Diabetes

Question 1

What method is used to give insulin and where is insulin derived from?

Answer 1

Given parenterally (not absorbed PO)
Derived from human insulin–more rapidly absorbed and less immunogenic than animal sources

Question 2

What is the standard preparation of insulin

Answer 2

100 units per milliliter

Question 3

List examples of immediate, short, intermediate, and long insulin drugs

Answer 3

Immediate –lispro, aspart, glulisine
Short – regular insulin
Intermediate – NPH
Long – Detemir, Glargine

Question 4

Which type of insulin lasts for 12 hours but peaks at four hours?

Answer 4

Intermediate (NPH)

Question 5

Which type of insulin most closely mimics human insulin?

Answer 5

Immediate (lispro)

Question 6

Which type of insulin requires the most frequent administrations?

Answer 6

Immediate (lispro)

Question 7

What is a conventional insulin prescription?

Answer 7

Two biphasic (70/30) injections daily with short acting agents PRN

Question 8

List six drugs that cause hyperglycemia

Answer 8

Glucagon, steroids, epinephrine, thyroid hormones, oral contraceptives, diuretics

Question 9

Describe how an all day insulin dose works

Answer 9

Long acting insulin agent (Glargine or detemir) covered by lispro

Question 10

What is added to insulin to make it long-acting?

Answer 10

Zinc and protamine

Question 11

What type of insulin is in an insulin pump?

Answer 11

Lispro (immediate)

Question 12

Who is more likely to be insulin dependent, patient under 30 with diabetes or a patient over 30 with diabetes?

Answer 12

Under 30 with diabetes always require insulin

Over 30 with diabetes can manage with diet, insulin, and PO agents

Question 13

Which types of insulin maybe mixed?

Answer 13

Shorter acting agents maybe mixed in one syringe and immediately used
long-acting insulin should never be mixed

Question 14

What happens to long acting insulin agents administered by IV?

Answer 14

They separate and precipitate (as all suspensions do) when administered IV
Only non-suspension insolent products should be administered via IV drip

Question 15

Why should insulin never be shaken?

Answer 15

Shaking denatures the protein (indicated by foam)

Instead, roll between hands to warm

Question 16

When should insulin be refrigerated?

Answer 16

If prepared more than 30 days in advance

Question 17

What size syringe should be used for insulin administration?

Answer 17

1 mL (or smaller, never larger)

Question 18

What are the four signs of hypoglycemia?

Answer 18

Tremor, headache, malaise, tachycardia

Question 19

How are pregnant patients with DM usually treated?

Answer 19

Switch to insulin – does not cross placenta

Question 20

Why should patients on beta blockers be careful when taking insulin?

Answer 20

Beta blockers can mask signs of hypoglycemia (decrease headache, treat tremor, prevent tachycardia)

Question 21

Describe a proper insulin injection

Answer 21

Subcutaneously in hip/flank at 45° angle

Question 22

Summarize the mechanism of sulfonylureas in treatment of DM

Answer 22

Increase insulin release and sensitivity

Question 23

Which type of oral diabetic agents require a 30% pancreatic function?

Answer 23

Sulfonylureas

Question 24

Which kind of sulfonylurea should be avoided in the elderly?

Answer 24

Long acting agents (chlorpropamide, tolbutamide)-can bottom out their blood sugar

Question 25

How are sulfonylureas excreted?

Answer 25

Renally, highly plasma protein bound

Question 26

What is the most common adverse effect of sulfonylureas?

Answer 26

Rash

Question 27

Which type of sulfonylurea may be coadministered with insulin?

Answer 27

Second or third generation (glimepiride, glyburide)

Question 28

Describe how biguanides work

Answer 28

They reduce hepatic glucose production (ineffective in absence of insulin)

Question 29

Why was phenformin removed from the market in 1970s?

Answer 29

It caused fatal lactic acidosis

Question 30

What is the only kind of biguanide agent still used?

Answer 30

Metformin (Glucophage)

Question 31

What is one added bonus of Exenatide (Byetta)?

Answer 31

Weight-loss

Question 32

Which patients should be extra cautious of taking biguanides (Metformin)?

Answer 32

Those with renal dysfunction – metformin can cause lactic acidosis, increased serum creatinine Also, patients with hepatic dysfunction, cardiogenic shock, and pregnancy

Question 33

How is metformin dosing altered with the use of contrast dye?

Answer 33

Hold for 24 to 48 hours before use of dye

Question 34

What is another name for thiazolidinediones?

Answer 34

Glitazones

Question 35

How do Glitazones work?

Answer 35

They reduce peripheral insulin resistance (stimulate PPAR gamma resulting in adipose tissue differentiation)

Question 36

Which of these three tend to be least effective in diabetes treatment – sulfonylureas, biguanide's, Glitazones ?

Answer 36

Glitazones are less effective

Question 37

List two common side effects of Glitazones

Answer 37

Weight gain and peripheral edema

Question 38

Which patients should avoid taking Glitazones?

Answer 38

Those with heart or hepatic failure

Question 39

How do Meglitinides work to treat diabetes?

Answer 39

Short acting secretagogues that release stored insulin (similar to sulfonylureas)

Question 40

List examples of two Meglitinides and when you should take them

Answer 40

Repaglinide (take QID 30 minutes before meal) and Nateglinide (TID)

Question 41

How does Exenatide work?

Answer 41

Functional analog of GLP-1 that enhances insulin secretion and delays gastric emptying, used as adjunct therapy with insulin or other oral

Question 42

What is an added bonus side effect of using Exenatide?

Answer 42

Weight loss

Question 43

List three major side effects of Exenatide

Answer 43

Nausea, vomiting, pancreatitis

Question 44

Why do long acting GLP-1 agonists come with a black box warning?

Answer 44

They can cause thyroid C cell tumors

Question 45

Explain the dosing of Exenatide

Answer 45

Take 5 to 10 µg b.i.d. one hour before morning and evening meals

Question 46

Explain how dipeptidylpeptidase-4 (DDP-4) inhibitors improve glucose control

Answer 46

They prevent metabolism of GLP-1 thereby enhancing insulin secretion and delaying gastric emptying

Question 47

List an example of a DPP-4 inhibitor

Answer 47

Januvia

Question 48

Explain how Acarbose and Miglitol work to control diabetes

Answer 48

Alpha–glucosidase inhibitor that reduces digestion of complex carbohydrates in the gut causing increased sugar excretion in stool (used as adjuncts with other diabetes meds)

Question 49

What are potential side effects of Acarbose and Miglitol?

Answer 49

Diarrhea, flatulence – bacteria in gut feed on undigested sugar

Question 50

Which 3 diabetes medications are given subcutaneously?

Answer 50

Insulin, Byetta, Symlin

Question 51

Describe how Pramlinitide (Symlin) works to control diabetes

Answer 51

Amylin analogue with longer half-life that reduces postprandial glucagon secretion, slows gastric emptying, reduces caloric intake and enhances effects of insulin

Question 52

What are 2 side effects of pramlintide (Symlin)?

Answer 52

Weight loss, nausea

Question 53

How is Symlin dosed?

Answer 53

15 µg subcutaneously just prior to large meals, titrate to 120 µg as tolerated

Question 54

How does Canaglifozin (Invokana) work to control diabetes?

Answer 54

Inhibits sodium–glucose cotransporter 2 (SGPT-2) in kidney to waste urinary glucose

Question 55

What are common side effects of Invokana?

Answer 55

Yeast infections, UTI, balanitis due to increased sugar in urine Also osteoporosis and osteopenia due to potential calcium excretion (?)

Question 56

How is Invokana usually dosed?

Answer 56

100 mg QD before first daily meal for type two diabetes only

Question 57

What two tests must be monitored for patients on Invokana?

Answer 57

CrCl and serum K levels