Week 11: Diabetes

Advantages of ultra-long-acting insulin

-stable glucose lowering effect -Flexibility for pt -lower risk for nocturnal hypoglycemia -good at room temp for 8wks -200 U/mL formulation for pts who need large volumes of insulin

Dosing of alpha glucosidase inhibitors

3x daily with meals

Dosing of meglitinides

3x daily with meals; skip dose if skip meal

Explain the 2 Step Strategy for Diagnosing pregnant women with GDM

1. 50g GLT test; if 1hr glucose is 140 or more, proceed to step 2 2. 100g OGTT when pt is fasting; check fasting, 1hr, 2hr, and 3hr glucose levels and if two or more of these levels are high diagnose GDM

What are the 8 main classes of non-insulin diabetes medications?

1. Biguanide (metformin) 2. Thiazolidinones (pioglitazone, rosiglitazone) 3. Sulfonylureas (glipizide, glyburide) 4. Meglitinides (repaglinide, nateglinide) 5. DPP-4 Inhibitors (sitagliptin) 6. Alpha-gluconidase inhibitors (acarbose, miglitol) 7. Na glucose co-transporter 2 inhibitors (-flozin) 8. Dopamine agonists (bromocriptine) 9. Bile acid sequestrants (colesevelam or welchol) 10. GLP 1 receptor agonist (exenetide, victoza/liraglutide)

What are the two classes of insulin sensitizers (increase sensitivity to insulin)?

1. Biguanides (metformin) 2. Thiazolidinones (pioglitzone, rosiglitazone)

Diabetes is a dysfunction characterized by hyperglycemia which is caused by what three factors?

1. Deficiency of insulin 2. Insulin resistance 3. Excessive glucagon secretion

What are the short acting insulins?

1. Humulin 2. Novolin

What are the main rapid acting insulins?

1. Insulin aspart: Novalog 2. Insulin glulisine: Apidra

What are two common issues with continuous insulin injections

1. Lipohypertrophy 2. Lipoatrophy

What are the 4 different therapy options for diabetes?

1. Monotherapy: Metformin 2. Dual Therapy: Metformin + one other med 3. Triple Therapy: Metformin + two other meds 4. Combination injectable therapy

What are the effects of insulin on organs?

1. Simulates skeletal muscle fibers 2. Simulates liver cells 3. Acts on fat cells 4. Inhibits production of certain enzymes *Triggers all of these by binding to receptors

What are the actions of insulin?

1. amino acid uptake > protein synthesis 2. glucose uptake > glycogen fat synthesis 3. enzyme production > glycogen breaking

What test would you perform if using the 1 step strategy for GDM?

75g OGTT; measure fasting, 1hr and 2hr glucose levels

What is the Ominous Octet?

8 Core Defects in Type 2 Diabetes: 1. Decreased insulin secretion from beta cells 2. Increased hepatic glucose production 3. Decreased cellular uptake of glucose 4. Increased lipolysis 5. Decreased incretin effect 6. Increased glucagon release from alpha cells 7. Increased glucose reabsorption (in kidneys) 8. Neurotransmitter dysfunction (appetite control)

How often are long acting insulins usually injected?

1x daily

Dosing of DPP 4 Inhibitors

1x daily with or without food at the same time each day

The drugs recommended by the American Academy of Pediatrics for use in children with diabetes (depending upon type of diabetes) are Select one: a. Metformin and insulin b. Sulfonylureas and insulin glargine c. Split-mixed dose insulin and GPL-1 agonists d. Biguanides and insulin lispro

A

The family nurse practitioner would expect which symptom to be a side effect of metformin (Glucophage)? A. GI upset B. Photophobia C. Hypoglycemia D. Skin eruptions

A

Which medication class produces GI discomfort, including gas production, to the point that many patients discontinue them secondary to these side effects Select one: a. Alpha-glucosidase inhibitors b. TZDs c. Amylin analogs d. GLP-1 agonists

A

When do you test pregnant women for gestational diabetes?

24-28wks gestation

What is the 50/50 rule?

50% basal for low continuous dose 50% bolus for meal time coverage

Dosing of metformin

500-2500mg 1x or 2x daily

When is the best time to give short acting insulin for best effect?

30-60min before meals

When should a provider use monotherapy for a diabetic pt?

ALWAYS unless: A1C 9% or more

A patient with type II diabetes is taking glipizide (Glucotrol) 10 mg PO b.i.d. In evaluating the medications effectiveness, the nurse practitioner knows that glipizide reduces blood glucose by: A. Delaying the cellular uptake of potassium and insulin B. Simulating insulin release from the pancreas C. Decreasing the bodies need for and utilization of insulin at the cellular level D. Interfering with the absorption and metabolism of fat and carbs

B

An adult male patient with type II diabetes has a creatinine level of 1.8 mg/dL which of the following drugs is contraindicated? A. Pioglitazone B. Metformin C. Rapaglinide D. Acarbose

B

Metformin is a primary choice of drug to treat hyperglycemia in type 2 diabetes because it Select one: a. Substitutes for insulin usually secreted by the pancreas b. Decreases gluconeogenesis by the liver c. Increases the release of insulin from beta cells d. Decreases peripheral glucose utilization

B

Mr. Smith has recently been discharged from the hospital with a diagnosis of acute pancreatitis and returns to your office for follow up. Which of the following medications is contraindicated for control of his Type 2 Diabetes, given this new diagnosis? Select one: a. Insulin b. GLP-1 agonists c. Metformin d. Amylin

B

One reason diabetic patients have difficulty losing weight is due to the effects of exogenous insulin. Which of the following effects most specifically relates to this inability to lose weight? Select one: a. Insulin acts on glucose cell membrane transporters and prevents the transport of glucose. b. Insulin increases the conversion of insulin to fat. c. Insulin acts on adipose tissue, increasing circulating free fatty acids. d. Insulin acts on muscle cell growth, promoting protein synthesis

B

Sulfonylureas may be added to a treatment regimen for type 2 diabetics when lifestyle modifications and metformin are insufficient to achieve target glucose levels. Sulfonylureas have been moved to Step 2 therapy because they Select one: a. Increase endogenous insulin secretion b. Have a significant risk for hypoglycemia c. Address the insulin resistance found in type 2 diabetics d. Improve insulin binding to receptors

B

What underlying physiological issue occurs in type 1 diabetes?

Absolute deficiency of insulin secretion usually due to autoimmune destruction

What are the to Alpha Glucosidase Inhibitors?

Acarbose, Miglitol

What is a major advantage of long acting insulins?

Allows more flexibility for pts and families

What are the main Long Acting Insulins?

Are basal insulins: 1. Glargine (Lantus) 2. Detemir (Levemir)

How long do you have to wait between dosing for ultra long acting insulin?

At least 8hrs between dosing

A patient who was just recently started on repaglinide (Prandin) has called in to ask for your advice. She will not be able to take time to eat lunch today and because she is on the medication three times daily, she needs to know what to do about her usual lunchtime dose. How should you advise her? Select one: a. Continue to take the medication as prescribed. b. Skip the lunch dose and double the dose for dinner. c. Skip the lunch dose and continue with the normal dose for dinner. d. Skip both the lunch and dinner doses

C

According to the ADA guidelines, SGLT-2 inhibitors are indicated to treat which type of patient Select one: a. Newly diagnosed patient with T1DM with moderate renal impairment (GFR< 45 ml/min) b. Newly diagnosed patient with T1DM who has not started insulin therapy c. Established T2DM patient whose HA1C remains elevated with metformin d. Established T2DM with moderate renal impairment (GFR < 45ml/min)

C

An example of a sulfonylurea is A. Glyburide B. Glipizide C. Both a and b D. Metformin

C

Both angiotensin-converting enzyme inhibitors and some angiotensin II receptor blockers have been approved in treating Select one: a. Hypertension in diabetic patients b. Diabetic nephropathy c. Both A and B d. Neither A nor B

C

Insulin is used to treat both types of diabetes. It acts by Select one: a. Increasing beta cell response to low blood-glucose levels b. Stimulating hepatic glucose production c. Increasing peripheral glucose uptake by skeletal muscle and fat d. Improving the circulation of free fatty acids

C

Patients started on metformin (Glucophage) need to be monitored closely for what potential side effects A. Significant increase in weight B. Elevation of LDL C. Lactic acidosis D. Increase in insulin requirements

C

The primary physiological problem in T2DM includes: Select one: a. Destruction of pancreatic beta cells b. Secondary disease such as pancreatitis c. Insulin resistance in tissues d. Decreased insulin production

C

Which of the following statements best describes the MOA of the GLP-1 agonists Select one: a. This oral medication stimulates to beta cell to increase insulin secretion regardless of food intake. b. This oral medication blocks the breakdown of the GLP-1 peptide. c. This injectable medication improves the glucose mediated insulin release from the beta cell. d. This injectable medication is a long acting insulin.

C

Are DPP 4 inhibitors used as monotherapy or in combination?

BOTH

MOA of Metformin

Decreases liver gluconeogenesis Decreases intestinal glucose absorption Increases insulin tissue sensitivity

Are large insulin dose injections absorbed faster or slower?

Delayed in action and duration

What are the consequences of type 2 diabetes?

Diabetic nephropathy Diabetic neuropathy Diabetic reinopathy Stroke, Heart disease, Vascular disease

Lifestyle changes for Diabetes

Dietary: decrease carbs, cholesterol and sweets Physical activity: 150 min/wk Smoking cessation

Are amylin analogs used in type 1 or 2 diabetes?

Can be used in either

What is the standout adverse effect of GLP1 agonists?

Can cause thyroid hyperplasia so contra in anyone with family history of thyroid cancer

How would you monitor the basal insulin effectiveness?

Check fasting blood glucose

How would you monitor the bolus insulin effectiveness?

Check postprandial blood glucose

When is minidose glucagon given?

Child/adolescent with type 1 diabetes can't consume/absorb oral carbs bc of N/V associated with gastroenteritis *Given to prevent impending hypoglycemia

Contraindications of Thiazolidinediones

Children DKA Black box warning for hepatic dysfunction and HF

Which medications can increase hyperglycemia?

Corticosteroids Estrogens Lithium Morphine sulfate Niacin Thiazide Diuretics HIV/AIDS treatment Organ transplant

Which factors should you consider when selecting diabetes treatment

Cost Age Obesity level Duration of diabetes Lifestyle Current meds Comorbidities Hypoglycemia history Lipid levels

Nonselective beta blockers and alcohol create serious drug interactions with insulin because they Select one: a. Increase blood glucose levels b. Produce unexplained diaphoresis c. Interfere with the ability of the body to metabolize glucose d. Mask the signs and symptoms of altered glucose levels

D

The action of DPP-4 medications is different from other antidiabetic agents because they Select one: a. Have a low risk for hypoglycemia b. Are not associated with weight gain c. Close ATP-dependent potassium channels in the beta cell d. Act on the incretin system to indirectly increase insulin secretion

D

Which of the following medications are not recommended for use in older adults with type 2 diabetes due to the risk of hypoglycemia? Select one: a. DPP-4 inhibitors b. Metformin c. Pioglitazone d. Second generation sulfonylureas

D

True/False: GLP 1 agonists are safe to use in type 1 diabetes

FALSE

True/False: GLP 1 receptor agonists can be used in type 1 diabetes

FALSE

True/False: Mixed insulins are used for intensive therapy

FALSE

True/False: mothers with gestational diabetes have to be diabetic previous to pregnancy

FALSE

True/False: Long acting insulin can be combined with other insulins

FALSE; cannot be combined with other insulins

For ONE step Strategy: At which glucose levels would you diagnose GDM for: -Fasting: -1hr glucose: -2hr glucose:

Fasting: >92 1hr: >180 2hr: >153

For TWO step Strategy: At which glucose levels would you diagnose GDM for: -Fasting: -1hr: -2hr: -3hr:

Fasting: >95 1hr: >180 2hr: >155 3hr: >140

What are the best sites for insulin injection?

Fatty areas; abdomen, thighs, back of arms, buttocks, flank areas

What is required in order to use mixed insulin injections?

Fixed meal times and stable carb intake

How should diabetes management be different for older adults?

For Functional, cognitively intact older adults the diabetes care/goals should be the same that are used for younger adults

Adverse effects of GLP 1 Receptor Agonists

GI effects: N/V/D Less common: pancreatitis, renal failure

Adverse effects of colesevelam use

GI effects: nausea, bloating, constipation Increased TG

Contraindications to alpha glucosidase inhibitors

GI issues: Short bowel syndrome, IBD, increased liver transaminases Renal impairment bc metabolites excreted in kidney

Adverse effects of Alpha Glucosidase Inhibitors

GI issues: gas, bloating, abd. pain

What are the two main non-insulin injectables?

GLP 1 agonists: 1. Exenatide 2. Victoza

Which diabetic medication is a non-insulin injectable formulation?

GLP 1 receptor agonist

What is the main incretin and what are its functions?

GLP-1 released from intestine in response to food intake >enhances glucose dependent insulin secretion >decrease glucagon secretion by alpha cells >promote satiety by activity in brain >slow gastric emptying to decrease appetite

Contraindications of GLP 1 Receptor Agonist use

Gastroparesis Thyroid hyperplasia

Which insulin can be used with exanetide?

Glargine or lantus

Which sulfonylurea has the least potential for prolonged hypoglycemia and is therefore considered the safest?

Glipizide

What is given for severe hypoglycemia? What does it do?

Glucagon IV or IM; promotes hepatic glycogenolysis and glucogenesis

Are DPP 4 inhibitors dependent or independent on glucose?

Glucose dependent release of insulin

What are the contraindications of TZDs

Heart failure Hepatic dysfunction **BLACK BOX

Which conditions increase lactic acid and therefore metformin therapy should NOT be used?

Heart failure Severe lung disease Severe liver disease or alcohol abuse Shock/sepsis

What instances increase absorption rate of injected insulin?

Heat Injection in Abdomen

Contraindications of Sulfonylureas

Hepatic dysfunction

When should a provider change the diabetes regimen from monotherapy to dual therapy?

If A1C target not achieved after 3 months If A1C target not achieved after 3 months of dual therapy move on to triple therapy

Which factors might necessitate insulin dose adjustments?

Illness Medication Physical activity Change in routine Change in diet

Both biguanides and thiazolidinediones improve the action of insulin without ____________________

Improve the action of insulin without directly increasing insulin secretion

MOA of DPP-4 Inhibitors

Increase insulin and decrease glucagon secretion by inhibiting the degradation of incretins

MOA of GLP 1 Receptor Agonists

Increase insulin secretion Decrease glucagon secretion Slow gastric emptying Promote satiety

MOA of Meglitinides

Increase insulin secretion DEPENDENT on food intake by binding to ATP potassium receptors on pancreas beta cells

MOA of Sulfonylureas

Increase insulin secretion INDEPENDENT of food intake by binding to ATP potassium receptors on pancreas beta cells

MOA of Sodium-glucose co-transporter 2 Inhibitors (SGL2)

Increase renal glucose excretion by decreasing renal glucose reabsorption and decreasing renal threshold for glucose

Long acting insulins

Lantus or glargine Levemir or detemir

Do you take colesevelam with or without meals?

Take with meals

How would you dose minidose glucagon?

Two units for 2year old; 1 more unit for each year older until 15; if >15, receive only 15 units

Indication for SGLT 2 Inhibitors

Type 2 who are failing with metformin therapy and weight is a large problem

Adverse effects of SGL 2 Inhibitors

UTI Increased urination Hypotension Hypoglycemia Increased LDL Electrolyte abnormalities: increased potassium

MOA of Bromocriptine

Unclear how dopamine agonists aid in diabetes

Which organ systems are affected by diabetes?

Urinary; polyuria, glycosuria Gastric: N/V, abd. pain Eyes Breath Neuro: polydipsia, polyphagia, lethargy Systemic: weight loss Respiratory: kussmaul breathing

Your first treatment of diabetes is always what?

Lifestyle modifications

When should open ryzodeg pens be discarded?

Within 56 days

Is the 50/50 rule a good starting point for both type 1 and type 2 patients?

YES

Do you take metformin with food?

Yes

Should unopened insulin be refrigerated?

Yes

Is the injection technique of an insulin pen the same as a traditional syringe and vial?

Yes, except the needle needs to be held in place for 5-10 seconds

What is an advantage to rapid acting insulin use?

Low risk of hypoglycemia; quick onset and short duration

What is the benefit of using ryzodeg?

Lower risk of hypoglycemia

Which med is considered the drug of choice for all type 2 diabetes?

METFORMIN (biguanide)

Which diabetic medications have modest effects on lowering A1C? 1% or less

Meglitinides .5-1% DPP 4 Inhibitors .5-1% Alpha Glucosidase Inhibitors .5-1% Sodium glucose co-transporter 2 Inhibitor .5-1% Colesevelam .5% Bromocriptine .5%

What is the onset of action and duration of action of long acting insulins

Onset: 1-2hrs Duration: 24hrs

What is the onset of action and duration of action of ultra long acting insulin?

Onset: 3-4 days Duration: more than 42hrs

What is the onset of action and duration of action of Short Acting Insulins?

Onset: 30-60 min Duration: 6 hours

Contraindications to colesevelam use

Pancreatitis Constipation issues

Contraindications of DPP 4 Inhibitors

Pancreatitis HF: may worsen it

What are the signs/symptoms of lactic acidosis?

N/V Abd. pain Tachycardia Increased RR

Adverse effects of bromocriptine

N/V Fatigue Hypotension, HA, syncope, dizziness

Side effects of glucagon

N/V HTN Tachycardia

Do patients with type 2 diabetes require insulin?

NO

Can you prescribe both a meglitinide and sulfonylurea together?

NOT recommended

What is the main intermediate acting insulin and what is its duration of action?

NPH 12 hour duration

Symptoms of diabetes

Polyuria Polyphagia Polydipsia Blurry vision Glycosuria N/V/abd. pain Acetone breath Kussmaul breathing Weight loss Lethargy

Indication for Alpha Glucosidase Inhibitors

Postprandial hyperglycemia Poor dietary adherence or high carb diet

Name the different types of insulin?

Rapid Acting Short Acting Intermediate Acting Long Acting Ultra-long Acting Pre Mixed

Which insulin is clear and which insulin is cloudy in appearance?

Rapid acting are clear Intermediate acting are cloudy

What is the major pre mixed insulin?

Ryzodeg Mix of long acting (Degludec) with rapid acting (aspart)

How is the mechanism of action different between meglitinides and sulfonylureas?

Same MOA but sulfonylureas work independently of glucose intake and meglitinides are dependent on glucose intake to have an effect

What sites should be avoided for insulin injection?

Scarring/hypertrophy Lipohypertrophy; delays absorption

Which insulin is usually used to treat diabetic ketoacidosis as IV insulin?

Short acting insulins (humulin, novolin)

Dosing of Sulfonylureas

Start at lowest possible dose Begin: 1x/daily dose at bfast Increase dose q2wks until desired response

What can be done to minimize side effects of metformin?

Start treatment at bedtime Prescribe extended release

When adding insulin to an oral diabetic regimen for a type 2 diabetes patient, what insulin dose do you start with and when?

Start with lantus (long acting) at 10 units and give at night; increase it from there

What should the starting dose be for Ultra-Long-Acting Insulin for Type 1 diabetes

Starting dose: 1/3 to 1/2 total prescribed daily insulin dose

What should the starting dose be for ultra-long acting insulin in a type 2 diabetic pt?

Starting dose: 10 units/day

For Normal Insulin Regimens: Starting insulin dose is based on ______ Average requirement range from ___ to _____ Basal requirement is ___ of total daily dose Bolus requirement is ___ of total daily dose

Starting insulin dose is based on weight Average requirement ranges from .4-1 unit/kg/day Basal requirement is 50% of total daily dose Bolus requirement is 50% of total daily dose

Storage of insulin in the home

Stored at room temp for 28days Never freeze Roll, don't shake Can store in fridge if unopened Shouldn't be any particles

What is LADA diabetes?

Subset of type 1 diabetes called latent autoimmune diabetes in adults which develops slowly over many years

Decrease ___________ dose to prevent hypoglycemia if used in conjunction with GLP 1 agonists

Sulfonylurea

What are the most common add ons to metformin administration?

Sulfonylurea (high effect, low cost) DPP 4 inhibitors (high tolerability) TZD GLP 1 receptor agonist Insulin

Which diabetes medications could cause hypoglycemia?

Sulfonylureas >contraindicated in elderly bc of this Meglitinides SLG 2 Inhibitors

Why would you recommend a sulfonylurea over a meglitinide?

Sulfonylureas are less expensive and have higher improvements on A1C than meglitinides

How can insulin be administered subcutaneously?

Syringe Insulin Pen Continuous insulin infusion pump

TRUE/FALSE: The action of alpha glucosidase inhibitors is limited to the intestine and they primarily decrease postprandial glucose levels

TRUE

TRUE/FALSE: insulin is the main management of type 1 diabetes and the treatment for type 2 diabetes

TRUE

True/False: Alpha glucosidase inhibitors are not associated with hypoglycemia, weight gain and are not used as monotherapy

TRUE

True/False: Amalyn analogues can be used in type 1 diabetes

TRUE

True/False: Caution use of SGL 2 inhibitors in patients taking digoxin

TRUE

True/False: D/C metformin 24-48hrs prior to diagnostic and surgical procedures

TRUE

True/False: DPP 4 inhibitors are weight neutral and reduce both pre and post prandial glucose levels

TRUE

True/False: GLP 1 has an indirect benefit on beta cell workload since decreased glucagon secretion will produce decreased postprandial hepatic glucose output.

TRUE

True/False: Glucose levels return to normal after delivery in gestational diabetes

TRUE

True/False: Glycemic goals for some older adults might be relaxed, but hyperglycemia leading to risk of acute hyperglycemic complications should still be avoided

TRUE

True/False: Insulin injection sites should be rotated

TRUE

True/False: Insulin should be given at room temperature

TRUE

True/False: Manual mixed insulins are declining in use and pre mixed insulins are increasing due to medical errors

TRUE

True/False: Metformin reduces fasting and postprandial hyperglycemia

TRUE

True/False: Mixed insulin are at fixed ratio formulations

TRUE

True/False: Older adults >65 have a higher risk for diabetes, polypharmacy, premature death, and depression

TRUE

True/False: Correction of the fasting blood glucose level by PM insulin may improve OA action

TRUE: Basal insulin at bedtime Dosing 6-1- units at bedtime and increase by 2 units every 2-3 days until FPG reaches goal

True/False: Mixed insulin is declining in use

TRUE: Basal/Bolus is more flexible

True/False: Rapid acting insulins have activity profiles similar to endogenous insulins

TRUE; developed to address problems with human insulins and provide better glucose control

True/False: Alpha glucosidase inhibitors do not act directly on defects of diabetes type 2

TRUE; just slow down carb breakdown

What is the additional benefit of colesevelam use?

additionally lowers LDL by 20%

What is the underlying physiological problem in type 2 diabetes

combo of resistance to insulin and inadequate insulin secretion

If you are maxed out on 2 medications but A1C is >9 and not yet at goal level you should ______________

consider adding a basal insulin

Which neurotransmitters control appetite?

dopamine, serotonin

Caution sulfonylurea use in which patients?

elderly; more risk for hypoglycemia

What is the standout se of TZDs?

increased risk of bone fractures

What do you have to evaluate when dosing DPP4 Inhibitors?

renal function

Why is it important to rotate insulin injection sites?

to stop lipohypertrophy from happening

Which diabetes medications do you take with food?

**Sulfonylureas: SKIP dose if SKIP meal **Meglitinide: SKIP dose if SKIP meal Metformin Bromocriptine Colesevelam Alpha glucosidase inhibitors

What is the formula for TDD insulin calculations?

.4-1unit/kg/day

What is considered a conservative insulin dose?

.5 unts/kg/day

How long until the full effects of Thiazolidinediones will be seen?

1-2 months

4 Common Issues that cause hyperglycemia

1. Abnormal islet cell function 2. Increased glucagon production by pancreatic cells further increases hepatic glucose production 3. Insulin resistance in target tissues 4. Abnormalities in the incretin system

What are your three options if: FPG >130 OR 2 hour postprandial >180 OR A1C > 7%

1. Add third OA 2. Add exenatide 3. Add insulin

What are the 3 Situations in which PreDiabetes Should be diagnosed?

1. FPG 100-125 2. 2hr glucose 140-199 3. A1C 5.7%-6.4%

What are the 4 Situations in which Diabetes Should be diagnosed?

1. FPG 126 or greater 2. 2hr glucose 200 or greater 3. A1C 6.5% or greater 4. Symptoms and random glucose 200 or greater

What are the treatment goals of diabetes?

1. FPG of 100 or less 2. 2hr glucose 70-130 3. A1C <7%

What are the 4 oral therapy and insulin combinations?

1. Sulfonylurea + insulin 2. Metformin + insulin 3. Acarbose + insulin 4. Pioglitazone + insulin

What are the two classes of insulin secretagogues (increase endogenous insulin)

1. Sulfonylureas (glyburide, glipizide) 2. Meglitinides (repaglinide, nateglinide)

How long until the full effects of GLP 1 Receptor agonists will be seen?

1.5-2 months

When would you inject ryzodeg?

1/2 injections/day with main meal

How long are premixed insulin and intermediate acting insulin pens good for?

10-14 days

When should you administer a rapid acting insulin for best results?

15 min. before meals

Calculate the insulin dosage for a pt who weighs 150lbs if you want to start with .5unit/kg/day

150/2.2 = 68kg 68kg x .5 units = 34unts/day Basal: 50% or .5 X 34 = 17 units/day Bolus: 50% or .5X 34 = 17 units/3 meals per day = 6 units with every meal

Are 1st or 2nd generation sulfonylureas more commonly used?

2nd more commonly used bc more potent

How long until the full effects of alpha glucosidase inhibitors will be seen?

2 weeks

How long until the full effects of Sulfonylureas will be seen?

2 weeks (like metformin)

How long until the full effects of metformin will be seen?

2 weeks; titrate q2wks

Dosing of sulfonylureas

2x daily with biggest meals; skip dose if skip meal

How often are mixed insulins usually injected?

2x/day

How long are prefilled pens with aspart, glulisine, lispro, detemir, glargine and regular good for?

28 days

About how long do rapid acting insulins last?

4 hours

What is the FG goal for diabetics?

<130

What is the postprandial glucose goal for diabetics?

<180

What are the A1C goals for diabetics?

<7% for most people less stringent = <7.5-8% more stringent = <6-6.5

What is the standard A1C treatment goal for non-pregnant adults?

<7% or ideally <6.5% <8% for pts with H/O severe hypoglycemia

Uncontrolled diabetes is marked by an A1C level of what?

>8%

How would you add insulin to an oral medication therapy if glucose levels are not controlled?

Add basal insulin ie. glargine or detemir at bedtime Dose 6-10units or .1unit/kg/day at bedtime and increase by 2 units every 2-3 days until reach goal

When do you want to dose other medications in adjunction with colesevelam?

Administer separately because colesevelam can bind to and inactivate other medications

Which substances can cause hypoglycemia?

Alcohol Beta blockers Sulfonamides Tetracyclines

Which sulfonylurea is considered the best for use and which is considered the worst?

Best: glipizide bc no active metabolites (safest on kidneys and lowest risk of hypoglycemia) Worst: glyburide bc metabolites are active (highest risk for hypoglycemia and renal injury)

Which diabetic medications are weight neutral or cause weight loss?

Biguanides: neutral or weight loss DPP 4 Inhibitors: weight loss GLP 1 receptor agonists: weight loss SGL 2 Inhibitors: weight loss

Which diabetes medications rarely cause hypoglycemia?

Biguinaides Thiazolidinediones Bromocriptine GLP 1 receptor agonists DPP 4 Inhibitors Alpha glucosidase inhibitors Colesevelam

Monitoring for Minidose Glucagon

Blood glucose q30min 1st hour; then hourly until blood glucose is 100 If glucose unchanged in 30min, can repeat and double dose

Cystic Fibrosis related diabetes

Caused by defect in a single gene Occurs in maturity

Adverse effects of Thiazolidinediones

Common: fluid retention, edema, weight gain Uncommon: liver injury, fractures Possible: MI risk with rosiglitazone Possible: bladder cancer risk with plioglitazone

Adverse effects of Sulfonylureas

Common: hypoglycemia, weight gain Uncommon: photosensitivity, rash, N/V

Which diabetic medication has the ability to cause pancreatitis?

DPP 4 Inhibitors

Which class of diabetic medication are incretin enhancers?

DPP-4 Inhibitors

MOA of Thiazolidinediones

Decrease liver gluconeogenesis Increase insulin tissue sensitivity

MOA of Bile acid sequestrants (Colesevelam)

Decrease liver glucose production by enhancing liver insulin sensitivity Also decrease intestinal glucose absorption

Contraindications of bromocriptine

Don't use in conjunction with antihypertensives bc can increase risk of hypotension

How would you dose ultra-long acting insulin for established type 1 or type 2 insulin users?

Dose equivalent to usual total dose of long or intermediate acting insulin

Which two medications should be used for patients with type 2 diabetes and cardiovascular disease? Why?

Empagliflozin OR Liraglutide Because reduce cardiovascular mortality

What are the benefits to Thiazolidinediones?

Highly durable with long lasting effects Rarely causes hypoglycemia

Pharmacodynamic factors of Thiazolidinediones

Highly protein bound Metabolism by CYP450

What is insulin?

Hormone produced by beta cells in islets of Langerhans in PANCREAS

Are Rapid-acting insulins from animals or humans?

Human analogs

Short acting insulins

Humulin Novolin Regular

Which condition may increase the need for insulin?

Hyperthyroidism

When are meglitinides contraindicated?

Hypoglycemia unawareness ie. elderly Poor renal function

When are sulfonylureas contraindicated?

Hypoglycemia unawareness ie. elderly Poor renal function

Adverse effects of meglitinides

Hypoglycemia, weight gain Increased uric acid

Which condition may decrease the need for insulin?

Hypothyroidism

In which situations does metformin use need to be temporarily discontinued?

IV contrast studies: hold day of, restart in 48hrs Before surgery

What are the benefits to Sulfonylureas?

Inexpensive (like metformin) Decreased microvascular risk with long term use

Which diabetic medications have the greatest effect on lowering A1C? between 1-2%

Insulin >1.5% Biguanides 1-2% Sulfonylurease 1-2% TZDs 1-1.5% GLP 1 receptor agonists 1-1.5%

Which diabetic medications are ok during pregnancy?

Insulin; preferred Glyburide Metformin

What do the pre mixed insulins consist of?

Intermediate insulin and short acting insulin SO.... NPH + humulin NPH + novolin NPH + novolog

What is the main ultra-long-acting insulin?

Is a basal Insulin: 1. Degludec (Tresiba)

Adverse effects of DPP 4 Inhibitors

Liver dysfunction although rare

When is metformin contraindicated

Liver impairment Alcoholism Renal impairment (creatinine >1.5)

What are the adverse effects of metformin?

Mostly GI; N/V, abd. pain Rarely lactic acidosis or B12 deficiency

What does insulin do?

Moves glucose from the plasma into cells to be stored or used for energy

What are the two ways to administer basal bolus dose insulin?

Multiple day injections OR Continuous subcutaneous insulin (CSII)

Rapid acting insulins

Novolog or aspart Humalog or lispro

What is the major cause of the increase in insulin resistance? (ie. type 2)

Obesity

Which conditions are associated with insulin resistance?

Obesity Acanthosis nigricans PCOS

Which factors put patients at increased risk for diabetes?

Obesity GDM Physical inactivity Family with diabetes HDL <35 or TG >250 HTN or CVD A1C > 5.7%

Name a specific amylin analog and the MOA

Pramlintide Delays gastric emptying which decreases postprandial glucose release, decrease glucagon release by alpha cells, increases satiety

When is metformin contraindicated?

Renal Impairment (bc fully eliminated by kidneys) GFR <30mL/min or creatinine >1.5: contraindicated GFR 30-45mL/min: precaution or dose reduction

Contraindications to SGL 2 Inhibitor use

Renal impairment, bladder cancer Stroke

How do insulin dose requirements differ in insulin resistance (type 2)

Require larger doses: >200units/day Standard formulation: 100unit/mL New formulations: 200 units/ mL or more

MOA of Alpha-glucosidase Inhibitors

Slow carb breakdown to glucose by inhibiting alpha enzymes in small intestine

What are the benefits to Metformin use?

Significantly reduces A1C: 1-2% No associated weight gain Inexpensive Rarely causes hypoglycemia Lowers MI and all cause mortality

What are the S/S of hypoglycemia?

Sweating Hunger Fatigue Shakiness, tremors Confusion N/V Dizziness

Describe the honeymoon period after initiation of insulin in type 1 patients

There is some recovery of B cell function > lower insulin requirement needed Max benefit to preserve beta cell function > highest dose that doesn't cause hypoglycemia

Which diabetic medications can cause weight gain?

Thiazolidinediones (TZDs) Sulfonylureas Meglitinides

What should the total dose of ultra-long-acting insulin be for type 1 diabetes pts that are insulin naive?

Total dose for insulin naive pt: .2-.4 unit/kg body weight Combine with short acting insulin with meals for full coverage

Do type 1 patients usually require less or more insulin?

Usually less insulin bc not insulin resistant

If you are maxed out on 2 medications but A1C <9 but not yet at goal level, you should add _____________

a third diabetic medication

What are the max doses of rosiglitazone and pioglitazone?

rosiglitazone: 8mg daily pioglitazone: 45mg daily

Which type of diabetes are completely dependent on exogenous insulin

type 1

Which type of diabetes is particularly at risk for ketoacidosis

type 1

Is diabetes type 1 or 2 more common?

type 2; 95% of all cases