Diabetes in Special Populations Flashcards
Gestational diabetes
-Type 1 and 2
gestational diabetes risks
-abortion
-anomalies
-preeclampsia
-fetal demise
-macrosomia
-neonatal HYPOglycemia
-hyperbilirubinemia
-RDS
Risks to mom
-diabetic retinopathy
-preeclampsia
Diabetic retinopathy gestational diabetes
-dilated eye exam before pregnancy or 1st trimester
-monitor every trimester and one year postpartum
Preeclampsia prevention gestational diabetes
-aspirin 81-150mg/day starting at 12-16 weeks if no contraindications
pre-conception counseling
-women w diabetes need to optimize tx first
-goal A1c < 6.5%
Glycemic Targets in pregnancy
-FBG: 70-95
-PPBG: 110-140 (1h) 100-120 (2h)
-A1c < 6%
-use CGMs
Changes to insulin physiology in pregnancy
-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
Management of pregnant type 1 DM
-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
Management of pregnant Type 2 pt
-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
weight control for pregnant T2DM
-overweight: gain 15-25 lb
-obese: 10-20lb
Gestational diabetes tx
-lifestyle changes essential
-insulin preferred
-metformin if no insulin
insulin dosing gestational diabetes
-0.7-1 unit/kg/day as basal-bolus
Metformin in gestational diabetes
-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
Meds to avoid in gestational diabetes
-sulfonylureas
-macrosomia and birth injury can occur
-others lack data
Gestational diabetes postpartum
-50-75% inc risk for diabetes after 15-25 years
-check OGTT 4-12 weeks postpartum
-check for diabetes every 1-3 years
GDM + prediabetes tx
-lifestyle changes + metformin
-dec progression to diabetes by 35-40% over 10 years
T2DM in kids
-different than adults
-more rapid decline in B function
-more accelerated development of complications
Target goals for T1DM and T2DM in kids
-similar to adults
-A1c<7%
-tighter control if hypoglycemia not an issue
T1DM tx in kids
-insulin
-pump preferred
-use CGM
-work w school
-psychosocial aspects
T2DM in kids initial tx
-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
T2DM in kids tx if not at goal
-GLP1 or empagliflozin if over 10 years old
-if still not at goal begin BOLUS insulin or change to insulin pump therapy
T2DM in kids w DKA tx
-SQ or IV insulin
-add metformin later
Targets in healthy old ppl
-A1c < 7-7.5%
-FBG: 80-130
-BG: 80-180
-BP: < 130/80
Targets in intermediate health old ppl (most pt)*
-might be fall risk
-A1c < 8%
-FBG: 90-150
-BG: 100-180
-BP: < 130/80
Targets in poor health old ppl
-dont worry about A1c, just avoid hypo and hyperglycemia
-FBG: 100-180
-BG: 110-200
-BP: < 140/90
Elderly diabetes tx
-try to cut doses
-cut bolus
-chart idk?
Diabetes care in the hospital
-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
Monitoring diabetes in hospitalized pt
-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
Diabetes in hospital tx
-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
Hypoglycemia management in hospital
-protocol should exist
-track frequency
-alter tx when BG under 70
-focus on prevention (insulin dosing errors, nutrition-insulin mismatches, AKI)
Glucocorticoid Therapy
-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
Perioperative management
-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
Metformin perioperative
-withhold day of surgery
SGLT perioperative
-withhold 3-4 days
