Diabetes (Kania) Flashcards
diabetic kidney disease nephropathy signs
- persistent proteinuria
- decreased eGFR
- increased arterial BP
normal urinary albumin-to-creatinine ratio
< 30 mg/g
normal eGFR
> 60 mL/min/1.73 m2
When to screen for microalbuminuria in T1DM patients
- ≥5 years after initial diagnosis
- if UACR > 300 mg/g and/or eGFR < 60 mL/min/1.73m2
when to screen for microalbuminuria in T2DM patients
- annual following diagnosis
-if UACR > 300 mg/g and/or eGFR < 60 mL/min/1.73m2
treatment for microalbuminuria
- ACEI or ARB
- non pregnant
-if UACR > 300 mg/g and/or eGFR < 60 mL/min/1.73m2
glucose control for patients with T2DM + kidney disease (UACR 200 mg/g)
- SGLT2I with evidence of decreased CKD progression if eGFR > 20 mL/min/1.73 m2
- recommend this if UACR is normal
- use GLP-1 with proven CVD benefit if SGLT2 is not tolerated or contraindicated
- can add ACE/ARB
blood pressure goal for T2DM
< 130/80
treatment for T2DM + DKD nephropathy + HTN
- do not discontinue ACEI/ARB for < 30% increase in SCr
- use non-steroidal MRA to decrease CKD progression and CV events if at risk for CV events
- limit protein intake to 0.8 mg/kg/day for non-dialysis patients
if patient’s have a UACR ≥ _____, goal is a _______% reduction
300 mg/g, 30%
_____ is the most common ocular complication
retinopathy (most frequent cause of blindness)
for ocular complications, it is important to manage:
- glycemic control
- blood pressure
- lipid management
when should a T1DM patient screen for ocular complications
have an initial eye exam within 5 years after onset of diabetes
when should a T2DM patient screen for ocular complications
have an initial eye exam at the time of diabetes diagnosis
after screening, if no evidence of retinopathy for one or more annual exams and glycemia is controlled, may extend exams to ________
every 1-2 years
if retinopathy present,
assess at least annually
treatment for ocular complications
- photocoagulation therapy
- anti-vascular endothelial growth factor
- ranibizumab
when to asses for peripheral neuropathy in T2DM patients
at the time of diagnosis
when to assess for peripheral neuropathy in T1DM patients
within 5 years
recommended treatment for peripheral neuropathy
- pregabalin
- duloxetine
- gabapentin
- start with low dose, titrate up to reduce risk of CNS adverse effects
other neuropathy complications
- GI neuropathies (gastroparesis, diarrhea/constipation, fecal incontinence)
- urinary retention
- postural hypotension
- erectile dysfunction
what is the leading cause of morbidity and mortality in T2DM patients
atherosclerotic cardiovascular disease (ASVD)
treatment for diabetes if patient also has ASCVD and/or HF
- SGLT-2 (empagliflozin, canagliflozin, dapagliflozin)
- GLP-1RAs (liraglutide, semaglutide, dulaglutide)
cardiovascular risk factors
-obesity
- htn
- hld
- smoking
- ckd
ADA BP goal in T2DM or T1DM patients
< 130/80
ADA BP goal in DM + pregnancy
110-135/85
ACC BP goal for patients with diabetes
< 130/80
acceptable SBP for elderly who are at risks for falls
< 140
preferred antihypertensive agents for diabetics with htn
ACEIs or ARBS
use at maximally tolerated doses
other antihypertensive options
-HCTZ
- chlorthalidone
- amlodipine
- spironolactone (MRAs)
statin dose for patients 20-39 yoa with no ASCVD risk considerations
none or moderate basked on risk factors
monitoring for primary prevention of lipid disorders for those age 20-39 with no ASVD risks
annually or as needed based on adherance
statin dose for patients 40-75 yoa with no ASCVD but ≥ 1 risk factor
- moderate intensity
- high intensity, decreased LDL by ≥ 50%, and target LDL < 70
monitoring for primary prevention of lipid disorders for those age 40-75 with no ASVD and ≥ 1 risk factor
annually and as needed to monitor for adherence
DM + ASCVD in all ages treatment
high intensity statin therapy and life style modifications
target goal of LDL in DM + ASCVD patients
- decrease LDL by ≥ 50%
- goal LDL < 55
if LDL elevated despite maximally tolerated statin dose, add
ezetimibe or PCSK 9 inhibitor
ACC/AHA recommendation for primary prevention of CV events in patients with diabetes
moderate-high intensity statin depending upon risk factors
ACC/AHA recommendatin for secondary prevention of CV events in patients with diabetes
high intensity statin and goal LDL < 70
high intensity statin dosage
- atorvastatin 40-80 mg/day
- rosuvastatin 20-40 mg/day
prevention of stroke in patients with DM and ASCVD
keep BP under control and smoking cessation
prevention of peripheral vascular disease
correct risk factors, exercise, surgery (amputation, bypass)
use of anti-platelet agents in patients with diabetes
use aspirin (75-162 mg/day) as secondary prevention in those with diabetes and history of CVD
for patients with aspirin allergy, what is the recommended anti-platelet agent to use for patients with CVD and diabetes
clopidogrel (75 mg/day)
when should you consider aspirin for primary prevention
- men or women ≥ 50 years old with once major risk failure who are not at increased risk of bleeding
do not use aspirin for these patient populations
- low CVD risk
- men or women < 50 yo with no major CVD risk factors
- risk of bleeding (already has had a bleed)
signs and symptoms of diabetes
- polyuria
- polydipsia
- polyphagia
- weight loss
- fatigue
- recurrent uti
- ketoacidosis
- blurred vision
goal fasting blood glucose (ADA)
80-130 mg/dL
goal fasting blood glucose (ACCE)
<110 mg/dL
random or postprandial blood glucose level (measure 1.5-2 hours after eating)
ADA <180 mg/dL
ACCE < 140 mg/dL
when to check blood glucose levels for patients on intensive insulin regimens
- prior to meals and snacks
- at bedtime
- postprandially
- suspicion of hypoglycemia and after treatment
when to check blood glucose levels for patients on a basal insulin ± non insulin medication
once daily (fasting blood glucose)
when to check blood glucose levels for patients on non-insulin regiments
- as needed
- can use in times where there is a suspicion of hypoglycemia
- effect of diet, activity, or medication change
CGM use
- can decrease hypoglycemia and improve A1C readings
- real time continuous glucose monitoring
Glycosylated hemoglobin
non-enzymatic irreversible glycosylation of hemoglobin A circulating in blood; amount formed is related to degree of hyperglycemia
normal A1c
4-6%
ADA target A1c
< 7% (consider <6% in pregnant patients)
AACE target
≤ 6.5%
Diabetes Control and Complications Trial (DCCT)
reduction in microvascular complications, CVD outcomes, nonfatal MI, stroke or CVD death in type I patients
UK Prospective Diabetes Study (UKPDS)
- 25% reduction in microvascular complications in intensively treated type II diabets
- every 1% drop in A1c, 18% reduction in risk of CVD events
- after 10 years of follow up, reduction in mortality and CVD events
Action to Control Cardiovascular Risk in Diabetes (ACCORD)
- patients had known CVD or 2+ major cardiovascular risk factors
- study terminated early due to increase risk of mortality in intensively manage patients (A1c < 6%)
- incidence of cardiovascual events reduced in intense group, but it was not statistically significant
Action in Diabetes and Vascular Disease - Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE)
- significant reduction in microvascular outcomes without a change in macrovascular events in intensively managed patients (A1C < 6.5%)
- no increase in cardiovascular mortality
VA Diabetes Trials (VADT)
- more CVD deaths in intensive vs standard, not SS
- duration of diabetes < 15 years had mortality benefit
- > 20 years of diabetes had higher mortality
when to use < 7% A1C goal for diabetic patients
- patients with short duration of diabetes
- no h/o severe hypoglycemia
- no CVD
- long life expectancy
when to use less stringent A1C goals
- frequent or history of severe hypoglycemia
- limited life expectancy
- significant vascular disease
- extensive co-morbid conditions
- long-standing uncontrolled diabetes
advantages of A1c
- can be monitored without fasting
- levels are not subject to acute changes in insulin dosing, exercise, or diet
disadvantages of A1c
- does not replace SMBG or CGM
- it is an average
- conditions that affect RBC turnover may impact results
when to measure A1c
- twice a year if meeting treatment goals
- quarterly if therapy has changed or not meeting treatment goals
post-prandial glucose impact on A1c
-PPG effects A1c at lower A1c ranges
- once patients achieve tighter control, assess PPG and utilize PPG medications to maintain lower A1c
_______ blood glucose level impacts A1c more at higher A1c levels
fasting
