Diabetes

Question 1

Screening targets

Answer 1

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).

Question 2

75g 2h OGTT

Answer 2

>=11.1 mmol/L is diagnostic

7.8-11.0 mmol/L is impaired glucose tolerance

<7.8 mmol/L is normal

Question 3

Prediabetes

Answer 3

A1C 6.0-6.4%

Question 4

Impaired fasting glucose

Answer 4

FPG 6.1-6.9 mmol/L

Question 5

Recommendation for impaired glucose tolerance

Answer 5

Use Metformin (Grade A)

Question 6

Indications for statins in DM

Answer 6

Any of:

• macrovascular disease
• age > 40
• age < 40 and 1 of
  
  • age > 30 + disease > 15 years
  • microvascular complications
  • warrants tx based on CCS guidelines

Question 7

Indications for ACE/ARB in DM

Answer 7

Any of:

• Clinical macrovascular disease
• Age >= 55
• Age < 55 + microvascular complications

Question 8

When to get ECG in DM (and how often to repeat)?

Answer 8

Any of:

• age 40
• age > 30 + disease > 15 years
• micro/macro complications
• other CV risk factors

Repeat every 2 years

Question 9

When to get GXT in DM

Answer 9

• anginal symptoms
• PAD
• carotid bruits
• TIA/stroke
• Resting abnormalities on ECG

Question 10

How often to screen for retinopathy in DM?

Answer 10

• yearly

Question 11

How often to screen with ACR in DM?

Answer 11

• yearly

Question 12

ED Screening in DM

Answer 12

• If +ve screen, test of hypogonadism
• if eugonadal, try PDE5 inhibitor
• if fails, refer

Question 13

When to Screen for DM

Answer 13

• Age > 40 (q 3 years)
• 1st degree relative with DM
• GDM or infant > 4 kg
• other risk factors

Question 14

GDM Screening

Answer 14

• 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

Question 15

Initial A1C goals in DM and initiating pharmacotherapy

Answer 15

• 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

Question 16

Sulfonylureas

Answer 16

• 0.8% A1C drop on average
• Insulin secretagogues
• Risk of hypoglycemia
• Use gliclazide (Diamicron, Diamicron MR)
• Don’t use glyburide (Gluconorm)

Question 17

DPP-4 inhibitors

Answer 17

• 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

Question 18

Thiazolidinediones (TZD’s)

Answer 18

• 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

Question 19

SGLT2 inhibitors

Answer 19

• 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

Question 20

Alpha-gluconidase inhibitor

Answer 20

• 0.6% reduction A1C
• inhibits breakdown of carbohydrates in gut
• weight neutral
• flatulence, GI upset
• acarbose

Question 21

GLP-1 Receptor Agonists

Answer 21

• 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