SOC 2 & 4: Classification/Dx & medical evaluation Flashcards
What is T1DM?
Autoimmune destruction of pancreatic B cells –>absolute insulin deficiency
What is T2DM?
Progressive loss of pancreatic B-cell insulin secretion usually on background of insulin resistance
What are the specifications for A1c to be able to be used for dx?
NGSP certified
In what individuals/dz states should A1c NOT be used?
conditions associated w/ RBC turnover:
- G6PD deficiency
- sickle cell dz
- HIV
- hemodialysis
- 2nd/3rd trimester pregnancy
- ESRD
- blood loss/transfusion
- erythropoietin therapy
How to verify dx of DM
- 2 abnormal tests- can be same sample or different day
When is confirmation of DM not necessary?
BG >200 with s/s of hyperglycemic crisis
What to do if pt is near margin of DM dx?
- re-test in 3-6 months
- tell them s/s to look out for
What % of total DM is T1D?
10%
What % of T1D present w/ DKA
1/3
Those w/ T1D are at risk for what other autoimmune dz?
- vitiligo
- myathenia gravis
- autoimmune hepatitis
- celiac dx
- addison’s dz
- grave’s dz
- hashimoto thyroiditis
- pernicious anemia
What is the average age for T1D dx?
10-14
Those w/ T1DM are insulin ______
sensitive
Typical insulin needs in T1D
0.5-1 g/kg/day
How can T1D be distinguished from T2D?
- C-peptide test
- Presence or absence of autoantibodies
S/s of DM
polyuria polydyspia polyphagia frequent urination, new bedwetting unexplained weight loss Dehydration
What are the most common autoantibodies in T1DM?
GAD glutamic acid decarboxylase
IAA insulin autoantibody
ICA islet cell cytoplasmic autoantibody
What did the TEDDY trial establish?
About 20% of kids <3 years old with 1 autoantibody later developed T1
What is insulin resistance?
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
What is insulin deficiency
insulin producing B-cells are damaged or destroyed and stop producing insulin
What meds may be associated w/ DKA in T2DM
atypical antipsychotics
SGLT2-i
corticosteroids
When should an overweight or obese adult be tested for pre-DM or DM?
- 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
When should women w/ prior GDM be tested for pre-DM/DM?
- 4-12 weeks PP
- if normal, every 3 years
How often should those w/ pre-DM, IFG, or IGT be tested?
Yearly
When should A1c testing start for all even if not overweight/obese?
Age 45
What % of people w/ DM in US are undx? What groups are chronically underdx?
25%; 50% of Asian Americans and Hispanic Americans
What is the appropriate interval b/w screens?
q 3 years
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
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
Factors associated w/ insulin resistance
- abdominal obesity
- OSA
- fatty liver
- CA
- acanthosis nigricans
- sedentary lifestyle
- genetics
- history of GDM
- PCOS
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
What is LADA?
When is it typically dx?
Latent Autoimmune Diabetes in Adults
>35 years old
What medical tx of LADA is appropriate?
start insulin w/ in 6 months; early insulin associated w/ preserved pancreatic ability to produce insulin
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
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
Post-transplant DM- how to test, when to test
- OGTT
- Test once pt stable on immunosuppressive regimen, no active infection
- insulin always works
What are monogenic DM? How common are they?
Rare- <5% of DM cases
Caused by single gene mutation
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
What are the most common types and associated tx?
GCK- no meds (HYPER is mild)
HNF- 1A, 4A, 1 B- sulfonylureas
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
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
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
What is GDM vs. diabetes in pregnancy?
Diabetes in pregnancy- dx within first 13 weeks gestation
GDM- dx 24-28 weeks gestation
Who should be tested for diabetes in pregnancy?
Overweight/obese women with 1+ standard risk factor, can use A1c
Women found to have pre-DM following GDM should be offered ____ and ____.
Intensive lifestyle intervention and Metformin
When to test new mom after GDM? Use what test?
4-12 weeks postpartum
75 g OGTT using normal (non-pregnant) criteria
What are 2 ways GDM is assessed?
Who endorses what method?
- 1 step- ADA endorsed
2. 2 Step- NIH endorsed- thought that 1 step would medicalize too many pregnancies
What is the dx criteria for step 1 GDM test?
Fasting >/= 92
1 H >/= 180
2 H >/= 153
What % of pregnancies are GDM?
7%
What is the medical management of GDM?
Many can be managed (80%) with diet/lifestyle. Otherwise, use insulin
What test is used as average of glycemia in GDM?
Fructosamine 2
2-3 week average glycemia
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
What % of women are dx with T2DM immediately postpartum?
5-10%
What % of women are dx with T2DM w/in 5 years of a GDM pregnancy?
50%
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
What is a patient centered way to say non-compliant?
ambivalent
chose not to/declines
What is a patient centered way to say controlled DM
managed
What type of language should be used?
Person w/ diabetes rather than diabetic
neutral, non-judgmental, factual language
What is the goal of patient centered communication?
- shared decision making
- educated, involved patient
- assessing numeracy, literacy, barriers
- elicit patient preferences and beliefs
Why are PWD at higher risk for Hep B?
- lower socioeconomic status
- may share needles, glucometers
How high is mortality rate of nosocomial bacteremia in PWD?
up to 50%
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
What are pt key characteristics?
lifestyle co-morbidities (HF, CKD, HF) HgbA1c, weight motivation, depression cultural, socioeconomic
How often should patient centered glycemic management cycle in T2DM be undertaken?
at least 1-2x/year
What are s/s of celiac dz?
diarrhea malabsorption osteoporosis abdominal pain vitamin deficiencies iron deficiency
When should PW T1DM be tested for thyroid dz?
soon after dx
When should pernicious anemia (B12) be suspected?
- unexplained anemia
- peripheral neuropathy
What CA’s are associated w/ DM
- liver, pancreas
- breast, colon, endometrial, bladder
Each what % A1c rise is associated w/ lower cognitive function in T2M
1%
How should tx regimen be changed if pt is cognitively impaired?
simplify as much as possible &
minimize risk of hypo
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)
Who should be evaluated for NASH or fibrosis of liver?
pre-DM or T2DM w/ elevated ALT or fatty liver on ultrasound
What % of PW Hepatitis c have DM?
How does hepatitis C affect glycemia?
- 1/3
- viral proteins, proinflammatory cytokines
Who should be considered for islet autotransplantation?
Undergoing total pacreatectomy
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
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
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
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
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
Why is OSA concerning?
High risk for CVD
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)
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
What % Americans have DM?
What % have it and are not dx?
13% (35 million)
20% don’t know they have it
What % Americans have pre-DM?
What % don’t know they have it?
35% (85 million)
85% don’t know they have it
Which 3 ethnic groups have highest prevalence?
- Mexicans/Puerto Ricans
- Indigenous people/Native Americans
- Asian Indian/Phillipino
How does education impact prevalence of DM?
7.5% >HS
10% HS
13%
What % pancreatic function associated w/ pre-DM vs. DM?
pre-DM- 50%
DM- 20%
Each % pt for A1c = BG?
1% = 29 points
