29: Management of Newly Diagnosed Diabetic Pt- Dodge

Question 1

which type of DM has high c peptide initially?

Answer 1

type 2 DM

Question 2

which type of DM has more genetic effect?

Answer 2

type 2 DM

Question 3

prediabetes/ increased risk of diabetes/ intermediate hyperglycemia lab values

Answer 3

• fasting glucose 100-125
• glucose tolearance 140-199
• HA1C 5.7 - 6.4%

Question 4

DM diagnostic lab values

Answer 4

• fasting glucose greater than 126
• glucose tolerance greater than 200
• random blood glucose greater than 200
• H1AC greater than 6.5%

Question 5

tx for A1c less than 7.5%

Answer 5

lifestyle and dietary changes if motivated

Question 6

tx for A1C 7.6-8.9%

Answer 6

monotherapy with metformin

Question 7

tx for A1C greater than 9%

Answer 7

recommend treatemtn with two oral agents or insulin monotherapy

Question 8

tx for A1C 10-12%

Answer 8

strong recommendation for insulin therapy

Question 9

tx for A1C 10-12% with ketosis and/or weight loss

Answer 9

insulin therapy required ***

Question 10

lifestyle modification recommendations

Answer 10

150 minutes/wk of moderate-intesnstiy cardio

3X/wk no more than 2 days off in between

resistance training at least twice per week

Question 11

_______ most important factor in reducing the A1C, some estimate a 0.5-1.0% decrease

Answer 11

weight loss

Question 12

treatment goals

Answer 12

A1C less than 7%

fasting glucose 70-130

peak post-eating glucose less than 180

Question 13

initial oral mono-therapy for type 2 DM

Answer 13

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

Question 14

contraindications for metformin

Answer 14

CHF
chronic hypoxia
pregnancy

stop if creatinine greater than 1.5 in men of 1.4 in women (kidney issues)

Question 15

stimulate insulin secretion by pancreas beta cells, decrease micorvascular complications

Answer 15

sulfonylureas (glyburide, glipizide, glimepiride)

contra for preggers

Question 16

sensitize muscle, fat, hepatocytes to insulin

Answer 16

thiazolidinediones (pioglitazone)

increased risk of fluid retention - contra for CHF

risk bladder cancer

Question 17

stimulate beta cells, mealtime dosing

Answer 17

glitinides

(nateglinide, repaglinide)

cause increased weight gain

Question 18

prevent absorption of simple sugars in gut

Answer 18

apha-glucosidase inhibitors (acarbose)

glatulence and GI side effects

Question 19

DPP-4 degrades incretin which stimulates insulin secretion

Answer 19

DPP4 inhibitors (sitagliptin)

pancreatitis, angioedema, urticaria

Question 20

increase insulin and decrease glucagon, increase satiety

Answer 20

GP1 receptor antagonist (exanatide)

hypoglycemia in combo, can cause weight LOSS

Question 21

block glucose reabsorption in kidney

Answer 21

sodium-glucose cotransporter 2 inhibitors

SGLTS2i (canagliflozin)

can cause dehydration
do not use in CKD

Question 22

insulin therapy for type 1 DM

Answer 22

• insulin required

- start at 0.5 units/kg/day

Question 23

insulin therapy for type 2 DM

Answer 23

• 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

Question 24

two options for type 1 DM insulin therapy

Answer 24

basal long acting insulin and prandial short acting insulin

continuous infusion short acting insulin via pump

Question 25

lispro
aspart
glulisine

Answer 25

short acting insulin

Question 26

glargine
detemir
degludec

Answer 26

longer acting insulin

Question 27

increased intracellular glucose leads to formation of …

Answer 27

AGEs

bind cell surface receptors, non enzymatic glycosylation

accelerate athersclerosis, promote glomerular dysfucntion, reduce NO synthesis, endothelial dysfunction

Question 28

DM =

Answer 28

coronary hear disease equivalent

increased cardiovascular disease CHF, MI, PAD, CHD

Question 29

goal blood pressure for diabetes

Answer 29

130/80

Question 30

when would you want to add statin therapy?

Answer 30

10 yr risk less than 7.5% give moderate intensity

high intensity if greater than 7.5% risk (atorvastatin, rosuvastatin)

Question 31

proliferative v. non-proliferative retinopathy?

increased risk in african american and hispanic pts

86% type I, 40% type II will develop a retinopathy

Answer 31

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

Question 32

when do you need opthamology exam?

Answer 32

at diagnosis of type II

w/i 5 yrs of onset of type 1 DM

followed by annual eye exmas

Question 33

when do you need to measure urine albumin:Cr ratio annually?

Answer 33

• 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

Question 34

ADA recommends yearly comprehensive foot exam ?

Answer 34

• at time of dx of type 2 DM

- at 5 yrs after onset of type 1 DM

Question 35

what can be used to promote gastric emptying?

Answer 35

dopamine antagonists such as metoclopramide

Question 36

__ of type 2 DM patients will develop foot ulcer

Answer 36

15%

most often of the great toe of MTP

Question 37

velvet like discoloration of the neck.axilla

Answer 37

acanthosis nigricans

severe insulin resistance