1
Q
What drugs or hormones increase insulin secretion?
A
Sulfonylureas
Meglitinides
Incretins
2
Q
What drugs or hormones decrease glucagon secretion?
A
Incretins
Amylin
3
Q
What drugs or hormones decrease glucose reabsorption?
A
SGLT2 inhibitors
4
Q
What drugs or hormones increase glucose uptake and utilization?
A
Thiazolidinediones
Metformin
5
Q
What drugs or hormones are correlated w/ lipotoxicity?
A
Thiazolidinediones
6
Q
What drugs or hormones decrease hepatic glucose output?
A
Thiazolidinediones
Metformin
7
Q
What are the pharmaceutical targets in regulating insulin secretion?
A
GI hormones
Pancreatic hormones
8
Q
Liver cells and carbohydrate metabolism, what is the metabolic action via insulin?
A
Gluconeogenesis goes down
Glycogenolysis goes down
Glycolysis goes up
Glycogenesis goes up
9
Q
Liver cells and fat metabolism, what is the metabolic action via insulin?
A
Lipogenesis goes up
Lipolysis goes down
10
Q
Liver cells and protein metabolism, what is the metabolic action via insulin?
A
Protein breakdown goes down
11
Q
Fat cells and carbohydrate metabolism, what is the metabolic action via insulin?
A
Glucose uptake increases
Glycerol synthesis increases
12
Q
Fat cells and fat metabolism, what is the metabolic action via insulin?
A
Synthesis of TG
Synthesis of FA
Lipolysis goes down
13
Q
Fat cells and protein metabolism, what is the metabolic action via insulin?
A
Nothing happens
14
Q
Muscles and carbohydrate metabolism, what is the metabolic action via insulin?
A
Glucose uptake increases
Glycolysis goes up
Glycogenesis goes up
15
Q
Muscles and fat metabolism, what is the metabolic action via insulin?
A
Nothing happens
16
Q
Muscles and protein metabolism, what is the metabolic action via insulin?
A
AA uptake increases
Protein synthesis increases
17
Q
What are the ultra-short acting insulins or rapid acting?
A
Lispro (Humalog)
Aspart (Novolog)
Glulisine (Apidra)
18
Q
What are the short acting insulins?
A
Regular insulin (Novolin)
19
Q
When Regular insulin (Novolin) in administered subcutaneously, what form does it inject as?
A
Hexamer then dimer then a monomer
20
Q
When should regular insulin (Novolin) be given?
A
30 to 45 min before meals
21
Q
What are the intermediate-acting insulins?
A
NPH (Humulin)
22
Q
NPH (Humulin) is a complex made up of…
A
Insulin + Protamine**
**Requires proteolytic degradation for absorption of insulin
23
Q
What are the long-acting insulins?
A
Insulin glargine (Lantus, Toujeo)
Insulin detemir (Levemir)
Insulin Degludec (Tresiba)
24
Q
MOA of Metformin?
A
Unknown but linked to decreased ATP and increased cAMP
Decreases hepatic glucose production
Decreases intestinal absorption of glucose
Enhances insulin sensitivity
25
What are some advantages of Metformin?
1. No Wt gain
2. No hypoglycemia
3. Significant lipid lowering effect
4. Works on those who are insulin resistant
26
AE of Metformin?
1. Vit. B12 deficiency
2. Lactic acidosis
3. Heptatitis
27
Contraindications of Metformin?
1. Metabolic acidosis or diabetic ketoacidosis
2. Renal insufficiency
3. Cardiac collapse / acute MI
4. Use w/ iodinated contrast
28
MOA of sulfonylureas?
Blocks ATP-sensitive K+ channels which leads to depolarization and influx of calcium
Results in insulin secretion which lowers blood glucose
29
Which Rx has extrapancreatic effect and what is it?
Sulfonylureas
Suppresses hepatic glucose output
30
Sulfonylurea AE?
1. Hypoglycemia
2. Tremors and nervousness
3. GI hemorrhage
4. Hemolytic + G6PD deficiency anemia
5. Cholestatic jaundice
6. Weight gain
31
Which sulfonylurea has active metabolites?
Glyburide
32
What are some Rx interactions w/ sulfonylureas?
Dulaglutide and acarbose
Causes hypoglycemia
**non-sulfonylurea insulin releasing agents also interact with these Rx^
33
What are the non-sulfonylurea insulin releasing agents?
Nateglinide (Starlix)
| Repaglinide (Prandin)
34
Compare the sulfonylureas with the non-sulfonylurea insulin releasing agents
Non-sulfonylurea agents have shorter half life and has rapid action (just take 30min before meals)
35
Non-sulfonylurea insulin releasing agent AE?
Hypoglycemia
Respiratory infection
Headaches
36
What drug is an alpha-glucosidase inhibitor?
Acarbose (Precose)
Miglitol (Glyset)
37
Acarbose MOA?
Inhibits digestion of complex sugars (take w/ meals)
Decreases carb uptake after a meal
38
Acarbose AE?
Causes flatulence, GI problems which leads to poor acceptance and compliance
39
Contraindications of Acarbose?
1. Major GI issues (ulcers, inflammatory, etc)
| 2. Liver cirrhosis
40
What are some drug interactions of Acarbose?
Dont take w/ another anti-diabetic (risk of hypoglycemia)
41
Pioglitazone MOA?
Stimulates PPAR gamma receptors in adipose tissue and other cells
Leads to activation of transcription factors
Decrease insulin resistance (increases sensitivity of insulin)
Increases glucose uptake and increases hepatic glucose output
42
Which diabetic Rx requires liver enzyme tests?
Pioglitazone
43
Pioglitazone AE?
1. Water retention and Wt gain
2. Anemia
3. Limb fractures
4. Respiratory infection
5. Heart, liver failure **can worsen congestive heart failure
6. Bladder cancer
7. Macular edema
44
What are some drug interactions with pioglitazone?
Decreased lvls of nifedipine
45
What diabetic Rx has a black box warning and what is the warning?
Exenatide - Causes medullary thyroid carcinoma
GLP-1 agonists = thyroid C-cell tumors
46
AE of Exenatide?
1. Hypoglycemia if combined w/ other antidiabetic Rx
2. Pancreatitis and pancreatic cancer
3. Acute renal failure
47
What are some contraindications of Exenatide (or just GLP-1 agonists)
Multiple endocrine neoplasia syndrome type 2
Family history of medullary thyroid carcinoma
***except with lixisenatide (Adlyxin)
48
Which Rx is the GLP-1 analog?
Exenatide, Liraglutide
49
Which Rx is the synthetic amylin analog?
Pramlinitide (Symlim)
50
Pramlinitide AE?
Weight loss
Decreased gastric emptying
Hypoglycemia
51
When is Pramlinitide used?
Adjunct to insulin
Injected before meals, just DONT mix with insulin
52
What are the DPP-4 inhibitors?
Sitagliptin
53
Sitagliptin MOA?
DPP-4 inhibitor
Degrades GLP-1 and GIP
Stimulates "glucose DEPENDENT" insulin secretion (just like GLP-1 agonists)
54
Sitagliptin AE?
Nasopharyngitis
Pancreatic cancer
Acute renal failure
SJS
Rhabdomyolisis
55
Which diabetic Rx can cause acute renal failure?
Exenatide
DPP-4 inhibitors
56
Which diabetic Rx can cause pancreatic cancer?
Exenatide
DPP-4 inhibitors
57
What kind of Rx is Canagliflozin?
SGLT-2 inhibitors
Reduces blood glucose
58
Which Rx works independently of insulin?
SGLT-2 inhibitors
59
SGLT-2 inhibitor AE?
Urinary infections
Hypovolemia
Diabetic ketoacidosis
Pancreatitis
Bone fractures
Renal impairment
60
SGLT-2 inhibitor contraindications
Severe renal impairment
Possibility of hypotension
Hyperkalemia
61
What are some drug interactions with SGLT-2 inhibitor?
Digoxin, increased levels
62
What are some clinical pearls of metformin?
Hold metformin during periods following stress due to increased %% of lactic acidosis
D/c metformin 48hrs prior to contrast dye due to acute renal damage
Second line therapy for GDM
63
What is the starting dose for metformin? Titrated? Max dose?
Start: 500mg BID or 850mg QD (IR)
500mg daily w/ evening meal (ER)
Titrated: 500mg weekly or 850mg every 2 wks (IR only)
Max: 2550mg (IR) + 2000mg (ER)
64
Does metformin need to be renally/hepatically adjusted? If so, how is it adjusted?
eGFR from 30 to 45 = do not start or adjust for 50% for existing therapy
Liver = caution due to %% of lactic acidosis
65
What diabetic Rx is concerned w/ Vit. B12 deficiency?
Metformin
66
What is the starting dose of pioglitazone? Titrated? Max?
Start: 15 or 30mg QD
Titrate: 15mg q4-6 wks
Max: 45mg
67
Does pioglitazone need to be renally/hepatically adjusted? If so, how is it adjusted?
No renal adjustments
Caution in liver impairment
68
When is pioglitazone contraindicated?
Initiation in pt w/ NYHA Class III/IV heart failure
69
What are some considerations you must think about when prescribing pioglitazone?
It has a delayed onset
70
What are the brand names for glyburide, glimepiride, and glipizide?
Glyburide - Diabeta
Glimepiride - Amaryl
Glipizide - Glucotrol
71
What are the generic names for Diabeta, Glucotrol, and Amaryl
Glyburide - Diabeta
Glimepiride - Amaryl
Glipizide - Glucotrol
72
What are some contraindications for sulfonylureas?
1. Used in T1DM or DKA
| 2. Sulfur allergy
73
Do sulfonylureas need to be renally/hepatically adjusted? If so, how is it adjusted?
Only Glimepiride needs to be renally adjusted. Start at 1mg in CKD
74
What is the starting dose of glyburide? Titrated? Max?
Start: 2.5 to 5mg daily w/ first meal (can start at 1.25 if sensitive to hypoglycemia)
Titrate: 2.5mg q1-2wks
Max: 20mg/day
Micronized formulation=
Start: 1.5 to 3mg daily with first meal (can start at 0.75mg)
Titrate: 1.5mg q1-2wks
Max 12mg/day
75
What is the starting dose of glimepiride? Titrated? Max?
Start: 1 to 2mg/day w/ first meal (can start at 1.25mg)
Titrate: 1 to 2mg q1-2wks
Max: 8mg
76
What is the starting dose of glipizide? Titrated? Max?
IR = Start: 2.5mg daily BEFORE first meal
Titrate: 2.5 to 5mg q1-2wks. Can be given BID 30min before meals
Max 20mg
ER = Start: 2.5 to 5mg daily BEFORE first meal
Titrate 5mg q1-2wks
Max 20mg
77
Which diabetic Rx is contraindicated with bosentan?
Glyburide
78
Which sulfonylurea is not the preferred agent in CKD or elderly patients?
Glyburide
79
Which sulfonylurea is preferred in renal dysfunction?
Glipizide
80
Brand names of Repaglinide and Nateglinide?
Repaglinide - Prandin
Nateglinide - Starlix
81
What is the starting dose of repaglinide? Titrated? Max?
Start: 0.5mg before meals (A1c<8) or 1 to 2mg (A1c>8)
Titrate: double dose q1-2wks
Max: 16mg/day
CrCl from 20-40 = initial is 0.5mg/day
W/ cyclosporine = max is 6mg/day
82
What is the starting dose of nateglinide? Titrated? Max?
Start: 120mg TID before meals. Can start at 60mg TID if close to A1c goal
Max: 360mg/day
If eGFR <30= initial is 60mg TID
83
What are some considerations to take with repaglinide?
Take w/ food (30min before)
Avoid use w/ clopidogrel or gemfibrozil
84
What are some considerations to take with nateglinide?
Take w/ food (30min before)
85
Which classes of diabetic Rx are "glucose-independent" insulin secretagogues?
Meglitinides (Repaglinide and Nateglinide) and sulfonylureas
86
What dosage form does Repaglinide and Nateglinide come in?
PO only
87
Clinical pearls of GLP-1 agonists?
GLP-1 agonists and DPP-4 inhibitors are usually not given together
Takes 6-7 wks to reach steady state
Not preferred in ppl w/ gastroparesis
Need to be hydrated
AB development
CV benefits in liraglutide, dulaglutide and semaglutide
88
Which GLP-1 agonists must be renally adjusted?
Lixisenatide and Exenatide
```
Lixisenatide = not recommended <15
Exenatide = not recommended for CrCl <30 (IR) and eGFR <45 (ER)
```
89
What is the starting dose of Lixisenatide? Titrated? Max?
Start: 10mcg daily for 14 days
Titrate: 20mcg daily
Max: 20mcg daily
90
What is the starting dose of Exenatide? Titrated? Max?
(IR) Start: 5mcg BID within 60min of meals (6 hrs apart)
Titrate: 10mcg BID after 1 month
(ER) Start 2mcg once weekly (no regard of meals)
91
What is the starting dose of liraglutide? Titrated? Max?
Start: 0.6mg SQ daily for 1 wk
Titrate: Then 1.2mg daily
Max: 1.8mg/day
92
Which diabetic Rx is approved for weight loss?
Liraglutide (3mg dose) + CV benefits
93
What is the starting dose of dulaglutide? Titrated? Max?
Start: 0.75mg once weekly
Titrate: May increase to 1.5mg once weekly
Max: 1.5mg/week
94
What is the starting dose of semaglutide? Titrated? Max?
SQ Start: 0.25mg weekly for 4 wks
Titrate: 0.5mg weekly for at least 4 wks (can increase to 1mg/week)
Oral Start: 3mg once daily for 30 days
Titrate: 7mg daily for 30 days (can increase to 14mg daily)
95
Which DPP-4 inhibitor must be renally adjusted?
Sitagliptin
Saxagliptin
Aloglipitin
(Linagliptin is the only one that isnt adjusted)
96
Brand names of the DPP-4 inhibitors?
Sitaglipin - Januvia
Saxagliptin - Onglyza
Linagliptin - Tradjenta
Alogliptin - Nesina
97
What is the starting dose of sitagliptin? Titrated? Max?
Start: 100mg daily
Max: 100mg daily
Renal dose eGFR 30-44 = 50mg daily
If <30 = 25mg daily
98
What is the starting dose of Saxagliptin? Titrated? Max?
Start: 2.5 to 5mg daily
Max: 5mg daily
Renal dose eGFR <45 = 2.5mg daily
99
What are some considerations when using DPP-4 inhibitors?
Only with Saxagliptin and Alogliptin, increased %% of hospitalization due to heart failure within first 12 months of therapy
100
What is the starting dose of linagliptin? Titrated? Max?
Start: 5mg daily
Max: 5mg daily
101
What is the starting dose of alogliptin? Titrated? Max?
Start: 25mg daily
Max: 25mg daily
Renal dose eGFR 30-59 = 12.5mg daily
<30 = 6.25mg daily
102
What is the starting dose of pramlinitide? Titrated? Max?
(SQ + T1DM) Start: 15mcg prior to major meals
Titrate: 15mcg q3days till 30 to 60 mcg before meals
(SQ + T2DM) Start 60mcg prior to meals
Titrate: 120mcg before meals
103
What is the starting dose of acarbose? Titrated? Max?
(PO) Start 25mg TID w/ first bite of meal
Titrate: 50 to 100mg TID (every 4 to 8 wks)
Max: 50mg TID (≤60kg) or 100mg TID (>60kg)
Renal dose not recommended if SCr >2 or CrCl <25
104
What is the starting dose of miglitol? Titrated? Max?
(PO) Start: 25mg TID w/ first bite of meal
Titrate: 50 to 100mg TID (every 4 to 8 wks)
Max: 100mg TID
Renal dose not recommended if SCr >2 or CrCl <25
105
SGLT-2 inhibitor MOA?
Inhibits SGLT2 cotransporter in proximal renal tubules and prevents reabsorption of glucose
106
What are the SGLT-2 inhibitors?
Canagliflozin - Invokana
Empagliflozin - Jardiance
Dapagliflozin - Farxiga
Ertugliflozin - Steaglatro
107
Which diabetic Rx are associated w/ weight loss?
Pramlinitide + SGLT-2 inhibitors
108
Which diabetic Rx class is associated w/ euglycemic ketoacidosis?
SGLT-2 inhibitors
109
What is the starting dose of canagliflozin? Titrated? Max?
Initial: 100mg daily
Max 300mg daily
Renal dose 30-59 eGFR = 100mg daily
<30 is contraindicated
Severe hepatic dysfunction, also not recommended
110
What is the starting dose of empagliflozin? Titrated? Max?
Initial: 10mg daily. May increase to 25mg
Max: 25mg daily
Renal dose 30-44 = do not initiate therapy
<30 = contraindicated
111
What are some additional monitoring parameters for canagliflozin?
Increased %% of limb amputations and hyperkalemia
but...increased CV benefits
112
What is the starting dose of dapagliflozin? Titrated? Max?
Initial 5mg daily
Max: 10mg daily
Renal dosing eGFR 30-44 - do not initiate
113
What is the starting dose of ertugliflozin? Titrated? Max?
Initial 5mg daily
Max 15mg daily
Renal dosing eGFR 30-59 - do not initiate
Severe hepatic dysfunction, also not recommended
114
Which SGLT-2 inhibitors should not be recommended with hepatic dysfunction?
Canagliflozin and ertugliflozin
115
What are some considerations when prescribing dapagliflozin?
Indicated for reduction of heart failure in pt w/ diabetes
116
When evaluating a patient with diabetes and they have ASCVD issues, what can you prescribe them?
GLP-1 agonists or SGLT-2 inhibitors
If A1c is above target, add another class
117
When evaluating a patient with diabetes and they have heart failure or CKD issues, what can you prescribe them?
SGLT-2 inhibitors first, if that doesnt work then add GLP-1 agonists
If A1c is above target, add another class except TZD
118
When evaluating a patient with diabetes and they do not have any ASCVD, heart failure, or CKD issues and A1c is above target + you want to minimize hypoglycemia, what can you prescribe them?
1. DPP-4 inhibitor
2. GLP-1 agonist
3. SGLT-2 inhibitors
4. TZD
119
When evaluating a patient with diabetes and they do not have any ASCVD, heart failure, or CKD issues and A1c is above target + you want to minimize wt gain or loss some weight, what can you prescribe them?
1. GLP-1 agonists
| 2. SGLT-2 inhibitors
120
When evaluating a patient with diabetes and they do not have any ASCVD, heart failure, or CKD issues and A1c is above target + cost is an issue, what can you prescribe them?
1. Sulfonylureas
| 2. TZD
121
What kind of concentrations exist for bolus insulin?
Typically U-100
+U-500 (Humulin R)
+U-200 (Humalog)
122
What kind of concentrations exist for basal insulin?
Typically U-100
+U-200 (Insulin degludec)
+U-300 (only concentration for insulin glargine)
123
Which basal insulin last the longest?
Insulin degludec (>42hrs)
124
When injectable therapy is needed to reduce A1c, what should you do?
Start with GLP-1 agonists prior to insulin
If that doesnt work or they were already on a GLP-1 agonist, add basal insulin or bedtime NPH
Initiation: 10IU/day or 0.1-0.2IU/kg/day
If that doesnt work, add prandial insulin or convert to twice daily NPH
Prandial insulin Initiation 4IU or 10% of basal dose
Titrate: Increase dose by 1-2IU or 10-15% twice weekly
125
When should you give regular insulin and rapid-acting insulins with regards to meals?
Regular = 30 min prior
Rapid-acting = 10-15 min prior
126
Where are the recommended injection sites for insulin?
1. Abs
2. Outer thigh
3. Back of arm
4. Upper butt
127
What is the rule of 1800 and 1500?
Rapid acting = 1800
Insulin sensitivity factor = 1800/TDD
Regular insulin = 1500
Insulin sensitivity factor = 1500/TDD
128
When treating hypoglycemia, what are some examples of 15-20g of simple carbs?
Glucose tabs
4oz juice or regular soda
1 tbl spoon of honey
8oz or nonfat or 1% milk
Hard candies
129
How would you treat hypoglycemia with the rule of 15?
Consume 15-20g of simple carbs
Check BG after 15min
Repeat process if BG <70
Once normal, eat small snack
Seek medical attention if BG is still <70 x 2 treatments
130
When should you check your BG when using basal or bolus insulin?
Basal = Fasting BG
Bolus = 2 hour postprandial glucose or before meals
131
What is the insulin sensitivity factor?
How much one unit of BOLUS insulin will degreat pt's BG
132
List the diabetic drugs in order of efficacy
Highest - insulins
Intermediates - SGLT2 + DPP4 + alpha-glucosidase inhibitors and amylin mimetics (pramlinitide)
Everything else is high
133
Which diabetic drugs are associated with weight gain?
TZD
Sulfonylureas
Insulins
Meglitinides
134
Which diabetic drugs provide CV benefits?
Metformin - benefits ASCVD only
Empagliflozin + Canagliflozin - benefit ASCVD and HF
Dulaglutide, semaglutide, and liraglutide - benefits CVD events
Pioglitazone
135
Which diabetic drugs increase risk of CV effects?
Saxagliptin + alogliptin
TZD
136
What are the high and medium cost diabetic Rx?
High - SGLT-2i, GLP1-a, DPP-4i, insulin, + Pramlintide
Medium - alpha glucosidase inhibitors + Meglitinides
137
Which diabetic Rx are given SQ?
GLP-1 agonist
Pramlintide
Insulin
138
Which diabetic Rx have a risk of hypoglycemia?
Insulin
Sulfonylureas
Pramlintide
Meglitinides
139
What is the inpatient definition of hypoglycemia?
Level 1 = BG from 54 to 69
Level 2 = BG<54
Level 3 = Severe event regardless of BG
140
What is the target BG in an inpatient setting?
BG from 140 to 180
**Cardiac surgery = 110 to 140
141
What is the inpatient definition of hyperglycemia?
BG >180
142
Which medications can cause hyperglycemia?
Corticosteroids
IV dextrose
Catecholamines
Immunosuppressants
Thiazides + Loop diuretics
Fluoroquinolones (can cause hypo as well)
143
What medications can cause hypoglycemia?
Insulins or secretagogues
Alcohol
ACEi/ARBs
Fluoroquinolones (can cause hyper as well)
144
What are some factors for DKA and HHS?
Infections
Rx noncompliance or dose inadequacy
Rx such as steroids, thiazides, cocaine, sympathomimetics, atypical antipsychotics
145
Mild, Moderate, and Severe DKA + HHS, what is the glucose range?
DKA > 250
HHS > 600
146
Mild, Moderate, and Severe DKA + HHS, which one has ketones?
All, sometimes HHS doesnt have it
147
Mild, Moderate, and Severe DKA + HHS, what is the arterial pH range?
Mild = 7.25 to 7.3
Moderate = 7 to 7.24
Severe = <7
HHS = >7.3
148
Mild, Moderate, and Severe DKA + HHS, what is the bicarb range?
Mild = 15 to 18
Moderate = 10 to 14.9
Severe = <10
HHS = >15
149
Mild, Moderate, and Severe DKA + HHS, what is the serum mOsm/kg?
DKA = variable
HHS = >320
150
Mild, Moderate, and Severe DKA + HHS, what is the anion gap?
Mild = >10
Moderate = >12
Severe = >12
HHS = variable
151
How do you calculate corrected Na?
Na + 1.6 for every 100 BG >100
152
How do you calculate anion gap?
Na - (Cl + Bicarb)
Normal <10
Gap >10
153
How do you calculate osmolality?
Na x 2 + Glucose/18
Normal 290
Hyperosmol >320
154
DKA diagnosis?
MUDPILES
```
Methanol
Uremia
DKA
Propylene glycol/paraldehyde
Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
```
155
How do you treat DKA or HHS with insulin?
Either give 0.1U/kg as bolus and 0.1U/kg/hr as continuous infusion
or
0.14U/kg/hr as continuous infusion
BG must drop at least 10% in the first hour, if not then give 0.14U/kg as bolus in addition
DKA = goal is under 200
HHS = goal is under 300
For both, reduce infusion to 0.02 to .05U/kg/hr
For DKA only, you could just do 0.1U/kg every 2 hrs instead of infusion
156
Potassium + DKA/HHS, how do you manage it?
<3.3 = hold insulin and give 20 to 30 mEq potassium/hr
>5.2 = do not give potassium + check potassium every 2hrs
3.3 to 5.2 = give 20 to 30 mEq of potassium in IV fluids
157
How often should you monitor A1C on someone who has stable control?
Twice yearly
158
How often should you monitor A1C on someone who has therapy changes or is not meeting goals?
3 months
159
What should the A1C goal be on someone that has T1DM?
≤6.5
160
A1C goal of ≤6.5 should be set or someone with T2DM if and only they....
are treated with lifestyle modifications or metformin alone
161
What is the A1C goal for DM in pregnancy?
<6
162
What is the A1C goal for GDM?
Not commonly done due to inaccuracies w/ pregnancy (increased RBC)
163
What is the fasting plasma glucose levels in DM in pregnancy + GDM?
<95
164
What is the post-prandial glucose levels in DM in pregnancy + GDM?
<140 (1hr)
<180 (2hr)
165
When should an individual monitor their blood glucose once?
Usually when fasting
Well-controlled diabetes w/ rare hypoglycemic episodes
On agents that are not likely to cause hypoglycemia
166
When should an individual monitor their blood glucose multiple times daily?
Recent change in regimen
On agents that are likely to cause hypoglycemia
T1DM
Acute illness
167
Symptoms of hypoglycemia can be masked by what?
Rx like beta blockers
168
When should an eye exam be performed once diagnosed w/ DM?
T1DM = 5 yrs after onset
T2DM = time of diagnosis
Screening time is the same for neuropathy
Screening 1-2 yrs may be considered if there is no evidence of retinopathy and if glycemia is controlled
If retinopathy is present, exam should be performed annually
169
How would you Tx retinopathy?
Optimize glycemic control, BP, and lipids
Refer pt if they have macular edema, nonproliferative diabetic retinopathy
**Presence of retinopathy is not a contraindication to aspirin therapy for CV protection
170
Which Rx are given to initially treat neuropathy?
Pregabalin
Duloxetine
Gabapentin
171
How often should someone with nephropathy be screened?
Once a year for:
T1DM for ≥5 yrs
Anyone w/ T2DM
Twice a year for:
Urinary albumin >30
eGFR <60
172
With someone that has nephropathy, what could you give them to slow the progression?
SGLT2 inhibitors (if eGFR≥30+albumin>30)
In pt with CKD and increased % of CV events, use a GLP-1 agonist
Do not d/c RAAS Rx in the absence of volume depletion
Dietary protein should be 0.8g/kg/day (higher in dialysis)
Nonpregnant pt = give ACE or ARB
ACE/ARB not recommended if they have normal BP, normal albumin to creatine (<30) and normal eGFR
173
What are some HTN goals for someone w/ diabetes?
If they have a ASCVD risk ≥15 = BP goal of <130/80
ASCVD risk of <15 = BP goal of <140/90
Pregnant = ≤135/85
If they have ≥160/100, give 2 Rx or 1 combination Rx
If BP is not met with 3 classes of HTN Rx, consider mineralocorticoid receptor antagonists
174
When should lipids be screened with diabetes?
When not on a statin:
At time of diagnosis of DM
At initial medical evaluation
Every 5 yrs if under 40 years
Obtain lipid prolife at initiation of lipid lowering Rx + at 4-12 wks after or change in dose + annually
175
How should you primarily manage lipids in diabetic pt?
Moderate intensity statin = aged 40 - 75
High intensity = 50 - 75
ASCVD risk of 20%+ = add ezetimibe to maximally tolerated statin to reduce LDL by 50%
176
What are the secondary prevention methods in lipid management for diabetic pt?
Any pt w/ ASCVD risk and at any age = high intensity statins
Statins are contraindicated in pregnancy
In pt with ASCVD and controlled LDL with elevated TG (135 to 499), add icosapent ethyl
177
Antiplatelet therapy and diabetic pt?
Aspirin 75-162mg/day as secondary prevention for ASCVD, may use as primary if you discussed benefits vs bleed risk
If allergic to aspirin, use clopidogrel 75mg/day
Dual low dose aspirin and P2Y12 inhibitor may be used for a year
178
How do you treat a diabetic pt w/ CV disease?
Just ASCVD = ACE or ARB with SGLT2i or GLP1 agonist
If they had prior MI = Beta blocker for at least 2 yrs
T2DM, stable HF = Metformin if eGFR >30
IPT: Endocrine
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