Chap.102 Diabetes GreenB Flashcards
1
Q
What is the most prevalent endocrinologic problem encountered in primary care practice?
A
diabetes mellitus
2
Q
What are the characteristics of diabetes mellitus?
A
hyperglycemia
relative or absolute deficiency of insulin
insulin resistance
risk of longterm microvascular and macrovascular complications
3
Q
What is the ultimate goal of therapy of DM?
A
the prevention of future complications such as: microvasular and macrovascular complications, consequences of diabetes that make the condition a major risk for cardiovascular disease, stroke, visual impairment, renal failure, impotence, peripheral neuropathy, foot ulcers, limb loss and death
4
Q
Effective management of DM requires care that is thoughtful and meticulous, incorporating intensive _______ involving the entire health care team.
A
patient education
5
Q
Euglycemic control, with the level of hemoglobin A1c kept less than _____ has emerged as a major treatment objective because of its oassocaition with a marked reduction in the risk for the microvasular complications.
A
7%
6
Q
What are 4 important things to consider in the treatment of a patient with DM?
A
lifestyle adjustments (exercise, weight reduction), determining when to initiate pharmacologic therapy, selection among available agents and setting an achievable goal for hyperglycemic control
7
Q
What characteristic of DM has gained more attention for its pathological significance and importance of early diagnosis?
A
hyperglycemia
8
Q
What is the threshold for diagnosis for the fasting plasma glucose level?
A
126 mg/dL
It has been revised downward from 140 to 126 to increase the sensitivity of determination
9
Q
What is deemed the preferred test to diagnose diabetes in children and nonpregnant adults?
A
fasting glucose level
10
Q
The diagnosis of DM can be made based on the presence of one of three glucose abnormalities found on two separate days. What are these abnormalities?
A
- Fasting plasma glucose 126 mg/dL or greater.
- Random plasma glucose 200 mg/dL or greater in a person with diabetes symptoms (polyuria, polydipsia, or weight loss)
- Two- hour postprandial plasma glucose level 200 mg/dL or greater after administration of the equivalent of a 75g oral glucose load (oral glucose tolerance test)
11
Q
What are the diagnostic criteria for normal fasting glucose and impaired fasting glucose?
A
normal- less than 100 mg/dL
impaired- 100-125 mg/dL
12
Q
Impaired glucose tolerance was refined as a fasting glucose less than ______ and a 2 hour PG of ____ to _____ mg/dL.
A
126 mg/dL
140-199 mg/dL
13
Q
What are considered “pre-diabetes” and are risk factors for the development of future diabetes and cardiovascular disease.
A
IFG and IGT
14
Q
Classification of Diabetes…. :)
A
DON’T YOU JUST LOVE IT!!!!!!
15
Q
The preferred approach to classification, as issued by the American Diabetes Association, is according to underlying __________.
A
pathophysiology
16
Q
Which type of diabetes is characterized by an autoimmune destruction of the pancreatic beta cells leading to an absolute deficiency of insulin - patients are ketosis prone and require insulin to live.
A
type 1 diabetes
17
Q
In which type of diabetes does peripheral insulin resistance a more contributing factor?
A
type 2
18
Q
Patients with type 1 diabetes may have detectable serum autoantibodies to such pancreatic antigens as ______ and _________.
A
islet cells
glutamic acid dehydrogenase
19
Q
Which type of diabetes is characterized by variable degrees of insulin secretory deficiency and resistance? –> insulin is present but in amts insufficient to meet metabolic needs in a timely fashion
A
type 2
20
Q
What is believed to be the major role in insulin resistance? (present in 60-80% of patients with type 2 diabetes)
A
obesity
21
Q
type 2 diabetics exhibit impaired ______ secretion at any plasma glucose conc. and ________.
A
insulin
insulin resistance
22
Q
What is the most common type of diabetes?
A
type 2
23
Q
What is used to identify a patient with impaired glucose tolerance?
A
fasting glucose less than 126 mg/dL and a 2 hour glucose level of 140 to 199 mg/dL
24
Q
Pts with experiencing impaired glucose tolerance are more at risk for what?
A
development of type 2 diabetes is increased as is the risk for cardiovascular disease
25
The principal pathology for type 1 diabetes is ___________, usually due to ________ destruction of the ________, which leads to a loss of insulin production.
pancreatic beta-cell destruction
| autoimmune destruction of the beta cells
26
The pathogenesis of Type 2 diabetes is characterized by ________ and _______.
impaired insulin secretion
| insulin resistance
27
What are the pathophysiologic hallmark signs of insulin resistance?
inappropriate hepatic glucose production and decreased muscle glucose uptake- these occur despite the secretion of insulin
28
What often precedes type 2 diabetes that is associated with caloric excess and inactivity.
metabolic syndrome
29
What are the features of metabolic syndrome?
```
insulin resistance
obesity
dyslipidemia
hypertension
strongly increased risk for macrovascular artherosclerotic disease--> coronary risk increased two to four fold
```
30
What is an important contributor to type 2 diabetes, exacerbating insulin resistance?
weight gain
31
Glucose intolerance in diabetic patients may be worsened by?
```
infection
stress
thiazides
glucocorticoids
pregnancy
```
32
Excess secretion of these things may contribute to glucose intolerance
```
GH
cortisol
catecholamines
glucagon
and diseases that destroy a substantial portion of the pancreas (chronic pancreatitis, hemochromatosis, cystic fibrosis)
```
33
Type 1 diabetes may present emergently as _______ or less dramatically with the classic triad of ______, ______ and _______.
ketoacidosis
| polyuria, polydipsia and polyphagia
34
Typically, the onset of type 1 is when?
in the first two decades of life, but may occur later
35
In which decade of life does incidence of type 2 rise significantly?
starting in the fourth decade
36
How is type 2 often discovered?
incidentally on a screening urinalysis or blood sugar measurement
37
Sometimes, _____ is the predominant symptom of diabetes (type 2).
fatigue
38
Type 1 diabetes may be found through a complication such as myocardial ischemia, stroke, intermittent claudication, impotence, peripheral neuropathy, proteinuria or retinopathy.
Hang in there :)
39
What is a common initial complaint in men with type 1 diabetes?
erectile dysfunction
40
The overall course of untreated diabetes is one of progressive worsening of glycemic control due to the combination of?
pancreatic endocrine failure and peripheral insulin resistance
41
The rate of clinical failure is typically rapid and progessive in type 1, following years of silent immune-mediated ______ destruction; however, early on, there may be a transit "honeymoon" period before ______ sets in.
islet cell
| beta cell exhaustion
42
Untreated type 2 diabetes is more heavily influenced by the state of _______.
insulin resistance
43
Early clinical type 2 disease is characterized by impaired timing of insulin producing postprandial hyperglycemia and the potential for episodes of _______-total insulin production may actually rise.
hypoglycemia
44
Complications of diabetes occur often and most correlate with the magnitude and duration of ________.
hyperglycemia- there does not seem to be a glycemic threshold for the development of complications
45
The major complications of diabetes can be classified as either _______ or ________.
microvascular
| macrovascular
46
Which type of diabetes complication causes things like retinopathy, neuropathy, and nephropathy? (microvascular or macro vascular)
microvascular
47
Which type of diabetes complication causes large vessel arteriosclerosis?
macrovascular disease
48
The effects of smoking, hypertension, and other risk factors for vascular disease appear to be synergistic with those of ________.
hyperglycemia
49
What reduces the risk for large-vessel artherosclerosis?
tight control of glucose
Major reductions in the risk for coronary events and stroke can be achieved by correcting other major cardiovascular risk factors such as smoking, hypertension, and hyperlipidemia.
50
Effective treatment of what risk factors appears more important than normalization of glucose per se in the prevention and limitation of cardiovascular complications?
smoking, hypertension and hyperlipidemia
51
_______ disease accounts for much of the morbidity of diabetes, causing neuropathy, retinopathy and nephropathy.
microvascular disease
52
________ ______ is one of the leading causes of end stage renal failure in adults, accounting for 25% of cases.
diabetic nephropathy
53
What are characteristic renal changes in a person with diabetic nephropathy?
glomerular basement membrane thickening and mesangial proliferation
54
Mesangial proliferation correlates strongly with the onset of ______ and _______.
proteinuria and hypertension
55
Will diabetic nephropathy or the stage of clinical proteinuria be present first?
Subclinical and histological findings for diabetic nephropathy are present long before the stage of clinical proteinuria.
56
What three things contribute to the progression of renal impairment?
elevated glomerular filtration rate (hyperfiltration)
genetic determinants
hypertension
57
With persistent proteinuria, _______ becomes established and glomerular filtration begins to decline at the rate of 1 mL/min per month.
hypertension
58
*The risk for the development of nephropathy correlates with the duration of disease and the degree of ______.
hyperglycemia
59
___________- can reduce the risk for renal failure, particularly as primary prevention and if done early.
tight control of the blood glucose
It can reverse mild proteinuria in type 1 diabetics who do not yet have renal insufficiency.
60
Bladder dysfunction and resultant ________ can also contribute to renal impairment in pts with diabetic nephropathy.
urinary tract infections
61
*The risk for retinopathic changes is related to the duration and degree of _________.
hyperglycemia
62
After 20 years of diabetes, ALL age groups show a ___% to ____% prevalence of retinopathy.
75-80%
63
The cumulative incidence of retinopathy can be reduced by more than 50% with?
intensive insulin therapy- greatest effect is in primary prevention and in those with mild to moderate nonproliferative retinopathy
64
What two things occur in increase frequency in patients with diabetic retinopathy?
cataracts and glaucoma
65
______ may develop in 50% of diabetics and lead to a peripheral sensory deficit, autonomic dysfunction or a mononeuritis.
Neuropathy
66
What are two mechanisms of neuropathy?
myo-inositol depletion in nerve cell membranes- prolongs the conduction time
hyperglycemia induced sorbitol accumulation in nerve tissues that have a polyol pathway for glucose metabolism (e.g.. Schwann cells)
67
What is believed to be responsible for mononeuropathy?
microangiopathic changes that decrease the blood supply to the myelin sheaths
68
Independent risk factors for neuropathy:
```
duration of diabetes
current level of glycosylated hemoglobin
BMI
Smoking
hypertension
presence of cardiovascular disease
```
69
Which type of neuropathy is predominately sensory, reducing sensation in the lower extremities?
peripheral neuropathy- may progress to cause pain and dysesthesias (abnormal sensation)
70
Which type of neuropathy often presents as impotence?
Autonomic neuropathy
71
Besides impotence, what are some other potential manifestations of autonomic neuropathy?
delayed gastric emptying
orthostatic hypotension
urinary retention
72
Which type of neuropathy is almost always seen in association with distal polyneuropathy?
polyneuropathy- disorders are often symmetric and frequently affect the feet and hands, causing weakness, loss of sensation, pins-and-needle sensations or burning pain
autonomic
73
Impaired leukocyte function, compromised vascular supply and neuropathy in patients with diabetes can cause?
It causes these patients to be more susceptible to infection.
74
Cellulitis and candidiasis infections can occur in ischemic foot lesions in patients with diabetes. Why would this be a bigger deal for diabetics?
Because they are more susceptible to infection, osteomyelitis may occur and may require amputation.
75
Screening to detect prediabetes (IFG or IGT) and diabetes should be considered in individuals ____ years or older- especially if their BMI is 25 or greater.
45 y/o
76
When should screening of individuals less than 45 years of age be considered?
if they are overweight and have other risk factors for diabetes
77
How often should screening be repeated?
every 3 years
78
_____, ______ and ______ are important in the prevention and treatment of type 2 diabetes.
diet
exercise
weight
79
A supervised program of modest weight reduction (sustained 7% weight loss), regular aerobic exercise ( ____ hrs/wk of moderately brisk walking), and a low-fat, low- calorie diet can prevent onset of diabetes when fully implemented and obtained.
2.5 hours/week
80
The principal goal of diabetes therapy is __________ to prevent the multisystem complications that may result from hyperglycemia.
normalization of blood glucose
81
The American Diabetes Association recommends a treatment goal of HbA1c less than _____% and as close to normal as possible without significant hypoglycemia.
less than 7%
82
How often should HbA1c levels be checked?
two times a year or more frequently in pts whose therapy has changed or who are not meeting glycemic goals
83
Normalization of _____ metabolism stands as a major treatment objective for all diabetics.
carbohydrate metabolism
84
The risk for ______ with intensive insulin therapy is a serious concern; it can be especially dangerous in patients who have underlying coronary or cerebrovascular disease.
hypoglycemia
However, the goal of safe and convenient glucose normalization is becoming easier to achieve.
85
Until implantable glucose sensors and insulin delivery systems automate the control process, the maintenance of normoglycemia will still require attention to the details of _____, _____, _______ and the many facets of medical therapy the achieve the best possible outcome.
diet
exercise
weight control
86
The overall treatment strategy of a diabetic patient is pathophysiology based, with a focus on the importance of establishing euglycemia as quickly as possible because diabetic complications are mostly a function of the degree and duration of ________.
hyperglycemia
WE WILL NOT MISS THIS QUESTION :)
87
What is the most important determinant of daily glycemia?
fasting glucose level
88
In type 1 diabetes, the emphasis of treatment is on?
intensive insulin therapy to make up for the loss of insulin production
Diet and exercise also play key roles but insulin resistance is the priority of treatment for type 1 diabetics.
89
In type 2 diabetes, insulin resistance is treated with?
diet, weight reduction and exercise
| if necessary- drug therapy
90
New recommendations for type 2 diabetics include drug therapy with the drug __________ in combination with lifestyle modification as the initial approach (followed by the early addition of other oral drugs or insulin if glycemic control is not readily achieved)
Metformin
91
Early drug therapy is indicated in which types of patients?
pregnant women
| if it is unlikely that the patient can lose weight
92
______ remains the first choice agent in patients with sever hyperglycemia, whether from type 1 or 2 diabetes.
insulin
93
What does a patients fasting glucose level need to be to be diagnosed as hyperglycemic?
>240 mg/dL
94
Can modest weight loss improve hyperglycemia?
Yes, a substantial reduction in blood glucose can be seen even within several days of instituting a low-calorie diet
95
______ ____ has been shown to enhance the sensitivity of peripheral insulin receptors to endogenous insulin and reduce the requirements for administered insulin.
weight loss
Hepatic glycogen stores are depleted rapidly with caloric restriction.
96
The glycemic response to weight loss is related to the initial ________.
fasting blood glucose level
Pts with lower fasting blood glucose levels will tend to normalize their blood glucose with less weight loss than those who start off with higher levels.
97
The hyperglycemia of most type 2 diabetics can be controlled by achieving an ideal body weight- such weight reduction is hard to be maintained because permanent restriction in caloric intake is required. The goal is gradual sustained weight reduction of approximately ____ pounds each week.
1 to 2 lbs each week
98
An effective exercise program is another cornerstone treatment of type 2 diabetes. Aerobic exercise facilitates ______ control independent of it effect on weight, reducing insulin resistance in _____ and _____.
facilitates glycemic control
| liver and muscle
99
_______ for type 2 diabetics is controversial and less critical than achieving and ideal body weight.
diet composition
100
The ADA recommends diets ____ in calories, ____ in fat and ______ in complex carbohydrates, with as much as ___% of total calories allowed from carbs for type 2 diabetics.
low in cals
low in fat
liberal in complex carbs
60%
101
Increasing ____ content in the diet is associated with a low prevalence of diabetes mellitus.
fiber
102
Special dietary considerations for patients on insulin
You aren't the only one, I'm bored out of my mind right now too!
103
For type 1 diabetics who are at their ideal body weight, the essential aspect of dietary therapy is the regulation of ______ and the _____ of meals.
regulation of CALORIC INTAKE and the SPACING of meals
104
________ are generally restricted from type 1 diabetics because they worsen postprandial (after eating) hyperglycemia.
simple sugars
105
ADA diets recommend 2/9 of calories of the calories throughout the day should be consumed at breakfast, 2/9 at lunch and _____ for dinner and _____ as snacks
4/9 for dinner
| 1/9 for snacks
106
Timing of meals must match peak insulin effects and activity schedules; increased activity requires what to prevent hypoglycemia?
increased food intake or decrease in insulin dose
107
What is used in treatment of diabetes that both increases glucose consumption and reduces insulin resistance?
exercise
108
Which forms of exercise improve insulin sensitivity?
all forms of aerobic exercise, even walking and other forms of nonvigorous activity
109
Significant improvement in glycemic control has been demonstrated in pts who exercise ___ times per week for ___ to ___ minutes.
three times a week
| 30-60 minutes
110
Precautions should be taken in patients planning to take part in more vigorous activity. The increased absorption of insulin in an exercising limb may precipitate _______ in patients on insulin; therefore, the _______ should be used as the site for insulin injection.
hypoglycemia
| abdomen
111
Because of the possibility of underlying ischemic heart disease, _______ should be considered before a rigorous exercise is undertaken by a sedentary person with longstanding diabetes or other atherosclerotic risk factors.
an exercise electrocardiogram
