Dm overview 2024 Flashcards
محاضرة عبدالعزيز
What percentage of individuals with type 2 diabetes in the U.S. have obesity?
One-third (33.33%)
What is the recommended screening strategy for LIVER FIBROSIS INpeople with prediabetes and type 2 diabetes in primary care?
Using the fibrosis-4 index (FIB-4)
Why would a screening strategy based only on elevated plasma aminotransferases miss most individuals with NASH?
It would miss clinically significant fibrosis
What are the upper limit ranges of normal ALT levels for male and female individuals?
29-33 units/L for males, 19-25 units/L for females
When should adults with type 2 diabetes or prediabetes be screened for liver fibrosis?
They should be screened even if they have normal liver enzymes
What does a negative FIB-4 result rule out regarding liver fibrosis?
A negative result rules out fibrosis
What additional risk assessmenttool is recommended for individuals with an indeterminate or high FIB-4?
Liver stiffness measurement or ELF blood test
What action should be taken for individuals at high risk for significant liver fibrosis?
They should be referred to a gastroenterologist or hepatologist
What is considered low risk and high risk levels for FIB-4 scores?
Low risk <1.3, high risk >2.67
What does liver stiffness measurement (LSM) <8.0 kPa indicate?
It indicates low risk for clinically significant fibrosis
What action is recommended if LSM is >12 kPa for people with diabetes?
They should be referred to a hepatologist
What is considered low risk in the Enhanced Liver Fibrosis (ELF) test?
<7.7 in the ELF test is considered low risk
Is routine screening for coronary artery disease recommended in asymptomatic individuals?
No, routine screening is not recommended
What does A1C 8.5% correspond to in mmol/mol?
69 mmol/mol
What do the initials BGM represent in diabetes management?
Blood Glucose Monitoring
Expand CGM in the context of diabetes monitoring.
Continuous Glucose Monitoring
Define DKA in the diabetic context.
Diabetic Ketoacidosis
Expand GLP-1 as used in diabetes treatment.
Glucagon-Like Peptide 1
What does HHNK stand for in the realm of diabetes complications?
Hyperosmolar Hyperglycemic Nonketotic Syndrome
Expand the abbreviation ‘MDI’ when related to diabetes treatment.
Multiple Daily Injections
According to the ADA position statement, who may consider metabolic surgery for Adolescents type 2 diabetes?
Adolescents with class 2 obesity, elevated A1C, and serious comorbidities.
What BMI threshold is recommended for considering metabolic surgery in adolescents with type 2 diabetes?
BMI?
PERCENTILE?
BMI >35 kg/m2 or 120% of 95th percentile for age and sex.
In which situations should metabolic surgery be considered for adolescents with type 2 diabetes as per the recommendation?
For those with elevated A1C and/or serious comorbidities despite lifestyle and pharmacologic intervention.
How many units of short- or rapid-acting insulin should be given for premeal glucose >250 mg/dL?
2 units
What should be done if more than 50% of premeal nger-stick values over 2 weeks are above the goal?
Increase the dose of medication
For premeal glucose >350 mg/dL, how many units of short- or rapid-acting insulin should be given?
4 units
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Name two examples of basal insulins.
Glargine U-100 and U-300, detemir, degludec, human NPH
What are examples of prandial insulins?
Short-acting (regular human insulin), rapid-acting (lispro, aspart, glulisine)
List three examples of premixed insulins.
70/30, 75/25, 50/50 products
Give examples of noninsulin agents for diabetes management.
Metformin, SGLT2 inhibitors, DPP-4 inhibitors, GLP-1 receptor agonists
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When should the screening for thyroid disease start in pediatric type 1 diabetes?
Soon after diagnosis
What follow-up frequency is recommended for thyroid disease screening in pediatric diabetes?
Every 1-2 years if normal
What is the treatment for hypertension in pediatric type 1 diabetes?
Optimize glycemia, lifestyle modification, ACE inhibitor or ARB therapy
How often should screening for hypertension be optimized in pediatric diabetes if normal?
Every 2 years if normal
What is the recommended LDL level in pediatric diabetes?
LDL <100 mg/dL
What classes of drugs are recommended for treating hypertension in individuals with diabetes?
ACE inhibitors, ARBs, dihydropyridine calcium channel blockers, and thiazide-like diuretics.
When should serum creatinine and potassium levels be monitored after initiation of ACE inhibitor, ARB, MRA, or diuretic therapy?
Within 7-14 days after initiation and at least annually thereafter.
How is chronic kidney disease (CKD) classified based on GFR and albuminuria levels?
CKD is classified based on GFR categories (G1-G5) and albuminuria levels (A1-A3).
What lifestyle reassessments are recommended for individuals at regular risk? At each visit?
Healthy diet, physical activity, smoking cessation, weight management every 3-6 months.
What drug is suggested as first-line therapy in individuals with CKD, hypertension, and eGFR 30 or above?
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SGLT2 inhibitors, metformin, RAS inhibitors at maximum tolerated dose, high-intensity statins.
What are the monitoring recommendations for prevalent CKD based on GFR and albuminuria?
Monitoring varies from once per year to every 1-3 months based on risks of CKD progression.
Which drug is recommended for individuals with ACR ≥30 mg/g and normal potassium to achieve clinical ASCVD risk?
Nonsteroidal MRA or dihydropyridine CCB or antiplatelet agents.
What test should be done if risk-based glycemic target and lipids are indicated?
Regular reassessment of glycemia, albuminuria, BP, CVD risk, and lipids.
What are the recommendations for screening and treatment of complications in pediatric type 2 diabetes?
Screening and treatment include monitoring blood pressure, foot exams, dilated fundoscopy, lipid profiles, AST and ALT levels, and more.
What is the goal for blood pressure management in pediatric type 2 diabetes?
The goal is to maintain blood pressure below the 90th percentile for age, sex, and height.
How often should individuals with pediatric type 2 diabetes have their blood pressure checked if it’s normal?
If normal, blood pressure should be checked annually.
What is the treatment approach for neuropathy in pediatric type 2 diabetes?
Optimize glycemia and provide referral to neurology if positive symptoms are present.
When should lifestyle modification be initiated in pediatric type 2 diabetes?
Lifestyle modification should be initiated at diagnosis for optimal management.
What should be the treatment strategy if LDL levels remain elevated in pediatric type 2 diabetes after 6 months?
Initiate statin therapy if LDL levels remain elevated above 130 mg/dL after 6 months.
What is recommended for new-onset diabetes in youth with overweight or obesity and clinical suspicion of type 2 diabetes?
Initiate lifestyle management, educate about diabetes, and determine A1C levels for appropriate management.
What is the recommended approach in case of acidosis and/or DKA and/or HHNK in new-onset diabetes in youth?
Administer metformin up to 2,000 mg per day and consider long-acting insulin until acidosis resolves.
What should be done if A1C goals are not met in new-onset diabetes in youth with overweight or obesity suspicion of type 2 diabetes?
Consider adding GLP-1 receptor agonist or SGLT2 inhibitor approved for youth with type 2 diabetes if A1C goals are not met.
What lifestyle changes are recommended for preventing type 2 diabetes?
Intensive lifestyle behavior change program: weight reduction and physical activity.
How much weight reduction is recommended to reduce the risk of incident type 2 diabetes?
At least 7% of initial body weight.
What activity level per week reduces the incidence of type 2 diabetes by 44%?
At least 150 minutes of physical activity per week.
Which medication is considered for prevention in adults at high risk of type 2 diabetes?
Metformin.
What are the common categories of medications shown to lower the incidence of diabetes in specific populations?
a-glucosidase inhibitors, incretin receptor agonists, thiazolidinedione, and insulin.
In the prevention of type 1 diabetes, what drug is used to delay the onset in selected individuals?
Teplizumab.
What were the median times to stage 3 type 1 diabetes diagnosis for individuals in the teplizumab and placebo groups?
Teplizumab group: 48.4 months, Placebo group: 24.4 months.
What were the common adverse reactions to teplizumab described in the study?
Transient lymphopenia (73%) and rash (36%).
What should be assessed in the assessment and treatment plan for diabetes complications?
ASCVD, heart failure history, kidney disease, hypoglycemia risk, retinopathy, neuropathy, NAFLD/NASH.
What are the general risk factors for bone health mentioned in the notes?
Osteoporotic fracture, low T-score, age over 65, low BMI.
What should be done if pancreatitis is suspected during clinical trials?
Discontinue the medication
What is the advice regarding gallbladder disease if suspected during treatment?
Evaluate for gallbladder disease
What is the renal dose consideration for a certain medication?
See label for renal dose considerations
For patients with renal impairment, what is the guidance regarding escalating doses?
Consider slower dose titration
Why is dual GIP and GLP-1 Receptor Agonist not recommended for individuals with a history of gastroparesis?
Their use is not recommended due to this history.
What potential issue has been noted in rodents regarding a certain medication?
High risk of thyroid C-cell tumors
What dietary modifications should be advised to mitigate GI side effects?
Guidance on dietary modifications (reduction in meal size, avoiding high-fat or spicy foods)
What adverse effect has been reported in clinical trials with DPP-4 inhibitors?
Pancreatitis
What caution is advised when using sulfonylureas in persons at risk for hypoglycemia?
Use with caution to avoid hypoglycemia
For patients with a history of gastroparesis, what is the recommendation for insulin therapy?
Start conservatively to avoid issues.
What should be monitored regularly in people with diabetes during treatment with a specific medication?
Monitor renal function
What special warning is associated with sulfonylureas based on studies?
Increased risk of CV mortality
What should be considered regarding screening in special conditions related to diabetes?
Consider screening for prediabetes or diabetes for individuals on certain medications.
What should be considered for monitoring of diabetes according to Dr. Abdulaziz Alharbi’s notes?
Serum Glycated Protein Assays as Alternatives to A1C, with Fructosamine and glycated albumin being approved measures.
What factors should be assessed when diagnosing suspected type 1 diabetes in adults?
Testing for islet autoantibodies and C-peptide levels along with considering features of monogenic diabetes.
When should individuals be screened for diabetes in special conditions like those prescribed second-generation antipsychotic medications?
Baselining and screening after 12-16 weeks, then annually, as clinically indicated.
What is the importance of C-peptide testing in diagnosis according to the notes?
It helps differentiate between type 1 and type 2 diabetes and aids in treatment decisions.
What are recommended screening guidelines for people with HIV according to the notes?
Screen for diabetes before starting antiretroviral therapy and 3-6 months after, then annually if initial results are normal.
What conditions warrant screening for diabetes, following an episode of acute pancreatitis?
People should be screened within 3-6 months post-acute pancreatitis episode and annually thereafter.
What does the head-to-head trial suggest about TCAs, SNRIs, and gabapentinoids for DPN pain?
Therapeutic equivalency and support for combination therapy over monotherapy.
What limitation may occur with tricyclic antidepressants in individuals over 65 years of age?
Anticholinergic side effects may be dose limiting.
How are tramadol classified in terms of their mechanism of action?
Centrally acting opioid analgesics.
What FDA-approved treatment exists for pain in DPN using a capsaicin patch?
8% capsaicin patch.
What is the recommended use of lidocaine patches in the context of DPN?
Not effective for widespread pain; may be useful for nocturnal neuropathic foot pain.
What is the diagnostic gold standard for gastroparesis?
Measurement of gastric emptying with scintigraphy of digestible solids.
Which drug is approved by the FDA for severe cases of gastroparesis?
Metoclopramide.
What is the fasting goal range for individuals on complex insulin therapy?
90-150 mg/dL (5.0-8.3 mmol/L).
How should prandial insulin doses be adjusted when adding noninsulin agents in complex insulin therapy?
Titrate down prandial insulin doses as noninsulin agent doses increase.
When should rapid- and short-acting insulin not be used in complex insulin therapy?
At bedtime.
How should insulin dosing be initiated?
Begin with 4 units per day or 10% of basal insulin dose.
What is the recommended approach for insulin titration?
Increase dose by 1-2 units or 10-15% twice weekly.
What should the total insulin dose be in initiating therapy?
Total dose should be 80% of current bedtime NPH dose.
How can hypoglycemia cause adjustments in insulin dosing?
Lower the basal dose by 4 units per day or 10% of basal dose.
What is the suggested split of insulin doses in the morning and at bedtime?
2/3 of insulin given in the morning and 1/3 at bedtime.
How should insulin be adjusted for patients above A1C target levels?
Consider self-mixed/split insulin regimen for better control.
What is the recommended NPH dose for a full basal-bolus regimen?
80% of the current NPH dose given before breakfast and dinner.
What should be added to each insulin injection for a basal-bolus regimen?
Add 4 units of short/rapid-acting insulin or 10% of reduced NPH dose.
How should SGLT2 inhibitors be monitored and managed for risks?
Monitor for DKA risk, rare in T2DM, and discontinue if suspected.
What is an important consideration when using GLP-1 receptor agonists?
Counsel patients about potential GI side effects and dietary modifications.
What is recommended bone mineral density screening interval for individuals with type 2 diabetes?
At least 5 years after diagnosis and every 2-3 years thereafter.
In individuals undergoing bariatric surgery, how often should bone mineral density screening be performed according to EASO guidelines?
Every two years.
Why is a T-score adjustment of -0.5 proposed for fracture prediction by DXA?
To improve fracture prediction.
What is the significance of a hip or vertebral fracture with low trauma in people aged 65 years or above?
It is diagnostic for osteoporosis and a strong risk factor for subsequent fractures.
How often should bone mineral density monitoring be performed in high-risk older adults with diabetes?
Every 2-3 years.
What should clinicians consider regarding pharmacological options for lowering glucose levels in people with diabetes?
The potential adverse impact on bone health.
Why should individuals with diabetes be advised on their intake of calcium and vitamin D?
To ensure they meet the recommended daily allowance for those at risk of fracture.
How can bone health risks be managed when setting glycaemic management goals for individuals with a high fracture risk?
Individualizing management goals and prioritizing glucose-lowering medications with low risk of hypoglycemia.
What fraction of people with type 2 diabetes is estimated to have NAFLD according to recent studies in the U.S.?
More than 70%.
How prevalent is NAFLD in individuals with type 1 diabetes according to recent meta-analysis?
Reported as 22%.
When are investigations for CAD recommended?
Investigations for CAD are recommended in the presence of atypical cardiac symptoms or signs of associated vascular disease.
when PAD should be screened in DM pt?
Screening for PAD should be considered in individuals with diabetes duration ≥10 years.
What is recommended for adults with diabetes to prevent stage C heart failure?
Consider screening adults with diabetes by measuring a natriuretic peptide to facilitate prevention of stage C heart failure.
How is screening for PAD recommended in asymptomatic individuals with diabetes age ≥50 years?
Screening for PAD with ankle-brachial index testing is recommended in asymptomatic individuals with diabetes age ≥50 years.
What physical behaviors are important for type 2 diabetes?
Sitting less, doing moderate-to-vigorous activity, and regular physical exercises are important for type 2 diabetes.
What is the association between sleep quantity and A1C levels?
Both long (>8 hours) and short (<6 hours) sleep negatively impact A1C levels.
What is the impact of evening chronotypes on glycemic levels?
Evening chronotypes may have poorer glycemic levels compared to morning chronotypes.
What is recommended as initial pharmacologic treatments for neuropathic pain in diabetes?
Gabapentinoids, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, and sodium channel blockers.
When should adults with type 1 diabetes have an initial eye examination?
Within 5 years after the onset of diabetes.
What is the only nonsteroidal mineralocorticoid receptor antagonist with proven clinical kidney and cardiovascular benefits?
Finerenone.
Why should individuals with pre-existing type 1 or type 2 diabetes have an eye exam before pregnancy?
To monitor their eye health and reduce the risk of complications during pregnancy.
When should individuals with pre-existing type 1 or type 2 diabetes receive an eye exam during pregnancy?
Before pregnancy, in the first trimester, every trimester, and 1 year postpartum.
What is indicated to reduce the risk of vision loss in individuals with high-risk PDR?
Panretinal laser photocoagulation therapy.
What is the frequency of eye screening recommended for individuals with no evidence of retinopathy and within goal range?
Every 1-2 years may be considered.
What should be considered as first-line therapy for hypertension when albuminuria is present?
ACE inhibitors or ARBs (angiotensin receptor blockers).
What should be monitored in individuals with pre-existing type 1 or type 2 diabetes during pregnancy?
Their eye health, every trimester, and for 1 year postpartum.
What are the key 24-hour physical behaviors important for type 2 diabetes?
Sitting/breaking up, prolonged sitting, stepping, sweating, strengthening, adequate sleep
What does T indicate in the context of physical behaviors for type 2 diabetes?
Higher levels/improvement in physical function and quality of life
What do yellow arrows indicate in Figure 5.1 regarding physical behaviors for type 2 diabetes?
Medium-strength evidence
What metric measures the spread of glucose values in CGM metrics?
Glycemic variability (%CV)
What percentage of time in range is considered a goal for glucose readings in adults?
Above 70%
How should clinicians assess individuals at risk for hypoglycemia?
History of hypoglycemia, awareness assessment, review of risk factors
What are the major social, cultural, and economic risk factors for hypoglycemia risk?
Food insecurity, low-income status, homelessness, fasting for reasons
What should clinicians consider for individuals treated with insulin regarding hypoglycemia?
Risk factors, awareness, interfering anxiety symptoms
What are some GLP-1 RA options for patients with A1C above target?
Metformin, Dulaglutide, Liraglutide
When should a GLP-1 RA or SGLTi be considered independent of metformin use?
In people with HF, CKD, established CVD, or multiple risk factors for CVD.
What cardiorenal risk reduction may be achieved with GLP-1 RA and SGLTi?
Reducing the risk of composite MACE, CV death, all-cause mortality, MI, HHF, and renal outcomes in T2D.
How should GLP-1 RA be used in adults with advanced CKD?
A GLP-1 RA is preferred due to lower risk of hypoglycemia and for cardiovascular event reduction.
What social determinants should be considered for goal achievement in diabetes management?
Identify and address SDOH that impact goal achievement.
