Diagnosis/Goals
Three ways to diagnose diabetes
A1c greater than or equal to 6.5%
Random sugar >200
Fasting sugar of 126
What are the therapeutic endpoints in the treatment of (1) DKA and (2) HHS?
(1) DKA: Closure of the anion gap
(2) HHS: Normalization of serum osmolarity
This type of ENT infection is almost exclusively seen in diabetics
Malignant Otitis Externa caused by pseudomonas
What kidney protecting medications should be used in diabetic patients with microalbuminuria when not contraindicated?
Ace inhibitors and ARBs
What class of medications reduces the risk of worsening heart failure or heart failure related hospitalizations?
SGLT2 inhibitors
What are exercise goals?
What are the five umbrella causes of DKA and HHS?
Five “I’s”: (1) Infection (2) Inflammation/Injury (3) Infarction (4) Intoxication (5) Iatrogenic
This class of medications is generally contraindicated in diabetics with CHF
TZDs (pioglitazone)
What 2 medication classes have a benefit of weight loss in addition to glucose lowering?
GLP1 receptor agonists and SGLT2 inhibitors
What are the two main side effects that limit use of sulfonylureas?
hypoglycemia and weight gain
How often should A1c be checked?
Uncontrolled: every 3 months
What are the three main elements of DKA/HHS management?
(1) Fluid resuscitation and repletion
(2) Insulin treatment
(3) Potassium correction/monitoring
This diabetic medication may contribute to neuropathy found in diabetics
Bonus: why?
Metformin
Reduces B12 absorption
What is the major risk and contraindication to using GLP1 agonists?
Risk of thyroid C-cell tumors.
contraindicated in patients with personal or family history of thyroid cancers
What other 3 disease states/concerns can diabetes medications improve?
cardiovascular disease/heart failure, chronic kidney disease, obesity
Name 3 labs that should be drawn at initial diagnosis visit
BMP, TSH, CBC, lipids, microalbumin
What is the average level of dehydration (fluid deficit) in HHS?
100 mL/kg or 7-10 L
These 2 medications have FDA approval for diabetic neuropathy
Duloxetine and pregabalin
What is the first line glucose lowering medication for most type 2 diabetic patients unless contraindicated?
What are the renal cutoffs for starting and stopping the medication?
Metformin
Dont use when eGFR < 45
Discontinue when eGFR < 30
What is the preferred way of initiating insulin and at what dose?
Start basal insulin at 10 units/day or 0.1-0.2 units/kg/day
Name 3 things (besides labs) that should be done at diagnosis
Immunizations
Diabetic Education
Set goals
Diabetic foot exam
Diabetic Testing Supplies
What is the underlying pathophysiologic process driving both DKA and HHS?
Unopposed glucagon (and other counterregulatory hormone) signaling during a metabolic stress state in the setting of insulin deficiency or inadequacy.
This class of medications should be used in patients with CKD who cannot take SGLT-2 inhibitors to reduce progression and CV risk
Minerlocorticoid receptor antagonists (finerenone)
Name the insulin secretors and insulin sensitizers
Insulin secretors: sulfonylureas, GLP1 agonists, DPP4 inhibitors
Insulin sensitizers: metformin and TZDs
At what A1c do we go right to insulin therapy?
Rank the 4 insulin options from quickest to slowest onset
A1c > or equal to 10
Rapid acting, regular insulin, NPH insulin, and long acting insulin