Endo Exam 3: LEWIS DM Complications

What are the four pillars of diabetes risk reduction?

What four buckets does Dr. Lewis say to address for every diabetes patient?

Glycemic management, BP management, lipid management, agents with CV and kidney benefit

Diabetes control, lipids, blood pressure, immunizations

What does the ABCDE prevention mnemonic stand for?

A1c control and antiplatelet therapy, BP control, cholesterol management, diet, exercise

What is the A1c goal for most nonpregnant adults with diabetes?

<7%, individualized

What A1c goal applies to very sick patients or those with a poor prognosis?

Less than 8%, to avoid hypoglycemia

What A1c goal applies to younger patients (30s to 50s) without complications and with a long life expectancy?

Less than 6.5%

What are the fasting and postprandial glucose goals?

Fasting 80 to 130 mg/dL, postprandial <180 mg/dL

Which drug classes have ASCVD benefit and should be considered regardless of A1c?

GLP-1 RAs and SGLT-2 inhibitors

Name the GLP-1 RAs with ASCVD benefit.

Liraglutide, dulaglutide, semaglutide, tirzepatide

What weight loss is recommended for patients who are overweight or obese?

What is the daily sodium limit, and what does it equal?

At least 7%

<2,300 mg, about 1 teaspoon of table salt

What are the daily alcohol limits?

What is the exercise goal?

Women 1 drink or less, men 2 drinks or less

At least 150 minutes per week of moderate-intensity aerobic activity, spread over at least 3 days

What fruit guidance does Dr. Lewis give?

Half an apple or half a banana at a time, berries have the least sugar and the most antioxidants

Which risk calculator should be used, and what should be calculated for every patient with diabetes?

AHA PREVENT ASCVD calculator (not heart failure option), 10-year ASCVD risk for every patient with diabetes

Who should be considered for primary prevention antiplatelet therapy?

Diabetes age 50 or older with at least one major risk factor and no increased bleeding risk

When is primary prevention antiplatelet therapy not recommended?

Diabetes age 50 or older with at least one major risk factor and no increased bleeding risk

When is primary prevention antiplatelet therapy not recommended?

Diabetes under age 50 with no other major ASCVD risk factors, also generally not recommended over age 70

What are the major ASCVD risk factors?

Family history of premature ASCVD, hypertension, dyslipidemia, smoking, CKD or albuminuria

Does CKD count as a major risk factor?

Yes for stages 1 to 3, dialysis is instead a bleeding risk factor

What are the bleeding risk factors?

Should aspirin be added to a patient already on an anticoagulant or antiplatelet?

Daily NSAIDs, SSRIs, SNRIs, anticoagulants, antiplatelets, age over 70, anemia, renal disease such as dialysis

No, dual therapy raises bleeding risk

What is the secondary prevention aspirin dose after MI or stroke?

75-162 mg daily

What is the clopidogrel dose if the patient is allergic to aspirin?

75 mg daily

What can be added to aspirin in CAD or PAD?

Low-dose rivaroxaban

What is the BP goal for patients with diabetes?

Less than 130/80 mmHg, per ADA and ACC/AHA, JNC-8 (less than 140/90) is outdated per Dr. Lewis

What defines hypertension for diagnosis?

SBP 130 or higher or DBP 80 or higher, average of 2 or more readings on 2 or more occasions

How is an initial BP of 130/80 to under 160/100 treated?

Lifestyle changes plus one agent, ACEi or ARB if albuminuria or CAD, otherwise ACEi/ARB, CCB, or diuretic

How is an initial BP of 160 systolic or 100 diastolic treated?

Start two agents, either number counts

What two-agent combination is used with albuminuria or CAD?

ACEi or ARB plus CCB or diuretic

What are the first-line BP drug classes?

ACE inhibitors, ARBs, thiazide diuretics, dihydropyridine CCBs

Are verapamil and diltiazem typically used for BP?

How often should BP be reassessed?

No

Every 3 to 6 months

What is the next step for resistant hypertension?

Spironolactone, watch for gynecomastia and hyperkalemia, check electrolytes in about 1 to 2 weeks

What are other resistant hypertension options?

Beta blockers (metoprolol preferred over propranolol), hydralazine

What labs are monitored after starting an ACEi, ARB, or diuretic?

Does amlodipine need lab monitoring?

BMP (SCr, eGFR, K+) 2 to 4 weeks after starting, then at least annually

No, peripheral edema is more common at 10 mg than 2.5 to 5 mg

What steps are needed for accurate BP measurement?

No smoking, caffeine, or exercise within 30 minutes, empty bladder, 5 minutes of rest, back supported, feet flat, legs uncrossed, arm at heart level, no talking, correct cuff size

When should a lipid panel be drawn?

At diagnosis, then every 5 years if under 40 with DM, then once a year for most, 4 to 12 weeks after therapy change (about 3 months per Dr. Lewis), 3 to 12 months on stable therapy

What is the ADA statin recommendation for ages 20 to 39 with DM?

Consider a statin only if additional ASCVD risk factors are present

What is the ADA statin recommendation for ages 40 to 75 with DM?

Nearly all need a statin, high intensity with at least one ASCVD risk factor and LDL goal under 70 mg/dL, most qualify for high intensity

What is the statin recommendation for age over 75 with DM?

Continue current statin or consider moderate intensity after weighing risks and benefits

For DM ages 40 to 75 with standard risk, what are the statin intensity and LDL goal?

Moderate intensity, LDL under 100

What are the ADA ASCVD risk factors?

LDL 100 or higher, hypertension, smoking, CKD, albuminuria, family history of premature ASCVD

For DM with multiple risk factors or diabetes-specific enhancers, what are the statin intensity and LDL goal?

High intensity, LDL <70

For PREVENT 10-year risk of 10% or higher, what are the statin intensity and LDL goal?

Maximally tolerated statin with or without ezetimibe or PCSK9 mAb, LDL <70

For young adults (30 or older) with borderline to intermediate risk, what are the statin intensity and LDL goal?

At least moderate intensity, LDL <100

What defines very high risk for secondary prevention?

Multiple major ASCVD events, or one major event plus multiple high-risk

What is the secondary prevention goal for very high risk?

High-intensity statin, at least 50% LDL reduction, LDL <55

What is the secondary prevention goal for not very high risk?

High-intensity statin, LDL <70 mg/dL

What are the high-risk conditions?

Prior MI, prior ischemic stroke, symptomatic PAD, ACS within 12 months, age over 65, prior revascularization, current smoking, diabetes, heart failure, hypertension, LDL over 100 despite maximally tolerated statin plus ezetimibe

LDL is controlled but TG is 150 to 499 mg/dL, what is added?

Icosapent ethyl (Vascepa)

LDL is above goal on a maximally tolerated statin, what is added?

Ezetimibe first, or bempedoic acid, or PCSK9 inhibitor

TG is 500 mg/dL or higher, what is used?

Icosapent ethyl or a fibrate, either lowers pancreatitis risk

If a fibrate is needed with a statin, which one?

Fenofibrate, not gemfibrozil (lower myopathy risk)

Is niacin used now?

Rarely, causes flushing, hepatotoxicity, and higher glucose, and has not improved ASCVD outcomes

What does bempedoic acid lower?

LDL only, not meaningfully TG or HDL

What are the high-intensity statin doses?

Atorvastatin 40-80 mg, rosuvastatin 20-40 mg

What are the moderate-intensity statin doses?

Atorvastatin 10-20 mg, rosuvastatin 5-10 mg, simvastatin 20-40 mg, pravastatin 40-80 mg, lovastatin 40 mg, fluvastatin XL 80 mg, pitavastatin 1-4 mg

When should retinopathy screening occur for T1DM and T2DM?

T1DM within 5 years of diagnosis, T2DM at diagnosis, Dr. Lewis’s clinic does yearly exams, ADA says annually if retinopathy is present, every 1-2 years if not

When should a patient be referred to ophthalmology?

Macular edema, severe non-proliferative retinopathy, or proliferative retinopathy

What are the intravitreal VEGF inhibitors?

Bevacizumab, ranibizumab, aflibercept

What are the uACR categories in mg/g?

Normal <30, microalbuminuria 30-299, macroalbuminuria 300 or higher

How often should nephropathy labs be checked?

eGFR annually, uACR annually or twice a year, uACR twice a year if 300 or higher or eGFR <60

What causes a false-positive uACR?

Exercise within 24 hours, infection or fever, CHF, marked hyperglycemia or HTN, menstruation

When should an SGLT-2 inhibitor be considered for kidney protection?

T2DM with eGFR 20 or higher, use for any albuminuria

When is an ACEi or ARB first-line for kidney protection?

Micro or macroalbuminuria, eGFR under 60, or hypertension, not needed for primary prevention when BP, uACR, and eGFR are all normal

If an SGLT-2 inhibitor is not tolerated, what is an alternative?

GLP-1 RA such as Ozempic, or finerenone with eGFR 25 or higher

What is the class and key feature of finerenone (Kerendia)?

Non-steroidal mineralocorticoid receptor antagonist, does not cause gynecomastia

What are the finerenone indications?

CKD in T1DM and T2DM, HFpEF with LVEF 40% or higher

What are the finerenone contraindications?

Strong CYP3A4 inhibitors, adrenal insufficiency

What should be monitored with finerenone?

K+ and eGFR

When should neuropathy screening occur?

T1DM within 5 years of diagnosis then annually, T2DM at diagnosis then annually

What is the screening tool most likely seen in clinic?

10-g monofilament

What are the first-line agents for painful peripheral neuropathy?

Gabapentinoids (gabapentin most used per Dr. Lewis) and SNRIs (duloxetine is FDA approved)

What are the daily doses for gabapentin, pregabalin, and duloxetine?

Gabapentin 900-3,600 mg, pregabalin 300-600 mg, duloxetine 40-60 mg

What are the symptomatic treatments for autonomic neuropathy?

Midodrine or droxidopa for orthostatic hypotension, metoclopramide for gastroparesis, PDE-5 inhibitors for erectile dysfunction

What are the symptoms of gastroparesis?

Early satiety, nausea, vomiting, bloating, constipation, abdominal pain, weight loss

What medications does the slide say to avoid in gastroparesis?

Opioids, anticholinergics, TCAs, GLP-1 RAs, pramlintide

Are GLP-1 RAs absolutely contraindicated in gastroparesis?

No per Dr. Lewis, stop if nausea, bloating, vomiting, or indigestion worsens, the exam may follow the slide

What are the diabetic foot care counseling points?

Never walk barefoot, inspect feet daily, moisturize but not between toes, wash in warm water daily and dry thoroughly, wear clean soft socks that fit, check shoes daily, annual foot exam

Who needs the influenza vaccine, and when?

All people with diabetes, annually, ideally September or October

Who needs pneumococcal vaccination?

All adults 19 or older with DM, PCV20 or PCV21 per Dr. Lewis, timing depends on history

What is the Tdap schedule?

What is the hepatitis B schedule for ages 19 to 59?

Every 10 years, extra dose in pregnancy

Heplisav-B 2 doses at least 4 weeks apart, Engerix-B or Twinrix 3 doses at 0, 1, and 6 months, accelerated Twinrix at 0, 7, 21 to 30 days with booster at 12 months

Who needs Shingrix, and how many doses?

What is the HPV schedule?

Adults 50 or older, or 18 to 49 if immunocompromised, 2 doses 2 to 6 months apart, also after a shingles episode

Ages 9 to 26, 3 doses at 0, 1 to 2, and 6 months, ages 27 to 45 discuss with provider

Who needs the RSV vaccine?

What is the COVID-19 vaccine recommendation?

Adults 75 or older, and ages 50 to 74 at increased risk (diabetes counts), one dose for now

Ages 6 months and older, recommendations change frequently

How often should A1c be checked?

How often should BP be checked?

Every 3 months if uncontrolled, every 6 months if at goal

At every visit, cross-referenced with home readings

How often should the lipid panel be checked?

How often should kidney and liver function, electrolytes, and CBC be checked?

How often should uACR be checked?

Once a year, unless not at goal or therapy is changing (then 4 to 12 weeks after the change)

At least annually

Once or twice a year

What other periodic lab is checked with metformin?

How often should eye and foot exams occur?

B12

Once a year

What is Dr. Lewis’s lab-batching advice?

Recheck labs in one batch around 3 months, not at 4 weeks and again at 3 months

58M, T2DM, HTN, dyslipidemia, ischemic stroke 2023, A1c 7.8%, LDL 88. Best next medication?

Ozempic (GLP-1 RA with CV benefit), Trulicity, Mounjaro, Farxiga, Jardiance, or Invokana also reasonable per Dr. Lewis, Actos lacks CV benefit, Januvia is weak for A1c

68F, T2DM, HTN, dyslipidemia, CKD stage 2, smoker, no documented ASCVD. Is aspirin appropriate?

Yes, aspirin 81 mg daily for primary prevention after weighing bleeding risk

58F, BP 142/81. What is the BP goal and why?

Less than 130/80 per ADA, JNC-8 target of less than 140/90 is outdated

62M, BP 168/94 and 160/92. Best regimen?

Olmesartan (ARB) plus amlodipine (CCB), a systolic over 160 qualifies for two agents, avoid lisinopril with telmisartan (dual RAAS blockade)

67F, LDL 140 on rosuvastatin 40 mg, TG 201. What is added?

Ezetimibe (Zetia), do not switch to Lipitor (both high intensity), do not add niacin, omega-3 is for TG when LDL is controlled

52M, T2DM, HTN, CKD, uACR 88 (up from 33), eGFR 77, A1c 8.4%, BP 125/76. Best agents?

Farxiga for kidney and glucose, losartan (ARB) first-line for albuminuria, Victoza for A1c above goal, glipizide XL 20 mg twice daily is wrong because XL is once daily

Which foot care counseling is correct?

Wear clean soft socks and replace daily, not barefoot walking, not weekly inspection, not lotion between toes

What does 2,300 mg sodium look like in practice?

About 1 teaspoon of table salt, avoid added salt, processed and fast food, canned or frozen foods with sauces, rinse canned vegetables

What should be asked if TG is over 500 mg/dL?

Diabetes control and alcohol use, if neither applies check A1c for undiagnosed diabetes

What should be counseled for SGLT-2 inhibitors?

Genital and urinary tract infections, dehydration, stop 3 to 4 days before surgery (euglycemic DKA risk), possible higher hematocrit

What is the most common GLP-1 RA problem, and what helps?

How should oral semaglutide be taken with levothyroxine or a bisphosphonate?

GI upset, stay hydrated, eat small meals often, avoid greasy foods

Oral semaglutide on an empty stomach, take the most important drug first, wait 30 minutes, then take the other drug