Diagnosis Flashcards
What is the criteria for diagnosis of diabetes?
Ie; the three parameters and whether the patient is symptomatic or not
FBG > or = 7
A1C > or = 6.5
2 hour gTt > or = 11.1
Random >= 11.1
Repeat of the same test on a different day is needed for diagnosis.
If first test was a random BG however, choose one of the other parameters as test # 2.
UNLESS patient is symptomatic, then only 1 test is needed.
When can an A1C be misleading?
Hemoglobinopathies Iron deficiency Hemolytic anemias Severe hepatic or renal disease. Graves disease Extrme alritude
Altered by ethnicity and aging
Cannot use to dianose in pregnancy or cystic fibrosis or suspicion of type 1
Which ethnicities have a different A1C than Caucasians?
Should you use A1C to diagnose Thea individuals?
Studies of various ethnicities indicate that African Americans, American Indians, Hispanics and Asians have A1C values that are up to 0.4% higher than those of Caucasian patients at similar levels of glycemia. Studies have not been done on similar Canadian ethnicities
***Use alternate diagnosis method. FBG or OGTT
Which lab test parameter is the best prediction for development of macrovascular ie. CV complications?
A1C
For A1C to be used, it must be standardized according to what?
In order to use A1C as a diagnostic criterion, A1C must be measured using a validated assay standardized to the National Glycohemoglobin Standardization Program-Diabetes Control and Complications Trial reference.
DCCT
When can you NOT use A1C to diagnose?
Kids Teens Pregnancy Suspected Type1 Cystic Fibrosis
What 2 diagnostic parameters together can predict 100% progression from pre-diabetes to diabetes?
A1C 6-6.4 plus. FBG 6.1- 6.9
What are the parameters for pre-diabetes diagnosis?
A1c
FBG
2hr PPOGT
A1C 6 - 6.4
FBG 6.1 to 6.9
2 hour PP 75g OGT 7.8 - 11
How is metabolic syndrome diagnosed?
3 or more of: Waist >= 102 men, 88 women (lower for other ethnicities.) TG > or = 1.7 HDL less than 1 (1.3 women) BP > or = 130/85 FBG >= 5.6
WC
ASIAN/central and south America 90/80
EUROPID. MIDDLE EASTERN MEDITERRANEAN AFRICA
94/80
Who should be screened for type 1?
No one. Screening is not cost effective
Who should be screened for type 2?
> = age 40 screen every 3 years OR if high risk using calculator.
More frequent or younger if:
very high risk on risk calc. or risk factors present. Eg. FBG 5.6-6. Or A1C 5.5-5.9 or
1st degree relative
Member of high risk popul
Hx of pre-diabetes
Hx of GD
Hx of macrosomic infant
Presence of micro or macrovascular complications
Vascular risks: abd obesity, overweight, HDL < 1 males <1.3 females, TG > 1.7, smoker, HTN
Presence of assocoated disease (list)
On meds that increase diabetes risk. Eg. Glucocorticoids. Antipsycho, statins, antiretroviral
List risk factors for type 2
9
First degree relative
A’s :Asian (and SEA) Aboriginal African and Hispanic, Arab
Hx of pre-D
Hx of gestational
Hx of macrosomal infant
Diagnosis of macro or micro disease associated with D
Vascular risks: HDL. TG. BP. Abd obeisity, BMI
Associated diseases: schizo. Depression. Bipolar. HIV. Sleep Apnea. PCOS. Acanthosis Nigrans.
Drugs: glucocorticoids. Antipsychotics. HAART. Statins. Thiazides.
When should you do an OGTT in a non pregnant patient?
FBG 6.1-6.9 or A1C 6-6.4
Could do one with FBF 5.6-6 or A1C 5.5-5.9
What 2 recommendations does CDA have to reduce progression of pre to D?
5 % loss of body weight reduces risk progression by 58%.
Drugs: metformin 850mg bid foe 2.8 years. Benefit persists even after washout for more than ten years. 30% resuction.
Acarbose. Reduction risk does not persist once stopped.
Note:liraglutide can reduce progression of IGT to type 2
How are cut off levels determined for diagnosis of diabetes?
The cut offs are the level that predicts the development of retinopathy.
How many Canadians have diabetes (2015)?
How many people with diabetes worldwide?
3.4 million or 9.3% population
300 million diagnosed with another 300 million at risk.
Note: 2009 was 6.8%
What Is the prevelance of GD in Canada in aboriginal and non aboriginal?
Non aboriginal is 3.7%
Aboriginal is 8-18%.
Who should be screened for GDM?
All pregnant women
What is the preferred screening method for GD?
50g OGTT between 24 and 28 weeks. Test earlier or at any time if deemed high risk.
1 hour later!! Test PG.
or = 7.8 to 11. Do 75OGGT
If 50g 1hourPG > or = 11.1 then dx GD
What is the alternative GD screening method?
75g OGGT FPG 1hr 2hr If 1 value is met then dx GD FBG > or = 5.1 1hrPP > or = 10 2 HR PP > or = 8.5
Which of the following is at increased risk for patients with pre-diabetes?
CV disease
Diabetic retinopathy
Diabetic nephropathy
CV Disease
Diabetes can be difficult to “type”. What percentage newly diagnosed pts fall outside the traditional classifications?
Up to one quarter
What percent of type two patients are obese?
70-80 percent
What drugs can cause hyperglycemia? Ie: listed under causes of diabetes
Thiazides Thyroid hormone Statins HAART Glucocorticoids Atypical antipsychotics Beta adrenergic agonists (i.e. Mimics epi and norepinephrine). Ventolin, epi, other bronchodilators. Diazoxide Pentamidine (Antibiotic in HIV pts) Nicotinic acid Ie niacin!! Alpha interferon.
Why do some people with IGT never proceed to type 2 D?
Some Individuals can compensate indefinitely with appropriate hyperinsulinemia. Those who progress to type two often have an additional defect in insulin secretion. Ie:beta cell dysfunction.
WhT is the initial event in the development of type 2
Genetic predisposition to glucose intolerance.
What is the prevelance of type One and two in Canada?
Out of the 3.4 million (9.3%) with D, approx 10% are type one. About 300,000
About 5.2% of all Canadians have type 2.
How many times higher is the prevelance of D in First Nations?
3 to 5 times higher
How much does genetics play a role in type one?
While having a first degree relative with type one increases risk, 85-90 percent of those diagnosed have no first degree relative with the disease.
Should you
Wait 3 months after a first a1c that is in the diabetes Range before testing a1c again to confirm diagnosis?
There is no need to wait. While guidelines don’t indicate when a second text should be done, it is prudent not to wait too long to confirm D
Give some examples of hemoglobinopathies that could affect A1C testing.
Sickle cell
Thalassemia
Hemoglobin C, E, S
Anything that shortens the erythrocyte life span can ____a1c
Reduce
Iron deficiency anemia can ___a1c
Increase
Is A1C accurate for patients on renal dialysis?
No
Vitamin C and E can falsely ____a1c
Lower
If your mother or father had type two or both, what is the increased risk for type two?
Father only 12%
Mother only 14%
Both 28 %
Which lab test parameters predicts microvascular complications? 3
All three. A1C. FPG. GTT
Parameters for Diagnosis of pre diabetes
A1C 6-6.4 = Pre-D
2hr PP GGT 7.8-11 = IGT
FPG 6.1-6.9 = IFG
What is CANRISK?
Canadian diabetes risk assessment questionaire. Statistically valid tool for over age 40 and suitable for canadas multi ethnic population
Primary approaches to preventing diabetes innrhe general population 3 “programs”
1- programs targeting high risk individuals
2- programs targeting high risk groups. Eg. ethnic
3- programs for general population such as those designed to promote physical activity, and healthy eating in adults and kids
What 7 disease states put you at risk of type two
schizo. Depression. Bipolar. HIV. Sleep Apnea. PCOS. Acanthosis Nigrans.
Which one is a role of insulin? 1- stimulates glycogenolysis 2- stimulates glycogenesis 3- stimulates gluconeogenesis 4- stimulates ketogenesis
2
Remember insulin deceases BG. So we want to make more glycogen. Not break it down.
Gluconeogenesis and ketogenesis are ways to produce fuel for the brain when BG is low. Insulin inhibits these.
