Diabetes Complications Flashcards
Long term complications of diabetes
-microvascular disease
-macrovascular disease
-periodontal diseases
-
Microvascular disease
-diabetic kidney disease nephropathy
-ocular complications
-neuropathy
Macrovascular disease
-cardiovascular disease
-stroke
-peripheral vascular disease
Diabetic kidney disease (neuropathy)
-proteinuria
-low GFR
-inc BP
-20-40% of pt w DM
-major cause of death in type 1
kidney disease monitoring
-screen for microalbuminuria
-optimize glucose control
-optimize blood pressure
microalbuminuria screening
-annual test to detect early kidney damage
-test all T2DM pt and pt w T1DM for over 5 years
-UACR and eGFR
goal UACR
<30mg/g
-urinary-albumin-to-creatinine ration
if UACR > 300mg/g or eGFR < 60mL/min/1.73m
-monitor twice a year
-ACEI or ARB tx (not for pregnant pts)
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
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
Ocular Complications (microvasc)
-blurred vision, cataracts, glaucoma
-retinopathy (most common)
-appears 15-20 years
Retinopathy
-most common cause of blindness
-pregnancy can make it worse
-appears in 15-20 years
-get eye exams
Retinopathy tx
-optimize glycemic control, BP, and lipid management
Retinopathy screening
-T1DM within 5 years of diagnosis
-T2DM at diagnosis
-exam every 1-2 years
-annually if retinopathy present
Neuropathy
-peripheral
-gastrointestinal
peripheral neuropathy tx
-annual monofilament test
-pregabalin, duloxetine, gabapentin
Gastrointestinal neuropathies
-gastroparesis
-diarrhea/constipation
-fecal incontinence
other microvascular complications
-urinary retention
-postural hypotension (drop BP when moving)
-erectile dysfunction
tx: optimize blood sugar
Macrovascular complications
-Artherosclerotic CVD
-heart failure
Atherosclerotic CVD
-coronary heeart disease
-cerebrovasc disease
-peipheral arterial disease
-leading cause of death in type 2 pt
Heart failure
-major cause of death
-hospitilizations are twice as high in DM pt
ASCVD or HF tx
-optimize tx of DM
-SGLT2
-GLP-1
CVD monitoring
-assess risk factors annually
-obesity, HTN, HLD, smoking, CKD
-metabolic syndrome: obesity, htn, hld
ADA BP goal (same as ACC)
< 130/80 for T2 or T1
-110-135/85 for DM + pregnancy
-<140 SBP ok for elderly
HTN tx in T2DM
- ACEIs or ARBs
-slow progression of proteinuria
-DO NOT USE BOTH in one pt
-use at max tolerated dose - 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
