Diabetes
Terms
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- multiple syndromes characterized by an elevation of blood glucose caused by a deficiency of insulin
- diabetes mellitus
- Type I DM
- insulin-dependent DM
- Type II DM
- non-insulin-dependent DM (90%)
- autoimmune destruction of the pancreatic islet B cell resulting in a loss of insulin secretion causes Type ___ DM
- I
- B-cell dysfunction, peripheral cell insulin resistance, abnormal intestinal glucose absorption, and obesity assoc w/ Type ___ DM
- II
- DM that usually develops before 20 y/o
- Type I
- risk factors for Type II DM
-
- FamHx
- Obese
- physical inactivity
- race (native , hispanic, asians, and african americans, and pacific islanders)
- Hx of glucose intolerance
- HTN
- HDL < 35
- TG > 250
- polycystic ovary syndrome - complication of DM
-
Acute
- diabetic ketoacidosis (type I)
- hyperosmolar nonketotic syndrome (type II)
Chronic
- microvascular (retinopathy, neuropathy, nephropathy)
- macrovascular (cardiac events, HTN) - metabolic syndrome characterized by:
-
- abdominal obesity
- atherogenic dyslipidemia (+TG, +LDL, -HDL)
- HTN
- insulin resistance - NML fasting plasma glucose
- < 100 mg/dL
- NML oral glucose tolerance test (2 hr)
- < 140 mg/dL
- Diagnose diabetes by any of following:
-
- classical s/sx (polyuria, polydipsia, unexplained wt loss) and random plasma glucose >200 mg/dL
- fasting plasma glucose >126 mg/dL
- oral glucose tolerance (2 hr) >200 mg/dL
* confirm on subsequent test - Tx of Type I DM
-
- Insulin
- diet
- exercise
- pt ed - Tx of Type II DM
-
- control blood glucose
- diet
- exercise
- oral hypoglycemic agents
- insulin
- pt ed - plasma glucose goals for diabetics
-
- preprandial 90-130 mg/dL
- peak postprandial <180 mg/dL
- HGb A1C <7% - standards of care for diabetics
-
- HbA1C <7%
- LDL <100 mg/dL
- HDL >40 mg/dL (male); >50 mg/dL (female)
- annual eye and foot exams
- albumin:creatinine ratio <30
- BP < 130/80 mmHg
- ASA 75-162 mg/d if > 40 y/o
- annual HIB vaccine
- pneumococcal vaccine at dx and rpt once when > 64 y/o -
insulin lispro (humalog)
insulin aspart (novolog) (BCF)
insulin glulisine (apidra) - ultra-short acting insulin
- regular insulin (humulin/novolin [BCF])
- short acting insulin
- only insulin that can be given IV or IM
- regular insulin
- isophane insulin suspension (NPH)
- intermediate-acting
- insulin glargin (lantus) [BCF]
- long-acting insulin
- onset, peak, and duration of ultra-short acting insulins
- 15 mins, 1-2 hrs, 4 hrs
- onset, peak, and duration of short-acting insulin
- .5-1 hr, 2-4 hrs, 8 hrs
- onset, peak, and duration of intermediate insulin
- 2 hrs, 8 hrs, and 24 hrs
- onset, peak, and duration of long-acting insulin
- NA, NA, 24 hrs
- insulins used for basal control
- intermediate (NPH) or long-acting (Lantus)
- insulins used for prandial control
- ultra-short (Novolog) or short-acting(regular insulin)
- how many units in 1cc of U-100 insulin?
- 100 units
- how often should pt test blood sugar (book answer)
- before each meal, 2 hrs after each meal, bed time, and occasionally at 3 a.m.
- what is std insulin dose?
- 0.5U/kg/d divided by basal and preprandial requirements
- blood glucose of < 50 mg/dL = ___ hypoglycemia
- mild
- blood glucose of < 20 mg/dL = ___ hypoglycemia
- severe
- which antidiabetic agents stimulate release of insulin from pancreas B cells?
- sulfonylureas
- SEs of sulfonylureas incl
- hypoglycemia and weight gain
- CIs for sulfonylureas
- hepatic and renal insufficiency, and pregnancy (glyburide is only cat B), sulfa allergies
- how long before a meal should 2nd gen sulfonylureas be taken?
- 30 min
- which sulfonylurea drug is not recommended if CrCl <50ml/min?
- glyburide
- which sulfonylurea drug is not recommended if CrCl is <10ml/min?
- glipizide
- which sulfonylurea drug is generally prescribed to the elderly?
- glipizide
- which sulfonylurea-like drugs are not sulfa drugs?
- meglitinides (secretogogues)
- which antidiabetic drug is prescribed to obese pts?
- metformin (glucophage) [BCF]
- what is the absolute CI for metformin?
- serum Cr > 1.5 mg/dL
- which antidiabetic drugs acts as an insulin sensitizer eo enhance the action of insulin in the liver and skeletal muscle?
- thiazolidinediones (gliltazones)
- what are the CIs for thiazolidinediones?
-
- class III/IV HF
- liver dysfunction (hepatotoxicity) - what must baseline LFT be for starting thiazolidinedieones?
- <2.5 ULN
- what must be present for thiazolidinediones to work?
- insulin must be on board
- what is a lipid SE of thiazolidinediones?
- raises LDL-C
- which class of drugs affect absorption of glucose?
- a-glucosidase inhibitors
- pioglitazone (actos)
- thiazolidinediones (glitazones)
- rosiglitazone (avandia) [BCF]
- thiazolidinediones (glitazones)
- acarbose (precose)
- a-glucosidase inhibitor
- miglitol (glyset)
- a-glucosidase inhibitor
- MOA for a-glucosidase inhibitors
- reversibly inhibits enzymes in the mucosa of the sm int from breaking down polysaccharides into absorbable sugars (delays the digestion of carbs resulting in a smaller rise in blood conc postprandial)
- CIs for a-glucosidase inhibitors
- inflammatory bowel dz; colonic ulcers; intestinal obstructions
- ARs of a-glucosidase inhibitors
-
abd pn; diarrhea; flatulence
(less carbs = less GI probs) - what must be monitored when using rosiglitazone/metformin [BCF] combi drug?
- renal and liver function (baseline LFTs and rpt q 2 mos x 1yr)
- Tx for Type II DM and HbA1C 7%
- therapeutic lifestyle changes
- Tx for Type II DM and HbA1C 7-8%
- single oral agent
- Tx for Type II DM and HbA1C 9-10%
- two or more oral agents needed
- which agent reduces FPG by ~50-70% and HbA1C by ~1-2%?
- Sulfonylureas and Metformin
- which agent reduces FPG by ~60% and HbA1C by ~1.7%?
- Meglitinides
- which agent reduces FPG by ~50% and HbA1C by ~1%?
- Glitazones
- which agent reduces FPG by ~10-20%, PPG by ~25-50%, and HbA1C by ~0.5-1%?
- a-glucosidase inhibitors
- which antidiabetic agent do you administer w/ first bite of food?
- a-glucosidase inhibitors
- what is algorithm for txing obese pts w/ type II DM?
-
- metformin or a-glucosidase inhibitor
- add SU, meglitinide, or glitazone
- add insulin - what is algorithm for txing non-obese pts w/ type II DM?
-
- SU or meglitinide
- add meformin or glitazone
- add insulin - what is algorithm for txing elderly w/ type II DM?
-
- SU or meglitinide or a-glucosidase inhibitor
- add or sub insulin
* no metformin because of renal function - what is only acceptable antidiabetic drug for prenancies?
- insulin (must have NML HbA1C prior to conception)
- when is the most important time to control glucose during prenancy/
- the first two months
- which antidiabetic drugs may be teratogenic or cause fetal hyperinsulinemia or hypoglycemia?
- oral antidiabetic agents
- pregnant women screened for GDM at ___ wks
- 24-28 (esp high risk)
- what is MC acute complication of type I DM?
- diabetic ketoacidosis
- s/sx of DKA
-
- hyperglycemia (>250)
- ketosis (fruity breath)
- acidosis (pH <7.3) - Tx for DKA
-
- fluids
- IV insulin (reg)
- electrolytes (esp K, even if it looks high)
- sodium bicarbs if severe acidosis - what syndrome occurs mainly in type II diabetics who are elderly, and physically impaired w/ limited access to water?
- hyperosmolar nonketotic syndrome (HNKS) - hyperglycemic hyperosmolar state
- s/sx for HNKS
- similar to DKA w/o acidosis, and w/ higher blood glucose (>600mg/dL)
- Tx for HNKS
-
- IV fluids
- insulin
- K replacement