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
2
Q
How often should patients with prediabetes, Impaired glucose tolerance or Impaired fasting glucose be tested?
A
Yearly
3
Q
How often should women diagnosed with a history of GDM be tested?
A
Every 3 years for life
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
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
6
Q
Diabetes A1c, fasting, 2hr and random glucose levels?
A
A1c: >= 6.5
Fasting: >= 126
2 hr 75g OGTT: >=200
Random: >= 200
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)
8
Q
Who should get metformin for DM prevention?
A
prediabetes with risk factors:
BMI >= 35
60 years and older
women with prior GDM
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
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.
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.
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
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
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
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
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
17
Q
Preferred initial treatment of Type II DM?
A
Metformin
Continue as long as tolerated and not contraindicated
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
19
Q
BP goal for patient with DM and existing ASCVD or ASCVD risk >15%?
A
<130/80
20
Q
BP goal for patient with DM and low CVD risk (ASCVD <15%)?
A
<140/90
21
Q
First line HTN treatment for patients with DM and CAD?
A
ACEi or ARB -Monitor Cr/GFR, K at least annually
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
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
24
Q
For patients with ASCVD, esp. CAD, why is ACEi/ARB recommended?
A
Reduce the risk of CV events
25
How long should patients with prior MI continue BB?
3 years after the event
26
Can patients with HF continue metformin?
Yes, if stable HF and GFR \>30 No, if unstable or hospitalized
27
How to screen for CKD in T1 and T2 DM patients?
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
28
Describes some renal benefits of GLP-1 receptor agonists
reduces renal end points, primarily albuminuria, progression of albuminuria, and CV events
29
Which DM patients should get and ACEi/ARB?
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
30
When to refer DM patients to Nephrology?
GFR \<30
Eitology unknown
Management issues
Rapidly progressing disease
31
How often to screen for diabetic retinopathy?
T2: At time of diagnosis then yearly
T1: 5 years after diagnosis the yearly
32
In patients with diabetic retinopathy should ASA be discontinued?
The presence of retinopathy is not a contraindication to aspirin therapy for cardioprotection, as aspirin does not increase the risk of retinal hemorrhage
33
How to screen for diabetic neuropathy?
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
34
When to refer DM patients to podiatry/foot specialist?
Smokers
Hx of prior lower-extremity complications, PAD
loss of protective sensation, structural abnormalities
35
When to get ABI or vascular eval?
Patients with symptoms of claudication or decreased/absent pedal pulses
36
History to obtain for DM foot care?
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).
37
A1c goals for elderly patients?
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%)
38
Considerations for elderly patients with DM
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
39
Considerations for preconception care in patients with DM: A1c goal and DM risks? Who should be apart of the multidisciplinary team?
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.
40
Treatment and medications to avoid for pregnant women with DM
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.
41
Postpartum care in women with hx of GDM? (3)
Screen at 4–12 weeks postpartum, using the 75-g oral glucose tolerance test
Lifestyle interventions +/- metformin
Screen for DM every 1-3 years
42
Should A1c be tested in hospitalized patients with DM?
A1C test on all patients with diabetes or hyperglycemia (blood glucose \>140) admitted to the hospital if not performed in the prior 3 months
43
Glycemic target for hospitalized patients with DM
Start insulin if BG persistently \>180
Goal 140-80 (110-140 if achieved with no hypogylcemia)
44
How do insulin requirements change in the first few days postpartum?
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
45
BP goals for pregnant women with DM and HTN?
110–135/ 85 mmHg
No ACEi/ARBs or statins
46
Diabetic retinopathy screening in women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant?
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
47
Name a biguanide and the dose
Metformin
1000mg BID or 2000mg daily XR
(Titrate up 1 tab per week)
Max effect is at 2 g daily
48
What is the MOA of metformin?
Decreases gluconeogenesis in the liver (dec glucose production)
Decreases intestinal absorption of glucose
Improves insulin sensitivity
Increases peripheral glucose uptake and used
49
Name the contraindications of Metformin (3)
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
50
List the side effects of Metformin
Diarrhea, GI upset (IR \> ER)
Ghost pills
B12 deficiency
51
How much does Metformin lower A1c?
1.5-2%
52
How should you manage the risk of B12 deficiency with Metformin?
Shared decision making:
1) Start B12 supplement ppx
2) Monitor B12 levels every few years then treat as needed
\*B12 deficiency can cause neuropathy\*
53
What symptoms does lactic acidosis present with?
Flu-like symptoms
54
Name 2 thiazolidinediones (TZD)
Pioglitazone (Actos), 15 or 30 mg (rarely 45 mg)
Rosiglitazone (Avandia) [not used much in USA]
55
What is the MOA of TZDs?
Activate PPAR-g
Acts on adipose to increase \*insulin sensitivity\*
Acts on muscles to increase glucose use
56
What are the contraindications of TZDs? (4)
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
57
What are the side effects of TZDs?
Weight gain
Edema
Fractures
58
What should you monitor in patiets taking a TZD?
LFTs prior to starting and during treatment
Weight, volume status
Symptoms of bladder cancer
59
How much do TZDs lower A1c?
About 1%
60
Name 3 SGLT-2 inhibitors and doses
## Footnote
Canagliflozen (Invokana) 100- 300 mg daily
Empagliflozen (Jardiance) 10-25 mg daily
Dapagliflozen (Farxiga) 10 mg daily
61
MOA of SGLT-2 inhibitors
Block glucose reabsorption in proximal convuluted tubule
Increase glucose secretion
62
Contraindications for SGLT-2 inhibitors
## Footnote
Type 1 DM
Hx of DKA
Severe hepatic impairment (Invokana)
GFR \< 30
63
What medications make up Invokamet XR/Xigduo XR/Synjardy XR?
metformin and an SGLT-2 inhibitor
64
How to renally dose SGLT-2 inhibitors?
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
65
Side effects of SGLT-2 inhibitors
Increased risk of UTI and genital infections
Increased urination
Hypotension
AKI
Bone Fracture
Amputation
Increase risk of DKA
66
Benefit of SGLT-2 inhibitors
weight loss
Slows progression of CKD, can delay dialysis need
Decrease blood pressure
Increase HDL
Decrease risk of MI, stroke
67
How much do SGLT-2 inhibitors lower A1c?
0.5-1%
68
Name 7 GLP-1 agonists and frequency of dose
Liroglutide (Victoza) daily
Dulaglutide (Trulicity) weekly
Exenatide (Byetta) BID
Exenatide XR (Bydureon) weekly
Albiglutide (Tanzeum) weekly
Semaglutide (Ozempic) weekly
Lixisenatide (Adlyxin) daily
69
MOA of GLP-1 agonists
Increase glucose dependent insulin secretion in the pancreas
Slow gastric emptying
Decrease appetite
Decreased post prandial glucagon secretion
70
Contraindications of GLP-1 agonists
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
Side effects of GLP-1 agonists
Nausea, vomiting, diarrhea, weight loss
72
How much do GLP-1 agonists lower A1c?
About 1%
73
Name 4 DPP4- Inhibitors
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
MOA of DPP4- Inhibitors
Decrease GLP deactivation (inc GLP)
75
Contraindications of DPP4- Inhibitors
Pancreatitis
CHF
High cost
Already on a GLP agonist
76
Side effect of DPP4- Inhibitors
Joint pain
77
How much do DPP4- Inhibitors lower A1c?
0.5-1%
78
Benefits of Metformin
No weight gain or loss
Potential ASCVD benefit
Cheap
Low cost
79
Benefits of TZDs
No hypoglycemia
Potential ASCVD benefit
Low cost
oral
Benefit in NASH patients
Good for insulin resistance, acanthosis nigricans, fatty liver, hypertrigylcerides
80
Benefits of SGLT2 inhibitors
No hypogylcemia
Weight loss
ASCVD and HF benefit
oral
Renal function benefit (slow CKD progression)
81
Risks of SGLT2 inhibitors
Expensive
risk of fourniers gangrene
Can increase LDL
\*Must d/c before surgery
82
Byetta dosing information
(Frequency, administration, storage, starting dose and titration, missed doses, needles rx?)
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
Bydureon dosing information
## Footnote
(Frequency, administration, storage, starting dose and titration, missed doses)
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
Ozempic dosing information
## Footnote
(Frequency, administration, storage, starting dose and titration, missed doses)
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
Rybelsus dosing information
## Footnote
(Frequency, administration, storage, starting dose and titration, missed doses)
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
Trulicity dosing information
## Footnote
(Frequency, administration, storage, starting dose and titration, missed doses)
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
Adlyxin dosing information
## Footnote
(Frequency, administration, storage, starting dose and titration, missed doses)
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
Victoza dosing information
## Footnote
(Frequency, administration, storage, starting dose and titration, missed doses)
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
Name 3 meds than can cause edema
Gabapentin
CCB
Pioglitazone
90
Name the 3 things to monitor with every drug
Adherence
Efficacy
Safety (side effects)
91
What conditions falsely elevate HbA1c?
Hypertrigylceridemia
Hyperbilirubinemia
Splenectomy
Renal Failure
Iron Deficiency Anemia/Aplastic Anemia\*
\*Due to small RBCs living longer and picking up more glucose
92
What conditions falsely lower HbA1c?
HIV medications
Liver Disease
Blood loss
Hemolytic Anemia
Hemoglobin varients (decrease lifespan of RBCs)
93
How do you measure long term sugar control in patients with conditions that falsely lower HbA1c?
Fructosamine Level
94
How does screening for complications differ between Type 1 and 2 DM?
Type 1: Screen 5 years after diagnosis
Type 2: Screen at diagnosis
95
How do C peptide levels differ between Type 1 and 2 DM?
Type 1: low C peptide with anti-GAD antibodies
Type 2: High C peptide
96
What is latent autoimmune diabetes of adulthood?
Type 1.5 DM
Presents like 2 in thin people but they quickly loose beta cell function and require insulin
97
What is Type 3c DM?
Post pancreatitis due to B cell destruction
Requires insulin
Malnutrition due to lack of panc enzymes
98
Pre-meal blood sugar goal in DM patients?
80-130
99
Benefits of Metformin
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
What medications affect B12 levels?
Metformin and SGLT2 inhibitors
101
Do you need to change Metformin use prior to recieving IV contrast?
Stop prior and for 48 hours after
102
Benefits of TZDs?
Improves cerebrovascular outcomes (ex: stroke) and nonfatal acute MI
Increases ovulation
Reduces risk of dementia
103
Name 3 sulfonylureas
Glipizide (Glucotrol)
Glyburide
Glimepiride (Amaryl)
104
MOA of sulfonylureas
Stimulate pancreatic beta cells to release insulin
105
Side effects of sulfonylureas
Weight gain
Hypoglycemia
106
Contraindications of sulfonylureas
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
Name 2 Meglitinides
Repaglinide (Prandin)
Nateglinide (Starlix)
108
MOA of Meglitinides
Rapid acting insulin secretagogues (like sulfonylureas)
109
Uses of Meglitinides
For the elderly, renal failure, cardiopulm disorders
Good if patients have erratic eating schedules (it is given with meals)
110
Name 2 alpha-glucosidase Inhibitors
Acarbose (Precose)
Miglitol (Glyset)
111
MOA of alpha-glucosidase inhibitors
Prevent disaccharide breakdown delaying carbohydrate absorption in the gut
Decreases peak glucose levels
112
Contraindications of alpha-glucosidase inhibitors
Cirrhosis
GI dysfunction
Renal dysfunction (Cr \>2)
Cause Gas
113
Benefits of alpha-glucosidase inhibitors
Reduces risk of CV events
Weight neutral
Cat B in pregnancy
Good for patients with erratic eating schedules
114
Important info to tell patients about alpha-glucosidase inhibitors
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
Which GLP1 agontist dose not have to be decreased in renal failure?
Liraglutide (Victoza)
\*All others d/c if GFR is less than 30
116
Benefits of Victoza
\*decreases CV risk, cardioprotective, decreases mortality, not renally excreted, improves beta cell function
\*Liscenced for weight loss (Saxenda)
117
Which DPP4 inhibitor is not renally excreted?
Linagliptin (Tradjenta)
Also good choice for elderly
118
Propose a mechanism for how SGLT2 inhibitors may increase risk of ampuation
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
Which medication should be added next after Metformin for better DM control?
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
How to dose insulin?
Average dose: 0.6-0.8 units/kg daily; half for basal, half with meals
121
How does the insulin injection site affect bioavailability?
Faster onset in abdomen compared to thigh
Unless thigh injectio is followed by exercise
122
Should insulin be used early in type 2 DM?
Yes, use early to reach BS goal
In T2DM insulin can be started and stopped depending on control
123
Duration of NPH
16-24 hours
Give 2/3 in AM, 1/3 in PM
124
Duration of Glargine
24 hours
split dose if greater than 60 units
125
Duration of Detemir
24 hours
Less weight gain
duration increases as dose increases
126
Duration of Degludec
24 hours
fewer hypogylcemic events in T1 DM
Lower fasting BG levels
127
Name 4 long acting insulins
NPH
Glargine
Detemir
Degludec
128
Name 3 rapid acting insulins
Lispro (humalog)
Aspart
Glulisine (Apidra)
129
Kinetics of rapid acting insulins
Onset 15 minutes
Peak 1-3 hours
Duration 2-5 hours
130
Name the 3 treatment choices for children with diabetes
Metformin (T2)
Liraglutide (T2)
Insulin (T1 and 2)
131
When to start screening kids with T1 DM for complications?
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
Should children with DM be screened for HLD?
If positive family history or risk factors
Use statins if older than 10
133
In kids with T2 DM what is the threshold to start insulin?
If glucose \>250 or A1c \>9
If lower try lifestyle change and metformin
134
Immunizations for DM (6)
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
DM in Asian Americans
Can develop in lower BMI and younger patients
More ESRD
136
Black people with diabetes have what increased risks compared to other populations?
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
DM in Latino-Americans
51% higher death rates
Rate in Latinos expected to double in 10 years
138
DM in Native Americans
Highest rates 15.9%
139
What comorbid conditions should be screened for in patients with DM?
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
How to prevent complications in DM?
Glycemic control (especially early on)
Blood pressure (\<120/80 recommended)
HLD treatment
Smoking cessation
Lifestyle modifications
ASA if indicated
141
Should DM patients be on Aspirin?
Low dose if no hx of vascular disease and ASCVD risk is \>10% and low bleeding risk
142
Criteria of DKA
Anion gap \>10
Glucose \>250
pH \<7.3
Bicarb \<18
Serum and urine ketones
143
DKA treatment?
**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
Treatment of Neuropathy in DM patients?
1st: Pregabalin or Duloxetine
2nd: Venlafaxine or gabapentin or TCAs
145
Threshold to start ACE/ARB based on urine albumin results?
microalbuminuria \>30 or HTN
146
Well controlled diabetic develops hypoglycemia, what is a possible cause?
Progessing renal failure
147
What is the best test for sensation in a DM foot exam?
Monofilament
148
What is the best indicator for successful wound healing?
Intact vascular supply (pulses)
149
What is charcot foot?
Recurrent erythema and edema with no signs of infection (fever/chills, WBC)
Inflammatory condition in obese people with neuropathy
150
How to treat charcot foot?
Immobilization with total contact casting for 3-12 months
May need surgery if severe dislocation or instability
151
What does having DM increase the risk of?
Cancers
Hearing impairment
OSA
Peridontal disese
Depression
Cognitive impairment
Fractures
Other endocrinopathies
152
Other complications of DM?
\*Just recognize the names
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
Inpatient Diabetes:
Ordering insulin home dose v. naive?
If using at home start 2/3 of their home dose
If naive start 0.3-0.5 units/kg/day
154
Inpatient DM
Types of insulin to order: eating v. NPO v. OR
Eating: basal + premeal + correctional
NPO: basal only
OR: 1/2-2/3 of basal dose the night before, hold all premeal
155
Formula for inpatient insulin dosing if on home insulin
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
Inpatient insulin dosing using body weight based on age and admission BG?
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
What inpatient factors affect glucose control?
NPO, percentage of meals eaten
Steroid use
Surgery
Inflammation, burns, infections
158
Inpatient fasting glucose \>140 v. \<70. How should you adjust their insulin regiment?
BG \>140: increase basal by about 20%
BG \<70: decrease basal by about 20%
159
Inpatient DM
Fasting BG \<140 but
Premeal BG \>140 or random BG \>180
How to adjust insulin regiment?
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
Inpatient DM
Fasting and pre meal BG \>140
How to adjust insulin regiment?
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
Can sliding scale insulin be used as monotherapy in the inpatient setting?
NO
162
Pre-meal BG goal in DM patients?
80-130
