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When to treat HTN if no risk factors (or target organ damage)
≥160/100 --> to a target of < 140/90
When to treat isolated HTN (ISH)?
SBP > 160 --> to a tagert of < 140
When to treat HTN in mod-high risk patient?
≥ 140/90 with a target of < 140/90
When to treat home bp measure in mod-high risk patient?
≥ 135/85 with a target of < 135/85
When to treat bp in renal disease?
≥ 130/80 to a target of <130/80
When to treat bp in DMII?
≥ 130/90 but ACCORD-BP study showed SBP<120 had no benefit over SBP < 140
What is the risk of CVD in a high risk patient?
≥ 20% risk of heart and stroke in 10 yrs
Risk of CVD in a mod CVD risk patient?
10-19% risk of heart and stroke event in 10 yrs
Risk of CVD in a low CVD risk patient?
< 10% risk over 10 yrs
Target LDL level in high CVD risk patient?
LDL < 2 or decrease LDL ≥ 50% (med and lifestyle changes at same time)
High patients includes all people with which conditions?
ALL ppl with CAD, CVD, PAD. Most DM (older & 2+ risk factors) and Chronic renal disease (CrCl< 30ml/min)
When to treat LDL in moderate risk CVD patients?
Treat if > 3.5 or if M>50, F>60, then check CRP.
If LDL < 3.5 in moderate risk CVD patient?
If M>50yrs, F>60yrs, do hsCRP 2x, 2 weeks apart. If >2mg/l then treat (Jupiter trial)
Treatment goal for LDL in moderate CVD risk patients?
Same as high risk - LDL<2 or decrease LDL ≥ 50%
When to treat LDL in low risk patients?
Treat if LDL ≥ 5. Target of ≥50% reduction in LDL
Other lipid profile targets for high risk?
LDL<2 or drop 50%, ApoB < 0.8, TC/HDL < 4
When to treat moderate CVD risk Pt for ApoB and TC/HDL ratio
Treat if LDL > 3.5 or if old with high CRP, ApoB > 0.8, TC/HDL >5
When to treat low CVD risk patients for lipid profile?
Treat if LDL≥5 or TC/HDL >6 - can do lifestyle only for 3-6 months 1st
*In low/mod risk pop'n, goal is 50% reduction in LDL but landmark trials showed decreased MI, CVA, death with only 18-35% using Simvastatin 40mg, Atorvastatin 10, or Pravastatin 40.
A1C, FPG and PPBG goals for most ppl with DM
A1C q3-6mon ≤ 7%, FPG 4-7mM, PPBG 2h 5-10 (5-8 if A1C too high)
Normal range for A1C, FBG, 2h PPBG
A1C ≤6, FPG 4-6, PPBG 5-8 - try for normal range if can do without hypoglycemia
How often to calibrate glucometer in DM?
What are CV events for CVD risk?
MI, new angina, ischemic stroke, TIA, PVD, CHF & CV death
What are the CV Risk Factors (based on CDN, JNC7 studies)
BMI>25, Waist M>102cm, F>88cm, Low HDL≤1, FHx premature heart dz (M<55, F<65), age (M>55,F>65), microalbuminuria
3 cardinal Sx of DM
polyuria, polydipsia, unexplained weight loss
What are Dx criteria for DM?
- FBG > 7 ( > 8 hr fasting)
- Casual/Spot BG > 11.1 + Symtoms
- 2h post-prandial BG in 75g OGTT ≥ 11.1 mM → but should retest
What are the criteria for normal and impaired fasting glucose?
- Normal fasting glucose - < 6
- Impaired fasting glucose – 6.1 to 6.9
What is criteria for Impaired Glucose Tolerance?
2h OGTT - >7.8 up to 11.0 = Impaired Glucose Tolerance
What are risk factors for DM? (double check this)
- Aboriginal Population
- RF for vascular disease
- Complications of vascular dz
- Hx GDM
- Hx macrosomic infant
How often to screen for DM and in whom?
- Q3yr screening in > 40 yr
- But increase frequency if increased RF’s
What values on FBG are normal, impaired FG and DM?
FBG > 7 is DM, 6.1-7 IFG, <6 is normal
What do you do if they are Impaired Fasting Glucose?
- If IFG → do Oral Glucose Tolerance
- Also, if borderline N with 1+ RF then do OGTT to look for IGT
What is the DM Target Control? (for most diabetics)
- A1C < 7%
- FBG/preprandial 4-7mM
- 2h pp BG – 5-10mM (lower to 5-8 if ↑A1C)
What are the Fasting Blood Glucose and 2h Post-prandial goals for DM if high A1C?
- FBG is still 4-7mM
- 2h pp BG is lowered to 5-8mM
How often to do HbA1C in DM?
HbA1C q3/12 then q1yr and decrease if at targets and stable
How often to do CBGMs in DM?
- At least 3x/d CBGM if using insulin – mainly to monitor hypoglycemia and commitment
- If not on insulin – individualized, no evidence for it
How long to get to target HbA1C?
Give 6-12 months to achieve this after Dx
How to treat hypoglycaemia in DM?
- Tx with 15g glucose if mild-moderate
- Tx with 20g glucose PO, 1mg glucagon IM/SC or 20-50cc D5W over 1-3 min
- 6 lifesavers or 1 tbsp honey also works
- 1 amp D50W
Other things you need to do to properly manage diabetics?
- Aerobic exercise
- Dietician/nutritionist referral on Dx
- Screen all DM’s for depression, Anxiety, eating disorders – especially DMI (CBT works well for eating d/o)
- Recommend 5-10% of initial body weight loss to increase insulin sensitivity
Who gets pneumovax?
*Pneumovax and Influenza for all > 65 yr x 1 or DM I/II, then can repeat
What is first line drug for DM?
- Metformin (aka Glucophage) (covered) – weight neutral
- 1st line, increases sensitivity to insulin, hard on liver and kidney
What are the 2 mechanisms of action of metformin?
2 MOA’s: liver → decreases GNG, peripheral - ↑ peripheral insulin sensitivity
What are 2nd line drugs for DM?
- Insulin secretagogues – sulfonylureas and meglitimides
- Good 2nd choice
- Sulfonureas (Diabeta) (covered)
- Glicazide (Diamicron) (private) – less hypoglycemia with this one
Which drug used to be 2nd line for DM but we don't use now and why?
TZD (thio…. – Actos, Avandia) – used to be 2nd line, increased CVD risk, so don’t use
What to guidelines say about high dose metformin vs low dose of metformin + insulin secretagogues?
Guidelines don’t compare increased dose of 1 vs 2 low dose
Under what circumstances should you start with Metformin on Dx of DM?
1) Hb A1C ≥ 9% @ Dx, 2) Dx with HONK/DKA → start with metformin and 2nd drug (insulin or 2nd line Diabeta (secretagogue))
What is genuvia?
- Incretin (DPP-4 inhibitor) – genuvia - ↓ A1C by 1% absolute value
- Or SQ – Victosa – wgt loss - “ “
- 1st choice to start
- Intermediate acting (covered) – NPH or Humulin N – up to 18h
- Long acting (not covered) – Levemir or Lantus – up to 24h
Ie ↓ glucose in am ac breakfast, don’t hold basal insulin
What are diabetics risk for CVD?
- Increased risk of CAD+ - macrovascular complications, occur 10-12 yrs before non-diabetics
- But mostly if M> 45 and F > 50 or known MI/CAD, Microvascular complications, or + RF’s
What is annual screening for patients with DM?
- Urine albumin-Cr ratio (Urine ACR)
- Dx CKD+ if GFR < 60 x 2 times 3 months apart
- Or Urine ACR 2/3 abN of 3 ACR’s
What is another microvascular complication besides kidney and what is the screening for it?
- Retinopathy – optomitrist @ Dx, then q1-2 yrs
- Occur in DM I – 5 yrs post Dx ie 17yrs then 22 yrs then q1y
How do we screen annually for neuropathy
10g monofilament @ great toe – screen annually for neuropathy
How do we treat Diabetic foot pain?
- Gabapentin (Lyrica)
- Oxycodon (last resort)
What sensitive subject should you ask all DM men about?
- Erectile dysfunction – ask about in all DM men
- Follow guidelines
How do you prevent CVD in DM?
- Tx – vascular protection – lifestyle, weight loss/diet, bp, good glucose control
- Tx bp if >130/>80
- Renal protection – ACEI or ARB if proteinuria
- Antiplatelet if high risk (ASA and statin)