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Endocrine Exam 1 > 16 and 17 - Overview of Diabetes > Flashcards

16 and 17 - Overview of Diabetes Flashcards

1
Q

What A1c is considered to be diagnostic for diabetes?

A

If the A1c is greater than 6.5%, this is diagnostic of diabetes

KNOW THIS ***

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2
Q

What can you look for in patients to see if they are type 1 or type 2?

A

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
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3
Q

What causes type 1 diabetes

A
  • 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
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4
Q

Describe diabetic ketoacidosis

A
  • 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 ***
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5
Q

Describe the cause of type 2 diabetes

A
  • 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
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6
Q

Describe the onset of type 2 diabetes

A
  • 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
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7
Q

What is GAD 65 antibody?

A

GAD65 antibody is the major pancreatic islet antibody and an important serological marker of predisposition to type 1 diabetes

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8
Q

When should you screen for type 2 diabetes?

A

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
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9
Q

When should you screen earlier?

A

Screen earlier if patient is overweight with at least one additional risk factor (HTN, PCOS, sedentary, etc)

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10
Q

What is “prediabetes” or the state of “increased risk for diabetes” or “intermediate hyperglycemia”?

A
  • Fasting glucose of 100-125
  • 2 hours post glucose of 140-199
  • A1c of 5.7-6.4%
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11
Q

What is diabetes?

A
  • Fasting glucose of 126+
  • 2 hours post glucose of 200+
  • A1c of 6.5%+
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12
Q

What is a reliable diagnostic indication of diabetes? ***

A

KNOW THIS

- If the A1c is greater than 6.5%, this is diagnostic of diabetes ***

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13
Q

What is fasting?

A

Fasting is considered to be at least 8 hours without caloric intake

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14
Q

How should you determine these lab values?

A

In general, there should be two values on separate days consistent with diabetes mellitus to confirm the diagnosis

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15
Q

Describe the general approach to treating diabetes mellitus

A
  • 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
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16
Q

What are the three different ways you can treat a type 1 diabetic?

A

Type 1 diabetics REQUIRE insulin

  • Basal/bolus
  • Continuous infusion
  • Split/mixed
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17
Q

Describe basal/bolus

A
  • Basal: once or twice daily long-acting insulin injection
  • Bolus: short-acting insulin bolus for meals

MOST COMMON

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18
Q

Describe continuous infusion

A
  • aka “insulin pump”, continuous infusion of short-insulin

- bolus of short-acting insulin with meals

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19
Q

Describe split/mixed

A

Not as common, not as good

  • multiple daily injections of combination of long and short acting insulin
  • generally worse glycemic control, more hypoglycemia
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20
Q

Describe the treatment of type 2 diabetes

A
  • 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
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21
Q

What is the first line initial treatment for type 2 diabetes?

A

Metformin

The only time you wouldn’t use metformin is if it is contraindicated

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22
Q

What intervention is recommended when the initial A1c is less than 7.5?

A

Lifestyle and dietary changes if motivated enough

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23
Q

What intervention is recommended when the initial A1c is 7.6-8.9?

A

Monotherapy with metformin

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24
Q

What intervention is recommended when the initial A1c is greater than 9?

A

Recommend treatment with two oral agents OR insulin monotherapy

25
Q

What intervention is recommended when the initial A1c is between 10-12?

A

Strong recommendation for insulin therapy

26
Q

What intervention is recommended when the initial A1c is 10-12 and there is ketosis and/or weight loss?

A

Insulin therapy is required

27
Q

What diet and lifestyle changes are recommended?

A
  • 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%
28
Q

What is one thing the patient can do that is the MOST important?

A

Lose weight

29
Q

How do you dose metformin?

A
  • 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

30
Q

When is metformin contraindicated?

A
  • 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)
31
Q

What are the side effects of metformin?

A

Common Side Effects: diarrhea, indigestion (resolve within weeks)

Severe Side Effects: lactic acidosis

32
Q

How does metformin work?

A

Decreases hepatic gluconeogenesis and glycogenolysis with increase in peripheral insulin sensitivity and glucose uptake

33
Q

What are the other oral therapies you can use?

A
  • 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)
34
Q

What treatment method is the BEST at reducing A1c?

A

Insulin ***

35
Q

What are the recommendations for adding a second drug to a metformin regimen?

A
  • 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
36
Q

What is the starting point for insulin therapy in type 2 diabetics?

A
  • 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
37
Q

What is the initial goal of insulin therapy in terms of morning fasting glucose?

A

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

38
Q

If the A1c is still not in range with long acting insulin, what is the next step?

A

If A1c is still not in range with adequate control of fasting glucose - add mealtime short-acting insulin

39
Q

What is the purpose of adding short acting insulin?

A
  • 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
40
Q

What are the names of short acting insulins?

A
  • Lispo
  • Aspart
  • Glulisine

Aspart = Novolog = most common

41
Q

What are the names of long acting insulins?

A
  • Glargine
  • Detemir

Glargine = lantus = most common

42
Q

What are the glycemic treatment goals for diabetics?

A
  • A1c less than 7 ***
  • Preprandial glucose (fasting glucose) of 70-130
  • Peak postprandial glucose (2 hours post snack) of less than 180
43
Q

What are other treatment goals for diabetics?

A
  • BP of 40 or 50 (men/women)

- Triglycerides

44
Q

What is the overall impact of bariatric surgery on diabetic patients

A
  • 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
45
Q

What other treatments can be beneficial to the patient?

A
  • 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
46
Q

Describe the benefit of screening

A

Screening can help prevent chronic complications or catch them early in disease progression

47
Q

What screening should you do annually on your diabetic patients to assess for complications?

A
  • Spot urine for the albumin to creatinine ratio
  • Foot exam with monofilament testing
  • Dilated eye exam by an ophthalmologist (for diabetic retinopathy)
48
Q

What complications of diabetes can be life threatening?

A
  • DKA

- Hypoglycemia

49
Q

Describe ketoacidosis

A

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
50
Q

Describe a hyperglycemic hyperosmolar state

A

HHS

  • More gradual (occurs over weeks)
  • Severe dehydration
  • Blood sugar over 1000
  • Common in type 2 elderly
  • Due to non-compliance, infection or ischemia
51
Q

Describe a hypoglycemic state

A
  • 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
52
Q

What are some chronic complications?

A

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

53
Q

Describe the way in which diabetes leads to tissue injury

A

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
54
Q

What is diabetes the #1 cause of?

A
  • Blindness in people aged 20-74
  • End stage renal disease
  • Non-traumatic lower extremity amputation
55
Q

What causes blindness in daibetics?

A

Macular edema and progressive retinopathy

56
Q

What causes end stage renal disease in diabetics?

A
  • Altered renal circulation and glomerular changes (proteins start leaking out)
  • Accompanied by hypertension
  • Use ACEi or ARBs
57
Q

What occurs in up to half of patients with long standing diabetes?

A

Neurologic problems

58
Q

What GI problem is common in diabetics?

A

Gastroparesis

Endocrine Exam 1 (18 decks)

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