Endo Diabetes

According to the ADA multifactorial framework for reducing diabetes complications, what four core pillars rest upon the foundation of lifestyle modification and diabetes education?

Glycemic Management, Blood Pressure Management, Lipid Management, Agents with Cardiovascular and Kidney Benefit

What are the two broad categories into which complications of diabetes mellitus are divided?

Macrovascular & microvascular

Which major clinical conditions are categorized as macrovascular complications resulting from hyperglycemia-induced damage to large blood vessels?

Cerebrovascular disease, coronary heart disease, and peripheral vascular disease.

What causes macrovascular complication?

Hyperglycemia

What is the primary cause of morbidity and mortality in individuals with diabetes?

ASCVD

What type of diseases can be caused by hyperglycemia?

Cerebrovascular, CHD, PVD

What are prevention strategies for macrovascular complications?

A1c / Antiplatelet Therapy, Blood Pressure Control, Cholesterol Management, Diet, Exercise.

What is the A1C goal for most non-pregnant adults?

<7%

What is the fasting blood glucose goal for most non-pregnant adults?

80-130

What is the post meal blood glucose goal for most non-pregnant adults?

< 180

Which GLP-1 and GLP-1/GIP receptor agonists have demonstrated proven ASCVD benefit?

Liraglutide, Dulaglutide, Semaglutide, & Tirzepatide

Which SGLT-2 inhibitors have demonstrated proven ASCVD benefit?

Dapagliflozin, Empagliflozin, & Canagliflozin

What are the major risk factors considered when evaluating a patient with diabetes for ASCVD primary prevention?

Family history, HTN, dyslipidemia, smoking, CKD

What should considered for patients with DM for antiplatelet therapy?

≥ 50 years with at least 1 major risk factor & without increased risk of bleeding

What should the blood pressure be for control?

<130/80

What should be avoided 30 minutes before taking BP?

Avoid smoking, Caffeinated beverages, exercise

How long should you rest before taking BP?

5 minutes

What should be monitored after starting ACE/ARBs?

SCr, K+

When should SCr/K be taken after starting ACE/ARB?

2-4 weeks after initiation

How often should cholesterol be check for patients with diabetes < 40 years old?

Every 5 years

When should cholesterol be checked after starting/changing lipid-lowering therapy?

4-12 weeks

What should a person with ASCVD at very high risk LDL goal be?

<55

What should a person with ASCVD not at very high risk LDL goal be?

<70

What is added to help control LDL if already maxed on statin?

ezetimibe or PCSK9 inhibitors

If a patient is overweight or obese, how much weight loss should they do?

≥ 7%

What should be avoided to help lose weight?

Sugar, sweetened beverages

How much exercise should a patient get a week?

at least 150 minutes

What causes microvascular complications?

Hyperglycemia

What can microvascular complications cause?

Retinopathy, Nephropathy, neuropathy

What is damage to the eye that may lead to impaired vision or even blindness?

Retinopathy

What is prevention/treatment for retinopathy?

Blood glucose & BP control

What are non-pharm treatment for retinopathy?

Panretinal laser photocoagulation

What are pharm treatment for retinopathy?

anti-VEGF inhibitors

What is damage to the kidneys that may lead to proteinuria or even renal failure?

Nephropathy

What is treatment/prevention for nephropathy?

Blood glucose & BP control

What drug class can be used to control A1c with T2DM with eGFR ≥ 20?

SGLT2 inhibitor

What can be use if SGLT2 inhibitor is contraindicated or intolerant?

GLP-1 receptor agonist or finerenone

What is a Non-steroidal Aldosterone Receptor Antagonist?

Finerenone

What should you monitor for finerenone?

K, eGFR

What medications can be used to treat peripheral neuropathy?

Duloxetine, pregabalin

What are symptoms of gastroparesis?

Nausea, vomiting, bloating

What medications should be avoided for gastroparesis?

Opioids, anticholinergics, TCAs

What can be used to treat Orthostatic Hypotension?

Midodrine, Droxidopa

What can be used to treat Gastroparesis?

Metoclopramide

What can be used to treat Erectile Dysfunction?

PDE-5 Inhibitorss

What vaccines are recommended for diabetes?

Flu, pneumococcal, tdap, Hep B, Shingles, RSV, HPV, Covid-19

When is T-dap given?

All adults

How often is flu and covid vaccine given?

Every year

How often is Tdap vaccine given?

every 10 years

Whe is Hep B recommended?

< 19-59 & ≥ 60

How often is shingles vaccine given?

≥ 50 or adults 18-49 who are immunocompromised

How often is pneumococcal vaccine given?

≥ 19 with diabetes

How often is HPV vaccine given?

9-26 & 27-45

How often is RSV vaccine given?

≥ 75 or 50-74 who are increased risk

What is serious, acute, life-threatening hyperglycemic?

Diabetic ketoacidosis

What age is DKA more common in?

18-44

What age is HHS more common in?

45-64

What are precipitating factor of DKA and HHS?

Infection, insulin therapy omission, acute illness

What is the DKA triad?

Hyperglycemia, increased ketones, metabolic acidosis

What do 10% of DKA patients present with?

Euglycemia

What can cause euglycemia?

reduced food intake, pregnancy, impaired gluconeogenesis

What leads to HHS?

Severe hyperglycemia, hyperosmolarity, dehydration

What is the onset of DKA?

Hours to days

What is the onset of HHS?

Days to weeks

Are patients alert in DKA?

Yes

Are patients alert in HHS?

No

What are signs of DKA?

N/V, abdominal pain

What are signs of HHS?

Presents with other acute illness

What glucose levels is present in DKA?

>200

What is the β-hydroxybutyrate level in mild to moderate DKA?

3-6

What is the β-hydroxybutyrate level in mild to moderate DKA?

>6

What is the pH for mild DKA?

7.25-7.3

What is the pH for moderate DKA?

7-7.25

What is the pH for severe DKA?

< 7

What is the glucose level for HHS?

≥ 600

What is the serum osmolarity for HHS?

>320 mOsm/kg

What is the level of β-hydroxybutyrate for HHS?

< 3

What is the pH for HHS?

≥ 7.3

What is done to correct DKA/HHS?

Dehydration, hyperglycemia, electrolyte imbalances

What is the fluid choice for DKA/HHS?

0.9% NaCl or balanced crystalloid

Which fluid leads to faster DKA resolution?

Balanced crystalloid

When should deficit be corrected with fluids?

Within 24-48 hours

What is the initial fluid rate?

500-1000 mL/hr

What happens when glucose falls <250 mg/dL during fluid replacement?

Add D5W or D10W

What type of insulin is used for mild DKA?

Rapid acting

How much units of insulin is used for mild DKA?

0.1-0.2 units

What type of insulin is used for moderate to severe DKA?

IV infusion

How much units of insulin is used for moderate to severe DKA?

0.1 units

What is the target glucose level after getting insulin for DKA?

150-200

What is the target glucose level after getting insulin for HHS?

200-250

What decreases during insulin therapy?

Potassium

What is the target serum potassium for potassium replacement?

4-5

What happens if potassium is < 3.5?

Delay insulin administration

How often should potassium be monitored after insulin administration?

Every 2 hours

What are electrolytes replacements?

Bicarbonate & phsophate

Which electrolyte replacement is not recommended for DKA/HHS?

Bicarbonate

What can bicarbonate electrolyte placement cause?

Hypokalemia

When can bicarbonate electrolyte replacement be used?

pH < 7

What type of electrolyte replacement is common in DKA?

Hypophosphatemia

When should phosphate replacement be used for DKA?

< 1 mmol/L WITH muscle weakness