Diabetes Flashcards
How do you diagnose diabetes?
- Fasting plasma glucose > 126 (standard)
- Random plasma glucose > 200 with classic symptoms of hyperglycemia
- HbA1C > 6.5
What can falsely elevated HbA1C?
Things that decrease erythrocytosis and increase lifespan of erythrocytes –> iron deficiency anemia, aplastic anemia, renal failure, hyperbilirubinemia
What can falsely lower HbA1C?
Things that decrease lifespan of erythrocytes –> Hemolytic anemia, HIV meds, liver disease, blood loss
When should you screen for complications in type 1 diabetes?
5 years after diagnosis
When should you screen for complications in type 2 DM
at diagnosis
What are the A1C goals in the following pts according to the ADA?
- new diagnosis and long life expectancy
- children (type 1)
- limited life expectancy, complex older patients
- new diagnosis and long life expectancy –> 6.5%
- children (type 1) –> 7.5%
- limited life expectancy, complex older patients –> 8.5%
What is the goal glucose pre meal?
80-130
Which is the only oral diabetes medication for use in children and adolescents?
Metformin
When should you hold metformin?
Stop if GFR < 30
Do not start if GFR < 45
Stop prior to IV contrast and 48 hours after
Which two oral diabetes medications are insulin sensitizers - meaning they increase insulin resistance?
Metformin and pioglitazone (actose)
Precautions for pioglitazone use
- cardiopulmonary disorders (fluid overload due to retention in class III and class IV HF)
- avoid in hepatic dysfunciton
- avoid in osteoporosis
- category C in pregnancy
- increased risk of pancreatic, bladder, prostate cancers
Which class of oral DM medications are most useful in “little old ladies who eat irregularly”?
Meglitinides like repaglinide and nateglinide
- helpful for erratic eating schedules because it only works when they eat
Side effects of sulfonylureas as a class
ex. glipizide, glyburide, glimepiride
- weight gain and hypoglycemia
Alpha glucosidase inhibitors
- MOA
- who shouldn’t take it
- precautions
ex. Acarbose and miglitol
- MOA: delays carb absorption in the gut
- avoid use in Cr > 2, cirrhosis, GI diseases
- must keep GLUCOSE available, OJ wont work because they can’t break down the disaccharides
Side effects of GLP1 inhibitors
- nausea, vomiting, diarrhea, WEIGHT LOSS
- Pancreatitis
- hypoglycemia with sulfonylureas
- thyroid C-cell tumor risk
Do GLP1 inhibitors need to be decreased in renal failure?
yes, except liraglutide (victoza)
Mechanism of action for GLP1 inhibitors
- potentiate insulin secretion
- suppress postprandial glucagon secretion
- slow gastric emptying
- promote satiety (no weight gain)
Mechanism of DPP4 inhibitors
blocks dipeptidyl peptidase 4, and enzyme that breaks down natural incretins. It allows natural GLP1 to remain in the system longer
Particularly good at postprandial blood sugar control
Side effects of DPP4 inhibitors
URI, sore throat, diarrhea, pancreatitis
- can have debilitating joint pains
weight neutral
Mechanism of SGLT2 inhibitors
- blocks re absorption of glucose in the kidney
- increased urinary excretion of glucose
- less effective as renal function decreases
Desirable and undesirable side effects of SGLT2 inhibitors
Desirable SE
- improve renal function
- lose weight
- lower BP
- increase HDL
DECREASED RISK OF MI, STROKE, CARDIOVASCULAR DEATH
Undesirable SE
- B12 deficiency
- predispose to DKA if lowers glucose too far
- increase fractures
- risk of foot amputation (glc in blood usually causes vasc dilitation)
- increased UTI and genital infections
Bioavailability of insulin:
- which site increases exercise induced hypoglycemia?
- which site decreases exercise induced hypoglycemia
- Exercise accelerates absorption in thigh
- arm reduces exercise induced hypoglycemia by 60%
- abdomen reduces exercise induced hypoglycemia by 60%
Which long acting insulin has less weight gain? Detemir (Levemir) or glargine (lantus)?
Detemir (levemir)
When should rapid acting insulins be added with meals in DM management?
Add with meals if 2 hour postprandial glucose level is high
Which three medications can be used to treat Diabetes in children?
- Metformin (type 2)
- Liraglutide (victoza) (type 2)
- Insulin (type 1 or 2)
Screening for complications in type 1 DM: when to start
- microalbumin
- retinopathy
- additional screening
- microalbumin yearly beginning age 10 or 5 years after onset
- retinopathy beginning age 15 or 5 years after onset
- screen for HTN
- screen for other autoimmune disorders: hypothyroidism, celiac disease (tissue transglutaminase IgA, endomysial antibody IgA)
- screen for lipids if + family hx
At what age can you start statins in children?
> 10 years old
Type 2 diabetes treatment in children: at what levels should you use oral meds vs insulin?
Start insulin if: glc > 250 or A1C > 9
meformin and lifestyle change: gluc < 250, A1C < 9
Which ethnic group has highest rate of Diabetes
Native American
How often should you screen lipids in diabetics
Yearly
- if well controlled every other year
First line treatment for gastroparesis
Reglan (metoclopramide)
Criteria for dx of Ketoacidosis
- anion gap
- glc
- pH
- bicarb
- additional evidence
- anion gap > 10
- glc > 250
- pH < 7.3
- bicarb < 18
- ketones in urine and serum
Ketoacidosis treatment
- Volume replacement 1 L NS/hr until dehydration resolved then 1/2 NS
- insulin drip (give K if < 3.3 before insulin) until acidosis resolves
- replace K
- add D5 when glucose around 250
- monitor hourly: electrolytes, glc, PH
When should you use bicarb in treatment of DKA?
Use bicarb for pH < 7 or HCO3 < 10
What is first line for symptomatic treatment of diabetic neuropathy?
Amitriptyline or nortiptyline, pregabalin (lyrica), duloxetine
the TCAs aren’t FDA approved for this use
What is the most common cause of hypoglycemia in previously well-controlled diabetes?
mos likely cause is progressing renal failure
Diabetic foot:
What is the best test for sensation?
Monofilament is best predictor of future ulcers
Diabetic foot:
What is the best test for osteo?
MRI
Diabetic foot:
What is the best indicator for successful healing?
Pulses - intact vascular supply
Assess with ABI if decreased pulses
Treatment of mild/moderate diabetic foot ulcer
dicloxacillin, cephalexin, augmentin, doxycycline, Bactrim
Treatment of severe diabetic foot ulcer
Vanc + Zosyn or cefepime
What is charcot foot?
How do you diagnose it?
- Inflammatory condition in obese individuals with peripheraly neuropathy
- recurrent erythema and edema like cellulitis but no fever, chills, WBC, or signs of infection
- MRI for definitive dx: bone marrow and soft tissue edema
Treatment of charcot foot
immobilization with total contact casting 3-12 months
may need surgery
What is the initial evaluation of Nonalcoholic fatty liver disease to rule out uncommon (but not rare) causes?
- viral hepatitis studies
- iron studies for hemochromatosis
- Serum albumin levels
- CBC
Which medication can help correct fatty liver disease?
Metformin - reduces fatty acid oxidation
Is there a specific Cr where ACE/ARB should be stopped?
Nope
