IC13 Diabetes Management Part 3

Question 1

_________ is the preferred initial pharmacologic agent for the treatment of type 2 diabetes and it should be _________________

Answer 1

Metformin; continued as long as possible

Question 2

If patient have Hx of ASCVD, HF or CKD, consider independently of A1c to add _____________. The reason is because _______. But not commonly done because ________.

Answer 2

➢ASCVD: GLP-1 agonist or SGLT2
➢HF: SGLT2
➢CKD: SGLT-2 > GLP-1 agonist

Strong evidence for additional benefits

Cost

Question 3

After adding Metformin, A1c still above target:
1) If you also need to minimize hypoglycemia (e.g. in elderly), avoid _____ & ________
2) If you need to promote weight loss, choose _____ or ______
3) If have financial difficulties, choose __ > ____ > _____

Answer 3

1) SU and insulin
2) GLP-1 or SGLT2i
3) SU > TZD > DPP4

Question 4

If need greater glucose lowering than can be obtained with oral agents, ________ is the preferred to ______ as the starting injectable. ________ will be considered instead when
1) ______
2) ______
3) ______
4) ______

Answer 4

GLP-1 is preferred over insulin

Insulin will be considered when:
1) Ongoing catabolism (weight loss)
2) Symptoms of hyperglycemia
3) HbA1c > 10%
4) BG > 16.7 mmol/L

Question 5

Insulin will normally be initiated with _______ control. ___ insulin < __ units at bedtime

Answer 5

Basal FBG

Intermediate, long, ultra-long acting:
NPH insulin < 10 units (Others: Glargine, detemir, degludec but costly)

Question 6

If HbA1c remains uncontrolled after initial insulin dosing, _____________. How to adjust dose?

Answer 6

Continue to act on FBG

➢ ↑ insulin 2 units every 3 days until FPG at goal
➢ May ↑ insulin 4 units every 3 days if FPG consistently > 10 mmol/L
➢ ↓ insulin by 10-20% if no clear reason for hypoglycemia

Question 7

If A1c still above goal, despite basal dose > 0.5 IU/kg OR FPG at goal, add ___________. If on bedtime NPH, ____________

Answer 7

Prandial coverage (either rapid/regular insulin)
- 1 dose with largest meal
- 4 IU or 10% of basal
- If A1c < 8%, to also decrease basal dose by 4 IU or 10%

Consider splitting dose for NPH into two doses, 2/3 in AM, 1/3 in evening

Question 8

Why do we stop increasing basal insulin dose once > 0.5 IU/Kg?

Answer 8

• Overbasalization!
• Basal insulin having a ceiling effective dose whereby fasting blood glucose reductions become proportionally smaller with increasing doses
• Potential results of this overuse of basal insulin may be unintended outcomes such as weight gain and hypoglycemia and postprandial hyperglycemia

Question 9

For multiple insulin dosing, basal usually consist of __% or more of total daily dose. What is the breakdown of injections like?

Answer 9

50%

Full basal bolus regimen:
1 basal (glargine) + 3 regular/rapid = 4 total

Twice daily pre-mix regimen:
NPH 2x/day + Regular Mixtard/rapid NovoMix = 2 total

Question 10

What leads to diabetic emergencies?

Answer 10

Ketone byproduct from fat metabolism

Question 11

Why is diabetic emergencies more common in type 1 than type 2 diabetes?

Answer 11

➢ An absolute/relative insulin deficiency leads to lipolysis + metabolism of free fatty acids, resulting in the formation of beta-hydroxybutyrate, acetoacetic acid, and acetone in the liver.

➢ Stress stimulates insulin counter-regulatory hormones (glucagon, catecholamines, glucocorticoids, growth hormone). Excess glucagon ↑ gluconeogenesis and ↓ peripheral ketone utilization.

Type 2 usually have residual insulin production, so they are protected against excess lipolysis and ketone production

Question 12

What are type 1 and type 2 diabetic emergencies? What are patient conditions and BG like in these cases?

Answer 12

Diabetic Ketoacidosis - Ketone formation; found in the blood and urine, fruity breath odor and acidosis. Patient is usually alert and BG > 14 mmol/L

Hyperglycemic Hyperosmolar State - Due to residual insulin, there is no ketones. Patient is usually extremely dehydrated with stupor and BG > 33 mmol/L

Question 13

What parameters are checked for diabetic emergencies and how do they fare in DKA vs HSS?

Answer 13

Plasma Glucose - 14 vs 33

Arterial/venous pH - May have acidosis vs basic

Bicarbonate level - May be acidic vs basic

Urine or blood acetoacetate (Nitroprusside reaction) - Positive vs Negative

Urine or Blood Beta-hydroxybutyrate - High vs Low

Serum osmolality is variable

Anion gap - Higher vs Lower

Alteration in sensorium - Alert vs Stupor

Question 14

_____ Effect and ______ Phenomenon both have high BG levels at dawn. How do we differentiate them? Which is more common?

Answer 14

Somogyi Effect and Dawn Phenomenon
- Due to cortisol vs Due to glucagon

Dawn phenomenon is more common

Question 15

What is the role aspirin in DM as a secondary and primary prevention strategy for ASCVD?

Answer 15

Secondary prevention for DM with ASCVD Hx
- Clopidogrel 75mg/day (if aspirin allergy)

Primary prevention for DM at increased CV risk
- Discuss benefit vs risk of bleeding
- Aspirin may be considered to reduce CV events but also increase bleeding events

Question 16

When is aspirin not recommended?

Answer 16

Low risk ASCVD patients
(1) < 50 years with DM AND
(2) No major ASCVD risk factors (e.g. LDL > 2.6 mmol/L, hypertension, smoking, CKD, albuminuria, family history of premature ASCVD)