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114 Cards in this Set
- Front
- Back
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which type:
immune system destroys beta cells of pancreas |
type I
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which type:
insulin resistance and decreased production |
type II
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which type starts as insulin resistence
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type II
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which type:
insulin resistance caused by pregnancy, increased risk for type II |
gestational
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why would you check a c peptide
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a protein that attaches to insulin when secreted by the pancreas, it breaks off and hangs around will be decreased in type I bc not much insulin - differentiate which type
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what is the honeymoon phase
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when increased insulin is secreted, will be a short time and then will stop
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why is gestational diabetes occur
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hormone from the placenta makes the body more resistance to insulin and pancreas needs to work harder, if cannot then develop gestational
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what is insulin resistence
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insulin not produced properly
muscle, fat, and hepatic cells do no respond to the insulin and this causes the pancreas to produce even more insulin overtime the pancreas wears out will develop into DM when pancreas unable to keep up, at diagnosis, pancreas works at 50% |
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how far in advance is insulin resistence before the diagnosis of DM
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5-10 years before - why important to educate on lifestyle changes
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what are the criteria for metabolic syndrome
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ANY 3:
1. waist >40in men or >35 female 2. TG >150mg/dl 3. HDL <40mg/dl 4. BP >130/80 5. FBS >100 or on med for high BS |
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this is a blood glucose level higher than normal but not high enough for DM
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pre DM
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how long in pre DM until develop type II
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10 years
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what are some interventions you need to do for pre-DM
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FOCUS on # not symptoms:
exercise - 5-7% wt loss decreases risk usually no symptoms - may have acanthosis check labs q 2 years |
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what is the diagnosis of DM vs Pre DM
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Pre - FBS >100 - 125
or OGGT 140 - 200 DM - FBS > 126 OGTT >200 |
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what is the ADA goal for DM type II and what is AACE goal
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ADA <7%
AACE <6.5% |
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why should you always test more than just a FBS
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because when borderline or been fasting for a while, the pancreas can compensate a little and make you WNL when fasting, its when eating the pancreas cannot compensate
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what HA1C should you stay under to decrease complications
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<6.5%
150 - 160mg/dl had 60% chance of developing complications - not too high |
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what type of diet should you encourage with DM type II
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carb counting
label reading meal planning low sodium low fat low cholesterol recipe adjustment * do not skip meals, space 4-6 hours, small evening snack, avoid high sugar foods or drinks Exercise |
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what are the benefits of physical activity
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increase insulin sensitivity
improve CV function reduce hyperinsulinemia - tell pancreas to calm down bc muscles using it improve lipid panel improve weight loss and controls weight enhance fibrinolysis help control BP decrease stress |
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what does sugar do to the vessels
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sugar changes the intima of the vessels, makes it sticky, hot and swollen - why ASA so good for CV disease, decrease enzymes that make it sticky
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why does high intensity exercise cause higher sugars
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bc only have a few seconds of sugar in the muscles, then get the sugar from the blood, once out, get from liver and the liver doesn't stop right away, but high sugars will decrease overtime
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what medications cause a risk of hypoglycemia with exercise
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insulin
meglitinides sulfonylureas |
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why do you need an eye exam by weight lifting
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because the vessels could pop, need to make sure vessels ok
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when should you check BS
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before meals or 2 hours after the START of eating. So change it up, do not do the same time everyday
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what are the goals of FBS and PPBS in ADA vs AACE
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ADA - 90 to 130
AACE - 70-110 ADA <180 AACE <140 |
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how long are control solutions good for
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3 months
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how long are test strips good for
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4 months
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as patients get closer to A1C goal, the need to manage what increases
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PPG - when HgA1c really high, FBS makes over 70% of the total A1c, the closer to 7% the higher the PPG contributes to the HgA1C
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when should you be testing PPG in patients with DM
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during gestational DM and all pregnant women with DM
in patients who achieve pre meal glucose targets whose HgA1C are high when monitoring treatment aimed specifically at lowering PPG When patient has low BS after eating - usually gastroparesis bc not going into blood stream |
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what are alpha-glucosidase inhibitors
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acarbose and miglitol
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what are the actions of alpha glucosidases
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delay the rate of glucose absorption by inhibiting alpha glycosidase enzyme in the brush border of the gut
reduce PPG slow digestion of complex carbs cause A1C decrease 0.5-1% when used along no hypoglycemia cause weight loss |
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how should you take alpha-glucosidases
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take with first bite of food only, if forget, cannot take it!
start with 25mg TID - weight based make adjustments based on PPG caution with insulin or sulfonylureas because of low BS monitor LFTs every 3-6 months blocks sucrose and starches so if low BS cannot have juice - must give MILK |
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what are SE of alpha- glucosidases
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GI - bad
increased LFTs |
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what are biguanides
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metformin
metformin XR Glumetza Riomet - liquid |
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what is the action of biguanides
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reduce hepatic glucose production
stimulate glucose transport in muscle and tissue decrease glucose absorption DOESNT CAUSE LOW BS!!! Type II has no feedback - sugar pushes out of liver when start to eat, then eat = high sugar, metformin helps decrease production of sugar surge DO not give with IBD - bc of increased GI effects |
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what are benefits of biguanides
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safe - lactic acidosis rare
decrease HgA1C 1-2% helps lipids can be used with PCOS helps loose weight good for pre DM and Metabolic syndrome MUST HOLD with any IVP dye!!! 48 hours Must check kidney and liver before start |
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what are the dosages for glucaphose - and for XR
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start low to decrease SE - GI
2550mg daily 2000 mg daily in pads Long acting - start 500-750 in the evening, max 2000 per day adjust every 14 days |
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what are examples of TZD
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avandia and actos
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what is the action of TZDs
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mainly reduce insulin resistance at cell level
decrease hepatic glucose production reduces both pre meal and PPG NO LOW BS!! decrease A1c 1-1.5% |
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what are advantages of TZDs
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can be given without regard to meals, do not need structured meal time
Actos is daily - max 45 Avandia is daily or BID - max 8 |
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what are SE of TZDs
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edema and weight gain, cannot give with HF!!!
link to bladder cancer increase lipids do not give if uncontrolled up to 20% LDL decrease OCP takes 3 weeks to see effects, 8-12 weeks for full effects |
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what are types of sulfonylureas
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glipizide - short 1/2 life
glyburide - long 1/2 life glimiperide - amaryl |
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what are the actions of sulfoylurea
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stimulate insulin secretion
can increase receipts of insulin on muscle and tissue some reduction in hepatic glucose production want shorter 1/2 life because can't get them out of hypoglycemia |
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what are changes of sulfa allergy with sulfoylurea
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16% will react, start really low and check for allergy then increase slowly
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what are benefits of sulfonylurea
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free at giant eagle
better when food in you, so less BS drop A1C drop 1-2% dose daily or bid glipizide shorter 1/2 life so less hypoglycemia SE |
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what are SE of sulfonylurea
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weight gain bc increased insulin and psych component
caution with kidney and liver disease AMARYL BEST with kidney disease MUST EAT ON A SCHEDULE - HAVE TO BE REGIMENTED or get low BS |
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what are types of meglitinides
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prandin or starlix
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what is the actions of meglitinides
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increase insulin production
decrease in action with lower the BS - good so you don't get low BS |
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what are benefits of meglitinides
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drop A1C 1-2 % prandin and 0.5-1.5% starlit
fast acting and shorter duration then sulfanyurea decrease PPG good for those with an erratic schedule glucose dependent take 0-30 minutes before meal - so can take whenever you eat |
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what are SE of meglitinides
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caution with HEPATIC impairment
cannot take even if take a bite or two of food, won't help |
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what are incretin mimetics
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Byetta
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what is the action of incretin mimetics
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incretin hormones are secreted by intestines in response to oral glucose load
GLP-1 increases insulin production by pancreas, decrease glucagon by alpha cells and increase satiety - GOOD GLP is degraded by DPP-4 DM patients GLP deficient |
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how do you administer incretin mimetic
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SubQ 5mg BID one hour before meals - increase monthly by 5
skip dose if already eating |
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what are SE of incretin mimetics
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PANCREATITIS
low BS - esp with sulfa NV HA Dizziness CAN ONLY USE WITH LONG ACTING - LANTUS * Nausea huge issue!!! cannot use with sever kidney disease or transplant |
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what is the new incretin mimetic - XL; what are the SE
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Bydureon - once weekly injection
in system a while, first use Byetta SE: lump at injection site, hurts - stays in skin and slowly released AVOID with thyroid cancer, even family history causes PANCREATITIS AVOID WITH KIDNEY DISEASE |
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What is victozia
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new GLP 1 analog
sub-q daily can give anytime regardless of meals, so convinenent. can use alone or with TZD, metformin, or sulfa DO NOT USE WITH INSULIN |
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what is the dose of victoza
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0.6g daily, increase to 1.2mg weekly, max 1.8mg
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what is the black box of victoza
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thyroid tumors
history of pancreatits - cannot give check for renal or hepatic impairment cause GI SE |
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what can you not administer with Victoza
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no DPP 4, amlyin or insulin products because already same class
must back off other meds because will increase insulin |
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what are Amylin analogues
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Pramlinitde
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what is the action of amylin
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secreted by the beta cells of the pancreas, helps to decrease glucagon production, patients with DM are deficient in amylin
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how do you administer amylin analogues
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SQ before each meal, used with patients using insulin only - type I and II,
can use with SI, TZD, and metformin |
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what are SE of amylin
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severe hypoglycemia esp with insulin
nv anorexia ha |
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what are DPP 4 inhibitors
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januvia
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what is the action of the DPP 4 inhibitors
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prevent degradation of GLP 1
increase first phase insulin production, decrease glucagon secretion, decrease hepatic glucose production ex. panc rush insulin when start to eat, then secrete slowly after dm II, with DM II do not get rush with januvia give the rush so PPG better, decrease glucose production |
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what are benefits of DPP 4
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can be used with biguanides, TZD or SU
higher the A1c the better the results |
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what are SE and dosages of DPP 4
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does - based on kidneys
100mg/dl with good kidney function decrease by half with GFR 30-50 Pharyngitis - loose voice hypoglycemia with SU or insulin - ADJUST other meds EXCRETED BY KIDNEYS!!! |
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what do you use with overweight patients
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glucophage
januvia prandin/starlix byetta TZD |
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what medications are good for hyperlipidemia
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actos
glucophage |
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what are medications good for kidney insufficiency
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amaryl
januvia prandin/starlix TZD |
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when you are treating DM what do you focus on first and then last
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first FBS - if pancreas cannot keep up then the PPG really high, if fasting decrease then everything else will
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what are long acting insulin and action
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levemir and lantus
starts 1.5 - 6 hours peak minimal last 24-36 hours take at same time everyday |
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what are rapid acting insulin types and action
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lispro, novalog and apidra
start 10-20 minutes peak 30-90 minutes lasts 3-5 hours food in front of you when you take, will decrease sugar |
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what is the action of regular insulin
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start 30-60 minutes
peak 2-5 hours lasts 4- 8 hours |
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what is intermediate insulin and action
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NPH
start 1-2 hours peak 4-15 hours and lasts 14-24 hours lower peak |
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what is 70/30 action
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start 15-30min
peak 2-3 hours lasts 18-24 hours |
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what are benefits of insulin vials and pens
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vial has 1000units
pen has 300 units with 5 pens can only use for 30 days once opened so if only use .2 of it have to throw awe, pens there is less in it so not throwing much away |
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what are the major complications of DM
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microvascular - nephropathy and retinopathy
macrovascular - CV disease - MI, stroke and PVD Neuropathy |
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HgA1C controls which type of complications
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microvascular, macro still affected because had pre-existing DM for a while, damage done
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how does retinopathy form
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detectable within 5 years of dx, many times at time of dx
starts with leakage of fluid from the blood vessels, l/t micro aneurysms, which are tiny vessels burst, hemorrhages and cap blockage neovascularizaiton follows, increases bleeding risk and loss of vision |
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what are cotton wool spots
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fluid collects, get stuck and thick, scar tissue forms
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what is seen before retinopathy on eye exam
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leakage in back of eye, retina a sponge and increase fluid, vessels become thinner and squeeze shut
MACULAR EDEMA - see on flouro |
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where do the tiny vessels form in the eye
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break and cause peripheral vision loss because the vessels never form in the center area of the optic nerve
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what do you see on exam with retinopathy that you know its no longer macular edema
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when the tiny vessels form off the vessels of the eye, will not form in center, why peripheral vision decreases first
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how often should DM patient see opthalmologist
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yearly for dilated eye exam, no matter what vision is
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what is the physiology of nephropathy, what starts first
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starts with hyper filtration and hypertrophy of kidneys, then structural changes occur
abnormal filtration of proteins l/t micro albumin and eventually protineuria will see high GFR >100 bc of vascular change, cause increase leakage and increased damage |
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who are HR for nephropathy
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40% of DM develop it
higher in minorities |
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what is the first sign of nephropathy
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microalbumin - must check at least yearly
normal <30 micro 30-299 macro >300 SEEN before creatinine changes |
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what is the treatment for microalbuminurea
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normoglycemia
ACE or ARB - help with congestion of kidney manage BP STOP smoking |
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what are macro vascular diseases
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CAD
PVD Cerebral VD |
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what are cardiovascular complications RF
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insulin resistence - IFG higher risk, PPG twice as likely to die
abdominal obesity increased FFA in blood - alter insulins control of glucose and increases CRP, cytokines, and other inflammatory markers and clotting Dyslipidemia - high LDL and TG, low HDL, high VLDL |
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what are goals of cholesterol in DM
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total <180
LDL <100, ideal <70 HDL >50 women and >40 men TG <150 |
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what cholesterol medications are used to decrease glucose
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Welchol - lower BS, LDL
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what are the goals of HTN and lifestyle modificaitons
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BP <130/80
Reduce weight exercise at least 30 minutes/day DASH diet low salt diet decrease ETOH 1-2 drinks NO SMOKING Start with ACE then HCTZ - check BP at every visit |
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what should you give with inflammation and hyper coagulation with CV RF
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ASA
if high CRP - estrogen, chronic inflammation and smoking elevate it |
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what are CV RF
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obesity, physical inactivity
obesity, unhealthy eating chronic stress depression nonmodifiable - age, gender, race, family history |
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what are symptoms of PVD
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claudication
lower leg foot ulcers > in type II than type I both smoking and high sugar raise plasma levels - clotting Send to vascular |
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what is treatment for PVD
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ASA
plavix or aggrenox, pletal encourage walking to increase circulation, must go until pain, will get better, build collateral control sugar, BP, lipids stop smoking |
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what autonomic nerve damage occurs with neuropathy
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affects heart, stomach, bladder, sexual function
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what sensory nerve damage occurs with neuropathy
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affects extremtities - arms, hands, feet, legs
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what are s/sx of sensory nerve damage
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may feel burning, tingling, numbness, pain from clothes touching, shooting pain at rest, inability to detect temp
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what is the treatment of sensory neuropathy
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control sugars
pain medications - Neurotin, Lyrica, start low and go slow, difficult sleeping and light headed relaxation techiniques |
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what issues can occur with untreated neuropathy
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total loss of feeling
loss of balance foot deformities ulcers calluses infections amputation |
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what can gastroperesis lead to
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n/v/d/c
must send to GI poor absorption PPG hypoglycemia bc no absorption |
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what are autonomic CV nerve damage symptoms
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dizziness from poor BP control
inability to change HR - when running should increase, it doesn't and causes syncope painless heart attack |
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what are autonomic neuropathy of the bladder lead to
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difficulty emptying bladder
frequent UTIs increase sugar increase bacterial men with UTI - check glucose |
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what autonomic neuropathy issues occur with sexual disfunction
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ED in men
vaginal dryness and infections |
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what is the prevention and treatment of autonomic neuropathy
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maintain sugar control
stop smoking use meds - impotence, gastric emptying, c/d, and pain consider antidepressants to treat depression |
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how do you prevent food problems with neuropathy
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maintain sugars
maintain circulation by exercise wear proper fitting clothes do not cut corns yourself take shoes off at every visit see podiatrist yearly |
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what is proper practice of daily foot care
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examine feet daily
do not go barefoot even at home check shoes for objects - SHAKE it out check temp of bath before step in avoid soaking in hot water - take moisture out cute toenails across moisturize, not between toes - fungal |
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what are guidelines for DM and cholesterol with DM
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hga1c <7% - check q 3-6 months
LDL <100 or 70 HDL >50 total <150 check cholesterol yearly if no HL yearly micro albumin and BMP BP <130/80 bring BG log to every visit check feet q3-6 months - monofilament and tuning fork eye exam yearly flu vaccine yearly pneumococcal vaccine shingles if >60 years |
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if you have a patient with a log book, checks BS every AM fasting and PPG for lunch
Lunch BS are high, AM ok what questions do you ask |
ask what he is having for lunch
should check before lunch BS because if you have high sugar breakfast, may be really high before lunch why you need to move times around |
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you have a patient on Lantus 15 unites at night, Glyburide BID 10mg
BS before lunch ok, elevated at night, slightly elevated at AM fasting what would you change |
adjust lantus because it affects fasting BS in between meals
log for a week and follow up for additional adjusting Glyburide only helps PPG - max |
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patient on 70/30 24 units in AM and 10 units in PM
Log book - AM fasting high, fasting Lunch not as high but elevated, PP breakfast higher but ok, lunch PP good and Dinner PP even better. HS BS high, what should you adjust |
night dose of 70/30, increase by 10% - the AM is the worst and then gets better, so the AM dose is good
this will help with AM fasting, so this will help through out the day as well, do not change both AM and PM at same time - too many variables Always work on fasting sugars first if there are a few lower, better numbers, should ask what they did that day, work out? |
