therapeutics exam 3 DM

T1D presentation

• <30 years old

• Abrupt onset

• lean

• Insulin resistance is absent

• Autoantibodies are often present

• syptomatic

• ketones at diagnosis

• immediate need for insulin therapy

• diabetic ketoacidosis

• no microvascular complications at diagnosis

• rare macrovascular complications at diagnosis

• low or no C-peptide level

T2D presentation

• >30 years old

• gradual onset

• obese or hx of obesity

• insulin resistance present

• autoantibodies are rarely present

• asymptomatic

• need for insulin therapy years after diagnosis

• hyperosmolar hyperglycemic state

• microvascular complications at diagnosis are common

• macrovascular complications at diagnosis are common

• normal or high C-peptide level

diagnosis of DM

• A1C ≥6.5%

• fasting glucose ≥126

• 2 hr postload glucose ≥200

tx goals

• normalize glucose metabolism

• reduce mortality

• reduce long-term complications

• initiate management of cardiovascular disease

glycemic goals of therapy

• pre-prandial glucose → 80-130

• postprandial glucose → <180

• A1C <7%

A1C

• Reflects average blood sugar for the last 3 months

• stable pt

  • 2x yearly

• Pt not meeting goals or change in therapy

  • Every 3 months

urine test

• glucose= not recommended

• ketones = T1D

GLP-1 agonist drugs

liraglutide→ MACE

dulaglutide→ MACE

semaglutide→ MACE

orforglipron

GLP-1 agonist MOA

• enhance insulin release from pancreatic B cells

• suppress inappropriate elevated glucagon secretion

• prolong gastric emptying times

• increase satiety

GLP-1 agonist affect on A1C

lowers it and is additive with other drugs

GLP-1 agonist when is it a 1st line

establish ASCVD or high for for ASCVD and/or CKD

semaglutide and DKD

slowing progression

GLP-1 agonist contraindicated

MEN- 2

GLP-1 agonist weight loss

• semaglutide= very high recomendation

• dulaglutide = high recommendation

should GLP-1 agonist be combined with DPP-4 inhibitors

no

guideline for GLP-1 agonist

• established ASCVD (>7.5%) or established CKD

• establish ASCVC or multiple risk factors

• CKD

GIP and GLP-1 agonist drugs

tirzepatide → MACE

GIP and GLP-1 agonist MOA

GIP

• Decreased insulin resistance

GLP1

• Same MOA as above

Decreases A1C and increases weight loss more than just GLP-1 (25 lbs)

Very high recommendation for weight loss

GIP and GLP-1 agonist major effect

post prandial glucose level

SGLT2 inhibitors drugs

• canagliflozin→ MACE

• dapagliflozin

• empagliflozin→ MACE

• ertugliflozin

• bexagliflozin

SGLT2 inhibitors MOA

increased urinary excretion of glucose

SGLT2 inhibitors 1st line in what

when pt had heart failure (HFrEF) or

CKD (eGFR 30-60) or

UACR >30

pt with T2D and DKD

SGLT2 is recommend to reduce CKD disease and cardiovascular event

SGLT2 inhibitors contraindicated in

end stage renal disease

SGLT2 inhibitors major ADR

• hyperkalemia

• genital fungal infection

• necrotizing fascitits of the perineum

• DKA

metformin MOA

• decrease hepatic glucose production

• decreases intestinal absorption of glucose

• decreases insulin resistance

does metformin cause hypoglycemia

no not by itself

what glucose levels does metformin improve

fasting and post prandial

do pt with eGFR >45 require renal adjustments

no but renal function should me monitored years

is metformin recommended in pt with eGFR 30-45

no but if it falls during therapy reduce dose by 50%

pt counseling for metformin

take with food

metformin BBW

lactic acidosis

Iodinated contrast dyes and surgery may cause decreased renal function; do not administer prior to or 48 hrs after contrast

advantages of metformin

• no hypoglycemia

• no weight gain

• ER formula

DPP-4 drugs

• Sitagliptin

• saxagliptin

• linagliptin

• alogliptin

DPP4 MOA

• prevents DP4 mediated breakdown of incretins

what is DPP4 major effect on

post prandial glucose levels

can DPP4 be combined with GLP1

no

Sulfonylureas MOA

stimulate release of insulin from functional pancreatic beta cells

sulfonylurea major effect

fasting blood glucose

what are sulfonylureas contraindicated in

ketoacidosis

sulfonylurea AE

hypoglycemia

• if you skip meals, or exercise vigorously

sulfonylurea drugs

• glipizide

• glyburide

• glimepride

TZD MOA

• decrease insulin resistance

• decease hepatic glucose output

how long does it take to see effect from TZD

6-12 weeks

TZD contraindications

pt with NYHA class 3 or 4 heart failure

TZD AE

• edema

• weight gain

• bladder cancer increase risk of fractures

TZD drugs

pioglitazone

meglitinides MOA

• stimulates release of insulin from functioning pancreatic beta cells

• Lowers postprandial glucose

how to take meglitinides

15-20 min prior to meal

meglitinides contraindication

diabetic ketoacidosis

meglitinides AE

hypoglycemia

meglitinides drugs

• repaglinide

• nateglinide

alpha glucosidase inhibitors MOA

inhibit absorption of glucose from intestine

alpha glucosidase inhibitors who is it good for

pt with near normal fasting blood glucose but postprandial hyperglycemia

alpha glucosidase inhibitors AE

• flatulence

• diarrhea

alpha glucosidase inhibitors contraindicated

• IBS

• cirrhosis

alpha glucosidase inhibitors what to use to reverse hypoglycemia

• not complex carbs

• cane sugar

alpha glucosidase inhibitors drugs

• acarbose

• miglitol

where can insulin be injected

• abdomen

• upper arm

• buttocks

• thigh

rate of insulin absorption in different spots order

abdomen>arm>buttocks>thigh

what is used in insulin pumps

rapid acting insulin

basal rate of insulin pumps

0.5-1 unit/hr

bolus dosing insulin pump

calculates bolus dose based on carb load of meal

fasting hyperglycemia

secondary to hypoglycemic event (2-3 am)

confirmed by taking BG at 3 am

fasting hyperglycemia tx

decrease LA insulin

decrease evening NPH

eat bedtime meal or snack

T1 pt initial doing for insulin

0.5-1 unit/kg/day

T2 pt initial doing for insulin

initial dosing is based in weight

0.5-1 unit/kg/day

glargine dosing

10-20units daily

degludec dosing

10 units daily

insulin icodec dosing

staring 70 units once weeks

• switching → 1.5x previous for 1 weeks then back to normal

NPH to glargine

controlled= decrease NPH by 20%

uncontrolled= 1:1

NPH to degludec

1:1

insulin sensitivity factor (ISF) if pt have high degree of insulin resistance

lower (more insulin needed)

insulin sensitivity factor (ISF) if pt have low degree of insulin resistance

higher (less insulin needed)

high degree of insulin resistance= ___ carb ratio

low (more insulin)

low degree of insulin resistance= ___ carb ratio

high (less insulin)

correction dose formula

(measured preprandial BG- goal BG)/ ISF

bolus dose formula

g of carbs eaten/ carb ratio

how to calculate total mealtime dose

add bolus dose to correction dose

level 1 glucose level

<70 and ≥54

level 2 glucose level

<54

level 3 glucose level

severe event with altered mental status

hypoglycemia sx

• dizziness

• tremor

• sweating

• HA

hypoglycemia tx

rule of 15

• 15g carb

• recheck BG in 15 min

• if <70 repeat 15g carb

retinopathy

• T1 should be evaluated with 5 years

• T2 should be evaluated right away

• annual eye exams

diabetic kidney disease

• optimize glucose and BP control

• UACR ≤ 30 is normal

• UACR > 30 is microalbuminuria

• UACR > 300 albuminuria

• TX

  • T2→ SGLT2

  • ACE-I or ARB should be used except during pregnancy or if they dont have high BP

peripheral neuropathy

• slow and gradual

• drugs

  • pregabalin

  • gabapentin

  • duloxetine

  • tapentadol

autonomic neuropathy

• Delayed, caused by delayed emptying

• Stop GLP-1 or anticholinergics

• start metoclopramide or erythromycin

foot care

• daily exam of feet

• early comprehensive foot exam

macrovascular disease

• Metabolic injury to large blood vessels

• ASCVD

• cerebrovascular disease

• peripheral vascular disease

what BP to aim for

< 130/80

lipid management

primary prevention

• moderate intensity stain

• high intensity statin for ASCD risk (>7.5)

secondary prevention

• high intensity statin

aspirin therpy

T1&2 w/ a hx of ASCVD

or for prevention