Chapter 44: Diabetes Flashcards
(224 cards)
1
Q
What is the primary function of insulin?
A
To move glucose out of the blood and into body cells for energy
2
Q
Which cells in the pancreas produce insulin?
A
Beta-cells
3
Q
What hormone is produced by alpha-cells in the pancreas?
A
Glucagon
4
Q
What does glucagon do when blood glucose is low?
A
Pulls glucose back into the blood by releasing glucose from glycogen
5
Q
What happens if glycogen is depleted?
A
Glucagon signals fat cells to make ketones as an alternative energy source
6
Q
What is the role of glucagon in glucose metabolism?
A
To increase blood glucose levels when they are low
7
Q
What causes Type 1 diabetes (TID)?
A
Autoimmune destruction of beta-cells in the pancreas
8
Q
What happens to insulin production in Type 1 diabetes?
A
Insulin cannot be produced
9
Q
Which tests can be done to differentiate between Type 1 diabetes and Type 2 diabetes?
A
Testing for islet autoantibodies and C-peptide
10
Q
What is C-peptide?
A
A substance released by the pancreas only when insulin is released
11
Q
What is the C-peptide level in Type 1 diabetes?
A
Very low or absent (undetectable)
12
Q
What treatment must patients with Type 1 diabetes receive?
A
Insulin
13
Q
What are the two primary factors contributing to T2D?
A
Insulin resistance and relative insulin deficiency
14
Q
List three strong associations with T2D.
A
- Obesity
- Physical inactivity
- Family history
15
Q
How can T2D be managed?
A
With lifestyle modifications alone or in combination with oral and/or injectable medications
16
Q
What can reduce the risk of progression from prediabetes to diabetes?
A
Following dietary and exercise recommendations.
17
Q
What medication can be used to improve BG levels in certain patients?
A
Metformin.
18
Q
In which patients is Metformin particularly recommended?
A
Patients with a BMI ≥ 35 kg/m², age 25 - 59 years, and women with a history of gestational diabetes mellitus (GDM).
19
Q
How often should individuals with prediabetes be monitored for diabetes development?
A
Annually.
20
Q
What are the two types of diabetes in pregnancy?
A
• Diabetes present prior to pregnancy
• Diabetes that develops during pregnancy (gestational diabetes mellitus)
21
Q
When is gestational diabetes mellitus (GDM) typically diagnosed?
A
In the second or third trimester
22
Q
What can hyperglycemia during pregnancy lead to in infants?
A
Larger than normal infants (macrosomia) and increased risk for obesity and diabetes later in life
23
Q
At what weeks of gestation are most pregnant women tested for GDM?
A
24 - 28 weeks
24
Q
What test is commonly used to diagnose gestational diabetes?
A
Oral glucose tolerance test (OGTT)
25
If medication is needed for diabetes in pregnancy, what is the preferred treatment?
Insulin
26
What are major risk factors for T2D?
Major risk factors for T2D include:
* Age
* Physical inactivity
* Overweight (BMI ≥ 25 kg/m² or ≥ 23 in Asian-Americans)
* Race or ethnicity
* History of gestational diabetes
* AIC ≥ 5.7% (i.e., prediabetes)
* First-degree relative with diabetes
27
What AIC level indicates prediabetes?
AIC ≥ 5.7%
28
What are the classic symptoms of hyperglycemia?
* Polyuria (excessive urination)
* Polyphagia (excessive hunger or increased appetite)
* Polydipsia (excessive thirst.)
29
What is the initial presentation often observed in Type 1 Diabetes (TID)?
DKA (Diabetic Ketoacidosis)
## Footnote
DKA is a serious complication that can occur in individuals with Type 1 Diabetes.
30
At what age should everyone begin testing for diabetes?
35 years old
31
Who should be tested for diabetes aside from those aged 35 and older?
Asymptomatic adults who are overweight or obese with at least one other risk factor
32
What are the three types of tests used to identify if prediabetes or diabetes is present?
* Hemoglobin AlC
* Plasma glucose
* OGTT
33
What does Hemoglobin AlC indicate?
The average blood glucose over approximately the past 3 months.
34
What is the fasting condition required for Plasma glucose testing?
Fasting for ≥ 8 hours.
35
What does the OGTT measure?
Blood glucose level 2 hours after drinking a high-sugar liquid.
36
What should be done if a positive test result is obtained?
Confirm with a second abnormal test result from either the same sample or a new sample.
37
What is the A1C percentage that indicates diabetes?
6.5% or higher
38
What A1C percentage range indicates prediabetes?
5.7% to 6.4%
39
What is the FPG (Fasting Plasma Glucose) level that indicates diabetes?
≥ 126 mg/dL
40
What FPG level range indicates prediabetes?
100-125 mg/dL
41
What is the random blood glucose (BG) level that indicates diabetes?
≥ 200 mg/dL
42
What random BG level range indicates prediabetes?
140-199 mg/dL
43
What is the OGTT, 2-hour BG level that indicates diabetes?
≥ 200 mg/dL
44
What OGTT, 2-hour BG level range indicates prediabetes?
140-199 mg/dL
45
What are the glycemic targets in non-pregnant diabetic patients?
* A1C: < 7%
* Preprandial: 80-130 mg/dL
* 2-hr PPG: < 180 mg/dL
46
What are the glycemic targets in pregnant diabetic patients?
* Preprandial: < 95 mg/dL
* 1-hr PPG: < 140 mg/dL
* 2-hr PPG: < 120 mg/dL
47
What does an A1C of 6% correspond to in estimated average glucose?
126 mg/dL
48
How much does each 1% increase in A1C affect estimated average glucose?
Each increace in A1C of 1% = increase in eAG of ~28 mg/dL
49
How often should glycemic control be assessed if not meeting goals?
Quarterly (every 3 months)
50
What is the recommended assessment frequency for glycemic control if at goal?
Biannually (every 6 months, or twice per year)
51
What is the goal weight loss percentage for diabetic individuals who are overweight or obese?
≥ 5% of body weight
52
What are natural sources of carbohydrates recommended for diabetes?
Vegetables, fruits, whole grains, legumes, dairy
53
What is the maximum recommended alcohol consumption for women and men?
≤ 1 drink/day for women, ≤ 2 drinks/day for men
54
How should prandial insulin doses be adjusted for patients with T1D?
Based on carbohydrate intake
55
What constitutes a carbohydrate serving in diabetes management?
15 grams
## Footnote
Examples include one small piece of fruit, 1 slice of bread, or ⅓ cup of cooked rice/pasta.
56
How many minutes of moderate-intensity aerobic activity should be performed weekly?
At least 150 minutes
57
What is a recommended strategy to reduce sedentary behavior?
Stand every 30 minutes
58
What is a key recommendation for patients who smoke?
Encourage quitting
59
Which natural products are commonly used in diabetes management despite limited evidence?
Cinnamon, alpha lipoic acid, chromium, magnesium, ginseng
60
What are the microvascular complications of diabetes?
Retinopathy, Diabetic kidney disease (nephropathy), Peripheral neuropathy
61
What are the macrovascular complications of diabetes?
Coronary artery disease (CAD), Cerebrovascular disease, Peripheral artery disease (PAD)
62
What is the recommended eye exam protocol for T2D at diagnosis?
Eye exam with dilation at diagnosis
63
How often should an eye exam be repeated if retinopathy is detected?
Annually
64
If no retinopathy is found, how often should the eye exam be repeated?
Every 1-2 years
65
What is Diabetic Kidney Disease defined as?
eGFR < 60 mL/min/1.73 m and/or albuminuria (urine albumin ≥ 30 mg/24 hrs or UACR ≥ 30 mg/g)
66
How often should urinary albumin and eGFR be monitored if kidney function is normal?
Annually
67
Which medications are used for the treatment of Diabetic Kidney Disease?
* ACE inhibitor or ARB
* SGLT2 inhibitor (if eGFR ≥ 20 mL/min/1.73 m2)
* Finerenone (once on a maximally tolerated dose of ACE inhibitor or ARB)
68
What is the annual test recommended for neuropathy assessment?
A 10-g monofilament test and 1 other test (e.g., pinprick, temperature, vibration)
69
How often should a comprehensive foot exam be performed for neuropathy?
At least annually
70
Name are treatment options for neuropathy.
Gabapentin, pregabalin, SNRIs (e.g., duloxetine), tricyclic antidepressants, and sodium channel blockers.
71
What is the recommended statin treatment for diabetic patients with comorbid ASCVD?
High-intensity statin with LDL goal < 55 mg/dL
72
What is the LDL goal for patients aged 40-75 years with at least one ASCVD risk factor?
LDL goal < 70 mg/dL with high-intensity statin treatment.
73
What type of statin is recommended for patients aged 40-75 years without ASCVD?
Moderate-intensity statin
74
What statin treatment is advised for patients aged 20-39 years with ASCVD risk factors?
Moderate-intensity statin
75
What add-on treatments are recommended if LDL remains above goal on maximally tolerated statin?
Ezetimibe or a PCSK9 inhibitor
76
Initial medication therapy based on baseline A1C
* < 8.5 %: monotherapy with oral or non-insulin injecetables
* 8.5-10%: Combination therapy
* >10%: insulin
77
What are the criteria to start a patient on insulin?
* A1C >10%
* BG > 300
* Unintended weight loss
* Classic symptoms of hyperglycemia prresent
78
Which GLP-1 agonists have shown to have cardiorenal benefits?
* Dulaglutide
* Liraglutide
* SC semaglutide
79
Which groups of diabetic patients require cardiorenal risk reduction?
* ASCVD or high risk
* Heart failure
* CKD
80
Which SGLT2i have shown to have cardiorenal benefits?
* Canagliflozin
* Dapagliflozin
* Empagliflozin
* Ertugliflozin
81
Which combination of glucose lowering medications should be avoided?
* DPP-4 inhibitor + GLP 1A
* Sulfonyurea + insulin
82
GLP-1A MOA?
Glucagon-like peptide 1 (GLP-1) agonists are analogs of the incretin hormone GLP-1, which 1 glucose-dependent insulin secretion, - glucagon secretion, slows gastric emptying, improves satiety and can result in weight loss.
83
Liraglutide
Victoza
84
Dulaglutide
Trulicity
85
Semaglutide
* Ozempic
* Rybelsus
86
Exenatide
* Byetta
* Bydureon BCise
87
All GLP-1A and GIP are administered ___, Except ____ is ____
* SC
* rybelsus
* PO
88
List differences between Exenatide products
1. Byetta is IR, avoid if CrCl < 30
2. Bydureon is ER, avoid if CrCl < 45
89
Which GLP-1A is given weekly?
* Trulicity
* Ozempic
* Bydureon
* Mounjaro
90
Which GLP-1A is given daily
* Victoza
* Rybelsus
91
How often is Byetta given?
Twice daily
92
What is the boxed warning associated with GLP-1a except byetta?
Risk of thyroid C-cell carcinoma
93
What are the warnings of GLP-1a?
* Pancreatitis
* Not recommended in severe GI diseases like gastroprosis
94
GLP-1a side effects?
* Weight loss
* N/V/D
95
When should byetta be given?
within 60 min before meals
96
SGLT2i MOA?
By inhibiting SGLT2, these drugs reduce reabsorption of glucose and I urinary glucose excretion, which / BG concentrations.
97
Canagliflozin
Invokana
98
Dapagliflozin
Farxiga
99
Empagliflozin
Jardiance
100
What are the warnings associated with SGLT2i?
* Ketoacidosis
* Genital mycotic and UTI
* Nectotizing fascitis
* Hypotension, AKI (due to volume depletion)
101
SGLT2i side effects?
increase urination and thirst
102
What are the warnings and SE associated with canagliflozin specifically?
* Increase risk of leg/foot amputation
* increase risk of fractures
* increase risk of hyperkalemia
103
What class of medication is metformin?
Biguanide
104
Metformin MOA?
Metformin primarily works by l hepatic glucose production, T insulin sensitivity and I intestinal absorption of glucose.
105
Metformin
Fortamet, Glumetza
106
Metformin initial dose
500 mg daily
107
How often can metformin be titrated?
Weekly
108
Metformin normal maintanance dose
1000mg BID
109
How to reduce GI side effects with metformin?
* Slow titration
* Taking with a meal
110
What is a patient counseling for metformin ER formulation?
It can leave a ghost tablet in stool
111
Metformin boxed warning
Lactic acidosis
112
What should be done with metformin before an imaging procedure involving iodinated contrast media?
Discontinue metformin to reduce the risk of lactic acidosis
113
When can metformin be restarted after an imaging procedure?
48 hours after the procedure if eGFR is stable
114
What is a contraindication for Metformin related to eGFR?
* eGFR < 30 mL/min/1.73 m²
* Metabolic acidosis
115
What are common side effects of Metformin?
* Gl effects (eg, nausea, diarrhea)
* Vitamin B12 deficiency with long term use
116
What is the mechanism of action of insulin secretagogues?
Stimulate pancreatic beta-cells to increase insulin secretion
117
What are the two main classes of insulin secretagogues?
* Sulfonylureas
* Meglitinides
118
What are the names of some sulfonylureas?
Glipizide, Glimepiride, Glyburide, Micronized glyburide
## Footnote
Glipizide is also known as Glucotrol XL and Micronized glyburide is known as Glynase.
119
What are the names of the meglitinides?
Repaglinide, Nateglinide
120
What is a contraindication for sulfonylureas?
Sulfa allergy
121
What warning is associated with sulfonylureas and meglitinides?
Hypoglycemia
122
What is a common side effect of sulfonylureas and meglitinides?
Weight gain
123
When should Glipizide IR be taken?
30 minutes before a meal
124
What should be done with doses of Glipizide if a patient is NPO?
May need to hold doses
125
What may Glucotrol XL leave behind in the stool?
Ghost tablet (empty shell)
126
Which SU medications are not preferred in the elderly according to the Beers criteria?
Glimepiride and glyburide Due to hypoglycemia risk
127
Sitagliptin
Januvia
128
Linagliptin
Tradjenta
129
Which DPP-4i does not require renal dose adjustment?
Linagliptin
130
Warnings associated with DPP-4i?
* Pancreatitis
* Arthralgia
* AKI
* HF with saxagliptin & alogliptin
131
TZD MOA?
Wroks by binding to and activating the proxisome proliferator activated receptor y (PPAR-y):
* increase peripheral insulin sensitivity
132
What is the only drug in TZD family?
Pioglitazone (Actos)
133
Warnings associated with Actos?
* Edema
* Risk of fractures
* unintended pregnancy
134
Actos side effects
* Peripheral edema
* Weight gain
135
Actos boxed warning
Heart failure
136
What should be used to treat hypoglycemia if patients are taking alpha-glucosidase inhibitors?
glucose tablet or gel
137
When should alpha-glucosidase inhibitors be taken?
each dose must be taken with first bite of food
138
alpha-glucosidase inhibitors side effects
* Flatulence
* Diarrhea
* Abdominal pain
139
Which medication is used for both diabetes and dyslipidemia?
Colesevelam
140
Actoplus Met
Metformin+Pioglitazone
141
Invokamet
canagliflozin + metformin
142
Janumet
Metformin+Sitagliptin
143
How is insulin administered in patients with diabetes?
Insulin is administered as a subcutaneous injection, intravenously, or inhaled.
144
What are the main types of basal insulin?
* Glargine
* Detemir
* Ultra-long acting degludec
145
What is the onset and duration of action for basal insulin?
Onset of 3 - 4 hours and duration ≥ 24 hours.
146
What is NPH insulin and its characteristics?
NPH is intermediate-acting with an onset of 1 - 2 hours, peaks at 4 - 12 hours, and has a variable duration of action (14 - 24 hours).
147
What are examples of rapid-acting insulin?
* Aspart
* Lispro
* Glulisine
148
What is the onset and duration of rapid-acting insulin?
* Onset ~15 minutes,
* peaks in 1 - 2 hours, and
* lasts 3 - 5 hours.
149
What is regular insulin classified as?
Short-acting insulin
150
What is the onset and duration of regular insulin U-100?
* onset 30 min
* duration 6 - 10 hours.
151
What is regular insulin U-500?
A very concentrated insulin with a duration close to NPH, lasting up to 24 hours.
152
How often is regular insulin U-500 typically dosed?
Twice daily or TID, before meals.
153
What is the absorption method for inhaled insulin?
Fast absorption through the lungs.
154
What is the primary function of basal insulin in diabetes management?
To mainly impact fasting glucose.
155
Warnings associated with insulin
* Hypoglycemia
* Hypokalemia
156
Side effects associated with insulin
* Weight gain
* Lipoatrophy
* Lipohypertrophy
157
What is the standard insulin concentration?
100 units/mL
158
How should insulin suspensions be handled?
Turn up and down slowly or roll between hands
## Footnote
Do not shake and avoid freezing or extreme heat exposure.
159
Where should unopened insulin vials and pens be stored?
In the refrigerator
160
Where can opened insulin vials and pens be stored?
At room temperature
161
What types of insulin can be mixed in the same syringe?
NPH and regular (or rapid-acting) insulins
162
Which insulin is drawn up first when mixing?
Regular insulin (or rapid-acting)
163
Insulin Aspart
Novolog, Novolog FlexPen
164
What is Lispro commonly marketed as?
Humalog, Humalog KwikPen
165
What is the administration method for rapid-acting insulin?
Inject SC 5-15 minutes before meals
166
What is the primary use of rapid-acting insulin?
Prandial insulin
167
What is a contraindication for inhaled insulin?
Any lung disease (asthma, COPD)
168
What is required for patients using inhaled insulin?
Pulmonary function tests (FEV,)
169
Can smokers use inhaled insulin?
No
170
Describe the physical characteristics of rapid-acting insulin.
Clear and colorless
171
What is the classification of Regular U-100 insulin?
Short-Acting (Bolus) Insulin
172
What are the physical characteristics of Regular U-100 insulin?
Clear and colorless
173
Is Regular U-100 insulin available by prescription or over-the-counter?
Rx and OTC
174
When should Regular U-100 insulin be injected?
30 minutes before meals
175
What is the primary use of Regular U-100 insulin?
Used as prandial insulin & Correction doses (sliding scale)
176
What type of insulin is preferred for IV infusion?
Regular U-100
177
What type of appearance does NPH have?
NPH is cloudy
178
Is NPH available over-the-counter or by prescription?
NPH is available OTC and Rx
179
What is a common side effect of NPH?
NPH causes more hypoglycemia
180
How often is NPH typically used?
NPH is typically used twice daily
181
What is the primary use of Long-Acting (Basal) Insulin?
To provide a steady level of insulin throughout the day
182
Name two types of Long-Acting Insulin.
* Insulin detemir (Levemir)
* Insulin glargine (Lantus, Toujeo, Basaglar)
183
Describe the appearance of Long-Acting Insulin.
Clear and colorless
184
How often is Long-Acting Insulin usually injected?
Usually injected once daily; detemir may need to be given twice daily
185
What is the concentration of Lantus insulin?
100 units/mL
186
What is the concentration of Toujeo insulin?
300 units/mL
187
What is the concentration of Tresiba in a vial?
100 units/mL
## Footnote
Tresiba is an ultra-long-acting insulin used for diabetes management.
188
What are the available concentrations of Tresiba in the Flextouch pen?
100 and 200 units/mL
## Footnote
The Flextouch pen format allows for flexible dosing.
189
What is the initial recommended dosage for starting basal insulin in Type 2 Diabetes?
10 units SC daily or 0.1-0.2 units/kg/day SC
190
How should basal insulin be titrated?
Based on fasting plasma glucose (FPG)
191
What is the recommended starting dose for prandial insulin?
4 units or 10% of basal dose SC once daily prior to the largest meal
192
What is the regimen if the patient is not at A1C goal?
* Full basal/bolus regimen: Basal insulin daily + prandial insulin before each meal
* Mixed insulin regimen: Twice daily NPH + short/rapid self-mixed or premixed insulin
193
What is a common treatment method for diabetes?
Insulin pump or multiple daily injections of insulin
194
What types of insulin are preferred in type 1 diabetes?
Rapid-acting injectable insulins and long-acting basal insulins
195
How to start a basal-bolus insulin regimen in T1D?
1. Typical starting dose: 0.5 units/kg/day (use TBW)
2. Divide the TDD into 50% basal and 50% bolus (rapid-acting) insulin
3. Divide the bolus insulin evenly among 3 meals
196
NPH dosed BID → insulin glargine (Toujeo) dosed daily
Use 80% of the NPH dose
197
Toujeo → insulin glargine or insulin detemir
Use 80% of the Toujeo dose
198
Most insulin
conversions are_____
1:1
199
What is the rule of 450 for ICR?
200
What is the rule of 500 for ICR?
201
Insulin correction factor for regular insulin
202
Insulin correction factor for rapid-acting insulin
203
Correction dose formula
204
What is the room temperature stability duration for Humalog Mix 50/50 and 75/25 pens?
1-2 Weeks
205
Which insulin has the room temperature stability duration for 2 Weeks?
* Humulin N pen
* Novolog Mix 70/30 pen
206
Which insulin has the room temperature stability duration for 4 Weeks?
* Apidra, Humalog, Novolog, Admelog, Lyumjev, and Fiasp vials and pens
* Humalog Mix 75/25 vial
* Novolog Mix 70/30 vial
* Novolin R U-100, N and 70/30 pens
* Humulin R U-500 pen
* Lantus, Basaglar, and Semglee vials and pens
* Humulin R U-100, N and 70/30 vials
207
Which insulin has the room temperature stability duration for 6 Weeks?
1. Humulin R U-500 vial
2. Novolin R U-100, N and 70/30 vials
3. Levemir vial and pen
208
Which insulin has the room temperature stability duration for 8 Weeks (56 days)?
1. Tresiba pen
2. Toujeo pen
209
What BG is defined as hypoglycemia?
BG < 70
210
List drugs that can cause low BG
* Beta blockers
* Quinolones
* Tramadol
211
List drugs that can cause increase BG
* Thiazide & Loop
Diuretics
* Tacrolimus,
* Cyclosporine
* Protease Inhibitors
* Quinolones*
* Antipsychotics (e.g., olanzapine, quetiapine)
* Statins
* Steroids (systemic)
* Cough Syrups
* Niacin
212
What is the definition of persistent hyperglycemia?
Persistent hyperglycemia is defined as BG ≥ 180 mg/dL
213
What is the target blood glucose range for non critically ill patients?
The target range is 100 - 180 mg/dL
214
What is the target blood glucose range for critically ill patients?
The target range is 140 - 180 mg/dL
215
When should treatment be initiated for hospitalized patients?
Treatment should be initiated for hospitalized patients with persistent hyperglycemia
216
What is diabetic ketoacidosis (DKA)?
A life-threatening crisis with high BG, ketoacidosis, and ketonuria.
217
What is the blood glucose (BG) level that indicates DKA?
> 250 mg/dL
218
What are the symptoms of DKA?
* Ketones in urine and serum (resulting in 'fruity' breath)
* Abdominal pain
* Nausea and vomiting
* Dehydration
219
What is the anion gap acidosis criteria for DKA?
Arterial pH < 7.35, anion gap > 12
220
What are the symptoms recognized by HHS?
Confusion, delirium, Extreme dehydration
221
What blood glucose level is associated with HHS?
BG > 600 mg/dL
222
What is the serum osmolality level indicative of HHS?
High (> 320 mOsm/L) serum osmolality
223
What is the pH level in HHS?
pH > 7.3
224
What is the treatment steps for DKA and HHS?
1. Fluid (first NS, then D5W added when BG < 250)
2. Regular insulin IV continuous infusion
3. Prevent hypokalemia
4. Treat acidosis if pH < 6.9 with sodium bicarbonate
