Wk 12 Flashcards
(229 cards)
1
Q
DM is a group of metabolic disorders characterized by:
A
hyperglycemia
impaired metabolism
impaired insulin secretion/insulin resistance
2
Q
Percentage of Type I cases
A
5-10%
3
Q
age of onset of type I
A
<30
4
Q
genetic link for type I
A
weak
5
Q
pathogenesis of type I
A
absolute deficiency of insulin production
6
Q
percentage of cases of type II
A
90+
7
Q
age of onset of type II
A
> 30
8
Q
genetic link of type II
A
strong
9
Q
pathogenesis of type II
A
insulin resistance, defective insulin release
10
Q
diagnosis of DM is confirmed by ___
A
repeat
11
Q
type I is typically due to an ____ mediated destruction of pancreatin B cells
A
autoimmune
12
Q
4 main features of type I
A
long pre-clinical period
hyperglycemia when 80-90% of B cells are destroyed
transient remission (honeymoon period)
established disease
13
Q
Type I tx is ____ to each patient
A
individualized
14
Q
goal of type I tx
A
to mimic normal physiologic levels
15
Q
single injection of long-acting insulin
A
basal
16
Q
> 1 injection of short-acting insulin at meal time
A
bolus
17
Q
basal bolus approach composed of a ___ for basal coverage and a ___ for bolus doses at mealtime
A
long acting insulin; short acting insulin
18
Q
Human insulin
A
regular, short acting
100 units/mL, 500 u/mL
19
Q
human insulin is ___ prone
A
error
20
Q
insulin analogs
A
rapid acting
long acting
21
Q
NPH insulin
A
intermediate acting
22
Q
types of insulin
A
human insulin
insulin analogs
NPH
mixtures
23
Q
oral administration of insulin destroys ___
A
protein
24
Q
insulin must be given ___, usually by ___
A
parenterally; subQ injection
25
using a SC injection of insulin slows ___
absorption
26
regular insulin may be given ___
IV
27
rapid absorption of insulin may be due to ____
reduced self-association
28
advantage of rapid acting insulin
may inject closer to meal time
29
long acting insulin have reduced ___, slowing ___
solubility; absorption
30
advantaged of long acting insulin
continuous coverage w/o injections
31
long acting insulin analogs
glargine
detemir
degludec
32
duration of glargine
22-36h
33
Lantus dosage
100 units/mL
34
tujeo dosage
300+ units/mL
35
advantage of tujeo (glargine)
causes less nocturnal hypoglycemia
36
duration of detemir
12-20h
37
detemir is dosed ___ x /d
1-2
38
degludec is ___ prone
error
39
duration fo degludec
>42h
40
dosage of tresiba (degludec)
100, 200 units/mL
41
NPH insulin =
neutral protamine hagedorn
42
NPH: suspension of:
crystalline zinc insulin
| positively charged polypeptide, protamine
43
NPH is absorbed slower after ____
subQ injection
44
duration of action for NPH is:
longer than regular (or analog) insulin
| shorter than glargine, detemir or degludec insulins
45
Humulin is manufactured by
Eli Lilly
46
Novolin is manufatured by
Novo Nordisk
47
Total daily dose of insulin required
~ 0.4-1 units/kg/d of actual body weight
48
decrease total daily dose of insulin during honeymoon period to ____
~0.2-0.5 units/kg/day
49
basal insulin in type I is approximately ____ total daily insulin dose
1/2
50
in type I, you Amy use _____ insulin
intermediate/long acting
51
in type I, ___ is perferred as it can be mixed
NPH
52
Detemir may require ___ dosing
q12h/BID
53
Meal time insulin in type I is ___% of total daily dose
50
54
meal time insulin for type I is divided between meals based on ___
type of meal
| patient characteristics
55
for meal time insulin w/ type I, u se ___ or ___ insulin
rapid acting/regular
56
non intensive insulin therapy has ____ dosing
split-mixed (2 daily injections)
57
2 daily injections fo non-intensive insulin:
2/3 TDD in morning
| 1/3 TDD in evening
58
basal insulin should be ___ as morning dose, ___ as evening dose
2/3; 1/3 (even if using NPH)
59
non intensive insulin therapy also has 3 daily injections. Dose:
same as "split mixed" but moves NPH to bedtime
60
non intensive insulin therapy with 3 injections reduces ___ and increases ___
nocturnal hypoglycemia; effect at dawn
61
intensive insulin therapy requires multiple ___ each day
self monitoring blood glucose checks
62
sliding scale insulin has two categories:
tight control
| regular control
63
blood glucose levels evaluates impact of ____
insulin on meals
64
SMBG measures:
fasting blood glucose
| post prandial glucose
65
glycosylated hemoglobin (HbA1c) assess ____ over 2-3 months
glycemic control
66
in non diabetics, HbA1c should be ___
4-6%
67
AACE guidelines recommend ___ A1c
<6.5%
68
ADA guidelines recommend ___ A1c
<7%
69
process of hba1c is
irreversible
70
A1c lasts life of the ___ (__ days)
RBC; 120 days
71
a1c reflects average ____
glucose over 3 months
72
type II DM is a disease of:
insulin secretion
insulin resistance
excess glucose production
OR all of the above
73
treatment for type II DM is based on:
age/comorbidities
| individualized
74
begin at diagnosis of type II DM with ___
pharmacotherapy
75
target weight loss for type II
>7kg
76
Therapeutic lifestyle changes for type II DM
weight reduction
tobacco cessation
minimize alcohol intake
nutritional counseling
77
weight reduction in type II DM may decrease A1c by ___%
1-2
78
insulin
route:
weight:
HG:
SC/IV
gain
mod-severe
79
SUs
Weight:
HG:
gain
| mod-severe
80
glinides
weight:
HG:
gain
| mild-moderate
81
TZDs
| weight:
gain
82
pramlintide
| route:
SC
83
GLP-1 RAs
| route:
SC
84
at dx of type II, start
TLCs and monotherapy w/ metformin
85
start dual therapy for type II if:
if not at target a1c after 3 mo of monotherapy OR
| if baseline a1c >9%
86
start triple therapy for type II if
if not at target a1c after 3 months of dual therapy
87
start COMBO injection therapy for type II if:
not at target a1c after 3 mo of triple therapy
blood glucose is >300-350 mg/dL and/or
a1c >10-12%
88
highly effective hypoglycemic agents
insulin
biguanides (metformin)
sulfonyureas
rapid-acting secretagogues (glinides)
89
in type II, insulin is now used earlier in ___
pharmacotherapy
| minimizes micro and macrovascular complications
90
in type II, ___ are being used earlier
multiple drugs
91
when to start insulin in type II DM
not at A1c goal arter >2 non insulin hypoglycemics
severe FBG levels
A1c levels >10%
DO NOT USE AS THREAT FOR NOT REACHING A1C GOALS
92
start with ___ insulin in type II DM
basal (long acting)
93
long acting insulin in type II DM causes less ___
hypoglycemia
94
both NPH and LA analogs are ____
equally effective
95
NPH is available ___ and is much ___
OTC; cheaper
96
starting insulin for type II DM:
1. start basal insulin once daily
2. adjust once or twice weekly
3. if not at Goa (or dose >0.5 u/kg/d) begin prandial rapid acting before largest meal (0-15 mins) or premixed insulin
4. if still not controlled, begin basal-bolus insulins (30 mins before meals)
97
biguanides route
PO
98
first line DOC for type II DM
metformin
99
MOA of metformin
reduces hepatic glucose production
reduces intestinal glucose absorption
increases insulin sensitivity
improves peripheral glucose uptake and utilization
100
metformin promotes modest ___ or ___
weight loss; weight neutral
101
metformin lowers fasting BC ___%, and A1c __%
20%; 1-2%
102
metformin has a synergistic effect with ___
SUs
103
metformin has minimal ___ as monotherapy
HG
104
metformin has a generally minimal ____
s/e profile
105
adverse reactions of metformin
```
primairly GI effects: N/V, diarrhea, flatulence
Lactic acidosis (death)
```
106
C/I of metformin
Male: SCr >1.5 mg/dL
Female: Screaming >1.4 mg/dL
CrCl <30 (CKD sag 4/5)
107
first biguanide was
phenformin
108
monitor metformin users with CrCL of
30-59
109
monitor metformin users for:
renal failure, dehydration
infections/sepsis
metformin overdose
110
SUs are usually given ___
once daily
111
downside of SUs
greater risk of HG w/ glimepiride
112
second line therapy after metformin for type II
SUs
113
all SUs are equally effective ____
within class
114
Cus are ___ effective as a class
moderately
115
efficacy of SUs ___ over time
decreases (beta cell burnout)
116
___ SUs are rarely used
first generation
117
___ SUs are preferred
second generation (less HG)
118
dose of glimepiride
q24h
119
s/e of glimepiride
causes more HG than glipizide
120
glipizide dosage
q12-24h
121
glyburie is not preferred due to ___
most HG of the 3 second generation SUs
122
dose of glyburide
q12-24h
123
MOA of SUs
stimulate release of insulin
requires presence of insulin (functioning pancreas)
not effective in type I
124
greatest concern with SUs
HG
125
rapid acting secretagogues AKA ___
glinides
126
nateglinide is dosed
ac tid
127
repaglinde is dosed
ac, 2-4xd
128
rapid acting secretagogues are ____ agents
oral antidiabetic
129
rapid acting secretagogues have ____ dosing than SUs
more frequent
130
MOA of rapid acting secretagogues
stimulates insulin release from pancreas
similar to SUs but shorter half life
Faster than SUs (rapid acting)
131
repaglinide is ____ effective than nateglinide
slightly more effective at A1c reduction
132
adverse effects of rapid acting secretagogues
hypoglycemia (less than SUs)
| weight gain
133
adrenergic manifestations of HG
shakiness, nervous, anxiety
| palpitations, achy, sweating (absent if on B blockers)
134
glucagon manifestations of HG
hunger, n/v , HA
135
neuroglycopenic manifestations of HG
impaired judgement, mentation
fatigue, lethargy, ataxia (mistaken for drunkenness)
stupor, coma, seizures
136
mild HG tx
glucose tablets
fruit juice
hard candy (no artificial sweeteners)
glucose gen
137
severe HG tx
glucagon injection
| 50% dextrose
138
moderately effective HG agents
TZDs
DPP4Is
SGLT2Is
139
available TZDs
rosiglitazone
| Pioglitazone
140
doseing of rosiglitazone
1-2xd
141
dosing of pioglitazone
once daily
142
TZDs have a synergistic effect when combined with
SUs
metformin
insulin
143
MOA of TZDs
increase insulin sensitivity by;
increasing glucose utilization
decreasing glucose production
(requires presence of insulin)
144
adverse effects of TZDs
weight gain (~9lbs)
increased total cholesterol, LDL, HDL
edema
hepatic metabolism
145
when should you avoid TZDs
if LFTs >2.5 ULN
146
rosiglitazone has an increased risk of ____
MI
| (FDA warning 5/21/2007(
147
record finding in 2013 found no difference in ___ between rosiglitazone or metformin/SU
CV risk
148
restrictions on TZDs removed in
2013
149
pioglitazone:
cost:
dose:
~$10
| once/d
150
rosiglitazone
cost:
dose:
~$90
| 1-2xd
151
intestinal incretin hormones
GLP1
| GIP
152
incretin hormones increase ____ in response to meals
insulin secretion
153
prolonging incretin levels (in DPP4Is):
stimulates insulin synth & release
| decreases glucagon secretion from pancreatic alpha cells
154
DDP4Is are ___ enhancers
incretin
155
net result of DPP4Is
prolonged basal insulin secretion
156
DPP4Is are __ anti diabetic agents, used ___
oral; once/daily
157
DPP4Is cause minimal __ and are weight ___
HG; neutral
158
DPP4Is are are costly:
$380/mo
159
renal adjustment for lingaliptin
NONE
160
DPP4Is have increased risk of ___, but no increased risk of hospitliization ___
HF; HF
161
SGLT2Is are a new class of ___ antidiabetics which are __ effective
oral; moderately
162
MOA of SGLT2I
SGLT2 recovers filtered glucose from urine
inhibition increase urinary glucose loss
lowers BP and decreases weight
163
adverse effects of SGLT2Is increase risk ooo ___
genital fungal infection, dehyration
164
recent FDA safety communication for SGLT2Is:
ketosis (73 cases)
| UTis, pyelonephritis (19 cases)
165
minimally effect HG agents
a-glucosidase inhibitors
pramlintide
glucagon-like peptide receptor agonists
166
AGIs are __ HG agents, dosed ___
oral; TID
167
most of AGI
$30-60 / 30 days of therapy
168
MOA fo AGI
inhibits pancreatic alpha-amylase and GI brush border alpha glucosidases
delays hydrolysis of ingested carbs
reduces postprandial insulin and glucose peaks
169
AGIs are effective for ___
type I and type II
170
AGIs do NOT cause ___
HG
171
AGIs are ___ between agents
equally effective
172
AGIs are typically combined with _____
metformin; SUs; insulin
173
SE of AGIs
flatulence (73%)
| diarrhea (31%)
174
pramlintide is a synthetic analog of ___
human amylin
175
pramlintide decreases ____
post prandial glucose levels
176
pramlintide does not act on ___
B cells (effective for type I and type II)
177
pramlintide
risk of HG:
affect on weight:
neutral
| loss
178
pramlintide has additional ___ separate from insulin injection prior to each ___
subcutaneous injection; meal
179
glucagon requires ___
SC injection
180
dose of liraglutide
once daily
181
dose of exenatide IR
| dose of eventide ER
BID
| once weekly
182
dose of albiglutide
once weekly (requires reconstitution before use)
183
MOA of GLP 1
```
incretin mimetic
enhances glucose dependent insulin secretion
inhibits release of glucagon
slows rate of gastric emptying
increases satiety
```
184
GLP 1 RAs
| weight:
loss
185
GLP1 RAs were recently ___
discontinued
186
type II recommendation: ___ initially
metformin
187
mono, dual, or triple therapy for ______
mild, moderate of severe type II DM
188
most type II diabetics will require ____
multiple medications eventually
189
DKA is mainly seen in ___
type I diabetics
190
DKA is most often precipitated by
omission of treatment (medication non-adherence)
infection (if percent, usually hyperthermic)
alcohol abuse
191
DKA presentation:
```
polyuria
polydipsia
polyphagia
weakness
N/V
dehydration
```
192
tx mild DKA ___
outpatient
193
tx mod-severe DKA ___
inpatient
194
if severe DKA admit to __
ICU
195
DKA tx
```
fluids
insulin
potassium
bicarb
sodium
```
196
biologically active thyroid hormones:
t4 (thyroxine)
| t3 (tri-iodothyronine)
197
___% of T3 produced in the thyroid gland
20%
198
___% of T3 produced peripherally by breakdown of T4
80
199
steady state of thyroid hormone
4-5 half lives
200
thyroid gland purpose:
regulation of hormone production
| hypothalamic-pituitary-thyroid axis
201
production of thyroid hormone regulated by two mechanisms:
TSH secretion by ant pit
| extra thyroidal conversion of t4 to t3.
202
primary hypothyroid:
disorder of thyroid gland
| hashimoto's thyroiditis
203
secondary hypothyroidism:
pituitary or hypothalalmic disorder
204
sx of hypothyroid
weight gain
| depression
205
when working up a pt for depression, ___ is essential
eval of thyroid function
206
hypothyroid lab tests
serum TSH
| free or total T4
207
subclinical hypothyroid:
TSH:
Free/total T4
high
| normal
208
hypothyroidism
TSH:
free/total t4
high
| low
209
DOC for hypothyroid
levothyroxine
| synthetic t4 -- long half life -- once daily dosing
210
dose IV dose at ___ of oral dose
50%
211
note: doses are in ___
MICROGRAMS
212
other hypothyroid tx
dessicated beef or pork thyroid gland (dosed in mg not mcg)
| t3 and t4 mixtures (liotrix)
213
S/E of desiccated beef or pork thyroid gland
potential for allergy
| considered obselete
214
cons of t3 and t4 mixtures
expensive, lacks therapeutic rationale
215
dosing for levothyroxine
take once daily in AM on empty stomach
216
typical dose of levo
100-112 mcg/day
217
use lower initial dose of levo in ___
elderly
| patients with CV disorder
218
pregnancy usually requires an __ in levo dose
increase
219
clinical presentaiton of hyperthyroid
nervousness/anxiety/palpitations
heat intolerance
finger tremor
cardinal sign: loss of weight
220
classic triad of grave's disease
hyperthyroidism
ophthalmopathy
dermopathy
221
hyperthyroidism
TSH
free/total t4
low
| high
222
tx of hyperthyroidism
antithyroid medications
| propylthiouracil PTU, methimazole
223
MOA of PTU
inhibits peripheral conversion fo t4 to t3
224
dosing of PTU
TID
225
eval patient ___ for recurrence of hyperthyroidism with PTU
q3mo
226
methimazole is ___ as potent as PTU
10x
227
MOA of methimazole
blocks oxidation of iodine in thyroid
| no effect on circulating t3 or t4
228
dosing of methimazole
TID
229
s/e of antithyroid medications
agranulocytosis
aplastic anemia
thrombocytopenia
