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Year 3 - Clinical > 26 - Diabetes > Flashcards

26 - Diabetes Flashcards

1
Q

Fasting blood glucose target for adults

A

4-7

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2
Q

Fasting blood glucose target for children

A
  • 4-8

- Consider target of 6-10 in children who have had severe or excessive hypoglycemia

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3
Q

2h post-prandial BG for aduts

A

5-10

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4
Q

2h post-prandial BG for children

A

5-10 (same as adults)

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5
Q

What can happen from BG levels that are too high?

A
  • Diabetic ketoacidosis
  • Body can’t take up glucose that is there b/c not enough insulin => high BG levels
  • Levels of 13-13.5 mmol/L causes body to start producing ketones, which are then filtered through kidneys and appear in urine
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6
Q

Why is it important to keep BG and A1c in recommended levels?

A
  • Can become symptomatic on day-to-day basis

- Can cause microvascular complications

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7
Q

Describe the possible microvascular complications of diabetes

A
  • Nephropathy (kidney damage)
  • Retinopathy = leading cause of blindness in Canada
  • Neuropathy (lack of sensation in extremities)
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8
Q

What are the most common neuropathies of diabetes?

A
  • Diabetic gastroparesis = neuropathy in GI tract so normal movement is impaired (feeling of food being stuck when swallowing)
  • Erectile dysfunction
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9
Q

What is the RRR for glucose control for microvascular complications?

A
  • 60% of nephropathy and retinopathy

- 45% of neuropathies

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10
Q

___ is a major complication of type 1 diabetes

A

Diabetic ketoacidosis

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11
Q

Major causes of diabetic ketoacidosis

A
  • Failing to take insulin

- Poor sick day management

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12
Q

Do you still need to take insulin on sick days?

A

Cold or flu causes stress that causes hormone release (norepinephrine, cortisol, and glucagon) that causes blood glucose to increase

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13
Q

Risk factors for diabetic ketoacidosis in children

A
  • Children w/ poor control or previous episodes of DKA
  • Peripubertal and adolescent girls (insulin causes weight gain)
  • Children on pumps or long-acting insulin
  • Children w/ psychiatric disorders
  • Those w/ difficult family considerations
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14
Q

What is A1C?

A

Glycated hemoglobin

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15
Q

What are the various A1C targets?

A
  • 6.5% or less in adults w/ T2DM who are at low risk of hypoglycemia to reduce risk of CKD & retinopathy
  • 7.0% or less in most adult’s w/ type 1 or 2 DM
  • 7.1-8% = functionally dependent
  • Goal 7.1-8.5% in px w/ recurrent severe hypoglycemia and/or hypoglycemia unawareness, limited life expectancy, or frail elderly and/or w/ dementia
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16
Q

What are the A1C targets for children and why?

A
  • A1c targets more relaxed for children b/c being too stringent increases risk of hypoglycemia (has been shown to cause more learning difficulties and cognitive difficulties in children following a tight glucose control)
  • < 18 y/o A1c = 7.5% or less
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17
Q

Is a 2% change in A1C a big deal?

A
  • YES!!

- Going from 7% to 9% is huge and has much greater risk of complications

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18
Q

What is the initial dosing range of insulin for type 1 diabetes?

A

0.5-1 U/kg/day

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19
Q

When may insulin dosing decrease?

A
  • Dose may decrease during a “honeymoon phase” (when insulin causes body to increase insulin production) which can last weeks to months after the initial diagnosis
  • 0.2-0.5 U/kg/day
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20
Q

When may insulin dosing increase?

A
  • Dose may increase for children as they enter puberty

- 0.5-1.5 U/kg/day

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21
Q

What should the ratio be for long-acting and rapid-acting insulin?

A

Typically dosing is approx. 50% basal and 50% rapid-acting split between 3 meals

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22
Q

of insulin units are adjusted based on ____

A
  • BG readings
  • Amount of carbs consumed at each meal
  • Expected exercise
  • Presence of illness
  • Changes in age and weight over time
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23
Q

Who requires a basal amount of insulin?

A

Everyone

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24
Q

What is basal insulin? Give examples

A
  • Long-acting (detemir, glargine; should be clear, throw away if cloudy)
  • Intermediate-acting (NPH; should be cloudy)
  • Both are given 1-2 times/day
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25
Q

Onset and duration of long-acting insulin

A
  • Onset 90 min
  • Duration 16-24 h (detemir) or 24 h (glargine)
  • Gives a small amount of insulin for 24 h, doesn’t have a peak
  • Glargine is pH dependent (formulated at pH 4)
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26
Q

When should detemir insulin be given and why?

A

At bed time and in the morning b/c doesn’t last until next bedtime dose if only given at bedtime

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27
Q

Onset and duration of intermediate-acting insulin

A
  • Onset 1-3 h

- Duration < 18 h

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28
Q

Which insulin therapy is preferred for adults and type 1 diabetics?

A

Basal-bolus insulin therapies (multiple daily injections or continuous subcutaneous insulin infusion)

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29
Q

When should a continuous subcutaneous insulin infusion be considered?

A

If glycemic targets not met w/ optimized multiple daily injections

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30
Q

What is prandial insulin? Give examples

A
  • Rapid-acting (aspart, glulisine, lispro)

- Short-acting (Humulin/Toronto)

31
Q

Onset and duration of rapid-acting insulin

A
  • Onset < 20 min

- Duration 3-5 h

32
Q

Onset and duration of short-acting (Toronto) insulin

A
  • Onset 30 min

- Duration 6.5 h (about 2x as long as rapid-acting)

33
Q

What is the advantage of rapid-acting insulin over short-acting?

A
  • Better for unpredictable eating schedules (ex: don’t know how much a child will eat, so can give insulin right when they start eating)
  • Rapid causes less late morning/afternoon hypoglycemia (short acting lasts longer so will push glucose levels down for more time) know this
34
Q

What is important to know about mixing insulin?

A
  • Can’t mix lispro and glargine, will change the PK profile

- Can mix Humalog w/ NPH

35
Q

Pediatric diabetic ketoacidosis causes increased risk for _____

A

Cerebral edema

36
Q

Describe proper insulin administration techniques

A
  • Rotate injection spots at the same site (not rotating will affect absorption and leave lumps under skin)
  • Inject into abdomen/stomach, outer thigh, or back of arm
  • Don’t inject into muscles that are going to be active (will increase absorption)
37
Q

What are some sx of hyperglycemia?

A
  • Polyuria (b/c high blood glucose makes the body want to pee it out, and water follows glucose)
  • Polydipsia (excessive thirst)
  • Weight loss (losing water weight)
38
Q

What is the proper management of hyperglycemia?

A
  • Monitor for trends in elevated BG and adjust when blood glucose results are consistently elevated; typically, don’t adjust insulin causing a single elevated BG reading
  • Adjust only 1 insulin at a time, unless the adjustment will cause low BG readings to occur later in the day
    • In most cases, insulin adjustments should approximate a 10% change to the insulin causing the effect (ex: originally using 4 U at breakfast, increase to 4.5 U)
39
Q

What are some drugs that can increase blood glucose?

A
  • Thiazides (only at higher doses; ex: HCTZ 12.5 mg isn’t concerning, but > 25 mg would require monitoring)
  • Prednisone (must monitor in first 1-3 weeks after starting)
  • Atypical antipsychotics
  • Niacin (doses > 1 g/day)
40
Q

When is a correction factor used?

A

When pt is very hyperglycemic

41
Q

Describe the correction factor/ insulin sensitivity factor

A
  • For rapid-acting insulin (aspart, glulisine, or lispro) divide 100 by the person’s total daily dose (TDD); result will estimate the reduction in BG for 1 U of insulin (ex: TDD = 33 U, 100 / 33 = 3 mmol/L approx.)
  • For short-acting insulin (Humulin R, Novolin ge Toronto) divide 85 by TDD; result will estimate the reduction in BG for 1 U of short-acting insulin (ex: TDD = 33 U, 85 / 33 = 2.6 mmol/L)
42
Q

Describe the insulin to carbohydrate ratio (ICR)

A
  • ICR = total grams of carbs consumed per day / total daily dose of insulin units (ex: 450 g / 33 U = 13.6 g -> 1 U of insulin required for every 13.6 g of carbs consumed)
  • Children = 450 g carbs
  • Adults = 500 g carbs
  • Can find out how many carbs are in different foods directly from “nutrition facts” labels (*don’t include fiber)
43
Q

What is hypoglycemia? What are some sx?

A
  • BG < 4 mmol/L

- Sx = sweaty and generally feeling unwell

44
Q

What is the tx for hypoglycemia?

A
  • Treat immediately w/ carbs and figure out the cause (ex: exercise, skipped meal, skipped insulin)
  • For children < 15 kg = 5 g carbs
  • For children 15-30 kg = 10 g carbs
  • For anyone > 30 kg = 15 g carbs (ex: 4 glucose tablets, 175 mL of juice or regular soft drink)
45
Q

What is a good option in regards to exercise and T1DM?

A

Decrease insulin if doing regularly scheduled exercise b/c too much insulin during activity may cause hypoglycemia and can prevent body from burning fat efficiently

46
Q

At what BG level should a person not exercise?

A

> 14 mmol/L w/ ketones or > 16.7 mmol/L

47
Q

What can cause hyperglycemia following cessation of high intensity exercise?

A
  • Insulin deficiency

- Stress response

48
Q

When does delayed hypoglycemia following moderate or strenuous activity generally occur?

A
  • 6-15 h following activity

- Can be responsible for hypoglycemia > 24 h later

49
Q

What are the general recommendations for people w/ diabetes and exercise?

A
  • Good idea to bring sugar tablets and snacks w/ you
  • Know sx of hypoglycemia and what to do to treat them
  • Monitoring BG before starting exercise and after; if exercise is long, check BG during
  • Stay hydrated
50
Q

Describe the recommendations for glycemic management of type 2 diabetes in adults

A
  • In the absence of metabolic decompensation, metformin should be initial agent of choice in people w/ newly diagnosed T2DM, unless contraindicated
    • Metabolic decompensation = marker hyperglycemia, ketosis, or unintentional weight loss
  • Contraindications to metformin = class 4 or 5 chronic kidney disease (CrCl < 30 mL/min) and hepatic failure
  • Initial use of combinations of submaximal doses of anti-hyperglycemic agents produces more rapid and improved glycemic control and fewer side effects compared to monotherapy at maximal doses
51
Q

What is the recommendation for insulin use in T2DM?

A
  • 3rd line behind metformin and gliclazide??
  • May be started on insulin at beginning, used to get them down to normal then started on oral meds to maintain
  • Still make insulin, so don’t have to worry about exact insulin injection amounts to account for carbs and stuff like that in type 2 diabetics
52
Q

How often should blood glucose and A1c be measured?

A
  • If using insulin pump, SMBG (self-monitoring of blood glucose) = 4 or more times/day
  • If using basal insulin, SMBG = at least as often as insulin is being given (ex: NPH/long-acting given at bedtime, SMBG before breakfast)
  • Daily SMBG not usually required if px has prediabetes or has diabetes and is being treated w/ behaviour interventions and is meeting glycemic targets
  • *People w/ type 1 diabetes should measure blood glucose about 4 times/day
  • Type 2 DM can measure once a day or less (depending on control)
  • A1c should be measured every 3 months
53
Q

Metformin – advantages, max dose, major SE, CI

A
  • One of the best agents to lower A1C
  • Also decreases microvascular complications & decrease CV events
  • Max dose = around 2500 mg/day; greater than that can cause lactic acidosis, which is 50% fatal
  • Major SE = nausea, diarrhea, stomach upset
  • Get concerned when CrCl < 40 mL/min b/c absolutely contraindicated in < 30 mL/min
54
Q

Sulfonylureas - CI, MOA, SE

A
  • Can increase weight, so avoid use in obese px
  • Glyburide stimulates release of insulin from pancreas (gliclazide very similar)
  • Don’t show decrease in CV events
  • SE = hypoglycemia & weight gain
55
Q

Acarbose - MOA, dose, efficacy, SE, monitoring

A
  • Blocks alpha-glucosidase (breaks long carbs into smaller carbs) in GI tract & pancreatic alpha-amylase, so delays carb digestion
  • Dose – 50 mg once to start, titrate up to 100 mg TID w/ meals; increase dose every 1-2 months
  • Takes about 8 weeks for maximal effect
  • Efficacy – commonly decreases A1c approx. 0.7-0.8%
  • Weight neutral or slight weight loss
  • Low risk of hypoglycemia when used alone
  • *Associated w/ significant GI effects (flatulence > 40%, diarrhea ~ 30%, abdominal pain)
  • Monitor liver function tests (AST, ALT) every 3 months for first year & reassess frequency
56
Q

Thiazolidinediones - example, indication, dose, efficacy, CI, SE, monitoring

A
  • Pioglitazone
  • Indicated for type 2 diabetes on high dose insulin (over 2 U/kg) & on maximally tolerated metformin who aren’t achieving optimal control
  • Helps increase sensitivity of cells to insulin so they can recognize glucose & uptake it
  • Delayed onset of 4 weeks, max effect in 8-16 weeks
  • Dose = typically 15-30 mg once daily
  • Efficacy – commonly decreases A1c ~ 0.8-0.9%
  • Weight gain (approx. 2.5-5 kg) b/c increased glucose uptake in cells
  • Minimal risk of hypoglycemia when used alone
  • Contraindicated in any amount of heart failure b/c worsens HF
  • Not indicated for use w/ insulin due to increased risk of HF
  • Edema 5%; rare = mild anemia
  • Increased incidence of fractures
  • Requires monitoring of liver function (ALT, AST) at baseline
  • Monitor for blood in urine & dysuria (rarely associated w/ bladder cancer)
57
Q

DPP-4 inhibitors - example, indication, dose, efficacy, SE

A
  • Sitagliptin
  • Indicated in type 2 diabetics who aren’t adequately controlled on or are intolerant to metformin & a sulfonylurea, and for whom insulin isn’t an option
  • Dose = typically 100 mg once daily (decrease dose in renal dysfunction)
  • Delayed onset < 4 weeks, max effect ~ 18 weeks
  • Efficacy = commonly decreases A1c ~ 0.5-0.7%
  • Weight neutral or slight weight loss (approx. 1-2 kg)
  • Minimal risk of hypoglycemia when used alone
  • Doesn’t appear to have beneficial CV outcomes (does have benefit for microvascular complications)
  • Caution w/ use in HR (especially saxagliptin)
  • Reports of arthralgias, joint pain
58
Q

GLP-1 receptor agonists - example, administration, indication, efficacy, SE, dose, CI, disadvantage

A
  • Liraglutide/ victoza
  • Subcut injectable (supplied as 6 mg/mL solution)
  • Indicated in combination w/ metformin, or metformin & a sulfonylurea, or metformin & basal insulin
  • Efficacy – commonly decreases A1c ~ 1%
  • CV benefit – for every 100 px w/ T2DM and high CV risk, tx w/ liraglutide for ~ 4 years will result in 2 less CV events, 2 less cases of nephropathy, but 1 extra case of acute gallbladder disease, and 2 extra cases of discontinuation due to adverse effects (ex: nausea, vomiting, diarrhea)
    • Studied in px that had a CV event and trying to control BG to prevent a second one
  • Increased incidence of nausea (39%), headache, diarrhea (21%), hives
  • Titrate dose upward; 0.6 mg subcut once daily x 1 week, then 1.2 mg subcut once daily, may increase to 1.8 mg subcut once daily
  • Weight neutral or slight weight loss (up to 3 kg)
  • Lower risk of hypoglycemia when used alone
  • Associated w/ medullary thyroid cancer & multiple endocrine neoplasia syndrome (rare); CI if personal or family hx; can still use in hypothyroidism
  • Very expensive!
59
Q

SGLT2 inhibitors - example, indication, efficacy, CV benefits, dose, CI, SE

A
  • Empagliflozin/ jardiance
  • Produces increased urinary glucose excretion (blocks re-uptake of glucose in kidneys so it stays in urine)
  • CV benefits & adverse effects aren’t consistent in this class of drugs
  • Indicated for:
    • Monotherapy (if CI/intolerance to metformin)
    • Combination w/ metformin
    • Combination w/ metformin or sulfonylurea
    • Combination w/ pioglitazone (alone or w/ metformin)
    • Combination w/ insulin (basal or prandial)
  • Efficacy = decreases A1c ~ 0.4-0.7%
  • CV benefits – reduced risk of composite major CV events and all cause death (why its increasing in popularity for T2DM)
    • Recommended for px w/ previous CV events
  • 10 mg daily dose provided virtually same benefit as 25 mg dose
    • Dose typically 10 mg daily w/ 1st meal of the day
  • CI in renally impaired px (eGFR < 45 mL/min) b/c drug is less effective
  • Weight neutral or weight loss (approx. 4 kg)
  • SE = UTI, 3-4-fold increased risk of genital fungal infections, rare DKA; canagliflozin associated w/ increased fractures & greater risk of lower limb amputation
    • Empagliflozin is a good option as long as pt doesn’t have recurrent UTI’s (b/c increases glucose in urine, which induces growth of bacteria)
    • Increased risk of Fourneir’s gangrene (necrotizing fasciitis) around perineum (very rare; inform pt to get checked if experiencing redness, swelling, or pain b/c not a normal UTI; tx = debridement) – not a reason to stop recommending
  • Reduced doubling of sCr, initiation of renal replacement therapy, or death due to renal disease
  • In adults w/ T2DM w/ clinical CKD in whom glycemic targets aren’t achieved w/ existing anti-hyperglycemic medications and w/ eGFR > 30, SGLT2 inhibitors w/ proven renal benefit may be considered to reduce risk of progression of nephropathy
60
Q

Which meds should be stopped on sick days if pt can’t stay hydrated?

A

SAD MANS = sulfonylureas, ACE inhibitors, diuretics/direct renin inhibitors, metformin, ARBs, NSAIDs, SGLT2 inhibitors

61
Q

What is the objective of sick day management in insulin-managed diabetes?

A
  • Minimize metabolic imbalance
  • Avoid severe hypoglycemia
  • Prevent hyperglycemia and ketosis leading to DKA
62
Q

What are 2 diabetes emergencies w/ similar qualities?

A

DKA (diabetic ketoacidosis) and HHS (hyperosmolar hyperglycemic state)

63
Q

Is DKA or HHS more common in T2DM

A

HHS b/c ketones aren’t present

64
Q

Why do BG and ketones increase on sick days?

A
  • Illness and infection allow the body to release counter-regulatory hormones that oppose the action of insulin; this allows circulating levels of glucose to rise quickly along w/ increase in circulating fat cells
  • W/ lower insulin levels, higher glucose levels, and increasing fat cells, blood becomes more acidic and ketone bodies increase
65
Q

When is ketone testing recommended?

A
  • All px w/ T1DM during periods of acute illness accompanied by elevated BG
  • Measured every 2-4 h around the clock as long as
66
Q

Should insulin be omitted on sick days?

A
  • Never
  • Supplemental rapid-acting or short-acting may be needed for hyperglycemia and ketosis
  • Can safely be given every 3-4 h w/o discussion w/ physician
67
Q

What is the target for BG and ketones during brief illness?

A
  • BG < 14 mmol/L

- Ketones negative

68
Q

What should be done if pt is having trouble eating and drinking?

A
  • 10-15 g of carbs should be taken every 1-2 h to prevent hypoglycemia
  • 250 mL an hour while awake can be recommended to prevent dehydration
69
Q

When should pharmacotherapy be initiated w/ gestational diabetes?

A

If pt doesn’t achieve BG targets w/in 2 weeks of initiation of nutritional therapy and exercise

70
Q

Which anti-hyperglycemics are safe in pregnancy?

A
  • Use of insulin to achieve glycemic targets has been shown to decrease fetal & maternal morbidity
  • Multiple daily injections are most effective
  • Metformin shown to be safe in pregnancy
  • In women w/ GDM who decline insulin & don’t tolerate or are inadequately controlled on metformin, glyburide may be used (glyburide = 3rd line after insulin & metformin)
71
Q

Why should gestational diabetes be diagnosed and treated?

A
  • Macrosomia (large baby)
  • Shoulder dystocia & nerve injury (during birth, babies’ shoulder is dislocated b/c is so big)
  • Neonatal hypoglycemia
  • Preterm delivery
  • Hyperbilirubinemia
  • C section
  • Offspring obesity
  • Offspring diabetes
72
Q

What are the targets for GDM?

A
  • Fasting & preprandial BG < 5.3 mmol/L
  • 1h postprandial BG < 7.8 mmol/L
  • 2h postprandial BG < 6.7 mmol/L
73
Q

Describe the recommendation for ASA use in diabetics?

A
  • ASA not routinely recommended for primary prevention of CVD among diabetics
  • Insufficient evidence to support use of ASA for primary prevention (weighing risk of bleeding vs. CVD protection = no benefit)

Year 3 - Clinical (30 decks)

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