Diabetes Flashcards
(149 cards)
1
Q
what is the A1c?
A
% of hemoglobin molecule glycosylated with glucose
2
Q
how often is the A1c ordered?
A
ordered at least 2x/year (if pt very well controlled)
-more commonly every 3 months
3
Q
what info does the A1c provide?
A
“long term” marker of glycemic control
4
Q
what do you use to help to explain A1c (%) to patients?
A
eAG - estimated average glucose
5
Q
rule of A1c?
A
A1c of 7% = eAG of 150
-every 1% increase of A1c add 30 to the 150
6
Q
what is normal blood sugar if fasting?
A
120
7
Q
what is normal blood sugar post-prandial?
A
140
8
Q
the higher the A1c means what?
A
the more contribution of fasting glucose
9
Q
the lower the A1c means what?
A
the more contribution of postprandial glucose
10
Q
what factors falsely decrease A1c?
A
any condition that shortens the life cycle of the RBC
- blood loss w/in 3 months - e.g., donated blood, had trauma
- hemolytic anemia
11
Q
what factors falsely increase A1c?
A
- iron deficiency anemia (that’s not treated)
- blood transfusion w/in 3 months
12
Q
what is the ADA recommendation for glycemic targets in adults for A1c?
A
< 7%
13
Q
what is the ADA recommendation for glycemic targets in adults for pre-prandial/fasting plasma glucose (FPG)?
A
80-130 mg/dL
14
Q
what is the ADA recommendation for glycemic targets in adults for 1-2 hr. post-prandial glucose (PPG)?
A
< 180 mg/dL
15
Q
what are the ADA recommendations for glycemic targets in adults older than 65 that are healthy?
(A1c, fasting/pre-prandial glucose, bedtime glucose)
A
A1c- < 7.5% (7-7.5%)
FPG- 90-130 mg/dL
Bedtime glucose- 90-150
16
Q
what are the ADA recommendations for glycemic targets in adults older than 65 that have complex/intermediate health?
(A1c, fasting/pre-prandial glucose, bedtime glucose)
A
A1c- < 8% (7.5-8%)
FPG- 90-150
Bedtime glucose- 100-180
17
Q
what are the ADA recommendations for glycemic targets in adults older than 65 that have very complex/poor health?
(A1c, fasting/pre-prandial glucose, bedtime glucose)
A
A1c- < 8.5% (8-9%)
FPG- 100-180
Bedtime glucose- 110-200
18
Q
what are the ADA recommendations for glycemic targets in children & adolescents < 18?
(A1c, pre-prandial/fasting plasma glucose, bedtime glucose)
A
A1c- <7.5%
FPG- 90-130 mg/dL
Bedtime- 90-150 mg/dL
19
Q
why are glycemic goals relaxed for children and adolescents <18?
A
glycemic goals are relaxed for children and adolescent to prevent cognitive impairment/worsening of brain development
-hypoglycemia can interfere with brain development and cognitive development
20
Q
what is the ADA recommendation for glycemic targets in pregnancy?
(A1c, FPG, 1hr post-prandial glucose, 2hr post-prandial glucose)
A
A1c- ≤ 6-6.5%
FPG- ≤ 95 mg/dL
1hr post-prandial glucose- ≤140 mg/dL
2hr post-prandial glucose- ≤120mg/dL
21
Q
what may gestational diabetes present with more?
A
postprandial hyperglycemia due to carbohydrate intolerance
22
Q
what is postprandial monitoring associated with when pregnant?
A
less preeclampsia
23
Q
who does hyperglycemia effect when pregnant?
A
mom and baby
24
Q
what is the FIRST LINE txt for someone with diabetes?
A
Metformin
25
why would a pt with diabetes not be on metformin?
if C/I due to can't stand GI effects or they have bad kidney function
26
what is the regimen for someone that didn't achieve goals in 3 months with just metformin?
dual therapy (metformin PLUS another medication)
27
what is the regimen for someone that didn't achieve goals in another 3 months with dual therapy?
triple therapy (metformin PLUS 2 more medications)
28
what is the regimen for someone that didn't achieve goals in another 3 months with triple therapy?
combination injectable therapy
29
pharmacotherapy selection considerations (2 types of factors)
patient factors and medication factors
30
pharmacotherapy selection considerations (patient factors)
- preference (e.g., do they want pill, injection, etc)
- co-morbid conditions
- insurance coverage
- duration of diabetes
- current weight
- hypoglycemia risk
- age
- aptitude for self-care
31
why is the duration of diabetes a factor when selecting pharmacotherapy?
medications that are reliant on beta cell function for use may not be applicable for someone that has had diabetes for years
32
pharmacotherapy selection (medication factors)
- safety (side effects)
- efficacy (A1c lowering effects/durability)
- targeted blood glucose effects
- ease of use/administration
- cost/generic availability
- dosage form availability
33
what do diabetics have an increased risk of in terms of infection?
have increased risk of developing infection and hard time clearing the infection
34
what is the number one cause of death in diabetic patients?
CVD: heart attacks and strokes
35
what is the blood pressure goal for someone with diabetes with comorbid HTN?
≤ 140/90
36
what are the recommendations for CVD risk management?
- BP ≤ 140/90 with co-morbid HTN
- low-dose aspirin therapy for those with increased CV risk
- statin therapy for those with ASCVD and those >40 years with increased CV risk (smokers, older, obese)
37
when do you screen for diabetic nephropathy?
yearly
| ACEi or ARB for those with urinary albumin excretion
38
how often do you screen for retinopathy?
year or every 2 years
39
how often do you screen for neuropathy?
yearly
40
what 2 types of insulin does pancreas secrete?
basal and bolus
41
what is basal insulin?
constant, low level release of insulin
| -role is to maintain glucose homeostasis in the fasting state
42
what is bolus insulin?
meal stimulated insulin
| -role is to cover meal stimulated bursts of glucose
43
what is A1c lowering ability?
approx. 1.5-3.5%
44
who needs insulin?
- type 1 diabetes
- gestational diabetes
- hyperglycemic crisis (DKA)
- type 2 diabetes
45
type 2 diabetes criteria that requires insulin?
- A1c ≥ 9%
- Glucose ≥ 300 mg/dL
- Marked hyperglycemia (classic six's)
- A1c above goal despite 3, non-insulin anti diabetic agents
46
what insulin can be used as a second line agent, after metformin?
basal insulin
47
what percent of beta cell function has been lost at time of diagnosis?
about 50% and decreases as the disease progresses
48
what route do you take afrezza insulin?
inhalation (pulmonary administration)
| -good for people that don't like injections
49
what type of insulin is afrezza?
dry powder of human (recombinant DNA) insulin
50
what is the onset, peak, and duration of afrezza?
onset- 12-15 min
peak- 30 min
duration- 3 hrs
51
what are the ads for afrezza?
| remember it is inhaled
- cough
- throat/mouth irritation
- hypoglycemia
- acute bronchospasm (pts w/restricted airway diseases)
- hypersensitivity rxns
52
what routine test is required when someone takes afrezza?
routine pulmonary fxn tests (PFTs) @ baseline, 6 months and annually
53
agrezza insulin is C/I in who?
- if pt has COPD and/or asthma
| - causes increased bronchoconstriction in asthma
54
what patients can you NOT use afrezza in?
smokers due to it having less efficacy in them
55
what dosages is inhaled insulin available in?
4 unit- blue
8 unit- green
12 unit- yellow
56
why do you need multiple cartridges for doses > 12 units of inhaled insulin?
b/c inhaled insulin only comes in 4, 8, and 12 units
| -if pt needs 17 units then need more cartridges
57
what is the dosage for a insulin naive patient taking inhaled insulin?
inhale 4 units with each meal
titrate every 7 days by 4 units per meal until PPG within goal range
58
what is the conversion for injected mealtime insulin dose of up to 4 units to afrezza dose?
4 units (1 blue)
59
what is the conversion for injected mealtime insulin dose of 5-8 units to afrezza dose?
8 units (1 green)
60
what is the conversion for injected mealtime insulin dose of 9-12 units to afrezza dose?
12 units (1 yellow)
61
what is the conversion for injected mealtime insulin dose of 13-16 units to afrezza dose?
16 units (2 green)
62
what is the conversion for injected mealtime insulin dose of 17-20 units to afrezza dose?
20 units (1 yellow, 1 green)
63
what is the conversion for injected mealtime insulin dose of 22-24 units to afrezza dose?
24 units (2 yellow)
64
what is the onset (hrs) and duration (hrs) of insulin glargine U-300 (Toujeo)?
Onset- 6 hrs
Duration- 36 hrs
65
what is the onset (hrs) and duration (hrs) of insulin degludec U-100/U-200 (Tresiba)?
Onset- 0.5-1.5 hrs
Duration- 42 hrs
66
what is the onset (hrs) and duration (hrs) of insulin glargine U-100 (Basaglar)?
Onset- 1-2 hrs
Duration- 10-24 hrs
67
what are the ultra long-acting insulin analogs?
insulin glargine U-300 (Toujeo) and insulin degludec U-100/U-200 (Tresiba)
68
what are some differences between insulin glargine U-300 and insulin glargine U-100?
- U-300 provides the same number of units as U-100 at a third of the volume
- U-300 is released more slowly from the SQ tissue to prolong its duration of action (~36 hrs)
- U-300 has more predictable absorption -> less inter patient variability
**less severe and nocturnal hypoglycemia with U-300
69
do insulin glargine U-300 and U-100 have comparable efficacy?
yes & also similar risk of weight gain
70
difference in hypoglycemia with U-300 and U-100?
U-300 has less severe and nocturnal hypoglycemia than U-100
71
what is the dosing of insulin glargine U-300 for an insulin-naive person that has type 1 diabetes?
0. 2 to 0.4 units/kg for total daily insulin dose
- recommended starting dose of U-300 glargine is 30-50% of the total daily dose & bolus insulin should satisfy the remainder
72
what is the dosing of insulin glargine U-300 for an insulin-naive person that has type 2 diabetes?
0.2 units/kg for initial dose
73
what is the dosing of insulin glargine U-300 for pt whose prior txt of insulin was once daily basal insulin in:
T1DM?
T2DM?
T1DM- 1:1 conversion given once daily
T2DM- 1:1 conversion given once daily
74
what is the dosing of glargine U-300 for a patient who's prior txt of insulin was twice daily NPH in:
T1DM?
T2DM?
T1DM- 80% of total NPH dose
T2DM- 80% of total NPH dose
75
what are some differences b/w insulin degludec and insulin glargine U-100?
- comparable efficacy to insulin glargine U-100
* -degludec has less nocturnal hypoglycemia
- degludec has flexible dosing (8-40 hrs)
**(Good for non-compliant pts or pts with weird schedules)
76
what is the starting dose of insulin degludec for:
- insulin naive?
- pt converting from another basal insulin?
insulin naive- 10 units daily
pt converting from another basal insulin- 1:1 conversion given once daily
77
what time of day do you administer insulin degludec?
any time of the day with 8 hours b/w doses
78
when is stead state achieved for insulin degludec?
steady state is achieved after 2-3 days
79
what is the recommended dose increase for insulin degludec?
no more frequent than every 3-4 days
80
who needs ultra long acting insulin?
- anyone that requires basal insulin
- pts at high risk of hypoglycemia
- pts experiencing hypoglycemia on NPH
- pts on 2x daily insulin glargine U-100 and deter
- pts who need flexible dosing schedules
- pts requiring high doses (> 80 units/day)
- pts who are not getting 24 hrs of coverage
- obese/insulin resistant pts
81
what type of insulin is insulin glargine U-100 (Basaglar)?
follow-on biologic
82
is insulin glargine U-100 (Basaglar) bioequivalent to insulin glargine U-100 (Lantus)?
NO!
-but it does have similar pk, safety, efficacy, comparable A1c lowering ability, and potential for weight gain
83
who is insulin lispro U-200 (Humalog kwikpen U-200) good for?
patients who require large mealtime doses
BUT most likely created because they wanted to keep their market share because its bioequivalent to U-100 Lispro
84
what are some differences b/w insulin lispro U-200 and insulin lispro U-100?
U-200 contains more insulin per pen
U-200 delivers half the volume vs U-100
-consider for those with high mealtime doses
85
do insulin lispro U-200 and insulin U-100 deliver the same dose?
YES!
| 1:1 conversion
86
what is the onset, peak, duration of Humulin R U-500?
Onset- 30 min
Peak- 1-3 hrs
Duration- 8-24 hrs
87
when should you consider prescribing Humulin R U-500?
patients on >200 units of insulin per day
| becomes their only insulin if switch them to U-500 insulin
88
what type of insulin is Humulin R U-500?
regular insulin, but behaves like NPH
- not a basal insulin
- dosed 2-3x/day
89
what is the concentration of Humulin R U-500?
high concentration delivered in a smaller volume
| SUPER CONCENTRATED
90
what forms is Humulin R U-500 available as?
vials (20ml) and pens
91
what is the conversion of insulin U-100 to U-500 insulin if its A1c >8%?
start 100% of the U-100 TDD (3x daily)
92
what is the conversion of insulin U-100 to U-500 insulin if its A1c < 8% or mean glucose <183 mg/dL for past 7 days?
start 80% of the U-100 TDD
93
what is the conversion of insulin U-100 to U-500 insulin you want to prescribe BID?
If BID, give 60% with breakfast & 40% with dinner
94
what is the conversion of insulin U-100 to U-500 insulin you want to prescribe TID?
If TID, give 40% with breakfast & 30% with lunch & 30% with dinner
95
what are some barriers to initiating insulin therapy?
- feelings of failure
- expensive
- compliance
- injection phobia
- concern for weight gain & hypoglycemia
- clinician thinks it's last resort
- limited training on use
96
what are advantages of early use of insulin?
- reduce glucose toxicity
- facilitates beta-cell "rest"; preserving fun
- prevent or minimize diabetes related complications
- may protect against endothelial damage
- overcome patient and clinician
97
what are disadvantages of early use of insulin?
- Most studies that show benefit use Multiple daily Injections or Extensive therapy
- complex instructions
- expensive
- more healthcare utilization
98
when should treatment intensify in a patient?
treatment intensification should occur every 3 months if not meeting goals
99
how do you overcome education as a patient barrier to insulin?
- discuss role of insulin at time of dx
- review progressive nature of the disease (have beta cell decline)
- ask about concerns (dispel misconceptions/myths)
100
how do you overcome injection phobia as a patient barrier to insulin?
- prescribe thinnest, shortest needles
- injection tolls (i.e. auto shield, injectese)
- try pens (vs. syringe)
101
how do you overcome hypoglycemia risk as a patient barrier to insulin?
-use rapid acting and long acting basal analogues
102
what type of insulin coverage does type 1 diabetes require?
both basal and bolus (b/c beta cells are destroyed and exogenous insulin is needed for survival)
103
what is the typical starting dose if pt is metabolically stable and type 1 dm?
- 0.5 units/kg/day
- 1/2 to 2/3rds = basal requirement
- 1/3 to 1/2 = bolus requirement (divided among meals)
104
what types of regimen are preferred when initiating insulin for T1DM? (physiologic or non-physiologic regimens?)
physiologic regimens
105
Explain the initiation of basal insulin in Type 2 diabetes
Start:
- 10 units/day OR 0.1-0.2 units/kg/day
Adjust:
- 10-15% OR 2-4 units 1-2 x/wk to reach FPG goal
For Hypo:
- determine and address cause; if no clear cause, decrease dose by 4 units or 10-20%
106
Explain how to add 1 Rapid acting insulin injection before the largest meal in T2
Start:
- 4 units, 0.1 unit/kg OR 10% of basal dose
Adjust:
- 10-15% or 1-2 units 1-2x/week until target reached
107
Explain how to change to premixed insulin twice daily (before breakfast and dinner) in T2
Start:
- Divide current basal dose into 2/3 am, 1/3 pm OR 1/2 am, 1/2 pm
Adjust:
- 10-15% or 1/2 units 1-2 times per week until target reached
108
what do you adjust if there is FPG dysfunction?
adjust basal insulin
109
what do you adjust if there is pre or post-prandial dysfunction?
adjust bolus insulin
110
what do you if pt has hyperglycemia all day?
"fix the fasting first"
| -then target post-prandial glucose
111
what is Humulin R?
short acting (regular) insulin
112
what is Humulin R U-500?
regular insulin but behaves like NPH
113
what is Novolin R?
short acting (regular) insulin
114
what is Lispro (Humalog) insulin?
rapid acting insulin
115
what is aspart (Novolog) insulin?
rapid acting insulin
116
what is glulisine (apidra) insulin?
rapid acting insulin
117
what is Humulin N (NPH) insulin?
intermediate acting insulin
118
what is Novolin N (NPH) insulin?
intermediate acting insulin
119
what is Glargine 100-U (Lantus) insulin?
long acting insulin
120
what is Glargine 300-U (Toujeo) insulin?
ultra-long acting insulin
121
what is glargine U-100 (Basaglar) insulin?
follow on biologic
| very equivalent to Lantus
122
what is Detemir (Levemir) insulin?
long acting insulin
123
what is Degludec (Tresiba) insulin?
ultra long acting insulin
124
if have dysfunctional glucose post-breakfast or before lunch, what insulin do you adjust?
pre-breakfast rapid or short acting insulin
125
if have dysfunctional glucose post-lunch or pre-dinner, what insulin do you adjust?
pre-lunch rapid or short acting insulin
126
if have dysfunctional glucose post-dinner or at bedtime, what insulin do you adjust?
pre-dinner rapid or short acting insulin
127
if have dysfunctional glucose in the early morning, what insulin do you adjust?
basal insulin or PM dose of NPH
128
insulin adjustments for NPH -> detemir?
1:1 conversion given once daily
129
insulin adjustments for NPH -> glargine U-100, U-300, insulin degludec?
Once daily NPH: 1:1 conversion given once daily
Twice daily NPH: 80% of TDD given once daily
130
insulin adjustments for insulin glargine -> insulin detemir or insulin detemir -> insulin glargine?
1:1 conversion
131
insulin adjustments for insulin glargine U-100 OR insulin detemir -> insulin glargine U-300 OR insulin degludec U-100/200?
1:1 conversion given once daily
132
insulin adjustments for insulin glargine U-100 OR detemir -> NPH?
1: 1 conversion
- give NPH 2x/day
- can consider 20% dose reduction to be conservative
133
insulin adjustments for rapid -> short acting or short acting -> rapid?
1:1 conversion; watch for meal timing
134
in the bolus category, what has the highest risk of hypoglycemia?
short-acting
135
in the basal category, what has the highest risk of hypoglycemia?
NPH
136
signs and symptoms of hypoglycemia?
- shaking
- hunger
- rapid heart beat
- sweating
- impaired vision
- anxious
- irritable
- weakness
- dizziness
(sympathetic activation)
137
what serum glucose constitutes hypoglycemia?
< 70 mg/dL
138
what serum glucose constitutes severe hypoglycemia?
< 50 mg/dL
139
when patient is hypoglycemic (glucose < 70) what is the txt?
ingestion of quick acting glucose; not complex carbs!
apply 15:15 rule
- check glucose
- consume 15g of carb (4oz or 1/2 cup of fruit juice, 1 tbsp sugar, 3-4 glucose tabs)
- recheck glucose 15 min later
- repeat until glucose normalizes
140
what does severe hypoglycemia require?
severe hypoglycemia requires assistance from another person
-can't be treat with oral carbs d/t state of unconsciousness
*USE GLUCAGON KIT! -> emergency!!!*
141
side effects of insulin injection?
lipohypertrophy
- accumulation of subcutaneous fat deposits
- can reduce the absorption of insulin
- may or may not be painful, but are hard bu
- due to repeated injections at same site OR reuse of needles (or length/thickness of needle)
142
how to reduce lipohyperatrophy from occurring?
rotate injection sites and use new needles with each injection!
143
what abbreviation should you avoid when prescribing insulin?
"U"
e.g.,:
Lantus inject 10 U SC daily -> INCORRECT
Lantus inject 10 units SC daily -> CORRECT
144
when prescribing insulin, how must you prescribe it?
requires separate prescriptions for the vial and syringes (or pen and needles)
145
what should you consider when prescribing insulin needles?
consider volume capacity (syringe), needle length and needle (gauge)
- length: expressed in inches or mm
- thickness: the higher the gauge, the thinner the needle
146
1mL (cc) syringe holds?
- each line represents?
- given to what patients?
1mL syringe holds up to 100 units of insulin
-each line represents 2 units
-given if patient on 50-100 units of insulin
147
0. 5mL (cc) syringe holds?
- each line represents?
- give to what patients?
0. 5mL syringe holds up to 50 units of insulin
- each line represents 2 units
-given if patient on 50 units or less of insulin
148
3/10mL (cc) syringe holds?
- each line represents?
- give to what patients?
3/10 mL holds up to 30 units of insulin
-each line represents 1 unit
-given if patient on < 30 units of insulin (unless expecting to titrate rapidly)
149
if patient is uses .5mL or 1mL syringe, what should you make the dose?
make the dose an even number b/c the increments are by 2 on these syringes
