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66 Cards in this Set
- Front
- Back
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For patients with an A1C level less than 7.5%, what are considered reasonable alternatives to metformin. |
Glucagon-like peptide-1 receptor agonists; dipeptidyl peptidase-4 inhibitors; and alpha glucosidease inhibitors. Caution is advised for the use of sodium-glucose co-transporter-2 inhibitors, thiazolidinediones, sulfonulureas, and meglitinides. |
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What are some additional considerations when choosing between a more stringent treatment plan and a less stringent plan. |
Patient attitude and expected treatment effort, risks potentially associated with hypoglycemia and other adverse events; disease duration; life expectancy; important co-morbidities; established vascular complications; and patient resources or support system. |
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Why is metformin suggested as the single monotherapy option? |
Low cost, low risk of hypoglycemia; and ability to achieve glycemic goals in most patients. Data suggesting metformin use within the first 3 months of diagnosis may preserve pancreatic beta cell function and delay the progression of diabetes. |
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What are the three classes of orally administered drugs for obesity management? |
Sympathomimetic agents; selective-serotonergic agents; lipase inhibitors. |
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Phentermine: action; expected weight loss; contraindications; interactions precautions? |
Drug class: Sympathomimetic agents Action: Reduces appetite by stimulating the hypothalamus to release norepinephrine. Similar to amphetamines. Expected weight loss: varies and weight typically returns to normal after treatment stops. Contraindications: Hx of cardiovascular disease; hyperthyroidism; hx of drug abuse; glaucoma, agitated states; monoamine oxidase inhibitor therapy; pregnancy. Interactions: Numerous drug-drug interactions related to stimulatory effects. Increased blood pressure and heart rate. Alcohol may enhance CNS adverse state. Precautions: May impair the ability to engage in potentially hazardous activities. Discontinue in patients experiencing new-onset chest pain; shortness of breath; or lower extremity edema. May be associated with development of valvular heart disease. Significant abuse potential. |
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Phentermine with Topiramate: action; expected weight loss; contraindications; interactions; precations |
Same as phentermine. Lower dose to minimize side effects yet achieves maximal weight loss of 5-10%. Drug class: Sympathomimetic agents Action: Reduces appetite by stimulating the hypothalamus to release norepinephrine. Similar to amphetamines. Expected weight loss: 5-10% and weight typically returns to normal after treatment stops. Contraindications: Hx of cardiovascular disease; hyperthyroidism; hx of drug abuse; glaucoma, agitated states; monoamine oxidase inhibitor therapy; pregnancy. Interactions: Numerous drug-drug interactions related to stimulatory effects. Increased blood pressure and heart rate. Alcohol may enhance CNS adverse state. Precautions: May impair the ability to engage in potentially hazardous activities. Discontinue in patients experiencing new-onset chest pain; shortness of breath; or lower extremity edema. May be associated with development of valvular heart disease. Significant abuse potential. |
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Orlistataction: expected weight loss; contraindications; interactions; precations |
Drug class: Lipase inhibitors Action: Inhibits gastrointestinal lipase resulting in decreased hydrolysis of dietary fat a step necessary for absorption. Expected weight loss: 2.8% of baseline weight. Contraindications: Chronic malabsorption syndrome, cholestasis. Pregnancy Category X. Interactions: Decreased vitamin K absorption may prolong bleeding for patients taking warfarin. Decreased absorption of cyclosporine and levothyroxine. Precautions: Gastrointestinal events may increase with high-fat diets. |
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Selective-serotoergic Agents: action; expected weight loss; contraindications; interactions; precations |
Drug class: Selective-serotoergic agents Action: Agonist of selective serotonin receptors in the hypothalamus resulting in decreased appetite. Expected weight loss: Approved for chronic weight management as adjunct to low-calorie diet and increased physical activity. Patients may lose 5% of baseline weight or 3 kg. Contraindications: Pregnancy category x Interactions: Use with other serotonergic drugs; serotonin-norepinephrine reuptake inhibitors; may increase risk of serotonin syndrome. May increase serum concentrations of cytochrome P450 2D6 substrates. Precautions: May be associated with development of valvular heart disease. May cause cognitive disturbances. May cause priapism. Significant abuse potential. |
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Sulfonylureas: action; expected weight loss; contraindications; interactions; precautions |
Action: Reduce glucose by increasing insulin secretion from pancreatic beta cells in patients with residual beta cell function Expected decrease in A1C with monotherapy: 1-2% Contraindications: Documented hypersensitivity; diabetic ketoacidosis; type 1 diabetes; Pregnancy category C Interactions: Numerous possible drug interactions, few clinically significant. Sulfonamides may enhance hypoglcyemic effect. Precautions: Hypoglycemia. Caution in hepatic or renal impairment; risk factors are older age, malnutrition, and irregular eating. May cause rash, sun sensitivity, nausea, vomiting, leukopenia, agranulocytosis, aplastic anemia, intrahepatic cholestasis, disulfiram-like reaction, flushing, headache, and SIADH causing hyponatremia. |
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Meglitinides: action; expected weight loss; contraindications; interactions; precautions |
Action: Short-acting insulin secretagogues; stimulate insulin release from pancreatic beta cells. Expected decrease in A1C with monotherapy: .5-1.5% Contraindications: Documented hypersensitivity; DKA; type 1 DM Interactions: CyP3A4 inhibitors decrease metabolism, increasing serum levels and effects. Thiazide diuretics corticosteroids, estrogens oral contraceptives, nocotinic acid, calcium channel blockers, phenothiazines, and thyroid products may lower glycemic control. Toxicity increased with highly protein-bonded drugs. Precautions: Hypoglycemia, especially if carbohydrate not eaten after drug. Caution in hepatic impairment. |
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Biguanides: action; expected weight loss; contraindications; interactions; precautions |
Action: Decrease hepatic gluconeogenesis and increase peripheral insulin sensitivity. Do not increase insulin levels or weight. Monotherapy does not commonly cause hypoglycemia. Expected decrease in A1C with monotherapy: 1-2% Contraindications: Serum creatinine level >1.5 mg/dl in men or >1.4 mg/dl in women or glomerular filtration rate <30 mL/min; hepatic dysfunction; acute or chronic acidosis; local or systemic tissue hypoxia; excessive alcohol intake; drug therapy for congestive heart failure. Interactions: Numerous possible drug interactions, few (if any) clinically significant. Can cause gastrointestinal upset, nausea, and diarrhea; take with food or milk to minimize GI effects. Pregnancy Category B. Precautions: Fatal lactic acidosis if given with contraindication. Discontinue before IV contrast enhancement; do not restart until Creatinine level normal. Withold in acute hypoxia. Check renal function regularly and discontinue if abnormal. Adverse effects including GI, especially diarrhea, may cause discontinuation. |
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Alpha-Glucosidase Inhibitors: action; expected weight loss; contraindications; interactions; precautions |
Action: Inhibit action of alpha-glucosidase, delaying and attenuating postprandial blood glucose peaks. Undigested sugars are delivered to the colon, where they are converted into short-chain fatty acids, methane, carbon dioxide, and hydrogen. Do not increase insulin levels or inhibit lactase; major effect is to lower postprandial glucose levels. Do not cause weight gain. May restore ovulation in anovulation due to insulin resistance. Expected decrease in A1C with monotherapy: .5-.8% Contraindications: Documented hypersensitivity, DKA, or cirrhosis; inflammatory bowel disease; colonic ulceration; serum creatinine level >2 mg/dL; elevated liver enzyme levels; partial or predisposition to intestinal obstruction Interactions: Hypoglycemia with insulin or sulfonylurea agents. May decrease absorption and bioavailability of digoxin, propranolol, and ranitidine. Digestive enzymes may reduce effects. Precautions: may cause GI symptoms not recommended in significant renal dysfunction. |
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Thiazolidinediones: action; expected weight loss; contraindications; interactions; precautions |
Action: Increase peripheral insulin sensitivity by increasing transcription of nuclear proteins that help increase uptake of glucose, probably with effects on free fatty acid levels. About 12-16 weeks to achieve maximal effect. May restore ovulation in anovulation due to insulin resistance. Improve target cell response to insulin without increasing insulin secretion from pancreas. Decrease heaptic glucose output and increase insulin-dependent glucose use in skeletal muscle and possibly liver and adipose tissue. Expected decrease in A1C with monotherapy: .5-1.4% Contraindications: Documented hypersensitivity; active liver disease; DKA; type 1 diabetes; class III or IV congestive heart failure. Interactions: With insulin or oral hypoglycemics (eg, sulfonylureas), may increase risk of hypoglycemia. Precautions: Monitor transaminases every 2 months for first year, periodically thereafter; discontinue if alanine aminotransferase is above 3x upper limit of normal. Caution in edema and congestive heart failure. May decrease hemoglobin, hematocrit, and white blood edema and congestive heart failure. May decrease hemoglobin, hematocrit, and white blood cell counts. Effects on lipids neutral or beneficial. May increase fracture risk. Increased risk of cardiovascular events with rosiglitazone. |
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Dipeptidyl peptidase-4 inhibitors: action; expected weight loss; contraindications; interactions; precautions |
Action: Slows inactivation of incretin hormones (GLP-1) by the enzyme DPP-4. Prolonged action of endogenous GLP-1 increases insulin release and decreases glucagon secretion from pancreatic cells, resulting in lower circulating glucose levels. Expected decrease in A1C with monotherapy: .5-.8% Interactions: With insulin secretagoguse may increase risk of hypoglycemia; not studied in combination with insulin. Coadministration of saxagliptin with strong CYP3A4/5 inhibitors significantly increases saxagliptin concentrations. Precautions: Reduced dose recommended with decreased renal function for all except linagliptin. Postmarketing reports of increased risk of acute pancreatitis associated with incretin mimetics |
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Dopamine Receptor Agonists: action; expected weight loss; contraindications; interactions; precautions |
Action: Ergot derivative that is a dopamine receptor agonist improves glycemic control by an unknown mechanism Expected decrease in A1C with monotherapy: .1-.4% Contraindications: Documented hypersensitivity to ergot-related drugs; history of syncopal migraines; nursing women; DKA or type 1 diabetes Interactions: Orthostatic hypotension with antihypertensive medications. May exacerbate psychotic disorders or reduce effectiveness of antipsychotic medications. Interaction with dopamine antagonists such as neuroleptic agents. May increase ergot-related side effects or reduce ergot effectiveness for migraines. Dopamine antagonists may decrease the effectiveness of bromocriptine. May increase unbound fraction of highly protein-bound therapies, altering their safety and efficacy. Extensively metabolized by CYP3A4. use caution when coadministered with strong inhibitors, inducers, or substrates for CYP3A4. Precautions: May cause somnolence. |
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Sodium-Glucose Co-transporter-2: action; expected weight loss; contraindications; interactions; precautions |
Action: Inhibits reabsorption of filtered glucose in the kidney. Expected decrease in A1C with monotherapy: .8%-1% Contraindications: Documented hypersensitivity; severe renal impairment (GFR<45 mL/min), end-stage renal disease, or on dialysis; nursing women. Interactions: Use caution when co-administered with UGT inducers. Digoxin concentrations may increase. Precautions: Hypotension related to hypovolemia especially in patients>65 years old. Hyperkalemia in patients with renal impairment. Increased risk of genital mycotic infections and urinary tract infections; increased urination.
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Actoplus met |
pioglitazone/metformin |
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Avandaryl |
Rosiglitazone/glimepiride |
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Avandamet |
rosiglitazone/metformin |
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Duetact |
pioglitazone/glimepiride |
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Glucovance |
glyburide/metformin |
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Metaglip |
Glipizide/metformin |
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Janumet |
sitagliptin/metformin |
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Name three GLP-1 Receptor agonists and describe how they are administered |
Exenatide; Exenatide lAR; Liraglutide Injected by subcutaneous injection in the thigh, upper arm, or abdomen. Exenatide LAR is injected once weekly. Exenatide is injected twice daily. Liraglutide is injected once daily. |
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Name four DPP-4 inhibitors and describe how they are administered |
Alogliptin; Linagliptin; Saxagliptin; sitagliptin. Administered once daily with or without food. |
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What is the substance used to form insulin |
pro insulin |
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What is amylin? |
A polypeptide released by the pancreas along with insulin to assist with regulating the effects of insulin. |
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What are the physiologic actions of insulin on body tissues? |
- Stimulates entry of amino acids into cells and enhances protein synthesis. -Enhances fat storage and prevents mobilization of fat for energy -Stimulates entry of glucose into cells for use as an energy source and promotes the resultant storage of glucose as glycogen in muscle and liver cells -Inhibits production of glucose from liver or muscle glycogen -Inhibits formation of glucose from non-carbohydrates, such as amino acids |
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What are the counter regulatory hormones that are antagonistic to insulin's hypoglycemic effects? |
Glucagon; norepinephrine; epinephrine; cortisol; growth hormone. |
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What are the concentrations of insulin currently available in the US? |
U-100 and U-500 (100 units per mL and 500 units per mL) |
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In what way do insulin products differ? |
Insulin products differ by onset, peak effect, and duration of action. They all dissociate differently but once absorbed into the blood stream they exert the same effect. |
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What short or rapid acting insulins are current available? |
Humalog (lispro) Novalog (aspart) Apidra (glulisine) |
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Which type of insulin is more likely to cause hypoglycemia? Rapid acting insulin or short acting? |
Short acting (regular insulin) |
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What is the onset, peak, and duration for rapid acting insulins? |
Onset: 5-15min Peak: 30-90 min Duration:<5h |
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What does NPH stand for? |
Neutral Protamine Hagedorn |
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What type of insulin is NPH? |
An intermediate acting insulin
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What is the onset, peak, and duration of NPH? |
Onset: 2-4 hours Peak: 4-10 hours Durration 10-16 hours |
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What are the two types of long acting insulins? |
Levimir (detemir) Lantus (glargine) |
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Why might Lantus (insulin glargine) cause a mild burning sensation when injected |
It is prepared in a solution with a pH of 4.0 which is highly acidic. |
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What is the onset, peak, and duration of lantus (insulin glargine) |
Onset: 2-4 h Peak: no peak Duration 20-24 h |
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What is the onset, peak, and duration of Levemir (insulin detemir)? |
Onset: 3-8h Peak: no peak Duration 5.7-24 h |
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What are the commercially available premixed insulins and insulin analogs? |
70/30 50/50 75/25 70/30 |
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What is the onset, peak and duration of 70/30 NPA/aspart ratio; 50/50, and 75/25? |
Onset: 5-15 min Peak: Dual Duration: 10-16 minutes |
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How do 70/30 NPH/regular ratio and 70/30 NPA/aspart ratio differ |
All premixed insulins have the same onset, peak, and duration. However, 70/30 NPH/regular ratio has an onset of 30-60 minutes instead of an onset of 5-15 minutes. |
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What is the physiologic insulin secretion rate? |
.5-1 unit per hour |
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What is the typical insulin requirement for indiduals with type 1 dm who are within 20% IBW? |
.5 to 1.0 units per kilogram of body weight per day |
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A 160lb man is newly diagnosed with dm. What is his likely starting insulin dose |
36-72 units per day based on .5 - 1 units per kilogram of body weight |
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When are insulin requirements highest in pregnant women and why? |
During the second and third trimester. The placenta produces counter regulatory hormones which oppose increases in plasma insulin |
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Why are women with gestational diabetes typically given a high dose of insulin before breakfast to initiate therapy? |
Before breakfast a rapid acting and intermediate acting insulin is often used with a rapid acting insulin given at night. This type of therapy can reduce the risk of nocturnal hypoglycemia, allow for better insulin coverage for early-morning hyperglycemia from the release of cortisol and growth hormone and in some cases may accommodate sleeping in |
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In type 2 dm what is typically the initial dose of insulin |
10 units or .2 units per kilogram of body weight. |
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What is a split mixed insulin regimen |
Using mixed doses in the morning and before the ening meal |
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How are split-mixed regimens typically administered? |
Usually... two thirds of the total daily dose of insulin is given before breakfast (using a ratio of 1 part rapid-acting or short-acting insulin to 2 parts intermediate acting insulin), and one third is given before the evening meal (using a ratio of 1:1 or 1:2, rapid-acting or short-acting to intermediate insulin). |
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When using a U-100 mL insulin concentration what type of syringe should be used for... <25 units < 30 units 50-100 units |
<25 units: .25mL <30 units: .3mL <50 units: .5mL 50-100 units: 1mL |
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What are the different needle lengths available? |
6mm (15/64-in) 8mm (5/16-in) 12.7mm (1/2-in) |
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What is considered the "short needle" and who is the short needle appropriate for? |
6mm and 8mm. It is appropriate for all patients regardless of BMI |
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What are jet injectors? |
Novel, needle-free systems that deliver insulin transcutaneously. They release a fine stream of insulin at high speed and under high pressure to penetrate the skin.
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What is exubera?
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An inhalation device that allows an inhalable form of recombinant human insulin. However its sale has been halted due to poor sales. |
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Why is c-peptide often used as a measure of endogenous insulin |
Because c-peptide and insulin are jointly secreted. It can be used as a marker of insulin type. Direct measurement of insulin secretion is difficult except under controlled or research conditions. |
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At what temperatures should insulin be stored? |
In the refrigerator at 36 to 46 degrees fahrenheit. |
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Where can insulin be injected? |
into the subcutaneous tissue of the upper arm, the anterior and lateral aspects of the thigh, the buttocks, and the abdomen. |
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What injection site has the greatest absorbability |
The abdomen |
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What are the symptoms of hypoglycemia |
Sweating; tremling; difficulty concentrating; lightheadedness; lack of coordination |
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Provide several examples of 15g glucose |
3 to 4 glucose tablets 8 to 10 life savers 2 tbsp raisins 4 to 6oz nondiet soft drink 4 to 6 oz fruit juice 1 piece of fruit 1 c low-fat or nonfat milk |
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When should an individual be given glucagon |
If they are experiencing hypoglycemia and are unable to swallow. |
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What is the effect of steroids on blood sugar |
decrease in blood glucose |
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What is the effect of corticosteroids on blood glucose |
increase |
