29 - Newly Diagnosed Diabetics Flashcards
Describe type 1 diabetes
Type 1
- Absolute insulin deficiency
- Younger, Autoimmune
- Less genetic effect
- Islet Cell Ab, low C peptide
- Insulin early
- No oral medication
Describe type 2 diabetes
Type 2
- Insulin resistance
- Older
- More genetic effect
- High C peptide (initially)
- Need insulin later (typically)
- Oral Medications early (typically)
What are the diagnostic criteria for “prediabetes”
AKA “increased risk of diabetes” or “intermediate hyperglycemia”
- Fasting plasma glucose: 100-125
- Glucose tolerance test: 149-199
- Hemoglobin A1c: 5.7-6.4%
What are the diagnostic criteria for diabetes?
- Fasting plasma glucose: 126+
- Glucose tolerance test: 200+
- Random blood glucose: 200+ with symptoms of DM
- Hemoglobin A1c: 6.5% +
What is important in history of a diabetic during the initial visits?
- Always important to get a good history from the patient regarding symptoms and family history
- Remember that Type 2 Diabetes is more common than Type 1 in adults
- Frequently, diagnosis of Type 2 DM is based on early changes on lab values rather than overt signs and symptoms of diabetes
What will you see in your review of systems?
General
- Fatigue
- Weight loss
- Sweating
Head and neck/chest
- Blurry vision, visual disturbances
- Dry mouth
- Neurologic tingling, numbness, pain
- Cardiac chest pain, palpitations, dyspnea on exertion, rest SOB, LE swelling, PAD (claudication)
Renal, abdominal, MSK
- Polyuria
- Urine output and color
- Heart burn, diarrhea, early satiety, nausea, vomiting
- Carpel tunnel syndrome
What additional history do you need to take?
- Smoking history*****
- Hypertension
- Hyperlipidemia, dyslipidemia
- Family history of diabetes - siblings, mother, father
- Hx of other endocrine disorder - thyroid disease, etc
- Lifestyle - job, activity, exercise, diet
- Cultural beliefs
- Psychosocial - depression, educational level, socioeconomic status
Why is the smoking history so important?
Need to know smoking history –> Do they smoke? Have they ever smoked? How much do they smoke? This is a huge modifiable risk factor for these patients
What does the treatment options for diabetes depend on?
The A1c of the patient
What is the treatment for an A1c less than 7.5%?
Lifestyle and dietary changes (if motivated)
What is the treatment for an A1c between 7.6 and 8.9%?
Monotherapy with metformin
What is the treatment for an A1c between 9 and 10%?
Recommend treatment with two oral agents OR insulin monotherapy
What is the treatment for an A1c between 10 and 12%?
Strong recommendation for insulin therapy
What is the treatment for an A1c between 10-12% WITH insulin therapy?
Insulin therapy REQUIRED
REMEMBER –> if they are above 10 and they have ketoacidosis or weight loss, they REQUIRE insulin
What are the lifestyle modifications recommended?
- ADA recommends 150 minutes/week of moderate-intensity cardio workouts***
- This means 3x/wk, no more than 2 days off in between
- ADA also recommends resistance training at least twice per week***
What is the most important FACTOR in reducing A1c?
Weight loss is the most important factor in reducing the A1c, some estimate a 0.5-1.0% decrease
What is the most effective DRUG in reducing A1c?
Insulin
Metformin is next
What are the treatment GOALS for diagnosed diabetics?
Hemoglobin A1c
- Less than 7%
Preprandial glucose (fasting) - 70-130
Peak postprandial glucose
- Less than 180
What is the primary oral medication used to treat diabetes?
Metformin
What does metformin do?
- Initial oral mono-therapy for Type 2 DM
- Increased peripheral nsulin sensitivity
- Decreased glucose production by liver
What do you need to know about dosing metformin?
- Start at 500 mg once or twice daily, double every week if tolerated by patient until goal of 1000 mg twice daily
- Do NOT use with CHF, chronic hypoxia, pregnancy
- Stop of Cr >1.5 in men or >1.4 in women
What is the other diabetic medication you need to know about?
- Sulfonylureas (glyburide, glipizide, glimepiride)
What do sulfonylureas do?
- Stimulate insulin secretion by pancreas, beta cells
- Decrease microvascular complications ***
- There can be decreased efficacy with time, therefore will need increasing doses
KNOW THIS
After starting metformin, if you need to add another oral agent, how do you pick one?
No recommendations
The second agent can just be based on side effects and comorbidities
What are the two options for insulin therapy in type 1 diabetics?
Insulin therapy is required
- Start at 0.5 U/kg/day
Option 1
- Basal long acting insulin plus prandial short acting insulin
Option 2
- Continuous infusion with short acting insulin via pump
What are the guidelines for insulin therapy in type 2 diabetics?
- Insulin may be required
- Start at 0.1-0.2 U/kg/day
- Initial goal is to get the morning fasting glucose below 130 ***
- Also check the A1c for improvement
- If you are not within goal, add prandial short acting insulin with meals
Describe the flow chart of initiating insulin dosing in type 2 diabetics
- First give glargine 10 units nightly and check glucose in morning
- Every third day, consider adjustment
- If the average blood sugar is 80-130, continue dose
- If the average blood sugar is 130-180, increase glargine by 2 units
- If the average blood sugar is above 180, increase glargine by 4 units
- Do this until mornign glucose is controlled
What are the common short acting insulins?
- Lispro
- Aspart (novolog)
- Glulisine
What is the common long acting insulin?
Insulin glargine (lantus)
What is the mechanism of tissue damage in diabetics?
- Increased intracellular glucose leads to formation of advanced glycosylation end products (AGEs)
- AGEs bind to cell surface receptors
- Remember they are formed by non-enzymatic glycosylation
What is the effect of AGEs?
- accelerate athersclerosis
- promote glomerular dysfunction
- reduces NO synthesis
- causes endothelial dysfunction
What are the MACROvascular complications we worry about in diabetics?
- coronary
- peripheral artery
- cerebrovascular disease
What are the MICROvascular complications we worry about in diabetics?
- retinopathy
- neuropathy
- nephropathy
We tend to follow the microvascular complications a lot closer
Describe cardiovascular risk in diabetics
- Increased cardiovascular disease
- Including CHF, MI, PAD, CHD
- Diabetes is a coronary heart disease equivalent
How do we control the cardiovascular risk factors?
Prevention of cardiovascular complications relies on risk factor modification
- Keep blood pressure is 130/80
- Use statins if needed
- Stop smoking ***
- Increase exercise
- Diet and weight loss
Describe the ophthalmologic side effects of diabetes
DM is the #1 cause of blindness in people age 20-74 in the United States
DM can cause both proliferative retinopathy and non-proliferative retinopathy
Describe proliferative retinopathy
- Neovascularization due to hypoxemia - new vessels rupture easier = hemorrhage
- Hemorrhage leads to aqueous fibrosis and eventual retinal detachment
Describe non-proliferative retinopathy
- Vascular micro aneurysms, blot hemorrhages, cotton-wool spots
- Retinal ischemia via change in retinal blood flow
What are the recommendations for monitoring ophthalmologic side effects in diabetics?
Initial dilated comprehensive eye exam by ophthalmologist
- At time of diagnosis of Type 2 DM
- Within 5 years of onset of Type 1 DM
- Followed by annual eye exams
Describe the renal side effects of diabetes
- Number 1 cause of End Stage Renal Disease (ESRD) in the United States
- Multiple mechanisms: altered renal circulation, glomerular changes
What do you need to assess annually in diabetics to monitor renal function?
Measure urine Albumin to Creatinine ratio ANNUALLY ***
- Starting at time of diagnosis in type 2 and within 5 years in type 1
What do you do if the albumin to creatinine ratio is greater than 30?
Use ACEi or ARB to reduce progression of proteinuria and decrease risk of End Stage Renal Disease
Describe the neurologic side effects that occur in diabetes
- Occurs in up to half of patients with long standing DM - myelinated and unmyelinated effected
- Distal symmetric polyneuropathy is most common (“Stocking-Glove” distribution)
Describe the neurologial symtpoms
- Numbness, tingling, sharpness, burning
- Eventually lose the painful sensations
- Loss of proprioception, ankle reflexes, and sensation
What is autonomic neuropathy?
AKA noradrenergic or cholinergic neuropathy
- Effects cardiovascular system (orthostatic hypertension)
- Effects GI system (gastroparesis)
- Anhidrosis common (dry skin)
What are the complications of neuropathy?
- falls
- ulcers (can’t feel it)
- poor sleep (one of the most common complaints – burning and tingling more severe at night)
What does the ADA recommend for a yearly comprehensive foot exam?
- At time of Dx of Type 2 DM
- At 5 years after onset of Type 1 DM
- Skin inspection
- Pedal pulses
- Sensation testing: monofilament, tuning fork
What are diabetic feet at risk for?
Increased risk for ulcers and poor wound healing due to impaired foot mechanics and loss of protective sensation/reflex
What are the GI side effects that can arise?
- Gastroparesis with long-standing DM; delay gastric emptying
- Early satiety, anorexia, vomiting
- Can use dopamine antagonists to promote gastric emptying such as metoclopramide
What are the GU side effects that can arise?
- Erectile dysfunction, female sexual dysfunction
- Cystopathy (unable to sense full bladder)
- Increased UTI in postmenopausal women
What is the most common cause of non-traumatic lower extremity amputation in the united states?
DIABETES
- Increased foot ulcers and infections
- Poor blood flow, poor wound healing, neuropathy, and altered walking mechanics (poor proprioception)
- 15% of type 2 DM patients will develop foot ulcer
- Most often of the great toe or MTP
What are the two other complications diabetics are at risk for?
- Infections
- Dermatology
Describe infections that diabetics are at risk for?
- increased common infections, as well as uncommon:Mucormycosis, emphasematous gallbladder infection/UTI
- Increased P. aeruginosa otitis externa
- Increased candidal infections and post-operative wound infection
- Poor phagocyte function, abnormal cell-mediated immunity
What are the dermatologic concerns diabetics are at risk for?
- Anhidrosis - dry skin, increased cracking, increased infection
- Acanthosis nigricans: velvet like discoloration of the neck/axilla - severe insulin resistance
