Diabetes Complications Flashcards by Brooke Thornburg

Long term complications of diabetes

-microvascular disease
-macrovascular disease
-periodontal diseases
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Microvascular disease

-diabetic kidney disease nephropathy
-ocular complications
-neuropathy

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Macrovascular disease

-cardiovascular disease
-stroke
-peripheral vascular disease

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Diabetic kidney disease (neuropathy)

-proteinuria
-low GFR
-inc BP
-20-40% of pt w DM
-major cause of death in type 1

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kidney disease monitoring

-screen for microalbuminuria
-optimize glucose control
-optimize blood pressure

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microalbuminuria screening

-annual test to detect early kidney damage
-test all T2DM pt and pt w T1DM for over 5 years
-UACR and eGFR

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goal UACR

<30mg/g
-urinary-albumin-to-creatinine ration

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if UACR > 300mg/g or eGFR < 60mL/min/1.73m

-monitor twice a year
-ACEI or ARB tx (not for pregnant pts)

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Optimizing glucose control in T2DM + kidney disease

SGLT2I w evidence of low CKD progression is eGFR > 20mL and UACR > 200mg/g or if UACR is normal (jardiance)
GLP-1 w CVD benefit if SGLT2 not tolerated/contraindicated

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Optimizing BP control in diabetes w kidney disease

-goal: < 130/80
-dont discontinue ACEI or ARB for small increases in SCr (<30%)
-consider SGLT2, GLP-1, or nonsteroidal mc receptor antagonist
-goal is 30% reduction if UACR > 300 mg/g
-limit protein intake to 0.8mg/kg/day for non-dialysis pt

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Ocular Complications (microvasc)

-blurred vision, cataracts, glaucoma
-retinopathy (most common)
-appears 15-20 years

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Retinopathy

-most common cause of blindness
-pregnancy can make it worse
-appears in 15-20 years
-get eye exams

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Retinopathy tx

-optimize glycemic control, BP, and lipid management

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Retinopathy screening

-T1DM within 5 years of diagnosis
-T2DM at diagnosis
-exam every 1-2 years
-annually if retinopathy present

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Neuropathy

-peripheral
-gastrointestinal

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peripheral neuropathy tx

-annual monofilament test
-pregabalin, duloxetine, gabapentin

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Gastrointestinal neuropathies

-gastroparesis
-diarrhea/constipation
-fecal incontinence

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other microvascular complications

-urinary retention
-postural hypotension (drop BP when moving)
-erectile dysfunction

tx: optimize blood sugar

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Macrovascular complications

-Artherosclerotic CVD
-heart failure

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Atherosclerotic CVD

-coronary heeart disease
-cerebrovasc disease
-peipheral arterial disease
-leading cause of death in type 2 pt

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Heart failure

-major cause of death
-hospitilizations are twice as high in DM pt

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ASCVD or HF tx

-optimize tx of DM
-SGLT2
-GLP-1

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CVD monitoring

-assess risk factors annually
-obesity, HTN, HLD, smoking, CKD
-metabolic syndrome: obesity, htn, hld

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ADA BP goal (same as ACC)

< 130/80 for T2 or T1
-110-135/85 for DM + pregnancy

-<140 SBP ok for elderly

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HTN tx in T2DM

1. ACEIs or ARBs -slow progression of proteinuria -DO NOT USE BOTH in one pt -use at max tolerated dose 2. HCTZ, chlorthalidone, amlodipine, MRAs next

ACEI and ARB combo

-dont combo -hyperkalemia, syncope, renal dysfunction

When to use statin for primary CV prevention

-low risk pt none to moderate statin dose -over 40 w more than one risk factor = high intensity statin

LDL target in primary prevention

-dec by more than 50% -goal: < 70

statin use for 2' prevention

-high intensity + LSM -ezetimibe or PCSK9 if LDL still high

LDL target in 2' prevention

-LDL < 55

intolerant to statin therapy in 2' prevention:

-PCSK9 inhibitor therapy w mAb tx -bempedoic acid therapy -PCSK9 therapy w inslisinan siRNA

more generally, recommendation for DM pt 40-75

-primary prevention: moderate to high intensity statin -secondary prevention: high intensity statin and goal LDL < 70 (?) (ACC guidelines prob not updated)

High intensity statin recs

-atorvastatin 40-80 mg/day -Rosuvastatin 20-40 mg/day

Moderate intensity statin recs

-atorvastatin 10-20 -rosuvastatin 5-10 -simvastatin 20-40 -pravastatin 40-80 -lovastatin 40 -fluvastatin 80 -pitavastatin 1-4

rx for statin intolerance

-bempedoic acid

statin dosing tips

-muscle pain -start at low dose and titrate up

Stroke tx

-keep BP under control -smoking cessation

Peripheral vascular disease

-amputations -leg pain, cold feet, absent pulses

peripheral vascular disease tx

-correct risk factors -exercise -surgery

Periodontal disease

-sugar damage to teeth

Use of antiplatelet agents (2' prevention)

-aspirin 75-162mg/day in DM + ASCVD -clopidogrel 75 if allergy -sometimes combine aspirin and P2Y12 inhibitor (bleeding risk)

aspirin + rivaroxaban therapy

-for pt w stable coronary or peripheral artery disease and low bleeding risk -prevent limb and CV events

Consider aspirin for primary prevention if

-over 50 w risk factor that are not at increased risk of bleeding -d/c over 70 -dont use if low CVD risk not worth it

DM monitoring parameters

-signs and sx -blood glucose tests -glycosylated hemoglobin

Blood glucose tests

-fasting target 80-130 mg/dL**** -after meal: <180 or <140 -bedtime glucose 90-150mg/dL

Self-monitoring blood glucose (SMBG)

-intensive insulin regimens -basal insulin +/- non-insulin meds -non-insulin regimens

Intensive insulin regimens (self monitoring)

-prior to meals and bedtime -prior to snacks or activity -suspicion of hypoglycemia and after tx

basal insulin +/- noninsulin regimen self-monitoring

-once daily while fasting

non-insulin regimen self-monitoring

as needed

Continuous Glucose Monitoring (CGM)

-decrease hypoglycemia and improve A1c readings

CGM goals

-generally 70-80 -idk man

Glycosylated hemoglobin (A1c)

-normal 4-6% -DM might be 10-15% -target less than 7%!! -target 6% in pregnancy -reflects average blood glucose over the past 8-12 weeks

benefits of A1c reduction DCCT type 1

-60% reduction in retinopathy, nephropathy, neuropathy -42% reduction in CVD -57% reduction in MI, stroke, CVD death -A1c 9 to 7 -type 1

benefits of A1c lowering type 2 (UKPDS)

-25% reduction in microvasc complications -16% reduction in fatal or nonfatal MI and sudden death -every 1% drop = 18% reduction in CVD risk

ACCORD trial

-ended study early

VADT trial

bottom line of a1c trials

-more aggressive therapy for newly diagnosed, no severe hypoglycemia, no CVD -caution for severe hypoglycemia, CVD, advanced disease

A1c to eAG ratio

-1% A1c = 28.7 inc in blood glucose

Advantages of A1c monitoring

-can measure w/o fasting -levels not subject to acute changes in insulin dosing, exercise, diet

Disadvantages of A1c monitoring

-does NOT replace SMBG or CGM -its an average of all numbers -conditions that affect RBC turnover will impact results

when to check A1c

-twice a year if meeting goals -4 times if not

PPG contribution to A1c

-when A1c is high, fasting BG is contributing most -closer to 7%: target postprandial BG

Monitoring parameters

-urine tests -BUN/SCr -fasting lipid profile -BP -electrolytes

Urine tests

-urine glucose -urine ketones (esp type 1) -microalbuminuria