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Pharmacology > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Diabetes Diganosis

A

Random Plasma Glucose (RPG)=>=200
Fasting Plasma Glucose (FPG) >=126
Tolerance (OGTT) >=200
HbA1C >=6.5%

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2
Q

HbA1C Postprandial Glucose

A

Major contributor to hyperglycemia at HbA1c <7.3 contributes 69.7%

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3
Q

HbA1C Fasting Plasma Glucose

A

Major contributor to hyperglycemia at HbA1c >10.2

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4
Q

Gestational Diabetes Mellitus

A

Insulin is the preferred medication; Requires frequent titration

Most Pregnancy B; Noninsulin Rxs cross placenta (Glyburide and Metformin)

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5
Q

Types of Insulin

A

Regular, Rapid-acting and NPH insulin

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6
Q

Insulin category C

A

Glragine and Glulisine

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7
Q

Mild Hypoglycemic Stage Treatment

A

Glucose = 60-70mg/dL

TX ; 15-15-15

15 G of CHO Glucose— Wait 15min. —– 15 G again

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8
Q

Moderate Hypoglycemic Stage Treatment

A

Glucose= 41-59 mg/dL S/S; Adre/neuro

Tx; 30-15-30

30 G of CHO —– wait 15min. —- 30G again

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9
Q

Severe Hypoglycemic Stage Treatment

A

Glucose= <40 mg/dL S/S; Adre/neuro (Req. Assist.)

Tx; Glucagon 1mg Subq/IM or 50mls D50W IV
6.5 min and 4 min.

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10
Q

Hyperglycemic Complications

A

Acidosis; Large Ketonemia or ketonuria ; Glucose >600mg/dL ; Ph>7.30; Onset over days to wks

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11
Q

Hyperglycemic Complication Treatment

A

Insulin: Regular

.1 U/Kg/ as I.V Bolus then .1 U/kg/hr infusion

.14 U/Kg Bwt/hr IV infusion

Serum Glucose Not <10% in 1st Hr .14 U/Kg IV bolus then continue previous infusion

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12
Q

Post Hyperglycemic treatment DKA Tx

A

Serum Glucose reduced 200mg/dL then .02-.05 U/kg/hr IV Add 20-30 mEq/L on fluid if K+ < 3.3

Rapid Acting Insulin at 0.1 U/kg SC every 2 hrs (Keep 150-200) until resolution

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13
Q

Post Hyperglycemic treatment HHS Tx

A

Serum Glucose reduced 300mg/dL then .02-.05 U/kg/hr IV keep glucose between 200-300 for 2 hrs then SC

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14
Q

Hyperosmolar Hyperglycemic State (HHS)

A

Significantly higher plasma glucose (600mg/dL)
Serum pH> 7.30

Onset occurs several days to wks

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15
Q

Metabolic Syndrome

A

Pts have a 5 fold increased risk fro T2DM

Has 3-5 components

  • Abd. Obesity - HDL Low -Triglycerides 150
  • BP SBP>130 DBP >85 -Fasting Glucose >100mg
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16
Q

DOC for Diabetics for Dyslipidemia

A

Statin Moderate to High intensity

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17
Q

Insulin

A

Replaces hormone in T1DM and supplements in T2DM
Facilitates Glucose uptake; reduces glucose in plasma

AE; Hypoglycemia, Weight Gain, lipodystrophies

Basal V.S Bolus

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18
Q

Rapid Acting Insulin

A

Lispro- Before or immediately after meals (CS II w/ NPH)

Aspart- Before meals (IV and CSII w NPH)

Glulisine- Before or w/in 20min after meals (IV and CSII w/NPH)

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19
Q

Short Acting Insulin

A

Regular (Humulin/Novolin)

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20
Q

Intermediate Acting Insulin

A

NPH intermediate-acting insulin with onset of action in 1 to 3 hours, duration of action up to 24 hours, and peak action from 6 to 8 hours

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21
Q

Long Acting Insulin

A

Glargine and Detemir

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22
Q

Afrezza

A

Inhaled

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23
Q

Afrezza

A

Tx; T2DM Hypergl Oral Inhaled insulin; At beginning of a meal.

CI; COPD, Asthma, smoke, lung cancer; T1DM needs a long acting insulin; Not for Ketoacidosis DKA

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24
Q

Humilin R-

Novolin R

A

Short Acting Insulin (Can mix w/ NPH) U100 and U500

U500= >200 U/day; 30 min. before meal. (Clear before cloudy) Duration 13-24 hrs

U100=Conyinous SC infusion CSII (duration=4-12 hrs)

DOC for infusion; IV drips preferred; Keep refrigerated

25
Q

U500

A

Highly concentrated form of human regular insulin.

Use; Pts w/ severe insulin resistance; Requires insulin doses> 200 Units/day

Onset and duration = that of NPH

26
Q

NPH (Humulin N)

NPH BNovolin

A

Intermediate Acting

Tx : Fasting Hyperglycemia Basal (Not in relation to meals; Duration 16-24 hrs

Can Mix w/ Lispro, Aspart, Glulisine

27
Q

Insulin Glargene

Insulin Demetir (Albumin bound)

A

Long acting Insulins; Basal (Not in relation to meals)

Not to be mixed w/ other insulins or dilute

28
Q

Insulin Mixture 70/30 Aspart/Protamine

Insulin Mixture 75/25 Lispro/Protamine

Insulin Mixture 50/50 Lispro/Protamine

A

Tx; Hyperglycemia

Meal timing w/15 min. before a meal (Cloudy) onset 30min. Duration <=24 hrs or > 22 hrs (50/50)

Do not mix

29
Q

NPH/Regular 70/30

Humulin) (Novolin

A

Tx : Hyperglycemia

Meal time 30-40 before meal (Cloudy)

Do not Mix

30
Q

Summary Bolus

A

Rapid acting-LAG= Less risk of Postpandrial hypoglycemia compared to insulin

Short-acting Regular U-100= DOC IV infusion
Regular U-500= Insulin resistant pts >200 units/day

Intermediate acting- NPH= Greater risk of nocturnal hypoglycemia (Cloudy)

Long Acting- Detemir/Glargine= Less nocturnal hypoglycemia comapred to NPH

31
Q

Type 1 DM Insulin Mgnt

A
  • Traditional Split
  • Split-Injections (Modified)
  • Basal Bolus (X1 Basal)
  • Basal Bolus (X2 Basal)
32
Q

Traditional Split

A

Intermediate Basal Morning and Afternoon/evening X2

Rapid short-acting Morning Evening X2

33
Q

Split-Injections (Modified)

A

Intermediate Basal morning and Night X2

Rapid short acting morning and Evening X2

34
Q

Basal bolus (Once daily basal)

A

Intermediate or long acting Evening X1

Rapid-short acting Morning-afternoon-evening X3

35
Q

Basal-Bolus (Twice Daily Basal)

A

Intermediate acting Morning and Evening X2

Rapid or Short-Acting M-A-E X3

36
Q

Insulin Basal-Bolus Regimen

A

75kg .4 U/kg/day =30 U TDD 1/2=15 1/2=15

Basal=15 U Bolus=15/ 3 meals =5 U/Meal

37
Q

Insulin Basal-Bolus Regimen

A

75kg .4 U/kg/day =30 U TDD 1/2=15 1/2=15

Basal=15 U Bolus=15/ 3 meals =5 U/Meal

38
Q

Insulin to carbohydrate calculation

A

Often 1 U for every 15G of Carbs
Obese= 1 U for every 5 G of carbs (1:5)
Lean= 1 U for every 20 G of carbs (1:20)

W/ Rapid Acting insulin Estimated 500/TDD=CHO cover

500/62= 8 G = For every unit insulin covers 8G Carbs

39
Q

Corrective or supplemental Dose

A

Added to bring glucose into desired range

Regular insulin Correction Factor= 1500/TDD
Rapid Acting Insulin correct factor= 1800/TDD

Correction Dose= Current BG - Desired BG 160-120

TDD=45 –> RAI Factor= 1800/TDD 1800/45=40

160-120= 40/Correction factor =40 =1 U

Total corrective daily dose TDD=30+5/meal =5+1/meal

40
Q

Dawn phenomenon

A

Hyperglycemia in AM from Insufficient evening Basal Insulin Solution= Increased. evening basal insulin

0200-0300 SMBG normal or elevated

41
Q

Somogyi Effect

A

Hypoglycemia at midnight from Too much evening basal insulin Solution= Decrease evening Basal insulin

0200-0300 SMBG decrease BG

42
Q

T2DM Starting Dose of insulin

A

1st Line = Biguanides and insulin 0.1-0.25 units/kg 100% Basal e.g.

  • 10 U NPH or 0.1-0.2 Units/kg at bedtime
  • 10 U Glargine 0.1-0.2 Units/kg once daily
  • 10 U Detemir or 0.1-0.2 Units/kg once daily

Consider 0.2-0.3 Units/kg/day initial in severe hyperglycemia BG 250> RPG >300 or A1C>10; not met–> 5-10% titration weekly

43
Q

Biguanides (Metformin)

A

Decreases Hepatic Glucose production; (Glycogenolysis) Enhances insulin sensitivity; 1st Line T2DM and PC Ovary System;

Give w/ largest meal min. GI SE; Caution renal Dysfx; Risk of Hypoglycemia; Lactic acidosis (rare)

CI; Scr>1.4 Lactic acidosis such as CHF, Elderly w/ dec. CrCl, liver disease; alcoholism ; sepsis; No I^131, 2-3 day and cimetidine

44
Q

Sulfonylureas

A

“Insulin secreteagogues” Binds to specific Recep. –> stimulation of Beta cells –> Insulin secretion

Use: 1st and 2nd Line T2DM; Reduced efficacy over time : AE-Hypoglycemia; Weight gain; Cholestasis; GI, hyponetremia

DI: Warfarin, phenytoin, Salicylates;; CYP2C9 Hepatic;; Chloropramide w/ renal dysfx;; GLP-1 Agonist and DPP-4 inhibitors=Consider dec. Sulfornylureas by 50%

45
Q

Sulfonylureas Agents 1st Generations

A
  • Chlorpropamide; Highest Hypoglycemic potential
  • Tolazamide
  • Tolbutamide (Shortest acting)
46
Q

Sulfonylureas Agents 2nd Generation

A

2nd Line therapies added to Metformin if A1C not met
1st Line if cannot take Metformin

  • Glipizide
  • Glyburide (Highest rates of hypoglycemia) Prego B
  • Glimepiride; Safe in renal Dysfx
47
Q

Meglitinides

A

1st Line if Sulfonylureas or Metformin/combo AE or CI
Stimulates insulin secretion from the B cells. Requires presence of Glucose to stimulate insulin secretion

Less risk of hypoglycemia; Useful for pts who skip meal
Consider insulin if hx of skipping meals; Weight neutral;; Less hypoglycemia than sulfonylureas;; URI Flu like

48
Q

Meglitinides Agents

A
  • Nateglinide; TID before meals CYP 2c9

- Repaglinide; TID before meals CYP 2c8

49
Q

Thiazolidinediones (TZDs)

A

Enhances insulin sensitivity in muscle and fat by increasing glucose transporter. binds PPAR-Y Inc sensi.

2nd /3rd Line for T2DM AE: Weight Gain, avoid in CHF, MI; Inc Fx rate; Fatal Hepatofailure; Inc. Bladder cancer; CHF inc. w/ insulin; MI risk w/ nitrates

50
Q

Thiazolidinediones (TZDs) Agents

A

Pioglitazone

Rosiglitazone

51
Q

Dipeptidyl Peptidase-4 (DPP-4)

A

Inhibits an enzyme which prevent incretin degradation
GLP-1 and GIP, which in crease insulin secretion
2nd and 3rd line for T2DM

Weight neutral, pancreatitis assoc, Incr of infx URI/UTI
worsen HF; Dec. sulfonyluria by 50% if combo

52
Q

Dipeptidyl Peptidase-4 (DPP-4)

A
  • Linagliptin; No adjust for renal or hepatic; CYP3A4
  • Alogliptin; Adjust for renal and hepatic
  • Salxagliptin; CYP3A4 substrate (URI, UTI, CHF)
  • Sitagliptin; Adjust for renal and hepatic
53
Q

Glucagon-like peptide (GLP-1)

A

Stimulates Receptors which increase insulin production and secretion in response to BG; 2nd 3rd Line

AE; Hypoglycemia; Assoc. w/ renal insuff; Thyroid cell cancer; Pancreatitis; CI-T1DM ; Delays GI absorp.
May decrease BP and improve lipid profile

54
Q

Glucagon-like peptide (GLP-1) Agents INJectables

A
  • Dulaglutide; No adjust for renal imapirment
  • Albiglutide;
  • Liraglutide; Weight loss (Weight mgnt)
  • Exanatide;not for renal impairment; reconstitute; less nausea; weight loss indicated
55
Q

Pramlitidine INJ (Synthetic Amylin Analogue)

A

Adjunct to insulin meal time SQ; Suppress innapropriate high prostprandial glucagon secretion; Increase satiety= weight loss T1 and 2DM

Compound hypoglycemia 2 fold in T1DM, dec. insulin 50%; may delay absorption of drugs; Skip dose if meal skipp

56
Q

Alpha Glucosidase Inhibitors

  • Acarbose
  • Miglitol
A

Inhibit enzyme in small intestine, delays breakdown of carbs and sucrose–> reduce post-prandial; 3rd Line T2DM

Glucose, lactose, fructose not affected

AE: Weight neutral; GI bloating, gas, diarrhea, pain
CI- Short bowel syndrome, IBS, Cirrhosis; Beano helps but decreases efficacy; No use w/ Scr>2mg/dL

57
Q

Selective sodium dependent Glucose Transporter Inh.

  • Dapagliflozin; Inc risk of bladder cancer
  • Empagliflozin
  • Canagliflozin; Inc risk of stroke
A

Inhibits transporter reducing reabsorption of filtered glucose In Nephron 3rd Line agent

AE; genital fungal infections and UTI; Incr. LDL; Polyuria
Do not use in renal dysfx

58
Q

Colesevalem (Bile Acid Sequestrans)

A

Bile acid binding agents T2DM; may reduce hepatic insulin resistance and reduce glucose absorption

Reduce CHD mortality, major coronary events
May increase TG concentration; Dec absorption of Rxs

59
Q

Bromocryptine (Dopamine Agonist)

A

May centraly reverse metabolic changes assoc w/ insulin resistance and obesity Reduce A1C 1%

AE; Nausea/vomiting and hypotension; Rhinitis and sinusitis

Pharmacology (5 decks)

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