Diabetes Flashcards
what are the 5 Rs to consider when organizing diabetes care in the office or clinic
recognize register resource relay recall
what three tests can be used for diabetes screening and diagnosis
- HbA1c
- fasting plasma glucose
- 2 hour plasma glucose
how do you determine a patients glycemic targets
patients age
duration of diabetes
risk of hypoglycemia
CV disease presence
life expectancy
how often should you do blood work for diabetes follow up
every 3 months HbA1c
can do every 6 months if targets consistently met and treatment and lifestyle are stable
what causes type 1 diabetes
beta celld estruction
leading to total insulin deficiency
susceptible to ketoacidosis
either autoimmune or unknown etiology
what is latent autoimmune diabetes
a slow progressive form of autoimmune diabetes that shares clinical characteristics of T2DM
it is a form of T1DM
what causes T2DM
combination of insulin resistance and inadequate insulin secretory response
risk factors for T2DM
age over 40
first degree relative with T2DM
member of high risk population i.e aboriginal, hispanic, south asian, asian, african descent
history of prediabetes
history of gestational diabetes
presence of vascular risk factors
presence of associated diseases
use of medications associated with diabetes
what vascular risk factors increase risk of T2DM
obesity
DLD
HTN
abdo obesity
vascular disease
what other diseases are associated with T2DM
PCOS
acanthosis nigricans
HIV
psychiatric disorders
what medications are associated with diabetes
atypical antipsychotics
highly active ART
glucocorticoids
can T1DM be prevented
no
can T2DM be prevented
yes–onset and course can be ameliorated using lifestyle modification and pharmacologic intervention
would you consider pharmacologic treatment even in patients without diabetes but with impaired glucose tolerance
yes–can consider metformin or acarbose
screening guidelines for T2DM
q3 years at age 40 and above or those at high risk
screen more frequently in people with additional risk factors for DM
what is a screening tool you can use for DM
the CANRISK questionnaire
Canadian Diabetes Risk Assessment Questionnaire
what criteria can be used to diagnose DM
fasting plasma glucose of 7 or higher
HbA1c of 6.5% or higher
2 hour plasma glucose of 11.1 or higher after a 75g oral glucose tolerance test
a random plasma glucose of 11.1 or higher in a patient with the classic symptoms of hyperglycemia
what are the classic symptoms of hyperglycemia
polyuria
polydipsia
unexplained weight loss
in a patient with no symptoms of diabetes/hyperglycemia, what do you do if one screening lab test returns in diabetes range?
a repeat, confirmatory test (preferably the same test) must be done another day (in a timely fashion) –if the results of the two different tests are both above diagnostic cutoff, dx is confirmed
*a repeat test is not required if they have symptoms
if you suspect T1DM, should you delay treatment while waiting for the confirmatory test
no
what does the following “R” suggest in the 5Rs of diabetes management:
recognize
consider diabetes risk factors for all patients and screen appropriately
what does the following “R” suggest in the 5Rs of diabetes management:
register
develop a list of patients with diabetes to facilitate recall ad track changes in practice management
what does the following “R” suggest in the 5Rs of diabetes management:
resource
support self management through the use of interprofessional teams including a PCP, DM care educator, nurses, dietician, pharmacist and specialist
consider referral to Diabetes education clinic
in which patients might a team specialized in diabetes be warranted?
patients with T1DM at diagnosis and at least annually
women with diabetes who require pregestational assessment and counselling
women with diabetes in pregancy
individuals with complex T2DM or who are not reaching target
what does the following “R” suggest in the 5Rs of diabetes management:
relay
facilitate information sharing between patient with diabetes and the diabetes care team
what does the following “R” suggest in the 5Rs of diabetes management:
recall
develop a system to remind patients of timely review and assessment
what is the focus of glycemic goals
achieving target A1c levels and minimizing symptomatic hyper- and hypoglycemia
what is the A1c target for most patients with diabetes
6.5-7%
in which patients might you consider an A1c target at or below 6.5%
in some patients with T2DM to further lower risk of nephropathy and retinopathy
must be balanced with the risk of hypoglycemia
in which patients might you consider an A1c target of 7.1-8.5%?
limited life expectancy
high functional dependency
extensive CAD at high risk of ischemic events
multiple co morbidities
hx of recurrent severe hypoglycemia
hypoglycemia unawareness
longstanding DM for whom it is difficult to achieve A1c 7 or below despite effective doses of multiple antihyperglycemic agents including insulin
risk factors for hypoglycemia
prior episode of severe hypoglycemia
long term diabetes
current A1c below 6
autonomic neuropathy
hypoglycemia unawareness
current treatment with insulin
elderly
what practical/reporting consideration is there in patients with diabetes/at high risk for hypoglycemia
a driver with a medical condition, like DM, that has the potential to affect their fitness to drive may be required to have a drivers medical exam report completed by their GP
how do you reduce the risk of hypoglycemia
increase frequency of blood glucose checks–including episodic assessment during sleeping hours
make glycemic targets less stringent
consider multiple insulin injections
in patients with T2DM and only using oral antihyperglycemics, how often should they check their blood glucose
1-2 times per week usually
how much should people exercise
at least 150 minutes per week of aerobic exercise and two sessions per week of resistance training
what insulin regimen should be suggested for people with T1DM
multiple (3-4) daily insulin injections or the use of continuous subcutaneous insulin infusion (insulin pump) should be considered as part of an intensive diabetes management program
should you use a CV risk assessment calculator in people with T1DM
no
how do you assess CV risk in the DM population
a CV risk assessment tool
medical history
physical exam
full fasting lipid profile
how do you approach CV risk protection
lifestyle management
glycemic control
BP control
pharmacological interventions
what is a mnemonic to help remember vascular protection strategies
ABCDEs
A1c and optimal glycemic control
Blood pressure
Cholesterol
Drugs for vascular protection
Exercise/eating
Smoking cessation
what drug might you consider for vascular protection in people with DM
ACEi
consider this in any patient 55 or older, or with evidence of organ damage, even in absence of hypertension
in patients with DM and HTN, consider ACEi or ARB
is the routine use of ASA in primary CV disease protection recommended
no–not even in people without DM
but especially in people with DM, the risk of bleeding is higher
what is the first line strategy for vascular protection from a lipid lowering standpoint
first line is lifestyle
second line is statins
–use in people with clinical macrovascular disease, 40 or older, younger than 40 but with DM for more than 15 years, microvascular complications or other circumstances that warrant therapy
should you use statins to treat to a specific lipid target?
no, not according to the BC guidelines, though the CCA and CDA recommend treating high risk and intermediate risk patients to a specific LDL-C target of 2.0 or less
how often should DM patients get dilated retinal pupil exam
at diagnosis then every 1-2 years or as indicated
for T1DM, first follow up exam is 5 years after dx then every 1-2 years
how can DM retinopathy change during pregnancy
can worsen–women with DM considering pregnancy or in early pregnancy should be assessed by ophtho
what is the best way to prevent diabetic neuropathy
achieve long term glycemic control
how do you screen for DM neuropathy
with 10g monofilament or 128 Hz tuning for during foot exam
signs of autonomic neuropathy
erectile dysfunction
GI disturbance
orthostatic hypotension
what psychiatric conditions should be screened for in DM
depression
anxiety
eating disorders
how do you manage a patient with DM initially
lifestyle intervention, consider metformin right away (but dont have to)
if A1c is less than 8.5, let them try lifestyle alone (or lifestyle with metformin) for 2-3 months
if A1c is above 8.5, initiate metformin immediately and consider combination with another antihyperglycemic agent
what happens if your patient cant achieve glycemic targets with just lifestyle alone
start (or increase) metformin
if still not at target after a trial of metformin or increased dose of metformin, then add an antihyperglycemic agent best suited to the individual based on patient characteristics, risks and benefits, and cost
if, after lifestyle changes, metformin, and a second anithyperglycemic agent, your patient is still not achieving glycemic targets, what do you do
add another agent from a different class or add/intensify insulin regimen
in a patient who started with an A1c above 8.5, and started metformin immediately, what do they do if you cant achieve glycemic goals
if still not at target after a trial of metformin or increased dose of metformin, then add an antihyperglycemic agent best suited to the individual based on patient characteristics, risks and benefits, and cost
if still not at target, ass another agent from a different class, or add/intensify insulin regimen
in which patients should you start insulin
those with symptomatic hyperglycemia with metabolic decompensation
(even with lifestyle changes and/or metformin )
