SOC 6: Glycemic targets Flashcards
What are 2 alternatives to A1c test?
Fructosamine & 1,5 andhydroglucitol
African Americans have what % point reduction in A1c if they have these variants?
Hbs- 0.3
G6PD- 0.8
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
How to prevent DKA?
Ensure adequate fluids & kcals
What poorly effects endothelial function?
Post prandial hyperglycemia
When is it appropriate to have pt monitor post prandial values?
When pre-meal is within target but A1c is elevated
What usually prompts an episode of DKA?
Stress, illness, trauma, mediation (steroids)
What should be encouraged immediately after HYPO episode?
Meal or snack
For whom should glucagon be prescribed?
Those @ risk for level 2 hypo
What is hypo associated autonomic failure?
hypo unawareness
Who is especially at risk for hypo unawareness?
Older individuals, African Americans, children
What is neuroendocrine response to hypo?
BG <70, adrenergic s/s like shakiness, sweating
What is neuroglycopenic response to hypo?
BG <54, brain cells deprived of glucose
Hypo is associated with what 3 conditions in the elderly?
Cognitive decline, dementia, mortality
Why should a CHO containing fat NOT be used to treat hypo?
Fat retards and prolongs BG recovery
Why should PRO containing CHO not be used to treat hypo?
PRO causes insulin response without BG recovery
What are two outcomes of interest in CGM studies?
- decrease A1c 0.3-0.6%
- decrease time spent in type 1 hypo <70 >54
TIR from CGM is associated with what?
Reduced risk of complications (particularly microvascular)
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
What are the standard CGM recommendations?
TIR: 70-180 >70% time >180: <25% time >250: <5% time >70: <4% time >54: <1% time
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
How many days should CGM be worn?
14 days
What % time CGM device is active is recommended?
> 70%
TIR of 70% = what A1c?
7%
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
