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88 Cards in this Set

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According to ADA guidelines, DM screening should begin for adults <45 years old when there is:
a) a family history of obesity
b) a personal history of LDL < 35
c) activity intolerance
d) poor response to efforts to maintain BMI
b) personal history of LDL < 35
According to the ADA, screening for asymptomatic DM should take place in all individuals over 45 every
a) year
b) 3 years
c) 5 years
d) 10 years
b) 3 years
The ADA recommends routine testing for type 2 DM in all people without risk factors over age:
45. Testing is every 3 years
When does BMI prompt DM screening earlier than age 45, according to ADA standards?
When BMI>=25 with other risk factors.

When the patient is severely obese.
Which of these people should have testing for DM 2 according to ADA standards? (Check all that apply)
a) Fit, healthy, African American male, 38 years old.
b) Overweight woman with polycystic ovarian syndrome
c) An inactive 18 year old woman who is overweight.
d) An overweight 25 year old woman who has poor response to diet and exercise.
e) A 30 year old man with BMI = 36.
f) An overweight 27 year old male with fasting HDL = 33.
In general, patients <45 must have BMI>=25 AND an additional risk factor.

a) Fit, healthy, African American male, 38 years old.--NO. Race = African, Latino, Native American, Asian and Pacific Islander is a risk factor.
b) Overweight woman with polycystic ovarian syndrome. --YES. PCOS is an additional risk factor.
c) An inactive 18 year old woman who is overweight. --YES. Inactivity is a risk factor.
d) An overweight 25 year old woman who has poor response to diet and exercise. --NO.
e) A 30 year old man with BMI = 36. --YES. Severe obesity counts as an additional risk factor.
f) An overweight 27 year old male with fasting HDL = 33. --YES. HDL<35 is an additional risk factor, as well as TG>250 and BP>=140/90
Is DM 2 hereditary?
Yes, family history is a risk factor.
Normal fasting glucose, 1-2 hour postprandial glucose and HgA1C:
Fasting <100 mg/dL
Postprandial < 140 mg/dL
A1C < 6%
ADA goal fasting, postprandial, and HgA1C values:
Fasting: 70-130
Postprandial <180
A1C <7%
About variation in HgA1C goals depending on patient characteristics.
For young patients with low hypoglycemia risk and long life expectancy, the goal can be as low as <6%

For elders with life expectancy <=5 years or significant fall risk it may be as high as <8%.
Patients must have no caloric intake for how many hours to be considered "fasting"?
8
Can HgA1C be used for screening?
Yes. A1C>6.5 indicates diabetes. Confirmation is not needed in the presence of symptoms or BG>200.
Describe three blood glucose measurements that indicate a state of increased risk for developing DM2:
Impaired fasting glucose (100-125)

Impaired glucose tolerance (140-199 2H pp 75g glucose load)

A1C = 5.7-6.4%
What are the cutoff values of blood sugar measurements used to diagnose DM?
Fasting glucose >=126

Random glucose >=200

Oral Glucose Tolerance Test (OGTT) >= 200 2h after 75 gram glucose load

A1C >= 6.5%
Does IGT or IFG develop first?
IGT. This is the earliest sign of impaired pancreatic function.
A1C of 7% corresponds with average blood sugar of
154 mg/d>
Name 3 sulfonylureas
glipizide
glyburide
glimipiride
mechanism of action of sulfonylureas
Increases insulin secretion (improves basal insulin over 24 hours, not for postprandial use)
Can sulfonylureas cause hypoglycemia?
Yes.
Which diabetes drug should be avoided in patients with anaphylaxis to TMP/SMX?
a) metformin
b) glyburide
c) repaglinide
d) acarbose
b) glyburide.

Sulfonylureas are sulfa drugs and are cross-allergic with TMP/Sulfamethoxazole.
Which class of antidiabetic drug is photosensitizing
a) sulfonylureas
b) amylin analogues
c) thiazolidinediones
d) biguanides
a) sulfonylureas
T/F: sulfonylureas are contraindicated in impaired renal function.
F. However, the dose should be adjusted.
Two factors that influence patient acceptability of metformin.
1. The pill is HUGE. Prewarn them.

2. It may cause GI upset. Take with the largest meal of the day to mitigate this.
Name a biguanide
metformin
Mechanism of action of biguanides.
Insulin sensitizer

Decreases hepatic glucose production
Rare but serious risk of metformin:
Lactic acidosis, particularly in the case of
impaired renal function
hypovolemia
low perfusion state
age >80
Monitoring needed with metformin use:
a) non
b) Cr
c) AST
d) ALT
b) Cr.

Discontinue if Cr>1.5 mg/dL. Impaired renal function increases risk for rare but serious lactic acidosis.
Metformin use is contraindicated in the presence of
a) COPD
b) sulfa allergy
c) heart failure
d) chronic liver disease
c) heart failure.

This is a low perfusion state which increases risk of rare but serious lactic acidosis.
What are the two contraindications to metformin use?
Heart failure
Renal impairment
T/F. There is significant risk for hypoglycemia from metformin monotherapy.
False.
A 48 year old man with DM2 well-controlled by metformin calls you with severe vomiting and diarrhea x 1 day. What action must the NP take to ensure patient safety?
N/V may cause dehydration leading to hypovolemia. This poses risk for lactic acidosis in metformin users.

Tell the patient to D/C metformin immediately and restart 48 hours after normal fluid intake has been restored.
Metformin must be stopped the day of, and restarted 48 hours after the following:
radiocontrast use

surgery

any procedure than may alter hydration status.
Name two thiazolidinediones
rosiglitazone
pioglitazone
ID this brand-name drug: Actos
Actos = pioglitazone, a TZD
Mechanism of action of TZDs:
Insulin sensitization
The following must be monitored during TZD therapy
a) ALT
b) AST
c) AP
d) Cr
a) ALT

There is a rare risk of hepatotoxicity with TZDs.
These two classes of antidiabetic drugs cannot be used in heart failure:
biguanides

TZDs
T/F. There is significant risk of hypoglycemia from TZD monotherapy.
False.
Concomittant use of a TZD with these medications is not recommended.
Insulin (this combination yields the largest volume expansion and edema risk)

Nitrates (this is a surrogate for CVD)
Which class of antidiabetic drug may cause edema/volume expansion and should not be used in heart failure.
TZD.
Name 2 incretin mimetics:
exenatide

liraglutide
Mechanisms of action of incretin mimetics:
Increases postprandial insulin release.

Slows gastric emptying, leading to decreased appetite.
These two drugs are often used off-label to facilitiate weight loss:
exenatide

pramlintide
What two classes of noninsulin antidiabetics are available in injection form only?
incretin mimetics and amylin analogues
Symptoms that should prompt immediate discontinuation of incretin mimetics:
persistent abdominal pain with nausea/vomiting. These may be signs of pancreatitis and the patient needs to seek medical care.
incretin mimetics should not be used in these three conditions:
Gastroparesis

Renal failure with CrCl<30 ml/min

History of pancreatitis
Name 2 DPP4 inhibitors.
sitagliptin

saxagliptin
T/F. There is significant hypoglycemia risk from montherapy with a DPP4 inhibitor.
False.
The FDA advises that patients should be monitored for _____ when a DPP4 inhibitor is initiated or the dose is increased.
pancreatitis.
ID this brand-name drug: Byetta
Byetta = Exenatide, an incretin mimetic.
Mechanism of action of incretin mimetics.
They bind to the GLP-1 receptor site on pancratic beta cells, stimulating increased insulin release.
Describe the physiology of incretins.
Incretins (GIP and GLP-1) are released in the intestin in the response to carbohydrate digestion. They bind to receptors in pancreatic beta cells to stimulate postprandial insulin release.
Describe the pharmacodynamics of two drugs working with the incretin system.
The incretin mimetics (exenatide and liraglutide) are GLP-1 receptor agonists. DPP-4 inhibitors (sitagliptin and saxagliptin) inhibit the enzyme that degrades incretin and thereby increases insulin release.
Name two meglitinides.
repaglinide

miglitol
Meglitinides have the same mechanism of action as:
Sulfonylureas.
ID this brand name drug: Prandin
Prandin = repaglinide, a meglitinide.
About timing of meglitinide dosing:
It is a short acting insulin segretagogue, and so it needs to be dosed 1-30 minutes before each meal.
Meglitinides should not be combined with this drug class.
SU. They bind to the same receptor site so there is no added benefit from combining them.
Name 2 alpha glucosidase inhibitors:
acarbose

miglitol
mechanism of action of alpha glucosidase inhibitors.
Delays digestion and absorption of carbohydrates.
What side effect of alpha glucosidase inhibitors is responsible for the nearly 40% drop-out rate?
flatulance.
Name the amlyn analogue.
Pramlintide
What drug carries a boxed warning about hypoglycemia?
pramlintide, the amylin analogue. It can only be used with meals of more than 250 cal with 30 g carbohydrates.
Mechanism of action of the amylin analogue, pramlintide
Delays gastric emptying, increases satiety, decreases glucagon release.
Indications for insulin use in DM2:
At initial diagnosis when sugars are 250--300

When acutely ill, an insulin sliding scale is used to keep BG at 110

When two or more oral agents at optimized dosage are inadequate for glycemic control.
Percent of insulin given as basal and prandial in DM1:
50/50
T/F. There are no contraindications to insulin use.
T.
Name three short-acting, rapid onset insulins:
aspart (NovoLog)
lispro (Humalog)
glulisine (Apidra)
Name a short-acting insulin
Regular (Humulin R, Novolin R)
Timing of regular insulin dosing:
Give 30-60 minutes before a meal. (Equivalent to onset of action)
Which insulin preparation is identical to endogenous insulin?
Regular insulin.
Peak of action of regular insulin:
2-3 hours.
Onset of short-acting, rapid-onset insulins.
10-30 min.
Peak of action of rapid insulins
30 min - 3 hours, depending on formulation.
Which insulin is cloudy?
NPH
Peak of action of NPH:
6-14 hours
Onset of NPH:
1-2 hours
Which insulin is sometimes dosed BID to approximate basal insulin?
NPH
Name two long-acting insulins
glargine

detemir
Name three antidiabetic drugs that can help the motivated patient with weight loss:
metformin

exenitatide

pramlintide
ABCDEFGs for diabetes care: A
Aspirin 75-162 mg/d
(clopidrogel = Plavix is an alternative)

ACEI or ARB
ABCDEFGs for diabetes care: B
Beta blocker or alpha beta blocker therapy for HTN
ABCDEFGs for diabetes care: C
Cholesterol goals:
LDL < 100
HDL > 45 in men, >55 in women

Check:
cholesterol, serum Cr, urine microalbumin, and GFR annually.
ABCDEFGs for diabetes care: D
Diet low in trans and saturated fats. Limit portions.
ABCDEFGs for diabetes care: E
Exercise at least 150 min/week with no gap of >48 hours.

Eye exam (dilated) annually or more.
ABCDEFGs for diabetes care: F
Foot exam:
Visual at every visit.
Monofilament, 128 Hz tuning fork, pinprick sensation, or ankle reflexes annually.
ABCDEFGs for diabetes care: G
Goals: review them periodically with the patient.
T/F. Beta blockers are contraindicated in DM.
False. The benefits outweigh the minimal risk.
What is the first warning of decreased renal function?
Urine microalbumin.