fmCase 6 Flashcards
T2DM diagnosis
- A1c > 6.5%
- Fasting BG > 126 mg/dl
- OGTT (more sensitive but difficult, poorly reproducible)
- Repeat unless symptoms of hyperglycemia
- Random BG > 200 mg/dl with symptoms
ADA T2DM screening
ADA:
- Overweight with another risk factor:
- Sedentary, race, first degree FHx, prior impair fasting BG, HTN, HDL250, GDM Hx, delivering baby >9 lb, PCOS, CV disease Hx, acanthosis nigricans
- Otherwise, screen starting age 45 q 3 years
USPSTF T2DM screening
- BP > 135/80 (treated or untreated)
DKA lab results
pH < 7.30 (anion gap metabolic acidosis) dehydration ketones serum glucose > 250 mg/dl life-threatening
Hyperosmolar hyperglycemic state labs
pH > 7.30 (not a metabolic acidosis, and bicarb > 15) dehydration ketones absent/min elevated serum glucose > 600 mg/dl life-threatening
DM vascular disease (types 1 and 2)
- heart, brain, kidneys, eyes, nerves
- HTN worsens it
DM end-organ disease
CAD and CVA
Retinopathy and blindness
Glaucoma
Neuropathy
Nephropathy
CAD and CVA in DM
- Leading cause of death in DM
- Risk 2-4x general population
- Worsens outcomes in DM
- DM = equivalent risk as previous MI
- Manage other CV risk factors!
Eye disease in DM
Retinopathy and blindness: among T2DM higher risk if on insulin; higher risk in T1DM; proliferative retinopathy in 25% with 25 years DM
Glaucoma: 40% more likely in DM, increases with duration and age
Neuropathy in DM
Focal / diffuse / sensory / motor / autonomic
- Defined by loss of ankle jerk reflex
- 50% at 25 years for T1 and T2DM
Nephropathy in DM
- 20-40% in DM
- DM most common cause of ESRD
Hispanic cultural views of health and illness
- Familismo
- Respeto/simpatia: to authorities, avoid confrontation
- Personalismo: relationships or institution, do not address by first name
- Fatalismo: external locus of control
- Faith/religion
- Body image: balance
- Language barriers/health literacy
- Complementary and alternative health practices: balance
Diabetic foot exam
Diagnosis and annually
- 10-gram monofilament, plus one of
- Vibration 128-Hz, pinprick, or ankle reflexes
- Pedal pulses (PVD is strongest risk factor for delayed ulcer healing and amputation)
- Inspection for pressure calluses, ulcers, bony abnormalities, hair loss, temperature, footwear
Recommended lab tests for the DM patient
A1c at diagnosis and twice a year (50; annually (ADA and USPSTF not for or against)
Fasting lipid profile at diagnosis and yearly, every 3 months until controlled
Fingerstick BG if acute symptoms of hyperG or hypoG (not useful to evaluate control)
A1c labs in DM
At diagnosis and twice a year (<7%)
Quarterly when changing tx or goal not met
ECG in DM
Baseline (CVD most common cause of death)
Spot urine albumin: creatinine ratio in DM
Annually
Drug tox and renal dz
B12 labs in DM
If neuropathy signs
Metformin SE
TSH in DM
Annually in T1DM, dyslipidemia, or women >50
ADA and USPSTF not for or against
Lipid labs in DM
Diagnosis and yearly
If abnormal, every 3 months until controlled
Fingerstick glucose in DM
If acute symptoms of hyperG or hypoG
not useful to evaluate control
1st Tier Management of T2DM (ADA/EASD)
- Diagnosis of A1c > 6.5%: Lifestyle + metformin
- If A1c continues > 8%: Add sulfonylurea or basal insulin or intermediate insulin
- If A1c continues > 8%: Add basal insulin or intensify insulin regimen. *Consider DCing sulfonylurea to avoid hypoG
Sulfonylureas
Glyburide
Glipizide
Glimepiride (3rd gen)
Basal insulin
Glargine (Lantus)
Detemir (Levemir)
Intermediate insulin
NPH (neutral protamine Hagedorn)
2nd Tier Management of T2DM
(Fewer well-validated studies in support)
- Add rapid insulin with meals.
- Thiazolidinediones (pioglitazone, rosiglitazone) for those who have GI side effects with metformin or hypoG with sulfonylureas, or in addition (their SE is heart failure, edema, bone fractures).
- Meglitinides (nateglinide, repaglinide)
- GLP-1 analogs (exenatide, liraglutide)
- DPP-4 inhibitors (dipeptidyl peptidase-4) (sitagliptin, saxagliptin)
- Amylin analog (pramlintide)
- Alpha-glucosidase inhibitors (acarboe, miglitol)
Lifestyle modification in preventing diabetes
58% risk reduction
Glycemic control in DM
- A1c < 7% prevents microvascular dz (retinopathy, nephropathy)
- Fasting BG goal 80-120 mg/dl
- Postprandial BG 1-2 hours goal < 180
- BP and lipid control better for CVD risk
Modifying CVD risk factors in DM
- Treat BP to < 140/90 with lifestyle + ACEI, ARB, thiazide, or CCB (ARBs in DM + CHF)
- Treat dyslipidemia with statin to LDL < 100, < 70 (known CVD, high dose statin); or LDL reduction of 30-40%
- Statin regardless of lipids, if known CVD or if >40yo with risk factor for CVD
- Weight loss, exercise, low fat
LDL goal if DM and dyslipidemia
LDL < 100
LDL < 70 if known CVD (use high dose statin)
or LDL reduction 30-40%
LDL and hyperTG
LDL-c unreliable in s/o hyperTG > 200 (NCEP ATP III)
So, target non-HDL cholesterol as second goal after LDL
Non-HDL cholesterol may be stronger predictor of CVD
Atherogenic VLDL remnants?
ASA in DM
- Secondary prevention in DM with h/o CVD, or in DM with 10-year risk > 10%
- Primary prevention in DM and >40yo, or other risk factors (HTN, smoking, dyslipidemia, FHx CVD, albuminura)
- 81mg daily
- Clopidogrel if ASA allergy
- No evidence for ASA in s syndrome)
Smoking cessation and DM
Efficacious and cost-effective
*QUIT not cut back
Smoking and DM
Higher risk of premature microvascular cx and CVD
Most important modifiable cause of premature death
Eye care in DM
Yearly exam: dilated indirect ophthalmoscopy + biomicroscopy or seven-standard field stereoscopic 30 degree fundus photography
T1DM: start 5 years after diagnosis
T2DM: At diagnosis (20% will have some retinopathy)
Timely laser photocoagulation can prevent vision loss
DM foot care
Diabetic shoes, podiatry referral, daily foot care
DM dental care
important
Immunizations
Annual influenza
Pneumococcal polysaccharide > 2yo, and one-time revaccination > 64yo (if no vaccine in 5 years), and revaccination if nephrotic syndrome or CKD or immunocompromised
