Diabetes Flashcards
Insulin is a hormone produced by ___ in the ___. It is responsible for moving glucose out from the blood and into body ___ to be used as ___.
Fill in the blanks
- Beta-cells
- Pancreas
- Cells
- Energy
The glucose is either moved to muscle cells for immediate use, or stored for later use by ___ cells as ___ or adipose (fat) cells.
Fill in the blanks
- Liver
- Glycogen
Glucagon is produced by ___ in the pancreas and works when ___ is ___. Glucagon pulls glucose back into the circulation by releasing ___ from ___. If ___ is depleted, glucagon will signal fat cells to make ___ as an alternative energy source.
Fill in the blanks
- Alpha-cells
- BG
- Low
- Glucose
- Glycogen
- Glycogen
- Ketones
What are the characteristics of T1D? How is it diagnosed and treated?
- T1D caused by an autoimmune destruction of beta-cells in the pancreas.
- Once beta-cells are destroyed, insulin cannot be produced
- The body starts to metabolize fat into ketones to use it as an alternative energy source
- Ketones are acidic and very high ketone levels can cause diabetic ketoacidosis (DKA)
- T1D usually diagnosed in children, but it can develop at any age
- The C-peptide test is used to determine if the patient is still producing insulin. If c-peptide level is very low or absent, the T1D is diagnosed
- Patients with T1D must be treated with insulin and should be screened for other autoimmune disorders (e.g., thyroid disorders, celiac disease)
What are the characteristics of T2D?
- T2D is due to both insulin resistance (decreased insulin sensitivity) and insulin deficiency
- T2D is strongly associated with obesity, physical inactivity, family hx and other comorbid conditions
- T2D can be managed with lifestyle modifications alone or in combination with oral and/or injectable medications
T2D (%95 of all cases) is more common than T1D (%5 of all cases)
What are the characteristics of prediabetes?
- Prediabetes means there is an increased risk of developing diabetes
- In prediabetes, BG is higher than normal, but not high enougy for a diabetes diagnosis
- Following exercise and dietary recommendations reduces the risk of progression from prediabetes to diabetes
- Annual monitoring for development of diabetes and tx of modifiable CVD risk factors are recommended
When can you initiate metformin in prediabates?
- Patients with a BMI >= 35 kg/m2
- Patients <60 years of age
- Women with a hx of gestational diabetes mellitus (GDM)
What are two types of diabetes in pregnancy?
- Diabetes that was present prior to becoming pregnant
- Diabetes that developed during pregnancy (GDM)
Note: In both types the BG goals during pregnancy are more stringent than the non-pregnant population with diabetes
What are the characteristics of babies born to mothers with hyperglycemia during pregnancy?
- Babies are larger than normal (macrosomia)
- Babies are at high risk of developing obesity and diabetes later in life
How do you test pregnant women for diabetes during pregnancy?
- Pregnant women are tested for GDM at 24-28 weeks gestation using the oral glucose tolerance test (OGTT)
- If hyperglycemia present, patients should be treated first with lifestyle modifications (diet and exercise)
- If medication is needed, insulin is preferred
What are the risk factors of developing prediabetes an T2D?
- Physical inactivity
- Overweight (BMI >=25 kg/m2 or >=23 in Asian-Americans)
- High-risk race or ethnicity: African-American, Asian-American, Latino/Hispanic-American, Native Americans or Pacific Islander)
- Hx of GDM
- A1C >= 5.7%
- First-degree relative with diabetes
- CVD hx or smoking hx
- HTN (>=140/90 mmHg or taking BP medication)
- HDL <35 mg/dL or TG >250 mg/dL
- Conditions that cause insulin resistance (e.g., acanthosis nigricans, POS)
What are the classic symptoms of diabetes?
- Polyuria
- Polyphagia
- Polydipsia
- Other: fatigue
Note: In T1D, DKA ia commonly the initial presentation due to total deficiency in insulin
Risk for diabetes increases with age. Everyone, even those with no other risk factors, should be tested beginning at ___ years old.
Fill in the blank
- 45
All asymptomatic children, adolescents and adults who are ___ with at least ___ other risk factor should be tested. If the results are normal, repeat testing every ___ years.
Fill in the blanks
- Overweight
- One
- 3
What tests are used to diagnose prediabetes or diabetes?Give details about the tests
- Hemoglobin A1C - indicates the average BG over approximately the past 3 months
- Fasting plasma glucose (FPG) - gives the BG at that moment, and is taken after fasting for >=8 hours
- The OGTT - determines how well glucose is tolerated by measuring the BG level 2 hours after drinking a liquid that in high in sugar (glucose)
Note: No single test is preferred. A positive test should be confirmed with a second abnormal test result from either the same sample or a new sample, unless there is clear clinical diagnosis (e.g., classic sxs of hyperglycemia + a random BG >=200 mg/dL)
What is the diagnostic criteria for prediabetes and diabetes?
Prediabetes
* A1C (%) = 5.7 - 6.4
- FPG (mg/dL) = 100 - 125
- OGTT (mg/dL) = 140 - 199
Diabetes
* A1C (%): >=6.5
- FPG (mg/dL): >=126
- OGTT (mg/dL): >=200
What are glycemic targets in diabetes for pregnant and non-pregnant patients?
Non-pregnant
* A1C (%) = <7*
- Preprandial (mg/dL) = 80 -130
- 1-hr PPG (mg/dL) = N/A
- 2-hr PPH (mg/dL) = <180
Pregnant
* A1C (%): N/A
- Preprandial (mg/dL): <=95
- 1-hr PPG (mg/dL): <=140
- 2-hr PPH (mg/dL): <=120
*An A1C goal of <6.5% may be acceptable, if it can be reached without significant hypoglycemia. A less-stringent goal of <8% may be appropriate (e.g., if severe hypoglycemia, or with a limited life-expectancy)
___ A1C test kits provide immediate results and can be used by prescribers or patients. Patients can measure their own BG using a ___ or with a ___ ( ___ ) device
Fill in the blanks
- Point-of-care
- Glucose meter
- Continuous glucose monitoring (CGM)
How often should glycemic control (A1C or another test) should be measured?
- Quarterly (every 3 months) if not yet at goal
- Biannually (every 6 months, or twice per year) if at goal
How do you interpret the A1C with the eAG?
- The estimated average glucose (eAG) is an interpretation of the A1C value that makes it appear similar to a glucose meter value
- An A1C of 6% is equivalent to an eAG of 126 mg/dL. Each additional 1% increases the eAG by 28 mg/dL
- Example: An A1C of 7% is 126 + 28 = 154 eAG
List lifestyle modifications in diabetes
- Weight loss
- Goal waist circumference (women): < 35 inches
- Goal waist circumference (males): < 40 inches
- Consume natural forms of carbonhydrates and sugars
- Patients with T1D: use carbonhydrate-counting where the prandial (mealtime) insulin dose is adjusted to the carbonhydrate intake
- A carbonhydrate serving is measured as 15 grams, which is approximately one small piece of fruit, 1 slice of bread or 1/3 cup of cooked rice/pasta
- Perform at least 150 minutes of moderate-intensity aerobic activity per week, spread over at least 3 days
- Reduce sedentary habits by standing every 30 minutes, at minimum
- Smoking cessation
What are the microvascular diseases of diabetes?
- Retinopathy
- Diabetic kidney disease (i.e., nephropathy)
- Peripheral neuropathy (i.e., loss of sensation, often in the feet), increased risk of foot infections and amputations
- Autonomic neuropathy (gastroparesis, loss of bladder control, erectile dysfunction)
What are the macrovascular diseases of diabetes?
- CAD, including MI
- Cerebrovascular disease, including stroke (CVA)
- Peripheral artery disease (PAD)
Macrovascular disease is the same as atherosclerotic cardiovascular disease (ASCVD)
What is antiplatelet therapy in diabetes?
- Aspirin 75-162 mg/day (usually given as 81 mg/day) is recommended for ASCVD secondary prevention (e.g., post-MI)
- If allergy: use clopidogrel 75 mg/day
- Not recommended for primary prevention (in most); the risk of bleeding is about equal to the benefit. Can consider if high risk
- CAD/PAD: aspirin + low-dose rivaroxaban can be added
- Used in pregnancy to decrease risk of preeclampsia
What exam should be done for diabetic retinopathy in diabetes?
- T2D: eye exam with dilation at diagnosis
- If retinopathy, repeat annually. If not, repeat every 1-2 years
What vaccines are given in diabetes?
Required, in addition to all childhood vaccines:
* Hepatitis B virus (HBV) series
- Influenza, annually
- Pneumovax 23: 1 dose between agaes 2 - 64, and another dose at age >= 65
How do you take care of neuropathy in diabetes?
- Annually: a 10-g monofilament test and 1 other test (e.g., pinprick, temperature, vibration) to assess sensation (feeling)
- Comprehensive foot exam at least annually. If high-risk, refer to podiatrist
- Treatment options: pregabalin, duloxetine or gabapentin
What are the counseling points for foot care in diabetes?
- Everyday: wash, dry and examine feet. Moisturize the top and bottom of feet, but not between the toes
- Each office visit: take off shoes to have feet checked
- Annual foot exam by a podiatrist (for most)
- Trim toenails with nail file; do not leave sharp edges from the clipper
- Wear socks and shoes. Elevate feet when sitting
What are the cholesterol control measures in diabetes?
High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) for:
* Diabetes + ASCVD
- Age 50 - 75 years with multiple ASCVD risk factors
Moderate-intensity statin for:
* Diabetes + age 40 - 75 years (no ASCVD)
- Diabetes + age < 40 years + ASCVD risk factors
Add-On Treatmet (to Maximally Tolerated Statin)
- Ezetimibe if ASCVD 10-yr risk >20%
- Icosapent ethyl (Vascepa) if LDL is controlled but TGs are 135-499 mg/dL
Monitoring: lipid panel annually and 4-12 weeks after starting a statin or increasing the dose
What are the BP control measures in diabetes?
BP Goal
* <130/80 mmHg (esp. if ASCVD or 10-year risk more than or equal to 15%)
- <140/90 mmHg acceptable if ASCVD risk < 15%
Treatment
* No albuminuria: thiazide, CCB, ACE inhibitor or ARB
- Albuminuria: ACE inhibitor or ARB
- CAD: ACE inhibitor or ARB
- Albuminuria is either a urine albumin >=30 mg/24 hours or a urine albumin-to-creatinine ratio (UACR) >=30 mg/g
- If pregnant – no ACE inhibitor, ARB or any other RAAS drug
How often do you check for diabetic kidney disease?
Check urine albumin and eGFR
- Annually if normal kidney function
- Twice yearly if reduced kidney function (eGFR 30-60 mL/min/1.73 m2 or urine albumin >=300)
