1 Given a symptomatic or asymptomatic patient at high risk for diabetes (e.g., patients with gestational diabetes, obese, certain ethnic groups, and those with a strong family history), screen at appropriate intervals with the right tests to confirm the diagnosis.
Who to screen
- All pt >=40yo
- Earlier if risk factors or at high / very high risk using a risk calculator “CANRISK”
How often & how to screen
- Screen Q3yr using a FPG and/or A1C
Risk Factors
- Age >=40yo
- 1o relative with DM2
- Aboriginal, African, Asian, Hispanic, or South Asian descent
- Hx of prediabetes (IGT, IFG, A1C 6-6.4%)
- GDM or delivery of a macrosomic infant
- Presence of end organ damage associated with DM
- Microvascular – retinopathy, neuropathy, nephropathy
- Macrovascular – coronary, cerebrovascular, peripheral, ED
- Presence of vascular risk factors
- HDL =1.7
- HTN, overweight, abdominal obesity
- Presence of associated diseases
- PCOS, Acanthosis nigricans, OSA
- psychiatric disorders (bipolar, depression, schizophrenia), HIV
- Use of drugs associated with DM
- Glucocorticoids, atypical antipsychotics, antiretroviral Tx
- Other secondary causes
Complications of DM
- Macrovascular: CVD, CVA, PAD, ED
- Microvascular: retinopathy, nephropathy, neuropathy
- infection
Dx
- FPG (no caloric intake >8hr) >=7 mmol/L
- Prediabetes – IFG – 6.1 – 6.9 mmol/L
- A1C >=6.5%
- Prediabetes 6-6.4%
- Not used in children, adolescents, pregnant women, suspected type 1 diabetes
- Affected by hemoglobinopathies, iron deficiency, hemolytic anemia, severe hepatic or renal dz
- 2hPG in a 75g OGTT >=11.1 mmol/L
- Prediabetes – IGT – 7.8-11.0 mmol/L
- Random PG >=11.1 mmol/L
In the asymptomatic hyperglycemia, a repeat confirmatory laboratory test (FPG, A1C, 2hPG) must be done on another day. Random PG should be confirmed with an alternate test.
3 Given a patient with established diabetes, advise about signs and treatment of hypoglycemia/hyperglycemia during an acute illness or stress (i.e., gastroenteritis, physiologic stress, decreased intake.
Hyperglycemia Symptoms:
- Polyuria, polydipsia, polyphagia, dry mouth, unexplained weight loss
- Blurred visioin, fatigue, itchy skin, parasthesia, arrhythmia, coma
HONK symptoms:
- Kussmaul’s breathing (deep rapid), confusion / ↓LOC, impaired cognitive function
- N/V, Abd pain, dehydration, fruity smelling breath
Hypoglycemia symptoms (PG <4):
- Palpitations, sweating, pallor, clammy, n/v, seizures
- Dilated pupils, blurred vision, numbness, confusion, coma
- Tx with 15g of carbs (3 tsp sugar, 3/4 cup juice, 6 lifesavers), retest in 15min & repeat carbs if PG <4
- Tx with 1mg glucagon sc/IM if severe
Sick Day protocol
- feeling sick or having a fever x few days not getting better
- Vomiting, diarrhea > 6hr
- Tx: Avoid exercise
- BG Q4h and more often if increasing
- Check urine or blood for ketones
- Modify insulin regimen: increase oral dose or insulin dose
- Maintain adequate food (>50g carb Q3-4h) and fluid
- If n/v, eat concentrated carbs – soft drink, juice, broth
- Call MD if glucose >13.3 and remain increase x 24 hr (on oral agents) or despite extra insulin (on insulin)
- ED if positive ketones, constitutional symptoms, ?DKA with glucose >14
5 In patients with established diabetes:
a) Look for complications (e.g., proteinuria).
b) Refer them as necessary.
Investigations:
Initial
- EKG if >40yo, DM >15yr, HTN, proteinuria, decrease pulse
- Stress test in high risk CVD before recommending exercise
Q3-6m
- BP (<130/80), A1C (<7%), creatinine if albuminuria
Annual
- Lipid panel, Ref to optometry / ophthalmologist , ACR, monofilament foot exam (also ROM, skin, neuropathy, PAD)
ECG Q2y
Referral:
- ACR>60, eGFR<30
- Persistent hyperkalemia
- >30% increase in Cr within 3mo of starting ACEi / ARB
- Retinopathy / vitreous hemorrhage / macular edema
- ED and PDE5 is contraindicated or no response
2 Given a patient diagnosed with diabetes, either new-onset or established, treat and modify treatment according to disease status (e.g., use oral hypoglycemic agents, insulin, diet, and/or lifestyle changes).
Prevention (IGT to DM2)
- Lifestyle modifications (wt loss 5-10% + exercise 150min/week)
- consider Metformin (RRR 30%) or acarbose
Rx
Lifestyle Modifications – monotherapy if A1C <8.5% & try 2-3mo
- Diet: Mediterranean, vegetarian > DASH
- <7% total energy from saturated fats
- EtOH 2-3 hr after dinner
- Moderate aerobic exercise 50-70% HR 150min over >3d / week, resistance exercise 3x/week, exercise >4hr/week
- Wt loss 5-10%
Pharmacotherapy
- Symptomatic hyperglycemia at Dx with metabolic decompensation
- Initiate Insullin +/- metformin
- At Dx if A1C <8.5% – start lifestyle intervention, if not at target in 2-3/12, start/increase metformin
- A1C >=8.5% – start lifestyle intervention & metformin & consider adding another agent
- If not at glycemic target – add an appropriate agent and make timely adjustment to attain target A1C in 3-6/12
- Flu shot, consider pneumococcal vaccine
Target A1C <=7.0%
- 1% ↓ A1C = 21%↓ mortality
- Self-monitoring of BG – ensure pt can use BG meter and has a monitoring schedule
- FPG or preprandial target of 4-7 mmol/L & a 2hr postprandial target of 5-10 mmol/L
- If A1C not at target, 2 hr postprandial target to 5-8 mmol/L
- No routine monitoring if on oral antihyperglycemics & monitoring when not in target w/ pre+postprandials
- Insulin 1/d – monitor >=1x/d
- Insulin >1/d – monitor >=3x/d w/ pre+postprandials
- a target A1C <6.5% may be considered to further lower the risk of nephropathy & retinopathy
- must balance against the risk of hypoglycemia
Target A1C 7.1-8.5% if
- Limited life expectancy, multiple commorbidities
- High level of functional dependency
- Extensive coronary artery disease at high risk of ischemic events
- Hx of recurrent severe hypoglycemia or hypoglycemia unawareness
- Longstanding DM – difficult to achemeve A1C target despite intensified basal-bolu insulin therapy
Pt characteristics
- Degree of hyperglycemia, risk of hypoglycemia, pt preferences
- Overweight / Obese, Commorbidities (renal, cardiac, hepatic)
Agent characteristics
- BG lowering efficacy & durability, risk of inducing hypoglycemia, cost and coverage
- Effect on weight, contraindications and s/e
- Biguanide – Metformin – 1st line
- <2550mg/d (Cr 60-90 <1700; Cr 30-60 <850)
- Alpha-glucosidase inhibitor – Acarbose ($$)
- ↓ A1C, rare hypoglycemia, ↓ wt, GI s/e
- Improve postprandial control
- Incretin agents: DPP-4 inhibitor – Januvia ($$$) or GLP-1 receptor agonist ($$$$)
- ↓↓ A1C, rare hypoglycemia, ↓/↓↓ wt, GI s/e
- Insulin ($-$$$$)
- ↓↓↓ A1C, + hypoglycemia, ↑↑ wt
- no dose ceiling, flexible regimens
- Insulin Secretagogue: ↓↓ A1C, + hypoglycemia,↑Wt
- Meglitinide ($$)
- GlucoNorm– Less hypoglycemia with missed meals but Tid – Qid dosing
- Sulfonylurea ($)
- Gliclazide & glimepiride less hypoglycemia than glyburide
- Meglitinide ($$)
- TZD – Actos ($$)
- ↓↓ A1C, rare hypoglycemia,↑↑ Wt
- CHF, edema, fracture, rare bladder ca (pioglitazone), CV controversy (rosiglitazone), 6-12 wk for max effect
- Wt loss agent ($$$) Orlistat
- ↓A1C, no hypoglycemia, ↓ Wt, GI s/E
- Subtype 2 Sodium-glucose transport protein inhibitor (SGLT2)- Invokana
4 In a patient with poorly controlled diabetes, use effective educational techniques to advise about the importance of optimal glycemic control through compliance, lifestyle modification, and appropriate follow-up and treatment.
Vascular Protection
- A1C – <=7%
- BP <130/80 mmHg
- Cholesterol LDL <=2.0mmol/L
- Drugs:
- ACEI/ARB if macrovascular or microvascular dz or age >=55yo
- Statin if macro/microvascular dz, age >=40yo, DM>15yr & age >30yo
- Exercise – Encourage moderate aerobic (50-70% max HR) 150min/wk & resistance exercise 3x/week – exercise >4hr/wk
- Smoking Cessation – encourage at every visit
DM Care visit
- Hx: Ask about hypoglycemia & CAD risk assessment & psychiatric disorder screening & ED screening
- O/E: BP (<130/80), BMI (18.5-24.9), waist circumference
- screen retinopathy Q1-2y, foot exam Q1y
- Investigations:
- A1C q3m (target <=7.0%)
- compare BG meter to lab results Q1y (within 20%);
- ACR & eGFR at Dx and Q1y (ACR <2.0mg/mmol & eGFR >60) – CKD screening
- ECG Q2y, lipid panel Q1y (LDL <=2)
- Encourage: smoking cessation, nutritional Tx,aerobic & resistance exercise
- Ensure: BG monitoring – Preprandial 4-7, Postprandial 5-10
- Flu shots & consider pneumococcal vaccine
- Psychosocial interventions: motivation interventions, stress management, coping skills training, family therapy
6 In the acutely ill diabetic patient, diagnose the underlying cause of the illness and investigate for diabetic ketoacidosis and hyperglycemia.
Hx:
- Polyuria, polydipsia
- fatigue, lethargy,
- Coma / decreased LOC (HHS)
- H/A, N/V, Abd pain, decreased appetite
O/E:
- decreased skin turgor, decreased sweat
- Postural HoTN
- Kussmaul breathing (deep rapid)
- Fruity smell breath (DKA)
Dx of DKA:
- BG >14, presence of urine/plasma ketones, pH<7.3, serum bicarbonate <18
Dx of HHS
- Glucose >33 often >55, pH>7.3 and mild to none ketosis
- Profound dehydration
Precipitants:
- Infection
- EtOH misuses
- Psychological stress
- CV events: MI, PE, stroke
- Trauma
- Pregnancy
- Cushing dz
- Acute GI dz: pancreatitis, obstruction
- Medications: corticosteroids, thiazide
Ix:
- Glucose, ketones,
- blood gas (pH),
- lytes, lipase (pancreatitis), Cr/Urea (dehydration),
- CBC, urine + blood Cx (infection),
- CXR (PNA), ECG (potassium, MI)
7 Given a patient with diabetic ketoacidosis, manage the problem appropriately and advise about preventing future episodes.
- Rehydration – NS 1L /hr (severe dehydration) or 500ml/hr (moderate dehydration) & add KCL if K <5.2 + pt urinating
- K <3.3 – no insulin and give 40mmol KCl/hr
- K 3.3-5.2 – give 20 mmol KCl /hr
- K >5.2 – check K q2hr
- lab work Q2h min
- Insulin (if K >3.3)
- Insulin Regular infusion 0.1u/kg/hr
- Give D5NS if BG<14
- Resolution if bicarb >15, pH >7.3, anion gap <12, glucose <11.1
Complications:
- Overhydration: Cerebral edema, ARDS
- Electrolytes imbalance: hypoglycemia, hypokalemia, hypophosphatemia
- Vascular occlusions, rhabdomyolysis
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