Diabetes

Question 1

DM Screening

Answer 1

Adults (any age) who are overweight and have one risk factor (familail, comorbids, inactivity, non-white)
Patients with pre-diabetes
Women diagnosed with gestational diabetes (test every 3 years)
Age 45+ (even if no risk factors)

Normal = re-test every 3 years or earlier if change in risk

Question 2

Hallmarks of Type 2 DM disease

Answer 2

Decreased glucose uptake (insulin resistance)
Increased hepatic glucose production
Impaired insulin resistance

Question 3

Type 2 Progression

Answer 3

As insulin resistance increases, postprandial glucose increases, insulin production wanes and fasting glucose increases.

Question 4

Metabolic Syndrome

Answer 4

Group of metabolic issues
Abdominal obesity, insulin resistance, elevated triglyceride, decreased HDL, hypertension, pro-inflammatory state

Precursor to DM often

Question 5

DM Presentation

Answer 5

polyuria, polydipsia, polyphagia, weight loss, blurred vision, and fatigue

Type 2 may be asymptomatic for years until above signs or signs of neuro-vascular issues

Question 6

Diabetes Periodic Exams

Answer 6

1 - evaluate glucose control
2 - assess for presence of end-organ damage
3 - assess for associated diseases such as other auto-immune or CV

Question 7

Diagnostic Criteria for T2DM

Answer 7

HbA1c of 6.5% or more
Fasting Glucose 126 or more
Random Glucose of 200 or more with symptoms
Glucose Tolerance Test of 200 or more

Question 8

Pre-diabetes Criteria

Answer 8

HbA1c 5.7 - 6.4 %
Fasting Glucose 100-125
Glucose Tolerance 140-199

Random glucose for pre-diabetes not recommended

Question 9

HbA1c Limits

Answer 9

May be inaccurate in anemia/blood disorders or transfusion
May be inaccurate in pregnancy and post-partum
Verify point of care tests with verified lab

Question 10

Secondary causes of DM

Answer 10

Cushing
Pheochromocytoma
Acromegaly
Hypokalemia
Hyperaldosteronism
Excess diuretic use
Pancreatitis
Infection

Question 11

Gestational Diabetes

Answer 11

Glucose intolerance onset during pregnancy, though an elevated A1c may indicate pre-existing diabetes

Question 12

HbA1c Goals

Answer 12

Less than 7% for most patients, less than 8% for some

Elderly - goal is to minimize hyperglycemia and hypoglycemia episodes

Question 13

DM and Exercise

Answer 13

Well controlled Type 1 can participate in exercise
Avoid exercise when glucose is 250+ with ketones or 300+ without ketones
Avoid exercise if less than 100
Exercise lag = glucose can drop after exercise, even many hours later (overnight)

Exercise is critical for T2DM management (150min per week, 2 session of strength training)

Question 14

DM Follow-ups

Answer 14

Every 3 months is ideal
HbA1c, BP, weight, eye exam, foot exam, lipids, renal
Liver at least yearly
EKG yearly after age 40

Question 15

Type 1 DM Insulin Requirements

Answer 15

Typically 20-40 units per 24 hours (may vary by patient response)
Half basal insulin, half bolus insulin
Consider starting 0.5 units per KG (half is basal)

Question 16

Postprandial Insulin Needs

Answer 16

Typically 1 unit per 2g of carbs

Can be as high as 1 unit per 30g of carbs in insulin sensitive patients

Question 17

Reducing/Increasing basal Insulin

Answer 17

If fasting glucose is less than 80, step down basal insulin

If fasting glucose is greater than 100, step up basal insulin

Question 18

Honeymoon Phase in Type 1 DM

Answer 18

Short term phase of recovered B-cell function that results in decreased injected insulin needs
Temporarily lower insulin dose

Question 19

Mainstay of T2DM Treatment

Answer 19

Education
Diet
Exercise
Maintain healthy weight

Question 20

Metformin

Answer 20

Initial med for T2DM and consider for pe-diabetes
Typically start at 500mg twice per day
Max dose 2,000mg per day

Question 21

Metformin side effects

Answer 21

N/D - take with meal
Stop metformin before contrast and hold for 2 days after contrast
Contraindicated if GFR is less than 30
B12 deficiency can occur, consider supplementing

Question 22

T2DM and Heart Patients

Answer 22

SGLT2 inhibitors recommended
(-flozin drugs)
Small A1c reduction but risk of UTIs
Hinder heart disease progression and renal benefit

GLP-1 agonists may also be used in CV patients
Injectables (expensive and inconvienient)
(-tide drugs)

Question 23

DPP-4 Inhibitors

Answer 23

Decrease glucagon levels
Risk of pancreatitis
Small A1c reduction
(-liptin drugs)

Question 24

Sulfonylureas

Answer 24

Moderate A1c lowering (1.5%)
Not as common now due to hypoglycemia and weight gain risks
Cheaper than other meds
Glyburide, Glipizide, Glimepiride

Stimulate insulin release

Question 25

Meglitinides

Answer 25

(-linide drugs) Must take before meal and hold if skipping meal Less hypoglycemia risk and short duration of action Stimulates insulin release

Question 26

Thiazolidinediones (TZDs)

Answer 26

``` (-litazone drugs) Improve cel sensitivity to insulin Reduce glucose output from liver Weight gain, higher lipids, and edema is common Takes weeks for effect ``` Never use on heart patients!

Question 27

T2DM when to start insulin

Answer 27

Consider first line if HbA1c is 10% or more, fasting glucose more than 250, fragile older adult, gestational Most common reason is failure of oral meds

Question 28

DM Referral

Answer 28

``` New onset of Type 1 Poor control of Type 2 Complication of DM After hospitalization Insulin pump initiation Planned or confirmed pregnancy Patient request endocrine management ```

Question 29

Refer to ED

Answer 29

DKA (BGL >250, ketones, acidic) HHS (BGL > 600 or serum osmolarity >320) Hyperglycemia and volume depletion Fasting glucose >300 or HbA1c >15

Question 30

DM and Feet

Answer 30

Always refer DM patients to podiatry for treatment of foot ulcers, nail care

Question 31

Gestational DM screening

Answer 31

At first visit, screen - elevated HbA1c means overt cause Fasting Glucose 92-125 = Gestational Diabetes 1 hour glucose tolerance 180+ = Gestational 2 hour tolerance 153+ = Gestational If normal, re-screen as 24-28 weeks

Question 32

DM patients who become pregnant or plan to

Answer 32

Stop metformin Stop sulfonyureas before labor Consider switch to insulin

Question 33

DM patients and illness

Answer 33

Monitor glucose every 4 hours If >250, test for ketones Stay hydrated Continue to take meds, glucose levels rise in illness even if not eating

Question 34

Diabetic Retinopathy

Answer 34

High risk among T2DM (80% develop it) High risk of vision loss Refer all DM for vision exams Fundoscopic exam at every visit to primary care

Question 35

T2DM and Statins

Answer 35

All T2DM should be on statins! | High dose if history of CVD or high ACSVD score (>7.5%)

Question 36

T2DM and Blood Pressure

Answer 36

Recommended goal is 130/80 of less with CVD | 140/90 or less for most others

Question 37

A patient with type 2 diabetes mellitus (DM) becomes insulin dependent after a year of therapy with oral diabetes medications. What will the primary care provider tell the patient when explaining this change in therapy? Strict diet and exercise measures may be relaxed with insulin therapy. This is because of the natural progression of the disease. It is necessary because the patient cannot comply with the previous regimen. The use of insulin therapy may be temporary.

Answer 37

Even after several years of therapy for type 2 DM well controlled with oral diabetic medications, diet, and exercise, the natural progression of the disease may require patients to become insulin dependent.