Diabetes Kania Part 4 Flashcards by Corey Brend

Fetal risks in diabetes in pregnancy

-Spontaneous abortion
-Fetal anomalies
-Preeclampsia
-Fetal demise
-Macrosomia – a baby who’s much larger than average
-Neonatal hypoglycemia
-Hyperbilirubinemia
-Neonatal respiratory distress syndrome

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Maternal risks in diabetes in pregnancy

-Retinopathy
-Pre-eclampsia

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Pre-conception counseling for women with diabetes

-Women with diabetes should have pre-conception counseling and establish care with multidisciplinary team
-Family planning should be discussed
-Diabetes treatment regimen and A1C should be optimized before pregnancy
-Goal A1C is less than 6.5% (pre-conception)

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FBS target in pregnancy

70-95 mg/dL

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1-hr postprandial targets in pregnancy

110-140 mg/dL

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2-hr postprandial target in pregnancy

100-120 mg/dL

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Ideal A1C target in pregnancy

Less than 6% is ideal but less than 7% is fine if trying to prevent hypoglycemia

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How does insulin physiology change during pregnancy?

-In early pregnancy, insulin sensitivity is enhanced and hypoglycemia can ensue, especially in patients with type 1 diabetes
-By 16 weeks, insulin resistance increases and total daily insulin dose increases ~5% per week through week 36
-Insulin requirement levels off in third trimester with placental aging
-A rapid reduction in insulin requirements may mean developmental placental insufficiency

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What happens to type 1 diabetes patients during pregnancy?

-Increased risk of hypoglycemia during first trimester
-Changes in counterregulatory hormones during prenancy may decrease hypoglycemia awareness
-Pregnancy is a ketogenic state, increasing risk of DKA
-DKA can increase stillbirths
-Insulin sensitivity increases with delivery of the placenta and returns to pre-pregnancy levels at 1-2 weeks

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What happens to type 2 diabetes patients during pregnancy?

-Risk for co-morbidities is higher
-Pregnancy loss is more common in third trimester vs first in type 1 patients
-Insulin requirements will drop significantly after delivery

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Target BP for a patient that has type 2 diabetes and is pregnant

110-135/85

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What is the recommended weight gain for overweight women during pregnancy?

15-20 pounds

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What is the recommended weight gain for obese women during pregnancy?

10-20 pounds

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Treatment for gestational diabetes

-Insulin is preferred
-Metformin can be used if patients cannot take insulin
-Avoid glyburide/glipizide because they can cause macrosomia and birth injury

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How to dose insulin for gestational diabetes

-0.7-1.0 units/kg/day
-Divide dose between basal-bolus insulins
-Adjust based on response

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How to monitor post-partum gestational diabetes

-Check OGTT 4-12 weeks postpartum
-Check for diabetes then every 1-3 years

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How is T2DM in pediatric patients different than T2DM in adults?

-More rapid decline in B-cell function
-More accelerated development of diabetes complications

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Target A1C goal for diabetic pediatric patients

A1C less than 7%

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How do you treat T1DM in pediatric patients?

-Treatment: Insulin
-Pump therapy preferred for most patients
-Use of CGM imperative for good control
-Work with the school system
-Be cognizant of psychosocial aspects of the disease in youth

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What is the most important thing to stress to pediatric patients suffering from T2DM?

Medical nutrition therapy and exercise important, especially in this population

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What initial treatment should be used for a pediatric patient with T2DM and an A1C less than 8.5%?

Metformin based on renal function

What initial treatment should be used for a pediatric patient with T2DM, an A1C of 8.5% or greater, and/or a BS of 250 or more without acidosis and is symptomatic?

Basal insulin + metformin

What treatment should be used for a pediatric patient with T2DM, an A1C of 8.5% or greater, and/or a BS of 250 or more without acidosis and is symptomatic after the initial treatment fails?

-GLP-1 agonists may be used in patients 10 years old or older as long as it is not contraindicated
-You can use liraglutide and exenatide

What treatment should be used for a pediatric patient with T2DM, an A1C of 8.5% or greater, and/or a BS of 250 or more without acidosis and is symptomatic after all treatments fail?

Begin bolus insulin or change to insulin pump therapy

How do you treat a pediatric patient with T2DM suffering from ketoacidosis?

-Treat with SQ or IV insulin -Can add metformin later

A1C goal for healthy older patients

less than 7-7.5%

Fasting glucose goal for healthy older patients

80-130 mg/dL

Bedtime glucose goal for healthy older patients

80-180 mg/dL

Blood pressure goal for healthy older patients

less than 130/80 mmHg

A1C goal for complex/intermediate older patients

less than 8%

Fasting glucose goal for complex/intermediate older patients

90-150 mg/dL

Bedtime glucose goal for complex/intermediate older patients

100-180 mg/dL

Blood pressure goal for complex/intermediate older patients

less than 130/80

A1C goal for very complex/poor health older patients

Avoid reliance on A1C; glucose control decisions should be based on avoiding hypoglycemia and signs/symptoms of high blood sugar

Fasting glucose goal for very complex/poor health older patients

100-180 mg/dL

Bedtime glucose goal for very complex/poor health older patients

110-200 mg/dL

Blood pressure goal for very complex/poor health older patients

less than 140/90 mmHg

General standards of care for hospitals

-Check A1C if not done in last 3 months -Administer insulin via written or computerized protocols to allow for adjustment -Initiate insulin for glucose of 180 or greater, then target 140-180

How to monitor hospitalized patients

-If patient is eating, check pre-prandial readings -If patient is not eating, check every 4-6 hours -If patient is on IV insulin, monitor every 30 minutes to 2 hours

How to treat diabetic hospitalized patients

-Basal insulin or basal-bolus is preferred for non-critically ill hospitalized patients along with the use of correction factor/insulin sensitivity factor -For critical care patients, use IV insulin -In some cases, may be able to continue non-insulin diabetes medication; others may be held and resumed just before or at discharge

What to do about hypoglycemia in a hospital setting

-Management protocol should exist -Frequency of events should be tracked -Treatment regimens should be altered when glucose falls below 70 mg/dL -Focus on prevention

How do glucocorticoids effect blood sugar levels?

-Morning dose of prednisone = hyperglycemia throughout the day but by nighttime levels are nearly back at baseline

How do you treat glucocorticoid-induced hyperglycemia?

-Adjust prandial dose or add AM NPH dose -Long-acting glucocorticoids (dexamethasone) may mean long-acting insulin may need adjustment -Monitor closely

What is target A1C for elective surgery?

Less than 8%

What is target blood glucose during perioperative period? (within 4 hours of surgery)

100-180 mg/dL

What do you do about basal insulin before a surgery?

Reduce basal insulin the evening before surgery by ~25%

What do you do about bolus insulin before a surgery?

Hold all bolus insulin once patient becomes NPO

What do you do about metformin before a surgery?

-Metformin should be withheld on the day of surgery -Can be resumed when patient is stable and adequate oral intake is reestablished

What do you do about SGLT2Is before a surgery?

-SGLT2Is should be held 3-4 days before surgery -Can be resumed when patient is stable and adequate oral intake is reestablished

What do you do with NPH the morning before a surgery?

Give half of the NPH dose

What do you do with long-acting or pump basal insulin the morning of surgery?

Give 75-80% of the dose

How do you monitor glucose and dose insulin while patient is taking nothing by mouth?

-Monitor glucose every 2-4 hours -Dose with short or rapid-acting insulin as needed based on correction dosing