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860-diabetes > pre-reading > Flashcards

pre-reading Flashcards

1
Q

o Type 1 diabetes

A

(due to b-cell destruction, usually leading to absolute insulin deficiency)
o “Honeymoon period”

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2
Q

o Type 2 diabetes

A

o Progressive insulin secretory defect
o Insulin resistance
 Normal insulin levels fail to stimulate adequate peripheral glucose uptake
 Results in increased hepatic glucose production

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3
Q

o Gestational diabetes mellitus (GDM)

A

diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes

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4
Q

o Drug- or chemical-induced diabetes

A

(HIV/AIDS treatment or after organ transplantation)

o HCTZ, protease inhibitors, glucocorticoids, atypical antipsychotics

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5
Q

o Prediabetes

A

o Two types (insulin resistance)
 Impaired fasting glucose (IFG): predominantly hepatic insulin resistance and normal muscle insulin sensitivity
 Impaired glucose tolerance (IGT): normal-slightly reduced hepatic insulin sensitivity and moderate-severe muscle insulin resistance

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6
Q

• Type 1 symptoms

A

: frequent urination, unusual thirst, extreme hunger, unusual weight loss, extreme fatigue and irritability

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7
Q

• Type 2 symptoms

A

Any of the Type 1 symptoms, frequent skin, gum or bladder infections, blurred vision, slow healing wounds or sores, numbness/tingling in the hands or feet

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8
Q

criteria for testing for diabetes or pre-diabetes in asymptomatic adults

A
  1. overweight or obese (BMI >= 25 or >=23 in asian americans…or these risk factors
    - first-degree relative with diabetes
    - high-risk/ethnicity (african americna, laino, native american, african american
    - history of CVD
    - hypertension >= 140/90 or on therapy for hypertension
    - HDL cholesterol levels <35
    - women with PCOS
    - physical inactivity
  2. patient with prediabetes a1c >= 5.7
  3. women diagnosed with GDM
  4. all patient should begin testing at age 45
  5. if normal results, testing should be repeated at a minimum of 3 years, maybe more frequent testing
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9
Q

criteria defining pre-diabetes

A

FPG 100 mg/dl to 125 mg/dl

2-h PG during 75-g OGTT 140 mg/dl to 199 mg/dl

AIC 5.7-6.4%

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10
Q

criteria for the diagnosis of diabetes

A

FPG>= 126 mg/dL

2-h PG >= 200mg/dL

AIC>= 6.5%

or patients with classic symptoms of hyperglycemia or hyperglycemia crisis,, a random plasma glucose >=200 mg/dL

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11
Q

• Medical nutrition therapy

A

effectiveness (A1c lowering) 0.3-1% in Type 1 and 0.3-2% in Type 2

includes

  • weight loss
  • diet
  • monitoring carbs
  • food substitute
  • fiber
  • sugar substitutes
  • limit or avoid intake of sugar-sweetened beverages
  • fat quality
  • no clear evidence of supplements
  • alcohol
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12
Q

weight loss

• Medical nutrition therapy

A

o Weight loss 2-8 kg may be beneficial for pts with diabetes
 7% weight loss goal in pre-diabetes for prevention of diabetes

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13
Q

diet

• Medical nutrition therapy

A

o No ideal diet; should be individualized
 Mediterranean, DASH and plant based have been shown to be helpful
 Low Carbohydrate diets may contribute to DKA in those taking SGLT2
 In patients with established Diabetic Kidney Disease (albuminuria or reduced eGFR) should maintain 0.8 g/kg body weight of daily protein intake. Reducing protein below recommended daily allowances does not reduce rate of glomerular filtration decline or glycemic levels

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14
Q

carbohydrate

• Medical nutrition therapy

A

o Monitoring carbohydrate intake is critical

 Carbohydrates from vegetables, fruit, legumes, whole grains, and dairy is preferred

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15
Q

• Medical nutrition therapy

substitute

A

o Substitute high glycemic foods for low glycemic foods
o Sugar substitutes: nonnutritive sweeteners may be helpful short term for those that have sugary
o Limit or avoid intake of sugar-sweetened beverages

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16
Q

fiber

• Medical nutrition therapy

A

o Fiber: 14 g/1000 kcal and at least half of grain intake should be whole grain

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17
Q

fat quality

• Medical nutrition therapy

A

o Fat quality is more important than fat quantity for blood sugar control
 Fatty fish at least twice a week
 Same recommendations as general population for other fat intake
 Fish oil supplements NOT recommended

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18
Q

supplementation

• Medical nutrition therapy

A

o No clear evidence of benefit for supplementation without documented deficiencies
 Chromium, magnesium, vitamin d, cinnamon
 E, c, and carotene due to efficacy and concerns for toxicity long term

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19
Q

alcohol

• Medical nutrition therapy

A

o Alcohol: men ≤ 2 drinks, women ≤ 1 drink per day

 Any alcohol puts patient at risk for delayed hypoglycemia

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20
Q

physical activity

A

(a1c lowering = 0.66%, prevent dm)

o Reduce sedentary time by reducing extended sitting time (>30 minutes)

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21
Q

physical activity

- children

A

o Children: 60 minutes each day moderate-vigorous intensity with muscle/bone strengthening 3 times per week

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22
Q

physical activity

- adults

A

o Adults: 150 minutes/week moderate intensity aerobic physical activity (50-70% maximum heart rate) spread over at least 3 days/ week, with no more than 2 consecutive days without exercise
 Resistance training at least twice per week

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23
Q

physical activity

- older adults

A

o Older Adults: Flexibility and balance training such as Yoga or tai chi

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24
Q

physical activity

- exercise regimens

A

 Hyperglycemia: Can exercise in presence of hyperglycemia, but patient must feel well and urine absent of ketones
 Hypoglycemia: if patient is taking insulin or insulin secretagogue, patient should have carb intake prior to exercise if blood glucose < 90 mg/dl
 Retinopathy: proliferative and severe non-proliferative: vigorous aerobic or resistance training can trigger vitreous hemorrhage or retinal detachment
 Peripheral neuropathy: wear proper footwear and examine feet daily
 If foot injury or open sore present, avoid weight bearing activities
 Autonomic neuropathy: cardiac evaluation prior to exercise more intense than patient accustomed to
 Diabetic Kidney disease: no specific restriction on vigorous intensity exercise, but patients need to hydrate

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25
Q

• Tobacco cessation

A

: tobacco increases the risk of type 2 diabetes
o Patients are also at increased risk in the years immediately following cessation and may be monitored more frequently
o E-cigarettes for smoking cessation are no more effective than usual care

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26
Q

treatment pearls

- pre-diabetes

A

o A1c goal <5.7%
o Target weight loss of 7% of body weight
o Moderate intensity physical activity to at least 150 minutes/week
o Metformin most beneficial in those with BMI > 35 kg/m2, age < 60, women with hx of GDM, or progressive hyperglycemia*
o Can use acarbose or glp-1’s if needed
o Annual monitoring for development of DM

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27
Q

basal insulin

A

provides continues coverage

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28
Q

basal insulin

- starting dose

A

 Starting dose Type 1: 0.5 units/kg/day (split 50/50 as basal/bolus)
• Type 2: 0.1-0.2 units/kg/day

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29
Q

basal insulin

- titration

A

 Basal titration: see algorithm or
• FBG>180 mg/dl: add 20% of TDD
• FBG 140-180 mg/dl: add 10% of TDD

30
Q

bolus

A 
premeal dosing 
three types 
- set dose 
- set does + correction factor
- carbohydrate counting + correction factor
31
Q

bolus

- set dose

A

o Set dose = Usual carbohydrates per meal/ (Carbohydrate/Insulin ratio)
o Adjustments: increase by 10% or 1-2 units if above 2 hr postprandial goal

32
Q

bolus

- set dose + correction factor

A

o Correction factor = (premeal BG reading-premeal BG goal)/insulin sensitivity
o Adjustments: add correction factor to previous meal’s set dose

33
Q

bolus

- carbohydrate counting + correction factor

A

o Carbohydrate counting = Total carbohydrates per meal/(Carbohydrate/Insulin ratio)
o Adjustments: reassess regimen, potentially adjust insulin/carb ratio

34
Q

• Insulin sensitivity

A

the amount in mg/dl you would expect the patient’s blood sugar to drop if they were given 1 unit of insulin

35
Q

insulin sensitivity how to calculate

rule of 1800
rule of 1500

A

o Rule of 1800 (rapid acting analogues)
 1800/current total daily insulin dose=mg/dl change/1 unit insulin
o Rule of 1500 (regular insulin)
 1500/current total daily insulin dose=mg/dl change/1 unit insulin

36
Q

pre-meal goal

A

: target blood sugar prior to eating (usually 140 mg/dl)

37
Q

correction factor

A

amount of insulin to correct blood sugars elevated over the pre-meal goal the goal is for the correction factor to be zero!

38
Q

carboydrate / insulin rule

A

the number of grams of carbohydrates you would expect 1 unit of insulin to cover for the patient
o Carbohydrate/insulin ratio
 Rule of 500
 500/current total daily insulin dose= carbohydrate/insulin ratio

39
Q

insulin adjustment

A

Fasting (pre-breakfast)= bedtime or pre-dinner detemir, NPH, glargine

pre-lunch= pre-breakfast regualr, aspart, glulisine, lispro

pre-dinner= pre-breakfast NPH/pre-lunch regular, aspart, glulisine, lispro

bedtime= pre-dinner regular, aspart, glulisine, lispro

40
Q

dawn phenomenon

A

surge of hormones that the body produces daily between 4 and 5 am. In DM, this can result in high fasting sugars due to the inappropriate response of the pancreas.
• To address: eat an earlier dinner or do something active after dinner

41
Q

somogyi effect

A

also known as the rebound effect. The body’s reaction to hypoglycemia by overcompensating, resulting in elevated blood glucose. Result of glucagon and epinephrine being released during hypoglycemia which triggers the breakdown of glycogen into glucose.
• To address: Check blood sugar between 2-3 am if suspected.
o Eat bedtime snack or reduce dinner insulin dose

42
Q

 Hypoglycemia Levels and insulin reduction

A

• Fasting or post prandial
o BG <80 mg/dl, reduce by 10-20%
o BG <40 mg/dl, reduce by 20-40%

43
Q

o Insulin Injection Sites

A

 Abdomen (not within 2 inches of navel)
 Upper arm
 Anterior and lateral aspects of thigh
 Hip

44
Q

o Insulin storage

A

 Unopened room temperature
 Loss of potency after 30 days
 Erratic blood glucose level

45
Q

treatment pearls

- type 1

A

o Multiple dose insulin (MDI) or continuous subcutaneous insulin infusion (CSII)
o Start both basal and bolus insulins at the same time
o Basal insulin: approximately 50% of insulin needs
o Bolus insulin: each meal approximately 10-20% of insulin needs

46
Q

treatment pearls

- type 2

A

o Lifestyle modifications for all
o Metformin preferred first line agent
 Long term therapy risk of B12 deficiency consider screening with long term use (>5 years) especially in presence of anemia or peripheral neuropathy symptoms
o If oral medication at maximum tolerated doses does not achieve control at 3 months, ADD patient specific second agent see figure 9.1
o Additional oral medication properties to consider: a1c lowering needed to meet goal, MOA, which part of the glucose profile needs lowering, adverse effects and patient characteristics when selecting therapies. Due to progressive disease, many type 2 patients with diabetes will require insulin long term.
o Considerations for starting insulin
 Severe hyperglycemia, symptoms, or catabolism present (weight loss, ketosis)
 Combination insulin therapy
• Blood glucose >/= 300-350 mg/dl
• A1c >/= 11%
 Mealtime insulin when postprandial levels > 180 mg/dl, FPG at goal and A1c not at goal
• Likely when basal insulin at 0.7-1 unit/kg/day

47
Q

treatment pearl

type 2 gestational diabetes

A

o A1c goal 6-6.5%
o Avoid teratogenic medications (statin, ACEI/ARB)
o TLC is first line therapy
o Insulin preferred agent (does not cross placenta barrier)
o Metformin and Glyburide can be used but both cross placenta, and there is new evidence Glyburide is not as effective as either Metformin or insulin

48
Q

treatment pearl
type 2
Diabetes in the Hospital
critically ill

A

o Sole use of sliding scale insulin (SSI) is strongly discouraged, use basal/bolus
o Critically ill patients
 IV insulin protocol started at >/=180 mg/dl
 Goal 140-180 mg/dl (NICE-SUGAR) (IMPORTANT)
 Consider 110-140 mg/dl in some patients if it can be achieved without hypoglycemia
 Monitor blood glucose every 30-120 minutes

49
Q

treatment pearl
type 2
Diabetes in the Hospital
non-critically ill patients

A

o Sole use of sliding scale insulin (SSI) is strongly discouraged, use basal/bolus
o Non-critically ill patients
 Goals: premeal <140 mg/dl and random <180 mg/dl
 Basal insulin plus correction regimen for NPO patients
• Monitor blood glucose every 4-6 hours
 Basal insulin plus nutritional plus correction regimen for good oral intake
 Obtain A1c if result within the last 3 months unavailable or suspect new diagnosis
• Monitor blood glucose fasting and prior to each meal

50
Q

treatment pearl
type 2
Diabetes in the Hospital
previous diagnosis while in hospital

A

 Insulin-based regimens
• Continue home regimen
• Patient may have higher insulin requirements during acute illness
 Non-insulin based regimens
• Discontinue home regimen upon admission; Inpatient regimen preferred to be insulin-based
• Transition back to oral regimen should take place 1-2 days prior to discharge (if controlled)
• May need to switch to insulin-based regimen if poor control

51
Q

goals of treatment

children

A

o Children: ADA A1c goal <7.5%

  • before meals= 90-130
  • bedatime/overnight= 90-150

o ADA A1c goals <6.5%, <7%, or <7.5%, <8%, <8.5%
o 7% is reasonable unless mitigating factors below

52
Q

montitoring each visit

A

o Symptoms
o Medication adverse effects (see table below)
o Blood glucose including hypoglycemia awareness / causes
o Eating patterns, physical activity and need for dietician or diabetes education classes
o Blood pressure
o Skin examination: acanthosis nigricans, injection sites
o Foot exam if high risk

53
Q

monitoring 3-6 months

A

• Hemoglobin A1c every 3 months if poor glycemic control or recent change in therapy
o Every 6 months if good glycemic control
o Loss of correlation to SMBG in conditions that effect red blood cell turnover (hemolysis, blood loss, sickle cell disease)
o Point of Care testing for A1c provides for more timely treatment changes

54
Q

monitoring yearly

A

o Labs: FLP, LFT’s, urine creatinine, SCr, eGFR, Serum Potassium if ACE/ARB or diuretic, B12 if on metformin
o Physical/Assessment: BMI, visual foot exam monofilament, PAD, depression screen, vaccination needs, thyroid palpation
o Referrals: dental visit, optho

55
Q

continues glucose monitoring (CGM’s)

A

 GGM must be worn and active at least 70% of the time over 14 days to be considered accurate
 Reports generate data based upon the amount of time patient is within their glucose goal ranges: Time In Range (TIR). Time Above Range (TAR) or Time Below Range (TBR)
 False blood glucose readings with monitors and CGM’s with acetaminophen, uric acid, galactose, L-Dopa, ascorbic acid

56
Q

dental

A

• Dental: periodontal disease
o 6-12-month screening and
o Normal hygiene recommendations

57
Q

• Thyroid dysfunction

A

• Thyroid dysfunction: screen patients with Type 1 soon after diagnosis
o Every 1-2 years thereafter or sooner if patient develops symptoms, impaired growth or erratic blood sugar control
o Type 2 with symptoms or dyslipidemia or women aged >50 yrs: initial screen
 Unclear recommendations for rescreening: 2-5 years with symptoms?

58
Q

• Psychosocial complications

A
  • At least yearly screening
  • > 65 years old high-risk population for cognitive impairment and depression
  • During diagnosis, new complications, hospitalization, or when problems with glucose control, quality of life are detected
  • Diabetes Distress: Common and distinct from other psychological disorders
  • Refer when gross disregard for health, overall stress, debilitating anxiety, depression, eating disorder
59
Q

vaccine

A

o In general patients with DM are more prone to complications from influenza and pneumonia
o Annually: influenza vaccine to all patients with DM >/= 6 months of age
o Administer
 Pneumococcal polysaccharide 23 (PPSV23) to children before the age of 2 per CDC infant vaccination schedule. All patients with DM >/= 2-64 years of age should receive PPSV23 if not previously vaccinated. PPSV23 is required at or after the age of 65, one year after PCV13, regardless of previous vaccination status.
 PCV13 in adults with DM to be administered to all adults 65 or older who have not previously received a dose
o Administer hepatitis b vaccination to unvaccinated adults with DM ages 19-59 years
 Consider administering to adults >/= 60 years of age

60
Q

Microvascular

A

: retinopathy, nephropathy, neuropathy: sensory (foot lesions) and autonomic (sex dysfunction and gastroparesis)

61
Q

o Retinopathy

A

 Non-proliferative: hard, yellow exudates, retinal edema, punctate hemorrhage
 Proliferative: Neovascularization
• Fibrosis, vitreous hemorrhage, retinal detachment
 Optimize blood glucose and pressure control

62
Q

o Retinopathy

- screening

A

 Screening: dilated, comprehensive eye exam
• Type 1: within 5 years of diagnosis, (starting at age 10 or onset of puberty whichever first)
• Type 2: soon after diagnosis
• Yearly screening thereafter
• GDM: screen in first trimester, consider in others depending on degree of retinopathy

63
Q

retinopathy

treatment

A
  • Laser photocoagulation for macular edema and severe non-proliferative diabetic retinopathy (NPDR)
  • Anti-vascular endothelial growth factor (VEGF) for proliferative diabetic retinopathy (PDR)
  • Refer to ophthalmologist
  • Retinopathy is not a contraindication for daily aspirin use
64
Q

o Gastroparesis

A

 Optimize blood glucose control
 Erythromycin 125-500 mg four times daily prior to meal
 Metoclopramide (restricted use of 12 weeks due to risk of extrapyramidal symptoms)
 Surgery electrical stimulation
o Diabetic diarrhea
 Clonidine

65
Q

o 2019 Update: If patient at A1c goal and established CVD

A

 If on dual therapy or multiple therapy replace one agent with SGLT2 inhibitor or GLP1
 Consider lowering A1c target and add SGLT2 inhibitor or GLP1
 Reassess A1c at 3-month intervals and add SGLT2 inhibitor or GLP1 if A1c above target

66
Q

o Lipids: Screen at diagnosis, every 5 years if under 40 and periodically (1-2 years) thereafter

A

o Primary Prevention
 Patients 20-39 with additional ASCVD risk factors  statin therapy is reasonable add on to lifestyle therapy
 Patient 40-75 without ASCVD  moderate intensity statin
• Patients 50-70 a high intensity may be considered
 Patients 40-75 with multiple ASCVD risk factors  high intensity statin
 Ezetimibe: For patients with 10-year ASCVD risk of 20% or higher as add on therapy to statin to provide additional cv benefit and lower LDL cholesterol by 50% or more total
o Secondary Prevention
 Patients of all ages with ASCVD should be on high intensity statin
 If LDL is ≥ 70 mg/dL on maximal tolerated statin consider ezetimibe or PCKS9 ($$)
• Ezetimibe may be preferred due to cost

67
Q

o Aspirin use

A

 Use daily aspirin for secondary prevention in diabetes with history of ASCVD
• May be used for primary prevention if increased cardiovascular risk
o To determine ASCVD risk, please use the ASCVD pooled cohorts equation (from lipid guidelines)
 If documented ASCVD and aspirin allergy, use clopidogrel 75 mg daily
 All pregnant women with preexisting type 1 or type 2 diabetes should consider low-dose aspirin daily starting at the end of their first trimester to reduce risk of pre-eclampsia

68
Q

hypoglycemia

A
  • Tremulousness
  • Nervousness/Anxiety
  • Diaphoretic
  • Tachycardic
  • Headache
  • Irritability
  • Confusion
  • Somnolence
69
Q

hypoglycemia treatment

A

• Level 1: BG <70 and ≥ 54 mg/dL
• Level 2: BG ≤ 54 mg/dL
o Glucagon should be prescribed for all individuals at risk of level 2 hypoglycemia
 Available in injection form and New Nasal Powder (Baqsimi)
• Baqsimi actuation into single nostril, no inhalation needed, may repeat in 15 minutes
 Immediate treatment with any carbohydrate
o 10 gm glucose raises BG ~40 mg/dL
o 20 gm glucose raises BG ~60 mg/dL

70
Q

sick day management

A

o DO NOT STOP INSULIN!
o Keep usual basal insulin
o Cover with quick-acting insulin
o Frequent finger stick monitoring
o Check urine ketones
o Use sports drinks to maintain hydration
o Supplemental calories to support insulin coverage
o If vomiting or altered consciousness, go to ER

860-diabetes (2 decks)

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