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2016 Endocrine > Test 2 Type 2 DM Therapeutics > Flashcards

Test 2 Type 2 DM Therapeutics Flashcards

1
Q

Diabetes Mellitus (DM) – Type 1 vs. Type 2

A
  • T1DM – do not make insulin; no pancreatic function
    • Mostly seen in adolescents
    • Insulin is mainstay treatment – beta-cells do not produce insulin
    • Must rely on exogenous source to survive
  • T2DM – Make insulin; have pancreatic function,, but may not be 100% (insulin resistance – the body does not know how to use insulin; liver, muscle, and fat cells are not responding to the insulin -> not taking up glucose)
    • Oral agents are mainstay of treatment; may use insulin if they are not responding
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2
Q

Overview of Pathophysiology

A
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3
Q

Progressive Deterioration in β-cell Function Over Time

A
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4
Q

Clinical Presentation

A
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5
Q

Risk Factors for Type 2 DM

A
  • Visceral fat – fat belly is seen in many patients
    • Obese/overweight
    • Lack of exercise
    • Poor diet
    • Family history
    • HTN
    • HLD (TG > 250)
    • Gestational diabetes (deliver baby > 9lb)

Diabetic triad:

  • HTN
  • HLD
  • DM
    • Treat all three together to prevent MI, stroke
  • Gestational diabetes → greater risk of developing T2DM over time
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6
Q

Classic Symptoms

A
  • 2/3 of patients present without symptoms
  • 3 P’s
    • Polyuria (frequent/increased urination)
    • Polydipsia (increased thirst)
    • Polyphagia (increased hunger)
  • Other symptoms include
    • Unexplained weight loss
    • Weakness
    • Fatigue
    • Dizziness
    • Blurred vision
    • Impaired wound healing
    • Increased number of infections – yeast infections in women
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7
Q

Diagnosis

A
  • Fasting glucose is the primary tool used for the diagnosis of diabetes
  • Four possible ways to diagnose diabetes
    • A1c (newest way to diagnose)
      • > 6.5
    • 2 hour post prandial glucose test
      • ≥ 200
    • Fasting plasma glucose test
      • ≥ 126 on 2 separate occasions
    • Random/casual glucose test (not commonly used)
      • ≥ 200 + presence of symptoms
  • Criteria for the diagnosis
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8
Q

Categorization of Glucose

A
  • Fasting plasma glucose (FPG) – minimum of 8 hours without food or drink (may have water)
    • Normal = < 100
    • Impaired fasting glucose (IFG) = 100 - 125
    • Diabetes mellitus = ≥ 126 on 2 consecutive lab draws (time between draws is not specified)
  • 2 hour post load plasma glucose (OGTT) – take a fasting lab first, then drink 75g sugar water, then wait 1, 2, 3 hours and draw labs à see how the body is responding to the sugar. 1 time test.
    • Normal = < 140
    • Impaired glucose tolerance (IGT) = 140 - 199
    • Diabetes mellitus = ≥ 200
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9
Q

Hemoglobin A1C (Hgb A1C)

A
  • 2 – 3 month average of glucose
    • 35 mg/dL for each % increase in A1c
  • Per ADA, If patient is achieving glycemic control à only measure 2 x per year
    • Rarely done this way à usually measured every 2 – 3 months
  • Fructosamine level – like the A1c – average of blood sugar over 2 – 3 weeks
    • May be used in a patient who is not well controlled, anemia patients, pregnant women, patients who receive frequent blood transfusions, or if A1c does not correlate with their daily glucose readings
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10
Q

Direct correlation between A1C levels and average blood glucose levels (don’t memorize)

A
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11
Q

Estimated Average Glucose (EAG)

A
  • The relationship between A1C and eAG is described by the formula
  • More closely related to what the patient sees on a daily basis when they take their glucose readings
  • The relationship between A1C and eAG is described by the formula: 28.7 X A1C – 46.7 = eAG (must know)
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12
Q

2016 ADA Guidelines: Summary of Revisions (Not responsible for these)

A
  • Classification and diagnosis
    • Changed BMI cutoff for Asian-Americans to 23
  • Foundations of care
    • Recommend that a patient not be sedentary for 2 consecutive days in a row
    • E-cigarettes are not considered smoking-cessation therapy
    • Pneumococcal recommendations
  • Glycemic targets
    • Fasting cutoff = 80 – 130
  • Glycemic treatment
    • Algorithm includes SGLT-2 inhibitors as treatment
  • CV disease and risk management
    • Diastolic BP goal is 90
  • Microvascular complications and foot care
    • Patient should be practicing good foot care
    • Providers should perform a thorough foot exam at each visit, not just with complications
  • Children and adolescents
    • Target A1c < 7.5%
  • Pregnancy
    • Complications, proper counseling, treatment options
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13
Q

Glycemic Goals of Therapy

A
  • know ADA and VA DoD
  • Patient should test at least 2 hours after a meal
    • Bedtime goal < 150
      • Should be > 3 hours after meal
  • Microvascular complications: retinopathy, neuropathy, and nephropathy
  • Macrovascular complications: CV disease, MI, stroke
  • For every 1% decrease in A1c, 40% reduction in microvascular complications and 24% reduction in macrovascular complications
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14
Q

Pivotal Trials in Diabetes (“The Evidence”)

A
  • Don’t need to know trials for exam
    • United Kingdom Prospective Diabetes Study (UKPDS)
      • Conventional vs intensive therapy
      • Sulfonylureas decrease incidence of microvascular complications
      • Metformin decreases incidence of microvascular and macrovascular complications
  • Action to Control Cardiovascular Risk in Diabetes (ACCORD)
    • Does lowering glucose levels reduce risk of CV event?
    • Standard vs intensive therapy (insulin)
    • Increased mortality/complications in patients < 6.5% A1c
      • Goal is < 8% for most patients with multiple comorbidities
    • Lower is not always better
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15
Q

Goals of Diabetes Management

A
  1. Prevent complications (microvascular and macrovascular)
    * Don’t want to lose eye sight, amputation
  2. Reduce hyperglycemia
    * Will reduce risk of complications
  3. Prevent mortality
  4. Improve quality of life
    * Tailor treatment to occupation
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16
Q

Self-Monitoring of Blood Glucose (SMBG)

A
  • Few studies have shown a positive correlation with home blood glucose testing for patients with type 2 diabetes
  • Role of SMBG in improving glycemic control in patients with type 2 diabetes is unproven and controversial
  • Frequency should be sufficient enough to help patients achieve their glycemic goal
  • For those patients on oral therapy
    • Every other day testing, or with symptoms
  • For those patients on insulin therapy, SMBG should be more intense and frequent
    • Test 3 – 4 x per day
  • Why do we do it? The only way to adjust therapy and achieve glycemic control is through SMBG. This also allows the patient to take control of their disease.
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17
Q

Definition of Hypoglycemia

A
  • Blood glucose < 70 + the presence of symptoms
  • Blood glucose may be > 70 + symptoms
  • Everyone may have a different threshold – determine what level they begin to experience symptoms
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18
Q

Signs and Symptoms of Hypoglycemia

A
  • Headache
  • Jittery/shaking
  • Confusion
  • Blurred vision
  • Sweating
  • Dizziness
  • Fast heartbeat
  • Weakness/fatigue
  • Irritability (uncommon)
  • Anxiety
  • Hunger
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19
Q

Treatment of Hypoglycemia

A
  • 15 g carbs in 15 minutes – correct the low sugar quickly
  • 1 g carbs increases glucose by 3 – 5 mg/dL
    • 4 oz soda (not diet coke)
    • 4 oz fruit juice
    • Orange juice
    • Whole milk (more fat and sugar than 1% or 2%)
    • Frosting
    • Glucose tablets (4 g per tab)
    • 4-5 tablets
    • 5 – 6 hard candies
    • honey
  • Meals and candy bars will not raise sugar quick enough
  • Wait and check glucose in 15 minutes
  • Once sugar is back to level, they should have a mea
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20
Q

Treatment of Type 2 Diabetes Mellitus

A
  1. Medical nutrition therapy (MNT)
  2. Exercise
  3. Oral agents
  4. Injectable therapy
  5. Insulin
21
Q

Medical Nutrition Therapy (MNT)

A
  • Low/moderate carbs
  • Low saturated fats
  • High protein
22
Q

Medical Nutrition Therapy (MNT): Carbohydrates

A
  • Carbohydrates
    • 3 servings per meal
    • 15 g carbs per serving
    • 45 g total per meal (per ADA)
    • May differ in each patient
      • White vs wheat
        • “The whiter the bread, the quicker you’re dead”
        • Encourage wheat bread
  • Make 2 dietary changes per visit – don’t change everything at once
    • Vegetables
      • Carrots, peas, and corn are high in carbs
      • Should eat more green veggies
    • Fruits
      • Berries – blueberries, blackberries, raspberries
      • Any fruit that you can eat the peel will have more fiber and less carbs
      • High sugar fruits – strawberries, bananas, watermelon, grapes
    • Frozen fruits/vegetables are better than canned
23
Q

Medical Nutrition Therapy (MNT): Fat and Cholesterol

A

limit to less than 7% of total calories

24
Q

Medical Nutrition Therapy (MNT): Fiber

A

At least 30 g per day

25
Q

Medical Nutrition Therapy (MNT): Protein

A

0.8 g/kg/day

26
Q

Medical Nutrition Therapy (MNT): Sweetners

A
  • Stevia – 3 g carbs per packet – better because it is natural and has low carbs
  • Sweet and Low
  • Equal
  • Aspartame
  • Truvia

Can still raise blood sugar, but if they are using less of it and not using regular sugar, they shouldn’t see much of an increase

27
Q

Medical Nutrition Therapy (MNT): Alcohol

A
  • Women are restricted to 1 drink, men to 2 drinks
  • Worry about binge drinking
  • Alcohol can increase sugar à prolonged use can cause hypoglycemia
28
Q

Medical Nutrition Therapy (MNT): Others

A
  • Micronutrients and Antioxidants
  • Cinnamon Supplements
    • Cinnamon supplements – may lower the blood sugar, but can also cause hypoglycemia at larger doses
29
Q

Treatment: Exercise

A
  • 30 min x 5 days a week
  • Moderate intensity aerobic exercise – make sure cardiac patients are cleared
    • Walking, bike riding, swimming, jogging
30
Q

Treatment: Pharmacologic Agents

A
  • know this table except 1st generation sulfonylureas
31
Q

2014 New Drugs

32
Q

2015 New Drugs

33
Q

2016 New Drugs

34
Q

Metformin (Glucophage)

35
Q

First Generation Sulfonylureas

36
Q

Second Generation Sulfonylureas

37
Q

Non-Sulfonylureas

38
Q

Thiazolidinediones

39
Q

Alpha-Glucosidase Inhibitors

40
Q

GLP-1 Agonists (Incretin Mimetics)

41
Q

GLP-1 Agonists Dosing Chart

42
Q

DPP- 4 Inhibitors

43
Q

Sodium Glucose Co-Transporter 2 (SGLT2) Inhibitors

44
Q

Amylin Agonist

45
Q

A1C Reduction – Summary Table

46
Q

Why would it be okay to add metformin or a TZD to therapy?

47
Q

Role of Insulin Therapy in Type 2 DM

48
Q

Evidence Based Treatment Algorithm – 2016 ADA Guidelines

49
Q

Evidence Based Treatment Algorithm - VA DoD Guidelines

2016 Endocrine (19 decks)

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