Exam 2: DM Flashcards
1
Q
Def: Basal Insulin
A
Longer acting insulin that is meant to cover the body’s basal metabolic
insulin requirement (regulating hepatic glucose production); basal
insulin controls blood glucose in the fasting state
2
Q
Def: Bolus insulin
A
Short or rapid acting insulin which is meant to reduce glycemic
excursions after meals
3
Q
Def: Diabetic ketoacidosis
A
Serious complication related to a deficiency of insulin and increase in
insulin counter-regulatory hormones
4
Q
Def: Dipeptidyl-peptidase 4
A
Enzyme that rapidly degrades active incretin hormones after they are
released
5
Q
Def: Euglycemia
A
Normal concentration of glucose in the blood. Also called normoglycemia
6
Q
Def: Fasting
A
No eating for the past 8 or more hours
7
Q
Def: Glucose
A
Major source of energy for the body
8
Q
Def: Glycogen
A
The stored form of glucose in the liver and skeletal muscle
9
Q
Def: Glycogenesis
A
The synthesis of glycogen from glucose that occurs chiefly in the livery and skeletal muscle
10
Q
Def: Glycogenolysis
A
The conversion of glycogen to glucose in the body
11
Q
Def: Gluconeogenesis
A
The synthesis of glucose in the body from non-carbohydrates, such as proteins and fats
12
Q
Def: Hemoglobin A1C
A
A value that represents the percent of hemoglobin in the blood that is
glycosylated. This percent reflects the glycemic control over the past 2 to 3 months
13
Q
Def: Hyperosmolar hyperglycemic state
A
Serious condition characterized by hyperglycemia, hyperosmolarity and dehydration and the absence of ketoacidosis that may occur in type 2 diabetes
14
Q
Def: Hypoglycemia
A
Most common acute complication of diabetes; occurs from a relative excess of insulin in the blood and is characterized by below-normal blood glucose levels
15
Q
Def: Insulin resistance
A
the inability of peripheral target tissues to respond properly to normal circulating concentrations of insulin
16
Q
Def: Ketosis
A
A condition characterized by the abnormal accumulation of ketones in the body tissues and fluid
17
Q
Def: Lipolysis
A
Breakdown of fats and lipids to fatty acids (alternative fuel source)
18
Q
Def: Macrovascular disease
A
Large blood vessels disease; most commonly affected are the coronary arteries, the large arteries in the brain, and large arteries in the periphery
19
Q
Def: Microvascular complications
A
Small blood vessel disease caused by long term exposure to hyperglycemia; most commonly affects the eyes, kidneys, and nerves
20
Q
Def: Nocturia
A
Excessive urination at night
21
Q
Def: Persistent albuminuria
A
A term that reflects when the kidney is allowing an abnormal amount of protein (> 30 μg/mg) to be filtered through the glomerulous.
Marker used in addition to serum creatinine and GFR to stage chronic
kidney disease
22
Q
Def: Polydipsia
A
Excessive thirst
23
Q
Def: Polyphagia
A
Excessive hunger
24
Q
Def: Polyuria
A
Excessive urination
25
Abbreviation: A1c
Hemoglobin A1c
26
Abbreviation: ASCVD
Atherosclerotic cardiovascular disease
27
Abbreviation: BG
Blood glucose
28
Abbreviation: BGM
Blood glucose monitoring
29
Abbreviation: CGM
Continuous glucose monitoring
30
Abbreviation: CKD
Chronic kidney disease
31
Abbreviation: CVOT
Cardiovascular outcome trial
32
Abbreviation: DKA
Diabetic ketoacidosis
33
Abbreviation: DPP-4
Dipeptidyl-peptidase 4
34
Abbreviation: FPG
Fasting plasma glucose
35
Abbreviation: GDM
Gestational diabetes mellitus
36
Abbreviation: GLP-1
Glucagon-like polypeptide 1
37
Abbreviation: hHF
Hospitalization for heart failure
38
Abbreviation: HHS
Hyperosmolar hyperglycemic state
39
Abbreviation: IFG
Impaired fasting glucose
40
Abbreviation: IGT
Impaired glucose tolerance
41
Abbreviation: MACE
Major adverse cardiovascular event
42
Abbreviation: OGTT
Oral glucose tolerance test
43
Abbreviation: PPG
Post prandial glucose
44
Abbreviation: SGLT-2
Sodium-glucose contransporter 2
45
Abbreviation: T1DM
Type 1 diabees
46
Abbreviation: T2DM
Type 2 diabetes
47
Abbreviation: TIR
Time in range
48
Abbreviation: UACR
Urine albumin to creatinine ratio
49
3 Hormones that control blood glucose
1. Pancreatic hormones
2. Counter-regulatory hormones
3. Gut-derived hormones
50
Def: Pancreas
Glandular organ that secretes digestive enzymes and hormones
51
Pancreas: Plays a fundamental role in ___ and ____
Digestion and food energy utilization
52
Def: Exocrine
Digestion break down
53
Def: Endocrine
Regulates immediate utilization and storage of food energy
54
Pancreas: Endocrine function: Alpha cells
Secrete glucagon
| Effect the breakdown of liver glycogen and increase glucose levels in the blood
55
Pancreas: Endocrine function: Beta cells
Secrete insulin and amylin
| Increase uptake of glucose into cells and facilitate conversion of glucose to glycogen in the liver
56
Insulin is a(n) ____ hormone
anabolic
57
Insulin is a key regulatory hormone of ______
glucose disappearance
58
Insulin secretion is regulated by __ and ___ hormones
Glucose and incretin
59
Insulin is ___ during absorptive state and ____ during post-absorptive state
Increased and decreased
60
Insulin effects in liver, muscle, and adipose tissues
Inhibits hepatic glucose production and glucagon secretion
stimulate glycogenesis in liver
stimulates glucose uptake in muscle fat tissue
61
Amylin co-secreted with insulin in response to ___
nutrient stimuli
62
Amylin inhibits:
postprandial glucose excursions
- suppresses digestive secretions
- slows gastric emptying
63
Glucagon is a(n) ___ hormone
catabolic
64
Glucagon is a key regulatory hormone of ____
glucose appearance
65
T/F: Glucagon works antagonistically to insulin
True
66
Glucagon release is inhibited by
Increased glucose levels and presence of fatty acids and ketones
67
Glucagon release is stimulated by
decreased glucose levels and presence of amino acids
68
Def: Counter-regulatory hormones
Counteract the storage functions of insulin in regulating blood glucose levels during periods of fasting, exercise, stress, and other situations that either limit glucose intake or deplete glucose stores
69
4 Counter-regulatory hormones
Glucagon
Epinephrine
Growth hormone
Cortisol
70
4 Counter-regulatory hormones
Glucagon
Epinephrine
Growth hormone
Cortisol
71
Counter-regulatory Hormones: What does glucagon do?
Promotes gluconeogenesis and glycogenolysis, increases release of fatty acids from adipose cells
72
Counter-regulatory Hormones: What does epinephrine do?
Increases the use of fat for energy, promotes glycogenolysis, inhibits insulin release
73
Counter-regulatory Hormones: What does growth hormones do?
decreases the peripheral use of glucose
74
Counter-regulatory Hormones: What does cortisol do?
critical during periods of fasting and starvation, increase gluconeogenesis
75
Function of Gut: Oral ingestion of food stimulates release of ____ from _____
incretin hormones from the small intestine
76
Function of gut: ____ released from L cells of ileum and colon
GLP-1
77
Function of gut: ___ released from K cells of duodenum
GIP
78
2 Intestinal hormones
GIP and GLP-1
79
Intestinal hormones: GIP: acts at ___
B-cell
80
Intestinal hormones: GIP: Effects
Enhances glucose-dependent insulin secretion
May act as an insulin sensitizer in adipocytes
GIP has NO effect on glucagon secretion, gastric motility, or satiety
81
Intestinal hormones: GLP-1: Acts at ___
Alpha and B-cells
82
Intestinal hormones: GLP-1: Effects
Enhances glucose-dependent insulin secretion
Suppresses glucagon secretion
Slows gastric emptying
Has satiety effect on the brain
83
Def: Diabetes
Chronic, progressive metabolic disorder characterized by abnormalities in the ability to metabolize carbohydrate, fat, and protein, leading to a hyperglycemic state
84
Diabetes: How many with diabetes
37.3 million
85
Diabetes: how many with prediabetes
96 million
86
Diabetes: National diabetes statistics: How many Americans diagnosed every year
1.4 million
87
T/F: racial and ethnic minorities continue to develop diabetes at lower rates
False - HIGHER rates
88
T/F: New diabetes cases higher in non-Hispanic black and people of Hispanic origin
True
89
T/F: Less people are developing diabetes during their youth
False - MORE
90
Diabetes: Accepted terminology key points
Type 1 and Type 2 diabetes
DO NOT USE: roman numerals, "insulin dependent" "non-insulin dependent" diabetes, "adult-onset" "juvenile-onset" diabetes, diabetic
91
Diabetes etiologic classification: Type 1 diabetes
Autoimmune B-cell destruction, usually leading to absolute insulin deficiency
92
Diabetes etiologic classification: Type 2 diabetes
Progressive loss of B-cell insulin secretion frequently on the background of insulin resistance
93
Diabetes etiologic classification: Gestational diabetes (GDM)
Diabetes that is first diagnosed in the 2nd or 3rd trimester that is not clearly pre-existing type 1 or type 2 diabetes
94
Diabetes etiologic classification: Other causes
genetic defects
disease of the exocrine pancreas (cystic fibrosis, pancreatitis)
Drug-induced hyperglycemia
95
Pathophysiology of T1DM: Defect in pancreatic B-cell function >>
Pancreatic B-cell fxn >> deficiency of insulin/amylin
96
Pathophysiology of T1DM: Relative increase in ___ and its effects
glucagon; disequilibrium is created with insulin
97
Pathophysiology of T1DM: Increase in BG fails to ______
suppress production of glucagon
98
Pathophysiology of T1DM: Effects metabolism of ____
fat, protein, and CHOs
99
Pathophysiology of T1DM: Protein and fat breakdown occurs because of ____
lack of insulin -- results in weight loss
100
Pathophysiology of T1DM: ____ will result if no treatment
Ketoacidosis
101
Stages of T1DM: Stage 1
Autoimmune
Normoglycemic
Presymptomatic
102
Stages of T1DM: Stage 2
Autoimmune
Dysglycemic
Presymptomatic
103
Stages of T1DM: Stage 3
Autoimmune
Hyperglycemic
Symptomatic
104
Progression of T1DM: Rate of progression dependent on
Age at first detection of autoantibody (younger > older)
Number of autoantibodies
Autoantibody specificity
Autoantibody titers
105
Metabolic defects: Muscle
Insulin resistance in muscle (inefficient glucose uptake)
106
Metabolic defects: Liver
Insulin resistance in liver (increases glucose secretion)
107
Metabolic defects: Pancreas
Pancreatic B-cell decline (reduced insulin secretion)
| Increased activity of alpha-cells in the pancreas (higher blood levels of glucagon increase BG levels)
108
Metabolic defects: fat cells
Increased free-fatty acid levels in the blood from fat cell breakdown (more insulin resistance, toxic to beta-cells)
109
Metabolic defects: gut
Loss of incretin function from gut (deficiency/resistance)
110
Metabolic defects: kidney
Sodium-glucose co-transporter up-regulation in the kidney (results in higher BG levels)
111
Metabolic defects: brain
Neurotransmitter dysfunction within the brain
112
Summary of pathophysiological defects in T1DM
Defect in pancreatic B-cell fxn
| Absolute insulin deficiency
113
Summary of Pathophysiological defects in T2DM
```
Insulin resistance involving muscle, liver, and adipocyte
Defects in insulin secretion
GLP-1 deficiency and resistance
Excess glucagon secretion
Reabsorption of glucose by the kideny
Defects in signaling to the brain
```
114
Def: Acanthosis nigricans
Manifestation of insulin resistance -- skin thickening and pigmentation occurring on neck or armpit
115
GDM: Risk factors
Overweight/obese
Older age (>30)
Family hx of T2DM
116
GDM: pathophysiology
Insulin resistance
| Diminished insulin secretory response (usually normal fasting glucose, PPG high)
117
GDM: Risks to mother and baby
```
Macrosomia (large head, complications for vag. birth)
Shoulder dystocia (shoulder gets stuck)
Preeclampsia
C-section
Stillbirth
```
118
DM: Clinical manifestations of hyperglycemia
Skin infections, genital pruritus, polydipsia, visual changes, polyuria, polyphagia, weight loss, fatigue, paresthesias
Summary: fungal microbiome growth, osmotic diuresis, poor use of food energy, tingling
119
Does food INCREASE/DECREASE glucose?
Increase
120
Does exercise INCREASE/DECREASE glucose?
Decrease
121
Does alcohol INCREASE/DECREASE glucose?
Decrease
122
Does stress/illness INCREASE/DECREASE glucose?
Increase
123
Glucocorticoids, Clozapine, Olanzapine INCREASE/DECREASE glucose?
Increase
124
T1DM: Screening: 2 most common
Islet cell autoantibodies (ICA)
| Glutamic acid decarboxylase autoantibodies (GAD65)
125
T2DM: Screening: Recommendations
1. any age with overweight with 1 or more risk factors
2. Patients with prediabetes test yearly
3. women diagnosed with GDM test every 3 years
4. All pts after age 35
5. Normal results --> test minimum every 3 years
6. people with HIV
126
T2DM: Screening and Tests
1. Fasting plasma glucose (FPG) - no eating at least 8 hrs
2. Casual plasma glucose
3. 2hr plasma glucose during oral glucose tolerance test (OGTT) -- usually for pregnant women for GDM, inconvenient for pt (75g glucose dissolved in water); diagnoses more pts than A1C and FPG
4. Hemoglobin A1C - predictive for complications with DM , reflects average glycemia over 3 months (RBC lifespan ~120 days)
127
T2DM: Screening and Tests: Advantages of A1C over FPG and OGTT
```
Greater convenience (fasting not required)
Less day to day variations during stress/illness
```
128
T2DM: Cons of A1c
Inaccurately reflects glycemia in conditions that alter RBC turnover
- sickle cell disease
- pregnancy
- G6PD
- ESRD
- Recent blood loss/transfusion
- Hemodialysis
129
Diagnosis for T1DM
Presence of 2 or more autoimmune markers
Plasma glucose rather than A1C is used to diagnosed
C-peptide matches insulin levels --> low levels of C-peptide = T1DM
130
Diagnosis: T2DM: Prediabetes
A1c: 5.7-6.4%
FPG: 100-125 mg/dL - impaired fasting glucose (IFP)
OGTT: 140-199 mg/dL - impaired glucose tolerance (IGT)
131
Diagnosis: T2DM: Diabetes
A1c: ≥6.5%
FPG: ≥ 126 mg/dL
OGTT: ≥200mg/dL
Random glucose: ≥200mg/dL plus classic symptoms of hyperglycemia or hyperglycemic crisis
*requires 2 abnormal tests from same sample or 2 separate test samples for diagnosis
132
DM: Goals of therapy
Attain optimal glycemic control
Reduce onset/progression of complications
Aggressively address CV risk factors
Improve QOL
133
Glycemic goals for T1DM and T2DM
A1c <7%
FG 80-130
Peak PPG <180 (measured 1-2 hours after the beginning of the meal)
134
Children/Adolescent gylcemic goals
A1c <7.5%
FG 90-130
Bedtime/overnight 90-130
135
Pregnant women gylcemic goals concepts
Test for undiagnosed DM at first prenatal visit if at risk
Test for GDM at 24-48 weeks of gestation with 75g OGTT
Stricter glycemic goals than non-pregnant women
Majority develop T2DM later on
136
Hospitalized patients gylcemic goals
Target glucose range 140-180 mg/dL (keep stable)
| Use insulin if persistent hyperglycemia >180
137
Older adults glycemic goals: Healthy
A1c <7-7.5
FG 80-130
Bedtime: 80-180
138
Older adults glycemic goals: Complex/intermediate
A1c: 8%
FG: 90-150
Bedtime glucose: 100-180
139
Older adults glycemic goals: Very complex/poor health
A1c: <8.5%
FG: 100-180
Bedtime glucose: 110-200
140
Why are A1c targets >8.5% not recommended?
Risk from glycosuria, dehydration, hyperosmolar hyperglycemic state (HHS), poor wound healing, etc.
141
A1c goals should be individualized based on
Duration of diabetes
Life expectance (age is just #, life expectancy tells you more)
Comorbidities
Known CVD or advanced microvascular complications
Risk of hypoglycemia
Individual patient considerations (motivation, adherence, caregiver?)
142
ADA Recommendations
Weight loss 5-10% (7% target)
Exercise: 150min/week at least
Treat other CVD
Monitor yearly
Metformin is not better than placebo for pts >60, metformin = LTC in obese pts, metformin+ LTC decrease 50% risk in women with h/o GDM
143
TLC
Weight loss: 7% with better food choices, less calories, more activity
Children 60min/day x3/week
Adults: at least 150min/week (no more than 2 consecutive days without exercise)
```
Decrease calories to increase insulin sensitivity
CHO counting (15g/serving, 3-4/meal, 1-2/snack)
```
25g/day fiber and whole grain
Sodium<2.3g/day
144
Drug therapy: T2DM suggestions: Start with ___ and then consider addition of agents after ____
Metformin and after 3 months
145
When to use insulin for T2DM
evidence of weight loss
A1c ≥10%
BG ≥300
Very symptomatic
146
Biguanide: Metformin: MOA
Inhibit hepatic glucose production
| Increase insulin sensitivity of hepatic and muscle tissues
147
Biguanide: Metformin: Contraindications
```
Known hypersensitivity
Medical surgeries (restart 2 days later if good renal fxn is established
Alcohol abuse (3x LFT)
Renal disease (risk of lactic acidosis) (eGFR <45 ok to continue but don't initiate, <30 d/c)
Iodinated contrast media with eGFR <60, hepatic disease, alcoholism, Hf, if receiving contract intra-arterially
```
148
Biguanide: Metformin: Adverse effects
GI: diarrhea, cramping, bloating (start at lower dose and titrate up to max dose or until therapeutic. Decrease dose and increase slowly)
Vit B12 deficiency (monitor 2-3 years, espp if develop neuropathic sx )
Lactic acidosis - d/c in acute medical situations
149
GLP-1 RA: MOA
Increase glucose-dependent insulin secretion
Decrease PP glucagon secretion
Increase satiety
Decrease gastric emptying time
150
GLP 1 RA: Dosing for exenatide (Byretta) and BG target
BID, post meal BG
151
GLP 1 RA: Dosing for exenatide XR (Bdureon) and BG target
QWeekly, mixed BG
152
GLP 1 RA: Dosing for liraglutide (Victoza) and BG target
QD, mixed BG
153
GLP 1 RA: Dosing for dulaglutide (Trulicity) and BG target
QWeekly, mixed BG
154
GLP 1 RA: Dosing for semaglutide (Ozempic) and BG target
Qweekly, mixed BG
155
GLP 1 RA: Which medications recommend to inject within 3 days of missed dose?
Exenatide XR (Bydureon) and dulglutide (Trulicity)
156
GLP 1 RA: Which medications recommend to inject within 5 days of missed dose?
Semaglutide (Ozempic)
157
GLP 1 RA: Exenatide XR (Bydureon): Effect in ___ and dosing/titration
Effect in 2 weeks
| No titration: 2mg SC once weekly
158
GLP 1 RA: Exenatide XR (Bydureon): Caution with renal fxn
Use with caution if eGFR 30-50ml/min
| dont use if <30ml/min
159
GLP 1 RA: dulaglutide (Trulicity): Effect in ___ and dosing/titration
Effect in 1 week, 0.75mg sc once weekly and titrate up at 4 week intervals (1.5, 3, 4.5mg)
160
GLP 1 RA: semaglutide (Ozempic): Dosing/titration
0.25mg SC once weekly and then titrate 0.5, 1mg at 4 week intervals
161
GLP 1 RA: liraglutide (Victoza): Effect in ____ and dose/titration
Effect in 1 week
0. 6mg daily for week 1
1. 2mg daily for week 2
1. 8mg daily thereafter
162
GLP 1 RA: Order of greatest to least weight loss
Sema
Lira
Dula
Exena
163
GLP 1 RA: Adverse effects
GI: N/V/D
Pancreatitis symptoms: severe abdominal pain, often radiating to the back // a/w N/V, fever
Sema: risk of DM retinopathy complications
Exenatide XR: small nodules/lumps at injection site, itchy, may be transient
164
GLP 1 RA: Contraindications
Thyroid C-cell tumors (personal/family hx of medullary thyroid carcinoma (MTC) or multiple endocrine neoplasia syndrome type 2 (MEN 2)
Hx Pancreatitis or TG >500
Hx Gallbladder disease
Hx gastroparesis or severe GI disorder
Alcoholism (serious disease can lead to pancreatitis)
165
SGLT2i: MOA
Inhibits SGLT2 in proximal tubule (decrease glucose reabsorption)
166
SLGT2i: Caution with eGFR
eGFR <45 not effective (if filtering doesn't work well, not much glucose to reabsorb)
Dapa: <45 --> AVOID for T2DM (All other indications eGFR <25 avoid starting)
Empa: <30 --> AVOID (HF patients with eGFR <20: not defined)
167
SLGT2i: Adverse effects
Polyuria (diuretic effect) -- take in AM, caution in elderly and pt using diuretics (dehydration)
Genital fungal infections (esp women)
UTI
Cana: DKA? amputations (2x risk once on black box, later removed)?
Monitor for volume depletion and hypotension
168
SU/Glinide: MOA
Increase insulin secretion (bind to B cells)
169
SU: dosing
Once daily or BID to minimize hypoglycemia
Take with food
Glyburide (Diabeta) - 20mg max dose (metabolized in liver to activate)
Glipizide (Glucotrol) - 40mg (or 20mg ER) [If CrCl <50 take 50% of dose]
170
Glinide: Repaglinide dose
Start at 0.5-1mg po TID, 15min before meal
Skip med if you skip meal
Increase dose every week as needed
Max dose 16mg/day
171
SU/Glinides: Generally achieve ____ efficacy at 1/2 max dose
80%
172
SU/Glinide: Beneficial for
```
Thin body type (less insulin resistance, more likely to have secretory defect that causes hyperglycemia)
Newly diagnosed (beta cell fxn more preserved)
Less significant hyperglycemia
```
173
SU/Glinide: Effect in ____
DAYS
174
SU/Glinide: Adverse Effects
HYPOglycemia
Weight gain
GI distress
Allergic skin rxn (but diff sulfa moiety)
Secondary failure: efficacy adequate at first and then diminishes over (beta cell decline) -- failure rate 5-10%/yr
175
SU/Glinide: Ramadan or fasting pt counseling
If A1C is higher, reduce dose to 50%
| If A1C is good, omit dose
176
DPP-4i: MOA
Inhibit DPP4 (inhibits breakdown of GLP-1 and GIP -- increase effect of endogenous incretin hormones)
Facilitates glucose-dependent insulin secretion
decrease PP glucagon secretion
177
DPP-4i: Don't use with which other class of DM medications?
GLP-1 RA
178
DPP-4i: Sitagliptin (Januvia) dosing
100mg PO QD
| Adjust dose for renal insufficiency (no need for hepatic)
179
DPP-4i: Linagliptin (Trudjenta): Dosing
5mg daily
| No dose adj for renal and hepatic insufficiency
180
DPP-4i: Good to use for
Frail, elderly pts that may not need significant decrease in A1C or have hypoglycemic risk, AE of other agents, or unable to use injectable
181
DPP-4i: Adverse effects
WELL TOLERATED
Risk of pancreatitis (rare)
Saxagliptin related to hospitalizations for HF
182
TZD: MOA
Activates PPAR-gamma (peroxisome-proliferator activated receptor)
Decrease insulin resistance (improve target cell insulin response) and increase uptake of glucose
183
TZD: Effect in _____
2-3 weeks due to need for G-protein turnover
| May take 3-4 months to see full effect
184
TZD: Pioglitazone (Actos): Dosing
15-30mg PO daily and then titration every 3-4 weeks to max of 45mg/day
No dose adj needed for renal or hepatic insufficiency (not recommended for renal insufficiency due to fluid retention)
185
TZD: Adverse effects
```
Fluid retention and edema
Weight gain
Fracture risk (decrease bone mass and increase fracture risk in women: upper arm, hand, foot but NOT spine/hip)
Macular edema (eye)
BLACKBOX: HF
Induces ovulation -- risk of pregnancy
```
186
TZD: Contraindications
```
NYHA class 3 or 4 HF
Use with caution in pts with edema or class 1 or 2 HF
Active liver disease (ALT >2.5x ULN at start of therapy and D/C LFTs >3x ULN)
```
187
Insulin: RAA and Short acting: How many minutes before meal
RAA: 15 min
| Short acting: 30min
188
Insulin: Intermediate-acting: Duration
10-16hr (usually BID)
189
Insulin: Long-acting: Duration
U-100 glargine/detemir: 24 hrs
U-300 glargine: 34hrs
degludec: 42hrs
190
Which insulins are cloudy?
NPH, premix analogs/NPH-regular
191
Insulin: Premix analogs/NPH-regular: Name all of them and dosing frequency
```
Humalog 75/25 + 50/50 - 15min before meal BID
Novolog 70/30 - 15 min before meal BID
Ryzodeg 70/30 - QD or BID with any meal
Humulin 70/30 - 30min before eating BID
Novolin 70/30 - 30min before eating BID
```
192
Insulin: T1DM: Dosing
Starting: 0.5U/kg/day (50% basal, 50% bolus (divided into 3 meals)
OR
Carb matching: 1U=15g/CHO + additional 1U/50 over glucose goal
193
Insulin: T2DM: Reasons to start/add insulin early
```
A1C >10%
Glucose ≥300
Symptoms of hyperglycemia
Ongoing catabolism (weight loss)
CI for GLP-1RA or unacceptable sx of GLP-1RA
```
194
Insulin: T2DM: Basal dosing
Starting dose: 10U/day or 0.1-0.2U/kg/day for obese pts - same time every day
Increase 2-4 U (10-15%) x1-2/week until fasting target is met
195
Insulin: T2DM: Basa: Overbasalization signs and what to do
Basal insulin dose >0.5/kg/day
High bedtime to morning (BeAM) or post to pre prandial glucose diff (>50mg/dL)
Hypoglycemia
High glycemic variability
Intensify therapy with GLP1 RA or add prandial insulin
196
Insulin: T2DM: Prandial dosing
Starting dose: 4U (or 0.1U/kg or 10% of basal dose) -- 15 min before meal (biggest meal)
Monitor PPG and increase 1-2 U 1-2x/weekly until target
D/C SU and DPP-4i, continue other oral meds
If A1C <8%, decrease basal dosing by # of prandial U
If A1C not controlled, do full basal/bolus therapy or premix
197
Insulin: T2DM: Pre-mixed insulin regimen
Usually BID -- inject 15min before meals
Increase 1-2U x1-2/weekly until target
D/C SU or DPP-4i
If A1C not controlled or hypoglycemia, change regimen
198
Complications: general A1C testing
every 6 months if treatment is going well, 3 months if it is not
199
What are some limitations to A1C
Doesn't show variability or hypoglycemia
200
BGM recommendations
4-10x/day esp for basal/bolus regiments
| For GDM 4-10x/day until controlled 1-2 days
201
CGM: How long can you wear and what are the goals
14 day wear
>70% in range
<30% above range
<5% below range
202
Complications: Hypoglycemia: diagnosis
BG <70mg/dL
Level 1 MILD <70
Level 2 MOD <54
Level 3 SEVERE
203
Complications: Hypoglycemia: Symptoms
Trembling, palpitations, dry mouth, sweating, hunger, anxiety, cognitive impairments, confusion, behavior change, headaches/seizures, slurred speech, weakness, loss of consciousness
* *if occurs during sleep: nightmares, night sweats, headache
* *BB can mask sx of hypoglycemia except sweating
204
Complications: Hypoglycemia: Consequences
Rebound hyperglycemia (dangerous bc doctor may continue to increase therapy)
Greater risk of dementia
Prolonged QT interval -- dysrhythmias, sudden death
Barrier to glycemic control/adherence bc of fears
205
Complications: Hypoglycemia: Risk factors
```
Fasting, delayed/missed meals
Exercise
Drug/alcohol
Unawareness of hypoglycemia
Use of insulin or SU/glinides
Older age/frail
Cognitive impairment
```
206
Complications: Hypoglycemia: Management
15g glucose - wait 15min - repeat if needed
If severe: give glucagon (IV, IM, SC, intranasal)
207
What are some equivalents to 15g of glucose?
3-5pieces of hard candy
3-4 pieces of glucose tabs
4oz of juice/soda
1 tbsp of honey/corn syrup/jelly
208
Complications: DKA: 3 Main ideas
Ketosis
Hyperglycemia
Metabolic acidosis
209
Complications: DKA: Pathophysiology
No insulin > glucose from food cannot be processed > increase counter-reg H > increase glucose production > increase BG
Body need fuel > lipolysis > ketone byproduct > ketoacidosis
Glucose and ketones peed out > bring more water with it > dehydration
OVERAL: Metabolic acidosis
210
Complications: DKA: Predisposing factors
Physical/emotional stress
| Insulin deficiency
211
Complications: DKA: Symptoms
Fatigue, headache, polyuria, polydipsia, weight loss, abdominal pain/tenderness, N/V, fruity/acetone breath, Kassmaul respirations, dry mouth, hypotension, tachycardia, mild hypothermia
212
Complications: DKA: Labs
Glucose > 250mg/dL
Low arterial pH <7.3
Low bicarb <18mEq/L
Ketonemia and moderate ketonuria
213
Complications: DKA: Complications
Cerebral edema (esp in children)
Respiratory distress syndrome
Thromboembolism
Rhabdomyolysis
214
Complications: HHS: 3 Main ideas
Hyperglycemia
Hyperosmolality
Dehydration
215
Complications: HHS: Pathophysiology
Little insulin > not enough cell energy > increase counter-reg hormones > increase glucose production > increase BG
Glucose peed out > osmotic diuresis (brings water) > dehydration and electrolyte abnormalities > hyperosmolality
216
Complications: HHS: Predisposing factors
```
Pancreatitis, severe infection/illness
MI
CHO diets (tube feedings, TPN)
Dialysis
medications antagonizing insulin
```
217
Complications: HHS: Symptoms
Weakness, polyuria, polydipsia, neurological signs, dehydration, seizures, coma
218
Complications: HHS: Labs
Glucose >600 mg/dL
| Plasma osmolality >320 mOsm/kg
219
Complications: HHS: Complications
Thromboembolism
| Rhabdomyolysis
220
Complications: HHS: Treatment: Add ____ when blood glucose decreases to ____
Dextrose when BG decreases to 250-300mg/dL
221
Landmark trials for T1DM
DCCT
222
Landmark trials for T2DM
UKPDS, ACCORD, ADVANCe, VADT
223
T/F: intensive glycemic controls prevent macrovascular complications
FALSE - they prevent MICROvascular complications -- Macrovascular complications come from BP/lipid/antiplatelet control
224
Which landmark trial says that intensive glycemic control can increase mortality?
ACCORD
225
What is considered ASCVD?
```
ACS
MI
Angina
Coronary revascularization
stroke
Transient ischemic attack (TIA)
Peripheral arterial disease (PAD)
```
226
Rates of HF hospitalizations ____ with DM
x2
227
What are some CV risk factors?
HLD, HTN, smoking, obesity, CKD, albuminuria, FHx of premature coronary disease (men <55 or women <65)
228
Chronic complications: Prevention: BP control
```
Goal: <130/80
Lifestyle interventions
Meds: ACEI/ARB, Thiazides, DHP-CCB
- if UACR >30 then 1st line is ACE/ARB
**ACEI/ARB contraindicated for pregnancy
```
Monitor BP every visit and at home
Monitor SCR, eGFr, and K annually
229
Chronic complications: Prevention: Lipid Control
Get lipid profile at diabetes diagnosis and then 5 years thereafter <40yo
Primary prevention 40-75yo: moderate statin
Secondary prevention: any age: high statin
Monitor at initiation, 4-12weeks later and then annually
**statins contraindicated in pregnancy
230
What are high intensity statins?
Atorvastatin 40-80
| Rosuvastatin 20-40
231
Chronic complications: Prevention: Antiplatelet control
Effective in reducing CV morbidity/mortality in high risk pts with previous MI/stroke (controversial for primary prevention due to bleeding risk)
Secondary prevention: low dose aspirin OR clopidogrel 75mg/day if ASA allergy
ASA in pt <21 yo contraindicated due to Reye's syndrome
232
Microvascular complications: DKD and screening
CKD due to DM
T1DM: annually after 5 yrs after diagnosis
T2DM: annually starting diagnosis
```
Albuminuria via UACR
- normal <30
- mod 30-300
- severe >300
eGFR <60ml/min is abnormal
**use UACR and eGFR to stage CKD
```
233
Microvascular complications: DKD: risk factors
HTN, poor glycemic control, HLD, smoking
234
Microvascular complications: DKD: treatment
ACEI/ARB for HTN with albuminuria
SGLT2 regardless of glycemic control (or nonsteroidal mineralocorticoid RA finerenone)
GLP1RA suggested for CV risk reduction and slow CKD progression
235
T/F: DM is leading cause of ESRD
True
236
Microvascular complications: Diabetic retinopathy
Strongly related to duration of DM and level of glycemic control
Risk factors: Hyperglycemia, nephropathy, HTN, dyslipidemia
237
Microvascular complications: Diabetic retinopathy: prevent
HTN, DM, HLD
238
Microvascular complications: Diabetic retinopathy: Screening
Dilated and comprehensive eye exam
T1DM: annually 5 yrs after diagnosis
T2DM: annually starting at diagnosis
239
Microvascular complications: Diabetic peripheral neuropathy (DPN)
associated with diminished perception of vibration, pain, and temperature in lower extremities (loss of feeling, touch, and position sense, paresthesias, numbness, or pain)
Cannot be reversed (prevent with glycemic control)
240
Microvascular complications: Diabetic peripheral neuropathy (DPN): Screening
Diabetic neuropathy and sensory function (pinprick, temp, vibration, pressure)
T1DM: annually after 5 yrs of diagnosis
T2DM: annually starting at diagnosis
241
Microvascular complications: Diabetic peripheral neuropathy (DPN): Treatment
Optimize glycemic control and foot self-care education and smoking cessation
Pregabalin and duloxetine and gabapentin (off-label)
**cannot reverse
242
Which interventions are done at every visit
BP and smoking cessation
243
Which interventions are done every 3 months
A1C
244
Which interventions are done yearly?
Dilated eye exam, comprehensive foot exam, UACR, SCr, eGFR, lipid panel
245
Which immunizations are recommended
Influenza yearly
Pneumococcal PPSV23 at diagnosis
Hep B at diagnosis (19-59 yo)
