what is the pathologic issue behind type 1 DM?
- B-cell destruction with lack of insulin.
what is the pathologic issue behind type II DM?
insuline resitance with insuline deficiency.
what are some of the causes of elevations or decreases in blood glucose maintainance
Genetic defects in B-cell function, exocrine pancreas diseases, endocrinopathies, and drug induced
what is the patholoogy involved in gestational DM?
insuline resitance with B-cell dysfunction
when does type I DM occur?
usually in children and young adults but can occur at any age
what cells are affected by DM type I
B-cells, the only cells that produce the hormone insuline
do people with type I have to take insuline?
what is a normal fasting glucose? (FPG)
what is normal 2-hr plasma glucose (PG) durning OGTT?
IFG (impaired fasting glucose) equals what?
>110 and < 126 on a fasting blood glucose
a 2 hour plasma glucose (FP) on Oral Glucose Tolerance testing (OGTT) comes back between 140 and 200 what does this suggest?
Impaired glucose Tolerance (IGT)
a 2 hour plasma glucose (FP) on oral glucose Tolerance test (OGTT) is greater than 200 what does this suggest?
what are the plasma glucose cutoff numbers for DM?
(do not confuse with imparired glucose numbers)
- (fasting plasma glucose) FPG of >/=126
- or a 2-hr plasma glucose during OGTT of >/=200
what are the major complications of DM? therefore you should be monitoring these things during exams!
heart disease, strok, blindness, renal failure, vascular disease/amputations.
diabetis complications include 3 major areas what are they
- microvascular: capillary and arteriole dysfunciton:retinopathy, nephropathy, neuropathy
- macrovascular; atherosclerosis CHD, amputations
- neuropathic: neuropathy lack of adequate blood supply to nerves so a little of both leads to pain
what diabetic syndrome is this?
elvated LDL & Triglycerides and low HDL
- metabolic syndrome
- may also find acanthosis with this pre-diabetic state.
when evaluating clients, what signifies "the deadly quartet"?
- insuline resistance
- elevated triglycerides
- central obesity
what is DM an independent risk factor for?
Clinet has FPG >110 but <126,
triglyceride >200 (H),
LDL >139 (Borderline high)
and HDL <40 (L)
what syndrome is this?
Random plasma glucose is >/=200 on 2 sperate occasions can you dx this as DM?
not with out sx (3 poly's) or additon testing.
FPG is >/=126 on 2 sepreate occtions can you dx this as DM
yes, but I would gather addition information to assist with management.
what are the 3 methods for diagonis of diabetes?
- criteria must be met on 2 seperate occasions:
- random plasma glucose >/= 200 + 3 polys
- FPG >/=126
- 2-hr plasma glucose >/=200 during OGTT
what are the 3 catagories of dyslipidemia medications:
- others: ASA, Niacin, Plavix, WelChol, Zetia, Omega-3 fatty acids, folic acid
atorvastatin, simvastatin, pravastatin are what kind of drugs
name some statins
what is an HMG-CoA reductase inhibitor?
what med treats primary hypercholesterolemia (elevated LDL is the primary lipid elevation with minor elevations in triglycerides)
- Lipitor is number one with least side effects and most supportive data
what are fibric acid derivatives indicated for?
gemfibrozil (Lopid) and fenofibrate (TriCor).
- reducing CHD risk in patients without a hx of CHD
- who have low HDL and elevated triglycerides.
- Consider this medications for adults with marked hypertriglyceridemia who are at risk of pancreatitis and who have not responded adeqately to dietary therapy.
patient is on cholestryramine (Questran) or WelChol what kind of medicaton is he on and why?
- these are bile acid sequestrants
- used as adjunctive therapy to diet
- for reducing LDL in patients with primary hypercholesterolemia.
- these meds cause bloating nausea and constipation generally not well tolerated, assess for compliance and side effects.
which anti-hyperlipidemic Agent is recommended for all forms of elevated total cholesterol or triglycerides?
Selective cholesterol absorption inhibitors, like exetimibe (Zetia) can be used alone or in combination with statins to chieve control of what levels in primary hypercholesterolemia?
- elevated total cholesterol
- elevated LDL
- and elevated apolipoprotein B (protien found in LDL)
what can you use to combat very high triglyceride levels in adults?
Omega-3 polyunsaturated fatty acids! (they are OTC)
which anti-hypertensives are renal protective?
- Ca channel blockers
give examples of peripheral neuropathies associated with DM (complications of)
- sensory deficits
- muscular weakness
Give examples of autonomic neropathic complications
- diabetic diarrhea
- neurogenic bladder
- male impotence
- impaired CV reflexes
Name some medication options for treating neuropathy
- Topical Lidoderm patch
- Topical cheyennne pepper
- referal to chronic pain clinic
treatment of patients with elevatred LDL cholesterol and no prior history of CHD is consider primary secondary or tertiary prevention?
Treatment (with anti-hyperlipidemia medications) of patients with elevated LDL cholesterol and CHD is considered primary, secondary or teritiary prevention?
what are the two major concerns with statins? what side effects should patients report immediately to the prescriber? what labs should be ordered if these side effects are reported?
- 2 major concerns are musclse toxicity and hpatotxicity
- report muscle weakness or pain or brown urine
- tests to check liver fx AST/ALT and CK-MM
fibric acid derivatives like fenofibrate and gemfibrozil are hightly effective in decreasing triglycerides and increasing HDL. But are they effective for lowering LDL?
- nope, and they may actually increase LDL. side effects include hepatotoxicity and cholelithiasis.
- they can also lower uric acid levels.
- when combined with a statin they can lower risk of developing peripheral neuropathy in DM!
what are the peripheral and automomic complications associated with DM?
- peripheral+parastheia/pain sensory deficiets
- autonomic=gastroparesis/diabetic diarrhea, neurogenic bladder
what meds are for neuropathy. neuronitin and what else
Lyrica, Cymbala, Elavil, topical Lidocain or cheyenne pepper.
what are the ED drugs?
Viagra, Levitra, Cialis
which is present or absent with type I
mode of onset: acute
- mode of onset: acute
- acanthosis: abscent
- DKA: present
- Insuline reserve: absent
- Auto antibodies: present
which is present or absent with type II DM
mode of onset: insidious
- mode of onset: insidious
- acanthosis: present
- DKA: absent
- Insuline reserve: present
- Auto antibodies: absent
screening recommendations for DM in the average joe
every 3 years starting at age 45
what is this the definition of?
inability of insluine to lower plasma BG through suppression of hepatic glucose production and stimulation of glucose utilzation in skeletal muscle and adipose tisse.
what are the acquired causes of insuline resistance?
- increased levels of free fatty acids
- effects of certain medications
can you name 3 clinical predictors of insuline resistance (there are 7)
- elevated triglycerides
- low HDL
- Glucose intolerance
insuline reistance with nromal B-cell function is when what occurs?
reduction in insuline sensitivity and the pancreas increases insuline production of crappy insuline
insuline resistance that occurs with impaired B-cell function occurs when what happens?
pacrease is unable to compensate for intake and person can become hyperglycemic
so what is pre-diabetes?
- IFG 100-125
- IGT 2 hr OGTT 140-199
Name 4 risk factors that predict future type II onset for patients
- Elevated FBG >120
- develops GDM before week 20 of gestation
- needs insuline during pregnancy
true or false
people with pre-diabetes can prevent or delay the onset of type II through lifestyle change and/or medication?
true, but no medication is approved for diabetes prevention.
what A1c is pre-diabetes?
A1c is 5.7-6.4
is it inevitable that someone who is pre-diabetes will progress to become diabetic?
what are the management goals of Type 2 diabetes?
- normalize metobolic parameters
- plama glucose,
- LDL,HDL, Triglycerides
- prevent complications
what are the treatment goals of Type 2 ?
- improve B-cell response and decrease insule resistance through
- diet and exercise
- oral hypoglcemic agents/insuline if needed
a series of moderat, maintained changes make a differnce in the successful management of DM. Follow dietary guidelines: increase whole grains, eat more vegies and decreaee what kind of fat?
how much fiber should you get in a 24 hour period?
how much fat is recommendated per day?
How much protien is recommended per day?
10-20% of cal/day
so with exercise does it have to be prolonged?
nope all movement counts and is beneficial
how much exercise is recommended?
- 150 min/week
- 20-60 min every other day
- don't forget to check your BG! it may be going down!
what are the glycemic control goals? where to you want them to be on successful therapy or lifestyle modifications?
(fasting, bedtime and HbA1c)
- fasting goal 80-120
- >140 change tx
- bedtime goal 100-140
- >160 change tx
- HbA1c goal <7
- >8 change tx
what are the pharmacologic steps for glucose control?
- one drug
- two or more drugs
- insuline and oral drugs
- insuline alone
at dx= lifestyle change + metformin step 1
step 2 Lifestyle change + metformin + ?
lifestyle +metoformin + sulfonurea (glyburide,glipizide)
name the a-glucosidase inhibitors
name the Thiazolidinediones
Avandia & Actos
What are the Biuanides (names)
- Glucophae XR, Riomet
Name the Meglitinides AKA Glinide.
Prandin & Starlix
Name the zillion Sulfonylurea's
DPP-4 name these (there are only 3 DDPP-4's, go figure :)
What is the Pramlintide/amylin analog?
What is the Dopamine agonist
What is the Bile Acid Sequesterant?
the Biuanides GlucophageXR, Riomet
Metformin, Fortamet and Glumetza have what common side effects?
diarrhea, nausea, abd cramping start low and progress to full dose. can be given qd or tid.
how do the Biuanides work?
(Metformin,. GlucophageXR, Fortamet Glumetza & Riomet)
decrease hepatic glucose production
how do the suflonylureas work?
stimulate insuline secretion
Can you name the sulfonylureas 1st generation?
- Orinase (tolbutamide)
- Tolinase (tolazamide)
- Diabinese (chlorpropamide)
What are the 2nd generation Sulfonylureas?
- Glucotrol (glipizide)
- GlucotrolXL (extended-release glipizide)
- Micronase, Diabeta (glyburide)
- Glynase (micronize3d glyburide)
- Amaryl (glimepiride)
TZDs (Thiazoliinediones) depend on isuline and what else?
resitance to the action of insuline
TZDs (Thiazoliinediones) have what side effects?
what are thiazolidinediones TZD's (only 2 of them)
- avandia (rosiglitazone)
- Actos (pioglitazone)
Glinides like prandix and Starlix require the presence of insule to work, what is theri mechanism of action?
Increase first phase of insulne release
can the glinides or meglitinides starlix and prandix cause hypolgycemia?
the a-Glucosidase inhibitors precose & glycet, delay carb absorption and depend on what to work?
post prandial hyperglycemia
glycet (myglitol) & prcarbose (acarbose) are a-glucosidase inhibitors and work for how long?
how do the DPP-4 Inhibitors work?
junavia, onglyza, trajenta
- increase insuline synthesis,
- decrease glucogon
- inhibits DPP-R enzyme
Incretin Mimetic/GLP-1's like, Byetta, Gydureon and Victoza work how?
increase insuline synthesis decrease glucagon and slows gastric emptying
Symlin is an Amylin Agonist and can cause hypoglycemia. it is an injection 60 &120mg how does it work?
- increases satiety
- decreases postprandial glucagon and slows gastric emptying.
what is the negative side efect of welchol? (bile acid sequestrant)
can increase triglycerides
the oral combo meds are motstly something and what?
combo oral agent avandamet is what
avandia + metformin
combo oral agent Glucovance is what
Glyburide + metformin
combo oral agent Metaglip is what
Glipizide + medformin
combo oral agent Janumetis what
Januvia + metformin
name the rapid acting insulin's
humalog, novalog, apidra
which insulin is short acting?
Name the intermediate acting insulin's
Name the long acting insulin's?
Insuline Mix preparations come in rapid/intermediate and short/intermediate formulations. name the Rapid/intermediate preperations
- humalog 75/25
- humalog 50/50
- novolog 70/30
Insuline Mix preparations come in rapid/intermediate and short/intermediate formulations. name the short/intermediate preperations
- humulin 70/30
- humulin 505/50
- novolin 70/30
humalog 75/25 is what kind of mix?
so if it is a log mix is it short or rapid
if it is a lin mix like humulin 70/30 is it short mix or rapid mix
every 1% point drop in the A1c (from 8-7 for example) reduces the risk of what complication by 40%?
hsould diabetics take an asprin a day?