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Endocrine Exam 2 > 29 - Newly Diagnosed Diabetics > Flashcards

29 - Newly Diagnosed Diabetics Flashcards

1
Q

Describe type 1 diabetes

A

Type 1

  • Absolute insulin deficiency
  • Younger, Autoimmune
  • Less genetic effect
  • Islet Cell Ab, low C peptide
  • Insulin early
  • No oral medication
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2
Q

Describe type 2 diabetes

A

Type 2

  • Insulin resistance
  • Older
  • More genetic effect
  • High C peptide (initially)
  • Need insulin later (typically)
  • Oral Medications early (typically)
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3
Q

What are the diagnostic criteria for “prediabetes”

AKA “increased risk of diabetes” or “intermediate hyperglycemia”

A
  • Fasting plasma glucose: 100-125
  • Glucose tolerance test: 149-199
  • Hemoglobin A1c: 5.7-6.4%
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4
Q

What are the diagnostic criteria for diabetes?

A
  • Fasting plasma glucose: 126+
  • Glucose tolerance test: 200+
  • Random blood glucose: 200+ with symptoms of DM
  • Hemoglobin A1c: 6.5% +
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5
Q

What is important in history of a diabetic during the initial visits?

A
  • 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
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6
Q

What will you see in your review of systems?

A

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
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7
Q

What additional history do you need to take?

A
  • 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
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8
Q

Why is the smoking history so important?

A

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

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9
Q

What does the treatment options for diabetes depend on?

A

The A1c of the patient

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10
Q

What is the treatment for an A1c less than 7.5%?

A

Lifestyle and dietary changes (if motivated)

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11
Q

What is the treatment for an A1c between 7.6 and 8.9%?

A

Monotherapy with metformin

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12
Q

What is the treatment for an A1c between 9 and 10%?

A

Recommend treatment with two oral agents OR insulin monotherapy

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13
Q

What is the treatment for an A1c between 10 and 12%?

A

Strong recommendation for insulin therapy

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14
Q

What is the treatment for an A1c between 10-12% WITH insulin therapy?

A

Insulin therapy REQUIRED

REMEMBER –> if they are above 10 and they have ketoacidosis or weight loss, they REQUIRE insulin

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15
Q

What are the lifestyle modifications recommended?

A
  • 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***
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16
Q

What is the most important FACTOR in reducing A1c?

A

Weight loss is the most important factor in reducing the A1c, some estimate a 0.5-1.0% decrease

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17
Q

What is the most effective DRUG in reducing A1c?

A

Insulin

Metformin is next

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18
Q

What are the treatment GOALS for diagnosed diabetics?

A

Hemoglobin A1c
- Less than 7%

Preprandial glucose (fasting)
- 70-130

Peak postprandial glucose
- Less than 180

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19
Q

What is the primary oral medication used to treat diabetes?

A

Metformin

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20
Q

What does metformin do?

A
  • Initial oral mono-therapy for Type 2 DM
  • Increased peripheral nsulin sensitivity
  • Decreased glucose production by liver
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21
Q

What do you need to know about dosing metformin?

A
  • 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
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22
Q

What is the other diabetic medication you need to know about?

A
  • Sulfonylureas (glyburide, glipizide, glimepiride)
23
Q

What do sulfonylureas do?

A
  • Stimulate insulin secretion by pancreas, beta cells
  • Decrease microvascular complications ***
  • There can be decreased efficacy with time, therefore will need increasing doses

KNOW THIS

24
Q

After starting metformin, if you need to add another oral agent, how do you pick one?

A

No recommendations

The second agent can just be based on side effects and comorbidities

25
Q

What are the two options for insulin therapy in type 1 diabetics?

A

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

26
Q

What are the guidelines for insulin therapy in type 2 diabetics?

A
  • 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
27
Q

Describe the flow chart of initiating insulin dosing in type 2 diabetics

A
  • 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
28
Q

What are the common short acting insulins?

A
  • Lispro
  • Aspart (novolog)
  • Glulisine
29
Q

What is the common long acting insulin?

A

Insulin glargine (lantus)

30
Q

What is the mechanism of tissue damage in diabetics?

A
  • 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
31
Q

What is the effect of AGEs?

A
  • accelerate athersclerosis
  • promote glomerular dysfunction
  • reduces NO synthesis
  • causes endothelial dysfunction
32
Q

What are the MACROvascular complications we worry about in diabetics?

A
  • coronary
  • peripheral artery
  • cerebrovascular disease
33
Q

What are the MICROvascular complications we worry about in diabetics?

A
  • retinopathy
  • neuropathy
  • nephropathy

We tend to follow the microvascular complications a lot closer

34
Q

Describe cardiovascular risk in diabetics

A
  • Increased cardiovascular disease
  • Including CHF, MI, PAD, CHD
  • Diabetes is a coronary heart disease equivalent
35
Q

How do we control the cardiovascular risk factors?

A

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
36
Q

Describe the ophthalmologic side effects of diabetes

A

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

37
Q

Describe proliferative retinopathy

A
  • Neovascularization due to hypoxemia - new vessels rupture easier = hemorrhage
  • Hemorrhage leads to aqueous fibrosis and eventual retinal detachment
38
Q

Describe non-proliferative retinopathy

A
  • Vascular micro aneurysms, blot hemorrhages, cotton-wool spots
  • Retinal ischemia via change in retinal blood flow
39
Q

What are the recommendations for monitoring ophthalmologic side effects in diabetics?

A

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
40
Q

Describe the renal side effects of diabetes

A
  • Number 1 cause of End Stage Renal Disease (ESRD) in the United States
  • Multiple mechanisms: altered renal circulation, glomerular changes
41
Q

What do you need to assess annually in diabetics to monitor renal function?

A

Measure urine Albumin to Creatinine ratio ANNUALLY ***

- Starting at time of diagnosis in type 2 and within 5 years in type 1

42
Q

What do you do if the albumin to creatinine ratio is greater than 30?

A

Use ACEi or ARB to reduce progression of proteinuria and decrease risk of End Stage Renal Disease

43
Q

Describe the neurologic side effects that occur in diabetes

A
  • Occurs in up to half of patients with long standing DM - myelinated and unmyelinated effected
  • Distal symmetric polyneuropathy is most common (“Stocking-Glove” distribution)
44
Q

Describe the neurologial symtpoms

A
  • Numbness, tingling, sharpness, burning
  • Eventually lose the painful sensations
  • Loss of proprioception, ankle reflexes, and sensation
45
Q

What is autonomic neuropathy?

A

AKA noradrenergic or cholinergic neuropathy

  • Effects cardiovascular system (orthostatic hypertension)
  • Effects GI system (gastroparesis)
  • Anhidrosis common (dry skin)
46
Q

What are the complications of neuropathy?

A
  • falls
  • ulcers (can’t feel it)
  • poor sleep (one of the most common complaints – burning and tingling more severe at night)
47
Q

What does the ADA recommend for a yearly comprehensive foot exam?

A
  • 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
48
Q

What are diabetic feet at risk for?

A

Increased risk for ulcers and poor wound healing due to impaired foot mechanics and loss of protective sensation/reflex

49
Q

What are the GI side effects that can arise?

A
  • Gastroparesis with long-standing DM; delay gastric emptying
  • Early satiety, anorexia, vomiting
  • Can use dopamine antagonists to promote gastric emptying such as metoclopramide
50
Q

What are the GU side effects that can arise?

A
  • Erectile dysfunction, female sexual dysfunction
  • Cystopathy (unable to sense full bladder)
  • Increased UTI in postmenopausal women
51
Q

What is the most common cause of non-traumatic lower extremity amputation in the united states?

A

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
52
Q

What are the two other complications diabetics are at risk for?

A
  • Infections

- Dermatology

53
Q

Describe infections that diabetics are at risk for?

A
  • 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
54
Q

What are the dermatologic concerns diabetics are at risk for?

A
  • Anhidrosis - dry skin, increased cracking, increased infection
  • Acanthosis nigricans: velvet like discoloration of the neck/axilla - severe insulin resistance

Endocrine Exam 2 (18 decks)

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