Case 6: Diabetes Flashcards Preview

Family Medicine > Case 6: Diabetes > Flashcards

Flashcards in Case 6: Diabetes Deck (51):

Relevant medical history for a patient w diabetes

- age at onset and characteristics of onset of diabetes
- previous Tx regimens
- response to Tx
- current treatment
- nutrition hx
- level of physical activity
- diabetes education history
- hyperglycemic and hypoglycemic episodes
- hypoglycemic awareness
- microvascular complications: retinopathy, nephropathy, neuropathy (sensory and autonomic)
- macrovascular complications: cardiovascular
- psychosocial problems: depression
- dental disease


T1D pathophysiology

Immunologic: pancreas is damaged and beta cells do not produce enough insulin


T2D pathophysiology

Body cannot recognize insulin produced by pancreas and use it properly (insulin resistance)


High blood pressure makes ....

vascular disease in diabetes much worse (high blood glucose affects blood vessels and organs throughout entire body)


Cardiovascular disease in diabetes

Most common cause of death in diabetes
- Dx of diabetes = risk to previous MI



Most common cause of new cases of blindness among adults of working age
- by the time vision is affected, substantial nerve damage may have already occurred

Must go annually to ophtho for dilated exam: detects retinal thickening (due to macular edema0
- T1D: first annual 5 years post Dx
- T2D: go right after Dx


Prevention of retionpathy

Laser photocoagulation treatment can slow progression of retinopathy and reduce vision loss but does not restore lost vision (do this!)


Fundoscopic features in severe, non proliferative retinopathy

1) cotton wool spots (areas of previous infarction)
2) retinal hemorrhages (partial obstruction and infarction)
3) microaneurysms (vascular dilation)


Proliferative retinopathy

Hallmark is neovascularization (growth of new vessels that is prompted by retinal vessel occlusion and hypoxia)



Sensory: distal peripheral neuropathy
Autonomic: gastroparesis, sexual dysfunction

Prevalence of neuropathy is defined by loss of ankle jerk reflexes


Most common cause of end stage renal disease

Diabetes (nephropathy is very common)


Is hyperthyroidism an end result of diabetes?



Hyperthyroidism and diabetes

The hypermetabolic state can unmask underlying glucose intolerance and adversely affect glucose control and lipid management

**Hypothyroidism can also complicate management of diabetes


Severe T2D can result in...

Hyperosmolar hyperglycemia syndrome (more commonly) but also DKA if insulin deficiency is severe enough: pt will produce ketones and develop hyperglycemia (eldelry patient with T2D who becomes acutely ill w pneumonia)


American Diabetes Association recommendations on who to screen for diabetes?

1. Patient > 45 years old
2. Overweight patient (over BMI 25) < 45 years old with at least one of eleven risk factors

If results are normal: screen every 3 years


11 risk factors of diabetes that ADA recommends screening patients <45 for

1. inactive
2. race (native american, AA, pacific islander, asian, latino)
3. First degree relative w diabetes
4. Previous dx of impaired fasting glucose (>125) or impaired GTT (2 hr > 140 after 75 g load)
5. HTN (BP 140/90 or higher)
6. HDL <35 or TGs >250
7. Hx of gestational diabetes or baby > 9 lbs
9. Hx of cardiovascular disease
10. HbA1C >/= 5.7
11. acanthos nigricans (signs of insulin resistance)


USPSTF recommendations for diabetic screening

Grade B recommendation: screen for T2D for BP > 135/80

(I recommendation if BP <135/80)


Diagnostic criteria for diabetes (4) - any of them fulfilled

1. Random glucose > 200 + Sx of hyperglycemia such as polyuria or unexplained weight loss
2. Fasting glucose > 126
3. HbA1C > 6.5
4. OGTT: >140 post 2 hrs of 75 g load

for 2, 3, 4 - must be confirmed on a different day unless patient has unequivocal or unquestionable Sx of hyperglycemia


Optimal range for glucose in diabetics
- fasting blood glucose
- post prandial glucose

Fasting BG: 80-120
PP glucose: <180 (1-2 hrs after meal)


LEARN model for two way dialogue to help pt understand their chronic disease

- Listen w empathy
- Explain your perception and strategy
- Acknowledge differences/similarities b/w your approach and patients approach
- Recommend treatment
- Negottiate agreement


Diabetics should have a foot exam...

Every year


2 risk factors for foot ulceration and subsequent amputation

- impaired sensation (distal symmetric polyneuropathy)
- impaired perfusion (peripheral vascular disease)


Foot exam should include testing for loss of protective sensation with following

1) Sensory testing w 10 g monofilament + any one of the following:
- vibration using 128 Hz tuning fork
- pinprick sensation
- ankle reflexes (Achilles, not patellar)

2) Assessment of pedal pulses: DP/PT

3) Inspection for skin change such as hair loss, temperature changes for signs of vascular insufficiency


Strongest risk factor for delayed ulcer healing and amputation in diabetes patients

Peripheral vascular disease


Hyperosmolar hyperglycemic state

Increases with increasing age and serum osmalility
- plasm glucose level > 600
- no metabolic acidosis or ketones

Characterized by severe fluid deficit (9L)
Precipitants: pneumonia, UTI, decreased fluid, stroke, MI< pulm embolism
Tx: fluid replacement


Diabetic ketoacidosis

If <65: mortality is 2%, whereas if 65, mortality is 22%
- metabolic gap acidosis + ketones
- lower plasma glucose level: ~250


Follow up diabetes studies (6)

1. HbA1C
a) if stable < 7: 2x/year
b) if not meeting goal: 4x/year

2. BMP to screen for nephropathy annually (and if on metformin: metabolic acidosis)
- use creatine to calculate GFR to stage chronic kidney dz

3. Spot urine albumin to creatinine ratio to screen for microalbuminuria annually

4. Serum B12 levels

5. TSH if not performed in last year and one of following...
- Type 1 Diabetes
- new Dx of dyslipidemia
- women over 50

6. Fasting lipid profile
- at time of Dx and
- annually



Glycosylated hemoglobin: represents plasma glucose concentrations over 4-12 week period of time
- only need to add fingerstick glucose if pt acutely endorses Sx of hyper or hypoglycemia @ time of visit


Metformin can cause (2)

- metabolic acidosis
- B12 deficiency


B12 can be low due to (2)

- metformin
- nutritional deficiency leading to B12 def (contributing to peripheral neuropathy rather than diabetes)


Management of ASCVD risk factors (to avoid CV and cerebrovascular pathology) includes (5)

- smoking cessation
- hypertension
- dyslipidemia
- life style modification: diet and exercise
- glycemic control
+/- aspirin


Smoking in diabetics

Advice all patients to QUIT, not just cut back
*smoking is most important modifiable cause of premature death


Hypertension in diabetics

Keep BP < 140/90
If above and > 18: initiate pharm Tx
- non blacks: ACEI, ARB, TZ, or CCB
- blacks: TZ, CCB


Is screening asx diabetics for coronary heart disease recommended when baseline EKG is normal?

- this approach fails to identify which pts will have silent ischemia on screening tests


Use ______ to prevent dyslipidemia in diabetics

STATINs for LDLc 70-189
- moderate for diabetics 40-75
- high for diabetics 40-75 w >7.5% est 10 yr ASCVD risk
- If <40 and >75 -- consider on case by case basis


Patients > 21 years old with or without diabetes who ahve LDL > ____ should be on statin



Target diabetics specifically with aspirin (75-162)?

Most common prescribed dose is 81 for aspirin

No- consider aspirin therapy just as we would in patient w/o diabetes because meta analysis only showed it reduced risk of MI in men


ADA (4) recommendations regarding aspirin use

1. Use aspirin as secondary prevention in diabetes pt with history of CVD

2. Consider aspirin as primary prevention strategy in diabetics w increased CV risk (10 year risk > 10%) - this group typically includes men > 50 and women > 60 who have at least one additional RF
- family Hx of CVD
- smoking
- dyslipidemia
- albuminuria

3. In patient in above age group with multiple RFs but estimated 10 year risk 5-10% also consider adding aspirin

4. Do not use aspirin for CVD preventions with low CVD risk (10 yr risk is <5%) such as men < 50 and women <60 with no additional risk factors bc adverse effects of bleeding is worse than benefits


USPSTF (2) recommendations regarding aspirin use

1. Use aspirin for men 45 to 79 when reducing MI benefit is > than harm due to GI hemorrhage

2. Use aspirin for women 55 to 79 when reducing ischemic stroke is > than harm due to GI hemorrhage


If CVD patient has documented aspirin allergy...

Give clopidogrel 75 mg


ADA/EASD consensus algorithm for management of T2D

FIRST TIER (well validated studies)
Step 1: Diagnosis
- HbA1C > 6.5%: lifestyle change + metformin
Step 2: Assessment - if HbA1C > 8
- continue lifestyle + metformin
- add sulfonylurea, glimepiride, or basal insulin on intermediate acting insulin (NPH)
Step 3: Reassessment - if HbA1C still > 8
- continue lifestlye + metformin
- add basal insulin or if already added, intensify insulin regimen
- discontinue sulfonylurea to avoid hypoglycemia

SECOND TIER (less well validated studies)
Step 4: Explore other treatment options
- rapid acting insulin with meals
- Thiazolidenideiones
- Meglitinides
- GLP 1 analogs
- DPP 4
- amylin analog
- alpha glucosidase inhibitors



- good for those who cannot tolerate GI side effects of metformin or who have hypoglycemia on other agents
- risks: heart failure, edema, bone fractures


Vaccines for patients with diabetes (3)

- influenza annually
- Hep B
- Pneumonia if pt > 2 yrs. Revaccinate at 65 if vaccine was first received over 5 years ago


Who gets Hep B

- diabetics
- immunocompromised
- liver disease


Who gets early pneumonia vaccine

- diabetics
- nephrotic syndrome
- chronic renal disease
- immunocompromised



Family is viewed as primary source of support
- ask patient if he or she wants to include family members in decision making


Respeto/Simpatia (respect)

Special respect shown to elders and authority figures
- Hispanics avoid disagreement - prefer communication based on politeness and respect (Simpatia)
- may agree to plan they do not want



- Value friendly relationship over formal one
- always address with Mr. or Mrs. or Ms. (not first name)



Holding belief that control over one's diabetes is external to self, thinking nothing can be done to improve diabetes or health "it's all out of my hands"
- address this by mantra, Help yourself and god will help you"


Body image

Patients may not accept the idea that thinner is healthier - approach diet from perspective of balance


Effects of hispanic culture on communication

- familismo
- respeto/simpatia
- personalismo
- fatalismo
- faith/religion
- body image
- language barriers
- health literacy
- complementary or alternative health practices