PCore Diabetes Flashcards
0
Q
Who to screen for diabetes and prediabetes
A
ppl age 45 and above
esp if bmi >= 25 (obese)*
may not be true for all ethnic groups PCOS (polycystic ovarian syndrome)
1
Q
Diabetes fasting glucose
A
126 mg/dL
2
Q
Screening people < 45 if one or more additional risk factor
A
- habitually physically inactive
- part of high risk ethnic group (african americans, latino, Native American, asian american, Pacific Islander)
- had baby weighing > 9 pounds or dx with gestational diabetes mellitus
- had impaired fasting glucose or impaired glucose tolerance on previous testing
- other clinical conditions assoc w insulin resistance acanthosis nigricans
- family hx (1st degree relative)
- PCOS
- HDL < 35 mg/dL or triglycerides > 250 mg/dL
- hx of vascular dz
- hypertensive (>= 140/90)
3
Q
Diagnosing diabetes based on Hg A1c
A
dx can be made based on elevated value
–> comparable in screening utility to fasting glucose and 2-hr 75 g glucose tolerance testing
a1c >= 6.5% : diagnostic for diabetes; test result must be repeated on subsequent day to rule out lab error, unless dx is evident on clinical grounds (hyperglycemia crisis for ex)
a1c 5.7-6.4% : diagnostic for pre-diabetes; test must also be repeated
4
Q
Pros and cons of using A1c to dx diabetes
A
pros: convenience over fasting glucose testing and 2 hr oral glucose tolerance test; no need to fast; less subject to daily fluctuations during periods of stress or illness;
cons: cost, limited availability in certain parts of world, race and age variability, inability to use in pts w certain anemias and hemoglobinopathies (eg sickle cell dz)
5
Q
Fasting plasma glucose to dx diabetes
A
- children and non pregnant adults
pros: easier to admin, acceptable to pts, costs less than oral glucose tolerance test
fasting: no calorie intake for >= 8 hrs
diabetes: fgp >= 126 mg/dL dx pts with diabetes!
pre-diabetes: >= 100 and < 126 ; impaired fasting glucose = elevated fasting plasma glucose
dx of prediabetes or diabetes must be repeated and confirmed on sepearate day unless sx of diabetes present
6
Q
Oral glucose tolerance test (OGTT)
A
75 g oral glucose tolerance test more sensitive, slightly more specific than FPG
cons: poorly reproducible, more $$$, inconvenient for patients, rarely used in clinical practice
diabetes: plasma glucose >= 200 mg/dL drawn 2 hrs post OGTT
pre-diabetes: *impaired glucose tolerance >= 140 and < 200 mg/dL) after 75 g oral glucose load on ogtt in presence of fpg concentration < 126 mg/dL
7
Q
Random / casual plasma glucose dx diabetes
+
A
any time of day regardless of last meal
if > 200 mg/dL + classic symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) makes dx and does not need to be repeated on subsequent day!
8
Q
Confirming dx with multiple screening tests in same person
A
- use same screening test in same person for confirmation
- if two diff screening tests used in same pt: if both tests reach diagnostic threshold, then dx can be confirmed at that time (even if both are initial screens)
- if 2 tests discordant, the test that is above threshold should be repeated and dx made based on confirmed test
9
Q
Criteria to test children for t2dm
initiate age 10 yrs or at onset of puberty (if puberty occurs at younger age);
repeat every 2 yrs
test used: fasting plasma glucose
A
overweight (bmi > 85th percentile for age and sex; weight for height > 85th percentile, or weight > 120 % of ideal for height)
+
any 2 of following risk factors:
- fam hx t2dm in 1st or 2nd degree relative
- race/ethnicity (Native American, african american, latino, asian american, Pacific Islander)
- signs of insulin resistance or conditions associated w insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or PCOS)
- maternal hx diabetes or gdm
10
Q
When to screen women postpartum with gdm
A
6 wks - 12 wks postpartum
should be followed up with subsequent screening for devt of diabetes or pre-diabetes
11
Q
Preventing diabetes progression in ppl at high risk or those with pre-diabetes
A
insulin secretion may be adequeate to maintain fasting blood glucose levels < 126 mg/dL but process of insulin resistance already present
modest weight loss and increasing phyiscal activity can reduce risk of diabetes by 50%
12
Q
Patients with IFG and IGT prediabetes and any of the following…
A
< 60 yrs age bmi >= 35 kg/m2 fam hx diabetes in 1st deg relative elevated triglycerides, reduced hdl htn a1c > 6%
in addition to lifestyle modification: metformin (850 mg 2x/day)
no other meds recommended for this group yet
13
Q
Prevention in pts with IFG or IGT prediabetes (ADA recommendations) and no other significant risks or categorizations (in another slide)
A
- lifestyle modification (5-10% weight loss and moderate intensity physical activity about 30 min/day)
2.
14
Q
Followup in pts with ifg/igt being treated with metformin
A
a1c: semi annually in ppl with ifg/igt being treated with metformin
assess and treat for other cardiovascular risk factors (hyperlipidemia, htn, tobacco use)
counsel for lifestyle modification
15
Q
follow up pts with ifg/igt not being treated with metformin
A
a1c: annually screen
assess and treat for other cardiovascular risk factors: hyperlipidemia, htn, tobacco use)
counsel for lifestyle modification
16
Q
Signs and symtpoms undiagnosed diabetes
A
most are asymptomatic!!!!
undiagnosed gluocse intolerance and perisistent hyperglycemia can eventually –> classic polydipsia, polyuria, fatigue, weight loss, blurry vision
other signs: obesity, evidence of metabolic syndrome or cardiovascular dz
17
Q
Assess risk factors for atherosclerosis
A
smoking, htn, obesity, dyslipidemia, fam hx
18
Q
Laboratory evaluation patients with diabetes risk or diabetes
A
a1c
fasting lipid profile: total cholesterol, hdl, triglycerides, LDL
microalbuminuria in t1dm pts who had diabetes for >= 5 yrs and in all patients with t2dm (some advocate testing pubertal children sooner than 5 yrs of diabetes)
serum creatinine in adults (children if proteinuria present)
TSH in all t1dm; t2dm if indicated
ekg in adults if clinically indicated
urinalysis for ketones, protein, sediment
19
Q
REcommendations to diabetic patients in managing brief illnesses (viral syndromes)
A
- continue taking medications
- check sugars more frequently (every 2-4 hrs)
- check ketones (every 4 hrs)
- drink lots of non-caffeinated fluids
call dr if cant hold down fluids or carb intake for > 6 hrs, cant eat regular food for one day, develop intractable heavy vomiting or diarrhea, drowsiness or recurrent hypoglycemia
20
Q
Complications in diabetes: Hypoglycemia
symptoms and plan
A
causes: taking too much diabetes medicine, missing a meal or snack, exercising too much, drinking alcohol
signs: feeling weak or dizzy; nervous, shaky, or confused; irritability; sweating more; noticing sudden changes in heartbeat; feeling very hungry; losing consciousness; develop seizures
plan: test blood glucose; if <= 70 mg/dL, eat one of the following right away:
2-3 glucose tablets; 1/2 cup (4 oz) any fruit juice, 1/2 cup regular non diet soft drink; 1 cup milk; 5-6 pieces hard candy; 1-2 teaspoons of sugar or honey
check blood glucose again 15 minutes after glucose intake
21
Q
Complications in diabetes: hyperglycemia
symptoms
A
causes: forgetting to take medicine on time, eating too much and getting too little exercise; being ill can also raise blood glucose levels
symptoms: frequent hunger; frequent thirst; frequent urination; blurred vision; fatigue; weight loss; poor wound healing
22
Q
Risk factors for depression in diabetic patients include
A
age >65; previous hx depression; unmarried; female; poor physical health; poor mental health
23
Q
Diabetes self-mgmt education programs (dsme)
A
diabetes care; skill based; pt centered; longitudinal
better outcomes
24
When to test glucose if pt is NOT on insulin if pt has new dx of diabetes, recent therapy adjustment, or glucose level outside of target
3x/day:
- before breakfast
- before main meal of day
- 2 hrs after start of main meal
25
When to test glucose if pt is NOT on insulin and glucose in target range
3x/day every 3rd day
26
When to test glucose if ON insulin
--> taking basal and bolus (meal-associated) insulin
test 4x/day:
- before breakfast
- mid-morning
- mid to late afternoon
- mid evening
27
When to test glucose if ON insulin
--> taking basal insulin only
test fasting glucose daily and perform other pre and post meal tests intermittently
28
In all diabetic pts takiing or not taking insulin, test:
1. whenever suspecting hypoglycemia
2. before driving if having trouble sensing hypoglycemia
dont forget to reassess self-monitored blood glucose skills periodically (esp if glucometer #s dont correspond to hga1c levels)
29
Hemoglobin A1c
patients average glycemic levels over past 2-3 months
without diabetes: 4-6% (4-6% of a non diabetic persons hemoglobin has nonenzymatically attached glucose)
30
HOw often to check A1c
patients whose therapy has changed recently: quarterly
patients not meeting glycemic control: quarterly
patients at glycemic control: 2x/yr
31
Effects of Lowering A1c levels in diabetes...
reduce neuropathic and microvascular complications
32
ADA recommendations to target goals for A1c and self-monitored blood glucose levels
hga1c for diabetic patients: < 180 mg/dL
33
Glycemic target goals american assoc clin endocrinologists
hgba1c: < 6.5%
premeal glucose < 110
postmeal glucose 140 mg/dL (2 hours)
34
Glycemic target goals international diabetes center
Hgba1c < 7%
premeal glucose 70-140
postmeal glucose <160 mg/dL (2 hrs)
35
Glycemic target goals american diabetes association
Hgba1c < 7%
premeal glucose 90-130 mg/dL
postmeal glucose < 180 mg/dL (1-2 hrs)
36
Medical nutrition therapy with registered nutritionist
can reduce a1c in newly diagnosed t2dm by 2% and by 1% with t2dm for 4 or more years
overall goals:
- prevent and manage chronic complications
- improve gneeral overall health thru food choices and physical activity
- achieve and maintain optimal metabolic outcomes
- address individual needs
focus: wt mgmt, carb counting, reduced dietary fat
37
Weight mgmt
strong link bw obese or overweight status and diabetes
obesity: independent risk factor for hyperlipidemia, htn, and cardiovascular dz
38
ADA recommendations of weight mgmt
- decrease in 500-1000 kcal/day will allow slow progressive wt loss of 1-2 lbs/week
- wt loss diets should supply 1000-1200 kcal/day for women and 1200-1600 kcal/day for men
- drug therapy for obesity may be appropriate to reduce wt in selected patients but lifestyle modifications still important
- severely obese pts: gastric bypass or gastroplasty may be appropriate alternative and can --> reduce doses or discontinuation of diabetes meds
39
Carb counting possible benefits
limit hyperglycemia
improve weight loss
reduce insulin resistance
prevent complications of diabetes
15 carbs = 1 carb "choice"
c""
40
International diabetes center recommended food plan
women
weight loss: 2-3 choices/meal
maintain wt: 3-4 choices/meal
for v active person: 4-5 choices/meal
men
weight loss: 3-4 choices/meal
maintain wt: 4-5 choices/meal
v active person: 4-6 choices/meal
41
Low carb diets not recommended for diabetic patients!
restricting carbs <130 grams/day may be below brain, nervous system, and other metabolic requirements
42
Dietary fat
total fat :
25-35% of total calories
saturated and tras fatty acids = principal dietary factors of LDL cholesterol (a major factor in cardiovascular dz)
43
Alcohol
not recommended but those who drink:
women: 1 or less/day
men: 2 or less/day
drink = 12 oz beer, 5 oz wine, 1.5 oz distilled spirits
44
PHysical activity benefits
reduce risk of cardiovascular dz, reduce insulin resistance, assist in wt reduction, assist in wt mgmt
45
Aerobic activity
moderate intensity: achieve 50-70% maximum heartrate
| vigorous aerobic exercise: > 70% max heartrate
46
Exercise recommendations
moderate intensity: >= 150 min/wk distributed over 3 days w no more than 2 days consecutively w out activity
vigorous intensity: >= 90 mins/wk over 3 days w no more than 2 consecutive days w out activity
47
Resistance activity
recommended! at least 3x/wk unless contraindication
resistance training improves insulin sensitivity just as well as aerobic activity
48
Cardiac stress testing before exercise
patients whose 10 yr risk of coronary event is >= 10%
stress test with EKG considered prior to beginning aerobic activity exceeding demands of everyday living
49
Exercise in presence of long term complications of diabetes
diabetic patients with retinopathy, peripheral neuropathy, autonomic dysfunction may need more individualized exercise recs
50
Metformin overview
increases insulin sensitivity more than sulfonylureas or insulin
(lower levels of insulin ahcieve same level of glycemic control)
less likely to see weight changes
51
7 classes of oral agents for diabetes
Secretagogues:
1. 1st generation sulfonylureas
2. 2nd generation sulfonylureas
3. meglitinide
4. d-phenylalanine
Insulin sensitizers:
5. biguianides
6. thiazolidinediones
7. alphaglucosidase inhibitor:
52
Secretagogues
allow pancreas beta cells to secrete insulin in response to glucose challenge
--> useful in patients with insulin deficiency
common side effects: hypoglycemia, weight gain, mild gastrointestinal complaints, rarely skin rxns, photosensitivity, and cholestatic hepatitis
most secretagogues contraindicated in pregnancy!
used with caution in pts with liver dz and renal dz (except repaglinide and nateglinide which dont have renal dosage reqs)
secretagogues: 1st and 2nd gen sulfonylureas, meglitinides, and d-phenylalanine derivatives
53
First and Second generation sulfonylureas
sulfonylureas bind to sulfonylureas receptors on beta cells which stimulate insulin secretion or sensitize beta cells to presence of glucose
2nd gen: more commonly prescribed than 1st gen; fewer side effects than 1st gen
a1c can decrease as much as 2.3% w sulfonylureas
most patients: begin w low dose of sulfonylurea and increase them at 1-2 wks intervals depending on self monitored glucose readings and a1c results
*once daily preps available*
as t2dm progresses, beta cells secrete less insulin and thus sulfonylureas will not be able to optimize glucose levels by themselves;
most clinicians dont d/c but add insulin sensitizers
54
Meglitinides
| repaglinide
```
rapid acting, short duration insulin secretagogues
repaglinide is only approved drug in class in US
```
as effective as a sulfonylurea
take before each meal and with any bedtime snacks
pro: allows patients flexibility to skip a dose if meal is skipped (prevents hypoglycemia)
con: pt must take several times a day for effectiveness
not contraindicated in renal insufficiency
55
D-phenylalanine derivatives
| nateglinide
faster acting and shorter duration than meglitinides (rapaglinide)
nateglinide is only member
can be used in patients with renal insufficiency
pro: useful in patients found to have optimal fasting glucose levels but high post-prandial glucose levels
con: take several times a day
56
INsulin sensitizers in non-diabetics
possible use for delaying t2dm in pts with insulin resistance, glucose intolerance (pre-diabetes), or have high risk for diabetes
used in pts with PCOS (carries component of insulin resistance)
57
Biguanides
metformin
INsulin sensitizers
decrease gluconeogenesis from liver
increases glucose uptake into muscle tissues
enhances basal metabolic rate
may lower food intake bc of its gastrointestinal side effects
do not: stimulate insulin secretion from pancreas
exact mxn of action not well understood
indications: pts with insulin resistance; good consideration in those with cholesterol issues
*only metformin in US*
can reduce a1c by 2% and fasting glucose levels by 60 mg/dL
can decrease or stabilize patient weight, can reduce cholesterol and triglyceride levels, and may reduce myocardial infarction risk
metformin should be started slow and low
500 mg dose start (at dinner) ; additional dose can be added to breakfast after 1 wk
(higher dose tablets and extended release tablets available)
* data shows most clinically effective dose: 2000 mg/day*
caution: those with liver dz, active pulmonary or cardiac dz; contraindicated in men with cr > 1.5 mg/dL or women with cr > 1.4 mg/dL ; withold prior to any radiology study requiring contrast dye or if going to surgery; restore once renal function normal
Metformin is category B drug (no evidence of risk in humans) in pregnancy and breastfeeding
Metformin side effects: flatulence, diarrhea, nausea, metallic taste
58
Thiazolidinediones
| rosiglitazone, pioglitazone
indicated for pts with insulin resistance
insulin sensitizing effect on peroxisome proliferator-activated nuclear receptors in liver cells, adipose tissue, muscle
side effects: mild anemia, weight gain, mild edema due to volume expansion
can be used in pts with renal insufficiency; liver function monitoring recommended periodically while using these drugs;
contraindicated in people with liver disease who have ALT > 2.5 times upper limit of normal; contraindicated in pregnancy; may stimulate ovulation in insulin-resistant anovulatory women
thiazolidinediones contraindicated in pts with class III or IV New YOrk Heart Association functional status
reduction of insulin resistance also reduces blood glucose levels
59
Specifically rosiglitazone risks (controversy)
| further details
assoc with significant increase in risk of myocardial infarction and w increase in risk of death from cardiovascular causes in 1 study
contradictory evidence in other studies...
pts taking rosiglitazone esp known to have underlying heart disease or at high risk of heart attack should talk to pcp about this
60
Carbohydrate absorption delay agents
| alpha glucosidase inhibitors
delay disaccharide and complex carbohydrate absorption in small intestine and allow it to occur instead in large intestine and colon
--> allows improvement of glucose control; does not have same effect on lactose
excellent for: pts w high 2 hr post meal hyperglycemia; can be used in ppl w both insulin resistance and deficiency
*must be used w each meal to be effective*
effects: reduce a1c by .5-1% when combined w other oral agents or insulin
2 alpha glucosidase drugs in US: acarbose and miglitol
side effects: diarrhea, flatulence
start low and slow to prevent these side efx
may cause reversible liver enzyme elevation (alpha glucosidease )
contraindicated in: pts with liver dz, inflammatory bowel dz
pros: do not cause hypoglycemia by themselves but if hypoglycemia develops in conjunction with sulfonylureas or insulin, pt may use milk to correct glucose levels
61
First line therapy acc to ADA
metformin** (most endocrinologists prefer)
thiazolidinediones,
secretagogues (if problem is more pancreatic dysfunction than insulin resistance)
62
Monotherapy vs. Combination therapy for t2dm
50% of pts require a second agent after 3 yrs of monotherapy
1 insulin sensitizer + secretagogue
or
2 insulin sensitizers
consider combo therapy sooner if: pts has a1c>9% before monotherapy has been instituted or a1c>8% after monotherapy tried
triple therapy becoming more common: consider whether these pts actually need insulin instead
63
Normal: basal and post prandial insulin
basal: pancreas constantly secretes basal levels of insulin comprising 50% of bodys requirement
bolus: remaining 50% after meals
(about 50% of t2 diabetics require insulin to keep their a1c < 7%)
64
Types of insulin:
bolus
rapid acting
covers meals
ex: lispro, aspart
lispro (humalog): onset 15 mins, peak 30-90 mins, duration 3-5 hrs
aspart (novolog): onset 15 mins, peak 40-50, duration 3-5 hrs
65
Types of insulin:
bolus insulin
short acting
regular insulin
covers meals
onset 30-60 mins, peak 50-120, duration 5-8 hrs
66
types of insulin
basal insulin
intermediate acting
background
| NPH, lente
67
types of insulin
basal insulin
extended intermediate acting
ultralente
background insulin
onset 4-8 hrs, peak 8-12, duration 36
68
types of insulin
premixed
intermediate acting + short acting
NPH/regular
69
types of insulin
premixed
intermediate acting + rapid acting
NPH/lispro
70
Bolus insulin
covers a meal
| either rapid or short acting
71
rapid acting bolus insulin
take within 15mins before meal
cleared from body in 3-5 hrs
monitor glucose 2 hrs post meal to make adjustment in dose
allows for: flexibility; pts can exercise at any time
postprandial glucose levels: tend to be lower in rapid acting than with short acting insulin
good choice for: ppl who dont snack throughout day,
72
short acting bolus insulin
better for pts who frequently delay eating after an injection or eat throughout the day
onset of action: 30 -60 mins
cleared from body in 5-8 hrs
73
basal insulin
| intermediate acting
covers baseline insulin needs of body
intermediate acting: NPH, lente
short duration of action
act quickly
NPH: onset 1-3 hrs, peak 8 hrs, duration 20 hrs
or : onset 1-2.5 hrs, peak 7-15 hrs, duration 18-24 hrs
74
types of insulin
basal insulin
long acting
glargine
background insulin
onset 1 hr, peak none, duration 24 hrs
75
basal insulin
| extended intermediate acting
ultralente
| acts somewhat longer than nph thus extended intermediate acting
76
types of insulin
basal insulin
long acting
```
glargine (brand name lantus)
long acting insulin analogue
formulated for delayed absorption over 24 hours w no peak levels
can be administered once a day
lower risk of hypoglycemia
```
cannot be mixed in same syringe w other insulin types!
usually used in conjunction w bolus insulin
77
types of insulin
| intermediate and short acting mixtures
onset, peak, and duration of action reflect composite of intermediate (NPH) and short (regular) or rapid (lispro, aspart) acting components
but ONE peak of action
78
INsulin regimens: basic insulin regimens
candidates: use for pts with 2 or more of following:
consistent schedule, regular mealtimes, < 10hours bw breakfast and dinner, not prepared to take multiple injections, unable to mix or measure insulin
79
rapid acting + NPH
| basic insulin regimen
use for pts who choose not to snack; consider when post meal hyperglycemis is present
AM: rapid acting + NPH
PM: rapid acting
bedtime: NPH
80
rapid acting + NPH premix pen
| basic insulin regimen
use premixed pen as easier way to start insulin or if unable to measure/mix: use for pts who choose not to snack; consider when post meal hyperglycemia is present
AM: rapid actig, NPH (pen)
PM: rapid acting, nph (pen)
bedtime: nothing
81
nph + regular
| basic insulin regimen
use for pts who choose to snack; may be cheaper than rapid acting + nph
am: regular, nph
pm: regular
bedtime: nph
82
nph + regular premix pen
| basic insulin regimens
use premixed pen as easier way to start insulin or if unable to measure/mix; use for pts who choose to snack; may be cheaper than rapid acting + nph
am: regular, nph (pen)
pm: regular, nph (pen)
bedtime: nothing
83
nph with oral agents
| basic insulin regimens
nph with oral agents
use for type 2 dm w high fasting glucose w or w out subsequent elevated pre meal glucose; continuing biguianides or thiazolidinediones to add glycemic control
am: oral agents
pm: oral agents
bedtime: nph
84
Glargine with oral agents
| basic insulin regimens
use for type 2 dm w high fasting glucose (w or w out subsequent elevated pre meal glucose); continue biguanides or thiazolidinedions to add glycemic control
am: oral agents
pm: oral agents
bedtime: glargine
85
Dosing of premixed insulin w nph and rapid acting component
more expensive but provides better post meal glucose control
| usual starting dose: .3-.5 u/kg/day then --> .7-1.2 u/kg/day
86
Dose of single nighttime glargine
initial dose: .1-.2 u/kg/day
recommended by manufacturer: initial dose of 10
target: morning fasting glucose of < 140 mg/dL
dose can be increased by 2-5 units every 4-7 days until morning fasting glucose has reached target
87
Basic vs advanced insulin regimens
basic: easier for new pts but inflexible and can increase risk of hypoglycemia
advanced: more flexible for pts life demands (exercise regimen, work schedules, meal intake variability)
- -> requires both increased freq of insulin admin and self monitored glucose levels
most advanced regimens: rapid acting insulin + long acting insulin
88
rapid acting + nph or ultralente
| advanced insulin regimens
am: ra+nph or ultralente
noon: ra only
pm: ra+nph or ultralente
bedtime: small dose of nph for some ppl
89
rapid acting + glargine
| advanced insulin regimens
am: ra
noon: ra
pm: ra
bedtime: glargine
90
Insulin dosage for advanced insulin therapy
initial: .4-.5 u/kg/day for pt naive to insulin, moves up to 1-2 u/kg/day
typically half of total goes to bolus dose and half to basal dose
91
Adjusting insulin dosage
always adjust for hypoglycemia first!
if all self monitored glucose levels > 200 mg/dL, then total daily dose of insulin should be increased by .1 u/kg/day
fasting and premeal glucose levels will help adjust basal insulin doses;
2 hr post meal glucose levels help adjust bolus insulin doses:
if current dose is < 10 u: dose can be increased by 1 u if glucose levels high or lowered by 1 u if glucose levels low
if current dose is > 10 u, dose can be increased by 10% if glucose levels high or lowered by 10% if glucose levels low
92
Target glucose levels for rapid acting insulin
achieved when 2 hr post meal glucose level is within 20-40 mg of pre meal glucose level
93
Side effects of injected insulin
lipodystrophy: at sites of injection,
- lipohypertrophy more often in men
- lipoatrophy more often in women
*changing injection sites can prevent this side effect
```
systemic rxns (rare): allergies can develop, varying from urticaria to anaphylaxis
more common in patients with penicillin allergies or atopic dermatitis
also occurs more frequently in pts using insulin intermittently
```
densensitization therapy now available
94
New agents: incretin mimetic agents
incretins = GI hormones
ex: glucagon like peptide 1
released during food intake --> promotes insulin secretion and suppression of glucagon from pancreas
exanetide: 1st drug in this class (incretin mimetic agents)
- improves glucose control by mimicking effects of glucagon like peptide 1 (natural mammalian incretin hormone)
use to treat t2dm in conjunction w metformin and/or sulfonylurea
recommended dosage: 5 mug to 10 mug 2x/day subcutaneously before breakfast and dinner
in RCT: exenatide improved glycemic control and promoted wt loss up to 2.8 kg
most common adverse effects: nausea, vom, diarrhea, dose dependent hypoglycemia
pts should be closely monitored for hypoglycemia, esp when exenatide added to sulfonylurea therapy
good option for: pts who fail to get glycemic control while on maximum dose metformin and/or sulfonylureas
alternative therapy for: pts who cant tolerate other antidiabetic drugs
95
Dipeptidyl peptidase-4 inhibitors
| new medications
dpp-4 is enzyme that normally breaks down and inactivates incretins
hypoglycemic drug!
by inhibiting breakdown of incretins, insulin secretion and glucagon suppression are both enhanced
as blood glucose levels normalize, amts of insulin released and glucagon suppressed diminishes
dpp4 inhibitors less suspectible to severe hypoglycemic episodes than other hypoglycemic meds
*sitagliptin*: first drug to be released in this class
intended for: ppl w t2dm, *contraindicated* in ppl w t1dm or in a state of "diabetic ketoacidosis"
must be used w caution in ppl w renal impairment
other drugs in this class pending approval
96
cardiovascular disease
| Prevention and Management of diabetic complications: cardiovascular disease
major cause of mortality in diabetic patients : cardiovascular disease
major cause of morbidity, direct, and indirect costs
t2dm: independent risk factor for macrovascular disease
common coexisting conditions of t2dm (metabolic syndrome) are also risk factors for macrovascular disease
signs and sx of cvd imp to recognize
97
Hypertension
| prevention and mgmt of diabetes complications
screening and dx: bp taken on diabetic pts at every clinic visit
pts with systolic pressure >= 130 or diastolic bp >= 80 should have bp checked on a diff day to confirm dx of prehtn or htn
goals: bp in diabetics; lower than gen pop
sbp=140 or dbp>=90) : drug therapy + lifestyle modifications (medical nutrition therapy and physical exercise)
2. diabetic patients with pre htn (sbp 130-139 or dbp 80-89) : 3 months lifestyle modifications; if not goal bp then RAAS blocker initiated (ARB, ACEi)
3. all diabetics wtih htn: regimen including ACEi or ARB bc of demonstrated renal protection; additional meds can be added if bp not optimized: diuretics, beta blockers, calciumchannel blockers)
--> most pts w htn need >1 med to optimize bp
4. in t2dm pts with htn and microalbuminuria, ACEi and ARBs delay nephropathy; in t2dm pts w htn and macroalbuminuria, ARBs shown to delay nephropathy; ACEi and ARBs contraindicated in pregnancy!
5. orthostatic bp measurements taken in pts w diabetes and htn to assess for autonomic dysfunction
98
Hyperlipidemia
| prevention and mgmt diabetic complications
screening: higher prevalence of dyslipidemia in pts with t2dm; in adult diabetes screening for lipid disorder recommended annually or more often (to achieve goals)
--> pts with low risk lipid values (LDL50, triglycerides40y: statin initiated to reduce LDL by 30-40% regardless of pts LDL baseline
if =40 and women to HDL >=50
(fibrates may be good option says module; this may change)
combo therapies not shown to decrease cvd at this time but may be needed
99
Antiplatelet agents
| prevention and mgmt diabetes complications
use aspiring thereapy (75-162 mg/day) as primary prevention strategy in t2dm pts at increased cvd risk, including: ppl >40y or who have additional risk factors (fam hx cvd, htn, smoking, dyslipidemia, albuminuria)
consider aspirin therapy in ppl bw 30-40 yrs, esp in presence of other cv risk factors; ppl s syndrome)
combo therapy using other antiplatelet agents (clopidogrel) in addition to aspirin should be used in pts w severe and progressive cvd
other antiplatelet agents may be reasonable alternative for high risk pts with aspirin allergy, bleeding tendency, receiving anti coagulant therapy, recent GI bleed, and clinically active hepatic dz (who are not candidates for aspirin therapy)
100
Smoking cessation
all patients! adivse not to smoke, discuss smoke cessation and treatment
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Coronary heart disease screening and treatment
recommendations from ADA:
pts >55y: w or w out htn, but w another cv risk factor (hx of cvd, dyslipidemia, microalbuminuria, or smoking), ACEi (if not contraindicated) should be considered (reduce risk of cv events)
pts w prior MI or pts undergoing major sx: beta blockers + ACEi considered to reduce mortality
asymptomatic pts: consider risk factor eval to stratify by 10yr risk and treat risk factors
--> pts w decompensated or acute CHF: metformin use contraindicated!
thiazolidinediones assoc w fluid retention; use can be complicated by devt of chf
caution in prescribing tzds in setting of known chf or other heart dz + pts w preexisting edema or concurrent insulin therapy required
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Nephropathy screening and treatment
| prevention and mgmt complications
goals: reduce risk and slow progress of nephropathy; optimize glucose control and bp control
- -> in ppl with any degree of chronic kidney dz, protein intake should be reduced : daily allowance .8g/kg
screening: all t2dm pts should be screened yearly for urine microalbumin (start at dx)
serum cr: measure annually to estimate GFR in all pts w diabetes (regardless of microalbuminuria)
--> dont use serum cr alone to measure renal function but use it to measure GFR and stage true renal function or dysfunction
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Treatment in diabetes (htn and renal)
t2dm:
-pts with htn and microalbuminuria: ACEi and ARB shown to delay progression to macroalbuminuria
- pts with htn and macroalbuminuria: ARBs shown to delay nephropathy
-->ACEi and ARB contraindicated in pregnancy
ADA: recommend continued surveillance of urine microalbumin/protein to assess therapy response and renal dz progression
presence of nephropathy: initiate protein restriction to dihydropyridine-sensitive calcium channel blockers not effective as initial therapy to slow progression of nephropathy and should only be used as adjunct to ACEi or ARB to lower bp
if ACEi, ARB, or diuretics used: check serum K levels (K will be high with ACEi and ARB and aldosterone inhibitors/K sparing; K will be low with loop and thiazide diuretics)
consider referral to renal specialists when GFR falls <60 mL/min or if mgmt of htn or hyperkalemia becomes hard
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DM and CKD
DM may not be cause of CKD in diabetic pt
specific cause of CKD should be investigated fully
term of "diabetic glomerulopathy" should be reserved for biopsy-proven kidney dz caused by diabetes
105
Retinopathy screening and treatment
| prevention and mgmt complications of diabetes
general: glycemic control can reduce risk an dprogression of diabetic retinopathy; optimal bp control can also reduce risk; *aspirin plays no role in preventing or exacerbating diabetic retinopathy*!!!
106
Diabetic retinopathy screening
comprehensive optho soon after dx made
repeat annual exams
screening less often if eye exam normal or more often if retinopathy found
Presence of retinopathy related to duration of diabetes
women with diabetes who become pregnant: full eye exam in 1st trimester, frequent repeat evals throughout; doesnt apply to women who develop gestational diabetes (bc these ppl not at increased risk for diabetic retinopathy)
see pics for proliferative vs non-proliferative retinopathy
107
Laser photocoagulation for diabetic retinopathy
effective at slowing progression of retinopathy and reducing visual loss but trtmt usually doesnt restore lost vision
108
Neuropathy screening and treatment
| prevention of complications and mgmt
1) diabetic peripheral neuropathy: all pts should be screened for distal symmetric polyneuropathy at dx and at least annually
dpn screening test: pinprick sensation, temperature, vibration perception, ankle reflex testing
128 hz tuning fork, reflex hammer, 10-g monofilament test
(>2 of these tests should occur annually)
-- > once dx of dpn established need specialized foot care to prevent risk of amputation ; inspect insensitive feet every 3-6 months, pts should be taught foot care
symptomatic treatment of dpn: start with optimize gluocse control (avoid extremes)
dpn pain manifestations can be managed with tricyclic drugs, gabapentin, 5-hydroxytryptamine, and norepinephrine reuptake inhibitors
2) diabetic autonomic neuropathy
major clinical manifestations: resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, impaired neurovascular function, hypoglycemic autonomic failure, "brittle diabetes"
assessment of autonomic dysfunction should occur at initial diagnosis of t2dm
treatment of diabetic autonomic neuropathy: metoclopramide for gastroparesis; bladder and erectile dysfunction medications
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ASsessing foot complications
refer patients who smoke or w prior lower extremity complications to foot care specialists for ongoing preventive care and life long surveillance
initial screen for peripheral artery dz should include hx for claudication and assessment of pedal pulses
(ankle brachial index may be helpful bc many pts with pad are asymptomatic)
--> amputation and foot ulceration = most common consequences of diabetic neuropathy and major causes of morbidity and disability in ppl with diabetes
increased risk of ulcers or amputations: ppl who had diabetes >10 yrs, male, poor glucose control, or have cv, retinal, or renal complications
110
Foot related risk conditions assoc w inc risk of foot amputation
increased risk of ulcers or amputations: ppl who had diabetes >10 yrs, male, poor glucose control, or have cv, retinal, or renal complications
conditions assoc:
peripheral neuropathy with loss of protective sensation, altered biomechanics (in presence of neuropathy), evidence of increased pressure (erythema, hemorrhage under a callus), bony deformity, peripheral vascular dz (dec or absent pedal pulses), hx of ulcers or amputation, severe nail pathology
111
Immunizations in diabetic patients
preventable: influenza (vaccinate all diabetic ppl >6months old), pneumonia (one lifetime vaccine for pneumococcus then again when age >64 yrs previously immunized if vaccine administered 5 years prior;
(both assoc w high morbidity and mortality) in elderly ppl with chronic dzs
112
Continuous quality improvement (CQI)
- concept origianted from world of buisiness and manufacturing
- undelying principle: always room for improvement
- ocnstantly improve operations, processes, activities to meet requirements in efficient, consistent , cost effective manner
- focus is not on individuals but on processes
- CQI promotes need for objective data to analyze and improve processes; also applicable in heatlh care settings
- effective cqi projects found to directly improve health outcomes
- ADA considers ongoing cqi vital to delivering quality diabetes care
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Improving diabetes care: alarming statistics
- 37% of diagnosed diabetes have a1c <=200
- only 7.3% diagnosed diabetes have all 3 parameters at target goal
largest obstacles to optimal care: fragmented health care delivery system that lacks clnical info capabilities, often duplicates services, not designed for delivering chronic health care
- interdisciplinary team approaches that collaborate w patients in self-empowerment and self-mgmt education have been found to be better suited for pts w chronic care issues
- *continuous quality improvement*: institute of medicine recommends changes to delivery systems so they provide care that is evidence based, patient centered, systems oriented, includes info technolgy
114
Continuous Quality Improvement (formal list: core concepts)
CORE CONCEPTS:
- quality is defined as meeting and/or exceeding expectations of customers (patients, families, communities); patients and families can participate at the practice level
- success achieved through meeting needs of those we serve
- most problems found in processes, not ppl; CQI doesnt seek to blame but rather to improve processes
- unintended variation in processes can lead to unwanted variation in outcomes, there fore we seek to reduce or eliminate unwanted variation
- its possible to achieve continual improvement through small, incremental changes using scientific method
- continuous improvement is most effective when it becomes natural part of way everyday work is done and not a peripheral periodic activity
115
Continuous Quality Improvement (formal list: core steps in continuous improvement)
CORE STEPS IN CONTINUOUS IMPROVEMENT
- define problem before trying to solve it
- understand process before attempt to control it
- identify which problems are priorities before attempting to correct everything
- no such thing as failure bc can learn from all processes
- form a team that has knowledge of system needing improvement
- understand needs of ppl who are served by system
- idenitfy and define measures of success
- brainstorm potential change strategies for producing improvemet
- plan, collect, use data for facilitating effective decision making
- apply scientific method to test and refine changes
116
Screening for diabetes
in patients 45+ (esp if bmi >= 25): if normal, test again in 3 years) if no other risk factors
--> expert opinion
