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Diabetes Canada guidelines > Adults - Management > Flashcards

Adults - Management Flashcards

1
Q

At time of diagnosis:

What are the next steps (before deciding on rx):

  1. Assess:
  2. Pick:
  3. Refer:
  4. Start:
A
  1. Assess:
    - cardiovascular status
    - renal status
    - diet
    - weight change
  2. Pick individualized A1C target
  3. Refer for diabetes education
  4. Start healthy behaviour interventions (smoking, exercise, diet, stress)
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2
Q

A1C Glycemic control target:

Most adults with DM type 1+2:

Adults with DM 2 to reduce risk of CKD and retinopathy:

Frail elderly, limited life expectancy, recurrent severe hypoglycemia or hypoglycemia unawareness:

A

Most adults: 7.0 and under

If low risk of hypoglycemia:
6.5 and under

If risk of hypoglycemia or frail:
7.1 to 8.5

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3
Q

At time of diagnosis of type 2 DM:

Goal: achieve A1C target by _____

Start _______ right away

Start metformin if:

Start insulin if:

A

Goal: target A1C by 3 months

Start lifestyle changes ASAP
*no rx

Start metformin:

  • if A1C not at target in 3 months with lifestyle changes
  • if A1C if >1.5% above target (start metformin with second agent)

Start insulin:
*if symptomatic hyperglycemia and/or metabolic decompensation

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4
Q

ABCDESSS of diabetes care stands for:

A 
A1C target
BP target
Cholesterol target
Drugs for CV/renal protection
Exercise and Eating
Screening for complications
Smoking cessation
Self-management and Stress
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5
Q

What is the BP target for DM:

A

BP <130/80

*assess for risk of falls

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6
Q

What is the LDL target for DM:

A

LDL-C <2.0 OR

50% reduction from baseline

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7
Q

Drugs for cardio/renal protection:

non-antihyperglycemic agents:

  • ACEi/ARB:
  • Statin:
  • ASA:
A

non-AHA:

ACEi/ARB: if CVD, 55+ with risk factors or diabetes complications

STATIN: if CVD, 40+ or diabetes complications

ASA: if CVD

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8
Q

Drugs for cardio/renal protection:

What class of antihyperglycemic medications have cardiorenal benefits?

A
  • SGLT2i

- GLP1RA

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9
Q

Goals for Exercise and Eating:

A

Exercise: 150 min/week moderate to vigorous aerobic activity
-2-3x/week resistance exercises

Eating: Mediterranean, low GI

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10
Q

Screening for complications:
what test and how often

Cardiac:
Foot:
Kidney:
Retinopathy:

A

ECG q3-5 years if 40+ or diabetes complications

Foot: monofilament/vibration annually minimum

Kidney: eGFR and ACR annually minimum

Retinopathy:
type 1: annual
type 2: q1-2 years

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11
Q

Sick day medication list

SADMANS:

  • what situation would you consider a sick day?
  • what are some non-pharm measures to do?
A

-risk of dehydration (vomiting, diarrhea)

  • hydrate with water, broth, diet soft drinks
  • avoid caffeine

-hold SADMANS meds, restart when eat/drinking normally

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12
Q

CV risk factors when looking at rx options:

A
  • smoking
  • dyslipidemia (on statins OR untreated LDL/HDL/TG)
  • hypertension (on anti-HTN or untreated SBP 140+ or DBP 95+)
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13
Q

Hypoglycemia signs and symptoms

A 
Trembling
Palpitations
Sweating
Anxiety
Hunger
Nausea
Tingling

Difficulty concentrating
Confusion, weakness, drowsiness, vision changes
Difficulty speaking, headache, dizziness

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14
Q

Hypoglycemia is defined as:

How do you treat?

A

plasma glucose <4 if on insulin or insulin secretagogue (sulfonylureas)

15 g of sugar for mild-moderate hypoglycemia
1 Tbsp honey
1 Tbsp sugar in water
150 ml juice
6 lifesavers
9 jelly beans
  • recheck in 15 min
  • if BS >4 and meal is >1 hr away: eat starch and protein
  • if driving: wait until BS >5
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15
Q

Initiation of basal insulin

  • examples of basal insulin?
  • starting dose?
  • titrate how?
  • maintain which meds?
  • target BG?
A

eg glargine (Lantus), determir (levemir), degludec (tresiba), NPH

10 u daily at bedtime
titrate 1 u/day until target fasting BG 4.0-7.0

maintain metformin and secretagogues

*do not increase if 2 hypo episodes (BG <4.0) in one week or any nocturnal hypo

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16
Q

Initiating bolus insulin ON TOP of basal

examples of bolus insulin?

  • starting dose?
  • titrate how?
  • target?
  • maintain which meds?
A

aspart (Novorapid), lispro (Humalug)

2-4 u with main meal or breakfast

  • 1 u/day
  • target 8.0 and under PC MEAL or 4.0-7.0 AC MEAL

-maintain metformin, stop secretaguge

17
Q

A1C targets in functionally independent older adults?

hypoglycemia unaware, recurrent severe hypoglycemia, limited life expectancy?

A

7.1 to 8.0%

if hypoglycemia unaware: 7.1-8.5%

18
Q

What medications are on SADMANS list?

A 
Sulfonylureas/secretagogues
ACE-I
Diuretics, direct renin inhibitors
Metformin
ARB
NSAIDs
SGLT2-i
19
Q

glycemic targets in functionally independent older adults?
frailty scale 1-3

A1C

  • if low risk hypoglycemia
  • if high risk hypoglycemia

random glucose

  • preprandial
  • postprandial
A

A1C:
7.0 and under

preprandial: 4-7
postprandial 5-10

20
Q

glycemic targets in functionally dependent older adults?
frailty scale 4-5

A1C

  • if low risk hypoglycemia
  • if high risk hypoglycemia

random glucose

  • preprandial
  • postprandial
A

A1C 8.0 and under if low risk hypo

A1C 7.1-8.0 if high risk hypo

preprandial 5-8
postprandial <12

21
Q

glycemic targets in frail and/or dementia?
clinical frailty 6-8

A1C

  • if low risk hypoglycemia
  • if high risk hypoglycemia

random glucose

  • preprandial
  • postprandial
A

A1C 8.5 and under if low risk hypo

A1C 7.1-8.0 if high risk hypo

preprandial 6-9
postprandial <14

22
Q

nonpharm management of DM in older adults

weight loss?
exercise?

A

weight loss not as important

higher activity = greater survival
assess for underlying CV, MSK issues
resistance training improves glycemic control

23
Q

risk of sulfonylureas in older adults?

A

+++ caution
risk severe hypo
glicazide&raquo_space;» glyburide

24
Q

DPP4 use in older adults
“gliptins”

  • hypoglycemia?
  • weight?
A

equivalent glycemic control as sulfonylureas or in combo with metformin, much lower rates of hypoglycemia

no weight gain

do not increase overall CV risk, pancreatitis

25
Q

use of SGLT-2 in older adults?

A

not as much research
-contraindicated in many due to GFR

  • less effect on A1C in older adults
  • need more studies re: CV

DPP4 should be considered prior to SGLT2

26
Q

treatment of HTN in older adults with DM

preferred combo to prevent CV events?

A

ACE and amlodipine (preferred over ACE + HCTZ)

ACE-I particularly valuable for DM2 and >1 CV risk factor

27
Q

vibration (in monofilament testing) is what neuro tract?

pain and temp?

A

vibration: dorsal column medial lemniscus

pain and temp: lateral spinaothalamic

28
Q

metformin

MOA?
side effect?
contraindication?

A

Metformin

First line tx

Decreased hepatic production and intestinal absorption of glucose and increase insulin sensitivity

Minimal hypoglycemia

No wt gain

SE: gi discomfort, diarrhea, wt loss

Contraindicated in GFR<30, liver, cardiac failure

29
Q

what is GLP-1?

two drug classes involved?

A

GLP-1 is an intestinal hormone (incretin) that stimulates the release of insulin as glucose rises in post prandial period - stimulated by food

GLP-1 agonist (“glutides”)

DPP4-I (“gliptins”)
-block breakdown of GLP-1

30
Q

considerations for DDP4-I

A

no hypoglycemia
can cause severe skin rash
with ACE-I - can cause angioedema

31
Q

SGLT-2

MOA?
Side effects?
Benefit?
caution?

A

SGLT-2

Oral agent that increase urinary excretion of glucose

Less risk of hypoglycemia if used once daily

Diuretic effect

May result in orthostatic hypotension, genital yeast, and UTI

Use with caution in older adults with CKD or other GU conditions

Cardioprotective

32
Q

what is SGLT-2

A

sodium glucose cotransporter 2

contributes to renal reabsorption of glucose

33
Q

what is Somogyi effect?

what is Dawn phenomenon?

A

somogyi: low BG at night –> AM rise in glucose

Dawn phenomenon: AM rise without preceding hypoglycemia

34
Q

what is the most common complication of DM?

symptoms?

A

neuropathy

peripheral (pain, loss of sensation, weakness, paresthesia, footdrop)

autonomic (tachycardia, ED, orthostatic hypotension, gastroparesis, diarrhea, constipation)

35
Q

what is the first manifestation of diabetic kidney dysfunction?

A

microalbuminuria

36
Q

how often to do ECG monitoring?

A

q3-5 years if 40+ or diabetes complications

37
Q

how often to do labwork?

A1C
eGFR and ACR
Lipids

A

A1C q3 months if not at target or adjusting rx
q6 months if stable

eGFR and ACR annually (more if abnormal)

lipids at time of dx

Diabetes Canada guidelines (4 decks)

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