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01 Family Medicine > Diabetes Guidelines and Medications > Flashcards

Diabetes Guidelines and Medications Flashcards

AAFP Board Review lecture: Diabetes ADA guidelines 2021

1
Q

Who to screen for diabetes if asymptomatic?

A

Obese or overweight adults and/or with one or more risk factors (esp. if planning for pregnancy)

Test everyone at age 45, repeat q3 years if normal

Overweight, obese children (after puberty or after age 10) who have risk factors

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2
Q

How often should patients with prediabetes, Impaired glucose tolerance or Impaired fasting glucose be tested?

A

Yearly

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3
Q

How often should women diagnosed with a history of GDM be tested?

A

Every 3 years for life

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4
Q

Risk factors for DM?

A
  • Overweight/Obesity (BMI >= 25)
  • Acanthosis nigricans
  • 1st degree relative with DM
  • Latino, African American, Native American, Asian, Pacific Islander
  • Hx of CVD
  • HTN (controlled or not)
  • Women with PCOS
  • HIV
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5
Q

Prediabetes A1c, fasting and 2hr glucose levels?

A

A1c: 5.7-6.4%

Fasting glucose: 100-125

2 hr 75g OGTT: 140-199

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6
Q

Diabetes A1c, fasting, 2hr and random glucose levels?

A

A1c: >= 6.5

Fasting: >= 126

2 hr 75g OGTT: >=200

Random: >= 200

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7
Q

Per USPTF guidelines, What is the weight loss and activity goal for intensive lifestyle behavior change in managing diabetes?

A

Achieve and maintain 7% loss of initial body weight

Increase moderate-intensity physical activity (such as brisk walking) for at least 150 minutes/ week. (20 mintues per day)

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8
Q

Who should get metformin for DM prevention?

A

prediabetes with risk factors:

BMI >= 35

60 years and older

women with prior GDM

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9
Q

Risk factors of DM for asymptomatic children/adolescents?

A

overweight/obese and:

  • hx of maternal DM or GDM during gestation
  • 1st or 2nd degree family hx
  • Latino, African American, Native American, Asian, Pacific Islander
  • Signs of insulin resistance or associated conditions (acanthosis nigricans, hypertension, dyslipidemia, PCOS or small-for-gestational-age birth weight
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10
Q

Physical activity goals for children with T1 or T2 DM?

A

60 minutes/day or more of moderate/vigorous aerobic activity

vigorous muscle and bone strengthening activities at least 3 days/week.

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11
Q

Physical activity goals for adults with T1 or T2 DM?

A

150 minutes or more of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity.

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12
Q

Exercise restrictions to consider in patients with diabetes complications?

A

Proliferative retinopathy- may trigger vitreous hemorrhage

Peripheral Neuropathy- Proper foot wear, good daily foot exams, NWB if open sore/injury

Autonomic Neuropathy- needs cardiac investigation prior to starting more intense exercise

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13
Q

How often to check A1c (or other gylcemic measurement) in patients with DM?

A

Stable control: every 6 months

uncontrolled or recent change in therapy: every 3 months

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14
Q

Gylcemic Goal for nonpregnant adults

A

<6.5%: new diagnosis, long life expectancy

<8%: long standing disease, advanced complications

<8.5%: limited life expectancy, complex elderly patients

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15
Q

Who needs less stringent A1c?

A

<8% long standing disease, advanced complications

<8.5% if limited life expectancy, harms > benefits, complex older adults, nursing home

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16
Q

Hypoglycemia levels

A

Level 1: <70

Level 2: <54

Level 3: Severe event, AMS

-Give patients with a history of level 2 or 3 hypogylcemic events a prescription for glucagon

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17
Q

Preferred initial treatment of Type II DM?

A

Metformin

Continue as long as tolerated and not contraindicated

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18
Q

When to start early initiation of insulin?

A

Evidence of ongoing catabolism (weight loss)

Symptoms of hyperglycemia

A1C levels >10%

Blood glucose levels >=300

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19
Q

BP goal for patient with DM and existing ASCVD or ASCVD risk >15%?

A

<130/80

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20
Q

BP goal for patient with DM and low CVD risk (ASCVD <15%)?

A

<140/90

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21
Q

First line HTN treatment for patients with DM and CAD?

A

ACEi or ARB -Monitor Cr/GFR, K at least annually

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22
Q

What population should get GLP-1 receptor agonists and why?

A

Patients with type 2 diabetes and established ASCVD or multiple risk factors for ASCVD CV benefit is recommended to reduce the risk of MACE

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23
Q

What population should get SGLT2 inhibitors and why? (2)

A

Patients with T2DM and ASCVD, multiple ASCVD risk factors, or Diabetic kidney disease

Reduce risk of worsening HF and CV death in patients with type 2 diabetes and established HFrEF

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24
Q

For patients with ASCVD, esp. CAD, why is ACEi/ARB recommended?

A

Reduce the risk of CV events

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25
Q

How long should patients with prior MI continue BB?

A

3 years after the event

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26
Q

Can patients with HF continue metformin?

A

Yes, if stable HF and GFR >30 No, if unstable or hospitalized

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27
Q

How to screen for CKD in T1 and T2 DM patients?

A

T1 >5 years, screen annually

T2: annually screen with urinary albumin and GFR

If urine albumin >300 or GFR 30-60, monitor twice per year

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28
Q

Describes some renal benefits of GLP-1 receptor agonists

A

reduces renal end points, primarily albuminuria, progression of albuminuria, and CV events

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29
Q

Which DM patients should get and ACEi/ARB?

A

nonpregnant with DM and HTN:

Moderate recommendation: UACr 20-299

Strong rec: UACr >300, GFR <60

Not for primary prevention in non-HTN and normal UACr and GFR patients

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30
Q

When to refer DM patients to Nephrology?

A

GFR <30

Eitology unknown

Management issues

Rapidly progressing disease

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31
Q

How often to screen for diabetic retinopathy?

A

T2: At time of diagnosis then yearly

T1: 5 years after diagnosis the yearly

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32
Q

In patients with diabetic retinopathy should ASA be discontinued?

A

The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage

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33
Q

How to screen for diabetic neuropathy?

A

History

temperature or pinprick sensation (small fiber testing) and vibration sensation using a 128-Hz tuning fork (large fiber testing)

annual 10-g monofilament testing

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34
Q

When to refer DM patients to podiatry/foot specialist?

A

Smokers

Hx of prior lower-extremity complications, PAD

loss of protective sensation, structural abnormalities

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35
Q

When to get ABI or vascular eval?

A

Patients with symptoms of claudication or decreased/absent pedal pulses

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36
Q

History to obtain for DM foot care?

A

Obtain a prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy, and renal disease

Assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (leg fatigue, claudication).

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37
Q

A1c goals for elderly patients?

A

Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (such as A1C <7.0–7.5%)

Those with multiple coexisting chronic illnesses, cognitive impairment, or functional dependence should have less stringent glycemic goals (such as A1C <8.0–8.5%)

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38
Q

Considerations for elderly patients with DM

A

Increased risk of hypoglycemia, medication classes with low risk of hypoglycemia are preferred.

Overtreatment/complex regiments are common - simplfy medications

Physical activity, weight loss, diet as tolerated

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39
Q

Considerations for preconception care in patients with DM: A1c goal and DM risks? Who should be apart of the multidisciplinary team?

A

Preconception counseling: address the importance of achieving glucose levels as close to normal as is safely possible, ideally A1C <6.5%, to reduce the risk of congenital anomalies, preeclampsia, macrosomia, preterm birth, and other complications.

Women with preexisting diabetes who are planning a pregnancy should ideally be managed beginning in preconception in a multidisciplinary clinic including an endocrinologist, maternal-fetal medicine specialist, RD/RDN, and CDCES, when available.

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40
Q

Treatment and medications to avoid for pregnant women with DM

A

Insulin is the preferred medication for treating hyperglycemia in GDM.

Metformin and glyburide should not be used as first-line agents, as both cross the placenta to the fetus.

Other oral and non- insulin injectable glucose-lowering medications lack long-term safety data.

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41
Q

Postpartum care in women with hx of GDM? (3)

A

Screen at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test

Lifestyle interventions +/- metformin

Screen for DM every 1-3 years

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42
Q

Should A1c be tested in hospitalized patients with DM?

A

A1C test on all patients with diabetes or hyperglycemia (blood glucose >140) admitted to the hospital if not performed in the prior 3 months

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43
Q

Glycemic target for hospitalized patients with DM

A

Start insulin if BG persistently >180

Goal 140-80 (110-140 if achieved with no hypogylcemia)

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44
Q

How do insulin requirements change in the first few days postpartum?

A

Insulin resistance decreases dramatically immediately postpartum, and insulin requirements need to be evaluated and adjusted, as they are often roughly half the pre-pregnancy requirements for the initial few days postpartum

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45
Q

BP goals for pregnant women with DM and HTN?

A

110–135/ 85 mmHg

No ACEi/ARBs or statins

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46
Q

Diabetic retinopathy screening in women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant?

A

Counsel on the risk of development and/or progression of diabetic retinopathy.

Dilated eye examinations should occur ideally before pregnancy or in the first trimester, and then patients should be monitored every trimester and for 1 year postpartum as indicated

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47
Q

Name a biguanide and the dose

A

Metformin

1000mg BID or 2000mg daily XR

(Titrate up 1 tab per week)

Max effect is at 2 g daily

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48
Q

What is the MOA of metformin?

A

Decreases gluconeogenesis in the liver (dec glucose production)

Decreases intestinal absorption of glucose

Improves insulin sensitivity

Increases peripheral glucose uptake and used

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49
Q

Name the contraindications of Metformin (3)

A

If GFR <30 don’t use/stop

If GFR 30-45 don’t start, if already on decrease dose by 50%

If patient has risk of lactic acidosis:

-unstable CHF exacerbation, DKA, shock, metabolic acidosis, hepatic impairment

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50
Q

List the side effects of Metformin

A

Diarrhea, GI upset (IR > ER)

Ghost pills

B12 deficiency

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51
Q

How much does Metformin lower A1c?

A

1.5-2%

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52
Q

How should you manage the risk of B12 deficiency with Metformin?

A

Shared decision making:

1) Start B12 supplement ppx
2) Monitor B12 levels every few years then treat as needed

*B12 deficiency can cause neuropathy*

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53
Q

What symptoms does lactic acidosis present with?

A

Flu-like symptoms

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54
Q

Name 2 thiazolidinediones (TZD)

A

Pioglitazone (Actos), 15 or 30 mg (rarely 45 mg)

Rosiglitazone (Avandia) [not used much in USA]

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55
Q

What is the MOA of TZDs?

A

Activate PPAR-g

Acts on adipose to increase *insulin sensitivity*

Acts on muscles to increase glucose use

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56
Q

What are the contraindications of TZDs? (4)

A

CHF NYHA class II or greater (not great for patients with CAD either)

Liver failure

Bladder Cancer: personal or family history

Osteoporosis (increased fracture risk, use with caution)

Cat C in pregnancy

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57
Q

What are the side effects of TZDs?

A

Weight gain

Edema

Fractures

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58
Q

What should you monitor in patiets taking a TZD?

A

LFTs prior to starting and during treatment

Weight, volume status

Symptoms of bladder cancer

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59
Q

How much do TZDs lower A1c?

A

About 1%

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60
Q

Name 3 SGLT-2 inhibitors and doses

A

Canagliflozen (Invokana) 100- 300 mg daily

Empagliflozen (Jardiance) 10-25 mg daily

Dapagliflozen (Farxiga) 10 mg daily

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61
Q

MOA of SGLT-2 inhibitors

A

Block glucose reabsorption in proximal convuluted tubule

Increase glucose secretion

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62
Q

Contraindications for SGLT-2 inhibitors

A

Type 1 DM

Hx of DKA

Severe hepatic impairment (Invokana)

GFR < 30

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63
Q

What medications make up Invokamet XR/Xigduo XR/Synjardy XR?

A

metformin and an SGLT-2 inhibitor

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64
Q

How to renally dose SGLT-2 inhibitors?

A

Treat all patients with DM, CKD and GFR >30 with an SGLT-2 inhibitor

*Adjust other medications (except metformin) to accomodate SGLT-2 inhibitors

If GFR <30 do not start this med

*If already on this med and GFR falls below 30, can continue until dialysis

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65
Q

Side effects of SGLT-2 inhibitors

A

Increased risk of UTI and genital infections

Increased urination

Hypotension

AKI

Bone Fracture

Amputation

Increase risk of DKA

66
Q

Benefit of SGLT-2 inhibitors

A

weight loss

Slows progression of CKD, can delay dialysis need

Decrease blood pressure

Increase HDL

Decrease risk of MI, stroke

67
Q

How much do SGLT-2 inhibitors lower A1c?

A

0.5-1%

68
Q

Name 7 GLP-1 agonists and frequency of dose

A

Liroglutide (Victoza) daily

Dulaglutide (Trulicity) weekly

Exenatide (Byetta) BID

Exenatide XR (Bydureon) weekly

Albiglutide (Tanzeum) weekly

Semaglutide (Ozempic) weekly

Lixisenatide (Adlyxin) daily

69
Q

MOA of GLP-1 agonists

A

Increase glucose dependent insulin secretion in the pancreas

Slow gastric emptying

Decrease appetite

Decreased post prandial glucagon secretion

70
Q

Contraindications of GLP-1 agonists

A

PGMART

Pancreatitis

Gastroparesis

MENS-2

Allergy/Angioedema hx (exenatide, liroglitide, lexisenatide)

Renal function (No exenatide if GFR <30, No Adlyxin if GFR <15)

Cat C in pregnancy

Medullary Thyroid cancer

*Expensive medications

71
Q

Side effects of GLP-1 agonists

A

Nausea, vomiting, diarrhea, weight loss

72
Q

How much do GLP-1 agonists lower A1c?

A

About 1%

73
Q

Name 4 DPP4- Inhibitors

A

Sitagliptin (Januvia) 100mg *must renally dose

Linagliptin (Tradjenta) 5 mg

Saxagliptin (Onglyza) 2.5- 5 mg *must renally dose

Alogliptin (Nesina) 25 mg *must renally dose

74
Q

MOA of DPP4- Inhibitors

A

Decrease GLP deactivation (inc GLP)

75
Q

Contraindications of DPP4- Inhibitors

A

Pancreatitis

CHF

High cost

Already on a GLP agonist

76
Q

Side effect of DPP4- Inhibitors

A

Joint pain

77
Q

How much do DPP4- Inhibitors lower A1c?

A

0.5-1%

78
Q

Benefits of Metformin

A

No weight gain or loss

Potential ASCVD benefit

Cheap

Low cost

79
Q

Benefits of TZDs

A

No hypoglycemia

Potential ASCVD benefit

Low cost

oral

Benefit in NASH patients

Good for insulin resistance, acanthosis nigricans, fatty liver, hypertrigylcerides

80
Q

Benefits of SGLT2 inhibitors

A

No hypogylcemia

Weight loss

ASCVD and HF benefit

oral

Renal function benefit (slow CKD progression)

81
Q

Risks of SGLT2 inhibitors

A

Expensive

risk of fourniers gangrene

Can increase LDL

*Must d/c before surgery

82
Q

Byetta dosing information

(Frequency, administration, storage, starting dose and titration, missed doses, needles rx?)

A

BID; 30 min to 1 hour before meals

Can be kept at room temp for 4 weeks

Start with 5 mg BID then after 4 weeks can increase to 10 mg BID

If dose missed, skip it and resume before next meal

Must write Rx for pen needles

83
Q

Bydureon dosing information

(Frequency, administration, storage, starting dose and titration, missed doses)

A

2 mg weekly

Room temp for up to 4 weeks

BydPen (comes with needles to attach)

BydBCise (needles attached)

If missed dose and there are more than 3 days before the next dose, take now

If missed dose and less than 3 days before next dose, skip

Patients may get excision site nodules

84
Q

Ozempic dosing information

(Frequency, administration, storage, starting dose and titration, missed doses)

A

Weekly

0.25 weekly for 4 weeks then 0.5 weekly

If needed can increase to 1 mg weekly after 4 weeks

If less than 5 days since skipped dose, take it; if more than 5 days skip

85
Q

Rybelsus dosing information

(Frequency, administration, storage, starting dose and titration, missed doses)

A

Daily Oral version of Ozempic

Take with less than 4 oz of water

Take at least 30 minutes prior to first meal in AM

3mg for 4 weeks then 7mg

Can increase to 14 mg after 4 weeks if needed

86
Q

Trulicity dosing information

(Frequency, administration, storage, starting dose and titration, missed doses)

A

Weekly

0.75 mg weekly for 4 weeks then 1.5 mg weekly

Can be stored at room temp for 2 weeks

Pen needles attached, easy to use

87
Q

Adlyxin dosing information

(Frequency, administration, storage, starting dose and titration, missed doses)

A

Daily

1 hour before breakfast

10 mcg daily for 14 days then 20 mcg daily

If missed then take 1 hour before next meal (don’t increase the dose)

Initally store in fridge then after 1st use can store at room air for 14 days

88
Q

Victoza dosing information

(Frequency, administration, storage, starting dose and titration, missed doses)

A

daily

0.6 mg daily for 1 week then 1.2 mg for 1 week then 1.8 mg

If dose missed for 3 days or more must retitrate

If tolerability is an issue can 0.6/1.2 or 1.2/1.8 until toleration acheived

Needs Rx for pen needles

89
Q

Name 3 meds than can cause edema

A

Gabapentin

CCB

Pioglitazone

90
Q

Name the 3 things to monitor with every drug

A

Adherence

Efficacy

Safety (side effects)

91
Q

What conditions falsely elevate HbA1c?

A

Hypertrigylceridemia

Hyperbilirubinemia

Splenectomy

Renal Failure

Iron Deficiency Anemia/Aplastic Anemia*

*Due to small RBCs living longer and picking up more glucose

92
Q

What conditions falsely lower HbA1c?

A

HIV medications

Liver Disease

Blood loss

Hemolytic Anemia

Hemoglobin varients (decrease lifespan of RBCs)

93
Q

How do you measure long term sugar control in patients with conditions that falsely lower HbA1c?

A

Fructosamine Level

94
Q

How does screening for complications differ between Type 1 and 2 DM?

A

Type 1: Screen 5 years after diagnosis

Type 2: Screen at diagnosis

95
Q

How do C peptide levels differ between Type 1 and 2 DM?

A

Type 1: low C peptide with anti-GAD antibodies

Type 2: High C peptide

96
Q

What is latent autoimmune diabetes of adulthood?

A

Type 1.5 DM

Presents like 2 in thin people but they quickly loose beta cell function and require insulin

97
Q

What is Type 3c DM?

A

Post pancreatitis due to B cell destruction

Requires insulin

Malnutrition due to lack of panc enzymes

98
Q

Pre-meal blood sugar goal in DM patients?

A

80-130

99
Q

Benefits of Metformin

A

Improves CV outcomes in overweight and newly diagnosed patients

Decreases MACE

Only oral med for kids/teens

Cat B in pregnancy

Useful in PCOS

100
Q

What medications affect B12 levels?

A

Metformin and SGLT2 inhibitors

101
Q

Do you need to change Metformin use prior to recieving IV contrast?

A

Stop prior and for 48 hours after

102
Q

Benefits of TZDs?

A

Improves cerebrovascular outcomes (ex: stroke) and nonfatal acute MI

Increases ovulation

Reduces risk of dementia

103
Q

Name 3 sulfonylureas

A

Glipizide (Glucotrol)

Glyburide

Glimepiride (Amaryl)

104
Q

MOA of sulfonylureas

A

Stimulate pancreatic beta cells to release insulin

105
Q

Side effects of sulfonylureas

A

Weight gain

Hypoglycemia

106
Q

Contraindications of sulfonylureas

A

Avoid Gylburide in the elderly or patients with renal failure

*Glipizide and Glimepiride can be used in low doses with the elderly and in patients with mild renal dysfunction

May increase risk of fractures

107
Q

Name 2 Meglitinides

A

Repaglinide (Prandin)

Nateglinide (Starlix)

108
Q

MOA of Meglitinides

A

Rapid acting insulin secretagogues (like sulfonylureas)

109
Q

Uses of Meglitinides

A

For the elderly, renal failure, cardiopulm disorders

Good if patients have erratic eating schedules (it is given with meals)

110
Q

Name 2 alpha-glucosidase Inhibitors

A

Acarbose (Precose)

Miglitol (Glyset)

111
Q

MOA of alpha-glucosidase inhibitors

A

Prevent disaccharide breakdown delaying carbohydrate absorption in the gut

Decreases peak glucose levels

112
Q

Contraindications of alpha-glucosidase inhibitors

A

Cirrhosis

GI dysfunction

Renal dysfunction (Cr >2)

Cause Gas

113
Q

Benefits of alpha-glucosidase inhibitors

A

Reduces risk of CV events

Weight neutral

Cat B in pregnancy

Good for patients with erratic eating schedules

114
Q

Important info to tell patients about alpha-glucosidase inhibitors

A

Patients must have glucose available at all time in case of hypoglycemia since disaccharides cannot be broken down- orange juice will not fix hypoglycemia

*low risk of hypoglycemia as monotherapy

115
Q

Which GLP1 agontist dose not have to be decreased in renal failure?

A

Liraglutide (Victoza)

*All others d/c if GFR is less than 30

116
Q

Benefits of Victoza

A

*decreases CV risk, cardioprotective, decreases mortality, not renally excreted, improves beta cell function

*Liscenced for weight loss (Saxenda)

117
Q

Which DPP4 inhibitor is not renally excreted?

A

Linagliptin (Tradjenta)

Also good choice for elderly

118
Q

Propose a mechanism for how SGLT2 inhibitors may increase risk of ampuation

A

Increased amount of glucose in blood -> vasodilation, more fluid in vessels

When glucose levels decrease -> vasoconstriction occurs

Now the tiny vessels to foot ulcers once dilated by inc glucose are now constricted -> lack of blood flow to wounds

119
Q

Which medication should be added next after Metformin for better DM control?

A

If cost is no problem: GLP1 agonist and/or SGLT2 inhibitors

If cost/coverage is a problem: sulfonylurea and/or piogliatzone

*Dont forget to check contraindications

120
Q

How to dose insulin?

A

Average dose: 0.6-0.8 units/kg daily; half for basal, half with meals

121
Q

How does the insulin injection site affect bioavailability?

A

Faster onset in abdomen compared to thigh

Unless thigh injectio is followed by exercise

122
Q

Should insulin be used early in type 2 DM?

A

Yes, use early to reach BS goal

In T2DM insulin can be started and stopped depending on control

123
Q

Duration of NPH

A

16-24 hours

Give 2/3 in AM, 1/3 in PM

124
Q

Duration of Glargine

A

24 hours

split dose if greater than 60 units

125
Q

Duration of Detemir

A

24 hours

Less weight gain

duration increases as dose increases

126
Q

Duration of Degludec

A

24 hours

fewer hypogylcemic events in T1 DM

Lower fasting BG levels

127
Q

Name 4 long acting insulins

A

NPH

Glargine

Detemir

Degludec

128
Q

Name 3 rapid acting insulins

A

Lispro (humalog)

Aspart

Glulisine (Apidra)

129
Q

Kinetics of rapid acting insulins

A

Onset 15 minutes

Peak 1-3 hours

Duration 2-5 hours

130
Q

Name the 3 treatment choices for children with diabetes

A

Metformin (T2)

Liraglutide (T2)

Insulin (T1 and 2)

131
Q

When to start screening kids with T1 DM for complications?

A

Microalbumin yearly at age 10 or 5 years after onset

Retinopathy at age 15 or 5 years after onset

Screen for HTN, hypothyroidism and celiac disease (tissue transglutaminase IgA, endomysial Ab IgA)

132
Q

Should children with DM be screened for HLD?

A

If positive family history or risk factors

Use statins if older than 10

133
Q

In kids with T2 DM what is the threshold to start insulin?

A

If glucose >250 or A1c >9

If lower try lifestyle change and metformin

134
Q

Immunizations for DM (6)

A

Yearly Flu

Pneumococcal once, then repeat at 65

PCV13 at 65 or if chronic renal failure

Hep B all <60 years old

Tdap

Zoster at 60

135
Q

DM in Asian Americans

A

Can develop in lower BMI and younger patients

More ESRD

136
Q

Black people with diabetes have what increased risks compared to other populations?

A

Retinopathy at lower A1c levels

Higher rates of renal failure and PAD

Risk of death from heart disease is higher if renal disease present

137
Q

DM in Latino-Americans

A

51% higher death rates

Rate in Latinos expected to double in 10 years

138
Q

DM in Native Americans

A

Highest rates 15.9%

139
Q

What comorbid conditions should be screened for in patients with DM?

A

BP at every visit

Lipids yearly

Hypothyroidism

Tobacco use

Depression (more prevelent in pts with chronic disease)

Celiac disease in T1 DM

Yearly dilated eye exam

Yearly urine microalbumin/Cr ratio (if not on ACE/ARB)

Yearly foot exam

Ask about autonomic dysfunction (gastroparesis, ED, hypotension)

140
Q

How to prevent complications in DM?

A

Glycemic control (especially early on)

Blood pressure (<120/80 recommended)

HLD treatment

Smoking cessation

Lifestyle modifications

ASA if indicated

141
Q

Should DM patients be on Aspirin?

A

Low dose if no hx of vascular disease and ASCVD risk is >10% and low bleeding risk

142
Q

Criteria of DKA

A

Anion gap >10

Glucose >250

pH <7.3

Bicarb <18

Serum and urine ketones

143
Q

DKA treatment?

A

Volume replacement: 1L NS/hour until dehydration resolved, then 1/2 NS @150-500 mL/hour

Insulin drip: 1-2 units/hour until acidosis resolved

*if K <3.3 must replete 1st

Monitor electrolytes, glucose, pH hourly

*Replete K as soon as it approaches 5

*Add D5 when glucose is about 250

*Bicarb only if pH <7 or bicarb <10

144
Q

Treatment of Neuropathy in DM patients?

A

1st: Pregabalin or Duloxetine
2nd: Venlafaxine or gabapentin or TCAs

145
Q

Threshold to start ACE/ARB based on urine albumin results?

A

microalbuminuria >30 or HTN

146
Q

Well controlled diabetic develops hypoglycemia, what is a possible cause?

A

Progessing renal failure

147
Q

What is the best test for sensation in a DM foot exam?

A

Monofilament

148
Q

What is the best indicator for successful wound healing?

A

Intact vascular supply (pulses)

149
Q

What is charcot foot?

A

Recurrent erythema and edema with no signs of infection (fever/chills, WBC)

Inflammatory condition in obese people with neuropathy

150
Q

How to treat charcot foot?

A

Immobilization with total contact casting for 3-12 months

May need surgery if severe dislocation or instability

151
Q

What does having DM increase the risk of?

A

Cancers

Hearing impairment

OSA

Peridontal disese

Depression

Cognitive impairment

Fractures

Other endocrinopathies

152
Q

Other complications of DM?

*Just recognize the names

A

Dupuytren’s contracture, Trigger finger, carpal tunnel, frozen shoulder

Necrobiosis lipoidica diabeticorum

Acrochoronds (skin tags)

Retinal vein occlusion

Necrotizing soft tissue infections

Perinephric abscess

153
Q

Inpatient Diabetes:

Ordering insulin home dose v. naive?

A

If using at home start 2/3 of their home dose

If naive start 0.3-0.5 units/kg/day

154
Q

Inpatient DM

Types of insulin to order: eating v. NPO v. OR

A

Eating: basal + premeal + correctional

NPO: basal only

OR: 1/2-2/3 of basal dose the night before, hold all premeal

155
Q

Formula for inpatient insulin dosing if on home insulin

A

Total daily dose = about 2/3 of home dose

1/2 of total daily dose = basal (detemir)

1/2 of total dailly dose = premeal (divide this second half into 3 premeal doses)

156
Q

Inpatient insulin dosing using body weight based on age and admission BG?

A

If 70+ or GFR <60 = 0.2-0.3 units/kg/day

If younger than 70, GFR >60, BG 140-200 on admission = 0.4 units/kg/day

If younger than 70, GFR >60, BG 201-400 on admission = 0.5 units/kg/day

157
Q

What inpatient factors affect glucose control?

A

NPO, percentage of meals eaten

Steroid use

Surgery

Inflammation, burns, infections

158
Q

Inpatient fasting glucose >140 v. <70. How should you adjust their insulin regiment?

A

BG >140: increase basal by about 20%

BG <70: decrease basal by about 20%

159
Q

Inpatient DM

Fasting BG <140 but

Premeal BG >140 or random BG >180

How to adjust insulin regiment?

A

Adjust premeal insulin

Add total amount of correctional insulin used in past 24 hours -> divide this number by the number of premeal doses for the next day

160
Q

Inpatient DM

Fasting and pre meal BG >140

How to adjust insulin regiment?

A

Adjust basal and premeal insulin

Add total amount of correctional insulin used in past 24 hours -> add 1/2 to basal and split the other half by 3 to add to each premeal dose

161
Q

Can sliding scale insulin be used as monotherapy in the inpatient setting?

A

NO

162
Q

Pre-meal BG goal in DM patients?

A

80-130

01 Family Medicine (16 decks)

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