Diabetes - Readings

What is the leading cause of adult-onset blindness?

Diabetes

Target blood pressure for people with diabetes

<130/80 mmHg

What is the requirement for CKD diagnosis?

eGFR <60 and/or random urine ACR 2.0 or more on at least 2 of 3 samples over a 3-month period

What medication should be added for adults with type 2 diabetes and CKD with eGFR >30?

An SGLT2 inhibitor (cana, dapa, empa) - reduces risk of progression of nephropathy

What can be used alone or in combination for symptomatic relief of peripheral neuropathic pain?

• Anticonvulsants (gabapentin, pregabalin, valproate)

• Antidepressants (amitriptyline, duloxetine, venlafaxine)

When can ASA be used in people with diabetes?

If patient has additional cardiovascular risk factors (not used for primary prevention for diabetes)

Which beta blocker has been shown to specifically improve glycemic control?

Carvedilol

What is first line therapy for glycemic control in patients who also have HF?

Metformin

Which antihyperglycemic agents are contraindicated in HF?

Thiazolidinediones (pioglitazone and rosiglitazone)

• Due to side effect of fluid retention

True or false. DPP-4 inhibitors are all safe to use in cardiovascular disease.

True

(but use caution with saxagliptin with hx of HF)

Which antihyperglycemic agents have shown benefit for HFrEF and eGFR >30?

SGLT2 inhibitors - reduce risk of hospitalization for HF or cardiovascular death

Starting dose of metformin

250-500mg BID (gradually increase to target of 2000mg daily)

Who cannot use metformin?

• hx of lactic acidosis

• eGFR <15

• severe hepatic dysfunction

Which has shown to have fewer side effects:

1. Starting with monotherapy at max doses

2. Starting with multiple agents at submaximal doses

2. Multiple agents at submaximal doses

When should maximum effect of non-insulin antihyperglycemic agent monotherapy be expected?

Within 3-6 months

When are GLP1ras and GIPras contraindicated?

With personal or family hx of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2

Which diabetic therapy has the highest risk of hypoglycemia?

Insulin (followed by secretagogues like sulfonylureas and meglitinides)

What is the maximum dose of insulin?

There isn’t one

Does gliclazide and glyburide cause weight loss or gain?

Weight gain

Which specific medication increases risk of fractures and lower extremity amputations?

Canagliflozin

Which antihyperglycemic medication class has a rare risk of euglycemic diabetic ketoacidosis?

SGLT2i

Which antihyperglycemic medication class has a risk of genital mycotic infections?

SGLT2i

Which antihyperglycemic agents should not be used with bladder cancer?

Dapagliflozin and pioglitazone

Which medication has controversy regarding MI risk?

Rosiglitazone

True or false. Incretin agents and SGLT2i are safe in pregnancy.

False - safety is unknown so should be avoided or stopped

True or false. All SGLT2i reduce risk of major adverse CV events (MACE) in high risk patients.

False - only canagliflozin and empagliflozin

Which 2 SGLT2i have shown cardiorenal benefits for HFrEF or HFpEF?

Dapagliflozin and empagliflozin

True or false. All SGLT2i reduce risk of adverse outcomes in patients with CKD.

True

Which medications should be stopped if insulin is started?

Sulfonylureas and meglitinides (insulin secretagogues)

Which is associated with lower rates of hypoglycemia?

• insulin degludec

• insulin glargine U-100

Insulin degludec

Which medications should be started when someone is started on insulin?

An incretin and/or SGLT2i

What does MODY stand for?

Maturity-onset diabetes of the young (AKA type 5 diabetes)

Examples of drugs that can cause dysglycemia

• beta blockers

• corticosteroids

• statins

• protease inhibitors (e.g., ritonavir)

• 2nd gen antipsychotics (clozapine, olanzapine, etc.)

• Thiazide or loop diuretics

If autoantibodies for beta cells are present in someone, are they guaranteed to develop type 1 DM?

No, presence does not guarantee that diabetes will occur

How often should Type 2 DM be screened for?

Every 3 years for those >40 yrs or those determined to be high risk via CANRISK score

During the honeymoon phase, how often should insulin therapy by adjusted?

Every 2-3 days according to BG readings

Why do short-acting GLP1As need to be administered with meals?

They work primarily on postprandial glucose

How often is liraglutide administered?

Once daily

How is oral semaglutide administered?

Daily on an empty stomach upon waking, with minimal water, and nothing else for 30 minutes

Which sulfonylurea is associated with higher risk of hypos than other 2nd gens

Glyburide (especially in elderly or renal impairment)

Can sulfonylureas be used as monotherapy?

Yes - if metformin is contraindicated

Are SGLT2i associated with weight gain or weight loss?

Weight loss

Are thiazolidinediones associated with weight gain or weight loss?

Weight gain

In which situations is it appropriate to use insulin therapy for T2DM?

• maxed out non-insulin agents

• end-organ damage so can’t use some other agents

• if A1c is 1.5% or more above target at diagnosis

• with metabolic decompensation

• in pregnancy and in patients planning to become pregnant

Why do patients with T2DM usually required insulin doses higher than 1 unit/kg?

To overcome their significant insulin resistance

(these high doses increase risk of AEs)

Why is metformin usually continued along with insulin in T2DM?

Due to metformin’s ability to:

• lower insulin requirements

• ameliorate weight gain

• reduce risk of hypoglycemia

When would a basal-bolus regimen be started at diagnosis of T2DM?

If glycemic values are extremely high

If initiating basal-bolus therapy for T2DM, how are doses calculated?

TDD = 0.5 units/kg

Basal = 40% of TDD

Bolus = 20% of TDD

What is a risk associated with children born to patients with diabetes?

Increased risk of developing diabetes in the future

What has a higher risk for a fetus, hypo or hyperglycemia?

Hyperglycemia

What can accelerate retinopathy resulting from poor glycemix control?

Pregnancy

Which diabetes medications can be continued during pregancy?

• insulin

• metformin

• glyburide

Which diabetes medications should be stopped during pregnancy?

• SGLT2i

• DPP-IV

• GLP1ra

What should be started in pregnant patients with pre-existing diabetes?

ASA 81mg daily should be started at 12-16 weeks' gestation

What are the recommended glycemic targets in pregnancy?

• FPG = <5.3

• 1 hr PPG = <7.8

• 2 hr PPG = <6.7

Why are patients with diabetes encouraged to breasfeed?

To reduce the risk of childhood obesity

How quickly can GDM resolve after giving birth?

Within 24 hrs

Which electrolytes are usually depleted with presentation of DKA?

• sodium

• potassium

• chloride

• water

Is serum potassium increased or decreased in DKA?

Increased (even tho overall body depletion)

(because lack of insulin means potassium can’t enter cells)

What is associated with DKA?

• severe or stressful illness

• surgery

• trauma

• MI

• use of SGLT2i in patients who were previously stable

General management of DKA

• fluids

• potassium

• insulin

• bicarbonate

• lab tests

• supportive care

Why can false negatives occur with ketostix?

Don’t detect hydroxybutyrate (only acetoacetate)