Clinical Therapeutics Exam Ii Diabetes Mellitus And Its Complications

Front 1

DM is a group of metabolic diseases characterized by hyperglycemia resulting from defects in what two things?

Back 1

Insulin Secretion

Insulin Action

Front 2

DM is chronically associated with long term damage, dysfunction and failure in what systems macrovascularly and microvascularly?

Back 2

Macrovascular: Heart and Blood Vessels

Microvascular: Eyes, Kidneys, Nerves

Front 3

What are the primary symptoms of hyperglycemia?

Back 3

Polyuria
Polydipsia
Weight loss in Type 1 DM

Front 4

This is DM with an absolute deficiency of insulin secretion?

Back 4

Type 1

Front 5

This is DM with resistance to insulin action and an inadequate compensatory insulin secretory response.

Back 5

Type 2

Front 6

This results from cellular-mediated autoimmune destruction of the B-cells of the pancreas.

Back 6

Type 1 DM

Front 7

What can be the first manifestation of DM type 1 in children/adolescents?

Back 7

DKA

Front 8

What are the four ways in which to diagnose DM?

Back 8

1. Symptoms of diabetes plus casual plasma glucose concentration of over 200mg/dl

2. FPG>126mg/dl

3. 2-h postload glucose > 200mg/dl during an OGTT (75g glucose)

4. A1C > 6.5%

Front 9

What drug can be considered for all "pre-diabetics"?

Back 9

Metformin

Front 10

What are the three key features of DKA?

Back 10

Hyperglycemia
Ketosis
Acidosis

Front 11

What are precipitating factors of DKA?

Back 11

Infection, concurrent illness, omission of insulin, inadequate insulin when sick.

Front 12

How do you treat DKA?

Back 12

Intensive fluid, immediate insulin, potassium replacement, treatment of underlying illness.

Front 13

What is the key difference between DKA and HHS?

Back 13

Key difference from DKA is insulin is present which prevents ketones/ketoacidosis.

Front 14

What is usually found with HHS?

Back 14

Severe hyperglycemia, dehydration, increased serum osmolarity, anion gap is usually normal.

Front 15

How do you treat HHS?

Back 15

Volume replacement, treat DM with po agents or insulin.

Front 16

When attempting to prevent microvascular problems in DM what are the goals?

Back 16

Achieve A1C goal
BP < 130/80
ACE-I in T1DM with microalbuminuria
ACE-I or ARB in T2DM with microalbuminuria
ARB in T2DM with macroalbuminuria
Foot care

Front 17

When attempting to prevent macrovascular problems in DM what are the goals?

Back 17

Achieve A1C goal
LDL <100 (or <70)
TG < 150
HDL >50
BP <130/80 - use ACE-I or ARB first
Aspirin daily (Only if at risk)
Quit smoking
(ACE-I, statin and aspirin if >40 yo and has another CV risk factor)

Front 18

This is the gold standard for monitoring glycemic control?

Back 18

A1C

Front 19

True or False:

Intensively lowered A1C to 6.5% or less doesn't reduce CV events in older, T2DM with a high risk of CVD?

Back 19

True

Front 20

What is an easy way to approximate A1C into blood glucose measurement?

Back 20

A1C - 2 X 30

Front 21

Concerning Lipid Panel, what is the order of priority in treating a patient with DM?

Back 21

LDL, HDL and then TG

Front 22

Combined hyperlipidemia, glycemic control first or in combination with lipid lowering therapy hopefully result in what goals?

Back 22

LDL <100, HDL >45, TG <150

Front 23

Of the nine drugs used for the treatment of T2DM what three have the highest effects?

Back 23

Insulin
Sulfonylureas
Biguanides

Front 24

What are the nine classes of drugs for treatment of T2DM?

Back 24

Insulin
Sulfonylureas
Biguanides
Alpha-glucosidase inhibitors
Glitazones
Glinides
GLP analogues
Amylin analogues
DPP-4 inhibitors

Front 25

What are two other drugs that are approved for the treatment of T2DM?

Back 25

Colesevelam
Bromocriptine

Front 26

For lipids (LDL), used as add on.
Lowers A1C - 0.5%
6 tablets once a day or 3 tablets twice a day.
Drug interactions; separate by four hours.

Back 26

Colesevelam

Front 27

For Parkinson's disease
Unknown mechanism, theory, reverses metabolic changes associated with insulin resistance/obesity
Lowers A1C - 0.5%
1.6-4.8mg only in the morning (glycemic effects related to circadian rhythm)

Back 27

Bromocriptine

Front 28

What are the four steps in treatment of type 2 diabetes?

Back 28

1. Diagnosis

2. Therapeutic lifestyle changes and Metformin

3. Combination therapy - Oral drugs only

4. Combination therapy - Oral drug with insulin

Front 29

These drugs decrease deaths and cardiac complications. They decrease hepatic glucose production and increase insulin mediated peripheral glucose uptake.

Back 29

Biguanides

Front 30

What are the drugs included in the biguanides?

Back 30

Metformin (Glucophage), Metformin hydrochloride extended release (Glucophage XR, Glumetza)

Front 31

Biguanides are contraindicated in what patients?

Back 31

Patients with impaired renal function.
(Serum Cr > 1.4 mg/dL for womeon or 1.5 mg/dL for men)

Front 32

These drugs increase endogenous insulin secretion, they also can cause hypoglycemia, weight gain, no specific effect on plasma lipids or blood pressure, and generally are the least expensive class of medication.

Back 32

Sulfonylureas

Front 33

What are the drugs included in the sulfonylurea class?

Back 33

First generation Sulfonylureas - Chlorpropamide (Diabinese), Tolazamide, acetohexamide (dymelor), tolbutamide.

Second generation sulfonylureas - Glyburide (micronase, glynase and diabeta), glimepiride (amaryl), glipizide (glucotrol, glucotrol XL)

Front 34

What is a good principle to use (dosage) when starting a sulfonylurea?

Back 34

Use Glipizide and start with 2.5mg, cut a 5mg pill in half.

Front 35

These drugs decrease insulin resistance by making muscle and adipose cells more sensitive to insulin. They also suppress hepatic glucose production.

Back 35

Thiazolidinediones

Front 36

What are some side effects of Thiazolidinediones?

Back 36

Weight gain
Edema
Hypoglycemia

Front 37

What patients should not take thiazolidinediones due to fluid retention/edema?

Back 37

Conraindicated in patients with CHF or abnormal liver function.

Front 38

What are the thiazolidinediones?

Back 38

Pioglitazone (actos), Rosiglitazone (Avandia)

Front 39

What thiazolidinedione has a link to myocardial infarction and what should be used instead?

Back 39

Rosiglitazone (avandia), Pioglitazone (actos) should be used instead.

Front 40

How long can it take for a thiazolidinedione to work and what is a good dosage to start at?

Back 40

It can take up to 3 months for it to work and 15mg is a good dose to start with.

Front 41

These drugs stimulate insulin secretion (rapidly and for a short duration) in the presence of glucose.

Back 41

Meglitinides

Front 42

These can be classified as short acting sulfonylureas and are very expensive.

Back 42

Meglitinides

Front 43

These are safer at higher levels of serum creatinin than sulfonylureas.

Back 43

Meglitinides

Front 44

What are the medications in the meglitinide class?

Back 44

Repaglinide (prandin), Nateglinide (starlix)

Only works if you take it when you eat, start low, go slow.

Front 45

These drugs block the enzymes that digest starches in the small intestines. Flatulance and abdominal discomfort can occur, contraindicated in patients with inflammatory bowel diseae or cirrhosis.

Back 45

Alpha-glucosidase inhibitors.

Front 46

What are the alpha-glucosidase inhibitors?

Back 46

acarbose (precose), miglitol (glyset)

Front 47

What is glucovance?

Back 47

glyburide/metformin

Front 48

What is metaglip?

Back 48

Glipizide/metformin

Front 49

What is Avandamet?

Back 49

rosiglitazone/metformin

Front 50

What is actopius met?

Back 50

pioglitazone/metformin

Front 51

What is Duetact?

Back 51

pioglitazone/glimepride

Front 52

What is Avandaryl?

Back 52

rosiglitazone/glimepiride?

Front 53

What is janumet?

Back 53

sitagliptin/metformin

Front 54

What is prandimet?

Back 54

repaglinide/metformin

Front 55

The drug pramlintide mimics three actions of what? What are the three actions mimicked?

Back 55

Pramlintide mimics three important actions of amylin that implacts glucose appearance.

1. Inhibits inappropriately high postprandial glucagon secretion

2. Slows gastric emptying

3. Promotes satiety and reduces caloric intake.

Front 56

What is the MOA of the amylinomimetic:Pramlintide?

Back 56

Analog of naturally occuring pancreatic hormone amylin

Suppresses glucagon secretion

Induces satiety and reduces food intake

Slows gastric emptying

Front 57

What are the indications for Pramlintide?

Back 57

DM2 as adjunct treatment who have failed to achieve glycemic control despite insulin therapy (with or without sulfonylurea and/or metformin)

DM1 as adjunct who have failed to achieve glycemic control with insulin

Front 58

How do you initiate pramlintide tx in Type 2 DM and for what reasons?

Back 58

Start at 60 micrograms and then go to 120 micrograms after 3-7 days. This is done to avoid severe nausea/vomiting.

Front 59

Initial dose is 60mcg SC immediately prior to major meals

Reduce preprandial insulin and mixed insulin by 50%

Increase to 120mcg when no significant nausea for 3-7 days

Adjust insulin doses accordingly

Back 59

Pramlintide in type 2 diabetics

Front 60

What is the Pramlintide dosing for Type 1 Diabetics?

Back 60

Initiate at 15mcg immediately prior to major meals

Reduce preprandial or mixed insulin by 50%

Increase to the next increment (30, 45, 60mcg) when no nausea has occurred for at least 3 days.

Adjust insulin dosing accordingly.

Front 61

Who is not a good candidate for pramlintide?

Back 61

Poor compliance with current insulin regimen

Poor compliance home glucose monitoring

A1C > 9%

Recurrent severe hypoglycemia requiring assistance during past 6 months.

Hypoglycemia unawareness

Confirmed gastroparesis diagnosis

Use of drugs that stimulate gastrointestinal mobility

Pediatric patients

Front 62

What are two important things to know about pramlintide and drug interactions/administration?

Back 62

Drug interactions:
Delays absorption
Give drugs that need a rapid onset 1 hour prior or 2 hours after injection

Administration:
Do not mix with insulin, give as a separate injection at a separate site at least 2 inches apart.

Front 63

These are gut hormones that enhance insulin secretion in response to food.

Enhances glucose dependent insulin secretion (beta cell response)

Back 63

Incretins - Glucagon LIke Peptide 1 (GLP-1)

Front 64

This is a drug that acts as a GLP-1/Incretin mimetic?

Back 64

Exanatide

Front 65

What are the properties of exanatide?

Back 65

It is long acting, in comparison to GLP-1.

It increase glucose dependent insulin secretion

Regulates gastric emptying

Decreases glucagon secretion

Decreases food intake

Decreases plasma glucose acutely to near normal levels

Resistant to DPP-IV degradation

Front 66

What is the MOA of exanatide?

Back 66

Mimics the action of gut incretin hormone GLP-1

Enhances glucose-dependent insulin secretion

Restores first phase insulin response

Suppresses glucagon secretion

Reduces food intake

Slows gastric emptying

Front 67

Exenatide is indicated for?

Back 67

Adjunctive therapy in T2DM who are taking metformin, a sulfonylurea, a glitazone (or in combination) and not achieving glycemic control (not in patients taking insulin).

Front 68

You do not use exenatide in patients with?

Back 68

gastroparesis

Some reports of kidney failure in people taking this.

Front 69

Exanatide can affect other drugs how?

Back 69

May reduce the rate and extent of absorption of orally administered drugs (care if rapid absorption needed, ie. contraceptives, antibiotics)

Front 70

This is a brand new GLP-1 analog that is long acting and requires only one daily dose. It shouldn't be given to anyone with a hx of thyroid cancer.

Back 70

Liraglutide

Front 71

GLP-1 and GIP are metabolized by?

Back 71

DPP4

Front 72

DPP4 inhibitors are?

Back 72

Sitagliptin (Januvia), Saxagliptin (onglyza),

Front 73

What is the dosing of saxagliptin?

Back 73

2.5-5mg daily - lower doses in renal dysfunction or if drug interaction with CYP3A4, inhibitor (ie. clarithryomycin)

Front 74

What is the dosing for sitagliptin?

Back 74

100mg qd

Front 75

What is the dosage of sitagliptin in a patient with moderate renal impairment?

Back 75

50mg qd

Front 76

What is the dosage of sitagliptin in ESRD patients?

Back 76

25mg qd

Front 77

What is the rapid acting insulin?

Back 77

Aspart (Novolog, glulisine (apidra), lispro (humalog)

Front 78

What is short acting insulin?

Back 78

Regular

Front 79

What is long acting insulin?

Back 79

Glargine (lantus), Detemir (levemir)

Front 80

This is when a patient has blood glucose < 50-60mg/dL, it is life threatening < 50mg/dL.

Back 80

Hypoglycemia

Front 81

The following are signs of what?

Cold sweats, faintness, dizzines
Headache
Tachycardia
Trembling, nervousness
Blurred vision
Hunger
Inability to awaken
Grouchiness
Personality change

Back 81

Hypoglycemia

Front 82

How do you treat hypoglycemia?

Back 82

Rule of 15: 15g of CHO, wait 15 minutes, check BS, repeat if needed.

Front 83

What are other ways to treat hypoglycemia?

Back 83

Chew 3 glucose tablets, tube of glucose gel, 1/2 cup of fruit juice, piece of fruit, 1 cup of milk, 1/2 cup of soda, 2 large or 5 small sugar cubes, 6-7 life savers, 2 tsp honey or corn syrup, glucagon injection.

Front 84

What are the causes of hypoglycemia?

Back 84

Too much insulin

Not enough food

Delayed meal

Exercise.