DM management condensed

Question 1

tx goals

Answer 1

-Alleviate symptoms
-Minimize development of long-term complications
-Enhance quality of life
-Reduce mortality

Question 2

target and goals: Nutrition Therapy

Answer 2

-Effectiveness of nutrition therapy
-Energy balance
-Eating patterns
-Dietary Fat - monounsaturated
-Protein
-Micronutrients, supplements

-Alcohol:
-Men vs. Women
-Delayed hypoglycemia with Insulin

-Sodium
-Non-nutritive sweeteners

Question 3

DASH

Answer 3

-Eating vegetables, fruits, and whole grains
-Including fat-free or low-fat dairy products, fish, poultry, beans, nuts, and vegetable oils
-Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils
-Limiting sugar-sweetened beverages and sweets.

Question 4

DSMS and DSME

Answer 4

-Four critical times when these have to be evaluated:
-At diagnosis
-Annually for assessment of education, nutrition, and emotional needs
-When new complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) arise that influence self-management
-When transitions in care occur

-Appropriate referrals should be made as needed

Question 5

key concepts in setting glycemic goals

Answer 5

-A1C is the primary target for glycemic control.
-Goals should be individualized based on:
-Duration of diabetes.
-Age/Life expectancy.
-Co-morbid conditions.
-Known ASCVD or advanced microvascular complications.
-Hypoglycemia unawareness.
-individual patient considerations

-More or less stringent glycemic goals may be appropriate for individual patients.
-Postprandial glucose may be targeted if A1C goals are not met despite reaching pre-prandial glucose goals

Question 6

treatment goals

Answer 6

-Good glycemic control
-Good control of blood pressure
-Lipid lowering
-Monitoring for and treatment of diabetic nephropathy
-Monitoring for and treatment of diabetic retinopathy
-Foot care
-Prevention and treatment of other complications
-Lifestyle management, e.g. smoking cessation, weight control, and dietary measures
-Care of pregnant women with diabetes and pre-pregnancy counseling

Question 7

role of GLP-1 and GIP in glucose homeostasis

Answer 7

-GLP-1 control intake
-glucose dependent

Question 8

non-insulin medications: metformin

Answer 8

-metformin first in any type 2 diabetic
-biguanide and insulin sensitizer; 2000mg ;
-Weight loss, decreased insulin, and lack of hypoglycemia.
-ADR: (know this)
-Diarrhea (temporary)
-lactic acidosis
-screen for B12 deficiency

Question 9

non-insulin medications: Glucagon-like peptide 1 (GLP-1) and dual GLP-1/gastric inhibitory peptide (GIP) receptor agonists (-enatides and -glutides)

Answer 9

-injectable; reduce dietary intake&raquo_space; weight loss. Sodium-glucose cotransporter 2 (SGLT2) inhibitors
-Dulaglutide (Trulicity); Exenatide (Byetta); semaglutide (Ozempic)

Question 10

SGLT2 inhibitors (-gliflozins)

Answer 10

-SGLT2 – resorbs glucose in PCT
-Increased glucosuria
-Can cause euglycemic DKA; oral (PO) medication; dapagliflozin (Farxiga), and empagliflozin (Jardiance)

Question 11

dipeptidyl peptidase 4 (DPP-4) inhibitors

Answer 11

-Prevent the breakdown of GLP-1 and GIP; weight loss and lack of hypoglycemia
-Sitagliptin (Januvia)

Question 12

sulfonylureas

Answer 12

-stimulate beta cells to release insulin; taken PO, AC;
-Hypoglycemia; weight gain * - not good
-Tolbutamide, glimepiride glipizide and glyburide

Question 13

thiazolidinediones (TZDs)

Answer 13

-Rosiglitazone (Avandia) and pioglitazone (Actos)
-Increased risk of heart failure, Fluid retention, osteoporosis- not good

Question 14

acarbose transplants

Answer 14

-also used for non-insulin medications
-osmotic diuresis- pts arnt compliant
-decrease absorption of nutrients of food

Question 15

insulin types

Answer 15

-Basal Insulins – Long acting; once or twice a day; rarely cause hypoglycemi -> Glargine; detemir; degludec
-rapid insulin=regular insulin
-Bolus Insulins – rapid acting insulins; pre-prandial use – first check blood glucose [BG] > Insulin > food intake; 15-30 mins effect; -> Lispro, aspart
-NPH – Intermediate acting insulin; can substitute for basal.
-Mixed Insulin – NPH and regular insulin (bolus/short acting); different ratios; (75/25; 70/30; 50/50)

Question 16

initiation and adjustment of insulin regimens in type 2 diabetes mellitus

Answer 16

-4x a day
-check before they eat, before they sleep, before injecting
-when you check glucose its telling you about the meal you ate before -> if glucose is high then you should have taken more insulin to cover the previous meal

Question 17

summary of bioavailability characteristics of insulins

Answer 17

Question 18

ADA recommendations for BP, lipids, etc.

Answer 18

-Tight BP control : ≤130/80 (<140/90)
-Use of ACEI/ARBS

-Lipid level goals:
-LDL <70mg/dL (<2.6mmol/L)
-Triglycerides <150mg/dL (<1.7mmol/L)
-HDL >40mg/dL (>1.1mmol/L) ; Rx: statin

-Increased risk of infections - Vaccines (flu and RSV)
-Regular ophthalmic, foot care;
-Other specialty referrals (cardiology; nephrology)
-Dental exam

Question 19

follow up management

Answer 19

-HbA1c
-Measured quarterly if treatment is changed or if the patient is not meeting management goals
-Every 6-12 months if stable
-Microalbuminuria (albumin/creatinine ratio)- At dx and then every year
-Blood lipids tested on initial visit and then annually, or as needed

Question 20

other lab evaluations

Answer 20

-A1C, if results not available within past 2–3 months
-If not performed/available within past year:
-Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides
-Liver function tests
-Test for urine albumin excretion with spot urine albumin-to-creatinine ratio
-Serum creatinine and calculated GFR
-TSH in type 1 diabetes, dyslipidemia or women over age 50

-C-peptide level: indicates production of insulin**
-insulinoma- rare but mass that secretes insulin -> C-peptide is high and so is insulin
-in diabetes Low level/ no insulin C-peptide) indicates that your pancreas is producing little or no insulin

Question 21

metabolic syndrome

Answer 21

-Synonyms (Syndrome X)
-Criteria - waist circumference, glucose levels, blood pressure, triglycerides, and HDL cholesterol
-With or without hyperglycemia but with increased insulin resistance
-Individuals with metabolic syndrome were thought to have an increased risk of atherosclerotic (CAD; stroke)
-no evidence that hyperinsulinemia andinsulinresistance play a direct role in these metabolic abnormalities.

Question 22

delivery of diabetes self-management education (DSME)

Answer 22

Increases adherence to standard of care and educating patients on glycemic targets and improves the percentage of patients who reach goal A1C

Question 23

self management training

Answer 23

-Management Principles and Complications:
-Initially and yearly
-Assess knowledge of diabetes, medications, self-monitoring, acute/chronic complications, and problem-solving skills
-Ongoing: Screen for problems with and barriers to self-care
-Sequential therapies, including insulin, likely to be necessary
-Lifestyle issues including nutrition, physical activity, and smoking cessation
-Assist patient to identify achievable self-care goals
-For children: As appropriate for developmental stage
-Resources available in the community
-Self-Glucose Monitoring: (SMBG)
-Type 1: Typically test 3-4 times a day
-Type 2 and others: As needed to meet treatment goals
-Medical Nutrition Therapy (by trained expert):
-Initially: Assess needs/condition; assist patient in setting nutrition goals
-Ongoing: Assess progress toward goals; identify problem areas
-Physical Activity: Initially and ongoing: Assess and prescribe physical activity based on patient’s needs/condition.
-Weight Management: Initially and ongoing: Must be individualized for patient

Question 24

interventions

Answer 24

-Preconception, Pregnancy, and Postpartum Counseling and Management:
-Consult with high-risk, multidisciplinary perinatal/neonatal programs and providers where available (e.g., California Diabetes and Pregnancy Program “Sweet Success”).
-For adolescents: Age-appropriate counseling advisable, beginning with puberty.
-*Aspirin Therapy: 81 to 325 mg/day or 325 mg every other day in adults as primary and secondary prevention of cardiovascular disease, unless contraindicated
-Smoking Cessation: Screen, advise, access readiness to quit, and assist at every diabetes care visit, adjusting the frequency as appropriate to the patient’s response
-Refer to Helpline
-Immunizations: Influenza and pneumococcal, COVID-19, RSV per CDC recommendations
-Psychosocial assessment: Barriers to self-care: common environmental obstacles, cultural issues, beliefs and feelings about diabetes, disorders of eating and mood, life stresses, and substance use

Question 25

dawn phenomena

Answer 25

-Pathophysiology
-Waning-off ofInsulinaction in AM hours
-Secondary to increased nocturnal GH output
-Results in high AMBlood Sugars

-Diagnosis
-Checking 3 amBlood Sugar

-Management
-Increase evening long actingInsulin(NPH) dose
-increase night insulin dose

Question 26

somogyi phenomena

Answer 26

-Rebound Hyperglycemia
-I.Pathophysiology
-Rebound Hyperglycemia inDiabetes Mellitus
-Follows a hypoglycemic reaction during the night

-II. Diagnosis
-Checking 3 amBlood Sugar

-III. Management
-Decrease evening long-actingInsulin(NPH) dose
-decrease night insulin

Question 27

gestational DM

Answer 27

-Glucose intolerance
-Insulin resistance related to the metabolic changes of late pregnancy increases insulin requirements and may lead to IGT
-Post-partum most revert to normal GT
-Substantial risk of developing DM later in life*

-Screen all pregnant women for GDM
-Low risk - screened at 24 to 28 weeks’ gestation
-High risk - screened at 20 weeks’ gestation

-Screening tests:
-“One-step” 75-g OGTT or
-“Two-step” approach with a 50-g (non fasting) screen followed by a 100-g OGTT for those who screen positive

Question 28

physical activity

Answer 28

-150mins- adults
-60 mins- children
-no more than 2 days without activity
-SMART goals

Question 29

risk factors of GDM

Answer 29

-> 25 years of age
-Overweight or obese state
-Family history of diabetes mellitus (i.e., in a first-degree relative)
-History of abnormal glucose metabolism
-History of poor obstetric outcome
-History of delivery of an infant with a birth weight >9 pounds
-History of polycystic ovary syndrome
-Latino/Hispanic, non-Hispanic black, Asian American, Native American, or Pacific Islander ethnicity
-Fasting plasma glucose concentration >85 mg/dL or
-2-hour postprandial glucose concentration >140 mg/dL -> Indicates need to perform a 75-g oral glucose tolerance test

Question 30

complications of GDM

Answer 30

-Fetal complications include:
-Congenital malformation
-Macrosomia
-Prematurity
-Respiratory distress syndrome
-Birth asphyxia

-Maternal complications:
-Hypertension
-Pre- eclampsia
-Spontaneous abortion
-Cesarean delivery
-Polyhydramnios