Chapter 44: Diabetes Flashcards
(137 cards)
1
Q
Without insulin, glucose cannot enter muscle cells and the body goes into starvation mode & starts to metabolize ___ into ___ to use an an alternative energy source
A
fat
ketones
(very high ketone levels can cause DKA)
2
Q
Which protein is used to test if T1D is present
A
C-peptide
3
Q
T1D is diagnosed when there is a ____ C-peptide level
A
very low or absent
C-peptide is released by the pancreas only when insulin is present
4
Q
Which factors can increase the likelihood of insulin resistance, and eventually T2D
A
lifestyle, genetics, other RF (low level of physical activity, being overweight or obese)
5
Q
Which drug is used to delay T2D if younger (< 60 years) but higher-risk, with moderate obesity (BMI > 35) and/or a history of gestational diabetes
A
Metformin
6
Q
T/F: prediabetes can be reversed
A
true - with a healthier lifestyle. BG should be checked annually to see if the condition has progressed to T2D
7
Q
Babies born to mothers who had hyperglycemia during the pregnancy are larger than normal, which is called
A
fetal macrosomia
These babies are at higher risk for developing obesity and diabetes later in life
8
Q
Which test is preferred for pregnant women to test for GDM
A
OGTT
9
Q
Which medication is preferred in pregnant women to reduce hyperglycemia
A
Insulin
Lifestyle with diet an exercise should be tried first
10
Q
What are the macrovascular diseases caused by diabetes
A
Atherosclerosis –> ASCVD (CAD, CVA, PAD)
11
Q
What are the microvascular diseases caused by diabetes
A
Retinopathy
Nephropathy
Neuropathy
Autonomic neuropathy (ED, gastroparesis, loss of bladder control, UTIs)
12
Q
What are the classic symptoms caused by high BG
A
Polyuria
Polyphagia
Polydipsia
(other sx which may be the only sx present in T2D include fatigue, blurry vision, ED, and vaginal fungal infections)
13
Q
Who should be tested for diabetes and at which age
A
Everyone starting at 35 with no RF, test everyone with at least 1 RF
14
Q
All asymptomatic children, adolescents and adults who are overweight (BMI >/= __ or >/= __ in Asian Americans) with at least one other RF (e.g., physical inactivity) should be tested for diabetes
A
25
23
15
Q
Diagnostic tests:
- Hgb A1c indicates the average BG over the past __ months
- FBG gives the BG at that moment, and is taken after an >/= __-hour fast
- OGTT measures how well a very sugary drink is tolerated by measuring ___ levels
A
3
8
PPG
16
Q
A positive result from diagnostic tests is an A1C >/= __% or FBG >/= __ mg/dL must be confirmed by testing again with the same or with a new blood sample or with another diagnostic test
A
6.5%
126 mg/dL
17
Q
The A1c should be measured every __ months if not yet at goal
If at goal, the test should be repeated every __ months
A
3 months (quarterly) 6 months
18
Q
Diagnosis for diabetes:
A1C:
FPG:
2-hour PPG after OGTT or classic sx + random BG:
A
> / = 6.5%
/ = 126 mg/dL
/ = 200
19
Q
Diagnosis for prediabetes:
A1C:
FPG:
2-hour PPG after OGTT or classic sx + random BG:
A
5.7-6.4%
100-125
140-199
20
Q
Treatment goals for non-pregnant patients with diabetes:
A1C:
Preprandial:
2-hr PPG:
A
< 7%
80-130
< 180
21
Q
Treatment goals for pregnant patients with diabetes:
Preprandial:
1-hr PPG:
2-hr PPG:
A
< / = 95
< / = 140
< / = 120
22
Q
The estimated eAG is an interpretation of the A1C value. An A1C of 6% is equivalent to an eAG of ___ mg/dL. Each additional 1% increases the eAG by ~___ mg/dL
A
126
28
23
Q
Everyone with any risk of diabetes, including simply getting older, should quit smoking and get moving, with at least __ min of physical activity weekly, spread over at least __ days, with aerobics and resistance exercise (e.g., with weights)
A
150 min
3 days
24
Q
Antiplatelet therapy:
Aspirin __ mg/day is recommended for ASCVD secondary prevention (e.g., post-MI), but not recommended for primary prevention.
It is used in pregnancy to ↓ risk of ___
A
81 mg/day
preeclampsia
**new update: ASA + low dose rivaroxaban can be added to pts wth CAD and/or PAD
25
Cholesterol control:
__ lipid pannel.
-Diabetes + ASCVD with multiple ASCVD RF should get which statins
-Diabetes without ASCVD and older should get which intensity statin
-Diabetes without ASCVD and younger (<40)
- High-intensity: atorvastatin 40-80 mg or rosuvastatin 20-40 mg
- moderate-intensity
- no ASCVD RF = no statin; ASCVD RF = moderate
26
Neuropathy:
- Annually, which tests should be performed
- What are treatment options
10-g monofilament test and 1 other test to assess sensation
Pregabalin, duloxetine, and gabapentin
27
Foot care counseling
- Every day: examine feet, wash and dry
- Annual foot exam
- Moisturize top and bottom of feet but not in between toes
- Trim toenails with nail file
- Wear socks and shoes. Elevate feet when sitting
28
Weight control:
| A healthy weight circumference is key to reducing insulin resistance (< __" females, < __" males)
35
| 40
29
Diabetic retinopathy:
- Type 2, when diagnosed, get eye exam with ___. If retinopathy, repeat ___.
- To ↓ risk/slow progression:
dilation
annually
stop smoking, control BG, BP and cholesterol
30
BP control & kidney disease:
- ACC/AHA goal BP
- ADA goal BP
- Diabetes with HTN, no albuminuria tx
- Diabetes with albuminuria +/- HTN tx
- Diabetes with CAD tx
- No kidney disease: check urine for albumin ___
- Kidney disease: check urine for albumin ___
- < 130/80
- < 130/80 if higher ASCVD risk (>/= 15%); if not, use < 140/90
- no albuminuria: Thiazide, CCB, ACEi, or ARB
- with albuminuria: ACEi or ARB
- CAD: ACEi or ARB (new update)***
- no kidney disease: yearly
- kidney disease: twice yearly
31
Albuminuria is either a urine albumin >/= __ mg/24 hours or a UACR >/= __ mg/g
30
| 30
32
Vaccinations for diabetes
- Hep B series
- Influenza annually
- PPSV23: one dose before age 65, another dose at age 65+ if it has been 5 years since the first dose
33
Natural products that can be used in diabetes
Cassia cinnamon
alpha lipoic acid
chromium
34
treatment for T2D:
If patient has HF, CKD, ASCVD/high ASCVD risk, everyone regardless of A1C should get which therapies if:
- ASCVD major issue
- HF or CKD major issue:
- ASCVD major issue: use GLP-1 with CVD benefit (dulaglutide, liraglutide, semaglutide SC inj only) OR SGLT2 (empagliflozin, canagliflozin) if eGFR adequate (CI if < 30)
- HF or CKD major issue: SGLT2 first that reduces HF and/or CKD progression (empa, cana, dapa) if eGFR adequate. If cannot use SGLT2, use dulaglutide, liraglutide, semaglutide SC inj only
35
Which drugs have little to no risk of hypoglycemia
DPP4i
GLP1
SGLT2
TZD
36
Which two diabetes meds have a similar MOA and should NOT be used together
DPP4 and GLP
37
Best options for T2D if need weight loss
GLP1 (sema, lira, dula) or SGLT2
38
First line treatment for T2D
Metformin
39
Metformin is CI in eGFR < ___
30
40
Insulin can be used initially if hyperglycemia is severe (A1C > ___ or BG > ___)
10%
| 300 mg/dL
41
How to add basal insulin in T2D
Start 10 units a day or 0.1-0.2 units/kg/day
| If hypoglycemia, ↓ dose by 10-20%
42
If patient is on bedtime NPH and you want to convert to BID NPH regimen, how would you convert it
Total dose = 80% of current bedtime NPH dose
2/3 given in AM
1/3 given at bedtime
43
How to add prandial insulin in T2D
Start 4 units a day or 10% of basal insulin dose
If A1C < 8%, consider ↓ basal dose by 4 units a day or 10% of basal dose
Titrate: ↑ dose by 1-2 units or 10-15% twice weekly
if hypoglycemia, ↓ dose by 10-20%
44
In T2D, which medication class should be started prior to insulin in most pts
GLP (exception is if A1C > 10% or BG > 300 mg/dL)
45
What are the 2 big similarities with the top 3 treatments for T2D
Weight loss and no hypoglycemia (Metformin, GLP and SGLT2)
46
Metformin MOA
↓ hepatic glucose output
47
Starting dose for metformin IR & ER
IR: 500 mg PO daily or BID
ER: 500 mg PO daily with dinner
48
ER formulation of metformin counseling point
Leaves a ghost tablet in the stool
49
Metformin BW
Lactic acidosis - ↑ risk with renal disease
50
Metformin warnings
Do not START with eGFR 30-45
B12 deficiency
Lactic acidosis ~ Stop prior to iodinated contrast media, incr risk with renal impairment, avoid excessive alcohol
51
Metformin CI
eGFR < 30
acute or chronic metabolic acidosis
52
Which drugs are TZDs
Pioglitazone (Actos)
| Rosiglitazone (Avandia)
53
TZD BW
Do not use with NYHA Class III/IV HF
Rosi: incr risk of MI
| TZDs are rosiglitazone and pioglitazone
54
TZD warnings/SE
Edema (macular, peripheral)
Weight gain
Can cause or worsen HF
Risk of fractures
[Can stimulate ovulation
Pioglitazone: avoid with bladder CA history]
55
SGLT2 inhibitors MOA
↑ BG renal excretion
by inhibiting SGLT2 in proximal tubule
56
All SGLT2s must have a dose decrease with
renal impairment
based on eGFR not CrCl
57
SGLT2 SE and warnings
Ketoacidosis, even when BG < 250 mg/dL
UTIs, genital fungal infection, weight loss
D/c 3 days prior to surgery to ↓ risk of
Fluid loss, hypotension (d/t combo w/ anti-HTN)
↑ LDL, hyperkalemia
Remember with SGLT2i, you are peeing the glucose out, so thats why you get UTIs, fluid loss
58
SGLT2i eGFR cutoffs
Jardiance - <30 not for glycemic control
Dapagliflozin - 25-45 (not for glycemic control), < 25 don't initiate
59
Canagliflozin BW
Incr risk of leg and foot amputations
60
Which drugs are SGLT2 inhibitors
Canagliflozin (Invokana)
Empagliflozin (Jardiance)
Dapagliflozin (Farxiga)
61
Which drugs are DPP4 inhibitors
Linagliptin (Tradjenta)
Sitgliptin (Januvia)
62
All DPP4 inhibitors should have a dose decrease with renal impairment, EXCEPT
Linagliptin
63
DPP4 warnings
```
Pancreatitis
Arthralgia
Renal failure
Alogliptin: hepatotoxicity
Alogliptin, saxagliptin: risk of HF
```
64
SU should not be used with which medication class
insulin or meglitinides
65
Glipizide IR dosing
30 min PO before meals; all other products take with breakfast
66
Glucotrol XL (glipizide) counseling point
OROS formulation; ghost tablet in stool
| ↓ efficacy after long-term use
67
SU contraindication
Sulfa allergy
68
SU A1c decrease
1-2%
69
SU should be avoided in which patient population
Elderly (BEERS criteria) due to hypoglycemia risk (esp glyburide and chlorpropamide)
70
Important counseling point if skipping a meal with meglitinides
skip meal = skip dose to avoid hypoglycemia
71
Which drugs are GLP1
Liraglutide (Victoza)
| Dulaglutide (Trulicity)
72
Liraglutide is dosed how many times per day
| Dulaglutide?
Lira - daily
| dula - weekly
73
Byetta and Adlyxin should be given within __ min of meals
60
74
Pen needles are provided with which GLPs
Weekly injections only (Trulicity, Byduron, Byduron BCise, Ozempic)
| Not with Byetta, Victoza, Adlyxin
75
GLP1s can cause
pancreatitis
76
Pramlintide is used in which type(s) of diabetes & what is the MOA & administration
Type 1 & 2
| Synthetic analog of amylin, slows gastric emptying & ↑ satiety, Subcut
77
Pramlintide CI
gastroparesis
78
Pramlintide SE
N/V
Anorexia
HA
79
Pramlintide BW
severe hypoglycemia
80
Alpha-glucosidase inhibitors (acarbose and miglitol) should be taken 3 times daily with
the first bite of each meal
81
Alpha-glucosidase inhibitors (acarbose and miglitol) SE
Flatulence, diarrhea
82
Alpha-glucosidase inhibitors (acarbose and miglitol) important counseling point about hypoglycemia
If hypoglycemia occurs due to another drug, the low BG CANNOT be treated with sucrose; need to treat it with glucose tabs or gel only
83
Bile-acid binding resin, colesevelam, decreases absorption of
vitamins ADEK
84
metformin/pioglitazone brand
Actoplus Met
85
Metformin/sitagliptin brand
Janumet
86
metformin/canagliflozin brand
Invokamet
87
Bile-acid binding resin, colesevelam, CI
TG > 500
| pancreatitis
88
Glucagon is produced by which cells in the pancreas
alpha cells
89
Basal insulin includes
glargine, detemir, and ultra-long acting degludec
90
the P in NPH stands for
protamine
91
Rapid acting insulin:
- Onset
- Peak
- Duration
onset: ~15 min
Peak: 1-2 hrs
Duration: 3-5 hours
92
Regular insulin:
- Onset
- Peak
- Duration
onset: 30 min
Peak: ~2 hrs
Duration: 6-10 hours
93
NPH insulin:
- Onset
- Peak
- Duration
Onset: 1-2 hrs
Peak: 4-12 hrs
Duration: 14-24 hrs
94
Inhaled insulin time of use
mealtime
95
```
Basal insulin:
All have no peak
Detemir: onset and duration
Glargine: onset and duration
Degludec: onset and duration
```
Detemir:
- Onset: 3-4 hrs
- Duration: 1 day
Glargine:
- onset: 3-4 hrs (Tujeo 6 hrs)
- Duration: 1 day
Degludec:
- onset: 1 hr
- duration: 42+ hrs
96
Insulin can cause hypoglycemia and
hypokalemia
weight gain
lipoatrophy/hypertrophy
97
Must reduce meal-time insulin by __% when starting pramlintide to avoid severe hypoglycemia
50%
98
Which insulins are rapid-acting
Aspart (Novolog)
| Lispro (Humalog) - remember humans have a lisp
99
When should rapid-acting insulins be injected
5-15 min before eating
100
Which insulins are short-acting
Regular (Humulin R, Novolin R)
101
Regular insulin is injected __ min before meals
30 min
102
When is regular insulin preferred over rapid-acting insulin
For IV infusions, including parenteral nutrition
103
regular insulin specific container
non-PVC
104
When regular (or rapid-acting) insulin and NPH are mixed in the same syringe, which should be drawn up into the syringe first?
Regular (or rapid-acting) first - clear solution
then NPH - cloudy solution
(clear before cloudy)
105
Which insulins are NPH
Humulin N, Novolin N
106
Which insulins are available OTC
NPH, Regular, and 70/30 premixes of NPH and Regular
107
when is Humulin R U-500 recommended
When > 200 units/day required
| Do NOT mix with other insulins
108
Which insulins are long-acting (basal)
Detemir (Levemir)
Glargine (Lantus, Tujeo, Basaglar)
(remember the brand names start with L for long-acting)
109
How to convert NPH given BID to Lantus, Basaglar, or Tujeo
Use 80% of NPH dose
110
How to convert Toujeo to Lantus or Basaglar
Use 80% of the Toujeo dose
111
Insulin Glargine as Lantus is ____ units/mL
| Glargine as Toujeo is ___ units/mL
100 units/mL
| 300 units/mL
112
What are the 2 sizes of Toujeo
SoloStar 1.5 mL
| Max SoloStar 3 mL pen
113
Ultra-long acting basal insulin, degludec (Tresiba), comes in which 2 sizes for the pen
100 units/mL and 200 units/mL
114
Insulin mixes come in which concentrations
70/30
75/25
50/50
(the NPH or protamine insulin is first, the short or rapid-acting insulin is second)
115
Typical insulin starting dose for T1D
0.5 units/kg/day (TBW)
Divide 50% basal and 50% bolus
Divide bolus evenly among 3 meals
116
What is a requirement for switching a patient to an insulin pump
Prior experience with multiple daily injections
117
Usually, dose of the new insulin is a 1:1 conversion. What are the exceptions
-NPH dosed BID --> Lantus, Basaglar or Toujeo dosed daily
Use 80% of the NPH dose
-Toujeo --> Lantus or Basaglar
Use 80% of the Toujeo dose
118
Which insulins come in concentrated formulations
Rapid acting: Humalog KwikPen (lispro) 200 units/mL
Regular: Humulin R U-500 KwikPen & vial 500 units/mL
Long-acting: Tresiba Flextouch (degludec) 200 units/mL & Tujeo Solostar (glargine) 300 units/mL
119
The correct insulin syringe size to number units
0.3 mL - up to 30 units
0.5 mL - 30-50 units
1 mL - 51-100 units
120
The U-500 Humulin vials have which color cap and the syringes have which color needle cover
green cap and green needle cover
121
The higher the gauge, the ___ the needle
thinner
122
The ICR indicates:
number of grams of carbs covered by 1 unit of insulin
123
How to start NPH and Regular insulin regimen
2/3 TDD as NPH and 1/3 as Regular
| not preferred regimen
124
ICR formula for regular insulin
450/ TDD of insulin = grams of carbs covered by 1 unit of regular insulin
125
ICR formula for rapid-acting insulin
500/ TDD of insulin = grams of carbs covered by 1 unit of rapid-acting insulin
126
What does the correction factor indicate
how much the BG will be lowered by 1 unit of insulin
127
What is the correction factor for regular insulin
1500/TDD = correction factor for 1 unit of regular insulin
128
What is the correction factor for rapid-acting insulin
1800/TDD = correction factor for 1 unit of rapid-acting insulin
129
Correction dose formula
(BG now) - (Target BG) / correction factor
130
With which needle sizes does the skin need to be pinched up
> 5 mm
131
All insulins are stable at RT for 28 days except:
```
Humalog mixes, pens - 10
Humulin N, N/R pen - 14
Novolog mixes in pens - 14
Humulin R vial - 31
Humulin R U-500 vial - 40
Novolin R, N, and N/R 70/30 vials - 42
Detemir (Levemir) - 42
Degludec (Tresiba) - 56
Glargine (Toujeo) - 56
```
(notice the vials have a longer stability than the pens)
| Most insulins stable for 28 days at room temp
132
What is the rule of 15 for hypoglycemia
Take 15 grams of glucose or simple carbs
Recheck BG after 15 min
Once BG is normal, eat a small meal or snack
133
If patient is unconscious and is hypoglycemic, what can be used
dextrose if IV access or glucagon
134
Causes of DKA
Insulin was not taken
Insulin was taken but the dose was inadequate d/t a stressor
Initial presentation in type 1, when the B cells are gone
135
How to recognize DKA
BG > 250 mg/dl
Ketones ("fruity breath")
Anion gap acidosis (arterial pH < 7.35, anion gap > 12)
136
How to recognize HHS
Confusion, delirium
BG > 600 mg/dL
Serum osmolality >320 mOsm/L
Extreme dehydration
pH > 7.3
137
DKA and HHS treatment
- Fluids first (NS); when BG reaches 200, change to D5W1/2NS
- Regular insulin infusion
- Replace K as needed
- Treat acidosis if pH < 6.9 with sodium bicarbonate
