Diabetes Flashcards
1
Q
What is the A1C criteria for diagnosis?
A
> /= 6.5^
2
Q
What is the FPG criteria for diagnosis?
A
> /= 126mg/dL
3
Q
what is the major cause of mortality in diabetic patients?
A
cardiovascular disease, also the major cause of morbidity and direct and indirect costs
4
Q
When should diabetics be put on HTN medication?
A
SBP >/= 140 or DBP >/=90
5
Q
When should a diabetic with Pre-HTN be put on medication (for HTN)?
A
After 3 months of trying to achieve optimal BP (<80) without success should be put on ACEi or ARB
6
Q
what is the primary LDL goal for Diabetic patients without cardiovascular disease?
A
LDL<100
7
Q
what is the triglyceride and HDL goal in Diabetic patients?
A
Triglycerides /= 40 in men and HDL >/= 50 in women
8
Q
when should diabetic patients with cardiovascular disease be treated?
A
all pts should be treated with a statin to achieve an LDL reduction of 30-40% regardless of baseline or reduce LDL <70 with statins
9
Q
what is the ADA recommendation regarding antiplatelet agents?
A
use aspirin therapy (75-162 mg/day) as a primary prevention strategy in those with T2D at increased cardiovascular risk, including those who are >40 years of age or who have additional risk factors
10
Q
when is aspirin therapy contraindicated?
A
people under age of 21- risk of Reye’s syndrome
11
Q
when should alternative therapy for antiplatelet be considered in diabetic patients?
A
patients with aspirin allergy, bleeding tendency, receiving anticoagulant therapy, recent GI bleed, clinically active hepatic disease
12
Q
when is metformin contraindicated?
A
in DB patients with decompensated or acute CHF
13
Q
what is the recommended protein intake for DB patients with CKD?
A
No more than .8g protein/kg
14
Q
how often should T2D pts be screened for urine microalbumin?
A
annually starting at diagnosis
15
Q
how often should serum creatinine be measured in DB pts?
A
annually-in all diabetic pts regardless of microalbuminuria-should not be used alone to measure renal function but used to measure the GFR and stage the tru renal function or dysfunction
16
Q
what is the best way to measure GFR?
A
MDRD equation
17
Q
which treatment is beneficial for persons with T2D and early nephropathy?
A
tight blood pressure control that includes an ACE
18
Q
in T2D pts with HTN and microalbuminura, which meds have been shown to delay progression to macroalbuminuria?
A
ACEi and ARBS
19
Q
in T2D pts with HTN and MACROalbuminura, which med has been shown to delay nephropathy?
A
ACEi
20
Q
when are ACEi and ARBs contraindicated?
A
In pregnant pts
21
Q
What is the recommended protein intake in DB pts wtih nephropathy?
A
<.8 gm/kg
22
Q
what is not effective initial therapy to slow progression of nephropathy?
A
Dihydropyridine sensitive ca channel blockers-should only be used as an adjunct to an ACEi or ARB to lower BP
23
Q
What should be checked if ACEis, ARBS or diuretics are used?
A
Serum Potassium levels
24
Q
when should referral to a renal specialist be considered?
A
when GFR falls below <60 ml/min per 1.73m^2 or if management of HTN or hyperkalemia becomes difficult
25
does aspirin prevent retinopathy in DB pts?
No, no role in prevention or exacerbation
26
when should women with DB that become pregnant have a full eye exam?
in the first trimester and frequent repeat ealuations throughout the pregnancy (not including women with gestational diabetes)-noneed to scren
27
are gestational diabetic patients at risk for diabetic retinopathy?
no
28
what is effective at slowing the progression of retinopathy and reducing vision loss? Can vision be restored with this treatment?
Laser photocoagulation-usually does not restore lost vision
29
when should pts be screened for distal symmetric polyneuropathy?
at diagnosis and at least annually every year after
30
how is the DPN screening test performed?
usually in a PCP office with pinprickl sensation, temp, vibration perception and ankle reflex more than two of these three tests should be performed annually, pressure sensation best at dorsal surface of both great toes proximal to the nail beds
31
when should insensitive feet be inspected?
every 3-6 months and pts should be taught rigorous foot care
32
How is DPN treated?
optimize glucose control
| pain manifestation can be managed with tricyclics, gabapentin, 5-hydroxytryptamine and NE reuptake inhibitors
33
what are major clinical manifestation of diabetic autonomic neuropathy?
resting tachycardia, exercise intolerance, orthostatic HTN, constipation, gastroparesis, erectile dysfunction, pseudomoto dysfunciton, impaired neurovascular funciton, hypofglycemi autonomic failur and :"brittle diabetes"
34
how is diabetic autonomic neuropathy treated?
metroclopramide for gastroparesis and the use of bladder and erectile dysfunction medications
35
what are the most common consequences of diabetic neuropathy?
amputation and foot ulceration-major causes of morbidity and mortality in diabetic patients
36
what should the initial screening for peripheral arterial disease include?
A history for claudication and an assessment of the pedal pulses
37
which diabetes pts have a higher risk of ulcers?
people who have had diabetes >10 years, are male, have poor glucose ontrol or have cardiovascular, retinal or renal complications
38
what are the risk conditions associated with an increased risk of amputation?
peripheral neuropathy with loss of protective sesnsation, altered biomechanics (in the presence of neuropathy), evidence of increased pressure (iarythema, hemorrhage under a cllus), bony deformity, peipheral vacular disease (decreaed or absent pedal pulses), a history of ulcers or amputation, severe nail pathology
39
which diabetic pts should be offered Influenza vaccine?
All over the afe of 6 months
40
Who should be offered pneumococal vaccine?
all pts-one lifetime vaccine, and revaccination for people >64 years previously immunized 5 years ago
41
what % of diabetic pts have an A1c of <7%?
37
42
what % have a BP of <130/80?
36%
43
what % have total cholesterol <200?
48$
44
what % of DB pts have all three parameters at target goal?
7.3%
45
what is the underlying CQI principle?
There is always room for improvement
46
what are the core concepts of CQI?
- quality is defined as meeting and/or exceeding the expectations of customers.
- success is achieved through meeting the needs of those we serve
- most problems are found in processes, not in people, CQI does not seek to blame but to rather improve processes
- unintended variation in processes can lead to unwanted variation in outcomes, and therefore we seek to reduce or eliminate unwanted variation
- it is porrible to acheive continual improvement through small, incremental changes using the scientific method
- continuous improvement is most effective when it becomes a natural part of the way everyday work is done and not a peripheral periodic activity
47
What are the core steps in continuous improvement?
- define the problem before trying to solve it
- understand a process before you attempt to control it
- identify which problems are priorities before attempting to correct everything
- there is no such thing as failure bc you can learn from all processes
- form a team that has knowledge of the system needing improvement
- understand the needs of the people who are served by the system
- identify and define measures of success
- brainstorm potential change strategies for producing improvement
- plan, collect, and use data for facilitating effective decision making
- apply the scientific method to test and refine changes
48
what is the pathophysiology of Type I Diabetes?
autoimmune destruction of beta cells in the pancreas leading to insulin deficiency (only 5-10% of all diabetes pts)
49
what is the pathophysiology of TIID?
progressive insulin secretory defect (Beta cell destruction) as well as increasing insulin resistance (cells do not respond to insulin)-90-95%of all db pts
50
Which type of diabetes has a strong genetic component?
Type II
51
What is the metabolic syndrome?
Dyslipidemia, HTN, obesity, TIID
52
what is the pathophysiology of gestational diabetes?
glucose intolerance during pregnancy, increasing insulin requirement during pregnancy-especially in third trimester, maternal insulin resistance increases as human placental lactogen levels increase
53
What are gestational diabetic pts more at risk for?
perinatal morbidity (fetal macrosomia), increased risk of C section, pregnancy induced hypertension, TIID,
54
when should gestational db pts be tested for diabetes?
6-12 weeks postpartum
55
what is prediabetes? what are the lab values?
insulin resistance may be present, insulin secretion is already increased but post prandial glucose blood levels may still be normal
HgA1c 5.7-6.4%
100<126
56
when should regular pts be tested for db and how often?
all pts above 45-especially if BMI>25, if normal repeated every three years
57
when are pts screened at an earlier age?
if physically inactive, have first degree relative with DB, ethnic, deliver baby >9lbs or GDM, HTN (>140/90), HDL 250, PCOS, IGT or IFG, vascular disease
58
when is HgA1C testing unable to be performed?
IN certain anemias and hemoglobinopathies ie sickle cell disease
59
How is DB diagnosed with A1c?
A1c >6.5%, test must be repeated on another day to rule out lab error
60
How is DB diagnosed with FPG?
no caloric intake for 8 hours, FPG>/= 126, test must be confirmed on another day unless unequivocal symptoms are present
61
How is DB diagnosed with plasma glucose (nonfasting)?
>200 and classic symptoms of diabetes, does NOT need to be repeated
62
Can two different tests be used to diagnose a pt?
yes, if two different screening tests are used on the same patient and reach diagnostic threshold, diagnosis can be confirmed
if the test are discrodant the test that was above threshold should be repeated
63
what children should be tested?
overweight-BMI >85% or wight 120% ideal for height, PLUS any two
- family history of TIID in 1st or 2nd degree relative
- ethnic
- signs of insulin resistance (acanthosis nigricans, HTN, dyslipidemia, PCOS (insulin stimulates androgen production in the ovaries))
64
how are children tested?
10 years or at initiation of puberty, every 2 years, FPG preferred
65
how much can weight loss and exercise reduce risk of db?
50%
66
when is metformin used?
when IFG and IGT are both noted
67
how often are individuals on metformin monitored?
semi-annually
68
how often are DB not on medication monitored?
annually
69
what are the signs and symptoms of undiagnosed diabetes?
increased thirst, polyuria, fatigue, weight loss, blurry vision, acanthosis nigricans, -obesity, metabolic syndrome, cardio-vascular disease
70
who should get microalbuminemia checked?
T1 pts who hace had it for 5 years and all pts with TII
71
who should get TSH labs checekd?
all TI, TII if clinically indicated
72
what is used in the setting of hypoglycemia?
glucagon
73
how are brief illnesses (ie viral) managed in DB pts?
- check sugars more frequently-every 2-4 hours
- check ketones every 4 hours
- drink a lot of non caffeinated fluid
- call Dr if cannot hold fluids or carbs down for 6 hrs, cannot eat regular food for one day, develop heavy vomiting, diarrhea, tachypnea, drowsiness or recurrent hypoglycemia
74
What are the acute complications of DB?
- infections
- hyperosmolar coma
- ketoacidosis
- hyperglycemia
- hypoglycemia
75
what are the causes and signs of hyperglycemia?
causes: forgetting to take medicines on time, eating too much, getting too little exercise, being ill
signs:
- frequent hunger
- frequent thirst
- polyuria
- blurred vission
- fatigue
- weight loss
- poor wound healing
76
What are the causes and signs of hypoglycemia?
causes: taking too much medication, missing a meal or snack, exercising too much, drinking alcohol
signs:
- feeling weak or dizzy
- feeling nervous, shaky or confused
- irritability
- sweating more
- noticing sudden changes in your heartbeat
- feeling hungry
- losing consciousness
- develop seizures
77
what should db pts due when feeling hypoglycemic?
```
test blood glucose right away and if 70 or less eat one of these:
-2-3 glucose tablets
-1/2 cup juice
-1/2 soft drink (not diet)
-1 cup milk
-5-6 pieces of hard candy
-1-2tsp sugar or honey
and then check glucose again in 15 min
```
78
what are the chronic complications of diabetes?
damage to eye, cardiovascular, skin damage, renal damage, nervous, GI, vascular symptoms, physiological issues, foot inspection
79
how many db pts have depression?
1/3
80
A pt has a new diagnosis of DB, recent therapy adjustment or glucose outside of target, they are not on insulin-when should they check their blood glucose?
3 times a day
- before breakfast
- before main meal of the day
- 2 hours after start of main meal
81
A pt has a new diagnosis of DB, recent therapy adjustment or glucose outside of target and they are on insulin-when should they check their blood glucose?
When taking basal and bolus (meal associated) insulin test 4 times a day
- before breakfast
- mid morning
- mid to late afternoon
- mid evening
when taking basal insulin only
-test fasting glucose daily and perform other pre-and post-meal tests intermittently
82
when would it be a good idea to test blood glucose in all db pts whether they are or are not on insulin?
when suspecting hypoglycemia or before driving when they have trouble sensing hypoglycemia
83
What is the HgA1C test?
measures pts average glycemic levels over past 2-3 months,
| ie if value =4% means 4% of a pts hemoglobin has nonenzymatically attached glucose
84
how often should a pts HgA1c be drawn if they are in glycemic control? What about if there therapy just changed?
twice a year if under glycemic control and quarterly if their therapy just changed
85
what is the HgA1C goal for db pts?
<7% but as close to 6% as possible without becoming hypoglycemic
86
what is the target premeal capillary glucose for DB pts? postmeal?
90-130 premeal and <180 postmeal
87
what are the overall goals of medical nutrition therapy?
- prevent and manage chronic complications
- improve generall overall health through food -choices and physical activity
- achieve and maintain optimal metabolic outcomes
- address individual needs
88
why is weight loss important?
can prevent diabetes in those with pre diabetes, can lower cardiovascular disease risk, can decrease abdominal fat and improve glucose control
89
What are the ADA wight management recommendations?
- decrease 500-1000 kcal/day (loss of 1-2lbs/wk)
- weight loss diet should supply 1000-1200 for women and 1200-1600 for men
- drug therapy for obesity may be appropratie to reduce weight in patients but lifestyle modification still impt
- gastric bypass or gastroplasty may be an appropriate alterantive and can lead to reduce doses or discontinuation of diabetes medication
90
are low card diets ie Atkins recommended for diabetic pts?
No-restricting carbd below 130g/day may be below brain, nervous system and other metabolic requirements
91
What % of total calories should come from fat sources?
25-35% with <7% of saturated fat
92
are chromium and antioxidant supplementation recommended in DB pts?
No-have not been studied
93
How does physical activity help in DB?
reduces risk of cardiovascular disease, reduces insulin resistance, and assists in weight management
94
How do the secretagogues work?
secretagogues-1st and 2nd sulfonylureas, meglitinides (repaglinide), and D-phenylalanine derivatives (nateglinide)
-allow pancreas beta cells to secrete insulin in response to glucose-useful in pts with insulin deficiency
95
what are the main side effects of the secretagogues?
hypoglycemia, weight gain, GI complications, rare skin reactions, photosensitivity or cholestatic hepatitis
(2nd generation have less side effects)
96
When are secretagogues contraindicated?
in pregnancy, used with caution in pts with liver disease and renal disease
97
how do sulfonylureas work?
(secretagogues)
- bind to sulfonylurea receptor on beta cells stimulating insulin secretion or sensitize the beta cells to the presence of glucose
- can decrease A1c by as much as 2.3%
- begin with low dose and add more-but as TIID progresses beta cells not able to produce as much insulin and usually have to add on insulin sensitizer (combo therapy)
98
How do meglitinides (repaglinide) work?
rapid acting, short duration insulin secretagogues, ass effective as sulfonyurea
99
when are meglitinide (repaglinide) taken?
before each meal and with any bedtime snacks
100
When are meglitinides (repaglinide) contraindicated?
Never-not contraindicated in renal insufficiency
101
How do D-phenylalanine derivatives (nateglinide) work? And when are they useful?
faster acting and shorter duration secretagogues than meglitinides
-useful in pts who are found to have optimal fasting glucose levels but high post prandial glucose levels-needs to be taken several times a day
102
when are D phenylalanine derivates (nateglinide) contraindicated?
never-can be used in renal insufficiency
103
What is used in the setting of PCOS?
Insulin sensitizers
- Biguanides (metformin)
- thiazolidinediones (rosiglitazone and pioglitazone)
104
How does metformin work?
decreases gluconeogenesis from the liver, increases glucose uptake in muscle tissues, enhances the BMR and may lower food intake bc of GI side effects
-exact mech not known
DO NOT stimulate insulin secretion from the pancreas
-can reduce A1c by 2% and FPG by 60mg/dL
105
when is metformin especially useful?
pts with cholesterol issues-can decrease or stabilize wt gain, reduce choelsterol and triglyceride levels, and reduce risk of MI
106
When is metformin contraindicated?
in men when creatinine >1.5mg/dL or in women when creatinine >1.4mg/dL
-careful in those with liver disease, active pulm or cardiac disease
(category B -ie no evidence of risk in humans during pregnancy)
107
what are the side effects of metformin?
flatulence, diarrhea, nausea, metallic tast
108
how do the thiazolidinediones 9
| rosiglitazone and pioglitazone) work?
insulin sensitizing effect on the peroxisome proliferator activated nuclear receptor in liver cells, adipose tissue and muscle
-get reduction of insulin resistance and reduced blood glucose levels
109
what are the side effects of the thiazolidinediones (rosiglitazone and pioglitazone)?
mild anemia
weight gain
mild edema due to volume expansion
110
when are thialidinediones (rosiglitazone and pioglitazone) contraindicated?
-ppl with liver disease and ALT >2.5 times upper limit of normal
-pregnancy
-pts with class III or IV New York heart association functional status
(can be used in pts with renal insufficiency)
111
which thizlidinedione is associated with a significant increase in risk of MI and with increase in death from cardiovascular causes?
Rosiglitazone-other dstudy did not show this though but discuss with pts
112
what are alpha glucosidase inhibitors?
acarbose and miglitol
carbohydrate absorption delay agents-delay disaccharide complex carbohydrate absorption in the small intestine and allow it to occur instead in the large intestine of the colon,
-allows improvement of glucose control, but does not have the same delay effect of lactose
-decrease A1c by /5-1% when used with other oral agents or insulin
113
when are alpha glucosidase inhibtors (acarbose and miglitol) most useful? when are they taken?
excellent for pts with high 2 hour post meal hyperglycemia and can be used in people with both insulin resistance and deficiency
-taken before each meal
114
what are the side effects of alpha glucosidase inhibitors?
diarrhea
flatulence
-may cause reversible liver enzyme elevation
115
when are slpha glucosidase inhibitors contraindicated?
in patients with liver disease and IBD
-do not cause hypoglycemia by themselves but may develop when used in conjunction with sulfonylureas or insulin-pt can drink milk
116
what are the choices for first line agents?
metformin
thiazolidinediones
secretagogues
117
when are secretagogues most appropriate for first line?
in pts with a great degree of pancreatic dysfunction as opposed to insulin resistance
-sulfonylureas, nateglinides, repaglinides
118
what are some examples of popular combination therapy?
* **50% of pts require combo therapy after 3 years monotherapy
- insulin sensitizing agent with secretagogue
- two insulin sensitizers
119
When is combination therapy considered for first line therapy?
- if pt has A1c >9% before medical nutrition therapy has been instituted
- if A1c >8% after medical nutrition therapy has been instituted
120
when is insulin used?
in T1D-insulin therapy is mandatory
| -in TIID insulin def. makes insulin a useful therapeutic tool (most potent therapy)
121
what are the types of basal insulin?
- NPH, lente: short acting short duration and act quickly
- Ultralente: extended intermediate acting, acts somewhat longer
- Glargine: long acting, delayed absorption over 24 hours with no peak levels, once a day with lower risk of hypoglycemia, cannot be mixed in the same syringe with other insulin types and is usually used with bolus insulin
122
what is a type of bolus insulin?
Lispro-taken 15 minutes before a meal and is cleared in 3-5 hours, rapid acting (usually recommended)
-there are also regular short acting types
123
which pts are candidates for insulin regimens?
2 or more of the following
- consistent schedule
- <10 hours between breakfast and dinner
- not prepared to take multiple injections
- unable to mix or measure insulin
124
What is the best insulin regimen for a pt who does not snack and has high post meal hyperglycemia?
Rapid acting + NPH
AM: RA, NPH
PM: RA
Bedtime: NPH
****can substitute NPH for NPH premix pen for pts who are unable to measure/mix
125
What is the best insulin regimen for a pt who snacks?
NPH + regular (bolus)
AM: Regular, NPH
PM: Regular
Bedtime: NPH
****can substitute NPH for NPH premix pen
126
What is the best insulin regimen for T2D pts wtih high fasting glucose?
NPH with oral agents
AM/PM: oral agents
Bedtime: NPH
127
What is the best insulin regimen for T2D pts with high fasting glucose, w/ or w/o subsequent elevated pre-meal glucose?
Largine with oral agents
AM/PM: oral agents
Bedtime: glargine
128
What is the recommended inital dose of nighttime glargline?
.1-.2 units/kg/day
129
what is the target monitoring fasting glucose for patients on insulin?
<140mg/dL
130
How can glargine dose be increased?
2-5 units every 4-7 days until target fasting glucose reached
131
What are the advanced insulin regimens?
```
RA + NPH or UL
AM: RA, NPH or UL
Noon: RA
PM: RA, NPH or UL
Bedtime:small dose of NPH for some
```
```
RA+Glargine
AM: RA
Noon: RA
PM: RA
Bedtime: Glargine
```
132
what is the initial dose for advanced insulin therapy?
.4-.5u/kg/day
133
when is the target level for RA insulin achieved?
when 2 hour post meal glucose level is within 20-40mg of the premeal glucose level
134
what are the side effects of injected insulin?
lipodystrophy-lipohypertrophy (usually in men) and lipoatrophy (more in women)
skin reactions-most resolve in 6 weeks, antihistamines ok
rare systemic allergies (more common in pts with penicillin allergies or atopic dermatitis, in pts using insulin intermittently)
135
What are incretin mimetics?
GI hormones-incretins like glucagon released and promote insulin secretion and glucagon suppression
-exenatide
136
what is the recommended dosing for incretin mimetics?
5mg-10mg tice daily subq before breakfast and dinner, used with metoformin and sulfonylureas
137
what are the side effects of incretin mimetics?
nausea, vomiting, diarrhea, hypoglycemia
138
What are dipeptidyl peptidase 4 inhibitors?
block action of dipeptidyl peptidase (which normally breaks down and inactivates incretins)
- less susceptible to severe hypoglycemic episodes
- sitagliptin
139
when are DPP4 inhibitors contraindicated?
In T1D or in state of ketoacidosis
| -used with caution in those with renal impairment
140
what is the BP goal for diabetic pts?
systolic <80mmhg
141
when should a DB pt without cardiovascular disease and normal LDL be placed on statin?
over age 40 to reduce LDL 30-40%
142
when should an ACEi be considered (W/o HTN)?
pts >55 with another CV risk factor
| -history of CVD, dyslipidemia, microalbuminuria or smoking
143
when should beta blocker be considered in DB pts?
prior MI, or undergoing major surgery
