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Normal bedtime blood glucose
<120
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Preprandial goal for DM
80-120
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Bedtime blood glucose goal for DM
100-140
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Action required for preprandial blood glucose
< 80 or > 140
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Action required for bedtime blood glucose
< 100 and > 160
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Action required for HbgA1C
>7%
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When is drug therapy indicated?
- 1) No progress with 3 months of diet and exercise
- 2) Symptoms of hyperglycemia, surgery, ketoacidosis
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Alpha glucosidase action and preferred patient type
Acts on GUT to reduce psotprandial carbohydrate absorption.
Good for postprandial hyperglycemia
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Biguanide action and preferred patient type
Acts on LIVER to decrease hepatic glucose output.
Good for overweight and insulin resistant
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Sulfonylurea (Glyburide, Glypizide) action and preferred patient type
Acts on PANCREAS to increase insulin secretion
Good for insulinopenic and lean
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Glitazone (TZD) (Actos) action and preferred patient type
Acts on SKELETAL MUSCLE to decrease insulin resistance.
Good for insulin resistant, and CRI
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When should you withhold metformin?
In conditions that predispose to renal insufficiency
- 1) Iodinated contrast media
- 2) Severe infection
- 3) Major surgical procedure
- 4) Acute MI or CHF
- 5) Hospitalization
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Metformin Rx and SE
Does not produce hypoglycemia
Metformin 500mg BID
SE: Mainly GI (bloating, N/D), usually self-limiting
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Glitazone (TZD) precautions
Caution in conditions predisposing to fluid overload
- 1) Recurrent CHF
- 2) Increased BNP
- 3) Chronic or worsened ankle edema
- 4) Class III or IV HF
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Actos Rx
Actos 15mg daily
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Action of incretin
- 1) Increases satiety
- 2) Decreases gastric emptying
- 3) Inhibits glucagon release
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Byetta (incretin mimetic)
Adjunct therapy with MET or SFU or in combo of the two.
Costly. Good effect in 20% of population
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Byetta Rx
Byetta 5mcg SQ BID within 60 minutes prior to meal
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Januvia (DPP-4 inhibitor) action
- 1) Increase incretin levels
- 2) Decrease glucagon
- 3) Increase insulin release
- 4) Decrease glucose after oral glucose load
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Indications for Januvia
- 1) Monotherapy
- 2) Adjunct with MET or TZD
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Acute complications of DM
- 1) HHNK (hyperosmolar, hyperglycemic, nonketotic coma), DKA
- 2) Hyperglycemia
- 3) Hypoglycemia
- 4) Decreasing GFR
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When is hypoglycemia severe?
Seizures, altered LOC, and requiring the assistance someone else
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Chronic complications of DM
- 1) Eye
- 2) Kidney
- 3) Peripheral nerve
- 4) Autonomic never (ED, bladder, GI motility)
- 5) Pulmonary
- 6) Ortho (trigger finger, adhesive capsulitis)
- 7) Skin (acanthosis nigricans, lipohypertrophy)
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