Integrated Diabetes Exam 1 (Midterm)

4 methods of diabetes diagnosis

A1c≥6.5%

FPG≥126 mg/dL

2 hour plasma glucose ≥200 mg/dL (after 75 g OGTT)

Classic symptoms of hyperglycemia and a random glucose of ≥200 mg/dL

Who should be screened for diabetes

Any adult that is overweight and has one additional risk factor:

1. First degree relative with diabetes

2. History of CVD

3. HTN (>130/80 or on meds)

4. Physical inactivity

5. High risk race/ethnicity

Overweight classification

BMI ≥25

BMI≥23 in individuals of Asian ancestry

When should testing begin for all individuals, regardless of risk factors

Age 35

Which medications increase of diabetes (and therefore people on them should be screened)

Steroids

Statins

Thiazide

HIV

2nd gen antipsychotics

When to repeat diabetes screening

If results are normal: 3 years

If results are abnormal: repeat ASAP (diagnosis requires 2 abnormal readings)

Pre Diabetes Criteria

A1C 5.7-6.4%

FPG: 100-125 mg/dL

2 hour plasma glucose in OGTT 140-199 mg/dL

Four critical time points when patients may be particularly vulnerable to psychosocial issues

At diagnosis

Annually

Transitions in care or life

During treatment changes

At disease progression/complication onset

5C intervention

Constructing a problem definition

Collaborative goal setting

Collaborative problem solving

Contracting for change

Continuing support

Questions for construction a problem

What is your greatest concern about your diabetes?

What is the hardest part about managing your diabetes? Can you give me an example?

What is causing you the most distress?

Questions for collaborative goal setting

What are your goals for changing your behavior?

How much? How often? Is that realistic?

Questions for collaborative problem solving

What could keep you from reaching your goal?

Why would that keep you from reaching your goal?

What are some steps you could take to overcome these barriers?

What are some strategies you have used in the past to deal with an issue that have been successful? Would that work now?

Questions for contracting for change

How will you know when you are successful?

How will you reward your success?

How will you track your efforts and progress?

Questions for continuing support

Everyone can occasionally get off track. What will you do when this happens?

What can you do to help prevent this from happening?

What can I do to help?

What percentage of adults with diabetes perceive financial stress

50%

What percentage of patients who are prescribed insulin report cost related insulin underuse

25%

What percentage of people report financial insecurity with healthcare and food insecurity

20%

Strategies to address social determinants of health in practice

Incorporate screening tools into practice workflow

Document those screening tools

Integration of screening as a team based effort

Connect and/or refer (follow up is essential)

What to asses for medical nutrition therapy

Current food intake

Lifestyle

Culture

Readiness to change

Goal setting for medical nutrition therapy

Prioritize with patient areas that need improvement

SMART goals

Evaluate and follow up medical nutrition therapy

SMBG to evaluate impact of food

Educate patients on carbohydrate monitoring, including basic carb counting, carb choices, and the plate method

Identify carbohydrate foods

Control portion sizes

Carb counting (grams of carbs/serving)

ICR

Insulin to carb ratio calculation

500/TDD

How to individualize insulin to carb ratio

Based on:

Pre meal glucose

Grams of carbs eaten

Dose of pre-meal (rapid/short acting) insulin

2 hour postprandial glucose level

Benefits of weight loss

Decreased insulin resistance

Prevent or delay onset of T2DM

Improve glucose, lipids, BP

Reduce risk of cardiovascular disease

Ways to lose weight

Nutrition changes

Reduce calorie intake by 500-750 per day

Increase physical activity

Medications

Physical activity recommendation

150 minutes/week of moderate to vigorous intensity aerobic physical activity spread over at least 3 days/weeks with no more than 2 consecutive days without activity

How often should patients resistance train

2-3x/week

Medications that can cause weight gain

Insulin

Sulfonyureas (glipizide, glimiperide, glyburide)

TZDs (pioglitazone)

Medications that cause weight loss

GLP1

SGLT2i

Weight neutral medication

Metformin

How to prevent hypoglycemia with physical activity

1. check blood sugars before exercise

2. if less than 90 mg/dL eat a snack

What to do if BG is regularly less than 90 mg/dL before exercise

reduce insulin dose

Impact of alcohol on blood sugars

Increased risk of delayed hypoglycemia

When does risk of delayed hypoglycemia increase with alcohol

If on insulin or secretagogues

When should alcohol be avoided (with which medication)

SGLT2i (-flozin)

Alcohol drinks for women and men

women: 1/day

men: 2/day

Dietary recommendations for treatment of hypoglycemia

15 grams of fast acting carbs every 15 minutes

Examples of 15 g of carbs

3-4 glucose tablets

4 oz juice

4 oz regular soda

1 cup skim milk

Goal FPG

80-130 mg/dL

Goal PPG

<180 mg/dL

Goal A1C

<7%

When should A1C be monitored

every 3 months if uncontrolled

every 6 months if well controlled

When do we use a less stringent (<8%) A1C goal

History of severe hypoglycemia

LImited life expectancy

Harms of treatment exceed the benefit

When are more stringent A1C goals used

When they can be achieved without hypoglycemia

Goal in range with a CGM

>70%

First line management of T2DM according to the ADA guidelines

Healthy lifestyle

Commonly- metformin (continue until not tolerated or c/i)

Management of T2DM in patients with ASCVD, HF, or CKD

treatment regimen should include agents that reduce the risk

When to consider combination therapy off the bat

If A1C>1.5-2% above target

When to consider insulin

A1C>10%

BG≥300 mg/dL

Symptoms of hyperglycemia

Ongoing catabolism

If ASCVD T2DM therapy should include

SGLT2i or GLP1

Which GLP1s have ASCVD benefit

Dulaglutide

Liraglutide

Semaglutide (SQ)

Which SGLT2i have ASCVD benefit

Canagliflozin

Empagliflozin

SGLT2i with HF benefit

Canagliflozin

Dapagliflozin

Empagliflozin

Ertugliflozin

TZDs in HF

SHOULD BE AVOIDED

Adults with T2DM, symptomatic HF, with HFpEF and obesity

GLP1

CKD and T2DM therapy

SGLT2i or GLP1

SGLT2i with CKD benefit

Canagliflozin

Dapagliflozin

Empagliflozin

GLP1 with CKD benefit

Dulaglutide

Liraglutide

Semaglutide

Meformin MOA

decreases hepatic glucose production

Glipizide (sulfonyurea) MOA

Stimulates pancreas to secrete insulin

Pioglitazone (TZDs) MOA

increases peripheral insulin sensitivity

Sitagliptan (DPP4) MOA

Inhibits DPP4 activity, increasing incretin concentrations

Exenatide (GLP) MOA

Activates GLP1 receptors

Canagliflozin (SGLT2i) MOA

Block glucose reabsorption in kidney by inhibiting SGLT2, increases urinary glucose excretion

Acarbos (AGI) MOA

slows intestinal carbohydrate digestion/absorption

Metformin starting dose

500 mg QD for seven days

Increase by 500 mg QW until 2000mg/day

When do avoid initiation of metformin

eGFR 30-45

C/I of metformin

CrCl<30

Acute or chronic metabolic acidosis

Metformin precaution

Hepatic impairment

Hypoxic states

ADE of metformin

GI: bloating, nausea, vomiting, diarrhea, lactic acidosis

Education points with metformin

Take with food

Metformin monitoring

eGFR at baseline and annually

B12 levels every 2-3 years

Secretagogues (glipize, glyburide, glimiperide) ADE

hypoglycemia

Weight gain

treatment failure

Secretagogues (glipize, glyburide, glimiperide) precautions

clearance can be reduced in renal impairment or hepatic impairtment (increased risk of hypoglycemia)

Secretagogues (glipize, glyburide, glimiperide) education points

take with breakfast or first main meal of the day

Glyburide c/i

renal impairment (bc of active metabolites)

TZDs (-glitazone) C/I

Class III/IV HF

TZDs (-glitazone) precautions

symptomatic HF

Active liver disease

ALT 3x ULN

TZDs (-glitazone) ADE

weight gain

edema

Increased risk of HF (BBW)

increased bone fracture risk

Bladder cancer risk

Potential for fluid retention

TZDs (-glitazone) education

full medication benefit may not be seen for up to 12 weeks; adherence

TZDs (-glitazone) monitoring

LFTs

GLP1 C/I

CrCl<30

Gastroparesis

Pancreatitis

Thyroid tumor

Gallbladder

GLP1 ADE

GI

ISR

Thyroid C Cell tumor

Acute pancreatitis

GLP1 education

time/frequency of administration

administration instruction

GLP1 monitoring

renal function

DPP4i (-gliptan) ADE

Intermediate efficacy

Renal dose adjustment

Joint pain

Which DPP4i does not require renal dose adjustment

linagliptan

Which DPP4i increase HF hospitalizations

saxagliptan

When do d/c DPP4i

pancreatitis suspected

Saxagliptan metabolism

CYP3A4

DPP4i education

Take once daily with or without food

DPP4i monitoring

SCr at baseline and periodically

SGLT2i (-flozin) precautions

h/o osteoporosis

SGLT2i (-flozin) ADE

DKA

Euglycemic DKI

UTI

Polyuria

Increased SCr

Increased risk of bone fracture

Risk of amputation

SGLT2i (-flozin) education

drink a lot of water

SGLT2i (-flozin) monitoring

Renal function

Regular insulin

Humulin and Novolin R

Intermediate acting insulin

Humulin and Novolin N

When should rapid acting insulin be administered

15 min before meal