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171 Cards in this Set
- Front
- Back
What are 2 major functions of the endocrine system?
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1. communicate
2. maintain homeostasis |
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Name 2 hormones secreted by the pancreas.
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1. glucagon
2. insulin |
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Which pancreatic cells secrete glucagon?
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alpha cells
|
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What does glucagon do?
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increases the hepatic glucose output .:. increases blood glucose concentration
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Which pancreatic cells secrete insulin?
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beta cells
|
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What is the function of insulin?
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promote the uptake, utilization, and storage of glucose .:. lowers blood glucose concentration
|
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What are 2 ways that insulin is normally secreted?
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1. BASALLY in small amounts between meals and overnight
2. BOLUSES in response to food; activated by an increased concentration of carbs in the gut |
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What percent of insulin is secreted by the pancreas as basal? As bolus?
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basal: 50%
bolus: 50% |
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Is our insulin level ever 0?
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no
|
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When do boluses of insulin build up in the plasma?
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about 30 min- 2 hour after you eat
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Define basal insulin and describe the frequency of its release.
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The natural amount of insulin in the body; small amounts are released by the pancreas every 24 hours
|
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What is the basal insulin rate of secretion in adults?
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adults secrete about 1 unit of insulin/hr, regardless of food intake
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What are 4 other names for bolus insulin?
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1. premeal
2. mealtime 3. prandial 4. nutritional insulin |
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What is the purpose of bolus insulin?
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It is used to limit postprandial hyperglycemia by stimulating glucose uptake in the peripheral tissue
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In response to food, the amount of insulin secretion increases or decreases?
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increases
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What determines the resting membrane potential in beta cells?
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ATP-sensitive K+ channels
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How does glucose enter beta cells?
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via the membrane transporter GLUT-2
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What happens when intracellular glucose blocks the ATP-sensitive K+ channels?
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membrane depolarization and the opening of Ca++ channels
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What does the Ca++ influx from glucose blackage of the ATP-sensitve K+ channels induce?
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insulin secretion
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What is diabetes mellitus?
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a syndrome that develops when insulin secretion or activity are not sufficient to maintain normal blood glucose levels
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What is another term for Type I diabetes?
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IDDM: Insulin dependent diabetes mellitus
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Who usually gets Type I diabetes?
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kids
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How does one develop Type I diabetes?
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altered immune function; usually viral destruction of beta cells
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What does Type I diabetes therapy require?
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always requires insulin replacement
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What is another term for Type II diabetes?
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adult onset aka noninsulin dependent diabetes mellitus
*now many kids are developing this |
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What is the physiologic cause of Type II diabetes?
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the body produces insulin, but not enough
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How do you treat Type II diabetes?
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1. oral antidiabetic medicines
2. diet *may be given insulin, usually after trying multiple meds |
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Define hypoglycemia.
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A pathologic state produced by a lower than normal amount of sugar (glucose) in the blood
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Define hyperglycemia.
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A condition in which an excessive amount of glucose is in the blood
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List 8 types of medications for diabetes mellitus.
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1. insulin
2. sulfonylureas 3. meglitinides 4. biguanides 5. alpha-glucosidase inhibitors 6. thiazolidinediones 7. incretin mimetics 8. amylin analogues |
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What is animal insulin?
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Preparations of insulin available from either beef or pork pancreas
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Why is animal insulin no longer used?
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people got allergic reactions
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How do scientists produce human insulin?
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through recombinant DNA techniques (with E. coli or yeast vectors)
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Why do we prefer recombinant human insulin over animal insulin?
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Less likely to have resistance, allergic reactions, or antibodies against it
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What type of molecule is insulin?
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a peptide hormone
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Can insulin be administered orally?
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no
|
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What is the half-life of natural circulating insulin?
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a few minutes
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Why does natural insulin have such a short half-life?
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due to rapid removal by liver and kidneys
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What are 4 classes of insulin preparations?
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1. rapid acting
2. short acting 3. intermediate acting 4. long acting |
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How are ALL insulin preparations administered?
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subQ
|
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What is another name for short acting insulin? What is another way that it can be administered?
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Regular insulin
IV |
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Why should you alternate injection sites?
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To prevent lipohypertrophy (if this occurs, insulin won't be absorbed in the body)
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If you have a patient that is taking insulin, but is still hypoglycemic, what could you assume?
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that the patient is not rotating sites
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What are 3 examples of rapid acting insulin preparations?
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1. Humalog (lispro)
2. Novolog (aspart) 3. Apidra |
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What is the onset of rapid acting insulin?
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quick
|
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When do rapids acting insulin preparations peak?
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30 minutes - 3 hrs
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What is the duration of action of rapid acting insulin?
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1 - 5 hours
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When should you administer rapid acting insulin?
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IMMEDIATELY before a meal
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What does rapid acting insulin mimic?
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endogenous insulin molecules
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Why is rapid acting insulin easy to use?
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because you can coordinate it with meals
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What is another name for short acting insulin?
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regular insulin
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Give an example of short acting insulin.
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Regular (Humulin R)
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What is the onset of short acting insulin?
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30 min-60 min
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When is the peak of short acting insulin?
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2-4 hours
|
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What is the duration of action of short acting insulin?
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8-12 hours
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When should you administer short acting insulin?
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30-45 min before meals
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Can short acting insulin be administered via IV?
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yes
|
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Why does short acting insulin have a shorter duration of action?
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because giving the drug by the IV route has a shorter duration of action than when it's given by subQ
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What is the onset of immediate acting drugs?
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1 - 1.5 hours
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What is the duration of action of immediate acting drugs?
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12 - 16 hours
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What does intermediate acting insulin look like?
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appears cloudy (the only insulin preparation that isn't clear)
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What is an example of intermediate acting insulin?
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NPH (humulin N)
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Can intermediate acting insulin be used for emergency IV use?
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no
|
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What usually fills the contents of an insulin pen?
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long acting insulin + regular acting insulin in 1 combination
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How do you draw a combo?
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-Draw up the regular first (always want the clear liquid in the syringe first)
-then draw up NPH |
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The intermediate acting insulin preparations vary on durations. How do you decide which to give to a patient?
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depends on the patient's need
|
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What is the onset of long acting insulin preparations?
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1-2 hours
|
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What is the peak for long acting insulin preparations?
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-6-8 hours for LEVEMIR (DETEMIR)
-NONE for GLARGINE |
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What is the duration of action for long acting agents?
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24 hours
*usually administered once daily |
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What are 2 examples of long acting insulin preparations?
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1. Lantus (glargine)
2. Levemir (detemir) |
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When is Lantus (glargine) usually given?
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at bed time
|
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Does Lantus have a peak?
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no
|
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What is a key benefit of Lantus?
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doesn't cause hypoglycemia because it has no peak
(in other drugs, if a patient is given too much meds [above the peak] the patient may develop hypoglycemia) |
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What does the FORM OF INSULIN ADMINISTERED determine?
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1. onset of action
2. peak action 3. duration of action **which one you give depends on the patient's needs |
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What is rapid/short acting insulin used for?
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1. covers meal intake
2. used for elevated glucose levels after a meal |
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What is intermediate/long acting insulin used for?
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used for basal insulin needs
|
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What is intermediate/long acting insulin NOT used for?
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not intended to cover meal
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Name a combination product.
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Novolin or Humulin 70/30
|
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What is contained in Novolin or Humulin 70/30?
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70% NPH (intermediate)
30% regular insulin (short) |
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What are the benefits of administering a combination product?
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1. longer coverage
2. decrease the number of injections (usually 2x/day dosing) |
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How do you administer combination products?
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pen or vial
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What do you base the insulin dose on? What units should you use in insulin dosing?
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total body weight
units |
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Which trends should you observe in insulin dosing?
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1. hypoglycemia
2. hyperglycemia **often you undergo trial and error dosing **monitor the patient with blood glucose monitors |
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What is the ONLY insulin that can be administered via IV?
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regular insulin
|
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What insulins can be administered SubQ?
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ALL
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Rank the SubQ areas for insulin injection.
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Abdomen>buttocks>arm/leg
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What 3 factors increase insulin absorption?
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1. exercise
2. rubbing 3. heat **all accelerate insulin absorption |
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Name 3 types of insulin administration mechanisms.
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1. portable pen injectors (if patient on short + intermediate)
2. infusion pump 3. vial & syringe |
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What are portable pen injectors?
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cartridges of insulin and replaceable needles
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Name 3 pros of portable pen injectors for insulin.
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1. more accurate dosing mechanisms (turn end to measure the amount of units)
2. faster/easier than conventional syringes 3. improved patient compliance (easier for kids too) |
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What is an insulin infusion pump?
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pump connected to an indwelling subcutaneous catheter to deliver short acting (regular) insulin
**needle is in the skin |
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Which patients typically use an insulin infusion pump?
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Type I patients
|
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What are the pros and cons of using an insulin infusion pump?
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PRO:
-reduced glycemic variability CON: -not always practical for routine use (may be useful in special circumstances) |
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Should you refridgerate vials of insulin that are not in use?
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yes
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How long might USED insulin be kept at room temperature?
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up to 28 days
|
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How should you store insulin?
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away from direct heat or light
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Before drawing or injecting insulin, what should you visually inspect?
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1. shouldn't be cloudy
2. look for particulate matter |
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Name 3 adverse effects associated with insulin. (*) the most common.
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1. hypoglycemia (*)
2. Insulin allergy (rare now, was common with pork or beef) 3. lipohypertrophy (lump under the skin caused by accumulation of extra fat from frequent injections at the same site) |
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What are signs and symptoms of hypoglycemia?
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1. tachycardia
2. confusion (from low blood glucose) 3. vertigo 4. diaphoresis |
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How should you treat mild hypoglycemia in a patient that is conscious and able to swallow?
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1. simple sugar or glucose should be administered
2. give OJ, hard candy, sugar packets, or glucose tablets/gels |
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What is severe hypoglycemia characterized by?
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unconsciousness or stupor
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To decrease the severity of severe hypoglycemia, what should you do?
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1. give 20-50 mL of 50% dextrose by the IV route
2. 1 mg glucagon either SubQ or IV |
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What should you always do before injecting a patient with insulin?
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Always check blood glucose level
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Should you shake insulin vials?
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No, gently roll
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How should your insulin injection site look?
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free of scarring or bruising
**ask patient where they prefer it (they usually know best) |
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the remaining drugs are for type II
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the remaining drugs are for type II
|
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What are 2 divisions of sulfonylureas?
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1. first generation
2. second generation |
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Name the 3 first generation sulfonylureas.
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1. chlorpropamide (diabinese)
2. tolbutamide (orinase) 3. tolazamide (tobinase) |
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Name the 3 second generation sulfonylureas.
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1. glyburide (DiaBeta, Micronase, Glynase Pres Tab)
2. Glipizide (Glucotrol, Glucotrol XL) 3. Glimepiride (Amaryl) |
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What must you be able to produce in order for sulfonylureas to work?
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insulin
|
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What is the MOA of sulfonylureas?
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1. sulfonylureas bind to the beta cell receptor
2. closing the K+ channels 3. causing a Ca++ influx 4. depolarization 5. insulin release |
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What are the primary and secondary effects of sulfonylureas?
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Primary: increase secretion of insulin from beta cells of the pancreas
Secondary: increase insulin receptor sensitivity and decrease hepatic glucose output |
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How are sulfonylureas absorbed?
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rapidly through the GI
|
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How are sulfonylureas metabolized?
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90-100% hepatic metabolism
|
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What is an exception to typical sulfonylurea metabolism?
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Glyburide
50% hepatic metabolism 50% renally excreted |
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What is the duration of action of sulfonylureas?
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approx 24 hr (1/day dosing)
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What cautions should you take when administering sulfonylureas?
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1. hepatic and/or renal disease
2. elderly (kidney function decreases) 3. patients with a "sulfa" allergy |
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What should you tell the patients who are taking drugs with sulfa moieties?
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wear sunscreen because sulfa drugs increase sun sensitivity
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What are the adverse effects for sulfonylureas? (*) the primary)
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1. hypoglycemia (*)
2. dermatologic reactions (rash, photosensitivity, hypersensitivity) 3. GI disturbances (N/V/abnormal liver function tests) 4. weight GAIN (not ideal, we want them to lose weight) |
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Name 2 Meglitinides.
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1. Repaglinide (prandin)
2. nateglinide (starlix) |
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What is the MOA of Meglitinides?
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increase secretion of insulin from beta cells by the same pathway as sulfonylureas
|
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How are Meglitinides and sulfonylureas similar? different?
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structurally related, but Meglitinides does not contain a sulfa moiety-->ideal for patients with allergies to sulfonylureas
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What is the onset of action for Meglitinides?
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15 minutes
|
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What is the duration of action of Meglitinides?
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<4 hours
|
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Where are Meglitinides metabolized?
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CYP 3A4 and CYP 2C9
|
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What are potential advantages of Meglitinides?
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1. rapid onset and shorter duration of action
2. ideal for elderly 3. may be useful in patients who skip meals or eat sporadically |
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What are 2 adverse effects associated with Meglitinides?
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1. hypoglycemia
2. weight gain |
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Give an example of a biguanide.
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Metformin (glucophage)
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Which are prescribed more often, biguanides or sulfonylureas/meglitinides?
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biguanides
|
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What is the biguanide MOA?
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1. decreased hepatic glucose output
2. increased peripheral glucose uptake and utilization **alter the glucose without altering the insulin! |
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What are biguanide advantages?
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1. does NOT cause hypoglycemia because it doesn't effect insulin release
2. causes weight loss |
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Are biguanides metabolized through the liver?
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no
|
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How are biguanides eliminated?
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100% excreted through the kidney
|
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Adverse effects associated with biguanides?
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1. GI: D
2. lactic acidosis (increase lactate production in the body) **monitor patients because they could go into anaerobic metabolism! |
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What must you test first before administering a biguanide?
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creatinine levels
|
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What creatinine levels indicate renal impairment in men and women?
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do NOT give a biguanide if:
M: >/= 1.5 mg/dL F: >/= 1.4 mg/dL |
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Why shouldn't you give someone a biguanide who has hepatic impairment?
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may have decreased ability to eliminate lactid acid (and increase the likelihood of lactic acidosis)
|
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What do biguanides interact with? Why?
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iodinated contrast materials
they are both renally excreted (must stop metformin 24hr before to 48 hr after administering iodine materials) |
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Name 2 alpha-glucosidase inhibitors.
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1. acarbose (precose)
2. miglitol (glyset) |
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What is alpha glucosidase?
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an enzyme in the gut that helps with the ingestion of carbs and causes an increase in blood glucose
|
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What is the MOA of alpha-glucosidase inhibitors?
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potent competitive inhibitor of brush border alpha glucosidases necessary for the breakdown of complex carbs (causes a decrease in glucose)
|
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What are 2 alpha-glucosidase inhibitors pros?
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1. won't alter actual insulin
2. doesn't cause hypoglycemia* |
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Where are alpha-glucosidase inhibitors absorbed?
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poorly in gut
|
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What is the onset of action of alpha-glucosidase inhibitors?
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6 hours
|
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Where are alpha-glucosidase inhibitors metabolized?
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by intestinal bacteria
*be careful in patient with a GI disorder |
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Adverse effects associated with alpha-glucosidase inhibitors?
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1. abdominal pain, flatulence, diarrhea
2. acarbose (hepatotoxicity at very high doses) |
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What conditions are CI for alpha-glucosidase inhibitors?
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patients with significant GI disorders
|
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Name 2 thiazolidinediones.
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1. rosiglitazone (avandia)
2. pioglitazone (actos) |
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What is the MOA of thiazolidinediones?
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binds to the nuclear steroid hormone receptor and promotes glucose uptake into skeletal and muscle/adipose tissue
|
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Do thiazolidinediones cause hypoglycemia?
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no
|
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Where are thiazolidinediones metabolized?
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extensively by the liver through the CYP 450
|
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What are the adverse effects associated with thiazolidinediones?
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1. hepatotoxicity
2. edema (worse if combined with insulin) |
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Why should you be careful administering thiazolidinediones to CHF patients?
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worsens accumulation of water in their body
|
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What are incretins?
|
intestional hormones that are released in response to glucose
|
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What is GLP-1?
|
glucose-like peptide-1
|
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What is GLP-1 rapidly degraded by?
|
DPP-4=dipeptidyl peptidase-4
|
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When is GLP-1 released?
|
in relation to when you eat
(GLP-1 rapidly rises within minutes of food ingestion) |
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What are the 4 actions of GLP-1?
|
1. enhancement of glucose-dependent insulin secretion on beta cells
2. suppression of glucagon secretion of alpha cells 3. slows the rate of gastric emptying 4. reduces appetite |
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Give an example of an incretin mimetic.
|
Exenatide (Byetta)
|
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What is the function of Exenatide?
|
GLP-1 agonist
|
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How/how often do you administer exenatide?
|
pre-filled pens for subcutaneous injection administered 2x/day
|
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Name 4 adverse effects with the increten mimetic, Exenatide.
|
1. Hypoglycemia (esp. in combo with sulfonylureas-->additive)
2. N/D 3. Headache 4. Pancreatitis |
|
Name 2 DPP4 Inhibitors.
|
1. Sitagliptin (Januvia)
2. Saxagliptin (Onglyza) |
|
What is the MOA for DPP4 Inhibitors?
|
Inhibit DPP-4 enzyme that is responsible for the breakdown of incretin GLP-1
|
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How/how often do you administer DPP-4 inhibitors?
|
orally 1x/day
|
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What are the adverse effects associated with DPP4-Inhibitors?
|
gew GI effects
*NO evidence of hypoglycemia *since it's a new drug, we're still looking out for side effects |
|
Give an example of an amylin analogue.
|
Pramlintide (Symlin)
|
|
What is the MOA for Pramlintide?
|
1. slows gastric emptying
2. suppresses glucagon secretion 3. decreases glucose output by the liver |
|
Which patients are indicated for a Pramlintide prescription?
|
Both Type I and Type II patients who have failed other meds
|
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How/when should you administer the amylin analogue Pramlintide?
|
SubQ injection
PRIOR to meals |
|
What are the adverse effects associated with Pramlintide?
|
1. severe hypoglycemia (for an unknown reason, since the drug doesn't alter insulin concentration)
2. GI disturbance: N/V |