Diabetes Flashcards
(173 cards)
1
Q
In type I diabetes, what cells do the antibodies attack?
A
the beta cells (islet cells)
these cells make insulin within the pancreas
2
Q
very high ketone levels can cause what?
A
DKA – medical emergency
3
Q
What protein is used to test if T1D is present?
A
C-peptide protein – VERY low levels or absent in T1D
-released by the pancreas only when insulin is released.
4
Q
How are women tested for diabetes in pregnancy?
A
oral glucose tolerance test (OGTT) *preferred
5
Q
What is the drug of choice in pregnancy for diabetes?
A
insulin
metformin and glyburide are sometimes used
6
Q
Retinopathy
Nephropathy
Neuropathy
Autonomic neuropathy
are all what type of damage?
A
mircovasular disease
7
Q
What is macrovascular disease?
A
ASCVD, including MI, CVA, PAD
8
Q
What are the classic symptoms caused by high BG?
A
polyuria - excessive urination
polyphagia - excessive hunger
polydipsia - excessive thirst
> fatigue, flurry vision, ED, vaginal fungal infections
9
Q
Risk factor for DM
HDL:
TG:
A
HDL < 35
TG>250
PCOS!!
10
Q
when should people start being tested for DM? regardless of risk factors
A
45y
11
Q
alll asx children, adolescents and adults who are overweight (BMI>25 or >23 in asian Americans) with at least one other risk factor (ie physical activity) should be tested. If neg, when should it be repeated?
A
3 years
12
Q
FPG is taken after how many hour fast?
A
8hr
> 126, must be confirmed again by testing with the same or with a new blood sample
13
Q
BG measured how often? (goal A1C<6.5/7%
not at goal =
at goal =
A
3 months
6 months
14
Q
Diagnostic criteria: diabetes
A1C
FPG
2hr PPG after OGTT
A
> 6.5
126
200
15
Q
Diagnostic criteria: prediabetes
A1C
FPG
2hr PPG after OGTT
A
5.7-6.4
100-125
140-199
16
Q
Treatment goals: not pregnant
preprandial
2hr PPG
A
80-130
<180
17
Q
Treatment goals: pregnant
preprandial
1hr PPG
2hr PPG
A
<95
<140
<120
18
Q
An A1c of 6% is equivalent to an eAG of 126mg/dL
Each addition 1% increases the eAG by how much?
A
28mg/dL
19
Q
Comprehensive care: anti platelet therapy
A
aspirin 81mg for ASCVD secondary prevention
- aspirin allergy = clopidogrel 75 daily
NOT RECOMMENDED FOR PRIMARY PREVENTION
20
Q
Comprehensive care: cholesterol control
A
ANNUAL lipid panel ; most need statins (recheck after 4-12 weeks of starting/incing dose)
can add ezetimibe to max tolerated dose of statin if ASCVD risk >20%
21
Q
What statin level?
Diabetes + ASCVD (post-MI, PAD), or 50-75y with multiple ASCVD risk factors
A
HIGH
atorvastatin 40-80mg
rosuvastatin 20-40mg
22
Q
What statin level?
diabetes without ASCVD and older (40-75)
A
moderate
23
Q
What statin level?
diabetes without ASCVD and younger <40
A
no risk factors for ASCVD –> no statin
ASCVD risk factors: moderate-intensity statin
24
Q
Peripheral neuropathy - how often get checked?
A
annually with a 10g monofilament & 1 other test to asses sensation
tx options: pregabalin, duloxetine, gabapentin
25
Diabetic retinopathy
how often?
when diagnosed --> eye exam with dilation
if retinopathy, annually, if not repeat Q1-2 years
26
Vaccinations for diabetes
HBV
flu
both Prevnar 13, pneumovax 23 [2-64, then another 65+]
shingrix
27
Blood pressure goal for diabetes
<130/80 (ACC/AHA)
<130/80 if ASCVD risk is high, if not >140/90 (ADA)
28
Diabetes with hypertension no albuminuria
treatment
thiazide, CCB, ACE, or ARB
29
Diabetes with albuminuria +/- HTN
treatment
ACE, ARB
30
how often check albumin if no kidney disease? if they have kidney disease?
yearly
twice yearly
31
What are natural products used to dec BG
cinnamon
alpha lipoic acid
chromium
32
First line treatment for DM
metformin + physical activity
33
patient has HF, CKD, ASCVD RISK/ASCVD, in everyone (regardless of A1c):
ASCVD major issue: treatment
GLP-1RA (dulaglutide, liraglutide, semaglutide SC in only)
OR
SGLT2i (empagliflozin, canagliflozin) if eGFR ok; CI if eGFR <30
34
diabetes treatment if HF or CKD major issue
SGLT-2i (empa, canag, dapa). IF eGFR ok (>30)
if cannot use, go with GLP-1RA (dulaglutide, liraglutide, semaglutide)
35
patient has HF, CKD, ASCVD RISK/ASCVD
>A1c 6.5% treatment options
add the other class SGLT2i or GLP-1RA, using the drugs with CVD benefit
if using SGLTi, can add DPP4i
add basal insulin with CVD benefit (glargine U100 or degludec
TZD - NOT WITH HF
SU
36
Do not use which agents with DPP4i?
GLP-1RA (same MOA)
37
Patient does not have ASCVD, HF or CKD but A1C >6.5%
goal: minimize hypoglycemia
DPP4i
GLP-1RA
SGLT-2i
TZD
38
Patient does not have ASCVD, HF or CKD but A1C >6.5%
goal: minimize hypoglycemia
remains elevated
add different class from
DPP4i
GLP-1RA
SGLT-2i
TZD
39
Patient does not have ASCVD, HF or CKD but A1C >6.5%
goal: weight loss
options with best evidence:
GLP-1RA (semaglutide, liraglutide, dulaglutide)
SGLT-2i
40
Patient does not have ASCVD, HF or CKD but A1C >6.5%
goal: weight loss
remains elevated
use other class (GLP-1RA or SGLT-2i)
41
Patient does not have ASCVD, HF or CKD but A1C >6.5%
goal: minimize hypoglycemia
remains elevated x2
if triple therapy is required or SGLT2i and/or GLP-1RA are CI: use DPP4i
if DPP4- not tolerated or CI or already on GLP-1RA, cautiously add either:
TZD
basal insulin
SU
42
when is metformin started in combo instead of alone?
A1c >1,5% goal
43
if eGFR <30 what treatment?
NO metformin
insulin can be used initially if hyperglycemia is severe BG>300/a1c >10%
44
Consider what agent before insulin if above A1c target goal?
GLP-1RA
45
Consider what options before full basal-bolus dose insulin if above A1c target goal?
remains elevated ---
add basal insulin or bedtime NPH insulin
46
Adding on basal insulin or bedtime NPH insulin, what's the starting dose?
0.1-0.2u/kg/day (TDD)
-set FPG target
- choose titration algorithm (inc 2u every 3 days)
if hypoglycemia dec dose by 10-20%
47
patient on GLP-1RA, NPH bedtime insulin with titrated dose... remains elevated...
add meal-time insulin, starting with ONE daily dose, before meal with highest carb intake or highest postprandial BG
additional prandial doses can be added up to 2-3 times daily prior to meals
if insufficient --> full basal-bolus regimen
48
Top 3 treatments:
metformin
GLP-1RAs
SGLT-2i
side effects
weight LOSS
NO hypoglycemia
49
Brand: Actoplus Met
generic: metformin/pioglitazone (TZD)
50
Brand: Janumet
generic: metformin/sitagliptin (DPP4i)
51
Brand: invokamet
generic: metformin/canagliflozin
52
MOA: dec hepatic glucose output
metformin (BIGUANIDE)
53
Brand: Glucophage, Glucophage XR, Fortamet, Glumetza
generic: metformin
54
Metformin boxed warnings
lactic acidosis - increase risk with renal disease!!
55
Brand: Actos
generic: pioglitazone
TZD
56
Brand: Avandia
generic: rosiglitazone
TZD
57
MOA: increase muscle cell-sensitivity to insulin to inc BG entry
TZDs
58
Which agent causes hypoglycemia when used with insulin so much that the insulin dose may need to be reduced?
& ALSO CAUSE WEIGHT GAIN
TZDs
59
Side effects of TZDs
edema, weight gain, bone fractures
60
Which diabetic agents should not be used in HF? (class III/IV)
TZD
| BBW
61
```
Warnings:
Hepatic failure
Edema
worsen HF
Fractures
stimulate ovulation
BLADDER CANCER
```
TZD
bladder cancer -- pioglitazone
62
Brand: invokana
generic: canagliflozin
63
Brand: Jardiance
generic: empaglyflozin
64
MOA: increase BG renal excretion via proximal tubule
SGLT2i
65
Which agent causes hypoglycemia when used with insulin so much that the insulin dose may need to be reduced?
& ALSO CAUSE WEIGHT LOSS
SGLT2i
66
Which SGLT2i have a BBW for amputation risk?
canagliflozin
67
```
Warnings:
inc LDL
inc K
fluid loss, hypotension
Ketoacidosis, even with BG <250
```
SGLT2i
68
How many days should you DC SGLT2i prior to surgery
3 days, to reduce the risk of ketoacidosis
69
Brand: januvia
generic: sitagliptin
70
Brand: tradjenta
generic: linagliptin
71
Which agent causes hypoglycemia when used with insulin so much that the insulin dose may need to be reduced?
& ALSO no difference in weight change
DPP4 inhibitors
72
MOA: inc incretin --> less glucagon --> lowers BG
DPP4i
73
What agent of the DPP4i can you use in renal impairment with no dose chagne
linagliptin
74
WARNINGS:
pancreatitis
severe joint pain
acute renal failure
DPP4i
alogliptin - hepatotoxicity
alogliptin & saxagliptin - avoid in HF
75
Brand: glucotrol, glucotrol XL
generic: glipizide
SU
76
Brand: Amaryl
generic: glimepiride
SU
77
Brand: glynase
generic: glyburide, micronized
SU -- highest risk for hypoglycemia (and chlorpropamide)
78
MOA: increase insulin secretion
sulfonylureas
79
These agents cause hypoglycemia, weight gain, and cannot use with insulin or with meglitidies
SU
80
What drugs are meglitinides?
repaglinide (Prandin)
| Nateglinide (Starlix)
81
MOA: increase insulin secretion
meglitinides
82
These agents have hypoglycemia especially is the meal is skipped and the dose Is still taken, and weight gain. this med also has to be taken 15-30 mins before meals
meglitinides
83
Do no use which meds with each other?
SU-meglitinides
GLP-1RA-DPP4i
84
Brand: Victoza
generic: liraglutide
85
Brand: Trulicity
generic: dulaglutide
86
MOA: "incretin mimetic"
GLP1RA
87
Which GLP1RA is dosed daily?
weekly?
daily - liraglutide
weekly - dulaglutide *needles provided
88
Which GLP1RA are given within 60 mins of meal
Byetta (exenatide)
| Adlyxin (lixisenatide)
89
WARNING:
| pancreatitis
GLP-1RAs
90
This agent is a synthetic analog of amylin
pramlintide (SymlinPen 60, 120)
91
What agent is used in both 1&2 DM
Pramlintide
92
This agent has a CI with gastroparesis
Pramlintide
SEVERE HYPOGLYCEMIA -- BBW
93
Uncommon use, not in guidelines medications
alpha-glucosidase inhibitors: MOA- inhibitors sucrose breakdown in gut
acarbose (Precose), miglitol (Glyset)
Bile-acid binding resin: colesevelam (Welchol)
Dopamine agonist: Bromocriptine (Cycloset) -- also used in PD
94
if present - cancer
avoid:
pioglitazone, dapa (bladder cancer), GLP1RA (thyroid,)
95
if present - elderly
avoid:
SU
96
if present - gastroparesis, GI disorders
avoid:
GLP1RAs, pramlintide
97
if present - UTI
avoid:
SGLT2i
98
if present - hepatotoxicity
avoid:
TZDs, alogliptin
99
if present - hypotension/dehydration
avoid:
SGLT2
100
if present - inc K
avoid:
canag
101
if present - low K
avoid:
insulin
102
if present - hypersensitivity
avoid:
DPP4i
103
if present - ketoacidosis
avoid:
SGLT2,
104
if present - lactic acidosis
avoid:
metformin
105
if present - osteoporosis
avoid:
canag, TZDs
106
if present - pancreatitis
avoid:
DPP4i, GLP1RA
107
if present - peripheral neuropathy, PAD, foot ulcers
avoid:
canag
108
if present - retinopathy
avoid:
semaglutide SC inj (ozempic)
109
if present - sulfa allergy
avoid:
SU
110
if present -renal insufficiency
avoid:
metformin, SGLT2, eventide, glyburide
111
if present - weight gain
avoid:
SU, meglitinides, TZD, insulin
112
What do alpha cells produce in the pancreas?
glucagon
beta cells -- insulin
113
Examples of basal insulin
glargine
detemir (binds to albumin!)
degludec
114
Rapid-acting and short-acting insulin examples
Fiasp (has niacinamide/vit B3) QUICK AF
Regular insulin
115
intermediate acting
NPH
116
Onset of detemir
3-4 hours lasts 1 day no peak
117
Onset of glargine
3-4 hours (Toujeo 6 hours) lasts 1 day, no peak
118
Onset of degludec
onset in 1 hour, lasts 42+ hours no peak
119
NPH onset
1-2 hours, peaks 4-12 hours, lasts 14-24 houra
120
Regular onset
30 mins, peaks 2 hours, lasts 6-10 hours
121
Rapid acting onset
15 min, peaks in 1-2 hours, lasts 3-5 hours
122
Brand: Novolog
generic: aspart
RA, preferred bolus, less hypoglycemia
123
Brand: Humalog
generic: lispro
RA, preferred bolus, less hypoglycemia
124
Brand: Humulin R, Novolin R
generic: regular
SA, can be mixed with NPH (regular drawn up first because its clear)
125
Brand: Humulin N, Novolin N
generic: NPH (CLOUDY)
intermediate acting
126
Brand: levemir
generic: detemir
do not mix
127
Brand: Lantus, Toujeo
generic: glargine
do not mix
128
What is the typical starting dose for T1D?
0.5units/kg/day
TBW
50% basal, 50% bolus (3 meals)
129
What is a requirement for switching to a pump?
prior experience with multiple daily injections
130
Insulin pumps deliver what type of insulin
```
rapid acting
(continous and bolus/ICR dosing)
```
~basal/long-acting
131
Usual conversion between insulins are 1:1 except:
NPH dose BID --> Lantus or Basaglar dosed daily
use 80% of NPH dose
example: NPH 30 units AC breakfast and 20 units AC dinner = 50 units NPH daily
50x0. 8= 40 units Lantus or basaglar
132
Usual conversion between insulins are 1:1 except:
Toujeo --> Lantus or Basaglar dosed daily
use 80% of the toujeo dose
133
Humulin 70/30
what is the regular insulin?
70 - NPH
30 - regular
134
All pens contain 3mL, EXCEPT:
Toujeo is concentrated glargine (U300), with two cartridge sizes = 1.5mL and 3mL
135
Which insulin comes concentrated?
Rapid acting:
Humalog Kwikpen (Lispro):
Regular:
Humulin R (PEN & VIAL):
Long-acting --
Tresiba Flextouch pen (degludec):
Toujeo Solostar, Toujeo Max Solostar (Glargine):
Rapid acting: Humalog Kwikpen (lsipro): 200U/mL
Regular: Humulin R U500 Kwikpen AND vial: 500U/mL (20mL total)
Long-acting --
Tresiba Flextouch pen (degludec) 200U/mL
Toujeo SoloStar, Toujeo Max Solostar pens (glargine): 300U/mL (1.5mL and 3mL)
136
What color is the cap to U500 insulin?
GREEN
U100 is orange
137
Regular ICR ... Rule of...
450
450/TDD = grams of carbs covered by 1 unit of R insulin
138
Rapid acting ICR... rule of..
500
500/TDD = grams of carbs covered by 1 unit of rapid-acting insulin
139
What is the correction factor?
how much the BG will be lowered by 1 unit of insulin
140
Correction factor for REGULAR
1500 rule
1500/TDD = correction factor for 1 unit of regular insulin
141
Correction factor for RAPID ACTING
1800 Rule
1800/TDD = correction factor for 1 unit of RA insulin
142
Calculating the correction dose -- both types use this forumula
BG now - target BG/ correction factor = correction dose
143
Prior to each injection prime the needle by turning the knob how many units
2
144
Insulin is best absorbed where
abdomen
alt: forarm, palm, thigh
145
Novolog pen (aspart) - lasts at room temp how long
14 days
146
What pen and vials last 56 days?
Degludec (tresiba) vial and pen)
Lantus vial and pen
147
Humalog mixes vials pens last how long?
PENS= 10
VIALS = 28
humulin R vial = 31 days
148
CGMS provide measurements of the glucose where?
interstitial fluid between the cells
149
Drugs that inc BG
```
BB
thiazide, loops
tacrolimus, cyclosporin
protease inhibitors
atiphyschotics (olanzapin, quetiapine)
statins
steroids
cough syrups
niacin
```
150
Drugs that DEC BG
```
linezolid
lorcaserin (Belviq)
Pentamidine
BB
quinolognes
tramadol
```
151
What drugs can cause both inc or dec BG
quinolone and BB
152
what is defined as hypoglycemia?
<70
153
What sx of hypoglycemia are not masked from BB?
sweating and hunger
154
Treatment if conscious
pure glucose - 15g then check
155
treatment if unconscious
dextrose IV or glucagon 1mg SC, nasal spray
156
BG >250
ketones, fruity breath
anion gap acidosis (arterial pH <7.35, anion gap>12)
what is this?
DKA
157
confusion, delirum
BG >600, osmolality >320
extreme dehydration
pH>7.3, bicarb >15
what is this?
HHS
158
Treatment for both DKA and HHS
fLUIDS!!!
NS then switch to D5W1/2NS when BG 200
watch for potassium
regular insulin infusion 0.1u/kg bolus, then 0.1u/kg/hr
sodium bicarb as needed
159
when are TZDs taken?
morning
160
GLP1RA which agents need needles to be purchased
Byetta, Victoza, Adlyxein
161
Albuminuria is defined as
>30mg/24 hr
162
Recommended BG while in the hospital?
140-180
163
Most insulins have how many units per mL?
100u/mL with 100mL (u-100)
164
Toujeo
glargine
*comes in 1.5mL and 3mL cartridges
165
Tresiba
degludec
166
which insulin comes in U-500 both pen and vial? (higher risk of fatality)
regular U-500
167
What insulin is stable at room temp for 28 days?
"LAG"
Humalog (lispro) vial, pen cartridge, mixes vials
Glargine (Basaglar) pen
Novolog (aspart) vial, pen, cartridge
Glulisine and lispro vial, pen
168
What insulin is stable at room temp for 10 days?
"L"
Humalog (lispro) mixes PEN!!
169
What insulin is stable at room temp for 31 days?
"HR"
Humulin R vial
170
What insulin is stable at room temp for 14 days?
"HN"
Humulin N (NPH), N/R PENS
171
What insulin is stable at room temp for 40 days?
"HR500"
Humulin R U-500 vial
172
What insulin is stable at room temp for 42 days?
"NRND"
Novolin R (regular)
Novolin N (NPH)
Novolin N/R
Novolin 70/30 NPH
VIALS!
detemir (levemir) vial and pen
173
What insulin is stable at room temp for 56 days?
"DG"
degludec (tresiba) vial and pen
Toujeo (glargine) pen
