EXAM 4 Diabetes Complications, Prevention, Footcare Dr. Hess

Question 1

A1c goal in most adult patients

Answer 1

< 7%

Question 2

Which diuretics are part of the strategies for preventing Macrovascular diseases?

Answer 2

Thiazides

MAR (spironolactone) in resistant HTN: the patient is on 3 antihypertensive drugs (1 of them is a diuretic) and still not at goal

Question 3

When is Aspirin in the prevention of macrovascular disease recommended?

Answer 3

secondary prevention

-after they had an event

Question 4

Should patients with diabetes be on Aspirin for primary prevention?

Answer 4

study with 100 mg ASA reduced MACE by 12%
but it also increased the risk for bleeding

Question 5

Which SGLT2is have shown CVD benefits?
REMINDER

Answer 5

-Jardiance (empiglaflozin)
-Invokana (canagliflozin)

Question 6

Which GLP-1R-agonists have shown CVD benefits?
REMINDER

Answer 6

-Victoza (liraglutide)
-Ozempic (semaglutide, injectable)
-Trulicity (dulaglutide)

Question 7

Which diuretics are part of the strategies for preventing Macrovascular diseases?

Answer 7

Thiazides

MAR (spironolactone) in resistant HTN: the patient is on 3 antihypertensive drugs (1 of them is a diuretic) and still not at goal

Question 8

Signs of Proliferative Retinopathy

Answer 8

-hyperglycemia -> Hemorrhage in the capillaries of the eye -> bleeding in the eye

-macula edema (sharp reading)
-Microaneurysm
-Cottonwool spots

Question 9

What is a possible consequence of the leaking and hemorrhage in the capillaries of the eye?

Answer 9

Ischemia in the eye

Question 10

Which stage of Retinopathy is the advanced form?

Answer 10

Proliferative Retinopathy

Question 11

What is the difference between the Non-proliferative and the proliferative state?

Answer 11

-Non-Proliferative:
no growth of new blood vessels

-Proliferative:
growth of blood vessels but they are prone to tear

Question 12

When does a diabetes patient have eye exams?

Answer 12

T1DM: 5 years after diagnosis then annually

T2DM: at diagnosis then annually
-> because they may be longer living with untreated diabetes

Question 13

What is a sign of diabetic nephropathy?

Answer 13

damaged nephron -> protein in the urine

Question 14

How often should patients get their kidneys checked for diabetic nephropathy?

Answer 14

annually
-At diagnosis with T2DM
-After 5 years of diagnosis with T1DM

-Urinary Albumin to Creatinine Ratio (UACR)

Question 15

What are the normal values of albumin in the urine?

Answer 15

< 30

> 30: Albuminuria

Question 16

Which drug is used in diabetic patients with albuminuria?

Answer 16

ACEi or ARB (kidney protective)
-even without HTN
-only if they have albuminuria

SGLT2i add protective effect

Question 17

Which SGLT2i have FDA-labeled indications to reduce CKD?

Answer 17

-Jardiance (empagliflozin)
-Invokana (canagliflozin)
-Farxiga (dapagliflozin)

Question 18

What are the FDA-indicated drugs used for diabetic neuropathy?

Answer 18

-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

Question 19

What is an example of autonomic neuropathy?

Answer 19

Diabetic Gastroparesis

Signs: N/V, bloating, early satiety

Question 20

What are the treatment options for diabetic gastroparesis?

Answer 20

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

Question 21

What are the complications in patients with gastroparesis who also take insulin?

Answer 21

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)

Question 22

Which drugs should be avoided in gastroparesis?

Answer 22

drugs that slow gastric emptying

-Narcotics
-TCA
-CCBs
-clonidine
-GLP-1 !!

Question 23

Which drug can be used in gastroparesis?

Answer 23

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)

Question 24

What is the BBW for Metoclopramide?

Answer 24

tardive dyskinesia

Question 25

How often should a foot exam be performed on diabetic patients?

Answer 25

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?

Question 26

What should be inspected during a foot exam?

Answer 26

-Inter-digitally
-Ulceration
-Erythema
-Callus
-Nail dystrophy
-Infections
-Hair growth
-Temperature differences

Question 27

Musculoskeletal signs for poor circulation on the foot

Answer 27

Hammertoe
Claw toes

-frictions increases risk for ulceration and foot injury

Question 28

What are the tools to assess blood circulation of the foot?

Answer 28

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

Question 29

Which blood vessels are inspected for the vascular assessment of the foot?

Answer 29

Palpitation of
-posterior tibial pulse
-dorsalis pedis pulses

Question 30

Patient education - Foot care

Answer 30

-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