Diabetes: Lecture 5 Flashcards
best way to asses Diabetes?
Combo of A1c, BG or Continuous glucose monitoring
Using A1c test frequency
every 3 months of not at goal
every 6 months in pt meeting goal
Limitation of A1c
does not provide a measure of glycemic variability or hypoglycemia
Time in range goal?
> 70%
Coefficient of variation Goal?
= 36%
measure of glucose variability ie Roller-coaster
Hypoglycemia
Defined as BG < 70
Rapid onset and progression of Symptoms
Classification of Hypoglycemia
Lvl 1 = <70 >54
Lvl 2 = < 54
Lvl 3 = altered mental and/or physical status requiring assistance for treatment of hypoglycemia
Cause of neurogenic symptoms of Hypoglycemia
Due to activation of autonomic nervous system
Cause of neuroglucopenic symptoms of Hypoglycemia
Due to inadequate glucose to the brain
How to treat mild to moderate hypoglycemia, pt can swallow.
Use 15 grams of glucose from carbs.... 3-5 hard candy 4 oz juice 3-4 glucose tablets soda
check after 15 min and if still under <70, repeat. Follow up with a snack after
How to treat severe hypoglycemia, cant safety swallow or unconscious
GlucaGen = injection Evoke = injection Baqsimi = spray nose
Diabetic Ketoacidosis defining features
Hyperglycemia
Ketosis
Metabolic acidosis
Who gets DKA?
usually Type 1
often how we diagnose
DKA presenting features?
Fatigue Headache Polyuria Polydipsia Weight loss Nausea
Labs of someone with DKA?
Glucose >250
Low serum bicarb <18
Low arterial pH <7.3
Ketonemia and moderate ketonuria
DKA complications
Cerebral edema (often kids)
Respiratory distress syndrome
Thromboembolism
Rhabdomyolysis
DKA management
Fluid admin Insulin replacement Potassium replacement Do a work-up Monitor pt Educate/Follow-up
HHS
Hyperosmolar Hyperglycemic state
Often seen in Type 2 Diabetes
don’t see the ketones, but dehydration is more profound
HHS defining features?
Hyperglycemia
Hyperosmolality
Dehydration
HHS onset?
Days to weeks
Labs for HHS
Glucose >600
Plasma osmolality >320 mOsm/kg
Presenting Symptoms HHS
Polyuria
Polydipsia
*Neurological signs
Dehydration
Big differences between DKA and HHS?
Glucose and Ketones (Neg for HHS, Pos for DKA)
Macrovascular diseases
Cerebrovascular disease
Coronary Heart Disease
Microvascualr diseases
Retinopathy
Nephropathy
Neuropathy
PVD
Landmark Trials Diabetes
DCCT = Type 1 UKPDS = Type 2
Helped establish glucose control for A1C <7%
Take home points of DCCT and UKPDS
Improved glycemic control is associated with decreased rates of microvascular complications
no sig correlation between tight glycemic control and reduction of CVD events
Long term follow up suggests that there is reduction in CVD events with tighter control
Trials to compare effects of intensive vs standard glycemic control on CVD outcomes in high risk patients with Type 2 diabetes?
Accord
Advance
VADT
ACCORD, ADVANCE, VADT
No sig risk reduction in microvascular events with tight glucose control
reduction in microvascular complications, but sig increase hypoglycemic events
Intensive treatment associated with increase all-cause mortality (ACCORD)
Neutral or increased risk of CV events n ACCORD
Cardiovascular risk factors w/ Diabetes
Dyslipidemia Hypertension Smoking Obesity/overweight CKD Presence of albuminuria
1st line for Hypertension w/ Diabetes
ACE, ARB, Thiazide, DHP CCB
monitor eGFR, Scr and K on ACE/ARB
Lipid screening w/ Diabetes
every 5 years <40 not on statin
Lipid Treatment w/ Diabetes
Primary prevention: aged 40-75 should be on Moderate statin unless contraindicated, if high risk use high intensity
2ndary prevention: any age, high intensity statin
high intensity statins
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
When to use Aspirin in patients with DM
2ndary prevention = recommended with h/o ASCVD event
controversial in primary prevention, can be considered but have to do pro/con
Who would not likely be recommended aspirin
DM pt that’s <50 yr old and not for those >70yrs old
Screening for Diabetic Kidney Disease
Type 1 = Typically develops after ~10yrs of diabetes, screen after 5
Type 2 = start screening at diagnosis
Decreasing eGFR and Increasing Albuminuria causes an……… in risk of Cardiovascular death
Increase
Treatment of Diabetic Kidney Disease
ACE or ARB recommended for Hypertension with Albuminuria
SGLT2i regardless of glycemic control
GLP1-RA (for benefit)
can use NSMineralocrticid RA Finerenone if unable to use SGLT2i
Diabetic Retinopathy prevalence strongly related to…..
duration of diabetes and level of glycemic control
Retinopathy screening
Annual eye exam
Type 1 - 5 years after diagnosis
Type 2 - start at diagnosis
Retinopathy treatment
Non to reverse it
can try laser or VEGF therapy
Diabetic Peripheral Neuropathy
diminished perception of vibration, pain, temp in lower extremities
Lea to ulcers and amputations
Best way to prevent Diabetic Neuropathy
Glycemic control
cant reverse
Diabetic Peripheral Neuropathy screening
Type 1 - 5 years after diagnosis
Type 2 - start at diagnosis, annually
How to assess Diabetic Peripheral Neuropathy
Pinprick
Temp
Vibration perception
Pressure sensation
Diabetic Peripheral Neuropathy treatment
Pregabalin
Duloxetine
Gabapentin (off-label)
