Diabetes *** Flashcards
Med for wt loss
Semaglutide 2.4mg SC q1weekly,
RF for T1
fam hx
Sx
Polyuria, polydipsia, wt loss
Complications
Macrovascular (CVD, CVA, PAD), microvascular (retinopathy, nephropathy, neuropathy), infection, ED
Hypoglycemia Sx
palpitations, sweating, trembling, anxiety, hunger, N/V, drowsiness, vision change, HA
Hypoglycemia RF
prior episode, low a1c, hypoglycemia unawareness, CKD, preschool/ adolescent/ pregnancy/ elderly
Hypoglycemia Rx
15g carbs (¾ cup juice, 1 tbsp honey) - restest in 15 mins and repeat if BG <4
Severe: 1mg glucagon SC/ IM
Hyperglycemia Sx
Polyphagia, polydipsia, polyuria, blurred vision, fatigue, paresthesia, arrhythmia
DKA sx
Kussmaul’s breathing, confusion, dehydration, impaired cognition, abdo pain, N/V
DKA precipitating factors
Infection, illness, missed insulin, infarction, intoxication
Dx of T1
If asymptomatic, repeat test on another day
8hr FPG >7
Random BG >11.1
Hba1c >6.5
Factors that increase a1c
iron deficiency, low B12, alcoholism, chronic opioid use
Factors that decrease a1c
use of iron/ B12/ ASA/ vit C, hemaglobinopathy, chronic liver disease, RA
Targets for pre + postprandial glucose (+ if frail)
Preprandial 4-7
Postprandial 5-10
If frail/ dementia = preprandial 6-9 and postprandial <14
Ix for new dx DM
ECG if >40 y/o, DM >15 yrs, end ogan damage, CVD RF (HTN, smoking, CKD, obesity, ED)
Stress test if cardiac sx
Monitoring (q6mo + annual)
q6mo
BP <130/80
A1C <7% adults, <7.5% children
Annual
Fasting lipids
Optometry (5 yrs after dx)
Albumin/Cr ratio + Cr (5 yrs after dx)
Monofilament + foot exam (5 yrs after dx)
Screen for ED, depression, eating disorder, NAFLD
Driving safety
Measure BG before driving
Keep supply of carbs in car
Do not drive if BG <4
Report to licensing if on insulin and 1) any severe hypo while driving in past 12 months or 2) >1 severe hypo while awake but not driving in past 6 months
Nutrition advice
Low glycemic index carbs
Fibre 30g day
Maintain consistent carb intake
Alcohol 2hrs after dinner can cause low glucose next AM
Exercise advice
Aerobic exercise 150 mins over >3d/week
Resistance training >2x/w
Consider extra carbs for exercise
Basal bolus regime
Basal
Long acting insulin e.g. glargine
Long acting degludec (reduced nocturnal hypoglycemia)
Bolus
Dose based on carb content, exercise, time since last dose and BG
Rapid acting (aspart) 0-15 mins before meal
Management of complications:
HTN, nephropathy, neuropathy, retinopathy, ED, macrovascular
HTN: target 130/80, use ACEi/ ARBs, CCB, thiazide
Nephropathy: CKD + HTN: ACEi/ ARB. Consider kidney + pancreas transplant in ESRD
Neuropathy: pregabalin 1st, 2nd line: gabapentin, valproate, amitriptyline, duloxetine
Retinopathy: laser therapy + vitrectomy
ED: PDE5 inhibitor, consider hypogonadism if ineffective
Statin +/- ezetimibe: if macrovascular disease, age >40, DM >15 yrs + microvascular disease
ACEi/ARB: if CVD, age >55 w/ CV RF, microvascular disease
ASA: if CVD
Metabolic syndrome measurements
Sex, Waist Circumference, Triglycerides, HDL, Blood Pressure, Fasting Glucose
Screening for T2
Adolescents: screen q2yr if 2-3 of following: obesity, high risk ethnic group, FDR, S+S insulin resistance, PCOS, AP use
Adults:
>40 y/o q3yr
<40 y/o + CANRISK score ‘high risk’ q3yr
Screen earlier if additional RF (e.g. prediabetes)
Prediabetes FPG + A1C
FPG 6.1-6.9
A1C 6-6.4
Prevention in prediabetes
Wt loss > 5%
Mediterranean or DASH diet
Exercise >150 mins week over 5d
Consider metformin, especially in pts <60 y/o, BMI >35, hx of GDM
Self monitoring when on insulin >1/d, 1/d or no insulin
On insulin >1/d = monitor >3x day w/ pre + postprandial
On insulin 1/d = FPG 1/d at varied times
no insulin = no CBG daily except if not on target or at risk of hypos
Management T2
Lifestyle measures - if not in target in 3mo, start metformin
Metformin
Add insulin if metabolic decompensation + symptomatic hyperglycemia
Start basal insulin + titrate to achieve target
If >1.5% above target, metformin plus another agent
Management of T2 + ASCVD, CKD, HF + CV RF
ASCVD: add dulaglutide (GLP1-RA) or empagliflozin (SGLT2i)
CKD: add empagliflozin (SGLT2i)
HF: add empagliflozin (SGLT2i)
CV RF: add dulaglutide (GLP1-RA)
Management on sick days
Vomiting or diarrhea >6 hrs, feeling sick or fevers x few days
Check sugars Q4H
Check urine for ketones
Maintain adequate food and fluids, if not able to then eat concentrated carbs
Hold metformin, sulfonylureas and SGLT2 inhibitors
Hold ACEi, ARBs, diuretics, NSAIDs
Call doc if glucose >13.3 or >11 if pregnant
call doc w/ signs of DKA or dehydration
Avoid exercise
HHS vs DKA pathology
HHS = Hyperglycemia -> intracellular water depletion -> osmotic diuresis
DKA = Absence of insulin -> reduced glucose utilisation -> increased TG breakdown -> ketone production
What do you need to watch out for with SGLT2i in DKA?
SGTL2i can cause euglycemic DKA
RF for DKA
Poor adherence ($, wt control, depression, understanding)
Not monitoring glucose
Precipitating factors for DKA
Infection
Alcohol
Stress
Pregnancy
CV events (stroke, MI)
Trauma
Meds (steroids, cocaine, APs, thiazide)
Cushings, thyrotoxicosis
GI disease (pancreatitis, obstruction)
No cause
Sx DKA
Polyuria, polydipsia, fatigue, weakness, AMS, HA
N/V, abdo pain
Tachycardia
Kussmaul breathing
Dehydration
Ix for DKA + Ix for secondary causes of DKA
Glucose
Cr, urea, lytes, bicarb
Blood gas
Serum + urine ketones
Secondary causes:
Amylase/ lipase (?pancreatitis)
CBC
Urine + BC
CXR
ECG
Rx for DKA in peds
Q1H glucose, lytes, ex lytes, urea, CBC, VBG, ECG
NS 10ml/kg over 1 hr then replace fluid deficit with 5ml/kg/hr NS + 40mmol KCl over next 24-48 hrs
When glucose <17 or dropping >5 mmol/hr, change to 0.45% NS and add dextrose (D51/2NS) and transition to SC insulin, then stop IV insulin
Start insulin 1-2 hrs after fluids at rate of 0.1 units/kg/hr
Rx for adult DKA
Q2H glucose, lytes, urea, bicarb, AG, osmolality, fluid status, mental status
NS 1-2L/hr
Once euvolemic, check corrected sodium
If corrected sodium low = continue NS
If normal or high = switch to ½ NS
When glucose <14, D5W or D10W to maintain glucose 12-14
When K+ <5.5 AND pt urinating = add KCl
Insulin infusion for DKA - when to start, when to reduce, dose
Start when K >3.3
0.1 units/kg/hr
When glucose <11.1, reduce to 0.02-0.05 units/kg/hr
Potassium in DKA - when to start, when to reduce, dose
<3.3 = no insulin, give 40mmol/ hr
3.3-5.5 = give 10-40 mmol/ hr
>5.5 = check K Q2H, don’t give more
Resolution of DKA criteria
Glucose <11.1
Bicarb >15
pH >7.3
AG <12
Complications of DKA/ HHS
Mortality
Cerebral edema
Hypogylcemia
AKI
PE, stroke, DVT
ARDS, shock
Meds that cause DM
glucocorticoids, atypical APs, statins, anti-rejection drugs
RF for hypoglycemia
increasing age, long duration of dz, prev episodes of hypoglycemia
