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Endocrinology > Type I Diabetes & Gestational Diabetes > Flashcards

Type I Diabetes & Gestational Diabetes Flashcards

1
Q

Diabetes mellitus is a chronic disorder associated with what?

Long term treatment emphasizes what?

A

Disturbances in carbohydrate, fat and protein characterized by hyperglycemia

Long term treatment emphasizes control of blood glucose levels to prevent the acute complications of ketosis and hyperglycemia

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2
Q

What are the four diabetes classifications?

4

A

Type 1 Diabetes (IDDM)

Latent autoimmune diabetes in adults (LADA)

Type 2 Diabetes (NIDM)

Gestational Diabetes

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3
Q
  1. Pathology of Type 1 diabetes?

2. How is it treated?

A
  1. Autoimmune disease that destroys the pancreatic beta cells causing absolute insulin deficiency

Bottom line: NO INSULIN BEING PRODUCED

  1. Oral agents INEFFECTIVE. Insulin therapy required
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4
Q

The age of presentation has a bimodal distribution:

When is the 1st peak and when is the 2nd?

A

1st peak at 4-6 years of age

2nd peak at 10- 14 years of age

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5
Q

Diabetes Mellitus Type 1
presentation?
5

A

new onset of chronic

  1. polydipsia,
  2. polyuria, and
  3. weight loss with hyperglycemia and ketonemia (or ketonuria)
  4. Diabetic ketoacidosis (DKA)
  5. Silent (asymptomatic) incidental discovery
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6
Q

What is the most common presentation of diabetes Type 1?

Second?

A

Most common: Hyperglycemia without acidosis

2nd most common: Diabetic ketoacidosis (hyperglycemia and ketoacidosis)

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7
Q

How does DKA present?

3

A
  1. Vomiting,
  2. dehydration,
  3. altered mental status (AMS).
    Often 4-8 L depleted!
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8
Q

What does DKA result from?

IN response to this the body switches to burning what instead of what?

A

Results from a shortage of insulin and corresponding increase in glucogon and the liver releases more glucose from glycogen

in response the body switches to burning fatty acids from adipose tissue and producing acidic ketone bodies that cause most of the symptoms and complications.

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9
Q

Describe osmotic diuresis from ketoacidosis?

What does it cause? 2

A

High glucose levels spill into urine taking water and Na+ and K+ along with it in a process known as osmotic diuresis

causing polyuria and dehydration

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10
Q

How do you treat DKA?

3

A

Treated with

  1. IV fluids,
  2. insulin,
  3. manage intercurrent illnesses, infection
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11
Q

Diabetes Presentation
Type 1 and 2 can be similiar. What are the symptoms? 10
(whats the triad of hyperglycemia?)

A 
Polyuria*
Polydipsia*
Polyphagia*
Lack of energy
Blurred vision
Pruritus
Candida infection 
Hyperglycemia
Glucosuria
Ketones in blood and urine
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12
Q

When do we often see polydipsia presented in DM?

2

A
  1. Non compliance of DM meds

2. Doses of DM meds not adequate

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13
Q

What is the pathology that causes polyphagia in DM pts? 2

How will this present?

A
  1. Mitochondria can’t get the glucose so metabolizes fat and protein
  2. Liver has to convert the fat and protein into ketones for energy

Excessive hunger and increased appetite with weight loss

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14
Q

WHy does diabtetes cause lack of energy?

2

A
  1. Lots of glucose in the blood but because the cells need insulin to get into the cell and they can’t.
  2. NO glucose in the cell then the mitochondria cant make ATP (energy)
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15
Q

Why does blurred vision happen in diabetes presentation?
(what part of the eye does it affect)

HOw can it improve or resolve?

A

Aqueous humor in the eye anteriorly

Glucose enters the aqueous humor and can distort the light

Improves or resolves with controlled glucose levels

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16
Q

WHy does itching occur with diabetes?

Where are candida infections found in pts with DM?
4

A

Irritated by the change in the osmolality

  1. Rash under breasts
  2. Vulvo-vaginal
    - -Repeated vulvitis
  3. Balanitis in men
  4. Diaper rash and recurrent thrush in infants
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17
Q

Diabetes diagnosis?

7

A
  1. Fasting blood sugar (FBS) >126 on two separate occasions
  2. Symptoms of hyperglycemia
  3. random blood sugar >200mg/dl
  4. Oral Glucose Tolerance Test (OGTT) >200
  5. Glycosylated hemoglobin (HgA1C) >6.5% (more on that later)
  6. Loss of C-peptide less than 0.8ng/dl (produced in the beta cells in the pancrease)
  7. Urine dipstick testing
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18
Q

What are we testing with urine dipstick tests for DM?

2

A
  1. +Glucose (Glucose starts “spilling” into the urine when serum >180)
  2. +Ketones
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19
Q

How do we differentiate between type 1 and type 2 diabetes?

2

A
  1. Antibodies – T1DM is suggested by the presence of circulating, islet-specific, pancreatic autoantibodies
  2. Insulin and C-peptide levels
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20
Q

What kind of antibodies will be present in diabetes Type 1? 3

If the pt doesnt have antibodies do they not have type 1?

A
  1. glutamic acid decarboxylase (GAD65)
  2. the 40K fragment of tyrosine phosphatase (IA2)
  3. insulin, and/or zinc transporter 8 (ZnT8).

absence of pancreatic autoantibodies does NOT rule out the possibility of T1DM.

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21
Q

Insulin and C-peptide levels
will be high in what type of diabetes?

Low in what type of diabetes?

A

High fasting insulin and C-peptide levels suggest T2DM.

Low levels or in the normal range relative to the concomitant plasma glucose concentration in T1DM.

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22
Q

Clinical Features in T1/T2?

  1. Typical onset age?
  2. Duration of symptoms?
  3. Body weight?
  4. Ketonuria?
  5. Rapid death?
  6. Autoantibodies?
  7. Complications at Diagnosis?
  8. Other autoimmune diseases?
A
  1. less than 30
  2. weeks
  3. Normal/low
  4. yes
  5. yes
  6. yes
  7. no
  8. common
  9. > 50
  10. months to years
  11. Obese
  12. no
  13. no
  14. no
  15. 25%
  16. uncommon
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23
Q

A1C describes what for the pt?

A

Glucose enters RBCs and links up (glycates) with hemoglobin

I explain to patients that their A1C is sort of a big picture measurement or batting average of how “sticky” their hemoglobin has gotten because of chronic elevated blood glucose

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24
Q

What are our goals for Hb A1C?

A

Healthy, non-diabetic….6.5%
ADA recommends measuring A1C 3-4x year for type 1 and controlled type 2 diabetics, and 2x year for well-controlled type 2 diabetics
Don’t need to be fasting

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25
Q

Making the diagnosis of Type 1 Diabetes:

  1. Symtpoms? 4
  2. Hgb A1C?
  3. Fasting plasma glucose?
  4. Oral glucose tolerance test?
  5. Random plasma glucose?
  6. Loss of C-peptide?
  7. Presence of islet autoantibodies? 4
A
  1. polyuria, dypsia, phagia and DKA
  2. 6.5% or over
  3. 126 or over
  4. 200 or over
  5. 200 and over
  6. less than 0.8
  7. GADA, ICA, IA-2A, IAA
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26
Q

Acute Type 1 Diabetes Complications?

4

A

Diabetic ketoacidosis (DKA)
Dehydration
Hyperglycemia
Infections

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27
Q

CHRONIC-END ORGAN DAMAGE diabetes complications are due to what?

A

Microvascular complications

Macrovascular complications

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28
Q

Microvascular complications for diabetes?
3

Macrovascular complications for diabetes?
3

A
  1. Diabetic Retinopathy
  2. Diabetic Nephropathy (most common cause of renal failure)
  3. Diabetic Neuropathy
  4. Cardiovascular Disease (CAD, MI,)
  5. Cerebrovascular Disease (TIA and Stroke)
  6. Peripheral Arterial Disease
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29
Q

Diabetes Management is targeted at what?

2

A
  1. Targeted glycemic goals- balancing act

2. Lower the risk of complications of hyperglycemia vs. hypoglycemia.

30
Q

Diabetes Management
consists of who?
5

A
  1. Primary care provider
  2. Endocrinologist
  3. Nurse educator
  4. Dietitian
  5. Mental health professional, who can provide pediatric-specific education and care. T1DM is a life changing diagnosis for your younger patients
31
Q

Training and care of the patient and family is divided into two management phases. What are they and describe them.

A

Initial phase-

  • -treatment with insulin is initiated
  • -the patient and family are taught the most essential skills to safely manage diabetes.

Second ongoing phase-
–the family is given further education and support to optimize glycemic control and long-term management.

32
Q

Diabetes Management
initial management?
5

A
  1. Education on disease process
  2. Insulin administration
  3. Blood glucose testing
  4. Testing for ketonuria (This is especially important in young children, insulin pump users, or those with a history of DKA)
  5. Hypoglycemia
33
Q

Self Monitoring Blood Glucose should be used for what pts? 2

Why should they do it?
3

A

1, All patients with DM who use insulin
2. Most patients who take other glucose lowering medications

  1. Glucose control
  2. Adjustments of insulin and diet
  3. Timely intervention to avoid serious hypoglycemic events
34
Q

GLycemic index describes what happens after consuming a carbohydrate contain gin food. What does it take into account?
2

A
  1. the rise in plasma glucose levels (looking at the peak)

2. The area under the curve for the 2 hour period after the food is consumed

35
Q

What is the standard reference value based on for the gylcemic index?
2

What kind of carb containing foods raise the plasma glucose rapidly?

A
  1. usually glucose or white bread
  2. All other foods are measured against this standard

Drinks because they dont have to be digested

36
Q 
THERAPEUTIC GOALS FOR GLYCEMIC CONTROL:
A1C goal?
At what level should we take action?
Older adults with no comorbidities?
Older pts with Complex/intermediate health?
Older pts with Very complex/poor health?
A

Goal of therapy: less than 7% A1C

Action suggested: >8% A1C

Older Adults: (healthy) less than 7.5%…..no comorbidities, longer life expectancy

Complex/intermediate health: less than 8.0%

Very complex/poor health: less than 8.5%

37
Q

THERAPEUTIC GOALS FOR GLYCEMIC CONTROL pediatric pts:

13-19 yrs?
6-12 yrs?
toddlers and preschoolers?

A

13-19 years: 7.5%
6-12 years: less than 8%
Toddlers and preschoolers: less than 8.5% but > 7.5%

38
Q

What are the types of DM type 1 insulin replacement therapy?

2

A
  1. fixed insulin dosing

2. insulin pump therapy

39
Q

Multiple daily injections
The MDI regimen combines a baseline level of insulin using what kind of insulin?

With premeal/snack boluses of what?

A

long-acting insulin

rapid- or short-acting insulin

40
Q

Pre-meal and pre-snack bolus doses of a rapid- or short-acting insulin are based upon three factors?

A
  1. Pre-meal blood glucose level
  2. Estimated amount of carbohydrates to be consumed
  3. Expected level of exercise after the meal
41
Q

What is the long acting insulin?

What is its duration?

Why do we need to divide the injection to two times a day?

A

Insulin glargine (Lantus) is the long-acting Insulin,

It usually has a duration of action of 20-24 hrs,

but the half-life is shorter in some patients, requiring division of the daily dose into 2 injections per day.

42
Q

Comprehensive Annual Examination PE for T1DM?

6

A
  1. Height and Weight
  2. Blood pressure determination
  3. Funduscopic examination
    - -Refer to ophthamology/optometry for annual exams
  4. Thyroid palpation
  5. Skin examination
  6. Neurological/foot examination
43
Q

Comprehensive Annual Exam laboratory evaluation for T1DM?

6

A
  1. HbA1c (q 3 months)
  2. Fasting lipid profile
  3. Liver Function Tests (LFTs)
  4. TSH
  5. Celiac disease screening (tTG Q 2-3 years)
  6. Kidney profile (CMP or Chem7)
44
Q

What is in the kidney profile for a T1DM pt?

3

A
  1. Serum creatinine and calculated GFR
  2. Urine albumin-to-creatinine (annually)
  3. UA
45
Q

Comprehensive Annual Exam refferals?

5

A
  1. Endocrinologist
  2. Ophthalmology
  3. Dietician
  4. Diabetes Educator
  5. Family Planning for women of reproductive age
46
Q

What are the two things pathologically that cause gestational diabetes?
2

Placenta produces larger quantities of more hormones than any other human organ. Name 4 examples?

A
  1. Insulin receptors do not function properly
  2. Hormonal changes make cells less responsive to insulin
  3. Human placental lactogen
  4. Estrogen
  5. Progesterone
  6. Cortisol

Vital hormones in pregnancy preservation

47
Q

Hormones from placenta block what?

What are the trimesters that mom needs the insulin the most and how much do they need?

A

the action of the mother’s insulin….leading to insulin resistance.

2nd and 3rd trimester – mom needs three times as much insulin as normal. Growing placenta continues with insulin resistance, leading to hyperglycemia in mom.

48
Q

What weeks does gestational diabetes occur and when can it be measured?

A

Usually occurs about the 20th to 24th week of
pregnancy.

Can be measured by the 24th to 28th week.

49
Q

Why does Gestational Diabetes lead to macrosomia….. “fat” baby….increased birth weight?
3

A
  1. Mom’s insulin doesn’t cross the placenta.
  2. Excess glucose from mom does.
  3. Baby produces more insulin to counter extra glucose crossing placenta.
50
Q

GD Risk Factors?

3

A
  1. Age (over 25)
  2. Family or personal history (family member with T2DM or occurred in previous preg)
  3. Weight (overweight before pregnancy)
51
Q

The ADA (American Diabetes Association) recommends that all pregnant women, who have not been identified with glucose intolerance earlier in pregnancy, be screened with a ________ between 24 and 28 weeks of pregnancy.

A

50-g 1-hour GCT

52
Q

GD Screening Recommendations:
If no risk factors what should we start screening at?

What is they have prior symtpoms that occur?

What are these sytmpoms?
6

A

screening starts at 24-28 weeks

Women with risk factors – screening at first prenatal visit and again at 24-28 weeks

  1. Increased thirst
  2. Increased urination
  3. Weight loss in spite of increased appetite
  4. Fatigue
  5. Nausea and vomiting
  6. Blurred vision
53
Q

Diagnosis for GD:

Initial test?

A

Glucose challenge test

54
Q

Descibe the glucose challenge test.

Have to be fasting?
How much glucose?
Wait how long?
Positive test result?

A

This test does not have to be fasting

50 grams of glucose orally (glucola)

Wait one hour and have blood glucose level drawn

A value equal to or above 140mg/dL should be used as the threshold level.

55
Q

Blood glucose above what requires a 2nd test for diagnosis?

A

Blood glucose above 130** requires a 2nd test for diagnosis.

Only about 1/3 of women who test positive on the glucose screen actually have GD.

56
Q

What is the second test if the pt is positive for the glucose challenge test?

When is this test done?
How much glucose?
When are glucose levels drawn?

A

3 hr Glucose Tolerance Test

This test is done in the AM after an overnight fast

100 grams of glucose solution orally

Blood glucose levels drawn at fasting, 1 hour, 2 hours and 3 hours

57
Q

What is a positive 3 hr glucose tolerance test?

Positive results: (two or more of the following 4)

A

Having at least two instances of abnormal blood glucose levels at any hour indicates GESTATIONAL DIABETES.

** Some practitioners just do a three hour fasting and use those results.

Fasting > 95
1 hour > 180
2 hours > 155
3 hours > 140

58
Q

What is macrosomia caused by?
2

What will the birth weight be to qualify as macrosomia?

A
  1. Extra glucose can cross the placenta and end up in the baby’s blood.
  2. Baby’s pancreas makes extra insulin to process the extra glucose, and this can cause the baby to grow too large (macrosomia).

For a full-term pregnancy, this means a birth weight of 4,500 grams (9 pounds, 14 ounces) or more.

59
Q

What is shoulder dystocia?

A

Baby’s shoulders may be too big to move through the birth canal. This results in a potentially life-threatening obstetrical emergency, known as shoulder dystocia

60
Q

Why would the baby be hypoglycemic slightly after birth?

How should we treat this?

A

The baby is accustomed to receiving large amounts of glucose from the mother, and their own insulin production is high.

May need to feed right away or give baby IV glucose solution

61
Q

Jaundice (hyperbilirubinemia)
is due to what?
2

A
  1. Perhaps due to high levels of insulin production which tend to produce extra RBC’s in utero.
  2. These RBC’s breakdown and bili builds up
62
Q

When is still birth or death a risk in GD mothers?

A

If GD goes undetected throughout the pregnancy

63
Q

Complications for the baby
after birth?
2

A
  1. Babies are at risk for obesity as children.

2. Increased susceptibility to Type 2 Diabetes as adults.

64
Q

Complications for mom due to GD?

5

A
  1. Preeclampsia
  2. Polyhydramnios
  3. Operative Delivery (C-Section)
  4. Develpo Type 2 diabetes
  5. GD in next pregnancy
65
Q

What is significanty increased in Preeclampsia (for GD) pts?
3

What is Polyhydramnios?
(how do we diagnose)

A

blood pressure,
edema,
proteinuria

Excess amniotic fluid around the baby.
Can do ultrasound to check fluid level.

66
Q

Tretament of GD?

A

CONTROL BLOOD SUGAR!

Insulin is FIRST-LINE rather than oral anti-hyperglycemic agents during pregnancy

67
Q

Women who do not achieve adequate glycemic control with nutritional therapy and exercise alone what should we treat with?

What do we want our levels to be:
FBG?
One hour?
Two hour?

A

Treat with insulin

FBG is ≥95
or one-hour postprandial BG is ≥130 or
two-hour glucose is >120, on two or more occasions within a one-week interval

68
Q

Alternative therapy for GD who fail exercise and diet and can’t/wont take insulin?

A

glyburide is a reasonable alternative for women who fail diet therapy and refuse to take, or are unable to comply with insulin therapy

69
Q

Optimal Glycemic Goals for Gestational Diabetes

  1. Preprandial:
  2. 1 hour post meal:
  3. 2 hour post meal:

For women with pre-existing Type 1 or Type 2 DM who become pregnant:

  1. Pre-meal, bedtime, overnight glucose:
  2. Peak post-prandial glucoxe:
  3. HbA1C:
A

Preprandial: less than 95 mg/dl
1 hour post meal: less than 140 mg/dl
2 hour post meal: less than 120 mg/dl

For women with pre-existing Type 1 or Type 2 DM who become pregnant:
Pre-meal, bedtime, overnight glucose: 60-99 mg/dl
Peak post-prandial glucoxe: 100-129 mg/dl
HbA1C: less than 6.0%

70
Q

What improves glycemic control and should be encouraged in women who had gestational diabetes?

Women with gestational diabetes should be tested for diabetes ______ via fasting blood glucose measurements on two occasions or a two-hour oral 75-g glucose tolerance test.

A

Breastfeeding

6-8 weeks after delivery

71
Q

Diabetes is the leading cause of what two things in the US?

A

Leading cause of blindness

Leading cause of kidney disease

Endocrinology (23 decks)

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