Diabetes Kania Part 4 Flashcards
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
Maternal risks in diabetes in pregnancy
-Retinopathy
-Pre-eclampsia
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)
FBS target in pregnancy
70-95 mg/dL
1-hr postprandial targets in pregnancy
110-140 mg/dL
2-hr postprandial target in pregnancy
100-120 mg/dL
Ideal A1C target in pregnancy
Less than 6% is ideal but less than 7% is fine if trying to prevent hypoglycemia
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
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
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
Target BP for a patient that has type 2 diabetes and is pregnant
110-135/85
What is the recommended weight gain for overweight women during pregnancy?
15-20 pounds
What is the recommended weight gain for obese women during pregnancy?
10-20 pounds
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
How to dose insulin for gestational diabetes
-0.7-1.0 units/kg/day
-Divide dose between basal-bolus insulins
-Adjust based on response
How to monitor post-partum gestational diabetes
-Check OGTT 4-12 weeks postpartum
-Check for diabetes then every 1-3 years
How is T2DM in pediatric patients different than T2DM in adults?
-More rapid decline in B-cell function
-More accelerated development of diabetes complications
Target A1C goal for diabetic pediatric patients
A1C less than 7%
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
What is the most important thing to stress to pediatric patients suffering from T2DM?
Medical nutrition therapy and exercise important, especially in this population
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
