Diabetes Flashcards
What medical history do you take for diabetes evaluation??
- Symptoms, results of laboratory tests, and special examination results related to the diagnosis of diabetes
- Prior A1C records
- Eating patterns, nutritional status, and weight history; growth and development in children and adolescents
- Details of previous treatment programs, including nutrition and diabetes self-management education, attitudes, and health beliefs
- Current treatment of diabetes, including medications, meal plan, and results of glucose monitoring and patients’ use of data
- Exercise history
- Frequency, severity, and cause of acute complications such as ketoacidosis and hypoglycemia
- Prior or current infections, particularly skin, foot, dental, and genitourinary infections
- Symptoms and treatment of chronic eye; kidney; nerve; genitourinary (including sexual), bladder, and gastrointestinal function (including symptoms of celiac disease in type 1 diabetic patients); heart; peripheral vascular; foot; and cerebrovascular complications associated with diabetes
- Other medications that may affect blood glucose levels
- Risk factors for atherosclerosis: smoking, hypertension, obesity, dyslipidemia, and family history
- History and treatment of other conditions, including endocrine and eating disorders
- Assessment for mood disorder
- Family history of diabetes and other endocrine disorders
- Lifestyle, cultural, psychosocial, educational, and economic factors that might influence the management of diabetes
- Tobacco, alcohol, and/or controlled substance use
- Contraception and reproductive and sexual history
Physical exam for diabetes evaluation
- Height and weight measurement (and comparison to norms in children and adolescents)
- Sexual maturation staging (during pubertal period)
- Blood pressure determination, including orthostatic measurements when indicated, and comparison to age-related norms
- Fundoscopic examination
- Oral examination
- Thyroid palpation
- Cardiac examination
- Abdominal examination (e.g., for hepatomegaly)
- Evaluation of pulses by palpation and with auscultation
- Hand/finger examination
- Foot examination
- Skin examination (for acanthosis nigricans and insulin-injection sites)
- Neurological examination
- Signs of diseases that can cause secondary diabetes (e.g., hemochromatosis, pancreatic disease)
Labs for diabetes evaluation
- A1C
- Fasting lipid profile, including total cholesterol, HDL cholesterol, triglycerides, and LDL cholesterol
- Test for microalbuminuria in type 1 diabetic patients who have had diabetes for at least 5 years and in all patients with type 2 diabetes; some advocate beginning screening of pubertal children before 5 years of diabetes
- Serum creatinine in adults (in children if proteinuria is present)
- Thyroid-stimulating hormone in all type 1 diabetic patients; in type 2 if clinically indicated
- Electrocardiogram in adults, if clinically indicated
- Urinalysis for ketones, protein, sediment
Referrals in diabetes evaluation
- Eye exam, if indicated
- Family planning for women of reproductive age
- Medical nutrition therapy as indicated
- Diabetes educator, if not provided by physician or practice staff
- Behavioral specialist, as indicated
- Foot specialist, as indicated
- Other specialties and services as appropriate
Signs of hypoglycemia v. signs of hyperglycemia
Hypo:
The signs of hypoglycemia:
• Feeling weak or dizzy
• Feeling nervous, shaky or confused
• Irritability
• Sweating more
• Noticing sudden changes in your heartbeat
• Feeling very hungry
• Losing consciousness
• Develop seizures
Hyper:
- Frequent hunger
- Frequent thirst
- Frequent urination
- Blurred vision
- Fatigue
- Weight loss
- Poor wound healing
When to test glucose if not on insulin:
If New diagnosis of diabetes or Recent therapy adjustment; or Glucose level is outside target: Test 3 times a day:
- Before breakfast
- Before main meal of day
- 2 hours after the start of main meal
If glucose is in target range: Test 3 times a day EVERY 3rd Day
When to test glucose if on insulin:
When taking basal and bolus (meal associated) insulin: Test 4 times a day
- Before breakfast
- Mid-morning
- Mid to late afternoon
- Mid-evening
If taking basal insulin only: Test fasting glucose daily and perform other pre- and post-meal tests intermittently
- *In all diabetic patients taking or not taking insulin, you should test:**
1. Whenever suspecting hypoglycemia
2. Before driving if you have trouble sensing hypoglycemia
How often should A1C be checked?
An A1C can be drawn quarterly in patients whose therapy has just changed or who are not meeting glycemic control. In patients who are at glycemic control, it can be drawn twice a year.
An A1C “point of care” test is also now available that allows rapid results during a physician visit if needed. Lowering A1C levels in diabetics reduces neuropathic and microvascular complications.
A1C testing is limited by any condition that affects erythrocyte turnover such as hemolytic diseases, recent blood loss, in people with hemoglobin variants.
Glycemic target goals - american diabetic association
- Hemoglobin A1C for diabetic patients in general <7%.
- Hemoglobin A1C for an individual diabetic patient as close to normal (<6%) as possible without significant hypoglycemia.
- Less stringent A1C may be considered in young children or older adults with limited life expectancies.
- Premeal capillary glucose of 90 – 130 mg/dL.
- Postmeal (1 – 2 hours) capillary glucose of <180 mg/dL.
Weight management in diabetes: goals, how to do it, carbohydrate counting
Goals: prevent diabetes if pre-diabetic, improve glucose control, decrease abdominal fat
Decrease 500-1000 kcal –> lose 1-2 lbs/week
Weight loss diets 1000-1200 kcal in women, 1200-1600 calores in men
Carbohydrate counting: 15g=1 choice
For Weight Loss: Women 2-3 choices/meal
men 3-4 choices/meal
To Maintain Weight: women 4-5 choices/meal,
Men 3-4 choices/meal
For Very Active People: 4-5 choices/meal 4-6 choices/meal
Exercise recommendations for diabetes
Aerobic Activity Recommendations in General Diabetic Patients
Moderate Intensity At least 150 min / week distributed over 3 days / week with no more than 2 consecutive days without activity.
AND / OR
Vigorous Intensity At least 90 min / week distributed over 3 days / week with no more than 2 consecutive days without activity.
Resistance exercise targeting all major muscle groups is recommended for all people with type 2 diabetes at least 3 times a week unless there is a contraindication. Patients should progress to 3 sets of 8 – 10 repetitions at a weight that can not be lifted more than 8 – 10 times. Resistance training improves insulin sensitivity just as well as aerobic activity.
Secretagogues: mechanism and SE
All secretagogues allow the pancreas β-cells to secrete insulin in response to a glucose challenge.
Common side effects include hypoglycemia, weight gain, mild gastrointestinal complaints, and rarely skin reactions, photosensitivity, and cholestatic hepatitis.
Contraindicated in pregnancy. Caution in renal and liver dz
Sulfonyureas
Secretagogues: Sulfonylureas bind to a sulfonylurea receptors on the β-cells which stimulate insulin secretion or sensitize the β-cells to the presence of glucose.
2nd gen > 1st gen: less SE, same efficacy
As type 2 diabetes progresses, β-cells secrete less and less insulin and thus sulfonylureas will not be able to optimize glucose levels by themselves. Most clinicians do not discontinue them, but rather add insulin sensitizers.
Meglitinides
Rapid acting short duration insulin secretagogues
Repaglinade = only approved one in the US
As effective as a sulfonylurea
Take before each meal & with any bedtime snacks
Not contraindicated in renal insufficiency
D-phenylalanine derivatives
Faster acting & shorter duration secretagogue than meglitinides
Nateglinide is the only member in this class
Can be used in renal insufficiency
Both nateglinide and rapaglinide can be used in pt with optimal fasting glucose but high post-prandial glucose
Insulin sensitizers: 2 classes?
Biguanides: metformin
Thiazolidinediones: rosiglitazone and pioglitazone
Metformin
Biguanide class: decreases gluconeogenesis in liver, increases glucose uptake in muscle, enhances basal metabolic rate, lower food intake bc GI SE
Indication= insulin resistance, also good if cholesterol high
Reduce A1C by 2% & fasting glucose by 60 mg/dL
Start slow and low, build up to 2000 mg/day (optimal dose)
Cant use in: liver dz, active pulmonary or cardiac dz, if creatinine >1.5 men 1.4 women
Withhold before radiology requiring contrast or if going to surgery - restore when renal function returns to normal
Category B drug: no evidence of risk in humans in preg & breastfeeding
SE: flatulence, diarrhea, nausea, metallic taste
Thiazolidinediones
Insulin sensitizing effect on the peroxisome proliferator activated nuclear receptors in liver cells, adipose tissue, and muscle
Rosiglitazone and pioglitazone are approved in US
Indicated in insulin resistance
SE: mild anemia, weight gain, mild edema
OK in renal insuffiency
Lliver monitoring is recommended; contraindicated in ALT 2.5x upper limit normal
Contraindicated in pregnancy; may stimulate ovulation in insulin resistant, anovulatory women
Contraindicated in Class III or IV NY heart association functional status
Rosiglitazone: controversial whether risk of death from CV causes
Alpha-glucosidase inhibitors
Delay disaccharide & complex carb absorption in small intest so it occurs in large intest & colon –> improves glucose control
Good in patients with insulin resistance and insulin defiency; excellent for pt with high 2 hr post meal hyperglycemia
Must be used with each meal
Reduce A1C by .5 to 1% when combined with other oral agents or insulin
Acarbose and miglitol are approved in the US
SE: diarrhea, flatulence; start low and slow to delay these
Can cause irreverible liver enzyme elevation
Contarinidcated with liver dz and IBD
Hypoglycemia can develo in conjunction with sulfonylureas or insulin –> use milk to correct glucose levels
