-23.6 million people with diabetes in the U.S. currently.  __million estimated to have Pre-diabetes

-What is Pre-Diabetes fasting glucose?

-9 out of 10 people with DM have which type?

-57

-Between 100 and 125.

Type 2

- 7%

- 24 and 28

-WHAT IS GOOD COUNSELING FOR THOSE WITH ImpairedGlucoseTolerance OR ImpairedFastingGlu?

-When should they be rechecked?

-At what age should someone at least be screened every 3 years even if they are negative?

-Lose 5-10% of your Body Weight

-Once per year

-45 yo

What must someones's fasting glucose be to be considered Diabetic?

-What about 2 hour post glucose challenge?

-126

-200

-Prediabetic post glu challenge safe range?

-What does insulin do to the production of glucose from liver or muscles glycogen?

-What does it do to Gluconeogenesis from amino acids?

-140-199

-Inhibits

-Inhibits

Name the 3 RAPID ACTING INSULINS

-How long till Onset?

-Peak?

-How long do they last?

- (NAH)

Novolog® (Aspart)
Apidra® (glulisine)

Humlog® (lispro)

-15-10 min

-Peak 1-2 hrs

-Lasts 4-5 hours

Short acting Insulins?

ONSET, PEAK, Duration?

-When should they be taken?

-Humulin R   (U-100 and U-500)
  Novolin R

1/2 hr-1hr, Peak 2-3 hrs, Duration 6-8 hrs

-1/2 hr to 1 hr prior to meal.

Intermediate Acting Insulins?

-How long till Onset...Peak...Duration?

-What does NPH stand for?

-Humulin NPH
Novoloin NPH
Humulin L

-3-4 hours, 4-6 hrs Peak, Duration: 14-18 hrs

-NPH is an abbreviation for neutral protamine Hagedorn. It is a neutral pH, contains the protein protamine (as well as zinc).  The zinc/protamine complex prolongs the duration of action.

Long-lasting (Basal Insulins)

Which is "peakless"

Lantus (glargine)
Onset 4-5 hours
Duration 24 hours

Levemir (detemir)
Onset 1-2 hours
Duration 20 hours

-LANTUS IS PEAKLESS!!

-What temp should insulin be stored at?

-What temp injected at?

-If insulin is kept at 59 to 86 degrees Farenheit, how long may it be kept?

-36 to 46 degrees F

-Room to avoid irritation (rollin hands to warm up real quick...DON"T SHAKE!!)

-1 Month

-Who is allowed to use teh short needles?

-Is it safe to mix Glargine (Lantus) with other insulins?

-Those with lower BMI (UNDER 27)

-No

-Increases release of insulin from the pancreas, especially at the onset of therapy.
-Lowers A1c by 1.5 to 2 percentage points
Absorption is generally rapid, fairly complete, and unaffected by food except for short-acting glipizide, which is most effective when taken on an empty stomach.
-Amaryl (glimepiride); DiaBeta(glyburide); Glucotrol (glipizide); Diabinese (chloropropamide)

Sulfonylureas

-Metabolism and excretion of these varies greatly. Most sulfonylureas are metabolized in the liver to active or inactive metabolites except for chlorpropamide which is partially excreted unchanged in the urine.

-What is most serious adverse effect of Sulfonylureas?

-Wt loss?

-What is primary failure rate of this drug to have any affect?

-Hypoglycemia (age related decline in renal fct can contribute to hypoglycemia in elderly)

-Nope Wt gain (considered to be a good thing since now you are able to store some of the glucose)

-20%!!

Oral med for Type II Diabetes:  These drugs increase insulin release in response to food, keeping blood glucose from rising too high after meals.

-Name them

-Meglitinides

-Repaglinide (PRANDIN)

-Nateglinide (STARLIX)

Which Meglitinide is this?: High fat meals reportedly result in 12% increase in max concentration and 52% reduction in the time to reach that concentration.

-Which is elimated via P-450 enzymes?

-Which causes hypoglycemia more frequently?

-Nateglinide (Starlix)

-Nateglinide (Starlix)

-Repaglinide (Prandin)

Which Drug class keeps the Liver from releasing too much glucose?

-What % of people on Metformin get hypoglycemia?

-Which process of the Kidney does it stop specifically?

-What does it do to Insulin resistance?

-Biguanides (Glucophage/Metformin)

-Zero it is not a hypoglycemic agent

-Glycogenolysis

-Lowers it

-What does Metformin do to LDL?

To HDL?

-To B12?

-Lowers by 8%

-Raises by 2%

-Reduces them (though no anemia cases reported)

Insuline Sensitizers (TZDS)....name the 2

-Cause hypoglycemia?

-How might TZDS lead to heart failure?

-Rosiglitazone (AVANDIA)

Pioglitazone (ACTOS)

-NOPE

-They cause fluid retention

What drugs slow digestion of carbohydrates which keeps blood glucose from rising too high after meals?

-Name 'em

-How do they affect A1C?

-Contraindicated in GI chronic dz?

-Alpha-Glucosidase Inhibitors

-Acarbose (Precose)

-Miglitol (Glyset)

-Lower by 0.5- 0.8%

-Yes

-Everyone's favorite SE of Alpha-Glucosidase Inhibitors

-Which is contraindicated in liver dz

-which is not reccommended for pts with Serum Creatinine levels greater than 2.0 mg/dL

-Flatulence

-Acarbose

-Acarbose

Which DM med group am I?: 

-Suppressess postprandial glucagons secretion from pancreas to decrease hepatic glucose output
-Slows emptying of the stomach to allow for timely glucose absorption.
-Enhances the feeling of fullness at meals to reduce food intake

Which Incretin am I: 

-Secreted by the K cells in the proximal small bowel
-Stimulates insulin secretion following oral CHO
-Accounts for only 20% of incretin effect on insulin

GIP (Glucose dependent insulinotropic polypeptide)

-Which Incretin am I?: 

-Suppresses glucagon secretion from the pancreas, which in turn, reduces hepatic glucose production.
-Delays gastric emptying and may have a central effect on satiety.
-Secreted by the L cells in the distal small bowel, colon, rectum following oral CHO load

-ACCOUNTS FOR 80% of incretin stimulation

-GLP-1 (Glucagon-like peptide)

-Which Incretin mimicks GLP-1?

When is it ok to use Byetta (incretin system drug) with DM I?

-What is huge SE of Byetta (2)?

-What is secondary effect that is good for DM II pts?

-Recommended for those with end-stage renal dz?

-Byetta

-It is not

-Nausea (50% in 1st month), mild pancreatitis

-Weight loss

-Nope

-What is Byetta's affect on A1C?

-What enzyme breaks down Incretins?

-Which Incretin Drug inhibits this enzyme, acting to indirectly increase overall GLP-1?

-Are either of the Incretins safe for use with Insulin?

-0.5 to 1%

-DPP-4

-Januvia

-Hasn't been studied

In combination with ________ drugs, Januvia (incretin drug) can cause hypoglycemia.

-How much weight do people usually lose on Januvia?

-Sulfonylureas

-They don't, only Byetta causes weight lose in the Incretin Drug class

-Eye exam when for DM I...for DMII (after diagnosis of both)

-The normal rate of albumin excretion is less than 20mg/day (15ug/min); persistent values between 30 to 300mg/day in a patient with diabetes is called _________.

-within 5 years for DM I...within the year of diagnosis for DM II

-microalbuminuria

WHich drug is usually given 1st line at Step 1 in DMII intervention

-Who should get insulin, at least initially, amongst the DM II pts?

-Metformin (Glucophage) (Biguanide=keeps Liver from releasing too much glucose...also lowers LDL and raises HDL)

-Those with acute symptoms of hyperglycemia (weight loss, seizures, etc)

-Most common cause of hyperthyroidism is?

-What is Tx of choice for this?

-Grave's Dz

-Radioactive Iodine

Which Grave's Dz med am I?

Thioamide derivative
Inhibits the formation of thyroid hormones through three not-completely known mechanisms:
 1. prevent the iodination reaction;
 2. inhibition of coupling reaction to form
        T3 and T4;
3. prevents the peripheral conversion of T3 to T4

-PTU (Propylthiouracil)

How does PTU affect WBC's?

-How does it affect bleeding?

-ALP ALT levels?

-Leukopenia

-Excess bleeding, easy bruising

-Both will be higher

HYPERTHYROID MED:

-A thyroid hormone synthesis inhibitor
-Its actions are similar to propylthiouracil
-Does not inactivate the existing T3 and T4 stored in the thyroid or in the blood .
-3 x more potent than PTU

Methazole (Tapazole)

-What is commonly used as adjunct therapy to help with the palpitations, anxiety, tremor, and heat intolerances associated with Hyperthyroidism?

-What is goal HR?

-  Beta-blockers

-Under 90 bpm

When do you use Rad-Iodine?

-How do you Tx a Thyroid storm?

-Graves and toxic nodules/goiters

-Suppresion of Thyroid Homone
Antadrenergic Therapy
Corticosteroids
Treatment of co-existing factors

Most common cause of Hypothyroidism is?

-Tx of choice?

-Autoimmune Thyroiditis (HASHIMOTO'S)

-Synthetic T4 (LEVOTHYROXINE..(SYNTHROID/LEVOTHYROID))

-When deciding dosing on hypothyroid pts....who gets higher starting dose (50mcg daily)...who does not?

-Is it okay to give teh same dosage IV that you give po?

-What is serious SE of Synthroid?

-Under 45 yo and no history of Heart dz....those who are older with preexisting conditions get half of normal starting dose (25 mcg with titrations)

-No reduce by 50% (this is only for people who are unable to take PO meds)

-Cardiac Hypertrophy

Other Hypothyroid Supplements:

1)  -Source Desicated Beef or Pork thyroid      gland
    -Unpredictable hormonal stability

2)  -Synthetic T3
    -Uniform absorption, rapid onset; half-life=1.5 days

-Thyroid USP (Armour Thyroid)

-Levoxyl and Cytomel

Are Cushings pts usually ACTH-dependent or independent types?

-Are Metyrapone and Aminoglutethimde  good as monotherapies for Cushings?

-Usually ACTH-dependent (Pituitary Adenomas or ectopic ACTH production)

-No, these STEROIDOGENIC INHIBITORS are not sufficient as monotherapy

How does Metyrapone (steroid inhibitor) work?

-How might this drug affect RBC's?

-Cause of Hirsutism?

-It reduces production of ACTH needed for Cortisol production

-Bone Marrow Supression

-Yes and Alopecia

-Which steroid Inhibitor works by inhibiting the conversion of cholestrol to pregnenolone early in the cortisol pathway (reduces plasma concentrations by 50%)

-

Whose SE profile is this:

-Severe sedation
-nausea
-ataxia
-skin rashes

Aminoglutehimide (Cytadren)

Which anti-Steroid Rx is this?

Adverse Effects  
Common
   -Dermatologic:  Pruritus, Stinging of skin,
   -Gastrointestinal: Abdominal pain, Nausea, Vomiting
   -Reproductive: Decreased testosterone level , gynecomastia
   -Other: Irritation symptom
Serious
    -Hepatic: Hepatotoxicity (rare)
    -Immunologic: Anaphylaxis (rare)

Ketoconazole (Nizoral®)

What type of Cushings Drug Class is this?

-Reduces the synthesis of cortisol and corticosterone
-Decreases cortisol secretion rate, plasma cortisol concentrations and urinary free cortisol
-Results in degeneration of cells within the adrenal glands which leads to atrophy

-Name the one Drug in this class?

ADRENOLYTIC AGENTS

Mitotane

T/F...Mitotane can be administered on an outpatient basis?

-What is a sign of hyperaldosteronism?

-What is a SE of Spironolacotne you need to watch out for?

-False, pt must be hospitalized prior to administration

-HTN, reduced glucose intolerance, METABOLIC ALKALOSIS, Polydipsia, nocturnal polyuria.

-Hyperkalemia (dehydration)

-How does Spironolactone work?

-How fast till improvements are seen in HTN?

-Weird SE?

-Competively inhibits Aldosterone

-4-8 weeks

-Gynecomastia

-Tx of Addison's...what 3 things need replacement?

1) Glucocorticoids (dexamethasone, prednisone, or hydrocortisone ...see slide for details)

2)  ACTH Mineralocorticoids (Fludrocortisone...liberal salt intake....monitor BP, salt levels, renin levels)

3)  Androgen Replacement (Dehydroepiandrosterone)

-ACROMEGALY:  Excessive production of ____ ____ by the ____ _____ gland.

Effects 50 to 70 adults per million
2 to 3 increase in mortality
Diagnosed at _____ age

-Who produces vasopressin and oxytocin?

-Growth Hormone, middle

-Posterior pituitary

-Somatostatin

-LH, GnRH

-Splanchic

-Insulin

When do we resort to pharms for Acromegaly...(after what 2 things have been tried?)

-Is Octreotide a PO?

-Transphenoidal Surgery

-then-

Radiation

-Nope IM injection given every  28DAYS (dose depends on GH and IGF-1 LEVELS)

What can Octretide do to HR?

To BS?

-To GI system (Majorly)

To Liver?

    -Sinus bradycardia (19 to 25%)

 -Hyperglycemia (15%)

-GI: Diarrhea (36% to 58%), abdominal pain, flatulence, constipation, nausea

   -Cholelithiasis

OCTREOTIDE and ACROMEGALY:

In a 6 months of multicenter trial:
70% of patient report improvement with ______.
50 to 70% reported improvement with ____ and ______ ______.

-Headaches

-sweating and joint pain

Hyperprolactinemia:

Presistent serum prolactin concentrations greater than _____mcg/L.

-Age group of women affected?

-Drug-induced?

-20mcg/L

-reproductive age.

-Yes...lots of them See slide 15 for the laundry list

Bromocriptine (Parlodel)

Bromocriptine:  CV affects include HYPOTENSION, VASOCONSTRICTION disorder of extremities and even _____.

-Neurologics include ____ and ____

-Psychiatric effects include ______ and _______ disorder.

-MI

-dizziness and HA

-Hallucinations and Psychotic disorder

Pergolide

Long-acting dopamine agonist
Contraindications  
history of pulmonary, pericardial, cardiac valvular, or retroperitoneal fibrotic disorders; increased risk of pleural effusion/pulmonary fibrosis
hypersensitivity to ergot derivatives
uncontrolled hypertension

USUALLY USED WHEN BROMOCRIPTINE IS INEFFECTIVE for PROLACTINOMAS

Cabergoline (Dostinex)