Diabetes Flashcards
FPG 100- 125 mg/dL or 2-h plasma glucose in the 75 g OGTT 140–199 mg/dL: IGT (affected 1st) OR A1C 5.7–6.4%
Prediabetes: Diagnosis Criteria
A1C ≥ 6.5% OR Fasting plasma glucose (FPG) ≥126 mg/dL OR 2-h plasma glucose ≥200 mg/dL during an OGTT OR A random plasma glucose ≥200 mg/dL
Diagnosis of Diabetes
what do you need to dx diabetes in the absence of unequivocal hyperglycemia
two abnormal test results
Type 2 Diabetes - Risk Factors
- First-degree relative with diabetes
- High-risk race/ethnicity (AA, Latino, NA, Asian A, Pacific Islander)
- History of CVD
- Hypertension >140/90 mmHg or on anti-HTN
- HDL cholesterol level <35 mg/dL
- Triglyceride level >250 mg/dL
- Polycystic ovary syndrome
- Physical Inactivity
- Conditions with insulin resistance (severe obesity, acanthosis nigricans)
Criteria for Screening:
Prediabetes and Type 2 Diabetes
Informal assessment of risk factors or validated tools should be considered in asymptomatic adults for prediabetes and T2DM . (B)
- Testing for overweight or obese (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and one + risk factors (B)
- Testing should begin at age 45 years. (B)
- If tests are normal, repeat testing at a minimum of 3-year intervals. (C)
When to screen for gestational diabetes?
At the first prenatal visit if pt has risk factors.
Test for GDM at 24-28 weeks of gestation in women not previously known to have diabetes (A)
When to test post-partum mom who had GDM for prediabetes/ diabetes
4-12 weeks postpartum, using the 75-g oral glucose tolerance test; lifelong screening Q3 years
*Intensive lifestyle interventions/ metformin
How is T2DM different in kids from adults?
- More rapidly progressive decline in Beta-cell function (can end up on insulin sooner)
- Accelerated development of diabetes complications
Criteria For Screening:
Youth and Adolescents for DM
Risk-based screening after puberty or ≥10 years of age
- overweight (BMI ≥85th percentile) or obese (BMI ≥95th percentile) and
- one or more additional risk factors for diabetes
• Repeat testing Q3 years or more frequently if BMI is
increasing (C)
• Overweight/obesity test pancreatic autoantibodies to exclude the possibility of autoimmune T1DM. (B)
Youth and Adolescent DM Risk Factors
• FH of T2DM in 1st or 2nd-degree relative
• Race/ethnicity: AA, NA, Asian A, Latino, Pacific Islander
• Signs/conditions associated with insulin resistance
– acanthosis nigricans, hypertension, dyslipidemia, PCOS, or SGA
• Maternal history of diabetes or GDM during gestation
A 63-year-old patient has a fasting blood glucose of
127 mg/dl. He has a BMI of 32, a HbA1c of 6.4%, and a
strong family history of type 2 diabetes. What is the
most prudent next step?
Tell him he needs a glucose tolerance test or repeat A1C
A 17-year-old patient has a BMI in the 86%. His social
history reveals he is a high school football player. His
family history is negative for type 2 diabetes. His
mother had GDM with him and she has a current A1C =
5.1. What is the most prudent next step?
Tell him he is at risk for developing diabetes and order an A1C for screening purposes.
components of diabetes physical exam
- BMI, BP
- Fundoscopic examination
- Thyroid palpation
- Skin examination for acanthosis nigricans and insulin injection sites
components of diabetes foot physical exam
Comprehensive foot examination at least yearly
• Inspection
• Palpation of dorsalis pedis and posterior tibial pulses
• Presence/absence of patellar and achilles reflexes
• Proprioception, vibration and monofilament sensation
how often to get A1c lab for Diabetes pts
At least twice a year of controlled.
A1C, every 3 months if not at target or if something has changed
yearly diabetes lab tests
- Fasting Lipid profile (Total, LDL, HDL and triglycerides)
- Liver function tests (esp if on metformin)
- Urine albumin-to-creatinine ratio
- Serum creatinine and calculated GFR
- TSH in T1DM, dyslipidemia, or women over 50 years
Immunizations needed for diabetes pts
- Influenza yearly
- Pneumonia
- PCV 13 and PPSV23 (additional dose at/after age 65)
- Hepatitis B vaccine ages 18 through 59 years.
- 3-dose series of hepatitis B vaccine to unvaccinated adults with diabetes ages ≥60 years.
American Diabetes Association Glycemic targets:
HbA1C:
Preprandial PG:
Postprandial PG:
HbA1C: <7.0%, PG: ~ 150–160 mg/dl
Preprandial PG: 80 - 130 mg/dl (7.2 mmol/l)
Postprandial PG: <180 mg/dl (10.0 mmol/l)
What should diabetic do if blood glucose is <70?
Glucose (15-20 g) for conscious individual
- Repeat SMBG 15 minutes after treatment and repeat treatment prn. Once
SMBG is normal, consume a meal/snack
What should diabetic pt take if blood glucose is <54?
Prescribe Glucagon if at risk of level 2 hypoglycemia (<54 mg/dL)
physical activity recommendation for children?
60 min/day at least 3 days/week of moderate/vigorous-intensity
aerobic and muscle/bone-strengthening activities.
physical activity recommendation for adults?
150 min at least 3 days/week of moderate/vigorous intensity aerobic activity with no more than 2 consecutive days without activity and 2-3 sessions/week of resistance exercise on nonconsecutive days
Prevention/Delay of Type 2 Diabetes
• Prediabetes:
- Targeting weight loss of 7% of body weight
- Increasing physical activity to at least 150 min/week of moderate activity (walking)
- Monitor for development of diabetes annually
- Screen for and treat modifiable risk factors for CVD
• Consider metformin
- Especially for those with BMI >35 kg/m2, age <60 years, and women with prior GDM (A)
what to know about metformin?
preferred first line agent
Once initiated, metformin should be continued; other agents, including insulin, should be added to metformin.
• Long-term use of metformin associated with vitamin B12 deficiency
When to start new dx diabetes pt on insulin?
Early introduction if ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels >10% or blood glucose
levels ≥300 mg/dL
… can take it for a bit to help clear insulin receptors and then go back to metformin
Type 2 Diabetes pt with Established ASCVD…
SGLT2, or GLP1 (demonstrated CVD benefit) are preferred
Type 2 Diabetes pt with Chronic kidney disease
SGLT2 or GLP1 shown to reduce risk of CKD
progression, CV events, or both
If pt does not tolerate metformin or has contraindications?
Dual therapy
Sulfonylurea/ Thiazolodine
What A1c to start Dial therapy?
HbA1c ≥9%
When to use triple therapy for diabetes management?
hyperglycemia
(catabolic features,
BG ≥300-350 mg/dl,
HbA1c ≥10-12%)
How often can you change diabetes meds to get sugars in control?
q 3 months
Purpose of Insulin Therapy
• Prevent and treat fasting and postprandial hyperglycemia
• Permit appropriate utilization of glucose and other nutrients by
peripheral tissues
• Suppress hepatic glucose production
• Prevent acute and chronic complications of uncontrolled
diabetes
Disadvantages of Insulin Therapy in Type 2 Diabetes
- Weight gain
* Hypoglycemia
Meds used for Pedi diabetes
Metformin and insulin
preferred agent (type 1 and type 2) in pregnancy
insulin
should be avoided in sexually active women of childbearing age who are not using reliable contraception.
ACE inhibitors, angiotensin receptor blockers, statins
glucose <70mg/dL (may be higher in pt with poor control)
Altered cerebral function
Shaking, trembling, sweating, weakness, tachycardia, lightheaded, irritability, confusion, drowsiness progressing to unconsciousness if severe
Hypoglycemia
How to tx Hypoglycemia
15-45g oral carb (depending on severity)
Glucagon IM if pt unconscious
Advise patients to keep a rapid-acting carb with them at all times, even next to bed
Hyperglycemia, ketonemia, acidemia
CM: rapid onset abdominal pain, n/v. Kussmaul respirations and dehydration. Fruity odor of breath
Tx: IV insulin and electrolyte replacement
Often how T1DM is diagnosed
DKA
Usu occurs in T2DM
CM: polyuria, polydipsia, altered LOC
Hyperglycemia, dehydration, absence of ketones
Hyperosmolar hyperglycemic State
When to give OGTT
24-28 weeks
Child who was in utero during mom’s gestational diabetes is at risk for developing diabetes
deformity of the foot caused by joint and bone dislocation and fractures due to neuropathy and loss of sensation to foot and ankle. If severe can include collapse of midfoot arch (rocker-bottom foot)
Charcot’s Foot and Ankle
state of insulin resistance A1C 5.7-6.4%; FBG 100-125; OTT 140-199; or diagnosis of metabolic syndrome (anyone with metabolic syndrome has prediabetes)
Pre-diabetes
How often to test microalbumin for nephropthy/ diabetes?
test microalbumin annually→ > 30mg /24hr; need to positive collections in a 3-6 month period → once confirmed tx with ACE-I or ARB
What to do if diabetic pt reports New onset report of “floaters” or “cobwebs”
urgent referral to ophthalmologist
Diabetes type 1.5. Often misdiagnosed, especially in the younger population. No response to traditional treatment. Subgroup of type 1. May present with both types. Lower BMI, older (young adults). C-peptide (undetectable in type 1, normal to high in T2DM; LADA low-normal) refer for antibody testing.
Tx with insulin!
Latent Immune Diabetes (LADA)
first line. Start with 500 ER to minimize GI upset, increase as tolerated up to 2000mg. Add other agents if needed.
Metformin
When is it ok to start using insulin early in a new diabetic?
if A1C>10 or BG >300
A1C>9 start with dual therapy
What meds to use for diabetic if they have CVD or CKD to reduce risk of complications
SGLT2 or GLP1
A1c for +65 years?
7.5% to 8%
What diabetic pts to refer?
Refer all T1DM, refer LADA
