03 Thera VI Management of DM Complications Mak Flashcards
Which patients have a higher risk of getting hypoglycemia?
Patients on medications that promote insulin release (Insulins, Sulfonylureas, Meglitinides)
When is hypoglycemia a concern?
In patients using fast acting and long-duration agents. Elderly with dementia. Long standing DM with defective counter-regulation (no glucagon release when glucose levels are low)
What is the primary complication of DM that leads to hospitalization?
Hypoglycemia
What is the 15-15-15 rule for hypoglycemia?
Give 15g of carbohydrates, wait 15 minutes, check glucose levels. If still low you can repeat
What are good quick carbohydrates to help with hypoglycemia?
Avoid high fat content (slows sugar absorption). Choose simple sugar (fruit juices, hard candies, glucose tablets). Glucose Gel (best choice)
What are the doses for glucagon injections (SQ, IM, IV)?
Adult: 1mg. Pediatric: 0.5mg (if over 20kg use adult dose)
What is done in the ER for hypoglycemia?
50ml D50W
What are the three main symptoms of Diabetic Ketoacidosis?
Kussmahl Breating (d/t acidosis, deep breaths). Glucose level >300s, usually >500s. Fruity breath/UA + Ketones
What type of DM is Ketoacidosis primarily found?
T1DM
What is the main contributor to the formation of Ketoacidosis?
Absolute Insulin Deficiency
What are the primary complications of HHS?
An increase in: Glucagon, Catecholamines, Cortisol, and Growth hormone. THese all lead to Hyperglycemia, which ultimately leads to Hyperosmolarity due to dehydration
What are the primary complications of DKA (Diabetic Ketoacidosis)?
Same as HHS (Hyperglycemia and Hyperosmolarity) as well as Ketoacidosis due to an absolute insulin deficiency
What type of DM patient is DKA primarily found in?
T1DM
What type of DM patient is HHS primarily found in?
More T2DM
What is the difference in symptom duration for DKA and HHS?
DKA: < 2 days. HHS: > 5 days
What is the difference in plasma glucose for DKA and HHS?
DKA: > 250. HHS: > 600
What is the difference in arterial pH for DKA and HHS?
DKA: more acidic
What are the difference in the U and S ketones for DKA and HHS?
Very high in DKA, low for HHS
What is the difference in the serum osmolality in DKA and HHS?
DKA: variable. HHS: > 320
What is the difference in the serum sodium in DKA and HHS?
DKA: 100-nl. HHS: nl-high
What is the difference in the CNS status of DKA and HHS?
DKA: alert to stupor. HHS: stupor/comatose
What is the difference in mortality for DKA and HHS?
DKA: 3-10%. HHS: 10-20%
What are the signature presentations of Diabetic Ketoacidosis (DKA)?
Moderate hyperglycemia (exacerbated 3Ps). Moderate dehydration (sunken eyes, tachycardia). Decreased Na, HCO3, pH, increased BUN/Scr. Large serum or urinary ketones
What are the precipitating factors of DKA?
Infection. Inadequate insulin dosing. Severe physical or emotional stress
What is the treatment of DKA and HHS?
Fluid replacement (need to alter therapy to avoid cerebral edema). Insulin infusion (decrease PG by 50-70 in 1st hour). Potassium replenishment. Bicarbonate (?): consider only if pH < 7.0
What should the normal diet look like?
2000 kcal/day: 60% CHO, 20% Protein, 20% Fat
Why is Fiber good for DM patients?
T2DM patients can significantly lower glucose and insulin levels (by 10%) if they eat a high fiber diet. Higher fiber content diet reduced incidence of GDM. 25g/d for women, 38g/d for men
What is the relationship between smoking and DM?
Increases risk of morbidity and premature deaths (increases macro- and microvascular complications). Associated with development of type 2 DM
What needs to be considered for DM patients and immunization?
Influenza vaccine annually to all DM patients > 6 months of age. Pneumococcal polysaccharide vaccine to ALL diabetic patients > 2 years (one time revaccination for those >64 years previously immunized < 65 years if > 5 years ago
What are the biggest risk reductions with 1% decline in annual mean A1c?
Microvascular disease (37%). PVD (43%)
When do DM patients usually get Diabetic Retinopathy (DR)?
> 20 years DM history or onset before 30. Almost all have retinopathy. 1/2 have proliferative disease. More prevalent in T1DM
What are the risk factors for Diabetic Retinopathy (DR)?
Age, genes, beyond puberty. HTN, dyslipidemia, smoking, pregnancy, nephropathy
What is the result of accumulation of fluid within the retina?
Diabetic Macular Edema (DME). Typically cause moderate visual loss in T2DM
What is the result of vascular wall distortions of the eye?
Nonproliferative Diabetic Retinopathy (NPDR)
What is the result of Neovascularization of the eye?
Proliferative Diabetic Retinopathy (PDR). Typically causing visual loss in T1DM
What is the screening for retinopathy like for T1DM?
Screen > 10 yo, dilated/comprehensive eye exam within 5 years after onset of disease
What is the screening for retinopathy like for T2DM?
Screen at time of diagnosis. Repeat annually; q2-3 years acceptable if there has been 1 or more normal exam. Screen during first trimester in pre-existing diabetes and 1 year postpartum
What is the current treatment for diabetic retinopathy?
No current treatment prevents or cures diabetic retinopathy
What can improve and slow down diabetic retinopathy (not cure or prevent)?
Glycemia and dyslipidemia therapy
What is Nephropathy like in DM patients?
ESRD more common in T1DM. Renal Insufficiency common in T2DM, elderly, HTN
What does Microalbuminuria lead to?
Macroalbuminuria, which leads to Scr doubling. Scr doubling leads to ESRD (if no dialysis, 7 month survival). ESRD leads to CVD
What happens when the kidneys function to remove water, urea, creatinine, metabolic wastes, preserve acid-base and electrolyte balance fails?
N/V/A, metallic taste. Edema, electrolyte imbalance (high K). Pruritus. Fatigue, cramps, change in mental status
What happens when the kidneys function to regulate blood pressure fails?
HTN, CHF, Atherosclerosis
What happens when the kidneys function to Synthesize erythropoietin fails?
Anemia, bleeding risk, also neutropenia
What happens when the kidneys function to form 1,25 dehydroxy-vitamin D fails?
Skeletal fractures, osteomalacia, altered calcium and phosphate metabolism
When should screening for nephropathy for T1DM be done?
Urine analysis at puberty, or 5 years after diagnosis. If positive do quantitative analysis
When should screening for nephropathy for T2DM be done?
Urine analysis at diagnosis. If positive, do quantitative analysis
When should urine analysis for nephropathy not be done?
During periods of urinary albumin excretion (UAE): UTI, hematuria, acute febrile illness, short-term hyperglycemia, vigorous exercise, uncontrolled HTN, HF
What can having a high proteinuria do for T2DM?
Increases incidence of CHD and Stroke
How is kidney function estimated?
Modified Diet in Renal Disease (MDRD). GFR = 186 x (Scr ^ -1.154) x (age ^ -0.203) x (0.742 if female) x (1.210 if AA)
What are two Nephroprotective agents used?
ACE-I or ARBs
What is the only FDA approved ACE-I for nephroprotection?
Captopril. Not used much due to BID dosing
What other ACE-I are clinically used for nephroprotection?
Enalapril. Lisinopril. Benazepril. Ramipril
Do ACE-I need renal adjustment?
Yes, all of them
What are the only FDA approved ARBs for nephroprotection?
Losartan. Irbesartan
What other ARBs are clnically used for nephroprotection?
Valsartan. Candesartan. Telmisartan
Do ARBs need renal adjustment?
No, none of them do
Whats the general information on Diabetic Neuropathy?
Affects 60-70% patients. Same frequency in T1DM and T2DM. Earliest detectable signs of long term complications. AA at higher risk than caucasians. Taller people at higher risk
What is Sensory Motor (peripheral) or Distal Symmetric Polyneuropathy?
Pain, numbness, tingling, burning of extremities
What is Autonomic Neuropathy?
Neurogenic bladder. Sexual dysfunction. Gastroparesis. Fecal incontinence. Decreased or absent response to light, decreasing pupil size
What is the mechanism of nerve damage that leads to Neuropathy?
Sorbitol Aldose Reductase Pathway (Polyol Pathway): Increased AGEs lead to inflammatory process, decreased synthesis of NO lead to vasoconstriction and decrease circulation
What are the FDA approved agents for Diabetic Peripheral Neuropathy?
Pregabalin. Duloxetine. Tapentadol ER. Often unresponsive to simple analgesics or even opiates
What is Cardiac Autonomic Neuropathy (CAN)?
Damage of nerves supplying the heart
What are the symptoms of CAN?
Resting tachycardia > 100bpm. Dizziness/vertigo. Exercise intolerance. Orthostatic hypotension (drop of 20 mmHg upon standing). Sudomotor dysfunction. Impaired neurovascular function. Brittle diabetes; hypoglycemic autonomic failure
What is the treatment for CAN?
Rising slowly. Compression stocking. Fludrocortisone. Midodrine
What is Gastroparesis?
Occurs in 20-60% of patients. Causes bloating, early satiety, reflux, vomiting, abdominal pain, loss of appetite, constipation. Suspect in patients with erratic glucose control
What is the treatment for Gastroparesis?
Frequent and smaller meals with low fiber/fat. Metoclopramide
What is the treatment for sexual dysfunction often seen in DM patients?
IP prostaglandins, papaverine, phentolamine, atropine. Vacuum pumps. Surgical implants. Sildenafil
What is the symptomology of Peripheral Vascular Disease (PVD or PAD)?
Asymptomatic. Intermittent claudication to rest pain. Nonhealing wounds and gangrene, infections, nerve damage (foot ulcers/infections, dental caries/infections)
When doing a foot exam, what should be you look for as a sign of risk for foot ulceration?
Venous filling time of > 20 seconds. Waxy skin, hair loss, distal digital cooling
How do you perform the 10-g monofilament test on feet?
Place the device perpendicular to the skin, with pressure applied until the monofilament buckles. Hold in place for 1 second and then release
What are some diabetes associated infections?
Fungal infections (Tinea pedis, Vaginitis). Bacterial Infections (UTIs, Cellulitis, Vaginitis, Foot ulcers). Dental infections (Gum disease, Dental caries/root canal)
How should symptomatic Peripheral Arterial Disease (PAD) be treated in DM patients?
Exercise rehabilitation, compression stocking. Pentoxyfyline, cilostazol. Treatment of ischemic foot (debridment, footwear, dressings). Treatment of infection. Analgesics. Revascularization (bypass)
What are nonmodifiable risk factors for cardiovascular complications (CAD, MI, PVD, CVA)?
Duration of DM, age, genetics, race, and gender
What are modifiable risk factors for cardiovascular complications (CAD, MI, PVD, CVA)?
Hyperglycemia. HTN. Dyslipidemia. Smoking. Diet and lifestyle
What is the ADA/AHA/ACC recommendations for use of ASA for primary prevention of CV events in patients with: 10 year risk of CVD events > 10%, most men > 50, women > 60 with smoking, HTN, dyslipidemia, premature CVD FHx, albuminuria?
Low does ASA use for prevention is REASONABLE for adults with diabetes and no previous history of vascular disease who are at increased CVD risk and who are not at increased risk for bleeding
What are the ABCs for DM care?
A: A1c < 7%. B: Blood pressure < 130/80. C: Cholesterol LDL < 100
