02 Thera VI Treatment Guidelines Gong Flashcards
What are the normal A1c levels for persons without diabetes?
~5.0%
Which type of diabetes cannot be treated with oral anti-diabetic therapy?
Type 1 Diabetes
How are A1c goals determined for patients with diabetes?
A1c goals are set at a point where there is a balance between adverse effects of microvascular complications vs. symptoms of acceptable hypoglycemia
What is the major cause of death in patients with diabetes?
Ischemic Heart Disease
How do patients with DM compare to those with MI’s?
Patients with DM have the same incidence of death as someone who had an MI
How is A1c associated with CHD?
A1c predicts CHD in type 2 DM. Once A1c gets above 7% CHD events greatly increase
What is Hemoglobin A1c?
A1c test is a reliable measurement of average blood glucose levels over a 3-month period. Glucose irreversibly glycates serum proteins proportional to the average glucose concentration. Should test A1c every couple of months when patient isn’t controlled, once controlled, 2 tests per year are ok
What does Hemoglobin A1c equal?
PPG + FPG
Which is more associated with CV risk, PPG or FPG?
PPG rather than FPG predicts CV events and all-cause mortality in people with T2DM
What are the ADA goals for A1c?
<7% (general goal)
What is the ADA goal for FPG?
70-130
What is the ADA goal for PPG?
< 180
What does an average blood glucose of 140 correlate to for A1c?
6.5%
How is insulin sensitivity related to weight loss?
Insulin sensitivity improved by 25% with 10% weight loss
How is insulin resistance related to aerobic exercise?
Bicycling at 60% max HR for 45 min 3x/week x6 weeks increased glucose uptake by 25% and glucose suppression by 28%
What is the approximate empiric dosing of insulin for T1DM?
0.5-0.8 u/kg/day. Every T1DM patient needs to be on insulin
How can just a 1% A1c decrease reduce risk of complications?
-37% microvascular complications. -21% diabetes-related death. -14% myocardial infarction. -14% all-cause mortality
How do you generally individualize glycemic targets for patients based on age?
Lower glucose targets for younger patients. Higher targets for older patients or patients with significant comorbidities to reduced hypoglycemia
What should the approach to manage hyperglycemia be for patients based on disease duration?
More stringent for newly diagnosed, less stringent for long-standing disease
What should the approach to manage hyperglycemia be for patients based on Life expectancy?
More stringent for patients with a long life expectancy, can be less stringent for patients with short life expectancy (usually older patients)
What should the approach to manage hyperglycemia be for patients based on established vascular complications?
Less stringent for patients with severe established vascular complications. More stringent if its absent
What are the 2012 recommendations for more stringent management?
Younger patients. Short disease duration. No significant cardiovascular disease
What are the 2012 recommendations for less stringent management?
Older patients. History of severe hypoglycemia. Significant comorbidity. Target is difficult to achieve despite non-drug and drug intervention, including insulin
What is the ideal exercise regimen for DM lifestyle interventions?
Ideally > 150 minutes moderate-intensity aerobics, resistance, and flexibility training weekly
What is usually done for new patients who are motivated and near target goals (A1c < 7.5)?
3-6 months lifestyle changes before medication initiation
What is the initial drug therapy for most patients?
Metformin initiated with low dose due to gastrointestinal side effects
What is the initial drug therapy for patients with high A1c (e.g. > 9%)?
Generally require combination therapy with two noninsulin therapies or initial treatment with insulin
What is the initial drug therapy for patients with significant hyperglycemic symptoms or very high glucose (glucose >300-350 or A1c >10-12%)?
Insulin (mandatory if catabolic features or ketonuria are present)
At what glucose levels should patients usually be hospitalized?
Beyond 400 for T1DM, 600 for T2DM
How long is initial monotherapy used for?
Used for 3 months then A1c test to see if target achieved (continue monotherapy if A1c target achieved)
If A1c target is not achieved after 3 months of monotherapy, what is the next step?
Add another therapy (second oral agent, GLP-1 receptor agonist, basal insulin)
What can you anticipate once second agent added?
~1% further reduction in A1c with second agent
What should be done if target A1c is not met after second therapy is added?
Discontinue second agent. Start different second therapy with different mechanism of action
What are the general thoughts of triple therapy?
Most patients with long-standing T2DM will eventually require insulin due to B-cell loss (insulin is preferred to triple therapy in patients with high hyperglycemia (e.g. > 8.5%)). If using 3 noninsulin agents, select agents with complementary mechanisms
How is insulin typically initiated in T2DM?
Initiated as basal insulin (unless marked hyperglycemia or patient is symptomatic). Usually intermediate- or long-acting insulin
How is initiated insulin basal dosing usually initiated?
Begin insulin with low basal dose: 0.1-0.2 u/kg/day. Larger doses are reasonable in patients with severe hyperglycemia. Most convenient as single injection. Reduce insulin dose if any indications of hypoglycemia
What are the options to consider for persistent hyperglycemia after basal dosing of insulin added?
1) Add 1-2 units. 2) Add 5-15% increments for patients on higher insulin dose. 3) Changes made once or twice weekly. 4) When near target, adjustment should be more modest and occur less frequently
When is adding prandial insulin dosing a possible need?
Postpradial glucose excursions are high (>180). Fasting glucose is at target but A1c remains above goal for 3-6 months with basal insulin. Increasing basal insulin results in large drops in overnight or between-meal glucose. Basal dose >0.5, especially as it approaches 1
What type of diabetes medication should generally be reduced or avoided with insulin?
Thiazolidinediones
What do all insulins increase risk for?
Weight gain and hypoglycemia
How do insulin effects differ by formulation duration?
Long-acting insulin reduces overnight hypoglycemia. Rapid-acting insulin reduces postprandial glucose but generally does not result in clinically significant lower A1c
What needs to be considered when deciding on therapy for overweight and obese patients?
Often require combination therapy. Metformin is similarly effective in overweight/obese vs. lean patients. Thiazolidinediones are more effective in patients with higher BMI, but may increase weight. GLP-1 receptor agonists are associated with weight reduction
What needs to be considered when deciding on therapy for DM patients with coronary artery disease?
Avoid hypoglycemia. Preferred drugs include: Metformin, Pioglitazone (unless co-morbid HF), Incretin-based therapies need long-term data
What needs to be considered when deciding on therapy for DM patients with HF?
Avoid thiazolidinediones. Metformin can be used if non-severe ventricular failure, stable cardiovascular status, and normal renal function. Incretin-based therapies need long-term data
What needs to be considered when treating DM patients with Chronic Kidney Disease?
Increased risk for hypoglycemia. Metformin should be avoided with more severe kidney disease (if Scr > 1.5 men and > 1.4 women). Drugs not eliminated by kidneys (no restrictions): Pioglitazone, Linagliptin. Caution with secretagogues (glyburide should be specifically avoided). Avoid exenatide if GFR < 30. All insulins are eliminated more slowly in patients with severe renal impairment
What needs to be considered when treating DM patients with liver disease?
Insulin is preferred in advanced disease. Pioglitazone may benefit fatty liver disease. Meglitinides can be used. Avoid secretagogues in severe disease. Avoid incretin-based drugs in comorbid pancreatitis
When should glucose testing be done in asymptomatic patients?
Testing should begin at age 25 for those individuals without risk factors. Considered in adults of any age who are overweight or obese (BMI > 25) and have 1 or more additional risk factor for diabetes
What are risk factors for diabetes?
Physical inactivity. Primary relative with DM. High-risk ethnic populations. Women who delivered baby > 9lbs or had GDM. HTN. HDL < 35 or TG > 250. etc.
What is the treatment consideration for patients with IFG or IGT?
Lifestyle modifications
What is the treatment consideration for patients with IFG and IGT and a risk factor?
Lifestyle modifications and/or metformin
What pharmacologic therapy should be included for patients with HTN?
An ACE-I or an ARB. If needed, a thiazide should be added to those with a GFR > 30 and a loop for those with a GFR < 30
How should lipid management be handled in DM patients?
Statin therapy should be added to lifestyle therapy regardless of baseline lipid levels for diabetic patients
What is the treatment like for nephropathy in patients with DM?
Patients with micro- or macroalbuminuria, either ACE-I or ARBs should be used. Reduction of protein intake is recommended to 0.8-1g/kg/d
What are the blood glucose goals for critically ill patients in the hospital?
Insulin should be initiated for persistent hyperglycemia starting at a threshold of no greater than 180. BG of 140-180 is recommended for the majority of critically ill patients. BG of 110-140 may be appropriate
What are the blood glucose goals for non-critically ill patients in the hospital?
If treated with insulin, the pre-meal BG should be < 140, with random BG < 180. More or less stringent targets may be appropriate depending on the patient
