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DM Therapeutics Exam 1 > Week 1: Guidelines, Studies, Lifestyle, Inpatient > Flashcards

Week 1: Guidelines, Studies, Lifestyle, Inpatient Flashcards

1
Q

Therapy for obese patients with no complications and BMI <27 or BMI >27

A

lifestyle modifications, MDIRD counseling, web program for weight loss

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2
Q

BMI >27 w complications treatment

A

low complication severity: lifestyle mod, med tx
medium severity: lifestyle, med
high: lifestyle mod, med, surgery (BMI>35)

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3
Q

two conditions that need to be treated in pre DM

A

hyperlipidemia and HTN

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4
Q

what happens if pre-DM progresses to overt?

A

Does pt have FPG>100 and/or 2=hePPG>140?
if just one consider increasing weight loss strategies
If both, consider metformin/acarbose + TZD/GLP-1RA w caution

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5
Q

DM risk factors

A 
CVD 
FH DM
dyslipidemia
HTN
sedentary
non-caucasian
overweight
metabolic syndrome
hx gestational DM
large child at birth
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6
Q

Fasting BG for normal, Pre DM and DM

A

normal preDM DM

<100 100-125 >126

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7
Q

2-hr post 75mg OGTT for normal, Pre DM and DM

A

normal preDM DM

<140 140-199 >200

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8
Q

A1C normal, Pre DM and DM

A

normal preDM DM

<5.4% 5.5-6.4% >6.5%

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9
Q

what causes an A1c to be misleading

A 
Hgbinopathies
iron deficiency
hemolytic anemias
thalassemias
spherocytosis
severe hepatic or renal disease
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10
Q

T1 DM characteristics

A 
onset <20 yo usually
lean
onset is acute
ketosis present
usually white
Abs present
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11
Q

T2 DM characteristics

A 
>40 yo usually
obese
onset subtle and slow
FHx common
no Abs present
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12
Q

When do we use strict targets for DM control? Which guideline? What parameters/goals? What color are the guidelines?

A

AACE (maroon and blue, wide)
<65 w no CVD

A1C <6.5%
FBG <110
PPG <140

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13
Q

When do we use loose targets for DM control? Which guideline? What parameters/goals? What color are the guidelines?

A

AACE (yellow, green, light blue, skinny)
>65 or >65 w CVD

A1C <7.5%
FBG <80-130
PPG <180

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14
Q

ADA guidelines
patient with….
ASCVD? HF? CKD? Dec. hypo-g? Weight loss? cost issue?

A

ASCVD HF CKD dec hypog
GLP1-RA SGLT2i SGLT2i DPP4i, GLP1RA,
SGLT2i (dapa, (cana, dapa) SGLT2i, TZD
empa) GLP-1RA (do two, then ins)
TZD
DPP4i
basal ins
SU

dec weight gain              cost issue
GLP1RA or SGLT2i          SU or TZD
                                         \+TZD or SU
\+DPP4i                       
                                          \+basal ins
\+SU
  TZD
   basal ins
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15
Q

AACE guidelines tx

A

A1C<7.5% A1C7.5-9.0% >9.0%
(monotherapy) (and if est CKD, HFrEF) nosx-dual/triple
Metformin (dual therapy) sx-ins+/-other tx
SGLT2i SGLT2i
DPP4i DPP4i
TZD TZD middle column
AGi GU/GLN and right column
SU/GLN basal ins. go on to basal ins
Colesevelam then + prandial
AGi
(tripple if no improvement in 3 mo)

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16
Q

How do we add basal and/or bolus insulin in AACE guidelines

A

Strict targets
If A1C <8%: 0.1-0.2 U/kg basal
If A1C >8%: 0.2-0.3 U/kg basal

If already on basal and are adding 1 bolus dose: 10% of basal dose or 5U
If starting basal AND bolus: 0.3-0.5U/kg/d, 50% basal and 50% prandial/3= per meal

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17
Q

How do we add basal and/or bolus insulin in ADA guidelines

A

Loose targets
Adding basal: 0.1-0.2U/kg/d
Adding bolus: 4U each bolus or 10% of basal

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18
Q

hypoglycemia s + sx stage 1

A 
nervous                  pallor
anxiety                   diaphoresis
palpitations            tachy-c
hunger
tremors
nausea
angina
irritable
numbness/tingling
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19
Q

hypoglycemia s + sx stage 2

A 
sudden fatigue
weakness
feeling cold
transient hemiplagia
dizzy
HA
impaired mentation
confusion
amnesia
drowsiness
belligerence
irrationality
aphasia
seizures
coma
death
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20
Q

hypoglycemia tx

A

Rule of 15: (first check BG to confirm) eat 15 g carbs (candy, oj, soda) and wait 15 min then re-check BG
follow up with substantial snack (protein, carb, fat)

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21
Q

severe hypoglycemia tx

A

glucagon recombinant (Glucagon, GlucaGen)

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22
Q

hyperglycemia s and sx

A 
weakness
malaise
visual changes
polyuria
polyphagia
weight loss
nocturia
23
Q

home management of hyperglycemia

A 
monitor BG frequently
insulin
rest
drink water
exercise
24
Q

microvascular complications

A

neuropathy, nephropathy, retinopathy

25
Q

macrovascular complications

A 
cerebrovascular disease (CVA, aneurysm, hemorrhagic stroke)
Heart Disease (CAD, angina, MI)
PVD (PAD, ulcers, amputations)
26
Q

macrovascular management

A

BP control: goal <130/80mmHg
ACEi, ARB, CCB, thiazides are first line
+ MRA for resistant HTN

cholesterol management: max statin
\+ezetimibe
\+PCSK9i
\+BAS
\+niacin

ASA tx
primary prevention: if ASCVD >10%
secondary prevention: all

obesity management, smoking cessation

immunizations: Influenza qyr, pneumococcus, HepB

27
Q

Which immunizations should diabetics receive

A

Influenza qyr, pneumococcus (19-64 yo = PPSV23, >65 yo = PCV13–1yr–> PPSV23), HepB all

28
Q

Retinopathy complications and when to monitor

A

hemorrhages, abnormal BV growth, aneurism, cotton wool spots. hard exudates
optimize BP, BG, and lipid control
T1DM: eye exam within 5 yrs of onset then q year
T2DM: eye exam @ dx then q year

29
Q

Nephropathy risk factors, tx, monitoring,

A

RF: hyperglycemia, HTN, proteinuria, dyslipidemia
Tx: SGLT2i or GLP1RA with CKD bennies (cana or dapa)
Monitoring: asses urinary albumin and eGFR q year

30
Q

Neuropathy (DPN) dx, tx, monitoring, when to see specialist

A

dx of exclusion
tx: Pregabalin, Duloxetine, Gabapentin
Monitoring: Foot exam q year
See specialist if smoker, poor BG control, hx of lower extremity issues, foot deformities, PAD, visual impairment, CKD

31
Q

What drugs cause hyperglycemia?

A 
atypical APs
BBs 
CCB
corticosteroids
fluoroquinolones
niacin
phenothiazines
protease inhibitors
thiazides
32
Q

What drugs cause hypoglycemia?

A 
ACEi
po anti-DM agents
fibric acid derivatives
SSAs + APAP
SSRis
quinine
pentamidine
MAOis
33
Q

DKA clinical presentation

A

thirst, hunger, abdominal pain, N/V, profound weakness, AMS

Kussmal respirations, acetone breath (fruity), hypothermia, tachycardia, dehydration, hypotonia

34
Q

DKA treatment

A

fluid replacement: 1-1.5L @ 250-500mL/hr (1/2NS if wnl Na, NS is Na low)
once BG is <200 can switch to 1/2NS in D5W

K replacement if needed

Insulin therapy - check K+ before initiation
want BG to decrease 50-75 in 1 hr, if it doesnt increase infusion rate until anion gap closes
0.1U/kg IV bolus –> 0.1U/kg/hr cont inf

35
Q

HHS (hyperosmolar hyperglycemic state) hx, PE, and treatment

A

hx: impaired consciousness, seizures
PE: extreme dehydration
Tx: fluid replacement (need more free H2O than with DKA)
electrolytes (K, Mg, phos, Ca)
insulin: check K+ before initiation
1-2U/h (do not exceed dec in BG >75-100/hr!)
close inpatient monitoring: finger sticks q1-2h
electrolytes q4h

36
Q

DCCT trial
DM type?
What was studied?
outcome?

A

T1DM
retin neuro and nephro pathy studied
outcome: microvasc is A1C dependent, takes 10 yrs for CV bennies

37
Q

UKPDS trial
DM type?
What was studied?
outcome?

A 
T2DM
metformin, SU, insulin
microvasc issues favor intensive tx
we <3 metformin
10 yr later trial analyzed long term
decreasing A1C decreased DM related death, MI and micro issues
38
Q

ADVANCE trial
DM type?
What was studied?
outcome?

A

T2DM
micro and macro
dec A1C helped nephropathy the most

39
Q

VADT trial
DM type?
What was studied?
outcome?

A 
T2DM and intensive control of BG
# of hypoglycemic events in past 30 d is primary predictor of inc CV mortality
40
Q

Lifestyle Management

A

MNT (medical nutrition therapy)
Physical activity (150+ min mod-vig aerobic/week)
Smoking cessation

41
Q

Pediatric T1DM
when to tx
A1C goal
screening/monitoring

A

tx if BP >130/80 +/or LDL-C>130
screen for microvascular complications once 10 y/o or has DM x5yrs
goal A1C,7.5%
MNT and exercise

42
Q 
Pediatric T2DM
when to dx
weight loss goal
screening/monitoring/management
A1C goal
tx
what to do after Abs testing?
A

> 10 y/o + BMI >85th percentile
aim for 7-10% weight loss
30-60min exercise 5d/wk
A1C goal <7%
A1C <8.5% - metformin po BID up to 2,000mg/d
A1C >8.5% - basal ins 0.5U/kg/d and metformin
if no Abs - consider liraglutide, add prandialor cont basal
if Abs - D/C Metformin and + pump insulin

43
Q

What is considered a sick day in DM?

How to manage?

A

infxn ,surgery, trauma, invasive op, major life stress

test BG q2h
T1DM --> teset ketones
monitor temp
keep hydrated
tx sx (N/V/thirst/pee)

continue basal ins at normal dose
if patient is eating can cont rapid ins @ normal dose
D/C all PO meds including Metformin, SGLT2i, GLP1RA
if N/V –> D/C ALL PO MEDS

44
Q 
Patient LM is a 70 y/o female who has had T2DM for 6 years. She is recovering from a femur fracture and surgery a week ago and begins to feel nauseous today in the afternoon. As the day goes on they become thirsty and have increased urination. She could not stomach lunch or dinner d/t nausea. 
PMH: HTN, T2DM, dyslipidemia
Meds
Basaglar U-100 qd
Metformin ER 1000mg po BID
Lisinopril 20 mg po qd
Empagliflozin 10mg po qd
Aspirin 81mg po qd
Atorvastatin 40mg po qd

Is this considered a sick day?
If so what should change about the med list?
What should be done to tx?

A

Yes, this is a sick day because of the trauma, major life stressor and sx

All po medications should be discontinued (if no NV, Lisinopril, Aspirin and Atorvastatin are homies)
Basaglar can be continued since it is a basal insulin

tx: test BG q2h
monitor temp
stay hydrated, track sx

on sick day, continue all po meds except Metformin, SGLT2i, and GLP1 RA because dont want to tank BG while they are continuing basal insulin and are likely NPO

45
Q

gestational DM preferred tx

A

insulin»

metformin and glyburide sparingly

46
Q

Upon admission, what should be checked for a patient w hx DM?

A

A1C and BG

47
Q

BG targets for an admitted DM patient who is not critically ill
when to change tx

A

FBG <110
PPG <180
change tx if BG<100

48
Q

When to add correctional insulin

How many U?

A

Usually started with admission as BG is checked frequently. Also used when pt is on basal and prandial and BG is still uncontrolled

BG       U
<150-->       0U
150-199---> 2U
200-249--> 4U
250-299--> 6U
300-349---> 8U
>350--------> 10U
49
Q

insulin related med errors causes

A

use of “U”
insulin at floor stock
many insulin concentrations available, non-standard Ko
testing and reporting errors w BG testing

50
Q

DKA onset, clinical sx, BG, pH, anion gap, ketones, Osm

A 
hrs -days onset
polyuria, polydipsia, weight loss, vomiting
BG >250
pH <7.3
anion gap >12
(+)ketones
<320 Osm
51
Q

HHS onset, clinical sx, BG, pH, anion gap, ketones, Osm

A 
days-wks onset
polyuria, polydipsia, weight loss, vomiting
BG >600
pH norm
anion gap variable
(-)ketones
>320 Osm
52
Q

DKA/HHS precipitating factors

A

infxns, MI, meds, non-adherence, poor sick day management, pancreatitis, wrong dose/ D/C ins, new onset T1DM

53
Q

What are the BG goals in DKA and HHS?

A

DKA goal : 200 (>250 @ dx)

HHS goal: 300 (>600 @dx)

54
Q

When administering insulin for DKA/HHS, we measure K+ beforehand. What K+ values determine insulin use?

A

<3.3 –> hold ins, replete @ 20-30mEq/hr
3.3-5.3 –> use ins, replete @ 20-30mEq/hr
>5.3 ——> dont give K+ until falls below uln

DM Therapeutics Exam 1 (2 decks)

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