DM - Guideline based approach, Luis Gonzales Flashcards
Based on trends, what percentage of North American/Caribbean residents will be diabetic in 2035?
About 37.3%, or a third of the population.
What number of US occupants aged 20-79 right now are diabetic?
24.4 million
What is the “Egregious Eleven” model, and how is it different from the previous model?
It is a beta-cell-centric construct, that says that the beta cell is the “common denominator” for beta cell damage. There a lot of factors that effect beta cell function and mass, but the main cause of diabetes is dysfunction of the beta cells, whether it is because of insulin resistance or beta-cell destruction. The old model focused on hyperglycemia as the main cause of diabetes.
What are the “egregious eleven?”
- Pancreatic beta cells
- Decreased incretin effect
- alpha-cell defect, increased glucagon
- Adipose (increased lipolysis)
- Muscle (decreased peripheral muscle uptake)
- Liver (increased glucose production)
- Brain (increased appetite, decreased morning DA surge, increased sympathetic tone)
- colon/biome (abnormal microbiota, possible decreased GLP-1 secretion)
- Immune inflammation/disregulation
- Stomach/small intestine (increased rate of glucose absorption), decreased amylin
- Kidney (increased glucose reabsorption)
What are the two guidelines used in the US, and what is the general difference between the two?
ADA (American Diabetes Association) - updated yearly
AACE (American Association of Clinical Endocrinology)- more strict
What are some of the important topics that were updated in the ADA guidelines recently?
- Beta-centric model, no more 9lb baby risk factor, risk tool use
- Comorbidities, such as sleep quality link with glycemic control
- Lifestyle management (protein, fat-counting)
- Monitor Vit B12 levels with metformin therapy to prevent/delay T2DM
- Glycemic targets, hypoglycemia
- Glycemic treatment changes (biosimilar insulin, therapy related to CV outcomes, cost added because of rising costs of medications, combo therapy data)
- CV disease section, classification
- Neuropathic pain, foot care recommendations
What are the four criteria used to diagnose DM?
- A1C - >/= 6.5%
- Fasting plasma glucose >126 mg/dL
- 2-hour fasting plasma glucose >200 mg/dL
- Random plasma glucose >200mg/dL
What are numbers for pre-diabetes?
- A1C 5.7-6.4% Average blood sugar over 2-3 months
- Impaired plasma blood glucose 100-125mg/dL
- Impaired 2 hr plasma glucose 140-199
If the results are borderline, what should you do?
Confirm the results via retesting.
An A1C of 6% correlates with what level of glucose?
126 mg/dL
Who should you test when a person is overweight?
BMI >25, with at least one additional risk factor
In those w/o other risk factors, test at age 45
What tests should you use to test for pre-diabetes?
A1C
FPG
2-hr OGTT
If tests come back normal for DM, what interval should be used for subsequent testing?
3 years minimum
Non-modifiable risk factors for DM:
- 1st degree relative w/ DM
- High-risk ethnicity (AA, Latino, Native American, Asian American, Pacific Islander)
- CVD history
- GDM (gestational)
- PCOS (polycystic vary syndrome)
What are modifiable risk factors for CVD?
- sedentary lifestyle
- Hypertension >140/90
- HDL <35mg/dL, TG > 250mg/dL
- A1C >/= 5.7%, IGT, IFG
- Conditions related to insulin resistance (obesity, acanthuses nigricans)
- Treatment with certain medications, such as glucocorticoids, antipsychotics)
What score on the ADA risk assessment tool suggests you are risk for diabetes? What condition does it exclude?
If you score 5 or higher you are at risk for DM.
Excludes GDM
After a DM screening, if a patient comes back pre-diabetic, what should you do?
- Refer to a DM prevention program (goals to achieve and maintain 7% weight loss, 150 min physical activity per week)
- Consider metformin for prevention of DM (particularly BMI >35, age >60, GDM, rising A1C w/ lifestyle interventions)
- Monitor annually for development of DM
- Screen and treat modifiable risk factors for CVD
What is high BMI/extreme obesity related to?
Either insulin resistance or beta-cell destruction
What are the components of a DM comprehensive medical evaluation?
- Medical history
- Physical exam
- Lab eval
- Referrals
When does this comprehensive DM eval occur?
At the initial visit
What are the steps in the patient care process?
Collect Assess Plan Implement Follow-up
What is included in the medical history component of the DM comprehensive exam?
- Age
- Lifestyle
- Social history
- Medication usage, including alternative medicine
- Comorbodities screening
- High BP history
- A1C records, previous treatment history
- Assess for barriers to med adherence
- Self-monitoring tools
- Immunization record review
- Hypoglycemic awareness
- Micro/macrovascular complications
- Family planning for women of childbearing capacity
What is involved in the physical examination part of the DM comprehensive exam?
- Vitals (RR, HR, BP, height, weight, waist circumference, BMI)
- eye exam
- Thyroid palpation
- skin examination(acanthuses nigerians, injection sites)
- Comprehensive foot exams
What is involved in the comprehensive foot exam?
Inspection
Palpation of dorsalis pedis and posterior tibial pulses, vibration and monofilament sensation.
What lab work is needed in the lab eval part of the DM comprehensive exam?
- A1C (if no values w/i 3 months)
- If not available w/i past year: fasting lipid profile, liver function tests, Spot urinary albumin-creatinine ratio, SCr, eGFR, TSH in T1DM)
What referrals during the initial visit are needed if a pt has DM?
- Optometrist
- Registered dietician
- Diabetes educator
- Dentist
- Mental health professional if needed
- Family planning for women of reproductive age
What are the A1C and FPG goals according to the ADA and AACE? When should you measure the postprandial glucose for each?
ADA- <7% A1C and 80-130 for FPG
PPG < 180 1-2 hours after meal
AACE - <6.5%, <110
PPG <140 2 hours after meal
Should you always stick to the goals in the guidelines when working with a patient?
They are guidelines, but it is important to individualize the plan to the patient.
When would someone need a more stringent or less stringent A1C goal?
More stringent:
- short duration of DM
- less complicated, such as metformin or lifestyle mods only
- Long life expectancy
- No CVD
Less stringent:
- Hypoglycemic history (severe)
- Limited life expectancy
- DM advanced complications
- Extensive comorbidities
- Uncontrolled, longstanding DM and interventions
What are the blood pressure goals for someone with DM?
<140/80 (goal could be lower if CVD risk is higher)
What is recommended if BP is
1) >120/80
2) >140/80
3) >160/100
1) Lifestyle modifications
2) Lifestyle mods + single therapy
3) Lifestyle mods + combo therapy
What kinds of lifestyle mods can you do for BP control wth DM?
- Weight loss (if overweight)
- Diet mods (DASH diet, increase K+ intake)
- Moderate alcohol use (men no more than 2 drinks a day, women no more than 1 drink a day)
- Increased physical activity
What pharmacological treatment is available for BP control for someone w/ or w/o albuminuria?
W/ albuminuria:
- ACE-I/ARB
- Thiazide-like diuretic
- Dihydropyridine CCB
W/o albuminuria:
- ACE-I/ARB
Multiple drug therapy may be needed to achieve goal
What do statins do in those w/ DM?
- Treat increased risk of lipid abnormalities that are present in T2DM pts (LDL cholesterol lowering)
- Treat high risk of ASCVD (cardioprotective)
If a DM pt has ASCVD, what statin intensity would they use?
If a DM pt does not have ASCVD, what intensity of statin would they use?
w/ ASCVD - high intensity unless over age 75 or not a candidate
w/o ASCVD: depends on 10-yr risk score. If 7.5% or higher, than use high-intensity. If score is lower than 7.5%, use moderate intensity statin.
If a person is intolerant of statins, what medication is usually added on?
Ezetimibe plus moderate-intensity statin.
What are the high-intensity statins? On average, how much do they lower LDL if given daily?
Atorvastatin 40-80mg
Rosuvastatin 20-40mg
Lower LDL by about >50%
If taken daily, what percentage do moderate-intensity statins generally decrease LDL by?
30-50%
What percentage do low-intensity statins decrease LDL by?
<30%
When would you consider aspirin therapy in DM patients?
Primary prevention: Consider in either T1DM or T2DM who are at increased cardiovascular risk.
- Most men/women >50 w/ at least one major risk factor (smoking, ASCVD, hypertension, dyslipidemia, albuminuria)
Secondary prevention in diabetic adults with ASCVD
(if aspirin allergy, use clopidogrel)
Over a certain age, aspirin is not recommended
