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114 Cards in this Set

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which type:
immune system destroys beta cells of pancreas
type I
which type:
insulin resistance and decreased production
type II
which type starts as insulin resistence
type II
which type:
insulin resistance caused by pregnancy, increased risk for type II
gestational
why would you check a c peptide
a protein that attaches to insulin when secreted by the pancreas, it breaks off and hangs around will be decreased in type I bc not much insulin - differentiate which type
what is the honeymoon phase
when increased insulin is secreted, will be a short time and then will stop
why is gestational diabetes occur
hormone from the placenta makes the body more resistance to insulin and pancreas needs to work harder, if cannot then develop gestational
what is insulin resistence
insulin not produced properly

muscle, fat, and hepatic cells do no respond to the insulin and this causes the pancreas to produce even more insulin

overtime the pancreas wears out

will develop into DM when pancreas unable to keep up, at diagnosis, pancreas works at 50%
how far in advance is insulin resistence before the diagnosis of DM
5-10 years before - why important to educate on lifestyle changes
what are the criteria for metabolic syndrome
ANY 3:
1. waist >40in men or >35 female
2. TG >150mg/dl
3. HDL <40mg/dl
4. BP >130/80
5. FBS >100 or on med for high BS
this is a blood glucose level higher than normal but not high enough for DM
pre DM
how long in pre DM until develop type II
10 years
what are some interventions you need to do for pre-DM
FOCUS on # not symptoms:

exercise - 5-7% wt loss decreases risk

usually no symptoms - may have acanthosis

check labs q 2 years
what is the diagnosis of DM vs Pre DM
Pre - FBS >100 - 125
or OGGT 140 - 200

DM - FBS > 126
OGTT >200
what is the ADA goal for DM type II and what is AACE goal
ADA <7%
AACE <6.5%
why should you always test more than just a FBS
because when borderline or been fasting for a while, the pancreas can compensate a little and make you WNL when fasting, its when eating the pancreas cannot compensate
what HA1C should you stay under to decrease complications
<6.5%
150 - 160mg/dl had 60% chance of developing complications - not too high
what type of diet should you encourage with DM type II
carb counting
label reading
meal planning
low sodium
low fat
low cholesterol
recipe adjustment

* do not skip meals, space 4-6 hours, small evening snack, avoid high sugar foods or drinks

Exercise
what are the benefits of physical activity
increase insulin sensitivity
improve CV function
reduce hyperinsulinemia - tell pancreas to calm down bc muscles using it
improve lipid panel
improve weight loss and controls weight
enhance fibrinolysis
help control BP
decrease stress
what does sugar do to the vessels
sugar changes the intima of the vessels, makes it sticky, hot and swollen - why ASA so good for CV disease, decrease enzymes that make it sticky
why does high intensity exercise cause higher sugars
bc only have a few seconds of sugar in the muscles, then get the sugar from the blood, once out, get from liver and the liver doesn't stop right away, but high sugars will decrease overtime
what medications cause a risk of hypoglycemia with exercise
insulin
meglitinides
sulfonylureas
why do you need an eye exam by weight lifting
because the vessels could pop, need to make sure vessels ok
when should you check BS
before meals or 2 hours after the START of eating. So change it up, do not do the same time everyday
what are the goals of FBS and PPBS in ADA vs AACE
ADA - 90 to 130
AACE - 70-110

ADA <180
AACE <140
how long are control solutions good for
3 months
how long are test strips good for
4 months
as patients get closer to A1C goal, the need to manage what increases
PPG - when HgA1c really high, FBS makes over 70% of the total A1c, the closer to 7% the higher the PPG contributes to the HgA1C
when should you be testing PPG in patients with DM
during gestational DM and all pregnant women with DM

in patients who achieve pre meal glucose targets whose HgA1C are high

when monitoring treatment aimed specifically at lowering PPG

When patient has low BS after eating - usually gastroparesis bc not going into blood stream
what are alpha-glucosidase inhibitors
acarbose and miglitol
what are the actions of alpha glucosidases
delay the rate of glucose absorption by inhibiting alpha glycosidase enzyme in the brush border of the gut

reduce PPG
slow digestion of complex carbs

cause A1C decrease 0.5-1%
when used along no hypoglycemia
cause weight loss
how should you take alpha-glucosidases
take with first bite of food only, if forget, cannot take it!

start with 25mg TID - weight based
make adjustments based on PPG
caution with insulin or sulfonylureas because of low BS
monitor LFTs every 3-6 months
blocks sucrose and starches so if low BS cannot have juice - must give MILK
what are SE of alpha- glucosidases
GI - bad
increased LFTs
what are biguanides
metformin
metformin XR
Glumetza
Riomet - liquid
what is the action of biguanides
reduce hepatic glucose production
stimulate glucose transport in muscle and tissue
decrease glucose absorption

DOESNT CAUSE LOW BS!!!

Type II has no feedback - sugar pushes out of liver when start to eat, then eat = high sugar, metformin helps decrease production of sugar surge

DO not give with IBD - bc of increased GI effects
what are benefits of biguanides
safe - lactic acidosis rare
decrease HgA1C 1-2%
helps lipids
can be used with PCOS
helps loose weight
good for pre DM and Metabolic syndrome

MUST HOLD with any IVP dye!!! 48 hours

Must check kidney and liver before start
what are the dosages for glucaphose - and for XR
start low to decrease SE - GI
2550mg daily
2000 mg daily in pads

Long acting - start 500-750 in the evening, max 2000 per day
adjust every 14 days
what are examples of TZD
avandia and actos
what is the action of TZDs
mainly reduce insulin resistance at cell level
decrease hepatic glucose production
reduces both pre meal and PPG

NO LOW BS!!
decrease A1c 1-1.5%
what are advantages of TZDs
can be given without regard to meals, do not need structured meal time
Actos is daily - max 45
Avandia is daily or BID - max 8
what are SE of TZDs
edema and weight gain, cannot give with HF!!!

link to bladder cancer
increase lipids do not give if uncontrolled up to 20% LDL

decrease OCP
takes 3 weeks to see effects, 8-12 weeks for full effects
what are types of sulfonylureas
glipizide - short 1/2 life
glyburide - long 1/2 life
glimiperide - amaryl
what are the actions of sulfoylurea
stimulate insulin secretion
can increase receipts of insulin on muscle and tissue
some reduction in hepatic glucose production

want shorter 1/2 life because can't get them out of hypoglycemia
what are changes of sulfa allergy with sulfoylurea
16% will react, start really low and check for allergy then increase slowly
what are benefits of sulfonylurea
free at giant eagle
better when food in you, so less BS drop

A1C drop 1-2%
dose daily or bid
glipizide shorter 1/2 life so less hypoglycemia SE
what are SE of sulfonylurea
weight gain bc increased insulin and psych component
caution with kidney and liver disease
AMARYL BEST with kidney disease

MUST EAT ON A SCHEDULE - HAVE TO BE REGIMENTED or get low BS
what are types of meglitinides
prandin or starlix
what is the actions of meglitinides
increase insulin production
decrease in action with lower the BS - good so you don't get low BS
what are benefits of meglitinides
drop A1C 1-2 % prandin and 0.5-1.5% starlit
fast acting and shorter duration then sulfanyurea
decrease PPG

good for those with an erratic schedule
glucose dependent
take 0-30 minutes before meal - so can take whenever you eat
what are SE of meglitinides
caution with HEPATIC impairment
cannot take even if take a bite or two of food, won't help
what are incretin mimetics
Byetta
what is the action of incretin mimetics
incretin hormones are secreted by intestines in response to oral glucose load
GLP-1 increases insulin production by pancreas, decrease glucagon by alpha cells and increase satiety - GOOD
GLP is degraded by DPP-4
DM patients GLP deficient
how do you administer incretin mimetic
SubQ 5mg BID one hour before meals - increase monthly by 5

skip dose if already eating
what are SE of incretin mimetics
PANCREATITIS
low BS - esp with sulfa
NV
HA
Dizziness

CAN ONLY USE WITH LONG ACTING - LANTUS

* Nausea huge issue!!!
cannot use with sever kidney disease or transplant
what is the new incretin mimetic - XL; what are the SE
Bydureon - once weekly injection

in system a while, first use Byetta
SE: lump at injection site, hurts - stays in skin and slowly released

AVOID with thyroid cancer, even family history
causes PANCREATITIS

AVOID WITH KIDNEY DISEASE
What is victozia
new GLP 1 analog
sub-q daily
can give anytime regardless of meals, so convinenent.
can use alone or with TZD, metformin, or sulfa

DO NOT USE WITH INSULIN
what is the dose of victoza
0.6g daily, increase to 1.2mg weekly, max 1.8mg
what is the black box of victoza
thyroid tumors
history of pancreatits - cannot give
check for renal or hepatic impairment
cause GI SE
what can you not administer with Victoza
no DPP 4, amlyin or insulin products because already same class
must back off other meds because will increase insulin
what are Amylin analogues
Pramlinitde
what is the action of amylin
secreted by the beta cells of the pancreas, helps to decrease glucagon production, patients with DM are deficient in amylin
how do you administer amylin analogues
SQ before each meal, used with patients using insulin only - type I and II,
can use with SI, TZD, and metformin
what are SE of amylin
severe hypoglycemia esp with insulin
nv
anorexia
ha
what are DPP 4 inhibitors
januvia
what is the action of the DPP 4 inhibitors
prevent degradation of GLP 1
increase first phase insulin production, decrease glucagon secretion, decrease hepatic glucose production

ex. panc rush insulin when start to eat, then secrete slowly after dm II, with DM II do not get rush

with januvia give the rush so PPG better, decrease glucose production
what are benefits of DPP 4
can be used with biguanides, TZD or SU
higher the A1c the better the results
what are SE and dosages of DPP 4
does - based on kidneys
100mg/dl with good kidney function
decrease by half with GFR 30-50

Pharyngitis - loose voice
hypoglycemia with SU or insulin - ADJUST other meds

EXCRETED BY KIDNEYS!!!
what do you use with overweight patients
glucophage
januvia
prandin/starlix
byetta
TZD
what medications are good for hyperlipidemia
actos
glucophage
what are medications good for kidney insufficiency
amaryl
januvia
prandin/starlix
TZD
when you are treating DM what do you focus on first and then last
first FBS - if pancreas cannot keep up then the PPG really high, if fasting decrease then everything else will
what are long acting insulin and action
levemir and lantus
starts 1.5 - 6 hours
peak minimal
last 24-36 hours

take at same time everyday
what are rapid acting insulin types and action
lispro, novalog and apidra

start 10-20 minutes
peak 30-90 minutes
lasts 3-5 hours

food in front of you when you take, will decrease sugar
what is the action of regular insulin
start 30-60 minutes
peak 2-5 hours
lasts 4- 8 hours
what is intermediate insulin and action
NPH
start 1-2 hours
peak 4-15 hours and lasts 14-24 hours
lower peak
what is 70/30 action
start 15-30min
peak 2-3 hours
lasts 18-24 hours
what are benefits of insulin vials and pens
vial has 1000units
pen has 300 units with 5 pens

can only use for 30 days once opened so if only use .2 of it have to throw awe, pens there is less in it so not throwing much away
what are the major complications of DM
microvascular - nephropathy and retinopathy

macrovascular - CV disease - MI, stroke and PVD
Neuropathy
HgA1C controls which type of complications
microvascular, macro still affected because had pre-existing DM for a while, damage done
how does retinopathy form
detectable within 5 years of dx, many times at time of dx

starts with leakage of fluid from the blood vessels, l/t micro aneurysms, which are tiny vessels burst, hemorrhages and cap blockage

neovascularizaiton follows, increases bleeding risk and loss of vision
what are cotton wool spots
fluid collects, get stuck and thick, scar tissue forms
what is seen before retinopathy on eye exam
leakage in back of eye, retina a sponge and increase fluid, vessels become thinner and squeeze shut

MACULAR EDEMA - see on flouro
where do the tiny vessels form in the eye
break and cause peripheral vision loss because the vessels never form in the center area of the optic nerve
what do you see on exam with retinopathy that you know its no longer macular edema
when the tiny vessels form off the vessels of the eye, will not form in center, why peripheral vision decreases first
how often should DM patient see opthalmologist
yearly for dilated eye exam, no matter what vision is
what is the physiology of nephropathy, what starts first
starts with hyper filtration and hypertrophy of kidneys, then structural changes occur
abnormal filtration of proteins l/t micro albumin and eventually protineuria

will see high GFR >100 bc of vascular change, cause increase leakage and increased damage
who are HR for nephropathy
40% of DM develop it
higher in minorities
what is the first sign of nephropathy
microalbumin - must check at least yearly
normal <30
micro 30-299
macro >300

SEEN before creatinine changes
what is the treatment for microalbuminurea
normoglycemia
ACE or ARB - help with congestion of kidney
manage BP
STOP smoking
what are macro vascular diseases
CAD
PVD
Cerebral VD
what are cardiovascular complications RF
insulin resistence - IFG higher risk, PPG twice as likely to die

abdominal obesity
increased FFA in blood - alter insulins control of glucose and increases CRP, cytokines, and other inflammatory markers and clotting

Dyslipidemia - high LDL and TG, low HDL, high VLDL
what are goals of cholesterol in DM
total <180
LDL <100, ideal <70
HDL >50 women and >40 men
TG <150
what cholesterol medications are used to decrease glucose
Welchol - lower BS, LDL
what are the goals of HTN and lifestyle modificaitons
BP <130/80
Reduce weight
exercise at least 30 minutes/day
DASH diet
low salt diet
decrease ETOH 1-2 drinks
NO SMOKING

Start with ACE then HCTZ - check BP at every visit
what should you give with inflammation and hyper coagulation with CV RF
ASA

if high CRP - estrogen, chronic inflammation and smoking elevate it
what are CV RF
obesity, physical inactivity
obesity, unhealthy eating
chronic stress
depression
nonmodifiable - age, gender, race, family history
what are symptoms of PVD
claudication
lower leg foot ulcers
> in type II than type I
both smoking and high sugar raise plasma levels - clotting

Send to vascular
what is treatment for PVD
ASA
plavix or aggrenox, pletal

encourage walking to increase circulation, must go until pain, will get better, build collateral

control sugar, BP, lipids
stop smoking
what autonomic nerve damage occurs with neuropathy
affects heart, stomach, bladder, sexual function
what sensory nerve damage occurs with neuropathy
affects extremtities - arms, hands, feet, legs
what are s/sx of sensory nerve damage
may feel burning, tingling, numbness, pain from clothes touching, shooting pain at rest, inability to detect temp
what is the treatment of sensory neuropathy
control sugars
pain medications - Neurotin, Lyrica, start low and go slow, difficult sleeping and light headed
relaxation techiniques
what issues can occur with untreated neuropathy
total loss of feeling
loss of balance
foot deformities
ulcers
calluses
infections
amputation
what can gastroperesis lead to
n/v/d/c
must send to GI
poor absorption PPG hypoglycemia bc no absorption
what are autonomic CV nerve damage symptoms
dizziness from poor BP control
inability to change HR - when running should increase, it doesn't and causes syncope
painless heart attack
what are autonomic neuropathy of the bladder lead to
difficulty emptying bladder
frequent UTIs
increase sugar increase bacterial
men with UTI - check glucose
what autonomic neuropathy issues occur with sexual disfunction
ED in men
vaginal dryness and infections
what is the prevention and treatment of autonomic neuropathy
maintain sugar control
stop smoking
use meds - impotence, gastric emptying, c/d, and pain
consider antidepressants to treat depression
how do you prevent food problems with neuropathy
maintain sugars
maintain circulation by exercise
wear proper fitting clothes
do not cut corns yourself
take shoes off at every visit
see podiatrist yearly
what is proper practice of daily foot care
examine feet daily
do not go barefoot even at home
check shoes for objects - SHAKE it out
check temp of bath before step in
avoid soaking in hot water - take moisture out
cute toenails across
moisturize, not between toes - fungal
what are guidelines for DM and cholesterol with DM
hga1c <7% - check q 3-6 months
LDL <100 or 70
HDL >50
total <150
check cholesterol yearly if no HL
yearly micro albumin and BMP

BP <130/80
bring BG log to every visit
check feet q3-6 months - monofilament and tuning fork
eye exam yearly
flu vaccine yearly
pneumococcal vaccine
shingles if >60 years
if you have a patient with a log book, checks BS every AM fasting and PPG for lunch
Lunch BS are high, AM ok

what questions do you ask
ask what he is having for lunch
should check before lunch BS because if you have high sugar breakfast, may be really high before lunch

why you need to move times around
you have a patient on Lantus 15 unites at night, Glyburide BID 10mg
BS before lunch ok, elevated at night, slightly elevated at AM fasting

what would you change
adjust lantus because it affects fasting BS in between meals

log for a week and follow up for additional adjusting

Glyburide only helps PPG - max
patient on 70/30 24 units in AM and 10 units in PM
Log book - AM fasting high, fasting Lunch not as high but elevated, PP breakfast higher but ok, lunch PP good and Dinner PP even better. HS BS high, what should you adjust
night dose of 70/30, increase by 10% - the AM is the worst and then gets better, so the AM dose is good
this will help with AM fasting, so this will help through out the day as well,
do not change both AM and PM at same time - too many variables

Always work on fasting sugars first

if there are a few lower, better numbers, should ask what they did that day, work out?