16 and 17 - Overview of Diabetes Flashcards
What A1c is considered to be diagnostic for diabetes?
If the A1c is greater than 6.5%, this is diagnostic of diabetes
KNOW THIS ***
What can you look for in patients to see if they are type 1 or type 2?
C peptide
- C peptide is found in endogenous insulin
- If the patient is type 1, they will have very low or no C peptide
- If the patient is type 2, they will have normal or even high C peptide
What causes type 1 diabetes
- Caused by complete or near complete insulin deficiency
- Don’t usually get symptoms until 70-80% of beta cells in the pancreas are gone
There are many genetic, environmental and immunologic - Identical twins: 40-60% chance that the other twin gets it
Describe diabetic ketoacidosis
- As many as 30% of children or adolescents are diagnosed with Type I DM after being treated for Diabetic Ketoacidosis
- DKA is a medical emergency ***
Describe the cause of type 2 diabetes
- Results from insulin resistance, abnormal insulin secretion, and abnormal fat metabolism
- Typically associated with obesity and other risk factors
- This type has a much stronger genetic component 70-90% twin concordance
Describe the onset of type 2 diabetes
- The onset of symptoms can be slow and insidious, especially in patients with Type II DM
- Consider this in patient who sleep poorly due to getting up every couple hours to urinate
What is GAD 65 antibody?
GAD65 antibody is the major pancreatic islet antibody and an important serological marker of predisposition to type 1 diabetes
When should you screen for type 2 diabetes?
KNOW THIS
- Some studies suggest that people may have Type II DM for 10 years before being diagnosed
- American Diabetes Association recommends screening individuals every 3 years starting at 45 years of age
When should you screen earlier?
Screen earlier if patient is overweight with at least one additional risk factor (HTN, PCOS, sedentary, etc)
What is “prediabetes” or the state of “increased risk for diabetes” or “intermediate hyperglycemia”?
- Fasting glucose of 100-125
- 2 hours post glucose of 140-199
- A1c of 5.7-6.4%
What is diabetes?
- Fasting glucose of 126+
- 2 hours post glucose of 200+
- A1c of 6.5%+
What is a reliable diagnostic indication of diabetes? ***
KNOW THIS
- If the A1c is greater than 6.5%, this is diagnostic of diabetes ***
What is fasting?
Fasting is considered to be at least 8 hours without caloric intake
How should you determine these lab values?
In general, there should be two values on separate days consistent with diabetes mellitus to confirm the diagnosis
Describe the general approach to treating diabetes mellitus
- Treatment is intended to lower glucose levels and reduce hemoglobin A1c
- The goal is to prevent complications, both acute and chronic, from chronic hyperglycemia
- Treatment of diabetes relies on good doctor-patient communication, clear goals and objectives
- Interdisciplinary teams have been shown to improve outcomes in diabetic patients
What are the three different ways you can treat a type 1 diabetic?
Type 1 diabetics REQUIRE insulin
- Basal/bolus
- Continuous infusion
- Split/mixed
Describe basal/bolus
- Basal: once or twice daily long-acting insulin injection
- Bolus: short-acting insulin bolus for meals
MOST COMMON
Describe continuous infusion
- aka “insulin pump”, continuous infusion of short-insulin
- bolus of short-acting insulin with meals
Describe split/mixed
Not as common, not as good
- multiple daily injections of combination of long and short acting insulin
- generally worse glycemic control, more hypoglycemia
Describe the treatment of type 2 diabetes
- Do not routinely require insulin at diagnosis
- Many will eventually require insulin as the disease progresses
- Choice of therapy depends on severity of hyperglycemia, patient comfort, patient willingness
- Typically will start with oral therapies and adjust as needed
What is the first line initial treatment for type 2 diabetes?
Metformin
The only time you wouldn’t use metformin is if it is contraindicated
What intervention is recommended when the initial A1c is less than 7.5?
Lifestyle and dietary changes if motivated enough
What intervention is recommended when the initial A1c is 7.6-8.9?
Monotherapy with metformin
What intervention is recommended when the initial A1c is greater than 9?
Recommend treatment with two oral agents OR insulin monotherapy
What intervention is recommended when the initial A1c is between 10-12?
Strong recommendation for insulin therapy
What intervention is recommended when the initial A1c is 10-12 and there is ketosis and/or weight loss?
Insulin therapy is required
What diet and lifestyle changes are recommended?
- ADA recommends 150 minutes/week of moderate-intensity cardio workouts
3x/wk, no more than 2 days off in between - ADA also recommends resistance training at least twice per week
- One study showed that combining cardiovascular exercise and resistance training, you can decrease A1c by 0.5%
What is one thing the patient can do that is the MOST important?
Lose weight
How do you dose metformin?
- Initial monotherapy when single agent is used
- Start dosing at 500 mg once or twice daily with meal(s)
- If you only do 1x/day, do it with the largest meal
- If patient continues to tolerate medication (not too bad of GI problems), double dose every 5-7 days until at goal of 1000mg twice daily
- This (as well as sulfonylureas) should not be used in women who are pregnant or may become pregnant
Goal of 1000 mg twice daily
When is metformin contraindicated?
- Renal or Hepatic impairment
- Binge drinking or cirrhosis of the liver
- Use of contrast dye
- Predisposition for lactic acidosis (CHF with hypoperfusion or chronic hypoxemia)
What are the side effects of metformin?
Common Side Effects: diarrhea, indigestion (resolve within weeks)
Severe Side Effects: lactic acidosis
How does metformin work?
Decreases hepatic gluconeogenesis and glycogenolysis with increase in peripheral insulin sensitivity and glucose uptake
What are the other oral therapies you can use?
- Sulfonylureas (glyburide, glipizide, glimepiride)
- Thiazolidinediones (pioglitazone)
- Glitinides (nateglinide, repaglinide)
- Alpha-glucosidase inhibitors (acarbose)
- DPP-4 inhibitors (sitagliptin)
- GLP-1 Receptor Antagonist (exanatide)
- Sodium-glucose co-transporter 2 (SGLT2) inhibitors (canagliflozin)
What treatment method is the BEST at reducing A1c?
Insulin ***
What are the recommendations for adding a second drug to a metformin regimen?
- The decision to add a second or third oral agent to metformin yields many options
- There is NO preferred second line agent
Decision on second or third agent is based on: - level of current glycemic control - contraindications side effect avoidance - co-morbidities
What is the starting point for insulin therapy in type 2 diabetics?
- Typically start with long-acting insulin once daily
- 0.1-0.2 Units/kg initially - 10 Units minimum
- You will need to monitor morning fasting glucose daily
What is the initial goal of insulin therapy in terms of morning fasting glucose?
Goal is 70-130 mg/dl
The initial goal of insulin therapy is to obtain fasting glucose levels less than 130 mg/dL in the morning
If the A1c is still not in range with long acting insulin, what is the next step?
If A1c is still not in range with adequate control of fasting glucose - add mealtime short-acting insulin
What is the purpose of adding short acting insulin?
- This is designed to mimic the insulin production by the pancreas, with a constant level of insulin at all times and bolus of insulin around meals
- Progression to a basal/bolus insulin regimen is ideal for best management of hyperglycemia if basal dosing is not adequate for getting A1c to goal
What are the names of short acting insulins?
- Lispo
- Aspart
- Glulisine
Aspart = Novolog = most common
What are the names of long acting insulins?
- Glargine
- Detemir
Glargine = lantus = most common
What are the glycemic treatment goals for diabetics?
- A1c less than 7 ***
- Preprandial glucose (fasting glucose) of 70-130
- Peak postprandial glucose (2 hours post snack) of less than 180
What are other treatment goals for diabetics?
- BP of 40 or 50 (men/women)
- Triglycerides
What is the overall impact of bariatric surgery on diabetic patients
- The gastric bypass groups also had significantly increase weight loss compared to the control, as well as requiring less insulin and anti hyperglycemic medications
- Bypass has shown significant promise and is being considered and suggested by more physicians
What other treatments can be beneficial to the patient?
- As noted prior, multidisciplinary approach can be helpful
- Maintaining food journals or diaries can be helpful
- Following with a nutritionist or diabetic educator to help with diet plan and nutritional counseling
Describe the benefit of screening
Screening can help prevent chronic complications or catch them early in disease progression
What screening should you do annually on your diabetic patients to assess for complications?
- Spot urine for the albumin to creatinine ratio
- Foot exam with monofilament testing
- Dilated eye exam by an ophthalmologist (for diabetic retinopathy)
What complications of diabetes can be life threatening?
- DKA
- Hypoglycemia
Describe ketoacidosis
Diabetic Ketoacidosis
- More often seen with type 1 DM
- Previously thought be a hallmark of type 1
- Nausea, vomiting, abdominal pain
- Elevated glucose = polyuria + N/V = dehydration
- Increased ketosis (fatty acid release) due to low insulin and high glucose
- Caused by increased insulin requirements: infection, pregnancy, ischemia or non-compliance
Describe a hyperglycemic hyperosmolar state
HHS
- More gradual (occurs over weeks)
- Severe dehydration
- Blood sugar over 1000
- Common in type 2 elderly
- Due to non-compliance, infection or ischemia
Describe a hypoglycemic state
- Occurs when glucose is below 70
- Diaphoresis, pale, tremor, tachycardia; can progress to coma in some circumstances
- Can be accidental
- Treat with glucose, dextrose or glucagon
What are some chronic complications?
Macrovascular (large vessels)
- Coronary artery disease
- Peripheral artery disease
- Cerebrovascular disease
Microvascular (small vessels)
- Retinopathy
- Neuropathy
- Nephropathy
DM is considered a coronary heart disease equivalent
Describe the way in which diabetes leads to tissue injury
Increased intracellular glucose leads to formation of advanced glycosylation end products (AGEs)
- AGEs bind cell surface receptors, non enzymatic glycosyalation
- This accelerates athersclerosis, promotes glomerular dysfunction, reduces NO synthesis, endothelial dysfunction
What is diabetes the #1 cause of?
- Blindness in people aged 20-74
- End stage renal disease
- Non-traumatic lower extremity amputation
What causes blindness in daibetics?
Macular edema and progressive retinopathy
What causes end stage renal disease in diabetics?
- Altered renal circulation and glomerular changes (proteins start leaking out)
- Accompanied by hypertension
- Use ACEi or ARBs
What occurs in up to half of patients with long standing diabetes?
Neurologic problems
What GI problem is common in diabetics?
Gastroparesis
