Study questions module 6

Study questions module 6 DM  What drugs are used to treat gestational diabetes?oGestational diabetes is managed in much the same manner as any other

diabetic pregnancy: blood glucose should be monitored and then controlled

with diet and insulin.oIn most cases, the diabetic state disappears almost immediately after delivery, permitting discontinuation of insulin.oHowever, if the diabetic state persists beyond parturition, it is no longer considered gestational and should be rediagnosed and treated accordingly.oIn women taking an oral drug for type 2 diabetes, current practice is to discontinue the oral drug and switch to insulin.The only exception is the oral agent metformin, which is often satisfactory for managing type 2 diabetes in pregnancy.Women who discontinue oral medications can resume oral therapy after delivery. What A1C value indicate DM? Pre-DM?oAn A1c value of 6.5% or higher is considered diagnostic.oA1c of 5.7% to 6.4% is considered prediabetes  What fasting and random values indicate DM?oTo determine FPG levels, blood is drawn at least 8 hours after the last meal.In normoglycemic individuals, FPG levels are less than 100 mg/ dL.If FPG glucose levels are 126 mg/ dL or higher, diabetes is present.oCasual Plasma Glucose Test - For this test, blood can be drawn at any time, without regard to meals. Fasting is not required. A plasma glucose level that is 200 mg/ dL or higher suggests diabetes.However, to make a definitive diagnosis, the patient must also display

classic signs of diabetes: polyuria, polydipsia, and rapid weight loss.

 What are complications of insulin therapy?oHypoglycemia (blood glucose below 70 mg/ dL) occurs when insulin levels exceed insulin needs.A major cause of insulin excess is overdose.Imbalance between insulin levels and insulin needs can also result from reduced intake of food, vomiting and diarrhea (which reduce absorption of nutrients), excessive consumption of alcohol (which promotes hypoglycemia), unusually intense exercise (which promotes cellular glucose uptake and metabolism), and childbirth (which reduces insulin requirements).

Rapid treatment of hypoglycemia is mandatory: if hypoglycemia is

allowed to persist, irreversible brain damage or even death may result.

1 1 / 4

Study questions module 6 In conscious patients, glucose levels can be restored with a fast-acting oral sugar (e.g., glucose tablets, orange juice, sugar cubes, honey, corn syrup, nondiet soda).However, if the swallowing reflex or the gag reflex is suppressed, nothing should be administered by mouth. In cases of severe hypoglycemia, intravenous (IV) glucose is the preferred treatment.Parenteral glucagon is an alternative treatment. (The pharmacology of glucagon is discussed at the end of the chapter.) In some patients, hypoglycemia occurs without producing the symptoms noted previously.This is known as hypoglycemia unawareness. As a result, the patient remains unaware of hypoglycemia until blood sugar has become dangerously low.Hypoglycemia unawareness is a particular problem among patients practicing tight glucose control. This is because as patients experience more frequent hypoglycemia, they start to have diminished symptoms over time.The risk for dangerous hypoglycemia can be minimized by frequently monitoring blood glucose.Additionally, current recommendations state that treatment goals should be temporarily loosened (such as for several weeks) for people experiencing hypoglycemia unawareness so that they can regain hypoglycemia awareness.oHypokalemia.Insulin promotes uptake of potassium by cells. Insulin activates a membrane-bound enzyme— Na +, K +-ATPase— that pumps potassium into cells and pumps sodium out.Hence, in addition to lowering blood levels of glucose, insulin can lower blood levels of potassium. When insulin dosage is proper, effects on potassium are unremarkable.However, if insulin dosage is excessive, clinically significant hypokalemia can result.

Effects on the heart are of greatest concern: hypokalemia can reduce

contractility and can cause potentially fatal dysrhythmias.oLipohypertrophy.Lipohypertrophy (accumulation of subcutaneous fat) can occur when insulin is injected too frequently at the same site.Fat accumulates because insulin stimulates fat synthesis. When use of the site is discontinued, excess fat is eventually lost.Lipohypertrophy can be minimized through systematic rotation of injection sites.oAllergic Reactions.Rarely, patients experience systemic allergic responses. These reactions develop rapidly and are characterized by the widespread appearance of red and intensely itchy welts.

2 2 / 4

Study questions module 6 Breathing difficulty may develop. If severe allergy develops in a patient who nonetheless must continue insulin use, a desensitization procedure can be performed.This process entails giving small initial doses of human insulin, followed by a series of progressively larger doses.Drug interactions of Insulin?oHypoglycemic Agents Drugs that lower blood glucose levels can intensify hypoglycemia induced by insulin.Among these drugs are sulfonylureas, glinides, and alcohol (used acutely or long term in excessive doses).When these drugs are combined with insulin, special care must be taken to ensure as best as possible that blood glucose does not fall too low.oHyperglycemic Agents Drugs that raise blood glucose (e.g., thiazide diuretics, glucocorticoids, sympathomimetics) can counteract the desired effects of insulin.When these agents are combined with insulin, insulin dosage may need to be increased. What effect do beta blockers have on insulin?oBeta blockers can delay awareness of and response to hypoglycemia by masking signs that are associated with stimulation of the sympathetic nervous system (e.g., tachycardia, palpitations) that hypoglycemia normally causes.oFurthermore, because beta blockade impairs glycogenolysis, and because glycogenolysis is one means by which the body can respond to and counteract a fall in blood glucose, beta blockers can make insulin-induced hypoglycemia even worse by preventing the body's natural counterregulatory response. What are other therapeutic uses of insulin besides DM?oHyperkalemia  Insulin dosage must be coordinated with what?oTo achieve optimal glucose control, insulin dosage must be closely matched with insulin needs.oIf carbohydrate intake is increased, insulin dosage must be increased, too.oWhen a meal is missed or is low in carbohydrates, or when physical activity levels increase, the dosage of insulin must be decreased.oDosing requires additional adjustments to meet specialized needs.For example, insulin needs are increased by infection, stress, obesity, the adolescent growth spurt, and pregnancy after the first trimester.Conversely, insulin needs are decreased by exercise and during the first trimester of pregnancy.oTo ensure that insulin dosage is coordinated with insulin requirements, the patient and the health care team must work together to establish an

3 3 / 4

Study questions module 6 integrated program of nutrition, exercise, insulin replacement therapy, and appropriate blood glucose monitoring. What is B/P goal in diabetic?oThe current goal, as set by the ADA, is to keep blood pressure at or below 140/ 90 mm Hg, with lower systolic blood pressure targets (< 140 mm Hg) appropriate for some individuals. What medications can be given to decrease risk of diabetic nephropathy?oAn angiotensin-converting enzyme (ACE) inhibitor (e.g., lisinopril) or an angiotensin II receptor blocker (ARB; e.g., losartan) can reduce the risk for diabetic nephropathy, a long-term consequence of poor glycemic control.oThese same drugs are preferred agents for managing diabetic hypertension. What role does exercise play in treatment of both type 1 and type 2 DM?oPhysical activity increases cellular responsiveness to insulin and may also increase glucose tolerance.oAccordingly, the ADA recommends that patients perform at least 150 minutes of moderate-intensity aerobic activity per week.oBecause strenuous exercise can produce hypoglycemia, patient and provider must work to establish a safe balance between activity level, caloric intake, and insulin dosage.oUnfortunately, although the benefits of physical activity are well established, long-term adherence to a program is often difficult to maintain. What are the 4 steps in the 4 step approach?oStep 1 - At diagnosis, initiate lifestyle changes plus metformin.oStep 2 - Continue lifestyle changes plus metformin, and add a second drug, either a sulfonylurea, a thiazolidinedione, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose cotransporter 2 (SGLT-2) inhibitor, a glucagon-like peptide-1 (GLP-1) receptor agonist, or basal insulin.The choice of agent is made in light of relative efficacy, hypoglycemia risk, tolerability, weight-related considerations, and cost.oStep 3 - Progress from step 2 to a three-drug combination (inclusive of metformin).Again, the choice of regimen used is determined based on drug- and patient-specific considerations.oStep 4 - If three-drug combination therapy that includes basal insulin fails to achieve treatment goals after 3 to 6 months, it is recommended to proceed to a more complex insulin regimen, usually in combination with one or more noninsulin medicines. When a patient is on insulin therapy what are blood glucose goals obefore meals? 70 - 130 oAt bedtime? 100 – 140

• / 4