Diabetes

Question 1

Diagnosis of diabetes excluding ______:

Answer 1

HbA1c >6.5, fasting plasma glucose >126, 2 hr plasma glucose >200 during oral GTT, random plasma glucose >200;
PREGNANCY

Question 2

Prediabetes defined as

Answer 2

1. FPG 100-125 mg/dL;
2. 2 hr plasma glucose at 140-199
3. A1c: 5.7-6.4

Question 3

Who to test for diabetes if asymp (adults):

Answer 3

1. Test overweight/obese adults (BMI > 25, Asians > 23) with one or more additional risk factors
2. without risk factors: begin testing at age 45 yrs;

consider physical inactivity, first-degree relative with diabetes, high-risk race/ethnicity (AA, Asian American, Native American), women with big baby or GDM, HTN, HDL cholesterol that’s low or high triglyceride, women with PCOS, A1c >5.7, CVD history

Question 4

Screening for T2DM in children:

Answer 4

Consider if they are overweight and have two or more additional risk factors for diabetes

Question 5

To detect and diagnose gestational diabetes mellitus:

Answer 5

1. screen for undiagnosed T2DM
2. screen at 24-28 wk point
3. screen for persistent diabetes at 6-12 wks postpartum, using oral GTT

Question 6

A1c targets for nonpreg individuals; what is critical when terating T2D?:

Answer 6

Youth: less than 7.5;
Adults: less than 7.0;
older adults: 7.5, 8.0, 8.5 if healthy, complex/intermediate, very complex/poor health;
INDIVIDUALIZE THERAPY based on diabetes duration, age/life expectancy, comorbidities, known CVD/advanced microvascular complications, hypoglycemia unawareness, individual patients considerations;

AVOID HYPOGLYCEMIA!!

Question 7

In T1DM, what should you consider screening for?

Answer 7

1. Thyroid (thyroid autoAb’s)
2. Vit B12 deficiency
3. Celiac
4. Addison’s

Question 8

Microvascular and macrovascular complications:

Answer 8

Micro: retinopathy, neuropathy, nephropathy;
Macro: heart, stroke, PVD

Question 9

Some labs to look at in diabetes?

Answer 9

1. HbA1c (2-4 times/yr)
2. Fasting lipid panel yearly
3. Annual renal assessment: serum Cr, eGFR, urine albumin:Cr
4. Liver function tests (pancreatitis)
5. TSH in T1DM
6. Celiac panel in T1DM

Question 10

Major cause of morbidity/mortality for those with diabetes; what are glycemic, blood pressure, and lipid levels we want in adults:

Answer 10

CVD: with T2DM, HTN, dyslipidemia;

A1c: less than 7.0;
BP: less than 140/90;
Lipids: LDL less than 100, but GIVE STATINS for those with MI history or age over 40 with other risk factors (even without risk factors, at 40-75 give statins)

Question 11

How do you deal with pt with BP greater than 120/80, 140/90?

Answer 11

1. Reduce Na, weight; exercise, lower booze intake
2. Start ACEi/ARB
3. Multiple drug therapy (maybe add thiazide diuretic);
4. NO ACEi or ARB in pregnant pts

Question 12

If at increased cardiovascular risk with diabetes, what can you give?

Answer 12

Aspirin (not recommended for CVD prevention) usually for men greater than 50, women greater than 60

Question 13

For CVD, treat with

Answer 13

ACEi, aspirin, statin; with prior MI, give beta-blockers for at least 2 years after event

Question 14

What do you screen for with nephropathy?

Answer 14

Urine albumin excretion

Question 15

What isn’t recommended for those with normal blood pressure and low albumin excretion who have diabetes?

Answer 15

ACEi/ARB; can use either in nonpreg patients with modestly elevated or high levels of urinary albumin excretion, but NOT BOTH

Question 16

For urinary albumin excretion, what’s abnormal? What is the GFR that causes us to worry, and what is kidney failure?

Answer 16

Greater than 30;

think less than 60, and less than 15 is kidney failure

Question 17

For all patients, regardless of GFR, what is needed? 45-60? Less than 30?

Answer 17

Cr, urinary albumin excretion, K;
eGFR every 6 months, look at electrolytes, dose adjustment, maybe refer to nephrologist; NEED

REFER TO NEPHROLOGIST

Question 18

For screening of retinopathy,

Answer 18

do dilated and comprehensive eye exam and do exam every 2 years if no retinopathy, ever year if diabetic retinopathy is found; if pregnant or want to become pregnant, do comprehensive eye exam during first trimester

Question 19

Treatment of retinopathy is

Answer 19

dealing right away with macular edema, non-prolif diabetic retinopathy or PDR; can do e.g. anti-VEGF injection

Question 20

What type of neuropathy are you worried about?

Answer 20

Diffuse (distal symmetric sensorimotor polyneuropathy); also autonomic with orthostatic hypotension, fixed tachy, SCD; gastropathy, constipation, diarrhea, bladder and erectile dysfunction

Question 21

Treatment of feet in diabetics;

Answer 21

1. Annual comprehensive foot examination
2. Do monofilament test
3. Food self-care education and refer to specialists
4. Screen for peripheral arterial disease (look for claudication)

Question 22

Common comorbid conditions of diabetes

Answer 22

1. depression
2. osa
3. fatty liver disease
4. cancer
5. fractures
6. cognitive impairment
7. low test in men
8. periodontal disease
9. hearing impairment;

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