DM - Diagnosis and Screening Management, part 1 Flashcards
Many s/s are related to _____, its resultant _____, and ______ associated with diabetes
hyperglycemia
hyperosmolality
glycosuria
what are the The Three Polys of general DM presentation
- Polyuria - increased urination
- Osmotic diuresis due to glycosuria - Polydipsia - increased thirst
- Attempt to correct fluid loss from diuresis - Polyphagia - increased hunger
- Depletion of cellular stores of
carbohydrates, fats, and proteins
how do the polys of type I DM show s/s
polyuria, polydipsia, polyphagia
1. Weight loss - initially due to depletion of water; later due to loss of muscle mass
2. Postural hypotension - water depletion and lowered plasma volume
3. Weakness - muscle mass loss
4. Blurred vision - exposure of lenses to hyperosmolar fluids
5. Peripheral neuropathy - neurotoxicity from sustained hyperglycemia
- Includes erectile dysfunction, GI dysmotility
6. Skin - chronic infections, dry skin, itching, poorly healing wounds
- In particular - chronic vulvovaginitis/balanoposthitis
7. Severe - marked dehydration, ketoacidosis
risk factors of type I DM
- Family History - + family hx of T1DM
- Genetics - loci associated with susceptibility to T1DM
- Geography - further from the equator = higher DM risk
- Age - dual peak incidence in childhood (4-7 y/o, 10-14 y/o)
- Environmental - low vitamin D, cow’s milk, viral exposure
what polys affect type II DM the most?
polyuria, polydipsia
how do the polys show s/s in type II
polyuria, polydipsia
1. wt - often overweight or obese (“apple” fat distribution)
2. Blurred vision - exposure of lenses to hyperosmolar fluids
3. Peripheral neuropathy - neurotoxicity from sustained hyperglycemia
- Includes erectile dysfunction, GI dysmotility
4. Skin - chronic infections, dry skin, itching, poorly healing wounds
- In particular - chronic vulvovaginitis/balanoposthitis
- May also see acanthosis nigricans
5. Severe - marked dehydration, hyperglycemic hyperosmolar state
Many patients have an insidious onset and have little to no s/s!
risk factors for type II DM
- FHX- + family hx of T2DM, “prediabetes”
- High-risk race/ethnicity - Native Americans, Blacks, Latino/a, Asians, NHOPI
- wt - overweight or obese status (lower threshold in Asian Americans!)
- Activity - physical inactivity
- Hyperglycemia - gestational DM, IGT, IFG, or A1c >5.6%
- Birth wt - women who delivered a baby >9 lb
- Other Conditions - any aspects of Metabolic Syndrome, acanthosis nigricans, polycystic ovarian syndrome (PCOS), cardiovascular disease
Signs/Symptoms - Hypoglycemia
- Symptoms are due to a combination of epinephrine and decreased CNS levels of glucose
- Neuro - confusion, irritability, drowsiness, dizziness, headache, blurred vision, feeling faint/actual loss of consciousness
- Autonomic - anxiety, palpitations, tachycardia, trembling, hunger, diaphoresis, pallor
- Correlate with a serum glucose level of <60-70 mg/dL
Screening for prediabetes and DM should be performed in:
- All adults beginning at age 45
- Patients of any age who are overweight or obese, and have 1+ DM risk factors
- Gestational DM - 1st prenatal visit if risk factors, otherwise at 24-28 weeks
- HIV + patients (due to ART)
you screened for DM and the test results are normal, what is the next step?
repeat at least every 3 years
CVD risk factors should also be identified and treated
DM screening can be done using what?
A1C, FPG, or 2-hr PG after 75-g OGTT
what are the Diagnostic Tests for Diabetes
- Fasting Plasma Glucose (FPG)
- 2-hr Plasma Glucose during OGTT (75-g)
- Hemoglobin A1C (*not preferred for T1DM)
- Random Plasma Glucose
a fasting glucose comes back as 70-99 mg/dL
is this normal?
normal
a 2-hr plasma glucose comes back as Less than 140 mg/dL
is this normal?
normal
the hemoglobin A1c comes back as 4.0-5.6%
is this normal?
normal
a fasting plasma glucose comes back as 100-125 mg/dL
is this normal?
no, prediabetes
2-hr plasma glucose comes back 140-199 mg/dL
is this normal?
no, prediabetes
a hemoglobin A1c comes back 5.7-6.4%
is this normal
no, prediabetes
fasting glucose comes back as 126 mg/dL or higher
is this normal?
no, diabetes
2-hr plasma glucose comes back as 200 mg/dL or higher
is this normal?
no, diabetes
hemoglobin A1c comes back as 6.5% or higher
is this normal?
no, diabetes
for diagnosing prediabetes and diabetes, how do you confirm dx?
results must be repeated
unless clear presentation (hyperglycemic crisis)
Identification of blood glucose levels; used most commonly in screening or monitoring for prediabetes/DM
what is this screening
Blood Glucose - Fasting, Capillary
what notes should be considered for Blood Glucose - Fasting, Capillary
- Fasting or Nonfasting - When did pt last eat/drink? Is this part of a GTT? Any IV fluids?
- Sample - Verify sample is plasma or whole blood (capillary)
- Plasma samples tend to be 10-12% higher than whole blood
- Example - 92 mg/dL (whole blood) = 102 mg/dL (plasma) - Site - Where we are getting the blood from?
- Direct venipuncture/arterial puncture takes time to process
how are arterial samples different from venous samples
Arterial samples tend to be 3-5 mg/dL higher than venous samples
Arterial = capillary samples
For glucometry, what locations have a delay of 5-20 minutes
arm, thigh
what can elevate Blood Glucose - Fasting, Capillary
- Major physical stressors (trauma, infection, MI, burns)
- Steroids
- Caffeine
- Hct < 40%
- Pregnancy
- IV fluids containing sugars
what can decrease Blood Glucose - Fasting, Capillary
- Acetaminophen
- Alcohol
- High uric acid levels
- Hct > 50%
pt comes back with high Blood Glucose - Fasting, Capillary
what is your interpretations
- Prediabetes - 100-125 mg/dL (fasting), 140-199 mg/dL (2-hr OGTT)
- Diabetes - ≥ 126 mg/dL (fasting), ≥ 200 mg/dL (2-hr OGTT or random)
- Increased (other causes) - acute stress response, Cushing syndrome, pheochromocytoma, pancreatitis, chronic renal failure
pt comes back with low Blood Glucose - Fasting, Capillary
what is your interpretations
- Hypoglycemia - < 60-70 mg/dL
- Other Causes of Decrease - Excess insulin, hypopituitarism, liver disease, Addison’s
diagnosis and monitoring of abnormal glycemic states, primarily prediabetes and DM
what is this test?
Hemoglobin A1c
notes to consider for Hemoglobin A1c
procedure
- 98% of Hb is HbA; 7% is HbA1, which can combine with glucose (glycosylation)
- HbA1c represents the amount of glycosylated Hb
- Measures glycemic state over the last 8-12 weeks
- more heavily weighted for the last 4 weeks
what can cause a false low of A1c
- Hemoglobinopathies, in particular high levels of HbF
- “Young” RBCs
- Shortened erythrocyte survival (e.g., hemolytic anemia)
- Decreased mean erythrocyte age (e.g., recent blood loss)
- IV iron or erythropoietic drugs - Abnormally low protein levels
what can cause false high of A1c
- “Old” RBCs (e.g., splenectomy)
- Prolonged or recurrent acute stress response
interpretations of high A1c
- Diabetes Mellitus
- Prediabetes
- Nondiabetic hyperglycemia
- Stress response, Cushings, acromegaly,
pregnancy, etc. - Splenectomy
interpretations of low A1c
- Hemolytic anemia
- Chronic blood loss
- Chronic renal failure
what A1c level suggests
Uncontrolled DM
Suggest clinical intervention/
adjustment of therapy
8-14%
Assist with DM diagnosis; assist with hypoglycemia evaluation
what is this testing
Glucose Tolerance Testing
notes to consider for Glucose Tolerance Testing
- Glucose load (75 g in 300 mL of water) is administered to patients
- Pediatric patients - 1.75 g of glucose per kg of weight - Plasma glucose measured at start of test and at 30 min, 1 hr, 2 hr, 3 hr, 4 hr
- SE - dizziness, tremors, anxiety, sweating, or fainting
what is the ideal time to collect the plasma glucose for glucose tolerance testing and why?
in the AM to avoid diurnal variations in glucose
Special education points prior to glucose tolerance testing
- Low-carb diets can interfere with insulin release and cause abnormal results
- Pts on low-carb diets should consume at least 150 g carbs/day for ~3 days before the test - Patients should avoid physical activity and smoking until the test is complete
Interfering Factors Glucose Tolerance Testing
- 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 Glucose Tolerance Testing results
- Fasting - 70-99 mg/dL
- 30 min - < 200 mg/dL
- 1 hr - < 200 mg/dL
- 2 hr - < 140 mg/dL
- 3 hr/4 hr - 70-115 mg/dL
Evaluation of beta-cell function; identify causes of hypoglycemia; evaluation of insulinomas
what is this testing
C-Peptide and C-Peptide/Insulin Ratio
notes to consider for C-Peptide and C-Peptide/Insulin Ratio
- Serum insulin levels can be measured directly
- C-peptide is more stable and has a longer half-life
- C-peptide/insulin ratio compares how much insulin vs. how much C-peptide is present
Measuring C-peptide can be helpful if:
- 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 can cause an increase in C-Peptide and C-Peptide/Insulin Ratio
renal failure; sulfonylureas; pancreas transplant
what can cause a decrease in C-Peptide and C-Peptide/Insulin Ratio
destruction of part or all of the pancreas
C-Peptide and C-Peptide/Insulin Ratio comes back 5.0-10.0
what is your interpretation
normal
high C-Peptide/high Insulin Ratio
what is your interpretation
- hypoglycemic meds - esp sulfonylureas
- insulinoma
- chronic renal failure
low C-Peptide/ low Insulin Ratio
what is your interpretation
DM
low C-Peptide/ high Insulin Ratio
what is your interpretation
exogenous insulin administration
Evaluate for the presence of ketosis
what is this testing
ketones
metabolic state wherein the body’s energy is coming from ketone bodies in the blood, instead of glucose
how can ketones be tested?
serum or urine
Ketosis may also be seen in that can inter with ketone testing:
- Altered nutrition - alcoholism, fasting, starvation, malnutrition, eating disorders, high-fat/low-carb diets
- Increased metabolic demands - strenuous exercise, exposure to cold, pregnancy
what 4 interfering factors must be considered for ketones
Vitamin C, levodopa, valproic acid, and phenazopyridine
3 ketone bodies, which one is the predominate one in severe diabetic ketoacidosis
- acetone, acetoacetate, beta-hydroxybutyrate
- Beta-hydroxybutyrate
what serum concentration of ketones is generally concerning?
> 3
General Goals of Treating DM
- Achieve glycemic control
- Eliminate symptoms of hyperglycemia
- Avoid evoking hypoglycemia - Reduce or eliminate the long-term complications (microvascular and macrovascular) of DM
- Maintain patient quality of life and overall wellbeing
- DMSES for all patients
Blood glucose targets for non-pregnant adult patients with DM
- Hemoglobin A1c - < 7.0%
- Check every 3-6 months - Preprandial capillary glucose - 80-130 mg/dL
- Fasting blood glucose, FBG - Postprandial capillary glucose (PPBG) - < 180 mg/dL
- 1-2 hours after start of meal
Consider lower target A1c (<6.5%) if:
- Short diabetes duration
- Long life expectancy
- T2DM tx with lifestyle or metformin only
- No significant CVD/vascular complications
Consider higher target A1c (<8.0%) if:
- Severe hypoglycemia history
- Severe disease:
- Limited life expectancy
- Advanced DM complications
- Extensive comorbidities - Long-term DM pts
Blood glucose targets for pediatric patients with DM
- Hemoglobin A1c - < 7.5% - May try for 7.0% if no hypoglycemic complications
- Check every 3-6 months - Preprandial capillary glucose - 90-130 mg/dL
- Fasting blood glucose, FBG - Postprandial capillary glucose (PPBG) - 90-150 mg/dL
- 1-2 hours after start of meal
Hypoglycemic Management Guidelines
- At each visit - routinely ask about hypoglycemic episodes (w/ or w/o symptoms)
- Advise pts to carry glucose tablets/gel
- May rx glucagon if pt at risk for severe hypoglycemia - Conscious Patient - 15-20 g of glucose orally
- Repeat in 15-20 min if self-monitored blood glucose (SMBG) is still low
- Eat a snack or meal when glucose returns to normal to prevent rebound hypoglycemia - Unconscious Patient - IV glucose, injectable or nasal glucagon kit
- If hypoglycemia is frequent, severe, or no s/s - re-evaluate therapy to reduce hypoglycemia incidence
- If pre-exercise glucose is <100 mg/dL, consider ingesting carbs
benefits of Self-Monitoring of Blood Glucose (SMBG)
standard of care for DM pts; allows pt to monitor BG at any time
method of Self-Monitoring of Blood Glucose (SMBG)
- home glucometry
- May require patient education
- Pts with cognitive impairment or poor dexterity may require assistance
frequency of Self-Monitoring of Blood Glucose (SMBG)
- T1DM - 3+ times/day
- T2DM - <1-2/day
When to monitor blood glucose at home:
- At directed times - fasting, prior to meals, postprandial
- Prior to beginning exercise or doing other critical tasks (e.g., driving)
- When hypoglycemia is suspected, and after treating hypoglycemia until it is resolved
option for some pts esp those requiring intensive insulin therapy, or pts who are unaware of hypoglycemia
Continuous Glucose Monitoring
individualized approach including assessment of nutritional status, nutrition therapy and education, food security, and appropriate supplements
Medical Nutrition Therapy
- Recommended for ALL DM pts (regardless of type)
- Preferred to use a diabetes educator or dietitian who is experienced with DM pts
Goals of MNT
- Healthful eating pattern to improve overall well-being
- Achieving goals for glycemic control, weight, BP and lipids
- Delay or prevent DM complications
general diet with medical nutrition therapy
- Low-carb, hypocaloric - 45-60% carbs, 25-35% fat, and 10-35% protein
- < 7% of fat should be saturated fat - preferred to use monounsaturated fats
- High protein diets may not be appropriate for pts with diabetic nephropathy
- Goal of 500-700 kcal/day calorie deficit if overweight/obese
- Dietitian can educate patients on carbohydrate counting, healthy food choices, glycemic index, etc.
Diet/Medical Nutrition Therapy pattern recommendation for type I DM
Encourage patients to eat consistently (amounts, foods, times)
Diet/Medical Nutrition Therapy pattern recommendation for type 2 DM
Encourage weight loss (even just 5-10%) to improve outcomes
Diet/Medical Nutrition Therapy pattern recommendation for Dietary Fiber
slows glucose absorption, better intestinal transit and gut health
how does glycemic index change with more cooked/processed food?
higher index
what are Low glycemic foods
fruits, vegetables, whole-grain products, legumes
what are high glycemic foods
“white foods” - white breads, white sugar, white rice, baked potato
exercise guidelines
- Benefits - weight control, improved insulin sensitivity, improved CV health
- Routine - regular exercise shows much more benefit than sporadic exercise
- Risks - risk of hypoglycemia, cardiovascular complications, and injury
- May need evaluated for presence of complications before beginning regimen - Recommendations
- At least 150 min/week (200-300 min/wk preferred) of moderate (50-70% max HR) aerobic exercise divided over 3+ days
- No more than 2 consecutive days without exercise
- Resistance training 2+ days/wk
- Try to spend no more than 30-90 minutes at a time in a sedentary position
immunization guidelines for DM
- All patients - Routine vaccinations according to CDC schedules
- Influenza vaccine - Annually in all DM patients aged 6+ months
- Pneumococcal vaccination - All DM patients aged 2+ years
- PCV20 vaccine alone or PCV15 followed by PPSV 23
- Adults who have only had PCV13 or PPSV23 should get PCV 20 at least 1 year later
- Adults who have had both PCV13 and PPSV23 may consider a PCV20 dose 5+ yrs later - Hepatitis B vaccine - All adult DM pts
- COVID-19 vaccine - Recommended,
unless known contraindications
HTN complications guidelines with DM
- BP evaluated at every visit
- Goal BP - <130/80 mmHg (start lifestyle changes if >120/80)
— Consider higher (<140/90 mmHg) if low risk factors for heart disease (10-yr ASCVD risk <15%)
- First-line pharm - ACE or ARB
- Other tx - lifestyle changes (weight loss, sodium <2300 mg/d, DASH diet)
hyperlipidemia complication guideline with DM
- Yearly lipid profile recommended
- Moderate-to-high intensity statin therapy depending on age and other risk factors for atherosclerotic CVD (or presence of atherosclerotic CVD)
antiplatelet complication guidelines with DM
- Consider 75-162 mg/day ASA for DM pts who have ASCVD or who are at increased ASCVD risk (10-yr risk >10%) and no increased bleeding risk
- Low ASCVD risk (10-yr risk <5%) - aspirin not recommended
- Intermediate ASCVD risk (10-yr risk 5-10%) - clinical judgement
- Risk factors for ASVCD - age ≥ 50 y/o, + family hx of premature ASCVD, HTN, smoking, HLD, albuminuria
- Generally use 81 mg enteric coated aspirin/day if indicated
Nephropathy Complications Guidelines with DM
early check of urinary albumin and eGFR in T1DM pts with ≥ 5-year duration of disease, T2DM pts from time of dx on, and all DM pts with HTN
1. Dietary protein intake should be 0.8 g/kg/day for pts with signs of proteinuria
2. ACE/ARB are preferred medications for pts who display signs of proteinuria
- Measure serum creatinine and potassium (BMP) periodically!
- Not for prevention in pts with normal BP and eGFR and no proteinuria
3. If proteinuria persists, may add SGLT-2 inhibitor and/or mineralocorticoid agonist
Retinopathy Complications Guidelines
with DM
- Optimize glycemic control, BP, and lipid control to reduce the risk or slow the progression of 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
Neuropathy Complications Guidelines
with DM
Yearly check in T1DM pts with ≥ 5-years of dx, T2DM pts from time of dx on
1. Screening should include - thorough hx for s/s, monofilament testing, and 1+ additional tests (pinprick, vibration, reflexes)
2. Foot care recommendations
- All pts - yrly foot exam for foot deformities, skin lesions, neurological exam, and vascular assessment
- All pts - educate on foot care including lotions, regular inspection, and protecting feet
- Pts with loss of foot sensation, deformities, peripheral arterial disease, or hx of foot ulcer or amputation - examine feet at every visit; referrals as indicated:
— May need podiatry referral if major structural abnormalities
— May need wound care/vascular referral if non-healing ulcer present
— May need referral for ABI and vascular provider if symptoms of arterial claudication or decreased/absent pedal pulses
Prediabetes Guidelines
- Prediabetes - Presence of IFG, IGT, or A1c of 5.7-6.4% - controversial!
- Behavioral counseling program - intensive diet and physical activity to achieve:
- 7% of body weight loss
- Increased physical activity (goal of minimum 150 min/week of moderate exercise) - Metformin - may consider to reduce risk of progression to DM, especially if:
- BMI > 35
- Age < 60 years
- Women with hx of gestational DM - Screening - screen for and treat risk factors for CVD (obesity, HTN, HLD)
- Education - putting patient in a diabetes self-management education program may help compliance with tx and reduce risk of progression to DM
Psychosocial Considerations with DM
- Acceptance - Pt must accept that he/she has a lifelong illness and may develop DM complications, even with effort to maintain euglycemia
- Self-Perception - Pt should have input into the care
plan, rather than feeling like a passive bystander
- Failure to involve pt - increased risk of noncompliance,
failure to follow-up, poor patient care outcomes - Psych - Increased risk of eating disorders in patients
with DM than general population
Screening and Follow-Up of psychosocial considerations with DM
- Attitudes and beliefs towards diabetes
- Expectations for medical management and outcomes
- Mood status
- Quality of life (and impact of DM on QOL)
- Psychiatric history
- Financial, social, and emotional support
- Food security status
Referral - significant mental illness (debilitating anxiety/depression, eating disorder, self-harm potential, etc.)
for DM, at least once a year, our patients should be receiving…
- H&P
- Diabetic eye exam
- Diabetic foot exam
- Blood pressure evaluation (every visit)
- Psychosocial evaluation
- Check in on ASA therapy (if taking) - Labs
- eGFR
- Urine albumin
- Lipid profile
- Hemoglobin A1c (at least twice a year) - Other interventions
- Yearly influenza vaccine
- Other screenings as indicated
— Mammograms
— Paps
— DREs
- Regular patient education on:
— Diet/Exercise
— Foot checks
— Medications
— SMBG
