398 DM Complications Flashcards
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
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
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
Most common and early complication of DM
Diabetic retinopathy
Refers to the rise of blood glucose after food intake
Glycemic index
Most physiologic way of administering insulin
1 basal and 3 pre prandial short acting insulin
Brand for insulin apart
NovoRapid
What is the target blood glucose for hospitalized patients
180 mg/dl
IV drug given for DM type 1 aside from insulin
Amylin antagonist
OHA that can be given to DM type 1
Alpha glucosidase: acarbose/voglibose
OHA known to decrease lipolysis
TZDs
Specific side effect of SGLT2 inhibitors
Genital infection
Why no ketosis in HHS?
Relative insulin deficiency
Add 5 more to the Ominous octet to make 13
Decrease vitamin D Decreased dopamine Decreased testosterone Kidney GUT/incretin
Hormones responsible for DKA
Decreased insulin
Excess glucagon
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
Preferred over regular insulin the the managed of post prandial coverage
Aspart
Lispro
Glulisine
Covers for basal insulin requirement
Long acting insulin such as NPH Glargine Detemir Degludec
What just the 70/30 in insulin pens mean?
70% NPH
30% regular insulin
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
What is the difference between insulin regimens versus endogenous insulin
Endogenous insulin: secreted into portal venous system
Insulin regimen: systemic circulation
How is prandial insulin dose computed
1 unit insult for ever 50 mg/dl over the preprandial glucose target
Another formula in formulating insulin to be given
Body weight in Kg x blood glucose - desired divided by 1500
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
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
- 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
