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Thera X > 9 Diabetes Chun > Flashcards

9 Diabetes Chun Flashcards

1
Q

What are the criteria to diagnose diabetes?

A

Symptoms of diabetes (3Ps) PLUS random plasma glucose > 200 mg/dl. OR. Fasting plasma glucose > 126. OR. 2 hour plasma glucose > 200 during OGTT. OR. Glycated hemoglobin A1c > 6.5%

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2
Q

What are the overall treatment guidelines for T1DM?

A

Insulin, Insulin, Insulin! Diet, Exercise, Education, Monitoring

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3
Q

What is T1DM like in infants < 1 year?

A

Highest risk of severe hypoglycemia (unable to communicate, nonspecific clinical signs (poor feeding, lethargy, jitterness, hypotonia), Neurologic complications (seizure, coma): effects on brain development and learning

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4
Q

Why is the management plan for T1DM in infants < 1 year difficult?

A

Due to frequent feeding schedule

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5
Q

What is T1DM like in toddlers (1-3 years)?

A

Main concern: Hypoglycemia (Erratic food intake and activity level, parent ability to recognize episode)

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6
Q

What is T1DM with school-aged (8-11) patients?

A

Child involvement w/ adult support. Routine insulin administration. Early independent self-management with minimal/not adult supervision results in poorer glycemic control

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7
Q

What is the concern with T1DM in school-aged (8-11) patients?

A

Psychological impact (Dx: depression, anxiety). Difficult social interactions

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8
Q

What is T1DM like in adolescents?

A

Increased independence and self-assertiveness. Poor control: parent-child conflict over daily management. Better control: shared management

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9
Q

What are some issues for T1DM in adolescents?

A

Driving, risky behavior (EtOH, tobacco, sex), psychatric. Patient w/ diabetes have more than 3x psychiatric d/o (depression, eating d/o)

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10
Q

What are the A1c goals for kids aged < 6 to 19?

A

< 6: 7.5-8.5%. Age 6-12: < 85. Age 13-19: < 7.5%

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11
Q

How often does the ADA recommend checking BG?

A

4x/day

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12
Q

When is more frequent BG monitoring done?

A

Those w/ increased risk for severe hypoglycemia (very young children, patients w/ intensive therapy w/ multiple meals/snacks)

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13
Q

What are the characteristics of Humalog?

A

Onset: 1/4 hour. Peak: 1 hr. Duration: 3-4 hours

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14
Q

What are the characteristics of Regular?

A

Onset: 1/2 hr. Peak: 2 hrs. Duration: 6 hrs

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15
Q

What are the characteristics of NPH (Humulin-N)?

A

Onset: 2 hrs. Peak: 4-6 hrs. Duration: 12-14 hrs

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16
Q

What are the characteristics of Glargine (Lantus)?

A

Onset: 2-3 hrs. Peak: None. Duration: 24 hrs

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17
Q

What is the base/basal dose range?

A

0.6-1 unit/kg/day. Pre-pubertal child: 0.6-0.7, Pubertal child: 0.8-1

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18
Q

What is the administration of base/basal dose broken down?

A

2/3 in AM (2/3 NPH + 1/3 H or R), 1/3 in PM (1/2 NPH + 1/2 H or R)

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19
Q

What are the characteristics of supplemental insulin (given on top of basal insulin)?

A

One-time dose of short-acting insulin determined by pre-dose glucose. Goal: Rapid return to target range glucose

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20
Q

What is the dosing of supplemental insulin like?

A

Based on prescribed guideline after validating on the patient. 1/2 or 1 unit of H or R per 50>200. Before each meal and before bedtime (never overnight, risk of hypoglycemia)

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21
Q

What are the characteristics of Glargine (Lantus)?

A

Provides 24 hour basal coverage. No pronounced peak. Better predictability

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22
Q

How is Glargine (Lantus) given for initiation for insulin naive patients?

A

Add 10 units daily to oral antidiabetic (OAD)

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23
Q

What is done with Glargine (Lantus) when switching from NPH once daily?

A

1 unit: 1 unit

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24
Q

What is done with Glargine (Lantus) when switching from NPH BID?

A

80% of total daily NPH

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25
Q

How is Glargine (Lantus) titrated?

A

Increase by 1 unit daily until FPH < 100, or adjust weekly to target FPG < 100

26
Q

What is the ADAs recommendation for a insulin pump?

A

Recurrent severe hypoglycemia. Wide BG fluctuations, regardless of A1c. Suboptimal diabetes control, increased A1c. Microvascular complications and/or risk factors for macrovascular complications. Good metabolic control, but insulin regimen compromises lifestyle

27
Q

What is the basal rate for the insulin pump?

A

40-50% total daily dose. Given in small aliquots every few minutes, evenly spaced over an hour. Rapid-acting insulin: most pumps. Short-acting insulin

28
Q

When should Ketonuria be checked?

A

If BG > 250 for 2+ readings

29
Q

What is some monitoring to be done with Diabetes?

A

A1c Q3 months. Annual microalbuminuria (for nephropathy). Annual opthalmologic (for retinopathy). Annual foot exam (for neuropathy). Celiac disease at diagnosis and every other year. Lipid profile at diagnosis (repeat Q5 years if normal). Thyroid function test. R/o Grave’s disease

30
Q

What is the diagnosis criteria for DKA?

A
  1. Hypoglycemia (BG > 200mg/dL) and 2) Metabolic acidosis (Venous pH > 7.3 and/or Plasma bicarbonate < 15 mEq/L). Accompanied by: Hyperketosis (urine dip: (+) Ketones), Hyperosmolality
31
Q

What are the different degrees of acidosis?

A

Mild (pH 7.2-7.3). Moderate (pH 7.1-7.2). Severe (pH < 7.1)

32
Q

What is Pseudohyponatremia in DKA?

A

Apparent hypo-Na d/t very high BG

33
Q

Why do Ketones develop in DKA?

A

No carbohydrate intake. Prolonged exercise, pregnancy. Lack of insulin activity. Increase in insulin resistance (infection, illness, surgery, stress). Alcohol, salicylate ingestion, inborn metabolic errors

34
Q

What are the DKA risk factors?

A

Initial presentation (young children < 6 yo, low socioeconomic). Recurrent DKA (High A1c and high reported insulin requirements, Female adolescents > 13 yo (>13 yo regardless of gender if underinsured or h/o psychiatric d/o), longer duration of DM)

35
Q

What initial laboratory exams must ALWAYS be performed in an ill child?

A

Glucose, Ketones

36
Q

What is initial therapy for DKA?

A

Fluids and Insulin

37
Q

What is fluid therapy like for DKA?

A

Slowly correct over 24-48 hours w/ isotonic solution. Re-establish circulation: NS (20ml/kg NS bolus over 30 min, repeat prn). Consider 1/2 NS when corrected Na is normal. Give Potassium 40mEq/L of KCl after initial resuscitation, unless oliguria or K > 5.5

38
Q

What is Insulin therapy like for DKA?

A

After completion of initial fluid bolus. Continuous infusion regular insulin (0.1 unit/kg/hr (to decrease BG by 50-100 per hour), can do 0.05 units/kg/hr for younger children who may be more sensitive to insulin). Subcutaneous insulin when: Glucose < 300, ketosis resolving (urine ketones < 1g), pH > 7.3, HCO3 > 15, willing to eat meal

39
Q

What is DKA mortality rate?

A

100% w/o insulin therapy. 60-90% of the deaths that occur are in association with signs of cerebral edema (CE)

40
Q

What is Cerebral Edema like in DKA?

A

Occurs in ~1% of episodes of DKA in children. High mortality rate. Mechanism poorly understood

41
Q

Who is at risk for Cerebral Edema with DKA?

A

Initial 24h of treatment. Baseline mental status abnormal. Newly diagnosed, younger children < 4-5y. Bicarbonate therapy used for DKA acidosis correction, etc.

42
Q

What are the “Major Criteria” for the signs and symptoms of Cerebral Edema?

A

Early signs of neurologic collapse (prior to head CT changes). AMS/ALOC. Sustained HR deceleration < 20 bpm. Age-inappropriate incontinence

43
Q

What are the “Minor Criteria” for the signs and symptoms of Cerebral Edema?

A

Severe HA, usually the 1st sign. Sudden onset/return of vomiting. Increased BP: DBP > 90mmHg. Lethargy

44
Q

What is the treatment for Cerebral Edema?

A

Reduce rate of fluid administration. Hypertonic agent (1. Mannitol, 2. Alternate, 3% NS). Intubation and mechanical ventilation may be required (avoid hyperventilation)

45
Q

How is Mannitol dosed?

A

0.25-1 g/kg IV over 20 min (MR x1 in 2 hours)

46
Q

How is NS dosed when treating Cerebral Edema?

A

3% NS 5-10 ml/kg over 30 minutes

47
Q

What is Acanthosis Nigricans (AN)?

A

Skin condition that signals high insulin levels in the body (“velvety” hyperpigmented skin change). Help identify high insulin levels, and those who may be at-risk for developing diabetes. Associated with polycystic ovarian syndrome (PCOS), irregular menses, acne, hirsutism

48
Q

What is considered Metabolic Syndrome (MS)?

A

3 or more of the following: Central or abdominal obesity (not defined in peds), Hypertriglyceridemia, HTN, Low HDL cholesterol, High fasting glucose level). MS is a major risk factor for CVD and T2DM

49
Q

What is done for Asymptomatic T2DM treatment?

A

B-cell secretory status presumed to be preserved. Therapy: Lifestyle modification

50
Q

What is done for Polyuria/dipsia and possibly polyphagia T2DM treatment?

A

B-cell secretory status presumed to be in between preserved and failed. Therapy: Metformin 500mg PO BID

51
Q

What is done for Weight loss, ketosis, DKA T2DM treatment?

A

B-cell secretory status presumed to be failed. Therapy: Insulin (as in T1DM)

52
Q

When is pharmacologic therapy used in asymptomatic patients of T2DM?

A

3 months after initiation of lifestyle modification, failed to achieve glycemic control

53
Q

How do Biguanides or Thiazolidinediones work?

A

Increase insulin responsiveness by increasing insulin sensitivity and decreasing hepatic glucose production

54
Q

How do Sulfonylureas or Meglitinides work?

A

Increase insulin secretion

55
Q

How do Alpha-Glucosidase Inhibitors work?

A

Delay absorption of carbohydrates or lipase inhibitors that decrease fat absorption

56
Q

What is the Biguanide used?

A

Metformin (Glucophage). Usually 1st line agent

57
Q

When is Metformin Contraindicated?

A

Impaired renal function d/t lactic acidosis

58
Q

What is the Sulfonylurea used?

A

Glimepiride (Amaryl). Similar A1c improvement and safety

59
Q

What are the ADRs with Sulfonylurea use?

A

Weight gain and risk of hypoglycemia

60
Q

When is Metformin used in children/adolescents w/ T2DM?

A

Fail to attain glycemic control 3 months after lifestyle modification. Present with mild symptoms and hyperglycemia. After BG approach (near) normal levels in patients w/ severe hyperglycemia and/or ketosis initially treated w/ insulin

61
Q

How is Metformin dosed in children/adolescents w/ T2DM?

A

Initial: 500mg PO QD. Increase by 500mg to 500mg PO BID, MDD 2000mg

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