DIABETES

Question 1

What is a good resource to turn to for DM management guidelines?

Answer 1

American Diabetes Association

Question 2

Which DM: The pancreas is damaged through autoimmune inflammation leading to the destruction of the beta cells. The loss of beta cells leads to the complete inability to produce insulin, (immunologic etiology).

Answer 2

Type 1

Question 3

Which DM: The body is unable to recognize the insulin produced by the pancreas and use it properly (insulin resistance). Increased beta cell insulin secretion may initially compensate, but over time beta cells fail.

Answer 3

Type 2

Question 4

Common manifestations of end-organ damage caused by type 2 diabetes

Answer 4

Cerebrovascular Disease
CAD/Peripheral Artery Disease
Nephropathy
Neuropathy
Retinopathy

Question 5

What crises can arise in Type 1 and Type 2 DM?

Answer 5

Type 1–> DKA
Type 2–> HHS

Question 6

How do ketones differ in HHS versus DKA?

Answer 6

Ketones are absent or barely elevated in HHS, in DKA the pt is in ketosis

Question 7

How does glucose differ in HHS versus DKA?

Answer 7

HHS youll have plasma glucose over 600

DKA plasma glucose closer to 250, not as high

Question 8

What are some of the most common underlying causes of HHS?

Answer 8

Infections, such as pneumonia and urinary tract infections, accompanied by decreased fluid intake, are the most common underlying causes of HHS. Other acute conditions, such as stroke, MI, or pulmonary embolism, may also precipitate HHS.

Question 9

When does screening for DM2 start according to ADA?

Answer 9

35 yo for all people. If results are normal, testing should be repeated at a minimum of three-year intervals, with consideration of more frequent testing depending on initial results and risk status.

Screening should begin earlier in adults who are overweight or obese (BMI ≥ 25 kg/m2 or ≥ 23 kg/m2 in Asian Americans*) who have one or more of the following risk factors:

First-degree relative with diabetes

High-risk race/ethnicity** (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

History of CVD

Hypertension (≥ 140/90 mmHg or on therapy for hypertension)

HDL cholesterol level < 35 mg/dL (0.90 mmol/L) and/or a triglyceride level > 250 mg/dL (2.82 mmol/L)

Women with polycystic ovary syndrome

History of gestational diabetes

Physical inactivity

Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

3. People with HIV: prior to starting antiretroviral therapy, at the time of switching antiretroviral therapy, and 3-6 months after starting or switching antiretroviral therapy. If initial screening results are normal, fasting glucose should be checked annually.
4. Patients with prediabetes (A1C ≥ 5.7%, impaired glucose tolerance (two-hour plasma glucose > 140 mg/dL following a 75 gram glucose load) should be tested annually.
5. People who were diagnosed with Gestational Diabetes Mellitus (GDM) should have lifelong testing at least every three years.

NOTE USPSTF recommends Adults aged 35 to 70 years whose weight is in the overweight or obesity category

Question 10

Dx criteria for DM

Answer 10

ADA:
A random glucose of 200 mg/dL or above, plus symptoms of hyperglycemia, such as polyuria or unexplained weight loss, or hyperglycemic crisis.

A fasting plasma glucose of greater than or equal to 126 mg/dL. Fasting is defined as no caloric intake for at least eight hours.

A hemoglobin A1C greater than or equal to 6.5%.

Two-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT).

The diagnosis requires two abnormal test results from the same sample or in two separate test samples unless there is a clear clinical diagnosis (e.g., patient in a hyperglycemic crisis or with classic symptoms of hyperglycemia and a random plasma glucose ≥ 200 mg/dL).

Question 11

How do we define ‘prediabetes’?

Answer 11

Prediabetes is defined as the presence of either impaired fasting glucose-IFG (fasting glucose 100—125 mg/dl) or impaired glucose tolerance-IGT (2 hr values of oral glucose tolerance testing 140—199 mg/dl).

Question 12

The most frequent cause of new blindness among adults

Answer 12

Diabetic retinopathy

Question 13

What is concerning for retinopathy on fundoscopic exam?

Answer 13

In severe, non-proliferative retinopathy, look for the following findings on a fundoscopic exam:

Retinal hemorrhages are dark blots with indistinct borders that indicate partial obstruction and infarction.

Cotton wool spots are white spots with fuzzy borders and they indicate areas of previous infarction. They accompany hemorrhages.

Microaneurysms are more punctate dark lesions that indicate vascular dilatation.

Neovascularization is the hallmark of proliferative retinopathy. The growth of new blood vessels is prompted by retinal vessel occlusion and hypoxia.

Question 14

What labs should you order in initial evaluation of a person for DM?

Answer 14

Question 15

For anyone on metformin, what should you order on labs annually?

Answer 15

Vit B12

Question 16

For diabetics on ACEs, ARBs, or diuretics, what electrolyte lab should you order annually?

Answer 16

Potassium

Question 17

What is hemoglobin A1C?

Answer 17

A1C is a measurement of glycosylated hemoglobin and represents plasma glucose concentrations over a four- to-12-week period of time.

Question 18

What is the standard of care for A1C testing?

Answer 18

Current standards of care recommend initial A1C testing at diagnosis, and follow-up testing at least two times a year in patients who are stable and whose A1C is less than 7

A1C quarterly in patients when therapy is changing or whose A1C is > 7

Question 19

How do we screen for diabetic nephropathy annually?

Answer 19

The spot urine albumin-to-creatinine ratio screens for microalbuminuria. In patients with urinary albumin > 30 mg/g creatinine and/or an eGFR < 60 mL/min/1.73 m2, consider monitoring twice annually. (24-hour or timed urine collections are difficult to obtain and add little to the spot urine measurements).

Question 20

When do we screen DM pts for autoimmune thyroid disease?

Answer 20

In type1 DM annually w/TSH levels

Question 21

Why do we check liver enzymes annually in diabetes pts?

Answer 21

Diabetes is associated with the development of nonalcoholic fatty liver disease, which can include nonalcoholic steatohepatitis, liver fibrosis, cirrhosis, and hepatocellular carcinoma.

Question 22

What are the ADA guidelines for HTN control in diabetics?

Answer 22

DM pts w/existing ASCVD or 10-year ASCVD risk ≥ 15%, a blood pressure target of < 130/80 mmHg may be appropriate if it can be safely attained. (ADA, level of evidence B)

For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year ASCVD risk < 15%), treat to a blood pressure target of < 140/90 mmHg. (ADA, level of evidence A)

In adults with diabetes and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mmHg or higher with a treatment goal of less than 130/80 mmHg. (ACC/AHA guidelines)

Question 23

In pts w/DM, when do we initiate htn tx according to ACC/AHA guidelines?

Answer 23

In adults with diabetes and hypertension, antihypertensive drug treatment should be initiated at a BP of 130/80 mmHg or higher with a treatment goal of less than 130/80 mmHg. (ACC/AHA guidelines)

Question 24

What are the recommendations from the ACC/AHA for pts w/DM and LDL-c 70—189 mg/dL?

Answer 24

Moderate-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus

High-intensity statin therapy should be initiated or continued for adults 40 to 75 years of age with diabetes mellitus and multiple ASCVD risk factors

High-intensity statin therapy is reasonable for adults 40 to 75 years of age with diabetes mellitus with a ≥ 7.5% estimated 10-year ASCVD risk unless contraindicated (level of evidence B).

Ezetimibe may be added to maximally tolerated statin therapy in adults with diabetes mellitus and ASCVD risk ≥ 20% (level of evidence C).

In adults with diabetes mellitus who are younger than 40 or older than 75 years of age, it is reasonable to evaluate the potential for ASCVD benefits and for adverse effects, for drug-drug interactions, and to consider patient preferences when deciding to initiate, continue, or intensify statin therapy (level of evidence C). Note, the ACC/AHA recommends all patients older than 21 (with or without diabetes) who have an LDL-c > 190 should be started on statin therapy (level of evidence B).

Question 25

For DM pts not at increased CV risk, what is the ADA rec on aspirin?

Answer 25

Aspirin therapy (75 to 162 mg/day) may be considered as a primary prevention strategy in those with diabetes who are at increased cardiovascular risk, after a discussion with the patient on the benefits versus increased risk of bleeding (level of evidence A).

Question 26

Vaccine recommendations for pts w/DM

Answer 26

Influenza vaccine is recommended annually. People with diabetes are advised not to receive the live attenuated influenza vaccine.

Pneumococcal vaccine is recommended for adults with diabetes who are between 19-64 years of age. One dose of PCV15 or one dose of PCV20 can be given. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose.

Hepatitis B vaccine is recommended for patients with diabetes who are younger than 60 (older patients should discuss the vaccine with their healthcare provider). There is evidence that patients with diabetes are at increased risk for developing hepatitis B, perhaps due to the frequent use of needles for injectable medications and glucometers.

Ensuring that all other age-group recommended vaccinations (particularly HPV, tdap, zoster, and COVID-19) are up to date is also important.

Question 27

How often should DM pts see an opthamologist?

Answer 27

Yearly**

Patients with type 1 diabetes should have their first annual eye exam five years after diagnosis. Patients with type 2 diabetes should have their first dilated exam at the time of diagnosis (evidence level B) because roughly 20% of patients will already have some degree of retinopathy at that time.

Question 28

What should we tell DM pts to aim for w/blood glucose?

Answer 28

Optimal range for blood glucose:

Fasting blood glucose goal between 80—120 mg/dl

Postprandial blood glucose (1-2 hours after a meal) goal of < 180 mg/dl

Conditions that can contribute to hyperglycemia:

Overeating, missing doses of medication, dehydration, infection and illness, stress.

Question 29

How do we define metabolic syndrome?

Answer 29

Fasting plasma glucose ≥ 100 mg/dL (or on medical therapy for hyperglycemia)

BP ≥ 130/85 mmHg (or on medical therapy for hypertension)

Triglycerides ≥ 150 mg/dL, non-fasting (or on medical therapy for hypertriglyceridemia)

High density lipoprotein (HDL) cholesterol < 40 mg/dL for men, < 50 mg/dL for women (or on medical therapy for low HDL cholesterol)

Abdominal obesity (waist circumference > 40” for men, > 35” for women)

Question 30

What is the underlying mechanism of metabolic syndrome?

Answer 30

Insulin resistance is believed to be the underlying mechanism of metabolic syndrome. There is some controversy about the existence of a metabolic syndrome, as opposed to a collection of independent risk factors; however, this distinction should not discourage appropriate risk factor management and risk reduction.

Question 31

Hb A1c considered ‘prediabetic’

Answer 31

> 6.5% = diabetes

5.7–6.4% = prediabetes

Question 32

Hb A1c considered diabetic

Answer 32

> 6.5% = diabetes

5.7–6.4% = prediabetes

Question 33

Who do we include in the “ASCVD statin benefit groups”?

Answer 33

Current clinical ASCVD

LDL cholesterol > 190 mg/dL

Diabetes (type 1 or 2) age 40-75 years with LDL > 70 mg/dL

Estimated 10-year ASCVD risk by Pooled Cohort Equations > 7.5%.