Diabetes Flashcards
lifestyle changes were more effective than
metformin in preventing development of DM2 in pts >age of 60.
what are lifestyle changes defined as for diabetes prevention
brisk walking for 30 minutes for 5 days a week with goal of losing about 5%-10% of body weight decrease insulin resistance by 60% in some studies
when to start metformin as primary prevention for diabetes
>age 60
prior gestational DM2
or those who are <60 but are high risk for development
what does intense lifestyle intervention do for patients with type 2 diabetes?
improved quality of life, mobility, fitness, urinary incontinence, depression and OSA and it lead to lower progression to insulin therapy and improvement in glycemic control.
Diabetic medications that lead to some benefit with cardiovascular protection include?
GLP-1 agonists, SGLT2 inhibitors,.
what intervention helped with decreasing cardiovascular dx and mortality in DM2?
weight loss surgery.
what is LADA or latent autoimmune diabetes of adulthood?
10% of all adults with presumed type 2 diabetes who actually have type 1 diabetes. PTs with LADA have circulating anti islet cell antibodies (ICA) and antibodies to glutamic acid decarboxylase (GAD)
pts who have LADA are at increased risk for
DKA, have a lower BMI and respond poorly to dietary therapy and oral diabetic medications and require insulin much sooner
clinical screening criteria for LADA
age of onset is >35 yrs but <50 yrs acute onset of symptoms personal and family history of autoimmune disease 2 or more of the above criteria associated with 90% sensitivity and 70% specificity for LADA
check for these antibodies if considering LADA?
basically DM1 that manifests later in life check anti islet cell and glutamic acid decarboxylase antibodies.
what antibody is found in DM1?
antiglutamic decarboxylase antibodies
what antibody is associated with Celiac’s dx
anti tissue transglutaminase antibodies.
what causes type 2 diabetes
complex interplay including insulin resistance and progressive beta cell failure (relative insulin deficiency) these patients transition from normoglycemia to hyperglycemia with their relative insulin deficiency is unable to overcome their insulin resistance
time course and natural history of diabetes will lead
pts who are welly controlled with one medication may need additional therapy after a few years to maintain their glycemic control.
Basal cell function in DM2 and the time course for DM2 insulin resistance
HgbA1c goal for older adults with complex medical history and significant comorbidities?
aim for A1c goal of 7.5-8%
arthritis, cancer, CHF, depression, emphysema, falls, HTN, incontinence, stage 3 or worse CKD and MI and stroke pts.
no targets for A1c in pts who have life expectancy <10 yrs due to advanced age 80 or older, residence in a nursing home, chronic conditions like dementia, cancer, ESRD and COPD or CHF because harms outweigh the risk. but maybe try to keep <8.5 due to risk for dehydration, glycosuria, infections and HHS.
goal A1c for someone with complex health or poor health
< 8.5%
poor health - long term care facility or end stage chronic dx (Stage 3 or 4 HF, oxygen dependent lung dx, ESRD, uncontrolled metastatic cancer) moderate to severe cognitive impairment or dementia or two or more dialy living activities are dependent.
disadvantages of using A1c for diagnosis of DM2
lower sesnitivity compared to fasting plasma glucose or 2hr post prandial glucose
erroneous increases pregnancy
erroneously decreased in : blood loss, hemolysis, Fe def anemia, CKD, liver dx (Faster turnover rate so less glycosolation)
Variation in AA, southeast Asian and Mediterrean
expensive
affected by G6PD variants
Fasting plasma glucose disadvantages for DM2 diagnosis
inconvenient needs 8 hr fasting required and restriction on time collection
affected by illness and stress
measures one time point
blood sample unstalbe after colection
diurnal variability
diabetic complications are not as closely linked to FPG as to A1c
assay standardization incomplete
disadvantages of using 2hr Post prandial glucose after an oral glucose test for diagnosis of DM1
same disadvantages as fasting plasma glucose:
measures one poitn in time,
inconvenient
risk of hypoglycemia at 4-6 hrs in normal persons
poor reproducibility
expensive.
Diagnosis of DM2 is based on:
random plasma glucose >200 + symptoms of hyperglycemia
fasting plasma glucose >126
2 hr plasma glucose during a oral glucose dose >200
HgbA1c>6.5%
pre diabetes is defined as A1c levels of
A1c: 5.7-6.4%
2 hr plasma glucose post OGTT: 140-199
fasting plasma glucose is 100-125
if there’s an abnormal fasting plasma glucose, OGTT, HgbA1c, what should be done to confirm DM2
repeat the same test on a separate day.
If two separate tests are have discordant resutls, repeat the test with abnormal results.
NEED AT LEAST TWO of the same test to be ABNORMAL TESTS.
A1c + FPG, repeat A1c or A1c + A1c on two separate times.
DM2 screening is for:
Screen overweight adults (BMI>25 or Asian >23)
Screen 1st degree relatives with DM2
Screen high risk race: AA, Hispanic, ASIAN, Native Hawaiin, Pacific Islander
Screen with gestational DM2
Screen CAD hx
Screen HTN, PCOS, prior abnormal screening DM2 exams
Screen ppl with HDL <35 and/or TG>250
Screen anyone from 40-70yrs who are overweight or asymptomatic OR has other risk factors like: high abd fat %, HLD, HTN, physical inactivity, and smoker
Who else to consider screening for DM2
overweight,
Race: AA, hispanic, Asians
Hx of gestational DM2, PCOS, abnormal DM2 screening
Physical inactivity
CAD hx, HTN hx, HDL<35 or TG>250
any condition concerning for DM2: severe obesity, acanthosis nigricans
Everyone >45 yrs old
anyone on steroids, thiazide diuretics, HIV medications and atypical 2nd gen antipsychotics.
If DM2 screening is negative this year, how often to rescreen individuals?
rescreen every 3 yrs.
Yearly screening is meant for prediabetics.
Retinal eye exam screening is started
At age of diagnosis for DM2
Gestational DM2 is defined as:
insulin resistance which is naturally seen in 2nd and 3rd trimester (by pregnancy hormones)
- see hyperglycemia in 2nd or 3rd trimester without a prepregnancy diagnosis of DM2.
Risk factors for gestational DM
Why is gestational DM2 bad?
age>25 yrs,
overweight status,
family history of DM2
high risk ethinicity groups
Bad: macrosomia, labor and delivery complicaitons, preeclampsia, fetal defects and neonatal hypoglycemia and spontaneous aborption and intrauterine fetal demise.
when to screen for gestational DM?
24 -28 weeks of gestation
all pregnant moms will be screened at start of pregnancy and if they have hyperglyceia in 1st trimester they are defined as having DM2 instead of gestational DM
Diagnosed with oral glucose OGTT.
prognosis for gestational DM2
Testing beyond gestation
most women will have resolution of diabetes and normal glucoses after pregnancy
can have reoccurance of gestational DM2 with pregnancy
Screen with a 75 g OGTT 4-12 weeks post partum for resolution of hyperglycemia
Screen lifelong every 1-3 years with 75 g OGTT, Hgb A1c and fasting plasma glucose for DM2
Gestational DM2 pt will need
lifelong screen every 1-3 years with 75 g OGTT, Hgb A1c and fasting plasma glucose for DM2
ASA + DM2
secondary prevention of CAD
primary prevention for CAD
secondary prevention: all people with CAD and DM2 need to be on aspirin for secondary prevention
For primary prevention (never had CAD) and has DM2: can be considered in people who are >50 yrs AND one additional ASCVD risk factor
Treatment of ACE i is NOT recommended in DM2 when:
pt is normotensive (no HTN), has urine albumin to cr ratio <30 mg/g Cr and has GFR>60.
CAN give ACEi in pt who has HTN, reduced GFR<60 andhas urine albumin/Cr ratio >300 mg/dl.
pt has a protein/cr ratio >300 what to do next?
Get GFR and need to have multiple measurements over 3 to 6 months to confirm diabetic nephropathy
(starts about 5-10 years after DM2 diagnosis)
Reason to recheck Protein/Cr ratio is that there’s multiple temporary elevation from biological variability with illness, hyperglycemia, heart fialure and HTN and exercise and menstruation.
if pt has a GFR<30 and diabetes
need to refer to nephrologist
Drugs that predispose DM2 are:
statins Higher dose higher risk
beta blockers except carvedilol
Hydrochlorothiazide
Niacin
Olanzapine
protease inhibitors
steroids
if pt has 3AM hypoglycemia and are on basal and bolus insulin what to do?
decrease long acting basal insulin by 10-20%
if pt is going to get a angiography and is on metformin when to stop it?
When to restart it?
stop metformin day of procedure
Then restart metformin 48 hrs after the procedure after a repeat BMP is checked.
insulin cards
When to start insulin:
A1c>10
fasting glucose is >300
symptoms of hyperglycemia
Titrate insulin to try to reach fasting glucose of 80 to 130 and postprandial insulin <180 and A1c<7% if no co-morbidities and >15 years life expectancy
ideal bedtime glucose would be 90-150
Targets for gestational diabetes treatmetn:
fasting glucose <95 and 1 hr post prandial <140 or 2 hrs post prandial <120
monitor blood sugars at least qid fasting and 1-2 hrs post prandial
start insulin or oral antihyperglycemis of pts do not achieve glycemic targets in 1 week .
1st line treatment of gestational diabetes medication
insulin- should use short and long activing insulin
determir or NPH are considered safe.
Short acting insulins : insulin regular, insulin lispro, and insulin aspart are considered safe.
Glybyride is ok for pregnancy in pts who don’t want to use insulin but it does cross the placenta nad no one knows long term safety of it is.
DDP4, GLP1 agonists are not recomended because of no long term data.
If someone is DM1 and has hypoglycemia after exercise what to do?
need to monitor blood sugars before, during and after exercise. Strenous exercise should be avoided in pts who have significant hyperglycemia >250 or ketosis cause could go into DKA
Things to watch out for:
- adequate fluid intake
- monitor blood sugars before, during and after exercise
- low blood sugar <100 before or during exercise take 15-30g of rapidly absorbed carbohydrates (hard candies, juice) are helpful
- delayed post exercise hypoglycemia (4-8 hrs after) slowly absorbed carbohydrates (dry fruit or nuts) are recommended
- decreasing insulin dose prior to exercise by 30%
hypoglycemia from insulin related to exercise:
15-30 g of rapidly absorbed carbohydrate before 15-30 minutes and every 30 minutes of exercise and adequate fluid intake
diabetics are encouarged to exercise
at least 150 minutes/week at moderate intensitiy to improve glycemic control and lose weight and improve cardiovascualr health.
A1c measurement in a pt who has iron deficiency anemia
A1c will be erroneously increased
due to less erythrocyte turnover and older cells since the bone marrow cannot make new RBCs since there’s a lack of iron.
A1c can be falsely elevated in Hgb fetal and falsely low in hemoglobin S.
Screen tests for DM2 and their values and cut offs are:
Who to screen for DM2?
overweight, obese
sedentary lifestyle
1st degree relative with hx of DM2
history of gestation DM2
new diagnosis of HTN
DKA is resolved when there’s
BG<250
arterial pH >7.3
no anion gap and bicarb >15
no variation between glucoses.
IVFs for DKA
need to correct for volume depletion and so need to give NS and add potassium depending on K at presentation.
Add K if potassium level is between 3.5-5.5 because this will fall as insulin drives K into cells. Remember there is total body depletion of K because with hyperglycemia, the body pees out extra K.
screening intervals for DM2
- repeat HgbA1c every 3 years in asymptomatic (can be evaluated person by person as this is a grade C recommendation
- pre-diabetics A1c>5.7 - should be tested yearly.
- women with gestational diabetes mellitis should be tested at least every 3 years for the rest of their life.
- general population should screen starting at age 45 yrs q3 years
