Term
| Glucose is stored in the body as _________. |
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Definition
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|
Term
| During times of fasting or increased need, _______________ and ______________ occurs in the liver. |
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Definition
| gluconeogenesis; glycogenolysis |
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Term
| What two hormones secreted from the pancreas work in opposing fashion to control blood glucose? |
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Definition
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|
Term
| When is insulin secreted? |
|
Definition
| blood glucose elevated (packs away glucose as glycogen/fat) |
|
|
Term
| When is glucagon secreted? |
|
Definition
| blood glucose low (raises blood glucose) |
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|
Term
| What is the key that unlocks the cells' ability to use glucose? |
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Definition
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Term
| What hormone is secreted from the pancreas at the same time as insulin? |
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Definition
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Term
|
Definition
-enhances satiety
-slows gastric emptying
-inhibits secretion of glucagon |
|
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Term
|
Definition
glucagon-like popypeptide (GLP-1)
gastric insulinotropic peptide (GIP) |
|
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Term
|
Definition
-stimulate (weakly) insulin secretion
-decrease glucagon secretion
-slow gastric emptying
-increase satiety |
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Term
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Definition
| enzyme that breaks down incretins (GLP-1 and GIP) |
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Term
| normal physiology when a patient eats |
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Definition
1. gut releases incretins
2. pancreas secretes insulin and amylin
3. glucagon will be suppressed
4. insulin unlocks cells so glucose can enter and be stored or used
5. DPP-4 breaks down incretins |
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Term
| normal physiology when patient has not eaten in awhile |
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Definition
1. pancreas secretes glucagon
2. liver will break down glycogen and make glucose so cells can function
3. pancreas is still producing a little insulin so the cells can use the glucose that is being produced |
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|
Term
| What cells produce insulin? |
|
Definition
| beta cells in the pancreas |
|
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Term
| pathophysiology of type 2 DM |
|
Definition
1. pt develops insulin resistance
2. insulin receptors on cells stop responding properly to insulin
3. body produces higher levels of insulin to compensate
4. eventually body cannot produce enough insulin to clear excess glucose out of bloodstream
5. pt now has pre-diabetes |
|
|
Term
| Aside from the insulin resistance problem in type 2 DM, what is the other problem? |
|
Definition
1.lack of enough insulin to move glucose from blood to cells is interpreted by the alpha cells to mean that blood glucose is low
2. alpha cells secrete glucagon
3. liver starts gluconeogenesis and glycogenolysis |
|
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Term
| Type 2 diabetics have ________ _________ of GLP-1 and ____ _______ of GIP to increase insulin secretion. |
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Definition
| decreased secretion; lose effect |
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Term
| In type 2 DM, ________ secretion, like insulin secretion, is deficient. |
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Definition
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Term
|
Definition
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Term
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Definition
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Term
|
Definition
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Term
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Definition
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Term
| What should the follow-up time be in a patient that you are initiating diet and exercise regimen in? |
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Definition
|
|
Term
| waist circumference associated with increased risk |
|
Definition
>35 in for women
>40 in for men |
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Term
| __________ _______ is an independent risk predictor when BMI is not markedly elevated. |
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Definition
|
|
Term
| general caloric intake for men and women |
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Definition
men: 1600 cal/day
women: 1200 cal/day |
|
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Term
|
Definition
| at least 30 min of moderate-intensity physical activity on most (at least 5) days of the week |
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Term
| At what point can you suggest pharmacotherapy as a weight loss intervention? |
|
Definition
BMI >30 or BMI >27 and risk factors or obesity-related disease is present
AND
lifestyle changes not effective after 6 months |
|
|
Term
| When can surgical intervention be suggested for weight loss? |
|
Definition
| BMI >40 or BMI >35 with serious comorbid condition |
|
|
Term
| How many Americans have pre-diabetes? |
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Definition
|
|
Term
| What FBG result leads to a diagnosis of pre-diabetes? |
|
Definition
| 100-126 mg/dl (more than once) |
|
|
Term
| What 2 hr GTT result leads to a diagnosis of pre-diabetes? |
|
Definition
|
|
Term
| What FBG result leads to a diagnosis of type 2 DM? |
|
Definition
| >126 mg/dl (more than once) |
|
|
Term
| What 2 hr GTT result leads to a diagnosis of type 2 DM? |
|
Definition
|
|
Term
| What does having pre-diabetes put you at risk for? |
|
Definition
|
|
Term
| screening criteria for pre-diabetes and diabetes in asymptomatic adults |
|
Definition
FBG at least every 3 years starting at age 45
consider at younger age and more frequently if pt is overweight and has one or more risk factor |
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Term
| Pre-diabetes is severely ____________ in America. |
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Definition
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|
Term
| Pre-diabetes raises short-term absolute risk of type 2 DM ___ to ____-fold. |
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Definition
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|
Term
| What medications have strong evidence for reduction in the development of diabetes from pre-diabetes? |
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Definition
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|
Term
| What is generally more important when trying to prevent pre-diabetes from progressing to diabetes: diet composition or total calories consumed? |
|
Definition
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|
Term
| What is more effective than any drug treatment in preventing progression to type 2 DM in patients with pre-diabetes? |
|
Definition
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|
Term
| Pre-diabetes is associated with significant ___________. |
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Definition
|
|
Term
| a cluster of conditions/risk factors that occur together and increase risk for CVD |
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Definition
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|
Term
| Metabolic syndrome has a cause that is unknown but is associated with... |
|
Definition
|
|
Term
| What conditions make up metabolic syndrome? |
|
Definition
-abdominal obesity
-elevated triglycerides (>150)
-low HDL (men <40, women <50)
-elevated BP (>130/85)
-elevated blood glucose (pre-diabetes) |
|
|
Term
| How many of the conditions must be present to diagnose someone with metabolic syndrome? |
|
Definition
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|
Term
| A weight loss of what percentage of body weight has a significant effect on lowering risk for diabetes and CVD? |
|
Definition
|
|
Term
| diagnostic criteria for type 2 DM |
|
Definition
-fasting blood glucose >126
-random blood glucose >200 with symptoms
-2 hr post-prandial >200
-HbA1c >6.5% |
|
|
Term
| Diabetes is the leading cause of what 2 things? |
|
Definition
new cases of blindness in adults
kidney failure |
|
|
Term
| A patient that has diabetes has a 2-4 times greater risk of death due to what 2 things? |
|
Definition
|
|
Term
| How much did diabetes cost the U.S. in 2007? |
|
Definition
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|
Term
| What is the gold standard for assessing glycemic control? |
|
Definition
|
|
Term
| What does the HbA1c represent? |
|
Definition
| sum of both fasting and post-prandial glucose excursions |
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Term
| The relative contribution of fasting and post-prandial glucose is dependent upon _________. |
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Definition
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Term
| The lower the A1c, the greater the contribution of the __________. |
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Definition
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Term
| The higher the A1c, the greater the contribution of the __________. |
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Definition
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|
Term
| Post-prandial glucose excursions are associated with ________. |
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Definition
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Term
| How often should a HbA1c be done in a patient that is not well-controlled? |
|
Definition
| every 3 months until they are well-controlled |
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|
Term
| There is a linear relationship between _______ and ________ _________ _______ _________. |
|
Definition
| A1c and average blood glucose levels |
|
|
Term
|
Definition
| estimated average glucose |
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|
Term
| HbA1c predicts ___________ of diabetes. |
|
Definition
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|
Term
| A 1% absolute increase in HbA1c predicts a ____% relative increase in incidence of CVD events. |
|
Definition
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|
Term
| A 1% reduction in HbA1c results in a ____% reduction in microvascular complications. |
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Definition
|
|
Term
| What are microvascular complications? |
|
Definition
retinopathy
neuropathy
nephropathy |
|
|
Term
| Intensive treatment of diabetes can decrease... |
|
Definition
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|
Term
| The lower the HbA1c (eAG), the lower the rate of _________. |
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Definition
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|
Term
| intensive blood glucose control |
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Definition
| controlling both fasting and post-prandial glucose |
|
|
Term
| evidence favoring intensive blood glucose control |
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Definition
-lowered risk of new or worsening microvascular complications, particularly kidney disease
-importance of comprehensive treatment of glycemia, BP, and dyslipidemia in type 2 DM |
|
|
Term
| evidence against intensive blood glucose control |
|
Definition
-did not decrease CV risk vs. usual care
-lower rates of primary CVD outcomes with intensive therapy not statistically significant
-increased risk of severe hypoglycemia
-one study found increased mortality with intensive therapy vs. control in pts with longstanding type 2 DM and known CVD or risk factors |
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|
Term
| What should glycemic targets be based on? |
|
Definition
life expectancy
advanced diabetes complications
hypoglycemia risk
comorbidities |
|
|
Term
| What HbA1c target level may be appropriate in high-risk patients with multiple risk factors and/or CVD? |
|
Definition
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|
Term
| What proportion of type 2 diabetes are not well-controlled? |
|
Definition
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|
Term
| How often should a HbA1c be done in a patient that is well-controlled? |
|
Definition
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|
Term
| How many agents should be used before you initiate insulin therapy? |
|
Definition
| 3 oral agents can be used, but insulin therapy is preferred |
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|
Term
| In a type 2 diabetic, you should intensify treatment until what HbA1c target is achieved? |
|
Definition
|
|
Term
| What patient factors influence achievement of glycemic goals? |
|
Definition
adherence
access
socioeconomic issues
health literacy
natural history of diabetes |
|
|
Term
| What physician factors influence achievement of glycemic goals? |
|
Definition
knowledge
presumptuous behavior
clinical inertia |
|
|
Term
| What process factors influence achievement of glycemic goals? |
|
Definition
17-min visit
clerical demands
1600 guidelines
clinical demands
fragmented system
lack of support
obesogenic culture |
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|
Term
| Medication adherence decreases as dose frequency _________. |
|
Definition
|
|
Term
| What is more important in promoting adherence than minimizing the total number of medications? |
|
Definition
| minimizing the total number of daily doses |
|
|
Term
| the capacity of individuals to access, understand, and use health information to make informed and appropriate health-related decisions |
|
Definition
|
|
Term
| Health literacy is lowest among who? |
|
Definition
| older adults and Hispanics |
|
|
Term
|
Definition
| diabetes self-management education |
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|
Term
| Depression and diabetes have a ___________ association. |
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Definition
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|
Term
| Those depressed have an increased risk to develop DM in the next... |
|
Definition
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|
Term
| Those with DM and who are treated show an increased risk for depression over the next... |
|
Definition
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|
Term
| ADA recommends routine screening of type 2 diabetics for __________. |
|
Definition
|
|
Term
|
Definition
| a "wait-until-next-visit" approach |
|
|
Term
| How much DSME should a diabetic patient get? |
|
Definition
| 10 hours at diagnosis and 2 hours per year after that |
|
|
Term
| A1c goal of therapy (ADA) |
|
Definition
|
|
Term
| eAG goal of therapy (ADA) |
|
Definition
|
|
Term
| pre-prandial glucose goal of therapy (ADA) |
|
Definition
|
|
Term
| 1-hr to 2-hr post-prandial glucose goal of therapy (ADA) |
|
Definition
|
|
Term
| blood pressure goal of therapy (ADA) |
|
Definition
|
|
Term
| LDL goal of therapy (ADA) |
|
Definition
|
|
Term
| What must you explain to patients before discussing treatments for diabetes? |
|
Definition
natural progression of diabetes
This will give the patient a realistic picture of their future. |
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|
Term
| How do alpha-glucosidase inhibitors work? |
|
Definition
| inhibit carbohydrate breakdown in the stomach |
|
|
Term
| How do thiazolidinediones work? |
|
Definition
-increase glucose intake in the fat
-decrease free fatty acid output from the fat
-increase glucose metabolism in the muscle
-suppress glucose production in the liver |
|
|
Term
|
Definition
-slow gastric emptying
-increase insulin secretion
-decrease glucagon secretion |
|
|
Term
| How do secretagogues work? |
|
Definition
| stimulate insulin secretion in the pancreas |
|
|
Term
| How do DPP-4 inhibitors work? |
|
Definition
increase insulin secretion
decrease glucagon secretion |
|
|
Term
|
Definition
-increases glucose metabolism in the muscle
-suppresses glucose production in the liver |
|
|
Term
| What should be initiated at diagnosis of type 2 DM? |
|
Definition
TLC (therapeutic lifestyle changes)
metformin |
|
|
Term
| What glucose excursion do you want to target in a patient with a lower but still abnormal HbA1c? |
|
Definition
|
|
Term
| What glucose excursion do you want to target in a patient with a very high HbA1c? |
|
Definition
|
|
Term
| When is a HbA1c inaccurate? |
|
Definition
| presence of hemoglobin variants or shortened RBC survival |
|
|
Term
| What other benefits does metformin have aside from lowering the A1c? |
|
Definition
-weight loss (or weight neutral)
-decreases LDL, TGs, and BP
-increases (or has neutral effect) on HDL
-decreases CV and total mortality rates |
|
|
Term
| contraindications for metformin |
|
Definition
elevated creatinine
IV contrast agents |
|
|
Term
| What is the most common side effect associated with metformin but can be avoided by slowly titrating up? |
|
Definition
|
|
Term
| black box warning for metformin |
|
Definition
|
|
Term
| What can cause lactic acidosis? |
|
Definition
-increased production of acids
-loss of alkaline substances
-inability of kidney to clear acids |
|
|
Term
| symptoms of lactic acidosis |
|
Definition
hyperventilation
lethargy
nausea/vomiting
hypotension
tachycardia |
|
|
Term
| Why is metformin usage linked to lactic acidosis? |
|
Definition
-lactate is a substrate for hepatic gluconeogenesis
-metformin inhibits hepatic gluconeogenesis
-lactate can build up |
|
|
Term
| What needs to be monitored in patients on metformin both before and during treatment? |
|
Definition
| kidney function (creatinine) |
|
|
Term
| Stop metformin use if creatinine is _____ in a female or ______ in a male. |
|
Definition
>1.4 in female
>1.5 in male |
|
|
Term
| How long should metformin be held before and after IV contrast? |
|
Definition
|
|
Term
| What concerns are there for TZD use? |
|
Definition
-potential risk of MI with rosiglitazone (Avandia)
-2-fold risk of fluid retention and resultant CHF
-increased risk of fractures |
|
|
Term
| What are the rapid-acting insulins? |
|
Definition
|
|
Term
| onset of rapid-acting insulins |
|
Definition
|
|
Term
| duration of rapid-acting insulins |
|
Definition
|
|
Term
| What is short-acting insulin? |
|
Definition
|
|
Term
| onset of short-acting insulin |
|
Definition
|
|
Term
| duration of short-acting insulin |
|
Definition
|
|
Term
| What is intermediate-acting insulin? |
|
Definition
|
|
Term
| onset of intermediate-acting insulin |
|
Definition
|
|
Term
| duration of intermediate-acting insulin |
|
Definition
|
|
Term
| What are the long-acting insulins? |
|
Definition
|
|
Term
| onset of long-acting insulins |
|
Definition
|
|
Term
| duration of long-acting insulins |
|
Definition
|
|
Term
| What is the cheapest type of insulin? |
|
Definition
|
|
Term
| What type of insulin is most expensive? |
|
Definition
|
|
Term
| How do you generally initiate insulin therapy? |
|
Definition
basal insulin first
get fasting down to <120 mg/dl (continue secretagoges and sensitizers at same dose)
If post-prandial remains high despite the normal fasting glucose, add prandial insulin. At this point, secretagogues can be stopped but insulin sensitizers should be continued. |
|
|
Term
| What two ways can you achieve basal insulin? |
|
Definition
1. NPH at bedtime
2. long-acting insulin once daily |
|
|
Term
| When is the insulin sliding scale used? |
|
Definition
| hospitalized or long-term care patients |
|
|
Term
| What type of insulin should be used when using the insulin sliding scale? |
|
Definition
| rapid-acting or short-acting |
|
|
Term
| What is the blood glucose goal when using the insulin sliding scale? |
|
Definition
|
|
Term
| Why is regular long-term use of the insulin sliding scale discouraged? |
|
Definition
-ineffective as monotherapy in pts with established insulin requirement
-high rates of hyper and hypoglycemia
-iatrogenic diabetic ketoacidosis |
|
|
Term
| How much of an A1c drop would you expect to see with an alpha-glucosidase inhibitor? |
|
Definition
|
|
Term
| How much of an A1c drop would you expect to see with a metaglitinide? |
|
Definition
|
|
Term
| How much of an A1c drop would you expect to see with pramlintide? |
|
Definition
|
|
Term
| How much of an A1c drop would you expect to see with a DPP-4 inhibitor? |
|
Definition
|
|
Term
| What class of diabetic drugs is associated with weight gain? |
|
Definition
|
|
Term
| What diabetic agent is an injectable synthetic amylin that can also be used in type 1 DM? |
|
Definition
|
|
Term
|
Definition
-works with insulin to reduce post-prandial glucose levels
-inhibits secretion of glucagon
-slows gastric emptying
-enhances satiety |
|
|
Term
| side effects of pramlintide |
|
Definition
|
|
Term
| action of incretin mimetics |
|
Definition
-augment insulin secretion
-lower glucagon levels
-slow gastric emptying
-increase satiety |
|
|
Term
|
Definition
|
|
Term
| side effects of incretin mimetics |
|
Definition
hypoglycemia (esp. with high dose)
nausea
weight loss |
|
|
Term
| action of DPP-4 inhibitors |
|
Definition
-augment insulin secretion
-inhibit glucagon release |
|
|
Term
| side effects of DPP-4 inhibitors |
|
Definition
nasopharyngitis
headache
diarrhea
URI
joint pain
UTI |
|
|
Term
|
Definition
|
|
Term
| What is the eAG for a HbA1c of 6? |
|
Definition
|
|
Term
| What is the eAG for a HbA1c of 7? |
|
Definition
|
|
Term
| What is the eAG for a HbA1c of 8? |
|
Definition
|
|
Term
| What is the eAG for a HbA1c of 9? |
|
Definition
|
|
Term
| What is the eAG for a HbA1c of 10? |
|
Definition
|
|
