Diabetes Flashcards

Question

In patient scenarios requiring insulin

Answer 1

Type 1 diabetics may require more than their normal dose – Type 2 diabetics who are not insulin-dependent may need it – Patients receiving total parenteral nutrition may require it – Even people who do not have a history of diabetes may require insulin and they or their families will be asking you why you are giving it to them.

Answer 2

Undetected hypoglycemia followed by rebound | hyperglycemia in AM

Answer 3

Rise in BG between 2-8 AM secondary to rise in counterregulatory hormones (inc. glucagon, growth hormone, cortisol) that are normally released, even by healthy people → patient will be hyperglycemic in AM

Answer 4

Indication – For Type 1 & insulin-using Type 2 patients (Used as supplement to Insulin) Mechanism – mimetic of human amylin. Slows gastric emptying, suppresses glucagon secretion, promotes satiety (prevents postprandial hyperglycemia) ADE: nausea, headache, hypoglycemia (due to concomitant insulin administration); caution if gastroparesis

Answer 5

Class: Biguanide • Indication – Type 2 DM (First-line therapy in T2DM). • Mechanism – increases sensitivity of insulin receptors AND decreases liver gluconeogenesis (weight-neutral, very low risk of hypoglycemia) Adverse effects – A/N/V/D (esp. first 2-3 weeks), lactic acidosis; avoid in significant hepatic or renal dysfunction, alcoholism; long-term use associated with B contribute to neuropathy. Interactions: alcohol (increases risk of lactic acidosis), caution with sulfonylureas, other DM medications (may enhance hypoglycemia risk)

Answer 6

Contraindicated in patients with an eGFR < 30. Test eGFR before initiating treatment with metformin. – Supplement with B12 if testing indicates deficiency

Answer 7

``` If eGFR < 60 or if the patient has a history of liver disease, alcoholism, or heart failure, metformin should be discontinued immediately prior to and for 48 hours after any radiologic procedure involving IV iodinated contrast material. ```

Answer 8

Class: Sulfonylurea • Indication – Type 2 DM • Mechanism – stimulates insulin release by blocking ATP-sensitive potassium channels → Ca++ influx → insulin release. Secretagogue. Take 30 mins. prior to first meal of the day and another meal if taking BID. Important to teach about taking with meals! ADE: hypoglycemia, weight gain – hepatotoxicity, rash; avoid in late pregnancy (1 month prior to delivery); Interactions: alcohol (potentiates hypoglycemic effects), β-blockers (may mask hypoglycemia Sx, can also suppress insulin release); DPP-4 inhibitors

Answer 9

This mechanism of insulin release by blocking ATP-sensitive potassium channels works the same as if endogenous glucose had stimulated insulin release. However, oral secretagogues do not require the presence of glucose to work. This is the main reason they can cause hypoglycemia.

Answer 10

Class: Meglitinide (also known as glinides) • Indication – Type 2 DM • Mechanism – same as sulfonylureas. Secretagogue TAKE WITH FOOD! Adverse effects – hypoglycemia, weight gain (fat lady by tree) Interactions: Gemfibrozil can inhibit metabolism of repaglinide → inc. risk of hypoglycemia; alcohol, β-blockers.

Answer 11

Stimulate insulin release regardless of food intake. → Risk of hypoglycemia. • Take them with (or right before) meals. • If N/V/A, skip the secretagogue until able to eat again!

Answer 12

• Class: α-Glucosidase inhibitor • Indication – Type 2 DM • Mechanism – inhibit α-Glucosidase enzyme at GI brush border → slowed absorption & digestion of carbohydrates. TAKE BEFORE EATING • Adverse effects – abdominal distension, cramps, flatulence, and diarrhea; hepatic dysfunction with long-term use, (monitor LFTs), decreased iron absorption → anemia; caution if bowel obstruction • Interactions – metformin (additive GI side effects), oral iron

Answer 13

• Class: Thiazolidinedione (TZD) • Indication – Type 2 DM • Mechanism – PPAR (peroxisome proliferator-activated receptor) gamma agonist; increases tissue insulin sensitivity, decreases hepatic glucose production • Adverse effects – fluid retention, edema, HF, anemia, ↑ LDL-C but ↑ HDL-C and ↓TGs, risk for bladder cancer, fractures in women; hepatotoxicity • Interactions: combination with insulin increases risk for hypoglycemia; CYP2C8 inhibitors (atorvastatin, ketoconazole) and CYP2C8 inducers (rifampin, cimetadine)

Answer 14

• Class: DPP-4 Inhibitor • Indication – Type 2 DM – third-line drug, usually used in combo with other anti-diabetic medications • Mechanism – inhibits DPP-4 enzyme and prevents inactivation of incretins. Interaction: Sulfonylureas Adverse effects: low risk of hypoglycemia when used alone. Increased risk of hypoglycemia when combined with sulfonylurea. Headache, edema, acute renal failure, upper respiratory infection, rare risk of pancreatitis, serious hypersensitivity reactions, Stevens-Johnson Syndrome. Reduce dose in renal disease.

Answer 15

Incretin hormones found in the gut (such as GLP-1) normally increase insulin synthesis and release and also inhibit glucagon. DPP-4 enzyme normally inactivates incretins. Sitagliptin inhibits DPP-4,thus increasing and prolonging action of incretins → ↑insulin and ↓ post-prandial glucagon.

Answer 16

Risk of hypoglycemia when used alone is low because sitagliptin extends the action of incretins, which require the presence of glucose to increase insulin secretion, as we will see shortly.

Answer 17

Class: SGLT2 inhibitor • Indication – Type 2 DM • Mechanism: Sodium-glucose co-transporter-2 (SGLT2) inhibitor in the kidney. Newest type of oral diabetes medication, first approved in 2013. Prevents reuptake of most filtered glucose by the kidney → glucose is diuresed and not returned to circulation. • Dose: 100 – 300 mg daily if eGFR > 60, 100 g daily of eGFR between 45-60; do not give to patients with eGFR < 45 Adverse effects: increased urination (osmotic diuresis), hypotension (potential for volume depletion), hypoglycemia (when used with insulin or secretagogues), hyperkalemia, decreased renal function (increased creatinine and decreased eGFR), acute kidney injury, urinary tract infection, genital yeast infections, bone fractures (as early as 12 weeks after initiating the drug) and atypical ketoacidosis. Interactions: Drug interactions: rifampin, phenytoin, phenobarbital, ritonavir (all decrease effectiveness of canagliflozin), digoxin (serum concentration of digoxin will be increased). – BBW: In 2017, FDA required BBW regarding increased risk of leg and foot amputation with this mediction.

Answer 18

Class: Incretin mimetic/GLP-1 receptor agonist • Indication – Type 2 DM • Mechanism: incretin-mimetic, analog of GLP-1 hormone, activates pancreatic receptors for GLP-1, increases glucose-dependent insulin secretion AND decreases post-prandial glucagon, slows gastric emptying, suppresses appetite • Administer: injectable only - prefilled pen formulation • Adverse effects: N/V/D, pancreatitis, nephrotoxicity, bile duct and gallbladder disease, hypoglycemia when combined with some oral DM medications, renal impairment, avoid in pregnancy (animal studies show fetal harm) Interaction: Can slow absorption of oral drugs, give oral drugs 1 hour before exenatide.

Answer 19

All incretin mimetics/GLP-1 analogs come with a BBW about thyroid C-cell tumors, including medullary thyroid carcinoma, due to increased incidence of these tumors in animal studies.

Diabetes Flashcards

(43 cards)