CDE stuff Flashcards
how often do you screen for diabetes if someone is <40 years old with no risk factors for DM?
no screen indicated
what is high risk of developing diabetes?
33% chance of developing diabetes within 10 years
what is VERY high risk of developing diabetes?
50% chance developing diabetes within 10 years
how often do you screen for diabetes in someone who is at least 40 years old with no risk factors?
every 3 years
how often do you screen for diabetes in someone with the presence of multiple risk factors?
every 6 to 12 months
what is the blood glucose range for impaired fasting glucose?
6.1 to 6.9mmol/L
at what blood glucose is fasting blood glucose considered diabetes?
7.0mmol/L
A1C range for pre-diabetes
6.1 to 6.4
A1C begins at ___ for diabetes
6.5
if symptomatic and a1c/fgb/2hPG/random PG) are in glucose range, do you need to repeat confirmatory test?
no
what microvascular complications do an A1C at 6.5 and below prevent?
chronic kidney disease and retinopathy
a1c target for functionally dependent?
7.1 to 8%
a1c target for frail elderly?
7.1 to 8.5
a1c target for limited life expectancy?
7.1 to 8.5
a1c target for severe recurrent hypoglycemia and/or hypoglycemia unawarenss
7.1 to 8.5
what does metabolic decompensation look like?
dehydration, HHS, DKA
first treatment option for a1c <1.5% above target?
physical activity, weight management. if not at target within 3 months, start/increase metformin
first treatment option for a1c> 1.5% above target?
physical acitivity, weight management, metformin +/- additional diabetes agent
first treatment option for symptomatic hyperglycemia and/or metabolic decompensatoin
insulin +/- metfomrin
diabetes agent with CV benefit?
empaglifozin, cannagliflozin, liraglutide
diabetes agent that has this contraindication: medullary thyroid cancer/MEN2
glp-1 agonist (liraglutide, exenatide, lixilgutide,
which class of medication can cause gallstone disease?
glp-1 agonists (liraglutide, exenatide, lixilgutide)
which class of medication can cause rare diabetic ketoacidosis (may occur with no hyperglycemia)?
sglt2-inhibitors
which medication can cause increased risk of fractures and amputations?
cannaglifozin
which class of medications can cause dose-related changes/increases of LDL-C?
sglt2inhibitors
bladder cancer is a contraindication for which drug - empaglifozin, dapa, or canna?
dapa
in those with clinical CVD, these 2 drugs can reduce CHF hospitalizations and progression of nephropathy?
empaglifozin and cannagliflozin
which drug may worsen heart failure?
saxagliptin (onglyza, komboglyze), TZD
which drugs are weight neutral?
acarbose, DPP4-inhibitors
TZD risks?
CHF, edema, fractures
rare bladder cancer is a risk of which drug?
pioglitazone
timeframe for getting to A1c targets?
3-6 months
rare joint pain is a side effect of which class of medications?
dpp-4 inhibitors
what’s included in cardiovascular disease?
cardiac ischemia (silent or overt), cerebrovascular/carotid disease, peripheral arterial disease
what is cardiac ischemia?
blocked blood flow to heart muscle
what is cerebrovascular disease?
reduced blood flow to the brain; can include stroke
what is carotid disease?
reduced blood flow in carotid arteries; 1 supplies blood to brain, the other to face/scalp/neck
what is peripheral arterial disease?
reduced blood flow to limbs, head, organs; may cause claudication (leg pain when walking)
if someone has CVD, what cardiovascular protection drugs do you need?
Statin + ACEI/R + ASA
if CVD, and already on Statin + ACEI/R + ASA but not at glycemic target, what other drug to use? (type 2 diabetes only)
start drug with CV benefit; liraglutide or empaglifozin or cannaglifozin
what is microvascular disease?
kidney disease (ACR at least 2), retinopathy, neuropathy
What CV protective drugs to start if someone has microvascular disease?
Statin + ACEI/R
What CV protective drugs to start if someone has retinopathy?
statin + ACEI/R
What CV protective drugs to start if someone has neuropathy?
statin + ACEI/R
What CV protective drugs to start if someone has kidney disease?
statin + ACEI/R
what risk factors other than microsvascular disease would be an indication to start Statin + ACEI/R (CV protection)
at least 55 yo + CV risk factors
when do you start a statin in the absence of CV and microvascular disease?
at least 40yo OR at least 30yo + >15 years duration of DM
ACEI/R doses with demonstrated vascular protection
perindopril 8mg daily, telmisartan 80mg daily, ramipril 10mg daily
How long can it take for brain function to be fully restored after hypoglycemia?
40 minutes
how often to check BG during long drives
before driving, then every 4 hours (unless unaware of hypoglycemia symptoms, then every 2 hours) or real-time continuous glucose monitor
BG needs to be at least ____ before driving?
5mmol/L
SADMANS stands for
sulfonylureas, ACEI, diuretics (or other direct renin inhibitor- aliskiren), Metformin, ARB, NSAIDs, sglt2-inhibitors
A1c target before pregnancy?
7% or less, but strive for 6.5
what drugs to stop prior to pregnancy?
non-insulin agents (except glyburide, metformin); ACEI/R unless overt nephropathy, in which case to continue until detection of pregnancy
blood pressure medications that can be used in pregnancy?
labetolol and nifedipine XL
if planning a pregnancy, what to start?
folic acid 1mg daily 3 months prior, insulin if a1c not at target with metformin/glyburide
what are SMART goals?
specific, measureable, achievable, realistic, timely
what is the cholesterol target in DM?
<2mmol/L or LDL-C 50% reduction from baseline
when to do an ECG?
every 3-5 y; if over 40yo , if >30 years and duration of diabetes >15 years, end-organ damage (micro, macrovascular), at least 1 CVD risk factor, age over 40 and planning to do vigorous activity
when to do a monofilament/vibration screening?
yearly or more if abnormal
when to do kidney eGFR , ACR?
yearly or more if abnormal
when to screen for retinopathy?
yearly if Type 1 (5 years after diagnosis, at least 15 years old), every1-2 years if type 2 (at diagnosis)
what is monogenic diabetes?
rare disorder caused by a genetic defect of beta cell function
what is latent autoimmune diabetes in adults (LADA)
apparent type 2 diabetes with immune mediated loss of of pancreatic beta cells
Type 1 usually occurs before what age and not usually before which age?
before 25yo but not before 6months
monogenic diabetes usually occurs in __?
less than 25 or less than 6 months
Baby <6 months has diabetes most likely has which kind?
monogenic/neonatal diabetes
monogenic or insulin or non-insulin dependent?
non-insulin dependent
what is an autosomal dominant disorder?
the mutated gene is a dominant gene located on one of the nonsex chromosomes (autosomes). You need only one mutated gene to be affected by this type of disorder.
what is C peptide
byproduct of formation of insulin ; usually absent in type 1, present in type 2 and monogenic diabetes
genetic testing is required to confirm which form of diabetes?
monogenic
diagnosis of diabetes is FBG ___
at least 7mmol/l
diagnosis of diabetes is A1C ___
at least 6.5%
diagnosis of diabetes is 2hPG 75g oral glucose tolerance test
at least 11.1mmo/l
diagnosis of diabetes is random BG
at least 11.1mmol/L
which test (a1c, FBG, 75OGTT) is the best predictor of CVD?
a1c
a1c, FBG, 75OGTT are all predictors of microvascular complications
true
A1c may be affected by ethnicity and age
true
a1c can be used for diagnostic purposes for children and adolescents?
no
a1c can be used for diagnostic purposes for screening gestational diabetes?
no
a1c can be used for diagnostic purposes for cystic fibrosis?
no
a1c can be used for diagnostic purposes for those suspected with type 1?
no
autoimmune markers that may be present in type 1 diabetes are :
GAD (anti-glutamic acid decarboxylase) and ICA (anti-islet cell auto-antibodies)
impaired glucose tolerance range (2hPG in a 75g OGTT)is
7.8 to 11.0 mmol/L
waist circumference cut off point for USA And Canada in Men
102cm
waist circumference cut off point for USA And Canada in women
88cm
waist circumference cut off point for asians, japanese, south & central americans in Men
90cm
waist circumference cut off point for asians, japanese, south & central americans in women
80cm
waist circumference cut off point for europeans, middle-eastern, sub-saharan african, mediterranen in Men
94cm
waist circumference cut off point for europeans, middle-eastern, sub-saharan african, mediterranen in women
80cm
metabolic syndrome requires at least 3 risk factors for diagnosis
yes
elevated TG risk factor is (for metabolic syndrome)
at least 1.7
elevated FBG risk factor (for metabolic syndrome) is
at least 5.6mmol/L
HDL-C risk factor in women for metabolic syndrome
less than 1.3
HDL-C risk factor in men (for metabolic syndrome)
less than 1
at risk, but not pre-diabetes is FBG and A1C
FBG 5.6-6mmol/L, A1C 5.5 to 5.9%
not at risk is FBG and A1C
FBG <5.6mmol and A1c <5.5%
cystic fibrosis is a risk factor for diabetes
true
obstructive sleep apnea is a risk factor diabetes
true
hyperuricemia/gout is a risk factor for diabetes
true
people with pre-diabetes at an increased risk of
CVD and developing DM
the CANRISK tool is intended for those ___ age
> at least 40 yo
losing 5% body weight can reduce risk of IFG&IGT developing into t2dm by?
60%
alternate health eating index can be used to reduce risk of diabetes
true
progession of diabetes from preidabetes can be redued by 30% with metformin
yes
metformin fro the prevention of diabetes may be more effective in:
those with a history of gestational DM, significant obesity (BMI>35), younger individuals (<60yo)
metformin can be used to prevent diabetes in those iwht
IGT/impaired glucose tolerance
improved glycemic control reduces risk of
CV and microvascular complications
UPKDS looked at those with long-standing or recently diagnosed diabetes?
recently diagnoses
trials that looked at intensive glycemic control on long-standing diabetes
ADVANCE, ACCORD, VADT
UKPDS and DCCT both showed
reduced microvascular complications but also reduced CV long-term in long-term follows
intensive glucose lowering therapy reduces the risk of
microvascular complications and composite of major adverse events (MACE) and MI
intensive glucose lowering therapy did not reduce risk of
CHF, total mortality, cardiac death, stroke
when a1c is higher, major contribution
is fasting glucose
when a1c is 7% or less (lower), major contribution is
postprandial glucose
a 2hppg <8mmol/L is about ___ a1c
<7%
in type 1 and 2 diabetes, an a1c of less than or equal to 7% can
reduce microvascular complications and CV complications (if implemented early enough)
if a1c less than 7% cannot be achieved with ppg 5-10mmol and fasting 4-7mmol, what targets should be implemented?
fasting 4-5.5mmol and postprandial 5-8mmol/L
mean blood glucose from days 90 to 120 contribute ___ % of a1c
10%
iron deficiency can increase or decrease A1c
increase
B12 deficiency can increase or decrease A1c
increase
decreased erythropoeisis can icnrease or decrease a1c
increase
alcoholism can increase or decrease a1c
increase
chronic renal failure can increase or decrease a1c
both
splenectomy can increase or decrease a1c
increase
increased lifespan of erythrocyte can increase or decrease a1c
increase
large doses of ASA can increase or decrease a1c
increase
hyperglyceridemia can increase or decrease a1c
decrease
chronic liver disease can increase or decrease a1c
decrease
use of erythropoetin, b12, iron can increase or decrease a1c
decrease
reticulocytosis can increase or decrease a1c
decrease
alternate site testing areas
palm, thigh, forearm
capillary testing of beta-OHB is preferred over urine testing of ketones because
earlier detection of ketosis and resolution
in type diabetes, when should test for ketones?
when prepandial BG is a tleast 14mmol/L or when symptoms of DKA are present
flash glucose monitoring may help reduce time spent in hypoglycemia in type 1 diabetes - true or false
true
what does moderate to high levels of physical activity reduce in diabetes?
morbidity (risk of CVD) and mortality
habitual, prolonged sitting can increase
risk of death cardiovascular events
cycling is considered to be aerobic exercise
true
walking is considered aerobic exercise
true
swimming is considered aerobic exercise
true
jogging is considered aerobic exercise
true
aerobic exercises uses rhythmic movements of large muscle groups
true
fast cycling is moderate or vigorous activity?
vigorous
climbing stairs or hill walking is moderate or vigorous activity?
vigorous
swimming is moderate or vigorous activity?
vigorous
aerobics is moderate or vigorous activity?
vigorous
brisk walking is moderate or vigorous?
moderate
dancing is moderate or vigorous?
moderate
light cycling is moderate or vigorous?
moderate
gardening and domestic chores is moderate or vigorous?
moderate
interval training can reduce risk of hypoglycemia in type __ diabetes
1
interval training can increase cardiorespiratory fitness gains in type __ diabetes
2
what are some strategies to reduce hypoglycemia during/after exercise in type 1 diabetes?
1) perform resistance exercise before aerobic exercise 2) perform brief maximmal-intensity sprints at start of exercise, periodically during activity and at end of exercise 3) reduce or suspend basal insulin if activity < or equal to 45 minutes 4) reduce total daily basal insulin by 20%.
how much can nutrition therapy reduce A1c?
1-2%
unsaturated oil is a preferred dietary fat
yes
nuts is a preferred dietary fat
yes
what is the recomended dietary intake of CHO?
no less than 130mg
total energy from CHO should be?
45-60%
total energy coming from protein should be
15-20%
total energy comng from fats is
20 to 35%
saturated fatty acids from diet should be no more than ___
9%
total energy intake from added sugars hould be no more than
10%
how much fibre should one consume daily?
30 to 50g
viscous soluble dietary fibre can improve __?
glycemic control
which diet can reduce cv events/
Mediterrance, vegan/vegetarian (reduce MI), DASH, dietary patterns emphasizing fruits+veggies, dietary pulses/legumes, fruits+vegetables, nuts
which can can reduce LDL-C
low GI, high fibre diet, vegan/vegetarianm DASH, dietary patterns emphasizing nuts, whole grains, dietary pulses/legumes
what is the max acceptable daily intake of sucralose?
8.8mg/kg/day
max of aspartame?
40mg/kg/day
max of acesulfame potassium?
15mg/kg/day
max of cyclamate?
11mg/kg/day
max of erythritol?
1000mg/kg/day
duration of insulin degludec is
42h
less stringent glycemic targets to help avoid hypoglycemia can be how many months
up to 3
if a type 1 diabetes patient is not achieving glycemic control with basal-bolus therapy, what is the next step?
use CSII with or without CGM
type1 diabetic on CSII should undergo periodic evaluation of continued CSII therapy
true
these agents increase insulin and lower glucagon levels
DPP4-inhibitors, GLP1-agonist
before intensifying insulin, if glycemic control is nto yet achieved, what agents can you add? to ensure less weight gain and minimize risk of hypoglycemia
DPP4, GLP1-agonist, SGL2 inhibitor
what is the A1c lowering effect of metformin?
1%
a1c lowering effect of DPP4?
0.5 to 0.7%
a1c loewring of GLP1-agonsit
1%
a1c lowering effect of SGLt2 inhibitor>
0.4 to 0.7%
a1c lowering effect of acarbose?
0.7 to 0.8%
how much weight can be lost with SGL2 i?
2 to 3 kg
how much weight can be lost with GLP1 agonists?
1.6 to 3kg
a1c lowering effect ofsulfonylureas/
0.7 to 1.3
a1c lowering effect of meglinitides
0.7 to 1.1
a1c lowering effect of TZDs?
0.8 to 0.9%
a1c lowering effect of orlistat?
0.2 to 0.4
insulin glargin U-300 vs. 100 reduces risk of overall and nocturnal hypoglycemia
true
withhold SLG2 prior to major surgery, during acute infections and serious illness to reduce risk of
ketoacidosis
your eGF should be at least __ to use acarbose
30ml/minute
your eGF should be at least __ to use metformin
30ml/minute
your eGF should be at least __ to use glyburide
60ml/minute
your eGF should be at least __ to use gliclazide, glimepiride,
30ml/minute
your eGF should be at least __ to use canna, dapa and empa
45for cana and empa, 60ml/minute for dapa
do not initiate canna or empa if your eGFR is less than
60 ml/minute (do not initiate between 45-60ml
your eGF should be at least __ to use pioglitazone and rosiglitazone
trick question; can use regardless
your eGF should be at least __ to use insulin
any; caution below 30ml/minute
this medication be used even regardless of kidney function
dulaglutide (cautionat <15ml), linagliptin, sitagliptin, (adjust dose), alogliptin (adjust dose), pioglitazone, rosiglitasone, repaglinide
your eGF should be at least __ to use exenatide and lixi
30ml.minute
your eGF should be at least __ to use liraglutide
15 ml/minute
your eGF should be at least __ to use saxagliptin
15ml/minute
after hypoglycemia is corrected, if the meal is >1h away, what hsould be consumed to prevent hypoglycemia?
15g CHO and a protein snack
in moderate hypoglycemia, these symptoms are present
neuroglyopenic and autonomic
in severe hypoglycemia, is what is the typical BG?
<2.8mmol
tingling is a___ symptom
autonomic
sweating is a ___ symptom
autonomic
anxiety is a ___ symptom
autonomic
headache is a ___ symptom
neuroglycopenic
low health literacy is a risk factor for hypoglycemia
true
long duration of insulin is a risk factor hypoglycemia
true
prior episode of severe hypoglycemia is a risk factor for hypoglycemia
true
current low a1c is a risk factor for hypoglycemia
true
autonomic neuropathy is a risk factor for hypoglycemia
true
chronic kidney disaese is a risk factor for hypoglycemia
true
15g of sugar is ___ cubes of sugar
5
15g of sugar is ___ ml of juice
150ml
islet or pancreas transplantation is a strategy used to redduce severe hypoglycemia and/or to attempt to regain hypoglycemia awareness.
true
how many of sugar do you need to treat severe hypoglycemia?
20g
how can you treat an unconscious patient with severe hypoglycemia
1) IV 10-25g glucoe (20-50ml d50w) over 3 minutes OR with no IV access 2) 1mg glucagon subcut/IM
how do youtreat diabetic ketoacidosis?
IV insulin 0.1 units per kg/h
do you need bicarbonate therapy for ketoacidosis?
only if pH is less than or equal to 7
a mildy elevated glucose level completely rules out DKA in pregnancy and SGLT2 inhibitor
false
what fluid do you need to treat DKA/HHS?
0.9% sodium chloride IV at 500ml/h for 4h, 250mg/h for 4h
what level beta-hydroxybutyrate warrants further testing of DKA after a capillary BG >14mmol/L?
> 1.5mmol/L
resolution of ketosis in DKA is done by??
normalization of plasma anion gap. once PG concentration falls to 14mmol/L, dextrose should be started to avoid hypoglycemia
hyperglycemia is associated with increased in-hospital
complications, mortality and longer length of stay
for noncritically ill hospitalized patients, preprandial glucose and random glucose target should be
5-8mmol/L, <10mmol/L
for critically ill in hospital patients, blood glucose shoudl be
6-10mmol/L
what BG target level is appropriate for diabetes patients undergoing CABG
5.5-11.1mmol/L IV, not subcut to prevent infection
waht is a healthy BMI?
18.5 to 24.9
when can bariatric surgery be considered? What BMI level?
35.5
for those with diabetes and end stage renal disease, which improves long-term outcomes: dialysis or transplant?
transplant
an examination to assess fitness to drive should be taken every ___ years
2
peolpe with a history of severe hypoglycemia or hypogylcemia unawareness are required to measure hteir BG every __- hours
2, OR wear a continous blood glucose monitor
when should a patient on insulin and/or insulin secretagogues be no longer able to drive?
after 1 episode of severe hypoglycemia while driving in the last 12 months ;more than 1 episode of severe hypo while awak but not driving in the last 6 months (12 months for commercial drivers)
how often should a resting ECG be done>
every 3 to 5 years
when should an ECGbe done?
> 40 years, 1 least 1 CV risk factor, >30 years and duration of diabetes >15, end organ damage, age 40+ planning to take vigorous activity
what does ezetimibe do?
lowers ldl-c
what do fibrates do?
lowers TG, variable effect on LDL-C, variable effect on HDL-C
what does niacin do?
raises HDL-C, lowers TG,, lowers LDL-C, lowers LipA
what do PCSK9 inhibitors do?
lowers LDL-C, lowers Lpa, modest effect in TG_lowering and HDL-C raising
lipid panel should be performed every ___
1 to 3 yeras
after tx for dyslipidemia is started, how often should lipid panel be checked?
every 3 to 6 months
in all people with ACS, if no history of diabetes, when would capillary bloog glucose testing be necessary in hospital?
if A1C is at least 6.5% and random BG is at least 11.1
the presence of heart failure is __ fold higher in diabetes than in non diabetes
2-4 fold
how does diabetes cause heart failure independent of ischemic hear disease?
by diabetic cardiomyopathy that reduces left ventricular ejection fraction
individuals with heart failure should receive the same HF therapies regardless of diabetes
true
beta blockers should still be precribed to HF patients when indicated
true
if RAAS employed in those with diabetes, HF and egfr <60ml/min, what should starting ACE/ACER dose be?
halved
chronic kidney disease increases risk of ___
cardioascular disease
if severe hyperkalemia, RAAS blockade should be
held or discontinued
if mild to moderate hyperkalemia, what are reasonable steps to take?
temporarily hold RAAS or reduce, consider a non potassium sparing diuretic, counsel on low potassium diet
stage 2 CKD is ___egfr
60 to 89ml/min
stage 3a CKD is ___ egfr
45 to 59ml/min
stage 3b CKD is ___ eGFR
30 to 44ml/min
stage 4 ckd is ___ eGFR
15 to 29
stage 5 CKD is
<15ml/min
in order to diagnose CKD in those with eGFR<60, ACR of at least 2mmol/L must be made __-
on at least 2 or 3 samples over a 3 month period
which drug can be used in addition to a statin to delay the progression of established retinopathy?
fenofibrate
what are risk factors for neuropathy?
increased BP, BG, TG, BMI, smoking
what are the tests used to screen for neuropathy?
10g monofilament (used on dorsal of great toe bilaterally) or vibration perception (128hz tuning fork)
what is usually affected first in neuropathy?
feet & legs, then hands and arms
what are symptoms of diabetic neuropathy?
affecting the legs and feet - shooting pain, burning, tingling, feeling of being pricked with pins, throbbing and numbness
when should neuropathy screening begin for type 1 diabetes?
5 years post pubertal
which 2 anticonvulsants are not health canada approved for the treatment of neuropathy but are still used off label?
gabapentin and valproate
which 2 antidepressants are not health canada approved for the treatment of neuropathy but are still used off label?
elavil, and venlafaxine
assessment of the foot should include
neuropathy, structural absnormalities (bone deformities,), skin changes (calluses, infections, ulcers), peripheral arterial disease
what is the prevalence of ED men with diabetes?
34-45%
hypogonadal men with diabetes have a higher risk of cardiovascular mortality than eugonadal men with diabetes
true
what are symptoms of low testosterone?
depressed mood and reduced energy, reduced lean body mass, reduced libido, ED
men who do not respond to PDE5I should be screened for
hypogonadism with a morning serum testosterone level taken before 7am
if a child is suspected with having diabetes, immediate diagnosis should be made to prevent
diabetic ketoacidosis
what is the concern with pediatric diabetic ketoacidosis
cerebral edema (increased risk vs adult diabetic ketoadisos)
what is the a1c target in a child with type 1 diabetes
7.5 or less
what is the fasting target in a child with type 1 diabetes
4 to 8 mmol/L
what is the 2h postprandial target in a child with type 1 diabetes
5-10mmol/l
in child with severe/excessive hypoglycemia (type1), what is a more appropriate preprandial target?
6-10mmol/L
how many carbs do you need to treat a <5yo with mild to moderate hypoglycemia
5g
how many carbs do you need to treat a 5-10yo with mild to moderate hypoglycemia
10g
severe hypogylcemia and later cognitive impairment is of more concern in this group of children
<6yo
treatment of choice for initial therapy in children with type 1 diabetes
longacting basal insulin + rapid acting insulin
in severe hypoglycemia in a child less than or equal 5yo, how much glucagon should be administered?
0.5mg
in severe hypoglycemia in a child over 5yo, how much glucagon should be administered?
1mg
mild or impending hypoglycemia in children can be treated with:
gluagon - 10mcg per year, minimum 20, maximum 150 mcg
how do you treat severe hypoglycemia in unconscious child in hospital?
0.5 to 1mg/kg IV over 1-3 minutes dextrose
what is the recommended physical activity for children? type 1, type 2?
type 1: at least 3 times per week, at least 60 minutes per week type 2: daily, 60 minutes minimum
in children with DKA, the administration of ___ has been associated with cerebral edema
sodium bicarbonate, as such, it is typically avoided
in children with DKA, insulin infusion is typically not started for
at least 1hr after fluid replacement therapy
how do you treat cerebral edema in children with DKA>
mannitol or hypertonic saline
how do you diagnose chronic kidney disease in children and when?
at least yr 12yo with diabetes duration >5y; morning ACR (preferred or random), followed by a repeat of morning ACR in 1 month, and if abnormal, then a 24h collection. should be persistent over 6-12 months
all children with type1 DM should be screened for HTN ___
at least twice annually
what is the prevalence of celiac disease in children with type1 diabetes?
4-9%
type 2 diabetes in childhood is associated with severe and early
cardiovascular and microvascular complications
screening for type 2 diabetes in children with risk factors should be conducted every __ years
2
BMI at ___ is a risk factor for diabetes in children
at least 95th percentile for age and gender
screen for diabetes in children if nonpubertal at 8yo if at least ___ risk factors
3
screen for diabetes in children if pubertal with at least __ risk factors
2
what is the physical activity recommendation in all children with type 2?
at least 60 minutes daily (moderate to vigorous)
how to treat a child with type 2 diabetes , A1c at least 9, with metabolic decompensation?
Insulin + metformin (unless acidosis is present)
what is the target a1c for most children with type 2?
less or equal to 7%
what is the a1c target during pregnancy? planning pregnancy?
less than or equal to 6.5%, less than or equal to 7% (ideally 6.5)
what is first line therapy for gestational diabetes?
diet and physical activity; if glycemic target not met, then metformin or insulin
in those with high risk of diabetes in pregnancy, how early can screening be started?
any stage
what is considered abnormal for 50g glucose challenge, 1hr test?
normal is <7.8mmol/L; diagnosis of GDM is at least 11.1mol/L, abnormal is 7.8 -11mmol/L
after the 50g glucose challenge, if abnormal, do the 75g 2h challenge, what confirms GDM?
fasting greater than or equal to 5.3mmol/L, 1h 10.6mmol, 2h 9.0
what is the alternate GDM screening protocol?
75g challenge, fasting at least 5.1mmol/L, 1h 10mmol/L, 8.5mmol/L
after giving birth, when should screening for type 2 diabetes begin? and with what? How often?
between 6 weeks and 6 months postpartum. 75g challenge; every 3 years
what benefit does breastfeeding (minimum 4 months) by a GDM women confer to child
reduced risk of hypoglycemia, obesity, development of diabetes
in pregnancy, poorly controlled diabetes increases risk of
stillborn, miscarriage, baby born with malformation
what is the prevalance of diabetes in pregnancy?
3 to 20%
all pregnant women without known pre-existing diabetes should be screened for GDM between __
24 to 28 weeks of pregnancy
at what age is it a risk factor for GDM?
35
preconception a1c of 7% or less can reduce the risk of
spontaenous abortion, stillbirth, congenital anomalies, pre-eclampsia, progression of retinopathy in type 1,
when should folic acid supplementation begin and for how long?
3 months prior to conception and 12 weeks after delivery
what is pre-eclampsia?
occurs only in pregnancy; hypertension and albuminuria
pregnant women with CKD or albuminuria is at risk of
hypertension and pre eclampsia
once pregnant, women should be switched to ___ for glycemic control
insulin
glucose targets in pregnancy are
fasting less than 5.3, 1hg pp less than 7.8, 2h pp <6.7mol/L
what can reduce the risk of pre-eclampsia in women with pre-existing diabetes?
ASA 81mg daily at weeks 12-16
what ist he BG target during labour and delviery to reduce risk of hypogylcemia in baby?
4to 7 mmol/L
why is frequent SMBG necessary in the few days postpartum
high risk of hypoglycemia
when should screening for postpartum thyroiditis be initiated in type 1 diabetes
2-4 months post partum
metformin and glyburide can be used during pregnanc
true
when can glyburide be used in pregnancy?
if insulin is declined and metformin not tolerated
in women with previous GDM and IGT postpartum, what drug can be used to prevent onset of diabetes?
metformin
the clock drawing test is used to test what?
capacity to inject insulin
how many canadians have diabetes?
about 10%
what reduces glucagon, food intake, blood glucose?
GIP and GLP1
what does amylin do?
complements action of insulin; promotes satiety
hormones that increase BG
catecholamines, growth hormon, glucagon, glucocorticosteroids
what percentage of t2dm is LADA?
15-20%%
what is the cutoff for elevated TG?
1.7
gluconeogensis and ketogenesis occur during
periods of low BG to produce fuel for the brain
energy per gm of carb?
4kcal
energey per gm of protein?
4kcal
energy per gm of fat?
9kcal
energy per gm of alcohol?
7kcal
energy per gm of sugar alcohol?
8kcal
how much of fat consumsed is converted into glucose
<10%
how much of protein is converted into glucose
58%
how much of carbs is converted into glucose?
90to100%
simple and complex carbs have __ effect on BG
same
fructose increases __?
uric acid, BG and TG
this sweetener should be avoided in pregnancy and pregnancy
cyclamate
a third or more of fibre should be viscous soluble fibre
true
insoluble fibres include
seeds, wheat bran, whole grains, skins of vegetables and fruits
soluble fibres include
psyllium, rice, barley, seeds, legumes, potatoes, some fruits, some vegetables
which fibre helps with constipation, BG and cholesterol?
soluble (insoluble helps with constipation only)
low GI is
<55
moderate GI is
56 to 69
high GI is
70 +
sweet potato, yam, legumes is: high low med GI
low
potato, sweet corn, popcorn is : high low med GI
med
french fries, pretzels, rice cakes, soda crackers, tropical fruit is high low med GI
high
barley, pasta/noodles, conerted rice is :high low med GI
low
brown rice is :high low med GI
med
short-grain rice is high low med GI
high
white bread & bagels is:
high GI
whole wheat and rye bread is :
med GI
pumpernickel and stone ground whole wheat is
low GI
bran flakes, corn flakes, rice krispiers is
high GI
all bran, oat bran is
low GI
grapenuts, puffed wheat, oatmeal is
med GI
saturated fats should make up max how much daily energy?
9%
MUFA should make up max daily energy?
20%
PUFAs should make up max faily energy?
10%
these fats raise blood cholesterol levels
saturated and trans
these fats lower blood cholesterol levels
MUFA and PUFA
what is 1 standard drink? in beer
341ml 5% beer
what is 1 standard drink? in alcohol spirits
43ml 40% alcohol spirit
what is 1 standard drink? g of alcohol
10
what is 1 standard drink? ml of wine
142ml of 12% wine
what does alcohol inhibit?
gluconeogensis
alcohol intake limit for women, men?
less than or 2 equal to 2 drinks, max 9 per week. less than or equate to 3 drinks per day, max 14 per week
alcohol can ___
increase ketones, mask hypoglycemia, inhibit hepatic production of glucose
what size cup is 15g worth of legumes (peas, lentils, beans)
1 cup
what size cup is 15g worth of parsnips, peas, qinter squash,
1 cup
what size cup is 15g worth of rasberries, blackberries and strawberries?
2 cups
juice of about 12-15g CHO is ___ ml
125ml
the following diets decrease a1c and increase HDL-C
low GI, dash, mediterraance, veggie/vegan
these diets redue BP
dash, mediterranean
this diet reduces TG
mediterrance, atkins
what is the ornish diet?
very low fat
what is the weight watches diet?
very low fat
what is the zone diet?
high protein
what is the atkins diet?
low carb
what is the starting dose of insulin in type 2?
0.1 to 0.2 units/kg or 10 units
what is the total basal-bolus dose?
0.3 to 0.5 untis per kg/d
how is insulin distrubted for basal-bolus regimen?
40% basal, 20% bolus (35% pre breakfast + dinner, 30% pre lunch)
infusion site in CSII needs to be changed every __
2 to 3 days
how much is basal insulin in CSII
50%
what are the contraindications to acarbose?
severe renal impairment, ulcers, cirrhosis, inflammatory bowel disease,
these 2 drugs cannot be used if hx of bladder cancer
dapaglifozin, pioglitazone
the following can be used in reduced renal dunction
repaglinide, linagliptin, dulaglutide, pio, rosiglitazone, insulin, alogliptin, sitagliptin
tingling of the lips and and tongue are symptoms of
nocturnal hypoglycemia
symptoms of nocturnal hypoglycemia
headache, difficulty getting up in morning, night sweats, nightmares, tingling of lips and tongue
risk factors for hypoglycemia unawarenss
smoking, obesity, long standing diabetes, age, history of bouts of hyp,
what is the dawn phenomenon?
increase in BG in morning due to body’s natural growth hormones in the morning or wearing off of previous day’s insulin
a 1% decrease in a1c is about a __ decrease in mmol/l
2
which is the major ketone body in ketosis?
3beta-hydroxybutyrate
urine ketone test measures
acetoacetate
when do you go to emergency?
ketones >12h, vomiting >2-4h, BG >16.6mmol/L
primary symptom in HHS is
dehydration
avoidance of hypo or hyperkalemia is important in HHS/DKA
hypo
these 2 statins are most effective - reduces ldl-C by at least 50%
lipitor 40-80, crestor 20-40
what is the percentage of people who will develop signs of kidney disease in diabetes?
50%
___ is the leading cause of CKD in developed countries
diabetes
___ is the leading cause of kidney failure in canada
diabetes
risk factors for CKD
duration of diabetes, male, HTN, poor BG control, obesity, smoking
kidney and __ disease are strongly related
heart
when to screen for nephropathy int ype 1?
diabetes > 5 years (at 12+ yo)
causes of transient albuminuria
febrile illness, mensutration, UTI, recent major exercise, decompensated HF, acute elevation in BP & BG
what percentage of men with diabetes have ED?
35to 45%
what percentage has bladder dysfunction?
37 to 50%
after 10 years with diabetes, what percentage develops peripheral neuropathy?
40 to 50%
what are the risk factors for neuropathy?
elevated BG, elevated TG, smoking, BMI, HTN
this occurs in almost everyone who has diabetes over 25 years
nonproliferative retinoatphy
proliferative retinopathy occurs in ___ of diabetes after 15 years
1/3
risk factors for reitnopathy
increased BP, a1c; long duration diabetes, pregnancy (with type 1), proteinuria, low hemoglobin level, dyslipiedmia
when to screen for retinopathy in type 1?
> 5 years duration in at least 15 yo
in men >60 yo with diabetes,___ % has complete ED
40%
at diagnosis of diabetes, ___ of men have ED
1/3
at 6 years after diagnosis with diabetes, ___ of men men ED
50%
ED is associated with CV events and mortality
true
risk factors for ED
increasing age, duration of diabetes, poor BG control, smoking, HTN, dyslipidemia, androgen def, CVD, retinopathy
hypogonadism occurs in ___ of men with diabetes
30-40%
retinopathy is more common in first nations
true
how often should fatty liver be screened in type 2 DM in kids?
yearl
how do you diagnose children with type 2?
A1c AND random/fasting. if discrepancy, use 75g oral glucose tt
list the 5 As of the empowerment model
acceptance, affect, autonomy, alliance, active participation
what are the stages of change?
precontemplation, contemplation, preparation, action, maintenance
prepration is when someone is ready to make a change in the next ___ days
30
contemplation is when the person is thinking about making changes in the next __ months
6
action is when someone is comitting to a change for ___
6 months
what are the principles of motivational interviewing?
express empathy, roll with resistance, develop discrepancy, resolve ambivalance, support self-effiaccy
what is the minimum eGFR for liraglutide?
15ml/min
what ist he minikmum eGFR for exenatide and lixixenatide?
30ml/min
what is the minimum egfr for saxagliptin?
15ml/min
how much weight can you use lose with orlistat?
2 to 4kg
how much weight can you gain with SU?
1.5 to 2.5kg
how much weight can yo gainw ith insulin? long acting?
4 to 5kg, 0 to 4kg (long acting analogue alone)
