Lecture 7-Glucose Control Flashcards
What protein is released from the CNS when there is glucose in the bloodstream; released to give you a feeling of fullness after eating; works in the pancreas to have the pancreas release insulin from the beta islet cells; and works in the liver to go from glycogenolysis to gluconeogenesis?
Glucagon like peptide (GLP1)
What protein breaks down GLP1 to stop its activity?
Dipeptidylpeptidase (DPP4)
Type I diabetes–historically ___ (juvenile/older) onset; ___ (abrupt/slow) onset; ___ (does/does not) require exogenous insulin to treat; ___ (prone/not prone to) ketoacidosis; ___ (small/large) fluctuations in blood glucose concentration; ___ (thin/thicker) body habitus
type I diabetes–historically juvenile onset; abrupt onset; does require exogenous insulin to treat; prone to ketoacidosis; large fluctuations in blood glucose concentration; thin body habitus
Patients are genetically predisposed to type I diabetes–T/F?
True
Genetic predisposition to type I diabetes is caused by altered human lymphocyte antigen on the short arm of chromosome ___; this defect causes “___itis”
chromosome 6; this defect causes “insulinitis”
Autoantibodies may be detected at the time of type I diabetes diagnosis but may be absent years later–T/F?
True
What are the main signs and symptoms at time of type I diabetes diagnosis?–___glycemia; ___acidosis; 3 P’s
- Hyperglycemia
- Ketoacidosis
- 3 P’s–polyuria, polyphagia, polydypsia
Type II diabetes–historically ___ (juvenile/adult) onset; ___ (does/does not) require exogenous insulin; ___ (prone/not prone to) ketoacidosis; ___ (stable/unstable) blood glucose concentration; ___ (thin/obese) body habitus
Type II diabetes–historically adult onset; does not require exogenous insulin (patients may still be on it though); not prone to ketoacidosis; stable blood glucose concentration; obese body habitus
What are (3) signs and symptoms of type II diabetes?
3 P’s–polyuria, polydypsia, polyphagia
The younger a patient is when they develop type II diabetes, the more likely they will require exogenous insulin (in addition to oral hypoglycemics)–T/F?
True
(4) medication classes that can cause hyperglycemia–gluco___; anti___; ___ medications; ___
glucocorticoids; antipsychotics; HIV medications; octreotide
(3) stressful situations that can cause hyperglycemia
illness, trauma, pregnancy
Diagnosis of diabetes–fasting blood glucose ___ mg/dl or greater; random blood glucose > ___ mg/dl
fasting blood glucose 126 mg/dl or greater; random blood glucose > 200 mg/dl
By the time patients are diagnosed with type II diabetes, ~90% of their beta islet cells are gone–T/F?
True–early diagnosis/treatment is key
BG monitoring–ISO guideline 15197 suggests that for glucose levels < 75 mg/dl, a meter should read within ___ mg/dl of the reference sample, and for levels > 75 mg/dl, the reading should be within ___%. A meter should also be able to meet these targets in at least ___% of the samples tested
for glucose levels < 75 mg/dl, a meter should read within 15 mg/dl of the reference sample, and for levels > 75 mg/dl, the reading should be within 20%. A meter should also be able to meet these targets in at least 95% of the samples tested.
Normal HgA1C = ___-___%
4-6%
ADA recommends HgA1C < ___-___%, depending on the age of the diabetic patient
< 7-8.5%
HgA1C gives an idea of the degree of control of blood glucose levels over the past ___ months
3 months
HgA1C assesses the long-range effectiveness of glucose control–T/F?
True
Urinary ___ are assessed by reagent strips if patients develop symptoms of cold, flu, vomiting, abdominal pain, polyuria, or on finding an unexpectedly high glucose level
Urinary ketones
Urinary ketones can be used to monitor patients at risk of going into diabetic ___, type ___ diabetics
diabetic ketoacidosis, type I diabetics
Diabetes treatment–___ changes are first line treatment for pre-diabetics
dietary changes are first line treatment for pre-diabetics
Diabetes treatment–oral ___ agents for type II diabetics
oral hypoglycemic agents for type II diabetics
Diabetes treatment–___ for type I and advanced type II diabetics
insulin for type I and advanced type II diabetics
What does PI-3K do?–It moves a ___ into the cell wall of cells
It moves a glucose transporter into the cell wall of cells
Insulin MOA–binds to plasma membrane ___ receptors; phosphorylated receptor substrates then activate or inactivate numerous enzymes and other mediating molecules; translocation of ___ to plasma membranes
binds to plasma membrane insulin receptors; phosphorylated receptor substrates then activate or inactivate numerous enzymes and other mediating molecules; translocation of glucose transporters to plasma membranes
Glucose transporters facilitate ___ diffusion into cells; shift intracellular glucose metabolism toward ___ (glyco___); stimulate cellular uptake of ___ acids, ___ate, ___ium, and ___ium; stimulate protein ___ and inhibit proteo___; regulate ___ expression via insulin regulatory elements in target DNA
Glucose transporters facilitate glucose diffusion into cells; shift intracellular glucose metabolism toward storage (glycogenesis); stimulate cellular uptake of amino acids, phosphate, potassium, and magnesium; stimulate protein synthesis and inhibit proteolysis; regulate gene expression via insulin regulatory elements in target DNA
___ occurs when there is an impaired intracellular insulin signal that results in decreased recruitment of glucose transport proteins to the plasma membrane and subsequent decreased glucose uptake
Insulin resistance
Compensatory ___insulinemia occurs to overcome insulin resistance
Compensatory hyperinsulinemia occurs to overcome insulin resistance
Cells send signals to the CNS that they’re starving (because insulin signal is messed up and isn’t bringing glucose into the cells); body sends signals to the pancreas to make more glucose/release more insulin, resulting in hyperinsulinemia; hyperinsulinemia leads to eventual burnout of the pancreas and worsening of diabetes
Insulin receptor saturation occurs with ___ (low/high) circulating concentrations of insulin; ___ (more/less) insulin receptors are popped into the cell walls as a result
Insulin receptor saturation occurs with low circulating concentrations of insulin; more insulin receptors are popped into the cell walls as a result
The number of insulin receptors in a cell wall is ___ (inversely/directly) related to the plasma concentration of insulin
The number of insulin receptors in a cell wall is inversely related to the plasma concentration of insulin
The higher the plasma concentration of insulin, the ___ (less/more) insulin receptors in the cell wall
The higher the plasma concentration of insulin, the less insulin receptors in the cell wall
The lower the plasma concentration of insulin, the ___ (less/more) insulin receptors in the cell wall
The lower the plasma concentration of insulin, the more insulin receptors in the cell wall
Insulin can up or down regulate its number of receptors in cell walls in response to circulating concentrations of insulin–T/F?
True
Elimination half-life of insulin is ___-___ minutes
5-10 minutes
Insulin is metabolized by the ___ and ___
kidneys and liver
___% of the insulin that reaches the liver via the portal circulation is metabolized on a single pass through the liver
50% of the insulin that reaches the liver via the portal circulation is metabolized on a single pass through the liver
What prolongs the elimination half-life of insulin more–kidney or liver disease?
Kidney disease prolongs the elimination half-life of insulin more than liver disease
Despite rapid clearance from the plasma, there is a sustained pharmacologic effect of insulin for ___-___ minutes because insulin is tightly bound to ___ receptors
Despite rapid clearance from the plasma, there is a sustained pharmacologic effect of insulin for 30-90 minutes because insulin is tightly bound to tissue receptors
Insulin administered subQ is released ___ (slowly/quickly) into the circulation to produce a sustained biological effect
Insulin administered subQ is released slowly into the circulation to produce a sustained biological effect
Basal rate of insulin secretion by the pancreas is ___ unit/hr
Basal rate of insulin secretion by the pancreas is 1 unit/hr
Food prompts a ___-___ fold increase in insulin secretion
Food prompts a 5-10 fold increase in insulin secretion
Total daily secretion of insulin is approximately ___ units/day
Total daily secretion of insulin is approximately 40 units/day
Insulin response to glucose is greater for IV infusion than oral ingestion–T/F?
FALSE–insulin response to glucose is greater for oral ingestion than IV infusion
Long acting insulins should be used for acute diabetic attacks–T/F?
FALSE–long acting insulins should NOT be used for acute diabetic attacks
What long acting insulin acts just like basal rate insulin; is sgiven once a day; good for people who have very brittle diabetes/lots of swings in glucose levels; also good for patients who are not good at keeping a schedule for giving themselves insulin?
Degludec (Tresiba)
Rates of hypoglycemia with Degludec (Tresiba) are no greater than any other insulins–T/F?
True
What insulin is given at bedtime and helps to counteract the morning burst of hormones?
Glargine (Lantus)
Insulin preparations–newer agents are produced by ___ technology
recombinant technology
What is the advantage of newer insulin preparations?–___ or ___ that could accompany administration of animal insulins is no longer a significant problem
Allergy or immunoresistance that could accompany administration of animal insulins is no longer a significant problem
Only ___ acting insulin may be given IV/via pump
only short acting insulin may be given IV/via pump
Side effects of insulin–___glycemia; ___kalemia; ___magnesemia; ___phosphatemia; ___ reactions; ___dystrophy; insulin ___; drug ___
hypoglycemia; hypokalemia; hypomagnesemia; hypophosphatemia; allergic reactions; lipodystrophy; insulin resistance; drug interactions
Hypokalemia/hypomagnesemia that may occur with insulin administration puts patients at risk for ___
arrhythmias
Hypophosphatemia that may occur with insulin administration puts patients at risk for respiratory ___
respiratory depression
___ syndrome can occur in patients who have been NPO for awhile; get ___ (up/down) regulation of insulin receptors because the cells are hungry and waiting for more glucose to be introduced into the body
Refeeding syndrome can occur in patients who have been NPO for awhile; get up regulation of insulin receptors because the cells are hungry and waiting for more glucose to be introduced into the body
What happens if you give someone who has been NPO for so long 100% of their caloric requirements for the day?
Refeeding syndrome–they will get massive rush of insulin release from the pancreas; insulin will bind to all of the up regulated receptors; and there will be a rush of potassium, magnesium, and phosphate into the cells
What is the most serious side effect of insulin?
Hypoglycemia
Symptoms of hypoglycemia reflect the compensatory effects of increased ___–___esis, ___cardia, ___tension
increased epinephrine–diaphoresis, tachycardia, hypertension
Epi is released in response to hypoglycemia because it kickstarts gluconeogenesis/glycogenolysis to increase blood glucose levels
Rebound ___glycemia caused by ___ (sympathetic/parasympathetic) nervous system activity in response to hypoglycemia may mask the correct diagnosis–this is known as the ___ Effect
Rebound hyperglycemia caused by sympathetic nervous system activity in response to hypoglycemia may mask the correct diagnosis–this is known as the Somogyi Effect
CNS symptoms of hypoglycemia include mental ___ progressing to ___ and ___
mental confusion progressing to seizures and coma
Diagnosis of hypoglycemia under general anesthesia is ___ (easy/difficult)
difficult
Treatment of hypoglycemia–___ and ___ IV
dextrose and glucagon IV
Use of human insulin has eliminated the problem with systemic allergic reactions that could be associated with animal preparations of insulin–T/F?
True
Local allergic reactions to insulin are red hardened areas that develop at the site of injection; they are due to non insulin materials in the preparation–T/F?
True
Chronic NPH administration may lead to the development of antibodies to ___
protamine
Lipodystrophy is atrophy of fat at sites of ___
subQ insulin injection
Lipodystrophy occurs if you continue to inject in the ___ spot
same spot
Lipodystrophy is minimized by ___ the site of injection
rotating the site of injection
Insulin resistance occurs in patients requiring > ___ units/day (remember avg daily insulin release from the body is ~___ units/day)
Insulin resistance occurs in patients requiring > 100 units/day (remember the avg daily insulin release from the body is ~40 units/day)
Acute insulin resistance is associated with ___, ___, and ___
trauma, surgery, and infection
___resistance has been eliminated with the switch from animal insulin to human insulin
Immunoresistance
Hypoglycemic effects of insulin are countered by ___ or ___ steroids; ___en; ___on
ACTH or glucocorticoid steroids; estrogen; glucagon
Insulin drug interactions–hypoglycemic effects of insulin are countered by ___ or ___ steroids; ___en; ___on
ACTH or glucocorticoid steroids; estrogen; glucagon
Insulin drug interactions–epinephrine ___ (inhibits/stimulates) the secretion of insulin; ___ (inhibits/stimulates) glycogenolysis
epinephrine inhibits the secretion of insulin; stimulates glycogenolysis
Insulin pumps are only for ___/___ insulins (___/___ acting)
regular/analog insulins (rapid/short acting)
Methods of insulin administration–multiple SQ insulin injections–administer 70% of total insulin dose as ___ or ___ acting at ___ (basal insulin); type I diabetics may require ___ or ___ acting insulin in the ___ as well
administer 70% of total insulin dose as intermediate or long acting at bedtime (basal insulin); type I diabetics may require intermediate or long acting insulin in the morning as well
Methods of insulin administration–multiple SQ insulin injections–administer a ___ acting insulin prep before each meal or snack; doses should be adjusted based on blood ___ level and/or anticipated ___ intake
administer a rapid acting insulin prep before each meal or snack; doses should be adjusted based on blood glucose level and/or anticipated carbohydrate intake
Methods of insulin administration–insulin pumps–pump site is changed every ___-___ days; use a ___ acting insulin (___ or ___); administer a ___ rate with preprandial ___; basal rate is usually ___-___ unit/hr
pump site is changed every 2-4 days; use a rapid acting insulin (regular or lispro); administer a basal rate with preprandial boluses; basal rate is usually 0.5-1 unit/hr
Inhaled insulin = ___
Afreeza
Inhaled insulin (Afreeza) is ___ (rapid/long) acting; onset ___-___ minutes; duration ___ hours; available as single use cartridges of ___, ___, and ___ units
Inhaled insulin (Afreeza) is rapid acting; onset 10-15 minutes; duration 3 hours; available as single use cartridges of 4, 8, and 12 units
Basal bolus insulin administration matches the ___ process
physiologic process
Basal bolus insulin administration–___% long acting, ___% divided to AC/HS
70% long acting, 30% divided to AC/HS
Insulin sliding scales should be used alone–T/F?
FALSE–should NOT be used alone…need some sort of basal glucose control
Rapid acting insulin only temporarily corrects elevated blood glucose–T/F?
True
Goals of insulin therapy = maintain blood glucose levels as close to ___ as possible; delay or minimize long term complications of ___
maintain blood glucose levels as close to normal as possible; delay or minimize long term complications of diabetes
Long term complications of diabetes = athero___; ___pathy; ___pathy; ___pathy
atherosclerosis; neuropathy; nephropathy; retinopathy
Risks of hyperglycemia in the perioperative period = micro___; impaired ___ function; cerebral ___; impaired ___ healing; postoperative ___; ___natremia
microangiopathy; impaired leukocyte function; cerebral edema; impaired wound healing; postoperative sepsis; hyponatremia
Microangiopathy = disease of the capillaries–walls become so thick/weak and bleed, leak protein, and slow the flow of blood
The key to managing blood glucose levels perioperatively = set ___ goals, monitor blood glucose ___, and ___ therapy to achieve these goals
set clear goals, monitor blood glucose frequently, and adjust therapy to achieve these goals
