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73 Cards in this Set

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What are characteristics of type I diabetes?
• insulin dependent diabetes • lack of insulin production by the pancreas • can be caused by viruses (Coxsackie), autoimmune disease, & genetic factors • early onset or adults under 40
What are characteristics of type II diabetes?
• not enough insulin is being produced or body is resistant to it • accounts of 75-80% of diabetes • can be caused by genetics • middle aged or elderly
What are other types of diabetes?
• Gestational diabetes • Diabetes caused by drugs & chemicals (glucocorticoids, protease inhibitors, atypical antypsychotics) • Pancreatic disease • Cystic fibrosis • Endocrinopathies (hyperthyroidism & Cushings syndrome)
How does a patient with diabetes clinically present?
• Blurred vision • Itchy, dry skin • Polyuria • Polydipsia • Polyphagia • Slow healing
What is the criteria used for diagnosing diabetes?
• random plasma glucose greater than 200 mg/dl with symptoms • fasting plasma glucose greater than 126 mg/dl • 2-hour post glucose greater than 200 mg/dl during an oral glucose tolerance test *should always be confirmed by repeat testing on a different day
How do you interpret the results of a fasting plasma glucose test?
• < 100 = normal fasting glucose • 100-125 = impaired fasting glucose • > 126 = provisional diagnosis of diabetes (must be confirmed by OGTT)
How do you interpret the results from an oral glucose tolerance test (OGTT)?
• 2-hr postload glucose < 140 = normal glucose tolerance • 2-hr postload glucose 140 - 199 = impaired glucose tolerance • 2-hr postload glucose > 200 = provisional diagnosis of diabetes
What are risk factors for diabetes?
• 1st degree relative w/ diabetes • High risk ethnic group • Had gestational diabetes • Hypertensive • HDL < 35 or TG > 250 • Obesity (BMI > 25) • Vascular Disease (PVD, ASHD)
What is glycosylated hemoglobin (HbA1C)?
• represents mean blood glucose over the last 3 months • normal value is 4-6%
What would you advise a type I diabetic, regarding diet and exercise?
• do not lose weight • proper nutrition (spread caolries throughout the day) • don't exercise before meals (will cause drop in blood glucose) • don't inject muscle you're working out
What would you advise a type II diabetic, regarding diet & exercise?
• decrease number of calories • weight reduction is a must • exercise
List the different classes of drugs used to treat diabetes
• Sulfonylureas • Biguanides • Alpha-glucosidase inhibitors • Thiazolinediones (TZD) • Meglitinides • Insulin • Insulin Secretins
What is the MOA of the sulfonylureas?
• stimulates insulin release from pancreatic beta cells (needs functioning beta cells) • decreases hepatic glucose • increases number of insulin receptors
What is the effect of sulfonylureas on HbA1C?
decreases A1C by 1-2%
What are the 2 classes of the Sulfonylureas?
• First generation • Second generation
List the 1st generation Sulfonylureas
• Acetohexamide • Chlorpropamide • Tolazamide • Tolbutamide
Which of the 1st generation sulfonylureas have active metabolites?
• Acetohexamide • Chloropropamide • Tolazamide (weak)
List the 2nd generation sulfonylureas
• Glyburide (Diabeta): comes in nonmicronized & micronized • Glipizide (Glucotrol) • Glimepiride (Amaryl)
What are adverse reactions of the sulfonylureas?
• Disulfiram-like reaction • GI (nausea/vomiting) • Hypoglycemia • Hematologic (1st gen. causes agranulocytosis) • Increased LFTs
What are should you be cautious of when administering sulfonylureas?
• reduce dose with hepatic impairment • renal dysfunction (mostly with glyburide) • be cautious in the elderly
True/False: Sulfonylureas have the greatest incidence of hypoglycemia of all the diabetic drugs
The correct answer is: True
What is the only Biguanide available?
Metformin (Glucophage)
What is the MOA of the Metformin (Glucophage)?
• decreases hepatic glucose • increases insulin sensitivity • decreases intestinal glucose absorption
What are added benefits of giving Metformin?
• decreases TG • increases HDL • weight loss
What is the dosage of Metformin?
• 500 - 2000 mg PO QD • max dose: 850 mg TID (can cause lactic acidosis) • starting dose: 500 mg PO BID
What are adverse effects of Metformin?
• Anorexia & nausea (at the start) • Lactic Acidosis (rare, caused by accumulation of Metformin) • Diarrhea/GI complaints
What can you give to a patient on Metformin who needs to undergo a contrast media procedure to avoid adverse effects?
• hold the Metformin for the day of the procedure and the day after • in an emergent situation, give Acetylcysteine (Mucomyst) 600 mg PO BID
What are contraindications of Metformin?
• CHF, hypoxic states, alcohol abuse • Hepatic impairment • Impaired renal dysfunction • Iodinated contrast media
At what serum creatinine do you not give Metformin, for a male and a female?
• Males: do not give Metformin if Scr > 1.4 • Females: do not give Metformin if Scr > 1.5
What is the MOA of alpha-glucosisase inhibitors?
• competitive, reversible inhibition of membrane-bound intestinal alpha-glucosidases • alpha-glucosidase response for breakdown of complex sugars to glucose • delays digestion of ingested carbohydrates, resulting in less hyperglycemia following a meal
Name the 2 alpha-glucosidase inhibtors and their dosing
• Acarbose (Precose) 25 - 100 mg divided breakfast, lunch, & dinner • Miglitol (Glyset) 25 - 100 mg divided breakfast, lunch, & dinner * drugs need to be taken with food (if you skip a meal, don't take drug)
True/False: Alpha-glucosidase inhibitors are commonly used as first-line drugs for diabetes
Alpha-Glucosidase inhibitors are not used as monotherapy or first-line, unless there is a contraindication for other agents The correct answer is: False
What are adverse effects of alpha-glucosidase inhibitors?
• GI symptoms (abdominal pain, diarrhea, and flatulence) • side effects are dose-related (higher doses produces more side effects)
What are contraindications of alpha-glucosidase inhibitors?
• inflammatory bowel disease • chronic ulcers • partial obstructions
What is the MOA of action of Thiazolidinediones (TZD)?
• lowers blood glucose by improving target cell response to insulin • decreases insulin resistance • increases insulin sensitivity • no effect on insulin secretion
How efficacious are Thiazolididones?
• decreases A1C 0.6-1.3% • can be used as monotherapy or combination
What are the 2 Thiazolidinediones?
• Rosigilitazone (Avandia) • Pioglitazone (Actos)
What are adverse effects of the TZDs?
• Hepatotoxicities • increase in plasma volume • anemia • resumption of ovulation
What are contraindications of the TZDs?
• acute decompensated CHF • severe hepatic impairment • increases in LFTs
What lab should be monitored when administering the TZDs?
• LFT (get baseline) • be concerned if LFT level is 3 times the upper limit
What are drugs that interact with TZDs?
• TZDs may decrease concentrations of oral estrogens (birth control) • Cholestyramine reduces absorption by binding w/ TZDs (can cause increase in blood glucose)
What is the MOA of Meglitindies?
stimulates insulin secretion from beta cells
What is the indications for using Meglitinides?
use as monotherapy (rare, only if contraindications with other drugs) or in combination with Metformin
What are adverse effects of Meglitindies?
• Hypoglycemia • GI effects • Weight gain
What are drug that interact with Meglitinides?
• Drugs that induce CYP 450 3A4 may increase metabolism (Barbituates, Carbamazepine, Griseofulvin, Rifampin, Phenytoin) • Safe with Digoxin, Warfarin, Theophylline
List the 2 Meglitinides
• Repaglinide (Prandin) • Nateglinide (Starlix)
How do you dose Repaglinide (Prandin)?
• No previous history with A1C > 8, start at 0.5 mg before every meal • Previous treatment with A1C > 8, start at 1-2 mg before every meal • Max dose in 16 mg per day * before meal = 30 min before meal
What are the 4 types of Insulin therapies?
• Rapid • Short • Intermediate • Long
What are the 2 rapid insulins?
• Lispro (Humalog) • Aspart (Novalog)
What is the onset, peak, and DOA of Insulin Lispro (Humalog)?
• onset = 15 min • peak = ½ - 1½ hr • DOA = 3 - 4 hrs
What is the onset, peak, and DOA of Insulin Aspart (Novalog)?
• Onset = ½ hr • Peak = 1 - 2 hrs • DOA = 3½ hrs
What is the onset, peak, and DOA of Insulin R?
• Onset = ½ - 1 hr • Peak = 2 - 3 hrs • DOA = 6 - 8 hrs
What are the 2 intermediate insulins?
• NPH (Insulin N) • Lente
What is onset, peak, and DOA of NPH (Insulin N)?
• Onset = 2 - 4 hrs • Peak = 4 - 6 hrs • DOA = 8 - 12 hrs
What is the onset, peak, and DOA of Insulin Lente?
• Onset = 3 - 4 hrs • Peak = 6 - 12 hrs • DOA = 12 - 18 hrs
What are the 2 long-acting insulins?
• Insulin Ultralente • Insulin Glargine (Lantus)
What is the onset, peak, and DOA of Insulin Ultralente?
• Onset = 6 - 10 hrs • Peak = 10 - 16 hrs • DOA = 18 - 20 hrs
What is the onset, peak, and DOA of Insulin Glargine (Lantus)?
• Onset = 4 hrs • Peak = Flat • DOA = 24 hrs
Which is the only insulin that can be given as a drip?
Insulin R
Insulin 70/30 is a combination of what?
70% Insulin R & 30% Insulin N
Which insulin is most similar to our body's insulin?
Insulin Glargine (Lantus)
What is the dosing of insulin for a type I diabetic?
inital dose: 0.5 - 0.8 units/kg/day
What is the insulin dosing for a patient in DKA?
• start an Insulin drip (with Insulin R) 100 units/100 cc NS • Insulin R 1.0 - 1.5 units/kg/day
What is the insulin dosing for a type 2 with severe insulin resistance?
0.7 - 2.5 units/kg/day
What is the fall-back method?
• the most recent peak of the insulin and/or the meal to identify what changes are needed • if morning glucose is low, adjust the previous insulin dose (previous evening dose)
What is the "Dawn Effect"?
early morning increase in glucose (usually between 4 am and 8 am)
What is the Symogi effect?
the tendency of blood sugar to rise as a result of low blood sugar. Low blood sugar can trigger release of hormones such as glucagon that raise blood sugar
What are adverse effects of insulin therapy?
• Lipodystrophies (rotate sites to avoid) • Allergy to insulin • Hypoglycermia • Insulin edema
What are the 2 new therapies?
• Byetta: used for type II • Symillin: used for type I & II
What is the MOA of Byetta & Symillin?
• both are Incretins (peptides) which enhance glucose-dependent insulin secretion • can increase insulin sensitivity by stimulating insulin receptors • reduce fasting and post-prandial glucose
What are complications of diabetes?
• Diabetic Ketoacidosis • Diabetic Nephropathy • Diabetic Neuropathy • Diabetic Retinopathy • Hypertension • Peripheral Arterial Disease
What is Exubera?
inhaled insulin
What is the disadvantage of Exubera?
• unknown effects on patients with respiratory problems (COPD, pulmonary fibrosis, smokers) • need to perform pulmonary function tests & peak flow test before starting