Goals
Per 2020 ADA guidelines, in a diabetic patient, what is the HbA1C goal with a life expectancy of > 10 years?
<7%
How often should patients with diabetes get an eye exam?
- DMT2: At diagnosis & annually
- DMT1: Within 5 years after Dx of DM.
Mention 1 of the mechanism of action of Metformin? Also, mention 1 of the parameters we check in patients on Metformin?
~MOA: Prevents gluconeogenesis/glycolysis, increases GLP-1 secretion, inhibits lipid and cholesterol synthesis; also, decrease intestinal glucose absorption
~Monitor: SCr, B12. Also, Lactate if concern for lactic acidosis.
When would you initiate insulin therapy?
~T1DM
~T2DM: Catabolic, symptomatic hyperglycemia or A1C >10% or glycemia > 300 mg/dL
Name 2 microvascular complications with diabetes
1) Retinopathy
2) Nephropathy
3) Neuropathy
Per 2020 ADA guidelines:
For elderly (76 yo) with HF, CKD stage 4 and COPD, what is the HbA1c % goal = _____
< 7.5 to 8.5, life expectancy < 10 years.
Name one exam that patients with diabetes should do daily and why (to prevent what?)
~Check feet
~Why? Diabetic Foot Infection (DFI)
Name two GLP1-RA with CV protective properties
Exenatide, Liraglutide, Semaglutide... All of them except for Lixisenatide.
Complications of insulin use:
- Hypoglycemia, weight gain, lipohyperthrophy, infection in injection site...
Name 2 macrovascular complications with diabetes
1) Cerebrovascular disease
2) Cardiovascular disease
3) Peripheral arterial disease
4) Impaired wound healing
Per 2020 ADA guidelines:
BP goal for diabetic patient = ____
<130/80 mmHg, if can be safely achieved and avoid symptomatic hypotension
How often is screening for Albuminuria recommended in patients with DMT2: ______
At least annually. If > 30 mg/g Cr or eGFR < 60 ml/min/1.73 m2, should be monitored twice annually.
Name two classes of drugs that should be avoided in diabetic patients who are obese and trying to lose weight?
1) SFU/Meglitinides
2) Insulin (unless symptomatic from hyperglycemia)
Mention type of basal insulin formulation
- Glargine: Lantus or Toujeo (~36 hrs)
- Detemir: Levemir
- Degludec: Tresiba (up to 42 hours).
Name 1 scenario in which Metabolic Surgery referral is recommended for the treatment of Diabetes.
1- BMI > 40 kg/m2
2- BMI 35-39.9, unable to achieve durable weight loss and unable to achieve improvement in comorbidities (including hyperglycemia) after 6 months of nonsurgical interventions/methods.
Diabetic patient presents with BP of 165/100 mmHG and Alb/Cr=40.
Per 2020 ADA guidelines, would you start this patient on HTN therapy? If so, give specific recommendation including drug(s) or drug classes.
ACE-I or ARB
+
CCB or diuretic
Recommended minimum time of moderate intensity physical activity per week:
At least 150 min/week of moderate exertion (walking, stain climbing). Increased as tolerated.
When should provider’s avoid prescribing SGLT-2 inhibitors for therapy?
~ Hx of urinary incontinence or frequent UTIs
~ Amputations risk (foot ulcers, PAD, osteoporosis)
~ Risk of DKA (acute illness, eating disorders, ETOH)
Mechanism of action by which Sulfonylureas increase insulin secretion?
Blockage of ATP-sensitive K channels of Beta cells in pancreas, facilitating depolarization and release of insulin.
Mention 1 condition that would give you a falsely decreased HbA1c level?
Pregnancy, Acute blood loss, Chronic Liver disease, Hemolytic anemias, Vitamin E and C.
Per 2020 ADA guidelines, what is the recommended Pre-prandial capillary plasma glucose goal: _______.
(Not pregnant, young, and otherwise healthy individuals)
80-130 mg/dL
Name 3 immunizations indicated for patients with diabetes.
1) PPSV23
2) Influenza
3) Hepatitis B
Which oral anti-diabetic drugs should be discontinued if patient has HF NYHA III-IV? And why?
1) Thiazolidinediones. Because of concern for fluid retention and worsening HF.
Calculate the TDD (total daily dose) of insulin, as well as the basal dose and bolus dose of insulin, in an insulin naive patient who weighs 100 kg:
TDD: 30 units
Basal: 15 units
Bolus: ~5 units before each meal
Name 1 contraindications of GLP-1 Receptor agonists
1- Personal or family of Medullary Thyroid Carcinoma Thyroid C-cell tumor) or MEN type 2
2- Hx of Pancreatitis