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for a therapeutic approach to type 1 DM, what is a primary need?
insulin
what is an adjunct therapy for type 1 diabetes?
amylin analog
what is allo-transplantation?
what type of DM normally gets this?
islets from the pancreas of a deceased organ donor are purified, processed, and transferred into another person, usually someone with type 1 DM
islet cells transferred into the liver; infused into the portal vein, become resident in hepatic sinusoids
when a person is undergoing islet cell transplantation, what is a precaution they must do in order to avoid rejection?
take immunosuppressive drugs
when does auto-transplantation occur?
after total pancreatectomy in patients (who don’t have type 1 DM) with severe chronic pancreatitis that cannot be managed by other treatments
what is the therapeutic approach for type 2 DM, what two things does it manage??
management of DM
management of co-morbidities
what is the first line pharmalogical treatment for type 2 DM?
metformin
what are secretagogues?
medications that increase insulin secretion
what increases the risk of hypoglycemia when taking diabetes medications?
taking multiple diabetes medications
what is the mechanism of action of insulin?
initiates glucose uptake into cells that are insulin-dependent
what is the mechanism of action for amylin analogs?
slows gastric emptying, suppresses glucagon secretion, promotes satiety
what hormone is typically co-secreted with insulin?
amylin
what is the mechanism of GLP-1 receptor agonists (incretin GLP-1 mimetics)? x 4 things
promotes glucose-dependent insulin secretion
inhibits post-prandial glucagon release
slows gastric emptying
suppresses appetite
what is the mechanism of combo GIP and GLP-1 receptor agonists?
effects are similar to GLP-1 receptor agonists, but act like both endogenous GIP and GLP-1
what is the mechanism of biguanides?
increase sensitivity of insulin receptors, decrease liver gluconeogenesis
what is the mechanism of sulfonylureas?
stimulate insulin release (secretagogue)
what is the mechanism of meglitinides?
stimulate insulin release (secretagogue)
what is the mechanism of a-glucosidase inhibitor?
inhibit enzymes at GI brush border, this inhibits absorption of ingested carbohydrates
what is the mechanism of thiazolidinediones (TZDs)?
insulin sensitizers
what is the mechanism of DPP-4 inhibitors?
slow incretin inactivation by DPP-4 enzyme, then stimulates glucose-dependent insulin release and inhibits post-prandial glucagon release
what is the mechanism of SGLT2 inhibitors
reduce the reabsorption of glucose by the kidnesy
what is the mechanism of oral GLP-1 receptor agonists?
promote glucose-dependents insulin secretion
inhibits post-prandial release of glucagon,
slows gastric emptying
suppresses appetite
what can lipohypertrophy result in ?
unpredictable insulin absorption rates if the site continues to be used for insulin injection
what can lipoatrophy result in?
unpredictable insulin absorption rates if site continues to be used for insulin injection
when does lipohypertrophy occur?
what is the technical description for it?
when a person w DM injects insulin into the same spot over and over
buildup of fat due to lipogenic properties of insulin
what does lipohypertrophy look like?
a lump in the skin
what does lipoatrophy lead to?
leads to decreased subcutaneous fat in the area of injection
what are 2 dangers of hypoglycemia?
syncope, can be fatal
hypoglycemic levels ______ from person to person.
vary
how many times more concentrated is U-500 insulin than U-100 insulin?
5 TIMES MORE CONCENTRATED
how many units per mL are there in a U-100 bottle of insulin?
what size bottle does U-100 insulin normally come in?
100 units per mL
10 mL bottles
how many units per mL are there in U-500 bottle of insulin?
what size bottle do U-500 insulin come in?
500 units of insulin per mL
20 mL bottles
what is U-500 insulin typically used for ?
about how much insulin per day would this person take?
people requiring large doses of insulin
200 units/day or more
U-500 insulin has what fraction liquid volume of U-100 insulin?
1/5th
do all insulin pens inject the same dose?
no
what color are U-500 syringes?
what color are U-100 syringes?
green
orange
TRUE OR FALE:
insulin pens should not be used for more than one patients
TRUE
what are three examples of RAPID-ACTING insulin?
aspart
lispro
glulisine
what is an example of SHORT-ACTING insulin?
regular/human
what are 2 examples of INTERMEDIATE-ACTING insulin?
NPH
detemir (lower doses)
what are 2 examples of LONG-ACTING insulins?
What is one examples of ultra-long acting insulin?
glargine, detemir (higher doses)
degludec
at 0.2 units/kg, what is the duration of detemir?
12 hours
at 0.4 units/kg, what is the duration of detemir?
20-24 hours
what route should insulin be administered through ??
subQ
what types of insulin can be administered IV?
short-acting (regular) and all rapid acting
what is the only type of intermediate and long-acting insulins that can be mixed in the same syringe with rapid/short-acting insulins?
ONLY NPH
what does injection of insulin IM result in?
much more rapid absorption of insulin
where should we avoid injecting insulin?
why is this?
directly around the navel
absorption can be erratic and unpredictable
when choosing an insulin injection site, we should rotate these sites in order to avoid ……
lipohypertrophy and lipoatrophy
what are 6 reasons to increase insulin dose?
increased calories, obesity, adolescent growth spurt
infection, stress, 2nd trimester pregnancy
what are 3 reasons for decreasing insulin dose?
exercise (generally speaking)
1st trimester, immediately post-partum
how many times should blood glucose be monitored in a day?
what if the BG is very uncontrolled?
2-5 times
more frequently
what does the basal/bolus method of insulin therapy do?
attempts to mimic the natural insulin secretion rhythms of the pancreas
what is the definition of basal insulin therapy
the steady, low level of insulin constantly secreted by the pancreas
what is the definition of bolus insulin therapy
the spikes in insulin secretion stimulated by glucose ingestion, especially at meals
what does a normal pancreas’ insulin secretion look like?
basal secretion at low level, and bolus when there is a meal
when is basal insulin injected
bedtime
when is basal insulin also known as?
what does bolus insulin require the person to count?
nutritional insulin
carbs
when is correction insulin often given and why?
mealtimes to account for the actual blood glucose reading prior to the meal
while type 1 diabetics are inpatient, they might require a ______ dose of insulin, compared to what they generally take?
higher dose
a person with type 2 DM who aren’t insulin dependent might need what while in the hospital?
insulin dose
what does illness promote increase circulation of that would cause someone to need insulin? x 2 things
circulating glucose and free fatty acids
what kind of insulin does a correction dose use?
what is a typical correction dose?
rapid or short acting
1-3 units for each 50 mg/dL over 150 mg/dL, based on their insulin sensitivity
are sliding scale insulin regimines recommended for inpatient hospital settings?
no, strongly discouraged
what is an example of a closed-loop system of glucose monitoring?
how do they do this?
minimed
use data from CGM, use an algorithm to automatically adjust basal insulin
what is the somogyi effect of insulin therapy?
undetected hypoglycemia followed by rebound hyperglycemia in AM
what is the process of somogyi effect of insulin therapy?
low 1-3 am blood glucose, may be 2/2 PM intermediate (NPH) dose peak
inc. glucose production in liver activated by counter-insulin hormones with AM hyperglycemia
how to diagnose somogyi effect of insulin therapy?
confirm with 3 am Blood glucose
would expect to see hypoglycemia if effect is happening
what is the dawn phenomenon of insulin therapy?
what is the result of this?
rise in BG between 2-8 am 2/2 riske in counter-insulin hormones that are normally release, even by people without DM
patient is hyperglycemic in AM
what is required to be done for diagnosis of Dawn Phenomenon of insulin therapy
check BG at 3 am
if hyperglycemia at 3 am, Dawn Phenomenon is more likely
if you check a patient’s blood glucose at 3 am and it is euglycemic, what is necessary to be done?
more detective work
BG checks at different times needed
TRUE OR FALSE
insulin and monitoring supplies are expensive
true
unopened vials/pens of insulin should be stored where?
refridgerator
never freeze
how long is room temperature storage of insulin that is already open?
1 month
what should we always check before injecting insulin?
blood glucose level
when a patient is sick, what should they continue to be diligent about monitoring and using?
blood glucose
using insulin
metformin is considered for prevention of progression from prediabetes to type 2 dm in people with what characteristics?
25-59 yr olds w BMI >35
higher fasting plasma glucose
higher A1c
those with prior gestational DM
prior and after radiologic procedures with IV dye, what should be done with metformin administration?
why do we do this?
d/c 48 hrs prior and after IV dye
to give time to assess post-procedure renal function
if the patient develops contrast dye-induced nephropathy, metformin would cause what to happen?
what does this condition have?
metformin accumulates and could cause lactic acidosis
high fatality rate
what are 4 risk factors for lactic acidosis?
severe kidney disease
severe liver disease
alcohol use disorder
heart failure
what is the general rule regarding lactic acidosis?
what population of patients is this important for ?
make sure patients are urinating normally after a procedure involving iodinated contrast dye
important for patients with CKD and other risk factors
what is the mechanism of glipizide?
does it require glucose to work?
blocks ATP-sensitive potassium channels, stimulates insulin release
no
what does the ADA recommend as the preferred pharma agent to treat DM during pregnancy?
insulin
what are the 2 types of secretagogues?
what do they do?
sulfonylureas and meglitinides
they stimulate insulin regardless of food intake
when should you take secretagogues?
30 min before or with meals
if a patient is N/V/A, what should they do regarding their secretagogue dose ?
what should they do during this time?
skip it until able to eat again
monitor BG closely, call the prescriber if BG goes high and remains high
if a patient is NPO, vomiting, or unable to eat, what should we do regarding administration of secretagogues?
hold these medications
what do incretin hormones found in the gut (such as GLP-1) normally increase?
insulin synthesis and release, and also inhibit glucagon
what does the DPP-4 enzyme normally do to incretins?
inactivate them
what is the mechanism of action of sitagliptin?
what does this do in the body?
inhibits DPP-4 enzyme and prevents inactivation of endogenous incretins
this increases and prolongs action of incretins, increases insulin and decreases post-prandial glucagon
with the drug sitagliptin, why is the risk of hypoglycemia low when used alone?
the drug extends the action of incretins, which require the presence of glucose to increase insulin secretion
when the SGLT2 receptor is blocked, what happens to the glucose in the body?
glucose is excreted in urine rather than returned to circulation
what drug blocks SGLT2 receptors
dapagliflozin
in patients with type 2 dm who need medication to intensify glycemic control, what class of medication is recommended to try first and why?
GLP-1 receptor agonis
lower risk of hypoglycemia than insulin
what does endogenous GLP-1 do in the pancreas? x 2 things
promotes glucose-dependent insulin secretion
inhibits glucagon secretion
how does endogenous GIP work in the pancreas? x 1 thing
promotes glucose-dependent insulin secretion
what are the two incretins in the body?
GIP and GLP-1