Learning Objectives Kania Flashcards
List the signs and symptoms of diabetes.
Signs and symptoms that result are related to alterations in carbohydrate, fat, and protein metabolism
Polyuria, polydipsia, polyphagia, weight loss, fatigue, UTIs, respiratory infections, ketoacidosis, blurred vision
Glucose uptake by brain is
insulin independent
Glucose uptake by other tissues (muscle, fat) is
insulin dependent
Understand the differences between T1DM and T2DM and know how to diagnose it.
T1DM: insulin-dependent DM; age of onset <30 yrs, peak is 12-14 yrs; FH not common; usually not obese; usually no pancreatic function; autoimmune beta cell destruction leading to absolute insulin deficiency
T2DM: non-insulin dependent DM; age of onset >40 yrs; FH is common; most are obese; progressive loss of adequate beta cell insulin secretion
Drugs that increase hepatic glucose output
Glucocorticoids, sympathomimetics, niacin
Drugs that decrease insulin secretion
Phenytoin, beta blockers, calcium channel blockers, immunosuppressant (cyclosporine, sirolimus, tacrolimus)
Drugs that increase insulin resistance
Thiazide diuretics, glucocorticoids and oral contraceptives, antipsychotics (clozapine, olanzapine)
Drugs that are toxic to beta cells
Pentamidine - prevents insulin secretion
Drugs that stimulate appetite
Phenothiazines, marijuana, androgens
Criteria for diagnosis of DM
FBG greater than/equal to 126 mg/dL OR
A1C greater than/equal to 6.5% (not for diagnosis in conditions associated with increased RBC turnover, sickle cell disease, pregnancy, hemodialyiss, blood loss or transfusion, severe anemia) OR
Random glucose greater than/equal to 200 mg/dL w/ sx of diabetes OR
2 hr postprandial glucose greater than/equal to 200 mg/dL during OGTT
Need 2 positive criteria in pt
Identify and discuss the goals of therapy in the treatment of T1DM and T2DM and describe how the patient should be monitored to establish whether these goals have been met.
Keep patient asymptomatic; prevent long-term complications; maintain patients near euglycemia; acheive/maintain appropriate body weight; eliminate/minimize all cardiovascular risk factors
Components of therapy: meals, monitoring, movement, medications
Discuss the long-term complications of diabetes on the kidneys.
Diabetic kidney disease nephropathy: persistent proteinuria, decreased eGFR, and increased arterial BP
Diabetic kidney disease is the major cause of death in T1 pts
Screen for microalbuminuria annually in pts with T1DM for >/= 5 yrs and in all pts with T2DM
ACEI or ARB recommended for non-pregnant pts
Optimize glucose control: SGLT2 or GLP-1 if SGLT2 contraindicated/not tolerated
Goal UACR:
<30 mg/g
if pts have UACR greater than or equal to 200, goal is a 30% reduction
If UACR > 300 mg/g or eGFR < 60 mL/min, check
both twice annually
Pts with CKD and albuminuria who are at risk for CV events use
nonsteroidal minerolocorticoid receptor antagnoist (finerenone)
Discuss the long-term complications of diabetes on the eyes.
Blurred vision, cataracts, glaucoma
Retinopathy is the most common complication
For T1DM, have an initial eye exam within 5 yrs after onset of diabetes; for T2DM, have an initial eye exam at time of diabetes diagnosis
Tx: photocoagulation therapy or anti-vascular endothelial growth factor, ranibizumab
Discuss the long-term complications of diabetes on the peripheral nervous system.
Peripheral neuropathy: annual monofilament testing; tx - pregabalin, duloxetine, gabapentin, tricyclic antidepressants, venlafaxine, carbamazepine, tramadol, capsaicin, tapentadol
GI neuropathies; urinary retention; postural hypotension; erectile dysfunction
Discuss the long-term complications of diabetes on the cardiovascular system.
Atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality in type 2 pts
Heart failure
Assess cardiovascular risk factors annually: obesity, HTN, HLD, smoking, CKD
ADA BP goal
<130/80 T2DM or T1DM
110-135/85 DM + pregnancy
For a patient with diabetes and concomitant hypertension, discuss the optimal treatment for the disease state.
SGLT-2Is: empagliflozin, canagliflozin, dapagliflozin
GLP-1RAs: liraglutide, semaglutide, dulaglutide
Preferred antihypertensive agents: ACEIs or ARBs (do NOT use in combo due to tisk of hyperkalemia, syncope, and renal dysfunction)
Other antihypertensive options: HCTZ, chlorthalidone, amlodipine, spironolactone
For a patient with diabetes and kidney disease, discuss the optimal treatment for the disease state.
Preferably use SGLT2I with evidence of decreased CKD progression; use GLP-1RA if SGLT2I not tolerated or contraindicated
For a patient with diabetes and hyperlipidemia, discuss the optimal treatment for the disease state.
High intensity: atorvastatin 40-80 mg/day OR rosuvastaton 20-40 mg/day
Moderate intensity: atorvastatin 10-20 mg/day, rosuvastatin 5-10 mg/day, simvastatin 20-40 mg/day, pravastatin 40-80 mg/day, lovastatin 40 mg/day, fluvastatin XL 80 mg/day, pitavastatin 1-4 mg/day
Primary prevention and statin treatment for 20-39 yo
Risk considerations: no ASCVD
Statin dose: none-moderate based on risk factors
Monitoring: annually or prn based on adherence
Primary prevention and statin treatment for 40-75 yo
Risk considerations: no ASCVD
Statin dose: moderate intensity
Risk considerations: >/= 1 risk factor
Statin dose: high intensity, decrease LDL by >/= 50% and target LDL < 70
Monitoring: annually and prn to monitor for adherence
Secondary prevention - have cardiovascular disease
DM + ASCVD in all ages = high intensity statin therapy + LSM
Target decrease LDL by >/= 50% and goal LDL < 55
If LDL elevated despite maximally tolerated statin dose, add ezetimibe or PCSK9 inhibitor
Use of antiplatelets agents in pts with diabetes
Aspirin (75-162 mg/day) as secondary prevention in those with diabetes and CVD
For pts with CVD and aspirin allergy, use clopidogrel (75mg/day)
Consider aspirin (75-162 mg/day) for primary prevention in men/women >/= 50 yrs with one major risk factor, not at an increased risk of bleeding
Do NOT use aspirin for primary prevention for those at low CVD risk - risk of bleeding
Fasting ADA target
80-130 mg/dL
Random or postprandial ADA
<180 mg/dL
can target bedtime glucose: 90-150 mg/dL
When to do self-monitoring blood glucose:
Intensive insulin regimens: prior to meals + at bedtime; prior to snacks/activity; postprandially; suspicion of hypoglycemia and after treatment
Basal insulin +/- non-insulin meds: once daily
Non-insulin regimens: as needed
Continuous glucose monitoring can
Decrease hypoglycemia and improve A1C readings
ADA target for A1C
<7%; consider <6% in individual pts + pregnant women
When to measure A1C
Twice a year if meeting treatment goals
Quarterly if therapy has changed or not meeting treatment goals
