IM DM

Card Set Information

Author:
TerryZ
ID:
246767
Filename:
IM DM
Updated:
2013-11-27 09:40:18
Tags:
internal medicine IM endocrine endo DM diabetes mellitus
Folders:
IM
Description:
Internal medicine - diabetes mellitus
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user TerryZ on FreezingBlue Flashcards. What would you like to do?


  1. Diabetes - type 1 vs type 2
    • Type 1        Type 2
    • 5-10%        90-95%
    • 90% β-cell   ()->FFA->resist
    • ins to live     β-cell desens
    • HLA assoc    None
    • Sxs dys-wks Discov in UA
    • Acute DKA   Complications
  2. Diabetes - testing recommendations
    • Screen: all adults >45 every 3 years; those w/RFs earlier
    • Tests: A1c, fasting glu, 2hr OGTT
  3. Diabetes - glucose tests
    • Test          tol        DM
    • Rand         N/A    >200w/sx
    • Fast8h    110-126 >126 x 2
    • 2hPP75g 140-200 >200
    • HgbA1c   5.7-6.4  >6.5(mo)
  4. DM - Tx categories
    Diet & exercise, Oral HGly drugs, Insulin
  5. DM - Oral HGly drugs, biguanides
    • X: metformin
    • M: inhib hepatic glucose prod <- insulin; targets fasting BG, LDL, TG
    • S: wt loss, GI probs, lactic acidosis (rare)
    • C: renal dz, hepatic dz, Cr>1.5, contrast/surg
  6. DM - Oral HGly drugs, α-glucosidase inhibitors
    • X: acarbose, miglitol
    • M: slows/delays intestinal carb digest/absorb
    • S: D, abd pain, flatulence
    • C: none - good safety profile
  7. DM - Oral HGly drugs, sulfonylureas
    • X: glyburide, glipizide, glimepiiride
    • M: stimulates insulin secretion from β-cells
    • S: HoGly, wt gain
    • C: sulfa allergy, caution hep/renal impair
  8. DM - Oral HGly drugs, meglitinides
    • X: repaglinide, nateglinide
    • M: stimulates acute insulin secretion from β-cells
    • S: hypoglycemia
    • C: caution hep/renal impair (N), hep impair (R)
  9. DM - Oral HGly drugs, thiazolidinediones
    • X: pioglitazone
    • M: /insulin sens in liver & peripheral tissues
    • S: edema, wt gain, CHF, bone fxs
    • C: CHF class III/IV, hep dz, EtOH abuse
  10. DM - Oral HGly drugs, incretin mim/GLP-1 agon
    • X: exenatide, liraglutide
    • M: Activate GLP-1 receptors, stim glucose-depend insulin prod, inhib glucagon after meals
    • S: N/V, wt loss, ?acute pancreatitis
    • C: ESRD, FHx MEN/medul Thy CA, hx pancreatitis
  11. DM - Oral HGly drugs, DPP-4 inhib (/incretin)
    • X: sitagliptan, saxagliptan, linagliptan
    • M: Inhib DPP-4 enz, restore incretin to /ins, gluc, & delay gastric emptying
    • S: not significant unless used w/sulfonylurea
    • C: Dose in renal dz with S&S
  12. DM - Oral HGly drugs, amylin analog
    • X: pramlintide
    • M: Synth amylin, gluc, gastric empty, /satiety
    • S: N?V, wr loss, HoGly
    • C: HoGly unaware, gastroparesis
  13. Insulin Tx - indications
    • T1DM: always
    • T2DM: w/FPG>250, A1c>10%, +urinary ketones
    • symptomatic: wt loss, polyuria, polydipsia
    • HGly: despite 2 ~DM meds at max eff dose
    • /insulin rqmts: illness, infection, glucocorticoids
    • CI to meds: renal insuf, CHF, preg, allergy, SEs
  14. DM - outpatient mgmt
    • monitor: {3mo} A1c (<7.0);                           {1yr} microalbumin (ACEI/ARB if +), BUN, Cr, eye screen, cholesterol (statin if LDL>100)         {visit} feet (hi-risk->pod), BP (ACEI/ARB if >130/80)
    • @home: check glucose AC, 90-120 PC, bedtime; feet for ulcers/neuropathy; daily ASA 30+
    • Vaccine: Pneumococcal
  15. Insulin table - basal
    • Tp    NPH  Glargine  Detemir
    • Br   NovN  Lantus    Levemir
    •      HumN
    • On   2-4hr   2-4hr    3-8hr
    • Pk   4-10hr   none    none
    • Dr 10-16hr  /24hr    /24hr
    • Ds  am+pm  once     once
    • hG   more    less      less
    • Wt  more     less      least
  16. Insulin table - bolus
    • Tp  Regular    Asp/Lisp/Glul
    • Br Nov/HumR Nov/Hum/Api
    • On  30-45min    5-15 min
    • Pk     2- 3hrs    30-90 min
    • Dr     4- 8hrs      3- 4 hrs
    • Ds  30-45mAC    5-15 mAC
    • hG    more            less
    • xc     more            less
  17. Insulin table - mixed
    • Human insulin
    • Humulin/Novolin 70/30: NPH, regular             (onset 30 min, duration 10-16 hrs)
    • Humulin 50/50: NPH, regular
    • Analog insulin
    • Humalog 75/25: protamine lispro, lispro
    • Humalog 50/50: protamine lispro, lispro
    • Novolog 70/30: protamine aspart, aspart
  18. Insulin tx - sliding scale
    • Regular insulin adjustments on top of intermediate-acting insulin
    • Monitor before breakfast and before bed
    • Reg: start 2/3 before breakfast, 1/3 before bed
    • 150-200: 2 units
    • 201-250: 4 units
    • 251-300: 6 units
    • 301-350: 8 units
    • >400: call somebody
  19. Basal insulin - dosing
    • 10 units @ bedtime
    • adjust on 3-day avg FBG
    • <80 -3u; >110 +3u
    • >= 0.5 u/kg, add meal ins
    • FBG<120 & A1c high->2hPP
  20. Premixed insulin - dosing
    • 5u pre-bkfst, 5u pre-supper
    • Adj pre-supper on 3 FBG
    • Adj pre-bkfst on 3 pre-sup
    •       <80: -2u
    •  80-110: nc
    • 111-140: +2u
    • 141-180: +4u
    •      >180: +6u
  21. Basal-bolus insulin - dosing
    • 50/50 (10-20% per meal)
    • Adding bolus, basal 10%
    • Start bolus 10% //basal
    • Adj to 3-day 2hPP
    •      <100: -2u
    • 100-140:  nc
    • 141-179: +1u
    •      >180: +2u
  22. Bolus insulin - dosing
    • Carb ratio & correction/ sensitivity factor
    • Carb ratio: 1u I:?15g HCO
    • Correct fct:                      1u I: ?50mg/dL BG >target
    • Mon BG b4 meals & PP
  23. DM - macrovascular complications
    • /athero: /stroke, MI, CHF
    • CAD: silent MIs
    • PVD: .
    • CVAs: .
    • TX: RFs (BP, statin, xSmoke, exer); ASA; Gly cntl
  24. DM - microvascular complications
    • Diabetic nephrop: -> ESRD (scrn microalb, tx ACEI/ARB)
    • Diabetic retinop: scrn/yr, ?photocoag tx
    • Diabetic neurop: periph neurop, CN complic, mononeurop, autonomic neurop (NSAIDs, TCAs, gabapentin); gastroparesis (metaclopramide)
    • Diabetic foot: best tx prevention
  25. DKA - etiology
    • acute,life-threat med emerg
    • T1DM >> T2DM
    • 2/2 ins & /glucagon -> /sev HGly & /ketogenesis
    • sev HGly->osmotic diuresis -> dehydr & vol
    • precip Fs: infect, trauma, MI, stroke, surg, sepsis, GIB, inadeq ins admin
  26. DKA - S/Sx
    • N/V, Abd P
    • Kussmaul's, fruity breath
    • //dehydr, orthostat HoTN
    • tachycardia, weakness
    • polydipsia,-uria,-phagia
    • AMS
    • HGly sx hrs-days (<24hrs)
  27. DKA - Dx
    • HGly: 450<Glu<850
    • Metabolic acidosis
    • - pH<7.3, bicarb<15-18
    • - /AG
    • - ketonemia/-uria (//acetoacetate, acetone, B-hydroxybutyrate)
    • - ketonemia & acidosis req!
    • - HOsm,HoNa,HoP,HoMg,HK
  28. DKA - Tx
    • IVF!: +5%Glu@250(~HoGly)
    • Ins!: prime w/0.1 u/kg reg, infus 0.1 u/kg/hr
  29. DKA – etiology
    • acute,life-threat med emerg
    • T1DM >> T2DM
    • 2/2 ins & /glucagon -> /sev HGly &
    • /ketogenesis
    • sev HGly->osmotic diuresis -> dehydr &
    • \vol
    • precip Fs: infect,
    • trauma, MI, stroke, surg, sepsis, GIB, inadeq ins admin
  30. DKA - S/Sx
    • N/V, Abd P
    • Kussmaul's, fruity breath
    • //dehydr, orthostat HoTN
    • tachycardia, weakness
    • polydipsia,-uria,-phagia
    • AMS
    • HGly sx hrs-days (<24hrs)
  31. DKA - Dx
    • HGly: 450<Glu<850
    • Metabolic acidosis
    • - pH<7.3, bicarb<15-18
    • - /AG
    • - ketonemia/-uria (//acetoacetate, acetone, B-hydroxybutyrate)
    • - ketonemia & acidosis req!
    • - HOsm,HoNa,HoP,HoMg,HK
  32. DKA - Tx
    • IVF!: +5%Glu@250(~HoGly)
    • Ins!: prime w/0.1u/kg reg, infus 0.1u/kg/hr
    • until: AG closes, metab acid corrected, urine ketones resolve
    • then: ins, Xition to SC when eating
    • HoK!: in 1-2hrs prophyl IV if urine
    • Misc: balance lytes; bicarb controversial
  33. HHNS - stands for...
    Hyperglycemic hyperosmolar nonketotic syndrome
  34. HHNS - etiology
    • Def: State of severe HGly, HOsm, dehydr'n
    • MC: Elderly T2DM
    • Path: vIns->sev HGly -> Osm diuresis -> dehydr. Resid Ins glucagon -> ketogen & acidosis. Pt can't drink enough.
  35. HHNS - S/Sx
    HGly sxs /dys-wks; thirst, polyuria, HoTN, tachyc, CNS & focal neuro (seiz), AMS mod-sev, leth, confus.
  36. HHNS - Tx
    • IVF: 1L ns 1st hr, 1L next 2 hrs, stable .5ns; cont Ins, Glu=250, add 5% Glu
    • Ins: IV bolus 5-10u, cont infus 2-4u/hr
    • Lyte: Tx disturb, esp K
  37. DKA vs HHNS
    • DvsH       DKA                     HHNS
    • Path  I->ket,pH,deh  Ins->HOsm,diur,deh
    • Lab G>450,pH<7.3,Kt G>900,O>320,pH>7.3
    • Tx        Ins, IVF, K         /IVF, low dose Ins
    • Mort        5-10%                   10-20%

What would you like to do?

Home > Flashcards > Print Preview