Diabetes Flashcards
DM Screening
Adults (any age) who are overweight and have one risk factor (familail, comorbids, inactivity, non-white)
Patients with pre-diabetes
Women diagnosed with gestational diabetes (test every 3 years)
Age 45+ (even if no risk factors)
Normal = re-test every 3 years or earlier if change in risk
Hallmarks of Type 2 DM disease
Decreased glucose uptake (insulin resistance)
Increased hepatic glucose production
Impaired insulin resistance
Type 2 Progression
As insulin resistance increases, postprandial glucose increases, insulin production wanes and fasting glucose increases.
Metabolic Syndrome
Group of metabolic issues
Abdominal obesity, insulin resistance, elevated triglyceride, decreased HDL, hypertension, pro-inflammatory state
Precursor to DM often
DM Presentation
polyuria, polydipsia, polyphagia, weight loss, blurred vision, and fatigue
Type 2 may be asymptomatic for years until above signs or signs of neuro-vascular issues
Diabetes Periodic Exams
1 - evaluate glucose control
2 - assess for presence of end-organ damage
3 - assess for associated diseases such as other auto-immune or CV
Diagnostic Criteria for T2DM
HbA1c of 6.5% or more
Fasting Glucose 126 or more
Random Glucose of 200 or more with symptoms
Glucose Tolerance Test of 200 or more
Pre-diabetes Criteria
HbA1c 5.7 - 6.4 %
Fasting Glucose 100-125
Glucose Tolerance 140-199
Random glucose for pre-diabetes not recommended
HbA1c Limits
May be inaccurate in anemia/blood disorders or transfusion
May be inaccurate in pregnancy and post-partum
Verify point of care tests with verified lab
Secondary causes of DM
Cushing Pheochromocytoma Acromegaly Hypokalemia Hyperaldosteronism Excess diuretic use Pancreatitis Infection
Gestational Diabetes
Glucose intolerance onset during pregnancy, though an elevated A1c may indicate pre-existing diabetes
HbA1c Goals
Less than 7% for most patients, less than 8% for some
Elderly - goal is to minimize hyperglycemia and hypoglycemia episodes
DM and Exercise
Well controlled Type 1 can participate in exercise
Avoid exercise when glucose is 250+ with ketones or 300+ without ketones
Avoid exercise if less than 100
Exercise lag = glucose can drop after exercise, even many hours later (overnight)
Exercise is critical for T2DM management (150min per week, 2 session of strength training)
DM Follow-ups
Every 3 months is ideal
HbA1c, BP, weight, eye exam, foot exam, lipids, renal
Liver at least yearly
EKG yearly after age 40
Type 1 DM Insulin Requirements
Typically 20-40 units per 24 hours (may vary by patient response)
Half basal insulin, half bolus insulin
Consider starting 0.5 units per KG (half is basal)
Postprandial Insulin Needs
Typically 1 unit per 2g of carbs
Can be as high as 1 unit per 30g of carbs in insulin sensitive patients
Reducing/Increasing basal Insulin
If fasting glucose is less than 80, step down basal insulin
If fasting glucose is greater than 100, step up basal insulin
Honeymoon Phase in Type 1 DM
Short term phase of recovered B-cell function that results in decreased injected insulin needs
Temporarily lower insulin dose
Mainstay of T2DM Treatment
Education
Diet
Exercise
Maintain healthy weight
Metformin
Initial med for T2DM and consider for pe-diabetes
Typically start at 500mg twice per day
Max dose 2,000mg per day
Metformin side effects
N/D - take with meal
Stop metformin before contrast and hold for 2 days after contrast
Contraindicated if GFR is less than 30
B12 deficiency can occur, consider supplementing
T2DM and Heart Patients
SGLT2 inhibitors recommended
(-flozin drugs)
Small A1c reduction but risk of UTIs
Hinder heart disease progression and renal benefit
GLP-1 agonists may also be used in CV patients
Injectables (expensive and inconvienient)
(-tide drugs)
DPP-4 Inhibitors
Decrease glucagon levels
Risk of pancreatitis
Small A1c reduction
(-liptin drugs)
Sulfonylureas
Moderate A1c lowering (1.5%)
Not as common now due to hypoglycemia and weight gain risks
Cheaper than other meds
Glyburide, Glipizide, Glimepiride
Stimulate insulin release
Meglitinides
(-linide drugs)
Must take before meal and hold if skipping meal
Less hypoglycemia risk and short duration of action
Stimulates insulin release
Thiazolidinediones (TZDs)
(-litazone drugs) Improve cel sensitivity to insulin Reduce glucose output from liver Weight gain, higher lipids, and edema is common Takes weeks for effect
Never use on heart patients!
T2DM when to start insulin
Consider first line if HbA1c is 10% or more, fasting glucose more than 250, fragile older adult, gestational
Most common reason is failure of oral meds
DM Referral
New onset of Type 1 Poor control of Type 2 Complication of DM After hospitalization Insulin pump initiation Planned or confirmed pregnancy Patient request endocrine management
Refer to ED
DKA (BGL >250, ketones, acidic)
HHS (BGL > 600 or serum osmolarity >320)
Hyperglycemia and volume depletion
Fasting glucose >300 or HbA1c >15
DM and Feet
Always refer DM patients to podiatry for treatment of foot ulcers, nail care
Gestational DM screening
At first visit, screen - elevated HbA1c means overt cause
Fasting Glucose 92-125 = Gestational Diabetes
1 hour glucose tolerance 180+ = Gestational
2 hour tolerance 153+ = Gestational
If normal, re-screen as 24-28 weeks
DM patients who become pregnant or plan to
Stop metformin
Stop sulfonyureas before labor
Consider switch to insulin
DM patients and illness
Monitor glucose every 4 hours
If >250, test for ketones
Stay hydrated
Continue to take meds, glucose levels rise in illness even if not eating
Diabetic Retinopathy
High risk among T2DM (80% develop it)
High risk of vision loss
Refer all DM for vision exams
Fundoscopic exam at every visit to primary care
T2DM and Statins
All T2DM should be on statins!
High dose if history of CVD or high ACSVD score (>7.5%)
T2DM and Blood Pressure
Recommended goal is 130/80 of less with CVD
140/90 or less for most others
A patient with type 2 diabetes mellitus (DM) becomes insulin dependent after a year of therapy with oral diabetes medications. What will the primary care provider tell the patient when explaining this change in therapy?
Strict diet and exercise measures may be relaxed with insulin therapy.
This is because of the natural progression of the disease.
It is necessary because the patient cannot comply with the previous regimen.
The use of insulin therapy may be temporary.
Even after several years of therapy for type 2 DM well controlled with oral diabetic medications, diet, and exercise, the natural progression of the disease may require patients to become insulin dependent.
