Diabetes Mellitus Flashcards by Jamaira Belmes

Testing should be considered in adults with OVERWEIGHT or OBESITY who have 1 or more of the ff risk factors

1st degree relative with diabetes
high risk race/ethnicity
history of CVD
HPN (>140/90 or on therapy for HPN)
HDL >35; TGL > 250
women w/ PCOS
physical inactivity
other clinical conditions associated with insulin resistance (severe obesity, acanthosis nigricans)

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Patients with prediabetes, impaired glucose tolerance or impaired fasting glucose should be tested

YEARLY

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Women w/ GDM

lifelong testing at least every 3 years

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All other patients testing should begin at age

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If results are normal, testing should be repeated at a minimum of

3 year intervals

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METFORMIN is recommended in prevention of type 2 DM in adults with prediabetes

25-59 years w/ BMI > 35 kg/m2
higher FPG > 110 mg/dL
higher A1C > 6 %
women with prior GDM

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Long term use of metformin

vitamin B12 deficiency

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Medical Nutrition Therapy

Type I - A1C decrease of 1.0 - 1.9 %

Type II - A1C decrease of 0.3 - 2.0 %

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Children and adolescents w/ type I or type 2 diabetes or prediabetes should engage in physical activity

60 minutes/ day of moderate or vigorous intensity aerobic activity at least 3 days/ week

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Adults with type I and type Ii diabetes

150 minutes or more of moderate to vigorous intensity aerobic activity per week spread over at least 3 days/ week

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For individuals w/ proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy

vigorous intensity aerobic or resistance exercise may be contraindicated
risk of trigerring VITREOUS HEMORRHAGE or RETINAL DETACHMENT

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Assesment of glycemic status

2 times a year - patients who meet treatment goals

quarterly - patients whose therapy has recently changed and/or who are not meeting glycemic goals

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Classification of Hypoglycemia

LEVEL 1 - glucose < 70 mg/dL and > 54 mg/dL

LEVEL 2 - glucose < 54 mg/dL

LEVEL 3 - severe event characterized by altered mental and/or physical status requiring assistance for treatment of hypoglycemia

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This should be prescribed for all individuals at increased risk of level 2 or 3 hypoglycemia

Glucagon

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Glucose lowering medications that cause WEIGHT LOSS

SGLT 2 inhibitors
GLP 1 receptor agonist

Metformin (moderate weight loss)

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Appropriate Initial Therapy for individuals w/ type 2 diabetes w/ or at high risk for ASCVD, HF and/or CKD

GLP 1 Receptor agonists

SGLT2 inhibitors

w/or w/o metformin

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Should be considered if there is evidence of:

ongoing catabolism (weight loss)
(+) symptoms of hyperglycemia
A1c levels > 10%
blood glucose levels of > 300 mg/dL

INSULIN - combined w/ GLP 1 receptor agonist

medication regimen should be reevaluated at regular intervals (every 3-6 mos)

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ASCVD/ Indicators of High Risk

GLP 1 RA w/ proven CVD benefit

SGLT2 (-) w/ proven CVD benefit

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ASCVD/ Indicators of High Risk

AIC above target

GLP 1 RA consider adding SGLT2I and vice versa

TZD

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SGLT2i w/ proven benefit in this population

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CKD and albuminuria (>200 mg/g creatinine)

SGLT2 (-) w/ primary evidence of reducing CKD progression

SGLT2 (-) w/ primary evidence of reducing CKD progression in CVO

GLP1 RA w/ proven CVD benefit, if SGLT2i not tolerated or CI

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CKD (-) albuminuria (eGFR < 60 mL/min/1.73 m2)

GLP1 RA w/ proven CVD benefit

SGLT2i w/ proven CVD benefit

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(-) ASCVD / indicators of high risk, HF, CKD

MINIMIZE HYPOGLYCEMIA

no/low inherent risk of hypoglycemia: DPP 4I, GLP 1 RA, TZD

for SU or basal insulin, consider agents w/ lower risk of hypoglycemia

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(-) ASCVD / indicators of high risk, HF, CKD

MINIMIZE WEIGHT GAIN/PROMOTE WEIGHT LOSS

GLP 1 RA w/ good efficacy for weight loss

SGLT2i

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(-) ASCVD / indicators of high risk, HF, CKD MINIMIZE WEIGHT GAIN/PROMOTE WEIGHT LOSS if A1C above target

GLP-1 RA - consider incorporating SGLT2i and vice versa | * if GLP 1 RA not tolerated or indicated consider DPP 4i (weight neutral)

(-) ASCVD / indicators of high risk CONSIDER COST AND ACCESS

certain insulins: consider INSULIN available at the lowest acquisition cost SU TZD

Anti-hyperglycemic treatment w/ HIGH efficacy

``` Metformin GLP 1 RAs Thiazolidinediones Sulfonylureas Human Insulin ```

Anti-hyperglycemic treatment in adults w/ Type 2 Diabetes w/ HYPOGLYCEMIC effect

Sulfonylureas | Insulin

Anti-hyperglycemic drugs in adults w/ Type 2 Diabetes that can cause WEIGHT LOSS

SGLT2i GLP-1 RAs Metformin (modest loss)

Metformin Contraindication and side effects

eGFR < 30 mL/min 1.73 m2 GI side effects (diarrhea, nausea) B12 deficiency

SGLT2 inhibitors

ASCVD BENEFIT: Empagliflozin Canagliflozin ``` HF BENEFIT: Empagliflozin Canagliflozin Dapagliflozin Ertugliflozin ``` DKD: Empagliflozin Canagliflozin Dapagliflozin

SGLT2 Inhibitors Side Effects

``` should be DISCONTINUED before any scheduled surgery to avoid potential risk for DKA DKA risk of BONE FRACTURES (Canagliflozin) GU infections risk of volume of depletion, hypotension increase LDL cholesterol risk of Fournier’s cholesterol ```

GLP-1 RAs

ASCVD BENEFIT: Dulaglutide Liraglutide Semaglutide (SQ) DKD BENEFIT Liraglutide Semaglutide (SQ) Dulaglutide

GLP 1 RA side effects

FDA black box: risk of thyroid c cell tumors in rodents, human relevance not determined GI side effects - nausea, vomiting, diarrhea injection site reactions

DPP 4 Inhibitors

HF POTENTIAL RISK | Saxagliptin

DPP 4 Inhibitors Side Effects

Joint Pain

Thiazolidinediones

ASCVD POTENTIAL BENEFIT Pioglitazone HF INCREASED RISK NOT recommended for RENAL IMPAIRMENT d.t. potential for fluid retention

Thiazolidenediones side effects

FDA Black Box: Congestive Heart Failure (Pioglitazone, Rosiglitazone) ``` fluid retention (edema, HF) benefit in NASH risk of bone fractures BLADDER CANCER (PIOGLITAZONE) INCREASE LDL CHOLESTEROL (ROSIGLITAZONE) ```

Sulfonylureas (2nd Generation)

RENAL EFFECTS Glyburide - NOT recommended in CKD Glipizide and Glimepiride - initiate conservatively to avoid hypoglycemia

BP target for individuals w/ DM and HPN at HIGHER CV risk (existing ASCVD or 10 year ASCVD risk > 15% )

130/80 mmHg

BP target for individuals w/ DM and HPN at LOWER CV risk (10 year ASCVD risk < 15% )

140/90 mmHg

BP >140/90 mmHg

lifestyle therapy | prompt initiation and timely titration of pharmacologic therapy to achieve BP goals

BP 160/100

lifestyle therapy | 2 drugs or a single pill combination of drugs

First line therapy for HPN in people with DIABETES and CAD

ACE inhibitors or Angiotensin Receptor Blockers

Patients with HPN who are not meeting BP targets on 3 classes of antihypertensive medications (including diuretic)

Mineralocorticoid Receptor Antagonist (MRA) Therapy

For patients w/ diabetes aged 40-75 years (-) ASCVD

Lifestyle | Moderate Intensity Statin Therapy

For patients w/ diabetes aged 20-39 years (+) ASCVD risk factors

lifestyle therapy | statin therapy

Diabetes at higher risk especially with multiple ASCVD risk factors or aged 50-70 years

High Intensity Statin therapy

Diabetes and 10 year ASCVD risk of 20% or higher

maximally tolerated statin therapy + EZETIMIBE - to reduce LDL cholesterol levels by 50% or more

Statin Treatment Intensity

LOW INTENSITY < 30% LDL C reduction Fluvastatin 20-40 mg Pravastatin 10-20 mg Simvastatin 10 mg ``` MODERATE INTENSITY 30 - 50% LDL C reduction Atorvastatin 10-20 mg Fluvastatin 80 mg Rosuvastatin 5-10 mg Simvastatin 20-40 mg Pravastatin 40- 80 mg Pitavastatin 2-4 mf ``` HIGH INTENSITY > 50% Atorvastatin 40-80 mg Rosuvastatin 20-40 mg

All ages (+) DM and (+) ASCVD

lifestyle therapy | HIGH intensity stain therapy

(+) DM and (+) ASCVD, LDL > 70 mg/dL

maximally tolerated statin dose + Ezetimibe or PCSK9 inhibitor

(+) ASCVD or other CV risk factors on a statin with controlled LDL cholesterol BUT with ELEVATED TRIGLYCERIDES (135-499 mg/dL)

ADD Icosapent Ethyl

For secondary prevention strategy in those diabetes and history of ASCVD

Aspirin (75-162 mg/day)

Patients with ASCVD and documented aspirin allergy

Clopidogrel (75 mg/day)

Reasonable for a year after an ACS and may have benefits beyond this period

Dual Antiplatelet Therapy (low dose aspirin and P2Y12 inhibitor)

Consider investigations for CAD in the presence of ANY of the ff:

Atypical cardiac symptoms (unexplained dyspnea, chest discomfort) Signs or symptoms of associated vascular disease (carotid bruits, TIA, stroke, claudification, PAD) Electrocardiogram abnormalities (i.e. Q waves)

Treatment of Type 2 diabetes and (+) ASCVD or multiple risk factors for ASCVD or diabetic kidney disease

SGLT2 inhibitor with demonstrated CV benefit

Treatment of Type 2 diabetes and (+) ASCVD or multiple risk factors for ASCVD

GLP 1 receptor agonist

May be considered for additive reduction in the risk of adverse CV and kidney events treatment of Type 2 diabetes and (+) ASCVD or multiple risk factors for ASCVD

SGLT2 inhibitor AND GLP 1 receptor agonist

In patients w/ type 2 diabetes and established HFrEF

SGLT2 (-)

MODY 1

Hepatocyte Nuclear Transcription Factor (HNF)

MODY 2

Glucokinase

MODY 3

HNF -1a

Genetic Defects in Insulin Action

Type A insulin resistance Leprechaunism Rabson Mendanhall syndrome Lipodystrophy syndrome

Genetic Syndromes associated with diabetes

``` Wolfram’s syndrome Down syndrome Turner syndrome Friedreich ataxia Huntington chorea Laurence Moon Biedl syndrome myotonic dystrophy porphyria Prader Willi syndrome ```

Stimulate insulin synthesis

> 3.9 mmol/L (70 mg/dL)

Rate limiting step that controls glucose regulated insulin secretion

glucose PHOSPHORYLATION by GLUCOKINASE

Major susceptible gene for type I DM

HLA region on chromosome 6

Diabetes Mellitus Flashcards

(69 cards)