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Name 3 out of 6 of the core elements of the chronic care model

1. Delivery system design that is proactive rather than reactive
2. Self-management support
3. Decision support
4. Clinical information systems
5. Community resources and policies for healthy lifestyles
6. Health systems


What are the key objectives of the chronic care model?

1. Optimize provider and team behavior
2. Support patient behavior change
3. Change the care system


Divides interventions into into those that affect processes of care and those that affect immediate outcomes

TRIAD (Translating research into action for diabetes)


TRIAD interventions

Processes of care, intermediate outcomes and treatment intensification, intermediate outcomes and adherance


What are some vulnerable populations that you need to tailor treatment to?

1. Ethnic, cultural, sex, socioeconomic differences
2. Access to health care
3. Addressing disparities


What are some disparities that you may need to address in vulnerable populations?

Lacking health insurance, food insecurity, cognitive dysfunction, diabetes care in patients with HIV


Homelessness, poor literacy, and poor numeracy often result in?

Food insecurity


When should you screen an HIV patient for diabetes and pre diabetes?

Prior to antiretroviral therapy and 3 months after starting/changing it


How often should you measure fasting glucose in an HIV patient?

Every year (if pre-diabetic, every 3-6 months)


What are the diagnostic criteria for the diagnosis of diabetes?

FPG greater than 126
OR 2 hour plasma glucose greater than 200
OR A1C greater than 6.5%
OR random plasma glucose greater than 200 with classic symptoms of hyper/hypoglycemic crisis


What puts patients at an increased risk for diabetes?

BMI grater than 25 with one additional risk factor


When should you begin testing for diabetes?

45 and then test every 3 years if normal


When should you consider diabetes testing in children?

Overweight children with 2+ risk factors


Name 5 risk factors for diabetes

Physical inactivity
1st degree relative with diabetes
high-risk race/ethnicity
Women who delivered a baby weighing greater than 9 lb or had GDM
HDL cholesterol less than 35 and trigs over 250
A1C greater than 5.7%, IGT, or IFG on previous testing
Clinical conditions associated with insulin resistance
History of CVD


What are the foundations of care when dealing with a patient with T2DM?

Holistic approach
Team approach
Patient on board


What are 5 components of the comprehensive diabetes medical evaluation - Medical history??

1. History of smoking, alcohol consumption, and substance use
2. DKA frequency, severity, and cause
3. Hypoglycemia episodes, awareness, and frequency and causes
4. History of increased BP or lipids, and tobacco use
5. Microvascular complications
6. Macrovascular complications
7. Age and characteristics of onset of diabetes


What are 5 components of the comprehensive diabetes medical evaluation - Physical exam??

1. Height, weight, BMI
2. BP determination including orthostatic measurements when indicated
3. Fundoycopic exam
4. Thyroid palpation
5. Skin examination
6. Complete foot examination


What lab evaluations should you perform on a patient with diabetes?

1. A1C if results are not available within the last 3 months
2. Fasting lipid profile
3. LFTs
4. Spot urinary albumin:creatinine ratio
5. Serum creatinine and GFR
6. TSH in patients with T1DM or dyslipidemia or women aged over 50 years


You have a new patient with diabetes, where should you refer them?

1. Eye care professional for annual dilated exam
2. Family planning for women of reproductive age
3. Registered dietitian for medical nutrition therapy
5. Dentist for comprehensive dental and periodontal exam
6. Mental health professional if indicated


What are the key outcomes of diabetes self care management education and support? (DSME)

Effective self management, improved outcomes, health status and quality of life

DSME helps sustain skills and behaviors needed for self management


What will medical nutrition therapy do for patients with DM?

1. Help with weight management (improves glycemic control and can delay progression)
2. Carb intake should be related to insulin use
3. Sodium should be limited to less than 2.3g/day for BP and kidneys


What are the physical activity recommendations for children with diabetes or pre diabetes?

60 min of physical activity per day


What are the physical activity recommendations for adults with diabetes or prediabetes?

150min/week of moderate intensity aerobic physical activity spread over at least 3d/week with no more than 2 consecutive days without exercise; Resistance training at least 2 times/week


What physical activity can adults AND kids do to help diabetes?

Sit for less than 90 min at a time


Which immunizations should patients with DM have?

Routine vaccinations, Hep B for those 19-59 and unvaccinated, influenza, pneumococcal pneumonia


What should you be doing to assess a patients psychosocial status in a patient with DM?

Routinely screen for psychosocial problems (depression, diabetic distress, anxiety, eating disorders, cog impairment)


If a patient is over 65 and has DM, what should you do to assess their psychosocial status?

Consider doing cognitive function and depression screen


Name 5 comorbidities associated with diabetes

1. Fatty liver disease
2. Obstructive sleep apnea
3. Cancer
4. Fx
5. Low testosterone (men)
6. Periodontal disease
7. Hearing impairment
8. Cognitive impairment


How should you advise you patient to assess their glycemic control?

Check blood sugar:
1. Before meals/snacks
2. Postprandially sometimes
3. At bedtime
4. Before exercise
5. When suspect low glucose
6. After treating low blood glucose
7. Prior to critical tasks such as driving


How often should you perform an A1C test?

2X/year in patients who are meeting treatment goals, 4X/year in patients whose therapy has changed or don't have stable glycemic control


When would you allow a patient to have a less stringent goal of A1C (8%)?

Severe hypoglycemia, limited life expectancy, advanced micro/macrovascular complications, extensive comorbid conditions, or long-standing DM in home a general goal is difficult to obtain


When would a patient need a more stringent goal of A1C (6.5%)?

Patients with short duration of DM, T2DM treated with lifestyle changes or metformin only, long life expectancy, or no significant CV disease


What is the preferred treatment for hypoglycemia?

15-20g of glucose; repeat glucose 15 min after tx if blood glucose shows hypoglycemia; Once normal, patient should consider a meal or snack to prevent recurrence


Who should be prescribed glucagon?

anyone at an increased risk of hypoglycemia


When should you re-evaluate and possibly change your patient's hypoglycemia regimen?

Hypoglycemia unawareness or 1+ episodes of severe hypoglycemia


What do you do if you have a diabetic patient who is taking insulin and has hypoglycemia unawareness or severe hypoglycemic episodes?

Raise glycemic targets for a few weeks


BP screening and diagnosis for HTN and BP control in diabetics

BP should be measured at every routine visit; if elevated BP should be confirmed on a different day


Systolic BP goal for diabetic patient

Less than 140mmHg


When would you consider a systolic goal of 130mmHg or a diastolic goal of 80mmHg for a diabetic patient?

Younger patients, those with albuminuria, or those with HTN and CVD risk factors


Diastolic BP goal for a diabetic patient

Less than 90mmHg


What are the BP goals for a pregnant diabetic patient?

110-129 systolic 65-79 diastolic


How do you treat a patient with a BP that is over 120/80 but under 140/90?

Lifestyle modification


How do you treat a patient with a BP greater than 140/90?

Drug therapy


What population would a BP goal of 130/70 NOT be recommended?

Older adults (diastolic of 70 is associated with higher mortality)


What lifestyle modifications should your patient with diabetes and HTN be making?

1. Weight loss
2. DASH diet (dietary approaches to stop HTN) = low sodium and high K
3. Moderation of ETOH
4. Physical activity


What is the ideal drug therapy for a diabetic patient with HTN?

ACE-I or ARB but not both
Multiple drug therapy (+thiazide) usually required


When should you get a lipid profile in a patient with diabetes?

1. At diagnosis
2. Initial medical evaluation
3. Every 5 years thereafter
4. When you start a statin


What should lifestyle modification focus on for lipid management in patients with DM?

Weight loss, reduced saturated fat, trans fat, and cholesterol intake; Increase Omega 3 FA, viscous fiber, and plant sterol intake; physical activity


When should you intensify lifestyle modification in patients with diabetes? (in relation to lipids)

Trigs over 150
HDL less than 40 male; less than 50 female


When do you have to evaluate secondary causes and worry about pancreatitis?

Trigs over 500


When do you add statins to a diabetic patients drug regimen?

DM with CVD; if less than 40 use mod-high intensity statins


If a patient is 40-75 without CVD risks, what statin do you prescribe?

Moderate intensity


If a patient is 40-75 WITH CVD risks, what statin do you prescribe?

High intensity


If a patient is over 75 without CVD risks, what type of statin do you use?



If a patient is over 75 WITH CVD risks, what type of statin do you use?



What drug can you add to a lipid regimen that has an additional CV benefit?



What are some specific cases where you should consider ezetimibe?

ACS or LDL greater than 50, those who can't tolerate high intensity statins


Statins and fibrate are not recommended unless....

Men with trigs greater than 204 and HDL less than 34


Statins and niacin increase risk of ???



Are statins okay to use in PG?

No, contraindicated


What should you prescribe to patients as a primary prevention strategy for patients with T1 or T2 diabetes who are at a 10y CV risk greater than 10% OR in patients who are over 50 with 1+ additional risk factor for CVD who are not at an increased risk for bleeding?



When would you NOT want to prescribe aspirin to a diabetic patient?

Adults with DM at low 10y CV risk bc risk of bleeding is worse than benefit


When would you use aspirin as a secondary prevention strategy?

Those with diabetes and a hx of atherosclerosis


What do you prescribe when someone has an aspirin allergy?



When is dual anti platelet therapy okay?

For up to one year post acute coronary syndrome


Is routine CAD screening recommended in asx patients?



When should you screen for CAD?

Atypical cardiac sx, s/s of associated vascular dz (carotid bruits, transient ischemic attack, stroke, claudication, PAD) or EKG abnormalities


How do you treat patients with DM and CAD?

ASA and statin, consider ACE-I; Prior MI = BB should be considered for 2 y after the event


When do you not want to use thiazolidiedione in a patient with diabetes?

Symptoms of HF


When should you avoid metformin in diabetics?

CHF patients who are unstable or hospitalized


How do you screen for diabetic kidney disease?

Assess urinary albumin and eGFR yearly in patients with T1DM of more than 5y, patients with T2DM, and patients with comorbid HTN


How do you treat diabetic kidney disease?

Optimize glucose control and BP to less than 140/90 to decrease risk of progressive kidney disease


What would you prescribe for:

- Nonpregnant patient with DM and modest elevation of albumin excretion (30-299)
- Urinary albumin excretion greater than 300 and eGFR less than 60



When should you evaluate and manage potential complications of chronic kidney disease?

eGFR less than 60


When should patients be referred for renal replacement therapy?

eGFR less than 30 (stage 4)


How can you reduce the risk or slow the progression of diabetic retinopathy?

Optimize glycemic control and BP


When should you screen T1DM diabetic patients for retinopathy?

Within 5 yrs after onset


When should you screen T2DM diabetic patients for retinopathy?

- At time of diagnosis
- No evidence of retinopathy for 1+ exams - every 2y
- If any evidence of retinopathy - yearly
- If retinopathy is progressing - repeat more frequently


What is a good screening tool for retinopathy?

Retinal photography


When should you do eye exams on a diabetic pregnant patient?

Before PG or in 1st trimester and for 1Y postpartum


How do you treat retinopathy?

Promptly refer for any macular edema, severe non- proliferative or proliferative retinopathy -- laser photocoagulation recommended for these patients


Is retinopathy C/I with ASA therapy?



When do you screen for neuropathy in a T1DM patient?

5 years after diagnosis and annually thereafter


When do you screen for neuropathy in T2DM patients?

At diagnosis and annually thereafter


What does the assessment of neuropathy include?

Careful history, 10g monofilament test, and at least one of the following:
- Pinprick
- Temperature
- Vibration sensation


When should you assess for s/s of neuropathy?

Microvascular and neuropathic complications


Treatment for neuropathy?

Optimize glucose control, assess and treat patients to reduce pain related to neuropathy


Recommendations for foot care in diabetic patients

Perform a comprehensive foot eval each year to identify risk factors for ulcers and amputations


What should you check for in patient history related to foot care?

History of ulcers, amputation, charcot foot, angioplasty, vascular surgery, cigarette smoking, retinopathy, and renal disease


When do you examine a patients foot at EVERY visit?

Increased risk of developing ulcers and amputations


What does the foot exam consist of?

Inspection of the skin
Assessment of foot deformities
Neuro assessment including 10gm monofilament test and pinprick or vibration test or assessment of feet and ankles
Vascular assessment including pulses in legs and feet


When should you refer a diabetic patient to a foot specialist?

Smoker, hx of prior lower extremity complications, loss of protective sensation, structural abnormalities, PAD