Week 5 Diabetes and Obesity Flashcards
Comorbidities related to obesity
DM, HTN, metabolic syndrome, OSA, osteoarthritis, CAD, stroke, dyslipidemia, CKD, fatty liver disease, varicose veins, GERD, gallbladder disease, certain cancers, sexual dysfunction, lower urinary tract symptoms, impaired cognitive function and dementia
Underweight BMI Classification
< 18.5
Normal BMI Classifications
18.5 - 24.9
Overweight BMI Classification
25.0-29.9
Class I Obesity
30.0-34.9
Class II Obesity
35.0-39.9
Class III Extreme Obesity
> 40.0
Type I Diabetes Related Genetics
HLA-DQ and HLA-DR
Signs of Type I Diabetes
polyphagia, polyuria, polydipsia, nocturnal enuresis, polyphagia with paradoxical weight loss, visual changes, fatigue, weakness and anorexia
Percentage of Diabetics with T1DM
5%
Percentage of Total Population with DM
9.4%
Adults 65 years and older with diabetes?
25.2%
T2DM is the ____ leading cause of death in the US.
7th
T1DM most common ethnicity
Caucasians of European descent
T2DM most common ethnicity
- Native Americans and Alaskan Natives
2. African American and Hispanics
Risk Factors for T1DM
- Caucasian
- Rubella infection, Coxsackie B4 virus, cytomegalovirus, adenovirus, mumps
- Genetic predisposition
- Cow’s milk protein
Risk Factors for T2DM
- 1st degree relative with T2DM
- BMI > 25
- Age > 45
- Hx of GDM, HTN, HLD,
- Women w/ PCOS
Medications that can cause hyperglycemia
- glucocorticoids
- hormonal therapies (oral contraceptives)
- immunosuppressants tacrolimus and cyclosporine
- nicotinic acid
- antiretroviral protease inhibitors for HIV
- several atypical antipsychotics: clozapine and olanzapine
- certain antihypertensives: beta blockers, calcium channel blockers, clonidine, thiazide diuretics
HgbA1c Diagnostic Criteria for Diabetes
6.5% or higher
HgbA1c Diagnostic Criteria for Prediabetes
5.7-6.4%
Fasting Glucose Diagnostic Criteria for DM
126 or higher on 2 occasions
Random Plasma Glucose Level Diagnostic Criteria for DM
200 or higher with symptoms of hyperglycemia (polyuria, polydipsia, weight loss)
2-hr Post Prandial Glucose Diagnostic Criteria
200 or higher during OGTT with 75 gram load
C-Peptide Levels in T1DM
decreased
C-Peptide Levels in T2DM
normal or elevated
First-line Treatment for T1DM
intensive insulin regimens to achieve glucose management goals
Goals of Glucose Management
before meals: 80-120
PP: < 180
A1c: < 7%
Medical Nutritional Therapy for DM
Mediterranean diet
Dietary Approaches to Stop HTN
Plant-based diets
Eating plan that maintains a healthy body weight, supports glycemic control, facilitates BP and lipid goals, and delays or prevent complications of DM
Hypoglycemia S/Sx
diaphoresis, tachycardia, shakiness, altered mentation, slurred speech, seizures, coma
Somogyi effect
patient develops hypoglycemia during the night with rebound hyperglycemia in the AM
Exercise in T1DM
- Check BS before exercise, every 30-60 minutes during and after exercise
- Avoid exercise if fasting glucose > 250 and ketosis is present or if the glucose level is > 300 regardless of whether ketosis is present
- Consume additional carbs if glucose less is < 100 and as needed to avoid hypoglycemia
Identify when changes in insulin dose or food intake are necessary
Urine Ketone Testing in T1DM
- Presence of hyperglycemia and/or stressful events that can lead to hyperglycemia (illness, N/V)
- BS > 240 check for ketones q 4 hrs
T2DM Physical Activity
- Increasing general movement through ADLs and decreasing sedentary behaviors
- 150 minutes of exercise a week of moderate to intensive physical activity at least 3 days a week; no more than 2 consecutive days without exercise
- Resistance training 2 days a week improves A1c control
Flexibility and balance training 2-3x a week in older adults
SMBG in T2DM on Insulin
2-3x/day
increase monitoring during illness, changes in diet and exercise or a change in medications
SMBG in T2DM not on Insulin
2-3x/week alternating before breakfast, evening meal and at bedtime with occasional 2hr PP
increase monitoring during illness, changes in diet and exercise or a change in medications
1st line Treatment for T2DM
metformin
AACE Recommends adding a 2nd agent if A1c is ______.
> 7.5%
ADA Recommends adding a 2nd agent if A1c is _____.
> 9%
AACE recommends starting insulin when A1c is _____.
9% or higher and pt is symptomatic
ADA recommends starting insulin when A1c is _____.
10% or higher with symptoms
What dose is basal insulin started at?
0.1-0.2 units/kg/day
How much do you increase the dose of insulin and based on what?
10-15% or 2-4 units once or twice a week based on FBS
What is the normal FBS target for T2DM
<140
Basal Insulins
NPH - intermediate
Glargine (Lantus), detemir (Levemir) - long acting
degludec (Tresiba) - ultra-long acting
Mealtime Bolus Insulins
Regular human insulin
Aspart (Novolog)
Glulisine (Apidra)
Lispro (Humalog)
Sliding scale for T2DM mealtime bolus insulins is based on:
preprandial glucose of next meal
Metformin Side Effects
GI disturbances and metallic taste
Metformin Prescribing Considerations
- watch for hypoglycemia, especially in older adults
- contraindicated in renal disease, renal function should be assessed before starting
First Generation Sulfonylureas (no longer recommended)
chlorpropamide (Diabinese)
tolbutamide (Orinase)
safety profile worse than 2nd generation
Second Generation Sulfonylureas
Glimepiride (Amaryl)
Glipizide (Glucotrol)
Glyburide (Diabeta, Micronase)
Sulfonylureas Side Effects
HYPOGLYCEMIA weight gain nausea weakness photosensitivity
Sulfonylureas Contraindications
DKA
Allergy to Sulfa
decreased renal function
Meglitinides
nateglinide (Starlix)
repaglinide (Prandin)
Meglitinide Contraindications
liver insufficiency
Meglitinide Side Effects
hypoglycemia, headache, upper respiratory infection, N/V/D, constipation, muscle aches and chest pain
Thiazolidinediones (TZDs)
pioglitazone (Actos)
rosiglitazone (Avandia)
TZDs Side Effects
Headache, weight gain, edema and anemia
TZDs Contraindications
Heart failure, bladder cancer, osteoporosis and liver disease
DPP-4s
sitagliptin (Januvia), linigliptin (Tradjenta), saxagliptin (Onglyza), and alogliptin (Nesina)
DPP-4s Contraindications
pancreatitis
DPP-4 Side Effects
upper respiratory infection, nasopharyngitis and headache
Alpha-glucosidase Inhibitors
acarbose (Precose)
miglitol (Glyset)
Alpha-glucosidase inhibitor side effects
flatulence, diarrhea, abdominal pain and rash
Alpha-glucosidse inhibitor contraindications
ketoacidosis, irritable bowel disease, intestinal obstruction or renal impairment
SGLT2 Inhibitors
dapagliflozin (Forxiga), canagliflozin (Invokana), empagliflozin (Jardiance), ertugliflozin (Steglatro)
Canagliflozin (Invokana) black box warning
2-fold increase of leg and foot amputations in those patients with T2DM and cardiovascular disease
SGLT2 Inhibitor Side Effects
acute renal failure, ketoacidosis, hypotension, urinary and/or genital fungal infections and nauseas
SGLT2 Inhibitors Contraindicated in:
CHF, nephrotoxicity, volume depletion
GLP-1 Receptor Agonist (Incretins) injected
exenatide (Byetta), liraglutide (Victoza), lixisenatide (Lyxumia), albiglutide (Tanzeum), dulaglutide (Trulicity) and semaglutide (Ozempic)
helps with weight loss
GLP-1 Side Effects
nausea and feeling of fullness that may dissipate after a few weeks
hypoglycemia when used with sulfonylureas or insulin, V/D, HA, nervousness and stomach discomfort, decreased appetite, acid reflux and increased sweating
GLP-1 Contraindications
DKA
GLP-1 Black Box Warning
medullary thyroid carcinoma or a family hx of that disease or with multiple endocrine neoplasia syndrome type 2
A1c goal for healthy older adults
<7.5%
Alc goal for complex/intermediate health older adults
<8.0%
A1c goal for very complex/poor health older adults
<8.5%
Healthy older adult means
few coexisting chronic illnesses, intact cognitive and functional status
Complex/intermediate older adult means
multiple coexisting chronic illnesses or 2+ instrumental ADL impairments or mild-to-moderate cognitive impairment
Very complex/poor health older adult means
LTC or end-stage chronic illnesses or moderate-to-severe cognitive impairment or 2+ ADL dependence
Fasting or Preprandial Glucose Goal for Healthy Older Adults
90-130
Fasting or Preprandial Glucose Goal for Complex/Intermediate Older Adults
90-150
Fasting or Preprandial Glucose Goal for Very Complex/poor health Older Adults
100-180
Bedtime Glucose Goal for Healthy Older Adults
90-150
Bedtime Glucose Goal for Complex/intermediate Older Adults
100-180
Bedtime Glucose Goal for Very Complex/poor health Older Adults
110-200
HgbA1c Goal that indicated strong control
< 7%
HgbA1c of < 6.5% has been shown to ___________________
significantly decrease the occurrence of complications, provided this can be achieved without hypoglycemia or other adverse effects
Weight Loss Recommendations to decrease risks related to diabetes; what percentage?
5%
What complications can occur due to diabetes/hyperglycemia?
loss of vision, renal failure, amputations, chronic foot ulcers, peripheral neuropathies, sexual problems, GU disorders, CVD. PVD, stroke, uncontrollable angina, bruits, EKG abnormalities, decreased immune system functioning, HHS and DKA
depression
Diabetes is the leading cause of what complication?
end-stage renal disease and acquired blindness in the US
Treatment of neuropathy
○ Non-opioid analgesics, TCAs, calcium channel blockers, narcotics, antiarrhythmics, local anesthetics
○ Pregabalin (Lyrica) and duloxetine (Cymbalta) FDA approved for treatment of neuropathic pain in DM
○ Opioid tapentadol (Nucynta, Palexia, Tapal) FDA approved as well but less evidence on effectiveness
○ Gabapentin, venlafaxine (Effexor), carbamazepine (Tegretol), tramadol (Ultram) and topical capsaicin
Treatment of Cardiovascular Complications or Prevention
ASA 81-165 mg daily
Treatment of Hyperlipidemia
statins
Treatment of Diabetic Kidney Disease
ACE inhibitors and ARBs
BP goal
BP < 140/90 is goal
What complications require immediate action?
DKA
Fasting hyperglycemia > 300
HgbA1c > 13%
Severe hypoglycemia with changes in sensorium, altered behavior, seizures or coma
Evaluations Required at EVERY Follow-Up Visit
Evaluate response (BS log/HgbA1c), tolerability to therapy, goal reassessment, and management of acute and chronic complications
○ BP
○ Review BS log
○ Review medications
○ Examination of feet for complications
○ Urinalysis, urine microalbumin/creat ratio
○ Serum creatinine levels and eGFR
○ HgbA1c q 3-6 months
○ Examine for neurovascular complications
○ Self-management education
○ Immunizations
How often should a patient with DM follow-up?
every 3-6 months
monthly if sudden change in health status or treatment regimen follow-up
Required Annual Evaluations of DM Patients
eye exam with dilation
EKG
Fasting lipids
Biannual oral examinations
Ophthalmologist Referrals
Dilated comprehensive eye exam done within first 5 years of diagnosis for T1DM
No retinopathy detected = eye exam q 2 years
Retinopathy detected = eye exam at least annually
Endocrinologist Referrals
T1DM
T2DM when FBS consistently > 300 and HgbA1c > 13%
