Diabetes Mellitus Flashcards
Testing should be considered in adults with OVERWEIGHT or OBESITY who have 1 or more of the ff risk factors
1st degree relative with diabetes high risk race/ethnicity history of CVD HPN (>140/90 or on therapy for HPN) HDL >35; TGL > 250 women w/ PCOS physical inactivity other clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans)
Patients with prediabetes, impaired glucose tolerance or impaired fasting glucose should be tested
YEARLY
Women w/ GDM
lifelong testing at least every 3 years
All other patients testing should begin at age
35
If results are normal, testing should be repeated at a minimum of
3 year intervals
METFORMIN is recommended in prevention of type 2 DM in adults with prediabetes
25-59 years w/ BMI > 35 kg/m2
higher FPG > 110 mg/dL
higher A1C > 6 %
women with prior GDM
Long term use of metformin
vitamin B12 deficiency
Medical Nutrition Therapy
Type I - A1C decrease of 1.0 - 1.9 %
Type II - A1C decrease of 0.3 - 2.0 %
Children and adolescents w/ type I or type 2 diabetes or prediabetes should engage in physical activity
60 minutes/ day of moderate or vigorous intensity aerobic activity at least 3 days/ week
Adults with type I and type Ii diabetes
150 minutes or more of moderate to vigorous intensity aerobic activity per week spread over at least 3 days/ week
For individuals w/ proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy
vigorous intensity aerobic or resistance exercise may be contraindicated
risk of trigerring VITREOUS HEMORRHAGE or RETINAL DETACHMENT
Assesment of glycemic status
2 times a year - patients who meet treatment goals
quarterly - patients whose therapy has recently changed and/or who are not meeting glycemic goals
Classification of Hypoglycemia
LEVEL 1 - glucose < 70 mg/dL and > 54 mg/dL
LEVEL 2 - glucose < 54 mg/dL
LEVEL 3 - severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia
This should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia
Glucagon
Glucose lowering medications that cause WEIGHT LOSS
SGLT 2 inhibitors
GLP 1 receptor agonist
Metformin (moderate weight loss)
Appropriate Initial Therapy for individuals w/ type 2 diabetes w/ or at high risk for ASCVD, HF and/or CKD
GLP 1 Receptor agonists
SGLT2 inhibitors
w/or w/o metformin
Should be considered if there is evidence of:
ongoing catabolism (weight loss)
(+) symptoms of hyperglycemia
A1c levels > 10%
blood glucose levels of > 300 mg/dL
INSULIN - combined w/ GLP 1 receptor agonist
medication regimen should be reevaluated at regular intervals (every 3-6 mos)
ASCVD/ Indicators of High Risk
GLP 1 RA w/ proven CVD benefit
OR
SGLT2 (-) w/ proven CVD benefit
ASCVD/ Indicators of High Risk
AIC above target
GLP 1 RA consider adding SGLT2I and vice versa
TZD
HF
SGLT2i w/ proven benefit in this population
CKD and albuminuria (>200 mg/g creatinine)
SGLT2 (-) w/ primary evidence of reducing CKD progression
OR
SGLT2 (-) w/ primary evidence of reducing CKD progression in CVO
OR
GLP1 RA w/ proven CVD benefit, if SGLT2i not tolerated or CI
CKD (-) albuminuria (eGFR < 60 mL/min/1.73 m2)
GLP1 RA w/ proven CVD benefit
OR
SGLT2i w/ proven CVD benefit
(-) ASCVD / indicators of high risk, HF, CKD
MINIMIZE HYPOGLYCEMIA
no/low inherent risk of hypoglycemia: DPP 4I, GLP 1 RA, TZD
for SU or basal insulin, consider agents w/ lower risk of hypoglycemia
(-) ASCVD / indicators of high risk, HF, CKD
MINIMIZE WEIGHT GAIN/PROMOTE WEIGHT LOSS
GLP 1 RA w/ good efficacy for weight loss
OR
SGLT2i
(-) ASCVD / indicators of high risk, HF, CKD
MINIMIZE WEIGHT GAIN/PROMOTE WEIGHT LOSS
if A1C above target
GLP-1 RA - consider incorporating SGLT2i and vice versa
* if GLP 1 RA not tolerated or indicated consider DPP 4i (weight neutral)
(-) ASCVD / indicators of high risk
CONSIDER COST AND ACCESS
certain insulins: consider INSULIN available at the lowest acquisition cost
SU
TZD
Anti-hyperglycemic treatment w/ HIGH efficacy
Metformin GLP 1 RAs Thiazolidinediones Sulfonylureas Human Insulin
Anti-hyperglycemic treatment in adults w/ Type 2 Diabetes w/ HYPOGLYCEMIC effect
Sulfonylureas
Insulin
Anti-hyperglycemic drugs in adults w/ Type 2 Diabetes that can cause WEIGHT LOSS
SGLT2i
GLP-1 RAs
Metformin (modest loss)
Metformin Contraindication and side effects
eGFR < 30 mL/min 1.73 m2
GI side effects (diarrhea, nausea)
B12 deficiency
SGLT2 inhibitors
ASCVD BENEFIT:
Empagliflozin
Canagliflozin
HF BENEFIT: Empagliflozin Canagliflozin Dapagliflozin Ertugliflozin
DKD:
Empagliflozin
Canagliflozin
Dapagliflozin
SGLT2 Inhibitors Side Effects
should be DISCONTINUED before any scheduled surgery to avoid potential risk for DKA DKA risk of BONE FRACTURES (Canagliflozin) GU infections risk of volume of depletion, hypotension increase LDL cholesterol risk of Fournier’s cholesterol
GLP-1 RAs
ASCVD BENEFIT:
Dulaglutide
Liraglutide
Semaglutide (SQ)
DKD BENEFIT
Liraglutide
Semaglutide (SQ)
Dulaglutide
GLP 1 RA side effects
FDA black box: risk of thyroid c cell tumors in rodents, human relevance not determined
GI side effects - nausea, vomiting, diarrhea
injection site reactions
DPP 4 Inhibitors
HF POTENTIAL RISK
Saxagliptin
DPP 4 Inhibitors Side Effects
Joint Pain
Thiazolidinediones
ASCVD POTENTIAL BENEFIT
Pioglitazone
HF INCREASED RISK
NOT recommended for RENAL IMPAIRMENT d.t. potential for fluid retention
Thiazolidenediones side effects
FDA Black Box: Congestive Heart Failure (Pioglitazone, Rosiglitazone)
fluid retention (edema, HF) benefit in NASH risk of bone fractures BLADDER CANCER (PIOGLITAZONE) INCREASE LDL CHOLESTEROL (ROSIGLITAZONE)
Sulfonylureas (2nd Generation)
RENAL EFFECTS
Glyburide - NOT recommended in CKD
Glipizide and Glimepiride - initiate conservatively to avoid hypoglycemia
BP target for individuals w/ DM and HPN at HIGHER CV risk (existing ASCVD or 10 year ASCVD risk > 15% )
130/80 mmHg
BP target for individuals w/ DM and HPN at LOWER CV risk (10 year ASCVD risk < 15% )
140/90 mmHg
BP >140/90 mmHg
lifestyle therapy
prompt initiation and timely titration of pharmacologic therapy to achieve BP goals
BP 160/100
lifestyle therapy
2 drugs or a single pill combination of drugs
First line therapy for HPN in people with DIABETES and CAD
ACE inhibitors or Angiotensin Receptor Blockers
Patients with HPN who are not meeting BP targets on 3 classes of antihypertensive medications (including diuretic)
Mineralocorticoid Receptor Antagonist (MRA) Therapy
For patients w/ diabetes aged 40-75 years (-) ASCVD
Lifestyle
Moderate Intensity Statin Therapy
For patients w/ diabetes aged 20-39 years (+) ASCVD risk factors
lifestyle therapy
statin therapy
Diabetes at higher risk especially with multiple ASCVD risk factors or aged 50-70 years
High Intensity Statin therapy
Diabetes and 10 year ASCVD risk of 20% or higher
maximally tolerated statin therapy + EZETIMIBE - to reduce LDL cholesterol levels by 50% or more
Statin Treatment Intensity
LOW INTENSITY < 30% LDL C reduction
Fluvastatin 20-40 mg
Pravastatin 10-20 mg
Simvastatin 10 mg
MODERATE INTENSITY 30 - 50% LDL C reduction Atorvastatin 10-20 mg Fluvastatin 80 mg Rosuvastatin 5-10 mg Simvastatin 20-40 mg Pravastatin 40- 80 mg Pitavastatin 2-4 mf
HIGH INTENSITY > 50%
Atorvastatin 40-80 mg
Rosuvastatin 20-40 mg
All ages (+) DM and (+) ASCVD
lifestyle therapy
HIGH intensity stain therapy
(+) DM and (+) ASCVD, LDL > 70 mg/dL
maximally tolerated statin dose + Ezetimibe or PCSK9 inhibitor
(+) ASCVD or other CV risk factors on a statin with controlled LDL cholesterol BUT with ELEVATED TRIGLYCERIDES (135-499 mg/dL)
ADD Icosapent Ethyl
For secondary prevention strategy in those diabetes and history of ASCVD
Aspirin (75-162 mg/day)
Patients with ASCVD and documented aspirin allergy
Clopidogrel (75 mg/day)
Reasonable for a year after an ACS and may have benefits beyond this period
Dual Antiplatelet Therapy (low dose aspirin and P2Y12 inhibitor)
Consider investigations for CAD in the presence of ANY of the ff:
Atypical cardiac symptoms (unexplained dyspnea, chest discomfort)
Signs or symptoms of associated vascular disease (carotid bruits, TIA, stroke, claudification, PAD)
Electrocardiogram abnormalities (i.e. Q waves)
Treatment of Type 2 diabetes and (+) ASCVD or multiple risk factors for ASCVD or diabetic kidney disease
SGLT2 inhibitor with demonstrated CV benefit
Treatment of Type 2 diabetes and (+) ASCVD or multiple risk factors for ASCVD
GLP 1 receptor agonist
May be considered for additive reduction in the risk of adverse CV and kidney events treatment of Type 2 diabetes and (+) ASCVD or multiple risk factors for ASCVD
SGLT2 inhibitor AND GLP 1 receptor agonist
In patients w/ type 2 diabetes and established HFrEF
SGLT2 (-)
MODY 1
Hepatocyte Nuclear Transcription Factor (HNF)
MODY 2
Glucokinase
MODY 3
HNF -1a
Genetic Defects in Insulin Action
Type A insulin resistance
Leprechaunism
Rabson Mendanhall syndrome
Lipodystrophy syndrome
Genetic Syndromes associated with diabetes
Wolfram’s syndrome Down syndrome Turner syndrome Friedreich ataxia Huntington chorea Laurence Moon Biedl syndrome myotonic dystrophy porphyria Prader Willi syndrome
Stimulate insulin synthesis
> 3.9 mmol/L (70 mg/dL)
Rate limiting step that controls glucose regulated insulin secretion
glucose PHOSPHORYLATION by GLUCOKINASE
Major susceptible gene for type I DM
HLA region on chromosome 6
