Lecture 15: Diabetes in Special Populations

Question 1

Diabetes in Pregnancy - maternal risk

retinopathy
- dilated eye exam before pregnancy or ___ trimester

pre - ___
- ____ 81-150 mg/day starting at ___ weeks, if no contraindications

Answer 1

• 1st
  eclampsia
• aspirin, 12-16

Question 2

macrosomia - a baby who’s much larger than avg weight ( > ___ lbs ___ oz)

Answer 2

8, 13

Question 3

Diabetes in Pregnancy - Fetal Risk

• spontaneous abortion
• fetal anomalies
• pre-eclampsia
• fetal demise
• macrosomia
• neonatal ____
• hyperbilirubinemia
• neonatal ___ distress syndrome

Answer 3

• hypoglycemia
• respiratory

Question 4

goal A1C pre-conception is < ___ %

Answer 4

6.5%

Question 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

Answer 5

• 70-95
• 110-140
• 100-120
• 6%, 7%
• CGM

Question 6

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

Answer 6

• hypoglycemia, 1
• 16 weeks, 5%, 36
• 2-3
• 3rd, placental
• placental

Question 7

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

Answer 7

• 1st
• hypoglycemia
• ketogenic, ketone test trips
• stillbirths
• increases, 1-2

Question 8

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

Answer 8

110-135/85
3rd, 1st
high
drop

Question 9

Treatment in Gestational Diabetes

Insulin is preferred
- starting dose ___ - ___ units/kg/day
- divide dose between basal-bolus insulins

Answer 9

0.7-1

Question 10

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

Answer 10

• crosses
• pre-term
• 1st

Question 11

Treatment in Gestational Diabetes

avoid glyburide/glipizide because ___ and birth injury can occur

Answer 11

macrosomia

Question 12

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

Answer 12

• 50-75%
• 35-40%
• 4-12
• 1-3

Question 13

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 < ___ %

Answer 13

• B-cell
• 7%

Question 14

Diabetes in Pediatic Populations

T1DM
- treatment: ___
- ___ preferred for most pts
- use of ___ important for control

Answer 14

• insulin
• pump
• CGM

Question 15

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 ___

Answer 15

• 10 yo
• metformin, renal
• 250 mg/dL
• basal insulin
• GLP-1
• bolus insulin

Question 16

Diabetes in Pediatic Populations - T2DM

GLP-1 may be used in children >/= age ___

the 2 GLP-1s that can be used:

Answer 16

• 10
• liraglutide
• exenatide

Question 17

Diabetes in Pediatic Populations - T2DM

if pts present with ketoacidosis, treat with ___ or ___ insulin
- add ___ later

Answer 17

SQ, IV
- metformin

Question 18

Diabetes in Pediatic Populations - T2DM

other medications have not been FDA approved in youth, but are being studied (2)

Answer 18

• SGLT2
• DPP-4

Question 19

Diabetes in older pts

if pts dont have long life expectancy, you dont need to treat aggressively.
- shift focus from A1C to avoiding ___ and ___

Answer 19

hypoglycemia, hyperglycemia

Question 20

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

Answer 20

180 mg/dL , 140-180 mg/dL
- 110-140 mg/dL, 100-180 mg/dL
- 250 mg/dL

Question 21

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

Answer 21

True

Question 22

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

Answer 22

• pre-prandial
• 4-6 hrs
• 30 min, 2 hrs

Question 23

T or F: CGM use is not FDA approved for inpatient settings, but becoming more common after COVID

Answer 23

True; Dr. Kania said that they are using them bc its easier

Question 24

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

Answer 24

• bolus
• correction
• sliding scale
• non-insulin

Question 25

Hypoglycemia

• treatment regimens should be altered when glucose falls < ___ mg/dL
• focus on prevention: dosing errors, timing of doses/eating, ___ leading to hypoglycemia

Answer 25

• 70 mg/dL
• AKI

Question 26

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

Answer 26

• prednisone, 4-6
• hyperglycemia
• prandial, NPH
• dexamethasone, long-acting

Question 27

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

Answer 27

• 8%
• 100-180 mg/dL , 4 hrs
• 25%
• NPO
• metformin
• SGLT2
• morning
• NPH, 75-80%, long, pump
• 2-4 hrs, NPO, short