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Clinical 3 > Readings > Flashcards

Readings Flashcards

1
Q

Which diabetic patients can fast during Ramadan?

A

• Well-controlled diabetes
• Treated by lifestyle alone or with: metformin,
acarbose, incretin therapies (DPP-4 inhibitors or GLP-1 RA), second-generation SU, SGLT2 inhibitors, TZD or basal insulin in otherwise healthy individuals

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2
Q

What is the definition of pre-diabetes

A

a state which places individuals at high risk of developing diabetes and its complications) is diagnosed by any of the following criteria:

a) IFG (FPG 6.1–6.9 mmol/L)
b) IGT (2hPG in a 75 g OGTT 7.8–11.0 mmol/L)
c) A1C6.0%–6.4%(for use in adults in the absence of factors that affect the accuracy of A1C and not for use in suspected type 1 diabetes)

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3
Q

Cut-offs to diagnose diabetes

A

FPG ≥7.0 mmol/L
A1C ≥6.5% (in adults)

2hPG in a 75 g OGTT ≥11.1 mmol/L
Random PG ≥11.1 mmol/L


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4
Q

Advantages and disadvantages of FPG

A 
Advantages: 
• Established standard
• Fast and easy
• Single sample
• Predicts microvascular complications
Dis:
• Sample not stable
• High day-to-day variability
• Inconvenient (fasting)
• Reflects glucose homeostasis at a single point in time
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5
Q

Advantages and disadvantages of 2hPG in a 75 g OGTT

A

Adv:
• Established standard
• Predicts microvascular complications

Dis:
• Sample not stable
• High day-to-day variability 
• Inconvenient
• Unpalatable
• Cost
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6
Q

Advantages and disadvantages of A1C

A

Adv:
• Convenient (measure any time of day)
• Single sample
• Predicts microvascular complications
• Better predictor of CVD than FPG or 2hPG in a 75 g OGTT
• Low day-to-day variability
• Reflects long-term glucose concentration

Dis:
• Cost
• Misleading in various medical conditions (e.g. hemoglobinopathies, iron deficiency,
hemolytic anemia, severe hepatic or renal disease)
• Altered by ethnicity and aging
• A1C is also a continuous cardiovascular (CV) risk factor and a better predictor of CV events than FPG or 2hPG
• Not for diagnostic use in children and adolescents† (as the sole diagnostic test),
pregnant women as part of routine screening for gestational diabetes‡, those with cystic fibrosis or those with suspected type 1 diabetes

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7
Q

Which diabetic test can also predict risk of CV events?

A

A1C is also a continuous cardiovascular (CV) risk factor and a better predictor of CV events than FPG or 2hPG

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8
Q

How many diabetic tests should be carried out to conclude a diagnosis when hyperglycemia symptoms are present? Absent?

A

In the presence of symptoms of hyperglycemia, a single test result in the diabetes range is sufficient to make the diagnosis of diabetes.
In the absence of symptoms of hyperglycemia, if a single laboratory test result is in the diabetes range, a repeat confirmatory laboratory test (FPG, A1C, 2hPG in a 75 g OGTT) must be done on another day.
It is preferable that the same test be repeated (in a timely fashion) for confirmation, but a random PG in the diabetes range in an asymptomatic individual should be confirmed with an alternate test. If results of 2 different tests are available and both are above the diagnostic cut points the diagnosis of diabetes is confirmed 


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9
Q

When you are 40+, how often should you be screended for DM? How?

A
  • If you are age 40 years or over, you are at risk for type 2 diabetes and should be tested at least every 3 years.
    How: Screen for type 2 diabetes using a fasting plasma glucose and/or glycated hemoglobin (A1C) every 3 years in individuals ≥40 years of age or in individuals at high risk on a risk calculator (33% chance of developing diabetes over 10 years)
  • If you have risk factors that increase the likelihood of developing type 2 diabetes, you should be tested more frequently and/or start regular screening earlier. Some of the risk factors include family history of diabetes; being a member of a high-risk population; history of prediabetes or gestational diabetes; and having overweight.
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10
Q

Risk factors for type 2 diabetes

A

• Age ≥40 years
• First-degree relative with type 2 diabetes
• Member of high-risk population (e.g. African, Arab, Asian, Hispanic, Indigenous or South Asian descent, low socioeconomic status)
• History of prediabetes (lGT, lFG or A1C 6.0%–6.4%)
• History of GDM

• History of delivery of a macrosomic infant

• Presence of end organ damage associated with diabetes:
- Microvascular (retinopathy, neuropathy, nephropathy)
- CV (coronary, cerebrovascular, peripheral)
• Presence of vascular risk factors:
◦ HDL-C <1.0 mmol/L in males, <1.3 mmol/L in females*
◦ TG≥1.7mmol/L

◦ Hypertension

◦ Overweight*
◦ Abdominal obesity*
◦ Smoking
• Presence of associated diseases:
◦ History of pancreatitis

◦ Polycystic ovary syndrome

◦ Acanthosis nigricans

◦ Hyperuricemia/gout

◦ Non-alcoholic steatohepatitis

◦ Psychiatric disorders (bipolar disorder, depression, schizophrenia†)
◦ HlV infection‡

◦ Obstructive sleep apnea§

◦ Cystic fibrosis
Use of drugs associated with diabetes:
◦ Glucocorticoids

◦ Atypical antipsychotics

◦ Statins
◦ Highly active antiretroviral therapy‡
◦ Anti-rejection drugs

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11
Q

Reducing the risk of developing diabetes

A

Behavioural interventions , 5% weight loss can reduce the progression of IFG or IGT to T2DM by almost 60%.
When initiated early, the effect of behaviour modifications are long lasting
Progression of T2DM can also be slowed down using medications such as metformin, Thiazolidinediones, orlistat
There is a strong evidence supporting the benefit of Mediterranean diet in diabetes prevention
Increased consumption of whole grains and dairy have shown promising results in decreasing incidence of T2DM

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12
Q

In people with T2, A1C target can be __ to reduce the risk of __

A

In people with T2, A1C target can be <6.5mmol/L to reduce the risk of chronic kidney disease and retinopathy

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13
Q

When would we consider a higher target for A1C?

A

A higher A1C target may be considered in people with diabetes with the goals of avoiding hypoglycemia and over-treatment related to antihyperglycemic therapy

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14
Q

How often SMBG should be carried out?

A

SMBG (self monitoring of blood glucose)
3+ times/day is recommended for people with T1DM
For T2 recommendations are less clear and should be individualized according to treatment, level of glycemic control and risk of hyperglycemia

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15
Q

Flash Glucose Monitoring vs Continous Glucose Monitoring

A

Both measure glucose subcutaneously
FGM is factory calibrated and does not require capillary blood glucose (with SMBG device) calibration.
For flash, BG levels are not continually displayed on a monitoring device but instead are displayed when the sensor is “flashed” with a reader device on demand.

In people with type1diabetes who have not achieved their glycemic target, real-time CGM may be offered to improve glycemic control

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16
Q

Hyperglycemia

Symptoms, causes, treatment

A

Symptoms: polyuria, polydipsia, blurred vision, polyphagia, weight loss
Causes: excess food, large meals, over-treatment of hypoglycemia, illness, stresss
Treatment: physical activity, regular SBGM

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17
Q

Dawn syndrome

Symptoms, causes, treatment

A

Symptoms: unexplained fasting hyperglycemia in AM
Causes: overnight release of hormones, insufficient insulin in PM, excessive food at bedtime
Treatment: adjust insulin doses

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18
Q

Ketoacidosis

Symptoms, causes, treatment

A

Symptoms: nausea, vomtiting, fruity breath, heavy breathing
Causes: lack of BGM, illness or infection, increased insulin needs
Treatment: regular BGM, insulin adjustment

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19
Q

HHS

Symptoms, causes, treatment

A

Causes: dehydration, excessive fluid loss, prolong hyperglycemia
Treatment: monitor fluid intake and BG

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20
Q

benefits of nutrition therapy for DM

A

Nutrition therapy can reduce glycated hemoglobin (A1C) by 1.0% to 2.0% and, when used with other components of diabetes care, can further improve clinical and metabolic outcomes.

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21
Q

benefits of low GI foods vs high GI foods

A

Replacing high-glycemic-index carbohydrates with low-glycemic-index carbohydrates in mixed meals has a clinically significant benefit for glycemic control in people with type 1 and type 2 diabetes.

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22
Q

benefits of consistency in spacing and intake of carbohydrate intake and in spacing and regularity in meal consumption

A

Consistency in spacing and intake of carbohydrate intake and in spacing and regularity in meal consumption may help control blood glucose and weight.

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23
Q

is it recommended to calorie restrict in DM?

A

Because an estimated 80% to 90% of people with type 2 diabe- tes have overweight or obesity, strategies that include energy restriction to achieve weight loss are a primary consideration

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24
Q

benefits of weight loss in T2

A

A modest weight loss of 5% to 10% of initial body weight can substantially improve insulin sensitivity, glycemic control, hypertension and dyslipidemia in people with type 2 diabetes and those at risk for type 2 diabetes

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25
Q

There may be a benefit of substituting __for carbohydrate

A

There may be a benefit of substituting fat as MUFA for carbohydrate

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26
Q

Ramadan and DM: who is ok to do it?

A

in people with well-controlled type 1 diabetes, complications from fasting are rare.

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27
Q

AMDR for diabetes

A

In adults with diabetes, the macronutrient distribution as a percentage of total energy can range from 45% to 60% carbohydrate, 15% to 20% protein and 20% to 35% fat to allow for individualization of nutrition therapy based on preferences and treatment goals

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28
Q

What should trans-fatty acids be replaced with?

A

PUFAs

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29
Q

The following dietary patterns may be considered in people with type 2 diabetes, incorporating patient preferences, including:

A

a. Mediterranean-style dietary pattern to reduce major CV events and improve glycemic control
b. Vegan or vegetarian dietary pattern to improve glycemic control, body weight, and blood lipids, including LDL-C and reduce myocardial infarction risk
c. DASH dietary pattern to improve glycemic control, BP, and LDL-C and reduce major CV events
d. Dietary patterns emphasizing dietary pulses (e.g. beans, peas, chickpeas, lentils) to improve glycemic control, systolic BP and body weight.
e. Dietary patterns emphasizing fruit and vegetables to improve glycemic control and reduce CV mortality
f. Dietary patterns emphasizing nuts to improve glycemic control and LDL-C

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30
Q

Alcohol, DM and drugs

A

People with diabetes using insulin and/or insulin secretagogues should be educated about the risk of hypoglycemia resulting from alcohol and should be advised on preventive actions, such as carbohydrate intake and/or insulin dose adjustments and increased BG monitoring

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31
Q

What is the preferred insulin regimen in T1

A

Basal-bolus insulin therapies (i.e. multiple daily injections or continuous subcutaneous insulin infusion) are the preferred insulin management regimens for adults with type 1 diabetes.

32
Q

what does bolus dose depend on?

A

carbohydrate content, carbohydrate-to-insulin ratio for each meal, planned exercise, time since last insulin dose and blood glucose level.

33
Q

what are the types of bolus?

A

Bolus insulins include rapid-acting insulin analogues (insulin aspart, insulin faster- acting aspart, insulin glargine, insulin lispro) and short-acting insulin (regular insulin).

34
Q

when should preprandial insulin be injected?

A

rapid insulin should be administered 0 to 15 minutes before the start of the meal while short- acting regular insulin should be administered 30 to 45 minutes before the start of the meal. Faster-acting insulin aspart may be administered at the start of the meal or, when necessary, up to 20 minutes after the start of the meal

35
Q

__ is the most common adverse effect of insulin therapy in people with type 1 diabetes

A

Hypoglycemia is the most common adverse effect of insulin therapy in people with type 1 diabetes

36
Q

what is better for hypoglycemia; rapid-acting insulin or regular?

A

The frequency of hypoglycemic events is reduced with rapid- acting insulin analogues compared with regular insulin

37
Q

which basal insulin is better at reducing hypoglycemia and nocturnal hypoglycemia

A

Long-acting insulin analogues reduce the incidence of hypoglycemia and nocturnal hypoglycemia when compared to
intermediate-acting insulin as the basal insulin

38
Q

What should be used instead of regular insulin in T1 and why?

A

In adults with type 1 diabetes using basal-bolus injection therapy or CSII, rapid-acting insulin analogues should be used in place of regular insulin to improve A1C and to minimize the risk of hypoglycemia and to achieve postprandial BG targets

39
Q

In adults with type 1 diabetes and hypoglycemia unawareness, the fol- lowing non-pharmacological strategies may be used to reduce the risk of hypoglycemia:

A

a. A standardized education program targeting rigorous avoidance of hypoglycemia while maintaining overall glycemic control
b. Increased frequency of SMBG, including periodic assessment during sleeping hours
c. CGM with high sensor adherence in those using CSII
d. Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months [

40
Q

what is the therapy in people with type 2 diabetes with A1C ≥1.5% above target

A

In people with type 2 diabetes with A1C ≥1.5% above target, antihyperglycemic agents should be initiated concomitantly with healthy behaviour interventions, and consideration could be given to initiating com- bination therapy with 2 agents.

41
Q

impaired glucose tolerance vs impaired fasting glucose

A

impaired glucose tolerance: two-hour glucose levels of 7.8 to 11.0 mmol)on the 75-g oral glucose tolerance test
Impaired fasting glucose is defined as glucose levels of 5.6 to 6.9 mmol/L in fasting patients.

42
Q

Which individuals should receive insulin immediately?

A

Insulin should be initiated immediately in individuals with metabolic decompensation and/or symptomatic hyperglycemia.

43
Q

What is advised for people with clinical cardiovascular (CV) disease in whom A1C targets are not achieved with existing pharmacotherapy

A

In people with clinical cardiovascular (CV) disease in whom A1C targets are not achieved with existing pharmacotherapy, an antihyperglycemic agent with demonstrated CV outcome benefit should be added to antihyperglycemic therapy to reduce CV risk.

44
Q

is it better to treat or prevent hypogycemia

A

prevent

45
Q

what is advised for people who experienced hypoglycemia and are not gonna eat for the next hour?

A

If a meal is >1 hour away, a snack (including 15 g carbohydrate and a protein source) should be consumed

46
Q

symptoms of hypoglycemia

A

Some of the more common symptoms of low blood glucose are trembling, sweating, anxiety, confusion, difficulty concentrating or nausea. Not all symptoms will be present and some individuals may have other or no symptoms.

47
Q

tips for avoidign hypoglycemia

A

Carry a source of fast-acting carbohydrate with you at all times, such as glucose tablets, Life SaversTM and/or a juice box

48
Q

definition of hypoglycemia

A

1) the development of autonomic or neuroglycopenic symptoms
2) a low plasma glucose (PG) level (<4.0 mmol/L for people with diabetes treated with insulin or an insulin secretagogue); and 3) symptoms responding to the administration of carbohydrate

49
Q

which DM type experiences hypoglycemia more frequently?

A

Hypoglycemia is most frequent in people with type 1 diabetes, followed by people with type 2 diabetes managed by insulin, and people with type 2 diabetes managed by sulfonylureas.

50
Q

3 types of severity of hypoglycemia

A

Mild: Autonomic symptoms are present. The individual is able to self-treat.
Moderate: Autonomic and neuroglycopenic symptoms are present. The individual is able to self-treat.
Severe: Individual requires assistance of another person. Unconsciousness may occur. PG is typically <2.8 mmol/L.

51
Q

Risk factors for severe hypoglycemia in people treated with sulfonylureas or insulin

A
  • Prior episode of severe hypoglycemia
  • Current low A1C (<6.0%)
  • Hypoglycemia unawareness
  • Long duration of insulin therapy
  • Autonomic neuropathy
  • Chronic kidney disease
  • Low economic status, food insecurity
  • Low health literacy
  • Preschool-aged children unable to detect and/or treat mild hypoglycemia on their own
  • Adolescence
  • Pregnancy
  • Elderly
  • Cognitive impairment
52
Q

how to reverse hypoglycemia unawareness and defective glucose counter- regulation are potentially reversible.

A

Strict avoidance of hypoglycemia for a period of 2 days to 3 months has been associated with improvement in the recognition of severe hypoglycemia

53
Q

tactics to reduce the risk of hypoglycemia:

A
  • education of both patient and relatives
  • avoidance of pharmacotherapies associated with increased risk of recurrent or severe hypoglycemia
  • increased frequency of SMBG
  • Less stringent glycemic targets with avoidance of hypoglycemia for up to 3 months
54
Q

mild/moderate vs severe hypoglycemia treatment

A

Mild-to-moderate hypoglycemia should be treated by the oral ingestion of 15 g carbohydrate, preferably as glucose or sucrose tablets or solution. These are preferable to orange juice and glucose gels. People with diabetes should retest BG in 15 minutes and
Severe hypoglycemia in a conscious person with diabetes should be treated by oral ingestion of 20 g carbohydrate, preferably as glucose tablets or equivalent. BG should be retested in 15 minutes and then re-treated with another 15 g glucose if the BG level remains <4.0 mmol/L

55
Q

main features of HHS

A

ECFV depletion and hyperosmolarity

56
Q

risk factors for DKA

A

new diagnosis of diabetes mellitus, insulin omission, infection, myocardial infarction (MI), abdominal crisis, trauma and, possibly, continuous subcutaneous insulin infusion (CSII) therapy,

57
Q

Would we considered weight management meds?

A

Weight management medication may be considered in people with diabetes and overweight or obesity to promote weight loss and improved glycemic control

58
Q

when would we consider bariatric surgery?

A

Bariatric surgery may be considered for selected adults with type 2 diabetes and obesity with BMI ≥35.0 when healthy behaviour interventions with or without weight management medication(s) are inadequate in achieving target glycemic control or healthy weight goals

59
Q

are alternative medications useful for diabetes?

A

There is insufficient evidence to make a recommendation regarding efficacy and safety of complementary or alternative medicine for individuals with diabetes

60
Q

Ask your doctor about the ABCDEs to reduce your risk of heart attack and stroke:

A

◦ A = A1C – Blood glucose control. The target is usually 7.0% or less.
◦ B = BP – Blood pressure control (less than 130/80 mmHg).
◦ C=Cholesterol–LDL-cholesterol less than2.0mmol/L. Your physician/
nurse practitioner may advise you to start cholesterol-lowering
medication.
◦ D = Drugs to protect your heart – These include blood pressure pills
(ACE inhibitors or ARBs), cholesterol-lowering medication (“statins”), and, in people with existing cardiovascular disease, certain blood glucose lowering medications. These blood glucose-lowering medi- cations can protect your heart even if your blood pressure and/or LDL- cholesterol are already at target.
◦ E=Exercise/Eating—Regular physical activity, which includes healthy eating, and achievement and maintenance of a healthy body weight.
◦ S = Stop smoking and manage stress.

61
Q

is there a risk of CDD in DM patients when LDL-C is normal

A

People with diabetes have an increased risk of cardiovascular diseases even if their LDL-cholesterol is “normal”.

62
Q

What are the Healthy behaviour interventions are supplementary to pharmacologic therapy for hypertension

A

reducing excess body weight, reducing sodium intake toward (2,000 mg/day), increasing consumption of fruits and vegetables (8 to 10 servings per day), low-fat dairy products (2 to 3 servings per day), avoiding excessive alcohol consumption (no more than 2 servings per day in men and no more than 1 serving per day in women) and increasing physi-
cal activity levels

63
Q

Most people with diabetes should receive ___ for initial management of hypertension; however, there is emerging evidence for supporting earlier use of s___

A

Most people with diabetes should receive standard-dose monotherapy for initial management of hypertension; however, there is emerging evidence for supporting earlier use of single pill combination therapy.

64
Q

how often should the blood pressure be checked?

A

Have your blood pressure checked at least once every year by a health-care provider or more often if your blood pressure is high.
• You can also check your blood pressure at home. If home blood pressure readings are done properly, they may reflect your usual blood pressure more than those done in the health-care provider’s office.

65
Q

For most people with diabetes, blood pressure should be __

A

For most people with diabetes, blood pressure should be less than 130/80 mmHg

66
Q

benefit of more more intensive BP lowering

A

it led to reductions in risk of microvascular diabetic endpoints and in stroke

67
Q

signs of a heat attack

A

A heart attack can manifest as chest discomfort or crushing pain; or as pain in the arms, back, neck, jaw and, even, the stomach. Shortness of breath, cold sweat, nausea and lightheadedness may also occur.

68
Q

screening tests recommended for all people with ACS

A

In all people with ACS ,a random BG and an A1C (if not done in the 3 months prior to admission) should be measured:

a. For people with a history of diabetes, to identify individuals that would benefit from glycemic optimization
b. For people without a history of diabetes, to identify individuals at risk for ongoing dysglycemia
i. If the A1Cis≥6.5% and/or random BG is>11.0mmol/L,in-hospital capillary blood glucose monitoring should be initiated
ii. If A1C is 5.5–6.4%, repeat screening for diabetes should be performed after discharge as per diabetes screening recommendations

69
Q

Identification of chronic kidney disease in people with diabetes requires:

A

screening for proteinuria, as well as an assessment of serum creatinine converted into an estimated glomerular function rate (eGFR).

70
Q

All individuals with chronic kidney disease should be considered at high risk for __ and should be __

A

All individuals with chronic kidney disease should be considered at high risk for cardiovascular events and should be treated to reduce these risks.

71
Q

how can development and progression of CKD in diabetes be reduced and slowed

A

The development and progression of renal damage in diabetes can be reduced and slowed through intensive glycemic control and optimization of blood pressure. Progression of chronic kidney disease in diabetes can also be slowed through the use of medications that disrupt the renin angiotensin aldosterone system.

72
Q

__is a major cause of CKD in diabetes

A

Diabetic nephropathy is a major cause of CKD in diabetes

73
Q

Screening for CKD in people with diabetes involves:

A

Screening for CKD in people with diabetes involves an assessment of urinary albumin excretion and a measurement of the overall level of kidney function through an eGFR

74
Q

A1C, Fasting/ 2-hour preprandial PG, postprandial PG* (mmol/L) targets for <18 yo

A

A!C ≤7.5
fasting PG: 4.0–8.0
2-h PP PG: 5.0–10.0

75
Q

to prevent DKA in children with diabetes:

A

a. Targeted public awareness campaigns should be considered to educate parents, other caregivers (e.g. teachers) and health-care providers about the early symptoms of diabetes
b. Immediate assessment of ketone and acid-base status should be done in any child presenting with new-onset diabetes
c. Comprehensive education and support services , as well as 24-hour telephone services should be available for families of children with diabetes.

Clinical 3 (17 decks)

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