Diabetes (Slide Deck 6) Flashcards
What is the definition of Hypoglycemia?
- Low BG level (< 4.0 mmol/L);
- Development of autonomic (adrenergic) or neuroglycopenic (CNS) symptoms; and
- Symptoms respond to the intake of carbohydrates
Common causes or risk factors of Hypoglycemia
- Not eating on time (missed meals), not eating enough
- Unusual amount (excessive) of physical exercise
- Taking too much of an anti-hyperglycemic medication
- Alcohol
- Prior episode of severe hypoglycemia; hypoglycemia unawareness
What are the Neurogenic (Autonomic) forms of hypoglycemia?
- Usually occurs first, at a BG level < 4.0 mmol/L
- Symptoms:trembling, palpitations, sweating, anxiety, hunger, nausea, tingling
What are the Neuroglycopenic symptoms of hypoglycemia?
- Usually occurs when BG level < 2.8 mmol/L
- Symptoms: difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness
What are the glucose levels of Mild, Moderate and Severe hypoglycemia?
Mild: Glucose < 3.9 mmol/L
Moderate: Glucose < 3.0 mmol/L USA
Severe: Glucose usually <2.8 mmol/L USA
Major risk factors of Hypoglycemia
in T1DM
- Prior episode of severe hypoglycemia
- Current low glycated A1C (< 6.0 %)
- Hypoglycemia Unawareness
- Long duration of diabetes
- Autonomic neuropathy
- Adolescence
- Preschool-aged children unable to
detect and/or treat mild hypoglycemia on their own
Major risk factors of Hypoglycemia in T2DM
- Advancing age
- Severe cognitive impairment
- Poor health literacy
- Food insecurity
- Increased A1C
- Hypoglycemia unawareness
- Duration of insulin therapy
- Renal impairment
- Neuropathy
What are the steps to address Hypoglycemia?
- Recognize autonomic or neuroglycopenic symptoms
- Confirm if possible (with CBG, FGM, CGM)
- Treat with “fast sugar” to relieve symptoms
- Retest in 15 minutes to ensure that BG > 4.0 mmol/L and retreat if needed
- Eat usual snack or meal due at that time of the day* or a snack with 15 g carbohydrate plus protein
What is the treatment steps of severe hypoglycemia? (Conscious)
- Treat with with oral ingestion of 20 g carbohydrate,
preferably as glucose tabs
* This will raise BG by ~ 3.5 mmol/L over 45 mins - Wait 15 mins and retest BG
- Retreat with another 15 g of glucose if the BG level remains < 4.0 mmol/L
- Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein
What is the treatment steps of severe hypoglycemia (Unconscious)
- Treat with glucagon
(1 mg IM or IV or 3mg nasal spray)
* E.g. GlucaGen® Hypokit, Glucagon®, Baqsimi®)
* Triggers the liver to release stored sugar - Call 911
- Turn the patient into recovery position
- Eat as soon as safely possible
- Discuss with health care team
What is Pseudo-hypoglycemia
A state in which an individual experiences symptoms of hypoglycemia despite having BG levels > 4.0 mmol/L
This usually occurs to people who have chronically high BG and have a rapid drop in BG levels
What are the usual causes of hyperglycemia?
- Too little / omission of insulin
- Illness (UTI, sepsis, pneumonia are common culprits of DKA) – see an increase in counter-regulatory hormones
- Infection
- Surgery
- Injury
- Stress; emotional or physical
- Increased food
- Exercise (in T1DM) with BG > 14 mmol/L and ketones
What is DKA?
DKA occurs as a result of insulin deficiency and is characterized
- Hyperglycemia (usually >14 mmol/L) Is serious!
- Ketonemia
- Metabolic acidosis (venous pH <7.3 and/or serum bicarbonate <15mmol/L, anion gap >12 mmol/L)
What does insulin deficiency lead to
Loss of water and electrolytes such as NA, K, Cl
ALSO
Stimulates lipolysis
What does insulin deficiency lead to
Loss of water and electrolytes such as NA, K, Cl
ALSO
Stimulates lipolysis
What is lipolysis?
breakdown of TGs into FFAs that are converted into ketone bodies by the liver and released into circulation; this causes acidosis
What are the symptoms of acidosis?
Abdominal pain
Air Hunger
Fruity acetone breath
Hyperventilation
Confusion
What is the general treatment protocol for metabolic acidosis?
Replace Fluids
Correct Potassium
Correct acidosis
Correct BG
What is Hyperosmolar hyperglycemic syndrome?
Characterized by extremely high sugar, increased osmolality, significant dehydration, and minimal ketoacidosis
Generally in older patients with T2DM
What is the main difference between DKA and HHS?
Ketogenesis does not occur in HHS
What is the general protocol for resolving HHS?
Fluids
Restore K
Insulin
Search for precipitating causes
What can be done to prevent DKA/HHS?
- Education around sick day management
- Adjust insulin dose as needed; continuation of
insulin even when not eating - Frequent monitoring of BG when ill * Check for ketones
What is the main difference in blood glucose between DKA/HHS
DKA = >14mmol
HHS= >34mmol
What is the normal range for blood glucose?
4.0-8.0mmol/l
What happens to blood glucose during infection?
Glucose generally increases in acute illness even with decreased caloric intake
What should a person do with T1DM if they are sick?
continue insulin, but adjust bolus based on BG, ketones, food intake (e.g. may have to ↑ by 10-20%TDD)
What should a person do with T2DM if they are sick?
Increase or decrease insulin (if taking) based on SMBG
What is the acronym SAD MANS and when is it used?
SU
Ace Inhibitors
Diuretics, Direct renin inhibitors
Metformin
ARBS
NSAIDS
SGLT2 Inhibitors
What does Diabetes increase the incidence of?
HF, ACS, Stroke
What are the ABCDESSS of risk reduction with diabetes management?
AC1
BP Targets
Cholesterol
Drugs for CVD risk reduction
Exercise
Screening
Smoking cessation
Self-management
What are the cholesterol targets for a diabetic?
<2.0mmol/L (LDL levels) or 50% reduction of LDL-C of current levels
What are the hypertension targets for diabetes management?
<130/80
What is the recommended CV medication for first-line therapy for diabetics with hypertension and with CV risk factors?
Ace/Arb
What are the recommended first-line agents for people with diabetes and without CV risk factors?
ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics.
What are some risk factors that we would recommend someone for a statin.
Clinical CVD, >55 years of age and additional CV risk factors, Microvascular complications
Most PWD have an indication to be on a statin?
Age >= 40
Age >= 30 and DM duration for greather then 15 years
Microvascular disease
What is the primary prevention for Dyslipidemia?
40-75, 50-70
40-75yo w/o atherosclerotic disease: moderate intensity statin (e.g. Atorvastatin10-20mg, Simvastatin 20-40mg, Rosuvastatin 5- 10mg)
50-70yo, multiple atherosclerotic risk factors: high dose statin (e.g. atorvastatin 40-80mg, rosuvastatin 20-40mg)
What is the secondary prevention for people who require additional statin therapy?
Consider a high dose statin, also ezetimibe should be considered.
PCSK9 inhibitors too, but is $$$
Should people with diabetes use ASA?
- 1° Prevention: ASA not routinely recommended
- 2° Prevention: Low dose ASA (81 – 162 mg) once daily is recommended to prevent future CV events
What is the primary cause of CKD in PWD?
Diabetic nephropathy
What are the risk factors that lead to diabetic nephropathy?
- Longer duration of diabetes
- Poor BG, BP, and lipid control
- Obesity
- Smoking
What is the criteria to be diagnosed with CKD?
CKD can be made if eGFR <60ml/min/1.73m2 +/or random urine ACR ≥ 2.0 mg/mmol on at least 2 of 3 samples over a 3 month period
What is the treatment utilized to slow the progression of albuminuria and a decline in eGFR?
- Optimize blood glucose control
* intensive BG control can slow the progression of kidney damage - Optimize blood pressure control
- Canada: goal BP <130/80mmHG
- PWD with albuminuria or hypertension should
receive an ACE-I or ARB as
What are the risk factors of Retinopathy?
- Duration of diabetes * Glycemiccontrol
- HTN, dyslipidemia
- Anemia
- Nephropathy
- Tobacco use
- African American
What is the recommended screening for T1DM for retinopathy?
T1DM: 5 yrs after diagnosis when ≥15yo (then annually)
What is the recommended screening for T2DM for retinopathy?
- T2DM: At diagnosis (then q 1-2yrs)
What is the primary prevention of retinopathy?
- Optimize glycemic control
- Optimize BP control
What are the two types of diabetic neuropathy?
- Distal Symmetric Poly-Neuropathy (DSPN)
- Diabetic Autonomic Neuropathy (DAN)
What is Diabetic Autonomic Neuropathy (DAN)?
- Involves the autonomic nervous system
- Includes the heart (cardiac autonomic neuropathy), GIT,
genitourinary system, sexual function, sudomotor abnormalities
What is Distal Symmetric Poly-Neuropathy (DSPN)?
- Most common
- Involves the sensorimotor nervous system
What are the risk factors of Diabetic neuropathy?
- Elevated BG
- Elevated triglycerides * High BMI
- Smoking
- Hypertension
What is the screening of Neuropathy for a T1DM?
- T1DM: After 5 years post-pubertal duration (then annually)
What is the screening of neuropathy for a T2DM?
- T2DM: At diagnosis (then annually)
What are 6 different areas that are affected by autonomic Neuropathy?
Gastrointestinal
Cardiovascular
Genitourinary
Sexual Dysfunction
Metabolic
Sudomotor
What are the early symptoms of peripheral neuropathy?
Small Fibers
* Pain
* Burning and tingling sensation
* Altered sense of temperature
Large Fibers
Loss of protective sensation
Numbness
What is the treatment for peripheral neuropathy?
Optimize BG and prevent further neuropathy.
Currently no disease-modifying treatments exist
What are the 4 different treatments that can be tried to reduce pain from Peripheral Neuropathy?
- Gabapentinoids (pregabalin, gabapentin)
- SNRIs (duloxetine, desvenlafaxine)
- Sodium channel blockers (valproic acid)
- TCAs (amitriptyline)
Capsaicin (Small effect)
