DM

Question 1

DM is the ___th leading cause of death in America.

Answer 1

7th

Question 2

What is the DM goal for HbA1C?

Answer 2

less than 7.0%

Question 3

What is the DM goal for preprandial glucose?

Answer 3

80-130 mg/dL

Question 4

What is the DM goal for postprandial glucose?

Answer 4

less than 180

Question 5

What is the DM goal for bp?

Answer 5

less than 140/90

Question 6

What is the DM goal for HDL?

Answer 6

> 40 mg/dL in males and > 50 mg/dL in females

Question 7

What is the DM goal for LDL?

Answer 7

no goal, just tx recommendations

Question 8

When might you recommend a lower bp of less than 130/90 in DM pts?

Answer 8

if you can lower the patient’s bp with few drugs, no side effects, and the pt is okay with it.

you usually want to aim for a lower bp goal if the patient has a longer life expectancy (young) to protect their kidneys or if the pt has a HIGH stroke risk

Question 9

What does the ADA say about a pt with DM + hyperlipidemia?

Answer 9

put them on a statin

Which dose? depends on age . . . (see later slides)

Question 10

What is the DM goal for TGs?

Answer 10

less than 150 mg/dL

Question 11

If the patient is > 75 yo and has overt CVD risk factors, what statin dose should you put the pt on?

Answer 11

HIGH

Question 12

According to the ADA, what are overt CVD risk factors?

Answer 12

previous CVD event(s)

acute coronary syndrome

Question 13

High Cardiovascular risk is considered . . .

Answer 13

most men > 50 yo and women > 60 yo with one additional risk factor:
     • FH of CVD 
     • HTN
     • Smoking
     • Overweight/obese
     • albuminuria

Question 14

In primary prevention if the pt has high cardiovascular risk, what should you give them? Allergy?

Answer 14

ASA 75-162 mg/day

if allergic to ASA, give Clopidogrel

Question 15

If the patient is between 40 and 75 yo and has overt CVD risk factors, what statin dose should you put the pt on?

Answer 15

HIGH

Question 16

What levels (albumin:creatinine ratio) are considered persistent “nephropathy”?

Answer 16

30-299 g/mg

Question 17

What levels (albumin:creatinine ratio) are considered “more progressive” persistent nephropathy?

Answer 17

≥ 300 g/mg

Question 18

If the patient is > 75 yo and has CVD risk factors, what statin dose should you put the pt on?

Answer 18

Moderate to High

Question 19

How often should you screen a DM pt’s serum creatinine?

Answer 19

annually

Question 20

According to the ADA, what are overt CVD risk factors?

Answer 20

previous CVD event(s)

acute coronary syndrome

Question 21

What is a normal albumin:creatinine ratio?

Answer 21

less than 30 g/mg

Question 22

How often should you screen a T1DM pt for albuminuria?

Answer 22

5 years after diabetes diagnosis, then annually

Question 23

How often should you screen a T2DM pt for albuminuria?

Answer 23

upon diagnosis, then annually

Question 24

How often should you screen a DM pt’s serum creatinine?

Answer 24

annually

Question 25

What is the goal of screening for nephropathy in diabetics?

Answer 25

to reduce/slow progression of nephropathy

Question 26

How do you try to slow the progression of nephropathy?

Answer 26

tight glycemic control | optimize bp control

Question 27

What do you do at the first sign of protein in the urine (albuminuria)?

Answer 27

start an ACEI or an ARB (no matter what their bp goal) | --for renal protection

Question 28

What drug class can you use in pts who cannot tolerate and ACEI or an ARB and have albuminuria?

Answer 28

non-DHP CCB (not as good as an ACEI or ARB, but better than nothing)

Question 29

When should you screen a DM patient for retinopathy?

Answer 29

Adults with Type 1 DM: dilated exam 5 years after diagnosis, and then annually after that Type 2 DM: dilated exam shortly after diagnosis (~ 6 months), then annually *if the pt has 2 normal exams, pt may consider having eye exams every 2 years

Question 30

Why do you not conduct an eye exam right at the time or DM diagnosis?

Answer 30

you should wait until that patient gains some control over their blood sugar, so that the excess sugar in the aqueous humor will go away and the vision can clear some to make the test more accurate (pg. 8)

Question 31

What are the 2 types of neuropathy?

Answer 31

1. DPN: chronic distal symmetric polyneuropathy | 2. Autonomic neuropathy

Question 32

What is chronic distal symmetric polyneuropathy (DPN)?

Answer 32

when the pt has loss of sensation in the feet and lower extremities

Question 33

What is autonomic neuropathy?

Answer 33

neuropathy that effects the firing of the heart (cardiac), delays gastric emptying (gastroparesis) and causes ED (sexual dysfunction)

Question 34

When do you begin screening for DPN in DM patients?

Answer 34

Type 1: 5 years after diagnosis, then annually | Type 2: annually

Question 35

How do you test for DPN?

Answer 35

pinprick sensation temperature changes vibration sensation monofilament test

Question 36

How do you treat DPN?

Answer 36

optimal glucose control to slow the progression of DPN (no therapy or cure to reverse the damage)

Question 37

What are some drugs that can help with pain caused by DPN?

Answer 37

anticonvulsants/antidepressants such as: • gabapentin • pregabalin • duloxetine

Question 38

What are some treatment options for autonomic neuropathy?

Answer 38

1. Gastroparesis: • small meals • metoclopramide (prokinetic) • erythromycin (irritates stomach enough to move food) 2. Cardiac • avoid meds that may cause orthostatic dysfunction

Question 39

What are some drugs that can chemically-induce diabetes?

Answer 39

"Becky got diabetes by not taking TAPPING lessons and taking one of these medications: Beta agonists ``` TH; Thiazides Atypical antipsychotics Phenytoin (Dilantin) Pentamidine Interferon-alfa Nicotinic Acid Glucocorticoids" ```

Question 40

When do you screen patients for T2DM?

Answer 40

45 yo: q 3 years

Question 41

What is the clinical presentation of DM?

Answer 41

Polyuria, polydipsia, polyphagia (very thirsty, hungry and has to pee a lot) Weight loss (especially in T1DM) Weakness and fatigue Dry skin Nocturia (peeing at night) Blurred vision (due to glucose in the aqueous humor) persistent recurrent infections DKA ( type 1) HHS: hyperosmolar hyperglycemia syndrome (type 2)

Question 42

What does preprandial mean?

Answer 42

plasma glucose measured before meals

Question 43

Peak post-prandial

Answer 43

plasma glucose measured 1-2 h after the beginning of the meal

Question 44

Fasting blood glucose

Answer 44

plasma glucose after at least 8 h without food

Question 45

A1C

Answer 45

long term measure of glucose results (3 months)

Question 46

How can you find the approx. mean plasma glucose if given a patient's A1C?

Answer 46

(A1C - 2) x 30 = approx. mean plasma glucose

Question 47

If your patient's A1C is less than 7.5%, then that means your ___________________ is driving your blood glucose. A. pre-prandial excursion B. post-prandial excursion C. equal mix of pre-prandial and post-prandial excursions

Answer 47

B

Question 48

``` [SATA] What trials made the A1C goal less than 7%? A. VADT trial B. DCCT trial (type 1) C. ACCORD trial D. UKPDS trial (type 2) ```

Answer 48

B. DCCT trial (type 1) | D. UKPDS trial (type 2)

Question 49

What is the initial dose of insulin for T1DM pts?

Answer 49

0.5-0.6 units/kg/day

Question 50

When does the 2/3 rule for insulin apply?

Answer 50

ONLY with NPH and regular insulin

Question 51

What is the 2/3 rule for insulin?

Answer 51

Give 2/3 of the total daily dose (TDD) in the AM: • 2/3 of that dose = NPH • 1/3 of that dose = regular Give 1/3 of TDD in the PM: • 2/3 of that dose = NPH • 1/3 of that dose = regular

Question 52

Why do you give 2/3 of the TDD of insulin in the morning with the 2/3 rule?

Answer 52

to avoid nocturnal hypoglycemia