kania pt 1 Flashcards
major cause of death in T1DM
diabetic kidney disease nephropathy
diabetic kidney disease nephropathy characteristics
persistent proteinuria
decreased eGFR
increased arterial BP
prevention of diabetic kidney disease nephropathy
screen for microalbuminuria annually in T1DM over 5 years and in T2DM; twice annually if UACR > 300 mg/g or eGFR <60mL
treatment of diabetic kidney disease nephropathy
ACEi or ARB if UACR > 300mg/g or eGFR <60mL/min
SGLT2I if eGFR > 20mL and UACR > 200mg/g wiht T2DM
GLP-1RA if SGLT2I is CI or not tolerated
finerenone
use to reduce CV risk if eGFR is <25mL/min
goal if UACR is > 300mg/g
30% reduction
ocular complications
blurred vision (likely due to decreased BP or BG)
retinopathy (if present screen 1x year), cataracts, glaucoma
treatment of ocular complications
photocoagulation therapy
anti-vascular endothelial growth factors (aflibercept or ranibizumab)`
peripheral neuropathy
annual monofilament test
initial treatment –> pregabalin, cymbalta, gabapentin
lsat resort of peripheral neuropathy
centrally acting opioid analgesic
ASCVD
atherosclerotic cardiovascular disease (coronary heart disease)
leading cause of morbidity and mortality
treatment of diabetes and CV complications
SGLT-2Is
GLP-1Ras
risk factors for CVD
obesity, HTN, HLD, smoking, and CKD
also metabolic syndrome
goal BP
< 130/80 for T2DM/T1DM
110 -135 / 85 for DM + pregnancy
maybe <140 for elderly patients
use of preferred antihypertensive agents for CV and diabetes
ACEis OR ARBs
use at max tolerated doses but not together due to risk of hyperkalemia, syncope, and renal dysfunction
if needed, add a second agent
other antihypertensive options
HCTZ
chlorothalidone
amlodipine
MRAs (spironolactone or eplerenone)
when to use none/moderate statin dose?
if patient is 20–39 with no ASCVD
monitor annually after
when to use moderate statin dose?
if patient is age 40-75 with no ASCVD
when to use high intensity stain dose?
if patient is age 40-75 with over 1 risk factor
if patient has DM and ASCVd in all agents (also lifestyle modifications)
**decrease LDL by over 50% and taget LDL under 70
statin use in over 75 yoa
if on a statin –> continue
if not on a statin –> moderate intensity after discussion
when should ezemtimibe or a PCSK9 inhibitor be added?
when pt has DM + ASCVD and currently on a statin, if LDL is still elevated despite maximal tolerated statin dose
target LDL level for DM + ASCVD
target decrease by greater than 50%
LDL under 55
high intensity statins
atorvastatin 40-80mg
rosuvastatin 20-40mg
moderate intensity statins
pitavastatin 1-4mg
rosuvastatin 5-10mg
atorvastatin 10-20mg
simvastatin 20-40mg
pravastatin 40-80mg
lovastatin 40mg
fluvastatin XL 80mg
low intensity statins
simvastatin 10mg
pravastatin 10-20mg
lovastatin 20mg
fluvastatin 20-40mg
prevention of muscle pain
often common with a statin
start at low dose of statin and generally work your way up
what should a patient use if they are intolerant of statins to treat CV complications?
bempedoic acid
antiplatelets
use aspirin as secondary prevention (clopidrogel if allergy, sometimes both)
hard to find a happy medium
aspirin plus rivaroxaban could be considered for pts with PAD and low bleeding risk
antiplatelets for primary prevention
consider in m/f over 50yoa with one major risk factor
probably not if over age of 70
do not use if there are no major CVD risk factors (risk of bleeding outweighs benefits)
different SMBG measuring times
intensive insulin regimens –> basically prior to everything also suspicion of hypoglycemia and after treatment
basal insulin/non-insulin medications –> once daily
non-insulin regimens –> prn
ADA target fasting
80 to 130 mg/dL
taret bedtime gluose
90 to 150 mg/dL
A1C target
ADA –> under 7%, consider under 6% in pregnancy
AACE –> under or equal to 6.5%
A1C
normal is 4-6%
average blood glucose concentration over 8-12 weeks
does not lie!
diabetes control and complications trial (DCCT)
T1DM patients
60% reduction in microvascular complications and 40-55% in CV complications in intensive treatment
UK Prospective Diabetes Study (UKPDS)
T2DM patients
every 1% drop in A1c –> 18% reduction in risk of CVD event
saw reductions in MI due to sulfonylureas, insulin, and metformin 10 years after
Action to Control CV Risk in Diabetes (ACCORD)
CVD or 2+ major risk factors
study terminated early due to increase risk of mortality in intensively manage patinets
not statistically significant at termination
Action in diabetes and vascular disease - preterax and diamicron modified release controlled evaluation (ADVANCE)
significant reduction in microvascular outcomes without a change in macrovascular events in intensively managed patients
no increase in CV mortality
VA diabetes trial (VADT)
more CVD deaths in the intensive arm vs standard, but not statistically significant
severe hypoglycemia associated with increased CVD mortality
When should A1C be targeted aggressively?
when a patient is newly diagnosed, no history of severe hypoglycemia, and no CVD
use in caution for patient with history of severe hypoglycemia, history of CVD or other extensive co-morbid conditions, and advanced disease where goal is difficult to achieve
***should be individualized regardless
what does a 1% change in A1C signal?
a 25 to 35 mg/dL change in mean blood glucose (eAG)
advantages of A1C
can be measured without fasting
levels are not subject to acute changes in insulin dosing, exercise, or diet
disadvantages of A1C
does not replace SMBG or CGM
remember –> its an average of all numbers
conditions that affect red blood cell turnover may impact result
when to measure A1C?
twice a year if meeting treatment goals
quarterly if therapy has changed or not meeting treatment goals
