PC707-Endocrine-Module 8 Exam Questions With Correct Answers

Is insulin required for type 1 diabetes? - Answer -yes--there is autoimmune pancreatic beta cell destruction and unable to produce endogenous insulin* What is the typical therapy for a type 1 diabetic: - Answer -life long insulin* -basal insulin -boluses of short-acting insulin to provide coverage for meals and snacks Symptoms of diabetes mellitus: - Answer -involuntary weight loss -polyuria -polydipsia -polyphagia Symptoms of ketoacidosis: - Answer -dehydration -abdominal pain -vomiting -decreased level of consciousness Symptoms of hypoglycemia: - Answer -dizziness, H/A, fatigue, weakness, shakiness, tachycardia, sweating, hunger, confusion Type 2 diabetes mellitus: - Answer -genetically predetermined & environmentally modified* -reduced tissue sensitivity to insulin* -euglycemia occurs due to body's response to hyperglycemia--causing hyperinsulinemia* -long term insulin resistance can cause beta cell destruction* What are the treatment options for type 2 diabetes: - Answer -first line--exercise & diabetic diet -oral hypoglycemics -insulin What is first line preferred pharmacologic treatment for type 2 diabetes? - Answer -glucophage (Metformin) Is tight control of diabetes recommended? - Answer -No -increased risk of hypoglycemia and mortality -do not lower A1C levels quickly or too low in those at high risk of CV events--may cause CV events* -do not aim for tight glucose control in the elderly Early treatment for type 2 diabetes with metformin has been shown to: - Answer -decrease mortality and diabetic related complications Insulin must be given by SQ injection or IV infusion because: - Answer -it is not bioavailable orally because it is a protein & is digested in the stomach* Types of insulin: - Answer -Rapid acting -Short acting -Intermediate acting -Long acting (basal) -Combination Rapid acting insulin: - Answer -works immediately (onset 5-15 minutes) -peak within 45 minutes-3 hours -duration 3-5 hours -can be used in insulin pumps as "boluses" for meals -administered with meals* -Ex: lispro (Humalog), aspart (Novolog), glulisine (Apidra) Short acting insulin: - Answer -onset 15-30 minutes -peak 2-4 hours -duration 5-8 hours -Ex: Regular, Humulin R, Novolin R Intermediate acting insulin: - Answer -onset 1-2 hours -peak 4-12 hours -duration 18-24 hours -Ex: NPH, Humulin N, Novolin N Long acting insulin (basal): - Answer -given once daily--but can be given BID if needed* -onset 1-2 hours -duration 24 hours -detemir (Levemir) peaks in 4 hours -glargine (Lantus) has NO peak* -do not mix Lantus with other insulins Intermediate/combo insulin preparations: - Answer -Novolog mix (70/30) -Humalog mix (75/25) -Humalog mix (50/50) -Humulin mix (70/30) -Novolin mix (70/30) --->onset 30 minutes --->peak 30 min-12 hours --->duration up to 24 hours Why should alcohol be avoided with use of insulin? - Answer -can increase risk of hypoglycemia Complications of insulin: - Answer -hypoglycemia -hypokalemia -lipohypertrophy (accumulation of SQ fat) -weight gain What is a good treatment option for a type 2 diabetic that is not responding to multiple dose injections of insulin? - Answer -insulin pump -delivers steady measured "basal" continuous dose -delivers "boluses" per patient around mealtimes -maintains good control of blood sugar (improving HgA1C) -patient can exercise without having to eat large amount of carbs -type 1 diabetics will ALWAYS use the basal + bolus -can cause weight gain -expensive -potential DKA if catheter comes out without notice* What is an insulin inhaler? - Answer -delivers insulin via nebulizer directly into the lungs -faster peak concentrations in the serum -rapid metabolism than injectables What are the drug interactions with insulin? - Answer -hypoglycemic agents (potentiates hypoglycemic effect) -drugs that cause hyperglycemia will cause a need for increase in insulin requirements (thiazides, oral steroids, sympathomimetics) -beta blockers (can mask signs and symptoms of hypoglycemia) Types of oral hypoglycemics: - Answer -biguanides -sulfonylureas -meglitidines -alpha-glucosidase inhibitors -thiazolidinediones -gliptins (DPP-4 inhibitors) Biguanides: - Answer -oral hypoglycemic -inhibits glucose production by the liver (gluconeogenesis) & liver breakdown of glycogen into glucose (glycolosis) -enhances tissue receptor sensitivity to insulin -does not "actively" reduce glucose levels--hypoglycemia is NOT a concern* -can be combined with other agents or insulin -helps regulate weight -great add on agent -take with meals* -Ex: glucophage (Metformin) What is the concern with IV contrast and metformin? - Answer -metformin is excreted unchanged and can cause stress on the kidneys--which alone can increase metformin to toxic levels* -IV contrast can induce acute renal failure--therefore enhancing the potential for metformin toxicity* -hold metformin prior to IV contrast & for 48 hours after Adverse effects of Metformin? - Answer -lactic acidosis -GI effects--alters gut microbiome (start low and increase slowly to decrease GI effects--usually subsides over time) -decreases B12 & folic acid -metallic taste What vitamin level should be checked in a patient with anemia or peripheral neuropathy prior to initiating Metformin? - Answer -B12 -Metformin can reduce levels even more* What lab should be checked in a patient at risk of developing renal impairment prior to & during treatment with Metformin? - Answer -renal function tests* What is an off-label use of Metformin? - Answer -PCOS (polycystic ovarian syndrome) -GDM (gestational diabetes mellitus) BBW for Metformin: - Answer -lactic acidosis--potentially fatal* -discontinue if suspected Lactic Acidosis: - Answer -build up of lactic acid (waste product) -Symptoms: tachypnea, tachycardia, abnormal heartbeat, vomiting, fatigue, SOB, severe loss of strength/energy, severe dizziness, cold, muscle cramps/pain, symptoms similar to low blood sugar, severe abdominal pain, symptoms similar to an allergic reaction -low pH, increased anion gap, elevated blood lactate -usually mild, transient, and reversible--as long as the contributing agent dose is reduced or discontinued* -supportive measures Contraindications for Metformin: - Answer -severe renal disease (GFR <30) -acute or chronic metabolic acidosis -hypersensitivity reactions Which drugs interact with Metformin? - Answer -Tagamet --may increase Metformin levels* -Sulfonylurea or insulin--could increase risk of hypoglycemia or lactic acidosis in those with impaired renal function Sulfonylureas: - Answer -stimulates beta cells to release insulin -enhances tissue receptor sensitivity to insulin -some insulin production is necessary to work--not used in type 1 diabetes* -1st and 2nd generation available--2nd generation has greater potency so less drug is needed -Ex: chlorpropamide (Diabinese), glyburide (Glynase) Adverse effects of sulfonylureas: - Answer -hypoglycemia -nausea -skin reactions -abnormal LFTs -weight gain Patient education on situations which increase risk of hypoglycemia while taking a sulfonylurea? - Answer -after exercise or missed meal -high dose -longer-acting (chlorpropamide) -undernourished or abuse alcohol -impaired renal or cardiac function -current GI disease -concurrent therapy with salicylates, sulfonamides, fibric acid derivatives, warfarin -after hospitalization -elderly should only use short-acting ones--increased risk of hypoglycemic reactions* Which diabetic patients are sulfonylureas most effective for? - Answer -those with normal weight or weight is only slightly increased* Are sulfonylureas contraindicated for those with a "sulfa" allergy? - Answer -No -different molecular structure -usually allergy is related to the "arylamine" group present in antibiotics only* -usually no cross-sensitivity -if a reaction occurs--most likely due to increased overall allergic susceptibility of the patient* Drug interactions with sulfonylureas: - Answer -Tagamet, Alcohol, NSAIDs,Sulfa ABX--these all increase risk of hypoglycemia -Beta blockers can decrease effectiveness by suppressing insulin release* DPP-4 inhibitors (Gliptins): - Answer -"incretin enhancers" -incretins increase insulin secretion, decrease glucagon secretion, decrease glucose production* -inhibits degradation of endogenous incretins -3rd line therapy and those with A1C>9 -do not use in those with hx pancreatitis* -caution in those with renal impairment* Ex: linagliptin (Tradjental), saxagliptin (Onglyza), sitagliptin (Januvia) Thiazolinediones: - Answer -increases sensitivity to insulin in skeletal muscle, fat, and partially the liver* -increases glucose utilization and decreases glucose production* -helps redistribute fat from visceral to subcutaneous (visceral is associated with insulin resistance) -does NOT cause hypoglycemia or hyperinsulinemia -not used in type 1 diabetes* -Ex: glitazone (Actos), pioglitazone, rosiglitazone (Avandia) BBW thiazolinediones: - Answer -may cause or exacerbate heart failure -have patients report symptoms of HF (rapid weight gain, dyspnea etc.) What is another concern with thiazolidinediones? - Answer -potential liver injury* -check LFTs prior to therapy & monitor throughout if concerned -have patients report symptoms (abdominal pain, nausea, vomiting, anorexia, jaundice, dark urine, etc.) Contraindications for thiazolideniones: - Answer -symptomatic HF -stage 3 or 4 HF Meglitinides: - Answer -stimulates the pancreas to release insulin -beneficial for erratic meal schedules with normal fasting but high postprandial -rapid onset, short half-life -risk of hypoglycemia--not as much as other agents -often combined with Metformin -3rd line therapy* -Ex: repaglinide (Prandin) & nateglinide (Starlix) Adverse effects of meglitinides: - Answer -bloating, abdominal cramps, diarrhea, flatulence Alpha-glucosidase inhibitors: - Answer -inhibits the enzyme alpha-glucosidase -this causes decreased intestinal secretion of glucose and slows absorption of glucose after meals -works in the gut--less risk of hypoglycemia* -only affects postprandial blood sugar levels -take with meals TID -not frequently used due to intolerance of side effects -more tolerated if reduces sugar intake* -A/E--flatulence & diarrhea SGLT2 inhibitors: - Answer -inhibits glucose transport* -prevents kidneys from reabsorbing glucose and increasing urinary excretion of glucose -NEW oral hypoglycemic drug* -Ex: canagliflozin (Invokana) -BBW--limb amputation* What hypoglycemic agents are available by injection besides insulin? - Answer -GLP-1 Agonists (incretin mimetics) -Amylin Analogs GLP-1 Agonists: - Answer -incretin mimetics -incretin increases insulin release, inhibits postprandial glucagon release, and decreases glucose production* -slows gastric emptying -Warning--may cause acute pancreatitis* -Ex: exlenatide (Byetta) and liraglutide (Victoza) Adverse effects of GLP 1 Agonists: - Answer -nausea, hypoglycemia, possible weight loss -warning--may cause acute pancreatitis* -BBW-->possible risk for thyroid tumors--seen in animal studies* Amylin Analogs: - Answer -slows gastric emptying -increases early satiety -decreases postprandial glucagon secretion -may promote weight loss -3rd line therapy--as effectiveness isn't substantially shown to decrease blood sugar -used as adjunct to insulin -A/E-->hypoglycemia & nausea -Ex: pramlinitide (Symlin)