2021 Standards of Care Flashcards
1
Q
Diabetes can be classified into which general categories?
A
Type 1, type 2, specific types of DM due to other causes (CF, chemical/drug induced, etc), and GDM
2
Q
Children with type 1 DM typically present with which symptoms?
A
polyuria, polydipsia, and DKA (1/3rd)
3
Q
True or false; recent ADA clinical guidance concluded that A1c, FPG, or 2 hr PG can be used to test for pre DM or DM in children and adolescents
A
True
4
Q
In conditions w/ increased red blood cell turnover, only ____ criteria should be used to dx DM
A
plasma glucose criteria
5
Q
Diagnosis from DM requires how many abnormal test results?
A
Two, either from the same sample or in two separate tests
If using two separate tests, rec’d that the second test (with repeat of initial test or different test) be performed w/out delay)
6
Q
For all people (regardless or risk), at what age should testing for DM begin?
A
45
7
Q
What are considerations for patients with HIV in regards to DM screening?
A
Screened for DM and pre DM with FBG before starting antiretroviral therapy, a time of switching ART, and 3-6 months after starting or switching ART. If normal, fasting glucose should be checked annually
8
Q
Women who have been diagnosed with GDM should be tested at least every ____ year(s)
A
three
9
Q
What strategies may improve insulin resistance?
A
Weight loss, exercise, and pharmacologic treatment.
Despite this, hyperglycemia is rarely restored to normal
10
Q
In general, BMI > ____ is considered a risk factor for DM
A
25 (overweight)
BMI should be lower for Asian Americans, ~23
11
Q
Why is A1c not recommended as a screening tool for pt’s with HIV?
A
Underestimates glycemia in ppl with HIV
ART (protease inhibitors and NRTIs) puts HIV pt’s at higher risk for pre DM and DM
12
Q
What is the appropriate interval between screening tests when testing patient’s for DM?
A
3 years.
In high risk pt’s shorter intervals may be useful
13
Q
Why is community screening outside a healthcare setting generally not recommended?
A
Pt’s w/ positive tests may not seek or have access to appropriate follow up testing
14
Q
How should a pt with Cystic fibrosis be tested for CFRD?
A
An OGTT beginning at age 10 (if not already diangosed). A1c is NOT recommended as a screening test for pt’s with CFRD.
15
Q
True or false: Pt’s with CFRD should be treated with insulin to attain goals
A
True
16
Q
What is the most common comorbidity for pt’s with CF?
A
CFRD
17
Q
What is the preferred method to diagnosing post transplant related DM?
A
OGTT
18
Q
When should a pt with GDM be retested postpartum?
A
4-12 weeks postpartum using a 75 g OGTT and clinically appropriate non pregnant criteria
19
Q
At least ____ monitoring for the development of DM2 is recommended in those with preDM
A
Annual
20
Q
True of false: screening for pre DM and DM2 risk though an informal assessment of risk factors is recommended
A
True; helps determine whether performing g a diagnostic test for pre DM and undiagnosed DM2 is appropriate
21
Q
What should be the initial lifestyle modifications be for pt’s dx’d with pre DM?
A
Referral to program for intensive lifestyle behavior changed modeled on DPP to achieve and maintain 7% initial BW los and increase physical activity to 150 mins/week
22
Q
True or false: All pt’s with DM2 should follow a lower CHO diet
A
False; a variety of eating patterns can be considered to prevent DM in patient’s w/ pre DM
23
Q
When should Metformin therapy be considered for pre DM?
A
Can be considered for all pt’s with pre DM, but esp for those w/ BMI > 35, <60 years old, and women with prior h/o GDM
24
Q
True or false: no pharmacologic agent has been approved by the US FDA specifically for DM prevention
A
True
25
Metformin was overall ___ effective than lifestyle modification in the DPP
less, though group differences declined over time and metformin may be cost saving over a 10 year period
26
Pt with DM1 should be screened for _____ soon after dx and periodically thereafter.
Pt's with DM1 should be screened for ____ in presence of GI symptoms or lab manifestations
Thyroid disease; Celiac disease
27
Measurement of vit B12 should be considered for pt's with DM1 with symptoms?
Peripheral neuropathy or unexplained anemia
28
Pt's with DM are at risk for which types of CA?
Increased risk of liver, pancreas, endometrium, colon/rectal, breast, and bladder
29
As cognitive function decreases, the risk of severe hypoglycemia ____
increases
30
Pt with DM 2 or preDM and elevated liver enzymes (ALT) or fatty liver on ultasound should be evaluated for what?
NASH and liver fibrosis
31
For patients with DM2 and risk of fractures, which DM medications should be used w/ caution?
TZDs and SGLT-2 inhibitors
32
At which four times should DSME be provided?
At time of dx, annually, when targets are not being met, and at times of transition
33
When does Medicare reimburse for DSMES?
When service meets national standards and is recognized by the ADA or ADCES.
Frequently reimbursed for in person service, phone call/telehealth may not always be reimbursed, though this may be changing
34
What is the recommendation re: dietary supplementation with vitamins, minerals, herbs, and spices?
No evidenced that they can improve outcomes in DM who do not have underlying deficiencies and are generally not recommended for glycemic control
35
True or false: Delayed hypoglycemia may happen after drinking ETOH
True; esp when using insulin or insulin secreatogues. The importance of monitoring BG after drinking should be emphasized
36
True or false: reducing overall carbohydrate intake for pt's with DM has demonstrated the most evidence for improving glycemia and may be applied in a variety of eating patterns that meet individual preferences
True
37
Why should low CHO diets be used with caution for pt's taking SGLT inhibitors?
Due to increased risk of ketoacidosis
38
True or false: The type of fat consumed is more important then the amount of fat when looking at metabolic goals and CVD risk
True; % of total kcals from sat fat should be limited
39
True or false: pt's with DM should routinely be rec'd to take EPA and DHA supplements for the prevention and/or treatment of CVD events
False; supplements do not improve glycemic management or lead to CV benefit in pt's with DM without evidenced of CVD
40
Why might hypoglycemia after exercise occur and last for several hours?
Due to increased insulin sensitivity; less common in pt's who are NOT treatment w/ insulin or insulin secreatgogues, and no routine measures for hypos are usually advised in these cases
41
What affect might physical activity have on urinary albumin excretion?
Can acutely increase urinary albumin excretion; however, no evidence that vigorous intensity exercise accelerates rate of progression of DKD and no need for specific exercise restrictions for pt's with DKD in general
42
For patient's meeting treatment goals, how often should A1c be assessed?
Twice a year
43
How often should glycemic goals be assessed for pt's not meeting treatment goals, or whose therapy has has changed?
Quarterly
44
70% TIR correlates with an A1c of what?
7%
45
If using ambulatory glucose profile/glucose management indicator to assess glycemic, a parallel goal is a time or range of > ___ and time below range < ____
70%; 4%
46
Less stringent A1c goals of
8%
47
What is the % for time that should be spend <54 mg/dL while wearing a CGM?
<1%
48
What is the % of time that should be spend >180 mg/dL while wearing a CGM?
<25%
49
What is the % of time that should be spent > 250 mg/dL when wearing a CGM?
<5%
50
True or false: The CV benefits of SGLT or GLP1 RA are not dependent upon A1c lowering; therefore, initiation can be considered in pt's with DM2 and CVD independent of current A1c or A1c goal or Metformin therapy
True
51
What is an absolute indication for the modification of treatment goals, including setting higher glycemic goals??
Severe or frequent hypoglycemia
52
What is level 1 hypoglycemia?
< 70 mg/dL but >54 mg/dL
53
What is level 2 hypoglycemia?
<54 mg/dL
54
What is level 3 hypoglycemia?
Defined as severe event characterized by AMS or physical functioning that requires assistance from another person for recovery
55
How often should intermittently scanned CGM devices be scanned?
At minimum, once q 8
56
What are the types of CGM devices?
Real time, Intermittently Scanned, and Professional
57
What are the most common syringe sizes for pt's administering insulin?
1 mL (100 units), 0.5 mL (50 units), and 0.3 mL (30 units)
58
What is a sensor augmented pump?
Suspends insulin when glucose is low or predicted to go low w/in the next 30 minutes
May be esp useful for pt's with h/o nocturnal hypoglycemia
59
True or false: Pt's using DM devices should be allowed to use them in an inpatient setting when proper supervision in available
True
60
Weight loss meds are effective as adjunct to diet, exercise, and behavioral counseling for selected pt's with DM2 and BMI > ___
27
Consider d/c'ing med if > 5% wt loss not seen in three months
61
Which oral DM med is weight neutral?
DPP-IV inhibitor
62
Which oral DM meds are associated w/ varying degrees of weight loss?
Metformin, alpha glucosidase inhibitors, SGLT2, GLP1 RA, and amylin mimetics
63
Which oral DM medications are often associated with weight gain?
Insulin, SU, and TZDs
64
Which concomitant medications may cause weight gain?
antipsychotics, some antidepressants, MAOIs, steroids, injectable progestins, some anticonvulsants and possibly sedating antihistamines and anticholinergics
65
True or false: Nearly all FDA approved meds for weight loss have been shown to improve glycemic control in pt's with DM2 and delay progression to DM2 in pt's at risk
True
66
When should bariatric surgery be considered for a patient with DM?
BMI > 40 or BMI 35-39.9 who do not achieve durable wt loss and improvement in comorbidities with nonsurgical methods
May be considered as an option to treat DM2 in BMI 30-34.9 who do not achieve durable wt loss and improvement in comorbidities with non surgical methods
67
True or false: metabolic surgery achieves superior glycemic control and reduction of CV risk factors in pt's with DM2 and obesity compared with various lifestyle/medical interventions?
True
68
What are the pharmacological and regimen design considerations for treating a pt with DM1?
1. Most should be treated with MDI injections of prandial and basal insulin or CSII
2. Most should use rapid acting analogs to reduce hypo risk
3. Most should receive education on how to match prandial insulin doses to CHO, premeal and anticipated physical activity
69
In pt's with DM2, ppl treatment with analog insulins have less what compared to those treated with regular insulin?
Less weight gain and lower A1c
70
IN general, pt's with DM1 require how much of their daily insulin as basal, and how much as prandial?
50%, 50%
TDD can be based on weight, with typical doses ranging from 0.4-1.0 unit/kgday
Higher amounts required during puberty, pregnancy, and illness
71
What is the typical starting insulin dose for a patient with DM1?
0.5 units/kg/day
72
What are the recommended sites for insulin injection?
Abd, thigh, buttocks, upper arm
73
What length of needle used to injected insulin is appropriate for most patient?
4 mm
74
Why should insulin not be injected into a lipohypetrophic area?
Can contribute to erratic insulin absorption, increased glycemic variability, and unexplained hypo episodes
75
Aside from insulin, which other injectable medication is approved for treatment of DM1?
Pramlintide
76
When should early introduction of insulin be considered for a patient with DM2?
evidence of ongoing weight loss, if, symptoms of hyperglycemia are present , when A1c >10% or BG levels >300 mg/dL
77
For pt's with established ASCVD or indicators of high risk, est KD or HF, which medications should be considered?
SGLT 2 inhibitor or GLP 1 RA
*considered independent of A1c
78
True or false: In pt's with DM2, a GLP 1 RA is preferred to insulin when possible
True
79
When should overbasalization be suspected?
When basal dose more than 0.5 u/kg, high bedtime-morning or post-preprandial glucose differential, hypos, and low variability
80
When should Meformin be started for a pt with DM2?
At diagnosis; may be monotherapy in addition to lifestyle modifications
81
What is the minimum GFR needed to take Metformin?
>30 mL/minute
82
Which SGLT inhibitors benefit ASCVD?
empagliflozin, canagliflozin
83
Which SGLT inhibors benefit DKD and HF?
empagliflozin, canagliflozin, dapagliflozin
84
Which GLP 1 RA benefit ASCVD and DKD?
Dulaglutide, liralgutide, semaglutide
85
When should combo oral therapy be considered for pt's with DM2?
When A1c >1.5-2% above target (most oral medication benefit on A1c lower rarely exceeds 1%)
86
If pt is on Metformin alone, at what point should treatment be intensified?
If A1c target not achieved after about 3 months
87
True or false: DM2 in a progressive disease?
True
88
For a patient with DM2, what is a good starting dose of basal insulin?
0.1-0.2 units/kg with individual titration over days to weeks as needed
89
What is the principle action of basal insulin?
Restrain hepatic glucose production and limit hyperglycemia overnight and between meals
90
Where is a good place to start when dosing prandial insulin for a patient with DM2?
4 units or 10% of amount of basal insulin at largest meal or meal with greatest post prandial excursion
Pt's with DM2 are more insulin resistant tahn type 1, often requiring higher daily doses (1 u/kg_
W/ additions to prandial insulin dose (esp with evening meal) consideation should be given to decreasing basal insulin
91
What is the treatment advantage to adding a GLP1 RA to basal insulin or multiple doses of insulin?
Potent glucose lowering actions with less weight gain and hypo compared with intensified insulin regimens
92
What is a useful tool to help estimated a pt's risk of ASCVD?
The ACC/ADA ASCVD risk calculator (Risk Estimator Plus)
93
What is the pharmacological drug of choice for LDL cholesterol lowering and cardioprotection?
Statin therapy (high v moderate, depending on risk)
94
When is aspirin therapy recommend for pt's with DM2?
for reducing CV morbidity and mortality in high risk pt's with previous MI or stroke (secondary prevention)
Dose: 75-162 mg/day
95
True or false: Screening of asymptomatic pt's with high ASCVD risk is not recommended
True
96
How often should UACR and eGFR be assessed in pt's with DM1 and DM2?
Annually (if DM1 > 5 years)
DM2 (annually, regardles of treatment)
Pts with urinary albumin > 300 and/or GFR < 30-60 should be monitored twice annually to guide therapy
97
True or false: It is rare for a person with DM1 to develop DK without retinopathy
True
98
Which HTN medications can cause hyperkalemia?
ACE inhibitors, ARBs adn diuretics
99
What is the recommended protein intake for pt's with non dialysis dependent CKD?
0.8 g/kg/day
100
True or false: ACE inhibitors or ARBs are recommended for pt's without HTN to prevent the development of CKD
False; they are NOT recommended in this case
101
What factors increase the risk of a pt with DM developing retinopathy?
DM duration, chronic hyperglycemia, nephropathy, HTN, and dyslipidemia
102
True or false: Pregnancy is associated w/ a rapid progression of diabetic retinopathy
True
**women who develop GDM do NOT appears to be at increased risk of developing diabetic retinopathy during pregnancy
103
Which test for DPN can assess small fiber function?
pinprick and temperature sensation
104
Which test for DPN can assess large fiber function?
vibration perception and 10 g monofilament
105
Which test for DPN can assess for protective sensation?
10 g monofilament
106
When should gastroparesis be suspected?
In pt with erratic glycemic control or w/ upper GI symptoms w/out another ID'd cause
107
What are the initial pharmacologic treatments for pt's with neuropathic diabetic pain?
pregabalin, duloxetine, or gabapentin
108
What should be considered when pt's with neuropathy present with the acute onset of a red, hot, or swollen foot or ankle?
Charcot neuroarthropathy
109
True or false: in older adults with DM2 at increased risk of hypo, med classes with a low hypoglycemia profile are preferred
True
110
What are the exercise goals for all children and adolescents?
60 minutes of moderate to vigorous intensity aerobic activity
111
For children and adolescents with DM, what should their pre exercise glucose be?
At least 90-250 mg/dL, and accessible CHO before, during, and after activty
112
For children and adolescents, when should intense activity be postponed?
When glucose > 350 mg/dL, moderate to large ketones, and B hydroxybutyrate > 1.5 mmol/L. Caution may be needed when B-OHB levels > 0.6 mmol/L
113
What are some stratagies for preventing and treating hypoglycemia associated w/ physical activity?
Decreasing prandial insulin for meal/snack before exercise and /or increasing food intake. Pt's on insulin pumps can lower basal rates by 10-50% (or more) or suspend for 1-2 hours after exercise. Decreasing basal rates or long acting insulin by 20% after exercise may reduce delayed exercise induced hypoglycemia
114
When should youth with DM be screened for psychosocial and DM related distress?
Starting around 7-8 years
115
When should youth with DM1 be screened for eating disorders?
Between 10-12 years, using the Diabetes Eating Problems Survey Revised (DEPS-R)
116
What is an appropriate A1c goal for most children?
<7%
117
True or false: Near normalization of BG levels was more difficult to to achieve in adolescents than adults
True
118
What is the most common autoimmune disorder associated with DM1?
Autoimmune thyroid disease (hypothyroidism is most common, though hyperthyroidism does occur)
119
When should initial lipid screening be done for a child/adolescent patient with DM1?
Should be done soon after diagnosis (> 2 years old)
DM predisposes development of accelerate arteriosclerosis
If screen is normal, subsequent screen may be done at 9-11
120
For both children and adolescents, ____ seems to be more predictive of persistent dyslipidemia
Non HDL cholesterol
121
What should an initial dietary plan for children and adolscents with high CVD risk?
Sat fat <7% total kcals and cholesterol 200 mg/day
Statins not approved for children < 10 years
122
When should children be screened for albuminuria?
At puberty or > 10 whichever is earlier and once the child has had DM for 5 years
123
For youth with DM2, what is the initial pharmacologic treatment of choice?
Metformin
124
What treatment regimen should be considered for children with DM2 with BG > 250 mg/dL and/or A1c >8.5% with polyuria, polydipsia and/or wt loss?
Basal insulin while metformin is initiated and titrated
125
What are the 3 pharmacologic treatment options for youth onset DM2?
Insulin, liraglutide (GLP 1 RA) and Metformin
126
True or false: there is a low risk of hypoglycemia in youth with DM2, even if they are being treated with insulin
True
127
An A1c test should be performed on all pt's w/ DM or hyperglycemia > ____ mg/dL admitted to the hospital if not performed in prior 3 months
> 140 mg/dL
128
In the hospital setting, insulin orders should be administered using what?
Validated written or computerized protocols that allow for predefined adjustments in insulin dosage based on glycemic fluctuations
129
In the hospitalized pt, insulin therapy should be initiated for persistent hyperglycemia starting of a threshold of ___ mg/dL
180 mg/L. Once started, a target glucose range of 140-180 mg/dL is recommended for majority of critically ill and noncritically ill patients
130
When should BG be checked in hospitalized pt's who are eating?
Before meals
131
When should BG be checked in hospitalized pt's that are not eating?
q 4-6 hours (more frequent q 30 mins-2 hours for those requiring IV insulin)
132
What is the preferred insulin treatment regimen for noncritically ill pt's who are NPO or who have poor PO intake
Basal or basal + bolus correction
133
What is the preferred insulin regimen for non critically ill hospitalized pt's with good PO intake?
Basal, prandial, and correction component
134
True or false: use of only a sliding scale insulin regimen in the inpatient hospital setting is strongly discouraged
True
135
What insulin regimen is the most effective method for achieving glycemic targets in the critical care setting?
Continuous IV insulin infusion
136
If oral DM meds are held in the hospital, when should they be resumed prior to pt d/c?
1-2 days before d/c
137
What insulin regimen should be considered in a patient who is NPO are receiving EN or PN?
Use of rapid acting or short acting insulin q 4-6
138
What insulin regimen may be considered for a patient who is eating but has poor oral intake/
Administer prandial insulin immediately after the pt eats, w/ dose adjusted based on amount consumed
139
Why are premixed insulin regimens such as NPH 7/30 not generally rec'd for inpatient use?
Due to higher risk of hypoglycemia
140
True or false: Pt's with renal insufficiency may need to be treated with lower doses on insulin
True
141
What insulin regimen is required for all pt's with DM1 who are hospitalized?
Basal and correctional + prandial if a patient is eating
142
When transitioning IV to subq insulin when should pt's receive a dose of basal insulin?
2 h before the IV insulin is d/c'd
Dose of basal insulin is best calculated on the basis of the insulin IV rate during the last 6 h when stable glycemic goals were acheived
143
What should occur when a hypoglycemic event occurs in the hospitalized setting?
Episode should be evaluated for a root cause and the episodes be aggregated and reviewed to address systemic issues
144
What are some possible causes of iatrogenic hypoglycemia?
Sudden reduction of corticosteriod dose, reduced oral intake, emesis, inappropriate timing of short or rapid acting insulin in related to meals, reduced infusion rate of IV dextrose, unexpected interruption of EN or PN, delayed/missed BG checks and altered ability of pt to report symptoms
145
True or false: In a pt with DM1 requiring EN, basal insulin should be continued even if feedings are d/c'd
True
146
If EN or PN in interrupted what should be started immediately to prevent hypoglycemia?
10% dextrose infusion (allows time to select more appropriate insulin doses)
147
For pt's receiving EN bolus feeds ~ ___ unit of regular human or rapid acting insulin should be given per ____ g of CHO
1; 10-15 g subq before each feeding
148
For pt's receiving EN bolus feeds ~ ___ unit of regular human or rapid acting insulin should be given per ____ g of CHO
1; 10-15 g subq before each feeding
149
In pt's receiving nocturnal TF what kind of insulin may be considered?
NPH insulin administered with the initiation of the nocturnal feeding
150
What is the starting dose of regular insulin to be added to PN?
1 unit per every 10 g of dextrose
Correctional insulin should be added subq
151
In pt's on once or twice daily short acting steriods (such as Prednisone) which insulin regimen is a standard approach?
once or twice daily NPH (because NPH peaks at 4-6 hours after administration, it is best to give concomitantly w/ sterios such as short acting glucocortidois such as prednisone which peak at 4-6 hours but have actions that last throughout the day
Usually in addition to daily basal bolus or in addition to oral anti DM meds
152
For long acting glucocorticoids such as dexamethasone and multidose or continuous glucocorticod use, ____ insulin may be required to control fasting BG
Long acting
153
How long before surgery should SGLTi be d/c'd?
3-4 dyas
154
True or false; bicarbonate is recommended in patient's with DKA
Fals
