Chronic Complications of Diabetes

Question 1

UKPDS Results

Answer 1

Decreased Glycemia = Decreased MICROvascular complication

Question 2

UKPDS Follow Up

Answer 2

Decreased Glycemia = Decreased MACRO and MICROvascular complications

Question 3

DCCT/EDIC Results

Answer 3

Decreased Glycemia = Prevention/Delay MICROvascular complications

Question 4

DCCT/EDIC Follow Up Results

Answer 4

Decreased Glycemia = Prevention/Delay MACRO and MIRCOvascular complication

Question 5

ACCORD Results

Answer 5

Decreased Glycemia = Increased MACROvascular complications

Question 6

ADVANCE Results

Answer 6

Decreased Glycemia = Decreased MICROvascular complications

Question 7

VADT Results

Answer 7

Decreased Glycemia = Decreased MICROvascular complications

Question 8

How does hyperglycemia affect nephropathy?

Answer 8

Structural changes in the kidney at the glomerulus leads to inappropriate filtration of albumin (increased)

Question 9

What are the microvascular complications of DM?

Answer 9

Nephropathy, Neuropathy, Retinopathy

Question 10

What is the screening for nephropathy?

Answer 10

T2: at diagnosis
T1: within 5 yrs of diagnosis, or at diagnosis if they have HTN

Question 11

What is the monitoring for nephropathy?

Answer 11

Annually, albumin/creatinine ratio, eGFR, and SCr

Question 12

When do you monitor bi-annually for nephropathy?

Answer 12

If UA> 300 or GFR <60

Question 13

What is diagnosis of albuminuria?

Answer 13

2 of 3 spot collections over a 3-6 month period

Question 14

What is the treatment for nephropathy?

Answer 14

ACE or ARB

Question 15

When do you NOT DC ACE/ARB in nephropathy?

Answer 15

Elevations in SCr <30%

Question 16

What add on therapy can be used in nephropathy to achieve maximal blood pressure goals?

Answer 16

Diuretics, CCB, and BB

Question 17

Should you restrict dietary protein in nephropathy?

Answer 17

Yes 0.8g/kg/day

Question 18

When should you avoid ACE/ARB in nephropathy?

Answer 18

If there is NO microalbuminuria <30 or no HTN

Question 19

Peripheral Neuropathy in DM affects what areas the most?

Answer 19

Lower limbs, hands, and fingers

Question 20

What are the symptoms when SMALL nerve fibers are affected?

Answer 20

Burning, stabbing, electric shocks, cold and hot discrimination reduced, pinprick sensation

Question 21

What are the symptoms when LARGE nerve fibers are affected?

Answer 21

Numbness, tingling, poor balance, and sensations

Question 22

What are the cardiovascular symptoms of autonomic neuropathy?

Answer 22

Orthostatic hypotension, resting tachycardia >100, and exercise intolerance

Question 23

What are the GI tract symptoms of autonomic neuropathy?

Answer 23

Constipation and Gastroparesis

Question 24

What are the GU tract symptoms of autonomic neuropathy?

Answer 24

Erectile Dysfunction and Bladder Dysfunction

Question 25

How is glucagon affected in autonomic neuropathy?

Answer 25

Failure in response to hypoglycemia, can no longer respond with glucagon naturally

Question 26

What is the screening for Neuropathy?

Answer 26

T2: at diagnosis T1: within 5 years of diagnosis

Question 27

What is the monitoring for neuropathy?

Answer 27

Annually, pressure sensation using a 10g monofilament

Question 28

What are the 3 components of neuropathy monitoring with a monofilament?

Answer 28

1. tests for pinprick sensation 2. temperature 3. vibration sensation

Question 29

How often should a foot exam be conducted?

Answer 29

Annually, however patients should visually check daily

Question 30

What is the visual inspection in a foot exam?

Answer 30

Dry skin, absence of hair, ingrown toenails, interspace maceration, ulceration, ulcers, corns or calluses, and deformities

Question 31

What is the vascular inspection of the foot exam?

Answer 31

ABI < 0.9 is consistent with peripheral arterial disease

Question 32

What is first line therapy for neuropathy?

Answer 32

Pregabalin/Lyrica, Gabapentin/Neurontin, and Duloxetine/Cymbalta

Question 33

What are the symptoms of retinopathy?

Answer 33

Blurry vision, floaters, dark areas, poor night vision, impaired color vision Asymptomatic in early stages

Question 34

With the progession of retinopathy what happens?

Answer 34

Breakdown of endothelial tissue, increased vascular endothelial growth factors VEGF, and increase of advanced glycation end-products AGE

Question 35

What is the screening for retinopathy?

Answer 35

T2: at diagnosis and after BS stabilizes T1: within 5 years of diagnosis

Question 36

What is the monitoring for retinopathy?

Answer 36

No retinopathy for one or more annual eye exams, then repeat every 2 years If retinopathy present, ANNUAL

Question 37

What are the two forms of retinopathy treatment?

Answer 37

1. Laser photocoagulation surgery 2. Anti-Vascular endothelial growth factor injections up to 12 months ANTI-VEGF

Question 38

What are the Macrovascular complications of DM?

Answer 38

CVD, CAD, PAD

Question 39

When should hypertension be screened/monitored in DM?

Answer 39

Every single routine visit

Question 40

What is the HTN BP Goal for individuals WITH DM and HTN at high CV risk (ASCVD >15% or have ASCVD)

Answer 40

<130/80

Question 41

What is the HTN BP Goal for individuals WITH DM and HTN at low CV risk (ASCVD <15%)

Answer 41

<140/90

Question 42

What are lifestyle changes that should be made for patients with HTN and DM?

Answer 42

Weight loss, DASH diet, physical activity, sodium restriction, and alcohol consumption

Question 43

If a patient has Albuminuria or CAD what is the first line agent started for kidney protection?

Answer 43

ACE or ARB

Question 44

What is the treatment for a patient with HTN, DM, and NO albuminuria?

Answer 44

Thiazides, ACE, ARB, Non-DHP CCB

Question 45

Why is an ACE/ARB always started first in CAD/Albuminuria?

Answer 45

Kidney Protection

Question 46

What is the screening for lipid management for patients with DM?

Answer 46

T2: at diagnosis T1: at diagnosis

Question 47

For patients with DM and ASCVD or Risk >20% what is the treatment?

Answer 47

HIGH intensity statin

Question 48

For patients with DM and Multiple ASCVD risk factors what is the treatment?

Answer 48

HIGH Intensity Statin

Question 49

For patients with DM, age 40-75, W/O ASCVD what is the treatment?

Answer 49

MODERATE intensity statin

Question 50

For patients with DM, age <40, with CVD what is the treatment?

Answer 50

Consider statin

Question 51

For patients with LDL >70 despite max tolerated statin what is the treatment?

Answer 51

Consider PCSK9-1 or Ezetimibe

Question 52

What is the range of ASA for Primary Prevention?

Answer 52

75-162 for those at INCREASED CV risk >50 yrs with DM with 1 major risk factor: FH premature ASCVD, HTN, dyslipidemia, and smoking

Question 53

What is the range of ASA in Secondary Prevention?

Answer 53

75-162 for patients WITH history of ASCVD

Question 54

If you cannot use ASA for antiplatelet therapy in DM, what should be considered?

Answer 54

Clopidogrel 75 mg/day

Question 55

Dental Concerns with DM?

Answer 55

Periodontal Disease

Question 56

Celiac Concerns with DM?

Answer 56

Screen at diagnosis If normal, do not recheck unless symptomatic

Question 57

Thyroid Disorder Concerns with DM?

Answer 57

Screen at diagnosis If normal, recheck every 1-2 yrs

Question 58

When do you give Hepatitis B vaccines?

Answer 58

Unvaccinated adults age 19-59, after that its a conversation with provider

Question 59

When do you give Pneumonia vaccines?

Answer 59

PCV15 or PCV20, if PCV15 is used follow with PPSV23 1 yr later

Question 60

When should patients with DM get the influenza vaccine?

Answer 60

>6 months of age, yearly 2 doses for children <9yrs