Term
| Preclinical Beta cell autoimmunity precedes the diagnosis of Type 1 by ____ years |
|
Definition
|
|
Term
| is there any screening available for T1DM? |
|
Definition
|
|
Term
|
Definition
T1DM
T2DM if failed other therapy
women w/gestational diabetes
diabetic ketoacidosis and hyperosmolar hyperglycemic state |
|
|
Term
| insulin is classified according to what 3 things |
|
Definition
strength
onset
duration of action |
|
|
Term
all insulin in the US is producing using what?
- Eli Lilly and Sanofi Aventus use what?
- Novo Nordisk uses what? |
|
Definition
- recombinant DNA technology
- non ds producing strain of E coli
- bakers yeast |
|
|
Term
| what are the 2 insulin strengths? |
|
Definition
|
|
Term
| which insulin controls post prandial glucose? fasting plasma glucose? |
|
Definition
|
|
Term
| Insulin requirements for individuals with type 1 diabetes and who are within 20% of ideal body weight are usually what? |
|
Definition
|
|
Term
| Insulin requirements will be ______ in the presence of illness or other metabolic instability. |
|
Definition
|
|
Term
| Insulin requirements will be _______during the honeymoon phase |
|
Definition
| less (0.1 to 0.4 unit/kg body wt/day) |
|
|
Term
| ___ of the daily insulin dose should be delivered as basal insulin and ____ for prandial |
|
Definition
|
|
Term
| how should the prandial insulin be divided for meals? |
|
Definition
20% Breakfast
15% Lunch
15% Supper |
|
|
Term
| major complication of insulin? 3 main complications of it? |
|
Definition
hypoglycemia
- Too much insulin or medication
Missed meals
Increased physical activity |
|
|
Term
| 3 rapid acting insulin examples |
|
Definition
|
|
Term
| 2 short acting insulin examples |
|
Definition
|
|
Term
| 2 intermediate acting insulin examples |
|
Definition
|
|
Term
| 2 long acting insulin examples |
|
Definition
|
|
Term
| where should you never inject long acting insulin? |
|
Definition
|
|
Term
| needles <___mm will not work in obese pts |
|
Definition
|
|
Term
| what are the best sites for insulin injection? |
|
Definition
| abdomen, then fat in back of arm |
|
|
Term
| what range is impaired glucose tolerance? what does it have a two fold increase in risk for? 10% of patients will develop ______ complications before meeting diagnostic criteria for diabetes |
|
Definition
|
|
Term
| 10% of patients will develop ______ complications before meeting diagnostic criteria for diabetes |
|
Definition
|
|
Term
| describe the diabetes progress (T2) |
|
Definition
| insulin resistance increases and blood glucose starts to rise. it reaches its breaking point and insulin production decreases while glucose continues to rise. |
|
|
Term
fasting plasma glucose levels
normal:
impaired:
DM: |
|
Definition
|
|
Term
A1C levels:
normal
increased risk of DM
DM |
|
Definition
|
|
Term
| how do sulfonylureas work? care must be taken to prevent what? |
|
Definition
help pancreas release more insulin, which lowers blood glucose
hypoglycemia |
|
|
Term
| what sulfonylurea should you make sure you get patients off of? |
|
Definition
|
|
Term
| people who are allergic to what need to avoid sulfonylureas? |
|
Definition
|
|
Term
| sulfonylureas stimulate the release of ____ from _____ of the ____ , especially in the onset of therapy |
|
Definition
insulin
beta cells
pancreas |
|
|
Term
| how much do sulfonylureas lower the A1C by |
|
Definition
|
|
Term
| Absorption of sulfonylureas are generally rapid, fairly complete, and unaffected by food except for short-acting ______, which is most effective when taken on an empty stomach. |
|
Definition
|
|
Term
| Contraindications or Precautions to sulfonylureas in: |
|
Definition
Sulfonylurea hypersensitivity
Diabetic ketoacidiosis
Severe Infections
Surgery, trauma, or other severe metabolic stressor
Elderly and patients with hepatic insufficiency are susceptible to the hypoglycemic effects of glucose-lowering agents |
|
|
Term
| what is the most serious complication to sulfonylureas? |
|
Definition
|
|
Term
| what may contribute to hypoglycemia in age related pts taking sulfonylureas? |
|
Definition
| renal/hepatic function decline |
|
|
Term
silfonylureas:
skin rash in __%
GI problems in __% |
|
Definition
|
|
Term
| Hematologic changes-like thrombocytopenia when taking sulfonylureas are associated with ___ generation, but rare with ____ generation. |
|
Definition
|
|
Term
| ____ of all patients with Type II Diabetes mellitus respond initially to sulfonylureas |
|
Definition
|
|
Term
Factors favoring a beneficial response to sulfonylureas
- Recently diagnosed ___ years
- ___+ yo
- Weight within ___% of ideal body weight
- FBG< ____mg/dl
- Never required insulin or requires less than ___ units/day |
|
Definition
|
|
Term
Sulfonylureas:
Usual reduction in FBG of ___ mg/dl
Usual reduction in A1c of ___%
___% of patients will experience secondary failure within ___ years |
|
Definition
|
|
Term
glyburide
starting dose:
max dose:
metabolized: |
|
Definition
|
|
Term
glyburide
starting dose
max dose
metabolized |
|
Definition
|
|
Term
glipizide
starting dose
max dose
metabolized where |
|
Definition
|
|
Term
glipizide xl
starting dose
max dose
metabolized where |
|
Definition
5 mg
20 mg
slow form release |
|
|
Term
| what is the only sulfonylurea metabolized in the liver? |
|
Definition
|
|
Term
glimepiride
starting dose
max dose
metabolized |
|
Definition
|
|
Term
| _____ drugs increase insulin release in response to food, keeping blood glucose from rising high after meals. MOA? |
|
Definition
meglitinides
-Stimulates insulin release from the beta-cells of the pancreas |
|
|
Term
| what drug acts like a sulfonylurea but is not one? |
|
Definition
| meglitinides/phenylalanies |
|
|
Term
______ Targets post-meal glucose spikes by significantly reducing prandial glucose elevations
Usual reduction in A1c is ____&____% when used in combination |
|
Definition
Meglitinies/Phenylalanies
1-2
2-3 |
|
|
Term
| what drug is good for shift workers? |
|
Definition
| Meglitinies/Phenylalanies |
|
|
Term
| contraindications to Meglitinies/Phenylalanies |
|
Definition
Known hypersensitivity to the drug or its inactive ingredients
Type 1 Diabetes
Diabetic ketoacidosis |
|
|
Term
Nateglinide (Starlix)
starting dose
max dose
metabolized |
|
Definition
120 mg w/meals
120 mg 3x/day
liver, eliminated renally |
|
|
Term
Repaglinide (Prandin)
starting dose
max dose
caution with? |
|
Definition
0.5-1 mg w/meals
16 mg/daily
* Caution with gemfibrozil or trimethoprim potential hypoglyemia |
|
|
Term
| ____ lowers blood glucose primarily by reducing glucose production in the liver. |
|
Definition
|
|
Term
|
Definition
1; decreases hepatic glucose production
2: improves insulin sensitivity, decreases intestinal absorption of glucose |
|
|
Term
| metformin (biguanides) is indicated in what ages? lowers A1C by? |
|
Definition
|
|
Term
| Metformin given as monotherapy in the UKPDS reduced all-cause mortality in obese patients by ____ |
|
Definition
|
|
Term
| ____ is associated with modest favorable effect on plasma lipid levels |
|
Definition
|
|
Term
| Biguanides contraindications |
|
Definition
- Patients with renal disease or impairment
- Congestive heart failure requiring pharmacologic treatment
- Acute or chronic metabolic acidosis
- Metformin should be discontinued in individuals scheduled to receive IV radiocontrast media at the time of procedure and for 48 hours thereafter, since these agents have been associated with acute renal dysfunction |
|
|
Term
|
Definition
|
|
Term
| metformin prescribing precautions |
|
Definition
- 80+ yo should not be titrated to max dose. monitor renal fxn
- conditions predisposing pts to renal insuff or hypoxia
- temp suspend prior to surgery
- liver ds
- hx of alcohol abuse |
|
|
Term
| MC side effect of Biguanides. others? |
|
Definition
diarrhea
GI distress, dermatologic, decrease B12 absorption, decrease folic acid absorption, blood dyscrasias, lactic acidosis |
|
|
Term
Metformin
starting dose
max dose
metabolism? |
|
Definition
500 mg bid
2,000 mg (1,000 bid)
- no metabolism. renally excreted |
|
|
Term
metformin XL
starting dose
max dose
metabolism? |
|
Definition
500-1,000 mg QPM
2,000 mg
take full dose w/evening meal or split |
|
|
Term
| ____is halted in the liver by metformin. excess is normally secreted via kidneys in healthy people but if kidney impairment they cannot. what can this lead to? |
|
Definition
gluconeogensis (LACTATE)
- metabolic acidosis |
|
|
Term
| what should you not use if you have Crohns/UC? |
|
Definition
|
|
Term
| names of 2 insulin sensitizers (1 is discontinued) |
|
Definition
|
|
Term
|
Definition
- Improvement in insulin sensitivity in skeletal muscle and adipose tissue
- secondary dec in hepatic glucose output |
|
|
Term
| do insulin sensitizers stimulate insulin secretion? what can happen from this? |
|
Definition
NO
- so it wont cause pt to become hypoglycemic |
|
|
Term
insulin sensitizers:
A1C reduction
___ weeks to see dec in blood glucose
what does it help improve? |
|
Definition
1.5-2.5%
2-4 weeks
maintain/improve beta cell function over time |
|
|
Term
| who should you not use insulin sensitizers in? |
|
Definition
pregnancy or breast feeding
CHF class 3 or 4 |
|
|
Term
| what further increases the risk of CHF in pts taking insulin sensitizers? |
|
Definition
| combo therapy with insulin |
|
|
Term
| increased incidence of what when taking insulin sensitizers? (4) |
|
Definition
CHF
macular edema
bone fx in females
resumption of ovulation in post menopausal women |
|
|
Term
| what can reverse anovulation? |
|
Definition
|
|
Term
| what should you check prior to starting insulin sensitizer therapy and periodically thereafter? |
|
Definition
LFTs
(dont ever start with statins bc you wont know which is impacting liver) |
|
|
Term
| what drugs work in the intestine to reduce glucose absorption? |
|
Definition
alpha-glucosidase inhibitors
(Acarbose, Miglitol) |
|
|
Term
| what are 2 examples of alpha-glucosidase inhibitors. how much do they lower the A1C by? |
|
Definition
Acarbose, Miglitol
0.5-0.8% |
|
|
Term
| what does synthetic amylin do? |
|
Definition
limits the amt of glucose released from liver
slows emptying of stomach
reduces amt insulin needed |
|
|
Term
| when should amylin therapy be considered? (2) |
|
Definition
- failed to achieve glycemic control despite insulin
- having ongoing care under HC professional skilled in use of insulin |
|
|
Term
| when should amylin not be used? |
|
Definition
A1C >9%
poor compliance
hypoglycemia
gastroparesis
pediatrics
pts requiring drugs that stimulate GI motility |
|
|
Term
| black box warning of amylin? |
|
Definition
its used w/insulin so its associated w/risk of insulin induced SEVERE HYPOGLYCEMIA in T1DM, often 3 hrs post use
**educate for when driving!!! |
|
|
Term
| ___ effect in diminished in T2DM pts. reduced circulation by as much as ___% |
|
Definition
|
|
Term
| Up to 60% of post-prandial insulin secretion in healthy individuals is attributable to the ____ effect |
|
Definition
|
|
Term
| 2 examples of incretin hormones released from intestinal mucosa upon GI exposure to nutrients inducing insulin secretion |
|
Definition
|
|
Term
GIP:
stimulates what?
effect on gastric emptying?
effect on satiety or weight?
glucagon secretion relationship? |
|
Definition
Stimulates insulin response from the beta cells in glucose-dependent manner
Has minimal effect on gastric emptying
Has no significant effects on satiety or body weight
Does not appear to inhibit glucagon secretion |
|
|
Term
GLP-1:
stimulates what?
gastric emptying effect?
effect on food intake and body weight?*** |
|
Definition
Stimulates insulin response from the beta cells in glucose dependent manner
Inhibits gastric emptying
Reduces food intake and body weight
Inhibits glucagon secretion from alpha cells in a glucose dependent manner |
|
|
Term
| how is the response to incretins in T2DM? examples? |
|
Definition
impaired
Decreased secretion of GLP-1
Decreased response to GIP |
|
|
Term
| GLP-1 and GIP therapy are limited by what? what are they rapidly degraded by? |
|
Definition
|
|
Term
| overall goal with incretins is to do what? how is this done? |
|
Definition
increase GLP-1
Add GLP-1 analogues with longer half life
Exenatide and Exenatide LAR (Byetta)
Liraglutide (Victoza)
Block the DDP-4 to slow the enzymatic degradation of GLP-1
Sitagliptin (Januvia)
Saxaglipton (Onglyza) |
|
|
Term
| what are 2 GLP-1 analogues with a longer half life? |
|
Definition
|
|
Term
| what 2 drugs are DDP-4 inhibitors? what do they do? |
|
Definition
Januvia, Onglyza
- slow the enzymatic degradation of GLP-1 |
|
|
Term
| what must used with DDP-4 to lower blood glucose in T2DM pts? |
|
Definition
|
|
Term
| what can DDP-4 inhibitors be combo'd with? |
|
Definition
| sulfonylurea, metformin and actos |
|
|
Term
|
Definition
| increases active incretin levels increases insulin release decreases glucagon secretion |
|
|
Term
| contraindications w/DPP-4s? |
|
Definition
| History of serious hypersensitivity reaction to sitagliptin (Januvia). These reactions include anaphylaxis, angioedema, and exfoliative skin conditions including Stevens-Johnson syndrome. |
|
|
Term
| Byetta does what? synthetic form of ______. binds to ____ but is resistant to _____ |
|
Definition
mimics GLP-1
salivary protein from Gila monster
binds GLP-1
resistant to DPP-4 degradation |
|
|
Term
| what GLP-1 agonist is good for grazers? why? |
|
Definition
Byetta
binds and activates GLP-1 receptor which leads to:
- inc insulin secretion w/meal
- dec glucagon secretion
- dec gastric emptying
- inc satiety effect |
|
|
Term
| what else do you need to write a prescription for with byetta? |
|
Definition
|
|
Term
Byetta:
- peak plasma concentration in ___
- eliminated ____
- not recommended if CrCl <_____ |
|
Definition
|
|
Term
what is byetta contraindicated in? (2)
precautions in? |
|
Definition
- T1DM, DKA
- kids, Preg C, nursing, renal ds, severe GI ds |
|
|
Term
| when should byetta never be administered? |
|
Definition
|
|
Term
| what are the possible byetta doses? initial? how much can you increase it by? |
|
Definition
5 mcg or 10 mcg pen
- initial: 5 mcg BID w/60 min period before AM and PM meal
- increase by 10 mcg SC twice after 1 month |
|
|
Term
| when do you have to adjust byetta? |
|
Definition
when its added to sulfonylurea (might reduce sulfonylurea to reduce hypoglycemic effect)
[not metformin or TZD] |
|
|
Term
| what are the byetta side effects like? what is a positive one? |
|
Definition
transient - N/V/D
+: lose 10 lbs |
|
|
Term
| in what situation would you NEVER give a pt byetta? why? |
|
Definition
pancreatitis or high triglycerides
- GLP-1 agonists can mask initial signs of pancreatitis |
|
|
Term
| which GLP-1 agonist has a longer half life? byetta or victoza? |
|
Definition
|
|
Term
| black box warning for victoza? |
|
Definition
| thyroid C cell tumors including medullary thyroid carcinoma |
|
|
Term
|
Definition
|
|
Term
|
Definition
daily, independent of meals
start: 0.6 mg
>1 week: 1.2 mg/day
max: 1.2-1.8 mg/day |
|
|
