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180 Cards in this Set
- Front
- Back
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what race are most predisposed to DM
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hispanic americans
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cost per year of inpatient visits for DM
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$25,000
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DM is most prevalent in what age/sex
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men
50-70 years |
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what was type I DM known as before
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insulin-dependent DM (IDDM)
or juvenile onset diabetes |
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type I DM usually strikes who
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children
young adults but can occur at any age |
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pathogenesis of type I DM
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pancreatic beta cells are destroyed by the immune system
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risk factors for type I DM
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autoimmune
genetic environmental |
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type 2 DM was known as...
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non-insulin dependent DM (NIDDM) or
adult onset diabetes |
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how does type 2 DM usually begin
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as insulin resistance
when cells do not use insulin properly |
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t/f there is a gradual increase of insulin produced by beta cells in type 2 dm
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F
gradual dec. |
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risk factors for type 2 dm
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older age
obesity family hx of dm hx of gestational diabetes impaired glucose metabolism physical inactivity race/ethnicity |
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what is the only tx for type 1 dm
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insulin therapy
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what is the usual tx for type 2 dim
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oral agents and then insulin for resistant cases
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t/f type 1 and 2 are the only kinds of diabetes
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F
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what are the other types of diabetes besides 1 and 2
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gestational
genetic defect in beta cell fxn exocrine pancreas dz endocrinopathy |
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what inc. the risk of gestational diabetes
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being overweight
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what is gestational diabetes
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preggos who have insulin resistance w/ beta cell dysfxn
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what are the 3 methods to dx DM
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random plasma glucose
fasting plasma glu oral glucose tolerance test |
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what test is used for gestational diabetes
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oral glucose tolerance
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what test is preferred for evaluating serum glucose conc.
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fasting plasma glucose
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normal, inc. and diabetic levels for an FPG
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normal <110 mg/dl
inc. 110-126 diabetes - >126 |
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what are the ADA criteria for type 2 DM dx
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symptoms w/ a casual plasma glu > or = 200
or FPG >or= 126 or 2-hour plasma glucose >or= 200 after a 75 gram glucose load |
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guidelines for glycemic control of non-diabetic
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preprandial <115
bedtime <120 HgbA1C <6 |
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guidelines for glycemic control for diabetic
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preprandial - 80-120
bedtime - 100-140 hgba1c - <7 |
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a HgbA1C of 7 is equal to and average glucose of...
9... 9... |
150
200 250 |
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characteristics of diabetic agents
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efficacy
MOA weight gain complication/tolerability hypoglycemia freq. compliance/complexity cost |
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role of podiatrist in DM tx
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constant assessment of pts
stress daily foot care |
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what is the workhorse drug for dm type 2
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metformin
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what drug class is good for overeaters and why
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a-glucosidase inhibitors
b/c they work on the GI tract |
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name the rapid-acting insulins
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lispro
aspart glulisine |
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name the short-acting (regular)insulins
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humulin R
novolin R |
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name the intermediate acting insulins (NPH)
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humulin R
novolin R |
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name the long-acting insulins
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glargine
detemir |
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are combo insulin products recommended
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nope
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name the combo insulin products
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lipro protamine-lispro
nph-regular aspart/insulin aspart protamine |
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what group of insulin products work well for pts who want to eat out
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rapid acting
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what type of insulin is bad for elderly pts and why
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Regular
holds onto the ACh receptor and can lead to hypoglycemia |
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onset
peak duration max duration of rapid acting |
onset .25-.5 hr
peak 1-2 hr duration 3-4/5 for aspart max duration 4/5-6 |
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onset
peak duration max duration of regular insulin |
onset .5-1
peak 2-3 duration 3-6 max duration 6-8 |
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onset
peak duration max duration of NPH |
onset 2-4
peak 4-6 duration 8-12 max duration 14-18 |
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onset
peak duration max duration of glargine |
onset 4-5
peak none duration 22-24 max duration 24 |
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onset
peak duration max duration of detemir |
onset 1-2
peak none duration 16-24 max duration 24 |
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what type(s) of insulin is/are cloudy
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NPH
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what are the 3 types of insulin requirements
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basal
prandial supplemental |
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what is basal insulin req. and what treats it
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meets fasting need
given regardless of PO status -glargine, detemir or NPH or regular IV insulin infusion |
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what is prandial insulin req. and what treats it
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covers enteral caloric intake
hold if pt is NPO except type I -subq short acting or rapid acting |
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what is supplemental insulin req. and what treats it
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used to maintain glu in normal range
-subQ short or rapid acting |
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t/f you never hold a type 1 dm pt's insulin
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T
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what is rapid acting insulin used for
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postprandial hyperglycemia control
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rapid acting insulin dec. risk of ____ and may cause more _____ but more closely replicates normal ______
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-less risk of late postprandial and nocturnal hypogly.
-more early onset hypogly -replicates normal physiology |
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when do you give lispro
aspart glulisine |
-15 min. before/immediately after meal
-immediately before -15 min. before or w/in 20 mins after starting meal |
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the PK of lispro makes it good for...
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kids
b/c of their unpredictable eating |
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what does lispro do the amino acids?
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reverses the sequence
leads to faster absorption/shorter duration |
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what does apart do to the AAs
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replaces B28 AA w/ aspartate
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benefit of aspart and glulisine over human insulin
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better postprandial glycemic control
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t/f PK of aspart and glulisine is similar to adults
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T
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what age group have a higher max insulin conc.
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teens
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what does glulisine do to the AAs
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lysine replaces aspargine at 3B
glutamic acid replace lysine at B29 |
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when do you prescrive rapid acting insulin
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rapid correction of hypergly
snacks varying sleep patterns (i.e. teenagers) evening meal is close to bedtime (i.e. someone who works night shift) |
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mary temple loves or hates regular insulin
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hates it
it's dangerous |
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regular insulin puts pt at a risk of...
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hypogly 4-6 hours postprandial
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t/f it's easier to manage pre-prandial hypergly on short acting insulin
|
F
more difficult |
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what happens when you mix Lente w/ regular insulin
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lose immediate effect
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regular insulin can hold on to what receptor
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ACh
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what insulin is associated w/ hyperglycemia by dinnertime and nocturnal hypogly
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NPH
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NPH has earlier peak of ___ hours making it good for coverage at ___-
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3 hrs
school |
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how do you correct the dinnertime hypergly w/ NPH
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give regular or lispro at lunch
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how do you manage the nocturnal hypogly. w/ NPH
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give dose at bedtime
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how often is NPH given
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BID
morning - basal during day and covers lunch evening - covers dinner and provides basal at night |
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bedtime NPH produces ____ weight gain
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less
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why do pts like glargine more than NPH
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glargine is QD
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MOA of glargine
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microcrystalline precipitate in subQ tisue, delays absorption and give constant insulin release for basal req.
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benefits of glargine
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QD dose
small initial rise less nocturnal hypogly |
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t/f you can add rapid acting insulin for meal coverage for glargine pt
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T
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t/f no injxn of glargine w/in 8 inches of injxn site
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F
3 inches hahaha! |
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what causes the precipitation of crystals w/ glargine
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the sol'n is acidic (pH 4) and sub Q tissue is pH 7.4
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t/f glargine cannot be mixed w/ other types of insulin
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T
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t/f be sure to shake glargine before giving it
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F
you'll break up the hexamers |
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t/f glargine can be given any time of the day
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T
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what causes injxn site pain w/ glargine
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acidic pH
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MOA of detemir
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self-aggregates into hexamers at injxn site then dissociates into dimers and monomers
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you see less _____ and ____ w/ detemir than w/ NPH
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weight gain
nocturnal hypogly |
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t/f don't mix detemir w/ other insulins
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T
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t/f you should start a pt on glargine BID
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nope
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what are your options if you pt is not getting adequate control w/ QD glargine or detemir
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FIRST be sure they have right amount of rapid acting
-give NPH -give glargine/determir BID if you need to |
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what types of insulin are used in pumps
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lispro
aspart regular |
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why don't teens like insulin tx
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makes them hungy
they eat they get fat |
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what is the preferred method of meal planning for insulin pump pts
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carb counting
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pump tx require blood glucose testing how often
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4X/day
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basal rate may ___ in the middle of the night due to...
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dec
nocturnal hypogly |
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basal rate may ____ before awakening due to ...
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inc.
dawn phenomenon |
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how often do insulin pump catheters need to be changed
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every 3 days
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when mixing short/rapid acting w/ NPH what do you draw up first?
do you use the same syringe? when do you inject it? |
short acting first
yes must be immediately injected |
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what type of insulin can't be mixed w/ other types.
why? |
glargine and detemir
the low pH of diluent |
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ADA guidelines for critically ill pt
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around 110
generally <180 |
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ADA guidelines for non-critically ill pt
pre-meal postprandial |
pre- 90-130
post- <180 |
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AACE guideline for hospitalized pt
preprandial peak postprandial critically ill |
pre- <110
post- <180 critically ill- 110 |
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what temp do you keep insulin at?
why? |
room
dec. painful injxn loss in potency shorter expiration date |
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how often is insulin dosing recommended by the ADA
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5x daily
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MOA of the sulfonylureas
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-stimulate insulin release from pancreas
-dec. glucose output from liver -inc. insulin sensitivity |
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ADRs of sulfonylureas
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*Hypogly
weight gain GI distubance derm disturbance |
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clinical pearls of sulfonylureas
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-administer 30 mins before meals, once or twice daily
-not best option for elderly -renal clearance of glyburide is high |
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do not use what sulfonylurea in renal dysfxn
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chlorpropamide
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what sulfonylurea is preferred in pts w/ moderate to severe renal dysfxn
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glipizide*
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what sulfonylurea has active metabolites that accumulate in CrCl less than 30 ml/min
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glyburide
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sulfonylurea DDIs
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phenylbutazone
thiazide diuretics* beta blockers* fluoroquinolones protein bound drugs phenytoin |
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how often do you adjust doses on sulfonylurea
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weekly
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what do you need to monitor w/ sulfonylurea
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serum blood glu
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who is the best candidate for sulfonylurea
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dz duration of <10 years
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name the sulfonylureas mentioned in the notes
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chlorpropamide
glyburide glipizide |
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MOA of metformin
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-dec. hepatic glucose production
-dec. intestinal absorption -improves insulin sens. |
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ADRs of metformin
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FLATULENCE
diarrhea NV weakness |
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when should you give metformin
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w/ meals to avoid GI upset
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t/f metformin is good for obese pts
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T
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use caution w/ metformin in what pts
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renal insufficiency
contrast studies d/c day of sx or procedure and restart 2 days later |
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CIs of metformin
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-SCr >1.5 males (>1.4 females)
-hepatic dysfxn -CHF requiring drug tx -binge drinkers -acute or chronic lactic acidosis **she TQ'd this slide |
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metformin precautions
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-elderly (renal probs)
-CHF (met. exacerbates it) -acute cond'n that predispose lactic acidosis -radiograph contrast procedure |
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best candidate for metformin is
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all pts w/ mild hypergly
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dosing guidelines for metformin
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start low and go slow
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when do you adjust dosing of metformin
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weekly if needed
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MOA of thiazolidinediones
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-dec. insulin resistance
-inc. insulin sens. **no effect on insulin secretion |
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ADRs of thiazolidinediones
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edema
heart failure weight gain 1-4 kg inc. plasma volume dec. Hgb/hematocrit |
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t/f you can administer thiazolidinediones w/o regard to meals
|
T
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CIs of thiazolidinediones
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abnormal LFTs (3x the upper limit of normal)
CHF |
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DDI of thiazolidinediones
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oral contraceptives
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name the two thiazolidinediones
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rosiglitazone
pioglitazone |
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physiologic effects of thiazolidinediones
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-dec. insulin req. of type 2 diabetic
-dec. FPG by 35-40 mg/dl -dec. HbA1c by .5-1.5% -onset in 2 weeks -max effect in 2-3 months |
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which thiazolidinediones has lipid effects
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rosiglitazone
(lipid effects make rosi fat) |
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which thiazolidinediones would be good for a pt w/ hyperlipidemia
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pioglitazone
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t/f thiazolidinediones may cause the resumption of ovulation
|
T
hence the DDI w/ oral contraceptives |
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best candidates for thiazolidinediones
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marked obesity
insulin resistance |
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how often do you adjust thiazolidinediones dosing
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every 4-8 weeks
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don't prescribe thiazolidinediones if ____ is above _____
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ALT
2.5x the upper limit of normal |
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what do you need to monitor w/ thiazolidinediones
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LFTs q 2 mos for the first yer then q 6 mos after that
-also blood glucose if no improvement in 12-16 week d/c drug |
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MOA of meglitinides
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stimulate insulin secretion in presence of glucose
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meglitinides work fast or slow?
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fast
and for a short duration |
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ADRs
|
Flatulence
weight gain hypogly is < or = to sulfonylureas |
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when do you administer meglitinides
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w/ first bite of each meal
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should pt still take meglitinides if they skip a meal
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hellz nah!
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DDIs of meglitinides
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*macrolide antibiotics
potent inhibitors of cyp450 (SSRIs, phenytoin, macrolide abx, etc..) |
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name the meglitinides
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nateglinide
repaglinide |
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best candidate for meglitinides tx
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dz duration less than 10 years
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meglitinides work best against...
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high glucose conc.
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effects of ______ are dose dependent
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repaglinide*
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which meglitinides has faster onset and less hypogly.
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nateglinide
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______ has faster onset and less hypogly than ______
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nateglinide
repaglinide |
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t/f you should skip your meglitinides if you miss a meal
|
T
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MOA of a-glucosidase inhibitors (AGIs)
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block enzymes that digest starches in small intestine
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ADRs of AGIs
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GI -diarrhea, farts
hypoglycemia dizziness Acarbose can inc. LFTs |
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t/f AGIs alone can cause severe hypoglycemia
|
F
can only occur in combo w/ other drugs |
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how do you treat hypoglycemia from AGIs
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glucose only
not sucrose, fruit juice b/c drug blocks the enzymes |
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when do you take AGIs
|
w/ a high carb meal
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phsiologic effects of AGIs
|
dec. FPG conc.
dec HbA1c by .7-1% dec. postprandial blood glucose minimal effects on cholesterol and body weight |
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Acarbose is metabolized by the ...
miglitol is metabolized by the .... |
liver
kidney ***TQ** |
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best candidate for ADIs
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pt w/ marked postprandial hypergly
-can't push away from the table |
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when are AGIs given
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w/ first bite of a high carb meal
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what do you monitor w/ AGIs
|
LFTs q 3 mos. for first year then periodically
random blood glucose postprandial glucose (important*) |
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MOA of DPP4 inhibitors
|
protects incretin (GLP-1 and GIP) which are released in response to meals to maintain glucose homeostasis
|
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ADRs of DPP4 inhibitors
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HA
upper resp. infxn nasopharyngitis |
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t/f the risk of hypogly. of DPP4 is dec. if taken w/ a sulfonylurea
|
F
inc. |
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t/f you must take a DPP4 w/ food
|
F
w/ or w/o food |
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MOA of glucagon-like peptide agonist (GLP ag)
|
inc. glucose mediated insulin secretion (rapidly dec. postprandial blood glucose)
delays gastric emptying inc. insulin synth provide inhib. signal of food intake |
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who should use glucagon-like peptide agonists
|
pts failing oral therapy
used as adjunctive tx |
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MOA of pramlintide
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supressed glucagon secretion
dec. gastric emptying improved glycemic control |
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ADRs of pramlintide
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inc. risk hypoglycemia w/ initial tx
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who should take pramlintide
|
type 1 or 2 diabetic on insulin w/ postprandial hypergly.
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|
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what drug causes weight loss of 1-1.5 kg
|
pramlintide
|
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what effect does pramlintide have on insulin dose
|
reduce insulin dose by 50%
|
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t/f dosing for pramlintide for type 1 and 2 diabetics is different
|
t
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what drugs are weight neutral/cause slight weight loss
|
metformin
meglitinides AGIs |
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what drugs cause weight gain
|
insulin
sulfonylureas TZDs |
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glyburide + metformin =
|
glucovance
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rosiglitazone + metformin =
|
avandamet
|
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glipizide + metformin =
|
metaglip
|
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what drug dec. FPG by 50-60 and HbA1c by 1.7-1.9%
|
glucovance
|
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t/f avandamet has no significant effect on HbA1c compared to metformin alone
|
F
significant dec. |
|
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CIs of avandamet
|
renal dz
CHF metabolic acidosis |
|
|
t/f avandamet has a high risk of hypogly.
|
F
low risk |
|
|
effects of avandamet
|
dec, HbA1c
improved insulin sens. reduced hepatic glucose output |
|
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when do you use combo therapy w/ oral drugs
|
when FPG is constantly >140
HbA1c is constantly >8% when secondary failure occurs |
