Term
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Definition
insulin resistance w/ resultant relative insulin deficiency;
Insulin resistance --> increased lipolysis, increased hepatic glucose production, decreased skeletal muscle uptake of glucose;
relative insulin deficiency --> insulin levels may be normal or elevated, beta-cell destruction progressive over time;
Glucose Toxicity --> beta-cells become stunned & unable to secrete insulin |
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Term
| Presentation of Type 2 DM |
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Definition
ASYMPTOMATIC;
Lethargy, nocturia, polyuria, polydipsia, polyphagia;
significant weight loss (less common) |
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Term
| Testing for DM in asymptomatic adults |
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Definition
Adults >= 45 yrs;
All overweight adults (BMI >=25) w/ additional risk factors:
- physical inactivity, 1st deg. relative w/ DM, high-risk ethnic pop, women delivering baby >9 lbs, Hx of gestational DM, HTN, HDL <35 or TG>250, PCOS, AIc >5.7%, sx of insulin resistance [severe obesity, acanthosis nigricans], hx of CVD |
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Term
| Testing for DM in Asymptomatic Children |
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Definition
Overweight + any 2 of following:
- family hx of Type 2 DM, high risk ethnicity, signs of insulin resistance (HTN, dyslipidemia, PCOS), maternal hx of DM;
Begin testing at 10 yrs or onset of puberty;
Repeat testing q3 yrs |
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Term
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Definition
A1c: 5.7-6.4%
FPG: 100-125 mg/dL
2-Hr PG during OGTT: 140-199 mg/dL
RPG: <200 mg/dL |
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Term
| Diagnosing Type 2 Diabetes |
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Definition
A1c: >=6.5%
FPG: >= 126 mg/dL
2-Hr PG during OGTT: >=200 mg/dL;
RPG: >= 200 mg/dL + Sx of DM |
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Term
| Goals of Type 2 DM Therapy |
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Definition
reduce risks for microvascular & macrovascular complications;
relieve present symptoms;
reduce mortality;
improve quality of life |
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Term
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Definition
| primary target for glycemic control in Type 2 DM |
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Term
| ADA Glycemic Goals in Type 2 DM |
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Definition
FPG: 70-130 mg/dL;
PPG: <180 mg/dL;
HbA1c: <7% |
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Term
| ADA Non-glycemic Goals for Type 2 DM |
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Definition
BP: <130/80 mmHg
LDL <100 mg/dL (<70 mg/dL optional);
HDL >40 mg/dL;
TG <150 mg/dL |
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Term
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Definition
| Education, Monitor BG (SMBG, HbA1c), Immunizations (influenza, pneumococcal), Regular exercise, medical nutrition therapy (MNT) |
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Term
| Immunizations required by Type 2 DM |
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Definition
influenza yearly;
pneumococcal --> at least 1 lifetime vaccine |
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Term
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Definition
Traditional:
3-4x/wk, 65-85% of maximal HR, minimum 20 min/session;
Alternative: physical activity every day, moderate intensity, accumulate 30 min or more every day |
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Term
| sulfonylureas - glipizide (Glucotrol, Glucotrol XL), glyburide (Micronase, DiaBeta), glimepride (Amaryl) |
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Definition
MoA: stimulates insulin release from beta cells;
Efficacy: reduces A1c 1-2%, reduces FPG 60-70 mg/dL;
C/I: hypersensitivity, Type 1 DM, DKA;
Use glipizide if renal impairment (CrCl >10 ml/min);
ADRs: hypoglycemia, weight gain;
MPs: A1c q3 months, SMBG at each visit, renal fcn at baseline & annually |
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Term
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Definition
sulfonylurea;
Starting Dose: 5 mg PO BID before meals;
Max Dose: 40 mg/day (20 mg BID) |
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Term
| short-acting insulin secretagogues (glinides) - nateglinide (Starlix), repaglinide (Prandin) |
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Definition
MoA: stimulates release of insulin from beta cells, glucose-dependent, targets post-meal glucose spikes (PPG elevations);
Efficacy: A1c reduces 0.6-1%;
ADRs: hypoglycemia (less), weight gain;
MPs: HbA1c q3 months & SMBG at every visit, Sx of hypoglycemia, weight;
Drug Interactions: gemfibrozil
Administer prior to each meal (up to 30 min);
CPs: decreased incidence of hypoglycemia, less efficacious, requires TID-QID dosing |
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Term
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Definition
glinide;
Starting Dose:
- 120 mg PO TID with each meal;
Max Dose:
- 120 mg TID |
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Term
| biguanide - metformin (Glucophage, Glucophage XR, Fortamet) |
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Definition
MoA: decreases hepatic glucose production, improves insulin sensitivity by increasing peripheral uptake, decreases intestinal absorption of glucose;
Efficacy:
A1c reduced by 1.5-2%;
Decreases TGs, LDLs, increases HDLs;
ADRs: weight loss, GI (diarrhea, Abd cramping, flatulence, N/V), lactic acidosis (muscle pain, SOB, weakness, fatigue, dizziness);
MPs: A1c q3 months, SMBG at each visit, Renal fcn baseline & annually, electrolytes annually;
Administration: take with meals, start low & titrate up to max tolerated dose;
Precautions: procedures using radiocontrast dye, liver dx, Hx of EtOH abuse;
C/Is: renal dysfunction (CrCl <= 60 mL/min), HF, acute or chronic metabolic acidosis; |
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Term
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Definition
biguanide
Starting Dose:
- 500 mg daily w/ evening meal, increasae to 500 mg BID in 1 week;
Max Dose:
- 2550 mg/day divided BID or TID |
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Term
| thiazolidinediones (TZDs or Glitazones) - rosiglitazone (Avandia), pioglitazone (Actos) |
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Definition
MoA: stimulates PPAR-gamma regulating GLUT-4 glucose transporter --> increase in insulin-dependent glucose disposal in skeletal muscle & adipocytes, decrease hepatic glucose production;
Efficacy: reduces A1c 1.5-2%;
Increases HDL, decreases TG;
ADRs: weight gain, edema, elevated LFTs, anemia;
Precautions: edema & risk for HF;
MPs: A1c q3 months, SMBG at each visit, hepatic fcn (baseline, annually), weight & presence of edema at each visit;
C/I: HF - NYHA Class III or IV, AST/ALT >3x ULN at basline |
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Term
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Definition
thiazolidinedione;
Starting Dose: 15 mg daily;
Max Dose: 45 mg daily |
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Term
| alpha-glucosidase inhbitors - acarbose (Precose), miglitol (Glyset) |
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Definition
MoA: reversible inhibition of alpha-glucosidases --> prolonged absorption of Carbs
Efficacy: A1c reduction 0.25-0.5%;
ADRs: VERY COMMON - Abd cramping, flatulence;
MPs: A1c q3 months, SBMG at each visit, renal fcn baseline & annually, ADRs;
Precautions: DON'T use in CrCl <25 ml/min;
Administration: prior to meals TID, titrate vERY SLOWLY;
CPs: rarely used, dose titration impractical, minimally efficacious |
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Term
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Definition
alpha-glucosidase inhibitor;
Starting Dose:
25 mg daily to TID (slowly titrate);
Max Dose:
100 mg TID |
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Term
| glucagon-lie peptide-1 (GLP-1) receptor agonists - exenatide (Byetta), liraglutide (Victoza) |
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Definition
MoA: enhances glucose-dependent insulin secretion & slow gastric emptying;
Efficacy: most effective for reducing PPG, decreases A1c 0.5-1.5% when combined with metformin or sulfonylurea;
ADRs: N/V/D;
Warnings: pancreatitis, thyroid T-cell tumors, serious hypoglycemia w/ sulfonylureas;
MPs: A1c q3 months, SMBG each visit, ADRs;
C/I: severe GI disease, renal insufficiency (CrCl <30 ml/min) |
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Term
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Definition
GLP-1 agonist;
Starting dose:
5 mcg SC BID
Max Dose:
10 mcg SC BID |
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Term
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Definition
DPP-IV inhibitor;
Starting Dose:
100 mg once daily;
Max Dose:
100 mg daily
CrCl 30-50 ml/min or SCr 1.7-3 mg/dL: 50 mg daily;
CrCl <30 ml/min, SCr >3 mg/dl, dialysis: 25 mg daily |
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Term
| dipeptidyl peptidase IV (DPP-IV) inhibitors - sitagliptin (Januvia), saxagliptin (Onglyza) |
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Definition
MoA: inhibits enzyme degradation of incretins (GLP-1 & GIP);
ADRs: URI, nasopharyngitis, HA;
Efficacy: decreases A1c 0.6-0.9%; |
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Term
| amylin agonist - pramlintide (Symlin) |
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Definition
Moa: slows gastric emptying, prevents PP glucagon secretion, promotes satiety;
Efficacy: most effective in reducing PPG - decreases A1c 0.5%;
ADRs: hypoglycemia, N/V;
Dosing:
Starting dose: 60 mcg SC prior to major meals & increased to 120 mcg as tolerated;
C/Is: gastroparesis, hypoglycemia unawareness, peds;
CPs: cannot mix with insulin, increased potential for hypoglycemia, new & expensive, may provide weight loss |
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Term
| Combination Therapy in Type 2 DM |
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Definition
meds from different classes CAN be used together;
2 drugs within same class should NOT be used together;
Add 2nd or 3rd drug to existing therapy & only withdraw med if C/I or intolerance develops |
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Term
| Insulin Dosing in Type 2 DM |
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Definition
Basal-bolus method if bolus recommended; sometimes only long-acting basal is only needed in combo with oral therapy;
Initiation:
- 10 units once daily (NPH, glargine, detemir) added to oral meds, timing of injection based on home blood glucose readings;
Adjusting Doses:
- adjust basal on fasting & pre-meal BG
- adjust bolus based on post-meal BG
Early initiation in Type 2 DM presenting w/ weight loss, more severe Sx, and glucose >250-300 mg/dL |
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