Diabetes Mellitus

Question 1

Criteria for diabetes testing in asymptomatic adults

Answer 1

should be considered in all adults who are overweight with risk factors
* physical inactivity
* 1st degree relative with T2DM
* high risk ethnic populations
* women who gave birth to baby >9lbs or were diagnosed with gestational DM (screen 6-12wks post partum)
* HTN
* HDL <35/or TG>250
* PCOS
* A1C >5.7, impared glucose tolerance, impared fasting glucose
* Hx of CVD

In abscence of risk factors, screening should begin at 45, with obesity screen at 35.

Question 2

Dx of Dm and pre-diabetes

Answer 2

DM
* plasma glucose fasting: >126, random >200 with symptoms (polyphagia, poliuria, polydipsia, unexplained weightloss. hyperglycemic crisis
* Oral glucose tolerance test: 2 hour plasma glucose >200
* A1c: >6.5

Increased risk/prediabetes
* impaired fasting glucose: 100-125
* Impaired glucose tolerance: 140-199
* A1C: 5.7-6.4

Question 3

Gycemic control targets

Answer 3

• NL A1c <5.6
• goal <7 for most, less stringent goals for individual patients based on factors as duration of diabetes, age/life expectancy, comorbids, and hypoglycemia unawreness
• Fasting preprandial: NL <100, goal: 80-130
• Peak postprandial: NL <140, goal <180

AIC test frequency:
* twice a year if meeting teatment goal and stable A1C
* 4 times a year or q3 months, if therapy has changed and/or are not meeting glycemic controls

Question 4

Pharmacologic Therapies for Type 2DM
Insulin sensitizers

Answer 4

Metformin
* decreases A1C 1-2%
* low hypoglygemia risk
* Neutraleffect on weight loss
* ADE: GI upset (avoided with ER), DC with eGFR <30, frilty, and advanced age (increased lactic acidosis)
* 1st line med

Thiazolidinediones (TZD) Pioglitazone
* decreases A1C 1-2%
* low hypoglygemia risk
* Weight gain due to fluid retention
* ADE: Edema, HF in at risk pt, fractures, do not use with nitrates

Question 5

Pharmacologic therapies for T2DM
Insulin releasers

Answer 5

Sulfonylureas: Glipizide
* constantly releases insulin regurdless of glucose level
* reduced A1C by 1-2%
* weight gain
* ADE: hypoglycemia
* low cost

DPP-4 Inhibitor: Sitagliptin (Januvia)
* insulin release post glucose rise, responds to increatin release from small intestine
* Low risk of hypoglycemia (smart insulin release)
* ADE: rare
* High cost
* minimal hypoglycemia risk

GLP1 Agonist: Semaglutide (Ozempic), Tirzepatide
* Increases glucose dependednt insulin secretion, decreases inappropriate glucagon secretion, slows gartic emptying, regulates appetite
* reduces A1C 1-2%
* low risk of hypoglycemia
* Weight loss (also used to treat obesity)
* ADE: GI upset, avoid in gastroparesis or pancreatits
* demonstrated benifits with ASCVD, CKD
* subcut injection

Question 6

Pharmacotheray for T2DM
Glucose offloader

Answer 6

SGLT-2 Inhibitor: Canagliflozin
* glucose offloading via kidney excretion, post glucose rise
* Decreases A1C 0.75%
* low hypoglycemia risk
* weight loss
* ADE: GU infection, increased candida, uti risk, dehydration, avoid initiation with eGFR <30
* high cost
* proven benifits with ASCVD, HF, CKD (also used in HF and kidney protection)

Question 7

When to initiate insulin treatment

Answer 7

T1DM: all individuals
* 50% basal long acting insulin
* 50% bolus short acting post prandial

T2DM
* at dx if A1C >9 with symptoms
* short course of 2-3 wks insulin helps acheive normoglycemia
* Hyperglycemia induces insulin resistance and inmares pancreatic be cell function
* When 2 or more oral/injectable agents at optimized dose are inadequate for glycemic control - marker of failing B cell function

Question 8

Insulin types onset and peak

Answer 8

peak is the most likely time for hypogkycemia reaction

Short/rapid acting insulin
* glulisine, lispro (humalog), aspart (novolog)
* onset 5 min, peak 1 hr

Short acting
* regular insulin (humalin, Novolin)
* onset 30 min, peak 2-3 hr

Intermediated -acting
* NPH/regular Novolin, Humulin
* used BID as alternate to Basal
* onset 1-2 hrs, peak 6-14 hr

Long-acting insulin (basal insulin
* demeter (levemir), glargine (lantus)
* onset 1-2hr, no peak

Question 9

ABCDEFG of T2DM treatment

Answer 9

• A - Asprin consider low dose for those at high risk for CVD
• B - BP ctrl with at least 2 agent thiazide, ccb and or ace/arb
• C - Cholesterol- statin therapy, Creatinine: check renal function anually: consider using SGLT2 inhibitor, GLP 1 antagonist, as well as ACEor ARB for renal protection
• D - Diet dash siet, Dental care
• E - exercise 150min /week, Eye exam- q1-2 years diabetic neropathy
• F - foot exam anually or every visit with hx os sensory loss or ulceration
• G - goals of therapy

Question 10

Metabolic Syndrome

Answer 10

• increased waistline >38 in in women and >40 in men
• TG >150
• low HDL: <50 in wmn, <40 in men
• high BP
• High glucose: FPG >100

condition increases the risk of heart disease, diabetes, renaldysfunction, and stroke. Treat each componenet to goal.

Question 11

Diabetic retinopathy presentation

Answer 11

DM retinopathy without fluid leak/bleed
* no vision complaint detected on dilated eye exam
* prevent disease progression with control of underlying condition

DM retinopathy with fluid leak or bleed, macular edema
* new onset vision blurring or rother visual changes
* flaoters, swisscheese, holes
* prevent disease progression
* photocoagulation, vitrectomy