Lecture 15: Diabetes in Special Populations Flashcards
Diabetes in Pregnancy - maternal risk
retinopathy
- dilated eye exam before pregnancy or ___ trimester
pre - ___
- ____ 81-150 mg/day starting at ___ weeks, if no contraindications
- 1st
eclampsia - aspirin, 12-16
macrosomia - a baby who’s much larger than avg weight ( > ___ lbs ___ oz)
8, 13
Diabetes in Pregnancy - Fetal Risk
- spontaneous abortion
- fetal anomalies
- pre-eclampsia
- fetal demise
- macrosomia
- neonatal ____
- hyperbilirubinemia
- neonatal ___ distress syndrome
- hypoglycemia
- respiratory
goal A1C pre-conception is < ___ %
6.5%
Glycemic Targets in Pregnancy
- FBG: ___ - ___ mg/dL
- 1 hr post prandial: ___ - ___ mg/dL
- 2 hr post pradial: ___ - ___ mg/dL
- A1C < ___ %, ideally , ___ % if necessary to prevent hypoglycemia
- use ___ when possible
- 70-95
- 110-140
- 100-120
- 6%, 7%
- CGM
Changes to insulin physiology during pregnancy
- early pregnancy: insulin sensitivity is enhanced and ___ can ensue (especially in pts with type ___ DM)
- by ___ weeks, insulin resistance increases and total daily insulin dose increases about ___ % per week through week ___
- may need ___ times pre-prandial
- insulin requirement levels off in ___ trimester with ___ aging
- a rapid reduction in insulin requirements may mean development of ___ insufficiency
- hypoglycemia, 1
- 16 weeks, 5%, 36
- 2-3
- 3rd, placental
- placental
Treatment in Pts with Diabetes Pre-Pregnancy - Type 1
- increased risk of hypoglycemia during ___ trimester
- changes in counterregulatory hormones during pregancy may decrease ___ awarness
- pregnancy is a ___ state, increasing risk of DKA ( ___ should be prescibed)
- DKA can increase ___
- insulin sensitivity ___ with delivery of the placenta and returned to pre-pregnancy levels at ___ weeks
- 1st
- hypoglycemia
- ketogenic, ketone test trips
- stillbirths
- increases, 1-2
Treatment in Pts with Diabetes Pre-Pregnancy - Type 2
- BP Target ___ - ___ /____ mmHg
- pregnancy loss is more common in ___ trimester vs ___ trimester in T1DM
- often require ___ insulin doses during pregnancy
- like T1DM, insulin requirements will ___ significanctly after delivery
110-135/85
3rd, 1st
high
drop
Treatment in Gestational Diabetes
Insulin is preferred
- starting dose ___ - ___ units/kg/day
- divide dose between basal-bolus insulins
0.7-1
Treatment in Gestational Diabetes
Metformin can be used if pts cannot take insulin
- ___ the placenta
- may be associated with ___ birth
- if taking for PCOS to induce to induce ovulation, discontinue by end of ___ trimester
- crosses
- pre-term
- 1st
Treatment in Gestational Diabetes
avoid glyburide/glipizide because ___ and birth injury can occur
macrosomia
Gestational Diabetes Post-Partum
- GDM associated with increased risk for diabetes at ___ - ___ % after 15-25 years
- in pts with GDM and prediabetes, lifestyle changes and metformin decrease progression by ___ - ___ % over 10 years
Postpartum
- check OGTT ___ - ___ weeks
- check for diabetes every ___ - ___ years
- 50-75%
- 35-40%
- 4-12
- 1-3
Diabetes in Pediatic Populations
T2DM in youth is different from T2DM in adults
- more rapid decline in ___ function
- accelerated development of diabetes complications
- target goals are similar to adults with A1C < ___ %
- B-cell
- 7%
Diabetes in Pediatic Populations
T1DM
- treatment: ___
- ___ preferred for most pts
- use of ___ important for control
- insulin
- pump
- CGM
Diabetes in Pediatic Populations
T2DM
- not common for < ___ yo
- A1C < 8.5%: ___ is the initial treatment, based on ___ function
- A1C > or = 8.5, BG > or = ___ mg/dL without acidosis who are symptomatic: ___ + metformin is initial treatment
- if not controlled in both of these, initiate ___
- if not controlled on these 3, inititate ___
- 10 yo
- metformin, renal
- 250 mg/dL
- basal insulin
- GLP-1
- bolus insulin
Diabetes in Pediatic Populations - T2DM
GLP-1 may be used in children >/= age ___
the 2 GLP-1s that can be used:
- 10
- liraglutide
- exenatide
Diabetes in Pediatic Populations - T2DM
if pts present with ketoacidosis, treat with ___ or ___ insulin
- add ___ later
SQ, IV
- metformin
Diabetes in Pediatic Populations - T2DM
other medications have not been FDA approved in youth, but are being studied (2)
- SGLT2
- DPP-4
Diabetes in older pts
if pts dont have long life expectancy, you dont need to treat aggressively.
- shift focus from A1C to avoiding ___ and ___
hypoglycemia, hyperglycemia
General Standards of care for hospitals
initiate insulin for glucose >/= ___ mg/dL, then target ___ - ___ mg/dL
- may use a target of ___ - ___ mg/dL or ___ - ___ mg/dL if it can be done without hypoglycemia
- can target glucose > ___ mg/dL in terminally ill pts
180 mg/dL , 140-180 mg/dL
- 110-140 mg/dL, 100-180 mg/dL
- 250 mg/dL
General Standards of care for hospitals
T or F: tight glycemic control in the hospital has been shown to increase rates of hypoglycemia 10-15 fold, leading to increased mortality
True
Monitoring of Pts
- if pt is eating, check ___ readings
- if pt is not eating, check every ___ hours
- if pt is on IV insulin, monitor every ___ min to ___ hours
- pre-prandial
- 4-6 hrs
- 30 min, 2 hrs
T or F: CGM use is not FDA approved for inpatient settings, but becoming more common after COVID
True; Dr. Kania said that they are using them bc its easier
Treatment
- ___ is preferred for noncritically ill hospitalized pts along with use of ___ factor
- use of ___ is discouraged
- for critical care pts, use ___ insulin
- in some cases, may be able to continue ___ diabetes medication. metformin or SGLT2s may be held and resumed just before or at discharge
- bolus
- correction
- sliding scale
- non-insulin
Hypoglycemia
- treatment regimens should be altered when glucose falls < ___ mg/dL
- focus on prevention: dosing errors, timing of doses/eating, ___ leading to hypoglycemia
- 70 mg/dL
- AKI
Glucocorticoids
- short-acting glucocorticoids like ___, reach peak plasma levels in ___ hours but have effects through out
- morning dose = ___ during the day, but nighttime levels are nearly back to baseline
- adjust ___ insulin or add AM ___ dose
- long-acting glucocorticoids like ___ may mean ___ insulin may need adjustment
- prednisone, 4-6
- hyperglycemia
- prandial, NPH
- dexamethasone, long-acting
Perioperative
- A1C target for elective surgery is < ___ %
- target BG of ___ - ___ mg/dL during perioperative period, within ___ hours of surgery
- reduce basal insulin the evening before surgery by ___ %
- hold all bolus insulin once the patient becomes ___
- ___ should be held on the day of surgery
- ___ should be held 3-4 days before surgery
- hold other oral glucose lowering medications ___ of surgery
- give half of ___ dose or ___ % of ___ acting insulin or ___ basal insulin, the morning of surgery
- monitor glucose at least every ___ hours while pt is ___ and dose with ___ acting insulin prn based on correction dosing
- 8%
- 100-180 mg/dL , 4 hrs
- 25%
- NPO
- metformin
- SGLT2
- morning
- NPH, 75-80%, long, pump
- 2-4 hrs, NPO, short
