1
Q
Diagnosis of Diabetes
A
Hgb A1c ≥ 6.5%
- Fasting plasma glucose ≥ 126 mg/dL (still the standard)
- 2-hr plasma glucose ≥ 200 mg/dL (75 g glucose load)
- Random plasma glucose ≥ 200 mg/dL with classic symptoms of hyperglycemia (polyuria, polydipsia)
2
Q
Type 1 versus Type 2 Diabetes
A
3
Q
Management Goals (ADA )
A
• A1C < 7%**
– < 6.5% for new diagnosis, long life expectancy
– < 7.5% for children (more commonly type 1)
– < 8% for longstanding disease, advanced complications
– < 8.5% for limited life expectancy, extremely complex older patients – Monitor every 3 months (every 6 months if well-controlled)
- Blood sugar: pre-meal 80-130
- Blood pressure: < 140/90 mm Hg (< 130/80 mm Hg preferred) • Lipids: lifestyle modification; statin management
4
Q
Pharmacological Therapy
A
5
Q
Biguanide – Metformin
A
6
Q
Metformin and IV contrast
A
- Stop prior to IV contrast** and 48 hours after** (angiography/ pyelography)
- Must check creatinine prior to use
- Rare cases of lactic acidosis* (recommended to stop at creatinine > 1.5 men, 1.4 women, but new data suggests that it can be renally dosed if GFR > 30 mL/min)
7
Q
What vitamin deficiency do you need to check for Diabetes?
A
• Check for B12 deficiency*
8
Q
Thiazolidinediones
A
• Pioglitazone (Actos), Rosiglitazone (Avandia)
– Insulin sensitizers** (decrease insulin resistance)*
– ↓ gluconeogenesis (increase hypoglycemia)
• Caution in cardiopulmonary disorders (volume overload)* Black Box warning for class III or IV heart failure
9
Q
Sulfonylureas
A
- Glipizide (Glucotrol), Glyburide, Glimepiride (Amaryl)
- Stimulate pancreatic beta cells to release insulin
- Weight gain and hypoglycemia
10
Q
Meglitinides
A
• Repaglinide (Prandin), Nateglinide (Starlix)
– Rapid-acting (half-life <1 hr) insulin secretagogues
11
Q
Alpha-glucosidase Inhibitors
A
• Acarbose (Precose) and Miglitol (Glyset )
– Delay carbohydrate absorption in gut
—decrease peak glucose levels, no hypoglycemia as monotherapy*
– Reduces risk of cardiovascular events*
– Not for use in renal dysfunction (creatinine > 2)* – Must keep glucose available
– Weight neutral
12
Q
GLP-1 Receptor Agonists
A
- May stabilize and lower blood sugar better than insulin, but more GI side effects and greater cost
- Decrease dose in renal failure (except liraglutide). Avoid if creatinine clearance < 30 mL/min
- Mechanism of action – Potentiate insulin secretion – Suppress postprandial glucagon secretion – Slow gastric emptying – Promote satiety (no weight gain) •
Side effects – Nausea, vomiting, diarrhea, weight loss* – Pancreatitis* – Hypoglycemia (with sulfonylurea) – Thyroid C-cell tumor risk
13
Q
DPP-4 Inhibitors
A
14
Q
SGLT2 Inhibitors
A
15
Q
Insulin
A
16
Q
Long Acting Insulin
A
17
Q
Rapid-Acting Analogues
A
- Lispro (Humalog), Aspart (Novolog), Glulisine (Apidra)
- Give with meals if 2-hour postprandial sugar is high*
- Onset 15 min, peak 1-3 hr, duration 2-5 hr
18
Q
Treatment in Children
A
- 2 choices: metformin (type 2) and/or insulin* (type 1 or 2)
- Screening for complications in Type 1
– Microalbumin yearly beginning age 10 or 5 years after onset
– Retinopathy beginning at age 15 or 5 years after onset
– Screen for celiac disease
– Screen for hypothyroidism
– Screen for hypertension
- Hypertension – ACE inhibitor for HTN or elevated albumin/creatinine
- Lipids – Check if positive family history – Use statins if > age 10
19
Q
Diabetic Immunizations
A
20
Q
In which group is the rate of diabetes the highest?
A
Native Americans – Highest rates at 15.9%
21
Q
Diabetes Screening for Comorbid Conditions
A
- Blood pressure at every visit
- Lipids yearly (every other year if well-controlled)
- Screen for hypothyroidism because it can contribute to dyslipidemia*
- Screen for tobacco use
- Screen for depression (more prevalent in patients with chronic disease)
- In type 1, screen for hypothyroidism and celiac disease
22
Q
Screening for Complications
A
23
Q
Ketoacidosis criteria
Why does it occur?
A
– Anion gap > 10
– Glucose ≥ 250
– pH < 7.3,
– Bicarbonate ≤ 18 *
– Serum and urine ketones
• Insufficient insulin; increased gluconeogenesis and fatty acid oxidation resulting in metabolic acidosis
24
Q
DKA management
A
- Volume replacement – 1 L NS/hr until dehydration resolved – Then ½ NS at 150-500 mL/hr)* (usually 5-8 L deficit)
- Continue insulin drip until acidosis is resolved *
- Hourly monitoring of electrolytes, glucose, and pH
- Replace K + as soon as it approaches 5 mg/dL*
- Add D5 when glucose is ~ 250 mg/dL*
- Bicarb only for pH < 7 or HCO 2 < 10 mEq/L*
25
Hyperosmolar, Hyperglycemic State
– Mortality \>\>\> DKA
* Insulin infusion (oral and SQ are inadequate)\*
* IV fluids (normal saline)
* Replace K+ as it falls near normal range
* Oral medications and/or subcutaneous insulin is restarted after blood sugars return to the 200 range
* Delirium or altered mental status usually clears with correction of metabolic abnormalities
26
Diabetic Neuropathy
* \*1st: amitriptyline or nortriptyline, gabapentin or pregabalin, duloxetine or venlafaxine, 5% lidocaine patch
* 2nd: topiramate, lamotrigine, carbamazepine, capsaicin cream
* 3rd: opioids, tramadol
27
Nephropathy Treatment
\*Avoid NSAIDs: they acutely reduce renal blood flow and may cause interstitial nephritis\*
Aggressive management of blood sugar and BP
Treat with increased doses of ACE inhibitors or switch to ARB if creatinine is increasing despite ACE therapy
Microalbumin yearly until on ACE or ARB, then questionable. If abnormal, repeat to confirm
28
57-year-old CM with diabetic foot ulcer. What is the best indicator of its ability to heal?
Patient’s pulse
29
Diabetic Foot
* Best test for **sensation** is a **monofilament**\*
* **Diabetic foot ulcer:** remove pressure; good wound care and debridement; no antibiotics if not infected
* **Osteomyelitis** usually occurs in the foot\*: best test is **MRI**\*\*
* **Best indicator for successful healing**: intact vascular supply (pulses)
\* Assess decreased pulse with noninvasive vascular studies (a**nkle-brachial index**)\*
Cover **MRSA** (10-32%) and Strep (dicloxacillin, cephalexin, augmentin, doxycycline, trimethoprim/sulfa). **Severe**: piperacillin/tazobactam with vancomycin\*
30
Endocrinologists’ Algorithm for Initiation of Therapy, Based on A1c Levels
31
Other Medications for Complications
**Post MI**
– Ticagrelor or prasugrel with aspirin are preferred
– If neither of these is an option, the new antiplatelet agent, vorapaxar with aspirin is recommended
**Diabetic macular edema**
– Ranibizumab (Lucentis – first approved), Bevacizumab (Avasti – cheapest), and aflibercept (Eylea – most expensive but probably the best)
32
Overweight and Obesity in Children
* Overweight: ≥ 25 kg/m2
* Obesity: ≥30 kg/m 2
* Overweight children \> 85th % for age and gender\*\* (25% in US)
* Obese children \> 95th % for age and gender (7% in US)
*Underweight \< 5th percentile*
33
Obesity Implications
* Doubles risk of, and mortality from, cardiovascular disease (CVD)
* Metabolic syndrome (MetS) = 5 times the risk of developing diabetes
34
Metabolic Syndrome
**Combination of 3 of the following:**
Fasting glucose ≥ 110 mg/dL
Waist circumference \> 40” men, \> 35” women
HDL \< 50 mg/dL women, \< 40 mg/dL men
Triglycerides ≥ 150 mg/dL
Blood pressure ≥ 130/85 mm Hg
35
Preventing obesity from conception through childhood
– Limit gestational weight gain
– No maternal smoking
– Breastfeed at least 12 months
– Infants should sleep at least 12 hours daily
– Delay solid foods until at least 4 months of age
– Daily activity for at least one hour
– Limit screen time to 2 hours/day
36
Prediabetes
• Increased risk of developing diabetes
– A1c 5.7-6.4%
– Impaired fasting glucose (100-125 mg/dL)
– Impaired glucose tolerance (140-199 mg/dL after 75 g load)
37
How to measure waist circumference for metabolic syndrome
Stand and place a tape measure around your middle, just above your hipbones.
Make sure tape is horizontal around the waist.
Keep the tape snug around the waist, but not compressing the skin.
Measure your waist just after you breathe out.
38
A 27-year-old female with a BMI of 39 requests help with a diet. You tell her?
There is no weight loss diet that is better than the others.
Mediterranean diet and DASH (not weight loss diets) are healthiest
39
Pharmacologic Treatment of Metabolic Syndrome
* Recommended diabetes medications for patients on a weight loss program: metformin, GLP-1 analogs, or SGLT-2 inhibitors
* In patient with cardiovascular disease, consider orlistat and lorcaserin
40
Weight Loss Medications
**• Orlistat (Xenical)** 120 mg tid or OTC as alli 60 mg tid (with meals) – Blocks fat breakdown and absorption; GI side effects – Supplement with vitamins if taking long-term
* **Lorcaserin** (Belviq) 5-HT2c (seratonin) receptor agonist 10 mg bid – Controlled substance, promotes satiety – Side effects: dizziness, fatigue, headaches, memory problems, constipation, possible serotonin syndrome with SSRI – Responders \> 5% weight loss, non-responders \< 2%
* **Phentermine-Topiramate (Qsymia)** 3.75/23 mg starting and increase to 7.5/46 mg/d – Approved for long-term use; 10-14% weight loss – Taper when stopping – Side effects: numbness, dizziness, insomnia, constipation – *Not for use in pregnancy*
**• Phentermine (Adipex)** 15, 30, 37.5 mg daily – Appetite suppressant, amphetamine derivative – Also: benzphetamine, diethylpropion, phendimetrazine – *Don’t use in hypertensive patients*
* **Bupropion-naltrexone (Contrave)** 8 mg/90 mg 2 bid – Decreases appetite and food cravings – *Increases seizure and suicide risk*
* **Liraglutide (Saxenda)** 0.6 mg/d SC; increase weekly to 3 mg/d – GLP-1 agonist – 1/3 lose 10% of body weight – Little CNS effect
41
Bariatric Surgery Indications
– BMI \> 40 kg/m 2 or \> 35 kg/m 2 with comorbid conditions
– Other weight loss methods have failed
– High risk for obesity-related morbidity and mortality
42
Which is a common complication of bariatric surgery?
Iron deficiency anemia
43
Gastric Banding
44
Sleeve Gastrectomy
45
Roux en Y
creating a stomach pouch out of a small portion of the stomach and attaching it directly to the small intestine, bypassing a large part of the stomach and duodenum.
46
Monitoring and Supplementation of bariatric surgery
47
The USPSTF recommends screening for diabetes in the following groups
All persons age 40-70 who are overweight
48
American Diabetes Association Screening Recommendations
* Screen at age 45 then every 3 years if normal
* Screen if BMI ≥ 25 (Asians BMI ≥ 23) and 1 additional risk factor – Physical inactivity – Family history of diabetes (esp. in 1st degree relative) – High-risk ethnic population – Previous Gestational Diabetes or baby \> 9 lbs – Hypertension – History of vascular disease – Dyslipidemia (HDL \< 35 / triglycerides \> 250) – History of impaired glucose tolerance – Clinical conditions associated with diabetes (acanthosis nigricans) – PCOS (polycystic ovary syndrome)
49
Screening for Type 2 Diabetes in Children
**• Every 2 years at age 10 or puberty if:**
* BMI or weight \> 85% (\> 120% of ideal)\*
* 2 of the following risk factors:
* Family history 1st or 2nd degree relative • High-risk ethnic/racial group • Signs or symptoms of insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovarian disease)
50
What is the recommended starting dose of levothyroxine in the non-elderly?
* Start at 1.6 mcg/kg/day
* Start lower in the elderly (1.0-1.25mcg/kg/day) • Steady state, re-evaluate: • 5-6 weeks after dosage change
* Recommend taking on fasting stomach & wait 30 mins before eating.
51
Workup of Hyperthyroidism
* TSH (A)
* Free T4 & T3: (A)
* CBC: (B)
* Radioactive uptake scan: (A)
* “Maybes”: ESR, ultrasound, thyroid antibodies: (C)
52
Differential diagnosis of low TSH
53
The preferred definitive treatment for Graves disease is:
Radioactive iodine ablation
54
Graves Disease Treatment
* Methimazole safer than PTU
* With PTU risk of serious liver injury is:
– Adults: 1:10,000 – Peds: 1:2,000
• PTU now considered a 2nd-line agent – EXCEPT during pregnancy & lactation •
– Monitor aminotransferases & CBC in both
55
Thyroid Nodules
• Start with TSH
56
Thyroid in Pregnancy
* Thyroid can increase 10% in size.
* A 50% increase in thyroid hormones and in iodine needed.
* 10% of gravid women in 1st trimester will be + for thyroid peroxidase or thyroglobulin Abs.
– 16% of them have hypothyroidism
– 33-50% develop pp thyroiditis
57
The Thyroid in Pregnancy goal and medication
* TSH goal in pregnancy \< 3.0
* Levothyroxine is indicated for subclinical hypothyroid (SbHypo) with + TPO Abs
* Gravid women with SbHypo not treated should have TSH & T4 checked q 4 weeks until 16-20 wks & then \> once from 26-32 weeks.
* Treatment not needed for isolated low T4
* Women already on levothyroxine should increase dose by 25-50% during pregnancy.
* Antithyroid meds are NOT indicated for women with gestational hypERthyroidism
* For Graves, use PTU in 1st trimester, then methimazole
* During PP thyroiditis toxic phase, don’t need antithyroid meds.
* Check TSH q 2 months after toxic phase
* Can try to wean off replacement @ 6-12 months after starting Rx • No radioactive iodine scanning during pregnancy
58
If breastfeeding, what thyroid medication is preferred?
• If breastfeeding, PTU is preferred as less is transferred thru milk
