DM management Flashcards
Diabetes Self-management Education and Support
-All pts -> diabetes self-management education and support -> for knowledge, decision-making, and skills mastery for diabetes self-care
-Clinical outcomes, health status, and well-being are key goals -> should be measured as part of routine care
-should be person-centered can be group or individual settings -> must be communicated with the entire diabetes care team
-Digital coaching and digital self-management interventions -> train care taker
-Reimbursement by 3rd party payers -> self-management education and support can improve outcomes and reduce costs -> advocate
-Identify and address barriers at the health system, payer, health care professional, and individual levels
-Include social determinants (SOD) of health with goal of health equity across all populations
-Consider addressing barriers to access through telehealth delivery of care
chronic care model
-A model with key elements of a health care system
-encourage high-quality chronic disease care
-at level of community, health system, self-management support, delivery system design, decision support and clinical information systems
-access to care, F/U, prevention of complications
-whole health care system!
4 critical time points for DSMES should be evaluated
-1. At diagnosis
-2. Annually and/or when not meeting treatment targets
-3. When complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) develop that influence self-management
-4. When transitions in life and care occur
goals of nutrition therapy for adults with diabetes
-1. promote healthy eating patterns, emphasizing nutrient-dense foods in appropriate portion
-achieve and maintain body weight goals
attain individualized glycemic, BP, and lipid goals
-refer to dietitian -> INDIVIDUALIZED diet plan- afford, culture
-delay or prevent complications of diabetes
-2. address individual nutrition needs based on personal and cultural preferences, health literacy, access to healthy foods, willingness and ability to make changes, and existing barriers to change
-3. maintain pleasure of eating by being nonjudgmental about food choices while limiting choices only when indicated by scientific evidence
-4. provide tools for developing healthy eating patterns rather than focusing on individual macronutrients, micronutrients, or single foods
physical activity
-Children and adolescents with type 1, or 2, or prediabetes- 60 min/day or more of moderate- or vigorous-intensity aerobic activity, with vigorous muscle-strengthening and bone-strengthening activities at least 3 days/week
-Adults with type 1 or 2 diabetes- 150 min or more of moderate- to vigorous-intensity aerobic activity per week, spread over at least 3 days/week, with no more than 2 consecutive days without activity
-Shorter durations (minimum 75 min/week) of vigorous-intensity or interval training may be sufficient for younger adult and more physically fit individuals
-measuring with a tape is more accurate than scale
-Adults, especially with type 2 diabetes -> decrease amount of time spent in daily sedentary behavior -> Prolonged sitting should be interrupted every 30 min for blood glucose benefits
-Flexibility training and balance training are recommended 2–3 times/week for older adults with diabetes -> Yoga and tai chi increase flexibility, muscular strength, and balance* -> frail
-Evaluate baseline physical activity and sedentary time
-ex- walking, yoga, housework, gardening, swimming, and dancing.
facilitating positive health behaviors and well being to improve health outcomes picture
-increase steps
-sleep- time and quality
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smoking cessation: tobacco and e-cigs
-Advise all pts not to use cigarettes, tobacco, or e-cigarettes
-After identification of tobacco or e-cigarette use, include smoking cessation counseling and other forms of tx as a routine care
-address smoking cessation as part of diabetes education programs for those in need
supporting positive health behaviors
-Behavioral strat should be used to support diabetes self-management and engagement in health behaviors (e.g., taking medications, using diabetes technologies, physical activity, healthy eating) to promote optimal diabetes health outcomes
psychosocial care
-should be provided to all with diabetes
-goal of optimizing health -> quality of life + health outcomes
-care is integrated with routine medical care
-When indicated -> targeted mental health care
-psychosocial screening protocols may include -> attitudes about diabetes, expectations, mood, stress and/or quality of life, available resources (financial, social, family, and emotional), and/or psychiatric history
-depression screening
-periodic screening intervals and when there is change in disease, tx, or life circumstances
-refer to mental health if needed -> distress, depression, suicidality, anxiety, treatment-related fear of hypoglycemia, disordered eating, and/or cognitive capacities
-should use age-appropriate standardized and validated tools and treatment approaches
-Consider screening older adults (aged ≥65 years) with diabetes for cognitive impairment, frailty, and depressive symptoms -> Monitoring of cognitive capacity (decision-making regarding treatment plan behaviors)
diabetes distress
-Routinely monitor pts with diabetes, caregivers, and family members for diabetes distress
-especially when tx targets are not met and/or at onset of complications
-Refer to mental health professional for further assessment and tx if indicated
-Screen for anxiety, depression, serious mental illness, and Cognitive Capacity/Impairment
sleep health
-Consider screening including symptoms of sleep disorders, disruptions to sleep due to diabetes symptoms or management needs, and worries about sleep
-Refer to sleep medicine as indicated
glycemic assessment
-Assess glycemic status (A1C or other glycemic measurement such as time in range or glucose management indicator) at least 2x a year in pts who are meeting tx goals (and who have stable glycemic control)
-Assess glycemic status at least quarterly and as needed in pts that tx has changed and/or not meeting glycemic goals
standardized CGM metrics
-number of days CGM is worn (recommended 14 days)
-% of time CGM is active (recommend 70% od data from 14 days)
-mean glucose
-glucose management indicator
-glycemic variability (%CV) target <=36*
-TAR: % of readings and time > 250 - LEVEL 2 hyperglycemia
-TAR: % of readings and time 181-250- LEVEL 1 hyperglycemia
-TIR: % of readings and time 70-180- IN RANGE
-TBR: % of readings and time 54-69- LEVEL 1 hypoglycemia
-TBR: % of readings and time < 54- LEVEL 2 hypoglycemia
glucose assessment by continuous glucose monitoring
-Standardized, single-page glucose reports from continuous glucose monitoring (CGM) devices with visual cues, such as the ambulatory glucose profile, should be considered as a standard summary for all CGM devices
-Time in range is associated with the risk of microvascular complications and can be used for assessment of glycemic control
-time below range and time above range are parameters for eval of tx plan
glycemic goals
-A1C goal (nonpregnant) adults of <7% w/o significant hypoglycemia is appropriate
-If using ambulatory glucose profile/glucose management indicator -> time in range of >70% with time below range <4% and time <54 mg/dL <1%
-For those with frailty or at high risk of hypoglycemia -> target of >50% time in range with <1% time below range is recommended
-A1C levels lower than goal of 7% may be acceptable or beneficial if achieved safely w/o significant hypoglycemia or SE (at pts and providers preference)
-Less stringent A1C goals (such as <8%) may be appropriate for pts with limited life expectancy or if tx harm is greater than benefits
-consider deintensification of therapy if appropriate to reduce risk of hypoglycemia in pts with inappropriate stringent A1C targets
-Reassess glycemic targets based on individualized criteria
-Reassess Setting a glycemic goal during consultations is likely to improve pt outcomes
glycemic recommendation for nonpregnant adults
-A1c <7
-preprandial capillary plasma glucose- 80-130
-peak postprandial capillary plasma glucose- <180
hypoglycemia
-Occurrence and risk reviewed at every encounter and investigated as indicated
-Awareness of hypoglycemia considered using validated tools
-Glucose (approximately 15–20 g) is preferred tx for conscious individual with blood glucose <70 mg/dL -> although any carb that contains glucose may be used
-15 mins after tx, if blood glucose monitoring (BGM) shows continued hypoglycemia -> tx should be repeated
-Once BGM or glucose pattern is trending up -> pt should consume a meal or snack to prevent recurrence of hypoglycemia
-Glucagon should be prescribed for all pts at increased risk of level 2 or 3 hypoglycemia (just in case)
-Caregivers, school, or family providing support should know where it is, when and how to administer it
-Glucagon administration is NOT limited to health care
-Hypoglycemia unawareness or 1 or more episodes of level 3 hypoglycemia -> give hypoglycemia avoidance education and reevaluation and adjustment of tx
-Insulin-treated pts with hypoglycemia unawareness, 1 level 3 hypoglycemic event, or a pattern of unexplained level 2 hypoglycemia should be advised to raise their glycemic targets to avoid hypoglycemia for at least several weeks to partially reverse hypoglycemia unawareness and reduce risk of future episodes
-Ongoing assessment of cognitive function is suggested with increased vigilance for hypoglycemia by clinician, pt, and caregivers if impaired or declining cognition is found
classification of hypoglycemia
-level 1- glucose < 70 and >=54
-level 2- glucose <54
-level 3- severe event characterized by AMS and/or physical status requiring assistance for tx of hypoglycemia
obesity assessment
-Use person-centered, nonjudgmental language -> collaboration
-person-first language (“person with obesity” rather than “obese person”)
-ht and wt and calculate BMI at annuals or more frequently -> Assess trajectory to inform tx
-Based on clinical considerations (comorbid HF or significant unexplained weight gain or loss -> weight may need to be monitored and eval more frequently)
-If deterioration of health is assoc with weight gain or loss -> inpatient eval should be considered -> especially focused on assoc between medication use, food intake, and glycemic status
-overweight/obese pts may benefit from modest or larger wt loss
-small weight loss (approx 3–7% of baseline weight) improves glycemia and other intermediate cardiovascular risk*
-Larger, sustained weight losses (>10%) usually confer greater benefits -> disease-modifying effects and possible remission of type 2 diabetes, and may improve long-term cardiovascular outcomes and mortality
nutritional, physical activity, and behavioral therapy
-achieve and maintain ≥5% wt loss -> recommended for most people with type 2 diabetes and overweight/obesity
-wt loss results in further improvements in management of diabetes and cardiovascular risk
-interventions should include high frequency of counseling (≥16 sessions in 6 months) and focus on nutrition changes, physical activity, and behavioral strats to achieve a 500–750 kcal/day energy deficit
-pts preferences, motivation, and life circumstances should be considered, along with medical status, when wt loss interventions are recommended
-Behavioral changes that create energy deficit, regardless of macronutrient composition, will result in weight loss
-Nutrition recommendations should be individualized to pts preferences and nutritional needs
-Eval systemic, structural, and socioeconomic factors that may impact nutrition patterns and food choices -> food insecurity and hunger, access to options, cultural circumstances, and social determinants of health
-pts who achieve wt loss goals, long-term (≥1 year) -> wt maintenance programs are recommended
-programs should provide monthly contact and support, recommend ongoing monitoring of body weight (weekly or more frequently) and other self-monitoring strategies, and encourage regular physical activity (200– 300 min/week)
-Short-term nutrition intervention using structured, very-low-calorie meals (800–1,000 kcal/day) may be prescribed for carefully selected pts with close monitoring -> Long-term, comprehensive weight maintenance strategies and counseling should be integrated to maintain wt loss
-no clear evidence that nutrition supplements are effective for wt loss
pharmacotherapy
-when choosing meds for type 2 -> consider meds effect on weight
-minimize meds for comorbid conditions that are associated with wt gain if you can
-Obesity pharmacotherapy is effective as an adjunct to nutrition, physical activity, and behavioral counseling for selected people with type 2 diabetes and BMI ≥27 kg/m2
-Potential benefits and risks must be considered
-If obesity pharmacotherapy is effective (typically defined as ≥5% weight loss after 3 months’ use) -> further wt loss is likely with continued use
-When early response is insufficient (typically <5% weight loss after 3 months’ use) or if significant safety or tolerability issues -> consider d/c of meds and evaluate alternative meds or tx approaches
metabolic surgery
-should be recommended option to treat type 2 diabetes in screened surgical candidates with BMI ≥40 kg/m2 (BMI ≥37.5 kg/m2 in Asian American individuals) and in adults with BMI 35.0–39.9 kg/m2 (32.5–37.4 kg/m2 in Asian American individuals) who dont achieve wt loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods
-CONSIDER as an option to treat type 2 diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in Asian American individuals) who do not achieve durable wt loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods
-performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in managing obesity, diabetes, and GI surgery
-pts being considered should be evaluated for comorbid psychological conditions and social and situational circumstances that have the potential to interfere with surgery outcomes
pharm therapy for adults with type 1
-Most pts with type 1 should be treated with multiple daily injections of prandial and basal insulin, or continuous subcutaneous insulin infusion
-rapid-acting insulin analogs are used to reduce hypoglycemia risk
-pts are educated on how to match mealtime insulin doses to carb intake, fat, and protein content, and anticipated physical activity
pharm therapy for adults with type 2
-lifestyle behaviors, diabetes self-management education and support, avoidance of clinical inertia, and social determinants of health
-Pharm therapy guided by person-centered tx factors -> comorbidities and tx goals
-if high risk of atherosclerotic/cardiovascular disease, HF, and/or chronic kidney disease -> tx includes meds to reduce cardiorenal risk
-Pharm approaches that can achieve and maintain tx goals should be considered -> metformin or other agents, including combination therapy
-Wt management
-Metformin should be continued upon initiation of insulin therapy (unless contraindicated or not tolerated) for ongoing glycemic and metabolic benefits
-Early combo therapy can be considered in pts at tx initiation to extend the time to tx failure
-early intro of insulin considered if evidence of ongoing catabolism (weight loss), symptoms of hyperglycemia are present, or A1C levels (>10% or blood glucose levels (≥300mg/dL) are very high
-person-centered approach -> consider effects on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost and access, risk for SE, and individual preferences
-atherosclerotic/cardiovascular disease or indicators of high cardiovascular risk, established kidney disease, or HF -> sodium–glucose cotransporter 2 inhibitor and/or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended -> independent of A1C and in consideration of person-specific factors
-for ALL - glucagon-like peptide 1 receptor agonist is preferred to insulin when possible
-If insulin is used, combo therapy with glucagon-like peptide 1 receptor agonist is recommended for greater efficacy, durability of tx effect, and wt and hypoglycemia benefit
-Recommendation for tx intensification for individuals not meeting tx goals should not be delayed
-Medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed
-Clinicians should be aware of overbasalization with insulin therapy -> eval if basal dose > ~0.5 units/kg/day, high bedtime–morning or postpreprandial glucose differential, hypoglycemia (aware or unaware), and high glycemic variability
-Indication of overbasalization should prompt reevaluation to further individualize therapy
management of type 2 diabetes chart
medications for lowering glucose chart
injectable therapy chart
cost of noninsulin glucose lowering agents
Median monthly cost AWP and NADAC of maximum approved daily dose of noninsulin glucose-lowering agents in the U.S.
cardiovascular disease and risk management
-glycemia management
-BP management
-lipid management
-agents with cardiovascular and kidney benefit
cardiovascular disease and risk management: screening and dx
-measured at every routine clinical visit
-if BP is high (120–129/<80 mmHg) -> BP confirmed including measurements on a separate day for def dx
-HTN- ≥130 OR ≥80 mmHg based on an average of ≥2 measurements obtained on ≥2 occasions
-≥180/110 mmHg and cardiovascular disease could be dx with HTN at a single visit
-All pts with HTN and diabetes should monitor their BP at home
cardiovascular ds and risk management: tx goals
-pts with diabetes and HTN- BP targets should be individualized through shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and pt preferences
-pts with diabetes and HTN qualify for antihypertensive drug therapy when BP is persistently elevated ≥130/80 mmHg
-on-tx (meds) target BP goal is <130/80 mmHg, if it can be safely attained
cardiovascular ds and risk management: tx: lifestyle
-pts with BP >120/80 mmHg -> lifestyle intervention -> weight loss when indicated, DASH diet (reducing sodium and increasing potassium intake), moderation of alcohol intake, and increased physical activity
cardiovascular ds and risk management: tx: pharm
-pts with confirmed BP ≥130/80 qualify for initiation and titration of pharm therapy to achieve BP goal of <130/80
-pts with confirmed BP ≥160/100 should, in addition to lifestyle therapy, have prompt initiation and titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in pts with diabetes
-tx for HTN should include drugs that reduce cardiovascular events in people with diabetes -> ACE inhibitors or ARB are 1st line therapy for HTN in pts with diabetes and CAD
-Multiple-drug therapy generally required to achieve BP targets -> However, combo of ACE inhibitors and ARB and combo of ACE inhibitors or ARB with direct renin inhibitors should NOT be used
-ACE inhibitor or ARB, at max tolerated dose indicated for BP tx is recommended 1st-line tx for HTN in pts with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine -> If one class is not tolerated, the other should be substituted
-pts taking ACE inhibitor, angiotensin receptor blocker, or diuretic -> serum creatinine/GFR and serum K levels should be monitored at least annually
if tx not meeting target/adverse event chart
lipid management- lifestyle tx
-Lifestyle mod focusing on wt loss (if indicated)
-Mediterranean or dash diet -> reduction of saturated fat and trans fat; increase of dietary n-3 fatty acids, viscous fiber, and plant stanols/sterols intake; and increased physical activity
-intensify lifestyle therapy and optimize glycemic control for pts with elevated triglyceride levels (≥150mg/dL) and/or low HDL cholesterol (<40 mg/dL for men, <50 mg/dL for women)
lipid management- ongoing therapy and monitoring with lipid panel
-adults not taking statins or other lipid-lowering therapy -> obtain lipid profile at the time of diabetes dx, at initial medical eval, and every 5 years thereafter if under the age of
-Obtain lipid profile at initiation of statins or other lipid-lowering therapy, 4–12 weeks after initiation or change in dose, and annually thereafter as it may help to monitor the response to therapy and inform medication taking
statin tx- primary prevention
-diabetes aged 40–75 years w/o atherosclerotic/cardiovascular disease -> moderate-intensity statin therapy in addition to lifestyle therapy
-diabetes aged 20–39 years with additional atherosclerotic/cardiovascular disease risk factors -> may be reasonable to initiate statin therapy in addition to lifestyle therapy
-diabetes aged 40–75 at higher cardiovascular risk -> pts with 1 or more atherosclerotic cardiovascular disease risk factors -> high-intensity statin therapy to reduce LDL cholesterol by ≥50% of baseline and to target an LDL cholesterol goal of <70 mg/dL
-diabetes aged 40–75 years at higher cardiovascular risk -> especially those with multiple atherosclerotic cardiovascular disease risk factors and an LDL cholesterol ≥70 mg/dL -> add ezetimibe or a PCSK9 inhibitor to max tolerated statin therapy
-diabetes aged >75 years already on statin therapy -> continue statin tx
-diabetes aged >75 years -> it may be reasonable to initiate moderate-intensity statin therapy after discussion of potential benefits and risks
-Statin therapy is contraindicated in pregnancy
statin tx- secondary prevention
-all ages with diabetes and atherosclerotic cardiovascular disease -> high intensity statin therapy should be added to lifestyle therapy
-diabetes and atherosclerotic cardiovascular disease -> tx with high intensity statin therapy is recommended to target an LDL cholesterol reduction of ≥50% from baseline and an LDL cholesterol goal of <55 mg/dL
-Addition of ezetimibe or PCSK9 inhibitor recommended if goal is not achieved on max tolerated statin therapy
-pts who dont tolerate the intended intensity, the max tolerated statin dose should be used
tx of other lipoprotein fractions or targets
-pts with fasting triglyceride levels ≥500 mg/dL -> eval for secondary causes of hypertriglyceridemia and consider medical therapy to reduce risk of pancreatitis.
-adults with moderate hypertriglyceridemia (fasting or nonfasting triglycerides 175–499 mg/dL) -> address lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides
-pts with atherosclerotic cardiovascular ds or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL) ->he addition of icosapent ethyl can be considered to reduce cardiovascular risk
antiplatelet agents
-Use aspirin therapy (75–162 mg/day) as secondary prevention in pts with diabetes and hx of atherosclerotic cardiovascular disease
-pts with atherosclerotic cardiovascular disease and documented aspirin allergy -> clopidogrel (75 mg/day) should be used
-Dual antiplatelet therapy (with low-dose aspirin and a P2Y12 inhibitor) -> reasonable for 1 year after acute coronary syndrome and may have benefits beyond this period
-Long-term treatment with dual antiplatelet therapy should be considered for pts with prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse cardiovascular events
-Combo therapy with aspirin plus low-dose rivaroxaban -> considered for pts with stable coronary and/or PAD and low bleeding risk to prevent major adverse limb and cardiovascular events
-Aspirin therapy (75–162 mg/day) may be considered as a primary prevention in pts with diabetes with increased cardiovascular risk, after discussion with pt on benefits vs risk of bleeding
chronic kidney disease- screening
-At least annually, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated GFR should be assessed in pts with type 1 with duration of ≥5 years and in all pts with type 2 regardless of tx
-pts with diabetic kidney disease, urinary albumin (e.g., spot urinary albumin-to-creatinine ratio) and estimated GFR should be monitored 1–4x per year depending on the stage of disease
chronic kidney disease- tx
-Optimize glucose control to reduce risk or slow progression of chronic kidney disease
-Optimize BP control and reduce BP variability to reduce risk or slow progression of chronic kidney disease
-nonpregnant pts with diabetes and HTN -> either ACE inhibitor or ARB is recommended for pts with moderately increased albuminuria (urinary albumin-to-creatinine ratio 30– 299 mg/g creatinine) -> strongly recommended for pts with severely increased albuminuria (urinary albuminto-creatinine ratio ≥300 mg/g creatinine) and/or estimated GFR <60 mL/min/1.73 m2
-refer to nephrologist for uncertainty about etiology of kidney disease, difficult management issues, and rapidly progressing kidney disease
hospital care delivery standards
-Perform A1C on all pts with diabetes or hyperglycemia (blood glucose >140 mg/dL) admitted to hospital if not performed in prior 3 months.
-Insulin should be administered using validated written or computerized protocols that allow for predefined adjustments in insulin dosage based on glycemic fluctuations
-consult with specialized diabetes or glucose management team when possible
