SOC 6: Glycemic targets Flashcards by Michelle Hyman

What are 2 alternatives to A1c test?

Fructosamine & 1,5 andhydroglucitol

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African Americans have what % point reduction in A1c if they have these variants?

Hbs- 0.3

G6PD- 0.8

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What is the legacy effect? What studies did it emerge from?

DCCT & UKPDS studies. Early intense BG MGMT is beneficial decades later even after tight control has ceased

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How to prevent DKA?

Ensure adequate fluids & kcals

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What poorly effects endothelial function?

Post prandial hyperglycemia

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When is it appropriate to have pt monitor post prandial values?

When pre-meal is within target but A1c is elevated

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What usually prompts an episode of DKA?

Stress, illness, trauma, mediation (steroids)

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What should be encouraged immediately after HYPO episode?

Meal or snack

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For whom should glucagon be prescribed?

Those @ risk for level 2 hypo

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What is hypo associated autonomic failure?

hypo unawareness

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Who is especially at risk for hypo unawareness?

Older individuals, African Americans, children

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What is neuroendocrine response to hypo?

BG <70, adrenergic s/s like shakiness, sweating

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What is neuroglycopenic response to hypo?

BG <54, brain cells deprived of glucose

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Hypo is associated with what 3 conditions in the elderly?

Cognitive decline, dementia, mortality

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Why should a CHO containing fat NOT be used to treat hypo?

Fat retards and prolongs BG recovery

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Why should PRO containing CHO not be used to treat hypo?

PRO causes insulin response without BG recovery

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What are two outcomes of interest in CGM studies?

decrease A1c 0.3-0.6%

- decrease time spent in type 1 hypo <70 >54

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TIR from CGM is associated with what?

Reduced risk of complications (particularly microvascular)

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What 7 things should be considered when individualizing glycemic targets (hint: 2 modifiable, 5 non-modifiable)

2 modifiable: patient preference, patient support system/resources
5 non-modifiable: risk of hypo, DM duration, life expectancy, vascular complications, other important co-morbidities

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What are the standard CGM recommendations?

TIR: 70-180 >70% time
>180: <25% time
>250: <5% time
>70: <4% time
>54: <1% time

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What is the standard % coefficient target for CGM? When may a lower % be warranted?

standard: = 36%
lower: <33% if on sulfonylurea or insulin to protect against hypo

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How many days should CGM be worn?

14 days

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What % time CGM device is active is recommended?

> 70%

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TIR of 70% = what A1c?

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When should a lower TIR (>60% time) be recommended? What does that correlate to in A1c?

In those <25 years old. | ~7.5%

How many BG points is 1% in A1c?

~29 points

How to calculate BG from A1c?

A1c x 28.7- 46.7

What is level 1 hypo?

<70 but >/= 54

What is level 2 hypo?

<54

What is level 3 hypo?

no # but individual has AMS or APS and needs assistance from other to treat

What are the FBG, A1c, 1 H PP and 2 H PP goals for GDM?

FPG- <95 A1c- 6-6.5% 1 H PP- <140 2 H PP-<120

What is BP target in GDM?

120-135/80-85

What is BG goal in hospitalized pts?

140-180

When do you start insulin on hospitalized pt?

BG >180

What is the BP goal in an older adult who is relatively healthy?

<140/90

What is the BP goal for an older adult who is in poor health?

<150/90

What is the general peds A1c goal?

<7%; <6.5 if at low risk for hypo

What is BP goal in peds?

<120/80

When can you start statin in peds?

>/= age 10 | LDL >160 or LDL >130 + 1 or more CVD risk factor

What is the LDL goal in peds?

<100

When to start statin in adult?

LDL >130

BP goal in healthy adult w/ pre-DM or DM?

<130/80

BP goal in healthy adult w/o DM

<120/80

Dx criteria for DM

FBG: >/= 126 2 H: >/= 200 A1c: >/=6.5%

Dx criteria pre-DM

FBG: 100-125 2 H: 140-199 A1c: 5.7-6.4%

Normal glycemic values

FBG: <100 2 H: <140 A1c: <5.7%

Exercise targets in T1DM

90-250 to start, 15 g CHO prior, 0.5-1 g CHO/kg/hr

When is exercise inappropriate in T1DM?

>240 w/ ketones or s/s | never if >350, B-OHB >1.5 mmol/L

Exercise targets in T2DM- when to avoid

>300 & ketones or s/s

If pre-exercise BG is <90- what to do

15-30 g CHO

If pre-exercise BG is 90-150

may need 15 g CHO depending on type of exercise

What should peds BG be before exercise?

90-250

What is peds fasting goal and HS goal?

Fasting- 90-130 | HS- 90-150

How often should A1c be tested if pt is stable, tx goals met?

2x/year

How often should A1c be tested if tx has changed or not meeting goals?

quarterly

What are limitations of A1c?

- does not reflect hypo or glycemic variability

Why is CGM helpful?

- can guide MNT - prevent hypo/recognize it earlier - provide info that guides changing meds - tells you hyper, hypo, glycemic variability, time in range

Based on DCCT trial, intense BG tx (A1c 7% vs. 9%) reduced microvascular complications by what %

50-75%

Who benefits from less strict A1c targets?

- those w/ severe hypo - older/frail - advanced atherosclerosis - history of hypo

Target PP BG

<180 1-2 H after meal

What is preferred tx for hypo?

Glucose 15-20 g | Glucose grams rather than CHO grams

Who is @ risk for level 3 hypo?

- insulin users - poor glycemic control - albuminuria - poor cognitive function - older African Americans - >60 years old

Why is level 3 hypo dangerous?

Seizure, coma, death, loss of consciousness, falls, MVA

How can the risk for hypo be reduced?

- Bed time snack - individualize BG targets - exercise MGMT - medication MGMT - Glu monitoring - pt ed

T1 DM + level 3 hypo may benefit from what?

human islet transplant

What increases risk for situational hypo?

- fasting for test - delayed meals - during/after ETOH - during/after intense exercise - during sleep

For what conditions would using A1c not be appropriate for?

G6PD deficiency 2nd, 3rd trimester pregnancy recent blood loss, blood transfusion ESRD/HD

When should assay interference be considered w/ A1c?

When A1c is vastly different/does not correlate from SMBG

Most assays in the US are accurate in people with ______ for most common variants

heterozygous

TIR is associated with decreased risk of ______ complications

microvascular

Better glycemic control is associated with ______ reduction in microvascular conditions? (DCCT) Which microvascular conditions?

50-75% | DKD, neuropathy, retinopathy

Achieving A1c of

<7%

Greatest # of complications reduced when A1c goes from ______ to _____ control

Poor --> fair/good

What is the ACCORD trial and why was it stopped early?

Tried to get A1c <6% in T2DM | Increased mortality rate & CVD deah

Severe hypoglycemia is associated with _____ and _______

CVD events and mortality

What are s/s of hypo?

``` Shaky Sweaty Irritable Confused Hungry Tachycardia ```

Why did ADA change low end of fasting goal from 70 to 80?

Higher glycemic target corresponded to A1c goals and provided safety net against hypo

What is a breakthough s/s of hypo for someone on B-blocker?

Sweaty

What % of pts meet A1c, BP, lipid + non-smoking target?

15%

What % of pts do not meet targets for A1c, BP, or lipids?

33-50%

When someone is dx with DM what % of pancreas is functioning?

20%

When someone is dx with pre-DM what % of pancreas is functioning?

50%

What are peds A1c goals?

<7 for most <7.5 if they can't articulate s/s hypo <6.5% if they can do it safely

What are the A1c and fasting BG recommendations for a older healthy adult versus an older adult with complications and risk for hypo?

<7.5/90-130 versus <8/90-150

What are A1c and fasting BG recommendations for an older adult who is chronically ill and in poor health?

<8.5, 100-180