Diabetes Flashcards
Type I Diabetes (TID):
- Autoimmune destruction of beta cells in the pancreas
- Loss of insulin production
- C-peptide test is used to determine if the patient is still producing insulin. C-peptide is released by the pancreas only when insulin is released. TID is diagnosed with there is a very low or absent (undetectable) C-peptide level.
- Patient TID must be treated with insulin and should be screened for other autoimmune disorders.
Type 2 Diabetes:
- Insulin resistance
- Less insulin production
- Obesity, physical activity & other risk factors
Prediabetes:
- BG higher than normal but not high enough for a type 2 diagnosis
- High risk for progressing to type 2
- Metformin can be used to improve BG levels, especially in patients with a BMI ≥ 35 kg/m2, age <60 years, and women with a history of gestational diabetes mellitus (GDM).
Gestational Diabetes. There are 2 types of diabetes in pregnancy.
• Diabetes that was present prior to becoming pregnant
• Diabetes that developed during pregnancy (GDM)
risks to baby:
- Macrosomia (newborn with excessive birth weight)
- Hypoglycemia
- Obesity and type 2
Gestational Diabetes:
Management
- Lifestyle first
- Insulin is DOC, used if needed
- Metformin and glyburide (not preferred, but may be considered)
Goals for Diabetes in Pregnancy (goals are stricter vs non-pregnant patients):
• Fasting: ≤ 95 mg/dL
- 1 hr post-meal: ≤ 140 mg/dL
- 2 hrs post-meal: ≤ 120 mg/dL
Most pregnant women are tested for GDM at…
24-48 weeks gestation using the oral glucose tolerance test (OGTT).
The presence of multiple risk factors increases the likelihood of prediabetes and T2D. Major risk factors include:
- Physical inactivity
- Overweight (BMI ≥ 25 kg/m2 or ≥ 23 in Asian-Americans)
- High-risk race or ethnicity: African-American, Asian-American, Latino/Hispanic-American, Native American or Pacific Islander
- History of gestational diabetes
- A1C 5.7%
- First-degree relative with diabetes
- HDL< 35 mg/dL or TG> 250 mg/dL
- Hypertension (≥ 140/90 mmHg or taking BP medication)
- CVD history or smoking history
- Conditions that cause insulin resistance (e.g. acanthosis nigricans, polycystic ovary syndrome)
Risk for diabetes increases with age. Everyone, even those with no risk factors, should be tested beginning at 45 years old. All asymptomatic children, adolescents, and adults who are overweight (BMI ≥ 25 or ≥ 23 in Asian-Americans) with at least one other risk factor (e.g. physical inactivity) should be tested. If the result is normal…
repeat testing every 3 years
Glycemic control (A1c or another test) should be measured:
- Quarterly (every 3 months) if not yet at goal
* Biannually (every 6 months, or twice per year) if at goal
The estimated average glucose (eAG) is an interpretation of the A1c value that makes it appear similar to a glucose meter value. An A1c of 6% is equivalent to…
an eAG of 126 mg/dL. Each additional 1% increases the eAG by ~ 28 mg/dL.
Diagnostic criteria for diabetes:
- ≥6.5% (A1c)
- ≥ 126 mg/dL (FPG)
- ≥ 200 mg/dL (OGTT)
Goal waist circumference is <35 inches for females and <40 inches for males. Overweight or obese patients should be encouraged to lose:
> 5% of their body weight
Individualized Medical Nutrition Therapy (MNT):
- Consume natural forms of carbs and sugars
- Avoid alcohol or drink in moderation
- Patients with TID should use carboohydrate-counting, where the prandial (mealtime) insulin dose is adjusted to the carb intake. A carbohydrate serving is measured as 15 g, which is approximately one small piece of fruit, 1 slice of bread or 1/3 cup of cooked rice/pasta.
Physical Activity:
- Perform at least 150 minutes of moderate-intensity aerobic activity per week spread over at least 3 days.
- Reduce sedentary (long hours of sitting) habits by standing every 30 minutes, at a minimum.
Smoking cessation:
• Encourage all patients who smoke to quit.
Diabetes complications include both microvascular and macrovascular ones:
- Microvascular: retinopathy; diabetic kidney disease (i.e. nephropathy), peripheral neuropathy (i.e. loss of sensation, often in the feet), increase risk of foot infections and amputations. Automatic neuropathy.
- Macrovascular Disease: Coronary artery disease (CAD), including MI; cerebrovascular disease, including stroke; peripheral artery disease (PAD).
Antiplatelet Therapy (Aspirin):
- Aspirin 75-162 mg/day (usually given as 81 mg/day) is recommended for ASCVD secondary prevention (e.g. post-MI).
- Not recommended in primary prevention (in most); the risk of bleeding is about equal to the benefit. Can consider if high risk.
- CAD/PAD: aspirin + low-dose rivaroxaban can be added
- Used in pregnancy to decrease the risk of preeclampsia.
Diabetic Retinopathy:
- T2D: eye exam with dilation at diagnosis.
* If retinopathy, repeat annually. If not, repeat every 1-2 yrs.
Vaccinations:
- Hepatitis B (HBV) series
- Influenza, annually
- Pneumovax 23: 1 dose between ages 2-64, and another dose at age ≥ 65.
Neuropathy:
- Annually: a 10-g monofilament test and 1 other test (e.g. pinprick, temperature, vibration) to assess sensation (feeling)
- Comprehensive foot exam at least annually. If high-risk, refer to the podiatrist.
- Treatment options: pregabalin, duloxetine, gabapentin
Foot Care Counseling:
- Every day: wash, dry, and examine feet. Moisture the top and bottom of feet, but not between the toes.
- Each office visit; take off shoes to have feet checked.
- Annual foot exam by a podiatrist (for most).
- Trim toenails with nail file; do not leave sharp edges from the clipper.
- Wear socks and shoes. Elevate feet when sitting.
Cholesterol Contol:
- High-intensity statin (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily for:
- Diabetes + ASCVD
- Age 50-75 years with multiple ASCVD risk factors
- Moderate-intensity statin for:
- Diabetes + age 40-75 years (no ASCVD)
- Diabetes + age < 40 years + ASCVD risk factors
Cholesterol Control:
- Ezetimibe if ASCVD 10-yr risk > 20%.
- Icosapent ethyl (Vascepa) if LDL is controlled but TGS are 135-499 mg/dL.
- Monitoring lipid panel annually and 4-12 weeks after starting a statin or increasing the dose.
BP Goal:
- 130/80 mmHg (esp, if ASCVD or 10-year risk ≥ 15%)
- ≥ 140/90 mmHg (acceptable if ASCVD risk < 15%
Treatment:
• No albuminuria*: thiazide, CCB, ACE inhibitor, ARB**
• Albuminuria: ACE inhibitor or ARB
• CAD: ACE inhibitor or ARB
Natural products are commonly used for T2D, with low or minimal efficacy. Products used to decrease BG include:
cassia, cinnamon, alpha lipoic acid, chromium, magnesium, Panax/American ginseng
In addition to metformin, a second drug from a different class, is recommended in the following instances:
- Start two drugs at baseline if the A1c is 8.5-10%.
- Start two drugs at baseline regardless of A1c if the patient has ASCVD, heart failure, or chronic kidney disease (CKD). A drug with proven benefit for these conditions should be used.
- Add on a second drug is the A1c remains above goal on metformin. In this case, treatment is driven by patient-specific factors (e.g., cost, risk of hypoglycemia, and weight).
- Insulin can be used initially if hyperglycemia is severe (A1C >10% or BG > 300 mg/dL).
Metformin primarily works by decreasing liver glucose production, decreasing intestinal absorption of glucose, and increasing insulin sensitivity. Metformin is first-line treatment for T2D and can be used in prediabetes. Use of metformin is dependent on eGFR.
Metformin (Glucophage, Glucophage XR, Fortamet, Glumetza, Riomet)
IR: 500, 850, 1,000 mg
ER: 500, 750, 1,000 mg
Riomet liquid: 500 mg/5mL
IR: 500 mg daily or BID
ER: 500-1,000 mg daily with dinner initially
• Titrate weekly, usual maintenance dose: 1,000 mg BID
• Max dose: 2,000-2,550 mg/day (varies by product)
• Give with a meal to decrease GI upset
• Boxed Warning: Lactic acidosis- risk by increasing with renal impairment, radiological studies with contrast, excessive alcohol, or certain drugs.
• C/Is: eGFR <30, acute or chronic metabolic acidosis (includes DKA)
• Warnings: Not recommended to start if eGFR 30-45; reassess if already taking at eGFR falls < 45; Vitamin B12 deficiency.
Side effects: GI effects: diarrhea, nausea, flatulence, cramping; usually transient (resolve over time)
• Notes: decrease A1c 1-2%, weight neutral, no hypoglycemia
ER: swallow whole; can leave a ghost tablet (empty shell) in the stool
Intravascular iodinated contrast media (used for imaging studies) can increase the risk of lactic acidosis. Discontinue metformin before the imaging procedure. Metformin can be restarted 48 hours after the procedure if eGFR if stable. Alcohol can increase the risk for lactic acidosis; excessive intake, acute or chronic, should avoided.
- Metformin can be restarted 48 hours after the procedure if eGFR if stable
- Alcohol can increase the risk for lactic acidosis
- Excessive alcohol intake, acute or chronic, should be avoided. • • Metformin and topiramate can increase the risk of metabolic acidosis.
Canagliflozin (Invokana)
Dosing: 100 mg daily prior to the first meal of the day; can increase to 300 mg daily
eGFR 30-59: max dose 100 mg/day
eGFR < 30: not recommended, unless albuminuria > 300 mg/day
Warnings: increased risk of leg and foot amputations, higher risk with history of amputation, PAD, peripheral neuropathy and/or diabetic foot ulcers; hyperkalemia risk when used with other drugs that increase K; risk of fractures
