Diabetes Flashcards by J L

Definition
▪ Diabetes mellitus is a disease complex with metabolic and vascular components
▪ Chronic disease characterized by \_\_\_\_\_
▪ Complications may include
 Vascular disease (macr0- and micro-)
 Nephropathy
 Retinopathy
 Neuropathy
 Poor wound healing

hyperglycemia

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Historical Persepctives
▪ Symptoms first recognized in _____ (1500 BCE)
 Excessive urination, weight loss
▪ Diabetes mellitus
 Greek physician Aretaeus (80 – 130 CE)
 Reflected sweet taste of urine in these individuals
▪ First measurement of increased glucose in urine  _____

ancient egypt

1776

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Epidemiology
▪ Globally >360 million people have DM

 Expected to reach >550 million by 2030
 >90% have Type _____

▪ >25 million people in the US have diabetes

▪ DM is a major risk factor for the development of _____
with vascular complications

2 DM

atherosclerosis

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Classification
▪ Type 1 DM
 \_\_\_\_\_-mediated 
 \_\_\_\_\_
▪ Type 2 DM 
 Obese
 Non - obese

immune

idiopathic

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Type 1 DM
▪ Accounts for up to _____ of all DM cases
 Immune mediated
> _____ of cases
 Idiopathic
< _____ of cases
▪ Circulating insulin is virtually absent
▪ Pancreatic B cells fail to respond to all _____ stimuli

▪ _____ onset (days to weeks)
▪ Majority of cases develop before age _____

10%
90%
10%
insulinogenic
acute
25

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Immune-mediated Type 1 DM
▪ Infectious or toxic insult to persons whose _____ is genetically predisposed
 Viruses
 Toxic chemical agents

▪ Develop a vigorous _____ response against pancreatic B cells

imune sytem

autoimmune

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Idiopathic Type 1 DM
▪ Fewer than _____ of subjects have no evidence of pancreatic Β cell autoimmunity

▪ Only a minority of patients with Type 1 diabetes fall into this group
 Majority are of _____ or African origin

10%

asian

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Signs and Symptoms of Type 1 DM

▪ Increased _____
 Consequence of osmotic diuresis
2o to sustained hyperglycemia

▪ _____ despite increased appetite
 Depletion of water, glycogen, and triglycerides

▪ Reduced _____
 Amino acids are diverted to form glucose and ketone bodies

▪ Lowered _____
 Hypotension

▪ _____
 Temporary dysfunction of
peripheral sensory nerves

▪ _____ changes
 Degree of hyperosmolality

urination
weight loss
muscle mass
plasma volume
paresthesias
mental status

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Type 2 DM
▪ More than _____ of all diabetics in the USA are included under this classification

▪ Circulating insulin is sufficient to prevent _____ but is inadequate to prevent _____ in the face of increased needs secondary to tissue insensitivity

▪ Cause is unknown in most cases
 High genetic predilection (_____ >_____)
 Lifestyle risk factors

90%
ketoacidosis
hyperglycemia
type 2
type 1

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Type 2 DM
Pathophysiologic defects in Type 2 DM:

▪ _____ to insulin in target cells (esp. muscle)
▪ Increased production of _____ by the liver
▪ Insulin secretory _____ of pancreatic B cells

peripheral resistance
glucose
defect

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Obese Type 2 DM

▪ Accounts for up to _____ of individuals with Type 2 DM
▪ _____ to extra-pancreatic factors that produce
insensitivity to endogenous insulin
 Defect of insulin production
 Resistance to insulin in target tissues of obese patients due to receptor defects in insulin action

70%

secondary

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Non-obese Type 2 DM
▪ Individuals demonstrate an _____ or blunted _____ of insulin release in response to glucose
▪ Majority are _____

absent
early phase
idiopathic

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Childhood type 2 diabetes
▪ Historically, childhood DM was \_\_\_\_\_
▪ Type 2 DM accounts for nearly \_\_\_\_\_ of new cases in children /
adolescents
▪ Global \_\_\_\_\_ in childhood obesity 
 Calorie-dense foods
 Sedentary lifestyle
 Easy access to transportation
▪ Higher \_\_\_\_\_ among specific ethnic groups 
 Hispanic
 African – American 
 Asian – American

type 1
45%
increase
prevalence

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Gestational Diabetes
▪ Occurs in _____ of pregnancies
▪ Increased risk with maternal obesity / advancing age
▪ Progressive maternal insensitivity to insulin
 Maternal hyperglycemia > fetal hyperinsulinemia

▪ Normoglycemic state returns s/p parturition
▪ Increased risk of developing: 
 Type 2 DM (\_\_\_\_\_)
 Metabolic Syndrome (\_\_\_\_\_)
 Cardiovascular disease (\_\_\_\_\_)
 Obesity (\_\_\_\_\_)

5%
maternal/fetal
maternal/fetal
maternal
fetal

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Signs and Symptoms of Type 2 DM
▪ Insidious onset
 Commonly _____

▪ May present with evidence of _____ or cardiovascular complications

▪ Should be considered in individuals with chronic _____
 Oral
 Genital

asymptomatic
neuropathic
candida infections

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Complications of Type 2 DM: _____ is often times a complication; _____ are normally seen in clinics treating DM

diabetic foot

podiatrists

Clinical features of diabetes at diagnosis:

Type 2: wins in _____ and _____

Type 1: wins in _____, weakness or _____, polyphagia with _____, and _____

peripheral neuropathy
often asymptomatic

polyuria & thirst
fatigue
weight loss
nocturnal enuresis

Laboratory Evaluation: Urinalysis
▪ \_\_\_\_\_
 Clinistix, Diastix
▪ \_\_\_\_\_
 Acetest, Ketostix

glucosuria

ketonuria

Blood testing procedures
▪ \_\_\_\_\_ glucose
▪ Oral glucose tolerance test (OGTT)
▪ Glycosylated hemoglobin (\_\_\_\_\_)(monitoring) 
▪ Self-monitoring

serum

HbA1C

Criteria for Diagnosis of Prediabetes and Diabetes

Memorize the NUMBERS

YES

Self Monitoring of Blood Glucose
▪ Capillary blood glucose measurements performed by the patient
▪ _____
▪ Glucose oxidase paper strips exposed to
capillary blood for _____

glucometer

seconds

Complications of DM
▪ Sustained \_\_\_\_\_ 
▪ Altered cellular function 
▪ Altered tissue structure
▪ AGEs
 \_\_\_\_\_ 
 Cell damage / apoptosis

▪ RAGEs
 Receptor for AGE
 Activates _____ pathways

hyperglycemia
advanced glycation end products
inflammatory

Chronic Complications of Diabetes
▪ Ketoacidosis (_____)
▪ Hyperosmolar nonketotic coma (_____)

▪ Ocular
 cataracts
 retinopathy 
 glaucoma
▪ Nephropathy
▪ Accelerated \_\_\_\_\_ 
 CAD
CVA
 Gangrene of feet

▪ _____
 peripheral
 painful
 autonomic

▪ Early Death

Type 1
Type 2

atherosclerosis
neuropathy

Chronic Complications of Diabetes
▪ Ketoacidosis (_____)
▪ Hyperosmolar nonketotic coma (_____)

▪ Ocular
 cataracts
 retinopathy 
 glaucoma
▪ Nephropathy
▪ Accelerated \_\_\_\_\_ 
 CAD
CVA
 Gangrene of feet

▪ _____
 peripheral
 painful
 autonomic

▪ Early Death

Type 1
Type 2

atherosclerosis
neuropathy

``` Diabetic Nephropathy ▪ Glomerular hyperfiltration ▪ Microalbuminemia ▪ Gross proteinuria ▪ Kimmelstiel – Wilson lesion Management ▪ Glycemic _____ ▪ _____ ▪ Protein restriction ▪ Combination therapy ``` long term management: better _____; less risk in forming tissue damage ACE inhibitors on _____ > taste, lesions > oral pathology

control inhibitors glycemic control oral cavity

``` Vascular complications ▪ _____ ▪ _____ oxidation of LDL’s ▪ _____ platelet aggregation ▪ _____ microvascular abnormalities ▪ _____ adaptive response of blood vessels ```

``` atherosclerosis increased increased increased decreased ```

Medical Management: Diet ▪ A well-balanced, nutritious diet ▪ _____ fiber ▪ Artificial _____* artificial sweeteners > have similar effects as _____ in metabolic effects

dietary sweeteners glucose/sugar

Old drugs ``` Increase insulin secretion: _____ Meglitinides _____ (acting on pancreas) _____ (acting on liver) ``` Increase glucose uptake: _____ (acting on muscle) Delay Glucose Absorption: _____ (acting on SI)

sulfonylureas phenylalanice derivatives biguanides thiazolidinediones alpha-glucosidase inhibitors

``` GLP-1 agonists ▪ Gut-derived hormone secreted in response to meals  Glucagon-like Peptide-1 ▪ Augment release of _____  Inactivated by _____ ▪ _____ (albiglutide) ▪ Trulicity (dulaglutide) ▪ Byetta (exenatide) ▪ _____ (liraglutide) ▪ Adlyxin (lixisenatide) ```

insulin DPP-4 enzyme tanzeum victoza

``` DPP-4 Inhibitors ▪ Prevents inactivation of GLP-1  Prolong activity of _____ released insulin ▪ Long _____ of action ▪ Nesina (alogliptin) ▪ Tradjenta (linagliptin) ▪ Onglyza (saxagliptin) ▪ _____ (sitagliptin) (MOST COMMON) ```

endogenously duration januvia

``` SGLT-2 Inhibitors HIGHEST RISK OF _____ ▪ Inhibits action of _____ in kidneys  Glucose reabsorption decreased  Glucose excretion _____ ▪ ADRs: hypotension, UTIs, RF, DKA, long _____ ▪ Invokana (Canagliflozin) ▪ Farxiga (Dapagliflozin) ▪ _____ (Empagliflozin) ```

``` adverse reactions Na-glucose co-transporter increased bone fractures jardiance ```

Further Treatment Modalities . . . ▪ Insulin pumps  Designed to deliver short, frequent pulses of insulin into _____ - Rapidly and more predictably absorbed compared to injections ``` ▪ Whole pancreas transplantation  Organ availability  Graft failure  Morbidity with long-term immunosuppression  Surgical complications ``` - Islet cell transplants  _____ DM  >1,500 patients in 40 international centers  _____ achieve insulin independence at 5 years

peritoneal cavity Type 1 50-70%

``` Oral Complications of DM ▪ _____ ▪ Increased incidence / severity of caries ▪ _____ ▪ Oral burning / _____ ▪ _____  Oral mucosal lesions ``` ▪ _____ / Sialadenosis ▪ Altered wound healing

xerostomia candidiasis glossodynia lichen planus parotitis

``` Periodontal Health and DM ▪ DM considered a risk factor for prevalence and severity of _____ ▪ Degree of glycemic control  Increased levels of gingivitis  Attachment loss  Progressive destructive periodontitis  Alteration in wound healing  ↑ risk of periodontal abscess formation ```

periodontal disease

Periodontal Health and DM ▪ Periodontal infection may adversely affect _____ ▪ Periodontitis may be associated with increased risk of developing _____ and _____ ▪ Aggressive periodontal treatment may positively affects glycemic control

glycemic control nephropathy macrovascular disease

``` Before Dental Treatment ▪ Determine _____ ▪ Antibiotic prophylaxis?  Lack of _____recommendations ▪ _____ appointments  1.5 - 3 hours after breakfast / insulin ▪ Avoid elective dental treatment with BG > _____ ▪ Have glucose source available ```

glycemic control (HbA1C) evidence-based short AM 400 mg/dl

Dental Treatment Recommendations vs HbA1 < 7%: _____ 7 to 9%: _____ risk for infections like candidiasis; may not be a good candidate for dental impllant > 9%: _____ only; systemic _____ before surgery; may need to adust _____ due to inabiliy to eat

``` no modifications increased urgent care antibiotics hypoglemia medications ```

During Dental Treatment ▪ Limit _____ in poorly controlled diabetics to minimize ↑ in blood glucose levels ▪ Keep glucose source available ▪ Recognize signs and symptoms of hyper- and hypoglycemia

epinephrine

After Dental Treatment ▪ Adjust insulin dose according to ability to maintain caloric intake ▪ Avoid _____ ▪ Post-operative antibiotics when appropriate

glucocorticosteroids