special populations Flashcards
kania pt 4
what are the maternal risk of gestational diabetes?
retinopathy –> must have dilated eye exam before pregnancy and in first trimeter; must be monitored at every trimester and postpartum
pre-eclampsia –> take aspirin starting at 12-16 weeks if no CI
what can a woman do pre-conception to prevent gestational diabetes?
if have diabetes –> have counseling and establish multidisciplinary team
family planning
goal A1c –> under 6.5%
what is the FBS target in pregnancy?
70 to 95 mg/dL
what is 1-hr postprandial target in pregnancy?
110 to 140 mg/dL
what is the 2-hour postprandial target in pregnancy?
100 to 120 mg/dL
what is A1c target in pregnancy?
under 6%
under 7% if necessary to prevent hypoglycemia
how does insulin sensitivity change throughout pregnancy?
early –> enhanced, hypoglycemia can ensue especially in T1DM
16 weeks –> resistance increases and TDD increases by 5% per week through week 36 (up to 2-3x start)
third trimester –> placental aging causes insulin level off
what does a rapid reduction in insulin requirement signify in pregnancy?
that the placenta is not developing sufficiently
something is wrong
what are some complications that can occur with pregnant T1DM pts?
increased risk of hypoglycemia in first trimester
decreased hypoglycemia awareness due to hormone changes
increased risk of DKA –> prescribe ketone strips, may cause still births
sensitivity to insulin
what are some complications that can occur with pregnant T2DM patients?
increased risk for comorbidities (HTN, etc) –> d/c potentially harmful medications like ACEis, ARBs, and statins
weight gain (control based on BMI)
requirement of high insulin dose –> maybe even concentrated insulin
what is the BP target in pregnant T2DM?
110 to 135/85 mmHg
when is pregnancy loss common in diabetes pts?
T2DM –> 3rd trimester
T1DM –> 1st trimester
what does treatment of gestational diabetes look like?
insulin preferred
metformin if pt cannot take insulin
avoid glyburide/glipizide (due to macrosomia and birth injury)
minimal data with other agents
what is the dosing for insulin in gestational diabetes?
0.7 to 1 units/kg/day
divide dose between basal/bolus
adjust base on response
why is metformin just ok to treat gestational diabetes?
only use if pt cannot take insulin due to it crossing the placenta
may be associated with pre-term birth
d/c if using for PCOS by end of 1st semester
how should gestational diabetes be treated postpartum?
check OGTT 4-12 weeks postpartum
then check for diabetes every 1-3 years due to increased risk
what are unique features of diabetes in pediatrics?
important to determine the true diagnosis of T1 vs T2
treating T2DM in youth is different than in adults
target A1c goal of 7% is similar to adults
why does T2DM look different in youth?
more rapid decline in B-cell function (might look more like T1 for a while)
more accelerated development of diabetes complications
how would you treat T1DM in pediatrics?
insulin (pump preferred but make sure they have education)
use of cGM!!
work with school systems for proper management
how would T2DM be treated in pediatrics?
medical nutrition therapy + exercise
based on A1c
if patient presents with ketoacidosis –> treat with SQ or IV insulin
how would a child with an A1c < 8.5 and T2DM be treated?
metformin first
based on renal function
how would a T2DM child with an A1c greater than 8.5%, blood sugar over 250 mg/dL without acidosis, and symptoms be treated?
basal insulin and metformin
how would a child not on goal who are already on metformin and insulin be treated?
GLP-1RAs and/or empagliflozin if older than 10 yo
how would a child who is not at goal on metformin, GLP-1RA, empagliflozin, and basal insulin be treated?
begin bolus insulin or change to insulin pump therapy
**harder to approve by insurances
what are the tx goals of a healthy geriatric patient?
A1c –> under 7-7.5%
FBG –> 80-130 mg/dL
Bedtime BG –> 80-180 mg/dL
BP –> under 130/80 mmHg
what are the tx goals of a complex/intermediate geriatric?
A1c –> under 8%
FBG –> 90-150 mg/dL
Bedtime BG –> 100-180 mg/dL
BP –> under 130/90 mmHg
what are tx goals of very complex/poor health geriatric patients?
A1c –> avoid reliance, should be based on avoid hypoglycemia and s/s of high BS
FBG –> 100-180 mg/dL
Bedtime glucose –> 110-200 mg/dL
BP –> under 140/90 mmHg
what are the general standards for diabetic pts in hospitals?
perform an A1c
administer insulin via written or computerized protocols
initiate insulin for glucose > 180, then target 140-180
how are diabetic pts treated in hospitals?
basal insulin or basal-bolus preferred for noncritical (along with correction factor)
no sliding scale insulin
use IV insulin for critical care
usually hold non-insulin diabetes medication
how do glucocorticoids related to diabetes?
short-acting gcs may cause hyperglycemia during the day with return to regular nighttime levels –> may need to adjust prandial insulin or add AM NPH dose
monitor closely
what are the target goals perioperative?
A1c –> under 8%
BG –> 100-180 mg/dL within 4 hours of surgery
how is metformin and SGLTs be managed perioperative?
metformin –> withheld on day of surgery
SGLT2 –> hold 3-4 days before surgery
both can be resume once patient is stable and back to baseline
how is insulin managed perioperative?
basal –> reduce by 25% on the evening before surgery
bolus –> hold once patients becomes NPO
NPH –> give half of dose morning of
long-acting/pump basal –> give 75-80% of dose morning of
how are other oral-glucose lowering medications managed perioperative?
hold the morning of the surgery
how often should glucose be monitored while perioperative?
2-4 hours while NPO
dose with short or rapid acting insulin prn based on correction dosing
