1
Q
Define diabetes mellitus
A
- Syndrome with altered metabolism & inappropriate hyperglycemia
A. CHO, protein & fat catabolism
B. Due to insulin deficiency, insulin resistance, or combination of both
2
Q
What is the cause of T1DM?
A
- Often due to autoimmune pancreatic Islet cell destruction
A. Associated w/ DKA
3
Q
What is the cause of T2DM?
A
- Results from insulin resistance & defect in compensatory insulin secretion
A. Drug induced DM
4
Q
How is DM diagnosed?
A
Diagnose with FBS; GTT; or HbA1c
5
Q
What are complications of DM?
A
- Blindness
- Renal failure
- Non-traumatic amputation
- TIA, CVA, dementia
- ACS, CHF
- PVD
- retinopathy, glaucoma, cataracts
- Peripheral, autonomic neuropathy
- Microalbuminuria, nephropathy, ESRD
6
Q
How does DM affect the risk of MI and stroke?
A
MI & stroke increased X 2
7
Q
What are the types of DM?
A
- Type I
- Type II
- Gestational
8
Q
What is the FBS level for impaired glucose tolerance/pre-diabetes?
A
FBS 100-126 mg/dL
9
Q
What is the random glucose level or 2 hr GTT that is indicative of DM?
A
> 200mg
10
Q
When does a fasting blood sugar need to be followedup with a 2 hr GTT?
A
If FBS ≥ 126 mg/dL, F/U with 2 hr GTT
11
Q
Define 2 hr GTT
A
- 75 gm glucose in 300 ml water
2. Blood samples obtained @ 0 and 120 mins after ingestion
12
Q
What is the 2 hr GTT result for impaired/pre-diabetes?
A
2 hr GTT 140-200 mg/dL
13
Q
What is a negative FBS?
A
< 100 mg/dl
14
Q
What is a negative 2 hr GTT?
A
< 140 mg/dl
15
Q
Define HbA1c
A
Reflects state of glycemia over past 8-12 weeks
16
Q
How does RBC life span influence HbA1C?
A
False low result in pts with shortened RBC life span
17
Q
What is the normal HbA1c?
A
HbA1c < 5.7 %
18
Q
What is prediabetes HbA1c?
A
HbA1c 5.7-6.4%
19
Q
What is diabetic HbA1c?
A
HbA1c ≥ 6.5%
20
Q
What are the HbA1c percentage correlations to mean glucose levels?
A
- HbA1c: 5, Gluc: 97
- HbA1c: 6, Gluc: 126
- HbA1c: 7, Gluc: 154
- HbA1c: 8, Gluc: 183
- HbA1c: 9, Gluc: 212
- HbA1c: 10, Gluc: 240
- HbA1c: 11, Gluc: 269
- HbA1c: 12, Gluc: 298
21
Q
What are common comorbidities for DM?
A
- Depression & anxiety
- Obstructive sleep apnea
- Fatty liver disease
- Cancer
- Fractures
- Cognitive impairment
- Low testosterone in men
- Periodontal disease
- Hearing impairment
- Other Autoimmune Disease (Type 1)
A. Celiac Dz
B. Thyroid Dz
22
Q
What are the non modifiable risk factors for macrovascular complications of DM?
A
Age
Male
Family History
23
Q
What are the modifiable risk factors for macrovascular complications of DM?
A
- Hyperglycemia
- Hypertension
- Dyslipidemia
- Smoking
- Thrombogenic factors
(use of antiplatelet agents)
24
Q
What is the HbA1c level goal to reduce risk of macrovascular complications?
A
- Goal HbA1c < 7.0 %
- Goal individualized & changes over time
A. Depends on presence/progression of comorbidities
B. Depends on risk of hypoglycemia
25
When does the risk of hypoglycemia increase?
Risk of hypoglycemia ↑ w/duration of DM and advancing age
26
What are the sxs of hyperglycemia?
1. Thirst
2. HUnger
3. Frequent urination
4. Fatigue
5. Nausea
6. HA
7. Blurred vision
8. Nervousness
9. Confusion
27
What are the causes of hyperglycemia?
1. Too much food
2. too little exercise
3. too little medications
4. Stress
5. Illness
6. Injury
7. Short time between meals and snacks
28
What are the sxs of hypoglycemia?
1. Shakiness
2. Sweaty
3. HUnger
4. Anxiety
5. Nervousness
6. Confusion
7. Irritable/anger
8. Slurred speech
9. HA
29
What are the causes of hypoglycemia?
1. too little food
2. too much medicine
3. more activity than usual
4. Too long between meals and snacks
5. Alcohol
30
What is the FBS goal according to ADA?
80 – 130 mg/dl
31
What is the PP glucose range 1-2 hours after a meal according to the ADA? < 180*
< 180*
32
What is the HbA1c goal according to the ADA?
< 7%
33
What is the BP goal to reduce macrovascular complications?
<140/90
34
What drug class are diabetic commonly prescribed for BP control? What else is recommended?
1. ACE inhibitor or ARB; if one class not tolerated, substitute the other. Do not use in pregnancy
2. Multiple drug therapy (≥ 2 agents) generally required
3. Administer one or more medications at bedtime
4. Lifestyle modification
35
How is dyslipidemia controlled to reduce macrovacular complications in diabetics?
1. Statins - drug of choice
| 2. Lifestyle modification
36
What are the t. chol, trig, and HDL goals for diabetics?
1. T. Chol < 200 mg/dL
2. Trig < 150 mg/dL
3. HDL > 40 mg/dL (men) > 50 mg/dL (women)
37
What is the goal LDL for pts without CVD?
Goal LDL-C <100 mg/dL
38
What is the goal LDL for pts with CVD?
- Goal LDL-C <70 mg/dL
39
What antiplt agent is used for secondary prevention (+) ASCVD (arteriosclerotic cardiovascular dz)?
- Aspirin 81mg/day
40
What antiplt agent is used for primary prevention (-) ASCVD?
- Aspirin 81mg/day for those at ↑ risk.
A. Men > 50 yr
B. Women > 60 yr w/ at least 1 additional major risk factor
41
What antiplt agent is used of the pt has an ASA allergy?
- Clopidogrel (Plavix) 75mg po qd
42
When is dual antiplt therapy indicated?
Use dual antiplatelet therapy after an acute coronary syndrome or stent placement
43
Why is smoking esp. deleterious for diabetic pts?
1. Smoking is a major risk factor for both microvascular disease & CVD
2. Include smoking cessation counseling & other forms of treatment as a routine component of care at each visit
3. Do not use e-cigarettes
4. Nicotine patch, gum, NS, inhaler, lozenges; Zyban (Bupropion); Chantix (verenicline)
44
What is the number one cause of blindness? How can risks be reduced?
1. Retinopathy
A. Annual dilated eye exams by specialist
B. Glycemic & BP control most important
45
What is the number 1 cause of end stage renal dz? How can risk be reduced?
1. Nephropathy
A. Follow GFR & urine microalbumin
B. Glycemic & BP control most important
46
What is the number 1 cause of atraumatic amputation? How can risk be reduced?
1. Neuropathy
A. Ask about symptoms of neuropathy
B. Good exam & foot care are crucial
C. Glycemic control most important
47
What are the ADA guidelines/goals for diabetes?
1. Annual dilated eye exam
2. Lipid profile at least yearly
3. BP checks - goal < 140/90
4. Urine microalbumin check annually
5. HbA1c goal < 7% (q 3-6 mo)
6. Foot exam/Dentist yearly/Hygiene
7. ASA therapy per indications
8. Smoking cessation
9. Healthy dietary guidelines
10. Daily physical activity
11. Annual flu vaccine
12. Pneumococcal vaccination
48
How is DM managed?
1. Diet
2. Exercise
3. Insulin
4. Oral hypoglycemics
5. ACEI or ARB
6. Lipid lowering agents
7. ASA or antiplatelet Tx if indicated
49
What are the key facts about insulin?
1. Used in Type I & Type II DM
2. Natural hormone, not a drug
3. Available in vial or pen device
4. Risk of hypoglycemia / weight gain
5. Know onset, peak and duration of a patient’s insulin
6. Understand timing with meals
50
What are the 2 ways insulin pumps supply doses?
1. Steady measured & continuous dose ("basal" insulin)
| 2. As a surge ("bolus") dose, at your direction, around mealtime.
51
What type of insulin is used by insulin pumps? Why?
1. Insulin pumps use rapid-acting insulins
A. Lispro, aspart and glulisine
2. Because the pump delivers tiny amounts of insulin every few minutes, longer-acting insulins are not necessary
52
What are the key nutrition points for diabetics?
1. Portion control
2. Total carbohydrate (CHO) per serving
3. Even distribution of CHO across the day
4. Low fat intake
5. Discuss cultural preferences
6. All CHO are not created equal
7. No 1 “diet for diabetes”
8. Food diaries: helpful tool
9. People w/ DM can have dessert w/ planning & moderation
53
How can hypoglycemia be managed acutely?
```
1. 15 gms of carbohydrates
A. 3-4 glucose tablets
B. 15gm tube of glucose gel
C. 1/2 cup fruit juice
D. 1/2 cup regular soda
2. Wait 15 mins, then check blood sugar
3. If <70, repeat glucose intake
4. If after three checks, hypoglycemia persists, call 911
```
54
What are the benefits of activity for diabetics?
↓ blood glucose, ↑ BP & pulse; ↑ HDL; helps weight loss
55
What is the goal of activity for children?
Goal - 60 minutes daily
56
What is the goal of activity for adults?
1. Adults: 30 minutes (10-10-10, break it up) most days of week = 150 min/wk of moderate-intensity aerobic activity
2. Use ADL’s for physical activity: garden, mow lawn, wash car, walk dog, dance
57
What is needed for foot care for diabetic pts?
1. All patients w/DM should receive an annual comprehensive foot exam
2. Patient with insensate feet, foot deformities, & ulcers should have their feet examined at every visit*
3. Provide foot self-care education
58
What are the carb recommendations for women trying to lose weight?
2-3 choices
(30-45 g)
Carbs/meal
59
What are the carb recommendations for women trying to maintain weight?
3-4 choices
(45-60g)
Carbs/meal
60
What are the carb recommendations for men trying to lose weight?
3-4 choices
(45-60g)
Carbs/meal
61
What are the carb recommendations for men trying to maintain weight?
4-5 choices
(60-75g)
Carbs/meal
Gen Med: Ednocrine
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