Adult DM2 Flashcards
(131 cards)
1
Q
4 classic symptoms of DM2
A
polyuria, polydipsia, polyphagia, weight loss
2
Q
What are the ADA diagnostic criteria?
A
- fasting glucose 126+
- 2-hour or 75-g OGTT 200+
- random BG 200+ with symptoms
3
Q
When should you test asymptomatic patients?
3 answers
A
- sustained BP > 135/80
- overweight with 1+ other risk factors
- age 45
4
Q
What are microvascular vs. macrovascular complications?
A
Micro- eye and kidney
Macro- coronary, cerebrovascular, peripheral vascular
5
Q
When should pts on intensive insulin regimens check BG?
A
- before meals
- at bedtime
- before exercise and critical tasks
- when hypoglycemic
6
Q
When should you check HbA1c?
A
Every 3-6 mo
7
Q
When should you check dilated eye exam?
A
Every year
8
Q
When should you check microalbumin?
A
Every year
9
Q
When should you perform a foot exam?
A
Every visit
10
Q
What are the 2 characteristics of DM2 (patho)?
A
insulin resistance and inadequate insulin secretion by the pancreas
11
Q
T/F
All overweight persons with insulin resistance have DM
A
False- DM only develops if the pancreas cannot produce enough insulin to compensate for the insulin resistance
12
Q
Which increases first in the progression of glucose tolerance? fasting or postprandial?
A
post prandial BG increases first. Fasting BG increases as suppression of hepatic gluconeogenesis fails.
13
Q
What diseases cause secondary DM?
A
hemochromatosis
pancreatitis
cystic fibrosis
pancreatic cancer
14
Q
What hormonal syndrome causes secondary DM (lowers insulin secretion)?
A
pheochromocytoma
15
Q
What hormonal syndrome causes peripheral insulin resistance?
A
acromegaly
Cushings syndrome
pheochromocytoma
16
Q
What drugs may cause secondary DM?
A
phenytoin
glucocorticoids
estrogens
17
Q
What percent of pregnancies are complicated by gestational diabetes?
A
4%
pregnancy increases insulin resistance
18
Q
Name the 5 subtypes of DM
A
- Severe autoimmune (SAID) and latent autoimmune (LADA)
- severe insulin-deficient (SIDD)
- severe insulin-resistant (SIRD)
- mild obesity-related (MOD)
- mild age-related (MARD)
19
Q
Characteristics of SAID and LADA
A
early onset, low BMI, poor metabolic control, impaired insulin production
*** glutamic acid decarboxylase antibody (GADA) positive
20
Q
Characteristics of SIDD
A
similar to SAID but GADA negative and high HbA1c
-highest risk for retinopathy
21
Q
Characteristics of SIRD
A
insulin resistance
high BMI
-greatest risk for nephropathy
22
Q
Characteristics of MOD
A
younger
obese
not insulin resistant
23
Q
Characteristics of MARD
A
older
metabolic alterations are moderate
24
Q
What is a diabetogenic lifestyle?
A
excessive calorie intake
inadequate caloric expenditure
obesity
***superimposed on susceptible genotype
25
Name 8 major risk factors for DM2
1. age> 45
2. weight > 120%
3. 1st degree family history
4. minority
5. history of impaired glucose tolerance
6. HTN > 140/90, cholesterol < 40, TG > 150
7. hx of gestational DM or baby > 9lbs
8. PCOS
26
What mitochondrial disorders can be associated with DM and what symptoms are present in them?
Kearns-Sayre syndrome and mitochondrial encephalopathy, lactic acidosis, and stroke like episode (MELAS)
- hearing loss
- myopathy
- seizure disorder
- strokelike episodes
- retinitis pigmentosa
- external opthalmoplegia
- cataracts
27
What percent of Americans will develop DM?
40% (50% in minorities)
28
What are pregnancy complications of gestational DM?
macrosomia, hypoglycemia, hypocalcemia, hyperbilirubinemia
29
What is the Dawn phenomenon?
BG increase > 20% occurring at the end of the night. Occurs in 50% of non-insulin treated pts.
30
Name the 5 stages of diabetic retinopathy.
1. dilation of retinal venules and formation of capillary microaneurysms.
2. increased vascular permeability
3. vascular occlusion and retinal ischemia
4. proliferation of new blood vessels on surface of retina
5. hemorrhage and contraction of the fibrovascular proliferation and the vitreous.
31
T/F
| Macular edema can cause vision loss?
True
| Refer to optho for laser therapy to preserve vision. Laser therapy can preserve not restore lost vision.
32
What are cotton-wool spots?
Seen in preproliferative retinopathy, microinfarcts caused by capillary occlusion; patches of off-white to gray, poorly defined margins.
33
What is proliferative retinopathy?
Neovascularization (development of fragile new vessels) seen on the optic disc or along main vascular arcades. During proliferation, fibrous adhesions develop between the vessels and the vitreous. Subsequent contraction of adhesions can result in traction on the retina and retinal detachment. Contraction also tears the new vessels, which hemorrhage into the vitreous.
34
How is a retinal hemorrhage described by a patient?
Fleeting, dark area, "floater" in the field of vision
35
What should be done for a pt with retinal hemorrhage?
OPTHO referral
limit activity
keep head upright so that the blood settles to the inferior portion of the retina, obscuring less central vision
-NO thrombolytic therapy
36
What is the association between gingival and retinal hemorrhage?
They are closely related, pts with gingival hemorrhage have a high prevalence of retinal hemorrhage.
37
How should you perform a foot examination?
- dorsalis pedis and posterior tibialis pulses
- Semmes Weinstein monofilament
- reflexes, position, and/or vibration sensation
38
What is metabolic syndrome?
3/5
- abdominal obesity (>102cm-men, >88-women)
- high triglycerides (>150)
- low HDL (<40-men, <50-women)
- high BP (>130/85)
- fasting BG 100+
39
How do you measure insulin resistance?
Trick question, not possible yet. Elevated fasting BG or triglyceride may be the first indication. Fasting insulin level are increased at an earlier stage but this is more related to insulin clearance rather than resistance.
40
What are the WHO criteria for impaired glucose tolerance?
-FPG less than 126 and a venous plasma 140-200 two ours after a 75-g glucose load with one intervening plasma value 200+
41
Does FPG or post-glucose load value predict microvascular risk better?
post-glucose load value
42
How is a plasma glucose drawn?
In a gray-top (sodium fluoride) tube, which inhibits red blood cell glycolysis.
43
How is a serum glucose drawn?
In a red or speckled-top tube. May be significantly lower than plasma glucose measurement.
44
How does HbA1c work?
Binding of glucose to hemoglobin A is a nonenzymatic process that occurs over the lifespan of a red blood cell, which averages 120 days.
45
What are the HbA1c targets for elderly patients (>60)?
Less than 8 but more that 6. Lower than 6 has a higher mortality rate.
46
What patients cannot use HbA1c?
- RBC turnover abnormalities like hemolysis or iron-deficiency anemia
- Neonates due to fetal hemoglobin
47
When should you check for microalbumin?
yearly
| because of a wide variability, microalbuminuria should be found on at least 2 of 3 samples over a 3-6 month period
48
What test detects microalbumin?
albumin-to-creatinine ratio in a spot sample
| -30-300 mg/day
49
What lab results indicate DM1 over DM2?
- Insulin levels and C-peptide suggest beta-cell function (DM2)
- autoantibodies (GAD65, IA2, anti-insulin)
- anti-GAD65 is most likely to be persistent over time.
50
What type of drug is metformin?
Biguanide
51
MOA of metformin
lowers basal and post prandial BG
- decreases hepatic gluconeogenesis production
- decreases intestinal glucose absorption
- increases peripheral glucose uptake
52
Does metformin typically cause hypoglycemia?
Nope
53
Weight loss or weight gain with metformin?
loss :)
54
Name 3 sulfonylureas
glyburide, glipizide, glimepiride
55
What is the MOA of sulfonylureas?
- insulin secretagogues
- stimulate insulin release from beta cells.
- may enhance peripheral sensitivity to insulin
56
Do sulfonylureas cause hypoglycemia?
Yes
57
What are meglitinides?
- repaglinide, nateglinide
| - shorter-acting insulin secretagogues than sulfonylureas but more expensive
58
When sould you use meglitinides?
- as monotherapy (add metformin or thiazolidinedione if uncontrolled)
- allergy to sulfonylureas
59
What are alpha-glucose inhibitors?
acarbose, miglitol, voglibose
- delay sugar absorption to prevent post prandial elevations
- cause flatulence (titrate slowly)
60
What are thiazolidinediones (TZD)?
pioglitazone, rosiglitazone
- Insulin sensitizers (require the presence of insulin)
- take 12-16 weeks to work
* only agent that has been shown to slow the progression of DM
- decrease TG and increase HDL
- increase LDL
61
What are side effects of TZDs
- edema (including macular)
- weight gain
- bladder cancer (>2 yr use)
- fracture risk
62
What are glucagonlike peptide-1 agonists (GLP-1)?
exenatide, liraglitude, albiglutide, dulaglutide
- stimulate glucose dependent insulin release
- reduce glucagon-slow gastric emptying
- reduce beta-cell apoptosis
63
Exenatide brand name, dose, adjunct to?
Bydureon
- once weekly
- adjunct to metformin or basal insulin
64
Liraglutide brand name, dose, adjunct to?
Victoza, Saxenda
- daily
- diet and exercise
65
Albiglutide brand name, dose, adjunct to?
Tanzeum
- weekly
- diet and exercise
66
Dulaglutide brand name, dose, adjunct to?
| Black box warning?
Trulicity
- weekly
- diet and exercise, monotherapy, combo therapy
- not first line
- medullary thyroid carcinoma
67
Lixisenatide brand name, dose, adjunct to?
Adlyxin
- daily 1hr before 1st meal
- diet and exercise
68
Semaglutide brand name, dose, adjunct to?
Ozempic
- weekly
- diet and exercise
69
What are dipeptidyl peptidase IV inhibtors (DPP-4)?
sitagliptin, saxagliptin, linagliptin
- prolong the action of incretin hormones
- DPP-4 degrades peptides (GLP-1 and GIP)
70
DPP-4 brand name, route, dosing, adjunct to?
Januvia
- oral
- daily
- monotherapy, metformin, TZD
71
What are selective sodium-glucose transporter-2 inhibitors (SGLT-2)?
Canagliflozin, dapagliglozin, empagliflozin
| -lowers renal glucose threshold resulting in increased urinary excretion
72
What precautions should be taken with SGLT-2 inhibitors?
- decrease dose in renal impairment
| - lower dose of insulin secretagogues to reduce risk of hypoglycemia
73
SGLT-2 inhibitor brand names, dose, adjunct to?
Invokana, Farxiga, Jardiance
- po daily
- monotherapy or add-on
74
Name the long acting insulins
glargine (Lantus, Tujeo)
| detemir (Levemir)
75
When should you dose Lantus QdD vs. BID?
BID for smaller doses
76
What is the difference between Lantus and Toujeo?
```
Lantus 100 U/ml
Toujeo 300 U/ml
Toujeo Max 160 U/ml (Tujeo)
-longer duration of action
-less nocturnal hypoglycemia
```
77
What is the ultralong-acting insulin?
```
Insulin degludec (Tresiba)
-depo effect = duration of action > 42 hours
```
78
What is the inhaled insulin?
Afrezza
- type 1 and 2
- rapid-acting
79
What is the new rapid acting insulin?
Insulin aspart (Fiasp)
- formulated with niacinamide (aids in the speed of absorption)
- dose at beginning of meal or 20min after start
80
What are amylinomimetics?
Pramlintide acetate
- mimics the effects of endogenous amylin
- delays gastric emptying
- decreases postprandial glucagon release
- modulates appetite
81
What bile acid sequestrant is indicated for adjunctive DM2 control?
Colesevelam
- favorable but insignificant impact on FPG and HbA1c
- use for LDL
- Never for hypertriglycerides
82
Which dopamine agonist is used for DM? How does it work?
bromocriptine mesylate (Cycloset)
- Daily in AM
- acts on circadian neuronal activities in the hypothalamus to reset the abnormally elevated drive for increased plasma glucose, TG and free fatty acid levels in insulin-resistant patients
83
Side effects of bromocriptine?
nausea, fatigue, vomiting, headache, dizziness, hypotension, syncope
-more likely in initial titration
84
What is the usual decrease in HbA1c with monotherapy vs. 2-drug combo?
monotherapy 1%
| 2-drug 2%
85
Which drugs have the most weight gain?
sulfonylureas and TZDs
86
Which has a higher risk for hypoglycemia, sulfonylurea or TZD?
sulfonylurea
87
What is the first line for:
- obese
- non-obese
- elderly
- Asian
- obese, metformin
- non-obese, SU or metformin
- elderly, low dose secretagogue (SU/meglinitides)
- Asian, glitazone
88
When should you add a second agent?
When goals are not met after monotherapy for 2-3 months.
89
What are 3rd line drugs?
- another oral agent
- basal insulin
- exenatide
90
What are preprandial BG goals for strict vs less strict regimens?
strict = 80-120 (at least 100 at night)
| less strict = 100-140
91
What is the easiest way to lower elevated fasting BG?
basal insulin
92
When should you add meal time insulin?
When oral agents and basal insulin fail to control BG
93
What necessary condition must be met for BID insulin regimens?
regimented lifestyle with regularly spaced meals and injections taken at the same time each day.
94
Who is a candidate for continuous subcutaneous insulin infusion (CSII)?
DM1 or intensively managed DM2 taking 4+ injections and checking BG 4+ times a day
95
How often should pts starting CSII see a provider?
3-7 days after initiation
- then weekly/biweekly
- monthly with specialist then at least Q3 mo
96
True/False
| Patient age and duration of DM should be factors in determining the transition from injections to CSII
False
97
Which drugs target postprandial glucose?
rapid acting insulins, short acting insulins, alpha-glucosidase inhibitors, short acting insulin secretagogues
98
When should bariatric surgery be recommended?
DM2 with class 3 obesity (BMI > 40) no matter what level of glycemic control has been achieved.
99
Which bariatric surgery has the most benefits for DM?
Roux-en-Y
100
What extra labs are needed with metformin?
creatinine and vitamin B12
101
What extra labs are needed with TZDs?
transaminases
102
What are cholesterol goals for pts with and without cardiovascular disease?
without: LDL-C < 100
with: LDL-C < 70
103
When should fibrates be used?
To increase HDL
104
What beta blocker is best for pts with DM2?
Carvedilol, which is a vasoDILATING beta blocker, has beneficial effects of cholesterol unlike metoprolol which is a vasoCONSTRICTING beta blocker that may decrease HDL, and increase LDL-C and TGs
105
What are the 3 age groups that the ADA divides pts into for statin therapy guidelines?
<40: no other CVD risk factors other than DM = no statin
- CVD risk factors present = moderate/high intensity statins
- overt CVD = high intensity
40-75: no risk factors = moderate intensity
- risk factors/overt = high intensity
75+: risk factors = moderate intensity
-overt = high intensity
106
When should you screen for DM in Asians?
BMI 23 (instead of 25)
107
How long should people limit their sitting time to?
90 min
108
What is the HbA1c target for children?
7.5%
109
What medication is used for gastroparesis? How should it be given?
Metoclopramide, only take for a few days at a time, long term use is associated with tardive dyskinesia.
110
How does illness affect BG?
increased insulin resistance due to increased counterregualatory hormones (anti-insulin).
- increase scheduled insulin (not SSI)
- decrease metformin if dehydrated due to increased risk for lactic acidosis
111
What drugs should be used in pts with DM and established athlerosclerotic cardiovascular disease (ASCVD)?
SGLT2 and GLP-1
- Invokana, Farxiga, Jardiance, Glyxambi, Synjardy, Xiguduo
- Byetta, Victoza, Saxenda, Lyxumia, Tanzeum, Trulicity, Ozempic
112
What drug is used for DM, ASCVD, and heart failure?
SGLT2
| -Invokana, Farxiga, Jardiance, Glyxambi, Synjardy, Xiguduo
113
What drugs are used for DM and CKD?
SGLT2 and GLP-1
- Invokana, Farxiga, Jardiance, Glyxambi, Synjardy, Xiguduo
- Byetta, Victoza, Saxenda, Lyxumia, Tanzeum, Trulicity, Ozempic
114
What drug is used in patients who need greater glucose-lowering effect of an injectable medication?
GLP-1
| -Byetta, Victoza, Saxenda, Lyxumia, Tanzeum, Trulicity, Ozempic
115
What drug is used in patients with extreme and symptomatic hyperglycemia?
Insulin
116
What class of drug is metformin?
Biguanide
117
Metformin:
1. primary effect
2. secondary effect
3. weight gain?
4. metabolized?
5. excreted?
6. effected by renal dx?
7. lactic acidosis?
8. increase insulin levels?
9. cause hypoglycemia?
10. plasma bound?
11. absorbed by?
1. decrease hepatic gluconeogenesis
2. increase peripheral insulin sensitivity
3. no
4. no
5. urine
6. increased in renal insuff
7. possible with renal insuff
8. no
9. no
10. no
11. intestines
118
Why don't we give metformin in the hospital setting?
It should not be given within 48 hours of iodinated contrast media
119
2 drugs that are secretagogues
sulfonylureas
| meglitinides
120
2 drugs that decrease glucagon levels
Januvia
| Symlin
121
Drug that increases satiety
Symlin
| DPP-4
122
Incretins and incretin mimetics
DPP-4
| Exenatide
123
Insulin sensitizers (3)
Biguanides
Thiazolidinedones
Exenatide
124
Drugs that slow absorption of glucose in the gut (3)
alpha-glucodiase inhibitors
Symlin
Exenitide
125
What drug is contraindicated in pts with medullary thyroid carcinoma?
Liraglutinde (Victoza)
126
What are contraindications for metformin?
renal insufficiency
treated CHF
binge ETOH
127
what are contraindications for TZDs?
active liver disease
transaminase elevation 2.5 x ULN at baseline
Class III and IV CHF
128
What are contraindications for GLP-1 analogs?
gastroparesis
| pancreatitis
129
What are the treatment recs for hypoglycemia?
15-20 g glucose for conscious individuals
- repeat in 15 min if still low
- once normal, consume a snack or meal
Glucagon prescription
130
What medications target postprandial hyperglycemia?
meglitinides
Acarbose
GLP-1
DPP-4
131
What are the glycemic goals (preprandial, postprandial, Hba1c)
preprandial 70-130
postprandial <180
HbA1c < 7%
