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Diagnosis Glucose intolerance

A1c > 5.7 - 6.4 , Fasting > 100, RBG > 140

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Diabetes - Details



38 questions
Diagnosis Glucose intolerance
A1c > 5.7 - 6.4 , Fasting > 100, RBG > 140
Metabolic syndrome
Obesity > 40 in men, > 35 in women, HTN > 130/80, HDL < 40 men, < 50 women, FBG > 110
Dx Diabetes
A1c > 6.5, FBG > 126, RBG > 200 Asymptomatic need two test,
DM Goals
BP < 130/80 , A1c < 7, LDL < 100 and < 70 with CAD, HDL > 40 men, > 50 women, TG < 150 and FBG < 120, PPBG < 160, Overnight change < 100
DM screen
Asymptomatic > 45 y.o even 3 years. Positive RF yearly: HTN, obesity> 25, gestational DM, Ethnic minority, Dyslipidemia, First degree relatives. Start meds at A1c > 7.5
DM monitoring
Yearly: microalbumin, Creatine, Lipids, A1c Q 3 mo. Each visit:BMI, BP, smoking, feet. Referral annual: Dentist, Opthomology. Vaccinate yearly for Flu, Once Tdap, Hep B, PCV 13 (preener) 1 dose > 65, followed by PPVC 23 one dose a year later. ,
Sglt2 sodium-glucose cotransporter-2
Empagliflozin(Jardiance), canagliflozin (Invokana), dapagliflozin ( Farxiga)
Proximal tubule excrete glucose
Effects of SGLT2
A1c .5-.7, Wt loss 2-3 kg, lower BP, Positive CVD outcome and with Nephropathy, No hypoglycemia
SGLT2 Contraindication
GFR< 30, Bladder cancer risk, Prior DKA
Side Effects of SGLT2
Lactic acidosis, GU infection, foot infection, bone fx, increase LDL, bladder cancer. Monitor Cr q 3 mo.
Insulin - When to start?
A1c > 9, FBG> 250, RBG> 300, Ketone in urine
Insulin replacement
0.6-1.0 U/kg as 50% basal (Glargine) and 50% prandial( Aspart/Lispro). Gen: Start 10 U Glargine at night and titrate up 2 U Q 3 days until FBG b/w 90-140. Can add Apart to largest meal at 2-3 U and titrate to PPG goal of < 180
Insulin types
Long acting : Glargine : (Lantus, Basaglar, Toujeo up to 36 hours, Degludec, Tresiba up to 42 hours. Insulin vials 1000 Units last 1 mo, Pens ( 300 U: Box of 5 pens ( 1500 U /box)
2nd generation: glyburide and glipizide - renal , 3rd generation: glimepiride- once a day with no renal clearance and 5x potent Short acting glipizide and glimepiride reduce hypoglycemia
Increase insulin sensitivity SE: wt gain, hypoglycemia
Thiazolidinediones- TZD
Pioglitazone (Actos) Rosiglitazone ( Avenida)
Inhibit hepatic gluconeogenesis
TZD Side Effects
Wt gain ( caution CHF) URI, Liver injury ( Actos) bladder cancer (Actos when used > 1 year) , MI ( Amanda)
TZD Contraindication
Class 3 and 4 CHF, pregnancy, Elevated transaminases
Dpp-4 inhibitors
Sitagliptin (Januvia), Saxagliptin ( Onglyza), Algogliptin, Linagliptin- Oral
Dpp-4 inhibitors MOA
Stimulate B cell to release insulin, Inhibits glucagon, enhance incretin decrease appetite and decrease gastric emptying.
Dpp-4 inhibitors Contranindication, Caution, SE
Concomitant use with GLP1A, Caution CHF, SE: Nausea, vomiting, pancreatitis, headache, URI, joint and muscle pain, hepatic dysfunction, inflammatory bowel
Dpp-4 inhibitors benefit
Weight neutral, OK with CKD, no hypoglycemia, OK with Insulin, metformin, TZD, SU, SLGT2.
GLP1A ( glucagon like polypeptide agonist)
Semaglutide (oral and injection), Exenatide, Dulaglutide, Liraglutide( Victoza) , lixsenatide : all injectable.
Decrease gastric emptying, suppress glucagon, proliferation of B cell, stimulate insuling release and decrease appetite.
GLP1A Contraindication
Severe kidney disease, Concomitant use with DPP4, Hx of pancreatitis, GFR < 30
Wt loss 1-3 kg, nausea, vomiting, diarrhea, antibody formation in 35%, hemorrhagic pancreatitis, impared renal function ( expecially with exenatide.
GlP1A Benefits
No hypoglycemia, A1c .5-.7, Positive CVD outcome with Lira and Sema. OK with CKD, OK with Met, Insulin, SU and TZD.
Metformin MOA
Decrease hepatic gluconeogenesis
Metformin Contraindication
Don't start if Cr > 1.4 in women and 1.5 in men or Alcoholic. Hold for Cr > 2.5, GFR < 30, Dehydreation, Azoteic, contrast study, surgery, acute CHF, sepsis. Monitor B12 level and Cr and GFR
Metformin SE
GI: Change to XL and take with food. Should subside in 2 wks. Lower dose for GFR 30-50 to no more than 1000 mg/d.
Diabetes musculoskeletal complications
Carpel tunnel, Dupuytren's, Flexortenosynovitis (trigger finger), neuropathic arthropathy (Charcot), OA, Rotator cuff tendonitis, adhesive capsulitis, calcific periartharitis, diffuse idiopathic skeletal hyperostosis ( DISH)
DM Neuropathy treatment
1st: SNRI ( duloxetine, venlafaxine), TCA ( Amitriptyline, Nortriptylene), Antileptic ( pregabalin, gabapentin), 2nd line ( capsaicin, lidocaine, TENS)
PAD in DM - Definition and screen
ABI < 0.9 at rest and exercise Screen: symptomatic, wounds or ulcer, DM > 50 years every 5 years, or < 50 with RF
PAD in DM Treatment
Risk Factor reduction: smoking cessation , antiplatelete, lipids, BP control, diet, exercise and foot care Rx: ASA ( 75-100 mg/d or Clopidrogel 75 mg, mod-high intensity statin, revascularization.
DM Foot Infection Osteo Risk
Osteo Risk: Wound > 2 cm, depth to bone, non healing ulcer > 2 wk, sausage toe, sed rate > 70, Xray: cortical erosion, periosteal reaction, mixedlucency, sclerosis, Definitive MRI Seveity: Mild: < 2 cm, limited to skin and sub Q
DM foot infection severity
Mild: < 2cm erythema /cellulitis, limited to skin, no systemic sx., Mod: Cellulitis > 2 cm, lymphatic streak, access, muscle tendon and bone involvement, Severe: Systemic toxicity