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4 categories if Diabetes Mellitus

Type1 insulin dependent
Type 2 non insulin dependent
Type 3 juvenile
Type 4 Gestational DM

1

insulin dependent DM

Type 1

2

non insulin dependent DM

Type 2

3

juvenile DM

Type 3

4

Gestational DM

Type 4

5

4 main cell types in pancreas

glucagon
insulin
somatostatin
pancreatic polypeptide

6

alpha pancreatic cells secrete

glucagon

7

beta pancreatic cells secrete

insulin

8

gamma pancreatic cells secrete

somatostatin

9

effects of insulin on liver

inhibit glycogenolysis
inhibit conversion of AA and FA to keto acids
inhibit AA to glucose
anabolic action

10

effects of insulin on muscle

increase CHON. synthesis, AA transport, ribosomal synthesis
increase glycogen synthesis, glucose trasport
inhibits phosphorylase

11

effects of insulin on adipose tissue

increase triglyceride stores
lipoprotein lipase induced
glucose transport into cells
inhibits intracellular lipase

12

rapidly acting insulin

Lispro
Aspart
Glulisine

13

rapidly acting insulin (1) onset of action and (2) peak

ONSET: 15 minutes
PEAK: 30-90minutes
taken before meals

14

duration of action is 3-5 hours

rapidly acting insulin

15

crystalline zinc insulin that is now made by recombinant DNA techniques

short acting insulin

16

short acting insulin onset of action

within 30 min

17

peak of short acting insulin

2-4 hours after SQ

18

short acting insulin duration of action

5-8 hours

19

regular insulin / short acting insulins

Novolin
Humulin

20

regular insulin should be administered within

30-45 mins

21

intermediate acting insulin which combines insulin and protamine

Neutral Protamine Hagedorn or isophane insulin

22

intermediate acting insulin onset of action

1-2 hours

23

intermediate acting insulin peak

8 hours

24

duraton of action is 12-16 hours

intermediate acting insulin

25

usually mixed with regular, lispro, aspart, or glulisine insulin

NPH or isophane intermediate acting insulin

26

duration of action >24 hours
onset of actin 1-2 hrs

DETEMIR long acting insulin

28

soluble "peakless" insulin given once daily

GLARGINE Long acting insulin

29

insulin glargine onset of action

slow onset of action 1-1.5 hrs

30

insulin lispro, aspart, glusine acutely mixed with NPH

Pre-mixed insulin (doesnt affect rapid absorption)

31

available concentration of insulin

100 U/ml

32

external open loop pump for insulin delivery

Continuous SQ insulin infusion device (abdomen, flank, thighs)

33

most recently developed long scting insulin
DOSE dependent

DETEMIR insulin

34

insulin therapy formula

(wt in lbs) / (4) or
(0.55) x (wt in kg)

35

conventional insulin therapy

for DM type 2
fixed dose of intermediate or long acting
vary dos of short or rapidly acting

36

condition caused by inadequate or absent insulin replacement

Diabetic Ketoacidosis (DKA)

37

Tx for DKA

regular insulin IV 0.1IU/kg/h + IV hydration

38

DM type 2 characterized by HYPERGLYCEMIA and DEHYDRATION

Hyperosmolar Hyperglycemic Syndrome (HHS)

39

Tx for Hyperosmolar Hyperglycemic Syndrome (HHS)

aggressive rehydration and restoration of glucose
LOW DOSE Insulin therapy

40

most common complication of insulin therapy

HYPOGLYCEMIA

41

2 major disorders of insulin therapy

insulin allergy
immune insulin resistance

42

immediate type hypersensitivity, rare condition

insulin allergy

43

disorder where low titer IgG anti insulin antibodies neutralize the action of insulin

immune insulin resistance

44

abnormal or degenerative conditionof the body's adipose tissue

Lipodystrophy

45

oral anti diabetic agents

Secretagogues
BIGuanides
Thiazolidinediones
Alpha-glucosidase inhibitors
Incretin based therapies
Amylin analogs

46

insulin secretagogues

Sulfonylureas

47

sulfonylureas MOA

increase insulin release
reduce serum glucagon levels
closure of K channels in extrapancreatic tissure

48

first generation of Sulfonylureas

Tolbutamide
Chlorpropamide
Tolazamide

49

safest sulfonylureas for elderly diabetics, short halflife

TOLBUTAMIDE
rapidly metabolized in liver

50

first gen sulfonylurea prolonged hypoglycemic reactions

Chlorpropamide

51

ADR of CHLORPROPAMIDE if given >500mg daily

Jaundice

52

more slowly absorbed than other sulfonylureas
half life: 7hours
duration: 10-14 hours

TOLAZAmide

53

Second generation sulfonylureas

Glyburide (aka Glibenclamide)
gLIPizide
gLIMEpiride

54

Second gen sulfonylureas used with caution on Px with CV DISEASE and the ELDERLY

gLIMEpiride

55

2nd gen sulfonylurea with very loew hypoglycemic effect

Glyburide (aka Glibenclamide)

56

dose of Glyburide (aka Glibenclamide)

starting dose: 2.5mg/day
maintainance: 5-10 mg/day

57

contraindicated in Glyburide (aka Glibenclamide) therapy

hepatic and renal impairment
alcohol intake

58

ADR of Glyburide (aka Glibenclamide) with alcohol intake

Flushing

59

2nd gen sulfonylurea with delayed absorption when taken with food (take 20min before breakfast)

gLIPizide

60

2nd gen sulfonylurea single dose 1mg use as MONOTHERAPY or in combination with insulin

gLIMEpiride

61

1st member of MEGLITINIDE group of insulin secretagogue

REPAglinide

62

Used for controlling pstprandial glucose excursion

REPAGLINIDE

63

latest insulin secretagogue available clinically

NATEGLINIDE

64

insulin secretagogue D phenylalanine derivative

NATEGLINIDE

65

stimulates very rapid insulin release from beta cells thru CLOSURE of ATP-sensitive K channel

NATEGLINIDE

66

Nateglinide metabolism

via liver CYP2C9 and CYP3A4

67

reduces glucose production thru AMPK

BIGuanides

68

BIGuanide minor MOA

IMPAIR renal gluconeogenesis, SLOWS GIT glucose abs
direct stimulation of glycolysis in tissues
INCREASE glucose removal in blood
REDUCE glucagon

69

first line therapy for DM type 2

METFORMIN

70

insulin sparing drug

METFORMIN

71

METFORMIN dosage

500mg to 2.55g daily

72

METFORMIN toxicity

GIT disorders (anorexia, NV, abd pain, diarrhea)
DECREASE vit B12 abs

73

METFORMIN contraindication

renal, hepatic disease, alcoholism
predispose to ANOXIA ( bec inc risk of LACTIC ACIDOSIS)

74

they act to decrease insulin resistance

THIAZOLIDINEDIONE

75

major site of THIAZOLIDINEDIONE

adipose tissue

76

In, THIAZOLIDINEDIONE ligands of peroxisomes proliferatior activates what receptor?

Receptor GAMMA

77

current available THIAZOLIDINEDIONE

PIOglitazone
ROSIglitazone

78

other THIAZOLIDINEDIONEs pulled from the market due to LIVER TOXICITY

TROglitazone
REZULIN

79

insulin sensitizer THIAZOLIDINEDIONE

PIOglitazone

80

attaches to insulin receptors throughout the body

PIOglitazone (insulin sensitizer!)

81

rapidly absorbed and highly protein bound THIAZOLIDINEDIONE

ROSIglitazone

82

not recommended for type 1 DM
MONOTHERAPY for type 2 DM

ROSIglitazone

83

ROSIglitazone adverse effects

Fluid retention (presented as MILD ANEMIA, EDEMA)
Bone fracture (decrease osteoblast formation)

84

alpha glucosidase inhibitors

ACARBOSE
MIGLITOL

85

competitive inhibitors of of intestinal Alpha GLUOSIDASES

ACARBOSE
MIGLITOL

86

Alpha GLUOSIDASES moa

reduces post meal glucose excursions

87

sugars that can only be transported out of the GIT

glucose and fructose

88

Alpha GLUOSIDASES with side effect of FLATULENCE and DIARRHEA

ACARBOSE

89

Synthetic analog of AMYLIN

PRAMLINTIDE

90

hyperglycemic agent modulates POST PRANDIAL GLUCOSE LEVEL
rapidly absorbed SQ admin

PRAMLINTIDE

91

synthetic analog of Glucagon-like polypeptide 1 (GLP-1 agonist)

Exenatide

92

1st INCRETIN therapy for Diabetes

EXENATIDE

93

Adjunctive therapy in persons with type 2 DM

EXENATIDE

94

EXENATIDE moa

potentiation of INSULIN SECRETION
supression of POSTPRANDIAL GLUCAGON release
DECREASE gastric emptying
REDUCE appetite
REDUCES liver fat content

95

EXENATIDE adr

Nausea, vomiting, diarrhea
risk for THYROID CA, ACUTE PANCREATITIS

96

inhibitor of dipeptidyl petidase 4 (DPP-4)

SITAglipin

97

SITAglipin MOA

increase GLP-1 and GIP
decreases post prandial glucose excusion

98

SITAglipin common side effects

Nasopaharyngitis, URTI, headaches

99

other DPP4 inhibitors

SAXAgliptin
LINAgliptin
ALOgliptin
VILDAgliptin

100

What do you give in combination therapy?

Initial therapy: BIGuanide
2nd line: Sulfonylureas or insulin (cost-efficient) ; EXENATIDE (aggressive control)

101

for concurrent mealtime administration in type 2 DM for early post prandial glucose excursion

combination therapy with PRAMALINTIDE

102

for adjunct to oral anti diabetic therapy in type 2 DM

Bedtime insulin

103

NOT approved for Tx of type 1 DM

insulin secretagogues, Tzds, biguanides, alpha glucosidase and incretin

104

insulin secretagogues

Sulfonylureas, Meglitidines, D phenylalanine derivatives

105

For concurrent meal time administration with type 1 DM who have POOR control despite optimal insulin therapy

Combination therapy with PRAMLINTIDE

106

synthesized in alpha cells of pancreas, degraded in liver and kidney

Glucagon

107

GLUCAGON is a precursor intermmediate of 69 AA peptide called

GLUCENTIN

108

Glucentin immuno reactivity found in small intestine and alpha cells

Gut Glucagon

109

predominant form of GLP in human intestine

glucagon like peptide GLP-1

110

potential therapeutic agent in type 2 D

GLP-1 aka INSULINOTROPIN

111

Metabolic effects of glucagon

increase gluconeogenesis and ketogenesis

112

clinical uses of glucagon

severe hypoglycemia (for emergency)
endocrine diagnosis
beta adrenoceptor blocker overdose
radiation of bowel

113

glucagon adverse reactions

NV

114

drug interaction with glucagon which result to greater risk of bleeding

WARFARIN

115

standard mode of insulin therapy

SQ