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When to treat HTN if no risk factors (or target organ damage)
≥160/100 --> to a target of < 140/90
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When to treat isolated HTN (ISH)?
SBP > 160 --> to a tagert of < 140
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When to treat HTN in mod-high risk patient?
≥ 140/90 with a target of < 140/90
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When to treat home bp measure in mod-high risk patient?
≥ 135/85 with a target of < 135/85
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When to treat bp in renal disease?
≥ 130/80 to a target of <130/80
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When to treat bp in DMII?
≥ 130/90 but ACCORD-BP study showed SBP<120 had no benefit over SBP < 140
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What is the risk of CVD in a high risk patient?
≥ 20% risk of heart and stroke in 10 yrs
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Risk of CVD in a mod CVD risk patient?
10-19% risk of heart and stroke event in 10 yrs
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Risk of CVD in a low CVD risk patient?
< 10% risk over 10 yrs
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Target LDL level in high CVD risk patient?
LDL < 2 or decrease LDL ≥ 50% (med and lifestyle changes at same time)
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High patients includes all people with which conditions?
ALL ppl with CAD, CVD, PAD. Most DM (older & 2+ risk factors) and Chronic renal disease (CrCl< 30ml/min)
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When to treat LDL in moderate risk CVD patients?
Treat if > 3.5 or if M>50, F>60, then check CRP.
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If LDL < 3.5 in moderate risk CVD patient?
If M>50yrs, F>60yrs, do hsCRP 2x, 2 weeks apart. If >2mg/l then treat (Jupiter trial)
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Treatment goal for LDL in moderate CVD risk patients?
Same as high risk - LDL<2 or decrease LDL ≥ 50%
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When to treat LDL in low risk patients?
Treat if LDL ≥ 5. Target of ≥50% reduction in LDL
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Other lipid profile targets for high risk?
LDL<2 or drop 50%, ApoB < 0.8, TC/HDL < 4
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When to treat moderate CVD risk Pt for ApoB and TC/HDL ratio
Treat if LDL > 3.5 or if old with high CRP, ApoB > 0.8, TC/HDL >5
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When to treat low CVD risk patients for lipid profile?
Treat if LDL≥5 or TC/HDL >6 - can do lifestyle only for 3-6 months 1st
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*In low/mod risk pop'n, goal is 50% reduction in LDL but landmark trials showed decreased MI, CVA, death with only 18-35% using Simvastatin 40mg, Atorvastatin 10, or Pravastatin 40.
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A1C, FPG and PPBG goals for most ppl with DM
A1C q3-6mon ≤ 7%, FPG 4-7mM, PPBG 2h 5-10 (5-8 if A1C too high)
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Normal range for A1C, FBG, 2h PPBG
A1C ≤6, FPG 4-6, PPBG 5-8 - try for normal range if can do without hypoglycemia
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How often to calibrate glucometer in DM?
q1yr
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What are CV events for CVD risk?
MI, new angina, ischemic stroke, TIA, PVD, CHF & CV death
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What are the CV Risk Factors (based on CDN, JNC7 studies)
BMI>25, Waist M>102cm, F>88cm, Low HDL≤1, FHx premature heart dz (M<55, F<65), age (M>55,F>65), microalbuminuria
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3 cardinal Sx of DM
polyuria, polydipsia, unexplained weight loss
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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
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What are the criteria for normal and impaired fasting glucose?
- Normal fasting glucose - < 6
- Impaired fasting glucose – 6.1 to 6.9
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What is criteria for Impaired Glucose Tolerance?
2h OGTT - >7.8 up to 11.0 = Impaired Glucose Tolerance
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What are risk factors for DM? (double check this)
- Aboriginal Population
- RF for vascular disease
- Complications of vascular dz
- Hx GDM
- Hx macrosomic infant
- HTN,
- Dyslipidemia
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How often to screen for DM and in whom?
- Q3yr screening in > 40 yr
- But increase frequency if increased RF’s
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What values on FBG are normal, impaired FG and DM?
FBG > 7 is DM, 6.1-7 IFG, <6 is normal
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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
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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)
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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
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How often to do HbA1C in DM?
HbA1C q3/12 then q1yr and decrease if at targets and stable
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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
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How long to get to target HbA1C?
Give 6-12 months to achieve this after Dx
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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
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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
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Who gets pneumovax?
*Pneumovax and Influenza for all > 65 yr x 1 or DM I/II, then can repeat
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What is first line drug for DM?
- Metformin (aka Glucophage) (covered) – weight neutral
- 1st line, increases sensitivity to insulin, hard on liver and kidney
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What are the 2 mechanisms of action of metformin?
2 MOA’s: liver → decreases GNG, peripheral - ↑ peripheral insulin sensitivity
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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
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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
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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
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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))
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What is genuvia?
- Incretin (DPP-4 inhibitor) – genuvia - ↓ A1C by 1% absolute value
- Or SQ – Victosa – wgt loss - “ “
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INSULIN
- 1st choice to start
- Intermediate acting (covered) – NPH or Humulin N – up to 18h
- Long acting (not covered) – Levemir or Lantus – up to 24h
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Ie ↓ glucose in am ac breakfast, don’t hold basal insulin
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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
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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
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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
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How do we screen annually for neuropathy
10g monofilament @ great toe – screen annually for neuropathy
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How do we treat Diabetic foot pain?
- Amitriptalin
- Gabapentin (Lyrica)
- Pregabulin
- Oxycodon (last resort)
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What sensitive subject should you ask all DM men about?
- Erectile dysfunction – ask about in all DM men
- Follow guidelines
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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)
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