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DCES exam 2021 > 2021 Standards of Care > Flashcards

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

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2
Q

Children with type 1 DM typically present with which symptoms?

A

polyuria, polydipsia, and DKA (1/3rd)

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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

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4
Q

In conditions w/ increased red blood cell turnover, only ____ criteria should be used to dx DM

A

plasma glucose criteria

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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)

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6
Q

For all people (regardless or risk), at what age should testing for DM begin?

A

45

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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

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8
Q

Women who have been diagnosed with GDM should be tested at least every ____ year(s)

A

three

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9
Q

What strategies may improve insulin resistance?

A

Weight loss, exercise, and pharmacologic treatment.

Despite this, hyperglycemia is rarely restored to normal

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10
Q

In general, BMI > ____ is considered a risk factor for DM

A

25 (overweight)

BMI should be lower for Asian Americans, ~23

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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

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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

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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

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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.

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15
Q

True or false: Pt’s with CFRD should be treated with insulin to attain goals

A

True

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16
Q

What is the most common comorbidity for pt’s with CF?

A

CFRD

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17
Q

What is the preferred method to diagnosing post transplant related DM?

A

OGTT

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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

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19
Q

At least ____ monitoring for the development of DM2 is recommended in those with preDM

A

Annual

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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

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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

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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

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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

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24
Q

True or false: no pharmacologic agent has been approved by the US FDA specifically for DM prevention

A

True

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25
Q

Metformin was overall ___ effective than lifestyle modification in the DPP

A

less, though group differences declined over time and metformin may be cost saving over a 10 year period

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26
Q

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

A

Thyroid disease; Celiac disease

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27
Q

Measurement of vit B12 should be considered for pt’s with DM1 with symptoms?

A

Peripheral neuropathy or unexplained anemia

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28
Q

Pt’s with DM are at risk for which types of CA?

A

Increased risk of liver, pancreas, endometrium, colon/rectal, breast, and bladder

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29
Q

As cognitive function decreases, the risk of severe hypoglycemia ____

A

increases

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30
Q

Pt with DM 2 or preDM and elevated liver enzymes (ALT) or fatty liver on ultasound should be evaluated for what?

A

NASH and liver fibrosis

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31
Q

For patients with DM2 and risk of fractures, which DM medications should be used w/ caution?

A

TZDs and SGLT-2 inhibitors

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32
Q

At which four times should DSME be provided?

A

At time of dx, annually, when targets are not being met, and at times of transition

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33
Q

When does Medicare reimburse for DSMES?

A

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

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34
Q

What is the recommendation re: dietary supplementation with vitamins, minerals, herbs, and spices?

A

No evidenced that they can improve outcomes in DM who do not have underlying deficiencies and are generally not recommended for glycemic control

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35
Q

True or false: Delayed hypoglycemia may happen after drinking ETOH

A

True; esp when using insulin or insulin secreatogues. The importance of monitoring BG after drinking should be emphasized

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36
Q

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

A

True

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37
Q

Why should low CHO diets be used with caution for pt’s taking SGLT inhibitors?

A

Due to increased risk of ketoacidosis

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38
Q

True or false: The type of fat consumed is more important then the amount of fat when looking at metabolic goals and CVD risk

A

True; % of total kcals from sat fat should be limited

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39
Q

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

A

False; supplements do not improve glycemic management or lead to CV benefit in pt’s with DM without evidenced of CVD

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40
Q

Why might hypoglycemia after exercise occur and last for several hours?

A

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

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41
Q

What affect might physical activity have on urinary albumin excretion?

A

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

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42
Q

For patient’s meeting treatment goals, how often should A1c be assessed?

A

Twice a year

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43
Q

How often should glycemic goals be assessed for pt’s not meeting treatment goals, or whose therapy has has changed?

A

Quarterly

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44
Q

70% TIR correlates with an A1c of what?

A

7%

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45
Q

If using ambulatory glucose profile/glucose management indicator to assess glycemic, a parallel goal is a time or range of > ___ and time below range < ____

A

70%; 4%

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46
Q

Less stringent A1c goals of

A

8%

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47
Q

What is the % for time that should be spend <54 mg/dL while wearing a CGM?

A

<1%

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48
Q

What is the % of time that should be spend >180 mg/dL while wearing a CGM?

A

<25%

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49
Q

What is the % of time that should be spent > 250 mg/dL when wearing a CGM?

A

<5%

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50
Q

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

A

True

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51
Q

What is an absolute indication for the modification of treatment goals, including setting higher glycemic goals??

A

Severe or frequent hypoglycemia

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52
Q

What is level 1 hypoglycemia?

A

< 70 mg/dL but >54 mg/dL

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53
Q

What is level 2 hypoglycemia?

A

<54 mg/dL

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54
Q

What is level 3 hypoglycemia?

A

Defined as severe event characterized by AMS or physical functioning that requires assistance from another person for recovery

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55
Q

How often should intermittently scanned CGM devices be scanned?

A

At minimum, once q 8

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56
Q

What are the types of CGM devices?

A

Real time, Intermittently Scanned, and Professional

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57
Q

What are the most common syringe sizes for pt’s administering insulin?

A

1 mL (100 units), 0.5 mL (50 units), and 0.3 mL (30 units)

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58
Q

What is a sensor augmented pump?

A

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

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59
Q

True or false: Pt’s using DM devices should be allowed to use them in an inpatient setting when proper supervision in available

A

True

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60
Q

Weight loss meds are effective as adjunct to diet, exercise, and behavioral counseling for selected pt’s with DM2 and BMI > ___

A

27

Consider d/c’ing med if > 5% wt loss not seen in three months

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61
Q

Which oral DM med is weight neutral?

A

DPP-IV inhibitor

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62
Q

Which oral DM meds are associated w/ varying degrees of weight loss?

A

Metformin, alpha glucosidase inhibitors, SGLT2, GLP1 RA, and amylin mimetics

63
Q

Which oral DM medications are often associated with weight gain?

A

Insulin, SU, and TZDs

64
Q

Which concomitant medications may cause weight gain?

A

antipsychotics, some antidepressants, MAOIs, steroids, injectable progestins, some anticonvulsants and possibly sedating antihistamines and anticholinergics

65
Q

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

A

True

66
Q

When should bariatric surgery be considered for a patient with DM?

A

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
Q

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?

A

True

68
Q

What are the pharmacological and regimen design considerations for treating a pt with DM1?

A
  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
Q

In pt’s with DM2, ppl treatment with analog insulins have less what compared to those treated with regular insulin?

A

Less weight gain and lower A1c

70
Q

IN general, pt’s with DM1 require how much of their daily insulin as basal, and how much as prandial?

A

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
Q

What is the typical starting insulin dose for a patient with DM1?

A

0.5 units/kg/day

72
Q

What are the recommended sites for insulin injection?

A

Abd, thigh, buttocks, upper arm

73
Q

What length of needle used to injected insulin is appropriate for most patient?

A

4 mm

74
Q

Why should insulin not be injected into a lipohypetrophic area?

A

Can contribute to erratic insulin absorption, increased glycemic variability, and unexplained hypo episodes

75
Q

Aside from insulin, which other injectable medication is approved for treatment of DM1?

A

Pramlintide

76
Q

When should early introduction of insulin be considered for a patient with DM2?

A

evidence of ongoing weight loss, if, symptoms of hyperglycemia are present , when A1c >10% or BG levels >300 mg/dL

77
Q

For pt’s with established ASCVD or indicators of high risk, est KD or HF, which medications should be considered?

A

SGLT 2 inhibitor or GLP 1 RA

*considered independent of A1c

78
Q

True or false: In pt’s with DM2, a GLP 1 RA is preferred to insulin when possible

A

True

79
Q

When should overbasalization be suspected?

A

When basal dose more than 0.5 u/kg, high bedtime-morning or post-preprandial glucose differential, hypos, and low variability

80
Q

When should Meformin be started for a pt with DM2?

A

At diagnosis; may be monotherapy in addition to lifestyle modifications

81
Q

What is the minimum GFR needed to take Metformin?

A

> 30 mL/minute

82
Q

Which SGLT inhibitors benefit ASCVD?

A

empagliflozin, canagliflozin

83
Q

Which SGLT inhibors benefit DKD and HF?

A

empagliflozin, canagliflozin, dapagliflozin

84
Q

Which GLP 1 RA benefit ASCVD and DKD?

A

Dulaglutide, liralgutide, semaglutide

85
Q

When should combo oral therapy be considered for pt’s with DM2?

A

When A1c >1.5-2% above target (most oral medication benefit on A1c lower rarely exceeds 1%)

86
Q

If pt is on Metformin alone, at what point should treatment be intensified?

A

If A1c target not achieved after about 3 months

87
Q

True or false: DM2 in a progressive disease?

A

True

88
Q

For a patient with DM2, what is a good starting dose of basal insulin?

A

0.1-0.2 units/kg with individual titration over days to weeks as needed

89
Q

What is the principle action of basal insulin?

A

Restrain hepatic glucose production and limit hyperglycemia overnight and between meals

90
Q

Where is a good place to start when dosing prandial insulin for a patient with DM2?

A

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
Q

What is the treatment advantage to adding a GLP1 RA to basal insulin or multiple doses of insulin?

A

Potent glucose lowering actions with less weight gain and hypo compared with intensified insulin regimens

92
Q

What is a useful tool to help estimated a pt’s risk of ASCVD?

A

The ACC/ADA ASCVD risk calculator (Risk Estimator Plus)

93
Q

What is the pharmacological drug of choice for LDL cholesterol lowering and cardioprotection?

A

Statin therapy (high v moderate, depending on risk)

94
Q

When is aspirin therapy recommend for pt’s with DM2?

A

for reducing CV morbidity and mortality in high risk pt’s with previous MI or stroke (secondary prevention)

Dose: 75-162 mg/day

95
Q

True or false: Screening of asymptomatic pt’s with high ASCVD risk is not recommended

A

True

96
Q

How often should UACR and eGFR be assessed in pt’s with DM1 and DM2?

A

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
Q

True or false: It is rare for a person with DM1 to develop DK without retinopathy

A

True

98
Q

Which HTN medications can cause hyperkalemia?

A

ACE inhibitors, ARBs adn diuretics

99
Q

What is the recommended protein intake for pt’s with non dialysis dependent CKD?

A

0.8 g/kg/day

100
Q

True or false: ACE inhibitors or ARBs are recommended for pt’s without HTN to prevent the development of CKD

A

False; they are NOT recommended in this case

101
Q

What factors increase the risk of a pt with DM developing retinopathy?

A

DM duration, chronic hyperglycemia, nephropathy, HTN, and dyslipidemia

102
Q

True or false: Pregnancy is associated w/ a rapid progression of diabetic retinopathy

A

True

**women who develop GDM do NOT appears to be at increased risk of developing diabetic retinopathy during pregnancy

103
Q

Which test for DPN can assess small fiber function?

A

pinprick and temperature sensation

104
Q

Which test for DPN can assess large fiber function?

A

vibration perception and 10 g monofilament

105
Q

Which test for DPN can assess for protective sensation?

A

10 g monofilament

106
Q

When should gastroparesis be suspected?

A

In pt with erratic glycemic control or w/ upper GI symptoms w/out another ID’d cause

107
Q

What are the initial pharmacologic treatments for pt’s with neuropathic diabetic pain?

A

pregabalin, duloxetine, or gabapentin

108
Q

What should be considered when pt’s with neuropathy present with the acute onset of a red, hot, or swollen foot or ankle?

A

Charcot neuroarthropathy

109
Q

True or false: in older adults with DM2 at increased risk of hypo, med classes with a low hypoglycemia profile are preferred

A

True

110
Q

What are the exercise goals for all children and adolescents?

A

60 minutes of moderate to vigorous intensity aerobic activity

111
Q

For children and adolescents with DM, what should their pre exercise glucose be?

A

At least 90-250 mg/dL, and accessible CHO before, during, and after activty

112
Q

For children and adolescents, when should intense activity be postponed?

A

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
Q

What are some stratagies for preventing and treating hypoglycemia associated w/ physical activity?

A

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
Q

When should youth with DM be screened for psychosocial and DM related distress?

A

Starting around 7-8 years

115
Q

When should youth with DM1 be screened for eating disorders?

A

Between 10-12 years, using the Diabetes Eating Problems Survey Revised (DEPS-R)

116
Q

What is an appropriate A1c goal for most children?

A

<7%

117
Q

True or false: Near normalization of BG levels was more difficult to to achieve in adolescents than adults

A

True

118
Q

What is the most common autoimmune disorder associated with DM1?

A

Autoimmune thyroid disease (hypothyroidism is most common, though hyperthyroidism does occur)

119
Q

When should initial lipid screening be done for a child/adolescent patient with DM1?

A

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
Q

For both children and adolescents, ____ seems to be more predictive of persistent dyslipidemia

A

Non HDL cholesterol

121
Q

What should an initial dietary plan for children and adolscents with high CVD risk?

A

Sat fat <7% total kcals and cholesterol 200 mg/day

Statins not approved for children < 10 years

122
Q

When should children be screened for albuminuria?

A

At puberty or > 10 whichever is earlier and once the child has had DM for 5 years

123
Q

For youth with DM2, what is the initial pharmacologic treatment of choice?

A

Metformin

124
Q

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?

A

Basal insulin while metformin is initiated and titrated

125
Q

What are the 3 pharmacologic treatment options for youth onset DM2?

A

Insulin, liraglutide (GLP 1 RA) and Metformin

126
Q

True or false: there is a low risk of hypoglycemia in youth with DM2, even if they are being treated with insulin

A

True

127
Q

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

A

> 140 mg/dL

128
Q

In the hospital setting, insulin orders should be administered using what?

A

Validated written or computerized protocols that allow for predefined adjustments in insulin dosage based on glycemic fluctuations

129
Q

In the hospitalized pt, insulin therapy should be initiated for persistent hyperglycemia starting of a threshold of ___ mg/dL

A

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
Q

When should BG be checked in hospitalized pt’s who are eating?

A

Before meals

131
Q

When should BG be checked in hospitalized pt’s that are not eating?

A

q 4-6 hours (more frequent q 30 mins-2 hours for those requiring IV insulin)

132
Q

What is the preferred insulin treatment regimen for noncritically ill pt’s who are NPO or who have poor PO intake

A

Basal or basal + bolus correction

133
Q

What is the preferred insulin regimen for non critically ill hospitalized pt’s with good PO intake?

A

Basal, prandial, and correction component

134
Q

True or false: use of only a sliding scale insulin regimen in the inpatient hospital setting is strongly discouraged

A

True

135
Q

What insulin regimen is the most effective method for achieving glycemic targets in the critical care setting?

A

Continuous IV insulin infusion

136
Q

If oral DM meds are held in the hospital, when should they be resumed prior to pt d/c?

A

1-2 days before d/c

137
Q

What insulin regimen should be considered in a patient who is NPO are receiving EN or PN?

A

Use of rapid acting or short acting insulin q 4-6

138
Q

What insulin regimen may be considered for a patient who is eating but has poor oral intake/

A

Administer prandial insulin immediately after the pt eats, w/ dose adjusted based on amount consumed

139
Q

Why are premixed insulin regimens such as NPH 7/30 not generally rec’d for inpatient use?

A

Due to higher risk of hypoglycemia

140
Q

True or false: Pt’s with renal insufficiency may need to be treated with lower doses on insulin

A

True

141
Q

What insulin regimen is required for all pt’s with DM1 who are hospitalized?

A

Basal and correctional + prandial if a patient is eating

142
Q

When transitioning IV to subq insulin when should pt’s receive a dose of basal insulin?

A

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
Q

What should occur when a hypoglycemic event occurs in the hospitalized setting?

A

Episode should be evaluated for a root cause and the episodes be aggregated and reviewed to address systemic issues

144
Q

What are some possible causes of iatrogenic hypoglycemia?

A

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
Q

True or false: In a pt with DM1 requiring EN, basal insulin should be continued even if feedings are d/c’d

A

True

146
Q

If EN or PN in interrupted what should be started immediately to prevent hypoglycemia?

A

10% dextrose infusion (allows time to select more appropriate insulin doses)

147
Q

For pt’s receiving EN bolus feeds ~ ___ unit of regular human or rapid acting insulin should be given per ____ g of CHO

A

1; 10-15 g subq before each feeding

148
Q

For pt’s receiving EN bolus feeds ~ ___ unit of regular human or rapid acting insulin should be given per ____ g of CHO

A

1; 10-15 g subq before each feeding

149
Q

In pt’s receiving nocturnal TF what kind of insulin may be considered?

A

NPH insulin administered with the initiation of the nocturnal feeding

150
Q

What is the starting dose of regular insulin to be added to PN?

A

1 unit per every 10 g of dextrose

Correctional insulin should be added subq

151
Q

In pt’s on once or twice daily short acting steriods (such as Prednisone) which insulin regimen is a standard approach?

A

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
Q

For long acting glucocorticoids such as dexamethasone and multidose or continuous glucocorticod use, ____ insulin may be required to control fasting BG

A

Long acting

153
Q

How long before surgery should SGLTi be d/c’d?

A

3-4 dyas

154
Q

True or false; bicarbonate is recommended in patient’s with DKA

A

Fals

DCES exam 2021 (35 decks)

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