Diabetes Flashcards
What is diabetes characterized by
hyperglycemia and varying degrees of insulin deficiency and resistance
What is impaired glucose tolerance
blood glucose varies between normal and overt DM (140-199) seen during an OGTT
What is impaired fasting glucose
FPG of 100-125
What is prediabetes
Increased risk for diabetes
Must have impaired GT, impaired FG, or A1C 5.7-6.4%
Who has the highest rates of diabetes Type 2
American indian/alaska native
What are RF for T2DM
genetics, FHx BMI, waist circumference lifestyle age 45+ Obesity (childhood weight) Physical inactivity smoking, diet, meds Pre-DM, gestational DM Dyslipidemia CVD (HF, MI, HTN) PCOS Metabolic syndrome Hyperuricemia (gout)
A few drugs that can impair glucose tolerance are
Fluoroquinolones
Thiazides
Systemis glucocorticoids
Oral contraceptives
What is Metabolic syndrome
3+ of the following: 1. Abd obesity (waist >40 in men, >35 in women) 2. TG 150+ Low HDL (<40 men, <50 women) BP >130/85 FPG >100
Some poor outcomes associated with metabolic syndrome are
Risk of T2DM, CVD (assess 10 year risk)
higher incidence with age, if overweight or obese
Management goals for metabolic syndrome are
treat underlying cause and CVD RF
How do you manage metabolic syndrome
- Lifestyle mod: Mediterranean, DASH, low glycemic index, high fiber
- 7-10% reduction in body weight in 1 year
- Increase physical activity to 150 min/wk
- Reduce other RF (stop smoking, Tx HTN, lower cholesterol, glycemic control if w/ DM)
- Metformin (often given to prevent DM)
What are the ways you get blood glucose
Diet (goes thru portal vein to liver)
Gluconeogenesis (AA + propionate= glucose)
Glycogenolysis of liver glycogen
What is glucose homeostasis
Hepatic glucose production is balanced with peripheral glucose uptake
Where is insulin made and what does it do
Hyperglycemia stimulates insulin production by beta cells in islets of Langerhans in the pancreas
Insulin causes glucose transport into adipose tissue
Where is glucagon made and what does it do
Hypoglycemia stimulates glucagon production in alpha cells of pancreatic islets
Glucagon causes glycogenolysis and gluconeogenesis
What regulates insulin secretion
glucose (mainly)
AA, ketones, various nutrients, GI peptides, and neurotransmitters
What is incretin
Enzymes released from neuroendocrine cells after a meal
Amplifies glucose stimulated insulin secretion and suppresses glucagon
What is the most potent incretin
GLP-1 (glucagon like peptide)
What happens during a fasting state
Low insulin, high glucagon
+gluconeogenesis, glycogenolysis
-glucose uptake in muscle/fat
What happens in post-prandial state
high insulin, low glucagon
+carb storage, fat/protein synthesis, skeletal muscle uptake
What is the pathophysiology behind diabetes
In insulin resistance, beta cells compensate by increasing insulin
In Impaired GT, beta cells can no longer sustain hyperinsulin state
In overt diabetes, beta cells fail and
you have fasting hyperglycemia
*Post-prandial state labs in a fasting state
What happens during insulin resistance
Decreased insulin effectiveness on target tissues (muscle, liver, fat), but Increased circulating insulin normalizes plasma glucose
Impairs glucose utilization= increased hepatic output
Affected by substances secreted by adipocytes (leptin, adiponectin, TNF-alpha, resistin)
What happens during impaired insulin secretion
Initially, increases response to insulin resistance. But then, Beta cells fail causing chronic hyperglycemia
High FFA and fat worsen islet fxn; low GLP-1 further reduces insulin secretion
What happens during excessive hepatic glucose production
insulin resistance in liver= failure of gluconeogenesis suppression= hyperglycemia and decreased glycogen storage in liver in post-prandial state
What happens during abnormal fat metabolism
insulin resistance causes increased lipolysis and FFA flux from adipocytes= increased VLDL and TG synthesis in liver Lipid storage (steatosis) leads to NAFLD and dyslipidemia
How does T2DM usually present
Asymptomatic! Hyperglycemia on routine labs
if severeL Polyuria, polydipsia, nocturia, blurred vision, weight loss
Who does the ADA say needs to be screened for T2DM
adults BMI 25+ andother RF, screen q 3 years
Everyone 45+: screen q3 years
Pre-diabetic: screen annually
Women with GDM: screen q3 years
Who does USPSTF say needs to be screened for T2DM
adults 40-70 overweight or obese: screen with CV risk assessment q3 years
What is your diagnostic criteria for T2DM
Sx + random blood glucose 200+
ASx + FPG 126+, OGTT 200+, A1c 6.5%+
-Must repeat on a different day
How do you repeat DM testing
1 abn: need 2 readings showing abnormal
2+ abn: make Dx that day
*What are normal values
FPG <100
OGTT 2 hr: <140
What is Glycated Hgb (A1c)
3 month average of glucose levels, mainly the last month
Convenient for patient (no fasting, any time of day)
BUT- can be affected by hemoglobinopathy and CKD
How is A1c affected by RBC turnover
low cell turnover: falsely high levels
-also in iron, B12, or folate deficiency
high cell turnover: falsely low levels
-also in hemolytic anemia, EPO use
What should be part of your T2DM evaluation
nutrition, weight, physical activity CV risk DM related complications hypoglycemic episodes Labs: A1c, fasting lipids, liver enzymes, urine albumin, SrCr
T2DM follow up care should include
Med compliance Med intolerance/ADE Self management behaviors nutrition psychosocial health need for referrals
How do you manage T2DM
glycemic control (pharm or non-pharm) Monitor/prevent complications (micro/macro vascular) Pt Ed (ntr, hypoglycemia, CV risk, vision, kidneys) Health maintenance
For T2DM, how often do we measure glycemic control
Controlled: 2x year
Uncontrolled/med change: q3 months
What are target A1c goals in T2DM
individualized, but for MOST < 7.0%
More stringent goal: < 6.5%
Less stringent goal: < 8.0% (Hx severe hypoglycemia, limited life expectancy, elderly, comorbidities)
When assessing how stringent to be on A1c goal, what should you consider
Risk of hypoglycemia disease duration life expectancy comorbidities existing vascular complications attitude and expected Tx efforts resources and support system
Is self monitoring necessary in T2DM
more frequently done in T1DM, BUT
should monitor several times/week when titrating meds
more frequent if w/ illness or change in diet/exercise
measure in AM or before dinner
Non-pharm therapy includes
diet
exercise
weight reduction
physiologic interventions
Goals for medical nutrition therapy if overweight are
lower kcal intake
increase physical activity
promote weight loss (correct insulin resistance
Goals for medical nutrition therapy is NOT overweight are
weight management
consistent day-to-day CHO intake
nutritional content of meals
Pharmacologic glycemic control goals are
Increase insulin availability
Improve insulin sensitivity
Delay delivery and absorption of CHO from GI
Increase urine glucose excretion
When should you start pharm therapy for glycemic control
Early! you get improved glycemic control over time, and decreased long term complications
If A1c >7.5% start Rx
If A1z <7.5 % AND highly motivated, trial 3-6 mo. lifestyle modification
Initial therapy for most T2DM patients is
Metformin!
Only start insulin if pt has a severely high A1c, is unmotivated, and not likely to make a lifestyle change
What are complications of T2DM
Microvasc: retinopathy, nephropathy, neuropathy
Macro: atherosclerosis (MI, CVA)
What is diabetic retinopathy
MCC of blindness in adults 20-74
Retinal injury and ischemia 2/2 vascular changes from hyperglycemia
-Macular edema, hemorrhage from new vessels, retinal detachment, neovascular glaucoma
ASYMPTOMATIC until late stages
Can be prevented with glycemic and BP control
PE findings in NON-proliferative diabetic retinopathy are
cotton woll spots hard exudates microaneurysms occluded vessels dilated, tortuour vessels visual loss 2/2 macular edema
PE findings in proliferative diabetic retinopathy are
Neovascularization pre-retinal and vitreous hemorrhage fibrosis retinal detachment visual loss 2/2 bleeding, retinal detachment, macular ischemia
How often do you screen for diabetic retinopathy
T2: at time of diagnosis, dilated and comprehensive eye exam by ophthalmologist
T1: w/in 5 years
Repeat annually
How do you treat diabetic retinopathy
laser therapy
IV ranibizumab injection (anti vascular growth)
Vitrectomy
What is diabetic nephropathy
leading cause of ESRD
Can be prevented by optimizing BP and glucose control
How do you screen for diabetic nephropathy
Urine albumin and eGFR T2: at time of diagnosis T1: w/in 5 years Screen all pts with comorbid HTN Repeat annually
Diagnostic criteria for diabetic nephropathy
Microalbuminuria (30-300) or Macroalbuminuria (>300)
Must have 2-3 abn specimens over 3-6 months (bc a lot of things cause increased albumin
How do you treat diabetic nephropathy
ACE or ARB (if mild UACR; 30-299) (strong recc. if UACR 300+ or GFR <60)
Protein intake
Refer for renal replacement Tx in GFR <30 (stage 4-5)
How does GFR correlate to stages of CKD
1: 90+
2: 60-89
3: 30-59
4: 15-29
5: <15
Complications of diabetic nephropathy are
high BP volume overload electrolyte abn metabolic acidosis anemia metabolic bone disease
MC complications of diabetic neuropathy are
Foot ulcers
amputation
*Can prevent by optimizing glucose control
RF for ulcers or amputations are
poor glycemic control peripheral neuropathy smoking foot deformities callous/corn PAD Hx foot ulcer amputation visual impairment DKD (esp on dialysis)
How do you screen for diabetic neuropathy
Annual history + temp or pinprick sensation + vibratory sensation annual monofilament testing visually inspect feet at every visit T2: at time of diagnosis T1: w/in 5 years
How do you treat diabetic neuropathy
Pregabalin or Duloxetine
Foot care education (well fitting shoes, white socks, caution w/ hot water, LOOK!)
What does a comprehensive yearly foot evaluation include
skin inspection
assess foot deformities
neuro assessment (monofilament, pin prick, temp)
vascular assessment
When would you consider ABI or vascular referral
If pt has claudication or decreased/absent pedal pulses
*Podiatry referral if smoker or Hx of LE complications
How do you preform the monofilament test
place device perpindicular to skin and press until it bends
hold for 1 second and release
Preform while pt eyes closed!
All patients with DM should be assessed for
CV RF
Goal BP for diabetic patients is
<140/90
anti-HTN Tx reduces ASCVD events, HF, and microvascular complications
How do you decide therapy based on BP level
If 140/90 to 160/100: One agent + lifestyle modifications
(if albuminuria, ACE or ARB- if not, ACE, ARB, CCB, or diuretic)
If >160/100: two agents + lifestyle mod (if albuminuria, ACE or ARB + CCB or diuretic- if not, ACE or ARB, CCB, or diuretic)
What are statin recommendations for diabetics based on age
<40 w/ ASCVD: high dose statin
40+ y/o w/ ASCVD: high dose statin
40+ y/o w/o ASCVD: moderate statin
(if w/ ASCVD, can consider adding ezetimibe of PCSK9 inhibitor if LAL if sill >70 on high dose statin)
Antiplatelet recommendation for diabetics (ranked A and B)
A: ASA as secondary prevention if w/ DM andHx of ASCVD
A: ASA (75-162) as primary prevention of with T1/T2DM and high CV risk
A: ASA + P2Y12 inhibitor for 1 year after ACS
B: ASA + P2Y12 inhibitor >1 year after ACS
B: Use Clopidogrel if w/ ASCVD but allergic to aspirin
What are screening recommendations for CHD
A: If ASx, routine screening not recommended
E: may investigate for CAD if w/ atypical cardiac Sx, S/Sx of associated vascular disease, or Q waves on ECG
Treatment recommendations for CHD are
A: If w/ ASCVD, ACE or ARB
A: T2DM w/ ASCVD, start on anti-hyperglycemic Tx with lifestyle management and metformin
B: if Hx MI, give BB for at least 2 years s/p event
B: T2DM w/ stable CHF, use metformin if GFR >30
B: do not give Metformin to T2DM if unstable or hospitalized with CHF
C: T2DM w/ ASCVD, consider adding canagliflozin after metformin and lifestyle mod
Common DM comorbidities are
T1DM cancer dementia fatty liver disease pancreatitis fractures hearing impairment HIV low testosterone in men OSA periodontal disease psychosocial disorder
Routine health maintenance includes
Yearly flu vaccine Pneumococcal vaccine HBV if 19-59 Updated tetanus + diphtheria reproductive counseling indicated screenings
