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Diabetes, FNP 1 Final

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What class of diabetic medications should not be given to patients with heart failure?
TZDs (thiazolidinediones) - cause increased reabsorption of sodium in the kidney, leads to water retention & edema

pioglitazone - Actos
rosiglitazone - Avandia
Pioglitazone (Actos) is contraindicated for patients with what diagnosis in their medical history?
bladder cancer
What are some autoimmune diseases associated with Type I diabetes?
Celiac disease (most common)
graves disease
hypothyroidism
adrenal insufficiency
pernicious anemia
What lab tests can u order to distinguish between Type I and Type II diabetes?
1. autoantibodies to islet cells (ICA) (= Type I diabetic)
2. Antibodies to glutamic acid decarboxylase 65 (GAD65) = present in Type I diabetics
3. C peptide = the presence of c-peptide indicates endogenous insulin production (= Type II diabetic)
4. insulin autoantibodies (only useful if pt has not yet been exposed to exogenous insulin)
When is pneumococcal revaccination recommended for diabetic patients?
patients older than 65 yr IF they were immunized over 5 years ago

nephrotic syndrome
immunosuppressed states
What immunizations are recommended for diabetics?
1. influenza yearly (starting at 6 mos old)
2. hepatitis B (all pts aged 19-59, consider for those 60+)
3. pneumococcal (starting at age 2 yo)
What referrals should you provide for diabetics?
1. dietician
2. diabetes self mgmt class
3. dentist
4. eye doctor
5. mental health (PRN)
6. family planning for women of childbearing age
7. podiatry (PRN)
How often should you follow up with your diabetic patients?
uncontrolled - every 3 mos
controlled - every 6 mos
When should you begin screening ADULTS for diabetes (prediabetes)?

What group of CHILDREN/ADOLESCENTS should be screened for diabetes?
1. all adults starting at age 45
2. any adult with a BMI of 25 + risk factors
3. any Asian with a BMI of 23 + risk factors

KIDS:
starting at age 10 OR at puberty:
screen overweight or obese children w/2+ risk factors q 3 YEARS:
1. GDM in mother
2. race (non-white)
3. fam hx of DM II in first or 2nd degree relative
4. conditions assoc w/insulin resistance (SGA, acanthosis nigricans, HTN, dyslipidemia, PCOS)
If you screen your 45+ yo pt for diabetes and the results come back normal, when should you retest?
every 3 yrs if results were normal
every year if pt has prediabetes
What risk factors should be considered when deciding whether to screen for diabetes / prediabetes?
1. physical inactivity
2. first degree relative
3. PCOS
4. HDL<35, triglycerides > 350
5. race
6. HTN (BP 140/90) or on meds for HTN
7. hx of CVD
8. conditions assoc w/insulin resistance
9. hx of IFG, IGT or A1C > 5.7%
What are the HgA1c parameters for a diagnosis of prediabetes?
5.7 - 6.4%
What are the parameters of an impaired fasting glucose (IFG)?

What lab values represent Impaired Glucose Tolerance (IGT) during an oral glucose tolerance test?
IFG = BG 100 - 125 mg/dL


IGT = 140 - 199 mg/dL after 2 hours
What are the lab values / test values that confirm a diagnosis of diabetes?
1. A1C> 6.5%
2. FPG > 126 mg/dl; fasting is defined as no caloric intake for at least 8 hours
3. 2-h plasma glucose > 200 mg/dL during an OGTT. The test should be performed with a glucose load of 7 5g dissolved in water (100 mg for pregnancy)
4. RPG > 200 mg/dl with classic hyperglycemic symptoms:
If two different tests are ordered to diagnose diabetes and they are discordant (say the FPG is 100 and A1C is 6.7%), what should the provider do?
Reorder the test with the result that is ABOVE/OUTSIDE the diagnostic point in order to confirm
What are the strategies for managing prediabetes?
Same as for diabetes =
1. 7% weight loss
2. 150 minutes/week of exercise
3. screen & tx HTN and hyperlipidemia
4. diet
5. therapeutic drugs
6. referral to a support program
When should you consider starting a pt with prediabetes on metformin?
ALL pts with IFG, IGT or an A1C 5.7 - 6.4% should be considered, ESPECIALLY if high risk:
1. BMI >35
2. age < 60 yrs
3. hx of gestational DM
4. pts w/ severe or progressive hyperglycemia
What are some conditions associated w/insulin resistance?
1. severe obesity
2. acanthosis nigricans
METFORMIN:

Drug class?
Mechanism of action?

common side effects?
CLASS: biguanide

MOA: decreases hepatic glucose production
increases peripheral glucose uptake and utilization
acts on fasting and postprandial glucose

SIDE EFFECTS:
1. GI - flatulence, bloating, abdominal cramping, diarrhea
2. lactic acidosis (rare)
3. B12 deficiency (d/t malabsorption)
Benefits of METFORMIN?



Contraindications?

How do u manage a pt on metformin who will be receiving contrast dye?
weight loss
low risk of hypoglycemia
decreases risk of CVD

1. reduced ejection fraction (heart failure)
2. reduced GFR / kidney failure (no metformin if GFR<45)
3. liver dx
4. etoh
5. pt's receiving IV contract dye

CONTRAST DYE: stop metformin use day of & at least 48 hrs prior to procedure, resume once baseline hydration & renal fnx have been established
SULFONYLUREAS:

Name common sulfonylureas?

Mechanism of action?
suffix is -zide or -ride

glypizide (Glucotrol)
glyburide (DiaBeta, Micronase)
glimepiride (Amaryl)

MOA: increases insulin secretion from pancreatic beta cells
SULFONYLUREAS:

Adverse effects?

What are some contraindications?

Significant drug interactions?
Adverse effects =
1. Hypoglycemia (avoid in elderly or with insulin use)
2. Weight gain
3. photosensitivity
(use cautiously in patients already taking insulin & pts concurrently taking insulin)

Contraindications =
pregnancy & lactation (gets into breast milk, teratogenic in animals) - Category C

DRUG INTERACTIONS:
1. alcohol
2. drugs that increase hypoglycemia = NSAIDs, sulfa antibiotics, ranitidine
3. beta blockers = mask effects of hypoglycemia
Which SULFONYLUREA is preferred in elderly pt:
GLIPIZIDE

Glyburide has longer half life - increased risk of hypoglycemia
What is the preferred treatment for the conscious individual with hypoglycemia?
1. Glucose 15-20 g
(although any carbohydrate w/glucose may be used)

2. Repeat treatment if SMBG shows continued hypoglycemia after 15 min

3. Consume a meal or snack once SMBG returns to normal to prevent recurrence of hypoglycemia
What should providers do to manage hypoglycemia?
1. Ask pts at risk for hypoglycemia about symptomatic and asymptomatic hypoglycemia at each encounter
2. Prescribe Glucagon for all pts at significant risk of severe hypoglycemia
3. Instruct caregivers/family members on glucagon administration
4. Ongoing assessment of cognitive function by the clinician, patient, and caregivers. Be extra watchful for hypoglycemia if low cognition and/or declining cognition is found (studies show link btw hx of severe hypoglycemia & dementia)
THIAZOLIDINEDIONES (TZDs)

Name common thiazolidinediones (TZDs) - also called glitazones

Mechanism of action?

Side effects of TZDs?
Actos (rosiglitazone)
Avandia (pioglitazone)

MOA: increases cell sensitivity to insulin (reduces insulin resistance)
acts on fasting and postprandial glucose

SIDE EFFECTS:
1. edema/heart failure
2. weight gain
3. bone fractures
4. increased LDL
What black box warning is associated with TZDs?

What lab should you monitor periodically when administering TZDs?
CHF

Monitor LIVER FUNCTION (AST / ALT)
What classes of diabetic meds can cause WEIGHT LOSS




What classes of diabetic meds cause WEIGHT GAIN?
WEIGHT LOSS:
metformin
GLP 1 receptor antagonists
SGLT2 inhibitors

WEIGHT GAIN
sulfonylureas
TZDs
insulin
DPP-4 INHIBITORS

Name common DPP-4 inhibitors

Mechanism of Action?
suffix - gliptin

saxagliptin (Januvia)
sitagliptin (Onglyza)

MOA: inhibits the activity of DPP-4, an enzyme that breaks down GLP-1 = increased postprandil GLP-1 levels
acts on POSTPRANDIAL GLUCOSE - only effective after eating

1.increases insulin secretion from pancreas (glucose dependent)
2. decreases glucagon secretion from pancreas (glucose dependent)
What are the adverse effects of DPP-4 inhibitors?
What are some contraindications?
Angioedema/urticaria & other immune mediated skin effects
Acute pancreatitis
Increased heart failure risk (possible)
Name some common GLP-1 RECEPTOR AGONISTS

MOA?

ROUTE OF ADMINISTRATION?
suffix -tide or -glutide

exenatide (Byetta)
liraglutide (Victoza)
dulaglutide (Trulicity)
albiglutide (Tanzeum)

MOA: activates GLP-1 receptors

has similar effects to human GLP-1 (a peptide in the incretin family):
1. lowering of glucose via glucose dependent beta cell stimulation
2. suppression of glucagon release from the liver
3. delay of gastric emptying
4. enhancing satiety

Route of Administration: SQ injection
What are the adverse effects of GLP-1 receptor agonists?



What are some contraindications?





What time of day should GLP-1 receptor agonists be given?
1. GI side effects (N/V/D)
2. Acute pancreatitis (discontinue the med for s/s of pancreatitis, esp abd pain + vomiting)

Contraindication: gastroparesis

HOW TO ADMINSITER:
administer with meals (breakfast/dinner)

these drugs have a brief time of duration (2.5 hrs), and their efficacy is glucose dependent = only exert their effects AFTER eating
Exenatide (Byetta) has its greatest effect on which of the following?

a Fasting blood sugar

b Post prandial blood glucose

c Equally for fasting and post prandial blood glucose

d DPP-IV action (Dipeptidyl Peptidase
b Post prandial blood glucose
What other class of antihyperglycemic should NOT be used with GLP-1 receptor agonists (incretin mimetics)?
DPP-4 inhibitors (incretin enhancers) - can cause hypoglycemia when these meds are used together
Name some common SGLT2 INHIBITORS?
(sodium glucose cotransporter 2)

Mechanism of Action?
suffix - glifozin

canaglifozin (Invokana)
dapaglifozin (Farxiga)
empaglifozin (Jarviance)

MOA: increases the excretion of glucose in the urine

inhibits the transporter that moves glucose from filtrate back into the blood in the kidney - increases glycosuria
ADVERSE EFFECTS of SGLT2 inhibitors?
all renal related

Genitourinary infections (genital candidiasis)
Polyuria
Volume depletion/hypotension/dizziness
Increased LDL and creatinine
DKA
If antihyperglycemic monotherapy is initiated and maximal tolerated dose does not achieve or maintain the A1C target over 3 months, what is the provider's next step?
add a second oral agent, a GLP-1 receptor agonist, or insulin
Your patient will be starting acarbose (Precose). Which condition would contraindicate use of acarbose?

COPD
Narrow angle glaucoma
Asthma
Pregnancy
Pregnancy

Acarbose is excreted in breast milk and should not be administered to nursing mothers.
The patient is being considered for treatment with the drug metformin (Glucophage). The health care provider recognizes that a contraindication to use of this drug with this patient would be his history of:

Asthma
Chronic bronchitis
Renal disease
Enlarged prostate
Renal disease


Metformin is contraindicated for use in patients with renal disease because of the tendency for the drug to accumulate.
What are the different types of insulin?
1. rapid-acting analogs (humalog, novolog, apidra)
2.short acting (regular human insulin - Humalin R)
3. intermediate acting (human NPH - Humalin N)
4. basal/long acting (glargine [Lantus], detemir [Levemir])
5. premixed (humalin 70/30, etc)
What is the mechanism of action of insulin?


What are some negative effects of insulin?
MOA:
activates insulin receptors on cells, stimulating the up take of insulin into cells

ADVERSE EFFECTS
Weight gain
Hypoglycemia
What are some broad descriptions of the peak & duration of action of each type of insulin?
rapid acting insulin = covers 1 meal
regular insulin = lasts from meal to meal
intermediate (NPH) insulin = lasts from breakfast to dinner
basal insulin = lasts all day
In caring for a patient with DM, how often should you measure microalbuminuria?
yearly

(confirm dx by obtaining 2 out of 3 positive specimens within a 3-6 mo period. be sure to collect a first morning specimen)
Which medications can cause secondary hyperglycemia?
niacin
steroids
thiazide diuretics
The usual dose of rapid-acting insulin is ____ unit(s) per 15 grams of carbohydrate
2
How often should you check A1c in a diabetic?
every 3 mos if making changes or not at goal
every 6 mos if at goal and stable
What modifiable and unmodifiable lifestyle risk factors contribute to insulin resistance?
genetics
obesity
physical inactivity
high carb diet (60% or more of calorie content)
What are some recommendations for preconception care of women with diabetes?
1. get A1C as close to normal (7%) before conceiving
2. evaluate & treat diabetic retinopathy, nephropathy, neuropathy, CVD
3. do preconception counseling & education for all women (starting at puberty) at each diabetes visit
4. evaluate pts meds to see if they are on anything that is contraindicated in pregnancy (statins, ACE, ARB, oral antidiabetics, etc)
What are the parameters for diagnosing gestational diabetes (using a 75 mg, 2 hr OGTT)?
FPG = 92 mg/dl or greater
1hr 180mg/dl
2hr value 153-199 mg/dl
At what stage in the pregnancy should a patient be tested for gestational diabetes mellitus (GDM)?

Risk factors ?
24-28 weeks

Risk factors:
1. obesity
2. fetal macrosomia (baby weighs 9 lbs or more)
3. hx of prior GDM
What is the A1c target for pregnant women with overt (prior) diabetes?
A1c < 7
GESTATIONAL DIABETES

What are the risk factors for gestational diabetes?

What is the first line treatment for gestational diabetes?
RISK FACTORS
1. obesity
2. fetal macrosomia (baby weighs 9 lbs or more)
3. hx of prior GDM

Lifestyle = diet and physical activity. check BG 4-6x daily

DIET:
Eat 3 meals daily w/2 - 3 snacks
Limit carbs

PHYSICAL ACTIVITY:
Exercise 30 min daily 5 days/week
Low impact exercise (walking, swimming) preferred
GESTATIONAL DIABETES

What antidiabetic medications are safe for pregnancy?
INSULIN and METFORMIN ONLY
(no others meds are recommended - not safe)

use if unable to control BG with lifestyle alone
When should you suspect overt diabetes (as opposed to GDM) in a pregnant patient?
FPG = greater than 126mg/dl
2-hr value = greater than 200mg/dl

(with a 75 g, 2 hr OGTT)
GDM postpartum care:

How long should you monitor BG levels after delivery?

How soon after delivery should you do a follow-up OGTT?

Should you do any additional monitoring after that?
24 - 72 hrs to ensure no ongoing hyperglycemia

POSTPARTUM FOLLOW-UP:
Screen w/OGTT 6 - 12 weeks after delivery
(do NOT use A1C)

- if NORMAL: Ongoing counseling on avoiding DM II
Repeat every 3 years
- if ABNORMAL: treat as DM II
GDM postpartum care: What information should be included in every child's permanent record?
1. birth weight
2. whether mother had GDM
GDM postpartum care: What additional lab work (besides BG checks) should you obtain for a Type I diabetic postpartum?
TSH at 3 mos & 6 mos postpartum
(screening for postpartum thyroiditis)
An A1c of 8.5% corresponds to an average BG level of ___?
~200 mg/dL
What is an appropriate A1C goal for an older / elderly adult who is healthy w/few chronic illnesses with intact cognitive and functional status?
7.5%
Adults aged 65+ with diabetes are a high priority population for screening and treatment of _____
depression
What is an appropriate A1C goal for an older / elderly adult with multiple coexisting chronic illnesses OR 2+ instrumental ADL impairments OR mild-to moderate cognitive impairments?
8%
What is an appropriate A1C goal for an older / elderly adult with Very complex/poor health (long-term care or endstage chronic illnesses OR moderate-to-severe
cognitive impairment or 2+ ADL dependencies)?
8.5%
Diabetes places elders at increased risk for what common geriatric syndromes?
polypharmacy
incontinence
falls w/injury
persistent pain
cognitive impairment
Can metformin be used safely in elders? How should it be managed?
safe to use - PREFERRED Initial Therapy
1. monitor GFR and Cr
2. caution in CKD patients; adjust dosage
3. DO NOT USE in pts w/Stage 4 kidney dx
What are some diabetes management strategies for older adults?
1. ENCOURAGE physical activity
2. IMPLEMENT medical nutrition therapy
3.DSME/T should consider sensory deficits, cognitive impairment, and different learning styles
4. SCREEN for cognitive fnx, fall risk, functional status
5. MONITOR for hypoglycemia
6. REDUCE treatment complexity as able
7. CONSIDER polypharmacy when choosing meds
How often should a Type I diabetic check their BG levels?

What pharmacological therapy is appropriate for Type I diabetics?
at least 4x daily (incl before meals and snacks)

basal-bolus therapy

long acting basal insulin (Lantus, Levamir) along with rapid or short acting meal time insulin
OR
continuous therapy with an insulin pump
What is the recommended A1C goal recommended across all pediatric age-groups?
7.5%
Why is it important to screen children for diabetic complications such as Retinopathy, nephropathy, and neuropathy?
these complications may start to occur at the onset of puberty OR after the child has had the disease for 5 - 10 years
Pediatric Diabetes Type I:

***IN GENERAL = if there are no other risk factors, screen for diabetic comorbidities & CVD risk factors (Retinopathy, nephropathy, neuropathy, hypelipidemia) at puberty or at age ≥10 years, whichever is earlier, once the youth has had diabetes for 5 years
...
How often should u screen a child with DM Type I for nephropathy? At what age should you start?




How should you treat a child with Type I diabetic nephropathy?
SCREENING:
Annually, starting at puberty or at age ≥10 years, whichever is earlier, once the youth has had diabetes for 5 years

screening for albumin levels, with a random spot urine sample for albumin-to-creatinine ratio (ACR)

TREATMENT:
1. 6-month trial of improving glycemic control and normalize blood pressure for age
2. confirm the elevated albumin-to-creatinine ratio (ACR) on two additional specimens from different days
3. ACE inhibitor
What is the definition of pediatric hypertension?
SBP or DBP consistently above the 95th percentile for age, sex, and height OR consistently >130/80 mmHg (if 95% exceeds that value)
Pediatric Diabetes Type I:
What is the first tx for pediatric HTN if child has Type I DM?

What do you do if that is not effective?
1. Dietary intervention and exercise, aimed at weight control; increased physical activity, if appropriate

2. After 3-6 months of lifestyle intervention consider MEDS
Pediatric Diabetes Type I: What is the Blood pressure goal for a child with Type I DM?
Blood pressure consistently <130/80 mmHg
or
Below the 90th percentile for age, sex, and height, whichever is lower
Pediatric Diabetes Type I: When should you screen for hyperlipidemia in a child with Type I DM?
A. No fam hx= initiate screening at age 10 or puberty, whichever comes 1st

B. obtaining a fasting lipid profile in children >2 years of age soon after diagnosis (after glucose control has been established) IF
1. family history of hypercholesterolemia
2. family hx of cardiovascular event before age 55 years
3. family history unknown
Pediatric Diabetes Type I:
1. What should you test for in your pediatric Type I patient if they display the following symptoms = growth failure, failure to gain weight, weight loss, diarrhea, flatulence, abdominal pain, signs of malabsorption, frequent unexplained hypoglycemia or deterioration in glycemic control?

2. How should you proceed if the patient has this problem?
1. CELIAC DISEASE
(common autoimmune disorder in type I DM)

2. gluten free diet
consult with dietician
Pediatric Diabetes Type I: When should you test your pediatric Type I patient for hypothyroidism?
as soon as glycemic control has been established (any age, no need to wait for puberty / age 10)
What are special considerations in managing children with diabetes (vs. adults)
physical growth and development, support system (family, caregivers, school), self esteem
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