Diabetes

Question 1

What populations are at an increased risk for diabetes?

Answer 1

African Americans, Hispanics, and Native Americans

Question 2

What is occurring in Type 1 diabetes?

Answer 2

Auto-immune destruction of Beta-cells in the pancreas. Mainly due to islet cell antibodies

Question 3

What is hyperglycemia?

Answer 3

Increase in blood sugar with glucosuria – leading to a loss of glucose as an energy source

Question 4

In diabetics, when fat and protein in being broken down, what is this known as?

Answer 4

Ketoacidosis

Question 5

What are both hyperglycemia & ketoacidosis apart of?

Answer 5

Catabolic disorder

Question 6

What are some causes of the auto-immune response in Type 1 diabetes?

Answer 6

viruses (mumps, coxsackie B-4, rubella) & toxic chemicals

Question 7

What is occurring in Type 2 diabetes?

Answer 7

It’s is a combo of insulin resistance & defect of Beta cells not secreting enough insulin in response to glucose. Thus a decrease in insulin production over time.

Question 8

Does Type 2 diabetes have the same catabolic disorders as type 1?

Answer 8

No, circulating insulin prevents ketosis. But type 2 is aggravated by increased hyperglycemia

Question 9

What would cause type 2 diabetes?

Answer 9

Genetic pre-disposition & sedentary life style is common

Central/visceral obesity = major factor in insulin resistance

Question 10

What defect occurs in Beta cells with Type 2 diabetes, what causes it?

Answer 10

Compensate via hyperplasia

Caused by insensitivity to circulating endogenous insulin. Early on there is increased insulin production to compensate and control Blood sugar – but eventually hyperplasia occurs & glucose tolerance develops (even with hyperinsulism)

Question 11

If the compensation via hyperplasia occurs for a long period of time, what happens to the beta cells?

Answer 11

Eventually get destroyed → diabetes develops and insulin levels decline

Question 12

What would cause insulin resistance?

Answer 12

Obesity (central fat distribution), storage of fat in muscle with inactivity
Hepatic insensitivity leads to increased gluconeogenesis when insulin is present (when normally insulin turns off gluconeogenesis)

Question 13

In a type 2 diabetic we have lots of hyperglycemia going on, what can occur with chronic hyperglycemia? Why is it so important to control hyperglycemia?

Answer 13

Glucotoxicity = Can worsen insulin resistance and destroy Beta cells faster/more permanently
We must control hyperglycemia to preserve any remaining Beta cell function

Question 14

So what lifestyle changes can a patient make to lower their insulin resistance?

Answer 14

Exercise (increases blood flow to muscles, increases muscle mass, and decreases muscle fat storage)

Diet/weight loss (decreases at storage deposits)

Together they can decrease hyperinsulinism & hyperglycemia; Can even reverse impaired glucose tolerance if started early

Question 15

What is metabolic syndrome? What does metabolic syndrome lead to? What are some qualifying factors for it?

Answer 15

Insulin resistance syndrome

Can lead to an increased risk of atherosclerosis

Central obesity (>88cm or 35” in women, >102cm or 40” in men); hyperglycemia >110; Hypertension 135/85; Triglycerides >150; Low HDL

Question 16

What are clinical findings for Type 1 DM?

Answer 16

Polyuria, thirst, weight loss, dehydration, polyphagia, ketoacidosis, hyperosmolality

Question 17

What are some clinical findings for Type 2 diabetes?

Answer 17

No symptoms early on. Polyuria, thirst, skin infections, vulvovaginitis, abnormal fat distribution, hyperglycemia

Question 18

What lab reflects long term control of DM?

Answer 18

Hemoglobin A1c; reflects state of glycemia over prior 8-12 weeks

Question 19

What is a normal A1c?

Answer 19

4-6%

Question 20

What A1c level confirms diabetes?

Answer 20

Greater than 6.5%

Question 21

What A1c levels indicate prediabetes?

Answer 21

5.7-6.4%

Question 22

For a diabetic, what is our goal for the A1C?

Question 23

How often do we measure A1c’s in a diabetic?

Answer 23

every 3-4 months

Question 24

Besides A1c, what other lab findings indicate diabetes?

Answer 24

Fasting blood glucose >125

2 hour glucose tolerance test >200

Random blood sugar >200 (confirm with fasting)

Question 25

What lab findings demonstrate impaired glucose tolerance?

Answer 25

Fasting blood glucose 100-125 2 hour GTT of 140-199

Question 26

What form of testing is considered a standard of care for all diabetics?

Answer 26

Self-monitored blood sugar

Question 27

Is type 1 or type 2 diabetes associated with lipoprotein abnormalities?

Answer 27

Type 2 = High triglycerides (3-400) and low HDL (

Question 28

What are our treatment goals for DM?

Answer 28

Diet, exercise, and medications

Question 29

What is a diabetic diet?

Answer 29

Get a dietician involved, weight reduction if needed. Total calories 25-35/kg/day Total cholesterol

Question 30

How would we tightly control Type 1 Dm?

Answer 30

Insulin

Question 31

How would we tightly control type 2 DM

Answer 31

``` oral agents/insulin; control BP ( ```

Question 32

What is our goal with tightly controlling DM?

Answer 32

Get HbA1c to

Question 33

What are the blood sugar goals with therapy?

Answer 33

Pre-prandial = 90-130 Bedtime = 100-140 Peak post-prandial =

Question 34

How would we calculate plasma blood sugar from blood sugar on a test strip?

Answer 34

Add 10mg

Question 35

What are the ABC’s of diabetes?

Answer 35

Aspirin, blood pressure, cholesterol, and diabetes management

Question 36

What must we always remember about diabetics and their platelets? What are they at risk for?

Answer 36

Abnormal platelet function → increased risk of small vessel thrombosis or atherosclerosis

Question 37

When should we prescribe aspirin for our diabetic patient?

Answer 37

If they have a >10% risk for a cardiac event over 10 years | Any diabetic patient with macrovascular

Question 38

What is the dose of aspirin & risks associated with aspirin?

Answer 38

75-162mg/day Risks = PUD, gastritis and bleeding ulcers

Question 39

If a diabetic patient has AV nicking or arteriolar narrowing what does that indicate?

Answer 39

Uncontrolled BP along with their diabetes

Question 40

What 2 diagnosis would we see high trigs & low HDL?

Answer 40

Diabetes & Hypothyroidism

Question 41

How many medications does the average diabetic need?

Answer 41

3 (to help control HTN)

Question 42

What does the diabetic work-up look like?

Answer 42

Family Hx, Complete H&P, CV risk factors, lipids, BUN, Cr, Electrolytes, UA +MicAl, ECG, Ophthalmology, Podiatry

Question 43

What must we evaluate every 3-6 months in a patient with diabetes?

Answer 43

Weight, BP, A1c, foot exam, home monitoring, Psychosocial function, intercurrent illness

Question 44

What must we evaluate every year in a patient in a patient with diabetes?

Answer 44

Lipids, UA, creatinine, microalbinuria, complete PE, Ophthalmologist, dental exam

Question 45

How many sites on the feet must we exam?

Answer 45

6 on each

Question 46

What if a patient cannot feel the microfilament in an area?

Answer 46

now at a higher risk for future ulceration

Question 47

What is the most important part of a diabetics treatment?

Answer 47

EDUCATION! They need to understand – especially all of their risks

Question 48

What does exercise help with in diabetics?

Answer 48

Increases the effectiveness of insulin, stabilize insulin, improve utilization of fat

Question 49

What is at the cornerstone of T2DM treatment?

Answer 49

Weight reduction, diet & exercise, decrease adipose stores, regain insulin sensitivity

Question 50

we start a patient on metformin, if their BG remains elevated, where do we start?

Answer 50

Sulfonylurea or insulin If that doesn’t do well - Pioglitazone, Exanatide

Question 51

What is the most effective combination with metformin?

Answer 51

Metfromin + insulin is more effective that 3 oral agents

Question 52

If a patient is overweight, what combo drugs would be best?

Answer 52

Metformin, Exantide, (possibly Alpha), or SGL2’s

Question 53

In a T2DM, what insulin regimen can we use?

Answer 53

Metformin + NPH/Regular 70:30 ratio – usually before breakfast and before dinner

Question 54

What does the T1DM insulin look like?

Answer 54

Take the total insulin needed and divide that between basal (Glargine) & prandial needs (Lispro)

Question 55

What must we remind our patients of when they are ill?

Answer 55

IF they are sick they must increase their insulin levels

Question 56

What’s the most common complication of insulin use?

Answer 56

Hypoglycemia

Question 57

What are the sxs we need to educate our patients about for hypoglycemia?

Answer 57

Sweating, tachycardia, hunger, tremulousness, nausea

Question 58

What drug may mask hypoglycemia?

Answer 58

Beta Blockers

Question 59

What BS level correlates with Hypoglycemia?

Question 60

How would we treat hypoglycemia?

Answer 60

Simple sugars (candy, sugar, OJ); 1mg injection of glucagon; IV glucose

Question 61

How much glucose raises BS by 25-50mg? How many carbs are in a soda?

Answer 61

15g of glucose | 30g of carbs

Question 62

What are the long term complications we must always be aware of with diabetics?

Answer 62

Retinopathy, nephropathy, neuropathy - Microvascular | Atherosclerosis – Macrovascular

Question 63

What are the 2 categories of retinopathy? Which is worse?

Answer 63

Non-proliferative or Proliferative (worse)

Question 64

What is occurring in proliferative retinopathy?

Answer 64

Formation of new blood vessels --> blindness

Question 65

What would we see on PE with non-proliferative retinopathy?

Answer 65

Microaneursysms, hemorrhages, exudates, retinal edema

Question 66

How do we prevent retinopathy?

Answer 66

TIGHT GLYCEMIA CONTROL - A1c, tight hypertension control, and annual eye exams

Question 67

What would make retinopathy worse?

Answer 67

Smoking & hypertension

Question 68

What complication can develop with chronic hyperglycemia and uncontrolled hypertension?

Answer 68

Nephropathy

Question 69

What is the leading cause of end-stage renal disease?

Answer 69

Nephropathy

Question 70

How do we prevent nephropathy?

Answer 70

Tight A1c control, tight BP control, and smoking cessation

Question 71

If we get a microalbuminuria in a diabetic patient and see 200mg in the urine, what is this called?

Answer 71

Proteinuria

Question 72

is a dipstick enough to detect small amounts of albumin?

Answer 72

No, need a radioimmunoassay (AKA Spot AM urine)

Question 73

What is a normal microalbuminuria?

Answer 73

less than 30

Question 74

What is the BP goal for diabetics, especially those presenting with complications?

Answer 74

less than 140/90

Question 75

If a patient is losing protein in the urine, what medication do we need to give them?

Answer 75

ACE!

Question 76

What would accelerate nephropathy?

Answer 76

The development of/or progression of HTN

Question 77

SO what’s the treatment for a diabetic presenting with Nephropathy?

Answer 77

Aggressive BP control, protein restriction, initiate an ACE

Question 78

When should we be initiating an ACE (Lisinopril) in diabetic patients?

Answer 78

EARLY – with the presence of microalbuminuria – even if BP is normal!!

Question 79

What must we be cautious about with ACE’s?

Answer 79

Creatinine >2g & hyperkalemia

Question 80

What is the goal BP for diabetics? What’s the first line medication for hypertension in a diabetic?

Answer 80

less than 140/90 ACE!

Question 81

What is the cause of >70% of deaths in diabetics?

Answer 81

Atherosclerosis

Question 82

Is diabetes a coronary risk factor?

Answer 82

Yes, but it’s actually a coronary risk equivalent

Question 83

What would further a diabetics risk for atherosclerosis?

Answer 83

Metabolic syndrome

Question 84

What would the screening look like for preventing atherosclerosis?

Answer 84

History, PE, ECG, and stress testing

Question 85

Persistently high insulin levels may cause what?

Answer 85

Atherosclerosis

Question 86

If we have a patient with ulcerations of the LE and minimal to faint pulses of the LE, what complication would this be?

Answer 86

Peripheral Vascular Disease

Question 87

How do we prevent PVD in a diabetic?

Answer 87

Regular foot exams, tight glycemic control, and STOP SMOKING!

Question 88

How does a diabetic ulcer formulate?

Answer 88

Decreased circulation, loss of sensation, local infection

Question 89

A diabetic patient presents with pain in their feet that is sharp and stabbing? What is going on, how does it progress?

Answer 89

Peripheral Neuropathy; presents in a stocking/glove ascending pattern. The nerve will eventually burn out

Question 90

If a diabetic patient has early satiety, nausea, and vomiting a couple hours after a meal, with constant feelings of diarrhea/constipation – what diagnosis are you thinking?

Answer 90

autonomic neuropathy

Question 91

Autonomic neuropathy presents with gastroparesis & diarrhea/constipation, but how else?

Answer 91

Sexual dysfunction and decreased bladder sensation – trouble voiding, hesitancy, incontinence

Question 92

What is a life threatening emergency for a type 1 diabetic?

Answer 92

Diabetic ketoacidosis

Question 93

What triggers DKA?

Answer 93

Infection, trauma, surgery, MI, or and increased insulin requirement

Question 94

How does a patient present with DKA?

Answer 94

Polyuria, polydipsia, abdominal pain, N/V, weakness, and fatigue

Question 95

What would you see on PE with DKA?

Answer 95

Increased pulse, LOW BP, dehydration, rapid breathing, fruity breath

Question 96

Why is the patient dehydrated & hypotensive in DKA?

Answer 96

The metabolic acidosis is placing more glucose in the urine – which is an osmotic diuretic

Question 97

What causes DKA?

Answer 97

Not enough insulin, leading to increased blood glucose & LOTS of fat & protein breakdown

Question 98

Why is there more glucose in the blood?

Answer 98

There is an increase in cortisol, glucagon, and growth hormone resulting in gluconeogenesis & glycogenolysis

Question 99

What is initially high in DKA, but is actually low in the body? Why?

Answer 99

Potassium – because glucosuria will turn on RAAS thus spilling out potassium

Question 100

What labs do you usually see with DKA?

Answer 100

BS >300; pH less than 7.3; bicard is low - increasing the anion gap; total body K is low

Question 101

How do you treat a patient with DKA?

Answer 101

Flow sheet (BS, electrolytes, pH, bicarb, ketones, BUN) Replace insulin with REGULAR Replace fluid loss Replace K loss