaglinide is contraindicated with ___

A

Gemfibrozil

129
Q

___ can increase the risk for delayed hypoglycemia when taking insulin or insulin secretagogues (SUs or meglitinides)

A

Alcohol

130
Q

DPP-4i prevent enzyme DPP-4 from breaking down ____

A

incretin hormones, GLP1 and GIP

131
Q

DPP-4i MOA

A

prevent DPP-4 breakdown of GLP1 and GIP, increase insulin release from pancreatic beta-cells and decrease glucagon secretion (decreases hepatic glucose production) from pancreatic alpha-cells
Enhance the effects of the body’s own incretins

132
Q

DPP-4i names end in “-___”

A

“-gliptin”

133
Q

Which DPP-4is require renal dose adj

A

Sitagliptin (Januvia)
Saxagliptin (Onglyza)
Alogliptin (Nesina)

134
Q

Which DPP-4is do NOT require renal dose adj

A

Linagliptin (Tradjenta)

135
Q

DPP-4i warnings

A

Pancreatitis, severe arthralgia (joint pain), acute renal failure, hypersensitivity reactions, bullous pemphigoid (blisters/erosions requiring hospitalization)
Risk of HF wtih saxagliptin and alogliptin, but warning added for class
Alogliptin: hepatotoxicity

136
Q

Which DPP-4i has warning of hepatotoxicity?

A

Alogliptin (Nesina)

137
Q

DDP-4i ADEs

A

generally well tolerated, can cause nasopharyngitis, URTIs, UTIs, peripheral edema, rash

138
Q

DPP-4i A1C lowering %

A

0.5-0.8%

139
Q

DPP-4i weight effect

A

neutral

140
Q

DPP-4i hypoglycemia risk

A

Low

141
Q

DPP-4i and ___ have overlapping mechanisms and should be used together

A

GLP1RA

142
Q

Saxagliptin is a major substrate of CYP___ and ___. Limit the dose to ___ with strong inhibitors including protease inhibitors (e.g. ___,____) and anti-infectives (___,___,___)

A

CYP3A4 and P-gp
Limit dose to 2.5mg
atazanavir, ritonavir
Clarithromycin,itraconazole, ketoconazole

143
Q

Linagliptin is a major substrate of CYP___ and ___. Decreased linagliptin levels with strong inducers (e.g. ___, ___, ___, ___)

A

3A4 and pgp
Carbamazepine, phenytoin, rifampin, St. John’s wort

144
Q

Thiazolidinediones (TZDs) MOA

A

Perozisome proliferator-activated receptor gamma (PPAR𝛾) agonist that increase peripheral insulin sensitivity (increase uptake and utilization of glucose by peripheral tissues, aka insulin sensitizers)

145
Q

___ is currently the only TZD available in the US

A

Pioglitazone

146
Q

TZD boxed warning

A

Can cause or exacerbate HR, do NOT use with NYHA class III/IV HF

147
Q

TZD Warning

A

Edema (including macular edema), risk of fractures, hepatic failure, can stimulate ovulation (can lead to unintended pregnancy)
Increase risk of bladder cancer (do NOT use in pts with hx of bladder cancer)

148
Q

TZD ADEs

A

Peripheral edema, weight gain, URTIs, myalgia

149
Q

TZD A1C Lowering

A

0.5-1.4%

150
Q

TZD hypoglycemia risk

A

Low

151
Q

TZD is a major substrate of CYP___, use caution with inducers (e.g. ___) or inhibitors (e.g.___)

A

2C8
rifampin
gemfibrozil

152
Q

When using ___ and hypoglycemia occurs, it cannot be treated with sucrose (fruit juices, table sugar, or candy); glucose tablets/gel must be used to treat hypoglycemia

A

Alpha-glucosidase inhibitors - acarbose or miglitol (Glyset)

153
Q

Alpha-glucosidase inhibitors (acarbose, miglotiol (Glyset)) administration instructions

A

Each dose should be taken with first bite of each meal

154
Q

Pramlintide (Symlin) hypogylcemia risk

A

Significant hypoglycemia risk - must reduce mealtime insulin dose by 50% when starting

155
Q

Basal insulin examples

A

glargine
detemir
degludec

156
Q

Rapid-acting insulin examples

A

aspart
lispro
glulisine

157
Q

Short-acting insulin

A

regular insulin

158
Q

What insulin is contraindicated in any lunch disease, including asthma or COPD?

A

Inhaled insulin (Afrezza)

159
Q

General side effects of insulin

A

Weight gain
Lipoatrophy (loss of SC fat at injection site, disfigures skin)
Lipohypertrophy (accumulation of fat lumps under injection site)
Tip: Rotate injection sites and use analog insulins (lower risk than older insulins)

160
Q

Most insulin vials are ___mL and most insulin pens are ___mL

A

10mL
3mL

161
Q

Any percentage mixture of NPH and regular (or rapid-acting) can be made by mixing in a syringe. Which insulin should be drawn up first?

A

Draw up regular insulin (or rapid-acting, clear insulin) first
Then NPH (cloudy)

162
Q

____ is a ready to use (TRU) regular insulin IV bag

A

Myxredlin

163
Q

___ insulin is preferred for IV infusions, including parenteral nutrition; less expensive than other insulins and onset is immediate when administered as continuous IV (Note: should be prepared in non-PVC container)

A

Regular insulin

164
Q

When should regular insulin be administered?

A

SC 30 min before meals

165
Q

When should aspart or lispro insulin be administered?

A

SC 5-15 min before meals
Lispro can also be administered right after eating
Fiasp-aspart and Lyumjev-lispro can be injected with first bite or within 20 min of starting a meal

166
Q

Regular U-500 has many safety risks. In what situations can you use it?

A

When patients require > 200 units of insulin per day
Note: U-500 insulin syringes must be prescribed to avoid errors, do NOT mix with any other insulin

167
Q
A

naplex 2024 (16 decks)

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