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Therapeutics II > DM > Flashcards

DM Flashcards

1
Q

what is the #1 killer in pts with DM

A
  • CVD
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2
Q

what is HbA1C

A
  • % of hb molecules glycosylated with glucose
  • measured q3 mo
  • provides long term glycemic control info
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3
Q

what is eAG

A
  • estimated average glucose

- used to explain BS levels to pts in comparison to A1C

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4
Q

target A1C

A
  • < 7%
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5
Q

target FPG

A
  • 80-130
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6
Q

target PPG 1-2 hours post

A
  • < 180
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7
Q

pts that qualify for A1C goal < 8

A
  • severe hypoglycemia
  • limited life expectancy
  • advanced complications. extensive comorbid conditions
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8
Q

pts that qualify for A1C goal < 6.5

A
  • young
  • no comorbid diseases
  • “pts that can handle it without hypoglycemia or other ADRs”
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9
Q

goal A1C in pts < 18

A
  • < 7.5%
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10
Q

goal FPG in pts < 18

A
  • 90-130
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11
Q

bedtime goal in pts < 18

A
  • 90- 150
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12
Q

why are goals different in children

A
  • prevent cognitive impairment/ worsening of brain dev
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13
Q

target A1C in pregnancy

A
  • < 6%
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14
Q

target FPG in pregnancy

A
  • < 95
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15
Q

target PPG in pregnancy

A
  • 1 hour pp: < 140

- 2 hours pp: < 120

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16
Q

interpreting A1C

A
  • higher= more contribution of FPG

- lower= more contribution of PPG

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17
Q

factors that falsely decrease A1C

A
  • anything that shortens lifespan of RBC
  • blood loss
  • heavy bleeding
  • hemolytic anemia
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18
Q

factors that falsely increase A1C

A
  • iron def anemia

- blood transfusion

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19
Q

vaccines recommended in DM

A
  • flu
  • pneumococcal
  • hep B
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20
Q

lifestyle management of DM

A
  • self mgmt education
  • individualized meal planning
  • weight mgmt
  • physical activity
  • tobacco cessation
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21
Q

physical activity recommendations for DM

A
  • 150 min/wk
  • 2-3 d/wk resistance
  • 2-3 d/wk flexibility
  • interrupt prolonged sitting every 30 min
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22
Q

BP goals in DM

A
  • <130/80 if HTN and ASCVD or ASCVD risk > 15%

- < 140/90 if ASCVD risk < 15%

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23
Q

what is basal insulin

A
  • constant low level

- maintains homeostasis in fasting state

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24
Q

what is bolus insulin

A
  • covers meal stimulated bursts of glucose
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25
Q

when is insulin indicated (not in DM2)

A
  • DM1
  • GDM
  • hyperglycemic crisis
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26
Q

when is insulin indicated in DM2

A
  • A1C > 10%
  • glucose > 300
  • marked hyperglycemia +/- wt loss
  • A1C above goal despite 3 non-insulin meds
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27
Q

beta cell function considerations with DM

A
  • at time of dx have already lost 50% of function

- beta cell function will continue to decline

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28
Q

advantages of early insulin

A
  • reduced glucose toxicity
  • facilitates beta cell rest -> preserved function
  • prevent/ minimize diabetes complications
  • protect against endothelial damage
  • overcome pt/ clinician barriers
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29
Q

disadvantages of early use of insulin

A
  • most studies that show benefit used multi daily inj or pumps
  • complex instructions
  • more health care utilization?
  • expensive
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30
Q

initiating insulin in DM1

A
  • reqires basal bolus coverage
  • TDD 0.4- 1 u/kg/d
  • typical starting TDD of 0.5 u/kg/day
  • half of TDD is basal insulin, other half is divided among meals
31
Q

how do you determine insulin: CHO ratio?

A
  • rule of 500

- 500/ TDD insulin

32
Q

initial insulin dosing in DM2

A
  • basal insulin: 10 u/d OR 0.2 u/kg/d

- bolus insulin: 4 units/d with largest meal or 10% of basal dose

33
Q

which insulin should be adjusted with FPG dysfunction

A
  • basal
34
Q

which insulin should be adjusted with pre/ post prandial dysfunction

A
  • bolus
35
Q

how do you adjust basal insulin

A
  • takes 3-5 days for basal to reach steady state
  • titrate 2-4 units 1-2X a week
  • if hypglycemia reduce dose by 10-20 %
36
Q

how do you adjust bolus insulin

A
  • increase meal time dose by 1-2 units twice weekly OR 10-15% twice weekly
  • every 3 mo add addition mealtime insulin if not at goal
37
Q

when should regular insulin be injected

A
  • 30-60 min before meal
38
Q

when should rapid acting insulin be injected

A
  • 5-15 min before meal
39
Q

switching between insulin preparations

A
  • generally 1:1
  • consider when insulin needs to be taken
  • exception: NHP -> glarginine or degludec is 80% of NHP TDD
40
Q

what is premixed insulin

A
  • combines NHP or NHP-like insulin with rapid or short acting
  • 2-3 injections/ day needed
41
Q

benefits of premixed insulin

A
  • simplifies mgmt
  • less costly?
  • less injections
  • good if predictable heating habits and low risk hypoglycemia
  • comparable A1C lowering ability
42
Q

cons of premixed insulin

A
  • must eat regular meals to avoid hypoglycemia
  • hard to dose adj
  • hard to customize regimen
  • should not be used in T1D
43
Q

definition of hypoglycemia

A
  • serum glucose < 70
44
Q

treatment of hypoglycemia

A
  • use 15:15 rule
  • check glucose
  • consume 15-20 g CHO
  • recheck glucose 15 min later
  • repeat until glucose normalizes
45
Q

severe hypoglycemia

A
  • < 54 OR requires assistance from another person
  • cant be treated with PO CHO d/t unconsciousness
  • use glucagon kit
46
Q

lipohypertrophy

A
  • accum of subcuatenous fat
  • can reduce insulin
  • +/- pain
  • d/t repeated injections at same site
47
Q

how do you prevent lipohypertrophy

A
  • rotate injection site

- use new needles with each injection

48
Q

treatment for DM in hospitalized pts

A
  • insulin preferred
  • initiate when persistent hyperglycemia > 180
  • target glucose range of 140-180
49
Q

treatment for NPO pts

A
  • bolus insulin + bolus correction of needed
50
Q

treatment for pts with good nutritional intake

A
  • basal insulin + bolus insulin at meals
51
Q

treatment for critically ill pts

A
  • cont IV
52
Q

add on treatment in DM2 with ASCVD

A
  • GLP1

- SGLT2

53
Q

add on treatment in DM2 with HF or CKD

A
  • SGLT2
54
Q

add on treatment in DM2 with need to minimize hypoglycemia

A
  • DPP4
  • GLP1
  • SGLT2
  • TZD
55
Q

add on treatment in DM2 with need to minimize wt gain/ promote wt loss

A
  • GLP1

- SGLT2

56
Q

add on treatment in DM2 with need to minimize cost

A
  • SU

- TZD

57
Q

how do you titrate metformin?

A
  • week 1: 500 mg
  • week 2: increase to 500 mg BID
  • week 3: increase to 500 mg in AM and 1000 mg in PM
  • week 4: 1000 mg BID
58
Q

which SU is safest in CKD

A
  • glipizide
59
Q

which SGLT2 have best CV benefit

A
  • empagliflozin

- canagliflozin

60
Q

which SGLT2 are best for renal disease

A
  • empagliflozin

- canagliflozin

61
Q

which GLP1 agonists have best CV data

A
  • in order of efficacy:
  • liraglutide
  • semaglutide
  • exenatide
62
Q

which GLP1 agonists ares daily drugs

A
  • exenatide
  • lizisenatide
  • liraglutide
63
Q

which GLP1 agonists are weekly long acting drugs

A
  • exenatide ER
  • dulaglutide
  • semaglutide
  • all impact FPG> PPG
64
Q

when should you intensify treatment?

A
  • every 3-6 mo until goal is met
  • start low and titrate to max dose or max tolerated dose before intensifying
  • triple combo may be needed
65
Q

injectable regimens for DM2-

A
  • basal insulin
  • basal + GLP1
  • basal + bolus
  • premixed insulin
  • usu keep metformin on board to mitigate wt gain and assist in insulin sensitivity
66
Q

combo meds to avoid

A
  • SU + glinide

- GLP1 + DPP4

67
Q

drugs to avoid in CVD

A
  • saxagliptin and alogliptin: increased hospitalizations or HF
  • TZDs- increased risk HF
  • SU?- conflicting data
68
Q

meds that delay renal disease progression

A

-TZDs empa and cana

69
Q

common meds to avoid or need reduction in renal disease

A
  • metformin
  • SU
  • DPP4 except linagliptin
  • exenatide
  • caution initiating SGLT2 in renal disease
70
Q

metformin considerations for renal disease

A
  • C/I in GFR < 30
  • do NOT initiate if GFR 30-45
  • if GFR 45-60 and already on metformin, can continue use, monitor renal fn
  • if GFR 30-45 and already on metformin weigh pros and cons, consider dose reduction by 50%
71
Q

drugs that cause weight loss

A
  • GLP1
  • amylin analog
  • SGLT2
72
Q

drugs that are weight neutral

A
  • metformin
  • DPP4
  • AGI
73
Q

drugs that cause weight gain

A
  • TZDs
  • SU
  • glinides
  • insulin

Therapeutics II (8 decks)

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