C-cell hyperplasia/ medullary thyroid tumors in animals
True/false: pancreas secretes 50% basal insulin and the other 50% comes from nutritional
True
What are therapeutic indications for insulin?
Glycemic control
Hyperkalemia
True/false: only 1% of insulin is absorbed subcutaneously
False; only 1% of oral insulin is absorbed. SubQ is the preferred route
What is the onset of rapid acting subcutaneous insulin?
Less than 15 minutes
What is the peak of rapid acting subcutaneous insulin?
1 hour
What is the duration of rapid acting subcutaneous insulin?
4 hours
Home insulin pumps are usually which type of subcutaneous insulin?
Rapid acting
True/false: rapid acting insulin can be given IV
True
What are the agents of rapid acting insulin?
Lispro
Aspart
Glulisine
What are agents of short acting insulin?
Regular U-100
What is the peak of shorting acting insulin?
2-4 hours
What is the onset of short acting insulin?
30-60 minutes
What is the duration for short acting insulin?
5-8 hours
True/false: short acting insulin can be given IV
True
What are agents of intermediate acting insulin?
NPH (neutral protamine Hagedorn)
What is the onset for NPH?
1-3 hours
What is the peak for NPH?
6-12 hours
What is duration for NPH?
14-24 hours
Which type of subcutaneous insulin is a cloudy suspension?
Neutral Protamine Hagedorn
Which subQ insulin can be given IV?
Rapid acting and short acting
What are agents of long acting subcutaneous insulin?
Glargine
Detemir
Degludec
What is onset of long acting insulin?
1-2 hours
What is peak long acting insulin?
Flat ... guessing this means that long acting is always there (basal insulin) so it never actually peaks
What is duration of long acting insulin
24 hours
Which subcutaneous insulin forms microdeposit at injection site?
Glargine – a long acting insulin
Which subQ insulin highly binds to albumin in tissues and blood?
Detemir – a long acting insulin
Which SubQ insulin forms multi-hexamers when injected into the subQ tissues resulting in an insulin depot?
Degludec – a long acting insulin
Which type of subQ insulin has the fastest onset?
Short acting
Which type of Sub Q insulin has fastest peak?
Short acting
Which type of subQ insulin has onset in about 30-60 minutes?
short acting
which type of subQ insulin has duration for about 14-24 hours?
Intermediate acting
Which type of SubQ insulin has peak in about 6-12 hour after injection?
Intermediate acting
What are factors that require an increased in insulin dosage?
not meeting glycemic control goals
Weight gain/ increased nutrition
Decreased activity
Stress/trauma/ infection
Vasopressors
Treatment doses of corticosteroids
What are factors that require a decrease in insulin dose?
Hypoglycemic episodes
Weight loss/ decreased nutrition
Exercise
Reversal of factors that increase dosage
Renal/hepatic failure
In renal/hepatic failure patients, what insulin dosage adjustment is required?
Decrease dosage
What are side effects of insulin?
Hypoglycemia
Allergy
Lipodystrophy (fat deposition at injection sites)
True/false: type 1 diabetics always need basal insulin
True
How can you prevent lipohypertrophy?
By rotating injection sites
What is the preferred initial pharmacologic agent for type 2 diabetes?
Metformin
What is the dual therapy for type 2 DM?
Metformin + insulin
Which diabetes drug is beneficial for patients with diabetic kidney disease, CHF or ASCVD?
SGLT-2 inhibitors
Which DM drugs have proven CVD benefits?
GLP-1 Receptor Agonists
SGLT2 inhibitor
If HbA1c is above target despite dual or triple therapy, what is the next step?
Add once a day injection of basal insulin
Entry A1c less that 7.5%, use ____therapy. If Entry A1C greater than 7.5% consider ___ therapy
Mono, usually metformin
Dual or triple, usually GLP1-RA with SGLT-2 inhibitor
If A1C is greater than 9% and patient is presenting with symptoms, treat with ________
Insulin and other agents
True/false: to intensify a treatment regimen, add prandial insulin (basal bolus)
True
True/false: most people with type 2 DM should be treated with multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion
False; this is true statement for type 1 DM, not type 2
Bolus insulin, aka mealtime/nutritional/prandial, is ______insulins. Dosage based on ingested _____.
Rapid-acting
Carbohydrates
What is the insulin: carbohydrate ration?
Amount of insulin needed to handle the grams of ingested carbs
What is insulin sensitivity factor?
Decrease in blood glucose from a unit of insulin
What are the 6 oral diabetic drugs?
sulfonylureas
Metformin (aka biguanides)
Meglitinides (-glinide)
SGLT2 inhibitor
Glitazones (TZDs)
DPP4 inhibitors
What is biguanides?
Fancy name for metformin
What is the MOA of metformin?
Stimulates AMP Kinase thereby decrease gluconeogenesis by the liver
Metformin _______ hepatic glucose output and ____ insulin sensitivity
Reduces
Improves
What are adverse effects of metformin?
N/v/d
Abdominal cramping
Vitamin B12 deficiency
Lactic acidosis
What is contraindicated with metformin use?
Renal failure (eGFR <30)
Acidosis
Hypoxia
dehydration
Which drug can lead to vitamin B12 deficiency?
metformin
True/false: high levels of metformin can lead to fatal drug-induced lactic metabolic acidosis
True
Sulfonylureas and meglitinides are also known as ______
Secretagogues
What are agents of sulfonylureas?
Glyburide
Glipizide
Glimepridie
What are agents of meglitinides?
Repaglinide
Netaglinide
What is a common name stem for meglitinides?
-glinide
What is the MOA of sulfonylureas and meglitinides?
Closing K+/ATP ase on surface of beta cells, so K+ stays in cell and positive voltage will result in membrane depolarization, leading to insulin secretion
What are adverse effects and contraindications for the secretagogues?
hypoglycemia
Weight gain
True/false: meglitinides are short acting
True
What are agents of SGLT-2 inhibitors?
canagliflozin
Empagliflozin
What is the common name stem for SGLT-2 inhibitors?
-gliflozin
What is the MOA for SGLT2 inhibitors?
Block SGLT2 receptors which are located on the proximal tubule and responsible for glucose reabsorption. Blockage of this receptor would lead to increased glucose in urine
Where are SGLT2 receptors located?
Proximal tubule of the nephron
Which oral DM drug has a black box warning for amputation risk?
SGLT-2 inhibitors
What are adverse effects and contraindications for SGLT2 inhibitors?
GU infections
Polyuria
Increased LDL and transient creatinine
DKA
UTI leading to pyelonephritis and urosepsis
Hypotension
Which oral DM drug could cause polyuria
SGLT1 inhibitor
Which oral DM durg would lead to increased glucosuria?
SGLT2 inhibitor
What is the mechanism of action of DPP4 inhibitor?
Blocking DPP 4, which is an enzyme that degrades GLP1, so blocking of DPP 4 would lead to more GLP 1 and hence stimulates insulin secretion and suppresses glucagon
What are agents of DPP4 inhibitor? Common name stem?
Sitaglipitin
Saxagliptin
Linagliptin
-gliptin
What are adverse effects for DPP4 inhibitors?
nothing!!!
Which oral DM drug has now known side effects/contraindications?
DPP 4 inhibitors!
What is the common name stem and agents of glitazones (TZDs)?
-glitazones
Pioglitazone
Rosiglitazone
What is the MOA of TZDs?
Agonists of nuclear hormone receptor PPAR-gamma
What are PPAR-gamma receptors?
expressed in fat cells and once stimulated would promote insulin sensitivity
Decreases hepatic gluconeogenesis
What are adverse effects of TZD?
Weight gain
Edema/heart failure
Which oral DM drug has a black box warning for congestive heart failure?
