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CDM Exam 2018 Standards of Care > CDE Exam Study Guide > Flashcards

CDE Exam Study Guide Flashcards

The learner will increase knowledge of the 2018 Diabetes Standard of Care

1
Q

The percentage of diabetes patients who do not meet A1C, Blood Pressure or Lipid targets.

A

33-49%

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2
Q

The 4 Classification of Diabetes

A
  1. Type 1 DM— beta cell destruction
  2. Type 2 DM - progressive insulin secretory defect
  3. Gestational Diabetes
  4. Other Specific types of DM duet to other causes (i.e. Monogenic diabetes syndromes, disease of exocrine pancreas, eg. cystic fibrosis, Drug or chemical induced diabetes)
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3
Q

Criteria for the Diagnosis of Diabetes Mellitus

A

FBG: ≥126 mg.dl
2 hr. PG ≥200 mg/dl
A1C ≥ 6.5%
RBG: ≥200 mg/dl

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4
Q

Criteria for the Diagnosis of Pre-Diabetes

A

FG: 100-125 mg/dl
2 hr. PG - IGT 140-199 mg/dl
A1C 5.7-6.4%

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5
Q

In addition to A1C testing, people with the following conditions should have further testing:

A

Individuals with red blood cell turnover *(i.e. sickle cell disease, pregnancy, hemodialysis, recent blood los or transfusion, erythropoietin therapy… only plasma blood glucose criteria should be used to diagnosis diabetes

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6
Q

4 Critical Time Points of Diabetes Self Management Education Delivery:

A
  1. At Diagnosis
  2. Annually for assessment of education, nutrition and emotional needs
  3. When new complication factors arise that influence self-mgt. (ie. health conditions, physical limitations, emotional factors or basic living needs)
  4. When transitions in care occur
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7
Q

Physical Activity Recommendations:

A
  1. Children and adolescents with diabetes or prediabetes should engage in 60 mins. or more of moderate or vigorous intensity aerobic activity, with muscle and bone strengthening activities at least 3 times per week.
  2. Adults— 150 mins aerobic activity per week spread over at least 3 days with no more than 2 consecutive days without activity. 75 mins.of vigorous activity or interval training may be sufficient for younger and more physically fit people.
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8
Q

What is Diabetes Distress?

A

A negative psychological; reaction related to emotional burden of managing a demanding chronic condition. Routine monitoring recommended especially when treatment targets are not met.

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9
Q

Prevention of Diabetes– Recommendations:

A
  • achieve weight loss of 7% of initial body weight and increase moderate-intense exercises to at least 150 mins/week
  • Metformin therapy should be considered for those with BMI ≥ 35; <60 years old and women with prior GDM
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10
Q

Pre-diabetes Glycemic Targets

A

A1C= <7%
FBG= 80-130 mg/dl
2 hours after meals= <180 mg/dl

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11
Q

Overweight/ Obesity Treatment Options in T2DM

A

BMI: ≥25 (23-26.9)— diet, exercise, behavioral therapy
BMI ≥27 to 29.9— add pharmacotherapy
BMI ≥ 30 to 34.9 (27.5-32.4) — add metabolic surgery
BMI ≥ 35 to 39.9 (32.5-37.4) add metabolic surgery
BMI ≥ 40 ( ≥ 37.5) metabolic surgery
(*cut off for Asian Americans)

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12
Q

T2DM Pharmacotherapy Recommendations

How long should they be monitored?

A
  • Mono Therapy- A1C < 9% (Metformin+Lifestyle )
  • > check @ 3 months
  • Dual Therapy— A1C > 9% (Metformin, Lifestyle + CVD agent for pt. with risk and/or combination med sulfonyurea , basal insulin, etc.)
  • Triple Therapy—(after 3 months dual drug therapy) -assess medication taking behavior and consider =>
  • Combination Injectable Therapy

Monitor every 3-6 months

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13
Q

Medication Recommendations for T2DM with ASCVD

A

*should begin with lifestyle mgt and metformin — then subsequently add:
empagliflozin and liraglutide
*after lifestyle mgt and metformin, the antihypergylcemic agent canagliflozin may be considered

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14
Q

Medication Treatment Recommendations of Confirmed HTN in People with T2DM

A
  • BP 140/90 -160/100 -> start one med.
    *w/ Albuminuria- ACE or ARB
    *w/o Albuminuria– ACE, ARB, CCB or Diuretic
    BP ≥160/100-> Start two meds.
    *w/ Albuminuria- ACE or ARB and CCB or Diuretic
    *w/o Albuminuria– ACE or ARB+CCB or Diuretic
  • ACE inhibitors and ARBs should NOT be combined.
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15
Q

Statin Recommendations and Combination Treatment

A

< 40 yo

  • with ASCVD = LDL ≥70 mg/dl = statin add additional LDL med. (ezetimibe or PCSK9 inhibitor), lifestyle therapy
  • w/o ASCVD = lifestyle therapy ++ Statin may be considered based on risk benefit and ASCVD risk factors

≥ 40 yo

  • with ASCVD + ≥ 70 mg/dl with statin add additional LDL med (ezetimibe or PCSK9 inhibitor)lifestyle therapy
  • w/o ASCVD lifestyle therapy + Statin may be considered based on risk benefit and ASCVD risk factors
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16
Q

Diabetic Retinopathy Treatment Recommendations

A
  • Panretinal laser photocoagulation therapy (to reduce vision loss in Proliferative Diabetic Retinopathy and in severe Non Proliferative Diabetic Retinopathy) PLUS ADD
  • Intravitreous injections of anti-vascular endothelial growth factor -Ranibizumab
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17
Q

New Drug Recommendations for Diabetes Neuropathy (2)

A

Drugs recommended as initial pharmacological treatments for neuropathic pain —pregabalin or duloxetine

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18
Q

Goals for Older Adults with DM and Pharmacological Therapy:

A

> decrease risk of hypoglycemia
avoid over treatment
simplify treatment regimen - use individualized A1C targets

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19
Q

Risk Based Screening Criteria for T2DM or Pre-Diabetes in Asymptomatic Children Age <18 yo

A

Overweight (BMI >85%ile) >120% IBW PLUS
maternal hx of diabetes or GDM
Family Hx of Type 2 DM (1st or 2nd degree relative)
Race/ Ethnicity
Signs of insulin resistance (HTN, Acanthosis, dyslipidemia, PCOS or small for gestational age birth weight)

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20
Q

Youth with Type 1 DM- Glucose and A1C Goals

A

Before meals: 90-130 mg/dl
Bedtime: 90-150 mg/dl
A1C: <7.5 %
All goals should be individualized especially with children with frequent hypoglycemia and unawareness

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21
Q

Type 2 DM in Youth– Incidence

A

rapid increase over past 20 years. (5,000 new cases per year in US)
More rapid decline in beta cell function and increase in DM complications.

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22
Q

T2DM Youth Pharmacological Treatment Recommendations:

A
  • Meds + Lifestyle therapy at T2DM DX
  • Metabolically stable (A1C<8.5% and asymptomatic) metformin if renal function is >30 ml/min.
  • Youth with marked hyperglycemia (≥250 mg/dl, A1C ≥ 8.5%) without ketoacidosis at dx and symptomatic treat initially with basal insulin while initiating metformin to achieve A1C goal.
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23
Q

Diabetes in Pregnancy: New Drug Recommendation? When should they start taking? To help reduce the risk of?

A

Women with T1 and T2 DM should be RX with low dose aspirin (60 mg-150 mg/day) usual dose 81 mg/day) from the end of the first trimester to the birth of baby to lower risk of pre-eclampsia.

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24
Q

BP Pressure Target Goals for Pregnant patients with Diabetes and Pre-existing HTN

A

120-160/80-105 mmHg

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25
Q

What are Moderate Intensity Statin Therapy Meds?
What are High Intensity Statin Therapy Meds?
How much reduction of LDL for each category?

A 
Moderate: 
Atorvastatin 10-20 mg; Rosuvastatin: 5-10mg;
Lovastatin 40 mg 
Pravaatatin
Fluvastatin
(30-50%)

High:
Atorvastatin 40-80 mg;
Rosuvastatin: 20-40 mg (≥50%)

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26
Q

What are CETP Inhibitors?

A

Medication that increases HDL cholesterol and further decreases LDL cholesterol in combination with statins. (not available for use, but have been studied)

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27
Q

Triglyceride Target Goals

A

< 150 mg/dl

≥ 500 mg/dl (consider medical therapy to reduce risk of pancreatitis)

> 1000 mg/dl (add fibric acid and/or fish oil and/or niacin to avoid acute pancreatitis)

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28
Q

Combination Therapy of Statin and Fibrate are associated with an increased risk of?

A
  • Abnormal transaminase levels
  • myositis
  • rhabdomyolysis (more common with high doses of statin and renal insufficiency combined with Gemfibrozil)
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29
Q

Is combination therapy of statin and niacin recommended for major ASCVD?

A

Not recommended given the lack of efficacy on major ASCVD outcomes and side effects.

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30
Q

Does statins or other lipid lowering meds cause cognitive dysfunction or dementia?

A

Current evidence and studies DO NOT support that these medications cause cognitive dysfunction or dementia in individuals with diabetes at high risk for ASCVD.

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31
Q

What is the starting dose for Insulin Therapy in Type 1 DM?

A

0.5 units/kg/day

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32
Q

What are Long Acting / Rapid Acting Analogs associated with? (3)

A
  • less hypoglycemia
  • less weight gain
  • lower A1C than human insulin
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33
Q

What is Pramlintide? How does it work? What do you need to do to decrease risk of severe hypoglycemia?

A

An amylin analog which:

  • Delays gastric emptying
  • Blunts pancreatic secretion of glucagon
  • Enhances satiety
  • Induces weight loss
  • Lowers insulin dosage.

Need to make sure you reduce prandial insulin dose to decrease risk of severe hypoglycemia

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34
Q

Which medications are not FDA approved for Type 1 DM?

A
  • Metformin
  • GLP-1 Receptors
  • DPP-4 Inhibitors
  • SGLT2 Inhibitors
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35
Q

Criteria for Pancreas Transplantation in Type 1 DM

A

Reserved for T1DM undergoing simultaneous renal transplantation or for those with recurrent ketoacidosis or severe hypoglycemia.

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36
Q

What vitamin deficiency is associated with long term Metformin use?

A

Vitamin B12

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37
Q

Which antiplatlet medication can be used if a person has a documented aspirin allergy?

A

Clopidogrel

38
Q

Dual Antiplatlet therapy consists of which meds?
How long can it be used?
Under what conditions can it be used?

A

low dose aspirin and P2Y12 Inhibitor
One year
Acute Coronary Syndrome

39
Q

Low Dose Aspirin Treatment Recommendations (primary prevention strategy)

A 
Type 1 or Type 2 DM:
with increased CVD risk  ≥ 50 y.o.:
*family hx of premature ASCVD
*HTN
*Dyslipidemia
*smoking
*albuminuria
*not at increased risk for bleeding
40
Q

Is aspirin therapy recommended for patients <50 y.o

A

No, unless they have documented major ASCVD risk factors.

41
Q

Under what conditions are ACE Inhibitors or Angiotensin Receptor Blocker Therapy recommended?

A

In patients with known ASCVD

42
Q

Beta Blockers are recommended for patients with?

For how long?

A

Prior MI

2 years

43
Q

In patients with T2DM and CHF metformin can be used if?

A

GFR is >30 ml/min

stable CHF

44
Q

Under what conditions should Thiazolidinedione be avoided in patients with T2DM?

A
  • In patients with symptomatic heart failure.
  • Up to as many as 50% of T2DM will develop heart failure.
  • These meds have a strong and consistent relationship with increased risk of heart failure.
45
Q

Which 3 medications have recently shown statistically significant reduction in cardiovascular events?

A

SGLT2 Inhibitors– empaglifozin and canaglifozin

GLP-1 Receptor Agonist- Liraglutide

46
Q

What is the starting dose for basal insulin in T2DM?
How would you adjust?
How should you address hypoglycemia?

A
  • 10 units/d or 0.1- 0.2 U/kg/d with A1C < 8%
    0. 2-0.3 U/kg/d with A1C > 8%
  • 10-15% or 2-4 units once or twice a week to reach FBG *goals
  • determine cause, if none then decrease dose by 4 units.
47
Q

What should you do if A1C is not controlled with basal insulin (in T2DM)?
What is the recommended starting dose?

A
  • Add one rapid acting insulin before largest meal.
  • 4 units (or 0.1 U of basal dose)
  • increase by 1-2 units once or twice a week until SMBG target reached.
  • you could add GLP-1 or change to 2 injection insulin regimen.
48
Q 
Metformin 
Efficacy?
Hypoglycemia?
Effect on weight?
CV/CHF Effects?
Cost?
Renal Effects?
Side Effects?
A 
decrease amount of sugar produced in the liver, increase muscle cell sensitivity to insulin
High
No
Neutral (modest weight loss)
Potential Benefit/ Neutral
Low Cost
Neutral (not with GFR<30)
GI Problems (D/N); Vit. B12 def.
49
Q 
SGLT Inhibitors (Canaglifozin; Empaglifozin) 
Efficacy?
Hypoglycemia?
Effect on weight?
CV/CHF Effects?
Cost?
Renal Effects?
Side Effects?
A 
Sodium Works by helping kidneys lower BG
Intermediate
No
Weight Loss, A1C, BP
Benefit
High Cost
Benefit
Risk of Amputation, Bone Fx, DKA?, Low BP, High LDL

Empaglifozin -> significantly lowers risk of CVD death and HF hospitalization

50
Q 
GLP-1 RA (Exenatide/ Liraglitide, Dulaglutide, oral semaglutide)
Efficacy?
Hypoglycemia?
Effect on weight?
CV/CHF Effects?
Cost?
Renal Effects?
Side Effects?
A 
Glucagon Like Peptides, Decrease BG, Increase insulin.
Lowers A1C
High
No
Weight Loss/ BP reduction
Neutral/Neutral
High
Not with GFR <30
N/V/D; Acute Pancreatitis 
Personal of Family HX of Thyroid Carcinoma -don't use.
51
Q 
DPP-4 Inhibitors (Sitagliptin, Saxagliptin, Alogliptin, Linagliptin
Efficacy?
Hypoglycemia?
Effect on weight?
CV/CHF Effects?
Cost?
Renal Effects? Can use in  poor renal function
Side Effects?
A 
increase incretin-> inhibit glucagon release, ->increases insulin secretion, decreases gastric emptying, and decreases blood glucose levels.
Modest lowering A1C
No hypo
Weight Neutral
CV Neutral/ CHF-Potential Risk
High Cost
Renal Neutral
Acute Pancreatitis, joint pain
52
Q 
Thiazolidinediones (pio and rosi)
Efficacy?
Hypoglycemia?
Effect on weight?
CV/CHF Effects?
Cost?
Renal Effects?
Side Effects?
A 
directly lowers insulin resistance
High
No Hypo
Weight Gain
CV- Potential Benefit/ CHF- Increased Risk
Low Cost
Renal- neutral
Fluid Retention, Bone Fx, Bladder Ca; Increase LDL (rosi)
53
Q 
Sulfonylureas (2nd Gen) -glipizide, glyburide,glimepiride
Efficacy?
Hypoglycemia?
Effect on weight?
CV/CHF Effects?
Cost?
Renal Effects?
Side Effects?
A

increase the secretion of insulin by pancreas.
High
Hypo– Yes
Weight Gain
CV/CHF-Neutral
Low Cost
Renal -Neutral/ Glyburide not recommended
Side Effects- FDA warning on increased risk of CVD based on studies with older sulfonyureas

54
Q

T2DM Screening

When should you start screening?

A 
Age: 45 yo (BMI <25)
All patients with BMI  ≥ 25 (or Asian American BMI ≥ 23)
with additional risk factors:
CVD
Family Hx
PCOS
HDL ≤ 35mg/dl
TG ≥ 250 mg/dl
inactivity
GDM hx
HTN ≥ 140/90 on meds
A1C ≥ 5.7%
High ethnic risk
55
Q

GDM Screening

When?

A 
At 24-28 weeks
After overnight Fast-- 75g OGTT- 
Fasting ≥ 92 mg/dl
1 h ≥ 180 mg/dl
2 hr≥153 mg/dl
3 hr >140 mg/dL

or can use 2 step:
50 g glucose load (non fasting) with PBG at 1 hr.
Step 1: ≥ 130-140 mg/dl
Step 2: 100 g OGTT (fasting)

56
Q

Use of Language in Diabetes Care and Education Recommendations (5 criteria)

A

Use language that

  1. is neutral, nonjudgmental, and based on facts, actions, or physiology/biology 2. is free from stigma
  2. is strengths based, respectful, inclusive, and imparts hope
  3. fosters collaboration between patients and providers
  4. is person centered
57
Q

What is strength based language?

A
  • Emphasizing what people know and what they can do.
  • Focusing on strengths that can empower people to take more control over their own health and healing.

Example: Lee takes her insulin 50% of the time because of cost concerns (instead of Lee is noncompliant/ nonadherent).

58
Q

What is Person-first Language?

A

*Words that indicate awareness, a sense of dignity, and positive attitudes toward people with a disability/disease. *Places emphasis on the person, rather than the disability/ disease.

Example: Lee has diabetes (instead of Lee is a diabetic).

59
Q

What are the 10 National Standards for Diabetes Self-Management Education and Support (DSMES)?

A

1) Internal Structure (mission, goals)
2) Stakeholder Input
3) Evaluation of Population Served
4) Quality Coordinator Oversees DSMES Services
5) DSMES Team
6) Curriculum
7) Individualization
8) On-Going Support
9) Participant Progress
10) Quality Improvement

60
Q

What is the focus of the National DSMES Standards?

A

The focus of the Standards should include helping the person with diabetes develop problem-solving skills and attain on-going decision-making support necessary to self-manage diabetes.

61
Q

What are the core content areas for AADE7 Self-Care Behaviors? (8)

A

1) Diabetes Pathophysiology and treatment options.
2) Healthy Eating
3) Physical Activity
4) Medication Usage
5) Monitoring and using Patient Generated Health Data (PGHD)
6) Preventing, detecting and treating acute and chronic complications
7) Healthy Coping with Psychosocial Issues and concerns
8) Problem Solving

62
Q

What is the key outcome of the AADE Outcome Standards for Diabetes Education?

A

Behavior Change

the AADE7 provide a useful framework for assessment, documentation and evaluation

63
Q

What are outcome measures?

A

indicate the results of a process (i.e. whether changes are eating to improvement0

64
Q

What are Process Measures?

A

Process measures are often targeted to those process that affect the most important outcomes. (behavior, clinical, operational, etc.)

65
Q

What are the key components of Lifestyle Therapy? (5)

A

1) Medical Nutrition Therapy
2) Regular Physical Activity
3) Adequate Sleep
4) Behavioral Support
5) Smoking Cessation/ Avoid All Tobacco Products

66
Q

What the risks associated with lack of 6-9 hours of adequate/ regular sleep?

A

Increases

  • Insulin Resistance
  • Hypertension
  • Hyperglycemia
  • Dyslipidemia
  • Inflammation of Cytokines
67
Q

What is the difference between Complications- Centric Model of Care and a BMI-Centric models in the treatment of patients who have obesity or are overweight?

A

Complication-Centric model focuses on evaluating risk of complications regardless of BMI to reduce long term risks.

68
Q

What are the short-term drugs (3 months) used for weight loss? (3)

A

Diethproprion
Phendimetrazine
Phentermine

69
Q

What are the long-term drugs used for weight loss? (5)

A 
Orlistat ( avoid fat)
Phentermine/topiramate (ER)
Locaserin (avoid SSRI medication Fluoxetine)
Naltrexone ER
Buproprion (ER)
Liragulatide 3 mg
70
Q

What is the primary goal of pre-dabetes management?

A

Weight Loss

71
Q

What is the A1C goals for older patients with a history of severe hypoglycemia?

A

7% to 8%

72
Q

What are AGIs? (alpha glucosidase inhibitors?

Acarbose, miglitol

A

Modest lowering effect on A1C and low risk for hypoglycemia.
Side effects: bloating, gas, diarrhea

73
Q

What are Colesvelam?

A

A bile acid sequestrant that modestly lower glucose, no hypoglycemia and decreases LDL but may worsen TG

74
Q

Which new insulin analogs have more prolonged and stable pharmacokinetics? (2)

A

Glargine U300

Degludec U100/ U200

75
Q

What are the risks of using ACE and ARBs in combinations?

A

It doubles the risk of renal failure and hyperkalemia.

76
Q

What are PCSK9 Inhibitors indicated for?

A

Adult patients with heterozygous familial hypercholesterolemia

77
Q

What is DSME/T?

diabetes self-mgt education and training

A

an interactive, collaborative, on-going process involving the person with diabetes and the educator that includes:

    • Assessing person education needs
    • Goal setting
    • Planning
    • Implementing the education and behavior interventions
    • Evaluating/ Monitoring goals and clinical outcomes.
78
Q

What are the 6 Standards of Practice for DM Educators? (AADE)

A

1) Assessment
2) Goal Setting
3) Planning
4) Implementation
5) Evaluation
6) Documentation

79
Q

Hyperosmolar hyperglycemic State- characteristics

A

Increase blood sugar
Increase osmolarity without ketosis
Symptoms: dehydration, weakness, leg cramps, trouble seeing

80
Q

Diabetic Ketoacidosis

A

Increased levels of ketones

Symptoms: hypokalemia, N/V, thirst, excess urine, abdominal pain, Kussmaul Respirations, extreme dehydration

81
Q

What is Pramlintide?

A 
An injectable amylin analog. 
Inhibits liver glucagon
Slows gastric emptying 
Promotes satiety 
Raises first phase insulin

Used by T1DM and T2DM

Lowers A1C by .5-7%
Promotes Weight Loss

NOT FOR:
gastroparesis or hypoglycemia unawareness

82
Q

Insulin Sensitivity (Correction) Factor

A

How many BS points will decrease with 1 unit of insulin

1800/TDD = # units of Insulin

83
Q

Insulin to CHO Ratio

A

The amount 1 unit of insulin will cover # of grams of CHO

500/TTD

84
Q

How to calculate Correction Bolus and Food. Bolus to calculate appropriate insulin dose?

A

Current Blood Glucose-Target Blood Glucose=BG difference

Correction Bolus=
Blood Glucose Difference/CHO Grams

Food Bolus=CHO grams/ Correction Factor

Insulin Amount=
Correction Bolus+ Food Bolus

85
Q

Best predictor of future Type 1 DM?

Islet cell antibodies

A

Glutamic avid decarboxylase

86
Q

Hypoglycemia Unawareness

A

Can result in Neuroglycopenia
Shortage of glucose in the brain

Failure of glucose-counter regulation to decrease glucagon and epinephrine

87
Q

What is PIPE Model?

A

Penetration
Implementation
Participation
Evaluation

88
Q

5 stages of Chronic Kidney Failure

A 
Stage 1: eGFR>90
Stage 2: eGFR 60-89
Stage 3: eGFR>30-59
Stage 4: eGFR>15-30
Stage 5: eGFR <15
89
Q

Newly DX T2DM -A1C >9%
Treatment
With Sx
Without Sx

A

With Sx: insulin + other agents

Without Sx: dual or triple Tx

90
Q

Meglitinides

Newer secretagogues

A

Repaglitide and Nateglinide
(Like sulfonyureas) stimulate burst of insulin from pancreas
Start working 15-30 and last for 1-2 hours
Lower A1C by 1.5%

CDM Exam 2018 Standards of Care (1 decks)

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