DM- Diagnosis and Management Part 1 - Exam 4 Flashcards
______ due to near-complete or total absence of circulating insulin
______ due to insulin resistance, decreased insulin secretion, increased hepatic glucose production
T1DM
T2DM
The presentation of DM have many s/s related to ______, its result is ______ and _____ associated with diabetes
hyperglycemia
hyperosmolality
glycosuria
What are the 3 Polys? Which one is more associated with T1DM?
Polyuria
Polydipsia
Polyphagia** associated with T1DM
Besides the 3 polys, name some additional s/s of T1DM
Weight loss
postural hypotension
weakness
blurred vision
peripheral neuropathy
chronic infections, dry skin, itching ,poorly healing wounds
vulvovaginitis
balanoposthitis
marked dehydration
ketoacidosis
Why do you see peripheral neuropathy with DM?
neurotoxicity from sustained hyperglycemia
Includes erectile dysfunction, GI dysmotility
aka sugar is toxic at high levels especially nerve endings and blood vessels, decreased blood vessel s
Geographically, what is the correlation to DM1? What are the age peaks?
Geography - further from the equator = higher T1DM risk
dual peak incidence in childhood (4-7 y/o, 10-14 y/o)
Will you see acanthosis nigricans in T1DM? Why or why not?
will NOT see it
acanthosis nigricans is due to insulin resistance not increased glucose
What are some environmental risk factors for T1DM?
low vit D, cow’s milk, viral exposure
What are some s/s of T2DM?
overweight, blurred vision, peripheral neuropathy, chronic skin infections, vulvovaginitis, balanoposthitis, acanthosis nigricans
diabetic ketoacidosis on a test should think ____. What is it called in T2DM?
T1DM
hyperglycemic hyperosmolar state
What is the association between birth weight and T2DM?
women who delivered a baby >9 lb
aka high sugar in mom= larger babies
Name some additional conditions that are risk factors for T2DM?
Metabolic Syndrome (including low HDL or high TG)
acanthosis nigricans
polycystic ovarian syndrome (PCOS)
cardiovascular disease
Nocturnal enuresis is more associated with _____
T1DM
What are the s/s of hypoglycemia due to?
due to a combination of epinephrine and decreased CNS levels of glucose
confusion, irritability, drowsiness, dizziness, headache, blurred vision, feeling faint/actual loss of consciousness
anxiety, palpitations, tachycardia, trembling, hunger, diaphoresis, pallor
What am I?
At what level?
hypoglycemia
serum glucose level of <60-70 mg/dL
Who needs to be screened for DM?
adults at age 35
anyone who has a hx of gestational DM, pancreatitis, or prediabetes
Are overweight or obese and have 1+ DM risk factors
Have symptoms suggestive of T1DM or T2DM
HIV pts
When should a pt be screened for gestational DM?
1st prenatal visit if risk factors, otherwise at 24-28 weeks
Why do HIV pts need to be be screened for DM?
ART therapy can cause DM
If the DM screen is negative, when do they need to be retested? What about if positive? What tests are acceptable to use as a screening tool?
negative: repeat at least every 3 years!
positive for prediabets: retest at least every year!
A1C, Fasting plasma glucose or 2-hr plasma glucose after 75-g OGTT
Which of the dx tests for DM is NOT preferred for T1DM?
A1C is not preferred
** What are the reference ranges for fasting plasma glucose for normal, preDM and DM?
Normal: 70-99
PreDM: 100-125
DM: 126 or higher
** What are the reference ranges for 2 hour- PG for normal, preDM and DM?
normal: less than 140
preDM: 140-199
DM: 200 or higher
** What are the A1C ranges for normal, preDM and DM?
normal: 4-5.6%
preDM: 5.7-6.4%
DM: 6.5% or higher
If presentation for DM is unclear, what must you do?
repeat lab results, must have 2 abnormal values
What is a normal random glucose value?
normal should be less than 200
What are some factors that could influence the blood glucose sample?
fasting/nonfasting
plasma or whole blood
site
plasma blood glucose samples tend to be _____ than whole blood. For glucometry, some locations _____ have a delay of 5-20 minutes
10-12% higher
(arm, thigh)
When treating a pt in an emergency setting, would you trust a DM pt’s arm sensor reading? Why or why not?
permanent arm sensors have a lag to them so always best to still get a finger stick to tell accurate BS in the moment
What are interfering factors that could cause an increase in blood glucose levels? Decrease?
increase:
Major physical stressors (trauma, infection, MI, burns)
Steroids
Caffeine
Hct < 40%
Pregnancy
IV fluids containing sugars
Decrease:
Acetaminophen
Alcohol
High uric acid levels
Hct > 50%
What does a high BG reading indicate?
PreDM: 100-125 fasting or 140-199 2hr OGTT
DM: greater than 126 fasting or greater than 200 2-hr OGTT or random
other causes: acute stress response, Cushing syndrome, pheochromocytoma, pancreatitis, chronic renal failure
What does a low BG reading indicate? What are the values?
Excess insulin, hypopituitarism, liver disease, Addison’s
hypoglycemia is 60-70
98% of Hb is _____ ; 7% is ____, which can combine with ____ through a process called _______. ____ represents the amount of glycosylated Hb. Measures glycemic state over the last ____ weeks. With more heavily weighted for the last ____
HbA
HbA1
glucose
(glycosylation)
HbA1c
8-12 weeks
4 weeks
What factors can make an A1C appear falsely low?
-Hemoglobinopathies, in particular high levels of HbF
-“Young” RBCs (hemolytic anemia, recent blood loss, IV iron or other erythropoietic drugs
- low protein levels
What factors can make A1C appear falsely high?
“Old” RBCs (e.g., splenectomy) aka older RBC are more likely to have glucose stuck to them
Prolonged or recurrent acute stress response
What does a high A1C indicate? low?
high:
DM
preDM
stress response
cushings
acromegaly
pregnancy
splenectomy
___________
Low:
hemolytic anemia
chronic blood loss
chronic renal failure
What is a normal AIC? PreDM? DM?
normal: 4-5.6
preDM: 5.7-6.4
DM: 6.5 and above
Describe the glucose tolerance test? What is the pt education?
Check BS
Glucose load (75 g in 300 mL of water) is administered to patients
Plasma glucose measured at start of test and at 30 min, 1 hr, 2 hr, 3 hr, 4 hr
_________
low carb diets can interfere with the results: need to consume at least 150 carbs for 3 days before the test
avoid physical activity and smoking
What about a pediatric glucose tolerance test?
Pediatric patients - 1.75 g of glucose per kg of weight
What are interfering factors of the glucose tolerance test?
Acute stress response
Endocrine disorders (especially those affecting endogenous steroids)
Exercise
Fasting or reduced dietary intake prior to test
Smoking
Vomiting
What are the normal results of a glucose tolerance test?
When is a C-peptide test / C-peptide insulin ration indicated?
Evaluation of beta-cell function; identify causes of hypoglycemia; evaluation of insulinomas
Why is a C-peptide considered more helpful than measuring insulin alone? Why is measuring C-peptide helpful?
C-peptide is more stable and has a longer half-life
Pt has anti-insulin antibodies
Pt has factitious hypoglycemia
Pt is on exogenous insulin (suppresses endogenous insulin production)
It is unknown if pt is a type 1 or type 2 diabetic
What are interfering factors of the C-peptide and ratio to be increased? Decreased?
Increased - renal failure; sulfonylureas; pancreas transplant
Decreased - destruction of part or all of the pancreas
What is a normal C-peptide/insulin ratio? What does a High C-peptide, high insulin indicate?
normal: 5-10
High C-peptide, high insulin: hypoglycemic meds, insulinoma, chronic renal failure
What does a Low C-peptide, low insulin indicate? Low C-peptide, high insulin?
Low C-peptide, low insulin-> DM
Low C-peptide, high insulin -> exogenous insulin administration
What are the 2 MC DM autoantibodies? ____ is the autoantibodies associated with childhood T1DM. ____ is also found in neural tissues
anti-GAD65
Isle Cell Antibodies
Insulin Autoantibodies (IAA)
GAD
When will you see ketones? Where are they present?
when the body is using ketones for energy instead of glucose such as in alcoholism, fasting, starvation, malnutrition, eating disorders, high-fat/low-carb diets, strenuous exercise, cold, pregnancy
present in serum or urine
What medications can interfere with measuring ketones? What are the 3 ketone bodies?
Vitamin C, levodopa, valproic acid, and phenazopyridine can interfere
acetone, acetoacetate, beta-hydroxybutyrate
_____ is the predominant ketone body in severe diabetic ketoacidosis.
Beta-hydroxybutyrate
At what level are you concerned about serum ketones? What level is ketoacidosis?
greater than 3 is concerning
15-25 is ketoacidosis
What are the general goals for treating DM?
achieve glycemic control
Reduce or eliminate the long-term complications (microvascular and macrovascular) of DM
maintain quality of life
What are the blood glucose targets for a non-pregnant adult pt with DM?
Under what conditions do you want to aim for a target A1c under 6.5%?
Short diabetes duration
Long life expectancy
T2DM tx with lifestyle or metformin only
No significant CVD/vascular complications
Under what conditions do you want to aim for a target A1c under 8.0%?
Severe hypoglycemia history
Severe disease:
Limited life expectancy
Advanced DM complications
Extensive comorbidities
Long-term DM pts
What are the blood glucose targets for ped pts with DM?
What are the hypoglycemic management guidelines?
if conscious: 15-20mg of glucose orally, recheck sugar levels in 15-20 minutes then eat a snack when glucose returns to normal
unconscious pt: IV glucose or injectable glucagon
How often should T1DM check BS? T2DM? When should they check it?
T1DM often needs 3+ times/day
T2DM may need less often (1-2/day or less)
At directed times - fasting, prior to meals, postprandial
What is the general diet recommendations for DM pts?
Low-carb, hypocaloric - 45-60% carbs, 25-35% fat, and 10-35% protein
overweight/obese pts: goal of 500-700 calorie deficit
It is important for DM pts to remain up to date on ____. Especially _____ and ______
vaccines
Tdap (pertussis is the main concern in that combo)
pneumococcal
____ are recommended for DM pts with hyperlipidemia. Need to asses _____.
Moderate-to-high intensity statin therapy
factors for atherosclerotic CVD (or presence of atherosclerotic CVD)
All DM adults need to be screened for ______. Need to screen for _____ if DM patient 50+ yrs old, or any DM patient diagnosed 10+ yrs ago.
Signs of end-organ damage from DM or foot complications.
heart failure
peripheral vascular disease
Consider _____ for DM pts who have ASCVD or who are at increased ASCVD risk (10-yr risk >10%) and no increased bleeding risk
75-162 mg/day of aspirin
Yearly check of _____ and _____ in T1DM pts with ≥ 5-year duration of dx, T2DM pts from time of dx on, and all DM pts with HTN. ____ are preferred medications for pts who display signs of proteinuria
urinary albumin and eGFR
ACE/ARB
If proteinuria persists in a pt with DM, may add _____ and/or ______
SGLT-2 inhibitor
mineralocorticoid agonist
How often should DM pts be screened for retinopathy?
T1DM pts (initial) - dilated and comprehensive eye exam within 5 yrs of DM onset
T2DM pts (initial) - dilated and comprehensive eye exam at the time of DM dx
No signs of retinopathy - Perform repeat eye exam every 1-2 years
Evidence of retinopathy - Perform repeated dilated retinal exam at least yearly
Approximately ___ of T2DM pts also have non-alcoholic fatty liver dz. What is the screening tool used? When do you screen?
70%
FIB-4 score
Presence of central obesity, CVD, insulin resistance
Patients >50 years of age
Patients with persistently high (>6 months) AST and ALT levels
If DM pt has an intermediate to high risk for NAFLD/NASH, what do you do? What medication?
refer to further testing and tx
advise weight loss and diet changes
GLP-1 receptor agonists
How often do you need to screen for signs of neuropathy? What does the screening include?
Yearly in T1DM pts with ≥ 5-years of dx
T2DM pts from time of dx on
Screening: good hx, monofilament testing and 1+ additional test (pinprick, vibration, reflexes)
What are the 4 categories of ulcer risks and what are the characteristics? How often does the pt need to get examined?
When is metformin considered appropriate in preDM?
BMI > 35
Age < 60 years
Women with hx of gestational DM
What increases the risk of noncompliance, failure to follow up and poor patient care outcomes?
failure to involve the patient!!
Give the recap of guidelines a DM pt should be receiving at least once a year!
