DMII

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Author:
wcameron
ID:
200363
Filename:
DMII
Updated:
2013-02-13 16:39:28
Tags:
Diabetes Management
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Description:
Diagnosis, treatment, & management of DMII
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  1. ADA Diagnostic Criteria for Prediabetes
    A1C 5.7-6.4

    OR

    FPG 100-125

    • OR
    •  
    • 2-h OGTT 140-199
  2. ADA Diagnostic Criteria for DMII
    A1C > or = 6.5             -OR-

    FPG > or = 126            -OR-

    2-h OGTT > or = 200      -OR-

    S&S of DM with random BG > or = 200
  3. ADA Goals of Treatment for DMII (non-pregnant adults)
    A1C < 7% (more stringent <6.5 for younger persons, longer life expectancy, no comorbidities, etc.) (Less stringent, <8, for lower life expectancy, hx severe hypoglycemia, advanced complications, extensive comorbid conditions, long-standing DM.)

    FBG 70-130

    Post-prandial <180
  4. 1st line medication therapy for DMII or Prediabetes
    metformin (biguanide) - decreases hepatic glucose production, increases peripheral skeletal muscle sensitivity to insulin.  

    Good for pre- and post-prandial control. Will lower A1C 1-2%.

    Advantage: weight loss, no effect on hypoglycemia, may decrease CVD risk.

    S.E.: GI side effects (diarrhea), lactic acidosis, Vitamin B12 def.

    Contraind. in ETOH, renal impairment or others at risk for lactic acidosis (dehydration, hypoxia).

    Renal impairment: Not for Men with Cr > 1.5, or women with Cr > 1.4.
  5. Consider dual medication therapy in DMII when...
    A1C > or = 9%.
  6. Consider insulin with initial treatment option when...
    A1C 10-12%
  7. Sulfonylureas
    glipizide, glyburide, glimeperide

    • NOT FOR PREGNANCY
    • NO glyburide in renal patients

    - insulin secretagogues, stimulate beta-cells to increase insulin secretion

    - given daily or 2x/daily

    - Can cause hypoglycemia, weight gain. May increase islet failure

    - May decrease CVD risk
  8. Meglitinides (glinides)
    repaglinide, nateglinide

    - short-acting insulin secretagogues; given before each meal

    - good for post-prandial hyperglycemia

    - less hypoglycemia (shorter acting)

    - weight gain, hypoglycemia
  9. Thiazolidinediones (TZD)
    pioglitazone (Actos)

    - PPAR-Y activator, increases insulin sensitivity; once daily

    - no hypoglycemia, may have beneficial CVD effects (increase HDL, lower TG)

    - Inc.risk of fractures, bladder CA, weight gain, edema/HF
  10. alpha-glucosidase inhibitors
    acarbose, miglitol, voglibose

    - inhibits intestinal a-glucosidase which slows intestinal carb.digestion/absorption

    - no hypoglycemia

    - good for post-prandial control (taken w/ meals), non-systemic

    - only modest A1C lowering, GI side effects (flatulence, diarrhea)
  11. DPP-4 Inhibitors
    sitagliptin (all -gliptins)

    - inhibit DPP-4 activity, which in turn increases incretin activity (GLP-1, GIP)

    - increased insulin secretion (glucose-dependent)

    - Decreased glucagon secretion (glucose-dependent)

    - no hypoglycemia

    - only modest A1C lowering, S.E. urticaria/angioedema, ? pancreatitis

    DECREASE DOSE IN RENAL PTS.
  12. GLP-1 receptor agonists
    exenatide (-tides) "Byetta"  

    injected

    - activates GLP-1 receptors

    - increases insulin secretion (glucose dependent)

    - decreased glucagon secretion (glucose dependent)

    - slows gastric emptying, increased satiety

    -may preserve/increase beta cell mass/function

    - no hypoglycemia, helps weight loss, CV protection?

    - S.E. GI (N/V)
  13. Amylin Mimetics
    pramlintide

    - injected

    - decreases glucagon secretion, slows gastric emptying, increases satiety

    - good for postprandial control & weight loss

    - only modest A1C lowering, GI side effects common, hypoglycemia w/ insulin

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