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Therapeutics II > Diabetes Kania Part 4 > Flashcards

Diabetes Kania Part 4 Flashcards

1
Q

Fetal risks in diabetes in pregnancy

A

-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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2
Q

Maternal risks in diabetes in pregnancy

A

-Retinopathy
-Pre-eclampsia

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3
Q

Pre-conception counseling for women with diabetes

A

-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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4
Q

FBS target in pregnancy

A

70-95 mg/dL

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5
Q

1-hr postprandial targets in pregnancy

A

110-140 mg/dL

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6
Q

2-hr postprandial target in pregnancy

A

100-120 mg/dL

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7
Q

Ideal A1C target in pregnancy

A

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

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8
Q

How does insulin physiology change during pregnancy?

A

-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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9
Q

What happens to type 1 diabetes patients during pregnancy?

A

-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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10
Q

What happens to type 2 diabetes patients during pregnancy?

A

-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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11
Q

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

A

110-135/85

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12
Q

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

A

15-20 pounds

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13
Q

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

A

10-20 pounds

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14
Q

Treatment for gestational diabetes

A

-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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15
Q

How to dose insulin for gestational diabetes

A

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

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16
Q

How to monitor post-partum gestational diabetes

A

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

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17
Q

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

A

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

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18
Q

Target A1C goal for diabetic pediatric patients

A

A1C less than 7%

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19
Q

How do you treat T1DM in pediatric patients?

A

-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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20
Q

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

A

Medical nutrition therapy and exercise important, especially in this population

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21
Q

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

A

Metformin based on renal function

22
Q

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?

A

Basal insulin + metformin

23
Q

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?

A

-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

24
Q

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?

A

Begin bolus insulin or change to insulin pump therapy

25
Q

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

A

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

26
Q

A1C goal for healthy older patients

A

less than 7-7.5%

27
Q

Fasting glucose goal for healthy older patients

A

80-130 mg/dL

28
Q

Bedtime glucose goal for healthy older patients

A

80-180 mg/dL

29
Q

Blood pressure goal for healthy older patients

A

less than 130/80 mmHg

30
Q

A1C goal for complex/intermediate older patients

A

less than 8%

31
Q

Fasting glucose goal for complex/intermediate older patients

A

90-150 mg/dL

32
Q

Bedtime glucose goal for complex/intermediate older patients

A

100-180 mg/dL

33
Q

Blood pressure goal for complex/intermediate older patients

A

less than 130/80

34
Q

A1C goal for very complex/poor health older patients

A

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

35
Q

Fasting glucose goal for very complex/poor health older patients

A

100-180 mg/dL

36
Q

Bedtime glucose goal for very complex/poor health older patients

A

110-200 mg/dL

37
Q

Blood pressure goal for very complex/poor health older patients

A

less than 140/90 mmHg

38
Q

General standards of care for hospitals

A

-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

39
Q

How to monitor hospitalized patients

A

-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

40
Q

How to treat diabetic hospitalized patients

A

-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

41
Q

What to do about hypoglycemia in a hospital setting

A

-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

42
Q

How do glucocorticoids effect blood sugar levels?

A

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

43
Q

How do you treat glucocorticoid-induced hyperglycemia?

A

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

44
Q

What is target A1C for elective surgery?

A

Less than 8%

45
Q

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

A

100-180 mg/dL

46
Q

What do you do about basal insulin before a surgery?

A

Reduce basal insulin the evening before surgery by ~25%

47
Q

What do you do about bolus insulin before a surgery?

A

Hold all bolus insulin once patient becomes NPO

48
Q

What do you do about metformin before a surgery?

A

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

49
Q

What do you do about SGLT2Is before a surgery?

A

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

50
Q

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

A

Give half of the NPH dose

51
Q

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

A

Give 75-80% of the dose

52
Q

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

A

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

Therapeutics II (33 decks)

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