Diabetes Flashcards
What is the A1C criteria for diagnosis?
> /= 6.5^
What is the FPG criteria for diagnosis?
> /= 126mg/dL
what is the major cause of mortality in diabetic patients?
cardiovascular disease, also the major cause of morbidity and direct and indirect costs
When should diabetics be put on HTN medication?
SBP >/= 140 or DBP >/=90
When should a diabetic with Pre-HTN be put on medication (for HTN)?
After 3 months of trying to achieve optimal BP (<80) without success should be put on ACEi or ARB
what is the primary LDL goal for Diabetic patients without cardiovascular disease?
LDL<100
what is the triglyceride and HDL goal in Diabetic patients?
Triglycerides /= 40 in men and HDL >/= 50 in women
when should diabetic patients with cardiovascular disease be treated?
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
what is the ADA recommendation regarding antiplatelet agents?
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
when is aspirin therapy contraindicated?
people under age of 21- risk of Reye’s syndrome
when should alternative therapy for antiplatelet be considered in diabetic patients?
patients with aspirin allergy, bleeding tendency, receiving anticoagulant therapy, recent GI bleed, clinically active hepatic disease
when is metformin contraindicated?
in DB patients with decompensated or acute CHF
what is the recommended protein intake for DB patients with CKD?
No more than .8g protein/kg
how often should T2D pts be screened for urine microalbumin?
annually starting at diagnosis
how often should serum creatinine be measured in DB pts?
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
what is the best way to measure GFR?
MDRD equation
which treatment is beneficial for persons with T2D and early nephropathy?
tight blood pressure control that includes an ACE
in T2D pts with HTN and microalbuminura, which meds have been shown to delay progression to macroalbuminuria?
ACEi and ARBS
in T2D pts with HTN and MACROalbuminura, which med has been shown to delay nephropathy?
ACEi
when are ACEi and ARBs contraindicated?
In pregnant pts
What is the recommended protein intake in DB pts wtih nephropathy?
<.8 gm/kg
what is not effective initial therapy to slow progression of nephropathy?
Dihydropyridine sensitive ca channel blockers-should only be used as an adjunct to an ACEi or ARB to lower BP
What should be checked if ACEis, ARBS or diuretics are used?
Serum Potassium levels
when should referral to a renal specialist be considered?
when GFR falls below <60 ml/min per 1.73m^2 or if management of HTN or hyperkalemia becomes difficult
does aspirin prevent retinopathy in DB pts?
No, no role in prevention or exacerbation
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
are gestational diabetic patients at risk for diabetic retinopathy?
no
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
when should pts be screened for distal symmetric polyneuropathy?
at diagnosis and at least annually every year after
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
when should insensitive feet be inspected?
every 3-6 months and pts should be taught rigorous foot care
How is DPN treated?
optimize glucose control
pain manifestation can be managed with tricyclics, gabapentin, 5-hydroxytryptamine and NE reuptake inhibitors
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”
how is diabetic autonomic neuropathy treated?
metroclopramide for gastroparesis and the use of bladder and erectile dysfunction medications
what are the most common consequences of diabetic neuropathy?
amputation and foot ulceration-major causes of morbidity and mortality in diabetic patients
what should the initial screening for peripheral arterial disease include?
A history for claudication and an assessment of the pedal pulses
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
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
which diabetic pts should be offered Influenza vaccine?
All over the afe of 6 months
Who should be offered pneumococal vaccine?
all pts-one lifetime vaccine, and revaccination for people >64 years previously immunized 5 years ago
what % of diabetic pts have an A1c of <7%?
37
what % have a BP of <130/80?
36%
what % have total cholesterol <200?
48$
what % of DB pts have all three parameters at target goal?
7.3%
what is the underlying CQI principle?
There is always room for improvement
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
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
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)
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
Which type of diabetes has a strong genetic component?
Type II
What is the metabolic syndrome?
Dyslipidemia, HTN, obesity, TIID
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
What are gestational diabetic pts more at risk for?
perinatal morbidity (fetal macrosomia), increased risk of C section, pregnancy induced hypertension, TIID,
when should gestational db pts be tested for diabetes?
6-12 weeks postpartum
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
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
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