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84 Cards in this Set
- Front
- Back
DM is a group of metabolic diseases characterized by hyperglycemia resulting from defects in what two things?
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Insulin Secretion
Insulin Action |
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DM is chronically associated with long term damage, dysfunction and failure in what systems macrovascularly and microvascularly?
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Macrovascular: Heart and Blood Vessels
Microvascular: Eyes, Kidneys, Nerves |
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What are the primary symptoms of hyperglycemia?
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Polyuria
Polydipsia Weight loss in Type 1 DM |
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This is DM with an absolute deficiency of insulin secretion?
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Type 1
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This is DM with resistance to insulin action and an inadequate compensatory insulin secretory response.
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Type 2
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This results from cellular-mediated autoimmune destruction of the B-cells of the pancreas.
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Type 1 DM
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What can be the first manifestation of DM type 1 in children/adolescents?
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DKA
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What are the four ways in which to diagnose DM?
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1. Symptoms of diabetes plus casual plasma glucose concentration of over 200mg/dl
2. FPG>126mg/dl 3. 2-h postload glucose > 200mg/dl during an OGTT (75g glucose) 4. A1C > 6.5% |
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What drug can be considered for all "pre-diabetics"?
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Metformin
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What are the three key features of DKA?
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Hyperglycemia
Ketosis Acidosis |
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What are precipitating factors of DKA?
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Infection, concurrent illness, omission of insulin, inadequate insulin when sick.
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How do you treat DKA?
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Intensive fluid, immediate insulin, potassium replacement, treatment of underlying illness.
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What is the key difference between DKA and HHS?
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Key difference from DKA is insulin is present which prevents ketones/ketoacidosis.
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What is usually found with HHS?
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Severe hyperglycemia, dehydration, increased serum osmolarity, anion gap is usually normal.
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How do you treat HHS?
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Volume replacement, treat DM with po agents or insulin.
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When attempting to prevent microvascular problems in DM what are the goals?
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Achieve A1C goal
BP < 130/80 ACE-I in T1DM with microalbuminuria ACE-I or ARB in T2DM with microalbuminuria ARB in T2DM with macroalbuminuria Foot care |
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When attempting to prevent macrovascular problems in DM what are the goals?
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Achieve A1C goal
LDL <100 (or <70) TG < 150 HDL >50 BP <130/80 - use ACE-I or ARB first Aspirin daily (Only if at risk) Quit smoking (ACE-I, statin and aspirin if >40 yo and has another CV risk factor) |
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This is the gold standard for monitoring glycemic control?
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A1C
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True or False:
Intensively lowered A1C to 6.5% or less doesn't reduce CV events in older, T2DM with a high risk of CVD? |
True
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What is an easy way to approximate A1C into blood glucose measurement?
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A1C - 2 X 30
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Concerning Lipid Panel, what is the order of priority in treating a patient with DM?
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LDL, HDL and then TG
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Combined hyperlipidemia, glycemic control first or in combination with lipid lowering therapy hopefully result in what goals?
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LDL <100, HDL >45, TG <150
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Of the nine drugs used for the treatment of T2DM what three have the highest effects?
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Insulin
Sulfonylureas Biguanides |
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What are the nine classes of drugs for treatment of T2DM?
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Insulin
Sulfonylureas Biguanides Alpha-glucosidase inhibitors Glitazones Glinides GLP analogues Amylin analogues DPP-4 inhibitors |
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What are two other drugs that are approved for the treatment of T2DM?
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Colesevelam
Bromocriptine |
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For lipids (LDL), used as add on.
Lowers A1C - 0.5% 6 tablets once a day or 3 tablets twice a day. Drug interactions; separate by four hours. |
Colesevelam
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For Parkinson's disease
Unknown mechanism, theory, reverses metabolic changes associated with insulin resistance/obesity Lowers A1C - 0.5% 1.6-4.8mg only in the morning (glycemic effects related to circadian rhythm) |
Bromocriptine
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What are the four steps in treatment of type 2 diabetes?
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1. Diagnosis
2. Therapeutic lifestyle changes and Metformin 3. Combination therapy - Oral drugs only 4. Combination therapy - Oral drug with insulin |
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These drugs decrease deaths and cardiac complications. They decrease hepatic glucose production and increase insulin mediated peripheral glucose uptake.
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Biguanides
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What are the drugs included in the biguanides?
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Metformin (Glucophage), Metformin hydrochloride extended release (Glucophage XR, Glumetza)
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Biguanides are contraindicated in what patients?
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Patients with impaired renal function.
(Serum Cr > 1.4 mg/dL for womeon or 1.5 mg/dL for men) |
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These drugs increase endogenous insulin secretion, they also can cause hypoglycemia, weight gain, no specific effect on plasma lipids or blood pressure, and generally are the least expensive class of medication.
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Sulfonylureas
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What are the drugs included in the sulfonylurea class?
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First generation Sulfonylureas - Chlorpropamide (Diabinese), Tolazamide, acetohexamide (dymelor), tolbutamide.
Second generation sulfonylureas - Glyburide (micronase, glynase and diabeta), glimepiride (amaryl), glipizide (glucotrol, glucotrol XL) |
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What is a good principle to use (dosage) when starting a sulfonylurea?
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Use Glipizide and start with 2.5mg, cut a 5mg pill in half.
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These drugs decrease insulin resistance by making muscle and adipose cells more sensitive to insulin. They also suppress hepatic glucose production.
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Thiazolidinediones
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What are some side effects of Thiazolidinediones?
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Weight gain
Edema Hypoglycemia |
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What patients should not take thiazolidinediones due to fluid retention/edema?
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Conraindicated in patients with CHF or abnormal liver function.
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What are the thiazolidinediones?
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Pioglitazone (actos), Rosiglitazone (Avandia)
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What thiazolidinedione has a link to myocardial infarction and what should be used instead?
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Rosiglitazone (avandia), Pioglitazone (actos) should be used instead.
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How long can it take for a thiazolidinedione to work and what is a good dosage to start at?
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It can take up to 3 months for it to work and 15mg is a good dose to start with.
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These drugs stimulate insulin secretion (rapidly and for a short duration) in the presence of glucose.
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Meglitinides
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These can be classified as short acting sulfonylureas and are very expensive.
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Meglitinides
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These are safer at higher levels of serum creatinin than sulfonylureas.
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Meglitinides
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What are the medications in the meglitinide class?
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Repaglinide (prandin), Nateglinide (starlix)
Only works if you take it when you eat, start low, go slow. |
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These drugs block the enzymes that digest starches in the small intestines. Flatulance and abdominal discomfort can occur, contraindicated in patients with inflammatory bowel diseae or cirrhosis.
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Alpha-glucosidase inhibitors.
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What are the alpha-glucosidase inhibitors?
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acarbose (precose), miglitol (glyset)
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What is glucovance?
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glyburide/metformin
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What is metaglip?
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Glipizide/metformin
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What is Avandamet?
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rosiglitazone/metformin
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What is actopius met?
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pioglitazone/metformin
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What is Duetact?
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pioglitazone/glimepride
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What is Avandaryl?
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rosiglitazone/glimepiride?
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What is janumet?
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sitagliptin/metformin
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What is prandimet?
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repaglinide/metformin
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The drug pramlintide mimics three actions of what? What are the three actions mimicked?
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Pramlintide mimics three important actions of amylin that implacts glucose appearance.
1. Inhibits inappropriately high postprandial glucagon secretion 2. Slows gastric emptying 3. Promotes satiety and reduces caloric intake. |
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What is the MOA of the amylinomimetic:Pramlintide?
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Analog of naturally occuring pancreatic hormone amylin
Suppresses glucagon secretion Induces satiety and reduces food intake Slows gastric emptying |
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What are the indications for Pramlintide?
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DM2 as adjunct treatment who have failed to achieve glycemic control despite insulin therapy (with or without sulfonylurea and/or metformin)
DM1 as adjunct who have failed to achieve glycemic control with insulin |
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How do you initiate pramlintide tx in Type 2 DM and for what reasons?
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Start at 60 micrograms and then go to 120 micrograms after 3-7 days. This is done to avoid severe nausea/vomiting.
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Initial dose is 60mcg SC immediately prior to major meals
Reduce preprandial insulin and mixed insulin by 50% Increase to 120mcg when no significant nausea for 3-7 days Adjust insulin doses accordingly |
Pramlintide in type 2 diabetics
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What is the Pramlintide dosing for Type 1 Diabetics?
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Initiate at 15mcg immediately prior to major meals
Reduce preprandial or mixed insulin by 50% Increase to the next increment (30, 45, 60mcg) when no nausea has occurred for at least 3 days. Adjust insulin dosing accordingly. |
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Who is not a good candidate for pramlintide?
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Poor compliance with current insulin regimen
Poor compliance home glucose monitoring A1C > 9% Recurrent severe hypoglycemia requiring assistance during past 6 months. Hypoglycemia unawareness Confirmed gastroparesis diagnosis Use of drugs that stimulate gastrointestinal mobility Pediatric patients |
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What are two important things to know about pramlintide and drug interactions/administration?
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Drug interactions:
Delays absorption Give drugs that need a rapid onset 1 hour prior or 2 hours after injection Administration: Do not mix with insulin, give as a separate injection at a separate site at least 2 inches apart. |
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These are gut hormones that enhance insulin secretion in response to food.
Enhances glucose dependent insulin secretion (beta cell response) |
Incretins - Glucagon LIke Peptide 1 (GLP-1)
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This is a drug that acts as a GLP-1/Incretin mimetic?
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Exanatide
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What are the properties of exanatide?
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It is long acting, in comparison to GLP-1.
It increase glucose dependent insulin secretion Regulates gastric emptying Decreases glucagon secretion Decreases food intake Decreases plasma glucose acutely to near normal levels Resistant to DPP-IV degradation |
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What is the MOA of exanatide?
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Mimics the action of gut incretin hormone GLP-1
Enhances glucose-dependent insulin secretion Restores first phase insulin response Suppresses glucagon secretion Reduces food intake Slows gastric emptying |
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Exenatide is indicated for?
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Adjunctive therapy in T2DM who are taking metformin, a sulfonylurea, a glitazone (or in combination) and not achieving glycemic control (not in patients taking insulin).
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You do not use exenatide in patients with?
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gastroparesis
Some reports of kidney failure in people taking this. |
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Exanatide can affect other drugs how?
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May reduce the rate and extent of absorption of orally administered drugs (care if rapid absorption needed, ie. contraceptives, antibiotics)
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This is a brand new GLP-1 analog that is long acting and requires only one daily dose. It shouldn't be given to anyone with a hx of thyroid cancer.
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Liraglutide
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GLP-1 and GIP are metabolized by?
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DPP4
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DPP4 inhibitors are?
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Sitagliptin (Januvia), Saxagliptin (onglyza),
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What is the dosing of saxagliptin?
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2.5-5mg daily - lower doses in renal dysfunction or if drug interaction with CYP3A4, inhibitor (ie. clarithryomycin)
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What is the dosing for sitagliptin?
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100mg qd
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What is the dosage of sitagliptin in a patient with moderate renal impairment?
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50mg qd
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What is the dosage of sitagliptin in ESRD patients?
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25mg qd
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What is the rapid acting insulin?
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Aspart (Novolog, glulisine (apidra), lispro (humalog)
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What is short acting insulin?
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Regular
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What is long acting insulin?
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Glargine (lantus), Detemir (levemir)
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This is when a patient has blood glucose < 50-60mg/dL, it is life threatening < 50mg/dL.
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Hypoglycemia
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The following are signs of what?
Cold sweats, faintness, dizzines Headache Tachycardia Trembling, nervousness Blurred vision Hunger Inability to awaken Grouchiness Personality change |
Hypoglycemia
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How do you treat hypoglycemia?
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Rule of 15: 15g of CHO, wait 15 minutes, check BS, repeat if needed.
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What are other ways to treat hypoglycemia?
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Chew 3 glucose tablets, tube of glucose gel, 1/2 cup of fruit juice, piece of fruit, 1 cup of milk, 1/2 cup of soda, 2 large or 5 small sugar cubes, 6-7 life savers, 2 tsp honey or corn syrup, glucagon injection.
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What are the causes of hypoglycemia?
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Too much insulin
Not enough food Delayed meal Exercise. |