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183 Cards in this Set
- Front
- Back
which type has reduction of c peptide due to destruction of beta cells
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type 1
|
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which type has normal insulin production
|
type 2
|
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dx of dm
FBG value |
>/= 126 mg/dl
|
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dx of dm
random glucose value |
> 200 mg/dl
+ symptoms |
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when will OGTT be used to dx dm
|
during pregnancy
|
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dx of dm
A1C value |
>/= 6.5%
symptoms BG > 200 |
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components of metabolic syndrome
abd obesity: men? women? |
men: > 40 in
women: > 35 in |
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components of metabolic syndrome
TG? |
> 150 mg/dl
|
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components of metabolic syndrome
HDL: Men? women? |
men: < 40
women: < 50 |
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components of metabolic syndrome
BP? |
> 130/85
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components of metabolic syndrome
FPG: |
> 110 mg/dl
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fasting plasma glucose
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not eaten in 8 hrs
|
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preprandial glucose
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before meals
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postprandial glucose
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1-2 hrs after meal
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according to DCCT intensive tx resulted in delay in onset and slowing of progression of ----- complications
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microvascular
|
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for a person w/ IGT or IFG what the % weight loss and amount of phy activity recommended
|
5-10% weight loss
150 min/week |
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what would you consider for high risk patients who are obese and under 60 yrs of age
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metformin
|
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why consider metformin
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less side effects
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what drugs can induce hyperglycemia
|
beta blockers
diuretics corticosteroids pentamidine phenytoin sympathomemetics nioctinic acid (keep dose below 1 gm) |
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what meds can induce hypoglycemia
|
salicylates in high doses
beta blockers alcohol quinine pentamindine ace inhibitors insulin,sulfonylureas, repaglinide |
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how will b blockers cause hyperglycemia
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decrease insulin secretion and tissue sensitivity to insulin
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how will b blockers cause hypoglycemia
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decreased glycogenolysis and warning signs
|
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rapid acting
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lispro (humalog)
aspart (novolog) insulin glulisine (apidra) |
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short acting
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regular ( humulin R, Novolin R)
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intermediate acting
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NPH (Humulin N, Novolin N)
|
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long acting
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insulin glargine (lantus)
insulin detemir (Levemir) |
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lispro (humalog)
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rapid acting
|
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insulin glargine (lantus)
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long acting
|
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NPH (humulin N, novolin N)
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intermediate acting
|
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regular (humulin R, Novolin R)
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short acting
|
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insulin glulisine (apidra)
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rapid acting
|
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aspart (Novolog)
|
rapid acting
|
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insulin glargine (lantus)
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long acting
|
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NPH (humulin N, novolin N)
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intermediate acting
|
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regular (humulin R, Novolin R)
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short acting
|
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insulin glulisine (apidra)
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rapid acting
|
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aspart (Novolog)
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rapid acting
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70/30 is mixed w/
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70% nph
30% regular |
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50/50 is mixed w/
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50% nph
30% regular |
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75/25 is mixed w/
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75% lispro protamine sulfate
25% lisporo |
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why add protamine
|
makes it longer acting
|
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side effects of insulin
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weight gain
hypoglycemia lipohypertrophy lipoatrophy |
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why should injection site be rotated
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can cause lipohypertrophy
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which insulins should you take just before a meal
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rapid
short |
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which are basal
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intermediate
long acting |
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rapid acting onset?
peak? duration? |
onset: 5-15 min
peak: 0.5 -1.5 hrs duration: < 5 |
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regular
onset? peak duration |
onset: 30-60 min
peak: 2-3 hrs duration: 5-8 hrs |
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When switching from bid NPH to glargine or detemir, reduce total daily NPH dose by --- %.
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20%
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When switching from bid --- to glargine or detemir, reduce total daily NPH dose by 20 %.
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NPH
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Least expensive oral agents available:
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Sulfonylureas
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Sulfonylureas exert their major effect on glucose by increasing ----- secretion from functioning beta cells in the pancrease and enchancing --- --- sensitivity
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Insulin; beta cells
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sulfo. also exert minor ---- ---- mechanism such as ----- hepatic glucose production and ----- insulin receptor sensitivity and/or number
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extrapancreatic
decreasing increasing |
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would you select a 1st or 2nd gen sulf?
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a 2nd
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SE of sulfon.
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hypoglycemia
weight gain GI (nausea, vomiting, heartburn) hematologic rxns skin rxns |
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---- gen sulf bind extensively to plasma proteins
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1st
|
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which 2nd gen of sulf has the highest incidence of hypoglycemia among 2nd generation agents
|
glyburide
|
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initial dose of glyburide
|
usu 2.5 mg qd am
1.5mg qd am w/ micronized glyburide |
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how much glyburide do you give to get the desired effect
|
may have to give bid
|
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max dose of glyburide
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20 mg
12 w/ micronized |
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safest 2nd gen sulfon for pt w/ renal failure
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glipizide
|
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initial dose of glipizide
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5 mg q day am
|
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to get the desired effect how much glipizide should you give
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glucotrol bid
|
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how often is glucotrol xl given
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daily
|
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make dose for glucotrol?
glucotrol xl |
glucotrol 40 mg
glucotrol XL: 20 mg |
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glimepiride is a true ---- daily sulfon
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once
|
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t/f
glimepiride binds to affect one part of the receptor complex |
f
affects different parts of the complex |
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which of the 2nd gen will cause less hypoglycemia
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glimepiride
|
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ex of meglitinides
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repaglinide (prandin)
nateglinide (starlix) |
|
meglitinides stimulates the release of insulin from ---- beta cells
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functioning
|
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why is there less likely chance of getting hypoglycemia from meglit
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insulin release is glucose dependent
the effects are dimished at low serum glucose conc |
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the least likely meg to cause hypoglycemia
most likely |
least: repaglinide
most: glyburide |
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metabolism of meg can be inhibited by
|
antifungal agents
mycins, fluoxetine nefazdoone |
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metabolism of meg induced by
|
rifampin
barbituates phenytoin carbamazepine |
|
t/f
interactions of meg are shown w/ dig, theophylline, and warfarin |
f
|
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would you give repaglinide for someone who's never used it and a A1c of 9
|
no
their A1c should be < 8%: in that case they should be give a dose of 0.5 mg |
|
you can give repaglinide to someone who's been treated an A1c >8% a dose of -- to ---
|
1 or 2 mg
|
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how often should replig be taken
|
2, 3, 4 x a day 0-30 min before each day
Noncompliance! |
|
for replig: skip a meal, ---- a dose; add a meal, --- a dose
|
skip
add |
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dosage of nateglinide
|
120 mg tid w/ meals
may start w/ 60 mg tid |
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ex of biguanides
|
metformin: glucophage, glucophage XR, fortamet, glumetza
|
|
t/f
metformin also available in combo |
t
|
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t/f
mod of action of metformin is to increase hepatic glucose production |
f
decrease hepatic glucose formation |
|
the 2ndary moa of biguan is to enhance --- muscle glucose uptake and ----- rate of GI glucose absorption
|
peripheral
reduce |
|
t/f
biguan stimulates insulin release |
f
it does NOT, but requires insulin presence to be effective |
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initial dose of biguan
|
500 mg bid
or 850 mg qd am |
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max dose of biguanide
|
2500 mg/day ( given 1000 mg q am, 500 mg q noon, 1000 mg q pm)
2550 mg/d ay (given 850 mg tid) |
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t/f
all doses of biguanides should be given w/ meals to reduce gi distress |
t
|
|
t/f
metformin should be given tid |
f
XR formulation given QD can also be given BID |
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why should you start low w/ big
|
to reduce GI effects
|
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t/f
bigu causes weight gain and you have to watch out for hypoglycemia |
f
neither happens |
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when can bigu cause hypoglycemia
|
in conjunction w/ sulfony, repag or insulin
|
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very rare SE of bigu
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lactic acidosis
|
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risk factor of getting lactic acidosis in biguan
|
renal failure
radiographic dye studies hypoxemia sepsis acute/chronic metabolic acidosis liver impairment |
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s/s of lactic acidosis
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malaise
myalgias resp distress somnolence abd distress hypothermia hypotension |
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bigu have drug interactions w/
|
cimetidine: increase met conc by 60%
cationic drugs: amilirde, dig, vanco so w/ these drugs you might have to reduce the dose of metformin |
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metformin decreases: -----, total and LDL cholesterol, and increases -----
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triglycerides
HDL (slightly) |
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when should metformin be held
|
2 days prior to and 2 days after radiographic dye studies
check renal fx prior to restarting metformin |
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who should you measure Cr levels in when wanting to rx metformin
|
> 80 yrs old
pt w/ CrCl below 50-60 mg/dl |
|
alpha glucosidase inhibitors examples
|
acarbose (precose)
miglitol (glyset) |
|
alpha ---- carb absorption and thus reduces the increase in ------ glucose conc
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delays
postprandial |
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t/f alpha affects absorption of lactose, fructose, glucose
|
f
does not |
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does alpha increase insulin levels or cause hypoglycemia when used along
|
no
|
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if you double the dose of metformin what will you double the efficacy
|
no
you'll just double the SE |
|
t/f
alpha works locally |
t
|
|
initial dose of alpha
|
25 mg tid
some may start qd and then increase |
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when should alpha be given
|
w/ 1st bite of each meal
|
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when is alpha dose adjusted
|
4-8 wk intervals
|
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max dose of alpha
|
50 mg tid for patients less than equal to 60 kg
100 mg tid for over 60 |
|
how are alpha available
|
in 25, 50, 100 mg tabs
|
|
SE of alpha
|
mostly GI
abd pain/d, fatulence: these minimized slowly elevated serum tranaminases: usu seen in high doses of 100 mg tid |
|
why should you titrate alpha up
|
to prevent gi effects
|
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what can reduce effect of acarbose and miglitol
|
digestive enzymes
intestinal adsorbents |
|
miglitol can decrease these meds
|
dig
propranolol ranitidine |
|
alpha contraindicated in
|
inflammatory bowel disease
cirrhosis colonic ulceration partioal intestinal obstruction dx of digestion or absorption SCr > 2.0 mg/dl |
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alpha have a neutral or slightly favorable effect on:
|
total cholesterol
LDL HDL triglycerides |
|
t/f
for hypoglycemia, ok to use sucrose |
f
need fructose, glucose tabs or gel ( apple/orange, or fruit or lactose milk) |
|
alpha delays absorption of ---
|
sucrose
|
|
thiazolidinediones examples
|
rosiglitazone (avandia)
pioglitazone (actos) |
|
thia stimulate teh ----- proliferator-activator receptor-gamma (PPAR-gamma)
|
perioxisome
this increase insulin sensitivity |
|
t/f
2ndary moa of thia: decreases hepatic glucose production |
t
|
|
thia reduces --- insulin levels
|
plasma
|
|
thia requires presence of --- to be effective
|
insulin
|
|
SE of thia
|
weight gain, anemia, edema, CHF
|
|
who should not received thia
|
NYHA class 3 or 4 heart failure
|
|
use thia w/ caution w/ this med
|
insulin
|
|
t/f
thia will cause hypoglycemia when used along |
f
|
|
when will there be a risk of hypoglycemia
|
when used w/ sulfon, repaglinide, insulin
|
|
don't give thia w/ osteoporosis
|
increase risk of bone fx
|
|
which test should you monitor w/ thia
|
LFT's
|
|
initial tx for rosi
|
4 mg/day po qd or bid
|
|
when can you increase rosi
|
after 12 weeks increase to 8 mgj/day po qd or bid
|
|
w/ combo when do you decrease sulf/insulin
|
if FBS falls below 120 mg/dl
|
|
t/f
ok to take rosi w/out meals |
t
take w/o regard to meals |
|
initail dose of pio
|
15-30 mg po qd
|
|
max dose of pio
|
45 mg qd
|
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when do you decrease combo tx w/ pio
|
FBS below 120 mg/dl
|
|
t/f
ok to take pio w/ out meals |
t
|
|
when will you not give thia
|
ALT > 2.5 x ULN
|
|
if on tx w/ thia when do you d/c
|
if ALT increases above 3 x ULN
|
|
with Thia what happens when ALT increases to more than 2.5 ULN
|
check LFT's more frequently until return to norm or increase
|
|
which thia will increase lipids
|
rosi
|
|
which will oral meds produce more insulin
|
due to incretins
|
|
incretin mimetics
|
GLP-1 agonist (byetta)
DPP-IV inhibitors ( januvia) |
|
dpp-4 will ---- GLP or GIP
|
disintegrate
|
|
thru GLP and GIP will --- insulin thru beta an ---- glucagon thru alpha
|
increase
decrease |
|
exanatide is indicated for --- tx of type 2 w/ metformin and/or sulfonyurea
|
adjunct
|
|
dose of byetta
|
5mcg sc bid
|
|
max dose of byetta
|
10 mcg sc bid
|
|
when should byetta be given
|
60 min before morning and evening meal
|
|
byetta --- gatric emptying, reduces food ----- and promotes beta cell proliferation
|
reduces
intake |
|
when does byetta peak
|
2 hrs
|
|
are there sign reductions in A1c w/ byetta
|
no
|
|
when is byetta contraindicated
|
severe GI disease
severe renal impairment |
|
SE of byetta
|
hypoglycemia
N/V (will go away in 2-3 weeks) pancreatitis antibody formation? |
|
where should you keep byetta
|
fridge
|
|
cost of byetta
|
$200/month
|
|
sitagliptin (januvia) inhibits DPP-4 for up to -- hrs
|
24
|
|
dose of januvia
|
100 mg po q day as monotheraphy or in combo w/ metform or glitazone
|
|
if CrCl 30-50ml/min what's the does
|
50 mg po qd
|
|
CrCl<30ml/min
|
25 mg po qd
|
|
cost of januvia
|
$175
|
|
which is better to reduce A1c januvia or byetta
|
januvia
w/ baseline of 9 there's a reduction of up to 1.5% |
|
amylin aka
|
pramlinitide (symlin)
|
|
amylin works w/ --- to suppress postprandial glucagon secretion and slow ---- absorption
|
insulin
carb |
|
when does amylin peak
|
20 min
|
|
duration of amylin
|
3 hrs
|
|
s/e of amyline
|
N/V
anorexia |
|
do not use amylin for --- pt
|
gastroparesis
|
|
when is amylin used
|
adjunct for type 1 or 2
uncontrolled patients using mealtime insulin |
|
why might some not take amylin
|
they might already be on insulin, so 2 shots needed
|
|
amylin dose for type 1
|
15mcg sc prior to each meal
titrate 30-60 mg |
|
amylin dose for type 2
|
60 mcg sc prior to each meal
titrate to 120 mcg |
|
how much does amylin reduce PPG by
|
65-125 mg/dl in Type 1
|
|
ADA
A1c |
<7%
|
|
ada
preprandial glucose: |
70-130 mg/dl
|
|
ada
postprandial |
< 180 mg/dl
|
|
ada
bedtime |
< 140 mg/dl
|
|
ada
Bp |
< 130/80
|
|
ada
lpids |
< 70
or < 100 mg/dl |
|
ada
TG |
< 150 mg/dl
|
|
ada
HDL |
>40 mg/dl
|
|
aace
a1c |
< 7%
|
|
aace
fpg |
<110
|