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ENDO/ID FInal > Diabetes > Flashcards

Diabetes Flashcards

1
Q

Pathophysiology – T1D

A

Autoimmune reaction that destroys the beta-cells

  • Immune mediated (T cell) 95% of cases
  • Idiopathic 5% of cases

Relative or absolute reduction in insulin

  • Decreased insulin –> Abnormal glucose homeostasis
  • Takes months to years to see symptoms from beta cell dysfunction
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2
Q

risk fx for T1DM

A
  • FHx
  • Genetics (HLA genes)
  • Monozygotic twins
  • Environmental influences
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3
Q

dx of T1DM

A

Capillary refil & one of the following :

  • Fasting plasma glucose (FPG) ≥ 126 mg/dL
  • Sx + random blood glu >200 mg/dL
  • 2-hour OGTT plasma glu >200 mg/dL
  • HgbA1c >6.5%
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4
Q

ALL NEW DM 1 DRAW:

A

T1D antibodies: Anti-pancreatic antibodies (insulin, GAD, IA2)

  • At least 2 abs usually present to tell if it is an immune attack

Thyroid Antibodies:

  • TSH not helpful initially due to loss of metabolic control, draw again in 6 mo after new onset DM 1

Celiac:

  • Anti-endomysial antibodies
  • tissue transglutaminase antibodies
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5
Q

new dx of T1DM should immediatekly go to ED due to risk of

A

DKA

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6
Q

tx of T1DM

A

Insulin – keeps glucose levels down

Glucagon (hypoglycemia) - emergent

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7
Q

complciations of T1DM

A

DKA

Diabetic retinopathy (non-proliferative–> proliferative)

Symmetrical sensory polyneuropathy (“stocking-glove”)

Nephropathy (albuminuria)

Pregnancy complications (ex. macrosomia)

CV – tachycardia

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8
Q

define DKA

A

Hyperglycemia –> INC ­ ketones from muscle/fat breakdown

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9
Q

si/sx of DKA

A

Can look just like flu or gastroenteritis!

  • Vomiting
  • Tachypnea
  • Abd pain
  • SOB
  • AMS 2° to metabolic derangement
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10
Q

Dx of DKA

A

BS >250

Metabolic acidosis (pH <7.3 or bicarb <18)

Moderate ketosis

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11
Q

Tx of DKA

A

IV fluids

Insulin – of of choice for BS contreol

Potassium – CHECK, if low then repleat BEFORE you give insulin – insulin depletes K

  • If normal insulin + K
  • If high just give insulin

Bicarb – if acidotic w/ pH of <6.9

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12
Q

define Hypoglycemia

A

BS <70

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13
Q

si/sx of hypoglycemia

A
  • Shakiness/ Dizziness / Anxious
  • Teeth chattering
  • Fatigue
  • Diaphoresis
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14
Q

tx of hypoglycemia

A

Glucagon

Fast acting carbs (ex. juice/soda, soft candy, sugar cubes, honey)

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15
Q

2 physiologic causes of hyperglycemia in the morning: check 2 AM blood sugars

Tx??

A

Dawn phenomenon : Surge of hormones daily around 4-5am

  • Treatment – increase overnight basal

Somogyi effect : patient low in the early morning à hormones are released and overshoot the correction

  • 2 AM BS is 60 (low)
  • Treatment – snack before bed or reduce overnight basal
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16
Q

list types of insulin

ultra rapid acitng

rapid acting

intermediate acting

long acting

inhaled

A

ultra rapid acitng (2-4 hrs)- lispro, aspart, glulisine

rapid acting (3-6 hrs)- humulin/novalinR

intermediate acting - humulin/novalinN

long acting (12-24 hrs) - glargine/detemir

inhaled (10-16 hrs)- exubera

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17
Q

name the types of Diabetic Retinopathy

A

Non-proliferative: Initial manifestation

  • _Dilation of small vessel_s; vascular closure –> ischemia –> ↑ permeability

Progressive Diabetic Retinopathy: Proliferative

  • Abnormal vascular proliferation (neovascularization)
  • Late stage
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18
Q

“cotton wool” spots

dx?

A

Diabetic Retinopathy - Non-proliferative

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19
Q

tx of diabetic retinopahty

proliferative

nonprolif

A

Non-proliferative:

  • Prophylactic laser photocoagulation - Fenofibrate

proliferative: VEGF inhibitors

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20
Q

si/sx of Peripheral neuropathy

A

Sensory loss ascends

By mid-calf, it begins in hands - “stocking-glove” pattern

vibratory sensation loss

altered proprioception

impaired pain, light touch, and temperature

↓ reflexes

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21
Q

leading cause of (CKD), & (ESRD) requiring dialysis

A

Nephropathy

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22
Q

T1D and nephropathy:

Dx?

A

up to 30% will have increased albuminuria after 15 year duration of T1D

  • Less than half of these will progress to nephropathy

dx:

  • Albuminuria
  • Sometimes hematuria
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23
Q

T1DM in pregnancy causes ???

A

Macrosomia (large baby)

  • Increased glucose crosses the placenta; injected Insulin does NOT
  • Fetus makes more insulin in response to high glucose (acts as growth factor for baby)
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24
Q

define T2DM & pathophys

A

Heterogeneous group of disorders which include some or all the following:

  • Insulin resistance
  • Impaired insulin secretion
  • ↑ glucose production

=== Resultant hyperglycemia

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25
Q

is the most important environmental factor causing insulin resistance

A

Obesity (BMI >25)

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26
Q

pathophys of T2DM

A
  • Dysregulation or deficiency in the release of insulin by beta cells
  • Inadequate or defective insulin receptors
  • Productive of inactive insulin or insulin that is destroyed

=== Results in inability to transport glucose into fat and muscle cells, thereby starving body cells and the breakdown of fat and protein is increased

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27
Q

si/sx of T2DM

A
  • Polyuria
  • Polydipsia – inc thirst
  • Polyphagia – inc hunger
  • Fatigue/weakness
  • Electrolyte disturbances
  • Chronic skin infection
  • Acanthosis nigricans
  • Loss of DTRs in ankles
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28
Q

use Oral Glucose Tolerance Test (OGTT) to dx prediabetes vs diabetes

A

Dx Pre-diabetes (impaired glucose tolerance IGT)

BG is 140-199 mg/dL after 2hrs

Dx Diabetes – BG is >200 mg/dL

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29
Q

dx critria for pre-diabtes

A

Fasting plasma glucose (FPG) 100-125 mg/dL

HgbA1c 5.7 – 6.4

2-hour OGTT plasma glu 140-199 mg/dL

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30
Q

dx criteria for diabetes

A

Fasting plasma glucose (FPG) ≥ 126 mg/dL

Sx + random blood glu >200 mg/dL

HgbA1c >6.5%

2-hour OGTT plasma glu >200 mg/dL

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31
Q

T2DM pharmacologic therapuy should be initiated when ..?

A

A1C >7.5 start at time of dx – early start of pharm therapy is assocw/ improved glycemic control over time and ↓ long-term complications

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32
Q

Screening for DM 2

A

All individuals ≥45yrs - if normal every 3 years

Earlier (<30 yr) in some pts

  • BMI≥ 25 or central obesity / Habitually sedentary
  • 1 st degree relative with DM
  • High-risk ethnic population
  • delivered a baby >9lbs
  • HTN (>140/90)
  • HDL < 35mg/dL or triglycerides >250 mg/dL
  • Hx prediabetes or CV dz
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33
Q

Routine Health Maintenance T2DM

A

Monitor Hgb A1C every 3 mo

urine microalbumin yearly as predictor of kidney disease

Podiatry & Ophthal referral

Self-monitoring of glucose levels with glucometer (check fingersticks) (1-4 times per day)

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34
Q

Long Term Complications T2DM

non-vascular

microvascular

macrovascular

A

Non-vascular

  • Gastroparesis
  • Sexual dysfunction
  • Glaucoma
  • Cataracts
  • Skin Δ
  • Infections

Microvascular

  • Retinopathy – leading cause of blindness in US
  • Neuropathy
  • Nephropathy

Macrovascular

  • CAD / MI/ stroke
  • PVD
  • Cerebrovascular disease
  • Nonhealing ulcers
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35
Q

target A1c T2DM

A

Target A1C - set higher for the elderly, pts with multiple comorbidities

•Goal - A1C value ≤7.0%

36
Q

defien Hyperglycemic Hyperosmolar State (HHS)

A

complication of T2DM

Hyperglycemic condition resulting in hypovolemia & electrolyte abnormalities

37
Q

Precipitating Factors of HHS

A

Major illness: MI, CVA, Sepsis, pancreatitis

Drugs that affect carb metabolism:

  • Glucocorticoids
  • thiazides
  • ‘atypical’ antipsychotic agents

Compliance issues

38
Q

dx HHS

A

Hyperglycemia (>1000 mg/dL)

Hyperosmolality

Pre-renal azotemia (volume depletion)

↓ potassium, Mg and phosphate

In contrast to DKA –> acidosis and ketonemia are absent or mild

39
Q

tx HHS

A

IV insulin infusion

IV fluid

Electrolyte monitoring and repletion (potassium, magnesium, phosphate)

40
Q

inital theray for T2DM

A

Metformin – 1st line in most guidelines for most patients

Add a second agent if/when goal A1C <7% is not achieved within 3 mo of initial therapy

  • Oral agent (sulfonylureas), insulin
  • Switch to insulin (A1C >8.5)

If goal A1C is not met while on 2 oral agents

  • add insulin (alternatively add GLP-1 receptor agonist)
41
Q

T2DM *Alternative 1st line therapy (also added to Metformin when necessarily)

A

Sulfonylurea

42
Q

Sulfonylurea safest in CKD

A

Glipizide

•metabolized by liver to inactive metabolites, excreted by kidney

43
Q

which T2DM medications have CVD benefit?

A

(GLP1) R agonists - “glutide”

  • Liraglutide (Victoza)
  • Semaglutide

(SGLT-2) - “liflozin”

  • Empagliflozin
  • Canagliflozin
44
Q

T2 DM med most likely to cause hypoglycemia

A

Sulfonylurea

Glyburide

Glipizide *safest in CKD

Glimepiride

45
Q

side effects of metformin

A

Can cause lactic acidosis (rare)

  • Impairs lactate uptake by liver (avoid in liver failure)
  • In renal failure patients, ↓ in metformin excretion, lactate excretion
46
Q

list DPP-4 inhibitors

A

“gliptin”

Sitagliptin (Januvia)

Saxagliptin (Onglyza)

Linagliptin (Tradjenta)

Alogliptin (Nesina)

47
Q

list GLP1 R agonists

A

“glutide” ELS

Exenatide (Byetta) -

Liraglutide (Victoza) - CVD benefit

Semaglutide - CVD benefit

48
Q

list SGLT-2 inhibitors

A

Empagliflozin ** CV benefit!

Canagliflozin *CV benefit!

49
Q

T2DM medication that

Black Box Warning: medullary thyroid ca. in mice

CI: personal or family hx thyroid cancer

A

(GLP1) R agonists

Exenatide (Byetta)

Liraglutide (Victoza) - CV benefit

Semaglutide - CV benefit

50
Q

tx of Diabetic nephropathy

A

Glycemic control & Strict blood pressure control

Administration of ACE-I or ARB

Avoid some glucose-lowering medications in advanced renal insufficiency (sulfonylureas and metformin)

Reduce daily protein intake

Nephrology consult

  • Referral for transplant with GFR approaches 20ml/min
51
Q

Diabetic Neuropathy most common type

A

Most commonly Distal Symmetric Polyneuropathy (DSPN)

52
Q

tx of Diabetic Neuropathy

A

Duloxetine (Cymbalta)

Pregabalin (Lyrica)

53
Q

decribe a normal erection

A
  • Increased arterial flow
  • Relaxation of smooth musculature in both corpora cavernosa
  • Increased venous resistance
  • Muscle contraction increases rigidity of penis w/ increase in intra-cavernous mmhg > systolic BP
54
Q

define ED

A

Consistent inability to attain or maintain sufficiently rigid penis for sexual performance

>50% 40-70 yo

55
Q

types of ED

A

Vascular -

  • Arterial (obstruction)
  • Venous (leak)

Neurogenic

  • Multiple sclerosis
  • Parkinson’s disease
  • CVA, Spinal injury/Tumor

Hormonal -

  • Hypogonadism
  • Hyperprolactinemia
  • HPA dysfunction
  • Hypothyroid

Drug induced (25%) – A

  • Antihypertensives
  • Antidepressants
  • Opioids

Psychogenic - Typically younger

Local penis factors

  • Peyronie’s Disease (5-10% >50yo)
  • Surgery, XRT, Pelvic trauma
56
Q

describe link b/w ED and CAD

A

ED may be early sign of CAD or just precedes it development

  • ED and CAD develop from endothelial dysfunction (same pathophysiology)
  • Endothelial dysfunction results from decrease in Nitric Oxide thus impaired arterial vasodilation
  • Share many RF’s
  • ED w/o obvious cause should be screened for CVD (esp before initiating pharmacologic therapy for sexual dysfunction)
57
Q

dx ED

A

Testosterone – Serum prolactin (if testosterone is low), LH

NPT testing (nocturnal penile tumescence testing)

Home testing kit : Rigi-Scan monitor

While sleeping detects number, tumescence, rigidity

  • _Normal NP_T = psychogenic or hormonal
  • Impaired NPT = vascular or neurogenic

Duplex Doppler Imaging or Angiography

  • Deep penile artery angio identifies obstruction
  • Doppler identifies venous leak
58
Q

NPT testing (nocturnal penile tumescence testing)

  • Normal NPT = indicates…??
  • Impaired NPT = indicates…??
A

Normal NPT = psychogenic or hormonal

Impaired NPT = vascular or neurogenic

59
Q

Duplex Doppler Imaging or Angiography

  • Deep penile artery angio identifies ____
  • Doppler identifies _____ ____
A

Duplex Doppler Imaging or Angiography

  • Deep penile _artery angio identifie_s obstruction
  • Doppler identifies venous leak
60
Q

what is the SHIM - 5 used to help dx??

mild

mild-mod

moderate

severe

A

ED - assess severity of sx

mild - 17-21

mild-mod - 12-16

moderate - 8-11

severe 1-7

61
Q

define Peyronie’s Disease

A
  • Penile deformity or curvature of varying degree (fibrotic disorder)
  • Etiology is from subtle trauma to penis and subsequent scarring
62
Q

tx for Low libido

A

SSRI

5-alpha-red- inhib (finasteride)

testosterone + PDE5 inhib (sildenifil)

63
Q

tx ability to sustain erection

A

pharmacologic - first line

vacuum assisted devices

penile self injecables

penile prothetics

64
Q

first line tx of ED

list options

CI

A

PD-5 Inhibitors

  • Sildenafil (Viagra) - 1 hr before sexual encounter and lasts 4 hrs ,
    • Diabetic, radical prostatectomy, parkinson’s
  • Vardenafil (Levitra) - 1hr/4hr but available in ODT for faster absorption
  • Tadalafil (Cialis) - Can take low dose daily esp for pt’s with “complete” ED,
    • Can also improve LUTS d/t BPH
  • Avanafil (Stendra) - rapid onset of action 15-30 min

Absolute CI use w nitrates = hypotension

Relative CI use w alpha-adrenergic antagonists = hypotension

65
Q

second line tx of ED

A

Vacuum Assisted Devices –

  • Devices applied for max 20-30min
  • Most often used by couples in stable relationships

Penile Injection: Injection or intraurethral placement of Prostaglandin-E1 directly into the corpus cavernosa and acts as smooth muscle vasodilator

  • Method of injection w/ insulin needle directly into corporeal body
  • Intraurethral placement & massage for 1 min to ensure = distrib into corpora cavernosa
  • Erection w/in minutes
66
Q

3rd line tx of ED

A

Penile prostheses - 3rd line when pharmacological and vacuum devices failed

  • Peyronie’s disease pts at time of reconstruction candidates for placement of prosthesis at time of surgery

Penile revascularization- Low success rates unless strict criteria young, nonsmoking, otherwise healthy w/ recent focal arterial occlusion (50-65% success)

67
Q

define Priapism

A

Prolonged >4-6 hours erection unresolved by ejaculation = urologic emergency

untreated leads to ischemia and then corporal fibrosis and necrosis of penis

68
Q

tx priapism

A

Intracavernosal phenylephrine (Neo-Synephrine) injection

Aspiration of the corpora cavernosa dark blood followed by saline irrigation and, if necessary, injection of an alpha-adrenergic agonist

  • A diluted solution of phenylephrine may be used for irrigation

Surgical intervention

69
Q

define BPH

A

Cellular proliferation of the prostate at the central transition zone = histologic dx (most common benign tumor in men)

70
Q

si/sx BPH

Storage/Irritative symptoms

Obstructive symptoms

A

Storage/Irritative symptoms

  • Urgency / Frequency
  • Nocturia
  • Incontinence

Obstructive symptoms

  • Hesitancy
  • ↓ force or caliber of stream
  • Splitting or spraying of the stream
  • Dribbling post-void
  • Straining to urinate
  • Unable to or incomplete emptying of bladder
71
Q

Dx BPH

A

Serum PSA (preferably 50-69yo)

  • Men w/ prostate CA can have normal PSA and men w/ high PSA can have prostatic dz other than CA

Upper tract imaging = U/S or CT

  • If Cr is high, UTI, hematuria, hx of calculi, CKD

Transrectal U/S can detect mass as well as total prostate volume (monitor for consideration of medical therapy vs surgical therapy w/ BPH)

72
Q

BPH tx options

A

Watchful waiting/Behavioral modifications - IPSS <8 (mild

Pharmacologic treatment - IPSS <20 w/o

  • Refractory retention
  • BPH induced
    • Kidney disease
    • Bladder calculi
    • Recurrent or persistent gross hematuria

Minimally invasive therapy

Conventional surgical therapy

73
Q

BPH pts what must we always do before starting tx

A

Must refer for urologic evaluation prior to tx

74
Q

what is the AUA?

Mild

Mod

Severe

A

assesses severity of sx of BPH

before staring therapy this must be calciulated - single most important tool in evaluation

Mild - 0-7

Mod - 8-19

Severe - 20-35

75
Q

optional BPH testing

A

Maximal urinary flow rate (urodynamic profile)

  • Flow rate >15ml/sec excludes clinically important BOO

Post-void residual volume -

  • Normal = <12ml
  • Bladder scanner (U/S)

Urine cytology

  • Mostly irritative sx’s & RF’s for bladder malignancy (ie smoking, industrial exposure)

Cystoscopy –Not routine recommendation

  • Assist in planning for surgical management of BPH
  • Useful for detecting bladder malignancy, urethral stricture, calculi
76
Q

BPH is not considered RF for prostate CA…?

A

as primarily central transition zone

versus prostate CA is peripheral part of prostate

77
Q

tx of BPH

first line

second line

ED and BPH

sx’s assoc w/ overactive bladder

A

first line- Alpha 1a blocker

  • Terazosin, Doxazosin, Tamulosin, Alfuzosin, Silodosin

second line- 5-alpha-reductase inhibitors

  • More effective in men with larger prostates (>40ml by TRUS)
  • Finasteride, Dutasteride

ED and BPH - PDE-5 Inhibitors

sx’s assoc w/ overactive bladder - Anticholinergic agents

  • No elevated post-void residuals
  • Oxybutynin, Tolterodine, Darifenacin, Solifenacin, Fesoterodine, Trospium
78
Q

BPH tx when to initate Combo Therapy

A
  • Severe symptoms of BPH IPSS>20
  • Poor response to monotherapy
  • Prostate >40ml
79
Q

what is BPH combo therapy

A

Alpha- blocker AND 5-alpha reductase inhibitor - Both are superior to either agent alone in men w/ large prostate

Combination therapy over long term improved sx’s and reduced risks of clinical progression, acute urinary retention, and prostate surgery significantly versus monotherapy (MTOPS trial w/ doxazosin and finasteride)

80
Q

BPH surgical options

A

Minimally invasive

  • Laser - TRUS guidance w/ TULIP
  • Microwave hyperthermia or electrovaporization - Transurethral catheter or rectoscope
  • Radiofrequencies -TUNA (transurethral needle ablation)

Conventional Surgical Options

  • TURP (transurethral resection prostatectomy
  • TUIP (transurethral incision of prostate)
    • small prostate severe sx
  • Open simple prostatectomy - Operation of choice if coinciding bladder pathology (diverticulum or calculi
81
Q

BPH pharm therapy should be initated when…?

A

mild to moderate IPSS <20 w/o

  • Refractory retention
  • BPH induced
    • Kidney disease
    • Bladder calculi
    • Recurrent or persistent gross hematuria
82
Q

list Alpha 1a blockers

A

Terazosin

Doxazosin

Tamulosin

Alfuzosin

Silodosin

83
Q

list 5-alpha-reductase inhibitors

more effective in??

A

More effective in men with larger prostates (>40ml by TRUS)

  • Finasteride
  • Dutasteride
84
Q

PDE-5 Inhibitors for BPH

A

Consider use if both ED and BPH <20 IPSS -

Tadalafil (Cialis)

85
Q

list Anticholinergic agents used in BPH

indication?

examples?

A

Predominantly irritative sx’s assoc w/ overactive bladder

No elevated post-void residuals

  • Oxybutynin
  • Tolterodine
  • Darifenacin
  • Solifenacin
  • Fesoterodine
  • Trospium

ENDO/ID FInal (4 decks)

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