diabetes

Question 1

Type 1 diabetes

Answer 1

Primary β-cell defect or failure results in severe insulin deficiency or no insulin secretion

Question 2

2 types of Type 1 diabetes

Answer 2

immune mediated
idiopathic

Question 3

type 2 diabetes

Answer 3

Insulin resistance with inadequate insulin secretion. Insulin resistance is universal and multifactorial. Insulin secretion declines over time

Question 4

diagnostic criteria of diabetes

Answer 4

FPG ≥ 7
or A1C ≥ 6.5
or 2hPG in a 75 g OCGTT ≥11.1
or random PG ≥ 11.1

If asymptomatic, need repeat confirmatory testing

Question 5

Hg A1C not commended for diagnosis in (special population

Answer 5

children & adolescents (as the sole diagnostic test)
pregnant individuals as part of routine screening for gestational diabetes
cystic fibrosis
suspected Type 1 diabetes

Question 6

factors affecting HgA1C accuracy

Answer 6

erythroproiesis (B12/Fe deficiency, chronic liver disease)

altered hemoglobin
altered glycation (CKD)
Erythrocyte destruction (splenectomy)
Assays (Hyperbilirubinemia, Etoh, chornic opiates)

• increase with Age
  may vary among ethic groups

Question 7

prediabetes criteria

Answer 7

fast glucose 6.1-6.9
2h PG in a 75g OGTT 7.8-11
A1C 6.0-6.4

Question 8

IFG (impaired fasting glucose)

Answer 8

due to increased hepatic glucose output caused by hepatic insulin resistance and increased glucagon levels

Question 9

IGT (impaired glucose tolerance)

Answer 9

due to decreased insulin secretion, primarily resulting from peripheral (muscle) insulin resistance

Question 10

LADA

Answer 10

latent autoimmune diabetes
antibodies targeting beta cells

Question 11

HgA1C is a better predictor to ____ than FPG or 2hPG

Answer 11

cardiovascular event

Question 12

To achieve A1C ≤7 aim for

Answer 12

FPG or preprandial PG target 4-7
2 hour post prandial 5-10

Question 13

Type1 goal A1C target

Answer 13

≤7.5

Question 14

signs and symptoms of type 1 diabetes

Answer 14

polyuria
polydipsia
polyphagia
fatigue
weight loss
poor wound healing
recurrent infections
genital pruritis
vision changes
paresthesias
CV symptoms

Question 15

diabetic ketoacidosis (DKA)

Answer 15

typically seen in Type 1
Absolute insulin deficiency and increased glucagon (must use insulin)

Risk Factors: new diagnosis of DM, insulin omission, infection, MI, abdominal crisis, trauma, possibly continuous subcutaneous insulin infusion therapy, thyrotoxicosis, cocaine, atypical antipsychotics, possibly interferon

Question 16

HYPEROSMOLAR HYPERGLYCEMIC STATE (HHS)

Answer 16

Extracellular fluid volume (ECFV) depletion and hyperosmolarity are predominant; typically seen in Type 2
Relative insulin deficiency; may need insulin (fluids are first priority)

Risk Factors: same as DKA plus cardiac surgery, CVD/renal disease, drugs (diuretics, glucocorticoids, lithium, atypical antipsychotics), infections in 40-60% of cases

Question 17

avoid SAD MANS to prevent dehydration

Answer 17

Sulfonylureas
ACE inhibitors
Diuretics
Metformin
Angiotensin receptor blocker
NSAID
SGLT2 inhibitors

Question 18

hypoglycemia

Answer 18

glucose < 3.9

Development of adrenergic (autonomic) symptoms typically progressing to neuroglycopenic symptoms

Question 19

potential complications of hypoglycemia

Answer 19

Neurologic:
short-term → impaired cognition, coma, death;
long-term → mild intellectual impairment, rare hemiparesis or pontine dysfunction

CV: ↑ mortality in T2DM + CVD

MSK: falls, fractures

Psychosocial: ↓ QoL, fear of hypoglycemia, 	burden/stress on support persons

Question 20

Nocturnal Hypoglycaemia
which insulin is used to reduce the risk

Answer 20

A long-acting insulin analogue (i.e. degludec and glargine) may be used in place of NPH (i.e. Humulin N) to reduce the risk of hypoglycemia, including nocturnal hypoglycemia

Question 21

Dawn phenomenon

Answer 21

An early morning rise in blood glucose level related to the physiologic release of GH, cortisol, and catecholamines without preceding hypoglycemia

Potential Causes:
The evening dose of intermediate-acting insulin is too low
Too much food before bed

Effect: Morning hyperglycemia WITHOUT overnight hypoglycemia

Question 22

SOMOGYI EFFECT
(Rebound hyperglycemia following nocturnal hypoglycemia)

Answer 22

Overnight hypoglycemia that results in a compensatory morning rise in blood glucose level

Hormones of adrenaline, glucagon, GH, and corticosteroids are released in response to the hypoglycemia

Potential Causes:
Dose of evening intermediate or long-acting insulin is too high
Not having enough food before bed
Increased exercise

Effect: Morning hyperglycemia CAUSED BY overnight hypoglycemia

Question 23

microvascular complications of diabetes

Answer 23

diabetic retinopathy
diabetic neuropathy
diabetic nephropathy

Question 24

macrovascular complications of diabetes

Answer 24

cardiovascular
cerebrovascular
peripheral vascular

Question 25

ABCDESSS for diabetes management

Answer 25

A1C targets BP targets (130/80) Cholesterol targets (LDL <2 or > 50% reduction) Drugs for CV and /or cardiorenal protection Exercise and healthy eating Screening for complications Smoking cessation Self-management, stress

Question 26

cardiovascular protection drugs

Answer 26

patients with cardiovascular disease (statin +ACEi/ARB+ASA) patient with microvascular disease (statin +ACEi/ARB) Patient age ≥55 with CV risk factors; age ≥40; age ≥ 30 and diabetes > 15 years (statin) * NO ACEi/ARB or statin for pregnancy

Question 27

complications of gestational diabetes

Answer 27

Neonatal hypoglycemia Preeclampsia Macrosomia: Increased placental transport of glucose, amino acids, and fatty acids stimulate the fetus’s endogenous production of insulin and insulin-like growth factor 1 (IGF-1) that result in fetal overgrowth Stillbirth

Question 28

glycemic targets for pregnancy

Answer 28

fasting and preprandial BG < 5.3 1h postprandial BG < 7.8 2h postprandial BG < 6.7

Question 29

pre-existing diabetes in pregnancy

Answer 29

Aim for A1C ≤6.5% during pregnancy (≤6.1% if possible), if can be achieved safely, to lower the risk of late stillbirth & infant death Screening for retinopathy & nephropathy Good BP control Start ASA 81mg at 12-16wks to ↓ risk of pre-eclampsia

Question 30

management of diabetes in pregnancy

Answer 30

Insulin (preferred) Metformin Glyburide (if insulin refusal or uncontrolled on metformin)

Question 31

screening for gestational diabetes

Answer 31

24-28 weeks

Question 32

postpartum management of diabetes

Answer 32

Encourage immediate breastfeeding to avoid neonatal hypoglycemia and continue at least 3-4 months to prevent childhood obesity Perform a 75g OGTT between 6 weeks to 6 months postpartum to screen for prediabetes and T2DM If pre-existing diabetes: should have frequent blood glucose monitoring in the first days postpartum, due to ↑ risk of hypoglycemia; Insulin doses should be decreased immediately after delivery to below pre-pregnant doses and titrated as needed to achieve good glycemic control If history of T1DM: screen for postpartum thyroiditis at 2-4 months postpartum with a TSH test

Question 33

management of diabetes during delivery

Answer 33

Induction of labour offered at 38-40 wks for GDM, and 38-39 weeks if pre-existing diabetes (earlier if poor glycemic control/complications) Maternal blood glucose levels should be kept between 4.0-7.0 mmol/L during L&D

Question 34

Pregnancy screening of diabetes

Answer 34

Early screening (< 20 weeks) if high risk of undiagnosed T2DM Consider increased fetal assessment in GDM that is poorly controlled +/- co-morbid conditions If pre-existing diabetes, initate fetal well-being assessment at 30 – 32 weeks, and continue weekly starting at 34-36 wks