Patho/PCT Exam 7 Diabetes Intro and Insulin PCT

CV, CKD

Adults with DM have a 2-4 fold higher risk for ____ disease and it is the leading cause of ____.

C-peptide and autoantibodies

What can be tested/screened for to test for T1D?

35, 3 years

All adults > ____ years old should be screened for T2D, as well as children overweight or obese + risk factors and pregnant women. How long do you wait to repeat if tests are normal?

Every year

If a person has prediabetes, how often do you retest?

Glucocorticoids, thiazides, HIV medications, atypical antipsychotics, statins

What medications may increase the risk of DM (5)?

5.7-6.4, 100-125, 140-199

Prediabetes diagnostic lab values:

A1c = ____-____%

Fasting plasma glucose = ____-____ mg/dL

Oral glucose tolerance test = ____-____ mg/dL

6.5, 126, 200, 200

Diabetes diagnostic lab values:

A1c >/= ____%

Fasting plasma glucose >/= ____ mg/dL

Oral glucose tolerance test >/= ____ mg/dL

Random plasma glucose >/= ____ mg/dL

Two

Diagnosis of prediabetes or diabetes requires ____ abnormal test results from the same sample or two separate test samples.

T2D, 7, 150, smoking

Prediabetes goal: prevent or delay onset of ____

1. Weight loss - ____% of initial body weight

2. Dietary counseling

3. Physical activity - >/= ____ minutes per week

4. ____ cessation

Metformin

What is the PCT of choice for prediabetes if high risk of T2D?

BP, lipid and glycemic management and agent with CV and kidney benefit

What are the 4 pillar in the multifactorial approach to reduction in risk of diabetes complications?

Lifestyle modification and education

What is the foundation of reduction in diabetes complications?

2, 4

In someone meeting their treatment goals, you assess glycemic status at least ____ times a year. In someone not at goal, you assess glycemic status at least ____ times a year.

3 months

A1c measures the average glycemia over how long?

3, 6

A1c should be checked every ____ months till at goal then every ____ months once at goal.

30, 180

Every 1% change in A1c is a ____ mg/dL change in average daily blood glucose. 8% A1c is ~ ____ mg/dL.

7, 80-130, 180, 70, 4

ADA glucose goals for diabetes:

A1c < ____%

Fasting BG ____-____ mg/dL

2 hour postprandial BG < ____ mg/dL

Time in range (if wearing CGM) > ____%

Time below range (if wearing CGM) < ____%

Nutrition, physical, hypoglycemia, medical

Glucose monitoring is useful to guide medical ____ therapy and ____ activity, prevent ____, and determine ____ management.

Glycemic excursions

Blood glucose monitoring (finger pricks) provides glucose value at a moment in time, so what is it not good at detecting?

Hypoglycemia

What is the most common and limiting factor in the management of DM?

Insulin, sulfonylureas, caloric, alcohol, kidney

Hypoglycemia increased risk with:

Intensive ____ targets

Use of ____

Decreased ____ intake or delayed meals

Exercise

____ comsumption

____ disease and cognitive impairment

70, 54, severe

Level 1 hypoglycemia is a glucose < ____ mg/dL. Level 2 is < ____ mg/dL. Level 3 is a ____ event characterized by altered mental status and/or physical status requiring assistance for treatment.

Seeing, thirst, dry, wound, urination

Signs and sx of hyperglycemia include trouble ____, extreme ____ or hunger, ____ skin, slow ____ healing, and frequent ____.

Sweating, shaking, tachycardia, dizziness, blurred vision, irritable, HA, confusion

What are signs and sx of hypoglycemia (8)?

BB

What drug can mask some of the sx of hypoglycemia?

Check, treat, check, eat

What is the typical hypoglycemia management order?

1/2 cup juice, 5-6 hard candies, 3-4 glucose tabs

In the treat step of hypoglycemia management, you treat with 15 g of sugar which could include what three things?

15 mins, repeat 15 g of sugar

After treating hypoglycemia, how long do you wait to recheck? If BG is still < 70, what do you do?

Complex carbs, protein, slows and prolongs acute glycemic response

After BG rises > 70 during hypoglycemia management, you should eat something with ____ ____ and ____ like crackers with peanut butter. Why not fat?

Glucagon, gel

If a hypoglycemic patient is unresponsive, use ____ or glucose ____.

Mediterranean, sodium, alcohol

Medical nutrition therapy is an important lifestyle modification. Healthy eating habits should be encouraged like ____ eating pattern, limit ____ to <2.3g/day, and limit ____ consumption.

0.5-2

Medical nutrition therapy can reduce A1c by ____-____% in T2DM.

45-60, 15

____-____ grams are recommended for a meal and ____ g are recommended for a snack.

150, 3, 30

Physical activity recommendations:

>/= ____ mins of moderate-vigorous a week over at least ____ days a week.

Interrupt prolonged sitting every ____ minutes.

Glucose-lowering, weight gain, adjuncts

One lifestyle modification is weight management. Should choose ____-____ agent with weight loss capabilities, minimize meds that may cause ____ ____, and consider approved weight loss meds as ____ to diet, physical activity, and behavioral counseling.

130/80, nephropathy

It is important to control BP to control CV risk factors of DM. BP should be < ____/____ mmHg. This will decrease the risk of CVD and ____.

40, statin

It is important to control cholesterol to control CV risk factors of DM. Basically everyone with diabetes and > ____ years old should be on ____ therapy to decrease CVD risk.

Secondary

Antithrombotic therapy (aspirin 75-162 mg/day) can be used for (primary/secondary) prevention in controlling CV risk factors.

70, 55

Age 40 to 75 LDL goal is < ____ mg/dL for primary prevention, but LDL goal < ____ mg/dL for secondary prevention.

Moderate, high

If a 40 to 75 year old patient has no ASCVD risk factors, they can be on a ____-intensity statin. If they have one or more ASCVD risk factors, they should be on a ____-intensity statin.

Influenza, pneumococcal, hep B, 10, 50, RSV, HPV

Vaccines with DM:

____ recommended every year for everyone

____ at diagnosis if not previously received

____ ____ at diagnosis if < 60 years old

Tdap booster every ____ years

Zoster when >/= ____ years old

____ >/= 50 yo at risk OR >/= 75 yo for all

____ if

Monoclonal antibody, pancreatic islets, transplant, 3

Celltrans/Lantidra (donislecel) is a ____ ____ used in the treatment of brittle T1DM. It is a suspension of allogenic ____ ____. It is considered a ____ requiring immunosuppressant therapy. Can receive up to ____ transplants separated by a year.

Pancreatic, transplanted, brittle, insulin

Celltrans/Lantidra (donislecel) MOA - purified ____ cells from deceased donor are ____ into recipient with ____ DM to supplement endogenous insulin and glucagon production to improve glucose control and may eliminate the need for ____ injections.

6.5, hypoglycemia, insulin

Celltrans/Lantidra (donislecel) efficacy outcomes show an A1c < ____% and the absence of severe ____ for 1 year after the last transplant. 67% met efficacy and required no ____ use at 6 years post transplant.

3, 2, 8

Teplizumab-mzwv (T-zield) is a mAb that delays onset of stage ____ T1DM by ____ years. It is used in patients ____ years and older with stage 2 T1DM (presence of 2 or more autoantibodies, impaired glycemic response to glucose load, no overt sx).

Hematological, infection

Teplizumab-mzwv (T-zield) ADE include ____ toxicity, hypersensitivity, and ____ risk. N/V/D, HA, fatigue are common SE.

Acetaminophen, antihistamine, antiemetic, 30, 14

Teplizumab-mzwv (T-zield) is premedicated with what three things for the first 5 days of infusion then prn? It is infused of ____ minutes and the treatment regimen lasts ____ days.

Vaccines, CBC and LFTs

When on teplizumab-mzwv (T-zield), ____ are less effective so they should be completed before treatment. Monitor hypersensitivity rxns as well as what two labs?

Beta, pre-proinsulin, insulin, C peptide

Insulin is produced in ____ cells which make up 75% of the Islet of Langerhans cells of pancreas. Insulin is synthesized as ____-____, a single polypeptide chain. It is then catalyzed by proteases to be ____ + ____ ____.

Animal, hypersensitivity, E. coli

Insulin was initially manufactured from ____ sources (pig and cow), but caused ____ rxns. Insulin is now made from ____ ____ by recombinant DNA technology.

Regular

Which insulin has an identical structure to that of native insulin?

100, ceiling

Insulin has a ____% efficacy and no ____ effect.

Rapid

Lispro (Humalog, Admelog and MerilogR), aspart (Novolog, Fiasp), and glulisine (Apidra) are all ____ acting insulins.

Short

Insulin regular is a ____ acting insulin.

Intermediate

NPH is a ____ acting insulin.

Long

Glargine (Basaglar, Lantus, Toujeo) and degludec (Tresiba) are ____ acting insulin.

Fatty acid, protein, lipoproteins, hydrolysis, amino acids, intra, K+

Insulin MOA:

Liver - stimulates hepatic glycogen and ____ ____ synthesis.

Skeletal muscles - increased synthesis of ____ and glycogen

Adipose - stimulates circulating ____ to provide free fatty acids, TG synthesis/storage, and inhibits ____ of TG

Other - stimulates cellular uptake of ____ ____ and causes an (intra/extra)cellular shift of ____

Edema, erythema, hypoglycemia, hypo, gain, anaphylaxis, hypertrophy

Insulin adverse effects:

CV - peripheral ____

Dermatologic - ____ at injection site

Endocrine/metabolic - ____, (hypo/hyper)kalemia, weight (loss/gain)

Hypersensitivity - ____ could occur

Local - ____/lipoatrophy from repeated injection in same location

TZDs

Insulin + ____ worsens edema and may cause HF exacerbation.

Hepatic, renal, geriatric, pregnancy

Lower insulin dose and frequency of admin. with monitoring is required in ____ and ____ failure, ____ patients (depending on functional abilities, life expectancy, and polyRx), and ____ (DOC cat. B).

Ketones, 250, carbs, no

Hyperglycemia management:

Check urine for ____ (if type 1)

Check BG and call MD if >3 readings above ____ mg/dL

Reduce intake of ____, continue meds, (extra/no) exercise if BG > 250 mg/dL

Finger prick

For acute highs and acute lows, you should look at (CGM/finger prick).

Syringe, pen needles, sensors and transmitter for CGM, alcohol swabs, glucometer, strips, lancets

What supplies will a diabetic patient need?

Strength

It is important to know the ____ and difference with insulins and insulin devices.

Triple, caregiver, demonstration, glucose

Insulin prescribing and education:

1. ____ check strength and dose

2. Educate - promote ____ support for poor vision, elderly, live alone

3. Technique - caregiver and patient should perform return ____

4. Monitoring - when changing insulin, recommend frequent ____ monitoring

Long, central, older, dementia

Patients more likely to experience hypoglycemic unawareness include (short/long) duration of diabetes, (central/peripheral) neuropathy, (younger/older) age, and patients with ____ (unable to recognize or communicate lows).

Sick day, food, more

It is important for everyone on insulin to have a ____ ____ policy/plan. Insulin dose may need to be adjusted based on ____ intake. Monitor glucose (less/more) often.

Glucocorticoids, anti-psychotics, niacin, and phenytoin

What are 4 problematic medications that may induce diabetes?

Natural rise in glucose in the mornings

What is the dawn insulin phenomenon?

A high bedtime dose will cause an early morning low that will cause rebound high in the morning

What is the Somogyi insulin phenomenon?

High, increased

Somogyi is often mistakenly treated as a ____ and the pm insulin dose is (increased/decreased) even more.

When the meal is in front of you, 30-60 mins before

Rapid acting insulin should be taken when in reference to a meal? Short acting?

1 hour, at bedtime

Intermediate (NPH) insulin should be taken up to how long before a meal? When should long acting be taken?

15 mins, 30 mins to an hour

Rapid acting insulin onset is within how long? Short acting?

Evening LA, morning RA/morning LA, morning LA/afternoon RA, evening RA

If a patient has abnormal glucose before breakfast or overnight, which insulin dose would you change? If before morning snack/lunch? Before dinner? Before bedtime?

Inhaled, rapid

What is different about Afrezza insulin? What type of acting insulin is it?

Regular, yes

What is the short acting insulin? Is there an OTC option?

Humulin R U-500

Which insulin product is indicated for patients on > 200 units of insulin per day, typically those with significant insulin resistance?

Needles, green

Humulin U-500 has special ____ with ____ shields.

NPH or Humulin N, 24

What is the intermediate insulin (OTC also available)? Intermediate insulin lasts for up to ____ hours.

Interchangeable, 24

Insulin glargine, basaglar, and semglee are all ____ LA insulins. They last for up to ____ hours and onset of 3-6 hours.

Glargine

Which LA insulin (and its biosimilars) is most commonly prescribed and has no peak?

Degludec, lasts 42 hours

What LA insulin is not a good choice for older patients, especially patients with dementia, long term complications, or polyRx? Why is this?

Different than

Novolin 70/30 is (the same as/different than) Novolog Mix 70/30.

NPH + regular, aspart protamine + aspart

What is in Novolin 70/30? What is in Novolog Mix 70/30? Difference in onset, peak, and duration; can't interchange without talking to doctor

LA insulin and GLP-1 agonist, insulin

Soliqua and Xultophy have what two components? They are dosed based on the ____ component.

Fixed insulin dose

What is the issue with LA insulin + GLP-1 agonist combo products?

Regular insulin 250 u/250 mL NS

What is a standard insulin drip for hospitalized patients?

0.1-0.2 u/kg/day, 1-1.5 u/kg/day

What is the starting dose of insulin in T2D? How high could they go based on insulin resistance?

Safety

Why do we use a standard insulin bag in hospitals?

20

How many units of insulin does a normal body produce per day?

Insulin pumps

What is the most intensive regimen that mimics physiological insulin release?

Carb counting

To use an insulin pump, you must know the insulin basics and ____ ____.

Hardware, rapid

T:slim X2 is the ____ or actual insulin pump. It uses ____ acting insulin.

T2D, tubeless, 72

Omnipod-5 is a simplified approach to an insulin pump and approval was recently expanded to ____. It is an automated, (tubed/tubeless) system integrated with Dexcom G6. It is changed every ____ hours and holds 85-200 units.

Patch, bolus, CGM, rapid

Cequr simplicity is a 3-day insulin ____ for (basal/bolus) dosing. It is not as intuitive and does not go along with a ____. The patch is patient filled with 100-200 u of ____ acting insulin. Uses 20 u to prime new patch.

Tubing, 300, waterproof

Minimed 780G is an insulin pump with extended ____ that can be replaced every 7 days as opposed to every 3 days. The maximum insulin capacity is ____ units per fill (more than others). It is ____ for 12ft up to 24 hours.

Closed loop

Ilet bionic pancreas aid system is a ____ ____ system that does it all.

Basal, bolus

Insulin pump dosing:

1. Start with ____ insulin infusion dose, reduce dose to less than TDD and divide LA units by 24

2. Add regular ____ with meals based on carb counting

They already make insulin but don't utilize it and it causes weight gain

Insulin's place in therapy for T2D is all the way at the bottom (last line). Why is this?