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Diabetes 6 Flashcards

1
Q

What is the definition of hypoglycemia?

A

low BG level (<4.0mmol/L)
development of autonomic (adrenergic) or neuroglycopenic (CNS) symptoms
symptoms respond to intake of CHO

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2
Q

What are risk factors for hypoglycemia?

A

missed meals or not eating enough
excessive amount of exercise
taking too much of an anti-hyperglycemic
alcohol
prior episode of severe hypoglycemia; hypo unawareness

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3
Q

At what BG level do neurogenic (autonomic) symptoms occur? What are the symptoms?

A

<4.0mmol (occurs before neuroglycopenic)
trembling, palpitations, sweating, anxiety, hunger, nausea, tingling

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4
Q

At what BG level do neuroglycopenic symptoms occur? What are the symptoms?

A

<2.8mmol/L
difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness

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5
Q

What are the different severities of hypoglycemia?

A

mild (level 1):
-<3.9mmol/L and >3.0mmol/L
-autonomic sx
-patient able to self-treat
moderate (level 2):
-<3.0mmol
-autonomic and neuroglycopenic sx
-patient able to self-treat
severe (level 3):
-<2.8mmol
-autonomic and neuroglycopenic sx
-unresponsiveness and unconscious
-unable to self-treat

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6
Q

What is hypoglycemic unawareness?

A

inability to recognize the early warning signs of low BG levels
-first sx of hypoglycemia will often be confusion or loss of
consciousness

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7
Q

What is hypoglycemic unawareness often a result of?

A

frequent lows due to:
-decrease in hormonal response that prevent hypo
(epinephrine and glucagon)
-lowering of threshold at which hypo sx are experienced
-beta blockers can contribute

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8
Q

What are the steps to address hypoglycemia?

A
  1. recognize autonomic or neuroglycopenic symptoms
  2. confirm if possible (with CBG, FGM, CGM)
  3. treat with “fast sugar” to relieve symptoms
  4. retest in 15 minutes to ensure that BG >4.0mmol/L and
    retreat if needed
  5. eat usual snack or meal at that time of the day or a snack
    with 15g carbohydrate plus protein
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9
Q

What is the treatment of mild to moderate hypoglycemia?

A
  1. eat or drink 15g of fast-acting carbohydrate
    -this will raise BG by ~2mmol/L within 20 minutes
  2. wait 15 mins then check BG again, if still low take 15g CHO
  3. once BG >4.0mmol/L, eat within the hour (meal including a
    starch and protein)
  4. wait until BG >5.0mmol/L before driving (~40mins)
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10
Q

What are examples of 15g of simple CHO?

A

Dex4 tabs
15ml of sugar dissolved in water
2/3 cup of juice or regular soft drink
6 Life Savers
15ml of honey

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11
Q

How do we treat severe hypoglycemia?

A

if the patient is conscious:
1. treat with 20g CHO preferably as glucose tabs (
-will raise BG by 3.5mmol/L over 45mins
2. wait 15min and retest BG
3. retreat with another 15g of glucose if BG <4.0mmol/L
4. eat usual snack or meal at that time of day or snack with 15g
CHO plus protein
if patient is unconscious:
1. treat with glucagon (1mg IM/IV or 3mg nasal spray)
2. call 911
3. turn patient into recovery position
4. eat as soon as safely possible
5. discuss with health care team

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12
Q

Differentiate between injectable and nasal glucagon.

A

injectable: Glucagen, Glucagen Hypokit, Glucagon rDNA
-injectable 1mg (IM: deltoid or thigh, SC: arm, thigh, butt)
-reconstitution is necessary
nasal: Baqsimi
-3mg nasal spray
-no priming/reconstitution
-keep in shrink wrap until ready to use
both have similar efficacy and response time

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13
Q

What is pseudo-hypoglycemia?

A

individual experiences hypo despite BG >4.0mmol/L
-usually individuals accustomed to chronic high BG and have a
rapid drop in BG once they start tx
-once under control the perception of these sx will dissipate at
higher BG

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14
Q

What are the usual causes of hyperglycemia?

A

too little insulin/omission of insulin
illness
infection
surgery
injury
stress
increased food
exercise (in T1DM) with BG >14mmol/L and ketones

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15
Q

What is DKA and why does it occur?

A

characterized by:
-hyperglycemia (usually >14mmol/L)
-ketonemia
-metabolic acidosis
occurs as a result of insulin deficiency

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16
Q

What does DKA cause?

A

significant loss of water and electrolytes through urine
-ECF volume depletion
stimulation of lipolysis
-this causes acidosis

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17
Q

What are the signs and symptoms of DKA?

A

hyperglycemia:
-excessive thirst
-excessive urination
-fatigue/weakness
-blurred vision
-change in appetite
acidosis:
-abdominal pain, nausea, vomiting
-air hunger
-fruity acetone breath
-hyperventilation
-confusion

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18
Q

What is the treatment of DKA?

A
  1. replacement of fluid loss
  2. replacement of K
  3. correction of metabolic acidosis
  4. if patient in shock of pH<7 , sodium bicarbonate
  5. once BG 14mmol/L, IV glucose should be added
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19
Q

True or false: hyperosmolar hyperglycemic syndrome is more common than DKA and is predominantly in younger patients with T1DM

A

false
predominantly in older patients with T2DM

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20
Q

What is hyperosmolar hyperglycemic syndrome?

A

extremely high sugar, increased osmolality, significant dehydration, and minimal ketoacidosis
usually precipitated by infection or another illness

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21
Q

True or false: ketogenesis occurs in hyperosmolar hyperglycemic syndrome

A

false

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22
Q

How is hyperosmolar hyperglycemic syndrome managed?

A

fluid resucitation
avoidance of hypokalemia
insulin administration
avoidance of rapidly falling osmolality
search for precipitating cause

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23
Q

How can DKA/HHS be prevented?

A

education around sick day management
adjust insulin as needed
frequent monitoring of BG when ill
check for ketones

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24
Q

PWD are at a greater risk of morbidity and mortality from which infections?

A

influenza
pneumonia
COVID

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25
Which vaccinations are highly recommended for diabetics?
annual influenza COVID-19 pneumococcal
26
What is the significance of illness with diabetes?
illness is a stressor causing exaggerated counterregulatory hormone response (overproduction of glucose) illness may be accompanied by dehydration and decreased appetite -increased urination, vomiting, and diarrhea *BG increases in acute illness even with reduced calories*
27
Describe sick day management.
monitor BG more frequently: every 2-4hrs T1: continue insulin, adjust bolus doses based on BG, ketones, food intake T2: increase or decrease insulin based on SMBG drink plenty of extra glucose-free fluids if unable to eat, replace solid foods with glucose-containing foods -Jello, popsicle, pop
28
What does the SICK acronym mean for diabetes?
S=blood sugar testing (q2-4hrs) I=insulin (continue to take it) C=carbs and fluids (CHO intake normal, increase fluids) K=ketone testing
29
If a diabetic is ill and is at risk of dehydration, what kind of medications will they be instructed to hold?
increase risk for decline in kidney function have reduced clearance and risk for AE (metformin, SU) SAD MANS -SU, ACEI, diuretics and DRI, metformin, ARB, NSAIDs, SGLT2i *stop for a few days until recover then start taking again(
30
True or false: diabetes increases the risk for many cardiovascular diseases such as HF, ACS, and stroke
true
31
What is the acronym to help remember the ways to reduce risk of cardiovascular disease as a diabetic?
ABCDESSS -A1C targets -BP targets -cholesterol agents -drugs for CVD risk reduction -exercise and healthy eating -screening for complications -smoking cessation -self management
32
Whats the proportion of PWD who have hypertension?
~70%
33
What is a major cause of microvascular and CV complications, especially for diabetics?
hypertension
34
What is the blood pressure target for diabetics?
<130/80
35
What is the recommended drug for patients with CVD or CKD, or with CV risk factors in addition to diabetes and hypertension?
ACEI or ARB
36
What are the drugs recommended for PWD and hypertension without CV risk factors?
ACEI ARB thiazide DHP CCB
37
True or false: PWD should be empirically put on an ACEI or ARB
false however many will derive benefits at some point based on their clinical factors (clinical CVD, age>55, microvascular complications, etc)
38
What is the significance of cholesterol and diabetics?
PWD have an increased risk of CV diseases even if their LDL is normal even higher risk if LDL is elevated
39
True or false: diabetes is a statin indicated condition
true most PWD have an indication to be on a statin -age>40 -age>30 and DM >15yrs -microvascular disease
40
What are the lipid targets for diabetics?
LDL < 2.0mmol/L or >50% reduction of LDL ApoB < 0.8g/L or non-HDL < 2.6mmol/L
41
Describe primary prevention of dyslipidemia/CV protection for diabetics.
1st line drug is a stain 40-75yrs w/o atherosclerosis=moderate intensity statin -atorv 10-20mg, simv 20-40mg, rosuv 5-10mg 50-70yrs, atherosclerotic risk factors=high dose statin -atorv 40-80mg, rosuv 20-40mg
42
Describe secondary prevention of dyslipidemia/CV protection for diabetics.
high dose statin 2nd line agent if targets not met -ezetimibe or PCSK9 inhibitor -others: bile acid sequestrants, icosapent ethyl
43
Should people with diabetes use ASA?
primary prevention: ASA not routinely recommended -risk of GI bleed>CV benefit secondary prevention: low dose ASA OD recommended -clopidogrel 75mg in those allergic/intolerant to ASA
44
What is key in preventing and/or delaying the progression of microvascular complications?
tight control of: -BP -BG -lipids
45
What are some cells that cannot down-regulate glucose entry?
glomeruli endothelium nerve cells
46
What is the primary cause of CKD in PWD?
diabetic nephropathy -slow and progressive increase in albuminuria followed by decrease in eGFR <60ml/min
47
What are risk factors for diabetic nephropathy?
longer duration of diabetes poor BG, BP, and lipid control obesity smoking
48
Describe the screening for CKD for diabetics.
T1DM: 5 years after diagnosis (then annually) T2DM: at diagnosis (then annually)
49
When can a diagnosis of CKD be made with diabetes?
eGFR <60ml/min +/- ACR >2.0mg/mmol on at least 2/3 samples over a 3 month period
50
What are some scenarios where you should not screen for CKD due to elevated ACR?
exercise within 24hr infection fever HF marked hyperglycemia menstruation marked HTN
51
What is the treatment of diabetic nephropathy?
aimed to slow progression of albuminuria and decline of eGFR 1. optimize BG control 2. optimize BP control 3. use of SGLT2i
52
What is diabetic retinopathy?
damage to the blood vessels of the retina that can cause them to bleed or leak fluid, distorting vision
53
What are the risk factors for diabetic retinopathy?
duration of diabetes glycemic control HTN, dyslipidemia anemia nephropathy tobacco use African American
54
True or false: glaucoma and cataracts occur earlier and more frequently in PWD
true
55
Describe the screening for retinopathy for diabetics.
T1DM: 5yrs after diagnosis when >15yo (then annually) T2DM: at diagnosis (then q 1-2yrs)
56
What is the prevention for diabetic retinopathy?
optimize glycemic control optimize BP control
57
What is the treatment for diabetic retinopathy?
varies based on the type of the ocular problem laser therapy, intraocular injections, and/or vitreoretinal surgery
58
What is diabetic neuropathy?
a type of nerve damage that can occur as a result of having diabetes most commonly results from reduced blood flow to nerves which is a result of damage to blood vessels from hyperglycemia chronic and often progressive
59
What are the different types of diabetic neuropathies?
distal symmetric poly-neuropathy (DSPN) -most common, sensorimotor nervous system diabetic autonomic neuropathy (DAN) -ANS (includes heart, GIT, genitourinary, sexual function)
60
What are the risk factors for diabetic neuropathy?
elevated BG elevated TG high BMI smoking HTN
61
Describe the screening for diabetic neuropathy.
T1DM: after 5yrs post-pubertal duration (then annually) T2DM: at diagnosis (then annually) assessed via loss of sensitivity to the 10g monofilament or loss of sensitivity to vibration at the dorsum of the great toe
62
What is the most common type of neuropathy?
peripheral neuropathy -will develop within 10yrs of the onset of diabetes in 40-50% of people with T1DM and T2DM
63
Where does peripheral neuropathy often present first? What does it predispose the patient to?
usually feet first predisposition to foot ulcers, infection, gangrene, amputation
64
What are the symptoms of peripheral neuropathy?
early symptoms as a result of small fibers -pain -burning and tingling -altered sense of temperature involvement of large fibers -loss of protective sensation -numbness
65
What is the treatment for peripheral neuropathy?
optimize BG -may prevent or delay onset in T1 -can slow progression of T2 *no disease modifying treatments exist*
66
What are options for pain management of peripheral neuropathy?
oral -gabapentinoids (pregabalin, gabapentin) -SNRIs (duloxetine, desvenlafaxine) -sodium channel blockers (valproic acid) -TCAs (amitriptyline) topical -capsaicin cognitive behavioral therapy
67
How much pain relief is usually considered a success?
30% pain reduction
68
True or false: pain management of peripheral neuropathy is for the numbness
false for pain
69
When should you start looking at a different agent for peripheral neuropathy?
no improvement after 12 weeks
70
What is a consequence of diabetic neuropathy and PAD?
foot ulcers and amputation
71
What are factors that contribute to amputation?
nerve damage or diabetic neuropathy skin changes calluses ulcers poor circulation smoking prolonged hyperglycemia hypertension nerve damage and poor circulation
72
How often should diabetics get foot exams?
annual
73
Describe general diabetic foot care.
wash feet in warm water using mild soap dry feet carefully, especially between toes check feet and in between toes for cuts, cracks, ingrown toenails, blisters, etc (use hand mirror) clean cuts with mild soap/water then cover with dressing trim nails straight across and file any sharp edges apply unscented lotion to heels and soles dont put lotion between toes wear clean socks and well-fitting shoes (never go bare) test bath water temp with your hand avoid sitting for long do not smoke
74
Describe how to perform a monofilament exam.
1. exam foot for abnormalities 2. show patient monofilament, apply to their upper arm 3. instruct patient to say "yes" every time monofilament is felt 4. have patient close eyes 5. apply monofilament to bottom of big toe using smooth motion so the monofilament is slightly bent for 1-2s 6. do not apply to calluses, ulcer, scar, or necrotic tissue 7. apply four times per foot in a random manner 8. if patient responds to <7 stimulus sites, refer (8 total)
75
True or false: diabetics experience higher prevalence of mental illness
true should be regularly screened for diabetes-related psychological disorders
76
What is obstructive sleep apnea? What is its relationship to diabetes?
sleep disorder with repetitive episodes of cessation of breathing followed by awakening to restart breathing OSA alters glucose metabolism and promotes insulin resistance
77
What are symptoms of OSA?
1. restless, non-refreshing sleep 2. snoring 3. breathing pauses 4. awakenings 5. insomnia 6. excessive daytime sleepiness of fatigue

PHAR152 (21 decks)

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