Diabetes Flashcards
Normal blood sugar
80-100 fasting
Fasting blood sugar
After eating 170-200
HbA1c criteria for diagnosis
> or equal to 6.5
Random blood sugar
> 200
75 g 2 hours glucose tolerance test > or =
200
Patient had a fasting sugar of 127, what to do next?
Check hgba1c
Patient had a fasting blood sugar 118 and hgba1c of 6.5%, what to do next?
Recheck hgba1c
A 35 year old patient with bp 135/80 or X year old patient with bmi of 26 and sedentary or a 40 year old patient; what will you check next?
Screen for diabetes, fasting blood sugar
Patient had FBS of 129, repeat 127, this patient has…
DM and at risk for retinopathy and nephropathy now
40 year old patient with vitiligo diagnosed a year ago, FBS of 140, relatives have type II DM, BMI 23; what will you do next?
Check islet cell antibodies and anti glutamic acid decarboxylase antibodies
Sulfonylureas
Glimepiride (amaryl) Glipizide (glucotrol) glyburide (diabeta, micronase); avoid in obese
Meglitinides
Repaglinide; excreted through bile; hence drug of choice in CKD; rapid acting
Biguanides
Metformin (glucophage); decrease hepatic gluconeogenesis, decrease insulin resistance, decrease weight, decrease cholesterol/TG’s; Tx of choice in obese patients and increased TG’s; 5% with lactic acidosis; b12 deficiency
Alpha glucocidase inhibitors
Acarbose (precose); inhibits breakdown of carbohydrates and decreases absorption of glucose; mainly for post prandial hyperglycemia; avoid in low GFR
Thiazolidinediones ‘glitazones’
Pioglitazone (actos); avoid in patients with CHF NYHA II; thigh high edema, associated with bladder cancer
Incretin mimetics(glp-1 agonists)
Exenatide (bydureon), liraglutide (victoza-approved for weight loss bmi>30 and no DM), Dulaglutide (Trulicity), Semaglutide (ozempic): glp1 agonist, decreases hepatic gluconeogenesis, decreases gastric emptying, weight loss, increased cell growth
Liraglutide (victoza), Semaglutide (ozempic) and dulaglutide (trulicity)
Have shown to decrease CV risk; good agents for obese patients failing meds
DPP4 inhibitors
Sitagliptin (januvia), saxagliptin (onglyza)-potential CH risk, linagliptin (tradjenta) andd alogliptin (nesina)
Side effects of GLP 1 agonists
Nausea and pancreatitis; contraindications: pancreatitis, family hx of MEN IIA/IIB (medullary thyroid carcinoma)
Amylin analogue
Pramlinitide (symlin); slows gastric emptying, decreases glucagon secreation, weight loss and early satiety; complementary to insulin; no hypoglycemia; good for obese patients failing insulin therapy with high post prandial BS and gaining weight on short acting insulin agents
SGL2 Inhibitors
Canagliflozin (invokana), Dapagliflozin (farxiga), empaglifozin (jardiance); block reabsorption of glucose by kidney thereby increasing excretion of glucose in the urine
Dapagliflozin (farxiga)
Shown to reduce heart failure hospitalizations in diabetic patients
Empagliflozin (Jardiance) and Canagliflozin (invokana)
Reduced the incidence of end stage renal disease and hospitalizations for heart failure; there was also a trend toward decreased cardiovscular death and all cause mortality
Side effects of SGL2 inhibitors
Reduced blood pressure, genital mycotic infections, euglycemic ketoacidosis especially at times of extreme stress; necrotizing fascitis of perineum aka Fournier’s gangrene; for example; in a patient with pneumonia taking SGL2 inhibitors, stop it
ADA blood sugar goals in DM
hgba1c low risk of hypoglycemia <7%
hgba1c high risk of hypoglycemia 7-8%
hgba1c with terminal or comorbid conditions >8%
Preprandial glucose between 80-130
Peak 2 hours post prandial glucose <180
Patient with a bmi of 32, FBS is 115; family hx is significant for DM; best way to prevent onset of DM?
Diet and exercise; aerobics and resistance training
Drugs that cause hyperglycemia
Statins, beta blockers except coreg, hydrochlorothiazide, niacin, olanzapine, protease inhibitors, steroids
Patient with type II diabetes mellitus responded well to metformin and sulfonylura previously, for several years hgba1c 7% but now has increasing blood sugars for the past year; no infections; hgba1c 8.8%, what to do next?
Add 24 hour glargine insulin; progressive insulin deficiency not insulin resistance
In above patient, what drug do you intend to keep with insulin?
Biguanide aka metformin
The above patient does well on glargine insulin at bedtime and metformin for a year; hgba1c 8.5%, but FBS 115 to 130 range, what to do next?
Start lispro insulin
When is metformin contraindicated?
GFR <30 ml and acute or unstable CHF
Patient started on metformin 2 days ago and complains of diarrhea after taking metformin, what to do next?
Continue for a week
Patient with DM on metformin 500mg once daily and hba1c is 7.8%, what to do?
Increase metformin dose to twice daily (max dose is 2.4 g)
Patient with DM on multiple medications; Cr is >1.5 and CHF with EF <35%, what to do?
Discontinue metformin and glitazone, start glargine or detemir and lispro or aspart
Patient is going for cardiac catheterization or any radiocontrast study; which drug will you stop on the day of the procedure?
Metformin
A 60 year old patient diagnosed with type II diabetes and bun/cr is 40/3.7; what is the best medication to start?
Repaglinide (linagliptin good choice too)
A 40 year old patient with type II diabetes mellitus was treated with metformin; a year later, he starts gaining weight, as he had stopped exercising; his blood sugars go up as well; what to do?
Start liraglutide (victoza)
Dawn phenomenon
Increased 3-7 am glucose secondary insulin resistance/ hormonal factors; treatment: increase PM NPH
Nocturnal Hypoglycemia
Patient with fatigue, increased sweating and waking up with headaches +/= vivid dreams (nightmares); FBS ranges between 120-145; takes NPH at supper, what to do next? Check nocturnal BS, if low, reduce NPH or move NPH to bedtime or change to long acting (glargine or detemir)
Palpitations, excessive sweating, nocturnal awakening, AM headaches, what to do next?
3 am blood sugar
Blood sugar at 3 am is 40, what to do next?
Change NPH to hs or switch to long acting insulin analogue has (glargine)
Persistently elevated FBS; 3am blood sugar 200, what to do?
Increase supper NPH or glargine dose
Blood sugar 30 and patient passes out at 12 noon on 20 unit NPH and 4 units ‘R’ in AM, what to do?
Discontinue ‘R’ in AM
Blood sugar at 4pm is 25 mg and at 10pm it is 210; patient is on 36 unit NPH in AM, what to do?
Change to 24 unit NPH in AM and 12 unit NPH in PM
Patient with fbs of 115, hgba1c is 8.5; he takes NPH or glargine at night and metformin, what to do next?
Check post prandial blood sugar
How would you start an insulin regimen of glargine and lispro in a patient who weighs 60 kg?
60 kg x .5 units = 30 units daily; give 1/2 or 15 units glargine with supper; give other 1/2 15 units lispro divided as tid aka 5 units b-l-s
You want to test the above regimen in 2-3 weeks time, what to do?
Fructosamine test (also in pregnant patients, hemolytic anemia and hemoglobinopathies)
An african american male diabetic patient returs for follow up; he shows his glucometer readings which show serial FBS in 115-130; hgba1c is 11% most likely etiology of the discrepancy is
Hemoglobinopathy
Falsely elevated Hgba1c (decreased RBC turnover, decreased reticulocyte count)
Iron def anemia, folate and b12 def, ESKD, asplenia, hemoglobinopathies, sickle cell trait, thalassemia trait
Falsely lower Hgba1c (Increased RBC turnover, increased reticulocyte count)
Hemolytic anemias, HIV, treating iron deficiency anemmia, folate and b12 deficiency or blood transfusions, ESKD on HD and erythropoietin
Patient with hgba1c of 6.6%; pre prandial and post prandial blood sugars range between 90-150 except at 5pm blood sugar is 280; she has a fresh fruit snack at 4pm; what is the etiology?
She is most likely not washing hands after eating fruit and checking blood glucose; educate patient to wash hands before checking blood glucose
Patient with diabetes with BS 540, TG’s 2400; is hospitalized with pancreatitis; the fastest way to control the triglycerides would be to
Give insulin
If hyperglycemia and worrisome features: hypocalcemia and lactic acidosis
Plasma exchange
Anion gap
NA- (bicar + Cl)
DKA treatment
Give subq insulin 60-120 min before stopping iv insulin drip
Patient withDKA BS 725, ketones +++, patient started on iv insulin drip and iv fluids at 10 am; at 7pm BS 200, what to do next?
Start IV infusions D51/2 NS and continue insulin drip
Best way to follow dka management is
Anion gap
Patient with diabetes mellitus admitted for surgery in AM; he is on glargine and lispro; what to do on morning of surgery? patient recieves glargine in am
Give 1/2 glargine and d/c lispro
If patient received glargine in pm, what to do?
Dc lispro
A 24 year old pregnant female in 24th week; FBS 115; repeat FBS 114; refuses insulin; what to do?
Give metformin
A 26 year old diabetic pregnant woman 24th week with FBS 120 and post prandial 180 on glyburide and metformin, what to do?
Give insulin
Pregnancy blood sugar
FBS <95
1 hr PP 140
2 hr PP 120
Elderly patient with type II diabetes mellitus brought with an episode of seizure; BS 1050, BUN 50 Cr 1.8 , ketones +
Hyperosmolar nonketotic coma –>IV flids –> insulin
Patient with type I DM presents with DKA; blood sugar 725 and ketones +++; patient started on insulin drip at 10 am; by 10pm the same day, the BS is 200 and ketones negative; bicarb has gone up from 4 to 18, K dropped from 5.7 to 4.5; patient complains of difficulty breathing and muscle weakness +; CPK MM increased, JVD 3 cm; most likely cause is
Hypophosphatemia
Complications of Diabetes Mellitus
Macrovascular: CAD, PAD: aggressive LDL control
Microvascular: Nephropathy: microalbuminuria: ACE I or ARB
Retinopathy: non proliferative –>tight glucose control
proliferative–> tight glucose control + laser therapy
Autonomic neuropathy
Impotence: phosphodiesterase inhibitors
Neurogenic bladder: urinary hesitency, dribbling,incomplete evacuation; urodynamic studies with retained urine: timed bathroom visits–>bethanechol
Orthostatic hyptension–>stockings–>high salt diet–>fludrocortisone
Gastroparesis: wide fluctuations in BS 50-400 in day
Foot drop, wrist drop; 3rd nerve palsy can resolve spontaneoously
Diabetic foot ulcers
Most common is staph; beta hemolytic strep; cause of ulcer is peripheral neuropathy; best way to prevent is monofilament testing
Patient with diabetes mellitus for 15 years on metformin +sulfonylurea/insulin with hypoglycemic attacks; post prandial early satiety with vomiting; BS varies from 50-400 daily
Diagnosis: gastroparesis –>delayed absorption secondary to autonomic neuropathy; Best test: scintiscan of residual gastric contents; ingest isotope and scan immediately; then 2-4 hours later
Treatment: small frequent meals of liquid or pureed diet with high protein, low fat and low in non digestible fiber –>metoclopramide/Domperidone
A nurse calls you to let you know a patients fasting blood sugar is 62; asymptomatic, what to do?
Adjust treatment regimen
Symptomatic with tachycardia; what to do?
15 g of carbohydrate (glucose tablets, candy or sweetened fruit juice)
Patient on insulin with loss of consciousness, BG 30; there were no premonitory symptoms
Hypoglycemic unawareness; Treatment: lower insulin dose to allow BG levels to increase for several weeks to restore sensitivity to hypoglycemia
Newly diagnosed patient with BG of 350; on insulin when BG drops to 130; patient becomes tachycardic and diaphoretic; what to do
Keep blood glucose below 200 first
Patient with BS of 35 and taking glipizide, metformin and acarbose; how to manage?
Discontinue glipizide; admit and iv dextrose; no iv line then glucagon
A 22 year old woman with recurrent dizzy attacks in ER; mother is diabetic; blood glucose –>35; insulin 25 (5-20) c peptide .7 (<.6); patient given dextrose and symptoms resolve; patient again has similar symptoms the next day; the next diagnostic test to find the cause of hypoglycemia is
Urine +/- sulfonurea screen
Best test for thyroid disease
TSH
Best test to follow for hypothyroidism treatment
TSH
Best test to follow for hyperthyroidism treatment
Free T4 and total T3; ultrasound: differentiate high risk vs low risk in cold nodules
