29: Management of Newly Diagnosed Diabetic Pt- Dodge Flashcards
which type of DM has high c peptide initially?
type 2 DM
which type of DM has more genetic effect?
type 2 DM
prediabetes/ increased risk of diabetes/ intermediate hyperglycemia lab values
- fasting glucose 100-125
- glucose tolearance 140-199
- HA1C 5.7 - 6.4%
DM diagnostic lab values
- fasting glucose greater than 126
- glucose tolerance greater than 200
- random blood glucose greater than 200
- H1AC greater than 6.5%
tx for A1c less than 7.5%
lifestyle and dietary changes if motivated
tx for A1C 7.6-8.9%
monotherapy with metformin
tx for A1C greater than 9%
recommend treatemtn with two oral agents or insulin monotherapy
tx for A1C 10-12%
strong recommendation for insulin therapy
tx for A1C 10-12% with ketosis and/or weight loss
insulin therapy required ***
lifestyle modification recommendations
150 minutes/wk of moderate-intesnstiy cardio
3X/wk no more than 2 days off in between
resistance training at least twice per week
_______ most important factor in reducing the A1C, some estimate a 0.5-1.0% decrease
weight loss
treatment goals
A1C less than 7%
fasting glucose 70-130
peak post-eating glucose less than 180
initial oral mono-therapy for type 2 DM
metformin
decreases glucose production by liver and increases peripheral insulin sensitivity
start at 500 mg once or twice daily, double every week if tolerated by pt until goal of 1000mg twice daily
contraindications for metformin
CHF
chronic hypoxia
pregnancy
stop if creatinine greater than 1.5 in men of 1.4 in women (kidney issues)
stimulate insulin secretion by pancreas beta cells, decrease micorvascular complications
sulfonylureas (glyburide, glipizide, glimepiride)
contra for preggers
sensitize muscle, fat, hepatocytes to insulin
thiazolidinediones (pioglitazone)
increased risk of fluid retention - contra for CHF
risk bladder cancer
stimulate beta cells, mealtime dosing
glitinides
(nateglinide, repaglinide)
cause increased weight gain
prevent absorption of simple sugars in gut
apha-glucosidase inhibitors (acarbose)
glatulence and GI side effects
DPP-4 degrades incretin which stimulates insulin secretion
DPP4 inhibitors (sitagliptin)
pancreatitis, angioedema, urticaria
increase insulin and decrease glucagon, increase satiety
GP1 receptor antagonist (exanatide)
hypoglycemia in combo, can cause weight LOSS
block glucose reabsorption in kidney
sodium-glucose cotransporter 2 inhibitors
SGLTS2i (canagliflozin)
can cause dehydration
do not use in CKD
insulin therapy for type 1 DM
- insulin required
- start at 0.5 units/kg/day
insulin therapy for type 2 DM
- insuliln may be required
- start at 0.1-0.2 units/kg/day
- goal to get morning fasting glucose less than 130
- if A1C not controlled, add prandail short acting insulin
two options for type 1 DM insulin therapy
basal long acting insulin and prandial short acting insulin
continuous infusion short acting insulin via pump
lispro
aspart
glulisine
short acting insulin
glargine
detemir
degludec
longer acting insulin
increased intracellular glucose leads to formation of …
AGEs
bind cell surface receptors, non enzymatic glycosylation
accelerate athersclerosis, promote glomerular dysfucntion, reduce NO synthesis, endothelial dysfunction
DM =
coronary hear disease equivalent
increased cardiovascular disease CHF, MI, PAD, CHD
goal blood pressure for diabetes
130/80
when would you want to add statin therapy?
10 yr risk less than 7.5% give moderate intensity
high intensity if greater than 7.5% risk (atorvastatin, rosuvastatin)
proliferative v. non-proliferative retinopathy?
increased risk in african american and hispanic pts
86% type I, 40% type II will develop a retinopathy
neovascularization due to hypoxemia - new vessels rupture easier = hemorrhage. hemorrhage leads to aqueous fibrosis and eventual retinal detachment
vascular micro aneurysms, blot hemorrhages, cotton-wool spots. retinal ischemia via change in retinal blood flow
when do you need opthamology exam?
at diagnosis of type II
w/i 5 yrs of onset of type 1 DM
followed by annual eye exmas
when do you need to measure urine albumin:Cr ratio annually?
- at dx of type 2 or w/i 5 yrs of type 1
if greater than 30 mg/g –> use ACEi or ARB to reduce progression of proteinuria and decrease risk of ESRD
ADA recommends yearly comprehensive foot exam ?
- at time of dx of type 2 DM
- at 5 yrs after onset of type 1 DM
what can be used to promote gastric emptying?
dopamine antagonists such as metoclopramide
__ of type 2 DM patients will develop foot ulcer
15%
most often of the great toe of MTP
velvet like discoloration of the neck.axilla
acanthosis nigricans
severe insulin resistance
