Diabetes week 1 Flashcards
Risk factors for pre-diabetes (4 main ones)
- family hx
- sedentary lifestyle
- overweight or obese
- being non white (hispanic or native american)
Type 1 diabetes
- insulin dependent
- <20 years old
- usually skinny
- Islet autoantibodies present
Type 2 diabetes
- initially non-insulin dependent
- > 40 y/o
- usually obese
- more common in minorities
- no autoantibodies present
development of type 2 diabetes depends on:
-abnormal beta cell function & relative insulin deficiency
Insulin resistance is when
there is a malfunction on the insulin receptor site and glucose spills over into the blood stream
what is the exercise prescription?
FITT
- frequency : T1: daily T2: 3-5 days
- Intensity: where they are seating and breathing heavily
- time: T1: 20-30 min T2: 20-60mins
- type: both aerobic and resistance
What is hypoglycemia and what is it caused by?
- BG < 70
- caused by food, exercise, medication or defect in glucagon secretion
Hypoglycemia stage 1 signs and symptoms
-nervousness, anxiety, hunger, nausea, numbness/tingling, pallor, tachycardia
Hypoglycemia stage 2 signs and symotoms:
-sudden fatigue, weakness, dizziness, confusion, amnesia, seizures, coma death…
How do you treat hypoglycemian?
RULE OF 15!!
- eat 15 gram carb load: orange juice, soda, candy
- *then follow up with a more substantial snack (protein, carbs and fat)
Severe hypoglycemia treatment:
-Glucagon recombinant: 1 mg IV, IM, SQ or NS
Hyperglycemia signs and symptoms:
- weakness, malaise, polyuria, weight loss, (develop over time)
- high BG levels (>250)
Hyperglycemia at home management:
- monitor BG
- insulin
- rest, water 7 EXERCISE
Hyperglycemia acute adverse effects:
- diabetic ketoacidosis (DKA)
- hyperglycemic hyperosmolar state (HHS)
Macro vascular complications
- CAD –> leading cause of death in diabetics
- PVD & PAD
- cerebrovascular disease, hemorrhagic, ischemic strokes
ADA Blood pressure guidelines/ tx
ASCVD <15%: <140/90
ASCVD >15%: <130/80
Pregnancy: 120-160/80-105
-no drug of choice but use acei/arb
AACE blood pressure guidelines/ tx:
BP goal < 130/80
-ACEi/ARB id drug of choice
ACC/AHA blood pressure guidelines/tx
- BP <130/80
- if CKD: acei
- if HF: dont use non-DHP CCB
- if black: use thiazide or CCB
ADA Aspirin therapy
- primary p: maybe in pts with high CVD risk(high risk is using clinical judgement in age and about 50 years old)
- secondary p: everyone!
AACE aspirin therapy
- primary p: when ASCVD score is > 10%
- secondary p: everyone!
Obesity management
- use diet and PE to achieve 5% weight loss
- weight loss medication if BMI > 27
- bariatric surgery if BMI > 35
ADA & AACE vaccine reqs
- flu- annually
- pneumococcus: 19-64 (PPSV23) >65 (PCV 13 –> on year apart PPSV23)
- hep B - all adults
Microvascular complications of DM
- retinopathy
- nephropathy
- neuropathy
prevention of diabetic retinopathy
- optimize glycemic control
- optimize blood pressure control
Diabetic retinopathy TDM1
- should have dilation of eyes within 5 years of diagnosis
- annual eye exam
Diabetic retinopathy TDM2
- should have dilation & exam of eyes at the time of diagnosis
- annual eye exam
Nephropathy risk factors
- hyperglycemia
- hypertension
- proteinuria
- dyslipidemia
CKD treatment
- optimize glucose control
- optimize blood pressure
- dietary protein intake should be ~.8g/kg per day
- ***assess urinary albumin once a year
- ACEi/ARB not primary prevention of CKD(they only help prevention when there’s albuminuria)
Diabetic Peripheral Neuropathy
- foot exams annually!
- risk factors: smokers, PAD, CKD, foot deformaties
Prediabetes and its treatment
-FPG 100mg/dl to 125mg/dl
-A1C 5.7-6.4%
Treatment:
-7% loss of initial body weight
-inc moderate-intensity physical activity
-Metformin therapy should be considered, especially for those with BMI>35KG/m2
Cholesterol management ADA Guideline
<40 ASCVD risk>20% high intensity
<40 ASCVD risk<20% no treatment require
>40 ASCVD risk>20% high intensity
>40 ASCVD risk<20% moderate intensity
Cholesterol management ACC/AHA Guideline
- DM go with moderate intensity statin
- ASCVD risk>20% High intensity
- ASCVD risk 7.5-20% Moderate intensity
DCCT: T1DM
Intensive insulin therapy (stricter goals) reduces A1C and T1DM microvascular complications → EDIC
UKPDS: T2DM
Intensive therapy (+metformin, SU) reduced microvascular events→ 10-year follow up: macrovascular; necessary to control BG, A1C, and BP
ACCORD: T2DM
Super intensive therapy (A1C < 6.0%) led to higher risk of death, especially if AIC >8.5, Hx of neuropathy, Hx ASA use
ADVANCE: T2DM
Corroborated with UKPDS 10-year follow-up with a decrease in micro- and macro- complications with intensive therapy
VADT: T2DM
Lower threshold to start insulin therapy decreased major microvascular complications; severe hypoglycemia in last 90 days is strong predictor of mortality
DM Lifestyle Management
Medical nutrition therapy (MNT) for all -Portion control and healthy food choices -Plate method(most important for T2DM) -Weight loss > 5% - Individualized meal plans -Alcohol consumption ↑ risk for hypoglycemia ● No more than 1 drink/day for women ● No more than 2 drinks/day for men ● Preferably drinking with food -Physical Activity -Smoking Cessation
Special Populations: Pediatric T1DM
-FBG90-130mg/dl,PPG 90-150mg/dl,A1c<7.5%
● BP: treat if consistently > 130/80
● Cholesterol: treat if LDL consistently> 130mg/dL
● Microvascular monitoring once > 10y/o OR had DM for 5 years
● 60 minute aerobic exercise with strength training at least 3x/wk
Special Populations: Pediatric T2DM
● Screening once > 10y/o AND BMI >85th percentile
● Aim for 7-10% weight loss
● 30-60 minutes of moderate vigorous physical activity 5x/wk with strength training for 3
● Goal A1C < 7% (6.5% reasonable if you can avoid hypoglycemia)
Special Populations: Geriatric
Functional, cognitively intact older adults can use goals
developed for younger adults. Otherwise…
● A1C goals more lenient < 7.5%
● AVOID HYPOGLYCEMIA
● Routinely consider de-escalating regimens
Sick Day Management
Sick day = infection, injury, surgery, trauma, invasive procedure,
major life stress
● Continue long-acting (basal) insulin as normal
● Use rapid-acting (bolus) insulin only if eating
● Continue PO medications EXCEPT: metformin, SGLT2i, GLP1-RA
○ D/C all PO medications if N/V/D
● Check OTC medications (sugar content)
Sick Day Management counseling points
- Test BG Q2H
- T1DM: urine/blood ketones Q4H
- Monitor Temp and hydration status
- Track symptoms: N/V, thirst, urination
Cystic Fibrosis-related DM (CFRD)
● Annually screen for CFRD in all CF patients > 10
○ Not recommended to use A1C
● Treat with insulin to attain individualized glycemic goals
● 5 years after diagnosis of CFRD, start annual monitoring for DM complications
Gestational DM vs Pregnant DM Patient
● Insulin is preferred agent
○ Gestational DM: after delivery, consider starting metformin
● Strict targets
○ A1C in pregnancy < 6%
○ FBG < 95mg/dL
○ One hour postprandial < 140mg/dL or two hour postprandial < 120mg/dL
