Lecture 25: DM Screening/Mgmt, Part 1 Flashcards
What are the S/S in DM usually caused by?
- Hyperglycemia
- Hyperosmolality
- Glycosuria
What are the 3 polys found in T1DM?
- Polyuria
- Polydipsia
- Polyphagia
What are the S/S of T1DM?
- 3 Polys
- Weight LOSS
- Postural hypotension
- Weakness
- Blurred vision (exposure of lens to hyperosmolar fluids)
- Peripheral neuropathy (neurotoxicity)
- Skin (dry, itchy, poor wound healing)
- Severe: Dehydration and ketoacidosis
What geographic factor increases T1DM risk?
Further distance from equator.
How does T2DM presentation onset vary from T1DM?
T2DM is more insidious in onset and has minimal S/S.
What S/S differ between T2DM and T1DM?
- T2DM: weight gain
- T2DM: Acanthosis nigricans
- T2DM: No polyphagia
Why is delivering a baby with large BW associated with T2DM risk?
High BW often implies that the mother had a high level of glucose.
Could be caused by mother with gestational diabetes.
What are the S/S of hypoglycemia caused by?
- Increased epi
- Decreased CNS levels of glucose
What serum level of glucose is typically seen in hypoglycemia S/S?
Usually < 60-70 mg/dL
What 4 types of patients should be routinely screened for prediabetes/DM?
- Anyone over 45y.
- Any obese/overweight pt with 1+ risk factor
- Gestational DM: 1st prenatal visit if risk factors present, otherwise 24-28 weeks.
- HIV+ pts on ART.
What tests can be used to screen for DM?
- HbA1c (not preferred for T1DM check)
- FPG
- 2 hr PG post 75g OGTT (least common but most accurate)
If a patient presents with a FPG of 150 mg/dL but no S/S, what is the next step?
Repeat to confirm.
What are the cutoffs for diabetes for FPG, 2 hr PG, and HbA1c?
- FPG: > 126 mg/dL
- 2 hr PG: > 200 mg/dL
- HbA1c: > 6.5%
What are the two types of samples we can obtain BG from?
- Plasma: 10-12% higher than whole blood
- Whole blood/capillary (aka fingersticks)
What kind of samples/sites may increase BG readings?
- Plasma samples are 10-12% higher.
- Arterial samples are 3-5 mg higher than venous.
Ideal is venipuncture
How does low hematocrit < 40% affect BG readings?
Elevates it.
What can decrease a BG reading?
- Acetaminophen
- Alcohol
- High uric acid levels
- Hct > 50%
What diseases might result in high BG?
- Cushing’s
- Pheo
- Pancreatitis
- Chronic renal failure
What diseases might result in low BG?
- Excess insulin
- Hypopituitarism
- Liver disease
- Addison’s
What does HbA1c represent?
Glycosylated HbA1, which is a subtype of HbA.
Generally averages the past 8-12 weeks, with emphasis on past 4.
When is HbA1c diagnostic for diabetes?
> 6.5% twice.
6.5 donuts
What can generally cause false lows of HbA1c?
- Hemoglobinopathies such as SCD (high HbF)
- “Young” RBCs
- Low protein levels
What can generally cause false elevations of HbA1c?
- Old RBCs: splenectomy
- Stress
What is the target A1c level for diabetics per the ADA?
7.0%
Higher is considered uncontrolled.
What is normal A1c?
< 5.6%
When is OGTT indicated?
- Assist with DM diagnosis
- Assist with hypoglycemia evaluation
How is an OGTT performed?
75g in 300 mL given to pt.
PG measured periodically.
Ideally done in the AM.
Peds get weight based dose.
What special considerations must be considered for an OGTT?
- Low-carb diets can interfere with insulin release. (need to eat 150g for 3 days prior to fix)
- Avoid PA and smoking until OGTT is done.
What is a normal glucose reading at 2 hrs post OGTT? Diabetic reading?
- < 140 mg
- > 200 mg
When is a C-peptide or C-peptide/Insulin ratio test indicated?
- Evaluation of beta-cell function
- Identify causes of hypoglycemia
- Evaluation of insulinomas
What is C-peptide?
Peptide found in preproinsulin and proinsulin. Only found from endogenous insulin.
Why is a C-peptide test sometimes preferred over serum insulin?
C-peptide has a long half-life and is more stable.
When is measuring C-peptide helpful?
- Anti-insulin antibodies
- Factitious hypoglycemia
- Exogenous insulin
- Unknown if T1 or T2.
What could increase C-peptide artificially?
- Renal failure
- Sulfonylureas
- Pancreas transplant
What C-peptide/insulin ratio suggests DM?
- Low C-peptide
- Low insulin
What C-peptide/insulin ratio suggests sulfonylurea use or chronic renal failure?
- High C-peptide
- High insulin
What insulin autoantibody is most useful in diagnosing childhood T1DM?
Insulin autoantibody (IAA)
Why are ketones measured for diabetics?
Checking if someone is in ketosis.
Urine or serum
What are the 3 ketone bodies that result in acidosis? MC?
- Acetone
- Acetoacetate
- Beta-hydroxybutyrate (MC for DKA)
Beta-hydroxybutyrate cannot be checked via urine ketone test!!!
What serum ketone level is concerning?
> 3 mmol
What are the general goals of treating DM?
- Achieving glycemic control.
- Reducing/eliminating long-term complications.
- Maintain quality of life (DSMES).
Diabetes Self Management Education and Support
What are the BG glucose targets for DM?
- HbA1c < 7.0%
- FBG: 80-130
- Postprandial: < 180
What are some of the hypoglycemic management guidelines?
- Carry glucose tablets
- If unconscious, IV glucose or nasal glucagon
- If persistent, re-evaluate therapy
How often is Self-monitoring of BG (SMBG) used?
- T1DM: 3+ times a day
- T2DM: 1-2 times a day
What is the recommended general diet of someone with DM?
- Low-carb
- Hypocaloric
- Aim for 500-700 kcal deficit daily if overweight
High protein can be dangerous in diabetic neuropathy.
What kind of exercise is recommended for DM?
Moderate (50-70% max HR) aerobic exercise.
When is pneumococcal vaccination recommended for DM pts?
PCV20 for anyone 2+.
What is first-line pharmacotherapy for a DM patient with risk of HTN?
ACEI or ARB
Aiming for < 130/80
When is enteric coated baby ASA indicated for DM pts?
Clinical ASCVD or > 10% ASCVD 10-year risk.
Cannot have any condition for increased bleeding risk.
How do we check nephropathy in DM pts?
- Urinary albumin
- eGFR
If a DM patient presents with proteinuria, what is the first-line pharmacotherapy?
ACEI or ARB.
What are the guidelines for retinopathy monitoring in diabetics?
- T1DM: dilated + comprehensive within 5 years of Dx.
- T2DM: dilated + comprehensive at time of Dx.
- Evidence of retinopathy: Dilated exam every year.
How do you check for neuropathy in diabetics?
- Diabetic Foot Exam (ANNUAL)
- Monofilament testing
- 2nd neuro sensation test
What medication may be used to prevent the progression of prediabetes? What are the indications?
Metformin.
- BMI > 35
- Age < 60y
- Hx of gestational diabetes
What should be encouraged regarding T1DM and eating?
They need to eat consistently!
