Diabetes Flashcards
Screening targets
1. FPG <5.6 mmol/L
HbA1C <5.5%
Q3y if no RF, q1y if RFs
2. FPG 5.6 - 6.0 mmol/L
HbA1C 5.5%-5.9%
Q1y if no RF
75g 2h OGTT if RF
3. FPG 6.1-6.9 mmol/L
A1C 6.0%-6.4%
75g 2h OGTT
4. FPG >=7.0
A1C >=6.5%
Diagnosis (if asymptomatic then confirm with same test on different day, ideally A1C. If results of two separate tests available or if symptomatic then Dx made).
75g 2h OGTT
>=11.1 mmol/L is diagnostic
7.8-11.0 mmol/L is impaired glucose tolerance
<7.8 mmol/L is normal
Prediabetes
A1C 6.0-6.4%
Impaired fasting glucose
FPG 6.1-6.9 mmol/L
Recommendation for impaired glucose tolerance
Use Metformin (Grade A)
Indications for statins in DM
Any of:
- macrovascular disease
- age > 40
- age < 40 and 1 of
- age > 30 + disease > 15 years
- microvascular complications
- warrants tx based on CCS guidelines
Indications for ACE/ARB in DM
Any of:
- Clinical macrovascular disease
- Age >= 55
- Age < 55 + microvascular complications
When to get ECG in DM (and how often to repeat)?
Any of:
- age 40
- age > 30 + disease > 15 years
- micro/macro complications
- other CV risk factors
Repeat every 2 years
When to get GXT in DM
- anginal symptoms
- PAD
- carotid bruits
- TIA/stroke
- Resting abnormalities on ECG
How often to screen for retinopathy in DM?
- yearly
How often to screen with ACR in DM?
- yearly
ED Screening in DM
- If +ve screen, test of hypogonadism
- if eugonadal, try PDE5 inhibitor
- if fails, refer
When to Screen for DM
- Age > 40 (q 3 years)
- 1st degree relative with DM
- GDM or infant > 4 kg
- other risk factors
GDM Screening
- All women 24-28 weeks GA
- Any time in pregnancy if risk factors
- 50 g 1 h OGCT
- <7.8 normal, recheck at 24-28 wks if done earlier
- >10.3 = GDM
- 7.8-10.2, go to 2h 75 g OGTT
- any of
- FPG >= 5.3
- 1h >= 10.6
- 2h >= 8.9
- any positive = GDM
- any of
Initial A1C goals in DM and initiating pharmacotherapy
- Goal is <7% within 3 months
- if symptomatic then Metformin + insulin
- if <8.5% then lifestyle x 3 months
- if still > 7%, start metformin
- if >8.5%, start metformin
Sulfonylureas
- 0.8% A1C drop on average
- Insulin secretagogues
- Risk of hypoglycemia
- Use gliclazide (Diamicron, Diamicron MR)
- Don’t use glyburide (Gluconorm)
DPP-4 inhibitors
- 0.7% A1C decrease on average
- Sitagliptin (Januvia) + Metformin = Janumet (needs renal adjustment)
- 50 mg BID
- Saxagliptin (Onglyza)
- Linagliptin (Trajenta) + Metformin = Jentadueto (no renal adjustment)
- 2.5 mg BID
Thiazolidinediones (TZD’s)
- enhance peripheral insulin sensitivity
- 0.8% decrease A1C on average
- negligible hypoglycemia risk
- pioglitzaone (Actos)
- higher risk bladder ca
- rosiglitazone (Avandia)
- higher risk of AMI
- Both have increased CHF (contraindication), bone fractures, weight gain
SGLT2 inhibitors
- 1-2% reduction A1C
- glycosuria by resorption of glucose by kidney
- decrease BP, weight loss, no significant risk of hypoglycemia
- increase genital fungal infections, increase LDL
- decrease BMD, increase fractures
- can cause DKA with relatively normal PG levels in T2DM
- dapagliflozin (Forxiga)
- canagliflozin (Invokana)
- renal adjustment
Alpha-gluconidase inhibitor
- 0.6% reduction A1C
- inhibits breakdown of carbohydrates in gut
- weight neutral
- flatulence, GI upset
- acarbose
GLP-1 Receptor Agonists
- 1% A1C reduction
- amplify incretin pathway by providing DDP4 resistant analgogue to GLP-1
- negligible hypoglycemia risk as monotherapy
- exenatide (Byetta)
- Liraglutide (Victoza)
- injectable, expensive
- weight loss, nxvx
- pancreatitis
- contraindicated in MEN2 syndrome or hx medullary thyroid ca
