Download T2 - 11-4-2016 PPT

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Therapeutics 2 Tutoring
Sarah Darby
[email protected]
November 4, 2016
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Lectures Covered
 Diabetes
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Diabetes
 FR
is a 58 yo WF. BMI = 32. PMH: HTN, asthma,
PCOS, hx of gest. diabetes, hysterectomy. She
lives alone, works long days at a desk job, and
spends her evenings binging on Netflix. How
many risk factors for DM does she have?
A.
4
B.
5
C.
6
D.
7
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Diabetes
 What
is the role of insulin in lowering blood
glucose?
A.
Insulin binds directly to glucose and transports it
across the cell membrane of muscle and fat
cells.
B.
Insulin binds to the insulin receptor, which
stimulates GLUT4 to move to the cell membrane
to allow glucose entry into the cell.
C.
Insulin binds to the GLUT4 receptor, which
increases membrane permeability to glucose.
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Diabetes
 Which
of the following does not occur in
the pathophysiology of T2DM?
A.
Decreased glucose uptake in muscle
B.
Increased glucose production in liver
C.
Increased lipolysis in adipocytes
D.
Decreased release of glucagon
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Diabetes
 RW
came to clinic this morning for a repeat
fasting blood glucose measurement. Which
of the following measurements would
indicate he has diabetes?
A.
95 mg/dL
B.
105mg/dL
C.
120mg/dL
D.
134mg/dL
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Diabetes
 JT’s
physician has ordered an oral glucose
tolerance test for him. At the 2 hour mark,
JT’s glucose level is 175mg/dL. This does not
confirm a diabetes diagnosis for JT.
 True
 False
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Diabetes
 DC
is in for his yearly check up. The nurse
tells you that his blood glucose is 324mg/dL
and he has complaints of increased thirst
and fatigue. This does not confirm a
diabetes diagnosis for DC.
 True
 False
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Diabetes
 Which
of the following patients does not
have diabetes?
A.
68 yo with SOB and RPG=170mg/dL
B.
54 yo with polyuria and FPG=145mg/dL
C.
57yo with 2HPG=220mg/dL
D.
65 yo with dehydration and A1C=6.2%
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Diabetes – diagnostic criteria
Random + Sx
≥ 200 mg/dL
2 hours after OGTT
≥ 200 mg/dL
Fasting
≥ 126 mg/dL
A1C
≥ 6.5%
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Diabetes
 MJ
has been really off his game since retiring
from the NBA. In clinic today, his fasting blood
glucose measurement was 123mg/dL. What
diagnosis can be made?
A.
Impaired glucose tolerance + diabetes
B.
Impaired fasting glucose + diabetes
C.
Impaired glucose tolerance + pre-diabetes
D.
Impaired fasting glucose + pre-diabetes
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Pre-Diabetes – diagnostic criteria
Impaired fasting
glucose
100-125mg/dl
Impaired glucose
tolerance
140-199mg/dl
A1C
5.7-6.4%
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Diabetes
 KM
is presenting for her first prenatal visit. Her
fasting blood glucose level = 155mg/dl. What
diagnosis can be made?
A.
Pre-diabetes
B.
T2DM
C.
T1DM
D.
Gestational diabetes
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Gestational Diabetes (24-28wks)
One Step
Two Step

OGTT 75g

OGTT 50g

Measure glucose:

Measure glucose:
 1 hour


Fasting

1 hour

If ≥140mg/dL , continue…

2 hour

OGTT 100g

Measure glucose:
 3 hours

GDM if:
 ≥ 140 mg/dL

First step is non-fasting. Second
step is fasting.
GDM if:

Fasting ≥ 92 mg/dL

1 hour ≥ 180 mg/dL

2 hour ≥ 153 mg/dL
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*Requires 8 hour fast
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Diabetes
 HH
is a 50 yo WF who recently had a FPG of
114mg/dL. Her BMI is 38. Which is the least
appropriate recommendation?
A.
Exercise 150min/week
B.
Lose 7% of body weight
C.
Initiate Metformin
D.
Initiate insulin
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Diabetes – goals
Non-pregnant
Gestational
diabetes
Pregnant w/ preexisting diabetes
A1C
Pre-prandial
Peak postprandial
<7.0%
80–130 mg/dL
<180 mg/dL
Fasting and preprandial
1 hour postprandial
1 hour postprandial
≤95mg/dL
≤140mg/dL
≤120mg/dL
A1C
Pre-meal,
bedtime,
overnight
Peak postprandial
<6%
60-99mg/dL
100-129mg/dL
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Diabetes
 PK
has recently been diagnosed with T2DM.
When he measures his blood glucose before
eating lunch, what is his goal?
A.
<100mg/dl
B.
100-125mg/dl
C.
80-130mg/dl
D.
126-180mg/dl
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Diabetes
 PK
has recently been diagnosed with T2DM.
When he measures his blood glucose 1-2
hours after his dinner, what is his goal?
A.
<200mg/dl
B.
<180mg/dl
C.
80-130mg/dl
D.
<100mg/dl
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Diabetes
 PK
has recently been diagnosed with T2DM.
What is the initial DOC for his therapy?
A.
Insulin
B.
Metformin
C.
Glipizide
D.
Pioglitazone
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Diabetes
 Which
agent has the highest risk of
hypoglycemia?
A.
Metformin
B.
Glimepiride
C.
Pioglitazone
D.
Insulin
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Diabetes
 Which
agent does not cause weight gain?
A.
Glyburide
B.
Pioglitazone
C.
Insulin
D.
Exenatide
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Diabetes
 Which
agent is not considered to be low
cost?
A.
Metformin
B.
Glipizide
C.
Canagliflozin
D.
Rosiglitazone
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Diabetes
 After
using max Metformin dosing and not
achieving the desired A1C target, when do
you add a second oral agent?
A.
2 weeks
B.
1 month
C.
3 months
D.
6 months
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Diabetes
 Which
of the following is not true about
Metformin?
A.
It is excreted unchanged in the urine.
B.
It should be titrated upward to help alleviate GI
upset/diarrhea.
C.
It may acutely increase vitamin B12 levels.
D.
It should be used with caution in alcoholics due
to the risk of lactic acidosis.
E.
It should be discontinued before receiving
iodinated contrast dyes.
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Diabetes
 Which
agents increase insulin secretion from
the pancreas?
A.
Sulfonylureas
B.
Thiazolidinediones
C.
Metformin
D.
SGLT2 inhibitors
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Diabetes
 Which
of the following is not true about
sulfonylureas?
A.
They should be D/C’d upon initiation of
prandial insulin.
B.
First generation agents are as equally effective
but have shorter half lives.
C.
All are metabolized to active metabolites.
D.
Important adverse effects include
hypoglycemia and weight gain.
E.
One disadvantage is low durability.
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Diabetes
 Which
of the following is not an adverse
effect of thiazolidinedione use?
A.
Heart failure
B.
Hepatic toxicity
C.
Acute renal failure
D.
Fractures
E.
Macular edema
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Diabetes
 Which
DPP-4 inhibitor does not require dose
adjustments based on renal or hepatic
function?
A.
Sitagliptin
B.
Saxagliptin
C.
Linagliptin
D.
Alogliptin
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Diabetes
 Which
agent increases urinary glucose
excretion by reducing the reabsorption of
filtered glucose?
A.
Canagliflozin
B.
Glyburide
C.
Pioglitazone
D.
Sitagliptin
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Diabetes
 Which
of the following is not true of SGLT2
inhibitors?
A.
They increase the risk of genital fungal
infections.
B.
Their metabolism may be induced by
phenytoin.
C.
They are safe in ESRD and dialysis.
D.
They may induce symptomatic hypotension.
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Diabetes
 CH
is visiting your clinic today to discuss
medication therapy for his diabetes. His blood
glucose levels have been all over the board
lately. He often skips meals because he gets busy
at work and forgets to eat. What might be a
good treatment option for him?
A.
Glipizide
B.
Linagliptin
C.
Repaglinide
D.
Acarbose
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Diabetes
 Which
of the following agents is given SQ
once weekly?
A.
Exenatide
B.
Liraglutide
C.
Albiglutide
D.
Dulaglutide
E.
A and B
F.
C and D
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Diabetes
 Which
of the following agents is given BID?
A.
Exenatide
B.
Liraglutide
C.
Albiglutide
D.
Dulaglutide
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Diabetes
 In
which patient should you avoid the use of
GLP-1 agonists?
A.
29 yo female on oral contraceptives
B.
54 yo female with family hx of thyroid
carcinoma
C.
65 yo male with COPD
D.
62 yo male with family hx of bipolar disorder
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Diabetes
 Which
agents have warning for use due to
pancreatitis or hx of pancreatitis?
A.
GLP-1 agonists
B.
Sulfonylureas
C.
DPP-4 inhibitors
D.
SGLT-2 inhibitors
E.
A and C
F.
A and B
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Diabetes
 Which
of the following is not an advantage to
GLP-1 agonists?
A.
Do not cause hypoglycemia
B.
Weight loss
C.
No GI side effects
D.
May decrease some CV risk factors
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Diabetes
 Which
of the following is not a rapid acting
insulin?
A.
Lispro
B.
Detemir
C.
Glulisine
D.
Aspart
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Diabetes
 Which
is not an advantage to using analog
insulin over regular insulin?
A.
More rapid onset of action
B.
Convenient administration
C.
Less variation in absorption
D.
Less expensive
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Diabetes
 Which
product has no peak of its action?
A.
Glargine
B.
Lispro
C.
Detemir
D.
Glargine concentrate
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Diabetes
 PK
(56kg) is starting insulin therapy with 4
injections daily. If we want his total daily dose
to be 0.5 units/kg/day, what should his basal
insulin dose be?
A.
7 units HS
B.
14 units HS
C.
28 units HS
D.
56 units HS
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Diabetes
 KM
(84kg) still has an A1C of 9.2% after being
adherent on multiple oral medications. How
do you start glargine? 0.1-0.2 units/kg/day
A.
4.2 units HS
B.
12 units HS
C.
22 units HS
D.
25 units HS
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Diabetes
 KM
(84kg) still has an A1C of 9.2% after being
adherent on multiple oral medications. He
started insulin glargine 12 units daily at his last
visit. His BG diary shows fasting glucose levels
of 140-160mg/dl. What do you recommend?
A.
Increase 2-4 units.
B.
Maintain therapy.
C.
Decrease 2-4 units.
D.
Discontinue.
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Diabetes
 WH
(60kg) has been taking detemir for the
past 3 months and has controlled her fasting
blood glucose levels. However, she now
needs to start before meal insulin. What do
you recommend?
A.
2 units TID AC
B.
6 units TID AC
C.
12 units TID AC
D.
18 units TID AC
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Diabetes
 FT
(60kg) has an A1C of 11.2% and is starting
basal/bolus insulin along with metformin.
Calculate his:
 Total
daily dose (0.5 units/kg/day): 30units/d
 Basal
dose: 30 units/2 = 15 units
 Bolus
dose per meal: 15units/3=5 units/meal
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Diabetes
Basal
Bolus
Start
0.1-0.2
units/kg/d or 10
units
0.1 units/kg or 4
units
Adjust
Inc. 2-4 units or
10-15%
Inc. 1-2 units or
10-15%
Hypoglycemia
Dec. by 4 units
or 10-20%
Dec. by 2-4 units
or 10-20%
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Diabetes
Expected A1C changes
Metformin
1-2%
Sulfonylureas
~1-2%
Thiazolidinediones
0.5-1.4%
DPP-4 inhibitors
0.5-0.9%
SGLT-2 inhibitors
0.7-1.0%
GLP-1 agonists
1-1.5%
Insulin
1.5-3.5%
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Diabetes
 Which
of the following is not an acute
complication of diabetes?
A.
DKA
B.
HHS
C.
Hypoglycemia
D.
Peripheral neuropathy
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Diabetes
A
patient has had T2DM for 10 years and
has recently developed numerous UTIs due
to a high post-void residual volume. This is
an example of autonomic neuropathy.
A.
True
B.
False
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Diabetes
 Which
of the following is false regarding diabetic
peripheral neuropathy?
A.
Pts with T2DM should be screened at diagnosis
B.
Pts with T1DM should be screened 10 years after
diagnosis
C.
The screening test should be performed with a
10g monofilament
D.
Tight glycemic control can slow the progression
of neuropathy
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Diabetes
 Which
agent has a level A recommendation
for the treatment of diabetic peripheral
neuropathy?
A.
Gabapentin
B.
Amitriptyline
C.
Pregabalin
D.
Tramadol
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Diabetes
 Which
of the following patients should be
taking an ACE inhibitor or ARB?
A.
33 yo female, T2DM, 2nd trimester of
pregnancy
B.
54 yo male, T2DM, no HTN
C.
49 yo female, T2DM, no HTN, urine albumin
150mg/day
D.
58 yo female, T2DM, HTN, urine albumin
320mg/day
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Diabetes
When this is elevated…
Change this…
BG before breakfast
Adjust nightly basal dose
BG before lunch
Adjust morning bolus dose
BG before dinner
Adjust lunch bolus dose
BG before bedtime
Adjust dinner bolus dose
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Therapeutics 2 Tutoring
Questions?
Sarah Darby
[email protected]
November 4, 2016