Diabetes

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what is preferred treatment in pregnant women with DM?
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Terms in this set (147)
what is preferred treatment in pregnant women with DM?
insulin
everyone should be tested for DM beginning at what age? regardless of risk factors
45 yo
How often should asymptomatic, overweight with at least one risk factor be tested?
if normal, repeat every 3 years
what are the three tests used to identify if prediabetes or diabetes if present?
A1c

fasting plasma glucose (FPG)

OGTT
what does an OGTT test determine?
how well glucose is tolerate by measuring BG level 2 hours after drinking a liquid high in sugar
Normally, a positive test would be followed up with another test to confirm DM diagnosis. When would a second test be unnecessary?
if there is a clear clinical diagnosis

ex. classic symptom of hyperglycemia PLUS a random BG >200
Diagnosing DM:

Diabetes: A1c? FPG? OGTT?
A1c: >6.5%

FPG > 126

OGTT >200
Diagnosing DM:

Prediabetes: A1c? FPG? OGTT?
5.7-6.4%

FPG 100-125

140-199
Diagnosing DM:

A1c threshold?

FPG?

OGTT?
>6.5%

>126

>200
Glycemic targets:

A1c?

Preprandial?

2hr PPG?
<7%

80-130

<180
Glycemic targets: Pregnant patients: preprandial? 1hr PPG? 2hr PPG?<95 <140 <120Testing frequency: if not yet at goal? if at goal?every 3 months every 6 monthAn A1c of ^% is equivalent to an eAG ofwhat?6%=126 eAGwhat is the formula for eAG?each additional 1% over 6% is about 28 mg/dL 126+(28 x every % over 6)what is the goal wait circumference in females? males?female >35 males >40how many grams is one carb serving?15 gwhat are some microvascular DM complications? (4)retinopathy, nephropathy, peripheral neuropathy, autonomic neuropathy the "-pathy"!!!!what are some macrovascular DM complications? (3)CAD (including MI) CVA PAD same as ASCVD!!!Comprehensive care: antiplatelet therapy?ASA 81 mg/d for secondary preventionComprehensive care: what do you use if DM patient also has CAD/PAD?ASA + low dose rivaroxabanComprehensive care: cholesterol control?high intensity for patients: DM + ASCVD, age 50-75 with multiple ASCVD risk factorsComprehensive care: when would you use moderate intensity statins in DM?DM + age 40-75 with no ASCVD DM + age <40 + ASCVD risk factorsComprehensive care: when are eye exams done?at diagnosis if retinopathy, every year if not, every 1-2 yearsComprehensive care: what vaccines are needed? (3)Hep B series flu every year Pneumovax 23: 1 dose age 2-64, another >65Comprehensive care: BP goals?<130/80 if ASCVD or 10 year risk >15% <140/90 if ASCVD <15%Comprehensive care: BP control with no albuminuria? with albuminuria?none: thiazide, CCB, ACE/ARB alb: ACE or ARBComprehensive care: when should foot exams be done?every year: 10 g monofilament and 1 other test for sensation comprehensive foot exam every yearComprehensive care: treatment options for neuropathy?pregabalin, duloxetine, gabapentinComprehensive care: what are some foot care counseling?every day: examine feet, moisturize top and bottom but not between toes trim nails with a file wear socks and shoes, elevate feet when sittingComprehensive care: when is kidney function tested?every year if normal twice a year if reduced function (eGFR 30-60 or alb >300)what are some natural products used to treat DM? (3)cinnamon, alpha lipoic acid, chromium cassia, magnesium, and panax/american ginsengwhat is first line treatment in T2DMmetformin duhhhT2DM treatment: when would you start two drugs? (2 scenarios)if baseline A1c 8.5-10% OR regardless of A1c if patient has ASCVD, HF, or CKDT2DM treatment: when would you start insulin initially?if hyperglycemia is severe (A1c >10% or BG >300)what SGLT2i have ASCVD/HF benefit?empa cana dapawhat GLP1RA have ASCVD/HF benefit?dula lira SC semawhat class of drugs are best for patient with hypoglycemia risk? (4)DPP-4i GLP-1 SGLT2i TZDwhat class of drugs are best for weight loss?GLP1 or SGLT2ihow does metformin work? (3 ways)dec hepatic glucose production dec intestinal absorption of glucose increase insulin sensitivitywhat are some brand names for metformin? (4)Glucophage Glucophage XR Fortamet Glumetzamax dose of metformin?2000-2550 mg/day depending on productwhat is the usual maintenance dose of metformin?1000 mg PO BIDwhat is the usual initial dose of metformin IR? ER?IR: 500 mg daily or BID ER: 500-1000 mg daily with dinnerwhat BW does metformin have? (3)lactic acidosis (inc risk with renal impairment) radiological studies with contrast excessive alcohol or certain drugswhat are metformin CI? (2)eGFR <30 acute or chronic metabolic acidosiswhat eGFR is metformin not recommended to start in?eGFR 30-45 do not startwhat deficiency is common with metformin?B12how much A1c lowering does metformin have?dec 1-2% weight neutral no hypoglycemiawhat is a counseling point with metformin ER?ghost tabletwhen would you restart metformin after an imaging study?48 hours after if eGFR is stableSGLT2i brand names?cana: invokana dapa: farxiga empa: jardiancewhat SGLT2i can be used in eGFR<30?cana not recommended unless albuminuria >300; all others are CIwhat electrolyte should be monitored with Invokana?potassium hyperkalemia risk when used with other drugs that can inc potassiumwhat SGLT2i have shown reductions in HF and CKD progression?dapa cana empawhat eGFR are most SGLT2i contraindicated?<30 cana is exceptionPen needles are not provided with which GLP?Byetta Victoza Adlyxin all others are weekly injections so they are providedwhat is the MOA of GLP1a? (4)inc glucose dep insulin secretion dec glucagon secretion slows gastric emptying improves satietywhich GLP1a comes as PO?semaglutide (Rybelsus)BW for all GLP1a? (except Byetta and Adlyxin)risk of thyroid C cell cancerwhich GLP01 have ASCVD benefit?lira dula semawhich GLP must be given within 60 min of meals?Byetta and AdlyxinGLP1a brand names: liraglutide? Dulaglutide? Exenatide? ER? Lixisenatide? Semaglutide?L: victoza and saxenda D: trulicity E: byetta and bydureon (ER) Lix: Adlyxin S: ozempic and rybelsus (PO)which GLP1a are weekly injections?trulicity, bydureon, SC semawhich GLP1a is not recommended with CrCl<30?Exenatide and ER (byetta and bydureon)what drugs are insulin secretagogues?Sulfonylureas Meglitinideswhat BG do insulin secretagogues work on?postprandial BGwhat is the onset of action of meglitinides?15-60 minutes!!!brand name for micronized glyburide?Glynasewhich SU is taken 30 minutes before a meal?glipizide IR all others are taken with breakfast or first mealwhat is the CI for SU?sulfa allergywhat is a counseling point for glucotrol XL?ghost tabletSU brand names: glipizide? glimepiride? glyburide?glip: glucotrol and XL glim: amaryl gly: glynase is micronizedwhat deficiency should you look for before starting a SU?G6PDwhich SU are on the Beers criteria?glimepiride and glyburidewhat CYP enzyme do SU interact with?they are 2C9 substratesAdmin of repaglinide? nateglinide?R: 15-30 min before meals N: 1-30 min before mealswhat are some DPP4i warnings? (3) specific to saxa and alo?pancreatitis, severe arthralgia, acute renal failure risk of HFwhich DPP4i has a warning for hepatoxicity?alogliptinDPP4i brand names: sitagliptin? linagliptin? saxagliptin? alogliptin?sita: januvia L: tradjenta Sax: onglyza alo: nesinawhich DPP4i are major substrates of 3A4 and Pgp?lina and saxawhat is the MOA of TZDs?PPAR-gamma agonists inc peripheral insulin sensitivityBW for TZDs?can cause or exacerbate HF do not use in class III/IV HFwhat are some warning for TZDs? (3)hepatic failure, edema, risk of fractureswhat is a warning specific to pioglitazone?inc risk of bladder cancerwhich drugs cannot be treated with sucrose and glucose tabs or gel need to purchased to treat hypoglycemia?alpha-glucosidase inhibitors Acarbose and miglitolwhich insulins are considered basal?glargine detemir degludecBasal insulins are "peakless" with an onset of what? duration?3-4 hr onset >24 hr durationBasal insulins mainly impact which BG?fastingwhich insulin is intermediate acting?NPHinsulin NPH onset? duration?1-2 hours 14-24 hr durationrapid acting insulin onset? peak? duration?15 minutes, 1-2 hrs, and 3-5 hourswhich insulin is considered short acting?regular insulinregular insulin onset? peak? duration?-Onset: 30 min -Peak: ~2 hrs -Duration: 6-10 hrsin general, most insulin vials are how many mL? pens? concentrations?10 mL 3 mL 100 units/mLunopened vials are stored where? open vials?fridge room tempwhich insulins can be mixed in the same syringe?NPH and regularhow do you mix two insulins in the same syringe?rapid/regular first then NPHwhich insulins are Rx and OTC?regular (humulin R, novolin R) NPH (Humulin N, novolin N) premixed 70/30when would U-500 insulin be recommended?patients who require >200 units/daydifference between Lantus and Toujeo?Toujeo is concentrated glargine: 300 units/mlwhen is Tresiba useful?when detemir or glargine cause nocturnal hypoglycemiawhat is the brand name of insulin degludecTresibain premixed insulins, what do the numbers mean? (ex 70/30)NPH is first then rapid/short is the other %what is preferred first line injectable in T2DM?GLP1a!!!!when starting insulin in T2DM which insulin is added first?basal first 10 units SC daily or 0.1-0.2 units/kg/daywhat is the starting dose of basal insulin in T2DM?10 units SC daily or 0.1-0.2 units/kg/dayhow would you know if prandial insulin is needed in addition to basal?FPG is at or below goal BUT a1c is still above!!!what is the starting dose of prandial insulin when added to basal in T2DM?4 units or 10% of basal dose admin prior to largest mealafter adding basal then prandial insulin, if still not at A1c goal, what are some regimen options?full basal/bolus regimen: basal daily + meal time prandial mixed insulin regimen: BID NPH + short/rapidwhat is the typical starting dose of insulin in T1DM?0.5 units/kg/day use TBWwhat are the steps in starting basal bolus regimen in T1DM? (3 steps)1. calc TDD (0.5 units/kg/day) 2. divide TDD into 50% basal and 50% bolus 3. divide bolus into 3 mealsNPH and regular regimen: how would you start this regimen?same TDD as basal bolus (0.5 units/kg/day) 2/3 TDD given as NPH and 1/3 given as regularAdjusting basal insulin: which BG are you looking at?fasting!!!!Adjusting basal insulin: low BG trend: what do you do?dec basal or NPHAdjusting basal insulin: high BG trend: what do you do?inc basal or NPHAdjusting meal time insulin: if postprandial BG is high or low following the same meal on most days, what should be done?if high: insulin taken PRIOR to that meal should be INC if low: insulin PRIOR to that meal should be DECAdjusting meal time insulin: if PREPRANDIAL BG is high or low before the same meal on most days, what should be done?if high: insulin taken before the PREVIOUS meal should be INC if low: insulin taken before the PREVIOUS meal should be DECcalculating insulin dose at each meal: the bolus dose is calculated using what?insulin to carb ratio (ICR)calculating insulin dose at each meal: what does the ICR indicate?the grams of carbs covered by 1 unit of insulincalculating insulin dose at each meal: what are the ICR formulas?regular insulin: rule of 450/TDD rapid acting: rule of 500/TDD TDD uses both basal and bolus insulinwhat is a correction factor?how much BG will be lowered by 1 unit of insulinhow do you calculate the correction factor?regular: rule of 1500/TDD rapid: rule of 1800/TDDhow do you calculate the correction DOSE?[BG now - target BG]/ correction factor = correction doseinsulin conversions?most are 1:1 exception: converting BID NPH and different forms of glargineconverting NPH BID to glargine daily?use 80% of NPH doseconverting Toujeo to insulin glargine or detemir?use 80% of Toujeo dosewhat sizes does Toujeo come in?3ml and 1.5mlwhat rapid acting insulin comes concentrated?Humalog Kwikpen and Lyumjev Kwikpen 200 units/mlwhat regular insulin comes concentrated?Humulin R U-500 Kwikpen and vial 500 units/mlwhat long acting insulin comes concentrated?Tresiba Flextouch pen: 200 units/ml Toujeo Solostar and Max Solostar pens: 300 units/mlhow long are rapid acting insulin good for at room temp?28 days!!!which insulin pens last longer than 28 days at room temp? how long do they last?Levemir vial and pen: 42 days Tresiba and Toujeo pen: 56 daysSyringe sizes: up to 30 units? 30-50 units? 51-100 units?0.3 mL 0.5 mL 1 mLhow can you tell a U-500 syring/vial from other insulins?U-500 products have GREEN capshow short are the shortest pen needles?4-5 mmwhat length pen needle would require patient to pinch up skin?8 mmwhat is the treatment for hypoglycemia if conscious and able to swallow?pure glucose, tabs or gel, preferred but any form will work rule of 15: take 15-20 g carbs and recheck in 15 minwhat is the treatment for hypoglycemia if unconscious?dextrose if IV access or glucagon 1 mg SC or nasal sprayhow many glucose tabs should a hypoglycemic patient take?3-4 tabswhat hypoglycemia symptoms are not masked by beta blockers?sweating and hungerkey drugs that can dec BG? (3)BB Quinolones Tramadolinpatient BG goal?140-180Recognizing DKA?BG >250 Ketones (urine and serum, or picked up as "fruity" breath) anion gap metabolic acidosis (arterial pH <7.35, anion gap >12)DKA vs HHS?DKA most common in T1DM HHS more common in T2DMRecognizing HHS?BG >600, with high serum osmolality >320 extreme dehydration, altered consciousness (confusion, dizziness, seizures) pH >7.3, bicarbonate >15what is the primary treatment for DKA and HHS?aggressive fluids first and insulin to treat hyperglycemiaDKA and HHS treatment: Fluids first: what fluid? when do you change? insulin infusion: what insulin? dose? prevent what electrolyte abnormality? treat acidosis if <____pH: use what if needed?NS first then when BG<200, change to D5W1/2NS Regular: 0.1 units/kg bolus, then 0.1 units/kg/hr OR 0.14 units/kg/hr cont infusion hypokalemia <6.9; sodium bicarb