fmCase 6

Question 1

T2DM diagnosis

Answer 1

• A1c > 6.5%
• Fasting BG > 126 mg/dl
• OGTT (more sensitive but difficult, poorly reproducible)
• Repeat unless symptoms of hyperglycemia
• Random BG > 200 mg/dl with symptoms

Question 2

ADA T2DM screening

Answer 2

ADA:

• Overweight with another risk factor:
  
  • Sedentary, race, first degree FHx, prior impair fasting BG, HTN, HDL250, GDM Hx, delivering baby >9 lb, PCOS, CV disease Hx, acanthosis nigricans
• Otherwise, screen starting age 45 q 3 years

Question 3

USPSTF T2DM screening

Answer 3

• BP > 135/80 (treated or untreated)

Question 4

DKA lab results

Answer 4

pH < 7.30 (anion gap metabolic acidosis)
dehydration
ketones
serum glucose > 250 mg/dl
life-threatening

Question 5

Hyperosmolar hyperglycemic state labs

Answer 5

pH > 7.30 (not a metabolic acidosis, and bicarb > 15)
dehydration
ketones absent/min elevated
serum glucose > 600 mg/dl
life-threatening

Question 6

DM vascular disease (types 1 and 2)

Answer 6

• heart, brain, kidneys, eyes, nerves

- HTN worsens it

Question 7

DM end-organ disease

Answer 7

CAD and CVA

Retinopathy and blindness

Glaucoma

Neuropathy

Nephropathy

Question 8

CAD and CVA in DM

Answer 8

• Leading cause of death in DM
• Risk 2-4x general population
• Worsens outcomes in DM
• DM = equivalent risk as previous MI
• Manage other CV risk factors!

Question 9

Eye disease in DM

Answer 9

Retinopathy and blindness: among T2DM higher risk if on insulin; higher risk in T1DM; proliferative retinopathy in 25% with 25 years DM

Glaucoma: 40% more likely in DM, increases with duration and age

Question 10

Neuropathy in DM

Answer 10

Focal / diffuse / sensory / motor / autonomic

• Defined by loss of ankle jerk reflex
• 50% at 25 years for T1 and T2DM

Question 11

Nephropathy in DM

Answer 11

• 20-40% in DM

- DM most common cause of ESRD

Question 12

Hispanic cultural views of health and illness

Answer 12

• Familismo
• Respeto/simpatia: to authorities, avoid confrontation
• Personalismo: relationships or institution, do not address by first name
• Fatalismo: external locus of control
• Faith/religion
• Body image: balance
• Language barriers/health literacy
• Complementary and alternative health practices: balance

Question 13

Diabetic foot exam

Answer 13

Diagnosis and annually

• 10-gram monofilament, plus one of
  
  • Vibration 128-Hz, pinprick, or ankle reflexes
• Pedal pulses (PVD is strongest risk factor for delayed ulcer healing and amputation)
• Inspection for pressure calluses, ulcers, bony abnormalities, hair loss, temperature, footwear

Question 14

Recommended lab tests for the DM patient

Answer 14

A1c at diagnosis and twice a year (50; annually (ADA and USPSTF not for or against)

Fasting lipid profile at diagnosis and yearly, every 3 months until controlled

Fingerstick BG if acute symptoms of hyperG or hypoG (not useful to evaluate control)

Question 15

A1c labs in DM

Answer 15

At diagnosis and twice a year (<7%)

Quarterly when changing tx or goal not met

Question 16

ECG in DM

Answer 16

Baseline (CVD most common cause of death)

Question 17

Spot urine albumin: creatinine ratio in DM

Answer 17

Annually

Drug tox and renal dz

Question 18

B12 labs in DM

Answer 18

If neuropathy signs

Metformin SE

Question 19

TSH in DM

Answer 19

Annually in T1DM, dyslipidemia, or women >50

ADA and USPSTF not for or against

Question 20

Lipid labs in DM

Answer 20

Diagnosis and yearly

If abnormal, every 3 months until controlled

Question 21

Fingerstick glucose in DM

Answer 21

If acute symptoms of hyperG or hypoG

not useful to evaluate control

Question 22

1st Tier Management of T2DM (ADA/EASD)

Answer 22

1. Diagnosis of A1c > 6.5%: Lifestyle + metformin
2. If A1c continues > 8%: Add sulfonylurea or basal insulin or intermediate insulin
3. If A1c continues > 8%: Add basal insulin or intensify insulin regimen. *Consider DCing sulfonylurea to avoid hypoG

Question 23

Sulfonylureas

Answer 23

Glyburide
Glipizide
Glimepiride (3rd gen)

Question 24

Basal insulin

Answer 24

Glargine (Lantus)

Detemir (Levemir)

Question 25

Intermediate insulin

Answer 25

NPH (neutral protamine Hagedorn)

Question 26

2nd Tier Management of T2DM

Answer 26

(Fewer well-validated studies in support) 4. - Add rapid insulin with meals. - Thiazolidinediones (pioglitazone, rosiglitazone) for those who have GI side effects with metformin or hypoG with sulfonylureas, or in addition (their SE is heart failure, edema, bone fractures). - Meglitinides (nateglinide, repaglinide) - GLP-1 analogs (exenatide, liraglutide) - DPP-4 inhibitors (dipeptidyl peptidase-4) (sitagliptin, saxagliptin) - Amylin analog (pramlintide) - Alpha-glucosidase inhibitors (acarboe, miglitol)

Question 27

Lifestyle modification in preventing diabetes

Answer 27

58% risk reduction

Question 28

Glycemic control in DM

Answer 28

- A1c < 7% prevents microvascular dz (retinopathy, nephropathy) - Fasting BG goal 80-120 mg/dl - Postprandial BG 1-2 hours goal < 180 - BP and lipid control better for CVD risk

Question 29

Modifying CVD risk factors in DM

Answer 29

- Treat BP to < 140/90 with lifestyle + ACEI, ARB, thiazide, or CCB (ARBs in DM + CHF) - Treat dyslipidemia with statin to LDL < 100, < 70 (known CVD, high dose statin); or LDL reduction of 30-40% - Statin regardless of lipids, if known CVD or if >40yo with risk factor for CVD - Weight loss, exercise, low fat

Question 30

LDL goal if DM and dyslipidemia

Answer 30

LDL < 100 LDL < 70 if known CVD (use high dose statin) or LDL reduction 30-40%

Question 31

LDL and hyperTG

Answer 31

LDL-c unreliable in s/o hyperTG > 200 (NCEP ATP III) So, target non-HDL cholesterol as second goal after LDL Non-HDL cholesterol may be stronger predictor of CVD Atherogenic VLDL remnants?

Question 32

ASA in DM

Answer 32

* Secondary prevention in DM with h/o CVD, or in DM with 10-year risk > 10% * Primary prevention in DM and >40yo, or other risk factors (HTN, smoking, dyslipidemia, FHx CVD, albuminura) * 81mg daily * Clopidogrel if ASA allergy * No evidence for ASA in s syndrome)

Question 33

Smoking cessation and DM

Answer 33

Efficacious and cost-effective | *QUIT not cut back

Question 34

Smoking and DM

Answer 34

Higher risk of premature microvascular cx and CVD | Most important modifiable cause of premature death

Question 35

Eye care in DM

Answer 35

Yearly exam: dilated indirect ophthalmoscopy + biomicroscopy or seven-standard field stereoscopic 30 degree fundus photography T1DM: start 5 years after diagnosis T2DM: At diagnosis (20% will have some retinopathy) Timely laser photocoagulation can prevent vision loss

Question 36

DM foot care

Answer 36

Diabetic shoes, podiatry referral, daily foot care

Question 37

DM dental care

Answer 37

important

Question 38

Immunizations

Answer 38

Annual influenza Pneumococcal polysaccharide > 2yo, and one-time revaccination > 64yo (if no vaccine in 5 years), and revaccination if nephrotic syndrome or CKD or immunocompromised