Chapter 44: Diabetes Flashcards
(145 cards)
1
Q
Without insulin, glucose cannot enter muscle cells and the body goes into starvation mode & starts to metabolize ___ into ___ to use as an alternative energy source.
A
fat into 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
- Obesity
- Physical inactivity
- Family history
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 and 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, even those with no other RF should be tested beginning at 35 years old.
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 or 23
15
Q
Hgb A1c indicates the average BG over the past __ .
A
3 months
16
Q
FBG gives the BG at that moment, and is taken after an >/= __-hour fast.
A
8 hours
17
Q
OGTT measures how well a very sugary drink is tolerated by measuring BG levels how long after drinking high glucose liquid?
A
2 hours
18
Q
What are the diagnostic criteria for Diabetes?
A
- A1c >= 6.5%
- FBG >= 126 mg/dL
- Random BG: >= 200
- OGTT >= 200
19
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
20
Q
Diagnosis criteria for prediabetes?
A
- A1C: 5.7-6.4%
- FPG: 100-125
- OGTT: 140-199
21
Q
Glycemic targets in diabetes?
A
- A1c: < 7%,
- FPG: 80-130,
- 2hr-PPG < 180
22
Q
What are the preprandial treatment goals for pregnant patients with diabetes?
A
< / = 95 mg/dL
23
Q
What is the 1-hr PPG treatment goal for pregnant patients with diabetes?
A
< / = 140 mg/dL
24
Q
What is the 2-hr PPG treatment goal for pregnant patients with diabetes?
A
< / = 120 mg/dL
25
What is the estimated eAG equivalent for an A1C of 6%?
126 mg/dL
## Footnote
Each additional 1% increases the eAG by ~28 mg/dL
26
How many minutes of physical activity should everyone with any risk of diabetes aim for weekly?
150 min
## Footnote
Spread over at least 3 days
27
What criterias require diabetes patient's to recieve high intensity statin?
Comorbid ASCVD or age 40-75 with more than 1 ASCVD risk factor
28
What is the LDL goal for diabetes patients with comorbid ASCVD?
Less than 55 mg/dL
29
What is the LDL goal for diabetes patients age 40-75 yo with more than one ASCVD risk factor
Less than 70 mg/dL
30
What is the recommended daily dosage of aspirin for ASCVD secondary prevention?
81 mg/day
## Footnote
It is used in pregnancy to ↓ risk of preeclampsia
31
Which diabetes patients should recieve moderate intensity statin?
No ASCVD or 20-39 yo with risk factors
32
When should a type 2 diabetes patient get an eye exam?
When diagnosed, get eye exam with dilation. If retinopathy, repeat **annually**.
33
What vaccinations are recommended 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.
34
What is Diabetic kidney disease defines as?
eGFR < 60 +/- albuminuria
## Footnote
Albuminuria is urine albumin >= 30 mg/24 hr or UACR >= 30 mg/g
35
What are the treatment options for diabetic kidney disease?
ACEi, ARBs, SGLT2i, Finerenone
36
What tests should be performed annually for neuropathy?
10-g monofilament test and 1 other test to assess sensation, and comperhensive foot exam
37
What are the treatment options for neuropathy?
Pregabalin, duloxetine, and gabapentin
38
What are the key components of 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.
39
What is the ACC/AHA goal BP for diabetes?
< 130/80
40
What is the treatment for diabetes with hypertension and no albuminuria?
Thiazide, DHP CCB, ACEi, or ARB
41
What is the treatment for diabetes with albuminuria +/- hypertension?
ACEi or ARB
42
# y
What is a healthy weight circumference to reduce insulin resistance?
< 35” for females, < 40” for males
43
How often should urine for albumin be checked in diabetes with no kidney disease?
Yearly
44
How often should urine for albumin be checked in diabetes with kidney disease?
Twice yearly
45
What defines albuminuria?
Urine albumin >/= 30 mg/24 hours or a UACR >/= 30 mg/g
46
What natural products can be used in diabetes?
* Cinnamon,
* Alpha lipoic acid
* Chromium
47
What therapies should be considered for T2D if ASCVD is a major issue?
Use GLP-1 with CVD benefit (dulaglutide, liraglutide, semaglutide SC inj only) OR SGLT2 (empagliflozin, canagliflozin) if eGFR adequate.
48
What therapies should be considered for T2D if HF or CKD is a 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.
49
Which diabetes medication classes have little to no risk of hypoglycemia?
DPP4i, GLP1, SGLT2, TZD
50
Which two diabetes medications have a similar MOA and should NOT be used together?
DPP4i and GLP-1a
51
When can insulin be used initially in diabetes?
If hyperglycemia is severe (A1C > 10% or BG > 300 mg/dL)
52
What are the best options for T2D if weight loss is needed?
GLP1 (sema, lira, dula) or SGLT2
53
GLP-1a MOA?
It's GLP-1 analog which increases glucose dependent insulin secretion, decreases glucogan secretion, and slows gastric emptying
54
Name GLP-1a
1. Liraglutide
2. Dulagluide
3. Semaglutide
4. Exenatide
55
What is the name of only Dual GLP-1 and GIP agonist?
Tirzepatide
56
Liraglutide Brand name for diabetes?
Victoza
57
Liraglutide brand name for weight loss?
Saxenda
58
Dulaglutide brand name?
Trulicity
59
Tirzepatide brand name for weight loss?
Zepbound
60
Which GLP 1a is adminestered SC daily?
Liraglutide
61
What is the box warning for all GLP-1a?
Risk of thyroid C-cell carcinomas
62
What are the warnings associated with GLP-1a?
* Pancreatitis
* Not recommended in patients with sever GI disease like gastroprosis
63
What are the side effects associated with GLP-1a?
* Weight loss
* **N**/V/D (reduced with dose titration
64
What is an imprtant patient counseling for Byetta (Exenatide)?
Give dose 60 minutes before meals
65
What is the mechanism of action (MOA) of SGLT2 inhibitors?
Reduce reabsorption of glucose and increase urinary glucose excretion
66
Canagliflozine brand name
Invokana
67
Dapagliflozin
Farxiga
68
Empagliflozin
Jardiance
69
What are warnings assiciated with SGLT2i?
* Ketoacidosis
* Genital mycotic infection & UTIs
* Necrotizing fascitis
* Hypotension
* AKI
* With Canagliflozin (increase risk of leg and foot amputation)
70
Side effects associated with SGLT2i?
Increase thirst and urination
* Canagliflozin has risk of hyperkalemia
71
Concurrent use of which drugs with SGLT2i, increase the risk of hypotension and AKi?
Diuretics
RAAS inhibitors
NSAIDs
72
What is the mechanism of action (MOA) of Metformin?
* ↓ hepatic glucose output
* Increase insulin sensitivity
* Decrease intestinal absorption of glucose
73
What is the first line treatment for T2D?
Metformin
74
Metformin brand name?
Fortament, Glumetza
75
In which condition is Metformin contraindicated?
eGFR < 30
76
What is the usual maintanance dose of metformin?
1000mg PO BID
77
What is the max daily dose of metformin?
2000-2250 mg/day
78
How to decrease GI upset with metformin?
Take with meal
79
What is the BW associated with metformin?
Lactic acidosis
(increased risk with renal impairment, contrast dye, alcohol)
80
Warnings associated with metformin?
Not recommended to start of eGFR 30-45
Can cause Vitamin B12 deficiency
81
Major (common) side effects with metformin?
Diarrhea, Nausea
82
What is a patient counseling point for ER formulation of metformin?
It can leave a ghost tablet (empty shell) in the stool
83
How long after the procedure with contrast dye, can metformin restart?
48 hours
84
Which medication class should sulfonylureas (SUs) not be used with?
Insulin or meglitinides
85
What is a counseling point for Glucotrol XL (glipizide)?
OROS formulation; ghost tablet in stool
## Footnote
↓ efficacy after long-term use
86
What is a contraindication (CI) for sulfonylureas (SUs)?
Sulfa allergy
87
In which patient population should sulfonylureas (SUs) be avoided?
Elderly (BEERS criteria) due to hypoglycemia risk (esp glyburide and chlorpropamide)
88
Common side effects with SUs?
Weight gain, nausea, hypoglycemia
89
What is an important counseling point if skipping a meal with meglitinides?
Skip meal = skip dose to avoid hypoglycemia
90
Name DPP4is for diabetes?
Sitagliptin
Linagliptin
Saxagliptin
Alogliptin
91
Sitagliptin brand name?
Januvia
92
Linagliptin brand name
Tradjenta
93
Which DPP4i does not require renal dose adjustment?
Linagliptin
94
What are the warnings associated with DPP4i?
* Pancreatitis
* Severe joint pain
* AKI
* HF (saxa and alo)
95
Which other antidiabetic medications have MOA overlaping with DPP4i and their concurrent use should be avoided?
GLP-1a
96
MOA of TZDs?
PPARy agonists that increase peripheral insulin sensitivity
97
Pioglitazone brand name?
Actos
98
What is the BW for Pioglitazone?
HF (Do not use in NYHA III/IV)
99
Side effects of TZDs?
* Edema
* Risk of fractures
* Can stimulate ovulation (unintended pregnancy)
* Weight gain
100
What is a contraindication for Pramlintide?
Gastroparesis
101
What is the black box warning for Pramlintide?
## Footnote
How to adjust insulin when starting?
Severe hypoglycemia
## Footnote
reduce mealtime insulin by 50%
102
Alpha-glucosidase inhibitors (acarbose and miglitol) should be taken how many times daily?
3 times daily with the first bite of each meal
103
What are the side effects of Alpha-glucosidase inhibitors (acarbose and miglitol)?
Flatulence, diarrhea, abdominal pain
104
What is an important counseling point about hypoglycemia for Alpha-glucosidase inhibitors?
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
105
Bile-acid binding resin, colesevelam, most common side effect?
Constipation
106
What does basal insulin include?
Glargine, detemir, and ultra-long acting degludec
107
What are the onset, peak, and duration of rapid acting insulin?
* Onset: ~15 min,
* Peak: 1-2 hrs,
* Duration: 3-5 hours
108
What are the onset, peak, and duration of regular insulin?
* Onset: 30 min,
* Peak: 2 hrs,
* Duration: 6-10 hours
109
What are the onset, peak, and duration of NPH insulin?
* Onset: 1-2 hrs,
* Peak: 4-12 hrs,
* Duration: 14-24 hrs
110
What is true about the peak of basal insulin?
All have no peak
111
What are the onset and duration of Basal insulin?
* Onset: 3-4 hrs,
* Duration: 1 day
112
What are the onset and duration of Degludec?
* Onset: 1 hr,
* Duration: 42+ hrs
113
Insulin can cause hypoglycemia and what other conditions?
Hypokalemia, weight gain, lipoatrophy
114
Which insulins are rapid-acting?
Aspart (Novolog), Lispro (Humalog)
115
When should rapid-acting insulins be injected?
5-15 min before eating
116
Which insulins are short-acting?
Regular (Humulin R, Novolin R)
117
Regular insulin is injected how many minutes before meals?
30 minutes
118
When is regular insulin preferred over rapid-acting insulin?
For IV infusions, including parenteral nutrition
119
When regular (or rapid-acting) insulin and NPH are mixed in the same syringe, which should be drawn up first?
Regular (or rapid-acting) first - clear solution, then NPH - cloudy solution (clear before cloudy)
120
Which insulins are NPH?
Humulin N, Novolin N
121
Which insulins are available OTC?
NPH and Regular
122
Which insulins are long-acting (basal)?
Detemir (Levemir), Glargine (Lantus, Tujeo, Basaglar)
## Footnote
Remember the brand names start with L for long-acting.
123
Insulin Glargine as Lantus is ____ units/mL and Glargine as Tujeo is ___ units/mL.
100 units/mL and 300 units/mL
124
Ultra-long acting basal insulin, degludec (Tresiba), comes in which 2 sizes for the pen?
100 units/mL and 200 units/mL
125
Insulin mixes come in which concentrations?
70/30, 75/25, 50/50
## Footnote
The NPH or protamine insulin is first, the short or rapid-acting insulin is second.
126
Typical insulin starting dose for T1D?
0.5 units/kg/day (TBW)
## Footnote
Divide 50% basal and 50% bolus. Divide bolus evenly among 3 meals.
127
What is a requirement for switching a patient to an insulin pump?
Prior experience with multiple daily injections
128
Usually, dose of the new insulin is a 1:1 conversion. What are the exceptions?
- NPH dosed BID –> Lantus, Basaglar or Tujeo dosed daily: Use 80% of the NPH dose
- Tujeo –> Lantus or Basaglar: Use 80% of the Tujeo dose
129
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
130
The higher the gauge, the ___ the needle.
thinner
131
The ICR indicates:
number of grams of carbs covered by 1 unit of insulin
132
ICR formula for regular insulin?
450/ TDD of insulin = grams of carbs covered by 1 unit of regular insulin
133
ICR formula for rapid-acting insulin?
500/ TDD of insulin = grams of carbs covered by 1 unit of rapid-acting insulin
134
What does the correction factor indicate?
how much the BG will be lowered by 1 unit of insulin
135
What is the correction factor for regular insulin?
1500/TDD = correction factor for 1 unit of regular insulin
136
What is the correction factor for rapid-acting insulin?
1800/TDD = correction factor for 1 unit of rapid-acting insulin
137
Correction dose formula?
(BG now) - (Target BG) / correction factor
138
With which needle sizes does the skin need to be pinched up?
> 5 mm
139
All insulins are stable at RT for 28 days except:
Humalog mixes, pens - 10, Humulin R vial - 31, Humulin N, N/R pen - 14, Humulin R U-500 vial - 40, Novolin R, Novolin N, Novolin N/R 70/30 vials - 42, Novolog mixes in pens - 14, Detemir (Levemir) - 42, Degludec (Tresiba) - 56, Glargine (Tujeo) - 56
## Footnote
Notice the vials have a longer stability than the pens.
140
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
141
If patient is unconscious and is hypoglycemic, what can be used?
dextrose if IV access or glucagon
142
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
143
How to recognize DKA?
BG > 250 mg/dl, Ketones (“fruity breath”), Anion gap acidosis (arterial pH < 7.35, anion gap > 12)
144
How to recognize HHS?
Confusion, delirium, BG > 600 mg/dL with high serum osmolality, Extreme dehydration, pH > 7.3
145
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
