ENDO- DM2 Flashcards
What are the classification of diabetes?
DM1A1B, DM2
3] Secondary diabetes: result of other disorders or treatments.,
4] GDM
What are the criteria for diagnosis?
1] Symptoms + >200mg/dl
2] (FPG) >126mg/dl or greater,
No food intake for at least 8hr
3] 2 hr plasma glucose of 200mg/dl during OGTT,
75g anhydrous glucose dissolved in water
4] HbA1c >6.5% as diagnostic tool
When is a HgbA1c diagnostic for diabetes
> 6.5%, with symptoms otherwise confirm 2 weeks later
What is the requirement before diagnosising diabetes for all tests?
confirmed on subsequent day unless symptoms of hyperglycemia are present.
What are Impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) patients at risk for?
can be diagnosed with hyperglycemia insufficient/insuline intensity
] IFG= FPG 100-125mg/dl,
2] IGT= 2 hr plasma glucose of 140-199mg/dl,
3] Pre Diabetes HbA1c between 5.7%-6.4%
Type 2 diabetes and CV
does not necessarily mean one will go on to get diabetes.
What is the most common cause of insulin resistance?
Obesity -not all
have adequate beta cell compensation and therefore do not get diabetes,
genetic predisposition to beta cell failure
STRESS
Pt ask how did I get Type 2 DM is a progressive disease. Explain
1] Beta cell dysfunction first leads to impaired glucose tolerance, which in some, progresses to Type 2 DM,
2] Beta cell dysfunction starts long before glucose rises and worsens after diabetes develops
What are the additional effects of hyperglycemia
addition defects in insulin secretion and insulin action (glucotoxicity)
Do all DM PT have symptoms?
NO
1] Asymptomatic until complications develop- 1/3 undiagnosed
2] MC Polyuria, polyphagia and weight loss occur long after hyperglycemia has been present,
3] Other symptoms include blurred vision, lower extremity paresthesias, yeast infections, balanitis in men.
What is the state that its initial presentation of type 2?
Hyperosmolar hyperglycemic State (HHS)
What is WHO’s diagnostic criteria for metabolic syndrome?
1] On antihypertensive therapy or BP>140/90,
2] Lipids: P TG >150, HDL 35,
3] BMI: >30 or waist:hip ratio: >.85-0.9,
4] Glucose: IGT or as Type II,
5] Microalbumin
DX
1] Type II DM or IGT + 2 of above,
2] if GT is normal 3 above
What is NCEP ATP III criteria/diagnostic for metabolic syndrome?
1] BP>130/85,
2] Lipids: P TG >150, HDL 40,
3] Waist circumference: >40 inches n M, 35 inches in women,
4] Glucose: FBG 110
DX
1} 3 of above criteria
What is AACE criteria for metabolic syndrome?
1] HTN
2] Lipids: P TG >150, HDL 35,
3] BMI: >30 or waist:hip ratio: >.85-0.9,
4] Glucose: IGT or as Type II,
5] Insulin resistance, acanthosis nigricans, hyperuricemia, CHD, PCOS,
DX
1] Type II DM or IGT and 2 of above, 2] if GT is normal 3 above
What things contribute to insulin resistance?
1] Genetics,
2] Obesity and inactivity,
3] Aging,
4] Medications
What disorders can insulin resistance lead to?
1] Type II DM, 2 ] Hypertension, 3] Dyslipidemia, 4] Atherosclerosis, 5] PCOS
How do you inspire Pt goals Type II management
REDUCE
1] Eliminate sx
2] Microvascular risk- eye and kidney disease) - BP and BG control
3] Macrovascular risk -heart disease and PAD by lipid and BP control, NO smoking, aspirin tx
4] Metabolic risk reduction through control of BG
Goal for Self Management Education
Instruct
patients on SMBG,
Diet and lifestyle recommendations.
psychosocial issues incl stress with management
Provide support and answer questions.
What are the Lifestyle modifications for Improved Metabolic Control
1] Physical Activity (best insulin sensitizer),
30 minutes and get a residual 4-6 hours of improves insulin sensitivity- Post big meal best
2] Reduce carbohydrate consumption- Avoid whites, sugars, CHO vegetables rather than grains,
3] Encourage above 1st-Wt loss via Restrict CHO
What are other recommendations for type II
1] NO smoke,
2] Aspirin Therapy 75-162mg/d w/ increased risk for CVD.,
2] Secondary prevention history of MI, bypass, stroke, TIA, PVD, claudication or angina.
What is the goal for A1C?
1] <6.5% for patients W/O COMORBID
2] >6.5% for patients W COMORBID
at low hypoglycemia risk
RX start @ A1C > 7.5%
What drugs are recommended for initial monotherapy
1] Metformin,
2] GLP 1 RA- glucagon like
peptide-1 (GLP-1)
3] SGLT-21-Sodium glucose co-transporters 2
4] DPP-4 Inhbitor, dipeptidyl peptidase-4
5] AGI-Alpha-Glucosidase Inhibitors
When is step up therapy recommended?
If goal not met in 3 months
Describe dual therapy
Met + 1st line monotherapy drug OR Colesevelam, Bromocriptine, AGI
Describe triple therapy
Met + (2) 1st line monotherapy drug OR Colesevelam, Bromocriptine, AGI
Pt is on dual therapy with A1c 8, FBS <130,
Start Insulin, titrate BUT
***D/C or reducing sulfonyureas
What is the initial dosing for insulin in type II management
1] A1C <8% 0.1-0.2 u/kg,
2] A1c 8% 0.2-0.3 u/kg
What are the glycemic goals
1] AACE HbA1c goal of <6.5%,
ADA HbA1c goal is <7%,
2] 2 hour post prandial measurement <140mg/dl,
3] BP <130/80
What are the KILLERS of DM complications ?
1] Coronary artery disease,
2] Myocardial infarction,
3] Peripheral vascular disease,
4] Cerebral vascular disease
What are the management to limit macrovascular complications?
All diabetics should: keep BP <130/80, LDL cholesterol <100, HDL >45 men, >55 women, TGs, <150, quit smoking daily aspirin prn
Pt c/o tingling in hands and feet. What are these sx? diabetic neuropathy
1] Distal symmetric polyneuropathy (stocking glove distribution),
2] Entrapment neuropathy,
3] Autonomic neuropathy
Foot ulcers- consequence of vascular disease, neuropathy and foot deformities.
Pt w/ DM c/o dec libido, what other complications to address? autonomic neuropathy
1] Neurogenic bladder-(flaccid or spastic), overflow incontinence, frequency, urgency, urge incontinence, and retention
2] Sexual dysfunction,
3] Gastroparesis- unable to empty
4] Orthostatic hypotension
What is MC of Nephropathy?
Diabetes.
What is MC of blindness in the U.S.
DM Retinoathy
List the modifiable risk factors for Diabetes management
C:control your glucose, blood pressure and cholesterol, E:early treatment of foot, eye, kidney and heart problems, N:o,
S:smoking,
E:education about diabetes, nutrition and exercise.
What are the guidelines for follow up for diabetes
1] NOT at goal-seen Q 3mo with HbA1c at each visit and (metabolic panel and lipid panel if indicated),
2] AT goal-seen Q4-6 mo unless longer duration causes deterioration in control,
3] Regular foot exams- 10g monofilament/yr
4] 24hr urine for microalbumin and creatinine clearance/yr
5] ophthalmologist annually.
6] At each visit glucose monitor- log or meter download.
7] DM2 - monitor 2 hr post meal and occasional fasting
8] MDI or CSII (DM1 pumps) should monitor at least 4 times/d.
Describe what additonal therapy other than DM management should be considered
1] ACE I or ARB therapy delay progression of proteinuria. Should be first line for treatment of hypertension and considered without hypertension with proteinuria.
2] Aspirin unless contraindicated
3] Statin therapy if history of MI or LDL >100.
When should stepping down be an option
A1c <5.2
