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Therapeutics II > Block 3: Chronic Complications of Diabetes > Flashcards

Block 3: Chronic Complications of Diabetes Flashcards

1
Q

Poor glycemic control and hyperglycemia can lead to?

A

Many of the long-term complications related to diabetes

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2
Q

What are the mascovascular complications?

A
  1. Cardiovascular Disease
  2. Hypertension
  3. Peripheral Vascular Disease
  4. Foot Ulcers
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3
Q

What are the microvascular complications?

A
  1. Neuropathy
  2. Retinopathy
  3. Nephropathy
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4
Q

How do you reduce diabetes complications?

A
  1. Glycemic management
  2. BP managment
  3. Lipid management
  4. Agents with CV and kidney benefit
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5
Q

What are the major risk factors of CV risk?

A
  1. > 40 YO
  2. HTN
  3. CKD >3a
  4. Smoking
  5. Premature ASCVD
  6. Low HDL
  7. High non HDL
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6
Q

How do you minimize CV risk?

A
  1. Smoking cessation
  2. Control weight
  3. Control blood glucose
  4. Control BP
  5. COntrol Lipids
  6. Anti-platelet therapy
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7
Q

Blood pressure catergories?

A
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8
Q

BP goal for DM and HTN?

A

130/80

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9
Q

Uncrontrolled HTN can lead to…

A

Microvascular and microvascular problems

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10
Q

HTN medication CI with pregnancy?

A

ACEI, ARB, spironolactone

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11
Q

Tx for BP cateogries?

A

BP>120/80 mmHg
* Lifestyle Modifications

BP>130/80 mmHg
* Lifestyle Modifications + 1 drug

BP>160/100 mmHg
* Lifestyle Modifications, + 2 drugs

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12
Q

HTN drug classes?

A
  1. ACE or ARB: 1st line for patients with
    urine albumin to creatinine ratio > 30 mg/g creatinine
    * Do not combine with each other or renin inhibitor
  2. Thiazinde
  3. DHP CCB
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13
Q

How do you monitor HTN?

A

Annually
1. Scr
2. eGFR
3. K

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14
Q

How often do you check lipid profiles?

A
  1. At diagnosis
  2. At initiation of lipid lowering therapy
  3. 4-12 weaks after lipid management therapy initiation/dose change
  4. Annually
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15
Q

Indications for lipid tx?

A

LDL > 100 mg/dl
* LDL > 70 mg/dl if DM & risk factors
* LDL > 55 mg/dL if DM & overt CVD

Triglycerides > 150 mg/dl
HDL < 40 (males), < 50 mg/dl (females)

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16
Q

Lifestyle modifications to improve lipid profile?

A
  1. Weight loss
  2. Mediterranean or DASH
  3. Physical activity
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17
Q

Lipid Goals?

A
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18
Q

Primary prevention HLD with DM?

A

CVD RF: LDL goal of <70 mg/dL

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19
Q

Secondary prevention of HLD with DM?

A
  1. All patient with DM and CVD: high intensity statin + lifestyle modifications
  2. Target 50% or more reduction of LDL from baseline and an LDL goal <55 mg/dL
  3. Add ezetimibe or a PCSK9 inhibitor to max tolerated statin dose if needed to reach LDL goal
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20
Q

What are the high intensity statins?

A
  1. Atorvastatin 40-80 mg
  2. Rosuvastatin 20-40 mg
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21
Q

What are the moderate intesity statins?

A
  1. Atorvastatin 10-20 mg
  2. Rosuvastatin 5-10 mg
  3. Simvastatin 20-40 mg
  4. Pravastatin 40-80
  5. Lovastatin 40 mg
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22
Q

When is aspirin used in secondary prevention?

A

Pts with DM and a hx of ASCVD

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23
Q

When is aspirin used for primary prevention?

A

Pts with DM and:
1. 50 years of age who have at least one additional major risk factor (family hx of CVD, HTN, smoking, DLD, CKD)
2. Not increased risk for bleeding

24
Q

Standard aspirin dosing?

A

81 mg QD

25
Q

Alternatives if aspirin can not be used?

A

Aspirin allergy, bleeding tendency, anticoagulation therapy, recent GI bleed, < 21 years of age (Reye’s syndrome risk):
1. Clopidogrel (75 mg)
2. Retinopathy is NOT a contraindication to ASA use for cardioprotection (Does NOT increase the risk of retinal hemorrhage)

26
Q

Approaches to address PVD and foot ulcers?

A

Prevent, Prevent, Prevent

Important to:
1. Stop smoking
2. Correct lipid problems
3. Anti-platelet therapy

Tx:
1. Pentoxifylline
2. Good foot care

27
Q

What are the types of self-inspection foot exams?

A
  1. QD
  2. Visual
  3. Manual
28
Q

When do you conduct a foot exam?

A

Pts with evidence of sensory loss or prior ulceration or amputation should have feet inspected at every visit

29
Q

What are the components of a comprehensive annual foot exam?

A
  1. Visual inspection of the skin
  2. Assessment of foot deformities
  3. Neurological Assessment: monofilament test, pin prick, temperature, vibration
  4. Vascular assessment: palpitation of the pulses in the legs and feet
30
Q

What are basic skin care tips?

A
  1. Bathe daily with mild soap and lukewarm water
  2. Pat skin dry; do not rub
  3. Use lotion to prevent dry skin
  4. Keep skin dry
  5. Wash cuts with soap and water and cover with bandage to avoid infection
  6. Dress warmly in cold weather to avoid chapped skin
31
Q

What is neuropathy?

A

Swelling and scarring of nerve cells, which over time can lead to loss of functionality

32
Q

What are the types of neuropathy?

A
  1. Peripheral: damage causes pain or loss of feeling
  2. Motor: damage causes muscle weakness
  3. Autonomic: sx of damage depend on the autonomic function of the nerve
33
Q

What is peripheral neuropathy?

A

Damage to sensory and motor nerves often in hands and feet

34
Q

What are the sx of peripheral neuropathy?

A
  1. Burning pain
  2. Numbness
  3. Tingling
  4. Loss of feeling
  5. Gait abnormalities
  6. Development of foot ulcers and lower extremity amputations
35
Q

How do you screen and prevent peripheral neuropathy?

A

Screening:
* Nomofilament test and others:
1. All patients with T1DM > 5 years in duration
2. All patients with T2DM beginning at diagnosis

Prevention:
1. Control bloog glucose
2. Reduce risk factors

36
Q

What is the tx for peripheral neuropathy?

A
  1. Capsaicin cream
  2. OTC pain meds
  3. Prescription meds
    * Low dose TCAD (amitryptyline, nortriptyline, imipramine)
    * Anticonvulvants (gabapentin, pregabalin)
    * Other AD (duloxetine)
    * Pain (tepentadol)
37
Q

Sx of autonomic neuropathy?

A
  1. Hypoglycemia unawareness
  2. Resting tachycardia
  3. Fecal Incontinence
  4. Increased or decreased sweating
38
Q

What is gastroparesis?

A

Delayed emptying of stomach
* Early satiety
* N
* Erratic BG levels due to erratic food absorption

39
Q

Stomach autonomic neuropathy?

Treatment

A

Gastroparesis:
1. COntrol glucose
2. DC meds that decreased motility (GLP1, pramlinitide, DPP4, opioids, anticholinergics, TCAD)
3. Short term improvement of motility (metoclopramide, erythromycin)

40
Q

Large intestine autonomic neuropathy?

Tx?

A
  1. Constipation
  2. Diabetic diarrhea:
    * Antibiotics (doxycycline or metronidazole) for bacterial overgrowth
    * Chloestrramine
    * Anti-diarrheal (diphenoxylate, loperamide)
    * Fiber
41
Q

Bladder autonomic neuropathy?

A

Neurogenic bladder: overflow incontinence and increased risk of UTI

42
Q

Sexual organs autonomic neuropathy?

Tx?

A

Impotence:
1. Control BG
2. Presciption med for ED (tadalafil, slidinafil)

43
Q

Heart autonomic neuropathy?

A

Orthostatic hypotension:
1. Adequate fluid and salt intake
2. Physical activity
3. Elastic stockings and get up slow when sitting or lying down
4. Medications: midodrine, droxidopa

44
Q

What is retinopathy?

A

Damage of small blood vessels of the eyes

Leading cause of adult blindness in US

45
Q

How do you screen for retinopathy?

A

Annual dilated eye exam:
1. All patients with T1DM > 5 years in duration
2. All patients with T2DM beginning at diagnosis

46
Q

How do you prevent retinopathy?

A
  1. Control blood glucose
  2. Control blood pressure
  3. Control lipids
  4. Stop smoking
47
Q

Tx for retinopathy?

A
  1. Laser photocoagulation therapy
  2. Anti-vascular endothelial growth factor (VEGF) therapy
48
Q

What is nephropathy?

A

Damage to small blood vessels in the kidneys with no early sx

49
Q

How do you screen for nephropathy?

A
  1. eGFR and Spot Urine Test -> Albumin:Creatinine
  2. Annual
    * All patients with T1DM > 5 years in duration
    * All patients with T2DM beginning at diagnosis
    * All patients with DM and HTN
  3. Screen 1 to 4 times a year when:
    * Urine Albumin : Creatinine >30 mg/g; OR
    * eGFR < 60 ml/min/1.73 m2
50
Q

What are the stages of CKD?

A
51
Q

What is the tx for nephropathy?

A
  1. Control BG (SGLT2, GLP1, metformin)
  2. Control BP
    * Urine Albumin : Creatinine >30 mg/g OR eGFR <60 ml/min/1.73 m2
    * ACE inhibitor or ARB
    * Diuretic for volume overload
  3. RAAS Blockade (ACE, ARB, direct renin inhibitor)
  4. Control lipids
  5. Stop smoking
  6. Lower protein diet: 0.8 gm/kg body wt per day
52
Q

Tx with kidney function is <10%?

A
  1. Dialysis
  2. Kidney transplant
53
Q

Preventive care for DM complications?

A
  1. Minimize CV RF
  2. Foot exam
  3. Skin care
  4. Eye exams
  5. Monitor kidney function
  6. Immunizations
  7. Dental care
  8. Assess co-morbidity condition
54
Q

Immunizations appropriate for DM?

A
  1. COVID-19
  2. Flu (Annually)
  3. HepB (<59YO)
  4. PCV (≥19YO)
  5. RZV (≥50YO)
  6. Tdap (Q10Y)
55
Q

How can DM cause tooth and gum problems?

A

High blood glucose

56
Q

What should oral hygiene include?

A
  1. Brush and flodd daily
  2. Use a soft toothbrush to prevent gum damage
  3. Check mouth and gums for sores or signs of yeast infections daily
  4. Dental visit at least every 6 months (or more often if recommended by dentist)
57
Q

What is the difference between continuous and individualized patient education?

A

Continuous: will need to educate for a lifetime
Individualized: treat patient what they need when they need it, use every opportunity

Need to enable patients to self-manage their DM

Therapeutics II (30 decks)

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