3 cardinal Sx of DM
polyuria, polydipsia, unexplained weight loss
What are Dx criteria for DM?
- FBG > 7 ( > 8 hr fasting)
- Casual/Spot BG > 11.1 + Symtoms
- 2h post-prandial BG in 75g OGTT ≥ 11.1 mM → but should retest
What are the criteria for normal and impaired fasting glucose?
- Normal fasting glucose - < 6
- Impaired fasting glucose – 6.1 to 6.9
What is criteria for Impaired Glucose Tolerance?
2h OGTT - >7.8 up to 11.0 = Impaired Glucose Tolerance
What are risk factors for DM? (double check this)
- Aboriginal Population
- RF for vascular disease
- Complications of vascular dz
- Hx GDM
- Hx macrosomic infant
How often to screen for DM and in whom?
- Q3yr screening in > 40 yr
- But increase frequency if increased RF’s
What values on FBG are normal, impaired FG and DM?
FBG > 7 is DM, 6.1-7 IFG, <6 is normal
What do you do if they are Impaired Fasting Glucose?
- If IFG → do Oral Glucose Tolerance
- Also, if borderline N with 1+ RF then do OGTT to look for IGT
What is the DM Target Control? (for most diabetics)
- A1C < 7%
- FBG/preprandial 4-7mM
- 2h pp BG – 5-10mM (lower to 5-8 if ↑A1C)
What are the Fasting Blood Glucose and 2h Post-prandial goals for DM if high A1C?
- FBG is still 4-7mM
- 2h pp BG is lowered to 5-8mM
How often to do HbA1C in DM?
HbA1C q3/12 then q1yr and decrease if at targets and stable
How often to do CBGMs in DM?
- At least 3x/d CBGM if using insulin – mainly to monitor hypoglycemia and commitment
- If not on insulin – individualized, no evidence for it
How long to get to target HbA1C?
Give 6-12 months to achieve this after Dx
How to treat hypoglycaemia in DM?
- Tx with 15g glucose if mild-moderate
- Tx with 20g glucose PO, 1mg glucagon IM/SC or 20-50cc D5W over 1-3 min
- 6 lifesavers or 1 tbsp honey also works
- 1 amp D50W
Other things you need to do to properly manage diabetics?
- Aerobic exercise
- Dietician/nutritionist referral on Dx
- Screen all DM’s for depression, Anxiety, eating disorders – especially DMI (CBT works well for eating d/o)
- Recommend 5-10% of initial body weight loss to increase insulin sensitivity
Who gets pneumovax?
*Pneumovax and Influenza for all > 65 yr x 1 or DM I/II, then can repeat
What is first line drug for DM?
- Metformin (aka Glucophage) (covered) – weight neutral
- 1st line, increases sensitivity to insulin, hard on liver and kidney
What are the 2 mechanisms of action of metformin?
2 MOA’s: liver → decreases GNG, peripheral - ↑ peripheral insulin sensitivity
What are 2nd line drugs for DM?
- Insulin secretagogues – sulfonylureas and meglitimides
- Good 2nd choice
- Sulfonureas (Diabeta) (covered)
- Glicazide (Diamicron) (private) – less hypoglycemia with this one
Which drug used to be 2nd line for DM but we don't use now and why?
TZD (thio…. – Actos, Avandia) – used to be 2nd line, increased CVD risk, so don’t use
What to guidelines say about high dose metformin vs low dose of metformin + insulin secretagogues?
Guidelines don’t compare increased dose of 1 vs 2 low dose
Under what circumstances should you start with Metformin on Dx of DM?
1) Hb A1C ≥ 9% @ Dx, 2) Dx with HONK/DKA → start with metformin and 2nd drug (insulin or 2nd line Diabeta (secretagogue))
What is genuvia?
- Incretin (DPP-4 inhibitor) – genuvia - ↓ A1C by 1% absolute value
- Or SQ – Victosa – wgt loss - “ “
- 1st choice to start
- Intermediate acting (covered) – NPH or Humulin N – up to 18h
- Long acting (not covered) – Levemir or Lantus – up to 24h
Ie ↓ glucose in am ac breakfast, don’t hold basal insulin
What are diabetics risk for CVD?
- Increased risk of CAD+ - macrovascular complications, occur 10-12 yrs before non-diabetics
- But mostly if M> 45 and F > 50 or known MI/CAD, Microvascular complications, or + RF’s
What is annual screening for patients with DM?
- Urine albumin-Cr ratio (Urine ACR)
- Dx CKD+ if GFR < 60 x 2 times 3 months apart
- Or Urine ACR 2/3 abN of 3 ACR’s
What is another microvascular complication besides kidney and what is the screening for it?
- Retinopathy – optomitrist @ Dx, then q1-2 yrs
- Occur in DM I – 5 yrs post Dx ie 17yrs then 22 yrs then q1y
How do we screen annually for neuropathy
10g monofilament @ great toe – screen annually for neuropathy
How do we treat Diabetic foot pain?
- Gabapentin (Lyrica)
- Oxycodon (last resort)
What sensitive subject should you ask all DM men about?
- Erectile dysfunction – ask about in all DM men
- Follow guidelines
How do you prevent CVD in DM?
- Tx – vascular protection – lifestyle, weight loss/diet, bp, good glucose control
- Tx bp if >130/>80
- Renal protection – ACEI or ARB if proteinuria
- Antiplatelet if high risk (ASA and statin)