DM management condensed Flashcards
tx goals
-Alleviate symptoms
-Minimize development of long-term complications
-Enhance quality of life
-Reduce mortality
target and goals: Nutrition Therapy
-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
DASH
-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.
DSMS and DSME
-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
key concepts in setting glycemic goals
-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
treatment goals
-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
role of GLP-1 and GIP in glucose homeostasis
-GLP-1 control intake
-glucose dependent
non-insulin medications: metformin
-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
non-insulin medications: Glucagon-like peptide 1 (GLP-1) and dual GLP-1/gastric inhibitory peptide (GIP) receptor agonists (-enatides and -glutides)
-injectable; reduce dietary intake»_space; weight loss. Sodium-glucose cotransporter 2 (SGLT2) inhibitors
-Dulaglutide (Trulicity); Exenatide (Byetta); semaglutide (Ozempic)
SGLT2 inhibitors (-gliflozins)
-SGLT2 – resorbs glucose in PCT
-Increased glucosuria
-Can cause euglycemic DKA; oral (PO) medication; dapagliflozin (Farxiga), and empagliflozin (Jardiance)
dipeptidyl peptidase 4 (DPP-4) inhibitors
-Prevent the breakdown of GLP-1 and GIP; weight loss and lack of hypoglycemia
-Sitagliptin (Januvia)
sulfonylureas
-stimulate beta cells to release insulin; taken PO, AC;
-Hypoglycemia; weight gain * - not good
-Tolbutamide, glimepiride glipizide and glyburide
thiazolidinediones (TZDs)
-Rosiglitazone (Avandia) and pioglitazone (Actos)
-Increased risk of heart failure, Fluid retention, osteoporosis- not good
acarbose transplants
-also used for non-insulin medications
-osmotic diuresis- pts arnt compliant
-decrease absorption of nutrients of food
insulin types
-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)
initiation and adjustment of insulin regimens in type 2 diabetes mellitus
-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
summary of bioavailability characteristics of insulins
ADA recommendations for BP, lipids, etc.
-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
follow up management
-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
other lab evaluations
-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
metabolic syndrome
-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.
delivery of diabetes self-management education (DSME)
Increases adherence to standard of care and educating patients on glycemic targets and improves the percentage of patients who reach goal A1C
self management training
-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
interventions
-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
