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63 Cards in this Set
- Front
- Back
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Define Type 1 DM
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hyperglycemia due to full beta cell destruction, usually leading to absolute insulin deficiency
- Can result from autoimmune process |
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Define Type 2 DM
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Hyperglycemia due to progressive insulin secretory defect w/ background of insulin resistance
- Comprise 80-90% of cases |
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Define Gestational DM
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Dx'd during pregnancy, not clearly overt DM. Need to watch for overt DM following delivery.
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ICD-9 Code for DM
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250.xx
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Common complaints assoc with Type 2 DM
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Fatigue
Gradual onset of classic symptoms (polyuria, polydipsia, polyphagia) May present in non-ketotic coma (if BG > 600 and dehydrated) |
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Risk factors for Type 2 DM
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Age ≥ 45
BMI ≥ 25 Physical inactivity 1st deg relative with DM (parent/sibling) Race - AA, Latino, NA, Asian Am, Pac Islander Clinical conditions assoc with insulin resistance - obesity, acanthosis nigricans |
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Medications that increase risk for Type 2 DM
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glucocorticoids
Antipsychotics |
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What factors should be present to screen for DM2 in children?
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- Overweight AND 2+ additional risk factors for DM
- Risk Factors: FH of DM2 in 1st or 2nd deg relative, Race (NA, AA, As. Am, Pac Isl), conditions assoc with insulin resistance, maternal h/x of GDM during child's gestation |
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Diagnostic criteria for DM2
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AIC ≥ 6.5%
Fasting Plasma Glucose ≥ 126mg/dL Two-hour PG ≥ 200mg/dL If pt has polys, random plasma glucose ≥ 200mg/dL |
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What constitutes Pre-Diabetes and how do we treat these individuals?
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FPG 100-125mg/dL
2-hr PG in 75 OGTT 140-199mg/dL AIC 5.7-6.4% Emphasize early recognition and intervention. Be aggressive to prevent full Type 2 DM. |
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Signs of hyperinsulinemia
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Acanthosis Nigricans
Development of excessive skin tags |
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Goals of initial evaluation of person with suspected diabetes
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Classify type of DM
Identify complications assoc wtih DM Make plan of care |
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Microvascular Complications assoc with DM
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Nephropathy
Retinopathy Neuropathy |
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Macrovascular complicaitons assoc with DM
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Cardiovascular
Peripheral Arterial Disease |
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Diagnostic Testing to perform on initial eval of DM patient
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A1C (if not done in past 2-3 mo)
Fasting lipids (total HDL, LDL, TG) LFTs Urine albumin excretion w/ spot urine albumin to Cre ratio Serum creatinine and calc GFR TSH in T1DM, dyslipidemia or women >50yrs Baseline EKG |
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What referrals would you make for pt with Type 2 DM?
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Ophthalmologist for dilated eye exam (every 2 years)
Family Planning for women of reproductive age OR provide preconception care. A1C < 7% before conceive. Dietitian for monitored nutritional therapy (MNT) Dentist Foot Exam Diabetes self-managment education program (DSME) |
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What are the cornerstones of managing diabetes?
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Glycemic control, self-management, nutritional therapy, Physical Activity, Chronic diseases
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What are the 2 primary techniques for measuring glycemic control?
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Patient self-monitoring of BG (SMBG)
A1C |
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How often to check A1C in person who has met goals, and achieved glycemic control?
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2x/year
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How often to check A1C in patients w/ change in therapy or who are not meeting goals?
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quarterly
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What can affect A1C levels? (things that might throw off the results)
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anything affecting RBC turnover rate - hemolysis, hemoglobinopathy
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An A1C of 7% translates to an average daily glucose of what?
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154
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Glycemic Goals in Non-pregnant patients:
Preprandial Peak postprandial |
Preprandial - 70-130mg/dL
Peak postprandial - < 180 mg/dL |
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What type of patient would be appropriate to set less stringent A1C goals?
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Asymptomatic hypoglycemia
Low life expectancy Long-standing disease duration Severe comorbidities Severe vascular complications Limited resources, support systems |
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Gestational DM goals
Preprandial, 1-h and 2-h post meals |
Pre- ≤ 95mg/dL
1-h- ≤ 140mg/dL 2-h- 120 mg/dL |
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Goal A1C
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ADA - < 7%
AACE - < 6.5% |
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What are the main lifestyle changes we recommend for patients with or at risk of developing Type 2 DM?
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Moderate weight loss (7% body wt) or 2-8kg
Regular physical activity - 150min over 3/wk Diet - reduce fat calories. Get 14g fiber/1000kcal. Whole grains should comprise 1/2 of intake. |
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What to tell pts with DM about alcohol intake?
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Use in moderation only.
May put pt at risk for delayed hypoglycemia (esp if taking insulin or insulin secretagogues) |
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How much sodium daily for patient with DM?
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<2300mg/day
Less if HTN + DM |
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How much physical activity to be recommended per day for chldren and adults?
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Children - 60mins/day
Adults - at least 150 min/week, spread out over 3 days. Include resistance training. Get to 50-70% of max HR. |
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Exercise is contraindicated for which conditions?
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Uncontrolled HTN
Severe autonomic neuropathy Severe peripheral neuropathy H/o Foot lesions Unstable proliferative retinopathy |
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Managing Chronic Conditions comorbid with DM: HTN
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Measure BP each visit.
SBP < 140 (<130 if younger patient), DBP < 80 Consider ACE-inhibitor or ARB - renal protective effects |
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Managing Chronic Conditions comorbid with DM: HLD
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Annual lipid screen for patients wiht DM
If no CVD, treat to LDL < 100 If CVD, treat to LDL < 70 |
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If patient with DM has Cardiovascular disease, what meds would they get?
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For known CVD + DM, treat with ACE inhibitor, aspirin and statin
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What DM meds should you avoid in a patient with heart failure?
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If pt with symptomatic heart failure, avoid thiazolidinediones - they cause fluid retention/edema, and can exacerbate HF
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What is first line treatment for Type 2 DM?
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Diet and Exercise
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What is an important piece of counseling to provide Type 2 DM patients?
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Most T2DM patients will eventually need insulin (5-7years after staring PO meds)
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Name the classifications of oral DM medications (9)
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Biguanides
Thiazolidinediones Secretagogues (Sulfonylureas & Meglitinides) Alpha Glucosidase Inhibitors Dipeptidyl-Peptidase-IV (DPP-IV) inhibitors Incretin Mimetics Sodium-Glucose co-transporter 2 (SGLT2) inhibitors Dopamine Agnonist Bile Acid Sequestrant |
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Biguanides:
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
ex: Metformin
MOA: Decreases hepatic production of glucose, intestinal absorption of glucose, increases peripheral glucose uptake and utilization Dosing: 500mg w/ evening meal to start. Max dose 2550mg/day Contraind: Age <10, >80. Avoid EtOH (icnreases lactic acidosis risk). Hold 48hrs before/after IV contrast dye. Do not use if CrCl < 60mL/min, or hepatic impairment Cre cutoff: women >1.4, Men > 1.5 S/E: transient n/v/d, gas/bloating. Metallic taste, anorexia, wt. loss. Rare: lactic acidosis Pregs: B |
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Thiazolidinediones (TZDs)
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Rosiglitazone (Avandia) & Pioglitazone (Actos)
MOA: improve insulin sensitivity, enhance glucose uptake in muscle/adipose. Inhibit gluconeogenesis. Selective agonist for PPAR-gamma. Mono-or combination therapy. Dosing: Once daily in AM, takes 1 mo to see effect. Pioglit - 15-45mg/day DAILY Rosiglit - 2-8mg/day (once or twice) Contraindication: use caution in hepatic or renal impairment - monitor LFTs at start. If ALT 2.5x normal, don't give it. S/E: (Usually well tolerated). Edema (caution in HF), wt. gain, URI, incrs'd bone fracture in women, incrs'd ovulation, bladder CA, macular edema Pregs: C, no breastfeed |
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Secretagogues: Sulfonylureas
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Glipizide, Glimepiride, Glyburide, Tolazamide, Tolbutamide, Chlorpropamide
MOA: stim insulin secretion from panc beta cells, reduce glucose output from liver, improve insulin sensitivity in periphery Dosing: once or twice daily, mg depnds on med. Adjust dosing with hepatic/renal impairment Precautions: elderly, those with sulfonamide allergy S/E: HYPOGLYCEMIA, photosensitivity, dizziness, thrombocytopenia, GI disturbances, allergic skin reaction, disulfiram-type rxn with alcohol. Pregs: C |
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Secretagogues: Meglitinides
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Natglinide (Starlix), Repaglinide
Dosing: TID with meals for both MOA: stim insulin release from panc beta cells Precautions: elderly, adrenal/pituitary insufficiency, severe renal insufficiency S/E: HYPOGLYCEMIA, HA, URI, dizziness, diarrhea Pregs: C |
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Alpha Glucosidase Inhibitors (not used often)
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Acarbose (Precose) - not used often
Dosing: 25-50mg TID with 1st bite of each meal MOA: inhibit breakdown of carbs in intestine (inhibits alpha glucosidase enzyme). Results in delayed absorption of glucose. Contraindications: IBD, colonic ulceration, intestinal obstruction, chronic intestinal disease, cirrhosis S/E: GAS, abd pain, diarrhea, elevated AST/ALT (check LFTs Q3mos) Pregs: B - no boob food |
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Dipeptidyl-Peptidase-IV (DPP-IV) inhibitors
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), Alogliptin (Nesina)
Dosing - DAILY MOA: potentiate effects of incretin hormones: glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP). Enhances beta-cell function. Mono or combination therapy. SAFE FOR USE in renal/hepatic impairment w/ dosing adjustment. S/E: (No GI s/e!) HA, URI, Nasopharyngitis, Periph edema, Hypoglycemia when used with secretagogues Adv: Weight neutral, well tolerated, once-daily dosing Disadv: $$, less A1C reduction c/w other meds Pregs: B, no boob food |
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Sodium-Glucose co-transporter 2 (SGLT2) inhibitors
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Canagliflozin, Dapagliflozin
Dosing: daily in AM MOA: block reabsorption of filtered glucose in kidney, leading to glucosuria Contraindications: eGFR < 45 S/E: genital fungal infections, increased urination, dehydration. **9 cases bladder CA** Drug Interactions - increase effect of ACE-i's, ARBs, k-sparing diuretics. Watch for hypotension w/ these meds. Pregs: C |
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Dopamine Agonist
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Bromocriptine (Cycloset)
Dosing: daily dose. Must take within 2 hours of waking up, or it won't work. Titrate up weekly to therapeutic dose. Monotherapy with diet/exercise. MOA: normalizes aberrant hypothalamic NT activities that induce, potentiate and maintain insulin resistant, glucose-intolerant state S/E: GI upset (take with food), n/v, dizziness, fatigue, HA Pregs: B |
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Bile Acid Sequestrant
Primary Example MOA Dosing Contraindications Side Effects Pregnancy Category |
Ex: Colesevelam
Dosing: 3.75g/day with food MOA: not understood S/E: constipation, HA, dyspepsia, dcrs'd absorption of other oral meds & fat-soluble vitamins (space administration of other meds) |
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Initiating therapy for DM - what do you start with?
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Lifestyle modification PLUS metformin monotherapy OR insulin therapy w/ or w/o additional agents.
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Why would you start a newly diagnosed Type 2 DM patient on insulin right away?
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Markedly symptomatic, very elevated BG levels or A1C
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Non-insulin monotherapy at max dose is not achieving target A1C over 3 mos. What next?
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Add second oral agent like GLP-1 or insulin
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What to do when glycemic goals are not met? (general)
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Rethink treatment regimen
Assess barriers - income, health literacy, depression Consider: LCSW for insurance, co-management w/ DM team |
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Case patient: Sally - newly diagnosed with DM, started on Metformin. When should she come back?
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2-4 weeks
3 months 3 months |
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At Sally's 2-4 week follow-up, what do you do at this visit?
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Check med adherence, side effects
Brief ROS - polys, S/S hypoglycemia PE - Wt, BP, Pulses, CV, Resp Home SMBG - once daily |
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Sally is back for a 3-month followup after her initial visit, and a 2-4 week f/u. What do you do at this visit?
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Assess med adherence, S/E
Review SMBG logs ROS - polys, S/S hypoglycemia PE - Wt, BP, Pulse, CV, Resp Check A1C today - is she at goal? |
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Medical plan for DM patients
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Annual PE
Annual lipids, CMP, A1C (3,6,12 mos), urine microalbumin Dilated eye exam Q2yrs Annual foot exam, incl monofilament BP < 140/80 LDL < 100 or <70 if CVD Daily ASA for ppl at high risk for CVD Consider ACE-inhibitor if >40yrs even if normotensive Immunizations: flue, PNA, HepB |
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What is the formula to calculate BMI?
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BMI = (lbs/inches^2) x 703
(use a calculator) |
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Name some medication associated with weight gain.
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Antidepressants, antipsychotics, anticonvulsants, mood stabilizers, and migraine prophylaxis agents. Antihistamines and beta-blockers also.
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Name criteria for metabolic syndrome (according to the International Diabetes Federation, NHLBI, American Heart Association, etc)
Buttaro p 122 |
- Elevated waist circumference
- Triglyceride levels >=150mg/dL (or tx for this) - Reduced HDL < 40mg/dL (or tx for this) - Elevated BP > 130/80 (or tx for HTN) - elevated FPG >= 100mg/dL (or tx for hyperglycemia) |
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When do we initiate screening for DM2?
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45 years. Or younger if BMI > 25 and 2+ risk factors present.
RF = sedentary, family hx, ethnicitiy, h/o GDM, HTN, HLD, PCOS in women, acanthosis nigricans, h/o CVD, previous A1C > 7.5% |
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What are possible secondary causes of DM?
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Excess counterregulatory hormones (Cushing's, pheochromocytoma & acromegaly)
Hypokalemia from glucose intolerance Hyperaldosteronism or diuretic use pancreatitis Hemochromatosis Drug-induced islet cell injury |
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Describe preconception care for women with Type 2 DM (or Type 1)
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Empower self-management of DM
Achieve optimal A1C before conception Contracept before glycemic control achieved watch for chronic complications before during & after preg Multidisciplinary obstetric and endocrine care team during pregnancy |
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Sick Day monitoring for DM patients
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Monitor Q4hrs w/ symptoms (nausea, anorexia, rising glucose)
Take DM meds, even if not eating. Might make more glucose when sick. Stay hydrated Antiemetics if needed |
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What are indications for cardiovascular testing in patients with DM?
Buttaro p 1080 |
Cardiac symptoms
Abnormal ECG Microalbuminuria Other atherosclerotic disease Autonomic neuropathy Unexplained dyspnea Plans to begin exercise program |
