Diabetes Lecture Flashcards
(161 cards)
1
Q
A syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or a combination of insulin resistance and inadequate insulin secretion to compensate
A
Diabetes Mellitus
2
Q
Normally, what is the rate of insulin production
A
1 unit/hour
3
Q
25 million diabetics in US
>90% are type ___
A
2
4
Q
2x more common:
African Americans
Hispanics
Native Americans
*genetic predisposition complex but applicable to Type 1 and type 2
A
Diabetes
5
Q
Polygenetic
at least 30 types of genes associated
A
Type 2 diabetes
6
Q
Is significant morbidity and mortality associated with both types of diabetes?
A
YES
7
Q
Primarily auto-immune mediated with presence of islet cell antibodies
*destruction of beta cells in pancreas**
A
Type 1
8
Q
Catabolic disorder: absence of insulin in response to glucose leads to :
*hyper glycemia
*fat and protein breakdown
A
Type 1
9
Q
Increase in blood sugar
Glycosuria
Loss of glucose as energy source
…due to?
A
Hyperglycemia (bc of absence of insulin)
10
Q
Infectious or toxic insult in genetically predisposed individuals;
autoimmune response against altered pancreatic beta cell antigens
A
Type 1 diabetes
11
Q
What is common in an untreated state of type 1 diabetes?
A
Ketosis
(raised levels of ketone bodies)
12
Q
Inappropriate fat and protein breakdown (due to absence of insulin in response to glucose) can cause..
A
Ketoacidosis
13
Q
Mumps
Coxsackie
B-4
Rubella
..these viruses can cause?
A
Type 1 Diabetes (thru damage of pancreas)
14
Q
Tx of type 1 diabetes
A
Exogenous insulin
15
Q
Generally in adults, but increasing rates in kids
circulating insulin prevents ketosis, not hyperglycemia
***TISSUE INSENSITIVTY TO CIRCULATING INSULIN… insulin resistance!
A
Type 2 diabetes
16
Q
Centrally located/ abdominal fat
Omental fat
Fat in liver
increases risk of…
A
Type 2 diabetes
17
Q
Combination of insulin resistance and defect of beta cells to secrete adequate insulin in response to glucose
*aggrevated by hyperglycemia
A
Type 2 diabetes
18
Q
Decreased insulin production (destruction of beta cells) occurs over time!
A
Type 2
19
Q
Strong genetic predisposition!
sedentary lifestyle
A
Type 2
20
Q
Which percentage of type 2 diabetics are obese?
A
70%
21
Q
Central/visceral obesity..MAJOR FACTOR IN INSULIN RESISTANCE
A
Type 2
22
Q
early on…increased insulin production compensates and blood sugar is controlled
(compensation= beta cell hyperplasia)
A
Pre diabetic state
23
Q
In early type 2…glucose levels will rise despite increased levels of…
A
insulin
(insulin resistance develops)
24
Q
What happens to insulin levels as the disease progresses?
A
Decrease/declie
25
Obsesity
Central fat distribution
Storage of fat in muscles
Inactivity
..all contribute to?
Insensitivity to insulin
26
Hepatic insensitivity results in **increased gluconeogenesis** in spite of presence of....
Insulin
27
Aggressive control of hyperglycemia is essential to preserve..
Remaining Beta cell function
28
What do beta cells produce?
Insulin
29
What do alpha cells produce?
Glucagon
30
What makes up the Islets of Langerhans?
Alpha and Beta cells
31
Major stimulus of ______ secretion is glucose absorbed from food
Insulin
32
Leads to rapid uptake, storage and use of glucose by all tissues (**esp liver, muscle, fat**)
Insulin
33
Following a high carb meal, _______ is stored in the liver
Glycogen
**liver stored = ~100 grams of glycogen**
34
Insulin levels drop
glycogen broken down (glycogenolysis)
glucose released into blood
...when does this happen?
In between meals/ during fasting
35
What happens when glycogen stores in the liver are full?
Insulin converts exces glucose to fatty acids --\> triglycerides --\> adipose tissue for storage
36
Insulin **inhibits** _________ in liver
Gluconeogenesis
37
\_\_\_\_\_ "spares" fat. inhibits glucose breakdown
Insulin
38
small amounts of insulin are needed for normal metabolism of...
free fatty acids (fat as energy source), when glycogen stores are depleted
39
In a resting state, **muscle energy** is supplied by....
Fatty acids
40
Glucose taken up by muscle
**\*requires little if any insulin, cells are directly permeable to glucose**
During **moderate to heavy exercise**
41
Insulin secretion is HIGH as glucose levels rise
\*glucose transported into muscle for storage as **glycogen** that can later be used for energy during exercise
After meals!
42
Following a meal, **insulin promotes** _________ synthesis and storage!
PROTEIN
43
Insulin promotes protein synthesis by stimulating transport of _______ into cells
Amino Acids
44
Insulin does what to the **break down (catabolism) of protein?**
Decreases!
45
Insulin does what to **gluconeogenesis in liver**?
Decreases!
(**suppression of gluconeogenesis conserves proteins!**)
46
Insulins suppression of gluconeogenesis conserves...
Proteins!
47
If no insulin, what happens to protein storage?
Protein storage stops
## Footnote
**muscle broken down! (catabolism)**
48
Which cells in the body are permeable to glucose **without insulin**
\*bc dependent on glucose for energy!
Brain cells
49
Brain cells are easily injured with hypoglycemia
S/S of this....
Hypoglycemic shock
fainting, seizures, coma, death
50
When carbs are present and glucose levels are high
..what is used for energy? does this require insulin?
Carbs used for energy
**requires insulin!**
51
When glucose and insulin levels are low
..what is used for energy?
Fat (lipids) broken down for energy bc no insulin required
52
Absence of insulin (**DM type 1**) leads to excessive fat breakdown and abnormal....
free fatty acid metabolism
53
Secreted by alpha cells
**increase glucose levels when needed
breaks down glycogen
increases gluconeogenesis**
\*\*works rapidly (minutes!) to increase glucose levels
Glucagon
54
Glucagon required ______ stores for major efect
Glycogen
55
What does chronic hyperglycemia do to peripheral insulin resistance?
**chronic hyperglycemia worsens peripheral insulin resistance**
..and eventually destroys beta cells permanently
56
Exercise **increases blood flow to muscles**:
\*\*increases muscle mass
\*\*decreases muscle fat storage
result in a diabetic= ?
Improved glucose utilization and **decreases insulin resistance!**
57
Diet/weight loss results in **decreased storage fat deposits**
...what is the result in a diabetic?
**decreased insulin resistance**
58
These lifestyle changes result in:
Decreased hyperinsulinism
Decreased hyperglycemia
**potential reversal of impaired glucose tolerance if initiated early**
Exercise, diet, weight loss
59
AKA insulin resistance syndrome
**increase pts risk of atherosclerosis (3x) when present**
\*present in about 20% of adults
\*often associated with Type 2 DM
Metabolic Syndrome
60
Metabolic syndrome increases a pt's risk of developing what?
3x more likely to develop **atherosclerosis**
61
* *1. Central obesity**
women: waist circumference \> 88 cm
men: waist circumference \>102 cm
**2. Hyperglycemia** Fasting BS \> 110 mg/dL
**3. HTN** BP \> 135/85
**4. Increased triglycerides** \>150 mg/dL
* *5. Decreased HDL**
women: \<50 mg/dL
men: \<40 d/L
3 out of 5 of these = **METABOLIC SYNDROME**
62
Polyuria, thirst
Wt loss, weakness
Dehydration
Polyphagia
Ketoacidosis
Hyperosmolality
Complications
Type 1 or Type 2?
Type 1
63
Often asymptomatic early
Polyuria, thirst
Skin infections
Vulvovaginitis
Abn fat distribution
Hyperglycemia
Complications
Type 1 or Type 2?
Type 2
64
Reflects long term control of DM
glucose + Hb
Glycated Hb (Hb**A1C**)
65
A1C reflects state of glycemia over prior.....
8-12 weeks
66
Normal A1C range
4-6%
67
Dx of diabetes if A1C is over...
6.5%
68
An A1C of 5.7-6.4%
Prediabetes
69
Goal A1C if diabetic
Under 7%
70
Must measure A1C in diabetics every...
3-4 months
71
Impaired glucose tolerance, AKA
Prediabetes
72
Fasting blood sugar \> 126 mg/dL
2 hr GTT BS \> 200 mg/dL
Random BS \> 200 mg/dL
HbA1c \> 6.5%
Labs in **diabetics**
73
FBS: 100-125 mg/dL
2 hr GTT BS: 140-199 mg/dL
HbA1c: 5.7-6.4%
labs in **prediabetes (impaired glucose tolerance)**
74
What will triglycerides and HDL levels look like in obese type 2 diabetics?
High triglycerides
Low HDL
75
Low HDL levels in type 2 diabetics correlates with...
**Macro**vascular disease
76
Diabetics age 40-75 with **LDL** **70-189 without ASCVD**
Use statins
77
Diabetics with a 10 year ASCVD risk \> 7.5%
..what strength of statin therapy?
High intensity statin
78
Diabetics with a 10 year ASCVD risk \< 7.5%
what intensity statin therapy?
Moderate intensity statin therapy
79
**Total calories: 25-35 KCAL (less if obese)**
**Total cholesterol:** \<300
**Protein**: 10-35% of calories
**Fat:** 25-35% of calories
**Sat fat:** \<7% total calories
**Carbs:** 45-65% total calories
(if type 2, decreased carb calories and replace with monosaturated fats/oils)
**Fiber:** 20-35 grams
Diabetic diet
80
How many alcoholic drinks should a diabetic limit self to?
less than 2 a day
81
Retinopathy
Nephropathy
Neuropathy
**Microvascular** diabetic complications
82
CHD
CVD
Stroke
PAD
**Macrovascular** diabetic complications
83
Type 1 diabetics who keep A1C below 7%
decrease microvascular complications by....
50-70%
84
Type 2 diabetics who keep A1C below 7%
decrease microvascular complications by...
25%
85
Intensive BP control (under 150/80) further decreases...
BOTH microvascular and macrovascular complications
86
* *Pre prandial:** 90-130
* *Bedtime:** 100-140
* *Peak post prandial (1 hr)**: \<180
* *2 hr post prandial**: \<150
Blood glucose goals
87
Adult diabetics with \>10% risk for a cardiac event over 10 years
put on ASPIRIN
88
Diabetic men over 50, women over 60
with 1 or more major risk factor for CHD
Put on ASPIRIN!
89
All adult diabetics with macrovascular (CHD, PVD, CVD) disease
Put on ASPIRIN
90
Dose: 75-162 mg/daily
Risks: PUD, gastritis, bleeding
Aspirin use in diabetics
91
**Decreases hepatic glucose production**
\*decreases gluconeogenesis
\*decreases fasting and post prandial blood sugar
Metformin
92
Increases glucose uptake by skeletal muscle
Slows GI absorption of glucose
**benefit= does not cause hypoglycemia or weight gain!**
Metformin
93
Activates AMPK activity, which **decreases hepatic gluconeogenesis**
Metformin
94
Metformin decreases A1c by...
1-2%
95
Used in adjunct with diet control of hyperglycemia in Type 2
## Footnote
**first line drug therapy for DM Type 2, especially if obese**
Metformin
96
Does metformin improve hypertriglyceridemia?
YES
97
Creatinine \>1.5 (males) or 1.4 (females)
GFR under 30
Hepatic insufficiency
Alcoholism
Contraindications of metformin
98
How do you start a person on Metformin?
Must titrate slowly!
| (up to max dose of 2000-2500)
99
SE=
Anorexia, N/V/D
Lactic acidosis
Metformin
100
**MUST HOLD METFORMIN ON DAY OF TEST AND FOR 48 HOURS IF GETTING CONTRAST**
..to avoid?
Lactic acidosis
101
Bind to beta cell receptor...increase insulin release!
caution= cause hypoglycemia
**used in conjunction with Metformin**
Sulfonylureas
102
Contraindications: severe renal or hepatic impairment
Adverse effects: **hypoglycemia!**, weight gain, skin and GI issues
Sulfonylureas
103
Glipizide
Glyburide
Glimeperide
..what class of drugs?
Sulfonylureas
104
Sensitize peripheral tissues to insulin
| (decrease peripheral insulin resistance)
TZD drugs
105
Piogliti**zone**
Roziglita**zone**
..what class of drugs?
TZD drugs
106
Weight gain is common
NO HYPOGLYCEMIA
beneficial effect on lipids
**decreases A1c by 1-2%**
TZD drugs
107
What must you check before starting a patient on a TZD?
**LFTs!!**
108
Can you use **TZD** drugs in patients with existing HF or LV dysfunction?
NO..bc TZD drugs **cause fluid retention and edema**
109
Competitively inhibit alpha-glucosidase enzymes in the intestines, which digest starch and sucrose
**decrease carb absorption in gut
lowers post prandial glucose by 30-50%**
**lowers A1c by 0.5-1.0%**
Alpha glucosidase inhibitors
**Acarbose**
(used for mild DM or adjunct therapy)
110
Why do 60% of patients stop taking alpha glucosidase inhibitors (ie Acarbose)?
SE of flatulence and diarrhea (GI issues)
111
Oral Rx for Type 2 DM
**inhibits DPP-4, the enzyme that inactivates/degrades incretin hormones**
\*\*result in **insulin synthesis and release**
decreases A1c by 0.5-0.8%
often used in combo wth other drugs, ie Metformin
Sitagliptin (Januva)
112
Inhibits SGLT2, a protein in proximal renal tubule that reabsorbs glucose in kidneys
**increases glucose excretion!**
decreases A1c by ~1%
decreases weight by 5-10 lbs
Canaglifoxin (Invokana)
113
Often used along with insulin
Stabilizes insulin dose and helps offset weight gain
Canaglifloxin (Invokana)
114
What happens if you combine Canaglifloxin (Invokana) with a sulfonylurea?
HYPOGLYCEMIA
115
Adverse effects:
Male/female genital yeast infections
Volume depletion, hypotension
Impaired renal fxn (**cant use with GFR under 30**)
Can cause hypoglycemia if used with sulfonylurea
Canaglifloxin (Invokana)
116
Type 1: mainstay of therapy
Type 2: can be used in adjunct with oral agents or tx for later stages when there is beta cell failure
Insulin
117
Human insulin (Humulin) via recombinant DNA and synthetics decreases the amount of...
insulin allergies and antibodies
118
Lispro insulin (Humalog)
rapid, short, intermediate or long acting?
Rapid!
119
Regular (Humulin-R)
rapid, short, intermediate or long acting?
Short
120
Neutral Protamine (Humulin-N)
Rapid, short, intermediate, or long acting?
Intermediate
121
Insulin Glargine
Rapid, short, intermediate, or long acting?
Long acting
122
Which insulin provides 24 hr coverage with steady state insulin levels
**bedtime dosing!** once a day
Insulin Glargine
123
Onset: 5-15 mins
Peak= 1-1.5 hrs
Duration= 3-5 hours
Rapid acting!
## Footnote
**Lispro (Humalog)**
124
```
Onset= 30 mins to an hour
Peak= 2-4 hours
Duration= 5-8 hours
```
Short acting
## Footnote
**Regular (Humulin-R)**
125
```
Onset= 2-4 hours
Peak= 4-10 hours
Duration= 10-24 hours
```
Intermediate acting
## Footnote
**Neutral Protamine (Humulin-N)**
126
```
Onset= 2-4 hours
Peak= none
Duration= 20-24 hours
```
Long acting
## Footnote
**Insulin Glargine
(comes in 100u or 300u)**
127
Lispro/Asparte is very rapid acting! and is ideal for...
pre meal!
128
once a day dosing for basal requirements
**CANNOT MIX WITH OTHER INSULINS**
Insulin Glargine (long acting)
129
Insulin: Lispro or regular
Benefit: tight glycemic control
Drawbacks: costly, skin infections, DKA
Insulin pump
130
**Incretin mimetics: potentiate insulin secretion**
\*promotes insulin release
\*suppress post prandial glucagon
\*delay gastric emptying, promotes satiety
\*decreases fasting and post meal glucose
**DOES NOT PROMOTE WEIGHT GAIN**.
alternative to insulin if pt is obsese and you dont want them to gain more wt
GLP-1 receptor agonist
(these are expensive!)
**SE= nausea, hypogycemia**
131
Exenatide (Byetta)
Liraglutide (Victoza)
What drug class? Which is more potent?
GLP-1 receptor agonists
## Footnote
**Liraglutide (Victoza) is more potent than Exenatide (Byetta)**
132
**Pancreas transplant..**. done in conjunction with renal transplant
85% chance of graft survivial
**Islet cell transplant**... short term benefits for up to 2 years
Other ways to manage DM
133
Weight, BP, postural
A1c
Foot exam..with microfilament
Home monitoring
Psychosocial fxn
Intercurrent illness
..needs to be done how often?
3-6 months
134
Lipids
UA
Creatinine
Microalbinuria
Complete PE
Opthalmologist
Dental exam
..should be done how often?
Yearly
135
Wt reduction
Diet and exercise
Behavior modification
Decrease adipose stores and regain insulin sensitivity
Cornerstone tx for DM type 2
(first line Rx= Metformin)
136
Recent evidence shows best control of A1c under 7% for DM Type 2 occurs once what is added?
Insulin
137
Type 1 diabetics should self monitor BS how many times daily?
4-6 times
138
MC complication seen with insulin and sulfonylurea
Hypoglycemia
139
Sweating
Tachycardia
Hunger
Tremulousness
Nausea
Sxs of hypoglycemia
(note: these are masked by beta blockers, esp non selective beta blockers)
140
Hypoglycemic syptoms correlate to blood sugars below...
50 mg/dL
141
If a hypoglycemic pt is unconscious or unable to eat, what can you give them?
1 mg IM injection of **Glucagon**
142
15 grams of glucose will increase blood sugar by....
25-50 mg/dL
143
Microaneurysms
Hemorrhages
Exudates
Retinal edema
..which type of diabetic retinopathy?
Non proliferative
144
Formation of new blood vessels..**blindness!**
Seen in both Type 1 and Type 2
Type 1: cumulative over years
Type 2: may be developing at time of presentation
..which type of diabetic retinopathy?
Proliferative
145
Severity of diabetic retinopathy correlates with...
Duration of DM
Glycemic control
146
Tight glycemic control (with an A1c under \_\_\_%) is **essential to prevent retinopathy**
7%
147
Retinopathy with smoking and HTN
MUCH worse!
148
Common microvascular complication
30-40% of Type 1 will develop over 20 years
15-20% of Type 2
## Footnote
**develops as a result of chronic hyperglycemia
and contributed to by uncontrolled HTN**
Nephropathy
149
**Leading cause of end stage renal failure in US**
(accelerated in smokers)
Nephropathy
150
Losing 30-300 mg albumin/day in urine
how do you detect this?
Microalbuminuria
(urine dipstick lacks sensitivity to detect...**need radioimmunoassay**)
151
If a diabetic has microalbuminuria (even if BP is norm), WHAT MUST THEY BE ON
ACE inhibitor
152
BP goal for diabetics
Under 140/90
153
\>70% of all deaths in diabetics is due to....
Atherosclerosis
154
True or false...
**DM is considered a coronary risk equivalent**
TRUE
155
Decreased circulation to skin
+
loss of pain sensation from neuropathy
+
local infection
=
?
Skin necrosis/diabetic ulcer
## Footnote
**very difficult to tx!**
156
Gastroparesis
Diarrhea/constipation
Orthostatic hypotension
Impotence
Cystopathy (decreased bladder sensation)
Autonomic neuropathy in diabetics
157
Seen in Type 1 diabetics
Trigger is usually infection, trauma, surgery, MI
(**which increases insulin requirements**)
S/S: polyuria, polydipsia, abdominal pain, N/V, weakness, fatigue
**decreased mentation, stupor and coma can occur**
Diabetic ketoacidosis (DKA)
158
Increased pulse
Decreased BP
Hypovolemic/dehydration
Rapid breathing
**Fruity breath**
Abdominal tenderness
Diabetic ketoacidosis (DKA)
159
Inadequate insulin resulting in increased blood sugar and increased fat/protein breakdown
## Footnote
**result= metabolic acidosis with anion gap**
Diabetic ketoacidosis (DKA)
160
Glycosuria and osmotic diuresis lead to volume depletion and electrolyte loss/imbalance
Labs:
Blood sugar over 300+
pH less than 7.3
initial serum K often high, but total body K is low
Tx: **insulin!** replace fluid and K loss
Diabetic ketoacidosis (DKA)
161
Repaglinide (Prandin) **can** be used in a diabetic with what type of allergy
Sulfa
