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Thera VI > 02 Thera VI Treatment Guidelines Gong > Flashcards

02 Thera VI Treatment Guidelines Gong Flashcards

1
Q

What are the normal A1c levels for persons without diabetes?

A

~5.0%

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2
Q

Which type of diabetes cannot be treated with oral anti-diabetic therapy?

A

Type 1 Diabetes

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3
Q

How are A1c goals determined for patients with diabetes?

A

A1c goals are set at a point where there is a balance between adverse effects of microvascular complications vs. symptoms of acceptable hypoglycemia

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4
Q

What is the major cause of death in patients with diabetes?

A

Ischemic Heart Disease

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5
Q

How do patients with DM compare to those with MI’s?

A

Patients with DM have the same incidence of death as someone who had an MI

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6
Q

How is A1c associated with CHD?

A

A1c predicts CHD in type 2 DM. Once A1c gets above 7% CHD events greatly increase

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7
Q

What is Hemoglobin A1c?

A

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

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8
Q

What does Hemoglobin A1c equal?

A

PPG + FPG

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9
Q

Which is more associated with CV risk, PPG or FPG?

A

PPG rather than FPG predicts CV events and all-cause mortality in people with T2DM

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10
Q

What are the ADA goals for A1c?

A

<7% (general goal)

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11
Q

What is the ADA goal for FPG?

A

70-130

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12
Q

What is the ADA goal for PPG?

A

< 180

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13
Q

What does an average blood glucose of 140 correlate to for A1c?

A

6.5%

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14
Q

How is insulin sensitivity related to weight loss?

A

Insulin sensitivity improved by 25% with 10% weight loss

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15
Q

How is insulin resistance related to aerobic exercise?

A

Bicycling at 60% max HR for 45 min 3x/week x6 weeks increased glucose uptake by 25% and glucose suppression by 28%

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16
Q

What is the approximate empiric dosing of insulin for T1DM?

A

0.5-0.8 u/kg/day. Every T1DM patient needs to be on insulin

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17
Q

How can just a 1% A1c decrease reduce risk of complications?

A

-37% microvascular complications. -21% diabetes-related death. -14% myocardial infarction. -14% all-cause mortality

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18
Q

How do you generally individualize glycemic targets for patients based on age?

A

Lower glucose targets for younger patients. Higher targets for older patients or patients with significant comorbidities to reduced hypoglycemia

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19
Q

What should the approach to manage hyperglycemia be for patients based on disease duration?

A

More stringent for newly diagnosed, less stringent for long-standing disease

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20
Q

What should the approach to manage hyperglycemia be for patients based on Life expectancy?

A

More stringent for patients with a long life expectancy, can be less stringent for patients with short life expectancy (usually older patients)

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21
Q

What should the approach to manage hyperglycemia be for patients based on established vascular complications?

A

Less stringent for patients with severe established vascular complications. More stringent if its absent

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22
Q

What are the 2012 recommendations for more stringent management?

A

Younger patients. Short disease duration. No significant cardiovascular disease

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23
Q

What are the 2012 recommendations for less stringent management?

A

Older patients. History of severe hypoglycemia. Significant comorbidity. Target is difficult to achieve despite non-drug and drug intervention, including insulin

24
Q

What is the ideal exercise regimen for DM lifestyle interventions?

A

Ideally > 150 minutes moderate-intensity aerobics, resistance, and flexibility training weekly

25
Q

What is usually done for new patients who are motivated and near target goals (A1c < 7.5)?

A

3-6 months lifestyle changes before medication initiation

26
Q

What is the initial drug therapy for most patients?

A

Metformin initiated with low dose due to gastrointestinal side effects

27
Q

What is the initial drug therapy for patients with high A1c (e.g. > 9%)?

A

Generally require combination therapy with two noninsulin therapies or initial treatment with insulin

28
Q

What is the initial drug therapy for patients with significant hyperglycemic symptoms or very high glucose (glucose >300-350 or A1c >10-12%)?

A

Insulin (mandatory if catabolic features or ketonuria are present)

29
Q

At what glucose levels should patients usually be hospitalized?

A

Beyond 400 for T1DM, 600 for T2DM

30
Q

How long is initial monotherapy used for?

A

Used for 3 months then A1c test to see if target achieved (continue monotherapy if A1c target achieved)

31
Q

If A1c target is not achieved after 3 months of monotherapy, what is the next step?

A

Add another therapy (second oral agent, GLP-1 receptor agonist, basal insulin)

32
Q

What can you anticipate once second agent added?

A

~1% further reduction in A1c with second agent

33
Q

What should be done if target A1c is not met after second therapy is added?

A

Discontinue second agent. Start different second therapy with different mechanism of action

34
Q

What are the general thoughts of triple therapy?

A

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

35
Q

How is insulin typically initiated in T2DM?

A

Initiated as basal insulin (unless marked hyperglycemia or patient is symptomatic). Usually intermediate- or long-acting insulin

36
Q

How is initiated insulin basal dosing usually initiated?

A

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

37
Q

What are the options to consider for persistent hyperglycemia after basal dosing of insulin added?

A

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

38
Q

When is adding prandial insulin dosing a possible need?

A

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

39
Q

What type of diabetes medication should generally be reduced or avoided with insulin?

A

Thiazolidinediones

40
Q

What do all insulins increase risk for?

A

Weight gain and hypoglycemia

41
Q

How do insulin effects differ by formulation duration?

A

Long-acting insulin reduces overnight hypoglycemia. Rapid-acting insulin reduces postprandial glucose but generally does not result in clinically significant lower A1c

42
Q

What needs to be considered when deciding on therapy for overweight and obese patients?

A

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

43
Q

What needs to be considered when deciding on therapy for DM patients with coronary artery disease?

A

Avoid hypoglycemia. Preferred drugs include: Metformin, Pioglitazone (unless co-morbid HF), Incretin-based therapies need long-term data

44
Q

What needs to be considered when deciding on therapy for DM patients with HF?

A

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

45
Q

What needs to be considered when treating DM patients with Chronic Kidney Disease?

A

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

46
Q

What needs to be considered when treating DM patients with liver disease?

A

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

47
Q

When should glucose testing be done in asymptomatic patients?

A

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

48
Q

What are risk factors for diabetes?

A

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.

49
Q

What is the treatment consideration for patients with IFG or IGT?

A

Lifestyle modifications

50
Q

What is the treatment consideration for patients with IFG and IGT and a risk factor?

A

Lifestyle modifications and/or metformin

51
Q

What pharmacologic therapy should be included for patients with HTN?

A

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

52
Q

How should lipid management be handled in DM patients?

A

Statin therapy should be added to lifestyle therapy regardless of baseline lipid levels for diabetic patients

53
Q

What is the treatment like for nephropathy in patients with DM?

A

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

54
Q

What are the blood glucose goals for critically ill patients in the hospital?

A

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

55
Q

What are the blood glucose goals for non-critically ill patients in the hospital?

A

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

Thera VI (27 decks)

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