Quiz #2 Flashcards Preview

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Flashcards in Quiz #2 Deck (75):
1

What is the expected clinical effect of the GLP-1 agonists on blood glucose control


about 1% (0.9% to be exact)


2

Contraindications to GLP-1 agonists

- Type 1 DM
- Ketoacidosis
- Severe GI dz
- Hx of pancreatitis

3

Additional contraindication to Byetta (GLP-1)

ESRD or severe renal impairment (CrCl <30 ml/min)

4

Additional contraindication to Victoza (GLP-1)

Hx or fam hx of medullary thyroid cancer (MTC) or hx of multiple endocrine neoplasia syndrome type 2 (MEN 2)

5

GLP-1 Agonist
- MoA

- Incretin analogue
- Activate GLP receptors on the cell surface of beta cells → insulin release in the presense of elevated blood glucose
- Decreases glucagon secretion in a glucose-dependent manner
- Lowers blood glucose by delaying gastric emptying

6

GLP-1 Agonist
- ADR (5)

1. (MC) mild to moderate dose-dependent nausea
• frequency and severity decrease over time with continued use
2. HA
3. Diarrhea
4. Hemorrhage and necrotizing pancreatitis
• Early in therapy (w/in 4-6 weeks)
• Rare
5. Serious hypoglycemia
• Seen when use in combo with secretagogue (sulfonylurea or meglitinide)

7

Novolog
- speed of onset
- bolus or basal

- rapid acting
- bolus

8

Humalog
- speed of onset
- bolus or basal

- rapid acting
- bolus

9

Apidra
- speed of onset
- bolus or basal

- rapid acting
- bolus

10

Lantus
- speed of onset
- bolus or basal

- long acting
- basal

11

Levemir
- speed of onset
- bolus or basal

- long acting
- basal

12

Regular
- name the two
- speed of onset
- bolus or basal

- Humulin R and Novolin R
- short acting
- bolus

13

NPH
- name the two
- speed of onset
- bolus or basal

- Humulin N and Novolin N
- intermediate acting
- basal

14

Which insulins are used as bolus

- Fiasp
- Humalog
- Novolog
- Apidra
- Regular

15

When should inject rapid acting insulin?

15 min before meal

16

When should inject short acting insulin?

30 min before meal

17

Which insulins are used as basal

- NPH
- Lantus
- Levemir
- Toujeo
- Basaglar
- Tresiba

18

What is the key to successful basal insulin injections?

inject at the same time every day without regard to meals

19

What does U-100, U-200, U-300 mean?

- U is the number of units of insulin per milliliter of fluid
- Ex: U-100 means there are 100 units of insulin per mL of fluid
- All vials are 10 mL (1,000 units of insulin per vial)

20

Choose the appropriate starting dose and monitoring parameters for a patient with T2DM starting insulin

- Start with 10 U of bedtime basal insulin (Lantus, Levemir, NPH)
- Monitor fasting am and pre-prandial glucose

Also:
- If A1C goal is not met within 2-3 months add bolus insulin
- Use A1C and pre-meal monitoring to guide
- If hypoglycemia occurs, reduce dose by 10%

21

How to initiate a bolus insulin dose in a patient who is already using basal insulin

- Add a rapid acting insulin for post-prandial control
- Start with the time of day blood sugar is highest
- Start with 4 Units, 0.1 U/kg, or 10% of basal dose (Letassy says 5-10 units is fine)
- Adjust dose by 1-2 U or 10-15% once or twice weekly until reach target glucose levels
- Dosing is best based on CHO counting

22

Given a pt at risk for DM, select the medication to reduce or prevent progression to DM based on the outcomes of the prevention studies

metformin

23

State the outcomes of the DCCT on the development or progression of microvascular diabetes complications

-this study proved normalizing blood glucose could prevent or delay progression of diabetic complications
-in the primary prevention group:
-76% RRR in the development of retinopathy
-34% reduction in nephropathy
-60% reduction in neuropathy
-secondary prevention group:
-54% RRR in retinopathy
-43% reduction in nephropathy

24

glycemic goals of therapy for a nonpregnant adult with T2DM
-a1c
-preprandial blood glucose

-A1c: <7%
-BG: 80-130

25

What are patient risk factors for the development of prediabetes/diabetes

-impaired fasting glucose
-impaired glucose tolerance test
-A1c > 5.7-6.4%
-BMI > 30
-< 60 yo
-women w/ hx of gestational DM

26

Place in therapy for metformin in the tx of T2D

if lifestyle changes fail to achieve glycemic goals and A1c is <7.5% then metformin is the drug of choice

27

expected clinical effect of metformin on the patient's blood glucose control

-lowers fasting plasma glucose concentrations by about 55 mg/dl
-reduces A1c by 1-2%
-no hypoglycemia
-no weight gain

28

contraindications to metformin

-renal function
-unstable CHF
-liver dz
-alcohol abuse
-pregnancy/lactation

29

renal function guidelines for metformin use

-DO NOT use in CKD stages 4 and 5
-do not initiate therapy at stage 3B but may continue use at 1000mg max dose
-avoid initiating therapy at stage 3A if expected to become unstable but may continue use at 2000mg max
-CKD stages 1 and 2: max dose 2550 mg

30

initial dose of metformin

500 mg once or twice daily (Letassy said she starts w/ once daily)

31

titration dose of metformin

-start at 500 mg daily
-dose should be increased at the rate of 1 tab weekly
-up to a max dose of 2500 mg per day

*her example:
500mg daily x 1 week; increase to 500 mg BID x 1 month; then add 500 mg where needed

32

ADRs of metformin

GI are MC
-early satiety and anorexia
-nausea w/ or w/o vomiting, anorexia, diarrhea, bloating, and abdominal discomfort

33

what needs to be monitored when taking metformin?

-B12 concentrations
-some pts may beed replacement

34

what is the expected clinical effect of the sulfonylureas and meglitinides on the pts BG control?

-fasting BG to drop 60-70 mg/dl
-A1c reduction of 1-2%

35

what is the expected clinical effect of pioglitozone on the pts BG control?

-average decrease in A1c is 1.5% (in pts w/ a baseline of 9%) and is seen after 12-14 weeks
-average decrease in A1c when added to another agent: 0.8-1.3%

(the numbers don't agree with this but the pack says it's more effected when used in combo)

36

what is the expected clinical effect of the DPP-4 inhibitors on the pts BG control?

0.6-0.8% drop in A1c

37

what is the expected clinical effect of the SGLT2 inhibitors on the pts BG control?

-A1c decrease of about 1%
-some weight loss d/t increased excretion of glucose

38

risk factors for euglycemia DKA d/t SGLT2 inhibitors

-major illness
-reduced fluid and food intake
-reduced insulin dose
-type 2 DM

**the packet doesn't specifically state the risk factors, this is just what I interpreted them as

39

given a child w/ T2D, select the most appropriate therapy

1. Insulin therapy indications:
-ketosis or DKA
-unclear if T1 or T2
-unusual cases like a random BG >250 or A1c >9%

*all other cases:
1. lifestyle changes: nutrition interventions and physical activity
2. metformin
-confirm T2
-start low (500mg) d/t GI side effects
-monitor for glycemic deterioration
-add insulin if needed
3. test A1c every 3 months
-target = <7%
-intensify tx if needed

40

consequences of absolute or relative lack of insulin on the liver

-glycogenolysis occurs to release glucose into the blood
-amino acids are released from the muscle and taken up by the liver to produce new glucose
-lipolysis occurs and releases free fatty acids into the blood which are taken up by the liver to produce ketones
-glycerol is released from adipose and can be taken up by the liver for gluconeogenesis

41

consequences of absolute or relative lack of insulin on the muscle

-protein breakdown occurs as well as decreased amino acid uptake by muscle
-protein breakdown occurs at a higher rate than protein synthesis and therefore there is a net loss of protein
-possible decreased muscle mass

42

consequences of absolute or relative lack of insulin on the adipose tissue

-lipoprotein lipase doesn't work well in the absence of insulin
-leads to increased lipolysis and decrease in triglyceride synthesis
-net result: weight loss and decreased fat stores
-liver converts free fatty acids to ketones which can lead to ketoacidosis

43

Which insulin types are insulin analogues?

- Novolog
- Humalog
- Apidra
- Lantus
- Levemir

44

Given a patient with newly diagnosed type 1 diabetes:
-Explain the concept of intensive insulin therapy

Intensive insulin therapy tries to achieve a more physiologic replacement of insulin by giving long acting insulin that provides basal insulin and by giving a rapid acting or short acting insulin before meals to provide a bolus of insulin.

45

Given a patient with newly diagnosed type 1 diabetes:
-Select the best basal/bolus insulin regimen for that person (include the amounts provided by basal and bolus insulin—percent breakdown)

50 to 70% of the total daily dose should be a basal insulin
-Basal insulins are glargine (Lantus®), detemir (Levemir®) and NPH

30 to 50% of the total daily dose should be given in divided doses before a meal with rapid-acting or short-acting insulin (bolus)
-Bolus or Preprandial insulins are Novolog®, Humalog®, Apidra®

46

Given a patient with newly diagnosed type 1 diabetes:
-Explain the rule of 500 and how to use it to establish an insulin:carb ratio

•Establishing insulin to carbohydrate ratios for each meal
-Insulin:Carb ratios will vary throughout the day
-Rule of 500 is the carbohydrate coverage ratio
-500 ÷ Total Daily Insulin Dose = 1-unit insulin covers so many grams of carbohydrate

47

Given a patient with newly diagnosed type 1 diabetes:
-Explain how the rule of 1800 is used to determine an insulin sensitivity factor

-use the “1800 rule” to calculate insulin sensitivity factor for people who use the rapid-acting insulin analogs lispro (brand name Humalog), aspart (NovoLog), and glulisine (Apidra)
-this is done by dividing 1800 by the total daily dose (TDD) of rapid-acting insulin
-if the total daily insulin dose is 40 units, the insulin sensitivity factor would be 1800 divided by 40 = 45

48

Given a patient with newly diagnosed type 1 diabetes:
-Explain how an insulin correction dose is used

-An insulin sensitivity factor is used to determine an insulin correction factor
-Insulin Correction factors are used to correct or adjust the premeal bolus insulin dose in order to cover the carbohydrate content in a meal plus “correct” a higher than desired blood preprandial blood glucose

49

Given a patient experiencing a hypoglycemic reaction:
-Identify common reasons for hypoglycemia

When the patient..
-skips a meal
-delays a meal
-eats less at a meal than usual and does not adjust insulin
-increases their activity
-commits a dosage error

50

Given a patient experiencing a hypoglycemic reaction:
-Identify symptoms commonly associated with hypoglycemia

-Headache
-Shaking
-Sweating
-Feeling tired
-Weakness
-Hunger
**Rapid onset

51

Determine the severity of the hypoglycemia
-Mild hypoglycemia

-Usually manifested as adrenergic symptoms (mediated by epinephrine).
-These symptoms are anxiety, sweating, tremulousness, tachycardia, hunger.
-Clinically significant hypoglycemia is defined as a glucose <54 mg/dL.

52

Determine the severity of the hypoglycemia
-Moderate hypoglycemia

-Includes adrenergic symptoms plus neuroglycopenic symptoms including headache, mood change, irritability, confused thinking, and slurred speech.
-These reactions are usually longer lasting, and the patients usually require assistance in obtaining a glucose source.
-A second dose of 10 to 15 grams of a simple sugar is usually required.

53

Determine the severity of the hypoglycemia
-Severe hypoglycemia

-Characterized by unresponsiveness, unconsciousness or convulsions.
-These reactions require emergency care with an intravenous dextrose or IM glucagon injection.

54

Given a patient experiencing a hypoglycemic reaction:
-Determine the appropriate course of treatment and monitoring to bring blood glucose back to normal.

-For severe hypoglycemic reactions in children and adults - use GlucaGen Hypokit (glucagon injection)
-Use food sources that provide 10 gm of carbohydrate (apple juice, orange juice, sugar, lifesavers, B/D glucose tablets)
-Use commercial products (Instant glucose, Dex4, cake frosting gel, monojel)
-To stabilize blood glucose and decrease risk of hypoglycemia use Extendbar and NiteBite

55

Given a patient experiencing a hypoglycemic reaction:
-Select the most likely cause of their hypoglycemia.

Medical causes:
-Altered kidney or liver function
-Hormonal deficiencies (e.g., pituitary or adrenal)
-Rapid gastric emptying
-Hypoglycemic unawareness: MC

56

Given a patient experiencing a hypoglycemic reaction:
-Explain the rule of 15

Check blood sugar --> eat 15 gm of carbs --> wait 15 min --> blood glucose will go up.

57

Identify the glycemic goals for children.

•A1c goal of < 7.5%
•90 to 130 mg/dL before meals
•90 to 150 mg/dL bedtime and overnight

58

Identify the screening for other autoimmune diseases in people with T1DM.
-Thyroid disease

Test for antithyroid peroxidase (ANTI-TPO) and antithyroglobulin (ANTI-TG) antibodies soon after the diagnosis
•Measure TSH soon after diagnosis
•If values are normal, consider rechecking every 1-2 years or sooner if symptoms occur.

59

Identify the screening for other autoimmune diseases in people with T1DM.
-Celiac disease

Consider screening for celiac disease by measuring either tissue transglutaminase or deamidated gliadin antibodies with normal total serum IgA levels.
•Consider screening in children who have a first degree relative with celiac disease, growth failure or failure to gain weight, weight loss, signs of malabsorption, unexplained hypoglycemia or a loss of glycemic control.
•Children with biopsy-confirmed celiac disease should be placed on a gluten-free diet and consult with dietician to help manage both diabetes and celiac disease.

60

Identify the screening for other autoimmune diseases in people with T1DM.
-In children

**hypothyroidism.
•Screen for thyroid peroxidase (TPO) and thyroglobulin antibodies at diagnosis.
•Monitor TSH after metabolic control is established.

61

Given a patient with diabetes, identify the symptoms consistent with hyperglycemia.

•Increased thirst that is not normal
•Increased need to urinate especially at night
•Unintended weight loss
•Repeated vaginal yeast infections (2-3 or more in a 6-month period) or yeast/fungal infections on other parts of the body (otitis externa or in body folds)
•Fatigue
•Repeated urinary tract infections
•Sores that do not heal
•Erectile dysfunction in men
•Blurred vision

62

Given a patient with diabetes, select the diagnostic modality.

•Fasting plasma glucose (FPG) (this one is commonly done) OR
•2-h plasma glucose (2-h PG) value after a 75-g oral glucose tolerance test (OGTT) (this one is not commonly done) OR
•A1c criteria (this one is commonly done in conjunction with FPG)

63

Select the diagnostic criteria (fasting blood glucose, A1c) for prediabetes.

•IFG (impaired fasting glucose) --fasting blood glucose > 100 mg/dl and <125 mg/dl OR
•IGT (impaired glucose tolerance) --2-hour plasma glucose 140 to 199 mg/dl OR
•A1c 5.7% to 6.4%

64

Select the diagnostic criteria (fasting blood glucose, A1c,) for diabetes.

•A1c > 6.5% OR
•Fasting plasma glucose > 126 mg/dl (fasting—no caloric intake for 8 hrs) OR
•A random (without regard to last food intake) plasma glucose level of >200 mg/dL plus clinical signs and symptoms of diabetes (polyuria, polyphagia, polydipsia, fatigue, weight loss or blurred vision and persistent hyperglycemia).

65

What is the renal threshold for glucose

180 mg/dL of glucose
- after this, glucose spills into urin

66

what's the normal range for serum sodium?

135-145 mEq/L

67

What is the effect of DKA on serum sodium

• Hyponatremic
• Osmotic changes pull water out of cells, reducing plasma Na concentration

68

What is the effect of DKA on serum potassium

- DKA causes a potassium deficit, average 300-600 mEq.
- Factors that cause hypokalemia:
• Urinary losses
• Glucose osmotic diuresis
• Excretion of potassium ketoacid anion salts

69

Presentations of potassium when in DKA

• Hyperkalemic: shift of K out of cells but hasn’t been peed out yet
• Eukalemic: shift of K out of the cells but have peed enough out that the serum concentration appears normal. Person has lost sig amts of K
• Hypokalemic: shift of K out of the cell and have peed it out, this is worst case scenario

70

What is the effect of DKA on serum phosphate

- Hypophosphatemia
- Causes
• Decreased intake
• Acidosis-related shift into ECF
• Phosphaturia dt osmotic diuresis
- Same as potassium, might present early with hyperphosphatemia or euphosphatemia

71

What is the effect of DKA on serum creatinine

• Acute elevations in serum Cr (and BUN)
• Reflects reduction in glomerular filtration dt hypovolemia

72

What is the effect of DKA on plasma osmolality

• Increased dt elevations in glucose
• Plasma osmolality = sodium + glucose + BUN (not full equation)

73

What is the effect of DKA on WBC count

Generally slightly elevated 12,000-13,000 (4,000-11,000 nl)

74

What is the effect of DKA on lipids

elevated TG

75

Given a blood glucose and a serum Na, determine the corrected sodium value

- Serum Na concentration will fall approx. 1.6 mEq/L (2) for every 100 mg/100mL increase in glucose concentration

Ex: If blood sugar is 550 and measured serum Na is 130
• 550-100 = 450, the amount of sugar above normal
• 450/100 = 4.5, conversion based on ratio
• (4.5)(2) = 9, amount serum Na is under reported
• 130 + 9 = actual serum sodium level