Diabetes Flashcards
(27 cards)
Is C-peptide high or low in a type 1 diabetic?
C-peptide is a substance that is released by the pancreas when insulin is released.
C-peptide is very low or undetectable in type 1 diabetics.
When should people be screened for diabetes?
If no other risk factors, all adults should be tested at 35 years old.
In asymptomatic adults who are overweight (BMI ≥ 25 or ≥ 23 in asian-americans) with at least one other risk factor should be tested.
- If result is normal, testing should be repeated every 3 years at minimum.
What is the diagnostic criteria for diabetes and prediabetes? (A1c, FPG, random BG, OGTT)
Diabetes:
- A1c ≥ 6.5%
- FPG ≥ 126 mg/dL
- Random BG ≥ 200 mg/dL
- OGTT ≥ 200 mg/dL
Prediabetes:
- A1c 5.7-6.4%
- FPG 100-125 mg/dL
- OGTT 140-199 mg/dL
What are the diabetes goals in a pregnant patient?
Preprandial BG <95 mg/dL
1-hr PPG <140 mg/dL
2-hr PPG <120 mg/dL
Targets are stricter than in non-pregnant patients due to risk to the baby from hyperglycemia.
How much does a 1% increase in A1c increase the average blood glucose over those 3 months?
1% increase equates to a ~28mg/dL blood sugar increase
What additional vaccines should all diabetics get?
In addition to all age-appropriate vaccines:
- Hepatitis B virus (HBV) series
- Influenza, annually
- Pneumococcal
- COVID-19
- RSV
What are the statin indications/LDL goals for diabetics in different risk groups?
High-intensity statin:
- ASCVD: LDL goal <55
- age 40-75 with at least 1 ASCVD risk factor: LDL goal < 70 mg/dL
* ASCVD risk factors: LDL ≥100 mg/dL, HTN, smoking, overweight, and family history of premature ASCVD
Moderate-intensity statin:
- age 40-75 with no ASCVD
- Age 20-39 with ASCVD risk factors
What medication(s) should be started at baseline if the pt has ASCVD, HF, or CKD?
GLP-1 agonist or SGLT2 inhibitor with proven benefit
When should 2 drugs be started at baseline? When can insulin be used initially?
Start 2 medications if A1c if 8.5-10%.
Insulin can be use initially if A1c >10% (or BG ≥ 300), weight loss (evidence of catabolism), or symptoms of hyperglycemia.
- Outside of these scenarios, GLP-1s or GLP1/GIP are preferred for injectable therapy.
What is the boxed warning for GLP-1 agonists?
For all GLP-1 agonists (except Byetta), there is a boxed warning for risk of thyroid C-cell carcinomas
There is a warning for pancreatitis, but it is not a boxed warning.
What is the unique side effect/risk with canagliflozin (invokana)?
canaglifloxin can have hyperkalemia risk when used with other medications that increase potassium
What are the 3 mechanisms of action of metformin? What are the boxed warning and contraindications? Can it be used in pregnancy?
MOA
1. Decreases hepatic glucose production
2. Increases insulin sensitivity
3. Decreases intestinal absorption of glucose
Boxed warning: lactic acidosis (increased risk with renal impairment)
Contraindications
- eGFR <30
- actue or chronic metabolic acidosis
What is a warning for the DPP4-inhibitors? Which DPP-4 does not have a renal dose adjustment?
DPP4 inhibitors have a warning for heart failure (esp saxagliptin and alogliptin)
Only linagliptin (Tradjenta) does NOT have a renal dose adjustment
What is the MOA of thiazolidinediones? What is the boxed warning for pioglitazone?
MOA: PPAR-y agonists that increase peripheral insulin sensitivity (increases uptake and utilization of glucose by the peripheral tissues)
Boxed warning: can exacerbate heart failure
- do not use in NYHA class III/IV heart failure
Warning
- can stimulate ovulation, which can lead to unintended pregnancy
What are the onsets, peak, and duration of these insulins:
- basal insulin
- insulin NPH
- regular insulin U-100
- rapid-acting insulin
Basal
- onset 3-4 hours
- no peak
- duration >24 hours
NPH
- onset 1-2 hours
- peak at 4-12 hours
- unpredictable duration 14-24 hours
Regular insulin U-100
- onset 30 minutes
- peak ~2 hours
- duration 6-10 hours
Rapid acting
- onset ~15 minuts
- peak 1-2 hours
- duration 3-5 hours
When mixing NPH and regular (or rapid-acting) insulin, which insulin should be drawn up first?
Draw the short acting insulin first (should be clear)
Draw the NPH last (should be cloudy)
Which insulins are available OTC?
Regular (Humulin R, Novolin R)
NPH (Humulin N, Novolin N)
70/30 mixes (70% NPH/30% regular; Humulin 70/30, Novolin 70/30)
What concentration is Toujeo? What concentrations does Tresiba come in?
Toujeo (insulin glargine) is concentrated insulin glargine with 300 units/mL
- Can be an option when over 20 units/day of glargine are needed
**Toujeo pens can be 1.5mL or 3mL
Tresiba (insulin degludec) comes in a vial that is 100u/mL. The Tresiba FlexTouch pens come in 100u/mL and 200u/mL
When starting insulin in a type 2 diabetic, how do you decide what dose to use? How do you initiate prandial insulin?
Start with basal insulin:
- 10 units daily OR 0.1-0.2u/kg/day
If still not at goal or if signs of prandial needed:
- 4 units OR 10% of basal dose once daily w/ largest meal
If still not at A1c goal: can do full basal/bolus regimen or mixed insulin regimen (BID NPH + short/rapid self-mixed or premixed)
How do you start basal-bolus insulin in a type 1 diabetic?
Typical starting dose for T1D is 0.5u/kg/day based on total body weight
- want to do 50% of TDD as basal and 50% as prandial
- divide the prandial by 3 for what to give at each meal
What are the rules used to calculate an insulin-to-carbohydrate ratio (ICR)?
Regular insulin uses the Rule of 450
450/TDD = grams of carbs covered by 1 unit of regular insulin
Rapid acting insulin uses the Rule of 500
500/TDD = grams of carbs covered by 1 unit of rapid-acting insulin
What are the rules used to calculate corrections doses for elevated blood glucose?
Regular insulin uses the Rule of 1500
1500/TDD = BG points that would lower from 1 unit
Rapid acting insulin uses the Rule of 1800
1800/TDD = BG points that would lower from 1 unit
Most insulins are a 1:1 conversion, but what are the 2 exceptions?
- If converting from NPH dosed BID to insulin glargine dosed QD, use 80% of the NPH dose
- If converting from Toujeo to insulin glargine or detemir, use 80% of the Toujeo dose
How may these drugs affect BG:
- thiazide & loop diuretics
- tacrolimus & cyclosporine
- beta blockers
- protease inhibitors
- quinolones
- antipsychotics
- statins
- steroids
- tramadol
- cough syrups
- niacin
- thiazide & loop diuretics: INCREASE
- tacrolimus & cyclosporine: INCREASE
- beta blockers: DECREASE (or increase)
- protease inhibitors: INCREASE
- quinolones: INCREASE OR DECREASE
- antipsychotics: INCREASE
- statins: INCREASE
- steroids: INCREASE
- tramadol: DECREASE
- cough syrups: INCREASE
- niacin: INCREASE
