Complication of diabetes Flashcards by Pierre Wadeie

DKA vs HHS (hyperosmolar hyperglycemic state)
Who is it more common in

DKA
- common in young people with type 1

HHS
- adult or elder with type 2

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DKA vs HHS
Glucose levels?

DKA
- normal-high glucose
- 14+ (or sometimes lower)

HHS
- Higher glucose >22

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DKA vs HHS
Symptoms?

DKA
- SOME reduced level of consciousness, hypokalemia, kussmal breathing, fruity breath

HHS
- SEVERELY reduced level of consioussness, hypokalemia
NO kussmal breathing or fruity breath, or positive urine acetone test

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DKA vs HHS
onset/mortality

DKA
- Fast onset
- Lower mortality rate

HHS
- Slow onset
- Higher mortality rate

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DKA vs HHS
pathophysiology

DKA
- Absolute insulin deficiency
- increased glucagon
- milder hyperosmolarity

HHS
- relative insulin deficiency
- no ketones present
- minimal acid-base problem

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DKA vs HHS
Treatment

DKA
- MUST use insulin
- IV fluids, Serum K+, Insulin

HHS
- MAY use insulin
- Hydration, Serum K+, +/- insulin

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What are common features of DKA vs HHS

Insulin deficiency –> hyperglycemia –> urinary loss of water + electrolytes
- volume depletion + electrolyte + hyperosmolarity

Both will be fluid depleted

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Is it possible that a patient with no diabetes get HHS?

Yes

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Which groups of people should you assess for DKA if symptoms are present but BG is not elevated

Pregnancy & SGLT2 use

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What specific test should be ordered to identify DKA and ketones in the blood?

B-hydroxy butyrate

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What are conditions that can make DKA diagnosis difficult (3)

Conditions that inc bicarb (eg. vomiting)
Significant osmotic diuresis –> loss of keto anions = normal anion gap
Pregnancy and SGLT2i –> mildly inc glucose

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What are common causes/precipitating factors of DKA

Insulin omission
New diagnosis of diabetes
infection/sepsis
MI
Thyrotoxicosis
Drugs

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How to prevent DKA in type 1 and type 2 diabetes

Type 1
- education around sick day management
- continuation of insulin EVEN when not eating (dose may need adjustment)
- frequent monitoring when ill

Type 2
- education around sick day management
- Frequent monitoring when ill

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SADMANS acronym

Solfunylurea
ACEi
Diuretics
Metformin
ARB
NSAIDs
SGLT2i

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How often should you check blood or urine ketones and BG when you’re sick?

Every 2-4 hours

or if symptoms of DKA are experienced (

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When should you seek your primary care provider or emergency when you’re sick with diabetes?

If vomiting occurs twice or more within 12 hours
on going diarrhea or getting worse
or when symptoms of DKA are experienced (nausea, vomiting or abdominal pain)

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If you cannot tolerate solid food when you are sick how much CHO should you aim for?

15g of CHO every hour

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Define microvascular, macrovascular and mixed complications

Microvascular: small BV
- Retinopathy
- Nephropathy
- Neuropathy

Macrovascular: large BV
- Atherosclerosis
- lipid abnormalities
- CHD coronary heart disease
- Cerebrovascular and peripheral vascular disease CVD and PVD
- hypertension
- Heart failure

Mixed complications
- combination of micro and macro and/or neuropathic changes
ex. foot problems and ED can be both

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What are symptoms of retinopathy?
Both eyes or one eye affected?

Seeing spots or floaters
Blurred vision
Having a dark/empty/black spots in the center of vision
Difficulty seeing well at night
Noticing colours appear faded or washed out losing vision

Both eyes

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What are the 4 forms of retinopathy. Define them

Macular edema
- diffuse or focal vascular leakage at the macula
Non-proliferative
- Microaneurysms, intraretinal hemmorage, vascular tortuosity, and vascular malformation
- Damaged BV leak fluids and fat into the retina
Proliferative
- abnormal vessel growth
- BV to retina therefore retina produces new abnormal BV
Retinal Capillary close
- Limited profusion

Most common cause of blindness among working age
in type 1
Type 2 on insulin
Type 2 not on insulin

Type 1:
- proliferative retinopathy

Type 2 insulin
- Macular edema

Type not on insulin
- Macular edema
- not as prevalent though

When to initiate screening for retinopathy in type 1 and 2

Type 1: 5 years after diagnosis if 15+

Type 2: everyone at diagnosis

How to prevent/delay getting retinopathy (3)

Glycemic control: A1C 7 or under
BP control: less than 130/80
Lipid-lowering therapy: Fibrates

Can retinopathy be treated? How?

Yes

Laser therapy (reduce blindness by 90% in non/proliferative retinopathy)
VEGF antagonists (pharmacologic options)
Surgery (removing vitreous humor)

How to diagnose CKD?

ACR (albumin-creatine ratio) 2.0 mg/mmol+ and/or eGFR <60 rescreen in 1 year

Define nephorpathy. What is the first/best marker for this condition?

Nephropathy - increase in proteinuria in people with longstanding diabetes, followed by declining function which can lead to end-stage First/best marker = microalbuminuria

What is the range for normal, microalbuminuria, overt nephropathy on a urine dipstick. (negative/positive)

Normal (negative) - ACR under 2 Microalbuminuria (negative) - ACR 2-20 Overt nephropathy/ macroalbuminuria (postive) - ACR over 20

What are potential causes of transient albuminuria/ when should you delay treatment?

Recent major exercise UTI Fever illness Decompensated CHF Menstruation Acute severe elevation in BG/BP

What is first line drug therapy for CKD and diabetes? in type 1 and type 2

Type 2: - SGLT2i if eGFR over 20 - Metformin if eGFR 30+ Type 1 and 2: - ACE/ARB if htn - Statin

Differentiate between glycemic control in micro vs macro albuminuria

Microalbuminuria - intensive therapy (lowering A1C target) can bring you back to normal levels Macro - intensive therapy can prevent progression to CKD (not as much benefit)

How to prevent progression of diabetic nephropathy?

- optimal glycemic control - optimal BP control - ACEi/ARB - SGLT2i - Non-steroidal MRA if ACR over 3 (finerenone)

Can you use ACEi and ARB to slow progression of nephropathy even in the absence of hypertension?

Yes

What will you expect with Cr when you start ACEi/ARB?

Can go up to 30% in the beginning Ok for renal function to go down a bit

What does neuropathy cause you to have an increased risk for?

- Foot ulceration and amputation - Neuropathic pain - Significant morbidity - Usage of healthcare resources

What are risk factors for neuropathy

- Elevated BG - elevated Triglycerides - High BMI - Smoking - Hypertesnion

What are autonomic neuropathies that can effect other biologic systems

1. GI - gastroparesis, constipation, diarrhea, esophageal dysmotility 2. CV neuropathy - exercise intolerance, postural hypotension, tachycardio 3. Genitourinary - incontinence, ED, female sexual dysfunction Sudomotor - sweating dysfunction, heat intolerance, dry skin Pupillary - pupil abnormalities Metabolic - hypoglycemia unawareness and unresponsiveness

Give 2 examples of screening for diabetic neuropathy

1. 10g semmes-weinstein monofilament - gauges the patients ability to perceive the sensation of a metal filament touching their big toe 2. 128Hz vibration tuning fork - testing if they can sense vibration on the bone of their toe for 40 seconds

What is first line, second line, and other options for treatment for neuropathic pain

First line - anticonvulsants - antidepressants 2nd line - opioids Other - topical nitrate - capsaicin - transcutaneous electrical nerve stimulation

What is the best anticonvulsant used for neuropathic pain approved? Other?

Pregablin (needs renal adjustment) Other: - gabapentin - valproate

What is the best antidepressant used for neuropathic pain approved? Other?

Duloxetine Other - amitriptyline - venlafaxine

Do people get full relief of neuropathy pain?

Yes, only a few people have complete relief A 30-50% reduction in pain is considered meaningful (hard to get complete relief)

Which method of CVD prevention was better in type 2 diabetes, intensive vs. conventional? What does it entail?

Intensive (BETTER) - therapies to achieve targets in glycemia, lipids, BP, albuminuria - follow-up q3months - ASA and ACEi (independant of BP) Conventional arm - follow clinical practice guidelines

Who should recieve statins (regardless of baseline LDL) (4)

- Clinical CVD - Age 40+ - Microvascular complications - Diabetes for over 15 years and age 30+

Who shouldn't be on a statin or ACE/ARB?

Women who are pregnant or trying to be.

Who should recieve ACEi/ARB therapy regardless of baseline BP? (3)

- Clinical CVD - Age 55+ with a CV Risk factor or end organ damage (albuminuria, retinopathy) - Microvascular complications

Which drugs help in reduction in MACE (major adverse cardio events)

SGLT2i GLP1-RA

Which drugs reduce hospitalization for heart failure

SGLT2i

Which drugs increase risk of hospitalization for heart failure

TZDs Saxagliptin

When should ASA be used in diabetes

For secondary prevention of CVD events No overall benefit for primary prevention - bleed risk outweighs benefits