Type Ii Diabetes

Front 1

What are the values of an impaired fasting blood glucose test for a patient classified as pre diabetes?

Back 1

> or = 100 mg/dl and < 125 mg/dl

Front 2

What are the values of an impaired glucose tolerance test for a patient with pre diabetes?

Back 2

-2 hour values on an oral glucose tolerance test of > or = to 140 to 199 mg/dl

Front 3

What is the A1c level classifying patient has pre diabetic?

Back 3

5.7-6.4%

Front 4

What is the A1c value for patient to be diagnosed as diabetic?

Back 4

>6.5%

Front 5

What is the fasting plasma glucose for patient to be diagnosed as diabetic?

Back 5

>126 mg/dl OR a random (without regard to last food intake) plasma glucose level of > or = to 200 mg/dl plus clinical signs and symptoms of diabetes

Front 6

What is the value of oral glucose tolerance test to diagnose patient as diabetic?

Back 6

2 hour glucose of > or = to 200 mg/dl.

Front 7

WHat are clinical signs of diabetes?

Back 7

- polyuria
-polyphagia
-polydipsia
-fatigue
-weight loss or blurred vision
-persistent hyperglycemia

Front 8

What are the risk factors for the development of diabetes/prediabetes?

Back 8

Testing should be done in all individuals with BMI > or = to 25 and at least one additional risk factor
• first-degree relative with diabetes (mother, father, brother or sister)
• member of a high-risk ethnic population
• delivered a baby weighing >9 lb or was diagnosed with gestational diabetes (GDM)
• hypertensive >140/90 or on therapy for hypertension
• on previous testing, had impaired glucose tolerance or impaired fasting glucose (blood glucose between 100 and 125 mg/dl)
• physically inactive (no regular exercise program)
• women with PCOS (polycystic ovarian syndrome)
• other clinical conditions associated with insulin resistance (e.g., severe obesity and Acanthosis nigricans)
• history of CVD

Front 9

What are the high risk ethnic populations?

Back 9

. African American, Hispanic, Native American, Asian American, Pacific Islander

Front 10

What are HDL and triglyceride levels that qualify as risk factors for DM??

Back 10

an HDL cholesterol level < 35 mg/dl and/or triglyceride level > 250 mg/dl

Front 11

At what age can children be tested for diabetes, how often should it be done, and what is the preferred testing method?

Back 11

1. at age 10 or at onset of puberty (if puberty is at younger age)
2. test every 3 years
3. fasting blood glucose test

Front 12

What are the risk factors for child to develop Type II DM?

Back 12

• overweight
• Plus any two of the following risk factors:
o Family history in first or second degree relatives
o Member of an at-risk ethnic group as listed above
o Signs of insulin resistance or conditions associated with insulin resistance: hypertension, PCOS, dyslipidemia, Acanthosis nigricans, small for gestational age birth weight
o History of maternal diabetes or gestational diabetes (GDM)

Front 13

What classifies child as overweight?

Back 13

BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% ideal

Front 14

What is goal A1c level for a nonpregnant adult patient?

Back 14

< 7% as long as it can be achieved without significant hypoglycemia

Front 15

What is normal fasting or preparandial blood glucose for patient without diabetes and patient with diabetes?

Back 15

normal: 70-99 mg/dl
diabetic: 70-130 mg/dl

Front 16

What is four basic components of a tx plan for prediabetic patient?

Back 16

1. lifestyle changes
2. possibly medication
3. treat other cardiovascular risk factors
4. monitor for development of diabetes annually

Front 17

What lifestyle changes should prediabetic patient make?

Back 17

-weight loss (5-10%)
- increase physical activity ( > or= to 150 min/wk)

Front 18

when should medications be used in prediabetic patient?

Back 18

- should be used for patients with the highest risk of developing diabetes which includes:
- impaired fasting glucose or impaired glucose tolerance
- A1C> 5.7-6.4 plus other risk factors such as BMI > 35, <60 yrs of age and women with history of gestational diabetes
-metformin is drug of choice

Front 19

When should metformin be initiated?

Back 19

When lifestyle changes fail to achieve glycemic goals and A1c is > 7.5%?

Front 20

What are the renal contraindications for metformin?

Back 20

-eliminated by the kidneys, so if kidney function is compromised then the patient is at risk for a serious adverse effect of lactic acidosis (fatal)
- SCr > or = 1.5 mg/dl men or 1.4 mg/dl for women

Front 21

What are the 4 other contraindications for metformin?

Back 21

1. unstable congestive heart failure
2. liver disease
3. alcohol abuse or regular moderate to heavy alcohol use
4. pregnancy/lactation

Front 22

What is the dosage range for metformin?

Back 22

500-2500 mg/dl

Front 23

What are the clinical effects of metformin?

Back 23

• lowers fasting plasma glucose concentrations by about 55 mg/dl
• reduces glycosylated hemoglobin A1c by 1 to 2%
• no hypoglycemia

Front 24

What is the most common side effect of metformin?

Back 24

-GI
•early satiety and anorexia
•nausea with or without vomiting, anorexia, diarrhea, bloating, and abdominal discomfort have been reported in 20 to 30% of patients.
• Symptoms more severe at initiation of therapy and diminish with continued use. Minimize symptoms by taking the dose with meals and increasing the dose slowly.
• Diarrhea is the most severe adverse effects and may persist in 5% of users. It is not associated with malabsorption but may require discontinuation of therapy.

Front 25

What is the route and frequency of admin for metformin?

Back 25

- oral
- can start at 500-800 daily with largest meal and if no GI problems then increase frequency to BID with meals

Front 26

WHat is the MOA for metformin?

Back 26

decreases hepatic glucose production from gluconeogenesis and glycogenolysis. *** This mechanism is metformin’s predominant mechanism for lowering blood glucose
• Metformin increases glucose uptake in the muscle by the increasing the movement of the glucose transporters to the cell membrane and by increasing their sensitivity to insulin and glucose.

Front 27

What are contraindications to insulin secretagogues?

Back 27

• Type 1 diabetes
• Diabetes due to pancreatic resection
• History of adverse reactions to sulfonylureas or related compounds (sulfa drugs)
• Stress: emotional, severe infection, trauma, major surgery
• Significant Renal or hepatic disease or those predisposed to significant hypoglycemia

Front 28

What can you expect form SU or meglitinides?

Back 28

-fasting blood glucose to drop 60-70 mg/dl
- ALc reduction of 1-2%

Front 29

What is the brand name for Glimepiride and the dose?

Back 29

- Amaryl
1-8 mg/QD

Front 30

brand name and dose for glipizide?

Back 30

- glucotrol
2.5-40 mg QD or BID

Front 31

What are the 3 types of sulfonylureas? (insulin secretagogues)

Back 31

1. glimepiride
2. glipizide
3. glyburide

Front 32

What is the brand name and dose for repaglinide?

Back 32

-prandin
.5-4 mg before each meal

Front 33

What are the GI associated side effects of insulin secretagogues?

Back 33

manifested as nausea, heartburn or fullness and can be relieved by reducing the dose or by taking with meals.

Front 34

What are the derm associated side effects of insulin secretagogues?

Back 34

• Most common -- rash and pruritus
• Usually minor and reversible with 2 to 14 days after drug discontinued
• Rash-- maculopapular, erythematous, discrete in nature involving the face, neck, upper trunk, and proximal portion or the arms. May progress to more severe form.
• Sulfa structure and hypersensitivity
• cross-sensitivity among the sulfonylureas

Front 35

What are the hypoglycemic risk with sulfonylureas?

Back 35

account for almost all cases of drug induced hypoglycemia for people> 60
- patients at risk- elderly, renal impairment

Front 36

How do insulin secretagogues work?

Back 36

(sulfonylureas and meglitinides are in this class)
- stimulate the beta cells to release more insulin

Front 37

What is the brand name for thiazolidinedione?

Back 37

Pioglitazone-- Acto

Front 38

What are contraindications for TZD?

Back 38

• Class III and Class IV congestive heart failure
• anemia
• impaired liver function
• type 1 diabetes
• pregnancy

Front 39

What are the clinical effects of TZD?

Back 39

-Maximal affect on Hgb A1c is seen after 12 to 14 weeks of therapy. Average decrease in A1c is 1.5% (in patients with a baseline A1c of 9%).
-More effective when used in combination with insulin, insulin secretagogues or insulin sensitizers.
- An average decrease of 0.8 to 1.3% in A1c when a glitazone is added to another agent.

Front 40

What is the dose for TZD?

Back 40

prioglitazone- 15-45 mg QD

Front 41

What are adverse effects of TZD?

Back 41

• Weight gain
• Edema
• Anemia – dilutional effect
• Heart failure and exacerbations of congestive heart failure –
• Skeletal effects
• Increased risk of heart disease—
• Macular edema – a rare side effect – more common in those patients who develop edema
• Increase is serum transaminases – routine monitoring is not recommended

Front 42

What are the specific skeletal effects of TZD?

Back 42

–decreases bone density and increased the risk of fractures in upper and lower limbs of women with type 2 diabetes (reported in the ADOPT trial)

Front 43

How to TZDs work?

Back 43

-interact with a nuclear receptor known as peroxisome-proliferator-activated receptor gamma
- the receptor is activated it can alter transcription of various genes involved in lipid and carb metabolism
- increased in GLUT1 AND GLUT4 which decrease insulin resistance in peripheral tissues

Front 44

What is the brand name of sitaglipitin?

Back 44

Januvia (DPP-4 inhibitor)

Front 45

What is the dose of Januvia?

Back 45

100 mg AD

Front 46

What is dosing of Januvia for patients with renal insufficiency?

Back 46

-CrCl= 30 to < 50
- 50 mg QD
- if CrCl is < 30 then dose should be 25 mg daily

Front 47

What is the clinical effects of Januvia?

Back 47

.6-.8 % drop in A1C

Front 48

What are the adverse effects of Januvia?

Back 48

- runny nose
- sore throat
- upper respiratory infection
- headache

Front 49

WHat are the serious hypersensitivity reactions of Januvia?

Back 49

-anaphylaxis
-angioedema
-exfoliative skin conditions
-Stephens- Johnson syndrome
occurred within the first 3 months

Front 50

What is the MOA for Januvia?

Back 50

Dipeptidyl peptidase-4 inhibitor (DPP-4 inhibitor).
- This class of drugs inactivates the enzyme DPP-4 that deactivates glucagon-like peptide-1 (GLP-1).
-This gut polypeptide (GLP-1) also referred to as an incretin slows gastric emptying and stimulates the pancreas to produce insulin in response to a meal.

Front 51

What is the brand name for exenatide?

Back 51

- Byetta; synthetic extendin 4 (GLP-1 agonist)

Front 52

What is the brand name for Liraglutide?

Back 52

Victoza ( GLP-1 agonist?

Front 53

What are contraindications for GLP-1 agonists?

Back 53

type 1 diabetes or ketoacidosis
b. severe gastrointestinal disease
c. Do not use in patients with history of pancreatitis. Patients at risk for pancreatitis are those with a h/o pancreatitis, gallstones, alcoholism, and elevated triglycerides

Front 54

What are specific contraindications for Byetta?

Back 54

(Exenatide)
- end stage renal disease or severe renal impairment (CrCl <30)

Front 55

What are specific contraindications for Victoza?

Back 55

(Liraglutide)
- patients with history of or family history of medullary throid cancer or history of multiple endocrine neoplasia syndrome type 2

Front 56

What is dosing for Byetta?

Back 56

5 mcg BID 60 minutes before meals. Increase to 10 mcg after one month based on response. Administer subcutaneously (SC) within 60 minutes before breakfast or supper. Do not give after a meal.

Front 57

What is dosing for Victoza?

Back 57

Starting dose 0.6 mg daily. Can be given any time of day with or without food. Dose is titrated to 1.2 mg daily after one week. Can titrate up to a top dose of 1.8 mg.

Front 58

What are the clinical effects of GLP-1 agonists?

Back 58

Average A1c drop is 0.9%. The average weight loss is 4 lbs. Most people who lose weight do so in the first month. The drop in A1c is independent of weight loss and nausea.

Front 59

What are the adverse effects of GLP-1 agonists?

Back 59

-mild to moderate dose dependent nausea
-usually decreases over time
-possible nausea, headache and diarrhea

Front 60

What are 2 serious side effects of GLP-1 agonists?

Back 60

- hemorrhagic and necrotizing pancreatitis
- serious hypoglycemia (when combined with insulin secretagogue)

Front 61

what is the MOA for GLP-1 agonists?

Back 61

release in the presence of elevated blood glucose. It decreases glucagaon secretion in a glucose-dependent manner. Also lowers blood glucose by delaying gastric emptying. They are stable against metabolism by DPP-IV enzymes thereby increasing their duration of action.

Front 62

What is the brand name for acarbose?

Back 62

Precose
(alpha glucosidase inhibitor)

Front 63

What are contraindications for acarbose?

Back 63

• known hypersensitivity
• diabetic ketoacidosis
• inflammatory bowel disease; colonic ulceration; partial intestinal obstruction
• malabsorption disorders

Front 64

What are the clinical effects of acarbose?

Back 64

• Decreases fasting blood glucose by 15 to 30 mg/dL
• Decreases postprandial blood glucose 50 to 60 mg/dL
• Decreases hemoglobin A1c by 0.5 to 1.0%

Front 65

What are the dose ranges for acarbose?

Back 65

- start at 25
-maintenance dose 50-100 mg

Front 66

What are the side effects of acarbose?

Back 66

• Primarily gastrointestinal: increase in gas formation secondary to fermentation of unabsorbed carbohydrate in the bowel.
• Elevated transaminases when dose >600 mg QD

Front 67

What is the MOA for acarbose?

Back 67

These agents are competitive inhibitors of intestinal brush border enzymes that hydrolyze carbohydrates. Normally, carbohydrates are metabolized by these enzymes very quickly allowing glucose and other simpler sugars to enter into the bloodstream quickly. Alpha glucosidase inhibitors reversibly bind with these enzymes and delay carbohydrate digestion so that it occurs throughout the small intestine rather than in the duodenum and upper third of the jejunum. The effect on the blood sugar is a delay in the rate of rise and amount of rise after a meal (decreases postprandial blood sugar rise)