398 DM Complications Flashcards by Medicine Katorse

A 56/M diabetic for 15 years on Empagliflozin+ Linagliptin 25/5 mg OD presents with 2 days diarrhea progressing to difficulty breathing and drowsiness. BP 110/60 mmHg, HR 116 bpm, RR 26 cpm, HbA1c of 6.8%, CBG is 120 mg/dl. ABG pH 7.26, HCO3 of 12 and ketonuria 4+. What is the likely diagnosis?

Euglycemic diabetic ketoacidosis

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43M DM was brought to ER for fever,cough and vomiting. PE drowsy, dry lips with poor skin turgor. BP 90/60. HR 112 bpm. RR 32 cpm. CBG 521 mg/dl. After assessing electrolyte and acid base status, which fluid must you infuse?
A. 0.9 Saline
B. D5 Normosol
C. 0.45 Saline
D. Lactated ringers

A. 0.9 Saline

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What is the recommended initial bolus dose of IV regular short acting, insulin in DKA and HHS?
A. 15 units/kg
B. 10 units/Kg
C. 1 unit/Kg
D. 0.1 unit/Kg

D. 0.1 unit/Kg

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Most common and early complication of DM

Diabetic retinopathy

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Refers to the rise of blood glucose after food intake

Glycemic index

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Most physiologic way of administering insulin

1 basal and 3 pre prandial short acting insulin

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Brand for insulin apart

NovoRapid

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What is the target blood glucose for hospitalized patients

180 mg/dl

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IV drug given for DM type 1 aside from insulin

Amylin antagonist

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OHA that can be given to DM type 1

Alpha glucosidase: acarbose/voglibose

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OHA known to decrease lipolysis

TZDs

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Specific side effect of SGLT2 inhibitors

Genital infection

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Why no ketosis in HHS?

Relative insulin deficiency

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Add 5 more to the Ominous octet to make 13

Decrease vitamin D
Decreased dopamine
Decreased testosterone
Kidney
GUT/incretin

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Hormones responsible for DKA

Decreased insulin

Excess glucagon

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What test will you do to assess diabetic nephropathy?
A. Serum creatinine
B. EGFR using CKD EPI formula
C. Urine Creatinine: protein ratio
D. 24 hr urine protein excretion

C. Urine Creatinine: protein ratio

Micral test

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Preferred over regular insulin the the managed of post prandial coverage

Aspart
Lispro
Glulisine

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Covers for basal insulin requirement

Long acting insulin such as
NPH
Glargine
Detemir
Degludec

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What just the 70/30 in insulin pens mean?

70% NPH

30% regular insulin

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When should insulin analogues injected before a meal? Regular insulin?

Insulin analogues less than 10 mins

Regular insulin 30-45 mins prior to a meal

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What is the difference between insulin regimens versus endogenous insulin

Endogenous insulin: secreted into portal venous system

Insulin regimen: systemic circulation

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How is prandial insulin dose computed

1 unit insult for ever 50 mg/dl over the preprandial glucose target

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Another formula in formulating insulin to be given

Body weight in Kg x blood glucose - desired divided by 1500

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How to avoid nocturnal hypoglycemia when using long acting insulin

Give long acting insulin at bedtime to that at the peak of the insulin action as glucose levels rise in the morning due to growth hormone and cortisol secretion

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General assumptions in SMBG

fasting glucose determined by prior evening long acting Pre lunch glucose determined by breakfast short acting insulin Pre supper glucose is determined by morning long acting insulin Bedtime glucose is function of pre supper short acting insulin

Dosage of long acting insulin

0.2-0.4 U/Kg per day

Ketone measure in blood

Beta hydorxybutarate

Ketone measured in urine

Acetone and acetoacetate

Indicator of DKA

Ketones

Prominent symptoms of DKA

Nausea and vomiting

Extremely serious complication of DKA

Cerebral edema

When is bicarbonate supplementation done in DKA?

pH less than 7.0

What is the fluid replacement in DKA?

2-3 L in first 3 hours or 10-20 ml/ Kg in first 3 hrs | PNSS

Is there serum potassium level requirement in giving insulin?

Replace serum potassium if less than 3.3 ml/dl

Why is PNSS replaced with D5. 045 if CBG equal to less than 250 mg/dl

To avoid hyperchloremia

mechanism behind the chronic complications of hypeglycemia

1. formation of advanced glycosylation end products and non enzymatic glycosylation of proteins 2. increased glucose metabolism via sorbitol pathway using the enzyme aldose reductase 3. increased formation of diacylglycerol leading to activation of protein kinase C 4. increased flux through the hexosamine

unifying mechanism in chronic DM complications

increased production of reactive oxygen species or superoxide in the mitochondria

play an important role in some diabetes related microvascular complications

growth factors

Landmark trial provided definitive proof that reduction in chronic hyperglycemia can prevent complication of T1DM

DCCT

trial the showed improvement of glycemic control reduced retinopathy, microalbuminuria, clinical nephropathy, and neuropathy

DCCT

trial that showed continuous relationship between glycemic control and development of complications

UKPDS

trial that showed that strict BP control reduce micro- and macrovascular complication greater than glycemic control

UKPDS

trial that showed intensive lifestyle changes delayed the development of T2DM

Diabetes Prevention Program (DPP)

trial that showed metformin delayed the development of T2DM by 31% compared to placebo

DPP

classification of diabetic retinopathy

proliferative and nonproliferative

what is the hallmark of proliferative retinopathy

appearance of neovascularization to retinal hypoxemia

True or false. Non all individual with nonproliferative retinopathy go on to develop proliferative retinopathy. The more severe the nonproliferative disease, the greater chance of evolution to proliferative retinopathy

True.

best predictor of retinopathy

duration of DM and degree of glycemic control

most effective therapy for diabetic retinopathy

prevention

treatment of proliferative retinopathy or macular edema

photocoagulation and or anti VEGF therapy

when does nonproliferative DM retinopathy occur

late in first decade or early in the second decade of disease

findings in non proliferative retinopathy

retinal vascular microaneurysm, blot hemorrhages and cotton wool spots

True or false. There is paradoxical transient worsening retinopathy during the 6-12 months of improved glycemic control

True.

Treatment for macular edema

focal laser photocoagulation

treatment for proliferative retinopathy

panretinal laser photocoagulation

True or false. Aspirin does not influence natural history of diabetic retinopathy

True.

pathophysiology of DM nephropathy

GFR increases in first few years; thickening of glomerular basement membrane, mesangial expansion, and glomerular hypertrophy occur; after 5-10 years T1DM excrete small amounts of albumin in the urine

stages of DM nephropathy

hyperfiltration, microalbuminura, macroalbuminuria

define albuminuria

albumin creatinine ration more than 30 mg/g Cr

when to screen for albuminuria

5 years from diagnosis of T1DM and at time of diagnosis for T2DM

True or false. Once macroalbuminuria is present, GFR decline is steady

True.

most common areas for T2DM to develop foot ulcer

great toe or metatasophalangeal areas

most common site of ulceration on the foot

plantar surface

most common pathogens of diabetic foot

aerobic gram postiive cocci (staphylococci MRSA, Group A and B streptococci)

most specific modality in assessing diabetic foot ulcer

MRI

interventions with demonstrated efficacy in diabetic foot ulcers

off loading, debridement, wound dressing, appropriate use of antibiotics, revascularization limited amputation

antibiotics for diabetic foot ulcer

dicloxacillin,cephalosporin, amoxicillin/clavulanate

studies that showed cardiovascular benefit with GLP1 samglutide

SUSTAIN 6

studies that showed cardiovascular benefit with GLP1 liraglutide

LEADER

studies that showed cardiovascular benefit with SGLT2 inhibitors empagliflozin

EMPA-REG

studies that showed cardiovascular benefit with SGLT2 inhibitors canagliflozin

CANVAS

age of diabetes that benefit from primary prevention of cardiovascular events with aspirin

men more than 50 and women more than 60

Aspirin for primary prevention in DM

age more than 50; increased CV risk of more than 10% OR at least one risk factor (hypertension, dyslipidemia, smoking, family history, or albuminuria

most common form of diabetic neuropathy

distal symmetric polyneuropathy which presents with distal sensory loss and pain

treatment for diabetic neuropathy

tricyclic antidepressant, gabapentin, venlafaxine, carbamazepine, tramadol, topical capsaicin

most common skin manifestation of DM

xerosis and pruritus

begins as erythematous macule or papule that evolves into an area of circular hyperpigmentation

pigmented pretibial papules or diabetic skin spots