How to detect facticious hypoglucemia with insulin injections?
−High plasma insulin levels ( greater then 15 U/ml) −Undetectable C-peptide and proinsulin levels* Exception: Renal failure---High C-peptide but low proinsulin
How to detect factisious hypoglycemia with sulfonylureas?
−High C-peptide and proinsulin −High sulfonylurea level
What is the ADA's HbA1c goal level?
less then 7 perc. **Both groups advocate individualization of targets based on patient characteristics.
What is the AACE/ACE HbA1c goal level?
less then 6.5 perc. **Both groups advocate individualization of targets based on patient characteristics.
What are the ADA;s 2 goals for vascualr disease prevention?
1. prevent and retard microvascular complications 2. Reduce macrovascular complications
What are the 2 ways to Prevent and retard microvascular complications?
Optimal glycemic control Optimal blood pressure control
What are the 5 ways to Reduce macrovascular complications?
1. BP less then 130-140/80-90 mm Hg (ACEI, ARB)* 2. Dyslipidemia mgt. 3. Weight loss about 5-10 percent of body weight (type 2); exercise 4. No smoking 5. ASA (age greater then 50 M and F + 1 or more CV risk factors or CVD)
how often should a pt with DM have their HbA1c chedcked?
Q 3-6 months
how often should a pt with DM have their BP checked?
how often should a pt with DM have their Lipid profile checked?
how often should a pt with DM have their urine microalbumin checked?
annually; type 1 greater then 5 year; type 2 at time of dx
how often should a pt with DM have their eye exam?
annually; type 1- 3-5 years; type 2- at dx
how often should a pt with DM have their foot examed?
how often should a pt with DM have their pneumo vaccine?
once, but repeat after 65 if their first was younger then 65 and more then 5 years ago
how often should a pt with DM have their flu vaccine?
Lispro/Aspart/ Glulisine is considered: 1. category 2. onset of action 3. peak 4. duration of action
1. rapid 2. 5-15 mins 3. 1-2 hours 4. 4-6 hours
Regular 1. category 2. onset of action 3. peak 4. duration of action
1. short 2. 30-60 mins 3. 2-4 hours 4. 4-10 hours
NPH 1. category 2. onset of action 3. peak 4. duration of action
1. intermediate 2. 1-2 hours 3. 4-8 hours 4. 10-20 hours
Glargine/ Detemir/Degluctec 1. category 2. onset of action 3. peak 4. duration of action
1. long 2. 1-2 hours 3. flat 4. about 24 hours
3 limitations of slow onset regular insulin?
Inconvenient administration (20-40 minutes prior to meal) Risk of hypoglycemia if meal is delayed Mismatch with postprandial hyperglycemic peak
3 limitations of long uration regular insulin?
Up to 10 hours’ duration Increased at higher dosages Potential for late postprandial hypoglycemia
SE of human NPH insulin?
5 advantages of rapid acting insulin (Lispro, Aspart, Glulisine)?
Convenient administration immediately prior to meals Faster onset of action Limit postprandial hyperglycemic peaks Shorter duration of activity (Reduce late postprandial hypoglycemia and frequent late postprandial hyperglycemia) Need for basal insulin replacement
The ideal basal insulin willl....
1. Mimic pancreatic basal insulin secretion 2. Last ~24 hours 3. Smooth peakless profile 4. Reduce risk of nocturnal hypoglycemia
2 perks of insulin Glargine?
Gradual release pattern from injection site Peakless, long-lasting insulin proflie
Mimicking Nature with Rapid-acting and Basal Insulin....
Give lispro at every meal and Glargine as basal insulin
MOA of Sulfonyureas
Increase basal and postprandial insulin secretion
MOA of Meglitinides
Increase postprandial insulin secretion
MOA of alpha- Glucosidase Inhibitors?
Decrease postprandial glucose absorption
MOA of Metformin
Enhances hepatic response to insulin and thereby reduces hepatic glucose production
MOA of Glitazones (TZD’s)
Improve insulin action in peripheral tissues (muscle and adipose tissue) and enhance glucose uptake
What is the power of THE INSULIN SECRETAGOGUES?
Decreases HbA1c 1-2 percent
SE of the THE INSULIN SECRETAGOGUES?
Main risk of THE INSULIN SECRETAGOGUES?
Metformin is NOT rec in?
Renal failure: creat. greater then 1.5 in men) and greater then 1.4 (women) CHF Liver disease
2 adv. of metformin?
Not associated with weight gain Does not cause hypoglycemia by itself
Power of metformin?
Decreases HbA1c 1-2 percent
SE of metformin?
Nausea, vomiting, diarrhea (less if taken with meals)
main risk of metformin?
stop therpahy of metformin for....
Dehydration, surgery, IV radiocontrast
power of the Glitazone's?
Decreases HbA1c 0.5 to 1.5 percent
SE of Glitazone's?
Edema, increased weight, anemia, fractures
main risks of glitazone's?
Hepatotoxicity; inducing or increasing CHF, bladder cancer (after 1 year of therapy)
Power of THE alpha-GLUCOSIDASE IHIBITORS
Decreases HbA1c 0.5 to 1 percent
SE of alpha- glucosidase inhibitors?
MOF of incretins?
1. stimulate insulin secretion 2. inhibit glucagon secretion 3. inibit gastric emptying and food intake **ll lower blood glucose levels
What is the MOA of DPP4?
inactivates incretins (causing increase in BS)
DPP-4 inhibitors moa?
blcok DPP4--> allows for the lowering of BS
What is the indiciation for DDP4 inhibitors?
Type 2 DM: Monotherapy or in combination with other antidiabetic drugs, including insulin
secondary failure rate in monotherpahy of DM type 2 is most commonly caused by....
decreasing beta cell function
over time, most pts will need....
BOTH basal and meal time insulin
Eventide (byetta and bydeuron) mimic....Power?
GPL-1; 0.8-1.0; given sq
What is the power of gliptins?
.6-.8; given PO **DDP-4 inhibitors**
what is the power to symlin?
"-gliflozen's" are.....MOA; SE?
sodium-glucose co-transport 2 inhibitors - inhibits NA and glucose reabsorption - SE- genital mycotic infections