SOC 2 & 4: Classification/Dx & medical evaluation Flashcards
1
Q
What is T1DM?
A
Autoimmune destruction of pancreatic B cells –>absolute insulin deficiency
2
Q
What is T2DM?
A
Progressive loss of pancreatic B-cell insulin secretion usually on background of insulin resistance
3
Q
What are the specifications for A1c to be able to be used for dx?
A
NGSP certified
4
Q
In what individuals/dz states should A1c NOT be used?
A
conditions associated w/ RBC turnover:
- G6PD deficiency
- sickle cell dz
- HIV
- hemodialysis
- 2nd/3rd trimester pregnancy
- ESRD
- blood loss/transfusion
- erythropoietin therapy
5
Q
How to verify dx of DM
A
- 2 abnormal tests- can be same sample or different day
6
Q
When is confirmation of DM not necessary?
A
BG >200 with s/s of hyperglycemic crisis
7
Q
What to do if pt is near margin of DM dx?
A
- re-test in 3-6 months
- tell them s/s to look out for
8
Q
What % of total DM is T1D?
A
10%
9
Q
What % of T1D present w/ DKA
A
1/3
10
Q
Those w/ T1D are at risk for what other autoimmune dz?
A
- vitiligo
- myathenia gravis
- autoimmune hepatitis
- celiac dx
- addison’s dz
- grave’s dz
- hashimoto thyroiditis
- pernicious anemia
11
Q
What is the average age for T1D dx?
A
10-14
12
Q
Those w/ T1DM are insulin ______
A
sensitive
13
Q
Typical insulin needs in T1D
A
0.5-1 g/kg/day
14
Q
How can T1D be distinguished from T2D?
A
- C-peptide test
- Presence or absence of autoantibodies
15
Q
S/s of DM
A
polyuria polydyspia polyphagia frequent urination, new bedwetting unexplained weight loss Dehydration
16
Q
What are the most common autoantibodies in T1DM?
A
GAD glutamic acid decarboxylase
IAA insulin autoantibody
ICA islet cell cytoplasmic autoantibody
17
Q
What did the TEDDY trial establish?
A
About 20% of kids <3 years old with 1 autoantibody later developed T1
18
Q
What is insulin resistance?
A
Muscle, fat, liver cells are not responding well to insulin, so pancreas makes more insulin. eventually pancreas can’t keep up and glucose isn’t entering cells, blood sugar rises causing hyperglycemia
19
Q
What is insulin deficiency
A
insulin producing B-cells are damaged or destroyed and stop producing insulin
20
Q
What meds may be associated w/ DKA in T2DM
A
atypical antipsychotics
SGLT2-i
corticosteroids
21
Q
When should an overweight or obese adult be tested for pre-DM or DM?
A
- if BMI >23 if Asian or >25 otherwise with 1 or more risk factor:
- 1st degree family member w/ T2DM
- high risk ethnic group (AA x 2, Native American, Pacific Islander, Latino)
- Physical inactivity
- HTN or HTN meds
- CVD hx
- HDL <35 or TG >250
- PCOS
- ancanthosis nigricans or severe obesity
22
Q
When should women w/ prior GDM be tested for pre-DM/DM?
A
- 4-12 weeks PP
- if normal, every 3 years
23
Q
How often should those w/ pre-DM, IFG, or IGT be tested?
A
Yearly
24
Q
When should A1c testing start for all even if not overweight/obese?
A
Age 45
25
What % of people w/ DM in US are undx? What groups are chronically underdx?
25%; 50% of Asian Americans and Hispanic Americans
26
What is the appropriate interval b/w screens?
q 3 years
27
Why is community screening not recommended?
- likely to get people already dx or at low risk
| - if someone is + may not have access to follow-up care
28
What is the ominous octet for t2DM?
- 80% loss of amylin at dx -->low satiety
- increased renal reabsorption
- decreased gut hormones GLP-1 and GIP
- increased lipolysis (free FA in blood --> insulin resistance)
- muscle insulin resistance
- liver insulin resistance
- increased alpa cell secretion of glucagon
29
Factors associated w/ insulin resistance
- abdominal obesity
- OSA
- fatty liver
- CA
- acanthosis nigricans
- sedentary lifestyle
- genetics
- history of GDM
- PCOS
30
What is acanthosis nigricans?
dark, velvety patches of skin where skin rubs together (neck, underarm, elbows)
- signals high insulin in blood
- skin tags or dark areas around nose/eyes
31
What is LADA?
| When is it typically dx?
Latent Autoimmune Diabetes in Adults
| >35 years old
32
What medical tx of LADA is appropriate?
start insulin w/ in 6 months; early insulin associated w/ preserved pancreatic ability to produce insulin
33
How/when to test for LADA
- GAD
- If there is:
- absence of metabolic dz (no HTN, no HLD, no obesity)
- no improvement w/ oral hypo agents
- other autoimmune dz
34
CF associated DM- how to test, when to test, prevalence, when to be concerned with complications
- OGTT
- Starting @ age 10, yearly
- 20% of kids, 40-50% adults
- assess for complications annually starting 5 years after dx
35
Post-transplant DM- how to test, when to test
- OGTT
- Test once pt stable on immunosuppressive regimen, no active infection
- insulin always works
36
What are monogenic DM? How common are they?
Rare- <5% of DM cases
| Caused by single gene mutation
37
What is MODY?
When is it diagnosed?
What is the effect on insulin production and action?
- Maturity Onset Diabetes of the Young
- Characterized by hyper before age 25
- Impaired insulin secretion w/o insulin resistance/obesity
38
What are the most common types and associated tx?
GCK- no meds (HYPER is mild)
| HNF- 1A, 4A, 1 B- sulfonylureas
39
Who should be tested for MODY?
- children/YA dx in early adulthood whose DM differs from T1 , T2
- ex: low renal threshold, lower than expected CRP, large increase in OTT (>90)
- ex: lean, autoantibody -, low HDL, high insulin sensitivity, strong family hx DM
40
Neonatal DM
- when is it dx?
- what are top 2 causes?
- dx w/in 1st 6 months of life
| - 80-85% are monogenic; insulin gene mutation is second most common cause
41
What is Type 3C DM?
What's another name for it?
What dz cause it?
What functions are impacted that result in dysglycemia?
Pancreatic DM, AKA pancroprivic DM
- structural and functional loss of glucose normalizing insulin secretion
- occurs from CF, pancreatitis, pancreatic cancer
- loss of both insulin and glucagon secretion --> hyper and hypoglycemia
- larger than expected insulin requirements
42
What is GDM vs. diabetes in pregnancy?
Diabetes in pregnancy- dx within first 13 weeks gestation
| GDM- dx 24-28 weeks gestation
43
Who should be tested for diabetes in pregnancy?
Overweight/obese women with 1+ standard risk factor, can use A1c
44
Women found to have pre-DM following GDM should be offered ____ and ____.
Intensive lifestyle intervention and Metformin
45
When to test new mom after GDM? Use what test?
4-12 weeks postpartum
| 75 g OGTT using normal (non-pregnant) criteria
46
What are 2 ways GDM is assessed?
| Who endorses what method?
1. 1 step- ADA endorsed
| 2. 2 Step- NIH endorsed- thought that 1 step would medicalize too many pregnancies
47
What is the dx criteria for step 1 GDM test?
Fasting >/= 92
1 H >/= 180
2 H >/= 153
48
What % of pregnancies are GDM?
7%
49
What is the medical management of GDM?
Many can be managed (80%) with diet/lifestyle. Otherwise, use insulin
50
What test is used as average of glycemia in GDM?
Fructosamine 2
| 2-3 week average glycemia
51
What is the dx criteria for 2 step method GDM?
```
1 step- no fasting required, 50g OGTT test- if >140, proceed on another day to 100g OGTT, need 2 criteria to dx
fasting- >/=95
1 H >/180
2 H >/= 155
3 H >/= 140
```
52
What % of women are dx with T2DM immediately postpartum?
5-10%
53
What % of women are dx with T2DM w/in 5 years of a GDM pregnancy?
50%
54
What should happen during initial medical eval for DM?
- confirm dx and classify type
- assess for complications and co-morbidities
- assess previous medical tx regimen, risk factor management
- patient engagement in plan
- plan for continuing care
55
What is a patient centered way to say non-compliant?
ambivalent
| chose not to/declines
56
What is a patient centered way to say controlled DM
managed
57
What type of language should be used?
Person w/ diabetes rather than diabetic
| neutral, non-judgmental, factual language
58
What is the goal of patient centered communication?
- shared decision making
- educated, involved patient
- assessing numeracy, literacy, barriers
- elicit patient preferences and beliefs
59
Why are PWD at higher risk for Hep B?
- lower socioeconomic status
| - may share needles, glucometers
60
How high is mortality rate of nosocomial bacteremia in PWD?
up to 50%
61
What factors impact choice of tx in T2DM?
- access to, cost, availability of meds
- individualized A1c target
- side effects of meds
- risk of hypo, weight gain
- complexity of regimen (frequency, administration)
- optimize pt adherence and persistence
62
What are pt key characteristics?
```
lifestyle
co-morbidities (HF, CKD, HF)
HgbA1c, weight
motivation, depression
cultural, socioeconomic
```
63
How often should patient centered glycemic management cycle in T2DM be undertaken?
at least 1-2x/year
64
What are s/s of celiac dz?
```
diarrhea
malabsorption
osteoporosis
abdominal pain
vitamin deficiencies
iron deficiency
```
65
When should PW T1DM be tested for thyroid dz?
soon after dx
66
When should pernicious anemia (B12) be suspected?
- unexplained anemia
| - peripheral neuropathy
67
What CA's are associated w/ DM
- liver, pancreas
| - breast, colon, endometrial, bladder
68
Each what % A1c rise is associated w/ lower cognitive function in T2M
1%
69
How should tx regimen be changed if pt is cognitively impaired?
simplify as much as possible &
| minimize risk of hypo
70
Risk factors associated w/ hypo
- use of insulin or insulin secretagogue (sulfonylureas or meglitinides)
- impaired kidney or liver function
- long duration of DM
- frail/older
- hypo unawareness
- physical or intellectual disability
- alcohol use
- polypharmacy (nonselective B blockers, ARB, ACE)
71
Who should be evaluated for NASH or fibrosis of liver?
pre-DM or T2DM w/ elevated ALT or fatty liver on ultrasound
72
What % of PW Hepatitis c have DM?
| How does hepatitis C affect glycemia?
- 1/3
| - viral proteins, proinflammatory cytokines
73
Who should be considered for islet autotransplantation?
Undergoing total pacreatectomy
74
Who is most at risk for age-specific risk factors and why?
- Both genders
- Both T1 & T2
- T1- osteoporosis
- T2- despite higher bone mineral density
75
Which of the 5 senses may be impaired?
Hearing loss- both high and low-mid frequency tone loss, due to neuropathy or vascular dz
smell loss
vision
76
Which HIV meds increase risk for DM?
Why is there increased risk?
When to test?
PI, NRTi
--> insulin resistance, apoptosis of B-cells
B4 starting tx, when switching tx, 3-6 months after starting tx, then annually
77
Who should have testosterone checked?
How to test?
What is a confounding variable?
S/s: Hypogonadism, decreased sex drive,
Erectile dysfunction
Test: using morning testosterone
Variable: obesity
78
What is the prevalence of OSA in DM?
| What are the s/s:
~20-25%
| daytime sleepiness, snoring, witnessed apnea, elevated WC/neck circumference/obesity
79
Why is OSA concerning?
High risk for CVD
80
When to test kids/adolescents for pre-DM/T2DM?
>/= age 10 or start of puberty + overweight >/=85% or obese >/=95% + at least 1 risk factor:
- 1st degree relative w/ T2DM
- SGA or mom had GDM during their pregnancy
- HTN, HLD, PCOS, acanthosis nigricans (insulin resistance)
- high risk ethnicity (African American, Asian American, Hispanic American,
Native American, Pacific Islander)
81
If kid @ risk for pre-DM/DM is found not to have pre-DM/DM based on testing, when should they be re-tested?
q 3 years
82
What % Americans have DM?
| What % have it and are not dx?
13% (35 million)
| 20% don't know they have it
83
What % Americans have pre-DM?
| What % don't know they have it?
35% (85 million)
| 85% don't know they have it
84
Which 3 ethnic groups have highest prevalence?
- Mexicans/Puerto Ricans
- Indigenous people/Native Americans
- Asian Indian/Phillipino
85
How does education impact prevalence of DM?
7.5% >HS
10% HS
13%
86
What % pancreatic function associated w/ pre-DM vs. DM?
pre-DM- 50%
| DM- 20%
87
Each % pt for A1c = BG?
1% = 29 points
