Diabetes Flashcards
(135 cards)
0
Q
Types of short acting insulin
A
Lispro (Humalog),Aspart (Novolog), Glulisine (Apidra)
(These are similar analogues of human insulin.)
Regular insulin
1
Q
Types of long acting insulin
A
NPH
Glargine (Lantos)
Detemir (levermir)
NPH+Humulin N
2
Q
Duration of action of NPH insulin
A
16 to 24 hours
3
Q
How is NPH insulin usually administered
A
Two thirds in the a.m. and one third in the p.m.
4
Q
How is Glargine insulin administered
A
It is started at 80% of the prior total insulin dose. It is split when the dose becomes greater than 60 units
5
Q
Describe detemir insulin
A
It is similar to glargine insulin. It is not supposed to cause weight gain and it’s length of activity increases with its dose
6
Q
Specifics about NPH combined with Humulin N insulin
A
It is actually intermediate acting. It’s onset is 1 to 2 hours, it peaks at 4 to 8 hours, and it lasts 10 to 20 hours. It is cheaper than long-acting insulin
7
Q
What is the onset and duration of action of the short acting human analog insulins?
A
Their onset is at 15 minutes, they peak at 1 to 3 hours, and their duration is 2 to 5 hours.
8
Q
How much of the daily dose of insulin in type one diabetics consists of short acting insulin?
A
One third of the daily insulin dose
9
Q
Describe regular insulin
A
It’s onset of action is 30 to 60 minutes, it’s peak is 2 to 4 hours, and it’s duration is 8 to 10 hours.
10
Q
What is the average dose of insulin according to the weight of the patient? How is it given?
A
.6 to .8 units per kilogram per day. One half is given for basal needs and one half at meals.
11
Q
Describe differences in insulin action according to injection site
A
Availability is faster in the abdomen and slower in the thigh. Exercise increases absorption from the thigh. Injection into the arm decreases exercise – induced hypoglycemia by 60%. Injection into the abdomen decreases exercise – induced hypoglycemia by 90%.
12
Q
Describe the dosing of glargine insulin.
A
It is usually started at 10 units per day and increased by 10 units per day until the fasting plasma glucose is less than 100.
13
Q
What is a positive 50 g glucose tolerance test for gestational diabetes? When is the test administered?
A
It is positive if it is over 130 to 140. It is administered at 24 to 28 weeks.
14
Q
How many grams of glucose are given for a three hour glucose tolerance test for gestational diabetes? What is a positive three hour glucose tolerance test?
A
100 g of glucose are given. A positive test consists of two or more of the following: fasting blood sugar of greater than 95, one hour greater than 180, two hours greater greater than 155, three hours greater than 140.
15
Q
What kind of ongoing screening for diabetes should a mother with gestational diabetes get postpartum?
A
She should be screened 6 to 12 weeks postpartum, and then every three years forever.
16
Q
How many jellybeans equals a 50 g glucose load?
A
18
17
Q
What children should be screened for diabetes?
A
Children who have a high body mass index or whose weight is greater than 85% for their age. Children with at least two of the following risks: family history of diabetes in a first or second degree relative, high-risk ethnicity, signs or symptoms of insulin resistance (acanthosis,hypertension, dyslipidemia or polycystic ovaries).
18
Q
When should children be screened for diabetes?
A
Every two years beginning at age 10 if they are at risk for diabetes.
19
Q
What are the ADA recommendations for screening adults for diabetes?
A
Adults with a body mass index of greater than or equal to 25+ one additional risk should be screened. Those risks include physical inactivity, a family history of diabetes especially in a first degree relative, a high-risk ethnicity, previous gestational diabetes, a previous baby weighing more than 9 pounds, hypertension, history of vascular disease, an HDL less than 35, triglycerides greater than 250, history of impaired glucose tolerance, acanthosis nigricans or other conditions associated with diabetes.
20
Q
How often and when should adults who are at risk for diabetes be screened?
A
They should be screened at age 45 and then every three years.
21
Q
Per the USPSTF, what is the most important risk factor in screening for diabetes?
A
HTN
22
Q
What is the treatment for pre-diabetes?
A
Lifestyle changes. Metformin if the patient is obese and less than 60 years old.
23
Q
What A1C level is considered to be pre-diabetes?
A
5.7 to 6.4
24
Define metabolic syndrome.
Greater than or equal to three of the following: insulin resistance/glucose intolerance (FBS greater than 100), obesity (waist greater than 40 inches in men or 35 inches in women), HDL less than 50 in women or less than 40 in women, blood pressure greater than 130/85, Microalbuminuria greater than 20 µg per minute.
25
Metformin dosing
Start at 500 mg extended release, titrate up to 2000 mg per day. Take with meals.
26
Metformin should be avoided in which patients?
It should be avoided in patients with liver dysfunction, metabolic acidosis, those who are undergoing studies with contrast, and those with a low GFR. A low GFR would mean less than 1.4 in women and less than 1.5 in men.
27
What ethnic groups are at high risk for diabetes?
Latinos, blacks, Asians, Pacific islanders, and native Americans.
28
In what ways does diabetes tend to be different and Asians?
It develops at a younger age, it is less likely to be associated with obesity, and there is a higher risk of renal failure than for whites with diabetes.
29
What lifestyle changes should be recommended to patients with impaired glucose intolerance?
Losing 5 to 10% of body weight and performing at least 30 minutes of moderate exercise such as walking daily
30
What is the blood glucose level goal for diabetics who are critically ill and in intensive care setting?
140 to 180 mg/dL
31
What is the blood glucose level goal for inpatients who are not in intensive care?
90 to110 fasting and less than 180 postprandial.
32
What is the LDL level goal in diabetic patients who are unable to reach target levels with either the maximum tolerated dose of statins or due to complications from statin therapy?
A decrease in LDL to 40% from baseline.
33
What drugs should a patient who is older than 40, has type two diabetes and another risk factory for coronary artery disease be taking?
A statin, an angiotensin-converting enzyme inhibitor and aspirin
34
What percent of US people over 20 have diabetes? What will that percentage be in 2030?
10.7% now and 33.9% by 2030.
35
Definition of impaired fasting glucose
Fasting plasma glucose level between 100 and 125 mg/dL
36
Definition of impaired glucose tolerance
This is diagnosed when the two hour oral glucose tolerance test measurement is between 140 and 199 mg/dL
37
When should fasting glucose testing be used as opposed to two hour postprandial testing as a screening test for diabetes? What are the advantages and disadvantages of each test?
Fasting plasma glucose is easier to use in terms of cost, convenience and patient acceptability. the oral glucose tolerance test is more sensitive and somewhat more specific but is used less often because it is not as reproducible and the test is longer and more complicated than the fasting test. FPG tests for abnormalities in basal insulin and the oral glucose tolerance test tests for abnormalities in carbohydrate metabolism. Therefore confirming an abnormal initial screening test result with the other test is a good idea.
38
Compared with intensive lifestyle efforts alone, metformin is most likely to prevent the progression of prediabetes to diabetes in which of the following patients?
A) a 65-year-old black individual
B) a 51 year old Latina woman with a body mass index of 36 kg/m²
C) a 27-year-old American Indian with gestational diabetes
D) a 49-year-old Asian individual with postprandial hyperglycemia
B
39
```
Which one of the following tess should be used to screen for diabetes in an asymptomatic 11-year-old patient with a body mass index greater than the 95th percentile for age and sex?
A. Fasting plasma glucose
B. Hemoglobin A-1 C
C. Two hour oral glucose tolerance
D. One hour postprandial blood glucose
```
A
40
A patient with type two diabetes asked about continuous subcutaneous insulin infusion. You should counsel him that compared with multiple daily injections of insulin, continuous subcutaneous insulin infusion with lispro is associated with which of the following?
A. more postprandial glucose fluctuations
B. Greater weight loss
C. Increased likelihood of hypoglycemia
D. Greater decrease in hemoglobin
A-1C level
E. Less overall expense
D
41
A patient with poorly controlled diabetes and a body mass index of 37 consults you about bariatric surgery. Which of the following statements is true?
A. Diabetes control only improves in 25% of patients
B. Weight loss is higher in patients with laparoscopic adjustable gastric banding than gastroplasty
C. After 10 years of follow-up, there is no difference in diabetic control or mortality in patients with bariatric surgery compared with patients who did not have surgery.
D. Lipid levels, hypertension, and obstructive sleep apnea improve in patients who have had surgery.
D
42
You are transitioning from insulin infusion to subcutaneous insulin in
a 110 kg inpatient with diabetes who now has a normal dietary intake. Which one of the following is a reasonable estimate of her basal insulin needs over 24 hours?
A. Five units per day
B. 10 units per day
C. 22 units per day
D. 62 units per day
E. 80 units per day
C
43
In managing the nutritional needs of an inpatient the diabetes, which one of the following should you recommend?
A. A specified number of carbohydrate servings
B. Avoidance of any added sugar.
C. Avoidance of concentrated sweets.
D. A liberal diabetic diet.
E. An American diabetes Association diet.
A
44
```
A patient with type two diabetes has an allergy to aspirin. Which of the following should be substituted for aspirin for the prevention of coronary artery events?
A. Diprydamole
B. Sulfapyrazine
C. Clopidogrel
D. Ticlodipine
E. Warfarin
```
C
45
True or false: a blood pressure level of 140/90 mm is an appropriate goal for a patient with type two diabetes.
False: the target blood pressure level goal for individuals with type two diabetes should be less than 130/80.
46
How are African-Americans with type two diabetes different from whites?
They have higher insulin resistance and somewhat lower body mass indexes than whites. They are at risk at 26 versus 30.
47
How do Latino Americans with type two diabetes differ from whites?
Peripheral vascular disease is 80% more common. Mortality is two times white. 50% of Latino children will develop diabetes. The rate in Latinos will double in the next 10 years.
48
How do you calculate the average blood sugar from the A-1 C value?
You multiply the (A-1 C value -2)x30
49
When do you add insulin to a diabetic regimen?
When the fasting blood sugar is consistently over 250 or a random glucose over 300.
50
What are exenatide and liraglutide and what do they do?
Byetta and Victoza. They are GLP-1 receptor agonists/incretin mimetics. They slow gastric emptying, promote satiety, and enhance weight loss.
51
Exenatide and liraglutide side effects and problems
They are very expensive. They are pregnancy category C. They may cause nausea, vomiting, diarrhea, dizziness and weight loss. They increase hypoglycemia especially with the sulfonylureas. Liraglutide may cause thyroid tumors.
52
What are the most effective medications to decrease postprandial glucose?
Incretin mimetics such as exenatide and liraglutide.
53
What are the differences in dosing between exenatide and liraglutide?
Both are injected. Exenatide is given twice per day. It may be given with insulin but not in the same syringe. Liraglutide is given once per day. it is better in renal failure. It does cause increased thyroid tumors which exenatide does not.
54
Which medications should be avoided in diabetic gastroparesis?
Incretin mimetics such as exenatide and liraglutide.
55
What is pioglitazone?
Actos, a thiazolidinedione. It is an insulin sensitizer in peripheral tissue, and decreases gluconeogenesis.
56
What are the side effects of pioglitazone?
It can cause of volume overload, and should be used with caution in the elderly and persons with cardiopulmonary disorders. It has a black box warning for class three or four heart failure. It causes weight gain. It can cause liver problems. Liver functions should be monitored in people who are taking it, and it should be avoided in patients with liver dysfunction, including non-alcoholic fatty liver. It is category C in pregnancy. It increases the risk for serious heart failure. It increases distal limb fractures in women. It may increase the risk for bladder cancer with use for over one year. It is expensive.
57
Besides better glucose control what are the positive effects of pioglitazone?
It decreases triglycerides and increases high-density lipoprotein. It decreases the risk of myocardial infarction, stroke and death.
58
What is the story with pioglitazone and bladder cancer?
One study showed increased risk, this was not confirmed by subsequent studies.
59
Which thiazolidinedione is associated with increased risk for myocardial infarction?
Rosaglitizone (Avandia)
60
What are acarbose and miglitol?
What is their mechanism of action?
(Precose and Glyset). They are alpha glucodiase inhibitors. They delay carbohydrate absorption in the gut, they decreased peak glucose levels,. They do not cause hyperglycemia.
61
What are the advantages of acarbose and miglitol?
They may delay the onset of type two diabetes. They decrease the risk of cardiovascular events. They are weight neutral. They are pregnancy category B.
62
What are the side effects and contraindications of acarbose and miglitol?
They may cause liver problems, and liver functions should be monitored. They should be avoided in cirrhosis. They should not be used if the creatinine level is greater than two. They have significant gastrointestinal side effects including flatulence, abdominal pain and diarrhea. They should be avoided in patients with gastrointestinal disease. They cause only a moderate glucose decrease for their cost.
63
What are repaglinide and nateglinid?
Mechanism of action?
Advantages and side effects?
Prandin and Starlix--meglitinides
Like short acting sulfonylureas. Insulin secretagogues with half-life of less than one hour. They have a high-cost for a moderate decrease in glucose. They may be used in the elderly, in those with renal failure, and those with cardiopulmonary disorders. They are helpful for erratic eating schedules. side effects include hypoglycemia, and weight gain which is less then with the sulfonylureas.
64
What are the sulfonylureas?
What is their mechanism of action?
Glipizide, glyburide and glimepyride
They stimulate pancreatic beta cells to release insulin via a potassium channel mechanism.
65
What are the advantages and the disadvantages and side effects of sulfonylureas?
They can be used in the elderly at low doses. They are okay in mild renal dysfunction except for glyburide. OK in cardiopulmonary problems including sleep apnea and congestive heart failure. They cause weight gain and they cause hypoglycemia.
66
Unusual aspects of glyburide
It should not be used in renal dysfunction, since it has an active metabolite that is eliminated by the kidneys. it is as effective as insulin in gestational diabetes with a fasting blood sugar of less than or equal to 140 though it is category C.
67
What diabetes medication should be held for a contrast procedure and why? When else should you hold it?
Metformin
Should be held for contrast procedures because there is increased risk for decreased renal function and renal damage. It also may cause lactic acidosis and should be held for serious illness and hospitalization.
68
What is the blood pressure goal in patients with diabetes?
Less than 130/80
69
What fluid is best for diabetic ketoacidosis?
Normal saline until potassium is 5.5, then add potassium. Continue normal saline until dehydration is resolved. Then use one half normal saline. Patients with diabetic ketoacidosis are usually down 5 to 8 L.
70
Dosing of insulin and dextrose in patients with diabetic ketoacidosis
An insulin drip should be used at 1 to 2 units per hour or 0.1 unit per kilogram per hour. D5 should be added when glucose is 250. Insulin should be decreased but not stopped if there is hypoglycemia.
71
Each one percent decrease in hemoglobin A-1 C results in what decrease in the complications of diabetes?
A 21% decrease in microvascular complications.
72
What are the goals in terms of numbers for treatment of diabetes?
Fasting blood sugar of less than 100. Bedtime glucose of less than 120. A-1 C less than 7%, many are now using 6.5%. Blood pressure of less than 130/80. Low-density lipoprotein of less than 100, less than 70 with cardiovascular disease.
73
In what patient populations should the goals for diabetic control be relaxed or strict?
They should be stricter for newly diagnosed diabetics, or those with a long life expectancy. They should be relaxed in patients who have been diabetic for more than 12 years, those with advanced complications, or limited life expectancy.
74
What is metformin and what is it mechanism of action?
A biguanide. It is a peripheral insulin sensitizer. It decreases glucose production in the liver. It decreases insulin and lipid levels.
75
Advantages of Metformin
It does not cause hypoglycemia or weight gain. It improves cardiovascular outcomes and decreases mortality and overweight in newly diagnosed type two diabetics. It is widely used for polycystic ovary disease. It is the only oral medication that can be given to children and adolescents. It is category B in pregnancy.
76
What are the side effects and cautions with Metformin?
It should be used with caution in elderly patients and those with renal dysfunction, hepatic disease, and cardiopulmonary disease. It may be used in stable congestive heart failure. It should be stopped prior to and until 48 hours after IV contrast is used. A creatinine level should be checked prior to use. It may be used judiciously in patients who have creatinine levels of up to 2.5, but it is recommended to stop at a creatinine of 1.5 in men and 1.4 in women. Its side effects include nausea vomiting anorexia and headache.
77
What are sitagliptin, saxagliptin, linagliptin, vildagliptin and algoliptin?
(Januvia, Onglyza. Tradjentin)
DPP-4 inhibitors/incretin enhancers.
They block dipeptidyl peptidase, The enzyme that breaks down incretins.
They cause better insulin release and postprandial glucose control
78
Side effects and cautions in DPP-4 inhibitor use
Side effects are minimal and include upper respiratory infection, sore throat, diarrhea, and pancreatitis. Their weight affect is usually neutral or they may actually decrease weight. They slow gastric emptying. They should be used with caution but they're not contraindicated in patients with gastroparesis. They should not be added to sulfonylureas in the elderly.
79
Each oral medication for diabetes will decrease A-1 C by how much? What does this mean in terms of when insulin will be needed?
Each oral medication decreases A-1 C from 0.5 to 1.0 in general. There are reported values from 0.5 to 2.5. This means that a patient will probably need insulin if the A-1 C is greater than nine, and especially it is if it is greater than about 11.
80
Angiotensin receptor blockers are indicated to prevent complications in which patients with diabetes?
Those who can't tolerate ACE inhibitors or those with serum creatinine of greater than 1.5.
81
In what ethnic groups do you see diabetic ketoacidosis in type two diabetics?
African Americans and Hispanics
82
When hyperglycemia occurs in a previously well controlled diabetic you should suspect what?
Renal failure
83
What are acceptable increases in creatinine and potassium levels after starting a patient with diabetes on an ACE or ARB?
An increase in creatinine of up to 30% and an increase potassium of up to 5.5 mEq per liter
84
Asians versus African-Americans versus Caucasians tend to develop diabetes at what body mass indices?
Asians at 24, African-Americans at 26, and Caucasians at 30.
85
Causes of diabetic ketoacidosis
The three I's: insulin – as in I'm out of my insulin, infection, and infarction (MI or CVA)
86
Causes of metabolic acidosis
MUDPLIES
```
M= methanol
U= uremia
D= diabetic ketoacidosis
P= paraldehyde
L= lactic acidosis
I= INH
E= ethylene glycol
S= Salicylates
```
87
Lifestyle management may improve outcomes in what percentage of diabetics?
Up to 60%
88
What is the most appropriate next step in treatment for an 81-year-old man with type two diabetes who has a hemoglobin A-1 C of 10.9%. he is already on the maximum dose of glipizide. His other medical problems include mild renal insufficiency and moderate ischemic cardiomyopathy.
He should be treated with insulin. Metformin is contraindicated in patients with renal insufficiency. Sitagliptin should not be added to a sulfonylurea drug initially and its dosage should be lowered in patients with renal insufficiency. Pioglitazone can cause fluid retention and therefore is not a good choice for a patient with cardiomyopathy.
89
What drugs reduce insulin resistance in diabetes?
Pioglitazone, rosiglitazone and metformin
90
What sulfonylurea can safely be given to diabetics with renal failure?
Glipizide does not have active metabolites, and is safe in patients with chronic renal disease. Glyburide has an active metabolite that is eliminated renally. This metabolite can accumulate in patients with chronic kidney disease, resulting in prolonged hypoglycemia.
91
What are the first and second line treatment for diabetic neuropathy?
Tricyclic antidepressants, gabapentin, pregabalin, and SNRIs such as duloxetine and venlafaxine are recommended as first-line treatment.
92
What is the mechanism of action of metformin?
It reduces hepatic glucose production, and to a lesser extent decreases insulin resistance peripherally in both fat and muscle.
93
What is the mechanism of action of exenatide and sitagliptin?
They reduce glucose production in the liver and enhance insulin secretion and release postprandially in the pancreas.
94
What is the mechanism of action of TZDs?
They decrease insulin resistance in peripheral tissue.
95
What is the mechanism of action of sulfonylureas?
The increase insulin release from the pancreas.
96
How much hemoglobin A-1 C decrease can be expected with lifestyle modification versus various classes of diabetic medications?
Lifestyle modification can result in a 1 to 2 point decrease. Metformin can result in a 1 to 2 point decrease. Sulfonylureas can result in a 1 to 2 point decrease. TZDs can result in a .5 to 1.4 point decrease. GLP-1 agonists can result in a .5 to 1 point decrease.
DPP-4 inhibitors can result in a 0.5 to 0.8 point decrease.
97
What treatment should be started as soon as the patient is diagnosed with diabetes?
Lifestyle modification and metformin.
98
How should metformin be started?
Start at a low dose, usually 500 mg just with dinner or b.i.d. with meals. After one week advance close to 850 to 1000 mg b.i.d. The maximum dose is usually 850 mg b.i.d.
99
What is step 2 treatment for a diabetic who is not well controlled with lifestyle modification and metformin?
Tier 1: Well validated core therapies include basal insulin or sulfonylurea. Tier2: Less well validated therapies include pioglitazone or a GLP-1 agonist.
Tier 2 therapies would be used when there is a particular concern about hypoglycemia or when weight-loss is important. Neither pioglitazone nor GLP-1 agonists cause hypoglycemia. Weight-loss is often improved with GLP-1 agonists more than with pioglitazone.
Pioglitazone may increase peripheral edema and should not be used in patients with CHF. In addition there may be an increase in osteoporosis with the use of TZDs.
100
How much weight gain is seen with insulin or sulfonylureas?
Typically about 5 pounds over the first year.
101
What should step three treatment be for diabetics who did not respond well to steps one and two?
Before beginning step three, a diabetic who did not respond well to tier 2 of step two therapy should be treated with either a sulfonylurea or insulin.
In step three, lifestyle intervention and metformin should be continued. Intensive insulin treatment should be started. Sulfonylureas and glinides should be discontinued.
102
In what diabetic patients would we consider going directly to insulin upon presentation?
Those with a fasting plasma glucose greater than 250, random glucose levels consistently higher than 300, and A1C greater than 10%, the presence of ketonuria, or symptomatic diabetes with polyuria, polydipsia and weight loss.
103
What are the concerns about TZDs and cardiovascular effects?
Rosiglitazone has been shown to have an increase in adverse cardiovascular events. Pioglitazone does not have significant adverse cardiovascular effects and may have beneficial effects.
Note that all TZD's may increase the incidence of congestive heart failure.
104
In what patients are fasting glucose levels more important as opposed to postprandial levels?
Fasting glucose levels are more important in patients whose A1 C levels are far from goal. Postprandial levels are more important in patients were close to their A1C goal.
105
What are the effects of exenatide?
What are its adverse effects?
It is a GLP one agonist and binds to GLP one receptors. It primarily lowers postprandial glucose. It causes a .5 to 1% decrease in A-1 C. It causes a 2 to 3 kg weight loss over six months primarily because of increased satiety and early satiety.
Adverse reactions include nausea vomiting diarrhea and dyspepsia. Some patients get neurologic symptoms such as jitteriness, dizziness or headache. There is a low incidence (3% or less) of hypoglycemia. Because of the slow gastric emptying, drugs such as oral contraceptives and antibiotics should be taken 1 to 2 hours before exenatide.
106
What patients should probably received incretin mimetics?
Those whose hemoglobin A-1 C is near seven, who have normal fasting glucose levels, and increased postprandial glucoses.
107
How do you start insulin in a patient who has previously failed management with lifestyle changes and other medications besides insulin?
Insulin N should be started QHS, or morning or QHS long acting insulin. The starting dose should be 10 units or .2 units per kilogram.
The patient should check their own fasting blood sugar. Insulin should be increased by two units every three days if the fasting blood sugar is over 130. If the fasting sugar is over 180 the insulin can be increased by four units every three days.
If they have hypoglycemic symptoms or the fasting sugar is less than 70, insulin should be decreased by four units or by 10% of the dose, whichever is greater.
An A-1 C should be checked after three months. If it is less than seven the same dose should be continued.
108
How should a patient's insulin regimen be changed if their fasting plasma glucose is less than 130 but their A1C is elevated?
The patient should check sugars before lunch, before dinner, and before bedtime in addition to fasting.
If the prelunch sugar is high, add rapid acting insulin before breakfast. If the predinner sugar is high, add insulin N at breakfast, or rapid acting insulin before lunch. If the pre-bedtime sugar is high, add rapid acting insulin at dinner.
Start by adding the appropriate insulin for the highest sugar that occurs pre-meal or bedtime. Add additional insulins if the hemoglobin A-1 C remains above seven.
If the A-1 C is still above seven, check the two hour postprandial glucose levels and add or adjust pre-meal rapid acting insulin.
109
What is the target blood pressure goal for patients with diabetes? In what order should antihypertensives be started and added?
130/80 or less. First-line therapy should be in ACE inhibitor or an ARB. Next, a diuretic should be added. If the patient's GFR is above 30, a thiazide diuretic is appropriate. If the GFR is less than 30, a loop diuretic should be used. It is important to monitor potassium levels for all diuretics. In addition ACE inhibitors and ARBs should have creatinine levels monitored.
110
Which diabetics should be started on a statin?
Staten therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients with overt cardiovascular disease. They should also be used in patients without cardiovascular disease who are over age 40 and who have one or more cardiovascular disease risk factors. For patients at lower risk than those above statin therapy should be considered in addition to lifestyle therapy if LDL-cholesterol remains above 100 mg/dL or in those with multiple cardiovascular disease risk factors.
111
What are the LDL cholesterol goals in diabetics?
Less than 100 in patients without overt cardiovascular disease, and less than 70 in patients with overt cardiovascular disease.
112
What is the risk of using niacin in a diabetic patient?
It may cause worsened hyperglycemia, or it may cause overt diabetes in a prediabetic patient. It may still be used if the risks are weighed.
113
How do you diagnose diabetic microalbuminurea? Which diabetics should be screened and how often?
Type one diabetic should be screened annually beginning at five years after diagnosis, and all type two diabetics should be screened annually beginning at diagnosis. A positive diagnosis of microalbuminurea can be made with two out of three spot urine checks positive for greater than or equal to 30 µg of protein. An annual creatinine check should also be made.
114
How should pregnant diabetics be screened for retinopathy?
Pregnant diabetics should be screened at baseline because there is a concern that intensive glycemic control in pregnancy can worsen retinopathy. Pregnant patients with known retinopathy should be screened at regular intervals throughout their pregnancy by an ophthalmologist.
115
What is the association of type two diabetes with sleep apnea?
They're highly associated, with some studies showing that up to 85% of type two diabetics have moderate to severe sleep apnea.
116
What medications used for diabetes may cause hypoglycemia?
Insulin, sulfonylureas and meglitinides (which have a low potential).
117
Diabetics should be told that what blood sugar level is the cut off for hypoglycemia?
70 or below
118
How should a diabetic treat an episode of hypoglycemia?
They should take 15 g of glucose or fast acting carbohydrate. This would be 4 ounces of orange juice or three or four glucose tablets. If the next mealtime is more than 30 to 60 minutes away they should take a fast acting carbs and a protein snack.
119
When are thiazolidinediones such as pioglitazone contraindicated?
There is a black box warning in cases of heart failure. These agents are also contraindicated in patients with type one diabetes or hepatic disease, and in premenopausal anovulatory women--may increase ovulation.
120
What is pramlintide?
Also called Symlin, it is an amylinomimetic. It decreases glucagon release, slows gastric emptying and decreases food intake. It may be given at the same time as insulin but not in the same syringe or the same area. Side effects include nausea and vomiting, Anorexia, and headache. It's substantially decreases glucose levels when combined with insulin. The insulin dose should be decreased by 50% when starting Pramlintide. It is contraindicated in gastroparesis.
121
Define mild versus severe DKA.
Mild: glucose less than 250, bicarb less than 15, and pH less than 7.3.
Severe: glucose more than 250 bicarb less than 10 and pH less than 7.0.
122
How is the diagnosis of type two diabetes made?
A fasting blood sugar of greater than or equal to 126 on two or more occasions; a random glucose of more than 200 in a patient with symptoms, i.e. polyuria and polydipsia; or a two hour glucose tolerance test of greater than 200 after a 75 glucose load; or a hemoglobin A-1 C greater than 6.5.
123
At what hemoglobin A-1 C levels is metformin appropriate monotherapy?
Hemoglobin A-1 C's of 6.5 to 7.5.
124
At what hemoglobin A-1 C levels is an additional agent added to metformin?
7.6 to 9. Usually the second agent is a sulfonylurea; or TZD, glinide, DPP4, or GLP1 agonist.
125
What is the initial insulin dosage for type one diabetics?
For newly diagnosed diabetics, who are still likely to have some endogenous insulin, the dosage of insulin is 0.2 to 0.6 units per kilogram per day. For longer duration diabetics the dose is 0.5 to 1unit per kilogram per day. The insulin is commonly split 50-50 between long-acting and short acting insulin. The short acting is given at meal times.
126
how is the diagnosis of type one diabetes made?
Primarily by the absence of C-peptide levels. Islet cell antibodies, glutamine acid decarboxylase autoantibodies, and tyrosine phosphatase autoantibodies are also present.
127
What are the values for a positive three hour glucose tolerance test in pregnancy?
Two or more of the following: A fasting level of greater than 95, a one hour level of greater than 180, a two-hour level of greater than 155, and a three hour level of greater than 140.
128
What blood sugar level is diagnostic for hyper osmolar hyperglycemic state?
Greater than 600
129
What is the mechanism of action of the thiazolidinediones? What are the concerning side effects of thiazolidinediones?
They improve glucose primarily by increasing insulin sensitivity.
Rosaglitazone may cause coronary events. Both pioglitazone and rosaglitazone increase the risk of heart failure, weight gain, edema, and fractures. They are contraindicated in patients with type one diabetes, in hepatic disease, and in premenopausal anovulatory women.
130
What conditions cause falsely low hemoglobin A-1 C values? What conditions cause falsely high values?
Hemoglobinopathies and conditions causing ? can cause measurements to be falsely low. African-Americans have higher Hemoglobin A-1 C measurements then whites along the continuum of glycemia. Hemoglobin A-1 C levels are falsely low in the first and last trimesters of pregnancy.
131
What are common head and neck findings in diabetes mellitus?
Sialadenosis, or enlarged salivary glands, in particular bilateral noninflammatory enlargement of the parotids glands. In addition periodontal bleeding and inflammation, candidiasis, and delayed wound healing are associated with diabetes.
132
What types of corticosteroid injections can affect glycemic control in diabetics? How long should they closely monitor glucose if they receive one?
Single intra-articular joint injections have little or no effect on glycemic control. Soft tissue or peritendinitis injections can affect blood glucose levels for 5 to 21 days however, and diabetic patients should closely monitor blood glucose levels for two weeks following these injections.
133
What are currently considered to be the normal values for fasting glucose and for two hour glucose level on an oral glucose tolerance test after a 75 g glucose load?
Fasting less than 100, and two hour glucose level less than 140.
134
What are the contraindications to thiazolidinedione use?
They have a black box warning for heart failure. They are also contraindicated in patients with type one diabetes, hepatic disease, and in pre-menopausal anovulatory women.
