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35 Cards in this Set
- Front
- Back
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What are the microvascular complications of DMII
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Retinopathy, neuropathy, nephropathy
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How are the microvascular complications of DMII screened?
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Spot urine creatinine to albumin ratio (nephropathy), microfilament test or evidence of callouses (neuropathy) and ophthamology exam (at the time of diagnosis)
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What 2 studies demonstrated that maintaining A1C at or below 7% reduced microvascular complications?
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DCCT (Diabetes Control and Complications Trial- performed in Type 1 Diabetics and excluded HTN, HLP, CAD) and UKPDS (UK Prospective Diabetes Study- DMII, 37% reduction in microvasc for every 1% reduction in A1C, no reduction in macrovasc)
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What did the ACCORD trial demonstrate?
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Maintaining A1C less than 6% produced significantly higher cardiovascular complications than A1C between 6% and 7%
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What did the ADVANCE trial demostrate?
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Maintaining A1C less than 6.5% produced less microvascular complications, but there was no reduction in macrovascular effects and the risk of cardiovascular events was higher.
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What did the VADT trial demonstrate?
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No benefit in macrovascular complications in intensive glucose control.
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What where the long term outcomes found from the populations studied in the DCCT and UKPDS studies?
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Both had significant cardiovascular event reductions 17 and 10 years following termination of the study.
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What has greater macrovascular effect reductions, glucose or BP control? What study demonstrated this effect?
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BP control, the UKPDS demonstrated this effect
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What are appropriate BP treatment goals in diabetics? Does more intensive treatment reduce risk further?
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less than 130 (JNC7), less than 135 (UKPDS). More intensive does not improve outcomes and increases risk of syncope.
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Who is most likely to benefit from tight glucose control?
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younger patients who do not have micro or macrovascular complications.
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What study demonstrated treatment benefit for intense LDL, TG, BP and AIC goals?
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Steno-2
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What is the recommended A1C treatment goal?
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7%
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What is the pre-prandial glucose treatment goal?
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90-130
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What is the post prandial glucose treatment goal?
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less than 180
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what is the blood pressure treatment goal in diabetics?
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less than 130/80
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what is the LDL treatment goal in diabetics?
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less than 100
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what is the triglyceride treatment goal in diabetics?
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less than 150
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what is the HDL treatment goal in diabetics?
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greater than 40
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What are the various methods and cutoffs to diagnose diabetes?
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A1C greater than 6.5%, Fasting glucose >126 (8 hours), post-75gm OGT greater than 200, or symptoms of diabetes and random glucose greater than 200.
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What is the proper method for starting metformin?
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Start at 500mg BID and double if no GI upset occurs after 1 week. recheck A1C in three months, if greater than 7%, add additional pharmacotherapy.
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Suppose a patient is found to be diabetic. What would preclude prescribing oral hypoglycemics and starting immediately on insulin.
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Evidence of severe hyperglycemia: fasting glucose greater than 250, Random glucose greater than 300, A1C greater than 10, ketonuria, polyuria + polydipsia + weight loss.
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What is the initial preferred treatment of DMII? What is suggested if A1C remains above 7? What is third line?
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Lifestyle and metformin. Add a sulfonurea. Alternatively an incretin memtic (GI upset) or pioglitazone (contraindicated in CHF). Third line includes adding basal insulin and then intensive insulin therapy.
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Should short or long acting insulin be started first? What is the dose? How should it be adjusted?
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Long acting insulin. Doses should start at 10U (0.2U/kg) and be increased by 2 units every 3rd day until Fasting glucose is 70-130 (increase by 4 if Fasting Glucose >180).
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When should additional doses of insulin be added? In what way should they be added?
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If A1C is not below 7 on basal insulin. Pre-lunch, pre-dinner and HS glucose should be measured. If prelunch is high, add lispro to breakfast, if predinner is high, add lispro to lunch or NPH to breakfast, if HS is high, add lispro to dinner.
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When starting insulin-only therapy, how should it be titrated?
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Start with basal only insulin. Check AM glucose every 3rd day. If less than 70, decrease by 4 units (or 10%), if 70-130, continue, if 130-180, increase by 2 units, if greater than 180, increase by 4 units.
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How are the macrovascular comorbidities screen in DMII?
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CAD- BP at every visit and lipid panel annually, PAD- check pulses every visit and consider an ABI, Cerebrovascular disease- no specific screening.
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What are the short acting insulins? How quick is their onset, peak and duration?
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Lispro, aspart and glulysine. Onset: 15min Peak: 30-90min Duration: 5 hours
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What is the onset, peak and duration of regular insulin?
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Onset: 30-60min, Peak: 2-3hrs, Duration: 8-10 hours
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What are the long acting insulins? How quick is their onset, peak and duration?
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NPH- O:2-4hr, P:4-10hr, D:12-18hr. Glargine- O:2-4hr, P:none, D:18-24hr. Detemir- O:1hr P:6-8hr, D:20hr
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What oral hypoglycemics carry the risk of hypoglycemia?
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Sulfonylureas and glinides
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What hypoglycemics carry the risk of weight gain?
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Insulin, sulfonylureas, TZDs, Glinides
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What are some examples of sulfonylureas? What is the expected decrease in A1C?
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glipizide, glemipride. 1.5%
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What are some examples of TZD? What is the expected decrease in A1C? What is the contraindication?
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pioglitazone, 0.5-1.4%, cannot be used in patients with CHF.
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What is the expected drop in A1C from metformin? What is the major side effect?
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1.5%, GI side effects.
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What hypoglycemics are associated with weight loss?
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incretin memtics and possibly metformin (at least neutral)
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