Diabetes

Question 1

Describe the epidemiology of diabetes

Answer 1

≈ 9.4% US population has diabetes
Type 2 diabetes mellitus (DM) accounts for 90-95% of diabetic cases
8th leading causes of death in the US per Centers for Disease Control and Prevention (CDC 2022)
Highest prevalence in South

Question 2

Differentiate between T1DM and T2DM

Answer 2

1) Type 1 diabetes is due to autoimmune β-cell destruction; usually leading to absolute insulin deficiency
2) Type 2 DM characterized by progressive loss of β-cell insulin secretion frequently on the background of insulin resistance

Question 3

List the Sx of T2DM

Answer 3

1) Hyperglycemia: Polyuria, polyphagia and polydipsia
2) Obesity
3) Macrovascular complications: Cardiovascular disease
4) Microvascular complications: Nephropathy, neuropathy & retinopathy

Question 4

When does the ADA say you should start insulin?

Answer 4

Initiate insulin for symptomatic patients when A1C > 10% or blood glucose ≥ 300 mg/dL

Question 5

List the ADA diagnostic criteria for DM

Answer 5

1) A1C >6.5%
2) Fasting plasma glucose >126 mg/dL
3) Two-hour plasma glucose >200 mg/dL during an oral glucose tolerance test
4) Symptomatic patients with a random plasma glucose >200 mg/dL

Question 6

What are the ADA Criteria for the Diagnosis of Prediabetes?

Answer 6

1) A1C >5.7%, but <6.5%
2) Fasting plasma glucose >100 mg/dL but <126 mg/dL
3) Two-hour plasma glucose >140 mg/dL during an oral glucose tolerance test, but <200 mg/dL

Question 7

What 2 drugs are commonly prescribed for prediabetes?

Answer 7

Metformin and liraglutide (Victoza)

Question 8

List some lifestyle modifications for DM

Answer 8

Obesity
ASCVD Risk Factor Modifications
Neuropathy and Depression
Immunizations
Retinopathy and Foot Care

Question 9

How can pts with obesity achieve > 7% - 15% total body weight loss over three months?

Answer 9

Exercise, diet, therapies, or bariatric surgery

Question 10

1) When should you consider medication therapy for obesity?
2) What medications?

Answer 10

1) Consider if BMI ≥ 27 kg/m2
2) Phentermine, phentermine/topiramate ER (Qsymia), naltrexone/bupropion ER (Contrave) and liraglutide (Saxenda)

Question 11

When should you consider bariatric surgery?

Answer 11

Consider if BMI ≥ 35 – 40 kg/m2

Question 12

How can you Tx neuropathy in DM?

Answer 12

Pregabalin (Lyrica) and duloxetine (Cymbalta)
Can consider gabapentin, TCAs, or other SRNIs

Question 13

CDC vaccines recommendations specific for adults with DM are what?

Answer 13

1) Hepatitis B: 2 or 3 shot series recommendation for patients at risk of percutaneous exposure to blood & > 60 years old; routinely recommended for adults ages 19-59 years old
Example: Engerix-B with 0-, 1- and 6-month schedule
2) Pneumonia: adults 19-50 years old
Example: 1 dose of PCV20 (Prevnar-20)

Question 14

What retinopathy and foot care should be done for DM pts?

Answer 14

Annual or more freq appts

Question 15

Name 1 way to prevent T1DM

Answer 15

Teplizumab-mzwv infusion (Tzield)

Question 16

Name 1 way to prevent T2DM

Answer 16

Vitamin D

Question 17

Metformin (Glucophage):
1) What is the MOA?
2) What is the target dose?
3) What is the A1C% reduction?

Answer 17

1) Decreases hepatic gluconeogenesis production, decreases intestinal absorption of glucose, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization
2) 1000mg PO BID
3) 1-1.5%

Question 18

Metformin (Glucophage):
1) Does it cause weight gain/loss?
2) Is there any CVD benefit?
3) What is the hypoglycemia risk?

Answer 18

1) No; neutral
2) May reduce cardiovascular mortality
3) Low

Question 19

Metformin (Glucophage):
1) What are 2 adverse effects?
2) When should you not initiate?
3) When should you d/c?

Answer 19

1) GI, B-12 malabsorption
2) If eGFR < 45 mL/min/1.73m2
3) If eGFR < 30 mL/min/1.73m2

Question 20

Sulfonylureas (Glipizide or Glimepiride):
1) MOA?
2) When should pts take their dose?
3) Does it cause weight gain/loss?

Answer 20

1) Stimulates pancreatic insulin secretion
2) 30 min before a meal
3) Gain

Question 21

Sulfonylureas (Glipizide or Glimepiride):
1) Is there CVD benefit?
2) What is the hypoglycemia risk?
3) What are 2 adverse effects?

Answer 21

1) No
2) High
3) Hypoglycemia and weight gain

Question 22

Sulfonylureas (Glipizide or Glimepiride):
1) What are the contraindications?
2) Which doesn’t have an extended release form?

Answer 22

1) Discontinue if initiating insulin; sulfa allergy (not likely to cross-react)
Avoid in elderly patients due to hypoglycemia (Beers Criteria)
2) Glimepiride (Amaryl)

Question 23

Dulaglutide (Trulicity)
1) How/ when is it dosed?
2) Is there weight gain or loss?
3) What is the hypoglycemia risk?

Answer 23

1) SUBQ once weekly
2) Loss (big time)
3) Low

Question 24

Dulaglutide (Trulicity):
1) Adverse effects?
2) Contraindications?
3) What is the formulation?

Answer 24

1) GI and rare pancreatitis
2) Family history of medullary thyroid carcinoma or those with multiple endocrine neoplasia syndrome type 2 – FDA Black Box warning for risk of thyroid C-cell tumors
3) Injectable

Question 25

Dulaglutide (Trulicity) 1) When/ how is it dosed? 2) Is there CVD benefit?

Answer 25

1) SQ once a week 2) May reduce cardiovascular mortality & slow progression of chronic kidney disease

Question 26

Exenatide (Byetta) 1) Is there any weight gain/ loss? 2) List the adverse effects 3) List the contraindications

Answer 26

1) None 2) GI, rare pancreatitis and gallbladder disease 3) Discontinue if eGFR < 30 mL/min/1.73m2 Family history of medullary thyroid carcinoma or those with multiple endocrine neoplasia syndrome type 2 – FDA Black Box warning for risk of thyroid C-cell tumors

Question 27

What is a contraindication of all Glucagon-like peptide-1 receptor agonists (GLP-1 RAs)?

Answer 27

Family history of medullary thyroid carcinoma or those with multiple endocrine neoplasia syndrome type 2 – FDA Black Box warning for risk of thyroid C-cell tumors

Question 28

Semaglutide (Ozempic): 1) What are the adverse effects? 2) Is there any weight gain/loss?

Answer 28

1) GI, rare pancreatitis and retinopathy 2) Loss

Question 29

GLP-1 RAs: What are the drug interactions?

Answer 29

1) May decrease efficacy of oral progestins and estrogens Consider IUD, patch, NuvaRing, condoms or sterilization 2) Do not use with DPP-4 inhibitors (overlapping MOA)

Question 30

GLP-1 RAs: How do you dose?

Answer 30

Initiate with low doses and titrate due to GI symptoms

Question 31

Dipeptidyl peptidase-4 inhibitors (DPP-4): 1) What is their MOA? 2) What is their A1C% ↓? 3) What is their adverse effect?

Answer 31

1) Blocks the DPP-4 enzyme to slow the breakdown of GLP-1 2) 0.5 – 0.8% 3) Joint pain and rare risk of pancreatitis

Question 32

Dipeptidyl peptidase-4 inhibitors (DPP-4): 1) Is there weight gain/loss? 2) What is the hypoglycemia risk?

Answer 32

1) No; neutral 2) Low

Question 33

Linagliptin (Tradjenta) (a DPP-4): 1) What are the contraindications? 2) What are the formulations? (idk if we need to know) 3) What is the dose?

Answer 33

1) CYP3A4 drug-drug interactions 2) Combination with metformin (Jentadueto) and empagliflozin (Glyxambi) 3) 5mg PO Qday

Question 34

Saxagliptin (Onglyza) (DPP-4): What are the formulations?

Answer 34

Combination with metformin (Kombiglyze), dapagliflozin (Qtern) or with metformin + dapagliflozin (Qternmet)

Question 35

Sitagliptin (Januvia): What formulation?

Answer 35

Combination with metformin (Janumet)

Question 36

Sodium-glucose co-transporter 2 inhibitors (SGLT-2): 1) What is their MOA? 2) What is their A1C% ↓? 3) What is their hypoglycemia risk?

Answer 36

1) Blocks glucose reabsorption in the kidneys and increases urinary excretion of glucose 2) 0.5 – 1% 3) Low

Question 37

Sodium-glucose co-transporter 2 inhibitors (SGLT-2): 1) What are their contraindications? 2) What are their adverse effects they all have?

Answer 37

1) D/c if eGFR < 45 mL/min/1.73m2 -Some clinicians will use if eGFR > 30 mL/min/1.73m2 (for Canagliflozin (Invokana), esp. if albuminuria > 300mg / day) 2) Genital yeast infections, UTI, necrotizing fasciitis of the perineum, ketoacidosis, hypotension, hyperkalemia, bone fractures, acute kidney injury and rare pancreatitis

Question 38

Canagliflozin (Invokana): Formulations?

Answer 38

Combination with metformin (Invokamet)

Question 39

Dapagliflozin (Farxiga): Formulations?

Answer 39

Combination with metformin (Xigduo), saxagliptin (Qtern) or with metformin + saxagliptin (Qternmet)

Question 40

Empagliflozin (Jardiance): Formulations?

Answer 40

Combination with metformin (Synjardy) and linagliptin (Glyxambi)

Question 41

____________ evidence for bladder cancer is stronger than pioglitazone evidence since it came from clinical trials (RCTs).

Answer 41

Dapagliflozin

Question 42

The FDA says to avoid _______________ for patients with active bladder cancer; caution use with a history of bladder cancer. Other SGLT2i do not have this warning in their drug monograph.

Answer 42

dapagliflozin

Question 43

Which drugs are potentially beneficial to slow progression of CKD per RCTs and observational trials?

Answer 43

1) GLP-1 RAs -Liraglutide -Semaglutide (SUBQ – not PO) -Dulaglutide 2) SGLT-2 Inhibitors -Canagliflozin -Empagliflozin -Dapagliflozin

Question 44

Acarbose, an alpha-glucosidase inhibitor, has what MOA?

Answer 44

Slows intestinal carbohydrate digestion / absorption; significant flatulence

Question 45

Nateglinide, a Meglitinide, has what MOA?

Answer 45

Stimulates pancreatic insulin secretion; DO NOT USE WITH SULFONYLUREAS

Question 46

Colesevelam, a bile acid sequestrant, has what MOA?

Answer 46

Reduce hepatic glucose production increase incretin levels and decrease glucose absorption -lots of drug interactions; separate other medications by four hours before or after (different drugs have different recommendations)

Question 47

Tirzepatide (Mounjaro): 1) What is the MOA? 2) What is an important aspect of dosing?

Answer 47

1) Glucose-dependent insulinotropic polypeptide (GIP) / GLP-1 agonist 2) Titrate

Question 48

Tirzepatide (Mounjaro): 1) Drug interactions? 2) What is the BBB?

Answer 48

1) May decrease the efficacy of oral hormonal contraception due to changes in gastric emptying; contraceptives administered by a nonoral route are not affected 2) Risk of thyroid C-cell tumors

Question 49

Tirzepatide (Mounjaro) 1) What is the A1c ↓? ≈ 1.5% 2) What is the weight ↓? 3) What is a downside?

Answer 49

1) ≈ 1.5% 2) ≈ 22.5% (average of 52 pounds) -Ancillary protocol for caloric reduction and standards of care -Placebo participants lost 2.4% of weight (average of 5 pounds 3) Expensive af

Question 50

Insulin: 1) MOA? 2) How/ when do you dose? 3) What is the A1C% ↓? 4) Weight loss or gain?

Answer 50

1) Promotes storage of glucose in muscle / fat tissues and inhibits production of glucose [in liver] 2) Basal Bolus = Prandial 3) 1.5 – 3.5% 4) Gain

Question 51

Insulin: 1) Adverse effects? 2) Contraindications? 3) Formulations?

Answer 51

1) Weight gain and hypoglycemia 2) None 3) Rapid, regular, intermediate, long-acting, ultra-long-acting and mixes Pens, vials or inhalation powder cartridge

Question 52

Insulin: 1) Concentrations: most are ____units / mL 2) Pens: typically ____mL; will require pen needles 3) Vials: typically ____mL; will require traditional needle/syringe or insulin pumps

Answer 52

1) 100 units/mL 2) 3mL 3) 10mL

Question 53

Describe the storage of insulin

Answer 53

Refrigeration: 1) Typically lasts 28 days at room temperature -Humulin 70/30 pen lasts 10 days -Tresiba pen lasts 56 days

Question 54

Give some examples of bolus insulin

Answer 54

Humulin R, Novolin R, insulin lispro, insulin aspart, insulin glulisine and insulin human

Question 55

Rapid-acting insulin injections: 1) What is a pro? What is a con? 2) When should you administer?

Answer 55

1) Less hypoglycemia compared to regular insulin More expensive than regular insulin 2) 15 minutes prior to meal

Question 56

Give and describe 2 examples of regular insulin injections (lasts < 8 hours; 500 units/mL < 21 hours)

Answer 56

1) Humulin R (100 units/mL or 500 units/mL) Recommend correct syringe for 500 units / mL Consider using 500 units / mL once patient is needing more than 200 units / day 2) Novolin R

Question 57

Regular insulin injections (lasts < 8 hours; 500 units/mL < 21 hours): When should you administer these?

Answer 57

30 mins prior to meal

Question 58

Ultra-long acting insulin injections (lasts >42hr): Describe this

Answer 58

Insulin degludec (Tresiba) has less hypoglycemia compared to Lantus & Levemir Administer regardless of meal

Question 59

Insulin injections mixes: 1) How long do they last? When do you dose? 2) Give examples

Answer 59

1) Lasts ≈ 24 hours with variability; Administer 15 to 30 minutes prior to meal depending on bolus component 2) NovoLog Mix 70/30 Humalog Mix 75/25 Humalog Mix 50/50 Humulin 70/30 Novolin 70/30

Question 60

When mixing insulin NPH (ex: Humalin N) with other insulins in a syringe, which should be drawn into the syringe after the other insulin preparations?

Answer 60

Insulin NPH (ex: Humalin N)

Question 61

Insulin inhalations: 1) Give an example and how long it lasts 2) When should you avoid these? 3) When do you administer? How long do they last outside refrigeration?

Answer 61

1) Insulin human (Afrezza) – lasts < 5 hours 2) Chronic lung disease 3) Administer at beginning of meal -Last 10-days outside of refrigeration

Question 62

Describe Self-Monitoring of Blood Glucose (SMBG)

Answer 62

1) Awakening & Bedtime; before meals; two hours after meals 2) **Continuous glucose monitoring:** like Dexcom or Freestyle Libre 2) **Finger-stick glucose monitoring:** Meter, test strips, lancets, lancing device and alcohol wipes -Always advise patients to clean fingers before use and to avoid applying lotions / creams prior to checking blood glucose

Question 63

Describe initiating basal insulin for DMII

Answer 63

1) Option 1: 0.2 units / kg 2) Option 2: 10 units SUBQ QHS (at night) -Increase or decrease by 10-20% based on fasting blood glucose

Question 64

Describe initiating basal + bolus insulin for DMII

Answer 64

Consider when total daily dose is greater 0.5 units / kg 1) Option 1: One prandial injection before largest meal 10% of basal dose or 5 units 2) Option 2: Three prandial injections 50% basal 50% bolus divided in three doses

Question 65

Describe initiating insulin for DMI

Answer 65

0.5 units/kg/day -50% prandial insulin -50% basal insulin

Question 66

What method of insulin admin is recommended for DM1?

Answer 66

Insulin pump + CGM is preferred

Question 67

Name an adjunct therapy for DM1

Answer 67

Pramlintide

Question 68

Inpatient blood glucose goals are less restrictive; Typically between ___________mg / dL

Answer 68

140 – 180

Question 69

True or false: When inpatient, sliding scale protocols + standards of care may be considered

Answer 69

True

Question 70

Define the 3 levels of hypoglycemia and what to do for each

Answer 70

Question 71

There is a _______ Regimen on Toujeo Max SoloStar **not U-100**

Answer 71

Fixed