Theratest1 Diabetes Part 1

Front 1

Glucose

Back 1

main energy source for our body

Brain is dependent on it

Front 2

Glycogen

Back 2

Storage molecule for excess glucose

Front 3

Glycogenolysis

Back 3

Breakdown of glycogen into glucose

Occurs during low blood glucose levels

Front 4

Gluconeogenesis

Back 4

Production of glucose from new sources

Front 5

Insulin

Back 5

Produced by the beta cells as proinsulin

Increases: glucose uptake into cells, synthesis of protein and TGs and fatty acids

Decreases: breakdown of glycogen and fat and protein, fatty acid oxidation, gluconeogenesis

Front 6

Amylin

Back 6

Produced by beta cells and co-secreted with insulin

decreases glucagon and slows gastric emptying

Front 7

Glucagon-like Peptide 1 (GLP-1)

Back 7

gut hormone released in response to food -- stimulates insulin secretion

Front 8

Selective sodium-dependent glucose cotransporter (SGLT-2)

Back 8

helps the kidney reabsorb glucose

if inhibited - allows glucose to pass into the urine

Front 9

Factors Decrease Blood glucose

Back 9

1. insulin
2. Excess DM meds
3. other meds
4. Lack of food
5. exercise
6. increased alcohol intake
7. decreased hepatic/renal function

Front 10

Factors increase blood glucose

Back 10

1. Counter-regulatory hormones
2. Insufficient DM meds
3. Other meds
5. Excess foods
6. Exercise
7. Illness
8. stress

Front 11

Medications that Increase Blood Glucose

Back 11

1. Corticosteroids
2. Thiazides
3. Protease Inhibitors (Ritonavir)
4. Antipsychotics
5. Phenytoin
6. Nicotinic Acid

Front 12

Medications that Decrease Blood Glucose

Back 12

1. DM meds
2. Antimalarial (quinine)
3. Antibiotics
4. Ranolazine
5. High dose salicylates

Front 13

Fasting Plasma Glucose (FPG)

Back 13

No caloric intake for 8 hours or more

Front 14

Random Plasma Glucose (RPG)

Back 14

Any time of day without regard to last meal

Front 15

Oral Glucose Tolerance Test (OGTT)

Back 15

Take 75g glucose drink and then glucose is measured 2 hours later

Front 16

Postprandial Glucose (PPG)

Back 16

Measured 2 hours after beginning of last meal

Front 17

Hemoglobin A1c

Back 17

*GOLD STANDARD FOR LONG TERM MONITORING*

Average glucose level over the past 2-3 months

Front 18

a) FPG for diagnosis of Diabetes

b) Goals of therapy for FPG

Back 18

a) 126 or higher

b) 70-130 mg/dL

Front 19

a) RPG for diagnosis of diabetes

Back 19

200 mg/dL plus symptoms of diabetes such as polyuria, polydipsia, polyphagia

Front 20

a) A1c for diagnosis of diabetes

b) Goals of therapy for A1c

Back 20

a) 6.5% or greater

b) less than 7%

Front 21

a) OGTT for diagnosis of diabetes

Back 21

200 mg/dL or higher

Front 22

Goal of therapy with Post Prandial Glucose

Back 22

less than 180 mg/dl

Front 23

Non-glycemic goals of diabetes

Back 23

BP: <140/80

LDL: <100 mg/dL (optional <70)

Front 24

Medical Nutrition Therapy

Back 24

Nutrition assessment generally provided by registered dietitians to evaluate a patient's food intake, metabolic status, lifestyle, and readiness for change

Personlized

Front 25

Goals of MNT for at risk patients

Back 25

reduce the risk of T2DM and CV disease by encouraging regular physical activity and weight loss

Front 26

Goals of MNT for patient with diabetes

Back 26

1. prevent and treat chronic complications by attaining and maintaining optimal metabolic outcomes (BG, A1c, lipids, BP, weight)

2. Healthy food choices and physical activity

3. Adress individual needs (personal and cultural preference)

Front 27

Protein

Back 27

Role: form/help repair body tissues

Found: meat, dairy, eggs, legumes

Impact on glucose: acute increase in insulin but doesn't increase circulating glucose

Front 28

Fat

Back 28

Role: provide essential fatty acids & carry fat-soluble vitamins

Found: oils, margarine, nuts, animal products

Impact on glucose: slows glucose absorption delaying peak

Front 29

Carbohydrates

Back 29

Role: provide sources of fuel for the body

Found: breads, pasta, rice, cereal, fruit, sweets

Impact on glucose: most direct on glucose levels

Front 30

MNT factors that affect blood glucose response

Back 30

1. amount of carbs
2. type of sugar or starch
3. processing (grinding, rolling, pressing)
4. food prep
5. physical form (juice vs whole)
6. ripeness

Front 31

Methods to monitor carb consumption

Back 31

1. Exchanges
2. Carb counting
3. plate method
4. Glycemic Index

Front 32

Exchanges for MNT

Back 32

Patients taught what quantity of a carb-containing food amounted to 10g, 12g, 15g

Front 33

Carb counting for MNT

Back 33

Meal planning method that involves keeping total carb intake at each meal consistent from day to day

Front 34

Plate Method for MNT

Back 34

Suggestive of portions

Plate is divided into sections

Front 35

Glycemic Index for MNT

Back 35

system for ranking carb foods according to their effect on postprandial glycemia

ranked on a scale of 0-100% when compared to blood glucose response of 50g of glucose

Front 36

Glucose change at beginning of exercise

Back 36

myosin ATPase breaks down ATP to produce energy

Carbs, fats, proteins are broken down

Front 37

Glucose change 5-10 minutes into exercise

Back 37

sustained movement allows carbs, fats, proteins to continually recharge

muscle glycogen breakdown decreases

Front 38

Glucose changes 20 minutes or more into exercise

Back 38

muscles' glycogen stores are depleted

blood glucose maintained by glycogenolysis

Front 39

Exercise's role in diabetes

Back 39

1. improve blood glucose control
2. reduce CV risk factors
3. weight loss
4. improve well-being

Front 40

Type 1 diabetes

Back 40

immune-mediated process that leads to destruction of beta cells - deficiency of insulin

Front 41

Clinical presentation of Type 1 diabetes

Back 41

1. incidence peaks at 10-14yo
2. 3 P's: polyuria, polyphagia, polydipsia
3. weight loss
4. fatigue
5. DKA

Front 42

Are ADA goals higher or lower for children?

Back 42

Higher goals are set

Front 43

Non-pharmacological treatment of Type 1 diabetes

Back 43

1. MNT
2. Exercise
3. SMBG
4. Education
5. Psychosocial support

Front 44

Insulin for Type 1 Diabetes

Back 44

essential for all patients with T1DM; initiate promptly after diagnosis

Front 45

MOA for insulin

Back 45

replaces insulin deficiency -- glucose uptake by cells with beneficial effects on protein, carbs, fat metabolism

Front 46

Rapid Acting Insulin (Bolus)

Back 46

1. Lispro (Humalog)
2. Aspart (Novolog)
3. Glulisine (Apidra)

Front 47

Short Acting Insulin (Bolus)

Back 47

Regular (Humulin R, Novolin R)

Front 48

Intermediate Acting (Basal)

Back 48

NPH (Humulin N, Novolin N)

Front 49

Long Acting (Basal)

Back 49

1. Glargine (Lantus)
2. Detemir (Levemir)

Front 50

Storage and stability of insulin

Back 50

Unopened: refridgerated

Opened: refrigerated
Vial: 28 days (Levemir 42 days)
Pen: 10-28 day (Levemir 42 days)

Front 51

When should rapid insulin be given

Back 51

15 minutes or less before a meal

Front 52

short acting insulin should be given

Back 52

30-45 minutes before a meal

Front 53

Intermediate and long acting insulin should be given

Back 53

1-2 times per day

Front 54

ADRs of Insulin

Back 54

1. Hypoglycemia
2. Weight Gain
3. Lipodystrophy

Front 55

Initial Dosing of Insulin in Type 1 diabetes

Back 55

Total Daily Dose (TDD)
Weight based: 0.5-1units/kg
or
Sliding Scale

Front 56

Regimens of Insulin

Back 56

1. Split mix regimen
2. Basal-bolus

Front 57

Split mix regimen of insulin

Back 57

**Intermediate acting w/ short acting

1. 2/3 of TDD given in morning, 1/3 given in evening
2. 2:1 ratio (I:S) for each dose OR 2:1 ratio I:S in morning and 1:1 ratio (I:S) in evening

Front 58

a) advantages of Split Mix

b) disadvantages

Back 58

a) fewer injections per day

b) adhere to strict timing of meals and injections
less physiologically accurate

Front 59

Basal-Bolus Regimen

Back 59

1. 50% TDD (Long acting - once daily; intermediate - 2/3 in morning, 1/3 in evening)

2. 50% TDD (split equally OR 20% breakfast, 15% lunch, 15% dinner)

Front 60

a) advantages to basal-bolus

b) disadvantages

Back 60

a) tighter control, flexibility, mimics real life

b) up to 5 injections per day, increased cost

Front 61

How to adjust basal insulin

Back 61

adjust based on fasting blood sugar

10-20% of TDD

Front 62

how to adjust bolus insulin

Back 62

adjust based on postprandial blood sugar

1-2 unit increments

Front 63

How to make advanced adjustments of bolus insulin

Back 63

1) Insulin:Carb ratio (tailor to specific meal)

2) Insulin Sensitivity Factor ("corrects" elevated glucose)

Front 64

Insulin:Carb Ratio formula

Back 64

500 / TDD = grams of carbs covered by 1 unit of rapid or short insulin

Front 65

Insulin Sensitivty Factor Formula

a) rapid insulin
b) short acting

Back 65

a) 1800/TDD

b) 1500/TDD

Front 66

Early Morning Hyperglycemia

Back 66

1. Somogyi Effect

2. Dawn Phenomenon

Front 67

Somogyi Effect

Back 67

1. hypoglycemia during the night -- increased secretion of counter-regulatory hormones -- hyperglycemia in the morning

3am glucose = LOW

Front 68

Possible adjustments for Somogyi effect

Back 68

1. decrease PM dose of intermediate insulin
2. move PM dose to later in the evening
3. Switch from intermediate to long acting

Front 69

Dawn Phenomenon

Back 69

morning hyperglycemia due to natural increase of glucose between 4-8am

3am glucose = NORMAL - SLIGHTLY HIGH

Front 70

Dosing with Insulin Pump

Back 70

TDD = 0.5-1 unit/kg

Decrease TDD by 10-30% = Pump TDD
Basal: 50% of pump TDD and divide by 24 hours
Bolus: 50% of pump TDD

Front 71

a) advantages of insulin pump

b) disadvantages

Back 71

a) improved glycemic control, very precise amounts, more flexibility, reduced hypoglycemia

b) cost, skin infections, DKA

Front 72

MOA of pramlintide

Back 72

mimics endogenous amylin -- slows gastric emptying, decreases glucagon secretion, increases feeling of fullness

decreases initial postprandial spike

Front 73

Dosing for T1DM of Pramlintide (Symlim)

Back 73

Initial: 15mcg subq prior to major meals
titrate up in 15mcg increments if no nausea x3days

Maintenance: 30-60mcg subq prior to major meals

Front 74

Decrease pre-prandial rapid acting/short acting insulin by 50%

Back 74

Very important note about insulin if patient is on pramlintide (Symlin)

Front 75

ADRs of pramlintide (Symlin)

Back 75

1) Hypoglycemia (within 3 hours of injection)
2) Nausea

Front 76

Monitoring for T1DM

Back 76

1. Urine Ketones
2. SMBG (6-8 times per day)
3. A1c (q3-6 months)