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PHAR 152 > Diabetes (Slide Deck 6) > Flashcards

Diabetes (Slide Deck 6) Flashcards

1
Q

What is the definition of Hypoglycemia?

A
  1. Low BG level (< 4.0 mmol/L);
  2. Development of autonomic (adrenergic) or neuroglycopenic (CNS) symptoms; and
  3. Symptoms respond to the intake of carbohydrates
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2
Q

Common causes or risk factors of Hypoglycemia

A
  • 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
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3
Q

What are the Neurogenic (Autonomic) forms of hypoglycemia?

A
  • Usually occurs first, at a BG level < 4.0 mmol/L
  • Symptoms:trembling, palpitations, sweating, anxiety, hunger, nausea, tingling
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4
Q

What are the Neuroglycopenic symptoms of hypoglycemia?

A
  • Usually occurs when BG level < 2.8 mmol/L
  • Symptoms: difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, headache, dizziness
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5
Q

What are the glucose levels of Mild, Moderate and Severe hypoglycemia?

A

Mild: Glucose < 3.9 mmol/L
Moderate: Glucose < 3.0 mmol/L USA
Severe: Glucose usually <2.8 mmol/L USA

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6
Q

Major risk factors of Hypoglycemia
in T1DM

A
  • 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
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7
Q

Major risk factors of Hypoglycemia in T2DM

A
  • Advancing age
  • Severe cognitive impairment
  • Poor health literacy
  • Food insecurity
  • Increased A1C
  • Hypoglycemia unawareness
  • Duration of insulin therapy
  • Renal impairment
  • Neuropathy
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8
Q

What are the steps to address Hypoglycemia?

A
  • 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
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9
Q

What is the treatment steps of severe hypoglycemia? (Conscious)

A
  1. 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
  2. Wait 15 mins and retest BG
  3. Retreat with another 15 g of glucose if the BG level remains < 4.0 mmol/L
  4. Eat usual snack or meal due at that time of day or a snack with 15 g carbohydrate plus protein
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10
Q

What is the treatment steps of severe hypoglycemia (Unconscious)

A
  1. 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
  2. Call 911
  3. Turn the patient into recovery position
  4. Eat as soon as safely possible
  5. Discuss with health care team
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11
Q

What is Pseudo-hypoglycemia

A

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

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12
Q

What are the usual causes of hyperglycemia?

A
  • 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
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13
Q

What is DKA?

A

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)
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14
Q

What does insulin deficiency lead to

A

Loss of water and electrolytes such as NA, K, Cl

ALSO

Stimulates lipolysis

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15
Q

What does insulin deficiency lead to

A

Loss of water and electrolytes such as NA, K, Cl

ALSO

Stimulates lipolysis

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16
Q

What is lipolysis?

A

breakdown of TGs into FFAs that are converted into ketone bodies by the liver and released into circulation; this causes acidosis

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17
Q

What are the symptoms of acidosis?

A

Abdominal pain
Air Hunger
Fruity acetone breath
Hyperventilation
Confusion

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18
Q

What is the general treatment protocol for metabolic acidosis?

A

Replace Fluids
Correct Potassium
Correct acidosis
Correct BG

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19
Q

What is Hyperosmolar hyperglycemic syndrome?

A

Characterized by extremely high sugar, increased osmolality, significant dehydration, and minimal ketoacidosis

Generally in older patients with T2DM

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20
Q

What is the main difference between DKA and HHS?

A

Ketogenesis does not occur in HHS

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21
Q

What is the general protocol for resolving HHS?

A

Fluids
Restore K
Insulin
Search for precipitating causes

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22
Q

What can be done to prevent DKA/HHS?

A
  • 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
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23
Q

What is the main difference in blood glucose between DKA/HHS

A

DKA = >14mmol

HHS= >34mmol

24
Q

What is the normal range for blood glucose?

A

4.0-8.0mmol/l

25
Q

What happens to blood glucose during infection?

A

Glucose generally increases in acute illness even with decreased caloric intake

26
Q

What should a person do with T1DM if they are sick?

A

continue insulin, but adjust bolus based on BG, ketones, food intake (e.g. may have to ↑ by 10-20%TDD)

27
Q

What should a person do with T2DM if they are sick?

A

Increase or decrease insulin (if taking) based on SMBG

28
Q

What is the acronym SAD MANS and when is it used?

A

SU
Ace Inhibitors
Diuretics, Direct renin inhibitors

Metformin
ARBS
NSAIDS
SGLT2 Inhibitors

29
Q

What does Diabetes increase the incidence of?

A

HF, ACS, Stroke

30
Q

What are the ABCDESSS of risk reduction with diabetes management?

A

AC1
BP Targets
Cholesterol
Drugs for CVD risk reduction
Exercise
Screening
Smoking cessation
Self-management

31
Q

What are the cholesterol targets for a diabetic?

A

<2.0mmol/L (LDL levels) or 50% reduction of LDL-C of current levels

32
Q

What are the hypertension targets for diabetes management?

A

<130/80

33
Q

What is the recommended CV medication for first-line therapy for diabetics with hypertension and with CV risk factors?

A

Ace/Arb

34
Q

What are the recommended first-line agents for people with diabetes and without CV risk factors?

A

ACE inhibitors, ARBs, dihydropyridine CCBs, and thiazide/thiazide-like diuretics.

35
Q

What are some risk factors that we would recommend someone for a statin.

A

Clinical CVD, >55 years of age and additional CV risk factors, Microvascular complications

36
Q

Most PWD have an indication to be on a statin?

A

Age >= 40
Age >= 30 and DM duration for greather then 15 years
Microvascular disease

37
Q

What is the primary prevention for Dyslipidemia?

40-75, 50-70

A

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)

38
Q

What is the secondary prevention for people who require additional statin therapy?

A

Consider a high dose statin, also ezetimibe should be considered.

PCSK9 inhibitors too, but is $$$

39
Q

Should people with diabetes use ASA?

A
  • 1° Prevention: ASA not routinely recommended
  • 2° Prevention: Low dose ASA (81 – 162 mg) once daily is recommended to prevent future CV events
40
Q

What is the primary cause of CKD in PWD?

A

Diabetic nephropathy

41
Q

What are the risk factors that lead to diabetic nephropathy?

A
  • Longer duration of diabetes
  • Poor BG, BP, and lipid control
  • Obesity
  • Smoking
42
Q

What is the criteria to be diagnosed with CKD?

A

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

43
Q

What is the treatment utilized to slow the progression of albuminuria and a decline in eGFR?

A
  1. Optimize blood glucose control
    * intensive BG control can slow the progression of kidney damage
  2. Optimize blood pressure control
    • Canada: goal BP <130/80mmHG
    • PWD with albuminuria or hypertension should
      receive an ACE-I or ARB as
44
Q

What are the risk factors of Retinopathy?

A
  • Duration of diabetes * Glycemiccontrol
  • HTN, dyslipidemia
  • Anemia
  • Nephropathy
  • Tobacco use
  • African American
45
Q

What is the recommended screening for T1DM for retinopathy?

A

T1DM: 5 yrs after diagnosis when ≥15yo (then annually)

46
Q

What is the recommended screening for T2DM for retinopathy?

A
  • T2DM: At diagnosis (then q 1-2yrs)
47
Q

What is the primary prevention of retinopathy?

A
  1. Optimize glycemic control
  2. Optimize BP control
48
Q

What are the two types of diabetic neuropathy?

A
  1. Distal Symmetric Poly-Neuropathy (DSPN)
  2. Diabetic Autonomic Neuropathy (DAN)
49
Q

What is Diabetic Autonomic Neuropathy (DAN)?

A
  • Involves the autonomic nervous system
  • Includes the heart (cardiac autonomic neuropathy), GIT,
    genitourinary system, sexual function, sudomotor abnormalities
50
Q

What is Distal Symmetric Poly-Neuropathy (DSPN)?

A
  • Most common
  • Involves the sensorimotor nervous system
51
Q

What are the risk factors of Diabetic neuropathy?

A
  • Elevated BG
  • Elevated triglycerides * High BMI
  • Smoking
  • Hypertension
52
Q

What is the screening of Neuropathy for a T1DM?

A
  • T1DM: After 5 years post-pubertal duration (then annually)
53
Q

What is the screening of neuropathy for a T2DM?

A
  • T2DM: At diagnosis (then annually)
54
Q

What are 6 different areas that are affected by autonomic Neuropathy?

A

Gastrointestinal
Cardiovascular
Genitourinary
Sexual Dysfunction
Metabolic
Sudomotor

55
Q

What are the early symptoms of peripheral neuropathy?

A

Small Fibers
* Pain
* Burning and tingling sensation
* Altered sense of temperature

Large Fibers
Loss of protective sensation
Numbness

56
Q

What is the treatment for peripheral neuropathy?

A

Optimize BG and prevent further neuropathy.

Currently no disease-modifying treatments exist

57
Q

What are the 4 different treatments that can be tried to reduce pain from Peripheral Neuropathy?

A
  • Gabapentinoids (pregabalin, gabapentin)
  • SNRIs (duloxetine, desvenlafaxine)
  • Sodium channel blockers (valproic acid)
  • TCAs (amitriptyline)

Capsaicin (Small effect)

PHAR 152 (8 decks)

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