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Fam Med: Diabetes > General Principles > Flashcards

General Principles Flashcards

1
Q

What is the definition of DM?

A

A syndrome with disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or a combination of insulin resistance and inadequate insulin secretion to compensate

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2
Q

Discuss the epidemiology of DM

A
  • >25 million diabetics in US with >90-95% being Type 2
  • Genetic predisposition
  • Significant morbidity and mortality
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3
Q

What are the four clinical classes of diabetes?

A
  • Type 1
  • Type 2
  • Gestational
  • Other specific types of DM (genetic defects in insulin secretion or action, pancreatic surgery or disease, endocrinopathies- Cushings, acromegaly, drugs, and diabetes associated with other syndromes)
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4
Q

Discuss the pathophysiology of T1DM

A

results from cellular-mediated autoimmune destruction of the beta (β) cells of the pancreas.

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5
Q

discuss presentation of T1DM in a child vs older adult

A
  • Rate of destruction of B cells is rapid in infants and children and slower in adults
    • Presentation in young- ketoacidosis
    • Presentation in adults-longer sx prodrome and may be diagnosed on basis of hyperglycemia and positive autoantibodies
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6
Q

discuss how long it takes for a T1 diabetic to develop ketosis without insulin

A

8-16 hours

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7
Q

How long does it take for a T1 diabetic to develop ketoacidosis without insulin?

A

12-24 hours

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8
Q

Why is it important for tight blood glucose (BG) control early on in a T1 diabetic?

A

It has been shown to preserve the residual B cell function and prevent or delay later complications

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9
Q

What is LADA?

A
  • Latent autoimmune diabetes in adults
    • Characterized by mild-moderate hyperglycemia at presentation that often responds to noninsulin therapies that progresses over months to years to insulin dependency
    • Will have 1 or more B cell specific autoantibodies and tend to require insulin sooner than those with Type 2
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10
Q

Discuss the pathophysiology of T2DM

A

Characterized by insulin resistance followed by reduced insulin secretion from B cells that are unable ti compensate for increased insulin requirements

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11
Q

Which races have a higher risk of developing T2DM than whites?

A
  • African Americans
  • Hispanics/Latinos
  • Asian Indians
  • Native Americans
  • Pacific Islanders
  • some groups of Asians
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12
Q

What are risk factors for developing T2DM?

A
  • Obesity
  • Family history of diabetes
  • History of gestational diabetes or prediabetes
  • HTN
  • physical inactivity
  • Race/ethnicity
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13
Q

What is gestational DM?

A

Any degree of glucose intolerance, with onset or diagnosis during pregnancy

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14
Q

What percentage of pregnant patients will go on to develop T2DM?

A

60% of women with GDM will develop T2DM in the ensuing 5-10 years and all remain at an increased risk for development of T2DM later in life

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15
Q

How is DM dx?

A
  • Hemoglobin A1C > 6.5%
  • Fasting plasma glucose >126mg/dL after an overnight fast (should be confirmed with repeat test)
  • Sx of diabetes (polyuria, polydipsia, fatigue, weight loss) and a random plasma glucose level of >200mg/dL
  • Oral glucose tolerance test that shows plasma glucose level of >200mg/dL at 2 hours after ingestion of 75g of glucose
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16
Q

What is the definition of prediabetes?

A
  • Impaired fasting glucose: FPG >100mg/dL and <125mg/dL
  • Impaired glucose intolerance: 2-hour glucose 140-199mg/dL after ingesting 75g glucose (OGTT)
  • A1C: 5.7-6.4%
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17
Q

How do you council someone with prediabetes in terms of lifestyle changes?

A
  • Balanced hypocaloric diet to achieve 7% weight loss in overweight patients
  • Regular exercise of >150mins per week
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18
Q

List major goals of therapy for DM

A
  • Alleviation of symptoms
  • Achievement of glycemic, blood pressure, and lipid targets
  • Prevention of acute and chronic complications
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19
Q

What are fasting/preprandial targets for DM?

A

Fasting/pre-prandial BS 70-130 mg/dL

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20
Q

What is the blood pressure target for diabetics?

A

<130/80mmHg

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21
Q

What is first line treatment for hypertension in diabetics?

A

ACE inhibitor (Lisinopril) or ARB (Losartan)

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22
Q

For patients not at goal with answer to the above question, what medication should you add for adjunct therapy if:

eGFR <30

A

Loop diuretic (Furosemide)

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23
Q

For patients not at goal with answer to the above question, what medication should you add for adjunct therapy if:

eGFR >30

A

Thiazide diuretic (HCTZ)

24
Q

What is the role of aspirin in the treatment of DM?

A
  • Diabetics have abnormal platelet function with increased incidence of small vessel thrombosis and atherosclerosis
  • 2013 ADA: ASA for adult diabetics with >10% risk for cardiac event over 10 years
  • Men >50 or women >60 with one or more major risk factors for CHD
  • ASA for all adult diabetics with macrovascular disease (CHD, PVD, CVD) and older than 40 years
  • Dose: 75-162 mg/daily
  • Risks: PUD, gastritis, bleeding
  • 2013 observational study of men/women with T@DM and no prior CVD: 4608 patients on ASA with 14,038 not on ASA- no benefits from ASA. Conclusion: more restrictive use of ASA in patients with T2DM and no CVD
25
Q

How often should diabetics be checking their blood glucose?

A
  • Patients with multiple daily insulin injections or insulin pumps: 3 or more times daily (can be done before meals and at bedtime or periodic testing 1-2 hours after eating to achieve postprandial glucose targets)
  • Less frequent testing may be appropriate for those on noninsulin therapies
26
Q

What is a hemoglobin A1c?

A

provides integrated measure of BG values over preceding 2-3 months

27
Q

Why is A1c checked every 3 mo?

A

A1c checks the amount of glucose bound to hemoglobin in the red blood cells – RBC only live for 3 months

28
Q

How often do you monitor A1cs?

A

Obtained every 3 months in patients not at goal or when either diabetes therapy or clinical conditions changes

Twice yearly in well-controlled patients

29
Q

When an A1c is higher than expected based off of pt’s glucose readings, what do you need to investigate?

A

Should be evaluated by diabetes educator to ensure meter accuracy, appropriate technique, and frequency of testing

30
Q

When an A1c is lower than expected based off of a pt’s glucose readings, what do you need to investigate?

A

Blood loss, transfusion, hemolysis, and hemoglobin variants

31
Q

How can a diabetic prevent ketoacidosis?

A
  • Checking ketones in fingerstick blood sample by measuring B-hydroxybutyrate with the handheld glucose/ketone meter, Precision Xtra.
  • Urine ketones can also be qualitatively identified using Ketostix or Acetest tablets
32
Q

When should pts with T1DM check for ketoacidosis?

A
  • Febrile illness
  • Persistent elevation of glucose (>300mg/dL) or signs of impending DKA
33
Q

What are signs of impending DKA?

A

Nausea, vomiting, abdominal pain

34
Q

What dietary recommendations would you make for a diabetic?

Calories

A

1,000-1,500 kcal/d for women and 1,200-1,800kcal/d for men depending on activity level and starting body weight

35
Q

What dietary recommendations would you make for a diabetic?

Carbs/proteins/fats

A
  • Carbs: 45-65%
  • Protein: 10-30%
  • Total fat: <30% (<7% saturated fat)
36
Q

What dietary recommendations would you make for a diabetic?

Cholesterol

A

<300mg/d

37
Q

What dietary recommendations would you make for a diabetic?

h/o CKD

A

protein restriction of 0.8g/kg/d along with additional restrictions of potassium and phosphorus containing foods if severe CKD

38
Q

What would you recommend for carbohydrate goals for a diabetic?

A

“carb counting” for patients on intensified insulin therapy who adjust insulin doses based on carb content of meals/snacks

39
Q

When should a diabetic be hospitalized?

A
  • DKA characterized by PBG >250mg/dL in association with an artierial pH <7.3 or serum bicarb level <15meq/L and moderate ketanemia or ketonuria
  • Hyperosmolar nonketoic state includes marked hyperglycemia (>400mg/dL) and elevated serum osmolality (>315 mOsm/kg) often accompanied by impaired mental status)
  • Hypoglycemia if induced sulfonylurea medication, is due to deliberate drug overdose, or results in coma, seizure, injury, or persistent neurologic change
  • Newly diagnosed T1DM or newly recognized GDM even in the absence of ketoacidosis
  • Patients with T2DM if initiation or change in insulin therapy unless hyperglycemia is severe and associates with mental status change or other organ dysfunction
40
Q

What is the definition of DKA?

A

DKA characterized by:

  • PBG >250mg/dL
  • arterial pH <7.3
  • or serum bicarb level <15meq/L and moderate ketanemia or ketonuria
41
Q

What is the definition of hyperosmotic nonketotic state?

A
  • marked hyperglycemia (>400mg/dL)
  • elevated serum osmolality (>315 mOsm/kg) often accompanied by impaired mental status)
42
Q

What are glucose targets for inpatients in critical care?

A

140-180 mg/dL with frequent monitoring recommended for scrupulous avoidance of hypoglycemia

43
Q

What are glucose targets for inpatients in noncritical care?

A

140mg/dL fasting and premeal, <180 mg/dL post meal or on a random glucose check

44
Q

What class of medication should be used in management of hyperglycemia in critical care settings?

A

Variable IV insulin infusion

45
Q

How often do you check glucose levels in a critical care setting?

A

hourly at bedside

46
Q

how do you prevent hypoglycemia and ketosis in a critical care setting?

A

IV infusion of a dextrose-containing solution or other caloric source should be provided to prevent

47
Q

Which type of fluid works best for patients with fluid restriction in a critical care setting?

A

10% dextrose in water (D10W) infused at a rate of 10-25mL/hr to provide steady, consistent source of calories

48
Q

What class of mediciation should be used management of hyperglycemia in noncritical care settings?

A

Insulin

49
Q

How often do you check glucose levels in a noncritical care setting?

A

On admission and 4x daily in hyperglycemia patients, especially treated with insulin

50
Q

How do you dose insulin and what type of insulin therapy works best in a noncritical care setting?

A
  • Patients native to insulin: starting dose of basal insulin should equal 0.2U/kg or 0.1U/lb
  • If BG level >200mg/dL, adding premeal insulin is appropriate and the dose should be 0.2U/kg divided by 3 meals
  • Patients with T1DM should continue home insulin doses and may continue use of an insulin pump if hospital policy is in place to do so
  • Insulin doses in patients with T2DM should be reduced by 20-50% on admission
51
Q

How do you manage hypoglycemia in noncritical care setting?

A
  • Treated promptly with oral or IV glucose and the capillary BG should be repeated every 10 mins until >100mg/dL stable
  • Reevaluation of scheduled doses and assessment of risk factors for hypoglycemia (declining renal function, hepatic impairment, poor intake) should be undertaken for any BG <70mg/dL
52
Q

What is the A1c cutoff for elective surgery?

A

>8.5%

53
Q

What labs do you need to check in a diabetic prior to surgery?

A
  • Glucose
  • Acid-base
  • Electrolyte (K, Mg, Phosphate)
  • Fluid status
54
Q

What are perioperative glucose targets?

A

108-180mg/dL (checked hourly in persons with diabetes who gave taken insulin or who require insulin perioperatively)

55
Q

For outpatient procedures, how should a diabetic manage their insulin?

A

Continue basal insulin doses and resume bolus doses with corrections as soon as possible postoperatively

56
Q

For emergency or major elective surgery, how is glucose in a diabetic on insulin managed?

A
  • Variable IV insulin infusion, supplemented with glucose and potassium as needed to achieve target BG levels
  • Hourly glucose measurements are mandatory to adjust insulin and glucose infusions
  • K+ should be monitored at least every 2 hours and replaced aggressively as required

Fam Med: Diabetes (4 decks)

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