DM

Question 1

Overall goal

Answer 1

Decrease risk factors and reduce cardiac risk

Target
A1c, lipids and BP

Question 2

Biggest DM problems

Answer 2

Kidney failure, limb amputation, blindness

Question 3

DMII mechanics

Answer 3

Insulin insufficiency - 50 % beta cells have failed by time of dx

Also insulin resistance and abnormal gloconeogenesis

Question 4

DMII risk populations

Answer 4

First degree relative
AA, Latino, NA , Asian , PI

Gestational DM or delivery of baby > 9

HTN , HDL < 35
Tri >250
PCOS

Question 5

DM II assessment findings

Answer 5

Polydipsia, polyuria, polyphagia
Weight loss
Blurred vision
Yeas or bacterial infections

Acanthosis nirvanas

Question 6

Screenings DMII

Answer 6

Every three years if
>25 BMI
With 1 risk factor or >45 yrs old

Earlier and or yearly if
1st degree relative
High risk population
HTN, HDL, POCS, pre dm, vascular dx

Question 7

Pre-DM numbers

Answer 7

Aic = 5.7-6.4
Fasting 100-125
OGTT - 140-199

Question 8

DM numbers

Answer 8

Aic > 6.5
Fasting >126 ( no intake for 8 hours)
Random blood glucose >200
OGTT > 200

Question 9

Normal numbers

Answer 9

Fasting 70-100
Peak post prandial <180
A1c < 6

Question 10

Goal numbers for non pregnant adult DM

Answer 10

BP 140/80
LDL <100
A1c < 7 (With increased risk) <6.5 if new onset < 8 if limited life expectancy 
Pre prandial 70-130
Post prandial <180

Question 11

Pre DM tx

Answer 11

Lifestyle

• weight loss 7 %
• exercise 150 min a week
• reduce calorie and fat and increased fiber
• refer to DM education
• consider metformin

Question 12

DM TX

Answer 12

dietary medication, weight loss and exercise

Nutrition = .25 -2.9 % in 3-6 m A1c
- low carb and meiterrranean

HTN
- < 120 for aggressive
- < 140 for standard
Immunization - hard to heal

Question 13

DM and HTN

Answer 13

Check albuminura

- if so 
     - start with an ACE or ARB - may help renal protection

Question 14

DM evaluation

Answer 14

A1c every 3 months until controlled then 6 months

Lipids, micoalbumin - annually

Electrolytes, liver function, and TSH - annually

BP, height, weight, feet, blood sugar - every visit

Question 15

Metformin

Answer 15

#1 treatment 
Decreases production of glucose in the liver which helps with a decrease in peripheral insulin resistance 

Helps with weight loss , no hypoglycemia

Improves macrosvasular outcomes

Monitor : vit b 12, lipids, LFT, creat

Risks: diarrhea, and flatulence

Dose: 500 mg QD or BID - 2000mg ( higher doses do not show improvement )

Contra - creat level above 1.4 , if getting contrast dye hold day of procedure and 48 hours after , dont give to people over 80, or people who are dehydrated

Question 16

Sulfonylureas

Answer 16

Long acting
Simulates the beta cells of the pancreases to secrete more insulin, pt must have beta cell production

Glipizide

• shorter acting than others
• 2.5 mg before breakfast
• improved micro vascular benefits

Side effects

• weight gain, elderly sensitive
• hypoglycemia

Question 17

Thiazolidineodiones TZD

Answer 17

15-45 mg max
Actos - pioglitazone

Enhances insulin sensitivity ( decreases peripheral tissue resistance ) and reduces gluconegenesis

Vascular benefits , beta cell preservation, approved as monotherapy

Risks: DONT give with III or IV heart disease or CHF sympotmatic 
Causes water retention and edema 
Check LFT’s 
Expensive, may cause bone fractures 
Slow onset ( 12 weeks )

Question 18

Meglitinide

Answer 18

Prandin - repaglinide

Stimulates pancreatic secretion of insulin good for patients with post prandial hypergylcemia

Concern with hypoglycemia 
   - rapid acting short half life < 1 hr
   - take before meals or up tp 30 min after
   - hold if skipping meals 
Can’t be used with sulfareas

Question 19

Alpha glucosidase inhibitors

Answer 19

Glyset precose ( miglitol, acarbose)

Delaying absorption of carbs

Start 50 mg TID no more than 100 TID
Take with first bite of meal

Side effect
- diarrhea and flatuence

Question 20

Starting insulin - general recs

Answer 20

Start if A1C and glucose levels are above goal despite optimal use of other dm medications

If Aic is very high >10

Question 21

Self monitoring blood glucose

Answer 21

Important for pt teaching

Goals

• fasting and pre meal < 130
• post prandial <180

If on oral meds, check 1-2 times a day

If on insulin check fasting and pre meal

Question 22

Long acting basal insulin

Answer 22

Lantus ( glargine ), levimer ( determir)

Onset : 1-3 hours , no PEAK, duration 24 hours

TX: stop every but metformin

- basal insulin .2 u/ kg at bedtime or 10 units
- 20 units if weight over 80 kg     - Lower to 1 u/kg if frail 

Titration :
Increase by 1 unit every until average blood sugar is < 130 , hold if they develop hypoglycemia

• pt should check post meal glucose and evaluate 1-2 months

Question 23

Meal time insulin

Answer 23

Rapid acting at meals (.1u/kg)

Pt have to check blood sugar 3-4 times a day

If A1c > 7 after 2-3 months of basal insulin or if pre lunch , dinner or bedtime BG are above goal (80-130) despite fasting at goal then should consider meal time insulin

Question 24

Short acting insulin

Answer 24

Basal blous regimen = 1 long acting injection and 3 short acting injections

Decrease in endogenous insulin, most physiologic regimen, and best control

Humalog, novolog,
Onset : 10-15 min
Peak 1-2 hours
Duration : 3-5 hours

Question 25

Regular insulin and NPH

Answer 25

Reg = less freq because of hypoglycemia NPH = BID dosing only use if insurance wont cover long acting, less costly - onset 1-3 hrs - peak 4-10 Duration - 10-18 hours

Question 26

Pre mixed insulin’s

Answer 26

``` Onset : 10-15 min Peak : 1-3 hours Duration : 10-16 hours Benefits - more convenient - BID dosing ```

Question 27

Other agents

Answer 27

DPP4 inhibitor - do not use with GLP -1

Question 28

Trulicity

Answer 28

DDP4 - do not use with GLP-1 No recommended by standard guidelines Weekly injection Reduce or d/c sulfonyrea

Question 29

Gestational DM

Answer 29

24-28 wks - OGTT and then 6-12 post OGTT - fasting 92-100, 1 hour 180-190 2 hour 150 BP: 110-129 / 65-79 - ace and arb’s are contraindicated - use labetalol, diet, clonidine - statins are contraindicated - metformin B others are C

Question 30

Gestational DM targets

Answer 30

Pre prandial < 95 Post 1 hr < 140 Post 2 hr <120 A1C < 6

Question 31

Type 1 DM

Answer 31

Pancreatic Insufficiency of insulin production Incidence : 8-12 yrs old male, cauc Assessment : acute onset of PPP, dehydration, decreased energy, fruity breath ``` DX: Fasting > 126 Random > 200 Glucose and ketones in Uriel Low sodium and high K ``` Refer to endocrine Less insulin required in 1 st year 1 unit of insulin for every 22 gram of carb 1 unit of insulin will lower glucose 77 points Concern for thyriod disease and celiac sprue

Question 32

Macrovasular effects

Answer 32

Stroke, heart disease, HTN, PVS, foot problems

Question 33

Microvascular effects

Answer 33

Blindness, retinopathy , cataracts Nephropathy, renal failure, nerve damage foot problems and amputations

Question 34

Diabetic ketoacidosis

Answer 34

Medical emergency - requiring admission for rehydration, electrolyte imbalance, insulin drip - glucose >250 - ketones in urine - anion gap >10 Ph < 7.30

Question 35

Sick day plan

Answer 35

When you are sick - continue meal and meds and increase fluids - call me if vomiting - check BG at least 4 times a day - check for ketones if BG >250 - call if fever over 100.5 , v/d x 2 hours - BG >250 after two check and levels down go down after more insulin

Question 36

Metabolic syndrome

Answer 36

HTN, increased waist circumference and elevated fasting glucose