DM


Diagnosis of Diabetes
• Hgb A1c ≥ 6.5%
• Fasting plasma glucose ≥ 126 mg/dL
• 2-hr plasma glucose ≥ 200 mg/dL (75g glucose)
• Random plasma glucose ≥ 200 mg/dL with classic symptoms of hyperglycemia
 
Differentiation
Type 1 Type 2
< 10% of diabetics > 90% of diabetics
Onset usually in childhood or adolescence Onset now common in adolescence
Loss of beta cells in the pancreas: insulin requiring
- Anti-islet cell Ab
Insulin resistance so high insulin levels
Weight loss is prevalent Obesity is prevalent
Sudden onset Insidious onset
Screen for complications 5 years after diagnosis Screen for complications at diagnosis
Incidence in children up 21% Incidence in children up 30%

Management Goals (ADA)
  • A1C < 7%**
    < 6.5% for new diagnosis, long life expectancy
    7.5% for children
    < 8% for older adults with diabetes and moderate comorbidities.
    < 8.5%  longstanding diabetes, advanced complications, limited life expectancy
    – Monitor every 3 months
     
  • Limit hypoglycemia
    – History of hypoglycemia is predictive of future episodes and increases morbidity and mortality*
    – Recommend range – not specific numbers
    – Avoid insulin for most outpatient adults
     
  • Blood pressure < 140/80 mmHg (< 130/80 preferred)***
     
  • LDL cholesterol (NEW Guidelines) < 100 mg/dL*
    – < 70 mg/dL with cardiovascular disease
    – Or reduction of 30-40% if can’t reach above goal
    Simvastatin should be discontinued and another statin prescribed.
       -- A high risk of myopathy and rhabdomyolysis is associated with high-dose simvastatin, and in 2012 the FDA issued a safety alert advising that the 80-mg dose of simvastatin be used only in patients who have been taking this dose for 12 months or more without evidence of muscle toxicity
     
  • DM and Weight
    • 5-10% weight loss reduces risk of Diabetes Mellitus in a pt with impaired glucose tolerance.
    • Diabetes Prevention Program Research Group found a reduction in the incidence of diabetes mellitus in persons at high risk using a lifestyle modification program with goals of at least a 7% weight loss and at least 150 minutes of physical activity per week (30 min/day, 5x a week)

Self Management

  • Self management that works
    – Motivational interviewing, collaborative problem solving, and negotiating individualized goals
    – Cognitive behavioral therapy
    – Nurse and dietitian-led training and education
     
  • Self monitoring indicated for:
    – Type 1 (3 x/d if multiple insulin injections or pump)
    – During illness
    – When oral medications are adjusted
    – During corticosteroid use
    – When postprandial hyperglycemia is a concern
    – When using oral sulfonylureas
    – Benefit in type 2 disappears by 1 year

[ DM Rx ]

Screening Guideline

DM Screening of asymptomatic pt. Risk Factors:
 - BMI > 25
 - (+) FHx
 - PCOS
 - HTN
 - HL
 - high-risk ethnicity
 - Gestational DM
 - Physical Inactivity.
(+) Risk factors Screen Now
(-) Risk Factors Screen at age 45 yr


102. According to the American Diabetes Association, screening for diabetes mellitus in the asymptomatic patient with no risk factors should begin at which age?
A) 25 years
B) 30 years
C) 35 years
D) 40 years
E) 45 years

ANSWER: E
Testing for diabetes mellitus should be considered in all asymptomatic adults who have a BMI 25 kg/m2 and have one or more additional risk factors such as physical inactivity, a first degree relative with diabetes, a high-risk ethnicity, hypertension, hyperlipidemia, or polycystic ovary syndrome.
In asymptomatic patients with no risk factors, screening should begin at age 45.


 



Target Glucose Levels:
Normal Fasting Sugar 70-100
Hypoglycemia < 60
Target pre-meal 80-120
Target in hospitalized pt 140-180
Pregnant Diabetic: - Fasting < 95
- 2hr postprandial < 120

Facts:
Lipid Lowering agent that can worsen DM
  • NIACIN
  • -Statin
Medications can cause hyperglycemia
  1. Niacin
  2. -Statin
  3. Glucocorticoids
  4. Thyroid hormone
  5. Diazoxide
  6. β-adrenergic agonists
  7. Thiazide diuretics
  8. Phenytoin
  9. Pentamidine
  10. α-interferon
Neurologic tests is most useful for predicting the future occurrence of a diabetic foot ulcer Vibratory sensation with a 128-mHz tuning fork
Microalbuminuria is the earliest indicator of renal disease.
Microalbuminuria in a type 2 diabetic is also a strong risk factor for coronary heart disease and cardiovascular death

 

 

ITE 2014 Q82. An 86-year-old female nursing-home resident has type 2 diabetes mellitus, chronic diastolic heart failure, chronic kidney disease, advanced osteoarthritis, hypertension, Alzheimer’s disease, and other comorbidities. She requires assistance with dressing, bathing, and feeding.
For this patient, the American Geriatrics Society recommends a hemoglobin A1c goal of
A) <7.0%
B) <8.0%
C) <8.5%
D) <9.0%
E) <9.5%

ANSWER: C