EXAM 4 Diabetes Complications, Prevention, Footcare Dr. Hess Flashcards
A1c goal in most adult patients
< 7%
Which diuretics are part of the strategies for preventing Macrovascular diseases?
Thiazides
MAR (spironolactone) in resistant HTN: the patient is on 3 antihypertensive drugs (1 of them is a diuretic) and still not at goal
When is Aspirin in the prevention of macrovascular disease recommended?
secondary prevention
-after they had an event
Should patients with diabetes be on Aspirin for primary prevention?
study with 100 mg ASA reduced MACE by 12%
but it also increased the risk for bleeding
Which SGLT2is have shown CVD benefits?
REMINDER
-Jardiance (empiglaflozin)
-Invokana (canagliflozin)
Which GLP-1R-agonists have shown CVD benefits?
REMINDER
-Victoza (liraglutide)
-Ozempic (semaglutide, injectable)
-Trulicity (dulaglutide)
Which diuretics are part of the strategies for preventing Macrovascular diseases?
Thiazides
MAR (spironolactone) in resistant HTN: the patient is on 3 antihypertensive drugs (1 of them is a diuretic) and still not at goal
Signs of Proliferative Retinopathy
-hyperglycemia -> Hemorrhage in the capillaries of the eye -> bleeding in the eye
-macula edema (sharp reading)
-Microaneurysm
-Cottonwool spots
What is a possible consequence of the leaking and hemorrhage in the capillaries of the eye?
Ischemia in the eye
Which stage of Retinopathy is the advanced form?
Proliferative Retinopathy
What is the difference between the Non-proliferative and the proliferative state?
-Non-Proliferative:
no growth of new blood vessels
-Proliferative:
growth of blood vessels but they are prone to tear
When does a diabetes patient have eye exams?
T1DM: 5 years after diagnosis then annually
T2DM: at diagnosis then annually
-> because they may be longer living with untreated diabetes
What is a sign of diabetic nephropathy?
damaged nephron -> protein in the urine
How often should patients get their kidneys checked for diabetic nephropathy?
annually
-At diagnosis with T2DM
-After 5 years of diagnosis with T1DM
-Urinary Albumin to Creatinine Ratio (UACR)
What are the normal values of albumin in the urine?
< 30
> 30: Albuminuria
Which drug is used in diabetic patients with albuminuria?
ACEi or ARB (kidney protective)
-even without HTN
-only if they have albuminuria
SGLT2i add protective effect
Which SGLT2i have FDA-labeled indications to reduce CKD?
-Jardiance (empagliflozin)
-Invokana (canagliflozin)
-Farxiga (dapagliflozin)
What are the FDA-indicated drugs used for diabetic neuropathy?
-Pregabalin
-Duloxetine
Off label:
-Gabapentin
-Venlafaxine
-TCAs (ex: Amitriptyline)
-Tramadol (last option)
-if a patient has depression using an SNRI would be beneficial
dont combine anticonvulsants Pregabalin and Gabapentin, dont combine SNRIs Duloxetine and Venlafaxine
-> may combine drugs outside of the drug class
What is an example of autonomic neuropathy?
Diabetic Gastroparesis
Signs: N/V, bloating, early satiety
What are the treatment options for diabetic gastroparesis?
diet modification
-low-fiber foods (high fiber causes slower emptying)
-small frequent meals are better than fewer larger meals
-eat while sitting up, chewing well
-solid foods during the day, more liquid (pureed) meals later
-take a walk after a meal
What are the complications in patients with gastroparesis who also take insulin?
glucose peak is delayed bc the food takes longer to get from the stomach into the small intestine -> may need to take the bolus insulin after the meal
-regular may be the better option (peaks later than rapid-acting)
-premixed is not preferred (has 2 peaks, not able to time it as well)
Which drugs should be avoided in gastroparesis?
drugs that slow gastric emptying
-Narcotics
-TCA
-CCBs
-clonidine
-GLP-1 !!
Which drug can be used in gastroparesis?
Metoclopramide (Reglan)
-Dopamine antagonist and enhances anticholinergic response in the GI
-stimulates contraction in the stomach and causes faster emptying
-decreases vomiting reflex, sensation of nausea
-not for long-term use (for up to 12 weeks)
What is the BBW for Metoclopramide?
tardive dyskinesia
How often should a foot exam be performed on diabetic patients?
annually
-at each visit if they have a hx of ulceration or LOPS
-assess loss of protective sensation (LOPS)
-asses blood circulation in the feet (can you feel the pulse?
What should be inspected during a foot exam?
-Inter-digitally
-Ulceration
-Erythema
-Callus
-Nail dystrophy
-Infections
-Hair growth
-Temperature differences
Musculoskeletal signs for poor circulation on the foot
Hammertoe
Claw toes
-frictions increases risk for ulceration and foot injury
What are the tools to assess blood circulation of the foot?
Monofilament test:
-Test of pressure sensation on 5-6 spots
-Avoid calluses
-eyes should be closed
128Hz tuning fork: Vibratory sensation
-if the tester feels the vibration and the patient sensation stops earlier -> sign for LOPS
Which blood vessels are inspected for the vascular assessment of the foot?
Palpitation of
-posterior tibial pulse
-dorsalis pedis pulses
Patient education - Foot care
-Check your feet daily
-Wash and dry your feet daily (avoid lotion in between the toes (moisture, fungal infection)
-Keep skin soft and smooth
-Trim toenails straight across and file edges
-Smooth corns and calluses gently
-Wear shoes and socks at ALL times
