Diabetes stuff.txt

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164004
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Diabetes stuff.txt
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2012-07-26 00:17:08
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Diabetes Family Medicine
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Diabetes Family Medicine
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  1. 3 cardinal Sx of DM
    polyuria, polydipsia, unexplained weight loss
  2. 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
  3. What are the criteria for normal and impaired fasting glucose?
    • Normal fasting glucose - < 6
    • Impaired fasting glucose – 6.1 to 6.9
  4. What is criteria for Impaired Glucose Tolerance?
    2h OGTT - >7.8 up to 11.0 = Impaired Glucose Tolerance
  5. What are risk factors for DM? (double check this)
    • Aboriginal Population
    • RF for vascular disease
    • Complications of vascular dz
    • Hx GDM
    • Hx macrosomic infant
    • HTN,
    • Dyslipidemia
  6. How often to screen for DM and in whom?
    • Q3yr screening in > 40 yr
    • But increase frequency if increased RF’s
  7. What values on FBG are normal, impaired FG and DM?
    FBG > 7 is DM, 6.1-7 IFG, <6 is normal
  8. 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
  9. 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)
  10. 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
  11. How often to do HbA1C in DM?
    HbA1C q3/12 then q1yr and decrease if at targets and stable
  12. 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
  13. How long to get to target HbA1C?
    Give 6-12 months to achieve this after Dx
  14. 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
  15. 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
  16. Who gets pneumovax?
    *Pneumovax and Influenza for all > 65 yr x 1 or DM I/II, then can repeat
  17. What is first line drug for DM?
    • Metformin (aka Glucophage) (covered) – weight neutral
    • 1st line, increases sensitivity to insulin, hard on liver and kidney
  18. What are the 2 mechanisms of action of metformin?
    2 MOA’s: liver → decreases GNG, peripheral - ↑ peripheral insulin sensitivity
  19. 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
  20. 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
  21. 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
  22. 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))
  23. What is genuvia?
    • Incretin (DPP-4 inhibitor) – genuvia - ↓ A1C by 1% absolute value
    • Or SQ – Victosa – wgt loss - “ “
  24. INSULIN
    • 1st choice to start
    • Intermediate acting (covered) – NPH or Humulin N – up to 18h
    • Long acting (not covered) – Levemir or Lantus – up to 24h
  25. Ie ↓ glucose in am ac breakfast, don’t hold basal insulin
  26. 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
  27. 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
  28. 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
  29. How do we screen annually for neuropathy
    10g monofilament @ great toe – screen annually for neuropathy
  30. How do we treat Diabetic foot pain?
    • Amitriptalin
    • Gabapentin (Lyrica)
    • Pregabulin
    • Oxycodon (last resort)
  31. What sensitive subject should you ask all DM men about?
    • Erectile dysfunction – ask about in all DM men
    • Follow guidelines
  32. 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)

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