special populations

Question 1

what are the maternal risk of gestational diabetes?

Answer 1

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

Question 2

what can a woman do pre-conception to prevent gestational diabetes?

Answer 2

if have diabetes –> have counseling and establish multidisciplinary team
family planning
goal A1c –> under 6.5%

Question 3

what is the FBS target in pregnancy?

Answer 3

70 to 95 mg/dL

Question 4

what is 1-hr postprandial target in pregnancy?

Answer 4

110 to 140 mg/dL

Question 5

what is the 2-hour postprandial target in pregnancy?

Answer 5

100 to 120 mg/dL

Question 6

what is A1c target in pregnancy?

Answer 6

under 6%
under 7% if necessary to prevent hypoglycemia

Question 7

how does insulin sensitivity change throughout pregnancy?

Answer 7

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

Question 8

what does a rapid reduction in insulin requirement signify in pregnancy?

Answer 8

that the placenta is not developing sufficiently
something is wrong

Question 9

what are some complications that can occur with pregnant T1DM pts?

Answer 9

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

Question 10

what are some complications that can occur with pregnant T2DM patients?

Answer 10

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

Question 11

what is the BP target in pregnant T2DM?

Answer 11

110 to 135/85 mmHg

Question 12

when is pregnancy loss common in diabetes pts?

Answer 12

T2DM –> 3rd trimester
T1DM –> 1st trimester

Question 13

what does treatment of gestational diabetes look like?

Answer 13

insulin preferred
metformin if pt cannot take insulin
avoid glyburide/glipizide (due to macrosomia and birth injury)
minimal data with other agents

Question 14

what is the dosing for insulin in gestational diabetes?

Answer 14

0.7 to 1 units/kg/day
divide dose between basal/bolus
adjust base on response

Question 15

why is metformin just ok to treat gestational diabetes?

Answer 15

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

Question 16

how should gestational diabetes be treated postpartum?

Answer 16

check OGTT 4-12 weeks postpartum
then check for diabetes every 1-3 years due to increased risk

Question 17

what are unique features of diabetes in pediatrics?

Answer 17

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

Question 18

why does T2DM look different in youth?

Answer 18

more rapid decline in B-cell function (might look more like T1 for a while)
more accelerated development of diabetes complications

Question 19

how would you treat T1DM in pediatrics?

Answer 19

insulin (pump preferred but make sure they have education)
use of cGM!!
work with school systems for proper management

Question 20

how would T2DM be treated in pediatrics?

Answer 20

medical nutrition therapy + exercise
based on A1c
if patient presents with ketoacidosis –> treat with SQ or IV insulin

Question 21

how would a child with an A1c < 8.5 and T2DM be treated?

Answer 21

metformin first
based on renal function

Question 22

how would a T2DM child with an A1c greater than 8.5%, blood sugar over 250 mg/dL without acidosis, and symptoms be treated?

Answer 22

basal insulin and metformin

Question 23

how would a child not on goal who are already on metformin and insulin be treated?

Answer 23

GLP-1RAs and/or empagliflozin if older than 10 yo

Question 24

how would a child who is not at goal on metformin, GLP-1RA, empagliflozin, and basal insulin be treated?

Answer 24

begin bolus insulin or change to insulin pump therapy
**harder to approve by insurances

Question 25

what are the tx goals of a healthy geriatric patient?

Answer 25

A1c –> under 7-7.5%
FBG –> 80-130 mg/dL
Bedtime BG –> 80-180 mg/dL
BP –> under 130/80 mmHg

Question 26

what are the tx goals of a complex/intermediate geriatric?

Answer 26

A1c –> under 8%
FBG –> 90-150 mg/dL
Bedtime BG –> 100-180 mg/dL
BP –> under 130/90 mmHg

Question 27

what are tx goals of very complex/poor health geriatric patients?

Answer 27

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

Question 28

what are the general standards for diabetic pts in hospitals?

Answer 28

perform an A1c
administer insulin via written or computerized protocols
initiate insulin for glucose > 180, then target 140-180

Question 29

how are diabetic pts treated in hospitals?

Answer 29

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

Question 30

how do glucocorticoids related to diabetes?

Answer 30

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

Question 31

what are the target goals perioperative?

Answer 31

A1c –> under 8%
BG –> 100-180 mg/dL within 4 hours of surgery

Question 32

how is metformin and SGLTs be managed perioperative?

Answer 32

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

Question 33

how is insulin managed perioperative?

Answer 33

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

Question 34

how are other oral-glucose lowering medications managed perioperative?

Answer 34

hold the morning of the surgery

Question 35

how often should glucose be monitored while perioperative?

Answer 35

2-4 hours while NPO
dose with short or rapid acting insulin prn based on correction dosing