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44 Cards in this Set

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Goals of treatment for Diabetes Mellitus
Improve symptoms of diabetes
Prevent metabolic complications (ketoacidosis)
Prevent long term complications
Reduce glucose and A1C to acceptable levels
Average prprandial blood glucose
ADA: 80-120 AACE: 110
Average 2hr postprandal glucose
ADA < 180 AACE <140
Average bedtime glucose
ADA 110-140
A1C Goal
ADA < 7.0% AACE <6.5%
Mechanism of action for Insulin
replaces insulin
Side effects of Insulin
hypoglycemia
Allergic reactions at the site of injection
Lipodystrophy
Special considerations for Insulin
Rotate sites
If refrigerated, unopened bottles are good through the expiration date
Once opened, usually good for 1 month
Store away from light
Roll bottle between palms to re-suspend suspensions
Always draw up reg first
Reg insulin is the only type for IV use
Mechanism of action for sulfonylureas
Increase release of endogenous insulin and increases insulin sensitivity at peripheral sites
Examples of Sulfonylureas
Glucatrol
Diabeta
Side effects of sulfonylureas
hypoglycemia
weight gain
disulfiram-like reaction (chlorpropamide)
Dilutional hyponatremia (Chlorpropamide)
Special considerations for sulfonylureas
Contraindicated in patients with sulfa allergy
Elderly more prone to hypoglycemia
Can be used as monotherapy but most patients show eventual decline in glucose control
Mechanism of action for biguanides
inhibits hepatic production of glucose
Example of biguanides
Metformin (Glucophage)
Side effects of biguanides
Diarrhea
Nausea, vomiting
Abdominal discomfort
Lactic acidosis (promarily in pats with renal insufficiency)
Special considerations for biguanides
does not cause hypoglycemia or weight gain
induces modest weight loss in most patients
Tolerance develops in most cases to GI effects
Contraindications to include:SrCr >1.5 mg/dL on men or > 1.4 mg/dL in women; radiologic studies involving IV contrast dyes; CHF and significant liver disease; dehydration
Mechanism of action for Alpha-Glucosidase Inhibitors
inhibits Alpha-glucosidase enzymes in the small intestine which slows digestion of ingested carbohydrates and thus delays glucose absorption
Examples of Alpha-Glucosidase Inhibitors
Acarbose
Miglitol
Side Effects of Alpha-Glucosidase
Diarrhea
Bloating
Flatulence
(GI effects are really bad and don't go away...given right before meals)
Special considerations for Alpha-Glucosidase Inhibitors
GI effects limit their use
Do not cause hypoglycemia when used as monotherapy
Given with each meal to prevent postprandial glucose spikes
Mechanism of action for thiazolidinedione
increase insulin sensitivity in muscle
Examples of thiazolidinedones
Rosiglitazone, Pioglitazone
Side effects of thiazolidinedione
weight gain
peripheral edema
idiosuncratic hepatovellular injury
Anemia
Special considerations for thiazolidinediones
do not cause hypoglycemia when used as monotherapy
Slow onset of action over 16 weeks
Monitor liver enzymes every 2 months for first year
Most expensive agents available
Contraindications: stage III or IV heart failure; liver abnormalities
Rosiglitazone may be associated with increased risk of heart attack
Mechanism of action for non-sulfonylreas
stimulate insulin secretion from the pancreas
Side effects of non-sulfonylureas
hypoglycemia
weight gain
examples of non-sulfonylureas
repaglinide, nateglinide
special considerations for non-sulfonylureas
only given with meals because of fast onset and short duration of action
main advantage is lowering of postprandial glucose
add or omit does if meal is added or omitted
expensive
Example of incretin mimetic
Byetta
Mechanism of action for incretin mimetics
stimulates insulin secretion by causing increased beta cell growth and replication; also slows gastric emptying and may decrease food intake
Side effects of increin mimetic
hypoglycemia
GI effects
dizziness, headache
Special considerations of incretin mimetics
administerd with sulfonylureas and/or metoformin
May cause weight loss
administer drugs which require optimal absorption one hour before byetta
administered twice daily-injections
Mechanism of action of DPP4 Inhibitors
Inhibit the breakdown of increin by dipptidyl peptidase IV, thus promoting insulin secretion
Examples of DPP4 Inhibitor
Januvia
Side effects of DPP4-Inhibitors
Upper respiratory tract infection
Stuffy or runny nose and sore throat
Headache
Special considerations for DPP4 Inhibitors
Usually used as second line agent
Lowers HbA1c 0.6-0.8
Does not appear to cause weight loss or nausea
Mechanism of action for Amylin Agonists
Mimics the action of naturally occuring pancreatic hormone amylin. By doing so, glcemic control s improved through the modulation of gastric emptying, prevention of postprandial rise in glgacon levels, and by increasing levels of satiety
Side effects of Amylin Agonists
nausea
anorexia, vomiting, and abdominal pain
weight loss
Special considerations for Amylin Agonists
only indicated for use with insulin
give sq before meals
preprandial rapid or short acting insulin doses must be reduced in order to reduce the risk of hypoglycemia
IDDM
Two daily injections with starting total daily dose of 0.6 units/kg.day
Combination of NPH and Reg before breakfast and before evening meal
Two thirds of toal dose given in morning and one-third in evening
Intermediate insulin (NPH) should compromis 2/3 of morning dose and 1/2 of evening dose
IDDM Four daily injections with starting daily dose of 0.6 units/kg/day
Basal insulin (Glargine) should be 45% of total daily dose
Prandial insulin (Lispro, Aspart) should be given 25% of toal before breakfast and 15% before lunch and dinner
Most patients require 0.5-1.0 units/kg/day
IDDm
Give enteric coated aspirin to all patients > 30 years old if no contraindications
NIDDM
First step
Lifestyle modifications and initiate metformin 500 mg qd-bid titratinf up to 850-1000 mg BID (unless they have renal dysfunction, increased LFTs, heart failure)
In NIDDM, if after 3 months HbA1c is greater than 7% then
add Sufonylurea or basal insulin or Pioglitzone or Rosiglitazone
If after 3 months, it is still high, add an additional agent or intensify insulin for those patients on insulin.