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FA17 Endocrine > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

(79 cards)

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1
Q

Type I DM pathophys

A

type 1A - immune mediated

type 1B - idiopathic (no apparent cause)

beta cell destruction causes levels of insulin to drop, until 80-90% gone and intake of food causes no response from pancreas

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2
Q

immune mediated T1Dm

A

vigorous autoimmune response to infectious or toxic insult

circulating Abs to islet cells tag and destroy them

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3
Q

Type I DM epidemiology

A

occurs MC in juveniles with greatest peak of early adolescence (13-14)

highest rates are in Scandinavian descent

type I DM affects about 1/400-600, more common in males, HLA subtypes

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4
Q

pathophysiology of Type II DM

A

state of hyperglycemia and hyperinsulinemia

deficient B cell response to hyperglycemia and tissue insensitivity to endogenous insulin

mechanisms are further aggravated by resultant hyperglycemia

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5
Q

deficient B cell response to hyperglycemia

A
  1. at first, B-cell hyperplasia and increased insulin production
  2. overdriving of pancreas will compensate for some time
  3. progressive amyloid deposition leads to B cell insufficiency and failure
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6
Q

how does T2DM cause vascular disease

A

hyperinsulinemia, hyperglycemia, and increased free fatty acid production causes endothelial cell dysfunction, inflammation (which causes increased insulin resistance)

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7
Q

when should you consider testing diabetes patients for autoantibodies

A

2 of following:

age of onset <50 y/o

acute symptoms

BMI <25

personal family history of autoimmune disease

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8
Q

LADA

A

adult onset of T1DM

no rapid decline of beta cells like in normal T1DM

may find high GAD Abs

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9
Q

MODY

A

T2DM in young patients

no antibodies

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10
Q

symptoms of T1DM

A
  1. weight loss/polyphagia (first due to loss of water weight, then depletion of H2O)
  2. Polyuria (increased urination)
  3. Polydipsia (thirst)
  4. Blurred Vision
  5. Postural Hypotension
  6. Paresthesias
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11
Q

diagnostic testing for type I DM

A

C Peptide levels (low C Peptide levels - T1DM)

Autoantibody tests (specific to insulin, GAD, Zinc transporter)

Autoabs to beta cells

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12
Q

C Peptide Function

A

produced by pancreas when proinsulin is cleaved to insulin

lasts 3-4x longer in serum than insulin

T1DM have LOW
T2DM have HIGH

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13
Q

T1DM screening in children

A

annual screening for children of T1DM before 10, then once again in adolescence

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14
Q

treatment of T1DM

A

multispecialty team

dietician to control diet, exercise

life long insulin therapy (7.5% HgbA1c goal)

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15
Q

T2DM risk factors

A
  1. obesity (central)
  2. ethnicity
  3. life style choices
  4. genetics
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16
Q

symptoms of T2DM

A

typically asymptomatic (4-7 yrs before diagnosis)

recurrent/chronic vaginal candidiasis 
OB complications 
balantitis 
UTI 
acanthus nigrans 
unintentional weight loss
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17
Q

lab analysis of T2DM

A

fasting plasma glycose

finger stick (not diagnostic)

glycated HgB

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18
Q

T2DM treatment

diet

A

very rare if they stick to it

limit hyperglycemia, lower LDL, lower hypertriglyceridemia

increase fiber intake and artificial sweeteners

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19
Q

initial DM treatment

A1c > 7 but < 9%

A

metformin + lifestyle modification

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20
Q

initial DM treatment

A1c > 9%

A

dual drug therapy + insulin

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21
Q

initial DM treatment

A1c > 10%

A

insulin immediately

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22
Q

commonly used drugs

A 
metformin
sulfonylureas 
GLP-1 agonists
DDP-4 inhibitors 
SGLT-2 
insulin
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23
Q

Metformin (Glucogphage)

works by

A

decreasing hepatic production of glucose and increasing muscle uptake of glucose from serum

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24
Q

advantages of Metformin (Glucophage)

A

absence of CI

reduces A1C by 1.5-2%

modest weight reduction or stabilization

monotherapy- doesn’t cause hypoglycemia

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25
disadvantages of Metformin
GI side effects metabolized in kidney (avoided in CKD) use with caution in those with IV contrast, hypotension, lactic acidosis)
26
sulfonylureas
stimulating pancreatic beta cells to secrete more insulin *regardless of blood glucose* - hypoglycemia effectiveness decreases over time, causes weight gain, increase mortality
27
incretin therapy
hormones released from gut with meal to promote insulin secretion proliferation and growth of beta cells and prevent apoptosis GLP-agonists and DDP-4 inhibitors
28
GLP-1 analogs MOA
glucose dependent insulin release reduce glucagon secretion slow gastric emptying may also stimulate beta cell recovery
29
disadvantages of GLP-1 analogs
administration is Sub Q can cause hypoglycemia and pancreatitis can be used in CKD up to stage 3B
30
DPP-IV
inhibits breakdown of endogenous GLP-1 weight neutral and less effective than GLP-1 RA bc rely on body to work normally lower A1c by 0.5-0.7%
31
DPP-IV negatives
associated with pancreatitis increase in URI's
32
SGLT2-Inhibitors
Inhibits transporter that is responsible for reabsorbing glucose from proximal renal tubule decrease the renal glucose threshold and increasing urinary glucose excretion lower A1c by 0.5-1%
33
benefits and negatives of SGLT-2 inhibitors
weight neutral and may predispose patient to weight loss increased risk of genitourinary infection and some bone loss must be dose adjusted in mild CKD (GFR <45) risk of hypoglycemia
34
thiazolidinoediones
lower blood glucose concentration by increasing glucose uptake in muscle and fatty tissues decrease hepatic glucose production do not cause hypoglycemia in mono therapy lower A1c by 0.5-1% weight gain and fluid retention
35
risks of thiazolidinediones
contraindicated in patients with NYHA class III or IV heart failure can be associated with bladder cancer higher risk of fracture
36
types of insulin
rapid acting regular insulin NPH long acting insulin ultra long acting insulin
37
rapid acting insulin
absorbed more quickly than regular insulin
38
regular insulin
same insulin your pancreas produces
39
when are rapid acting and regular insulin typically used
mealtimes to provide coverage of prandial hyperglycemia
40
basal insulins
give 1-2 injections daily to maintain all day control of blood sugar NPH insulin Insulin glargine and deter Insulin degludec
41
NPH insulin
inexpensive req. two daily injections
42
Insulin glargine and deter
require 1 (or 2) injections nearly peak less expensive
43
Insulin degludec
daily injections provide steady state lasts almost 2 days in the body
44
how is insulin therapy given in type II patient
long acting basal bolus + rapid acting insulin to get best results must have multiple injections
45
complications of insulin therapy
insulin allergy lipodystrophy hypoglycemic reactions
46
lipodystrophy two types
complication of insulin therapy atrophy (SC fatty tissue from immune run, loss of tissue) Lipohypertrophy (SC of fatty tissue from repeated injection of insulin at same site)
47
hypoglycemic reactions
most common in older diabetics, those on insulin pimp, pts with pumps nc more likely to forget to eat or take meds improper management of pump
48
slow development of hypoglycemia symptoms
confusion, seizures neuroglycopenic
49
rapid development of hypoglycemia symptoms
catecholemine reactions | Epinephrine
50
blunting of sympathetic system
body doesn't have typical reactions to hypoglycemia blunting of sympathetic system by age, beta blocker therapy, repeated hypoglycemia increases risk of complications
51
goals of T2DM treatment
obtain level of glucose control for individual pt without causing fq. hypoglycemia
52
glycemic targets HgB A1c 6.5%
for otherwise healthy patients with DM of short duration, w/o CVD, long line expectancy
53
glycemic targets HgB A1c 7% or less
pts with longer duration DM, those with significant CVD
54
glycemic targets HgB A1c 8% or Less
pts with severe comorbidities, limited life expectancy those with freq. hypoglycemia
55
importance of early DM control
intensity glycemic control at diagnosis have continued benefits and prevention of complications
56
treatment guidelines for T2DM HgB A1c less than 7.5% @ diagnosis
lifestyle changes + metformin
57
alternatives to metformin less than 7.5%
``` GLP-1 RA SLGT2-I DPP4 TZDs Alpha glycosides inhibitors sulfonylureas ```
58
treatment guidelines for T2DM HgB A1c > or = to
lifestyle changes and dual therapy with metformin and another agent
59
if pt on monotherapy does not achieve goal A1c in 3 months
dual therapy ``` GLP-1 RA SGLT2 DPP4-I TZDs Basal Insulin, alpha glucosidase, sulfonylureas ```
60
if dual therapy with metformin and another agent are initiated and the patient does not achieve goal A1c in 3 months
triple therapy is indicated
61
what is triple therapy
metformin another first line agent plus: GLP RA, SGLT2, TZD (caution), Basal insulin, DPP4, alpha glucosidade inhibitors, sulfonylureas
62
if triple therapy does not achieve goal of A1c in 3 months
insulin is added or intensified until goal is achieved
63
patient has A1c > 9%
dual therapy is immediately initiated if patient is asymptomatic Insulin +/- other agents
64
surgical treatment for diabetes
pats with obesity (BMI > 30) should be considered can be curative lap band and roux-en-y gastric bypass
65
lap band
band is surgically implanted around the stomach and restricted to limit gastric size, procedure is reversible, performed laparoscopically
66
drawbacks of weight loss surgery
protein/calorie malnutrition surgical complications anastomotic leak (decreased protein and decreased healing)
67
somogyi effect
notctural hypoglycemia leads to a surge of counter regulatory hormones hyperglycemia by 7am glucose drops overnight then rises so hyperglycemic by 7 AM
68
how do we fix somogyi
eliminate dinnertime intermediate insulin and give it back at a lower dose at bedtime alternative give a snack at bedtime
69
dawn phenomenon
secretion of GH overnight or cortisol surge causes increased insulin resistance and morning hyperglycemia
70
health care management of diabetic (10)
PCP visit 3-6 months exam of feet screen for albuminuria, CAD/lipids asses glycemic control smoking cessation ASA, BP control routine cancer screenings dental disease vaccination contraception and pre-preg
71
diabetics and surgery outcomes
hyperglycemia is significant cause of M & M B/c: all infectious issues are worse, poor healing of typically go for < 180
72
T2DM and glucose control minor procedures or non-general anesthesia
meds up to day of surgery on day of hold meds and resume after procedure
73
T2DM and glucose control general anesthesia
have their oral and non-insulin injectable meds held on day of surgery and added back as diet is advanced sliding scale insulin in mean time
74
T1DM/insulin dependent T2 and glucose control surgery
reduced dose of usual insulin on morning of surgery
75
T2DM and glucose control long surgery
performed if long/ocmplex simultaneous insulin got with dextrose containing IV solutions to avoid starvation ketosis
76
gestational diabetes
pregnancy and hormones associated with it causes increased tissue resistance to insulin screening b/t 24th and 28th week of pregnancy increased risk of developing frank DM in 10-15 years
77
diabetes and pregnancy pre pregnancy
counseling and eval of HgbA1c asses baseline renal, ocular, and CV disease try to get HgB A1c to 6%
78
first trimester and diabetes
congenital abnormalities result from hyperglycemia during organogenesis in first 4-8 weeks principal cause of perinatal fetal death (miscarriage)
79
third trimester and diabetes
fluctuations in blood glucose grow worse regular antepartum fetal testing is indicated to see how much longer the pregnancy can go true to deliver b/t 38-39 weeks

FA17 Endocrine (10 decks)

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