Module 7 quiz Flashcards
(40 cards)
Medications that reduce the incidence of diabetic nephropathy
Insulin + ACEI or ARBs (prevention of nephropathy and HTN)
BP goal
<140/90
Action of Insulin
Stimulates uptake of glucose, amino acids, nucleotides & K promotes synthesis of complex organic molecules
Rapid acting insulin
Lispro/Humalog
Onset: 15 mins
Duration: 3-6 hours
Admin: must give with meals
Goal: Post-prandial BG control, between meals and at night
Note: Must be used with intermediate or long acting agent in DM I
Short Acting Insulin
Regular/Humalin R
Onset: 30-60 min
Duration: 6-10 hours
Admin: Must be given immediately before or after eating or via infusion pump
Goal: Post-prandial BG control when given before meals, basal control via pump
Notes: Slower onset than rapid acting, and faster onset than longer acting. Most on pumps use rapid not regular
Intermediate insulin
NPH (Humalin N/ Novolin N)
Onset: 60-120 mins
Duration: 16-24 hours
Admin: Can NOT be given at meal times to control post prandial BG. Instead BID or TID dosing.
Goal: Control b/w meals and night
Notes: Only longer acting insulin suitable for mixing with short acting (Regular, Lispro, Aspart, Gluisine)
Mixing tips: Draw short acting first to not contaminate NPH vial (clear then cloudy)
Long duration- Glargine
Onset:70min
Duration:18-24 hours
Admin: QD or BID in some to achieve full basal coverage
Goal: Prolonged control up to 24 hours
Notes:Dosing at anytime of day, must be consistent though. achieves steady state BG control throughout day
Ultralong duration
Glargine 300
Onset: 360 min
Duration: >24 hours
Admin: only insulin analog that lasts up to 42 hours
Goal: basal glycemic control
Notes: similar to glargine 100, does not have a peak
Long duration-Detemir
Onset: 60-120min
Duration: varies
Goal: basal glycemic control
Notes: slow onset, dose dependent duration of action, low doses up to 12 hours. Higher doses up to 20-24 hours
Biguanides action and SE
Metformin
-Drug of choice for initial therapy, can be used alone or in combination
-Action: does not drive blood glucose down. Inhibits glucose production in liver, reduces absorption in the gut and sensitizes insulin receptors=increased uptake
SEs: diarrhea, nausea, lactic acidosis
Sulfonylureas
Glipizide
First oral anti-diabetic drug, can be used alone or in combo
-Action: promote insulin release by stimulation of beta cells. Only used in DM II. May also increase target cell sensitivity to Insulin.
SEs: Can cause weight gain, and dose dependent hypoglycemia (may be persistent=D5 infusion)
Notes: 1st generation=less potent, more dug-drug interactions. 2nd gen=more potent, fewer interactions, used more often
Alpha Glucosidase Inhibitors
Acarbose
Monotherapy or combination therapy
Action: Act in intestines delaying absorption of carbs=reduces rise in BG after meals
SEs: R/t bacterial fermentation of carbs: flatulence, cramps, boborygmus, diarrhea, No hypoglycemia w/ monotherapy
Notes: Can decrease iron absorption. Liver dysfunction can occur-Monitor LFTs
Androgens (produced, actions, uses, adverse effects)
Produces by testes, adrenal cortex, and ovaries
Actions: promote male secondary sex characteristics
uses: management of androgen deficiency in males
Adverse effects: virilization & hepatotoxicity
Testosterone and testosterone esters
Approved for those with documented testosterone deficiency d/t hypogonadism
Indications: delayed puberty, therapy in menopausal women, cachexia, refractory anemias, drug therapy for transgender men
Adverse effects: virilization in women, girls and boys, hepatotoxicity, negative effects on blood lipids, abuse potential, thromboembolism
5 Alpha Reductase inhibitors
Finasteride
Action: Reduced DHT in blood by 70%. Does NOT reduce testosterone=promotes regression of prostate epithelial tissue and relieves mechanical obstruction
Considerations: most effective in men w/ very enlarged prostates, decrease in ejaculate and libido in 5-10%, risk for gynocomastia
Alpha receptor blockers
Flomax
Action: Blockade of alpha 1 receptors-relaxation of bladder neck (trigone/sphincter), prostate capsule, and prostatic urethra decreasing dynamic obstruction
Considerations: Therapy must be continued life long, bloackade of alpha 1 results in systemic vasodilation and may cause hypotension, overall tolerated well, may interact w/ beta blockers
Estrogen type: steroidal hormone
Actions: supports maturation of female secondary sex characteristics, increases bone mass, reduces CVD, promotes and supresses coagulation, neuroprotective
Uses: contraceptive & non contraceptive, HRT (w/ progestin), hypogonadism, acne, cancer palliation (prostate and metastatic breast ca), GAT (off label)
Adverse effects: endometrial hyperplasia, breast ca, thromboembolic events
Side effects: nausea, headache including migraine
Contraindications: liver disease, hx of breast ca
Drug-Drug interactions: estrogens are major substrates of CYP system
Progestins
Naturally produced
help prevent endometrial CA, used in IVF
SEs: breast tenderness
DONT GIVE TO PATIENTS W/ UNDIAGNOSED VAGINAL BLEEDING
Levothyroxine
synthroid: identical to natural hormone T4
-Indications: All forms of hypothyroidism
SEs: Rare but many drug-drug interactions=reduced absorption (PPIs, sucralfate, antacids, Ca+, and iron supplements)
-Reduced absorption w/ food/take on empty stomach 30-60 mins before breakfast
-Highly protein bound w/ prolonged half life (7 days)
-Levels remain steady even w/ QD dosing
-Takes 1 month for levels to reach steady state
-Narrow therapeutic range- DON’T CHANGE BRANDS
Recommendations for prescribing oral hypoglycemic agents
Hypoglycemia-BS <70
Fast acting oral sugar to be given PO for patients not NPO
-glucose tabs, orange juice, sugar carbs, honey corn syrup/soda
-15 grams of fast acting carbohydrate
Comorbid illnesses that may impact the dose of insulin required (7)
-surgery
-acute illness
-enteral/parental nutrition
-steroids
-epi infusion
-inflammatory response
-critical illness
Discuss dual agent therapy in the treatment of DM
4 step approach ( 2019 ADA standards)
1. Lifestyle changes + metformin (diagnosis)
2. Add second agent (efficacy, tolerability, hypoglycemia risk, weight considerations, cost). If A1C>9%/fasting BS>300, or BIG symptoms-start at step 2 (include injectable-basal insulin)
3. Progress to three drug combo (includes metformin)
4. After 3-6 months of #3 (including basal insulin)-combo injectable regimen (insulin +GLP-1receptor agonist)
Describe risks for hypoglycemic episodes (9)
-use of insulin or oral anti-diabetics
-impaired kidney or hepatic function
-longer duration of DM
-Frailty or old age
-Cognitive impirement
-impaired counterregulatory repsonse/hypoglycemia unawareness
-physical or intellectual disability that can impair behavioral response to hypoglycemia
-alcohol use
-polypharmacy (w/ ACE/ARBS, nonselective BB)
Treatment of hypoglycemia
Considerations: NPO status, LOC, Absorptive capacity of gut (edema/ileus), IV access, potential for prolonged hypoglycemia
Options: 15 grams of fast acting carb
-glucagon
-glucose tabs
-Dextrose IV or Continuous infusion
