Learning Objectives Kania

Question 1

List the signs and symptoms of diabetes.

Answer 1

Signs and symptoms that result are related to alterations in carbohydrate, fat, and protein metabolism
Polyuria, polydipsia, polyphagia, weight loss, fatigue, UTIs, respiratory infections, ketoacidosis, blurred vision

Question 2

Glucose uptake by brain is

Answer 2

insulin independent

Question 3

Glucose uptake by other tissues (muscle, fat) is

Answer 3

insulin dependent

Question 4

Understand the differences between T1DM and T2DM and know how to diagnose it.

Answer 4

T1DM: insulin-dependent DM; age of onset <30 yrs, peak is 12-14 yrs; FH not common; usually not obese; usually no pancreatic function; autoimmune beta cell destruction leading to absolute insulin deficiency
T2DM: non-insulin dependent DM; age of onset >40 yrs; FH is common; most are obese; progressive loss of adequate beta cell insulin secretion

Question 5

Drugs that increase hepatic glucose output

Answer 5

Glucocorticoids, sympathomimetics, niacin

Question 6

Drugs that decrease insulin secretion

Answer 6

Phenytoin, beta blockers, calcium channel blockers, immunosuppressant (cyclosporine, sirolimus, tacrolimus)

Question 7

Drugs that increase insulin resistance

Answer 7

Thiazide diuretics, glucocorticoids and oral contraceptives, antipsychotics (clozapine, olanzapine)

Question 8

Drugs that are toxic to beta cells

Answer 8

Pentamidine - prevents insulin secretion

Question 9

Drugs that stimulate appetite

Answer 9

Phenothiazines, marijuana, androgens

Question 10

Criteria for diagnosis of DM

Answer 10

FBG greater than/equal to 126 mg/dL OR
A1C greater than/equal to 6.5% (not for diagnosis in conditions associated with increased RBC turnover, sickle cell disease, pregnancy, hemodialyiss, blood loss or transfusion, severe anemia) OR
Random glucose greater than/equal to 200 mg/dL w/ sx of diabetes OR
2 hr postprandial glucose greater than/equal to 200 mg/dL during OGTT
Need 2 positive criteria in pt

Question 11

Identify and discuss the goals of therapy in the treatment of T1DM and T2DM and describe how the patient should be monitored to establish whether these goals have been met.

Answer 11

Keep patient asymptomatic; prevent long-term complications; maintain patients near euglycemia; acheive/maintain appropriate body weight; eliminate/minimize all cardiovascular risk factors
Components of therapy: meals, monitoring, movement, medications

Question 12

Discuss the long-term complications of diabetes on the kidneys.

Answer 12

Diabetic kidney disease nephropathy: persistent proteinuria, decreased eGFR, and increased arterial BP
Diabetic kidney disease is the major cause of death in T1 pts
Screen for microalbuminuria annually in pts with T1DM for >/= 5 yrs and in all pts with T2DM
ACEI or ARB recommended for non-pregnant pts
Optimize glucose control: SGLT2 or GLP-1 if SGLT2 contraindicated/not tolerated

Question 13

Goal UACR:

Answer 13

<30 mg/g
if pts have UACR greater than or equal to 200, goal is a 30% reduction

Question 14

If UACR > 300 mg/g or eGFR < 60 mL/min, check

Answer 14

both twice annually

Question 15

Pts with CKD and albuminuria who are at risk for CV events use

Answer 15

nonsteroidal minerolocorticoid receptor antagnoist (finerenone)

Question 16

Discuss the long-term complications of diabetes on the eyes.

Answer 16

Blurred vision, cataracts, glaucoma
Retinopathy is the most common complication
For T1DM, have an initial eye exam within 5 yrs after onset of diabetes; for T2DM, have an initial eye exam at time of diabetes diagnosis
Tx: photocoagulation therapy or anti-vascular endothelial growth factor, ranibizumab

Question 17

Discuss the long-term complications of diabetes on the peripheral nervous system.

Answer 17

Peripheral neuropathy: annual monofilament testing; tx - pregabalin, duloxetine, gabapentin, tricyclic antidepressants, venlafaxine, carbamazepine, tramadol, capsaicin, tapentadol
GI neuropathies; urinary retention; postural hypotension; erectile dysfunction

Question 18

Discuss the long-term complications of diabetes on the cardiovascular system.

Answer 18

Atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality in type 2 pts
Heart failure
Assess cardiovascular risk factors annually: obesity, HTN, HLD, smoking, CKD

Question 19

ADA BP goal

Answer 19

<130/80 T2DM or T1DM
110-135/85 DM + pregnancy

Question 20

For a patient with diabetes and concomitant hypertension, discuss the optimal treatment for the disease state.

Answer 20

SGLT-2Is: empagliflozin, canagliflozin, dapagliflozin
GLP-1RAs: liraglutide, semaglutide, dulaglutide
Preferred antihypertensive agents: ACEIs or ARBs (do NOT use in combo due to tisk of hyperkalemia, syncope, and renal dysfunction)
Other antihypertensive options: HCTZ, chlorthalidone, amlodipine, spironolactone

Question 21

For a patient with diabetes and kidney disease, discuss the optimal treatment for the disease state.

Answer 21

Preferably use SGLT2I with evidence of decreased CKD progression; use GLP-1RA if SGLT2I not tolerated or contraindicated

Question 22

For a patient with diabetes and hyperlipidemia, discuss the optimal treatment for the disease state.

Answer 22

High intensity: atorvastatin 40-80 mg/day OR rosuvastaton 20-40 mg/day
Moderate intensity: atorvastatin 10-20 mg/day, rosuvastatin 5-10 mg/day, simvastatin 20-40 mg/day, pravastatin 40-80 mg/day, lovastatin 40 mg/day, fluvastatin XL 80 mg/day, pitavastatin 1-4 mg/day

Question 23

Primary prevention and statin treatment for 20-39 yo

Answer 23

Risk considerations: no ASCVD
Statin dose: none-moderate based on risk factors
Monitoring: annually or prn based on adherence

Question 24

Primary prevention and statin treatment for 40-75 yo

Answer 24

Risk considerations: no ASCVD
Statin dose: moderate intensity
Risk considerations: >/= 1 risk factor
Statin dose: high intensity, decrease LDL by >/= 50% and target LDL < 70
Monitoring: annually and prn to monitor for adherence

Question 25

Secondary prevention - have cardiovascular disease

Answer 25

DM + ASCVD in all ages = high intensity statin therapy + LSM
Target decrease LDL by >/= 50% and goal LDL < 55
If LDL elevated despite maximally tolerated statin dose, add ezetimibe or PCSK9 inhibitor

Question 26

Use of antiplatelets agents in pts with diabetes

Answer 26

Aspirin (75-162 mg/day) as secondary prevention in those with diabetes and CVD
For pts with CVD and aspirin allergy, use clopidogrel (75mg/day)
Consider aspirin (75-162 mg/day) for primary prevention in men/women >/= 50 yrs with one major risk factor, not at an increased risk of bleeding
Do NOT use aspirin for primary prevention for those at low CVD risk - risk of bleeding

Question 27

Fasting ADA target

Answer 27

80-130 mg/dL

Question 28

Random or postprandial ADA

Answer 28

<180 mg/dL
can target bedtime glucose: 90-150 mg/dL

Question 29

When to do self-monitoring blood glucose:

Answer 29

Intensive insulin regimens: prior to meals + at bedtime; prior to snacks/activity; postprandially; suspicion of hypoglycemia and after treatment
Basal insulin +/- non-insulin meds: once daily
Non-insulin regimens: as needed

Question 30

Continuous glucose monitoring can

Answer 30

Decrease hypoglycemia and improve A1C readings

Question 31

ADA target for A1C

Answer 31

<7%; consider <6% in individual pts + pregnant women

Question 32

When to measure A1C

Answer 32

Twice a year if meeting treatment goals
Quarterly if therapy has changed or not meeting treatment goals