diabetes management dr hurd

this is for pdat gi this is the white girl that gave the lecture

what are the 2 reasons someone would have diabetes?

either because the body doesnt have enough insulin or sometimes it cant use its insulin effectively

what is the process of insulin in the body after eating in a normal healthy person?

glucose rises after you eat, pancreas release beta cells with insulin, insulin travels to muscles, fat, and liver, insulin binds to receptors allowing glucose to enter the cell and we use it for energy. in a normal person glucose levels are regulated 

what are important organs that are regulators in diabetes?

liver (glycogen and glucose) and pancreas (alpha cells-glucagon) and beta cells (insulin)

what is type 1 diabetes?

autoimmune destruction of the pancreatic beta cells and insulin deficiency

what is type 2 diabetes?

insulin resistance and target cell impairment. cells will not respond to insulin

why do people have insulin deficiency later on in type 2 diabetes?

beta cell dysfunction because the pancreas cant keep up with glucose production so insulin cant be produced 

what is gestational diabetes

no history of diabetes prior to being pregnant

what is the pathophysiology of antibodies in type 1 diabetes?

antibodies attack and destroy the beta cells in the pancreas

can type 1 diabetes occur at any age?

yes and misdiagnosis can occur in up to 40% of adults

in type 1 diabetes does everyone require insulin?

yes

why can people with type 1 diabetes maintain sufficent insulin secretion?

that is because it is a slow progression

at the time of diagnosis what is a common symptom for children with type 1 diabetes?

diabetic ketoacidosis

why does diabetic ketoacidosis happen in type 1 diabetes?

this is because beta cells are destroyed which decreases insulin. insulin brings glucose into fat cells liver cells and muscle cells and gives them energy. so without insulin your body needs energy so it uses ketones for energy leading to ketoacidosis

what is the pathophysiology for type 1 diabetes?

most cases are due to genetic predisposistion then later on in life there is a immunologic trigger that initiates an immune response, this leads to a progressive impairment of insulin release due to beta cell destruction which leads to diabetes

what test are used to screen for type 1 diabetes in presymptomatic individuals?

antibody test such as glutamic acid decarboxylase (GAD), islet antigen 2, and zin transporter 8

do people with type 1 diabetes always have impaired insulin their whole life?

no they actually have normal insulin until the immunologic trigger occurs

what is a new pharmacological intervention for type 1 diabetes? what does it do? 

teplizumab. it prevents the progression of stage 1 or stage 2 type 1 diabetes to stage 3 

how often is teplizumab infused?

once daily for 14 days via iv

what are the 2 things that drives type 2 diabetes?

defective insulin secretion and insulin resistance

how does defective insulin secretion occur in type 2 diabetes?

the outburst of insulin right after eating is not as high as it would usually be in a normal person leading to high postgrandial glucose

how does someone with type 2 diabetes have high postgrandial glucose?

after eating usually food gets made into glucose and insulin brings it into cells, however since insulin is low in type 2 the glucose sits there

what is the earliest abnormality in type 2 diabetes?

insulin resistance

what percent of beta cell function is lost per year in type 2 diabetes?

5 to 7%

why do patients need multiple medications targeting different things in type 2 diabetes?

it is multifactorial, remember the egregious eleven

what are the microvascular complications of type 2 diabetes?

leading cause of blindness (which is retinopathy), esrd (enstage renal disease) which is nephropathy, and amputations which is neuropathy

how does type 2 diabetes lead to blindness?

high blood sugar can damage your eye blood vessels

how does type 2 diabetes cause esrd (enstage renal disease)?

high blood sugar causes the kidneys to overwork

how does type 2 diabetes lead to amputations?

high blood sugar can make your blood vessels shrink which makes not as much blood flow enter your feet. this can make foot wounds heal slowly which can lead to complications

what is a macrovascular complication in both type 1 and 2 diabetes? but which type of diabetes is it most common with?

stroke, peripheral vascular disease, and cardiovascular events. they are most common cause of death in type 2 diabetes

what are the different body habits for type 1 vs type 2 diabetes?

in type 1 people are usually more lean or normal weight but in type 2 people are usually overweight or obese

in terms of progression what is the difference between type 1 and 2?

type 1 is abrupt progression over a few days while type 2 is gradual progression over a few years

what is the difference between type 1 and type 2 in terms of symptoms?

type 1 has polyphagia, polydispia, weight loss and fatigue,. type 2 has mild or absent symptoms

who are patients that should be screened for diabetes?

patients that arent asian with a bmi over 25 or asian patients with a bmi over 23 with one additional risk factor and patients over 35 years should be tested yearly

what are risk factors for diabetes?

first degree relative with diabetes, high risk race/ethinicity, history of cardiovascular disease, low good cholesterol, individuals with polycystic ovary syndrome, and anything associated with insulin resistance

how often should an adult that is 35 years that has normal results be screened for diabetes?

if results are normal test every 3 years

how often should adults that are pre diabetic be tested?

yearly

how often should adults that have gestational diabetes be tested?

every 1-3 years

how often should people prescribed secind generation antipsychotic medications be screened?

they should have a baseline test and then repeat 12-16 weeks after medication initiation

when should a child be screened for diabetes?

after the onset of puberty and are overweight (85% isle or higher) or obese and have one additional risk factor

what is a test that we can use to diagnose diabetes and what does it measure?

we can use a hemoglobin a1c test. this measures the amount of glucose bound to hemoglobin in the blood

what duration does the a1c test give?

it gives an estimate of blood sugar levels over the past 2-3 months

why is an a1c test liked in the clinic?

patients do not have to fast for this test therefore its convenient in clinic

why are continuous glucose monitors (cgm) recommended for patients?

they give real time readings

should we rely on a1c alone to tell if someone has hyperlgycemia?

no you can still have goal a1c and have hyperglycemia

an increase in 1% of a1c means what in terms of blood glucose?

an increase in 1% of a1c means a 30 mg increase in blood glucose

if a1c is high do we assume blood glucose is high or low?

we assume blood glucose is high because the higher the a1c the higher the blood glucose

when someones a1c is at the goal then what is elevation in blood glucose driven by? why?

elevations are driven by postprandial glucose (glucose after eating). this is because when a1c is at goal the average blood glucose is good but meals are still causing spikes

so when someone has goal a1c and still has hyperglycemia, what type of sugar is it based on? why?

it is based on fasting sugar because that is controlled by postprandial sugar which is the sugar right after eating

how often should a1c be monitored if someone is not at the goal? what about at goal?

every 3 months if not at the goal. if at the goal every 6 months

what is the a1c level that deems someone having type 2 diabetes?

greater than or equal to 6.5

what is the a1c level for someone to be pre diabetic?

a1c 5.7-6.4

what are the ada guidelines in terms of diagnosing someone with diabetes?

you must do a 2nd test from the same blood sample either the same day or on a different day unless blood glucose is greater than or equal to 200

what defines fasting?

no caloric intake for at least 8 hours

what is a second test we can use to diagnose?

2 hour pg test which is when patient fast for 8 hours then have a fasting glucose drawn then take 75 g of glucose

what is something that must be done before doing oral gluocose tolerance testing?

adequate carbohydrate intake (at least 150 g/day) should be assured for 3 days prior to the test

once someone has diabetes what is their goal postgrandial glucose level (PPG)? (glucose after eating)

less than 180

to be diagnosed with diabetes what does your fasting glucose (in g) have to be?

greater than or equal to 126 

what is the goal fasting glucose (FPG) grams after being diagnosed with diabetes?

80-130 

in diabetes are treatment blood glucose numbers lower or hgiher than diagnostic?

lower

when choosing an a1c goal how should it be chosen?

it should be individualized 

in pregnant individuals what a1c percent is typically the goal?

6% and below

what is typically the goal a1c percent in non pregnant individuals?

less than 7%

what is fpg in test?

fasting glucose

based off the landmark trials what was found?

intensive treatment of glucose control vs normal is a lot more beneficial and it reduced cardiovascular events

what are the 2 populations that a1c levels in terms of treatment do not have to be as strict?

pediatric and elderly

when setting treatment a1c goals for the elderly how should you approach it?

be very conservative weigh long term benefit and the risk of hypoglycemia

in pregnant patients should you be strict or not in a1c goal setting?

be the most strict make sure the a1c is less than 6%

what should everyone w diabetes be also put on? why?

they should all be put on a moderate intensity statin to reduce cardiovascular events

what test should be given for gestational diabetes and when?

Glucose tolerance test 24-28 weeks of gestation

in UKPDS 33 landmark trial what were the findings in regards to intensive therapy and type 2 diabetes?

it showd that intensive therapy in type 2 diabetes reduced macrovascular complications but not microvascular complications

in UKPDS 34 landmark trial what does the results state in terms of type 2 diabetes?

it found that metformin prevents microvascular and macrovascular complications and is good for overweight patients

who should have more strict a1c goals outside of pregnant patients?

Young, new diagnosis, no history of severe or frequent hypoglycemia,

w/o serious comorbid conditions (heart disease, stroke, etc)