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Primary Care > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What 3 end-organ complications are diabetes the leading cause of in Canadian adults? (CDA)

A
  • Blindness
  • ESRD
  • Nontraumatic amputation
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2
Q

What is the leading cause of death in individuals with diabetes? (CDA)

A
  • Cardiovascular disease – 2-4x higher incidence than in people without diabetes
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3
Q

What is the definition of diabetes mellitus? (CDA)

A
  • A metabolic disorder characterized by the presence of hyperglycemia due to defective insulin secretion, defective insulin action or both
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4
Q

What is the difference between Type 1, Type 2 and Gestational diabetes? (CDA)

A
  • Type 1 Diabetes: diabetes that is primarily a result of pancreatic beta cell destruction (immune-mediated process) and is prone to ketoacidosis
  • Type 2 Diabetes: diabetes may range from predominant insulin resistance with relative insulin deficiency to a predominant secretory defect with insulin resistance
  • Gestational Diabetes: glucose intolerance with onset or first recognition during pregnancy
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5
Q

What are the diagnostic criteria for diabetes based on? (CDA)

A
  • Thresholds of glycemia that are associated with microvascular disease, especially retinopathy
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6
Q

What are the diagnostic criteria for diabetes? (CDA)

A

Fasting Plasma Glucose

≥7.0 mmol/L

2-hour plasma glucose after a 75 g oral GTT

≥11.1 mmol/L

Glycated hemoglobin (A1c)

≥6.5%

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7
Q

What are 5 reasons why A1c may be preferable to FPG or 2hPG? (CDA)

A
  • Measured at any time of day
  • More convenient
  • Reflects the average PG over the previous 2 to 3 months
  • Continuous cardiovascular (CV) risk factor
  • Better predictor of MACROvascular events than FPG or 2hPG
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8
Q

In which patients may A1c be misleading? (CDA)

A
  • Hemoglobinopathies
  • Iron deficiency
  • Hemolytic anemias
  • Severe hepatic disease
  • Severe renal disease
  • Ethnicities (African Americans, American Indians, Hispanics, Asians)
  • Age (increase by 0.1% per decade of life)
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9
Q

In which type of patients is A1c not recommended for the diagnosis of diabetes? (CDA)

A
  • Children
  • Adolescents
  • Pregnant women
  • Suspected Type 1 Diabetes
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10
Q

When the result for one test for diabetes is in the diagnostic range, what should then be done to confirm the diagnosis? (CDA)

A
  • In the absence of symptomatic hyperglycemia, a REPEAT confirmatory laboratory test must be done on ANOTHER day
  • It is preferable that the SAME test be repeated for confirmation
  • If the results of more than one type of test for diabetes are available and are discordant, the test whose result is above the diagnostic cut point should be repeated
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11
Q

What are the diagnostic criteria for prediabetes? (CDA)

A

Impaired Fasting Glucose (IFG)

6.1-6.9 mmol/L

Impaired Glucose Tolerance (IGT)

7.8-11.0 mmol/L

Prediabetes

6.0-6.4%

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12
Q

What combination of plasma glucose tests are predictive of 100% progression to type 2 diabetes over a 5-year period? (CDA)

A
  • FPG 6.1 to 6.9 mmol/L AND A1c 6.0 to 6.4%
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13
Q

What is the definition of the metabolic syndrome? (CDA)

A

≥3 measures to make the diagnosis of metabolic syndrome

Waist Circumference

≥102 cm (Men) / ≥88 cm (Women)

TG

≥1.7 mmol/L

HDL

<1.0 mmol/L (Men) / <1.3 mmol/L (Women)

BP

SBP ≥130 mm Hg and/or DBP ≥85 mm Hg

FPG

≥5.6 mmol/L

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14
Q

What is the evidence to support a strategy of population-based screening for type 2 diabetes? (CDA)

A
  • No current evidence of clinical benefit
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15
Q

When does the CDA recommend that screening for diabetes begin? (CDA)

A
  • Screening for diabetes using FPG and/or A1c should be performed every 3 years in individuals ≥40 years of age or at high risk using a risk calculator?
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16
Q

What are 10 risk factors for type 2 diabetes? (CDA)

A
  • 1st degree relative with type 2 diabetes
  • Ethnicity (Aboriginal, African, Asian, Hispanic or South Asian)
  • History of prediabetes
  • History of gestational diabetes mellitus
  • History of delivery of a macrosomic infant
  • Presence of end organ damage complications associated with diabetes
    • Microvascular (retinopathy, neuropathy, nephropathy)
    • Macrovascular (coronary, cerebrovascular, peripheral)
  • Presence of vascular risk factors (Metabolic Syndrome)
  • Presence of associated diseases
    • PCOS
    • Acanthosis nigricans
    • OSA
    • Psychiatrics disorders (bipolar, depression, schizophrenia)
    • HIV
  • Use of drugs associated with diabetes
    • Glucocorticoids
    • Atypical antipsychotics
    • HAART
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17
Q

In what 2 circumstances does the CDA recommend using the 2hPG in a 75 g OGTT for diabetes screening? (CDA)

A
  • Individuals with a FPG 6.1-6.9 mmol/L and/or A1c 6.0-6.4% (Prediabetes)
  • Individuals with FPG 5.6-6.0 mmol/L and/or A1c 5.5-5.9% and ≥1 risk factor
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18
Q

What does the CDA recommend as options to prevent type 2 diabetes in individuals with IGT? What is the evidence for these? (CDA)

A
  • Structured program of lifestyle modification and regular physical activity that includes moderate weight loss (Grade A, Level 1A)
    • Dietary modification (low-calorie, low-fat, low-saturated fat, high-fibre diet) and moderate-intensity physical activity (at least 150 minutes per week) resulted in moderate weight loss of approximately 5% of initial body weight
    • Reduced risk of DM2 by 58% at 4 years
  • Metformin 850 mg BID (Grade A, Level 1A)
    • ~30% reduction at 2.8 years
    • No effect in older age group (≥60 years) and in non-obese (BMI<35)
  • Acarbose 100 mg TID (Grade A, Level 1A)
    • ~30% reduction but did not persist when discontinued
    • 49% reduction in CV events
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19
Q

What target glucose level is recommended for treating patients with diabetes? (CDA)

A
  • Therapy in most individuals with type 1 or type 2 diabetes should be targeted to achieve an A1c 7.0% in order to reduce the risk of microvascular and, IF IMPLEMENTED EARLY in the course of disease, macrovascular complications [Grade B, Level 3]
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20
Q

What are the glycemic targets for patients with diabetes in the fasting and postprandial states? (CDA)

A
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21
Q

In which patients may less stringent A1c targets (7.1-8.5%) be appropriate? (CDA)

A
  • Limited life expectancy
  • High level of functional dependency
  • Extensive CAD at high risk of ischemic events
  • Multiple comorbidities
  • History of recurrent severe hypoglycemia
  • Hypoglycemia unawareness
  • Longstanding diabetes for whom it is difficult to achieve an A1c ≤7.0% despite effective doses of multiple antihyperglycemic agents, including intensified basal-bolus insulin therapy
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22
Q

What is the evidence regarding improved glycemic control in diabetes from randomized controlled studies? (CDA)

A
  • Reduces the risk of MICROvascular complications
  • NO significant effect on MACROvascular outcomes in recently diagnosed type 1 and type 2 diabetes, as well as more long-standing type 2 diabetes
    • Follow-up data from DCCT and UKPDS studies (conducted in RECENTLY DIAGNOSED diabetes) found benefit with CV outcomes in those originally randomized to intensive treatment [THIS IS WHY RECOMMENDATION SPECIFIES “IF IMPLEMENTED EARLY”]
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23
Q

What did the UKPDS trial find that supports the A1c target of <7.0%? (TFP)

A
  • NEWLY diagnosed diabetics, age ~50s, few co-morbidities, receiving single glucose-lowering therapy (to start) versus diet
    • Sulfonylurea or insulin – median 10 year A1c 7.0% vs 7.9%
      • Reduction in death (NNT=29) and MI (NNT=36)
    • Metformin – median 10 year A1c 7.4% vs 8.0%

Reduction in death (NNT=14) and MI (NNT=16

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24
Q

What are the 3 major trials that looked at the effect of intensive glycemic control on patients with long-standing type 2 diabetes? (CDA)

A
  • ACCORD
  • ADVANCE
  • VADT
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25
Q

What was the significant outcome from the ACCORD trial? (CDA)

A
  • Intensive glucose control arm was prematurely terminated after 3.5 years due to HIGHER mortality associated with assignment to this treatment
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26
Q

What was the significant finding from these 3 (ACCORD, ADVANCE, VADT) trials? (CDA)

A
  • Intensive glycemic control improves MICROvascular outcomes
    • ACCORD improved albuminuria and diabetic retinopathy
    • ADVANCE improved nephropathy
    • VADT improved albuminuria
  • NO benefit on MACROvascular outcomes
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27
Q

What was the major risk associated with intensive glycemic control from these 3 trials? (CDA)

A
  • 2-fold increase in the risk of severe hypoglycemia
  • Higher mortality reported in participants with 1 or more episodes of severe hypoglycemia in both ACCORD and ADVANCE, irrespective of which treatment arm patients were in
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28
Q

How often should patients with diabetes have their A1c measured? (CDA)

A
  • Every 3 months
    • When glycemic targets are not being met and when diabetes therapy is being adjusted
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29
Q

When can patients with diabetes have their A1c measured every 6 months? (CDA)

A
  • Periods of treatment and lifestyle stability when glycemic targets have been consistently achieved
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30
Q

By what % does the mean plasma glucose in the previous 120 days contributed to the A1c value? (CDA)

A
  • <30 days prior = 50%
  • 31 to 90 days prior= 40%
  • 90 to 120 days prior = 10%
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31
Q

For which patients with diabetes does the CDA recommend should use self-monitoring of blood glucose (SMBG)? (CDA)

A
  • Type 1 Diabetes with Insulin >1x per day (Grade A, Level 1)
  • Type 2 Diabetes with Insulin >1x per day (Grade C, Level 3)
  • Type 2 Diabetes with Insulin 1x daily (Grade D, Consensus)
  • Type 2 Diabetes without Insulin but in whom glycemic control is NOT being achieved (Grade B, Level 2)
  • Consider in Type 2 Diabetes on an insulin secretagogue
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32
Q

How often should SMBG be performed per day in patients with diabetes? (CDA)

A
  • 3+ times per day (including both pre- and postprandial measurements)
    • Preprandial
    • 2-hour postprandial
    • Occasional nocturnal (unrecognized nocturnal hypoglycemia)
  • 1+ times per day (DM2 with once daily insulin)
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33
Q

What are 5 benefits of SMBG in patients with diabetes? (CDA)

A
  • Only way to confirm, and appropriately treat, hypoglycemia
  • Provide feedback on the results of lifestyle and pharmacological treatments
  • Increase patient empowerment and adherence to treatment
  • Provide information to both the patient and healthcare professional to facilitate longer-term treatment modifications and titrations as well as short-term treatment decisions
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34
Q

By how much has SMBG been shown to improve the A1c in type 2 diabetes not treated with insulin? (CDA)

A
  • 0.2-0.5%
    • Series of recent meta-analyses
    • Greater reductions in those performed SMBG when the baseline A1c was >8%
    • Most effective within the first 6 months after diagnosis
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35
Q

What is the evidence for routine SMBG in type 2 diabetes who do not use insulin? (TFP)

A
  • No clinical benefits
    • A1c reduced by 0.2 – 0.35% (0.5% considered minimum clinically important)
  • Not cost-effective
  • May reduce quality of life (depressive symptoms)
  • Should still know HOW to test their blood glucose in case it is low, they are feeling ill, or they are interested in seeing the impacts of lifestyle behaviours
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36
Q

How does SMBG affect patient satisfaction, general well-being or general health-related quality of life in patients with type 2 diabetes not treated with insulin? (CDA)

A
  • No evidence of any benefit
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37
Q

In which patients is ketone testing recommended for? (CDA)

A
  • Type 1 diabetes:
    • During periods of acute illness accompanied by elevated BG
    • When preprandial BG levels remain elevated (>14.0 mmol/L)
    • Symptoms of DKA (e.g. nausea, vomiting, abdominal pain)
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38
Q

What is the recommended amount of exercise for adults with diabetes? (CDA)

A
  • Minimum of 150 minutes of moderate- to vigorous-intensity aerobic exercise each week
    • Spread over at least 3 days of the week
    • No more than 2 consecutive days without exercise
  • Resistance exercise at least 2x per week (preferably 3x per week) IN ADDITION to aerobic exercise
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39
Q

What is the recommended amount of exercise for children with type 2 diabetes? (CDA)

A
  • 60 minutes daily of moderate to vigorous physical activity
  • Limit sedentary screen time to <2 hours per day
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40
Q

For patients that struggle with pain upon walking (e.g. due to osteoarthritis), what is an alternative form of aerobic exercise? (CDA)

A
  • Semi-recumbent cycling
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41
Q

What are examples of moderate and vigorous aerobic exercise for most middle-aged individuals? (CDA)

A
  • Moderate: brisk walking on level ground, semirecumbent cycling
  • Vigorous: brisk walking up an incline, jogging
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42
Q

In which patients with diabetes should medical evaluation be performed prior to engaging in exercise? (CDA)

A
  • People with diabetes with possible CVD or microvascular complications of diabetes who wish to undertake exercise that is substantially more vigorous than brisk walking
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43
Q

What medical evaluation is recommended for patients with diabetes prior to engaging in exercise? (CDA)

A
  • History
  • Physical examination
    • Fundoscopic exam
    • Foot exam
    • Neuropathy screening
  • Resting ECG
  • (Possibly) Exercise ECG Stress Testing
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44
Q

What is the evidence for exercise ECG stress testing in asymptomatic people with diabetes? (CDA)

A
  • 2 randomized trials found it had no impact on the risk of major cardiovascular events
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45
Q

What are 4 complications of diabetes that might pose an increased risk with certain type of exercise? (CDA)

A
  • Severe autonomic neuropathy
  • Severe peripheral neuropathy
  • Preproliferative or Proliferative Retinopathy
  • Unstable angina
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46
Q

What should patients with severe peripheral neuropathy be instructed to do prior to exercise? (CDA)

A
  • Inspect feet daily
  • Wear appropriate footwear
  • Do not engage in exercise with active foot ulcers
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47
Q

What should individuals with diabetes (type 1 or type 2 using insulin or insulin secretagogues) do if their pre-exercise blood glucose levels are <5.5 mmol/L? (CDA)

A
  • Ingest 15-30 g of carbohydrates before exercise
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48
Q

How does exercise acutely affect blood glucose levels? (CDA)

A
  • ↓BG (during and after) due to increased glucose disposal and insulin sensitivity
  • ↑BG (during and after) VERY INTENSE exercise (e.g. hockey, basketball, intense resistance training) due to increased glucose production that exceeds increases in glucose disposal
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49
Q

By how much has nutrition therapy been shown to reduce A1c in patients with diabetes? (CDA)

A
  • 1.0 to 2.0%
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50
Q

What guide are individuals with diabetes recommended to follow regarding their nutrition? (CDA)

A
  • Eating Well with Canada’s Food Guide
    • Emphasis on foods low in energy density and high in volume to optimize satiety and discourage overconsumption
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51
Q

What % of people with type 2 diabetes are overweight or obese? (CDA)

A
  • 80-90%
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52
Q

What macronutrient distribution as a % of total energy is recommended for adults with diabetes? (CDA)

A
  • Can vary to allow for individualization of nutrition therapy
    • Carbohydrates 45-60%
    • Protein 15-20%
    • Fat 20-35%
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53
Q

What is the evidence for CHO-restricted (4% to 45% of total energy per day) diets in people with type 2 diabetes? (CDA)

A
  • Improved A1c and TG
  • Did NOT improve TC, HDL, LDL or body weight compared to higher-CHO diet
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54
Q

What does the Glycemic Index (GI) represent? (CDA)

A
  • Assessment of the quality of the CHO-containing foods based on their ability to raise blood glucose
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55
Q

What are examples of low-GI and high-GI food sources? (CDA)

A
  • Low-GI
    • Beans, peas, lentils, pasta, pumpernickel or rye breads, parboiled rice, bulgur, barley, oats, quinoa
    • Temperate fruit (apples, pears, oranges, peaches, plums, apricots, cherries, berries)
  • High-GI
    • White or whole wheat bread, potatoes, highly extruded or crispy puffed breakfast cereals (corn flakes, puffed rice, puffed oats, puffed wheat)
    • Tropical fruit (pineapple, mango, papaya, cantaloupe, watermelon)
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56
Q

Why is soluble dietary fibre considered beneficial for patients with diabetes? (CDA)

A
  • Slows gastric emptying
  • Delays the absorption of glucose in the small intestine
  • Improves postprandial BG control
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57
Q

How many services of vegetables and fruit per day is recommended in Eating Well with Canada’s Food Guide? (CDA)

A
  • 7 to 10 servings per day
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58
Q

What is the maximum % of total daily energy adults with diabetes should get from saturated fats? (CDA)

A
  • 7%
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59
Q

What dietary recommendation should be considered for patients with diabetes who have chronic kidney disease (CKD)? (CDA)

A
  • Restricting dietary protein to 0.8 g/kg body weight per day
    • 1 to 1.5 g/kg body weight per day normal (15-20% of total energy intake)
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60
Q

What are 4 alternative dietary patterns that people with type 2 diabetes can follow that have been shown to improve glycemic control? (CDA)

A
  • Mediterranean-style
  • Vegan or Vegetarian
  • Incorporation of dietary pulses (beans, peas, chick peas, lentils)
  • Dietary Approaches to Stop Hypertension (DASH)
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61
Q

What study reported a significant benefit for the Mediterranean diet in regards to major cardiovascular events? (CDA)

A
  • PREDIMED study: Spanish multicenter, RCT of Mediterranean diet supplemented with EVOO or mixed nuts compared with a low-fat control diet
    • Stopped early for benefit
    • Reduced the incidence of MCE by ~30% over median follow-up of 4.8 years
    • No difference between those with and without diabetes (49% of participants had DM2)
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62
Q

What is the concern regarding the DASH diet in patients with diabetes? (CDA)

A
  • Low sodium intakes may be associated with increased mortality in people with type 1 and type 2 diabetes
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63
Q

What is the maximum amount of alcohol recommended? (CDA)

A
  • Males: ≤3 standard drinks per day and <15 drinks per week
  • Females: ≤2 standard drinks per day and <10 drinks per week
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64
Q

What is the concern with alcohol consumption in people with diabetes using insulin or insulin secretagogues? (CDA)

A
  • Risk of delayed hypoglycemia (if alcohol consumed with or after the previous evening’s meal)
    • Next morning after breakfast or as late as 24 hours after alcohol consumption
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65
Q

What is the insulin regimen of choice for all adults with type 1 diabetes? (CDA)

A
  • Basal-bolus insulin regiments
    • Multiple daily injections or continuous subcutaneous insulin infusion (CSII)
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66
Q

Why are rapid-acting bolus insulin analogues, in combination with adequate basal insulin, recommended instead of regular insulin in type 1 diabetes? (CDA)

A
  • Minimizes the occurrence of hypoglycemia
  • Improves A1c
  • Achieves postprandial glucose targets
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67
Q

Which rapid-acting insulin analogues should be used with CSII in adults with type 1 diabetes? (CDA)

A
  • Aspart or Lispro
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68
Q

Which long-acting insulin analogues should be used as basal insulin in adults with type 1 diabetes? (CDA)

A
  • Determir or Glargine
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69
Q

What is the advantage of using long-acting insulin analogues over NPH as basal insulin in adults with type 1 diabetes? (CDA/TFP)

A
  • Lower A1c
  • Reduced risk of hypoglycemia
  • Reduced risk of nocturnal hypoglycemia (Detemir)
  • ***TFP – no advantage in A1c, no evidence for hard outcomes, no difference in severe hypoglycemia ***
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70
Q

How often are long-acting insulin analogues administered in adults with type 1 diabetes and why? (CDA)

A
  • Twice-daily
  • 15-30% of patients using insulin glargine will experience preinjection hyperglycemia (on once daily regimen)
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71
Q

What are 3 rapid-acting insulin analogues? (CDA)

A
  • Insulin aspart (NovoRapid)
  • Insulin glulisine (Apidra)
  • Insulin lispro (Humalog)
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72
Q

What is the typical onset, peak and duration of the rapid-acting insulin analogues? (CDA)

A
  • Onset = 10-15 min
  • Peak = 1-1.5h (1-2h with Humalog)
  • Duration = 3-5h (3.5-4.75h with Humalog)
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73
Q

How does the administration of preprandial insulin differ between rapid-acting insulin analogues and short-acting insulin? (CDA)

A
  • Regular insulin: 30-45 minutes prior to a meal
  • Rapid-acting insulin: 0-15 minutes prior to or up to 15 minutes after a meal
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74
Q

What are 3 long-acting insulin analogues? (CDA)

A
  • Insulin detemir (Levemir)
  • Insulin glargine (Lantus)
  • Insulin glargine U300 (Toujeo)
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75
Q

What is the typical onset and duration for the long-acting insulin analogues? (CDA)

A
  • Onset = 90 min (up to 6h with Toujeo)
  • Duration =
    • 30h (Glargine U300/Toujeo)
    • 24h (Glargine/Lantus)
    • 16-24h (Demetir/Levemir)
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76
Q

What are the short-acting and intermediate-acting insulins? (CDA)

A
  • Short-acting insulins
    • Humulin-R
    • Novolin ge Toronto
  • Long-acting insulins
    • Humulin-N
    • Novolin ge NPH
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77
Q

What should patients with type 1 diabetes being initiated on insulin be educated on? (CDA)

A
  • How to care for and use insulin
  • Prevention, recognition and treatment of hypoglycemia
  • Sick-day management
  • Adjustments for food intake (e.g. carbohydrate counting) and physical activity
  • Self-monitoring of blood glucose (SMBG)
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78
Q

What can some patients with type 1 diabetes experience after insulin initiation? (CDA)

A
  • “Honeymoon period” – insulin requirements decrease transiently (weeks to months)
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79
Q

What is the evidence for using metformin in type 1 diabetes? (CDA)

A
  • Off-label
  • Potentially harmful in patients with renal or heart failure
  • No improvement in A1c
  • May improve insulin sensitivity
  • Reduces insulin requirements
  • Reduces TC/LDL ratio
  • May lead to modest weight loss
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80
Q

What is the most common adverse effect of intensive insulin therapy in patients with type 1 diabetes? (CDA)

A
  • Hypoglycemia
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81
Q

What is hypoglycemia unawareness? (CDA)

A
  • Threshold for the development of autonomic warning symptoms is close to, or lower than, the threshold for the neuroglycopenic symptoms
  • First sign of hypoglycemia is confusion or loss of consciousness
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82
Q

What are 3 strategies for hypoglycemia unawareness to reduce the risk of hypoglycemia in type 1 diabetes patients? (CDA)

A
  • Increased frequency of SMBG, including periodic assessment during sleeping hours
  • Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months
  • A psychobehavioral intervention program (blood glucose awareness training)
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83
Q

What % of patients with type 2 diabetes present with microvascular and/or macrovascular complications at the time of diagnosis? (CDA)

A
  • 20 to 50%
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84
Q

In patients with type 2 diabetes, when should antihyperglycemic agent therapy be started if glycemic targets are not achieved using lifestyle management? (CDA)

A
  • 2-3 months
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85
Q

When should target A1c levels be attained once starting pharmacotherapy for type 2 diabetes? (CDA)

A
  • 3 to 6 months
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86
Q

When will the maximum effect of oral antihyperglycemic agent monotherapy be seen at? (CDA)

A
  • 3 to 6 months
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87
Q

Which is better, maximal dose monotherapy or combinations of submaximal doses of antihyperglycemic agents and why? (CDA)

A
  • Combination of submaximal doses of antihyperglycemic agents
    • More rapid and improved glycemic control
    • Fewer side effects
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88
Q

What are 5 patient characteristics and 6 treatment characteristics that should be taken into account when starting pharmacotherapy for patients with type 2 diabetes? (CDA)

A
  • Patient
    • Degree of hyperglycemia
    • Overweight or obese
    • Patient preference
    • Presence of comorbidities (renal, cardiac, hepatic)
    • Ability to access treatments
  • Treatment
    • Effectiveness and durability of lowering BG
    • Risk of hypoglycemia
    • Effectiveness at reducing diabetes complications
    • Effect on body weight
    • Side effects and contraindications
    • Cost and coverage
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89
Q

What should be the initial drug use for overweight patients with type 2 diabetes? (CDA)

A
  • Metformin
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90
Q

How does metformin work to treat diabetes? (CDA)

A
  • Enhances insulin sensitivity in liver and peripheral tissues by activation of AMP-activated protein kinase
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91
Q

Why is metformin recommended as the initial agent in most patients with type 2 diabetes? (CDA)

A
  • Effectiveness in lowering BG
  • Relatively mild side effect profile
  • Long-term safety track record
  • Negligible risk of hypoglycemia
  • Lack of causing weight gain
  • Cardiovascular benefit in overweight patients
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92
Q

By how much is metformin expected to decrease A1c? (CDA)

A
  • 1.0-1.5%
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93
Q

What is the risk of hypoglycemia with metformin? (CDA)

A
  • Negligible
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94
Q

How does metformin affect weight? (CDA)

A
  • Weight neutral
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95
Q

What are 4 contraindications to metformin use? (UTD)

A
  • Renal Failure (eGFR <30)
    • ½ dose eGFR 30 to <60
  • Lactic acidosis
  • Decompensated CHF
  • Hepatic dysfunction
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96
Q

What are 8 classes of antihyperglycemic medications? (CDA)

A
  • Alpha-glucosidase inhibitor
  • Incretin agents
  • Insulin
  • Insulin secretagogue
  • Metformin
  • SGLT2 inhibitor
  • Thiazolidinedione (TZD)
  • Weight loss agent (Orlistat)
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97
Q

In patients with clinical cardiovascular disease (prior MI, CAD, unstable angina, stroke, occlusive PAD) in whom glycemic targets are not met, what medication should be added to antihyperglycemic therapy? (CDA)

A
  • SGLT2 inhibitor (Empagliflozin)
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98
Q

What is an example of an alpha-glucosidase inhibitor? (CDA)

A
  • Acarbose (Glucobay)
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99
Q

By how much is acarbose expected to decrease A1c? (CDA)

A
  • 0.6%
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100
Q

What is the risk of hypoglycemia with acarbose? (CDA)

A
  • Negligible
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101
Q

How does acarbose affect weight? (CDA)

A

What are the main side effects associated with acarbose? (CDA)

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102
Q

What are the two types of incretin agents used in diabetes? (CDA)

A
  • DPP-4 inhibitor
  • GLP-1 receptor agonist
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103
Q

What are 2 examples of DPP-4 inhibitors? (CDA)

A
  • Sitagliptin (Januvia)
  • Linagliptin (Trajenta)
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104
Q

By how much are DPP-4 inhibitors expected to decrease A1c? (CDA)

A
  • 0.7%
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105
Q

What is the risk of hypoglycemia with DPP-4 inhibitors? (CDA)

A
  • Negligible
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106
Q

How do DPP-4 inhibitors affect weight? (CDA)

A
  • Weight neutral
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107
Q

What are the main side effects associated with DPP-4 inhibitors? (CDA)

A
  • Rare cases of pancreatitis
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108
Q

What is the evidence for DPP-4 inhibitors modifying CVD or mortality? (TFP)

A
  • No evidence of benefit or harm
  • Possible increased risk in pancreatitis (NNH = 798)
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109
Q

What is an example of a GLP-1 receptor agonist? (CDA)

A
  • Liraglutide (Victoza)
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110
Q

By how much are GLP-1 receptor agonists expected to decrease A1c? (CDA)

A
  • 1.0%
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111
Q

What is the risk of hypoglycemia with GLP-1 receptor agonists? (CDA)

A
  • Negligible
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112
Q

How do GLP-1 receptor agonists affect weight? (CDA)

A
  • Significant weight loss
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113
Q

What might deter patients from using GLP-1 receptor agonists? (CDA)

A
  • Parenteral administration
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114
Q

What are the main side effects associated with GLP-1 receptor agonists? (CDA)

A
  • Nausea and vomiting
  • Rare cases of pancreatitis
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115
Q

In whom would GLP-1 receptor agonists be contraindicated? (CDA)

A
  • Personal/family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2 (MEN2)
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116
Q

By how much would insulin be expected to decrease A1c? (CDA)

A
  • 0.9-1.1%
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117
Q

How do insulin secretagogues work to treat diabetes? (CDA)

A
  • Activate sulfonylurea receptor on beta cell to stimulate endogenous insulin secretion
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118
Q

What are 2 types of insulin secretagogues? (CDA)

A
  • Sulfonylureas
  • Meglitinides
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119
Q

What are 2 examples of sulfonylureas? (CDA)

A
  • Gliclazide (Diamicron, Diamicron MR)
  • Glyburide (Diabeta)
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120
Q

By how much would sulfonylureas be expected to decrease A1c? (CDA)

A
  • 0.8%
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121
Q

What is the risk of hypoglycemia with sulfonylureas? (CDA)

A
  • Gliclazide = Minimal/moderate risk
  • Glyburide = Significant risk
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122
Q

What are two common side effects of glyburide? (CDA)

A
  • Hypoglycemia
  • Weight gain
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123
Q

What is an example of a meglitinide? (CDA)

A
  • Repaglinide (GlucoNorm)
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124
Q

By how much would meglitinides be expected to decrease A1c? (CDA)

A
  • 0.7%
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125
Q

What is the risk of hypoglycemia with meglitinides? (CDA)

A
  • Minimal/moderate risk
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126
Q

Which of sulfonylureas or meglitinides are associated with less hypoglycemia and why? (CDA)

A
  • Meglitinides – shorter duration of action allowing medication to be held when forgoing a meal
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127
Q

How do sodium-glucose linked transporter 2 (SGLT2) inhibitors work to treat diabetes? (CDA)

A
  • Enhances urinary glucose excretion by inhibiting glucose reabsorption in the proximal renal tubule
128
Q

What are 3 examples of SGLT2 inhibitors? (CDA)

A
  • Canagliflozin (Invokana)
  • Dapagliflozin (Forxiga)
  • Empagliflozin (Jardiance)
129
Q

By how much would SGLT2 inhibitors be expected to decrease A1c? (CDA)

A
  • 0.7-1.0%
130
Q

What is the risk of hypoglycemia with SGLT2 inhibitors? (CDA)

A
  • Negligible
131
Q

How do SGLT2 inhibitors affect weight? (CDA)

A
  • Weight loss
132
Q

What are the main side effects associated with SGLT2 inhibitors? (CDA)

A
  • Genital infections (Fungal)
  • UTI
  • Hypotension (Osmotic diuresis)
  • Increase in LDL
  • Caution with renal dysfunction and loop diuretics
  • Rare diabetic ketoacidosis (may occur with no hyperglycemia
133
Q

In which patients on an SGLT2 inhibitor would you suspect DKA and what should be done? (CDA)

A
  • Symptoms of breathing difficulty, nausea, vomiting, abdominal pain, confusion or fatigue
  • +/- hyperglycemia
  • Evaluate for ketoacidosis
134
Q

How do thiazolidinediones (TZD) work to treat diabetes? (CDA)

A
  • Enhances insulin sensitivity in liver and peripheral tissues by activation of peroxisome proliferator-activated receptor-gamma receptors
    • Similar to metformin which activates AMP-activated protein kinase
135
Q

What are 2 examples of TZDs? (CDA)

A
  • Pioglitazone (Actos)
  • Rosiglitazone (Avandia)
136
Q

By how much would TZDs be expected to decrease A1c? (CDA)

A
  • 0.8%
137
Q

What is the risk of hypoglycemia with TZDs? (CDA)

A
  • Negligible
138
Q

How do TZDs affect weight? (CDA)

A
  • Weight gain
139
Q

What are the main side effects associated with TZDs? (CDA)

A
  • CHF
  • Edema
  • Fractures
  • ALT elevations – must monitor and discontinue at 3x ULN
  • ?MI (Rosiglitazone)
  • Bladder cancer (Pioglitazone)
140
Q

By how much would Orlistat be expected to decrease A1c? (CDA)

A
  • 0.5%
141
Q

What is the risk of hypoglycemia with Orlistat? (CDA)

A
  • Negligible
142
Q

What is the main side effect associated with Orlistat? (CDA)

A
  • Abdominal bloating, pain and cramping
  • Steatorrhea
  • Fecal incontinence
143
Q

Rank the antihyperglycemic medications based on relative A1c lowering. (CDA)

A
  1. Metformin = 1.0-1.5%
  2. Insulin = 0.9-1.1%
  3. GLP-1 receptor agonist (Liraglutide – Victoza) = 1.0%
  4. SGLT2 inhibitors (Empagliflozin – Jardiance or Canagliflozin – Invokana) =
    1. Sulfonylureas (Gliclazide – Diamicron) = 0.8%
  6. TZD (Pioglitazone or Rosiglitazone) = 0.8%
  7. DPP-4 inhibitors (Sitagliptin – Januvia or Linagliptin – Trajenta) = 0.7%
  8. Meglitinides (Repaglinide – Gluconorm) = 0.7%
  9. Alpha-glucosidase inhibitor (Acarbose) = 0.6%
  10. Orlistat = 0.5%
144
Q

Which class of antihyperglycemic medications, other than insulin, have the highest risk of hypoglycemia? (CDA)

A
  • Insulin secretagogues
    • Glyburide > Gliclazide > Repaglinide (GlucoNorm)
145
Q

Which antihyperglycemic medications typically are associated with weight gain? (CDA)

A
  • Insulin (fast acting, NPH) > TZDs > Sulphonylureas > Meglitinides
    • TZDs
    • Insulin secretagogues
    • Insulin
146
Q

In patients with type 2 diabetes marked hyperglycemia (A1c ≥8.5%), what therapy should be considered? (CDA)

A
  • Initiating combination therapy with 2 agents – 1 of which may be insulin
147
Q

How do the antihyperglycemic medications compare in cost? (CDA)

A
148
Q

How does renal function affect the use of antihyperglycemic medications? (CDA)

A
149
Q

What is the evidence for pioglitazone in preventing CVD? (NEJM 2016)

A
  • IRIS Trial
  • Double-blind RCT of 3876 patients with a recent ischemic stroke or TIA randomized to pioglitazone 45 mg daily or placebo
  • Patients did NOT have diabetes but had insulin resistance (score >3.0 on HOMA-IR index)
  • At 4.8 years, pioglitazone group had lower rate of primary outcome (fatal or nonfatal stroke or MI) 9.0% vs 11.8%, HR 0.76
  • No significant difference in all-cause mortality
  • Pioglitazone associated with a lower risk of diabetes (???)
  • Pioglitazone associated with a greater frequency of weight gain exceeding 4.5 kg (10 lbs!), edema and bone fracture requiring surgery or hospitalization
150
Q

What study demonstrated a cardiovascular benefit with SGLT2 for patients with type 2 diabetes and clinical cardiovascular disease (CVD)? Describe the study, patients and findings. (CDA)

A
  • The Empagliflozin Cardiovascular Outcome Event Trial (EMPA-REG OUTCOME)
  • Randomized 7020 patients with DM2 and clinical CVD (prior MI, CAD, unstable angina, stroke or occlusive PAD) and eGFR ≥30 mL/min to empagliflozin (10mg or 25mg) or placebo
    • 98% of patients were receiving antihyperglycemic agents prior to randomization
      • 75% taking metformin
    • Baseline A1c levels between 7 and 10%
      • Mean 8.1%
    • 82% had had diabetes for more than 5 years
    • 80% were taking RAAS inhibitors, statins and ASA
  • 1.6% ARR (10.5% vs 12.1%, HR 0.86) for the composite cardiovascular end-point of death from cardiovascular causes, nonfatal MI or nonfatal stroke
    • Driven mainly by a 38% RRR in cardiovascular death
    • No reduction in the rate of nonfatal MI or nonfatal stroke
  • 1.4% ARR (2.7% vs 4.1%, HR 0.65, NNT = 71 in hospitalization for heart failure
  • 2.6% ARR (5.7% vs 8.3%, NNT = 38) in total mortality
151
Q

What did the EMPA-REG OUTCOME study demonstrate in regards to progression of renal disease? (NEJM)

A
  • Primary outcome was a composite of progression to microalbuminuria, a doubling of serum creatinine, having to start renal replacement therapy, or death due to renal disease
  • Improvement in progression to microalbuminuria
    • 11.2% vs 16.2%, NNT = 20
  • Improvement in doubling of serum creatinine
    • 1.5% vs 2.6%, NNT = 90
  • Improvement in need for RRT
    • 0.3% vs 0.6%, NNT = 333
152
Q

What study demonstrated a cardiovascular benefit with a GLP-1 receptor agonist for patients with type 2 diabetes and high cardiovascular risk? Describe the study, patients and findings. (NEJM)

A
  • Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER)
  • Randomized 9340 patients with DM2 and high cardiovascular risk to maximum tolerated dose liraglutide (0.6 to 1.8 mg) or placebo
    • Age 50 years or more with at least one cardiovascular coexisting condition (coronary heart disease, cerebrovascular disease, PVD, CKD of stage 3 or greater, CHF NYHA class II or III)
    • Age 60 years or more with at least one cardiovascular risk factors (microalbuminuria or proteinuria, hypertension and LVH, left ventricular systolic or diastolic dysfunction, ABI <0.9)
    • Mean duration of diabetes was 12.8 years
    • Mean A1c level 8.7%
  • 1.9% ARR (13.0% vs 14.9%, HR 0.87, 13% RRR, NNT=53) for the primary composite outcome of the first occurrence of death from cardiovascular causes, nonfatal MI or nonfatal stroke after 3.5 years
    • Driven mainly by a 22% RRR (1.3% ARR) in cardiovascular death
    • No reduction in the rate of nonfatal MI or nonfatal stroke
  • 15% RRR (1.4% ARR – 8.2% vs 9.6%, NNT=71) in total mortality
153
Q

What type of basal insulin should be used when added to antihyperglycemic agents in patients with type 2 diabetes and why? (CDA)

A
  • Long-acting insulin analogues (e.g. detemir or glargine)
  • Reduces the risk of nocturnal and symptomatic hypoglycemia compared to intermediate-acting NPH
154
Q

What should all patients with type 2 diabetes be counseled on when using or starting therapy with insulin or insulin secretagogues? (CDA)

A
  • Prevention, recognition and treatment of drug-induced hypoglycemia
155
Q

In what % of patients taking insulin secretagogues does hypoglycemia occur annually? (CDA)

A
  • 20%
156
Q

What type of bolus insulin should be used when added to antihyperglycemic agents in patients with type 2 diabetes and why? (CDA)

A
  • Rapid-acting insulin analogues (e.g. Aspart or Lispro)
  • Improves glycemic control and reduces the risk of hypoglycemia compared to regular (short-acting) insulin
157
Q

In general, when bolus insulin is added to the treatment regimen in patients with type 2 diabetes, what class of medication is usually discontinued? (CDA)

A
  • Insulin secretagogues
    • Sulfonylureas
    • Meglitinides
158
Q

How should patients with type 2 diabetes be started on basal insulin? (CDA)

A
  • Start at 10 nits at bedtime (lower if <50 kg)
  • Self-titrate by increasing the dose by 1 unit every night until fasting BG target of 4-7 mmol/L is achieved
  • Can continue metformin +/- secretagogue
  • Should monitor blood sugar once daily (fasting most indicative of effect)
159
Q

What is the evidence for initiating basal insulin in poorly controlled type 2 diabetes with oral agents compared to prandial or biphasic insulin? (TFP)

A
  • Similar A1c reductions
  • Less weight gain
  • Less hypoglycemia
160
Q

How should patients with type 2 diabetes be started on basal and bolus insulin? (CDA)

A
  • Current Basal Users
    • Add 10% bolus insulin at each meal
  • New Basal + Bolus Users
    • Calculate total daily insulin dose 0.5 units/kg
      • 40% of TDI dose as basal insulin
      • 20% of TDI dose as bolus insulin prior to each meal
    • Titrate BASAL to FASTING BG level
    • Titrate BOLUS to POSTPRANDIAL BG levels
    • Continue Metformin but likely stop secretagogue
    • Monitor blood sugar at least 3 times per day, both pre- and post-prandial
161
Q

How is hypoglycemia defined? (CDA)

A
  1. Development of autonomic or neuroglycopenic symptoms
  2. Low plasma glucose level (<4.0 mmol/L for patients treated with insulin or an insulin secretagogue)
  3. Symptoms responding to the administration of carbohydrate
162
Q

What are 7 neurogenic (autonomic) symptoms of hypoglycemia? (CDA)

A
  • Trembling
  • Palpitations
  • Sweating
  • Anxiety
  • Hunger
  • Nausea
  • Tingling
163
Q

What are 8 neuroglycopenic symptoms of hypoglycemia? (CDA)

A
  • Difficulty concentrating
  • Confusion
  • Weakness
  • Drowsiness
  • Vision changes
  • Difficulty speaking
  • Headache
  • Dizziness
164
Q

What are the 3 levels of severity of hypoglycemia? (CDA)

A
  • Mild – autonomic symptoms present – individual able to self-treat
  • Moderate – autonomic and neuroglycopenic symptoms present – individual able to self-treat
  • Severe – individual requires assistance of another person – PG typically <2.8 mmol/L
    • May become unconscious
165
Q

What is the potential long-term complication of severe hypoglycemia in patients with type 2 diabetes? (CDA)

A
  • Dementia
166
Q

What are 10 risk factors for hypoglycemia? (CDA)

A
  • Prior episode of severe hypoglycemia
  • Current low A1c (<6.0%)
  • Hypoglycemia unawareness
  • Long duration of insulin therapy
  • Autonomic neuropathy
  • Low economic status
  • Food insecurity
  • Low health literacy
  • Cognitive impairment
  • Adolescence
  • Preschool-age children unable to detect and/or treat mild hypoglycemia on their own
167
Q

What should patients at high risk for severe hypoglycemia be counseled on? (CDA)

A
  • Preventing and treating hypoglycemia (including use of glucagon)
  • Preventing driving and industrial accidents through SMBG and taking appropriate precautions prior to the activity
  • Documenting BD readings taken during sleeping hours
168
Q

How should mild to moderate hypoglycemia be treated? (CDA)

A
  • Oral ingestion of 15 g carbohydrate
  • Retest BG in 15 minutes and re-treat with another 15 g carbohydrate if the BG level remains <4.0 mmol/L
169
Q

How should severe hypoglycemia be treated in a conscious person? (CDA)

A
  • Oral ingestion of 20 g carbohydrate
  • Retest BG in 15 minutes and re-treat with another 15 g carbohydrate if the BG level remains <4.0 mmol/L
170
Q

How should severe hypoglycemia be treated in an unconscious person? (CDA)

A
  • No IV Access: Glucagon 1 mg SC or IM
  • IV Access: 10-25 g (20-50 cc of D50W) of glucose given IV over 1-3 minutes
171
Q

What should be done after hypoglycemia has been reversed? (CDA)

A
  • Should have the usual meal or snack that is due at that time of the day to prevent repeated hypoglycemia
  • If a meal is >1 hour away, a snack (including 15 g carbohydrate and a protein source) should be consumed
172
Q

By how much does 15 g and 20 g glucose increase the BG? (CDA)

A
  • 15 g – 2.1 mmol/L within 20 minutes
  • 20 g – 3.6 mmol/L within 45 minutes
173
Q

What are 5 examples of 15 g carbohydrate for the treatment of mild to moderate hypoglycemia? (CDA)

A
  • 15 g glucose (e.g. glucose tablets)
  • 3 packets of table sugar dissolved in water
  • ¾ cup of juice or regular soft drink
  • 6 LifeSavers
  • 1 tablespoon of honey
174
Q

Why are glucose or sucrose tablets or solution preferred to orange juice and glucose gels? (CDA)

A
  • Orange juice = slower to increase BG levels
  • Glucose gel = slow and must be swallowed to have a significant effect
175
Q

By how much does 1 mg Glucagon SC/IM increase the BG? (CDA)

A
  • Increase from 3.0 to 12.0 mmol/L within 60 minutes
176
Q

How does hyperglycemia lead to DKA? (CDA)

A
  • Hyperglycemia causes urinary losses of water and electrolytes (Na, K, Cl)
  • Results in extracellular fluid volume (ECFV) depletion
  • Potassium shifted out of cells (potassium deficit and abnormal concentration)
  • Metabolic acidosis
  • Hyperosmolality (water deficit leading to increased corrected sodium concentration plus hyperglycemia
177
Q

What are 6 risk factors or precipitating causes of DKA/HHS? (CDA)

A
  • New diagnosis of diabetes
  • Insulin omission
  • Infection
  • Myocardial infarction
  • Thyrotoxicosis
  • Drugs (e.g. cocaine, atypical antipyschotics, lithium)
  • 6 Is (Infection, Infarction, Intoxication, Insulin missed, Iatrogenic/Steroids, Intra-abdominal mass – pancreatitis, cholecystitis)
178
Q

What are 7 symptoms or signs of DKA? (CDA)

A
  • Symptoms of hyperglycemia (polyuria, polydipsia, blurred vision)
  • Kussmaul respiration (deep labored breathing with severe metabolic acidosis)
  • Acetone-odoured breath
  • ECFV contraction (tachycardia, hypotension, confusion)
  • Nausea/Vomiting
  • Abdominal pain
  • Decreased LOC
  • Hyperglycemia – polyuria, polydipsia, blurred vision
  • Ketosis – nausea/vomiting, abdominal pain, fruity odor
  • Dehydration – tachycardia, hypotension, confusion
  • Metabolic acidosis – tachypnea, Kussmaul respiration
179
Q

How does HHS typically present different than DKA? (CDA)

A
  • HHS more profound ECFV contraction and decreased LOC
    • Seizures
    • Stroke-like state
180
Q

What test can be done in the hospital to screen for DKA in patients with type 1 diabetes with capillary glucose >14.0 mmol/L? (CDA)

A
  • Point-of-care capillary beta-hydroxybutyrate
    • >1.5 mmol/L warrants further testing
181
Q

What is unique to pregnant women presenting with DKA? (CDA)

A
  • Lower glucose levels
    • Case reports of euglycemic DKA
182
Q

In individuals suspected of having DKA or HHS, what 8 investigations should be done? (CDA)

A
  • Electrolytes
  • Anion gap – >10
    • AG = (Na + K) – (Cl + HCO3)
  • Glucose – typically >14
  • Creatinine
  • Osmolality
  • Beta-hydroxybutyric acid
  • Blood gases – pH < 7.3
  • Serum and urine ketones
183
Q

How does plasma osmolality typically differ between DKA and HHS? (CDA)

A
  • ≤320 mmol/kg – DKA
  • >320 mmol/kg - HHS
184
Q

In adults presenting with DKA, what are 5 principles of treatment? (CDA)

A
  1. Fluid resuscitation
  2. Avoidance of hypokalemia
  3. Insulin administration
  4. Avoidance of rapidly falling serum osmolality
  5. Search for precipitating cause
185
Q

In adults presenting with HHS, what are 5 principles of treatment? (CDA)

A
  1. Fluid resuscitation
  2. Avoidance of hypokalemia
  3. Avoidance of rapidly falling serum osmolality
  4. Search for precipitating cause
  5. Possibly insulin administration to further reduce hyperglycemia
186
Q

In individuals with DKA, how should fluid administration be given? (CDA)

A
  • IV 0.9% NS at 500 mL/h for 4 hours THEN
    • Consider higher rate (1-2 L/h) in the presence of shock
  • 250 mL/h for 4 hours
187
Q

What is the concern with overly rapid correction of hyponatremia in HHS? (CDA)

A
  • Central pontine myelinolysis
188
Q

How should potassium be managed in patients with DKA? (CDA)

A

True K is MUCH LOWER as acidosis shifts potassium OUT of cells (i.e. artificial elevation)

  • Hyperkalemia
    • Start K supplementation when plasma gets <5.0 to 5.5 mmol/L
  • Hypokalemia/Normokalemia
    • Give K immediately with IV fluid (between 10 and 40 mmol/L)
  • Hypokalemia <3.3 mmol/L
    • Withhold insulin until K ≥3.3 mmol/L
189
Q

How should insulin be given in patients with DKA? (CDA)

A
  • Infusion of short-acting IV insulin of 0.10 U/kg/h
  • Insulin infusion rate should be maintained until the resolution of ketosis as measured by the normalization of the plasma anion gap
190
Q

How should hypoglycemia be avoided in patients with DKA receiving an insulin infusion? (CDA)

A
  • IV dextrose started once plasma glucose concentration reaches 14.0 mmol/L
191
Q

When would bicarbonate therapy be used for DKA? (CDA)

A
  • Only in extreme acidosis of pH ≤ 7.0
192
Q

Which 3 antidepressants have been shown to cause weight gain of between 2 to 3 kg within a 1-year time frame? (CDA)

A
  • Amitriptyline
  • Mirtazapine
  • Paroxetine
193
Q

What are the 4 types of bariatric surgery? (CDA)

A
194
Q

What is the recommendation for immunizations in patients with diabetes? (CDA)

A
  • Annual influenza immunization
  • Pneumococcal immunization
    • Single dose for those >18 years of age
    • 1-time revaccination for those >65 years of age (if the original vaccine was given when they were <65 years of age) with at least 5 years between administrations
195
Q

What % of patients with diabetes report taking a natural health product for various indications? (CDA)

A
  • 78%
196
Q

What does the CDA recommend regarding the use of natural health products for glycemic control for individuals with diabetes? (CDA)

A
  • Against – insufficient evidence regarding efficacy and safety
  • Some NHPS have been shown to lower A1c by ≥0.5% in trials lasting at least 3 months in adults with type 2 diabetes
197
Q

By how much do persons with diabetes generally have a cardiovascular age in advance of their chronological age? (CDA)

A
  • 10 to 15 years
198
Q

Which trial showed the long-term benefits of an intensive multifactorial management strategy in patients with type 2 diabetes and microalbuminuria? (CDA)

A
  • STENO-2 trial
199
Q

What is the target BP for patients with diabetes? (CDA)

A
  • <130/80
200
Q

Which patients with diabetes should be treated with statins? (CDA)

A
  • Clinical macrovascular disease
  • Age ≥ 40 years for type 2 diabetes
  • Age < 40 years and 1 of the following:
    • Diabetes duration >15 years and age >30 years
    • Microvascular complications
    • Warrants therapy based on the presence of other risk factors according to the CCS guidelines
201
Q

What studies supported the use of statins for all patients with diabetes ≥40 years of age with or without 1 CV risk factor? (CDA)

A
  • HPS – Simvastatin 40 mg daily
  • CARDS (1 CV risk factor) – Atorvastatin 10 mg daily
202
Q

Which patients with diabetes but without hypertension should be treated with an ACEi or ARB? (CDA)

A
  • Clinical macrovascular disease
  • Age ≥ 55 years
  • Age < 55 years and microvascular complications
    • Should only be used if there is reliable contraception for women with childbearing potential
203
Q

Which trials showed a benefit for ACEi and ARBs in patients with type 2 diabetes? (CDA)

A
  • HOPE trial
    • Ramipril 10 mg
  • ONTARGET
    • Ramipril 10 mg
    • Telmisartan 80 mg
204
Q

What is the recommendation for ASA for the primary prevention of CVD in people with diabetes? (CDA)

A
  • No ASA
    • No reduction of CAD event s and stroke
    • Increase in GI hemorrhage
205
Q

For patients for whom ASA is recommended for secondary prevention of CVD, what can be used as an alternative in people unable to tolerate ASA? (CDA)

A
  • Clopidogrel 75 mg daily
206
Q

What % of people with diabetes will die from heart disease? (CDA)

A
  • 65-80%
207
Q

What % of MIs in diabetics occur without recognized or typical symptoms (silent MIs)? (CDA)

A
  • 1/3
208
Q

In which patients with diabetes is it recommended to have a baseline resting ECG? (CDA)

A
  • Age >40 years
  • Duration of diabetes >15 years and age >30 years
  • End organ damage (microvascular, macrovascular)
  • Cardiac risk factors
209
Q

How often should a repeat resting ECG be performed in patients with diabetes? (CDA)

A
  • Every 2 years
210
Q

What are 3 reasons for patients with diabetes to undergo exercise ECG stress testing as the initial test for CAD investigation? (CDA)

A
  • Typical or atypical cardiac symptoms (e.g. unexplained dyspnea, chest discomfort)
  • Signs or symptoms of associated disease
    • Peripheral arterial disease (abnormal ABI)
    • Carotid bruits
    • TIA
    • Stroke
  • Resting abnormalities on ECG (e.g. Q waves)
211
Q

In which patients with diabetes should pharmacological stress echocardiography or nuclear imaging be used instead of exercise ECG stress testing based on the resting ECG? (CDA)

A
  • Resting ST depression (≥1 mm)
  • LBBB or RBBB
  • Intraventricular conduction defect with QRS duration >120 ms
  • Ventricular paced rhythm or preexcitation
212
Q

What lipid testing should be done at the time of diabetes diagnosis? (CDA)

A
  • Fasting (8-hour fast) lipid profile (TC, HDL-C, TG, calculated LDL-C) OR
  • Nonfasting lipid profile (apo B, non-HDL-C calculation)
213
Q

If lipid lowering treatment is not initiated in patients with diabetes, how often is repeat testing recommended? (CDA)

A
  • Yearly
214
Q

What is the target LDL-C level for patients with diabetes? (CDA)

A
  • ≤2.0 mmol/L
215
Q

Why is a treatment target of ≤2.0 mmol/L for LDL-C advised for patients with diabetes? (CDA)

A
  • Linear relationship between the proportional CVD risk reduction and LDL-C lowering à suggests that there is NO lower limit of LDL-C
  • CARDS (Collaborative Atorvastatin Diabetes Study) trial randomized type 2 diabetics without known vascular disease but with at least 1 CVD risk factor (hypertension, retinopathy, microalbuminuria or microalbuminuria, current smoking) to Atorvastatin 10 mg daily or placebo
    • Treatment resulted in a mean LDL-C of 2.0 mmol/L from a mean baseline of 3.1 mmol/L
    • Reduced risk for CV events and stroke of 37% and 48%
  • TNT (Treating to New Targets) trial subgroup analysis of diabetics with stable CAD
    • Randomized to Atorvastatin 80 mg daily vs Atorvastatin 10 mg daily
    • Atorvastatin 80 mg daily achieved a mean LDL-C of 2.0 mmol/L had 25% fewer major CVD events than those treated with Atorvastatin 10 mg daily who achieved a mean LDL-C of 2.5 mmol/L
216
Q

For every 1.0 mmol/L reduction in LDL-C, what % reduction is seen in CVD events, regardless of baseline LDL-C? (CDA)

A
  • 20%
    • Based on Cholesterol Treatment Trialists’ (CTT) Collaboration meta-analysis of >170,000 statin-treated subjects
    • Similar for those with and without diabetes
217
Q

For diabetes patients NOT at LDL-C target despite statin therapy, which second-line agents can be considered? (CDA)

A
  • Bile acid sequestrants – e.g. Cholestyramine (Questran)
  • Cholesterol absorption inhibitor – e.g. Ezetimibe (Ezetrol)
  • Fibrates – e.g. Fenofibrate (Lipidil)
  • Nicotinic – e.g. Niacin
218
Q

What is the evidence supporting the addition of lipid-modifying agents to statin therapy for patients with diabetes? (CDA)

A
  • No evidence
    • ACCORD trial found no benefit with the addition of fenofibrate to statin therapy in patients already meeting LDL-C targets
219
Q

What is the recommended management for diabetics with a serum TG >10.0 mmol/L and why? (CDA)

A
  • Fibrate
    • Reduces the risk of pancreatitis
220
Q

What TG level is considered optimal for patients with diabetes? (CDA)

A
  • <1.5 mmol/L
221
Q

What is the blood pressure treatment threshold and blood pressure target for patients with diabetes? (CDA)

A
  • < 130/80 mm Hg
222
Q

When would combination therapy using 2 first-line agents be considered as initial treatment of hypertension in diabetes? (CDA)

A
  • SBP ≥20 mm Hg above target
  • DBP ≥10 mm Hg above target
223
Q

What is recommended as first-line initial therapy for hypertension in patients with diabetes? (CDA)

A
  • ACEi or ARB
224
Q

After an ACEi or ARB, what are two other antihypertensive classes to consider next for patients with diabetes? (CDA)

A
  • Dihydropyridine CCBs (e.g. Amlodipine, Nifedipine)
  • Thiazide/Thiazide-like diuretics
225
Q

For diabetes patients being treated with an ACEi for hypertension, what is recommended for combination therapy: dihydropyridine CCB or thiazide? (CDA)

A
  • Dihydropyridine CCB
226
Q

What were the main findings of the ACCORD trial? (CDA)

A
  • Randomized diabetic patients to target SBP <140 mm Hg or <120 mm Hg
  • No benefit in primary outcome (MI, stroke, and cardiovascular death) with intensive treatment
  • 41% reduction in risk of stroke with intensive treatment
  • Increased risk of hypotension and hyperkalemia with intensive treatment
227
Q

What is considered the earliest clinical sign of diabetic nephropathy? (CDA

A
  • Albuminuria
228
Q

What are the stages of diabetic nephropathy based on urinary albumin level? (CDA)

A
229
Q

What are two other common types of kidney disease that can occur in diabetics? (CDA)

A
  • Hypertensive nephropathy
  • Ischemic nephropathy
230
Q

How should screening for CKD in diabetes be conducted and how often? (CDA)

A
  • Random urine ACR and serum creatinine (eGFR)
  • Yearly
  • Commence at diagnosis of type 2 diabetes or 5 years after diagnosis in type 1 diabetes
231
Q

How should individuals be counseled to perform a 24-hour urine collection? (CDA)

A
  • Discard 1st morning urine on the day of collection
  • Collect all subsequent urine for a 24-hr period
  • Include the 1st morning urine of the next day
232
Q

What is the most common method of estimating renal function in Canada using the eGFR? (CDA)

A
  • MDRD (Modification of Diet in Renal Disease)
    • Age
    • Sex
    • Serum Cr
    • Race
  • Performs well when the GFR is <60 mL/min
233
Q

How is a diagnosis of CKD in diabetes made? (CDA)

A
  • Random urine ACR ≥2.0 mg/mmol and/or eGFR <60 mL/min in at least 2 of 3 samples over a 3-month period
234
Q

In which circumstance would confirmatory testing be unnecessary for diabetic nephropathy? (CDA)

A
  • Random urine ACR in overt nephropathy range (>20 mg/mmol)
235
Q

What are 7 conditions that can cause transient albuminuria? (CDA)

A
236
Q

Once a diagnosis of CKD has been made, what 2 tests should be ordered? (CDA)

A
  • Urine dipstick
  • Urine microscopy
237
Q

What is the only finding on urine dipstick and urine microscopy that would be typical of diabetic nephropathy? (CDA)

A
  • Proteinuria
  • 20% of people have persistent microscopic hematuria but cause needs to be further investigated
238
Q

What factors would favour the diagnosis of classical diabetic nephropathy vs an alternative renal diagnosis? (CDA)

A
239
Q

What medication should patients with diabetes and CKD with either hypertension or albuminuria be on? (CDA)

A
  • ACEi or ARB to delay progression of CKD (Grade A, Level 1A in type 2 diabetes)
240
Q

According to the CDA guidelines, which medication (ACEi or ARB) is better for cardiorenal protection in diabetes? (CDA)

A
  • Equal
241
Q

How should patients with diabetes on an ACEi or ARB be monitored? (CDA)

A
  • Serum Cr and K levels checked at baseline and within 1 to 2 weeks of initiation or titration of therapy and during times of acute illness
242
Q

What changes in Cr or K levels would be concerning in patients started on or treated with an ACEi or ARB? (CDA)

A
  • Hyperkalemia
  • Cr increases by more than 30% from baseline
243
Q

In patients treated with either an ACEi or ARB with diabetes, how should mild-to-moderate hyperkalemia and severe hyperkalemia be managed? (CDA)

A
  • Mild-to-moderate stable hyperkalemia
    • Counsel on a low-potassium diet
    • Non-potassium-sparing diuretics (Furosemide) and/or oral sodium bicarbonate 500 to 1300 mg PO BID (if metabolic acidosis) should be considered
    • Consider temporarily holding RAAS blockade
  • Severe hyperkalemia
    • Emergency management strategies
    • Hold or discontinue RAAS blockade
244
Q

Are ACEi or ARBs safe in pregnant women? (CDA)

A
  • No – increased risk of congenital malformations
245
Q

What should patients with diabetes and CKD be counselled on during times of acute illness? (CDA)

A
  • “Sick Day” medication list – SADMAN
    • Sulfonylureas
    • ACE-inhibitors
    • Diuretics, direct renin inhibitors
    • Metformin
    • Angiotensin receptor blockers
    • NSAIDs
246
Q

What are the 5 stages of CKD based on renal function? (CDA)

A
247
Q

What are 5 indications to refer a patient with diabetes and CKD to a nephrologist? (CDA)

A
  • Chronic, progressive loss of kidney function
  • ACR persistently >60 mg/mmol
  • eGFR <30 mL/min
  • Unable to remain on renal-protective therapies due to adverse effects such as hyperkalemia or >30% increase in serum creatinine within 3 months of starting an ACE inhibitor or ARB
  • Unable to achieve target BP
248
Q

What are the 3 forms of diabetic retinopathy? (CDA)

A
  1. Macular edema
  2. Non-proliferative diabetic retinopathy à Proliferative diabetic retinopathy
    1. Microaneurysms
    2. Intraretinal hemorrhage
    3. Vascular tortuosity
    4. Vascular malformation
  3. Retinal capillary closure (no treatment options)
249
Q

How often should screening and evaluation for diabetic retinopathy be performed? (CDA)

A
  • Type 1 Diabetes
    • Annually starting 5 years after the onset of diabetes
  • Type 2 Diabetes
    • Every 1-2 years starting at the time of diagnosis
250
Q

What did the Diabetes Control and Complications Trial (DCCT) and the UKPDS demonstrate in regards to the development and progression of retinopathy? (CDA)

A
  • Reduced with intensive glycemic control (A1c ≤7%)
251
Q

What is the evidence for BP control to reduce the risk of diabetic retinopathy progression? (CDA)

A
  • UKPDS with target BP <150/85 resulted in significant reduction in retinopathy progression compared to BP <180/105
  • ACCORD and ADVANCE found no difference for aggressive BP lowering <140/80
252
Q

What medication may be added to statin therapy to slow the progression of established retinopathy? (CDA)

A
  • Fenofibrate
253
Q

What are 3 treatment options for patients with sight-threatening diabetic retinopathy? (CDA)

A
  • Laser therapy (Retinal Photocoagulation)
  • Vitrectomy (Vitreoretinal surgery)
  • Intraocular injection of pharmacological agents (anti-VEGF)
    • Ranibizumab (Lucentis)
    • Bevacizumab (Avastin)
254
Q

When should screening for peripheral neuropathy be started and how often should it be performed in patients with diabetes? (CDA)

A
  • Type 1 Diabetes
    • Annually starting 5 years after the onset of diabetes
  • Type 2 Diabetes
    • Annually starting at the time of diagnosis
255
Q

How should screening for peripheral neuropathy be performed? (CDA)

A
  • 10-g monofilament
  • 128-Hz tuning fork – vibration at the dorsum of the great toe
256
Q

What % reduction in baseline pain in considered to be a clinically meaningful response when treating painful peripheral neuropathy? (CDA)

A
  • 30 to 50%
257
Q

What are the two classes of first-line agents for painful peripheral neuropathy? (CDA)

A
  • Anticonvulsants
  • Antidepressants
258
Q

What are 3 examples of anticonvulsants that can be prescribed for painful peripheral neuropathy? (CDA)

A
  • Pregabalin (Grade A, Level 1)
    • 75 mg BID titrate up to 300 mg PO BID (max 600 mg/day)
  • Gabapentin (Grade B, Level 2)
    • 300 mg BID titrate up to 600 mg PO QID (max 3600 mg/day)
  • Valproate (Grade B, Level 2)
259
Q

What are 3 examples of antidepressants that can be prescribed for painful peripheral neuropathy? (CDA)

A
  • Amitriptyline
    • 10 mg qhs titrate up to 100 mg qhs (max 150 mg/day)
  • Duloxetine
    • 30 mg daily titrate up to 60 mg daily (max 120 mg/day)
  • Venlafaxine
    • 37.5 mg BID titrate up to 150 mg BID (max 300 mg/day)
260
Q

What is the class of third-line agents for painful peripheral neuropathy? (CDA)

A
  • Opioids
261
Q

What are 2 topical agents that can be prescribed for painful peripheral neuropathy? (CDA)

A
  • Topical nitrate sprays
    • 30 mg spray to legs qhs titrate up to BID
  • Topical capsaicin 0.075% cream applied 3-4 times per day titrate up to 5-6 times per day
262
Q

What are 8 risk factors for ulceration in persons with diabetes? (CDA)

A
  • Peripheral neuropathy
  • Previous ulceration or amputation
  • Structural deformity
  • Limited joint mobility
  • PAD
  • Microvascular complications
  • High A1c levels
  • Onychomycosis
263
Q

How often should foot examinations be performed for patients with diabetes? (CDA)

A
  • Annually
    • Higher frequency in those at high risk)
264
Q

What should be examined for in a foot examination for patients with diabetes? (CDA)

A
  • Skin changes
  • Structural abnormalities (range of motion of ankles and toe joints, callus pattern, bony deformities)
  • Skin temperature
  • Evaluation for neuropathy
  • Evaluation for PAD
  • Ulcerations
  • Evidence of infection
265
Q

What are 2 noninvasive assessments for PAD in diabetes? (CDA)

A
  • Ankle-brachial blood pressure index (ABI)
  • Systolic toe pressure by photoplethysmography (PPG)
266
Q

What diagnosis is difficult to differentiate from osteomyelitis in diabetes? (CDA)

A
  • Charcot foot
267
Q

What are 3 things that should be discussed with diabetics at high risk of foot ulceration and amputation? (CDA)

A
  • Foot care education (counselling to avoid foot trauma)
  • Professionally fitted footwear
  • Early referrals to a healthcare professional trained in foot care management
268
Q

What are the 3 most frequently encountered pathogens when infection complicates a foot ulcer?

A
  • Staphylococcus aureus
  • Streptococcus pyogenes (GAS)
  • Streptococcus agalactiae (group B streptococcus)
269
Q

What % of adult men with diabetes have erectile dysfunction? (CDA)

A
  • 34 to 45%
270
Q

What % of men newly diagnosed with diabetes have erectile dysfunction at presentation? (CDA)

A
  • 1/3
271
Q

What are the recommended glycemic targets for children and adolescents with type 1 diabetes?

A
272
Q

What is the concern with minimizing severe hypoglycemia in children <6 years of age? (CDA)

A
  • Cognitive impairment
273
Q

What is the honeymoon period in type 1 diabetes? (CDA)

A
  • Good glycemic control and low insulin requirements (<0.5 units/kg/day) in the first 2 years after diagnosis
274
Q

What are 2 methods of intensive diabetes management in type 1 diabetes in children? (CDA)

A
  • Basal-Bolus regiments
  • Continuous Subcutaneous Insulin Infusion (CSII)
275
Q

How can hypoglycemia be managed at home with mild or impending hypoglycemia associated with inability or refusal to take oral carbohydrate? (CDA)

A
  • Mini-doses of glucagon
    • 10 ug per year of age
    • Minimum dose 20 ug and maximum dose 150 ug
276
Q

How can severe hypoglycemia in an unconscious child >5 years of age be treated at home? (CDA)

A
  • 1 mg Glucagon SC or IM
    • 0.5 mg Glucagon in children ≤5 years of age
277
Q

What adverse effect of DKA can occur in children but is rarely seen in adults? (CDA)

A
  • Cerebral edema
278
Q

How should DKA in children be assessed and managed? (CDA)

A
279
Q

What % of female adolescents with type 1 diabetes meet the DSM-IV criteria for eating disorders? (CDA)

A
  • 10% (compared to 4% in age-matched peers without diabetes)
280
Q

What 3 comorbid conditions should children with type 1 diabetes be screened for and how? (CDA)

A
281
Q

What % of individuals with type 1 diabetes have clinical autoimmune thyroid disease? (CDA)

A
  • 15 to 30%
282
Q

What % of children with type 1 diabetes have celiac disease, and what % are asymptomatic? (CDA)

A
  • 4 to 9%
    • 60 to 70% asymptomatic
283
Q

What is the controversy regarding Celiac disease screening in patients with type 1 diabetes? (CDA)

A
  • No evidence that untreated asymptomatic celiac disease is associated with short- or long-term health risks or that a gluten-free diet improves health in these individuals
284
Q

When should children with type 1 diabetes be screened for diabetes complications? (CDA)

A
285
Q

What % of young adults with type 1 diabetes have no medical follow-up during the transition from pediatric to adult diabetes care services? (CDA)

A
  • 25 to 65%
286
Q

How do children with type 1 diabetes typically differ from those with type 2 diabetes? (CDA)

A

Characteristic

Type 1

Type 2

Body habitus

Not overweight

Recent history of weight loss

Overweight (BMI >85th %ile)

Age at diagnosis

Before puberty

After puberty

Insulin resistance

Acanthosis nigricans, hypertension, dyslipidemia, PCOS

Family history

Yes

Yes

287
Q

In which children should screening for type 2 diabetes be performed? (CDA)

A
  • ≥3 risk factors in nonpubertal or ≥2 risk factors in pubertal children
    • Obesity (BMI ≥95th %ile for age and gender
    • Member of a high-risk ethnic group (e.g. Aboriginal, African, Asian, Hispanic or South Asian descent)
    • Family history of type 2 diabetes and/or exposure to hyperglycemia in utero
    • Signs or symptoms of insulin resistance:
      • Acanthosis nigricans
      • Hypertension
      • Dyslipidemia
      • NAFLD (ALT >3x upper limit of normal or fatty liver on ultrasound)
      • PCOS
  • Impaired fasting glucose or impaired glucose tolerance
  • Use of atypical antipsychotic medications
288
Q

How often should screening for type 2 diabetes be performed? (CDA)

A
  • Every 2 years
289
Q

What test should be used to screen for type 2 diabetes in children? (CDA)

A
  • FPG
290
Q

When could an oral GTT (1.75 g/kg; maximum 75 g) be used for screening of type 2 diabetes in children? (CDA)

A
  • Very obese (BMI ≥99th %ile for age and gender
  • Multiple risk factors
291
Q

What is the target A1c for most children with type 2 diabetes? (CDA)

A
  • ≤7.0%
292
Q

When should insulin therapy be considered in children with type 2 diabetes? (CDA)

A
  • A1c ≥9.0%
  • Severe metabolic decompensation (e.g. DKA)
293
Q

What are 3 pharmacologic options for treating children with type 2 diabetes? (CDA)

A
  • Metformin
  • Glimepiride
  • Insulin
294
Q

How much physical activity is recommended for children with type 2 diabetes? (CDA)

A
  • Same as general population
  • 60 minutes daily of moderate-to-vigorous physical activity
  • Limiting sedentary screen time to no more than 2 hours per day
295
Q

When should children with type 2 diabetes start screening for microvascular complications of diabetes? (CDA)

A
  • Annually at time of diagnosis
296
Q

How should children with type 2 diabetes be screened for diabetes complications and comorbidities? (CDA)

A
297
Q

For women with pregestational diabetes, what are the benefits of attaining a preconception A1c ≤7.0%? (CDA)

A
  • Spontaneous abortion
  • Congenital anomalies
  • Preeclampsia
  • Progression of retinopathy of pregnancy
298
Q

For women with pregestational diabetes, what supplements are recommended? (CDA)

A
  • 5 mg Folic acid at least 3 months preconception and continuing until at least 12 weeks postconception
  • Continue with multivitamin containing 0.4 to 1.0 mg folic acid from 12 weeks postconception to 6 weeks postpartum (or as long as breastfeeding continue)
299
Q

What medication should women discontinue with pregestational diabetes? (CDA)

A
  • ACEi and ARBs prior to conception or upon detection of pregnancy
  • Statins
300
Q

What should women with type 2 diabetes consider doing with their diabetes medications when planning a pregnancy? (CDA)

A
  • Switch from noninsulin antihyperglycemic agents to insulin
301
Q

What are the target glucose values for women with pregestational diabetes when pregnant? (CDA)

A
  • Fasting PG = <5.3 mmol/L
  • 1-hour postprandial = <7.8 mmol/L
  • 2-hour postprandial = <6.7 mmol/L
302
Q

What is the target maternal blood glucose level for women intrapartum to minimize the risk of neonatal hypoglycemia? (CDA)

A
  • 4.0 to 7.0 mmol/L
303
Q

What oral antihyperglycemic medications are safe during breastfeeding? (CDA)

A
  • Metformin
  • Glyburide
304
Q

What screening should women with type 1 diabetes in pregnancy be screened for postpartum? (CDA)

A
  • Thyroiditis = TSH test at 6-8 week postpartum
305
Q

What are 9 risk factors for GDM? (CDA)

A
  • Previous diagnosis of GDM
  • Prediabetes
  • Member of a high-risk population (Aboriginal, Hispanic, South Asian, Asian, African)
  • Age 35 years
  • BMI 30
  • PCOS, acanthosis nigricans
  • Corticosteroid use
  • History of macrosomic infant
  • Current fetal macrosomia or polyhydramnios
306
Q

When should all pregnant women be screened for GDM? (CDA)

A
  • 24 to 28 weeks
307
Q

What is the preferred approach to screening and diagnosis of GDM? (CDA)

A
308
Q

What is the alternative approach to screening and diagnosis of GDM? (CDA)

A
309
Q

What are the target glucose values for women with GDM? (CDA)

A
  • Fasting PG = <5.3 mmol/L
  • 1-hour postprandial = <7.8 mmol/L
  • 2-hour postprandial = <6.7 mmol/L
310
Q

How long should women with GDM be trialed on nutritional therapy alone before starting insulin therapy? (CDA)

A
  • 2 weeks
311
Q

What oral agents can be used for GDM in women who are nonadherent to or refuse to use insulin? (CDA)

A
  • Metformin
  • Glyburide
312
Q

What is the evidence comparing metformin to insulin in GDM? (TFP)

A
  • Metformin results in 1kg less maternal weight gain
  • Less severe neonatal hypoglycaemia for 1 in 22 babies
  • Earlier delivery by about 1 day
  • Other clinical outcomes unchanged
  • Long-term safety reassuring
313
Q

Why should women with GDM be encouraged to breastfeed immediately after delivery and to continue at least 3 months postpartum? (CDA)

A
  • Avoids neonatal hypoglycemia
  • Prevent childhood obesity
  • Reduce risk of maternal hyperglycemia
314
Q

When should women be screened for prediabetes and diabetes postpartum? (CDA)

A
  • 75 g OGTT between 6 weeks and 6 months
315
Q

What are the recommended glycemic targets in the frail elderly with diabetes? (CDA)

A
  • A1c ≤8.5% and fasting plasma glucose or preprandial PG 5.0 – 12.0 mmol/L
316
Q

Which medications should be used with caution in elderly people with type 2 diabetes? (CDA)

A
  • Sulphonylureas – risk of hypoglycemia
    • Gliclazide and Gliclazide MR preferred over Glyburide
  • Thiazolidinediones – risk of fractures and heart failure

Primary Care (12 decks)

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