1. Krisa Christian MD

2. Diabetes 1 in every 14 Americans has diabetes The disease accounts for 200,000 deaths, 82,000 amputations, 44,400 cases of ESRD, and 24,000 cases of blindness National Health and Nutritional Examination Survey (1999-2000) found that only 7 percent of adults with diabetes achieved glycemic, lipid, and blood pressure goals

3. Diagnosis fasting BG 2 hr Oral GTT no diabetes <100 mg/dL<140 Prediabetes100 – 125 140 – 199 Diabetes >126 200

4. The American Diabetes Association recommends which of the following to reduce macrovascular disease?: a. ASA 75 – 162mg daily b. Blood pressure controlled to 130/80 mmHg or less with an ACE-I c. Achieve an LDL of 130 mg/Dl or less d. Smoking cessation

5. Macrovascular disease Atherosclerosis

6. Aspirin Therapy ASA 75 – 162mg per day for secondary prevention in diabetics with a history of CAD, MI, CVA or TIA, claudication or PVD, angina ASA 75 – 162mg per day for primary prevention in any diabetic with an additional CV risk factor Not recommended for under 21 yrs (Reye’s syndrome) ***United States Physician’s Health Study

7. Blood pressure control Minimal incidence of complications when BP < 130/80 mm Hg, even lower with nephropathy Generally recommend treatment with low- dose thiazide for diabetics with HTN, unless there is an indication for another antihypertensive agent *** ALLHAT trial, JAMA 2002

8. Lipid Control In a diabetic patient, goal lipid control is defined as which of the following?: A. LDL <100 mg/dl B. HDL > 50 mg/dl C. Triglycerides < 150 mg/dl D. All of the above

9. Glycemic Control In a diabetic patient, goal A1C value is which of the following?: A. <7 percent B. <6.1 percent C. 80 – 150 mg/dl D. depends on the age/circumstance of the patient

10. A1C A 1% change in an A1c result reflects a change of about 30 mg/dL (1.67 mmol/L) in average blood glucose. For instance, an A1c of 6% corresponds to an average glucose of 135 mg/dL (7.5 mmol/L), while an A1c of 9% corresponds to an average glucose of 240 mg/dL (13.5 mmol/L). The closer a diabetic can keep their A1c to 6%, the better their diabetes is in control. As the A1c increases, so does the risk of complications.

11. Glycemic Control Intensive therapy aimed at improved glycemic control reduce the rates of microvascular complications: Neuropathy Nephropathy Retinopathy

12. Glycemic Control How often should you check a hemoglobin A1C? A. Every 3 months B. Twice yearly C. Once yearly D. Only if you are unaware of the patient’s average blood glucose reading

13. Secretion of Insulin Pancreatic beta cell hormones Insulin Amylin Pancreatic alpha cell hormones Glucagon Gastrointestinal peptides Glucagon-like peptide - 1 Gastric inhibitory peptide

16. Treatment For a type II diabetic, the best initial treatment includes which of the following?: Biguanides Sulfonylureas Thiazolidinediones Alpha-glucosidase inhibitors Amylin and GLP-1 based therapies Insulin

17. Oral Medications (insulin sensitizers) Biguanides METFORMIN Effective only in the presence of insulin Major effect is to increase insulin action Possibly by suppressing hepatic glucose output Increased insulin-medicated glucose utilization in peripheral tissues Antilipolytic effect that lowers serum free fatty acids, reducing substrate availability for gluconeogenesis

18. Oral Medications, cont METFORMIN Promotes modest weight reduction or at least weight stabilization Lowers fasting blood glucose concentrations by at least 20 percent

19. Oral Medications, cont METFORMIN Less likely to cause hypoglycemia (does not increase insulin secretion) Has prominent lipid lowering activity (decreases serum TG and free fatty acid concentrations, small decrease in LDL, increase in HDL) Disadvantages --- 1. Risk of lactic acidosis (esp with radiologic procedures involving contrast material – hold metformin for 48 hours following) 2. Gastrointestinal side effects (metallic taste, mild anorexia, nausea, abdominal discomfort and diarrhea). 3. May decrease absorption of vitamin B12 by 30% but rarely causes megaloblastic anemia. 4. Avoid if renal or hepatic impairment or NYHA class III or IV HF

20. Oral Medications (insulin sensitizer) Thiazolidinediones (Pioglitazone) Increase insulin sensitivity by acting on liver and muscle to increase glucose utilization and decrease glucose production Monotherapy or combination More expensive Side Effects: potential hepatotoxicity (,weight gain (can be substantial), fluid retention (may precipitate CHF)

21. Oral Medications (Insulin sensitizer) Alpha-glucosidase inhibitors and lipase inhibitors (acarbose and miglitol) Inhibit gastrointestinal enzymes that convert carbohydrates into monosaccharides in a dose-dependent fashion Slow absorption of glucose (decreases post- prandial hyperglycemia) Potentially benefit type 1 and type 2 diabetes

22. Oral Medications Alpha-glucosidase inhibitors Acarbose 100mg TID showed benefit on LDL/HDL ratios Side effects are flatulence (73% vs 39% placebo) – may be less with slow increases in dosage.

23. Oral Medications (insulin secretagogues) Sulfonylureas Stimulates insulin secretion from the pancreatic beta-islet cells Useful only when beta-islet cell function exists. Suppress overnight hepatic glucose output Lower blood glucose concentrations by about 20% (similar to a once or twice daily long acting insulin)

24. Oral Medications Sulfonylureas Side Effects Hypoglycemia especially with longer acting sulfonylureas (chlorpropamide, glyburide) Nausea Weight gain Skin reactions Abnormal LFTs Specific to chlorpropamide –flushing reaction when used with alcohol, hyponatremia (SIADH) Best to avoid if renal disease, elderly or infrequent mealtimes

25. Oral Medications Meglitinides Structurally different than sulfonylureas but act similarly to regulate ATP-dependent potassium channels in pancreatic beta-cells to increase insulin secretion Repaglinide (Prandin) Nateglinide (Starlix) Sometimes used if infrequent meals, renal disease, or post-prandial hyperglycemia

26. Oral Medications (novel therapies) Dipeptidyl Peptidase IV inhibitors Sitagliptin (Januvia) and Vildagliptin (pending FDA approval) DPP IV = the enzyme that degrades endogenous secreted incretins (GLP-1 and glucose-dependent insulinotropic polypeptide Lead to increased secretion and suppression of glucagon secretion

27. Oral medications, cont DPP IV inhibitors Are weight neutral Does not cause hypoglycemia Drawbacks: Remember to reduce dosing in patients with renal insufficiency Side effects include nasopharyngitis and headache

28. A 56 year old with type II diabetes is scheduled to undergo a diagnostic angiogram following a positive stress test. Which of the following medications should be held prior to the angiogram? A. Lisinopril (ACE-I) B. Simvastatin (statin for cholesterol therapy) C. Metformin (biguanide for diabetes) D. Insulin E. ASA

29. A 42 year old male comes in for his annual physical. He reports only increased fatigue as of late. VS – weight 323#, height 6’2’’ bp 142/84, p 86 exam remarkable only for morbid obesity fasting glucose of 260, a1c 9.1% urine microalbumin is negative You make the diagnosis of diabetes type II and start: A. Metformin 500 mg at night, titrating up as tolerated B. Hydrochlorthiazide 12.5mg daily C. ASA 81mg daily D. Insulin 70/30 10 units SQ in the morning and at night

30. Subcutaneous medications Pramlintide (Amylin analog) Decreases rate of gastric emptying Suppresses glucagon secretion (and hepatic glucose production) Promotes satiety (decreases appetite) Less hypoglycemia, some weight loss Approved for type I

31. Subcutaneous medications Exenitide (synthetic exendin-4, a peptide with GLP-1 like actions) Slows gastric emptying Supresses inappropriately elevated glucagon levels Insulinotropic (augments insulin secretion), a dose dependent and glucose dependent phenomenon Not currently approved for use with insulin therapy

32. Subcutaneous medications Insulin Stimulates glucose uptake in muscles and fat Inhibits lipolysis Promotes glycogen deposition Enhances protein synthesis

33. Insulin Dosing range and Average Daily Dosing Multiple daily injections Initial dose Average total daily dose Type I DM 0.2 U/kg/d 0.4 – 0.6 U/kg/d Type II DM 0.3-0.5 U/kg/d 0.8 – 1.2 U/kg/d

34. Pre meal sliding scale insulin adjustment of mealtime insulin THE 1800 RULE 1800/total daily insulin dose = mg/dl that 1 unit of insulin will decrease blood glucose Example – if our patient requires 50 units per day 1800/50 = 36 That means that 1 unit of insulin will decrease BG by 36 units If pre-prandial blood glucose is 150, you may want to give the patient 1 Unit of shorter acting insulin to decrease her blood sugar to a goal of 110.

35. Treatment For a type I diabetic, treatment should include which of the following?: A. Basal dose of insulin with pre-meal bolus (intensive therapy) B. Continuous SQ insulin infusion (insulin pump) C. Oral agents D. Diet therapy

36. A 65 year old female with type II diabetes and CHF is not achieving adequate blood glucose control. She is taking maximum doses of metformin and glimepiride. Which diabetic agent could you add to help improve her A1C? A. Rosiglitazone B. Simvastatin C. Exenetide D. Insulin

37. A 17 year old man develops polyuria, polydipsia and rapid weight loss. He comes to see you in your clinic and you run some labs, only to discover the following: Serum sodium 132 mmol/L (normal is 135 – 140) Serum potassium 5.3 mmol/l (normal is 3.6 – 5.4) Serum glucose 416 mg/dL (normal is 70 – 100) He is not acidotic and shows no signs of infection. You diagnose Type I diabetes melitus and decide to start insulin.

38. A good starting range would be: a. 0.2 U/kg/d b. 1 unit for every 100 mg/dL his blood glucose is above 100 c. 0.5 U/kg/d d. 10 units twice a day e. you opt to start him on oral medications instead

39. The 1800 Rule helps you to: a. Calculate the amount 1 unit of insulin will decrease BG based on the patient’s usual daily dosing b. Calculate the total amount of insulin needed for a new patient starting on insulin c. Calculate body mass index d. Assign a schedule of insulin based on military time e. Calculate the amount of fluid needed for a patient in diabetic ketoacidosis

40. A good patient to start on insulin would be: a. A patient with a pre-meal blood glucose consistently >250 mg/dl despite oral therapy b. A patient with symptomatic hyperglycemia (polyuria. polydipsia, weight loss due to dehydration, etc) c. All Type I and DM due to pancreatic failure d. Type II not reaching glycemic goals with nutrition and oral drug therapy