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Flashcards

Diabetes

Dilini Siriwardena English 47 cards

What is the screening and diagnosis algorithm for fasting blood glucose?

Cards in this deck (47)

  1. 1What are the goals for optimum management of diabetes.1) Diet - according to Australian Dietary guidelines. If high risk CVD advise individual review with dietician
    2) BMI - therapeutic goal is 5-10% weight loss for people who are overweight or obese. Those with BMI >35 and comorbidities or BMI ≥40 aim for greater weight loss
    3) Physical Activity - at least 30 minutes of moderate physical activity on most days (total 150 minutes/week)
    4) Cigarettes - 0
    5) Alcohol Advise <2 standart drinks per day for men and women
    6) BGL - advise 6-8mmol/L fasting and 8-10 mmol/L postprandial. self monitoring of BGL for people on insulin, people on suphyureas, when unwell with illness due to risk of hyperglycaemia, in pregnancy, patients with haemoglobinopathies. Routine self monitoring of BGL in low risk patients on orals (with exception of sulphonyureas) is not recommended
    7) HBA1C - Generally <53mmol/mmol or <7%
    8)Cholesterol - initiation of pharmacology is dependent on CVD Risk
    9) BP - <130/80mmHg
    10) Urine albumin excretion - women <3.5mg/mmol, men <2.5mg/mmol, Overnight collect <20mcg/min
    11) Vaccination - inflluenza, pneumococcal and DTP
  2. 2What are the 4 clinical classes of diabetes?1) Type 1 Diabetes - results from the b cell destruction due to an autoimmune process usually leading to insulin deficiency
    2) Type 2 Diabetes - Results from progressive insulin secretory defect on the background of insulin resistance
    3) Gestational Diabetes - glucose intolerance with onset or first recognized during pregnancy
    4) Other - genetic defects in b cell function, genetic defects in insulin action, diseases of the exocrine pancreas (eg. CF), drug induced or after organ transplantation
  3. 3When and how often should people be screened for risk of T2DM and how is it done?People should be screened for risk of diabetes every 3 years from 40 years of age using AUSDRISK?
    Aboriginal and Torres Straight Islanders should be screened for 18 years of age
  4. 4Who are the people who are considered to be high risk of T2DM?1) AUSDRISK greater or equal to 12
    2) People at any age with impaired glucose tolerance or impaired fasting glucose
    3) All patients with a history of a cardiovascular event (eg. AMI, angina, PVD or stroke)
    4) People aged ≥35 originating from the Pacific Islands, Indian subcontinent or China
    5) People aged ≥40 with BMI ≥30kg/m2 or Hypertension
    6) Women with a history of Gestational Diabetes
    7) Women with PCOS
    8) Patients taking anti-psychotic medication
  5. 5What is the appropriate screening method for T2DM in high risk patients? What is the appropriate method for T2DM in low risk patients?High risk patients screen with fasting blood glucose of HBA1C every 3 years
    Low risk patients screen with AUSDRISK every 3 years
  6. 6What are the clinical symptoms suggestive of diabetes?Lethargy, polyuria or polydipsia
    Frequent fungal or bacterial infections
    Blurred vision
    Loss of sensation (ie touch, vibration, cold)
    Poor wound healing
    Weight Loss
  7. 7What are the clinical signs of insulin resistance?1) Acanthosis Nigricans (hyperpigmentation and velvety change in texture - often at neck and axillae)
    2) Skin Tags
    3) Central Obesity
    4) Hirsuitism
  8. 8What are the diagnostic criteria for T2DM?SYMPTOMATIC
    - a single fasting blood glucose ≥7 or a random blood glucose ≥11.1
    ASYMPTOMATIC
    - FBG ≥7 or RBG ≥11.1 confirmed by a second abnormal FBG on a separate date
    - OGTT - fasting and 2 hours post the 75g glucose load is taken. Diabetes is diagnosed as FBG ≥7.0 or 2 hours blood glucose ≥11.1
    - HBA1C ≥48mmol/mol or 6.5% on 2 separate occasions
  9. 9What is the screening and diagnosis algorithm for fasting blood glucose?What is the screening and diagnosis algorithm for fasting blood glucose?
  10. 10What is the screening and diagnosis algorithm for OGTT?What is the screening and diagnosis algorithm for OGTT?
  11. 11What are the instances where HBA1C lacks accuracy?1) Acute onset glycaemic states
    2) Haemoglobinopathies or haemolysis
    3) Advanced CKD
    4) Iron Deficiency (artificially elevated)
  12. 12When should you consider Type 1 diabetes instead of Type 2 and what are the tests that can help confirm this?Type 1
    - Ketosis/Ketonuria
    - Weight Loss or BMI <25kg/m2
    - <50 years of age
    - Personal or FHx of autoimmune disease
    - Rapid Onset of Symptoms
    Tests
    - GAD (glutamic aciddecaboxylase)
    - IA2 (Insulinoma Antigen 2)
    - C-peptide level on non fasting sample
  13. 13What is Latent Autoimmune Diabetes of Adults (LADA) and what are the features?LADA is diabetes with b-islet cell antibodies more commonly occuring in adulthood
    - more rapid course of b-cell destruction,
    - poor response to sulphonurea
    - more rapid progression to insulin requiring
  14. 14What is Monogenic Diabetes and what are the features?MODY
    - transcription factor gene mutation (except type II)
    - Onset before 25 years of age
    - Non ketotic Diabetes often with stable lower level hyperglycaemia
    - Autosomal Dominant inheritance
    - Primary defect in the function of the pancreatic B cells
  15. 15What are the weight recommendations for those with T2DM?1)Adults with impaired fasting glucose, impaired glucose tolerance
    or diabetes can be strongly advised that the health benefits of
    5–10% weight loss
    2) For adults with body mass index (BMI) >40 kg/m2 or BMI>35 kg/m2
    and comorbidities that may improve with weight loss, bariatric surgery may be considered,
  16. 16What are the things that should be explored in the history of T2DM?- Symptoms of hyperglycaemia - polyuria, polydipisia, weight loss, nocturia
    - Complications of Diabetes - Cardiovascular symptoms, Retinopathy, Nephropathy, Peripheral Neuropathy, Sexual Function, Postural Hypotension, Recurrent Infections, Dental hygiene
    - Risk Factors - Family History, Cultural Group, Overweight, Hypertension, PCOS, pancreatic disease
    - Obstetric History - macrosomic babies, gestational diabetes
    - Medication that may cause hyperglycaemia
    - Hx of haemochromatosis
    - Personal or FHx of other autoimmune diseases (eg. thyroid)
    - Other co-morbidities - Smoking, hypertension, hyperlipidaemia, depression
    - Social History
    - Immunisation Status
  17. 17What are the recommended immunisations of a person with T2DM?- Influenza - once a year
    - Pneumococcal - Non indigenous (<65 years then single dose and revaccinate at 65 years of age or after 10 years whichever is later) or (>65 - single dose and the re-vaccinate after 5 years). Indigenous (<50 years then single dose and revaccinate at 50 years of age or after 10 years whichever is later, >50 years - single dosea nd then revaccinate after 5 years)
    - Tetanyus - booster at 50 years of age (unless booster has been given within 10 years)
  18. 18What are the microalbuminuria cut offs for diabetes?ACR ≥ 2.5mg/mmol (men) or ≥3,5mg/mmol (women) or albumin concentration ≥ 20mg/L
  19. 19What are the things to review at the annual review in a person with T2DM?HISTORY
    - Review issues specific to diabetes - hyperglycaemia, hypoglycaemia and diabetes complications
    - Preventative health issues - smoking, nutrition, alcohol intake, physical activity
    - Adequacy or problems with team care arrangements
    - immunisations
    - psychological status
    EXAMINATION
    - visual acuity, retinal screening
    - cardiovascular system - postural BP, peripheral vascular system
    - weight, height
    - feet examination - without shoes
    INVESTIGATIONS
    - lipid parameters - if low CVD risk can be done every 3 years otherwise every year
    - urine microalbumin annually
  20. 20When is self monitoring recommeded in diabetes?people on insulin, people on suphyureas, when unwell with illness due to risk of hyperglycaemia, in pregnancy, patients with haemoglobinopathies (as HBA1C estimations are unreliable)
  21. 21What are the causes of an abnormally low HBA1C? What are the causes of an abnormally high HBA1C?Abnormally low HBA1C
    - Haemolytic anaemias (spherocytosis, elliptocytosis, haemoglobinopathies)
    - Recovery from acute blood loss
    - chronic blood loss
    - Chronic Renal Failure
    Abnormally high HBA1C
    - Fe deficiency anaemia
    - Splenectomy
    - Alcoholism
    - Steroid Therapy
  22. 22What is the general HBA1c target in a patient with T2DM?HBA1C ≤ 53mmol/mol (≤7%)
  23. 23What the characteristics that would indicate a more stringent HBA1C is appropriate?- Low risk of hypoglycaemia
    - newly diagnosed
    - long life expectancy
    - absent/few comorbidities
    - absent/few established vascular complications
  24. 24What is the medication algorithm for T2DM?What is the medication algorithm for T2DM?
  25. 25What are the clinical considerations of Metformin?- Neutral in patients with established or high risk of CVD
    - lower rates of hypoglycaemia when compared to sulphonyureas
    - causes diarrhoea (GI upset)
    - neutral on weight
    - Renal dysfunction - reduce dose at eGFR 30-60, contraindicated in eGFR <30
  26. 26What are the clinical considerations of Sulphylureas?- increased risk in patients with established of high risk CVD when compared to metformin monotherapy but neutral when used in combination
    - Higher risk of hypoglycaemia (gliclazide better than glimepride)
    - Neutral on GI symptoms
    - Gliclazide neutral on weight, modest gain with other suphonyureas
    - Renal Dysfunction - hypoglycaemia risk increases
  27. 27What are the clinical considerations of DDP4 inhibitors?- Neutral in patients with established or high risk CVD
    - Lower rates of hypoglycaemia when compared with sulphyureas
    - Neutral on GI symptoms
    - Less weight gain than sulphyureas
    - Renal Dysfunction - safe with dose reduction
    - Contraindicated to be used with a GLP-1
  28. 28What are the clinical considerations of Arcobose?- Neutral with hypoglycamiea
    - increased rates of Gi upset - bloating and flatulence
    - neutral on weight
    - renal dysnfunction - contraindicated in severe renal impairment
  29. 29What are the clinical considerations of Thiazolidinediones?- Contraindicated in symptomatic heart failure
    - lower rates of hypoglycaemia when compared to sulphonyureas
    - Neutral with GI symptoms
    - Modest weight gain
    - Renal dysfunction - neutral
    - Increased atypical fractures risk
  30. 30What are the clinical considerations with SGLT2 inhibitors?- selective benefit in those with established or high risk CVD (empagliflocin)
    - lower rates of hypoglycaemia compared to sulphonyureas
    - neutral on GI symptoms
    - modest weight loss
    - renal dysfunction - efficacy decreases therefore contraindicated in moderate renal impariement
    - Modest BP lowering
    - Increased UTIs
    - Rare euglycaemic ketoacidosis
  31. 31What are the clinical considerations of GLP1 agonists?- Selective benefit in those with established or high risk CVD
    - lower rates of hypoglcycaemic compared to sulphonyrea
    - known GI upset - nausea, vomiting and diarrhoea
    - causes weight loss
    - renal dysfunction - contraindicated in eGFR <30
    - Contraindicated in combination with DPP4-I
  32. 32What are the clinical considerations of Insulin?- neutral in those with established or high risk CVD
    - neutral with GI upset
    - modest weight gain
    - renal dysfunction - hypoglycaemia risk increases
    - does require to be titrated to glycaeamic goals
  33. 33What are the high risk categories of CVD?1) Risk calculator (Franmingham)
    2) Diabetes and >60 years of age
    3) Diabetes and microalbuminuris
    4) Moderate or severe CKD (persistent proteinuria of eGFR <45)
    5) Previous diagnosis of familial hypercholesterolemia
    6) SBP ≥180mmHg or diastolic BP ≥110mmHg
    7) Total Cholesterol >7.5mmol/L
  34. 34What are the general BP targets?<140/90mmHg in the general population and those with CKD
    <130/80 in those with diabetes and those with microalbumineia
  35. 35What are the general pharmacological interventions for BP in patient's with diabetes?1) ACE-I or ARB
    2) if monotherapy does not sufficiently reduce BP than add one of the following - Calcium channel blocker or low dose thiazide
  36. 36What are the recommendations for anti-thrombotic therapy in patients with diabetes?1) All patients with T2DM and history of stroke/TIA should receive wither low dose aspirin, clopidogrel or combination aspirin and extended release dipyridamole
    2) All patients with T2DM and history of CAD but no acute event in the past 12 months should receive either low dose aspirin or clopidogrel if intolerant to aspirin
    3) All patients with T2DM and recent Coronary syndrome of stent in last 12 months should receive either combination of aspirin/clopidogrel or aspirin/prasugrel or aspirin/ticagrelor
  37. 37What are the 3 common types of diabetic retinopathy and what are the features of each?1) Non-proliferative - retinal haemorrhages and exudates
    2) Proliferative - new blood vessel growth (neovascularisation)
    3) Macular Oedema - exudes impact the macula
  38. 38What are the risk factors for the development and progression of diabetic retinopathy?Existing diabetic retinopathy
    Poor glycaemic control
    Raised BP
    Duration of Diabetes >10 years
    Microalbuminuria
    Dyslipidemia
    Anaemia
    Pregnancy
  39. 39What are the causes of sudden loss of vision?1) Central retinal artery occlusion
    2) Retinal detachment
    3) Vitreous Haemorrhage
  40. 40What are the features of autonomic neuropathy?Orthostatic Hypotension >20mmHg
    Gastroparesis - impaired gastric emptying
    Erectile Dysfunction
    Loss of Cardiac Pain - 'silent' ischaemia
    Hypoglycaemic unawareness
  41. 41What are the stages of CKD?STAGE 1 - eGFR >90
    STAGE 2 - eGFR 60-89
    STAGE 3a - eGFR 45-59
    STAGE 3b - eGFR 30-44
    STAGE 4 - eGFR 15-29
    STAGE 5 - eGFR <15 or on dialysis
  42. 42What are the indications for referral to renal specialist in CKD?- eGFR <30 (Stage 4 and 5)
    - Persistent significant albuminia (ACR ≥30)
    - Sustaned decreased in eGFR>25%
    - CKD with hypertension that is hard to get to target despite at least 3 anti-hypertensive agents
  43. 43What are the recommendations for women considering pregnant with pre-existing diabetes?1) Pre-pregnanct glycaemic control should be maintained as close to the non-diabetic range as possible
    2) All women should be prescribed high dose pre-pregnancy folate supplementation until 12 weeks gestation
    3) All women with pre-gestational diabetes should be encouraged to achieve excellent glycaemic control
    4) Post-prandial glucose monitoring should be carried out
    5) MDT involvement - specialist endocrine and obstetric referrals best practice
    6) advised examination of retina prior to conception and during each trimester
  44. 44What are the medications that need to be discontinued in pregnancy?Metformin - Category C
    ACE-I and ARBS - Category D
    CCB - Category C
    Beta Blockers - Category C (except labetalol and oxprenolol)
    Thiazides and Loop Diuretics - Category C
    Statins
  45. 45How is gestational diabetes screened?- All pregnant women should be screened between 26-28 weeks with non fasting glucose challenge
    - women at high risk should be screened at the first opportunity early in pregnant and then repeat if negative at 24-28 weeks
    - women whose levels are ≥7.8mmol/L should have a formal 75g OGTT
    - The diagnosis of GDM is made on the basis of a 75g OGTT
  46. 46What is the follow up of patients who have had gestational diabetes?- 75g OGTT 6-12 weeks post-partum
    - Thereafter a fasting blood glucose or HBA1c test every 3 years
  47. 47What are the general considerations in the sick day plan for a T2DM?1) When to commence action plan - when feeling unwell, Blood glucose >15mmol/L on 2 readings
    2) Monitoring - 2-4 hourly monitoring or more frequent if blood sugar low
    3) Medications - should be continued but if vomiting orals may not stay in system and metformin and GLP-1 can increase vomiting. Also hypoglycaemia may occur if meals are not able to be maintained
    4) Food and Water intake - should try and maintain their normal meal plans, fluid intake should be increased to prevent dehydration
    - advise about easy to digest foods such as soups
    5) Seek assistance

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Flashcards on Diabetes, created by Dilini Siriwardena on 15/02/2019.
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