Diabetes Flashcards
(77 cards)
1
Q
Type I Diabetes (TID):
A
- Autoimmune destruction of beta cells in the pancreas
- Loss of insulin production
- C-peptide test is used to determine if the patient is still producing insulin. C-peptide is released by the pancreas only when insulin is released. TID is diagnosed with there is a very low or absent (undetectable) C-peptide level.
- Patient TID must be treated with insulin and should be screened for other autoimmune disorders.
2
Q
Type 2 Diabetes:
A
- Insulin resistance
- Less insulin production
- Obesity, physical activity & other risk factors
3
Q
Prediabetes:
A
- BG higher than normal but not high enough for a type 2 diagnosis
- High risk for progressing to type 2
- Metformin can be used to improve BG levels, especially in patients with a BMI ≥ 35 kg/m2, age <60 years, and women with a history of gestational diabetes mellitus (GDM).
4
Q
Gestational Diabetes. There are 2 types of diabetes in pregnancy.
• Diabetes that was present prior to becoming pregnant
• Diabetes that developed during pregnancy (GDM)
risks to baby:
A
- Macrosomia (newborn with excessive birth weight)
- Hypoglycemia
- Obesity and type 2
5
Q
Gestational Diabetes:
Management
A
- Lifestyle first
- Insulin is DOC, used if needed
- Metformin and glyburide (not preferred, but may be considered)
6
Q
Goals for Diabetes in Pregnancy (goals are stricter vs non-pregnant patients):
A
• Fasting: ≤ 95 mg/dL
- 1 hr post-meal: ≤ 140 mg/dL
- 2 hrs post-meal: ≤ 120 mg/dL
7
Q
Most pregnant women are tested for GDM at…
A
24-48 weeks gestation using the oral glucose tolerance test (OGTT).
8
Q
The presence of multiple risk factors increases the likelihood of prediabetes and T2D. Major risk factors include:
A
- Physical inactivity
- Overweight (BMI ≥ 25 kg/m2 or ≥ 23 in Asian-Americans)
- High-risk race or ethnicity: African-American, Asian-American, Latino/Hispanic-American, Native American or Pacific Islander
- History of gestational diabetes
- A1C 5.7%
- First-degree relative with diabetes
- HDL< 35 mg/dL or TG> 250 mg/dL
- Hypertension (≥ 140/90 mmHg or taking BP medication)
- CVD history or smoking history
- Conditions that cause insulin resistance (e.g. acanthosis nigricans, polycystic ovary syndrome)
9
Q
Risk for diabetes increases with age. Everyone, even those with no risk factors, should be tested beginning at 45 years old. All asymptomatic children, adolescents, and adults who are overweight (BMI ≥ 25 or ≥ 23 in Asian-Americans) with at least one other risk factor (e.g. physical inactivity) should be tested. If the result is normal…
A
repeat testing every 3 years
10
Q
Glycemic control (A1c or another test) should be measured:
A
- Quarterly (every 3 months) if not yet at goal
* Biannually (every 6 months, or twice per year) if at goal
11
Q
The estimated average glucose (eAG) is an interpretation of the A1c value that makes it appear similar to a glucose meter value. An A1c of 6% is equivalent to…
A
an eAG of 126 mg/dL. Each additional 1% increases the eAG by ~ 28 mg/dL.
12
Q
Diagnostic criteria for diabetes:
A
- ≥6.5% (A1c)
- ≥ 126 mg/dL (FPG)
- ≥ 200 mg/dL (OGTT)
13
Q
Goal waist circumference is <35 inches for females and <40 inches for males. Overweight or obese patients should be encouraged to lose:
A
> 5% of their body weight
14
Q
Individualized Medical Nutrition Therapy (MNT):
A
- Consume natural forms of carbs and sugars
- Avoid alcohol or drink in moderation
- Patients with TID should use carboohydrate-counting, where the prandial (mealtime) insulin dose is adjusted to the carb intake. A carbohydrate serving is measured as 15 g, which is approximately one small piece of fruit, 1 slice of bread or 1/3 cup of cooked rice/pasta.
15
Q
Physical Activity:
A
- Perform at least 150 minutes of moderate-intensity aerobic activity per week spread over at least 3 days.
- Reduce sedentary (long hours of sitting) habits by standing every 30 minutes, at a minimum.
16
Q
Smoking cessation:
A
• Encourage all patients who smoke to quit.
17
Q
Diabetes complications include both microvascular and macrovascular ones:
A
- Microvascular: retinopathy; diabetic kidney disease (i.e. nephropathy), peripheral neuropathy (i.e. loss of sensation, often in the feet), increase risk of foot infections and amputations. Automatic neuropathy.
- Macrovascular Disease: Coronary artery disease (CAD), including MI; cerebrovascular disease, including stroke; peripheral artery disease (PAD).
18
Q
Antiplatelet Therapy (Aspirin):
A
- Aspirin 75-162 mg/day (usually given as 81 mg/day) is recommended for ASCVD secondary prevention (e.g. post-MI).
- Not recommended in primary prevention (in most); the risk of bleeding is about equal to the benefit. Can consider if high risk.
- CAD/PAD: aspirin + low-dose rivaroxaban can be added
- Used in pregnancy to decrease the risk of preeclampsia.
19
Q
Diabetic Retinopathy:
A
- T2D: eye exam with dilation at diagnosis.
* If retinopathy, repeat annually. If not, repeat every 1-2 yrs.
20
Q
Vaccinations:
A
- Hepatitis B (HBV) series
- Influenza, annually
- Pneumovax 23: 1 dose between ages 2-64, and another dose at age ≥ 65.
21
Q
Neuropathy:
A
- Annually: a 10-g monofilament test and 1 other test (e.g. pinprick, temperature, vibration) to assess sensation (feeling)
- Comprehensive foot exam at least annually. If high-risk, refer to the podiatrist.
- Treatment options: pregabalin, duloxetine, gabapentin
22
Q
Foot Care Counseling:
A
- Every day: wash, dry, and examine feet. Moisture the top and bottom of feet, but not between the toes.
- Each office visit; take off shoes to have feet checked.
- Annual foot exam by a podiatrist (for most).
- Trim toenails with nail file; do not leave sharp edges from the clipper.
- Wear socks and shoes. Elevate feet when sitting.
23
Q
Cholesterol Contol:
A
- High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily for:
- Diabetes + ASCVD
- Age 50-75 years with multiple ASCVD risk factors
- Moderate-intensity statin for:
- Diabetes + age 40-75 years (no ASCVD)
- Diabetes + age < 40 years + ASCVD risk factors
24
Q
Cholesterol Control:
A
- Ezetimibe if ASCVD 10-yr risk > 20%.
- Icosapent ethyl (Vascepa) if LDL is controlled but TGS are 135-499 mg/dL.
- Monitoring lipid panel annually and 4-12 weeks after starting a statin or increasing the dose.
25
BP Goal:
* 130/80 mmHg (esp, if ASCVD or 10-year risk ≥ 15%)
* ≥ 140/90 mmHg (acceptable if ASCVD risk < 15%
Treatment:
• No albuminuria*: thiazide, CCB, ACE inhibitor, ARB**
• Albuminuria: ACE inhibitor or ARB
• CAD: ACE inhibitor or ARB
26
Natural products are commonly used for T2D, with low or minimal efficacy. Products used to decrease BG include:
cassia, cinnamon, alpha lipoic acid, chromium, magnesium, Panax/American ginseng
27
In addition to metformin, a second drug from a different class, is recommended in the following instances:
* Start two drugs at baseline if the A1c is 8.5-10%.
* Start two drugs at baseline regardless of A1c if the patient has ASCVD, heart failure, or chronic kidney disease (CKD). A drug with proven benefit for these conditions should be used.
* Add on a second drug is the A1c remains above goal on metformin. In this case, treatment is driven by patient-specific factors (e.g., cost, risk of hypoglycemia, and weight).
* Insulin can be used initially if hyperglycemia is severe (A1C >10% or BG > 300 mg/dL).
28
Metformin primarily works by decreasing liver glucose production, decreasing intestinal absorption of glucose, and increasing insulin sensitivity. Metformin is first-line treatment for T2D and can be used in prediabetes. Use of metformin is dependent on eGFR.
Metformin (Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet)
IR: 500, 850, 1,000 mg
ER: 500, 750, 1,000 mg
Riomet liquid: 500 mg/5mL
IR: 500 mg daily or BID
ER: 500-1,000 mg daily with dinner initially
• Titrate weekly, usual maintenance dose: 1,000 mg BID
• Max dose: 2,000-2,550 mg/day (varies by product)
• Give with a meal to decrease GI upset
• Boxed Warning: Lactic acidosis- risk by increasing with renal impairment, radiological studies with contrast, excessive alcohol, or certain drugs.
• C/Is: eGFR <30, acute or chronic metabolic acidosis (includes DKA)
• Warnings: Not recommended to start if eGFR 30-45; reassess if already taking at eGFR falls < 45; Vitamin B12 deficiency.
Side effects: GI effects: diarrhea, nausea, flatulence, cramping; usually transient (resolve over time)
• Notes: decrease A1c 1-2%, weight neutral, no hypoglycemia
ER: swallow whole; can leave a ghost tablet (empty shell) in the stool
29
Intravascular iodinated contrast media (used for imaging studies) can increase the risk of lactic acidosis. Discontinue metformin before the imaging procedure. Metformin can be restarted 48 hours after the procedure if eGFR if stable. Alcohol can increase the risk for lactic acidosis; excessive intake, acute or chronic, should avoided.
* Metformin can be restarted 48 hours after the procedure if eGFR if stable
* Alcohol can increase the risk for lactic acidosis
* Excessive alcohol intake, acute or chronic, should be avoided. • • Metformin and topiramate can increase the risk of metabolic acidosis.
30
Canagliflozin (Invokana)
Dosing: 100 mg daily prior to the first meal of the day; can increase to 300 mg daily
eGFR 30-59: max dose 100 mg/day
eGFR < 30: not recommended, unless albuminuria > 300 mg/day
Warnings: increased risk of leg and foot amputations, higher risk with history of amputation, PAD, peripheral neuropathy and/or diabetic foot ulcers; hyperkalemia risk when used with other drugs that increase K; risk of fractures
31
Dapagliflozin (Farxiga)
5 mg daily in the morning, can increase to 10 mg daily
eGFR 30-45: not recommended
eGFR< 30: contraindicated
32
Empagliflozin (Jardiance)
10 mg daily in the morning; can increase to 25 mg daily
eGFR 30-44: not recommended
eGFR < 30: contraindicated
33
Ertugliflozin (Steglatro)
5 mg daily in the morning; can increase to 15 mg daily
eGFR 30-59: not recommended
eGFR<30: contraindicated
34
SGLT2 inhibitors
Notes: decrease A1c 0.7-1%, low hypoglycemia risk (unless used with insulin)
Contraindications: Dialysis
Warnings: Ketoacidosis (can occur with BG< 250 mg/dL, d/c prior to surgery due to risk). Genital mycotic infections, urosepsis and pyelonephrtiis, necrotizing fascitis of the perineum. Hypotension, AKI and renal impairment (due to intravascular volume depletion)
Side effects: weight loss, increased urination, increased thirst, hypoglycemia, increased Mg/PO4.
35
SGLT2 inhibitor drug interactions:
* Increased risk of intravascular volume depletion (causing hypotension and AKI) is used in combination with diuretics, RAAS inhibitors or NSAIDs.
* Uridine diphosphate glucuronosyltransferase (UGT) inducers (e.g. rifampin, phenytoin, phenobarbital) can decrease levels of canagliflozin; consider using 300 mg dose if used in combo and eGFR ≥60 mL/min.
36
Glucagon-like peptide 1 (GLP-1) agonists are analogs of the incretin hormone GLP-1, which increases glucose-dependent insulin secretion, decreases glucagon secretion, slows gastric emptying, improves satiety and can result in weight loss. They are all subcutaneous injections available in...
either single-dose or multidose pens, except semaglutide also comes as an oral tablet.
Notes: decreases A1c 0.5-1.5%; decreases postprandial BG, low hypoglycemia risk. Do not use with DDP-4 inhibitors. Liraglutide, dulaglutide and semaglutide have demonstrated ASCVD benefit.
37
GLP-1
Safety/Side effects/Monitoring
Boxed warning: All (except Byetta and Adlyxin): risk of thyroid C-cell carcinomas; do not use if personal of family history of medullary thyroid carcinoma (MTC) or with MEN 2
Warnings: Pancreatitis (can be fatal, risk factors: gallstones, alcoholism, or increased TGs). Not recommended in patients with severe GI disease, including gastroparesis. Bydureon- serious injection-site reactions (eg, abscess, cellulitis, necrosis) with or without SC nodules
Ozempic: increased complications with diabetic retinopathy
Side effects: weight loss, nausea, vomiting, diarrhea, hypoglycemia, injection site reactions
38
Liraglutide (Victoza)
• 0.6 mg SC daily x 1 week, then increase to 1.2 mg SC daily; can increase to 1.8 mg SC daily
39
Dulaglutide (Trulicity)
0.75 mg SC once weekly; can increase to 1.5 mg SC once weekly
40
Exenatide (Byetta)
5 mcg SC BID for 1 month; can increase to 10 mcg SC BID
CrCl< 30: not recommended
Counseling point: Give dose within 60 minutes of meals; others anytime
41
Exenatide ER (Bydureon, Bydureon BCise)
2 mg SC once weekly
CrCl< 30: not recommended
Bydureon BCise: shake the injection well to mix the medication. Look in the window to check for drug particles; if present, shake agian.
42
Lixisenatide (Adlyxin)
10 mcg SC daily x 14 days, then increase to 20 mcg SC daily
eGFR< 15: not recommended
43
Semaglutide (Ozempic- SC, Rybelsus-oral)
SC: 0.25 mg SC once weekly x 4 weeks, then increase to 0.5 mg SC weekly; can increase to 1 mg SC weekly
PO: 3 mg PO daily x 30 days, then increase to 7 mg daily; can increase to 14 mg
44
GLP-1 Agonist Drug Interactions:
* These drugs slow gastric emptying can reduce the absorption of orall administered drugs. Use caution with narrow therapeutic index drugs or drugs that require thershold concentrations for efficacy (eg, antibiotics, oral contraceptives).
* Take oral contraceptives at least one hour before exenatide or Adlyxin and at least 11 hours after Adylxin.
* Can increase the INR in patients on warfarin, monitor INR.
45
Sulfonylureas (SUs) and meglitinides are known as insulin secretagougues; they work by stimulating insulin secretion from the pancreatic beta-cells to decrease postprandial BG. Meglitinides have a faster onset (15-60 minutes) and a shorter duration of action compared to the SU. Older, first generation SUs (chlorpropamide, tolazamide, and tolbutamide) should not be...
used as as they can prolonged hypoglycemia.
Notes: Decrease A1c 1-2%; decrease efficacy after long-term use (as pancreatic beta-cell function declines). Patients with G6PD deficiency can be at increased risk of hemolytic anemia with sulfonylureas.
Counseling: Take sulfonylureas with breakfast, except glipizide IR. Take 30 minutes before breakfast. Take meglitinides 15-30 minutes before meals. Do not take if skipping the meal.
46
Glipizide (Glucotrol, Glucotrol XL, Glipizide XL) *has the least hypoglycemia risk
IR: 5 mg daily, titrate to a max dose of 40 mg/day
Doses> 15 mg should be divided BID.
Counseling: Glipizide IR shoud be taken 30 minutes before a meal
XL: 5 mg daily, titrate to a max dose of 20 mg/day.
Glucotrol XL is an OROS formulation and can leave a ghost tablet (empty shell) in the stool
47
Glimepiride (Amaryl)
1-2 mg daily, titrate to a max dose of 8 mg/day
48
Glyburide
Micronized glyburide (Glynase)
Glyburide: 2.5-5 mg daily, titrate to a max dose of 20 mg/day
Glynase: 1.5-3 mg daily, titrate to a max dose of 12 mg/day
49
Insulin sulfonylureas:
C/Is: Sulfa allergy (not likely to cross-react)
Warnings: hypoglycemia
Side effects: weight gain, nausea
50
Repaglinide
0.5-2 mg TID AC. Max dose: 16 mg daily.
| Counseing: take 15-30 minutes before meals
51
Nateglinide (Starlix)
60-120 mg TID before meals
52
Meglitinides
Notes: Decrease A1c 0.5-1.5%
Safety/Side Effects/Monitoring:
C/I: T1D, DKA
Warnings: hypoglycemia, caution with severe liver/renal impairment
Side effects: Weight gain, headache, upper respiratory tract infections
53
Sulfonylurea and Meglitinide Drug Interactions:
* Insulin in combo with either SUs or meglitinides increase the risk of hypoglycemia and should be avoided. Use caution with other drugs that can decrease BG.
* SUs are CYP2C9 substrates; use caution with 2C9 inducers or inhibitors.
* Gemfibrozil and clopidogrel can increase repaglinide, leading to decrease BG. Repaglinide is C/I with gemfibrozil.
* Alcohol can increase the risk for delayed hypoglycemia when taking insulin or insulin secretagogues.
54
Dipeptidyl peptidase 4 (DDP-4) inhibitors prevent the enzyme DPP-4 from breaking down incretin hormones, glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP). These hormones help to regulate BG levels by...
increasing insulin release from the pancreatic beta-cells and decreasing glucagon secretion from pancreatic alpha-cells. These drugs enhance the effects of the body's own incretins.
Notes: decrease A1C 0.5-0.8%, weight neutral, low hypogycemia risk
*Do not use with GLP-1 agonists (overlapping mechanism)
55
Sitagliptin (Januvia)
100 mg daily
CrCl 30-49: 50 mg daily
CrCl < 30: 25 mg daily
56
Linagliptin (Tradjenta)
5 mg daily
| No renal dose adjustments
57
Saxagliptin (Onglyza)
2.5-5 mg daily
eGFR< 45: 2.5 mg daily
58
Alogliptin (Nesina)
25 mg daily
CrCl 30-59: 12.5 mg daily
CrCl < 30: 6.25 mg daily
Warning: liver toxicity
59
DDP-4 inhibitors
Safety/Side effects/Monitoring:
Warnings:
Pancreatitis, severe arthralgia (joint pain), acute renal failure, hypersensitivity reactions, bullous pemphigoid (blisters/erosions requiring hospitalization)
• Risk of heart faillure seen with saxagliptin and alogliptin, but warning added for class.
Side effects: Generally well tolerated, can cause nasopharyngitis, URTIs, UTIs, peripheral edema, rash
60
DPP-4 Inhibitor Drug Interactions:
* Saxagliptin is major substate of CYP450 3A4 and P-gp. Limit the dose to 2.5 mg with strong CYP3A4 inhibitors, including protease inhibitors (eg. atazanavir, ritonavir), clarithromycin, itraconazole, ketoconazole.
* Linagliptin is a major substrate of CYP3A4 and P-gp. Linagliptin levels decrease by strong CYP3A4 inducers (eg, carbamazepine, phenytoin, rifampin, St. John's wort)
61
Thiazolidinediones are peroxisome proliferator-activated receptor gamma (PPARγ) agonists that increase peripheral insulin sensitivity (increase uptake and utilization of glucose by the peripheral tissues).
Notes: decrease A1c by 0.5-1.4%, low risk of hypoglycemia
62
Thiazolidinedione Drug Interactions:
• Use caution with CYP2C8 inducers (e.g. rifampin) or inhibitors (e.g. gemfibrozil).
63
Pioglitazone (Actos)
• Initial: 15-30 mg daily
• Max dose: 45 mg daily
Warnings: can increase risk of bladder cancer; do not use in patients with a history of bladder cancer
64
Rosiglitazone (Avandia)
• 4-8 mg daily
Max dose: 8 mg daily
Boxed Warning: Increased risk of MI
Side effects: Increase LDL, HDL and total cholesterol
65
TZDs: Safety/Side Effects/ Monitoring
Boxed Warnings: can cause or exacerbate heart failure, do not use with NYHA Class III/IV heart failure
Warnings: Liver failure, edema (including macular edema), risk of fractures. Can stimulate ovulation, which can lead to unintended pregnancy; may need contraception.
Side effects: Peripheral edema, weight gain, URTIs, myalgia
66
Alpha-Glucosidase Inhibitors:
acarbose (Precose); miglitol (Glyset)
MOA: inhibit the metabolism of intestinal sucrose, which delays glucose absorption.
Do not cause hypoglycemia alone, but if hypoglycemia occurs due to another drug, it cannot be treated with sucrose. Each dose should be taken with the first bite of each meal. GI side effects are common (flatulence, diarrhea, abdominal pain).
67
Bile Acid Binding Resins:
| Colesevelam (Welchol)
Also indicated for dyslipidemia. Constipation is the most common s/e. Can bind and decrease absorption of other drugs and fat-soluble vitamins (A, D, E, K).
68
Dopamine Agonist:
| Bromocriptine (Cycloset)
Contraindicated in patients with syncopal migraines (can cause hypotension and orthostasis) and those who are breastfeeding (inhibits lactation). Should not be used with metoclopramide or other domapine agonists.
69
Amylin Analog:
Pramlintide (Symlin)
SC injection
MOA: helps control PPG by slowing gastric emptying, which suppresses glucagon secretion following a meal, and increases satiety. Can be used in type 1 or type 2 diabetes, administered SC before each major meal. Skip dose if skipping meal. Contraindicated in gastroparesis. Significant hypoglycemia risk; must reduce mealtime insulin dose by 50% when starting.
Side effects include: nausea, vomiting, anorexia, and weight loss.
70
Metformin/pioglitazone (Actoplus Met)
71
Basal insulin includes:
glargine, determir, and ultra-long degludec. These insulins are "peakless" with an onset of 3-4 hours and duration ≥ 24 hours. They mainly impact fasting glucose.
72
Insulin NPH is intermediate-acting but it can be used as a basal insulin. NPH has an onset of 1-2 hours, and it peaks at 4-12 hours, which can cause hypoglycemia. BG control is further complicated by the variable, unpredictable duration of action (14-24 hours).
The P in NPH is a protamine, which helps to delay absorption/extend the duration of effect. Protamine also comes in lispro-protamine and aspart-protamine, which have the same onset, peak and duration as NPH. These come in premixed solutions only and are combined with standard rapid-acting insulin (aspart and lispro).
73
Rapid-acting insulin includes apart, lispro, and glulisine. These provide a bolus dose, similar to the pancreas releasing a burst of insulin in response to food. They have a...
fast onset (~ 15 min), peak in 1-2 hours, and a duration of 3-5 hours (gone by the next meal).
74
Regular insulin U-100 is considered a short-acting insulin; it can be given as a bolus at mealtimes like rapid-acting insulin, but has a slower onset and lasts longer than needed for a meal. Regular insulin has an...
onset of 30 minutes, peaks at ~ 2 hours and lasts 6-10 hours.
75
Regular U-500 is very concentrated insulin. The onset is the same as regular insulin U-100, but the duration is closer to NPH; it can last up to 24 hours. It is often dosed...
BID or TID, before meals
76
Inhaled insulin is not used commonly. It is a mealtime insulin with...
fast absorption through the lungs
77
Insulin; Safety issues and notes
C/Is: Do not adminster during episodes of hypoglycemia
Warnings: Hypoglycemia, hypokalemia
Side effects: weight gain: insuin causes excess glucose to move into adipose cells
Lipoatrophy: loss of SC fat at the injection site (which disfigures the skin) and lipohypertrophy (accumulation of fat lumps uner injection site). Avoid both by rotating injection sites and using analog insulins.
Storage and Administration Notes
• Most vials are 10 mL and most pens are 3 mL. Insulin concentrations are 100 units/mL.
• Do not shake; turn suspensions
