Diabetes in Special Populations

Question 1

Gestational diabetes

Answer 1

-Type 1 and 2

Question 2

gestational diabetes risks

Answer 2

-abortion
-anomalies
-preeclampsia
-fetal demise
-macrosomia
-neonatal HYPOglycemia
-hyperbilirubinemia
-RDS

Question 3

Risks to mom

Answer 3

-diabetic retinopathy
-preeclampsia

Question 4

Diabetic retinopathy gestational diabetes

Answer 4

-dilated eye exam before pregnancy or 1st trimester
-monitor every trimester and one year postpartum

Question 5

Preeclampsia prevention gestational diabetes

Answer 5

-aspirin 81-150mg/day starting at 12-16 weeks if no contraindications

Question 6

pre-conception counseling

Answer 6

-women w diabetes need to optimize tx first
-goal A1c < 6.5%

Question 7

Glycemic Targets in pregnancy

Answer 7

-FBG: 70-95
-PPBG: 110-140 (1h) 100-120 (2h)
-A1c < 6%
-use CGMs

Question 8

Changes to insulin physiology in pregnancy

Answer 8

-EARLY PREG: insulin sensitivity enhanced = HYPOglycemia
-16 weeks: insulin resistance inc (might need 2-3x more)
-3rd trimester: insulin requirement levels off
-rapid reduction in insulin requirements may mean placental insufficiency

Question 9

Management of pregnant type 1 DM

Answer 9

-inc risk of hypoglycemia during 1st trimester
-change in hormones may dec hypglycemia awareness
-inc risk of DKA (prescribe ketone strips!)
-DKA can inc stillbirths
-insulin sensitivity inc w delivery of placenta and returns to pre-pregnacy levels at 1-2 weeks
-pregnancy loss more common 1st trimester

Question 10

Management of pregnant Type 2 pt

Answer 10

-risk of co-morbidities is higher
-BP goal 110-135/85
-d/c ACEIs, ARBs, statins
-pregnancy loss more common in 3rd trimester
-control weight
-often need high insulin dose during pregnancy and insulin requirements drop after delivery

Question 11

weight control for pregnant T2DM

Answer 11

-overweight: gain 15-25 lb
-obese: 10-20lb

Question 12

Gestational diabetes tx

Answer 12

-lifestyle changes essential
-insulin preferred
-metformin if no insulin

Question 13

insulin dosing gestational diabetes

Answer 13

-0.7-1 unit/kg/day as basal-bolus

Question 14

Metformin in gestational diabetes

Answer 14

-can use if pt cant take insulin
-can cross placenta
-maybe cause pre-term birth
-if taking for PCOS to induce ovulation, d/c at end of 1st trimester

Question 15

Meds to avoid in gestational diabetes

Answer 15

-sulfonylureas
-macrosomia and birth injury can occur
-others lack data

Question 16

Gestational diabetes postpartum

Answer 16

-50-75% inc risk for diabetes after 15-25 years
-check OGTT 4-12 weeks postpartum
-check for diabetes every 1-3 years

Question 17

GDM + prediabetes tx

Answer 17

-lifestyle changes + metformin
-dec progression to diabetes by 35-40% over 10 years

Question 18

T2DM in kids

Answer 18

-different than adults
-more rapid decline in B function
-more accelerated development of complications

Question 19

Target goals for T1DM and T2DM in kids

Answer 19

-similar to adults
-A1c<7%
-tighter control if hypoglycemia not an issue

Question 20

T1DM tx in kids

Answer 20

-insulin
-pump preferred
-use CGM
-work w school
-psychosocial aspects

Question 21

T2DM in kids initial tx

Answer 21

-not common under 10 years
-diet/exercise
-A1c < 8.5%: metformin based on renal function
-A1c > 8.5%, BG >250 w/o acidosis: basal insulin + metformin

Question 22

T2DM in kids tx if not at goal

Answer 22

-GLP1 or empagliflozin if over 10 years old
-if still not at goal begin BOLUS insulin or change to insulin pump therapy

Question 23

T2DM in kids w DKA tx

Answer 23

-SQ or IV insulin
-add metformin later

Question 24

Targets in healthy old ppl

Answer 24

-A1c < 7-7.5%
-FBG: 80-130
-BG: 80-180
-BP: < 130/80

Question 25

Targets in intermediate health old ppl (most pt)*

Answer 25

-might be fall risk
-A1c < 8%
-FBG: 90-150
-BG: 100-180
-BP: < 130/80

Question 26

Targets in poor health old ppl

Answer 26

-dont worry about A1c, just avoid hypo and hyperglycemia
-FBG: 100-180
-BG: 110-200
-BP: < 140/90

Question 27

Elderly diabetes tx

Answer 27

-try to cut doses
-cut bolus
-chart idk?

Question 28

Diabetes care in the hospital

Answer 28

-perform A1c if not done in last 3 months
-admin insulin via protocols to allow for adjustment
-initiate insulin for glucose >180 then target 140-180 (110-140 if no hypoglycemic risk but tight control in hospital usually inc mortality)
-can target glucose > 250 in terminally ill pt

Question 29

Monitoring diabetes in hospitalized pt

Answer 29

-if pt is eating check FBG
-if pt not eating check every 4-6h
-if pt on IV insulin check q30min-2hours
-CGM not FDA approved in hospital but becoming more common

Question 30

Diabetes in hospital tx

Answer 30

-basal or basal-bolus insulin for non-critical pt w along w CF use
-dont use sliding scale only insulin
-IV insulin for critical pt
-insulin pens can be used
-might be able to continue other meds, might need to hold metformin or SGLT2s and resume at discharge

Question 31

Hypoglycemia management in hospital

Answer 31

-protocol should exist
-track frequency
-alter tx when BG under 70
-focus on prevention (insulin dosing errors, nutrition-insulin mismatches, AKI)

Question 32

Glucocorticoid Therapy

Answer 32

-short-acting (prednisone) peak 4-6h but effect throughout the day
-morning dose prednisone = hypreglycemia during day but back to normal at bedtime (adjust prandial insulin or AM NPH)
-long-acting (dexamethasone) may need adjustment
-monitor closely

Question 33

Perioperative management

Answer 33

-target 100-180
-reduce basal insulin the evening before surgery by 25%
-hold all bolus insulin once pt becomes NPO
-metformin (day of) and SGLT (3-4 days) withheld before surgery
-resume when stable
-hold other oral DM meds morning of
-give half NPH dose or 75-80% of long acting or pump basal insulin morning of
-monitor BG q2-4h while pt is NPO and dose w short insulin PRN

Question 34

Metformin perioperative

Answer 34

-withhold day of surgery

Question 35

SGLT perioperative

Answer 35

-withhold 3-4 days