RT Integrated Diabetes Final

What are HTN screening recommendations?

measure BP at every routine visit; patients with DM and HTN should monitor BP at home

What are BP goals?

<130/20 if it can be safely attained

What is the treatment if initial BP >130/80 and <150/90?

lifestyle managmagement + one agent

What is the preferred BP drug if the patient has albuminuria or CAD?

ACEI or ARB

What is the initial treatment if the initial BP is >150/90 mmHg?

lifestyle management and start 2 drugs

What do we use if we need two drugs for BP and the patient has albuminuria or CAD?

ACE or ARB + CCB (DHP) or diuretic

After assessing BP control and s/e, if the patient is not meeting target, what should be done?

add agent from completmentary drug class: ACEI or ARB, CCB (DHP), or diuretic

If still not at target: consider addition of mineralcorticoid RA (spironolactone or aldactone)

For HTN management, what combinations should be avoided?

ACEI + ARB or ARB + direct renin inhibitor

increases risk of hyperkalemia, syncope, and AKI

What is the role of BBs in HTN management?

indicated in MI, active angina, and HFrEF, but do not reduce mortality as BP lowering agents in the absence of these conditions

(continue for 3 years after MI)

What are monitoring parameters needed for ACEI, ARBs, and diuetics?

electrolytes (K+, Na+), kidney function

What is the lipid screening recommendations for adults who are NOT taking statins?

lipid profile at the time of diagosis and every 5 years if under 40

if over 40: should be started on a moderate intensity statin

What is lipid screening recommended for adults that are on statin therapy?

obtain lipid profile at initiation of statin therapy, 4-12 weeks after ititiation or dose change, then annually to assess adherence and response

What are ASCVD RFs?

obesity/overweight, HTN, dyslipidemia, smoking, CKD, albuminuria, FH of premature coronary disease

What is the primary prevention for statin therapy in patients 20-39 without risk factors?

lifestyle only

What is the primary prevention for statin therapy in patients 20-39 with risk factors?

consider statin

What is the primary prevention for statin therapy in patients 40-75, no ASCVD?

moderate intensity statin

What is the primary prevention for statin therapy in patients 40-75, with high risk (one or more RF)?

high intensity statin

target is <70 mg/dL

What is primary prevention statin therapy for age 40-75 with multiple ASCVD RFs and LDL >70?

consider adding ezetimibe or PCSK9 to maximize tolerated statin therapy

What is primary prevention statin therapy for age >75?

evaluate risk, generally moderate intensity statin or continue on previously initiated therapy

What is secondary prevention statin therapy for all ages with ASCVD?

high intensity statin

target LDL <55 mg/dL, add ezetimibe or PCSK9 inhibitor if LDL goal is not met

What is ASCVD?

acute coronary syndrome, MI, angina, stroke, TIA, PAD (including aortic aneurysm), coronary or other arterial revascularization

Can statins be used in pregnancy?

no

What drugs are high intensity statins?

Atorvastatin 40-80 mg

Rosuvastatin 20-40 mg

What are moderate intensity statins?

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10 20 40 40 80 80

Rosuvastatin: 5-10 mg

Atorvastatin: 10-20 mg

Simvastatin 20-40 mg

Lovastatin 40 mg

Pitavastatin: 40-80 mg

Fluvastatin: 80 mg

What is management of hypertriglyceridemia?

assess with dietary and lifestyle changes, including abstinence from alcohol

If TGs 500+: consider medication (fibrate and/or fish oil)

What are risks related to extremely elevated TGs?

pancreatitis

When is statin/vascepa used?

consider in patients with ASCVD/RFs on statin but with elevated TGs (135-499) to reduce CV risk

When is statin/ezetimibe used?

CV benefit in patients with recent ACS; can also consider ezetimibe alone if statin intolerant

When is statin/PCSK9 used?

LDL reducation of 36-59%, significantly reduced composite outcome of CV death, MI, stroke in patient with ASCVD (secondary prevention only)

When is statin/fibrate used?

not recommended

When is statin/niacin combination used?

not recommended

When is ASA therapy (75-160 mg/day) recommended?

secondary prevention in patients with ASCVD + DM

primary prevnetion in patients with DM at increased CV risk: 50 y/o+ and 1 additional RF (discuss risks/benefit w/patients)

What are major CV risk factors?`

FH premature ASCVD, HTN, smoking, dyslipidemia, CKD, or albuminuria

What do we use if patients are allergic to ASA?

clopidogrel 75 mg/day

When ASA not recommended?

age <50 w/ no other major ASCVD risk factors

age >70 for primary prevention

bleeding RFs (older age, anemia, renal disease)

age <21 (reye syndrome)

For a patient with ASCVD or indicators of high ASCVD risk, what therapy should be used?

GLP1 or SGLT2 with demonstrated CV benefit

if A1C remains above target, consider using both

When are patients at high risk for ASCVD?

age >55 with 2+ RFs:

obesity, hypertension, smoking, dyslipidemia, or albuminuria

Which GLP1s have proven ASCVD benefit?

semaglutide (ozempic)

liraglutide (victoza)

dulaglutide (trulicity)

What SGLTs have

canagliflozin (Invokana)

empagliflozin (Jardiance)

In patients w/ current or prior symptoms of HF with documented HFrEF or HFpEF, what should therapy include?

select SGLT2 inhibitor with demonstrated benefit reducng HF

avoid TZDs, saxagliptin

Which DM drugs have proven HF benefit?

canagliflozin (invokana)

dapagliflozin (Farxiga)

Empagliflozin (Jardiance)

Ertugliflozin (Steglatro)

What drugs have CKD benefit?

SGLT2 (preferred): canagliflozin, dapagliflozin, empagliflozin

GLP1: dulaglutide, liraglutide, semaglutide (SQ)

What are generally screening recommendations for nephropathy (microvascular complications)?

assess urinary albumin (UACR) and eGFR at least once a year regardless of treatment

all patients with T2D, patients with T1D for 5+ years

What is normal UACR? What is albuminuria?

30 mg/g or less

albuminuria: >30 mg/g

If a patient has CKD, how often should nephropathy screening occur?

1-4 times/year depending on CKD stage

If UACR >300 mg/g, how much do we want to reduce it by?

by 30% to slow CKD progression

When are patients defined as having CKD?

eGFR <60 OR albuminuria (UACR >30)

What is the preferred therapy for CKD, if the patient is on a maximally tolerated dose of ACEI or ARB?

preferred: SGLT2s - canagliflozin, empagliflozin, dapagliflozin

if not tolerated or C/I: GLP-1 - liraglutide, semaglutide, dulaglutide

When are SGLT2s less effective based on eGFR?

<45 mL/min, but still recommended if GFR >20 regardless

How long do we use SGLT2s for CKD?

until dialysis or treatment

What are the considerations for metformin in nephropathy?

C/I in <30 mL/min

eGFR 30-45 mg/mL: avoid initiation, consider dose adjustment and/or risk vs benefit if already taking

What are treatment recommendations for nephropathy?

optimize BP control: use ACEI or ARB if UACR >30

not superior to other BP meds in patients with normal UACR and eGFR (not recommended for patients without HTN)

What are initial screening recommendations for retinopathy?

annual dilated and comprehensive eye examination

T1D: initial exam w/in 5 years after onset of DM

T2D: initial exam at the time of diagnosis

What are repeat screening recommendations for retinopathy?

no evidence of retinopathy for 1 or more annual eye exams + glucose well controlled: q1-2 years

evidence of retinopathy: repeat at least annually, more frequently if progresses

How do we reduce risk or slow progression of retinopathy?

optimize glycemic control, optimize BP and lipids

How is retinopathy treated?

laser photocoagulation therapy, intravitreal VEGF for macular edema, intravitreal inj. of corticosteroids

Is the presence of retinopathy a C/I for ASA therapy?

no, this therapy does not increase the risk of retinal hemorrhage

What are screening recommendations for neuropathy?

all patients should be screening annually for diabetic peripheral neuropathy

start at diagnosis of T2D and 5 years after diagnosis of T1D

What are clinical tests that may be included in Diabetic Peripheral Neuropathy (DPN) testing?

visual inspection, pinprick sensation, temp sensation, vibration perception (tuning fork), 10 g monofilament

What are s/s of DPN?

burning, tingling, knife-like electrical sensations, pins and needles, numbness

What are non-pharm recommendations for DM patients at high risk of DPN?

specialized footwear

What are footcare recommendations for DM patients?

inspect feet daily, clean feet daily and dry b/w toes, moisturize feet (avoid areas b/w toes), keep toenails trimmed, always wear shoes or slippers, wear shoes that fit well, do not remove corns or calluses yourself and don't use OTC products to remove them

What are symptomatic treatment recommendations for diabetic neuropathy?

tight glycemic control early after diagnosis

gabapentin, pregabalin, SNRI (duloxetine, venlafaxine), TCAs (amitriptyline), NAa+ channel blockers (lamotrigine, VPA, oxacarbazepine, lacosamide)

others: tramadol, topical capsaicin, carbamazepine

What are meds to avoid in diabetic neuropathy?

opioids

What are diet recommondations for gastroparesis (autonomic neuropathy)?

low-fiber, low-fat, small/frequent meals and greater liquid intake

What meds do we avoid in gastroparesis (autonomic neuropathy)?

meds that impact GI motility (opioids, TCAs, and anticholinergics)

What are prokinetic meds that can be used to help with gastroparesis?

metoclopramide (weak evidence)

What are immunization recommendations for DM?

influenza annually for all patients >6 months

hep B (2 or 3 doses): unvaccinated adults w/ DM <60 y/o, consider for adults w/ DM 60+

others: COVID, HPV, Tdap, zoster, RSV

What are pneumococcal vaccine recommendations in DM?

aged 19-64 y/o w/ DM who are unvaccinated:

1 dose of PCV15 PLUS PPSV23 one year later

1 dose PCV20

age 65+ w/ or w/o DM: same as above; repeat doses are not recommended

What is the brand name of atorvastatin?

Lipitor

What is the brand name of lisinopril?

Zestril

What is the brand name of amlodipine?

Norvasc

What is the brand name of metoprolol?

Lopressor

What is the brand name of losartan?

Cozaar

What is the brand name of gabapentin?

Neurontin

What is the brand name of HCTZ?

Microzide

What is the brand name of rosuvastatin?

Crestor

What is the brand name of simvastatin?

Zocor

What is the brand name of carvedilol?

Coreg

What is the brand name of aspirin?

Bayer

What is the brand name of clopidogrel?

Plavix

What is the brand name of pravastatin?

Pravachol

What is the brand name of atenolol?

Tenormin

What is the brand name of pregabalin?

Lyrica

What is the brand name of fenofibrate?

Tricor

What is the brand name of lovastatin?

Mevacor

What is the brand name of amitriptyline?

Elavil

What is the brand name of valsartan?

Diovan

What is the brand name of chlorthalidone?

Thalitone

What is the brand name of nortriptyline?

Pamelor

What is the brand name of benazepril?

Lotensin

What is the brand name of irbesartan?

Avapro

What is the brand name of gemfibrozil?

Lopid

What is BG monitoring for intensive insulin therapy?

prior to meals/snacks, bedtime, occasionally PP, prior to exercise, symptoms of hypoglycemia (and after treatment), prior to critical tasks

What is the BG monitoring for basal insulin therapy?

fasting sugars (1 or 2 times/day b/c there is not much you can do to adjust compared to bolus)

What is BG monitoring for oral/non-insulin therapies?

routine glucose monitoring may be of limited clinical benefit

What are factors that can affect BG readings?

oxygen, tempurature, interfering substances

How does O2 affect BG?

low O2 (high altitude, hypoxia, COPD) - falsely high reading

high O2 (on oxygen therapy) - falsely low reading

What are substances that interfere with glucose meter readings?

APAP

vitamin C

When are CGMs indicated?

adults with DM on MDI or insulin pump therapy, basal insulin

childrne with DM on MDI or insulin pump

pregnancy when used as adjunctive to BGM