FNP Endocrine QUIZLET FOR ENDOCRINE FNP Endocrine QUIZLET FOR ENDOCRINE

ADA Diagnostic Criteria for T2DM 1. A1C6.5 or 2. FPG126(no caloric intake for atleast 8 hours) OR 3. 2 hours plasma glucose 200mg/dl during an OGTT OR 4. Random BG 200mg/dl witht the symptoms of hyperglycemia. 3 Ps: polyphagia, polydipsia, and polyuria. Criteria 1-3 should be confirmed by repeating testing unless hyperglycemia is uneuivocal. ADA Diagnostic Criteria for IFG (pre-diabetics) Impaired fasting glucose 100-125mg/dl constitutes to prediabetic (must be confirmed on subsequent day) 2 hours PG on the 75-g OGTT 140-199mg/dl A1C 5.7-6.4% Intial Management - Set A1C goal -Reduce cardiovascular risk factors -Evaluate use of metformin -Physical exam and monitoring What is a reasonable A1C goal for a newly diagnosed patient with diabetes? A1C 7% for most adults with Type 2 diabetes. A1C 8% for older patients A1C 6% for type 1 diabetes and pregnant woman. Treatment Goals Cardiovascular risk reduction Aspirin 81mg a day Metformin Smoking cessation serum lipids Exercise ADA treatment for IFG or A1C 5.7-6.4% -weight loss 7% body weight -physical activity 150 min/week of mod activity When to consider Metformin A1C 5.7-6.4% Less than 60 years old BMI 35 Women with history of gestational diabetes ADA first line treatment Evidence Level A: Metformin is first choice of oral treatment unless there is a contraindication. Metformin reduces CV risks. what is a contraindication for initiating metformin in a newly diagnosed patient with diabetes 1. Concurrent liver disease 2. Increase serum creatinine 3. Heart failure 4. Alcohol abuse a person who binges on metformin? they produces lactic acidosis Metformin is often chose for 1. effect on glucose 2. absence of weight gain or hypoglycema 3. low incidence of side effects 4. low cost 5. Reduction in all cost mortality How much metformin expected to decrease A1C% in a patient who take moderate dose daily? 1-2% Upgrade to remove ads Only $35.99/year Exercise decreases A1C to 1-2% Metformin plus what other meds: Sulfonylurea or insulin Sulfonylurea potential insulin secretions may cause hypoglycemia, tend to cause weight gain Reduced A1C 1-2% use in a combo or monotherapy DPP4 agents -dipeptidyl peptidase-4 inhibitor -slows inactivation of the incretin hormone (which lower blood glucose) -use in combo or monotherapy by not intial -reduces A1C about 0.7% Gliptins (januvia, tidjenta, Ognlyza) TZDs -Thiazolidinedione (Pioglitazone, rosiglitazone) -Preserve beta cell funtions, improves insulin insesitivity -high dose associated with bone fractures, osteopenia. --Contraindication in heart failure -reduces a1c about 0.7% (actose and avandia) GLP-1 Agonists (injectable) -Glucagon like peptide -Increase production of insulin in response to elevated BG levels -decreases a1c1-1.5% advantage in weight loss Mr. Jones is a active 60 y/o retired patient who was diagnosed with type 2 diabetes 6 months ago. what is the appropriate action today according to ADA? Timeframe A1C Value Action 6 months ago 8.5% Metformin 500 mg BID 3 months ago 7.8% Metformin 1000 mg BID Today 8.5% 1. Initiate 10-20 units basal insulin 2. Add 2.5 mg glyburide daily 3. Wait 3 months, recheck A1C 4. Recheck the A1C today Answer:1 and 2 What meds are safe when combined? Metformin Plus EVERYTHING! • Insulin* Plus Any of these: Metformin, GLP-1 agonists, DPP-4 inhibitors, SGLT2 inhibitors (invocana) *Usually discontinue sulfonylureas, glitazones after initiating insulin SU plus insulin is less efficacious, more weight gain; can use insulin alone and achieve same result for less cost A1C 5.9%, newly diagnosed with IFG Metformin Upgrade to remove ads Only $35.99/year 55 y/o female, intolerant of metformin, A1C 10.2% Insulin 79 y/o male, A1C 8.9%, newly diagnosed DM Metformin 62 y/o female taking metformin, A1C 7.9%, fixed budget Sulfaneurea (inexpensive) 27 y/o male, A1C 6.9%, newly diagnosed T2DM Metformin 62 y/o female who takes metformin, A1C 7.5%, fixed budget continue with metformin, just want him around 8 so no other med needs 55 y/o female, takes metformin plus glipizide, A1C 10.2% DC sulfaneuriea, continue metformin, introduce insulin Cashopenic the state of your wallet being seriously intolerant of spending more money on medications When should you consider insulin? Regular and NPH insulin are available OTC Consider initially when A1C 10% • Fasting glucose 250 mg/dL • After maxing out orals • Symptoms of hyperglycemia • Pregnant patients • Consider it EARLY! Insulin Type: Immediate Onset of Action: 25min, Duration: 2-4 hours, 3-5 hours (Novalog, humalog, Apidra) Regular Onset of Action: 30min, Duration: 6-8 hours , 3-5 hours (Humulin, Novolin)