Diabetes Flashcards by Carolyn Hardie

How often to screen diabetes

T1DM: When symptomatic
T2DM: Every 3 years after age 35 (unless risk factors)
Prediabetes: Annually to see if T2DM
Gestational: first prenatal visit if risk factors, then at 24-28 weeks, then 4-12 weeks after delivery, then every 3 years for T2DM

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T1 & T2DM Diagnosis Criteria

FPG >=126
Random glucose >=200
75 g OGTT >=200
A1C >=6.5%

Requires 2 abnormal tests from same sample OR 2 separate test samples of same test

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Gestational Diabetes diagnosis

Use OGTT at 24-28 weeks
If 75 g test:
Fasting >=92
1 hr post >= 180
2 hr post >=153

If 50g test:
1hr post >=140
requires additional 100g test

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Prediabetes diagnosis

FPG 100-125
OGTT 75g 2 hour post 140-199
A1C 5.7-6.4%

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T1 & T2DM Glycemic Goals

A1C <7.0%
FPG 80-130
Postprandial <180
If CGM: Time in range >=70%, time below range <4%

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Gestational DM Glycemic Goals

FPG <= 95
1 hour postprandial <140
2 hour postprandial <120

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BP goal in DM

<130/80

Reduces microvascular AND macrovascular sequelae

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Lipid goals DM

-ASCVD Risk Factor: High intensity w/ goal <70
-Established ASCVD: High intensity w/ goal <55
-40-75 w/ DM: Moderate intensity
-50-75 with risks: High intensity

If not at goal, add ezetimibe or PSK9i

Reduces macrovascular sequelae

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Insulin affecting prandial glucose

Rapid acting & Short acting

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Insulin affecting fasting glucose

Intermediate & Long acting

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Initial total insulin dose for naive

0.3-0.6 unit/kg/day

Basal is usually 50% TDI

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Insulin to Carbohydrate Ratio (ICR)

TDI/500 = amount of carbs (in g) that 1 unit of rapid acting insulin will cover

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Insulin Sensitivity Factor (ISF)

1800/TDI = how much 1 unit of rapid-acting insulin will lower blood glucose

Human insulin = 1500

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Pramlintide MOA, administration, BBW, A1c reduction

MOA: Amylin analog (cosecreted with insulin, similar to GLP1)

Administered SC before meals with insulin

**Must reduce rapid/short/combination insulin by 50%

BBW: Severe hypoglycemia

0.5-1% A1C reduction

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Initial DOC for T2DM

Metformin

Consider combination therapy is initial A1C>= 1.5% personal goal

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When to consider insulin therapy

AIc >- 10%
A1C > 2% above goal

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Initial dosing basal insulin & how to adjust

0.1-0.3 units/kg/day

Adjust by 10-15% or 2-4 units 1-2x weekly until target FPG reached

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When to add bolus insulin

If basal insulin dose >= 0.5 units/kg/day or if significant postprandial glucose excursions

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Metformin MOA, renal adjustment, A1C effect

MOA: reduces hepatic gluconeogensis, increases insulin sensitivity, increases intestinal absorption of glucose

Renal adj:
CrCl <45: do not initiate. reduce dose by 50%
CrCl <30: do not initiate. discontinue.

1-2% A1C reduction

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Sulfonylureas MOA, AE, A1C, glycemic effect

MOA: bind to receptors on pancreatic B cells to stimulate insulin secretion

AE: Hypoglycemia, weight gain

Glipizide > glyburide or glimepiride for older adults or renal impairment

Reduce or d/c when starting bolus insulin d/t hypoglycemia

1-2% A1C reduction

Fasting & prancial glucose

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Meglitinides MOA, AE, A1C reduction, glycemic effect

Nateglinide, repaglinide
MOA: increase insulin secretion from pancreas

AE: hypoglycemia, weight gain
Caution repaglinide + gemfibrozil

0.5-1.5% A1C reduction

Prandial glucose

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Pioglitazone MOA, AE, BBW, A1C reduction, glycemic effect

MOA: improves insulin sensitivity

AE: weight gain (by fluid retention), proximal bone fracture, bladder cancer

BBW: Use in heart failure

Reduce dose or d/c when starting insulin due to edema

0.5-1.4% A1C reduction

Fasting & prandial

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DPP-4 inhibitors MOA, AE, CI, A1C reduction, glycemic effect

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Sitagliptin, saxagliptin, linagliptin, alogliptin
MOA: Inhibit enzyme responsible for breakdown of GLP-1 – although weight neutral

AE: HA, arthralgia,
Sitagliptin only: pancreatitis, angeioedema, SJS, anaphylaxis

CI: heart faliure (saxagliptin, alogliptin)

0.5-0.8% A1C reduction

Prandial

Sitagliptin renal adjustment

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Usual: 100mg daily
GFR 30-45: 50mg daily
GFR <30: 25mg daily

Saxagliptin renal adjustment

Usual: 5mg daily GFR <45: 2.5mg daily Strong 3A4 inhibitor: 2.5mg daily

Alogliptin renal adjustment

Usual: 25mg daily CrCl 30-59: 12.5mg CrCl < 30: 6.25mg

SGLT2i MOA, A1C reduction, glycemic effect

Canagliflozin, dapagliflozin, empagliflozin, ertugliflozin, bexagliflozin MOA: Increase urinary glucose excretion by blocking normal reabsorption in proximal convoluted tubule AE: rare euglycemic DKA & fournier's gangrene D/C 3-4 days before surgery 0.5-0.8% A1C reduction Fasting & prandial

SGLT2i with CV benefit

Empagliflozin Dapagliflozin Canagliflozin

SGLT2i with renal benefit

Empagliflozin Dapagliflozin Canagliflozin Initiate if GFR >20 and Urinary albumin:creatinine >=200; target 30% albuminuria reduction

SGLT2i with HF benefit

Empagliflozin Dapagliflozin Canagliflozin Ertugliflozin

Canagliflozin renal dosing

Usual: 100mg - 300mg max (before first meal) GFR 30-59: 100mg daily GFR <30: do not initiate. May continue if already on if albuminuria >300

Dapagliflozin renal dosing

Usual: 5-10mg qAM GFR <25: not recommended. May continue if already on until dialysis

Empagliflozin renal dosing

Usual: 10-25mg qAM GFR <20: do not initiate, but may continue until dialysis

Ertugliflozin renal dosing

Usual 5-15mg qAM GFR <45: do not initiate; discontinue

Bexagliflozin renal dosing

Usual: 20mg qAM GFR <30: do not initiate; discontinue

GLP-1 agonists for DM (AE, A1C reduction, glycemic effect)

Exenatide, Liraglutide, Lixisenatide, Dulaglutide, Semaglutide Hypoglycemia may occur with sulfonylurea Caution: hx of pancreatitis, gastroparesis, Personal/family hx medullary thyroid cancer (lira, sema, dula, exena) 0.8-1.6% A1C reduction Daily dosing: prandial Weekly dosing: Fasting

Tirzepatide A1C reduction, glycemic effect

2-2.3% Fasting & prandial

Alpha-glucosidase inhibitors MOA, CI, A1C reduction, glycemic effect

Acarbose, miglitol MOA: slow absorption of glucose by slowing breakdown of large carbs into smaller sugars CI: IBD, intestinal obstruction 0.5-0.8% A1C reduction Prandial Weight loss

Colesevelam CI, A1C reduction, glycemic effect

Bile acid sequesterant that reduces hepatic gluconeogenesis CI: TG > 500 0.3-0.5% A1C reduction Prandial

Bromocriptine MOA, AE, A1C reduction, glycemic effect

MOA: Dopamine agonist; may reset circadian rhythm to reduce caloric intake - not well understood AE: N/V/HA, syncope Caution with other dopamine antagonists 0.1-0.6% reduction in A1C Fasting & prandial Possible CV benefit

Inpatient glycemic goal

140-180 Start insulin if >180

Inpatient glycemic management

Basal insulin +/- bolus insulin if eating Do not only use sliding scale

Level 1 hypoglycemia

<70 but >=54 with or without symptoms Give 15-20g glucose, check BG 15min, give another dose until normalized then eat meal/snack

Level 2 hypoglycemia

<54 - clinically significant Give 15-20 g glucose, recheck BG after 15 min, then give another 15-20g if needed, once normal give meal/snack

Level 3 hypoglycemia

Altered mental and/or physical status Glucagon 1mg SC or IM or 3mg nasally

DKA fluid replacement

0.45-0.9% NS Change to D5W1/2NS when BG <200

DKA insulin therapy

0.1 unit/kg regular insulin Then 0.1 unit/kg/hr drip Recheck BG at first hour. If <10% decrease, give 0.14 unit/kg IV bolus Reduce to 0.02-0.05 unit/kg/hr when BG <200 Pause if K<3.3

DKA Potassium therapy

Hold if >5.3 <5.3 but >3.3: Fluids containing 20-30mEq/L K <3.3: potassium 20-30 mEq/hr

DKA Bicarbonate therapy

May use if serum pH <6.9

DKA Goals of Therapy (considered resolved when..)

Venous pH >7.3 Serum bicarbonate >= 15 Anion gap <= 12

Albuminuria

Need 2/3 specimens with urinary albumin excretion >30mg/g over 3-6 months for diagnosis Use ACE/ARB

When to screen microvascular complications

Initially at T2DM Diagnosis After 5 years of T1DM Diagnosis Then Annually

Neuropathy Treatment

TOC: glycemic control to minimize progression TCAs (amitriptyline, desipramine) Gabapentin, pregabalin, lamotrigine Duloxetine, paroxetine, citalopram, venlafaxine Tramadol, APAP Tapentadol ER Topical capsaicin

FDA approved neuropathy agents

TCAs Pregabalin Duloxetine Tapentadol ER

Diabetes Insipidus, central & nephrogenic tx

Decreased antidiuretic hormone (vasopressin) Central: desompressin with or without chlorpropamide, carbamazepine Nephrogenic: thiazide, indomethacin, Na restriction

Diabetes Flashcards

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