DM 2 Flashcards
1
Q
dx of metabolic syndrome
A
≥ 102 cm abdominal obesity in Men
≥ 88 cm abdominal obestity in Women
Elevated triglycerides (≥ 150 mg/dL)
Low HDL (men < 40 mg/dL ; women < 50 mg/dL)
Elevated blood pressure (≥ 130/85 mmHg)
Elevated fasting glucose (≥ 100 mg/dL)
atleast 3 of the above
2
Q
syndrome X
AKA
A
metabolic syndrome
OR
insulin resistance syndrome
3
Q
metabolic syndrome definition
A
metabolic risk factors for BOTH diabetes & cardiovascular disease
4
Q
metabolic syndrome has a higher prevalance with what 2 things
A
overweight
obesity
5
Q
pharmacologic tx of metabolic syndrome
A
metformin
6
Q
if you have prediabetes, how often should you monitor for T2DM?
A
annually
7
Q
Prediabetes drug tx
A
metformin
8
Q
what type of diabetes should you consider in children & adults dx in early adulthood?
A
monogenic dx in first 6 months of life
9
Q
clinical px of monogenic diabetes
A
no diabetes associated antibodies
nonobese
no other metabolic features
stable, mild fasting hyperglycemia
10
Q
impaired fasting glucose
A
hepatic insulin resistance
11
Q
impaired glucose tolerance
A
muscle insulin resistance
12
Q
what consists of prediabetes?
A
IGT or IFG or both
or
A1c of 5.7-6-4%
13
Q
Main risk factors of T2DM
A
Prediabetes, metabolic syndrome, insulin resistance conditions (PCOS, AN)
Overweight
> 45 y/o
Immediate relative with T2DM
< 3 days/week physical activity
PMH gestational DM or given birth to baby weighing > 9 lbs
African American, Hispanic/Latino American, American Indian, Alaska Native
Genes/lifestyle/env/meds
14
Q
what cells produce insulin?
A
Insulin produced by beta cells in the islets of Langerhans in the pancreas
15
Q
what stimulates insulin production?
A
hyperglycemia
16
Q
insulin causes glucose transport into which tissues?
A
Insulin causes glucose transport into adipose tissue and muscle
17
Q
Physiology of fasting state
A
low insulin, high glucagon
+ glucagon further stimulates gluconeogenesis & glycogenolysis
18
Q
Postprandial physiology
A
high insulin, low glucagon
+ carbohydrate storage
+ fat and protein synthesis
+ skeletal muscle uptake
19
Q
Clinical Px of T2DM
A
usually asx
hyperglycemia (polyuria, polydipsia, nocturia, blurred vision, weight loss)
20
Q
ADA Screening guidelines
A
All adults with BMI ≥ 25 + additional risk factor(s): q 3 years
Start at age 45 for everybody else
pts with prediabetes: annually
Women with GDM: q 3 years
21
Q
T2DM USPSTF screening
A
Adults 40-70 y/o who are overweight/obese should be screened as a part of CV risk assessment q 3 years
22
Q
T2DM Dx criteria if sx
A
Symptoms + random blood glucose ≥ 200 mg/dL
23
Q
T2DM Dx criteria if asx
A
If asymptomatic:
FPG ≥ 126 mg/dL
2 hour glucose ≥ 200 mg/dL during OGTT
A1c ≥ 6.5%
Repeat on a different day
24
Q
What are normal lab values of FPG, OGTT, A1c?
A
FPG < 100 mg/dL
2-hr glucose during OGTT < 140 mg/dL
A1c: <5.7
25
Pre-diabetic Dx criteria
IFG: **FPG 100-125 mg/dL**
IGT: 2-hr glucose during **OGTT 140-199 mg/dL**
A1c: **5.7 – 6.4%**
26
What can cause falsely high levels of A1c?
**Low cell turnover** = falsely high levels
## Footnote
**Iron, vitamin B12, or folate deficiency**
27
What can cause falsely low levels of A1c?
**High cell turnove**r = falsely low levels
**Hemolytic anemia, treated iron/B12/folate deficiency, erythropoietin use`**
28
Main mgmt goals for T2DM
- **Glycemic** control
- Monitoring/prevent **micro/macrovascular complications**
- Patient education: **Nutrition, Hypoglycemia, CV risk, vision, kidneys**
- Health maintenance
29
how do you approach a T2DM pt?
pt centered: **active listening**
multi-disciplinary:
- Primary care
- Specialty care: Podiatry, Ophthalmology, Mental health, Ob/gyn, Endocrine, Dieticians, Exercise specialists
30
How often do you monitor glycemic control in controlled T2DM pts?
**2x/yr**
31
How often do you manage glycemic control in T2DM pts with changes in therapy or those who are not meeting goals?
**4x/yr**
32
A1c goals for diff types of pts
Most patients **\< 7.0%**
stringent goals: **\< 6.5%**
Less stringent: **\< 8.0% if...**
- Hx **_severe hypoglycemia_**
- **_Limited life expectancy_**
- **_Older adults_**
- **_Comorbid conditions_**
33
more often self monitoring of blood glucose in T1DM when...
**titrating medications associated with hypoglycemia**
Several times/wk – **morning or before dinner**
**illness or changes in diet/exercise**
34
**Non-pharmacologic** therapy options for T2DM
- Diet
- Physical activity
- Weight reduction/management
- Smoking cessation
- Psychological interventions (diabetes distress)
35
most imp nutrition pearls
- eat high **fiber/nutrient dense foods** (fruits & vegetables)
- **count carbs for bolus insulin**
- avoid carb sources high in protein
- **meditteranean diet** = good
- eat **fatty fish and foods rich in long-chain n-3 fatty acids**
36
dietary restrictions in T2DM
alcohol in moderation: (**≤ 1/d women, ≤ 2/day men)**
## Footnote
**\<2300mg/day Na**
**dec. nonnutritive sweeteners**
37
Goals of pharmacologic tx
Inc. **insulin availability**
dec. **sensitivity to insulin**
Delay delivery and absorption of **carbohydrates from the GI tract**
**Inc. urinary glucose excretion**
38
A1c levels in regards to Rx
**A1c \> 7.5-8%** at dx – **start Rx**
**A1c \< 7.5%** at dx – **3-6 month trial of lifestyle modification (if highly motivated)**
39
**Initial pharmacologic therapy** for T2DM pts
**-Metformin**
-Consider **dual therapy**
**-Insulin** may be considered
-Consider **comorbidities (ASCVD, HF, CKD),** hypoglycemia risk, impact on weight, cost, risk for side effects, patient preferences
40
Tx options
- Metformin
- Sulfonylureas
- GLP-1 RA
- (DPP-4)
- (SGLT2) inhibitor
- TZD
- Meglitinides
- Alpha-glucosidase inhibitor
- Insulin
41
Decrease hepatic glucose output by **inhibiting gluconeogenesis**
Increases insulin-mediated glucose utilization in **peripheral tissues (muscle, liver)**
MOA of which drug?
Metformin (biguanide)
42
1st line tx of DM2
Metformin
43
A1c % drop w/Metformin
1-2% drop in A1c
44
ADE/CI of metformin
**GI** side effects
Can reduce intestinal absorption of **vitamin B12**
Contraindicated with renal insufficiency, **eGFR \< 30 mL/min**
IV contrast concerns
45
weight neutral meds
Metformin
DPP-4 Inhibitors
alpha-glucosidase inhibitors
46
which meds inc weight
TZD
Meglitinides
Insulin
sulfonylureas
47
which meds dc weight
GLP-1 RA
SGLT2-I
48
Stimulate insulin secretion from pancreatic beta cells
MOA of which drug?
**sulfonylureas**
- **Glip**izide
- **Gly**buride
- **Glim**epiride
49
ADE of sulfonylureas
risk of hypoglycemia
50
A1c% drop of sulfonylureas
1-2%
51
what is the incretin effect
**oral glucose better stimulates insulin secretion** than IV glucose secondary to GI peptides (GLP-1) released in response to a meal stimulating insulin synthesis and secretion
52
stimulates glucose dependent insulin release from pancreatic islet cells
slows gastric emptying
inhibits post-meal glucagon release
MOA of what drug?
GLP-1 RA
53
what special pt populations are you more likely to give a GLP-1 RA to?
pts w/ **ASCVD**
reduce risk of **CKD progression and CV events**
54
what are the add-on therapies?
SGLT2-Inhibitor
TZD
DPP-4 Inhibitors
Meglitinides
55
Possible **improved CV outcomes** with which **GLP-1 RAs?**
liraglutide
semaglutide
56
A1c% drop w/GLP-1 RA
0.5-1% drop
57
ADE of GLP-1 RA
GI: N/V/D
58
which drug has the same MOA as GLP-1 RA (this is the reason you cannot give both drugs at once)
DPP-4 Inhibitors
59
increase urinary glucose excretion leading to reduced blood glucose
MOA of which drug?
SGLT2 inhibitors
60
in which pt populations should you use SGLT2 Inhibitors with?
pts w/**ASCVD**
high risk of **HF** or **w/comorbid HF**
Shown to reduce risk of **CKD progression and CV events**
61
ADE of SGLT2 inhibitors
vulvovaginal candidiasis, UTIs
62
SGLT2 % decrease in A1c?
0.5-0.7%
63
Improve insulin action
Increase insulin sensitivity by acting on **adipose, muscle, and liver** to increase glucose utilization and decrease glucose production
MOA of which drug?
TZD
64
ADEs of TZD
Fluid retention, HF, weight gain, bone fractures,
possible _increase in MI_ **(rosiglitazone)**
possible increase in _bladder cancer_ **(pioglitazone)**
65
CIs of TZDs
symptomatic or **class III-IV HF,** bladder cancer, high fracture risk, liver disease
66
Administered with meals to reduce postprandial hyperglycemia
Which drug?
Meglitinides
67
ADE of meglitinides
risk of hypoglycemia
68
% dec in A1c
0.5-1% decrease in A1c
69
ADE of alpha-glucosidase inhibitors
flatulence and diarrhea
70
% decrease in A1c of alpha-glucosidase inhibitors
0.5-0.8%
71
types of insulin
**Basal:**
- NPH (Humulin N, Novolin N)
- Glargine (Lantus, Toujeo, Basaglar)
- Detemir (Levemir)
- Degludec (Tresiba)
**Prandial**
- Short-acting: Regular (Humilin R, Novolin R)
- Rapid-acting: lispro (Admelog, Humalog), aspart (Fiasp, Novolog), glulisine (Apidra)
**Premixed combination of intermediate acting and short or rapid acting**
72
If **A1C is above target** despite recommended first-line treatment and A**SCVD predominates**, what should you give?
GLP-1 RA or SGLT-2 I
73
If **A1C is above targe**t despite recommended first-line treatment and **HF or CKD** predominates, what should you give?
SGLT-2 I (1st choice)
or
GLP-1 RA
74
examples of micro & macrovascular dz
Microvascular disease: **Retinopathy, Nephropathy, Neuropathy**
Macrovascular disease: **Atherosclerosis (MI, PAD, CVA)**
75
Most common cause of blindness in adults aged 20-74
diabetic retinopathy
76
what 4 things cause diabetic retinopathy
Macular edema
Hemorrhage from new vessels
Retinal detachment
Neovascular glaucoma
77
**Cotton wool spots**
Intraretinal hemorrhages
Hard **exudates**
Microaneurysms
**Occluded vessels**
Dilated or **tortuous vessels**
Visual loss through **macular edema**
What type of diabetic retinopathy?
Nonproliferative diabetic retinopathy
78
**Neovascularization**
Preretinal and vitreous hemorrhage
**Fibrosis**
**Retinal detachment**
Visual loss from bleeding, retinal detachment ischemia of macula
What type of diabetic retinopathy?
proliferative
79
nonproliferative diabetic retinopathy: appearance of fundus
retinal hemorrhages
yellow lipid exudates
dull white cotton wool spots (nerve fiber layer infarcts)
80
proliferative diabetic retinopathy showing neovascularization at the disc
81
severe traction retinal detachment in proliferative Diabetic retinopathy
elevation & distortion of macula due to overgrowth and contraction of neovascular proliferations
82
vitreous hemorrhage: appearance on fundus
arising from neovascularization
83
clinical px of diabetic retinopathy
asx untul late stages
84
diabetic retinopathy screening
**Dilated and comprehensive eye exam**
**At the time of diagnosis in type 2**
**Within 5 years in type 1**
Repeat **annually**
85
diabetic retinopathy tx
**Laser** photocoagulation
**Intravitreous injections** of anti-vascular endothelial growth factor **(ranibizumab)**
86
leading cause of ESRD
diabetic kidney dz
87
diabetic kidney dz screening
Assess **urinary albumin**
Spot urinary **albumin-to-creatinine ratio**
* Assess **eGFR**
* **At time of diagnosis in type 2**
* Within **5 years of diagnosis in type 1**
* In all patients **with comorbid HTN**
* Repeat **annually**
88
dx criteria for diabetic kidney dz
- Moderately increased albuminuria **(“microalbuminuria”)**
- **30-300 mg/day** (normal \< 30 mg/day)
- **\> 300 mg/day** = severely increased albuminuria **(“macroalbuminuria”)**
- Requires **2 of 3 specimens abnormal over 3-6 months**
89
diabetic kidney dz tx
Consider **SGLT2** inhibitor or **GLP1** receptor agonist
**ACE-I or ARB**: if modest UACR elevation (**30-299** mg/g Cr) & Strongly recommended for **UACR ≥ 300** mg/g Cr and/or **eGFR \< 60**
Protein intake: Nondialysis-dependent: **0.8** g/kg/d & Dialysis-dependent: **\> 0.8**
•Refer for renal replacement treatment if **eGFR \< 30**
90
what is common in diabetic neuropathy?
foot ulcers & amputation
91
diabetic neuropathy screening
- Assess with **history** and either **temperature or pinprick sensation and vibration sensation**
- Annual **monofilament testing**
- At time of diagnosis for type 2
- Within 5 years of diagnosis for type 1
- Repeat **annually**
92
diabetic neuropathy tx
- First line Rx for **neuropathic pain:****pregabalin, duloxetine, or gabapentin**
- Foot self care **education** to all patients
- Specialized **therapeutic footwear for high-risk patients** with severe neuropathy, foot deformities or history of amputation
93
what does the annual comprehensive foot evaluation consist of
**Skin** inspection
Assess for **foot deformities**
Neurologic assessment (**monofilament + pinprick or temperature or vibration**)
**Vascular** assessment
94
consider ABI/vascular referral for which sxs?
**claudication or decreased or absent pedal pulses**
95
consider podiatry for which pts?
**smokers** or
**hx** of prior LE complications
loss of **protective sensation**
structural abnormalities
**PAD**
96
goal BP for diabetics
**High** CV risk = **\< 130/80**
**Lower** risk = **\< 140/90**
97
at what BP do you implement lifestyle interventions?
BP \> 120/80
98
at what BP do you implement dual therapy?
≥ 160/100
99
Meds with demonstrated reduction of CV events
ACE-I
ARB
Thiazide diuretic
Dihydropyridine CCB
100
ASCVD or 10-yr risk \> 20%
OR
Multiple ASCVD risk factors
what tx?
high intensity statin therapy
101
\< 40 y/o with ASCVD risk factors
OR
40-75 and \> 75 without ASCVD risk factors
what tx?
moderate intensity statin
102
ASCVD and LDL ≥ 70 and on maximally tolerated statin
what tx?
additional LDL-lowering therapy **(ezetimibe or PCSK9 inhibitor)**
103
Secondary prevention in patients with ASCVD
what tx?
aspirin 75-162 mg/d
104
One year post ACS
what tx?
dual antiplatelet therapy with low dose aspirin and P2Y12 inhibitor
105
Primary prevention with what if inc CV risk?
aspirin
106
